hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|CA,"To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.",general_contract_provisions,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Good Samaritan Hospital,12/17/2024,2.1.0,"Good Samaritan Hospital|Suffern, NY","255 Lafayette Ave, Suffern, NY 10901",4329000H|New York,TRUE,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
description,code|1,code|1|type,modifiers,code|2,code|2|type,code|3,code|3|type,code|4,code|4|type,setting,drug_unit_of_measurement,drug_type_of_measurement,standard_charge|gross,standard_charge|discounted_cash,standard_charge|discounted_cash|negotiated_percentage,standard_charge|discounted_cash|negotiated_algorithm,estimated_amount|discounted_cash,standard_charge|discounted_cash|methodology,additional_payer_notes|discounted_cash,standard_charge|Medicare_Advantage|negotiated_dollar,standard_charge|Medicare_Advantage|negotiated_percentage,standard_charge|Medicare_Advantage|negotiated_algorithm,estimated_amount|Medicare_Advantage,standard_charge|Medicare_Advantage|methodology,additional_payer_notes|Medicare_Advantage,standard_charge|Aetna|HMO_PPO|negotiated_dollar,standard_charge|Aetna|HMO_PPO|negotiated_percentage,standard_charge|Aetna|HMO_PPO|negotiated_algorithm,estimated_amount|Aetna|HMO_PPO,standard_charge|Aetna|HMO_PPO|methodology,additional_payer_notes|Aetna|HMO_PPO,standard_charge|Aetna|High_Performance_Network|negotiated_dollar,standard_charge|Aetna|High_Performance_Network|negotiated_percentage,standard_charge|Aetna|High_Performance_Network|negotiated_algorithm,estimated_amount|Aetna|High_Performance_Network,standard_charge|Aetna|High_Performance_Network|methodology,additional_payer_notes|Aetna|High_Performance_Network,standard_charge|Blue_Cross|PPO_Indemnity|negotiated_dollar,standard_charge|Blue_Cross|PPO_Indemnity|negotiated_percentage,standard_charge|Blue_Cross|PPO_Indemnity|negotiated_algorithm,estimated_amount|Blue_Cross|PPO_Indemnity,standard_charge|Blue_Cross|PPO_Indemnity|methodology,additional_payer_notes|Blue_Cross|PPO_Indemnity,standard_charge|Blue_Cross|Access|negotiated_dollar,standard_charge|Blue_Cross|Access|negotiated_percentage,standard_charge|Blue_Cross|Access|negotiated_algorithm,estimated_amount|Blue_Cross|Access,standard_charge|Blue_Cross|Access|methodology,additional_payer_notes|Blue_Cross|Access,standard_charge|Blue_Cross|Connection|negotiated_dollar,standard_charge|Blue_Cross|Connection|negotiated_percentage,standard_charge|Blue_Cross|Connection|negotiated_algorithm,estimated_amount|Blue_Cross|Connection,standard_charge|Blue_Cross|Connection|methodology,additional_payer_notes|Blue_Cross|Connection,standard_charge|CDPHP|HMO_Exchange|negotiated_dollar,standard_charge|CDPHP|HMO_Exchange|negotiated_percentage,standard_charge|CDPHP|HMO_Exchange|negotiated_algorithm,estimated_amount|CDPHP|HMO_Exchange,standard_charge|CDPHP|HMO_Exchange|methodology,additional_payer_notes|CDPHP|HMO_Exchange,standard_charge|Cigna|HMO_PPO|negotiated_dollar,standard_charge|Cigna|HMO_PPO|negotiated_percentage,standard_charge|Cigna|HMO_PPO|negotiated_algorithm,estimated_amount|Cigna|HMO_PPO,standard_charge|Cigna|HMO_PPO|methodology,additional_payer_notes|Cigna|HMO_PPO,standard_charge|Emblem|Exchange|negotiated_dollar,standard_charge|Emblem|Exchange|negotiated_percentage,standard_charge|Emblem|Exchange|negotiated_algorithm,estimated_amount|Emblem|Exchange,standard_charge|Emblem|Exchange|methodology,additional_payer_notes|Emblem|Exchange,standard_charge|Fidelis|Exchange|negotiated_dollar,standard_charge|Fidelis|Exchange|negotiated_percentage,standard_charge|Fidelis|Exchange|negotiated_algorithm,estimated_amount|Fidelis|Exchange,standard_charge|Fidelis|Exchange|methodology,additional_payer_notes|Fidelis|Exchange,standard_charge|Emblem_GHI|HMO|negotiated_dollar,standard_charge|Emblem_GHI|HMO|negotiated_percentage,standard_charge|Emblem_GHI|HMO|negotiated_algorithm,estimated_amount|Emblem_GHI|HMO,standard_charge|Emblem_GHI|HMO|methodology,additional_payer_notes|Emblem_GHI|HMO,standard_charge|Emblem_GHI|PPO|negotiated_dollar,standard_charge|Emblem_GHI|PPO|negotiated_percentage,standard_charge|Emblem_GHI|PPO|negotiated_algorithm,estimated_amount|Emblem_GHI|PPO,standard_charge|Emblem_GHI|PPO|methodology,additional_payer_notes|Emblem_GHI|PPO,standard_charge|Emblem_GHI|CBP|negotiated_dollar,standard_charge|Emblem_GHI|CBP|negotiated_percentage,standard_charge|Emblem_GHI|CBP|negotiated_algorithm,estimated_amount|Emblem_GHI|CBP,standard_charge|Emblem_GHI|CBP|methodology,additional_payer_notes|Emblem_GHI|CBP,standard_charge|Emblem_HIP|HMO|negotiated_dollar,standard_charge|Emblem_HIP|HMO|negotiated_percentage,standard_charge|Emblem_HIP|HMO|negotiated_algorithm,estimated_amount|Emblem_HIP|HMO,standard_charge|Emblem_HIP|HMO|methodology,additional_payer_notes|Emblem_HIP|HMO,standard_charge|Emblem_HIP|PPO|negotiated_dollar,standard_charge|Emblem_HIP|PPO|negotiated_percentage,standard_charge|Emblem_HIP|PPO|negotiated_algorithm,estimated_amount|Emblem_HIP|PPO,standard_charge|Emblem_HIP|PPO|methodology,additional_payer_notes|Emblem_HIP|PPO,standard_charge|Magnacare|Preferred|negotiated_dollar,standard_charge|Magnacare|Preferred|negotiated_percentage,standard_charge|Magnacare|Preferred|negotiated_algorithm,estimated_amount|Magnacare|Preferred,standard_charge|Magnacare|Preferred|methodology,additional_payer_notes|Magnacare|Preferred,standard_charge|Magnacare|Standard|negotiated_dollar,standard_charge|Magnacare|Standard|negotiated_percentage,standard_charge|Magnacare|Standard|negotiated_algorithm,estimated_amount|Magnacare|Standard,standard_charge|Magnacare|Standard|methodology,additional_payer_notes|Magnacare|Standard,standard_charge|MVP|HMO|negotiated_dollar,standard_charge|MVP|HMO|negotiated_percentage,standard_charge|MVP|HMO|negotiated_algorithm,estimated_amount|MVP|HMO,standard_charge|MVP|HMO|methodology,additional_payer_notes|MVP|HMO,standard_charge|MVP|Exchange|negotiated_dollar,standard_charge|MVP|Exchange|negotiated_percentage,standard_charge|MVP|Exchange|negotiated_algorithm,estimated_amount|MVP|Exchange,standard_charge|MVP|Exchange|methodology,additional_payer_notes|MVP|Exchange,standard_charge|Oxford|HMO_PPO|negotiated_dollar,standard_charge|Oxford|HMO_PPO|negotiated_percentage,standard_charge|Oxford|HMO_PPO|negotiated_algorithm,estimated_amount|Oxford|HMO_PPO,standard_charge|Oxford|HMO_PPO|methodology,additional_payer_notes|Oxford|HMO_PPO,standard_charge|Oxford|Metro|negotiated_dollar,standard_charge|Oxford|Metro|negotiated_percentage,standard_charge|Oxford|Metro|negotiated_algorithm,estimated_amount|Oxford|Metro,standard_charge|Oxford|Metro|methodology,additional_payer_notes|Oxford|Metro,standard_charge|United_Healthcare|HMO_PPO|negotiated_dollar,standard_charge|United_Healthcare|HMO_PPO|negotiated_percentage,standard_charge|United_Healthcare|HMO_PPO|negotiated_algorithm,estimated_amount|United_Healthcare|HMO_PPO,standard_charge|United_Healthcare|HMO_PPO|methodology,additional_payer_notes|United_Healthcare|HMO_PPO,standard_charge|United_Healthcare|Compass|negotiated_dollar,standard_charge|United_Healthcare|Compass|negotiated_percentage,standard_charge|United_Healthcare|Compass|negotiated_algorithm,estimated_amount|United_Healthcare|Compass,standard_charge|United_Healthcare|Compass|methodology,additional_payer_notes|United_Healthcare|Compass,standard_charge|Medicaid_Advantage|negotiated_dollar,standard_charge|Medicaid_Advantage|negotiated_percentage,standard_charge|Medicaid_Advantage|negotiated_algorithm,estimated_amount|Medicaid_Advantage,standard_charge|Medicaid_Advantage|methodology,additional_payer_notes|Medicaid_Advantage,standard_charge|Child_Health_PLus|negotiated_dollar,standard_charge|Child_Health_Plus|negotiated_percentage,standard_charge|Child_Health_Plus|negotiated_algorithm,estimated_amount|Child_Health_Plus,standard_charge|Child_Health_Plus|methodology,additional_payer_notes|Child_Health_Plus,standard_charge|Fidelis|Child_Health_PLus|negotiated_dollar,standard_charge|Fidelis|Child_Health_Plus|negotiated_percentage,standard_charge|Fidelis|Child_Health_Plus|negotiated_algorithm,estimated_amount|Fidelis|Child_Health_Plus,standard_charge|Fidelis|Child_Health_Plus|methodology,additional_payer_notes|Fidelis|Child_Health_Plus,standard_charge|United_Healthcare|Child_Health_PLus|negotiated_dollar,standard_charge|United_Healthcare|Child_Health_Plus|negotiated_percentage,standard_charge|United_Healthcare|Child_Health_Plus|negotiated_algorithm,estimated_amount|United_Healthcare|Child_Health_Plus,standard_charge|United_Healthcare|Child_Health_Plus|methodology,additional_payer_notes|United_Healthcare|Child_Health_Plus,standard_charge|Essential_3_&_4|negotiated_dollar,standard_charge|Essential_3_&_4|negotiated_percentage,standard_charge|Essential_3_&_4|negotiated_algorithm,estimated_amount|Essential_3_&_4,standard_charge|Essential_3_&_4|methodology,additional_payer_notes|Essential_3_&_4,standard_charge|Affinity|Essential_1_&_2|negotiated_dollar,standard_charge|Affinity|Essential_1_&_2|negotiated_percentage,standard_charge|Affinity|Essential_1_&_2|negotiated_algorithm,estimated_amount|Affinity|Essential_1_&_2,standard_charge|Affinity|Essential_1_&_2|methodology,additional_payer_notes|Affinity|Essential_1_&_2,standard_charge|CDPHP|Essential_1_&_2|negotiated_dollar,standard_charge|CDPHP|Essential_1_&_2|negotiated_percentage,standard_charge|CDPHP|Essential_1_&_2|negotiated_algorithm,estimated_amount|CDPHP|Essential_1_&_2,standard_charge|CDPHP|Essential_1_&_2|methodology,additional_payer_notes|CDPHP|Essential_1_&_2,standard_charge|Empire_HealthPlus|Essential_1_&_2|negotiated_dollar,standard_charge|Empire_HealthPlus|Essential_1_&_2|negotiated_percentage,standard_charge|Empire_HealthPlus|Essential_1_&_2|negotiated_algorithm,estimated_amount|Empire_HealthPlus|Essential_1_&_2,standard_charge|Empire_HealthPlus|Essential_1_&_2|methodology,additional_payer_notes|Empire_HealthPlus|Essential_1_&_2,standard_charge|Empire_HealthPlus|Exchange|negotiated_dollar,standard_charge|Empire_HealthPlus|Exchange|negotiated_percentage,standard_charge|Empire_HealthPlus|Exchange|negotiated_algorithm,estimated_amount|Empire_HealthPlus|Exchange,standard_charge|Empire_HealthPlus|Exchange|methodology,additional_payer_notes|Empire_HealthPlus|Exchange,standard_charge|Fidelis|Essential_1_&_2|negotiated_dollar,standard_charge|Fidelis|Essential_1_&_2|negotiated_percentage,standard_charge|Fidelis|Essential_1_&_2|negotiated_algorithm,estimated_amount|Fidelis|Essential_1_&_2,standard_charge|Fidelis|Essential_1_&_2|methodology,additional_payer_notes|Fidelis|Essential_1_&_2,standard_charge|HealthFirst|Essential_1_&_2|negotiated_dollar,standard_charge|HealthFirst|Essential_1_&_2|negotiated_percentage,standard_charge|HealthFirst|Essential_1_&_2|negotiated_algorithm,estimated_amount|HealthFirst|Essential_1_&_2,standard_charge|HealthFirst|Essential_1_&_2|methodology,additional_payer_notes|HealthFirst|Essential_1_&_2,standard_charge|HealthFirst|Exchange|negotiated_dollar,standard_charge|HealthFirst|Exchange|negotiated_percentage,standard_charge|HealthFirst|Exchange|negotiated_algorithm,estimated_amount|HealthFirst|Exchange,standard_charge|HealthFirst|Exchange|methodology,additional_payer_notes|HealthFirst|Exchange,standard_charge|MVP|Essential_1_&_2|negotiated_dollar,standard_charge|MVP|Essential_1_&_2|negotiated_percentage,standard_charge|MVP|Essential_1_&_2|negotiated_algorithm,estimated_amount|MVP|Essential_1_&_2,standard_charge|MVP|Essential_1_&_2|methodology,additional_payer_notes|MVP|Essential_1_&_2,standard_charge|MVP|Essential_3_&_4|negotiated_dollar,standard_charge|MVP|Essential_3_&_4|negotiated_percentage,standard_charge|MVP|Essential_3_&_4|negotiated_algorithm,estimated_amount|MVP|Essential_3_&_4,standard_charge|MVP|Essential_3_&_4|methodology,additional_payer_notes|MVP|Essential_3_&_4,standard_charge|United_Healthcare|Essential_1_to_4|negotiated_dollar,standard_charge|United_Healthcare|Essential_1_to_4|negotiated_percentage,standard_charge|United_Healthcare|Essential_1_to_4|negotiated_algorithm,estimated_amount|United_Healthcare|Essential_1_to_4,standard_charge|United_Healthcare|Essential_1_to_4|methodology,additional_payer_notes|United_Healthcare|Essential_1_to_4,standard_charge|min,standard_charge|max,additional_generic_notes
BRILLIANT BLUE G OPHTH 0.025%   ,,,,40500126,CDM,250,RC,68803-0722-25,NDC,both,0.5,ML,490,193.39,39.4668,,193.39,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,147,30,,147,percent of total billed charges,"Drugs, Inpatient Only",147,30,,147,percent of total billed charges,"Drugs, Inpatient Only",147,30,,147,percent of total billed charges,"Drugs, Inpatient Only",245,50,,245,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,260.4,,,260.4,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,343,70,,343,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,140,,,140,Other,Drug Cost,140,,,140,Other,Drug Cost,140,,,140,Other,Drug Cost,140,,,140,Other,Drug Cost,140,,,140,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,140,,,140,Other,Drug Cost,315,,,315,Other,225% Medicaid APG methodology,196,,,196,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,140,,,140,Other,Drug Cost,140,,,140,Other,Drug Cost,175,,,175,Other,125% Medicaid APG methodology,0.01,343,
DEXTROSE 10% IN WATER  500 ML   ,,,,40500183,CDM,250,RC,00264-7520-10,NDC,both,500,ML,17.5,6.91,39.4668,,6.91,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.25,30,,5.25,percent of total billed charges,"Drugs, Inpatient Only",5.25,30,,5.25,percent of total billed charges,"Drugs, Inpatient Only",5.25,30,,5.25,percent of total billed charges,"Drugs, Inpatient Only",8.75,50,,8.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.3,,,9.3,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.25,70,,12.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5,,,5,Other,Drug Cost,5,,,5,Other,Drug Cost,5,,,5,Other,Drug Cost,5,,,5,Other,Drug Cost,5,,,5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,5,,,5,Other,Drug Cost,11.25,,,11.25,Other,225% Medicaid APG methodology,7,,,7,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5,,,5,Other,Drug Cost,5,,,5,Other,Drug Cost,6.25,,,6.25,Other,125% Medicaid APG methodology,0.01,12.25,
ESTRADIOL TWICE WEEKLY FILM     ,,,,40500241,CDM,250,RC,65162-0992-08,NDC,both,1,EA,28.21,11.13,39.4668,,11.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.46,30,,8.46,percent of total billed charges,"Drugs, Inpatient Only",8.46,30,,8.46,percent of total billed charges,"Drugs, Inpatient Only",8.46,30,,8.46,percent of total billed charges,"Drugs, Inpatient Only",14.11,50,,14.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.28,,,4.28,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.75,70,,19.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.3,,,2.3,Other,Drug Cost,2.3,,,2.3,Other,Drug Cost,2.3,,,2.3,Other,Drug Cost,2.3,,,2.3,Other,Drug Cost,2.3,,,2.3,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.3,,,2.3,Other,Drug Cost,5.18,,,5.18,Other,225% Medicaid APG methodology,3.22,,,3.22,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.3,,,2.3,Other,Drug Cost,2.3,,,2.3,Other,Drug Cost,2.88,,,2.88,Other,125% Medicaid APG methodology,0.01,19.75,
"ESTRADIOL WEEKLY TD FILM, ER    ",,,,40500258,CDM,250,RC,00378-3360-99,NDC,both,1,EA,60.41,23.84,39.4668,,23.84,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,18.12,30,,18.12,percent of total billed charges,"Drugs, Inpatient Only",18.12,30,,18.12,percent of total billed charges,"Drugs, Inpatient Only",18.12,30,,18.12,percent of total billed charges,"Drugs, Inpatient Only",30.21,50,,30.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.3,,,8.3,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,42.29,70,,42.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.46,,,4.46,Other,Drug Cost,4.46,,,4.46,Other,Drug Cost,4.46,,,4.46,Other,Drug Cost,4.46,,,4.46,Other,Drug Cost,4.46,,,4.46,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.46,,,4.46,Other,Drug Cost,10.04,,,10.04,Other,225% Medicaid APG methodology,6.24,,,6.24,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.46,,,4.46,Other,Drug Cost,4.46,,,4.46,Other,Drug Cost,5.58,,,5.58,Other,125% Medicaid APG methodology,0.01,42.29,
CENOBAMATE 100 MG TAB           ,,,,40500357,CDM,250,RC,71699-0100-30,NDC,both,1,EA,120.47,47.55,39.4668,,47.55,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,36.14,30,,36.14,percent of total billed charges,"Drugs, Inpatient Only",36.14,30,,36.14,percent of total billed charges,"Drugs, Inpatient Only",36.14,30,,36.14,percent of total billed charges,"Drugs, Inpatient Only",60.24,50,,60.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,42.8,,,42.8,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,84.33,70,,84.33,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,23.01,,,23.01,Other,Drug Cost,23.01,,,23.01,Other,Drug Cost,23.01,,,23.01,Other,Drug Cost,23.01,,,23.01,Other,Drug Cost,23.01,,,23.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,23.01,,,23.01,Other,Drug Cost,51.77,,,51.77,Other,225% Medicaid APG methodology,32.21,,,32.21,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,23.01,,,23.01,Other,Drug Cost,23.01,,,23.01,Other,Drug Cost,28.76,,,28.76,Other,125% Medicaid APG methodology,0.01,84.33,
GALANTAMINE 24 MG ER CAP        ,,,,40500654,CDM,250,RC,47335-0837-83,NDC,both,1,EA,4.17,1.65,39.4668,,1.65,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.25,30,,1.25,percent of total billed charges,"Drugs, Inpatient Only",1.25,30,,1.25,percent of total billed charges,"Drugs, Inpatient Only",1.25,30,,1.25,percent of total billed charges,"Drugs, Inpatient Only",2.09,50,,2.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.67,,,0.67,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.92,70,,2.92,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.36,,,0.36,Other,Drug Cost,0.81,,,0.81,Other,225% Medicaid APG methodology,0.5,,,0.5,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.45,,,0.45,Other,125% Medicaid APG methodology,0.01,2.92,
ACETIC ACID 0.25% IRRIG 250 ML  ,,,,40505026,CDM,250,RC,00990-6143-22,NDC,both,250,ML,17.08,6.74,39.4668,,6.74,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.12,30,,5.12,percent of total billed charges,"Drugs, Inpatient Only",5.12,30,,5.12,percent of total billed charges,"Drugs, Inpatient Only",5.12,30,,5.12,percent of total billed charges,"Drugs, Inpatient Only",8.54,50,,8.54,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.24,,,4.24,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.96,70,,11.96,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.28,,,2.28,Other,Drug Cost,2.28,,,2.28,Other,Drug Cost,2.28,,,2.28,Other,Drug Cost,2.28,,,2.28,Other,Drug Cost,2.28,,,2.28,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.28,,,2.28,Other,Drug Cost,5.13,,,5.13,Other,225% Medicaid APG methodology,3.19,,,3.19,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.28,,,2.28,Other,Drug Cost,2.28,,,2.28,Other,Drug Cost,2.85,,,2.85,Other,125% Medicaid APG methodology,0.01,11.96,
CARIPRAZINE 3 MG CAP            ,,,,40505075,CDM,250,RC,61874-0130-20,NDC,both,1,EA,142.24,56.14,39.4668,,56.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,42.67,30,,42.67,percent of total billed charges,"Drugs, Inpatient Only",42.67,30,,42.67,percent of total billed charges,"Drugs, Inpatient Only",42.67,30,,42.67,percent of total billed charges,"Drugs, Inpatient Only",71.12,50,,71.12,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,43.3,,,43.3,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,99.57,70,,99.57,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,23.28,,,23.28,Other,Drug Cost,23.28,,,23.28,Other,Drug Cost,23.28,,,23.28,Other,Drug Cost,23.28,,,23.28,Other,Drug Cost,23.28,,,23.28,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,23.28,,,23.28,Other,Drug Cost,52.38,,,52.38,Other,225% Medicaid APG methodology,32.59,,,32.59,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,23.28,,,23.28,Other,Drug Cost,23.28,,,23.28,Other,Drug Cost,29.1,,,29.1,Other,125% Medicaid APG methodology,0.01,99.57,
GRISEOFULVIN MICRO 500 MG TAB   ,,,,40505091,CDM,250,RC,62135-0496-01,NDC,both,1,EA,23.8,9.39,39.4668,,9.39,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.14,30,,7.14,percent of total billed charges,"Drugs, Inpatient Only",7.14,30,,7.14,percent of total billed charges,"Drugs, Inpatient Only",7.14,30,,7.14,percent of total billed charges,"Drugs, Inpatient Only",11.9,50,,11.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.55,,,10.55,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,16.66,70,,16.66,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.67,,,5.67,Other,Drug Cost,5.67,,,5.67,Other,Drug Cost,5.67,,,5.67,Other,Drug Cost,5.67,,,5.67,Other,Drug Cost,5.67,,,5.67,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,5.67,,,5.67,Other,Drug Cost,12.76,,,12.76,Other,225% Medicaid APG methodology,7.94,,,7.94,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.67,,,5.67,Other,Drug Cost,5.67,,,5.67,Other,Drug Cost,7.09,,,7.09,Other,125% Medicaid APG methodology,0.01,16.66,
ALOGLIPTIN 6.25 MG TAB          ,,,,40505174,CDM,250,RC,64764-0625-30,NDC,both,1,EA,44.31,17.49,39.4668,,17.49,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.29,30,,13.29,percent of total billed charges,"Drugs, Inpatient Only",13.29,30,,13.29,percent of total billed charges,"Drugs, Inpatient Only",13.29,30,,13.29,percent of total billed charges,"Drugs, Inpatient Only",22.16,50,,22.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.53,,,1.53,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,31.02,70,,31.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.82,,,0.82,Other,Drug Cost,1.85,,,1.85,Other,225% Medicaid APG methodology,1.15,,,1.15,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,1.03,,,1.03,Other,125% Medicaid APG methodology,0.01,31.02,
ALOGLIPTIN 25 MG TAB            ,,,,40505182,CDM,250,RC,64764-0250-30,NDC,both,1,EA,44.31,17.49,39.4668,,17.49,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.29,30,,13.29,percent of total billed charges,"Drugs, Inpatient Only",13.29,30,,13.29,percent of total billed charges,"Drugs, Inpatient Only",13.29,30,,13.29,percent of total billed charges,"Drugs, Inpatient Only",22.16,50,,22.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,31.02,70,,31.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,31.02,
AMOXICILLIN 875 MG TAB          ,,,,40505232,CDM,250,RC,00781-5061-20,NDC,both,1,EA,0.63,0.25,39.4668,,0.25,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.32,50,,0.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.44,70,,0.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% Medicaid APG methodology,0.1,,,0.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.44,
DIAZEPAM 20 MG RECTAL KIT       ,,,,40505315,CDM,250,RC,00187-0659-20,NDC,both,1,EA,372.4,146.97,39.4668,,146.97,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,111.72,30,,111.72,percent of total billed charges,"Drugs, Inpatient Only",111.72,30,,111.72,percent of total billed charges,"Drugs, Inpatient Only",111.72,30,,111.72,percent of total billed charges,"Drugs, Inpatient Only",186.2,50,,186.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,62.4,,,62.4,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,260.68,70,,260.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,33.55,,,33.55,Other,Drug Cost,33.55,,,33.55,Other,Drug Cost,33.55,,,33.55,Other,Drug Cost,33.55,,,33.55,Other,Drug Cost,33.55,,,33.55,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,33.55,,,33.55,Other,Drug Cost,75.49,,,75.49,Other,225% Medicaid APG methodology,46.97,,,46.97,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,33.55,,,33.55,Other,Drug Cost,33.55,,,33.55,Other,Drug Cost,41.94,,,41.94,Other,125% Medicaid APG methodology,0.01,260.68,
NESIRITIDE 1.5 MG IV INJ        ,,,,40505406,CDM,250,RC,65847-0205-25,NDC,both,1,EA,3704.79,1462.16,39.4668,,1462.16,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1111.44,30,,1111.44,percent of total billed charges,"Drugs, Inpatient Only",1111.44,30,,1111.44,percent of total billed charges,"Drugs, Inpatient Only",1111.44,30,,1111.44,percent of total billed charges,"Drugs, Inpatient Only",1852.4,50,,1852.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1968.83,,,1968.83,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2593.35,70,,2593.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1058.51,,,1058.51,Other,Drug Cost,1058.51,,,1058.51,Other,Drug Cost,1058.51,,,1058.51,Other,Drug Cost,1058.51,,,1058.51,Other,Drug Cost,1058.51,,,1058.51,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1058.51,,,1058.51,Other,Drug Cost,2381.65,,,2381.65,Other,225% Medicaid APG methodology,1481.91,,,1481.91,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1058.51,,,1058.51,Other,Drug Cost,1058.51,,,1058.51,Other,Drug Cost,1323.14,,,1323.14,Other,125% Medicaid APG methodology,0.01,2593.35,
NA HYPO 0.125% TOP SOLN 473 ML  ,,,,40505570,CDM,250,RC,39328-0064-12,NDC,both,473,ML,34.58,13.65,39.4668,,13.65,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.37,30,,10.37,percent of total billed charges,"Drugs, Inpatient Only",10.37,30,,10.37,percent of total billed charges,"Drugs, Inpatient Only",10.37,30,,10.37,percent of total billed charges,"Drugs, Inpatient Only",17.29,50,,17.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.79,,,19.79,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,24.21,70,,24.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.64,,,10.64,Other,Drug Cost,10.64,,,10.64,Other,Drug Cost,10.64,,,10.64,Other,Drug Cost,10.64,,,10.64,Other,Drug Cost,10.64,,,10.64,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,10.64,,,10.64,Other,Drug Cost,23.94,,,23.94,Other,225% Medicaid APG methodology,14.9,,,14.9,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,10.64,,,10.64,Other,Drug Cost,10.64,,,10.64,Other,Drug Cost,13.3,,,13.3,Other,125% Medicaid APG methodology,0.01,24.21,
DIVALPROEX SOD 250 MG ER TAB    ,,,,40505588,CDM,250,RC,00904-6363-45,NDC,both,1,EA,4.2,1.66,39.4668,,1.66,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.26,30,,1.26,percent of total billed charges,"Drugs, Inpatient Only",1.26,30,,1.26,percent of total billed charges,"Drugs, Inpatient Only",1.26,30,,1.26,percent of total billed charges,"Drugs, Inpatient Only",2.1,50,,2.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.21,,,1.21,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.94,70,,2.94,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.65,,,0.65,Other,Drug Cost,1.46,,,1.46,Other,225% Medicaid APG methodology,0.91,,,0.91,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.81,,,0.81,Other,125% Medicaid APG methodology,0.01,2.94,
FLUVOXAMINE 25 MG TAB           ,,,,40505604,CDM,250,RC,62559-0158-01,NDC,both,1,EA,0.42,0.17,39.4668,,0.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.21,50,,0.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,70,,0.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.29,
LANSOPRAZOLE 30 MG DIS TAB      ,,,,40505646,CDM,250,RC,00093-3009-93,NDC,both,1,EA,38.82,15.32,39.4668,,15.32,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.65,30,,11.65,percent of total billed charges,"Drugs, Inpatient Only",11.65,30,,11.65,percent of total billed charges,"Drugs, Inpatient Only",11.65,30,,11.65,percent of total billed charges,"Drugs, Inpatient Only",19.41,50,,19.41,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.13,,,8.13,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,27.17,70,,27.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.37,,,4.37,Other,Drug Cost,4.37,,,4.37,Other,Drug Cost,4.37,,,4.37,Other,Drug Cost,4.37,,,4.37,Other,Drug Cost,4.37,,,4.37,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.37,,,4.37,Other,Drug Cost,9.83,,,9.83,Other,225% Medicaid APG methodology,6.12,,,6.12,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.37,,,4.37,Other,Drug Cost,4.37,,,4.37,Other,Drug Cost,5.46,,,5.46,Other,125% Medicaid APG methodology,0.01,27.17,
BET-CLOT 0.05%-1% CREAM 15 G    ,,,,40505653,CDM,250,RC,68462-0298-17,NDC,both,15,GM,15.19,6,39.4668,,6,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.56,30,,4.56,percent of total billed charges,"Drugs, Inpatient Only",4.56,30,,4.56,percent of total billed charges,"Drugs, Inpatient Only",4.56,30,,4.56,percent of total billed charges,"Drugs, Inpatient Only",7.6,50,,7.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.97,,,1.97,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.63,70,,10.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.06,,,1.06,Other,Drug Cost,1.06,,,1.06,Other,Drug Cost,1.06,,,1.06,Other,Drug Cost,1.06,,,1.06,Other,Drug Cost,1.06,,,1.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.06,,,1.06,Other,Drug Cost,2.39,,,2.39,Other,225% Medicaid APG methodology,1.48,,,1.48,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.06,,,1.06,Other,Drug Cost,1.06,,,1.06,Other,Drug Cost,1.33,,,1.33,Other,125% Medicaid APG methodology,0.01,10.63,
METFORMIN 500 MG ER TAB         ,,,,40505661,CDM,250,RC,67877-0159-01,NDC,both,1,EA,0.11,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.06,50,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.09,
NATEGLINIDE 60 MG TAB           ,,,,40505679,CDM,250,RC,68382-0721-16,NDC,both,1,EA,1.61,0.64,39.4668,,0.64,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.48,30,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.48,30,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.48,30,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.81,50,,0.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.13,70,,1.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% Medicaid APG methodology,0.11,,,0.11,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,1.13,
NIACIN 500 MG ER TAB            ,,,,40505687,CDM,250,RC,50268-0584-13,NDC,both,1,EA,5.43,2.14,39.4668,,2.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.63,30,,1.63,percent of total billed charges,"Drugs, Inpatient Only",1.63,30,,1.63,percent of total billed charges,"Drugs, Inpatient Only",1.63,30,,1.63,percent of total billed charges,"Drugs, Inpatient Only",2.72,50,,2.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.88,,,1.88,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.8,70,,3.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.01,,,1.01,Other,Drug Cost,1.01,,,1.01,Other,Drug Cost,1.01,,,1.01,Other,Drug Cost,1.01,,,1.01,Other,Drug Cost,1.01,,,1.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.01,,,1.01,Other,Drug Cost,2.27,,,2.27,Other,225% Medicaid APG methodology,1.41,,,1.41,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.01,,,1.01,Other,Drug Cost,1.01,,,1.01,Other,Drug Cost,1.26,,,1.26,Other,125% Medicaid APG methodology,0.01,3.8,
POTASSIUM CIT 10 MEQ ER TAB     ,,,,40505695,CDM,250,RC,68084-0850-32,NDC,both,1,EA,7.49,2.96,39.4668,,2.96,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.25,30,,2.25,percent of total billed charges,"Drugs, Inpatient Only",2.25,30,,2.25,percent of total billed charges,"Drugs, Inpatient Only",2.25,30,,2.25,percent of total billed charges,"Drugs, Inpatient Only",3.75,50,,3.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.05,,,3.05,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.24,70,,5.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.64,,,1.64,Other,Drug Cost,1.64,,,1.64,Other,Drug Cost,1.64,,,1.64,Other,Drug Cost,1.64,,,1.64,Other,Drug Cost,1.64,,,1.64,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.64,,,1.64,Other,Drug Cost,3.69,,,3.69,Other,225% Medicaid APG methodology,2.3,,,2.3,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.64,,,1.64,Other,Drug Cost,1.64,,,1.64,Other,Drug Cost,2.05,,,2.05,Other,125% Medicaid APG methodology,0.01,5.24,
RISPERIDONE 1 MG DIS TAB        ,,,,40505703,CDM,250,RC,00781-5311-08,NDC,both,1,EA,15.82,6.24,39.4668,,6.24,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.75,30,,4.75,percent of total billed charges,"Drugs, Inpatient Only",4.75,30,,4.75,percent of total billed charges,"Drugs, Inpatient Only",4.75,30,,4.75,percent of total billed charges,"Drugs, Inpatient Only",7.91,50,,7.91,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.41,,,8.41,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.07,70,,11.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.52,,,4.52,Other,Drug Cost,4.52,,,4.52,Other,Drug Cost,4.52,,,4.52,Other,Drug Cost,4.52,,,4.52,Other,Drug Cost,4.52,,,4.52,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.52,,,4.52,Other,Drug Cost,10.17,,,10.17,Other,225% Medicaid APG methodology,6.33,,,6.33,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.52,,,4.52,Other,Drug Cost,4.52,,,4.52,Other,Drug Cost,5.65,,,5.65,Other,125% Medicaid APG methodology,0.01,11.07,
SIMVASTATIN 40 MG TAB           ,,,,40505711,CDM,250,RC,63739-0573-10,NDC,both,1,EA,0.32,0.13,39.4668,,0.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.16,50,,0.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,70,,0.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.25,,,0.25,Other,225% Medicaid APG methodology,0.15,,,0.15,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.14,,,0.14,Other,125% Medicaid APG methodology,0.01,0.25,
TORSEMIDE 100 MG TAB            ,,,,40505737,CDM,250,RC,50268-0757-15,NDC,both,1,EA,1.44,0.57,39.4668,,0.57,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.43,30,,0.43,percent of total billed charges,"Drugs, Inpatient Only",0.43,30,,0.43,percent of total billed charges,"Drugs, Inpatient Only",0.43,30,,0.43,percent of total billed charges,"Drugs, Inpatient Only",0.72,50,,0.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.47,,,0.47,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.01,70,,1.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.56,,,0.56,Other,225% Medicaid APG methodology,0.35,,,0.35,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.31,,,0.31,Other,125% Medicaid APG methodology,0.01,1.01,
VERAPAMIL 40 MG TAB             ,,,,40505760,CDM,250,RC,23155-0059-01,NDC,both,1,EA,0.46,0.18,39.4668,,0.18,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.14,30,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,30,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,30,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.23,50,,0.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.32,70,,0.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.32,
LIDOCAINE 1.5% PF SOLN 20 ML    ,,,,40505802,CDM,250,RC,63323-0493-91,NDC,both,20,ML,28.81,11.37,39.4668,,11.37,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.64,30,,8.64,percent of total billed charges,"Drugs, Inpatient Only",8.64,30,,8.64,percent of total billed charges,"Drugs, Inpatient Only",8.64,30,,8.64,percent of total billed charges,"Drugs, Inpatient Only",14.41,50,,14.41,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.15,,,9.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,20.17,70,,20.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.92,,,4.92,Other,Drug Cost,4.92,,,4.92,Other,Drug Cost,4.92,,,4.92,Other,Drug Cost,4.92,,,4.92,Other,Drug Cost,4.92,,,4.92,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.92,,,4.92,Other,Drug Cost,11.07,,,11.07,Other,225% Medicaid APG methodology,6.89,,,6.89,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.92,,,4.92,Other,Drug Cost,4.92,,,4.92,Other,Drug Cost,6.15,,,6.15,Other,125% Medicaid APG methodology,0.01,20.17,
BARIUM SULFATE 0.1% SUS 450 ML  ,,,,40505893,CDM,250,RC,32909-0945-03,NDC,both,450,ML,24.89,9.82,39.4668,,9.82,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.47,30,,7.47,percent of total billed charges,"Drugs, Inpatient Only",7.47,30,,7.47,percent of total billed charges,"Drugs, Inpatient Only",7.47,30,,7.47,percent of total billed charges,"Drugs, Inpatient Only",12.45,50,,12.45,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.22,,,13.22,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,17.42,70,,17.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.11,,,7.11,Other,Drug Cost,7.11,,,7.11,Other,Drug Cost,7.11,,,7.11,Other,Drug Cost,7.11,,,7.11,Other,Drug Cost,7.11,,,7.11,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,7.11,,,7.11,Other,Drug Cost,16,,,16,Other,225% Medicaid APG methodology,9.95,,,9.95,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.11,,,7.11,Other,Drug Cost,7.11,,,7.11,Other,Drug Cost,8.89,,,8.89,Other,125% Medicaid APG methodology,0.01,17.42,
CAL-MAG 119 MG-71.5 MG DR TAB   ,,,,40505943,CDM,250,RC,67618-0107-60,NDC,both,1,EA,0.56,0.22,39.4668,,0.22,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.28,50,,0.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.39,70,,0.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.16,,,0.16,Other,Drug Cost,0.36,,,0.36,Other,225% Medicaid APG methodology,0.22,,,0.22,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.2,,,0.2,Other,125% Medicaid APG methodology,0.01,0.39,
CALCIUM-VIT D 600 MG-400 U TAB  ,,,,40505950,CDM,250,RC,50268-0150-15,NDC,both,1,EA,1.47,0.58,39.4668,,0.58,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.44,30,,0.44,percent of total billed charges,"Drugs, Inpatient Only",0.44,30,,0.44,percent of total billed charges,"Drugs, Inpatient Only",0.44,30,,0.44,percent of total billed charges,"Drugs, Inpatient Only",0.74,50,,0.74,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.47,,,0.47,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.03,70,,1.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.56,,,0.56,Other,225% Medicaid APG methodology,0.35,,,0.35,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.31,,,0.31,Other,125% Medicaid APG methodology,0.01,1.03,
POVIDONE IODINE 10% OIN 28.4 G  ,,,,40505968,CDM,250,RC,00536-1271-80,NDC,both,1,GM,0.18,0.07,39.4668,,0.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.09,50,,0.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,70,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.13,
BACIT 500 UNITS/G OINT 14 G     ,,,,40505984,CDM,250,RC,45802-0060-01,NDC,both,14,GM,5.18,2.04,39.4668,,2.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.55,30,,1.55,percent of total billed charges,"Drugs, Inpatient Only",1.55,30,,1.55,percent of total billed charges,"Drugs, Inpatient Only",1.55,30,,1.55,percent of total billed charges,"Drugs, Inpatient Only",2.59,50,,2.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.21,,,1.21,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.63,70,,3.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.65,,,0.65,Other,Drug Cost,1.46,,,1.46,Other,225% Medicaid APG methodology,0.91,,,0.91,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.81,,,0.81,Other,125% Medicaid APG methodology,0.01,3.63,
HYDROCORT-PRAM 2.5%-1% CRE 4 G  ,,,,40506008,CDM,250,RC,45802-0472-65,NDC,both,1,GM,6.13,2.42,39.4668,,2.42,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.84,30,,1.84,percent of total billed charges,"Drugs, Inpatient Only",1.84,30,,1.84,percent of total billed charges,"Drugs, Inpatient Only",1.84,30,,1.84,percent of total billed charges,"Drugs, Inpatient Only",3.07,50,,3.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.86,,,1.86,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.29,70,,4.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1,,,1,Other,Drug Cost,2.25,,,2.25,Other,225% Medicaid APG methodology,1.4,,,1.4,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1.25,,,1.25,Other,125% Medicaid APG methodology,0.01,4.29,
FLUTIC-VIL 100 MCG-25 MCG IN P  ,,,,40506032,CDM,250,RC,00173-0859-14,NDC,both,1,EA,7,2.76,39.4668,,2.76,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.1,30,,2.1,percent of total billed charges,"Drugs, Inpatient Only",2.1,30,,2.1,percent of total billed charges,"Drugs, Inpatient Only",2.1,30,,2.1,percent of total billed charges,"Drugs, Inpatient Only",3.5,50,,3.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1,,,1,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.9,70,,4.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.54,,,0.54,Other,Drug Cost,1.22,,,1.22,Other,225% Medicaid APG methodology,0.76,,,0.76,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.68,,,0.68,Other,125% Medicaid APG methodology,0.01,4.9,
GUAIFENESIN 600 MG ER TAB       ,,,,40506040,CDM,250,RC,00904-6718-39,NDC,both,1,EA,2.35,0.93,39.4668,,0.93,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.71,30,,0.71,percent of total billed charges,"Drugs, Inpatient Only",0.71,30,,0.71,percent of total billed charges,"Drugs, Inpatient Only",0.71,30,,0.71,percent of total billed charges,"Drugs, Inpatient Only",1.18,50,,1.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.23,,,1.23,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.65,70,,1.65,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.66,,,0.66,Other,Drug Cost,0.66,,,0.66,Other,Drug Cost,0.66,,,0.66,Other,Drug Cost,0.66,,,0.66,Other,Drug Cost,0.66,,,0.66,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.66,,,0.66,Other,Drug Cost,1.49,,,1.49,Other,225% Medicaid APG methodology,0.92,,,0.92,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.66,,,0.66,Other,Drug Cost,0.66,,,0.66,Other,Drug Cost,0.83,,,0.83,Other,125% Medicaid APG methodology,0.01,1.65,
FLUTIC FUR 200 MCG INH POWDER   ,,,,40506065,CDM,250,RC,00173-0876-14,NDC,both,1,EA,20.62,8.14,39.4668,,8.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.19,30,,6.19,percent of total billed charges,"Drugs, Inpatient Only",6.19,30,,6.19,percent of total billed charges,"Drugs, Inpatient Only",6.19,30,,6.19,percent of total billed charges,"Drugs, Inpatient Only",10.31,50,,10.31,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.71,,,1.71,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.43,70,,14.43,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.92,,,0.92,Other,Drug Cost,2.07,,,2.07,Other,225% Medicaid APG methodology,1.29,,,1.29,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,1.15,,,1.15,Other,125% Medicaid APG methodology,0.01,14.43,
P OXYTOCIN 30 UNI IN NS 500 ML  ,,,,40506073,CDM,250,RC,70092-1552-07,NDC,both,500,ML,70.21,27.71,39.4668,,27.71,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,21.06,30,,21.06,percent of total billed charges,"Drugs, Inpatient Only",21.06,30,,21.06,percent of total billed charges,"Drugs, Inpatient Only",21.06,30,,21.06,percent of total billed charges,"Drugs, Inpatient Only",35.11,50,,35.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,37.31,,,37.31,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,49.15,70,,49.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,20.06,,,20.06,Other,Drug Cost,20.06,,,20.06,Other,Drug Cost,20.06,,,20.06,Other,Drug Cost,20.06,,,20.06,Other,Drug Cost,20.06,,,20.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,20.06,,,20.06,Other,Drug Cost,45.14,,,45.14,Other,225% Medicaid APG methodology,28.08,,,28.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,20.06,,,20.06,Other,Drug Cost,20.06,,,20.06,Other,Drug Cost,25.08,,,25.08,Other,125% Medicaid APG methodology,0.01,49.15,
BET VALERATE 0.1% CREAM 15 G    ,,,,40506123,CDM,250,RC,00168-0040-15,NDC,both,15,GM,72.8,28.73,39.4668,,28.73,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,21.84,30,,21.84,percent of total billed charges,"Drugs, Inpatient Only",21.84,30,,21.84,percent of total billed charges,"Drugs, Inpatient Only",21.84,30,,21.84,percent of total billed charges,"Drugs, Inpatient Only",36.4,50,,36.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,57.47,,,57.47,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,50.96,70,,50.96,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,30.9,,,30.9,Other,Drug Cost,30.9,,,30.9,Other,Drug Cost,30.9,,,30.9,Other,Drug Cost,30.9,,,30.9,Other,Drug Cost,30.9,,,30.9,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,30.9,,,30.9,Other,Drug Cost,69.53,,,69.53,Other,225% Medicaid APG methodology,43.26,,,43.26,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,30.9,,,30.9,Other,Drug Cost,30.9,,,30.9,Other,Drug Cost,38.63,,,38.63,Other,125% Medicaid APG methodology,0.01,69.53,
BET DIPROP 0.05% CREAM 15 G     ,,,,40506131,CDM,250,RC,00168-0055-15,NDC,both,15,GM,137.48,54.26,39.4668,,54.26,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,41.24,30,,41.24,percent of total billed charges,"Drugs, Inpatient Only",41.24,30,,41.24,percent of total billed charges,"Drugs, Inpatient Only",41.24,30,,41.24,percent of total billed charges,"Drugs, Inpatient Only",68.74,50,,68.74,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.36,,,6.36,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,96.24,70,,96.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.42,,,3.42,Other,Drug Cost,3.42,,,3.42,Other,Drug Cost,3.42,,,3.42,Other,Drug Cost,3.42,,,3.42,Other,Drug Cost,3.42,,,3.42,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.42,,,3.42,Other,Drug Cost,7.7,,,7.7,Other,225% Medicaid APG methodology,4.79,,,4.79,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.42,,,3.42,Other,Drug Cost,3.42,,,3.42,Other,Drug Cost,4.28,,,4.28,Other,125% Medicaid APG methodology,0.01,96.24,
UMECLIDINIUM-VIL 62.5-25 MCG    ,,,,40506149,CDM,250,RC,00173-0869-10,NDC,both,1,EA,25.73,10.15,39.4668,,10.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.72,30,,7.72,percent of total billed charges,"Drugs, Inpatient Only",7.72,30,,7.72,percent of total billed charges,"Drugs, Inpatient Only",7.72,30,,7.72,percent of total billed charges,"Drugs, Inpatient Only",12.87,50,,12.87,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.73,,,0.73,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,18.01,70,,18.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.39,,,0.39,Other,Drug Cost,0.88,,,0.88,Other,225% Medicaid APG methodology,0.55,,,0.55,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.49,,,0.49,Other,125% Medicaid APG methodology,0.01,18.01,
CHLORDIAZ-CLID 5 MG-2.5 MG CAP  ,,,,40506206,CDM,250,RC,60687-0639-94,NDC,both,1,EA,13.76,5.43,39.4668,,5.43,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.13,30,,4.13,percent of total billed charges,"Drugs, Inpatient Only",4.13,30,,4.13,percent of total billed charges,"Drugs, Inpatient Only",4.13,30,,4.13,percent of total billed charges,"Drugs, Inpatient Only",6.88,50,,6.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.92,,,6.92,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.63,70,,9.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.72,,,3.72,Other,Drug Cost,3.72,,,3.72,Other,Drug Cost,3.72,,,3.72,Other,Drug Cost,3.72,,,3.72,Other,Drug Cost,3.72,,,3.72,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.72,,,3.72,Other,Drug Cost,8.37,,,8.37,Other,225% Medicaid APG methodology,5.21,,,5.21,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.72,,,3.72,Other,Drug Cost,3.72,,,3.72,Other,Drug Cost,4.65,,,4.65,Other,125% Medicaid APG methodology,0.01,9.63,
NEBIVOLOL 2.5 MG TAB            ,,,,40506214,CDM,250,RC,00456-1402-30,NDC,both,1,EA,18.83,7.43,39.4668,,7.43,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.65,30,,5.65,percent of total billed charges,"Drugs, Inpatient Only",5.65,30,,5.65,percent of total billed charges,"Drugs, Inpatient Only",5.65,30,,5.65,percent of total billed charges,"Drugs, Inpatient Only",9.42,50,,9.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.18,70,,13.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,13.18,
AL-MG 200-200 MG/5 ORAL 30 ML   ,,,,40506230,CDM,250,RC,00121-1760-30,NDC,both,30,ML,11.94,4.71,39.4668,,4.71,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.58,30,,3.58,percent of total billed charges,"Drugs, Inpatient Only",3.58,30,,3.58,percent of total billed charges,"Drugs, Inpatient Only",3.58,30,,3.58,percent of total billed charges,"Drugs, Inpatient Only",5.97,50,,5.97,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.5,,,0.5,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.36,70,,8.36,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.27,,,0.27,Other,Drug Cost,0.61,,,0.61,Other,225% Medicaid APG methodology,0.38,,,0.38,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.34,,,0.34,Other,125% Medicaid APG methodology,0.01,8.36,
CYANOCOBALAMIN 100 MCG TAB      ,,,,40506255,CDM,250,RC,80681-0071-00,NDC,both,1,EA,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.02,50,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.03,
DOXERCALCIFEROL 0.5 MCG CAP     ,,,,40506263,CDM,250,RC,00054-0338-19,NDC,both,1,EA,40.18,15.86,39.4668,,15.86,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.05,30,,12.05,percent of total billed charges,"Drugs, Inpatient Only",12.05,30,,12.05,percent of total billed charges,"Drugs, Inpatient Only",12.05,30,,12.05,percent of total billed charges,"Drugs, Inpatient Only",20.09,50,,20.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,21.35,,,21.35,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,28.13,70,,28.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.48,,,11.48,Other,Drug Cost,11.48,,,11.48,Other,Drug Cost,11.48,,,11.48,Other,Drug Cost,11.48,,,11.48,Other,Drug Cost,11.48,,,11.48,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,11.48,,,11.48,Other,Drug Cost,25.83,,,25.83,Other,225% Medicaid APG methodology,16.07,,,16.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,11.48,,,11.48,Other,Drug Cost,11.48,,,11.48,Other,Drug Cost,14.35,,,14.35,Other,125% Medicaid APG methodology,0.01,28.13,
INDAPAMIDE 2.5 MG TAB           ,,,,40506305,CDM,250,RC,00378-0080-77,NDC,both,1,EA,1.12,0.44,39.4668,,0.44,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.34,30,,0.34,percent of total billed charges,"Drugs, Inpatient Only",0.34,30,,0.34,percent of total billed charges,"Drugs, Inpatient Only",0.34,30,,0.34,percent of total billed charges,"Drugs, Inpatient Only",0.56,50,,0.56,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.6,,,0.6,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.78,70,,0.78,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.32,,,0.32,Other,Drug Cost,0.72,,,0.72,Other,225% Medicaid APG methodology,0.45,,,0.45,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.4,,,0.4,Other,125% Medicaid APG methodology,0.01,0.78,
KETAMINE 10 MG/ML INJ 20 ML     ,,,,40506313,CDM,250,RC,55150-0438-10,NDC,both,20,ML,47.36,18.69,39.4668,,18.69,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.21,30,,14.21,percent of total billed charges,"Drugs, Inpatient Only",14.21,30,,14.21,percent of total billed charges,"Drugs, Inpatient Only",14.21,30,,14.21,percent of total billed charges,"Drugs, Inpatient Only",23.68,50,,23.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,21.58,,,21.58,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,33.15,70,,33.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.6,,,11.6,Other,Drug Cost,11.6,,,11.6,Other,Drug Cost,11.6,,,11.6,Other,Drug Cost,11.6,,,11.6,Other,Drug Cost,11.6,,,11.6,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,11.6,,,11.6,Other,Drug Cost,26.1,,,26.1,Other,225% Medicaid APG methodology,16.24,,,16.24,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,11.6,,,11.6,Other,Drug Cost,11.6,,,11.6,Other,Drug Cost,14.5,,,14.5,Other,125% Medicaid APG methodology,0.01,33.15,
METFORMIN 1000 MG TAB           ,,,,40506321,CDM,250,RC,00904-7164-61,NDC,both,1,EA,0.32,0.13,39.4668,,0.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.16,50,,0.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,70,,0.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% Medicaid APG methodology,0.1,,,0.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.22,
METFORMIN 750 MG ER TAB         ,,,,40506339,CDM,250,RC,53746-0179-01,NDC,both,1,EA,0.81,0.32,39.4668,,0.32,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.24,30,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.24,30,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.24,30,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.41,50,,0.41,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.43,,,0.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.57,70,,0.57,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.23,,,0.23,Other,Drug Cost,0.52,,,0.52,Other,225% Medicaid APG methodology,0.32,,,0.32,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.29,,,0.29,Other,125% Medicaid APG methodology,0.01,0.57,
MORPHINE 20 MG/ML O CONC 50 ML  ,,,,40506354,CDM,250,RC,68094-0754-58,NDC,both,1,EA,7.35,2.9,39.4668,,2.9,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.21,30,,2.21,percent of total billed charges,"Drugs, Inpatient Only",2.21,30,,2.21,percent of total billed charges,"Drugs, Inpatient Only",2.21,30,,2.21,percent of total billed charges,"Drugs, Inpatient Only",3.68,50,,3.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.91,,,3.91,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.15,70,,5.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.1,,,2.1,Other,Drug Cost,2.1,,,2.1,Other,Drug Cost,2.1,,,2.1,Other,Drug Cost,2.1,,,2.1,Other,Drug Cost,2.1,,,2.1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.1,,,2.1,Other,Drug Cost,4.73,,,4.73,Other,225% Medicaid APG methodology,2.94,,,2.94,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.1,,,2.1,Other,Drug Cost,2.1,,,2.1,Other,Drug Cost,2.63,,,2.63,Other,125% Medicaid APG methodology,0.01,5.15,
OXYBUTYNIN 15 MG/24 HR ER TAB   ,,,,40506362,CDM,250,RC,00093-5208-01,NDC,both,1,EA,4.45,1.76,39.4668,,1.76,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.34,30,,1.34,percent of total billed charges,"Drugs, Inpatient Only",1.34,30,,1.34,percent of total billed charges,"Drugs, Inpatient Only",1.34,30,,1.34,percent of total billed charges,"Drugs, Inpatient Only",2.23,50,,2.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.36,,,2.36,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.12,70,,3.12,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.27,,,1.27,Other,Drug Cost,1.27,,,1.27,Other,Drug Cost,1.27,,,1.27,Other,Drug Cost,1.27,,,1.27,Other,Drug Cost,1.27,,,1.27,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.27,,,1.27,Other,Drug Cost,2.86,,,2.86,Other,225% Medicaid APG methodology,1.78,,,1.78,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.27,,,1.27,Other,Drug Cost,1.27,,,1.27,Other,Drug Cost,1.59,,,1.59,Other,125% Medicaid APG methodology,0.01,3.12,
PARICALCITOL 1 MCG CAP          ,,,,40506370,CDM,250,RC,49483-0687-03,NDC,both,1,EA,3.26,1.29,39.4668,,1.29,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.98,30,,0.98,percent of total billed charges,"Drugs, Inpatient Only",0.98,30,,0.98,percent of total billed charges,"Drugs, Inpatient Only",0.98,30,,0.98,percent of total billed charges,"Drugs, Inpatient Only",1.63,50,,1.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.69,,,1.69,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.28,70,,2.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.91,,,0.91,Other,Drug Cost,2.05,,,2.05,Other,225% Medicaid APG methodology,1.27,,,1.27,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,1.14,,,1.14,Other,125% Medicaid APG methodology,0.01,2.28,
RISPERIDONE 0.5 MG DIS TAB      ,,,,40506388,CDM,250,RC,00378-6043-28,NDC,both,1,EA,11.31,4.46,39.4668,,4.46,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.39,30,,3.39,percent of total billed charges,"Drugs, Inpatient Only",3.39,30,,3.39,percent of total billed charges,"Drugs, Inpatient Only",3.39,30,,3.39,percent of total billed charges,"Drugs, Inpatient Only",5.66,50,,5.66,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.01,,,6.01,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.92,70,,7.92,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.23,,,3.23,Other,Drug Cost,3.23,,,3.23,Other,Drug Cost,3.23,,,3.23,Other,Drug Cost,3.23,,,3.23,Other,Drug Cost,3.23,,,3.23,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.23,,,3.23,Other,Drug Cost,7.27,,,7.27,Other,225% Medicaid APG methodology,4.52,,,4.52,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.23,,,3.23,Other,Drug Cost,3.23,,,3.23,Other,Drug Cost,4.04,,,4.04,Other,125% Medicaid APG methodology,0.01,7.92,
RISPERIDONE 4 MG TAB            ,,,,40506396,CDM,250,RC,00904-6362-61,NDC,both,1,EA,0.63,0.25,39.4668,,0.25,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.32,50,,0.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.44,70,,0.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.29,,,0.29,Other,225% Medicaid APG methodology,0.18,,,0.18,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.16,,,0.16,Other,125% Medicaid APG methodology,0.01,0.44,
ROSUVASTATIN 40 MG TAB          ,,,,40506404,CDM,250,RC,65862-0296-30,NDC,both,1,EA,0.63,0.25,39.4668,,0.25,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.32,50,,0.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.44,70,,0.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.44,
ACET-TRAM 325 MG-37.5 MG TAB    ,,,,40506412,CDM,250,RC,68084-0825-01,NDC,both,1,EA,1.16,0.46,39.4668,,0.46,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.35,30,,0.35,percent of total billed charges,"Drugs, Inpatient Only",0.35,30,,0.35,percent of total billed charges,"Drugs, Inpatient Only",0.35,30,,0.35,percent of total billed charges,"Drugs, Inpatient Only",0.58,50,,0.58,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.81,70,,0.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.27,,,0.27,Other,225% Medicaid APG methodology,0.17,,,0.17,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.15,,,0.15,Other,125% Medicaid APG methodology,0.01,0.81,
"OPH IRR, INTRA (BSS) 500 ML     ",,,,40506420,CDM,250,RC,00065-0795-50,NDC,both,500,ML,34.16,13.48,39.4668,,13.48,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.25,30,,10.25,percent of total billed charges,"Drugs, Inpatient Only",10.25,30,,10.25,percent of total billed charges,"Drugs, Inpatient Only",10.25,30,,10.25,percent of total billed charges,"Drugs, Inpatient Only",17.08,50,,17.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,68.45,,,68.45,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,23.91,70,,23.91,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,36.8,,,36.8,Other,Drug Cost,36.8,,,36.8,Other,Drug Cost,36.8,,,36.8,Other,Drug Cost,36.8,,,36.8,Other,Drug Cost,36.8,,,36.8,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,36.8,,,36.8,Other,Drug Cost,82.8,,,82.8,Other,225% Medicaid APG methodology,51.52,,,51.52,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,36.8,,,36.8,Other,Drug Cost,36.8,,,36.8,Other,Drug Cost,46,,,46,Other,125% Medicaid APG methodology,0.01,82.8,
LISINOPRIL 40 MG TAB            ,,,,40506446,CDM,250,RC,51079-0984-20,NDC,both,1,EA,0.56,0.22,39.4668,,0.22,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.28,50,,0.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.39,70,,0.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.16,,,0.16,Other,Drug Cost,0.36,,,0.36,Other,225% Medicaid APG methodology,0.22,,,0.22,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.2,,,0.2,Other,125% Medicaid APG methodology,0.01,0.39,
LIDOCAINE 1.5% PF SOLN 10 ML    ,,,,40506479,CDM,250,RC,63323-0493-97,NDC,both,10,ML,20.3,8.01,39.4668,,8.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.09,30,,6.09,percent of total billed charges,"Drugs, Inpatient Only",6.09,30,,6.09,percent of total billed charges,"Drugs, Inpatient Only",6.09,30,,6.09,percent of total billed charges,"Drugs, Inpatient Only",10.15,50,,10.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.59,,,4.59,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.21,70,,14.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.47,,,2.47,Other,Drug Cost,2.47,,,2.47,Other,Drug Cost,2.47,,,2.47,Other,Drug Cost,2.47,,,2.47,Other,Drug Cost,2.47,,,2.47,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.47,,,2.47,Other,Drug Cost,5.56,,,5.56,Other,225% Medicaid APG methodology,3.46,,,3.46,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.47,,,2.47,Other,Drug Cost,2.47,,,2.47,Other,Drug Cost,3.09,,,3.09,Other,125% Medicaid APG methodology,0.01,14.21,
VALSARTAN 320 MG TAB            ,,,,40506511,CDM,250,RC,50268-0786-13,NDC,both,1,EA,3.99,1.57,39.4668,,1.57,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.2,30,,1.2,percent of total billed charges,"Drugs, Inpatient Only",1.2,30,,1.2,percent of total billed charges,"Drugs, Inpatient Only",1.2,30,,1.2,percent of total billed charges,"Drugs, Inpatient Only",2,50,,2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.12,,,2.12,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.79,70,,2.79,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.14,,,1.14,Other,Drug Cost,2.57,,,2.57,Other,225% Medicaid APG methodology,1.6,,,1.6,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,1.43,,,1.43,Other,125% Medicaid APG methodology,0.01,2.79,
LEVETIRACETAM 500 MG ER TAB     ,,,,40506529,CDM,250,RC,43547-0345-06,NDC,both,1,EA,0.6,0.24,39.4668,,0.24,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.18,30,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.18,30,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.18,30,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.3,50,,0.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.42,70,,0.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% Medicaid APG methodology,0.11,,,0.11,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.42,
"OPH IRR, EXTRA OPH SOLN 120 ML  ",,,,40506537,CDM,250,RC,00065-0530-04,NDC,both,120,ML,105,41.44,39.4668,,41.44,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,31.5,30,,31.5,percent of total billed charges,"Drugs, Inpatient Only",31.5,30,,31.5,percent of total billed charges,"Drugs, Inpatient Only",31.5,30,,31.5,percent of total billed charges,"Drugs, Inpatient Only",52.5,50,,52.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,55.8,,,55.8,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,73.5,70,,73.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,30,,,30,Other,Drug Cost,30,,,30,Other,Drug Cost,30,,,30,Other,Drug Cost,30,,,30,Other,Drug Cost,30,,,30,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,30,,,30,Other,Drug Cost,67.5,,,67.5,Other,225% Medicaid APG methodology,42,,,42,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,30,,,30,Other,Drug Cost,30,,,30,Other,Drug Cost,37.5,,,37.5,Other,125% Medicaid APG methodology,0.01,73.5,
BARIUM 40% ORAL PASTE 230 ML    ,,,,40506545,CDM,250,RC,32909-0120-22,NDC,both,230,ML,163.98,64.72,39.4668,,64.72,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,49.19,30,,49.19,percent of total billed charges,"Drugs, Inpatient Only",49.19,30,,49.19,percent of total billed charges,"Drugs, Inpatient Only",49.19,30,,49.19,percent of total billed charges,"Drugs, Inpatient Only",81.99,50,,81.99,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,87.14,,,87.14,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,114.79,70,,114.79,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,46.85,,,46.85,Other,Drug Cost,46.85,,,46.85,Other,Drug Cost,46.85,,,46.85,Other,Drug Cost,46.85,,,46.85,Other,Drug Cost,46.85,,,46.85,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,46.85,,,46.85,Other,Drug Cost,105.41,,,105.41,Other,225% Medicaid APG methodology,65.59,,,65.59,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,46.85,,,46.85,Other,Drug Cost,46.85,,,46.85,Other,Drug Cost,58.56,,,58.56,Other,125% Medicaid APG methodology,0.01,114.79,
BET DIPROP 0.05% OINT 15 G      ,,,,40506636,CDM,250,RC,00168-0056-15,NDC,both,15,GM,160.06,63.17,39.4668,,63.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,48.02,30,,48.02,percent of total billed charges,"Drugs, Inpatient Only",48.02,30,,48.02,percent of total billed charges,"Drugs, Inpatient Only",48.02,30,,48.02,percent of total billed charges,"Drugs, Inpatient Only",80.03,50,,80.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.07,,,12.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,112.04,70,,112.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.49,,,6.49,Other,Drug Cost,6.49,,,6.49,Other,Drug Cost,6.49,,,6.49,Other,Drug Cost,6.49,,,6.49,Other,Drug Cost,6.49,,,6.49,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,6.49,,,6.49,Other,Drug Cost,14.6,,,14.6,Other,225% Medicaid APG methodology,9.09,,,9.09,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.49,,,6.49,Other,Drug Cost,6.49,,,6.49,Other,Drug Cost,8.11,,,8.11,Other,125% Medicaid APG methodology,0.01,112.04,
BET VALERATE 0.1% LOTION 60 ML  ,,,,40506644,CDM,250,RC,00168-0041-60,NDC,both,60,ML,195.23,77.05,39.4668,,77.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,58.57,30,,58.57,percent of total billed charges,"Drugs, Inpatient Only",58.57,30,,58.57,percent of total billed charges,"Drugs, Inpatient Only",58.57,30,,58.57,percent of total billed charges,"Drugs, Inpatient Only",97.62,50,,97.62,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,24.14,,,24.14,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,136.66,70,,136.66,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.98,,,12.98,Other,Drug Cost,12.98,,,12.98,Other,Drug Cost,12.98,,,12.98,Other,Drug Cost,12.98,,,12.98,Other,Drug Cost,12.98,,,12.98,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,12.98,,,12.98,Other,Drug Cost,29.21,,,29.21,Other,225% Medicaid APG methodology,18.17,,,18.17,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,12.98,,,12.98,Other,Drug Cost,12.98,,,12.98,Other,Drug Cost,16.23,,,16.23,Other,125% Medicaid APG methodology,0.01,136.66,
BET VALERATE 0.1% OINT 15 G     ,,,,40506651,CDM,250,RC,00168-0033-15,NDC,both,15,GM,29.79,11.76,39.4668,,11.76,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.94,30,,8.94,percent of total billed charges,"Drugs, Inpatient Only",8.94,30,,8.94,percent of total billed charges,"Drugs, Inpatient Only",8.94,30,,8.94,percent of total billed charges,"Drugs, Inpatient Only",14.9,50,,14.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.46,,,4.46,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,20.85,70,,20.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.4,,,2.4,Other,Drug Cost,5.4,,,5.4,Other,225% Medicaid APG methodology,3.36,,,3.36,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,3,,,3,Other,125% Medicaid APG methodology,0.01,20.85,
BUP-FE 0.0625%-2 MCG NS 250 ML  ,,,,40506669,CDM,250,RC,63323-0806-20a,NDC,both,250,ML,33.43,13.19,39.4668,,13.19,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.03,30,,10.03,percent of total billed charges,"Drugs, Inpatient Only",10.03,30,,10.03,percent of total billed charges,"Drugs, Inpatient Only",10.03,30,,10.03,percent of total billed charges,"Drugs, Inpatient Only",16.72,50,,16.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13,,,13,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,23.4,70,,23.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.99,,,6.99,Other,Drug Cost,6.99,,,6.99,Other,Drug Cost,6.99,,,6.99,Other,Drug Cost,6.99,,,6.99,Other,Drug Cost,6.99,,,6.99,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,6.99,,,6.99,Other,Drug Cost,15.73,,,15.73,Other,225% Medicaid APG methodology,9.79,,,9.79,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.99,,,6.99,Other,Drug Cost,6.99,,,6.99,Other,Drug Cost,8.74,,,8.74,Other,125% Medicaid APG methodology,0.01,23.4,
NEBIVOLOL 10 MG TAB             ,,,,40506677,CDM,250,RC,00904-7190-04,NDC,both,1,EA,7.53,2.97,39.4668,,2.97,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.26,30,,2.26,percent of total billed charges,"Drugs, Inpatient Only",2.26,30,,2.26,percent of total billed charges,"Drugs, Inpatient Only",2.26,30,,2.26,percent of total billed charges,"Drugs, Inpatient Only",3.77,50,,3.77,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.05,,,3.05,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.27,70,,5.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.64,,,1.64,Other,Drug Cost,1.64,,,1.64,Other,Drug Cost,1.64,,,1.64,Other,Drug Cost,1.64,,,1.64,Other,Drug Cost,1.64,,,1.64,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.64,,,1.64,Other,Drug Cost,3.69,,,3.69,Other,225% Medicaid APG methodology,2.3,,,2.3,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.64,,,1.64,Other,Drug Cost,1.64,,,1.64,Other,Drug Cost,2.05,,,2.05,Other,125% Medicaid APG methodology,0.01,5.27,
ACET-HYDROCOD 325 MG-5 MG TAB   ,,,,40506685,CDM,250,RC,68084-0895-09,NDC,both,1,EA,0.95,0.37,39.4668,,0.37,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.48,50,,0.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.67,70,,0.67,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.67,
FER GLU 324 MG (38 MG IRO) TAB  ,,,,40506693,CDM,250,RC,00574-0508-11,NDC,both,1,EA,0.35,0.14,39.4668,,0.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.18,50,,0.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,70,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.23,,,0.23,Other,225% Medicaid APG methodology,0.14,,,0.14,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.13,,,0.13,Other,125% Medicaid APG methodology,0.01,0.25,
OXYCODONE 10 MG TAB             ,,,,40506701,CDM,250,RC,68084-0968-01,NDC,both,1,EA,2.14,0.84,39.4668,,0.84,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.64,30,,0.64,percent of total billed charges,"Drugs, Inpatient Only",0.64,30,,0.64,percent of total billed charges,"Drugs, Inpatient Only",0.64,30,,0.64,percent of total billed charges,"Drugs, Inpatient Only",1.07,50,,1.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.91,,,0.91,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.5,70,,1.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.49,,,0.49,Other,Drug Cost,0.49,,,0.49,Other,Drug Cost,0.49,,,0.49,Other,Drug Cost,0.49,,,0.49,Other,Drug Cost,0.49,,,0.49,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.49,,,0.49,Other,Drug Cost,1.1,,,1.1,Other,225% Medicaid APG methodology,0.69,,,0.69,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.49,,,0.49,Other,Drug Cost,0.49,,,0.49,Other,Drug Cost,0.61,,,0.61,Other,125% Medicaid APG methodology,0.01,1.5,
PERAMPANEL 2 MG TAB             ,,,,40506719,CDM,250,RC,69616-0272-30,NDC,both,1,EA,67.27,26.55,39.4668,,26.55,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,20.18,30,,20.18,percent of total billed charges,"Drugs, Inpatient Only",20.18,30,,20.18,percent of total billed charges,"Drugs, Inpatient Only",20.18,30,,20.18,percent of total billed charges,"Drugs, Inpatient Only",33.64,50,,33.64,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.21,,,13.21,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,47.09,70,,47.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.1,,,7.1,Other,Drug Cost,7.1,,,7.1,Other,Drug Cost,7.1,,,7.1,Other,Drug Cost,7.1,,,7.1,Other,Drug Cost,7.1,,,7.1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,7.1,,,7.1,Other,Drug Cost,15.98,,,15.98,Other,225% Medicaid APG methodology,9.94,,,9.94,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.1,,,7.1,Other,Drug Cost,7.1,,,7.1,Other,Drug Cost,8.88,,,8.88,Other,125% Medicaid APG methodology,0.01,47.09,
MIDODRINE 10 MG TAB             ,,,,40506727,CDM,250,RC,60687-0409-25,NDC,both,1,EA,4.59,1.81,39.4668,,1.81,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.38,30,,1.38,percent of total billed charges,"Drugs, Inpatient Only",1.38,30,,1.38,percent of total billed charges,"Drugs, Inpatient Only",1.38,30,,1.38,percent of total billed charges,"Drugs, Inpatient Only",2.3,50,,2.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.53,,,1.53,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.21,70,,3.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.82,,,0.82,Other,Drug Cost,1.85,,,1.85,Other,225% Medicaid APG methodology,1.15,,,1.15,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,1.03,,,1.03,Other,125% Medicaid APG methodology,0.01,3.21,
BISOPROLOL 5 MG TAB             ,,,,40506776,CDM,250,RC,29300-0126-13,NDC,both,1,EA,2.42,0.96,39.4668,,0.96,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.73,30,,0.73,percent of total billed charges,"Drugs, Inpatient Only",0.73,30,,0.73,percent of total billed charges,"Drugs, Inpatient Only",0.73,30,,0.73,percent of total billed charges,"Drugs, Inpatient Only",1.21,50,,1.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.69,70,,1.69,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,1.69,
IVABRADINE 7.5 MG ORAL TABLET   ,,,,40506784,CDM,250,RC,55513-0810-60,NDC,both,1,EA,30.42,12.01,39.4668,,12.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.13,30,,9.13,percent of total billed charges,"Drugs, Inpatient Only",9.13,30,,9.13,percent of total billed charges,"Drugs, Inpatient Only",9.13,30,,9.13,percent of total billed charges,"Drugs, Inpatient Only",15.21,50,,15.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.29,,,15.29,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,21.29,70,,21.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.22,,,8.22,Other,Drug Cost,8.22,,,8.22,Other,Drug Cost,8.22,,,8.22,Other,Drug Cost,8.22,,,8.22,Other,Drug Cost,8.22,,,8.22,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,8.22,,,8.22,Other,Drug Cost,18.5,,,18.5,Other,225% Medicaid APG methodology,11.51,,,11.51,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,8.22,,,8.22,Other,Drug Cost,8.22,,,8.22,Other,Drug Cost,10.28,,,10.28,Other,125% Medicaid APG methodology,0.01,21.29,
LANTHANUM CARB 500 MG CHEW TAB  ,,,,40506792,CDM,250,RC,69097-0934-98,NDC,both,1,EA,11.2,4.42,39.4668,,4.42,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.36,30,,3.36,percent of total billed charges,"Drugs, Inpatient Only",3.36,30,,3.36,percent of total billed charges,"Drugs, Inpatient Only",3.36,30,,3.36,percent of total billed charges,"Drugs, Inpatient Only",5.6,50,,5.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.36,,,9.36,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.84,70,,7.84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.03,,,5.03,Other,Drug Cost,5.03,,,5.03,Other,Drug Cost,5.03,,,5.03,Other,Drug Cost,5.03,,,5.03,Other,Drug Cost,5.03,,,5.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,5.03,,,5.03,Other,Drug Cost,11.32,,,11.32,Other,225% Medicaid APG methodology,7.04,,,7.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.03,,,5.03,Other,Drug Cost,5.03,,,5.03,Other,Drug Cost,6.29,,,6.29,Other,125% Medicaid APG methodology,0.01,11.32,
LEVETIRACETAM 750 MG TAB        ,,,,40506826,CDM,250,RC,00904-6053-61,NDC,both,1,EA,0.98,0.39,39.4668,,0.39,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.49,50,,0.49,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.52,,,0.52,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.69,70,,0.69,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,Drug Cost,0.63,,,0.63,Other,225% Medicaid APG methodology,0.39,,,0.39,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.35,,,0.35,Other,125% Medicaid APG methodology,0.01,0.69,
LIDOCAINE 4% PF INJ SOLN 5 ML   ,,,,40506834,CDM,250,RC,00409-4283-01,NDC,both,5,ML,9.17,3.62,39.4668,,3.62,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.75,30,,2.75,percent of total billed charges,"Drugs, Inpatient Only",2.75,30,,2.75,percent of total billed charges,"Drugs, Inpatient Only",2.75,30,,2.75,percent of total billed charges,"Drugs, Inpatient Only",4.59,50,,4.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.43,,,4.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.42,70,,6.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.38,,,2.38,Other,Drug Cost,2.38,,,2.38,Other,Drug Cost,2.38,,,2.38,Other,Drug Cost,2.38,,,2.38,Other,Drug Cost,2.38,,,2.38,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.38,,,2.38,Other,Drug Cost,5.36,,,5.36,Other,225% Medicaid APG methodology,3.33,,,3.33,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.38,,,2.38,Other,Drug Cost,2.38,,,2.38,Other,Drug Cost,2.98,,,2.98,Other,125% Medicaid APG methodology,0.01,6.42,
MESALAMINE 500 MG ER CAP        ,,,,40506842,CDM,250,RC,54092-0191-12,NDC,both,1,EA,19.74,7.79,39.4668,,7.79,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.92,30,,5.92,percent of total billed charges,"Drugs, Inpatient Only",5.92,30,,5.92,percent of total billed charges,"Drugs, Inpatient Only",5.92,30,,5.92,percent of total billed charges,"Drugs, Inpatient Only",9.87,50,,9.87,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.45,,,0.45,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.82,70,,13.82,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,Drug Cost,0.54,,,0.54,Other,225% Medicaid APG methodology,0.34,,,0.34,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.3,,,0.3,Other,125% Medicaid APG methodology,0.01,13.82,
MOMETASONE 0.1% CREAM 15 G      ,,,,40506859,CDM,250,RC,00713-0634-15,NDC,both,1,GM,1.44,0.57,39.4668,,0.57,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.43,30,,0.43,percent of total billed charges,"Drugs, Inpatient Only",0.43,30,,0.43,percent of total billed charges,"Drugs, Inpatient Only",0.43,30,,0.43,percent of total billed charges,"Drugs, Inpatient Only",0.72,50,,0.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.01,70,,1.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,Drug Cost,0.34,,,0.34,Other,225% Medicaid APG methodology,0.21,,,0.21,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.19,,,0.19,Other,125% Medicaid APG methodology,0.01,1.01,
TRACE 0.3-55-60-3/ML IV 1 ML    ,,,,40506875,CDM,250,RC,00517-9305-25,NDC,both,1,ML,63.32,24.99,39.4668,,24.99,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19,30,,19,percent of total billed charges,"Drugs, Inpatient Only",19,30,,19,percent of total billed charges,"Drugs, Inpatient Only",19,30,,19,percent of total billed charges,"Drugs, Inpatient Only",31.66,50,,31.66,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,21.04,,,21.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,44.32,70,,44.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.31,,,11.31,Other,Drug Cost,11.31,,,11.31,Other,Drug Cost,11.31,,,11.31,Other,Drug Cost,11.31,,,11.31,Other,Drug Cost,11.31,,,11.31,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,11.31,,,11.31,Other,Drug Cost,25.45,,,25.45,Other,225% Medicaid APG methodology,15.83,,,15.83,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,11.31,,,11.31,Other,Drug Cost,11.31,,,11.31,Other,Drug Cost,14.14,,,14.14,Other,125% Medicaid APG methodology,0.01,44.32,
TRIHEXYPHENIDYL 5 MG ORAL TAB   ,,,,40506891,CDM,250,RC,70954-0211-10,NDC,both,1,EA,0.32,0.13,39.4668,,0.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.16,50,,0.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,70,,0.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.22,
BAC/NEO/POL B 400-3.5-5000 OIN  ,,,,40506909,CDM,250,RC,00904-8805-67,NDC,both,1,EA,0.42,0.17,39.4668,,0.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.21,50,,0.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,70,,0.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% Medicaid APG methodology,0.11,,,0.11,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.29,
PAN 10-32-42 UNITS DR CAP       ,,,,40506925,CDM,250,RC,73562-0110-01,NDC,both,1,EA,11.8,4.66,39.4668,,4.66,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.54,30,,3.54,percent of total billed charges,"Drugs, Inpatient Only",3.54,30,,3.54,percent of total billed charges,"Drugs, Inpatient Only",3.54,30,,3.54,percent of total billed charges,"Drugs, Inpatient Only",5.9,50,,5.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.26,70,,8.26,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,8.26,
BARIUM SUL 105% REC SUS 750 ML  ,,,,40506941,CDM,250,RC,32909-0167-55,NDC,both,1,ML,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.04,50,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
PHENOL 1.4% TOP SPRAY 177 ML    ,,,,40506966,CDM,250,RC,00536-1228-58,NDC,both,177,ML,7.81,3.08,39.4668,,3.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.34,30,,2.34,percent of total billed charges,"Drugs, Inpatient Only",2.34,30,,2.34,percent of total billed charges,"Drugs, Inpatient Only",2.34,30,,2.34,percent of total billed charges,"Drugs, Inpatient Only",3.91,50,,3.91,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.66,,,3.66,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.47,70,,5.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.97,,,1.97,Other,Drug Cost,1.97,,,1.97,Other,Drug Cost,1.97,,,1.97,Other,Drug Cost,1.97,,,1.97,Other,Drug Cost,1.97,,,1.97,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.97,,,1.97,Other,Drug Cost,4.43,,,4.43,Other,225% Medicaid APG methodology,2.76,,,2.76,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.97,,,1.97,Other,Drug Cost,1.97,,,1.97,Other,Drug Cost,2.46,,,2.46,Other,125% Medicaid APG methodology,0.01,5.47,
NS IV SOLN 50 ML ADD-VANTAGE    ,,,,40507006,CDM,250,RC,00409-7101-66,NDC,both,50,ML,4.94,1.95,39.4668,,1.95,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.48,30,,1.48,percent of total billed charges,"Drugs, Inpatient Only",1.48,30,,1.48,percent of total billed charges,"Drugs, Inpatient Only",1.48,30,,1.48,percent of total billed charges,"Drugs, Inpatient Only",2.47,50,,2.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.86,,,0.86,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.46,70,,3.46,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.46,,,0.46,Other,Drug Cost,1.04,,,1.04,Other,225% Medicaid APG methodology,0.64,,,0.64,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.58,,,0.58,Other,125% Medicaid APG methodology,0.01,3.46,
NS IV SOLN 100 ML ADD-VANTAGE   ,,,,40507014,CDM,250,RC,00409-7101-67,NDC,both,100,ML,4.94,1.95,39.4668,,1.95,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.48,30,,1.48,percent of total billed charges,"Drugs, Inpatient Only",1.48,30,,1.48,percent of total billed charges,"Drugs, Inpatient Only",1.48,30,,1.48,percent of total billed charges,"Drugs, Inpatient Only",2.47,50,,2.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.69,,,1.69,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.46,70,,3.46,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.91,,,0.91,Other,Drug Cost,2.05,,,2.05,Other,225% Medicaid APG methodology,1.27,,,1.27,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,1.14,,,1.14,Other,125% Medicaid APG methodology,0.01,3.46,
D5W IV SOLN 100 ML ADD-VANTAGE  ,,,,40507071,CDM,250,RC,00409-7100-67,NDC,both,100,ML,5.01,1.98,39.4668,,1.98,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.5,30,,1.5,percent of total billed charges,"Drugs, Inpatient Only",1.5,30,,1.5,percent of total billed charges,"Drugs, Inpatient Only",1.5,30,,1.5,percent of total billed charges,"Drugs, Inpatient Only",2.51,50,,2.51,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.69,,,1.69,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.51,70,,3.51,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.91,,,0.91,Other,Drug Cost,2.05,,,2.05,Other,225% Medicaid APG methodology,1.27,,,1.27,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,1.14,,,1.14,Other,125% Medicaid APG methodology,0.01,3.51,
TB 5 UNITS/0.1 ML INTRAD 0.1ML  ,,,,40507089,CDM,250,RC,42023-0104-01a,NDC,both,0.1,ML,26.74,10.55,39.4668,,10.55,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.02,30,,8.02,percent of total billed charges,"Drugs, Inpatient Only",8.02,30,,8.02,percent of total billed charges,"Drugs, Inpatient Only",8.02,30,,8.02,percent of total billed charges,"Drugs, Inpatient Only",13.37,50,,13.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.21,,,14.21,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,18.72,70,,18.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.64,,,7.64,Other,Drug Cost,7.64,,,7.64,Other,Drug Cost,7.64,,,7.64,Other,Drug Cost,7.64,,,7.64,Other,Drug Cost,7.64,,,7.64,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,7.64,,,7.64,Other,Drug Cost,17.19,,,17.19,Other,225% Medicaid APG methodology,10.7,,,10.7,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.64,,,7.64,Other,Drug Cost,7.64,,,7.64,Other,Drug Cost,9.55,,,9.55,Other,125% Medicaid APG methodology,0.01,18.72,
SUCROSE 24% ORAL 15 ML CUP      ,,,,40507097,CDM,250,RC,99991-0720-22,NDC,both,1,EA,0.18,0.07,39.4668,,0.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.09,50,,0.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,70,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.13,
BARIUM 40% 30% ORAL SUSP 20 ML  ,,,,40507105,CDM,250,RC,32909-0115-00a,NDC,both,1,ML,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.11,50,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.15,
BARIUM SUL 40% 30% PASTE 20 ML  ,,,,40507113,CDM,250,RC,32909-0120-22a,NDC,both,1,ML,0.7,0.28,39.4668,,0.28,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.21,30,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.21,30,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.21,30,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.35,50,,0.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,,,0.37,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.49,70,,0.49,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.45,,,0.45,Other,225% Medicaid APG methodology,0.28,,,0.28,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.25,,,0.25,Other,125% Medicaid APG methodology,0.01,0.49,
BARIUM 40% 29% (3000) SU 20 ML  ,,,,40507121,CDM,250,RC,32909-0122-07a,NDC,both,1,ML,0.7,0.28,39.4668,,0.28,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.21,30,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.21,30,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.21,30,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.35,50,,0.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.41,,,0.41,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.49,70,,0.49,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.5,,,0.5,Other,225% Medicaid APG methodology,0.31,,,0.31,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.28,,,0.28,Other,125% Medicaid APG methodology,0.01,0.5,
BISMUTH SUBCARBONATE POW 15 G   ,,,,40507139,CDM,250,RC,38779-0659-05a,NDC,both,1,EA,3.5,1.38,39.4668,,1.38,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.05,30,,1.05,percent of total billed charges,"Drugs, Inpatient Only",1.05,30,,1.05,percent of total billed charges,"Drugs, Inpatient Only",1.05,30,,1.05,percent of total billed charges,"Drugs, Inpatient Only",1.75,50,,1.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.86,,,1.86,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.45,70,,2.45,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1,,,1,Other,Drug Cost,2.25,,,2.25,Other,225% Medicaid APG methodology,1.4,,,1.4,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1.25,,,1.25,Other,125% Medicaid APG methodology,0.01,2.45,
DEXTROSE 40% GEL 0.8 G          ,,,,40507147,CDM,250,RC,99996-0720-22,NDC,both,1,EA,0.39,0.15,39.4668,,0.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.2,50,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.27,70,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.25,,,0.25,Other,225% Medicaid APG methodology,0.15,,,0.15,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.14,,,0.14,Other,125% Medicaid APG methodology,0.01,0.27,
BISMUTH SUBCARB POWDER 100 G    ,,,,40507162,CDM,250,RC,38779-0659-05,NDC,both,1,EA,0.95,0.37,39.4668,,0.37,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.48,50,,0.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.5,,,0.5,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.67,70,,0.67,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.27,,,0.27,Other,Drug Cost,0.61,,,0.61,Other,225% Medicaid APG methodology,0.38,,,0.38,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.34,,,0.34,Other,125% Medicaid APG methodology,0.01,0.67,
BARIUM 40% ORAL SUSP 240 ML     ,,,,40507188,CDM,250,RC,32909-0115-00,NDC,both,240,ML,42,16.58,39.4668,,16.58,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.6,30,,12.6,percent of total billed charges,"Drugs, Inpatient Only",12.6,30,,12.6,percent of total billed charges,"Drugs, Inpatient Only",12.6,30,,12.6,percent of total billed charges,"Drugs, Inpatient Only",21,50,,21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,26.78,,,26.78,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,29.4,70,,29.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.4,,,14.4,Other,Drug Cost,14.4,,,14.4,Other,Drug Cost,14.4,,,14.4,Other,Drug Cost,14.4,,,14.4,Other,Drug Cost,14.4,,,14.4,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,14.4,,,14.4,Other,Drug Cost,32.4,,,32.4,Other,225% Medicaid APG methodology,20.16,,,20.16,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,14.4,,,14.4,Other,Drug Cost,14.4,,,14.4,Other,Drug Cost,18,,,18,Other,125% Medicaid APG methodology,0.01,32.4,
BIS SUB 262 MG/15 ML SU 120 ML  ,,,,40507212,CDM,250,RC,01490-0039-04,NDC,both,120,ML,9.7,3.83,39.4668,,3.83,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.91,30,,2.91,percent of total billed charges,"Drugs, Inpatient Only",2.91,30,,2.91,percent of total billed charges,"Drugs, Inpatient Only",2.91,30,,2.91,percent of total billed charges,"Drugs, Inpatient Only",4.85,50,,4.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.15,,,5.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.79,70,,6.79,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.77,,,2.77,Other,Drug Cost,2.77,,,2.77,Other,Drug Cost,2.77,,,2.77,Other,Drug Cost,2.77,,,2.77,Other,Drug Cost,2.77,,,2.77,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.77,,,2.77,Other,Drug Cost,6.23,,,6.23,Other,225% Medicaid APG methodology,3.88,,,3.88,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.77,,,2.77,Other,Drug Cost,2.77,,,2.77,Other,Drug Cost,3.46,,,3.46,Other,125% Medicaid APG methodology,0.01,6.79,
CADEXOMER IODINE 0.9% GEL 10 G  ,,,,40507220,CDM,250,RC,40565-1225-65,NDC,both,10,GM,45.71,18.04,39.4668,,18.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.71,30,,13.71,percent of total billed charges,"Drugs, Inpatient Only",13.71,30,,13.71,percent of total billed charges,"Drugs, Inpatient Only",13.71,30,,13.71,percent of total billed charges,"Drugs, Inpatient Only",22.86,50,,22.86,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,47.73,,,47.73,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,32,70,,32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,25.66,,,25.66,Other,Drug Cost,25.66,,,25.66,Other,Drug Cost,25.66,,,25.66,Other,Drug Cost,25.66,,,25.66,Other,Drug Cost,25.66,,,25.66,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,25.66,,,25.66,Other,Drug Cost,57.74,,,57.74,Other,225% Medicaid APG methodology,35.92,,,35.92,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,25.66,,,25.66,Other,Drug Cost,25.66,,,25.66,Other,Drug Cost,32.08,,,32.08,Other,125% Medicaid APG methodology,0.01,57.74,
AMINO ACID 10% IV SOL 2000 ML   ,,,,40507253,CDM,250,RC,00338-0644-06,NDC,both,2000,ML,131.04,51.72,39.4668,,51.72,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,39.31,30,,39.31,percent of total billed charges,"Drugs, Inpatient Only",39.31,30,,39.31,percent of total billed charges,"Drugs, Inpatient Only",39.31,30,,39.31,percent of total billed charges,"Drugs, Inpatient Only",65.52,50,,65.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,33.85,,,33.85,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,91.73,70,,91.73,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,18.2,,,18.2,Other,Drug Cost,18.2,,,18.2,Other,Drug Cost,18.2,,,18.2,Other,Drug Cost,18.2,,,18.2,Other,Drug Cost,18.2,,,18.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,18.2,,,18.2,Other,Drug Cost,40.95,,,40.95,Other,225% Medicaid APG methodology,25.48,,,25.48,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,18.2,,,18.2,Other,Drug Cost,18.2,,,18.2,Other,Drug Cost,22.75,,,22.75,Other,125% Medicaid APG methodology,0.01,91.73,
CIT/SI/SO 1.53-0.04-2.21/4 G E  ,,,,40507279,CDM,250,RC,10361-0793-01,NDC,both,1,EA,6.93,2.74,39.4668,,2.74,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.08,30,,2.08,percent of total billed charges,"Drugs, Inpatient Only",2.08,30,,2.08,percent of total billed charges,"Drugs, Inpatient Only",2.08,30,,2.08,percent of total billed charges,"Drugs, Inpatient Only",3.47,50,,3.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5,,,5,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.85,70,,4.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.69,,,2.69,Other,Drug Cost,2.69,,,2.69,Other,Drug Cost,2.69,,,2.69,Other,Drug Cost,2.69,,,2.69,Other,Drug Cost,2.69,,,2.69,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.69,,,2.69,Other,Drug Cost,6.05,,,6.05,Other,225% Medicaid APG methodology,3.77,,,3.77,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.69,,,2.69,Other,Drug Cost,2.69,,,2.69,Other,Drug Cost,3.36,,,3.36,Other,125% Medicaid APG methodology,0.01,6.05,
FACTOR IX COMPLEX HUMAN IV INJ  ,,,,40507287,CDM,250,RC,64193-0244-02,NDC,both,1,EA,0.32,0.13,39.4668,,0.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.16,50,,0.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.64,,,1.64,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,70,,0.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.88,,,0.88,Other,Drug Cost,1.98,,,1.98,Other,225% Medicaid APG methodology,1.23,,,1.23,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,1.1,,,1.1,Other,125% Medicaid APG methodology,0.01,1.98,
BARIUM SULF 2% SUS LIQ 450 ML   ,,,,40507295,CDM,250,RC,32909-0756-03,NDC,both,450,ML,15.75,6.22,39.4668,,6.22,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.73,30,,4.73,percent of total billed charges,"Drugs, Inpatient Only",4.73,30,,4.73,percent of total billed charges,"Drugs, Inpatient Only",4.73,30,,4.73,percent of total billed charges,"Drugs, Inpatient Only",7.88,50,,7.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.37,,,8.37,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.03,70,,11.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.5,,,4.5,Other,Drug Cost,4.5,,,4.5,Other,Drug Cost,4.5,,,4.5,Other,Drug Cost,4.5,,,4.5,Other,Drug Cost,4.5,,,4.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.5,,,4.5,Other,Drug Cost,10.13,,,10.13,Other,225% Medicaid APG methodology,6.3,,,6.3,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.5,,,4.5,Other,Drug Cost,4.5,,,4.5,Other,Drug Cost,5.63,,,5.63,Other,125% Medicaid APG methodology,0.01,11.03,
BARIUM 96% ORAL SUSP. 176G      ,,,,40507303,CDM,250,RC,32909-0750-03,NDC,both,176,GM,6.16,2.43,39.4668,,2.43,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.85,30,,1.85,percent of total billed charges,"Drugs, Inpatient Only",1.85,30,,1.85,percent of total billed charges,"Drugs, Inpatient Only",1.85,30,,1.85,percent of total billed charges,"Drugs, Inpatient Only",3.08,50,,3.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.55,,,6.55,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.31,70,,4.31,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.52,,,3.52,Other,Drug Cost,3.52,,,3.52,Other,Drug Cost,3.52,,,3.52,Other,Drug Cost,3.52,,,3.52,Other,Drug Cost,3.52,,,3.52,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.52,,,3.52,Other,Drug Cost,7.92,,,7.92,Other,225% Medicaid APG methodology,4.93,,,4.93,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.52,,,3.52,Other,Drug Cost,3.52,,,3.52,Other,Drug Cost,4.4,,,4.4,Other,125% Medicaid APG methodology,0.01,7.92,
BARIUM SULFATE 700 MG TAB       ,,,,40507311,CDM,250,RC,10361-0778-31,NDC,both,1,EA,6.79,2.68,39.4668,,2.68,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.04,30,,2.04,percent of total billed charges,"Drugs, Inpatient Only",2.04,30,,2.04,percent of total billed charges,"Drugs, Inpatient Only",2.04,30,,2.04,percent of total billed charges,"Drugs, Inpatient Only",3.4,50,,3.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.35,,,4.35,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.75,70,,4.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.34,,,2.34,Other,Drug Cost,2.34,,,2.34,Other,Drug Cost,2.34,,,2.34,Other,Drug Cost,2.34,,,2.34,Other,Drug Cost,2.34,,,2.34,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.34,,,2.34,Other,Drug Cost,5.27,,,5.27,Other,225% Medicaid APG methodology,3.28,,,3.28,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.34,,,2.34,Other,Drug Cost,2.34,,,2.34,Other,Drug Cost,2.93,,,2.93,Other,125% Medicaid APG methodology,0.01,5.27,
BARIUM 40% ORAL SUSP 250 ML     ,,,,40507337,CDM,250,RC,32909-0121-07,NDC,both,250,ML,157.5,62.16,39.4668,,62.16,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,47.25,30,,47.25,percent of total billed charges,"Drugs, Inpatient Only",47.25,30,,47.25,percent of total billed charges,"Drugs, Inpatient Only",47.25,30,,47.25,percent of total billed charges,"Drugs, Inpatient Only",78.75,50,,78.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,97.65,,,97.65,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,110.25,70,,110.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,52.5,,,52.5,Other,Drug Cost,52.5,,,52.5,Other,Drug Cost,52.5,,,52.5,Other,Drug Cost,52.5,,,52.5,Other,Drug Cost,52.5,,,52.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,52.5,,,52.5,Other,Drug Cost,118.13,,,118.13,Other,225% Medicaid APG methodology,73.5,,,73.5,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,52.5,,,52.5,Other,Drug Cost,52.5,,,52.5,Other,Drug Cost,65.63,,,65.63,Other,125% Medicaid APG methodology,0.01,118.13,
CLINIMIX 4.25% W/ D5W 2000 ML   ,,,,40507394,CDM,250,RC,00338-1089-04,NDC,both,2000,ML,165.9,65.48,39.4668,,65.48,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,49.77,30,,49.77,percent of total billed charges,"Drugs, Inpatient Only",49.77,30,,49.77,percent of total billed charges,"Drugs, Inpatient Only",49.77,30,,49.77,percent of total billed charges,"Drugs, Inpatient Only",82.95,50,,82.95,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,33.85,,,33.85,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,116.13,70,,116.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,18.2,,,18.2,Other,Drug Cost,18.2,,,18.2,Other,Drug Cost,18.2,,,18.2,Other,Drug Cost,18.2,,,18.2,Other,Drug Cost,18.2,,,18.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,18.2,,,18.2,Other,Drug Cost,40.95,,,40.95,Other,225% Medicaid APG methodology,25.48,,,25.48,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,18.2,,,18.2,Other,Drug Cost,18.2,,,18.2,Other,Drug Cost,22.75,,,22.75,Other,125% Medicaid APG methodology,0.01,116.13,
CLINIMIX 5% W/ D20W 2000 ML     ,,,,40507402,CDM,250,RC,00338-1101-04,NDC,both,2000,ML,200.06,78.96,39.4668,,78.96,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,60.02,30,,60.02,percent of total billed charges,"Drugs, Inpatient Only",60.02,30,,60.02,percent of total billed charges,"Drugs, Inpatient Only",60.02,30,,60.02,percent of total billed charges,"Drugs, Inpatient Only",100.03,50,,100.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,35.71,,,35.71,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,140.04,70,,140.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.2,,,19.2,Other,Drug Cost,19.2,,,19.2,Other,Drug Cost,19.2,,,19.2,Other,Drug Cost,19.2,,,19.2,Other,Drug Cost,19.2,,,19.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,19.2,,,19.2,Other,Drug Cost,43.2,,,43.2,Other,225% Medicaid APG methodology,26.88,,,26.88,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,19.2,,,19.2,Other,Drug Cost,19.2,,,19.2,Other,Drug Cost,24,,,24,Other,125% Medicaid APG methodology,0.01,140.04,
CLINIMIX E 5% W/ D20W 1000 ML   ,,,,40507410,CDM,250,RC,00338-1148-03,NDC,both,1000,ML,118.65,46.83,39.4668,,46.83,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,35.6,30,,35.6,percent of total billed charges,"Drugs, Inpatient Only",35.6,30,,35.6,percent of total billed charges,"Drugs, Inpatient Only",35.6,30,,35.6,percent of total billed charges,"Drugs, Inpatient Only",59.33,50,,59.33,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,20.57,,,20.57,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,83.06,70,,83.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.06,,,11.06,Other,Drug Cost,11.06,,,11.06,Other,Drug Cost,11.06,,,11.06,Other,Drug Cost,11.06,,,11.06,Other,Drug Cost,11.06,,,11.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,11.06,,,11.06,Other,Drug Cost,24.89,,,24.89,Other,225% Medicaid APG methodology,15.48,,,15.48,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,11.06,,,11.06,Other,Drug Cost,11.06,,,11.06,Other,Drug Cost,13.83,,,13.83,Other,125% Medicaid APG methodology,0.01,83.06,
CLINIMIX E 5% W/ D20W 2000 ML   ,,,,40507428,CDM,250,RC,00338-1125-04,NDC,both,2000,ML,204.82,80.84,39.4668,,80.84,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,61.45,30,,61.45,percent of total billed charges,"Drugs, Inpatient Only",61.45,30,,61.45,percent of total billed charges,"Drugs, Inpatient Only",61.45,30,,61.45,percent of total billed charges,"Drugs, Inpatient Only",102.41,50,,102.41,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,41.44,,,41.44,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,143.37,70,,143.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,22.28,,,22.28,Other,Drug Cost,22.28,,,22.28,Other,Drug Cost,22.28,,,22.28,Other,Drug Cost,22.28,,,22.28,Other,Drug Cost,22.28,,,22.28,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,22.28,,,22.28,Other,Drug Cost,50.13,,,50.13,Other,225% Medicaid APG methodology,31.19,,,31.19,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,22.28,,,22.28,Other,Drug Cost,22.28,,,22.28,Other,Drug Cost,27.85,,,27.85,Other,125% Medicaid APG methodology,0.01,143.37,
FENTANYL 200 MCG LOZENGE        ,,,,40507444,CDM,250,RC,00406-9202-30,NDC,both,1,EA,42.67,16.84,39.4668,,16.84,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.8,30,,12.8,percent of total billed charges,"Drugs, Inpatient Only",12.8,30,,12.8,percent of total billed charges,"Drugs, Inpatient Only",12.8,30,,12.8,percent of total billed charges,"Drugs, Inpatient Only",21.34,50,,21.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,22.67,,,22.67,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,29.87,70,,29.87,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.19,,,12.19,Other,Drug Cost,12.19,,,12.19,Other,Drug Cost,12.19,,,12.19,Other,Drug Cost,12.19,,,12.19,Other,Drug Cost,12.19,,,12.19,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,12.19,,,12.19,Other,Drug Cost,27.43,,,27.43,Other,225% Medicaid APG methodology,17.07,,,17.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,12.19,,,12.19,Other,Drug Cost,12.19,,,12.19,Other,Drug Cost,15.24,,,15.24,Other,125% Medicaid APG methodology,0.01,29.87,
BUP-FEN 0.125%-2 MCG/ML-NS 250  ,,,,40507451,CDM,250,RC,63323-0806-20b,NDC,both,250,ML,33.43,13.19,39.4668,,13.19,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.03,30,,10.03,percent of total billed charges,"Drugs, Inpatient Only",10.03,30,,10.03,percent of total billed charges,"Drugs, Inpatient Only",10.03,30,,10.03,percent of total billed charges,"Drugs, Inpatient Only",16.72,50,,16.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13,,,13,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,23.4,70,,23.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.99,,,6.99,Other,Drug Cost,6.99,,,6.99,Other,Drug Cost,6.99,,,6.99,Other,Drug Cost,6.99,,,6.99,Other,Drug Cost,6.99,,,6.99,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,6.99,,,6.99,Other,Drug Cost,15.73,,,15.73,Other,225% Medicaid APG methodology,9.79,,,9.79,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.99,,,6.99,Other,Drug Cost,6.99,,,6.99,Other,Drug Cost,8.74,,,8.74,Other,125% Medicaid APG methodology,0.01,23.4,
MORPH 60 MG/8 TO 12 HR ER TAB   ,,,,40507469,CDM,250,RC,00406-8380-01,NDC,both,1,EA,8.09,3.19,39.4668,,3.19,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.43,30,,2.43,percent of total billed charges,"Drugs, Inpatient Only",2.43,30,,2.43,percent of total billed charges,"Drugs, Inpatient Only",2.43,30,,2.43,percent of total billed charges,"Drugs, Inpatient Only",4.05,50,,4.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.54,,,0.54,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.66,70,,5.66,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.29,,,0.29,Other,Drug Cost,0.65,,,0.65,Other,225% Medicaid APG methodology,0.41,,,0.41,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.36,,,0.36,Other,125% Medicaid APG methodology,0.01,5.66,
BAR SULF 40% ORAL SUSP 20 ML    ,,,,40507485,CDM,250,RC,32909-0121-07a,NDC,both,1,ML,0.67,0.26,39.4668,,0.26,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,30,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.2,30,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.2,30,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.34,50,,0.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.41,,,0.41,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.47,70,,0.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.5,,,0.5,Other,225% Medicaid APG methodology,0.31,,,0.31,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.28,,,0.28,Other,125% Medicaid APG methodology,0.01,0.5,
VW FAC-ANTIHE 500 UNIT (HUM P)  ,,,,40507535,CDM,250,RC,63833-0626-01,NDC,both,1,EA,3.61,1.42,39.4668,,1.42,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.08,30,,1.08,percent of total billed charges,"Drugs, Inpatient Only",1.08,30,,1.08,percent of total billed charges,"Drugs, Inpatient Only",1.08,30,,1.08,percent of total billed charges,"Drugs, Inpatient Only",1.81,50,,1.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.56,,,1.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.53,70,,2.53,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.84,,,0.84,Other,Drug Cost,1.89,,,1.89,Other,225% Medicaid APG methodology,1.18,,,1.18,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,1.05,,,1.05,Other,125% Medicaid APG methodology,0.01,2.53,
PEGIN AL-2A 180 MCG/ML SQ 1 ML  ,,,,40507642,CDM,250,RC,00004-0350-09,NDC,both,1,ML,3575.22,1411.02,39.4668,,1411.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1072.57,30,,1072.57,percent of total billed charges,"Drugs, Inpatient Only",1072.57,30,,1072.57,percent of total billed charges,"Drugs, Inpatient Only",1072.57,30,,1072.57,percent of total billed charges,"Drugs, Inpatient Only",1787.61,50,,1787.61,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1899.97,,,1899.97,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2502.65,70,,2502.65,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1021.49,,,1021.49,Other,Drug Cost,1021.49,,,1021.49,Other,Drug Cost,1021.49,,,1021.49,Other,Drug Cost,1021.49,,,1021.49,Other,Drug Cost,1021.49,,,1021.49,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1021.49,,,1021.49,Other,Drug Cost,2298.35,,,2298.35,Other,225% Medicaid APG methodology,1430.09,,,1430.09,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1021.49,,,1021.49,Other,Drug Cost,1021.49,,,1021.49,Other,Drug Cost,1276.86,,,1276.86,Other,125% Medicaid APG methodology,0.01,2502.65,
FLUDEOXYGLUCOSE F-18 IV SOLN    ,,,,40507675,CDM,250,RC,40028-0511-30,NDC,both,1,EA,2275,897.87,39.4668,,897.87,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,682.5,30,,682.5,percent of total billed charges,"Drugs, Inpatient Only",682.5,30,,682.5,percent of total billed charges,"Drugs, Inpatient Only",682.5,30,,682.5,percent of total billed charges,"Drugs, Inpatient Only",1137.5,50,,1137.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1209,,,1209,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1592.5,70,,1592.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,650,,,650,Other,Drug Cost,650,,,650,Other,Drug Cost,650,,,650,Other,Drug Cost,650,,,650,Other,Drug Cost,650,,,650,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,650,,,650,Other,Drug Cost,1462.5,,,1462.5,Other,225% Medicaid APG methodology,910,,,910,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,650,,,650,Other,Drug Cost,650,,,650,Other,Drug Cost,812.5,,,812.5,Other,125% Medicaid APG methodology,0.01,1592.5,
INDIUM CHL IN-111 5 MCI/0.5 ML  ,,,,40507725,CDM,250,RC,17156-0523-01,NDC,both,0.5,EA,2148.72,848.03,39.4668,,848.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,644.62,30,,644.62,percent of total billed charges,"Drugs, Inpatient Only",644.62,30,,644.62,percent of total billed charges,"Drugs, Inpatient Only",644.62,30,,644.62,percent of total billed charges,"Drugs, Inpatient Only",1074.36,50,,1074.36,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1141.89,,,1141.89,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1504.1,70,,1504.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,613.92,,,613.92,Other,Drug Cost,613.92,,,613.92,Other,Drug Cost,613.92,,,613.92,Other,Drug Cost,613.92,,,613.92,Other,Drug Cost,613.92,,,613.92,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,613.92,,,613.92,Other,Drug Cost,1381.32,,,1381.32,Other,225% Medicaid APG methodology,859.49,,,859.49,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,613.92,,,613.92,Other,Drug Cost,613.92,,,613.92,Other,Drug Cost,767.4,,,767.4,Other,125% Medicaid APG methodology,0.01,1504.1,
IND PE IN-111 3 MCI/ML KIT      ,,,,40507758,CDM,250,RC,00019-9050-40,NDC,both,1,EA,8232,3248.91,39.4668,,3248.91,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2469.6,30,,2469.6,percent of total billed charges,"Drugs, Inpatient Only",2469.6,30,,2469.6,percent of total billed charges,"Drugs, Inpatient Only",2469.6,30,,2469.6,percent of total billed charges,"Drugs, Inpatient Only",4116,50,,4116,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4374.72,,,4374.72,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5762.4,70,,5762.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2352,,,2352,Other,Drug Cost,2352,,,2352,Other,Drug Cost,2352,,,2352,Other,Drug Cost,2352,,,2352,Other,Drug Cost,2352,,,2352,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2352,,,2352,Other,Drug Cost,5292,,,5292,Other,225% Medicaid APG methodology,3292.8,,,3292.8,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2352,,,2352,Other,Drug Cost,2352,,,2352,Other,Drug Cost,2940,,,2940,Other,125% Medicaid APG methodology,0.01,5762.4,
SODIUM FLUORIDE F-18 IV SOLN    ,,,,40507808,CDM,250,RC,40028-0512-30,NDC,both,1,EA,2275,897.87,39.4668,,897.87,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,682.5,30,,682.5,percent of total billed charges,"Drugs, Inpatient Only",682.5,30,,682.5,percent of total billed charges,"Drugs, Inpatient Only",682.5,30,,682.5,percent of total billed charges,"Drugs, Inpatient Only",1137.5,50,,1137.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1209,,,1209,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1592.5,70,,1592.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,650,,,650,Other,Drug Cost,650,,,650,Other,Drug Cost,650,,,650,Other,Drug Cost,650,,,650,Other,Drug Cost,650,,,650,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,650,,,650,Other,Drug Cost,1462.5,,,1462.5,Other,225% Medicaid APG methodology,910,,,910,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,650,,,650,Other,Drug Cost,650,,,650,Other,Drug Cost,812.5,,,812.5,Other,125% Medicaid APG methodology,0.01,1592.5,
SODIUM IODID I-123 200 UCI CAP  ,,,,40507816,CDM,250,RC,17156-0522-05,NDC,both,1,EA,0.18,0.07,39.4668,,0.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.09,50,,0.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,70,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.13,
TEC TC-99M OXIDRONA (HDP) INJ   ,,,,40507923,CDM,250,RC,69945-0091-20,NDC,both,1,EA,0.7,0.28,39.4668,,0.28,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.21,30,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.21,30,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.21,30,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.35,50,,0.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,,,0.37,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.49,70,,0.49,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.45,,,0.45,Other,225% Medicaid APG methodology,0.28,,,0.28,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.25,,,0.25,Other,125% Medicaid APG methodology,0.01,0.49,
TEC TC-99M PENTE ACI 20 MG INJ  ,,,,40507949,CDM,250,RC,65174-0288-30,NDC,both,1,EA,700,276.27,39.4668,,276.27,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,210,30,,210,percent of total billed charges,"Drugs, Inpatient Only",210,30,,210,percent of total billed charges,"Drugs, Inpatient Only",210,30,,210,percent of total billed charges,"Drugs, Inpatient Only",350,50,,350,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,372,,,372,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,490,70,,490,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,200,,,200,Other,Drug Cost,200,,,200,Other,Drug Cost,200,,,200,Other,Drug Cost,200,,,200,Other,Drug Cost,200,,,200,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,200,,,200,Other,Drug Cost,450,,,450,Other,225% Medicaid APG methodology,280,,,280,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,200,,,200,Other,Drug Cost,200,,,200,Other,Drug Cost,250,,,250,Other,125% Medicaid APG methodology,0.01,490,
TEC TC-99M PYROPHOS (PYP) INJ   ,,,,40507956,CDM,250,RC,45567-0060-02,NDC,both,1,EA,233.1,92,39.4668,,92,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,69.93,30,,69.93,percent of total billed charges,"Drugs, Inpatient Only",69.93,30,,69.93,percent of total billed charges,"Drugs, Inpatient Only",69.93,30,,69.93,percent of total billed charges,"Drugs, Inpatient Only",116.55,50,,116.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,123.88,,,123.88,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,163.17,70,,163.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,66.6,,,66.6,Other,Drug Cost,66.6,,,66.6,Other,Drug Cost,66.6,,,66.6,Other,Drug Cost,66.6,,,66.6,Other,Drug Cost,66.6,,,66.6,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,66.6,,,66.6,Other,Drug Cost,149.85,,,149.85,Other,225% Medicaid APG methodology,93.24,,,93.24,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,66.6,,,66.6,Other,Drug Cost,66.6,,,66.6,Other,Drug Cost,83.25,,,83.25,Other,125% Medicaid APG methodology,0.01,163.17,
TEC TC-99M NA PE (99MTCO4) INJ  ,,,,40507972,CDM,250,RC,11994-0090-36,NDC,both,1,EA,425.95,168.11,39.4668,,168.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,127.79,30,,127.79,percent of total billed charges,"Drugs, Inpatient Only",127.79,30,,127.79,percent of total billed charges,"Drugs, Inpatient Only",127.79,30,,127.79,percent of total billed charges,"Drugs, Inpatient Only",212.98,50,,212.98,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,226.36,,,226.36,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,298.17,70,,298.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,121.7,,,121.7,Other,Drug Cost,121.7,,,121.7,Other,Drug Cost,121.7,,,121.7,Other,Drug Cost,121.7,,,121.7,Other,Drug Cost,121.7,,,121.7,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,121.7,,,121.7,Other,Drug Cost,273.83,,,273.83,Other,225% Medicaid APG methodology,170.38,,,170.38,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,121.7,,,121.7,Other,Drug Cost,121.7,,,121.7,Other,Drug Cost,152.13,,,152.13,Other,125% Medicaid APG methodology,0.01,298.17,
THAL CH TL-201 37MBQ/ML 8.8 ML  ,,,,40508020,CDM,250,RC,17156-0299-18,NDC,both,8.8,ML,42330.89,16706.65,39.4668,,16706.65,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12699.27,30,,12699.27,percent of total billed charges,"Drugs, Inpatient Only",12699.27,30,,12699.27,percent of total billed charges,"Drugs, Inpatient Only",12699.27,30,,12699.27,percent of total billed charges,"Drugs, Inpatient Only",21165.45,50,,21165.45,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,22495.84,,,22495.84,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,29631.62,70,,29631.62,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12094.54,,,12094.54,Other,Drug Cost,12094.54,,,12094.54,Other,Drug Cost,12094.54,,,12094.54,Other,Drug Cost,12094.54,,,12094.54,Other,Drug Cost,12094.54,,,12094.54,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,12094.54,,,12094.54,Other,Drug Cost,27212.72,,,27212.72,Other,225% Medicaid APG methodology,16932.36,,,16932.36,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,12094.54,,,12094.54,Other,Drug Cost,12094.54,,,12094.54,Other,Drug Cost,15118.18,,,15118.18,Other,125% Medicaid APG methodology,0.01,29631.62,
MAGNES CHLORIDE 200 MG/ML SOL   ,,,,40508103,CDM,250,RC,67457-0134-50,NDC,both,1,ML,1.33,0.52,39.4668,,0.52,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.4,30,,0.4,percent of total billed charges,"Drugs, Inpatient Only",0.4,30,,0.4,percent of total billed charges,"Drugs, Inpatient Only",0.4,30,,0.4,percent of total billed charges,"Drugs, Inpatient Only",0.67,50,,0.67,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.43,,,0.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.93,70,,0.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.23,,,0.23,Other,Drug Cost,0.52,,,0.52,Other,225% Medicaid APG methodology,0.32,,,0.32,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.29,,,0.29,Other,125% Medicaid APG methodology,0.01,0.93,
TESTO 20.25 MG/ACT (1.62%)75 G  ,,,,40508129,CDM,250,RC,00051-8462-33,NDC,both,75,GM,2173.71,857.89,39.4668,,857.89,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,652.11,30,,652.11,percent of total billed charges,"Drugs, Inpatient Only",652.11,30,,652.11,percent of total billed charges,"Drugs, Inpatient Only",652.11,30,,652.11,percent of total billed charges,"Drugs, Inpatient Only",1086.86,50,,1086.86,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1155.17,,,1155.17,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1521.6,70,,1521.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,621.06,,,621.06,Other,Drug Cost,621.06,,,621.06,Other,Drug Cost,621.06,,,621.06,Other,Drug Cost,621.06,,,621.06,Other,Drug Cost,621.06,,,621.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,621.06,,,621.06,Other,Drug Cost,1397.39,,,1397.39,Other,225% Medicaid APG methodology,869.48,,,869.48,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,621.06,,,621.06,Other,Drug Cost,621.06,,,621.06,Other,Drug Cost,776.33,,,776.33,Other,125% Medicaid APG methodology,0.01,1521.6,
"BUPRENORPH 20 MCG/HR FILM, ER   ",,,,40508137,CDM,250,RC,59011-0752-04,NDC,both,1,EA,693.84,273.84,39.4668,,273.84,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,208.15,30,,208.15,percent of total billed charges,"Drugs, Inpatient Only",208.15,30,,208.15,percent of total billed charges,"Drugs, Inpatient Only",208.15,30,,208.15,percent of total billed charges,"Drugs, Inpatient Only",346.92,50,,346.92,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,485.69,70,,485.69,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,485.69,
KETA 10 MG/ML 5 ML (PREM SYR)   ,,,,40508145,CDM,250,RC,69374-0982-55,NDC,both,5,ML,22.75,8.98,39.4668,,8.98,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.83,30,,6.83,percent of total billed charges,"Drugs, Inpatient Only",6.83,30,,6.83,percent of total billed charges,"Drugs, Inpatient Only",6.83,30,,6.83,percent of total billed charges,"Drugs, Inpatient Only",11.38,50,,11.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.09,,,12.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.93,70,,15.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.5,,,6.5,Other,Drug Cost,6.5,,,6.5,Other,Drug Cost,6.5,,,6.5,Other,Drug Cost,6.5,,,6.5,Other,Drug Cost,6.5,,,6.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,6.5,,,6.5,Other,Drug Cost,14.63,,,14.63,Other,225% Medicaid APG methodology,9.1,,,9.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.5,,,6.5,Other,Drug Cost,6.5,,,6.5,Other,Drug Cost,8.13,,,8.13,Other,125% Medicaid APG methodology,0.01,15.93,
PHENYLEPHRINE 2.5% OPHTH 10 ML  ,,,,40508152,CDM,250,RC,42702-0102-10,NDC,both,10,ML,252,99.46,39.4668,,99.46,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,75.6,30,,75.6,percent of total billed charges,"Drugs, Inpatient Only",75.6,30,,75.6,percent of total billed charges,"Drugs, Inpatient Only",75.6,30,,75.6,percent of total billed charges,"Drugs, Inpatient Only",126,50,,126,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,176.4,70,,176.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.2,,,0.2,Other,225% Medicaid APG methodology,0.13,,,0.13,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,176.4,
CLINIMIX 4.25% W/ D10W 1000 ML  ,,,,40508160,CDM,250,RC,00338-1134-03,NDC,both,1000,ML,98.77,38.98,39.4668,,38.98,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,29.63,30,,29.63,percent of total billed charges,"Drugs, Inpatient Only",29.63,30,,29.63,percent of total billed charges,"Drugs, Inpatient Only",29.63,30,,29.63,percent of total billed charges,"Drugs, Inpatient Only",49.39,50,,49.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,17.47,,,17.47,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,69.14,70,,69.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.39,,,9.39,Other,Drug Cost,9.39,,,9.39,Other,Drug Cost,9.39,,,9.39,Other,Drug Cost,9.39,,,9.39,Other,Drug Cost,9.39,,,9.39,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,9.39,,,9.39,Other,Drug Cost,21.13,,,21.13,Other,225% Medicaid APG methodology,13.15,,,13.15,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,9.39,,,9.39,Other,Drug Cost,9.39,,,9.39,Other,Drug Cost,11.74,,,11.74,Other,125% Medicaid APG methodology,0.01,69.14,
CLINIMIX E 4.25% D10W 1000 ML   ,,,,40508178,CDM,250,RC,00338-1145-03,NDC,both,1000,ML,106.26,41.94,39.4668,,41.94,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,31.88,30,,31.88,percent of total billed charges,"Drugs, Inpatient Only",31.88,30,,31.88,percent of total billed charges,"Drugs, Inpatient Only",31.88,30,,31.88,percent of total billed charges,"Drugs, Inpatient Only",53.13,50,,53.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,17.34,,,17.34,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,74.38,70,,74.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.32,,,9.32,Other,Drug Cost,9.32,,,9.32,Other,Drug Cost,9.32,,,9.32,Other,Drug Cost,9.32,,,9.32,Other,Drug Cost,9.32,,,9.32,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,9.32,,,9.32,Other,Drug Cost,20.97,,,20.97,Other,225% Medicaid APG methodology,13.05,,,13.05,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,9.32,,,9.32,Other,Drug Cost,9.32,,,9.32,Other,Drug Cost,11.65,,,11.65,Other,125% Medicaid APG methodology,0.01,74.38,
CLINIMIX 5% W/ D15W 1000 ML     ,,,,40508186,CDM,250,RC,00338-1137-03,NDC,both,1000,ML,106.44,42.01,39.4668,,42.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,31.93,30,,31.93,percent of total billed charges,"Drugs, Inpatient Only",31.93,30,,31.93,percent of total billed charges,"Drugs, Inpatient Only",31.93,30,,31.93,percent of total billed charges,"Drugs, Inpatient Only",53.22,50,,53.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.75,,,19.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,74.51,70,,74.51,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.62,,,10.62,Other,Drug Cost,10.62,,,10.62,Other,Drug Cost,10.62,,,10.62,Other,Drug Cost,10.62,,,10.62,Other,Drug Cost,10.62,,,10.62,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,10.62,,,10.62,Other,Drug Cost,23.9,,,23.9,Other,225% Medicaid APG methodology,14.87,,,14.87,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,10.62,,,10.62,Other,Drug Cost,10.62,,,10.62,Other,Drug Cost,13.28,,,13.28,Other,125% Medicaid APG methodology,0.01,74.51,
BEN/BUT/TET 14%-2%-2% AERO 5 G  ,,,,40508202,CDM,250,RC,10223-0201-04,NDC,both,5,GM,188.34,74.33,39.4668,,74.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,56.5,30,,56.5,percent of total billed charges,"Drugs, Inpatient Only",56.5,30,,56.5,percent of total billed charges,"Drugs, Inpatient Only",56.5,30,,56.5,percent of total billed charges,"Drugs, Inpatient Only",94.17,50,,94.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,100.09,,,100.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,131.84,70,,131.84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,53.81,,,53.81,Other,Drug Cost,53.81,,,53.81,Other,Drug Cost,53.81,,,53.81,Other,Drug Cost,53.81,,,53.81,Other,Drug Cost,53.81,,,53.81,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,53.81,,,53.81,Other,Drug Cost,121.07,,,121.07,Other,225% Medicaid APG methodology,75.33,,,75.33,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,53.81,,,53.81,Other,Drug Cost,53.81,,,53.81,Other,Drug Cost,67.26,,,67.26,Other,125% Medicaid APG methodology,0.01,131.84,
CADEXOMER IODINE 0.9% GEL 40 G  ,,,,40508228,CDM,250,RC,40565-0122-49,NDC,both,40,GM,146.27,57.73,39.4668,,57.73,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,43.88,30,,43.88,percent of total billed charges,"Drugs, Inpatient Only",43.88,30,,43.88,percent of total billed charges,"Drugs, Inpatient Only",43.88,30,,43.88,percent of total billed charges,"Drugs, Inpatient Only",73.14,50,,73.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,77.73,,,77.73,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,102.39,70,,102.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,41.79,,,41.79,Other,Drug Cost,41.79,,,41.79,Other,Drug Cost,41.79,,,41.79,Other,Drug Cost,41.79,,,41.79,Other,Drug Cost,41.79,,,41.79,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,41.79,,,41.79,Other,Drug Cost,94.03,,,94.03,Other,225% Medicaid APG methodology,58.51,,,58.51,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,41.79,,,41.79,Other,Drug Cost,41.79,,,41.79,Other,Drug Cost,52.24,,,52.24,Other,125% Medicaid APG methodology,0.01,102.39,
CA CARB 500MG (200MG CA) CHEW   ,,,,40508236,CDM,250,RC,68084-0988-32,NDC,both,1,EA,3.08,1.22,39.4668,,1.22,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.92,30,,0.92,percent of total billed charges,"Drugs, Inpatient Only",0.92,30,,0.92,percent of total billed charges,"Drugs, Inpatient Only",0.92,30,,0.92,percent of total billed charges,"Drugs, Inpatient Only",1.54,50,,1.54,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.64,,,1.64,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.16,70,,2.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.88,,,0.88,Other,Drug Cost,1.98,,,1.98,Other,225% Medicaid APG methodology,1.23,,,1.23,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,1.1,,,1.1,Other,125% Medicaid APG methodology,0.01,2.16,
CEFAZOLIN 3 G/100 ML-NS SOL     ,,,,40508251,CDM,250,RC,70092-1623-03,NDC,both,100,ML,62.93,24.84,39.4668,,24.84,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,18.88,30,,18.88,percent of total billed charges,"Drugs, Inpatient Only",18.88,30,,18.88,percent of total billed charges,"Drugs, Inpatient Only",18.88,30,,18.88,percent of total billed charges,"Drugs, Inpatient Only",31.47,50,,31.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,33.44,,,33.44,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,44.05,70,,44.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,17.98,,,17.98,Other,Drug Cost,17.98,,,17.98,Other,Drug Cost,17.98,,,17.98,Other,Drug Cost,17.98,,,17.98,Other,Drug Cost,17.98,,,17.98,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,17.98,,,17.98,Other,Drug Cost,40.46,,,40.46,Other,225% Medicaid APG methodology,25.17,,,25.17,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,17.98,,,17.98,Other,Drug Cost,17.98,,,17.98,Other,Drug Cost,22.48,,,22.48,Other,125% Medicaid APG methodology,0.01,44.05,
CEPHAL 125 MG/5 ML LIQ 100 ML   ,,,,40508269,CDM,250,RC,00093-4175-73,NDC,both,100,ML,182.7,72.11,39.4668,,72.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,54.81,30,,54.81,percent of total billed charges,"Drugs, Inpatient Only",54.81,30,,54.81,percent of total billed charges,"Drugs, Inpatient Only",54.81,30,,54.81,percent of total billed charges,"Drugs, Inpatient Only",91.35,50,,91.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,97.09,,,97.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,127.89,70,,127.89,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,52.2,,,52.2,Other,Drug Cost,52.2,,,52.2,Other,Drug Cost,52.2,,,52.2,Other,Drug Cost,52.2,,,52.2,Other,Drug Cost,52.2,,,52.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,52.2,,,52.2,Other,Drug Cost,117.45,,,117.45,Other,225% Medicaid APG methodology,73.08,,,73.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,52.2,,,52.2,Other,Drug Cost,52.2,,,52.2,Other,Drug Cost,65.25,,,65.25,Other,125% Medicaid APG methodology,0.01,127.89,
CHOLESTYRAM 4 G/5.5 G ORAL POW  ,,,,40508277,CDM,250,RC,68382-0529-60,NDC,both,1,EA,6.69,2.64,39.4668,,2.64,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.01,30,,2.01,percent of total billed charges,"Drugs, Inpatient Only",2.01,30,,2.01,percent of total billed charges,"Drugs, Inpatient Only",2.01,30,,2.01,percent of total billed charges,"Drugs, Inpatient Only",3.35,50,,3.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.55,,,3.55,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.68,70,,4.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.91,,,1.91,Other,Drug Cost,1.91,,,1.91,Other,Drug Cost,1.91,,,1.91,Other,Drug Cost,1.91,,,1.91,Other,Drug Cost,1.91,,,1.91,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.91,,,1.91,Other,Drug Cost,4.3,,,4.3,Other,225% Medicaid APG methodology,2.67,,,2.67,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.91,,,1.91,Other,Drug Cost,1.91,,,1.91,Other,Drug Cost,2.39,,,2.39,Other,125% Medicaid APG methodology,0.01,4.68,
CYANOCOBALAMIN 250 MCG TAB      ,,,,40508301,CDM,250,RC,50268-0853-15,NDC,both,1,EA,0.49,0.19,39.4668,,0.19,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.25,50,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.34,70,,0.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.29,,,0.29,Other,225% Medicaid APG methodology,0.18,,,0.18,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.16,,,0.16,Other,125% Medicaid APG methodology,0.01,0.34,
DEX-GUAI 10-100MG/5ML ORAL LIQ  ,,,,40508319,CDM,250,RC,00121-0638-05,NDC,both,5,EA,174.83,69,39.4668,,69,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,52.45,30,,52.45,percent of total billed charges,"Drugs, Inpatient Only",52.45,30,,52.45,percent of total billed charges,"Drugs, Inpatient Only",52.45,30,,52.45,percent of total billed charges,"Drugs, Inpatient Only",87.42,50,,87.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,92.91,,,92.91,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,122.38,70,,122.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,49.95,,,49.95,Other,Drug Cost,49.95,,,49.95,Other,Drug Cost,49.95,,,49.95,Other,Drug Cost,49.95,,,49.95,Other,Drug Cost,49.95,,,49.95,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,49.95,,,49.95,Other,Drug Cost,112.39,,,112.39,Other,225% Medicaid APG methodology,69.93,,,69.93,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,49.95,,,49.95,Other,Drug Cost,49.95,,,49.95,Other,Drug Cost,62.44,,,62.44,Other,125% Medicaid APG methodology,0.01,122.38,
ERYTHROMYCIN 250 MG DR CAP      ,,,,40508368,CDM,250,RC,00247-0110-01,NDC,both,1,EA,2.59,1.02,39.4668,,1.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.78,30,,0.78,percent of total billed charges,"Drugs, Inpatient Only",0.78,30,,0.78,percent of total billed charges,"Drugs, Inpatient Only",0.78,30,,0.78,percent of total billed charges,"Drugs, Inpatient Only",1.3,50,,1.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.38,,,1.38,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.81,70,,1.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.74,,,0.74,Other,Drug Cost,0.74,,,0.74,Other,Drug Cost,0.74,,,0.74,Other,Drug Cost,0.74,,,0.74,Other,Drug Cost,0.74,,,0.74,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.74,,,0.74,Other,Drug Cost,1.67,,,1.67,Other,225% Medicaid APG methodology,1.04,,,1.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.74,,,0.74,Other,Drug Cost,0.74,,,0.74,Other,Drug Cost,0.93,,,0.93,Other,125% Medicaid APG methodology,0.01,1.81,
FELODIPINE 2.5 MG ER TAB        ,,,,40508384,CDM,250,RC,13668-0132-01,NDC,both,1,EA,0.49,0.19,39.4668,,0.19,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.25,50,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.34,70,,0.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.34,
FENOFIBRATE 145 MG TAB          ,,,,40508392,CDM,250,RC,51079-0608-20,NDC,both,1,EA,3.75,1.48,39.4668,,1.48,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.13,30,,1.13,percent of total billed charges,"Drugs, Inpatient Only",1.13,30,,1.13,percent of total billed charges,"Drugs, Inpatient Only",1.13,30,,1.13,percent of total billed charges,"Drugs, Inpatient Only",1.88,50,,1.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.04,,,4.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.63,70,,2.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.17,,,2.17,Other,Drug Cost,2.17,,,2.17,Other,Drug Cost,2.17,,,2.17,Other,Drug Cost,2.17,,,2.17,Other,Drug Cost,2.17,,,2.17,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.17,,,2.17,Other,Drug Cost,4.88,,,4.88,Other,225% Medicaid APG methodology,3.04,,,3.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.17,,,2.17,Other,Drug Cost,2.17,,,2.17,Other,Drug Cost,2.71,,,2.71,Other,125% Medicaid APG methodology,0.01,4.88,
GLYBURIDE MICRONIZED 3 MG TAB   ,,,,40508400,CDM,250,RC,00093-8035-01,NDC,both,1,EA,0.35,0.14,39.4668,,0.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.18,50,,0.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,70,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.25,
LACTULOSE 10 G/15 ML SYRUP      ,,,,40508434,CDM,250,RC,00121-4577-15,NDC,both,15,ML,2.84,1.12,39.4668,,1.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.85,30,,0.85,percent of total billed charges,"Drugs, Inpatient Only",0.85,30,,0.85,percent of total billed charges,"Drugs, Inpatient Only",0.85,30,,0.85,percent of total billed charges,"Drugs, Inpatient Only",1.42,50,,1.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.51,,,1.51,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.99,70,,1.99,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.81,,,0.81,Other,Drug Cost,0.81,,,0.81,Other,Drug Cost,0.81,,,0.81,Other,Drug Cost,0.81,,,0.81,Other,Drug Cost,0.81,,,0.81,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.81,,,0.81,Other,Drug Cost,1.82,,,1.82,Other,225% Medicaid APG methodology,1.13,,,1.13,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.81,,,0.81,Other,Drug Cost,0.81,,,0.81,Other,Drug Cost,1.01,,,1.01,Other,125% Medicaid APG methodology,0.01,1.99,
LIDO-PRILO 2.5%-2.5% CREAM 30G  ,,,,40508467,CDM,250,RC,00115-1468-45,NDC,both,30,GM,16.28,6.43,39.4668,,6.43,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.88,30,,4.88,percent of total billed charges,"Drugs, Inpatient Only",4.88,30,,4.88,percent of total billed charges,"Drugs, Inpatient Only",4.88,30,,4.88,percent of total billed charges,"Drugs, Inpatient Only",8.14,50,,8.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.56,,,0.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.4,70,,11.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.68,,,0.68,Other,225% Medicaid APG methodology,0.42,,,0.42,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.38,,,0.38,Other,125% Medicaid APG methodology,0.01,11.4,
MEN-METHYL SAL 10%-15% CR 85GM  ,,,,40508483,CDM,250,RC,00536-1349-57,NDC,both,85,GM,8.93,3.52,39.4668,,3.52,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.68,30,,2.68,percent of total billed charges,"Drugs, Inpatient Only",2.68,30,,2.68,percent of total billed charges,"Drugs, Inpatient Only",2.68,30,,2.68,percent of total billed charges,"Drugs, Inpatient Only",4.47,50,,4.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.33,,,3.33,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.25,70,,6.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.79,,,1.79,Other,Drug Cost,1.79,,,1.79,Other,Drug Cost,1.79,,,1.79,Other,Drug Cost,1.79,,,1.79,Other,Drug Cost,1.79,,,1.79,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.79,,,1.79,Other,Drug Cost,4.03,,,4.03,Other,225% Medicaid APG methodology,2.51,,,2.51,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.79,,,1.79,Other,Drug Cost,1.79,,,1.79,Other,Drug Cost,2.24,,,2.24,Other,125% Medicaid APG methodology,0.01,6.25,
NIACIN 750 MG ER TAB            ,,,,40508509,CDM,250,RC,47335-0614-81,NDC,both,1,EA,1.75,0.69,39.4668,,0.69,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.53,30,,0.53,percent of total billed charges,"Drugs, Inpatient Only",0.53,30,,0.53,percent of total billed charges,"Drugs, Inpatient Only",0.53,30,,0.53,percent of total billed charges,"Drugs, Inpatient Only",0.88,50,,0.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.23,70,,1.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,1.23,
PHENYLEPHRIN 0.125% NASAL 15ML  ,,,,40508525,CDM,250,RC,56184-0121-05,NDC,both,15,ML,13.44,5.3,39.4668,,5.3,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.03,30,,4.03,percent of total billed charges,"Drugs, Inpatient Only",4.03,30,,4.03,percent of total billed charges,"Drugs, Inpatient Only",4.03,30,,4.03,percent of total billed charges,"Drugs, Inpatient Only",6.72,50,,6.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.14,,,7.14,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.41,70,,9.41,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.84,,,3.84,Other,Drug Cost,3.84,,,3.84,Other,Drug Cost,3.84,,,3.84,Other,Drug Cost,3.84,,,3.84,Other,Drug Cost,3.84,,,3.84,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.84,,,3.84,Other,Drug Cost,8.64,,,8.64,Other,225% Medicaid APG methodology,5.38,,,5.38,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.84,,,3.84,Other,Drug Cost,3.84,,,3.84,Other,Drug Cost,4.8,,,4.8,Other,125% Medicaid APG methodology,0.01,9.41,
PHENYLEPHRINE 1% NASAL 15 ML    ,,,,40508533,CDM,250,RC,00024-1352-02,NDC,both,15,ML,12.85,5.07,39.4668,,5.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.86,30,,3.86,percent of total billed charges,"Drugs, Inpatient Only",3.86,30,,3.86,percent of total billed charges,"Drugs, Inpatient Only",3.86,30,,3.86,percent of total billed charges,"Drugs, Inpatient Only",6.43,50,,6.43,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.83,,,6.83,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9,70,,9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.67,,,3.67,Other,Drug Cost,3.67,,,3.67,Other,Drug Cost,3.67,,,3.67,Other,Drug Cost,3.67,,,3.67,Other,Drug Cost,3.67,,,3.67,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.67,,,3.67,Other,Drug Cost,8.26,,,8.26,Other,225% Medicaid APG methodology,5.14,,,5.14,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.67,,,3.67,Other,Drug Cost,3.67,,,3.67,Other,Drug Cost,4.59,,,4.59,Other,125% Medicaid APG methodology,0.01,9,
PRAMIPEXOLE 0.25 MG TAB         ,,,,40508541,CDM,250,RC,13668-0092-90,NDC,both,1,EA,0.18,0.07,39.4668,,0.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.09,50,,0.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,70,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.13,
VITAMIN B COMPLEX WITH C TAB    ,,,,40508616,CDM,250,RC,31604-0133-08,NDC,both,1,EA,0.28,0.11,39.4668,,0.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.14,50,,0.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,70,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% Medicaid APG methodology,0.11,,,0.11,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.2,
FAMCICLOVIR 250 MG TAB          ,,,,40508624,CDM,250,RC,33342-0025-07,NDC,both,1,EA,0.7,0.28,39.4668,,0.28,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.21,30,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.21,30,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.21,30,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.35,50,,0.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.49,70,,0.49,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.23,,,0.23,Other,225% Medicaid APG methodology,0.14,,,0.14,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.13,,,0.13,Other,125% Medicaid APG methodology,0.01,0.49,
FENOFIBRATE 48 MG TAB           ,,,,40508632,CDM,250,RC,51079-0599-20,NDC,both,1,EA,0.7,0.28,39.4668,,0.28,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.21,30,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.21,30,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.21,30,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.35,50,,0.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.58,,,1.58,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.49,70,,0.49,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.85,,,0.85,Other,Drug Cost,1.91,,,1.91,Other,225% Medicaid APG methodology,1.19,,,1.19,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,1.06,,,1.06,Other,125% Medicaid APG methodology,0.01,1.91,
SOTALOL 120 MG TAB              ,,,,40508640,CDM,250,RC,60505-0159-00,NDC,both,1,EA,0.25,0.1,39.4668,,0.1,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.13,50,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.18,70,,0.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.18,
OFLOXACIN 0.3% OTIC SOLN 5 ML   ,,,,40508657,CDM,250,RC,60505-0363-01,NDC,both,5,ML,539.98,213.11,39.4668,,213.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,161.99,30,,161.99,percent of total billed charges,"Drugs, Inpatient Only",161.99,30,,161.99,percent of total billed charges,"Drugs, Inpatient Only",161.99,30,,161.99,percent of total billed charges,"Drugs, Inpatient Only",269.99,50,,269.99,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,286.96,,,286.96,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,377.99,70,,377.99,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,154.28,,,154.28,Other,Drug Cost,154.28,,,154.28,Other,Drug Cost,154.28,,,154.28,Other,Drug Cost,154.28,,,154.28,Other,Drug Cost,154.28,,,154.28,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,154.28,,,154.28,Other,Drug Cost,347.13,,,347.13,Other,225% Medicaid APG methodology,215.99,,,215.99,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,154.28,,,154.28,Other,Drug Cost,154.28,,,154.28,Other,Drug Cost,192.85,,,192.85,Other,125% Medicaid APG methodology,0.01,377.99,
MOMETASONE 0.1% TOP OINT 15 G   ,,,,40508665,CDM,250,RC,45802-0119-37,NDC,both,15,GM,85.05,33.57,39.4668,,33.57,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,25.52,30,,25.52,percent of total billed charges,"Drugs, Inpatient Only",25.52,30,,25.52,percent of total billed charges,"Drugs, Inpatient Only",25.52,30,,25.52,percent of total billed charges,"Drugs, Inpatient Only",42.53,50,,42.53,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,45.2,,,45.2,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,59.54,70,,59.54,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,24.3,,,24.3,Other,Drug Cost,24.3,,,24.3,Other,Drug Cost,24.3,,,24.3,Other,Drug Cost,24.3,,,24.3,Other,Drug Cost,24.3,,,24.3,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,24.3,,,24.3,Other,Drug Cost,54.68,,,54.68,Other,225% Medicaid APG methodology,34.02,,,34.02,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,24.3,,,24.3,Other,Drug Cost,24.3,,,24.3,Other,Drug Cost,30.38,,,30.38,Other,125% Medicaid APG methodology,0.01,59.54,
MICONAZOLE 2% TOP OINT 57 G     ,,,,40508673,CDM,250,RC,11701-0067-23,NDC,both,1,GM,0.53,0.21,39.4668,,0.21,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.27,50,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,70,,0.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,Drug Cost,0.34,,,0.34,Other,225% Medicaid APG methodology,0.21,,,0.21,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.19,,,0.19,Other,125% Medicaid APG methodology,0.01,0.37,
AA 10% (TROPHAMINE) IV 500 ML   ,,,,40508681,CDM,250,RC,00264-1933-10,NDC,both,500,ML,137.1,54.11,39.4668,,54.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,41.13,30,,41.13,percent of total billed charges,"Drugs, Inpatient Only",41.13,30,,41.13,percent of total billed charges,"Drugs, Inpatient Only",41.13,30,,41.13,percent of total billed charges,"Drugs, Inpatient Only",68.55,50,,68.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,31.58,,,31.58,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,95.97,70,,95.97,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,16.98,,,16.98,Other,Drug Cost,16.98,,,16.98,Other,Drug Cost,16.98,,,16.98,Other,Drug Cost,16.98,,,16.98,Other,Drug Cost,16.98,,,16.98,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,16.98,,,16.98,Other,Drug Cost,38.21,,,38.21,Other,225% Medicaid APG methodology,23.77,,,23.77,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,16.98,,,16.98,Other,Drug Cost,16.98,,,16.98,Other,Drug Cost,21.23,,,21.23,Other,125% Medicaid APG methodology,0.01,95.97,
AA 10% (TRAVASOL) IV 1000 ML    ,,,,40508699,CDM,250,RC,00338-0644-04,NDC,both,1000,ML,112.81,44.52,39.4668,,44.52,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,33.84,30,,33.84,percent of total billed charges,"Drugs, Inpatient Only",33.84,30,,33.84,percent of total billed charges,"Drugs, Inpatient Only",33.84,30,,33.84,percent of total billed charges,"Drugs, Inpatient Only",56.41,50,,56.41,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,16.85,,,16.85,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,78.97,70,,78.97,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.06,,,9.06,Other,Drug Cost,9.06,,,9.06,Other,Drug Cost,9.06,,,9.06,Other,Drug Cost,9.06,,,9.06,Other,Drug Cost,9.06,,,9.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,9.06,,,9.06,Other,Drug Cost,20.39,,,20.39,Other,225% Medicaid APG methodology,12.68,,,12.68,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,9.06,,,9.06,Other,Drug Cost,9.06,,,9.06,Other,Drug Cost,11.33,,,11.33,Other,125% Medicaid APG methodology,0.01,78.97,
D70W IV SOLN 2000 ML            ,,,,40508707,CDM,250,RC,00409-7120-07,NDC,both,2000,ML,92.68,36.58,39.4668,,36.58,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,27.8,30,,27.8,percent of total billed charges,"Drugs, Inpatient Only",27.8,30,,27.8,percent of total billed charges,"Drugs, Inpatient Only",27.8,30,,27.8,percent of total billed charges,"Drugs, Inpatient Only",46.34,50,,46.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,49.25,,,49.25,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,64.88,70,,64.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,26.48,,,26.48,Other,Drug Cost,26.48,,,26.48,Other,Drug Cost,26.48,,,26.48,Other,Drug Cost,26.48,,,26.48,Other,Drug Cost,26.48,,,26.48,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,26.48,,,26.48,Other,Drug Cost,59.58,,,59.58,Other,225% Medicaid APG methodology,37.07,,,37.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,26.48,,,26.48,Other,Drug Cost,26.48,,,26.48,Other,Drug Cost,33.1,,,33.1,Other,125% Medicaid APG methodology,0.01,64.88,
STERILE WATER INJ SOLN 500 ML   ,,,,40508715,CDM,250,RC,00264-7850-10,NDC,both,500,ML,9.03,3.56,39.4668,,3.56,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.71,30,,2.71,percent of total billed charges,"Drugs, Inpatient Only",2.71,30,,2.71,percent of total billed charges,"Drugs, Inpatient Only",2.71,30,,2.71,percent of total billed charges,"Drugs, Inpatient Only",4.52,50,,4.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.8,,,4.8,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.32,70,,6.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.58,,,2.58,Other,Drug Cost,2.58,,,2.58,Other,Drug Cost,2.58,,,2.58,Other,Drug Cost,2.58,,,2.58,Other,Drug Cost,2.58,,,2.58,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.58,,,2.58,Other,Drug Cost,5.81,,,5.81,Other,225% Medicaid APG methodology,3.61,,,3.61,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.58,,,2.58,Other,Drug Cost,2.58,,,2.58,Other,Drug Cost,3.23,,,3.23,Other,125% Medicaid APG methodology,0.01,6.32,
PIFLUFOLASTAT F-18 - IV INJ     ,,,,40508749,CDM,250,RC,71258-0022-01,NDC,both,1,EA,16583,6544.78,39.4668,,6544.78,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4974.9,30,,4974.9,percent of total billed charges,"Drugs, Inpatient Only",4974.9,30,,4974.9,percent of total billed charges,"Drugs, Inpatient Only",4974.9,30,,4974.9,percent of total billed charges,"Drugs, Inpatient Only",8291.5,50,,8291.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8812.68,,,8812.68,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11608.1,70,,11608.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4738,,,4738,Other,Drug Cost,4738,,,4738,Other,Drug Cost,4738,,,4738,Other,Drug Cost,4738,,,4738,Other,Drug Cost,4738,,,4738,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4738,,,4738,Other,Drug Cost,10660.5,,,10660.5,Other,225% Medicaid APG methodology,6633.2,,,6633.2,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4738,,,4738,Other,Drug Cost,4738,,,4738,Other,Drug Cost,5922.5,,,5922.5,Other,125% Medicaid APG methodology,0.01,11608.1,
CEFAZOLIN 3000 MG INJ           ,,,,40508764,CDM,250,RC,00143-9140-25,NDC,both,1,EA,17.08,6.74,39.4668,,6.74,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.12,30,,5.12,percent of total billed charges,"Drugs, Inpatient Only",5.12,30,,5.12,percent of total billed charges,"Drugs, Inpatient Only",5.12,30,,5.12,percent of total billed charges,"Drugs, Inpatient Only",8.54,50,,8.54,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.3,,,8.3,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.96,70,,11.96,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.46,,,4.46,Other,Drug Cost,4.46,,,4.46,Other,Drug Cost,4.46,,,4.46,Other,Drug Cost,4.46,,,4.46,Other,Drug Cost,4.46,,,4.46,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.46,,,4.46,Other,Drug Cost,10.04,,,10.04,Other,225% Medicaid APG methodology,6.24,,,6.24,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.46,,,4.46,Other,Drug Cost,4.46,,,4.46,Other,Drug Cost,5.58,,,5.58,Other,125% Medicaid APG methodology,0.01,11.96,
FENTANYL 300 MCG IN NS 30 ML    ,,,,40508772,CDM,250,RC,63323-0806-13a,NDC,both,30,ML,63,24.86,39.4668,,24.86,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,18.9,30,,18.9,percent of total billed charges,"Drugs, Inpatient Only",18.9,30,,18.9,percent of total billed charges,"Drugs, Inpatient Only",18.9,30,,18.9,percent of total billed charges,"Drugs, Inpatient Only",31.5,50,,31.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,33.48,,,33.48,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,44.1,70,,44.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,18,,,18,Other,Drug Cost,18,,,18,Other,Drug Cost,18,,,18,Other,Drug Cost,18,,,18,Other,Drug Cost,18,,,18,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,18,,,18,Other,Drug Cost,40.5,,,40.5,Other,225% Medicaid APG methodology,25.2,,,25.2,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,18,,,18,Other,Drug Cost,18,,,18,Other,Drug Cost,22.5,,,22.5,Other,125% Medicaid APG methodology,0.01,44.1,
TRIAM 55 MCG/INH NASAL 16.9 ML  ,,,,40508780,CDM,250,RC,41167-5800-05,NDC,both,16.9,ML,68.15,26.9,39.4668,,26.9,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,20.45,30,,20.45,percent of total billed charges,"Drugs, Inpatient Only",20.45,30,,20.45,percent of total billed charges,"Drugs, Inpatient Only",20.45,30,,20.45,percent of total billed charges,"Drugs, Inpatient Only",34.08,50,,34.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,36.21,,,36.21,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,47.71,70,,47.71,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.47,,,19.47,Other,Drug Cost,19.47,,,19.47,Other,Drug Cost,19.47,,,19.47,Other,Drug Cost,19.47,,,19.47,Other,Drug Cost,19.47,,,19.47,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,19.47,,,19.47,Other,Drug Cost,43.81,,,43.81,Other,225% Medicaid APG methodology,27.26,,,27.26,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,19.47,,,19.47,Other,Drug Cost,19.47,,,19.47,Other,Drug Cost,24.34,,,24.34,Other,125% Medicaid APG methodology,0.01,47.71,
LACTO ACI AND BUL ORAL GRANULE  ,,,,40508871,CDM,250,RC,64980-0146-12,NDC,both,1,EA,7.11,2.81,39.4668,,2.81,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.13,30,,2.13,percent of total billed charges,"Drugs, Inpatient Only",2.13,30,,2.13,percent of total billed charges,"Drugs, Inpatient Only",2.13,30,,2.13,percent of total billed charges,"Drugs, Inpatient Only",3.56,50,,3.56,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.78,,,3.78,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.98,70,,4.98,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.03,,,2.03,Other,Drug Cost,2.03,,,2.03,Other,Drug Cost,2.03,,,2.03,Other,Drug Cost,2.03,,,2.03,Other,Drug Cost,2.03,,,2.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.03,,,2.03,Other,Drug Cost,4.57,,,4.57,Other,225% Medicaid APG methodology,2.84,,,2.84,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.03,,,2.03,Other,Drug Cost,2.03,,,2.03,Other,Drug Cost,2.54,,,2.54,Other,125% Medicaid APG methodology,0.01,4.98,
LACTULOSE 20 G ORAL POWD-RECON  ,,,,40508905,CDM,250,RC,66220-0729-30,NDC,both,1,EA,28.25,11.15,39.4668,,11.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.48,30,,8.48,percent of total billed charges,"Drugs, Inpatient Only",8.48,30,,8.48,percent of total billed charges,"Drugs, Inpatient Only",8.48,30,,8.48,percent of total billed charges,"Drugs, Inpatient Only",14.13,50,,14.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.58,,,9.58,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.78,70,,19.78,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.15,,,5.15,Other,Drug Cost,5.15,,,5.15,Other,Drug Cost,5.15,,,5.15,Other,Drug Cost,5.15,,,5.15,Other,Drug Cost,5.15,,,5.15,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,5.15,,,5.15,Other,Drug Cost,11.59,,,11.59,Other,225% Medicaid APG methodology,7.21,,,7.21,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.15,,,5.15,Other,Drug Cost,5.15,,,5.15,Other,Drug Cost,6.44,,,6.44,Other,125% Medicaid APG methodology,0.01,19.78,
EPISHUGARCAINE 16 ML            ,,,,40508939,CDM,250,RC,99990-0614-23,NDC,both,1,ML,6.79,2.68,39.4668,,2.68,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.04,30,,2.04,percent of total billed charges,"Drugs, Inpatient Only",2.04,30,,2.04,percent of total billed charges,"Drugs, Inpatient Only",2.04,30,,2.04,percent of total billed charges,"Drugs, Inpatient Only",3.4,50,,3.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.85,,,3.85,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.75,70,,4.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.07,,,2.07,Other,Drug Cost,2.07,,,2.07,Other,Drug Cost,2.07,,,2.07,Other,Drug Cost,2.07,,,2.07,Other,Drug Cost,2.07,,,2.07,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.07,,,2.07,Other,Drug Cost,4.66,,,4.66,Other,225% Medicaid APG methodology,2.9,,,2.9,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.07,,,2.07,Other,Drug Cost,2.07,,,2.07,Other,Drug Cost,2.59,,,2.59,Other,125% Medicaid APG methodology,0.01,4.75,
SODIUM CHLORIDE 0.9% INJ 50 ML  ,,,,40508954,CDM,250,RC,00409-4888-50,NDC,both,50,ML,7.77,3.07,39.4668,,3.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.33,30,,2.33,percent of total billed charges,"Drugs, Inpatient Only",2.33,30,,2.33,percent of total billed charges,"Drugs, Inpatient Only",2.33,30,,2.33,percent of total billed charges,"Drugs, Inpatient Only",3.89,50,,3.89,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.46,,,4.46,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.44,70,,5.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.4,,,2.4,Other,Drug Cost,5.4,,,5.4,Other,225% Medicaid APG methodology,3.36,,,3.36,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,3,,,3,Other,125% Medicaid APG methodology,0.01,5.44,
COLLAG 250 UN/G TOP OINT 2.5 G  ,,,,40508996,CDM,250,RC,50484-0010-30a,NDC,both,2.5,GM,61.01,24.08,39.4668,,24.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,18.3,30,,18.3,percent of total billed charges,"Drugs, Inpatient Only",18.3,30,,18.3,percent of total billed charges,"Drugs, Inpatient Only",18.3,30,,18.3,percent of total billed charges,"Drugs, Inpatient Only",30.51,50,,30.51,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,42.71,70,,42.71,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,Drug Cost,0.32,,,0.32,Other,225% Medicaid APG methodology,0.2,,,0.2,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.18,,,0.18,Other,125% Medicaid APG methodology,0.01,42.71,
THEOPHYLLINE 300 MG ER TAB      ,,,,40509267,CDM,250,RC,62332-0025-31,NDC,both,1,EA,8.33,3.29,39.4668,,3.29,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.5,30,,2.5,percent of total billed charges,"Drugs, Inpatient Only",2.5,30,,2.5,percent of total billed charges,"Drugs, Inpatient Only",2.5,30,,2.5,percent of total billed charges,"Drugs, Inpatient Only",4.17,50,,4.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.83,70,,5.83,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,5.83,
AMINOPHYLLINE SUPP 500MG        ,,,,40509291,CDM,250,RC,00409-5921-01,NDC,both,10,ML,37.98,14.99,39.4668,,14.99,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.39,30,,11.39,percent of total billed charges,"Drugs, Inpatient Only",11.39,30,,11.39,percent of total billed charges,"Drugs, Inpatient Only",11.39,30,,11.39,percent of total billed charges,"Drugs, Inpatient Only",18.99,50,,18.99,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.37,,,4.37,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,26.59,70,,26.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.35,,,2.35,Other,Drug Cost,2.35,,,2.35,Other,Drug Cost,2.35,,,2.35,Other,Drug Cost,2.35,,,2.35,Other,Drug Cost,2.35,,,2.35,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.35,,,2.35,Other,Drug Cost,5.29,,,5.29,Other,225% Medicaid APG methodology,3.29,,,3.29,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.35,,,2.35,Other,Drug Cost,2.35,,,2.35,Other,Drug Cost,2.94,,,2.94,Other,125% Medicaid APG methodology,0.01,26.59,
ZOLPIDEM 5 MG TAB               ,,,,40509358,CDM,250,RC,00904-6082-61,NDC,both,1,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.11,50,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.15,
ZOLPIDEM 10 MG TAB              ,,,,40509366,CDM,250,RC,63739-0526-10,NDC,both,1,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.11,50,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.15,
URSODIOL 300 MG CAP             ,,,,40509465,CDM,250,RC,51224-0151-50,NDC,both,1,EA,15.19,6,39.4668,,6,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.56,30,,4.56,percent of total billed charges,"Drugs, Inpatient Only",4.56,30,,4.56,percent of total billed charges,"Drugs, Inpatient Only",4.56,30,,4.56,percent of total billed charges,"Drugs, Inpatient Only",7.6,50,,7.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.93,,,0.93,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.63,70,,10.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.5,,,0.5,Other,Drug Cost,1.13,,,1.13,Other,225% Medicaid APG methodology,0.7,,,0.7,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.63,,,0.63,Other,125% Medicaid APG methodology,0.01,10.63,
DISOPYRAMIDE 100 MG CAP         ,,,,40509564,CDM,250,RC,59762-0386-01,NDC,both,1,EA,6.48,2.56,39.4668,,2.56,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.94,30,,1.94,percent of total billed charges,"Drugs, Inpatient Only",1.94,30,,1.94,percent of total billed charges,"Drugs, Inpatient Only",1.94,30,,1.94,percent of total billed charges,"Drugs, Inpatient Only",3.24,50,,3.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.63,,,0.63,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.54,70,,4.54,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.34,,,0.34,Other,Drug Cost,0.77,,,0.77,Other,225% Medicaid APG methodology,0.48,,,0.48,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.43,,,0.43,Other,125% Medicaid APG methodology,0.01,4.54,
DISOPYRAMIDE 150 MG CAP         ,,,,40509572,CDM,250,RC,00093-3129-01,NDC,both,1,EA,4.13,1.63,39.4668,,1.63,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.24,30,,1.24,percent of total billed charges,"Drugs, Inpatient Only",1.24,30,,1.24,percent of total billed charges,"Drugs, Inpatient Only",1.24,30,,1.24,percent of total billed charges,"Drugs, Inpatient Only",2.07,50,,2.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.89,70,,2.89,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,Drug Cost,0.34,,,0.34,Other,225% Medicaid APG methodology,0.21,,,0.21,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.19,,,0.19,Other,125% Medicaid APG methodology,0.01,2.89,
HYDRALAZINE 10 MG TAB           ,,,,40509630,CDM,250,RC,00904-6440-61,NDC,both,1,EA,0.35,0.14,39.4668,,0.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.18,50,,0.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,70,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.25,
HYDRALAZINE 25 MG TAB           ,,,,40509655,CDM,250,RC,60687-0822-01,NDC,both,1,EA,0.56,0.22,39.4668,,0.22,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.28,50,,0.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.33,,,0.33,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.39,70,,0.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.18,,,0.18,Other,Drug Cost,0.41,,,0.41,Other,225% Medicaid APG methodology,0.25,,,0.25,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.23,,,0.23,Other,125% Medicaid APG methodology,0.01,0.41,
HYDRALAZINE 50 MG TAB           ,,,,40509663,CDM,250,RC,60687-0833-01,NDC,both,1,EA,0.77,0.3,39.4668,,0.3,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.23,30,,0.23,percent of total billed charges,"Drugs, Inpatient Only",0.23,30,,0.23,percent of total billed charges,"Drugs, Inpatient Only",0.23,30,,0.23,percent of total billed charges,"Drugs, Inpatient Only",0.39,50,,0.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.43,,,0.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.54,70,,0.54,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.23,,,0.23,Other,Drug Cost,0.52,,,0.52,Other,225% Medicaid APG methodology,0.32,,,0.32,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.29,,,0.29,Other,125% Medicaid APG methodology,0.01,0.54,
PRAZOSIN 1 MG CAP               ,,,,40509671,CDM,250,RC,70377-0066-11,NDC,both,1,EA,0.67,0.26,39.4668,,0.26,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,30,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.2,30,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.2,30,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.34,50,,0.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.47,70,,0.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.47,
DIAZOXIDE 50MG/ML ORLSUSP 30ML  ,,,,40509721,CDM,250,RC,00254-1010-19,NDC,both,30,ML,817.04,322.46,39.4668,,322.46,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,245.11,30,,245.11,percent of total billed charges,"Drugs, Inpatient Only",245.11,30,,245.11,percent of total billed charges,"Drugs, Inpatient Only",245.11,30,,245.11,percent of total billed charges,"Drugs, Inpatient Only",408.52,50,,408.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,284.23,,,284.23,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,571.93,70,,571.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,152.81,,,152.81,Other,Drug Cost,152.81,,,152.81,Other,Drug Cost,152.81,,,152.81,Other,Drug Cost,152.81,,,152.81,Other,Drug Cost,152.81,,,152.81,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,152.81,,,152.81,Other,Drug Cost,343.82,,,343.82,Other,225% Medicaid APG methodology,213.93,,,213.93,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,152.81,,,152.81,Other,Drug Cost,152.81,,,152.81,Other,Drug Cost,191.01,,,191.01,Other,125% Medicaid APG methodology,0.01,571.93,
MINOXIDIL 10 MG TAB             ,,,,40509739,CDM,250,RC,49884-0257-01,NDC,both,1,EA,1.47,0.58,39.4668,,0.58,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.44,30,,0.44,percent of total billed charges,"Drugs, Inpatient Only",0.44,30,,0.44,percent of total billed charges,"Drugs, Inpatient Only",0.44,30,,0.44,percent of total billed charges,"Drugs, Inpatient Only",0.74,50,,0.74,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.03,70,,1.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,1.03,
MINOXIDIL 2.5 MG TAB            ,,,,40509747,CDM,250,RC,68084-0204-01,NDC,both,1,EA,1.61,0.64,39.4668,,0.64,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.48,30,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.48,30,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.48,30,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.81,50,,0.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.35,,,0.35,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.13,70,,1.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,Drug Cost,0.43,,,0.43,Other,225% Medicaid APG methodology,0.27,,,0.27,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.24,,,0.24,Other,125% Medicaid APG methodology,0.01,1.13,
CLONIDINE 0.1 MG TAB            ,,,,40509788,CDM,250,RC,50268-0192-15,NDC,both,1,EA,1.05,0.41,39.4668,,0.41,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.32,30,,0.32,percent of total billed charges,"Drugs, Inpatient Only",0.32,30,,0.32,percent of total billed charges,"Drugs, Inpatient Only",0.32,30,,0.32,percent of total billed charges,"Drugs, Inpatient Only",0.53,50,,0.53,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.74,70,,0.74,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.74,
CLONIDINE 0.2 MG TAB            ,,,,40509796,CDM,250,RC,00228-2128-10,NDC,both,1,EA,0.14,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.07,50,,0.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.1,
CAPTOPRIL 25 MG TAB             ,,,,40509853,CDM,250,RC,00904-7106-61,NDC,both,1,EA,4.24,1.67,39.4668,,1.67,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.27,30,,1.27,percent of total billed charges,"Drugs, Inpatient Only",1.27,30,,1.27,percent of total billed charges,"Drugs, Inpatient Only",1.27,30,,1.27,percent of total billed charges,"Drugs, Inpatient Only",2.12,50,,2.12,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.12,,,2.12,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.97,70,,2.97,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.14,,,1.14,Other,Drug Cost,2.57,,,2.57,Other,225% Medicaid APG methodology,1.6,,,1.6,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,1.43,,,1.43,Other,125% Medicaid APG methodology,0.01,2.97,
CAPTOPRIL 12.5 MG TAB           ,,,,40509879,CDM,250,RC,60687-0304-21,NDC,both,1,EA,3.4,1.34,39.4668,,1.34,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.02,30,,1.02,percent of total billed charges,"Drugs, Inpatient Only",1.02,30,,1.02,percent of total billed charges,"Drugs, Inpatient Only",1.02,30,,1.02,percent of total billed charges,"Drugs, Inpatient Only",1.7,50,,1.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.47,,,0.47,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.38,70,,2.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.56,,,0.56,Other,225% Medicaid APG methodology,0.35,,,0.35,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.31,,,0.31,Other,125% Medicaid APG methodology,0.01,2.38,
CARVEDILOL 25 MG TAB            ,,,,40509895,CDM,250,RC,00904-6303-61,NDC,both,1,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.11,50,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.15,
CARVEDILOL 6.25 MG TAB          ,,,,40509903,CDM,250,RC,00904-6301-61,NDC,both,1,EA,0.28,0.11,39.4668,,0.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.14,50,,0.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,70,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.2,
FLECAINIDE 50 MG TAB            ,,,,40509929,CDM,250,RC,00054-0010-20,NDC,both,1,EA,1.82,0.72,39.4668,,0.72,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.55,30,,0.55,percent of total billed charges,"Drugs, Inpatient Only",0.55,30,,0.55,percent of total billed charges,"Drugs, Inpatient Only",0.55,30,,0.55,percent of total billed charges,"Drugs, Inpatient Only",0.91,50,,0.91,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.27,70,,1.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,1.27,
VERAPAMIL 2.5MG/ML IV SOLN 2ML  ,,,,40509937,CDM,250,RC,00409-4011-01,NDC,both,2,ML,51.1,20.17,39.4668,,20.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.33,30,,15.33,percent of total billed charges,"Drugs, Inpatient Only",15.33,30,,15.33,percent of total billed charges,"Drugs, Inpatient Only",15.33,30,,15.33,percent of total billed charges,"Drugs, Inpatient Only",25.55,50,,25.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,22.06,,,22.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,35.77,70,,35.77,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.86,,,11.86,Other,Drug Cost,11.86,,,11.86,Other,Drug Cost,11.86,,,11.86,Other,Drug Cost,11.86,,,11.86,Other,Drug Cost,11.86,,,11.86,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,11.86,,,11.86,Other,Drug Cost,26.69,,,26.69,Other,225% Medicaid APG methodology,16.6,,,16.6,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,11.86,,,11.86,Other,Drug Cost,11.86,,,11.86,Other,Drug Cost,14.83,,,14.83,Other,125% Medicaid APG methodology,0.01,35.77,
NITROGLYCERIN 5MG/ML IV  10ML   ,,,,40509960,CDM,250,RC,00517-4810-25,NDC,both,10,ML,35.35,13.95,39.4668,,13.95,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.61,30,,10.61,percent of total billed charges,"Drugs, Inpatient Only",10.61,30,,10.61,percent of total billed charges,"Drugs, Inpatient Only",10.61,30,,10.61,percent of total billed charges,"Drugs, Inpatient Only",17.68,50,,17.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.86,,,9.86,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,24.75,70,,24.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.3,,,5.3,Other,Drug Cost,5.3,,,5.3,Other,Drug Cost,5.3,,,5.3,Other,Drug Cost,5.3,,,5.3,Other,Drug Cost,5.3,,,5.3,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,5.3,,,5.3,Other,Drug Cost,11.93,,,11.93,Other,225% Medicaid APG methodology,7.42,,,7.42,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.3,,,5.3,Other,Drug Cost,5.3,,,5.3,Other,Drug Cost,6.63,,,6.63,Other,125% Medicaid APG methodology,0.01,24.75,
SOD POLYSTYREN SULFON 15G 60ML  ,,,,40509978,CDM,250,RC,62559-0356-01,NDC,both,60,ML,80.57,31.8,39.4668,,31.8,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,24.17,30,,24.17,percent of total billed charges,"Drugs, Inpatient Only",24.17,30,,24.17,percent of total billed charges,"Drugs, Inpatient Only",24.17,30,,24.17,percent of total billed charges,"Drugs, Inpatient Only",40.29,50,,40.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,32.07,,,32.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,56.4,70,,56.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,17.24,,,17.24,Other,Drug Cost,17.24,,,17.24,Other,Drug Cost,17.24,,,17.24,Other,Drug Cost,17.24,,,17.24,Other,Drug Cost,17.24,,,17.24,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,17.24,,,17.24,Other,Drug Cost,38.79,,,38.79,Other,225% Medicaid APG methodology,24.14,,,24.14,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,17.24,,,17.24,Other,Drug Cost,17.24,,,17.24,Other,Drug Cost,21.55,,,21.55,Other,125% Medicaid APG methodology,0.01,56.4,
NITROGLYCERIN 0.4MG/HR TD ER    ,,,,40510000,CDM,250,RC,68382-0310-30,NDC,both,1,EA,1.4,0.55,39.4668,,0.55,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.42,30,,0.42,percent of total billed charges,"Drugs, Inpatient Only",0.42,30,,0.42,percent of total billed charges,"Drugs, Inpatient Only",0.42,30,,0.42,percent of total billed charges,"Drugs, Inpatient Only",0.7,50,,0.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,,,0.37,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.98,70,,0.98,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.45,,,0.45,Other,225% Medicaid APG methodology,0.28,,,0.28,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.25,,,0.25,Other,125% Medicaid APG methodology,0.01,0.98,
NITROGLYCERIN 0.1MG/HR TD ER    ,,,,40510018,CDM,250,RC,00378-9102-93,NDC,both,1,EA,1.72,0.68,39.4668,,0.68,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.52,30,,0.52,percent of total billed charges,"Drugs, Inpatient Only",0.52,30,,0.52,percent of total billed charges,"Drugs, Inpatient Only",0.52,30,,0.52,percent of total billed charges,"Drugs, Inpatient Only",0.86,50,,0.86,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.48,,,0.48,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.2,70,,1.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,Drug Cost,0.59,,,0.59,Other,225% Medicaid APG methodology,0.36,,,0.36,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.33,,,0.33,Other,125% Medicaid APG methodology,0.01,1.2,
NITROGLYCERIN 0.2MG/HR TD ER    ,,,,40510034,CDM,250,RC,00378-9104-93,NDC,both,1,EA,1.93,0.76,39.4668,,0.76,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.58,30,,0.58,percent of total billed charges,"Drugs, Inpatient Only",0.58,30,,0.58,percent of total billed charges,"Drugs, Inpatient Only",0.58,30,,0.58,percent of total billed charges,"Drugs, Inpatient Only",0.97,50,,0.97,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.47,,,0.47,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.35,70,,1.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.56,,,0.56,Other,225% Medicaid APG methodology,0.35,,,0.35,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.31,,,0.31,Other,125% Medicaid APG methodology,0.01,1.35,
NITROGLYCERIN 0.4 MG SL TAB     ,,,,40510059,CDM,250,RC,43598-0436-11,NDC,both,25,EA,70.35,27.76,39.4668,,27.76,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,21.11,30,,21.11,percent of total billed charges,"Drugs, Inpatient Only",21.11,30,,21.11,percent of total billed charges,"Drugs, Inpatient Only",21.11,30,,21.11,percent of total billed charges,"Drugs, Inpatient Only",35.18,50,,35.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.05,,,6.05,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,49.25,70,,49.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.25,,,3.25,Other,Drug Cost,3.25,,,3.25,Other,Drug Cost,3.25,,,3.25,Other,Drug Cost,3.25,,,3.25,Other,Drug Cost,3.25,,,3.25,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.25,,,3.25,Other,Drug Cost,7.31,,,7.31,Other,225% Medicaid APG methodology,4.55,,,4.55,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.25,,,3.25,Other,Drug Cost,3.25,,,3.25,Other,Drug Cost,4.06,,,4.06,Other,125% Medicaid APG methodology,0.01,49.25,
ISOSORBIDE DINITRATE 10 MG TAB  ,,,,40510091,CDM,250,RC,63739-0569-10,NDC,both,1,EA,1.75,0.69,39.4668,,0.69,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.53,30,,0.53,percent of total billed charges,"Drugs, Inpatient Only",0.53,30,,0.53,percent of total billed charges,"Drugs, Inpatient Only",0.53,30,,0.53,percent of total billed charges,"Drugs, Inpatient Only",0.88,50,,0.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.87,,,0.87,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.23,70,,1.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.47,,,0.47,Other,Drug Cost,1.06,,,1.06,Other,225% Medicaid APG methodology,0.66,,,0.66,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.59,,,0.59,Other,125% Medicaid APG methodology,0.01,1.23,
ISOSORBIDE DINITRATE 20 MG TAB  ,,,,40510117,CDM,250,RC,50268-0449-15,NDC,both,1,EA,3.15,1.24,39.4668,,1.24,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.95,30,,0.95,percent of total billed charges,"Drugs, Inpatient Only",0.95,30,,0.95,percent of total billed charges,"Drugs, Inpatient Only",0.95,30,,0.95,percent of total billed charges,"Drugs, Inpatient Only",1.58,50,,1.58,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.15,,,1.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.21,70,,2.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.62,,,0.62,Other,Drug Cost,1.4,,,1.4,Other,225% Medicaid APG methodology,0.87,,,0.87,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.78,,,0.78,Other,125% Medicaid APG methodology,0.01,2.21,
DIPYRIDAMOLE 25 MG TAB          ,,,,40510125,CDM,250,RC,64980-0133-01,NDC,both,1,EA,3.64,1.44,39.4668,,1.44,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.09,30,,1.09,percent of total billed charges,"Drugs, Inpatient Only",1.09,30,,1.09,percent of total billed charges,"Drugs, Inpatient Only",1.09,30,,1.09,percent of total billed charges,"Drugs, Inpatient Only",1.82,50,,1.82,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.55,70,,2.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,2.55,
VERAPAMIL 120 MG TAB            ,,,,40510208,CDM,250,RC,00904-2924-61,NDC,both,1,EA,0.28,0.11,39.4668,,0.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.14,50,,0.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,70,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% Medicaid APG methodology,0.1,,,0.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.2,
VERAPAMIL 80 MG TAB             ,,,,40510216,CDM,250,RC,00904-2920-61,NDC,both,1,EA,0.25,0.1,39.4668,,0.1,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.13,50,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.18,70,,0.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.18,
NIFEDIPINE 10 MG CAP            ,,,,40510224,CDM,250,RC,43386-0440-24,NDC,both,1,EA,1.23,0.49,39.4668,,0.49,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,30,,0.37,percent of total billed charges,"Drugs, Inpatient Only",0.37,30,,0.37,percent of total billed charges,"Drugs, Inpatient Only",0.37,30,,0.37,percent of total billed charges,"Drugs, Inpatient Only",0.62,50,,0.62,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.35,,,0.35,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.86,70,,0.86,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,Drug Cost,0.43,,,0.43,Other,225% Medicaid APG methodology,0.27,,,0.27,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.24,,,0.24,Other,125% Medicaid APG methodology,0.01,0.86,
DILTIAZEM 30 MG TAB             ,,,,40510232,CDM,250,RC,00093-0318-01,NDC,both,1,EA,0.32,0.13,39.4668,,0.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.16,50,,0.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,70,,0.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.22,
DILTIAZEM 60 MG TAB             ,,,,40510240,CDM,250,RC,00093-0319-01,NDC,both,1,EA,0.53,0.21,39.4668,,0.21,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.27,50,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,70,,0.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.37,
SOD CHL 0.9% INH SLN 3ML        ,,,,40510257,CDM,250,RC,76204-0300-03,NDC,both,3,ML,0.42,0.17,39.4668,,0.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.21,50,,0.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,70,,0.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.23,,,0.23,Other,225% Medicaid APG methodology,0.14,,,0.14,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.13,,,0.13,Other,125% Medicaid APG methodology,0.01,0.29,
NIMODIPINE 30 MG CAP            ,,,,40510315,CDM,250,RC,69452-0209-13,NDC,both,1,EA,9.35,3.69,39.4668,,3.69,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.81,30,,2.81,percent of total billed charges,"Drugs, Inpatient Only",2.81,30,,2.81,percent of total billed charges,"Drugs, Inpatient Only",2.81,30,,2.81,percent of total billed charges,"Drugs, Inpatient Only",4.68,50,,4.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.02,,,1.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.55,70,,6.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.55,,,0.55,Other,Drug Cost,0.55,,,0.55,Other,Drug Cost,0.55,,,0.55,Other,Drug Cost,0.55,,,0.55,Other,Drug Cost,0.55,,,0.55,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.55,,,0.55,Other,Drug Cost,1.24,,,1.24,Other,225% Medicaid APG methodology,0.77,,,0.77,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.55,,,0.55,Other,Drug Cost,0.55,,,0.55,Other,Drug Cost,0.69,,,0.69,Other,125% Medicaid APG methodology,0.01,6.55,
GUAIFENESIN 200MG ORLIQ 10ML    ,,,,40510349,CDM,250,RC,50383-0063-12,NDC,both,10,ML,1.75,0.69,39.4668,,0.69,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.53,30,,0.53,percent of total billed charges,"Drugs, Inpatient Only",0.53,30,,0.53,percent of total billed charges,"Drugs, Inpatient Only",0.53,30,,0.53,percent of total billed charges,"Drugs, Inpatient Only",0.88,50,,0.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,,,0.37,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.23,70,,1.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.45,,,0.45,Other,225% Medicaid APG methodology,0.28,,,0.28,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.25,,,0.25,Other,125% Medicaid APG methodology,0.01,1.23,
STERILE WATER INJ SOLN 2000 ML  ,,,,40510380,CDM,250,RC,00338-0013-06,NDC,both,2000,ML,18.06,7.13,39.4668,,7.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.42,30,,5.42,percent of total billed charges,"Drugs, Inpatient Only",5.42,30,,5.42,percent of total billed charges,"Drugs, Inpatient Only",5.42,30,,5.42,percent of total billed charges,"Drugs, Inpatient Only",9.03,50,,9.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.86,,,9.86,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.64,70,,12.64,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.3,,,5.3,Other,Drug Cost,5.3,,,5.3,Other,Drug Cost,5.3,,,5.3,Other,Drug Cost,5.3,,,5.3,Other,Drug Cost,5.3,,,5.3,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,5.3,,,5.3,Other,Drug Cost,11.93,,,11.93,Other,225% Medicaid APG methodology,7.42,,,7.42,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.3,,,5.3,Other,Drug Cost,5.3,,,5.3,Other,Drug Cost,6.63,,,6.63,Other,125% Medicaid APG methodology,0.01,12.64,
SODIUM BICARB 8.4% IV SLN 10ML  ,,,,40510414,CDM,250,RC,00409-4900-14,NDC,both,10,ML,404.43,159.62,39.4668,,159.62,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,121.33,30,,121.33,percent of total billed charges,"Drugs, Inpatient Only",121.33,30,,121.33,percent of total billed charges,"Drugs, Inpatient Only",121.33,30,,121.33,percent of total billed charges,"Drugs, Inpatient Only",202.22,50,,202.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,156.78,,,156.78,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,283.1,70,,283.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,84.29,,,84.29,Other,Drug Cost,84.29,,,84.29,Other,Drug Cost,84.29,,,84.29,Other,Drug Cost,84.29,,,84.29,Other,Drug Cost,84.29,,,84.29,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,84.29,,,84.29,Other,Drug Cost,189.65,,,189.65,Other,225% Medicaid APG methodology,118.01,,,118.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,84.29,,,84.29,Other,Drug Cost,84.29,,,84.29,Other,Drug Cost,105.36,,,105.36,Other,125% Medicaid APG methodology,0.01,283.1,
SOD BICARB 8.4% IV  50ML VIAL   ,,,,40510422,CDM,250,RC,51754-5001-04,NDC,both,50,ML,17.89,7.06,39.4668,,7.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.37,30,,5.37,percent of total billed charges,"Drugs, Inpatient Only",5.37,30,,5.37,percent of total billed charges,"Drugs, Inpatient Only",5.37,30,,5.37,percent of total billed charges,"Drugs, Inpatient Only",8.95,50,,8.95,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.97,,,8.97,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.52,70,,12.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.82,,,4.82,Other,Drug Cost,4.82,,,4.82,Other,Drug Cost,4.82,,,4.82,Other,Drug Cost,4.82,,,4.82,Other,Drug Cost,4.82,,,4.82,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.82,,,4.82,Other,Drug Cost,10.85,,,10.85,Other,225% Medicaid APG methodology,6.75,,,6.75,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.82,,,4.82,Other,Drug Cost,4.82,,,4.82,Other,Drug Cost,6.03,,,6.03,Other,125% Medicaid APG methodology,0.01,12.52,
BERACTANT25MG/ML INTRACHEAL8ML  ,,,,40510455,CDM,250,RC,00074-1040-08,NDC,both,8,ML,1570.52,619.83,39.4668,,619.83,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,471.16,30,,471.16,percent of total billed charges,"Drugs, Inpatient Only",471.16,30,,471.16,percent of total billed charges,"Drugs, Inpatient Only",471.16,30,,471.16,percent of total billed charges,"Drugs, Inpatient Only",785.26,50,,785.26,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,648.77,,,648.77,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1099.36,70,,1099.36,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,348.8,,,348.8,Other,Drug Cost,348.8,,,348.8,Other,Drug Cost,348.8,,,348.8,Other,Drug Cost,348.8,,,348.8,Other,Drug Cost,348.8,,,348.8,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,348.8,,,348.8,Other,Drug Cost,784.8,,,784.8,Other,225% Medicaid APG methodology,488.32,,,488.32,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,348.8,,,348.8,Other,Drug Cost,348.8,,,348.8,Other,Drug Cost,436,,,436,Other,125% Medicaid APG methodology,0.01,1099.36,
SOD ACE 2 MEQ/ML IV SLN 20ML    ,,,,40510471,CDM,250,RC,00409-7299-25,NDC,both,20,ML,9.8,3.87,39.4668,,3.87,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.94,30,,2.94,percent of total billed charges,"Drugs, Inpatient Only",2.94,30,,2.94,percent of total billed charges,"Drugs, Inpatient Only",2.94,30,,2.94,percent of total billed charges,"Drugs, Inpatient Only",4.9,50,,4.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.21,,,5.21,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.86,70,,6.86,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.8,,,2.8,Other,Drug Cost,2.8,,,2.8,Other,Drug Cost,2.8,,,2.8,Other,Drug Cost,2.8,,,2.8,Other,Drug Cost,2.8,,,2.8,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.8,,,2.8,Other,Drug Cost,6.3,,,6.3,Other,225% Medicaid APG methodology,3.92,,,3.92,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.8,,,2.8,Other,Drug Cost,2.8,,,2.8,Other,Drug Cost,3.5,,,3.5,Other,125% Medicaid APG methodology,0.01,6.86,
SOD CHL 0.45% IV SLN 1000ML     ,,,,40510505,CDM,250,RC,00409-7985-09,NDC,both,1000,ML,18.38,7.25,39.4668,,7.25,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.51,30,,5.51,percent of total billed charges,"Drugs, Inpatient Only",5.51,30,,5.51,percent of total billed charges,"Drugs, Inpatient Only",5.51,30,,5.51,percent of total billed charges,"Drugs, Inpatient Only",9.19,50,,9.19,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.77,,,9.77,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.87,70,,12.87,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.25,,,5.25,Other,Drug Cost,5.25,,,5.25,Other,Drug Cost,5.25,,,5.25,Other,Drug Cost,5.25,,,5.25,Other,Drug Cost,5.25,,,5.25,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,5.25,,,5.25,Other,Drug Cost,11.81,,,11.81,Other,225% Medicaid APG methodology,7.35,,,7.35,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.25,,,5.25,Other,Drug Cost,5.25,,,5.25,Other,Drug Cost,6.56,,,6.56,Other,125% Medicaid APG methodology,0.01,12.87,
SOD CHL 0.9% IV SLN 250ML       ,,,,40510521,CDM,250,RC,00338-0049-02,NDC,both,250,ML,8.75,3.45,39.4668,,3.45,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.63,30,,2.63,percent of total billed charges,"Drugs, Inpatient Only",2.63,30,,2.63,percent of total billed charges,"Drugs, Inpatient Only",2.63,30,,2.63,percent of total billed charges,"Drugs, Inpatient Only",4.38,50,,4.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.65,,,4.65,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.13,70,,6.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.5,,,2.5,Other,Drug Cost,5.63,,,5.63,Other,225% Medicaid APG methodology,3.5,,,3.5,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,3.13,,,3.13,Other,125% Medicaid APG methodology,0.01,6.13,
SOD CHL 0.9% IV SLN 100ML       ,,,,40510539,CDM,250,RC,00338-0049-18,NDC,both,100,ML,7,2.76,39.4668,,2.76,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.1,30,,2.1,percent of total billed charges,"Drugs, Inpatient Only",2.1,30,,2.1,percent of total billed charges,"Drugs, Inpatient Only",2.1,30,,2.1,percent of total billed charges,"Drugs, Inpatient Only",3.5,50,,3.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.72,,,3.72,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.9,70,,4.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2,,,2,Other,Drug Cost,4.5,,,4.5,Other,225% Medicaid APG methodology,2.8,,,2.8,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,2.5,,,2.5,Other,125% Medicaid APG methodology,0.01,4.9,
SOD CHL 0.9% IV SLN 500ML       ,,,,40510547,CDM,250,RC,00338-0049-03,NDC,both,500,ML,5.25,2.07,39.4668,,2.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.58,30,,1.58,percent of total billed charges,"Drugs, Inpatient Only",1.58,30,,1.58,percent of total billed charges,"Drugs, Inpatient Only",1.58,30,,1.58,percent of total billed charges,"Drugs, Inpatient Only",2.63,50,,2.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.79,,,2.79,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.68,70,,3.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.5,,,1.5,Other,Drug Cost,3.38,,,3.38,Other,225% Medicaid APG methodology,2.1,,,2.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.88,,,1.88,Other,125% Medicaid APG methodology,0.01,3.68,
SOD CHL 0.9% PF IV SLN 50ML     ,,,,40510554,CDM,250,RC,00338-0049-11,NDC,both,50,ML,5.25,2.07,39.4668,,2.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.58,30,,1.58,percent of total billed charges,"Drugs, Inpatient Only",1.58,30,,1.58,percent of total billed charges,"Drugs, Inpatient Only",1.58,30,,1.58,percent of total billed charges,"Drugs, Inpatient Only",2.63,50,,2.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.79,,,2.79,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.68,70,,3.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.5,,,1.5,Other,Drug Cost,3.38,,,3.38,Other,225% Medicaid APG methodology,2.1,,,2.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.88,,,1.88,Other,125% Medicaid APG methodology,0.01,3.68,
SOD CHL 0.9% MEDICATION BOLUS   ,,,,40510562,CDM,250,RC,00338-0049-04,NDC,both,1000,ML,8.05,3.18,39.4668,,3.18,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.42,30,,2.42,percent of total billed charges,"Drugs, Inpatient Only",2.42,30,,2.42,percent of total billed charges,"Drugs, Inpatient Only",2.42,30,,2.42,percent of total billed charges,"Drugs, Inpatient Only",4.03,50,,4.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.14,,,7.14,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.64,70,,5.64,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.84,,,3.84,Other,Drug Cost,3.84,,,3.84,Other,Drug Cost,3.84,,,3.84,Other,Drug Cost,3.84,,,3.84,Other,Drug Cost,3.84,,,3.84,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.84,,,3.84,Other,Drug Cost,8.64,,,8.64,Other,225% Medicaid APG methodology,5.38,,,5.38,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.84,,,3.84,Other,Drug Cost,3.84,,,3.84,Other,Drug Cost,4.8,,,4.8,Other,125% Medicaid APG methodology,0.01,8.64,
SOD CHL 3% IV SLN 500ML         ,,,,40510588,CDM,250,RC,00338-0054-03,NDC,both,500,ML,10.82,4.27,39.4668,,4.27,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.25,30,,3.25,percent of total billed charges,"Drugs, Inpatient Only",3.25,30,,3.25,percent of total billed charges,"Drugs, Inpatient Only",3.25,30,,3.25,percent of total billed charges,"Drugs, Inpatient Only",5.41,50,,5.41,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.46,,,8.46,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.57,70,,7.57,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.55,,,4.55,Other,Drug Cost,4.55,,,4.55,Other,Drug Cost,4.55,,,4.55,Other,Drug Cost,4.55,,,4.55,Other,Drug Cost,4.55,,,4.55,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.55,,,4.55,Other,Drug Cost,10.24,,,10.24,Other,225% Medicaid APG methodology,6.37,,,6.37,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.55,,,4.55,Other,Drug Cost,4.55,,,4.55,Other,Drug Cost,5.69,,,5.69,Other,125% Medicaid APG methodology,0.01,10.24,
SOD CHL 0.9% MINIBAG 50ML       ,,,,40510596,CDM,250,RC,00338-9151-30,NDC,both,50,ML,11.24,4.44,39.4668,,4.44,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.37,30,,3.37,percent of total billed charges,"Drugs, Inpatient Only",3.37,30,,3.37,percent of total billed charges,"Drugs, Inpatient Only",3.37,30,,3.37,percent of total billed charges,"Drugs, Inpatient Only",5.62,50,,5.62,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.23,,,2.23,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.87,70,,7.87,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.2,,,1.2,Other,Drug Cost,2.7,,,2.7,Other,225% Medicaid APG methodology,1.68,,,1.68,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,1.5,,,1.5,Other,125% Medicaid APG methodology,0.01,7.87,
SOD CHL 0.9% PF INJ SLN 10ML    ,,,,40510638,CDM,250,RC,00409-4888-10,NDC,both,10,ML,1.75,0.69,39.4668,,0.69,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.53,30,,0.53,percent of total billed charges,"Drugs, Inpatient Only",0.53,30,,0.53,percent of total billed charges,"Drugs, Inpatient Only",0.53,30,,0.53,percent of total billed charges,"Drugs, Inpatient Only",0.88,50,,0.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.74,,,0.74,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.23,70,,1.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.4,,,0.4,Other,Drug Cost,0.4,,,0.4,Other,Drug Cost,0.4,,,0.4,Other,Drug Cost,0.4,,,0.4,Other,Drug Cost,0.4,,,0.4,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.4,,,0.4,Other,Drug Cost,0.9,,,0.9,Other,225% Medicaid APG methodology,0.56,,,0.56,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.4,,,0.4,Other,Drug Cost,0.4,,,0.4,Other,Drug Cost,0.5,,,0.5,Other,125% Medicaid APG methodology,0.01,1.23,
SODIUM CHLORIDE 1000 MG TAB     ,,,,40510653,CDM,250,RC,48433-0128-01,NDC,both,1,EA,0.88,0.35,39.4668,,0.35,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.26,30,,0.26,percent of total billed charges,"Drugs, Inpatient Only",0.26,30,,0.26,percent of total billed charges,"Drugs, Inpatient Only",0.26,30,,0.26,percent of total billed charges,"Drugs, Inpatient Only",0.44,50,,0.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.47,,,0.47,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.62,70,,0.62,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.56,,,0.56,Other,225% Medicaid APG methodology,0.35,,,0.35,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.31,,,0.31,Other,125% Medicaid APG methodology,0.01,0.62,
SOD PHOS 3 MML/ML INJ SLN 15ML  ,,,,40510661,CDM,250,RC,63323-0170-15,NDC,both,15,ML,73.5,29.01,39.4668,,29.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,22.05,30,,22.05,percent of total billed charges,"Drugs, Inpatient Only",22.05,30,,22.05,percent of total billed charges,"Drugs, Inpatient Only",22.05,30,,22.05,percent of total billed charges,"Drugs, Inpatient Only",36.75,50,,36.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,28.46,,,28.46,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,51.45,70,,51.45,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.3,,,15.3,Other,Drug Cost,15.3,,,15.3,Other,Drug Cost,15.3,,,15.3,Other,Drug Cost,15.3,,,15.3,Other,Drug Cost,15.3,,,15.3,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,15.3,,,15.3,Other,Drug Cost,34.43,,,34.43,Other,225% Medicaid APG methodology,21.42,,,21.42,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,15.3,,,15.3,Other,Drug Cost,15.3,,,15.3,Other,Drug Cost,19.13,,,19.13,Other,125% Medicaid APG methodology,0.01,51.45,
POT ACE 2 MEQ/ML IV SLN 20ML    ,,,,40510679,CDM,250,RC,00409-8183-01,NDC,both,20,ML,9.84,3.88,39.4668,,3.88,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.95,30,,2.95,percent of total billed charges,"Drugs, Inpatient Only",2.95,30,,2.95,percent of total billed charges,"Drugs, Inpatient Only",2.95,30,,2.95,percent of total billed charges,"Drugs, Inpatient Only",4.92,50,,4.92,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.83,,,3.83,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.89,70,,6.89,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.06,,,2.06,Other,Drug Cost,2.06,,,2.06,Other,Drug Cost,2.06,,,2.06,Other,Drug Cost,2.06,,,2.06,Other,Drug Cost,2.06,,,2.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.06,,,2.06,Other,Drug Cost,4.64,,,4.64,Other,225% Medicaid APG methodology,2.88,,,2.88,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.06,,,2.06,Other,Drug Cost,2.06,,,2.06,Other,Drug Cost,2.58,,,2.58,Other,125% Medicaid APG methodology,0.01,6.89,
POT CL 20 MEQ ORL POW           ,,,,40510778,CDM,250,RC,00603-1554-04,NDC,both,1,EA,12.22,4.82,39.4668,,4.82,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.67,30,,3.67,percent of total billed charges,"Drugs, Inpatient Only",3.67,30,,3.67,percent of total billed charges,"Drugs, Inpatient Only",3.67,30,,3.67,percent of total billed charges,"Drugs, Inpatient Only",6.11,50,,6.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.25,,,2.25,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.55,70,,8.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.21,,,1.21,Other,Drug Cost,1.21,,,1.21,Other,Drug Cost,1.21,,,1.21,Other,Drug Cost,1.21,,,1.21,Other,Drug Cost,1.21,,,1.21,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.21,,,1.21,Other,Drug Cost,2.72,,,2.72,Other,225% Medicaid APG methodology,1.69,,,1.69,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.21,,,1.21,Other,Drug Cost,1.21,,,1.21,Other,Drug Cost,1.51,,,1.51,Other,125% Medicaid APG methodology,0.01,8.55,
NICOTINE 7 MG/24 HR TD ER FILM  ,,,,40510786,CDM,250,RC,00536-5894-53,NDC,both,1,EA,5.29,2.09,39.4668,,2.09,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.59,30,,1.59,percent of total billed charges,"Drugs, Inpatient Only",1.59,30,,1.59,percent of total billed charges,"Drugs, Inpatient Only",1.59,30,,1.59,percent of total billed charges,"Drugs, Inpatient Only",2.65,50,,2.65,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.49,,,1.49,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.7,70,,3.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.8,,,0.8,Other,Drug Cost,1.8,,,1.8,Other,225% Medicaid APG methodology,1.12,,,1.12,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,1,,,1,Other,125% Medicaid APG methodology,0.01,3.7,
NICOTINE 14MG/24 HR TD ER FILM  ,,,,40510794,CDM,250,RC,00536-1107-88,NDC,both,1,EA,6.37,2.51,39.4668,,2.51,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.91,30,,1.91,percent of total billed charges,"Drugs, Inpatient Only",1.91,30,,1.91,percent of total billed charges,"Drugs, Inpatient Only",1.91,30,,1.91,percent of total billed charges,"Drugs, Inpatient Only",3.19,50,,3.19,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.67,,,1.67,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.46,70,,4.46,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.9,,,0.9,Other,Drug Cost,0.9,,,0.9,Other,Drug Cost,0.9,,,0.9,Other,Drug Cost,0.9,,,0.9,Other,Drug Cost,0.9,,,0.9,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.9,,,0.9,Other,Drug Cost,2.03,,,2.03,Other,225% Medicaid APG methodology,1.26,,,1.26,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.9,,,0.9,Other,Drug Cost,0.9,,,0.9,Other,Drug Cost,1.13,,,1.13,Other,125% Medicaid APG methodology,0.01,4.46,
NICOTINE 21MG/24 HR TD ER FILM  ,,,,40510802,CDM,250,RC,00536-1108-88,NDC,both,1,EA,6.37,2.51,39.4668,,2.51,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.91,30,,1.91,percent of total billed charges,"Drugs, Inpatient Only",1.91,30,,1.91,percent of total billed charges,"Drugs, Inpatient Only",1.91,30,,1.91,percent of total billed charges,"Drugs, Inpatient Only",3.19,50,,3.19,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.66,,,1.66,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.46,70,,4.46,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.89,,,0.89,Other,Drug Cost,0.89,,,0.89,Other,Drug Cost,0.89,,,0.89,Other,Drug Cost,0.89,,,0.89,Other,Drug Cost,0.89,,,0.89,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.89,,,0.89,Other,Drug Cost,2,,,2,Other,225% Medicaid APG methodology,1.25,,,1.25,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.89,,,0.89,Other,Drug Cost,0.89,,,0.89,Other,Drug Cost,1.11,,,1.11,Other,125% Medicaid APG methodology,0.01,4.46,
POT CL 10 MEQ ER TAB            ,,,,40510828,CDM,250,RC,00904-7292-61,NDC,both,1,EA,9.73,3.84,39.4668,,3.84,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.92,30,,2.92,percent of total billed charges,"Drugs, Inpatient Only",2.92,30,,2.92,percent of total billed charges,"Drugs, Inpatient Only",2.92,30,,2.92,percent of total billed charges,"Drugs, Inpatient Only",4.87,50,,4.87,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.26,,,5.26,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.81,70,,6.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.83,,,2.83,Other,Drug Cost,2.83,,,2.83,Other,Drug Cost,2.83,,,2.83,Other,Drug Cost,2.83,,,2.83,Other,Drug Cost,2.83,,,2.83,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.83,,,2.83,Other,Drug Cost,6.37,,,6.37,Other,225% Medicaid APG methodology,3.96,,,3.96,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.83,,,2.83,Other,Drug Cost,2.83,,,2.83,Other,Drug Cost,3.54,,,3.54,Other,125% Medicaid APG methodology,0.01,6.81,
POT PHOS 3 MMOL/ML IV SLN 15ML  ,,,,40510844,CDM,250,RC,63323-0086-15,NDC,both,15,ML,100.28,39.58,39.4668,,39.58,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,30.08,30,,30.08,percent of total billed charges,"Drugs, Inpatient Only",30.08,30,,30.08,percent of total billed charges,"Drugs, Inpatient Only",30.08,30,,30.08,percent of total billed charges,"Drugs, Inpatient Only",50.14,50,,50.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.9,,,15.9,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,70.2,70,,70.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.55,,,8.55,Other,Drug Cost,8.55,,,8.55,Other,Drug Cost,8.55,,,8.55,Other,Drug Cost,8.55,,,8.55,Other,Drug Cost,8.55,,,8.55,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,8.55,,,8.55,Other,Drug Cost,19.24,,,19.24,Other,225% Medicaid APG methodology,11.97,,,11.97,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,8.55,,,8.55,Other,Drug Cost,8.55,,,8.55,Other,Drug Cost,10.69,,,10.69,Other,125% Medicaid APG methodology,0.01,70.2,
METOCLOPRAMIDE 10MG/10ML SYR    ,,,,40510851,CDM,250,RC,00121-1576-10,NDC,both,10,ML,3.85,1.52,39.4668,,1.52,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.16,30,,1.16,percent of total billed charges,"Drugs, Inpatient Only",1.16,30,,1.16,percent of total billed charges,"Drugs, Inpatient Only",1.16,30,,1.16,percent of total billed charges,"Drugs, Inpatient Only",1.93,50,,1.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.56,,,0.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.7,70,,2.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.68,,,0.68,Other,225% Medicaid APG methodology,0.42,,,0.42,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.38,,,0.38,Other,125% Medicaid APG methodology,0.01,2.7,
CALCIUM CARBONATE 1.25 GM TAB   ,,,,40510869,CDM,250,RC,43292-0555-65,NDC,both,1,EA,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.04,50,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
CALCIUM CHLORIDE 1000MG SYR     ,,,,40510877,CDM,250,RC,76329-3304-01,NDC,both,10,ML,28,11.05,39.4668,,11.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.4,30,,8.4,percent of total billed charges,"Drugs, Inpatient Only",8.4,30,,8.4,percent of total billed charges,"Drugs, Inpatient Only",8.4,30,,8.4,percent of total billed charges,"Drugs, Inpatient Only",14,50,,14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.91,,,3.91,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.6,70,,19.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.1,,,2.1,Other,Drug Cost,2.1,,,2.1,Other,Drug Cost,2.1,,,2.1,Other,Drug Cost,2.1,,,2.1,Other,Drug Cost,2.1,,,2.1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.1,,,2.1,Other,Drug Cost,4.73,,,4.73,Other,225% Medicaid APG methodology,2.94,,,2.94,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.1,,,2.1,Other,Drug Cost,2.1,,,2.1,Other,Drug Cost,2.63,,,2.63,Other,125% Medicaid APG methodology,0.01,19.6,
MAG OX 400MG(240MG ELE MAG)TAB  ,,,,40510935,CDM,250,RC,10006-0730-38,NDC,both,1,EA,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.04,50,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
DONEPEZIL 5 MG TAB              ,,,,40511024,CDM,250,RC,00904-6477-61,NDC,both,1,EA,0.35,0.14,39.4668,,0.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.18,50,,0.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,70,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% Medicaid APG methodology,0.11,,,0.11,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.25,
FERROUS SULF 300MG/5ML LIQ 5ML  ,,,,40511057,CDM,250,RC,00121-0530-05,NDC,both,5,ML,7.35,2.9,39.4668,,2.9,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.21,30,,2.21,percent of total billed charges,"Drugs, Inpatient Only",2.21,30,,2.21,percent of total billed charges,"Drugs, Inpatient Only",2.21,30,,2.21,percent of total billed charges,"Drugs, Inpatient Only",3.68,50,,3.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.53,,,3.53,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.15,70,,5.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.9,,,1.9,Other,Drug Cost,1.9,,,1.9,Other,Drug Cost,1.9,,,1.9,Other,Drug Cost,1.9,,,1.9,Other,Drug Cost,1.9,,,1.9,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.9,,,1.9,Other,Drug Cost,4.28,,,4.28,Other,225% Medicaid APG methodology,2.66,,,2.66,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.9,,,1.9,Other,Drug Cost,1.9,,,1.9,Other,Drug Cost,2.38,,,2.38,Other,125% Medicaid APG methodology,0.01,5.15,
FERROUS SULF 325MG TAB          ,,,,40511073,CDM,250,RC,00904-7591-82,NDC,both,1,EA,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.02,50,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.03,
ZINC SULFATE 220 MG CAP         ,,,,40511115,CDM,250,RC,68585-0008-01,NDC,both,1,EA,0.39,0.15,39.4668,,0.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.2,50,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.27,70,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.27,
SUMATRIPTAN 50 MG TAB           ,,,,40511214,CDM,250,RC,55111-0292-09,NDC,both,1,EA,5.88,2.32,39.4668,,2.32,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.76,30,,1.76,percent of total billed charges,"Drugs, Inpatient Only",1.76,30,,1.76,percent of total billed charges,"Drugs, Inpatient Only",1.76,30,,1.76,percent of total billed charges,"Drugs, Inpatient Only",2.94,50,,2.94,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.33,,,0.33,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.12,70,,4.12,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.18,,,0.18,Other,Drug Cost,0.41,,,0.41,Other,225% Medicaid APG methodology,0.25,,,0.25,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.23,,,0.23,Other,125% Medicaid APG methodology,0.01,4.12,
SUMATRIPTAN 25 MG TAB           ,,,,40511222,CDM,250,RC,65862-0146-36,NDC,both,1,EA,2.84,1.12,39.4668,,1.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.85,30,,0.85,percent of total billed charges,"Drugs, Inpatient Only",0.85,30,,0.85,percent of total billed charges,"Drugs, Inpatient Only",0.85,30,,0.85,percent of total billed charges,"Drugs, Inpatient Only",1.42,50,,1.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.33,,,0.33,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.99,70,,1.99,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.18,,,0.18,Other,Drug Cost,0.41,,,0.41,Other,225% Medicaid APG methodology,0.25,,,0.25,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.23,,,0.23,Other,125% Medicaid APG methodology,0.01,1.99,
GLYBURIDE 2.5 MG TAB            ,,,,40511230,CDM,250,RC,00093-9433-01,NDC,both,1,EA,0.32,0.13,39.4668,,0.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.16,50,,0.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,70,,0.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.22,
GLYBURIDE 5 MG TAB              ,,,,40511248,CDM,250,RC,63739-0119-10,NDC,both,1,EA,0.42,0.17,39.4668,,0.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.21,50,,0.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,70,,0.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,Drug Cost,0.34,,,0.34,Other,225% Medicaid APG methodology,0.21,,,0.21,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.19,,,0.19,Other,125% Medicaid APG methodology,0.01,0.34,
GLIMEPIRIDE 1 MG TAB            ,,,,40511289,CDM,250,RC,68084-0788-25,NDC,both,1,EA,2.24,0.88,39.4668,,0.88,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.67,30,,0.67,percent of total billed charges,"Drugs, Inpatient Only",0.67,30,,0.67,percent of total billed charges,"Drugs, Inpatient Only",0.67,30,,0.67,percent of total billed charges,"Drugs, Inpatient Only",1.12,50,,1.12,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.12,,,1.12,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.57,70,,1.57,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.6,,,0.6,Other,Drug Cost,1.35,,,1.35,Other,225% Medicaid APG methodology,0.84,,,0.84,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.75,,,0.75,Other,125% Medicaid APG methodology,0.01,1.57,
GLIMEPIRIDE 2 MG TAB            ,,,,40511297,CDM,250,RC,16729-0002-01,NDC,both,1,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.11,50,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.15,
D5W IN WATER MEDICATION BOLUS   ,,,,40511347,CDM,250,RC,00338-0017-04,NDC,both,1000,ML,8.54,3.37,39.4668,,3.37,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.56,30,,2.56,percent of total billed charges,"Drugs, Inpatient Only",2.56,30,,2.56,percent of total billed charges,"Drugs, Inpatient Only",2.56,30,,2.56,percent of total billed charges,"Drugs, Inpatient Only",4.27,50,,4.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.37,,,7.37,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.98,70,,5.98,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.96,,,3.96,Other,Drug Cost,3.96,,,3.96,Other,Drug Cost,3.96,,,3.96,Other,Drug Cost,3.96,,,3.96,Other,Drug Cost,3.96,,,3.96,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.96,,,3.96,Other,Drug Cost,8.91,,,8.91,Other,225% Medicaid APG methodology,5.54,,,5.54,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.96,,,3.96,Other,Drug Cost,3.96,,,3.96,Other,Drug Cost,4.95,,,4.95,Other,125% Medicaid APG methodology,0.01,8.91,
D5W IN WATER IV SOLN 50 ML      ,,,,40511354,CDM,250,RC,00338-0017-31,NDC,both,50,ML,5.25,2.07,39.4668,,2.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.58,30,,1.58,percent of total billed charges,"Drugs, Inpatient Only",1.58,30,,1.58,percent of total billed charges,"Drugs, Inpatient Only",1.58,30,,1.58,percent of total billed charges,"Drugs, Inpatient Only",2.63,50,,2.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.79,,,2.79,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.68,70,,3.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.5,,,1.5,Other,Drug Cost,3.38,,,3.38,Other,225% Medicaid APG methodology,2.1,,,2.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.88,,,1.88,Other,125% Medicaid APG methodology,0.01,3.68,
D5W IN WATER MINIBAG 100 ML     ,,,,40511362,CDM,250,RC,00338-0551-18,NDC,both,1,ML,0.11,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.06,50,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.47,,,0.47,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.56,,,0.56,Other,225% Medicaid APG methodology,0.35,,,0.35,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.31,,,0.31,Other,125% Medicaid APG methodology,0.01,0.56,
D5W IN WATER IV SOLN 250 ML     ,,,,40511370,CDM,250,RC,00338-0017-02,NDC,both,250,ML,8.75,3.45,39.4668,,3.45,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.63,30,,2.63,percent of total billed charges,"Drugs, Inpatient Only",2.63,30,,2.63,percent of total billed charges,"Drugs, Inpatient Only",2.63,30,,2.63,percent of total billed charges,"Drugs, Inpatient Only",4.38,50,,4.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.65,,,4.65,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.13,70,,6.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.5,,,2.5,Other,Drug Cost,5.63,,,5.63,Other,225% Medicaid APG methodology,3.5,,,3.5,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,3.13,,,3.13,Other,125% Medicaid APG methodology,0.01,6.13,
D5W IN WATER IV SOLN 500 ML     ,,,,40511388,CDM,250,RC,00338-0017-03,NDC,both,500,ML,7.04,2.78,39.4668,,2.78,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.11,30,,2.11,percent of total billed charges,"Drugs, Inpatient Only",2.11,30,,2.11,percent of total billed charges,"Drugs, Inpatient Only",2.11,30,,2.11,percent of total billed charges,"Drugs, Inpatient Only",3.52,50,,3.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.95,,,5.95,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.93,70,,4.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.2,,,3.2,Other,Drug Cost,7.2,,,7.2,Other,225% Medicaid APG methodology,4.48,,,4.48,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,4,,,4,Other,125% Medicaid APG methodology,0.01,7.2,
D10W IV SLN 250ML               ,,,,40511404,CDM,250,RC,00338-0023-02,NDC,both,250,ML,8.75,3.45,39.4668,,3.45,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.63,30,,2.63,percent of total billed charges,"Drugs, Inpatient Only",2.63,30,,2.63,percent of total billed charges,"Drugs, Inpatient Only",2.63,30,,2.63,percent of total billed charges,"Drugs, Inpatient Only",4.38,50,,4.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.65,,,4.65,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.13,70,,6.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.5,,,2.5,Other,Drug Cost,5.63,,,5.63,Other,225% Medicaid APG methodology,3.5,,,3.5,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,3.13,,,3.13,Other,125% Medicaid APG methodology,0.01,6.13,
D10W MEDICATION BOLUS           ,,,,40511412,CDM,250,RC,00338-0023-04,NDC,both,1000,ML,16.1,6.35,39.4668,,6.35,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.83,30,,4.83,percent of total billed charges,"Drugs, Inpatient Only",4.83,30,,4.83,percent of total billed charges,"Drugs, Inpatient Only",4.83,30,,4.83,percent of total billed charges,"Drugs, Inpatient Only",8.05,50,,8.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.56,,,8.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.27,70,,11.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.6,,,4.6,Other,Drug Cost,4.6,,,4.6,Other,Drug Cost,4.6,,,4.6,Other,Drug Cost,4.6,,,4.6,Other,Drug Cost,4.6,,,4.6,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.6,,,4.6,Other,Drug Cost,10.35,,,10.35,Other,225% Medicaid APG methodology,6.44,,,6.44,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.6,,,4.6,Other,Drug Cost,4.6,,,4.6,Other,Drug Cost,5.75,,,5.75,Other,125% Medicaid APG methodology,0.01,11.27,
D5W0.9% NACL IV SLN 1000ML      ,,,,40511461,CDM,250,RC,00338-0089-04,NDC,both,1000,ML,8.51,3.36,39.4668,,3.36,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.55,30,,2.55,percent of total billed charges,"Drugs, Inpatient Only",2.55,30,,2.55,percent of total billed charges,"Drugs, Inpatient Only",2.55,30,,2.55,percent of total billed charges,"Drugs, Inpatient Only",4.26,50,,4.26,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.44,,,7.44,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.96,70,,5.96,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4,,,4,Other,Drug Cost,4,,,4,Other,Drug Cost,4,,,4,Other,Drug Cost,4,,,4,Other,Drug Cost,4,,,4,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4,,,4,Other,Drug Cost,9,,,9,Other,225% Medicaid APG methodology,5.6,,,5.6,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4,,,4,Other,Drug Cost,4,,,4,Other,Drug Cost,5,,,5,Other,125% Medicaid APG methodology,0.01,9,
D5W0.45% NACL IV SLN 1000ML     ,,,,40511487,CDM,250,RC,00338-0085-04,NDC,both,1000,ML,9.24,3.65,39.4668,,3.65,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.77,30,,2.77,percent of total billed charges,"Drugs, Inpatient Only",2.77,30,,2.77,percent of total billed charges,"Drugs, Inpatient Only",2.77,30,,2.77,percent of total billed charges,"Drugs, Inpatient Only",4.62,50,,4.62,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.81,,,7.81,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.47,70,,6.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.2,,,4.2,Other,Drug Cost,4.2,,,4.2,Other,Drug Cost,4.2,,,4.2,Other,Drug Cost,4.2,,,4.2,Other,Drug Cost,4.2,,,4.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.2,,,4.2,Other,Drug Cost,9.45,,,9.45,Other,225% Medicaid APG methodology,5.88,,,5.88,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.2,,,4.2,Other,Drug Cost,4.2,,,4.2,Other,Drug Cost,5.25,,,5.25,Other,125% Medicaid APG methodology,0.01,9.45,
D5W0.2% NACL IV SLN 1000ML      ,,,,40511537,CDM,250,RC,00264-7616-00,NDC,both,1000,ML,13.9,5.49,39.4668,,5.49,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.17,30,,4.17,percent of total billed charges,"Drugs, Inpatient Only",4.17,30,,4.17,percent of total billed charges,"Drugs, Inpatient Only",4.17,30,,4.17,percent of total billed charges,"Drugs, Inpatient Only",6.95,50,,6.95,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.38,,,7.38,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.73,70,,9.73,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.97,,,3.97,Other,Drug Cost,3.97,,,3.97,Other,Drug Cost,3.97,,,3.97,Other,Drug Cost,3.97,,,3.97,Other,Drug Cost,3.97,,,3.97,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.97,,,3.97,Other,Drug Cost,8.93,,,8.93,Other,225% Medicaid APG methodology,5.56,,,5.56,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.97,,,3.97,Other,Drug Cost,3.97,,,3.97,Other,Drug Cost,4.96,,,4.96,Other,125% Medicaid APG methodology,0.01,9.73,
D5W LACTATED RINGERS IV 1000ML  ,,,,40511560,CDM,250,RC,00338-0125-04,NDC,both,1000,ML,9.07,3.58,39.4668,,3.58,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.72,30,,2.72,percent of total billed charges,"Drugs, Inpatient Only",2.72,30,,2.72,percent of total billed charges,"Drugs, Inpatient Only",2.72,30,,2.72,percent of total billed charges,"Drugs, Inpatient Only",4.54,50,,4.54,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.94,,,7.94,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.35,70,,6.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.27,,,4.27,Other,Drug Cost,4.27,,,4.27,Other,Drug Cost,4.27,,,4.27,Other,Drug Cost,4.27,,,4.27,Other,Drug Cost,4.27,,,4.27,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.27,,,4.27,Other,Drug Cost,9.61,,,9.61,Other,225% Medicaid APG methodology,5.98,,,5.98,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.27,,,4.27,Other,Drug Cost,4.27,,,4.27,Other,Drug Cost,5.34,,,5.34,Other,125% Medicaid APG methodology,0.01,9.61,
ALLOPURINOL 100 MG TAB          ,,,,40511578,CDM,250,RC,00904-7041-61,NDC,both,1,EA,0.63,0.25,39.4668,,0.25,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.32,50,,0.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.33,,,0.33,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.44,70,,0.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.18,,,0.18,Other,Drug Cost,0.41,,,0.41,Other,225% Medicaid APG methodology,0.25,,,0.25,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.23,,,0.23,Other,125% Medicaid APG methodology,0.01,0.44,
ALLOPURINOL 300 MG TAB          ,,,,40511586,CDM,250,RC,51079-0206-20,NDC,both,1,EA,2.07,0.82,39.4668,,0.82,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.62,30,,0.62,percent of total billed charges,"Drugs, Inpatient Only",0.62,30,,0.62,percent of total billed charges,"Drugs, Inpatient Only",0.62,30,,0.62,percent of total billed charges,"Drugs, Inpatient Only",1.04,50,,1.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.45,70,,1.45,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1.45,
SOD THIOSULFATE 25% IV  50ML    ,,,,40511636,CDM,250,RC,60267-0705-50,NDC,both,50,ML,311.5,122.94,39.4668,,122.94,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,93.45,30,,93.45,percent of total billed charges,"Drugs, Inpatient Only",93.45,30,,93.45,percent of total billed charges,"Drugs, Inpatient Only",93.45,30,,93.45,percent of total billed charges,"Drugs, Inpatient Only",155.75,50,,155.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,165.54,,,165.54,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,218.05,70,,218.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,89,,,89,Other,Drug Cost,89,,,89,Other,Drug Cost,89,,,89,Other,Drug Cost,89,,,89,Other,Drug Cost,89,,,89,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,89,,,89,Other,Drug Cost,200.25,,,200.25,Other,225% Medicaid APG methodology,124.6,,,124.6,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,89,,,89,Other,Drug Cost,89,,,89,Other,Drug Cost,111.25,,,111.25,Other,125% Medicaid APG methodology,0.01,218.05,
CLOTRIMAZOLE 10 MG LOZENGE      ,,,,40511735,CDM,250,RC,00054-8146-22,NDC,both,1,EA,2.87,1.13,39.4668,,1.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.86,30,,0.86,percent of total billed charges,"Drugs, Inpatient Only",0.86,30,,0.86,percent of total billed charges,"Drugs, Inpatient Only",0.86,30,,0.86,percent of total billed charges,"Drugs, Inpatient Only",1.44,50,,1.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.43,,,0.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.01,70,,2.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.23,,,0.23,Other,Drug Cost,0.52,,,0.52,Other,225% Medicaid APG methodology,0.32,,,0.32,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.29,,,0.29,Other,125% Medicaid APG methodology,0.01,2.01,
SODIUM BICARBONATE 650 MG TAB   ,,,,40511743,CDM,250,RC,77333-0827-10,NDC,both,1,EA,0.42,0.17,39.4668,,0.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.21,50,,0.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,70,,0.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.29,,,0.29,Other,225% Medicaid APG methodology,0.18,,,0.18,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.16,,,0.16,Other,125% Medicaid APG methodology,0.01,0.29,
MAG HYDROXIDE 8% ORL 30ML UD    ,,,,40511750,CDM,250,RC,66689-0053-99,NDC,both,30,ML,6.3,2.49,39.4668,,2.49,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.89,30,,1.89,percent of total billed charges,"Drugs, Inpatient Only",1.89,30,,1.89,percent of total billed charges,"Drugs, Inpatient Only",1.89,30,,1.89,percent of total billed charges,"Drugs, Inpatient Only",3.15,50,,3.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.35,,,3.35,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.41,70,,4.41,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.8,,,1.8,Other,Drug Cost,1.8,,,1.8,Other,Drug Cost,1.8,,,1.8,Other,Drug Cost,1.8,,,1.8,Other,Drug Cost,1.8,,,1.8,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.8,,,1.8,Other,Drug Cost,4.05,,,4.05,Other,225% Medicaid APG methodology,2.52,,,2.52,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.8,,,1.8,Other,Drug Cost,1.8,,,1.8,Other,Drug Cost,2.25,,,2.25,Other,125% Medicaid APG methodology,0.01,4.41,
SUCRALFATE 1 G TAB              ,,,,40511800,CDM,250,RC,60687-0695-01,NDC,both,1,EA,1.02,0.4,39.4668,,0.4,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.31,30,,0.31,percent of total billed charges,"Drugs, Inpatient Only",0.31,30,,0.31,percent of total billed charges,"Drugs, Inpatient Only",0.31,30,,0.31,percent of total billed charges,"Drugs, Inpatient Only",0.51,50,,0.51,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.52,,,0.52,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.71,70,,0.71,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,Drug Cost,0.63,,,0.63,Other,225% Medicaid APG methodology,0.39,,,0.39,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.35,,,0.35,Other,125% Medicaid APG methodology,0.01,0.71,
MISOPROSTOL 200 MCG TAB         ,,,,40511826,CDM,250,RC,43386-0161-01,NDC,both,1,EA,2.31,0.91,39.4668,,0.91,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.69,30,,0.69,percent of total billed charges,"Drugs, Inpatient Only",0.69,30,,0.69,percent of total billed charges,"Drugs, Inpatient Only",0.69,30,,0.69,percent of total billed charges,"Drugs, Inpatient Only",1.16,50,,1.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.73,,,0.73,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.62,70,,1.62,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.39,,,0.39,Other,Drug Cost,0.88,,,0.88,Other,225% Medicaid APG methodology,0.55,,,0.55,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.49,,,0.49,Other,125% Medicaid APG methodology,0.01,1.62,
MISOPROSTOL 100 MCG TAB         ,,,,40511834,CDM,250,RC,70954-0443-10,NDC,both,1,EA,3.43,1.35,39.4668,,1.35,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.03,30,,1.03,percent of total billed charges,"Drugs, Inpatient Only",1.03,30,,1.03,percent of total billed charges,"Drugs, Inpatient Only",1.03,30,,1.03,percent of total billed charges,"Drugs, Inpatient Only",1.72,50,,1.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.82,,,1.82,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.4,70,,2.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.98,,,0.98,Other,Drug Cost,2.21,,,2.21,Other,225% Medicaid APG methodology,1.37,,,1.37,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,1.23,,,1.23,Other,125% Medicaid APG methodology,0.01,2.4,
SIMETHICONE 40MG/0.6ML ORL30ML  ,,,,40511842,CDM,250,RC,70000-0051-01,NDC,both,30,ML,11.55,4.56,39.4668,,4.56,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.47,30,,3.47,percent of total billed charges,"Drugs, Inpatient Only",3.47,30,,3.47,percent of total billed charges,"Drugs, Inpatient Only",3.47,30,,3.47,percent of total billed charges,"Drugs, Inpatient Only",5.78,50,,5.78,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.14,,,6.14,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.09,70,,8.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.3,,,3.3,Other,Drug Cost,3.3,,,3.3,Other,Drug Cost,3.3,,,3.3,Other,Drug Cost,3.3,,,3.3,Other,Drug Cost,3.3,,,3.3,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.3,,,3.3,Other,Drug Cost,7.43,,,7.43,Other,225% Medicaid APG methodology,4.62,,,4.62,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.3,,,3.3,Other,Drug Cost,3.3,,,3.3,Other,Drug Cost,4.13,,,4.13,Other,125% Medicaid APG methodology,0.01,8.09,
LOPERAMIDE 2 MG CAP             ,,,,40511909,CDM,250,RC,51079-0690-20,NDC,both,1,EA,2.28,0.9,39.4668,,0.9,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.68,30,,0.68,percent of total billed charges,"Drugs, Inpatient Only",0.68,30,,0.68,percent of total billed charges,"Drugs, Inpatient Only",0.68,30,,0.68,percent of total billed charges,"Drugs, Inpatient Only",1.14,50,,1.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.6,70,,1.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% Medicaid APG methodology,0.11,,,0.11,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,1.6,
PRAZIQUANTEL 600 MG TAB         ,,,,40511941,CDM,250,RC,50419-0747-01,NDC,both,1,EA,269.61,106.41,39.4668,,106.41,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,80.88,30,,80.88,percent of total billed charges,"Drugs, Inpatient Only",80.88,30,,80.88,percent of total billed charges,"Drugs, Inpatient Only",80.88,30,,80.88,percent of total billed charges,"Drugs, Inpatient Only",134.81,50,,134.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,188.73,70,,188.73,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,188.73,
CILOSTAZOL 50 MG TAB            ,,,,40511966,CDM,250,RC,00054-0028-21,NDC,both,1,EA,1.02,0.4,39.4668,,0.4,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.31,30,,0.31,percent of total billed charges,"Drugs, Inpatient Only",0.31,30,,0.31,percent of total billed charges,"Drugs, Inpatient Only",0.31,30,,0.31,percent of total billed charges,"Drugs, Inpatient Only",0.51,50,,0.51,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.71,70,,0.71,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.23,,,0.23,Other,225% Medicaid APG methodology,0.14,,,0.14,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.13,,,0.13,Other,125% Medicaid APG methodology,0.01,0.71,
SENNA 8.6 MG TAB                ,,,,40511990,CDM,250,RC,00904-7252-61,NDC,both,1,EA,0.11,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.06,50,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.08,
BISACODYL 10 MG RECTAL SUPP     ,,,,40512006,CDM,250,RC,00904-7142-12,NDC,both,1,EA,0.74,0.29,39.4668,,0.29,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,30,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.22,30,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.22,30,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.37,50,,0.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.52,70,,0.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.27,,,0.27,Other,225% Medicaid APG methodology,0.17,,,0.17,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.15,,,0.15,Other,125% Medicaid APG methodology,0.01,0.52,
BISACODYL 5 MG EC TAB           ,,,,40512022,CDM,250,RC,00904-6748-60,NDC,both,1,EA,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.02,50,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.03,
GLYCERIN ADULT RECTAL SUPP      ,,,,40512030,CDM,250,RC,57237-0325-21,NDC,both,1,EA,0.46,0.18,39.4668,,0.18,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.14,30,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,30,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,30,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.23,50,,0.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.65,,,0.65,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.32,70,,0.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.35,,,0.35,Other,Drug Cost,0.35,,,0.35,Other,Drug Cost,0.35,,,0.35,Other,Drug Cost,0.35,,,0.35,Other,Drug Cost,0.35,,,0.35,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.35,,,0.35,Other,Drug Cost,0.79,,,0.79,Other,225% Medicaid APG methodology,0.49,,,0.49,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.35,,,0.35,Other,Drug Cost,0.35,,,0.35,Other,Drug Cost,0.44,,,0.44,Other,125% Medicaid APG methodology,0.01,0.79,
GLYCERIN PEDIATRIC RECTAL SUPP  ,,,,40512048,CDM,250,RC,00132-0081-12,NDC,both,1,EA,0.39,0.15,39.4668,,0.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.2,50,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.27,70,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.25,,,0.25,Other,225% Medicaid APG methodology,0.15,,,0.15,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.14,,,0.14,Other,125% Medicaid APG methodology,0.01,0.27,
MIRTAZAPINE 15 MG TAB           ,,,,40512055,CDM,250,RC,00904-6519-61,NDC,both,1,EA,0.39,0.15,39.4668,,0.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.2,50,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.27,70,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% Medicaid APG methodology,0.11,,,0.11,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.27,
MIRTAZAPINE 30 MG TAB           ,,,,40512063,CDM,250,RC,68084-0120-01,NDC,both,1,EA,1.12,0.44,39.4668,,0.44,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.34,30,,0.34,percent of total billed charges,"Drugs, Inpatient Only",0.34,30,,0.34,percent of total billed charges,"Drugs, Inpatient Only",0.34,30,,0.34,percent of total billed charges,"Drugs, Inpatient Only",0.56,50,,0.56,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.78,70,,0.78,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.25,,,0.25,Other,225% Medicaid APG methodology,0.15,,,0.15,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.14,,,0.14,Other,125% Medicaid APG methodology,0.01,0.78,
MINERAL OIL LIGHT STERILE 10ML  ,,,,40512105,CDM,250,RC,63323-0254-10,NDC,both,10,ML,45.15,17.82,39.4668,,17.82,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.55,30,,13.55,percent of total billed charges,"Drugs, Inpatient Only",13.55,30,,13.55,percent of total billed charges,"Drugs, Inpatient Only",13.55,30,,13.55,percent of total billed charges,"Drugs, Inpatient Only",22.58,50,,22.58,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,23.62,,,23.62,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,31.61,70,,31.61,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.7,,,12.7,Other,Drug Cost,12.7,,,12.7,Other,Drug Cost,12.7,,,12.7,Other,Drug Cost,12.7,,,12.7,Other,Drug Cost,12.7,,,12.7,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,12.7,,,12.7,Other,Drug Cost,28.58,,,28.58,Other,225% Medicaid APG methodology,17.78,,,17.78,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,12.7,,,12.7,Other,Drug Cost,12.7,,,12.7,Other,Drug Cost,15.88,,,15.88,Other,125% Medicaid APG methodology,0.01,31.61,
MINERAL OIL ORLIQ 30 ML         ,,,,40512121,CDM,250,RC,48433-0202-30,NDC,both,480,ML,50.4,19.89,39.4668,,19.89,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.12,30,,15.12,percent of total billed charges,"Drugs, Inpatient Only",15.12,30,,15.12,percent of total billed charges,"Drugs, Inpatient Only",15.12,30,,15.12,percent of total billed charges,"Drugs, Inpatient Only",25.2,50,,25.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,26.78,,,26.78,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,35.28,70,,35.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.4,,,14.4,Other,Drug Cost,14.4,,,14.4,Other,Drug Cost,14.4,,,14.4,Other,Drug Cost,14.4,,,14.4,Other,Drug Cost,14.4,,,14.4,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,14.4,,,14.4,Other,Drug Cost,32.4,,,32.4,Other,225% Medicaid APG methodology,20.16,,,20.16,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,14.4,,,14.4,Other,Drug Cost,14.4,,,14.4,Other,Drug Cost,18,,,18,Other,125% Medicaid APG methodology,0.01,35.28,
MINERAL OIL ENEMA 133 ML        ,,,,40512139,CDM,250,RC,00132-0301-40,NDC,both,133,ML,6.79,2.68,39.4668,,2.68,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.04,30,,2.04,percent of total billed charges,"Drugs, Inpatient Only",2.04,30,,2.04,percent of total billed charges,"Drugs, Inpatient Only",2.04,30,,2.04,percent of total billed charges,"Drugs, Inpatient Only",3.4,50,,3.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.61,,,3.61,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.75,70,,4.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.94,,,1.94,Other,Drug Cost,4.37,,,4.37,Other,225% Medicaid APG methodology,2.72,,,2.72,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,2.43,,,2.43,Other,125% Medicaid APG methodology,0.01,4.75,
DOCUSATE SODIUM 100 MG CAP      ,,,,40512147,CDM,250,RC,00904-7183-61,NDC,both,1,EA,0.14,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.07,50,,0.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.1,
MAG CITRATE 1.745 G/30ML 300ML  ,,,,40512188,CDM,250,RC,70000-0424-01,NDC,both,300,ML,4.2,1.66,39.4668,,1.66,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.26,30,,1.26,percent of total billed charges,"Drugs, Inpatient Only",1.26,30,,1.26,percent of total billed charges,"Drugs, Inpatient Only",1.26,30,,1.26,percent of total billed charges,"Drugs, Inpatient Only",2.1,50,,2.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.82,,,1.82,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.94,70,,2.94,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.98,,,0.98,Other,Drug Cost,2.21,,,2.21,Other,225% Medicaid APG methodology,1.37,,,1.37,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,1.23,,,1.23,Other,125% Medicaid APG methodology,0.01,2.94,
PSYLLIUM 3.4 G/5.8 G ORL POW    ,,,,40512196,CDM,250,RC,37000-0024-04,NDC,both,1,EA,1.44,0.57,39.4668,,0.57,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.43,30,,0.43,percent of total billed charges,"Drugs, Inpatient Only",0.43,30,,0.43,percent of total billed charges,"Drugs, Inpatient Only",0.43,30,,0.43,percent of total billed charges,"Drugs, Inpatient Only",0.72,50,,0.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.76,,,0.76,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.01,70,,1.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.41,,,0.41,Other,Drug Cost,0.92,,,0.92,Other,225% Medicaid APG methodology,0.57,,,0.57,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.51,,,0.51,Other,125% Medicaid APG methodology,0.01,1.01,
LACTULOSE 10 G/15ML ORL 30ML    ,,,,40512345,CDM,250,RC,00116-4005-11,NDC,both,30,ML,4.9,1.93,39.4668,,1.93,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.47,30,,1.47,percent of total billed charges,"Drugs, Inpatient Only",1.47,30,,1.47,percent of total billed charges,"Drugs, Inpatient Only",1.47,30,,1.47,percent of total billed charges,"Drugs, Inpatient Only",2.45,50,,2.45,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.57,,,2.57,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.43,70,,3.43,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.38,,,1.38,Other,Drug Cost,1.38,,,1.38,Other,Drug Cost,1.38,,,1.38,Other,Drug Cost,1.38,,,1.38,Other,Drug Cost,1.38,,,1.38,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.38,,,1.38,Other,Drug Cost,3.11,,,3.11,Other,225% Medicaid APG methodology,1.93,,,1.93,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.38,,,1.38,Other,Drug Cost,1.38,,,1.38,Other,Drug Cost,1.73,,,1.73,Other,125% Medicaid APG methodology,0.01,3.43,
LABETALOL 100 MG TAB            ,,,,40512428,CDM,250,RC,68382-0798-01,NDC,both,1,EA,0.63,0.25,39.4668,,0.25,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.32,50,,0.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.44,70,,0.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% Medicaid APG methodology,0.11,,,0.11,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.44,
OXANDROLONE 2.5 MG TAB          ,,,,40512469,CDM,250,RC,00245-0271-11,NDC,both,1,EA,7.21,2.85,39.4668,,2.85,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.16,30,,2.16,percent of total billed charges,"Drugs, Inpatient Only",2.16,30,,2.16,percent of total billed charges,"Drugs, Inpatient Only",2.16,30,,2.16,percent of total billed charges,"Drugs, Inpatient Only",3.61,50,,3.61,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.06,,,1.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.05,70,,5.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.57,,,0.57,Other,Drug Cost,0.57,,,0.57,Other,Drug Cost,0.57,,,0.57,Other,Drug Cost,0.57,,,0.57,Other,Drug Cost,0.57,,,0.57,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.57,,,0.57,Other,Drug Cost,1.28,,,1.28,Other,225% Medicaid APG methodology,0.8,,,0.8,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.57,,,0.57,Other,Drug Cost,0.57,,,0.57,Other,Drug Cost,0.71,,,0.71,Other,125% Medicaid APG methodology,0.01,5.05,
GLIPIZIDE 5 MG TAB              ,,,,40512485,CDM,250,RC,51079-0810-20,NDC,both,1,EA,0.98,0.39,39.4668,,0.39,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.49,50,,0.49,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.69,70,,0.69,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.69,
GLIPIZIDE 10 MG TAB             ,,,,40512493,CDM,250,RC,51079-0811-20,NDC,both,1,EA,1.75,0.69,39.4668,,0.69,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.53,30,,0.53,percent of total billed charges,"Drugs, Inpatient Only",0.53,30,,0.53,percent of total billed charges,"Drugs, Inpatient Only",0.53,30,,0.53,percent of total billed charges,"Drugs, Inpatient Only",0.88,50,,0.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.23,70,,1.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1.23,
GLIPIZIDE 10 MG ER TAB          ,,,,40512501,CDM,250,RC,68084-0112-01,NDC,both,1,EA,2.21,0.87,39.4668,,0.87,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.66,30,,0.66,percent of total billed charges,"Drugs, Inpatient Only",0.66,30,,0.66,percent of total billed charges,"Drugs, Inpatient Only",0.66,30,,0.66,percent of total billed charges,"Drugs, Inpatient Only",1.11,50,,1.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.5,,,0.5,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.55,70,,1.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.27,,,0.27,Other,Drug Cost,0.61,,,0.61,Other,225% Medicaid APG methodology,0.38,,,0.38,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.34,,,0.34,Other,125% Medicaid APG methodology,0.01,1.55,
AMIODARONE 200 MG TAB           ,,,,40512535,CDM,250,RC,00904-6993-61,NDC,both,1,EA,0.63,0.25,39.4668,,0.25,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.32,50,,0.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.41,,,0.41,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.44,70,,0.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.5,,,0.5,Other,225% Medicaid APG methodology,0.31,,,0.31,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.28,,,0.28,Other,125% Medicaid APG methodology,0.01,0.5,
CONJ ESTROGENS 0.625 MG TAB     ,,,,40512543,CDM,250,RC,00046-1102-81,NDC,both,1,EA,21.77,8.59,39.4668,,8.59,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.53,30,,6.53,percent of total billed charges,"Drugs, Inpatient Only",6.53,30,,6.53,percent of total billed charges,"Drugs, Inpatient Only",6.53,30,,6.53,percent of total billed charges,"Drugs, Inpatient Only",10.89,50,,10.89,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.24,70,,15.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,15.24,
CONJ ESTROGENS 0.3 MG TAB       ,,,,40512550,CDM,250,RC,00046-1100-81,NDC,both,1,EA,21.77,8.59,39.4668,,8.59,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.53,30,,6.53,percent of total billed charges,"Drugs, Inpatient Only",6.53,30,,6.53,percent of total billed charges,"Drugs, Inpatient Only",6.53,30,,6.53,percent of total billed charges,"Drugs, Inpatient Only",10.89,50,,10.89,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.24,70,,15.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,15.24,
NITROFURANTOIN MACOBID100MGCAP  ,,,,40512576,CDM,250,RC,00904-7137-61,NDC,both,1,EA,7.35,2.9,39.4668,,2.9,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.21,30,,2.21,percent of total billed charges,"Drugs, Inpatient Only",2.21,30,,2.21,percent of total billed charges,"Drugs, Inpatient Only",2.21,30,,2.21,percent of total billed charges,"Drugs, Inpatient Only",3.68,50,,3.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.75,,,2.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.15,70,,5.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.48,,,1.48,Other,Drug Cost,3.33,,,3.33,Other,225% Medicaid APG methodology,2.07,,,2.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,1.85,,,1.85,Other,125% Medicaid APG methodology,0.01,5.15,
SERTRALINE 100 MG TAB           ,,,,40512592,CDM,250,RC,50268-0770-15,NDC,both,1,EA,1.47,0.58,39.4668,,0.58,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.44,30,,0.44,percent of total billed charges,"Drugs, Inpatient Only",0.44,30,,0.44,percent of total billed charges,"Drugs, Inpatient Only",0.44,30,,0.44,percent of total billed charges,"Drugs, Inpatient Only",0.74,50,,0.74,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.76,,,0.76,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.03,70,,1.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.41,,,0.41,Other,Drug Cost,0.92,,,0.92,Other,225% Medicaid APG methodology,0.57,,,0.57,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.51,,,0.51,Other,125% Medicaid APG methodology,0.01,1.03,
FINASTERIDE 5 MG TAB            ,,,,40512618,CDM,250,RC,16729-0090-01,NDC,both,1,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.11,50,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.15,
DILTIAZEM 120MG/24 HOURS ERCAP  ,,,,40512634,CDM,250,RC,60687-0195-01,NDC,both,1,EA,0.7,0.28,39.4668,,0.28,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.21,30,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.21,30,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.21,30,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.35,50,,0.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.39,,,0.39,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.49,70,,0.49,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.21,,,0.21,Other,Drug Cost,0.47,,,0.47,Other,225% Medicaid APG methodology,0.29,,,0.29,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.26,,,0.26,Other,125% Medicaid APG methodology,0.01,0.49,
DILTIAZEM 180MG/24H ER CAP      ,,,,40512642,CDM,250,RC,50742-0249-90,NDC,both,1,EA,0.7,0.28,39.4668,,0.28,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.21,30,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.21,30,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.21,30,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.35,50,,0.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.49,70,,0.49,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.49,
FLUOXETINE 10 MG CAP            ,,,,40512659,CDM,250,RC,00904-5784-61,NDC,both,1,EA,0.28,0.11,39.4668,,0.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.14,50,,0.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,70,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.2,
HYOSCYAMINE 0.125 MG TAB        ,,,,40512675,CDM,250,RC,43199-0013-01,NDC,both,1,EA,0.32,0.13,39.4668,,0.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.16,50,,0.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,70,,0.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% Medicaid APG methodology,0.1,,,0.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.22,
DILTIAZEM 240MG/24H ER CAP      ,,,,40512683,CDM,250,RC,60687-0217-01,NDC,both,1,EA,1.86,0.73,39.4668,,0.73,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.56,30,,0.56,percent of total billed charges,"Drugs, Inpatient Only",0.56,30,,0.56,percent of total billed charges,"Drugs, Inpatient Only",0.56,30,,0.56,percent of total billed charges,"Drugs, Inpatient Only",0.93,50,,0.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.84,,,0.84,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.3,70,,1.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.45,,,0.45,Other,Drug Cost,1.01,,,1.01,Other,225% Medicaid APG methodology,0.63,,,0.63,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.56,,,0.56,Other,125% Medicaid APG methodology,0.01,1.3,
DILTIAZEM 300MG/24H ER CAP      ,,,,40512691,CDM,250,RC,60687-0228-01,NDC,both,1,EA,5.18,2.04,39.4668,,2.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.55,30,,1.55,percent of total billed charges,"Drugs, Inpatient Only",1.55,30,,1.55,percent of total billed charges,"Drugs, Inpatient Only",1.55,30,,1.55,percent of total billed charges,"Drugs, Inpatient Only",2.59,50,,2.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.63,70,,3.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.27,,,0.27,Other,225% Medicaid APG methodology,0.17,,,0.17,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.15,,,0.15,Other,125% Medicaid APG methodology,0.01,3.63,
MEGESTROL 40MG/ML ORL 10ML UD   ,,,,40512709,CDM,250,RC,68094-0250-62,NDC,both,10,ML,10.85,4.28,39.4668,,4.28,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.26,30,,3.26,percent of total billed charges,"Drugs, Inpatient Only",3.26,30,,3.26,percent of total billed charges,"Drugs, Inpatient Only",3.26,30,,3.26,percent of total billed charges,"Drugs, Inpatient Only",5.43,50,,5.43,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.09,,,4.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.6,70,,7.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.2,,,2.2,Other,Drug Cost,2.2,,,2.2,Other,Drug Cost,2.2,,,2.2,Other,Drug Cost,2.2,,,2.2,Other,Drug Cost,2.2,,,2.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.2,,,2.2,Other,Drug Cost,4.95,,,4.95,Other,225% Medicaid APG methodology,3.08,,,3.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.2,,,2.2,Other,Drug Cost,2.2,,,2.2,Other,Drug Cost,2.75,,,2.75,Other,125% Medicaid APG methodology,0.01,7.6,
SERTRALINE 50 MG TAB            ,,,,40512717,CDM,250,RC,60687-0242-01,NDC,both,1,EA,0.91,0.36,39.4668,,0.36,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.27,30,,0.27,percent of total billed charges,"Drugs, Inpatient Only",0.27,30,,0.27,percent of total billed charges,"Drugs, Inpatient Only",0.27,30,,0.27,percent of total billed charges,"Drugs, Inpatient Only",0.46,50,,0.46,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.64,70,,0.64,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.23,,,0.23,Other,225% Medicaid APG methodology,0.14,,,0.14,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.13,,,0.13,Other,125% Medicaid APG methodology,0.01,0.64,
BENZTROPINE 1 MG TAB            ,,,,40512725,CDM,250,RC,00904-7289-61,NDC,both,1,EA,1.44,0.57,39.4668,,0.57,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.43,30,,0.43,percent of total billed charges,"Drugs, Inpatient Only",0.43,30,,0.43,percent of total billed charges,"Drugs, Inpatient Only",0.43,30,,0.43,percent of total billed charges,"Drugs, Inpatient Only",0.72,50,,0.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.82,,,0.82,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.01,70,,1.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.44,,,0.44,Other,Drug Cost,0.44,,,0.44,Other,Drug Cost,0.44,,,0.44,Other,Drug Cost,0.44,,,0.44,Other,Drug Cost,0.44,,,0.44,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.44,,,0.44,Other,Drug Cost,0.99,,,0.99,Other,225% Medicaid APG methodology,0.62,,,0.62,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.44,,,0.44,Other,Drug Cost,0.44,,,0.44,Other,Drug Cost,0.55,,,0.55,Other,125% Medicaid APG methodology,0.01,1.01,
RISPERIDONE 1 MG TAB            ,,,,40512733,CDM,250,RC,68382-0114-14,NDC,both,1,EA,0.11,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.06,50,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.08,
CLARITHROMYCIN 500 MG TAB       ,,,,40512758,CDM,250,RC,60687-0435-21,NDC,both,1,EA,11.69,4.61,39.4668,,4.61,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.51,30,,3.51,percent of total billed charges,"Drugs, Inpatient Only",3.51,30,,3.51,percent of total billed charges,"Drugs, Inpatient Only",3.51,30,,3.51,percent of total billed charges,"Drugs, Inpatient Only",5.85,50,,5.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.03,,,6.03,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.18,70,,8.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.24,,,3.24,Other,Drug Cost,3.24,,,3.24,Other,Drug Cost,3.24,,,3.24,Other,Drug Cost,3.24,,,3.24,Other,Drug Cost,3.24,,,3.24,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.24,,,3.24,Other,Drug Cost,7.29,,,7.29,Other,225% Medicaid APG methodology,4.54,,,4.54,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.24,,,3.24,Other,Drug Cost,3.24,,,3.24,Other,Drug Cost,4.05,,,4.05,Other,125% Medicaid APG methodology,0.01,8.18,
DAPSONE 100 MG TAB              ,,,,40512766,CDM,250,RC,49938-0101-30,NDC,both,1,EA,9.1,3.59,39.4668,,3.59,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.73,30,,2.73,percent of total billed charges,"Drugs, Inpatient Only",2.73,30,,2.73,percent of total billed charges,"Drugs, Inpatient Only",2.73,30,,2.73,percent of total billed charges,"Drugs, Inpatient Only",4.55,50,,4.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.91,,,4.91,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.37,70,,6.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.64,,,2.64,Other,Drug Cost,2.64,,,2.64,Other,Drug Cost,2.64,,,2.64,Other,Drug Cost,2.64,,,2.64,Other,Drug Cost,2.64,,,2.64,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.64,,,2.64,Other,Drug Cost,5.94,,,5.94,Other,225% Medicaid APG methodology,3.7,,,3.7,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.64,,,2.64,Other,Drug Cost,2.64,,,2.64,Other,Drug Cost,3.3,,,3.3,Other,125% Medicaid APG methodology,0.01,6.37,
FELBAMATE 400 MG TAB            ,,,,40512782,CDM,250,RC,65162-0734-03,NDC,both,1,EA,13.83,5.46,39.4668,,5.46,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.15,30,,4.15,percent of total billed charges,"Drugs, Inpatient Only",4.15,30,,4.15,percent of total billed charges,"Drugs, Inpatient Only",4.15,30,,4.15,percent of total billed charges,"Drugs, Inpatient Only",6.92,50,,6.92,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.64,,,1.64,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.68,70,,9.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.88,,,0.88,Other,Drug Cost,1.98,,,1.98,Other,225% Medicaid APG methodology,1.23,,,1.23,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.88,,,0.88,Other,Drug Cost,0.88,,,0.88,Other,Drug Cost,1.1,,,1.1,Other,125% Medicaid APG methodology,0.01,9.68,
DOLUTEGRAVIR 50 MG TAB          ,,,,40512790,CDM,250,RC,49702-0228-13,NDC,both,1,EA,242.38,95.66,39.4668,,95.66,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,72.71,30,,72.71,percent of total billed charges,"Drugs, Inpatient Only",72.71,30,,72.71,percent of total billed charges,"Drugs, Inpatient Only",72.71,30,,72.71,percent of total billed charges,"Drugs, Inpatient Only",121.19,50,,121.19,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,51.6,,,51.6,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,169.67,70,,169.67,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,27.74,,,27.74,Other,Drug Cost,27.74,,,27.74,Other,Drug Cost,27.74,,,27.74,Other,Drug Cost,27.74,,,27.74,Other,Drug Cost,27.74,,,27.74,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,27.74,,,27.74,Other,Drug Cost,62.42,,,62.42,Other,225% Medicaid APG methodology,38.84,,,38.84,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,27.74,,,27.74,Other,Drug Cost,27.74,,,27.74,Other,Drug Cost,34.68,,,34.68,Other,125% Medicaid APG methodology,0.01,169.67,
ITRACONAZOLE 100MG CAPSULE      ,,,,40512816,CDM,250,RC,67877-0454-30,NDC,both,1,EA,5.53,2.18,39.4668,,2.18,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.66,30,,1.66,percent of total billed charges,"Drugs, Inpatient Only",1.66,30,,1.66,percent of total billed charges,"Drugs, Inpatient Only",1.66,30,,1.66,percent of total billed charges,"Drugs, Inpatient Only",2.77,50,,2.77,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.87,70,,3.87,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.27,,,0.27,Other,225% Medicaid APG methodology,0.17,,,0.17,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.15,,,0.15,Other,125% Medicaid APG methodology,0.01,3.87,
WARFARIN 10 MG TAB              ,,,,40512824,CDM,250,RC,00832-1219-01,NDC,both,1,EA,0.98,0.39,39.4668,,0.39,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.49,50,,0.49,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.69,70,,0.69,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.69,
LISINOPRIL 10 MG TAB            ,,,,40512832,CDM,250,RC,68180-0980-01,NDC,both,1,EA,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.04,50,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.05,
BUMETANIDE 1 MG TAB             ,,,,40512857,CDM,250,RC,51672-4224-01,NDC,both,1,EA,2.21,0.87,39.4668,,0.87,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.66,30,,0.66,percent of total billed charges,"Drugs, Inpatient Only",0.66,30,,0.66,percent of total billed charges,"Drugs, Inpatient Only",0.66,30,,0.66,percent of total billed charges,"Drugs, Inpatient Only",1.11,50,,1.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.55,70,,1.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,1.55,
DANAZOL 50 MG CAP               ,,,,40512873,CDM,250,RC,00527-1392-01,NDC,both,1,EA,6.97,2.75,39.4668,,2.75,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.09,30,,2.09,percent of total billed charges,"Drugs, Inpatient Only",2.09,30,,2.09,percent of total billed charges,"Drugs, Inpatient Only",2.09,30,,2.09,percent of total billed charges,"Drugs, Inpatient Only",3.49,50,,3.49,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.88,70,,4.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,4.88,
LITHIUM CARBONATE 450MG ER TAB  ,,,,40512899,CDM,250,RC,68084-0655-01,NDC,both,1,EA,1.79,0.71,39.4668,,0.71,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.54,30,,0.54,percent of total billed charges,"Drugs, Inpatient Only",0.54,30,,0.54,percent of total billed charges,"Drugs, Inpatient Only",0.54,30,,0.54,percent of total billed charges,"Drugs, Inpatient Only",0.9,50,,0.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.45,,,0.45,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.25,70,,1.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,Drug Cost,0.54,,,0.54,Other,225% Medicaid APG methodology,0.34,,,0.34,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.3,,,0.3,Other,125% Medicaid APG methodology,0.01,1.25,
RISPERIDONE 2 MG TAB            ,,,,40512907,CDM,250,RC,00904-7363-61,NDC,both,1,EA,1.02,0.4,39.4668,,0.4,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.31,30,,0.31,percent of total billed charges,"Drugs, Inpatient Only",0.31,30,,0.31,percent of total billed charges,"Drugs, Inpatient Only",0.31,30,,0.31,percent of total billed charges,"Drugs, Inpatient Only",0.51,50,,0.51,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.61,,,0.61,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.71,70,,0.71,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.33,,,0.33,Other,Drug Cost,0.74,,,0.74,Other,225% Medicaid APG methodology,0.46,,,0.46,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.41,,,0.41,Other,125% Medicaid APG methodology,0.01,0.74,
RISPERIDONE 3 MG TAB            ,,,,40512915,CDM,250,RC,00904-7364-61,NDC,both,1,EA,1.3,0.51,39.4668,,0.51,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.39,30,,0.39,percent of total billed charges,"Drugs, Inpatient Only",0.39,30,,0.39,percent of total billed charges,"Drugs, Inpatient Only",0.39,30,,0.39,percent of total billed charges,"Drugs, Inpatient Only",0.65,50,,0.65,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.69,,,0.69,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.91,70,,0.91,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,,,0.37,Other,Drug Cost,0.37,,,0.37,Other,Drug Cost,0.37,,,0.37,Other,Drug Cost,0.37,,,0.37,Other,Drug Cost,0.37,,,0.37,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.37,,,0.37,Other,Drug Cost,0.83,,,0.83,Other,225% Medicaid APG methodology,0.52,,,0.52,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.37,,,0.37,Other,Drug Cost,0.37,,,0.37,Other,Drug Cost,0.46,,,0.46,Other,125% Medicaid APG methodology,0.01,0.91,
FELBAMATE 120MG/ML ORL60ML BTL  ,,,,40512923,CDM,250,RC,51525-0442-08,NDC,both,60,ML,228.9,90.34,39.4668,,90.34,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,68.67,30,,68.67,percent of total billed charges,"Drugs, Inpatient Only",68.67,30,,68.67,percent of total billed charges,"Drugs, Inpatient Only",68.67,30,,68.67,percent of total billed charges,"Drugs, Inpatient Only",114.45,50,,114.45,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.93,,,8.93,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,160.23,70,,160.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.8,,,4.8,Other,Drug Cost,10.8,,,10.8,Other,225% Medicaid APG methodology,6.72,,,6.72,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,6,,,6,Other,125% Medicaid APG methodology,0.01,160.23,
FLUPHENAZINE 1 MG TAB           ,,,,40512931,CDM,250,RC,70954-0273-10,NDC,both,1,EA,1.33,0.52,39.4668,,0.52,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.4,30,,0.4,percent of total billed charges,"Drugs, Inpatient Only",0.4,30,,0.4,percent of total billed charges,"Drugs, Inpatient Only",0.4,30,,0.4,percent of total billed charges,"Drugs, Inpatient Only",0.67,50,,0.67,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.93,70,,0.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.23,,,0.23,Other,225% Medicaid APG methodology,0.14,,,0.14,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.13,,,0.13,Other,125% Medicaid APG methodology,0.01,0.93,
SIMETHICONE 80 MG CHEW TAB      ,,,,40513004,CDM,250,RC,70000-0434-01,NDC,both,1,EA,0.11,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.06,50,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.08,
POT CL 20 MEQ ER TAB            ,,,,40513038,CDM,250,RC,00904-7086-61,NDC,both,1,EA,1.02,0.4,39.4668,,0.4,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.31,30,,0.31,percent of total billed charges,"Drugs, Inpatient Only",0.31,30,,0.31,percent of total billed charges,"Drugs, Inpatient Only",0.31,30,,0.31,percent of total billed charges,"Drugs, Inpatient Only",0.51,50,,0.51,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.54,,,0.54,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.71,70,,0.71,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.29,,,0.29,Other,Drug Cost,0.65,,,0.65,Other,225% Medicaid APG methodology,0.41,,,0.41,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.36,,,0.36,Other,125% Medicaid APG methodology,0.01,0.71,
FLUCONAZOLE 200 MG TAB          ,,,,40513046,CDM,250,RC,63739-0115-10,NDC,both,1,EA,5.88,2.32,39.4668,,2.32,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.76,30,,1.76,percent of total billed charges,"Drugs, Inpatient Only",1.76,30,,1.76,percent of total billed charges,"Drugs, Inpatient Only",1.76,30,,1.76,percent of total billed charges,"Drugs, Inpatient Only",2.94,50,,2.94,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.22,,,3.22,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.12,70,,4.12,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.73,,,1.73,Other,Drug Cost,1.73,,,1.73,Other,Drug Cost,1.73,,,1.73,Other,Drug Cost,1.73,,,1.73,Other,Drug Cost,1.73,,,1.73,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.73,,,1.73,Other,Drug Cost,3.89,,,3.89,Other,225% Medicaid APG methodology,2.42,,,2.42,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.73,,,1.73,Other,Drug Cost,1.73,,,1.73,Other,Drug Cost,2.16,,,2.16,Other,125% Medicaid APG methodology,0.01,4.12,
CIPROFLOXACIN 750 MG TAB        ,,,,40513053,CDM,250,RC,55111-0128-50,NDC,both,1,EA,1.05,0.41,39.4668,,0.41,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.32,30,,0.32,percent of total billed charges,"Drugs, Inpatient Only",0.32,30,,0.32,percent of total billed charges,"Drugs, Inpatient Only",0.32,30,,0.32,percent of total billed charges,"Drugs, Inpatient Only",0.53,50,,0.53,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.74,70,,0.74,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.23,,,0.23,Other,225% Medicaid APG methodology,0.14,,,0.14,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.13,,,0.13,Other,125% Medicaid APG methodology,0.01,0.74,
METRONIDAZOLE 0.75% VAGGEL 70G  ,,,,40513087,CDM,250,RC,00781-7077-87,NDC,both,70,GM,404.25,159.54,39.4668,,159.54,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,121.28,30,,121.28,percent of total billed charges,"Drugs, Inpatient Only",121.28,30,,121.28,percent of total billed charges,"Drugs, Inpatient Only",121.28,30,,121.28,percent of total billed charges,"Drugs, Inpatient Only",202.13,50,,202.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,36.46,,,36.46,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,282.98,70,,282.98,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.6,,,19.6,Other,Drug Cost,19.6,,,19.6,Other,Drug Cost,19.6,,,19.6,Other,Drug Cost,19.6,,,19.6,Other,Drug Cost,19.6,,,19.6,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,19.6,,,19.6,Other,Drug Cost,44.1,,,44.1,Other,225% Medicaid APG methodology,27.44,,,27.44,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,19.6,,,19.6,Other,Drug Cost,19.6,,,19.6,Other,Drug Cost,24.5,,,24.5,Other,125% Medicaid APG methodology,0.01,282.98,
ISOSORBIDE MONO 60MG ER TAB     ,,,,40513111,CDM,250,RC,00904-6450-61,NDC,both,1,EA,0.98,0.39,39.4668,,0.39,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.49,50,,0.49,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.41,,,0.41,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.69,70,,0.69,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.5,,,0.5,Other,225% Medicaid APG methodology,0.31,,,0.31,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.28,,,0.28,Other,125% Medicaid APG methodology,0.01,0.69,
MESALAMINE 250 MG ER CAP        ,,,,40513137,CDM,250,RC,54092-0189-81,NDC,both,1,EA,10.05,3.97,39.4668,,3.97,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.02,30,,3.02,percent of total billed charges,"Drugs, Inpatient Only",3.02,30,,3.02,percent of total billed charges,"Drugs, Inpatient Only",3.02,30,,3.02,percent of total billed charges,"Drugs, Inpatient Only",5.03,50,,5.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.04,70,,7.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,7.04,
DOXAZOSIN 2 MG TAB              ,,,,40513152,CDM,250,RC,00049-2760-66,NDC,both,1,EA,15.4,6.08,39.4668,,6.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.62,30,,4.62,percent of total billed charges,"Drugs, Inpatient Only",4.62,30,,4.62,percent of total billed charges,"Drugs, Inpatient Only",4.62,30,,4.62,percent of total billed charges,"Drugs, Inpatient Only",7.7,50,,7.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.78,70,,10.78,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,10.78,
GABAPENTIN 300 MG CAP           ,,,,40513160,CDM,250,RC,67877-0223-01,NDC,both,1,EA,0.14,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.07,50,,0.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.1,
METOPROLOL SUCC 50MG ER TAB     ,,,,40513186,CDM,250,RC,60687-0402-65,NDC,both,1,EA,2.28,0.9,39.4668,,0.9,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.68,30,,0.68,percent of total billed charges,"Drugs, Inpatient Only",0.68,30,,0.68,percent of total billed charges,"Drugs, Inpatient Only",0.68,30,,0.68,percent of total billed charges,"Drugs, Inpatient Only",1.14,50,,1.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.21,,,1.21,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.6,70,,1.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.65,,,0.65,Other,Drug Cost,1.46,,,1.46,Other,225% Medicaid APG methodology,0.91,,,0.91,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.81,,,0.81,Other,125% Medicaid APG methodology,0.01,1.6,
DOXAZOSIN 4 MG TAB              ,,,,40513194,CDM,250,RC,16729-0213-01,NDC,both,1,EA,0.42,0.17,39.4668,,0.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.21,50,,0.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,70,,0.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.29,
LAMOTRIGINE 25 MG TAB           ,,,,40513285,CDM,250,RC,00904-7007-61,NDC,both,1,EA,0.39,0.15,39.4668,,0.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.2,50,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.27,70,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.27,,,0.27,Other,225% Medicaid APG methodology,0.17,,,0.17,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.15,,,0.15,Other,125% Medicaid APG methodology,0.01,0.27,
AMLODIPINE 2.5 MG TAB           ,,,,40513293,CDM,250,RC,00069-1520-68,NDC,both,1,EA,26.18,10.33,39.4668,,10.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.85,30,,7.85,percent of total billed charges,"Drugs, Inpatient Only",7.85,30,,7.85,percent of total billed charges,"Drugs, Inpatient Only",7.85,30,,7.85,percent of total billed charges,"Drugs, Inpatient Only",13.09,50,,13.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,18.33,70,,18.33,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,18.33,
FELODIPINE 5 MG ER TAB          ,,,,40513343,CDM,250,RC,23155-0049-01,NDC,both,1,EA,1.82,0.72,39.4668,,0.72,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.55,30,,0.55,percent of total billed charges,"Drugs, Inpatient Only",0.55,30,,0.55,percent of total billed charges,"Drugs, Inpatient Only",0.55,30,,0.55,percent of total billed charges,"Drugs, Inpatient Only",0.91,50,,0.91,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.27,70,,1.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% Medicaid APG methodology,0.11,,,0.11,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,1.27,
GLIPIZIDE 5 MG ER TAB           ,,,,40513376,CDM,250,RC,68084-0111-01,NDC,both,1,EA,1.79,0.71,39.4668,,0.71,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.54,30,,0.54,percent of total billed charges,"Drugs, Inpatient Only",0.54,30,,0.54,percent of total billed charges,"Drugs, Inpatient Only",0.54,30,,0.54,percent of total billed charges,"Drugs, Inpatient Only",0.9,50,,0.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.32,,,0.32,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.25,70,,1.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,Drug Cost,0.38,,,0.38,Other,225% Medicaid APG methodology,0.24,,,0.24,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.21,,,0.21,Other,125% Medicaid APG methodology,0.01,1.25,
GABAPENTIN 100 MG CAP           ,,,,40513426,CDM,250,RC,63739-0902-10,NDC,both,1,EA,0.28,0.11,39.4668,,0.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.14,50,,0.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,70,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.2,
METFORMIN 500 MG TAB            ,,,,40513434,CDM,250,RC,00904-7162-61,NDC,both,1,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.11,50,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.15,
METFORMIN 850 MG TAB            ,,,,40513442,CDM,250,RC,23155-0103-01,NDC,both,1,EA,0.11,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.06,50,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.08,
ESTRADIOL 1 MG TAB              ,,,,40513475,CDM,250,RC,70954-0565-10,NDC,both,1,EA,0.35,0.14,39.4668,,0.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.18,50,,0.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,70,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% Medicaid APG methodology,0.1,,,0.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.25,
BICITRA 334-500MG/5ML 15ML      ,,,,40513483,CDM,250,RC,00904-7316-80,NDC,both,15,ML,13.83,5.46,39.4668,,5.46,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.15,30,,4.15,percent of total billed charges,"Drugs, Inpatient Only",4.15,30,,4.15,percent of total billed charges,"Drugs, Inpatient Only",4.15,30,,4.15,percent of total billed charges,"Drugs, Inpatient Only",6.92,50,,6.92,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.37,,,7.37,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.68,70,,9.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.96,,,3.96,Other,Drug Cost,3.96,,,3.96,Other,Drug Cost,3.96,,,3.96,Other,Drug Cost,3.96,,,3.96,Other,Drug Cost,3.96,,,3.96,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.96,,,3.96,Other,Drug Cost,8.91,,,8.91,Other,225% Medicaid APG methodology,5.54,,,5.54,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.96,,,3.96,Other,Drug Cost,3.96,,,3.96,Other,Drug Cost,4.95,,,4.95,Other,125% Medicaid APG methodology,0.01,9.68,
HCTZ-TRIAMTERENE 25-37.5MG CAP  ,,,,40513491,CDM,250,RC,00527-1632-01,NDC,both,1,EA,0.39,0.15,39.4668,,0.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.2,50,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.27,70,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.27,
ATOVAQUONE 750MG/5ML ORL 5ML    ,,,,40513533,CDM,250,RC,50268-0086-12,NDC,both,5,ML,39.76,15.69,39.4668,,15.69,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.93,30,,11.93,percent of total billed charges,"Drugs, Inpatient Only",11.93,30,,11.93,percent of total billed charges,"Drugs, Inpatient Only",11.93,30,,11.93,percent of total billed charges,"Drugs, Inpatient Only",19.88,50,,19.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.6,,,13.6,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,27.83,70,,27.83,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.31,,,7.31,Other,Drug Cost,7.31,,,7.31,Other,Drug Cost,7.31,,,7.31,Other,Drug Cost,7.31,,,7.31,Other,Drug Cost,7.31,,,7.31,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,7.31,,,7.31,Other,Drug Cost,16.45,,,16.45,Other,225% Medicaid APG methodology,10.23,,,10.23,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.31,,,7.31,Other,Drug Cost,7.31,,,7.31,Other,Drug Cost,9.14,,,9.14,Other,125% Medicaid APG methodology,0.01,27.83,
ASPIRIN 81 MG EC TAB            ,,,,40513608,CDM,250,RC,63739-0522-10,NDC,both,1,EA,0.14,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.07,50,,0.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.1,
GABAPENTIN 400 MG CAP           ,,,,40513699,CDM,250,RC,67877-0224-01,NDC,both,1,EA,0.18,0.07,39.4668,,0.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.09,50,,0.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,70,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.13,
SUCRALFATE 1 G/10ML 10ML CUP    ,,,,40513707,CDM,250,RC,63739-0193-51,NDC,both,10,ML,26.64,10.51,39.4668,,10.51,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.99,30,,7.99,percent of total billed charges,"Drugs, Inpatient Only",7.99,30,,7.99,percent of total billed charges,"Drugs, Inpatient Only",7.99,30,,7.99,percent of total billed charges,"Drugs, Inpatient Only",13.32,50,,13.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.82,,,13.82,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,18.65,70,,18.65,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.43,,,7.43,Other,Drug Cost,7.43,,,7.43,Other,Drug Cost,7.43,,,7.43,Other,Drug Cost,7.43,,,7.43,Other,Drug Cost,7.43,,,7.43,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,7.43,,,7.43,Other,Drug Cost,16.72,,,16.72,Other,225% Medicaid APG methodology,10.4,,,10.4,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.43,,,7.43,Other,Drug Cost,7.43,,,7.43,Other,Drug Cost,9.29,,,9.29,Other,125% Medicaid APG methodology,0.01,18.65,
LAMIVUDINE 150 MG TAB           ,,,,40513715,CDM,250,RC,60687-0720-21,NDC,both,1,EA,24.36,9.61,39.4668,,9.61,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.31,30,,7.31,percent of total billed charges,"Drugs, Inpatient Only",7.31,30,,7.31,percent of total billed charges,"Drugs, Inpatient Only",7.31,30,,7.31,percent of total billed charges,"Drugs, Inpatient Only",12.18,50,,12.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.14,,,11.14,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,17.05,70,,17.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.99,,,5.99,Other,Drug Cost,5.99,,,5.99,Other,Drug Cost,5.99,,,5.99,Other,Drug Cost,5.99,,,5.99,Other,Drug Cost,5.99,,,5.99,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,5.99,,,5.99,Other,Drug Cost,13.48,,,13.48,Other,225% Medicaid APG methodology,8.39,,,8.39,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.99,,,5.99,Other,Drug Cost,5.99,,,5.99,Other,Drug Cost,7.49,,,7.49,Other,125% Medicaid APG methodology,0.01,17.05,
LAMIVUDINE 10MG/ML ORL  60ML    ,,,,40513723,CDM,250,RC,57237-0274-24,NDC,both,60,ML,67.2,26.52,39.4668,,26.52,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,20.16,30,,20.16,percent of total billed charges,"Drugs, Inpatient Only",20.16,30,,20.16,percent of total billed charges,"Drugs, Inpatient Only",20.16,30,,20.16,percent of total billed charges,"Drugs, Inpatient Only",33.6,50,,33.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.51,,,14.51,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,47.04,70,,47.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.8,,,7.8,Other,Drug Cost,7.8,,,7.8,Other,Drug Cost,7.8,,,7.8,Other,Drug Cost,7.8,,,7.8,Other,Drug Cost,7.8,,,7.8,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,7.8,,,7.8,Other,Drug Cost,17.55,,,17.55,Other,225% Medicaid APG methodology,10.92,,,10.92,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.8,,,7.8,Other,Drug Cost,7.8,,,7.8,Other,Drug Cost,9.75,,,9.75,Other,125% Medicaid APG methodology,0.01,47.04,
LABETALOL 300 MG TAB            ,,,,40513731,CDM,250,RC,70377-0062-12,NDC,both,1,EA,0.7,0.28,39.4668,,0.28,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.21,30,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.21,30,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.21,30,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.35,50,,0.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.49,70,,0.49,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% Medicaid APG methodology,0.1,,,0.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.49,
LABETALOL 200 MG TAB            ,,,,40513749,CDM,250,RC,60687-0450-01,NDC,both,1,EA,1.16,0.46,39.4668,,0.46,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.35,30,,0.35,percent of total billed charges,"Drugs, Inpatient Only",0.35,30,,0.35,percent of total billed charges,"Drugs, Inpatient Only",0.35,30,,0.35,percent of total billed charges,"Drugs, Inpatient Only",0.58,50,,0.58,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.86,,,0.86,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.81,70,,0.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.46,,,0.46,Other,Drug Cost,1.04,,,1.04,Other,225% Medicaid APG methodology,0.64,,,0.64,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.58,,,0.58,Other,125% Medicaid APG methodology,0.01,1.04,
CLOMIPRAMINE 50 MG CAP          ,,,,40513764,CDM,250,RC,51672-4012-06,NDC,both,1,EA,15.4,6.08,39.4668,,6.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.62,30,,4.62,percent of total billed charges,"Drugs, Inpatient Only",4.62,30,,4.62,percent of total billed charges,"Drugs, Inpatient Only",4.62,30,,4.62,percent of total billed charges,"Drugs, Inpatient Only",7.7,50,,7.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.42,,,2.42,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.78,70,,10.78,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.3,,,1.3,Other,Drug Cost,1.3,,,1.3,Other,Drug Cost,1.3,,,1.3,Other,Drug Cost,1.3,,,1.3,Other,Drug Cost,1.3,,,1.3,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.3,,,1.3,Other,Drug Cost,2.93,,,2.93,Other,225% Medicaid APG methodology,1.82,,,1.82,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.3,,,1.3,Other,Drug Cost,1.3,,,1.3,Other,Drug Cost,1.63,,,1.63,Other,125% Medicaid APG methodology,0.01,10.78,
ISOSORBIDE MONO 30MG ER TAB     ,,,,40513780,CDM,250,RC,62175-0128-37,NDC,both,1,EA,1.37,0.54,39.4668,,0.54,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.41,30,,0.41,percent of total billed charges,"Drugs, Inpatient Only",0.41,30,,0.41,percent of total billed charges,"Drugs, Inpatient Only",0.41,30,,0.41,percent of total billed charges,"Drugs, Inpatient Only",0.69,50,,0.69,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.96,70,,0.96,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.96,
TRETINOIN 10 MG CAP             ,,,,40513798,CDM,250,RC,68462-0792-01,NDC,both,1,EA,33.99,13.41,39.4668,,13.41,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.2,30,,10.2,percent of total billed charges,"Drugs, Inpatient Only",10.2,30,,10.2,percent of total billed charges,"Drugs, Inpatient Only",10.2,30,,10.2,percent of total billed charges,"Drugs, Inpatient Only",17,50,,17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.37,,,8.37,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,23.79,70,,23.79,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.5,,,4.5,Other,Drug Cost,4.5,,,4.5,Other,Drug Cost,4.5,,,4.5,Other,Drug Cost,4.5,,,4.5,Other,Drug Cost,4.5,,,4.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.5,,,4.5,Other,Drug Cost,10.13,,,10.13,Other,225% Medicaid APG methodology,6.3,,,6.3,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.5,,,4.5,Other,Drug Cost,4.5,,,4.5,Other,Drug Cost,5.63,,,5.63,Other,125% Medicaid APG methodology,0.01,23.79,
WARFARIN 1 MG TAB               ,,,,40513822,CDM,250,RC,00832-1211-01,NDC,both,1,EA,0.98,0.39,39.4668,,0.39,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.49,50,,0.49,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.69,70,,0.69,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.69,
CALCIUM CARB 1250MG/5ML CUP     ,,,,40513855,CDM,250,RC,00121-4766-05,NDC,both,5,ML,5.95,2.35,39.4668,,2.35,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.79,30,,1.79,percent of total billed charges,"Drugs, Inpatient Only",1.79,30,,1.79,percent of total billed charges,"Drugs, Inpatient Only",1.79,30,,1.79,percent of total billed charges,"Drugs, Inpatient Only",2.98,50,,2.98,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,,,0.37,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.17,70,,4.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.45,,,0.45,Other,225% Medicaid APG methodology,0.28,,,0.28,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.25,,,0.25,Other,125% Medicaid APG methodology,0.01,4.17,
METOPROLOL SUCC 100MG ER TAB    ,,,,40513871,CDM,250,RC,63739-0454-10,NDC,both,1,EA,2.8,1.11,39.4668,,1.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.84,30,,0.84,percent of total billed charges,"Drugs, Inpatient Only",0.84,30,,0.84,percent of total billed charges,"Drugs, Inpatient Only",0.84,30,,0.84,percent of total billed charges,"Drugs, Inpatient Only",1.4,50,,1.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.54,,,1.54,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.96,70,,1.96,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.83,,,0.83,Other,Drug Cost,0.83,,,0.83,Other,Drug Cost,0.83,,,0.83,Other,Drug Cost,0.83,,,0.83,Other,Drug Cost,0.83,,,0.83,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.83,,,0.83,Other,Drug Cost,1.87,,,1.87,Other,225% Medicaid APG methodology,1.16,,,1.16,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.83,,,0.83,Other,Drug Cost,0.83,,,0.83,Other,Drug Cost,1.04,,,1.04,Other,125% Medicaid APG methodology,0.01,1.96,
LAMOTRIGINE 100 MG TAB          ,,,,40513905,CDM,250,RC,00904-7008-61,NDC,both,1,EA,0.39,0.15,39.4668,,0.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.2,50,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.27,70,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.2,,,0.2,Other,225% Medicaid APG methodology,0.13,,,0.13,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,0.27,
SALIVA SUBS ORL SPRAY 44.3ML    ,,,,40513921,CDM,250,RC,48582-0001-55,NDC,both,44.3,ML,20.44,8.07,39.4668,,8.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.13,30,,6.13,percent of total billed charges,"Drugs, Inpatient Only",6.13,30,,6.13,percent of total billed charges,"Drugs, Inpatient Only",6.13,30,,6.13,percent of total billed charges,"Drugs, Inpatient Only",10.22,50,,10.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.86,,,10.86,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.31,70,,14.31,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.84,,,5.84,Other,Drug Cost,5.84,,,5.84,Other,Drug Cost,5.84,,,5.84,Other,Drug Cost,5.84,,,5.84,Other,Drug Cost,5.84,,,5.84,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,5.84,,,5.84,Other,Drug Cost,13.14,,,13.14,Other,225% Medicaid APG methodology,8.18,,,8.18,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.84,,,5.84,Other,Drug Cost,5.84,,,5.84,Other,Drug Cost,7.3,,,7.3,Other,125% Medicaid APG methodology,0.01,14.31,
VALACYCLOVIR 500 MG TAB         ,,,,40514010,CDM,250,RC,00904-6565-61,NDC,both,1,EA,4.59,1.81,39.4668,,1.81,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.38,30,,1.38,percent of total billed charges,"Drugs, Inpatient Only",1.38,30,,1.38,percent of total billed charges,"Drugs, Inpatient Only",1.38,30,,1.38,percent of total billed charges,"Drugs, Inpatient Only",2.3,50,,2.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.77,,,1.77,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.21,70,,3.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.95,,,0.95,Other,Drug Cost,0.95,,,0.95,Other,Drug Cost,0.95,,,0.95,Other,Drug Cost,0.95,,,0.95,Other,Drug Cost,0.95,,,0.95,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.95,,,0.95,Other,Drug Cost,2.14,,,2.14,Other,225% Medicaid APG methodology,1.33,,,1.33,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.95,,,0.95,Other,Drug Cost,0.95,,,0.95,Other,Drug Cost,1.19,,,1.19,Other,125% Medicaid APG methodology,0.01,3.21,
HYDROCORTISONE 10 MG TAB        ,,,,40514036,CDM,250,RC,59762-0074-01,NDC,both,1,EA,0.95,0.37,39.4668,,0.37,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.48,50,,0.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.67,70,,0.67,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.2,,,0.2,Other,225% Medicaid APG methodology,0.13,,,0.13,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,0.67,
AZITHROMYCIN 600 MG TAB         ,,,,40514051,CDM,250,RC,50111-0789-10,NDC,both,1,EA,14.95,5.9,39.4668,,5.9,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.49,30,,4.49,percent of total billed charges,"Drugs, Inpatient Only",4.49,30,,4.49,percent of total billed charges,"Drugs, Inpatient Only",4.49,30,,4.49,percent of total billed charges,"Drugs, Inpatient Only",7.48,50,,7.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.73,,,0.73,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.47,70,,10.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.39,,,0.39,Other,Drug Cost,0.88,,,0.88,Other,225% Medicaid APG methodology,0.55,,,0.55,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.49,,,0.49,Other,125% Medicaid APG methodology,0.01,10.47,
TORSEMIDE 10 MG TAB             ,,,,40514069,CDM,250,RC,31722-0530-01,NDC,both,1,EA,0.28,0.11,39.4668,,0.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.14,50,,0.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,70,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.2,
DONEPEZIL 10 MG TAB             ,,,,40514077,CDM,250,RC,00904-6478-61,NDC,both,1,EA,0.32,0.13,39.4668,,0.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.16,50,,0.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,70,,0.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% Medicaid APG methodology,0.11,,,0.11,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.22,
NEVIRAPINE 200 MG TAB           ,,,,40514101,CDM,250,RC,00597-0046-60,NDC,both,1,EA,51.52,20.33,39.4668,,20.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.46,30,,15.46,percent of total billed charges,"Drugs, Inpatient Only",15.46,30,,15.46,percent of total billed charges,"Drugs, Inpatient Only",15.46,30,,15.46,percent of total billed charges,"Drugs, Inpatient Only",25.76,50,,25.76,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.44,,,3.44,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,36.06,70,,36.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.85,,,1.85,Other,Drug Cost,1.85,,,1.85,Other,Drug Cost,1.85,,,1.85,Other,Drug Cost,1.85,,,1.85,Other,Drug Cost,1.85,,,1.85,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.85,,,1.85,Other,Drug Cost,4.16,,,4.16,Other,225% Medicaid APG methodology,2.59,,,2.59,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.85,,,1.85,Other,Drug Cost,1.85,,,1.85,Other,Drug Cost,2.31,,,2.31,Other,125% Medicaid APG methodology,0.01,36.06,
RAMIPRIL 5 MG CAP               ,,,,40514119,CDM,250,RC,65862-0476-01,NDC,both,1,EA,0.18,0.07,39.4668,,0.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.09,50,,0.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,70,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.13,
PILOCARPINE 5 MG TAB            ,,,,40514168,CDM,250,RC,62856-0705-10,NDC,both,1,EA,5.57,2.2,39.4668,,2.2,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.67,30,,1.67,percent of total billed charges,"Drugs, Inpatient Only",1.67,30,,1.67,percent of total billed charges,"Drugs, Inpatient Only",1.67,30,,1.67,percent of total billed charges,"Drugs, Inpatient Only",2.79,50,,2.79,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.9,70,,3.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,Drug Cost,0.32,,,0.32,Other,225% Medicaid APG methodology,0.2,,,0.2,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.18,,,0.18,Other,125% Medicaid APG methodology,0.01,3.9,
CARVEDILOL 3.125 MG TAB         ,,,,40514192,CDM,250,RC,00904-6300-61,NDC,both,1,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.11,50,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.15,
CARVEDILOL 12.5 MG TAB          ,,,,40514200,CDM,250,RC,68382-0094-01,NDC,both,1,EA,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.04,50,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.05,
LITHIUM CARBONATE 300MG ER TAB  ,,,,40514226,CDM,250,RC,68084-0640-01,NDC,both,1,EA,1.05,0.41,39.4668,,0.41,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.32,30,,0.32,percent of total billed charges,"Drugs, Inpatient Only",0.32,30,,0.32,percent of total billed charges,"Drugs, Inpatient Only",0.32,30,,0.32,percent of total billed charges,"Drugs, Inpatient Only",0.53,50,,0.53,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.41,,,0.41,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.74,70,,0.74,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.5,,,0.5,Other,225% Medicaid APG methodology,0.31,,,0.31,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.28,,,0.28,Other,125% Medicaid APG methodology,0.01,0.74,
LEVOFLOXACIN 250 MG TAB         ,,,,40514234,CDM,250,RC,55111-0279-50,NDC,both,1,EA,0.35,0.14,39.4668,,0.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.18,50,,0.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,70,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% Medicaid APG methodology,0.11,,,0.11,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.25,
LEVOFLOXACIN 500 MG TAB         ,,,,40514242,CDM,250,RC,00904-6352-61,NDC,both,1,EA,0.77,0.3,39.4668,,0.3,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.23,30,,0.23,percent of total billed charges,"Drugs, Inpatient Only",0.23,30,,0.23,percent of total billed charges,"Drugs, Inpatient Only",0.23,30,,0.23,percent of total billed charges,"Drugs, Inpatient Only",0.39,50,,0.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.54,70,,0.54,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.29,,,0.29,Other,225% Medicaid APG methodology,0.18,,,0.18,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.16,,,0.16,Other,125% Medicaid APG methodology,0.01,0.54,
NIFEDIPINE 30 MG ER TAB         ,,,,40514267,CDM,250,RC,68084-0597-01,NDC,both,1,EA,3.89,1.54,39.4668,,1.54,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.17,30,,1.17,percent of total billed charges,"Drugs, Inpatient Only",1.17,30,,1.17,percent of total billed charges,"Drugs, Inpatient Only",1.17,30,,1.17,percent of total billed charges,"Drugs, Inpatient Only",1.95,50,,1.95,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.08,,,1.08,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.72,70,,2.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.58,,,0.58,Other,Drug Cost,0.58,,,0.58,Other,Drug Cost,0.58,,,0.58,Other,Drug Cost,0.58,,,0.58,Other,Drug Cost,0.58,,,0.58,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.58,,,0.58,Other,Drug Cost,1.31,,,1.31,Other,225% Medicaid APG methodology,0.81,,,0.81,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.58,,,0.58,Other,Drug Cost,0.58,,,0.58,Other,Drug Cost,0.73,,,0.73,Other,125% Medicaid APG methodology,0.01,2.72,
NIFEDIPINE 60 MG ER TAB         ,,,,40514275,CDM,250,RC,50742-0621-01,NDC,both,1,EA,0.81,0.32,39.4668,,0.32,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.24,30,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.24,30,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.24,30,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.41,50,,0.41,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.57,70,,0.57,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% Medicaid APG methodology,0.1,,,0.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.57,
TAMSULOSIN 0.4 MG CAP           ,,,,40514283,CDM,250,RC,00904-6401-61,NDC,both,1,EA,0.84,0.33,39.4668,,0.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,30,,0.25,percent of total billed charges,"Drugs, Inpatient Only",0.25,30,,0.25,percent of total billed charges,"Drugs, Inpatient Only",0.25,30,,0.25,percent of total billed charges,"Drugs, Inpatient Only",0.42,50,,0.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.59,70,,0.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.59,
NIFEDIPINE 90 MG ER TAB         ,,,,40514309,CDM,250,RC,00904-7082-04,NDC,both,1,EA,8.44,3.33,39.4668,,3.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.53,30,,2.53,percent of total billed charges,"Drugs, Inpatient Only",2.53,30,,2.53,percent of total billed charges,"Drugs, Inpatient Only",2.53,30,,2.53,percent of total billed charges,"Drugs, Inpatient Only",4.22,50,,4.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.39,,,5.39,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.91,70,,5.91,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.9,,,2.9,Other,Drug Cost,2.9,,,2.9,Other,Drug Cost,2.9,,,2.9,Other,Drug Cost,2.9,,,2.9,Other,Drug Cost,2.9,,,2.9,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.9,,,2.9,Other,Drug Cost,6.53,,,6.53,Other,225% Medicaid APG methodology,4.06,,,4.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.9,,,2.9,Other,Drug Cost,2.9,,,2.9,Other,Drug Cost,3.63,,,3.63,Other,125% Medicaid APG methodology,0.01,6.53,
CARBAMAZEPINE 100 MG ER TAB     ,,,,40514317,CDM,250,RC,50742-0257-01,NDC,both,1,EA,0.74,0.29,39.4668,,0.29,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,30,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.22,30,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.22,30,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.37,50,,0.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.52,70,,0.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.2,,,0.2,Other,225% Medicaid APG methodology,0.13,,,0.13,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,0.52,
CARBAMAZEPINE 200 MG ER TAB     ,,,,40514325,CDM,250,RC,50742-0258-01,NDC,both,1,EA,1.26,0.5,39.4668,,0.5,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.38,30,,0.38,percent of total billed charges,"Drugs, Inpatient Only",0.38,30,,0.38,percent of total billed charges,"Drugs, Inpatient Only",0.38,30,,0.38,percent of total billed charges,"Drugs, Inpatient Only",0.63,50,,0.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.88,70,,0.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,Drug Cost,0.32,,,0.32,Other,225% Medicaid APG methodology,0.2,,,0.2,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.18,,,0.18,Other,125% Medicaid APG methodology,0.01,0.88,
LAMIVUDINE-ZIDOVU 150-300MGTAB  ,,,,40514341,CDM,250,RC,68084-0416-25,NDC,both,1,EA,30.87,12.18,39.4668,,12.18,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.26,30,,9.26,percent of total billed charges,"Drugs, Inpatient Only",9.26,30,,9.26,percent of total billed charges,"Drugs, Inpatient Only",9.26,30,,9.26,percent of total billed charges,"Drugs, Inpatient Only",15.44,50,,15.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.95,,,13.95,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,21.61,70,,21.61,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.5,,,7.5,Other,Drug Cost,7.5,,,7.5,Other,Drug Cost,7.5,,,7.5,Other,Drug Cost,7.5,,,7.5,Other,Drug Cost,7.5,,,7.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,7.5,,,7.5,Other,Drug Cost,16.88,,,16.88,Other,225% Medicaid APG methodology,10.5,,,10.5,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.5,,,7.5,Other,Drug Cost,7.5,,,7.5,Other,Drug Cost,9.38,,,9.38,Other,125% Medicaid APG methodology,0.01,21.61,
CLOPIDOGREL 75 MG TAB           ,,,,40514366,CDM,250,RC,00904-6294-61,NDC,both,1,EA,0.46,0.18,39.4668,,0.18,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.14,30,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,30,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,30,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.23,50,,0.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.32,70,,0.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.27,,,0.27,Other,225% Medicaid APG methodology,0.17,,,0.17,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.15,,,0.15,Other,125% Medicaid APG methodology,0.01,0.32,
LINEZOLID 600 MG TAB            ,,,,40514440,CDM,250,RC,60687-0309-21,NDC,both,1,EA,11.38,4.49,39.4668,,4.49,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.41,30,,3.41,percent of total billed charges,"Drugs, Inpatient Only",3.41,30,,3.41,percent of total billed charges,"Drugs, Inpatient Only",3.41,30,,3.41,percent of total billed charges,"Drugs, Inpatient Only",5.69,50,,5.69,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.91,,,4.91,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.97,70,,7.97,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.64,,,2.64,Other,Drug Cost,2.64,,,2.64,Other,Drug Cost,2.64,,,2.64,Other,Drug Cost,2.64,,,2.64,Other,Drug Cost,2.64,,,2.64,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.64,,,2.64,Other,Drug Cost,5.94,,,5.94,Other,225% Medicaid APG methodology,3.7,,,3.7,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.64,,,2.64,Other,Drug Cost,2.64,,,2.64,Other,Drug Cost,3.3,,,3.3,Other,125% Medicaid APG methodology,0.01,7.97,
PIOGLITAZONE 15 MG TAB          ,,,,40514457,CDM,250,RC,64764-0151-04,NDC,both,1,EA,42.04,16.59,39.4668,,16.59,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.61,30,,12.61,percent of total billed charges,"Drugs, Inpatient Only",12.61,30,,12.61,percent of total billed charges,"Drugs, Inpatient Only",12.61,30,,12.61,percent of total billed charges,"Drugs, Inpatient Only",21.02,50,,21.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.99,,,0.99,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,29.43,70,,29.43,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.53,,,0.53,Other,Drug Cost,0.53,,,0.53,Other,Drug Cost,0.53,,,0.53,Other,Drug Cost,0.53,,,0.53,Other,Drug Cost,0.53,,,0.53,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.53,,,0.53,Other,Drug Cost,1.19,,,1.19,Other,225% Medicaid APG methodology,0.74,,,0.74,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.53,,,0.53,Other,Drug Cost,0.53,,,0.53,Other,Drug Cost,0.66,,,0.66,Other,125% Medicaid APG methodology,0.01,29.43,
PIOGLITAZONE 30 MG TAB          ,,,,40514465,CDM,250,RC,64764-0301-14,NDC,both,1,EA,64.26,25.36,39.4668,,25.36,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.28,30,,19.28,percent of total billed charges,"Drugs, Inpatient Only",19.28,30,,19.28,percent of total billed charges,"Drugs, Inpatient Only",19.28,30,,19.28,percent of total billed charges,"Drugs, Inpatient Only",32.13,50,,32.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.92,,,1.92,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,44.98,70,,44.98,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.03,,,1.03,Other,Drug Cost,1.03,,,1.03,Other,Drug Cost,1.03,,,1.03,Other,Drug Cost,1.03,,,1.03,Other,Drug Cost,1.03,,,1.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.03,,,1.03,Other,Drug Cost,2.32,,,2.32,Other,225% Medicaid APG methodology,1.44,,,1.44,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.03,,,1.03,Other,Drug Cost,1.03,,,1.03,Other,Drug Cost,1.29,,,1.29,Other,125% Medicaid APG methodology,0.01,44.98,
PIOGLITAZONE 45 MG TAB          ,,,,40514473,CDM,250,RC,64764-0451-24,NDC,both,1,EA,69.72,27.52,39.4668,,27.52,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,20.92,30,,20.92,percent of total billed charges,"Drugs, Inpatient Only",20.92,30,,20.92,percent of total billed charges,"Drugs, Inpatient Only",20.92,30,,20.92,percent of total billed charges,"Drugs, Inpatient Only",34.86,50,,34.86,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.12,,,2.12,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,48.8,70,,48.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.14,,,1.14,Other,Drug Cost,2.57,,,2.57,Other,225% Medicaid APG methodology,1.6,,,1.6,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,1.43,,,1.43,Other,125% Medicaid APG methodology,0.01,48.8,
LOPNAVIR-RITONAVIR 200-50MGTAB  ,,,,40514481,CDM,250,RC,42385-0934-12,NDC,both,1,EA,19.11,7.54,39.4668,,7.54,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.73,30,,5.73,percent of total billed charges,"Drugs, Inpatient Only",5.73,30,,5.73,percent of total billed charges,"Drugs, Inpatient Only",5.73,30,,5.73,percent of total billed charges,"Drugs, Inpatient Only",9.56,50,,9.56,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.37,,,8.37,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.38,70,,13.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.5,,,4.5,Other,Drug Cost,4.5,,,4.5,Other,Drug Cost,4.5,,,4.5,Other,Drug Cost,4.5,,,4.5,Other,Drug Cost,4.5,,,4.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.5,,,4.5,Other,Drug Cost,10.13,,,10.13,Other,225% Medicaid APG methodology,6.3,,,6.3,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.5,,,4.5,Other,Drug Cost,4.5,,,4.5,Other,Drug Cost,5.63,,,5.63,Other,125% Medicaid APG methodology,0.01,13.38,
LOPI-RITO 400MG100MG/5ML 160ML  ,,,,40514499,CDM,250,RC,00074-3956-46,NDC,both,160,ML,1747.2,689.56,39.4668,,689.56,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,524.16,30,,524.16,percent of total billed charges,"Drugs, Inpatient Only",524.16,30,,524.16,percent of total billed charges,"Drugs, Inpatient Only",524.16,30,,524.16,percent of total billed charges,"Drugs, Inpatient Only",873.6,50,,873.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,479.14,,,479.14,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1223.04,70,,1223.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,257.6,,,257.6,Other,Drug Cost,257.6,,,257.6,Other,Drug Cost,257.6,,,257.6,Other,Drug Cost,257.6,,,257.6,Other,Drug Cost,257.6,,,257.6,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,257.6,,,257.6,Other,Drug Cost,579.6,,,579.6,Other,225% Medicaid APG methodology,360.64,,,360.64,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,257.6,,,257.6,Other,Drug Cost,257.6,,,257.6,Other,Drug Cost,322,,,322,Other,125% Medicaid APG methodology,0.01,1223.04,
BUPIV-EPI .25%-1:200000PF 30ML  ,,,,40514531,CDM,250,RC,00409-9042-17,NDC,both,30,ML,8.4,3.32,39.4668,,3.32,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.52,30,,2.52,percent of total billed charges,"Drugs, Inpatient Only",2.52,30,,2.52,percent of total billed charges,"Drugs, Inpatient Only",2.52,30,,2.52,percent of total billed charges,"Drugs, Inpatient Only",4.2,50,,4.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.23,,,2.23,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.88,70,,5.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.2,,,1.2,Other,Drug Cost,2.7,,,2.7,Other,225% Medicaid APG methodology,1.68,,,1.68,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,1.5,,,1.5,Other,125% Medicaid APG methodology,0.01,5.88,
SOD CHL 0.9% INJ FLUSH SLN 3ML  ,,,,40514648,CDM,250,RC,08290-3065-44,NDC,both,3,ML,1.37,0.54,39.4668,,0.54,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.41,30,,0.41,percent of total billed charges,"Drugs, Inpatient Only",0.41,30,,0.41,percent of total billed charges,"Drugs, Inpatient Only",0.41,30,,0.41,percent of total billed charges,"Drugs, Inpatient Only",0.69,50,,0.69,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.67,,,0.67,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.96,70,,0.96,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.36,,,0.36,Other,Drug Cost,0.81,,,0.81,Other,225% Medicaid APG methodology,0.5,,,0.5,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.45,,,0.45,Other,125% Medicaid APG methodology,0.01,0.96,
NICARDIPINE 2.5MG/ML IV  10ML   ,,,,40514788,CDM,250,RC,00143-9689-10,NDC,both,10,ML,51.8,20.44,39.4668,,20.44,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.54,30,,15.54,percent of total billed charges,"Drugs, Inpatient Only",15.54,30,,15.54,percent of total billed charges,"Drugs, Inpatient Only",15.54,30,,15.54,percent of total billed charges,"Drugs, Inpatient Only",25.9,50,,25.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.02,,,13.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,36.26,70,,36.26,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7,,,7,Other,Drug Cost,7,,,7,Other,Drug Cost,7,,,7,Other,Drug Cost,7,,,7,Other,Drug Cost,7,,,7,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,7,,,7,Other,Drug Cost,15.75,,,15.75,Other,225% Medicaid APG methodology,9.8,,,9.8,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7,,,7,Other,Drug Cost,7,,,7,Other,Drug Cost,8.75,,,8.75,Other,125% Medicaid APG methodology,0.01,36.26,
ROCURONIUM BR 10MG/ML 10ML VL   ,,,,40514820,CDM,250,RC,00409-9558-10,NDC,both,10,ML,16.1,6.35,39.4668,,6.35,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.83,30,,4.83,percent of total billed charges,"Drugs, Inpatient Only",4.83,30,,4.83,percent of total billed charges,"Drugs, Inpatient Only",4.83,30,,4.83,percent of total billed charges,"Drugs, Inpatient Only",8.05,50,,8.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.25,,,7.25,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.27,70,,11.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.9,,,3.9,Other,Drug Cost,3.9,,,3.9,Other,Drug Cost,3.9,,,3.9,Other,Drug Cost,3.9,,,3.9,Other,Drug Cost,3.9,,,3.9,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.9,,,3.9,Other,Drug Cost,8.78,,,8.78,Other,225% Medicaid APG methodology,5.46,,,5.46,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.9,,,3.9,Other,Drug Cost,3.9,,,3.9,Other,Drug Cost,4.88,,,4.88,Other,125% Medicaid APG methodology,0.01,11.27,
CISATRACURIUM 2MG/ML IV  10ML   ,,,,40515082,CDM,250,RC,00781-3152-95,NDC,both,10,ML,32.55,12.85,39.4668,,12.85,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.77,30,,9.77,percent of total billed charges,"Drugs, Inpatient Only",9.77,30,,9.77,percent of total billed charges,"Drugs, Inpatient Only",9.77,30,,9.77,percent of total billed charges,"Drugs, Inpatient Only",16.28,50,,16.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,17.3,,,17.3,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,22.79,70,,22.79,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.3,,,9.3,Other,Drug Cost,9.3,,,9.3,Other,Drug Cost,9.3,,,9.3,Other,Drug Cost,9.3,,,9.3,Other,Drug Cost,9.3,,,9.3,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,9.3,,,9.3,Other,Drug Cost,20.93,,,20.93,Other,225% Medicaid APG methodology,13.02,,,13.02,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,9.3,,,9.3,Other,Drug Cost,9.3,,,9.3,Other,Drug Cost,11.63,,,11.63,Other,125% Medicaid APG methodology,0.01,22.79,
VALPROIC ACID 100MG/ML IV 5ML   ,,,,40515371,CDM,250,RC,63323-0494-05,NDC,both,5,ML,22.05,8.7,39.4668,,8.7,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.62,30,,6.62,percent of total billed charges,"Drugs, Inpatient Only",6.62,30,,6.62,percent of total billed charges,"Drugs, Inpatient Only",6.62,30,,6.62,percent of total billed charges,"Drugs, Inpatient Only",11.03,50,,11.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.02,,,5.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.44,70,,15.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.7,,,2.7,Other,Drug Cost,6.08,,,6.08,Other,225% Medicaid APG methodology,3.78,,,3.78,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,3.38,,,3.38,Other,125% Medicaid APG methodology,0.01,15.44,
D5W 0.45% NACL KCL 20MEQ/L IV   ,,,,40515801,CDM,250,RC,00338-0671-04,NDC,both,1000,ML,9.94,3.92,39.4668,,3.92,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.98,30,,2.98,percent of total billed charges,"Drugs, Inpatient Only",2.98,30,,2.98,percent of total billed charges,"Drugs, Inpatient Only",2.98,30,,2.98,percent of total billed charges,"Drugs, Inpatient Only",4.97,50,,4.97,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.56,,,8.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.96,70,,6.96,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.6,,,4.6,Other,Drug Cost,4.6,,,4.6,Other,Drug Cost,4.6,,,4.6,Other,Drug Cost,4.6,,,4.6,Other,Drug Cost,4.6,,,4.6,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.6,,,4.6,Other,Drug Cost,10.35,,,10.35,Other,225% Medicaid APG methodology,6.44,,,6.44,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.6,,,4.6,Other,Drug Cost,4.6,,,4.6,Other,Drug Cost,5.75,,,5.75,Other,125% Medicaid APG methodology,0.01,10.35,
NITROGLYCERIN 0.3MG/HR TD ER    ,,,,40515850,CDM,250,RC,50742-0515-30,NDC,both,1,EA,172.41,68.04,39.4668,,68.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,51.72,30,,51.72,percent of total billed charges,"Drugs, Inpatient Only",51.72,30,,51.72,percent of total billed charges,"Drugs, Inpatient Only",51.72,30,,51.72,percent of total billed charges,"Drugs, Inpatient Only",86.21,50,,86.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,120.69,70,,120.69,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,120.69,
NITROGLYCERIN 0.6MG/HR TD ER    ,,,,40515868,CDM,250,RC,00378-9116-93,NDC,both,1,EA,2.63,1.04,39.4668,,1.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.79,30,,0.79,percent of total billed charges,"Drugs, Inpatient Only",0.79,30,,0.79,percent of total billed charges,"Drugs, Inpatient Only",0.79,30,,0.79,percent of total billed charges,"Drugs, Inpatient Only",1.32,50,,1.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.76,,,0.76,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.84,70,,1.84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.41,,,0.41,Other,Drug Cost,0.92,,,0.92,Other,225% Medicaid APG methodology,0.57,,,0.57,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.51,,,0.51,Other,125% Medicaid APG methodology,0.01,1.84,
CLONIDINE 0.1MG/24 HR TD ER     ,,,,40515884,CDM,250,RC,00378-0871-99,NDC,both,1,EA,34.55,13.64,39.4668,,13.64,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.37,30,,10.37,percent of total billed charges,"Drugs, Inpatient Only",10.37,30,,10.37,percent of total billed charges,"Drugs, Inpatient Only",10.37,30,,10.37,percent of total billed charges,"Drugs, Inpatient Only",17.28,50,,17.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.41,,,5.41,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,24.19,70,,24.19,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.91,,,2.91,Other,Drug Cost,2.91,,,2.91,Other,Drug Cost,2.91,,,2.91,Other,Drug Cost,2.91,,,2.91,Other,Drug Cost,2.91,,,2.91,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.91,,,2.91,Other,Drug Cost,6.55,,,6.55,Other,225% Medicaid APG methodology,4.07,,,4.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.91,,,2.91,Other,Drug Cost,2.91,,,2.91,Other,Drug Cost,3.64,,,3.64,Other,125% Medicaid APG methodology,0.01,24.19,
CLONIDINE 0.2MG/24 HR TD ER     ,,,,40515892,CDM,250,RC,00378-0872-99,NDC,both,1,EA,55.3,21.83,39.4668,,21.83,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,16.59,30,,16.59,percent of total billed charges,"Drugs, Inpatient Only",16.59,30,,16.59,percent of total billed charges,"Drugs, Inpatient Only",16.59,30,,16.59,percent of total billed charges,"Drugs, Inpatient Only",27.65,50,,27.65,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.5,,,9.5,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,38.71,70,,38.71,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.11,,,5.11,Other,Drug Cost,5.11,,,5.11,Other,Drug Cost,5.11,,,5.11,Other,Drug Cost,5.11,,,5.11,Other,Drug Cost,5.11,,,5.11,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,5.11,,,5.11,Other,Drug Cost,11.5,,,11.5,Other,225% Medicaid APG methodology,7.15,,,7.15,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.11,,,5.11,Other,Drug Cost,5.11,,,5.11,Other,Drug Cost,6.39,,,6.39,Other,125% Medicaid APG methodology,0.01,38.71,
CLONIDINE 0.3MG/24 HR TD ER     ,,,,40515900,CDM,250,RC,00378-0873-99,NDC,both,1,EA,60.55,23.9,39.4668,,23.9,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,18.17,30,,18.17,percent of total billed charges,"Drugs, Inpatient Only",18.17,30,,18.17,percent of total billed charges,"Drugs, Inpatient Only",18.17,30,,18.17,percent of total billed charges,"Drugs, Inpatient Only",30.28,50,,30.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.74,,,12.74,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,42.39,70,,42.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.85,,,6.85,Other,Drug Cost,6.85,,,6.85,Other,Drug Cost,6.85,,,6.85,Other,Drug Cost,6.85,,,6.85,Other,Drug Cost,6.85,,,6.85,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,6.85,,,6.85,Other,Drug Cost,15.41,,,15.41,Other,225% Medicaid APG methodology,9.59,,,9.59,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.85,,,6.85,Other,Drug Cost,6.85,,,6.85,Other,Drug Cost,8.56,,,8.56,Other,125% Medicaid APG methodology,0.01,42.39,
ECONAZOLE 1% CREAM 15 G         ,,,,40515918,CDM,250,RC,45802-0466-35,NDC,both,15,GM,306.08,120.8,39.4668,,120.8,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,91.82,30,,91.82,percent of total billed charges,"Drugs, Inpatient Only",91.82,30,,91.82,percent of total billed charges,"Drugs, Inpatient Only",91.82,30,,91.82,percent of total billed charges,"Drugs, Inpatient Only",153.04,50,,153.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,44.64,,,44.64,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,214.26,70,,214.26,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,24,,,24,Other,Drug Cost,24,,,24,Other,Drug Cost,24,,,24,Other,Drug Cost,24,,,24,Other,Drug Cost,24,,,24,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,24,,,24,Other,Drug Cost,54,,,54,Other,225% Medicaid APG methodology,33.6,,,33.6,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,24,,,24,Other,Drug Cost,24,,,24,Other,Drug Cost,30,,,30,Other,125% Medicaid APG methodology,0.01,214.26,
HYDROCORTISONE 2.5% CREAM 30 G  ,,,,40515934,CDM,250,RC,00168-0080-31,NDC,both,30,GM,6.3,2.49,39.4668,,2.49,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.89,30,,1.89,percent of total billed charges,"Drugs, Inpatient Only",1.89,30,,1.89,percent of total billed charges,"Drugs, Inpatient Only",1.89,30,,1.89,percent of total billed charges,"Drugs, Inpatient Only",3.15,50,,3.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.23,,,2.23,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.41,70,,4.41,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.2,,,1.2,Other,Drug Cost,2.7,,,2.7,Other,225% Medicaid APG methodology,1.68,,,1.68,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,1.5,,,1.5,Other,125% Medicaid APG methodology,0.01,4.41,
DINOPROSTONE 10 MG INS          ,,,,40515975,CDM,250,RC,55566-2800-01,NDC,both,1,EA,1358.88,536.31,39.4668,,536.31,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,407.66,30,,407.66,percent of total billed charges,"Drugs, Inpatient Only",407.66,30,,407.66,percent of total billed charges,"Drugs, Inpatient Only",407.66,30,,407.66,percent of total billed charges,"Drugs, Inpatient Only",679.44,50,,679.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,237.56,,,237.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,951.22,70,,951.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,127.72,,,127.72,Other,Drug Cost,127.72,,,127.72,Other,Drug Cost,127.72,,,127.72,Other,Drug Cost,127.72,,,127.72,Other,Drug Cost,127.72,,,127.72,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,127.72,,,127.72,Other,Drug Cost,287.37,,,287.37,Other,225% Medicaid APG methodology,178.81,,,178.81,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,127.72,,,127.72,Other,Drug Cost,127.72,,,127.72,Other,Drug Cost,159.65,,,159.65,Other,125% Medicaid APG methodology,0.01,951.22,
HYDROCORTISONE 25MG RECTSUPP    ,,,,40516015,CDM,250,RC,65649-0411-24,NDC,both,1,EA,20.69,8.17,39.4668,,8.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.21,30,,6.21,percent of total billed charges,"Drugs, Inpatient Only",6.21,30,,6.21,percent of total billed charges,"Drugs, Inpatient Only",6.21,30,,6.21,percent of total billed charges,"Drugs, Inpatient Only",10.35,50,,10.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.22,,,3.22,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.48,70,,14.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.73,,,1.73,Other,Drug Cost,1.73,,,1.73,Other,Drug Cost,1.73,,,1.73,Other,Drug Cost,1.73,,,1.73,Other,Drug Cost,1.73,,,1.73,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.73,,,1.73,Other,Drug Cost,3.89,,,3.89,Other,225% Medicaid APG methodology,2.42,,,2.42,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.73,,,1.73,Other,Drug Cost,1.73,,,1.73,Other,Drug Cost,2.16,,,2.16,Other,125% Medicaid APG methodology,0.01,14.48,
MESALAMINE 1000 MG RECTAL SUPP  ,,,,40516031,CDM,250,RC,58914-0501-56,NDC,both,1,EA,128.17,50.58,39.4668,,50.58,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,38.45,30,,38.45,percent of total billed charges,"Drugs, Inpatient Only",38.45,30,,38.45,percent of total billed charges,"Drugs, Inpatient Only",38.45,30,,38.45,percent of total billed charges,"Drugs, Inpatient Only",64.09,50,,64.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,89.72,70,,89.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,89.72,
BETAXOLOL 0.25% OPT SUSP 10ML   ,,,,40516098,CDM,250,RC,00065-0246-10,NDC,both,10,ML,1010.35,398.75,39.4668,,398.75,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,303.11,30,,303.11,percent of total billed charges,"Drugs, Inpatient Only",303.11,30,,303.11,percent of total billed charges,"Drugs, Inpatient Only",303.11,30,,303.11,percent of total billed charges,"Drugs, Inpatient Only",505.18,50,,505.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,707.25,70,,707.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.23,,,0.23,Other,225% Medicaid APG methodology,0.14,,,0.14,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.13,,,0.13,Other,125% Medicaid APG methodology,0.01,707.25,
TROPICAMIDE 0.5% OPT SLN 15ML   ,,,,40516114,CDM,250,RC,61314-0354-01,NDC,both,15,ML,70.88,27.97,39.4668,,27.97,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,21.26,30,,21.26,percent of total billed charges,"Drugs, Inpatient Only",21.26,30,,21.26,percent of total billed charges,"Drugs, Inpatient Only",21.26,30,,21.26,percent of total billed charges,"Drugs, Inpatient Only",35.44,50,,35.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.93,,,8.93,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,49.62,70,,49.62,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.8,,,4.8,Other,Drug Cost,10.8,,,10.8,Other,225% Medicaid APG methodology,6.72,,,6.72,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,6,,,6,Other,125% Medicaid APG methodology,0.01,49.62,
LATANOPROST 0.005% OPT 2.5ML    ,,,,40516163,CDM,250,RC,24208-0463-25,NDC,both,2.5,ML,58.49,23.08,39.4668,,23.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,17.55,30,,17.55,percent of total billed charges,"Drugs, Inpatient Only",17.55,30,,17.55,percent of total billed charges,"Drugs, Inpatient Only",17.55,30,,17.55,percent of total billed charges,"Drugs, Inpatient Only",29.25,50,,29.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.09,,,3.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,40.94,70,,40.94,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.66,,,1.66,Other,Drug Cost,1.66,,,1.66,Other,Drug Cost,1.66,,,1.66,Other,Drug Cost,1.66,,,1.66,Other,Drug Cost,1.66,,,1.66,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.66,,,1.66,Other,Drug Cost,3.74,,,3.74,Other,225% Medicaid APG methodology,2.32,,,2.32,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.66,,,1.66,Other,Drug Cost,1.66,,,1.66,Other,Drug Cost,2.08,,,2.08,Other,125% Medicaid APG methodology,0.01,40.94,
IPRATROPIUM 0.5MG/2.5ML INH     ,,,,40516221,CDM,250,RC,76204-0100-30,NDC,both,2.5,ML,0.53,0.21,39.4668,,0.21,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.27,50,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,70,,0.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% Medicaid APG methodology,0.1,,,0.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.37,
CALCITONIN 200UNIT NASAL 3.7ML  ,,,,40516254,CDM,250,RC,49884-0161-11,NDC,both,3.7,ML,81.34,32.1,39.4668,,32.1,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,24.4,30,,24.4,percent of total billed charges,"Drugs, Inpatient Only",24.4,30,,24.4,percent of total billed charges,"Drugs, Inpatient Only",24.4,30,,24.4,percent of total billed charges,"Drugs, Inpatient Only",40.67,50,,40.67,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,56.94,70,,56.94,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% Medicaid APG methodology,0.1,,,0.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,56.94,
VORICONAZOLE 200 MG TAB         ,,,,40516270,CDM,250,RC,63739-0008-33,NDC,both,1,EA,64.19,25.33,39.4668,,25.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.26,30,,19.26,percent of total billed charges,"Drugs, Inpatient Only",19.26,30,,19.26,percent of total billed charges,"Drugs, Inpatient Only",19.26,30,,19.26,percent of total billed charges,"Drugs, Inpatient Only",32.1,50,,32.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.41,,,0.41,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,44.93,70,,44.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.5,,,0.5,Other,225% Medicaid APG methodology,0.31,,,0.31,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.28,,,0.28,Other,125% Medicaid APG methodology,0.01,44.93,
ARIPIPRAZOLE 10 MG TAB          ,,,,40516288,CDM,250,RC,00904-7368-61,NDC,both,1,EA,12.95,5.11,39.4668,,5.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.89,30,,3.89,percent of total billed charges,"Drugs, Inpatient Only",3.89,30,,3.89,percent of total billed charges,"Drugs, Inpatient Only",3.89,30,,3.89,percent of total billed charges,"Drugs, Inpatient Only",6.48,50,,6.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.37,,,8.37,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.07,70,,9.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.5,,,4.5,Other,Drug Cost,4.5,,,4.5,Other,Drug Cost,4.5,,,4.5,Other,Drug Cost,4.5,,,4.5,Other,Drug Cost,4.5,,,4.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.5,,,4.5,Other,Drug Cost,10.13,,,10.13,Other,225% Medicaid APG methodology,6.3,,,6.3,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.5,,,4.5,Other,Drug Cost,4.5,,,4.5,Other,Drug Cost,5.63,,,5.63,Other,125% Medicaid APG methodology,0.01,10.13,
ARIPIPRAZOLE 15 MG TAB          ,,,,40516296,CDM,250,RC,50268-0090-12,NDC,both,1,EA,19.18,7.57,39.4668,,7.57,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.75,30,,5.75,percent of total billed charges,"Drugs, Inpatient Only",5.75,30,,5.75,percent of total billed charges,"Drugs, Inpatient Only",5.75,30,,5.75,percent of total billed charges,"Drugs, Inpatient Only",9.59,50,,9.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.3,,,10.3,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.43,70,,13.43,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.54,,,5.54,Other,Drug Cost,5.54,,,5.54,Other,Drug Cost,5.54,,,5.54,Other,Drug Cost,5.54,,,5.54,Other,Drug Cost,5.54,,,5.54,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,5.54,,,5.54,Other,Drug Cost,12.47,,,12.47,Other,225% Medicaid APG methodology,7.76,,,7.76,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.54,,,5.54,Other,Drug Cost,5.54,,,5.54,Other,Drug Cost,6.93,,,6.93,Other,125% Medicaid APG methodology,0.01,13.43,
METRONIDAZOLE 500 MG TAB        ,,,,40516338,CDM,250,RC,72578-0008-01,NDC,both,1,EA,0.53,0.21,39.4668,,0.21,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.27,50,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,70,,0.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.37,
METOPROLOL TARTRATE 25 MG TAB   ,,,,40516379,CDM,250,RC,51079-0255-20,NDC,both,1,EA,0.18,0.07,39.4668,,0.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.09,50,,0.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,70,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.13,
EPLERENONE 25 MG TAB            ,,,,40516403,CDM,250,RC,00378-1030-93,NDC,both,1,EA,3.71,1.46,39.4668,,1.46,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.11,30,,1.11,percent of total billed charges,"Drugs, Inpatient Only",1.11,30,,1.11,percent of total billed charges,"Drugs, Inpatient Only",1.11,30,,1.11,percent of total billed charges,"Drugs, Inpatient Only",1.86,50,,1.86,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.63,,,0.63,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.6,70,,2.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.34,,,0.34,Other,Drug Cost,0.77,,,0.77,Other,225% Medicaid APG methodology,0.48,,,0.48,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.43,,,0.43,Other,125% Medicaid APG methodology,0.01,2.6,
MEDROXYPROGESTERONE 10 MG TAB   ,,,,40516429,CDM,250,RC,00009-0050-02,NDC,both,1,EA,16.28,6.43,39.4668,,6.43,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.88,30,,4.88,percent of total billed charges,"Drugs, Inpatient Only",4.88,30,,4.88,percent of total billed charges,"Drugs, Inpatient Only",4.88,30,,4.88,percent of total billed charges,"Drugs, Inpatient Only",8.14,50,,8.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.4,70,,11.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,11.4,
MEDROXYPROGESTERONE 2.5 MG TAB  ,,,,40516437,CDM,250,RC,59762-0055-01,NDC,both,1,EA,0.49,0.19,39.4668,,0.19,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.25,50,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.34,70,,0.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.34,
MEDROXYPROGESTERONE 5 MG TAB    ,,,,40516445,CDM,250,RC,00555-0873-02,NDC,both,1,EA,0.42,0.17,39.4668,,0.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.21,50,,0.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,70,,0.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.29,
METHYLERGONOVINE 0.2 MG TAB     ,,,,40516486,CDM,250,RC,27437-0050-57,NDC,both,1,EA,206.01,81.31,39.4668,,81.31,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,61.8,30,,61.8,percent of total billed charges,"Drugs, Inpatient Only",61.8,30,,61.8,percent of total billed charges,"Drugs, Inpatient Only",61.8,30,,61.8,percent of total billed charges,"Drugs, Inpatient Only",103.01,50,,103.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,85.84,,,85.84,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,144.21,70,,144.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,46.15,,,46.15,Other,Drug Cost,46.15,,,46.15,Other,Drug Cost,46.15,,,46.15,Other,Drug Cost,46.15,,,46.15,Other,Drug Cost,46.15,,,46.15,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,46.15,,,46.15,Other,Drug Cost,103.84,,,103.84,Other,225% Medicaid APG methodology,64.61,,,64.61,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,46.15,,,46.15,Other,Drug Cost,46.15,,,46.15,Other,Drug Cost,57.69,,,57.69,Other,125% Medicaid APG methodology,0.01,144.21,
CARBOPROST 250 MCG/ML INJ  1ML  ,,,,40516502,CDM,250,RC,00009-0856-08,NDC,both,1,ML,897.33,354.15,39.4668,,354.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,269.2,30,,269.2,percent of total billed charges,"Drugs, Inpatient Only",269.2,30,,269.2,percent of total billed charges,"Drugs, Inpatient Only",269.2,30,,269.2,percent of total billed charges,"Drugs, Inpatient Only",448.67,50,,448.67,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,628.13,70,,628.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,628.13,
BUPIV 0.25% PF INJ SLN 30ML     ,,,,40516577,CDM,250,RC,00409-1159-02,NDC,both,30,ML,4.2,1.66,39.4668,,1.66,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.26,30,,1.26,percent of total billed charges,"Drugs, Inpatient Only",1.26,30,,1.26,percent of total billed charges,"Drugs, Inpatient Only",1.26,30,,1.26,percent of total billed charges,"Drugs, Inpatient Only",2.1,50,,2.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.79,,,2.79,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.94,70,,2.94,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.5,,,1.5,Other,Drug Cost,3.38,,,3.38,Other,225% Medicaid APG methodology,2.1,,,2.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.88,,,1.88,Other,125% Medicaid APG methodology,0.01,3.38,
BUPIV 0.5% PF INJ SLN 30ML      ,,,,40516585,CDM,250,RC,55150-0170-30,NDC,both,30,ML,7.35,2.9,39.4668,,2.9,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.21,30,,2.21,percent of total billed charges,"Drugs, Inpatient Only",2.21,30,,2.21,percent of total billed charges,"Drugs, Inpatient Only",2.21,30,,2.21,percent of total billed charges,"Drugs, Inpatient Only",3.68,50,,3.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.23,,,2.23,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.15,70,,5.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.2,,,1.2,Other,Drug Cost,2.7,,,2.7,Other,225% Medicaid APG methodology,1.68,,,1.68,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,1.5,,,1.5,Other,125% Medicaid APG methodology,0.01,5.15,
PENTOXIFYLLINE 400 MG ER TAB    ,,,,40516643,CDM,250,RC,00904-5448-61,NDC,both,1,EA,0.42,0.17,39.4668,,0.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.21,50,,0.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,70,,0.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.29,,,0.29,Other,225% Medicaid APG methodology,0.18,,,0.18,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.16,,,0.16,Other,125% Medicaid APG methodology,0.01,0.29,
LIDOCAINE 1% INJ SOLN 20 ML     ,,,,40516692,CDM,250,RC,70756-0646-25,NDC,both,20,ML,3.15,1.24,39.4668,,1.24,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.95,30,,0.95,percent of total billed charges,"Drugs, Inpatient Only",0.95,30,,0.95,percent of total billed charges,"Drugs, Inpatient Only",0.95,30,,0.95,percent of total billed charges,"Drugs, Inpatient Only",1.58,50,,1.58,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.69,,,1.69,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.21,70,,2.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.91,,,0.91,Other,Drug Cost,2.05,,,2.05,Other,225% Medicaid APG methodology,1.27,,,1.27,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,1.14,,,1.14,Other,125% Medicaid APG methodology,0.01,2.21,
LIDOCAINE 2% INJ SOLN 20 ML     ,,,,40516700,CDM,250,RC,55150-0255-20,NDC,both,20,ML,2.91,1.15,39.4668,,1.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.87,30,,0.87,percent of total billed charges,"Drugs, Inpatient Only",0.87,30,,0.87,percent of total billed charges,"Drugs, Inpatient Only",0.87,30,,0.87,percent of total billed charges,"Drugs, Inpatient Only",1.46,50,,1.46,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.45,,,1.45,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.04,70,,2.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.78,,,0.78,Other,Drug Cost,0.78,,,0.78,Other,Drug Cost,0.78,,,0.78,Other,Drug Cost,0.78,,,0.78,Other,Drug Cost,0.78,,,0.78,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.78,,,0.78,Other,Drug Cost,1.76,,,1.76,Other,225% Medicaid APG methodology,1.09,,,1.09,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.78,,,0.78,Other,Drug Cost,0.78,,,0.78,Other,Drug Cost,0.98,,,0.98,Other,125% Medicaid APG methodology,0.01,2.04,
LIDOCAINE 2% TOPICAL GEL 30 ML  ,,,,40516718,CDM,250,RC,17478-0711-30,NDC,both,30,ML,253.05,99.87,39.4668,,99.87,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,75.92,30,,75.92,percent of total billed charges,"Drugs, Inpatient Only",75.92,30,,75.92,percent of total billed charges,"Drugs, Inpatient Only",75.92,30,,75.92,percent of total billed charges,"Drugs, Inpatient Only",126.53,50,,126.53,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.56,,,0.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,177.14,70,,177.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.68,,,0.68,Other,225% Medicaid APG methodology,0.42,,,0.42,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.38,,,0.38,Other,125% Medicaid APG methodology,0.01,177.14,
LIDOCAINE 5% TOPICAL OINT 35 G  ,,,,40516726,CDM,250,RC,69680-0120-35,NDC,both,35,GM,169.05,66.72,39.4668,,66.72,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,50.72,30,,50.72,percent of total billed charges,"Drugs, Inpatient Only",50.72,30,,50.72,percent of total billed charges,"Drugs, Inpatient Only",50.72,30,,50.72,percent of total billed charges,"Drugs, Inpatient Only",84.53,50,,84.53,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.02,,,13.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,118.34,70,,118.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7,,,7,Other,Drug Cost,7,,,7,Other,Drug Cost,7,,,7,Other,Drug Cost,7,,,7,Other,Drug Cost,7,,,7,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,7,,,7,Other,Drug Cost,15.75,,,15.75,Other,225% Medicaid APG methodology,9.8,,,9.8,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7,,,7,Other,Drug Cost,7,,,7,Other,Drug Cost,8.75,,,8.75,Other,125% Medicaid APG methodology,0.01,118.34,
LIDOCAINE 2% MUCOUS MEMB 15ML   ,,,,40516742,CDM,250,RC,00121-4950-40,NDC,both,15,ML,18.2,7.18,39.4668,,7.18,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.46,30,,5.46,percent of total billed charges,"Drugs, Inpatient Only",5.46,30,,5.46,percent of total billed charges,"Drugs, Inpatient Only",5.46,30,,5.46,percent of total billed charges,"Drugs, Inpatient Only",9.1,50,,9.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.24,,,8.24,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.74,70,,12.74,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.43,,,4.43,Other,Drug Cost,4.43,,,4.43,Other,Drug Cost,4.43,,,4.43,Other,Drug Cost,4.43,,,4.43,Other,Drug Cost,4.43,,,4.43,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.43,,,4.43,Other,Drug Cost,9.97,,,9.97,Other,225% Medicaid APG methodology,6.2,,,6.2,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.43,,,4.43,Other,Drug Cost,4.43,,,4.43,Other,Drug Cost,5.54,,,5.54,Other,125% Medicaid APG methodology,0.01,12.74,
LIDOCAINE 4% TOPICAL SOLN 50ML  ,,,,40516759,CDM,250,RC,52565-0009-50,NDC,both,50,ML,105,41.44,39.4668,,41.44,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,31.5,30,,31.5,percent of total billed charges,"Drugs, Inpatient Only",31.5,30,,31.5,percent of total billed charges,"Drugs, Inpatient Only",31.5,30,,31.5,percent of total billed charges,"Drugs, Inpatient Only",52.5,50,,52.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,27.9,,,27.9,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,73.5,70,,73.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15,,,15,Other,Drug Cost,15,,,15,Other,Drug Cost,15,,,15,Other,Drug Cost,15,,,15,Other,Drug Cost,15,,,15,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,15,,,15,Other,Drug Cost,33.75,,,33.75,Other,225% Medicaid APG methodology,21,,,21,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,15,,,15,Other,Drug Cost,15,,,15,Other,Drug Cost,18.75,,,18.75,Other,125% Medicaid APG methodology,0.01,73.5,
MEXILETINE 150 MG CAP           ,,,,40516858,CDM,250,RC,50742-0239-01,NDC,both,1,EA,1.12,0.44,39.4668,,0.44,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.34,30,,0.34,percent of total billed charges,"Drugs, Inpatient Only",0.34,30,,0.34,percent of total billed charges,"Drugs, Inpatient Only",0.34,30,,0.34,percent of total billed charges,"Drugs, Inpatient Only",0.56,50,,0.56,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.78,70,,0.78,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.16,,,0.16,Other,Drug Cost,0.36,,,0.36,Other,225% Medicaid APG methodology,0.22,,,0.22,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.2,,,0.2,Other,125% Medicaid APG methodology,0.01,0.78,
MEXILETINE 200 MG CAP           ,,,,40516866,CDM,250,RC,50742-0240-01,NDC,both,1,EA,1.61,0.64,39.4668,,0.64,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.48,30,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.48,30,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.48,30,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.81,50,,0.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.35,,,0.35,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.13,70,,1.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,Drug Cost,0.43,,,0.43,Other,225% Medicaid APG methodology,0.27,,,0.27,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.24,,,0.24,Other,125% Medicaid APG methodology,0.01,1.13,
PROPAFENONE 150 MG TAB          ,,,,40516890,CDM,250,RC,59651-0256-01,NDC,both,1,EA,0.53,0.21,39.4668,,0.21,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.27,50,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,70,,0.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.37,
ISOFLURANE 100% INH LIQ 100ML   ,,,,40516981,CDM,250,RC,10019-0360-40,NDC,both,100,ML,80.5,31.77,39.4668,,31.77,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,24.15,30,,24.15,percent of total billed charges,"Drugs, Inpatient Only",24.15,30,,24.15,percent of total billed charges,"Drugs, Inpatient Only",24.15,30,,24.15,percent of total billed charges,"Drugs, Inpatient Only",40.25,50,,40.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.16,,,11.16,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,56.35,70,,56.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6,,,6,Other,Drug Cost,6,,,6,Other,Drug Cost,6,,,6,Other,Drug Cost,6,,,6,Other,Drug Cost,6,,,6,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,6,,,6,Other,Drug Cost,13.5,,,13.5,Other,225% Medicaid APG methodology,8.4,,,8.4,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6,,,6,Other,Drug Cost,6,,,6,Other,Drug Cost,7.5,,,7.5,Other,125% Medicaid APG methodology,0.01,56.35,
KETAMINE 45MG NS 45ML           ,,,,40517054,CDM,250,RC,00143-9509-10,NDC,both,5,ML,33.25,13.12,39.4668,,13.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.98,30,,9.98,percent of total billed charges,"Drugs, Inpatient Only",9.98,30,,9.98,percent of total billed charges,"Drugs, Inpatient Only",9.98,30,,9.98,percent of total billed charges,"Drugs, Inpatient Only",16.63,50,,16.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.02,,,9.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,23.28,70,,23.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.85,,,4.85,Other,Drug Cost,4.85,,,4.85,Other,Drug Cost,4.85,,,4.85,Other,Drug Cost,4.85,,,4.85,Other,Drug Cost,4.85,,,4.85,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.85,,,4.85,Other,Drug Cost,10.91,,,10.91,Other,225% Medicaid APG methodology,6.79,,,6.79,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.85,,,4.85,Other,Drug Cost,4.85,,,4.85,Other,Drug Cost,6.06,,,6.06,Other,125% Medicaid APG methodology,0.01,23.28,
PHENOBARBITAL 20MG/5ML ORL ELX  ,,,,40517088,CDM,250,RC,16571-0675-16a,NDC,both,1,ML,0.14,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.07,50,,0.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.1,
VALGANCICLOVIR 450 MG TAB       ,,,,40517146,CDM,250,RC,50268-0787-12,NDC,both,1,EA,51.8,20.44,39.4668,,20.44,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.54,30,,15.54,percent of total billed charges,"Drugs, Inpatient Only",15.54,30,,15.54,percent of total billed charges,"Drugs, Inpatient Only",15.54,30,,15.54,percent of total billed charges,"Drugs, Inpatient Only",25.9,50,,25.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,22.95,,,22.95,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,36.26,70,,36.26,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.34,,,12.34,Other,Drug Cost,12.34,,,12.34,Other,Drug Cost,12.34,,,12.34,Other,Drug Cost,12.34,,,12.34,Other,Drug Cost,12.34,,,12.34,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,12.34,,,12.34,Other,Drug Cost,27.77,,,27.77,Other,225% Medicaid APG methodology,17.28,,,17.28,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,12.34,,,12.34,Other,Drug Cost,12.34,,,12.34,Other,Drug Cost,15.43,,,15.43,Other,125% Medicaid APG methodology,0.01,36.26,
CITALOPRAM 20 MG TAB            ,,,,40517351,CDM,250,RC,00904-6085-61,NDC,both,1,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.11,50,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.15,
ZIPRASIDONE 20 MG CAP           ,,,,40517401,CDM,250,RC,00904-6269-08,NDC,both,1,EA,8.26,3.26,39.4668,,3.26,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.48,30,,2.48,percent of total billed charges,"Drugs, Inpatient Only",2.48,30,,2.48,percent of total billed charges,"Drugs, Inpatient Only",2.48,30,,2.48,percent of total billed charges,"Drugs, Inpatient Only",4.13,50,,4.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.25,,,2.25,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.78,70,,5.78,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.21,,,1.21,Other,Drug Cost,1.21,,,1.21,Other,Drug Cost,1.21,,,1.21,Other,Drug Cost,1.21,,,1.21,Other,Drug Cost,1.21,,,1.21,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.21,,,1.21,Other,Drug Cost,2.72,,,2.72,Other,225% Medicaid APG methodology,1.69,,,1.69,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.21,,,1.21,Other,Drug Cost,1.21,,,1.21,Other,Drug Cost,1.51,,,1.51,Other,125% Medicaid APG methodology,0.01,5.78,
ZIPRASIDONE 40 MG CAP           ,,,,40517419,CDM,250,RC,63739-0005-32,NDC,both,1,EA,9.07,3.58,39.4668,,3.58,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.72,30,,2.72,percent of total billed charges,"Drugs, Inpatient Only",2.72,30,,2.72,percent of total billed charges,"Drugs, Inpatient Only",2.72,30,,2.72,percent of total billed charges,"Drugs, Inpatient Only",4.54,50,,4.54,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.55,,,2.55,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.35,70,,6.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.37,,,1.37,Other,Drug Cost,1.37,,,1.37,Other,Drug Cost,1.37,,,1.37,Other,Drug Cost,1.37,,,1.37,Other,Drug Cost,1.37,,,1.37,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.37,,,1.37,Other,Drug Cost,3.08,,,3.08,Other,225% Medicaid APG methodology,1.92,,,1.92,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.37,,,1.37,Other,Drug Cost,1.37,,,1.37,Other,Drug Cost,1.71,,,1.71,Other,125% Medicaid APG methodology,0.01,6.35,
CALCIUM ACETATE 667 MG CAP      ,,,,40517476,CDM,250,RC,68094-0044-61,NDC,both,1,EA,3.4,1.34,39.4668,,1.34,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.02,30,,1.02,percent of total billed charges,"Drugs, Inpatient Only",1.02,30,,1.02,percent of total billed charges,"Drugs, Inpatient Only",1.02,30,,1.02,percent of total billed charges,"Drugs, Inpatient Only",1.7,50,,1.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.19,,,1.19,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.38,70,,2.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.64,,,0.64,Other,Drug Cost,0.64,,,0.64,Other,Drug Cost,0.64,,,0.64,Other,Drug Cost,0.64,,,0.64,Other,Drug Cost,0.64,,,0.64,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.64,,,0.64,Other,Drug Cost,1.44,,,1.44,Other,225% Medicaid APG methodology,0.9,,,0.9,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.64,,,0.64,Other,Drug Cost,0.64,,,0.64,Other,Drug Cost,0.8,,,0.8,Other,125% Medicaid APG methodology,0.01,2.38,
HYDROXYZINE HCL 10 MG TAB       ,,,,40517559,CDM,250,RC,60687-0664-01,NDC,both,1,EA,0.49,0.19,39.4668,,0.19,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.25,50,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.34,70,,0.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.2,,,0.2,Other,225% Medicaid APG methodology,0.13,,,0.13,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,0.34,
HYDROXYZINE HCL 25 MG TAB       ,,,,40517575,CDM,250,RC,68084-0254-01,NDC,both,1,EA,0.53,0.21,39.4668,,0.21,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.27,50,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,70,,0.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.29,,,0.29,Other,225% Medicaid APG methodology,0.18,,,0.18,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.16,,,0.16,Other,125% Medicaid APG methodology,0.01,0.37,
HYDROXYZINE HCL 50 MG TAB       ,,,,40517583,CDM,250,RC,23155-0502-01,NDC,both,1,EA,0.42,0.17,39.4668,,0.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.21,50,,0.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,70,,0.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.29,
CHLORDIAZEPOXIDE 10 MG CAP      ,,,,40517625,CDM,250,RC,51079-0375-20,NDC,both,1,EA,1.61,0.64,39.4668,,0.64,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.48,30,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.48,30,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.48,30,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.81,50,,0.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.13,70,,1.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.25,,,0.25,Other,225% Medicaid APG methodology,0.15,,,0.15,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.14,,,0.14,Other,125% Medicaid APG methodology,0.01,1.13,
CHLORDIAZEPOXIDE 25 MG CAP      ,,,,40517633,CDM,250,RC,00555-0159-02,NDC,both,1,EA,0.53,0.21,39.4668,,0.21,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.27,50,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,70,,0.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.37,
CHLORDIAZEPOXIDE 5 MG CAP       ,,,,40517641,CDM,250,RC,51079-0374-20,NDC,both,1,EA,2.1,0.83,39.4668,,0.83,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.63,30,,0.63,percent of total billed charges,"Drugs, Inpatient Only",0.63,30,,0.63,percent of total billed charges,"Drugs, Inpatient Only",0.63,30,,0.63,percent of total billed charges,"Drugs, Inpatient Only",1.05,50,,1.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.47,70,,1.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.23,,,0.23,Other,225% Medicaid APG methodology,0.14,,,0.14,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.13,,,0.13,Other,125% Medicaid APG methodology,0.01,1.47,
LORAZEPAM 0.5 MG TAB            ,,,,40517708,CDM,250,RC,69315-0904-01,NDC,both,1,EA,0.14,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.07,50,,0.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.1,
LORAZEPAM 1 MG TAB              ,,,,40517716,CDM,250,RC,13107-0084-01,NDC,both,1,EA,0.18,0.07,39.4668,,0.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.09,50,,0.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,70,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.13,
DIAZEPAM 2 MG TAB               ,,,,40517740,CDM,250,RC,00172-3925-60,NDC,both,1,EA,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.04,50,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.05,
DIAZEPAM 5 MG TAB               ,,,,40517757,CDM,250,RC,51079-0285-20,NDC,both,1,EA,0.18,0.07,39.4668,,0.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.09,50,,0.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,70,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.13,
ALPRAZOLAM 0.25 MG TAB          ,,,,40517765,CDM,250,RC,00781-1061-01,NDC,both,1,EA,0.11,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.06,50,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.08,
ALPRAZOLAM 0.5 MG TAB           ,,,,40517773,CDM,250,RC,00781-1077-05,NDC,both,1,EA,0.11,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.06,50,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.08,
CHLORPROMAZINE 10 MG TAB        ,,,,40517807,CDM,250,RC,00832-0300-00,NDC,both,1,EA,5.18,2.04,39.4668,,2.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.55,30,,1.55,percent of total billed charges,"Drugs, Inpatient Only",1.55,30,,1.55,percent of total billed charges,"Drugs, Inpatient Only",1.55,30,,1.55,percent of total billed charges,"Drugs, Inpatient Only",2.59,50,,2.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.63,70,,3.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,3.63,
CHLORPROMAZINE 25 MG TAB        ,,,,40517815,CDM,250,RC,50268-0163-15,NDC,both,1,EA,9.87,3.9,39.4668,,3.9,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.96,30,,2.96,percent of total billed charges,"Drugs, Inpatient Only",2.96,30,,2.96,percent of total billed charges,"Drugs, Inpatient Only",2.96,30,,2.96,percent of total billed charges,"Drugs, Inpatient Only",4.94,50,,4.94,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.46,,,8.46,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.91,70,,6.91,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.55,,,4.55,Other,Drug Cost,4.55,,,4.55,Other,Drug Cost,4.55,,,4.55,Other,Drug Cost,4.55,,,4.55,Other,Drug Cost,4.55,,,4.55,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.55,,,4.55,Other,Drug Cost,10.24,,,10.24,Other,225% Medicaid APG methodology,6.37,,,6.37,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.55,,,4.55,Other,Drug Cost,4.55,,,4.55,Other,Drug Cost,5.69,,,5.69,Other,125% Medicaid APG methodology,0.01,10.24,
CHLORPROMAZINE 50 MG TAB        ,,,,40517823,CDM,250,RC,00832-0302-00,NDC,both,1,EA,6.9,2.72,39.4668,,2.72,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.07,30,,2.07,percent of total billed charges,"Drugs, Inpatient Only",2.07,30,,2.07,percent of total billed charges,"Drugs, Inpatient Only",2.07,30,,2.07,percent of total billed charges,"Drugs, Inpatient Only",3.45,50,,3.45,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.83,70,,4.83,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,4.83,
CHLORPROMAZINE 100 MG TAB       ,,,,40517831,CDM,250,RC,50268-0165-15,NDC,both,1,EA,13.51,5.33,39.4668,,5.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.05,30,,4.05,percent of total billed charges,"Drugs, Inpatient Only",4.05,30,,4.05,percent of total billed charges,"Drugs, Inpatient Only",4.05,30,,4.05,percent of total billed charges,"Drugs, Inpatient Only",6.76,50,,6.76,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.1,,,5.1,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.46,70,,9.46,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.74,,,2.74,Other,Drug Cost,2.74,,,2.74,Other,Drug Cost,2.74,,,2.74,Other,Drug Cost,2.74,,,2.74,Other,Drug Cost,2.74,,,2.74,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.74,,,2.74,Other,Drug Cost,6.17,,,6.17,Other,225% Medicaid APG methodology,3.84,,,3.84,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.74,,,2.74,Other,Drug Cost,2.74,,,2.74,Other,Drug Cost,3.43,,,3.43,Other,125% Medicaid APG methodology,0.01,9.46,
FLUPHENAZINE 2.5MG/ML INJ 10ML  ,,,,40517856,CDM,250,RC,63323-0281-10,NDC,both,10,ML,297.85,117.55,39.4668,,117.55,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,89.36,30,,89.36,percent of total billed charges,"Drugs, Inpatient Only",89.36,30,,89.36,percent of total billed charges,"Drugs, Inpatient Only",89.36,30,,89.36,percent of total billed charges,"Drugs, Inpatient Only",148.93,50,,148.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,143.96,,,143.96,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,208.5,70,,208.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,77.4,,,77.4,Other,Drug Cost,77.4,,,77.4,Other,Drug Cost,77.4,,,77.4,Other,Drug Cost,77.4,,,77.4,Other,Drug Cost,77.4,,,77.4,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,77.4,,,77.4,Other,Drug Cost,174.15,,,174.15,Other,225% Medicaid APG methodology,108.36,,,108.36,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,77.4,,,77.4,Other,Drug Cost,77.4,,,77.4,Other,Drug Cost,96.75,,,96.75,Other,125% Medicaid APG methodology,0.01,208.5,
FLUPHENAZINE 2.5 MG TAB         ,,,,40517880,CDM,250,RC,70954-0274-10,NDC,both,1,EA,1.61,0.64,39.4668,,0.64,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.48,30,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.48,30,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.48,30,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.81,50,,0.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.93,,,0.93,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.13,70,,1.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.5,,,0.5,Other,Drug Cost,1.13,,,1.13,Other,225% Medicaid APG methodology,0.7,,,0.7,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.63,,,0.63,Other,125% Medicaid APG methodology,0.01,1.13,
FLUPHENAZINE 5 MG TAB           ,,,,40517898,CDM,250,RC,70954-0275-10,NDC,both,1,EA,1.96,0.77,39.4668,,0.77,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.59,30,,0.59,percent of total billed charges,"Drugs, Inpatient Only",0.59,30,,0.59,percent of total billed charges,"Drugs, Inpatient Only",0.59,30,,0.59,percent of total billed charges,"Drugs, Inpatient Only",0.98,50,,0.98,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1,,,1,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.37,70,,1.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.54,,,0.54,Other,Drug Cost,1.22,,,1.22,Other,225% Medicaid APG methodology,0.76,,,0.76,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.68,,,0.68,Other,125% Medicaid APG methodology,0.01,1.37,
TIZANIDINE 2 MG TAB             ,,,,40517948,CDM,250,RC,57664-0502-89,NDC,both,1,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.11,50,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.15,
PROCHLORPERAZINE 25MG RECTSUPP  ,,,,40517989,CDM,250,RC,00713-0135-12,NDC,both,1,EA,19.78,7.81,39.4668,,7.81,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.93,30,,5.93,percent of total billed charges,"Drugs, Inpatient Only",5.93,30,,5.93,percent of total billed charges,"Drugs, Inpatient Only",5.93,30,,5.93,percent of total billed charges,"Drugs, Inpatient Only",9.89,50,,9.89,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.88,,,6.88,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.85,70,,13.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.7,,,3.7,Other,Drug Cost,3.7,,,3.7,Other,Drug Cost,3.7,,,3.7,Other,Drug Cost,3.7,,,3.7,Other,Drug Cost,3.7,,,3.7,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.7,,,3.7,Other,Drug Cost,8.33,,,8.33,Other,225% Medicaid APG methodology,5.18,,,5.18,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.7,,,3.7,Other,Drug Cost,3.7,,,3.7,Other,Drug Cost,4.63,,,4.63,Other,125% Medicaid APG methodology,0.01,13.85,
PROCHLORPERAZINE 10 MG TAB      ,,,,40518011,CDM,250,RC,70710-1668-01,NDC,both,1,EA,1.19,0.47,39.4668,,0.47,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.36,30,,0.36,percent of total billed charges,"Drugs, Inpatient Only",0.36,30,,0.36,percent of total billed charges,"Drugs, Inpatient Only",0.36,30,,0.36,percent of total billed charges,"Drugs, Inpatient Only",0.6,50,,0.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.43,,,0.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.83,70,,0.83,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.23,,,0.23,Other,Drug Cost,0.52,,,0.52,Other,225% Medicaid APG methodology,0.32,,,0.32,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.29,,,0.29,Other,125% Medicaid APG methodology,0.01,0.83,
TENOFOVIR 300 MG TAB            ,,,,40518078,CDM,250,RC,33342-0096-07,NDC,both,1,EA,3.29,1.3,39.4668,,1.3,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.99,30,,0.99,percent of total billed charges,"Drugs, Inpatient Only",0.99,30,,0.99,percent of total billed charges,"Drugs, Inpatient Only",0.99,30,,0.99,percent of total billed charges,"Drugs, Inpatient Only",1.65,50,,1.65,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.21,,,1.21,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.3,70,,2.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.65,,,0.65,Other,Drug Cost,1.46,,,1.46,Other,225% Medicaid APG methodology,0.91,,,0.91,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.81,,,0.81,Other,125% Medicaid APG methodology,0.01,2.3,
TRIFLUOPERAZINE 1 MG TAB        ,,,,40518086,CDM,250,RC,51079-0572-20,NDC,both,1,EA,3.47,1.37,39.4668,,1.37,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.04,30,,1.04,percent of total billed charges,"Drugs, Inpatient Only",1.04,30,,1.04,percent of total billed charges,"Drugs, Inpatient Only",1.04,30,,1.04,percent of total billed charges,"Drugs, Inpatient Only",1.74,50,,1.74,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.52,,,0.52,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.43,70,,2.43,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,Drug Cost,0.63,,,0.63,Other,225% Medicaid APG methodology,0.39,,,0.39,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.35,,,0.35,Other,125% Medicaid APG methodology,0.01,2.43,
TRIFLUOPERAZINE 2 MG TAB        ,,,,40518102,CDM,250,RC,00378-2402-01,NDC,both,1,EA,2.28,0.9,39.4668,,0.9,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.68,30,,0.68,percent of total billed charges,"Drugs, Inpatient Only",0.68,30,,0.68,percent of total billed charges,"Drugs, Inpatient Only",0.68,30,,0.68,percent of total billed charges,"Drugs, Inpatient Only",1.14,50,,1.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.6,70,,1.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% Medicaid APG methodology,0.1,,,0.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,1.6,
TRIFLUOPERAZINE 5 MG TAB        ,,,,40518110,CDM,250,RC,51079-0574-20,NDC,both,1,EA,6.58,2.6,39.4668,,2.6,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.97,30,,1.97,percent of total billed charges,"Drugs, Inpatient Only",1.97,30,,1.97,percent of total billed charges,"Drugs, Inpatient Only",1.97,30,,1.97,percent of total billed charges,"Drugs, Inpatient Only",3.29,50,,3.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.95,,,0.95,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.61,70,,4.61,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.51,,,0.51,Other,Drug Cost,1.15,,,1.15,Other,225% Medicaid APG methodology,0.71,,,0.71,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.64,,,0.64,Other,125% Medicaid APG methodology,0.01,4.61,
LOSARTAN 25 MG TAB              ,,,,40518136,CDM,250,RC,00904-7047-61,NDC,both,1,EA,1.12,0.44,39.4668,,0.44,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.34,30,,0.34,percent of total billed charges,"Drugs, Inpatient Only",0.34,30,,0.34,percent of total billed charges,"Drugs, Inpatient Only",0.34,30,,0.34,percent of total billed charges,"Drugs, Inpatient Only",0.56,50,,0.56,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.54,,,0.54,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.78,70,,0.78,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.29,,,0.29,Other,Drug Cost,0.65,,,0.65,Other,225% Medicaid APG methodology,0.41,,,0.41,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.36,,,0.36,Other,125% Medicaid APG methodology,0.01,0.78,
LOSARTAN 50 MG TAB              ,,,,40518144,CDM,250,RC,68084-0347-01,NDC,both,1,EA,1.44,0.57,39.4668,,0.57,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.43,30,,0.43,percent of total billed charges,"Drugs, Inpatient Only",0.43,30,,0.43,percent of total billed charges,"Drugs, Inpatient Only",0.43,30,,0.43,percent of total billed charges,"Drugs, Inpatient Only",0.72,50,,0.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.35,,,0.35,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.01,70,,1.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,Drug Cost,0.43,,,0.43,Other,225% Medicaid APG methodology,0.27,,,0.27,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.24,,,0.24,Other,125% Medicaid APG methodology,0.01,1.01,
THIORIDAZINE 25 MG TAB          ,,,,40518177,CDM,250,RC,51079-0566-20,NDC,both,1,EA,1.65,0.65,39.4668,,0.65,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.5,30,,0.5,percent of total billed charges,"Drugs, Inpatient Only",0.5,30,,0.5,percent of total billed charges,"Drugs, Inpatient Only",0.5,30,,0.5,percent of total billed charges,"Drugs, Inpatient Only",0.83,50,,0.83,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.56,,,0.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.16,70,,1.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.68,,,0.68,Other,225% Medicaid APG methodology,0.42,,,0.42,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.38,,,0.38,Other,125% Medicaid APG methodology,0.01,1.16,
THIORIDAZINE 100 MG TAB         ,,,,40518201,CDM,250,RC,00378-0618-01,NDC,both,1,EA,3.12,1.23,39.4668,,1.23,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.94,30,,0.94,percent of total billed charges,"Drugs, Inpatient Only",0.94,30,,0.94,percent of total billed charges,"Drugs, Inpatient Only",0.94,30,,0.94,percent of total billed charges,"Drugs, Inpatient Only",1.56,50,,1.56,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.48,,,0.48,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.18,70,,2.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,Drug Cost,0.59,,,0.59,Other,225% Medicaid APG methodology,0.36,,,0.36,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.33,,,0.33,Other,125% Medicaid APG methodology,0.01,2.18,
PROMETHAZINE 25 MG TAB          ,,,,40518243,CDM,250,RC,00904-7304-61,NDC,both,1,EA,0.49,0.19,39.4668,,0.19,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.25,50,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.34,70,,0.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.29,,,0.29,Other,225% Medicaid APG methodology,0.18,,,0.18,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.16,,,0.16,Other,125% Medicaid APG methodology,0.01,0.34,
OLANZAPINE 7.5 MG TAB           ,,,,40518250,CDM,250,RC,00093-5769-56,NDC,both,1,EA,0.98,0.39,39.4668,,0.39,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.49,50,,0.49,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.52,,,0.52,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.69,70,,0.69,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,Drug Cost,0.63,,,0.63,Other,225% Medicaid APG methodology,0.39,,,0.39,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.35,,,0.35,Other,125% Medicaid APG methodology,0.01,0.69,
OLANZAPINE 5 MG TAB             ,,,,40518268,CDM,250,RC,00904-6377-61,NDC,both,1,EA,0.6,0.24,39.4668,,0.24,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.18,30,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.18,30,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.18,30,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.3,50,,0.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.42,70,,0.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.42,
OLANZAPINE 2.5 MG TAB           ,,,,40518276,CDM,250,RC,60505-3110-00,NDC,both,1,EA,0.67,0.26,39.4668,,0.26,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,30,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.2,30,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.2,30,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.34,50,,0.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.47,70,,0.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.47,
PHENELZINE 15 MG TAB            ,,,,40518284,CDM,250,RC,59762-0119-01,NDC,both,1,EA,1.68,0.66,39.4668,,0.66,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.5,30,,0.5,percent of total billed charges,"Drugs, Inpatient Only",0.5,30,,0.5,percent of total billed charges,"Drugs, Inpatient Only",0.5,30,,0.5,percent of total billed charges,"Drugs, Inpatient Only",0.84,50,,0.84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.35,,,0.35,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.18,70,,1.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,Drug Cost,0.43,,,0.43,Other,225% Medicaid APG methodology,0.27,,,0.27,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.24,,,0.24,Other,125% Medicaid APG methodology,0.01,1.18,
IMIPRAMINE 25 MG TAB            ,,,,40518300,CDM,250,RC,49884-0055-01,NDC,both,1,EA,0.77,0.3,39.4668,,0.3,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.23,30,,0.23,percent of total billed charges,"Drugs, Inpatient Only",0.23,30,,0.23,percent of total billed charges,"Drugs, Inpatient Only",0.23,30,,0.23,percent of total billed charges,"Drugs, Inpatient Only",0.39,50,,0.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.54,70,,0.54,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.54,
AMITRIPTYLINE 100 MG TAB        ,,,,40518326,CDM,250,RC,16729-0175-01,NDC,both,1,EA,1.96,0.77,39.4668,,0.77,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.59,30,,0.59,percent of total billed charges,"Drugs, Inpatient Only",0.59,30,,0.59,percent of total billed charges,"Drugs, Inpatient Only",0.59,30,,0.59,percent of total billed charges,"Drugs, Inpatient Only",0.98,50,,0.98,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.37,70,,1.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,1.37,
AMITRIPTYLINE 25 MG TAB         ,,,,40518334,CDM,250,RC,50268-0038-15,NDC,both,1,EA,1.26,0.5,39.4668,,0.5,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.38,30,,0.38,percent of total billed charges,"Drugs, Inpatient Only",0.38,30,,0.38,percent of total billed charges,"Drugs, Inpatient Only",0.38,30,,0.38,percent of total billed charges,"Drugs, Inpatient Only",0.63,50,,0.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.73,,,0.73,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.88,70,,0.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.39,,,0.39,Other,Drug Cost,0.88,,,0.88,Other,225% Medicaid APG methodology,0.55,,,0.55,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.49,,,0.49,Other,125% Medicaid APG methodology,0.01,0.88,
AMITRIPTYLINE 50 MG TAB         ,,,,40518342,CDM,250,RC,50268-0039-15,NDC,both,1,EA,1.68,0.66,39.4668,,0.66,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.5,30,,0.5,percent of total billed charges,"Drugs, Inpatient Only",0.5,30,,0.5,percent of total billed charges,"Drugs, Inpatient Only",0.5,30,,0.5,percent of total billed charges,"Drugs, Inpatient Only",0.84,50,,0.84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.95,,,0.95,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.18,70,,1.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.51,,,0.51,Other,Drug Cost,1.15,,,1.15,Other,225% Medicaid APG methodology,0.71,,,0.71,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.64,,,0.64,Other,125% Medicaid APG methodology,0.01,1.18,
NORTRIPTYLINE 10 MG CAP         ,,,,40518367,CDM,250,RC,50268-0603-15,NDC,both,1,EA,0.91,0.36,39.4668,,0.36,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.27,30,,0.27,percent of total billed charges,"Drugs, Inpatient Only",0.27,30,,0.27,percent of total billed charges,"Drugs, Inpatient Only",0.27,30,,0.27,percent of total billed charges,"Drugs, Inpatient Only",0.46,50,,0.46,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.54,,,0.54,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.64,70,,0.64,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.29,,,0.29,Other,Drug Cost,0.65,,,0.65,Other,225% Medicaid APG methodology,0.41,,,0.41,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.36,,,0.36,Other,125% Medicaid APG methodology,0.01,0.65,
NORTRIPTYLINE 25 MG CAP         ,,,,40518375,CDM,250,RC,51672-4002-05,NDC,both,1,EA,0.46,0.18,39.4668,,0.18,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.14,30,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,30,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,30,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.23,50,,0.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.32,70,,0.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.32,
NORTRIPTYLINE 50 MG CAP         ,,,,40518383,CDM,250,RC,50268-0605-15,NDC,both,1,EA,1.61,0.64,39.4668,,0.64,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.48,30,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.48,30,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.48,30,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.81,50,,0.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.6,,,0.6,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.13,70,,1.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.32,,,0.32,Other,Drug Cost,0.72,,,0.72,Other,225% Medicaid APG methodology,0.45,,,0.45,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.4,,,0.4,Other,125% Medicaid APG methodology,0.01,1.13,
DESIPRAMINE 25 MG TAB           ,,,,40518425,CDM,250,RC,23155-0579-01,NDC,both,1,EA,2.63,1.04,39.4668,,1.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.79,30,,0.79,percent of total billed charges,"Drugs, Inpatient Only",0.79,30,,0.79,percent of total billed charges,"Drugs, Inpatient Only",0.79,30,,0.79,percent of total billed charges,"Drugs, Inpatient Only",1.32,50,,1.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.48,,,0.48,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.84,70,,1.84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,Drug Cost,0.59,,,0.59,Other,225% Medicaid APG methodology,0.36,,,0.36,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.33,,,0.33,Other,125% Medicaid APG methodology,0.01,1.84,
DESIPRAMINE 50 MG TAB           ,,,,40518433,CDM,250,RC,50742-0114-01,NDC,both,1,EA,0.95,0.37,39.4668,,0.37,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.48,50,,0.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.67,70,,0.67,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.67,
DOXEPIN 10 MG CAP               ,,,,40518441,CDM,250,RC,51079-0436-20,NDC,both,1,EA,1.75,0.69,39.4668,,0.69,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.53,30,,0.53,percent of total billed charges,"Drugs, Inpatient Only",0.53,30,,0.53,percent of total billed charges,"Drugs, Inpatient Only",0.53,30,,0.53,percent of total billed charges,"Drugs, Inpatient Only",0.88,50,,0.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.23,70,,1.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.25,,,0.25,Other,225% Medicaid APG methodology,0.15,,,0.15,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.14,,,0.14,Other,125% Medicaid APG methodology,0.01,1.23,
DOXEPIN 25 MG CAP               ,,,,40518458,CDM,250,RC,51079-0437-20,NDC,both,1,EA,2.28,0.9,39.4668,,0.9,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.68,30,,0.68,percent of total billed charges,"Drugs, Inpatient Only",0.68,30,,0.68,percent of total billed charges,"Drugs, Inpatient Only",0.68,30,,0.68,percent of total billed charges,"Drugs, Inpatient Only",1.14,50,,1.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.6,70,,1.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,Drug Cost,0.34,,,0.34,Other,225% Medicaid APG methodology,0.21,,,0.21,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.19,,,0.19,Other,125% Medicaid APG methodology,0.01,1.6,
DOXEPIN 50 MG CAP               ,,,,40518466,CDM,250,RC,51079-0438-20,NDC,both,1,EA,3.15,1.24,39.4668,,1.24,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.95,30,,0.95,percent of total billed charges,"Drugs, Inpatient Only",0.95,30,,0.95,percent of total billed charges,"Drugs, Inpatient Only",0.95,30,,0.95,percent of total billed charges,"Drugs, Inpatient Only",1.58,50,,1.58,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.41,,,0.41,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.21,70,,2.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.5,,,0.5,Other,225% Medicaid APG methodology,0.31,,,0.31,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.28,,,0.28,Other,125% Medicaid APG methodology,0.01,2.21,
TRAZODONE 100 MG TAB            ,,,,40518490,CDM,250,RC,50111-0434-01,NDC,both,1,EA,0.14,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.07,50,,0.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.1,
TRAZODONE 50 MG TAB             ,,,,40518508,CDM,250,RC,00904-6868-61,NDC,both,1,EA,0.35,0.14,39.4668,,0.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.18,50,,0.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,70,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.25,
HALOPERIDOL 2MG/ML ORLIQ 120ML  ,,,,40518540,CDM,250,RC,54838-0501-40,NDC,both,120,ML,92.4,36.47,39.4668,,36.47,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,27.72,30,,27.72,percent of total billed charges,"Drugs, Inpatient Only",27.72,30,,27.72,percent of total billed charges,"Drugs, Inpatient Only",27.72,30,,27.72,percent of total billed charges,"Drugs, Inpatient Only",46.2,50,,46.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.93,,,8.93,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,64.68,70,,64.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.8,,,4.8,Other,Drug Cost,10.8,,,10.8,Other,225% Medicaid APG methodology,6.72,,,6.72,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,6,,,6,Other,125% Medicaid APG methodology,0.01,64.68,
HALOPERIDOL 0.5 MG TAB          ,,,,40518557,CDM,250,RC,51079-0733-20,NDC,both,1,EA,0.95,0.37,39.4668,,0.37,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.48,50,,0.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.67,70,,0.67,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.29,,,0.29,Other,225% Medicaid APG methodology,0.18,,,0.18,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.16,,,0.16,Other,125% Medicaid APG methodology,0.01,0.67,
HALOPERIDOL 1 MG TAB            ,,,,40518565,CDM,250,RC,00832-1520-01,NDC,both,1,EA,11.17,4.41,39.4668,,4.41,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.35,30,,3.35,percent of total billed charges,"Drugs, Inpatient Only",3.35,30,,3.35,percent of total billed charges,"Drugs, Inpatient Only",3.35,30,,3.35,percent of total billed charges,"Drugs, Inpatient Only",5.59,50,,5.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.26,,,1.26,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.82,70,,7.82,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.68,,,0.68,Other,Drug Cost,0.68,,,0.68,Other,Drug Cost,0.68,,,0.68,Other,Drug Cost,0.68,,,0.68,Other,Drug Cost,0.68,,,0.68,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.68,,,0.68,Other,Drug Cost,1.53,,,1.53,Other,225% Medicaid APG methodology,0.95,,,0.95,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.68,,,0.68,Other,Drug Cost,0.68,,,0.68,Other,Drug Cost,0.85,,,0.85,Other,125% Medicaid APG methodology,0.01,7.82,
HALOPERIDOL 2 MG TAB            ,,,,40518581,CDM,250,RC,00904-7391-61,NDC,both,1,EA,1.82,0.72,39.4668,,0.72,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.55,30,,0.55,percent of total billed charges,"Drugs, Inpatient Only",0.55,30,,0.55,percent of total billed charges,"Drugs, Inpatient Only",0.55,30,,0.55,percent of total billed charges,"Drugs, Inpatient Only",0.91,50,,0.91,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.02,,,1.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.27,70,,1.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.55,,,0.55,Other,Drug Cost,0.55,,,0.55,Other,Drug Cost,0.55,,,0.55,Other,Drug Cost,0.55,,,0.55,Other,Drug Cost,0.55,,,0.55,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.55,,,0.55,Other,Drug Cost,1.24,,,1.24,Other,225% Medicaid APG methodology,0.77,,,0.77,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.55,,,0.55,Other,Drug Cost,0.55,,,0.55,Other,Drug Cost,0.69,,,0.69,Other,125% Medicaid APG methodology,0.01,1.27,
HALOPERIDOL 5 MG TAB            ,,,,40518599,CDM,250,RC,68382-0079-01,NDC,both,1,EA,2.03,0.8,39.4668,,0.8,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.61,30,,0.61,percent of total billed charges,"Drugs, Inpatient Only",0.61,30,,0.61,percent of total billed charges,"Drugs, Inpatient Only",0.61,30,,0.61,percent of total billed charges,"Drugs, Inpatient Only",1.02,50,,1.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.42,70,,1.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,Drug Cost,0.32,,,0.32,Other,225% Medicaid APG methodology,0.2,,,0.2,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.18,,,0.18,Other,125% Medicaid APG methodology,0.01,1.42,
LOXAPINE 25 MG CAP              ,,,,40518615,CDM,250,RC,00527-1396-01,NDC,both,1,EA,3.57,1.41,39.4668,,1.41,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.07,30,,1.07,percent of total billed charges,"Drugs, Inpatient Only",1.07,30,,1.07,percent of total billed charges,"Drugs, Inpatient Only",1.07,30,,1.07,percent of total billed charges,"Drugs, Inpatient Only",1.79,50,,1.79,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.32,,,0.32,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.5,70,,2.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,Drug Cost,0.38,,,0.38,Other,225% Medicaid APG methodology,0.24,,,0.24,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.21,,,0.21,Other,125% Medicaid APG methodology,0.01,2.5,
SELEGILINE 5 MG CAP             ,,,,40518649,CDM,250,RC,60505-0055-01,NDC,both,1,EA,2.52,0.99,39.4668,,0.99,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.76,30,,0.76,percent of total billed charges,"Drugs, Inpatient Only",0.76,30,,0.76,percent of total billed charges,"Drugs, Inpatient Only",0.76,30,,0.76,percent of total billed charges,"Drugs, Inpatient Only",1.26,50,,1.26,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.74,,,0.74,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.76,70,,1.76,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.4,,,0.4,Other,Drug Cost,0.4,,,0.4,Other,Drug Cost,0.4,,,0.4,Other,Drug Cost,0.4,,,0.4,Other,Drug Cost,0.4,,,0.4,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.4,,,0.4,Other,Drug Cost,0.9,,,0.9,Other,225% Medicaid APG methodology,0.56,,,0.56,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.4,,,0.4,Other,Drug Cost,0.4,,,0.4,Other,Drug Cost,0.5,,,0.5,Other,125% Medicaid APG methodology,0.01,1.76,
THIOTHIXENE 5 MG CAP            ,,,,40518730,CDM,250,RC,00378-3005-01,NDC,both,1,EA,6.3,2.49,39.4668,,2.49,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.89,30,,1.89,percent of total billed charges,"Drugs, Inpatient Only",1.89,30,,1.89,percent of total billed charges,"Drugs, Inpatient Only",1.89,30,,1.89,percent of total billed charges,"Drugs, Inpatient Only",3.15,50,,3.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.89,,,0.89,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.41,70,,4.41,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.48,,,0.48,Other,Drug Cost,1.08,,,1.08,Other,225% Medicaid APG methodology,0.67,,,0.67,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.6,,,0.6,Other,125% Medicaid APG methodology,0.01,4.41,
LITHIUM CARBONATE 300 MG CAP    ,,,,40518748,CDM,250,RC,00054-8527-25,NDC,both,1,EA,0.35,0.14,39.4668,,0.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.18,50,,0.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,70,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.25,
LITHIUM 300MG/5ML ORL  5ML UD   ,,,,40518763,CDM,250,RC,68094-0757-62,NDC,both,5,ML,4.03,1.59,39.4668,,1.59,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.21,30,,1.21,percent of total billed charges,"Drugs, Inpatient Only",1.21,30,,1.21,percent of total billed charges,"Drugs, Inpatient Only",1.21,30,,1.21,percent of total billed charges,"Drugs, Inpatient Only",2.02,50,,2.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.67,,,1.67,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.82,70,,2.82,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.9,,,0.9,Other,Drug Cost,0.9,,,0.9,Other,Drug Cost,0.9,,,0.9,Other,Drug Cost,0.9,,,0.9,Other,Drug Cost,0.9,,,0.9,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.9,,,0.9,Other,Drug Cost,2.03,,,2.03,Other,225% Medicaid APG methodology,1.26,,,1.26,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.9,,,0.9,Other,Drug Cost,0.9,,,0.9,Other,Drug Cost,1.13,,,1.13,Other,125% Medicaid APG methodology,0.01,2.82,
CYPROHEPTADINE 4 MG TAB         ,,,,40518771,CDM,250,RC,52817-0210-10,NDC,both,1,EA,0.67,0.26,39.4668,,0.26,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,30,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.2,30,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.2,30,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.34,50,,0.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.47,70,,0.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.47,
VALSARTAN 80 MG TAB             ,,,,40518789,CDM,250,RC,60687-0623-01,NDC,both,1,EA,3.22,1.27,39.4668,,1.27,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.97,30,,0.97,percent of total billed charges,"Drugs, Inpatient Only",0.97,30,,0.97,percent of total billed charges,"Drugs, Inpatient Only",0.97,30,,0.97,percent of total billed charges,"Drugs, Inpatient Only",1.61,50,,1.61,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.8,,,1.8,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.25,70,,2.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.97,,,0.97,Other,Drug Cost,2.18,,,2.18,Other,225% Medicaid APG methodology,1.36,,,1.36,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,1.21,,,1.21,Other,125% Medicaid APG methodology,0.01,2.25,
VALSARTAN 160 MG TAB            ,,,,40518797,CDM,250,RC,59746-0362-90,NDC,both,1,EA,0.84,0.33,39.4668,,0.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,30,,0.25,percent of total billed charges,"Drugs, Inpatient Only",0.25,30,,0.25,percent of total billed charges,"Drugs, Inpatient Only",0.25,30,,0.25,percent of total billed charges,"Drugs, Inpatient Only",0.42,50,,0.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.59,70,,0.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.59,
METHYLPHENIDATE 10 MG TAB       ,,,,40518805,CDM,250,RC,00115-1801-01,NDC,both,1,EA,0.42,0.17,39.4668,,0.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.21,50,,0.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,70,,0.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.29,
HYDROMORPHONE 2 MG TAB          ,,,,40518995,CDM,250,RC,42858-0301-01,NDC,both,1,EA,0.28,0.11,39.4668,,0.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.14,50,,0.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,70,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.2,
OXYCODONE 10 MG ER TAB          ,,,,40519043,CDM,250,RC,59011-0410-20,NDC,both,1,EA,13.37,5.28,39.4668,,5.28,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.01,30,,4.01,percent of total billed charges,"Drugs, Inpatient Only",4.01,30,,4.01,percent of total billed charges,"Drugs, Inpatient Only",4.01,30,,4.01,percent of total billed charges,"Drugs, Inpatient Only",6.69,50,,6.69,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.36,70,,9.36,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,9.36,
OXYCODONE 20 MG ER TAB          ,,,,40519050,CDM,250,RC,59011-0420-20,NDC,both,1,EA,24.92,9.84,39.4668,,9.84,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.48,30,,7.48,percent of total billed charges,"Drugs, Inpatient Only",7.48,30,,7.48,percent of total billed charges,"Drugs, Inpatient Only",7.48,30,,7.48,percent of total billed charges,"Drugs, Inpatient Only",12.46,50,,12.46,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,17.44,70,,17.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,17.44,
OXYCODONE 40 MG ER TAB          ,,,,40519068,CDM,250,RC,59011-0440-20,NDC,both,1,EA,42.63,16.82,39.4668,,16.82,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.79,30,,12.79,percent of total billed charges,"Drugs, Inpatient Only",12.79,30,,12.79,percent of total billed charges,"Drugs, Inpatient Only",12.79,30,,12.79,percent of total billed charges,"Drugs, Inpatient Only",21.32,50,,21.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,29.84,70,,29.84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,29.84,
OXYCODONE 5 MG TAB              ,,,,40519076,CDM,250,RC,42806-0005-01,NDC,both,1,EA,0.32,0.13,39.4668,,0.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.16,50,,0.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,70,,0.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.22,
CLOMIPRAMINE 25 MG CAP          ,,,,40519092,CDM,250,RC,68084-0790-25,NDC,both,1,EA,31.96,12.61,39.4668,,12.61,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.59,30,,9.59,percent of total billed charges,"Drugs, Inpatient Only",9.59,30,,9.59,percent of total billed charges,"Drugs, Inpatient Only",9.59,30,,9.59,percent of total billed charges,"Drugs, Inpatient Only",15.98,50,,15.98,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.21,,,15.21,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,22.37,70,,22.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.18,,,8.18,Other,Drug Cost,8.18,,,8.18,Other,Drug Cost,8.18,,,8.18,Other,Drug Cost,8.18,,,8.18,Other,Drug Cost,8.18,,,8.18,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,8.18,,,8.18,Other,Drug Cost,18.41,,,18.41,Other,225% Medicaid APG methodology,11.45,,,11.45,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,8.18,,,8.18,Other,Drug Cost,8.18,,,8.18,Other,Drug Cost,10.23,,,10.23,Other,125% Medicaid APG methodology,0.01,22.37,
METHADONE 10 MG TAB             ,,,,40519134,CDM,250,RC,00054-0710-25,NDC,both,1,EA,0.39,0.15,39.4668,,0.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.2,50,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.27,70,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.27,
METHADONE ORAL SOLN (FOR MMTP)  ,,,,40519159,CDM,250,RC,00406-5755-62,NDC,both,1,EA,0.84,0.33,39.4668,,0.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,30,,0.25,percent of total billed charges,"Drugs, Inpatient Only",0.25,30,,0.25,percent of total billed charges,"Drugs, Inpatient Only",0.25,30,,0.25,percent of total billed charges,"Drugs, Inpatient Only",0.42,50,,0.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.59,70,,0.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.59,
MORPHINE 30 MG ER TAB           ,,,,40519241,CDM,250,RC,00904-6558-61,NDC,both,1,EA,3.54,1.4,39.4668,,1.4,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.06,30,,1.06,percent of total billed charges,"Drugs, Inpatient Only",1.06,30,,1.06,percent of total billed charges,"Drugs, Inpatient Only",1.06,30,,1.06,percent of total billed charges,"Drugs, Inpatient Only",1.77,50,,1.77,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.8,,,0.8,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.48,70,,2.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.43,,,0.43,Other,Drug Cost,0.43,,,0.43,Other,Drug Cost,0.43,,,0.43,Other,Drug Cost,0.43,,,0.43,Other,Drug Cost,0.43,,,0.43,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.43,,,0.43,Other,Drug Cost,0.97,,,0.97,Other,225% Medicaid APG methodology,0.6,,,0.6,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.43,,,0.43,Other,Drug Cost,0.43,,,0.43,Other,Drug Cost,0.54,,,0.54,Other,125% Medicaid APG methodology,0.01,2.48,
MORPHINE 15 MG ER TAB           ,,,,40519266,CDM,250,RC,00904-6557-61,NDC,both,1,EA,1.82,0.72,39.4668,,0.72,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.55,30,,0.55,percent of total billed charges,"Drugs, Inpatient Only",0.55,30,,0.55,percent of total billed charges,"Drugs, Inpatient Only",0.55,30,,0.55,percent of total billed charges,"Drugs, Inpatient Only",0.91,50,,0.91,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.73,,,0.73,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.27,70,,1.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.39,,,0.39,Other,Drug Cost,0.88,,,0.88,Other,225% Medicaid APG methodology,0.55,,,0.55,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.49,,,0.49,Other,125% Medicaid APG methodology,0.01,1.27,
ASPIRIN 600 MG RECTAL SUPP      ,,,,40519282,CDM,250,RC,00574-7036-12,NDC,both,1,EA,4.48,1.77,39.4668,,1.77,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.34,30,,1.34,percent of total billed charges,"Drugs, Inpatient Only",1.34,30,,1.34,percent of total billed charges,"Drugs, Inpatient Only",1.34,30,,1.34,percent of total billed charges,"Drugs, Inpatient Only",2.24,50,,2.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.8,,,1.8,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.14,70,,3.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.97,,,0.97,Other,Drug Cost,2.18,,,2.18,Other,225% Medicaid APG methodology,1.36,,,1.36,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,1.21,,,1.21,Other,125% Medicaid APG methodology,0.01,3.14,
ASPIRIN 300 MG RECTAL SUPP      ,,,,40519290,CDM,250,RC,00574-7034-12,NDC,both,1,EA,4.34,1.71,39.4668,,1.71,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.3,30,,1.3,percent of total billed charges,"Drugs, Inpatient Only",1.3,30,,1.3,percent of total billed charges,"Drugs, Inpatient Only",1.3,30,,1.3,percent of total billed charges,"Drugs, Inpatient Only",2.17,50,,2.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.66,,,1.66,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.04,70,,3.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.89,,,0.89,Other,Drug Cost,0.89,,,0.89,Other,Drug Cost,0.89,,,0.89,Other,Drug Cost,0.89,,,0.89,Other,Drug Cost,0.89,,,0.89,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.89,,,0.89,Other,Drug Cost,2,,,2,Other,225% Medicaid APG methodology,1.25,,,1.25,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.89,,,0.89,Other,Drug Cost,0.89,,,0.89,Other,Drug Cost,1.11,,,1.11,Other,125% Medicaid APG methodology,0.01,3.04,
ASPIRIN 325 MG TAB              ,,,,40519308,CDM,250,RC,57896-0901-01,NDC,both,1,EA,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.02,50,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.03,
ASPIRIN 325 MG EC TAB           ,,,,40519324,CDM,250,RC,57896-0921-01,NDC,both,1,EA,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.02,50,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.03,
ACETAMINOPHEN 120MG RECTALSUPP  ,,,,40519365,CDM,250,RC,45802-0732-30,NDC,both,1,EA,0.53,0.21,39.4668,,0.21,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.27,50,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,70,,0.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.27,,,0.27,Other,225% Medicaid APG methodology,0.17,,,0.17,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.15,,,0.15,Other,125% Medicaid APG methodology,0.01,0.37,
ACETAMINOPHEN 650MG RECTAL SUP  ,,,,40519373,CDM,250,RC,45802-0730-32,NDC,both,1,EA,1.05,0.41,39.4668,,0.41,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.32,30,,0.32,percent of total billed charges,"Drugs, Inpatient Only",0.32,30,,0.32,percent of total billed charges,"Drugs, Inpatient Only",0.32,30,,0.32,percent of total billed charges,"Drugs, Inpatient Only",0.53,50,,0.53,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.35,,,0.35,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.74,70,,0.74,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,Drug Cost,0.43,,,0.43,Other,225% Medicaid APG methodology,0.27,,,0.27,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.24,,,0.24,Other,125% Medicaid APG methodology,0.01,0.74,
ACETAMINOPHEN 160MG/5ML ORLSUS  ,,,,40519381,CDM,250,RC,00904-7278-70,NDC,both,5,ML,2.21,0.87,39.4668,,0.87,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.66,30,,0.66,percent of total billed charges,"Drugs, Inpatient Only",0.66,30,,0.66,percent of total billed charges,"Drugs, Inpatient Only",0.66,30,,0.66,percent of total billed charges,"Drugs, Inpatient Only",1.11,50,,1.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.26,,,1.26,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.55,70,,1.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.68,,,0.68,Other,Drug Cost,0.68,,,0.68,Other,Drug Cost,0.68,,,0.68,Other,Drug Cost,0.68,,,0.68,Other,Drug Cost,0.68,,,0.68,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.68,,,0.68,Other,Drug Cost,1.53,,,1.53,Other,225% Medicaid APG methodology,0.95,,,0.95,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.68,,,0.68,Other,Drug Cost,0.68,,,0.68,Other,Drug Cost,0.85,,,0.85,Other,125% Medicaid APG methodology,0.01,1.55,
ACETAMIN160MG/5ML ORLIQ 20.3ML  ,,,,40519399,CDM,250,RC,39328-0034-99,NDC,both,20.3,ML,5.22,2.06,39.4668,,2.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.57,30,,1.57,percent of total billed charges,"Drugs, Inpatient Only",1.57,30,,1.57,percent of total billed charges,"Drugs, Inpatient Only",1.57,30,,1.57,percent of total billed charges,"Drugs, Inpatient Only",2.61,50,,2.61,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.77,,,2.77,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.65,70,,3.65,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.49,,,1.49,Other,Drug Cost,3.35,,,3.35,Other,225% Medicaid APG methodology,2.09,,,2.09,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,1.86,,,1.86,Other,125% Medicaid APG methodology,0.01,3.65,
ACETAMINOPHEN 325 MG TAB        ,,,,40519415,CDM,250,RC,63739-0087-02,NDC,both,1,EA,0.14,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.07,50,,0.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.1,
NALTREXONE 50 MG TAB            ,,,,40519423,CDM,250,RC,68094-0853-62,NDC,both,1,EA,7.98,3.15,39.4668,,3.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.39,30,,2.39,percent of total billed charges,"Drugs, Inpatient Only",2.39,30,,2.39,percent of total billed charges,"Drugs, Inpatient Only",2.39,30,,2.39,percent of total billed charges,"Drugs, Inpatient Only",3.99,50,,3.99,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.72,,,2.72,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.59,70,,5.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.46,,,1.46,Other,Drug Cost,1.46,,,1.46,Other,Drug Cost,1.46,,,1.46,Other,Drug Cost,1.46,,,1.46,Other,Drug Cost,1.46,,,1.46,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.46,,,1.46,Other,Drug Cost,3.29,,,3.29,Other,225% Medicaid APG methodology,2.04,,,2.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.46,,,1.46,Other,Drug Cost,1.46,,,1.46,Other,Drug Cost,1.83,,,1.83,Other,125% Medicaid APG methodology,0.01,5.59,
PHENYTOIN 25MG/ML ORL SUSP 4ML  ,,,,40519464,CDM,250,RC,00904-7079-57,NDC,both,4,ML,12.85,5.07,39.4668,,5.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.86,30,,3.86,percent of total billed charges,"Drugs, Inpatient Only",3.86,30,,3.86,percent of total billed charges,"Drugs, Inpatient Only",3.86,30,,3.86,percent of total billed charges,"Drugs, Inpatient Only",6.43,50,,6.43,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.04,,,8.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9,70,,9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.32,,,4.32,Other,Drug Cost,4.32,,,4.32,Other,Drug Cost,4.32,,,4.32,Other,Drug Cost,4.32,,,4.32,Other,Drug Cost,4.32,,,4.32,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.32,,,4.32,Other,Drug Cost,9.72,,,9.72,Other,225% Medicaid APG methodology,6.05,,,6.05,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.32,,,4.32,Other,Drug Cost,4.32,,,4.32,Other,Drug Cost,5.4,,,5.4,Other,125% Medicaid APG methodology,0.01,9.72,
PHENYTOIN 50 MG CHEW TAB        ,,,,40519472,CDM,250,RC,00071-0007-40,NDC,both,1,EA,6.93,2.74,39.4668,,2.74,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.08,30,,2.08,percent of total billed charges,"Drugs, Inpatient Only",2.08,30,,2.08,percent of total billed charges,"Drugs, Inpatient Only",2.08,30,,2.08,percent of total billed charges,"Drugs, Inpatient Only",3.47,50,,3.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.6,,,0.6,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.85,70,,4.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.32,,,0.32,Other,Drug Cost,0.72,,,0.72,Other,225% Medicaid APG methodology,0.45,,,0.45,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.4,,,0.4,Other,125% Medicaid APG methodology,0.01,4.85,
VALPROIC ACID 250MG/5ML ORL5ML  ,,,,40519480,CDM,250,RC,00121-4675-00,NDC,both,5,ML,1.23,0.49,39.4668,,0.49,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,30,,0.37,percent of total billed charges,"Drugs, Inpatient Only",0.37,30,,0.37,percent of total billed charges,"Drugs, Inpatient Only",0.37,30,,0.37,percent of total billed charges,"Drugs, Inpatient Only",0.62,50,,0.62,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.86,70,,0.86,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.23,,,0.23,Other,225% Medicaid APG methodology,0.14,,,0.14,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.13,,,0.13,Other,125% Medicaid APG methodology,0.01,0.86,
DIVALPROEX SODIUM 250MG DR TAB  ,,,,40519498,CDM,250,RC,68084-0776-01,NDC,both,1,EA,0.49,0.19,39.4668,,0.19,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.25,50,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.34,70,,0.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.27,,,0.27,Other,225% Medicaid APG methodology,0.17,,,0.17,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.15,,,0.15,Other,125% Medicaid APG methodology,0.01,0.34,
PRIMIDONE 250 MG TAB            ,,,,40519522,CDM,250,RC,68084-0203-01,NDC,both,1,EA,1.65,0.65,39.4668,,0.65,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.5,30,,0.5,percent of total billed charges,"Drugs, Inpatient Only",0.5,30,,0.5,percent of total billed charges,"Drugs, Inpatient Only",0.5,30,,0.5,percent of total billed charges,"Drugs, Inpatient Only",0.83,50,,0.83,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.16,70,,1.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,Drug Cost,0.32,,,0.32,Other,225% Medicaid APG methodology,0.2,,,0.2,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.18,,,0.18,Other,125% Medicaid APG methodology,0.01,1.16,
PRIMIDONE 50 MG TAB             ,,,,40519530,CDM,250,RC,00527-1301-01,NDC,both,1,EA,1.26,0.5,39.4668,,0.5,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.38,30,,0.38,percent of total billed charges,"Drugs, Inpatient Only",0.38,30,,0.38,percent of total billed charges,"Drugs, Inpatient Only",0.38,30,,0.38,percent of total billed charges,"Drugs, Inpatient Only",0.63,50,,0.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.88,70,,0.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.88,
DIVALPROEX 125MG DR SPRKLE CAP  ,,,,40519555,CDM,250,RC,68084-0313-01,NDC,both,1,EA,2.73,1.08,39.4668,,1.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.82,30,,0.82,percent of total billed charges,"Drugs, Inpatient Only",0.82,30,,0.82,percent of total billed charges,"Drugs, Inpatient Only",0.82,30,,0.82,percent of total billed charges,"Drugs, Inpatient Only",1.37,50,,1.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.8,,,0.8,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.91,70,,1.91,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.43,,,0.43,Other,Drug Cost,0.43,,,0.43,Other,Drug Cost,0.43,,,0.43,Other,Drug Cost,0.43,,,0.43,Other,Drug Cost,0.43,,,0.43,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.43,,,0.43,Other,Drug Cost,0.97,,,0.97,Other,225% Medicaid APG methodology,0.6,,,0.6,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.43,,,0.43,Other,Drug Cost,0.43,,,0.43,Other,Drug Cost,0.54,,,0.54,Other,125% Medicaid APG methodology,0.01,1.91,
CARBAMAZEPINE 200 MG TAB        ,,,,40519605,CDM,250,RC,68084-0444-01,NDC,both,1,EA,1.86,0.73,39.4668,,0.73,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.56,30,,0.56,percent of total billed charges,"Drugs, Inpatient Only",0.56,30,,0.56,percent of total billed charges,"Drugs, Inpatient Only",0.56,30,,0.56,percent of total billed charges,"Drugs, Inpatient Only",0.93,50,,0.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.84,,,0.84,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.3,70,,1.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.45,,,0.45,Other,Drug Cost,1.01,,,1.01,Other,225% Medicaid APG methodology,0.63,,,0.63,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.56,,,0.56,Other,125% Medicaid APG methodology,0.01,1.3,
CARBAMAZEPINE 100 MG CHEW TAB   ,,,,40519613,CDM,250,RC,00904-3854-61,NDC,both,1,EA,0.95,0.37,39.4668,,0.37,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.48,50,,0.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.67,70,,0.67,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.2,,,0.2,Other,225% Medicaid APG methodology,0.13,,,0.13,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,0.67,
CLONAZEPAM 0.5 MG TAB           ,,,,40519621,CDM,250,RC,00904-7227-61,NDC,both,1,EA,1.33,0.52,39.4668,,0.52,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.4,30,,0.4,percent of total billed charges,"Drugs, Inpatient Only",0.4,30,,0.4,percent of total billed charges,"Drugs, Inpatient Only",0.4,30,,0.4,percent of total billed charges,"Drugs, Inpatient Only",0.67,50,,0.67,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.87,,,0.87,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.93,70,,0.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.47,,,0.47,Other,Drug Cost,1.06,,,1.06,Other,225% Medicaid APG methodology,0.66,,,0.66,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.59,,,0.59,Other,125% Medicaid APG methodology,0.01,1.06,
CLONAZEPAM 1 MG TAB             ,,,,40519639,CDM,250,RC,43547-0407-10,NDC,both,1,EA,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.04,50,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
AMANTADINE 100 MG CAP           ,,,,40519670,CDM,250,RC,00904-7042-06,NDC,both,1,EA,2.84,1.12,39.4668,,1.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.85,30,,0.85,percent of total billed charges,"Drugs, Inpatient Only",0.85,30,,0.85,percent of total billed charges,"Drugs, Inpatient Only",0.85,30,,0.85,percent of total billed charges,"Drugs, Inpatient Only",1.42,50,,1.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.58,,,1.58,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.99,70,,1.99,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.85,,,0.85,Other,Drug Cost,1.91,,,1.91,Other,225% Medicaid APG methodology,1.19,,,1.19,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,1.06,,,1.06,Other,125% Medicaid APG methodology,0.01,1.99,
AMANTADINE 50MG/5ML ORSYR 10ML  ,,,,40519688,CDM,250,RC,39328-0530-99,NDC,both,10,ML,11.2,4.42,39.4668,,4.42,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.36,30,,3.36,percent of total billed charges,"Drugs, Inpatient Only",3.36,30,,3.36,percent of total billed charges,"Drugs, Inpatient Only",3.36,30,,3.36,percent of total billed charges,"Drugs, Inpatient Only",5.6,50,,5.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.8,,,5.8,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.84,70,,7.84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.12,,,3.12,Other,Drug Cost,3.12,,,3.12,Other,Drug Cost,3.12,,,3.12,Other,Drug Cost,3.12,,,3.12,Other,Drug Cost,3.12,,,3.12,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.12,,,3.12,Other,Drug Cost,7.02,,,7.02,Other,225% Medicaid APG methodology,4.37,,,4.37,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.12,,,3.12,Other,Drug Cost,3.12,,,3.12,Other,Drug Cost,3.9,,,3.9,Other,125% Medicaid APG methodology,0.01,7.84,
TRIHEXYPHENIDYL 2 MG TAB        ,,,,40519696,CDM,250,RC,00591-5335-01,NDC,both,1,EA,0.49,0.19,39.4668,,0.19,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.25,50,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.34,70,,0.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.34,
BENZTROPINE 0.5 MG TAB          ,,,,40519738,CDM,250,RC,68084-0381-01,NDC,both,1,EA,1.61,0.64,39.4668,,0.64,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.48,30,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.48,30,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.48,30,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.81,50,,0.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.71,,,0.71,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.13,70,,1.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.38,,,0.38,Other,Drug Cost,0.86,,,0.86,Other,225% Medicaid APG methodology,0.53,,,0.53,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.48,,,0.48,Other,125% Medicaid APG methodology,0.01,1.13,
BENZTROPINE 2 MG TAB            ,,,,40519746,CDM,250,RC,00904-7290-61,NDC,both,1,EA,1.75,0.69,39.4668,,0.69,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.53,30,,0.53,percent of total billed charges,"Drugs, Inpatient Only",0.53,30,,0.53,percent of total billed charges,"Drugs, Inpatient Only",0.53,30,,0.53,percent of total billed charges,"Drugs, Inpatient Only",0.88,50,,0.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1,,,1,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.23,70,,1.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.54,,,0.54,Other,Drug Cost,1.22,,,1.22,Other,225% Medicaid APG methodology,0.76,,,0.76,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.68,,,0.68,Other,125% Medicaid APG methodology,0.01,1.23,
PHENYTOIN 100 MG ER CAP         ,,,,40519753,CDM,250,RC,65862-0692-01,NDC,both,1,EA,1.09,0.43,39.4668,,0.43,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.33,30,,0.33,percent of total billed charges,"Drugs, Inpatient Only",0.33,30,,0.33,percent of total billed charges,"Drugs, Inpatient Only",0.33,30,,0.33,percent of total billed charges,"Drugs, Inpatient Only",0.55,50,,0.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.76,70,,0.76,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.76,
ESCITALOPRAM 10 MG TAB          ,,,,40519779,CDM,250,RC,00904-6426-61,NDC,both,1,EA,0.49,0.19,39.4668,,0.19,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.25,50,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.34,70,,0.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.34,
METHOCARBAMOL 500 MG TAB        ,,,,40519803,CDM,250,RC,76385-0123-01,NDC,both,1,EA,0.25,0.1,39.4668,,0.1,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.13,50,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.18,70,,0.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.18,
CARISOPRODOL 350MG TABLET       ,,,,40519811,CDM,250,RC,50228-0109-01,NDC,both,1,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.11,50,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.15,
DANTROLENE 100 MG CAP           ,,,,40519829,CDM,250,RC,00115-4433-01,NDC,both,1,EA,3.4,1.34,39.4668,,1.34,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.02,30,,1.02,percent of total billed charges,"Drugs, Inpatient Only",1.02,30,,1.02,percent of total billed charges,"Drugs, Inpatient Only",1.02,30,,1.02,percent of total billed charges,"Drugs, Inpatient Only",1.7,50,,1.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.58,,,0.58,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.38,70,,2.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.31,,,0.31,Other,Drug Cost,0.7,,,0.7,Other,225% Medicaid APG methodology,0.43,,,0.43,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.39,,,0.39,Other,125% Medicaid APG methodology,0.01,2.38,
DANTROLENE 25 MG CAP            ,,,,40519837,CDM,250,RC,00904-7211-04,NDC,both,1,EA,4.48,1.77,39.4668,,1.77,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.34,30,,1.34,percent of total billed charges,"Drugs, Inpatient Only",1.34,30,,1.34,percent of total billed charges,"Drugs, Inpatient Only",1.34,30,,1.34,percent of total billed charges,"Drugs, Inpatient Only",2.24,50,,2.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.4,,,2.4,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.14,70,,3.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.29,,,1.29,Other,Drug Cost,1.29,,,1.29,Other,Drug Cost,1.29,,,1.29,Other,Drug Cost,1.29,,,1.29,Other,Drug Cost,1.29,,,1.29,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.29,,,1.29,Other,Drug Cost,2.9,,,2.9,Other,225% Medicaid APG methodology,1.81,,,1.81,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.29,,,1.29,Other,Drug Cost,1.29,,,1.29,Other,Drug Cost,1.61,,,1.61,Other,125% Medicaid APG methodology,0.01,3.14,
DANTROLENE 20 MG IV INJ         ,,,,40519845,CDM,250,RC,27505-0003-67,NDC,both,1,EA,35.98,14.2,39.4668,,14.2,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.79,30,,10.79,percent of total billed charges,"Drugs, Inpatient Only",10.79,30,,10.79,percent of total billed charges,"Drugs, Inpatient Only",10.79,30,,10.79,percent of total billed charges,"Drugs, Inpatient Only",17.99,50,,17.99,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,103.01,,,103.01,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,25.19,70,,25.19,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,55.38,,,55.38,Other,Drug Cost,55.38,,,55.38,Other,Drug Cost,55.38,,,55.38,Other,Drug Cost,55.38,,,55.38,Other,Drug Cost,55.38,,,55.38,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,55.38,,,55.38,Other,Drug Cost,124.61,,,124.61,Other,225% Medicaid APG methodology,77.53,,,77.53,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,55.38,,,55.38,Other,Drug Cost,55.38,,,55.38,Other,Drug Cost,69.23,,,69.23,Other,125% Medicaid APG methodology,0.01,124.61,
BUDESONIDE 0.25MG/2ML INH 2ML   ,,,,40519852,CDM,250,RC,00093-6815-55,NDC,both,2,ML,15.68,6.19,39.4668,,6.19,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.7,30,,4.7,percent of total billed charges,"Drugs, Inpatient Only",4.7,30,,4.7,percent of total billed charges,"Drugs, Inpatient Only",4.7,30,,4.7,percent of total billed charges,"Drugs, Inpatient Only",7.84,50,,7.84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.89,,,0.89,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.98,70,,10.98,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.48,,,0.48,Other,Drug Cost,1.08,,,1.08,Other,225% Medicaid APG methodology,0.67,,,0.67,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.6,,,0.6,Other,125% Medicaid APG methodology,0.01,10.98,
BUDESONIDE 0.5MG/2ML INH  2ML   ,,,,40519860,CDM,250,RC,00186-1989-04,NDC,both,2,ML,33.36,13.17,39.4668,,13.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.01,30,,10.01,percent of total billed charges,"Drugs, Inpatient Only",10.01,30,,10.01,percent of total billed charges,"Drugs, Inpatient Only",10.01,30,,10.01,percent of total billed charges,"Drugs, Inpatient Only",16.68,50,,16.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.97,,,5.97,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,23.35,70,,23.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.21,,,3.21,Other,Drug Cost,3.21,,,3.21,Other,Drug Cost,3.21,,,3.21,Other,Drug Cost,3.21,,,3.21,Other,Drug Cost,3.21,,,3.21,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.21,,,3.21,Other,Drug Cost,7.22,,,7.22,Other,225% Medicaid APG methodology,4.49,,,4.49,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.21,,,3.21,Other,Drug Cost,3.21,,,3.21,Other,Drug Cost,4.01,,,4.01,Other,125% Medicaid APG methodology,0.01,23.35,
BACLOFEN 10 MG TAB              ,,,,40519886,CDM,250,RC,60687-0815-01,NDC,both,1,EA,1.51,0.6,39.4668,,0.6,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.45,30,,0.45,percent of total billed charges,"Drugs, Inpatient Only",0.45,30,,0.45,percent of total billed charges,"Drugs, Inpatient Only",0.45,30,,0.45,percent of total billed charges,"Drugs, Inpatient Only",0.76,50,,0.76,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.71,,,0.71,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.06,70,,1.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.38,,,0.38,Other,Drug Cost,0.86,,,0.86,Other,225% Medicaid APG methodology,0.53,,,0.53,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.48,,,0.48,Other,125% Medicaid APG methodology,0.01,1.06,
CYCLOBENZAPRINE 10 MG TAB       ,,,,40519894,CDM,250,RC,69097-0846-07,NDC,both,1,EA,0.11,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.06,50,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.08,
BUPROPION 75 MG TAB             ,,,,40519936,CDM,250,RC,62332-0118-31,NDC,both,1,EA,0.25,0.1,39.4668,,0.1,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.13,50,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.18,70,,0.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% Medicaid APG methodology,0.11,,,0.11,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.18,
BUPROPION 100 MG TAB            ,,,,40519944,CDM,250,RC,60505-0157-01,NDC,both,1,EA,0.74,0.29,39.4668,,0.29,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,30,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.22,30,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.22,30,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.37,50,,0.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.52,70,,0.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.52,
CLOZAPINE 25 MG TAB             ,,,,40519951,CDM,250,RC,00904-7089-61,NDC,both,1,EA,0.84,0.33,39.4668,,0.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,30,,0.25,percent of total billed charges,"Drugs, Inpatient Only",0.25,30,,0.25,percent of total billed charges,"Drugs, Inpatient Only",0.25,30,,0.25,percent of total billed charges,"Drugs, Inpatient Only",0.42,50,,0.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.47,,,0.47,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.59,70,,0.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.56,,,0.56,Other,225% Medicaid APG methodology,0.35,,,0.35,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.31,,,0.31,Other,125% Medicaid APG methodology,0.01,0.59,
CLOZAPINE 100 MG TAB            ,,,,40519969,CDM,250,RC,00093-7772-01,NDC,both,1,EA,7.56,2.98,39.4668,,2.98,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.27,30,,2.27,percent of total billed charges,"Drugs, Inpatient Only",2.27,30,,2.27,percent of total billed charges,"Drugs, Inpatient Only",2.27,30,,2.27,percent of total billed charges,"Drugs, Inpatient Only",3.78,50,,3.78,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.29,70,,5.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.2,,,0.2,Other,225% Medicaid APG methodology,0.13,,,0.13,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,5.29,
SCOPOLAMINE 1.5MG/72HRS PCH     ,,,,40519977,CDM,250,RC,50742-0505-24,NDC,both,1,EA,21.98,8.67,39.4668,,8.67,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.59,30,,6.59,percent of total billed charges,"Drugs, Inpatient Only",6.59,30,,6.59,percent of total billed charges,"Drugs, Inpatient Only",6.59,30,,6.59,percent of total billed charges,"Drugs, Inpatient Only",10.99,50,,10.99,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.42,,,3.42,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.39,70,,15.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.84,,,1.84,Other,Drug Cost,1.84,,,1.84,Other,Drug Cost,1.84,,,1.84,Other,Drug Cost,1.84,,,1.84,Other,Drug Cost,1.84,,,1.84,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.84,,,1.84,Other,Drug Cost,4.14,,,4.14,Other,225% Medicaid APG methodology,2.58,,,2.58,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.84,,,1.84,Other,Drug Cost,1.84,,,1.84,Other,Drug Cost,2.3,,,2.3,Other,125% Medicaid APG methodology,0.01,15.39,
MECLIZINE 12.5 MG TAB           ,,,,40520009,CDM,250,RC,60687-0775-01,NDC,both,1,EA,1.47,0.58,39.4668,,0.58,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.44,30,,0.44,percent of total billed charges,"Drugs, Inpatient Only",0.44,30,,0.44,percent of total billed charges,"Drugs, Inpatient Only",0.44,30,,0.44,percent of total billed charges,"Drugs, Inpatient Only",0.74,50,,0.74,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.61,,,0.61,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.03,70,,1.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.33,,,0.33,Other,Drug Cost,0.74,,,0.74,Other,225% Medicaid APG methodology,0.46,,,0.46,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.41,,,0.41,Other,125% Medicaid APG methodology,0.01,1.03,
MECLIZINE 25 MG TAB             ,,,,40520017,CDM,250,RC,00904-7376-61,NDC,both,1,EA,1.4,0.55,39.4668,,0.55,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.42,30,,0.42,percent of total billed charges,"Drugs, Inpatient Only",0.42,30,,0.42,percent of total billed charges,"Drugs, Inpatient Only",0.42,30,,0.42,percent of total billed charges,"Drugs, Inpatient Only",0.7,50,,0.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.61,,,0.61,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.98,70,,0.98,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.33,,,0.33,Other,Drug Cost,0.74,,,0.74,Other,225% Medicaid APG methodology,0.46,,,0.46,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.41,,,0.41,Other,125% Medicaid APG methodology,0.01,0.98,
BETHANECHOL 10 MG TAB           ,,,,40520025,CDM,250,RC,00832-0511-00,NDC,both,1,EA,0.81,0.32,39.4668,,0.32,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.24,30,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.24,30,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.24,30,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.41,50,,0.41,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.57,70,,0.57,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.25,,,0.25,Other,225% Medicaid APG methodology,0.15,,,0.15,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.14,,,0.14,Other,125% Medicaid APG methodology,0.01,0.57,
BETHANECHOL 25 MG TAB           ,,,,40520033,CDM,250,RC,00832-0512-01,NDC,both,1,EA,1.75,0.69,39.4668,,0.69,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.53,30,,0.53,percent of total billed charges,"Drugs, Inpatient Only",0.53,30,,0.53,percent of total billed charges,"Drugs, Inpatient Only",0.53,30,,0.53,percent of total billed charges,"Drugs, Inpatient Only",0.88,50,,0.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.32,,,0.32,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.23,70,,1.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,Drug Cost,0.38,,,0.38,Other,225% Medicaid APG methodology,0.24,,,0.24,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.21,,,0.21,Other,125% Medicaid APG methodology,0.01,1.23,
PHYSOSTIGMINE 1MG/ML INJ 2ML    ,,,,40520058,CDM,250,RC,17478-0510-02,NDC,both,2,ML,259.07,102.25,39.4668,,102.25,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,77.72,30,,77.72,percent of total billed charges,"Drugs, Inpatient Only",77.72,30,,77.72,percent of total billed charges,"Drugs, Inpatient Only",77.72,30,,77.72,percent of total billed charges,"Drugs, Inpatient Only",129.54,50,,129.54,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,181.35,70,,181.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,181.35,
PYRIDOSTIGMINE 60 MG TAB        ,,,,40520082,CDM,250,RC,00187-3010-30,NDC,both,1,EA,64.02,25.27,39.4668,,25.27,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.21,30,,19.21,percent of total billed charges,"Drugs, Inpatient Only",19.21,30,,19.21,percent of total billed charges,"Drugs, Inpatient Only",19.21,30,,19.21,percent of total billed charges,"Drugs, Inpatient Only",32.01,50,,32.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,44.81,70,,44.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,44.81,
BENZOIN COMPOUND TINCTURE 60ML  ,,,,40520157,CDM,250,RC,00395-0243-92,NDC,both,60,ML,23.1,9.12,39.4668,,9.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.93,30,,6.93,percent of total billed charges,"Drugs, Inpatient Only",6.93,30,,6.93,percent of total billed charges,"Drugs, Inpatient Only",6.93,30,,6.93,percent of total billed charges,"Drugs, Inpatient Only",11.55,50,,11.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.28,,,12.28,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,16.17,70,,16.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.6,,,6.6,Other,Drug Cost,6.6,,,6.6,Other,Drug Cost,6.6,,,6.6,Other,Drug Cost,6.6,,,6.6,Other,Drug Cost,6.6,,,6.6,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,6.6,,,6.6,Other,Drug Cost,14.85,,,14.85,Other,225% Medicaid APG methodology,9.24,,,9.24,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.6,,,6.6,Other,Drug Cost,6.6,,,6.6,Other,Drug Cost,8.25,,,8.25,Other,125% Medicaid APG methodology,0.01,16.17,
GLYCOPYRROLATE 1 MG TAB         ,,,,40520199,CDM,250,RC,23155-0606-01,NDC,both,1,EA,0.49,0.19,39.4668,,0.19,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.25,50,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.34,70,,0.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.34,
FENTANYL 25 MCG/HR TD FILM ER   ,,,,40520207,CDM,250,RC,47781-0424-47,NDC,both,1,EA,23.59,9.31,39.4668,,9.31,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.08,30,,7.08,percent of total billed charges,"Drugs, Inpatient Only",7.08,30,,7.08,percent of total billed charges,"Drugs, Inpatient Only",7.08,30,,7.08,percent of total billed charges,"Drugs, Inpatient Only",11.8,50,,11.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.62,,,1.62,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,16.51,70,,16.51,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.87,,,0.87,Other,Drug Cost,0.87,,,0.87,Other,Drug Cost,0.87,,,0.87,Other,Drug Cost,0.87,,,0.87,Other,Drug Cost,0.87,,,0.87,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.87,,,0.87,Other,Drug Cost,1.96,,,1.96,Other,225% Medicaid APG methodology,1.22,,,1.22,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.87,,,0.87,Other,Drug Cost,0.87,,,0.87,Other,Drug Cost,1.09,,,1.09,Other,125% Medicaid APG methodology,0.01,16.51,
FENTANYL 50 MCG/HR TD FILM ER   ,,,,40520215,CDM,250,RC,00406-9050-76,NDC,both,1,EA,41.93,16.55,39.4668,,16.55,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.58,30,,12.58,percent of total billed charges,"Drugs, Inpatient Only",12.58,30,,12.58,percent of total billed charges,"Drugs, Inpatient Only",12.58,30,,12.58,percent of total billed charges,"Drugs, Inpatient Only",20.97,50,,20.97,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.18,,,2.18,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,29.35,70,,29.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.17,,,1.17,Other,Drug Cost,1.17,,,1.17,Other,Drug Cost,1.17,,,1.17,Other,Drug Cost,1.17,,,1.17,Other,Drug Cost,1.17,,,1.17,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.17,,,1.17,Other,Drug Cost,2.63,,,2.63,Other,225% Medicaid APG methodology,1.64,,,1.64,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.17,,,1.17,Other,Drug Cost,1.17,,,1.17,Other,Drug Cost,1.46,,,1.46,Other,125% Medicaid APG methodology,0.01,29.35,
FENTANYL 100 MCG/HR TD FILM ER  ,,,,40520223,CDM,250,RC,00406-9000-76,NDC,both,1,EA,91.21,36,39.4668,,36,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,27.36,30,,27.36,percent of total billed charges,"Drugs, Inpatient Only",27.36,30,,27.36,percent of total billed charges,"Drugs, Inpatient Only",27.36,30,,27.36,percent of total billed charges,"Drugs, Inpatient Only",45.61,50,,45.61,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.12,,,3.12,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,63.85,70,,63.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.68,,,1.68,Other,Drug Cost,1.68,,,1.68,Other,Drug Cost,1.68,,,1.68,Other,Drug Cost,1.68,,,1.68,Other,Drug Cost,1.68,,,1.68,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.68,,,1.68,Other,Drug Cost,3.78,,,3.78,Other,225% Medicaid APG methodology,2.35,,,2.35,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.68,,,1.68,Other,Drug Cost,1.68,,,1.68,Other,Drug Cost,2.1,,,2.1,Other,125% Medicaid APG methodology,0.01,63.85,
DICYCLOMINE 10 MG CAP           ,,,,40520231,CDM,250,RC,00591-0794-01,NDC,both,1,EA,0.53,0.21,39.4668,,0.21,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.27,50,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,70,,0.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.37,
OXYBUTYNIN 5 MG TAB             ,,,,40520264,CDM,250,RC,00904-2821-61,NDC,both,1,EA,1.16,0.46,39.4668,,0.46,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.35,30,,0.35,percent of total billed charges,"Drugs, Inpatient Only",0.35,30,,0.35,percent of total billed charges,"Drugs, Inpatient Only",0.35,30,,0.35,percent of total billed charges,"Drugs, Inpatient Only",0.58,50,,0.58,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.61,,,0.61,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.81,70,,0.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.33,,,0.33,Other,Drug Cost,0.74,,,0.74,Other,225% Medicaid APG methodology,0.46,,,0.46,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.41,,,0.41,Other,125% Medicaid APG methodology,0.01,0.81,
NOREPINEPH 1MG/ML IV SLN 4ML    ,,,,40520314,CDM,250,RC,36000-0162-10,NDC,both,4,ML,23.8,9.39,39.4668,,9.39,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.14,30,,7.14,percent of total billed charges,"Drugs, Inpatient Only",7.14,30,,7.14,percent of total billed charges,"Drugs, Inpatient Only",7.14,30,,7.14,percent of total billed charges,"Drugs, Inpatient Only",11.9,50,,11.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.12,,,3.12,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,16.66,70,,16.66,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.68,,,1.68,Other,Drug Cost,1.68,,,1.68,Other,Drug Cost,1.68,,,1.68,Other,Drug Cost,1.68,,,1.68,Other,Drug Cost,1.68,,,1.68,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.68,,,1.68,Other,Drug Cost,3.78,,,3.78,Other,225% Medicaid APG methodology,2.35,,,2.35,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.68,,,1.68,Other,Drug Cost,1.68,,,1.68,Other,Drug Cost,2.1,,,2.1,Other,125% Medicaid APG methodology,0.01,16.66,
ISOPROTERENOL 0.2MG/ML INJ 1ML  ,,,,40520322,CDM,250,RC,69918-0731-10,NDC,both,1,ML,149.66,59.07,39.4668,,59.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,44.9,30,,44.9,percent of total billed charges,"Drugs, Inpatient Only",44.9,30,,44.9,percent of total billed charges,"Drugs, Inpatient Only",44.9,30,,44.9,percent of total billed charges,"Drugs, Inpatient Only",74.83,50,,74.83,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,138.48,,,138.48,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,104.76,70,,104.76,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,74.45,,,74.45,Other,Drug Cost,74.45,,,74.45,Other,Drug Cost,74.45,,,74.45,Other,Drug Cost,74.45,,,74.45,Other,Drug Cost,74.45,,,74.45,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,74.45,,,74.45,Other,Drug Cost,167.51,,,167.51,Other,225% Medicaid APG methodology,104.23,,,104.23,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,74.45,,,74.45,Other,Drug Cost,74.45,,,74.45,Other,Drug Cost,93.06,,,93.06,Other,125% Medicaid APG methodology,0.01,167.51,
MOXIFLOXACIN 0.5% OPT SLN 3ML   ,,,,40520330,CDM,250,RC,68180-0421-01,NDC,both,3,ML,476.39,188.02,39.4668,,188.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,142.92,30,,142.92,percent of total billed charges,"Drugs, Inpatient Only",142.92,30,,142.92,percent of total billed charges,"Drugs, Inpatient Only",142.92,30,,142.92,percent of total billed charges,"Drugs, Inpatient Only",238.2,50,,238.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,25.46,,,25.46,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,333.47,70,,333.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.69,,,13.69,Other,Drug Cost,13.69,,,13.69,Other,Drug Cost,13.69,,,13.69,Other,Drug Cost,13.69,,,13.69,Other,Drug Cost,13.69,,,13.69,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,13.69,,,13.69,Other,Drug Cost,30.8,,,30.8,Other,225% Medicaid APG methodology,19.17,,,19.17,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,13.69,,,13.69,Other,Drug Cost,13.69,,,13.69,Other,Drug Cost,17.11,,,17.11,Other,125% Medicaid APG methodology,0.01,333.47,
VECURONIUM 10 MG IV INJ         ,,,,40520348,CDM,250,RC,00703-2914-03,NDC,both,1,EA,13.27,5.24,39.4668,,5.24,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.98,30,,3.98,percent of total billed charges,"Drugs, Inpatient Only",3.98,30,,3.98,percent of total billed charges,"Drugs, Inpatient Only",3.98,30,,3.98,percent of total billed charges,"Drugs, Inpatient Only",6.64,50,,6.64,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.44,,,3.44,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.29,70,,9.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.85,,,1.85,Other,Drug Cost,1.85,,,1.85,Other,Drug Cost,1.85,,,1.85,Other,Drug Cost,1.85,,,1.85,Other,Drug Cost,1.85,,,1.85,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.85,,,1.85,Other,Drug Cost,4.16,,,4.16,Other,225% Medicaid APG methodology,2.59,,,2.59,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.85,,,1.85,Other,Drug Cost,1.85,,,1.85,Other,Drug Cost,2.31,,,2.31,Other,125% Medicaid APG methodology,0.01,9.29,
VECURONIUM 20 MG IV INJ         ,,,,40520355,CDM,250,RC,63323-0782-20,NDC,both,1,EA,36.4,14.37,39.4668,,14.37,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.92,30,,10.92,percent of total billed charges,"Drugs, Inpatient Only",10.92,30,,10.92,percent of total billed charges,"Drugs, Inpatient Only",10.92,30,,10.92,percent of total billed charges,"Drugs, Inpatient Only",18.2,50,,18.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,16.39,,,16.39,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,25.48,70,,25.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.81,,,8.81,Other,Drug Cost,8.81,,,8.81,Other,Drug Cost,8.81,,,8.81,Other,Drug Cost,8.81,,,8.81,Other,Drug Cost,8.81,,,8.81,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,8.81,,,8.81,Other,Drug Cost,19.82,,,19.82,Other,225% Medicaid APG methodology,12.33,,,12.33,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,8.81,,,8.81,Other,Drug Cost,8.81,,,8.81,Other,Drug Cost,11.01,,,11.01,Other,125% Medicaid APG methodology,0.01,25.48,
TERBUTALINE 5 MG TAB            ,,,,40520496,CDM,250,RC,00115-2622-01,NDC,both,1,EA,16.73,6.6,39.4668,,6.6,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.02,30,,5.02,percent of total billed charges,"Drugs, Inpatient Only",5.02,30,,5.02,percent of total billed charges,"Drugs, Inpatient Only",5.02,30,,5.02,percent of total billed charges,"Drugs, Inpatient Only",8.37,50,,8.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.71,70,,11.71,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,11.71,
TERBUTALINE 2.5 MG TAB          ,,,,40520504,CDM,250,RC,00115-2611-01,NDC,both,1,EA,12.74,5.03,39.4668,,5.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.82,30,,3.82,percent of total billed charges,"Drugs, Inpatient Only",3.82,30,,3.82,percent of total billed charges,"Drugs, Inpatient Only",3.82,30,,3.82,percent of total billed charges,"Drugs, Inpatient Only",6.37,50,,6.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.92,70,,8.92,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,8.92,
EPHEDRINE 50MG/ML IV SOLN 1ML   ,,,,40520561,CDM,250,RC,17478-0415-10,NDC,both,1,ML,68.11,26.88,39.4668,,26.88,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,20.43,30,,20.43,percent of total billed charges,"Drugs, Inpatient Only",20.43,30,,20.43,percent of total billed charges,"Drugs, Inpatient Only",20.43,30,,20.43,percent of total billed charges,"Drugs, Inpatient Only",34.06,50,,34.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.29,,,19.29,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,47.68,70,,47.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.37,,,10.37,Other,Drug Cost,10.37,,,10.37,Other,Drug Cost,10.37,,,10.37,Other,Drug Cost,10.37,,,10.37,Other,Drug Cost,10.37,,,10.37,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,10.37,,,10.37,Other,Drug Cost,23.33,,,23.33,Other,225% Medicaid APG methodology,14.52,,,14.52,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,10.37,,,10.37,Other,Drug Cost,10.37,,,10.37,Other,Drug Cost,12.96,,,12.96,Other,125% Medicaid APG methodology,0.01,47.68,
FLUVOXAMINE 50 MG TAB           ,,,,40520579,CDM,250,RC,62559-0159-01,NDC,both,1,EA,1.19,0.47,39.4668,,0.47,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.36,30,,0.36,percent of total billed charges,"Drugs, Inpatient Only",0.36,30,,0.36,percent of total billed charges,"Drugs, Inpatient Only",0.36,30,,0.36,percent of total billed charges,"Drugs, Inpatient Only",0.6,50,,0.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.83,70,,0.83,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.83,
PSEUDOEPHEDRINE 30 MG TAB       ,,,,40520637,CDM,250,RC,00904-5053-59,NDC,both,1,EA,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.04,50,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
PSEUDOEPHEDRINE 60 MG TAB       ,,,,40520645,CDM,250,RC,00904-6728-52,NDC,both,1,EA,0.11,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.06,50,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.08,
PROPRANOLOL 10 MG TAB           ,,,,40520736,CDM,250,RC,69238-2077-01,NDC,both,1,EA,0.35,0.14,39.4668,,0.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.18,50,,0.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,70,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.25,
PROPRANOLOL 20 MG TAB           ,,,,40520744,CDM,250,RC,50268-0663-15,NDC,both,1,EA,1.33,0.52,39.4668,,0.52,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.4,30,,0.4,percent of total billed charges,"Drugs, Inpatient Only",0.4,30,,0.4,percent of total billed charges,"Drugs, Inpatient Only",0.4,30,,0.4,percent of total billed charges,"Drugs, Inpatient Only",0.67,50,,0.67,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.63,,,0.63,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.93,70,,0.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.34,,,0.34,Other,Drug Cost,0.77,,,0.77,Other,225% Medicaid APG methodology,0.48,,,0.48,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.43,,,0.43,Other,125% Medicaid APG methodology,0.01,0.93,
METOPROLOL TARTRATE 100 MG TAB  ,,,,40520777,CDM,250,RC,62584-0267-01,NDC,both,1,EA,0.42,0.17,39.4668,,0.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.21,50,,0.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,70,,0.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.29,
METOPROLOL TARTRATE 50 MG TAB   ,,,,40520785,CDM,250,RC,62332-0113-31,NDC,both,1,EA,1.93,0.76,39.4668,,0.76,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.58,30,,0.58,percent of total billed charges,"Drugs, Inpatient Only",0.58,30,,0.58,percent of total billed charges,"Drugs, Inpatient Only",0.58,30,,0.58,percent of total billed charges,"Drugs, Inpatient Only",0.97,50,,0.97,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.02,,,1.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.35,70,,1.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.55,,,0.55,Other,Drug Cost,0.55,,,0.55,Other,Drug Cost,0.55,,,0.55,Other,Drug Cost,0.55,,,0.55,Other,Drug Cost,0.55,,,0.55,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.55,,,0.55,Other,Drug Cost,1.24,,,1.24,Other,225% Medicaid APG methodology,0.77,,,0.77,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.55,,,0.55,Other,Drug Cost,0.55,,,0.55,Other,Drug Cost,0.69,,,0.69,Other,125% Medicaid APG methodology,0.01,1.35,
NADOLOL 40 MG TAB               ,,,,40520793,CDM,250,RC,00378-1171-01,NDC,both,1,EA,10.5,4.14,39.4668,,4.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.15,30,,3.15,percent of total billed charges,"Drugs, Inpatient Only",3.15,30,,3.15,percent of total billed charges,"Drugs, Inpatient Only",3.15,30,,3.15,percent of total billed charges,"Drugs, Inpatient Only",5.25,50,,5.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.35,70,,7.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.25,,,0.25,Other,225% Medicaid APG methodology,0.15,,,0.15,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.14,,,0.14,Other,125% Medicaid APG methodology,0.01,7.35,
METOCLOPRAMIDE 10 MG TAB        ,,,,40520827,CDM,250,RC,51079-0888-20,NDC,both,1,EA,2.24,0.88,39.4668,,0.88,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.67,30,,0.67,percent of total billed charges,"Drugs, Inpatient Only",0.67,30,,0.67,percent of total billed charges,"Drugs, Inpatient Only",0.67,30,,0.67,percent of total billed charges,"Drugs, Inpatient Only",1.12,50,,1.12,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.57,70,,1.57,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% Medicaid APG methodology,0.1,,,0.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,1.57,
METOCLOPRAMIDE 5 MG TAB         ,,,,40520835,CDM,250,RC,60687-0620-01,NDC,both,1,EA,1.86,0.73,39.4668,,0.73,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.56,30,,0.56,percent of total billed charges,"Drugs, Inpatient Only",0.56,30,,0.56,percent of total billed charges,"Drugs, Inpatient Only",0.56,30,,0.56,percent of total billed charges,"Drugs, Inpatient Only",0.93,50,,0.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.97,,,0.97,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.3,70,,1.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.52,,,0.52,Other,Drug Cost,0.52,,,0.52,Other,Drug Cost,0.52,,,0.52,Other,Drug Cost,0.52,,,0.52,Other,Drug Cost,0.52,,,0.52,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.52,,,0.52,Other,Drug Cost,1.17,,,1.17,Other,225% Medicaid APG methodology,0.73,,,0.73,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.52,,,0.52,Other,Drug Cost,0.52,,,0.52,Other,Drug Cost,0.65,,,0.65,Other,125% Medicaid APG methodology,0.01,1.3,
TORSEMIDE 5 MG TAB              ,,,,40520876,CDM,250,RC,50268-0754-15,NDC,both,1,EA,0.77,0.3,39.4668,,0.3,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.23,30,,0.23,percent of total billed charges,"Drugs, Inpatient Only",0.23,30,,0.23,percent of total billed charges,"Drugs, Inpatient Only",0.23,30,,0.23,percent of total billed charges,"Drugs, Inpatient Only",0.39,50,,0.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.54,70,,0.54,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.54,
TORSEMIDE 20 MG TAB             ,,,,40520884,CDM,250,RC,31722-0531-01,NDC,both,1,EA,0.42,0.17,39.4668,,0.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.21,50,,0.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,70,,0.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.29,
VITAMIN A & D TOPICAL OINT 5 G  ,,,,40520967,CDM,250,RC,54162-0000-05,NDC,both,5,GM,2.8,1.11,39.4668,,1.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.84,30,,0.84,percent of total billed charges,"Drugs, Inpatient Only",0.84,30,,0.84,percent of total billed charges,"Drugs, Inpatient Only",0.84,30,,0.84,percent of total billed charges,"Drugs, Inpatient Only",1.4,50,,1.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.86,,,1.86,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.96,70,,1.96,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1,,,1,Other,Drug Cost,2.25,,,2.25,Other,225% Medicaid APG methodology,1.4,,,1.4,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1.25,,,1.25,Other,125% Medicaid APG methodology,0.01,2.25,
ALENDRONATE 10 MG TAB           ,,,,40520975,CDM,250,RC,64980-0340-01,NDC,both,1,EA,0.35,0.14,39.4668,,0.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.18,50,,0.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,70,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.25,
AQUAPHOR HEALING TOP OINT 120G  ,,,,40520983,CDM,250,RC,72140-0003-75,NDC,both,50,GM,14.6,5.76,39.4668,,5.76,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.38,30,,4.38,percent of total billed charges,"Drugs, Inpatient Only",4.38,30,,4.38,percent of total billed charges,"Drugs, Inpatient Only",4.38,30,,4.38,percent of total billed charges,"Drugs, Inpatient Only",7.3,50,,7.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.76,,,7.76,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.22,70,,10.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.17,,,4.17,Other,Drug Cost,4.17,,,4.17,Other,Drug Cost,4.17,,,4.17,Other,Drug Cost,4.17,,,4.17,Other,Drug Cost,4.17,,,4.17,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.17,,,4.17,Other,Drug Cost,9.38,,,9.38,Other,225% Medicaid APG methodology,5.84,,,5.84,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.17,,,4.17,Other,Drug Cost,4.17,,,4.17,Other,Drug Cost,5.21,,,5.21,Other,125% Medicaid APG methodology,0.01,10.22,
OXCARBAZEPINE 300 MG TAB        ,,,,40520991,CDM,250,RC,51991-0293-01,NDC,both,1,EA,0.53,0.21,39.4668,,0.21,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.27,50,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,70,,0.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% Medicaid APG methodology,0.11,,,0.11,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.37,
OXCARBAZEPINE 60MG/ML ORLSUSP   ,,,,40521007,CDM,250,RC,65162-0649-78,NDC,both,1,ML,1.37,0.54,39.4668,,0.54,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.41,30,,0.41,percent of total billed charges,"Drugs, Inpatient Only",0.41,30,,0.41,percent of total billed charges,"Drugs, Inpatient Only",0.41,30,,0.41,percent of total billed charges,"Drugs, Inpatient Only",0.69,50,,0.69,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,,,0.37,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.96,70,,0.96,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.45,,,0.45,Other,225% Medicaid APG methodology,0.28,,,0.28,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.25,,,0.25,Other,125% Medicaid APG methodology,0.01,0.96,
OXCARBAZEPINE 150 MG TAB        ,,,,40521015,CDM,250,RC,68084-0845-01,NDC,both,1,EA,1.16,0.46,39.4668,,0.46,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.35,30,,0.35,percent of total billed charges,"Drugs, Inpatient Only",0.35,30,,0.35,percent of total billed charges,"Drugs, Inpatient Only",0.35,30,,0.35,percent of total billed charges,"Drugs, Inpatient Only",0.58,50,,0.58,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.81,70,,0.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.27,,,0.27,Other,225% Medicaid APG methodology,0.17,,,0.17,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.15,,,0.15,Other,125% Medicaid APG methodology,0.01,0.81,
CALAMINE-ZINC OXIDE 8-8% 177ML  ,,,,40521031,CDM,250,RC,00904-2533-21,NDC,both,177,ML,6.2,2.45,39.4668,,2.45,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.86,30,,1.86,percent of total billed charges,"Drugs, Inpatient Only",1.86,30,,1.86,percent of total billed charges,"Drugs, Inpatient Only",1.86,30,,1.86,percent of total billed charges,"Drugs, Inpatient Only",3.1,50,,3.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.29,,,3.29,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.34,70,,4.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.77,,,1.77,Other,Drug Cost,1.77,,,1.77,Other,Drug Cost,1.77,,,1.77,Other,Drug Cost,1.77,,,1.77,Other,Drug Cost,1.77,,,1.77,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.77,,,1.77,Other,Drug Cost,3.98,,,3.98,Other,225% Medicaid APG methodology,2.48,,,2.48,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.77,,,1.77,Other,Drug Cost,1.77,,,1.77,Other,Drug Cost,2.21,,,2.21,Other,125% Medicaid APG methodology,0.01,4.34,
EZETIMIBE 10 MG TAB             ,,,,40521049,CDM,250,RC,00781-5690-31,NDC,both,1,EA,6.93,2.74,39.4668,,2.74,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.08,30,,2.08,percent of total billed charges,"Drugs, Inpatient Only",2.08,30,,2.08,percent of total billed charges,"Drugs, Inpatient Only",2.08,30,,2.08,percent of total billed charges,"Drugs, Inpatient Only",3.47,50,,3.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.85,70,,4.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,4.85,
ZINC OXIDE 20%TOPICAL OINT 30G  ,,,,40521122,CDM,250,RC,00536-1316-28,NDC,both,30,GM,6.23,2.46,39.4668,,2.46,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.87,30,,1.87,percent of total billed charges,"Drugs, Inpatient Only",1.87,30,,1.87,percent of total billed charges,"Drugs, Inpatient Only",1.87,30,,1.87,percent of total billed charges,"Drugs, Inpatient Only",3.12,50,,3.12,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.07,,,3.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.36,70,,4.36,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.65,,,1.65,Other,Drug Cost,1.65,,,1.65,Other,Drug Cost,1.65,,,1.65,Other,Drug Cost,1.65,,,1.65,Other,Drug Cost,1.65,,,1.65,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.65,,,1.65,Other,Drug Cost,3.71,,,3.71,Other,225% Medicaid APG methodology,2.31,,,2.31,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.65,,,1.65,Other,Drug Cost,1.65,,,1.65,Other,Drug Cost,2.06,,,2.06,Other,125% Medicaid APG methodology,0.01,4.36,
ANAGRELIDE 0.5 MG CAP           ,,,,40521171,CDM,250,RC,13668-0453-01,NDC,both,1,EA,1.89,0.75,39.4668,,0.75,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.57,30,,0.57,percent of total billed charges,"Drugs, Inpatient Only",0.57,30,,0.57,percent of total billed charges,"Drugs, Inpatient Only",0.57,30,,0.57,percent of total billed charges,"Drugs, Inpatient Only",0.95,50,,0.95,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.47,,,0.47,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.32,70,,1.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.56,,,0.56,Other,225% Medicaid APG methodology,0.35,,,0.35,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.31,,,0.31,Other,125% Medicaid APG methodology,0.01,1.32,
ALBUTEROL 2MG/5ML ORL 60ML BTL  ,,,,40521205,CDM,250,RC,70752-0102-12,NDC,both,60,ML,9.42,3.72,39.4668,,3.72,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.83,30,,2.83,percent of total billed charges,"Drugs, Inpatient Only",2.83,30,,2.83,percent of total billed charges,"Drugs, Inpatient Only",2.83,30,,2.83,percent of total billed charges,"Drugs, Inpatient Only",4.71,50,,4.71,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.95,,,1.95,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.59,70,,6.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.05,,,1.05,Other,Drug Cost,1.05,,,1.05,Other,Drug Cost,1.05,,,1.05,Other,Drug Cost,1.05,,,1.05,Other,Drug Cost,1.05,,,1.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.05,,,1.05,Other,Drug Cost,2.36,,,2.36,Other,225% Medicaid APG methodology,1.47,,,1.47,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.05,,,1.05,Other,Drug Cost,1.05,,,1.05,Other,Drug Cost,1.31,,,1.31,Other,125% Medicaid APG methodology,0.01,6.59,
AMMONIUM LACTATE12% LOTION225G  ,,,,40521262,CDM,250,RC,51672-1300-05,NDC,both,225,GM,58.94,23.26,39.4668,,23.26,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,17.68,30,,17.68,percent of total billed charges,"Drugs, Inpatient Only",17.68,30,,17.68,percent of total billed charges,"Drugs, Inpatient Only",17.68,30,,17.68,percent of total billed charges,"Drugs, Inpatient Only",29.47,50,,29.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.3,,,14.3,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,41.26,70,,41.26,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.69,,,7.69,Other,Drug Cost,7.69,,,7.69,Other,Drug Cost,7.69,,,7.69,Other,Drug Cost,7.69,,,7.69,Other,Drug Cost,7.69,,,7.69,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,7.69,,,7.69,Other,Drug Cost,17.3,,,17.3,Other,225% Medicaid APG methodology,10.77,,,10.77,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.69,,,7.69,Other,Drug Cost,7.69,,,7.69,Other,Drug Cost,9.61,,,9.61,Other,125% Medicaid APG methodology,0.01,41.26,
SELENIUM SULFIDE 2.5%LOT 120ML  ,,,,40521395,CDM,250,RC,45802-0040-64,NDC,both,118,ML,24.78,9.78,39.4668,,9.78,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.43,30,,7.43,percent of total billed charges,"Drugs, Inpatient Only",7.43,30,,7.43,percent of total billed charges,"Drugs, Inpatient Only",7.43,30,,7.43,percent of total billed charges,"Drugs, Inpatient Only",12.39,50,,12.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.78,,,8.78,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,17.35,70,,17.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.72,,,4.72,Other,Drug Cost,4.72,,,4.72,Other,Drug Cost,4.72,,,4.72,Other,Drug Cost,4.72,,,4.72,Other,Drug Cost,4.72,,,4.72,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.72,,,4.72,Other,Drug Cost,10.62,,,10.62,Other,225% Medicaid APG methodology,6.61,,,6.61,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.72,,,4.72,Other,Drug Cost,4.72,,,4.72,Other,Drug Cost,5.9,,,5.9,Other,125% Medicaid APG methodology,0.01,17.35,
ANASTROZOLE 1 MG TAB            ,,,,40521403,CDM,250,RC,60687-0112-21,NDC,both,1,EA,2.59,1.02,39.4668,,1.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.78,30,,0.78,percent of total billed charges,"Drugs, Inpatient Only",0.78,30,,0.78,percent of total billed charges,"Drugs, Inpatient Only",0.78,30,,0.78,percent of total billed charges,"Drugs, Inpatient Only",1.3,50,,1.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.45,,,0.45,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.81,70,,1.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,Drug Cost,0.54,,,0.54,Other,225% Medicaid APG methodology,0.34,,,0.34,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.3,,,0.3,Other,125% Medicaid APG methodology,0.01,1.81,
LEVALBUTEROL 1.25MG/3ML INHSLN  ,,,,40521429,CDM,250,RC,76204-0900-25,NDC,both,3,ML,3.89,1.54,39.4668,,1.54,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.17,30,,1.17,percent of total billed charges,"Drugs, Inpatient Only",1.17,30,,1.17,percent of total billed charges,"Drugs, Inpatient Only",1.17,30,,1.17,percent of total billed charges,"Drugs, Inpatient Only",1.95,50,,1.95,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.76,,,0.76,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.72,70,,2.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.41,,,0.41,Other,Drug Cost,0.92,,,0.92,Other,225% Medicaid APG methodology,0.57,,,0.57,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.51,,,0.51,Other,125% Medicaid APG methodology,0.01,2.72,
LAMOTRIGINE 25 MG DIS TAB       ,,,,40521437,CDM,250,RC,49884-0484-11,NDC,both,1,EA,16.77,6.62,39.4668,,6.62,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.03,30,,5.03,percent of total billed charges,"Drugs, Inpatient Only",5.03,30,,5.03,percent of total billed charges,"Drugs, Inpatient Only",5.03,30,,5.03,percent of total billed charges,"Drugs, Inpatient Only",8.39,50,,8.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.7,,,3.7,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.74,70,,11.74,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.99,,,1.99,Other,Drug Cost,1.99,,,1.99,Other,Drug Cost,1.99,,,1.99,Other,Drug Cost,1.99,,,1.99,Other,Drug Cost,1.99,,,1.99,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.99,,,1.99,Other,Drug Cost,4.48,,,4.48,Other,225% Medicaid APG methodology,2.79,,,2.79,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.99,,,1.99,Other,Drug Cost,1.99,,,1.99,Other,Drug Cost,2.49,,,2.49,Other,125% Medicaid APG methodology,0.01,11.74,
FAT EMULSION IV 20% IV  250ML   ,,,,40521551,CDM,250,RC,00264-4460-30,NDC,both,250,ML,82.78,32.67,39.4668,,32.67,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,24.83,30,,24.83,percent of total billed charges,"Drugs, Inpatient Only",24.83,30,,24.83,percent of total billed charges,"Drugs, Inpatient Only",24.83,30,,24.83,percent of total billed charges,"Drugs, Inpatient Only",41.39,50,,41.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,16,,,16,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,57.95,70,,57.95,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.6,,,8.6,Other,Drug Cost,8.6,,,8.6,Other,Drug Cost,8.6,,,8.6,Other,Drug Cost,8.6,,,8.6,Other,Drug Cost,8.6,,,8.6,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,8.6,,,8.6,Other,Drug Cost,19.35,,,19.35,Other,225% Medicaid APG methodology,12.04,,,12.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,8.6,,,8.6,Other,Drug Cost,8.6,,,8.6,Other,Drug Cost,10.75,,,10.75,Other,125% Medicaid APG methodology,0.01,57.95,
GEMFIBROZIL 600 MG TAB          ,,,,40521619,CDM,250,RC,60687-0224-01,NDC,both,1,EA,0.7,0.28,39.4668,,0.28,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.21,30,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.21,30,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.21,30,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.35,50,,0.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,,,0.37,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.49,70,,0.49,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.45,,,0.45,Other,225% Medicaid APG methodology,0.28,,,0.28,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.25,,,0.25,Other,125% Medicaid APG methodology,0.01,0.49,
FLUTAMIDE 125 MG CAP            ,,,,40521700,CDM,250,RC,00591-2466-18,NDC,both,1,EA,5.43,2.14,39.4668,,2.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.63,30,,1.63,percent of total billed charges,"Drugs, Inpatient Only",1.63,30,,1.63,percent of total billed charges,"Drugs, Inpatient Only",1.63,30,,1.63,percent of total billed charges,"Drugs, Inpatient Only",2.72,50,,2.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.88,,,2.88,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.8,70,,3.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.55,,,1.55,Other,Drug Cost,1.55,,,1.55,Other,Drug Cost,1.55,,,1.55,Other,Drug Cost,1.55,,,1.55,Other,Drug Cost,1.55,,,1.55,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.55,,,1.55,Other,Drug Cost,3.49,,,3.49,Other,225% Medicaid APG methodology,2.17,,,2.17,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.55,,,1.55,Other,Drug Cost,1.55,,,1.55,Other,Drug Cost,1.94,,,1.94,Other,125% Medicaid APG methodology,0.01,3.8,
WARFARIN 2 MG TAB               ,,,,40521718,CDM,250,RC,62584-0984-01,NDC,both,1,EA,0.81,0.32,39.4668,,0.32,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.24,30,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.24,30,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.24,30,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.41,50,,0.41,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.57,70,,0.57,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.25,,,0.25,Other,225% Medicaid APG methodology,0.15,,,0.15,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.14,,,0.14,Other,125% Medicaid APG methodology,0.01,0.57,
WARFARIN 5 MG TAB               ,,,,40521726,CDM,250,RC,62584-0994-01,NDC,both,1,EA,0.81,0.32,39.4668,,0.32,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.24,30,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.24,30,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.24,30,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.41,50,,0.41,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.57,70,,0.57,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.27,,,0.27,Other,225% Medicaid APG methodology,0.17,,,0.17,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.15,,,0.15,Other,125% Medicaid APG methodology,0.01,0.57,
WARFARIN 2.5 MG TAB             ,,,,40521734,CDM,250,RC,51672-4029-01,NDC,both,1,EA,0.77,0.3,39.4668,,0.3,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.23,30,,0.23,percent of total billed charges,"Drugs, Inpatient Only",0.23,30,,0.23,percent of total billed charges,"Drugs, Inpatient Only",0.23,30,,0.23,percent of total billed charges,"Drugs, Inpatient Only",0.39,50,,0.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.54,70,,0.54,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.54,
WARFARIN 7.5 MG TAB             ,,,,40521742,CDM,250,RC,00832-1218-00,NDC,both,1,EA,0.56,0.22,39.4668,,0.22,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.28,50,,0.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.39,70,,0.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% Medicaid APG methodology,0.1,,,0.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.39,
BROMOCRIPTINE 2.5 MG TAB        ,,,,40521882,CDM,250,RC,00574-0106-03,NDC,both,1,EA,8.12,3.2,39.4668,,3.2,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.44,30,,2.44,percent of total billed charges,"Drugs, Inpatient Only",2.44,30,,2.44,percent of total billed charges,"Drugs, Inpatient Only",2.44,30,,2.44,percent of total billed charges,"Drugs, Inpatient Only",4.06,50,,4.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.97,,,0.97,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.68,70,,5.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.52,,,0.52,Other,Drug Cost,0.52,,,0.52,Other,Drug Cost,0.52,,,0.52,Other,Drug Cost,0.52,,,0.52,Other,Drug Cost,0.52,,,0.52,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.52,,,0.52,Other,Drug Cost,1.17,,,1.17,Other,225% Medicaid APG methodology,0.73,,,0.73,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.52,,,0.52,Other,Drug Cost,0.52,,,0.52,Other,Drug Cost,0.65,,,0.65,Other,125% Medicaid APG methodology,0.01,5.68,
DESMOPRESSIN 0.1 MG TAB         ,,,,40521957,CDM,250,RC,69918-0101-01,NDC,both,1,EA,2.14,0.84,39.4668,,0.84,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.64,30,,0.64,percent of total billed charges,"Drugs, Inpatient Only",0.64,30,,0.64,percent of total billed charges,"Drugs, Inpatient Only",0.64,30,,0.64,percent of total billed charges,"Drugs, Inpatient Only",1.07,50,,1.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.5,70,,1.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.23,,,0.23,Other,225% Medicaid APG methodology,0.14,,,0.14,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.13,,,0.13,Other,125% Medicaid APG methodology,0.01,1.5,
DESMOPRESSIN 0.2 MG TAB         ,,,,40521965,CDM,250,RC,60687-0732-21,NDC,both,1,EA,8.65,3.41,39.4668,,3.41,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.6,30,,2.6,percent of total billed charges,"Drugs, Inpatient Only",2.6,30,,2.6,percent of total billed charges,"Drugs, Inpatient Only",2.6,30,,2.6,percent of total billed charges,"Drugs, Inpatient Only",4.33,50,,4.33,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.63,,,4.63,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.06,70,,6.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.49,,,2.49,Other,Drug Cost,2.49,,,2.49,Other,Drug Cost,2.49,,,2.49,Other,Drug Cost,2.49,,,2.49,Other,Drug Cost,2.49,,,2.49,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.49,,,2.49,Other,Drug Cost,5.6,,,5.6,Other,225% Medicaid APG methodology,3.49,,,3.49,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.49,,,2.49,Other,Drug Cost,2.49,,,2.49,Other,Drug Cost,3.11,,,3.11,Other,125% Medicaid APG methodology,0.01,6.06,
DESMOPRESSIN 10 MCG/INH NAS5ML  ,,,,40521973,CDM,250,RC,47335-0788-91,NDC,both,5,ML,255.85,100.98,39.4668,,100.98,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,76.76,30,,76.76,percent of total billed charges,"Drugs, Inpatient Only",76.76,30,,76.76,percent of total billed charges,"Drugs, Inpatient Only",76.76,30,,76.76,percent of total billed charges,"Drugs, Inpatient Only",127.93,50,,127.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,41.85,,,41.85,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,179.1,70,,179.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,22.5,,,22.5,Other,Drug Cost,22.5,,,22.5,Other,Drug Cost,22.5,,,22.5,Other,Drug Cost,22.5,,,22.5,Other,Drug Cost,22.5,,,22.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,22.5,,,22.5,Other,Drug Cost,50.63,,,50.63,Other,225% Medicaid APG methodology,31.5,,,31.5,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,22.5,,,22.5,Other,Drug Cost,22.5,,,22.5,Other,Drug Cost,28.13,,,28.13,Other,125% Medicaid APG methodology,0.01,179.1,
THYROID DESICCATED 30 MG TAB    ,,,,40522005,CDM,250,RC,00456-0458-01,NDC,both,1,EA,2.98,1.18,39.4668,,1.18,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.89,30,,0.89,percent of total billed charges,"Drugs, Inpatient Only",0.89,30,,0.89,percent of total billed charges,"Drugs, Inpatient Only",0.89,30,,0.89,percent of total billed charges,"Drugs, Inpatient Only",1.49,50,,1.49,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.33,,,0.33,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.09,70,,2.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.18,,,0.18,Other,Drug Cost,0.41,,,0.41,Other,225% Medicaid APG methodology,0.25,,,0.25,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.23,,,0.23,Other,125% Medicaid APG methodology,0.01,2.09,
THYROID DESICCATED 60 MG TAB    ,,,,40522013,CDM,250,RC,00456-0459-01,NDC,both,1,EA,3.29,1.3,39.4668,,1.3,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.99,30,,0.99,percent of total billed charges,"Drugs, Inpatient Only",0.99,30,,0.99,percent of total billed charges,"Drugs, Inpatient Only",0.99,30,,0.99,percent of total billed charges,"Drugs, Inpatient Only",1.65,50,,1.65,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,,,0.37,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.3,70,,2.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.45,,,0.45,Other,225% Medicaid APG methodology,0.28,,,0.28,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.25,,,0.25,Other,125% Medicaid APG methodology,0.01,2.3,
REPAGLINIDE 1 MG TAB            ,,,,40522039,CDM,250,RC,57237-0158-01,NDC,both,1,EA,0.74,0.29,39.4668,,0.29,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,30,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.22,30,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.22,30,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.37,50,,0.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.52,70,,0.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.52,
REPAGLINIDE 2 MG TAB            ,,,,40522047,CDM,250,RC,68084-0967-25,NDC,both,1,EA,9.66,3.81,39.4668,,3.81,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.9,30,,2.9,percent of total billed charges,"Drugs, Inpatient Only",2.9,30,,2.9,percent of total billed charges,"Drugs, Inpatient Only",2.9,30,,2.9,percent of total billed charges,"Drugs, Inpatient Only",4.83,50,,4.83,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.33,,,4.33,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.76,70,,6.76,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.33,,,2.33,Other,Drug Cost,2.33,,,2.33,Other,Drug Cost,2.33,,,2.33,Other,Drug Cost,2.33,,,2.33,Other,Drug Cost,2.33,,,2.33,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.33,,,2.33,Other,Drug Cost,5.24,,,5.24,Other,225% Medicaid APG methodology,3.26,,,3.26,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.33,,,2.33,Other,Drug Cost,2.33,,,2.33,Other,Drug Cost,2.91,,,2.91,Other,125% Medicaid APG methodology,0.01,6.76,
LEVOTHYROXINE 25 MCG TAB        ,,,,40522054,CDM,250,RC,51079-0444-20,NDC,both,1,EA,1.54,0.61,39.4668,,0.61,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.46,30,,0.46,percent of total billed charges,"Drugs, Inpatient Only",0.46,30,,0.46,percent of total billed charges,"Drugs, Inpatient Only",0.46,30,,0.46,percent of total billed charges,"Drugs, Inpatient Only",0.77,50,,0.77,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.08,70,,1.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.23,,,0.23,Other,225% Medicaid APG methodology,0.14,,,0.14,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.13,,,0.13,Other,125% Medicaid APG methodology,0.01,1.08,
LEVOTHYROXINE 50 MCG TAB        ,,,,40522062,CDM,250,RC,00904-6950-61,NDC,both,1,EA,1.09,0.43,39.4668,,0.43,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.33,30,,0.33,percent of total billed charges,"Drugs, Inpatient Only",0.33,30,,0.33,percent of total billed charges,"Drugs, Inpatient Only",0.33,30,,0.33,percent of total billed charges,"Drugs, Inpatient Only",0.55,50,,0.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.61,,,0.61,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.76,70,,0.76,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.33,,,0.33,Other,Drug Cost,0.74,,,0.74,Other,225% Medicaid APG methodology,0.46,,,0.46,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.41,,,0.41,Other,125% Medicaid APG methodology,0.01,0.76,
LEVOTHYROXINE 100 MCG TAB       ,,,,40522070,CDM,250,RC,00074-6624-11,NDC,both,1,EA,4.87,1.92,39.4668,,1.92,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.46,30,,1.46,percent of total billed charges,"Drugs, Inpatient Only",1.46,30,,1.46,percent of total billed charges,"Drugs, Inpatient Only",1.46,30,,1.46,percent of total billed charges,"Drugs, Inpatient Only",2.44,50,,2.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.49,,,1.49,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.41,70,,3.41,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.8,,,0.8,Other,Drug Cost,1.8,,,1.8,Other,225% Medicaid APG methodology,1.12,,,1.12,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,1,,,1,Other,125% Medicaid APG methodology,0.01,3.41,
LEVOTHYROXINE 75 MCG TAB        ,,,,40522088,CDM,250,RC,00074-5182-11,NDC,both,1,EA,4.87,1.92,39.4668,,1.92,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.46,30,,1.46,percent of total billed charges,"Drugs, Inpatient Only",1.46,30,,1.46,percent of total billed charges,"Drugs, Inpatient Only",1.46,30,,1.46,percent of total billed charges,"Drugs, Inpatient Only",2.44,50,,2.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.43,,,1.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.41,70,,3.41,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.77,,,0.77,Other,Drug Cost,0.77,,,0.77,Other,Drug Cost,0.77,,,0.77,Other,Drug Cost,0.77,,,0.77,Other,Drug Cost,0.77,,,0.77,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.77,,,0.77,Other,Drug Cost,1.73,,,1.73,Other,225% Medicaid APG methodology,1.08,,,1.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.77,,,0.77,Other,Drug Cost,0.77,,,0.77,Other,Drug Cost,0.96,,,0.96,Other,125% Medicaid APG methodology,0.01,3.41,
LEVOTHYROXINE 125 MCG TAB       ,,,,40522096,CDM,250,RC,00074-7068-90,NDC,both,1,EA,4.87,1.92,39.4668,,1.92,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.46,30,,1.46,percent of total billed charges,"Drugs, Inpatient Only",1.46,30,,1.46,percent of total billed charges,"Drugs, Inpatient Only",1.46,30,,1.46,percent of total billed charges,"Drugs, Inpatient Only",2.44,50,,2.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.53,,,1.53,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.41,70,,3.41,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.82,,,0.82,Other,Drug Cost,1.85,,,1.85,Other,225% Medicaid APG methodology,1.15,,,1.15,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,1.03,,,1.03,Other,125% Medicaid APG methodology,0.01,3.41,
LEVOTHYROXINE 150 MCG TAB       ,,,,40522104,CDM,250,RC,00074-7069-11,NDC,both,1,EA,4.87,1.92,39.4668,,1.92,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.46,30,,1.46,percent of total billed charges,"Drugs, Inpatient Only",1.46,30,,1.46,percent of total billed charges,"Drugs, Inpatient Only",1.46,30,,1.46,percent of total billed charges,"Drugs, Inpatient Only",2.44,50,,2.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.58,,,1.58,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.41,70,,3.41,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.85,,,0.85,Other,Drug Cost,1.91,,,1.91,Other,225% Medicaid APG methodology,1.19,,,1.19,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,1.06,,,1.06,Other,125% Medicaid APG methodology,0.01,3.41,
LIOTHYRONINE 25 MCG TAB         ,,,,40522112,CDM,250,RC,70377-0115-12,NDC,both,1,EA,1.96,0.77,39.4668,,0.77,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.59,30,,0.59,percent of total billed charges,"Drugs, Inpatient Only",0.59,30,,0.59,percent of total billed charges,"Drugs, Inpatient Only",0.59,30,,0.59,percent of total billed charges,"Drugs, Inpatient Only",0.98,50,,0.98,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.73,,,0.73,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.37,70,,1.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.39,,,0.39,Other,Drug Cost,0.88,,,0.88,Other,225% Medicaid APG methodology,0.55,,,0.55,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.49,,,0.49,Other,125% Medicaid APG methodology,0.01,1.37,
LIOTHYRONINE 5 MCG TAB          ,,,,40522120,CDM,250,RC,60793-0115-01,NDC,both,1,EA,6.58,2.6,39.4668,,2.6,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.97,30,,1.97,percent of total billed charges,"Drugs, Inpatient Only",1.97,30,,1.97,percent of total billed charges,"Drugs, Inpatient Only",1.97,30,,1.97,percent of total billed charges,"Drugs, Inpatient Only",3.29,50,,3.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.61,70,,4.61,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,4.61,
PROPYLTHIOURACIL 50 MG TAB      ,,,,40522138,CDM,250,RC,68084-0964-25,NDC,both,1,EA,5.67,2.24,39.4668,,2.24,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.7,30,,1.7,percent of total billed charges,"Drugs, Inpatient Only",1.7,30,,1.7,percent of total billed charges,"Drugs, Inpatient Only",1.7,30,,1.7,percent of total billed charges,"Drugs, Inpatient Only",2.84,50,,2.84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.79,,,1.79,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.97,70,,3.97,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.96,,,0.96,Other,Drug Cost,0.96,,,0.96,Other,Drug Cost,0.96,,,0.96,Other,Drug Cost,0.96,,,0.96,Other,Drug Cost,0.96,,,0.96,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.96,,,0.96,Other,Drug Cost,2.16,,,2.16,Other,225% Medicaid APG methodology,1.34,,,1.34,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.96,,,0.96,Other,Drug Cost,0.96,,,0.96,Other,Drug Cost,1.2,,,1.2,Other,125% Medicaid APG methodology,0.01,3.97,
METHIMAZOLE 10 MG TAB           ,,,,40522146,CDM,250,RC,23155-0071-01,NDC,both,1,EA,0.6,0.24,39.4668,,0.24,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.18,30,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.18,30,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.18,30,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.3,50,,0.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.42,70,,0.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.42,
METHIMAZOLE 5 MG TAB            ,,,,40522153,CDM,250,RC,23155-0070-01,NDC,both,1,EA,0.28,0.11,39.4668,,0.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.14,50,,0.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,70,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.2,
SIMVASTATIN 20 MG TAB           ,,,,40522278,CDM,250,RC,63739-0572-10,NDC,both,1,EA,0.28,0.11,39.4668,,0.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.14,50,,0.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,70,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% Medicaid APG methodology,0.1,,,0.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.2,
HYDROCORTISONE 20 MG TAB        ,,,,40522419,CDM,250,RC,50268-0407-15,NDC,both,1,EA,5.92,2.34,39.4668,,2.34,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.78,30,,1.78,percent of total billed charges,"Drugs, Inpatient Only",1.78,30,,1.78,percent of total billed charges,"Drugs, Inpatient Only",1.78,30,,1.78,percent of total billed charges,"Drugs, Inpatient Only",2.96,50,,2.96,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.26,,,3.26,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.14,70,,4.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.75,,,1.75,Other,Drug Cost,1.75,,,1.75,Other,Drug Cost,1.75,,,1.75,Other,Drug Cost,1.75,,,1.75,Other,Drug Cost,1.75,,,1.75,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.75,,,1.75,Other,Drug Cost,3.94,,,3.94,Other,225% Medicaid APG methodology,2.45,,,2.45,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.75,,,1.75,Other,Drug Cost,1.75,,,1.75,Other,Drug Cost,2.19,,,2.19,Other,125% Medicaid APG methodology,0.01,4.14,
HYDROCORTISONE 5 MG TAB         ,,,,40522427,CDM,250,RC,00115-1696-06,NDC,both,1,EA,0.95,0.37,39.4668,,0.37,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.48,50,,0.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.67,70,,0.67,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.25,,,0.25,Other,225% Medicaid APG methodology,0.15,,,0.15,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.14,,,0.14,Other,125% Medicaid APG methodology,0.01,0.67,
FLUDROCORTISONE 0.1 MG TAB      ,,,,40522708,CDM,250,RC,70954-0252-20,NDC,both,1,EA,1.72,0.68,39.4668,,0.68,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.52,30,,0.52,percent of total billed charges,"Drugs, Inpatient Only",0.52,30,,0.52,percent of total billed charges,"Drugs, Inpatient Only",0.52,30,,0.52,percent of total billed charges,"Drugs, Inpatient Only",0.86,50,,0.86,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.43,,,0.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.2,70,,1.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.23,,,0.23,Other,Drug Cost,0.52,,,0.52,Other,225% Medicaid APG methodology,0.32,,,0.32,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.23,,,0.23,Other,Drug Cost,0.23,,,0.23,Other,Drug Cost,0.29,,,0.29,Other,125% Medicaid APG methodology,0.01,1.2,
SPIRONOLACTONE 25 MG TAB        ,,,,40522716,CDM,250,RC,00904-6927-61,NDC,both,1,EA,0.35,0.14,39.4668,,0.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.18,50,,0.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,70,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.2,,,0.2,Other,225% Medicaid APG methodology,0.13,,,0.13,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,0.25,
AMILORIDE 5 MG TAB              ,,,,40522724,CDM,250,RC,00574-0292-01,NDC,both,1,EA,0.74,0.29,39.4668,,0.29,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,30,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.22,30,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.22,30,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.37,50,,0.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.52,70,,0.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% Medicaid APG methodology,0.11,,,0.11,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.52,
FLUORESCEIN 10% IV SOLN 5 ML    ,,,,40522757,CDM,250,RC,14789-0122-05,NDC,both,5,ML,668.22,263.73,39.4668,,263.73,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,200.47,30,,200.47,percent of total billed charges,"Drugs, Inpatient Only",200.47,30,,200.47,percent of total billed charges,"Drugs, Inpatient Only",200.47,30,,200.47,percent of total billed charges,"Drugs, Inpatient Only",334.11,50,,334.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,463.29,,,463.29,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,467.75,70,,467.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,249.08,,,249.08,Other,Drug Cost,249.08,,,249.08,Other,Drug Cost,249.08,,,249.08,Other,Drug Cost,249.08,,,249.08,Other,Drug Cost,249.08,,,249.08,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,249.08,,,249.08,Other,Drug Cost,560.43,,,560.43,Other,225% Medicaid APG methodology,348.71,,,348.71,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,249.08,,,249.08,Other,Drug Cost,249.08,,,249.08,Other,Drug Cost,311.35,,,311.35,Other,125% Medicaid APG methodology,0.01,560.43,
FLUORESCEIN 1 MG OPHTH STRIP    ,,,,40522765,CDM,250,RC,17478-0404-01,NDC,both,1,EA,0.49,0.19,39.4668,,0.19,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.25,50,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.34,70,,0.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,Drug Cost,0.32,,,0.32,Other,225% Medicaid APG methodology,0.2,,,0.2,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.18,,,0.18,Other,125% Medicaid APG methodology,0.01,0.34,
DRONABINOL 5 MG CAP             ,,,,40522807,CDM,250,RC,00904-6746-04,NDC,both,1,EA,33.74,13.32,39.4668,,13.32,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.12,30,,10.12,percent of total billed charges,"Drugs, Inpatient Only",10.12,30,,10.12,percent of total billed charges,"Drugs, Inpatient Only",10.12,30,,10.12,percent of total billed charges,"Drugs, Inpatient Only",16.87,50,,16.87,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,17.93,,,17.93,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,23.62,70,,23.62,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.64,,,9.64,Other,Drug Cost,9.64,,,9.64,Other,Drug Cost,9.64,,,9.64,Other,Drug Cost,9.64,,,9.64,Other,Drug Cost,9.64,,,9.64,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,9.64,,,9.64,Other,Drug Cost,21.69,,,21.69,Other,225% Medicaid APG methodology,13.5,,,13.5,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,9.64,,,9.64,Other,Drug Cost,9.64,,,9.64,Other,Drug Cost,12.05,,,12.05,Other,125% Medicaid APG methodology,0.01,23.62,
FLUMAZENIL 0.1MG/ML IV SLN 5ML  ,,,,40522815,CDM,250,RC,63323-0424-05,NDC,both,5,ML,22.4,8.84,39.4668,,8.84,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.72,30,,6.72,percent of total billed charges,"Drugs, Inpatient Only",6.72,30,,6.72,percent of total billed charges,"Drugs, Inpatient Only",6.72,30,,6.72,percent of total billed charges,"Drugs, Inpatient Only",11.2,50,,11.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.95,,,5.95,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.68,70,,15.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.2,,,3.2,Other,Drug Cost,7.2,,,7.2,Other,225% Medicaid APG methodology,4.48,,,4.48,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,4,,,4,Other,125% Medicaid APG methodology,0.01,15.68,
VENLAFAXINE 37.5 MG TAB         ,,,,40522831,CDM,250,RC,50268-0799-15,NDC,both,1,EA,2.07,0.82,39.4668,,0.82,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.62,30,,0.62,percent of total billed charges,"Drugs, Inpatient Only",0.62,30,,0.62,percent of total billed charges,"Drugs, Inpatient Only",0.62,30,,0.62,percent of total billed charges,"Drugs, Inpatient Only",1.04,50,,1.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.58,,,0.58,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.45,70,,1.45,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.31,,,0.31,Other,Drug Cost,0.7,,,0.7,Other,225% Medicaid APG methodology,0.43,,,0.43,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.39,,,0.39,Other,125% Medicaid APG methodology,0.01,1.45,
VENLAFAXINE 50 MG TAB           ,,,,40522849,CDM,250,RC,57237-0174-01,NDC,both,1,EA,0.46,0.18,39.4668,,0.18,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.14,30,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,30,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,30,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.23,50,,0.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.32,70,,0.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.32,
VENLAFAXINE 75 MG TAB           ,,,,40522856,CDM,250,RC,57664-0395-88,NDC,both,1,EA,0.63,0.25,39.4668,,0.25,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.32,50,,0.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.44,70,,0.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.44,
VENLAFAXINE 75 MG ER CAP        ,,,,40522872,CDM,250,RC,00904-7077-61,NDC,both,1,EA,1.26,0.5,39.4668,,0.5,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.38,30,,0.38,percent of total billed charges,"Drugs, Inpatient Only",0.38,30,,0.38,percent of total billed charges,"Drugs, Inpatient Only",0.38,30,,0.38,percent of total billed charges,"Drugs, Inpatient Only",0.63,50,,0.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.69,,,0.69,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.88,70,,0.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,,,0.37,Other,Drug Cost,0.37,,,0.37,Other,Drug Cost,0.37,,,0.37,Other,Drug Cost,0.37,,,0.37,Other,Drug Cost,0.37,,,0.37,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.37,,,0.37,Other,Drug Cost,0.83,,,0.83,Other,225% Medicaid APG methodology,0.52,,,0.52,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.37,,,0.37,Other,Drug Cost,0.37,,,0.37,Other,Drug Cost,0.46,,,0.46,Other,125% Medicaid APG methodology,0.01,0.88,
VENLAFAXINE 37.5 MG ER CAP      ,,,,40522880,CDM,250,RC,50268-0817-15,NDC,both,1,EA,1.19,0.47,39.4668,,0.47,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.36,30,,0.36,percent of total billed charges,"Drugs, Inpatient Only",0.36,30,,0.36,percent of total billed charges,"Drugs, Inpatient Only",0.36,30,,0.36,percent of total billed charges,"Drugs, Inpatient Only",0.6,50,,0.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.65,,,0.65,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.83,70,,0.83,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.35,,,0.35,Other,Drug Cost,0.35,,,0.35,Other,Drug Cost,0.35,,,0.35,Other,Drug Cost,0.35,,,0.35,Other,Drug Cost,0.35,,,0.35,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.35,,,0.35,Other,Drug Cost,0.79,,,0.79,Other,225% Medicaid APG methodology,0.49,,,0.49,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.35,,,0.35,Other,Drug Cost,0.35,,,0.35,Other,Drug Cost,0.44,,,0.44,Other,125% Medicaid APG methodology,0.01,0.83,
DIBUCAINE TOP 1% TOP ONT 28 G   ,,,,40522898,CDM,250,RC,45802-0050-03,NDC,both,28,GM,10.78,4.25,39.4668,,4.25,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.23,30,,3.23,percent of total billed charges,"Drugs, Inpatient Only",3.23,30,,3.23,percent of total billed charges,"Drugs, Inpatient Only",3.23,30,,3.23,percent of total billed charges,"Drugs, Inpatient Only",5.39,50,,5.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.73,,,5.73,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.55,70,,7.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.08,,,3.08,Other,Drug Cost,3.08,,,3.08,Other,Drug Cost,3.08,,,3.08,Other,Drug Cost,3.08,,,3.08,Other,Drug Cost,3.08,,,3.08,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.08,,,3.08,Other,Drug Cost,6.93,,,6.93,Other,225% Medicaid APG methodology,4.31,,,4.31,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.08,,,3.08,Other,Drug Cost,3.08,,,3.08,Other,Drug Cost,3.85,,,3.85,Other,125% Medicaid APG methodology,0.01,7.55,
MIDODRINE 5 MG TAB              ,,,,40522948,CDM,250,RC,63739-0145-10,NDC,both,1,EA,1.37,0.54,39.4668,,0.54,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.41,30,,0.41,percent of total billed charges,"Drugs, Inpatient Only",0.41,30,,0.41,percent of total billed charges,"Drugs, Inpatient Only",0.41,30,,0.41,percent of total billed charges,"Drugs, Inpatient Only",0.69,50,,0.69,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.96,70,,0.96,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.96,
MIDODRINE 2.5 MG TAB            ,,,,40522955,CDM,250,RC,00245-0211-11,NDC,both,1,EA,1.02,0.4,39.4668,,0.4,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.31,30,,0.31,percent of total billed charges,"Drugs, Inpatient Only",0.31,30,,0.31,percent of total billed charges,"Drugs, Inpatient Only",0.31,30,,0.31,percent of total billed charges,"Drugs, Inpatient Only",0.51,50,,0.51,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.71,70,,0.71,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.71,
CONJ ESTRGENS 0.625MG/G VAG CR  ,,,,40522963,CDM,250,RC,00046-0872-21,NDC,both,30,GM,1235.85,487.75,39.4668,,487.75,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,370.76,30,,370.76,percent of total billed charges,"Drugs, Inpatient Only",370.76,30,,370.76,percent of total billed charges,"Drugs, Inpatient Only",370.76,30,,370.76,percent of total billed charges,"Drugs, Inpatient Only",617.93,50,,617.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.56,,,0.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,865.1,70,,865.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.68,,,0.68,Other,225% Medicaid APG methodology,0.42,,,0.42,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.38,,,0.38,Other,125% Medicaid APG methodology,0.01,865.1,
BUSPIRONE 5 MG TAB              ,,,,40523052,CDM,250,RC,64380-0741-06,NDC,both,1,EA,0.14,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.07,50,,0.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.1,
BUSPIRONE 10 MG TAB             ,,,,40523060,CDM,250,RC,00378-1150-01,NDC,both,1,EA,0.35,0.14,39.4668,,0.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.18,50,,0.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,70,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.25,
SILVER NITRATE STICK            ,,,,40523094,CDM,250,RC,12870-0001-02,NDC,both,1,EA,1.61,0.64,39.4668,,0.64,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.48,30,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.48,30,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.48,30,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.81,50,,0.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.86,,,0.86,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.13,70,,1.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.46,,,0.46,Other,Drug Cost,1.04,,,1.04,Other,225% Medicaid APG methodology,0.64,,,0.64,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.58,,,0.58,Other,125% Medicaid APG methodology,0.01,1.13,
LEVOCARNITINE100MG/ML ORL118ML  ,,,,40523110,CDM,250,RC,52817-0830-04,NDC,both,118,ML,66.64,26.3,39.4668,,26.3,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.99,30,,19.99,percent of total billed charges,"Drugs, Inpatient Only",19.99,30,,19.99,percent of total billed charges,"Drugs, Inpatient Only",19.99,30,,19.99,percent of total billed charges,"Drugs, Inpatient Only",33.32,50,,33.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.59,,,15.59,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,46.65,70,,46.65,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.38,,,8.38,Other,Drug Cost,8.38,,,8.38,Other,Drug Cost,8.38,,,8.38,Other,Drug Cost,8.38,,,8.38,Other,Drug Cost,8.38,,,8.38,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,8.38,,,8.38,Other,Drug Cost,18.86,,,18.86,Other,225% Medicaid APG methodology,11.73,,,11.73,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,8.38,,,8.38,Other,Drug Cost,8.38,,,8.38,Other,Drug Cost,10.48,,,10.48,Other,125% Medicaid APG methodology,0.01,46.65,
POVIDONE IODINE 5% OPT  30ML    ,,,,40523151,CDM,250,RC,00065-0411-30,NDC,both,30,ML,30.45,12.02,39.4668,,12.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.14,30,,9.14,percent of total billed charges,"Drugs, Inpatient Only",9.14,30,,9.14,percent of total billed charges,"Drugs, Inpatient Only",9.14,30,,9.14,percent of total billed charges,"Drugs, Inpatient Only",15.23,50,,15.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.12,,,1.12,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,21.32,70,,21.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.6,,,0.6,Other,Drug Cost,1.35,,,1.35,Other,225% Medicaid APG methodology,0.84,,,0.84,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.75,,,0.75,Other,125% Medicaid APG methodology,0.01,21.32,
RIFABUTIN 150 MG CAP            ,,,,40523169,CDM,250,RC,00013-5301-17,NDC,both,1,EA,105.04,41.46,39.4668,,41.46,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,31.51,30,,31.51,percent of total billed charges,"Drugs, Inpatient Only",31.51,30,,31.51,percent of total billed charges,"Drugs, Inpatient Only",31.51,30,,31.51,percent of total billed charges,"Drugs, Inpatient Only",52.52,50,,52.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.43,,,5.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,73.53,70,,73.53,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.92,,,2.92,Other,Drug Cost,2.92,,,2.92,Other,Drug Cost,2.92,,,2.92,Other,Drug Cost,2.92,,,2.92,Other,Drug Cost,2.92,,,2.92,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.92,,,2.92,Other,Drug Cost,6.57,,,6.57,Other,225% Medicaid APG methodology,4.09,,,4.09,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.92,,,2.92,Other,Drug Cost,2.92,,,2.92,Other,Drug Cost,3.65,,,3.65,Other,125% Medicaid APG methodology,0.01,73.53,
BENZONATATE 100 MG CAP          ,,,,40523177,CDM,250,RC,42806-0714-01,NDC,both,1,EA,0.32,0.13,39.4668,,0.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.16,50,,0.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,70,,0.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.22,
NYSTATIN 100000UNITS/G CRM15G   ,,,,40523201,CDM,250,RC,00713-0678-15,NDC,both,15,GM,42.21,16.66,39.4668,,16.66,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.66,30,,12.66,percent of total billed charges,"Drugs, Inpatient Only",12.66,30,,12.66,percent of total billed charges,"Drugs, Inpatient Only",12.66,30,,12.66,percent of total billed charges,"Drugs, Inpatient Only",21.11,50,,21.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.75,,,2.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,29.55,70,,29.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.48,,,1.48,Other,Drug Cost,3.33,,,3.33,Other,225% Medicaid APG methodology,2.07,,,2.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,1.85,,,1.85,Other,125% Medicaid APG methodology,0.01,29.55,
NYSTATIN 100000UNIT/G OINT15G   ,,,,40523227,CDM,250,RC,00713-0686-15,NDC,both,15,GM,11.27,4.45,39.4668,,4.45,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.38,30,,3.38,percent of total billed charges,"Drugs, Inpatient Only",3.38,30,,3.38,percent of total billed charges,"Drugs, Inpatient Only",3.38,30,,3.38,percent of total billed charges,"Drugs, Inpatient Only",5.64,50,,5.64,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.29,,,2.29,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.89,70,,7.89,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.23,,,1.23,Other,Drug Cost,1.23,,,1.23,Other,Drug Cost,1.23,,,1.23,Other,Drug Cost,1.23,,,1.23,Other,Drug Cost,1.23,,,1.23,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.23,,,1.23,Other,Drug Cost,2.77,,,2.77,Other,225% Medicaid APG methodology,1.72,,,1.72,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.23,,,1.23,Other,Drug Cost,1.23,,,1.23,Other,Drug Cost,1.54,,,1.54,Other,125% Medicaid APG methodology,0.01,7.89,
CLOTRIMAZOLE 1% CREAM 15 G      ,,,,40523268,CDM,250,RC,00904-7822-36,NDC,both,15,GM,4.73,1.87,39.4668,,1.87,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.42,30,,1.42,percent of total billed charges,"Drugs, Inpatient Only",1.42,30,,1.42,percent of total billed charges,"Drugs, Inpatient Only",1.42,30,,1.42,percent of total billed charges,"Drugs, Inpatient Only",2.37,50,,2.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.12,,,1.12,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.31,70,,3.31,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.6,,,0.6,Other,Drug Cost,1.35,,,1.35,Other,225% Medicaid APG methodology,0.84,,,0.84,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.75,,,0.75,Other,125% Medicaid APG methodology,0.01,3.31,
MICONAZOLE 2% CREAM 15 G        ,,,,40523284,CDM,250,RC,65197-0103-05,NDC,both,14,GM,16.56,6.54,39.4668,,6.54,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.97,30,,4.97,percent of total billed charges,"Drugs, Inpatient Only",4.97,30,,4.97,percent of total billed charges,"Drugs, Inpatient Only",4.97,30,,4.97,percent of total billed charges,"Drugs, Inpatient Only",8.28,50,,8.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.8,,,8.8,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.59,70,,11.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.73,,,4.73,Other,Drug Cost,4.73,,,4.73,Other,Drug Cost,4.73,,,4.73,Other,Drug Cost,4.73,,,4.73,Other,Drug Cost,4.73,,,4.73,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.73,,,4.73,Other,Drug Cost,10.64,,,10.64,Other,225% Medicaid APG methodology,6.62,,,6.62,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.73,,,4.73,Other,Drug Cost,4.73,,,4.73,Other,Drug Cost,5.91,,,5.91,Other,125% Medicaid APG methodology,0.01,11.59,
COCAINE 4% TOPICAL SOLN 4 ML    ,,,,40523359,CDM,250,RC,00527-1961-74,NDC,both,4,ML,715.96,282.57,39.4668,,282.57,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,214.79,30,,214.79,percent of total billed charges,"Drugs, Inpatient Only",214.79,30,,214.79,percent of total billed charges,"Drugs, Inpatient Only",214.79,30,,214.79,percent of total billed charges,"Drugs, Inpatient Only",357.98,50,,357.98,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,372.3,,,372.3,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,501.17,70,,501.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,200.16,,,200.16,Other,Drug Cost,200.16,,,200.16,Other,Drug Cost,200.16,,,200.16,Other,Drug Cost,200.16,,,200.16,Other,Drug Cost,200.16,,,200.16,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,200.16,,,200.16,Other,Drug Cost,450.36,,,450.36,Other,225% Medicaid APG methodology,280.22,,,280.22,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,200.16,,,200.16,Other,Drug Cost,200.16,,,200.16,Other,Drug Cost,250.2,,,250.2,Other,125% Medicaid APG methodology,0.01,501.17,
HYDROCORTISONE 1% CREAM 30 G    ,,,,40523383,CDM,250,RC,70000-0543-01,NDC,both,28,GM,6.79,2.68,39.4668,,2.68,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.04,30,,2.04,percent of total billed charges,"Drugs, Inpatient Only",2.04,30,,2.04,percent of total billed charges,"Drugs, Inpatient Only",2.04,30,,2.04,percent of total billed charges,"Drugs, Inpatient Only",3.4,50,,3.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.99,,,2.99,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.75,70,,4.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.61,,,1.61,Other,Drug Cost,1.61,,,1.61,Other,Drug Cost,1.61,,,1.61,Other,Drug Cost,1.61,,,1.61,Other,Drug Cost,1.61,,,1.61,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.61,,,1.61,Other,Drug Cost,3.62,,,3.62,Other,225% Medicaid APG methodology,2.25,,,2.25,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.61,,,1.61,Other,Drug Cost,1.61,,,1.61,Other,Drug Cost,2.01,,,2.01,Other,125% Medicaid APG methodology,0.01,4.75,
HYDROCORTISONE 1% TOPOINT 30 G  ,,,,40523391,CDM,250,RC,45802-0276-03,NDC,both,28,GM,4.9,1.93,39.4668,,1.93,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.47,30,,1.47,percent of total billed charges,"Drugs, Inpatient Only",1.47,30,,1.47,percent of total billed charges,"Drugs, Inpatient Only",1.47,30,,1.47,percent of total billed charges,"Drugs, Inpatient Only",2.45,50,,2.45,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.56,,,1.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.43,70,,3.43,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.84,,,0.84,Other,Drug Cost,1.89,,,1.89,Other,225% Medicaid APG methodology,1.18,,,1.18,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,1.05,,,1.05,Other,125% Medicaid APG methodology,0.01,3.43,
HYDROCORTISONE 2.5%OINT 28.35G  ,,,,40523409,CDM,250,RC,00168-0146-30,NDC,both,28.35,GM,8.93,3.52,39.4668,,3.52,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.68,30,,2.68,percent of total billed charges,"Drugs, Inpatient Only",2.68,30,,2.68,percent of total billed charges,"Drugs, Inpatient Only",2.68,30,,2.68,percent of total billed charges,"Drugs, Inpatient Only",4.47,50,,4.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.58,,,1.58,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.25,70,,6.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.85,,,0.85,Other,Drug Cost,1.91,,,1.91,Other,225% Medicaid APG methodology,1.19,,,1.19,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.85,,,0.85,Other,Drug Cost,0.85,,,0.85,Other,Drug Cost,1.06,,,1.06,Other,125% Medicaid APG methodology,0.01,6.25,
ACYCLOVIR 5% TOPICAL OINT 15 G  ,,,,40523516,CDM,250,RC,65162-0835-94,NDC,both,15,GM,126,49.73,39.4668,,49.73,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,37.8,30,,37.8,percent of total billed charges,"Drugs, Inpatient Only",37.8,30,,37.8,percent of total billed charges,"Drugs, Inpatient Only",37.8,30,,37.8,percent of total billed charges,"Drugs, Inpatient Only",63,50,,63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,20.93,,,20.93,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,88.2,70,,88.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.25,,,11.25,Other,Drug Cost,11.25,,,11.25,Other,Drug Cost,11.25,,,11.25,Other,Drug Cost,11.25,,,11.25,Other,Drug Cost,11.25,,,11.25,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,11.25,,,11.25,Other,Drug Cost,25.31,,,25.31,Other,225% Medicaid APG methodology,15.75,,,15.75,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,11.25,,,11.25,Other,Drug Cost,11.25,,,11.25,Other,Drug Cost,14.06,,,14.06,Other,125% Medicaid APG methodology,0.01,88.2,
CLINDAMYCIN 1% TOPICAL SLN30ML  ,,,,40523532,CDM,250,RC,45802-0562-01,NDC,both,30,ML,27.3,10.77,39.4668,,10.77,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.19,30,,8.19,percent of total billed charges,"Drugs, Inpatient Only",8.19,30,,8.19,percent of total billed charges,"Drugs, Inpatient Only",8.19,30,,8.19,percent of total billed charges,"Drugs, Inpatient Only",13.65,50,,13.65,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.7,,,6.7,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.11,70,,19.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.6,,,3.6,Other,Drug Cost,3.6,,,3.6,Other,Drug Cost,3.6,,,3.6,Other,Drug Cost,3.6,,,3.6,Other,Drug Cost,3.6,,,3.6,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.6,,,3.6,Other,Drug Cost,8.1,,,8.1,Other,225% Medicaid APG methodology,5.04,,,5.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.6,,,3.6,Other,Drug Cost,3.6,,,3.6,Other,Drug Cost,4.5,,,4.5,Other,125% Medicaid APG methodology,0.01,19.11,
GENTAMICIN 0.1%TOPICAL OINT15G  ,,,,40523557,CDM,250,RC,45802-0046-35,NDC,both,15,GM,130.73,51.59,39.4668,,51.59,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,39.22,30,,39.22,percent of total billed charges,"Drugs, Inpatient Only",39.22,30,,39.22,percent of total billed charges,"Drugs, Inpatient Only",39.22,30,,39.22,percent of total billed charges,"Drugs, Inpatient Only",65.37,50,,65.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.95,,,13.95,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,91.51,70,,91.51,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.5,,,7.5,Other,Drug Cost,7.5,,,7.5,Other,Drug Cost,7.5,,,7.5,Other,Drug Cost,7.5,,,7.5,Other,Drug Cost,7.5,,,7.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,7.5,,,7.5,Other,Drug Cost,16.88,,,16.88,Other,225% Medicaid APG methodology,10.5,,,10.5,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.5,,,7.5,Other,Drug Cost,7.5,,,7.5,Other,Drug Cost,9.38,,,9.38,Other,125% Medicaid APG methodology,0.01,91.51,
KETOCONAZOLE 2% CREAM 15 G      ,,,,40523573,CDM,250,RC,21922-0025-04,NDC,both,15,GM,48.76,19.24,39.4668,,19.24,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.63,30,,14.63,percent of total billed charges,"Drugs, Inpatient Only",14.63,30,,14.63,percent of total billed charges,"Drugs, Inpatient Only",14.63,30,,14.63,percent of total billed charges,"Drugs, Inpatient Only",24.38,50,,24.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.56,,,1.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,34.13,70,,34.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.84,,,0.84,Other,Drug Cost,1.89,,,1.89,Other,225% Medicaid APG methodology,1.18,,,1.18,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,1.05,,,1.05,Other,125% Medicaid APG methodology,0.01,34.13,
CLOBETASOL 0.05% TOP OINT 15 G  ,,,,40523656,CDM,250,RC,51672-1259-01,NDC,both,15,GM,32.55,12.85,39.4668,,12.85,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.77,30,,9.77,percent of total billed charges,"Drugs, Inpatient Only",9.77,30,,9.77,percent of total billed charges,"Drugs, Inpatient Only",9.77,30,,9.77,percent of total billed charges,"Drugs, Inpatient Only",16.28,50,,16.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.07,,,3.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,22.79,70,,22.79,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.65,,,1.65,Other,Drug Cost,1.65,,,1.65,Other,Drug Cost,1.65,,,1.65,Other,Drug Cost,1.65,,,1.65,Other,Drug Cost,1.65,,,1.65,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.65,,,1.65,Other,Drug Cost,3.71,,,3.71,Other,225% Medicaid APG methodology,2.31,,,2.31,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.65,,,1.65,Other,Drug Cost,1.65,,,1.65,Other,Drug Cost,2.06,,,2.06,Other,125% Medicaid APG methodology,0.01,22.79,
CLOBETASOL 0.05% CREAM 15 G     ,,,,40523664,CDM,250,RC,68180-0956-01,NDC,both,15,GM,18.69,7.38,39.4668,,7.38,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.61,30,,5.61,percent of total billed charges,"Drugs, Inpatient Only",5.61,30,,5.61,percent of total billed charges,"Drugs, Inpatient Only",5.61,30,,5.61,percent of total billed charges,"Drugs, Inpatient Only",9.35,50,,9.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.42,,,3.42,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.08,70,,13.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.84,,,1.84,Other,Drug Cost,1.84,,,1.84,Other,Drug Cost,1.84,,,1.84,Other,Drug Cost,1.84,,,1.84,Other,Drug Cost,1.84,,,1.84,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.84,,,1.84,Other,Drug Cost,4.14,,,4.14,Other,225% Medicaid APG methodology,2.58,,,2.58,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.84,,,1.84,Other,Drug Cost,1.84,,,1.84,Other,Drug Cost,2.3,,,2.3,Other,125% Medicaid APG methodology,0.01,13.08,
VERAPAMIL 240MG/12H ER TAB      ,,,,40523730,CDM,250,RC,68462-0260-01,NDC,both,1,EA,0.67,0.26,39.4668,,0.26,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,30,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.2,30,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.2,30,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.34,50,,0.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.47,70,,0.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.47,
VERAPAMIL 180MG/12H ER TAB      ,,,,40523755,CDM,250,RC,68462-0293-01,NDC,both,1,EA,0.63,0.25,39.4668,,0.25,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.32,50,,0.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.44,70,,0.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% Medicaid APG methodology,0.11,,,0.11,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.44,
PILOCARPINE 2% OPHTH SOLN 15ML  ,,,,40523821,CDM,250,RC,70069-0191-01,NDC,both,15,ML,136.47,53.86,39.4668,,53.86,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,40.94,30,,40.94,percent of total billed charges,"Drugs, Inpatient Only",40.94,30,,40.94,percent of total billed charges,"Drugs, Inpatient Only",40.94,30,,40.94,percent of total billed charges,"Drugs, Inpatient Only",68.24,50,,68.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,39.88,,,39.88,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,95.53,70,,95.53,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,21.44,,,21.44,Other,Drug Cost,21.44,,,21.44,Other,Drug Cost,21.44,,,21.44,Other,Drug Cost,21.44,,,21.44,Other,Drug Cost,21.44,,,21.44,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,21.44,,,21.44,Other,Drug Cost,48.24,,,48.24,Other,225% Medicaid APG methodology,30.02,,,30.02,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,21.44,,,21.44,Other,Drug Cost,21.44,,,21.44,Other,Drug Cost,26.8,,,26.8,Other,125% Medicaid APG methodology,0.01,95.53,
PILOCARPINE 4% OPHTH SOLN 15ML  ,,,,40523854,CDM,250,RC,61314-0206-15,NDC,both,15,ML,279.83,110.44,39.4668,,110.44,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,83.95,30,,83.95,percent of total billed charges,"Drugs, Inpatient Only",83.95,30,,83.95,percent of total billed charges,"Drugs, Inpatient Only",83.95,30,,83.95,percent of total billed charges,"Drugs, Inpatient Only",139.92,50,,139.92,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,40.73,,,40.73,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,195.88,70,,195.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,21.9,,,21.9,Other,Drug Cost,21.9,,,21.9,Other,Drug Cost,21.9,,,21.9,Other,Drug Cost,21.9,,,21.9,Other,Drug Cost,21.9,,,21.9,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,21.9,,,21.9,Other,Drug Cost,49.28,,,49.28,Other,225% Medicaid APG methodology,30.66,,,30.66,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,21.9,,,21.9,Other,Drug Cost,21.9,,,21.9,Other,Drug Cost,27.38,,,27.38,Other,125% Medicaid APG methodology,0.01,195.88,
TIMOLOL 0.5% OPHTH SOLN 5 ML    ,,,,40523912,CDM,250,RC,61314-0227-05,NDC,both,5,ML,31.85,12.57,39.4668,,12.57,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.56,30,,9.56,percent of total billed charges,"Drugs, Inpatient Only",9.56,30,,9.56,percent of total billed charges,"Drugs, Inpatient Only",9.56,30,,9.56,percent of total billed charges,"Drugs, Inpatient Only",15.93,50,,15.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.14,,,2.14,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,22.3,70,,22.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.15,,,1.15,Other,Drug Cost,1.15,,,1.15,Other,Drug Cost,1.15,,,1.15,Other,Drug Cost,1.15,,,1.15,Other,Drug Cost,1.15,,,1.15,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.15,,,1.15,Other,Drug Cost,2.59,,,2.59,Other,225% Medicaid APG methodology,1.61,,,1.61,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.15,,,1.15,Other,Drug Cost,1.15,,,1.15,Other,Drug Cost,1.44,,,1.44,Other,125% Medicaid APG methodology,0.01,22.3,
TETRACAINE 0.5% OPHTH SOLN 4ML  ,,,,40523920,CDM,250,RC,00065-0741-14,NDC,both,4,ML,33.88,13.37,39.4668,,13.37,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.16,30,,10.16,percent of total billed charges,"Drugs, Inpatient Only",10.16,30,,10.16,percent of total billed charges,"Drugs, Inpatient Only",10.16,30,,10.16,percent of total billed charges,"Drugs, Inpatient Only",16.94,50,,16.94,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.18,,,15.18,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,23.72,70,,23.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.16,,,8.16,Other,Drug Cost,8.16,,,8.16,Other,Drug Cost,8.16,,,8.16,Other,Drug Cost,8.16,,,8.16,Other,Drug Cost,8.16,,,8.16,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,8.16,,,8.16,Other,Drug Cost,18.36,,,18.36,Other,225% Medicaid APG methodology,11.42,,,11.42,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,8.16,,,8.16,Other,Drug Cost,8.16,,,8.16,Other,Drug Cost,10.2,,,10.2,Other,125% Medicaid APG methodology,0.01,23.72,
ATROPINE 1% OPHTH SOLN 2 ML     ,,,,40523938,CDM,250,RC,17478-0215-02,NDC,both,2,ML,123.06,48.57,39.4668,,48.57,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,36.92,30,,36.92,percent of total billed charges,"Drugs, Inpatient Only",36.92,30,,36.92,percent of total billed charges,"Drugs, Inpatient Only",36.92,30,,36.92,percent of total billed charges,"Drugs, Inpatient Only",61.53,50,,61.53,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.47,,,5.47,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,86.14,70,,86.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.94,,,2.94,Other,Drug Cost,2.94,,,2.94,Other,Drug Cost,2.94,,,2.94,Other,Drug Cost,2.94,,,2.94,Other,Drug Cost,2.94,,,2.94,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.94,,,2.94,Other,Drug Cost,6.62,,,6.62,Other,225% Medicaid APG methodology,4.12,,,4.12,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.94,,,2.94,Other,Drug Cost,2.94,,,2.94,Other,Drug Cost,3.68,,,3.68,Other,125% Medicaid APG methodology,0.01,86.14,
ATROPINE 1% OPHTH SOLN 5 ML     ,,,,40523946,CDM,250,RC,60219-1749-03,NDC,both,5,ML,120.54,47.57,39.4668,,47.57,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,36.16,30,,36.16,percent of total billed charges,"Drugs, Inpatient Only",36.16,30,,36.16,percent of total billed charges,"Drugs, Inpatient Only",36.16,30,,36.16,percent of total billed charges,"Drugs, Inpatient Only",60.27,50,,60.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,37.2,,,37.2,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,84.38,70,,84.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,20,,,20,Other,Drug Cost,20,,,20,Other,Drug Cost,20,,,20,Other,Drug Cost,20,,,20,Other,Drug Cost,20,,,20,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,20,,,20,Other,Drug Cost,45,,,45,Other,225% Medicaid APG methodology,28,,,28,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,20,,,20,Other,Drug Cost,20,,,20,Other,Drug Cost,25,,,25,Other,125% Medicaid APG methodology,0.01,84.38,
TROPICAMIDE OPHT 1% 3ML         ,,,,40524001,CDM,250,RC,61314-0355-01,NDC,both,3,ML,33.71,13.3,39.4668,,13.3,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.11,30,,10.11,percent of total billed charges,"Drugs, Inpatient Only",10.11,30,,10.11,percent of total billed charges,"Drugs, Inpatient Only",10.11,30,,10.11,percent of total billed charges,"Drugs, Inpatient Only",16.86,50,,16.86,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.01,,,3.01,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,23.6,70,,23.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.62,,,1.62,Other,Drug Cost,1.62,,,1.62,Other,Drug Cost,1.62,,,1.62,Other,Drug Cost,1.62,,,1.62,Other,Drug Cost,1.62,,,1.62,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.62,,,1.62,Other,Drug Cost,3.65,,,3.65,Other,225% Medicaid APG methodology,2.27,,,2.27,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.62,,,1.62,Other,Drug Cost,1.62,,,1.62,Other,Drug Cost,2.03,,,2.03,Other,125% Medicaid APG methodology,0.01,23.6,
PREDNISOLONE ACE 1% OPT  5ML    ,,,,40524076,CDM,250,RC,11980-0180-05,NDC,both,5,ML,445.38,175.78,39.4668,,175.78,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,133.61,30,,133.61,percent of total billed charges,"Drugs, Inpatient Only",133.61,30,,133.61,percent of total billed charges,"Drugs, Inpatient Only",133.61,30,,133.61,percent of total billed charges,"Drugs, Inpatient Only",222.69,50,,222.69,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,311.77,70,,311.77,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,311.77,
BETAXOLOL 0.5% OPHTH SOLN 5 ML  ,,,,40524092,CDM,250,RC,61314-0245-03,NDC,both,5,ML,154,60.78,39.4668,,60.78,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,46.2,30,,46.2,percent of total billed charges,"Drugs, Inpatient Only",46.2,30,,46.2,percent of total billed charges,"Drugs, Inpatient Only",46.2,30,,46.2,percent of total billed charges,"Drugs, Inpatient Only",77,50,,77,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,21.54,,,21.54,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,107.8,70,,107.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.58,,,11.58,Other,Drug Cost,11.58,,,11.58,Other,Drug Cost,11.58,,,11.58,Other,Drug Cost,11.58,,,11.58,Other,Drug Cost,11.58,,,11.58,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,11.58,,,11.58,Other,Drug Cost,26.06,,,26.06,Other,225% Medicaid APG methodology,16.21,,,16.21,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,11.58,,,11.58,Other,Drug Cost,11.58,,,11.58,Other,Drug Cost,14.48,,,14.48,Other,125% Medicaid APG methodology,0.01,107.8,
FLUOROMETHOLONE 0.1% OPT 5ML    ,,,,40524126,CDM,250,RC,60758-0880-05,NDC,both,5,ML,235.2,92.83,39.4668,,92.83,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,70.56,30,,70.56,percent of total billed charges,"Drugs, Inpatient Only",70.56,30,,70.56,percent of total billed charges,"Drugs, Inpatient Only",70.56,30,,70.56,percent of total billed charges,"Drugs, Inpatient Only",117.6,50,,117.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,164.64,70,,164.64,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,164.64,
LEVOBUNOLOL 0.5% OPHTH SLN 5ML  ,,,,40524134,CDM,250,RC,24208-0505-05,NDC,both,5,ML,6.3,2.49,39.4668,,2.49,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.89,30,,1.89,percent of total billed charges,"Drugs, Inpatient Only",1.89,30,,1.89,percent of total billed charges,"Drugs, Inpatient Only",1.89,30,,1.89,percent of total billed charges,"Drugs, Inpatient Only",3.15,50,,3.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.53,,,3.53,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.41,70,,4.41,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.9,,,1.9,Other,Drug Cost,1.9,,,1.9,Other,Drug Cost,1.9,,,1.9,Other,Drug Cost,1.9,,,1.9,Other,Drug Cost,1.9,,,1.9,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.9,,,1.9,Other,Drug Cost,4.28,,,4.28,Other,225% Medicaid APG methodology,2.66,,,2.66,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.9,,,1.9,Other,Drug Cost,1.9,,,1.9,Other,Drug Cost,2.38,,,2.38,Other,125% Medicaid APG methodology,0.01,4.41,
SOD SULFACETAMIDE 10% OPT 15ML  ,,,,40524159,CDM,250,RC,24208-0670-04,NDC,both,15,ML,110.25,43.51,39.4668,,43.51,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,33.08,30,,33.08,percent of total billed charges,"Drugs, Inpatient Only",33.08,30,,33.08,percent of total billed charges,"Drugs, Inpatient Only",33.08,30,,33.08,percent of total billed charges,"Drugs, Inpatient Only",55.13,50,,55.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.79,,,14.79,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,77.18,70,,77.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.95,,,7.95,Other,Drug Cost,7.95,,,7.95,Other,Drug Cost,7.95,,,7.95,Other,Drug Cost,7.95,,,7.95,Other,Drug Cost,7.95,,,7.95,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,7.95,,,7.95,Other,Drug Cost,17.89,,,17.89,Other,225% Medicaid APG methodology,11.13,,,11.13,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.95,,,7.95,Other,Drug Cost,7.95,,,7.95,Other,Drug Cost,9.94,,,9.94,Other,125% Medicaid APG methodology,0.01,77.18,
HYDROXYPROL METHCELL 2.5% 15ML  ,,,,40524167,CDM,250,RC,17478-0064-12,NDC,both,15,ML,65.63,25.9,39.4668,,25.9,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.69,30,,19.69,percent of total billed charges,"Drugs, Inpatient Only",19.69,30,,19.69,percent of total billed charges,"Drugs, Inpatient Only",19.69,30,,19.69,percent of total billed charges,"Drugs, Inpatient Only",32.82,50,,32.82,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,34.88,,,34.88,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,45.94,70,,45.94,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,18.75,,,18.75,Other,Drug Cost,18.75,,,18.75,Other,Drug Cost,18.75,,,18.75,Other,Drug Cost,18.75,,,18.75,Other,Drug Cost,18.75,,,18.75,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,18.75,,,18.75,Other,Drug Cost,42.19,,,42.19,Other,225% Medicaid APG methodology,26.25,,,26.25,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,18.75,,,18.75,Other,Drug Cost,18.75,,,18.75,Other,Drug Cost,23.44,,,23.44,Other,125% Medicaid APG methodology,0.01,45.94,
OCULAR LUBRICANT OPT 15ML       ,,,,40524217,CDM,250,RC,10119-0020-03,NDC,both,15,ML,15.75,6.22,39.4668,,6.22,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.73,30,,4.73,percent of total billed charges,"Drugs, Inpatient Only",4.73,30,,4.73,percent of total billed charges,"Drugs, Inpatient Only",4.73,30,,4.73,percent of total billed charges,"Drugs, Inpatient Only",7.88,50,,7.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.37,,,8.37,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.03,70,,11.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.5,,,4.5,Other,Drug Cost,4.5,,,4.5,Other,Drug Cost,4.5,,,4.5,Other,Drug Cost,4.5,,,4.5,Other,Drug Cost,4.5,,,4.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.5,,,4.5,Other,Drug Cost,10.13,,,10.13,Other,225% Medicaid APG methodology,6.3,,,6.3,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.5,,,4.5,Other,Drug Cost,4.5,,,4.5,Other,Drug Cost,5.63,,,5.63,Other,125% Medicaid APG methodology,0.01,11.03,
TRIFLURIDINE 1% OPT SLN 7.5ML   ,,,,40524233,CDM,250,RC,61314-0044-75,NDC,both,7.5,ML,426.58,168.36,39.4668,,168.36,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,127.97,30,,127.97,percent of total billed charges,"Drugs, Inpatient Only",127.97,30,,127.97,percent of total billed charges,"Drugs, Inpatient Only",127.97,30,,127.97,percent of total billed charges,"Drugs, Inpatient Only",213.29,50,,213.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,62.5,,,62.5,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,298.61,70,,298.61,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,33.6,,,33.6,Other,Drug Cost,33.6,,,33.6,Other,Drug Cost,33.6,,,33.6,Other,Drug Cost,33.6,,,33.6,Other,Drug Cost,33.6,,,33.6,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,33.6,,,33.6,Other,Drug Cost,75.6,,,75.6,Other,225% Medicaid APG methodology,47.04,,,47.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,33.6,,,33.6,Other,Drug Cost,33.6,,,33.6,Other,Drug Cost,42,,,42,Other,125% Medicaid APG methodology,0.01,298.61,
CIPROFLOXACIN 0.3% OPT  2.5ML   ,,,,40524308,CDM,250,RC,69315-0308-02,NDC,both,2.5,ML,23.38,9.23,39.4668,,9.23,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.01,30,,7.01,percent of total billed charges,"Drugs, Inpatient Only",7.01,30,,7.01,percent of total billed charges,"Drugs, Inpatient Only",7.01,30,,7.01,percent of total billed charges,"Drugs, Inpatient Only",11.69,50,,11.69,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.98,,,4.98,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,16.37,70,,16.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.68,,,2.68,Other,Drug Cost,2.68,,,2.68,Other,Drug Cost,2.68,,,2.68,Other,Drug Cost,2.68,,,2.68,Other,Drug Cost,2.68,,,2.68,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.68,,,2.68,Other,Drug Cost,6.03,,,6.03,Other,225% Medicaid APG methodology,3.75,,,3.75,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.68,,,2.68,Other,Drug Cost,2.68,,,2.68,Other,Drug Cost,3.35,,,3.35,Other,125% Medicaid APG methodology,0.01,16.37,
GENTAMICIN 0.3% OPT OINT 3.5 G  ,,,,40524316,CDM,250,RC,17478-0284-35,NDC,both,3.5,GM,93.84,37.04,39.4668,,37.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,28.15,30,,28.15,percent of total billed charges,"Drugs, Inpatient Only",28.15,30,,28.15,percent of total billed charges,"Drugs, Inpatient Only",28.15,30,,28.15,percent of total billed charges,"Drugs, Inpatient Only",46.92,50,,46.92,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.5,,,7.5,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,65.69,70,,65.69,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.03,,,4.03,Other,Drug Cost,4.03,,,4.03,Other,Drug Cost,4.03,,,4.03,Other,Drug Cost,4.03,,,4.03,Other,Drug Cost,4.03,,,4.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.03,,,4.03,Other,Drug Cost,9.07,,,9.07,Other,225% Medicaid APG methodology,5.64,,,5.64,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.03,,,4.03,Other,Drug Cost,4.03,,,4.03,Other,Drug Cost,5.04,,,5.04,Other,125% Medicaid APG methodology,0.01,65.69,
GENTAMICIN 0.3% OPHTH SOLN 5ML  ,,,,40524324,CDM,250,RC,61314-0633-05,NDC,both,5,ML,19.95,7.87,39.4668,,7.87,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.99,30,,5.99,percent of total billed charges,"Drugs, Inpatient Only",5.99,30,,5.99,percent of total billed charges,"Drugs, Inpatient Only",5.99,30,,5.99,percent of total billed charges,"Drugs, Inpatient Only",9.98,50,,9.98,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.09,,,4.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.97,70,,13.97,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.2,,,2.2,Other,Drug Cost,2.2,,,2.2,Other,Drug Cost,2.2,,,2.2,Other,Drug Cost,2.2,,,2.2,Other,Drug Cost,2.2,,,2.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.2,,,2.2,Other,Drug Cost,4.95,,,4.95,Other,225% Medicaid APG methodology,3.08,,,3.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.2,,,2.2,Other,Drug Cost,2.2,,,2.2,Other,Drug Cost,2.75,,,2.75,Other,125% Medicaid APG methodology,0.01,13.97,
TOBRAMYCIN 0.3% OPT OINT 3.5 G  ,,,,40524332,CDM,250,RC,00065-0644-35,NDC,both,3.5,GM,705.99,278.63,39.4668,,278.63,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,211.8,30,,211.8,percent of total billed charges,"Drugs, Inpatient Only",211.8,30,,211.8,percent of total billed charges,"Drugs, Inpatient Only",211.8,30,,211.8,percent of total billed charges,"Drugs, Inpatient Only",353,50,,353,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,494.19,70,,494.19,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,494.19,
TOBRAMYCIN 0.3% OPHTH SOLN 5ML  ,,,,40524340,CDM,250,RC,17478-0290-10,NDC,both,5,ML,38.5,15.19,39.4668,,15.19,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.55,30,,11.55,percent of total billed charges,"Drugs, Inpatient Only",11.55,30,,11.55,percent of total billed charges,"Drugs, Inpatient Only",11.55,30,,11.55,percent of total billed charges,"Drugs, Inpatient Only",19.25,50,,19.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.14,,,2.14,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,26.95,70,,26.95,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.15,,,1.15,Other,Drug Cost,1.15,,,1.15,Other,Drug Cost,1.15,,,1.15,Other,Drug Cost,1.15,,,1.15,Other,Drug Cost,1.15,,,1.15,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.15,,,1.15,Other,Drug Cost,2.59,,,2.59,Other,225% Medicaid APG methodology,1.61,,,1.61,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.15,,,1.15,Other,Drug Cost,1.15,,,1.15,Other,Drug Cost,1.44,,,1.44,Other,125% Medicaid APG methodology,0.01,26.95,
PAROXETINE 20 MG TAB            ,,,,40524381,CDM,250,RC,68084-0045-01,NDC,both,1,EA,0.6,0.24,39.4668,,0.24,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.18,30,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.18,30,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.18,30,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.3,50,,0.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.42,70,,0.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.42,
PAROXETINE 10 MG TAB            ,,,,40524399,CDM,250,RC,63739-0888-10,NDC,both,1,EA,2.14,0.84,39.4668,,0.84,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.64,30,,0.64,percent of total billed charges,"Drugs, Inpatient Only",0.64,30,,0.64,percent of total billed charges,"Drugs, Inpatient Only",0.64,30,,0.64,percent of total billed charges,"Drugs, Inpatient Only",1.07,50,,1.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.67,,,0.67,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.5,70,,1.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.36,,,0.36,Other,Drug Cost,0.81,,,0.81,Other,225% Medicaid APG methodology,0.5,,,0.5,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.45,,,0.45,Other,125% Medicaid APG methodology,0.01,1.5,
ROPINIROLE 1 MG TAB             ,,,,40524456,CDM,250,RC,43547-0270-10,NDC,both,1,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.11,50,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.15,
CARBAMIDE PEROXIDE6.5% AU 15ML  ,,,,40524498,CDM,250,RC,11527-0143-51,NDC,both,15,ML,4.8,1.89,39.4668,,1.89,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.44,30,,1.44,percent of total billed charges,"Drugs, Inpatient Only",1.44,30,,1.44,percent of total billed charges,"Drugs, Inpatient Only",1.44,30,,1.44,percent of total billed charges,"Drugs, Inpatient Only",2.4,50,,2.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.55,,,2.55,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.36,70,,3.36,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.37,,,1.37,Other,Drug Cost,1.37,,,1.37,Other,Drug Cost,1.37,,,1.37,Other,Drug Cost,1.37,,,1.37,Other,Drug Cost,1.37,,,1.37,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.37,,,1.37,Other,Drug Cost,3.08,,,3.08,Other,225% Medicaid APG methodology,1.92,,,1.92,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.37,,,1.37,Other,Drug Cost,1.37,,,1.37,Other,Drug Cost,1.71,,,1.71,Other,125% Medicaid APG methodology,0.01,3.36,
ACETAZOLAMIDE 500 MG ER CAP     ,,,,40524563,CDM,250,RC,50742-0233-01,NDC,both,1,EA,2.31,0.91,39.4668,,0.91,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.69,30,,0.69,percent of total billed charges,"Drugs, Inpatient Only",0.69,30,,0.69,percent of total billed charges,"Drugs, Inpatient Only",0.69,30,,0.69,percent of total billed charges,"Drugs, Inpatient Only",1.16,50,,1.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.52,,,0.52,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.62,70,,1.62,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,Drug Cost,0.63,,,0.63,Other,225% Medicaid APG methodology,0.39,,,0.39,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.35,,,0.35,Other,125% Medicaid APG methodology,0.01,1.62,
ACETAZOLAMIDE 250 MG TAB        ,,,,40524571,CDM,250,RC,51672-4023-01,NDC,both,1,EA,7.67,3.03,39.4668,,3.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.3,30,,2.3,percent of total billed charges,"Drugs, Inpatient Only",2.3,30,,2.3,percent of total billed charges,"Drugs, Inpatient Only",2.3,30,,2.3,percent of total billed charges,"Drugs, Inpatient Only",3.84,50,,3.84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.45,,,0.45,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.37,70,,5.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,Drug Cost,0.54,,,0.54,Other,225% Medicaid APG methodology,0.34,,,0.34,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.3,,,0.3,Other,125% Medicaid APG methodology,0.01,5.37,
METHAZOLAMIDE 50 MG TAB         ,,,,40524589,CDM,250,RC,62559-0241-01,NDC,both,1,EA,29.93,11.81,39.4668,,11.81,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.98,30,,8.98,percent of total billed charges,"Drugs, Inpatient Only",8.98,30,,8.98,percent of total billed charges,"Drugs, Inpatient Only",8.98,30,,8.98,percent of total billed charges,"Drugs, Inpatient Only",14.97,50,,14.97,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.2,,,4.2,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,20.95,70,,20.95,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.26,,,2.26,Other,Drug Cost,2.26,,,2.26,Other,Drug Cost,2.26,,,2.26,Other,Drug Cost,2.26,,,2.26,Other,Drug Cost,2.26,,,2.26,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.26,,,2.26,Other,Drug Cost,5.09,,,5.09,Other,225% Medicaid APG methodology,3.16,,,3.16,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.26,,,2.26,Other,Drug Cost,2.26,,,2.26,Other,Drug Cost,2.83,,,2.83,Other,125% Medicaid APG methodology,0.01,20.95,
HYDROCHLOROTHIAZIDE 25 MG TAB   ,,,,40524621,CDM,250,RC,16729-0183-01,NDC,both,1,EA,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.02,50,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.03,
HYDROCHLOROTHIAZIDE 50 MG TAB   ,,,,40524639,CDM,250,RC,23155-0009-01,NDC,both,1,EA,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.04,50,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.05,
ETHACRYNIC ACID 50 MG IV INJ    ,,,,40524647,CDM,250,RC,69315-0701-50,NDC,both,1,EA,6181.84,2439.77,39.4668,,2439.77,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1854.55,30,,1854.55,percent of total billed charges,"Drugs, Inpatient Only",1854.55,30,,1854.55,percent of total billed charges,"Drugs, Inpatient Only",1854.55,30,,1854.55,percent of total billed charges,"Drugs, Inpatient Only",3090.92,50,,3090.92,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2742.16,,,2742.16,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4327.29,70,,4327.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1474.28,,,1474.28,Other,Drug Cost,1474.28,,,1474.28,Other,Drug Cost,1474.28,,,1474.28,Other,Drug Cost,1474.28,,,1474.28,Other,Drug Cost,1474.28,,,1474.28,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1474.28,,,1474.28,Other,Drug Cost,3317.13,,,3317.13,Other,225% Medicaid APG methodology,2063.99,,,2063.99,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1474.28,,,1474.28,Other,Drug Cost,1474.28,,,1474.28,Other,Drug Cost,1842.85,,,1842.85,Other,125% Medicaid APG methodology,0.01,4327.29,
ETHACRYNIC ACID 25 MG TAB       ,,,,40524654,CDM,250,RC,00054-0415-25,NDC,both,1,EA,33.04,13.04,39.4668,,13.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.91,30,,9.91,percent of total billed charges,"Drugs, Inpatient Only",9.91,30,,9.91,percent of total billed charges,"Drugs, Inpatient Only",9.91,30,,9.91,percent of total billed charges,"Drugs, Inpatient Only",16.52,50,,16.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.6,,,0.6,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,23.13,70,,23.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.32,,,0.32,Other,Drug Cost,0.72,,,0.72,Other,225% Medicaid APG methodology,0.45,,,0.45,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.4,,,0.4,Other,125% Medicaid APG methodology,0.01,23.13,
FUROSEMIDE 20 MG TAB            ,,,,40524738,CDM,250,RC,51079-0072-20,NDC,both,1,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.11,50,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.15,
FUROSEMIDE 40 MG TAB            ,,,,40524746,CDM,250,RC,00904-7178-61,NDC,both,1,EA,1.96,0.77,39.4668,,0.77,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.59,30,,0.59,percent of total billed charges,"Drugs, Inpatient Only",0.59,30,,0.59,percent of total billed charges,"Drugs, Inpatient Only",0.59,30,,0.59,percent of total billed charges,"Drugs, Inpatient Only",0.98,50,,0.98,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.97,,,0.97,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.37,70,,1.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.52,,,0.52,Other,Drug Cost,0.52,,,0.52,Other,Drug Cost,0.52,,,0.52,Other,Drug Cost,0.52,,,0.52,Other,Drug Cost,0.52,,,0.52,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.52,,,0.52,Other,Drug Cost,1.17,,,1.17,Other,225% Medicaid APG methodology,0.73,,,0.73,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.52,,,0.52,Other,Drug Cost,0.52,,,0.52,Other,Drug Cost,0.65,,,0.65,Other,125% Medicaid APG methodology,0.01,1.37,
FUROSEMIDE 80 MG TAB            ,,,,40524753,CDM,250,RC,51079-0527-20,NDC,both,1,EA,0.39,0.15,39.4668,,0.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.2,50,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.27,70,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.27,
METOLAZONE 2.5 MG TAB           ,,,,40524779,CDM,250,RC,00904-7328-61,NDC,both,1,EA,8.68,3.43,39.4668,,3.43,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.6,30,,2.6,percent of total billed charges,"Drugs, Inpatient Only",2.6,30,,2.6,percent of total billed charges,"Drugs, Inpatient Only",2.6,30,,2.6,percent of total billed charges,"Drugs, Inpatient Only",4.34,50,,4.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.56,,,4.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.08,70,,6.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.45,,,2.45,Other,Drug Cost,2.45,,,2.45,Other,Drug Cost,2.45,,,2.45,Other,Drug Cost,2.45,,,2.45,Other,Drug Cost,2.45,,,2.45,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.45,,,2.45,Other,Drug Cost,5.51,,,5.51,Other,225% Medicaid APG methodology,3.43,,,3.43,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.45,,,2.45,Other,Drug Cost,2.45,,,2.45,Other,Drug Cost,3.06,,,3.06,Other,125% Medicaid APG methodology,0.01,6.08,
METOLAZONE 5 MG TAB             ,,,,40524787,CDM,250,RC,60687-0635-01,NDC,both,1,EA,8.58,3.39,39.4668,,3.39,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.57,30,,2.57,percent of total billed charges,"Drugs, Inpatient Only",2.57,30,,2.57,percent of total billed charges,"Drugs, Inpatient Only",2.57,30,,2.57,percent of total billed charges,"Drugs, Inpatient Only",4.29,50,,4.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.02,,,5.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.01,70,,6.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.7,,,2.7,Other,Drug Cost,6.08,,,6.08,Other,225% Medicaid APG methodology,3.78,,,3.78,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,3.38,,,3.38,Other,125% Medicaid APG methodology,0.01,6.08,
TRIAMTERENE 50 MG CAP           ,,,,40524803,CDM,250,RC,59212-0002-01,NDC,both,1,EA,41.65,16.44,39.4668,,16.44,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.5,30,,12.5,percent of total billed charges,"Drugs, Inpatient Only",12.5,30,,12.5,percent of total billed charges,"Drugs, Inpatient Only",12.5,30,,12.5,percent of total billed charges,"Drugs, Inpatient Only",20.83,50,,20.83,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.38,,,19.38,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,29.16,70,,29.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.42,,,10.42,Other,Drug Cost,10.42,,,10.42,Other,Drug Cost,10.42,,,10.42,Other,Drug Cost,10.42,,,10.42,Other,Drug Cost,10.42,,,10.42,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,10.42,,,10.42,Other,Drug Cost,23.45,,,23.45,Other,225% Medicaid APG methodology,14.59,,,14.59,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,10.42,,,10.42,Other,Drug Cost,10.42,,,10.42,Other,Drug Cost,13.03,,,13.03,Other,125% Medicaid APG methodology,0.01,29.16,
PROBENECID 500 MG TAB           ,,,,40524811,CDM,250,RC,00591-5347-01,NDC,both,1,EA,1.93,0.76,39.4668,,0.76,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.58,30,,0.58,percent of total billed charges,"Drugs, Inpatient Only",0.58,30,,0.58,percent of total billed charges,"Drugs, Inpatient Only",0.58,30,,0.58,percent of total billed charges,"Drugs, Inpatient Only",0.97,50,,0.97,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.48,,,0.48,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.35,70,,1.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,Drug Cost,0.59,,,0.59,Other,225% Medicaid APG methodology,0.36,,,0.36,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.33,,,0.33,Other,125% Medicaid APG methodology,0.01,1.35,
COLCHICINE 0.6MG TABLET         ,,,,40524886,CDM,250,RC,70010-0002-01,NDC,both,1,EA,3.5,1.38,39.4668,,1.38,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.05,30,,1.05,percent of total billed charges,"Drugs, Inpatient Only",1.05,30,,1.05,percent of total billed charges,"Drugs, Inpatient Only",1.05,30,,1.05,percent of total billed charges,"Drugs, Inpatient Only",1.75,50,,1.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.82,,,1.82,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.45,70,,2.45,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.98,,,0.98,Other,Drug Cost,2.21,,,2.21,Other,225% Medicaid APG methodology,1.37,,,1.37,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,1.23,,,1.23,Other,125% Medicaid APG methodology,0.01,2.45,
INDOMETHACIN 25 MG CAP          ,,,,40524894,CDM,250,RC,50268-0430-15,NDC,both,1,EA,0.84,0.33,39.4668,,0.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,30,,0.25,percent of total billed charges,"Drugs, Inpatient Only",0.25,30,,0.25,percent of total billed charges,"Drugs, Inpatient Only",0.25,30,,0.25,percent of total billed charges,"Drugs, Inpatient Only",0.42,50,,0.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.59,70,,0.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.29,,,0.29,Other,225% Medicaid APG methodology,0.18,,,0.18,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.16,,,0.16,Other,125% Medicaid APG methodology,0.01,0.59,
IBUPROFEN 400 MG TAB            ,,,,40524902,CDM,250,RC,67877-0319-01,NDC,both,1,EA,0.14,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.07,50,,0.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.1,
IBUPROFEN 600 MG TAB            ,,,,40524910,CDM,250,RC,00904-5854-61,NDC,both,1,EA,0.25,0.1,39.4668,,0.1,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.13,50,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.18,70,,0.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.18,
NAPROXEN 250 MG TAB             ,,,,40524928,CDM,250,RC,68462-0188-01,NDC,both,1,EA,0.18,0.07,39.4668,,0.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.09,50,,0.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,70,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.13,
NAPROXEN 375 MG TAB             ,,,,40524936,CDM,250,RC,50268-0595-15,NDC,both,1,EA,0.91,0.36,39.4668,,0.36,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.27,30,,0.27,percent of total billed charges,"Drugs, Inpatient Only",0.27,30,,0.27,percent of total billed charges,"Drugs, Inpatient Only",0.27,30,,0.27,percent of total billed charges,"Drugs, Inpatient Only",0.46,50,,0.46,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.64,70,,0.64,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,Drug Cost,0.32,,,0.32,Other,225% Medicaid APG methodology,0.2,,,0.2,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.18,,,0.18,Other,125% Medicaid APG methodology,0.01,0.64,
PETROLATUM TOPICAL OINT 5 G     ,,,,40525032,CDM,250,RC,67777-0211-01,NDC,both,5,GM,0.18,0.07,39.4668,,0.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.09,50,,0.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,70,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.13,
TOPIRAMATE 100 MG TAB           ,,,,40525040,CDM,250,RC,68084-0344-01,NDC,both,1,EA,1.33,0.52,39.4668,,0.52,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.4,30,,0.4,percent of total billed charges,"Drugs, Inpatient Only",0.4,30,,0.4,percent of total billed charges,"Drugs, Inpatient Only",0.4,30,,0.4,percent of total billed charges,"Drugs, Inpatient Only",0.67,50,,0.67,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.93,70,,0.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.29,,,0.29,Other,225% Medicaid APG methodology,0.18,,,0.18,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.16,,,0.16,Other,125% Medicaid APG methodology,0.01,0.93,
TOPIRAMATE 25 MG TAB            ,,,,40525065,CDM,250,RC,68084-0342-01,NDC,both,1,EA,0.77,0.3,39.4668,,0.3,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.23,30,,0.23,percent of total billed charges,"Drugs, Inpatient Only",0.23,30,,0.23,percent of total billed charges,"Drugs, Inpatient Only",0.23,30,,0.23,percent of total billed charges,"Drugs, Inpatient Only",0.39,50,,0.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.54,70,,0.54,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% Medicaid APG methodology,0.1,,,0.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.54,
GLUCOSE 40% ORLGEL 15 G/37.5ML  ,,,,40525172,CDM,250,RC,00574-0069-30,NDC,both,37.5,GM,11.83,4.67,39.4668,,4.67,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.55,30,,3.55,percent of total billed charges,"Drugs, Inpatient Only",3.55,30,,3.55,percent of total billed charges,"Drugs, Inpatient Only",3.55,30,,3.55,percent of total billed charges,"Drugs, Inpatient Only",5.92,50,,5.92,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.29,,,6.29,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.28,70,,8.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.38,,,3.38,Other,Drug Cost,3.38,,,3.38,Other,Drug Cost,3.38,,,3.38,Other,Drug Cost,3.38,,,3.38,Other,Drug Cost,3.38,,,3.38,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.38,,,3.38,Other,Drug Cost,7.61,,,7.61,Other,225% Medicaid APG methodology,4.73,,,4.73,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.38,,,3.38,Other,Drug Cost,3.38,,,3.38,Other,Drug Cost,4.23,,,4.23,Other,125% Medicaid APG methodology,0.01,8.28,
MERCAPTOPURINE 50 MG TAB        ,,,,40525453,CDM,250,RC,00054-4581-11,NDC,both,1,EA,2.84,1.12,39.4668,,1.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.85,30,,0.85,percent of total billed charges,"Drugs, Inpatient Only",0.85,30,,0.85,percent of total billed charges,"Drugs, Inpatient Only",0.85,30,,0.85,percent of total billed charges,"Drugs, Inpatient Only",1.42,50,,1.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.5,,,0.5,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.99,70,,1.99,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.27,,,0.27,Other,Drug Cost,0.61,,,0.61,Other,225% Medicaid APG methodology,0.38,,,0.38,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.34,,,0.34,Other,125% Medicaid APG methodology,0.01,1.99,
MEGESTROL 20 MG TAB             ,,,,40525628,CDM,250,RC,64380-0158-01,NDC,both,1,EA,0.63,0.25,39.4668,,0.25,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.32,50,,0.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.44,70,,0.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.44,
MEGESTROL 40 MG TAB             ,,,,40525636,CDM,250,RC,00904-3571-61,NDC,both,1,EA,0.63,0.25,39.4668,,0.25,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.32,50,,0.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.44,70,,0.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.25,,,0.25,Other,225% Medicaid APG methodology,0.15,,,0.15,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.14,,,0.14,Other,125% Medicaid APG methodology,0.01,0.44,
PENICILLIN V POT 250MG TAB      ,,,,40525867,CDM,250,RC,65862-0175-01,NDC,both,1,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.11,50,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.15,
DICLOXACILLIN 250 MG CAP        ,,,,40526055,CDM,250,RC,00093-3123-01,NDC,both,1,EA,1.44,0.57,39.4668,,0.57,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.43,30,,0.43,percent of total billed charges,"Drugs, Inpatient Only",0.43,30,,0.43,percent of total billed charges,"Drugs, Inpatient Only",0.43,30,,0.43,percent of total billed charges,"Drugs, Inpatient Only",0.72,50,,0.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.01,70,,1.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.2,,,0.2,Other,225% Medicaid APG methodology,0.13,,,0.13,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,1.01,
AMOXICILLIN 250 MG CAP          ,,,,40526097,CDM,250,RC,00781-2020-01,NDC,both,1,EA,0.11,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.06,50,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.08,
AMOXICILLIN 500 MG CAP          ,,,,40526105,CDM,250,RC,00781-2613-01,NDC,both,1,EA,0.28,0.11,39.4668,,0.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.14,50,,0.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,70,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.2,
AMOX 250MG/5ML ORAL SUSP 80ML   ,,,,40526113,CDM,250,RC,00781-6041-58,NDC,both,80,ML,8.4,3.32,39.4668,,3.32,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.52,30,,2.52,percent of total billed charges,"Drugs, Inpatient Only",2.52,30,,2.52,percent of total billed charges,"Drugs, Inpatient Only",2.52,30,,2.52,percent of total billed charges,"Drugs, Inpatient Only",4.2,50,,4.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.49,,,1.49,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.88,70,,5.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.8,,,0.8,Other,Drug Cost,1.8,,,1.8,Other,225% Medicaid APG methodology,1.12,,,1.12,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,1,,,1,Other,125% Medicaid APG methodology,0.01,5.88,
CEPHALEXIN 250 MG CAP           ,,,,40526154,CDM,250,RC,67877-0220-01,NDC,both,1,EA,0.32,0.13,39.4668,,0.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.16,50,,0.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,70,,0.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.22,
CEPHALEXIN 500 MG CAP           ,,,,40526162,CDM,250,RC,00904-7337-61,NDC,both,1,EA,1.05,0.41,39.4668,,0.41,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.32,30,,0.32,percent of total billed charges,"Drugs, Inpatient Only",0.32,30,,0.32,percent of total billed charges,"Drugs, Inpatient Only",0.32,30,,0.32,percent of total billed charges,"Drugs, Inpatient Only",0.53,50,,0.53,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.54,,,0.54,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.74,70,,0.74,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.29,,,0.29,Other,Drug Cost,0.65,,,0.65,Other,225% Medicaid APG methodology,0.41,,,0.41,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.36,,,0.36,Other,125% Medicaid APG methodology,0.01,0.74,
CEPHALEXIN 50MG/ML ORLIQ 100ML  ,,,,40526188,CDM,250,RC,00093-4177-73,NDC,both,100,ML,77,30.39,39.4668,,30.39,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,23.1,30,,23.1,percent of total billed charges,"Drugs, Inpatient Only",23.1,30,,23.1,percent of total billed charges,"Drugs, Inpatient Only",23.1,30,,23.1,percent of total billed charges,"Drugs, Inpatient Only",38.5,50,,38.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.44,,,7.44,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,53.9,70,,53.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4,,,4,Other,Drug Cost,4,,,4,Other,Drug Cost,4,,,4,Other,Drug Cost,4,,,4,Other,Drug Cost,4,,,4,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4,,,4,Other,Drug Cost,9,,,9,Other,225% Medicaid APG methodology,5.6,,,5.6,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4,,,4,Other,Drug Cost,4,,,4,Other,Drug Cost,5,,,5,Other,125% Medicaid APG methodology,0.01,53.9,
PANTOPRAZOLE 40 MG DR TAB       ,,,,40526352,CDM,250,RC,00904-6474-61,NDC,both,1,EA,0.67,0.26,39.4668,,0.26,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,30,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.2,30,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.2,30,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.34,50,,0.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.47,70,,0.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,Drug Cost,0.34,,,0.34,Other,225% Medicaid APG methodology,0.21,,,0.21,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.19,,,0.19,Other,125% Medicaid APG methodology,0.01,0.47,
ACTHIB VACCINE                  ,,,,40526360,CDM,250,RC,58160-0818-11,NDC,both,1,EA,33.99,13.41,39.4668,,13.41,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.2,30,,10.2,percent of total billed charges,"Drugs, Inpatient Only",10.2,30,,10.2,percent of total billed charges,"Drugs, Inpatient Only",10.2,30,,10.2,percent of total billed charges,"Drugs, Inpatient Only",17,50,,17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,18.34,,,18.34,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,23.79,70,,23.79,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.86,,,9.86,Other,Drug Cost,9.86,,,9.86,Other,Drug Cost,9.86,,,9.86,Other,Drug Cost,9.86,,,9.86,Other,Drug Cost,9.86,,,9.86,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,9.86,,,9.86,Other,Drug Cost,22.19,,,22.19,Other,225% Medicaid APG methodology,13.8,,,13.8,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,9.86,,,9.86,Other,Drug Cost,9.86,,,9.86,Other,Drug Cost,12.33,,,12.33,Other,125% Medicaid APG methodology,0.01,23.79,
DEMECLOCYCLINE 150 MG TAB       ,,,,40526386,CDM,250,RC,62584-0159-01,NDC,both,1,EA,10.71,4.23,39.4668,,4.23,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.21,30,,3.21,percent of total billed charges,"Drugs, Inpatient Only",3.21,30,,3.21,percent of total billed charges,"Drugs, Inpatient Only",3.21,30,,3.21,percent of total billed charges,"Drugs, Inpatient Only",5.36,50,,5.36,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.04,,,4.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.5,70,,7.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.17,,,2.17,Other,Drug Cost,2.17,,,2.17,Other,Drug Cost,2.17,,,2.17,Other,Drug Cost,2.17,,,2.17,Other,Drug Cost,2.17,,,2.17,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.17,,,2.17,Other,Drug Cost,4.88,,,4.88,Other,225% Medicaid APG methodology,3.04,,,3.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.17,,,2.17,Other,Drug Cost,2.17,,,2.17,Other,Drug Cost,2.71,,,2.71,Other,125% Medicaid APG methodology,0.01,7.5,
DOXYCYCLINE HYCLATE 100 MG CAP  ,,,,40526394,CDM,250,RC,00143-9803-50,NDC,both,1,EA,0.56,0.22,39.4668,,0.22,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.28,50,,0.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.39,70,,0.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.39,
CLINDAMYCIN 150 MG CAP          ,,,,40526543,CDM,250,RC,00904-5959-61,NDC,both,1,EA,0.53,0.21,39.4668,,0.21,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.27,50,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,70,,0.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% Medicaid APG methodology,0.11,,,0.11,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.37,
MIDAZOLAM 2MG/ML ORL SYR 1ML    ,,,,40526634,CDM,250,RC,00054-3566-99,NDC,both,1,ML,1.33,0.52,39.4668,,0.52,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.4,30,,0.4,percent of total billed charges,"Drugs, Inpatient Only",0.4,30,,0.4,percent of total billed charges,"Drugs, Inpatient Only",0.4,30,,0.4,percent of total billed charges,"Drugs, Inpatient Only",0.67,50,,0.67,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.33,,,0.33,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.93,70,,0.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.18,,,0.18,Other,Drug Cost,0.41,,,0.41,Other,225% Medicaid APG methodology,0.25,,,0.25,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.23,,,0.23,Other,125% Medicaid APG methodology,0.01,0.93,
CLINDAMYCIN 15MG/ML ORLIQ100ML  ,,,,40526642,CDM,250,RC,64980-0511-10,NDC,both,5,ML,2.94,1.16,39.4668,,1.16,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.88,30,,0.88,percent of total billed charges,"Drugs, Inpatient Only",0.88,30,,0.88,percent of total billed charges,"Drugs, Inpatient Only",0.88,30,,0.88,percent of total billed charges,"Drugs, Inpatient Only",1.47,50,,1.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.58,,,0.58,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.06,70,,2.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.31,,,0.31,Other,Drug Cost,0.7,,,0.7,Other,225% Medicaid APG methodology,0.43,,,0.43,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.39,,,0.39,Other,125% Medicaid APG methodology,0.01,2.06,
NEOMYCIN 500 MG TAB             ,,,,40526725,CDM,250,RC,39822-0310-05,NDC,both,1,EA,2.87,1.13,39.4668,,1.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.86,30,,0.86,percent of total billed charges,"Drugs, Inpatient Only",0.86,30,,0.86,percent of total billed charges,"Drugs, Inpatient Only",0.86,30,,0.86,percent of total billed charges,"Drugs, Inpatient Only",1.44,50,,1.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1,,,1,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.01,70,,2.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.54,,,0.54,Other,Drug Cost,1.22,,,1.22,Other,225% Medicaid APG methodology,0.76,,,0.76,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.68,,,0.68,Other,125% Medicaid APG methodology,0.01,2.01,
RIFAMPIN 300 MG CAP             ,,,,40526873,CDM,250,RC,61748-0018-01,NDC,both,1,EA,4.17,1.65,39.4668,,1.65,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.25,30,,1.25,percent of total billed charges,"Drugs, Inpatient Only",1.25,30,,1.25,percent of total billed charges,"Drugs, Inpatient Only",1.25,30,,1.25,percent of total billed charges,"Drugs, Inpatient Only",2.09,50,,2.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.6,,,0.6,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.92,70,,2.92,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.32,,,0.32,Other,Drug Cost,0.72,,,0.72,Other,225% Medicaid APG methodology,0.45,,,0.45,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.4,,,0.4,Other,125% Medicaid APG methodology,0.01,2.92,
POLYMYXIN B SULF 500000 UNITS   ,,,,40526964,CDM,250,RC,63323-0367-11,NDC,both,1,EA,36.4,14.37,39.4668,,14.37,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.92,30,,10.92,percent of total billed charges,"Drugs, Inpatient Only",10.92,30,,10.92,percent of total billed charges,"Drugs, Inpatient Only",10.92,30,,10.92,percent of total billed charges,"Drugs, Inpatient Only",18.2,50,,18.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.91,,,5.91,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,25.48,70,,25.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.18,,,3.18,Other,Drug Cost,3.18,,,3.18,Other,Drug Cost,3.18,,,3.18,Other,Drug Cost,3.18,,,3.18,Other,Drug Cost,3.18,,,3.18,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.18,,,3.18,Other,Drug Cost,7.16,,,7.16,Other,225% Medicaid APG methodology,4.45,,,4.45,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.18,,,3.18,Other,Drug Cost,3.18,,,3.18,Other,Drug Cost,3.98,,,3.98,Other,125% Medicaid APG methodology,0.01,25.48,
SULFADIAZINE 500 MG TAB         ,,,,40527004,CDM,250,RC,00185-0757-01,NDC,both,1,EA,9.07,3.58,39.4668,,3.58,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.72,30,,2.72,percent of total billed charges,"Drugs, Inpatient Only",2.72,30,,2.72,percent of total billed charges,"Drugs, Inpatient Only",2.72,30,,2.72,percent of total billed charges,"Drugs, Inpatient Only",4.54,50,,4.54,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.47,,,2.47,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.35,70,,6.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.33,,,1.33,Other,Drug Cost,1.33,,,1.33,Other,Drug Cost,1.33,,,1.33,Other,Drug Cost,1.33,,,1.33,Other,Drug Cost,1.33,,,1.33,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.33,,,1.33,Other,Drug Cost,2.99,,,2.99,Other,225% Medicaid APG methodology,1.86,,,1.86,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.33,,,1.33,Other,Drug Cost,1.33,,,1.33,Other,Drug Cost,1.66,,,1.66,Other,125% Medicaid APG methodology,0.01,6.35,
LEVETIRACETAM 250 MG TAB        ,,,,40527046,CDM,250,RC,00904-7123-61,NDC,both,1,EA,0.6,0.24,39.4668,,0.24,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.18,30,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.18,30,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.18,30,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.3,50,,0.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.32,,,0.32,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.42,70,,0.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,Drug Cost,0.38,,,0.38,Other,225% Medicaid APG methodology,0.24,,,0.24,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.21,,,0.21,Other,125% Medicaid APG methodology,0.01,0.42,
LEVETIRACETAM 500 MG TAB        ,,,,40527053,CDM,250,RC,31722-0537-12,NDC,both,1,EA,0.28,0.11,39.4668,,0.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.14,50,,0.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,70,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.2,
SULFASALAZINE 500 MG DR TAB     ,,,,40527061,CDM,250,RC,59762-0104-01,NDC,both,1,EA,0.67,0.26,39.4668,,0.26,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,30,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.2,30,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.2,30,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.34,50,,0.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.47,70,,0.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.2,,,0.2,Other,225% Medicaid APG methodology,0.13,,,0.13,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,0.47,
ALBUTEROL 5MG/ML(0.5%)INH 20ML  ,,,,40527079,CDM,250,RC,50383-0741-20,NDC,both,20,ML,156.17,61.64,39.4668,,61.64,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,46.85,30,,46.85,percent of total billed charges,"Drugs, Inpatient Only",46.85,30,,46.85,percent of total billed charges,"Drugs, Inpatient Only",46.85,30,,46.85,percent of total billed charges,"Drugs, Inpatient Only",78.09,50,,78.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.33,,,0.33,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,109.32,70,,109.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.18,,,0.18,Other,Drug Cost,0.41,,,0.41,Other,225% Medicaid APG methodology,0.25,,,0.25,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.23,,,0.23,Other,125% Medicaid APG methodology,0.01,109.32,
ALBUTEROL 2.5MG/3ML(0.083%)NEB  ,,,,40527087,CDM,250,RC,60687-0395-83,NDC,both,3,ML,0.56,0.22,39.4668,,0.22,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.28,50,,0.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.39,70,,0.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.16,,,0.16,Other,Drug Cost,0.36,,,0.36,Other,225% Medicaid APG methodology,0.22,,,0.22,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.2,,,0.2,Other,125% Medicaid APG methodology,0.01,0.39,
ISONIAZID 300 MG TAB            ,,,,40527129,CDM,250,RC,51079-0083-20,NDC,both,1,EA,3.15,1.24,39.4668,,1.24,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.95,30,,0.95,percent of total billed charges,"Drugs, Inpatient Only",0.95,30,,0.95,percent of total billed charges,"Drugs, Inpatient Only",0.95,30,,0.95,percent of total billed charges,"Drugs, Inpatient Only",1.58,50,,1.58,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.21,70,,2.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.23,,,0.23,Other,225% Medicaid APG methodology,0.14,,,0.14,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.13,,,0.13,Other,125% Medicaid APG methodology,0.01,2.21,
PYRAZINAMIDE 500 MG TAB         ,,,,40527137,CDM,250,RC,60687-0789-01,NDC,both,1,EA,18.87,7.45,39.4668,,7.45,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.66,30,,5.66,percent of total billed charges,"Drugs, Inpatient Only",5.66,30,,5.66,percent of total billed charges,"Drugs, Inpatient Only",5.66,30,,5.66,percent of total billed charges,"Drugs, Inpatient Only",9.44,50,,9.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.48,,,8.48,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.21,70,,13.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.56,,,4.56,Other,Drug Cost,4.56,,,4.56,Other,Drug Cost,4.56,,,4.56,Other,Drug Cost,4.56,,,4.56,Other,Drug Cost,4.56,,,4.56,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.56,,,4.56,Other,Drug Cost,10.26,,,10.26,Other,225% Medicaid APG methodology,6.38,,,6.38,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.56,,,4.56,Other,Drug Cost,4.56,,,4.56,Other,Drug Cost,5.7,,,5.7,Other,125% Medicaid APG methodology,0.01,13.21,
ETHAMBUTOL 400 MG TAB           ,,,,40527152,CDM,250,RC,68850-0012-02,NDC,both,1,EA,2.52,0.99,39.4668,,0.99,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.76,30,,0.76,percent of total billed charges,"Drugs, Inpatient Only",0.76,30,,0.76,percent of total billed charges,"Drugs, Inpatient Only",0.76,30,,0.76,percent of total billed charges,"Drugs, Inpatient Only",1.26,50,,1.26,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.6,,,0.6,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.76,70,,1.76,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.32,,,0.32,Other,Drug Cost,0.72,,,0.72,Other,225% Medicaid APG methodology,0.45,,,0.45,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.4,,,0.4,Other,125% Medicaid APG methodology,0.01,1.76,
CELECOXIB 100 MG CAP            ,,,,40527251,CDM,250,RC,69097-0422-07,NDC,both,1,EA,0.56,0.22,39.4668,,0.22,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.28,50,,0.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.39,70,,0.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.2,,,0.2,Other,225% Medicaid APG methodology,0.13,,,0.13,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,0.39,
PHENAZOPYRIDINE 100 MG TAB      ,,,,40527277,CDM,250,RC,75826-0114-10,NDC,both,1,EA,1.44,0.57,39.4668,,0.57,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.43,30,,0.43,percent of total billed charges,"Drugs, Inpatient Only",0.43,30,,0.43,percent of total billed charges,"Drugs, Inpatient Only",0.43,30,,0.43,percent of total billed charges,"Drugs, Inpatient Only",0.72,50,,0.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.36,,,1.36,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.01,70,,1.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.73,,,0.73,Other,Drug Cost,0.73,,,0.73,Other,Drug Cost,0.73,,,0.73,Other,Drug Cost,0.73,,,0.73,Other,Drug Cost,0.73,,,0.73,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.73,,,0.73,Other,Drug Cost,1.64,,,1.64,Other,225% Medicaid APG methodology,1.02,,,1.02,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.73,,,0.73,Other,Drug Cost,0.73,,,0.73,Other,Drug Cost,0.91,,,0.91,Other,125% Medicaid APG methodology,0.01,1.64,
FLUCONAZOLE 100 MG TAB          ,,,,40527285,CDM,250,RC,00904-6500-61,NDC,both,1,EA,3.78,1.49,39.4668,,1.49,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.13,30,,1.13,percent of total billed charges,"Drugs, Inpatient Only",1.13,30,,1.13,percent of total billed charges,"Drugs, Inpatient Only",1.13,30,,1.13,percent of total billed charges,"Drugs, Inpatient Only",1.89,50,,1.89,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.13,,,1.13,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.65,70,,2.65,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.61,,,0.61,Other,Drug Cost,0.61,,,0.61,Other,Drug Cost,0.61,,,0.61,Other,Drug Cost,0.61,,,0.61,Other,Drug Cost,0.61,,,0.61,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.61,,,0.61,Other,Drug Cost,1.37,,,1.37,Other,225% Medicaid APG methodology,0.85,,,0.85,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.61,,,0.61,Other,Drug Cost,0.61,,,0.61,Other,Drug Cost,0.76,,,0.76,Other,125% Medicaid APG methodology,0.01,2.65,
FLUCONAZOLE 50 MG TAB           ,,,,40527293,CDM,250,RC,68462-0101-30,NDC,both,1,EA,1.86,0.73,39.4668,,0.73,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.56,30,,0.56,percent of total billed charges,"Drugs, Inpatient Only",0.56,30,,0.56,percent of total billed charges,"Drugs, Inpatient Only",0.56,30,,0.56,percent of total billed charges,"Drugs, Inpatient Only",0.93,50,,0.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.3,70,,1.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.29,,,0.29,Other,225% Medicaid APG methodology,0.18,,,0.18,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.16,,,0.16,Other,125% Medicaid APG methodology,0.01,1.3,
TRIMETHOPRIM 100 MG TAB         ,,,,40527301,CDM,250,RC,43386-0330-01,NDC,both,1,EA,0.77,0.3,39.4668,,0.3,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.23,30,,0.23,percent of total billed charges,"Drugs, Inpatient Only",0.23,30,,0.23,percent of total billed charges,"Drugs, Inpatient Only",0.23,30,,0.23,percent of total billed charges,"Drugs, Inpatient Only",0.39,50,,0.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.54,70,,0.54,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.23,,,0.23,Other,225% Medicaid APG methodology,0.14,,,0.14,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.13,,,0.13,Other,125% Medicaid APG methodology,0.01,0.54,
IPRATROPIUM 17 MCG/INH 12.9 G   ,,,,40527327,CDM,250,RC,00597-0087-17,NDC,both,12.9,GM,1284.54,506.97,39.4668,,506.97,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,385.36,30,,385.36,percent of total billed charges,"Drugs, Inpatient Only",385.36,30,,385.36,percent of total billed charges,"Drugs, Inpatient Only",385.36,30,,385.36,percent of total billed charges,"Drugs, Inpatient Only",642.27,50,,642.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,899.18,70,,899.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.29,,,0.29,Other,225% Medicaid APG methodology,0.18,,,0.18,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.16,,,0.16,Other,125% Medicaid APG methodology,0.01,899.18,
NYSTATIN 100000UNIT/ML ORL5ML   ,,,,40527368,CDM,250,RC,60687-0800-17,NDC,both,5,ML,5.95,2.35,39.4668,,2.35,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.79,30,,1.79,percent of total billed charges,"Drugs, Inpatient Only",1.79,30,,1.79,percent of total billed charges,"Drugs, Inpatient Only",1.79,30,,1.79,percent of total billed charges,"Drugs, Inpatient Only",2.98,50,,2.98,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.77,,,2.77,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.17,70,,4.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.49,,,1.49,Other,Drug Cost,3.35,,,3.35,Other,225% Medicaid APG methodology,2.09,,,2.09,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,1.86,,,1.86,Other,125% Medicaid APG methodology,0.01,4.17,
FLUCYTOSINE 500 MG CAP          ,,,,40527384,CDM,250,RC,00904-6835-07,NDC,both,1,EA,432.85,170.83,39.4668,,170.83,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,129.86,30,,129.86,percent of total billed charges,"Drugs, Inpatient Only",129.86,30,,129.86,percent of total billed charges,"Drugs, Inpatient Only",129.86,30,,129.86,percent of total billed charges,"Drugs, Inpatient Only",216.43,50,,216.43,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,223.57,,,223.57,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,303,70,,303,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,120.2,,,120.2,Other,Drug Cost,120.2,,,120.2,Other,Drug Cost,120.2,,,120.2,Other,Drug Cost,120.2,,,120.2,Other,Drug Cost,120.2,,,120.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,120.2,,,120.2,Other,Drug Cost,270.45,,,270.45,Other,225% Medicaid APG methodology,168.28,,,168.28,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,120.2,,,120.2,Other,Drug Cost,120.2,,,120.2,Other,Drug Cost,150.25,,,150.25,Other,125% Medicaid APG methodology,0.01,303,
KETOCONAZOLE 200 MG TAB         ,,,,40527400,CDM,250,RC,64380-0827-06,NDC,both,1,EA,3.5,1.38,39.4668,,1.38,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.05,30,,1.05,percent of total billed charges,"Drugs, Inpatient Only",1.05,30,,1.05,percent of total billed charges,"Drugs, Inpatient Only",1.05,30,,1.05,percent of total billed charges,"Drugs, Inpatient Only",1.75,50,,1.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.08,,,1.08,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.45,70,,2.45,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.58,,,0.58,Other,Drug Cost,0.58,,,0.58,Other,Drug Cost,0.58,,,0.58,Other,Drug Cost,0.58,,,0.58,Other,Drug Cost,0.58,,,0.58,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.58,,,0.58,Other,Drug Cost,1.31,,,1.31,Other,225% Medicaid APG methodology,0.81,,,0.81,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.58,,,0.58,Other,Drug Cost,0.58,,,0.58,Other,Drug Cost,0.73,,,0.73,Other,125% Medicaid APG methodology,0.01,2.45,
QUININE 324 MG CAP              ,,,,40527434,CDM,250,RC,68180-0560-06,NDC,both,1,EA,6.93,2.74,39.4668,,2.74,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.08,30,,2.08,percent of total billed charges,"Drugs, Inpatient Only",2.08,30,,2.08,percent of total billed charges,"Drugs, Inpatient Only",2.08,30,,2.08,percent of total billed charges,"Drugs, Inpatient Only",3.47,50,,3.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.89,,,0.89,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.85,70,,4.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.48,,,0.48,Other,Drug Cost,1.08,,,1.08,Other,225% Medicaid APG methodology,0.67,,,0.67,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.6,,,0.6,Other,125% Medicaid APG methodology,0.01,4.85,
STERILE WATER INJ SOLN 10 ML    ,,,,40527442,CDM,250,RC,63323-0185-10,NDC,both,10,ML,11.34,4.48,39.4668,,4.48,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.4,30,,3.4,percent of total billed charges,"Drugs, Inpatient Only",3.4,30,,3.4,percent of total billed charges,"Drugs, Inpatient Only",3.4,30,,3.4,percent of total billed charges,"Drugs, Inpatient Only",5.67,50,,5.67,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.08,,,2.08,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.94,70,,7.94,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.12,,,1.12,Other,Drug Cost,1.12,,,1.12,Other,Drug Cost,1.12,,,1.12,Other,Drug Cost,1.12,,,1.12,Other,Drug Cost,1.12,,,1.12,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.12,,,1.12,Other,Drug Cost,2.52,,,2.52,Other,225% Medicaid APG methodology,1.57,,,1.57,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.12,,,1.12,Other,Drug Cost,1.12,,,1.12,Other,Drug Cost,1.4,,,1.4,Other,125% Medicaid APG methodology,0.01,7.94,
CHLOROQUINE 500 MG TAB          ,,,,40527467,CDM,250,RC,00143-2125-22,NDC,both,1,EA,14.18,5.6,39.4668,,5.6,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.25,30,,4.25,percent of total billed charges,"Drugs, Inpatient Only",4.25,30,,4.25,percent of total billed charges,"Drugs, Inpatient Only",4.25,30,,4.25,percent of total billed charges,"Drugs, Inpatient Only",7.09,50,,7.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.44,,,7.44,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.93,70,,9.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4,,,4,Other,Drug Cost,4,,,4,Other,Drug Cost,4,,,4,Other,Drug Cost,4,,,4,Other,Drug Cost,4,,,4,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4,,,4,Other,Drug Cost,9,,,9,Other,225% Medicaid APG methodology,5.6,,,5.6,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4,,,4,Other,Drug Cost,4,,,4,Other,Drug Cost,5,,,5,Other,125% Medicaid APG methodology,0.01,9.93,
PRIMAQUINE 26.3MG TAB           ,,,,40527483,CDM,250,RC,00024-1596-01,NDC,both,1,EA,6.65,2.62,39.4668,,2.62,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2,30,,2,percent of total billed charges,"Drugs, Inpatient Only",2,30,,2,percent of total billed charges,"Drugs, Inpatient Only",2,30,,2,percent of total billed charges,"Drugs, Inpatient Only",3.33,50,,3.33,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.82,,,0.82,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.66,70,,4.66,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.44,,,0.44,Other,Drug Cost,0.44,,,0.44,Other,Drug Cost,0.44,,,0.44,Other,Drug Cost,0.44,,,0.44,Other,Drug Cost,0.44,,,0.44,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.44,,,0.44,Other,Drug Cost,0.99,,,0.99,Other,225% Medicaid APG methodology,0.62,,,0.62,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.44,,,0.44,Other,Drug Cost,0.44,,,0.44,Other,Drug Cost,0.55,,,0.55,Other,125% Medicaid APG methodology,0.01,4.66,
HYDROXYCHLOROQUINE 200 MG TAB   ,,,,40527517,CDM,250,RC,66993-0057-02,NDC,both,1,EA,3.92,1.55,39.4668,,1.55,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.18,30,,1.18,percent of total billed charges,"Drugs, Inpatient Only",1.18,30,,1.18,percent of total billed charges,"Drugs, Inpatient Only",1.18,30,,1.18,percent of total billed charges,"Drugs, Inpatient Only",1.96,50,,1.96,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.74,70,,2.74,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,Drug Cost,0.32,,,0.32,Other,225% Medicaid APG methodology,0.2,,,0.2,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.18,,,0.18,Other,125% Medicaid APG methodology,0.01,2.74,
PENTAMIDINE 300 MG INJ          ,,,,40527533,CDM,250,RC,63323-0113-10,NDC,both,1,EA,373.98,147.6,39.4668,,147.6,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,112.19,30,,112.19,percent of total billed charges,"Drugs, Inpatient Only",112.19,30,,112.19,percent of total billed charges,"Drugs, Inpatient Only",112.19,30,,112.19,percent of total billed charges,"Drugs, Inpatient Only",186.99,50,,186.99,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,96.76,,,96.76,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,261.79,70,,261.79,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,52.02,,,52.02,Other,Drug Cost,52.02,,,52.02,Other,Drug Cost,52.02,,,52.02,Other,Drug Cost,52.02,,,52.02,Other,Drug Cost,52.02,,,52.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,52.02,,,52.02,Other,Drug Cost,117.05,,,117.05,Other,225% Medicaid APG methodology,72.83,,,72.83,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,52.02,,,52.02,Other,Drug Cost,52.02,,,52.02,Other,Drug Cost,65.03,,,65.03,Other,125% Medicaid APG methodology,0.01,261.79,
METRONIDAZOLE 250 MG TAB        ,,,,40527582,CDM,250,RC,00904-1453-61,NDC,both,1,EA,0.74,0.29,39.4668,,0.29,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,30,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.22,30,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.22,30,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.37,50,,0.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.52,70,,0.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.2,,,0.2,Other,225% Medicaid APG methodology,0.13,,,0.13,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,0.52,
DAPSONE 25 MG TAB               ,,,,40527640,CDM,250,RC,49938-0102-30,NDC,both,1,EA,7.42,2.93,39.4668,,2.93,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.23,30,,2.23,percent of total billed charges,"Drugs, Inpatient Only",2.23,30,,2.23,percent of total billed charges,"Drugs, Inpatient Only",2.23,30,,2.23,percent of total billed charges,"Drugs, Inpatient Only",3.71,50,,3.71,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4,,,4,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.19,70,,5.19,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.15,,,2.15,Other,Drug Cost,2.15,,,2.15,Other,Drug Cost,2.15,,,2.15,Other,Drug Cost,2.15,,,2.15,Other,Drug Cost,2.15,,,2.15,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.15,,,2.15,Other,Drug Cost,4.84,,,4.84,Other,225% Medicaid APG methodology,3.01,,,3.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.15,,,2.15,Other,Drug Cost,2.15,,,2.15,Other,Drug Cost,2.69,,,2.69,Other,125% Medicaid APG methodology,0.01,5.19,
ACYCLOVIR 200 MG CAP            ,,,,40527905,CDM,250,RC,00904-5789-61,NDC,both,1,EA,0.46,0.18,39.4668,,0.18,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.14,30,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,30,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,30,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.23,50,,0.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.32,70,,0.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.2,,,0.2,Other,225% Medicaid APG methodology,0.13,,,0.13,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,0.32,
TUBERCULIN PPD 5 UN/0.1ML 1ML   ,,,,40528028,CDM,250,RC,42023-0104-01,NDC,both,0.1,ML,264.11,104.24,39.4668,,104.24,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,79.23,30,,79.23,percent of total billed charges,"Drugs, Inpatient Only",79.23,30,,79.23,percent of total billed charges,"Drugs, Inpatient Only",79.23,30,,79.23,percent of total billed charges,"Drugs, Inpatient Only",132.06,50,,132.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,140.36,,,140.36,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,184.88,70,,184.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,75.46,,,75.46,Other,Drug Cost,75.46,,,75.46,Other,Drug Cost,75.46,,,75.46,Other,Drug Cost,75.46,,,75.46,Other,Drug Cost,75.46,,,75.46,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,75.46,,,75.46,Other,Drug Cost,169.79,,,169.79,Other,225% Medicaid APG methodology,105.64,,,105.64,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,75.46,,,75.46,Other,Drug Cost,75.46,,,75.46,Other,Drug Cost,94.33,,,94.33,Other,125% Medicaid APG methodology,0.01,184.88,
PERMETHRIN 1% LOTION 60 ML      ,,,,40528127,CDM,250,RC,63736-0120-02,NDC,both,60,ML,31.5,12.43,39.4668,,12.43,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.45,30,,9.45,percent of total billed charges,"Drugs, Inpatient Only",9.45,30,,9.45,percent of total billed charges,"Drugs, Inpatient Only",9.45,30,,9.45,percent of total billed charges,"Drugs, Inpatient Only",15.75,50,,15.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,16.74,,,16.74,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,22.05,70,,22.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9,,,9,Other,Drug Cost,9,,,9,Other,Drug Cost,9,,,9,Other,Drug Cost,9,,,9,Other,Drug Cost,9,,,9,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,9,,,9,Other,Drug Cost,20.25,,,20.25,Other,225% Medicaid APG methodology,12.6,,,12.6,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,9,,,9,Other,Drug Cost,9,,,9,Other,Drug Cost,11.25,,,11.25,Other,125% Medicaid APG methodology,0.01,22.05,
ZIDOVUDINE 100 MG CAP           ,,,,40528135,CDM,250,RC,65862-0107-01,NDC,both,1,EA,3.4,1.34,39.4668,,1.34,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.02,30,,1.02,percent of total billed charges,"Drugs, Inpatient Only",1.02,30,,1.02,percent of total billed charges,"Drugs, Inpatient Only",1.02,30,,1.02,percent of total billed charges,"Drugs, Inpatient Only",1.7,50,,1.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.87,,,0.87,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.38,70,,2.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.47,,,0.47,Other,Drug Cost,1.06,,,1.06,Other,225% Medicaid APG methodology,0.66,,,0.66,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.59,,,0.59,Other,125% Medicaid APG methodology,0.01,2.38,
SOD HYPOCHL 0.5% TOP SLN 473ML  ,,,,40528259,CDM,250,RC,39328-0062-50,NDC,both,473,ML,33.11,13.07,39.4668,,13.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.93,30,,9.93,percent of total billed charges,"Drugs, Inpatient Only",9.93,30,,9.93,percent of total billed charges,"Drugs, Inpatient Only",9.93,30,,9.93,percent of total billed charges,"Drugs, Inpatient Only",16.56,50,,16.56,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,17.6,,,17.6,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,23.18,70,,23.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.46,,,9.46,Other,Drug Cost,9.46,,,9.46,Other,Drug Cost,9.46,,,9.46,Other,Drug Cost,9.46,,,9.46,Other,Drug Cost,9.46,,,9.46,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,9.46,,,9.46,Other,Drug Cost,21.29,,,21.29,Other,225% Medicaid APG methodology,13.24,,,13.24,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,9.46,,,9.46,Other,Drug Cost,9.46,,,9.46,Other,Drug Cost,11.83,,,11.83,Other,125% Medicaid APG methodology,0.01,23.18,
PROPRANOLOL 20MG/5ML ORL5ML UD  ,,,,40528275,CDM,250,RC,00054-3727-63,NDC,both,5,ML,1.58,0.62,39.4668,,0.62,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.47,30,,0.47,percent of total billed charges,"Drugs, Inpatient Only",0.47,30,,0.47,percent of total billed charges,"Drugs, Inpatient Only",0.47,30,,0.47,percent of total billed charges,"Drugs, Inpatient Only",0.79,50,,0.79,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.56,,,0.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.11,70,,1.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.68,,,0.68,Other,225% Medicaid APG methodology,0.42,,,0.42,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.38,,,0.38,Other,125% Medicaid APG methodology,0.01,1.11,
STERILE WATER IRRIGAT  1000ML   ,,,,40528325,CDM,250,RC,00338-0004-04,NDC,both,1000,ML,9.91,3.91,39.4668,,3.91,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.97,30,,2.97,percent of total billed charges,"Drugs, Inpatient Only",2.97,30,,2.97,percent of total billed charges,"Drugs, Inpatient Only",2.97,30,,2.97,percent of total billed charges,"Drugs, Inpatient Only",4.96,50,,4.96,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.15,,,5.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.94,70,,6.94,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.77,,,2.77,Other,Drug Cost,2.77,,,2.77,Other,Drug Cost,2.77,,,2.77,Other,Drug Cost,2.77,,,2.77,Other,Drug Cost,2.77,,,2.77,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.77,,,2.77,Other,Drug Cost,6.23,,,6.23,Other,225% Medicaid APG methodology,3.88,,,3.88,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.77,,,2.77,Other,Drug Cost,2.77,,,2.77,Other,Drug Cost,3.46,,,3.46,Other,125% Medicaid APG methodology,0.01,6.94,
STERILE WATER IRRIGAT  3000ML   ,,,,40528366,CDM,250,RC,00338-0003-47,NDC,both,3000,ML,33.92,13.39,39.4668,,13.39,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.18,30,,10.18,percent of total billed charges,"Drugs, Inpatient Only",10.18,30,,10.18,percent of total billed charges,"Drugs, Inpatient Only",10.18,30,,10.18,percent of total billed charges,"Drugs, Inpatient Only",16.96,50,,16.96,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,23.44,,,23.44,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,23.74,70,,23.74,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.6,,,12.6,Other,Drug Cost,12.6,,,12.6,Other,Drug Cost,12.6,,,12.6,Other,Drug Cost,12.6,,,12.6,Other,Drug Cost,12.6,,,12.6,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,12.6,,,12.6,Other,Drug Cost,28.35,,,28.35,Other,225% Medicaid APG methodology,17.64,,,17.64,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,12.6,,,12.6,Other,Drug Cost,12.6,,,12.6,Other,Drug Cost,15.75,,,15.75,Other,125% Medicaid APG methodology,0.01,28.35,
SOD CHLORIDE 0.9% IRRIG 3000ML  ,,,,40528374,CDM,250,RC,00338-0047-47,NDC,both,3000,ML,94.5,37.3,39.4668,,37.3,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,28.35,30,,28.35,percent of total billed charges,"Drugs, Inpatient Only",28.35,30,,28.35,percent of total billed charges,"Drugs, Inpatient Only",28.35,30,,28.35,percent of total billed charges,"Drugs, Inpatient Only",47.25,50,,47.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.16,,,11.16,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,66.15,70,,66.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6,,,6,Other,Drug Cost,6,,,6,Other,Drug Cost,6,,,6,Other,Drug Cost,6,,,6,Other,Drug Cost,6,,,6,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,6,,,6,Other,Drug Cost,13.5,,,13.5,Other,225% Medicaid APG methodology,8.4,,,8.4,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6,,,6,Other,Drug Cost,6,,,6,Other,Drug Cost,7.5,,,7.5,Other,125% Medicaid APG methodology,0.01,66.15,
SOD CHL 0.9% IRRIGATION 1000ML  ,,,,40528382,CDM,250,RC,00338-0048-04,NDC,both,1000,ML,10.82,4.27,39.4668,,4.27,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.25,30,,3.25,percent of total billed charges,"Drugs, Inpatient Only",3.25,30,,3.25,percent of total billed charges,"Drugs, Inpatient Only",3.25,30,,3.25,percent of total billed charges,"Drugs, Inpatient Only",5.41,50,,5.41,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.84,,,5.84,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.57,70,,7.57,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.14,,,3.14,Other,Drug Cost,3.14,,,3.14,Other,Drug Cost,3.14,,,3.14,Other,Drug Cost,3.14,,,3.14,Other,Drug Cost,3.14,,,3.14,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.14,,,3.14,Other,Drug Cost,7.07,,,7.07,Other,225% Medicaid APG methodology,4.4,,,4.4,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.14,,,3.14,Other,Drug Cost,3.14,,,3.14,Other,Drug Cost,3.93,,,3.93,Other,125% Medicaid APG methodology,0.01,7.57,
ACETIC ACID 0.25% IRRG  1000ML  ,,,,40528390,CDM,250,RC,00409-6143-09,NDC,both,1000,ML,14,5.53,39.4668,,5.53,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.2,30,,4.2,percent of total billed charges,"Drugs, Inpatient Only",4.2,30,,4.2,percent of total billed charges,"Drugs, Inpatient Only",4.2,30,,4.2,percent of total billed charges,"Drugs, Inpatient Only",7,50,,7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.86,,,1.86,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.8,70,,9.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1,,,1,Other,Drug Cost,2.25,,,2.25,Other,225% Medicaid APG methodology,1.4,,,1.4,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1.25,,,1.25,Other,125% Medicaid APG methodology,0.01,9.8,
DIPHENHYDRAMINE 25 MG CAP       ,,,,40528499,CDM,250,RC,00536-1010-01,NDC,both,1,EA,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.04,50,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.05,
DIPHENHYDRAMINE 50 MG CAP       ,,,,40528507,CDM,250,RC,00904-2056-61,NDC,both,1,EA,0.14,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.07,50,,0.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.1,
FAMOTIDINE 20 MG TAB            ,,,,40528606,CDM,250,RC,50268-0299-15,NDC,both,1,EA,0.35,0.14,39.4668,,0.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.18,50,,0.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,70,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.23,,,0.23,Other,225% Medicaid APG methodology,0.14,,,0.14,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.13,,,0.13,Other,125% Medicaid APG methodology,0.01,0.25,
CIPROFLOXACIN 250 MG TAB        ,,,,40528812,CDM,250,RC,65862-0076-01,NDC,both,1,EA,47.08,18.58,39.4668,,18.58,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.12,30,,14.12,percent of total billed charges,"Drugs, Inpatient Only",14.12,30,,14.12,percent of total billed charges,"Drugs, Inpatient Only",14.12,30,,14.12,percent of total billed charges,"Drugs, Inpatient Only",23.54,50,,23.54,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,32.96,70,,32.96,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,32.96,
CIPROFLOXACIN 500 MG TAB        ,,,,40528820,CDM,250,RC,61442-0223-01,NDC,both,1,EA,0.98,0.39,39.4668,,0.39,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.49,50,,0.49,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.5,,,0.5,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.69,70,,0.69,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.27,,,0.27,Other,Drug Cost,0.61,,,0.61,Other,225% Medicaid APG methodology,0.38,,,0.38,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.34,,,0.34,Other,125% Medicaid APG methodology,0.01,0.69,
TERAZOSIN 1 MG CAP              ,,,,40528846,CDM,250,RC,59746-0383-06,NDC,both,1,EA,0.49,0.19,39.4668,,0.19,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.25,50,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.34,70,,0.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.34,
TERAZOSIN 2 MG CAP              ,,,,40528853,CDM,250,RC,59746-0384-06,NDC,both,1,EA,0.6,0.24,39.4668,,0.24,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.18,30,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.18,30,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.18,30,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.3,50,,0.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.42,70,,0.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.42,
TERAZOSIN 5 MG CAP              ,,,,40528861,CDM,250,RC,59746-0385-06,NDC,both,1,EA,0.6,0.24,39.4668,,0.24,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.18,30,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.18,30,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.18,30,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.3,50,,0.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.42,70,,0.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.42,
FLUOXETINE 20 MG CAP            ,,,,40528895,CDM,250,RC,65862-0193-01,NDC,both,1,EA,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.04,50,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.05,
LISINOPRIL 5 MG TAB             ,,,,40528903,CDM,250,RC,68180-0513-01,NDC,both,1,EA,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.02,50,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.03,
LISINOPRIL 2.5 MG TAB           ,,,,40528929,CDM,250,RC,68084-0765-25,NDC,both,1,EA,1.82,0.72,39.4668,,0.72,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.55,30,,0.55,percent of total billed charges,"Drugs, Inpatient Only",0.55,30,,0.55,percent of total billed charges,"Drugs, Inpatient Only",0.55,30,,0.55,percent of total billed charges,"Drugs, Inpatient Only",0.91,50,,0.91,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.74,,,0.74,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.27,70,,1.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.4,,,0.4,Other,Drug Cost,0.4,,,0.4,Other,Drug Cost,0.4,,,0.4,Other,Drug Cost,0.4,,,0.4,Other,Drug Cost,0.4,,,0.4,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.4,,,0.4,Other,Drug Cost,0.9,,,0.9,Other,225% Medicaid APG methodology,0.56,,,0.56,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.4,,,0.4,Other,Drug Cost,0.4,,,0.4,Other,Drug Cost,0.5,,,0.5,Other,125% Medicaid APG methodology,0.01,1.27,
MESALAMINE 4 G/60ML ENEMA 60ML  ,,,,40528937,CDM,250,RC,45802-0098-51,NDC,both,60,ML,25.2,9.95,39.4668,,9.95,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.56,30,,7.56,percent of total billed charges,"Drugs, Inpatient Only",7.56,30,,7.56,percent of total billed charges,"Drugs, Inpatient Only",7.56,30,,7.56,percent of total billed charges,"Drugs, Inpatient Only",12.6,50,,12.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.7,,,6.7,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,17.64,70,,17.64,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.6,,,3.6,Other,Drug Cost,3.6,,,3.6,Other,Drug Cost,3.6,,,3.6,Other,Drug Cost,3.6,,,3.6,Other,Drug Cost,3.6,,,3.6,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.6,,,3.6,Other,Drug Cost,8.1,,,8.1,Other,225% Medicaid APG methodology,5.04,,,5.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.6,,,3.6,Other,Drug Cost,3.6,,,3.6,Other,Drug Cost,4.5,,,4.5,Other,125% Medicaid APG methodology,0.01,17.64,
CEFUROXIME 250 MG TAB           ,,,,40528945,CDM,250,RC,68180-0302-60,NDC,both,1,EA,5.5,2.17,39.4668,,2.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.65,30,,1.65,percent of total billed charges,"Drugs, Inpatient Only",1.65,30,,1.65,percent of total billed charges,"Drugs, Inpatient Only",1.65,30,,1.65,percent of total billed charges,"Drugs, Inpatient Only",2.75,50,,2.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.85,70,,3.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% Medicaid APG methodology,0.11,,,0.11,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,3.85,
MUPIROCIN 2% OINTMENT 22 G      ,,,,40528952,CDM,250,RC,51672-1312-00,NDC,both,22,GM,15.4,6.08,39.4668,,6.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.62,30,,4.62,percent of total billed charges,"Drugs, Inpatient Only",4.62,30,,4.62,percent of total billed charges,"Drugs, Inpatient Only",4.62,30,,4.62,percent of total billed charges,"Drugs, Inpatient Only",7.7,50,,7.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.68,,,3.68,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.78,70,,10.78,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.98,,,1.98,Other,Drug Cost,1.98,,,1.98,Other,Drug Cost,1.98,,,1.98,Other,Drug Cost,1.98,,,1.98,Other,Drug Cost,1.98,,,1.98,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.98,,,1.98,Other,Drug Cost,4.46,,,4.46,Other,225% Medicaid APG methodology,2.77,,,2.77,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.98,,,1.98,Other,Drug Cost,1.98,,,1.98,Other,Drug Cost,2.48,,,2.48,Other,125% Medicaid APG methodology,0.01,10.78,
MYCOPHENOLATE MOFETIL 500MG IV  ,J7519,HCPCS,,40528994,CDM,250,RC,42023-0172-04,NDC,both,1,EA,223.69,7.17,,,7.17,Other,150% of Medicare + 9.63% HCRA Surcharge,4.36,,,4.36,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,67.11,30,,67.11,percent of total billed charges,"Drugs, Inpatient Only",67.11,30,,67.11,percent of total billed charges,"Drugs, Inpatient Only",67.11,30,,67.11,percent of total billed charges,"Drugs, Inpatient Only",111.85,50,,111.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,79.05,,,79.05,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,156.58,70,,156.58,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,42.5,,,42.5,Other,Drug Cost,42.5,,,42.5,Other,Drug Cost,42.5,,,42.5,Other,Drug Cost,42.5,,,42.5,Other,Drug Cost,42.5,,,42.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,42.5,,,42.5,Other,Drug Cost,95.63,,,95.63,Other,225% Medicaid APG methodology,59.5,,,59.5,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,6.98,,,6.98,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,42.5,,,42.5,Other,Drug Cost,42.5,,,42.5,Other,Drug Cost,53.13,,,53.13,Other,125% Medicaid APG methodology,0.01,156.58,
ENALAPRILAT 1.25MG/ML IV  1ML   ,,,,40529000,CDM,250,RC,00143-9787-10,NDC,both,1,ML,11.69,4.61,39.4668,,4.61,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.51,30,,3.51,percent of total billed charges,"Drugs, Inpatient Only",3.51,30,,3.51,percent of total billed charges,"Drugs, Inpatient Only",3.51,30,,3.51,percent of total billed charges,"Drugs, Inpatient Only",5.85,50,,5.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.23,,,1.23,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.18,70,,8.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.66,,,0.66,Other,Drug Cost,0.66,,,0.66,Other,Drug Cost,0.66,,,0.66,Other,Drug Cost,0.66,,,0.66,Other,Drug Cost,0.66,,,0.66,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.66,,,0.66,Other,Drug Cost,1.49,,,1.49,Other,225% Medicaid APG methodology,0.92,,,0.92,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.66,,,0.66,Other,Drug Cost,0.66,,,0.66,Other,Drug Cost,0.83,,,0.83,Other,125% Medicaid APG methodology,0.01,8.18,
RAMIPRIL 1.25 MG CAP            ,,,,40529042,CDM,250,RC,65862-0474-01,NDC,both,1,EA,0.28,0.11,39.4668,,0.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.14,50,,0.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,70,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.2,
RAMIPRIL 2.5 MG CAP             ,,,,40529059,CDM,250,RC,65862-0475-01,NDC,both,1,EA,0.14,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.07,50,,0.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.1,
FLUOXETINE 20MG/5ML CUP         ,,,,40529075,CDM,250,RC,70954-0600-10,NDC,both,5,ML,3.5,1.38,39.4668,,1.38,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.05,30,,1.05,percent of total billed charges,"Drugs, Inpatient Only",1.05,30,,1.05,percent of total billed charges,"Drugs, Inpatient Only",1.05,30,,1.05,percent of total billed charges,"Drugs, Inpatient Only",1.75,50,,1.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.12,,,1.12,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.45,70,,2.45,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.6,,,0.6,Other,Drug Cost,1.35,,,1.35,Other,225% Medicaid APG methodology,0.84,,,0.84,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.75,,,0.75,Other,125% Medicaid APG methodology,0.01,2.45,
AZITHROMYCIN 250 MG TAB         ,,,,40529125,CDM,250,RC,00904-7350-61,NDC,both,1,EA,3.75,1.48,39.4668,,1.48,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.13,30,,1.13,percent of total billed charges,"Drugs, Inpatient Only",1.13,30,,1.13,percent of total billed charges,"Drugs, Inpatient Only",1.13,30,,1.13,percent of total billed charges,"Drugs, Inpatient Only",1.88,50,,1.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.53,,,2.53,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.63,70,,2.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.36,,,1.36,Other,Drug Cost,1.36,,,1.36,Other,Drug Cost,1.36,,,1.36,Other,Drug Cost,1.36,,,1.36,Other,Drug Cost,1.36,,,1.36,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.36,,,1.36,Other,Drug Cost,3.06,,,3.06,Other,225% Medicaid APG methodology,1.9,,,1.9,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.36,,,1.36,Other,Drug Cost,1.36,,,1.36,Other,Drug Cost,1.7,,,1.7,Other,125% Medicaid APG methodology,0.01,3.06,
CLARITHROMYCIN 250 MG TAB       ,,,,40529133,CDM,250,RC,50268-0178-15,NDC,both,1,EA,6.44,2.54,39.4668,,2.54,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.93,30,,1.93,percent of total billed charges,"Drugs, Inpatient Only",1.93,30,,1.93,percent of total billed charges,"Drugs, Inpatient Only",1.93,30,,1.93,percent of total billed charges,"Drugs, Inpatient Only",3.22,50,,3.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.06,,,5.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.51,70,,4.51,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.72,,,2.72,Other,Drug Cost,2.72,,,2.72,Other,Drug Cost,2.72,,,2.72,Other,Drug Cost,2.72,,,2.72,Other,Drug Cost,2.72,,,2.72,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.72,,,2.72,Other,Drug Cost,6.12,,,6.12,Other,225% Medicaid APG methodology,3.81,,,3.81,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.72,,,2.72,Other,Drug Cost,2.72,,,2.72,Other,Drug Cost,3.4,,,3.4,Other,125% Medicaid APG methodology,0.01,6.12,
LETROZOLE 2.5 MG TAB            ,,,,40529216,CDM,250,RC,51991-0759-33,NDC,both,1,EA,0.32,0.13,39.4668,,0.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.16,50,,0.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,70,,0.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.22,
CAFEINE-SOD BENZ 125-125MG/ML   ,,,,40529240,CDM,250,RC,00517-2502-10,NDC,both,2,ML,61.32,24.2,39.4668,,24.2,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,18.4,30,,18.4,percent of total billed charges,"Drugs, Inpatient Only",18.4,30,,18.4,percent of total billed charges,"Drugs, Inpatient Only",18.4,30,,18.4,percent of total billed charges,"Drugs, Inpatient Only",30.66,50,,30.66,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.47,,,6.47,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,42.92,70,,42.92,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.48,,,3.48,Other,Drug Cost,3.48,,,3.48,Other,Drug Cost,3.48,,,3.48,Other,Drug Cost,3.48,,,3.48,Other,Drug Cost,3.48,,,3.48,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.48,,,3.48,Other,Drug Cost,7.83,,,7.83,Other,225% Medicaid APG methodology,4.87,,,4.87,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.48,,,3.48,Other,Drug Cost,3.48,,,3.48,Other,Drug Cost,4.35,,,4.35,Other,125% Medicaid APG methodology,0.01,42.92,
OFLOXACIN 0.3% OPHTH SOLN 5 ML  ,,,,40529315,CDM,250,RC,64980-0515-05,NDC,both,5,ML,35.88,14.16,39.4668,,14.16,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.76,30,,10.76,percent of total billed charges,"Drugs, Inpatient Only",10.76,30,,10.76,percent of total billed charges,"Drugs, Inpatient Only",10.76,30,,10.76,percent of total billed charges,"Drugs, Inpatient Only",17.94,50,,17.94,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.09,,,12.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,25.12,70,,25.12,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.5,,,6.5,Other,Drug Cost,6.5,,,6.5,Other,Drug Cost,6.5,,,6.5,Other,Drug Cost,6.5,,,6.5,Other,Drug Cost,6.5,,,6.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,6.5,,,6.5,Other,Drug Cost,14.63,,,14.63,Other,225% Medicaid APG methodology,9.1,,,9.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.5,,,6.5,Other,Drug Cost,6.5,,,6.5,Other,Drug Cost,8.13,,,8.13,Other,125% Medicaid APG methodology,0.01,25.12,
ALBENDAZOLE 200 MG TAB          ,,,,40529364,CDM,250,RC,31722-0935-02,NDC,both,1,EA,355.43,140.28,39.4668,,140.28,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,106.63,30,,106.63,percent of total billed charges,"Drugs, Inpatient Only",106.63,30,,106.63,percent of total billed charges,"Drugs, Inpatient Only",106.63,30,,106.63,percent of total billed charges,"Drugs, Inpatient Only",177.72,50,,177.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.51,,,1.51,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,248.8,70,,248.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.81,,,0.81,Other,Drug Cost,0.81,,,0.81,Other,Drug Cost,0.81,,,0.81,Other,Drug Cost,0.81,,,0.81,Other,Drug Cost,0.81,,,0.81,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.81,,,0.81,Other,Drug Cost,1.82,,,1.82,Other,225% Medicaid APG methodology,1.13,,,1.13,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.81,,,0.81,Other,Drug Cost,0.81,,,0.81,Other,Drug Cost,1.01,,,1.01,Other,125% Medicaid APG methodology,0.01,248.8,
FLUTICASONE 110MCG/INH  12G     ,,,,40529372,CDM,250,RC,66993-0079-96,NDC,both,12,GM,520.63,205.48,39.4668,,205.48,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,156.19,30,,156.19,percent of total billed charges,"Drugs, Inpatient Only",156.19,30,,156.19,percent of total billed charges,"Drugs, Inpatient Only",156.19,30,,156.19,percent of total billed charges,"Drugs, Inpatient Only",260.32,50,,260.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,141.69,,,141.69,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,364.44,70,,364.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,76.18,,,76.18,Other,Drug Cost,76.18,,,76.18,Other,Drug Cost,76.18,,,76.18,Other,Drug Cost,76.18,,,76.18,Other,Drug Cost,76.18,,,76.18,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,76.18,,,76.18,Other,Drug Cost,171.41,,,171.41,Other,225% Medicaid APG methodology,106.65,,,106.65,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,76.18,,,76.18,Other,Drug Cost,76.18,,,76.18,Other,Drug Cost,95.23,,,95.23,Other,125% Medicaid APG methodology,0.01,364.44,
RALOXIFENE 60 MG TAB            ,,,,40529513,CDM,250,RC,50268-0694-15,NDC,both,1,EA,7.35,2.9,39.4668,,2.9,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.21,30,,2.21,percent of total billed charges,"Drugs, Inpatient Only",2.21,30,,2.21,percent of total billed charges,"Drugs, Inpatient Only",2.21,30,,2.21,percent of total billed charges,"Drugs, Inpatient Only",3.68,50,,3.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.38,,,5.38,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.15,70,,5.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.89,,,2.89,Other,Drug Cost,2.89,,,2.89,Other,Drug Cost,2.89,,,2.89,Other,Drug Cost,2.89,,,2.89,Other,Drug Cost,2.89,,,2.89,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.89,,,2.89,Other,Drug Cost,6.5,,,6.5,Other,225% Medicaid APG methodology,4.05,,,4.05,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.89,,,2.89,Other,Drug Cost,2.89,,,2.89,Other,Drug Cost,3.61,,,3.61,Other,125% Medicaid APG methodology,0.01,6.5,
TERBINAFINE 250 MG TAB          ,,,,40529547,CDM,250,RC,69097-0859-02,NDC,both,1,EA,0.35,0.14,39.4668,,0.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.18,50,,0.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,70,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.25,
OPT IRRIGA (BALSALTSLN) 15ML    ,,,,40529570,CDM,250,RC,00065-0795-15,NDC,both,15,ML,18.38,7.25,39.4668,,7.25,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.51,30,,5.51,percent of total billed charges,"Drugs, Inpatient Only",5.51,30,,5.51,percent of total billed charges,"Drugs, Inpatient Only",5.51,30,,5.51,percent of total billed charges,"Drugs, Inpatient Only",9.19,50,,9.19,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.56,,,0.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.87,70,,12.87,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.68,,,0.68,Other,225% Medicaid APG methodology,0.42,,,0.42,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.38,,,0.38,Other,125% Medicaid APG methodology,0.01,12.87,
FLUTICASONE 50MCG/INH NAS 16G   ,,,,40529588,CDM,250,RC,60505-0829-01,NDC,both,16,GM,11.76,4.64,39.4668,,4.64,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.53,30,,3.53,percent of total billed charges,"Drugs, Inpatient Only",3.53,30,,3.53,percent of total billed charges,"Drugs, Inpatient Only",3.53,30,,3.53,percent of total billed charges,"Drugs, Inpatient Only",5.88,50,,5.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.76,,,4.76,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.23,70,,8.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.56,,,2.56,Other,Drug Cost,2.56,,,2.56,Other,Drug Cost,2.56,,,2.56,Other,Drug Cost,2.56,,,2.56,Other,Drug Cost,2.56,,,2.56,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.56,,,2.56,Other,Drug Cost,5.76,,,5.76,Other,225% Medicaid APG methodology,3.58,,,3.58,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.56,,,2.56,Other,Drug Cost,2.56,,,2.56,Other,Drug Cost,3.2,,,3.2,Other,125% Medicaid APG methodology,0.01,8.23,
CARBID-LEVO 10MG-100MG TAB      ,,,,40529620,CDM,250,RC,62756-0517-88,NDC,both,1,EA,0.32,0.13,39.4668,,0.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.16,50,,0.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,70,,0.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.22,
CARBID-LEVO 25MG-100MG TAB      ,,,,40529638,CDM,250,RC,00904-7347-61,NDC,both,1,EA,0.88,0.35,39.4668,,0.35,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.26,30,,0.26,percent of total billed charges,"Drugs, Inpatient Only",0.26,30,,0.26,percent of total billed charges,"Drugs, Inpatient Only",0.26,30,,0.26,percent of total billed charges,"Drugs, Inpatient Only",0.44,50,,0.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.47,,,0.47,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.62,70,,0.62,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.56,,,0.56,Other,225% Medicaid APG methodology,0.35,,,0.35,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.31,,,0.31,Other,125% Medicaid APG methodology,0.01,0.62,
CARBID-LEVO 25MG-250MG TAB      ,,,,40529646,CDM,250,RC,60687-0836-01,NDC,both,1,EA,0.88,0.35,39.4668,,0.35,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.26,30,,0.26,percent of total billed charges,"Drugs, Inpatient Only",0.26,30,,0.26,percent of total billed charges,"Drugs, Inpatient Only",0.26,30,,0.26,percent of total billed charges,"Drugs, Inpatient Only",0.44,50,,0.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.45,,,0.45,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.62,70,,0.62,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,Drug Cost,0.54,,,0.54,Other,225% Medicaid APG methodology,0.34,,,0.34,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.3,,,0.3,Other,125% Medicaid APG methodology,0.01,0.62,
AL HYD/MAG HYD/SIME ORSUSP30ML  ,,,,40529695,CDM,250,RC,00536-1293-30,NDC,both,30,ML,3.78,1.49,39.4668,,1.49,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.13,30,,1.13,percent of total billed charges,"Drugs, Inpatient Only",1.13,30,,1.13,percent of total billed charges,"Drugs, Inpatient Only",1.13,30,,1.13,percent of total billed charges,"Drugs, Inpatient Only",1.89,50,,1.89,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.01,,,2.01,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.65,70,,2.65,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.08,,,1.08,Other,Drug Cost,1.08,,,1.08,Other,Drug Cost,1.08,,,1.08,Other,Drug Cost,1.08,,,1.08,Other,Drug Cost,1.08,,,1.08,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.08,,,1.08,Other,Drug Cost,2.43,,,2.43,Other,225% Medicaid APG methodology,1.51,,,1.51,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.08,,,1.08,Other,Drug Cost,1.08,,,1.08,Other,Drug Cost,1.35,,,1.35,Other,125% Medicaid APG methodology,0.01,2.65,
DIPHENOXYL/ATROP 2.5/.025 TAB   ,,,,40529737,CDM,250,RC,00025-0061-31,NDC,both,1,EA,9.7,3.83,39.4668,,3.83,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.91,30,,2.91,percent of total billed charges,"Drugs, Inpatient Only",2.91,30,,2.91,percent of total billed charges,"Drugs, Inpatient Only",2.91,30,,2.91,percent of total billed charges,"Drugs, Inpatient Only",4.85,50,,4.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.79,70,,6.79,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,6.79,
SOD BIPHOS-SOD PHOS AD ENEMA    ,,,,40529752,CDM,250,RC,00536-7415-51,NDC,both,133,ML,4.66,1.84,39.4668,,1.84,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.4,30,,1.4,percent of total billed charges,"Drugs, Inpatient Only",1.4,30,,1.4,percent of total billed charges,"Drugs, Inpatient Only",1.4,30,,1.4,percent of total billed charges,"Drugs, Inpatient Only",2.33,50,,2.33,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.47,,,2.47,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.26,70,,3.26,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.33,,,1.33,Other,Drug Cost,1.33,,,1.33,Other,Drug Cost,1.33,,,1.33,Other,Drug Cost,1.33,,,1.33,Other,Drug Cost,1.33,,,1.33,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.33,,,1.33,Other,Drug Cost,2.99,,,2.99,Other,225% Medicaid APG methodology,1.86,,,1.86,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.33,,,1.33,Other,Drug Cost,1.33,,,1.33,Other,Drug Cost,1.66,,,1.66,Other,125% Medicaid APG methodology,0.01,3.26,
AMOX-CLAV 250MG-125MG TAB       ,,,,40529778,CDM,250,RC,00781-1874-31,NDC,both,1,EA,5.01,1.98,39.4668,,1.98,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.5,30,,1.5,percent of total billed charges,"Drugs, Inpatient Only",1.5,30,,1.5,percent of total billed charges,"Drugs, Inpatient Only",1.5,30,,1.5,percent of total billed charges,"Drugs, Inpatient Only",2.51,50,,2.51,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.56,,,1.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.51,70,,3.51,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.84,,,0.84,Other,Drug Cost,1.89,,,1.89,Other,225% Medicaid APG methodology,1.18,,,1.18,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,1.05,,,1.05,Other,125% Medicaid APG methodology,0.01,3.51,
AMOX-CLAV 500MG-125MG TAB       ,,,,40529786,CDM,250,RC,00093-2274-34,NDC,both,1,EA,0.74,0.29,39.4668,,0.29,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,30,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.22,30,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.22,30,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.37,50,,0.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.41,,,0.41,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.52,70,,0.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.5,,,0.5,Other,225% Medicaid APG methodology,0.31,,,0.31,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.28,,,0.28,Other,125% Medicaid APG methodology,0.01,0.52,
AMOX-CLAV 875MG-125MG TAB       ,,,,40529794,CDM,250,RC,00093-2275-34,NDC,both,1,EA,0.91,0.36,39.4668,,0.36,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.27,30,,0.27,percent of total billed charges,"Drugs, Inpatient Only",0.27,30,,0.27,percent of total billed charges,"Drugs, Inpatient Only",0.27,30,,0.27,percent of total billed charges,"Drugs, Inpatient Only",0.46,50,,0.46,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.64,70,,0.64,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.16,,,0.16,Other,Drug Cost,0.36,,,0.36,Other,225% Medicaid APG methodology,0.22,,,0.22,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.2,,,0.2,Other,125% Medicaid APG methodology,0.01,0.64,
AMOX-CLAV 400MG-57MG/5ML 50ML   ,,,,40529836,CDM,250,RC,65862-0534-50,NDC,both,50,ML,15.75,6.22,39.4668,,6.22,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.73,30,,4.73,percent of total billed charges,"Drugs, Inpatient Only",4.73,30,,4.73,percent of total billed charges,"Drugs, Inpatient Only",4.73,30,,4.73,percent of total billed charges,"Drugs, Inpatient Only",7.88,50,,7.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.79,,,2.79,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.03,70,,11.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.5,,,1.5,Other,Drug Cost,3.38,,,3.38,Other,225% Medicaid APG methodology,2.1,,,2.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.88,,,1.88,Other,125% Medicaid APG methodology,0.01,11.03,
QUETIAPINE 200 MG TAB           ,,,,40529877,CDM,250,RC,00904-6641-61,NDC,both,1,EA,1.26,0.5,39.4668,,0.5,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.38,30,,0.38,percent of total billed charges,"Drugs, Inpatient Only",0.38,30,,0.38,percent of total billed charges,"Drugs, Inpatient Only",0.38,30,,0.38,percent of total billed charges,"Drugs, Inpatient Only",0.63,50,,0.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.88,70,,0.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.88,
EPINEPH-LIDO 1:100000-1% 20ML   ,,,,40529893,CDM,250,RC,63323-0482-27,NDC,both,20,ML,9.1,3.59,39.4668,,3.59,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.73,30,,2.73,percent of total billed charges,"Drugs, Inpatient Only",2.73,30,,2.73,percent of total billed charges,"Drugs, Inpatient Only",2.73,30,,2.73,percent of total billed charges,"Drugs, Inpatient Only",4.55,50,,4.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.12,,,1.12,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.37,70,,6.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.6,,,0.6,Other,Drug Cost,1.35,,,1.35,Other,225% Medicaid APG methodology,0.84,,,0.84,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.75,,,0.75,Other,125% Medicaid APG methodology,0.01,6.37,
EPINEPH-LIDO 1:100000-2% 20ML   ,,,,40529901,CDM,250,RC,63323-0483-27,NDC,both,20,ML,9.1,3.59,39.4668,,3.59,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.73,30,,2.73,percent of total billed charges,"Drugs, Inpatient Only",2.73,30,,2.73,percent of total billed charges,"Drugs, Inpatient Only",2.73,30,,2.73,percent of total billed charges,"Drugs, Inpatient Only",4.55,50,,4.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.86,,,1.86,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.37,70,,6.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1,,,1,Other,Drug Cost,2.25,,,2.25,Other,225% Medicaid APG methodology,1.4,,,1.4,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1.25,,,1.25,Other,125% Medicaid APG methodology,0.01,6.37,
EPI-LIDO1:200000-2%PF INJ20ML   ,,,,40529919,CDM,250,RC,63323-0489-27,NDC,both,20,ML,38.5,15.19,39.4668,,15.19,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.55,30,,11.55,percent of total billed charges,"Drugs, Inpatient Only",11.55,30,,11.55,percent of total billed charges,"Drugs, Inpatient Only",11.55,30,,11.55,percent of total billed charges,"Drugs, Inpatient Only",19.25,50,,19.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,20.46,,,20.46,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,26.95,70,,26.95,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11,,,11,Other,Drug Cost,11,,,11,Other,Drug Cost,11,,,11,Other,Drug Cost,11,,,11,Other,Drug Cost,11,,,11,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,11,,,11,Other,Drug Cost,24.75,,,24.75,Other,225% Medicaid APG methodology,15.4,,,15.4,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,11,,,11,Other,Drug Cost,11,,,11,Other,Drug Cost,13.75,,,13.75,Other,125% Medicaid APG methodology,0.01,26.95,
ACETA-OXYCODONE 325MG-5MG TAB   ,,,,40530032,CDM,250,RC,47781-0196-01,NDC,both,1,EA,0.28,0.11,39.4668,,0.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.14,50,,0.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,70,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.2,
ACET/BUT/CAF 325MG-50MG-40MGTB  ,,,,40530065,CDM,250,RC,70010-0149-01,NDC,both,1,EA,0.6,0.24,39.4668,,0.24,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.18,30,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.18,30,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.18,30,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.3,50,,0.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.42,70,,0.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% Medicaid APG methodology,0.11,,,0.11,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.42,
PHENYLEPHRINE 0.25% RECT SUPP   ,,,,40530628,CDM,250,RC,00113-0279-53,NDC,both,1,EA,0.56,0.22,39.4668,,0.22,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.28,50,,0.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.39,70,,0.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% Medicaid APG methodology,0.11,,,0.11,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.39,
NYSTATIN-TRIAMCIN CR 15G        ,,,,40530677,CDM,250,RC,68462-0314-17,NDC,both,15,GM,40.95,16.16,39.4668,,16.16,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.29,30,,12.29,percent of total billed charges,"Drugs, Inpatient Only",12.29,30,,12.29,percent of total billed charges,"Drugs, Inpatient Only",12.29,30,,12.29,percent of total billed charges,"Drugs, Inpatient Only",20.48,50,,20.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.84,,,0.84,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,28.67,70,,28.67,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.45,,,0.45,Other,Drug Cost,1.01,,,1.01,Other,225% Medicaid APG methodology,0.63,,,0.63,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.56,,,0.56,Other,125% Medicaid APG methodology,0.01,28.67,
GALANTAMINE 4 MG TAB            ,,,,40530701,CDM,250,RC,70436-0004-06,NDC,both,1,EA,1.75,0.69,39.4668,,0.69,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.53,30,,0.53,percent of total billed charges,"Drugs, Inpatient Only",0.53,30,,0.53,percent of total billed charges,"Drugs, Inpatient Only",0.53,30,,0.53,percent of total billed charges,"Drugs, Inpatient Only",0.88,50,,0.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.5,,,0.5,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.23,70,,1.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.27,,,0.27,Other,Drug Cost,0.61,,,0.61,Other,225% Medicaid APG methodology,0.38,,,0.38,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.34,,,0.34,Other,125% Medicaid APG methodology,0.01,1.23,
ALENDRONATE 70 MG TAB           ,,,,40530719,CDM,250,RC,69543-0131-20,NDC,both,1,EA,8.54,3.37,39.4668,,3.37,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.56,30,,2.56,percent of total billed charges,"Drugs, Inpatient Only",2.56,30,,2.56,percent of total billed charges,"Drugs, Inpatient Only",2.56,30,,2.56,percent of total billed charges,"Drugs, Inpatient Only",4.27,50,,4.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.98,70,,5.98,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,5.98,
POLYETHYLENE GLYCOL 3350 17 G   ,,,,40530784,CDM,250,RC,00904-6931-86,NDC,both,1,EA,3.64,1.44,39.4668,,1.44,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.09,30,,1.09,percent of total billed charges,"Drugs, Inpatient Only",1.09,30,,1.09,percent of total billed charges,"Drugs, Inpatient Only",1.09,30,,1.09,percent of total billed charges,"Drugs, Inpatient Only",1.82,50,,1.82,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.15,,,1.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.55,70,,2.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.62,,,0.62,Other,Drug Cost,1.4,,,1.4,Other,225% Medicaid APG methodology,0.87,,,0.87,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.78,,,0.78,Other,125% Medicaid APG methodology,0.01,2.55,
BACI/NEOMY/POLY OPT OINT 3.5G   ,,,,40530842,CDM,250,RC,24208-0780-55,NDC,both,3.5,GM,150.82,59.52,39.4668,,59.52,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,45.25,30,,45.25,percent of total billed charges,"Drugs, Inpatient Only",45.25,30,,45.25,percent of total billed charges,"Drugs, Inpatient Only",45.25,30,,45.25,percent of total billed charges,"Drugs, Inpatient Only",75.41,50,,75.41,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.32,,,9.32,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,105.57,70,,105.57,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.01,,,5.01,Other,Drug Cost,5.01,,,5.01,Other,Drug Cost,5.01,,,5.01,Other,Drug Cost,5.01,,,5.01,Other,Drug Cost,5.01,,,5.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,5.01,,,5.01,Other,Drug Cost,11.27,,,11.27,Other,225% Medicaid APG methodology,7.01,,,7.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.01,,,5.01,Other,Drug Cost,5.01,,,5.01,Other,Drug Cost,6.26,,,6.26,Other,125% Medicaid APG methodology,0.01,105.57,
GRAMICID/NEOMYC/POLY OPT 10ML   ,,,,40530859,CDM,250,RC,24208-0790-62,NDC,both,10,ML,153.65,60.64,39.4668,,60.64,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,46.1,30,,46.1,percent of total billed charges,"Drugs, Inpatient Only",46.1,30,,46.1,percent of total billed charges,"Drugs, Inpatient Only",46.1,30,,46.1,percent of total billed charges,"Drugs, Inpatient Only",76.83,50,,76.83,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.93,,,8.93,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,107.56,70,,107.56,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.8,,,4.8,Other,Drug Cost,10.8,,,10.8,Other,225% Medicaid APG methodology,6.72,,,6.72,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,6,,,6,Other,125% Medicaid APG methodology,0.01,107.56,
HC/NEOMYCI/POLY OPT SUSP 7.5ML  ,,,,40530875,CDM,250,RC,61314-0641-75,NDC,both,7.5,ML,364.88,144.01,39.4668,,144.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,109.46,30,,109.46,percent of total billed charges,"Drugs, Inpatient Only",109.46,30,,109.46,percent of total billed charges,"Drugs, Inpatient Only",109.46,30,,109.46,percent of total billed charges,"Drugs, Inpatient Only",182.44,50,,182.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,92.22,,,92.22,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,255.42,70,,255.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,49.58,,,49.58,Other,Drug Cost,49.58,,,49.58,Other,Drug Cost,49.58,,,49.58,Other,Drug Cost,49.58,,,49.58,Other,Drug Cost,49.58,,,49.58,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,49.58,,,49.58,Other,Drug Cost,111.56,,,111.56,Other,225% Medicaid APG methodology,69.41,,,69.41,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,49.58,,,49.58,Other,Drug Cost,49.58,,,49.58,Other,Drug Cost,61.98,,,61.98,Other,125% Medicaid APG methodology,0.01,255.42,
DEXA/NEOMY/POLY OPT SUSP 5ML    ,,,,40530891,CDM,250,RC,24208-0830-60,NDC,both,5,ML,32.2,12.71,39.4668,,12.71,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.66,30,,9.66,percent of total billed charges,"Drugs, Inpatient Only",9.66,30,,9.66,percent of total billed charges,"Drugs, Inpatient Only",9.66,30,,9.66,percent of total billed charges,"Drugs, Inpatient Only",16.1,50,,16.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.16,,,7.16,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,22.54,70,,22.54,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.85,,,3.85,Other,Drug Cost,3.85,,,3.85,Other,Drug Cost,3.85,,,3.85,Other,Drug Cost,3.85,,,3.85,Other,Drug Cost,3.85,,,3.85,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.85,,,3.85,Other,Drug Cost,8.66,,,8.66,Other,225% Medicaid APG methodology,5.39,,,5.39,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.85,,,3.85,Other,Drug Cost,3.85,,,3.85,Other,Drug Cost,4.81,,,4.81,Other,125% Medicaid APG methodology,0.01,22.54,
AMLODIPINE 5 MG TAB             ,,,,40530917,CDM,250,RC,00904-6370-61,NDC,both,1,EA,0.25,0.1,39.4668,,0.1,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.13,50,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.18,70,,0.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.18,
SOTALOL 80 MG TAB               ,,,,40530925,CDM,250,RC,00245-0012-01,NDC,both,1,EA,3.36,1.33,39.4668,,1.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.01,30,,1.01,percent of total billed charges,"Drugs, Inpatient Only",1.01,30,,1.01,percent of total billed charges,"Drugs, Inpatient Only",1.01,30,,1.01,percent of total billed charges,"Drugs, Inpatient Only",1.68,50,,1.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.87,,,0.87,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.35,70,,2.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.47,,,0.47,Other,Drug Cost,1.06,,,1.06,Other,225% Medicaid APG methodology,0.66,,,0.66,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.47,,,0.47,Other,Drug Cost,0.47,,,0.47,Other,Drug Cost,0.59,,,0.59,Other,125% Medicaid APG methodology,0.01,2.35,
HETASTARCH 30G NACL IV 500ML    ,,,,40530982,CDM,250,RC,00264-1965-10,NDC,both,500,ML,70,27.63,39.4668,,27.63,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,21,30,,21,percent of total billed charges,"Drugs, Inpatient Only",21,30,,21,percent of total billed charges,"Drugs, Inpatient Only",21,30,,21,percent of total billed charges,"Drugs, Inpatient Only",35,50,,35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,18.6,,,18.6,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,49,70,,49,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10,,,10,Other,Drug Cost,10,,,10,Other,Drug Cost,10,,,10,Other,Drug Cost,10,,,10,Other,Drug Cost,10,,,10,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,10,,,10,Other,Drug Cost,22.5,,,22.5,Other,225% Medicaid APG methodology,14,,,14,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,10,,,10,Other,Drug Cost,10,,,10,Other,Drug Cost,12.5,,,12.5,Other,125% Medicaid APG methodology,0.01,49,
HC/NEOMYCIN/POLY OTIC SLN 10ML  ,,,,40531170,CDM,250,RC,24208-0631-10,NDC,both,10,ML,218.75,86.33,39.4668,,86.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,65.63,30,,65.63,percent of total billed charges,"Drugs, Inpatient Only",65.63,30,,65.63,percent of total billed charges,"Drugs, Inpatient Only",65.63,30,,65.63,percent of total billed charges,"Drugs, Inpatient Only",109.38,50,,109.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,18.6,,,18.6,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,153.13,70,,153.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10,,,10,Other,Drug Cost,10,,,10,Other,Drug Cost,10,,,10,Other,Drug Cost,10,,,10,Other,Drug Cost,10,,,10,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,10,,,10,Other,Drug Cost,22.5,,,22.5,Other,225% Medicaid APG methodology,14,,,14,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,10,,,10,Other,Drug Cost,10,,,10,Other,Drug Cost,12.5,,,12.5,Other,125% Medicaid APG methodology,0.01,153.13,
SMX-TMP 400MG-80MG TAB          ,,,,40531360,CDM,250,RC,50268-0728-15,NDC,both,1,EA,0.98,0.39,39.4668,,0.39,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.49,50,,0.49,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,,,0.37,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.69,70,,0.69,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.45,,,0.45,Other,225% Medicaid APG methodology,0.28,,,0.28,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.25,,,0.25,Other,125% Medicaid APG methodology,0.01,0.69,
SMX-TMP 800MG-160MG TAB         ,,,,40531378,CDM,250,RC,00904-2725-61,NDC,both,1,EA,0.42,0.17,39.4668,,0.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.21,50,,0.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,70,,0.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.29,
RIVASTIGMINE 1.5 MG CAP         ,,,,40531386,CDM,250,RC,00904-6587-61,NDC,both,1,EA,7.11,2.81,39.4668,,2.81,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.13,30,,2.13,percent of total billed charges,"Drugs, Inpatient Only",2.13,30,,2.13,percent of total billed charges,"Drugs, Inpatient Only",2.13,30,,2.13,percent of total billed charges,"Drugs, Inpatient Only",3.56,50,,3.56,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.68,,,2.68,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.98,70,,4.98,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.44,,,1.44,Other,Drug Cost,1.44,,,1.44,Other,Drug Cost,1.44,,,1.44,Other,Drug Cost,1.44,,,1.44,Other,Drug Cost,1.44,,,1.44,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.44,,,1.44,Other,Drug Cost,3.24,,,3.24,Other,225% Medicaid APG methodology,2.02,,,2.02,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.44,,,1.44,Other,Drug Cost,1.44,,,1.44,Other,Drug Cost,1.8,,,1.8,Other,125% Medicaid APG methodology,0.01,4.98,
LEVONORGESTREL 1.5 MG TAB       ,,,,40531519,CDM,250,RC,68180-0852-11,NDC,both,1,EA,35.63,14.06,39.4668,,14.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.69,30,,10.69,percent of total billed charges,"Drugs, Inpatient Only",10.69,30,,10.69,percent of total billed charges,"Drugs, Inpatient Only",10.69,30,,10.69,percent of total billed charges,"Drugs, Inpatient Only",17.82,50,,17.82,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.82,,,8.82,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,24.94,70,,24.94,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.74,,,4.74,Other,Drug Cost,4.74,,,4.74,Other,Drug Cost,4.74,,,4.74,Other,Drug Cost,4.74,,,4.74,Other,Drug Cost,4.74,,,4.74,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.74,,,4.74,Other,Drug Cost,10.67,,,10.67,Other,225% Medicaid APG methodology,6.64,,,6.64,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.74,,,4.74,Other,Drug Cost,4.74,,,4.74,Other,Drug Cost,5.93,,,5.93,Other,125% Medicaid APG methodology,0.01,24.94,
VITAMIN A 10000 UNITS CAP       ,,,,40531576,CDM,250,RC,00904-2085-60,NDC,both,1,EA,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.04,50,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
VITAMIN B COMPLEX TAB           ,,,,40531592,CDM,250,RC,54629-0563-01,NDC,both,1,EA,0.25,0.1,39.4668,,0.1,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.13,50,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.18,70,,0.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% Medicaid APG methodology,0.1,,,0.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.18,
ASCORBIC ACID 500 MG TAB        ,,,,40531642,CDM,250,RC,00904-0523-61,NDC,both,1,EA,0.11,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.06,50,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.08,
ERGOCALCIFEROL 8000U/ML 60ML    ,,,,40531675,CDM,250,RC,47781-0647-26,NDC,both,60,ML,102.27,40.36,39.4668,,40.36,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,30.68,30,,30.68,percent of total billed charges,"Drugs, Inpatient Only",30.68,30,,30.68,percent of total billed charges,"Drugs, Inpatient Only",30.68,30,,30.68,percent of total billed charges,"Drugs, Inpatient Only",51.14,50,,51.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,36.9,,,36.9,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,71.59,70,,71.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.84,,,19.84,Other,Drug Cost,19.84,,,19.84,Other,Drug Cost,19.84,,,19.84,Other,Drug Cost,19.84,,,19.84,Other,Drug Cost,19.84,,,19.84,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,19.84,,,19.84,Other,Drug Cost,44.64,,,44.64,Other,225% Medicaid APG methodology,27.78,,,27.78,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,19.84,,,19.84,Other,Drug Cost,19.84,,,19.84,Other,Drug Cost,24.8,,,24.8,Other,125% Medicaid APG methodology,0.01,71.59,
MONTELUKAST 5 MG CHEW TAB       ,,,,40531733,CDM,250,RC,33342-0111-07,NDC,both,1,EA,0.39,0.15,39.4668,,0.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.2,50,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.27,70,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% Medicaid APG methodology,0.1,,,0.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.27,
MONTELUKAST 10 MG TAB           ,,,,40531741,CDM,250,RC,00904-6808-61,NDC,both,1,EA,0.81,0.32,39.4668,,0.32,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.24,30,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.24,30,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.24,30,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.41,50,,0.41,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.41,,,0.41,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.57,70,,0.57,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.5,,,0.5,Other,225% Medicaid APG methodology,0.31,,,0.31,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.28,,,0.28,Other,125% Medicaid APG methodology,0.01,0.57,
CALCITRIOL 0.25 MCG CAP         ,,,,40531782,CDM,250,RC,64380-0723-06,NDC,both,1,EA,3.12,1.23,39.4668,,1.23,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.94,30,,0.94,percent of total billed charges,"Drugs, Inpatient Only",0.94,30,,0.94,percent of total billed charges,"Drugs, Inpatient Only",0.94,30,,0.94,percent of total billed charges,"Drugs, Inpatient Only",1.56,50,,1.56,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.18,70,,2.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,2.18,
VITAMIN E 400 INTLUN CAP        ,,,,40531824,CDM,250,RC,50268-0870-13,NDC,both,1,EA,20.2,7.97,39.4668,,7.97,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.06,30,,6.06,percent of total billed charges,"Drugs, Inpatient Only",6.06,30,,6.06,percent of total billed charges,"Drugs, Inpatient Only",6.06,30,,6.06,percent of total billed charges,"Drugs, Inpatient Only",10.1,50,,10.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.37,,,7.37,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.14,70,,14.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.96,,,3.96,Other,Drug Cost,3.96,,,3.96,Other,Drug Cost,3.96,,,3.96,Other,Drug Cost,3.96,,,3.96,Other,Drug Cost,3.96,,,3.96,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.96,,,3.96,Other,Drug Cost,8.91,,,8.91,Other,225% Medicaid APG methodology,5.54,,,5.54,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.96,,,3.96,Other,Drug Cost,3.96,,,3.96,Other,Drug Cost,4.95,,,4.95,Other,125% Medicaid APG methodology,0.01,14.14,
ABACAVIR 300 MG TAB             ,,,,40531857,CDM,250,RC,68084-0021-21,NDC,both,1,EA,23.73,9.37,39.4668,,9.37,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.12,30,,7.12,percent of total billed charges,"Drugs, Inpatient Only",7.12,30,,7.12,percent of total billed charges,"Drugs, Inpatient Only",7.12,30,,7.12,percent of total billed charges,"Drugs, Inpatient Only",11.87,50,,11.87,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.45,,,10.45,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,16.61,70,,16.61,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.62,,,5.62,Other,Drug Cost,5.62,,,5.62,Other,Drug Cost,5.62,,,5.62,Other,Drug Cost,5.62,,,5.62,Other,Drug Cost,5.62,,,5.62,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,5.62,,,5.62,Other,Drug Cost,12.65,,,12.65,Other,225% Medicaid APG methodology,7.87,,,7.87,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.62,,,5.62,Other,Drug Cost,5.62,,,5.62,Other,Drug Cost,7.03,,,7.03,Other,125% Medicaid APG methodology,0.01,16.61,
PHYTONADIONE 5 MG TAB           ,,,,40531873,CDM,250,RC,00187-1704-05,NDC,both,1,EA,164.29,64.84,39.4668,,64.84,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,49.29,30,,49.29,percent of total billed charges,"Drugs, Inpatient Only",49.29,30,,49.29,percent of total billed charges,"Drugs, Inpatient Only",49.29,30,,49.29,percent of total billed charges,"Drugs, Inpatient Only",82.15,50,,82.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,115,70,,115,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,115,
FOLIC ACID 1 MG TAB             ,,,,40531915,CDM,250,RC,11534-0165-01,NDC,both,1,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.11,50,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.15,
FOLIC ACID 5MG/ML INJ SLN 10ML  ,,,,40531923,CDM,250,RC,63323-0184-10,NDC,both,1,ML,7.56,2.98,39.4668,,2.98,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.27,30,,2.27,percent of total billed charges,"Drugs, Inpatient Only",2.27,30,,2.27,percent of total billed charges,"Drugs, Inpatient Only",2.27,30,,2.27,percent of total billed charges,"Drugs, Inpatient Only",3.78,50,,3.78,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.31,,,2.31,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.29,70,,5.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.24,,,1.24,Other,Drug Cost,1.24,,,1.24,Other,Drug Cost,1.24,,,1.24,Other,Drug Cost,1.24,,,1.24,Other,Drug Cost,1.24,,,1.24,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.24,,,1.24,Other,Drug Cost,2.79,,,2.79,Other,225% Medicaid APG methodology,1.74,,,1.74,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.24,,,1.24,Other,Drug Cost,1.24,,,1.24,Other,Drug Cost,1.55,,,1.55,Other,125% Medicaid APG methodology,0.01,5.29,
LEUCOVORIN 5 MG TAB             ,,,,40531949,CDM,250,RC,42806-0358-30,NDC,both,1,EA,2.77,1.09,39.4668,,1.09,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.83,30,,0.83,percent of total billed charges,"Drugs, Inpatient Only",0.83,30,,0.83,percent of total billed charges,"Drugs, Inpatient Only",0.83,30,,0.83,percent of total billed charges,"Drugs, Inpatient Only",1.39,50,,1.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.45,,,0.45,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.94,70,,1.94,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,Drug Cost,0.54,,,0.54,Other,225% Medicaid APG methodology,0.34,,,0.34,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.3,,,0.3,Other,125% Medicaid APG methodology,0.01,1.94,
LEUCOVORIN 25 MG TAB            ,,,,40531956,CDM,250,RC,60687-0227-94,NDC,both,1,EA,27.76,10.96,39.4668,,10.96,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.33,30,,8.33,percent of total billed charges,"Drugs, Inpatient Only",8.33,30,,8.33,percent of total billed charges,"Drugs, Inpatient Only",8.33,30,,8.33,percent of total billed charges,"Drugs, Inpatient Only",13.88,50,,13.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.33,,,12.33,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.43,70,,19.43,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.63,,,6.63,Other,Drug Cost,6.63,,,6.63,Other,Drug Cost,6.63,,,6.63,Other,Drug Cost,6.63,,,6.63,Other,Drug Cost,6.63,,,6.63,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,6.63,,,6.63,Other,Drug Cost,14.92,,,14.92,Other,225% Medicaid APG methodology,9.28,,,9.28,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.63,,,6.63,Other,Drug Cost,6.63,,,6.63,Other,Drug Cost,8.29,,,8.29,Other,125% Medicaid APG methodology,0.01,19.43,
NIACIN 500 MG TAB               ,,,,40531998,CDM,250,RC,00904-2272-60,NDC,both,1,EA,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.04,50,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
THIAMINE 100 MG TAB             ,,,,40532061,CDM,250,RC,54629-0057-01,NDC,both,1,EA,0.14,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.07,50,,0.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.1,
ENTACAPONE 200 MG TAB           ,,,,40532079,CDM,250,RC,00904-6822-07,NDC,both,1,EA,12.04,4.75,39.4668,,4.75,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.61,30,,3.61,percent of total billed charges,"Drugs, Inpatient Only",3.61,30,,3.61,percent of total billed charges,"Drugs, Inpatient Only",3.61,30,,3.61,percent of total billed charges,"Drugs, Inpatient Only",6.02,50,,6.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.34,,,6.34,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.43,70,,8.43,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.41,,,3.41,Other,Drug Cost,3.41,,,3.41,Other,Drug Cost,3.41,,,3.41,Other,Drug Cost,3.41,,,3.41,Other,Drug Cost,3.41,,,3.41,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.41,,,3.41,Other,Drug Cost,7.67,,,7.67,Other,225% Medicaid APG methodology,4.77,,,4.77,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.41,,,3.41,Other,Drug Cost,3.41,,,3.41,Other,Drug Cost,4.26,,,4.26,Other,125% Medicaid APG methodology,0.01,8.43,
ASPRIN-DIPYRDAMLE25-200MGERCAP  ,,,,40532103,CDM,250,RC,65162-0596-06,NDC,both,1,EA,16.52,6.52,39.4668,,6.52,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.96,30,,4.96,percent of total billed charges,"Drugs, Inpatient Only",4.96,30,,4.96,percent of total billed charges,"Drugs, Inpatient Only",4.96,30,,4.96,percent of total billed charges,"Drugs, Inpatient Only",8.26,50,,8.26,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.98,,,4.98,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.56,70,,11.56,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.68,,,2.68,Other,Drug Cost,2.68,,,2.68,Other,Drug Cost,2.68,,,2.68,Other,Drug Cost,2.68,,,2.68,Other,Drug Cost,2.68,,,2.68,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.68,,,2.68,Other,Drug Cost,6.03,,,6.03,Other,225% Medicaid APG methodology,3.75,,,3.75,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.68,,,2.68,Other,Drug Cost,2.68,,,2.68,Other,Drug Cost,3.35,,,3.35,Other,125% Medicaid APG methodology,0.01,11.56,
PRENATAL MULTI FOLIC 0.8MGTAB   ,,,,40532111,CDM,250,RC,77333-0715-10,NDC,both,1,EA,0.46,0.18,39.4668,,0.18,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.14,30,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,30,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,30,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.23,50,,0.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.32,70,,0.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.25,,,0.25,Other,225% Medicaid APG methodology,0.15,,,0.15,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.14,,,0.14,Other,125% Medicaid APG methodology,0.01,0.32,
MULTIPLE VITAMINS TAB           ,,,,40532145,CDM,250,RC,20555-0027-00,NDC,both,1,EA,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.02,50,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.03,
MISOPROSTOL 25 MCG TAB          ,,,,40533507,CDM,250,RC,59762-5007-01Q,NDC,both,1,EA,0.53,0.21,39.4668,,0.21,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.27,50,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,70,,0.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.37,
OXCARBAZEPINE 600 MG TAB        ,,,,40533531,CDM,250,RC,50268-0681-15,NDC,both,1,EA,5.04,1.99,39.4668,,1.99,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.51,30,,1.51,percent of total billed charges,"Drugs, Inpatient Only",1.51,30,,1.51,percent of total billed charges,"Drugs, Inpatient Only",1.51,30,,1.51,percent of total billed charges,"Drugs, Inpatient Only",2.52,50,,2.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.57,,,2.57,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.53,70,,3.53,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.38,,,1.38,Other,Drug Cost,1.38,,,1.38,Other,Drug Cost,1.38,,,1.38,Other,Drug Cost,1.38,,,1.38,Other,Drug Cost,1.38,,,1.38,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.38,,,1.38,Other,Drug Cost,3.11,,,3.11,Other,225% Medicaid APG methodology,1.93,,,1.93,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.38,,,1.38,Other,Drug Cost,1.38,,,1.38,Other,Drug Cost,1.73,,,1.73,Other,125% Medicaid APG methodology,0.01,3.53,
QUETIAPINE 100 MG TAB           ,,,,40533564,CDM,250,RC,00904-6640-61,NDC,both,1,EA,0.46,0.18,39.4668,,0.18,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.14,30,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,30,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,30,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.23,50,,0.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.32,70,,0.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.27,,,0.27,Other,225% Medicaid APG methodology,0.17,,,0.17,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.15,,,0.15,Other,125% Medicaid APG methodology,0.01,0.32,
QUETIAPINE 300 MG TAB           ,,,,40533572,CDM,250,RC,67877-0247-60,NDC,both,1,EA,0.56,0.22,39.4668,,0.22,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.28,50,,0.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.39,70,,0.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.39,
DIVALPROEX SODIUM 500MG DR TAB  ,,,,40533580,CDM,250,RC,62756-0798-88,NDC,both,1,EA,0.53,0.21,39.4668,,0.21,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.27,50,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,70,,0.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.37,
ARIPIPRAZOLE 5 MG TAB           ,,,,40533598,CDM,250,RC,00904-7367-06,NDC,both,1,EA,1.4,0.55,39.4668,,0.55,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.42,30,,0.42,percent of total billed charges,"Drugs, Inpatient Only",0.42,30,,0.42,percent of total billed charges,"Drugs, Inpatient Only",0.42,30,,0.42,percent of total billed charges,"Drugs, Inpatient Only",0.7,50,,0.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.84,,,0.84,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.98,70,,0.98,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.45,,,0.45,Other,Drug Cost,1.01,,,1.01,Other,225% Medicaid APG methodology,0.63,,,0.63,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.56,,,0.56,Other,125% Medicaid APG methodology,0.01,1.01,
ARIPIPRAZOLE 20 MG TAB          ,,,,40533606,CDM,250,RC,50268-0091-12,NDC,both,1,EA,51.17,20.2,39.4668,,20.2,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.35,30,,15.35,percent of total billed charges,"Drugs, Inpatient Only",15.35,30,,15.35,percent of total billed charges,"Drugs, Inpatient Only",15.35,30,,15.35,percent of total billed charges,"Drugs, Inpatient Only",25.59,50,,25.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,16.87,,,16.87,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,35.82,70,,35.82,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.07,,,9.07,Other,Drug Cost,9.07,,,9.07,Other,Drug Cost,9.07,,,9.07,Other,Drug Cost,9.07,,,9.07,Other,Drug Cost,9.07,,,9.07,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,9.07,,,9.07,Other,Drug Cost,20.41,,,20.41,Other,225% Medicaid APG methodology,12.7,,,12.7,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,9.07,,,9.07,Other,Drug Cost,9.07,,,9.07,Other,Drug Cost,11.34,,,11.34,Other,125% Medicaid APG methodology,0.01,35.82,
BICALUTAMIDE 50 MG TAB          ,,,,40533689,CDM,250,RC,00904-6019-46,NDC,both,1,EA,0.95,0.37,39.4668,,0.37,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.48,50,,0.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.39,,,0.39,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.67,70,,0.67,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.21,,,0.21,Other,Drug Cost,0.47,,,0.47,Other,225% Medicaid APG methodology,0.29,,,0.29,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.26,,,0.26,Other,125% Medicaid APG methodology,0.01,0.67,
ATENOLOL 50 MG TAB              ,,,,40533721,CDM,250,RC,00093-0752-01,NDC,both,1,EA,0.11,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.06,50,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.08,
ERGOCALCIFEROL (1.25MG) CAP     ,,,,40533762,CDM,250,RC,64380-0737-06,NDC,both,1,EA,0.46,0.18,39.4668,,0.18,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.14,30,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,30,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,30,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.23,50,,0.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.32,70,,0.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.32,
PREGABALIN 25 MG CAP            ,,,,40533846,CDM,250,RC,00071-1012-68,NDC,both,1,EA,29.3,11.56,39.4668,,11.56,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.79,30,,8.79,percent of total billed charges,"Drugs, Inpatient Only",8.79,30,,8.79,percent of total billed charges,"Drugs, Inpatient Only",8.79,30,,8.79,percent of total billed charges,"Drugs, Inpatient Only",14.65,50,,14.65,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.52,,,0.52,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,20.51,70,,20.51,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,Drug Cost,0.63,,,0.63,Other,225% Medicaid APG methodology,0.39,,,0.39,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.35,,,0.35,Other,125% Medicaid APG methodology,0.01,20.51,
PREGABALIN 50 MG CAP            ,,,,40533853,CDM,250,RC,69097-0678-05,NDC,both,1,EA,0.25,0.1,39.4668,,0.1,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.13,50,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.18,70,,0.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.18,
TRAMADOL 50 MG TAB              ,,,,40533861,CDM,250,RC,51079-0991-20,NDC,both,1,EA,0.18,0.07,39.4668,,0.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.09,50,,0.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,70,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.13,
QUETIAPINE 25 MG TAB            ,,,,40533887,CDM,250,RC,67877-0242-01,NDC,both,1,EA,0.11,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.06,50,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.08,
METOPROLOL SUCC 25MG ER TAB     ,,,,40533895,CDM,250,RC,70436-0202-01,NDC,both,1,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.11,50,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.15,
MAG SULF TOP POWDER-RECON 454G  ,,,,40533945,CDM,250,RC,70000-0021-01,NDC,both,454,GM,5.95,2.35,39.4668,,2.35,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.79,30,,1.79,percent of total billed charges,"Drugs, Inpatient Only",1.79,30,,1.79,percent of total billed charges,"Drugs, Inpatient Only",1.79,30,,1.79,percent of total billed charges,"Drugs, Inpatient Only",2.98,50,,2.98,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.12,,,3.12,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.17,70,,4.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.68,,,1.68,Other,Drug Cost,1.68,,,1.68,Other,Drug Cost,1.68,,,1.68,Other,Drug Cost,1.68,,,1.68,Other,Drug Cost,1.68,,,1.68,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.68,,,1.68,Other,Drug Cost,3.78,,,3.78,Other,225% Medicaid APG methodology,2.35,,,2.35,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.68,,,1.68,Other,Drug Cost,1.68,,,1.68,Other,Drug Cost,2.1,,,2.1,Other,125% Medicaid APG methodology,0.01,4.17,
DOCUSATE 10MG/ML ORLIQ 10ML     ,,,,40533952,CDM,250,RC,50383-0771-11,NDC,both,10,ML,1.37,0.54,39.4668,,0.54,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.41,30,,0.41,percent of total billed charges,"Drugs, Inpatient Only",0.41,30,,0.41,percent of total billed charges,"Drugs, Inpatient Only",0.41,30,,0.41,percent of total billed charges,"Drugs, Inpatient Only",0.69,50,,0.69,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.96,70,,0.96,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.2,,,0.2,Other,225% Medicaid APG methodology,0.13,,,0.13,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,0.96,
ACETIC ACID 5% COMPO SOLN473ML  ,,,,40534059,CDM,250,RC,51552-0055-06,NDC,both,473,ML,66.22,26.13,39.4668,,26.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.87,30,,19.87,percent of total billed charges,"Drugs, Inpatient Only",19.87,30,,19.87,percent of total billed charges,"Drugs, Inpatient Only",19.87,30,,19.87,percent of total billed charges,"Drugs, Inpatient Only",33.11,50,,33.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,35.19,,,35.19,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,46.35,70,,46.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,18.92,,,18.92,Other,Drug Cost,18.92,,,18.92,Other,Drug Cost,18.92,,,18.92,Other,Drug Cost,18.92,,,18.92,Other,Drug Cost,18.92,,,18.92,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,18.92,,,18.92,Other,Drug Cost,42.57,,,42.57,Other,225% Medicaid APG methodology,26.49,,,26.49,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,18.92,,,18.92,Other,Drug Cost,18.92,,,18.92,Other,Drug Cost,23.65,,,23.65,Other,125% Medicaid APG methodology,0.01,46.35,
BUPIV 0.75%-D8.25% PF IT 2ML    ,,,,40534125,CDM,250,RC,36000-0092-10,NDC,both,2,ML,4.97,1.96,39.4668,,1.96,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.49,30,,1.49,percent of total billed charges,"Drugs, Inpatient Only",1.49,30,,1.49,percent of total billed charges,"Drugs, Inpatient Only",1.49,30,,1.49,percent of total billed charges,"Drugs, Inpatient Only",2.49,50,,2.49,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.94,,,2.94,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.48,70,,3.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.58,,,1.58,Other,Drug Cost,1.58,,,1.58,Other,Drug Cost,1.58,,,1.58,Other,Drug Cost,1.58,,,1.58,Other,Drug Cost,1.58,,,1.58,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.58,,,1.58,Other,Drug Cost,3.56,,,3.56,Other,225% Medicaid APG methodology,2.21,,,2.21,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.58,,,1.58,Other,Drug Cost,1.58,,,1.58,Other,Drug Cost,1.98,,,1.98,Other,125% Medicaid APG methodology,0.01,3.56,
DEX/NEOMY/POLY OPT OINT 3.5 G   ,,,,40534133,CDM,250,RC,61314-0631-36,NDC,both,3.5,GM,59.54,23.5,39.4668,,23.5,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,17.86,30,,17.86,percent of total billed charges,"Drugs, Inpatient Only",17.86,30,,17.86,percent of total billed charges,"Drugs, Inpatient Only",17.86,30,,17.86,percent of total billed charges,"Drugs, Inpatient Only",29.77,50,,29.77,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.68,,,2.68,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,41.68,70,,41.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.44,,,1.44,Other,Drug Cost,1.44,,,1.44,Other,Drug Cost,1.44,,,1.44,Other,Drug Cost,1.44,,,1.44,Other,Drug Cost,1.44,,,1.44,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.44,,,1.44,Other,Drug Cost,3.24,,,3.24,Other,225% Medicaid APG methodology,2.02,,,2.02,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.44,,,1.44,Other,Drug Cost,1.44,,,1.44,Other,Drug Cost,1.8,,,1.8,Other,125% Medicaid APG methodology,0.01,41.68,
DEXTROSE 50%IV SOL 50ML VIAL    ,,,,40534265,CDM,250,RC,00409-6648-02,NDC,both,50,ML,8.75,3.45,39.4668,,3.45,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.63,30,,2.63,percent of total billed charges,"Drugs, Inpatient Only",2.63,30,,2.63,percent of total billed charges,"Drugs, Inpatient Only",2.63,30,,2.63,percent of total billed charges,"Drugs, Inpatient Only",4.38,50,,4.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.79,,,2.79,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.13,70,,6.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.5,,,1.5,Other,Drug Cost,3.38,,,3.38,Other,225% Medicaid APG methodology,2.1,,,2.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.88,,,1.88,Other,125% Medicaid APG methodology,0.01,6.13,
POLYET GLY 3350 ELE ORL 4000ML  ,,,,40534281,CDM,250,RC,43386-0090-19,NDC,both,4000,ML,34.86,13.76,39.4668,,13.76,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.46,30,,10.46,percent of total billed charges,"Drugs, Inpatient Only",10.46,30,,10.46,percent of total billed charges,"Drugs, Inpatient Only",10.46,30,,10.46,percent of total billed charges,"Drugs, Inpatient Only",17.43,50,,17.43,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.46,,,11.46,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,24.4,70,,24.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.16,,,6.16,Other,Drug Cost,6.16,,,6.16,Other,Drug Cost,6.16,,,6.16,Other,Drug Cost,6.16,,,6.16,Other,Drug Cost,6.16,,,6.16,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,6.16,,,6.16,Other,Drug Cost,13.86,,,13.86,Other,225% Medicaid APG methodology,8.62,,,8.62,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.16,,,6.16,Other,Drug Cost,6.16,,,6.16,Other,Drug Cost,7.7,,,7.7,Other,125% Medicaid APG methodology,0.01,24.4,
OXYMETAZOLINE0.05% NASSPR 30ML  ,,,,40534430,CDM,250,RC,70000-0001-01,NDC,both,30,ML,12.57,4.96,39.4668,,4.96,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.77,30,,3.77,percent of total billed charges,"Drugs, Inpatient Only",3.77,30,,3.77,percent of total billed charges,"Drugs, Inpatient Only",3.77,30,,3.77,percent of total billed charges,"Drugs, Inpatient Only",6.29,50,,6.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.68,,,6.68,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.8,70,,8.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.59,,,3.59,Other,Drug Cost,3.59,,,3.59,Other,Drug Cost,3.59,,,3.59,Other,Drug Cost,3.59,,,3.59,Other,Drug Cost,3.59,,,3.59,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.59,,,3.59,Other,Drug Cost,8.08,,,8.08,Other,225% Medicaid APG methodology,5.03,,,5.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.59,,,3.59,Other,Drug Cost,3.59,,,3.59,Other,Drug Cost,4.49,,,4.49,Other,125% Medicaid APG methodology,0.01,8.8,
CYCLOPENTOLATE 1% OPT SLN 2ML   ,,,,40534463,CDM,250,RC,17478-0100-02,NDC,both,2,ML,22.4,8.84,39.4668,,8.84,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.72,30,,6.72,percent of total billed charges,"Drugs, Inpatient Only",6.72,30,,6.72,percent of total billed charges,"Drugs, Inpatient Only",6.72,30,,6.72,percent of total billed charges,"Drugs, Inpatient Only",11.2,50,,11.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.46,,,2.46,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.68,70,,15.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.32,,,1.32,Other,Drug Cost,1.32,,,1.32,Other,Drug Cost,1.32,,,1.32,Other,Drug Cost,1.32,,,1.32,Other,Drug Cost,1.32,,,1.32,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.32,,,1.32,Other,Drug Cost,2.97,,,2.97,Other,225% Medicaid APG methodology,1.85,,,1.85,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.32,,,1.32,Other,Drug Cost,1.32,,,1.32,Other,Drug Cost,1.65,,,1.65,Other,125% Medicaid APG methodology,0.01,15.68,
TIMOLOL 0.25% OPHTH SOLN 5 ML   ,,,,40534505,CDM,250,RC,61314-0226-05,NDC,both,5,ML,17.15,6.77,39.4668,,6.77,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.15,30,,5.15,percent of total billed charges,"Drugs, Inpatient Only",5.15,30,,5.15,percent of total billed charges,"Drugs, Inpatient Only",5.15,30,,5.15,percent of total billed charges,"Drugs, Inpatient Only",8.58,50,,8.58,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.67,,,1.67,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.01,70,,12.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.9,,,0.9,Other,Drug Cost,0.9,,,0.9,Other,Drug Cost,0.9,,,0.9,Other,Drug Cost,0.9,,,0.9,Other,Drug Cost,0.9,,,0.9,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.9,,,0.9,Other,Drug Cost,2.03,,,2.03,Other,225% Medicaid APG methodology,1.26,,,1.26,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.9,,,0.9,Other,Drug Cost,0.9,,,0.9,Other,Drug Cost,1.13,,,1.13,Other,125% Medicaid APG methodology,0.01,12.01,
DEXAMETHASONE 0.5MG/5ML 60ML    ,,,,40534604,CDM,250,RC,00054-3177-63,NDC,both,500,ML,49.67,19.6,39.4668,,19.6,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.9,30,,14.9,percent of total billed charges,"Drugs, Inpatient Only",14.9,30,,14.9,percent of total billed charges,"Drugs, Inpatient Only",14.9,30,,14.9,percent of total billed charges,"Drugs, Inpatient Only",24.84,50,,24.84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,27.34,,,27.34,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,34.77,70,,34.77,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.7,,,14.7,Other,Drug Cost,14.7,,,14.7,Other,Drug Cost,14.7,,,14.7,Other,Drug Cost,14.7,,,14.7,Other,Drug Cost,14.7,,,14.7,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,14.7,,,14.7,Other,Drug Cost,33.08,,,33.08,Other,225% Medicaid APG methodology,20.58,,,20.58,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,14.7,,,14.7,Other,Drug Cost,14.7,,,14.7,Other,Drug Cost,18.38,,,18.38,Other,125% Medicaid APG methodology,0.01,34.77,
LIDOCAINE/PRILO CREAM 2.5% 5GM  ,,,,40534679,CDM,250,RC,00168-0357-55,NDC,both,5,GM,23.63,9.33,39.4668,,9.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.09,30,,7.09,percent of total billed charges,"Drugs, Inpatient Only",7.09,30,,7.09,percent of total billed charges,"Drugs, Inpatient Only",7.09,30,,7.09,percent of total billed charges,"Drugs, Inpatient Only",11.82,50,,11.82,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.35,,,7.35,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,16.54,70,,16.54,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.95,,,3.95,Other,Drug Cost,3.95,,,3.95,Other,Drug Cost,3.95,,,3.95,Other,Drug Cost,3.95,,,3.95,Other,Drug Cost,3.95,,,3.95,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.95,,,3.95,Other,Drug Cost,8.89,,,8.89,Other,225% Medicaid APG methodology,5.53,,,5.53,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.95,,,3.95,Other,Drug Cost,3.95,,,3.95,Other,Drug Cost,4.94,,,4.94,Other,125% Medicaid APG methodology,0.01,16.54,
ASPIRIN 81 MG CHEW TAB          ,,,,40534737,CDM,250,RC,48433-0129-01,NDC,both,1,EA,0.28,0.11,39.4668,,0.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.08,30,,0.08,percent of total billed charges,"Drugs, Inpatient Only",0.14,50,,0.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,70,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% Medicaid APG methodology,0.11,,,0.11,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.2,
NITROPRUSSIDE 25MG/ML IV  2ML   ,,,,40534752,CDM,250,RC,25021-0310-02,NDC,both,2,ML,63.7,25.14,39.4668,,25.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.11,30,,19.11,percent of total billed charges,"Drugs, Inpatient Only",19.11,30,,19.11,percent of total billed charges,"Drugs, Inpatient Only",19.11,30,,19.11,percent of total billed charges,"Drugs, Inpatient Only",31.85,50,,31.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,91.77,,,91.77,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,44.59,70,,44.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,49.34,,,49.34,Other,Drug Cost,49.34,,,49.34,Other,Drug Cost,49.34,,,49.34,Other,Drug Cost,49.34,,,49.34,Other,Drug Cost,49.34,,,49.34,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,49.34,,,49.34,Other,Drug Cost,111.02,,,111.02,Other,225% Medicaid APG methodology,69.08,,,69.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,49.34,,,49.34,Other,Drug Cost,49.34,,,49.34,Other,Drug Cost,61.68,,,61.68,Other,125% Medicaid APG methodology,0.01,111.02,
AMITRIPTYLINE 10 MG TAB         ,,,,40534760,CDM,250,RC,50268-0037-15,NDC,both,1,EA,1.26,0.5,39.4668,,0.5,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.38,30,,0.38,percent of total billed charges,"Drugs, Inpatient Only",0.38,30,,0.38,percent of total billed charges,"Drugs, Inpatient Only",0.38,30,,0.38,percent of total billed charges,"Drugs, Inpatient Only",0.63,50,,0.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.73,,,0.73,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.88,70,,0.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.39,,,0.39,Other,Drug Cost,0.88,,,0.88,Other,225% Medicaid APG methodology,0.55,,,0.55,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.39,,,0.39,Other,Drug Cost,0.39,,,0.39,Other,Drug Cost,0.49,,,0.49,Other,125% Medicaid APG methodology,0.01,0.88,
BUPIV 0.75% PF INJ SLN 10ML     ,,,,40534828,CDM,250,RC,63323-0472-17,NDC,both,10,ML,11.55,4.56,39.4668,,4.56,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.47,30,,3.47,percent of total billed charges,"Drugs, Inpatient Only",3.47,30,,3.47,percent of total billed charges,"Drugs, Inpatient Only",3.47,30,,3.47,percent of total billed charges,"Drugs, Inpatient Only",5.78,50,,5.78,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.93,,,0.93,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.09,70,,8.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.5,,,0.5,Other,Drug Cost,1.13,,,1.13,Other,225% Medicaid APG methodology,0.7,,,0.7,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.63,,,0.63,Other,125% Medicaid APG methodology,0.01,8.09,
BUPROPION 150MG/12H ER TAB      ,,,,40534836,CDM,250,RC,00904-6585-61,NDC,both,1,EA,1.26,0.5,39.4668,,0.5,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.38,30,,0.38,percent of total billed charges,"Drugs, Inpatient Only",0.38,30,,0.38,percent of total billed charges,"Drugs, Inpatient Only",0.38,30,,0.38,percent of total billed charges,"Drugs, Inpatient Only",0.63,50,,0.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.88,70,,0.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.29,,,0.29,Other,225% Medicaid APG methodology,0.18,,,0.18,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.16,,,0.16,Other,125% Medicaid APG methodology,0.01,0.88,
ESCITALOPRAM 20 MG TAB          ,,,,40534844,CDM,250,RC,00904-6427-61,NDC,both,1,EA,0.53,0.21,39.4668,,0.21,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.27,50,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,70,,0.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.2,,,0.2,Other,225% Medicaid APG methodology,0.13,,,0.13,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,0.37,
QUETIAPINE 50 MG TAB            ,,,,40534869,CDM,250,RC,67877-0249-01,NDC,both,1,EA,0.14,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.07,50,,0.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.1,
PORACTANT ALFA  80MG/ML VIAL    ,,,,40534885,CDM,250,RC,10122-0510-03,NDC,both,3,ML,3001.95,1184.77,39.4668,,1184.77,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,900.59,30,,900.59,percent of total billed charges,"Drugs, Inpatient Only",900.59,30,,900.59,percent of total billed charges,"Drugs, Inpatient Only",900.59,30,,900.59,percent of total billed charges,"Drugs, Inpatient Only",1500.98,50,,1500.98,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,825.28,,,825.28,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2101.37,70,,2101.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,443.7,,,443.7,Other,Drug Cost,443.7,,,443.7,Other,Drug Cost,443.7,,,443.7,Other,Drug Cost,443.7,,,443.7,Other,Drug Cost,443.7,,,443.7,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,443.7,,,443.7,Other,Drug Cost,998.33,,,998.33,Other,225% Medicaid APG methodology,621.18,,,621.18,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,443.7,,,443.7,Other,Drug Cost,443.7,,,443.7,Other,Drug Cost,554.63,,,554.63,Other,125% Medicaid APG methodology,0.01,2101.37,
BUPROPION 100MG/12H ER TAB      ,,,,40534893,CDM,250,RC,43547-0288-10,NDC,both,1,EA,0.53,0.21,39.4668,,0.21,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.27,50,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,70,,0.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.37,
ATOMOXETINE 40 MG CAP           ,,,,40534919,CDM,250,RC,68462-0268-30,NDC,both,1,EA,6.83,2.7,39.4668,,2.7,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.05,30,,2.05,percent of total billed charges,"Drugs, Inpatient Only",2.05,30,,2.05,percent of total billed charges,"Drugs, Inpatient Only",2.05,30,,2.05,percent of total billed charges,"Drugs, Inpatient Only",3.42,50,,3.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.45,,,1.45,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.78,70,,4.78,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.78,,,0.78,Other,Drug Cost,0.78,,,0.78,Other,Drug Cost,0.78,,,0.78,Other,Drug Cost,0.78,,,0.78,Other,Drug Cost,0.78,,,0.78,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.78,,,0.78,Other,Drug Cost,1.76,,,1.76,Other,225% Medicaid APG methodology,1.09,,,1.09,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.78,,,0.78,Other,Drug Cost,0.78,,,0.78,Other,Drug Cost,0.98,,,0.98,Other,125% Medicaid APG methodology,0.01,4.78,
ATOMOXETINE 10 MG CAP           ,,,,40534943,CDM,250,RC,68462-0265-30,NDC,both,1,EA,7.7,3.04,39.4668,,3.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.31,30,,2.31,percent of total billed charges,"Drugs, Inpatient Only",2.31,30,,2.31,percent of total billed charges,"Drugs, Inpatient Only",2.31,30,,2.31,percent of total billed charges,"Drugs, Inpatient Only",3.85,50,,3.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.41,,,0.41,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.39,70,,5.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.5,,,0.5,Other,225% Medicaid APG methodology,0.31,,,0.31,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.28,,,0.28,Other,125% Medicaid APG methodology,0.01,5.39,
DORZOLAMIDE 2% OPHTH SOLN 10ML  ,,,,40535007,CDM,250,RC,72266-0197-01,NDC,both,10,ML,48.76,19.24,39.4668,,19.24,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.63,30,,14.63,percent of total billed charges,"Drugs, Inpatient Only",14.63,30,,14.63,percent of total billed charges,"Drugs, Inpatient Only",14.63,30,,14.63,percent of total billed charges,"Drugs, Inpatient Only",24.38,50,,24.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.59,,,15.59,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,34.13,70,,34.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.38,,,8.38,Other,Drug Cost,8.38,,,8.38,Other,Drug Cost,8.38,,,8.38,Other,Drug Cost,8.38,,,8.38,Other,Drug Cost,8.38,,,8.38,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,8.38,,,8.38,Other,Drug Cost,18.86,,,18.86,Other,225% Medicaid APG methodology,11.73,,,11.73,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,8.38,,,8.38,Other,Drug Cost,8.38,,,8.38,Other,Drug Cost,10.48,,,10.48,Other,125% Medicaid APG methodology,0.01,34.13,
PILOCARPINE 1% OPHTH SOLN 15ML  ,,,,40535015,CDM,250,RC,00998-0203-15,NDC,both,15,ML,306.6,121.01,39.4668,,121.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,91.98,30,,91.98,percent of total billed charges,"Drugs, Inpatient Only",91.98,30,,91.98,percent of total billed charges,"Drugs, Inpatient Only",91.98,30,,91.98,percent of total billed charges,"Drugs, Inpatient Only",153.3,50,,153.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,118.02,,,118.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,214.62,70,,214.62,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,63.45,,,63.45,Other,Drug Cost,63.45,,,63.45,Other,Drug Cost,63.45,,,63.45,Other,Drug Cost,63.45,,,63.45,Other,Drug Cost,63.45,,,63.45,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,63.45,,,63.45,Other,Drug Cost,142.76,,,142.76,Other,225% Medicaid APG methodology,88.83,,,88.83,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,63.45,,,63.45,Other,Drug Cost,63.45,,,63.45,Other,Drug Cost,79.31,,,79.31,Other,125% Medicaid APG methodology,0.01,214.62,
FENTANYL 75 MCG/HR TD FILM ER   ,,,,40535023,CDM,250,RC,00406-9075-76,NDC,both,1,EA,66.26,26.15,39.4668,,26.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.88,30,,19.88,percent of total billed charges,"Drugs, Inpatient Only",19.88,30,,19.88,percent of total billed charges,"Drugs, Inpatient Only",19.88,30,,19.88,percent of total billed charges,"Drugs, Inpatient Only",33.13,50,,33.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.47,,,2.47,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,46.38,70,,46.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.33,,,1.33,Other,Drug Cost,1.33,,,1.33,Other,Drug Cost,1.33,,,1.33,Other,Drug Cost,1.33,,,1.33,Other,Drug Cost,1.33,,,1.33,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.33,,,1.33,Other,Drug Cost,2.99,,,2.99,Other,225% Medicaid APG methodology,1.86,,,1.86,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.33,,,1.33,Other,Drug Cost,1.33,,,1.33,Other,Drug Cost,1.66,,,1.66,Other,125% Medicaid APG methodology,0.01,46.38,
NYSTATIN-TRIAMCIN OINT 15 G     ,,,,40535049,CDM,250,RC,45802-0244-14,NDC,both,15,GM,28.35,11.19,39.4668,,11.19,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.51,30,,8.51,percent of total billed charges,"Drugs, Inpatient Only",8.51,30,,8.51,percent of total billed charges,"Drugs, Inpatient Only",8.51,30,,8.51,percent of total billed charges,"Drugs, Inpatient Only",14.18,50,,14.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.46,,,4.46,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.85,70,,19.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.4,,,2.4,Other,Drug Cost,5.4,,,5.4,Other,225% Medicaid APG methodology,3.36,,,3.36,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,3,,,3,Other,125% Medicaid APG methodology,0.01,19.85,
NITROGLYCERIN 50MG/D5W 250ML    ,,,,40535106,CDM,250,RC,00338-1049-02,NDC,both,250,ML,43.75,17.27,39.4668,,17.27,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.13,30,,13.13,percent of total billed charges,"Drugs, Inpatient Only",13.13,30,,13.13,percent of total billed charges,"Drugs, Inpatient Only",13.13,30,,13.13,percent of total billed charges,"Drugs, Inpatient Only",21.88,50,,21.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.65,,,4.65,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,30.63,70,,30.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.5,,,2.5,Other,Drug Cost,5.63,,,5.63,Other,225% Medicaid APG methodology,3.5,,,3.5,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,3.13,,,3.13,Other,125% Medicaid APG methodology,0.01,30.63,
SIMVASTATIN 10 MG TAB           ,,,,40535205,CDM,250,RC,68084-0511-01,NDC,both,1,EA,0.32,0.13,39.4668,,0.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.16,50,,0.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,70,,0.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.22,
DIPHHEN/LIDOCAINE/NYSTATIN 15M  ,,,,40535452,CDM,250,RC,50383-0775-04Y,NDC,both,15,ML,42.63,16.82,39.4668,,16.82,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.79,30,,12.79,percent of total billed charges,"Drugs, Inpatient Only",12.79,30,,12.79,percent of total billed charges,"Drugs, Inpatient Only",12.79,30,,12.79,percent of total billed charges,"Drugs, Inpatient Only",21.32,50,,21.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.11,,,3.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,29.84,70,,29.84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.67,,,1.67,Other,Drug Cost,1.67,,,1.67,Other,Drug Cost,1.67,,,1.67,Other,Drug Cost,1.67,,,1.67,Other,Drug Cost,1.67,,,1.67,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.67,,,1.67,Other,Drug Cost,3.76,,,3.76,Other,225% Medicaid APG methodology,2.34,,,2.34,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.67,,,1.67,Other,Drug Cost,1.67,,,1.67,Other,Drug Cost,2.09,,,2.09,Other,125% Medicaid APG methodology,0.01,29.84,
PYRIDOXINE 50 MG TAB            ,,,,40535684,CDM,250,RC,77333-0940-10,NDC,both,1,EA,0.39,0.15,39.4668,,0.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.2,50,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.27,70,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.23,,,0.23,Other,225% Medicaid APG methodology,0.14,,,0.14,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.13,,,0.13,Other,125% Medicaid APG methodology,0.01,0.27,
PED MVI (POLY-VI-SOL) LIQ 50ML  ,,,,40535734,CDM,250,RC,00087-0402-03,NDC,both,50,ML,52.5,20.72,39.4668,,20.72,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.75,30,,15.75,percent of total billed charges,"Drugs, Inpatient Only",15.75,30,,15.75,percent of total billed charges,"Drugs, Inpatient Only",15.75,30,,15.75,percent of total billed charges,"Drugs, Inpatient Only",26.25,50,,26.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,27.9,,,27.9,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,36.75,70,,36.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15,,,15,Other,Drug Cost,15,,,15,Other,Drug Cost,15,,,15,Other,Drug Cost,15,,,15,Other,Drug Cost,15,,,15,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,15,,,15,Other,Drug Cost,33.75,,,33.75,Other,225% Medicaid APG methodology,21,,,21,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,15,,,15,Other,Drug Cost,15,,,15,Other,Drug Cost,18.75,,,18.75,Other,125% Medicaid APG methodology,0.01,36.75,
CASTOR OIL ORAL LIQUID 60 ML    ,,,,40535999,CDM,250,RC,00395-0515-92,NDC,both,60,ML,11.2,4.42,39.4668,,4.42,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.36,30,,3.36,percent of total billed charges,"Drugs, Inpatient Only",3.36,30,,3.36,percent of total billed charges,"Drugs, Inpatient Only",3.36,30,,3.36,percent of total billed charges,"Drugs, Inpatient Only",5.6,50,,5.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.99,,,5.99,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.84,70,,7.84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.22,,,3.22,Other,Drug Cost,3.22,,,3.22,Other,Drug Cost,3.22,,,3.22,Other,Drug Cost,3.22,,,3.22,Other,Drug Cost,3.22,,,3.22,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.22,,,3.22,Other,Drug Cost,7.25,,,7.25,Other,225% Medicaid APG methodology,4.51,,,4.51,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.22,,,3.22,Other,Drug Cost,3.22,,,3.22,Other,Drug Cost,4.03,,,4.03,Other,125% Medicaid APG methodology,0.01,7.84,
VALPROIC ACID 10MG/ML NS        ,,,,40537433,CDM,250,RC,00143-9785-10p,NDC,both,1,ML,1.54,0.61,39.4668,,0.61,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.46,30,,0.46,percent of total billed charges,"Drugs, Inpatient Only",0.46,30,,0.46,percent of total billed charges,"Drugs, Inpatient Only",0.46,30,,0.46,percent of total billed charges,"Drugs, Inpatient Only",0.77,50,,0.77,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.97,,,0.97,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.08,70,,1.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.52,,,0.52,Other,Drug Cost,0.52,,,0.52,Other,Drug Cost,0.52,,,0.52,Other,Drug Cost,0.52,,,0.52,Other,Drug Cost,0.52,,,0.52,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.52,,,0.52,Other,Drug Cost,1.17,,,1.17,Other,225% Medicaid APG methodology,0.73,,,0.73,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.52,,,0.52,Other,Drug Cost,0.52,,,0.52,Other,Drug Cost,0.65,,,0.65,Other,125% Medicaid APG methodology,0.01,1.17,
MAGIC MOUTH (BLM) SUSP 15 ML    ,,,,40537813,CDM,250,RC,65628-0050-04,NDC,both,15,ML,36.86,14.55,39.4668,,14.55,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.06,30,,11.06,percent of total billed charges,"Drugs, Inpatient Only",11.06,30,,11.06,percent of total billed charges,"Drugs, Inpatient Only",11.06,30,,11.06,percent of total billed charges,"Drugs, Inpatient Only",18.43,50,,18.43,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.59,,,19.59,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,25.8,70,,25.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.53,,,10.53,Other,Drug Cost,10.53,,,10.53,Other,Drug Cost,10.53,,,10.53,Other,Drug Cost,10.53,,,10.53,Other,Drug Cost,10.53,,,10.53,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,10.53,,,10.53,Other,Drug Cost,23.69,,,23.69,Other,225% Medicaid APG methodology,14.74,,,14.74,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,10.53,,,10.53,Other,Drug Cost,10.53,,,10.53,Other,Drug Cost,13.16,,,13.16,Other,125% Medicaid APG methodology,0.01,25.8,
NITROGLYCERIN 2% TD OINT 1 G    ,,,,40537862,CDM,250,RC,00281-0326-08,NDC,both,1,GM,6.51,2.57,39.4668,,2.57,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.95,30,,1.95,percent of total billed charges,"Drugs, Inpatient Only",1.95,30,,1.95,percent of total billed charges,"Drugs, Inpatient Only",1.95,30,,1.95,percent of total billed charges,"Drugs, Inpatient Only",3.26,50,,3.26,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.23,,,2.23,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.56,70,,4.56,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.2,,,1.2,Other,Drug Cost,2.7,,,2.7,Other,225% Medicaid APG methodology,1.68,,,1.68,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.2,,,1.2,Other,Drug Cost,1.2,,,1.2,Other,Drug Cost,1.5,,,1.5,Other,125% Medicaid APG methodology,0.01,4.56,
SERTRALINE 25 MG TAB            ,,,,40537870,CDM,250,RC,60687-0231-01,NDC,both,1,EA,0.91,0.36,39.4668,,0.36,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.27,30,,0.27,percent of total billed charges,"Drugs, Inpatient Only",0.27,30,,0.27,percent of total billed charges,"Drugs, Inpatient Only",0.27,30,,0.27,percent of total billed charges,"Drugs, Inpatient Only",0.46,50,,0.46,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.64,70,,0.64,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.25,,,0.25,Other,225% Medicaid APG methodology,0.15,,,0.15,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.14,,,0.14,Other,125% Medicaid APG methodology,0.01,0.64,
LIDOCAINE 1% PF INJ SOLN 5 ML   ,,,,40537896,CDM,250,RC,63323-0492-57,NDC,both,5,ML,8.16,3.22,39.4668,,3.22,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.45,30,,2.45,percent of total billed charges,"Drugs, Inpatient Only",2.45,30,,2.45,percent of total billed charges,"Drugs, Inpatient Only",2.45,30,,2.45,percent of total billed charges,"Drugs, Inpatient Only",4.08,50,,4.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.48,,,0.48,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.71,70,,5.71,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,Drug Cost,0.59,,,0.59,Other,225% Medicaid APG methodology,0.36,,,0.36,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.33,,,0.33,Other,125% Medicaid APG methodology,0.01,5.71,
ALBUTEROL-IPRAT 2.5-0.5MG/3ML   ,,,,40537912,CDM,250,RC,00487-0201-01,NDC,both,3,ML,1.61,0.64,39.4668,,0.64,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.48,30,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.48,30,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.48,30,,0.48,percent of total billed charges,"Drugs, Inpatient Only",0.81,50,,0.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.45,,,0.45,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.13,70,,1.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,Drug Cost,0.54,,,0.54,Other,225% Medicaid APG methodology,0.34,,,0.34,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.3,,,0.3,Other,125% Medicaid APG methodology,0.01,1.13,
RACEPINEPH 2.25% INH SLN 0.5ML  ,,,,40537938,CDM,250,RC,00487-5901-99,NDC,both,1,EA,5.74,2.27,39.4668,,2.27,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.72,30,,1.72,percent of total billed charges,"Drugs, Inpatient Only",1.72,30,,1.72,percent of total billed charges,"Drugs, Inpatient Only",1.72,30,,1.72,percent of total billed charges,"Drugs, Inpatient Only",2.87,50,,2.87,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.14,,,2.14,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.02,70,,4.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.15,,,1.15,Other,Drug Cost,1.15,,,1.15,Other,Drug Cost,1.15,,,1.15,Other,Drug Cost,1.15,,,1.15,Other,Drug Cost,1.15,,,1.15,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.15,,,1.15,Other,Drug Cost,2.59,,,2.59,Other,225% Medicaid APG methodology,1.61,,,1.61,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.15,,,1.15,Other,Drug Cost,1.15,,,1.15,Other,Drug Cost,1.44,,,1.44,Other,125% Medicaid APG methodology,0.01,4.02,
IBUPROFEN 100MG/5ML ORLSUSP     ,,,,40537953,CDM,250,RC,68094-0600-62,NDC,both,5,ML,2.77,1.09,39.4668,,1.09,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.83,30,,0.83,percent of total billed charges,"Drugs, Inpatient Only",0.83,30,,0.83,percent of total billed charges,"Drugs, Inpatient Only",0.83,30,,0.83,percent of total billed charges,"Drugs, Inpatient Only",1.39,50,,1.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.15,,,1.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.94,70,,1.94,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.62,,,0.62,Other,Drug Cost,1.4,,,1.4,Other,225% Medicaid APG methodology,0.87,,,0.87,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.78,,,0.78,Other,125% Medicaid APG methodology,0.01,1.94,
AMIODARONE 400 MG TAB           ,,,,40537961,CDM,250,RC,00245-1645-30,NDC,both,1,EA,1.19,0.47,39.4668,,0.47,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.36,30,,0.36,percent of total billed charges,"Drugs, Inpatient Only",0.36,30,,0.36,percent of total billed charges,"Drugs, Inpatient Only",0.36,30,,0.36,percent of total billed charges,"Drugs, Inpatient Only",0.6,50,,0.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.61,,,0.61,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.83,70,,0.83,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.33,,,0.33,Other,Drug Cost,0.74,,,0.74,Other,225% Medicaid APG methodology,0.46,,,0.46,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.41,,,0.41,Other,125% Medicaid APG methodology,0.01,0.83,
PHENOBARBITAL 60 MG TAB         ,,,,40537987,CDM,250,RC,00143-1455-01,NDC,both,1,EA,0.84,0.33,39.4668,,0.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,30,,0.25,percent of total billed charges,"Drugs, Inpatient Only",0.25,30,,0.25,percent of total billed charges,"Drugs, Inpatient Only",0.25,30,,0.25,percent of total billed charges,"Drugs, Inpatient Only",0.42,50,,0.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.59,70,,0.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.59,
SILVER SULFADIAZINE1% CREAM25G  ,,,,40538092,CDM,250,RC,67877-0124-25,NDC,both,25,GM,14.88,5.87,39.4668,,5.87,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.46,30,,4.46,percent of total billed charges,"Drugs, Inpatient Only",4.46,30,,4.46,percent of total billed charges,"Drugs, Inpatient Only",4.46,30,,4.46,percent of total billed charges,"Drugs, Inpatient Only",7.44,50,,7.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.93,,,0.93,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.42,70,,10.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.5,,,0.5,Other,Drug Cost,1.13,,,1.13,Other,225% Medicaid APG methodology,0.7,,,0.7,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.63,,,0.63,Other,125% Medicaid APG methodology,0.01,10.42,
RISPERIDONE 0.5 MG TAB          ,,,,40538159,CDM,250,RC,68084-0271-01,NDC,both,1,EA,0.81,0.32,39.4668,,0.32,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.24,30,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.24,30,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.24,30,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.41,50,,0.41,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.47,,,0.47,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.57,70,,0.57,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.56,,,0.56,Other,225% Medicaid APG methodology,0.35,,,0.35,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.31,,,0.31,Other,125% Medicaid APG methodology,0.01,0.57,
OLANZAPINE 5 MG ODT             ,,,,40538167,CDM,250,RC,50268-0615-13,NDC,both,1,EA,6.06,2.39,39.4668,,2.39,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.82,30,,1.82,percent of total billed charges,"Drugs, Inpatient Only",1.82,30,,1.82,percent of total billed charges,"Drugs, Inpatient Only",1.82,30,,1.82,percent of total billed charges,"Drugs, Inpatient Only",3.03,50,,3.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.72,,,2.72,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.24,70,,4.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.46,,,1.46,Other,Drug Cost,1.46,,,1.46,Other,Drug Cost,1.46,,,1.46,Other,Drug Cost,1.46,,,1.46,Other,Drug Cost,1.46,,,1.46,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.46,,,1.46,Other,Drug Cost,3.29,,,3.29,Other,225% Medicaid APG methodology,2.04,,,2.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.46,,,1.46,Other,Drug Cost,1.46,,,1.46,Other,Drug Cost,1.83,,,1.83,Other,125% Medicaid APG methodology,0.01,4.24,
MEMANTINE 5 MG TAB              ,,,,40538183,CDM,250,RC,00591-3870-44,NDC,both,1,EA,0.84,0.33,39.4668,,0.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,30,,0.25,percent of total billed charges,"Drugs, Inpatient Only",0.25,30,,0.25,percent of total billed charges,"Drugs, Inpatient Only",0.25,30,,0.25,percent of total billed charges,"Drugs, Inpatient Only",0.42,50,,0.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.59,70,,0.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% Medicaid APG methodology,0.1,,,0.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.59,
MEMANTINE 10 MG TAB             ,,,,40538191,CDM,250,RC,00904-6506-61,NDC,both,1,EA,0.88,0.35,39.4668,,0.35,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.26,30,,0.26,percent of total billed charges,"Drugs, Inpatient Only",0.26,30,,0.26,percent of total billed charges,"Drugs, Inpatient Only",0.26,30,,0.26,percent of total billed charges,"Drugs, Inpatient Only",0.44,50,,0.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.54,,,0.54,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.62,70,,0.62,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.29,,,0.29,Other,Drug Cost,0.65,,,0.65,Other,225% Medicaid APG methodology,0.41,,,0.41,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.29,,,0.29,Other,Drug Cost,0.29,,,0.29,Other,Drug Cost,0.36,,,0.36,Other,125% Medicaid APG methodology,0.01,0.65,
DIPHENHYDRAMINE 25MG/10ML CUP   ,,,,40538225,CDM,250,RC,69339-0152-19,NDC,both,10,ML,8.79,3.47,39.4668,,3.47,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.64,30,,2.64,percent of total billed charges,"Drugs, Inpatient Only",2.64,30,,2.64,percent of total billed charges,"Drugs, Inpatient Only",2.64,30,,2.64,percent of total billed charges,"Drugs, Inpatient Only",4.4,50,,4.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.29,,,3.29,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.15,70,,6.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.77,,,1.77,Other,Drug Cost,1.77,,,1.77,Other,Drug Cost,1.77,,,1.77,Other,Drug Cost,1.77,,,1.77,Other,Drug Cost,1.77,,,1.77,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.77,,,1.77,Other,Drug Cost,3.98,,,3.98,Other,225% Medicaid APG methodology,2.48,,,2.48,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.77,,,1.77,Other,Drug Cost,1.77,,,1.77,Other,Drug Cost,2.21,,,2.21,Other,125% Medicaid APG methodology,0.01,6.15,
ERYTHROMYCIN 0.5% OPT OINT 1 G  ,,,,40538233,CDM,250,RC,24208-0910-19,NDC,both,1,GM,30.56,12.06,39.4668,,12.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.17,30,,9.17,percent of total billed charges,"Drugs, Inpatient Only",9.17,30,,9.17,percent of total billed charges,"Drugs, Inpatient Only",9.17,30,,9.17,percent of total billed charges,"Drugs, Inpatient Only",15.28,50,,15.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.14,,,3.14,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,21.39,70,,21.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.69,,,1.69,Other,Drug Cost,1.69,,,1.69,Other,Drug Cost,1.69,,,1.69,Other,Drug Cost,1.69,,,1.69,Other,Drug Cost,1.69,,,1.69,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.69,,,1.69,Other,Drug Cost,3.8,,,3.8,Other,225% Medicaid APG methodology,2.37,,,2.37,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.69,,,1.69,Other,Drug Cost,1.69,,,1.69,Other,Drug Cost,2.11,,,2.11,Other,125% Medicaid APG methodology,0.01,21.39,
ESMOLOL 10 MG/ML IV SOLN 10 ML  ,,,,40538324,CDM,250,RC,67457-0182-10,NDC,both,10,ML,23.1,9.12,39.4668,,9.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.93,30,,6.93,percent of total billed charges,"Drugs, Inpatient Only",6.93,30,,6.93,percent of total billed charges,"Drugs, Inpatient Only",6.93,30,,6.93,percent of total billed charges,"Drugs, Inpatient Only",11.55,50,,11.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.95,,,5.95,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,16.17,70,,16.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.2,,,3.2,Other,Drug Cost,7.2,,,7.2,Other,225% Medicaid APG methodology,4.48,,,4.48,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,4,,,4,Other,125% Medicaid APG methodology,0.01,16.17,
"MGW 123 REC ENEMA NS 1,000 ML   ",,,,40538530,CDM,250,RC,99991-0926-23,NDC,both,1000,ML,117.99,46.57,39.4668,,46.57,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,35.4,30,,35.4,percent of total billed charges,"Drugs, Inpatient Only",35.4,30,,35.4,percent of total billed charges,"Drugs, Inpatient Only",35.4,30,,35.4,percent of total billed charges,"Drugs, Inpatient Only",59,50,,59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,49.09,,,49.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,82.59,70,,82.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,26.39,,,26.39,Other,Drug Cost,26.39,,,26.39,Other,Drug Cost,26.39,,,26.39,Other,Drug Cost,26.39,,,26.39,Other,Drug Cost,26.39,,,26.39,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,26.39,,,26.39,Other,Drug Cost,59.38,,,59.38,Other,225% Medicaid APG methodology,36.95,,,36.95,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,26.39,,,26.39,Other,Drug Cost,26.39,,,26.39,Other,Drug Cost,32.99,,,32.99,Other,125% Medicaid APG methodology,0.01,82.59,
LUBIPROSTONE 8 MCG CAP UD       ,,,,40538662,CDM,250,RC,00480-3479-06,NDC,both,1,EA,4.55,1.8,39.4668,,1.8,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.37,30,,1.37,percent of total billed charges,"Drugs, Inpatient Only",1.37,30,,1.37,percent of total billed charges,"Drugs, Inpatient Only",1.37,30,,1.37,percent of total billed charges,"Drugs, Inpatient Only",2.28,50,,2.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.61,,,0.61,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.19,70,,3.19,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.33,,,0.33,Other,Drug Cost,0.74,,,0.74,Other,225% Medicaid APG methodology,0.46,,,0.46,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.41,,,0.41,Other,125% Medicaid APG methodology,0.01,3.19,
ULIPRISTAL 30 MG TAB            ,,,,40538688,CDM,250,RC,73302-0456-01,NDC,both,1,EA,125.93,49.7,39.4668,,49.7,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,37.78,30,,37.78,percent of total billed charges,"Drugs, Inpatient Only",37.78,30,,37.78,percent of total billed charges,"Drugs, Inpatient Only",37.78,30,,37.78,percent of total billed charges,"Drugs, Inpatient Only",62.97,50,,62.97,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,29.5,,,29.5,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,88.15,70,,88.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.86,,,15.86,Other,Drug Cost,15.86,,,15.86,Other,Drug Cost,15.86,,,15.86,Other,Drug Cost,15.86,,,15.86,Other,Drug Cost,15.86,,,15.86,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,15.86,,,15.86,Other,Drug Cost,35.69,,,35.69,Other,225% Medicaid APG methodology,22.2,,,22.2,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,15.86,,,15.86,Other,Drug Cost,15.86,,,15.86,Other,Drug Cost,19.83,,,19.83,Other,125% Medicaid APG methodology,0.01,88.15,
COD-GUAI 10-100 MG/5 ML 5 ML    ,,,,40538696,CDM,250,RC,00121-1775-00,NDC,both,5,ML,1.68,0.66,39.4668,,0.66,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.5,30,,0.5,percent of total billed charges,"Drugs, Inpatient Only",0.5,30,,0.5,percent of total billed charges,"Drugs, Inpatient Only",0.5,30,,0.5,percent of total billed charges,"Drugs, Inpatient Only",0.84,50,,0.84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.61,,,0.61,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.18,70,,1.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.33,,,0.33,Other,Drug Cost,0.74,,,0.74,Other,225% Medicaid APG methodology,0.46,,,0.46,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.41,,,0.41,Other,125% Medicaid APG methodology,0.01,1.18,
MORPHINE 10MG 0.5 ML ORAL SYR   ,,,,40538704,CDM,250,RC,68094-0045-58,NDC,both,1,EA,9.63,3.8,39.4668,,3.8,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.89,30,,2.89,percent of total billed charges,"Drugs, Inpatient Only",2.89,30,,2.89,percent of total billed charges,"Drugs, Inpatient Only",2.89,30,,2.89,percent of total billed charges,"Drugs, Inpatient Only",4.82,50,,4.82,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.88,,,2.88,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.74,70,,6.74,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.55,,,1.55,Other,Drug Cost,1.55,,,1.55,Other,Drug Cost,1.55,,,1.55,Other,Drug Cost,1.55,,,1.55,Other,Drug Cost,1.55,,,1.55,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.55,,,1.55,Other,Drug Cost,3.49,,,3.49,Other,225% Medicaid APG methodology,2.17,,,2.17,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.55,,,1.55,Other,Drug Cost,1.55,,,1.55,Other,Drug Cost,1.94,,,1.94,Other,125% Medicaid APG methodology,0.01,6.74,
BEMPEDOIC ACID 180 MG TAB       ,,,,40538720,CDM,250,RC,72426-0118-03,NDC,both,1,EA,42.91,16.94,39.4668,,16.94,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.87,30,,12.87,percent of total billed charges,"Drugs, Inpatient Only",12.87,30,,12.87,percent of total billed charges,"Drugs, Inpatient Only",12.87,30,,12.87,percent of total billed charges,"Drugs, Inpatient Only",21.46,50,,21.46,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.2,,,12.2,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,30.04,70,,30.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.56,,,6.56,Other,Drug Cost,6.56,,,6.56,Other,Drug Cost,6.56,,,6.56,Other,Drug Cost,6.56,,,6.56,Other,Drug Cost,6.56,,,6.56,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,6.56,,,6.56,Other,Drug Cost,14.76,,,14.76,Other,225% Medicaid APG methodology,9.18,,,9.18,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.56,,,6.56,Other,Drug Cost,6.56,,,6.56,Other,Drug Cost,8.2,,,8.2,Other,125% Medicaid APG methodology,0.01,30.04,
LIDOCAINE 4% TOPICAL PATCH      ,,,,40538753,CDM,250,RC,00536-1202-07,NDC,both,1,EA,3.15,1.24,39.4668,,1.24,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.95,30,,0.95,percent of total billed charges,"Drugs, Inpatient Only",0.95,30,,0.95,percent of total billed charges,"Drugs, Inpatient Only",0.95,30,,0.95,percent of total billed charges,"Drugs, Inpatient Only",1.58,50,,1.58,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.19,,,1.19,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.21,70,,2.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.64,,,0.64,Other,Drug Cost,0.64,,,0.64,Other,Drug Cost,0.64,,,0.64,Other,Drug Cost,0.64,,,0.64,Other,Drug Cost,0.64,,,0.64,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.64,,,0.64,Other,Drug Cost,1.44,,,1.44,Other,225% Medicaid APG methodology,0.9,,,0.9,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.64,,,0.64,Other,Drug Cost,0.64,,,0.64,Other,Drug Cost,0.8,,,0.8,Other,125% Medicaid APG methodology,0.01,2.21,
BARI SULF 40% ORAL PASTE 20 ML  ,,,,40538829,CDM,250,RC,32909-0125-22a,NDC,both,20,ML,14.25,5.62,39.4668,,5.62,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.28,30,,4.28,percent of total billed charges,"Drugs, Inpatient Only",4.28,30,,4.28,percent of total billed charges,"Drugs, Inpatient Only",4.28,30,,4.28,percent of total billed charges,"Drugs, Inpatient Only",7.13,50,,7.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.41,,,8.41,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.98,70,,9.98,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.52,,,4.52,Other,Drug Cost,4.52,,,4.52,Other,Drug Cost,4.52,,,4.52,Other,Drug Cost,4.52,,,4.52,Other,Drug Cost,4.52,,,4.52,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.52,,,4.52,Other,Drug Cost,10.17,,,10.17,Other,225% Medicaid APG methodology,6.33,,,6.33,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.52,,,4.52,Other,Drug Cost,4.52,,,4.52,Other,Drug Cost,5.65,,,5.65,Other,125% Medicaid APG methodology,0.01,10.17,
BARI SULF 40% ORAL SUSP 20 ML   ,,,,40538837,CDM,250,RC,32909-0116-00a,NDC,both,1,ML,3.5,1.38,39.4668,,1.38,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.05,30,,1.05,percent of total billed charges,"Drugs, Inpatient Only",1.05,30,,1.05,percent of total billed charges,"Drugs, Inpatient Only",1.05,30,,1.05,percent of total billed charges,"Drugs, Inpatient Only",1.75,50,,1.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.86,,,1.86,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.45,70,,2.45,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1,,,1,Other,Drug Cost,2.25,,,2.25,Other,225% Medicaid APG methodology,1.4,,,1.4,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1.25,,,1.25,Other,125% Medicaid APG methodology,0.01,2.45,
DEX-GUA 10 -100 MG/5 ML UD      ,,,,40538886,CDM,250,RC,00121-0638-00,NDC,both,5,ML,28.18,11.12,39.4668,,11.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.45,30,,8.45,percent of total billed charges,"Drugs, Inpatient Only",8.45,30,,8.45,percent of total billed charges,"Drugs, Inpatient Only",8.45,30,,8.45,percent of total billed charges,"Drugs, Inpatient Only",14.09,50,,14.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.3,,,1.3,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.73,70,,19.73,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.7,,,0.7,Other,Drug Cost,0.7,,,0.7,Other,Drug Cost,0.7,,,0.7,Other,Drug Cost,0.7,,,0.7,Other,Drug Cost,0.7,,,0.7,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.7,,,0.7,Other,Drug Cost,1.58,,,1.58,Other,225% Medicaid APG methodology,0.98,,,0.98,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.7,,,0.7,Other,Drug Cost,0.7,,,0.7,Other,Drug Cost,0.88,,,0.88,Other,125% Medicaid APG methodology,0.01,19.73,
MINOCYCLINE 100 MG CAP          ,,,,40538894,CDM,250,RC,00904-6888-06,NDC,both,1,EA,26.85,10.6,39.4668,,10.6,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.06,30,,8.06,percent of total billed charges,"Drugs, Inpatient Only",8.06,30,,8.06,percent of total billed charges,"Drugs, Inpatient Only",8.06,30,,8.06,percent of total billed charges,"Drugs, Inpatient Only",13.43,50,,13.43,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.36,,,14.36,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,18.8,70,,18.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.72,,,7.72,Other,Drug Cost,7.72,,,7.72,Other,Drug Cost,7.72,,,7.72,Other,Drug Cost,7.72,,,7.72,Other,Drug Cost,7.72,,,7.72,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,7.72,,,7.72,Other,Drug Cost,17.37,,,17.37,Other,225% Medicaid APG methodology,10.81,,,10.81,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.72,,,7.72,Other,Drug Cost,7.72,,,7.72,Other,Drug Cost,9.65,,,9.65,Other,125% Medicaid APG methodology,0.01,18.8,
NF - CENOBAMATE 50 MG TAB       ,,,,40538910,CDM,250,RC,71699-0050-30,NDC,both,1,EA,120.47,47.55,39.4668,,47.55,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,36.14,30,,36.14,percent of total billed charges,"Drugs, Inpatient Only",36.14,30,,36.14,percent of total billed charges,"Drugs, Inpatient Only",36.14,30,,36.14,percent of total billed charges,"Drugs, Inpatient Only",60.24,50,,60.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,44.08,,,44.08,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,84.33,70,,84.33,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,23.7,,,23.7,Other,Drug Cost,23.7,,,23.7,Other,Drug Cost,23.7,,,23.7,Other,Drug Cost,23.7,,,23.7,Other,Drug Cost,23.7,,,23.7,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,23.7,,,23.7,Other,Drug Cost,53.33,,,53.33,Other,225% Medicaid APG methodology,33.18,,,33.18,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,23.7,,,23.7,Other,Drug Cost,23.7,,,23.7,Other,Drug Cost,29.63,,,29.63,Other,125% Medicaid APG methodology,0.01,84.33,
AVACOPAN 10 MG CAP              ,,,,40538944,CDM,250,RC,73556-0168-02,NDC,both,1,EA,280.95,110.88,39.4668,,110.88,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,84.29,30,,84.29,percent of total billed charges,"Drugs, Inpatient Only",84.29,30,,84.29,percent of total billed charges,"Drugs, Inpatient Only",84.29,30,,84.29,percent of total billed charges,"Drugs, Inpatient Only",140.48,50,,140.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,149.3,,,149.3,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,196.67,70,,196.67,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,80.27,,,80.27,Other,Drug Cost,80.27,,,80.27,Other,Drug Cost,80.27,,,80.27,Other,Drug Cost,80.27,,,80.27,Other,Drug Cost,80.27,,,80.27,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,80.27,,,80.27,Other,Drug Cost,180.61,,,180.61,Other,225% Medicaid APG methodology,112.38,,,112.38,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,80.27,,,80.27,Other,Drug Cost,80.27,,,80.27,Other,Drug Cost,100.34,,,100.34,Other,125% Medicaid APG methodology,0.01,196.67,
FORMOTEROL-MOMETASONE 5-200MCG  ,,,,40538985,CDM,250,RC,78206-0126-01,NDC,both,13,GM,1062.43,419.31,39.4668,,419.31,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,318.73,30,,318.73,percent of total billed charges,"Drugs, Inpatient Only",318.73,30,,318.73,percent of total billed charges,"Drugs, Inpatient Only",318.73,30,,318.73,percent of total billed charges,"Drugs, Inpatient Only",531.22,50,,531.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,743.7,70,,743.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.27,,,0.27,Other,225% Medicaid APG methodology,0.17,,,0.17,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.15,,,0.15,Other,125% Medicaid APG methodology,0.01,743.7,
AMOXICILLIN 125 MG/5 ML SUSP    ,,,,40539447,CDM,250,RC,00143-9888-01,NDC,both,5,ML,0.39,0.15,39.4668,,0.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.2,50,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.27,70,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.27,
DIAZEPAM 2.5 MG RECTAL KIT      ,,,,40539496,CDM,250,RC,68682-0650-20,NDC,both,1,EA,607.46,239.75,39.4668,,239.75,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,182.24,30,,182.24,percent of total billed charges,"Drugs, Inpatient Only",182.24,30,,182.24,percent of total billed charges,"Drugs, Inpatient Only",182.24,30,,182.24,percent of total billed charges,"Drugs, Inpatient Only",303.73,50,,303.73,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,151.44,,,151.44,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,425.22,70,,425.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,81.42,,,81.42,Other,Drug Cost,81.42,,,81.42,Other,Drug Cost,81.42,,,81.42,Other,Drug Cost,81.42,,,81.42,Other,Drug Cost,81.42,,,81.42,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,81.42,,,81.42,Other,Drug Cost,183.2,,,183.2,Other,225% Medicaid APG methodology,113.99,,,113.99,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,81.42,,,81.42,Other,Drug Cost,81.42,,,81.42,Other,Drug Cost,101.78,,,101.78,Other,125% Medicaid APG methodology,0.01,425.22,
FLUTICASONE-SALMETEROL 500-50   ,,,,40539777,CDM,250,RC,00173-0697-04,NDC,both,1,EA,56.91,22.46,39.4668,,22.46,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,17.07,30,,17.07,percent of total billed charges,"Drugs, Inpatient Only",17.07,30,,17.07,percent of total billed charges,"Drugs, Inpatient Only",17.07,30,,17.07,percent of total billed charges,"Drugs, Inpatient Only",28.46,50,,28.46,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,39.84,70,,39.84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,39.84,
ONDANSETRON 4 MG ODT            ,,,,40539819,CDM,250,RC,62756-0240-64,NDC,both,1,EA,0.63,0.25,39.4668,,0.25,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.32,50,,0.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.44,70,,0.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.44,
ATENOLOL 25 MG TAB              ,,,,40539827,CDM,250,RC,00093-0787-01,NDC,both,1,EA,0.11,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.06,50,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.08,
SOD BIPHOS-SOD PHOS PED ENEMA   ,,,,40539835,CDM,250,RC,00132-0202-20,NDC,both,66,ML,4.62,1.82,39.4668,,1.82,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.39,30,,1.39,percent of total billed charges,"Drugs, Inpatient Only",1.39,30,,1.39,percent of total billed charges,"Drugs, Inpatient Only",1.39,30,,1.39,percent of total billed charges,"Drugs, Inpatient Only",2.31,50,,2.31,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.46,,,2.46,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.23,70,,3.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.32,,,1.32,Other,Drug Cost,1.32,,,1.32,Other,Drug Cost,1.32,,,1.32,Other,Drug Cost,1.32,,,1.32,Other,Drug Cost,1.32,,,1.32,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.32,,,1.32,Other,Drug Cost,2.97,,,2.97,Other,225% Medicaid APG methodology,1.85,,,1.85,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.32,,,1.32,Other,Drug Cost,1.32,,,1.32,Other,Drug Cost,1.65,,,1.65,Other,125% Medicaid APG methodology,0.01,3.23,
NYSTATIN 100000UNITS/G  15G     ,,,,40539959,CDM,250,RC,68382-0370-01,NDC,both,15,GM,22.75,8.98,39.4668,,8.98,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.83,30,,6.83,percent of total billed charges,"Drugs, Inpatient Only",6.83,30,,6.83,percent of total billed charges,"Drugs, Inpatient Only",6.83,30,,6.83,percent of total billed charges,"Drugs, Inpatient Only",11.38,50,,11.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.92,,,1.92,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.93,70,,15.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.03,,,1.03,Other,Drug Cost,1.03,,,1.03,Other,Drug Cost,1.03,,,1.03,Other,Drug Cost,1.03,,,1.03,Other,Drug Cost,1.03,,,1.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.03,,,1.03,Other,Drug Cost,2.32,,,2.32,Other,225% Medicaid APG methodology,1.44,,,1.44,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.03,,,1.03,Other,Drug Cost,1.03,,,1.03,Other,Drug Cost,1.29,,,1.29,Other,125% Medicaid APG methodology,0.01,15.93,
OXYBUTYNIN 5 MG ER TAB          ,,,,40539983,CDM,250,RC,63739-0548-33,NDC,both,1,EA,7.6,3,39.4668,,3,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.28,30,,2.28,percent of total billed charges,"Drugs, Inpatient Only",2.28,30,,2.28,percent of total billed charges,"Drugs, Inpatient Only",2.28,30,,2.28,percent of total billed charges,"Drugs, Inpatient Only",3.8,50,,3.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.18,,,3.18,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.32,70,,5.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.71,,,1.71,Other,Drug Cost,1.71,,,1.71,Other,Drug Cost,1.71,,,1.71,Other,Drug Cost,1.71,,,1.71,Other,Drug Cost,1.71,,,1.71,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.71,,,1.71,Other,Drug Cost,3.85,,,3.85,Other,225% Medicaid APG methodology,2.39,,,2.39,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.71,,,1.71,Other,Drug Cost,1.71,,,1.71,Other,Drug Cost,2.14,,,2.14,Other,125% Medicaid APG methodology,0.01,5.32,
RISPERIDONE 0.25 MG TAB         ,,,,40540163,CDM,250,RC,00904-7360-61,NDC,both,1,EA,0.67,0.26,39.4668,,0.26,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,30,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.2,30,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.2,30,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.34,50,,0.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,,,0.37,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.47,70,,0.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.45,,,0.45,Other,225% Medicaid APG methodology,0.28,,,0.28,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.25,,,0.25,Other,125% Medicaid APG methodology,0.01,0.47,
LEVOTHYROXINE 88 MCG TAB        ,,,,40540197,CDM,250,RC,42292-0038-20,NDC,both,1,EA,1.79,0.71,39.4668,,0.71,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.54,30,,0.54,percent of total billed charges,"Drugs, Inpatient Only",0.54,30,,0.54,percent of total billed charges,"Drugs, Inpatient Only",0.54,30,,0.54,percent of total billed charges,"Drugs, Inpatient Only",0.9,50,,0.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.25,70,,1.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.23,,,0.23,Other,225% Medicaid APG methodology,0.14,,,0.14,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.13,,,0.13,Other,125% Medicaid APG methodology,0.01,1.25,
CLOPIDOGREL 300 MG TAB          ,,,,40540247,CDM,250,RC,00904-6467-07,NDC,both,1,EA,30.94,12.21,39.4668,,12.21,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.28,30,,9.28,percent of total billed charges,"Drugs, Inpatient Only",9.28,30,,9.28,percent of total billed charges,"Drugs, Inpatient Only",9.28,30,,9.28,percent of total billed charges,"Drugs, Inpatient Only",15.47,50,,15.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.4,,,6.4,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,21.66,70,,21.66,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.44,,,3.44,Other,Drug Cost,3.44,,,3.44,Other,Drug Cost,3.44,,,3.44,Other,Drug Cost,3.44,,,3.44,Other,Drug Cost,3.44,,,3.44,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.44,,,3.44,Other,Drug Cost,7.74,,,7.74,Other,225% Medicaid APG methodology,4.82,,,4.82,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.44,,,3.44,Other,Drug Cost,3.44,,,3.44,Other,Drug Cost,4.3,,,4.3,Other,125% Medicaid APG methodology,0.01,21.66,
SILDENAFIL 20 MG ORAL TABLET    ,,,,40540270,CDM,250,RC,00904-6671-04,NDC,both,1,EA,2.17,0.86,39.4668,,0.86,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.65,30,,0.65,percent of total billed charges,"Drugs, Inpatient Only",0.65,30,,0.65,percent of total billed charges,"Drugs, Inpatient Only",0.65,30,,0.65,percent of total billed charges,"Drugs, Inpatient Only",1.09,50,,1.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.67,,,0.67,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.52,70,,1.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.36,,,0.36,Other,Drug Cost,0.81,,,0.81,Other,225% Medicaid APG methodology,0.5,,,0.5,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.45,,,0.45,Other,125% Medicaid APG methodology,0.01,1.52,
CHLORHEXIDINE 0.12% ORL 15ML    ,,,,40540395,CDM,250,RC,81033-0512-50,NDC,both,15,ML,44.14,17.42,39.4668,,17.42,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.24,30,,13.24,percent of total billed charges,"Drugs, Inpatient Only",13.24,30,,13.24,percent of total billed charges,"Drugs, Inpatient Only",13.24,30,,13.24,percent of total billed charges,"Drugs, Inpatient Only",22.07,50,,22.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,23.98,,,23.98,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,30.9,70,,30.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.89,,,12.89,Other,Drug Cost,12.89,,,12.89,Other,Drug Cost,12.89,,,12.89,Other,Drug Cost,12.89,,,12.89,Other,Drug Cost,12.89,,,12.89,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,12.89,,,12.89,Other,Drug Cost,29,,,29,Other,225% Medicaid APG methodology,18.05,,,18.05,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,12.89,,,12.89,Other,Drug Cost,12.89,,,12.89,Other,Drug Cost,16.11,,,16.11,Other,125% Medicaid APG methodology,0.01,30.9,
ZONISAMIDE 25 MG CAP            ,,,,40540403,CDM,250,RC,29300-0428-01,NDC,both,1,EA,0.53,0.21,39.4668,,0.21,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.27,50,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,70,,0.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.37,
SULFASALAZINE 500 MG TAB        ,,,,40540817,CDM,250,RC,59762-5000-06,NDC,both,1,EA,0.6,0.24,39.4668,,0.24,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.18,30,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.18,30,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.18,30,,0.18,percent of total billed charges,"Drugs, Inpatient Only",0.3,50,,0.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.42,70,,0.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% Medicaid APG methodology,0.11,,,0.11,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.42,
FLUTICASONE FUROATE 100 MCG     ,,,,40540874,CDM,250,RC,00173-0874-14,NDC,both,1,EA,15.4,6.08,39.4668,,6.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.62,30,,4.62,percent of total billed charges,"Drugs, Inpatient Only",4.62,30,,4.62,percent of total billed charges,"Drugs, Inpatient Only",4.62,30,,4.62,percent of total billed charges,"Drugs, Inpatient Only",7.7,50,,7.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.28,,,1.28,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.78,70,,10.78,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.69,,,0.69,Other,Drug Cost,0.69,,,0.69,Other,Drug Cost,0.69,,,0.69,Other,Drug Cost,0.69,,,0.69,Other,Drug Cost,0.69,,,0.69,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.69,,,0.69,Other,Drug Cost,1.55,,,1.55,Other,225% Medicaid APG methodology,0.97,,,0.97,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.69,,,0.69,Other,Drug Cost,0.69,,,0.69,Other,Drug Cost,0.86,,,0.86,Other,125% Medicaid APG methodology,0.01,10.78,
CANAGLIFLOZIN 100 MG TAB        ,,,,40540940,CDM,250,RC,50458-0140-30,NDC,both,1,EA,64.75,25.55,39.4668,,25.55,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.43,30,,19.43,percent of total billed charges,"Drugs, Inpatient Only",19.43,30,,19.43,percent of total billed charges,"Drugs, Inpatient Only",19.43,30,,19.43,percent of total billed charges,"Drugs, Inpatient Only",32.38,50,,32.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,32.85,,,32.85,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,45.33,70,,45.33,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,17.66,,,17.66,Other,Drug Cost,17.66,,,17.66,Other,Drug Cost,17.66,,,17.66,Other,Drug Cost,17.66,,,17.66,Other,Drug Cost,17.66,,,17.66,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,17.66,,,17.66,Other,Drug Cost,39.74,,,39.74,Other,225% Medicaid APG methodology,24.72,,,24.72,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,17.66,,,17.66,Other,Drug Cost,17.66,,,17.66,Other,Drug Cost,22.08,,,22.08,Other,125% Medicaid APG methodology,0.01,45.33,
ARMODAFINIL 250 MG TAB          ,,,,40540957,CDM,250,RC,00378-3433-93,NDC,both,1,EA,56.77,22.41,39.4668,,22.41,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,17.03,30,,17.03,percent of total billed charges,"Drugs, Inpatient Only",17.03,30,,17.03,percent of total billed charges,"Drugs, Inpatient Only",17.03,30,,17.03,percent of total billed charges,"Drugs, Inpatient Only",28.39,50,,28.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.06,,,1.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,39.74,70,,39.74,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.57,,,0.57,Other,Drug Cost,0.57,,,0.57,Other,Drug Cost,0.57,,,0.57,Other,Drug Cost,0.57,,,0.57,Other,Drug Cost,0.57,,,0.57,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.57,,,0.57,Other,Drug Cost,1.28,,,1.28,Other,225% Medicaid APG methodology,0.8,,,0.8,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.57,,,0.57,Other,Drug Cost,0.57,,,0.57,Other,Drug Cost,0.71,,,0.71,Other,125% Medicaid APG methodology,0.01,39.74,
SIMETHICONE 40 MG/0.6 ML LIQ    ,,,,40540965,CDM,250,RC,62372-0630-15,NDC,both,15,ML,17.12,6.76,39.4668,,6.76,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.14,30,,5.14,percent of total billed charges,"Drugs, Inpatient Only",5.14,30,,5.14,percent of total billed charges,"Drugs, Inpatient Only",5.14,30,,5.14,percent of total billed charges,"Drugs, Inpatient Only",8.56,50,,8.56,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.1,,,9.1,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.98,70,,11.98,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.89,,,4.89,Other,Drug Cost,4.89,,,4.89,Other,Drug Cost,4.89,,,4.89,Other,Drug Cost,4.89,,,4.89,Other,Drug Cost,4.89,,,4.89,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.89,,,4.89,Other,Drug Cost,11,,,11,Other,225% Medicaid APG methodology,6.85,,,6.85,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.89,,,4.89,Other,Drug Cost,4.89,,,4.89,Other,Drug Cost,6.11,,,6.11,Other,125% Medicaid APG methodology,0.01,11.98,
BICTEGRA/EMTR/TENO 30-120-15MG  ,,,,40540973,CDM,250,RC,61958-2505-01,NDC,both,1,EA,431.73,170.39,39.4668,,170.39,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,129.52,30,,129.52,percent of total billed charges,"Drugs, Inpatient Only",129.52,30,,129.52,percent of total billed charges,"Drugs, Inpatient Only",129.52,30,,129.52,percent of total billed charges,"Drugs, Inpatient Only",215.87,50,,215.87,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,164.05,,,164.05,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,302.21,70,,302.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,88.2,,,88.2,Other,Drug Cost,88.2,,,88.2,Other,Drug Cost,88.2,,,88.2,Other,Drug Cost,88.2,,,88.2,Other,Drug Cost,88.2,,,88.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,88.2,,,88.2,Other,Drug Cost,198.45,,,198.45,Other,225% Medicaid APG methodology,123.48,,,123.48,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,88.2,,,88.2,Other,Drug Cost,88.2,,,88.2,Other,Drug Cost,110.25,,,110.25,Other,125% Medicaid APG methodology,0.01,302.21,
PROVAYBLUE 5MG  ML 10 ML        ,,,,40541070,CDM,250,RC,00517-0374-05,NDC,both,10,ML,661.85,261.21,39.4668,,261.21,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,198.56,30,,198.56,percent of total billed charges,"Drugs, Inpatient Only",198.56,30,,198.56,percent of total billed charges,"Drugs, Inpatient Only",198.56,30,,198.56,percent of total billed charges,"Drugs, Inpatient Only",330.93,50,,330.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,244.22,,,244.22,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,463.3,70,,463.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,131.3,,,131.3,Other,Drug Cost,131.3,,,131.3,Other,Drug Cost,131.3,,,131.3,Other,Drug Cost,131.3,,,131.3,Other,Drug Cost,131.3,,,131.3,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,131.3,,,131.3,Other,Drug Cost,295.43,,,295.43,Other,225% Medicaid APG methodology,183.82,,,183.82,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,131.3,,,131.3,Other,Drug Cost,131.3,,,131.3,Other,Drug Cost,164.13,,,164.13,Other,125% Medicaid APG methodology,0.01,463.3,
KETOCONAZOLE 2% SHAMPOO 120 ML  ,,,,40541120,CDM,250,RC,45802-0465-64,NDC,both,120,ML,197.4,77.91,39.4668,,77.91,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,59.22,30,,59.22,percent of total billed charges,"Drugs, Inpatient Only",59.22,30,,59.22,percent of total billed charges,"Drugs, Inpatient Only",59.22,30,,59.22,percent of total billed charges,"Drugs, Inpatient Only",98.7,50,,98.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.93,,,8.93,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,138.18,70,,138.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.8,,,4.8,Other,Drug Cost,10.8,,,10.8,Other,225% Medicaid APG methodology,6.72,,,6.72,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,6,,,6,Other,125% Medicaid APG methodology,0.01,138.18,
BUPROPION-DEXTROMETH 105-45 MG  ,,,,40541153,CDM,250,RC,81968-0045-30,NDC,both,1,EA,56.7,22.38,39.4668,,22.38,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,17.01,30,,17.01,percent of total billed charges,"Drugs, Inpatient Only",17.01,30,,17.01,percent of total billed charges,"Drugs, Inpatient Only",17.01,30,,17.01,percent of total billed charges,"Drugs, Inpatient Only",28.35,50,,28.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,29.56,,,29.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,39.69,70,,39.69,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.89,,,15.89,Other,Drug Cost,15.89,,,15.89,Other,Drug Cost,15.89,,,15.89,Other,Drug Cost,15.89,,,15.89,Other,Drug Cost,15.89,,,15.89,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,15.89,,,15.89,Other,Drug Cost,35.75,,,35.75,Other,225% Medicaid APG methodology,22.25,,,22.25,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,15.89,,,15.89,Other,Drug Cost,15.89,,,15.89,Other,Drug Cost,19.86,,,19.86,Other,125% Medicaid APG methodology,0.01,39.69,
PRAVASTATIN 80 MG TAB           ,,,,40541245,CDM,250,RC,70377-0048-12,NDC,both,1,EA,0.39,0.15,39.4668,,0.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.2,50,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.27,70,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.27,,,0.27,Other,225% Medicaid APG methodology,0.17,,,0.17,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.15,,,0.15,Other,125% Medicaid APG methodology,0.01,0.27,
NALOXEGOL 12.5 MG TAB           ,,,,40541302,CDM,250,RC,57841-1300-01,NDC,both,1,EA,41.55,16.4,39.4668,,16.4,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.47,30,,12.47,percent of total billed charges,"Drugs, Inpatient Only",12.47,30,,12.47,percent of total billed charges,"Drugs, Inpatient Only",12.47,30,,12.47,percent of total billed charges,"Drugs, Inpatient Only",20.78,50,,20.78,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.73,,,5.73,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,29.09,70,,29.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.08,,,3.08,Other,Drug Cost,3.08,,,3.08,Other,Drug Cost,3.08,,,3.08,Other,Drug Cost,3.08,,,3.08,Other,Drug Cost,3.08,,,3.08,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.08,,,3.08,Other,Drug Cost,6.93,,,6.93,Other,225% Medicaid APG methodology,4.31,,,4.31,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.08,,,3.08,Other,Drug Cost,3.08,,,3.08,Other,Drug Cost,3.85,,,3.85,Other,125% Medicaid APG methodology,0.01,29.09,
ASCIMINIB 40 MG TAB             ,,,,40541419,CDM,250,RC,00078-1098-20,NDC,both,1,EA,1172.82,462.87,39.4668,,462.87,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,351.85,30,,351.85,percent of total billed charges,"Drugs, Inpatient Only",351.85,30,,351.85,percent of total billed charges,"Drugs, Inpatient Only",351.85,30,,351.85,percent of total billed charges,"Drugs, Inpatient Only",586.41,50,,586.41,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,436.34,,,436.34,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,820.97,70,,820.97,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,234.59,,,234.59,Other,Drug Cost,234.59,,,234.59,Other,Drug Cost,234.59,,,234.59,Other,Drug Cost,234.59,,,234.59,Other,Drug Cost,234.59,,,234.59,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,234.59,,,234.59,Other,Drug Cost,527.83,,,527.83,Other,225% Medicaid APG methodology,328.43,,,328.43,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,234.59,,,234.59,Other,Drug Cost,234.59,,,234.59,Other,Drug Cost,293.24,,,293.24,Other,125% Medicaid APG methodology,0.01,820.97,
SOTORASIB 120 MG TAB            ,,,,40541427,CDM,250,RC,55513-0488-02,NDC,both,1,EA,351.93,138.9,39.4668,,138.9,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,105.58,30,,105.58,percent of total billed charges,"Drugs, Inpatient Only",105.58,30,,105.58,percent of total billed charges,"Drugs, Inpatient Only",105.58,30,,105.58,percent of total billed charges,"Drugs, Inpatient Only",175.97,50,,175.97,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,187.02,,,187.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,246.35,70,,246.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,100.55,,,100.55,Other,Drug Cost,100.55,,,100.55,Other,Drug Cost,100.55,,,100.55,Other,Drug Cost,100.55,,,100.55,Other,Drug Cost,100.55,,,100.55,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,100.55,,,100.55,Other,Drug Cost,226.24,,,226.24,Other,225% Medicaid APG methodology,140.77,,,140.77,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,100.55,,,100.55,Other,Drug Cost,100.55,,,100.55,Other,Drug Cost,125.69,,,125.69,Other,125% Medicaid APG methodology,0.01,246.35,
VORTIOXETINE 20 MG TAB          ,,,,40541757,CDM,250,RC,64764-0750-30,NDC,both,1,EA,50.54,19.95,39.4668,,19.95,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.16,30,,15.16,percent of total billed charges,"Drugs, Inpatient Only",15.16,30,,15.16,percent of total billed charges,"Drugs, Inpatient Only",15.16,30,,15.16,percent of total billed charges,"Drugs, Inpatient Only",25.27,50,,25.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.37,,,4.37,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,35.38,70,,35.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.35,,,2.35,Other,Drug Cost,2.35,,,2.35,Other,Drug Cost,2.35,,,2.35,Other,Drug Cost,2.35,,,2.35,Other,Drug Cost,2.35,,,2.35,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.35,,,2.35,Other,Drug Cost,5.29,,,5.29,Other,225% Medicaid APG methodology,3.29,,,3.29,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.35,,,2.35,Other,Drug Cost,2.35,,,2.35,Other,Drug Cost,2.94,,,2.94,Other,125% Medicaid APG methodology,0.01,35.38,
NA PHENYLBUTYRATE-TAUR 3G-1G    ,,,,40541765,CDM,250,RC,73063-0035-04,NDC,both,1,EA,937.83,370.13,39.4668,,370.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,281.35,30,,281.35,percent of total billed charges,"Drugs, Inpatient Only",281.35,30,,281.35,percent of total billed charges,"Drugs, Inpatient Only",281.35,30,,281.35,percent of total billed charges,"Drugs, Inpatient Only",468.92,50,,468.92,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,498.39,,,498.39,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,656.48,70,,656.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,267.95,,,267.95,Other,Drug Cost,267.95,,,267.95,Other,Drug Cost,267.95,,,267.95,Other,Drug Cost,267.95,,,267.95,Other,Drug Cost,267.95,,,267.95,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,267.95,,,267.95,Other,Drug Cost,602.89,,,602.89,Other,225% Medicaid APG methodology,375.13,,,375.13,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,267.95,,,267.95,Other,Drug Cost,267.95,,,267.95,Other,Drug Cost,334.94,,,334.94,Other,125% Medicaid APG methodology,0.01,656.48,
VERICIGUAT 2.5 MG TAB           ,,,,40541914,CDM,250,RC,00006-5028-01,NDC,both,1,EA,69.62,27.48,39.4668,,27.48,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,20.89,30,,20.89,percent of total billed charges,"Drugs, Inpatient Only",20.89,30,,20.89,percent of total billed charges,"Drugs, Inpatient Only",20.89,30,,20.89,percent of total billed charges,"Drugs, Inpatient Only",34.81,50,,34.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,23.66,,,23.66,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,48.73,70,,48.73,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.72,,,12.72,Other,Drug Cost,12.72,,,12.72,Other,Drug Cost,12.72,,,12.72,Other,Drug Cost,12.72,,,12.72,Other,Drug Cost,12.72,,,12.72,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,12.72,,,12.72,Other,Drug Cost,28.62,,,28.62,Other,225% Medicaid APG methodology,17.81,,,17.81,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,12.72,,,12.72,Other,Drug Cost,12.72,,,12.72,Other,Drug Cost,15.9,,,15.9,Other,125% Medicaid APG methodology,0.01,48.73,
LIDOCAINE 2% TOPICAL GEL 5ML    ,,,,40542029,CDM,250,RC,76329-3012-05,NDC,both,5,ML,14.7,5.8,39.4668,,5.8,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.41,30,,4.41,percent of total billed charges,"Drugs, Inpatient Only",4.41,30,,4.41,percent of total billed charges,"Drugs, Inpatient Only",4.41,30,,4.41,percent of total billed charges,"Drugs, Inpatient Only",7.35,50,,7.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.51,,,6.51,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.29,70,,10.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.5,,,3.5,Other,Drug Cost,3.5,,,3.5,Other,Drug Cost,3.5,,,3.5,Other,Drug Cost,3.5,,,3.5,Other,Drug Cost,3.5,,,3.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.5,,,3.5,Other,Drug Cost,7.88,,,7.88,Other,225% Medicaid APG methodology,4.9,,,4.9,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.5,,,3.5,Other,Drug Cost,3.5,,,3.5,Other,Drug Cost,4.38,,,4.38,Other,125% Medicaid APG methodology,0.01,10.29,
CARBACHOL 0.01% INTRAOU  1.5ML  ,,,,40542037,CDM,250,RC,00065-0023-15,NDC,both,1.5,ML,42.21,16.66,39.4668,,16.66,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.66,30,,12.66,percent of total billed charges,"Drugs, Inpatient Only",12.66,30,,12.66,percent of total billed charges,"Drugs, Inpatient Only",12.66,30,,12.66,percent of total billed charges,"Drugs, Inpatient Only",21.11,50,,21.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.31,,,6.31,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,29.55,70,,29.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.39,,,3.39,Other,Drug Cost,3.39,,,3.39,Other,Drug Cost,3.39,,,3.39,Other,Drug Cost,3.39,,,3.39,Other,Drug Cost,3.39,,,3.39,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.39,,,3.39,Other,Drug Cost,7.63,,,7.63,Other,225% Medicaid APG methodology,4.75,,,4.75,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.39,,,3.39,Other,Drug Cost,3.39,,,3.39,Other,Drug Cost,4.24,,,4.24,Other,125% Medicaid APG methodology,0.01,29.55,
EPINEPH-LIDO 1:100000-1% 10ML   ,,,,40542060,CDM,250,RC,63323-0482-17,NDC,both,10,ML,9.45,3.73,39.4668,,3.73,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.84,30,,2.84,percent of total billed charges,"Drugs, Inpatient Only",2.84,30,,2.84,percent of total billed charges,"Drugs, Inpatient Only",2.84,30,,2.84,percent of total billed charges,"Drugs, Inpatient Only",4.73,50,,4.73,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.56,,,0.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.62,70,,6.62,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.68,,,0.68,Other,225% Medicaid APG methodology,0.42,,,0.42,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.38,,,0.38,Other,125% Medicaid APG methodology,0.01,6.62,
LIDOCAINE 4% SLN 4ML            ,,,,40542532,CDM,250,RC,76329-6300-05,NDC,both,4,ML,75.74,29.89,39.4668,,29.89,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,22.72,30,,22.72,percent of total billed charges,"Drugs, Inpatient Only",22.72,30,,22.72,percent of total billed charges,"Drugs, Inpatient Only",22.72,30,,22.72,percent of total billed charges,"Drugs, Inpatient Only",37.87,50,,37.87,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.9,,,2.9,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,53.02,70,,53.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.56,,,1.56,Other,Drug Cost,1.56,,,1.56,Other,Drug Cost,1.56,,,1.56,Other,Drug Cost,1.56,,,1.56,Other,Drug Cost,1.56,,,1.56,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.56,,,1.56,Other,Drug Cost,3.51,,,3.51,Other,225% Medicaid APG methodology,2.18,,,2.18,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.56,,,1.56,Other,Drug Cost,1.56,,,1.56,Other,Drug Cost,1.95,,,1.95,Other,125% Medicaid APG methodology,0.01,53.02,
GLIPIZIDE 2.5 MG ER TAB         ,,,,40542540,CDM,250,RC,59651-0268-30,NDC,both,1,EA,0.32,0.13,39.4668,,0.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.16,50,,0.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,70,,0.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.22,
NICARDIPINE20MG NS 0.86% 200ML  ,,,,40543043,CDM,250,RC,43066-0009-10,NDC,both,200,ML,156.17,61.64,39.4668,,61.64,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,46.85,30,,46.85,percent of total billed charges,"Drugs, Inpatient Only",46.85,30,,46.85,percent of total billed charges,"Drugs, Inpatient Only",46.85,30,,46.85,percent of total billed charges,"Drugs, Inpatient Only",78.09,50,,78.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,70.98,,,70.98,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,109.32,70,,109.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,38.16,,,38.16,Other,Drug Cost,38.16,,,38.16,Other,Drug Cost,38.16,,,38.16,Other,Drug Cost,38.16,,,38.16,Other,Drug Cost,38.16,,,38.16,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,38.16,,,38.16,Other,Drug Cost,85.86,,,85.86,Other,225% Medicaid APG methodology,53.42,,,53.42,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,38.16,,,38.16,Other,Drug Cost,38.16,,,38.16,Other,Drug Cost,47.7,,,47.7,Other,125% Medicaid APG methodology,0.01,109.32,
FLUPHENAZINE 0.5MG/ML ORAL SYR  ,,,,40543407,CDM,250,RC,00121-0654-02,NDC,both,1,ML,1.09,0.43,39.4668,,0.43,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.33,30,,0.33,percent of total billed charges,"Drugs, Inpatient Only",0.33,30,,0.33,percent of total billed charges,"Drugs, Inpatient Only",0.33,30,,0.33,percent of total billed charges,"Drugs, Inpatient Only",0.55,50,,0.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.35,,,0.35,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.76,70,,0.76,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,Drug Cost,0.43,,,0.43,Other,225% Medicaid APG methodology,0.27,,,0.27,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.24,,,0.24,Other,125% Medicaid APG methodology,0.01,0.76,
ROCURONIUM 10MG/ML IV SOLN 5ML  ,,,,40543498,CDM,250,RC,43547-0530-10,NDC,both,5,ML,10.19,4.02,39.4668,,4.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.06,30,,3.06,percent of total billed charges,"Drugs, Inpatient Only",3.06,30,,3.06,percent of total billed charges,"Drugs, Inpatient Only",3.06,30,,3.06,percent of total billed charges,"Drugs, Inpatient Only",5.1,50,,5.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.28,,,5.28,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.13,70,,7.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.84,,,2.84,Other,Drug Cost,2.84,,,2.84,Other,Drug Cost,2.84,,,2.84,Other,Drug Cost,2.84,,,2.84,Other,Drug Cost,2.84,,,2.84,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.84,,,2.84,Other,Drug Cost,6.39,,,6.39,Other,225% Medicaid APG methodology,3.98,,,3.98,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.84,,,2.84,Other,Drug Cost,2.84,,,2.84,Other,Drug Cost,3.55,,,3.55,Other,125% Medicaid APG methodology,0.01,7.13,
FENTANYL 12 MCG/HR TD FILM ER   ,,,,40543571,CDM,250,RC,00378-9119-98,NDC,both,1,EA,27.79,10.97,39.4668,,10.97,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.34,30,,8.34,percent of total billed charges,"Drugs, Inpatient Only",8.34,30,,8.34,percent of total billed charges,"Drugs, Inpatient Only",8.34,30,,8.34,percent of total billed charges,"Drugs, Inpatient Only",13.9,50,,13.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.89,,,3.89,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.45,70,,19.45,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.09,,,2.09,Other,Drug Cost,2.09,,,2.09,Other,Drug Cost,2.09,,,2.09,Other,Drug Cost,2.09,,,2.09,Other,Drug Cost,2.09,,,2.09,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.09,,,2.09,Other,Drug Cost,4.7,,,4.7,Other,225% Medicaid APG methodology,2.93,,,2.93,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.09,,,2.09,Other,Drug Cost,2.09,,,2.09,Other,Drug Cost,2.61,,,2.61,Other,125% Medicaid APG methodology,0.01,19.45,
KETAMINE 50MG/ML INJ SOLN 10ML  ,,,,40543621,CDM,250,RC,42023-0114-10,NDC,both,10,ML,23.1,9.12,39.4668,,9.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.93,30,,6.93,percent of total billed charges,"Drugs, Inpatient Only",6.93,30,,6.93,percent of total billed charges,"Drugs, Inpatient Only",6.93,30,,6.93,percent of total billed charges,"Drugs, Inpatient Only",11.55,50,,11.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.81,,,7.81,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,16.17,70,,16.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.2,,,4.2,Other,Drug Cost,4.2,,,4.2,Other,Drug Cost,4.2,,,4.2,Other,Drug Cost,4.2,,,4.2,Other,Drug Cost,4.2,,,4.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.2,,,4.2,Other,Drug Cost,9.45,,,9.45,Other,225% Medicaid APG methodology,5.88,,,5.88,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.2,,,4.2,Other,Drug Cost,4.2,,,4.2,Other,Drug Cost,5.25,,,5.25,Other,125% Medicaid APG methodology,0.01,16.17,
WARFARIN 3 MG TAB               ,,,,40543670,CDM,250,RC,00832-1214-01,NDC,both,1,EA,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.02,50,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.14,
LEVOTHYROXINE 112 MCG TAB       ,,,,40543803,CDM,250,RC,42292-0039-20,NDC,both,1,EA,2.07,0.82,39.4668,,0.82,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.62,30,,0.62,percent of total billed charges,"Drugs, Inpatient Only",0.62,30,,0.62,percent of total billed charges,"Drugs, Inpatient Only",0.62,30,,0.62,percent of total billed charges,"Drugs, Inpatient Only",1.04,50,,1.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.45,70,,1.45,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.2,,,0.2,Other,225% Medicaid APG methodology,0.13,,,0.13,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,1.45,
VALSARTAN 40 MG TAB             ,,,,40543811,CDM,250,RC,43547-0367-09,NDC,both,1,EA,0.56,0.22,39.4668,,0.22,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.28,50,,0.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.41,,,0.41,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.39,70,,0.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.5,,,0.5,Other,225% Medicaid APG methodology,0.31,,,0.31,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.28,,,0.28,Other,125% Medicaid APG methodology,0.01,0.5,
FAT EMULSION IV 20% IV  500ML   ,,,,40543886,CDM,250,RC,00338-0519-13,NDC,both,500,ML,52.5,20.72,39.4668,,20.72,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.75,30,,15.75,percent of total billed charges,"Drugs, Inpatient Only",15.75,30,,15.75,percent of total billed charges,"Drugs, Inpatient Only",15.75,30,,15.75,percent of total billed charges,"Drugs, Inpatient Only",26.25,50,,26.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,27.9,,,27.9,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,36.75,70,,36.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15,,,15,Other,Drug Cost,15,,,15,Other,Drug Cost,15,,,15,Other,Drug Cost,15,,,15,Other,Drug Cost,15,,,15,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,15,,,15,Other,Drug Cost,33.75,,,33.75,Other,225% Medicaid APG methodology,21,,,21,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,15,,,15,Other,Drug Cost,15,,,15,Other,Drug Cost,18.75,,,18.75,Other,125% Medicaid APG methodology,0.01,36.75,
AZITHROMYCIN 200MG/5ML ORL SYR  ,,,,40543951,CDM,250,RC,00093-2026-23,NDC,both,5,ML,28.39,11.2,39.4668,,11.2,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.52,30,,8.52,percent of total billed charges,"Drugs, Inpatient Only",8.52,30,,8.52,percent of total billed charges,"Drugs, Inpatient Only",8.52,30,,8.52,percent of total billed charges,"Drugs, Inpatient Only",14.2,50,,14.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.69,,,1.69,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.87,70,,19.87,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.91,,,0.91,Other,Drug Cost,2.05,,,2.05,Other,225% Medicaid APG methodology,1.27,,,1.27,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,1.14,,,1.14,Other,125% Medicaid APG methodology,0.01,19.87,
SPIRONOLACTONE 50 MG TAB        ,,,,40543993,CDM,250,RC,53746-0514-01,NDC,both,1,EA,1.47,0.58,39.4668,,0.58,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.44,30,,0.44,percent of total billed charges,"Drugs, Inpatient Only",0.44,30,,0.44,percent of total billed charges,"Drugs, Inpatient Only",0.44,30,,0.44,percent of total billed charges,"Drugs, Inpatient Only",0.74,50,,0.74,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.03,70,,1.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,1.03,
THERA MULTIPLE VITA MIN TAB     ,,,,40544009,CDM,250,RC,57896-0621-01,NDC,both,1,EA,0.11,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.06,50,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.08,
CALCITRIOL 1 MCG/ML ORLIQ 15ML  ,,,,40544074,CDM,250,RC,00054-3120-41,NDC,both,15,ML,213.15,84.12,39.4668,,84.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,63.95,30,,63.95,percent of total billed charges,"Drugs, Inpatient Only",63.95,30,,63.95,percent of total billed charges,"Drugs, Inpatient Only",63.95,30,,63.95,percent of total billed charges,"Drugs, Inpatient Only",106.58,50,,106.58,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,64.73,,,64.73,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,149.21,70,,149.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,34.8,,,34.8,Other,Drug Cost,34.8,,,34.8,Other,Drug Cost,34.8,,,34.8,Other,Drug Cost,34.8,,,34.8,Other,Drug Cost,34.8,,,34.8,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,34.8,,,34.8,Other,Drug Cost,78.3,,,78.3,Other,225% Medicaid APG methodology,48.72,,,48.72,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,34.8,,,34.8,Other,Drug Cost,34.8,,,34.8,Other,Drug Cost,43.5,,,43.5,Other,125% Medicaid APG methodology,0.01,149.21,
RIFAXIMIN 200MG TABLET          ,,,,40544090,CDM,250,RC,65649-0301-03,NDC,both,1,EA,33.25,13.12,39.4668,,13.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.98,30,,9.98,percent of total billed charges,"Drugs, Inpatient Only",9.98,30,,9.98,percent of total billed charges,"Drugs, Inpatient Only",9.98,30,,9.98,percent of total billed charges,"Drugs, Inpatient Only",16.63,50,,16.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,23.28,70,,23.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,23.28,
LEVETIRACETAM 100MG/ML ORL 5ML  ,,,,40544124,CDM,250,RC,00904-7265-92,NDC,both,5,ML,8.82,3.48,39.4668,,3.48,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.65,30,,2.65,percent of total billed charges,"Drugs, Inpatient Only",2.65,30,,2.65,percent of total billed charges,"Drugs, Inpatient Only",2.65,30,,2.65,percent of total billed charges,"Drugs, Inpatient Only",4.41,50,,4.41,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.87,,,4.87,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.17,70,,6.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.62,,,2.62,Other,Drug Cost,2.62,,,2.62,Other,Drug Cost,2.62,,,2.62,Other,Drug Cost,2.62,,,2.62,Other,Drug Cost,2.62,,,2.62,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.62,,,2.62,Other,Drug Cost,5.9,,,5.9,Other,225% Medicaid APG methodology,3.67,,,3.67,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.62,,,2.62,Other,Drug Cost,2.62,,,2.62,Other,Drug Cost,3.28,,,3.28,Other,125% Medicaid APG methodology,0.01,6.17,
STERILE WATER INJ SOLN 100 ML   ,,,,40544181,CDM,250,RC,63323-0185-00,NDC,both,100,ML,24.96,9.85,39.4668,,9.85,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.49,30,,7.49,percent of total billed charges,"Drugs, Inpatient Only",7.49,30,,7.49,percent of total billed charges,"Drugs, Inpatient Only",7.49,30,,7.49,percent of total billed charges,"Drugs, Inpatient Only",12.48,50,,12.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.98,,,12.98,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,17.47,70,,17.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.98,,,6.98,Other,Drug Cost,6.98,,,6.98,Other,Drug Cost,6.98,,,6.98,Other,Drug Cost,6.98,,,6.98,Other,Drug Cost,6.98,,,6.98,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,6.98,,,6.98,Other,Drug Cost,15.71,,,15.71,Other,225% Medicaid APG methodology,9.77,,,9.77,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.98,,,6.98,Other,Drug Cost,6.98,,,6.98,Other,Drug Cost,8.73,,,8.73,Other,125% Medicaid APG methodology,0.01,17.47,
VERAPAMIL 120MG/12H ER TAB      ,,,,40544322,CDM,250,RC,00025-1901-31,NDC,both,1,EA,20.2,7.97,39.4668,,7.97,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.06,30,,6.06,percent of total billed charges,"Drugs, Inpatient Only",6.06,30,,6.06,percent of total billed charges,"Drugs, Inpatient Only",6.06,30,,6.06,percent of total billed charges,"Drugs, Inpatient Only",10.1,50,,10.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.14,70,,14.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,14.14,
CARBAMAZEPINE 100MG/5ML ORL5ML  ,,,,40544355,CDM,250,RC,68094-0007-62,NDC,both,5,ML,9.8,3.87,39.4668,,3.87,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.94,30,,2.94,percent of total billed charges,"Drugs, Inpatient Only",2.94,30,,2.94,percent of total billed charges,"Drugs, Inpatient Only",2.94,30,,2.94,percent of total billed charges,"Drugs, Inpatient Only",4.9,50,,4.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.09,,,4.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.86,70,,6.86,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.2,,,2.2,Other,Drug Cost,2.2,,,2.2,Other,Drug Cost,2.2,,,2.2,Other,Drug Cost,2.2,,,2.2,Other,Drug Cost,2.2,,,2.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.2,,,2.2,Other,Drug Cost,4.95,,,4.95,Other,225% Medicaid APG methodology,3.08,,,3.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.2,,,2.2,Other,Drug Cost,2.2,,,2.2,Other,Drug Cost,2.75,,,2.75,Other,125% Medicaid APG methodology,0.01,6.86,
DULOXETINE 30 MG DR CAP         ,,,,40544363,CDM,250,RC,60687-0734-01,NDC,both,1,EA,3.19,1.26,39.4668,,1.26,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.96,30,,0.96,percent of total billed charges,"Drugs, Inpatient Only",0.96,30,,0.96,percent of total billed charges,"Drugs, Inpatient Only",0.96,30,,0.96,percent of total billed charges,"Drugs, Inpatient Only",1.6,50,,1.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.33,,,2.33,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.23,70,,2.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.25,,,1.25,Other,Drug Cost,1.25,,,1.25,Other,Drug Cost,1.25,,,1.25,Other,Drug Cost,1.25,,,1.25,Other,Drug Cost,1.25,,,1.25,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.25,,,1.25,Other,Drug Cost,2.81,,,2.81,Other,225% Medicaid APG methodology,1.75,,,1.75,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.25,,,1.25,Other,Drug Cost,1.25,,,1.25,Other,Drug Cost,1.56,,,1.56,Other,125% Medicaid APG methodology,0.01,2.81,
DEXMEDETOMIDINE 100 MCG/ML 2ML  ,,,,40544397,CDM,250,RC,00781-3297-95,NDC,both,2,ML,92.68,36.58,39.4668,,36.58,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,27.8,30,,27.8,percent of total billed charges,"Drugs, Inpatient Only",27.8,30,,27.8,percent of total billed charges,"Drugs, Inpatient Only",27.8,30,,27.8,percent of total billed charges,"Drugs, Inpatient Only",46.34,50,,46.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.69,,,5.69,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,64.88,70,,64.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.06,,,3.06,Other,Drug Cost,3.06,,,3.06,Other,Drug Cost,3.06,,,3.06,Other,Drug Cost,3.06,,,3.06,Other,Drug Cost,3.06,,,3.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.06,,,3.06,Other,Drug Cost,6.89,,,6.89,Other,225% Medicaid APG methodology,4.28,,,4.28,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.06,,,3.06,Other,Drug Cost,3.06,,,3.06,Other,Drug Cost,3.83,,,3.83,Other,125% Medicaid APG methodology,0.01,64.88,
MORPHINE 10MG/5ML ORL  5ML UD   ,,,,40544579,CDM,250,RC,00121-0904-94,NDC,both,5,ML,3.4,1.34,39.4668,,1.34,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.02,30,,1.02,percent of total billed charges,"Drugs, Inpatient Only",1.02,30,,1.02,percent of total billed charges,"Drugs, Inpatient Only",1.02,30,,1.02,percent of total billed charges,"Drugs, Inpatient Only",1.7,50,,1.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.38,70,,2.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,2.38,
DULOXETINE 20 MG DR CAP         ,,,,40544645,CDM,250,RC,50268-0269-15,NDC,both,1,EA,3.5,1.38,39.4668,,1.38,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.05,30,,1.05,percent of total billed charges,"Drugs, Inpatient Only",1.05,30,,1.05,percent of total billed charges,"Drugs, Inpatient Only",1.05,30,,1.05,percent of total billed charges,"Drugs, Inpatient Only",1.75,50,,1.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.8,,,1.8,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.45,70,,2.45,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.97,,,0.97,Other,Drug Cost,2.18,,,2.18,Other,225% Medicaid APG methodology,1.36,,,1.36,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,1.21,,,1.21,Other,125% Medicaid APG methodology,0.01,2.45,
RISPERIDONE 2 MG DIS TAB        ,,,,40545006,CDM,250,RC,59746-0030-22,NDC,both,1,EA,2.7,1.07,39.4668,,1.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.81,30,,0.81,percent of total billed charges,"Drugs, Inpatient Only",0.81,30,,0.81,percent of total billed charges,"Drugs, Inpatient Only",0.81,30,,0.81,percent of total billed charges,"Drugs, Inpatient Only",1.35,50,,1.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.04,,,1.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.89,70,,1.89,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.56,,,0.56,Other,Drug Cost,1.26,,,1.26,Other,225% Medicaid APG methodology,0.78,,,0.78,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,0.7,,,0.7,Other,125% Medicaid APG methodology,0.01,1.89,
K PHOS-SOD PHOS250-45-298MGTAB  ,,,,40545014,CDM,250,RC,64980-0104-01,NDC,both,1,EA,0.63,0.25,39.4668,,0.25,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.32,50,,0.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.44,70,,0.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.25,,,0.25,Other,225% Medicaid APG methodology,0.15,,,0.15,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.14,,,0.14,Other,125% Medicaid APG methodology,0.01,0.44,
DORZOLA-TIMOL 2.23%-0.68% 10ML  ,,,,40545022,CDM,250,RC,65862-0946-01,NDC,both,1,ML,6.51,2.57,39.4668,,2.57,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.95,30,,1.95,percent of total billed charges,"Drugs, Inpatient Only",1.95,30,,1.95,percent of total billed charges,"Drugs, Inpatient Only",1.95,30,,1.95,percent of total billed charges,"Drugs, Inpatient Only",3.26,50,,3.26,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.47,,,0.47,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.56,70,,4.56,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.56,,,0.56,Other,225% Medicaid APG methodology,0.35,,,0.35,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.31,,,0.31,Other,125% Medicaid APG methodology,0.01,4.56,
ROSUVASTATIN 20 MG TAB          ,,,,40545303,CDM,250,RC,50268-0710-15,NDC,both,1,EA,1.75,0.69,39.4668,,0.69,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.53,30,,0.53,percent of total billed charges,"Drugs, Inpatient Only",0.53,30,,0.53,percent of total billed charges,"Drugs, Inpatient Only",0.53,30,,0.53,percent of total billed charges,"Drugs, Inpatient Only",0.88,50,,0.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.49,,,1.49,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.23,70,,1.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.8,,,0.8,Other,Drug Cost,1.8,,,1.8,Other,225% Medicaid APG methodology,1.12,,,1.12,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,1,,,1,Other,125% Medicaid APG methodology,0.01,1.8,
ROSUVASTATIN 10 MG TAB          ,,,,40545311,CDM,250,RC,60687-0245-01,NDC,both,1,EA,3.47,1.37,39.4668,,1.37,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.04,30,,1.04,percent of total billed charges,"Drugs, Inpatient Only",1.04,30,,1.04,percent of total billed charges,"Drugs, Inpatient Only",1.04,30,,1.04,percent of total billed charges,"Drugs, Inpatient Only",1.74,50,,1.74,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.43,70,,2.43,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.16,,,0.16,Other,Drug Cost,0.36,,,0.36,Other,225% Medicaid APG methodology,0.22,,,0.22,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.2,,,0.2,Other,125% Medicaid APG methodology,0.01,2.43,
ROSUVASTATIN 5 MG TAB           ,,,,40545329,CDM,250,RC,60687-0234-01,NDC,both,1,EA,4.03,1.59,39.4668,,1.59,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.21,30,,1.21,percent of total billed charges,"Drugs, Inpatient Only",1.21,30,,1.21,percent of total billed charges,"Drugs, Inpatient Only",1.21,30,,1.21,percent of total billed charges,"Drugs, Inpatient Only",2.02,50,,2.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.99,,,1.99,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.82,70,,2.82,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.07,,,1.07,Other,Drug Cost,1.07,,,1.07,Other,Drug Cost,1.07,,,1.07,Other,Drug Cost,1.07,,,1.07,Other,Drug Cost,1.07,,,1.07,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.07,,,1.07,Other,Drug Cost,2.41,,,2.41,Other,225% Medicaid APG methodology,1.5,,,1.5,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.07,,,1.07,Other,Drug Cost,1.07,,,1.07,Other,Drug Cost,1.34,,,1.34,Other,125% Medicaid APG methodology,0.01,2.82,
ATAZANAVIR 150 MG CAP           ,,,,40545576,CDM,250,RC,00093-5526-06,NDC,both,1,EA,69.72,27.52,39.4668,,27.52,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,20.92,30,,20.92,percent of total billed charges,"Drugs, Inpatient Only",20.92,30,,20.92,percent of total billed charges,"Drugs, Inpatient Only",20.92,30,,20.92,percent of total billed charges,"Drugs, Inpatient Only",34.86,50,,34.86,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.42,,,2.42,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,48.8,70,,48.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.3,,,1.3,Other,Drug Cost,1.3,,,1.3,Other,Drug Cost,1.3,,,1.3,Other,Drug Cost,1.3,,,1.3,Other,Drug Cost,1.3,,,1.3,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.3,,,1.3,Other,Drug Cost,2.93,,,2.93,Other,225% Medicaid APG methodology,1.82,,,1.82,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.3,,,1.3,Other,Drug Cost,1.3,,,1.3,Other,Drug Cost,1.63,,,1.63,Other,125% Medicaid APG methodology,0.01,48.8,
ATAZANAVIR 200 MG CAP           ,,,,40545584,CDM,250,RC,65862-0712-60,NDC,both,1,EA,9.66,3.81,39.4668,,3.81,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.9,30,,2.9,percent of total billed charges,"Drugs, Inpatient Only",2.9,30,,2.9,percent of total billed charges,"Drugs, Inpatient Only",2.9,30,,2.9,percent of total billed charges,"Drugs, Inpatient Only",4.83,50,,4.83,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.53,,,1.53,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.76,70,,6.76,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.82,,,0.82,Other,Drug Cost,1.85,,,1.85,Other,225% Medicaid APG methodology,1.15,,,1.15,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,1.03,,,1.03,Other,125% Medicaid APG methodology,0.01,6.76,
SODIUM BICARB 4.2% IV SLN 10ML  ,,,,40545634,CDM,250,RC,00409-5534-34,NDC,both,10,ML,29.05,11.47,39.4668,,11.47,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.72,30,,8.72,percent of total billed charges,"Drugs, Inpatient Only",8.72,30,,8.72,percent of total billed charges,"Drugs, Inpatient Only",8.72,30,,8.72,percent of total billed charges,"Drugs, Inpatient Only",14.53,50,,14.53,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.79,,,10.79,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,20.34,70,,20.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.8,,,5.8,Other,Drug Cost,5.8,,,5.8,Other,Drug Cost,5.8,,,5.8,Other,Drug Cost,5.8,,,5.8,Other,Drug Cost,5.8,,,5.8,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,5.8,,,5.8,Other,Drug Cost,13.05,,,13.05,Other,225% Medicaid APG methodology,8.12,,,8.12,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.8,,,5.8,Other,Drug Cost,5.8,,,5.8,Other,Drug Cost,7.25,,,7.25,Other,125% Medicaid APG methodology,0.01,20.34,
MODAFINIL 100 MG TAB            ,,,,40545725,CDM,250,RC,50268-0570-12,NDC,both,1,EA,18.06,7.13,39.4668,,7.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.42,30,,5.42,percent of total billed charges,"Drugs, Inpatient Only",5.42,30,,5.42,percent of total billed charges,"Drugs, Inpatient Only",5.42,30,,5.42,percent of total billed charges,"Drugs, Inpatient Only",9.03,50,,9.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.98,,,6.98,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.64,70,,12.64,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.75,,,3.75,Other,Drug Cost,3.75,,,3.75,Other,Drug Cost,3.75,,,3.75,Other,Drug Cost,3.75,,,3.75,Other,Drug Cost,3.75,,,3.75,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.75,,,3.75,Other,Drug Cost,8.44,,,8.44,Other,225% Medicaid APG methodology,5.25,,,5.25,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.75,,,3.75,Other,Drug Cost,3.75,,,3.75,Other,Drug Cost,4.69,,,4.69,Other,125% Medicaid APG methodology,0.01,12.64,
WARFARIN 4 MG TAB               ,,,,40545741,CDM,250,RC,00093-1716-01,NDC,both,1,EA,0.49,0.19,39.4668,,0.19,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.25,50,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.34,70,,0.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.34,
PRAMIPEXOLE 0.125 MG TAB        ,,,,40545816,CDM,250,RC,13668-0091-90,NDC,both,1,EA,0.42,0.17,39.4668,,0.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.21,50,,0.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,70,,0.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.29,
ROPINIROLE 0.25 MG TAB          ,,,,40545832,CDM,250,RC,50268-0741-15,NDC,both,1,EA,1.12,0.44,39.4668,,0.44,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.34,30,,0.34,percent of total billed charges,"Drugs, Inpatient Only",0.34,30,,0.34,percent of total billed charges,"Drugs, Inpatient Only",0.34,30,,0.34,percent of total billed charges,"Drugs, Inpatient Only",0.56,50,,0.56,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.56,,,0.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.78,70,,0.78,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.68,,,0.68,Other,225% Medicaid APG methodology,0.42,,,0.42,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.38,,,0.38,Other,125% Medicaid APG methodology,0.01,0.78,
PORACTANT 80MG/ML ENDOTRA1.5ML  ,,,,40545865,CDM,250,RC,10122-0510-01,NDC,both,1.5,ML,1411.69,557.15,39.4668,,557.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,423.51,30,,423.51,percent of total billed charges,"Drugs, Inpatient Only",423.51,30,,423.51,percent of total billed charges,"Drugs, Inpatient Only",423.51,30,,423.51,percent of total billed charges,"Drugs, Inpatient Only",705.85,50,,705.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,422.28,,,422.28,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,988.18,70,,988.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,227.03,,,227.03,Other,Drug Cost,227.03,,,227.03,Other,Drug Cost,227.03,,,227.03,Other,Drug Cost,227.03,,,227.03,Other,Drug Cost,227.03,,,227.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,227.03,,,227.03,Other,Drug Cost,510.82,,,510.82,Other,225% Medicaid APG methodology,317.84,,,317.84,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,227.03,,,227.03,Other,Drug Cost,227.03,,,227.03,Other,Drug Cost,283.79,,,283.79,Other,125% Medicaid APG methodology,0.01,988.18,
CINACALCET 30 MG TAB            ,,,,40545881,CDM,250,RC,55513-0073-30,NDC,both,1,EA,88.2,34.81,39.4668,,34.81,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,26.46,30,,26.46,percent of total billed charges,"Drugs, Inpatient Only",26.46,30,,26.46,percent of total billed charges,"Drugs, Inpatient Only",26.46,30,,26.46,percent of total billed charges,"Drugs, Inpatient Only",44.1,50,,44.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.96,,,2.96,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,61.74,70,,61.74,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.59,,,1.59,Other,Drug Cost,1.59,,,1.59,Other,Drug Cost,1.59,,,1.59,Other,Drug Cost,1.59,,,1.59,Other,Drug Cost,1.59,,,1.59,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.59,,,1.59,Other,Drug Cost,3.58,,,3.58,Other,225% Medicaid APG methodology,2.23,,,2.23,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.59,,,1.59,Other,Drug Cost,1.59,,,1.59,Other,Drug Cost,1.99,,,1.99,Other,125% Medicaid APG methodology,0.01,61.74,
SOD CHL 23.4% IV SLN 30ML       ,,,,40545907,CDM,250,RC,63323-0187-30,NDC,both,30,ML,14.7,5.8,39.4668,,5.8,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.41,30,,4.41,percent of total billed charges,"Drugs, Inpatient Only",4.41,30,,4.41,percent of total billed charges,"Drugs, Inpatient Only",4.41,30,,4.41,percent of total billed charges,"Drugs, Inpatient Only",7.35,50,,7.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.91,,,3.91,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.29,70,,10.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.1,,,2.1,Other,Drug Cost,2.1,,,2.1,Other,Drug Cost,2.1,,,2.1,Other,Drug Cost,2.1,,,2.1,Other,Drug Cost,2.1,,,2.1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.1,,,2.1,Other,Drug Cost,4.73,,,4.73,Other,225% Medicaid APG methodology,2.94,,,2.94,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.1,,,2.1,Other,Drug Cost,2.1,,,2.1,Other,Drug Cost,2.63,,,2.63,Other,125% Medicaid APG methodology,0.01,10.29,
EMTRCITBINE-TENOF 200-300MGTAB  ,,,,40545915,CDM,250,RC,60687-0719-25,NDC,both,1,EA,29.75,11.74,39.4668,,11.74,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.93,30,,8.93,percent of total billed charges,"Drugs, Inpatient Only",8.93,30,,8.93,percent of total billed charges,"Drugs, Inpatient Only",8.93,30,,8.93,percent of total billed charges,"Drugs, Inpatient Only",14.88,50,,14.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.78,,,13.78,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,20.83,70,,20.83,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.41,,,7.41,Other,Drug Cost,7.41,,,7.41,Other,Drug Cost,7.41,,,7.41,Other,Drug Cost,7.41,,,7.41,Other,Drug Cost,7.41,,,7.41,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,7.41,,,7.41,Other,Drug Cost,16.67,,,16.67,Other,225% Medicaid APG methodology,10.37,,,10.37,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.41,,,7.41,Other,Drug Cost,7.41,,,7.41,Other,Drug Cost,9.26,,,9.26,Other,125% Medicaid APG methodology,0.01,20.83,
GUAIFENESIN 5ML CUP             ,,,,40545923,CDM,250,RC,00121-1744-00,NDC,both,5,ML,1.58,0.62,39.4668,,0.62,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.47,30,,0.47,percent of total billed charges,"Drugs, Inpatient Only",0.47,30,,0.47,percent of total billed charges,"Drugs, Inpatient Only",0.47,30,,0.47,percent of total billed charges,"Drugs, Inpatient Only",0.79,50,,0.79,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,,,0.37,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.11,70,,1.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.45,,,0.45,Other,225% Medicaid APG methodology,0.28,,,0.28,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.25,,,0.25,Other,125% Medicaid APG methodology,0.01,1.11,
KETOROLAC 0.5% OPHTH SOLN 5 ML  ,,,,40545949,CDM,250,RC,42571-0137-25,NDC,both,5,ML,36.33,14.34,39.4668,,14.34,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.9,30,,10.9,percent of total billed charges,"Drugs, Inpatient Only",10.9,30,,10.9,percent of total billed charges,"Drugs, Inpatient Only",10.9,30,,10.9,percent of total billed charges,"Drugs, Inpatient Only",18.17,50,,18.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,50.76,,,50.76,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,25.43,70,,25.43,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,27.29,,,27.29,Other,Drug Cost,27.29,,,27.29,Other,Drug Cost,27.29,,,27.29,Other,Drug Cost,27.29,,,27.29,Other,Drug Cost,27.29,,,27.29,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,27.29,,,27.29,Other,Drug Cost,61.4,,,61.4,Other,225% Medicaid APG methodology,38.21,,,38.21,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,27.29,,,27.29,Other,Drug Cost,27.29,,,27.29,Other,Drug Cost,34.11,,,34.11,Other,125% Medicaid APG methodology,0.01,61.4,
CLONAZEPAM 0.25 MG ODT          ,,,,40546004,CDM,250,RC,00093-9291-67,NDC,both,1,EA,1.82,0.72,39.4668,,0.72,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.55,30,,0.55,percent of total billed charges,"Drugs, Inpatient Only",0.55,30,,0.55,percent of total billed charges,"Drugs, Inpatient Only",0.55,30,,0.55,percent of total billed charges,"Drugs, Inpatient Only",0.91,50,,0.91,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.52,,,0.52,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.27,70,,1.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,Drug Cost,0.63,,,0.63,Other,225% Medicaid APG methodology,0.39,,,0.39,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.35,,,0.35,Other,125% Medicaid APG methodology,0.01,1.27,
RANOLAZINE 500 MG ER TAB        ,,,,40546012,CDM,250,RC,45963-0418-06,NDC,both,1,EA,4.62,1.82,39.4668,,1.82,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.39,30,,1.39,percent of total billed charges,"Drugs, Inpatient Only",1.39,30,,1.39,percent of total billed charges,"Drugs, Inpatient Only",1.39,30,,1.39,percent of total billed charges,"Drugs, Inpatient Only",2.31,50,,2.31,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.23,70,,3.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,3.23,
THROMB BOV 5000 INT UN TOP POW  ,,,,40546038,CDM,250,RC,60793-0705-05,NDC,both,1,EA,188.97,74.58,39.4668,,74.58,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,56.69,30,,56.69,percent of total billed charges,"Drugs, Inpatient Only",56.69,30,,56.69,percent of total billed charges,"Drugs, Inpatient Only",56.69,30,,56.69,percent of total billed charges,"Drugs, Inpatient Only",94.49,50,,94.49,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,132.28,70,,132.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,132.28,
SILVER SULFADIAZINE1% CREAM50G  ,,,,40546046,CDM,250,RC,67877-0124-05,NDC,both,50,GM,22.75,8.98,39.4668,,8.98,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.83,30,,6.83,percent of total billed charges,"Drugs, Inpatient Only",6.83,30,,6.83,percent of total billed charges,"Drugs, Inpatient Only",6.83,30,,6.83,percent of total billed charges,"Drugs, Inpatient Only",11.38,50,,11.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.86,,,1.86,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.93,70,,15.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1,,,1,Other,Drug Cost,2.25,,,2.25,Other,225% Medicaid APG methodology,1.4,,,1.4,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1.25,,,1.25,Other,125% Medicaid APG methodology,0.01,15.93,
CITALOPRAM 10 MG TAB            ,,,,40546160,CDM,250,RC,00904-6084-61,NDC,both,1,EA,0.18,0.07,39.4668,,0.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.09,50,,0.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,70,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.13,
"IOPAMIDOL 41% 10ML, P1ML        ",Q9966,HCPCS,,40546277,CDM,250,RC,00270-1411-11,NDC,both,10,ML,33.18,3.68,,,3.68,Other,150% of Medicare + 9.63% HCRA Surcharge,2.24,,,2.24,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.95,30,,9.95,percent of total billed charges,"Drugs, Inpatient Only",9.95,30,,9.95,percent of total billed charges,"Drugs, Inpatient Only",9.95,30,,9.95,percent of total billed charges,"Drugs, Inpatient Only",16.59,50,,16.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,55.78,,,55.78,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,23.23,70,,23.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,29.99,,,29.99,Other,Drug Cost,29.99,,,29.99,Other,Drug Cost,29.99,,,29.99,Other,Drug Cost,29.99,,,29.99,Other,Drug Cost,29.99,,,29.99,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,29.99,,,29.99,Other,Drug Cost,67.48,,,67.48,Other,225% Medicaid APG methodology,41.99,,,41.99,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,3.58,,,3.58,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,29.99,,,29.99,Other,Drug Cost,29.99,,,29.99,Other,Drug Cost,37.49,,,37.49,Other,125% Medicaid APG methodology,0.01,67.48,
"IOPAMIDOL 41% 20ML, P 1ML       ",Q9966,HCPCS,,40546350,CDM,250,RC,00270-1411-25,NDC,both,20,ML,45.47,3.68,,,3.68,Other,150% of Medicare + 9.63% HCRA Surcharge,2.24,,,2.24,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.64,30,,13.64,percent of total billed charges,"Drugs, Inpatient Only",13.64,30,,13.64,percent of total billed charges,"Drugs, Inpatient Only",13.64,30,,13.64,percent of total billed charges,"Drugs, Inpatient Only",22.74,50,,22.74,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,76.43,,,76.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,31.83,70,,31.83,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,41.09,,,41.09,Other,Drug Cost,41.09,,,41.09,Other,Drug Cost,41.09,,,41.09,Other,Drug Cost,41.09,,,41.09,Other,Drug Cost,41.09,,,41.09,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,41.09,,,41.09,Other,Drug Cost,92.45,,,92.45,Other,225% Medicaid APG methodology,57.53,,,57.53,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,3.58,,,3.58,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,41.09,,,41.09,Other,Drug Cost,41.09,,,41.09,Other,Drug Cost,51.36,,,51.36,Other,125% Medicaid APG methodology,0.01,92.45,
"IOPAMIDOL 61% 15ML, 1ML         ",Q9967,HCPCS,,40546400,CDM,250,RC,00270-1412-15,NDC,both,15,ML,44.1,1.16,,,1.16,Other,150% of Medicare + 9.63% HCRA Surcharge,0.71,,,0.71,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.23,30,,13.23,percent of total billed charges,"Drugs, Inpatient Only",13.23,30,,13.23,percent of total billed charges,"Drugs, Inpatient Only",13.23,30,,13.23,percent of total billed charges,"Drugs, Inpatient Only",22.05,50,,22.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,74.12,,,74.12,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,30.87,70,,30.87,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,39.85,,,39.85,Other,Drug Cost,39.85,,,39.85,Other,Drug Cost,39.85,,,39.85,Other,Drug Cost,39.85,,,39.85,Other,Drug Cost,39.85,,,39.85,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,39.85,,,39.85,Other,Drug Cost,89.66,,,89.66,Other,225% Medicaid APG methodology,55.79,,,55.79,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,1.13,,,1.13,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,39.85,,,39.85,Other,Drug Cost,39.85,,,39.85,Other,Drug Cost,49.81,,,49.81,Other,125% Medicaid APG methodology,0.01,89.66,
SOD CHL 0.45%KCL 20 MEQ/L 1L    ,,,,40546566,CDM,250,RC,00338-0704-34,NDC,both,1000,ML,12.25,4.83,39.4668,,4.83,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.68,30,,3.68,percent of total billed charges,"Drugs, Inpatient Only",3.68,30,,3.68,percent of total billed charges,"Drugs, Inpatient Only",3.68,30,,3.68,percent of total billed charges,"Drugs, Inpatient Only",6.13,50,,6.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.49,,,10.49,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.58,70,,8.58,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.64,,,5.64,Other,Drug Cost,5.64,,,5.64,Other,Drug Cost,5.64,,,5.64,Other,Drug Cost,5.64,,,5.64,Other,Drug Cost,5.64,,,5.64,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,5.64,,,5.64,Other,Drug Cost,12.69,,,12.69,Other,225% Medicaid APG methodology,7.9,,,7.9,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.64,,,5.64,Other,Drug Cost,5.64,,,5.64,Other,Drug Cost,7.05,,,7.05,Other,125% Medicaid APG methodology,0.01,12.69,
D5W 0.2% NACL KCL 20 MEQ/1L IV  ,,,,40546574,CDM,250,RC,00338-0663-04,NDC,both,1000,ML,16.84,6.65,39.4668,,6.65,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.05,30,,5.05,percent of total billed charges,"Drugs, Inpatient Only",5.05,30,,5.05,percent of total billed charges,"Drugs, Inpatient Only",5.05,30,,5.05,percent of total billed charges,"Drugs, Inpatient Only",8.42,50,,8.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.58,,,13.58,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.79,70,,11.79,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.3,,,7.3,Other,Drug Cost,7.3,,,7.3,Other,Drug Cost,7.3,,,7.3,Other,Drug Cost,7.3,,,7.3,Other,Drug Cost,7.3,,,7.3,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,7.3,,,7.3,Other,Drug Cost,16.43,,,16.43,Other,225% Medicaid APG methodology,10.22,,,10.22,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.3,,,7.3,Other,Drug Cost,7.3,,,7.3,Other,Drug Cost,9.13,,,9.13,Other,125% Medicaid APG methodology,0.01,16.43,
D5W 0.9% NACL & KCL 20 MEQ/1L   ,,,,40546590,CDM,250,RC,00338-0803-04,NDC,both,1000,ML,17.22,6.8,39.4668,,6.8,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.17,30,,5.17,percent of total billed charges,"Drugs, Inpatient Only",5.17,30,,5.17,percent of total billed charges,"Drugs, Inpatient Only",5.17,30,,5.17,percent of total billed charges,"Drugs, Inpatient Only",8.61,50,,8.61,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.14,,,14.14,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.05,70,,12.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.6,,,7.6,Other,Drug Cost,7.6,,,7.6,Other,Drug Cost,7.6,,,7.6,Other,Drug Cost,7.6,,,7.6,Other,Drug Cost,7.6,,,7.6,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,7.6,,,7.6,Other,Drug Cost,17.1,,,17.1,Other,225% Medicaid APG methodology,10.64,,,10.64,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.6,,,7.6,Other,Drug Cost,7.6,,,7.6,Other,Drug Cost,9.5,,,9.5,Other,125% Medicaid APG methodology,0.01,17.1,
EMTRICITABINE 200 MG CAP        ,,,,40546624,CDM,250,RC,65862-0301-30,NDC,both,1,EA,50.58,19.96,39.4668,,19.96,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.17,30,,15.17,percent of total billed charges,"Drugs, Inpatient Only",15.17,30,,15.17,percent of total billed charges,"Drugs, Inpatient Only",15.17,30,,15.17,percent of total billed charges,"Drugs, Inpatient Only",25.29,50,,25.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.52,,,3.52,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,35.41,70,,35.41,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.89,,,1.89,Other,Drug Cost,1.89,,,1.89,Other,Drug Cost,1.89,,,1.89,Other,Drug Cost,1.89,,,1.89,Other,Drug Cost,1.89,,,1.89,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.89,,,1.89,Other,Drug Cost,4.25,,,4.25,Other,225% Medicaid APG methodology,2.65,,,2.65,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.89,,,1.89,Other,Drug Cost,1.89,,,1.89,Other,Drug Cost,2.36,,,2.36,Other,125% Medicaid APG methodology,0.01,35.41,
TESTOSTERONE 1% TD GEL 5 G      ,,,,40546673,CDM,250,RC,00832-1120-35,NDC,both,5,GM,13.44,5.3,39.4668,,5.3,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.03,30,,4.03,percent of total billed charges,"Drugs, Inpatient Only",4.03,30,,4.03,percent of total billed charges,"Drugs, Inpatient Only",4.03,30,,4.03,percent of total billed charges,"Drugs, Inpatient Only",6.72,50,,6.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.59,,,2.59,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.41,70,,9.41,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.39,,,1.39,Other,Drug Cost,1.39,,,1.39,Other,Drug Cost,1.39,,,1.39,Other,Drug Cost,1.39,,,1.39,Other,Drug Cost,1.39,,,1.39,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.39,,,1.39,Other,Drug Cost,3.13,,,3.13,Other,225% Medicaid APG methodology,1.95,,,1.95,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.39,,,1.39,Other,Drug Cost,1.39,,,1.39,Other,Drug Cost,1.74,,,1.74,Other,125% Medicaid APG methodology,0.01,9.41,
FOSAMPRENAVIR 700MG TABLET      ,,,,40546749,CDM,250,RC,49702-0207-18,NDC,both,1,EA,65.91,26.01,39.4668,,26.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.77,30,,19.77,percent of total billed charges,"Drugs, Inpatient Only",19.77,30,,19.77,percent of total billed charges,"Drugs, Inpatient Only",19.77,30,,19.77,percent of total billed charges,"Drugs, Inpatient Only",32.96,50,,32.96,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.1,,,14.1,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,46.14,70,,46.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.58,,,7.58,Other,Drug Cost,7.58,,,7.58,Other,Drug Cost,7.58,,,7.58,Other,Drug Cost,7.58,,,7.58,Other,Drug Cost,7.58,,,7.58,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,7.58,,,7.58,Other,Drug Cost,17.06,,,17.06,Other,225% Medicaid APG methodology,10.61,,,10.61,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.58,,,7.58,Other,Drug Cost,7.58,,,7.58,Other,Drug Cost,9.48,,,9.48,Other,125% Medicaid APG methodology,0.01,46.14,
ARIPIPRAZOLE 2 MG TAB           ,,,,40546939,CDM,250,RC,00904-7366-04,NDC,both,1,EA,20.06,7.92,39.4668,,7.92,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.02,30,,6.02,percent of total billed charges,"Drugs, Inpatient Only",6.02,30,,6.02,percent of total billed charges,"Drugs, Inpatient Only",6.02,30,,6.02,percent of total billed charges,"Drugs, Inpatient Only",10.03,50,,10.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.63,,,13.63,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.04,70,,14.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.33,,,7.33,Other,Drug Cost,7.33,,,7.33,Other,Drug Cost,7.33,,,7.33,Other,Drug Cost,7.33,,,7.33,Other,Drug Cost,7.33,,,7.33,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,7.33,,,7.33,Other,Drug Cost,16.49,,,16.49,Other,225% Medicaid APG methodology,10.26,,,10.26,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.33,,,7.33,Other,Drug Cost,7.33,,,7.33,Other,Drug Cost,9.16,,,9.16,Other,125% Medicaid APG methodology,0.01,16.49,
DEUTETRABENAZINE ER 12 MG TAB   ,,,,40547119,CDM,250,RC,68546-0471-56,NDC,both,1,EA,861.42,339.97,39.4668,,339.97,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,258.43,30,,258.43,percent of total billed charges,"Drugs, Inpatient Only",258.43,30,,258.43,percent of total billed charges,"Drugs, Inpatient Only",258.43,30,,258.43,percent of total billed charges,"Drugs, Inpatient Only",430.71,50,,430.71,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,218.42,,,218.42,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,602.99,70,,602.99,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,117.43,,,117.43,Other,Drug Cost,117.43,,,117.43,Other,Drug Cost,117.43,,,117.43,Other,Drug Cost,117.43,,,117.43,Other,Drug Cost,117.43,,,117.43,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,117.43,,,117.43,Other,Drug Cost,264.22,,,264.22,Other,225% Medicaid APG methodology,164.4,,,164.4,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,117.43,,,117.43,Other,Drug Cost,117.43,,,117.43,Other,Drug Cost,146.79,,,146.79,Other,125% Medicaid APG methodology,0.01,602.99,
HEPS A PED VAC 25 U/0.5 IM SUS  ,90633,CPT,,40547739,CDM,250,RC,00006-4095-02,NDC,both,0.5,ML,45.85,18.1,39.4668,,18.1,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.76,30,,13.76,percent of total billed charges,"Drugs, Inpatient Only",13.76,30,,13.76,percent of total billed charges,"Drugs, Inpatient Only",13.76,30,,13.76,percent of total billed charges,"Drugs, Inpatient Only",22.93,50,,22.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,34.08,,,34.08,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,32.1,70,,32.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,18.32,,,18.32,Other,Drug Cost,18.32,,,18.32,Other,Drug Cost,18.32,,,18.32,Other,Drug Cost,18.32,,,18.32,Other,Drug Cost,18.32,,,18.32,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,18.32,,,18.32,Other,Drug Cost,41.22,,,41.22,Other,225% Medicaid APG methodology,25.65,,,25.65,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,18.32,,,18.32,Other,Drug Cost,18.32,,,18.32,Other,Drug Cost,22.9,,,22.9,Other,125% Medicaid APG methodology,0.01,41.22,
NIRMATRELVIR-RITON150-100RENAL  ,,,,40547804,CDM,250,RC,00069-5317-20,NDC,both,1,EA,225.82,89.12,39.4668,,89.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,67.75,30,,67.75,percent of total billed charges,"Drugs, Inpatient Only",67.75,30,,67.75,percent of total billed charges,"Drugs, Inpatient Only",67.75,30,,67.75,percent of total billed charges,"Drugs, Inpatient Only",112.91,50,,112.91,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,96.48,,,96.48,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,158.07,70,,158.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,51.87,,,51.87,Other,Drug Cost,51.87,,,51.87,Other,Drug Cost,51.87,,,51.87,Other,Drug Cost,51.87,,,51.87,Other,Drug Cost,51.87,,,51.87,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,51.87,,,51.87,Other,Drug Cost,116.71,,,116.71,Other,225% Medicaid APG methodology,72.62,,,72.62,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,51.87,,,51.87,Other,Drug Cost,51.87,,,51.87,Other,Drug Cost,64.84,,,64.84,Other,125% Medicaid APG methodology,0.01,158.07,
OSELTAMIVIR 75 MG CAP           ,,,,40570236,CDM,250,RC,64380-0799-01,NDC,both,1,EA,6.02,2.38,39.4668,,2.38,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.81,30,,1.81,percent of total billed charges,"Drugs, Inpatient Only",1.81,30,,1.81,percent of total billed charges,"Drugs, Inpatient Only",1.81,30,,1.81,percent of total billed charges,"Drugs, Inpatient Only",3.01,50,,3.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.41,,,0.41,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.21,70,,4.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.5,,,0.5,Other,225% Medicaid APG methodology,0.31,,,0.31,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.28,,,0.28,Other,125% Medicaid APG methodology,0.01,4.21,
PLASMA-LYTE/NORMO-R/ISOLY S 1L  ,,,,40570251,CDM,250,RC,00338-0221-04,NDC,both,1000,ML,16.98,6.7,39.4668,,6.7,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.09,30,,5.09,percent of total billed charges,"Drugs, Inpatient Only",5.09,30,,5.09,percent of total billed charges,"Drugs, Inpatient Only",5.09,30,,5.09,percent of total billed charges,"Drugs, Inpatient Only",8.49,50,,8.49,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,16.93,,,16.93,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.89,70,,11.89,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.1,,,9.1,Other,Drug Cost,9.1,,,9.1,Other,Drug Cost,9.1,,,9.1,Other,Drug Cost,9.1,,,9.1,Other,Drug Cost,9.1,,,9.1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,9.1,,,9.1,Other,Drug Cost,20.48,,,20.48,Other,225% Medicaid APG methodology,12.74,,,12.74,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,9.1,,,9.1,Other,Drug Cost,9.1,,,9.1,Other,Drug Cost,11.38,,,11.38,Other,125% Medicaid APG methodology,0.01,20.48,
LACOSAMIDE 50 MG TAB            ,,,,40570558,CDM,250,RC,60687-0676-57,NDC,both,1,EA,6.37,2.51,39.4668,,2.51,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.91,30,,1.91,percent of total billed charges,"Drugs, Inpatient Only",1.91,30,,1.91,percent of total billed charges,"Drugs, Inpatient Only",1.91,30,,1.91,percent of total billed charges,"Drugs, Inpatient Only",3.19,50,,3.19,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.33,,,3.33,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.46,70,,4.46,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.79,,,1.79,Other,Drug Cost,1.79,,,1.79,Other,Drug Cost,1.79,,,1.79,Other,Drug Cost,1.79,,,1.79,Other,Drug Cost,1.79,,,1.79,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.79,,,1.79,Other,Drug Cost,4.03,,,4.03,Other,225% Medicaid APG methodology,2.51,,,2.51,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.79,,,1.79,Other,Drug Cost,1.79,,,1.79,Other,Drug Cost,2.24,,,2.24,Other,125% Medicaid APG methodology,0.01,4.46,
THROMBIN TOP RECOMB 5000 POW    ,,,,40570707,CDM,250,RC,65293-0006-41,NDC,both,1,EA,139.9,55.21,39.4668,,55.21,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,41.97,30,,41.97,percent of total billed charges,"Drugs, Inpatient Only",41.97,30,,41.97,percent of total billed charges,"Drugs, Inpatient Only",41.97,30,,41.97,percent of total billed charges,"Drugs, Inpatient Only",69.95,50,,69.95,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,69.04,,,69.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,97.93,70,,97.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,37.12,,,37.12,Other,Drug Cost,37.12,,,37.12,Other,Drug Cost,37.12,,,37.12,Other,Drug Cost,37.12,,,37.12,Other,Drug Cost,37.12,,,37.12,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,37.12,,,37.12,Other,Drug Cost,83.52,,,83.52,Other,225% Medicaid APG methodology,51.97,,,51.97,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,37.12,,,37.12,Other,Drug Cost,37.12,,,37.12,Other,Drug Cost,46.4,,,46.4,Other,125% Medicaid APG methodology,0.01,97.93,
ZONISAMIDE 100 MG CAP           ,,,,40570848,CDM,250,RC,69097-0861-07,NDC,both,1,EA,1.19,0.47,39.4668,,0.47,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.36,30,,0.36,percent of total billed charges,"Drugs, Inpatient Only",0.36,30,,0.36,percent of total billed charges,"Drugs, Inpatient Only",0.36,30,,0.36,percent of total billed charges,"Drugs, Inpatient Only",0.6,50,,0.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.83,70,,0.83,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.83,
ALISKIREN 150MG TABLET          ,,,,40570921,CDM,250,RC,70839-0150-30,NDC,both,1,EA,28.84,11.38,39.4668,,11.38,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.65,30,,8.65,percent of total billed charges,"Drugs, Inpatient Only",8.65,30,,8.65,percent of total billed charges,"Drugs, Inpatient Only",8.65,30,,8.65,percent of total billed charges,"Drugs, Inpatient Only",14.42,50,,14.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,20.19,70,,20.19,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,20.19,
SOD CHL 0.9% INJ SLN 20ML       ,,,,40571267,CDM,250,RC,63323-0186-20,NDC,both,20,ML,3.71,1.46,39.4668,,1.46,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.11,30,,1.11,percent of total billed charges,"Drugs, Inpatient Only",1.11,30,,1.11,percent of total billed charges,"Drugs, Inpatient Only",1.11,30,,1.11,percent of total billed charges,"Drugs, Inpatient Only",1.86,50,,1.86,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.25,,,1.25,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.6,70,,2.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.67,,,0.67,Other,Drug Cost,0.67,,,0.67,Other,Drug Cost,0.67,,,0.67,Other,Drug Cost,0.67,,,0.67,Other,Drug Cost,0.67,,,0.67,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.67,,,0.67,Other,Drug Cost,1.51,,,1.51,Other,225% Medicaid APG methodology,0.94,,,0.94,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.67,,,0.67,Other,Drug Cost,0.67,,,0.67,Other,Drug Cost,0.84,,,0.84,Other,125% Medicaid APG methodology,0.01,2.6,
NF-LEFLUNOMIDE 20 MG TAB        ,,,,40571283,CDM,250,RC,23155-0044-03,NDC,both,1,EA,2.91,1.15,39.4668,,1.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.87,30,,0.87,percent of total billed charges,"Drugs, Inpatient Only",0.87,30,,0.87,percent of total billed charges,"Drugs, Inpatient Only",0.87,30,,0.87,percent of total billed charges,"Drugs, Inpatient Only",1.46,50,,1.46,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.04,70,,2.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,Drug Cost,0.32,,,0.32,Other,225% Medicaid APG methodology,0.2,,,0.2,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.18,,,0.18,Other,125% Medicaid APG methodology,0.01,2.04,
SOD CHL 3% INH SLN 15ML         ,,,,40571440,CDM,250,RC,00378-6997-89,NDC,both,15,ML,2.1,0.83,39.4668,,0.83,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.63,30,,0.63,percent of total billed charges,"Drugs, Inpatient Only",0.63,30,,0.63,percent of total billed charges,"Drugs, Inpatient Only",0.63,30,,0.63,percent of total billed charges,"Drugs, Inpatient Only",1.05,50,,1.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.12,,,1.12,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.47,70,,1.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.6,,,0.6,Other,Drug Cost,1.35,,,1.35,Other,225% Medicaid APG methodology,0.84,,,0.84,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.75,,,0.75,Other,125% Medicaid APG methodology,0.01,1.47,
DULOXETINE 60 MG DR CAP         ,,,,40571507,CDM,250,RC,50268-0288-13,NDC,both,1,EA,2.31,0.91,39.4668,,0.91,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.69,30,,0.69,percent of total billed charges,"Drugs, Inpatient Only",0.69,30,,0.69,percent of total billed charges,"Drugs, Inpatient Only",0.69,30,,0.69,percent of total billed charges,"Drugs, Inpatient Only",1.16,50,,1.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.56,,,1.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.62,70,,1.62,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.84,,,0.84,Other,Drug Cost,1.89,,,1.89,Other,225% Medicaid APG methodology,1.18,,,1.18,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,1.05,,,1.05,Other,125% Medicaid APG methodology,0.01,1.89,
PRASUGREL 5 MG TAB              ,,,,40571515,CDM,250,RC,00002-5121-52,NDC,both,1,EA,50.65,19.99,39.4668,,19.99,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.2,30,,15.2,percent of total billed charges,"Drugs, Inpatient Only",15.2,30,,15.2,percent of total billed charges,"Drugs, Inpatient Only",15.2,30,,15.2,percent of total billed charges,"Drugs, Inpatient Only",25.33,50,,25.33,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.04,,,5.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,35.46,70,,35.46,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.71,,,2.71,Other,Drug Cost,2.71,,,2.71,Other,Drug Cost,2.71,,,2.71,Other,Drug Cost,2.71,,,2.71,Other,Drug Cost,2.71,,,2.71,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.71,,,2.71,Other,Drug Cost,6.1,,,6.1,Other,225% Medicaid APG methodology,3.79,,,3.79,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.71,,,2.71,Other,Drug Cost,2.71,,,2.71,Other,Drug Cost,3.39,,,3.39,Other,125% Medicaid APG methodology,0.01,35.46,
PRASUGREL 10 MG TAB             ,,,,40571523,CDM,250,RC,00002-5123-30,NDC,both,1,EA,50.65,19.99,39.4668,,19.99,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.2,30,,15.2,percent of total billed charges,"Drugs, Inpatient Only",15.2,30,,15.2,percent of total billed charges,"Drugs, Inpatient Only",15.2,30,,15.2,percent of total billed charges,"Drugs, Inpatient Only",25.33,50,,25.33,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.02,,,5.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,35.46,70,,35.46,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.7,,,2.7,Other,Drug Cost,6.08,,,6.08,Other,225% Medicaid APG methodology,3.78,,,3.78,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,3.38,,,3.38,Other,125% Medicaid APG methodology,0.01,35.46,
IBUPROFEN 200 MG TAB            ,,,,40571531,CDM,250,RC,00904-7914-61,NDC,both,1,EA,0.18,0.07,39.4668,,0.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.09,50,,0.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,70,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.13,
STERILE WATER INJ SOLN 50 ML    ,,,,40571580,CDM,250,RC,63323-0185-50,NDC,both,50,ML,19.18,7.57,39.4668,,7.57,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.75,30,,5.75,percent of total billed charges,"Drugs, Inpatient Only",5.75,30,,5.75,percent of total billed charges,"Drugs, Inpatient Only",5.75,30,,5.75,percent of total billed charges,"Drugs, Inpatient Only",9.59,50,,9.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.97,,,9.97,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.43,70,,13.43,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.36,,,5.36,Other,Drug Cost,5.36,,,5.36,Other,Drug Cost,5.36,,,5.36,Other,Drug Cost,5.36,,,5.36,Other,Drug Cost,5.36,,,5.36,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,5.36,,,5.36,Other,Drug Cost,12.06,,,12.06,Other,225% Medicaid APG methodology,7.5,,,7.5,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.36,,,5.36,Other,Drug Cost,5.36,,,5.36,Other,Drug Cost,6.7,,,6.7,Other,125% Medicaid APG methodology,0.01,13.43,
ENTECAVIR 0.5 MG TAB            ,,,,40571622,CDM,250,RC,51991-0895-33,NDC,both,1,EA,4.59,1.81,39.4668,,1.81,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.38,30,,1.38,percent of total billed charges,"Drugs, Inpatient Only",1.38,30,,1.38,percent of total billed charges,"Drugs, Inpatient Only",1.38,30,,1.38,percent of total billed charges,"Drugs, Inpatient Only",2.3,50,,2.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.21,70,,3.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,3.21,
CONIVAPTAN 20MG 100ML IV D5W    ,,,,40571630,CDM,250,RC,66220-0160-10,NDC,both,100,ML,2900,1144.54,39.4668,,1144.54,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,870,30,,870,percent of total billed charges,"Drugs, Inpatient Only",870,30,,870,percent of total billed charges,"Drugs, Inpatient Only",870,30,,870,percent of total billed charges,"Drugs, Inpatient Only",1450,50,,1450,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,504.75,,,504.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2030,70,,2030,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,271.37,,,271.37,Other,Drug Cost,271.37,,,271.37,Other,Drug Cost,271.37,,,271.37,Other,Drug Cost,271.37,,,271.37,Other,Drug Cost,271.37,,,271.37,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,271.37,,,271.37,Other,Drug Cost,610.58,,,610.58,Other,225% Medicaid APG methodology,379.92,,,379.92,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,271.37,,,271.37,Other,Drug Cost,271.37,,,271.37,Other,Drug Cost,339.21,,,339.21,Other,125% Medicaid APG methodology,0.01,2030,
D5W IN WATER MINIBAG 50 ML      ,,,,40571648,CDM,250,RC,00338-0551-11,NDC,both,1,ML,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.11,50,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.15,
ACIDOPHILUS TABLET              ,,,,40572166,CDM,250,RC,74312-0026-10,NDC,both,1,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.11,50,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.15,
RIBAVIRIN 200 MG CAP            ,,,,40572174,CDM,250,RC,65862-0290-84,NDC,both,1,EA,4.13,1.63,39.4668,,1.63,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.24,30,,1.24,percent of total billed charges,"Drugs, Inpatient Only",1.24,30,,1.24,percent of total billed charges,"Drugs, Inpatient Only",1.24,30,,1.24,percent of total billed charges,"Drugs, Inpatient Only",2.07,50,,2.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.89,70,,2.89,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,2.89,
REMIFENTANIL 1 MG IV INJ        ,,,,40572208,CDM,250,RC,00143-9391-10,NDC,both,1,EA,149.45,58.98,39.4668,,58.98,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,44.84,30,,44.84,percent of total billed charges,"Drugs, Inpatient Only",44.84,30,,44.84,percent of total billed charges,"Drugs, Inpatient Only",44.84,30,,44.84,percent of total billed charges,"Drugs, Inpatient Only",74.73,50,,74.73,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,46.02,,,46.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,104.62,70,,104.62,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,24.74,,,24.74,Other,Drug Cost,24.74,,,24.74,Other,Drug Cost,24.74,,,24.74,Other,Drug Cost,24.74,,,24.74,Other,Drug Cost,24.74,,,24.74,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,24.74,,,24.74,Other,Drug Cost,55.67,,,55.67,Other,225% Medicaid APG methodology,34.64,,,34.64,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,24.74,,,24.74,Other,Drug Cost,24.74,,,24.74,Other,Drug Cost,30.93,,,30.93,Other,125% Medicaid APG methodology,0.01,104.62,
HYDROMORPHONE 4 MG TAB          ,,,,40572232,CDM,250,RC,42858-0302-01,NDC,both,1,EA,0.35,0.14,39.4668,,0.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.18,50,,0.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,70,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.25,
RALTEGRAVIR 400 MG TAB          ,,,,40572455,CDM,250,RC,00006-0227-61,NDC,both,1,EA,108.64,42.88,39.4668,,42.88,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,32.59,30,,32.59,percent of total billed charges,"Drugs, Inpatient Only",32.59,30,,32.59,percent of total billed charges,"Drugs, Inpatient Only",32.59,30,,32.59,percent of total billed charges,"Drugs, Inpatient Only",54.32,50,,54.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,18.75,,,18.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,76.05,70,,76.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.08,,,10.08,Other,Drug Cost,10.08,,,10.08,Other,Drug Cost,10.08,,,10.08,Other,Drug Cost,10.08,,,10.08,Other,Drug Cost,10.08,,,10.08,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,10.08,,,10.08,Other,Drug Cost,22.68,,,22.68,Other,225% Medicaid APG methodology,14.11,,,14.11,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,10.08,,,10.08,Other,Drug Cost,10.08,,,10.08,Other,Drug Cost,12.6,,,12.6,Other,125% Medicaid APG methodology,0.01,76.05,
D5W 0.45% NACL KCL 10MEQ/L IV   ,,,,40572463,CDM,250,RC,00264-7634-00,NDC,both,1000,ML,26.85,10.6,39.4668,,10.6,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.06,30,,8.06,percent of total billed charges,"Drugs, Inpatient Only",8.06,30,,8.06,percent of total billed charges,"Drugs, Inpatient Only",8.06,30,,8.06,percent of total billed charges,"Drugs, Inpatient Only",13.43,50,,13.43,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.03,,,2.03,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,18.8,70,,18.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.09,,,1.09,Other,Drug Cost,1.09,,,1.09,Other,Drug Cost,1.09,,,1.09,Other,Drug Cost,1.09,,,1.09,Other,Drug Cost,1.09,,,1.09,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.09,,,1.09,Other,Drug Cost,2.45,,,2.45,Other,225% Medicaid APG methodology,1.53,,,1.53,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.09,,,1.09,Other,Drug Cost,1.09,,,1.09,Other,Drug Cost,1.36,,,1.36,Other,125% Medicaid APG methodology,0.01,18.8,
D5W WATERKCL 20MEQ/L IV 1000ML  ,,,,40572471,CDM,250,RC,00338-0683-04,NDC,both,1000,ML,17.54,6.92,39.4668,,6.92,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.26,30,,5.26,percent of total billed charges,"Drugs, Inpatient Only",5.26,30,,5.26,percent of total billed charges,"Drugs, Inpatient Only",5.26,30,,5.26,percent of total billed charges,"Drugs, Inpatient Only",8.77,50,,8.77,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.86,,,14.86,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.28,70,,12.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.99,,,7.99,Other,Drug Cost,7.99,,,7.99,Other,Drug Cost,7.99,,,7.99,Other,Drug Cost,7.99,,,7.99,Other,Drug Cost,7.99,,,7.99,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,7.99,,,7.99,Other,Drug Cost,17.98,,,17.98,Other,225% Medicaid APG methodology,11.19,,,11.19,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.99,,,7.99,Other,Drug Cost,7.99,,,7.99,Other,Drug Cost,9.99,,,9.99,Other,125% Medicaid APG methodology,0.01,17.98,
AMLODIPINE 10 MG TAB            ,,,,40572570,CDM,250,RC,00069-1540-41,NDC,both,1,EA,35.91,14.17,39.4668,,14.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.77,30,,10.77,percent of total billed charges,"Drugs, Inpatient Only",10.77,30,,10.77,percent of total billed charges,"Drugs, Inpatient Only",10.77,30,,10.77,percent of total billed charges,"Drugs, Inpatient Only",17.96,50,,17.96,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,25.14,70,,25.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,25.14,
PERMETHRIN 5% CREAM 60 G        ,,,,40572612,CDM,250,RC,00472-0242-60,NDC,both,60,GM,92.4,36.47,39.4668,,36.47,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,27.72,30,,27.72,percent of total billed charges,"Drugs, Inpatient Only",27.72,30,,27.72,percent of total billed charges,"Drugs, Inpatient Only",27.72,30,,27.72,percent of total billed charges,"Drugs, Inpatient Only",46.2,50,,46.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,20.09,,,20.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,64.68,70,,64.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.8,,,10.8,Other,Drug Cost,10.8,,,10.8,Other,Drug Cost,10.8,,,10.8,Other,Drug Cost,10.8,,,10.8,Other,Drug Cost,10.8,,,10.8,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,10.8,,,10.8,Other,Drug Cost,24.3,,,24.3,Other,225% Medicaid APG methodology,15.12,,,15.12,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,10.8,,,10.8,Other,Drug Cost,10.8,,,10.8,Other,Drug Cost,13.5,,,13.5,Other,125% Medicaid APG methodology,0.01,64.68,
MICONAZOLE 2% VAGINAL CRM 45G   ,,,,40572687,CDM,250,RC,51672-2035-06,NDC,both,45,GM,11.52,4.55,39.4668,,4.55,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.46,30,,3.46,percent of total billed charges,"Drugs, Inpatient Only",3.46,30,,3.46,percent of total billed charges,"Drugs, Inpatient Only",3.46,30,,3.46,percent of total billed charges,"Drugs, Inpatient Only",5.76,50,,5.76,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.65,,,5.65,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.06,70,,8.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.04,,,3.04,Other,Drug Cost,3.04,,,3.04,Other,Drug Cost,3.04,,,3.04,Other,Drug Cost,3.04,,,3.04,Other,Drug Cost,3.04,,,3.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.04,,,3.04,Other,Drug Cost,6.84,,,6.84,Other,225% Medicaid APG methodology,4.26,,,4.26,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.04,,,3.04,Other,Drug Cost,3.04,,,3.04,Other,Drug Cost,3.8,,,3.8,Other,125% Medicaid APG methodology,0.01,8.06,
DRONEDARONE 400 MG TAB          ,,,,40572695,CDM,250,RC,00024-4142-60,NDC,both,1,EA,40.29,15.9,39.4668,,15.9,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.09,30,,12.09,percent of total billed charges,"Drugs, Inpatient Only",12.09,30,,12.09,percent of total billed charges,"Drugs, Inpatient Only",12.09,30,,12.09,percent of total billed charges,"Drugs, Inpatient Only",20.15,50,,20.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.75,,,2.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,28.2,70,,28.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.48,,,1.48,Other,Drug Cost,3.33,,,3.33,Other,225% Medicaid APG methodology,2.07,,,2.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,1.85,,,1.85,Other,125% Medicaid APG methodology,0.01,28.2,
ACETAMINOPHEN 325MG RECTAL SUP  ,,,,40572786,CDM,250,RC,51672-2116-02,NDC,both,1,EA,2.31,0.91,39.4668,,0.91,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.69,30,,0.69,percent of total billed charges,"Drugs, Inpatient Only",0.69,30,,0.69,percent of total billed charges,"Drugs, Inpatient Only",0.69,30,,0.69,percent of total billed charges,"Drugs, Inpatient Only",1.16,50,,1.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.62,70,,1.62,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1.62,
NAPHCON-A 0.025%-0.3% 15ML      ,,,,40572893,CDM,250,RC,00065-0085-15,NDC,both,15,ML,27.83,10.98,39.4668,,10.98,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.35,30,,8.35,percent of total billed charges,"Drugs, Inpatient Only",8.35,30,,8.35,percent of total billed charges,"Drugs, Inpatient Only",8.35,30,,8.35,percent of total billed charges,"Drugs, Inpatient Only",13.92,50,,13.92,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.16,,,11.16,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.48,70,,19.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6,,,6,Other,Drug Cost,6,,,6,Other,Drug Cost,6,,,6,Other,Drug Cost,6,,,6,Other,Drug Cost,6,,,6,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,6,,,6,Other,Drug Cost,13.5,,,13.5,Other,225% Medicaid APG methodology,8.4,,,8.4,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6,,,6,Other,Drug Cost,6,,,6,Other,Drug Cost,7.5,,,7.5,Other,125% Medicaid APG methodology,0.01,19.48,
NF-LEFLUNOMIDE 10 MG TAB        ,,,,40572968,CDM,250,RC,60505-2502-01,NDC,both,1,EA,8.68,3.43,39.4668,,3.43,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.6,30,,2.6,percent of total billed charges,"Drugs, Inpatient Only",2.6,30,,2.6,percent of total billed charges,"Drugs, Inpatient Only",2.6,30,,2.6,percent of total billed charges,"Drugs, Inpatient Only",4.34,50,,4.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.32,,,0.32,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.08,70,,6.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,Drug Cost,0.38,,,0.38,Other,225% Medicaid APG methodology,0.24,,,0.24,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.21,,,0.21,Other,125% Medicaid APG methodology,0.01,6.08,
NF- BUPRENORPHINE 2 MG SL TAB   ,,,,40573073,CDM,250,RC,50383-0924-93,NDC,both,1,EA,2.35,0.93,39.4668,,0.93,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.71,30,,0.71,percent of total billed charges,"Drugs, Inpatient Only",0.71,30,,0.71,percent of total billed charges,"Drugs, Inpatient Only",0.71,30,,0.71,percent of total billed charges,"Drugs, Inpatient Only",1.18,50,,1.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.65,70,,1.65,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.25,,,0.25,Other,225% Medicaid APG methodology,0.15,,,0.15,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.14,,,0.14,Other,125% Medicaid APG methodology,0.01,1.65,
TROPICAMIDE 1% 2ML EYE DRP      ,,,,40573099,CDM,250,RC,24208-0585-59,NDC,both,2,ML,12.5,4.93,39.4668,,4.93,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.75,30,,3.75,percent of total billed charges,"Drugs, Inpatient Only",3.75,30,,3.75,percent of total billed charges,"Drugs, Inpatient Only",3.75,30,,3.75,percent of total billed charges,"Drugs, Inpatient Only",6.25,50,,6.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.64,,,6.64,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.75,70,,8.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.57,,,3.57,Other,Drug Cost,3.57,,,3.57,Other,Drug Cost,3.57,,,3.57,Other,Drug Cost,3.57,,,3.57,Other,Drug Cost,3.57,,,3.57,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.57,,,3.57,Other,Drug Cost,8.03,,,8.03,Other,225% Medicaid APG methodology,5,,,5,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.57,,,3.57,Other,Drug Cost,3.57,,,3.57,Other,Drug Cost,4.46,,,4.46,Other,125% Medicaid APG methodology,0.01,8.75,
DTAP-HEPB-IPV 0.5ML SYR         ,,,,40573115,CDM,250,RC,58160-0811-52,NDC,both,0.5,ML,219.98,86.82,39.4668,,86.82,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,65.99,30,,65.99,percent of total billed charges,"Drugs, Inpatient Only",65.99,30,,65.99,percent of total billed charges,"Drugs, Inpatient Only",65.99,30,,65.99,percent of total billed charges,"Drugs, Inpatient Only",109.99,50,,109.99,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,111.82,,,111.82,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,153.99,70,,153.99,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,60.12,,,60.12,Other,Drug Cost,60.12,,,60.12,Other,Drug Cost,60.12,,,60.12,Other,Drug Cost,60.12,,,60.12,Other,Drug Cost,60.12,,,60.12,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,60.12,,,60.12,Other,Drug Cost,135.27,,,135.27,Other,225% Medicaid APG methodology,84.17,,,84.17,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,60.12,,,60.12,Other,Drug Cost,60.12,,,60.12,Other,Drug Cost,75.15,,,75.15,Other,125% Medicaid APG methodology,0.01,153.99,
BISMUTH SUBSALICYLATE ORL 30ML  ,,,,40573222,CDM,250,RC,37000-0032-30,NDC,both,30,ML,1.05,0.41,39.4668,,0.41,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.32,30,,0.32,percent of total billed charges,"Drugs, Inpatient Only",0.32,30,,0.32,percent of total billed charges,"Drugs, Inpatient Only",0.32,30,,0.32,percent of total billed charges,"Drugs, Inpatient Only",0.53,50,,0.53,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.56,,,0.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.74,70,,0.74,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.68,,,0.68,Other,225% Medicaid APG methodology,0.42,,,0.42,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.38,,,0.38,Other,125% Medicaid APG methodology,0.01,0.74,
FEBUXOSTAT 40 MG TAB            ,,,,40573313,CDM,250,RC,64764-0918-30,NDC,both,1,EA,35.7,14.09,39.4668,,14.09,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.71,30,,10.71,percent of total billed charges,"Drugs, Inpatient Only",10.71,30,,10.71,percent of total billed charges,"Drugs, Inpatient Only",10.71,30,,10.71,percent of total billed charges,"Drugs, Inpatient Only",17.85,50,,17.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.58,,,4.58,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,24.99,70,,24.99,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.46,,,2.46,Other,Drug Cost,2.46,,,2.46,Other,Drug Cost,2.46,,,2.46,Other,Drug Cost,2.46,,,2.46,Other,Drug Cost,2.46,,,2.46,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.46,,,2.46,Other,Drug Cost,5.54,,,5.54,Other,225% Medicaid APG methodology,3.44,,,3.44,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.46,,,2.46,Other,Drug Cost,2.46,,,2.46,Other,Drug Cost,3.08,,,3.08,Other,125% Medicaid APG methodology,0.01,24.99,
SOD CHL 0.9%KCL 20MEQ IV1000ML  ,,,,40573438,CDM,250,RC,00338-0691-04,NDC,both,1000,ML,16.91,6.67,39.4668,,6.67,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.07,30,,5.07,percent of total billed charges,"Drugs, Inpatient Only",5.07,30,,5.07,percent of total billed charges,"Drugs, Inpatient Only",5.07,30,,5.07,percent of total billed charges,"Drugs, Inpatient Only",8.46,50,,8.46,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.14,,,14.14,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.84,70,,11.84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.6,,,7.6,Other,Drug Cost,7.6,,,7.6,Other,Drug Cost,7.6,,,7.6,Other,Drug Cost,7.6,,,7.6,Other,Drug Cost,7.6,,,7.6,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,7.6,,,7.6,Other,Drug Cost,17.1,,,17.1,Other,225% Medicaid APG methodology,10.64,,,10.64,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.6,,,7.6,Other,Drug Cost,7.6,,,7.6,Other,Drug Cost,9.5,,,9.5,Other,125% Medicaid APG methodology,0.01,17.1,
INSULIN REGULAR100UNIT NS100ML  ,,,,40573453,CDM,250,RC,00338-0126-12,NDC,both,100,ML,8.79,3.47,39.4668,,3.47,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.64,30,,2.64,percent of total billed charges,"Drugs, Inpatient Only",2.64,30,,2.64,percent of total billed charges,"Drugs, Inpatient Only",2.64,30,,2.64,percent of total billed charges,"Drugs, Inpatient Only",4.4,50,,4.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.4,,,19.4,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.15,70,,6.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.43,,,10.43,Other,Drug Cost,10.43,,,10.43,Other,Drug Cost,10.43,,,10.43,Other,Drug Cost,10.43,,,10.43,Other,Drug Cost,10.43,,,10.43,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,10.43,,,10.43,Other,Drug Cost,23.47,,,23.47,Other,225% Medicaid APG methodology,14.6,,,14.6,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,10.43,,,10.43,Other,Drug Cost,10.43,,,10.43,Other,Drug Cost,13.04,,,13.04,Other,125% Medicaid APG methodology,0.01,23.47,
CABERGOLINE 0.5 MG TAB          ,,,,40573495,CDM,250,RC,50742-0118-08,NDC,both,1,EA,10.15,4.01,39.4668,,4.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.05,30,,3.05,percent of total billed charges,"Drugs, Inpatient Only",3.05,30,,3.05,percent of total billed charges,"Drugs, Inpatient Only",3.05,30,,3.05,percent of total billed charges,"Drugs, Inpatient Only",5.08,50,,5.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.86,,,0.86,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.11,70,,7.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.46,,,0.46,Other,Drug Cost,1.04,,,1.04,Other,225% Medicaid APG methodology,0.64,,,0.64,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.58,,,0.58,Other,125% Medicaid APG methodology,0.01,7.11,
BUDESONIDE 3 MG EC CAP          ,,,,40573511,CDM,250,RC,65162-0778-10,NDC,both,1,EA,6.9,2.72,39.4668,,2.72,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.07,30,,2.07,percent of total billed charges,"Drugs, Inpatient Only",2.07,30,,2.07,percent of total billed charges,"Drugs, Inpatient Only",2.07,30,,2.07,percent of total billed charges,"Drugs, Inpatient Only",3.45,50,,3.45,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.99,,,0.99,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.83,70,,4.83,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.53,,,0.53,Other,Drug Cost,0.53,,,0.53,Other,Drug Cost,0.53,,,0.53,Other,Drug Cost,0.53,,,0.53,Other,Drug Cost,0.53,,,0.53,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.53,,,0.53,Other,Drug Cost,1.19,,,1.19,Other,225% Medicaid APG methodology,0.74,,,0.74,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.53,,,0.53,Other,Drug Cost,0.53,,,0.53,Other,Drug Cost,0.66,,,0.66,Other,125% Medicaid APG methodology,0.01,4.83,
DEXMDETOMIDINE 200 MCG/NS 50ML  ,,,,40573586,CDM,250,RC,70121-1711-09,NDC,both,50,ML,27.09,10.69,39.4668,,10.69,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.13,30,,8.13,percent of total billed charges,"Drugs, Inpatient Only",8.13,30,,8.13,percent of total billed charges,"Drugs, Inpatient Only",8.13,30,,8.13,percent of total billed charges,"Drugs, Inpatient Only",13.55,50,,13.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,25.95,,,25.95,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,18.96,70,,18.96,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.95,,,13.95,Other,Drug Cost,13.95,,,13.95,Other,Drug Cost,13.95,,,13.95,Other,Drug Cost,13.95,,,13.95,Other,Drug Cost,13.95,,,13.95,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,13.95,,,13.95,Other,Drug Cost,31.39,,,31.39,Other,225% Medicaid APG methodology,19.53,,,19.53,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,13.95,,,13.95,Other,Drug Cost,13.95,,,13.95,Other,Drug Cost,17.44,,,17.44,Other,125% Medicaid APG methodology,0.01,31.39,
SEVELAMER CARB 800MG ORL POW    ,,,,40573602,CDM,250,RC,43598-0478-90,NDC,both,1,EA,19.81,7.82,39.4668,,7.82,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.94,30,,5.94,percent of total billed charges,"Drugs, Inpatient Only",5.94,30,,5.94,percent of total billed charges,"Drugs, Inpatient Only",5.94,30,,5.94,percent of total billed charges,"Drugs, Inpatient Only",9.91,50,,9.91,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.03,,,3.03,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.87,70,,13.87,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.63,,,1.63,Other,Drug Cost,1.63,,,1.63,Other,Drug Cost,1.63,,,1.63,Other,Drug Cost,1.63,,,1.63,Other,Drug Cost,1.63,,,1.63,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.63,,,1.63,Other,Drug Cost,3.67,,,3.67,Other,225% Medicaid APG methodology,2.28,,,2.28,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.63,,,1.63,Other,Drug Cost,1.63,,,1.63,Other,Drug Cost,2.04,,,2.04,Other,125% Medicaid APG methodology,0.01,13.87,
GENTAMICIN ONCE DAILY P80MG     ,,,,40573636,CDM,250,RC,63323-0010-20,NDC,both,20,ML,702.77,277.36,39.4668,,277.36,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,210.83,30,,210.83,percent of total billed charges,"Drugs, Inpatient Only",210.83,30,,210.83,percent of total billed charges,"Drugs, Inpatient Only",210.83,30,,210.83,percent of total billed charges,"Drugs, Inpatient Only",351.39,50,,351.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.07,,,19.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,491.94,70,,491.94,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.25,,,10.25,Other,Drug Cost,10.25,,,10.25,Other,Drug Cost,10.25,,,10.25,Other,Drug Cost,10.25,,,10.25,Other,Drug Cost,10.25,,,10.25,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,10.25,,,10.25,Other,Drug Cost,23.06,,,23.06,Other,225% Medicaid APG methodology,14.35,,,14.35,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,10.25,,,10.25,Other,Drug Cost,10.25,,,10.25,Other,Drug Cost,12.81,,,12.81,Other,125% Medicaid APG methodology,0.01,491.94,
EFAVIRENZ 600 MG TAB            ,,,,40573651,CDM,250,RC,69097-0301-02,NDC,both,1,EA,21.28,8.4,39.4668,,8.4,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.38,30,,6.38,percent of total billed charges,"Drugs, Inpatient Only",6.38,30,,6.38,percent of total billed charges,"Drugs, Inpatient Only",6.38,30,,6.38,percent of total billed charges,"Drugs, Inpatient Only",10.64,50,,10.64,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.71,,,1.71,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.9,70,,14.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.92,,,0.92,Other,Drug Cost,2.07,,,2.07,Other,225% Medicaid APG methodology,1.29,,,1.29,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.92,,,0.92,Other,Drug Cost,0.92,,,0.92,Other,Drug Cost,1.15,,,1.15,Other,125% Medicaid APG methodology,0.01,14.9,
DIGOXIN 125 MCG (0.125 MG) TAB  ,,,,40573842,CDM,250,RC,60687-0540-01,NDC,both,1,EA,3.43,1.35,39.4668,,1.35,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.03,30,,1.03,percent of total billed charges,"Drugs, Inpatient Only",1.03,30,,1.03,percent of total billed charges,"Drugs, Inpatient Only",1.03,30,,1.03,percent of total billed charges,"Drugs, Inpatient Only",1.72,50,,1.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.93,,,1.93,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.4,70,,2.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.04,,,1.04,Other,Drug Cost,1.04,,,1.04,Other,Drug Cost,1.04,,,1.04,Other,Drug Cost,1.04,,,1.04,Other,Drug Cost,1.04,,,1.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.04,,,1.04,Other,Drug Cost,2.34,,,2.34,Other,225% Medicaid APG methodology,1.46,,,1.46,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.04,,,1.04,Other,Drug Cost,1.04,,,1.04,Other,Drug Cost,1.3,,,1.3,Other,125% Medicaid APG methodology,0.01,2.4,
DIGOXIN 250 MCG (0.25 MG) TAB   ,,,,40573859,CDM,250,RC,60687-0551-01,NDC,both,1,EA,3.26,1.29,39.4668,,1.29,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.98,30,,0.98,percent of total billed charges,"Drugs, Inpatient Only",0.98,30,,0.98,percent of total billed charges,"Drugs, Inpatient Only",0.98,30,,0.98,percent of total billed charges,"Drugs, Inpatient Only",1.63,50,,1.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.93,,,1.93,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.28,70,,2.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.04,,,1.04,Other,Drug Cost,1.04,,,1.04,Other,Drug Cost,1.04,,,1.04,Other,Drug Cost,1.04,,,1.04,Other,Drug Cost,1.04,,,1.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.04,,,1.04,Other,Drug Cost,2.34,,,2.34,Other,225% Medicaid APG methodology,1.46,,,1.46,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.04,,,1.04,Other,Drug Cost,1.04,,,1.04,Other,Drug Cost,1.3,,,1.3,Other,125% Medicaid APG methodology,0.01,2.34,
LIDOCAINE 2% PF INJ SOLN 5 ML   ,,,,40573891,CDM,250,RC,55150-0165-05,NDC,both,5,ML,3.78,1.49,39.4668,,1.49,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.13,30,,1.13,percent of total billed charges,"Drugs, Inpatient Only",1.13,30,,1.13,percent of total billed charges,"Drugs, Inpatient Only",1.13,30,,1.13,percent of total billed charges,"Drugs, Inpatient Only",1.89,50,,1.89,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.61,,,3.61,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.65,70,,2.65,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.94,,,1.94,Other,Drug Cost,4.37,,,4.37,Other,225% Medicaid APG methodology,2.72,,,2.72,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,2.43,,,2.43,Other,125% Medicaid APG methodology,0.01,4.37,
NICOTINE 2 MG GUM               ,,,,40574105,CDM,250,RC,00536-3112-01,NDC,both,1,EA,0.63,0.25,39.4668,,0.25,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.19,30,,0.19,percent of total billed charges,"Drugs, Inpatient Only",0.32,50,,0.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.35,,,0.35,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.44,70,,0.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,Drug Cost,0.43,,,0.43,Other,225% Medicaid APG methodology,0.27,,,0.27,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.24,,,0.24,Other,125% Medicaid APG methodology,0.01,0.44,
PETROLATUM OPT OINT 3.5 G       ,,,,40574170,CDM,250,RC,00023-0312-04,NDC,both,3.5,GM,36.26,14.31,39.4668,,14.31,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.88,30,,10.88,percent of total billed charges,"Drugs, Inpatient Only",10.88,30,,10.88,percent of total billed charges,"Drugs, Inpatient Only",10.88,30,,10.88,percent of total billed charges,"Drugs, Inpatient Only",18.13,50,,18.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.53,,,14.53,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,25.38,70,,25.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.81,,,7.81,Other,Drug Cost,7.81,,,7.81,Other,Drug Cost,7.81,,,7.81,Other,Drug Cost,7.81,,,7.81,Other,Drug Cost,7.81,,,7.81,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,7.81,,,7.81,Other,Drug Cost,17.57,,,17.57,Other,225% Medicaid APG methodology,10.93,,,10.93,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.81,,,7.81,Other,Drug Cost,7.81,,,7.81,Other,Drug Cost,9.76,,,9.76,Other,125% Medicaid APG methodology,0.01,25.38,
TRANXAMIC ACID 100MG/ML IV10ML  ,,,,40574188,CDM,250,RC,72485-0510-10,NDC,both,10,ML,10.01,3.95,39.4668,,3.95,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3,30,,3,percent of total billed charges,"Drugs, Inpatient Only",3,30,,3,percent of total billed charges,"Drugs, Inpatient Only",3,30,,3,percent of total billed charges,"Drugs, Inpatient Only",5.01,50,,5.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.61,,,3.61,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.01,70,,7.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.94,,,1.94,Other,Drug Cost,4.37,,,4.37,Other,225% Medicaid APG methodology,2.72,,,2.72,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,2.43,,,2.43,Other,125% Medicaid APG methodology,0.01,7.01,
CISATRACURIUM 2MG/ML IV 5ML     ,,,,40574311,CDM,250,RC,00781-3150-95,NDC,both,5,ML,17.5,6.91,39.4668,,6.91,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.25,30,,5.25,percent of total billed charges,"Drugs, Inpatient Only",5.25,30,,5.25,percent of total billed charges,"Drugs, Inpatient Only",5.25,30,,5.25,percent of total billed charges,"Drugs, Inpatient Only",8.75,50,,8.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.3,,,9.3,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.25,70,,12.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5,,,5,Other,Drug Cost,5,,,5,Other,Drug Cost,5,,,5,Other,Drug Cost,5,,,5,Other,Drug Cost,5,,,5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,5,,,5,Other,Drug Cost,11.25,,,11.25,Other,225% Medicaid APG methodology,7,,,7,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5,,,5,Other,Drug Cost,5,,,5,Other,Drug Cost,6.25,,,6.25,Other,125% Medicaid APG methodology,0.01,12.25,
RIFAXIMIN 550 MG TAB            ,,,,40574410,CDM,250,RC,65649-0303-03,NDC,both,1,EA,130.66,51.57,39.4668,,51.57,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,39.2,30,,39.2,percent of total billed charges,"Drugs, Inpatient Only",39.2,30,,39.2,percent of total billed charges,"Drugs, Inpatient Only",39.2,30,,39.2,percent of total billed charges,"Drugs, Inpatient Only",65.33,50,,65.33,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.63,,,12.63,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,91.46,70,,91.46,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.79,,,6.79,Other,Drug Cost,6.79,,,6.79,Other,Drug Cost,6.79,,,6.79,Other,Drug Cost,6.79,,,6.79,Other,Drug Cost,6.79,,,6.79,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,6.79,,,6.79,Other,Drug Cost,15.28,,,15.28,Other,225% Medicaid APG methodology,9.51,,,9.51,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.79,,,6.79,Other,Drug Cost,6.79,,,6.79,Other,Drug Cost,8.49,,,8.49,Other,125% Medicaid APG methodology,0.01,91.46,
FERROUS SULF 15MG/ML LIQ 50ML   ,,,,40574428,CDM,250,RC,54838-0011-50,NDC,both,50,ML,10.5,4.14,39.4668,,4.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.15,30,,3.15,percent of total billed charges,"Drugs, Inpatient Only",3.15,30,,3.15,percent of total billed charges,"Drugs, Inpatient Only",3.15,30,,3.15,percent of total billed charges,"Drugs, Inpatient Only",5.25,50,,5.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.65,,,4.65,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.35,70,,7.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.5,,,2.5,Other,Drug Cost,5.63,,,5.63,Other,225% Medicaid APG methodology,3.5,,,3.5,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,3.13,,,3.13,Other,125% Medicaid APG methodology,0.01,7.35,
RITONAVIR 100 MG TAB            ,,,,40574436,CDM,250,RC,00054-0407-13,NDC,both,1,EA,17.36,6.85,39.4668,,6.85,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.21,30,,5.21,percent of total billed charges,"Drugs, Inpatient Only",5.21,30,,5.21,percent of total billed charges,"Drugs, Inpatient Only",5.21,30,,5.21,percent of total billed charges,"Drugs, Inpatient Only",8.68,50,,8.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.47,,,1.47,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.15,70,,12.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.79,,,0.79,Other,Drug Cost,0.79,,,0.79,Other,Drug Cost,0.79,,,0.79,Other,Drug Cost,0.79,,,0.79,Other,Drug Cost,0.79,,,0.79,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.79,,,0.79,Other,Drug Cost,1.78,,,1.78,Other,225% Medicaid APG methodology,1.11,,,1.11,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.79,,,0.79,Other,Drug Cost,0.79,,,0.79,Other,Drug Cost,0.99,,,0.99,Other,125% Medicaid APG methodology,0.01,12.15,
CARDIOPLEGIA ST THOMAS HIGH K   ,,,,40574618,CDM,250,RC,71285-0209-01,NDC,both,1000,ML,210,82.88,39.4668,,82.88,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,63,30,,63,percent of total billed charges,"Drugs, Inpatient Only",63,30,,63,percent of total billed charges,"Drugs, Inpatient Only",63,30,,63,percent of total billed charges,"Drugs, Inpatient Only",105,50,,105,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,111.6,,,111.6,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,147,70,,147,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,60,,,60,Other,Drug Cost,60,,,60,Other,Drug Cost,60,,,60,Other,Drug Cost,60,,,60,Other,Drug Cost,60,,,60,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,60,,,60,Other,Drug Cost,135,,,135,Other,225% Medicaid APG methodology,84,,,84,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,60,,,60,Other,Drug Cost,60,,,60,Other,Drug Cost,75,,,75,Other,125% Medicaid APG methodology,0.01,147,
L CARDIOPLGIA PLASMLYTE1000ML   ,,,,40574626,CDM,250,RC,71285-0211-01,NDC,both,1000,ML,245,96.69,39.4668,,96.69,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,73.5,30,,73.5,percent of total billed charges,"Drugs, Inpatient Only",73.5,30,,73.5,percent of total billed charges,"Drugs, Inpatient Only",73.5,30,,73.5,percent of total billed charges,"Drugs, Inpatient Only",122.5,50,,122.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,130.2,,,130.2,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,171.5,70,,171.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,70,,,70,Other,Drug Cost,70,,,70,Other,Drug Cost,70,,,70,Other,Drug Cost,70,,,70,Other,Drug Cost,70,,,70,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,70,,,70,Other,Drug Cost,157.5,,,157.5,Other,225% Medicaid APG methodology,98,,,98,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,70,,,70,Other,Drug Cost,70,,,70,Other,Drug Cost,87.5,,,87.5,Other,125% Medicaid APG methodology,0.01,171.5,
COLLAGENASE 250UNIT/G OINT 30G  ,,,,40574675,CDM,250,RC,50484-0010-30,NDC,both,30,GM,731.85,288.84,39.4668,,288.84,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,219.56,30,,219.56,percent of total billed charges,"Drugs, Inpatient Only",219.56,30,,219.56,percent of total billed charges,"Drugs, Inpatient Only",219.56,30,,219.56,percent of total billed charges,"Drugs, Inpatient Only",365.93,50,,365.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,31.81,,,31.81,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,512.3,70,,512.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,17.1,,,17.1,Other,Drug Cost,17.1,,,17.1,Other,Drug Cost,17.1,,,17.1,Other,Drug Cost,17.1,,,17.1,Other,Drug Cost,17.1,,,17.1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,17.1,,,17.1,Other,Drug Cost,38.48,,,38.48,Other,225% Medicaid APG methodology,23.94,,,23.94,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,17.1,,,17.1,Other,Drug Cost,17.1,,,17.1,Other,Drug Cost,21.38,,,21.38,Other,125% Medicaid APG methodology,0.01,512.3,
SOD CHOND-HYALURON  0.5ML       ,,,,40574774,CDM,250,RC,08065-1839-05,NDC,both,0.5,ML,216.69,85.52,39.4668,,85.52,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,65.01,30,,65.01,percent of total billed charges,"Drugs, Inpatient Only",65.01,30,,65.01,percent of total billed charges,"Drugs, Inpatient Only",65.01,30,,65.01,percent of total billed charges,"Drugs, Inpatient Only",108.35,50,,108.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,272.49,,,272.49,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,151.68,70,,151.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,146.5,,,146.5,Other,Drug Cost,146.5,,,146.5,Other,Drug Cost,146.5,,,146.5,Other,Drug Cost,146.5,,,146.5,Other,Drug Cost,146.5,,,146.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,146.5,,,146.5,Other,Drug Cost,329.63,,,329.63,Other,225% Medicaid APG methodology,205.1,,,205.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,146.5,,,146.5,Other,Drug Cost,146.5,,,146.5,Other,Drug Cost,183.13,,,183.13,Other,125% Medicaid APG methodology,0.01,329.63,
PREDNISOLONE 15MG/5ML ORL 5ML   ,,,,40574832,CDM,250,RC,50383-0042-48,NDC,both,5,ML,2.87,1.13,39.4668,,1.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.86,30,,0.86,percent of total billed charges,"Drugs, Inpatient Only",0.86,30,,0.86,percent of total billed charges,"Drugs, Inpatient Only",0.86,30,,0.86,percent of total billed charges,"Drugs, Inpatient Only",1.44,50,,1.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.01,70,,2.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,2.01,
DABIGATRAN 150 MG CAP           ,,,,40574865,CDM,250,RC,00597-0360-82,NDC,both,1,EA,21.49,8.48,39.4668,,8.48,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.45,30,,6.45,percent of total billed charges,"Drugs, Inpatient Only",6.45,30,,6.45,percent of total billed charges,"Drugs, Inpatient Only",6.45,30,,6.45,percent of total billed charges,"Drugs, Inpatient Only",10.75,50,,10.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.04,70,,15.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,15.04,
BUPIV-EPI .25%-1:200000PF 10ML  ,,,,40574915,CDM,250,RC,63323-0468-17,NDC,both,10,ML,11.9,4.7,39.4668,,4.7,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.57,30,,3.57,percent of total billed charges,"Drugs, Inpatient Only",3.57,30,,3.57,percent of total billed charges,"Drugs, Inpatient Only",3.57,30,,3.57,percent of total billed charges,"Drugs, Inpatient Only",5.95,50,,5.95,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.16,,,3.16,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.33,70,,8.33,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.7,,,1.7,Other,Drug Cost,1.7,,,1.7,Other,Drug Cost,1.7,,,1.7,Other,Drug Cost,1.7,,,1.7,Other,Drug Cost,1.7,,,1.7,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.7,,,1.7,Other,Drug Cost,3.83,,,3.83,Other,225% Medicaid APG methodology,2.38,,,2.38,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.7,,,1.7,Other,Drug Cost,1.7,,,1.7,Other,Drug Cost,2.13,,,2.13,Other,125% Medicaid APG methodology,0.01,8.33,
ASCORBIC ACID 500MG/ML INJ50ML  ,,,,40574980,CDM,250,RC,67457-0118-50,NDC,both,50,ML,299.25,118.1,39.4668,,118.1,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,89.78,30,,89.78,percent of total billed charges,"Drugs, Inpatient Only",89.78,30,,89.78,percent of total billed charges,"Drugs, Inpatient Only",89.78,30,,89.78,percent of total billed charges,"Drugs, Inpatient Only",149.63,50,,149.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.3,,,9.3,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,209.48,70,,209.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5,,,5,Other,Drug Cost,5,,,5,Other,Drug Cost,5,,,5,Other,Drug Cost,5,,,5,Other,Drug Cost,5,,,5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,5,,,5,Other,Drug Cost,11.25,,,11.25,Other,225% Medicaid APG methodology,7,,,7,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5,,,5,Other,Drug Cost,5,,,5,Other,Drug Cost,6.25,,,6.25,Other,125% Medicaid APG methodology,0.01,209.48,
D5W IN WATER IV SOLN 100 ML     ,,,,40575011,CDM,250,RC,00338-0017-18,NDC,both,100,ML,7,2.76,39.4668,,2.76,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.1,30,,2.1,percent of total billed charges,"Drugs, Inpatient Only",2.1,30,,2.1,percent of total billed charges,"Drugs, Inpatient Only",2.1,30,,2.1,percent of total billed charges,"Drugs, Inpatient Only",3.5,50,,3.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.72,,,3.72,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.9,70,,4.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2,,,2,Other,Drug Cost,4.5,,,4.5,Other,225% Medicaid APG methodology,2.8,,,2.8,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,2.5,,,2.5,Other,125% Medicaid APG methodology,0.01,4.9,
CYCLOPENTOLATE 0.5% OPT 15ML    ,,,,40575110,CDM,250,RC,00065-0395-15,NDC,both,15,ML,252,99.46,39.4668,,99.46,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,75.6,30,,75.6,percent of total billed charges,"Drugs, Inpatient Only",75.6,30,,75.6,percent of total billed charges,"Drugs, Inpatient Only",75.6,30,,75.6,percent of total billed charges,"Drugs, Inpatient Only",126,50,,126,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,96.53,,,96.53,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,176.4,70,,176.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,51.9,,,51.9,Other,Drug Cost,51.9,,,51.9,Other,Drug Cost,51.9,,,51.9,Other,Drug Cost,51.9,,,51.9,Other,Drug Cost,51.9,,,51.9,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,51.9,,,51.9,Other,Drug Cost,116.78,,,116.78,Other,225% Medicaid APG methodology,72.66,,,72.66,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,51.9,,,51.9,Other,Drug Cost,51.9,,,51.9,Other,Drug Cost,64.88,,,64.88,Other,125% Medicaid APG methodology,0.01,176.4,
CYANOCOBALAMIN 1000 MCG TAB     ,,,,40575185,CDM,250,RC,00904-7403-61,NDC,both,1,EA,0.46,0.18,39.4668,,0.18,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.14,30,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,30,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,30,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.23,50,,0.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.32,70,,0.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,Drug Cost,0.32,,,0.32,Other,225% Medicaid APG methodology,0.2,,,0.2,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.18,,,0.18,Other,125% Medicaid APG methodology,0.01,0.32,
DABIGATRAN 75 MG CAP            ,,,,40575276,CDM,250,RC,00597-0355-56,NDC,both,1,EA,116.13,45.83,39.4668,,45.83,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,34.84,30,,34.84,percent of total billed charges,"Drugs, Inpatient Only",34.84,30,,34.84,percent of total billed charges,"Drugs, Inpatient Only",34.84,30,,34.84,percent of total billed charges,"Drugs, Inpatient Only",58.07,50,,58.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,81.29,70,,81.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,81.29,
INDOCYANINE GREEN 25 MG INJ     ,,,,40575367,CDM,250,RC,17238-0424-06,NDC,both,1,EA,231.67,91.43,39.4668,,91.43,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,69.5,30,,69.5,percent of total billed charges,"Drugs, Inpatient Only",69.5,30,,69.5,percent of total billed charges,"Drugs, Inpatient Only",69.5,30,,69.5,percent of total billed charges,"Drugs, Inpatient Only",115.84,50,,115.84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,118.59,,,118.59,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,162.17,70,,162.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,63.76,,,63.76,Other,Drug Cost,63.76,,,63.76,Other,Drug Cost,63.76,,,63.76,Other,Drug Cost,63.76,,,63.76,Other,Drug Cost,63.76,,,63.76,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,63.76,,,63.76,Other,Drug Cost,143.46,,,143.46,Other,225% Medicaid APG methodology,89.26,,,89.26,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,63.76,,,63.76,Other,Drug Cost,63.76,,,63.76,Other,Drug Cost,79.7,,,79.7,Other,125% Medicaid APG methodology,0.01,162.17,
ACARBOSE 25 MG TAB              ,,,,40575375,CDM,250,RC,00054-0140-25,NDC,both,1,EA,0.46,0.18,39.4668,,0.18,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.14,30,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,30,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.14,30,,0.14,percent of total billed charges,"Drugs, Inpatient Only",0.23,50,,0.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.32,70,,0.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.32,
SOD BICARB ABOJET 8.4%INJ 50ML  ,,,,40575383,CDM,250,RC,00409-6637-34,NDC,both,50,ML,26.25,10.36,39.4668,,10.36,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.88,30,,7.88,percent of total billed charges,"Drugs, Inpatient Only",7.88,30,,7.88,percent of total billed charges,"Drugs, Inpatient Only",7.88,30,,7.88,percent of total billed charges,"Drugs, Inpatient Only",13.13,50,,13.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.37,,,8.37,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,18.38,70,,18.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.5,,,4.5,Other,Drug Cost,4.5,,,4.5,Other,Drug Cost,4.5,,,4.5,Other,Drug Cost,4.5,,,4.5,Other,Drug Cost,4.5,,,4.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.5,,,4.5,Other,Drug Cost,10.13,,,10.13,Other,225% Medicaid APG methodology,6.3,,,6.3,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.5,,,4.5,Other,Drug Cost,4.5,,,4.5,Other,Drug Cost,5.63,,,5.63,Other,125% Medicaid APG methodology,0.01,18.38,
BACITRACIN 500UNIT/G OPT 3.5 G  ,,,,40575391,CDM,250,RC,00574-4022-35,NDC,both,3.5,GM,290.47,114.64,39.4668,,114.64,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,87.14,30,,87.14,percent of total billed charges,"Drugs, Inpatient Only",87.14,30,,87.14,percent of total billed charges,"Drugs, Inpatient Only",87.14,30,,87.14,percent of total billed charges,"Drugs, Inpatient Only",145.24,50,,145.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,86.01,,,86.01,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,203.33,70,,203.33,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,46.24,,,46.24,Other,Drug Cost,46.24,,,46.24,Other,Drug Cost,46.24,,,46.24,Other,Drug Cost,46.24,,,46.24,Other,Drug Cost,46.24,,,46.24,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,46.24,,,46.24,Other,Drug Cost,104.04,,,104.04,Other,225% Medicaid APG methodology,64.74,,,64.74,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,46.24,,,46.24,Other,Drug Cost,46.24,,,46.24,Other,Drug Cost,57.8,,,57.8,Other,125% Medicaid APG methodology,0.01,203.33,
PALIPERIDONE 3 MG ER TAB        ,,,,40575441,CDM,250,RC,43975-0350-03,NDC,both,1,EA,7.04,2.78,39.4668,,2.78,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.11,30,,2.11,percent of total billed charges,"Drugs, Inpatient Only",2.11,30,,2.11,percent of total billed charges,"Drugs, Inpatient Only",2.11,30,,2.11,percent of total billed charges,"Drugs, Inpatient Only",3.52,50,,3.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.93,70,,4.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,Drug Cost,0.34,,,0.34,Other,225% Medicaid APG methodology,0.21,,,0.21,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.19,,,0.19,Other,125% Medicaid APG methodology,0.01,4.93,
TETRACAINE 1% INJ SOLN 2ML      ,,,,40575730,CDM,250,RC,17478-0045-32,NDC,both,2,ML,251.3,99.18,39.4668,,99.18,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,75.39,30,,75.39,percent of total billed charges,"Drugs, Inpatient Only",75.39,30,,75.39,percent of total billed charges,"Drugs, Inpatient Only",75.39,30,,75.39,percent of total billed charges,"Drugs, Inpatient Only",125.65,50,,125.65,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,133.14,,,133.14,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,175.91,70,,175.91,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,71.58,,,71.58,Other,Drug Cost,71.58,,,71.58,Other,Drug Cost,71.58,,,71.58,Other,Drug Cost,71.58,,,71.58,Other,Drug Cost,71.58,,,71.58,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,71.58,,,71.58,Other,Drug Cost,161.06,,,161.06,Other,225% Medicaid APG methodology,100.21,,,100.21,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,71.58,,,71.58,Other,Drug Cost,71.58,,,71.58,Other,Drug Cost,89.48,,,89.48,Other,125% Medicaid APG methodology,0.01,175.91,
NF-NEBIVOLOL 5 MG TAB           ,,,,40575896,CDM,250,RC,00456-1405-30,NDC,both,1,EA,18.83,7.43,39.4668,,7.43,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.65,30,,5.65,percent of total billed charges,"Drugs, Inpatient Only",5.65,30,,5.65,percent of total billed charges,"Drugs, Inpatient Only",5.65,30,,5.65,percent of total billed charges,"Drugs, Inpatient Only",9.42,50,,9.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.18,70,,13.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,13.18,
VANCOMYCIN 250MG/5ML ORAL SYR   ,,,,40576001,CDM,250,RC,65628-0206-05C,NDC,both,5,ML,13.83,5.46,39.4668,,5.46,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.15,30,,4.15,percent of total billed charges,"Drugs, Inpatient Only",4.15,30,,4.15,percent of total billed charges,"Drugs, Inpatient Only",4.15,30,,4.15,percent of total billed charges,"Drugs, Inpatient Only",6.92,50,,6.92,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.49,,,5.49,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.68,70,,9.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.95,,,2.95,Other,Drug Cost,2.95,,,2.95,Other,Drug Cost,2.95,,,2.95,Other,Drug Cost,2.95,,,2.95,Other,Drug Cost,2.95,,,2.95,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.95,,,2.95,Other,Drug Cost,6.64,,,6.64,Other,225% Medicaid APG methodology,4.13,,,4.13,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.95,,,2.95,Other,Drug Cost,2.95,,,2.95,Other,Drug Cost,3.69,,,3.69,Other,125% Medicaid APG methodology,0.01,9.68,
OSELTAMIVIR 45MG CAPSULE        ,,,,40576167,CDM,250,RC,68180-0676-11,NDC,both,1,EA,5.53,2.18,39.4668,,2.18,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.66,30,,1.66,percent of total billed charges,"Drugs, Inpatient Only",1.66,30,,1.66,percent of total billed charges,"Drugs, Inpatient Only",1.66,30,,1.66,percent of total billed charges,"Drugs, Inpatient Only",2.77,50,,2.77,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.12,,,2.12,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.87,70,,3.87,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.14,,,1.14,Other,Drug Cost,2.57,,,2.57,Other,225% Medicaid APG methodology,1.6,,,1.6,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.14,,,1.14,Other,Drug Cost,1.14,,,1.14,Other,Drug Cost,1.43,,,1.43,Other,125% Medicaid APG methodology,0.01,3.87,
CALCIUM CHLORIDE 10MG/ML  D5W   ,,,,40576274,CDM,250,RC,76329-3304-01p,NDC,both,1,ML,2.8,1.11,39.4668,,1.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.84,30,,0.84,percent of total billed charges,"Drugs, Inpatient Only",0.84,30,,0.84,percent of total billed charges,"Drugs, Inpatient Only",0.84,30,,0.84,percent of total billed charges,"Drugs, Inpatient Only",1.4,50,,1.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.39,,,0.39,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.96,70,,1.96,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.21,,,0.21,Other,Drug Cost,0.47,,,0.47,Other,225% Medicaid APG methodology,0.29,,,0.29,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.26,,,0.26,Other,125% Medicaid APG methodology,0.01,1.96,
PHENYLEPHRINE 2.5% OPT SLN 2ML  ,,,,40576290,CDM,250,RC,17478-0201-02,NDC,both,2,ML,101.08,39.89,39.4668,,39.89,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,30.32,30,,30.32,percent of total billed charges,"Drugs, Inpatient Only",30.32,30,,30.32,percent of total billed charges,"Drugs, Inpatient Only",30.32,30,,30.32,percent of total billed charges,"Drugs, Inpatient Only",50.54,50,,50.54,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.39,,,12.39,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,70.76,70,,70.76,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.66,,,6.66,Other,Drug Cost,6.66,,,6.66,Other,Drug Cost,6.66,,,6.66,Other,Drug Cost,6.66,,,6.66,Other,Drug Cost,6.66,,,6.66,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,6.66,,,6.66,Other,Drug Cost,14.99,,,14.99,Other,225% Medicaid APG methodology,9.32,,,9.32,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.66,,,6.66,Other,Drug Cost,6.66,,,6.66,Other,Drug Cost,8.33,,,8.33,Other,125% Medicaid APG methodology,0.01,70.76,
PHENYLEPHRINE 2.5% OPTSLN 15ML  ,,,,40576373,CDM,250,RC,17478-0201-15,NDC,both,15,ML,278.25,109.82,39.4668,,109.82,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,83.48,30,,83.48,percent of total billed charges,"Drugs, Inpatient Only",83.48,30,,83.48,percent of total billed charges,"Drugs, Inpatient Only",83.48,30,,83.48,percent of total billed charges,"Drugs, Inpatient Only",139.13,50,,139.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,92.91,,,92.91,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,194.78,70,,194.78,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,49.95,,,49.95,Other,Drug Cost,49.95,,,49.95,Other,Drug Cost,49.95,,,49.95,Other,Drug Cost,49.95,,,49.95,Other,Drug Cost,49.95,,,49.95,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,49.95,,,49.95,Other,Drug Cost,112.39,,,112.39,Other,225% Medicaid APG methodology,69.93,,,69.93,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,49.95,,,49.95,Other,Drug Cost,49.95,,,49.95,Other,Drug Cost,62.44,,,62.44,Other,125% Medicaid APG methodology,0.01,194.78,
CANDIDA ALBICANS SKIN TEST 1ML  ,,,,40576639,CDM,250,RC,59584-0138-01,NDC,both,1,ML,961.84,379.61,39.4668,,379.61,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,288.55,30,,288.55,percent of total billed charges,"Drugs, Inpatient Only",288.55,30,,288.55,percent of total billed charges,"Drugs, Inpatient Only",288.55,30,,288.55,percent of total billed charges,"Drugs, Inpatient Only",480.92,50,,480.92,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,502.83,,,502.83,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,673.29,70,,673.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,270.34,,,270.34,Other,Drug Cost,270.34,,,270.34,Other,Drug Cost,270.34,,,270.34,Other,Drug Cost,270.34,,,270.34,Other,Drug Cost,270.34,,,270.34,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,270.34,,,270.34,Other,Drug Cost,608.27,,,608.27,Other,225% Medicaid APG methodology,378.48,,,378.48,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,270.34,,,270.34,Other,Drug Cost,270.34,,,270.34,Other,Drug Cost,337.93,,,337.93,Other,125% Medicaid APG methodology,0.01,673.29,
CEPHALEXIN 50MG/ML 5ML ORL SYR  ,,,,40576670,CDM,250,RC,67877-0545-88b,NDC,both,5,ML,1.96,0.77,39.4668,,0.77,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.59,30,,0.59,percent of total billed charges,"Drugs, Inpatient Only",0.59,30,,0.59,percent of total billed charges,"Drugs, Inpatient Only",0.59,30,,0.59,percent of total billed charges,"Drugs, Inpatient Only",0.98,50,,0.98,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.37,70,,1.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% Medicaid APG methodology,0.1,,,0.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,1.37,
DOFETILIDE 500 MCG CAP          ,,,,40576811,CDM,250,RC,69452-0133-17,NDC,both,1,EA,5.29,2.09,39.4668,,2.09,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.59,30,,1.59,percent of total billed charges,"Drugs, Inpatient Only",1.59,30,,1.59,percent of total billed charges,"Drugs, Inpatient Only",1.59,30,,1.59,percent of total billed charges,"Drugs, Inpatient Only",2.65,50,,2.65,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.66,,,1.66,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.7,70,,3.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.89,,,0.89,Other,Drug Cost,0.89,,,0.89,Other,Drug Cost,0.89,,,0.89,Other,Drug Cost,0.89,,,0.89,Other,Drug Cost,0.89,,,0.89,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.89,,,0.89,Other,Drug Cost,2,,,2,Other,225% Medicaid APG methodology,1.25,,,1.25,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.89,,,0.89,Other,Drug Cost,0.89,,,0.89,Other,Drug Cost,1.11,,,1.11,Other,125% Medicaid APG methodology,0.01,3.7,
OSELTAMIVIR 6MG/ML ORL 60ML     ,,,,40576860,CDM,250,RC,47781-0384-26,NDC,both,60,ML,186.9,73.76,39.4668,,73.76,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,56.07,30,,56.07,percent of total billed charges,"Drugs, Inpatient Only",56.07,30,,56.07,percent of total billed charges,"Drugs, Inpatient Only",56.07,30,,56.07,percent of total billed charges,"Drugs, Inpatient Only",93.45,50,,93.45,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,29.02,,,29.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,130.83,70,,130.83,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.6,,,15.6,Other,Drug Cost,15.6,,,15.6,Other,Drug Cost,15.6,,,15.6,Other,Drug Cost,15.6,,,15.6,Other,Drug Cost,15.6,,,15.6,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,15.6,,,15.6,Other,Drug Cost,35.1,,,35.1,Other,225% Medicaid APG methodology,21.84,,,21.84,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,15.6,,,15.6,Other,Drug Cost,15.6,,,15.6,Other,Drug Cost,19.5,,,19.5,Other,125% Medicaid APG methodology,0.01,130.83,
LIDOCAINE 1% INJ SOLN 10 ML     ,,,,40576936,CDM,250,RC,55150-0251-10,NDC,both,10,ML,6.44,2.54,39.4668,,2.54,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.93,30,,1.93,percent of total billed charges,"Drugs, Inpatient Only",1.93,30,,1.93,percent of total billed charges,"Drugs, Inpatient Only",1.93,30,,1.93,percent of total billed charges,"Drugs, Inpatient Only",3.22,50,,3.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.75,,,1.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.51,70,,4.51,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.94,,,0.94,Other,Drug Cost,0.94,,,0.94,Other,Drug Cost,0.94,,,0.94,Other,Drug Cost,0.94,,,0.94,Other,Drug Cost,0.94,,,0.94,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.94,,,0.94,Other,Drug Cost,2.12,,,2.12,Other,225% Medicaid APG methodology,1.32,,,1.32,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.94,,,0.94,Other,Drug Cost,0.94,,,0.94,Other,Drug Cost,1.18,,,1.18,Other,125% Medicaid APG methodology,0.01,4.51,
LIDOCAINE 1% INJ SOLN 50 ML     ,,,,40576944,CDM,250,RC,00143-9577-10,NDC,both,50,ML,0.56,0.22,39.4668,,0.22,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.28,50,,0.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.09,,,3.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.39,70,,0.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.66,,,1.66,Other,Drug Cost,1.66,,,1.66,Other,Drug Cost,1.66,,,1.66,Other,Drug Cost,1.66,,,1.66,Other,Drug Cost,1.66,,,1.66,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.66,,,1.66,Other,Drug Cost,3.74,,,3.74,Other,225% Medicaid APG methodology,2.32,,,2.32,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.66,,,1.66,Other,Drug Cost,1.66,,,1.66,Other,Drug Cost,2.08,,,2.08,Other,125% Medicaid APG methodology,0.01,3.74,
LIDOCAINE 1% PF INJ SOLN 2 ML   ,,,,40576951,CDM,250,RC,70756-0640-25,NDC,both,2,ML,4.06,1.6,39.4668,,1.6,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.22,30,,1.22,percent of total billed charges,"Drugs, Inpatient Only",1.22,30,,1.22,percent of total billed charges,"Drugs, Inpatient Only",1.22,30,,1.22,percent of total billed charges,"Drugs, Inpatient Only",2.03,50,,2.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.34,,,1.34,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.84,70,,2.84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.72,,,0.72,Other,Drug Cost,0.72,,,0.72,Other,Drug Cost,0.72,,,0.72,Other,Drug Cost,0.72,,,0.72,Other,Drug Cost,0.72,,,0.72,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.72,,,0.72,Other,Drug Cost,1.62,,,1.62,Other,225% Medicaid APG methodology,1.01,,,1.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.72,,,0.72,Other,Drug Cost,0.72,,,0.72,Other,Drug Cost,0.9,,,0.9,Other,125% Medicaid APG methodology,0.01,2.84,
EPINEPH-LIDO 1:100000-1% 30ML   ,,,,40576985,CDM,250,RC,00409-3178-02,NDC,both,30,ML,10.5,4.14,39.4668,,4.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.15,30,,3.15,percent of total billed charges,"Drugs, Inpatient Only",3.15,30,,3.15,percent of total billed charges,"Drugs, Inpatient Only",3.15,30,,3.15,percent of total billed charges,"Drugs, Inpatient Only",5.25,50,,5.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.79,,,2.79,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.35,70,,7.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.5,,,1.5,Other,Drug Cost,3.38,,,3.38,Other,225% Medicaid APG methodology,2.1,,,2.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.88,,,1.88,Other,125% Medicaid APG methodology,0.01,7.35,
FIDAXOMICIN 200 MG TAB          ,,,,40577025,CDM,250,RC,52015-0080-01,NDC,both,1,EA,762.76,301.04,39.4668,,301.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,228.83,30,,228.83,percent of total billed charges,"Drugs, Inpatient Only",228.83,30,,228.83,percent of total billed charges,"Drugs, Inpatient Only",228.83,30,,228.83,percent of total billed charges,"Drugs, Inpatient Only",381.38,50,,381.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,92.91,,,92.91,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,533.93,70,,533.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,49.95,,,49.95,Other,Drug Cost,49.95,,,49.95,Other,Drug Cost,49.95,,,49.95,Other,Drug Cost,49.95,,,49.95,Other,Drug Cost,49.95,,,49.95,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,49.95,,,49.95,Other,Drug Cost,112.39,,,112.39,Other,225% Medicaid APG methodology,69.93,,,69.93,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,49.95,,,49.95,Other,Drug Cost,49.95,,,49.95,Other,Drug Cost,62.44,,,62.44,Other,125% Medicaid APG methodology,0.01,533.93,
VALGANICLOVIR 50MG/ML LIQ100ML  ,,,,40577082,CDM,250,RC,31722-0837-10,NDC,both,100,ML,2215.96,874.57,39.4668,,874.57,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,664.79,30,,664.79,percent of total billed charges,"Drugs, Inpatient Only",664.79,30,,664.79,percent of total billed charges,"Drugs, Inpatient Only",664.79,30,,664.79,percent of total billed charges,"Drugs, Inpatient Only",1107.98,50,,1107.98,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1149.11,,,1149.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1551.17,70,,1551.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,617.8,,,617.8,Other,Drug Cost,617.8,,,617.8,Other,Drug Cost,617.8,,,617.8,Other,Drug Cost,617.8,,,617.8,Other,Drug Cost,617.8,,,617.8,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,617.8,,,617.8,Other,Drug Cost,1390.05,,,1390.05,Other,225% Medicaid APG methodology,864.92,,,864.92,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,617.8,,,617.8,Other,Drug Cost,617.8,,,617.8,Other,Drug Cost,772.25,,,772.25,Other,125% Medicaid APG methodology,0.01,1551.17,
TICAGRELOR 90 MG TAB            ,,,,40577090,CDM,250,RC,00186-0777-39,NDC,both,1,EA,23.7,9.35,39.4668,,9.35,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.11,30,,7.11,percent of total billed charges,"Drugs, Inpatient Only",7.11,30,,7.11,percent of total billed charges,"Drugs, Inpatient Only",7.11,30,,7.11,percent of total billed charges,"Drugs, Inpatient Only",11.85,50,,11.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.09,,,3.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,16.59,70,,16.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.66,,,1.66,Other,Drug Cost,1.66,,,1.66,Other,Drug Cost,1.66,,,1.66,Other,Drug Cost,1.66,,,1.66,Other,Drug Cost,1.66,,,1.66,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.66,,,1.66,Other,Drug Cost,3.74,,,3.74,Other,225% Medicaid APG methodology,2.32,,,2.32,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.66,,,1.66,Other,Drug Cost,1.66,,,1.66,Other,Drug Cost,2.08,,,2.08,Other,125% Medicaid APG methodology,0.01,16.59,
ALBUTEROL MDI 90 MCG/INH 18G    ,,,,40577132,CDM,250,RC,00173-0682-20,NDC,both,18,GM,181.44,71.61,39.4668,,71.61,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,54.43,30,,54.43,percent of total billed charges,"Drugs, Inpatient Only",54.43,30,,54.43,percent of total billed charges,"Drugs, Inpatient Only",54.43,30,,54.43,percent of total billed charges,"Drugs, Inpatient Only",90.72,50,,90.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,36.49,,,36.49,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,127.01,70,,127.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.62,,,19.62,Other,Drug Cost,19.62,,,19.62,Other,Drug Cost,19.62,,,19.62,Other,Drug Cost,19.62,,,19.62,Other,Drug Cost,19.62,,,19.62,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,19.62,,,19.62,Other,Drug Cost,44.15,,,44.15,Other,225% Medicaid APG methodology,27.47,,,27.47,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,19.62,,,19.62,Other,Drug Cost,19.62,,,19.62,Other,Drug Cost,24.53,,,24.53,Other,125% Medicaid APG methodology,0.01,127.01,
OXYMETAZOLINE0.05% NASSPR 15ML  ,,,,40577140,CDM,250,RC,37000-0803-01,NDC,both,15,ML,14.7,5.8,39.4668,,5.8,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.41,30,,4.41,percent of total billed charges,"Drugs, Inpatient Only",4.41,30,,4.41,percent of total billed charges,"Drugs, Inpatient Only",4.41,30,,4.41,percent of total billed charges,"Drugs, Inpatient Only",7.35,50,,7.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.81,,,7.81,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.29,70,,10.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.2,,,4.2,Other,Drug Cost,4.2,,,4.2,Other,Drug Cost,4.2,,,4.2,Other,Drug Cost,4.2,,,4.2,Other,Drug Cost,4.2,,,4.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.2,,,4.2,Other,Drug Cost,9.45,,,9.45,Other,225% Medicaid APG methodology,5.88,,,5.88,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.2,,,4.2,Other,Drug Cost,4.2,,,4.2,Other,Drug Cost,5.25,,,5.25,Other,125% Medicaid APG methodology,0.01,10.29,
ATORVASTATIN 80 MG TAB          ,,,,40577157,CDM,250,RC,00904-6293-04,NDC,both,1,EA,0.95,0.37,39.4668,,0.37,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.48,50,,0.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.67,70,,0.67,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,Drug Cost,0.34,,,0.34,Other,225% Medicaid APG methodology,0.21,,,0.21,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.19,,,0.19,Other,125% Medicaid APG methodology,0.01,0.67,
OLANZAPINE 10 MG TAB            ,,,,40577165,CDM,250,RC,00904-6376-61,NDC,both,1,EA,0.53,0.21,39.4668,,0.21,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.27,50,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,70,,0.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.29,,,0.29,Other,225% Medicaid APG methodology,0.18,,,0.18,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.16,,,0.16,Other,125% Medicaid APG methodology,0.01,0.37,
LANOLIN OINT 28GM TUBE          ,,,,40577173,CDM,250,RC,54162-0595-01,NDC,both,30,GM,7.98,3.15,39.4668,,3.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.39,30,,2.39,percent of total billed charges,"Drugs, Inpatient Only",2.39,30,,2.39,percent of total billed charges,"Drugs, Inpatient Only",2.39,30,,2.39,percent of total billed charges,"Drugs, Inpatient Only",3.99,50,,3.99,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.24,,,4.24,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.59,70,,5.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.28,,,2.28,Other,Drug Cost,2.28,,,2.28,Other,Drug Cost,2.28,,,2.28,Other,Drug Cost,2.28,,,2.28,Other,Drug Cost,2.28,,,2.28,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.28,,,2.28,Other,Drug Cost,5.13,,,5.13,Other,225% Medicaid APG methodology,3.19,,,3.19,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.28,,,2.28,Other,Drug Cost,2.28,,,2.28,Other,Drug Cost,2.85,,,2.85,Other,125% Medicaid APG methodology,0.01,5.59,
BUPIV 0.25% PF INJ SLN 10ML     ,,,,40577207,CDM,250,RC,63323-0464-17,NDC,both,10,ML,12.95,5.11,39.4668,,5.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.89,30,,3.89,percent of total billed charges,"Drugs, Inpatient Only",3.89,30,,3.89,percent of total billed charges,"Drugs, Inpatient Only",3.89,30,,3.89,percent of total billed charges,"Drugs, Inpatient Only",6.48,50,,6.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.79,,,2.79,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.07,70,,9.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.5,,,1.5,Other,Drug Cost,3.38,,,3.38,Other,225% Medicaid APG methodology,2.1,,,2.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.88,,,1.88,Other,125% Medicaid APG methodology,0.01,9.07,
CAFFEINE CITRATE20MG/ML ORL3ML  ,,,,40577215,CDM,250,RC,51754-0501-03,NDC,both,3,ML,29.82,11.77,39.4668,,11.77,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.95,30,,8.95,percent of total billed charges,"Drugs, Inpatient Only",8.95,30,,8.95,percent of total billed charges,"Drugs, Inpatient Only",8.95,30,,8.95,percent of total billed charges,"Drugs, Inpatient Only",14.91,50,,14.91,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.43,,,10.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,20.87,70,,20.87,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.61,,,5.61,Other,Drug Cost,5.61,,,5.61,Other,Drug Cost,5.61,,,5.61,Other,Drug Cost,5.61,,,5.61,Other,Drug Cost,5.61,,,5.61,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,5.61,,,5.61,Other,Drug Cost,12.62,,,12.62,Other,225% Medicaid APG methodology,7.85,,,7.85,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.61,,,5.61,Other,Drug Cost,5.61,,,5.61,Other,Drug Cost,7.01,,,7.01,Other,125% Medicaid APG methodology,0.01,20.87,
TOLVAPTAN 15 MG TAB             ,,,,40577223,CDM,250,RC,59148-0020-50,NDC,both,1,EA,1811.6,714.98,39.4668,,714.98,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,543.48,30,,543.48,percent of total billed charges,"Drugs, Inpatient Only",543.48,30,,543.48,percent of total billed charges,"Drugs, Inpatient Only",543.48,30,,543.48,percent of total billed charges,"Drugs, Inpatient Only",905.8,50,,905.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,354.33,,,354.33,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1268.12,70,,1268.12,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,190.5,,,190.5,Other,Drug Cost,190.5,,,190.5,Other,Drug Cost,190.5,,,190.5,Other,Drug Cost,190.5,,,190.5,Other,Drug Cost,190.5,,,190.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,190.5,,,190.5,Other,Drug Cost,428.63,,,428.63,Other,225% Medicaid APG methodology,266.7,,,266.7,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,190.5,,,190.5,Other,Drug Cost,190.5,,,190.5,Other,Drug Cost,238.13,,,238.13,Other,125% Medicaid APG methodology,0.01,1268.12,
REPAGLINIDE 0.5 MG TAB          ,,,,40577249,CDM,250,RC,57237-0157-01,NDC,both,1,EA,0.56,0.22,39.4668,,0.22,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.28,50,,0.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.39,70,,0.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.39,
NADOLOL 20 MG TAB               ,,,,40577256,CDM,250,RC,69097-0867-07,NDC,both,1,EA,1.65,0.65,39.4668,,0.65,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.5,30,,0.5,percent of total billed charges,"Drugs, Inpatient Only",0.5,30,,0.5,percent of total billed charges,"Drugs, Inpatient Only",0.5,30,,0.5,percent of total billed charges,"Drugs, Inpatient Only",0.83,50,,0.83,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.16,70,,1.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,1.16,
LANOLIN CREAM 7 G               ,,,,40577280,CDM,250,RC,44677-0102-02,NDC,both,7,GM,7.6,3,39.4668,,3,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.28,30,,2.28,percent of total billed charges,"Drugs, Inpatient Only",2.28,30,,2.28,percent of total billed charges,"Drugs, Inpatient Only",2.28,30,,2.28,percent of total billed charges,"Drugs, Inpatient Only",3.8,50,,3.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.04,,,4.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.32,70,,5.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.17,,,2.17,Other,Drug Cost,2.17,,,2.17,Other,Drug Cost,2.17,,,2.17,Other,Drug Cost,2.17,,,2.17,Other,Drug Cost,2.17,,,2.17,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.17,,,2.17,Other,Drug Cost,4.88,,,4.88,Other,225% Medicaid APG methodology,3.04,,,3.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.17,,,2.17,Other,Drug Cost,2.17,,,2.17,Other,Drug Cost,2.71,,,2.71,Other,125% Medicaid APG methodology,0.01,5.32,
LACTULOSE 10 G/15ML 300MLENEMA  ,,,,40577330,CDM,250,RC,64980-0592-48,NDC,both,300,ML,16.45,6.49,39.4668,,6.49,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.94,30,,4.94,percent of total billed charges,"Drugs, Inpatient Only",4.94,30,,4.94,percent of total billed charges,"Drugs, Inpatient Only",4.94,30,,4.94,percent of total billed charges,"Drugs, Inpatient Only",8.23,50,,8.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.63,,,8.63,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.52,70,,11.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.64,,,4.64,Other,Drug Cost,4.64,,,4.64,Other,Drug Cost,4.64,,,4.64,Other,Drug Cost,4.64,,,4.64,Other,Drug Cost,4.64,,,4.64,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.64,,,4.64,Other,Drug Cost,10.44,,,10.44,Other,225% Medicaid APG methodology,6.5,,,6.5,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.64,,,4.64,Other,Drug Cost,4.64,,,4.64,Other,Drug Cost,5.8,,,5.8,Other,125% Medicaid APG methodology,0.01,11.52,
DOFETILIDE 250 MCG CAP          ,,,,40577363,CDM,250,RC,72205-0040-60,NDC,both,1,EA,1.89,0.75,39.4668,,0.75,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.57,30,,0.57,percent of total billed charges,"Drugs, Inpatient Only",0.57,30,,0.57,percent of total billed charges,"Drugs, Inpatient Only",0.57,30,,0.57,percent of total billed charges,"Drugs, Inpatient Only",0.95,50,,0.95,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.32,70,,1.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.2,,,0.2,Other,225% Medicaid APG methodology,0.13,,,0.13,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,1.32,
LEVOTHYROXINE 100 MCG IV INJ    ,,,,40577470,CDM,250,RC,70860-0451-10,NDC,both,1,EA,307.48,121.35,39.4668,,121.35,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,92.24,30,,92.24,percent of total billed charges,"Drugs, Inpatient Only",92.24,30,,92.24,percent of total billed charges,"Drugs, Inpatient Only",92.24,30,,92.24,percent of total billed charges,"Drugs, Inpatient Only",153.74,50,,153.74,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,117.81,,,117.81,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,215.24,70,,215.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,63.34,,,63.34,Other,Drug Cost,63.34,,,63.34,Other,Drug Cost,63.34,,,63.34,Other,Drug Cost,63.34,,,63.34,Other,Drug Cost,63.34,,,63.34,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,63.34,,,63.34,Other,Drug Cost,142.52,,,142.52,Other,225% Medicaid APG methodology,88.68,,,88.68,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,63.34,,,63.34,Other,Drug Cost,63.34,,,63.34,Other,Drug Cost,79.18,,,79.18,Other,125% Medicaid APG methodology,0.01,215.24,
IVERMECTIN 3 MG TAB             ,,,,40577520,CDM,250,RC,00006-0032-20,NDC,both,1,EA,15.12,5.97,39.4668,,5.97,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.54,30,,4.54,percent of total billed charges,"Drugs, Inpatient Only",4.54,30,,4.54,percent of total billed charges,"Drugs, Inpatient Only",4.54,30,,4.54,percent of total billed charges,"Drugs, Inpatient Only",7.56,50,,7.56,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.25,,,6.25,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.58,70,,10.58,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.36,,,3.36,Other,Drug Cost,3.36,,,3.36,Other,Drug Cost,3.36,,,3.36,Other,Drug Cost,3.36,,,3.36,Other,Drug Cost,3.36,,,3.36,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.36,,,3.36,Other,Drug Cost,7.56,,,7.56,Other,225% Medicaid APG methodology,4.7,,,4.7,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.36,,,3.36,Other,Drug Cost,3.36,,,3.36,Other,Drug Cost,4.2,,,4.2,Other,125% Medicaid APG methodology,0.01,10.58,
RIVAROXABAN 10 MG TAB           ,,,,40577884,CDM,250,RC,50458-0580-10,NDC,both,1,EA,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.02,50,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.03,
RIVAROXABAN 15 MG TAB           ,,,,40577892,CDM,250,RC,50458-0578-30,NDC,both,1,EA,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.02,50,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.03,
RIVAROXABAN 20 MG TAB           ,,,,40577900,CDM,250,RC,50458-0579-10,NDC,both,1,EA,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.02,50,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.03,
INDOMTHCIN 2MG/ML ORL 50ML BTL  ,,,,40578122,CDM,250,RC,50268-0430-15a,NDC,both,50,ML,36.75,14.5,39.4668,,14.5,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.03,30,,11.03,percent of total billed charges,"Drugs, Inpatient Only",11.03,30,,11.03,percent of total billed charges,"Drugs, Inpatient Only",11.03,30,,11.03,percent of total billed charges,"Drugs, Inpatient Only",18.38,50,,18.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.09,,,12.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,25.73,70,,25.73,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.5,,,6.5,Other,Drug Cost,6.5,,,6.5,Other,Drug Cost,6.5,,,6.5,Other,Drug Cost,6.5,,,6.5,Other,Drug Cost,6.5,,,6.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,6.5,,,6.5,Other,Drug Cost,14.63,,,14.63,Other,225% Medicaid APG methodology,9.1,,,9.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.5,,,6.5,Other,Drug Cost,6.5,,,6.5,Other,Drug Cost,8.13,,,8.13,Other,125% Medicaid APG methodology,0.01,25.73,
PHENOBARBITAL 32.4 MG TAB       ,,,,40578304,CDM,250,RC,00603-5166-21,NDC,both,1,EA,1.75,0.69,39.4668,,0.69,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.53,30,,0.53,percent of total billed charges,"Drugs, Inpatient Only",0.53,30,,0.53,percent of total billed charges,"Drugs, Inpatient Only",0.53,30,,0.53,percent of total billed charges,"Drugs, Inpatient Only",0.88,50,,0.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.23,70,,1.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% Medicaid APG methodology,0.11,,,0.11,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,1.23,
CLOBAZAM 10 MG TAB              ,,,,40578312,CDM,250,RC,00832-0580-11,NDC,both,1,EA,1.58,0.62,39.4668,,0.62,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.47,30,,0.47,percent of total billed charges,"Drugs, Inpatient Only",0.47,30,,0.47,percent of total billed charges,"Drugs, Inpatient Only",0.47,30,,0.47,percent of total billed charges,"Drugs, Inpatient Only",0.79,50,,0.79,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.11,70,,1.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.29,,,0.29,Other,225% Medicaid APG methodology,0.18,,,0.18,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.16,,,0.16,Other,125% Medicaid APG methodology,0.01,1.11,
LIDOCAINE 1% PF INJ SOLN 30 ML  ,,,,40578320,CDM,250,RC,00409-4279-02,NDC,both,30,ML,5.5,2.17,39.4668,,2.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.65,30,,1.65,percent of total billed charges,"Drugs, Inpatient Only",1.65,30,,1.65,percent of total billed charges,"Drugs, Inpatient Only",1.65,30,,1.65,percent of total billed charges,"Drugs, Inpatient Only",2.75,50,,2.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.11,,,3.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.85,70,,3.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.67,,,1.67,Other,Drug Cost,1.67,,,1.67,Other,Drug Cost,1.67,,,1.67,Other,Drug Cost,1.67,,,1.67,Other,Drug Cost,1.67,,,1.67,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.67,,,1.67,Other,Drug Cost,3.76,,,3.76,Other,225% Medicaid APG methodology,2.34,,,2.34,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.67,,,1.67,Other,Drug Cost,1.67,,,1.67,Other,Drug Cost,2.09,,,2.09,Other,125% Medicaid APG methodology,0.01,3.85,
BUPIV 0.5% PF INJ SLN 10ML      ,,,,40578338,CDM,250,RC,70594-0117-02,NDC,both,10,ML,18.34,7.24,39.4668,,7.24,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.5,30,,5.5,percent of total billed charges,"Drugs, Inpatient Only",5.5,30,,5.5,percent of total billed charges,"Drugs, Inpatient Only",5.5,30,,5.5,percent of total billed charges,"Drugs, Inpatient Only",9.17,50,,9.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.53,,,3.53,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.84,70,,12.84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.9,,,1.9,Other,Drug Cost,1.9,,,1.9,Other,Drug Cost,1.9,,,1.9,Other,Drug Cost,1.9,,,1.9,Other,Drug Cost,1.9,,,1.9,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.9,,,1.9,Other,Drug Cost,4.28,,,4.28,Other,225% Medicaid APG methodology,2.66,,,2.66,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.9,,,1.9,Other,Drug Cost,1.9,,,1.9,Other,Drug Cost,2.38,,,2.38,Other,125% Medicaid APG methodology,0.01,12.84,
SODIUM BICARB 4.2% IV SLN 5ML   ,,,,40578411,CDM,250,RC,63323-0083-05,NDC,both,5,ML,62.3,24.59,39.4668,,24.59,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,18.69,30,,18.69,percent of total billed charges,"Drugs, Inpatient Only",18.69,30,,18.69,percent of total billed charges,"Drugs, Inpatient Only",18.69,30,,18.69,percent of total billed charges,"Drugs, Inpatient Only",31.15,50,,31.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,16.37,,,16.37,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,43.61,70,,43.61,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.8,,,8.8,Other,Drug Cost,8.8,,,8.8,Other,Drug Cost,8.8,,,8.8,Other,Drug Cost,8.8,,,8.8,Other,Drug Cost,8.8,,,8.8,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,8.8,,,8.8,Other,Drug Cost,19.8,,,19.8,Other,225% Medicaid APG methodology,12.32,,,12.32,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,8.8,,,8.8,Other,Drug Cost,8.8,,,8.8,Other,Drug Cost,11,,,11,Other,125% Medicaid APG methodology,0.01,43.61,
ESCITALOPRAM 5 MG TAB           ,,,,40578445,CDM,250,RC,65862-0373-01,NDC,both,1,EA,0.81,0.32,39.4668,,0.32,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.24,30,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.24,30,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.24,30,,0.24,percent of total billed charges,"Drugs, Inpatient Only",0.41,50,,0.41,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.57,70,,0.57,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.57,
BUPRENORPHINE 8 MG SL TAB       ,,,,40578627,CDM,250,RC,00054-0177-13,NDC,both,1,EA,3.68,1.45,39.4668,,1.45,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.1,30,,1.1,percent of total billed charges,"Drugs, Inpatient Only",1.1,30,,1.1,percent of total billed charges,"Drugs, Inpatient Only",1.1,30,,1.1,percent of total billed charges,"Drugs, Inpatient Only",1.84,50,,1.84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.65,,,0.65,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.58,70,,2.58,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.35,,,0.35,Other,Drug Cost,0.35,,,0.35,Other,Drug Cost,0.35,,,0.35,Other,Drug Cost,0.35,,,0.35,Other,Drug Cost,0.35,,,0.35,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.35,,,0.35,Other,Drug Cost,0.79,,,0.79,Other,225% Medicaid APG methodology,0.49,,,0.49,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.35,,,0.35,Other,Drug Cost,0.35,,,0.35,Other,Drug Cost,0.44,,,0.44,Other,125% Medicaid APG methodology,0.01,2.58,
NF-RILUZOLE 50 MG TAB           ,,,,40578635,CDM,250,RC,67877-0286-60,NDC,both,1,EA,3.33,1.31,39.4668,,1.31,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1,30,,1,percent of total billed charges,"Drugs, Inpatient Only",1,30,,1,percent of total billed charges,"Drugs, Inpatient Only",1,30,,1,percent of total billed charges,"Drugs, Inpatient Only",1.67,50,,1.67,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.35,,,0.35,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.33,70,,2.33,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,Drug Cost,0.43,,,0.43,Other,225% Medicaid APG methodology,0.27,,,0.27,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.24,,,0.24,Other,125% Medicaid APG methodology,0.01,2.33,
TRYPAN BLUE 0.06% INTRAOC0.5ML  ,,,,40578668,CDM,250,RC,68803-0612-10,NDC,both,0.5,ML,192.15,75.84,39.4668,,75.84,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,57.65,30,,57.65,percent of total billed charges,"Drugs, Inpatient Only",57.65,30,,57.65,percent of total billed charges,"Drugs, Inpatient Only",57.65,30,,57.65,percent of total billed charges,"Drugs, Inpatient Only",96.08,50,,96.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,102.11,,,102.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,134.51,70,,134.51,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,54.9,,,54.9,Other,Drug Cost,54.9,,,54.9,Other,Drug Cost,54.9,,,54.9,Other,Drug Cost,54.9,,,54.9,Other,Drug Cost,54.9,,,54.9,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,54.9,,,54.9,Other,Drug Cost,123.53,,,123.53,Other,225% Medicaid APG methodology,76.86,,,76.86,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,54.9,,,54.9,Other,Drug Cost,54.9,,,54.9,Other,Drug Cost,68.63,,,68.63,Other,125% Medicaid APG methodology,0.01,134.51,
ROTAVIRUS VACC PENTAV ORL 2ML   ,,,,40578817,CDM,250,RC,00006-4047-20,NDC,both,2,ML,253.4,100.01,39.4668,,100.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,76.02,30,,76.02,percent of total billed charges,"Drugs, Inpatient Only",76.02,30,,76.02,percent of total billed charges,"Drugs, Inpatient Only",76.02,30,,76.02,percent of total billed charges,"Drugs, Inpatient Only",126.7,50,,126.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,143.15,,,143.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,177.38,70,,177.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,76.96,,,76.96,Other,Drug Cost,76.96,,,76.96,Other,Drug Cost,76.96,,,76.96,Other,Drug Cost,76.96,,,76.96,Other,Drug Cost,76.96,,,76.96,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,76.96,,,76.96,Other,Drug Cost,173.16,,,173.16,Other,225% Medicaid APG methodology,107.74,,,107.74,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,76.96,,,76.96,Other,Drug Cost,76.96,,,76.96,Other,Drug Cost,96.2,,,96.2,Other,125% Medicaid APG methodology,0.01,177.38,
DISULFIRAM 250 MG TAB           ,,,,40578858,CDM,250,RC,00054-0356-25,NDC,both,1,EA,7.18,2.83,39.4668,,2.83,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.15,30,,2.15,percent of total billed charges,"Drugs, Inpatient Only",2.15,30,,2.15,percent of total billed charges,"Drugs, Inpatient Only",2.15,30,,2.15,percent of total billed charges,"Drugs, Inpatient Only",3.59,50,,3.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.71,,,0.71,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.03,70,,5.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.38,,,0.38,Other,Drug Cost,0.86,,,0.86,Other,225% Medicaid APG methodology,0.53,,,0.53,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.48,,,0.48,Other,125% Medicaid APG methodology,0.01,5.03,
CHOLECALCIFEROL 400 UNITS TAB   ,,,,40578999,CDM,250,RC,77333-0948-10,NDC,both,1,EA,0.49,0.19,39.4668,,0.19,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.15,30,,0.15,percent of total billed charges,"Drugs, Inpatient Only",0.25,50,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.34,70,,0.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.29,,,0.29,Other,225% Medicaid APG methodology,0.18,,,0.18,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.16,,,0.16,Other,125% Medicaid APG methodology,0.01,0.34,
INDOMETHACIN 50 MG RECTAL SUPP  ,,,,40579062,CDM,250,RC,70710-1852-07,NDC,both,1,EA,690.1,272.36,39.4668,,272.36,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,207.03,30,,207.03,percent of total billed charges,"Drugs, Inpatient Only",207.03,30,,207.03,percent of total billed charges,"Drugs, Inpatient Only",207.03,30,,207.03,percent of total billed charges,"Drugs, Inpatient Only",345.05,50,,345.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,466.26,,,466.26,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,483.07,70,,483.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,250.68,,,250.68,Other,Drug Cost,250.68,,,250.68,Other,Drug Cost,250.68,,,250.68,Other,Drug Cost,250.68,,,250.68,Other,Drug Cost,250.68,,,250.68,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,250.68,,,250.68,Other,Drug Cost,564.03,,,564.03,Other,225% Medicaid APG methodology,350.95,,,350.95,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,250.68,,,250.68,Other,Drug Cost,250.68,,,250.68,Other,Drug Cost,313.35,,,313.35,Other,125% Medicaid APG methodology,0.01,564.03,
SEVOFLURANE INH LIQUID 250 ML   ,,,,40579070,CDM,250,RC,10019-0651-64,NDC,both,250,ML,446.25,176.12,39.4668,,176.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,133.88,30,,133.88,percent of total billed charges,"Drugs, Inpatient Only",133.88,30,,133.88,percent of total billed charges,"Drugs, Inpatient Only",133.88,30,,133.88,percent of total billed charges,"Drugs, Inpatient Only",223.13,50,,223.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,120.9,,,120.9,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,312.38,70,,312.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,65,,,65,Other,Drug Cost,65,,,65,Other,Drug Cost,65,,,65,Other,Drug Cost,65,,,65,Other,Drug Cost,65,,,65,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,65,,,65,Other,Drug Cost,146.25,,,146.25,Other,225% Medicaid APG methodology,91,,,91,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,65,,,65,Other,Drug Cost,65,,,65,Other,Drug Cost,81.25,,,81.25,Other,125% Medicaid APG methodology,0.01,312.38,
DESFLURANE INH LIQUID 240 ML    ,,,,40579088,CDM,250,RC,10019-0641-34,NDC,both,240,ML,468.55,184.92,39.4668,,184.92,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,140.57,30,,140.57,percent of total billed charges,"Drugs, Inpatient Only",140.57,30,,140.57,percent of total billed charges,"Drugs, Inpatient Only",140.57,30,,140.57,percent of total billed charges,"Drugs, Inpatient Only",234.28,50,,234.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,37.91,,,37.91,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,327.99,70,,327.99,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,20.38,,,20.38,Other,Drug Cost,20.38,,,20.38,Other,Drug Cost,20.38,,,20.38,Other,Drug Cost,20.38,,,20.38,Other,Drug Cost,20.38,,,20.38,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,20.38,,,20.38,Other,Drug Cost,45.86,,,45.86,Other,225% Medicaid APG methodology,28.53,,,28.53,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,20.38,,,20.38,Other,Drug Cost,20.38,,,20.38,Other,Drug Cost,25.48,,,25.48,Other,125% Medicaid APG methodology,0.01,327.99,
OSELTAMIVIR 30 MG CAP           ,,,,40579104,CDM,250,RC,68180-0675-11,NDC,both,1,EA,13.76,5.43,39.4668,,5.43,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.13,30,,4.13,percent of total billed charges,"Drugs, Inpatient Only",4.13,30,,4.13,percent of total billed charges,"Drugs, Inpatient Only",4.13,30,,4.13,percent of total billed charges,"Drugs, Inpatient Only",6.88,50,,6.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.45,,,0.45,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.63,70,,9.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,Drug Cost,0.54,,,0.54,Other,225% Medicaid APG methodology,0.34,,,0.34,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,Drug Cost,0.24,,,0.24,Other,Drug Cost,0.3,,,0.3,Other,125% Medicaid APG methodology,0.01,9.63,
ALBUTEROL-IPRAT 100-20MCG 4G    ,,,,40579328,CDM,250,RC,00597-0024-02,NDC,both,4,GM,1131.76,446.67,39.4668,,446.67,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,339.53,30,,339.53,percent of total billed charges,"Drugs, Inpatient Only",339.53,30,,339.53,percent of total billed charges,"Drugs, Inpatient Only",339.53,30,,339.53,percent of total billed charges,"Drugs, Inpatient Only",565.88,50,,565.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,281.53,,,281.53,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,792.23,70,,792.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,151.36,,,151.36,Other,Drug Cost,151.36,,,151.36,Other,Drug Cost,151.36,,,151.36,Other,Drug Cost,151.36,,,151.36,Other,Drug Cost,151.36,,,151.36,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,151.36,,,151.36,Other,Drug Cost,340.56,,,340.56,Other,225% Medicaid APG methodology,211.9,,,211.9,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,151.36,,,151.36,Other,Drug Cost,151.36,,,151.36,Other,Drug Cost,189.2,,,189.2,Other,125% Medicaid APG methodology,0.01,792.23,
AMMONIA INHALANTS               ,,,,40579369,CDM,250,RC,39822-9900-01,NDC,both,1,EA,1.72,0.68,39.4668,,0.68,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.52,30,,0.52,percent of total billed charges,"Drugs, Inpatient Only",0.52,30,,0.52,percent of total billed charges,"Drugs, Inpatient Only",0.52,30,,0.52,percent of total billed charges,"Drugs, Inpatient Only",0.86,50,,0.86,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.2,70,,1.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.27,,,0.27,Other,225% Medicaid APG methodology,0.17,,,0.17,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.15,,,0.15,Other,125% Medicaid APG methodology,0.01,1.2,
PROMETHAZINE 25 MG RECTAL SUPP  ,,,,40579419,CDM,250,RC,00591-2992-39,NDC,both,1,EA,32.27,12.74,39.4668,,12.74,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.68,30,,9.68,percent of total billed charges,"Drugs, Inpatient Only",9.68,30,,9.68,percent of total billed charges,"Drugs, Inpatient Only",9.68,30,,9.68,percent of total billed charges,"Drugs, Inpatient Only",16.14,50,,16.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.93,,,0.93,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,22.59,70,,22.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.5,,,0.5,Other,Drug Cost,1.13,,,1.13,Other,225% Medicaid APG methodology,0.7,,,0.7,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.63,,,0.63,Other,125% Medicaid APG methodology,0.01,22.59,
DILTIAZEM 5MG/ML IV SOLN 25ML   ,,,,40579427,CDM,250,RC,00641-9219-10,NDC,both,25,ML,16.63,6.56,39.4668,,6.56,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.99,30,,4.99,percent of total billed charges,"Drugs, Inpatient Only",4.99,30,,4.99,percent of total billed charges,"Drugs, Inpatient Only",4.99,30,,4.99,percent of total billed charges,"Drugs, Inpatient Only",8.32,50,,8.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.84,,,8.84,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.64,70,,11.64,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.75,,,4.75,Other,Drug Cost,4.75,,,4.75,Other,Drug Cost,4.75,,,4.75,Other,Drug Cost,4.75,,,4.75,Other,Drug Cost,4.75,,,4.75,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.75,,,4.75,Other,Drug Cost,10.69,,,10.69,Other,225% Medicaid APG methodology,6.65,,,6.65,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.75,,,4.75,Other,Drug Cost,4.75,,,4.75,Other,Drug Cost,5.94,,,5.94,Other,125% Medicaid APG methodology,0.01,11.64,
CISATRACURIUM 10MG/ML IV  20ML  ,,,,40579435,CDM,250,RC,00781-3153-95,NDC,both,20,ML,478.1,188.69,39.4668,,188.69,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,143.43,30,,143.43,percent of total billed charges,"Drugs, Inpatient Only",143.43,30,,143.43,percent of total billed charges,"Drugs, Inpatient Only",143.43,30,,143.43,percent of total billed charges,"Drugs, Inpatient Only",239.05,50,,239.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,254.08,,,254.08,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,334.67,70,,334.67,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,136.6,,,136.6,Other,Drug Cost,136.6,,,136.6,Other,Drug Cost,136.6,,,136.6,Other,Drug Cost,136.6,,,136.6,Other,Drug Cost,136.6,,,136.6,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,136.6,,,136.6,Other,Drug Cost,307.35,,,307.35,Other,225% Medicaid APG methodology,191.24,,,191.24,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,136.6,,,136.6,Other,Drug Cost,136.6,,,136.6,Other,Drug Cost,170.75,,,170.75,Other,125% Medicaid APG methodology,0.01,334.67,
TRIAMCINOLONE 0.1%  PASTE 5 G   ,,,,40579518,CDM,250,RC,00713-0655-40,NDC,both,5,GM,99.75,39.37,39.4668,,39.37,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,29.93,30,,29.93,percent of total billed charges,"Drugs, Inpatient Only",29.93,30,,29.93,percent of total billed charges,"Drugs, Inpatient Only",29.93,30,,29.93,percent of total billed charges,"Drugs, Inpatient Only",49.88,50,,49.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,24.27,,,24.27,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,69.83,70,,69.83,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.05,,,13.05,Other,Drug Cost,13.05,,,13.05,Other,Drug Cost,13.05,,,13.05,Other,Drug Cost,13.05,,,13.05,Other,Drug Cost,13.05,,,13.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,13.05,,,13.05,Other,Drug Cost,29.36,,,29.36,Other,225% Medicaid APG methodology,18.27,,,18.27,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,13.05,,,13.05,Other,Drug Cost,13.05,,,13.05,Other,Drug Cost,16.31,,,16.31,Other,125% Medicaid APG methodology,0.01,69.83,
DARUNAVIR 800 MG TAB            ,,,,40579534,CDM,250,RC,59651-0086-30,NDC,both,1,EA,22.16,8.75,39.4668,,8.75,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.65,30,,6.65,percent of total billed charges,"Drugs, Inpatient Only",6.65,30,,6.65,percent of total billed charges,"Drugs, Inpatient Only",6.65,30,,6.65,percent of total billed charges,"Drugs, Inpatient Only",11.08,50,,11.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.59,,,11.59,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.51,70,,15.51,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.23,,,6.23,Other,Drug Cost,6.23,,,6.23,Other,Drug Cost,6.23,,,6.23,Other,Drug Cost,6.23,,,6.23,Other,Drug Cost,6.23,,,6.23,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,6.23,,,6.23,Other,Drug Cost,14.02,,,14.02,Other,225% Medicaid APG methodology,8.72,,,8.72,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.23,,,6.23,Other,Drug Cost,6.23,,,6.23,Other,Drug Cost,7.79,,,7.79,Other,125% Medicaid APG methodology,0.01,15.51,
EPI-LIDO 1:200000-1.5%PF 30ML   ,,,,40579559,CDM,250,RC,63323-0488-37,NDC,both,30,ML,33.6,13.26,39.4668,,13.26,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.08,30,,10.08,percent of total billed charges,"Drugs, Inpatient Only",10.08,30,,10.08,percent of total billed charges,"Drugs, Inpatient Only",10.08,30,,10.08,percent of total billed charges,"Drugs, Inpatient Only",16.8,50,,16.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,17.86,,,17.86,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,23.52,70,,23.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.6,,,9.6,Other,Drug Cost,9.6,,,9.6,Other,Drug Cost,9.6,,,9.6,Other,Drug Cost,9.6,,,9.6,Other,Drug Cost,9.6,,,9.6,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,9.6,,,9.6,Other,Drug Cost,21.6,,,21.6,Other,225% Medicaid APG methodology,13.44,,,13.44,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,9.6,,,9.6,Other,Drug Cost,9.6,,,9.6,Other,Drug Cost,12,,,12,Other,125% Medicaid APG methodology,0.01,23.52,
LIDOCAINE 2% INJ SOLN 50 ML     ,,,,40579567,CDM,250,RC,63323-0486-57,NDC,both,50,ML,12.04,4.75,39.4668,,4.75,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.61,30,,3.61,percent of total billed charges,"Drugs, Inpatient Only",3.61,30,,3.61,percent of total billed charges,"Drugs, Inpatient Only",3.61,30,,3.61,percent of total billed charges,"Drugs, Inpatient Only",6.02,50,,6.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.74,,,4.74,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.43,70,,8.43,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.55,,,2.55,Other,Drug Cost,2.55,,,2.55,Other,Drug Cost,2.55,,,2.55,Other,Drug Cost,2.55,,,2.55,Other,Drug Cost,2.55,,,2.55,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.55,,,2.55,Other,Drug Cost,5.74,,,5.74,Other,225% Medicaid APG methodology,3.57,,,3.57,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.55,,,2.55,Other,Drug Cost,2.55,,,2.55,Other,Drug Cost,3.19,,,3.19,Other,125% Medicaid APG methodology,0.01,8.43,
LIDOCAINE 2% PF INJ SOLN 2 ML   ,,,,40579575,CDM,250,RC,63323-0495-27,NDC,both,2,ML,6.16,2.43,39.4668,,2.43,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.85,30,,1.85,percent of total billed charges,"Drugs, Inpatient Only",1.85,30,,1.85,percent of total billed charges,"Drugs, Inpatient Only",1.85,30,,1.85,percent of total billed charges,"Drugs, Inpatient Only",3.08,50,,3.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.58,,,0.58,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.31,70,,4.31,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.31,,,0.31,Other,Drug Cost,0.7,,,0.7,Other,225% Medicaid APG methodology,0.43,,,0.43,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.39,,,0.39,Other,125% Medicaid APG methodology,0.01,4.31,
SOD CHL 0.9% MINIBAG 100ML      ,,,,40579591,CDM,250,RC,00338-9159-30,NDC,both,100,ML,10.5,4.14,39.4668,,4.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.15,30,,3.15,percent of total billed charges,"Drugs, Inpatient Only",3.15,30,,3.15,percent of total billed charges,"Drugs, Inpatient Only",3.15,30,,3.15,percent of total billed charges,"Drugs, Inpatient Only",5.25,50,,5.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.86,,,1.86,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.35,70,,7.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1,,,1,Other,Drug Cost,2.25,,,2.25,Other,225% Medicaid APG methodology,1.4,,,1.4,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1.25,,,1.25,Other,125% Medicaid APG methodology,0.01,7.35,
DOFETILIDE 125 MCG CAP          ,,,,40579609,CDM,250,RC,00904-6681-08,NDC,both,1,EA,14.28,5.64,39.4668,,5.64,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.28,30,,4.28,percent of total billed charges,"Drugs, Inpatient Only",4.28,30,,4.28,percent of total billed charges,"Drugs, Inpatient Only",4.28,30,,4.28,percent of total billed charges,"Drugs, Inpatient Only",7.14,50,,7.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.61,,,7.61,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10,70,,10,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.09,,,4.09,Other,Drug Cost,4.09,,,4.09,Other,Drug Cost,4.09,,,4.09,Other,Drug Cost,4.09,,,4.09,Other,Drug Cost,4.09,,,4.09,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.09,,,4.09,Other,Drug Cost,9.2,,,9.2,Other,225% Medicaid APG methodology,5.73,,,5.73,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.09,,,4.09,Other,Drug Cost,4.09,,,4.09,Other,Drug Cost,5.11,,,5.11,Other,125% Medicaid APG methodology,0.01,10,
DEXMDETOMIDINE 400MCG/NS 100ML  ,,,,40579831,CDM,250,RC,55150-0297-10,NDC,both,100,ML,71.02,28.03,39.4668,,28.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,21.31,30,,21.31,percent of total billed charges,"Drugs, Inpatient Only",21.31,30,,21.31,percent of total billed charges,"Drugs, Inpatient Only",21.31,30,,21.31,percent of total billed charges,"Drugs, Inpatient Only",35.51,50,,35.51,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,45.01,,,45.01,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,49.71,70,,49.71,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,24.2,,,24.2,Other,Drug Cost,24.2,,,24.2,Other,Drug Cost,24.2,,,24.2,Other,Drug Cost,24.2,,,24.2,Other,Drug Cost,24.2,,,24.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,24.2,,,24.2,Other,Drug Cost,54.45,,,54.45,Other,225% Medicaid APG methodology,33.88,,,33.88,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,24.2,,,24.2,Other,Drug Cost,24.2,,,24.2,Other,Drug Cost,30.25,,,30.25,Other,125% Medicaid APG methodology,0.01,54.45,
LURASIDONE 20 MG TAB            ,,,,40579849,CDM,250,RC,47335-0578-83,NDC,both,1,EA,0.53,0.21,39.4668,,0.21,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.27,50,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.25,,,2.25,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,70,,0.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.21,,,1.21,Other,Drug Cost,1.21,,,1.21,Other,Drug Cost,1.21,,,1.21,Other,Drug Cost,1.21,,,1.21,Other,Drug Cost,1.21,,,1.21,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.21,,,1.21,Other,Drug Cost,2.72,,,2.72,Other,225% Medicaid APG methodology,1.69,,,1.69,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.21,,,1.21,Other,Drug Cost,1.21,,,1.21,Other,Drug Cost,1.51,,,1.51,Other,125% Medicaid APG methodology,0.01,2.72,
APIXABAN 5 MG TAB               ,,,,40579948,CDM,250,RC,00003-0894-31,NDC,both,1,EA,5.25,2.07,39.4668,,2.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.58,30,,1.58,percent of total billed charges,"Drugs, Inpatient Only",1.58,30,,1.58,percent of total billed charges,"Drugs, Inpatient Only",1.58,30,,1.58,percent of total billed charges,"Drugs, Inpatient Only",2.63,50,,2.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.57,,,2.57,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.68,70,,3.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.38,,,1.38,Other,Drug Cost,1.38,,,1.38,Other,Drug Cost,1.38,,,1.38,Other,Drug Cost,1.38,,,1.38,Other,Drug Cost,1.38,,,1.38,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.38,,,1.38,Other,Drug Cost,3.11,,,3.11,Other,225% Medicaid APG methodology,1.93,,,1.93,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.38,,,1.38,Other,Drug Cost,1.38,,,1.38,Other,Drug Cost,1.73,,,1.73,Other,125% Medicaid APG methodology,0.01,3.68,
APIXABAN 2.5 MG TAB             ,,,,40579955,CDM,250,RC,00003-0893-31,NDC,both,1,EA,5.25,2.07,39.4668,,2.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.58,30,,1.58,percent of total billed charges,"Drugs, Inpatient Only",1.58,30,,1.58,percent of total billed charges,"Drugs, Inpatient Only",1.58,30,,1.58,percent of total billed charges,"Drugs, Inpatient Only",2.63,50,,2.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.81,,,2.81,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.68,70,,3.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.51,,,1.51,Other,Drug Cost,1.51,,,1.51,Other,Drug Cost,1.51,,,1.51,Other,Drug Cost,1.51,,,1.51,Other,Drug Cost,1.51,,,1.51,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.51,,,1.51,Other,Drug Cost,3.4,,,3.4,Other,225% Medicaid APG methodology,2.11,,,2.11,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.51,,,1.51,Other,Drug Cost,1.51,,,1.51,Other,Drug Cost,1.89,,,1.89,Other,125% Medicaid APG methodology,0.01,3.68,
RALTEGRAVIR 100 MG CHEW TAB     ,,,,40580094,CDM,250,RC,00006-0477-61,NDC,both,1,EA,27.16,10.72,39.4668,,10.72,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.15,30,,8.15,percent of total billed charges,"Drugs, Inpatient Only",8.15,30,,8.15,percent of total billed charges,"Drugs, Inpatient Only",8.15,30,,8.15,percent of total billed charges,"Drugs, Inpatient Only",13.58,50,,13.58,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.6,,,6.6,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.01,70,,19.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.55,,,3.55,Other,Drug Cost,3.55,,,3.55,Other,Drug Cost,3.55,,,3.55,Other,Drug Cost,3.55,,,3.55,Other,Drug Cost,3.55,,,3.55,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.55,,,3.55,Other,Drug Cost,7.99,,,7.99,Other,225% Medicaid APG methodology,4.97,,,4.97,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.55,,,3.55,Other,Drug Cost,3.55,,,3.55,Other,Drug Cost,4.44,,,4.44,Other,125% Medicaid APG methodology,0.01,19.01,
THIOTHIXENE 1 MG CAP            ,,,,40580169,CDM,250,RC,00378-1001-01,NDC,both,1,EA,2.21,0.87,39.4668,,0.87,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.66,30,,0.66,percent of total billed charges,"Drugs, Inpatient Only",0.66,30,,0.66,percent of total billed charges,"Drugs, Inpatient Only",0.66,30,,0.66,percent of total billed charges,"Drugs, Inpatient Only",1.11,50,,1.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.6,,,0.6,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.55,70,,1.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.32,,,0.32,Other,Drug Cost,0.72,,,0.72,Other,225% Medicaid APG methodology,0.45,,,0.45,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.4,,,0.4,Other,125% Medicaid APG methodology,0.01,1.55,
BUPIV-EPI 0.25%-1:200000 50ML   ,,,,40580177,CDM,250,RC,63323-0461-57,NDC,both,50,ML,29.75,11.74,39.4668,,11.74,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.93,30,,8.93,percent of total billed charges,"Drugs, Inpatient Only",8.93,30,,8.93,percent of total billed charges,"Drugs, Inpatient Only",8.93,30,,8.93,percent of total billed charges,"Drugs, Inpatient Only",14.88,50,,14.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.09,,,12.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,20.83,70,,20.83,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.5,,,6.5,Other,Drug Cost,6.5,,,6.5,Other,Drug Cost,6.5,,,6.5,Other,Drug Cost,6.5,,,6.5,Other,Drug Cost,6.5,,,6.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,6.5,,,6.5,Other,Drug Cost,14.63,,,14.63,Other,225% Medicaid APG methodology,9.1,,,9.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.5,,,6.5,Other,Drug Cost,6.5,,,6.5,Other,Drug Cost,8.13,,,8.13,Other,125% Medicaid APG methodology,0.01,20.83,
CHLORTHALIDONE 25 MG TAB        ,,,,40580235,CDM,250,RC,60687-0317-01,NDC,both,1,EA,6.37,2.51,39.4668,,2.51,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.91,30,,1.91,percent of total billed charges,"Drugs, Inpatient Only",1.91,30,,1.91,percent of total billed charges,"Drugs, Inpatient Only",1.91,30,,1.91,percent of total billed charges,"Drugs, Inpatient Only",3.19,50,,3.19,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.77,,,1.77,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.46,70,,4.46,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.95,,,0.95,Other,Drug Cost,0.95,,,0.95,Other,Drug Cost,0.95,,,0.95,Other,Drug Cost,0.95,,,0.95,Other,Drug Cost,0.95,,,0.95,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.95,,,0.95,Other,Drug Cost,2.14,,,2.14,Other,225% Medicaid APG methodology,1.33,,,1.33,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.95,,,0.95,Other,Drug Cost,0.95,,,0.95,Other,Drug Cost,1.19,,,1.19,Other,125% Medicaid APG methodology,0.01,4.46,
HYDROCHLOROTHIAZIDE 12.5MG CAP  ,,,,40580243,CDM,250,RC,60687-0683-01,NDC,both,1,EA,0.56,0.22,39.4668,,0.22,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.17,30,,0.17,percent of total billed charges,"Drugs, Inpatient Only",0.28,50,,0.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.39,70,,0.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,Drug Cost,0.32,,,0.32,Other,225% Medicaid APG methodology,0.2,,,0.2,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.18,,,0.18,Other,125% Medicaid APG methodology,0.01,0.39,
MORPHINE 15 MG TAB              ,,,,40580250,CDM,250,RC,00054-0235-24,NDC,both,1,EA,2.45,0.97,39.4668,,0.97,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.74,30,,0.74,percent of total billed charges,"Drugs, Inpatient Only",0.74,30,,0.74,percent of total billed charges,"Drugs, Inpatient Only",0.74,30,,0.74,percent of total billed charges,"Drugs, Inpatient Only",1.23,50,,1.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.72,70,,1.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,1.72,
SIMVASTATIN 5 MG TAB            ,,,,40580284,CDM,250,RC,70377-0001-14,NDC,both,1,EA,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.04,50,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.05,
PYRIDOXINE 25 MG TAB            ,,,,40580292,CDM,250,RC,00536-4406-01,NDC,both,1,EA,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.02,50,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.03,
FUROSEMIDE 10MG ORL  SYR 1ML    ,,,,40580433,CDM,250,RC,00054-3294-46,NDC,both,1,ML,0.32,0.13,39.4668,,0.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.1,30,,0.1,percent of total billed charges,"Drugs, Inpatient Only",0.16,50,,0.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,70,,0.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.22,
POSACONAZOLE 100MG DR TAB       ,,,,40580565,CDM,250,RC,50268-0683-12,NDC,both,1,EA,396.69,156.56,39.4668,,156.56,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,119.01,30,,119.01,percent of total billed charges,"Drugs, Inpatient Only",119.01,30,,119.01,percent of total billed charges,"Drugs, Inpatient Only",119.01,30,,119.01,percent of total billed charges,"Drugs, Inpatient Only",198.35,50,,198.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,161.17,,,161.17,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,277.68,70,,277.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,86.65,,,86.65,Other,Drug Cost,86.65,,,86.65,Other,Drug Cost,86.65,,,86.65,Other,Drug Cost,86.65,,,86.65,Other,Drug Cost,86.65,,,86.65,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,86.65,,,86.65,Other,Drug Cost,194.96,,,194.96,Other,225% Medicaid APG methodology,121.31,,,121.31,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,86.65,,,86.65,Other,Drug Cost,86.65,,,86.65,Other,Drug Cost,108.31,,,108.31,Other,125% Medicaid APG methodology,0.01,277.68,
CHOLECALCIFEROL 1000 UNIT TAB   ,,,,40580623,CDM,250,RC,00904-5824-60,NDC,both,1,EA,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.02,50,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.03,
NOREPINEPH 8MG NS 250ML         ,,,,40580722,CDM,250,RC,70092-9035-05,NDC,both,250,ML,127.4,50.28,39.4668,,50.28,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,38.22,30,,38.22,percent of total billed charges,"Drugs, Inpatient Only",38.22,30,,38.22,percent of total billed charges,"Drugs, Inpatient Only",38.22,30,,38.22,percent of total billed charges,"Drugs, Inpatient Only",63.7,50,,63.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,67.7,,,67.7,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,89.18,70,,89.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,36.4,,,36.4,Other,Drug Cost,36.4,,,36.4,Other,Drug Cost,36.4,,,36.4,Other,Drug Cost,36.4,,,36.4,Other,Drug Cost,36.4,,,36.4,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,36.4,,,36.4,Other,Drug Cost,81.9,,,81.9,Other,225% Medicaid APG methodology,50.96,,,50.96,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,36.4,,,36.4,Other,Drug Cost,36.4,,,36.4,Other,Drug Cost,45.5,,,45.5,Other,125% Medicaid APG methodology,0.01,89.18,
NF-EDOXABAN 30 MG TAB           ,,,,40581142,CDM,250,RC,65597-0202-30,NDC,both,1,EA,42.11,16.62,39.4668,,16.62,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.63,30,,12.63,percent of total billed charges,"Drugs, Inpatient Only",12.63,30,,12.63,percent of total billed charges,"Drugs, Inpatient Only",12.63,30,,12.63,percent of total billed charges,"Drugs, Inpatient Only",21.06,50,,21.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.24,,,12.24,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,29.48,70,,29.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.58,,,6.58,Other,Drug Cost,6.58,,,6.58,Other,Drug Cost,6.58,,,6.58,Other,Drug Cost,6.58,,,6.58,Other,Drug Cost,6.58,,,6.58,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,6.58,,,6.58,Other,Drug Cost,14.81,,,14.81,Other,225% Medicaid APG methodology,9.21,,,9.21,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.58,,,6.58,Other,Drug Cost,6.58,,,6.58,Other,Drug Cost,8.23,,,8.23,Other,125% Medicaid APG methodology,0.01,29.48,
OXYCODONE 5MG/5ML ORL SLN 5ML   ,,,,40581225,CDM,250,RC,00904-6828-94,NDC,both,5,ML,12.6,4.97,39.4668,,4.97,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.78,30,,3.78,percent of total billed charges,"Drugs, Inpatient Only",3.78,30,,3.78,percent of total billed charges,"Drugs, Inpatient Only",3.78,30,,3.78,percent of total billed charges,"Drugs, Inpatient Only",6.3,50,,6.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.4,,,3.4,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.82,70,,8.82,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.83,,,1.83,Other,Drug Cost,1.83,,,1.83,Other,Drug Cost,1.83,,,1.83,Other,Drug Cost,1.83,,,1.83,Other,Drug Cost,1.83,,,1.83,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.83,,,1.83,Other,Drug Cost,4.12,,,4.12,Other,225% Medicaid APG methodology,2.56,,,2.56,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.83,,,1.83,Other,Drug Cost,1.83,,,1.83,Other,Drug Cost,2.29,,,2.29,Other,125% Medicaid APG methodology,0.01,8.82,
IDARUCIZUMAB 50MG/ML IN IV50ML  ,,,,40581241,CDM,250,RC,00597-0197-05,NDC,both,50,ML,6492.5,2562.38,39.4668,,2562.38,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1947.75,30,,1947.75,percent of total billed charges,"Drugs, Inpatient Only",1947.75,30,,1947.75,percent of total billed charges,"Drugs, Inpatient Only",1947.75,30,,1947.75,percent of total billed charges,"Drugs, Inpatient Only",3246.25,50,,3246.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2624.46,,,2624.46,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4544.75,70,,4544.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1411,,,1411,Other,Drug Cost,1411,,,1411,Other,Drug Cost,1411,,,1411,Other,Drug Cost,1411,,,1411,Other,Drug Cost,1411,,,1411,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1411,,,1411,Other,Drug Cost,3174.75,,,3174.75,Other,225% Medicaid APG methodology,1975.4,,,1975.4,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1411,,,1411,Other,Drug Cost,1411,,,1411,Other,Drug Cost,1763.75,,,1763.75,Other,125% Medicaid APG methodology,0.01,4544.75,
BUPRENORPHINE-NALOX 8MG-2MG SL  ,,,,40581282,CDM,250,RC,12496-1208-03,NDC,both,1,EA,29.23,11.54,39.4668,,11.54,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.77,30,,8.77,percent of total billed charges,"Drugs, Inpatient Only",8.77,30,,8.77,percent of total billed charges,"Drugs, Inpatient Only",8.77,30,,8.77,percent of total billed charges,"Drugs, Inpatient Only",14.62,50,,14.62,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.91,,,5.91,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,20.46,70,,20.46,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.18,,,3.18,Other,Drug Cost,3.18,,,3.18,Other,Drug Cost,3.18,,,3.18,Other,Drug Cost,3.18,,,3.18,Other,Drug Cost,3.18,,,3.18,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.18,,,3.18,Other,Drug Cost,7.16,,,7.16,Other,225% Medicaid APG methodology,4.45,,,4.45,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.18,,,3.18,Other,Drug Cost,3.18,,,3.18,Other,Drug Cost,3.98,,,3.98,Other,125% Medicaid APG methodology,0.01,20.46,
BUPRERPHINE-NALOX 2-0.5MG SL    ,,,,40581324,CDM,250,RC,12496-1202-03,NDC,both,1,EA,16.31,6.44,39.4668,,6.44,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.89,30,,4.89,percent of total billed charges,"Drugs, Inpatient Only",4.89,30,,4.89,percent of total billed charges,"Drugs, Inpatient Only",4.89,30,,4.89,percent of total billed charges,"Drugs, Inpatient Only",8.16,50,,8.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.26,,,3.26,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.42,70,,11.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.75,,,1.75,Other,Drug Cost,1.75,,,1.75,Other,Drug Cost,1.75,,,1.75,Other,Drug Cost,1.75,,,1.75,Other,Drug Cost,1.75,,,1.75,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.75,,,1.75,Other,Drug Cost,3.94,,,3.94,Other,225% Medicaid APG methodology,2.45,,,2.45,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.75,,,1.75,Other,Drug Cost,1.75,,,1.75,Other,Drug Cost,2.19,,,2.19,Other,125% Medicaid APG methodology,0.01,11.42,
SUGAMMADEX 100MG/ML IV SLN 2ML  ,,,,40581415,CDM,250,RC,00006-5423-12,NDC,both,2,ML,421.33,166.29,39.4668,,166.29,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,126.4,30,,126.4,percent of total billed charges,"Drugs, Inpatient Only",126.4,30,,126.4,percent of total billed charges,"Drugs, Inpatient Only",126.4,30,,126.4,percent of total billed charges,"Drugs, Inpatient Only",210.67,50,,210.67,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,151.18,,,151.18,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,294.93,70,,294.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,81.28,,,81.28,Other,Drug Cost,81.28,,,81.28,Other,Drug Cost,81.28,,,81.28,Other,Drug Cost,81.28,,,81.28,Other,Drug Cost,81.28,,,81.28,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,81.28,,,81.28,Other,Drug Cost,182.88,,,182.88,Other,225% Medicaid APG methodology,113.79,,,113.79,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,81.28,,,81.28,Other,Drug Cost,81.28,,,81.28,Other,Drug Cost,101.6,,,101.6,Other,125% Medicaid APG methodology,0.01,294.93,
SUGAMMADEX 100MG/ML IV SLN 5ML  ,,,,40581423,CDM,250,RC,00006-5425-15,NDC,both,1,ML,154.35,60.92,39.4668,,60.92,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,46.31,30,,46.31,percent of total billed charges,"Drugs, Inpatient Only",46.31,30,,46.31,percent of total billed charges,"Drugs, Inpatient Only",46.31,30,,46.31,percent of total billed charges,"Drugs, Inpatient Only",77.18,50,,77.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,53.25,,,53.25,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,108.05,70,,108.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,28.63,,,28.63,Other,Drug Cost,28.63,,,28.63,Other,Drug Cost,28.63,,,28.63,Other,Drug Cost,28.63,,,28.63,Other,Drug Cost,28.63,,,28.63,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,28.63,,,28.63,Other,Drug Cost,64.42,,,64.42,Other,225% Medicaid APG methodology,40.08,,,40.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,28.63,,,28.63,Other,Drug Cost,28.63,,,28.63,Other,Drug Cost,35.79,,,35.79,Other,125% Medicaid APG methodology,0.01,108.05,
PANTOPRAZOLE 40MGORL GRANULEDR  ,,,,40581449,CDM,250,RC,27241-0256-38,NDC,both,1,EA,34.16,13.48,39.4668,,13.48,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.25,30,,10.25,percent of total billed charges,"Drugs, Inpatient Only",10.25,30,,10.25,percent of total billed charges,"Drugs, Inpatient Only",10.25,30,,10.25,percent of total billed charges,"Drugs, Inpatient Only",17.08,50,,17.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.04,,,10.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,23.91,70,,23.91,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.4,,,5.4,Other,Drug Cost,5.4,,,5.4,Other,Drug Cost,5.4,,,5.4,Other,Drug Cost,5.4,,,5.4,Other,Drug Cost,5.4,,,5.4,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,5.4,,,5.4,Other,Drug Cost,12.15,,,12.15,Other,225% Medicaid APG methodology,7.56,,,7.56,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.4,,,5.4,Other,Drug Cost,5.4,,,5.4,Other,Drug Cost,6.75,,,6.75,Other,125% Medicaid APG methodology,0.01,23.91,
ATORVASTATIN 40 MG TAB          ,,,,40581456,CDM,250,RC,67877-0513-90,NDC,both,1,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.11,50,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.15,
SACUBITR-VALSART 24MG-26MG TAB  ,,,,40581464,CDM,250,RC,00078-0659-67,NDC,both,1,EA,36.75,14.5,39.4668,,14.5,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.03,30,,11.03,percent of total billed charges,"Drugs, Inpatient Only",11.03,30,,11.03,percent of total billed charges,"Drugs, Inpatient Only",11.03,30,,11.03,percent of total billed charges,"Drugs, Inpatient Only",18.38,50,,18.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.28,,,9.28,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,25.73,70,,25.73,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.99,,,4.99,Other,Drug Cost,4.99,,,4.99,Other,Drug Cost,4.99,,,4.99,Other,Drug Cost,4.99,,,4.99,Other,Drug Cost,4.99,,,4.99,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.99,,,4.99,Other,Drug Cost,11.23,,,11.23,Other,225% Medicaid APG methodology,6.99,,,6.99,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.99,,,4.99,Other,Drug Cost,4.99,,,4.99,Other,Drug Cost,6.24,,,6.24,Other,125% Medicaid APG methodology,0.01,25.73,
SACUBITR-VALSART 49MG-51MG TAB  ,,,,40581472,CDM,250,RC,00078-0777-20,NDC,both,1,EA,36.19,14.28,39.4668,,14.28,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.86,30,,10.86,percent of total billed charges,"Drugs, Inpatient Only",10.86,30,,10.86,percent of total billed charges,"Drugs, Inpatient Only",10.86,30,,10.86,percent of total billed charges,"Drugs, Inpatient Only",18.1,50,,18.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.8,,,8.8,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,25.33,70,,25.33,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.73,,,4.73,Other,Drug Cost,4.73,,,4.73,Other,Drug Cost,4.73,,,4.73,Other,Drug Cost,4.73,,,4.73,Other,Drug Cost,4.73,,,4.73,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.73,,,4.73,Other,Drug Cost,10.64,,,10.64,Other,225% Medicaid APG methodology,6.62,,,6.62,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.73,,,4.73,Other,Drug Cost,4.73,,,4.73,Other,Drug Cost,5.91,,,5.91,Other,125% Medicaid APG methodology,0.01,25.33,
SACUBITR-VALSART 97MG-103MG TB  ,,,,40581480,CDM,250,RC,00078-0696-20,NDC,both,1,EA,27.79,10.97,39.4668,,10.97,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.34,30,,8.34,percent of total billed charges,"Drugs, Inpatient Only",8.34,30,,8.34,percent of total billed charges,"Drugs, Inpatient Only",8.34,30,,8.34,percent of total billed charges,"Drugs, Inpatient Only",13.9,50,,13.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.22,,,8.22,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.45,70,,19.45,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.42,,,4.42,Other,Drug Cost,4.42,,,4.42,Other,Drug Cost,4.42,,,4.42,Other,Drug Cost,4.42,,,4.42,Other,Drug Cost,4.42,,,4.42,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.42,,,4.42,Other,Drug Cost,9.95,,,9.95,Other,225% Medicaid APG methodology,6.19,,,6.19,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.42,,,4.42,Other,Drug Cost,4.42,,,4.42,Other,Drug Cost,5.53,,,5.53,Other,125% Medicaid APG methodology,0.01,19.45,
GENTAMICIN FORTIFIED OPTH7.1ML  ,,,,40581522,CDM,250,RC,61314-0633-05a,NDC,both,7.1,ML,18.97,7.49,39.4668,,7.49,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.69,30,,5.69,percent of total billed charges,"Drugs, Inpatient Only",5.69,30,,5.69,percent of total billed charges,"Drugs, Inpatient Only",5.69,30,,5.69,percent of total billed charges,"Drugs, Inpatient Only",9.49,50,,9.49,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.62,,,2.62,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.28,70,,13.28,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.41,,,1.41,Other,Drug Cost,1.41,,,1.41,Other,Drug Cost,1.41,,,1.41,Other,Drug Cost,1.41,,,1.41,Other,Drug Cost,1.41,,,1.41,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.41,,,1.41,Other,Drug Cost,3.17,,,3.17,Other,225% Medicaid APG methodology,1.97,,,1.97,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.41,,,1.41,Other,Drug Cost,1.41,,,1.41,Other,Drug Cost,1.76,,,1.76,Other,125% Medicaid APG methodology,0.01,13.28,
GENVOYA 150-150-200-10 MG TAB   ,,,,40581894,CDM,250,RC,61958-1901-01,NDC,both,1,EA,431.73,170.39,39.4668,,170.39,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,129.52,30,,129.52,percent of total billed charges,"Drugs, Inpatient Only",129.52,30,,129.52,percent of total billed charges,"Drugs, Inpatient Only",129.52,30,,129.52,percent of total billed charges,"Drugs, Inpatient Only",215.87,50,,215.87,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,122.44,,,122.44,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,302.21,70,,302.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,65.83,,,65.83,Other,Drug Cost,65.83,,,65.83,Other,Drug Cost,65.83,,,65.83,Other,Drug Cost,65.83,,,65.83,Other,Drug Cost,65.83,,,65.83,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,65.83,,,65.83,Other,Drug Cost,148.12,,,148.12,Other,225% Medicaid APG methodology,92.16,,,92.16,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,65.83,,,65.83,Other,Drug Cost,65.83,,,65.83,Other,Drug Cost,82.29,,,82.29,Other,125% Medicaid APG methodology,0.01,302.21,
IVABRADINE 5 MG TAB             ,,,,40582041,CDM,250,RC,55513-0800-60,NDC,both,1,EA,23.42,9.24,39.4668,,9.24,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.03,30,,7.03,percent of total billed charges,"Drugs, Inpatient Only",7.03,30,,7.03,percent of total billed charges,"Drugs, Inpatient Only",7.03,30,,7.03,percent of total billed charges,"Drugs, Inpatient Only",11.71,50,,11.71,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.69,,,8.69,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,16.39,70,,16.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.67,,,4.67,Other,Drug Cost,4.67,,,4.67,Other,Drug Cost,4.67,,,4.67,Other,Drug Cost,4.67,,,4.67,Other,Drug Cost,4.67,,,4.67,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.67,,,4.67,Other,Drug Cost,10.51,,,10.51,Other,225% Medicaid APG methodology,6.54,,,6.54,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.67,,,4.67,Other,Drug Cost,4.67,,,4.67,Other,Drug Cost,5.84,,,5.84,Other,125% Medicaid APG methodology,0.01,16.39,
ISOPROTERENOL 0.2MG/ML INJ 5ML  ,,,,40582389,CDM,250,RC,69918-0735-10,NDC,both,5,ML,189.49,74.79,39.4668,,74.79,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,56.85,30,,56.85,percent of total billed charges,"Drugs, Inpatient Only",56.85,30,,56.85,percent of total billed charges,"Drugs, Inpatient Only",56.85,30,,56.85,percent of total billed charges,"Drugs, Inpatient Only",94.75,50,,94.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,130.18,,,130.18,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,132.64,70,,132.64,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,69.99,,,69.99,Other,Drug Cost,69.99,,,69.99,Other,Drug Cost,69.99,,,69.99,Other,Drug Cost,69.99,,,69.99,Other,Drug Cost,69.99,,,69.99,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,69.99,,,69.99,Other,Drug Cost,157.48,,,157.48,Other,225% Medicaid APG methodology,97.99,,,97.99,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,69.99,,,69.99,Other,Drug Cost,69.99,,,69.99,Other,Drug Cost,87.49,,,87.49,Other,125% Medicaid APG methodology,0.01,157.48,
BACLOFEN 20 MG TAB              ,,,,40582488,CDM,250,RC,00172-4097-60,NDC,both,1,EA,0.42,0.17,39.4668,,0.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.21,50,,0.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,70,,0.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.29,
POT PHOS 3 MMOL/ML IV SLN 5ML   ,,,,40582595,CDM,250,RC,65219-0052-29,NDC,both,5,ML,65.1,25.69,39.4668,,25.69,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.53,30,,19.53,percent of total billed charges,"Drugs, Inpatient Only",19.53,30,,19.53,percent of total billed charges,"Drugs, Inpatient Only",19.53,30,,19.53,percent of total billed charges,"Drugs, Inpatient Only",32.55,50,,32.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,17.3,,,17.3,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,45.57,70,,45.57,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.3,,,9.3,Other,Drug Cost,9.3,,,9.3,Other,Drug Cost,9.3,,,9.3,Other,Drug Cost,9.3,,,9.3,Other,Drug Cost,9.3,,,9.3,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,9.3,,,9.3,Other,Drug Cost,20.93,,,20.93,Other,225% Medicaid APG methodology,13.02,,,13.02,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,9.3,,,9.3,Other,Drug Cost,9.3,,,9.3,Other,Drug Cost,11.63,,,11.63,Other,125% Medicaid APG methodology,0.01,45.57,
MOXIFLOXACIN 400 MG TAB         ,,,,40582793,CDM,250,RC,55111-0112-30,NDC,both,1,EA,9.59,3.78,39.4668,,3.78,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.88,30,,2.88,percent of total billed charges,"Drugs, Inpatient Only",2.88,30,,2.88,percent of total billed charges,"Drugs, Inpatient Only",2.88,30,,2.88,percent of total billed charges,"Drugs, Inpatient Only",4.8,50,,4.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.86,,,0.86,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.71,70,,6.71,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.46,,,0.46,Other,Drug Cost,1.04,,,1.04,Other,225% Medicaid APG methodology,0.64,,,0.64,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.58,,,0.58,Other,125% Medicaid APG methodology,0.01,6.71,
COLLAGENASE 250UNIT/G OINT 90G  ,,,,40582975,CDM,250,RC,50484-0010-90,NDC,both,90,GM,2088.45,824.24,39.4668,,824.24,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,626.54,30,,626.54,percent of total billed charges,"Drugs, Inpatient Only",626.54,30,,626.54,percent of total billed charges,"Drugs, Inpatient Only",626.54,30,,626.54,percent of total billed charges,"Drugs, Inpatient Only",1044.23,50,,1044.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,95.42,,,95.42,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1461.92,70,,1461.92,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,51.3,,,51.3,Other,Drug Cost,51.3,,,51.3,Other,Drug Cost,51.3,,,51.3,Other,Drug Cost,51.3,,,51.3,Other,Drug Cost,51.3,,,51.3,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,51.3,,,51.3,Other,Drug Cost,115.43,,,115.43,Other,225% Medicaid APG methodology,71.82,,,71.82,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,51.3,,,51.3,Other,Drug Cost,51.3,,,51.3,Other,Drug Cost,64.13,,,64.13,Other,125% Medicaid APG methodology,0.01,1461.92,
THEOPHYLLINE 80MG ORL 15ML  UD  ,,,,40583106,CDM,250,RC,00121-4820-40,NDC,both,1,ML,2.03,0.8,39.4668,,0.8,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.61,30,,0.61,percent of total billed charges,"Drugs, Inpatient Only",0.61,30,,0.61,percent of total billed charges,"Drugs, Inpatient Only",0.61,30,,0.61,percent of total billed charges,"Drugs, Inpatient Only",1.02,50,,1.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.39,,,0.39,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.42,70,,1.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.21,,,0.21,Other,Drug Cost,0.47,,,0.47,Other,225% Medicaid APG methodology,0.29,,,0.29,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.21,,,0.21,Other,Drug Cost,0.21,,,0.21,Other,Drug Cost,0.26,,,0.26,Other,125% Medicaid APG methodology,0.01,1.42,
ALBUTEROL 2.5MG/0.5ML(0.5%)NEB  ,,,,40583114,CDM,250,RC,00487-9901-30,NDC,both,1,EA,1.23,0.49,39.4668,,0.49,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,30,,0.37,percent of total billed charges,"Drugs, Inpatient Only",0.37,30,,0.37,percent of total billed charges,"Drugs, Inpatient Only",0.37,30,,0.37,percent of total billed charges,"Drugs, Inpatient Only",0.62,50,,0.62,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.5,,,0.5,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.86,70,,0.86,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.27,,,0.27,Other,Drug Cost,0.61,,,0.61,Other,225% Medicaid APG methodology,0.38,,,0.38,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.34,,,0.34,Other,125% Medicaid APG methodology,0.01,0.86,
SOD PHOS 3 MMOL/ML INJ SLN 5ML  ,,,,40583130,CDM,250,RC,63323-0170-05,NDC,both,5,ML,53.38,21.07,39.4668,,21.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,16.01,30,,16.01,percent of total billed charges,"Drugs, Inpatient Only",16.01,30,,16.01,percent of total billed charges,"Drugs, Inpatient Only",16.01,30,,16.01,percent of total billed charges,"Drugs, Inpatient Only",26.69,50,,26.69,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.49,,,9.49,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,37.37,70,,37.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.1,,,5.1,Other,Drug Cost,5.1,,,5.1,Other,Drug Cost,5.1,,,5.1,Other,Drug Cost,5.1,,,5.1,Other,Drug Cost,5.1,,,5.1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,5.1,,,5.1,Other,Drug Cost,11.48,,,11.48,Other,225% Medicaid APG methodology,7.14,,,7.14,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.1,,,5.1,Other,Drug Cost,5.1,,,5.1,Other,Drug Cost,6.38,,,6.38,Other,125% Medicaid APG methodology,0.01,37.37,
HYDROXOCOBALAMIN 5 G IV INJ     ,,,,40583403,CDM,250,RC,11704-0370-01,NDC,both,1,EA,2826.95,1115.71,39.4668,,1115.71,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,848.09,30,,848.09,percent of total billed charges,"Drugs, Inpatient Only",848.09,30,,848.09,percent of total billed charges,"Drugs, Inpatient Only",848.09,30,,848.09,percent of total billed charges,"Drugs, Inpatient Only",1413.48,50,,1413.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1497.56,,,1497.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1978.87,70,,1978.87,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,805.14,,,805.14,Other,Drug Cost,805.14,,,805.14,Other,Drug Cost,805.14,,,805.14,Other,Drug Cost,805.14,,,805.14,Other,Drug Cost,805.14,,,805.14,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,805.14,,,805.14,Other,Drug Cost,1811.57,,,1811.57,Other,225% Medicaid APG methodology,1127.2,,,1127.2,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,805.14,,,805.14,Other,Drug Cost,805.14,,,805.14,Other,Drug Cost,1006.43,,,1006.43,Other,125% Medicaid APG methodology,0.01,1978.87,
DIGOXIN 50 MCG/ML ELIXIR SYR    ,,,,40583478,CDM,250,RC,00054-0057-46,NDC,both,1,ML,6.51,2.57,39.4668,,2.57,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.95,30,,1.95,percent of total billed charges,"Drugs, Inpatient Only",1.95,30,,1.95,percent of total billed charges,"Drugs, Inpatient Only",1.95,30,,1.95,percent of total billed charges,"Drugs, Inpatient Only",3.26,50,,3.26,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.58,,,0.58,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.56,70,,4.56,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.31,,,0.31,Other,Drug Cost,0.7,,,0.7,Other,225% Medicaid APG methodology,0.43,,,0.43,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.31,,,0.31,Other,Drug Cost,0.31,,,0.31,Other,Drug Cost,0.39,,,0.39,Other,125% Medicaid APG methodology,0.01,4.56,
CYCLOPENTOLATE 1% OPT SLN 5ML   ,,,,40583577,CDM,250,RC,00065-0396-05,NDC,both,5,ML,158.38,62.51,39.4668,,62.51,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,47.51,30,,47.51,percent of total billed charges,"Drugs, Inpatient Only",47.51,30,,47.51,percent of total billed charges,"Drugs, Inpatient Only",47.51,30,,47.51,percent of total billed charges,"Drugs, Inpatient Only",79.19,50,,79.19,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,57.85,,,57.85,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,110.87,70,,110.87,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,31.1,,,31.1,Other,Drug Cost,31.1,,,31.1,Other,Drug Cost,31.1,,,31.1,Other,Drug Cost,31.1,,,31.1,Other,Drug Cost,31.1,,,31.1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,31.1,,,31.1,Other,Drug Cost,69.98,,,69.98,Other,225% Medicaid APG methodology,43.54,,,43.54,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,31.1,,,31.1,Other,Drug Cost,31.1,,,31.1,Other,Drug Cost,38.88,,,38.88,Other,125% Medicaid APG methodology,0.01,110.87,
CARBAMAZEPINE 20MG/ML ORL SYR   ,,,,40583627,CDM,250,RC,51672-4047-09,NDC,both,1,ML,0.42,0.17,39.4668,,0.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.13,30,,0.13,percent of total billed charges,"Drugs, Inpatient Only",0.21,50,,0.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,70,,0.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.29,
CITALOPRAM 10MG/5ML ORL 60ML    ,,,,40583643,CDM,250,RC,31722-0564-24,NDC,both,60,ML,46.2,18.23,39.4668,,18.23,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.86,30,,13.86,percent of total billed charges,"Drugs, Inpatient Only",13.86,30,,13.86,percent of total billed charges,"Drugs, Inpatient Only",13.86,30,,13.86,percent of total billed charges,"Drugs, Inpatient Only",23.1,50,,23.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.04,,,10.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,32.34,70,,32.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.4,,,5.4,Other,Drug Cost,5.4,,,5.4,Other,Drug Cost,5.4,,,5.4,Other,Drug Cost,5.4,,,5.4,Other,Drug Cost,5.4,,,5.4,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,5.4,,,5.4,Other,Drug Cost,12.15,,,12.15,Other,225% Medicaid APG methodology,7.56,,,7.56,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.4,,,5.4,Other,Drug Cost,5.4,,,5.4,Other,Drug Cost,6.75,,,6.75,Other,125% Medicaid APG methodology,0.01,32.34,
WITCH HAZEL 50% TOPICAL PAD     ,,,,40583809,CDM,250,RC,50289-3250-01,NDC,both,1,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.11,50,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,,,0.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,0.15,
MULTI VITA MINERALS LIQ 15MLUD  ,,,,40583817,CDM,250,RC,68094-0120-61,NDC,both,15,ML,7.7,3.04,39.4668,,3.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.31,30,,2.31,percent of total billed charges,"Drugs, Inpatient Only",2.31,30,,2.31,percent of total billed charges,"Drugs, Inpatient Only",2.31,30,,2.31,percent of total billed charges,"Drugs, Inpatient Only",3.85,50,,3.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.39,,,3.39,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.39,70,,5.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.82,,,1.82,Other,Drug Cost,1.82,,,1.82,Other,Drug Cost,1.82,,,1.82,Other,Drug Cost,1.82,,,1.82,Other,Drug Cost,1.82,,,1.82,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.82,,,1.82,Other,Drug Cost,4.1,,,4.1,Other,225% Medicaid APG methodology,2.55,,,2.55,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.82,,,1.82,Other,Drug Cost,1.82,,,1.82,Other,Drug Cost,2.28,,,2.28,Other,125% Medicaid APG methodology,0.01,5.39,
BUPIV 0.75% PF INJ SLN 30ML     ,,,,40583924,CDM,250,RC,55150-0172-30,NDC,both,30,ML,7.35,2.9,39.4668,,2.9,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.21,30,,2.21,percent of total billed charges,"Drugs, Inpatient Only",2.21,30,,2.21,percent of total billed charges,"Drugs, Inpatient Only",2.21,30,,2.21,percent of total billed charges,"Drugs, Inpatient Only",3.68,50,,3.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.46,,,4.46,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.15,70,,5.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.4,,,2.4,Other,Drug Cost,5.4,,,5.4,Other,225% Medicaid APG methodology,3.36,,,3.36,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,3,,,3,Other,125% Medicaid APG methodology,0.01,5.4,
NF-CLOZAPINE 100 MG ODT         ,,,,40584021,CDM,250,RC,00093-5419-84,NDC,both,1,EA,18.17,7.17,39.4668,,7.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.45,30,,5.45,percent of total billed charges,"Drugs, Inpatient Only",5.45,30,,5.45,percent of total billed charges,"Drugs, Inpatient Only",5.45,30,,5.45,percent of total billed charges,"Drugs, Inpatient Only",9.09,50,,9.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.04,,,5.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.72,70,,12.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.71,,,2.71,Other,Drug Cost,2.71,,,2.71,Other,Drug Cost,2.71,,,2.71,Other,Drug Cost,2.71,,,2.71,Other,Drug Cost,2.71,,,2.71,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.71,,,2.71,Other,Drug Cost,6.1,,,6.1,Other,225% Medicaid APG methodology,3.79,,,3.79,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.71,,,2.71,Other,Drug Cost,2.71,,,2.71,Other,Drug Cost,3.39,,,3.39,Other,125% Medicaid APG methodology,0.01,12.72,
BUPIV-EPI0.5%-1:200000PF 30ML   ,,,,40584161,CDM,250,RC,63323-0462-37,NDC,both,30,ML,21,8.29,39.4668,,8.29,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.3,30,,6.3,percent of total billed charges,"Drugs, Inpatient Only",6.3,30,,6.3,percent of total billed charges,"Drugs, Inpatient Only",6.3,30,,6.3,percent of total billed charges,"Drugs, Inpatient Only",10.5,50,,10.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.93,,,8.93,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.7,70,,14.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.8,,,4.8,Other,Drug Cost,10.8,,,10.8,Other,225% Medicaid APG methodology,6.72,,,6.72,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.8,,,4.8,Other,Drug Cost,4.8,,,4.8,Other,Drug Cost,6,,,6,Other,125% Medicaid APG methodology,0.01,14.7,
BUPIV-EPI0.5%-1:200000PF 10ML   ,,,,40584187,CDM,250,RC,63323-0462-17,NDC,both,10,ML,12.25,4.83,39.4668,,4.83,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.68,30,,3.68,percent of total billed charges,"Drugs, Inpatient Only",3.68,30,,3.68,percent of total billed charges,"Drugs, Inpatient Only",3.68,30,,3.68,percent of total billed charges,"Drugs, Inpatient Only",6.13,50,,6.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.98,,,2.98,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.58,70,,8.58,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.6,,,1.6,Other,Drug Cost,1.6,,,1.6,Other,Drug Cost,1.6,,,1.6,Other,Drug Cost,1.6,,,1.6,Other,Drug Cost,1.6,,,1.6,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.6,,,1.6,Other,Drug Cost,3.6,,,3.6,Other,225% Medicaid APG methodology,2.24,,,2.24,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.6,,,1.6,Other,Drug Cost,1.6,,,1.6,Other,Drug Cost,2,,,2,Other,125% Medicaid APG methodology,0.01,8.58,
HEPLISAV-B 20 MCG/0.5 ML INJ    ,,,,40584211,CDM,250,RC,43528-0003-05,NDC,both,1,ML,662.41,261.43,39.4668,,261.43,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,198.72,30,,198.72,percent of total billed charges,"Drugs, Inpatient Only",198.72,30,,198.72,percent of total billed charges,"Drugs, Inpatient Only",198.72,30,,198.72,percent of total billed charges,"Drugs, Inpatient Only",331.21,50,,331.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,344.51,,,344.51,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,463.69,70,,463.69,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,185.22,,,185.22,Other,Drug Cost,185.22,,,185.22,Other,Drug Cost,185.22,,,185.22,Other,Drug Cost,185.22,,,185.22,Other,Drug Cost,185.22,,,185.22,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,185.22,,,185.22,Other,Drug Cost,416.75,,,416.75,Other,225% Medicaid APG methodology,259.31,,,259.31,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,185.22,,,185.22,Other,Drug Cost,185.22,,,185.22,Other,Drug Cost,231.53,,,231.53,Other,125% Medicaid APG methodology,0.01,463.69,
BENZOCAINE 20% MUCOUS  SPRAY    ,,,,40584237,CDM,250,RC,00283-0610-11,NDC,both,1,EA,35.14,13.87,39.4668,,13.87,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.54,30,,10.54,percent of total billed charges,"Drugs, Inpatient Only",10.54,30,,10.54,percent of total billed charges,"Drugs, Inpatient Only",10.54,30,,10.54,percent of total billed charges,"Drugs, Inpatient Only",17.57,50,,17.57,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,22.58,,,22.58,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,24.6,70,,24.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.14,,,12.14,Other,Drug Cost,12.14,,,12.14,Other,Drug Cost,12.14,,,12.14,Other,Drug Cost,12.14,,,12.14,Other,Drug Cost,12.14,,,12.14,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,12.14,,,12.14,Other,Drug Cost,27.32,,,27.32,Other,225% Medicaid APG methodology,17,,,17,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,12.14,,,12.14,Other,Drug Cost,12.14,,,12.14,Other,Drug Cost,15.18,,,15.18,Other,125% Medicaid APG methodology,0.01,27.32,
EPINEPH-LIDO 1:100000-1% 50ML   ,,,,40584294,CDM,250,RC,00409-3178-03,NDC,both,50,ML,7,2.76,39.4668,,2.76,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.1,30,,2.1,percent of total billed charges,"Drugs, Inpatient Only",2.1,30,,2.1,percent of total billed charges,"Drugs, Inpatient Only",2.1,30,,2.1,percent of total billed charges,"Drugs, Inpatient Only",3.5,50,,3.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.65,,,4.65,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.9,70,,4.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.5,,,2.5,Other,Drug Cost,5.63,,,5.63,Other,225% Medicaid APG methodology,3.5,,,3.5,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,3.13,,,3.13,Other,125% Medicaid APG methodology,0.01,5.63,
FOSFOMYCIN 3000MG ORL POW       ,,,,40584328,CDM,250,RC,00456-4300-01,NDC,both,1,EA,287.67,113.53,39.4668,,113.53,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,86.3,30,,86.3,percent of total billed charges,"Drugs, Inpatient Only",86.3,30,,86.3,percent of total billed charges,"Drugs, Inpatient Only",86.3,30,,86.3,percent of total billed charges,"Drugs, Inpatient Only",143.84,50,,143.84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.36,,,19.36,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,201.37,70,,201.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.41,,,10.41,Other,Drug Cost,10.41,,,10.41,Other,Drug Cost,10.41,,,10.41,Other,Drug Cost,10.41,,,10.41,Other,Drug Cost,10.41,,,10.41,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,10.41,,,10.41,Other,Drug Cost,23.42,,,23.42,Other,225% Medicaid APG methodology,14.57,,,14.57,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,10.41,,,10.41,Other,Drug Cost,10.41,,,10.41,Other,Drug Cost,13.01,,,13.01,Other,125% Medicaid APG methodology,0.01,201.37,
LIDOCAINE 2% INJ SOLN 10 ML     ,,,,40584419,CDM,250,RC,63323-0486-17,NDC,both,10,ML,9.45,3.73,39.4668,,3.73,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.84,30,,2.84,percent of total billed charges,"Drugs, Inpatient Only",2.84,30,,2.84,percent of total billed charges,"Drugs, Inpatient Only",2.84,30,,2.84,percent of total billed charges,"Drugs, Inpatient Only",4.73,50,,4.73,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.02,,,5.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.62,70,,6.62,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.7,,,2.7,Other,Drug Cost,6.08,,,6.08,Other,225% Medicaid APG methodology,3.78,,,3.78,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,3.38,,,3.38,Other,125% Medicaid APG methodology,0.01,6.62,
EPI-LIDO1:200000-1%PF INJ30ML   ,,,,40584427,CDM,250,RC,63323-0487-37,NDC,both,30,ML,25.2,9.95,39.4668,,9.95,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.56,30,,7.56,percent of total billed charges,"Drugs, Inpatient Only",7.56,30,,7.56,percent of total billed charges,"Drugs, Inpatient Only",7.56,30,,7.56,percent of total billed charges,"Drugs, Inpatient Only",12.6,50,,12.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.46,,,4.46,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,17.64,70,,17.64,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.4,,,2.4,Other,Drug Cost,5.4,,,5.4,Other,225% Medicaid APG methodology,3.36,,,3.36,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,3,,,3,Other,125% Medicaid APG methodology,0.01,17.64,
VANCOMYCIN 125MG/2.5ML ORL SYR  ,,,,40584666,CDM,250,RC,65628-0206-05A,NDC,both,2.5,ML,6.93,2.74,39.4668,,2.74,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.08,30,,2.08,percent of total billed charges,"Drugs, Inpatient Only",2.08,30,,2.08,percent of total billed charges,"Drugs, Inpatient Only",2.08,30,,2.08,percent of total billed charges,"Drugs, Inpatient Only",3.47,50,,3.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.75,,,2.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.85,70,,4.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.48,,,1.48,Other,Drug Cost,3.33,,,3.33,Other,225% Medicaid APG methodology,2.07,,,2.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,1.85,,,1.85,Other,125% Medicaid APG methodology,0.01,4.85,
TROPICAMIDE 1% OPHTH SOLN 15ML  ,,,,40584823,CDM,250,RC,17478-0102-12,NDC,both,15,ML,16.28,6.43,39.4668,,6.43,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.88,30,,4.88,percent of total billed charges,"Drugs, Inpatient Only",4.88,30,,4.88,percent of total billed charges,"Drugs, Inpatient Only",4.88,30,,4.88,percent of total billed charges,"Drugs, Inpatient Only",8.14,50,,8.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.09,,,8.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.4,70,,11.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.35,,,4.35,Other,Drug Cost,4.35,,,4.35,Other,Drug Cost,4.35,,,4.35,Other,Drug Cost,4.35,,,4.35,Other,Drug Cost,4.35,,,4.35,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.35,,,4.35,Other,Drug Cost,9.79,,,9.79,Other,225% Medicaid APG methodology,6.09,,,6.09,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.35,,,4.35,Other,Drug Cost,4.35,,,4.35,Other,Drug Cost,5.44,,,5.44,Other,125% Medicaid APG methodology,0.01,11.4,
FERRIC SUBSULFATE TOPICAL  8ML  ,,,,40584898,CDM,250,RC,48783-0112-08,NDC,both,8,ML,53.48,21.11,39.4668,,21.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,16.04,30,,16.04,percent of total billed charges,"Drugs, Inpatient Only",16.04,30,,16.04,percent of total billed charges,"Drugs, Inpatient Only",16.04,30,,16.04,percent of total billed charges,"Drugs, Inpatient Only",26.74,50,,26.74,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,28.42,,,28.42,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,37.44,70,,37.44,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.28,,,15.28,Other,Drug Cost,15.28,,,15.28,Other,Drug Cost,15.28,,,15.28,Other,Drug Cost,15.28,,,15.28,Other,Drug Cost,15.28,,,15.28,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,15.28,,,15.28,Other,Drug Cost,34.38,,,34.38,Other,225% Medicaid APG methodology,21.39,,,21.39,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,15.28,,,15.28,Other,Drug Cost,15.28,,,15.28,Other,Drug Cost,19.1,,,19.1,Other,125% Medicaid APG methodology,0.01,37.44,
SOD HYPOCHLORITE 0.25% 473ML    ,,,,40585051,CDM,250,RC,39328-0063-25,NDC,both,473,ML,33.11,13.07,39.4668,,13.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.93,30,,9.93,percent of total billed charges,"Drugs, Inpatient Only",9.93,30,,9.93,percent of total billed charges,"Drugs, Inpatient Only",9.93,30,,9.93,percent of total billed charges,"Drugs, Inpatient Only",16.56,50,,16.56,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,17.6,,,17.6,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,23.18,70,,23.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.46,,,9.46,Other,Drug Cost,9.46,,,9.46,Other,Drug Cost,9.46,,,9.46,Other,Drug Cost,9.46,,,9.46,Other,Drug Cost,9.46,,,9.46,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,9.46,,,9.46,Other,Drug Cost,21.29,,,21.29,Other,225% Medicaid APG methodology,13.24,,,13.24,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,9.46,,,9.46,Other,Drug Cost,9.46,,,9.46,Other,Drug Cost,11.83,,,11.83,Other,125% Medicaid APG methodology,0.01,23.18,
TETRACAINE 0.5% OPHTH SLN 15ML  ,,,,40585176,CDM,250,RC,68682-0920-64,NDC,both,15,ML,277.2,109.4,39.4668,,109.4,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,83.16,30,,83.16,percent of total billed charges,"Drugs, Inpatient Only",83.16,30,,83.16,percent of total billed charges,"Drugs, Inpatient Only",83.16,30,,83.16,percent of total billed charges,"Drugs, Inpatient Only",138.6,50,,138.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,121.37,,,121.37,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,194.04,70,,194.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,65.25,,,65.25,Other,Drug Cost,65.25,,,65.25,Other,Drug Cost,65.25,,,65.25,Other,Drug Cost,65.25,,,65.25,Other,Drug Cost,65.25,,,65.25,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,65.25,,,65.25,Other,Drug Cost,146.81,,,146.81,Other,225% Medicaid APG methodology,91.35,,,91.35,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,65.25,,,65.25,Other,Drug Cost,65.25,,,65.25,Other,Drug Cost,81.56,,,81.56,Other,125% Medicaid APG methodology,0.01,194.04,
CYCLOPNTOLATE-PE0.2%-1% OPT2ML  ,,,,40585366,CDM,250,RC,00065-0359-02,NDC,both,2,ML,92.12,36.36,39.4668,,36.36,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,27.64,30,,27.64,percent of total billed charges,"Drugs, Inpatient Only",27.64,30,,27.64,percent of total billed charges,"Drugs, Inpatient Only",27.64,30,,27.64,percent of total billed charges,"Drugs, Inpatient Only",46.06,50,,46.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,31.95,,,31.95,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,64.48,70,,64.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,17.18,,,17.18,Other,Drug Cost,17.18,,,17.18,Other,Drug Cost,17.18,,,17.18,Other,Drug Cost,17.18,,,17.18,Other,Drug Cost,17.18,,,17.18,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,17.18,,,17.18,Other,Drug Cost,38.66,,,38.66,Other,225% Medicaid APG methodology,24.05,,,24.05,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,17.18,,,17.18,Other,Drug Cost,17.18,,,17.18,Other,Drug Cost,21.48,,,21.48,Other,125% Medicaid APG methodology,0.01,64.48,
DEXA-TOBRA OPT OINT 3.5G        ,,,,40585382,CDM,250,RC,00078-0876-01,NDC,both,3.5,GM,775.74,306.16,39.4668,,306.16,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,232.72,30,,232.72,percent of total billed charges,"Drugs, Inpatient Only",232.72,30,,232.72,percent of total billed charges,"Drugs, Inpatient Only",232.72,30,,232.72,percent of total billed charges,"Drugs, Inpatient Only",387.87,50,,387.87,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,543.02,70,,543.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,543.02,
DEXA-TOBRA OPT SUSP 2.5ML       ,,,,40585390,CDM,250,RC,24208-0295-25,NDC,both,2.5,ML,138.43,54.63,39.4668,,54.63,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,41.53,30,,41.53,percent of total billed charges,"Drugs, Inpatient Only",41.53,30,,41.53,percent of total billed charges,"Drugs, Inpatient Only",41.53,30,,41.53,percent of total billed charges,"Drugs, Inpatient Only",69.22,50,,69.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,28.68,,,28.68,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,96.9,70,,96.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.42,,,15.42,Other,Drug Cost,15.42,,,15.42,Other,Drug Cost,15.42,,,15.42,Other,Drug Cost,15.42,,,15.42,Other,Drug Cost,15.42,,,15.42,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,15.42,,,15.42,Other,Drug Cost,34.7,,,34.7,Other,225% Medicaid APG methodology,21.59,,,21.59,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,15.42,,,15.42,Other,Drug Cost,15.42,,,15.42,Other,Drug Cost,19.28,,,19.28,Other,125% Medicaid APG methodology,0.01,96.9,
SOD POLYSTYRENE SULFONATE 15G   ,,,,40585630,CDM,250,RC,10702-0036-15,NDC,both,1,GM,2.77,1.09,39.4668,,1.09,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.83,30,,0.83,percent of total billed charges,"Drugs, Inpatient Only",0.83,30,,0.83,percent of total billed charges,"Drugs, Inpatient Only",0.83,30,,0.83,percent of total billed charges,"Drugs, Inpatient Only",1.39,50,,1.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.94,70,,1.94,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% Medicaid APG methodology,0.1,,,0.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,1.94,
BUPRENORPHINE 5 MCG/HR TD ER    ,,,,40585648,CDM,250,RC,59011-0750-04,NDC,both,1,EA,218.89,86.39,39.4668,,86.39,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,65.67,30,,65.67,percent of total billed charges,"Drugs, Inpatient Only",65.67,30,,65.67,percent of total billed charges,"Drugs, Inpatient Only",65.67,30,,65.67,percent of total billed charges,"Drugs, Inpatient Only",109.45,50,,109.45,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,153.22,70,,153.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,153.22,
EPI-LIDO 1:200000-1.5% PF 5ML   ,,,,40585697,CDM,250,RC,00409-1209-01,NDC,both,5,ML,10.33,4.08,39.4668,,4.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.1,30,,3.1,percent of total billed charges,"Drugs, Inpatient Only",3.1,30,,3.1,percent of total billed charges,"Drugs, Inpatient Only",3.1,30,,3.1,percent of total billed charges,"Drugs, Inpatient Only",5.17,50,,5.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.42,,,2.42,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.23,70,,7.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.3,,,1.3,Other,Drug Cost,1.3,,,1.3,Other,Drug Cost,1.3,,,1.3,Other,Drug Cost,1.3,,,1.3,Other,Drug Cost,1.3,,,1.3,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.3,,,1.3,Other,Drug Cost,2.93,,,2.93,Other,225% Medicaid APG methodology,1.82,,,1.82,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.3,,,1.3,Other,Drug Cost,1.3,,,1.3,Other,Drug Cost,1.63,,,1.63,Other,125% Medicaid APG methodology,0.01,7.23,
LIDOCAINE 2% TOPICAL GEL 11ML   ,,,,40585762,CDM,250,RC,25021-0673-77,NDC,both,11,ML,166.71,65.8,39.4668,,65.8,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,50.01,30,,50.01,percent of total billed charges,"Drugs, Inpatient Only",50.01,30,,50.01,percent of total billed charges,"Drugs, Inpatient Only",50.01,30,,50.01,percent of total billed charges,"Drugs, Inpatient Only",83.36,50,,83.36,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,98.21,,,98.21,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,116.7,70,,116.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,52.8,,,52.8,Other,Drug Cost,52.8,,,52.8,Other,Drug Cost,52.8,,,52.8,Other,Drug Cost,52.8,,,52.8,Other,Drug Cost,52.8,,,52.8,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,52.8,,,52.8,Other,Drug Cost,118.8,,,118.8,Other,225% Medicaid APG methodology,73.92,,,73.92,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,52.8,,,52.8,Other,Drug Cost,52.8,,,52.8,Other,Drug Cost,66,,,66,Other,125% Medicaid APG methodology,0.01,118.8,
POT-SOD PHOS 250MG280MG160MG    ,,,,40585788,CDM,250,RC,60258-0006-01,NDC,both,100,EA,115.5,45.58,39.4668,,45.58,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,34.65,30,,34.65,percent of total billed charges,"Drugs, Inpatient Only",34.65,30,,34.65,percent of total billed charges,"Drugs, Inpatient Only",34.65,30,,34.65,percent of total billed charges,"Drugs, Inpatient Only",57.75,50,,57.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,55.8,,,55.8,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,80.85,70,,80.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,30,,,30,Other,Drug Cost,30,,,30,Other,Drug Cost,30,,,30,Other,Drug Cost,30,,,30,Other,Drug Cost,30,,,30,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,30,,,30,Other,Drug Cost,67.5,,,67.5,Other,225% Medicaid APG methodology,42,,,42,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,30,,,30,Other,Drug Cost,30,,,30,Other,Drug Cost,37.5,,,37.5,Other,125% Medicaid APG methodology,0.01,80.85,
CHARCOAL 25 G ORAL SUSP 120 ML  ,,,,40585853,CDM,250,RC,00574-0521-74,NDC,both,120,ML,43.4,17.13,39.4668,,17.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.02,30,,13.02,percent of total billed charges,"Drugs, Inpatient Only",13.02,30,,13.02,percent of total billed charges,"Drugs, Inpatient Only",13.02,30,,13.02,percent of total billed charges,"Drugs, Inpatient Only",21.7,50,,21.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,18.43,,,18.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,30.38,70,,30.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.91,,,9.91,Other,Drug Cost,9.91,,,9.91,Other,Drug Cost,9.91,,,9.91,Other,Drug Cost,9.91,,,9.91,Other,Drug Cost,9.91,,,9.91,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,9.91,,,9.91,Other,Drug Cost,22.3,,,22.3,Other,225% Medicaid APG methodology,13.87,,,13.87,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,9.91,,,9.91,Other,Drug Cost,9.91,,,9.91,Other,Drug Cost,12.39,,,12.39,Other,125% Medicaid APG methodology,0.01,30.38,
LOPERAMIDE 1MG/7.5ML CUP        ,,,,40585895,CDM,250,RC,68094-0107-62,NDC,both,7.5,ML,5.53,2.18,39.4668,,2.18,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.66,30,,1.66,percent of total billed charges,"Drugs, Inpatient Only",1.66,30,,1.66,percent of total billed charges,"Drugs, Inpatient Only",1.66,30,,1.66,percent of total billed charges,"Drugs, Inpatient Only",2.77,50,,2.77,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.66,,,2.66,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.87,70,,3.87,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.43,,,1.43,Other,Drug Cost,1.43,,,1.43,Other,Drug Cost,1.43,,,1.43,Other,Drug Cost,1.43,,,1.43,Other,Drug Cost,1.43,,,1.43,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.43,,,1.43,Other,Drug Cost,3.22,,,3.22,Other,225% Medicaid APG methodology,2,,,2,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.43,,,1.43,Other,Drug Cost,1.43,,,1.43,Other,Drug Cost,1.79,,,1.79,Other,125% Medicaid APG methodology,0.01,3.87,
BRIVARACETAM 25MG TABLET        ,,,,40585929,CDM,250,RC,50474-0470-66,NDC,both,1,EA,74.41,29.37,39.4668,,29.37,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,22.32,30,,22.32,percent of total billed charges,"Drugs, Inpatient Only",22.32,30,,22.32,percent of total billed charges,"Drugs, Inpatient Only",22.32,30,,22.32,percent of total billed charges,"Drugs, Inpatient Only",37.21,50,,37.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,20.03,,,20.03,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,52.09,70,,52.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.77,,,10.77,Other,Drug Cost,10.77,,,10.77,Other,Drug Cost,10.77,,,10.77,Other,Drug Cost,10.77,,,10.77,Other,Drug Cost,10.77,,,10.77,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,10.77,,,10.77,Other,Drug Cost,24.23,,,24.23,Other,225% Medicaid APG methodology,15.08,,,15.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,10.77,,,10.77,Other,Drug Cost,10.77,,,10.77,Other,Drug Cost,13.46,,,13.46,Other,125% Medicaid APG methodology,0.01,52.09,
OCULAR LUBRICANT OPT DRP 0.4ML  ,,,,40585945,CDM,250,RC,00023-0506-50,NDC,both,1,EA,0.98,0.39,39.4668,,0.39,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.29,30,,0.29,percent of total billed charges,"Drugs, Inpatient Only",0.49,50,,0.49,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.47,,,0.47,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.69,70,,0.69,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.56,,,0.56,Other,225% Medicaid APG methodology,0.35,,,0.35,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.31,,,0.31,Other,125% Medicaid APG methodology,0.01,0.69,
RIVAROXABAN 2.5 MG TAB          ,,,,40585952,CDM,250,RC,50458-0577-10,NDC,both,1,EA,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.02,50,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.03,
BUPROPION 150MG/24H ER TAB      ,,,,40586133,CDM,250,RC,00904-7084-61,NDC,both,1,EA,4.34,1.71,39.4668,,1.71,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.3,30,,1.3,percent of total billed charges,"Drugs, Inpatient Only",1.3,30,,1.3,percent of total billed charges,"Drugs, Inpatient Only",1.3,30,,1.3,percent of total billed charges,"Drugs, Inpatient Only",2.17,50,,2.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.93,,,1.93,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.04,70,,3.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.04,,,1.04,Other,Drug Cost,1.04,,,1.04,Other,Drug Cost,1.04,,,1.04,Other,Drug Cost,1.04,,,1.04,Other,Drug Cost,1.04,,,1.04,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.04,,,1.04,Other,Drug Cost,2.34,,,2.34,Other,225% Medicaid APG methodology,1.46,,,1.46,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.04,,,1.04,Other,Drug Cost,1.04,,,1.04,Other,Drug Cost,1.3,,,1.3,Other,125% Medicaid APG methodology,0.01,3.04,
BUPROPION 300MG/24H ER TAB      ,,,,40586141,CDM,250,RC,60687-0793-21,NDC,both,1,EA,4.24,1.67,39.4668,,1.67,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.27,30,,1.27,percent of total billed charges,"Drugs, Inpatient Only",1.27,30,,1.27,percent of total billed charges,"Drugs, Inpatient Only",1.27,30,,1.27,percent of total billed charges,"Drugs, Inpatient Only",2.12,50,,2.12,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.1,,,2.1,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.97,70,,2.97,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.13,,,1.13,Other,Drug Cost,1.13,,,1.13,Other,Drug Cost,1.13,,,1.13,Other,Drug Cost,1.13,,,1.13,Other,Drug Cost,1.13,,,1.13,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.13,,,1.13,Other,Drug Cost,2.54,,,2.54,Other,225% Medicaid APG methodology,1.58,,,1.58,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.13,,,1.13,Other,Drug Cost,1.13,,,1.13,Other,Drug Cost,1.41,,,1.41,Other,125% Medicaid APG methodology,0.01,2.97,
THROMBIN RECOMB 20000 UN POW    ,,,,40587594,CDM,250,RC,00338-0326-01,NDC,both,1,EA,1138.52,449.34,39.4668,,449.34,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,341.56,30,,341.56,percent of total billed charges,"Drugs, Inpatient Only",341.56,30,,341.56,percent of total billed charges,"Drugs, Inpatient Only",341.56,30,,341.56,percent of total billed charges,"Drugs, Inpatient Only",569.26,50,,569.26,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,603.11,,,603.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,796.96,70,,796.96,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,324.25,,,324.25,Other,Drug Cost,324.25,,,324.25,Other,Drug Cost,324.25,,,324.25,Other,Drug Cost,324.25,,,324.25,Other,Drug Cost,324.25,,,324.25,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,324.25,,,324.25,Other,Drug Cost,729.56,,,729.56,Other,225% Medicaid APG methodology,453.95,,,453.95,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,324.25,,,324.25,Other,Drug Cost,324.25,,,324.25,Other,Drug Cost,405.31,,,405.31,Other,125% Medicaid APG methodology,0.01,796.96,
ACAMPROSATE 333 MG DR TAB       ,,,,40587685,CDM,250,RC,68462-0435-18,NDC,both,1,EA,1.79,0.71,39.4668,,0.71,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.54,30,,0.54,percent of total billed charges,"Drugs, Inpatient Only",0.54,30,,0.54,percent of total billed charges,"Drugs, Inpatient Only",0.54,30,,0.54,percent of total billed charges,"Drugs, Inpatient Only",0.9,50,,0.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.35,,,0.35,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.25,70,,1.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,Drug Cost,0.43,,,0.43,Other,225% Medicaid APG methodology,0.27,,,0.27,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.24,,,0.24,Other,125% Medicaid APG methodology,0.01,1.25,
AMANTADINE 10MG/ML ORLSYR SYRN  ,,,,40587792,CDM,250,RC,50383-0807-16,NDC,both,1,ML,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.01,30,,0.01,percent of total billed charges,"Drugs, Inpatient Only",0.02,50,,0.02,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,70,,0.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.03,
AMOX-CLAV 250-62.5MG/5ML BTL    ,,,,40587818,CDM,250,RC,59651-0026-75,NDC,both,75,ML,97.27,38.39,39.4668,,38.39,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,29.18,30,,29.18,percent of total billed charges,"Drugs, Inpatient Only",29.18,30,,29.18,percent of total billed charges,"Drugs, Inpatient Only",29.18,30,,29.18,percent of total billed charges,"Drugs, Inpatient Only",48.64,50,,48.64,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,25.74,,,25.74,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,68.09,70,,68.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.84,,,13.84,Other,Drug Cost,13.84,,,13.84,Other,Drug Cost,13.84,,,13.84,Other,Drug Cost,13.84,,,13.84,Other,Drug Cost,13.84,,,13.84,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,13.84,,,13.84,Other,Drug Cost,31.14,,,31.14,Other,225% Medicaid APG methodology,19.38,,,19.38,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,13.84,,,13.84,Other,Drug Cost,13.84,,,13.84,Other,Drug Cost,17.3,,,17.3,Other,125% Medicaid APG methodology,0.01,68.09,
ATOVQUONE-PROGNIL 250-100MGTAB  ,,,,40587867,CDM,250,RC,00173-0675-02,NDC,both,1,EA,22.3,8.8,39.4668,,8.8,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.69,30,,6.69,percent of total billed charges,"Drugs, Inpatient Only",6.69,30,,6.69,percent of total billed charges,"Drugs, Inpatient Only",6.69,30,,6.69,percent of total billed charges,"Drugs, Inpatient Only",11.15,50,,11.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.54,,,1.54,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.61,70,,15.61,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.83,,,0.83,Other,Drug Cost,0.83,,,0.83,Other,Drug Cost,0.83,,,0.83,Other,Drug Cost,0.83,,,0.83,Other,Drug Cost,0.83,,,0.83,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.83,,,0.83,Other,Drug Cost,1.87,,,1.87,Other,225% Medicaid APG methodology,1.16,,,1.16,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.83,,,0.83,Other,Drug Cost,0.83,,,0.83,Other,Drug Cost,1.04,,,1.04,Other,125% Medicaid APG methodology,0.01,15.61,
BACITRACIN 500UNITS/G OINT0.9G  ,,,,40587883,CDM,250,RC,45802-0060-70,NDC,both,1,EA,0.35,0.14,39.4668,,0.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.18,50,,0.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,70,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.25,
BIKTARVY 50-200-25 MG ORL TAB   ,,,,40587933,CDM,250,RC,61958-2501-01,NDC,both,1,EA,431.73,170.39,39.4668,,170.39,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,129.52,30,,129.52,percent of total billed charges,"Drugs, Inpatient Only",129.52,30,,129.52,percent of total billed charges,"Drugs, Inpatient Only",129.52,30,,129.52,percent of total billed charges,"Drugs, Inpatient Only",215.87,50,,215.87,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,135.28,,,135.28,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,302.21,70,,302.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,72.73,,,72.73,Other,Drug Cost,72.73,,,72.73,Other,Drug Cost,72.73,,,72.73,Other,Drug Cost,72.73,,,72.73,Other,Drug Cost,72.73,,,72.73,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,72.73,,,72.73,Other,Drug Cost,163.64,,,163.64,Other,225% Medicaid APG methodology,101.82,,,101.82,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,72.73,,,72.73,Other,Drug Cost,72.73,,,72.73,Other,Drug Cost,90.91,,,90.91,Other,125% Medicaid APG methodology,0.01,302.21,
BRIMONIDINE 0.2% OPHTH SLN 5ML  ,,,,40587966,CDM,250,RC,70069-0231-01,NDC,both,5,ML,50.23,19.82,39.4668,,19.82,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.07,30,,15.07,percent of total billed charges,"Drugs, Inpatient Only",15.07,30,,15.07,percent of total billed charges,"Drugs, Inpatient Only",15.07,30,,15.07,percent of total billed charges,"Drugs, Inpatient Only",25.12,50,,25.12,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.51,,,14.51,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,35.16,70,,35.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.8,,,7.8,Other,Drug Cost,7.8,,,7.8,Other,Drug Cost,7.8,,,7.8,Other,Drug Cost,7.8,,,7.8,Other,Drug Cost,7.8,,,7.8,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,7.8,,,7.8,Other,Drug Cost,17.55,,,17.55,Other,225% Medicaid APG methodology,10.92,,,10.92,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.8,,,7.8,Other,Drug Cost,7.8,,,7.8,Other,Drug Cost,9.75,,,9.75,Other,125% Medicaid APG methodology,0.01,35.16,
TICAGRELOR 60 MG TAB            ,,,,40588030,CDM,250,RC,00186-0776-60,NDC,both,1,EA,23.7,9.35,39.4668,,9.35,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.11,30,,7.11,percent of total billed charges,"Drugs, Inpatient Only",7.11,30,,7.11,percent of total billed charges,"Drugs, Inpatient Only",7.11,30,,7.11,percent of total billed charges,"Drugs, Inpatient Only",11.85,50,,11.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.97,,,4.97,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,16.59,70,,16.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.67,,,2.67,Other,Drug Cost,2.67,,,2.67,Other,Drug Cost,2.67,,,2.67,Other,Drug Cost,2.67,,,2.67,Other,Drug Cost,2.67,,,2.67,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.67,,,2.67,Other,Drug Cost,6.01,,,6.01,Other,225% Medicaid APG methodology,3.74,,,3.74,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.67,,,2.67,Other,Drug Cost,2.67,,,2.67,Other,Drug Cost,3.34,,,3.34,Other,125% Medicaid APG methodology,0.01,16.59,
CEFUROXIME 500 MG TAB           ,,,,40588063,CDM,250,RC,68180-0303-60,NDC,both,1,EA,10.68,4.22,39.4668,,4.22,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.2,30,,3.2,percent of total billed charges,"Drugs, Inpatient Only",3.2,30,,3.2,percent of total billed charges,"Drugs, Inpatient Only",3.2,30,,3.2,percent of total billed charges,"Drugs, Inpatient Only",5.34,50,,5.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.48,70,,7.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,Drug Cost,0.34,,,0.34,Other,225% Medicaid APG methodology,0.21,,,0.21,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.19,,,0.19,Other,125% Medicaid APG methodology,0.01,7.48,
CIPROFLOXACIN 0.3% OPT SLN 5ML  ,,,,40588147,CDM,250,RC,00065-0656-05,NDC,both,5,ML,398.13,157.13,39.4668,,157.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,119.44,30,,119.44,percent of total billed charges,"Drugs, Inpatient Only",119.44,30,,119.44,percent of total billed charges,"Drugs, Inpatient Only",119.44,30,,119.44,percent of total billed charges,"Drugs, Inpatient Only",199.07,50,,199.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,278.69,70,,278.69,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,278.69,
BICITRA 334-500MG/5ML 30ML      ,,,,40588170,CDM,250,RC,00121-1190-00,NDC,both,30,ML,6.3,2.49,39.4668,,2.49,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.89,30,,1.89,percent of total billed charges,"Drugs, Inpatient Only",1.89,30,,1.89,percent of total billed charges,"Drugs, Inpatient Only",1.89,30,,1.89,percent of total billed charges,"Drugs, Inpatient Only",3.15,50,,3.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.56,,,0.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.41,70,,4.41,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.68,,,0.68,Other,225% Medicaid APG methodology,0.42,,,0.42,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.38,,,0.38,Other,125% Medicaid APG methodology,0.01,4.41,
CLOZAPINE 25 MG ODT             ,,,,40588204,CDM,250,RC,00093-5417-84,NDC,both,1,EA,7.95,3.14,39.4668,,3.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.39,30,,2.39,percent of total billed charges,"Drugs, Inpatient Only",2.39,30,,2.39,percent of total billed charges,"Drugs, Inpatient Only",2.39,30,,2.39,percent of total billed charges,"Drugs, Inpatient Only",3.98,50,,3.98,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.8,,,1.8,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.57,70,,5.57,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.97,,,0.97,Other,Drug Cost,2.18,,,2.18,Other,225% Medicaid APG methodology,1.36,,,1.36,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,1.21,,,1.21,Other,125% Medicaid APG methodology,0.01,5.57,
COLCHICINE 0.6 MG CAP           ,,,,40588220,CDM,250,RC,00904-6732-04,NDC,both,1,EA,14.63,5.77,39.4668,,5.77,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.39,30,,4.39,percent of total billed charges,"Drugs, Inpatient Only",4.39,30,,4.39,percent of total billed charges,"Drugs, Inpatient Only",4.39,30,,4.39,percent of total billed charges,"Drugs, Inpatient Only",7.32,50,,7.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.8,,,5.8,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.24,70,,10.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.12,,,3.12,Other,Drug Cost,3.12,,,3.12,Other,Drug Cost,3.12,,,3.12,Other,Drug Cost,3.12,,,3.12,Other,Drug Cost,3.12,,,3.12,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.12,,,3.12,Other,Drug Cost,7.02,,,7.02,Other,225% Medicaid APG methodology,4.37,,,4.37,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.12,,,3.12,Other,Drug Cost,3.12,,,3.12,Other,Drug Cost,3.9,,,3.9,Other,125% Medicaid APG methodology,0.01,10.24,
CYCLOPENTOLATE 1% OPT SLN 15ML  ,,,,40588238,CDM,250,RC,17478-0100-12,NDC,both,15,ML,48.3,19.06,39.4668,,19.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.49,30,,14.49,percent of total billed charges,"Drugs, Inpatient Only",14.49,30,,14.49,percent of total billed charges,"Drugs, Inpatient Only",14.49,30,,14.49,percent of total billed charges,"Drugs, Inpatient Only",24.15,50,,24.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,18.41,,,18.41,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,33.81,70,,33.81,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.9,,,9.9,Other,Drug Cost,9.9,,,9.9,Other,Drug Cost,9.9,,,9.9,Other,Drug Cost,9.9,,,9.9,Other,Drug Cost,9.9,,,9.9,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,9.9,,,9.9,Other,Drug Cost,22.28,,,22.28,Other,225% Medicaid APG methodology,13.86,,,13.86,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,9.9,,,9.9,Other,Drug Cost,9.9,,,9.9,Other,Drug Cost,12.38,,,12.38,Other,125% Medicaid APG methodology,0.01,33.81,
D5W LR KCL 20 MEQ/L SLN 1000ML  ,,,,40588444,CDM,250,RC,00338-0811-04,NDC,both,1000,ML,19.04,7.51,39.4668,,7.51,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.71,30,,5.71,percent of total billed charges,"Drugs, Inpatient Only",5.71,30,,5.71,percent of total billed charges,"Drugs, Inpatient Only",5.71,30,,5.71,percent of total billed charges,"Drugs, Inpatient Only",9.52,50,,9.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,16.29,,,16.29,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.33,70,,13.33,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.76,,,8.76,Other,Drug Cost,8.76,,,8.76,Other,Drug Cost,8.76,,,8.76,Other,Drug Cost,8.76,,,8.76,Other,Drug Cost,8.76,,,8.76,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,8.76,,,8.76,Other,Drug Cost,19.71,,,19.71,Other,225% Medicaid APG methodology,12.26,,,12.26,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,8.76,,,8.76,Other,Drug Cost,8.76,,,8.76,Other,Drug Cost,10.95,,,10.95,Other,125% Medicaid APG methodology,0.01,19.71,
DILTIAZEM 5MG/ML IV SOLN 10ML   ,,,,40588493,CDM,250,RC,17478-0937-10,NDC,both,10,ML,9.8,3.87,39.4668,,3.87,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.94,30,,2.94,percent of total billed charges,"Drugs, Inpatient Only",2.94,30,,2.94,percent of total billed charges,"Drugs, Inpatient Only",2.94,30,,2.94,percent of total billed charges,"Drugs, Inpatient Only",4.9,50,,4.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.79,,,2.79,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.86,70,,6.86,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.5,,,1.5,Other,Drug Cost,3.38,,,3.38,Other,225% Medicaid APG methodology,2.1,,,2.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.88,,,1.88,Other,125% Medicaid APG methodology,0.01,6.86,
DIVALPROEX SODIUM 125MG DR TAB  ,,,,40588527,CDM,250,RC,62756-0796-88,NDC,both,1,EA,0.11,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.06,50,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.08,
VALPROIC ACID 250 MG CAP        ,,,,40588550,CDM,250,RC,69452-0150-20,NDC,both,1,EA,0.53,0.21,39.4668,,0.21,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.16,30,,0.16,percent of total billed charges,"Drugs, Inpatient Only",0.27,50,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,70,,0.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.23,,,0.23,Other,225% Medicaid APG methodology,0.14,,,0.14,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.13,,,0.13,Other,125% Medicaid APG methodology,0.01,0.37,
EMOLLIENTS TOPICAL CREAM 113 G  ,,,,40588576,CDM,250,RC,72140-0000-22,NDC,both,113,GM,19.78,7.81,39.4668,,7.81,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.93,30,,5.93,percent of total billed charges,"Drugs, Inpatient Only",5.93,30,,5.93,percent of total billed charges,"Drugs, Inpatient Only",5.93,30,,5.93,percent of total billed charges,"Drugs, Inpatient Only",9.89,50,,9.89,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.51,,,10.51,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.85,70,,13.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.65,,,5.65,Other,Drug Cost,5.65,,,5.65,Other,Drug Cost,5.65,,,5.65,Other,Drug Cost,5.65,,,5.65,Other,Drug Cost,5.65,,,5.65,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,5.65,,,5.65,Other,Drug Cost,12.71,,,12.71,Other,225% Medicaid APG methodology,7.91,,,7.91,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.65,,,5.65,Other,Drug Cost,5.65,,,5.65,Other,Drug Cost,7.06,,,7.06,Other,125% Medicaid APG methodology,0.01,13.85,
ENALAPRILAT 1.25MG/ML IV  2ML   ,,,,40588592,CDM,250,RC,00143-9786-10,NDC,both,2,ML,20.86,8.23,39.4668,,8.23,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.26,30,,6.26,percent of total billed charges,"Drugs, Inpatient Only",6.26,30,,6.26,percent of total billed charges,"Drugs, Inpatient Only",6.26,30,,6.26,percent of total billed charges,"Drugs, Inpatient Only",10.43,50,,10.43,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.03,,,6.03,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.6,70,,14.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.24,,,3.24,Other,Drug Cost,3.24,,,3.24,Other,Drug Cost,3.24,,,3.24,Other,Drug Cost,3.24,,,3.24,Other,Drug Cost,3.24,,,3.24,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.24,,,3.24,Other,Drug Cost,7.29,,,7.29,Other,225% Medicaid APG methodology,4.54,,,4.54,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.24,,,3.24,Other,Drug Cost,3.24,,,3.24,Other,Drug Cost,4.05,,,4.05,Other,125% Medicaid APG methodology,0.01,14.6,
EPINEPH-LIDO 1:100000-2% 50ML   ,,,,40588600,CDM,250,RC,63323-0483-57,NDC,both,50,ML,17.5,6.91,39.4668,,6.91,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.25,30,,5.25,percent of total billed charges,"Drugs, Inpatient Only",5.25,30,,5.25,percent of total billed charges,"Drugs, Inpatient Only",5.25,30,,5.25,percent of total billed charges,"Drugs, Inpatient Only",8.75,50,,8.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.65,,,4.65,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.25,70,,12.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.5,,,2.5,Other,Drug Cost,5.63,,,5.63,Other,225% Medicaid APG methodology,3.5,,,3.5,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,3.13,,,3.13,Other,125% Medicaid APG methodology,0.01,12.25,
FAT EMULFISH MCHAIN 20% 100ML   ,,,,40588683,CDM,250,RC,63323-0820-00,NDC,both,100,ML,59.5,23.48,39.4668,,23.48,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,17.85,30,,17.85,percent of total billed charges,"Drugs, Inpatient Only",17.85,30,,17.85,percent of total billed charges,"Drugs, Inpatient Only",17.85,30,,17.85,percent of total billed charges,"Drugs, Inpatient Only",29.75,50,,29.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.72,,,3.72,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,41.65,70,,41.65,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2,,,2,Other,Drug Cost,4.5,,,4.5,Other,225% Medicaid APG methodology,2.8,,,2.8,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,2.5,,,2.5,Other,125% Medicaid APG methodology,0.01,41.65,
HAEMOPHB CONJ(PRP-OMP)VAC0.5ML  ,,,,40588766,CDM,250,RC,00006-4897-00,NDC,both,0.5,ML,82.74,32.65,39.4668,,32.65,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,24.82,30,,24.82,percent of total billed charges,"Drugs, Inpatient Only",24.82,30,,24.82,percent of total billed charges,"Drugs, Inpatient Only",24.82,30,,24.82,percent of total billed charges,"Drugs, Inpatient Only",41.37,50,,41.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,46.07,,,46.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,57.92,70,,57.92,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,24.77,,,24.77,Other,Drug Cost,24.77,,,24.77,Other,Drug Cost,24.77,,,24.77,Other,Drug Cost,24.77,,,24.77,Other,Drug Cost,24.77,,,24.77,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,24.77,,,24.77,Other,Drug Cost,55.73,,,55.73,Other,225% Medicaid APG methodology,34.68,,,34.68,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,24.77,,,24.77,Other,Drug Cost,24.77,,,24.77,Other,Drug Cost,30.96,,,30.96,Other,125% Medicaid APG methodology,0.01,57.92,
TET-DIP TOX(TD) 5UN-0.5ML SUSP  ,,,,40588915,CDM,250,RC,49281-0215-15,NDC,both,0.5,ML,98.46,38.86,39.4668,,38.86,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,29.54,30,,29.54,percent of total billed charges,"Drugs, Inpatient Only",29.54,30,,29.54,percent of total billed charges,"Drugs, Inpatient Only",29.54,30,,29.54,percent of total billed charges,"Drugs, Inpatient Only",49.23,50,,49.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,51.52,,,51.52,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,68.92,70,,68.92,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,27.7,,,27.7,Other,Drug Cost,27.7,,,27.7,Other,Drug Cost,27.7,,,27.7,Other,Drug Cost,27.7,,,27.7,Other,Drug Cost,27.7,,,27.7,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,27.7,,,27.7,Other,Drug Cost,62.33,,,62.33,Other,225% Medicaid APG methodology,38.78,,,38.78,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,27.7,,,27.7,Other,Drug Cost,27.7,,,27.7,Other,Drug Cost,34.63,,,34.63,Other,125% Medicaid APG methodology,0.01,68.92,
IODINE-POT IODI 5%-10% SL 15ML  ,,,,40589053,CDM,250,RC,48433-0230-15,NDC,both,15,ML,101.85,40.2,39.4668,,40.2,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,30.56,30,,30.56,percent of total billed charges,"Drugs, Inpatient Only",30.56,30,,30.56,percent of total billed charges,"Drugs, Inpatient Only",30.56,30,,30.56,percent of total billed charges,"Drugs, Inpatient Only",50.93,50,,50.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,54.13,,,54.13,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,71.3,70,,71.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,29.1,,,29.1,Other,Drug Cost,29.1,,,29.1,Other,Drug Cost,29.1,,,29.1,Other,Drug Cost,29.1,,,29.1,Other,Drug Cost,29.1,,,29.1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,29.1,,,29.1,Other,Drug Cost,65.48,,,65.48,Other,225% Medicaid APG methodology,40.74,,,40.74,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,29.1,,,29.1,Other,Drug Cost,29.1,,,29.1,Other,Drug Cost,36.38,,,36.38,Other,125% Medicaid APG methodology,0.01,71.3,
LEVOFLOXACIN 750 MG TAB         ,,,,40589202,CDM,250,RC,00904-6353-61,NDC,both,1,EA,1.12,0.44,39.4668,,0.44,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.34,30,,0.34,percent of total billed charges,"Drugs, Inpatient Only",0.34,30,,0.34,percent of total billed charges,"Drugs, Inpatient Only",0.34,30,,0.34,percent of total billed charges,"Drugs, Inpatient Only",0.56,50,,0.56,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.41,,,0.41,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.78,70,,0.78,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.5,,,0.5,Other,225% Medicaid APG methodology,0.31,,,0.31,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.28,,,0.28,Other,125% Medicaid APG methodology,0.01,0.78,
LIDOCAINE 2% MUCOUS MEMB 100ML  ,,,,40589244,CDM,250,RC,62135-0712-42,NDC,both,100,ML,318.5,125.7,39.4668,,125.7,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,95.55,30,,95.55,percent of total billed charges,"Drugs, Inpatient Only",95.55,30,,95.55,percent of total billed charges,"Drugs, Inpatient Only",95.55,30,,95.55,percent of total billed charges,"Drugs, Inpatient Only",159.25,50,,159.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,165.17,,,165.17,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,222.95,70,,222.95,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,88.8,,,88.8,Other,Drug Cost,88.8,,,88.8,Other,Drug Cost,88.8,,,88.8,Other,Drug Cost,88.8,,,88.8,Other,Drug Cost,88.8,,,88.8,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,88.8,,,88.8,Other,Drug Cost,199.8,,,199.8,Other,225% Medicaid APG methodology,124.32,,,124.32,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,88.8,,,88.8,Other,Drug Cost,88.8,,,88.8,Other,Drug Cost,111,,,111,Other,125% Medicaid APG methodology,0.01,222.95,
LIDOCAINE 2% TOPICAL GEL 10 ML  ,,,,40589269,CDM,250,RC,76329-3013-05,NDC,both,10,ML,19.6,7.74,39.4668,,7.74,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.88,30,,5.88,percent of total billed charges,"Drugs, Inpatient Only",5.88,30,,5.88,percent of total billed charges,"Drugs, Inpatient Only",5.88,30,,5.88,percent of total billed charges,"Drugs, Inpatient Only",9.8,50,,9.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.63,,,7.63,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.72,70,,13.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.1,,,4.1,Other,Drug Cost,4.1,,,4.1,Other,Drug Cost,4.1,,,4.1,Other,Drug Cost,4.1,,,4.1,Other,Drug Cost,4.1,,,4.1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.1,,,4.1,Other,Drug Cost,9.23,,,9.23,Other,225% Medicaid APG methodology,5.74,,,5.74,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.1,,,4.1,Other,Drug Cost,4.1,,,4.1,Other,Drug Cost,5.13,,,5.13,Other,125% Medicaid APG methodology,0.01,13.72,
LIDOCAINE 2% TOPICAL GEL 6ML    ,,,,40589285,CDM,250,RC,25021-0673-76,NDC,both,6,ML,11.97,4.72,39.4668,,4.72,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.59,30,,3.59,percent of total billed charges,"Drugs, Inpatient Only",3.59,30,,3.59,percent of total billed charges,"Drugs, Inpatient Only",3.59,30,,3.59,percent of total billed charges,"Drugs, Inpatient Only",5.99,50,,5.99,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.02,,,5.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.38,70,,8.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.7,,,2.7,Other,Drug Cost,6.08,,,6.08,Other,225% Medicaid APG methodology,3.78,,,3.78,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.7,,,2.7,Other,Drug Cost,2.7,,,2.7,Other,Drug Cost,3.38,,,3.38,Other,125% Medicaid APG methodology,0.01,8.38,
NF-LORATADINE 10 MG TAB         ,,,,40589343,CDM,250,RC,00904-6852-07,NDC,both,1,EA,0.21,0.08,39.4668,,0.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.06,30,,0.06,percent of total billed charges,"Drugs, Inpatient Only",0.11,50,,0.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,,,0.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,70,,0.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.15,
LOSARTAN 100 MG TAB             ,,,,40589350,CDM,250,RC,68084-0348-01,NDC,both,1,EA,1.51,0.6,39.4668,,0.6,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.45,30,,0.45,percent of total billed charges,"Drugs, Inpatient Only",0.45,30,,0.45,percent of total billed charges,"Drugs, Inpatient Only",0.45,30,,0.45,percent of total billed charges,"Drugs, Inpatient Only",0.76,50,,0.76,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.71,,,0.71,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.06,70,,1.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.38,,,0.38,Other,Drug Cost,0.86,,,0.86,Other,225% Medicaid APG methodology,0.53,,,0.53,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.48,,,0.48,Other,125% Medicaid APG methodology,0.01,1.06,
MANNITOL 20% IV SOLN  500 ML    ,,,,40589400,CDM,250,RC,00338-0357-03,NDC,both,500,ML,114.94,45.36,39.4668,,45.36,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,34.48,30,,34.48,percent of total billed charges,"Drugs, Inpatient Only",34.48,30,,34.48,percent of total billed charges,"Drugs, Inpatient Only",34.48,30,,34.48,percent of total billed charges,"Drugs, Inpatient Only",57.47,50,,57.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,25.04,,,25.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,80.46,70,,80.46,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.46,,,13.46,Other,Drug Cost,13.46,,,13.46,Other,Drug Cost,13.46,,,13.46,Other,Drug Cost,13.46,,,13.46,Other,Drug Cost,13.46,,,13.46,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,13.46,,,13.46,Other,Drug Cost,30.29,,,30.29,Other,225% Medicaid APG methodology,18.84,,,18.84,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,13.46,,,13.46,Other,Drug Cost,13.46,,,13.46,Other,Drug Cost,16.83,,,16.83,Other,125% Medicaid APG methodology,0.01,80.46,
MESALAMINE 400 MG DR CAP        ,,,,40589509,CDM,250,RC,00023-5853-18,NDC,both,1,EA,12.85,5.07,39.4668,,5.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.86,30,,3.86,percent of total billed charges,"Drugs, Inpatient Only",3.86,30,,3.86,percent of total billed charges,"Drugs, Inpatient Only",3.86,30,,3.86,percent of total billed charges,"Drugs, Inpatient Only",6.43,50,,6.43,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9,70,,9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,9,
METHENAMINE HIPURATE 1000MGTAB  ,,,,40589525,CDM,250,RC,60687-0694-21,NDC,both,1,EA,6.72,2.65,39.4668,,2.65,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.02,30,,2.02,percent of total billed charges,"Drugs, Inpatient Only",2.02,30,,2.02,percent of total billed charges,"Drugs, Inpatient Only",2.02,30,,2.02,percent of total billed charges,"Drugs, Inpatient Only",3.36,50,,3.36,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.61,,,3.61,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.7,70,,4.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.94,,,1.94,Other,Drug Cost,4.37,,,4.37,Other,225% Medicaid APG methodology,2.72,,,2.72,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,2.43,,,2.43,Other,125% Medicaid APG methodology,0.01,4.7,
METHYLPREDNISOLONE ACE 80MG/ML  ,,,,40589566,CDM,250,RC,00009-3475-03,NDC,both,1,ML,46.1,18.19,39.4668,,18.19,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.83,30,,13.83,percent of total billed charges,"Drugs, Inpatient Only",13.83,30,,13.83,percent of total billed charges,"Drugs, Inpatient Only",13.83,30,,13.83,percent of total billed charges,"Drugs, Inpatient Only",23.05,50,,23.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.69,,,9.69,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,32.27,70,,32.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.21,,,5.21,Other,Drug Cost,5.21,,,5.21,Other,Drug Cost,5.21,,,5.21,Other,Drug Cost,5.21,,,5.21,Other,Drug Cost,5.21,,,5.21,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,5.21,,,5.21,Other,Drug Cost,11.72,,,11.72,Other,225% Medicaid APG methodology,7.29,,,7.29,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.21,,,5.21,Other,Drug Cost,5.21,,,5.21,Other,Drug Cost,6.51,,,6.51,Other,125% Medicaid APG methodology,0.01,32.27,
DICLOXACILLIN 500 MG CAP        ,,,,40589715,CDM,250,RC,00093-3125-01,NDC,both,1,EA,2.84,1.12,39.4668,,1.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.85,30,,0.85,percent of total billed charges,"Drugs, Inpatient Only",0.85,30,,0.85,percent of total billed charges,"Drugs, Inpatient Only",0.85,30,,0.85,percent of total billed charges,"Drugs, Inpatient Only",1.42,50,,1.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.48,,,0.48,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.99,70,,1.99,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,Drug Cost,0.59,,,0.59,Other,225% Medicaid APG methodology,0.36,,,0.36,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.33,,,0.33,Other,125% Medicaid APG methodology,0.01,1.99,
HYOSCYAMINE 0.125MG DIS TAB     ,,,,40589756,CDM,250,RC,43199-0012-01,NDC,both,1,EA,0.35,0.14,39.4668,,0.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.18,50,,0.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,70,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.25,
HYOSCYAMINE 0.125MG SL TAB      ,,,,40589764,CDM,250,RC,43199-0011-01,NDC,both,1,EA,0.35,0.14,39.4668,,0.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.18,50,,0.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.09,,,0.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,70,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.11,,,0.11,Other,225% Medicaid APG methodology,0.07,,,0.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.05,,,0.05,Other,Drug Cost,0.05,,,0.05,Other,Drug Cost,0.06,,,0.06,Other,125% Medicaid APG methodology,0.01,0.25,
NICARDIPINE 20 MG/D4.8W 200 ML  ,,,,40589780,CDM,250,RC,10122-0314-10,NDC,both,200,ML,355.78,140.41,39.4668,,140.41,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,106.73,30,,106.73,percent of total billed charges,"Drugs, Inpatient Only",106.73,30,,106.73,percent of total billed charges,"Drugs, Inpatient Only",106.73,30,,106.73,percent of total billed charges,"Drugs, Inpatient Only",177.89,50,,177.89,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,189.07,,,189.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,249.05,70,,249.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,101.65,,,101.65,Other,Drug Cost,101.65,,,101.65,Other,Drug Cost,101.65,,,101.65,Other,Drug Cost,101.65,,,101.65,Other,Drug Cost,101.65,,,101.65,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,101.65,,,101.65,Other,Drug Cost,228.71,,,228.71,Other,225% Medicaid APG methodology,142.31,,,142.31,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,101.65,,,101.65,Other,Drug Cost,101.65,,,101.65,Other,Drug Cost,127.06,,,127.06,Other,125% Medicaid APG methodology,0.01,249.05,
OCULAR LUBRICANT OPT GEL PACK   ,,,,40589848,CDM,250,RC,00023-0403-30,NDC,both,1,EA,1.02,0.4,39.4668,,0.4,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.31,30,,0.31,percent of total billed charges,"Drugs, Inpatient Only",0.31,30,,0.31,percent of total billed charges,"Drugs, Inpatient Only",0.31,30,,0.31,percent of total billed charges,"Drugs, Inpatient Only",0.51,50,,0.51,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.37,,,0.37,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.71,70,,0.71,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.45,,,0.45,Other,225% Medicaid APG methodology,0.28,,,0.28,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.2,,,0.2,Other,Drug Cost,0.2,,,0.2,Other,Drug Cost,0.25,,,0.25,Other,125% Medicaid APG methodology,0.01,0.71,
ROPINIROLE 0.5 MG TAB           ,,,,40589871,CDM,250,RC,43547-0269-10,NDC,both,1,EA,0.18,0.07,39.4668,,0.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.05,30,,0.05,percent of total billed charges,"Drugs, Inpatient Only",0.09,50,,0.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,70,,0.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.13,
RABIES IMGLOB 300 INTUN/ML 5ML  ,,,,40590002,CDM,250,RC,13533-0318-05,NDC,both,5,ML,8048.78,3176.6,39.4668,,3176.6,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2414.63,30,,2414.63,percent of total billed charges,"Drugs, Inpatient Only",2414.63,30,,2414.63,percent of total billed charges,"Drugs, Inpatient Only",2414.63,30,,2414.63,percent of total billed charges,"Drugs, Inpatient Only",4024.39,50,,4024.39,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4087.07,,,4087.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5634.15,70,,5634.15,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2197.35,,,2197.35,Other,Drug Cost,2197.35,,,2197.35,Other,Drug Cost,2197.35,,,2197.35,Other,Drug Cost,2197.35,,,2197.35,Other,Drug Cost,2197.35,,,2197.35,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2197.35,,,2197.35,Other,Drug Cost,4944.04,,,4944.04,Other,225% Medicaid APG methodology,3076.29,,,3076.29,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2197.35,,,2197.35,Other,Drug Cost,2197.35,,,2197.35,Other,Drug Cost,2746.69,,,2746.69,Other,125% Medicaid APG methodology,0.01,5634.15,
ROFLUMILAST 500 MCG TAB         ,,,,40590044,CDM,250,RC,00310-0095-30,NDC,both,1,EA,46.62,18.4,39.4668,,18.4,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.99,30,,13.99,percent of total billed charges,"Drugs, Inpatient Only",13.99,30,,13.99,percent of total billed charges,"Drugs, Inpatient Only",13.99,30,,13.99,percent of total billed charges,"Drugs, Inpatient Only",23.31,50,,23.31,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.32,,,6.32,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,32.63,70,,32.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.4,,,3.4,Other,Drug Cost,3.4,,,3.4,Other,Drug Cost,3.4,,,3.4,Other,Drug Cost,3.4,,,3.4,Other,Drug Cost,3.4,,,3.4,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.4,,,3.4,Other,Drug Cost,7.65,,,7.65,Other,225% Medicaid APG methodology,4.76,,,4.76,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.4,,,3.4,Other,Drug Cost,3.4,,,3.4,Other,Drug Cost,4.25,,,4.25,Other,125% Medicaid APG methodology,0.01,32.63,
SOD CHL 0.45% IV SLN 500ML      ,,,,40590200,CDM,250,RC,00338-0043-03,NDC,both,500,ML,7.91,3.12,39.4668,,3.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.37,30,,2.37,percent of total billed charges,"Drugs, Inpatient Only",2.37,30,,2.37,percent of total billed charges,"Drugs, Inpatient Only",2.37,30,,2.37,percent of total billed charges,"Drugs, Inpatient Only",3.96,50,,3.96,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.42,,,3.42,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.54,70,,5.54,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.84,,,1.84,Other,Drug Cost,1.84,,,1.84,Other,Drug Cost,1.84,,,1.84,Other,Drug Cost,1.84,,,1.84,Other,Drug Cost,1.84,,,1.84,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.84,,,1.84,Other,Drug Cost,4.14,,,4.14,Other,225% Medicaid APG methodology,2.58,,,2.58,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.84,,,1.84,Other,Drug Cost,1.84,,,1.84,Other,Drug Cost,2.3,,,2.3,Other,125% Medicaid APG methodology,0.01,5.54,
SOD CHL 0.9% IRRIGATION 500ML   ,,,,40590218,CDM,250,RC,00338-0048-03,NDC,both,500,ML,17.5,6.91,39.4668,,6.91,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.25,30,,5.25,percent of total billed charges,"Drugs, Inpatient Only",5.25,30,,5.25,percent of total billed charges,"Drugs, Inpatient Only",5.25,30,,5.25,percent of total billed charges,"Drugs, Inpatient Only",8.75,50,,8.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.3,,,9.3,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.25,70,,12.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5,,,5,Other,Drug Cost,5,,,5,Other,Drug Cost,5,,,5,Other,Drug Cost,5,,,5,Other,Drug Cost,5,,,5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,5,,,5,Other,Drug Cost,11.25,,,11.25,Other,225% Medicaid APG methodology,7,,,7,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5,,,5,Other,Drug Cost,5,,,5,Other,Drug Cost,6.25,,,6.25,Other,125% Medicaid APG methodology,0.01,12.25,
SOD CHL 0.9%KCL 40MEQ IV1000ML  ,,,,40590226,CDM,250,RC,00338-0695-04,NDC,both,1000,ML,18.73,7.39,39.4668,,7.39,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.62,30,,5.62,percent of total billed charges,"Drugs, Inpatient Only",5.62,30,,5.62,percent of total billed charges,"Drugs, Inpatient Only",5.62,30,,5.62,percent of total billed charges,"Drugs, Inpatient Only",9.37,50,,9.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.96,,,15.96,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.11,70,,13.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.58,,,8.58,Other,Drug Cost,8.58,,,8.58,Other,Drug Cost,8.58,,,8.58,Other,Drug Cost,8.58,,,8.58,Other,Drug Cost,8.58,,,8.58,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,8.58,,,8.58,Other,Drug Cost,19.31,,,19.31,Other,225% Medicaid APG methodology,12.01,,,12.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,8.58,,,8.58,Other,Drug Cost,8.58,,,8.58,Other,Drug Cost,10.73,,,10.73,Other,125% Medicaid APG methodology,0.01,19.31,
SOD HYALUR 10MG/ML INTOC 0.4ML  ,,,,40590267,CDM,250,RC,08065-1830-04,NDC,both,0.4,ML,135.7,53.56,39.4668,,53.56,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,40.71,30,,40.71,percent of total billed charges,"Drugs, Inpatient Only",40.71,30,,40.71,percent of total billed charges,"Drugs, Inpatient Only",40.71,30,,40.71,percent of total billed charges,"Drugs, Inpatient Only",67.85,50,,67.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,202.37,,,202.37,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,94.99,70,,94.99,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,108.8,,,108.8,Other,Drug Cost,108.8,,,108.8,Other,Drug Cost,108.8,,,108.8,Other,Drug Cost,108.8,,,108.8,Other,Drug Cost,108.8,,,108.8,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,108.8,,,108.8,Other,Drug Cost,244.8,,,244.8,Other,225% Medicaid APG methodology,152.32,,,152.32,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,108.8,,,108.8,Other,Drug Cost,108.8,,,108.8,Other,Drug Cost,136,,,136,Other,125% Medicaid APG methodology,0.01,244.8,
SMX-TMP 200MG-40MG/5ML ORL20ML  ,,,,40590309,CDM,250,RC,70954-0258-10,NDC,both,20,ML,4.8,1.89,39.4668,,1.89,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.44,30,,1.44,percent of total billed charges,"Drugs, Inpatient Only",1.44,30,,1.44,percent of total billed charges,"Drugs, Inpatient Only",1.44,30,,1.44,percent of total billed charges,"Drugs, Inpatient Only",2.4,50,,2.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.15,,,1.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.36,70,,3.36,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.62,,,0.62,Other,Drug Cost,1.4,,,1.4,Other,225% Medicaid APG methodology,0.87,,,0.87,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.78,,,0.78,Other,125% Medicaid APG methodology,0.01,3.36,
SMX-TMP 80MG-16MG/ML IV  10ML   ,,,,40590317,CDM,250,RC,00703-9514-03,NDC,both,10,ML,25.48,10.06,39.4668,,10.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.64,30,,7.64,percent of total billed charges,"Drugs, Inpatient Only",7.64,30,,7.64,percent of total billed charges,"Drugs, Inpatient Only",7.64,30,,7.64,percent of total billed charges,"Drugs, Inpatient Only",12.74,50,,12.74,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.06,,,13.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,17.84,70,,17.84,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.02,,,7.02,Other,Drug Cost,7.02,,,7.02,Other,Drug Cost,7.02,,,7.02,Other,Drug Cost,7.02,,,7.02,Other,Drug Cost,7.02,,,7.02,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,7.02,,,7.02,Other,Drug Cost,15.8,,,15.8,Other,225% Medicaid APG methodology,9.83,,,9.83,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,7.02,,,7.02,Other,Drug Cost,7.02,,,7.02,Other,Drug Cost,8.78,,,8.78,Other,125% Medicaid APG methodology,0.01,17.84,
THROMB BOV 5000 INTL NASAL POW  ,,,,40590366,CDM,250,RC,60793-0205-05,NDC,both,1,EA,198.45,78.32,39.4668,,78.32,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,59.54,30,,59.54,percent of total billed charges,"Drugs, Inpatient Only",59.54,30,,59.54,percent of total billed charges,"Drugs, Inpatient Only",59.54,30,,59.54,percent of total billed charges,"Drugs, Inpatient Only",99.23,50,,99.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,138.92,70,,138.92,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,138.92,
VANCOMYCIN 500MG/10ML ORAL SYR  ,,,,40590457,CDM,250,RC,65628-0206-05B,NDC,both,10,ML,27.65,10.91,39.4668,,10.91,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.3,30,,8.3,percent of total billed charges,"Drugs, Inpatient Only",8.3,30,,8.3,percent of total billed charges,"Drugs, Inpatient Only",8.3,30,,8.3,percent of total billed charges,"Drugs, Inpatient Only",13.83,50,,13.83,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.97,,,10.97,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.36,70,,19.36,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.9,,,5.9,Other,Drug Cost,5.9,,,5.9,Other,Drug Cost,5.9,,,5.9,Other,Drug Cost,5.9,,,5.9,Other,Drug Cost,5.9,,,5.9,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,5.9,,,5.9,Other,Drug Cost,13.28,,,13.28,Other,225% Medicaid APG methodology,8.26,,,8.26,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.9,,,5.9,Other,Drug Cost,5.9,,,5.9,Other,Drug Cost,7.38,,,7.38,Other,125% Medicaid APG methodology,0.01,19.36,
ETOMIDATE 2MG/ML IV SOLN 20ML   ,,,,40590507,CDM,250,RC,00143-9507-10,NDC,both,20,ML,12.6,4.97,39.4668,,4.97,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.78,30,,3.78,percent of total billed charges,"Drugs, Inpatient Only",3.78,30,,3.78,percent of total billed charges,"Drugs, Inpatient Only",3.78,30,,3.78,percent of total billed charges,"Drugs, Inpatient Only",6.3,50,,6.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.95,,,5.95,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.82,70,,8.82,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.2,,,3.2,Other,Drug Cost,7.2,,,7.2,Other,225% Medicaid APG methodology,4.48,,,4.48,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.2,,,3.2,Other,Drug Cost,3.2,,,3.2,Other,Drug Cost,4,,,4,Other,125% Medicaid APG methodology,0.01,8.82,
NICU CLINDAMYCIN 12 MG/ML D5W   ,,,,40590564,CDM,250,RC,00009-0870-26o,NDC,both,1,ML,2.91,1.15,39.4668,,1.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.87,30,,0.87,percent of total billed charges,"Drugs, Inpatient Only",0.87,30,,0.87,percent of total billed charges,"Drugs, Inpatient Only",0.87,30,,0.87,percent of total billed charges,"Drugs, Inpatient Only",1.46,50,,1.46,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.04,70,,2.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,2.04,
STERILE WATER INJ SOLN 1000 ML  ,,,,40590648,CDM,250,RC,00338-0013-04,NDC,both,1000,ML,14.74,5.82,39.4668,,5.82,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.42,30,,4.42,percent of total billed charges,"Drugs, Inpatient Only",4.42,30,,4.42,percent of total billed charges,"Drugs, Inpatient Only",4.42,30,,4.42,percent of total billed charges,"Drugs, Inpatient Only",7.37,50,,7.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.83,,,12.83,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.32,70,,10.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.9,,,6.9,Other,Drug Cost,6.9,,,6.9,Other,Drug Cost,6.9,,,6.9,Other,Drug Cost,6.9,,,6.9,Other,Drug Cost,6.9,,,6.9,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,6.9,,,6.9,Other,Drug Cost,15.53,,,15.53,Other,225% Medicaid APG methodology,9.66,,,9.66,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.9,,,6.9,Other,Drug Cost,6.9,,,6.9,Other,Drug Cost,8.63,,,8.63,Other,125% Medicaid APG methodology,0.01,15.53,
ALBUTEROL 0.4MG/ML ORL  SYR     ,,,,40590697,CDM,250,RC,00472-0825-16b,NDC,both,1,ML,0.14,0.06,39.4668,,0.06,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.04,30,,0.04,percent of total billed charges,"Drugs, Inpatient Only",0.07,50,,0.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.1,70,,0.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.1,
AMOXI 50MG/ML ORAL SUSP SYR     ,,,,40590713,CDM,250,RC,00143-9889-01a,NDC,both,1,ML,0.11,0.04,39.4668,,0.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.03,30,,0.03,percent of total billed charges,"Drugs, Inpatient Only",0.06,50,,0.06,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,70,,0.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.08,
AMOX-CLAV 400MG-57MG/5ML ORL    ,,,,40590739,CDM,250,RC,65862-0534-50b,NDC,both,1,ML,0.39,0.15,39.4668,,0.15,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.12,30,,0.12,percent of total billed charges,"Drugs, Inpatient Only",0.2,50,,0.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.27,70,,0.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.27,
THEOPHYLLINE 5.33MG/ML ORL SYR  ,,,,40591125,CDM,250,RC,27808-0033-01a,NDC,both,1,ML,6.51,2.57,39.4668,,2.57,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.95,30,,1.95,percent of total billed charges,"Drugs, Inpatient Only",1.95,30,,1.95,percent of total billed charges,"Drugs, Inpatient Only",1.95,30,,1.95,percent of total billed charges,"Drugs, Inpatient Only",3.26,50,,3.26,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.6,,,1.6,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.56,70,,4.56,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.86,,,0.86,Other,Drug Cost,0.86,,,0.86,Other,Drug Cost,0.86,,,0.86,Other,Drug Cost,0.86,,,0.86,Other,Drug Cost,0.86,,,0.86,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.86,,,0.86,Other,Drug Cost,1.94,,,1.94,Other,225% Medicaid APG methodology,1.2,,,1.2,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.86,,,0.86,Other,Drug Cost,0.86,,,0.86,Other,Drug Cost,1.08,,,1.08,Other,125% Medicaid APG methodology,0.01,4.56,
ZIDOVUDINE 10MG/ML ORL  SYR     ,,,,40591141,CDM,250,RC,65862-0048-24a,NDC,both,1,ML,0.35,0.14,39.4668,,0.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.11,30,,0.11,percent of total billed charges,"Drugs, Inpatient Only",0.18,50,,0.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,70,,0.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% Medicaid APG methodology,0.1,,,0.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,0.25,
CARBID-LEVO 25MG-100MG ER TAB   ,,,,40591422,CDM,250,RC,68084-0281-01,NDC,both,1,EA,2.38,0.94,39.4668,,0.94,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.71,30,,0.71,percent of total billed charges,"Drugs, Inpatient Only",0.71,30,,0.71,percent of total billed charges,"Drugs, Inpatient Only",0.71,30,,0.71,percent of total billed charges,"Drugs, Inpatient Only",1.19,50,,1.19,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.32,,,0.32,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.67,70,,1.67,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,Drug Cost,0.38,,,0.38,Other,225% Medicaid APG methodology,0.24,,,0.24,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.17,,,0.17,Other,Drug Cost,0.17,,,0.17,Other,Drug Cost,0.21,,,0.21,Other,125% Medicaid APG methodology,0.01,1.67,
PHENYLEPHRINE 10% OPT SLN 5ML   ,,,,40591463,CDM,250,RC,17478-0206-05,NDC,both,5,ML,121.28,47.87,39.4668,,47.87,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,36.38,30,,36.38,percent of total billed charges,"Drugs, Inpatient Only",36.38,30,,36.38,percent of total billed charges,"Drugs, Inpatient Only",36.38,30,,36.38,percent of total billed charges,"Drugs, Inpatient Only",60.64,50,,60.64,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,42.04,,,42.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,84.9,70,,84.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,22.6,,,22.6,Other,Drug Cost,22.6,,,22.6,Other,Drug Cost,22.6,,,22.6,Other,Drug Cost,22.6,,,22.6,Other,Drug Cost,22.6,,,22.6,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,22.6,,,22.6,Other,Drug Cost,50.85,,,50.85,Other,225% Medicaid APG methodology,31.64,,,31.64,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,22.6,,,22.6,Other,Drug Cost,22.6,,,22.6,Other,Drug Cost,28.25,,,28.25,Other,125% Medicaid APG methodology,0.01,84.9,
OXYCODONE 15 MG TAB             ,,,,40592123,CDM,250,RC,68094-0005-61,NDC,both,1,EA,1.93,0.76,39.4668,,0.76,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.58,30,,0.58,percent of total billed charges,"Drugs, Inpatient Only",0.58,30,,0.58,percent of total billed charges,"Drugs, Inpatient Only",0.58,30,,0.58,percent of total billed charges,"Drugs, Inpatient Only",0.97,50,,0.97,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.76,,,0.76,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.35,70,,1.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.41,,,0.41,Other,Drug Cost,0.92,,,0.92,Other,225% Medicaid APG methodology,0.57,,,0.57,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.51,,,0.51,Other,125% Medicaid APG methodology,0.01,1.35,
ALBUTEROL MDI 90 MCG/INH 8G     ,,,,40592214,CDM,250,RC,00173-0682-24,NDC,both,8,GM,69.44,27.41,39.4668,,27.41,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,20.83,30,,20.83,percent of total billed charges,"Drugs, Inpatient Only",20.83,30,,20.83,percent of total billed charges,"Drugs, Inpatient Only",20.83,30,,20.83,percent of total billed charges,"Drugs, Inpatient Only",34.72,50,,34.72,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,16.07,,,16.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,48.61,70,,48.61,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.64,,,8.64,Other,Drug Cost,8.64,,,8.64,Other,Drug Cost,8.64,,,8.64,Other,Drug Cost,8.64,,,8.64,Other,Drug Cost,8.64,,,8.64,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,8.64,,,8.64,Other,Drug Cost,19.44,,,19.44,Other,225% Medicaid APG methodology,12.1,,,12.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,8.64,,,8.64,Other,Drug Cost,8.64,,,8.64,Other,Drug Cost,10.8,,,10.8,Other,125% Medicaid APG methodology,0.01,48.61,
RISPERIDONE 1MG/ML ORL  30ML    ,,,,40592404,CDM,250,RC,65162-0673-84,NDC,both,30,ML,28.35,11.19,39.4668,,11.19,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.51,30,,8.51,percent of total billed charges,"Drugs, Inpatient Only",8.51,30,,8.51,percent of total billed charges,"Drugs, Inpatient Only",8.51,30,,8.51,percent of total billed charges,"Drugs, Inpatient Only",14.18,50,,14.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.25,,,7.25,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.85,70,,19.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.9,,,3.9,Other,Drug Cost,3.9,,,3.9,Other,Drug Cost,3.9,,,3.9,Other,Drug Cost,3.9,,,3.9,Other,Drug Cost,3.9,,,3.9,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.9,,,3.9,Other,Drug Cost,8.78,,,8.78,Other,225% Medicaid APG methodology,5.46,,,5.46,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.9,,,3.9,Other,Drug Cost,3.9,,,3.9,Other,Drug Cost,4.88,,,4.88,Other,125% Medicaid APG methodology,0.01,19.85,
EPINEPH 1:1000 TOPICAL 30ML     ,,,,40592412,CDM,250,RC,42023-0103-01,NDC,both,30,ML,688.8,271.85,39.4668,,271.85,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,206.64,30,,206.64,percent of total billed charges,"Drugs, Inpatient Only",206.64,30,,206.64,percent of total billed charges,"Drugs, Inpatient Only",206.64,30,,206.64,percent of total billed charges,"Drugs, Inpatient Only",344.4,50,,344.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,439.15,,,439.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,482.16,70,,482.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,236.1,,,236.1,Other,Drug Cost,236.1,,,236.1,Other,Drug Cost,236.1,,,236.1,Other,Drug Cost,236.1,,,236.1,Other,Drug Cost,236.1,,,236.1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,236.1,,,236.1,Other,Drug Cost,531.23,,,531.23,Other,225% Medicaid APG methodology,330.54,,,330.54,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,236.1,,,236.1,Other,Drug Cost,236.1,,,236.1,Other,Drug Cost,295.13,,,295.13,Other,125% Medicaid APG methodology,0.01,531.23,
FLURBIPROFEN 0.03% OPT  2.5ML   ,,,,40592479,CDM,250,RC,69292-0722-25,NDC,both,2.5,ML,119.11,47.01,39.4668,,47.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,35.73,30,,35.73,percent of total billed charges,"Drugs, Inpatient Only",35.73,30,,35.73,percent of total billed charges,"Drugs, Inpatient Only",35.73,30,,35.73,percent of total billed charges,"Drugs, Inpatient Only",59.56,50,,59.56,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,61.1,,,61.1,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,83.38,70,,83.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,32.85,,,32.85,Other,Drug Cost,32.85,,,32.85,Other,Drug Cost,32.85,,,32.85,Other,Drug Cost,32.85,,,32.85,Other,Drug Cost,32.85,,,32.85,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,32.85,,,32.85,Other,Drug Cost,73.91,,,73.91,Other,225% Medicaid APG methodology,45.99,,,45.99,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,32.85,,,32.85,Other,Drug Cost,32.85,,,32.85,Other,Drug Cost,41.06,,,41.06,Other,125% Medicaid APG methodology,0.01,83.38,
MUPIROCIN 2% CREAM 15 G         ,,,,40592503,CDM,250,RC,68462-0564-17,NDC,both,15,GM,566.48,223.57,39.4668,,223.57,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,169.94,30,,169.94,percent of total billed charges,"Drugs, Inpatient Only",169.94,30,,169.94,percent of total billed charges,"Drugs, Inpatient Only",169.94,30,,169.94,percent of total billed charges,"Drugs, Inpatient Only",283.24,50,,283.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,30.97,,,30.97,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,396.54,70,,396.54,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,16.65,,,16.65,Other,Drug Cost,16.65,,,16.65,Other,Drug Cost,16.65,,,16.65,Other,Drug Cost,16.65,,,16.65,Other,Drug Cost,16.65,,,16.65,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,16.65,,,16.65,Other,Drug Cost,37.46,,,37.46,Other,225% Medicaid APG methodology,23.31,,,23.31,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,16.65,,,16.65,Other,Drug Cost,16.65,,,16.65,Other,Drug Cost,20.81,,,20.81,Other,125% Medicaid APG methodology,0.01,396.54,
VANCOMYCIN 5MG/0.5ML INTRAVIT   ,,,,40592552,CDM,250,RC,67457-0339-50B,NDC,both,0.5,ML,25.83,10.19,39.4668,,10.19,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.75,30,,7.75,percent of total billed charges,"Drugs, Inpatient Only",7.75,30,,7.75,percent of total billed charges,"Drugs, Inpatient Only",7.75,30,,7.75,percent of total billed charges,"Drugs, Inpatient Only",12.92,50,,12.92,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.72,,,3.72,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,18.08,70,,18.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2,,,2,Other,Drug Cost,4.5,,,4.5,Other,225% Medicaid APG methodology,2.8,,,2.8,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,2.5,,,2.5,Other,125% Medicaid APG methodology,0.01,18.08,
CEFTAZ 11.25MG/0.5ML INTRAVIT   ,,,,40592560,CDM,250,RC,00409-5082-16C,NDC,both,0.5,ML,10.54,4.16,39.4668,,4.16,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.16,30,,3.16,percent of total billed charges,"Drugs, Inpatient Only",3.16,30,,3.16,percent of total billed charges,"Drugs, Inpatient Only",3.16,30,,3.16,percent of total billed charges,"Drugs, Inpatient Only",5.27,50,,5.27,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.46,,,4.46,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.38,70,,7.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.4,,,2.4,Other,Drug Cost,5.4,,,5.4,Other,225% Medicaid APG methodology,3.36,,,3.36,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,3,,,3,Other,125% Medicaid APG methodology,0.01,7.38,
DEXAMETHASO 2MG/0.5ML INTRAVIT  ,,,,40592651,CDM,250,RC,67457-0423-12E,NDC,both,0.5,ML,1.58,0.62,39.4668,,0.62,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.47,30,,0.47,percent of total billed charges,"Drugs, Inpatient Only",0.47,30,,0.47,percent of total billed charges,"Drugs, Inpatient Only",0.47,30,,0.47,percent of total billed charges,"Drugs, Inpatient Only",0.79,50,,0.79,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.93,,,0.93,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.11,70,,1.11,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.5,,,0.5,Other,Drug Cost,1.13,,,1.13,Other,225% Medicaid APG methodology,0.7,,,0.7,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.63,,,0.63,Other,125% Medicaid APG methodology,0.01,1.13,
PATIROMER 8400MG ORL POW        ,,,,40593022,CDM,250,RC,53436-0084-04,NDC,both,1,EA,121.35,47.89,39.4668,,47.89,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,36.41,30,,36.41,percent of total billed charges,"Drugs, Inpatient Only",36.41,30,,36.41,percent of total billed charges,"Drugs, Inpatient Only",36.41,30,,36.41,percent of total billed charges,"Drugs, Inpatient Only",60.68,50,,60.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,27.75,,,27.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,84.95,70,,84.95,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.92,,,14.92,Other,Drug Cost,14.92,,,14.92,Other,Drug Cost,14.92,,,14.92,Other,Drug Cost,14.92,,,14.92,Other,Drug Cost,14.92,,,14.92,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,14.92,,,14.92,Other,Drug Cost,33.57,,,33.57,Other,225% Medicaid APG methodology,20.89,,,20.89,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,14.92,,,14.92,Other,Drug Cost,14.92,,,14.92,Other,Drug Cost,18.65,,,18.65,Other,125% Medicaid APG methodology,0.01,84.95,
STERILE WATER INJ SOLN 20 ML    ,,,,40593204,CDM,250,RC,00409-4887-20,NDC,both,20,ML,3.5,1.38,39.4668,,1.38,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.05,30,,1.05,percent of total billed charges,"Drugs, Inpatient Only",1.05,30,,1.05,percent of total billed charges,"Drugs, Inpatient Only",1.05,30,,1.05,percent of total billed charges,"Drugs, Inpatient Only",1.75,50,,1.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.49,,,1.49,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.45,70,,2.45,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.8,,,0.8,Other,Drug Cost,1.8,,,1.8,Other,225% Medicaid APG methodology,1.12,,,1.12,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.8,,,0.8,Other,Drug Cost,0.8,,,0.8,Other,Drug Cost,1,,,1,Other,125% Medicaid APG methodology,0.01,2.45,
SELENIUM SULFIDE 1%SHAMP 207ML  ,,,,40593261,CDM,250,RC,00536-1995-53,NDC,both,207,ML,7.25,2.86,39.4668,,2.86,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.18,30,,2.18,percent of total billed charges,"Drugs, Inpatient Only",2.18,30,,2.18,percent of total billed charges,"Drugs, Inpatient Only",2.18,30,,2.18,percent of total billed charges,"Drugs, Inpatient Only",3.63,50,,3.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.85,,,3.85,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.08,70,,5.08,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.07,,,2.07,Other,Drug Cost,2.07,,,2.07,Other,Drug Cost,2.07,,,2.07,Other,Drug Cost,2.07,,,2.07,Other,Drug Cost,2.07,,,2.07,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.07,,,2.07,Other,Drug Cost,4.66,,,4.66,Other,225% Medicaid APG methodology,2.9,,,2.9,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.07,,,2.07,Other,Drug Cost,2.07,,,2.07,Other,Drug Cost,2.59,,,2.59,Other,125% Medicaid APG methodology,0.01,5.08,
ZINC OXIDE 20%TOPICAL OINT 60G  ,,,,40593279,CDM,250,RC,75834-0170-02,NDC,both,60,GM,29.4,11.6,39.4668,,11.6,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.82,30,,8.82,percent of total billed charges,"Drugs, Inpatient Only",8.82,30,,8.82,percent of total billed charges,"Drugs, Inpatient Only",8.82,30,,8.82,percent of total billed charges,"Drugs, Inpatient Only",14.7,50,,14.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.62,,,15.62,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,20.58,70,,20.58,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.4,,,8.4,Other,Drug Cost,8.4,,,8.4,Other,Drug Cost,8.4,,,8.4,Other,Drug Cost,8.4,,,8.4,Other,Drug Cost,8.4,,,8.4,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,8.4,,,8.4,Other,Drug Cost,18.9,,,18.9,Other,225% Medicaid APG methodology,11.76,,,11.76,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,8.4,,,8.4,Other,Drug Cost,8.4,,,8.4,Other,Drug Cost,10.5,,,10.5,Other,125% Medicaid APG methodology,0.01,20.58,
RITONAVIR 100MG ORL POW         ,,,,40593428,CDM,250,RC,00074-3399-30,NDC,both,1,EA,29.26,11.55,39.4668,,11.55,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.78,30,,8.78,percent of total billed charges,"Drugs, Inpatient Only",8.78,30,,8.78,percent of total billed charges,"Drugs, Inpatient Only",8.78,30,,8.78,percent of total billed charges,"Drugs, Inpatient Only",14.63,50,,14.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.66,,,11.66,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,20.48,70,,20.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.27,,,6.27,Other,Drug Cost,6.27,,,6.27,Other,Drug Cost,6.27,,,6.27,Other,Drug Cost,6.27,,,6.27,Other,Drug Cost,6.27,,,6.27,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,6.27,,,6.27,Other,Drug Cost,14.11,,,14.11,Other,225% Medicaid APG methodology,8.78,,,8.78,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.27,,,6.27,Other,Drug Cost,6.27,,,6.27,Other,Drug Cost,7.84,,,7.84,Other,125% Medicaid APG methodology,0.01,20.48,
SALMETEROL 50 MCG INH POWDER    ,,,,40593436,CDM,250,RC,00173-0521-00,NDC,both,1,EA,21.18,8.36,39.4668,,8.36,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.35,30,,6.35,percent of total billed charges,"Drugs, Inpatient Only",6.35,30,,6.35,percent of total billed charges,"Drugs, Inpatient Only",6.35,30,,6.35,percent of total billed charges,"Drugs, Inpatient Only",10.59,50,,10.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.83,70,,14.83,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,14.83,
PHENYLEPHRINE 0.5% NASSPR 15ML  ,,,,40593469,CDM,250,RC,69536-0050-15,NDC,both,15,ML,11.55,4.56,39.4668,,4.56,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.47,30,,3.47,percent of total billed charges,"Drugs, Inpatient Only",3.47,30,,3.47,percent of total billed charges,"Drugs, Inpatient Only",3.47,30,,3.47,percent of total billed charges,"Drugs, Inpatient Only",5.78,50,,5.78,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.14,,,6.14,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.09,70,,8.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.3,,,3.3,Other,Drug Cost,3.3,,,3.3,Other,Drug Cost,3.3,,,3.3,Other,Drug Cost,3.3,,,3.3,Other,Drug Cost,3.3,,,3.3,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.3,,,3.3,Other,Drug Cost,7.43,,,7.43,Other,225% Medicaid APG methodology,4.62,,,4.62,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.3,,,3.3,Other,Drug Cost,3.3,,,3.3,Other,Drug Cost,4.13,,,4.13,Other,125% Medicaid APG methodology,0.01,8.09,
PREGABALIN 100 MG CAP           ,,,,40593642,CDM,250,RC,00904-7001-61,NDC,both,1,EA,1.19,0.47,39.4668,,0.47,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.36,30,,0.36,percent of total billed charges,"Drugs, Inpatient Only",0.36,30,,0.36,percent of total billed charges,"Drugs, Inpatient Only",0.36,30,,0.36,percent of total billed charges,"Drugs, Inpatient Only",0.6,50,,0.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.8,,,0.8,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.83,70,,0.83,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.43,,,0.43,Other,Drug Cost,0.43,,,0.43,Other,Drug Cost,0.43,,,0.43,Other,Drug Cost,0.43,,,0.43,Other,Drug Cost,0.43,,,0.43,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.43,,,0.43,Other,Drug Cost,0.97,,,0.97,Other,225% Medicaid APG methodology,0.6,,,0.6,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.43,,,0.43,Other,Drug Cost,0.43,,,0.43,Other,Drug Cost,0.54,,,0.54,Other,125% Medicaid APG methodology,0.01,0.97,
SEVELAMER CARBONATE 800 MG TAB  ,,,,40593667,CDM,250,RC,65162-0058-27,NDC,both,1,EA,6.13,2.42,39.4668,,2.42,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.84,30,,1.84,percent of total billed charges,"Drugs, Inpatient Only",1.84,30,,1.84,percent of total billed charges,"Drugs, Inpatient Only",1.84,30,,1.84,percent of total billed charges,"Drugs, Inpatient Only",3.07,50,,3.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.71,,,0.71,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.29,70,,4.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.38,,,0.38,Other,Drug Cost,0.86,,,0.86,Other,225% Medicaid APG methodology,0.53,,,0.53,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.48,,,0.48,Other,125% Medicaid APG methodology,0.01,4.29,
SOD CHL 0.65% NASAL GEL 14.1 G  ,,,,40593675,CDM,250,RC,00225-0525-47,NDC,both,14.1,GM,9.38,3.7,39.4668,,3.7,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.81,30,,2.81,percent of total billed charges,"Drugs, Inpatient Only",2.81,30,,2.81,percent of total billed charges,"Drugs, Inpatient Only",2.81,30,,2.81,percent of total billed charges,"Drugs, Inpatient Only",4.69,50,,4.69,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.98,,,4.98,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.57,70,,6.57,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.68,,,2.68,Other,Drug Cost,2.68,,,2.68,Other,Drug Cost,2.68,,,2.68,Other,Drug Cost,2.68,,,2.68,Other,Drug Cost,2.68,,,2.68,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.68,,,2.68,Other,Drug Cost,6.03,,,6.03,Other,225% Medicaid APG methodology,3.75,,,3.75,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.68,,,2.68,Other,Drug Cost,2.68,,,2.68,Other,Drug Cost,3.35,,,3.35,Other,125% Medicaid APG methodology,0.01,6.57,
SOD ZIRCONUM CYCLOSLICATE 10G   ,,,,40593972,CDM,250,RC,00310-1110-30,NDC,both,1,EA,45.26,17.86,39.4668,,17.86,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.58,30,,13.58,percent of total billed charges,"Drugs, Inpatient Only",13.58,30,,13.58,percent of total billed charges,"Drugs, Inpatient Only",13.58,30,,13.58,percent of total billed charges,"Drugs, Inpatient Only",22.63,50,,22.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,18.41,,,18.41,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,31.68,70,,31.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.9,,,9.9,Other,Drug Cost,9.9,,,9.9,Other,Drug Cost,9.9,,,9.9,Other,Drug Cost,9.9,,,9.9,Other,Drug Cost,9.9,,,9.9,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,9.9,,,9.9,Other,Drug Cost,22.28,,,22.28,Other,225% Medicaid APG methodology,13.86,,,13.86,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,9.9,,,9.9,Other,Drug Cost,9.9,,,9.9,Other,Drug Cost,12.38,,,12.38,Other,125% Medicaid APG methodology,0.01,31.68,
VENLAFAXINE 150 MG ER CAP       ,,,,40594020,CDM,250,RC,00904-6470-61,NDC,both,1,EA,1.3,0.51,39.4668,,0.51,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.39,30,,0.39,percent of total billed charges,"Drugs, Inpatient Only",0.39,30,,0.39,percent of total billed charges,"Drugs, Inpatient Only",0.39,30,,0.39,percent of total billed charges,"Drugs, Inpatient Only",0.65,50,,0.65,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.33,,,0.33,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.91,70,,0.91,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.18,,,0.18,Other,Drug Cost,0.41,,,0.41,Other,225% Medicaid APG methodology,0.25,,,0.25,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.23,,,0.23,Other,125% Medicaid APG methodology,0.01,0.91,
TOLNAFTATE TOP 1% POWDER        ,,,,40594053,CDM,250,RC,00904-0726-45,NDC,both,45,GM,9.45,3.73,39.4668,,3.73,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.84,30,,2.84,percent of total billed charges,"Drugs, Inpatient Only",2.84,30,,2.84,percent of total billed charges,"Drugs, Inpatient Only",2.84,30,,2.84,percent of total billed charges,"Drugs, Inpatient Only",4.73,50,,4.73,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.35,,,3.35,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.62,70,,6.62,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.8,,,1.8,Other,Drug Cost,1.8,,,1.8,Other,Drug Cost,1.8,,,1.8,Other,Drug Cost,1.8,,,1.8,Other,Drug Cost,1.8,,,1.8,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.8,,,1.8,Other,Drug Cost,4.05,,,4.05,Other,225% Medicaid APG methodology,2.52,,,2.52,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.8,,,1.8,Other,Drug Cost,1.8,,,1.8,Other,Drug Cost,2.25,,,2.25,Other,125% Medicaid APG methodology,0.01,6.62,
METHADONE 5MG TAB (DETOX ONLY)  ,,,,40594145,CDM,250,RC,60687-0214-01,NDC,both,1,EA,0.67,0.26,39.4668,,0.26,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,30,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.2,30,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.2,30,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.34,50,,0.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.28,,,0.28,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.47,70,,0.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,Drug Cost,0.34,,,0.34,Other,225% Medicaid APG methodology,0.21,,,0.21,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,Drug Cost,0.15,,,0.15,Other,Drug Cost,0.19,,,0.19,Other,125% Medicaid APG methodology,0.01,0.47,
METHADONE 10MG TAB              ,,,,40594152,CDM,250,RC,00904-7417-61,NDC,both,1,EA,0.67,0.26,39.4668,,0.26,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.2,30,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.2,30,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.2,30,,0.2,percent of total billed charges,"Drugs, Inpatient Only",0.34,50,,0.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.35,,,0.35,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.47,70,,0.47,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,Drug Cost,0.43,,,0.43,Other,225% Medicaid APG methodology,0.27,,,0.27,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.24,,,0.24,Other,125% Medicaid APG methodology,0.01,0.47,
TIMOLOL 0.5% OPHTH SOLN 10 ML   ,,,,40594251,CDM,250,RC,61314-0227-10,NDC,both,10,ML,46.9,18.51,39.4668,,18.51,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.07,30,,14.07,percent of total billed charges,"Drugs, Inpatient Only",14.07,30,,14.07,percent of total billed charges,"Drugs, Inpatient Only",14.07,30,,14.07,percent of total billed charges,"Drugs, Inpatient Only",23.45,50,,23.45,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.28,,,4.28,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,32.83,70,,32.83,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.3,,,2.3,Other,Drug Cost,2.3,,,2.3,Other,Drug Cost,2.3,,,2.3,Other,Drug Cost,2.3,,,2.3,Other,Drug Cost,2.3,,,2.3,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.3,,,2.3,Other,Drug Cost,5.18,,,5.18,Other,225% Medicaid APG methodology,3.22,,,3.22,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.3,,,2.3,Other,Drug Cost,2.3,,,2.3,Other,Drug Cost,2.88,,,2.88,Other,125% Medicaid APG methodology,0.01,32.83,
ALVIMOPAN 12 MG CAP             ,,,,40594418,CDM,250,RC,00254-3012-55,NDC,both,1,EA,375.27,148.11,39.4668,,148.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,112.58,30,,112.58,percent of total billed charges,"Drugs, Inpatient Only",112.58,30,,112.58,percent of total billed charges,"Drugs, Inpatient Only",112.58,30,,112.58,percent of total billed charges,"Drugs, Inpatient Only",187.64,50,,187.64,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,112.36,,,112.36,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,262.69,70,,262.69,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,60.41,,,60.41,Other,Drug Cost,60.41,,,60.41,Other,Drug Cost,60.41,,,60.41,Other,Drug Cost,60.41,,,60.41,Other,Drug Cost,60.41,,,60.41,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,60.41,,,60.41,Other,Drug Cost,135.92,,,135.92,Other,225% Medicaid APG methodology,84.57,,,84.57,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,60.41,,,60.41,Other,Drug Cost,60.41,,,60.41,Other,Drug Cost,75.51,,,75.51,Other,125% Medicaid APG methodology,0.01,262.69,
MUPIROCIN 2% OINT 1G            ,,,,40594442,CDM,250,RC,50268-0572-60,NDC,both,1,GM,14.14,5.58,39.4668,,5.58,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.24,30,,4.24,percent of total billed charges,"Drugs, Inpatient Only",4.24,30,,4.24,percent of total billed charges,"Drugs, Inpatient Only",4.24,30,,4.24,percent of total billed charges,"Drugs, Inpatient Only",7.07,50,,7.07,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.71,,,4.71,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.9,70,,9.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.53,,,2.53,Other,Drug Cost,2.53,,,2.53,Other,Drug Cost,2.53,,,2.53,Other,Drug Cost,2.53,,,2.53,Other,Drug Cost,2.53,,,2.53,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.53,,,2.53,Other,Drug Cost,5.69,,,5.69,Other,225% Medicaid APG methodology,3.54,,,3.54,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.53,,,2.53,Other,Drug Cost,2.53,,,2.53,Other,Drug Cost,3.16,,,3.16,Other,125% Medicaid APG methodology,0.01,9.9,
MULTIPLE VITAMINS IV SOLN 10ML  ,,,,40594491,CDM,250,RC,54643-5649-01,NDC,both,10,ML,23.1,9.12,39.4668,,9.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.93,30,,6.93,percent of total billed charges,"Drugs, Inpatient Only",6.93,30,,6.93,percent of total billed charges,"Drugs, Inpatient Only",6.93,30,,6.93,percent of total billed charges,"Drugs, Inpatient Only",11.55,50,,11.55,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.56,,,0.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,16.17,70,,16.17,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.68,,,0.68,Other,225% Medicaid APG methodology,0.42,,,0.42,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.3,,,0.3,Other,Drug Cost,0.3,,,0.3,Other,Drug Cost,0.38,,,0.38,Other,125% Medicaid APG methodology,0.01,16.17,
PRAMOXINE 1% RECTAL FOAM 15 G   ,,,,40594509,CDM,250,RC,51862-0180-15,NDC,both,15,GM,135.45,53.46,39.4668,,53.46,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,40.64,30,,40.64,percent of total billed charges,"Drugs, Inpatient Only",40.64,30,,40.64,percent of total billed charges,"Drugs, Inpatient Only",40.64,30,,40.64,percent of total billed charges,"Drugs, Inpatient Only",67.73,50,,67.73,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,54.68,,,54.68,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,94.82,70,,94.82,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,29.4,,,29.4,Other,Drug Cost,29.4,,,29.4,Other,Drug Cost,29.4,,,29.4,Other,Drug Cost,29.4,,,29.4,Other,Drug Cost,29.4,,,29.4,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,29.4,,,29.4,Other,Drug Cost,66.15,,,66.15,Other,225% Medicaid APG methodology,41.16,,,41.16,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,29.4,,,29.4,Other,Drug Cost,29.4,,,29.4,Other,Drug Cost,36.75,,,36.75,Other,125% Medicaid APG methodology,0.01,94.82,
SOD CHL 0.65% NASAL SPRAY 44ML  ,,,,40594566,CDM,250,RC,00904-3865-75,NDC,both,44,ML,3.08,1.22,39.4668,,1.22,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.92,30,,0.92,percent of total billed charges,"Drugs, Inpatient Only",0.92,30,,0.92,percent of total billed charges,"Drugs, Inpatient Only",0.92,30,,0.92,percent of total billed charges,"Drugs, Inpatient Only",1.54,50,,1.54,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.82,,,0.82,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.16,70,,2.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.44,,,0.44,Other,Drug Cost,0.44,,,0.44,Other,Drug Cost,0.44,,,0.44,Other,Drug Cost,0.44,,,0.44,Other,Drug Cost,0.44,,,0.44,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.44,,,0.44,Other,Drug Cost,0.99,,,0.99,Other,225% Medicaid APG methodology,0.62,,,0.62,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.44,,,0.44,Other,Drug Cost,0.44,,,0.44,Other,Drug Cost,0.55,,,0.55,Other,125% Medicaid APG methodology,0.01,2.16,
AZITHROMYCIN 500MG TABLET       ,,,,40594822,CDM,250,RC,00069-3070-30,NDC,both,1,EA,9.7,3.83,39.4668,,3.83,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.91,30,,2.91,percent of total billed charges,"Drugs, Inpatient Only",2.91,30,,2.91,percent of total billed charges,"Drugs, Inpatient Only",2.91,30,,2.91,percent of total billed charges,"Drugs, Inpatient Only",4.85,50,,4.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.3,,,1.3,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.79,70,,6.79,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.7,,,0.7,Other,Drug Cost,0.7,,,0.7,Other,Drug Cost,0.7,,,0.7,Other,Drug Cost,0.7,,,0.7,Other,Drug Cost,0.7,,,0.7,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.7,,,0.7,Other,Drug Cost,1.58,,,1.58,Other,225% Medicaid APG methodology,0.98,,,0.98,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.7,,,0.7,Other,Drug Cost,0.7,,,0.7,Other,Drug Cost,0.88,,,0.88,Other,125% Medicaid APG methodology,0.01,6.79,
SOD ZIRCONIUM CYCLOSILICATE 5G  ,,,,40594962,CDM,250,RC,00310-1105-39,NDC,both,1,EA,45.36,17.9,39.4668,,17.9,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.61,30,,13.61,percent of total billed charges,"Drugs, Inpatient Only",13.61,30,,13.61,percent of total billed charges,"Drugs, Inpatient Only",13.61,30,,13.61,percent of total billed charges,"Drugs, Inpatient Only",22.68,50,,22.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,18.47,,,18.47,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,31.75,70,,31.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.93,,,9.93,Other,Drug Cost,9.93,,,9.93,Other,Drug Cost,9.93,,,9.93,Other,Drug Cost,9.93,,,9.93,Other,Drug Cost,9.93,,,9.93,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,9.93,,,9.93,Other,Drug Cost,22.34,,,22.34,Other,225% Medicaid APG methodology,13.9,,,13.9,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,9.93,,,9.93,Other,Drug Cost,9.93,,,9.93,Other,Drug Cost,12.41,,,12.41,Other,125% Medicaid APG methodology,0.01,31.75,
AL HYD/MAG HYD/SIME ORSUS355ML  ,,,,40595159,CDM,250,RC,57896-0629-12,NDC,both,355,ML,4.97,1.96,39.4668,,1.96,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.49,30,,1.49,percent of total billed charges,"Drugs, Inpatient Only",1.49,30,,1.49,percent of total billed charges,"Drugs, Inpatient Only",1.49,30,,1.49,percent of total billed charges,"Drugs, Inpatient Only",2.49,50,,2.49,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.64,,,2.64,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.48,70,,3.48,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.42,,,1.42,Other,Drug Cost,1.42,,,1.42,Other,Drug Cost,1.42,,,1.42,Other,Drug Cost,1.42,,,1.42,Other,Drug Cost,1.42,,,1.42,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.42,,,1.42,Other,Drug Cost,3.2,,,3.2,Other,225% Medicaid APG methodology,1.99,,,1.99,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.42,,,1.42,Other,Drug Cost,1.42,,,1.42,Other,Drug Cost,1.78,,,1.78,Other,125% Medicaid APG methodology,0.01,3.48,
MAGNESIUM SULF 50% PF INJ 2 ML  ,,,,40595308,CDM,250,RC,63323-0064-23a,NDC,both,2,ML,3.71,1.46,39.4668,,1.46,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.11,30,,1.11,percent of total billed charges,"Drugs, Inpatient Only",1.11,30,,1.11,percent of total billed charges,"Drugs, Inpatient Only",1.11,30,,1.11,percent of total billed charges,"Drugs, Inpatient Only",1.86,50,,1.86,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.41,,,0.41,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.6,70,,2.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.5,,,0.5,Other,225% Medicaid APG methodology,0.31,,,0.31,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.28,,,0.28,Other,125% Medicaid APG methodology,0.01,2.6,
HYPERHEP-B IM SOLN 5 ML         ,,,,40595365,CDM,250,RC,13533-0636-05,NDC,both,5,ML,2275.63,898.12,39.4668,,898.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,682.69,30,,682.69,percent of total billed charges,"Drugs, Inpatient Only",682.69,30,,682.69,percent of total billed charges,"Drugs, Inpatient Only",682.69,30,,682.69,percent of total billed charges,"Drugs, Inpatient Only",1137.82,50,,1137.82,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,913.54,,,913.54,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1592.94,70,,1592.94,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,491.15,,,491.15,Other,Drug Cost,491.15,,,491.15,Other,Drug Cost,491.15,,,491.15,Other,Drug Cost,491.15,,,491.15,Other,Drug Cost,491.15,,,491.15,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,491.15,,,491.15,Other,Drug Cost,1105.09,,,1105.09,Other,225% Medicaid APG methodology,687.61,,,687.61,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,491.15,,,491.15,Other,Drug Cost,491.15,,,491.15,Other,Drug Cost,613.94,,,613.94,Other,125% Medicaid APG methodology,0.01,1592.94,
CYCLOPENTOLATE 2% OPTH 2 ML     ,,,,40595399,CDM,250,RC,00065-0397-02,NDC,both,2,ML,116.76,46.08,39.4668,,46.08,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,35.03,30,,35.03,percent of total billed charges,"Drugs, Inpatient Only",35.03,30,,35.03,percent of total billed charges,"Drugs, Inpatient Only",35.03,30,,35.03,percent of total billed charges,"Drugs, Inpatient Only",58.38,50,,58.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,23.05,,,23.05,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,81.73,70,,81.73,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.39,,,12.39,Other,Drug Cost,12.39,,,12.39,Other,Drug Cost,12.39,,,12.39,Other,Drug Cost,12.39,,,12.39,Other,Drug Cost,12.39,,,12.39,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,12.39,,,12.39,Other,Drug Cost,27.88,,,27.88,Other,225% Medicaid APG methodology,17.35,,,17.35,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,12.39,,,12.39,Other,Drug Cost,12.39,,,12.39,Other,Drug Cost,15.49,,,15.49,Other,125% Medicaid APG methodology,0.01,81.73,
D5% 0.9% NACL AND KCL 40 MEQ/L  ,,,,40595407,CDM,250,RC,00338-0807-04,NDC,both,1000,ML,14,5.53,39.4668,,5.53,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.2,30,,4.2,percent of total billed charges,"Drugs, Inpatient Only",4.2,30,,4.2,percent of total billed charges,"Drugs, Inpatient Only",4.2,30,,4.2,percent of total billed charges,"Drugs, Inpatient Only",7,50,,7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.86,,,1.86,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.8,70,,9.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1,,,1,Other,Drug Cost,2.25,,,2.25,Other,225% Medicaid APG methodology,1.4,,,1.4,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1.25,,,1.25,Other,125% Medicaid APG methodology,0.01,9.8,
NEVIRAPINE 10MG/ML ORAL SYR     ,,,,40595811,CDM,250,RC,65862-0057-24a,NDC,both,1,ML,2.07,0.82,39.4668,,0.82,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.62,30,,0.62,percent of total billed charges,"Drugs, Inpatient Only",0.62,30,,0.62,percent of total billed charges,"Drugs, Inpatient Only",0.62,30,,0.62,percent of total billed charges,"Drugs, Inpatient Only",1.04,50,,1.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.6,,,0.6,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.45,70,,1.45,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.32,,,0.32,Other,Drug Cost,0.72,,,0.72,Other,225% Medicaid APG methodology,0.45,,,0.45,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.32,,,0.32,Other,Drug Cost,0.32,,,0.32,Other,Drug Cost,0.4,,,0.4,Other,125% Medicaid APG methodology,0.01,1.45,
STERILE TALC INTRAPL POW 2G     ,,,,40595910,CDM,250,RC,62327-0222-42,NDC,both,2,GM,350,138.13,39.4668,,138.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,105,30,,105,percent of total billed charges,"Drugs, Inpatient Only",105,30,,105,percent of total billed charges,"Drugs, Inpatient Only",105,30,,105,percent of total billed charges,"Drugs, Inpatient Only",175,50,,175,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,186,,,186,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,245,70,,245,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,100,,,100,Other,Drug Cost,100,,,100,Other,Drug Cost,100,,,100,Other,Drug Cost,100,,,100,Other,Drug Cost,100,,,100,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,100,,,100,Other,Drug Cost,225,,,225,Other,225% Medicaid APG methodology,140,,,140,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,100,,,100,Other,Drug Cost,100,,,100,Other,Drug Cost,125,,,125,Other,125% Medicaid APG methodology,0.01,245,
INSULIN LISP 100 UNITS/ML 3ML   ,J1815,HCPCS,,40595936,CDM,250,RC,00002-7533-01a,NDC,both,3,ML,43.96,17.35,39.4668,,17.35,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.19,30,,13.19,percent of total billed charges,"Drugs, Inpatient Only",13.19,30,,13.19,percent of total billed charges,"Drugs, Inpatient Only",13.19,30,,13.19,percent of total billed charges,"Drugs, Inpatient Only",21.98,50,,21.98,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,30.77,70,,30.77,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,30.77,
RHO(D) IMM GLOB 300MCG IM SOLN  ,,,,40596108,CDM,250,RC,00562-7805-05,NDC,both,1,EA,231.04,91.18,39.4668,,91.18,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,69.31,30,,69.31,percent of total billed charges,"Drugs, Inpatient Only",69.31,30,,69.31,percent of total billed charges,"Drugs, Inpatient Only",69.31,30,,69.31,percent of total billed charges,"Drugs, Inpatient Only",115.52,50,,115.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,103.19,,,103.19,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,161.73,70,,161.73,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,55.48,,,55.48,Other,Drug Cost,55.48,,,55.48,Other,Drug Cost,55.48,,,55.48,Other,Drug Cost,55.48,,,55.48,Other,Drug Cost,55.48,,,55.48,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,55.48,,,55.48,Other,Drug Cost,124.83,,,124.83,Other,225% Medicaid APG methodology,77.67,,,77.67,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,55.48,,,55.48,Other,Drug Cost,55.48,,,55.48,Other,Drug Cost,69.35,,,69.35,Other,125% Medicaid APG methodology,0.01,161.73,
ATORVASTATIN 10 MG TAB          ,,,,40596215,CDM,250,RC,68084-0097-01,NDC,both,1,EA,1.02,0.4,39.4668,,0.4,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.31,30,,0.31,percent of total billed charges,"Drugs, Inpatient Only",0.31,30,,0.31,percent of total billed charges,"Drugs, Inpatient Only",0.31,30,,0.31,percent of total billed charges,"Drugs, Inpatient Only",0.51,50,,0.51,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.71,70,,0.71,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% Medicaid APG methodology,0.11,,,0.11,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.71,
ATORVASTATIN 20 MG TAB          ,,,,40596223,CDM,250,RC,00904-6291-61,NDC,both,1,EA,0.7,0.28,39.4668,,0.28,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.21,30,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.21,30,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.21,30,,0.21,percent of total billed charges,"Drugs, Inpatient Only",0.35,50,,0.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,,,0.22,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.49,70,,0.49,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.27,,,0.27,Other,225% Medicaid APG methodology,0.17,,,0.17,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.15,,,0.15,Other,125% Medicaid APG methodology,0.01,0.49,
ERYTHROMYCIN ORAL LIQ 100ML     ,,,,40596272,CDM,250,RC,60219-1503-01,NDC,both,100,ML,427.95,168.9,39.4668,,168.9,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,128.39,30,,128.39,percent of total billed charges,"Drugs, Inpatient Only",128.39,30,,128.39,percent of total billed charges,"Drugs, Inpatient Only",128.39,30,,128.39,percent of total billed charges,"Drugs, Inpatient Only",213.98,50,,213.98,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,95.88,,,95.88,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,299.57,70,,299.57,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,51.55,,,51.55,Other,Drug Cost,51.55,,,51.55,Other,Drug Cost,51.55,,,51.55,Other,Drug Cost,51.55,,,51.55,Other,Drug Cost,51.55,,,51.55,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,51.55,,,51.55,Other,Drug Cost,115.99,,,115.99,Other,225% Medicaid APG methodology,72.17,,,72.17,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,51.55,,,51.55,Other,Drug Cost,51.55,,,51.55,Other,Drug Cost,64.44,,,64.44,Other,125% Medicaid APG methodology,0.01,299.57,
MENTHOL-ZINC OXIDE OINT 3.5G    ,,,,40596348,CDM,250,RC,00799-0001-05,NDC,both,3.5,GM,4.83,1.91,39.4668,,1.91,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.45,30,,1.45,percent of total billed charges,"Drugs, Inpatient Only",1.45,30,,1.45,percent of total billed charges,"Drugs, Inpatient Only",1.45,30,,1.45,percent of total billed charges,"Drugs, Inpatient Only",2.42,50,,2.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.57,,,2.57,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.38,70,,3.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.38,,,1.38,Other,Drug Cost,1.38,,,1.38,Other,Drug Cost,1.38,,,1.38,Other,Drug Cost,1.38,,,1.38,Other,Drug Cost,1.38,,,1.38,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.38,,,1.38,Other,Drug Cost,3.11,,,3.11,Other,225% Medicaid APG methodology,1.93,,,1.93,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.38,,,1.38,Other,Drug Cost,1.38,,,1.38,Other,Drug Cost,1.73,,,1.73,Other,125% Medicaid APG methodology,0.01,3.38,
NF - DEXTRO-GUAIFEN LIQ 10ML    ,,,,40596355,CDM,250,RC,00121-1276-00,NDC,both,10,ML,0.84,0.33,39.4668,,0.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,30,,0.25,percent of total billed charges,"Drugs, Inpatient Only",0.25,30,,0.25,percent of total billed charges,"Drugs, Inpatient Only",0.25,30,,0.25,percent of total billed charges,"Drugs, Inpatient Only",0.42,50,,0.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.29,,,3.29,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.59,70,,0.59,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.77,,,1.77,Other,Drug Cost,1.77,,,1.77,Other,Drug Cost,1.77,,,1.77,Other,Drug Cost,1.77,,,1.77,Other,Drug Cost,1.77,,,1.77,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.77,,,1.77,Other,Drug Cost,3.98,,,3.98,Other,225% Medicaid APG methodology,2.48,,,2.48,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.77,,,1.77,Other,Drug Cost,1.77,,,1.77,Other,Drug Cost,2.21,,,2.21,Other,125% Medicaid APG methodology,0.01,3.98,
NF - NYSTATIN TOPICAL POWD 30G  ,,,,40596371,CDM,250,RC,00574-2008-30,NDC,both,30,GM,126.28,49.84,39.4668,,49.84,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,37.88,30,,37.88,percent of total billed charges,"Drugs, Inpatient Only",37.88,30,,37.88,percent of total billed charges,"Drugs, Inpatient Only",37.88,30,,37.88,percent of total billed charges,"Drugs, Inpatient Only",63.14,50,,63.14,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.99,,,5.99,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,88.4,70,,88.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.22,,,3.22,Other,Drug Cost,3.22,,,3.22,Other,Drug Cost,3.22,,,3.22,Other,Drug Cost,3.22,,,3.22,Other,Drug Cost,3.22,,,3.22,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.22,,,3.22,Other,Drug Cost,7.25,,,7.25,Other,225% Medicaid APG methodology,4.51,,,4.51,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.22,,,3.22,Other,Drug Cost,3.22,,,3.22,Other,Drug Cost,4.03,,,4.03,Other,125% Medicaid APG methodology,0.01,88.4,
MIDAZOLAM 10 MG ORAL  5 ML UD   ,,,,40596512,CDM,250,RC,00904-7113-93,NDC,both,5,ML,17.57,6.93,39.4668,,6.93,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.27,30,,5.27,percent of total billed charges,"Drugs, Inpatient Only",5.27,30,,5.27,percent of total billed charges,"Drugs, Inpatient Only",5.27,30,,5.27,percent of total billed charges,"Drugs, Inpatient Only",8.79,50,,8.79,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7.16,,,7.16,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.3,70,,12.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.85,,,3.85,Other,Drug Cost,3.85,,,3.85,Other,Drug Cost,3.85,,,3.85,Other,Drug Cost,3.85,,,3.85,Other,Drug Cost,3.85,,,3.85,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.85,,,3.85,Other,Drug Cost,8.66,,,8.66,Other,225% Medicaid APG methodology,5.39,,,5.39,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.85,,,3.85,Other,Drug Cost,3.85,,,3.85,Other,Drug Cost,4.81,,,4.81,Other,125% Medicaid APG methodology,0.01,12.3,
FLUTICASONE FUR 100 MCG INH     ,,,,40596579,CDM,250,RC,00173-0874-10,NDC,both,30,EA,464.17,183.19,39.4668,,183.19,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,139.25,30,,139.25,percent of total billed charges,"Drugs, Inpatient Only",139.25,30,,139.25,percent of total billed charges,"Drugs, Inpatient Only",139.25,30,,139.25,percent of total billed charges,"Drugs, Inpatient Only",232.09,50,,232.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,56.97,,,56.97,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,324.92,70,,324.92,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,30.63,,,30.63,Other,Drug Cost,30.63,,,30.63,Other,Drug Cost,30.63,,,30.63,Other,Drug Cost,30.63,,,30.63,Other,Drug Cost,30.63,,,30.63,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,30.63,,,30.63,Other,Drug Cost,68.92,,,68.92,Other,225% Medicaid APG methodology,42.88,,,42.88,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,30.63,,,30.63,Other,Drug Cost,30.63,,,30.63,Other,Drug Cost,38.29,,,38.29,Other,125% Medicaid APG methodology,0.01,324.92,
HAEMOPHILUS B-HEPATITIS B VACC  ,,,,40596603,CDM,250,RC,00006-4898-00,NDC,both,0.5,ML,176.65,69.72,39.4668,,69.72,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,53,30,,53,percent of total billed charges,"Drugs, Inpatient Only",53,30,,53,percent of total billed charges,"Drugs, Inpatient Only",53,30,,53,percent of total billed charges,"Drugs, Inpatient Only",88.33,50,,88.33,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,93.87,,,93.87,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,123.66,70,,123.66,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,50.47,,,50.47,Other,Drug Cost,50.47,,,50.47,Other,Drug Cost,50.47,,,50.47,Other,Drug Cost,50.47,,,50.47,Other,Drug Cost,50.47,,,50.47,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,50.47,,,50.47,Other,Drug Cost,113.56,,,113.56,Other,225% Medicaid APG methodology,70.66,,,70.66,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,50.47,,,50.47,Other,Drug Cost,50.47,,,50.47,Other,Drug Cost,63.09,,,63.09,Other,125% Medicaid APG methodology,0.01,123.66,
NF REMDESIVIR 5 MG/ML 20 ML     ,,,,40596678,CDM,250,RC,61958-2902-01,NDC,both,20,ML,1820,718.3,39.4668,,718.3,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,546,30,,546,percent of total billed charges,"Drugs, Inpatient Only",546,30,,546,percent of total billed charges,"Drugs, Inpatient Only",546,30,,546,percent of total billed charges,"Drugs, Inpatient Only",910,50,,910,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,967.2,,,967.2,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1274,70,,1274,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,520,,,520,Other,Drug Cost,520,,,520,Other,Drug Cost,520,,,520,Other,Drug Cost,520,,,520,Other,Drug Cost,520,,,520,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,520,,,520,Other,Drug Cost,1170,,,1170,Other,225% Medicaid APG methodology,728,,,728,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,520,,,520,Other,Drug Cost,520,,,520,Other,Drug Cost,650,,,650,Other,125% Medicaid APG methodology,0.01,1274,
NF PEDS REMDESIVIR 100 MG INJ   ,,,,40596686,CDM,250,RC,61958-2901-01p,NDC,both,1,ML,22.75,8.98,39.4668,,8.98,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.83,30,,6.83,percent of total billed charges,"Drugs, Inpatient Only",6.83,30,,6.83,percent of total billed charges,"Drugs, Inpatient Only",6.83,30,,6.83,percent of total billed charges,"Drugs, Inpatient Only",11.38,50,,11.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.09,,,12.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.93,70,,15.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.5,,,6.5,Other,Drug Cost,6.5,,,6.5,Other,Drug Cost,6.5,,,6.5,Other,Drug Cost,6.5,,,6.5,Other,Drug Cost,6.5,,,6.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,6.5,,,6.5,Other,Drug Cost,14.63,,,14.63,Other,225% Medicaid APG methodology,9.1,,,9.1,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.5,,,6.5,Other,Drug Cost,6.5,,,6.5,Other,Drug Cost,8.13,,,8.13,Other,125% Medicaid APG methodology,0.01,15.93,
DORNASE 5 MG 50 ML NS  SYRINGE  ,,,,40596819,CDM,250,RC,50242-0100-40a,NDC,both,1,EA,299.11,118.05,39.4668,,118.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,89.73,30,,89.73,percent of total billed charges,"Drugs, Inpatient Only",89.73,30,,89.73,percent of total billed charges,"Drugs, Inpatient Only",89.73,30,,89.73,percent of total billed charges,"Drugs, Inpatient Only",149.56,50,,149.56,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,29.16,,,29.16,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,209.38,70,,209.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.68,,,15.68,Other,Drug Cost,15.68,,,15.68,Other,Drug Cost,15.68,,,15.68,Other,Drug Cost,15.68,,,15.68,Other,Drug Cost,15.68,,,15.68,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,15.68,,,15.68,Other,Drug Cost,35.28,,,35.28,Other,225% Medicaid APG methodology,21.95,,,21.95,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,15.68,,,15.68,Other,Drug Cost,15.68,,,15.68,Other,Drug Cost,19.6,,,19.6,Other,125% Medicaid APG methodology,0.01,209.38,
NF - TIMOLOL 0.25% OPHTH 10 ML  ,,,,40596843,CDM,250,RC,60758-0802-10,NDC,both,10,ML,18.9,7.46,39.4668,,7.46,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.67,30,,5.67,percent of total billed charges,"Drugs, Inpatient Only",5.67,30,,5.67,percent of total billed charges,"Drugs, Inpatient Only",5.67,30,,5.67,percent of total billed charges,"Drugs, Inpatient Only",9.45,50,,9.45,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.14,,,6.14,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.23,70,,13.23,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.3,,,3.3,Other,Drug Cost,3.3,,,3.3,Other,Drug Cost,3.3,,,3.3,Other,Drug Cost,3.3,,,3.3,Other,Drug Cost,3.3,,,3.3,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.3,,,3.3,Other,Drug Cost,7.43,,,7.43,Other,225% Medicaid APG methodology,4.62,,,4.62,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.3,,,3.3,Other,Drug Cost,3.3,,,3.3,Other,Drug Cost,4.13,,,4.13,Other,125% Medicaid APG methodology,0.01,13.23,
METRONIDAZOLE250MG PREMIX50 ML  ,,,,40596850,CDM,250,RC,00338-1055-48a,NDC,both,50,ML,3.5,1.38,39.4668,,1.38,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.05,30,,1.05,percent of total billed charges,"Drugs, Inpatient Only",1.05,30,,1.05,percent of total billed charges,"Drugs, Inpatient Only",1.05,30,,1.05,percent of total billed charges,"Drugs, Inpatient Only",1.75,50,,1.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.93,,,0.93,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.45,70,,2.45,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.5,,,0.5,Other,Drug Cost,1.13,,,1.13,Other,225% Medicaid APG methodology,0.7,,,0.7,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.63,,,0.63,Other,125% Medicaid APG methodology,0.01,2.45,
BARICITINIB 2 MG TAB            ,,,,40596884,CDM,250,RC,00002-4182-30,NDC,both,1,EA,293.79,115.95,39.4668,,115.95,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,88.14,30,,88.14,percent of total billed charges,"Drugs, Inpatient Only",88.14,30,,88.14,percent of total billed charges,"Drugs, Inpatient Only",88.14,30,,88.14,percent of total billed charges,"Drugs, Inpatient Only",146.9,50,,146.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,93.56,,,93.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,205.65,70,,205.65,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,50.3,,,50.3,Other,Drug Cost,50.3,,,50.3,Other,Drug Cost,50.3,,,50.3,Other,Drug Cost,50.3,,,50.3,Other,Drug Cost,50.3,,,50.3,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,50.3,,,50.3,Other,Drug Cost,113.18,,,113.18,Other,225% Medicaid APG methodology,70.42,,,70.42,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,50.3,,,50.3,Other,Drug Cost,50.3,,,50.3,Other,Drug Cost,62.88,,,62.88,Other,125% Medicaid APG methodology,0.01,205.65,
THEOPHYLLINE 200MG/24HR ER CAP  ,,,,40596967,CDM,250,RC,52244-0200-10,NDC,both,1,EA,11.66,4.6,39.4668,,4.6,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.5,30,,3.5,percent of total billed charges,"Drugs, Inpatient Only",3.5,30,,3.5,percent of total billed charges,"Drugs, Inpatient Only",3.5,30,,3.5,percent of total billed charges,"Drugs, Inpatient Only",5.83,50,,5.83,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.92,,,2.92,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.16,70,,8.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.57,,,1.57,Other,Drug Cost,1.57,,,1.57,Other,Drug Cost,1.57,,,1.57,Other,Drug Cost,1.57,,,1.57,Other,Drug Cost,1.57,,,1.57,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.57,,,1.57,Other,Drug Cost,3.53,,,3.53,Other,225% Medicaid APG methodology,2.2,,,2.2,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.57,,,1.57,Other,Drug Cost,1.57,,,1.57,Other,Drug Cost,1.96,,,1.96,Other,125% Medicaid APG methodology,0.01,8.16,
KETOROLAC 0.5% OPHTH SOLN 10ML  ,,,,40596983,CDM,250,RC,17478-0209-11,NDC,both,10,ML,208.36,82.23,39.4668,,82.23,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,62.51,30,,62.51,percent of total billed charges,"Drugs, Inpatient Only",62.51,30,,62.51,percent of total billed charges,"Drugs, Inpatient Only",62.51,30,,62.51,percent of total billed charges,"Drugs, Inpatient Only",104.18,50,,104.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.33,,,11.33,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,145.85,70,,145.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.09,,,6.09,Other,Drug Cost,6.09,,,6.09,Other,Drug Cost,6.09,,,6.09,Other,Drug Cost,6.09,,,6.09,Other,Drug Cost,6.09,,,6.09,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,6.09,,,6.09,Other,Drug Cost,13.7,,,13.7,Other,225% Medicaid APG methodology,8.53,,,8.53,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,6.09,,,6.09,Other,Drug Cost,6.09,,,6.09,Other,Drug Cost,7.61,,,7.61,Other,125% Medicaid APG methodology,0.01,145.85,
NF - LEVALBUTEROL AEROSOL 15G   ,,,,40597163,CDM,250,RC,00591-2927-54,NDC,both,15,GM,169.75,66.99,39.4668,,66.99,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,50.93,30,,50.93,percent of total billed charges,"Drugs, Inpatient Only",50.93,30,,50.93,percent of total billed charges,"Drugs, Inpatient Only",50.93,30,,50.93,percent of total billed charges,"Drugs, Inpatient Only",84.88,50,,84.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,48.14,,,48.14,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,118.83,70,,118.83,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,25.88,,,25.88,Other,Drug Cost,25.88,,,25.88,Other,Drug Cost,25.88,,,25.88,Other,Drug Cost,25.88,,,25.88,Other,Drug Cost,25.88,,,25.88,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,25.88,,,25.88,Other,Drug Cost,58.23,,,58.23,Other,225% Medicaid APG methodology,36.23,,,36.23,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,25.88,,,25.88,Other,Drug Cost,25.88,,,25.88,Other,Drug Cost,32.35,,,32.35,Other,125% Medicaid APG methodology,0.01,118.83,
NF - DUPILUMAB 300 MG/2 ML SOL  ,,,,40597171,CDM,250,RC,00024-5914-01,NDC,both,2,ML,5211.29,2056.73,39.4668,,2056.73,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1563.39,30,,1563.39,percent of total billed charges,"Drugs, Inpatient Only",1563.39,30,,1563.39,percent of total billed charges,"Drugs, Inpatient Only",1563.39,30,,1563.39,percent of total billed charges,"Drugs, Inpatient Only",2605.65,50,,2605.65,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1912.94,,,1912.94,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3647.9,70,,3647.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1028.46,,,1028.46,Other,Drug Cost,1028.46,,,1028.46,Other,Drug Cost,1028.46,,,1028.46,Other,Drug Cost,1028.46,,,1028.46,Other,Drug Cost,1028.46,,,1028.46,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1028.46,,,1028.46,Other,Drug Cost,2314.04,,,2314.04,Other,225% Medicaid APG methodology,1439.84,,,1439.84,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1028.46,,,1028.46,Other,Drug Cost,1028.46,,,1028.46,Other,Drug Cost,1285.58,,,1285.58,Other,125% Medicaid APG methodology,0.01,3647.9,
NF -AA 5% WITH D20 (CLINIMIX)   ,,,,40597239,CDM,250,RC,00338-1138-03,NDC,both,1000,ML,101.36,40,39.4668,,40,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,30.41,30,,30.41,percent of total billed charges,"Drugs, Inpatient Only",30.41,30,,30.41,percent of total billed charges,"Drugs, Inpatient Only",30.41,30,,30.41,percent of total billed charges,"Drugs, Inpatient Only",50.68,50,,50.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,18.08,,,18.08,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,70.95,70,,70.95,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.72,,,9.72,Other,Drug Cost,9.72,,,9.72,Other,Drug Cost,9.72,,,9.72,Other,Drug Cost,9.72,,,9.72,Other,Drug Cost,9.72,,,9.72,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,9.72,,,9.72,Other,Drug Cost,21.87,,,21.87,Other,225% Medicaid APG methodology,13.61,,,13.61,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,9.72,,,9.72,Other,Drug Cost,9.72,,,9.72,Other,Drug Cost,12.15,,,12.15,Other,125% Medicaid APG methodology,0.01,70.95,
DAPAGLIFLOZIN 10 MG TAB         ,,,,40597437,CDM,250,RC,00310-6210-39,NDC,both,1,EA,61.25,24.17,39.4668,,24.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,18.38,30,,18.38,percent of total billed charges,"Drugs, Inpatient Only",18.38,30,,18.38,percent of total billed charges,"Drugs, Inpatient Only",18.38,30,,18.38,percent of total billed charges,"Drugs, Inpatient Only",30.63,50,,30.63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,42.88,70,,42.88,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,42.88,
OXCARBAZEPINE 300 MG/5 ML SUSP  ,,,,40597502,CDM,250,RC,68094-0123-62,NDC,both,5,ML,22.47,8.87,39.4668,,8.87,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6.74,30,,6.74,percent of total billed charges,"Drugs, Inpatient Only",6.74,30,,6.74,percent of total billed charges,"Drugs, Inpatient Only",6.74,30,,6.74,percent of total billed charges,"Drugs, Inpatient Only",11.24,50,,11.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.73,,,10.73,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.73,70,,15.73,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.77,,,5.77,Other,Drug Cost,5.77,,,5.77,Other,Drug Cost,5.77,,,5.77,Other,Drug Cost,5.77,,,5.77,Other,Drug Cost,5.77,,,5.77,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,5.77,,,5.77,Other,Drug Cost,12.98,,,12.98,Other,225% Medicaid APG methodology,8.08,,,8.08,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,5.77,,,5.77,Other,Drug Cost,5.77,,,5.77,Other,Drug Cost,7.21,,,7.21,Other,125% Medicaid APG methodology,0.01,15.73,
NF - VALBENAZINE 40 MG CAP      ,,,,40597544,CDM,250,RC,70370-2040-01,NDC,both,1,EA,851.9,336.22,39.4668,,336.22,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,255.57,30,,255.57,percent of total billed charges,"Drugs, Inpatient Only",255.57,30,,255.57,percent of total billed charges,"Drugs, Inpatient Only",255.57,30,,255.57,percent of total billed charges,"Drugs, Inpatient Only",425.95,50,,425.95,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,259.64,,,259.64,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,596.33,70,,596.33,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,139.59,,,139.59,Other,Drug Cost,139.59,,,139.59,Other,Drug Cost,139.59,,,139.59,Other,Drug Cost,139.59,,,139.59,Other,Drug Cost,139.59,,,139.59,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,139.59,,,139.59,Other,Drug Cost,314.08,,,314.08,Other,225% Medicaid APG methodology,195.43,,,195.43,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,139.59,,,139.59,Other,Drug Cost,139.59,,,139.59,Other,Drug Cost,174.49,,,174.49,Other,125% Medicaid APG methodology,0.01,596.33,
NF - BRIVARACETAM 10 MG/ML SOL  ,,,,40597569,CDM,250,RC,50474-0970-75,NDC,both,5,ML,84.7,33.43,39.4668,,33.43,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,25.41,30,,25.41,percent of total billed charges,"Drugs, Inpatient Only",25.41,30,,25.41,percent of total billed charges,"Drugs, Inpatient Only",25.41,30,,25.41,percent of total billed charges,"Drugs, Inpatient Only",42.35,50,,42.35,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,40.01,,,40.01,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,59.29,70,,59.29,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,21.51,,,21.51,Other,Drug Cost,21.51,,,21.51,Other,Drug Cost,21.51,,,21.51,Other,Drug Cost,21.51,,,21.51,Other,Drug Cost,21.51,,,21.51,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,21.51,,,21.51,Other,Drug Cost,48.4,,,48.4,Other,225% Medicaid APG methodology,30.11,,,30.11,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,21.51,,,21.51,Other,Drug Cost,21.51,,,21.51,Other,Drug Cost,26.89,,,26.89,Other,125% Medicaid APG methodology,0.01,59.29,
BRIMONIDINE-TIMOLOL OPTH 5 ML   ,,,,40597635,CDM,250,RC,82182-0455-05,NDC,both,5,ML,270.31,106.68,39.4668,,106.68,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,81.09,30,,81.09,percent of total billed charges,"Drugs, Inpatient Only",81.09,30,,81.09,percent of total billed charges,"Drugs, Inpatient Only",81.09,30,,81.09,percent of total billed charges,"Drugs, Inpatient Only",135.16,50,,135.16,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,20.09,,,20.09,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,189.22,70,,189.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.8,,,10.8,Other,Drug Cost,10.8,,,10.8,Other,Drug Cost,10.8,,,10.8,Other,Drug Cost,10.8,,,10.8,Other,Drug Cost,10.8,,,10.8,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,10.8,,,10.8,Other,Drug Cost,24.3,,,24.3,Other,225% Medicaid APG methodology,15.12,,,15.12,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,10.8,,,10.8,Other,Drug Cost,10.8,,,10.8,Other,Drug Cost,13.5,,,13.5,Other,125% Medicaid APG methodology,0.01,189.22,
LUBIPROSTONE 24 MCG CAP         ,,,,40598138,CDM,250,RC,64764-0240-60,NDC,both,1,EA,19.92,7.86,39.4668,,7.86,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.98,30,,5.98,percent of total billed charges,"Drugs, Inpatient Only",5.98,30,,5.98,percent of total billed charges,"Drugs, Inpatient Only",5.98,30,,5.98,percent of total billed charges,"Drugs, Inpatient Only",9.96,50,,9.96,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.47,,,0.47,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.94,70,,13.94,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.56,,,0.56,Other,225% Medicaid APG methodology,0.35,,,0.35,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.31,,,0.31,Other,125% Medicaid APG methodology,0.01,13.94,
NICU DEXMEDETOMIDINE 2 MCG/ML   ,,,,40598229,CDM,250,RC,16729-0239-93n,NDC,both,1,ML,0.07,0.03,39.4668,,0.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.02,30,,0.02,percent of total billed charges,"Drugs, Inpatient Only",0.04,50,,0.04,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.06,,,0.06,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.05,70,,0.05,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.07,
EPHEDRINE 50 MG IN 10 ML INJ    ,,,,40598302,CDM,250,RC,42023-0243-01,NDC,both,10,ML,78.02,30.79,39.4668,,30.79,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,23.41,30,,23.41,percent of total billed charges,"Drugs, Inpatient Only",23.41,30,,23.41,percent of total billed charges,"Drugs, Inpatient Only",23.41,30,,23.41,percent of total billed charges,"Drugs, Inpatient Only",39.01,50,,39.01,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,27.66,,,27.66,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,54.61,70,,54.61,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14.87,,,14.87,Other,Drug Cost,14.87,,,14.87,Other,Drug Cost,14.87,,,14.87,Other,Drug Cost,14.87,,,14.87,Other,Drug Cost,14.87,,,14.87,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,14.87,,,14.87,Other,Drug Cost,33.46,,,33.46,Other,225% Medicaid APG methodology,20.82,,,20.82,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,14.87,,,14.87,Other,Drug Cost,14.87,,,14.87,Other,Drug Cost,18.59,,,18.59,Other,125% Medicaid APG methodology,0.01,54.61,
ND-SOD CHONDROITIN-HYALURONATE  ,,,,40598641,CDM,250,RC,08065-1831-50,NDC,both,1.05,ML,206.68,81.57,39.4668,,81.57,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,62,30,,62,percent of total billed charges,"Drugs, Inpatient Only",62,30,,62,percent of total billed charges,"Drugs, Inpatient Only",62,30,,62,percent of total billed charges,"Drugs, Inpatient Only",103.34,50,,103.34,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,109.83,,,109.83,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,144.68,70,,144.68,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,59.05,,,59.05,Other,Drug Cost,59.05,,,59.05,Other,Drug Cost,59.05,,,59.05,Other,Drug Cost,59.05,,,59.05,Other,Drug Cost,59.05,,,59.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,59.05,,,59.05,Other,Drug Cost,132.86,,,132.86,Other,225% Medicaid APG methodology,82.67,,,82.67,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,59.05,,,59.05,Other,Drug Cost,59.05,,,59.05,Other,Drug Cost,73.81,,,73.81,Other,125% Medicaid APG methodology,0.01,144.68,
CLINOLIPID 100 ML               ,,,,40598666,CDM,250,RC,00338-9540-05,NDC,both,100,ML,40.18,15.86,39.4668,,15.86,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.05,30,,12.05,percent of total billed charges,"Drugs, Inpatient Only",12.05,30,,12.05,percent of total billed charges,"Drugs, Inpatient Only",12.05,30,,12.05,percent of total billed charges,"Drugs, Inpatient Only",20.09,50,,20.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.69,,,1.69,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,28.13,70,,28.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.91,,,0.91,Other,Drug Cost,2.05,,,2.05,Other,225% Medicaid APG methodology,1.27,,,1.27,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,1.14,,,1.14,Other,125% Medicaid APG methodology,0.01,28.13,
DROXIDOPA 100 MG CAP            ,,,,40598849,CDM,250,RC,70710-1389-09,NDC,both,1,EA,13.3,5.25,39.4668,,5.25,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.99,30,,3.99,percent of total billed charges,"Drugs, Inpatient Only",3.99,30,,3.99,percent of total billed charges,"Drugs, Inpatient Only",3.99,30,,3.99,percent of total billed charges,"Drugs, Inpatient Only",6.65,50,,6.65,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.34,,,1.34,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.31,70,,9.31,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.72,,,0.72,Other,Drug Cost,0.72,,,0.72,Other,Drug Cost,0.72,,,0.72,Other,Drug Cost,0.72,,,0.72,Other,Drug Cost,0.72,,,0.72,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.72,,,0.72,Other,Drug Cost,1.62,,,1.62,Other,225% Medicaid APG methodology,1.01,,,1.01,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.72,,,0.72,Other,Drug Cost,0.72,,,0.72,Other,Drug Cost,0.9,,,0.9,Other,125% Medicaid APG methodology,0.01,9.31,
LANSOPRAZOLE 15 MG DIS TAB      ,,,,40598971,CDM,250,RC,65862-0895-78,NDC,both,1,EA,17.19,6.78,39.4668,,6.78,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.16,30,,5.16,percent of total billed charges,"Drugs, Inpatient Only",5.16,30,,5.16,percent of total billed charges,"Drugs, Inpatient Only",5.16,30,,5.16,percent of total billed charges,"Drugs, Inpatient Only",8.6,50,,8.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9.19,,,9.19,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12.03,70,,12.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.94,,,4.94,Other,Drug Cost,4.94,,,4.94,Other,Drug Cost,4.94,,,4.94,Other,Drug Cost,4.94,,,4.94,Other,Drug Cost,4.94,,,4.94,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,4.94,,,4.94,Other,Drug Cost,11.12,,,11.12,Other,225% Medicaid APG methodology,6.92,,,6.92,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,4.94,,,4.94,Other,Drug Cost,4.94,,,4.94,Other,Drug Cost,6.18,,,6.18,Other,125% Medicaid APG methodology,0.01,12.03,
BRIVARACETAM 50 MG TAB          ,,,,40599078,CDM,250,RC,50474-0570-66,NDC,both,1,EA,74.41,29.37,39.4668,,29.37,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,22.32,30,,22.32,percent of total billed charges,"Drugs, Inpatient Only",22.32,30,,22.32,percent of total billed charges,"Drugs, Inpatient Only",22.32,30,,22.32,percent of total billed charges,"Drugs, Inpatient Only",37.21,50,,37.21,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.51,,,19.51,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,52.09,70,,52.09,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.49,,,10.49,Other,Drug Cost,10.49,,,10.49,Other,Drug Cost,10.49,,,10.49,Other,Drug Cost,10.49,,,10.49,Other,Drug Cost,10.49,,,10.49,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,10.49,,,10.49,Other,Drug Cost,23.6,,,23.6,Other,225% Medicaid APG methodology,14.69,,,14.69,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,10.49,,,10.49,Other,Drug Cost,10.49,,,10.49,Other,Drug Cost,13.11,,,13.11,Other,125% Medicaid APG methodology,0.01,52.09,
AFLURIA 6 MONTH+                ,,,,40599086,CDM,250,RC,33332-0322-03,NDC,both,0.5,ML,183.33,72.35,39.4668,,72.35,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,55,30,,55,percent of total billed charges,"Drugs, Inpatient Only",55,30,,55,percent of total billed charges,"Drugs, Inpatient Only",55,30,,55,percent of total billed charges,"Drugs, Inpatient Only",91.67,50,,91.67,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,97.43,,,97.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,128.33,70,,128.33,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,52.38,,,52.38,Other,Drug Cost,52.38,,,52.38,Other,Drug Cost,52.38,,,52.38,Other,Drug Cost,52.38,,,52.38,Other,Drug Cost,52.38,,,52.38,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,52.38,,,52.38,Other,Drug Cost,117.86,,,117.86,Other,225% Medicaid APG methodology,73.33,,,73.33,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,52.38,,,52.38,Other,Drug Cost,52.38,,,52.38,Other,Drug Cost,65.48,,,65.48,Other,125% Medicaid APG methodology,0.01,128.33,
LEVOTHYROXINE 200 MCG TAB       ,,,,40599490,CDM,250,RC,68180-0975-03,NDC,both,1,EA,0.74,0.29,39.4668,,0.29,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.22,30,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.22,30,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.22,30,,0.22,percent of total billed charges,"Drugs, Inpatient Only",0.37,50,,0.37,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.15,,,0.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.52,70,,0.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% Medicaid APG methodology,0.11,,,0.11,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.52,
THIORIDAZINE 10 MG TAB          ,,,,40599573,CDM,250,RC,00378-0612-01,NDC,both,1,EA,1.47,0.58,39.4668,,0.58,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.44,30,,0.44,percent of total billed charges,"Drugs, Inpatient Only",0.44,30,,0.44,percent of total billed charges,"Drugs, Inpatient Only",0.44,30,,0.44,percent of total billed charges,"Drugs, Inpatient Only",0.74,50,,0.74,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.24,,,0.24,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.03,70,,1.03,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.29,,,0.29,Other,225% Medicaid APG methodology,0.18,,,0.18,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.16,,,0.16,Other,125% Medicaid APG methodology,0.01,1.03,
PREMIX NOREPI 8MG IN D5W 250ML  ,,,,40599607,CDM,250,RC,00338-0108-20,NDC,both,250,ML,101.85,40.2,39.4668,,40.2,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,30.56,30,,30.56,percent of total billed charges,"Drugs, Inpatient Only",30.56,30,,30.56,percent of total billed charges,"Drugs, Inpatient Only",30.56,30,,30.56,percent of total billed charges,"Drugs, Inpatient Only",50.93,50,,50.93,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,54.13,,,54.13,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,71.3,70,,71.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,29.1,,,29.1,Other,Drug Cost,29.1,,,29.1,Other,Drug Cost,29.1,,,29.1,Other,Drug Cost,29.1,,,29.1,Other,Drug Cost,29.1,,,29.1,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,29.1,,,29.1,Other,Drug Cost,65.48,,,65.48,Other,225% Medicaid APG methodology,40.74,,,40.74,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,29.1,,,29.1,Other,Drug Cost,29.1,,,29.1,Other,Drug Cost,36.38,,,36.38,Other,125% Medicaid APG methodology,0.01,71.3,
UMECLIDINIUM 62.5MCG/INH POW    ,,,,40599623,CDM,250,RC,00173-0873-10,NDC,both,1,EA,38.36,15.14,39.4668,,15.14,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11.51,30,,11.51,percent of total billed charges,"Drugs, Inpatient Only",11.51,30,,11.51,percent of total billed charges,"Drugs, Inpatient Only",11.51,30,,11.51,percent of total billed charges,"Drugs, Inpatient Only",19.18,50,,19.18,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.85,,,2.85,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,26.85,70,,26.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.53,,,1.53,Other,Drug Cost,1.53,,,1.53,Other,Drug Cost,1.53,,,1.53,Other,Drug Cost,1.53,,,1.53,Other,Drug Cost,1.53,,,1.53,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.53,,,1.53,Other,Drug Cost,3.44,,,3.44,Other,225% Medicaid APG methodology,2.14,,,2.14,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.53,,,1.53,Other,Drug Cost,1.53,,,1.53,Other,Drug Cost,1.91,,,1.91,Other,125% Medicaid APG methodology,0.01,26.85,
ETHYL ALCOHOL 99% INJ SOLN 5ML  ,,,,40599698,CDM,250,RC,54288-0105-15,NDC,both,5,ML,2667.88,1052.93,39.4668,,1052.93,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,800.36,30,,800.36,percent of total billed charges,"Drugs, Inpatient Only",800.36,30,,800.36,percent of total billed charges,"Drugs, Inpatient Only",800.36,30,,800.36,percent of total billed charges,"Drugs, Inpatient Only",1333.94,50,,1333.94,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1683.39,,,1683.39,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1867.52,70,,1867.52,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,905.05,,,905.05,Other,Drug Cost,905.05,,,905.05,Other,Drug Cost,905.05,,,905.05,Other,Drug Cost,905.05,,,905.05,Other,Drug Cost,905.05,,,905.05,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,905.05,,,905.05,Other,Drug Cost,2036.36,,,2036.36,Other,225% Medicaid APG methodology,1267.07,,,1267.07,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,905.05,,,905.05,Other,Drug Cost,905.05,,,905.05,Other,Drug Cost,1131.31,,,1131.31,Other,125% Medicaid APG methodology,0.01,2036.36,
FLUTICASONE-VILANTEROL 200-25   ,,,,40599748,CDM,250,RC,00173-0882-10,NDC,both,1,EA,19.57,7.72,39.4668,,7.72,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.87,30,,5.87,percent of total billed charges,"Drugs, Inpatient Only",5.87,30,,5.87,percent of total billed charges,"Drugs, Inpatient Only",5.87,30,,5.87,percent of total billed charges,"Drugs, Inpatient Only",9.79,50,,9.79,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.27,,,2.27,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13.7,70,,13.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.22,,,1.22,Other,Drug Cost,1.22,,,1.22,Other,Drug Cost,1.22,,,1.22,Other,Drug Cost,1.22,,,1.22,Other,Drug Cost,1.22,,,1.22,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,1.22,,,1.22,Other,Drug Cost,2.75,,,2.75,Other,225% Medicaid APG methodology,1.71,,,1.71,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,1.22,,,1.22,Other,Drug Cost,1.22,,,1.22,Other,Drug Cost,1.53,,,1.53,Other,125% Medicaid APG methodology,0.01,13.7,
CENOBAMATE 25 MG TAB            ,,,,40599771,CDM,250,RC,71699-0201-28,NDC,both,1,EA,12.43,4.91,39.4668,,4.91,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.73,30,,3.73,percent of total billed charges,"Drugs, Inpatient Only",3.73,30,,3.73,percent of total billed charges,"Drugs, Inpatient Only",3.73,30,,3.73,percent of total billed charges,"Drugs, Inpatient Only",6.22,50,,6.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.58,,,4.58,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.7,70,,8.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.46,,,2.46,Other,Drug Cost,2.46,,,2.46,Other,Drug Cost,2.46,,,2.46,Other,Drug Cost,2.46,,,2.46,Other,Drug Cost,2.46,,,2.46,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.46,,,2.46,Other,Drug Cost,5.54,,,5.54,Other,225% Medicaid APG methodology,3.44,,,3.44,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.46,,,2.46,Other,Drug Cost,2.46,,,2.46,Other,Drug Cost,3.08,,,3.08,Other,125% Medicaid APG methodology,0.01,8.7,
CENOBAMATE 12.5 MG TAB          ,,,,40599821,CDM,250,RC,71699-0201-28a,NDC,both,1,EA,11.8,4.66,39.4668,,4.66,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.54,30,,3.54,percent of total billed charges,"Drugs, Inpatient Only",3.54,30,,3.54,percent of total billed charges,"Drugs, Inpatient Only",3.54,30,,3.54,percent of total billed charges,"Drugs, Inpatient Only",5.9,50,,5.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.19,,,4.19,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8.26,70,,8.26,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2.25,,,2.25,Other,Drug Cost,2.25,,,2.25,Other,Drug Cost,2.25,,,2.25,Other,Drug Cost,2.25,,,2.25,Other,Drug Cost,2.25,,,2.25,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,2.25,,,2.25,Other,Drug Cost,5.06,,,5.06,Other,225% Medicaid APG methodology,3.15,,,3.15,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,2.25,,,2.25,Other,Drug Cost,2.25,,,2.25,Other,Drug Cost,2.81,,,2.81,Other,125% Medicaid APG methodology,0.01,8.26,
"IODIXANOL 320 100ML, P1ML       ",Q9967,HCPCS,,40546368,CDM,255,RC,00407-2223-64,NDC,both,100,ML,119.88,1.16,,,1.16,Other,150% of Medicare + 9.63% HCRA Surcharge,0.71,,,0.71,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,35.96,30,,35.96,percent of total billed charges,"Drugs, Inpatient Only",35.96,30,,35.96,percent of total billed charges,"Drugs, Inpatient Only",35.96,30,,35.96,percent of total billed charges,"Drugs, Inpatient Only",59.94,50,,59.94,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,197.03,,,197.03,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,83.92,70,,83.92,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,105.93,,,105.93,Other,Drug Cost,105.93,,,105.93,Other,Drug Cost,105.93,,,105.93,Other,Drug Cost,105.93,,,105.93,Other,Drug Cost,105.93,,,105.93,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,105.93,,,105.93,Other,Drug Cost,238.34,,,238.34,Other,225% Medicaid APG methodology,148.3,,,148.3,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,1.13,,,1.13,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,105.93,,,105.93,Other,Drug Cost,105.93,,,105.93,Other,Drug Cost,132.41,,,132.41,Other,125% Medicaid APG methodology,0.01,238.34,
IOHEXOL 240MG/ML INJ SOLN 50ML  ,Q9967,HCPCS,,47822036,CDM,255,RC,00407-1412-30,NDC,both,50,ML,14.63,1.16,,,1.16,Other,150% of Medicare + 9.63% HCRA Surcharge,0.71,,,0.71,Fee Schedule,Average Sale Price (ASP) x 6,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4.39,30,,4.39,percent of total billed charges,"Drugs, Inpatient Only",4.39,30,,4.39,percent of total billed charges,"Drugs, Inpatient Only",4.39,30,,4.39,percent of total billed charges,"Drugs, Inpatient Only",7.32,50,,7.32,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5.8,,,5.8,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10.24,70,,10.24,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3.12,,,3.12,Other,Drug Cost,3.12,,,3.12,Other,Drug Cost,3.12,,,3.12,Other,Drug Cost,3.12,,,3.12,Other,Drug Cost,3.12,,,3.12,Other,Drug Cost,0.01,,,0.01,Other,Non-covered service,3.12,,,3.12,Other,Drug Cost,7.02,,,7.02,Other,225% Medicaid APG methodology,4.37,,,4.37,Other,140% Medicaid APG methodology,0.01,,,0.01,Other,Non-covered service,1.13,,,1.13,Other,160% Medicare Fee Schedule,0.01,,,0.01,Other,Non-covered service,3.12,,,3.12,Other,Drug Cost,3.12,,,3.12,Other,Drug Cost,3.9,,,3.9,Other,125% Medicaid APG methodology,0.01,10.24,
APPLICATON ON-BODY INJECTOR     ,96377,CPT,,40800898,CDM,260,RC,,,both,,,742,90.33,,,90.33,Other,150% of Medicare + 9.63% HCRA Surcharge,54.93,,,54.93,Other,Medicare OPPS methodology,65.8,,,65.8,Fee Schedule,,59.26,,,59.26,Fee Schedule,,17.4,,,17.4,Fee Schedule,,17.4,,,17.4,Fee Schedule,,17.4,,,17.4,Fee Schedule,,371,50,,371,percent of total billed charges,All Other,519.4,70,,519.4,percent of total billed charges,All Other,504.56,68,,504.56,percent of total billed charges,All Other,116.47,,,116.47,Other,186% Medicaid methodology,593.6,80,,593.6,percent of total billed charges,All Other,615.86,83,,615.86,percent of total billed charges,All Other,615.86,83,,615.86,percent of total billed charges,All Other,593.6,80,,593.6,percent of total billed charges,All Other,615.86,83,,615.86,percent of total billed charges,All Other,667.8,90,,667.8,percent of total billed charges,All Other,519.4,70,,519.4,percent of total billed charges,All Other,92.4,,,92.4,Fee Schedule,,78.4,,,78.4,Fee Schedule,,824,,,824,Case Rate,IV Therapy Per Visit,748,,,748,Case Rate,IV Therapy Per Visit,831,,,831,Case Rate,IV Therapy Per Visit,706,,,706,Case Rate,IV Therapy Per Visit,62.62,,,62.62,Other,New York Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,95.8,,,95.8,Other,153% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,87.66,,,87.66,Other,140% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,162.81,,,162.81,Other,260% Medicaid APG methodology,202.88,,,202.88,Other,324% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,78.27,,,78.27,Other,125% Medicaid APG methodology,17.4,831,
TX/PRO/DX INJ SAME DRUG ADDON   ,96376,CPT,,44101319,CDM,260,RC,,,both,,,742,292.84,,,292.84,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,371,50,,371,percent of total billed charges,All Other Outpatient,333.9,45,,333.9,percent of total billed charges,All Other Outpatient,371,50,,371,percent of total billed charges,All Other Outpatient,333.9,45,,333.9,percent of total billed charges,All Other Outpatient,319.06,43,,319.06,percent of total billed charges,All Other Outpatient,371,50,,371,percent of total billed charges,All Other,519.4,70,,519.4,percent of total billed charges,All Other,504.56,68,,504.56,percent of total billed charges,All Other Outpatient,116.47,,,116.47,Other,186% Medicaid methodology,593.6,80,,593.6,percent of total billed charges,All Other Outpatient,615.86,83,,615.86,percent of total billed charges,All Other Outpatient,615.86,83,,615.86,percent of total billed charges,All Other Outpatient,593.6,80,,593.6,percent of total billed charges,All Other Outpatient,615.86,83,,615.86,percent of total billed charges,All Other Outpatient,667.8,90,,667.8,percent of total billed charges,All Other,519.4,70,,519.4,percent of total billed charges,All Other,371,50,,371,percent of total billed charges,All Other,371,50,,371,percent of total billed charges,All Other,824,,,824,Case Rate,IV Therapy Per Visit,748,,,748,Case Rate,IV Therapy Per Visit,831,,,831,Case Rate,IV Therapy Per Visit,706,,,706,Case Rate,IV Therapy Per Visit,62.62,,,62.62,Other,New York Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,95.8,,,95.8,Other,153% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,87.66,,,87.66,Other,140% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,162.81,,,162.81,Other,260% Medicaid APG methodology,202.88,,,202.88,Other,324% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,78.27,,,78.27,Other,125% Medicaid APG methodology,0.01,831,
THER/PROPH/DIAG IV INF INIT     ,96365,CPT,,48300958,CDM,260,RC,,,both,,,1752,407.6,,,407.6,Other,150% of Medicare + 9.63% HCRA Surcharge,247.86,,,247.86,Other,Medicare OPPS methodology,876,50,,876,percent of total billed charges,All Other Outpatient,788.4,45,,788.4,percent of total billed charges,All Other Outpatient,1342,,,1342,Case Rate,IV Therapy Per Visit,1208,,,1208,Case Rate,IV Therapy Per Visit,1141,,,1141,Case Rate,IV Therapy Per Visit,876,50,,876,percent of total billed charges,All Other,1226.4,70,,1226.4,percent of total billed charges,All Other,1191.36,68,,1191.36,percent of total billed charges,All Other,577.69,,,577.69,Other,186% Medicaid methodology,1401.6,80,,1401.6,percent of total billed charges,All Other,1454.16,83,,1454.16,percent of total billed charges,All Other,1454.16,83,,1454.16,percent of total billed charges,All Other,1401.6,80,,1401.6,percent of total billed charges,All Other,1454.16,83,,1454.16,percent of total billed charges,All Other,1576.8,90,,1576.8,percent of total billed charges,All Other,1226.4,70,,1226.4,percent of total billed charges,All Other,330,,,330,Fee Schedule,,280,,,280,Fee Schedule,,824,,,824,Case Rate,IV Therapy Per Visit,748,,,748,Case Rate,IV Therapy Per Visit,831,,,831,Case Rate,IV Therapy Per Visit,706,,,706,Case Rate,IV Therapy Per Visit,310.58,,,310.58,Other,New York Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,475.19,,,475.19,Other,153% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,434.82,,,434.82,Other,140% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,807.52,,,807.52,Other,260% Medicaid APG methodology,1006.29,,,1006.29,Other,324% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,388.23,,,388.23,Other,125% Medicaid APG methodology,247.86,1576.8,
TX/PRO/DX INJ SAME DRUG ADDON   ,96376,CPT,,48301808,CDM,260,RC,,,both,,,674,266.01,,,266.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,337,50,,337,percent of total billed charges,All Other Outpatient,303.3,45,,303.3,percent of total billed charges,All Other Outpatient,337,50,,337,percent of total billed charges,All Other Outpatient,303.3,45,,303.3,percent of total billed charges,All Other Outpatient,289.82,43,,289.82,percent of total billed charges,All Other Outpatient,337,50,,337,percent of total billed charges,All Other,471.8,70,,471.8,percent of total billed charges,All Other,458.32,68,,458.32,percent of total billed charges,All Other Outpatient,116.47,,,116.47,Other,186% Medicaid methodology,539.2,80,,539.2,percent of total billed charges,All Other Outpatient,559.42,83,,559.42,percent of total billed charges,All Other Outpatient,559.42,83,,559.42,percent of total billed charges,All Other Outpatient,539.2,80,,539.2,percent of total billed charges,All Other Outpatient,559.42,83,,559.42,percent of total billed charges,All Other Outpatient,606.6,90,,606.6,percent of total billed charges,All Other,471.8,70,,471.8,percent of total billed charges,All Other,337,50,,337,percent of total billed charges,All Other,337,50,,337,percent of total billed charges,All Other,824,,,824,Case Rate,IV Therapy Per Visit,748,,,748,Case Rate,IV Therapy Per Visit,831,,,831,Case Rate,IV Therapy Per Visit,706,,,706,Case Rate,IV Therapy Per Visit,62.62,,,62.62,Other,New York Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,95.8,,,95.8,Other,153% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,87.66,,,87.66,Other,140% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,162.81,,,162.81,Other,260% Medicaid APG methodology,202.88,,,202.88,Other,324% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,78.27,,,78.27,Other,125% Medicaid APG methodology,0.01,831,
THER/PROPH/DIAG IV INF INIT     ,96365,CPT,,40800013,CDM,269,RC,,,both,,,1928,407.6,,,407.6,Other,150% of Medicare + 9.63% HCRA Surcharge,247.86,,,247.86,Other,Medicare OPPS methodology,964,50,,964,percent of total billed charges,All Other Outpatient,867.6,45,,867.6,percent of total billed charges,All Other Outpatient,1342,,,1342,Case Rate,IV Therapy Per Visit,1208,,,1208,Case Rate,IV Therapy Per Visit,1141,,,1141,Case Rate,IV Therapy Per Visit,964,50,,964,percent of total billed charges,All Other,1349.6,70,,1349.6,percent of total billed charges,All Other,1311.04,68,,1311.04,percent of total billed charges,All Other,577.69,,,577.69,Other,186% Medicaid methodology,1542.4,80,,1542.4,percent of total billed charges,All Other,1600.24,83,,1600.24,percent of total billed charges,All Other,1600.24,83,,1600.24,percent of total billed charges,All Other,1542.4,80,,1542.4,percent of total billed charges,All Other,1600.24,83,,1600.24,percent of total billed charges,All Other,1735.2,90,,1735.2,percent of total billed charges,All Other,1349.6,70,,1349.6,percent of total billed charges,All Other,330,,,330,Fee Schedule,,280,,,280,Fee Schedule,,824,,,824,Case Rate,IV Therapy Per Visit,748,,,748,Case Rate,IV Therapy Per Visit,831,,,831,Case Rate,IV Therapy Per Visit,706,,,706,Case Rate,IV Therapy Per Visit,310.58,,,310.58,Other,New York Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,475.19,,,475.19,Other,153% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,434.82,,,434.82,Other,140% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,807.52,,,807.52,Other,260% Medicaid APG methodology,1006.29,,,1006.29,Other,324% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,388.23,,,388.23,Other,125% Medicaid APG methodology,247.86,1735.2,
THER/PROPH/DIAG IV INF ADDON    ,96366,CPT,,40800021,CDM,269,RC,,,both,,,460,90.33,,,90.33,Other,150% of Medicare + 9.63% HCRA Surcharge,54.93,,,54.93,Other,Medicare OPPS methodology,230,50,,230,percent of total billed charges,All Other Outpatient,207,45,,207,percent of total billed charges,All Other Outpatient,1342,,,1342,Case Rate,IV Therapy Per Visit,1208,,,1208,Case Rate,IV Therapy Per Visit,1141,,,1141,Case Rate,IV Therapy Per Visit,230,50,,230,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,312.8,68,,312.8,percent of total billed charges,All Other,1474.51,,,1474.51,Other,186% Medicaid methodology,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,414,90,,414,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,102.3,,,102.3,Fee Schedule,,86.8,,,86.8,Fee Schedule,,824,,,824,Case Rate,IV Therapy Per Visit,748,,,748,Case Rate,IV Therapy Per Visit,831,,,831,Case Rate,IV Therapy Per Visit,706,,,706,Case Rate,IV Therapy Per Visit,792.75,,,792.75,Other,New York Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1212.91,,,1212.91,Other,153% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1109.85,,,1109.85,Other,140% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,2061.15,,,2061.15,Other,260% Medicaid APG methodology,2568.51,,,2568.51,Other,324% Medicaid APG methodology,1704.41,,,1704.41,Other,215% Medicaid APG methodology,1704.41,,,1704.41,Other,215% Medicaid APG methodology,990.94,,,990.94,Other,125% Medicaid APG methodology,54.93,2568.51,
HYDRATION IV INFUSION INIT      ,96360,CPT,,40800179,CDM,269,RC,,,both,,,1946,407.6,,,407.6,Other,150% of Medicare + 9.63% HCRA Surcharge,247.86,,,247.86,Other,Medicare OPPS methodology,973,50,,973,percent of total billed charges,All Other Outpatient,875.7,45,,875.7,percent of total billed charges,All Other Outpatient,1342,,,1342,Case Rate,IV Therapy Per Visit,1208,,,1208,Case Rate,IV Therapy Per Visit,1141,,,1141,Case Rate,IV Therapy Per Visit,973,50,,973,percent of total billed charges,All Other,1362.2,70,,1362.2,percent of total billed charges,All Other,1323.28,68,,1323.28,percent of total billed charges,All Other,577.69,,,577.69,Other,186% Medicaid methodology,1556.8,80,,1556.8,percent of total billed charges,All Other,1615.18,83,,1615.18,percent of total billed charges,All Other,1615.18,83,,1615.18,percent of total billed charges,All Other,1556.8,80,,1556.8,percent of total billed charges,All Other,1615.18,83,,1615.18,percent of total billed charges,All Other,1751.4,90,,1751.4,percent of total billed charges,All Other,1362.2,70,,1362.2,percent of total billed charges,All Other,166.65,,,166.65,Fee Schedule,,141.4,,,141.4,Fee Schedule,,824,,,824,Case Rate,IV Therapy Per Visit,748,,,748,Case Rate,IV Therapy Per Visit,831,,,831,Case Rate,IV Therapy Per Visit,706,,,706,Case Rate,IV Therapy Per Visit,310.58,,,310.58,Other,New York Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,475.19,,,475.19,Other,153% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,434.82,,,434.82,Other,140% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,807.52,,,807.52,Other,260% Medicaid APG methodology,1006.29,,,1006.29,Other,324% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,388.23,,,388.23,Other,125% Medicaid APG methodology,141.4,1751.4,
HYDRATE IV INFUSION ADD-ON      ,96361,CPT,,40800187,CDM,269,RC,,,both,,,465,90.33,,,90.33,Other,150% of Medicare + 9.63% HCRA Surcharge,54.93,,,54.93,Other,Medicare OPPS methodology,232.5,50,,232.5,percent of total billed charges,All Other Outpatient,209.25,45,,209.25,percent of total billed charges,All Other Outpatient,1342,,,1342,Case Rate,IV Therapy Per Visit,1208,,,1208,Case Rate,IV Therapy Per Visit,1141,,,1141,Case Rate,IV Therapy Per Visit,232.5,50,,232.5,percent of total billed charges,All Other,325.5,70,,325.5,percent of total billed charges,All Other,316.2,68,,316.2,percent of total billed charges,All Other,1474.51,,,1474.51,Other,186% Medicaid methodology,372,80,,372,percent of total billed charges,All Other,385.95,83,,385.95,percent of total billed charges,All Other,385.95,83,,385.95,percent of total billed charges,All Other,372,80,,372,percent of total billed charges,All Other,385.95,83,,385.95,percent of total billed charges,All Other,418.5,90,,418.5,percent of total billed charges,All Other,325.5,70,,325.5,percent of total billed charges,All Other,62.7,,,62.7,Fee Schedule,,53.2,,,53.2,Fee Schedule,,824,,,824,Case Rate,IV Therapy Per Visit,748,,,748,Case Rate,IV Therapy Per Visit,831,,,831,Case Rate,IV Therapy Per Visit,706,,,706,Case Rate,IV Therapy Per Visit,792.75,,,792.75,Other,New York Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1212.91,,,1212.91,Other,153% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1109.85,,,1109.85,Other,140% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,2061.15,,,2061.15,Other,260% Medicaid APG methodology,2568.51,,,2568.51,Other,324% Medicaid APG methodology,1704.41,,,1704.41,Other,215% Medicaid APG methodology,1704.41,,,1704.41,Other,215% Medicaid APG methodology,990.94,,,990.94,Other,125% Medicaid APG methodology,53.2,2568.51,
TX/PROPH/DG ADDL SEQ IV INF     ,96367,CPT,,40800195,CDM,269,RC,,,both,,,722,133.96,,,133.96,Other,150% of Medicare + 9.63% HCRA Surcharge,81.46,,,81.46,Other,Medicare OPPS methodology,361,50,,361,percent of total billed charges,All Other Outpatient,324.9,45,,324.9,percent of total billed charges,All Other Outpatient,1342,,,1342,Case Rate,IV Therapy Per Visit,1208,,,1208,Case Rate,IV Therapy Per Visit,1141,,,1141,Case Rate,IV Therapy Per Visit,361,50,,361,percent of total billed charges,All Other,505.4,70,,505.4,percent of total billed charges,All Other,490.96,68,,490.96,percent of total billed charges,All Other,577.69,,,577.69,Other,186% Medicaid methodology,577.6,80,,577.6,percent of total billed charges,All Other,599.26,83,,599.26,percent of total billed charges,All Other,599.26,83,,599.26,percent of total billed charges,All Other,577.6,80,,577.6,percent of total billed charges,All Other,599.26,83,,599.26,percent of total billed charges,All Other,649.8,90,,649.8,percent of total billed charges,All Other,505.4,70,,505.4,percent of total billed charges,All Other,146.85,,,146.85,Fee Schedule,,124.6,,,124.6,Fee Schedule,,824,,,824,Case Rate,IV Therapy Per Visit,748,,,748,Case Rate,IV Therapy Per Visit,831,,,831,Case Rate,IV Therapy Per Visit,706,,,706,Case Rate,IV Therapy Per Visit,310.58,,,310.58,Other,New York Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,475.19,,,475.19,Other,153% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,434.82,,,434.82,Other,140% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,807.52,,,807.52,Other,260% Medicaid APG methodology,1006.29,,,1006.29,Other,324% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,388.23,,,388.23,Other,125% Medicaid APG methodology,81.46,1342,
THER/DIAG CONCURRENT INF        ,96368,CPT,,40800203,CDM,269,RC,,,both,,,327,129.06,,,129.06,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,163.5,50,,163.5,percent of total billed charges,All Other Outpatient,147.15,45,,147.15,percent of total billed charges,All Other Outpatient,1342,,,1342,Case Rate,IV Therapy Per Visit,1208,,,1208,Case Rate,IV Therapy Per Visit,1141,,,1141,Case Rate,IV Therapy Per Visit,163.5,50,,163.5,percent of total billed charges,All Other,228.9,70,,228.9,percent of total billed charges,All Other,222.36,68,,222.36,percent of total billed charges,All Other,577.69,,,577.69,Other,186% Medicaid methodology,261.6,80,,261.6,percent of total billed charges,All Other,271.41,83,,271.41,percent of total billed charges,All Other,271.41,83,,271.41,percent of total billed charges,All Other,261.6,80,,261.6,percent of total billed charges,All Other,271.41,83,,271.41,percent of total billed charges,All Other,294.3,90,,294.3,percent of total billed charges,All Other,228.9,70,,228.9,percent of total billed charges,All Other,99,,,99,Fee Schedule,,84,,,84,Fee Schedule,,824,,,824,Case Rate,IV Therapy Per Visit,748,,,748,Case Rate,IV Therapy Per Visit,831,,,831,Case Rate,IV Therapy Per Visit,706,,,706,Case Rate,IV Therapy Per Visit,310.58,,,310.58,Other,New York Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,475.19,,,475.19,Other,153% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,434.82,,,434.82,Other,140% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,807.52,,,807.52,Other,260% Medicaid APG methodology,1006.29,,,1006.29,Other,324% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,388.23,,,388.23,Other,125% Medicaid APG methodology,0.01,1342,
SC THER INFUSION UP TO 1 HR     ,96369,CPT,,40800732,CDM,269,RC,,,both,,,1446,407.6,,,407.6,Other,150% of Medicare + 9.63% HCRA Surcharge,247.86,,,247.86,Other,Medicare OPPS methodology,723,50,,723,percent of total billed charges,All Other Outpatient,650.7,45,,650.7,percent of total billed charges,All Other Outpatient,1342,,,1342,Case Rate,IV Therapy Per Visit,1208,,,1208,Case Rate,IV Therapy Per Visit,1141,,,1141,Case Rate,IV Therapy Per Visit,723,50,,723,percent of total billed charges,All Other,1012.2,70,,1012.2,percent of total billed charges,All Other,983.28,68,,983.28,percent of total billed charges,All Other,577.69,,,577.69,Other,186% Medicaid methodology,1156.8,80,,1156.8,percent of total billed charges,All Other,1200.18,83,,1200.18,percent of total billed charges,All Other,1200.18,83,,1200.18,percent of total billed charges,All Other,1156.8,80,,1156.8,percent of total billed charges,All Other,1200.18,83,,1200.18,percent of total billed charges,All Other,1301.4,90,,1301.4,percent of total billed charges,All Other,1012.2,70,,1012.2,percent of total billed charges,All Other,704.55,,,704.55,Fee Schedule,,597.8,,,597.8,Fee Schedule,,824,,,824,Case Rate,IV Therapy Per Visit,748,,,748,Case Rate,IV Therapy Per Visit,831,,,831,Case Rate,IV Therapy Per Visit,706,,,706,Case Rate,IV Therapy Per Visit,310.58,,,310.58,Other,New York Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,475.19,,,475.19,Other,153% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,434.82,,,434.82,Other,140% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,807.52,,,807.52,Other,260% Medicaid APG methodology,1006.29,,,1006.29,Other,324% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,388.23,,,388.23,Other,125% Medicaid APG methodology,247.86,1342,
SC THER INFUSION RESET PUMP     ,96371,CPT,,40800740,CDM,269,RC,,,both,,,294,133.96,,,133.96,Other,150% of Medicare + 9.63% HCRA Surcharge,81.46,,,81.46,Other,Medicare OPPS methodology,222.61,,,222.61,Fee Schedule,,200.49,,,200.49,Fee Schedule,,147,50,,147,percent of total billed charges,All Other Outpatient,132.3,45,,132.3,percent of total billed charges,All Other Outpatient,126.42,43,,126.42,percent of total billed charges,All Other Outpatient,147,50,,147,percent of total billed charges,All Other,205.8,70,,205.8,percent of total billed charges,All Other,199.92,68,,199.92,percent of total billed charges,All Other,577.69,,,577.69,Other,186% Medicaid methodology,235.2,80,,235.2,percent of total billed charges,All Other,244.02,83,,244.02,percent of total billed charges,All Other,244.02,83,,244.02,percent of total billed charges,All Other,235.2,80,,235.2,percent of total billed charges,All Other,244.02,83,,244.02,percent of total billed charges,All Other,264.6,90,,264.6,percent of total billed charges,All Other,205.8,70,,205.8,percent of total billed charges,All Other,285.45,,,285.45,Fee Schedule,,242.2,,,242.2,Fee Schedule,,824,,,824,Case Rate,IV Therapy Per Visit,748,,,748,Case Rate,IV Therapy Per Visit,831,,,831,Case Rate,IV Therapy Per Visit,706,,,706,Case Rate,IV Therapy Per Visit,310.58,,,310.58,Other,New York Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,475.19,,,475.19,Other,153% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,434.82,,,434.82,Other,140% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,807.52,,,807.52,Other,260% Medicaid APG methodology,1006.29,,,1006.29,Other,324% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,388.23,,,388.23,Other,125% Medicaid APG methodology,81.46,1006.29,
SC THER INFUSION ADDL HR        ,96370,CPT,,40800989,CDM,269,RC,,,both,,,356,90.33,,,90.33,Other,150% of Medicare + 9.63% HCRA Surcharge,54.93,,,54.93,Other,Medicare OPPS methodology,57.1,,,57.1,Fee Schedule,,51.42,,,51.42,Fee Schedule,,178,50,,178,percent of total billed charges,All Other Outpatient,160.2,45,,160.2,percent of total billed charges,All Other Outpatient,153.08,43,,153.08,percent of total billed charges,All Other Outpatient,178,50,,178,percent of total billed charges,All Other,249.2,70,,249.2,percent of total billed charges,All Other,242.08,68,,242.08,percent of total billed charges,All Other,1474.51,,,1474.51,Other,186% Medicaid methodology,284.8,80,,284.8,percent of total billed charges,All Other,295.48,83,,295.48,percent of total billed charges,All Other,295.48,83,,295.48,percent of total billed charges,All Other,284.8,80,,284.8,percent of total billed charges,All Other,295.48,83,,295.48,percent of total billed charges,All Other,320.4,90,,320.4,percent of total billed charges,All Other,249.2,70,,249.2,percent of total billed charges,All Other,74.25,,,74.25,Fee Schedule,,63,,,63,Fee Schedule,,824,,,824,Case Rate,IV Therapy Per Visit,748,,,748,Case Rate,IV Therapy Per Visit,831,,,831,Case Rate,IV Therapy Per Visit,706,,,706,Case Rate,IV Therapy Per Visit,792.75,,,792.75,Other,New York Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1212.91,,,1212.91,Other,153% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1109.85,,,1109.85,Other,140% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,2061.15,,,2061.15,Other,260% Medicaid APG methodology,2568.51,,,2568.51,Other,324% Medicaid APG methodology,1704.41,,,1704.41,Other,215% Medicaid APG methodology,1704.41,,,1704.41,Other,215% Medicaid APG methodology,990.94,,,990.94,Other,125% Medicaid APG methodology,51.42,2568.51,
THER/PROPH/DIAG INJ SC/IM       ,96372,CPT,,44100980,CDM,269,RC,,,both,,,725,133.96,,,133.96,Other,150% of Medicare + 9.63% HCRA Surcharge,81.46,,,81.46,Other,Medicare OPPS methodology,51.11,,,51.11,Fee Schedule,,46.03,,,46.03,Fee Schedule,,362.5,50,,362.5,percent of total billed charges,All Other Outpatient,326.25,45,,326.25,percent of total billed charges,All Other Outpatient,311.75,43,,311.75,percent of total billed charges,All Other Outpatient,362.5,50,,362.5,percent of total billed charges,All Other,507.5,70,,507.5,percent of total billed charges,All Other,493,68,,493,percent of total billed charges,All Other,116.47,,,116.47,Other,186% Medicaid methodology,580,80,,580,percent of total billed charges,All Other,601.75,83,,601.75,percent of total billed charges,All Other,601.75,83,,601.75,percent of total billed charges,All Other,580,80,,580,percent of total billed charges,All Other,601.75,83,,601.75,percent of total billed charges,All Other,652.5,90,,652.5,percent of total billed charges,All Other,507.5,70,,507.5,percent of total billed charges,All Other,69.3,,,69.3,Fee Schedule,,58.8,,,58.8,Fee Schedule,,824,,,824,Case Rate,IV Therapy Per Visit,748,,,748,Case Rate,IV Therapy Per Visit,831,,,831,Case Rate,IV Therapy Per Visit,706,,,706,Case Rate,IV Therapy Per Visit,62.62,,,62.62,Other,New York Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,95.8,,,95.8,Other,153% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,87.66,,,87.66,Other,140% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,162.81,,,162.81,Other,260% Medicaid APG methodology,202.88,,,202.88,Other,324% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,78.27,,,78.27,Other,125% Medicaid APG methodology,46.03,831,
HYDRATION IV INFUSION INIT      ,96360,CPT,,48300933,CDM,269,RC,,,both,,,1769,407.6,,,407.6,Other,150% of Medicare + 9.63% HCRA Surcharge,247.86,,,247.86,Other,Medicare OPPS methodology,884.5,50,,884.5,percent of total billed charges,All Other Outpatient,796.05,45,,796.05,percent of total billed charges,All Other Outpatient,1342,,,1342,Case Rate,IV Therapy Per Visit,1208,,,1208,Case Rate,IV Therapy Per Visit,1141,,,1141,Case Rate,IV Therapy Per Visit,884.5,50,,884.5,percent of total billed charges,All Other,1238.3,70,,1238.3,percent of total billed charges,All Other,1202.92,68,,1202.92,percent of total billed charges,All Other,577.69,,,577.69,Other,186% Medicaid methodology,1415.2,80,,1415.2,percent of total billed charges,All Other,1468.27,83,,1468.27,percent of total billed charges,All Other,1468.27,83,,1468.27,percent of total billed charges,All Other,1415.2,80,,1415.2,percent of total billed charges,All Other,1468.27,83,,1468.27,percent of total billed charges,All Other,1592.1,90,,1592.1,percent of total billed charges,All Other,1238.3,70,,1238.3,percent of total billed charges,All Other,166.65,,,166.65,Fee Schedule,,141.4,,,141.4,Fee Schedule,,824,,,824,Case Rate,IV Therapy Per Visit,748,,,748,Case Rate,IV Therapy Per Visit,831,,,831,Case Rate,IV Therapy Per Visit,706,,,706,Case Rate,IV Therapy Per Visit,310.58,,,310.58,Other,New York Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,475.19,,,475.19,Other,153% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,434.82,,,434.82,Other,140% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,807.52,,,807.52,Other,260% Medicaid APG methodology,1006.29,,,1006.29,Other,324% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,388.23,,,388.23,Other,125% Medicaid APG methodology,141.4,1592.1,
HYDRATE IV INFUSION ADD-ON      ,96361,CPT,,48300941,CDM,269,RC,,,both,,,422,90.33,,,90.33,Other,150% of Medicare + 9.63% HCRA Surcharge,54.93,,,54.93,Other,Medicare OPPS methodology,211,50,,211,percent of total billed charges,All Other Outpatient,189.9,45,,189.9,percent of total billed charges,All Other Outpatient,1342,,,1342,Case Rate,IV Therapy Per Visit,1208,,,1208,Case Rate,IV Therapy Per Visit,1141,,,1141,Case Rate,IV Therapy Per Visit,211,50,,211,percent of total billed charges,All Other,295.4,70,,295.4,percent of total billed charges,All Other,286.96,68,,286.96,percent of total billed charges,All Other,1474.51,,,1474.51,Other,186% Medicaid methodology,337.6,80,,337.6,percent of total billed charges,All Other,350.26,83,,350.26,percent of total billed charges,All Other,350.26,83,,350.26,percent of total billed charges,All Other,337.6,80,,337.6,percent of total billed charges,All Other,350.26,83,,350.26,percent of total billed charges,All Other,379.8,90,,379.8,percent of total billed charges,All Other,295.4,70,,295.4,percent of total billed charges,All Other,62.7,,,62.7,Fee Schedule,,53.2,,,53.2,Fee Schedule,,824,,,824,Case Rate,IV Therapy Per Visit,748,,,748,Case Rate,IV Therapy Per Visit,831,,,831,Case Rate,IV Therapy Per Visit,706,,,706,Case Rate,IV Therapy Per Visit,792.75,,,792.75,Other,New York Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1212.91,,,1212.91,Other,153% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1109.85,,,1109.85,Other,140% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,2061.15,,,2061.15,Other,260% Medicaid APG methodology,2568.51,,,2568.51,Other,324% Medicaid APG methodology,1704.41,,,1704.41,Other,215% Medicaid APG methodology,1704.41,,,1704.41,Other,215% Medicaid APG methodology,990.94,,,990.94,Other,125% Medicaid APG methodology,53.2,2568.51,
CATH BLLN PTA OTW 5X10MM,C1725,HCPCS,,42130369,CDM,272,RC,,,both,,,727.5,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,363.75,50,,363.75,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,509.25,70,,509.25,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,509.25,
CATH ATHRCTMY ORBIT SC 2.00MM,C1724,HCPCS,,42162206,CDM,272,RC,,,both,,,18975,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9487.5,50,,9487.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,13282.5,70,,13282.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,13282.5,
CATHETER GUIDING                ,C1887,HCPCS,,42500215,CDM,272,RC,,,both,,,165000,65120.22,,,65120.22,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,82500,50,,82500,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,115500,70,,115500,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,115500,
TRANSLUM ANGIO NON-LASER CATH   ,C1725,HCPCS,,42500397,CDM,272,RC,,,both,,,23500,9274.7,,,9274.7,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11750,50,,11750,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,16450,70,,16450,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,16450,
DRAINAGE CATH                   ,C1729,HCPCS,,42500538,CDM,272,RC,,,both,,,22804.6,9000.25,,,9000.25,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11402.3,50,,11402.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15963.22,70,,15963.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,15963.22,
INTRO/SHEATH NON-LASER          ,C1894,HCPCS,,42500777,CDM,272,RC,,,both,,,12500,4933.35,,,4933.35,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6250,50,,6250,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8750,70,,8750,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,8750,
GUIDE WIRE                      ,C1769,HCPCS,,42500959,CDM,272,RC,,,both,,,9555,3771.05,,,3771.05,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4777.5,50,,4777.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6688.5,70,,6688.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,6688.5,
THROMBECT/EMBOLECTOMY CATH      ,C1757,HCPCS,,42501239,CDM,272,RC,,,both,,,60000,23680.08,,,23680.08,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,30000,50,,30000,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,42000,70,,42000,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,42000,
RET DEV INSERTABLE              ,C1773,HCPCS,,42501247,CDM,272,RC,,,both,,,16500,6512.02,,,6512.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8250,50,,8250,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11550,70,,11550,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,11550,
CATH INTRAVAS ULTRASOUND        ,C1753,HCPCS,,42501395,CDM,272,RC,,,both,,,23500,9274.7,,,9274.7,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11750,50,,11750,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,16450,70,,16450,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,16450,
NONVASC BALLN TISS DISECT CATH  ,C1727,HCPCS,,42501650,CDM,272,RC,,,both,,,1822.2,719.16,,,719.16,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,911.1,50,,911.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1275.54,70,,1275.54,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1275.54,
MIDLINE INFUSION CATH           ,C1751,HCPCS,,42501668,CDM,272,RC,,,both,,,11875,4686.68,,,4686.68,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5937.5,50,,5937.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8312.5,70,,8312.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,8312.5,
CATH EP DIAG/ABL 3D/VECT        ,C1732,HCPCS,,42502021,CDM,272,RC,,,both,,,17660,6969.84,,,6969.84,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8830,50,,8830,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12362,70,,12362,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,12362,
CATH EP 20 OR MORE ELEC         ,C1731,HCPCS,,42502484,CDM,272,RC,,,both,,,15950,6294.95,,,6294.95,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7975,50,,7975,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11165,70,,11165,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,11165,
CATHETER URETERAL               ,C1758,HCPCS,,42502799,CDM,272,RC,,,both,,,457.45,180.54,,,180.54,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,228.73,50,,228.73,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,320.22,70,,320.22,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,320.22,
CATH EP COOL-TIP                ,C2630,HCPCS,,42502831,CDM,272,RC,,,both,,,16430,6484.4,,,6484.4,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8215,50,,8215,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11501,70,,11501,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,11501,
NON-VASC BALLOON DILATN CATH    ,C1726,HCPCS,,42507384,CDM,272,RC,,,both,,,50250,19832.07,,,19832.07,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,25125,50,,25125,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,35175,70,,35175,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,35175,
VASCULAR CLOSURE DEVICE         ,C1760,HCPCS,,42509182,CDM,272,RC,,,both,,,2770,1093.23,,,1093.23,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1385,50,,1385,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1939,70,,1939,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1939,
CATH EP 19 OR FEW ELECT         ,C1730,HCPCS,,42509208,CDM,272,RC,,,both,,,15950,6294.95,,,6294.95,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7975,50,,7975,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11165,70,,11165,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,11165,
CATH EP OTHR THAN COOL-TIP      ,C1733,HCPCS,,42510248,CDM,272,RC,,,both,,,24000,9472.03,,,9472.03,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12000,50,,12000,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,16800,70,,16800,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,16800,
CATH INTRA ECHOCARDIOGRAPHY     ,C1759,HCPCS,,42560433,CDM,272,RC,,,both,,,18320,7230.32,,,7230.32,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9160,50,,9160,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12824,70,,12824,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,12824,
ENDOSCOPE SINGLE USE URINARY    ,C1747,HCPCS,,42561464,CDM,272,RC,,,both,,,7500,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3750,50,,3750,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5250,70,,5250,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,5250,
CATH  TRANS INTRA LITHO CORO    ,C1761,HCPCS,,42563882,CDM,272,RC,,,both,,,13750,5426.69,,,5426.69,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6875,50,,6875,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9625,70,,9625,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,9625,
TRNSLUM ATHERECT DIRECTNL CATH  ,C1714,HCPCS,,42580126,CDM,272,RC,,,both,,,18225,7192.82,,,7192.82,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9112.5,50,,9112.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12757.5,70,,12757.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,12757.5,
TRANSL ATHERECT ROTATN CATH     ,C1724,HCPCS,,42580142,CDM,272,RC,,,both,,,20975,8278.16,,,8278.16,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10487.5,50,,10487.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,14682.5,70,,14682.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,14682.5,
BRACHYTH SEED ADMIN CATH        ,C1728,HCPCS,,42580159,CDM,272,RC,,,both,,,13750,5426.69,,,5426.69,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6875,50,,6875,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9625,70,,9625,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,9625,
CATHETER INTRASPINAL            ,C1755,HCPCS,,42580167,CDM,272,RC,,,both,,,6913.45,2728.52,,,2728.52,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3456.73,50,,3456.73,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4839.42,70,,4839.42,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,4839.42,
EP STEERABLE GUIDING INTRODUCR  ,C1766,HCPCS,,42580183,CDM,272,RC,,,both,,,12500,4933.35,,,4933.35,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6250,50,,6250,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8750,70,,8750,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,8750,
MORCELLATOR                     ,C1782,HCPCS,,42580225,CDM,272,RC,,,both,,,3334.8,1316.14,,,1316.14,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1667.4,50,,1667.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2334.36,70,,2334.36,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,2334.36,
TRANSL ANGIO LASER CATH         ,C1885,HCPCS,,42580340,CDM,272,RC,,,both,,,22475,8870.16,,,8870.16,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11237.5,50,,11237.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15732.5,70,,15732.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,15732.5,
CATHETER                        ,C1886,HCPCS,,42580357,CDM,272,RC,,,both,,,23500,9274.7,,,9274.7,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11750,50,,11750,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,16450,70,,16450,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,16450,
EP INTRA FIX-CURVE GUID INTROD  ,C1892,HCPCS,,42580381,CDM,272,RC,,,both,,,3895,1537.23,,,1537.23,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1947.5,50,,1947.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2726.5,70,,2726.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,2726.5,
PROBE NEEDLE                    ,C2618,HCPCS,,42580456,CDM,272,RC,,,both,,,22500,8880.03,,,8880.03,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11250,50,,11250,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15750,70,,15750,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,15750,
CATHETER TRANSLUMINAL           ,C2623,HCPCS,,42580464,CDM,272,RC,,,both,,,12750,5032.02,,,5032.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6375,50,,6375,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8925,70,,8925,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,8925,
CATH SUPRAPUBIC/CYSTOSCOPIC     ,C2627,HCPCS,,42580480,CDM,272,RC,,,both,,,471.8,186.2,,,186.2,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,235.9,50,,235.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,330.26,70,,330.26,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,330.26,
CATHETER OCCLUSION              ,C2628,HCPCS,,42580498,CDM,272,RC,,,both,,,8950,3532.28,,,3532.28,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4475,50,,4475,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6265,70,,6265,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,6265,
INTRO/SHEATH LASER              ,C2629,HCPCS,,42580506,CDM,272,RC,,,both,,,14975,5910.15,,,5910.15,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7487.5,50,,7487.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,10482.5,70,,10482.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,10482.5,
URI INCONT REP DEV WO SLG GRFT  ,C2631,HCPCS,,42580514,CDM,272,RC,,,both,,,11039.7,4357.02,,,4357.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5519.85,50,,5519.85,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7727.79,70,,7727.79,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,7727.79,
"INTRO/SHEATH,STRBLE,NON-PEEL    ",C1766,HCPCS,,44601698,CDM,272,RC,,,both,,,5465,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2732.5,50,,2732.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3825.5,70,,3825.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,3825.5,
PACING CATHETER                 ,C1887,HCPCS,,44603165,CDM,272,RC,,,both,,,2450,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1225,50,,1225,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1715,70,,1715,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1715,
CLOSURE PER CLOSE               ,C1760,HCPCS,,44609980,CDM,272,RC,,,both,,,1225,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,612.5,50,,612.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,857.5,70,,857.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,857.5,
CATH GUIDING                    ,C1887,HCPCS,,44611887,CDM,272,RC,,,both,,,1950,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,975,50,,975,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1365,70,,1365,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1365,
LCB                             ,C1887,HCPCS,,44616811,CDM,272,RC,,,both,,,38.75,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,19.38,50,,19.38,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,27.13,70,,27.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,27.13,
D EVOLUTFX2329                  ,C1894,HCPCS,,44617223,CDM,272,RC,,,both,,,10550,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5275,50,,5275,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7385,70,,7385,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,7385,
GUIDEWIRE VASCULAR              ,C1769,HCPCS,,44621373,CDM,272,RC,,,both,,,700,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,350,50,,350,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,490,70,,490,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,490,
CATH ULTRASOUND ACCUNAV         ,C1759,HCPCS,,44630242,CDM,272,RC,,,both,,,4241.3,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2120.65,50,,2120.65,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2968.91,70,,2968.91,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,2968.91,
ROTA PRO CATHETER               ,C1724,HCPCS,,44693257,CDM,272,RC,,,both,,,10475,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5237.5,50,,5237.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7332.5,70,,7332.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,7332.5,
GUIDEWIRE                       ,C1769,HCPCS,,44693281,CDM,272,RC,,,both,,,3300,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1650,50,,1650,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2310,70,,2310,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,2310,
CATHETER TRANSLUMIN ANGIO LASR  ,C1885,HCPCS,,44693356,CDM,272,RC,,,both,,,14000,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7000,50,,7000,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9800,70,,9800,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,9800,
SHOCKWAVE MS IVL CATHETER       ,C1725,HCPCS,,44693422,CDM,272,RC,,,both,,,13750,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,6875,50,,6875,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,9625,70,,9625,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,9625,
CATH OCTARAY                    ,C1730,HCPCS,,44693539,CDM,272,RC,,,both,,,15950,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,7975,50,,7975,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,11165,70,,11165,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,11165,
SHOCKWAVE MS IVL CATHETER       ,C1725,HCPCS,,44693729,CDM,272,RC,,,both,,,17250,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,8625,50,,8625,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,12075,70,,12075,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,12075,
CATHETER GUIDING                ,C1887,HCPCS,,44693737,CDM,272,RC,,,both,,,2175,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1087.5,50,,1087.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1522.5,70,,1522.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1522.5,
GUIDEWIRE 501-600               ,C1769,HCPCS,,47803796,CDM,272,RC,,,both,,,1590,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,795,50,,795,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1113,70,,1113,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1113,
SHEATH GUIDING CATH             ,C1887,HCPCS,,47805080,CDM,272,RC,,,both,,,52.25,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,26.13,50,,26.13,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,36.58,70,,36.58,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,36.58,
CATHETER GUIDING                ,C1887,HCPCS,,47805759,CDM,272,RC,,,both,,,812,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,406,50,,406,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,568.4,70,,568.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,568.4,
MICROCATHETER MAGIC             ,C1887,HCPCS,,47838693,CDM,272,RC,,,both,,,725,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,362.5,50,,362.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,507.5,70,,507.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,507.5,
GIDING CATHETER SOFIA           ,C1887,HCPCS,,47847173,CDM,272,RC,,,both,,,7220,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3610,50,,3610,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,5054,70,,5054,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,5054,
MICROCATHETER PROGREAT          ,C1887,HCPCS,,47847231,CDM,272,RC,,,both,,,309,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,154.5,50,,154.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,216.3,70,,216.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,216.3,
CATHETER BENCHMARK              ,C1887,HCPCS,,47847298,CDM,272,RC,,,both,,,4875,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2437.5,50,,2437.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3412.5,70,,3412.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,3412.5,
AURICULAR PROSTHESIS            ,L8045,HCPCS,,42560847,CDM,274,RC,,,both,,,951.75,375.63,,,375.63,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,190.35,20,,190.35,percent of total billed charges,Implant Device,190.35,20,,190.35,percent of total billed charges,Implant Device,190.35,20,,190.35,percent of total billed charges,Implant Device,190.35,20,,190.35,percent of total billed charges,Implant Device,190.35,20,,190.35,percent of total billed charges,Implant Device,475.88,50,,475.88,percent of total billed charges,All Other,190.35,20,,190.35,percent of total billed charges,Implant Device,190.35,20,,190.35,percent of total billed charges,Implant Device,323.6,34,"Charges > $500, x 34%",323.6,percent of total billed charges,Implant Device,190.35,20,,190.35,percent of total billed charges,Implant Device,190.35,20,,190.35,percent of total billed charges,Implant Device,190.35,20,,190.35,percent of total billed charges,Implant Device,190.35,20,,190.35,percent of total billed charges,Implant Device,190.35,20,,190.35,percent of total billed charges,Implant Device,190.35,20,,190.35,percent of total billed charges,Implant Device,190.35,20,,190.35,percent of total billed charges,Implant Device,190.35,20,,190.35,percent of total billed charges,Implant Device,190.35,20,,190.35,percent of total billed charges,Implant Device,190.35,20,,190.35,percent of total billed charges,Implant Device,190.35,20,,190.35,percent of total billed charges,Implant Device,190.35,20,,190.35,percent of total billed charges,Implant Device,190.35,20,,190.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,475.88,
EXTERNAL RECHARGE SYS INTERN    ,L8689,HCPCS,,42561001,CDM,274,RC,,,both,,,11950,4716.28,,,4716.28,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,2390,20,,2390,percent of total billed charges,Implant Device,2390,20,,2390,percent of total billed charges,Implant Device,2390,20,,2390,percent of total billed charges,Implant Device,2390,20,,2390,percent of total billed charges,Implant Device,2390,20,,2390,percent of total billed charges,Implant Device,5975,50,,5975,percent of total billed charges,All Other,2390,20,,2390,percent of total billed charges,Implant Device,2390,20,,2390,percent of total billed charges,Implant Device,4063,34,"Charges > $500, x 34%",4063,percent of total billed charges,Implant Device,2390,20,,2390,percent of total billed charges,Implant Device,2390,20,,2390,percent of total billed charges,Implant Device,2390,20,,2390,percent of total billed charges,Implant Device,2390,20,,2390,percent of total billed charges,Implant Device,2390,20,,2390,percent of total billed charges,Implant Device,2390,20,,2390,percent of total billed charges,Implant Device,2390,20,,2390,percent of total billed charges,Implant Device,2390,20,,2390,percent of total billed charges,Implant Device,2390,20,,2390,percent of total billed charges,Implant Device,2390,20,,2390,percent of total billed charges,Implant Device,2390,20,,2390,percent of total billed charges,Implant Device,2390,20,,2390,percent of total billed charges,Implant Device,2390,20,,2390,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,4063,34,"If Charge > 2,000, then 34 percent",4063,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,5975,
TRACHEOSTOMY SPEAKING VALVE     ,L8501,HCPCS,,42563908,CDM,274,RC,,,both,,,905.95,357.55,,,357.55,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,181.19,20,,181.19,percent of total billed charges,Implant Device,181.19,20,,181.19,percent of total billed charges,Implant Device,181.19,20,,181.19,percent of total billed charges,Implant Device,181.19,20,,181.19,percent of total billed charges,Implant Device,181.19,20,,181.19,percent of total billed charges,Implant Device,452.98,50,,452.98,percent of total billed charges,All Other,181.19,20,,181.19,percent of total billed charges,Implant Device,181.19,20,,181.19,percent of total billed charges,Implant Device,308.02,34,"Charges > $500, x 34%",308.02,percent of total billed charges,Implant Device,181.19,20,,181.19,percent of total billed charges,Implant Device,181.19,20,,181.19,percent of total billed charges,Implant Device,181.19,20,,181.19,percent of total billed charges,Implant Device,181.19,20,,181.19,percent of total billed charges,Implant Device,181.19,20,,181.19,percent of total billed charges,Implant Device,181.19,20,,181.19,percent of total billed charges,Implant Device,181.19,20,,181.19,percent of total billed charges,Implant Device,181.19,20,,181.19,percent of total billed charges,Implant Device,181.19,20,,181.19,percent of total billed charges,Implant Device,181.19,20,,181.19,percent of total billed charges,Implant Device,181.19,20,,181.19,percent of total billed charges,Implant Device,181.19,20,,181.19,percent of total billed charges,Implant Device,181.19,20,,181.19,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,452.98,
PROSTHETIC EYE OTHER TYPE       ,V2629,HCPCS,,42563957,CDM,274,RC,,,both,,,175,69.07,,,69.07,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,35,20,,35,percent of total billed charges,Implant Device,35,20,,35,percent of total billed charges,Implant Device,35,20,,35,percent of total billed charges,Implant Device,35,20,,35,percent of total billed charges,Implant Device,35,20,,35,percent of total billed charges,Implant Device,87.5,50,,87.5,percent of total billed charges,All Other,35,20,,35,percent of total billed charges,Implant Device,35,20,,35,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,35,20,,35,percent of total billed charges,Implant Device,35,20,,35,percent of total billed charges,Implant Device,35,20,,35,percent of total billed charges,Implant Device,35,20,,35,percent of total billed charges,Implant Device,35,20,,35,percent of total billed charges,Implant Device,35,20,,35,percent of total billed charges,Implant Device,35,20,,35,percent of total billed charges,Implant Device,35,20,,35,percent of total billed charges,Implant Device,35,20,,35,percent of total billed charges,Implant Device,35,20,,35,percent of total billed charges,Implant Device,35,20,,35,percent of total billed charges,Implant Device,35,20,,35,percent of total billed charges,Implant Device,35,20,,35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,87.5,
IMPL DUAL CHAMB RR PACEMAKER    ,C1785,HCPCS,,42501031,CDM,275,RC,,,both,,,115020,45394.71,,,45394.71,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,23004,20,,23004,percent of total billed charges,Implant Device,23004,20,,23004,percent of total billed charges,Implant Device,23004,20,,23004,percent of total billed charges,Implant Device,23004,20,,23004,percent of total billed charges,Implant Device,23004,20,,23004,percent of total billed charges,Implant Device,57510,50,,57510,percent of total billed charges,All Other,23004,20,,23004,percent of total billed charges,Implant Device,23004,20,,23004,percent of total billed charges,Implant Device,39106.8,34,"Charges > $500, x 34%",39106.8,percent of total billed charges,Implant Device,23004,20,,23004,percent of total billed charges,Implant Device,23004,20,,23004,percent of total billed charges,Implant Device,23004,20,,23004,percent of total billed charges,Implant Device,23004,20,,23004,percent of total billed charges,Implant Device,23004,20,,23004,percent of total billed charges,Implant Device,23004,20,,23004,percent of total billed charges,Implant Device,23004,20,,23004,percent of total billed charges,Implant Device,23004,20,,23004,percent of total billed charges,Implant Device,23004,20,,23004,percent of total billed charges,Implant Device,23004,20,,23004,percent of total billed charges,Implant Device,23004,20,,23004,percent of total billed charges,Implant Device,23004,20,,23004,percent of total billed charges,Implant Device,23004,20,,23004,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,39106.8,34,"If Charge > 2,000, then 34 percent",39106.8,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,57510,
IMPL SGL CHAMBR RR PACEMAKER    ,C1786,HCPCS,,42501049,CDM,275,RC,,,both,,,91475,36102.26,,,36102.26,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,18295,20,,18295,percent of total billed charges,Implant Device,18295,20,,18295,percent of total billed charges,Implant Device,18295,20,,18295,percent of total billed charges,Implant Device,18295,20,,18295,percent of total billed charges,Implant Device,18295,20,,18295,percent of total billed charges,Implant Device,45737.5,50,,45737.5,percent of total billed charges,All Other,18295,20,,18295,percent of total billed charges,Implant Device,18295,20,,18295,percent of total billed charges,Implant Device,31101.5,34,"Charges > $500, x 34%",31101.5,percent of total billed charges,Implant Device,18295,20,,18295,percent of total billed charges,Implant Device,18295,20,,18295,percent of total billed charges,Implant Device,18295,20,,18295,percent of total billed charges,Implant Device,18295,20,,18295,percent of total billed charges,Implant Device,18295,20,,18295,percent of total billed charges,Implant Device,18295,20,,18295,percent of total billed charges,Implant Device,18295,20,,18295,percent of total billed charges,Implant Device,18295,20,,18295,percent of total billed charges,Implant Device,18295,20,,18295,percent of total billed charges,Implant Device,18295,20,,18295,percent of total billed charges,Implant Device,18295,20,,18295,percent of total billed charges,Implant Device,18295,20,,18295,percent of total billed charges,Implant Device,18295,20,,18295,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,31101.5,34,"If Charge > 2,000, then 34 percent",31101.5,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,45737.5,
AICD DUAL CHAMBER               ,C1721,HCPCS,,42501056,CDM,275,RC,,,both,,,425000,167733.9,,,167733.9,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,212500,50,,212500,percent of total billed charges,All Other,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,144500,34,"Charges > $500, x 34%",144500,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,144500,34,"If Charge > 2,000, then 34 percent",144500,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,212500,
AICD OTHER THAN SING/DUAL       ,C1882,HCPCS,,42501296,CDM,275,RC,,,both,,,425000,167733.9,,,167733.9,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,212500,50,,212500,percent of total billed charges,All Other,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,144500,34,"Charges > $500, x 34%",144500,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,144500,34,"If Charge > 2,000, then 34 percent",144500,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,212500,
AICD SINGLE CHAMBER             ,C1722,HCPCS,,42502153,CDM,275,RC,,,both,,,425000,167733.9,,,167733.9,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,212500,50,,212500,percent of total billed charges,All Other,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,144500,34,"Charges > $500, x 34%",144500,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,85000,20,,85000,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,144500,34,"If Charge > 2,000, then 34 percent",144500,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,212500,
IMPL PACEMAK NOT SGL/DUAL CHAM  ,C2621,HCPCS,,42502914,CDM,275,RC,,,both,,,115445,45562.45,,,45562.45,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,23089,20,,23089,percent of total billed charges,Implant Device,23089,20,,23089,percent of total billed charges,Implant Device,23089,20,,23089,percent of total billed charges,Implant Device,23089,20,,23089,percent of total billed charges,Implant Device,23089,20,,23089,percent of total billed charges,Implant Device,57722.5,50,,57722.5,percent of total billed charges,All Other,23089,20,,23089,percent of total billed charges,Implant Device,23089,20,,23089,percent of total billed charges,Implant Device,39251.3,34,"Charges > $500, x 34%",39251.3,percent of total billed charges,Implant Device,23089,20,,23089,percent of total billed charges,Implant Device,23089,20,,23089,percent of total billed charges,Implant Device,23089,20,,23089,percent of total billed charges,Implant Device,23089,20,,23089,percent of total billed charges,Implant Device,23089,20,,23089,percent of total billed charges,Implant Device,23089,20,,23089,percent of total billed charges,Implant Device,23089,20,,23089,percent of total billed charges,Implant Device,23089,20,,23089,percent of total billed charges,Implant Device,23089,20,,23089,percent of total billed charges,Implant Device,23089,20,,23089,percent of total billed charges,Implant Device,23089,20,,23089,percent of total billed charges,Implant Device,23089,20,,23089,percent of total billed charges,Implant Device,23089,20,,23089,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,39251.3,34,"If Charge > 2,000, then 34 percent",39251.3,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,57722.5,
LEAD AICD ENDO SINGLE COIL      ,C1777,HCPCS,,42504431,CDM,275,RC,,,both,,,27500,10853.37,,,10853.37,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,5500,20,,5500,percent of total billed charges,Implant Device,5500,20,,5500,percent of total billed charges,Implant Device,5500,20,,5500,percent of total billed charges,Implant Device,5500,20,,5500,percent of total billed charges,Implant Device,5500,20,,5500,percent of total billed charges,Implant Device,13750,50,,13750,percent of total billed charges,All Other,5500,20,,5500,percent of total billed charges,Implant Device,5500,20,,5500,percent of total billed charges,Implant Device,9350,34,"Charges > $500, x 34%",9350,percent of total billed charges,Implant Device,5500,20,,5500,percent of total billed charges,Implant Device,5500,20,,5500,percent of total billed charges,Implant Device,5500,20,,5500,percent of total billed charges,Implant Device,5500,20,,5500,percent of total billed charges,Implant Device,5500,20,,5500,percent of total billed charges,Implant Device,5500,20,,5500,percent of total billed charges,Implant Device,5500,20,,5500,percent of total billed charges,Implant Device,5500,20,,5500,percent of total billed charges,Implant Device,5500,20,,5500,percent of total billed charges,Implant Device,5500,20,,5500,percent of total billed charges,Implant Device,5500,20,,5500,percent of total billed charges,Implant Device,5500,20,,5500,percent of total billed charges,Implant Device,5500,20,,5500,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,9350,34,"If Charge > 2,000, then 34 percent",9350,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,13750,
LEAD PMKR TRANSVENOUS VDD       ,C1779,HCPCS,,42560458,CDM,275,RC,,,both,,,17000,6709.36,,,6709.36,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,8500,50,,8500,percent of total billed charges,All Other,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,5780,34,"Charges > $500, x 34%",5780,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,5780,34,"If Charge > 2,000, then 34 percent",5780,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,8500,
IMPL DUAL CHAMB NRR PACEMAKER   ,C2619,HCPCS,,42560474,CDM,275,RC,,,both,,,19915,7859.81,,,7859.81,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,3983,20,,3983,percent of total billed charges,Implant Device,3983,20,,3983,percent of total billed charges,Implant Device,3983,20,,3983,percent of total billed charges,Implant Device,3983,20,,3983,percent of total billed charges,Implant Device,3983,20,,3983,percent of total billed charges,Implant Device,9957.5,50,,9957.5,percent of total billed charges,All Other,3983,20,,3983,percent of total billed charges,Implant Device,3983,20,,3983,percent of total billed charges,Implant Device,6771.1,34,"Charges > $500, x 34%",6771.1,percent of total billed charges,Implant Device,3983,20,,3983,percent of total billed charges,Implant Device,3983,20,,3983,percent of total billed charges,Implant Device,3983,20,,3983,percent of total billed charges,Implant Device,3983,20,,3983,percent of total billed charges,Implant Device,3983,20,,3983,percent of total billed charges,Implant Device,3983,20,,3983,percent of total billed charges,Implant Device,3983,20,,3983,percent of total billed charges,Implant Device,3983,20,,3983,percent of total billed charges,Implant Device,3983,20,,3983,percent of total billed charges,Implant Device,3983,20,,3983,percent of total billed charges,Implant Device,3983,20,,3983,percent of total billed charges,Implant Device,3983,20,,3983,percent of total billed charges,Implant Device,3983,20,,3983,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,6771.1,34,"If Charge > 2,000, then 34 percent",6771.1,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,9957.5,
LEAD AICD NON SING/DUAL         ,C1896,HCPCS,,42580415,CDM,275,RC,,,both,,,47500,18746.73,,,18746.73,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,23750,50,,23750,percent of total billed charges,All Other,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,16150,34,"Charges > $500, x 34%",16150,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,16150,34,"If Charge > 2,000, then 34 percent",16150,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,23750,
PACEMAKER ADAPTA DR DEVICE      ,C1785,HCPCS,,44612687,CDM,275,RC,,,both,,,15500,6117.35,,,6117.35,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,3100,20,,3100,percent of total billed charges,Implant Device,3100,20,,3100,percent of total billed charges,Implant Device,3100,20,,3100,percent of total billed charges,Implant Device,3100,20,,3100,percent of total billed charges,Implant Device,3100,20,,3100,percent of total billed charges,Implant Device,7750,50,,7750,percent of total billed charges,All Other,3100,20,,3100,percent of total billed charges,Implant Device,3100,20,,3100,percent of total billed charges,Implant Device,5270,34,"Charges > $500, x 34%",5270,percent of total billed charges,Implant Device,3100,20,,3100,percent of total billed charges,Implant Device,3100,20,,3100,percent of total billed charges,Implant Device,3100,20,,3100,percent of total billed charges,Implant Device,3100,20,,3100,percent of total billed charges,Implant Device,3100,20,,3100,percent of total billed charges,Implant Device,3100,20,,3100,percent of total billed charges,Implant Device,3100,20,,3100,percent of total billed charges,Implant Device,3100,20,,3100,percent of total billed charges,Implant Device,3100,20,,3100,percent of total billed charges,Implant Device,3100,20,,3100,percent of total billed charges,Implant Device,3100,20,,3100,percent of total billed charges,Implant Device,3100,20,,3100,percent of total billed charges,Implant Device,3100,20,,3100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,5270,34,"If Charge > 2,000, then 34 percent",5270,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,7750,
LENS IOC ANT EQCON LI22UV +5 TO +30D 13.75MM 6.0MM OPTIC,V2630,HCPCS,,42104323,CDM,276,RC,,,both,,,625,246.67,,,246.67,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,312.5,50,,312.5,percent of total billed charges,All Other,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,212.5,34,"Charges > $500, x 34%",212.5,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,312.5,
LENS IOC ANT CHAMBER SOFTPORT SE LI61SE 11.0D,V2632,HCPCS,,42104331,CDM,276,RC,,,both,,,687.5,271.33,,,271.33,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,137.5,20,,137.5,percent of total billed charges,Implant Device,137.5,20,,137.5,percent of total billed charges,Implant Device,137.5,20,,137.5,percent of total billed charges,Implant Device,137.5,20,,137.5,percent of total billed charges,Implant Device,137.5,20,,137.5,percent of total billed charges,Implant Device,343.75,50,,343.75,percent of total billed charges,All Other,137.5,20,,137.5,percent of total billed charges,Implant Device,137.5,20,,137.5,percent of total billed charges,Implant Device,233.75,34,"Charges > $500, x 34%",233.75,percent of total billed charges,Implant Device,137.5,20,,137.5,percent of total billed charges,Implant Device,137.5,20,,137.5,percent of total billed charges,Implant Device,137.5,20,,137.5,percent of total billed charges,Implant Device,137.5,20,,137.5,percent of total billed charges,Implant Device,137.5,20,,137.5,percent of total billed charges,Implant Device,137.5,20,,137.5,percent of total billed charges,Implant Device,137.5,20,,137.5,percent of total billed charges,Implant Device,137.5,20,,137.5,percent of total billed charges,Implant Device,137.5,20,,137.5,percent of total billed charges,Implant Device,137.5,20,,137.5,percent of total billed charges,Implant Device,137.5,20,,137.5,percent of total billed charges,Implant Device,137.5,20,,137.5,percent of total billed charges,Implant Device,137.5,20,,137.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,343.75,
LENS INTRAOCULAR POSTERIOR BICONVEX ACRYSOF SN60WF +17.5D 6X13,V2632,HCPCS,,42133124,CDM,276,RC,,,both,,,875,345.33,,,345.33,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,437.5,50,,437.5,percent of total billed charges,All Other,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,297.5,34,"Charges > $500, x 34%",297.5,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,437.5,
IOL PC W/EYELETS 10,V2632,HCPCS,,42136119,CDM,276,RC,,,both,,,625,246.67,,,246.67,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,312.5,50,,312.5,percent of total billed charges,All Other,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,212.5,34,"Charges > $500, x 34%",212.5,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,125,20,,125,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,312.5,
LENS INTRAOCULAR ANTERIOR BICONVEX ACRYSOF SN60AT +11.5D 6X13MM,V2632,HCPCS,,42136267,CDM,276,RC,,,both,,,875,345.33,,,345.33,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,437.5,50,,437.5,percent of total billed charges,All Other,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,297.5,34,"Charges > $500, x 34%",297.5,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,175,20,,175,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,437.5,
TELESCOPIC INTRAOCULAR LENS     ,C1840,HCPCS,,42580308,CDM,276,RC,,,both,,,78725,31070.24,,,31070.24,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,15745,20,,15745,percent of total billed charges,Implant Device,15745,20,,15745,percent of total billed charges,Implant Device,15745,20,,15745,percent of total billed charges,Implant Device,15745,20,,15745,percent of total billed charges,Implant Device,15745,20,,15745,percent of total billed charges,Implant Device,39362.5,50,,39362.5,percent of total billed charges,All Other,15745,20,,15745,percent of total billed charges,Implant Device,15745,20,,15745,percent of total billed charges,Implant Device,26766.5,34,"Charges > $500, x 34%",26766.5,percent of total billed charges,Implant Device,15745,20,,15745,percent of total billed charges,Implant Device,15745,20,,15745,percent of total billed charges,Implant Device,15745,20,,15745,percent of total billed charges,Implant Device,15745,20,,15745,percent of total billed charges,Implant Device,15745,20,,15745,percent of total billed charges,Implant Device,15745,20,,15745,percent of total billed charges,Implant Device,15745,20,,15745,percent of total billed charges,Implant Device,15745,20,,15745,percent of total billed charges,Implant Device,15745,20,,15745,percent of total billed charges,Implant Device,15745,20,,15745,percent of total billed charges,Implant Device,15745,20,,15745,percent of total billed charges,Implant Device,15745,20,,15745,percent of total billed charges,Implant Device,15745,20,,15745,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,26766.5,34,"If Charge > 2,000, then 34 percent",26766.5,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,39362.5,
PRESBYOPIA-CORRECT FUNCTION     ,V2788,HCPCS,,42580761,CDM,276,RC,,,both,,,5075,2002.94,,,2002.94,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,1015,20,,1015,percent of total billed charges,Implant Device,1015,20,,1015,percent of total billed charges,Implant Device,1015,20,,1015,percent of total billed charges,Implant Device,1015,20,,1015,percent of total billed charges,Implant Device,1015,20,,1015,percent of total billed charges,Implant Device,2537.5,50,,2537.5,percent of total billed charges,All Other,1015,20,,1015,percent of total billed charges,Implant Device,1015,20,,1015,percent of total billed charges,Implant Device,1725.5,34,"Charges > $500, x 34%",1725.5,percent of total billed charges,Implant Device,1015,20,,1015,percent of total billed charges,Implant Device,1015,20,,1015,percent of total billed charges,Implant Device,1015,20,,1015,percent of total billed charges,Implant Device,1015,20,,1015,percent of total billed charges,Implant Device,1015,20,,1015,percent of total billed charges,Implant Device,1015,20,,1015,percent of total billed charges,Implant Device,1015,20,,1015,percent of total billed charges,Implant Device,1015,20,,1015,percent of total billed charges,Implant Device,1015,20,,1015,percent of total billed charges,Implant Device,1015,20,,1015,percent of total billed charges,Implant Device,1015,20,,1015,percent of total billed charges,Implant Device,1015,20,,1015,percent of total billed charges,Implant Device,1015,20,,1015,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,1725.5,34,"If Charge > 2,000, then 34 percent",1725.5,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,2537.5,
ANTERIOR CHAMBER IOL            ,V2630,HCPCS,,42581371,CDM,276,RC,,,both,,,1500,592,,,592,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,300,20,,300,percent of total billed charges,Implant Device,300,20,,300,percent of total billed charges,Implant Device,300,20,,300,percent of total billed charges,Implant Device,300,20,,300,percent of total billed charges,Implant Device,300,20,,300,percent of total billed charges,Implant Device,750,50,,750,percent of total billed charges,All Other,300,20,,300,percent of total billed charges,Implant Device,300,20,,300,percent of total billed charges,Implant Device,510,34,"Charges > $500, x 34%",510,percent of total billed charges,Implant Device,300,20,,300,percent of total billed charges,Implant Device,300,20,,300,percent of total billed charges,Implant Device,300,20,,300,percent of total billed charges,Implant Device,300,20,,300,percent of total billed charges,Implant Device,300,20,,300,percent of total billed charges,Implant Device,300,20,,300,percent of total billed charges,Implant Device,300,20,,300,percent of total billed charges,Implant Device,300,20,,300,percent of total billed charges,Implant Device,300,20,,300,percent of total billed charges,Implant Device,300,20,,300,percent of total billed charges,Implant Device,300,20,,300,percent of total billed charges,Implant Device,300,20,,300,percent of total billed charges,Implant Device,300,20,,300,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,750,
POSTERIOR CHAMBR IOL            ,V2632,HCPCS,,42581389,CDM,276,RC,,,both,,,4975,1963.47,,,1963.47,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,2487.5,50,,2487.5,percent of total billed charges,All Other,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,1691.5,34,"Charges > $500, x 34%",1691.5,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,1691.5,34,"If Charge > 2,000, then 34 percent",1691.5,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,2487.5,
ASTIGMATISM-CORRECT FUNCTION    ,V2787,HCPCS,,42581397,CDM,276,RC,,,both,,,4920,1941.77,,,1941.77,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,984,20,,984,percent of total billed charges,Implant Device,984,20,,984,percent of total billed charges,Implant Device,984,20,,984,percent of total billed charges,Implant Device,984,20,,984,percent of total billed charges,Implant Device,984,20,,984,percent of total billed charges,Implant Device,2460,50,,2460,percent of total billed charges,All Other,984,20,,984,percent of total billed charges,Implant Device,984,20,,984,percent of total billed charges,Implant Device,1672.8,34,"Charges > $500, x 34%",1672.8,percent of total billed charges,Implant Device,984,20,,984,percent of total billed charges,Implant Device,984,20,,984,percent of total billed charges,Implant Device,984,20,,984,percent of total billed charges,Implant Device,984,20,,984,percent of total billed charges,Implant Device,984,20,,984,percent of total billed charges,Implant Device,984,20,,984,percent of total billed charges,Implant Device,984,20,,984,percent of total billed charges,Implant Device,984,20,,984,percent of total billed charges,Implant Device,984,20,,984,percent of total billed charges,Implant Device,984,20,,984,percent of total billed charges,Implant Device,984,20,,984,percent of total billed charges,Implant Device,984,20,,984,percent of total billed charges,Implant Device,984,20,,984,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,1672.8,34,"If Charge > 2,000, then 34 percent",1672.8,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,2460,
STENT COR DRIVER 3.0 X 30,C1876,HCPCS,,42103911,CDM,278,RC,,,both,,,4750,1874.67,,,1874.67,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,2375,50,,2375,percent of total billed charges,All Other,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,1615,34,"Charges > $500, x 34%",1615,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,1615,34,"If Charge > 2,000, then 34 percent",1615,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,2375,
GRAFT PUTTY MATRIX BONE DEMINERALIZED GRAFTON LD 10ML 523110,C1713,HCPCS,,42105841,CDM,278,RC,,,both,,,5975,2358.14,,,2358.14,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,1195,20,,1195,percent of total billed charges,Implant Device,1195,20,,1195,percent of total billed charges,Implant Device,1195,20,,1195,percent of total billed charges,Implant Device,1195,20,,1195,percent of total billed charges,Implant Device,1195,20,,1195,percent of total billed charges,Implant Device,2987.5,50,,2987.5,percent of total billed charges,All Other,1195,20,,1195,percent of total billed charges,Implant Device,1195,20,,1195,percent of total billed charges,Implant Device,2031.5,34,"Charges > $500, x 34%",2031.5,percent of total billed charges,Implant Device,1195,20,,1195,percent of total billed charges,Implant Device,1195,20,,1195,percent of total billed charges,Implant Device,1195,20,,1195,percent of total billed charges,Implant Device,1195,20,,1195,percent of total billed charges,Implant Device,1195,20,,1195,percent of total billed charges,Implant Device,1195,20,,1195,percent of total billed charges,Implant Device,1195,20,,1195,percent of total billed charges,Implant Device,1195,20,,1195,percent of total billed charges,Implant Device,1195,20,,1195,percent of total billed charges,Implant Device,1195,20,,1195,percent of total billed charges,Implant Device,1195,20,,1195,percent of total billed charges,Implant Device,1195,20,,1195,percent of total billed charges,Implant Device,1195,20,,1195,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,2031.5,34,"If Charge > 2,000, then 34 percent",2031.5,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,2987.5,
GRAFT MATRIX BONE CRUNCH DEMINERALIZED 15CC 524115,C1713,HCPCS,,42105866,CDM,278,RC,,,both,,,6875,2713.34,,,2713.34,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,1375,20,,1375,percent of total billed charges,Implant Device,1375,20,,1375,percent of total billed charges,Implant Device,1375,20,,1375,percent of total billed charges,Implant Device,1375,20,,1375,percent of total billed charges,Implant Device,1375,20,,1375,percent of total billed charges,Implant Device,3437.5,50,,3437.5,percent of total billed charges,All Other,1375,20,,1375,percent of total billed charges,Implant Device,1375,20,,1375,percent of total billed charges,Implant Device,2337.5,34,"Charges > $500, x 34%",2337.5,percent of total billed charges,Implant Device,1375,20,,1375,percent of total billed charges,Implant Device,1375,20,,1375,percent of total billed charges,Implant Device,1375,20,,1375,percent of total billed charges,Implant Device,1375,20,,1375,percent of total billed charges,Implant Device,1375,20,,1375,percent of total billed charges,Implant Device,1375,20,,1375,percent of total billed charges,Implant Device,1375,20,,1375,percent of total billed charges,Implant Device,1375,20,,1375,percent of total billed charges,Implant Device,1375,20,,1375,percent of total billed charges,Implant Device,1375,20,,1375,percent of total billed charges,Implant Device,1375,20,,1375,percent of total billed charges,Implant Device,1375,20,,1375,percent of total billed charges,Implant Device,1375,20,,1375,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,2337.5,34,"If Charge > 2,000, then 34 percent",2337.5,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,3437.5,
SCREW CRTX SELF TAPPING TTNM 2.4X18MM,C1713,HCPCS,,42106153,CDM,278,RC,,,both,,,221.45,87.4,,,87.4,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,110.73,50,,110.73,percent of total billed charges,All Other,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,110.73,
SCREW LOCKING TTNM 3X14MM,C1713,HCPCS,,42106161,CDM,278,RC,,,both,,,432.15,170.56,,,170.56,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,86.43,20,,86.43,percent of total billed charges,Implant Device,86.43,20,,86.43,percent of total billed charges,Implant Device,86.43,20,,86.43,percent of total billed charges,Implant Device,86.43,20,,86.43,percent of total billed charges,Implant Device,86.43,20,,86.43,percent of total billed charges,Implant Device,216.08,50,,216.08,percent of total billed charges,All Other,86.43,20,,86.43,percent of total billed charges,Implant Device,86.43,20,,86.43,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,86.43,20,,86.43,percent of total billed charges,Implant Device,86.43,20,,86.43,percent of total billed charges,Implant Device,86.43,20,,86.43,percent of total billed charges,Implant Device,86.43,20,,86.43,percent of total billed charges,Implant Device,86.43,20,,86.43,percent of total billed charges,Implant Device,86.43,20,,86.43,percent of total billed charges,Implant Device,86.43,20,,86.43,percent of total billed charges,Implant Device,86.43,20,,86.43,percent of total billed charges,Implant Device,86.43,20,,86.43,percent of total billed charges,Implant Device,86.43,20,,86.43,percent of total billed charges,Implant Device,86.43,20,,86.43,percent of total billed charges,Implant Device,86.43,20,,86.43,percent of total billed charges,Implant Device,86.43,20,,86.43,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,216.08,
SCREW LOCKING TTNM RECON PLATE 2.4X14MM,C1713,HCPCS,,42106229,CDM,278,RC,,,both,,,371.95,146.8,,,146.8,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,185.98,50,,185.98,percent of total billed charges,All Other,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,185.98,
SCREW CRTX SELF TAPPING CRUCIFORM RECESS TTNM 2.4X8MM,C1713,HCPCS,,42106278,CDM,278,RC,,,both,,,221.45,87.4,,,87.4,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,110.73,50,,110.73,percent of total billed charges,All Other,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,110.73,
GRAFT DURAMATRIX ONLAY PLUS 5X7,C1763,HCPCS,,42106567,CDM,278,RC,,,both,,,7477.55,2951.15,,,2951.15,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,1495.51,20,,1495.51,percent of total billed charges,Implant Device,1495.51,20,,1495.51,percent of total billed charges,Implant Device,1495.51,20,,1495.51,percent of total billed charges,Implant Device,1495.51,20,,1495.51,percent of total billed charges,Implant Device,1495.51,20,,1495.51,percent of total billed charges,Implant Device,3738.78,50,,3738.78,percent of total billed charges,All Other,1495.51,20,,1495.51,percent of total billed charges,Implant Device,1495.51,20,,1495.51,percent of total billed charges,Implant Device,2542.37,34,"Charges > $500, x 34%",2542.37,percent of total billed charges,Implant Device,1495.51,20,,1495.51,percent of total billed charges,Implant Device,1495.51,20,,1495.51,percent of total billed charges,Implant Device,1495.51,20,,1495.51,percent of total billed charges,Implant Device,1495.51,20,,1495.51,percent of total billed charges,Implant Device,1495.51,20,,1495.51,percent of total billed charges,Implant Device,1495.51,20,,1495.51,percent of total billed charges,Implant Device,1495.51,20,,1495.51,percent of total billed charges,Implant Device,1495.51,20,,1495.51,percent of total billed charges,Implant Device,1495.51,20,,1495.51,percent of total billed charges,Implant Device,1495.51,20,,1495.51,percent of total billed charges,Implant Device,1495.51,20,,1495.51,percent of total billed charges,Implant Device,1495.51,20,,1495.51,percent of total billed charges,Implant Device,1495.51,20,,1495.51,percent of total billed charges,Implant Device,1296.65,,,1296.65,Other,New York Medicaid APG methodology,1296.65,,,1296.65,Other,100% Medicaid APG methodology,1296.65,,,1296.65,Other,100% Medicaid APG methodology,1296.65,,,1296.65,Other,100% Medicaid APG methodology,2917.46,,,2917.46,Other,225% Medicaid APG methodology,2917.46,,,2917.46,Other,225% Medicaid APG methodology,1983.88,,,1983.88,Other,153% Medicaid APG methodology,2917.46,,,2917.46,Other,225% Medicaid APG methodology,1815.31,,,1815.31,Other,140% Medicaid APG methodology,2542.37,34,"If Charge > 2,000, then 34 percent",2542.37,percent of total billed charges,Implants,3371.29,,,3371.29,Other,260% Medicaid APG methodology,4201.15,,,4201.15,Other,324% Medicaid APG methodology,2787.8,,,2787.8,Other,215% Medicaid APG methodology,2787.8,,,2787.8,Other,215% Medicaid APG methodology,1620.81,,,1620.81,Other,125% Medicaid APG methodology,0.01,4201.15,
PLATE TNSN BAND COMPRES TTNM 4H 2.4X26MM,C1713,HCPCS,,42106757,CDM,278,RC,,,both,,,877.2,346.2,,,346.2,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,175.44,20,,175.44,percent of total billed charges,Implant Device,175.44,20,,175.44,percent of total billed charges,Implant Device,175.44,20,,175.44,percent of total billed charges,Implant Device,175.44,20,,175.44,percent of total billed charges,Implant Device,175.44,20,,175.44,percent of total billed charges,Implant Device,438.6,50,,438.6,percent of total billed charges,All Other,175.44,20,,175.44,percent of total billed charges,Implant Device,175.44,20,,175.44,percent of total billed charges,Implant Device,298.25,34,"Charges > $500, x 34%",298.25,percent of total billed charges,Implant Device,175.44,20,,175.44,percent of total billed charges,Implant Device,175.44,20,,175.44,percent of total billed charges,Implant Device,175.44,20,,175.44,percent of total billed charges,Implant Device,175.44,20,,175.44,percent of total billed charges,Implant Device,175.44,20,,175.44,percent of total billed charges,Implant Device,175.44,20,,175.44,percent of total billed charges,Implant Device,175.44,20,,175.44,percent of total billed charges,Implant Device,175.44,20,,175.44,percent of total billed charges,Implant Device,175.44,20,,175.44,percent of total billed charges,Implant Device,175.44,20,,175.44,percent of total billed charges,Implant Device,175.44,20,,175.44,percent of total billed charges,Implant Device,175.44,20,,175.44,percent of total billed charges,Implant Device,175.44,20,,175.44,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,438.6,
WASHER SPIKED FOOTBALL GEOFIT 10X14MM,C1713,HCPCS,,42108035,CDM,278,RC,,,both,,,1315,518.99,,,518.99,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,263,20,,263,percent of total billed charges,Implant Device,263,20,,263,percent of total billed charges,Implant Device,263,20,,263,percent of total billed charges,Implant Device,263,20,,263,percent of total billed charges,Implant Device,263,20,,263,percent of total billed charges,Implant Device,657.5,50,,657.5,percent of total billed charges,All Other,263,20,,263,percent of total billed charges,Implant Device,263,20,,263,percent of total billed charges,Implant Device,447.1,34,"Charges > $500, x 34%",447.1,percent of total billed charges,Implant Device,263,20,,263,percent of total billed charges,Implant Device,263,20,,263,percent of total billed charges,Implant Device,263,20,,263,percent of total billed charges,Implant Device,263,20,,263,percent of total billed charges,Implant Device,263,20,,263,percent of total billed charges,Implant Device,263,20,,263,percent of total billed charges,Implant Device,263,20,,263,percent of total billed charges,Implant Device,263,20,,263,percent of total billed charges,Implant Device,263,20,,263,percent of total billed charges,Implant Device,263,20,,263,percent of total billed charges,Implant Device,263,20,,263,percent of total billed charges,Implant Device,263,20,,263,percent of total billed charges,Implant Device,263,20,,263,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,657.5,
GRAFT PUTTY MATRIX BONE DEMINERALIZED GRAFTON LOW DOSE 1ML 5,C1713,HCPCS,,42108571,CDM,278,RC,,,both,,,955,376.91,,,376.91,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,191,20,,191,percent of total billed charges,Implant Device,191,20,,191,percent of total billed charges,Implant Device,191,20,,191,percent of total billed charges,Implant Device,191,20,,191,percent of total billed charges,Implant Device,191,20,,191,percent of total billed charges,Implant Device,477.5,50,,477.5,percent of total billed charges,All Other,191,20,,191,percent of total billed charges,Implant Device,191,20,,191,percent of total billed charges,Implant Device,324.7,34,"Charges > $500, x 34%",324.7,percent of total billed charges,Implant Device,191,20,,191,percent of total billed charges,Implant Device,191,20,,191,percent of total billed charges,Implant Device,191,20,,191,percent of total billed charges,Implant Device,191,20,,191,percent of total billed charges,Implant Device,191,20,,191,percent of total billed charges,Implant Device,191,20,,191,percent of total billed charges,Implant Device,191,20,,191,percent of total billed charges,Implant Device,191,20,,191,percent of total billed charges,Implant Device,191,20,,191,percent of total billed charges,Implant Device,191,20,,191,percent of total billed charges,Implant Device,191,20,,191,percent of total billed charges,Implant Device,191,20,,191,percent of total billed charges,Implant Device,191,20,,191,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,477.5,
GRAFT VASCULAR WOVEN STRAIGHT HEMASHIELD PLATINUM 24MMX30CM,C1768,HCPCS,,42109280,CDM,278,RC,,,both,,,2812.5,1110,,,1110,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,562.5,20,,562.5,percent of total billed charges,Implant Device,562.5,20,,562.5,percent of total billed charges,Implant Device,562.5,20,,562.5,percent of total billed charges,Implant Device,562.5,20,,562.5,percent of total billed charges,Implant Device,562.5,20,,562.5,percent of total billed charges,Implant Device,1406.25,50,,1406.25,percent of total billed charges,All Other,562.5,20,,562.5,percent of total billed charges,Implant Device,562.5,20,,562.5,percent of total billed charges,Implant Device,956.25,34,"Charges > $500, x 34%",956.25,percent of total billed charges,Implant Device,562.5,20,,562.5,percent of total billed charges,Implant Device,562.5,20,,562.5,percent of total billed charges,Implant Device,562.5,20,,562.5,percent of total billed charges,Implant Device,562.5,20,,562.5,percent of total billed charges,Implant Device,562.5,20,,562.5,percent of total billed charges,Implant Device,562.5,20,,562.5,percent of total billed charges,Implant Device,562.5,20,,562.5,percent of total billed charges,Implant Device,562.5,20,,562.5,percent of total billed charges,Implant Device,562.5,20,,562.5,percent of total billed charges,Implant Device,562.5,20,,562.5,percent of total billed charges,Implant Device,562.5,20,,562.5,percent of total billed charges,Implant Device,562.5,20,,562.5,percent of total billed charges,Implant Device,562.5,20,,562.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,956.25,34,"If Charge > 2,000, then 34 percent",956.25,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1406.25,
GRAFT VASCULAR WOVEN STRAIGHT HEMASHIELD PLATINUM 26MMX30CM,C1768,HCPCS,,42109330,CDM,278,RC,,,both,,,2925,1154.4,,,1154.4,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,585,20,,585,percent of total billed charges,Implant Device,585,20,,585,percent of total billed charges,Implant Device,585,20,,585,percent of total billed charges,Implant Device,585,20,,585,percent of total billed charges,Implant Device,585,20,,585,percent of total billed charges,Implant Device,1462.5,50,,1462.5,percent of total billed charges,All Other,585,20,,585,percent of total billed charges,Implant Device,585,20,,585,percent of total billed charges,Implant Device,994.5,34,"Charges > $500, x 34%",994.5,percent of total billed charges,Implant Device,585,20,,585,percent of total billed charges,Implant Device,585,20,,585,percent of total billed charges,Implant Device,585,20,,585,percent of total billed charges,Implant Device,585,20,,585,percent of total billed charges,Implant Device,585,20,,585,percent of total billed charges,Implant Device,585,20,,585,percent of total billed charges,Implant Device,585,20,,585,percent of total billed charges,Implant Device,585,20,,585,percent of total billed charges,Implant Device,585,20,,585,percent of total billed charges,Implant Device,585,20,,585,percent of total billed charges,Implant Device,585,20,,585,percent of total billed charges,Implant Device,585,20,,585,percent of total billed charges,Implant Device,585,20,,585,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,994.5,34,"If Charge > 2,000, then 34 percent",994.5,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1462.5,
GRAFT PUTTY DBX GRAFTON 5CC,C1713,HCPCS,,42109686,CDM,278,RC,,,both,,,3499.4,1381.1,,,1381.1,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,699.88,20,,699.88,percent of total billed charges,Implant Device,699.88,20,,699.88,percent of total billed charges,Implant Device,699.88,20,,699.88,percent of total billed charges,Implant Device,699.88,20,,699.88,percent of total billed charges,Implant Device,699.88,20,,699.88,percent of total billed charges,Implant Device,1749.7,50,,1749.7,percent of total billed charges,All Other,699.88,20,,699.88,percent of total billed charges,Implant Device,699.88,20,,699.88,percent of total billed charges,Implant Device,1189.8,34,"Charges > $500, x 34%",1189.8,percent of total billed charges,Implant Device,699.88,20,,699.88,percent of total billed charges,Implant Device,699.88,20,,699.88,percent of total billed charges,Implant Device,699.88,20,,699.88,percent of total billed charges,Implant Device,699.88,20,,699.88,percent of total billed charges,Implant Device,699.88,20,,699.88,percent of total billed charges,Implant Device,699.88,20,,699.88,percent of total billed charges,Implant Device,699.88,20,,699.88,percent of total billed charges,Implant Device,699.88,20,,699.88,percent of total billed charges,Implant Device,699.88,20,,699.88,percent of total billed charges,Implant Device,699.88,20,,699.88,percent of total billed charges,Implant Device,699.88,20,,699.88,percent of total billed charges,Implant Device,699.88,20,,699.88,percent of total billed charges,Implant Device,699.88,20,,699.88,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,1189.8,34,"If Charge > 2,000, then 34 percent",1189.8,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1749.7,
GRAFT STENT AAA ILIAC CUFF XCELERANT DELIVERY 15X15MMX5.5CM,C1876,HCPCS,,42110742,CDM,278,RC,,,both,,,11125,4390.68,,,4390.68,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,2225,20,,2225,percent of total billed charges,Implant Device,2225,20,,2225,percent of total billed charges,Implant Device,2225,20,,2225,percent of total billed charges,Implant Device,2225,20,,2225,percent of total billed charges,Implant Device,2225,20,,2225,percent of total billed charges,Implant Device,5562.5,50,,5562.5,percent of total billed charges,All Other,2225,20,,2225,percent of total billed charges,Implant Device,2225,20,,2225,percent of total billed charges,Implant Device,3782.5,34,"Charges > $500, x 34%",3782.5,percent of total billed charges,Implant Device,2225,20,,2225,percent of total billed charges,Implant Device,2225,20,,2225,percent of total billed charges,Implant Device,2225,20,,2225,percent of total billed charges,Implant Device,2225,20,,2225,percent of total billed charges,Implant Device,2225,20,,2225,percent of total billed charges,Implant Device,2225,20,,2225,percent of total billed charges,Implant Device,2225,20,,2225,percent of total billed charges,Implant Device,2225,20,,2225,percent of total billed charges,Implant Device,2225,20,,2225,percent of total billed charges,Implant Device,2225,20,,2225,percent of total billed charges,Implant Device,2225,20,,2225,percent of total billed charges,Implant Device,2225,20,,2225,percent of total billed charges,Implant Device,2225,20,,2225,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,3782.5,34,"If Charge > 2,000, then 34 percent",3782.5,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,5562.5,
GRAFT STENT AAA ILIAC CUFF XCELERANT DELIVERY 16X16MMX8.5CM,C1768,HCPCS,,42110908,CDM,278,RC,,,both,,,13375,5278.68,,,5278.68,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,2675,20,,2675,percent of total billed charges,Implant Device,2675,20,,2675,percent of total billed charges,Implant Device,2675,20,,2675,percent of total billed charges,Implant Device,2675,20,,2675,percent of total billed charges,Implant Device,2675,20,,2675,percent of total billed charges,Implant Device,6687.5,50,,6687.5,percent of total billed charges,All Other,2675,20,,2675,percent of total billed charges,Implant Device,2675,20,,2675,percent of total billed charges,Implant Device,4547.5,34,"Charges > $500, x 34%",4547.5,percent of total billed charges,Implant Device,2675,20,,2675,percent of total billed charges,Implant Device,2675,20,,2675,percent of total billed charges,Implant Device,2675,20,,2675,percent of total billed charges,Implant Device,2675,20,,2675,percent of total billed charges,Implant Device,2675,20,,2675,percent of total billed charges,Implant Device,2675,20,,2675,percent of total billed charges,Implant Device,2675,20,,2675,percent of total billed charges,Implant Device,2675,20,,2675,percent of total billed charges,Implant Device,2675,20,,2675,percent of total billed charges,Implant Device,2675,20,,2675,percent of total billed charges,Implant Device,2675,20,,2675,percent of total billed charges,Implant Device,2675,20,,2675,percent of total billed charges,Implant Device,2675,20,,2675,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,4547.5,34,"If Charge > 2,000, then 34 percent",4547.5,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,6687.5,
GRAFT STENT AAA ILIAC CUFF XCELERANT DELIVERY 18X18MMX8.5CM,C1768,HCPCS,,42110957,CDM,278,RC,,,both,,,13875,5476.02,,,5476.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,2775,20,,2775,percent of total billed charges,Implant Device,2775,20,,2775,percent of total billed charges,Implant Device,2775,20,,2775,percent of total billed charges,Implant Device,2775,20,,2775,percent of total billed charges,Implant Device,2775,20,,2775,percent of total billed charges,Implant Device,6937.5,50,,6937.5,percent of total billed charges,All Other,2775,20,,2775,percent of total billed charges,Implant Device,2775,20,,2775,percent of total billed charges,Implant Device,4717.5,34,"Charges > $500, x 34%",4717.5,percent of total billed charges,Implant Device,2775,20,,2775,percent of total billed charges,Implant Device,2775,20,,2775,percent of total billed charges,Implant Device,2775,20,,2775,percent of total billed charges,Implant Device,2775,20,,2775,percent of total billed charges,Implant Device,2775,20,,2775,percent of total billed charges,Implant Device,2775,20,,2775,percent of total billed charges,Implant Device,2775,20,,2775,percent of total billed charges,Implant Device,2775,20,,2775,percent of total billed charges,Implant Device,2775,20,,2775,percent of total billed charges,Implant Device,2775,20,,2775,percent of total billed charges,Implant Device,2775,20,,2775,percent of total billed charges,Implant Device,2775,20,,2775,percent of total billed charges,Implant Device,2775,20,,2775,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,4717.5,34,"If Charge > 2,000, then 34 percent",4717.5,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,6937.5,
GRAFT STENT AAA ILIAC CUFF XCELERANT DELIVERY 16X16MMX11.5CM,C1874,HCPCS,,42110973,CDM,278,RC,,,both,,,15250,6018.69,,,6018.69,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,3050,20,,3050,percent of total billed charges,Implant Device,3050,20,,3050,percent of total billed charges,Implant Device,3050,20,,3050,percent of total billed charges,Implant Device,3050,20,,3050,percent of total billed charges,Implant Device,3050,20,,3050,percent of total billed charges,Implant Device,7625,50,,7625,percent of total billed charges,All Other,3050,20,,3050,percent of total billed charges,Implant Device,3050,20,,3050,percent of total billed charges,Implant Device,5185,34,"Charges > $500, x 34%",5185,percent of total billed charges,Implant Device,3050,20,,3050,percent of total billed charges,Implant Device,3050,20,,3050,percent of total billed charges,Implant Device,3050,20,,3050,percent of total billed charges,Implant Device,3050,20,,3050,percent of total billed charges,Implant Device,3050,20,,3050,percent of total billed charges,Implant Device,3050,20,,3050,percent of total billed charges,Implant Device,3050,20,,3050,percent of total billed charges,Implant Device,3050,20,,3050,percent of total billed charges,Implant Device,3050,20,,3050,percent of total billed charges,Implant Device,3050,20,,3050,percent of total billed charges,Implant Device,3050,20,,3050,percent of total billed charges,Implant Device,3050,20,,3050,percent of total billed charges,Implant Device,3050,20,,3050,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,5185,34,"If Charge > 2,000, then 34 percent",5185,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,7625,
GRAFT STENT AAA ILIAC CUFF XCELERANT DELIVERY 14X14MMX11.5CM,C1768,HCPCS,,42111146,CDM,278,RC,,,both,,,14125,5574.69,,,5574.69,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,2825,20,,2825,percent of total billed charges,Implant Device,2825,20,,2825,percent of total billed charges,Implant Device,2825,20,,2825,percent of total billed charges,Implant Device,2825,20,,2825,percent of total billed charges,Implant Device,2825,20,,2825,percent of total billed charges,Implant Device,7062.5,50,,7062.5,percent of total billed charges,All Other,2825,20,,2825,percent of total billed charges,Implant Device,2825,20,,2825,percent of total billed charges,Implant Device,4802.5,34,"Charges > $500, x 34%",4802.5,percent of total billed charges,Implant Device,2825,20,,2825,percent of total billed charges,Implant Device,2825,20,,2825,percent of total billed charges,Implant Device,2825,20,,2825,percent of total billed charges,Implant Device,2825,20,,2825,percent of total billed charges,Implant Device,2825,20,,2825,percent of total billed charges,Implant Device,2825,20,,2825,percent of total billed charges,Implant Device,2825,20,,2825,percent of total billed charges,Implant Device,2825,20,,2825,percent of total billed charges,Implant Device,2825,20,,2825,percent of total billed charges,Implant Device,2825,20,,2825,percent of total billed charges,Implant Device,2825,20,,2825,percent of total billed charges,Implant Device,2825,20,,2825,percent of total billed charges,Implant Device,2825,20,,2825,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,4802.5,34,"If Charge > 2,000, then 34 percent",4802.5,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,7062.5,
GRAFT STENT AAA ILIAC CUFF XCELERANT DELIVERY 16X20MMX11.5CM,C1768,HCPCS,,42111336,CDM,278,RC,,,both,,,17250,6808.02,,,6808.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,3450,20,,3450,percent of total billed charges,Implant Device,3450,20,,3450,percent of total billed charges,Implant Device,3450,20,,3450,percent of total billed charges,Implant Device,3450,20,,3450,percent of total billed charges,Implant Device,3450,20,,3450,percent of total billed charges,Implant Device,8625,50,,8625,percent of total billed charges,All Other,3450,20,,3450,percent of total billed charges,Implant Device,3450,20,,3450,percent of total billed charges,Implant Device,5865,34,"Charges > $500, x 34%",5865,percent of total billed charges,Implant Device,3450,20,,3450,percent of total billed charges,Implant Device,3450,20,,3450,percent of total billed charges,Implant Device,3450,20,,3450,percent of total billed charges,Implant Device,3450,20,,3450,percent of total billed charges,Implant Device,3450,20,,3450,percent of total billed charges,Implant Device,3450,20,,3450,percent of total billed charges,Implant Device,3450,20,,3450,percent of total billed charges,Implant Device,3450,20,,3450,percent of total billed charges,Implant Device,3450,20,,3450,percent of total billed charges,Implant Device,3450,20,,3450,percent of total billed charges,Implant Device,3450,20,,3450,percent of total billed charges,Implant Device,3450,20,,3450,percent of total billed charges,Implant Device,3450,20,,3450,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,5865,34,"If Charge > 2,000, then 34 percent",5865,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,8625,
GRAFT STENT AAA ILIAC CUFF XCELERANT DELIVERY 16X20MMX13.5CM,C1768,HCPCS,,42111369,CDM,278,RC,,,both,,,18250,7202.69,,,7202.69,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,3650,20,,3650,percent of total billed charges,Implant Device,3650,20,,3650,percent of total billed charges,Implant Device,3650,20,,3650,percent of total billed charges,Implant Device,3650,20,,3650,percent of total billed charges,Implant Device,3650,20,,3650,percent of total billed charges,Implant Device,9125,50,,9125,percent of total billed charges,All Other,3650,20,,3650,percent of total billed charges,Implant Device,3650,20,,3650,percent of total billed charges,Implant Device,6205,34,"Charges > $500, x 34%",6205,percent of total billed charges,Implant Device,3650,20,,3650,percent of total billed charges,Implant Device,3650,20,,3650,percent of total billed charges,Implant Device,3650,20,,3650,percent of total billed charges,Implant Device,3650,20,,3650,percent of total billed charges,Implant Device,3650,20,,3650,percent of total billed charges,Implant Device,3650,20,,3650,percent of total billed charges,Implant Device,3650,20,,3650,percent of total billed charges,Implant Device,3650,20,,3650,percent of total billed charges,Implant Device,3650,20,,3650,percent of total billed charges,Implant Device,3650,20,,3650,percent of total billed charges,Implant Device,3650,20,,3650,percent of total billed charges,Implant Device,3650,20,,3650,percent of total billed charges,Implant Device,3650,20,,3650,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,6205,34,"If Charge > 2,000, then 34 percent",6205,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,9125,
PLATE BNE SEMI TUBLR 5H 87MM,C1713,HCPCS,,42117572,CDM,278,RC,,,both,,,145,57.23,,,57.23,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,29,20,,29,percent of total billed charges,Implant Device,29,20,,29,percent of total billed charges,Implant Device,29,20,,29,percent of total billed charges,Implant Device,29,20,,29,percent of total billed charges,Implant Device,29,20,,29,percent of total billed charges,Implant Device,72.5,50,,72.5,percent of total billed charges,All Other,29,20,,29,percent of total billed charges,Implant Device,29,20,,29,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,29,20,,29,percent of total billed charges,Implant Device,29,20,,29,percent of total billed charges,Implant Device,29,20,,29,percent of total billed charges,Implant Device,29,20,,29,percent of total billed charges,Implant Device,29,20,,29,percent of total billed charges,Implant Device,29,20,,29,percent of total billed charges,Implant Device,29,20,,29,percent of total billed charges,Implant Device,29,20,,29,percent of total billed charges,Implant Device,29,20,,29,percent of total billed charges,Implant Device,29,20,,29,percent of total billed charges,Implant Device,29,20,,29,percent of total billed charges,Implant Device,29,20,,29,percent of total billed charges,Implant Device,29,20,,29,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,72.5,
SCREW LOCKING TTNM 2.4X8MM,C1713,HCPCS,,42120139,CDM,278,RC,,,both,,,371.95,146.8,,,146.8,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,185.98,50,,185.98,percent of total billed charges,All Other,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,185.98,
STENT BILI BLLN EXP 10X40MM,C1877,HCPCS,,42123067,CDM,278,RC,,,both,,,4750,1874.67,,,1874.67,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,2375,50,,2375,percent of total billed charges,All Other,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,1615,34,"Charges > $500, x 34%",1615,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,950,20,,950,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,1615,34,"If Charge > 2,000, then 34 percent",1615,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,2375,
CATH ASH SPLIT KIDNEY DIALYSIS 14FR 28CM,C1750,HCPCS,,42130294,CDM,278,RC,,,both,,,1950,769.6,,,769.6,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,390,20,,390,percent of total billed charges,Implant Device,390,20,,390,percent of total billed charges,Implant Device,390,20,,390,percent of total billed charges,Implant Device,390,20,,390,percent of total billed charges,Implant Device,390,20,,390,percent of total billed charges,Implant Device,975,50,,975,percent of total billed charges,All Other,390,20,,390,percent of total billed charges,Implant Device,390,20,,390,percent of total billed charges,Implant Device,663,34,"Charges > $500, x 34%",663,percent of total billed charges,Implant Device,390,20,,390,percent of total billed charges,Implant Device,390,20,,390,percent of total billed charges,Implant Device,390,20,,390,percent of total billed charges,Implant Device,390,20,,390,percent of total billed charges,Implant Device,390,20,,390,percent of total billed charges,Implant Device,390,20,,390,percent of total billed charges,Implant Device,390,20,,390,percent of total billed charges,Implant Device,390,20,,390,percent of total billed charges,Implant Device,390,20,,390,percent of total billed charges,Implant Device,390,20,,390,percent of total billed charges,Implant Device,390,20,,390,percent of total billed charges,Implant Device,390,20,,390,percent of total billed charges,Implant Device,390,20,,390,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,975,
IMPLANT COLLAGEN DERMAL PERMACOL 2X5CMX0.5MM,C1763,HCPCS,,42131052,CDM,278,RC,,,both,,,2200,868.27,,,868.27,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,440,20,,440,percent of total billed charges,Implant Device,440,20,,440,percent of total billed charges,Implant Device,440,20,,440,percent of total billed charges,Implant Device,440,20,,440,percent of total billed charges,Implant Device,440,20,,440,percent of total billed charges,Implant Device,1100,50,,1100,percent of total billed charges,All Other,440,20,,440,percent of total billed charges,Implant Device,440,20,,440,percent of total billed charges,Implant Device,748,34,"Charges > $500, x 34%",748,percent of total billed charges,Implant Device,440,20,,440,percent of total billed charges,Implant Device,440,20,,440,percent of total billed charges,Implant Device,440,20,,440,percent of total billed charges,Implant Device,440,20,,440,percent of total billed charges,Implant Device,440,20,,440,percent of total billed charges,Implant Device,440,20,,440,percent of total billed charges,Implant Device,440,20,,440,percent of total billed charges,Implant Device,440,20,,440,percent of total billed charges,Implant Device,440,20,,440,percent of total billed charges,Implant Device,440,20,,440,percent of total billed charges,Implant Device,440,20,,440,percent of total billed charges,Implant Device,440,20,,440,percent of total billed charges,Implant Device,440,20,,440,percent of total billed charges,Implant Device,1296.65,,,1296.65,Other,New York Medicaid APG methodology,1296.65,,,1296.65,Other,100% Medicaid APG methodology,1296.65,,,1296.65,Other,100% Medicaid APG methodology,1296.65,,,1296.65,Other,100% Medicaid APG methodology,2917.46,,,2917.46,Other,225% Medicaid APG methodology,2917.46,,,2917.46,Other,225% Medicaid APG methodology,1983.88,,,1983.88,Other,153% Medicaid APG methodology,2917.46,,,2917.46,Other,225% Medicaid APG methodology,1815.31,,,1815.31,Other,140% Medicaid APG methodology,748,34,"If Charge > 2,000, then 34 percent",748,percent of total billed charges,Implants,3371.29,,,3371.29,Other,260% Medicaid APG methodology,4201.15,,,4201.15,Other,324% Medicaid APG methodology,2787.8,,,2787.8,Other,215% Medicaid APG methodology,2787.8,,,2787.8,Other,215% Medicaid APG methodology,1620.81,,,1620.81,Other,125% Medicaid APG methodology,0.01,4201.15,
STENT VARIABLE LENGTH PERCUFLEX 4.8 10-16W .035GW,C2625,HCPCS,,42131276,CDM,278,RC,,,both,,,770,303.89,,,303.89,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,154,20,,154,percent of total billed charges,Implant Device,154,20,,154,percent of total billed charges,Implant Device,154,20,,154,percent of total billed charges,Implant Device,154,20,,154,percent of total billed charges,Implant Device,154,20,,154,percent of total billed charges,Implant Device,385,50,,385,percent of total billed charges,All Other,154,20,,154,percent of total billed charges,Implant Device,154,20,,154,percent of total billed charges,Implant Device,261.8,34,"Charges > $500, x 34%",261.8,percent of total billed charges,Implant Device,154,20,,154,percent of total billed charges,Implant Device,154,20,,154,percent of total billed charges,Implant Device,154,20,,154,percent of total billed charges,Implant Device,154,20,,154,percent of total billed charges,Implant Device,154,20,,154,percent of total billed charges,Implant Device,154,20,,154,percent of total billed charges,Implant Device,154,20,,154,percent of total billed charges,Implant Device,154,20,,154,percent of total billed charges,Implant Device,154,20,,154,percent of total billed charges,Implant Device,154,20,,154,percent of total billed charges,Implant Device,154,20,,154,percent of total billed charges,Implant Device,154,20,,154,percent of total billed charges,Implant Device,154,20,,154,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,385,
PLATE LOCKING MINI NRW TTNM 4H 2MM,C1713,HCPCS,,42132282,CDM,278,RC,,,both,,,806.25,318.2,,,318.2,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,161.25,20,,161.25,percent of total billed charges,Implant Device,161.25,20,,161.25,percent of total billed charges,Implant Device,161.25,20,,161.25,percent of total billed charges,Implant Device,161.25,20,,161.25,percent of total billed charges,Implant Device,161.25,20,,161.25,percent of total billed charges,Implant Device,403.13,50,,403.13,percent of total billed charges,All Other,161.25,20,,161.25,percent of total billed charges,Implant Device,161.25,20,,161.25,percent of total billed charges,Implant Device,274.13,34,"Charges > $500, x 34%",274.13,percent of total billed charges,Implant Device,161.25,20,,161.25,percent of total billed charges,Implant Device,161.25,20,,161.25,percent of total billed charges,Implant Device,161.25,20,,161.25,percent of total billed charges,Implant Device,161.25,20,,161.25,percent of total billed charges,Implant Device,161.25,20,,161.25,percent of total billed charges,Implant Device,161.25,20,,161.25,percent of total billed charges,Implant Device,161.25,20,,161.25,percent of total billed charges,Implant Device,161.25,20,,161.25,percent of total billed charges,Implant Device,161.25,20,,161.25,percent of total billed charges,Implant Device,161.25,20,,161.25,percent of total billed charges,Implant Device,161.25,20,,161.25,percent of total billed charges,Implant Device,161.25,20,,161.25,percent of total billed charges,Implant Device,161.25,20,,161.25,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,403.13,
PORT VASCULAR LOW PROFILE CATHETER TITANIUM VORTEX LP 6.9FR,C1788,HCPCS,,42132431,CDM,278,RC,,,both,,,2755,1087.31,,,1087.31,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,551,20,,551,percent of total billed charges,Implant Device,551,20,,551,percent of total billed charges,Implant Device,551,20,,551,percent of total billed charges,Implant Device,551,20,,551,percent of total billed charges,Implant Device,551,20,,551,percent of total billed charges,Implant Device,1377.5,50,,1377.5,percent of total billed charges,All Other,551,20,,551,percent of total billed charges,Implant Device,551,20,,551,percent of total billed charges,Implant Device,936.7,34,"Charges > $500, x 34%",936.7,percent of total billed charges,Implant Device,551,20,,551,percent of total billed charges,Implant Device,551,20,,551,percent of total billed charges,Implant Device,551,20,,551,percent of total billed charges,Implant Device,551,20,,551,percent of total billed charges,Implant Device,551,20,,551,percent of total billed charges,Implant Device,551,20,,551,percent of total billed charges,Implant Device,551,20,,551,percent of total billed charges,Implant Device,551,20,,551,percent of total billed charges,Implant Device,551,20,,551,percent of total billed charges,Implant Device,551,20,,551,percent of total billed charges,Implant Device,551,20,,551,percent of total billed charges,Implant Device,551,20,,551,percent of total billed charges,Implant Device,551,20,,551,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,936.7,34,"If Charge > 2,000, then 34 percent",936.7,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1377.5,
SCREW LOCKING TTNM RECON PLATE 2.4X10MM,C1713,HCPCS,,42134288,CDM,278,RC,,,both,,,371.95,146.8,,,146.8,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,185.98,50,,185.98,percent of total billed charges,All Other,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,74.39,20,,74.39,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,185.98,
CATH INT THCL RADPQ 12-81CM,C1755,HCPCS,,42136416,CDM,278,RC,,,both,,,3475,1371.47,,,1371.47,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,695,20,,695,percent of total billed charges,Implant Device,695,20,,695,percent of total billed charges,Implant Device,695,20,,695,percent of total billed charges,Implant Device,695,20,,695,percent of total billed charges,Implant Device,695,20,,695,percent of total billed charges,Implant Device,1737.5,50,,1737.5,percent of total billed charges,All Other,695,20,,695,percent of total billed charges,Implant Device,695,20,,695,percent of total billed charges,Implant Device,1181.5,34,"Charges > $500, x 34%",1181.5,percent of total billed charges,Implant Device,695,20,,695,percent of total billed charges,Implant Device,695,20,,695,percent of total billed charges,Implant Device,695,20,,695,percent of total billed charges,Implant Device,695,20,,695,percent of total billed charges,Implant Device,695,20,,695,percent of total billed charges,Implant Device,695,20,,695,percent of total billed charges,Implant Device,695,20,,695,percent of total billed charges,Implant Device,695,20,,695,percent of total billed charges,Implant Device,695,20,,695,percent of total billed charges,Implant Device,695,20,,695,percent of total billed charges,Implant Device,695,20,,695,percent of total billed charges,Implant Device,695,20,,695,percent of total billed charges,Implant Device,695,20,,695,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,1181.5,34,"If Charge > 2,000, then 34 percent",1181.5,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1737.5,
ANCHOR GII ETHBND SZ 2 CP2,C1713,HCPCS,,42159822,CDM,278,RC,,,both,,,3000,1184,,,1184,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,600,20,,600,percent of total billed charges,Implant Device,600,20,,600,percent of total billed charges,Implant Device,600,20,,600,percent of total billed charges,Implant Device,600,20,,600,percent of total billed charges,Implant Device,600,20,,600,percent of total billed charges,Implant Device,1500,50,,1500,percent of total billed charges,All Other,600,20,,600,percent of total billed charges,Implant Device,600,20,,600,percent of total billed charges,Implant Device,1020,34,"Charges > $500, x 34%",1020,percent of total billed charges,Implant Device,600,20,,600,percent of total billed charges,Implant Device,600,20,,600,percent of total billed charges,Implant Device,600,20,,600,percent of total billed charges,Implant Device,600,20,,600,percent of total billed charges,Implant Device,600,20,,600,percent of total billed charges,Implant Device,600,20,,600,percent of total billed charges,Implant Device,600,20,,600,percent of total billed charges,Implant Device,600,20,,600,percent of total billed charges,Implant Device,600,20,,600,percent of total billed charges,Implant Device,600,20,,600,percent of total billed charges,Implant Device,600,20,,600,percent of total billed charges,Implant Device,600,20,,600,percent of total billed charges,Implant Device,600,20,,600,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,1020,34,"If Charge > 2,000, then 34 percent",1020,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1500,
CATH VTC STD RIGHT ANG STER 3CM 23064B,C1729,HCPCS,,42163352,CDM,278,RC,,,both,,,846,333.89,,,333.89,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,169.2,20,,169.2,percent of total billed charges,Implant Device,169.2,20,,169.2,percent of total billed charges,Implant Device,169.2,20,,169.2,percent of total billed charges,Implant Device,169.2,20,,169.2,percent of total billed charges,Implant Device,169.2,20,,169.2,percent of total billed charges,Implant Device,423,50,,423,percent of total billed charges,All Other,169.2,20,,169.2,percent of total billed charges,Implant Device,169.2,20,,169.2,percent of total billed charges,Implant Device,287.64,34,"Charges > $500, x 34%",287.64,percent of total billed charges,Implant Device,169.2,20,,169.2,percent of total billed charges,Implant Device,169.2,20,,169.2,percent of total billed charges,Implant Device,169.2,20,,169.2,percent of total billed charges,Implant Device,169.2,20,,169.2,percent of total billed charges,Implant Device,169.2,20,,169.2,percent of total billed charges,Implant Device,169.2,20,,169.2,percent of total billed charges,Implant Device,169.2,20,,169.2,percent of total billed charges,Implant Device,169.2,20,,169.2,percent of total billed charges,Implant Device,169.2,20,,169.2,percent of total billed charges,Implant Device,169.2,20,,169.2,percent of total billed charges,Implant Device,169.2,20,,169.2,percent of total billed charges,Implant Device,169.2,20,,169.2,percent of total billed charges,Implant Device,169.2,20,,169.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,423,
EXTRA CELLULAR MATRIX STRILE CARDIAC TISSUE REPAIR 2CM X 10CM,C1763,HCPCS,,42163790,CDM,278,RC,,,both,,,1400,552.54,,,552.54,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,280,20,,280,percent of total billed charges,Implant Device,280,20,,280,percent of total billed charges,Implant Device,280,20,,280,percent of total billed charges,Implant Device,280,20,,280,percent of total billed charges,Implant Device,280,20,,280,percent of total billed charges,Implant Device,700,50,,700,percent of total billed charges,All Other,280,20,,280,percent of total billed charges,Implant Device,280,20,,280,percent of total billed charges,Implant Device,476,34,"Charges > $500, x 34%",476,percent of total billed charges,Implant Device,280,20,,280,percent of total billed charges,Implant Device,280,20,,280,percent of total billed charges,Implant Device,280,20,,280,percent of total billed charges,Implant Device,280,20,,280,percent of total billed charges,Implant Device,280,20,,280,percent of total billed charges,Implant Device,280,20,,280,percent of total billed charges,Implant Device,280,20,,280,percent of total billed charges,Implant Device,280,20,,280,percent of total billed charges,Implant Device,280,20,,280,percent of total billed charges,Implant Device,280,20,,280,percent of total billed charges,Implant Device,280,20,,280,percent of total billed charges,Implant Device,280,20,,280,percent of total billed charges,Implant Device,280,20,,280,percent of total billed charges,Implant Device,1296.65,,,1296.65,Other,New York Medicaid APG methodology,1296.65,,,1296.65,Other,100% Medicaid APG methodology,1296.65,,,1296.65,Other,100% Medicaid APG methodology,1296.65,,,1296.65,Other,100% Medicaid APG methodology,2917.46,,,2917.46,Other,225% Medicaid APG methodology,2917.46,,,2917.46,Other,225% Medicaid APG methodology,1983.88,,,1983.88,Other,153% Medicaid APG methodology,2917.46,,,2917.46,Other,225% Medicaid APG methodology,1815.31,,,1815.31,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,3371.29,,,3371.29,Other,260% Medicaid APG methodology,4201.15,,,4201.15,Other,324% Medicaid APG methodology,2787.8,,,2787.8,Other,215% Medicaid APG methodology,2787.8,,,2787.8,Other,215% Medicaid APG methodology,1620.81,,,1620.81,Other,125% Medicaid APG methodology,0.01,4201.15,
PLATE FRACTURE UNIV TTNM WITH ANG 4X4H 32X32X2.4MM,C1713,HCPCS,,42169979,CDM,278,RC,,,both,,,2461.75,971.57,,,971.57,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,492.35,20,,492.35,percent of total billed charges,Implant Device,492.35,20,,492.35,percent of total billed charges,Implant Device,492.35,20,,492.35,percent of total billed charges,Implant Device,492.35,20,,492.35,percent of total billed charges,Implant Device,492.35,20,,492.35,percent of total billed charges,Implant Device,1230.88,50,,1230.88,percent of total billed charges,All Other,492.35,20,,492.35,percent of total billed charges,Implant Device,492.35,20,,492.35,percent of total billed charges,Implant Device,837,34,"Charges > $500, x 34%",837,percent of total billed charges,Implant Device,492.35,20,,492.35,percent of total billed charges,Implant Device,492.35,20,,492.35,percent of total billed charges,Implant Device,492.35,20,,492.35,percent of total billed charges,Implant Device,492.35,20,,492.35,percent of total billed charges,Implant Device,492.35,20,,492.35,percent of total billed charges,Implant Device,492.35,20,,492.35,percent of total billed charges,Implant Device,492.35,20,,492.35,percent of total billed charges,Implant Device,492.35,20,,492.35,percent of total billed charges,Implant Device,492.35,20,,492.35,percent of total billed charges,Implant Device,492.35,20,,492.35,percent of total billed charges,Implant Device,492.35,20,,492.35,percent of total billed charges,Implant Device,492.35,20,,492.35,percent of total billed charges,Implant Device,492.35,20,,492.35,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,837,34,"If Charge > 2,000, then 34 percent",837,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1230.88,
PLATE LOCKING TTNM LG 12H 2MM,C1713,HCPCS,,42170084,CDM,278,RC,,,both,,,1782.35,703.44,,,703.44,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,356.47,20,,356.47,percent of total billed charges,Implant Device,356.47,20,,356.47,percent of total billed charges,Implant Device,356.47,20,,356.47,percent of total billed charges,Implant Device,356.47,20,,356.47,percent of total billed charges,Implant Device,356.47,20,,356.47,percent of total billed charges,Implant Device,891.18,50,,891.18,percent of total billed charges,All Other,356.47,20,,356.47,percent of total billed charges,Implant Device,356.47,20,,356.47,percent of total billed charges,Implant Device,606,34,"Charges > $500, x 34%",606,percent of total billed charges,Implant Device,356.47,20,,356.47,percent of total billed charges,Implant Device,356.47,20,,356.47,percent of total billed charges,Implant Device,356.47,20,,356.47,percent of total billed charges,Implant Device,356.47,20,,356.47,percent of total billed charges,Implant Device,356.47,20,,356.47,percent of total billed charges,Implant Device,356.47,20,,356.47,percent of total billed charges,Implant Device,356.47,20,,356.47,percent of total billed charges,Implant Device,356.47,20,,356.47,percent of total billed charges,Implant Device,356.47,20,,356.47,percent of total billed charges,Implant Device,356.47,20,,356.47,percent of total billed charges,Implant Device,356.47,20,,356.47,percent of total billed charges,Implant Device,356.47,20,,356.47,percent of total billed charges,Implant Device,356.47,20,,356.47,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,891.18,
PLATE LOCKING MINI BROAD CVD TTNM 4H 2MM,C1713,HCPCS,,42170167,CDM,278,RC,,,both,,,1176.05,464.15,,,464.15,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,235.21,20,,235.21,percent of total billed charges,Implant Device,235.21,20,,235.21,percent of total billed charges,Implant Device,235.21,20,,235.21,percent of total billed charges,Implant Device,235.21,20,,235.21,percent of total billed charges,Implant Device,235.21,20,,235.21,percent of total billed charges,Implant Device,588.03,50,,588.03,percent of total billed charges,All Other,235.21,20,,235.21,percent of total billed charges,Implant Device,235.21,20,,235.21,percent of total billed charges,Implant Device,399.86,34,"Charges > $500, x 34%",399.86,percent of total billed charges,Implant Device,235.21,20,,235.21,percent of total billed charges,Implant Device,235.21,20,,235.21,percent of total billed charges,Implant Device,235.21,20,,235.21,percent of total billed charges,Implant Device,235.21,20,,235.21,percent of total billed charges,Implant Device,235.21,20,,235.21,percent of total billed charges,Implant Device,235.21,20,,235.21,percent of total billed charges,Implant Device,235.21,20,,235.21,percent of total billed charges,Implant Device,235.21,20,,235.21,percent of total billed charges,Implant Device,235.21,20,,235.21,percent of total billed charges,Implant Device,235.21,20,,235.21,percent of total billed charges,Implant Device,235.21,20,,235.21,percent of total billed charges,Implant Device,235.21,20,,235.21,percent of total billed charges,Implant Device,235.21,20,,235.21,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,588.03,
PLATE LOCKING TTNM LG 20H 2MM,C1713,HCPCS,,42171009,CDM,278,RC,,,both,,,2455.3,969.03,,,969.03,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,491.06,20,,491.06,percent of total billed charges,Implant Device,491.06,20,,491.06,percent of total billed charges,Implant Device,491.06,20,,491.06,percent of total billed charges,Implant Device,491.06,20,,491.06,percent of total billed charges,Implant Device,491.06,20,,491.06,percent of total billed charges,Implant Device,1227.65,50,,1227.65,percent of total billed charges,All Other,491.06,20,,491.06,percent of total billed charges,Implant Device,491.06,20,,491.06,percent of total billed charges,Implant Device,834.8,34,"Charges > $500, x 34%",834.8,percent of total billed charges,Implant Device,491.06,20,,491.06,percent of total billed charges,Implant Device,491.06,20,,491.06,percent of total billed charges,Implant Device,491.06,20,,491.06,percent of total billed charges,Implant Device,491.06,20,,491.06,percent of total billed charges,Implant Device,491.06,20,,491.06,percent of total billed charges,Implant Device,491.06,20,,491.06,percent of total billed charges,Implant Device,491.06,20,,491.06,percent of total billed charges,Implant Device,491.06,20,,491.06,percent of total billed charges,Implant Device,491.06,20,,491.06,percent of total billed charges,Implant Device,491.06,20,,491.06,percent of total billed charges,Implant Device,491.06,20,,491.06,percent of total billed charges,Implant Device,491.06,20,,491.06,percent of total billed charges,Implant Device,491.06,20,,491.06,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,834.8,34,"If Charge > 2,000, then 34 percent",834.8,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1227.65,
CEMENT BNE FST SET PUTTY 5ML,C1713,HCPCS,,42171322,CDM,278,RC,,,both,,,4780,1886.51,,,1886.51,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,956,20,,956,percent of total billed charges,Implant Device,956,20,,956,percent of total billed charges,Implant Device,956,20,,956,percent of total billed charges,Implant Device,956,20,,956,percent of total billed charges,Implant Device,956,20,,956,percent of total billed charges,Implant Device,2390,50,,2390,percent of total billed charges,All Other,956,20,,956,percent of total billed charges,Implant Device,956,20,,956,percent of total billed charges,Implant Device,1625.2,34,"Charges > $500, x 34%",1625.2,percent of total billed charges,Implant Device,956,20,,956,percent of total billed charges,Implant Device,956,20,,956,percent of total billed charges,Implant Device,956,20,,956,percent of total billed charges,Implant Device,956,20,,956,percent of total billed charges,Implant Device,956,20,,956,percent of total billed charges,Implant Device,956,20,,956,percent of total billed charges,Implant Device,956,20,,956,percent of total billed charges,Implant Device,956,20,,956,percent of total billed charges,Implant Device,956,20,,956,percent of total billed charges,Implant Device,956,20,,956,percent of total billed charges,Implant Device,956,20,,956,percent of total billed charges,Implant Device,956,20,,956,percent of total billed charges,Implant Device,956,20,,956,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,1625.2,34,"If Charge > 2,000, then 34 percent",1625.2,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,2390,
KIT CRANIOPLASTIC 431050,C1713,HCPCS,,42172155,CDM,278,RC,,,both,,,1180.2,465.79,,,465.79,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,236.04,20,,236.04,percent of total billed charges,Implant Device,236.04,20,,236.04,percent of total billed charges,Implant Device,236.04,20,,236.04,percent of total billed charges,Implant Device,236.04,20,,236.04,percent of total billed charges,Implant Device,236.04,20,,236.04,percent of total billed charges,Implant Device,590.1,50,,590.1,percent of total billed charges,All Other,236.04,20,,236.04,percent of total billed charges,Implant Device,236.04,20,,236.04,percent of total billed charges,Implant Device,401.27,34,"Charges > $500, x 34%",401.27,percent of total billed charges,Implant Device,236.04,20,,236.04,percent of total billed charges,Implant Device,236.04,20,,236.04,percent of total billed charges,Implant Device,236.04,20,,236.04,percent of total billed charges,Implant Device,236.04,20,,236.04,percent of total billed charges,Implant Device,236.04,20,,236.04,percent of total billed charges,Implant Device,236.04,20,,236.04,percent of total billed charges,Implant Device,236.04,20,,236.04,percent of total billed charges,Implant Device,236.04,20,,236.04,percent of total billed charges,Implant Device,236.04,20,,236.04,percent of total billed charges,Implant Device,236.04,20,,236.04,percent of total billed charges,Implant Device,236.04,20,,236.04,percent of total billed charges,Implant Device,236.04,20,,236.04,percent of total billed charges,Implant Device,236.04,20,,236.04,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,590.1,
STENT URETERAL SET DOUBLE PIGTAIL POSITIONER CATHETER POLYURETHANE 5FR 12CM,C2617,HCPCS,,42175190,CDM,278,RC,,,both,,,618.05,243.92,,,243.92,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,123.61,20,,123.61,percent of total billed charges,Implant Device,123.61,20,,123.61,percent of total billed charges,Implant Device,123.61,20,,123.61,percent of total billed charges,Implant Device,123.61,20,,123.61,percent of total billed charges,Implant Device,123.61,20,,123.61,percent of total billed charges,Implant Device,309.03,50,,309.03,percent of total billed charges,All Other,123.61,20,,123.61,percent of total billed charges,Implant Device,123.61,20,,123.61,percent of total billed charges,Implant Device,210.14,34,"Charges > $500, x 34%",210.14,percent of total billed charges,Implant Device,123.61,20,,123.61,percent of total billed charges,Implant Device,123.61,20,,123.61,percent of total billed charges,Implant Device,123.61,20,,123.61,percent of total billed charges,Implant Device,123.61,20,,123.61,percent of total billed charges,Implant Device,123.61,20,,123.61,percent of total billed charges,Implant Device,123.61,20,,123.61,percent of total billed charges,Implant Device,123.61,20,,123.61,percent of total billed charges,Implant Device,123.61,20,,123.61,percent of total billed charges,Implant Device,123.61,20,,123.61,percent of total billed charges,Implant Device,123.61,20,,123.61,percent of total billed charges,Implant Device,123.61,20,,123.61,percent of total billed charges,Implant Device,123.61,20,,123.61,percent of total billed charges,Implant Device,123.61,20,,123.61,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,309.03,
SCREW CRTX SELF TAPPING CRUCIFORM RECESS TTNM 2.4X16MM,C1713,HCPCS,,42180497,CDM,278,RC,,,both,,,221.45,87.4,,,87.4,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,110.73,50,,110.73,percent of total billed charges,All Other,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,44.29,20,,44.29,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,110.73,
SCREW BNE 13X95MM LAG CANC STD RECESS CANN SS DH-DC SYS,C1713,HCPCS,,42186460,CDM,278,RC,,,both,,,1344.45,530.61,,,530.61,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,268.89,20,,268.89,percent of total billed charges,Implant Device,268.89,20,,268.89,percent of total billed charges,Implant Device,268.89,20,,268.89,percent of total billed charges,Implant Device,268.89,20,,268.89,percent of total billed charges,Implant Device,268.89,20,,268.89,percent of total billed charges,Implant Device,672.23,50,,672.23,percent of total billed charges,All Other,268.89,20,,268.89,percent of total billed charges,Implant Device,268.89,20,,268.89,percent of total billed charges,Implant Device,457.11,34,"Charges > $500, x 34%",457.11,percent of total billed charges,Implant Device,268.89,20,,268.89,percent of total billed charges,Implant Device,268.89,20,,268.89,percent of total billed charges,Implant Device,268.89,20,,268.89,percent of total billed charges,Implant Device,268.89,20,,268.89,percent of total billed charges,Implant Device,268.89,20,,268.89,percent of total billed charges,Implant Device,268.89,20,,268.89,percent of total billed charges,Implant Device,268.89,20,,268.89,percent of total billed charges,Implant Device,268.89,20,,268.89,percent of total billed charges,Implant Device,268.89,20,,268.89,percent of total billed charges,Implant Device,268.89,20,,268.89,percent of total billed charges,Implant Device,268.89,20,,268.89,percent of total billed charges,Implant Device,268.89,20,,268.89,percent of total billed charges,Implant Device,268.89,20,,268.89,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,672.23,
SCREW BNE 13X125MM LAG CANC STD RECESS CANN SS DH-DC SYS,C1713,HCPCS,,42186999,CDM,278,RC,,,both,,,2965,1170.19,,,1170.19,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,593,20,,593,percent of total billed charges,Implant Device,593,20,,593,percent of total billed charges,Implant Device,593,20,,593,percent of total billed charges,Implant Device,593,20,,593,percent of total billed charges,Implant Device,593,20,,593,percent of total billed charges,Implant Device,1482.5,50,,1482.5,percent of total billed charges,All Other,593,20,,593,percent of total billed charges,Implant Device,593,20,,593,percent of total billed charges,Implant Device,1008.1,34,"Charges > $500, x 34%",1008.1,percent of total billed charges,Implant Device,593,20,,593,percent of total billed charges,Implant Device,593,20,,593,percent of total billed charges,Implant Device,593,20,,593,percent of total billed charges,Implant Device,593,20,,593,percent of total billed charges,Implant Device,593,20,,593,percent of total billed charges,Implant Device,593,20,,593,percent of total billed charges,Implant Device,593,20,,593,percent of total billed charges,Implant Device,593,20,,593,percent of total billed charges,Implant Device,593,20,,593,percent of total billed charges,Implant Device,593,20,,593,percent of total billed charges,Implant Device,593,20,,593,percent of total billed charges,Implant Device,593,20,,593,percent of total billed charges,Implant Device,593,20,,593,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,1008.1,34,"If Charge > 2,000, then 34 percent",1008.1,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1482.5,
PLATE LOCKING X- MLP TTNM 20H 2MM,C1713,HCPCS,,42191379,CDM,278,RC,,,both,,,2577.85,1017.39,,,1017.39,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,515.57,20,,515.57,percent of total billed charges,Implant Device,515.57,20,,515.57,percent of total billed charges,Implant Device,515.57,20,,515.57,percent of total billed charges,Implant Device,515.57,20,,515.57,percent of total billed charges,Implant Device,515.57,20,,515.57,percent of total billed charges,Implant Device,1288.93,50,,1288.93,percent of total billed charges,All Other,515.57,20,,515.57,percent of total billed charges,Implant Device,515.57,20,,515.57,percent of total billed charges,Implant Device,876.47,34,"Charges > $500, x 34%",876.47,percent of total billed charges,Implant Device,515.57,20,,515.57,percent of total billed charges,Implant Device,515.57,20,,515.57,percent of total billed charges,Implant Device,515.57,20,,515.57,percent of total billed charges,Implant Device,515.57,20,,515.57,percent of total billed charges,Implant Device,515.57,20,,515.57,percent of total billed charges,Implant Device,515.57,20,,515.57,percent of total billed charges,Implant Device,515.57,20,,515.57,percent of total billed charges,Implant Device,515.57,20,,515.57,percent of total billed charges,Implant Device,515.57,20,,515.57,percent of total billed charges,Implant Device,515.57,20,,515.57,percent of total billed charges,Implant Device,515.57,20,,515.57,percent of total billed charges,Implant Device,515.57,20,,515.57,percent of total billed charges,Implant Device,515.57,20,,515.57,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,876.47,34,"If Charge > 2,000, then 34 percent",876.47,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1288.93,
COVER BUR HOLE NEURO LOW PROF 12MM,C1713,HCPCS,,42193797,CDM,278,RC,,,both,,,632.1,249.47,,,249.47,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,126.42,20,,126.42,percent of total billed charges,Implant Device,126.42,20,,126.42,percent of total billed charges,Implant Device,126.42,20,,126.42,percent of total billed charges,Implant Device,126.42,20,,126.42,percent of total billed charges,Implant Device,126.42,20,,126.42,percent of total billed charges,Implant Device,316.05,50,,316.05,percent of total billed charges,All Other,126.42,20,,126.42,percent of total billed charges,Implant Device,126.42,20,,126.42,percent of total billed charges,Implant Device,214.91,34,"Charges > $500, x 34%",214.91,percent of total billed charges,Implant Device,126.42,20,,126.42,percent of total billed charges,Implant Device,126.42,20,,126.42,percent of total billed charges,Implant Device,126.42,20,,126.42,percent of total billed charges,Implant Device,126.42,20,,126.42,percent of total billed charges,Implant Device,126.42,20,,126.42,percent of total billed charges,Implant Device,126.42,20,,126.42,percent of total billed charges,Implant Device,126.42,20,,126.42,percent of total billed charges,Implant Device,126.42,20,,126.42,percent of total billed charges,Implant Device,126.42,20,,126.42,percent of total billed charges,Implant Device,126.42,20,,126.42,percent of total billed charges,Implant Device,126.42,20,,126.42,percent of total billed charges,Implant Device,126.42,20,,126.42,percent of total billed charges,Implant Device,126.42,20,,126.42,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,316.05,
SCR ANT CERV VAR SD VNTR 4X15M,C1713,HCPCS,,42194431,CDM,278,RC,,,both,,,2111.9,833.5,,,833.5,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,422.38,20,,422.38,percent of total billed charges,Implant Device,422.38,20,,422.38,percent of total billed charges,Implant Device,422.38,20,,422.38,percent of total billed charges,Implant Device,422.38,20,,422.38,percent of total billed charges,Implant Device,422.38,20,,422.38,percent of total billed charges,Implant Device,1055.95,50,,1055.95,percent of total billed charges,All Other,422.38,20,,422.38,percent of total billed charges,Implant Device,422.38,20,,422.38,percent of total billed charges,Implant Device,718.05,34,"Charges > $500, x 34%",718.05,percent of total billed charges,Implant Device,422.38,20,,422.38,percent of total billed charges,Implant Device,422.38,20,,422.38,percent of total billed charges,Implant Device,422.38,20,,422.38,percent of total billed charges,Implant Device,422.38,20,,422.38,percent of total billed charges,Implant Device,422.38,20,,422.38,percent of total billed charges,Implant Device,422.38,20,,422.38,percent of total billed charges,Implant Device,422.38,20,,422.38,percent of total billed charges,Implant Device,422.38,20,,422.38,percent of total billed charges,Implant Device,422.38,20,,422.38,percent of total billed charges,Implant Device,422.38,20,,422.38,percent of total billed charges,Implant Device,422.38,20,,422.38,percent of total billed charges,Implant Device,422.38,20,,422.38,percent of total billed charges,Implant Device,422.38,20,,422.38,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,718.05,34,"If Charge > 2,000, then 34 percent",718.05,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1055.95,
IMPL INDWELLING PORT            ,C1788,HCPCS,,42500009,CDM,278,RC,,,both,,,475000,187467.3,,,187467.3,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,95000,20,,95000,percent of total billed charges,Implant Device,95000,20,,95000,percent of total billed charges,Implant Device,95000,20,,95000,percent of total billed charges,Implant Device,95000,20,,95000,percent of total billed charges,Implant Device,95000,20,,95000,percent of total billed charges,Implant Device,237500,50,,237500,percent of total billed charges,All Other,95000,20,,95000,percent of total billed charges,Implant Device,95000,20,,95000,percent of total billed charges,Implant Device,161500,34,"Charges > $500, x 34%",161500,percent of total billed charges,Implant Device,95000,20,,95000,percent of total billed charges,Implant Device,95000,20,,95000,percent of total billed charges,Implant Device,95000,20,,95000,percent of total billed charges,Implant Device,95000,20,,95000,percent of total billed charges,Implant Device,95000,20,,95000,percent of total billed charges,Implant Device,95000,20,,95000,percent of total billed charges,Implant Device,95000,20,,95000,percent of total billed charges,Implant Device,95000,20,,95000,percent of total billed charges,Implant Device,95000,20,,95000,percent of total billed charges,Implant Device,95000,20,,95000,percent of total billed charges,Implant Device,95000,20,,95000,percent of total billed charges,Implant Device,95000,20,,95000,percent of total billed charges,Implant Device,95000,20,,95000,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,161500,34,"If Charge > 2,000, then 34 percent",161500,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,237500,
ANCHOR/SCREW BN/BN TIS/BN       ,C1713,HCPCS,,42500017,CDM,278,RC,,,both,,,244351.1,96437.56,,,96437.56,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,48870.22,20,,48870.22,percent of total billed charges,Implant Device,48870.22,20,,48870.22,percent of total billed charges,Implant Device,48870.22,20,,48870.22,percent of total billed charges,Implant Device,48870.22,20,,48870.22,percent of total billed charges,Implant Device,48870.22,20,,48870.22,percent of total billed charges,Implant Device,122175.55,50,,122175.55,percent of total billed charges,All Other,48870.22,20,,48870.22,percent of total billed charges,Implant Device,48870.22,20,,48870.22,percent of total billed charges,Implant Device,83079.37,34,"Charges > $500, x 34%",83079.37,percent of total billed charges,Implant Device,48870.22,20,,48870.22,percent of total billed charges,Implant Device,48870.22,20,,48870.22,percent of total billed charges,Implant Device,48870.22,20,,48870.22,percent of total billed charges,Implant Device,48870.22,20,,48870.22,percent of total billed charges,Implant Device,48870.22,20,,48870.22,percent of total billed charges,Implant Device,48870.22,20,,48870.22,percent of total billed charges,Implant Device,48870.22,20,,48870.22,percent of total billed charges,Implant Device,48870.22,20,,48870.22,percent of total billed charges,Implant Device,48870.22,20,,48870.22,percent of total billed charges,Implant Device,48870.22,20,,48870.22,percent of total billed charges,Implant Device,48870.22,20,,48870.22,percent of total billed charges,Implant Device,48870.22,20,,48870.22,percent of total billed charges,Implant Device,48870.22,20,,48870.22,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,83079.37,34,"If Charge > 2,000, then 34 percent",83079.37,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,122175.55,
MESH (IMPLANTABLE)              ,C1781,HCPCS,,42500389,CDM,278,RC,,,both,,,205000,80906.94,,,80906.94,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,41000,20,,41000,percent of total billed charges,Implant Device,41000,20,,41000,percent of total billed charges,Implant Device,41000,20,,41000,percent of total billed charges,Implant Device,41000,20,,41000,percent of total billed charges,Implant Device,41000,20,,41000,percent of total billed charges,Implant Device,102500,50,,102500,percent of total billed charges,All Other,41000,20,,41000,percent of total billed charges,Implant Device,41000,20,,41000,percent of total billed charges,Implant Device,69700,34,"Charges > $500, x 34%",69700,percent of total billed charges,Implant Device,41000,20,,41000,percent of total billed charges,Implant Device,41000,20,,41000,percent of total billed charges,Implant Device,41000,20,,41000,percent of total billed charges,Implant Device,41000,20,,41000,percent of total billed charges,Implant Device,41000,20,,41000,percent of total billed charges,Implant Device,41000,20,,41000,percent of total billed charges,Implant Device,41000,20,,41000,percent of total billed charges,Implant Device,41000,20,,41000,percent of total billed charges,Implant Device,41000,20,,41000,percent of total billed charges,Implant Device,41000,20,,41000,percent of total billed charges,Implant Device,41000,20,,41000,percent of total billed charges,Implant Device,41000,20,,41000,percent of total billed charges,Implant Device,41000,20,,41000,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,69700,34,"If Charge > 2,000, then 34 percent",69700,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,102500,
STENT NON-COR TEM W/O DEL       ,C2617,HCPCS,,42500439,CDM,278,RC,,,both,,,170000,67093.56,,,67093.56,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,34000,20,,34000,percent of total billed charges,Implant Device,34000,20,,34000,percent of total billed charges,Implant Device,34000,20,,34000,percent of total billed charges,Implant Device,34000,20,,34000,percent of total billed charges,Implant Device,34000,20,,34000,percent of total billed charges,Implant Device,85000,50,,85000,percent of total billed charges,All Other,34000,20,,34000,percent of total billed charges,Implant Device,34000,20,,34000,percent of total billed charges,Implant Device,57800,34,"Charges > $500, x 34%",57800,percent of total billed charges,Implant Device,34000,20,,34000,percent of total billed charges,Implant Device,34000,20,,34000,percent of total billed charges,Implant Device,34000,20,,34000,percent of total billed charges,Implant Device,34000,20,,34000,percent of total billed charges,Implant Device,34000,20,,34000,percent of total billed charges,Implant Device,34000,20,,34000,percent of total billed charges,Implant Device,34000,20,,34000,percent of total billed charges,Implant Device,34000,20,,34000,percent of total billed charges,Implant Device,34000,20,,34000,percent of total billed charges,Implant Device,34000,20,,34000,percent of total billed charges,Implant Device,34000,20,,34000,percent of total billed charges,Implant Device,34000,20,,34000,percent of total billed charges,Implant Device,34000,20,,34000,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,57800,34,"If Charge > 2,000, then 34 percent",57800,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,85000,
STENT NON-COA/NON-COV W/DEL     ,C1876,HCPCS,,42500504,CDM,278,RC,,,both,,,72675,28682.5,,,28682.5,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,14535,20,,14535,percent of total billed charges,Implant Device,14535,20,,14535,percent of total billed charges,Implant Device,14535,20,,14535,percent of total billed charges,Implant Device,14535,20,,14535,percent of total billed charges,Implant Device,14535,20,,14535,percent of total billed charges,Implant Device,36337.5,50,,36337.5,percent of total billed charges,All Other,14535,20,,14535,percent of total billed charges,Implant Device,14535,20,,14535,percent of total billed charges,Implant Device,24709.5,34,"Charges > $500, x 34%",24709.5,percent of total billed charges,Implant Device,14535,20,,14535,percent of total billed charges,Implant Device,14535,20,,14535,percent of total billed charges,Implant Device,14535,20,,14535,percent of total billed charges,Implant Device,14535,20,,14535,percent of total billed charges,Implant Device,14535,20,,14535,percent of total billed charges,Implant Device,14535,20,,14535,percent of total billed charges,Implant Device,14535,20,,14535,percent of total billed charges,Implant Device,14535,20,,14535,percent of total billed charges,Implant Device,14535,20,,14535,percent of total billed charges,Implant Device,14535,20,,14535,percent of total billed charges,Implant Device,14535,20,,14535,percent of total billed charges,Implant Device,14535,20,,14535,percent of total billed charges,Implant Device,14535,20,,14535,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,24709.5,34,"If Charge > 2,000, then 34 percent",24709.5,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,36337.5,
SEPTAL DEFECT IMPL SYSTEM       ,C1817,HCPCS,,42500967,CDM,278,RC,,,both,,,56940,22472.4,,,22472.4,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,11388,20,,11388,percent of total billed charges,Implant Device,11388,20,,11388,percent of total billed charges,Implant Device,11388,20,,11388,percent of total billed charges,Implant Device,11388,20,,11388,percent of total billed charges,Implant Device,11388,20,,11388,percent of total billed charges,Implant Device,28470,50,,28470,percent of total billed charges,All Other,11388,20,,11388,percent of total billed charges,Implant Device,11388,20,,11388,percent of total billed charges,Implant Device,19359.6,34,"Charges > $500, x 34%",19359.6,percent of total billed charges,Implant Device,11388,20,,11388,percent of total billed charges,Implant Device,11388,20,,11388,percent of total billed charges,Implant Device,11388,20,,11388,percent of total billed charges,Implant Device,11388,20,,11388,percent of total billed charges,Implant Device,11388,20,,11388,percent of total billed charges,Implant Device,11388,20,,11388,percent of total billed charges,Implant Device,11388,20,,11388,percent of total billed charges,Implant Device,11388,20,,11388,percent of total billed charges,Implant Device,11388,20,,11388,percent of total billed charges,Implant Device,11388,20,,11388,percent of total billed charges,Implant Device,11388,20,,11388,percent of total billed charges,Implant Device,11388,20,,11388,percent of total billed charges,Implant Device,11388,20,,11388,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,19359.6,34,"If Charge > 2,000, then 34 percent",19359.6,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,28470,
NEURAGEN NERVE GUIDE PER CM     ,C9352,HCPCS,,42501312,CDM,278,RC,,,both,,,6806.3,2686.23,,,2686.23,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,1361.26,20,,1361.26,percent of total billed charges,Implant Device,1361.26,20,,1361.26,percent of total billed charges,Implant Device,1361.26,20,,1361.26,percent of total billed charges,Implant Device,1361.26,20,,1361.26,percent of total billed charges,Implant Device,1361.26,20,,1361.26,percent of total billed charges,Implant Device,3403.15,50,,3403.15,percent of total billed charges,All Other,1361.26,20,,1361.26,percent of total billed charges,Implant Device,1361.26,20,,1361.26,percent of total billed charges,Implant Device,2314.14,34,"Charges > $500, x 34%",2314.14,percent of total billed charges,Implant Device,1361.26,20,,1361.26,percent of total billed charges,Implant Device,1361.26,20,,1361.26,percent of total billed charges,Implant Device,1361.26,20,,1361.26,percent of total billed charges,Implant Device,1361.26,20,,1361.26,percent of total billed charges,Implant Device,1361.26,20,,1361.26,percent of total billed charges,Implant Device,1361.26,20,,1361.26,percent of total billed charges,Implant Device,1361.26,20,,1361.26,percent of total billed charges,Implant Device,1361.26,20,,1361.26,percent of total billed charges,Implant Device,1361.26,20,,1361.26,percent of total billed charges,Implant Device,1361.26,20,,1361.26,percent of total billed charges,Implant Device,1361.26,20,,1361.26,percent of total billed charges,Implant Device,1361.26,20,,1361.26,percent of total billed charges,Implant Device,1361.26,20,,1361.26,percent of total billed charges,Implant Device,1296.64,,,1296.64,Other,New York Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,1983.87,,,1983.87,Other,153% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,1815.3,,,1815.3,Other,140% Medicaid APG methodology,2314.14,34,"If Charge > 2,000, then 34 percent",2314.14,percent of total billed charges,Implants,3371.27,,,3371.27,Other,260% Medicaid APG methodology,4201.13,,,4201.13,Other,324% Medicaid APG methodology,2787.78,,,2787.78,Other,215% Medicaid APG methodology,2787.78,,,2787.78,Other,215% Medicaid APG methodology,1620.81,,,1620.81,Other,125% Medicaid APG methodology,0.01,4201.13,
VENA CAVA FILTER                ,C1880,HCPCS,,42501783,CDM,278,RC,,,both,,,22745.45,8976.9,,,8976.9,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,4549.09,20,,4549.09,percent of total billed charges,Implant Device,4549.09,20,,4549.09,percent of total billed charges,Implant Device,4549.09,20,,4549.09,percent of total billed charges,Implant Device,4549.09,20,,4549.09,percent of total billed charges,Implant Device,4549.09,20,,4549.09,percent of total billed charges,Implant Device,11372.73,50,,11372.73,percent of total billed charges,All Other,4549.09,20,,4549.09,percent of total billed charges,Implant Device,4549.09,20,,4549.09,percent of total billed charges,Implant Device,7733.45,34,"Charges > $500, x 34%",7733.45,percent of total billed charges,Implant Device,4549.09,20,,4549.09,percent of total billed charges,Implant Device,4549.09,20,,4549.09,percent of total billed charges,Implant Device,4549.09,20,,4549.09,percent of total billed charges,Implant Device,4549.09,20,,4549.09,percent of total billed charges,Implant Device,4549.09,20,,4549.09,percent of total billed charges,Implant Device,4549.09,20,,4549.09,percent of total billed charges,Implant Device,4549.09,20,,4549.09,percent of total billed charges,Implant Device,4549.09,20,,4549.09,percent of total billed charges,Implant Device,4549.09,20,,4549.09,percent of total billed charges,Implant Device,4549.09,20,,4549.09,percent of total billed charges,Implant Device,4549.09,20,,4549.09,percent of total billed charges,Implant Device,4549.09,20,,4549.09,percent of total billed charges,Implant Device,4549.09,20,,4549.09,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,7733.45,34,"If Charge > 2,000, then 34 percent",7733.45,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,11372.73,
EMBOLIZ PROTECT SYS             ,C1884,HCPCS,,42501940,CDM,278,RC,,,both,,,17750,7005.36,,,7005.36,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,3550,20,,3550,percent of total billed charges,Implant Device,3550,20,,3550,percent of total billed charges,Implant Device,3550,20,,3550,percent of total billed charges,Implant Device,3550,20,,3550,percent of total billed charges,Implant Device,3550,20,,3550,percent of total billed charges,Implant Device,8875,50,,8875,percent of total billed charges,All Other,3550,20,,3550,percent of total billed charges,Implant Device,3550,20,,3550,percent of total billed charges,Implant Device,6035,34,"Charges > $500, x 34%",6035,percent of total billed charges,Implant Device,3550,20,,3550,percent of total billed charges,Implant Device,3550,20,,3550,percent of total billed charges,Implant Device,3550,20,,3550,percent of total billed charges,Implant Device,3550,20,,3550,percent of total billed charges,Implant Device,3550,20,,3550,percent of total billed charges,Implant Device,3550,20,,3550,percent of total billed charges,Implant Device,3550,20,,3550,percent of total billed charges,Implant Device,3550,20,,3550,percent of total billed charges,Implant Device,3550,20,,3550,percent of total billed charges,Implant Device,3550,20,,3550,percent of total billed charges,Implant Device,3550,20,,3550,percent of total billed charges,Implant Device,3550,20,,3550,percent of total billed charges,Implant Device,3550,20,,3550,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,6035,34,"If Charge > 2,000, then 34 percent",6035,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,8875,
STENT NON-COAT/COV W/O DEL      ,C1877,HCPCS,,42502328,CDM,278,RC,,,both,,,66825,26373.69,,,26373.69,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,13365,20,,13365,percent of total billed charges,Implant Device,13365,20,,13365,percent of total billed charges,Implant Device,13365,20,,13365,percent of total billed charges,Implant Device,13365,20,,13365,percent of total billed charges,Implant Device,13365,20,,13365,percent of total billed charges,Implant Device,33412.5,50,,33412.5,percent of total billed charges,All Other,13365,20,,13365,percent of total billed charges,Implant Device,13365,20,,13365,percent of total billed charges,Implant Device,22720.5,34,"Charges > $500, x 34%",22720.5,percent of total billed charges,Implant Device,13365,20,,13365,percent of total billed charges,Implant Device,13365,20,,13365,percent of total billed charges,Implant Device,13365,20,,13365,percent of total billed charges,Implant Device,13365,20,,13365,percent of total billed charges,Implant Device,13365,20,,13365,percent of total billed charges,Implant Device,13365,20,,13365,percent of total billed charges,Implant Device,13365,20,,13365,percent of total billed charges,Implant Device,13365,20,,13365,percent of total billed charges,Implant Device,13365,20,,13365,percent of total billed charges,Implant Device,13365,20,,13365,percent of total billed charges,Implant Device,13365,20,,13365,percent of total billed charges,Implant Device,13365,20,,13365,percent of total billed charges,Implant Device,13365,20,,13365,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,22720.5,34,"If Charge > 2,000, then 34 percent",22720.5,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,33412.5,
JOINT DEVICE (IMPLANTABLE)      ,C1776,HCPCS,,42502534,CDM,278,RC,,,both,,,257568,101653.85,,,101653.85,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,51513.6,20,,51513.6,percent of total billed charges,Implant Device,51513.6,20,,51513.6,percent of total billed charges,Implant Device,51513.6,20,,51513.6,percent of total billed charges,Implant Device,51513.6,20,,51513.6,percent of total billed charges,Implant Device,51513.6,20,,51513.6,percent of total billed charges,Implant Device,128784,50,,128784,percent of total billed charges,All Other,51513.6,20,,51513.6,percent of total billed charges,Implant Device,51513.6,20,,51513.6,percent of total billed charges,Implant Device,87573.12,34,"Charges > $500, x 34%",87573.12,percent of total billed charges,Implant Device,51513.6,20,,51513.6,percent of total billed charges,Implant Device,51513.6,20,,51513.6,percent of total billed charges,Implant Device,51513.6,20,,51513.6,percent of total billed charges,Implant Device,51513.6,20,,51513.6,percent of total billed charges,Implant Device,51513.6,20,,51513.6,percent of total billed charges,Implant Device,51513.6,20,,51513.6,percent of total billed charges,Implant Device,51513.6,20,,51513.6,percent of total billed charges,Implant Device,51513.6,20,,51513.6,percent of total billed charges,Implant Device,51513.6,20,,51513.6,percent of total billed charges,Implant Device,51513.6,20,,51513.6,percent of total billed charges,Implant Device,51513.6,20,,51513.6,percent of total billed charges,Implant Device,51513.6,20,,51513.6,percent of total billed charges,Implant Device,51513.6,20,,51513.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,87573.12,34,"If Charge > 2,000, then 34 percent",87573.12,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,128784,
CONN TISS NON-HUMAN             ,C1763,HCPCS,,42503961,CDM,278,RC,,,both,,,120481.5,47550.19,,,47550.19,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,24096.3,20,,24096.3,percent of total billed charges,Implant Device,24096.3,20,,24096.3,percent of total billed charges,Implant Device,24096.3,20,,24096.3,percent of total billed charges,Implant Device,24096.3,20,,24096.3,percent of total billed charges,Implant Device,24096.3,20,,24096.3,percent of total billed charges,Implant Device,60240.75,50,,60240.75,percent of total billed charges,All Other,24096.3,20,,24096.3,percent of total billed charges,Implant Device,24096.3,20,,24096.3,percent of total billed charges,Implant Device,40963.71,34,"Charges > $500, x 34%",40963.71,percent of total billed charges,Implant Device,24096.3,20,,24096.3,percent of total billed charges,Implant Device,24096.3,20,,24096.3,percent of total billed charges,Implant Device,24096.3,20,,24096.3,percent of total billed charges,Implant Device,24096.3,20,,24096.3,percent of total billed charges,Implant Device,24096.3,20,,24096.3,percent of total billed charges,Implant Device,24096.3,20,,24096.3,percent of total billed charges,Implant Device,24096.3,20,,24096.3,percent of total billed charges,Implant Device,24096.3,20,,24096.3,percent of total billed charges,Implant Device,24096.3,20,,24096.3,percent of total billed charges,Implant Device,24096.3,20,,24096.3,percent of total billed charges,Implant Device,24096.3,20,,24096.3,percent of total billed charges,Implant Device,24096.3,20,,24096.3,percent of total billed charges,Implant Device,24096.3,20,,24096.3,percent of total billed charges,Implant Device,1296.65,,,1296.65,Other,New York Medicaid APG methodology,1296.65,,,1296.65,Other,100% Medicaid APG methodology,1296.65,,,1296.65,Other,100% Medicaid APG methodology,1296.65,,,1296.65,Other,100% Medicaid APG methodology,2917.46,,,2917.46,Other,225% Medicaid APG methodology,2917.46,,,2917.46,Other,225% Medicaid APG methodology,1983.88,,,1983.88,Other,153% Medicaid APG methodology,2917.46,,,2917.46,Other,225% Medicaid APG methodology,1815.31,,,1815.31,Other,140% Medicaid APG methodology,40963.71,34,"If Charge > 2,000, then 34 percent",40963.71,percent of total billed charges,Implants,3371.29,,,3371.29,Other,260% Medicaid APG methodology,4201.15,,,4201.15,Other,324% Medicaid APG methodology,2787.8,,,2787.8,Other,215% Medicaid APG methodology,2787.8,,,2787.8,Other,215% Medicaid APG methodology,1620.81,,,1620.81,Other,125% Medicaid APG methodology,0.01,60240.75,
OTHER PACEMAKER LEAD            ,C1898,HCPCS,,42504407,CDM,278,RC,,,both,,,42800,16891.79,,,16891.79,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,8560,20,,8560,percent of total billed charges,Implant Device,8560,20,,8560,percent of total billed charges,Implant Device,8560,20,,8560,percent of total billed charges,Implant Device,8560,20,,8560,percent of total billed charges,Implant Device,8560,20,,8560,percent of total billed charges,Implant Device,21400,50,,21400,percent of total billed charges,All Other,8560,20,,8560,percent of total billed charges,Implant Device,8560,20,,8560,percent of total billed charges,Implant Device,14552,34,"Charges > $500, x 34%",14552,percent of total billed charges,Implant Device,8560,20,,8560,percent of total billed charges,Implant Device,8560,20,,8560,percent of total billed charges,Implant Device,8560,20,,8560,percent of total billed charges,Implant Device,8560,20,,8560,percent of total billed charges,Implant Device,8560,20,,8560,percent of total billed charges,Implant Device,8560,20,,8560,percent of total billed charges,Implant Device,8560,20,,8560,percent of total billed charges,Implant Device,8560,20,,8560,percent of total billed charges,Implant Device,8560,20,,8560,percent of total billed charges,Implant Device,8560,20,,8560,percent of total billed charges,Implant Device,8560,20,,8560,percent of total billed charges,Implant Device,8560,20,,8560,percent of total billed charges,Implant Device,8560,20,,8560,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,14552,34,"If Charge > 2,000, then 34 percent",14552,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,21400,
EVENT RECORDER CARDIAC          ,C1764,HCPCS,,42506428,CDM,278,RC,,,both,,,27475,10843.5,,,10843.5,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,5495,20,,5495,percent of total billed charges,Implant Device,5495,20,,5495,percent of total billed charges,Implant Device,5495,20,,5495,percent of total billed charges,Implant Device,5495,20,,5495,percent of total billed charges,Implant Device,5495,20,,5495,percent of total billed charges,Implant Device,13737.5,50,,13737.5,percent of total billed charges,All Other,5495,20,,5495,percent of total billed charges,Implant Device,5495,20,,5495,percent of total billed charges,Implant Device,9341.5,34,"Charges > $500, x 34%",9341.5,percent of total billed charges,Implant Device,5495,20,,5495,percent of total billed charges,Implant Device,5495,20,,5495,percent of total billed charges,Implant Device,5495,20,,5495,percent of total billed charges,Implant Device,5495,20,,5495,percent of total billed charges,Implant Device,5495,20,,5495,percent of total billed charges,Implant Device,5495,20,,5495,percent of total billed charges,Implant Device,5495,20,,5495,percent of total billed charges,Implant Device,5495,20,,5495,percent of total billed charges,Implant Device,5495,20,,5495,percent of total billed charges,Implant Device,5495,20,,5495,percent of total billed charges,Implant Device,5495,20,,5495,percent of total billed charges,Implant Device,5495,20,,5495,percent of total billed charges,Implant Device,5495,20,,5495,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,9341.5,34,"If Charge > 2,000, then 34 percent",9341.5,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,13737.5,
STENT COATED/COV W/DEL SYS      ,C1874,HCPCS,,42506444,CDM,278,RC,,,both,,,109310,43141.16,,,43141.16,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,21862,20,,21862,percent of total billed charges,Implant Device,21862,20,,21862,percent of total billed charges,Implant Device,21862,20,,21862,percent of total billed charges,Implant Device,21862,20,,21862,percent of total billed charges,Implant Device,21862,20,,21862,percent of total billed charges,Implant Device,54655,50,,54655,percent of total billed charges,All Other,21862,20,,21862,percent of total billed charges,Implant Device,21862,20,,21862,percent of total billed charges,Implant Device,37165.4,34,"Charges > $500, x 34%",37165.4,percent of total billed charges,Implant Device,21862,20,,21862,percent of total billed charges,Implant Device,21862,20,,21862,percent of total billed charges,Implant Device,21862,20,,21862,percent of total billed charges,Implant Device,21862,20,,21862,percent of total billed charges,Implant Device,21862,20,,21862,percent of total billed charges,Implant Device,21862,20,,21862,percent of total billed charges,Implant Device,21862,20,,21862,percent of total billed charges,Implant Device,21862,20,,21862,percent of total billed charges,Implant Device,21862,20,,21862,percent of total billed charges,Implant Device,21862,20,,21862,percent of total billed charges,Implant Device,21862,20,,21862,percent of total billed charges,Implant Device,21862,20,,21862,percent of total billed charges,Implant Device,21862,20,,21862,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,37165.4,34,"If Charge > 2,000, then 34 percent",37165.4,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,54655,
LEAD CORONARY VENOUS            ,C1900,HCPCS,,42507269,CDM,278,RC,,,both,,,17000,6709.36,,,6709.36,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,8500,50,,8500,percent of total billed charges,All Other,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,5780,34,"Charges > $500, x 34%",5780,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,3400,20,,3400,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,5780,34,"If Charge > 2,000, then 34 percent",5780,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,8500,
CATH HEMODIALYSIS SHORT-TERM    ,C1752,HCPCS,,42509745,CDM,278,RC,,,both,,,2970,1172.16,,,1172.16,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,594,20,,594,percent of total billed charges,Implant Device,594,20,,594,percent of total billed charges,Implant Device,594,20,,594,percent of total billed charges,Implant Device,594,20,,594,percent of total billed charges,Implant Device,594,20,,594,percent of total billed charges,Implant Device,1485,50,,1485,percent of total billed charges,All Other,594,20,,594,percent of total billed charges,Implant Device,594,20,,594,percent of total billed charges,Implant Device,1009.8,34,"Charges > $500, x 34%",1009.8,percent of total billed charges,Implant Device,594,20,,594,percent of total billed charges,Implant Device,594,20,,594,percent of total billed charges,Implant Device,594,20,,594,percent of total billed charges,Implant Device,594,20,,594,percent of total billed charges,Implant Device,594,20,,594,percent of total billed charges,Implant Device,594,20,,594,percent of total billed charges,Implant Device,594,20,,594,percent of total billed charges,Implant Device,594,20,,594,percent of total billed charges,Implant Device,594,20,,594,percent of total billed charges,Implant Device,594,20,,594,percent of total billed charges,Implant Device,594,20,,594,percent of total billed charges,Implant Device,594,20,,594,percent of total billed charges,Implant Device,594,20,,594,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,1009.8,34,"If Charge > 2,000, then 34 percent",1009.8,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1485,
ADHESION BARRIER                ,C1765,HCPCS,,42509810,CDM,278,RC,,,both,,,4975,1963.47,,,1963.47,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,2487.5,50,,2487.5,percent of total billed charges,All Other,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,1691.5,34,"Charges > $500, x 34%",1691.5,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,1691.5,34,"If Charge > 2,000, then 34 percent",1691.5,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,2487.5,
CATH HEMODIALYSIS LONG-TERM     ,C1750,HCPCS,,42510131,CDM,278,RC,,,both,,,20050,7913.09,,,7913.09,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,4010,20,,4010,percent of total billed charges,Implant Device,4010,20,,4010,percent of total billed charges,Implant Device,4010,20,,4010,percent of total billed charges,Implant Device,4010,20,,4010,percent of total billed charges,Implant Device,4010,20,,4010,percent of total billed charges,Implant Device,10025,50,,10025,percent of total billed charges,All Other,4010,20,,4010,percent of total billed charges,Implant Device,4010,20,,4010,percent of total billed charges,Implant Device,6817,34,"Charges > $500, x 34%",6817,percent of total billed charges,Implant Device,4010,20,,4010,percent of total billed charges,Implant Device,4010,20,,4010,percent of total billed charges,Implant Device,4010,20,,4010,percent of total billed charges,Implant Device,4010,20,,4010,percent of total billed charges,Implant Device,4010,20,,4010,percent of total billed charges,Implant Device,4010,20,,4010,percent of total billed charges,Implant Device,4010,20,,4010,percent of total billed charges,Implant Device,4010,20,,4010,percent of total billed charges,Implant Device,4010,20,,4010,percent of total billed charges,Implant Device,4010,20,,4010,percent of total billed charges,Implant Device,4010,20,,4010,percent of total billed charges,Implant Device,4010,20,,4010,percent of total billed charges,Implant Device,4010,20,,4010,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,6817,34,"If Charge > 2,000, then 34 percent",6817,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,10025,
GRAFT VASCULAR                  ,C1768,HCPCS,,42510305,CDM,278,RC,,,both,,,113700,44873.75,,,44873.75,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,22740,20,,22740,percent of total billed charges,Implant Device,22740,20,,22740,percent of total billed charges,Implant Device,22740,20,,22740,percent of total billed charges,Implant Device,22740,20,,22740,percent of total billed charges,Implant Device,22740,20,,22740,percent of total billed charges,Implant Device,56850,50,,56850,percent of total billed charges,All Other,22740,20,,22740,percent of total billed charges,Implant Device,22740,20,,22740,percent of total billed charges,Implant Device,38658,34,"Charges > $500, x 34%",38658,percent of total billed charges,Implant Device,22740,20,,22740,percent of total billed charges,Implant Device,22740,20,,22740,percent of total billed charges,Implant Device,22740,20,,22740,percent of total billed charges,Implant Device,22740,20,,22740,percent of total billed charges,Implant Device,22740,20,,22740,percent of total billed charges,Implant Device,22740,20,,22740,percent of total billed charges,Implant Device,22740,20,,22740,percent of total billed charges,Implant Device,22740,20,,22740,percent of total billed charges,Implant Device,22740,20,,22740,percent of total billed charges,Implant Device,22740,20,,22740,percent of total billed charges,Implant Device,22740,20,,22740,percent of total billed charges,Implant Device,22740,20,,22740,percent of total billed charges,Implant Device,22740,20,,22740,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,38658,34,"If Charge > 2,000, then 34 percent",38658,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,56850,
INFUSION PUMP PROGRAMMABLE      ,C1772,HCPCS,,42560441,CDM,278,RC,,,both,,,62245,24566.11,,,24566.11,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,12449,20,,12449,percent of total billed charges,Implant Device,12449,20,,12449,percent of total billed charges,Implant Device,12449,20,,12449,percent of total billed charges,Implant Device,12449,20,,12449,percent of total billed charges,Implant Device,12449,20,,12449,percent of total billed charges,Implant Device,31122.5,50,,31122.5,percent of total billed charges,All Other,12449,20,,12449,percent of total billed charges,Implant Device,12449,20,,12449,percent of total billed charges,Implant Device,21163.3,34,"Charges > $500, x 34%",21163.3,percent of total billed charges,Implant Device,12449,20,,12449,percent of total billed charges,Implant Device,12449,20,,12449,percent of total billed charges,Implant Device,12449,20,,12449,percent of total billed charges,Implant Device,12449,20,,12449,percent of total billed charges,Implant Device,12449,20,,12449,percent of total billed charges,Implant Device,12449,20,,12449,percent of total billed charges,Implant Device,12449,20,,12449,percent of total billed charges,Implant Device,12449,20,,12449,percent of total billed charges,Implant Device,12449,20,,12449,percent of total billed charges,Implant Device,12449,20,,12449,percent of total billed charges,Implant Device,12449,20,,12449,percent of total billed charges,Implant Device,12449,20,,12449,percent of total billed charges,Implant Device,12449,20,,12449,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,21163.3,34,"If Charge > 2,000, then 34 percent",21163.3,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,31122.5,
STENT COATED/COV W/O DEL SYS    ,C1875,HCPCS,,42560466,CDM,278,RC,,,both,,,29355,11585.48,,,11585.48,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,5871,20,,5871,percent of total billed charges,Implant Device,5871,20,,5871,percent of total billed charges,Implant Device,5871,20,,5871,percent of total billed charges,Implant Device,5871,20,,5871,percent of total billed charges,Implant Device,5871,20,,5871,percent of total billed charges,Implant Device,14677.5,50,,14677.5,percent of total billed charges,All Other,5871,20,,5871,percent of total billed charges,Implant Device,5871,20,,5871,percent of total billed charges,Implant Device,9980.7,34,"Charges > $500, x 34%",9980.7,percent of total billed charges,Implant Device,5871,20,,5871,percent of total billed charges,Implant Device,5871,20,,5871,percent of total billed charges,Implant Device,5871,20,,5871,percent of total billed charges,Implant Device,5871,20,,5871,percent of total billed charges,Implant Device,5871,20,,5871,percent of total billed charges,Implant Device,5871,20,,5871,percent of total billed charges,Implant Device,5871,20,,5871,percent of total billed charges,Implant Device,5871,20,,5871,percent of total billed charges,Implant Device,5871,20,,5871,percent of total billed charges,Implant Device,5871,20,,5871,percent of total billed charges,Implant Device,5871,20,,5871,percent of total billed charges,Implant Device,5871,20,,5871,percent of total billed charges,Implant Device,5871,20,,5871,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,9980.7,34,"If Charge > 2,000, then 34 percent",9980.7,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,14677.5,
WIRELESS PRESSURE SENSOR        ,C2624,HCPCS,,42560482,CDM,278,RC,,,both,,,124750,49234.83,,,49234.83,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,24950,20,,24950,percent of total billed charges,Implant Device,24950,20,,24950,percent of total billed charges,Implant Device,24950,20,,24950,percent of total billed charges,Implant Device,24950,20,,24950,percent of total billed charges,Implant Device,24950,20,,24950,percent of total billed charges,Implant Device,62375,50,,62375,percent of total billed charges,All Other,24950,20,,24950,percent of total billed charges,Implant Device,24950,20,,24950,percent of total billed charges,Implant Device,42415,34,"Charges > $500, x 34%",42415,percent of total billed charges,Implant Device,24950,20,,24950,percent of total billed charges,Implant Device,24950,20,,24950,percent of total billed charges,Implant Device,24950,20,,24950,percent of total billed charges,Implant Device,24950,20,,24950,percent of total billed charges,Implant Device,24950,20,,24950,percent of total billed charges,Implant Device,24950,20,,24950,percent of total billed charges,Implant Device,24950,20,,24950,percent of total billed charges,Implant Device,24950,20,,24950,percent of total billed charges,Implant Device,24950,20,,24950,percent of total billed charges,Implant Device,24950,20,,24950,percent of total billed charges,Implant Device,24950,20,,24950,percent of total billed charges,Implant Device,24950,20,,24950,percent of total billed charges,Implant Device,24950,20,,24950,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,42415,34,"If Charge > 2,000, then 34 percent",42415,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,62375,
SURGIMEND FETAL PER 0.5 SQ CM   ,C9358,HCPCS,,42560490,CDM,278,RC,,,both,,,8500,3354.68,,,3354.68,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,1700,20,,1700,percent of total billed charges,Implant Device,1700,20,,1700,percent of total billed charges,Implant Device,1700,20,,1700,percent of total billed charges,Implant Device,1700,20,,1700,percent of total billed charges,Implant Device,1700,20,,1700,percent of total billed charges,Implant Device,4250,50,,4250,percent of total billed charges,All Other,1700,20,,1700,percent of total billed charges,Implant Device,1700,20,,1700,percent of total billed charges,Implant Device,2890,34,"Charges > $500, x 34%",2890,percent of total billed charges,Implant Device,1700,20,,1700,percent of total billed charges,Implant Device,1700,20,,1700,percent of total billed charges,Implant Device,1700,20,,1700,percent of total billed charges,Implant Device,1700,20,,1700,percent of total billed charges,Implant Device,1700,20,,1700,percent of total billed charges,Implant Device,1700,20,,1700,percent of total billed charges,Implant Device,1700,20,,1700,percent of total billed charges,Implant Device,1700,20,,1700,percent of total billed charges,Implant Device,1700,20,,1700,percent of total billed charges,Implant Device,1700,20,,1700,percent of total billed charges,Implant Device,1700,20,,1700,percent of total billed charges,Implant Device,1700,20,,1700,percent of total billed charges,Implant Device,1700,20,,1700,percent of total billed charges,Implant Device,1296.64,,,1296.64,Other,New York Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,1983.87,,,1983.87,Other,153% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,1815.3,,,1815.3,Other,140% Medicaid APG methodology,2890,34,"If Charge > 2,000, then 34 percent",2890,percent of total billed charges,Implants,3371.27,,,3371.27,Other,260% Medicaid APG methodology,4201.13,,,4201.13,Other,324% Medicaid APG methodology,2787.78,,,2787.78,Other,215% Medicaid APG methodology,2787.78,,,2787.78,Other,215% Medicaid APG methodology,1620.81,,,1620.81,Other,125% Medicaid APG methodology,0.01,4250,
SURGIMEND NEONATAL 0.5 SQ CM    ,C9360,HCPCS,,42560508,CDM,278,RC,,,both,,,110000,43413.48,,,43413.48,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,22000,20,,22000,percent of total billed charges,Implant Device,22000,20,,22000,percent of total billed charges,Implant Device,22000,20,,22000,percent of total billed charges,Implant Device,22000,20,,22000,percent of total billed charges,Implant Device,22000,20,,22000,percent of total billed charges,Implant Device,55000,50,,55000,percent of total billed charges,All Other,22000,20,,22000,percent of total billed charges,Implant Device,22000,20,,22000,percent of total billed charges,Implant Device,37400,34,"Charges > $500, x 34%",37400,percent of total billed charges,Implant Device,22000,20,,22000,percent of total billed charges,Implant Device,22000,20,,22000,percent of total billed charges,Implant Device,22000,20,,22000,percent of total billed charges,Implant Device,22000,20,,22000,percent of total billed charges,Implant Device,22000,20,,22000,percent of total billed charges,Implant Device,22000,20,,22000,percent of total billed charges,Implant Device,22000,20,,22000,percent of total billed charges,Implant Device,22000,20,,22000,percent of total billed charges,Implant Device,22000,20,,22000,percent of total billed charges,Implant Device,22000,20,,22000,percent of total billed charges,Implant Device,22000,20,,22000,percent of total billed charges,Implant Device,22000,20,,22000,percent of total billed charges,Implant Device,22000,20,,22000,percent of total billed charges,Implant Device,1296.64,,,1296.64,Other,New York Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,1983.87,,,1983.87,Other,153% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,1815.3,,,1815.3,Other,140% Medicaid APG methodology,37400,34,"If Charge > 2,000, then 34 percent",37400,percent of total billed charges,Implants,3371.27,,,3371.27,Other,260% Medicaid APG methodology,4201.13,,,4201.13,Other,324% Medicaid APG methodology,2787.78,,,2787.78,Other,215% Medicaid APG methodology,2787.78,,,2787.78,Other,215% Medicaid APG methodology,1620.81,,,1620.81,Other,125% Medicaid APG methodology,0.01,55000,
OCULAR IMPLANT                  ,L8610,HCPCS,,42560516,CDM,278,RC,,,both,,,4975,1963.47,,,1963.47,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,2487.5,50,,2487.5,percent of total billed charges,All Other,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,1691.5,34,"Charges > $500, x 34%",1691.5,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,995,20,,995,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,1691.5,34,"If Charge > 2,000, then 34 percent",1691.5,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,2487.5,
CYMETRA INJECTABLE 1 CC         ,Q4112,HCPCS,,42560557,CDM,278,RC,,,both,,,3024.25,1193.57,,,1193.57,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,604.85,20,,604.85,percent of total billed charges,Implant Device,604.85,20,,604.85,percent of total billed charges,Implant Device,604.85,20,,604.85,percent of total billed charges,Implant Device,604.85,20,,604.85,percent of total billed charges,Implant Device,604.85,20,,604.85,percent of total billed charges,Implant Device,1512.13,50,,1512.13,percent of total billed charges,All Other,604.85,20,,604.85,percent of total billed charges,Implant Device,604.85,20,,604.85,percent of total billed charges,Implant Device,1028.25,34,"Charges > $500, x 34%",1028.25,percent of total billed charges,Implant Device,604.85,20,,604.85,percent of total billed charges,Implant Device,604.85,20,,604.85,percent of total billed charges,Implant Device,604.85,20,,604.85,percent of total billed charges,Implant Device,604.85,20,,604.85,percent of total billed charges,Implant Device,604.85,20,,604.85,percent of total billed charges,Implant Device,604.85,20,,604.85,percent of total billed charges,Implant Device,604.85,20,,604.85,percent of total billed charges,Implant Device,604.85,20,,604.85,percent of total billed charges,Implant Device,604.85,20,,604.85,percent of total billed charges,Implant Device,604.85,20,,604.85,percent of total billed charges,Implant Device,604.85,20,,604.85,percent of total billed charges,Implant Device,604.85,20,,604.85,percent of total billed charges,Implant Device,604.85,20,,604.85,percent of total billed charges,Implant Device,1296.64,,,1296.64,Other,New York Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,1983.87,,,1983.87,Other,153% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,1815.3,,,1815.3,Other,140% Medicaid APG methodology,1028.25,34,"If Charge > 2,000, then 34 percent",1028.25,percent of total billed charges,Implants,3371.27,,,3371.27,Other,260% Medicaid APG methodology,4201.13,,,4201.13,Other,324% Medicaid APG methodology,2787.78,,,2787.78,Other,215% Medicaid APG methodology,2787.78,,,2787.78,Other,215% Medicaid APG methodology,1620.81,,,1620.81,Other,125% Medicaid APG methodology,0.01,4201.13,
AMNIOTIC MEMBRANE               ,V2790,HCPCS,,42560573,CDM,278,RC,,,both,,,4745,1872.7,,,1872.7,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,949,20,,949,percent of total billed charges,Implant Device,949,20,,949,percent of total billed charges,Implant Device,949,20,,949,percent of total billed charges,Implant Device,949,20,,949,percent of total billed charges,Implant Device,949,20,,949,percent of total billed charges,Implant Device,2372.5,50,,2372.5,percent of total billed charges,All Other,949,20,,949,percent of total billed charges,Implant Device,949,20,,949,percent of total billed charges,Implant Device,1613.3,34,"Charges > $500, x 34%",1613.3,percent of total billed charges,Implant Device,949,20,,949,percent of total billed charges,Implant Device,949,20,,949,percent of total billed charges,Implant Device,949,20,,949,percent of total billed charges,Implant Device,949,20,,949,percent of total billed charges,Implant Device,949,20,,949,percent of total billed charges,Implant Device,949,20,,949,percent of total billed charges,Implant Device,949,20,,949,percent of total billed charges,Implant Device,949,20,,949,percent of total billed charges,Implant Device,949,20,,949,percent of total billed charges,Implant Device,949,20,,949,percent of total billed charges,Implant Device,949,20,,949,percent of total billed charges,Implant Device,949,20,,949,percent of total billed charges,Implant Device,949,20,,949,percent of total billed charges,Implant Device,1296.64,,,1296.64,Other,New York Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,1983.87,,,1983.87,Other,153% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,1815.3,,,1815.3,Other,140% Medicaid APG methodology,1613.3,34,"If Charge > 2,000, then 34 percent",1613.3,percent of total billed charges,Implants,3371.27,,,3371.27,Other,260% Medicaid APG methodology,4201.13,,,4201.13,Other,324% Medicaid APG methodology,2787.78,,,2787.78,Other,215% Medicaid APG methodology,2787.78,,,2787.78,Other,215% Medicaid APG methodology,1620.81,,,1620.81,Other,125% Medicaid APG methodology,0.01,4201.13,
IMPLANTABLE TISSUE MARKER       ,A4648,HCPCS,,42560706,CDM,278,RC,,,both,,,895,353.23,,,353.23,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,179,20,,179,percent of total billed charges,Implant Device,179,20,,179,percent of total billed charges,Implant Device,179,20,,179,percent of total billed charges,Implant Device,179,20,,179,percent of total billed charges,Implant Device,179,20,,179,percent of total billed charges,Implant Device,447.5,50,,447.5,percent of total billed charges,All Other,179,20,,179,percent of total billed charges,Implant Device,179,20,,179,percent of total billed charges,Implant Device,304.3,34,"Charges > $500, x 34%",304.3,percent of total billed charges,Implant Device,179,20,,179,percent of total billed charges,Implant Device,179,20,,179,percent of total billed charges,Implant Device,179,20,,179,percent of total billed charges,Implant Device,179,20,,179,percent of total billed charges,Implant Device,179,20,,179,percent of total billed charges,Implant Device,179,20,,179,percent of total billed charges,Implant Device,179,20,,179,percent of total billed charges,Implant Device,179,20,,179,percent of total billed charges,Implant Device,179,20,,179,percent of total billed charges,Implant Device,179,20,,179,percent of total billed charges,Implant Device,179,20,,179,percent of total billed charges,Implant Device,179,20,,179,percent of total billed charges,Implant Device,179,20,,179,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,447.5,
TISSUE LOCALIZATION-EXCISION    ,C1819,HCPCS,,42560789,CDM,278,RC,,,both,,,16100,6354.15,,,6354.15,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,3220,20,,3220,percent of total billed charges,Implant Device,3220,20,,3220,percent of total billed charges,Implant Device,3220,20,,3220,percent of total billed charges,Implant Device,3220,20,,3220,percent of total billed charges,Implant Device,3220,20,,3220,percent of total billed charges,Implant Device,8050,50,,8050,percent of total billed charges,All Other,3220,20,,3220,percent of total billed charges,Implant Device,3220,20,,3220,percent of total billed charges,Implant Device,5474,34,"Charges > $500, x 34%",5474,percent of total billed charges,Implant Device,3220,20,,3220,percent of total billed charges,Implant Device,3220,20,,3220,percent of total billed charges,Implant Device,3220,20,,3220,percent of total billed charges,Implant Device,3220,20,,3220,percent of total billed charges,Implant Device,3220,20,,3220,percent of total billed charges,Implant Device,3220,20,,3220,percent of total billed charges,Implant Device,3220,20,,3220,percent of total billed charges,Implant Device,3220,20,,3220,percent of total billed charges,Implant Device,3220,20,,3220,percent of total billed charges,Implant Device,3220,20,,3220,percent of total billed charges,Implant Device,3220,20,,3220,percent of total billed charges,Implant Device,3220,20,,3220,percent of total billed charges,Implant Device,3220,20,,3220,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,5474,34,"If Charge > 2,000, then 34 percent",5474,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,8050,
INTERSPINOUS IMPLANT            ,C1821,HCPCS,,42560797,CDM,278,RC,,,both,,,55000,21706.74,,,21706.74,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,11000,20,,11000,percent of total billed charges,Implant Device,11000,20,,11000,percent of total billed charges,Implant Device,11000,20,,11000,percent of total billed charges,Implant Device,11000,20,,11000,percent of total billed charges,Implant Device,11000,20,,11000,percent of total billed charges,Implant Device,27500,50,,27500,percent of total billed charges,All Other,11000,20,,11000,percent of total billed charges,Implant Device,11000,20,,11000,percent of total billed charges,Implant Device,18700,34,"Charges > $500, x 34%",18700,percent of total billed charges,Implant Device,11000,20,,11000,percent of total billed charges,Implant Device,11000,20,,11000,percent of total billed charges,Implant Device,11000,20,,11000,percent of total billed charges,Implant Device,11000,20,,11000,percent of total billed charges,Implant Device,11000,20,,11000,percent of total billed charges,Implant Device,11000,20,,11000,percent of total billed charges,Implant Device,11000,20,,11000,percent of total billed charges,Implant Device,11000,20,,11000,percent of total billed charges,Implant Device,11000,20,,11000,percent of total billed charges,Implant Device,11000,20,,11000,percent of total billed charges,Implant Device,11000,20,,11000,percent of total billed charges,Implant Device,11000,20,,11000,percent of total billed charges,Implant Device,11000,20,,11000,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,18700,34,"If Charge > 2,000, then 34 percent",18700,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,27500,
DEXTRANOMER HYALUR ACID 1 ML    ,L8604,HCPCS,,42560854,CDM,278,RC,,,both,,,14443,5700.19,,,5700.19,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,2888.6,20,,2888.6,percent of total billed charges,Implant Device,2888.6,20,,2888.6,percent of total billed charges,Implant Device,2888.6,20,,2888.6,percent of total billed charges,Implant Device,2888.6,20,,2888.6,percent of total billed charges,Implant Device,2888.6,20,,2888.6,percent of total billed charges,Implant Device,7221.5,50,,7221.5,percent of total billed charges,All Other,2888.6,20,,2888.6,percent of total billed charges,Implant Device,2888.6,20,,2888.6,percent of total billed charges,Implant Device,4910.62,34,"Charges > $500, x 34%",4910.62,percent of total billed charges,Implant Device,2888.6,20,,2888.6,percent of total billed charges,Implant Device,2888.6,20,,2888.6,percent of total billed charges,Implant Device,2888.6,20,,2888.6,percent of total billed charges,Implant Device,2888.6,20,,2888.6,percent of total billed charges,Implant Device,2888.6,20,,2888.6,percent of total billed charges,Implant Device,2888.6,20,,2888.6,percent of total billed charges,Implant Device,2888.6,20,,2888.6,percent of total billed charges,Implant Device,2888.6,20,,2888.6,percent of total billed charges,Implant Device,2888.6,20,,2888.6,percent of total billed charges,Implant Device,2888.6,20,,2888.6,percent of total billed charges,Implant Device,2888.6,20,,2888.6,percent of total billed charges,Implant Device,2888.6,20,,2888.6,percent of total billed charges,Implant Device,2888.6,20,,2888.6,percent of total billed charges,Implant Device,1296.64,,,1296.64,Other,New York Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,1983.87,,,1983.87,Other,153% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,1815.3,,,1815.3,Other,140% Medicaid APG methodology,4910.62,34,"If Charge > 2,000, then 34 percent",4910.62,percent of total billed charges,Implants,3371.27,,,3371.27,Other,260% Medicaid APG methodology,4201.13,,,4201.13,Other,324% Medicaid APG methodology,2787.78,,,2787.78,Other,215% Medicaid APG methodology,2787.78,,,2787.78,Other,215% Medicaid APG methodology,1620.81,,,1620.81,Other,125% Medicaid APG methodology,0.01,7221.5,
NEUROSTIMULATOR KIT             ,C1822,HCPCS,,42560979,CDM,278,RC,,,both,,,180000,71040.24,,,71040.24,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,36000,20,,36000,percent of total billed charges,Implant Device,36000,20,,36000,percent of total billed charges,Implant Device,36000,20,,36000,percent of total billed charges,Implant Device,36000,20,,36000,percent of total billed charges,Implant Device,36000,20,,36000,percent of total billed charges,Implant Device,90000,50,,90000,percent of total billed charges,All Other,36000,20,,36000,percent of total billed charges,Implant Device,36000,20,,36000,percent of total billed charges,Implant Device,61200,34,"Charges > $500, x 34%",61200,percent of total billed charges,Implant Device,36000,20,,36000,percent of total billed charges,Implant Device,36000,20,,36000,percent of total billed charges,Implant Device,36000,20,,36000,percent of total billed charges,Implant Device,36000,20,,36000,percent of total billed charges,Implant Device,36000,20,,36000,percent of total billed charges,Implant Device,36000,20,,36000,percent of total billed charges,Implant Device,36000,20,,36000,percent of total billed charges,Implant Device,36000,20,,36000,percent of total billed charges,Implant Device,36000,20,,36000,percent of total billed charges,Implant Device,36000,20,,36000,percent of total billed charges,Implant Device,36000,20,,36000,percent of total billed charges,Implant Device,36000,20,,36000,percent of total billed charges,Implant Device,36000,20,,36000,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,61200,34,"If Charge > 2,000, then 34 percent",61200,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,90000,
ADATO RETINAL OIL SILICONE      ,C1814,HCPCS,,42561043,CDM,278,RC,,,both,,,2299.75,907.64,,,907.64,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,459.95,20,,459.95,percent of total billed charges,Implant Device,459.95,20,,459.95,percent of total billed charges,Implant Device,459.95,20,,459.95,percent of total billed charges,Implant Device,459.95,20,,459.95,percent of total billed charges,Implant Device,459.95,20,,459.95,percent of total billed charges,Implant Device,1149.88,50,,1149.88,percent of total billed charges,All Other,459.95,20,,459.95,percent of total billed charges,Implant Device,459.95,20,,459.95,percent of total billed charges,Implant Device,781.92,34,"Charges > $500, x 34%",781.92,percent of total billed charges,Implant Device,459.95,20,,459.95,percent of total billed charges,Implant Device,459.95,20,,459.95,percent of total billed charges,Implant Device,459.95,20,,459.95,percent of total billed charges,Implant Device,459.95,20,,459.95,percent of total billed charges,Implant Device,459.95,20,,459.95,percent of total billed charges,Implant Device,459.95,20,,459.95,percent of total billed charges,Implant Device,459.95,20,,459.95,percent of total billed charges,Implant Device,459.95,20,,459.95,percent of total billed charges,Implant Device,459.95,20,,459.95,percent of total billed charges,Implant Device,459.95,20,,459.95,percent of total billed charges,Implant Device,459.95,20,,459.95,percent of total billed charges,Implant Device,459.95,20,,459.95,percent of total billed charges,Implant Device,459.95,20,,459.95,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,781.92,34,"If Charge > 2,000, then 34 percent",781.92,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1149.88,
EXALT MODEL D DUODENOSCOPE      ,C1748,HCPCS,,42561050,CDM,278,RC,,,both,,,22000,8682.7,,,8682.7,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,4400,20,,4400,percent of total billed charges,Implant Device,4400,20,,4400,percent of total billed charges,Implant Device,4400,20,,4400,percent of total billed charges,Implant Device,4400,20,,4400,percent of total billed charges,Implant Device,4400,20,,4400,percent of total billed charges,Implant Device,11000,50,,11000,percent of total billed charges,All Other,4400,20,,4400,percent of total billed charges,Implant Device,4400,20,,4400,percent of total billed charges,Implant Device,7480,34,"Charges > $500, x 34%",7480,percent of total billed charges,Implant Device,4400,20,,4400,percent of total billed charges,Implant Device,4400,20,,4400,percent of total billed charges,Implant Device,4400,20,,4400,percent of total billed charges,Implant Device,4400,20,,4400,percent of total billed charges,Implant Device,4400,20,,4400,percent of total billed charges,Implant Device,4400,20,,4400,percent of total billed charges,Implant Device,4400,20,,4400,percent of total billed charges,Implant Device,4400,20,,4400,percent of total billed charges,Implant Device,4400,20,,4400,percent of total billed charges,Implant Device,4400,20,,4400,percent of total billed charges,Implant Device,4400,20,,4400,percent of total billed charges,Implant Device,4400,20,,4400,percent of total billed charges,Implant Device,4400,20,,4400,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,7480,34,"If Charge > 2,000, then 34 percent",7480,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,11000,
SYNTHETIC  IMPLANT URINARY      ,L8606,HCPCS,,42561068,CDM,278,RC,,,both,,,5750,2269.34,,,2269.34,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,1150,20,,1150,percent of total billed charges,Implant Device,1150,20,,1150,percent of total billed charges,Implant Device,1150,20,,1150,percent of total billed charges,Implant Device,1150,20,,1150,percent of total billed charges,Implant Device,1150,20,,1150,percent of total billed charges,Implant Device,2875,50,,2875,percent of total billed charges,All Other,1150,20,,1150,percent of total billed charges,Implant Device,1150,20,,1150,percent of total billed charges,Implant Device,1955,34,"Charges > $500, x 34%",1955,percent of total billed charges,Implant Device,1150,20,,1150,percent of total billed charges,Implant Device,1150,20,,1150,percent of total billed charges,Implant Device,1150,20,,1150,percent of total billed charges,Implant Device,1150,20,,1150,percent of total billed charges,Implant Device,1150,20,,1150,percent of total billed charges,Implant Device,1150,20,,1150,percent of total billed charges,Implant Device,1150,20,,1150,percent of total billed charges,Implant Device,1150,20,,1150,percent of total billed charges,Implant Device,1150,20,,1150,percent of total billed charges,Implant Device,1150,20,,1150,percent of total billed charges,Implant Device,1150,20,,1150,percent of total billed charges,Implant Device,1150,20,,1150,percent of total billed charges,Implant Device,1150,20,,1150,percent of total billed charges,Implant Device,1296.64,,,1296.64,Other,New York Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,1983.87,,,1983.87,Other,153% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,1815.3,,,1815.3,Other,140% Medicaid APG methodology,1955,34,"If Charge > 2,000, then 34 percent",1955,percent of total billed charges,Implants,3371.27,,,3371.27,Other,260% Medicaid APG methodology,4201.13,,,4201.13,Other,324% Medicaid APG methodology,2787.78,,,2787.78,Other,215% Medicaid APG methodology,2787.78,,,2787.78,Other,215% Medicaid APG methodology,1620.81,,,1620.81,Other,125% Medicaid APG methodology,0.01,4201.13,
"ORTH/DEVIC/DRUG BN/BN,TIS/BN    ",C1734,HCPCS,,42561100,CDM,278,RC,,,both,,,34865,13760.1,,,13760.1,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,6973,20,,6973,percent of total billed charges,Implant Device,6973,20,,6973,percent of total billed charges,Implant Device,6973,20,,6973,percent of total billed charges,Implant Device,6973,20,,6973,percent of total billed charges,Implant Device,6973,20,,6973,percent of total billed charges,Implant Device,17432.5,50,,17432.5,percent of total billed charges,All Other,6973,20,,6973,percent of total billed charges,Implant Device,6973,20,,6973,percent of total billed charges,Implant Device,11854.1,34,"Charges > $500, x 34%",11854.1,percent of total billed charges,Implant Device,6973,20,,6973,percent of total billed charges,Implant Device,6973,20,,6973,percent of total billed charges,Implant Device,6973,20,,6973,percent of total billed charges,Implant Device,6973,20,,6973,percent of total billed charges,Implant Device,6973,20,,6973,percent of total billed charges,Implant Device,6973,20,,6973,percent of total billed charges,Implant Device,6973,20,,6973,percent of total billed charges,Implant Device,6973,20,,6973,percent of total billed charges,Implant Device,6973,20,,6973,percent of total billed charges,Implant Device,6973,20,,6973,percent of total billed charges,Implant Device,6973,20,,6973,percent of total billed charges,Implant Device,6973,20,,6973,percent of total billed charges,Implant Device,6973,20,,6973,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,11854.1,34,"If Charge > 2,000, then 34 percent",11854.1,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,17432.5,
IMPLANT BREAST                  ,L8600,HCPCS,,42561142,CDM,278,RC,,,both,,,11475,4528.82,,,4528.82,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,2295,20,,2295,percent of total billed charges,Implant Device,2295,20,,2295,percent of total billed charges,Implant Device,2295,20,,2295,percent of total billed charges,Implant Device,2295,20,,2295,percent of total billed charges,Implant Device,2295,20,,2295,percent of total billed charges,Implant Device,5737.5,50,,5737.5,percent of total billed charges,All Other,2295,20,,2295,percent of total billed charges,Implant Device,2295,20,,2295,percent of total billed charges,Implant Device,3901.5,34,"Charges > $500, x 34%",3901.5,percent of total billed charges,Implant Device,2295,20,,2295,percent of total billed charges,Implant Device,2295,20,,2295,percent of total billed charges,Implant Device,2295,20,,2295,percent of total billed charges,Implant Device,2295,20,,2295,percent of total billed charges,Implant Device,2295,20,,2295,percent of total billed charges,Implant Device,2295,20,,2295,percent of total billed charges,Implant Device,2295,20,,2295,percent of total billed charges,Implant Device,2295,20,,2295,percent of total billed charges,Implant Device,2295,20,,2295,percent of total billed charges,Implant Device,2295,20,,2295,percent of total billed charges,Implant Device,2295,20,,2295,percent of total billed charges,Implant Device,2295,20,,2295,percent of total billed charges,Implant Device,2295,20,,2295,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,3901.5,34,"If Charge > 2,000, then 34 percent",3901.5,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,5737.5,
OSSICULAR IMPLANT               ,L8613,HCPCS,,42561225,CDM,278,RC,,,both,,,1709,674.49,,,674.49,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341.8,20,,341.8,percent of total billed charges,Implant Device,341.8,20,,341.8,percent of total billed charges,Implant Device,341.8,20,,341.8,percent of total billed charges,Implant Device,341.8,20,,341.8,percent of total billed charges,Implant Device,341.8,20,,341.8,percent of total billed charges,Implant Device,854.5,50,,854.5,percent of total billed charges,All Other,341.8,20,,341.8,percent of total billed charges,Implant Device,341.8,20,,341.8,percent of total billed charges,Implant Device,581.06,34,"Charges > $500, x 34%",581.06,percent of total billed charges,Implant Device,341.8,20,,341.8,percent of total billed charges,Implant Device,341.8,20,,341.8,percent of total billed charges,Implant Device,341.8,20,,341.8,percent of total billed charges,Implant Device,341.8,20,,341.8,percent of total billed charges,Implant Device,341.8,20,,341.8,percent of total billed charges,Implant Device,341.8,20,,341.8,percent of total billed charges,Implant Device,341.8,20,,341.8,percent of total billed charges,Implant Device,341.8,20,,341.8,percent of total billed charges,Implant Device,341.8,20,,341.8,percent of total billed charges,Implant Device,341.8,20,,341.8,percent of total billed charges,Implant Device,341.8,20,,341.8,percent of total billed charges,Implant Device,341.8,20,,341.8,percent of total billed charges,Implant Device,341.8,20,,341.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,854.5,
PROPEL SINUS SUPPLY             ,C2625,HCPCS,,42561233,CDM,278,RC,,,both,,,8250,3256.01,,,3256.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,1650,20,,1650,percent of total billed charges,Implant Device,1650,20,,1650,percent of total billed charges,Implant Device,1650,20,,1650,percent of total billed charges,Implant Device,1650,20,,1650,percent of total billed charges,Implant Device,1650,20,,1650,percent of total billed charges,Implant Device,4125,50,,4125,percent of total billed charges,All Other,1650,20,,1650,percent of total billed charges,Implant Device,1650,20,,1650,percent of total billed charges,Implant Device,2805,34,"Charges > $500, x 34%",2805,percent of total billed charges,Implant Device,1650,20,,1650,percent of total billed charges,Implant Device,1650,20,,1650,percent of total billed charges,Implant Device,1650,20,,1650,percent of total billed charges,Implant Device,1650,20,,1650,percent of total billed charges,Implant Device,1650,20,,1650,percent of total billed charges,Implant Device,1650,20,,1650,percent of total billed charges,Implant Device,1650,20,,1650,percent of total billed charges,Implant Device,1650,20,,1650,percent of total billed charges,Implant Device,1650,20,,1650,percent of total billed charges,Implant Device,1650,20,,1650,percent of total billed charges,Implant Device,1650,20,,1650,percent of total billed charges,Implant Device,1650,20,,1650,percent of total billed charges,Implant Device,1650,20,,1650,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,2805,34,"If Charge > 2,000, then 34 percent",2805,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,4125,
"IMPLANT/INSERT DEVICE, NOC      ",C1889,HCPCS,,42561266,CDM,278,RC,,,both,,,150000,59200.2,,,59200.2,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,75000,50,,75000,percent of total billed charges,All Other,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,51000,34,"Charges > $500, x 34%",51000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,51000,34,"If Charge > 2,000, then 34 percent",51000,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,75000,
AQUEOUS SHUNT                   ,L8612,HCPCS,,42561274,CDM,278,RC,,,both,,,8329.65,3287.45,,,3287.45,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,1665.93,20,,1665.93,percent of total billed charges,Implant Device,1665.93,20,,1665.93,percent of total billed charges,Implant Device,1665.93,20,,1665.93,percent of total billed charges,Implant Device,1665.93,20,,1665.93,percent of total billed charges,Implant Device,1665.93,20,,1665.93,percent of total billed charges,Implant Device,4164.83,50,,4164.83,percent of total billed charges,All Other,1665.93,20,,1665.93,percent of total billed charges,Implant Device,1665.93,20,,1665.93,percent of total billed charges,Implant Device,2832.08,34,"Charges > $500, x 34%",2832.08,percent of total billed charges,Implant Device,1665.93,20,,1665.93,percent of total billed charges,Implant Device,1665.93,20,,1665.93,percent of total billed charges,Implant Device,1665.93,20,,1665.93,percent of total billed charges,Implant Device,1665.93,20,,1665.93,percent of total billed charges,Implant Device,1665.93,20,,1665.93,percent of total billed charges,Implant Device,1665.93,20,,1665.93,percent of total billed charges,Implant Device,1665.93,20,,1665.93,percent of total billed charges,Implant Device,1665.93,20,,1665.93,percent of total billed charges,Implant Device,1665.93,20,,1665.93,percent of total billed charges,Implant Device,1665.93,20,,1665.93,percent of total billed charges,Implant Device,1665.93,20,,1665.93,percent of total billed charges,Implant Device,1665.93,20,,1665.93,percent of total billed charges,Implant Device,1665.93,20,,1665.93,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,2832.08,34,"If Charge > 2,000, then 34 percent",2832.08,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,4164.83,
UROLIFT SYSTEM                  ,L8699,HCPCS,,42561357,CDM,278,RC,,,both,,,4875,1924.01,,,1924.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,975,20,,975,percent of total billed charges,Implant Device,975,20,,975,percent of total billed charges,Implant Device,975,20,,975,percent of total billed charges,Implant Device,975,20,,975,percent of total billed charges,Implant Device,975,20,,975,percent of total billed charges,Implant Device,2437.5,50,,2437.5,percent of total billed charges,All Other,975,20,,975,percent of total billed charges,Implant Device,975,20,,975,percent of total billed charges,Implant Device,1657.5,34,"Charges > $500, x 34%",1657.5,percent of total billed charges,Implant Device,975,20,,975,percent of total billed charges,Implant Device,975,20,,975,percent of total billed charges,Implant Device,975,20,,975,percent of total billed charges,Implant Device,975,20,,975,percent of total billed charges,Implant Device,975,20,,975,percent of total billed charges,Implant Device,975,20,,975,percent of total billed charges,Implant Device,975,20,,975,percent of total billed charges,Implant Device,975,20,,975,percent of total billed charges,Implant Device,975,20,,975,percent of total billed charges,Implant Device,975,20,,975,percent of total billed charges,Implant Device,975,20,,975,percent of total billed charges,Implant Device,975,20,,975,percent of total billed charges,Implant Device,975,20,,975,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,1657.5,34,"If Charge > 2,000, then 34 percent",1657.5,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,2437.5,
IMPLANT METACARPOPHALANGEAL     ,L8630,HCPCS,,42561365,CDM,278,RC,,,both,,,9685.4,3822.52,,,3822.52,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,1937.08,20,,1937.08,percent of total billed charges,Implant Device,1937.08,20,,1937.08,percent of total billed charges,Implant Device,1937.08,20,,1937.08,percent of total billed charges,Implant Device,1937.08,20,,1937.08,percent of total billed charges,Implant Device,1937.08,20,,1937.08,percent of total billed charges,Implant Device,4842.7,50,,4842.7,percent of total billed charges,All Other,1937.08,20,,1937.08,percent of total billed charges,Implant Device,1937.08,20,,1937.08,percent of total billed charges,Implant Device,3293.04,34,"Charges > $500, x 34%",3293.04,percent of total billed charges,Implant Device,1937.08,20,,1937.08,percent of total billed charges,Implant Device,1937.08,20,,1937.08,percent of total billed charges,Implant Device,1937.08,20,,1937.08,percent of total billed charges,Implant Device,1937.08,20,,1937.08,percent of total billed charges,Implant Device,1937.08,20,,1937.08,percent of total billed charges,Implant Device,1937.08,20,,1937.08,percent of total billed charges,Implant Device,1937.08,20,,1937.08,percent of total billed charges,Implant Device,1937.08,20,,1937.08,percent of total billed charges,Implant Device,1937.08,20,,1937.08,percent of total billed charges,Implant Device,1937.08,20,,1937.08,percent of total billed charges,Implant Device,1937.08,20,,1937.08,percent of total billed charges,Implant Device,1937.08,20,,1937.08,percent of total billed charges,Implant Device,1937.08,20,,1937.08,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,3293.04,34,"If Charge > 2,000, then 34 percent",3293.04,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,4842.7,
INTERPHALANGEAL JOINT SPACER    ,L8658,HCPCS,,42561373,CDM,278,RC,,,both,,,4642.65,1832.31,,,1832.31,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,928.53,20,,928.53,percent of total billed charges,Implant Device,928.53,20,,928.53,percent of total billed charges,Implant Device,928.53,20,,928.53,percent of total billed charges,Implant Device,928.53,20,,928.53,percent of total billed charges,Implant Device,928.53,20,,928.53,percent of total billed charges,Implant Device,2321.33,50,,2321.33,percent of total billed charges,All Other,928.53,20,,928.53,percent of total billed charges,Implant Device,928.53,20,,928.53,percent of total billed charges,Implant Device,1578.5,34,"Charges > $500, x 34%",1578.5,percent of total billed charges,Implant Device,928.53,20,,928.53,percent of total billed charges,Implant Device,928.53,20,,928.53,percent of total billed charges,Implant Device,928.53,20,,928.53,percent of total billed charges,Implant Device,928.53,20,,928.53,percent of total billed charges,Implant Device,928.53,20,,928.53,percent of total billed charges,Implant Device,928.53,20,,928.53,percent of total billed charges,Implant Device,928.53,20,,928.53,percent of total billed charges,Implant Device,928.53,20,,928.53,percent of total billed charges,Implant Device,928.53,20,,928.53,percent of total billed charges,Implant Device,928.53,20,,928.53,percent of total billed charges,Implant Device,928.53,20,,928.53,percent of total billed charges,Implant Device,928.53,20,,928.53,percent of total billed charges,Implant Device,928.53,20,,928.53,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,1578.5,34,"If Charge > 2,000, then 34 percent",1578.5,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,2321.33,
COLLAGEN IMP URINARY 2.5 ML     ,L8603,HCPCS,,42561571,CDM,278,RC,,,both,,,117.5,46.37,,,46.37,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,23.5,20,,23.5,percent of total billed charges,Implant Device,23.5,20,,23.5,percent of total billed charges,Implant Device,23.5,20,,23.5,percent of total billed charges,Implant Device,23.5,20,,23.5,percent of total billed charges,Implant Device,23.5,20,,23.5,percent of total billed charges,Implant Device,58.75,50,,58.75,percent of total billed charges,All Other,23.5,20,,23.5,percent of total billed charges,Implant Device,23.5,20,,23.5,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,23.5,20,,23.5,percent of total billed charges,Implant Device,23.5,20,,23.5,percent of total billed charges,Implant Device,23.5,20,,23.5,percent of total billed charges,Implant Device,23.5,20,,23.5,percent of total billed charges,Implant Device,23.5,20,,23.5,percent of total billed charges,Implant Device,23.5,20,,23.5,percent of total billed charges,Implant Device,23.5,20,,23.5,percent of total billed charges,Implant Device,23.5,20,,23.5,percent of total billed charges,Implant Device,23.5,20,,23.5,percent of total billed charges,Implant Device,23.5,20,,23.5,percent of total billed charges,Implant Device,23.5,20,,23.5,percent of total billed charges,Implant Device,23.5,20,,23.5,percent of total billed charges,Implant Device,23.5,20,,23.5,percent of total billed charges,Implant Device,1296.64,,,1296.64,Other,New York Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,1983.87,,,1983.87,Other,153% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,1815.3,,,1815.3,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,3371.27,,,3371.27,Other,260% Medicaid APG methodology,4201.13,,,4201.13,Other,324% Medicaid APG methodology,2787.78,,,2787.78,Other,215% Medicaid APG methodology,2787.78,,,2787.78,Other,215% Medicaid APG methodology,1620.81,,,1620.81,Other,125% Medicaid APG methodology,0.01,4201.13,
GENERATOR CCM IMPLANT           ,C1824,HCPCS,,42564187,CDM,278,RC,,,both,,,130000,51306.84,,,51306.84,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,26000,20,,26000,percent of total billed charges,Implant Device,26000,20,,26000,percent of total billed charges,Implant Device,26000,20,,26000,percent of total billed charges,Implant Device,26000,20,,26000,percent of total billed charges,Implant Device,26000,20,,26000,percent of total billed charges,Implant Device,65000,50,,65000,percent of total billed charges,All Other,26000,20,,26000,percent of total billed charges,Implant Device,26000,20,,26000,percent of total billed charges,Implant Device,44200,34,"Charges > $500, x 34%",44200,percent of total billed charges,Implant Device,26000,20,,26000,percent of total billed charges,Implant Device,26000,20,,26000,percent of total billed charges,Implant Device,26000,20,,26000,percent of total billed charges,Implant Device,26000,20,,26000,percent of total billed charges,Implant Device,26000,20,,26000,percent of total billed charges,Implant Device,26000,20,,26000,percent of total billed charges,Implant Device,26000,20,,26000,percent of total billed charges,Implant Device,26000,20,,26000,percent of total billed charges,Implant Device,26000,20,,26000,percent of total billed charges,Implant Device,26000,20,,26000,percent of total billed charges,Implant Device,26000,20,,26000,percent of total billed charges,Implant Device,26000,20,,26000,percent of total billed charges,Implant Device,26000,20,,26000,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,44200,34,"If Charge > 2,000, then 34 percent",44200,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,65000,
SPEEDPLATE 18X14MM RAPID COMPRESSION IMPLANT,C1713,HCPCS,,42567099,CDM,278,RC,,,both,,,17975,7094.16,,,7094.16,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,3595,20,,3595,percent of total billed charges,Implant Device,3595,20,,3595,percent of total billed charges,Implant Device,3595,20,,3595,percent of total billed charges,Implant Device,3595,20,,3595,percent of total billed charges,Implant Device,3595,20,,3595,percent of total billed charges,Implant Device,8987.5,50,,8987.5,percent of total billed charges,All Other,3595,20,,3595,percent of total billed charges,Implant Device,3595,20,,3595,percent of total billed charges,Implant Device,6111.5,34,"Charges > $500, x 34%",6111.5,percent of total billed charges,Implant Device,3595,20,,3595,percent of total billed charges,Implant Device,3595,20,,3595,percent of total billed charges,Implant Device,3595,20,,3595,percent of total billed charges,Implant Device,3595,20,,3595,percent of total billed charges,Implant Device,3595,20,,3595,percent of total billed charges,Implant Device,3595,20,,3595,percent of total billed charges,Implant Device,3595,20,,3595,percent of total billed charges,Implant Device,3595,20,,3595,percent of total billed charges,Implant Device,3595,20,,3595,percent of total billed charges,Implant Device,3595,20,,3595,percent of total billed charges,Implant Device,3595,20,,3595,percent of total billed charges,Implant Device,3595,20,,3595,percent of total billed charges,Implant Device,3595,20,,3595,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,6111.5,34,"If Charge > 2,000, then 34 percent",6111.5,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,8987.5,
GEN NEURO IMP LED EX CNTR       ,C1827,HCPCS,,42567115,CDM,278,RC,,,both,,,166851,65850.75,,,65850.75,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,33370.2,20,,33370.2,percent of total billed charges,Implant Device,33370.2,20,,33370.2,percent of total billed charges,Implant Device,33370.2,20,,33370.2,percent of total billed charges,Implant Device,33370.2,20,,33370.2,percent of total billed charges,Implant Device,33370.2,20,,33370.2,percent of total billed charges,Implant Device,83425.5,50,,83425.5,percent of total billed charges,All Other,33370.2,20,,33370.2,percent of total billed charges,Implant Device,33370.2,20,,33370.2,percent of total billed charges,Implant Device,56729.34,34,"Charges > $500, x 34%",56729.34,percent of total billed charges,Implant Device,33370.2,20,,33370.2,percent of total billed charges,Implant Device,33370.2,20,,33370.2,percent of total billed charges,Implant Device,33370.2,20,,33370.2,percent of total billed charges,Implant Device,33370.2,20,,33370.2,percent of total billed charges,Implant Device,33370.2,20,,33370.2,percent of total billed charges,Implant Device,33370.2,20,,33370.2,percent of total billed charges,Implant Device,33370.2,20,,33370.2,percent of total billed charges,Implant Device,33370.2,20,,33370.2,percent of total billed charges,Implant Device,33370.2,20,,33370.2,percent of total billed charges,Implant Device,33370.2,20,,33370.2,percent of total billed charges,Implant Device,33370.2,20,,33370.2,percent of total billed charges,Implant Device,33370.2,20,,33370.2,percent of total billed charges,Implant Device,33370.2,20,,33370.2,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,56729.34,34,"If Charge > 2,000, then 34 percent",56729.34,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,83425.5,
BRACHYTHERAPY NEEDLE            ,C1715,HCPCS,,42580134,CDM,278,RC,,,both,,,100,39.47,,,39.47,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,20,20,,20,percent of total billed charges,Implant Device,20,20,,20,percent of total billed charges,Implant Device,20,20,,20,percent of total billed charges,Implant Device,20,20,,20,percent of total billed charges,Implant Device,20,20,,20,percent of total billed charges,Implant Device,50,50,,50,percent of total billed charges,All Other,20,20,,20,percent of total billed charges,Implant Device,20,20,,20,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,20,20,,20,percent of total billed charges,Implant Device,20,20,,20,percent of total billed charges,Implant Device,20,20,,20,percent of total billed charges,Implant Device,20,20,,20,percent of total billed charges,Implant Device,20,20,,20,percent of total billed charges,Implant Device,20,20,,20,percent of total billed charges,Implant Device,20,20,,20,percent of total billed charges,Implant Device,20,20,,20,percent of total billed charges,Implant Device,20,20,,20,percent of total billed charges,Implant Device,20,20,,20,percent of total billed charges,Implant Device,20,20,,20,percent of total billed charges,Implant Device,20,20,,20,percent of total billed charges,Implant Device,20,20,,20,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,50,
CONN TISS HUMAN (INC FASCIA)    ,C1762,HCPCS,,42580175,CDM,278,RC,,,both,,,54975,21696.87,,,21696.87,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,10995,20,,10995,percent of total billed charges,Implant Device,10995,20,,10995,percent of total billed charges,Implant Device,10995,20,,10995,percent of total billed charges,Implant Device,10995,20,,10995,percent of total billed charges,Implant Device,10995,20,,10995,percent of total billed charges,Implant Device,27487.5,50,,27487.5,percent of total billed charges,All Other,10995,20,,10995,percent of total billed charges,Implant Device,10995,20,,10995,percent of total billed charges,Implant Device,18691.5,34,"Charges > $500, x 34%",18691.5,percent of total billed charges,Implant Device,10995,20,,10995,percent of total billed charges,Implant Device,10995,20,,10995,percent of total billed charges,Implant Device,10995,20,,10995,percent of total billed charges,Implant Device,10995,20,,10995,percent of total billed charges,Implant Device,10995,20,,10995,percent of total billed charges,Implant Device,10995,20,,10995,percent of total billed charges,Implant Device,10995,20,,10995,percent of total billed charges,Implant Device,10995,20,,10995,percent of total billed charges,Implant Device,10995,20,,10995,percent of total billed charges,Implant Device,10995,20,,10995,percent of total billed charges,Implant Device,10995,20,,10995,percent of total billed charges,Implant Device,10995,20,,10995,percent of total billed charges,Implant Device,10995,20,,10995,percent of total billed charges,Implant Device,1296.65,,,1296.65,Other,New York Medicaid APG methodology,1296.65,,,1296.65,Other,100% Medicaid APG methodology,1296.65,,,1296.65,Other,100% Medicaid APG methodology,1296.65,,,1296.65,Other,100% Medicaid APG methodology,2917.46,,,2917.46,Other,225% Medicaid APG methodology,2917.46,,,2917.46,Other,225% Medicaid APG methodology,1983.88,,,1983.88,Other,153% Medicaid APG methodology,2917.46,,,2917.46,Other,225% Medicaid APG methodology,1815.31,,,1815.31,Other,140% Medicaid APG methodology,18691.5,34,"If Charge > 2,000, then 34 percent",18691.5,percent of total billed charges,Implants,3371.29,,,3371.29,Other,260% Medicaid APG methodology,4201.15,,,4201.15,Other,324% Medicaid APG methodology,2787.8,,,2787.8,Other,215% Medicaid APG methodology,2787.8,,,2787.8,Other,215% Medicaid APG methodology,1620.81,,,1620.81,Other,125% Medicaid APG methodology,0.01,27487.5,
GENERATOR NEURO NON-RECHARGE    ,C1767,HCPCS,,42580191,CDM,278,RC,,,both,,,177370,70002.26,,,70002.26,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,35474,20,,35474,percent of total billed charges,Implant Device,35474,20,,35474,percent of total billed charges,Implant Device,35474,20,,35474,percent of total billed charges,Implant Device,35474,20,,35474,percent of total billed charges,Implant Device,35474,20,,35474,percent of total billed charges,Implant Device,88685,50,,88685,percent of total billed charges,All Other,35474,20,,35474,percent of total billed charges,Implant Device,35474,20,,35474,percent of total billed charges,Implant Device,60305.8,34,"Charges > $500, x 34%",60305.8,percent of total billed charges,Implant Device,35474,20,,35474,percent of total billed charges,Implant Device,35474,20,,35474,percent of total billed charges,Implant Device,35474,20,,35474,percent of total billed charges,Implant Device,35474,20,,35474,percent of total billed charges,Implant Device,35474,20,,35474,percent of total billed charges,Implant Device,35474,20,,35474,percent of total billed charges,Implant Device,35474,20,,35474,percent of total billed charges,Implant Device,35474,20,,35474,percent of total billed charges,Implant Device,35474,20,,35474,percent of total billed charges,Implant Device,35474,20,,35474,percent of total billed charges,Implant Device,35474,20,,35474,percent of total billed charges,Implant Device,35474,20,,35474,percent of total billed charges,Implant Device,35474,20,,35474,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,60305.8,34,"If Charge > 2,000, then 34 percent",60305.8,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,88685,
REP DEV URINARY W/SLING         ,C1771,HCPCS,,42580209,CDM,278,RC,,,both,,,28585,11281.58,,,11281.58,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,5717,20,,5717,percent of total billed charges,Implant Device,5717,20,,5717,percent of total billed charges,Implant Device,5717,20,,5717,percent of total billed charges,Implant Device,5717,20,,5717,percent of total billed charges,Implant Device,5717,20,,5717,percent of total billed charges,Implant Device,14292.5,50,,14292.5,percent of total billed charges,All Other,5717,20,,5717,percent of total billed charges,Implant Device,5717,20,,5717,percent of total billed charges,Implant Device,9718.9,34,"Charges > $500, x 34%",9718.9,percent of total billed charges,Implant Device,5717,20,,5717,percent of total billed charges,Implant Device,5717,20,,5717,percent of total billed charges,Implant Device,5717,20,,5717,percent of total billed charges,Implant Device,5717,20,,5717,percent of total billed charges,Implant Device,5717,20,,5717,percent of total billed charges,Implant Device,5717,20,,5717,percent of total billed charges,Implant Device,5717,20,,5717,percent of total billed charges,Implant Device,5717,20,,5717,percent of total billed charges,Implant Device,5717,20,,5717,percent of total billed charges,Implant Device,5717,20,,5717,percent of total billed charges,Implant Device,5717,20,,5717,percent of total billed charges,Implant Device,5717,20,,5717,percent of total billed charges,Implant Device,5717,20,,5717,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,9718.9,34,"If Charge > 2,000, then 34 percent",9718.9,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,14292.5,
LEAD NEUROSTIMULATOR            ,C1778,HCPCS,,42580217,CDM,278,RC,,,both,,,51270,20234.63,,,20234.63,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,10254,20,,10254,percent of total billed charges,Implant Device,10254,20,,10254,percent of total billed charges,Implant Device,10254,20,,10254,percent of total billed charges,Implant Device,10254,20,,10254,percent of total billed charges,Implant Device,10254,20,,10254,percent of total billed charges,Implant Device,25635,50,,25635,percent of total billed charges,All Other,10254,20,,10254,percent of total billed charges,Implant Device,10254,20,,10254,percent of total billed charges,Implant Device,17431.8,34,"Charges > $500, x 34%",17431.8,percent of total billed charges,Implant Device,10254,20,,10254,percent of total billed charges,Implant Device,10254,20,,10254,percent of total billed charges,Implant Device,10254,20,,10254,percent of total billed charges,Implant Device,10254,20,,10254,percent of total billed charges,Implant Device,10254,20,,10254,percent of total billed charges,Implant Device,10254,20,,10254,percent of total billed charges,Implant Device,10254,20,,10254,percent of total billed charges,Implant Device,10254,20,,10254,percent of total billed charges,Implant Device,10254,20,,10254,percent of total billed charges,Implant Device,10254,20,,10254,percent of total billed charges,Implant Device,10254,20,,10254,percent of total billed charges,Implant Device,10254,20,,10254,percent of total billed charges,Implant Device,10254,20,,10254,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,17431.8,34,"If Charge > 2,000, then 34 percent",17431.8,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,25635,
OCULAR IMP AQUEOUS DRAIN        ,C1783,HCPCS,,42580233,CDM,278,RC,,,both,,,12750,5032.02,,,5032.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,2550,20,,2550,percent of total billed charges,Implant Device,2550,20,,2550,percent of total billed charges,Implant Device,2550,20,,2550,percent of total billed charges,Implant Device,2550,20,,2550,percent of total billed charges,Implant Device,2550,20,,2550,percent of total billed charges,Implant Device,6375,50,,6375,percent of total billed charges,All Other,2550,20,,2550,percent of total billed charges,Implant Device,2550,20,,2550,percent of total billed charges,Implant Device,4335,34,"Charges > $500, x 34%",4335,percent of total billed charges,Implant Device,2550,20,,2550,percent of total billed charges,Implant Device,2550,20,,2550,percent of total billed charges,Implant Device,2550,20,,2550,percent of total billed charges,Implant Device,2550,20,,2550,percent of total billed charges,Implant Device,2550,20,,2550,percent of total billed charges,Implant Device,2550,20,,2550,percent of total billed charges,Implant Device,2550,20,,2550,percent of total billed charges,Implant Device,2550,20,,2550,percent of total billed charges,Implant Device,2550,20,,2550,percent of total billed charges,Implant Device,2550,20,,2550,percent of total billed charges,Implant Device,2550,20,,2550,percent of total billed charges,Implant Device,2550,20,,2550,percent of total billed charges,Implant Device,2550,20,,2550,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,4335,34,"If Charge > 2,000, then 34 percent",4335,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,6375,
PT PROGR NEUROSTIM              ,C1787,HCPCS,,42580241,CDM,278,RC,,,both,,,61250,24173.42,,,24173.42,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,12250,20,,12250,percent of total billed charges,Implant Device,12250,20,,12250,percent of total billed charges,Implant Device,12250,20,,12250,percent of total billed charges,Implant Device,12250,20,,12250,percent of total billed charges,Implant Device,12250,20,,12250,percent of total billed charges,Implant Device,30625,50,,30625,percent of total billed charges,All Other,12250,20,,12250,percent of total billed charges,Implant Device,12250,20,,12250,percent of total billed charges,Implant Device,20825,34,"Charges > $500, x 34%",20825,percent of total billed charges,Implant Device,12250,20,,12250,percent of total billed charges,Implant Device,12250,20,,12250,percent of total billed charges,Implant Device,12250,20,,12250,percent of total billed charges,Implant Device,12250,20,,12250,percent of total billed charges,Implant Device,12250,20,,12250,percent of total billed charges,Implant Device,12250,20,,12250,percent of total billed charges,Implant Device,12250,20,,12250,percent of total billed charges,Implant Device,12250,20,,12250,percent of total billed charges,Implant Device,12250,20,,12250,percent of total billed charges,Implant Device,12250,20,,12250,percent of total billed charges,Implant Device,12250,20,,12250,percent of total billed charges,Implant Device,12250,20,,12250,percent of total billed charges,Implant Device,12250,20,,12250,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,20825,34,"If Charge > 2,000, then 34 percent",20825,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,30625,
PROSTHESIS BREAST IMP           ,C1789,HCPCS,,42580258,CDM,278,RC,,,both,,,14975,5910.15,,,5910.15,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,2995,20,,2995,percent of total billed charges,Implant Device,2995,20,,2995,percent of total billed charges,Implant Device,2995,20,,2995,percent of total billed charges,Implant Device,2995,20,,2995,percent of total billed charges,Implant Device,2995,20,,2995,percent of total billed charges,Implant Device,7487.5,50,,7487.5,percent of total billed charges,All Other,2995,20,,2995,percent of total billed charges,Implant Device,2995,20,,2995,percent of total billed charges,Implant Device,5091.5,34,"Charges > $500, x 34%",5091.5,percent of total billed charges,Implant Device,2995,20,,2995,percent of total billed charges,Implant Device,2995,20,,2995,percent of total billed charges,Implant Device,2995,20,,2995,percent of total billed charges,Implant Device,2995,20,,2995,percent of total billed charges,Implant Device,2995,20,,2995,percent of total billed charges,Implant Device,2995,20,,2995,percent of total billed charges,Implant Device,2995,20,,2995,percent of total billed charges,Implant Device,2995,20,,2995,percent of total billed charges,Implant Device,2995,20,,2995,percent of total billed charges,Implant Device,2995,20,,2995,percent of total billed charges,Implant Device,2995,20,,2995,percent of total billed charges,Implant Device,2995,20,,2995,percent of total billed charges,Implant Device,2995,20,,2995,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,5091.5,34,"If Charge > 2,000, then 34 percent",5091.5,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,7487.5,
INFLATABLE PENILE PROSTHESIS    ,C1813,HCPCS,,42580266,CDM,278,RC,,,both,,,57850,22831.54,,,22831.54,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,11570,20,,11570,percent of total billed charges,Implant Device,11570,20,,11570,percent of total billed charges,Implant Device,11570,20,,11570,percent of total billed charges,Implant Device,11570,20,,11570,percent of total billed charges,Implant Device,11570,20,,11570,percent of total billed charges,Implant Device,28925,50,,28925,percent of total billed charges,All Other,11570,20,,11570,percent of total billed charges,Implant Device,11570,20,,11570,percent of total billed charges,Implant Device,19669,34,"Charges > $500, x 34%",19669,percent of total billed charges,Implant Device,11570,20,,11570,percent of total billed charges,Implant Device,11570,20,,11570,percent of total billed charges,Implant Device,11570,20,,11570,percent of total billed charges,Implant Device,11570,20,,11570,percent of total billed charges,Implant Device,11570,20,,11570,percent of total billed charges,Implant Device,11570,20,,11570,percent of total billed charges,Implant Device,11570,20,,11570,percent of total billed charges,Implant Device,11570,20,,11570,percent of total billed charges,Implant Device,11570,20,,11570,percent of total billed charges,Implant Device,11570,20,,11570,percent of total billed charges,Implant Device,11570,20,,11570,percent of total billed charges,Implant Device,11570,20,,11570,percent of total billed charges,Implant Device,11570,20,,11570,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,19669,34,"If Charge > 2,000, then 34 percent",19669,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,28925,
IMPL URINARY SPHINCTER PROSTH   ,C1815,HCPCS,,42580274,CDM,278,RC,,,both,,,38050,15017.12,,,15017.12,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,7610,20,,7610,percent of total billed charges,Implant Device,7610,20,,7610,percent of total billed charges,Implant Device,7610,20,,7610,percent of total billed charges,Implant Device,7610,20,,7610,percent of total billed charges,Implant Device,7610,20,,7610,percent of total billed charges,Implant Device,19025,50,,19025,percent of total billed charges,All Other,7610,20,,7610,percent of total billed charges,Implant Device,7610,20,,7610,percent of total billed charges,Implant Device,12937,34,"Charges > $500, x 34%",12937,percent of total billed charges,Implant Device,7610,20,,7610,percent of total billed charges,Implant Device,7610,20,,7610,percent of total billed charges,Implant Device,7610,20,,7610,percent of total billed charges,Implant Device,7610,20,,7610,percent of total billed charges,Implant Device,7610,20,,7610,percent of total billed charges,Implant Device,7610,20,,7610,percent of total billed charges,Implant Device,7610,20,,7610,percent of total billed charges,Implant Device,7610,20,,7610,percent of total billed charges,Implant Device,7610,20,,7610,percent of total billed charges,Implant Device,7610,20,,7610,percent of total billed charges,Implant Device,7610,20,,7610,percent of total billed charges,Implant Device,7610,20,,7610,percent of total billed charges,Implant Device,7610,20,,7610,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,12937,34,"If Charge > 2,000, then 34 percent",12937,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,19025,
GENERATOR NEUROSTIMULATOR       ,C1820,HCPCS,,42580290,CDM,278,RC,,,both,,,130725,51592.97,,,51592.97,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,26145,20,,26145,percent of total billed charges,Implant Device,26145,20,,26145,percent of total billed charges,Implant Device,26145,20,,26145,percent of total billed charges,Implant Device,26145,20,,26145,percent of total billed charges,Implant Device,26145,20,,26145,percent of total billed charges,Implant Device,65362.5,50,,65362.5,percent of total billed charges,All Other,26145,20,,26145,percent of total billed charges,Implant Device,26145,20,,26145,percent of total billed charges,Implant Device,44446.5,34,"Charges > $500, x 34%",44446.5,percent of total billed charges,Implant Device,26145,20,,26145,percent of total billed charges,Implant Device,26145,20,,26145,percent of total billed charges,Implant Device,26145,20,,26145,percent of total billed charges,Implant Device,26145,20,,26145,percent of total billed charges,Implant Device,26145,20,,26145,percent of total billed charges,Implant Device,26145,20,,26145,percent of total billed charges,Implant Device,26145,20,,26145,percent of total billed charges,Implant Device,26145,20,,26145,percent of total billed charges,Implant Device,26145,20,,26145,percent of total billed charges,Implant Device,26145,20,,26145,percent of total billed charges,Implant Device,26145,20,,26145,percent of total billed charges,Implant Device,26145,20,,26145,percent of total billed charges,Implant Device,26145,20,,26145,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,44446.5,34,"If Charge > 2,000, then 34 percent",44446.5,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,65362.5,
RETINAL PROSTH INT/EST COMP     ,L8699,HCPCS,,42580316,CDM,278,RC,,,both,,,240,94.72,,,94.72,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,48,20,,48,percent of total billed charges,Implant Device,48,20,,48,percent of total billed charges,Implant Device,48,20,,48,percent of total billed charges,Implant Device,48,20,,48,percent of total billed charges,Implant Device,48,20,,48,percent of total billed charges,Implant Device,120,50,,120,percent of total billed charges,All Other,48,20,,48,percent of total billed charges,Implant Device,48,20,,48,percent of total billed charges,Implant Device,0.01,34,"Charges > $500, x 34%",0.01,percent of total billed charges,Implant Device,48,20,,48,percent of total billed charges,Implant Device,48,20,,48,percent of total billed charges,Implant Device,48,20,,48,percent of total billed charges,Implant Device,48,20,,48,percent of total billed charges,Implant Device,48,20,,48,percent of total billed charges,Implant Device,48,20,,48,percent of total billed charges,Implant Device,48,20,,48,percent of total billed charges,Implant Device,48,20,,48,percent of total billed charges,Implant Device,48,20,,48,percent of total billed charges,Implant Device,48,20,,48,percent of total billed charges,Implant Device,48,20,,48,percent of total billed charges,Implant Device,48,20,,48,percent of total billed charges,Implant Device,48,20,,48,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,120,
IMPL SYNTH VOCAL CORD           ,C1878,HCPCS,,42580324,CDM,278,RC,,,both,,,3125,1233.34,,,1233.34,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,625,20,,625,percent of total billed charges,Implant Device,625,20,,625,percent of total billed charges,Implant Device,625,20,,625,percent of total billed charges,Implant Device,625,20,,625,percent of total billed charges,Implant Device,625,20,,625,percent of total billed charges,Implant Device,1562.5,50,,1562.5,percent of total billed charges,All Other,625,20,,625,percent of total billed charges,Implant Device,625,20,,625,percent of total billed charges,Implant Device,1062.5,34,"Charges > $500, x 34%",1062.5,percent of total billed charges,Implant Device,625,20,,625,percent of total billed charges,Implant Device,625,20,,625,percent of total billed charges,Implant Device,625,20,,625,percent of total billed charges,Implant Device,625,20,,625,percent of total billed charges,Implant Device,625,20,,625,percent of total billed charges,Implant Device,625,20,,625,percent of total billed charges,Implant Device,625,20,,625,percent of total billed charges,Implant Device,625,20,,625,percent of total billed charges,Implant Device,625,20,,625,percent of total billed charges,Implant Device,625,20,,625,percent of total billed charges,Implant Device,625,20,,625,percent of total billed charges,Implant Device,625,20,,625,percent of total billed charges,Implant Device,625,20,,625,percent of total billed charges,Implant Device,1296.64,,,1296.64,Other,New York Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,1983.87,,,1983.87,Other,153% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,1815.3,,,1815.3,Other,140% Medicaid APG methodology,1062.5,34,"If Charge > 2,000, then 34 percent",1062.5,percent of total billed charges,Implants,3371.27,,,3371.27,Other,260% Medicaid APG methodology,4201.13,,,4201.13,Other,324% Medicaid APG methodology,2787.78,,,2787.78,Other,215% Medicaid APG methodology,2787.78,,,2787.78,Other,215% Medicaid APG methodology,1620.81,,,1620.81,Other,125% Medicaid APG methodology,0.01,4201.13,
IMPL EXTENS PACING LEAD/NEURO   ,C1883,HCPCS,,42580332,CDM,278,RC,,,both,,,14015,5531.27,,,5531.27,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,2803,20,,2803,percent of total billed charges,Implant Device,2803,20,,2803,percent of total billed charges,Implant Device,2803,20,,2803,percent of total billed charges,Implant Device,2803,20,,2803,percent of total billed charges,Implant Device,2803,20,,2803,percent of total billed charges,Implant Device,7007.5,50,,7007.5,percent of total billed charges,All Other,2803,20,,2803,percent of total billed charges,Implant Device,2803,20,,2803,percent of total billed charges,Implant Device,4765.1,34,"Charges > $500, x 34%",4765.1,percent of total billed charges,Implant Device,2803,20,,2803,percent of total billed charges,Implant Device,2803,20,,2803,percent of total billed charges,Implant Device,2803,20,,2803,percent of total billed charges,Implant Device,2803,20,,2803,percent of total billed charges,Implant Device,2803,20,,2803,percent of total billed charges,Implant Device,2803,20,,2803,percent of total billed charges,Implant Device,2803,20,,2803,percent of total billed charges,Implant Device,2803,20,,2803,percent of total billed charges,Implant Device,2803,20,,2803,percent of total billed charges,Implant Device,2803,20,,2803,percent of total billed charges,Implant Device,2803,20,,2803,percent of total billed charges,Implant Device,2803,20,,2803,percent of total billed charges,Implant Device,2803,20,,2803,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,4765.1,34,"If Charge > 2,000, then 34 percent",4765.1,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,7007.5,
NON-CARDIAC ENDOVASC CATH       ,C1888,HCPCS,,42580365,CDM,278,RC,,,both,,,4500,1776.01,,,1776.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,900,20,,900,percent of total billed charges,Implant Device,900,20,,900,percent of total billed charges,Implant Device,900,20,,900,percent of total billed charges,Implant Device,900,20,,900,percent of total billed charges,Implant Device,900,20,,900,percent of total billed charges,Implant Device,2250,50,,2250,percent of total billed charges,All Other,900,20,,900,percent of total billed charges,Implant Device,900,20,,900,percent of total billed charges,Implant Device,1530,34,"Charges > $500, x 34%",1530,percent of total billed charges,Implant Device,900,20,,900,percent of total billed charges,Implant Device,900,20,,900,percent of total billed charges,Implant Device,900,20,,900,percent of total billed charges,Implant Device,900,20,,900,percent of total billed charges,Implant Device,900,20,,900,percent of total billed charges,Implant Device,900,20,,900,percent of total billed charges,Implant Device,900,20,,900,percent of total billed charges,Implant Device,900,20,,900,percent of total billed charges,Implant Device,900,20,,900,percent of total billed charges,Implant Device,900,20,,900,percent of total billed charges,Implant Device,900,20,,900,percent of total billed charges,Implant Device,900,20,,900,percent of total billed charges,Implant Device,900,20,,900,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,1530,34,"If Charge > 2,000, then 34 percent",1530,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,2250,
IMPLANT INSERT DEVICE           ,C1889,HCPCS,,42580373,CDM,278,RC,,,both,,,1503,593.19,,,593.19,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,300.6,20,,300.6,percent of total billed charges,Implant Device,300.6,20,,300.6,percent of total billed charges,Implant Device,300.6,20,,300.6,percent of total billed charges,Implant Device,300.6,20,,300.6,percent of total billed charges,Implant Device,300.6,20,,300.6,percent of total billed charges,Implant Device,751.5,50,,751.5,percent of total billed charges,All Other,300.6,20,,300.6,percent of total billed charges,Implant Device,300.6,20,,300.6,percent of total billed charges,Implant Device,511.02,34,"Charges > $500, x 34%",511.02,percent of total billed charges,Implant Device,300.6,20,,300.6,percent of total billed charges,Implant Device,300.6,20,,300.6,percent of total billed charges,Implant Device,300.6,20,,300.6,percent of total billed charges,Implant Device,300.6,20,,300.6,percent of total billed charges,Implant Device,300.6,20,,300.6,percent of total billed charges,Implant Device,300.6,20,,300.6,percent of total billed charges,Implant Device,300.6,20,,300.6,percent of total billed charges,Implant Device,300.6,20,,300.6,percent of total billed charges,Implant Device,300.6,20,,300.6,percent of total billed charges,Implant Device,300.6,20,,300.6,percent of total billed charges,Implant Device,300.6,20,,300.6,percent of total billed charges,Implant Device,300.6,20,,300.6,percent of total billed charges,Implant Device,300.6,20,,300.6,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,751.5,
EP INTRA FIX-CURVE GUID INTROD  ,C1893,HCPCS,,42580399,CDM,278,RC,,,both,,,22700,8958.96,,,8958.96,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,4540,20,,4540,percent of total billed charges,Implant Device,4540,20,,4540,percent of total billed charges,Implant Device,4540,20,,4540,percent of total billed charges,Implant Device,4540,20,,4540,percent of total billed charges,Implant Device,4540,20,,4540,percent of total billed charges,Implant Device,11350,50,,11350,percent of total billed charges,All Other,4540,20,,4540,percent of total billed charges,Implant Device,4540,20,,4540,percent of total billed charges,Implant Device,7718,34,"Charges > $500, x 34%",7718,percent of total billed charges,Implant Device,4540,20,,4540,percent of total billed charges,Implant Device,4540,20,,4540,percent of total billed charges,Implant Device,4540,20,,4540,percent of total billed charges,Implant Device,4540,20,,4540,percent of total billed charges,Implant Device,4540,20,,4540,percent of total billed charges,Implant Device,4540,20,,4540,percent of total billed charges,Implant Device,4540,20,,4540,percent of total billed charges,Implant Device,4540,20,,4540,percent of total billed charges,Implant Device,4540,20,,4540,percent of total billed charges,Implant Device,4540,20,,4540,percent of total billed charges,Implant Device,4540,20,,4540,percent of total billed charges,Implant Device,4540,20,,4540,percent of total billed charges,Implant Device,4540,20,,4540,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,7718,34,"If Charge > 2,000, then 34 percent",7718,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,11350,
LEAD AICD ENDO DUAL COIL        ,C1895,HCPCS,,42580407,CDM,278,RC,,,both,,,47500,18746.73,,,18746.73,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,23750,50,,23750,percent of total billed charges,All Other,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,16150,34,"Charges > $500, x 34%",16150,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,9500,20,,9500,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,16150,34,"If Charge > 2,000, then 34 percent",16150,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,23750,
IMPL NEUROSTIM LEAD TEST KIT    ,C1897,HCPCS,,42580423,CDM,278,RC,,,both,,,12000,4736.02,,,4736.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,2400,20,,2400,percent of total billed charges,Implant Device,2400,20,,2400,percent of total billed charges,Implant Device,2400,20,,2400,percent of total billed charges,Implant Device,2400,20,,2400,percent of total billed charges,Implant Device,2400,20,,2400,percent of total billed charges,Implant Device,6000,50,,6000,percent of total billed charges,All Other,2400,20,,2400,percent of total billed charges,Implant Device,2400,20,,2400,percent of total billed charges,Implant Device,4080,34,"Charges > $500, x 34%",4080,percent of total billed charges,Implant Device,2400,20,,2400,percent of total billed charges,Implant Device,2400,20,,2400,percent of total billed charges,Implant Device,2400,20,,2400,percent of total billed charges,Implant Device,2400,20,,2400,percent of total billed charges,Implant Device,2400,20,,2400,percent of total billed charges,Implant Device,2400,20,,2400,percent of total billed charges,Implant Device,2400,20,,2400,percent of total billed charges,Implant Device,2400,20,,2400,percent of total billed charges,Implant Device,2400,20,,2400,percent of total billed charges,Implant Device,2400,20,,2400,percent of total billed charges,Implant Device,2400,20,,2400,percent of total billed charges,Implant Device,2400,20,,2400,percent of total billed charges,Implant Device,2400,20,,2400,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,4080,34,"If Charge > 2,000, then 34 percent",4080,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,6000,
LUNG BX PLUG W/DEL SYS          ,C2613,HCPCS,,42580431,CDM,278,RC,,,both,,,1575,621.6,,,621.6,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,315,20,,315,percent of total billed charges,Implant Device,315,20,,315,percent of total billed charges,Implant Device,315,20,,315,percent of total billed charges,Implant Device,315,20,,315,percent of total billed charges,Implant Device,315,20,,315,percent of total billed charges,Implant Device,787.5,50,,787.5,percent of total billed charges,All Other,315,20,,315,percent of total billed charges,Implant Device,315,20,,315,percent of total billed charges,Implant Device,535.5,34,"Charges > $500, x 34%",535.5,percent of total billed charges,Implant Device,315,20,,315,percent of total billed charges,Implant Device,315,20,,315,percent of total billed charges,Implant Device,315,20,,315,percent of total billed charges,Implant Device,315,20,,315,percent of total billed charges,Implant Device,315,20,,315,percent of total billed charges,Implant Device,315,20,,315,percent of total billed charges,Implant Device,315,20,,315,percent of total billed charges,Implant Device,315,20,,315,percent of total billed charges,Implant Device,315,20,,315,percent of total billed charges,Implant Device,315,20,,315,percent of total billed charges,Implant Device,315,20,,315,percent of total billed charges,Implant Device,315,20,,315,percent of total billed charges,Implant Device,315,20,,315,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,787.5,
IMPL PULMON LIQUID SEALANT      ,C2615,HCPCS,,42580449,CDM,278,RC,,,both,,,3435.25,1355.78,,,1355.78,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,687.05,20,,687.05,percent of total billed charges,Implant Device,687.05,20,,687.05,percent of total billed charges,Implant Device,687.05,20,,687.05,percent of total billed charges,Implant Device,687.05,20,,687.05,percent of total billed charges,Implant Device,687.05,20,,687.05,percent of total billed charges,Implant Device,1717.63,50,,1717.63,percent of total billed charges,All Other,687.05,20,,687.05,percent of total billed charges,Implant Device,687.05,20,,687.05,percent of total billed charges,Implant Device,1167.99,34,"Charges > $500, x 34%",1167.99,percent of total billed charges,Implant Device,687.05,20,,687.05,percent of total billed charges,Implant Device,687.05,20,,687.05,percent of total billed charges,Implant Device,687.05,20,,687.05,percent of total billed charges,Implant Device,687.05,20,,687.05,percent of total billed charges,Implant Device,687.05,20,,687.05,percent of total billed charges,Implant Device,687.05,20,,687.05,percent of total billed charges,Implant Device,687.05,20,,687.05,percent of total billed charges,Implant Device,687.05,20,,687.05,percent of total billed charges,Implant Device,687.05,20,,687.05,percent of total billed charges,Implant Device,687.05,20,,687.05,percent of total billed charges,Implant Device,687.05,20,,687.05,percent of total billed charges,Implant Device,687.05,20,,687.05,percent of total billed charges,Implant Device,687.05,20,,687.05,percent of total billed charges,Implant Device,1296.64,,,1296.64,Other,New York Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,1983.87,,,1983.87,Other,153% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,1815.3,,,1815.3,Other,140% Medicaid APG methodology,1167.99,34,"If Charge > 2,000, then 34 percent",1167.99,percent of total billed charges,Implants,3371.27,,,3371.27,Other,260% Medicaid APG methodology,4201.13,,,4201.13,Other,324% Medicaid APG methodology,2787.78,,,2787.78,Other,215% Medicaid APG methodology,2787.78,,,2787.78,Other,215% Medicaid APG methodology,1620.81,,,1620.81,Other,125% Medicaid APG methodology,0.01,4201.13,
STENT NON-COR TEM W/DEL SYSTEM  ,C2625,HCPCS,,42580472,CDM,278,RC,,,both,,,8475,3344.81,,,3344.81,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,1695,20,,1695,percent of total billed charges,Implant Device,1695,20,,1695,percent of total billed charges,Implant Device,1695,20,,1695,percent of total billed charges,Implant Device,1695,20,,1695,percent of total billed charges,Implant Device,1695,20,,1695,percent of total billed charges,Implant Device,4237.5,50,,4237.5,percent of total billed charges,All Other,1695,20,,1695,percent of total billed charges,Implant Device,1695,20,,1695,percent of total billed charges,Implant Device,2881.5,34,"Charges > $500, x 34%",2881.5,percent of total billed charges,Implant Device,1695,20,,1695,percent of total billed charges,Implant Device,1695,20,,1695,percent of total billed charges,Implant Device,1695,20,,1695,percent of total billed charges,Implant Device,1695,20,,1695,percent of total billed charges,Implant Device,1695,20,,1695,percent of total billed charges,Implant Device,1695,20,,1695,percent of total billed charges,Implant Device,1695,20,,1695,percent of total billed charges,Implant Device,1695,20,,1695,percent of total billed charges,Implant Device,1695,20,,1695,percent of total billed charges,Implant Device,1695,20,,1695,percent of total billed charges,Implant Device,1695,20,,1695,percent of total billed charges,Implant Device,1695,20,,1695,percent of total billed charges,Implant Device,1695,20,,1695,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,2881.5,34,"If Charge > 2,000, then 34 percent",2881.5,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,4237.5,
VERITAS COLLAGEN MATRIX CM2     ,C9354,HCPCS,,42580530,CDM,278,RC,,,both,,,1008.5,398.02,,,398.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,201.7,20,,201.7,percent of total billed charges,Implant Device,201.7,20,,201.7,percent of total billed charges,Implant Device,201.7,20,,201.7,percent of total billed charges,Implant Device,201.7,20,,201.7,percent of total billed charges,Implant Device,201.7,20,,201.7,percent of total billed charges,Implant Device,504.25,50,,504.25,percent of total billed charges,All Other,201.7,20,,201.7,percent of total billed charges,Implant Device,201.7,20,,201.7,percent of total billed charges,Implant Device,342.89,34,"Charges > $500, x 34%",342.89,percent of total billed charges,Implant Device,201.7,20,,201.7,percent of total billed charges,Implant Device,201.7,20,,201.7,percent of total billed charges,Implant Device,201.7,20,,201.7,percent of total billed charges,Implant Device,201.7,20,,201.7,percent of total billed charges,Implant Device,201.7,20,,201.7,percent of total billed charges,Implant Device,201.7,20,,201.7,percent of total billed charges,Implant Device,201.7,20,,201.7,percent of total billed charges,Implant Device,201.7,20,,201.7,percent of total billed charges,Implant Device,201.7,20,,201.7,percent of total billed charges,Implant Device,201.7,20,,201.7,percent of total billed charges,Implant Device,201.7,20,,201.7,percent of total billed charges,Implant Device,201.7,20,,201.7,percent of total billed charges,Implant Device,201.7,20,,201.7,percent of total billed charges,Implant Device,1296.64,,,1296.64,Other,New York Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,1983.87,,,1983.87,Other,153% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,1815.3,,,1815.3,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,3371.27,,,3371.27,Other,260% Medicaid APG methodology,4201.13,,,4201.13,Other,324% Medicaid APG methodology,2787.78,,,2787.78,Other,215% Medicaid APG methodology,2787.78,,,2787.78,Other,215% Medicaid APG methodology,1620.81,,,1620.81,Other,125% Medicaid APG methodology,0.01,4201.13,
TENOGLIDE TENDON PROT CM2       ,C9356,HCPCS,,42580548,CDM,278,RC,,,both,,,22364.15,8826.41,,,8826.41,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,4472.83,20,,4472.83,percent of total billed charges,Implant Device,4472.83,20,,4472.83,percent of total billed charges,Implant Device,4472.83,20,,4472.83,percent of total billed charges,Implant Device,4472.83,20,,4472.83,percent of total billed charges,Implant Device,4472.83,20,,4472.83,percent of total billed charges,Implant Device,11182.08,50,,11182.08,percent of total billed charges,All Other,4472.83,20,,4472.83,percent of total billed charges,Implant Device,4472.83,20,,4472.83,percent of total billed charges,Implant Device,7603.81,34,"Charges > $500, x 34%",7603.81,percent of total billed charges,Implant Device,4472.83,20,,4472.83,percent of total billed charges,Implant Device,4472.83,20,,4472.83,percent of total billed charges,Implant Device,4472.83,20,,4472.83,percent of total billed charges,Implant Device,4472.83,20,,4472.83,percent of total billed charges,Implant Device,4472.83,20,,4472.83,percent of total billed charges,Implant Device,4472.83,20,,4472.83,percent of total billed charges,Implant Device,4472.83,20,,4472.83,percent of total billed charges,Implant Device,4472.83,20,,4472.83,percent of total billed charges,Implant Device,4472.83,20,,4472.83,percent of total billed charges,Implant Device,4472.83,20,,4472.83,percent of total billed charges,Implant Device,4472.83,20,,4472.83,percent of total billed charges,Implant Device,4472.83,20,,4472.83,percent of total billed charges,Implant Device,4472.83,20,,4472.83,percent of total billed charges,Implant Device,1296.64,,,1296.64,Other,New York Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,1983.87,,,1983.87,Other,153% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,1815.3,,,1815.3,Other,140% Medicaid APG methodology,7603.81,34,"If Charge > 2,000, then 34 percent",7603.81,percent of total billed charges,Implants,3371.27,,,3371.27,Other,260% Medicaid APG methodology,4201.13,,,4201.13,Other,324% Medicaid APG methodology,2787.78,,,2787.78,Other,215% Medicaid APG methodology,2787.78,,,2787.78,Other,215% Medicaid APG methodology,1620.81,,,1620.81,Other,125% Medicaid APG methodology,0.01,11182.08,
PORCINE IMPLANT PERMACOL SQ CM  ,C9364,HCPCS,,42580555,CDM,278,RC,,,both,,,142041.35,56059.18,,,56059.18,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,28408.27,20,,28408.27,percent of total billed charges,Implant Device,28408.27,20,,28408.27,percent of total billed charges,Implant Device,28408.27,20,,28408.27,percent of total billed charges,Implant Device,28408.27,20,,28408.27,percent of total billed charges,Implant Device,28408.27,20,,28408.27,percent of total billed charges,Implant Device,71020.68,50,,71020.68,percent of total billed charges,All Other,28408.27,20,,28408.27,percent of total billed charges,Implant Device,28408.27,20,,28408.27,percent of total billed charges,Implant Device,48294.06,34,"Charges > $500, x 34%",48294.06,percent of total billed charges,Implant Device,28408.27,20,,28408.27,percent of total billed charges,Implant Device,28408.27,20,,28408.27,percent of total billed charges,Implant Device,28408.27,20,,28408.27,percent of total billed charges,Implant Device,28408.27,20,,28408.27,percent of total billed charges,Implant Device,28408.27,20,,28408.27,percent of total billed charges,Implant Device,28408.27,20,,28408.27,percent of total billed charges,Implant Device,28408.27,20,,28408.27,percent of total billed charges,Implant Device,28408.27,20,,28408.27,percent of total billed charges,Implant Device,28408.27,20,,28408.27,percent of total billed charges,Implant Device,28408.27,20,,28408.27,percent of total billed charges,Implant Device,28408.27,20,,28408.27,percent of total billed charges,Implant Device,28408.27,20,,28408.27,percent of total billed charges,Implant Device,28408.27,20,,28408.27,percent of total billed charges,Implant Device,1296.64,,,1296.64,Other,New York Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,1983.87,,,1983.87,Other,153% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,1815.3,,,1815.3,Other,140% Medicaid APG methodology,48294.06,34,"If Charge > 2,000, then 34 percent",48294.06,percent of total billed charges,Implants,3371.27,,,3371.27,Other,260% Medicaid APG methodology,4201.13,,,4201.13,Other,324% Medicaid APG methodology,2787.78,,,2787.78,Other,215% Medicaid APG methodology,2787.78,,,2787.78,Other,215% Medicaid APG methodology,1620.81,,,1620.81,Other,125% Medicaid APG methodology,0.01,71020.68,
COCHLEAR DEVICE                 ,L8614,HCPCS,,42580589,CDM,278,RC,,,both,,,175000,69066.9,,,69066.9,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,35000,20,,35000,percent of total billed charges,Implant Device,35000,20,,35000,percent of total billed charges,Implant Device,35000,20,,35000,percent of total billed charges,Implant Device,35000,20,,35000,percent of total billed charges,Implant Device,35000,20,,35000,percent of total billed charges,Implant Device,87500,50,,87500,percent of total billed charges,All Other,35000,20,,35000,percent of total billed charges,Implant Device,35000,20,,35000,percent of total billed charges,Implant Device,59500,34,"Charges > $500, x 34%",59500,percent of total billed charges,Implant Device,35000,20,,35000,percent of total billed charges,Implant Device,35000,20,,35000,percent of total billed charges,Implant Device,35000,20,,35000,percent of total billed charges,Implant Device,35000,20,,35000,percent of total billed charges,Implant Device,35000,20,,35000,percent of total billed charges,Implant Device,35000,20,,35000,percent of total billed charges,Implant Device,35000,20,,35000,percent of total billed charges,Implant Device,35000,20,,35000,percent of total billed charges,Implant Device,35000,20,,35000,percent of total billed charges,Implant Device,35000,20,,35000,percent of total billed charges,Implant Device,35000,20,,35000,percent of total billed charges,Implant Device,35000,20,,35000,percent of total billed charges,Implant Device,35000,20,,35000,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,59500,34,"If Charge > 2,000, then 34 percent",59500,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,87500,
METATARSAL JOINT IMPLANT        ,L8641,HCPCS,,42580597,CDM,278,RC,,,both,,,8675,3423.74,,,3423.74,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,1735,20,,1735,percent of total billed charges,Implant Device,1735,20,,1735,percent of total billed charges,Implant Device,1735,20,,1735,percent of total billed charges,Implant Device,1735,20,,1735,percent of total billed charges,Implant Device,1735,20,,1735,percent of total billed charges,Implant Device,4337.5,50,,4337.5,percent of total billed charges,All Other,1735,20,,1735,percent of total billed charges,Implant Device,1735,20,,1735,percent of total billed charges,Implant Device,2949.5,34,"Charges > $500, x 34%",2949.5,percent of total billed charges,Implant Device,1735,20,,1735,percent of total billed charges,Implant Device,1735,20,,1735,percent of total billed charges,Implant Device,1735,20,,1735,percent of total billed charges,Implant Device,1735,20,,1735,percent of total billed charges,Implant Device,1735,20,,1735,percent of total billed charges,Implant Device,1735,20,,1735,percent of total billed charges,Implant Device,1735,20,,1735,percent of total billed charges,Implant Device,1735,20,,1735,percent of total billed charges,Implant Device,1735,20,,1735,percent of total billed charges,Implant Device,1735,20,,1735,percent of total billed charges,Implant Device,1735,20,,1735,percent of total billed charges,Implant Device,1735,20,,1735,percent of total billed charges,Implant Device,1735,20,,1735,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,2949.5,34,"If Charge > 2,000, then 34 percent",2949.5,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,4337.5,
HALLUX IMPLANT                  ,L8642,HCPCS,,42580605,CDM,278,RC,,,both,,,18544,7318.72,,,7318.72,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,3708.8,20,,3708.8,percent of total billed charges,Implant Device,3708.8,20,,3708.8,percent of total billed charges,Implant Device,3708.8,20,,3708.8,percent of total billed charges,Implant Device,3708.8,20,,3708.8,percent of total billed charges,Implant Device,3708.8,20,,3708.8,percent of total billed charges,Implant Device,9272,50,,9272,percent of total billed charges,All Other,3708.8,20,,3708.8,percent of total billed charges,Implant Device,3708.8,20,,3708.8,percent of total billed charges,Implant Device,6304.96,34,"Charges > $500, x 34%",6304.96,percent of total billed charges,Implant Device,3708.8,20,,3708.8,percent of total billed charges,Implant Device,3708.8,20,,3708.8,percent of total billed charges,Implant Device,3708.8,20,,3708.8,percent of total billed charges,Implant Device,3708.8,20,,3708.8,percent of total billed charges,Implant Device,3708.8,20,,3708.8,percent of total billed charges,Implant Device,3708.8,20,,3708.8,percent of total billed charges,Implant Device,3708.8,20,,3708.8,percent of total billed charges,Implant Device,3708.8,20,,3708.8,percent of total billed charges,Implant Device,3708.8,20,,3708.8,percent of total billed charges,Implant Device,3708.8,20,,3708.8,percent of total billed charges,Implant Device,3708.8,20,,3708.8,percent of total billed charges,Implant Device,3708.8,20,,3708.8,percent of total billed charges,Implant Device,3708.8,20,,3708.8,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,6304.96,34,"If Charge > 2,000, then 34 percent",6304.96,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,9272,
AUD OSSEO DEV INT/EXT COMP      ,L8690,HCPCS,,42580621,CDM,278,RC,,,both,,,78250,30882.77,,,30882.77,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,15650,20,,15650,percent of total billed charges,Implant Device,15650,20,,15650,percent of total billed charges,Implant Device,15650,20,,15650,percent of total billed charges,Implant Device,15650,20,,15650,percent of total billed charges,Implant Device,15650,20,,15650,percent of total billed charges,Implant Device,39125,50,,39125,percent of total billed charges,All Other,15650,20,,15650,percent of total billed charges,Implant Device,15650,20,,15650,percent of total billed charges,Implant Device,26605,34,"Charges > $500, x 34%",26605,percent of total billed charges,Implant Device,15650,20,,15650,percent of total billed charges,Implant Device,15650,20,,15650,percent of total billed charges,Implant Device,15650,20,,15650,percent of total billed charges,Implant Device,15650,20,,15650,percent of total billed charges,Implant Device,15650,20,,15650,percent of total billed charges,Implant Device,15650,20,,15650,percent of total billed charges,Implant Device,15650,20,,15650,percent of total billed charges,Implant Device,15650,20,,15650,percent of total billed charges,Implant Device,15650,20,,15650,percent of total billed charges,Implant Device,15650,20,,15650,percent of total billed charges,Implant Device,15650,20,,15650,percent of total billed charges,Implant Device,15650,20,,15650,percent of total billed charges,Implant Device,15650,20,,15650,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,26605,34,"If Charge > 2,000, then 34 percent",26605,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,39125,
AOI SND PROC REPL EXCL ACTUA    ,L8691,HCPCS,,42580639,CDM,278,RC,,,both,,,60500,23877.41,,,23877.41,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,12100,20,,12100,percent of total billed charges,Implant Device,12100,20,,12100,percent of total billed charges,Implant Device,12100,20,,12100,percent of total billed charges,Implant Device,12100,20,,12100,percent of total billed charges,Implant Device,12100,20,,12100,percent of total billed charges,Implant Device,30250,50,,30250,percent of total billed charges,All Other,12100,20,,12100,percent of total billed charges,Implant Device,12100,20,,12100,percent of total billed charges,Implant Device,20570,34,"Charges > $500, x 34%",20570,percent of total billed charges,Implant Device,12100,20,,12100,percent of total billed charges,Implant Device,12100,20,,12100,percent of total billed charges,Implant Device,12100,20,,12100,percent of total billed charges,Implant Device,12100,20,,12100,percent of total billed charges,Implant Device,12100,20,,12100,percent of total billed charges,Implant Device,12100,20,,12100,percent of total billed charges,Implant Device,12100,20,,12100,percent of total billed charges,Implant Device,12100,20,,12100,percent of total billed charges,Implant Device,12100,20,,12100,percent of total billed charges,Implant Device,12100,20,,12100,percent of total billed charges,Implant Device,12100,20,,12100,percent of total billed charges,Implant Device,12100,20,,12100,percent of total billed charges,Implant Device,12100,20,,12100,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,20570,34,"If Charge > 2,000, then 34 percent",20570,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,30250,
PROSTH IMPL NOS                 ,L8699,HCPCS,,42580647,CDM,278,RC,,,both,,,92500,36506.79,,,36506.79,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,18500,20,,18500,percent of total billed charges,Implant Device,18500,20,,18500,percent of total billed charges,Implant Device,18500,20,,18500,percent of total billed charges,Implant Device,18500,20,,18500,percent of total billed charges,Implant Device,18500,20,,18500,percent of total billed charges,Implant Device,46250,50,,46250,percent of total billed charges,All Other,18500,20,,18500,percent of total billed charges,Implant Device,18500,20,,18500,percent of total billed charges,Implant Device,31450,34,"Charges > $500, x 34%",31450,percent of total billed charges,Implant Device,18500,20,,18500,percent of total billed charges,Implant Device,18500,20,,18500,percent of total billed charges,Implant Device,18500,20,,18500,percent of total billed charges,Implant Device,18500,20,,18500,percent of total billed charges,Implant Device,18500,20,,18500,percent of total billed charges,Implant Device,18500,20,,18500,percent of total billed charges,Implant Device,18500,20,,18500,percent of total billed charges,Implant Device,18500,20,,18500,percent of total billed charges,Implant Device,18500,20,,18500,percent of total billed charges,Implant Device,18500,20,,18500,percent of total billed charges,Implant Device,18500,20,,18500,percent of total billed charges,Implant Device,18500,20,,18500,percent of total billed charges,Implant Device,18500,20,,18500,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,31450,34,"If Charge > 2,000, then 34 percent",31450,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,46250,
IMPLANTABLE                     ,C1889,HCPCS,,42580688,CDM,278,RC,,,both,,,495000,195360.66,,,195360.66,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,99000,20,,99000,percent of total billed charges,Implant Device,99000,20,,99000,percent of total billed charges,Implant Device,99000,20,,99000,percent of total billed charges,Implant Device,99000,20,,99000,percent of total billed charges,Implant Device,99000,20,,99000,percent of total billed charges,Implant Device,247500,50,,247500,percent of total billed charges,All Other,99000,20,,99000,percent of total billed charges,Implant Device,99000,20,,99000,percent of total billed charges,Implant Device,168300,34,"Charges > $500, x 34%",168300,percent of total billed charges,Implant Device,99000,20,,99000,percent of total billed charges,Implant Device,99000,20,,99000,percent of total billed charges,Implant Device,99000,20,,99000,percent of total billed charges,Implant Device,99000,20,,99000,percent of total billed charges,Implant Device,99000,20,,99000,percent of total billed charges,Implant Device,99000,20,,99000,percent of total billed charges,Implant Device,99000,20,,99000,percent of total billed charges,Implant Device,99000,20,,99000,percent of total billed charges,Implant Device,99000,20,,99000,percent of total billed charges,Implant Device,99000,20,,99000,percent of total billed charges,Implant Device,99000,20,,99000,percent of total billed charges,Implant Device,99000,20,,99000,percent of total billed charges,Implant Device,99000,20,,99000,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,168300,34,"If Charge > 2,000, then 34 percent",168300,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,247500,
NEURAWRAP  C9353                ,C9353,HCPCS,,42581405,CDM,278,RC,,,both,,,31270,12341.27,,,12341.27,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,6254,20,,6254,percent of total billed charges,Implant Device,6254,20,,6254,percent of total billed charges,Implant Device,6254,20,,6254,percent of total billed charges,Implant Device,6254,20,,6254,percent of total billed charges,Implant Device,6254,20,,6254,percent of total billed charges,Implant Device,15635,50,,15635,percent of total billed charges,All Other,6254,20,,6254,percent of total billed charges,Implant Device,6254,20,,6254,percent of total billed charges,Implant Device,10631.8,34,"Charges > $500, x 34%",10631.8,percent of total billed charges,Implant Device,6254,20,,6254,percent of total billed charges,Implant Device,6254,20,,6254,percent of total billed charges,Implant Device,6254,20,,6254,percent of total billed charges,Implant Device,6254,20,,6254,percent of total billed charges,Implant Device,6254,20,,6254,percent of total billed charges,Implant Device,6254,20,,6254,percent of total billed charges,Implant Device,6254,20,,6254,percent of total billed charges,Implant Device,6254,20,,6254,percent of total billed charges,Implant Device,6254,20,,6254,percent of total billed charges,Implant Device,6254,20,,6254,percent of total billed charges,Implant Device,6254,20,,6254,percent of total billed charges,Implant Device,6254,20,,6254,percent of total billed charges,Implant Device,6254,20,,6254,percent of total billed charges,Implant Device,1296.64,,,1296.64,Other,New York Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,1983.87,,,1983.87,Other,153% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,1815.3,,,1815.3,Other,140% Medicaid APG methodology,10631.8,34,"If Charge > 2,000, then 34 percent",10631.8,percent of total billed charges,Implants,3371.27,,,3371.27,Other,260% Medicaid APG methodology,4201.13,,,4201.13,Other,324% Medicaid APG methodology,2787.78,,,2787.78,Other,215% Medicaid APG methodology,2787.78,,,2787.78,Other,215% Medicaid APG methodology,1620.81,,,1620.81,Other,125% Medicaid APG methodology,0.01,15635,
NEUROMATRIX NERVE CUFF          ,C9355,HCPCS,,42581413,CDM,278,RC,,,both,,,10755,4244.65,,,4244.65,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,2151,20,,2151,percent of total billed charges,Implant Device,2151,20,,2151,percent of total billed charges,Implant Device,2151,20,,2151,percent of total billed charges,Implant Device,2151,20,,2151,percent of total billed charges,Implant Device,2151,20,,2151,percent of total billed charges,Implant Device,5377.5,50,,5377.5,percent of total billed charges,All Other,2151,20,,2151,percent of total billed charges,Implant Device,2151,20,,2151,percent of total billed charges,Implant Device,3656.7,34,"Charges > $500, x 34%",3656.7,percent of total billed charges,Implant Device,2151,20,,2151,percent of total billed charges,Implant Device,2151,20,,2151,percent of total billed charges,Implant Device,2151,20,,2151,percent of total billed charges,Implant Device,2151,20,,2151,percent of total billed charges,Implant Device,2151,20,,2151,percent of total billed charges,Implant Device,2151,20,,2151,percent of total billed charges,Implant Device,2151,20,,2151,percent of total billed charges,Implant Device,2151,20,,2151,percent of total billed charges,Implant Device,2151,20,,2151,percent of total billed charges,Implant Device,2151,20,,2151,percent of total billed charges,Implant Device,2151,20,,2151,percent of total billed charges,Implant Device,2151,20,,2151,percent of total billed charges,Implant Device,2151,20,,2151,percent of total billed charges,Implant Device,1296.64,,,1296.64,Other,New York Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,1296.64,,,1296.64,Other,100% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,1983.87,,,1983.87,Other,153% Medicaid APG methodology,2917.45,,,2917.45,Other,225% Medicaid APG methodology,1815.3,,,1815.3,Other,140% Medicaid APG methodology,3656.7,34,"If Charge > 2,000, then 34 percent",3656.7,percent of total billed charges,Implants,3371.27,,,3371.27,Other,260% Medicaid APG methodology,4201.13,,,4201.13,Other,324% Medicaid APG methodology,2787.78,,,2787.78,Other,215% Medicaid APG methodology,2787.78,,,2787.78,Other,215% Medicaid APG methodology,1620.81,,,1620.81,Other,125% Medicaid APG methodology,0.01,5377.5,
STENT HERCU/LINK                ,C1876,HCPCS,,44610970,CDM,278,RC,,,both,,,6750,2664.01,,,2664.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,1350,20,,1350,percent of total billed charges,Implant Device,1350,20,,1350,percent of total billed charges,Implant Device,1350,20,,1350,percent of total billed charges,Implant Device,1350,20,,1350,percent of total billed charges,Implant Device,1350,20,,1350,percent of total billed charges,Implant Device,3375,50,,3375,percent of total billed charges,All Other,1350,20,,1350,percent of total billed charges,Implant Device,1350,20,,1350,percent of total billed charges,Implant Device,2295,34,"Charges > $500, x 34%",2295,percent of total billed charges,Implant Device,1350,20,,1350,percent of total billed charges,Implant Device,1350,20,,1350,percent of total billed charges,Implant Device,1350,20,,1350,percent of total billed charges,Implant Device,1350,20,,1350,percent of total billed charges,Implant Device,1350,20,,1350,percent of total billed charges,Implant Device,1350,20,,1350,percent of total billed charges,Implant Device,1350,20,,1350,percent of total billed charges,Implant Device,1350,20,,1350,percent of total billed charges,Implant Device,1350,20,,1350,percent of total billed charges,Implant Device,1350,20,,1350,percent of total billed charges,Implant Device,1350,20,,1350,percent of total billed charges,Implant Device,1350,20,,1350,percent of total billed charges,Implant Device,1350,20,,1350,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,2295,34,"If Charge > 2,000, then 34 percent",2295,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,3375,
EXPRESS BILIARY LD STENT        ,C1876,HCPCS,,44615532,CDM,278,RC,,,both,,,5629.1,2221.63,,,2221.63,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,1125.82,20,,1125.82,percent of total billed charges,Implant Device,1125.82,20,,1125.82,percent of total billed charges,Implant Device,1125.82,20,,1125.82,percent of total billed charges,Implant Device,1125.82,20,,1125.82,percent of total billed charges,Implant Device,1125.82,20,,1125.82,percent of total billed charges,Implant Device,2814.55,50,,2814.55,percent of total billed charges,All Other,1125.82,20,,1125.82,percent of total billed charges,Implant Device,1125.82,20,,1125.82,percent of total billed charges,Implant Device,1913.89,34,"Charges > $500, x 34%",1913.89,percent of total billed charges,Implant Device,1125.82,20,,1125.82,percent of total billed charges,Implant Device,1125.82,20,,1125.82,percent of total billed charges,Implant Device,1125.82,20,,1125.82,percent of total billed charges,Implant Device,1125.82,20,,1125.82,percent of total billed charges,Implant Device,1125.82,20,,1125.82,percent of total billed charges,Implant Device,1125.82,20,,1125.82,percent of total billed charges,Implant Device,1125.82,20,,1125.82,percent of total billed charges,Implant Device,1125.82,20,,1125.82,percent of total billed charges,Implant Device,1125.82,20,,1125.82,percent of total billed charges,Implant Device,1125.82,20,,1125.82,percent of total billed charges,Implant Device,1125.82,20,,1125.82,percent of total billed charges,Implant Device,1125.82,20,,1125.82,percent of total billed charges,Implant Device,1125.82,20,,1125.82,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,1913.89,34,"If Charge > 2,000, then 34 percent",1913.89,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,2814.55,
COREVALVE                       ,C1889,HCPCS,,44689065,CDM,278,RC,,,both,,,150000,59200.2,,,59200.2,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,75000,50,,75000,percent of total billed charges,All Other,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,51000,34,"Charges > $500, x 34%",51000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,30000,20,,30000,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,51000,34,"If Charge > 2,000, then 34 percent",51000,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,75000,
MOUNTED COVERED CP STENT        ,C1874,HCPCS,,44690733,CDM,278,RC,,,both,,,33500,13221.38,,,13221.38,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,6700,20,,6700,percent of total billed charges,Implant Device,6700,20,,6700,percent of total billed charges,Implant Device,6700,20,,6700,percent of total billed charges,Implant Device,6700,20,,6700,percent of total billed charges,Implant Device,6700,20,,6700,percent of total billed charges,Implant Device,16750,50,,16750,percent of total billed charges,All Other,6700,20,,6700,percent of total billed charges,Implant Device,6700,20,,6700,percent of total billed charges,Implant Device,11390,34,"Charges > $500, x 34%",11390,percent of total billed charges,Implant Device,6700,20,,6700,percent of total billed charges,Implant Device,6700,20,,6700,percent of total billed charges,Implant Device,6700,20,,6700,percent of total billed charges,Implant Device,6700,20,,6700,percent of total billed charges,Implant Device,6700,20,,6700,percent of total billed charges,Implant Device,6700,20,,6700,percent of total billed charges,Implant Device,6700,20,,6700,percent of total billed charges,Implant Device,6700,20,,6700,percent of total billed charges,Implant Device,6700,20,,6700,percent of total billed charges,Implant Device,6700,20,,6700,percent of total billed charges,Implant Device,6700,20,,6700,percent of total billed charges,Implant Device,6700,20,,6700,percent of total billed charges,Implant Device,6700,20,,6700,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,11390,34,"If Charge > 2,000, then 34 percent",11390,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,16750,
CATHETER                        ,C1757,HCPCS,,47844881,CDM,278,RC,,,both,,,29975,11830.17,,,11830.17,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,5995,20,,5995,percent of total billed charges,Implant Device,5995,20,,5995,percent of total billed charges,Implant Device,5995,20,,5995,percent of total billed charges,Implant Device,5995,20,,5995,percent of total billed charges,Implant Device,5995,20,,5995,percent of total billed charges,Implant Device,14987.5,50,,14987.5,percent of total billed charges,All Other,5995,20,,5995,percent of total billed charges,Implant Device,5995,20,,5995,percent of total billed charges,Implant Device,10191.5,34,"Charges > $500, x 34%",10191.5,percent of total billed charges,Implant Device,5995,20,,5995,percent of total billed charges,Implant Device,5995,20,,5995,percent of total billed charges,Implant Device,5995,20,,5995,percent of total billed charges,Implant Device,5995,20,,5995,percent of total billed charges,Implant Device,5995,20,,5995,percent of total billed charges,Implant Device,5995,20,,5995,percent of total billed charges,Implant Device,5995,20,,5995,percent of total billed charges,Implant Device,5995,20,,5995,percent of total billed charges,Implant Device,5995,20,,5995,percent of total billed charges,Implant Device,5995,20,,5995,percent of total billed charges,Implant Device,5995,20,,5995,percent of total billed charges,Implant Device,5995,20,,5995,percent of total billed charges,Implant Device,5995,20,,5995,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,10191.5,34,"If Charge > 2,000, then 34 percent",10191.5,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,14987.5,
TRIAL LEAD DRG KIT              ,C1778,HCPCS,,47845003,CDM,278,RC,,,both,,,8750,3453.35,,,3453.35,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,4375,50,,4375,percent of total billed charges,All Other,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,2975,34,"Charges > $500, x 34%",2975,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,2975,34,"If Charge > 2,000, then 34 percent",2975,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,4375,
TRIAL LEAD DRG KIT              ,C1778,HCPCS,,47845011,CDM,278,RC,,,both,,,8750,3453.35,,,3453.35,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,4375,50,,4375,percent of total billed charges,All Other,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,2975,34,"Charges > $500, x 34%",2975,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,1750,20,,1750,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,2975,34,"If Charge > 2,000, then 34 percent",2975,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,4375,
SYSTEM TRIAL KIT                ,C1897,HCPCS,,47845334,CDM,278,RC,,,both,,,5397.5,2130.22,,,2130.22,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,1079.5,20,,1079.5,percent of total billed charges,Implant Device,1079.5,20,,1079.5,percent of total billed charges,Implant Device,1079.5,20,,1079.5,percent of total billed charges,Implant Device,1079.5,20,,1079.5,percent of total billed charges,Implant Device,1079.5,20,,1079.5,percent of total billed charges,Implant Device,2698.75,50,,2698.75,percent of total billed charges,All Other,1079.5,20,,1079.5,percent of total billed charges,Implant Device,1079.5,20,,1079.5,percent of total billed charges,Implant Device,1835.15,34,"Charges > $500, x 34%",1835.15,percent of total billed charges,Implant Device,1079.5,20,,1079.5,percent of total billed charges,Implant Device,1079.5,20,,1079.5,percent of total billed charges,Implant Device,1079.5,20,,1079.5,percent of total billed charges,Implant Device,1079.5,20,,1079.5,percent of total billed charges,Implant Device,1079.5,20,,1079.5,percent of total billed charges,Implant Device,1079.5,20,,1079.5,percent of total billed charges,Implant Device,1079.5,20,,1079.5,percent of total billed charges,Implant Device,1079.5,20,,1079.5,percent of total billed charges,Implant Device,1079.5,20,,1079.5,percent of total billed charges,Implant Device,1079.5,20,,1079.5,percent of total billed charges,Implant Device,1079.5,20,,1079.5,percent of total billed charges,Implant Device,1079.5,20,,1079.5,percent of total billed charges,Implant Device,1079.5,20,,1079.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,1835.15,34,"If Charge > 2,000, then 34 percent",1835.15,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,2698.75,
SYSTEM TRIAL KIT                ,C1897,HCPCS,,47845342,CDM,278,RC,,,both,,,7522.5,2968.89,,,2968.89,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,1504.5,20,,1504.5,percent of total billed charges,Implant Device,1504.5,20,,1504.5,percent of total billed charges,Implant Device,1504.5,20,,1504.5,percent of total billed charges,Implant Device,1504.5,20,,1504.5,percent of total billed charges,Implant Device,1504.5,20,,1504.5,percent of total billed charges,Implant Device,3761.25,50,,3761.25,percent of total billed charges,All Other,1504.5,20,,1504.5,percent of total billed charges,Implant Device,1504.5,20,,1504.5,percent of total billed charges,Implant Device,2557.65,34,"Charges > $500, x 34%",2557.65,percent of total billed charges,Implant Device,1504.5,20,,1504.5,percent of total billed charges,Implant Device,1504.5,20,,1504.5,percent of total billed charges,Implant Device,1504.5,20,,1504.5,percent of total billed charges,Implant Device,1504.5,20,,1504.5,percent of total billed charges,Implant Device,1504.5,20,,1504.5,percent of total billed charges,Implant Device,1504.5,20,,1504.5,percent of total billed charges,Implant Device,1504.5,20,,1504.5,percent of total billed charges,Implant Device,1504.5,20,,1504.5,percent of total billed charges,Implant Device,1504.5,20,,1504.5,percent of total billed charges,Implant Device,1504.5,20,,1504.5,percent of total billed charges,Implant Device,1504.5,20,,1504.5,percent of total billed charges,Implant Device,1504.5,20,,1504.5,percent of total billed charges,Implant Device,1504.5,20,,1504.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,2557.65,34,"If Charge > 2,000, then 34 percent",2557.65,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,3761.25,
ADAPTER-M 8-CHANNEL 10 CM,C1883,HCPCS,,47846019,CDM,278,RC,,,both,,,4037.5,1593.47,,,1593.47,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,2018.75,50,,2018.75,percent of total billed charges,All Other,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,1372.75,34,"Charges > $500, x 34%",1372.75,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,1372.75,34,"If Charge > 2,000, then 34 percent",1372.75,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,2018.75,
ADAPTER-B 8-CHANNEL 60 CM,C1883,HCPCS,,47846043,CDM,278,RC,,,both,,,4037.5,1593.47,,,1593.47,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,2018.75,50,,2018.75,percent of total billed charges,All Other,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,1372.75,34,"Charges > $500, x 34%",1372.75,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,807.5,20,,807.5,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,1372.75,34,"If Charge > 2,000, then 34 percent",1372.75,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,2018.75,
MULTILEAD TRIAL CABLE,C1897,HCPCS,,47846068,CDM,278,RC,,,both,,,940,370.99,,,370.99,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,188,20,,188,percent of total billed charges,Implant Device,188,20,,188,percent of total billed charges,Implant Device,188,20,,188,percent of total billed charges,Implant Device,188,20,,188,percent of total billed charges,Implant Device,188,20,,188,percent of total billed charges,Implant Device,470,50,,470,percent of total billed charges,All Other,188,20,,188,percent of total billed charges,Implant Device,188,20,,188,percent of total billed charges,Implant Device,319.6,34,"Charges > $500, x 34%",319.6,percent of total billed charges,Implant Device,188,20,,188,percent of total billed charges,Implant Device,188,20,,188,percent of total billed charges,Implant Device,188,20,,188,percent of total billed charges,Implant Device,188,20,,188,percent of total billed charges,Implant Device,188,20,,188,percent of total billed charges,Implant Device,188,20,,188,percent of total billed charges,Implant Device,188,20,,188,percent of total billed charges,Implant Device,188,20,,188,percent of total billed charges,Implant Device,188,20,,188,percent of total billed charges,Implant Device,188,20,,188,percent of total billed charges,Implant Device,188,20,,188,percent of total billed charges,Implant Device,188,20,,188,percent of total billed charges,Implant Device,188,20,,188,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,470,
DEVICE COMANECI                 ,C2617,HCPCS,,47847314,CDM,278,RC,,,both,,,21500,8485.36,,,8485.36,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,4300,20,,4300,percent of total billed charges,Implant Device,4300,20,,4300,percent of total billed charges,Implant Device,4300,20,,4300,percent of total billed charges,Implant Device,4300,20,,4300,percent of total billed charges,Implant Device,4300,20,,4300,percent of total billed charges,Implant Device,10750,50,,10750,percent of total billed charges,All Other,4300,20,,4300,percent of total billed charges,Implant Device,4300,20,,4300,percent of total billed charges,Implant Device,7310,34,"Charges > $500, x 34%",7310,percent of total billed charges,Implant Device,4300,20,,4300,percent of total billed charges,Implant Device,4300,20,,4300,percent of total billed charges,Implant Device,4300,20,,4300,percent of total billed charges,Implant Device,4300,20,,4300,percent of total billed charges,Implant Device,4300,20,,4300,percent of total billed charges,Implant Device,4300,20,,4300,percent of total billed charges,Implant Device,4300,20,,4300,percent of total billed charges,Implant Device,4300,20,,4300,percent of total billed charges,Implant Device,4300,20,,4300,percent of total billed charges,Implant Device,4300,20,,4300,percent of total billed charges,Implant Device,4300,20,,4300,percent of total billed charges,Implant Device,4300,20,,4300,percent of total billed charges,Implant Device,4300,20,,4300,percent of total billed charges,Implant Device,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,7310,34,"If Charge > 2,000, then 34 percent",7310,percent of total billed charges,Implants,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,10750,
LIPOPROTEIN BLD QUAN PART       ,83704,CPT,,40120313,CDM,300,RC,,,both,,,544,56.22,,,56.22,Other,150% of Medicare + 9.63% HCRA Surcharge,34.19,,,34.19,Fee Schedule,Mediare Clinical Lab,65.99,,,65.99,Fee Schedule,,59.49,,,59.49,Fee Schedule,,205.42,,,205.42,Fee Schedule,,184.82,,,184.82,Fee Schedule,,174.52,,,174.52,Fee Schedule,,272,50,,272,percent of total billed charges,All Other,72.22,,,72.22,Fee Schedule,,107.7,,,107.7,Fee Schedule,,117.69,,,117.69,Other,186% Medicaid methodology,126.84,,,126.84,Fee Schedule,,337.28,,,337.28,Fee Schedule,,71.8,,,71.8,Fee Schedule,,126.84,,,126.84,Fee Schedule,,337.28,,,337.28,Fee Schedule,,135.05,,,135.05,Fee Schedule,,380.8,70,,380.8,percent of total billed charges,All Other,163.02,,,163.02,Fee Schedule,,138.32,,,138.32,Fee Schedule,,41.03,,,41.03,Fee Schedule,,41.03,,,41.03,Fee Schedule,,41.03,,,41.03,Fee Schedule,,41.03,,,41.03,Fee Schedule,,63.28,,,63.28,Other,New York Medicaid APG methodology,63.28,,,63.28,Other,100% Medicaid APG methodology,63.28,,,63.28,Other,100% Medicaid APG methodology,63.28,,,63.28,Other,100% Medicaid APG methodology,142.37,,,142.37,Other,225% Medicaid APG methodology,142.37,,,142.37,Other,225% Medicaid APG methodology,96.81,,,96.81,Other,153% Medicaid APG methodology,142.37,,,142.37,Other,225% Medicaid APG methodology,88.59,,,88.59,Other,140% Medicaid APG methodology,142.37,,,142.37,Other,225% Medicaid APG methodology,164.52,,,164.52,Other,260% Medicaid APG methodology,205.01,,,205.01,Other,324% Medicaid APG methodology,136.04,,,136.04,Other,215% Medicaid APG methodology,136.04,,,136.04,Other,215% Medicaid APG methodology,79.09,,,79.09,Other,125% Medicaid APG methodology,34.19,380.8,
Celiac Disease HLA DQ Assoc. (Ref Lab Only),81377,CPT,,40121733,CDM,300,RC,,,both,,,1507,594.76,,,594.76,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,182.85,,,182.85,Fee Schedule,,164.85,,,164.85,Fee Schedule,,58.63,,,58.63,Fee Schedule,,58.63,,,58.63,Fee Schedule,,58.63,,,58.63,Fee Schedule,,753.5,50,,753.5,percent of total billed charges,All Other,200.14,,,200.14,Fee Schedule,,1024.76,68,,1024.76,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,1205.6,80,,1205.6,percent of total billed charges,All Other Outpatient,1250.81,83,,1250.81,percent of total billed charges,All Other Outpatient,1250.81,83,,1250.81,percent of total billed charges,All Other Outpatient,1205.6,80,,1205.6,percent of total billed charges,All Other Outpatient,1250.81,83,,1250.81,percent of total billed charges,All Other Outpatient,1356.3,90,,1356.3,percent of total billed charges,All Other,1054.9,70,,1054.9,percent of total billed charges,All Other,451.71,,,451.71,Fee Schedule,,383.27,,,383.27,Fee Schedule,,113.69,,,113.69,Fee Schedule,,113.69,,,113.69,Fee Schedule,,113.69,,,113.69,Fee Schedule,,113.69,,,113.69,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1356.3,
PSA SCREENING                   ,G0103,HCPCS,,40122038,CDM,300,RC,,,both,,,293,31.75,,,31.75,Other,150% of Medicare + 9.63% HCRA Surcharge,19.31,,,19.31,Fee Schedule,Mediare Clinical Lab,37.27,,,37.27,Fee Schedule,,33.6,,,33.6,Fee Schedule,,185.89,,,185.89,Fee Schedule,,167.25,,,167.25,Fee Schedule,,157.93,,,157.93,Fee Schedule,,146.5,50,,146.5,percent of total billed charges,All Other,40.79,,,40.79,Fee Schedule,,60.83,,,60.83,Fee Schedule,,64.67,,,64.67,Other,186% Medicaid methodology,71.64,,,71.64,Fee Schedule,,181.66,,,181.66,Fee Schedule,,40.55,,,40.55,Fee Schedule,,71.64,,,71.64,Fee Schedule,,181.66,,,181.66,Fee Schedule,,76.27,,,76.27,Fee Schedule,,205.1,70,,205.1,percent of total billed charges,All Other,92.07,,,92.07,Fee Schedule,,78.12,,,78.12,Fee Schedule,,23.17,,,23.17,Fee Schedule,,23.17,,,23.17,Fee Schedule,,23.17,,,23.17,Fee Schedule,,23.17,,,23.17,Fee Schedule,,34.77,,,34.77,Other,New York Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,53.2,,,53.2,Other,153% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,48.68,,,48.68,Other,140% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,90.41,,,90.41,Other,260% Medicaid APG methodology,112.66,,,112.66,Other,324% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,43.46,,,43.46,Other,125% Medicaid APG methodology,19.31,205.1,
ASSAY OF FOLIC ACID SERUM       ,82746,CPT,,40140204,CDM,300,RC,,,both,,,235,24.17,,,24.17,Other,150% of Medicare + 9.63% HCRA Surcharge,14.7,,,14.7,Fee Schedule,Mediare Clinical Lab,28.37,,,28.37,Fee Schedule,,25.58,,,25.58,Fee Schedule,,148.55,,,148.55,Fee Schedule,,133.66,,,133.66,Fee Schedule,,126.21,,,126.21,Fee Schedule,,117.5,50,,117.5,percent of total billed charges,All Other,31.07,,,31.07,Fee Schedule,,46.31,,,46.31,Fee Schedule,,23.48,,,23.48,Other,186% Medicaid methodology,54.54,,,54.54,Fee Schedule,,145.7,,,145.7,Fee Schedule,,30.87,,,30.87,Fee Schedule,,54.54,,,54.54,Fee Schedule,,145.7,,,145.7,Fee Schedule,,58.07,,,58.07,Fee Schedule,,164.5,70,,164.5,percent of total billed charges,All Other,70.09,,,70.09,Fee Schedule,,59.47,,,59.47,Fee Schedule,,17.64,,,17.64,Fee Schedule,,17.64,,,17.64,Fee Schedule,,17.64,,,17.64,Fee Schedule,,17.64,,,17.64,Fee Schedule,,12.63,,,12.63,Fee Schedule,Medicaid Laboratory Fee Schedule,12.63,,,12.63,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.63,,,12.63,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.63,,,12.63,Fee Schedule,100% Medicaid Laboratory Fee Schedule,28.41,,,28.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,28.41,,,28.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.32,,,19.32,Fee Schedule,153% Medicaid Laboratory Fee Schedule,28.41,,,28.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.68,,,17.68,Fee Schedule,140% Medicaid Laboratory Fee Schedule,28.41,,,28.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,32.83,,,32.83,Fee Schedule,260% Medicaid Laboratory Fee Schedule,40.91,,,40.91,Fee Schedule,324% Medicaid Laboratory Fee Schedule,27.14,,,27.14,Fee Schedule,215% Medicaid Laboratory Fee Schedule,27.14,,,27.14,Fee Schedule,215% Medicaid Laboratory Fee Schedule,15.78,,,15.78,Fee Schedule,125% Medicaid Laboratory Fee Schedule,12.63,164.5,
THROMBOPLASTIN TIME PARTIAL     ,85730,CPT,,40140444,CDM,300,RC,,,both,,,96,9.88,,,9.88,Other,150% of Medicare + 9.63% HCRA Surcharge,6.01,,,6.01,Fee Schedule,Mediare Clinical Lab,11.6,,,11.6,Fee Schedule,,10.46,,,10.46,Fee Schedule,,60.67,,,60.67,Fee Schedule,,54.59,,,54.59,Fee Schedule,,51.55,,,51.55,Fee Schedule,,48,50,,48,percent of total billed charges,All Other,12.71,,,12.71,Fee Schedule,,18.93,,,18.93,Fee Schedule,,11.18,,,11.18,Other,186% Medicaid methodology,22.3,,,22.3,Fee Schedule,,59.52,,,59.52,Fee Schedule,,12.62,,,12.62,Fee Schedule,,22.3,,,22.3,Fee Schedule,,59.52,,,59.52,Fee Schedule,,23.74,,,23.74,Fee Schedule,,67.2,70,,67.2,percent of total billed charges,All Other,28.66,,,28.66,Fee Schedule,,24.31,,,24.31,Fee Schedule,,7.21,,,7.21,Fee Schedule,,7.21,,,7.21,Fee Schedule,,7.21,,,7.21,Fee Schedule,,7.21,,,7.21,Fee Schedule,,6.01,,,6.01,Fee Schedule,Medicaid Laboratory Fee Schedule,6.01,,,6.01,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.01,,,6.01,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.01,,,6.01,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.52,,,13.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.52,,,13.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.2,,,9.2,Fee Schedule,153% Medicaid Laboratory Fee Schedule,13.52,,,13.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.41,,,8.41,Fee Schedule,140% Medicaid Laboratory Fee Schedule,13.52,,,13.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.63,,,15.63,Fee Schedule,260% Medicaid Laboratory Fee Schedule,19.47,,,19.47,Fee Schedule,324% Medicaid Laboratory Fee Schedule,12.92,,,12.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,12.92,,,12.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,7.51,,,7.51,Fee Schedule,125% Medicaid Laboratory Fee Schedule,6.01,67.2,
FECES CULTURE AEROBIC BACT      ,87045,CPT,,40160400,CDM,300,RC,,,both,,,151,15.52,,,15.52,Other,150% of Medicare + 9.63% HCRA Surcharge,9.44,,,9.44,Fee Schedule,Mediare Clinical Lab,18.22,,,18.22,Fee Schedule,,16.43,,,16.43,Fee Schedule,,95.35,,,95.35,Fee Schedule,,85.79,,,85.79,Fee Schedule,,81.01,,,81.01,Fee Schedule,,75.5,50,,75.5,percent of total billed charges,All Other,19.96,,,19.96,Fee Schedule,,29.74,,,29.74,Fee Schedule,,15.31,,,15.31,Other,186% Medicaid methodology,35.02,,,35.02,Fee Schedule,,93.62,,,93.62,Fee Schedule,,19.82,,,19.82,Fee Schedule,,35.02,,,35.02,Fee Schedule,,93.62,,,93.62,Fee Schedule,,37.29,,,37.29,Fee Schedule,,105.7,70,,105.7,percent of total billed charges,All Other,45.01,,,45.01,Fee Schedule,,38.19,,,38.19,Fee Schedule,,11.33,,,11.33,Fee Schedule,,11.33,,,11.33,Fee Schedule,,11.33,,,11.33,Fee Schedule,,11.33,,,11.33,Fee Schedule,,8.23,,,8.23,Fee Schedule,Medicaid Laboratory Fee Schedule,8.23,,,8.23,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.23,,,8.23,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.23,,,8.23,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.52,,,18.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.52,,,18.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.59,,,12.59,Fee Schedule,153% Medicaid Laboratory Fee Schedule,18.52,,,18.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.52,,,11.52,Fee Schedule,140% Medicaid Laboratory Fee Schedule,18.52,,,18.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.4,,,21.4,Fee Schedule,260% Medicaid Laboratory Fee Schedule,26.67,,,26.67,Fee Schedule,324% Medicaid Laboratory Fee Schedule,17.7,,,17.7,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.7,,,17.7,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.29,,,10.29,Fee Schedule,125% Medicaid Laboratory Fee Schedule,8.23,105.7,
Clobazam (ONFI)  LC,80299,CPT,,40171407,CDM,300,RC,,,both,,,1511,596.34,,,596.34,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,35.98,,,35.98,Fee Schedule,,32.43,,,32.43,Fee Schedule,,138.36,,,138.36,Fee Schedule,,124.48,,,124.48,Fee Schedule,,117.55,,,117.55,Fee Schedule,,755.5,50,,755.5,percent of total billed charges,All Other,39.39,,,39.39,Fee Schedule,,1027.48,68,,1027.48,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,1208.8,80,,1208.8,percent of total billed charges,All Other Outpatient,1254.13,83,,1254.13,percent of total billed charges,All Other Outpatient,1254.13,83,,1254.13,percent of total billed charges,All Other Outpatient,1208.8,80,,1208.8,percent of total billed charges,All Other Outpatient,1254.13,83,,1254.13,percent of total billed charges,All Other Outpatient,1359.9,90,,1359.9,percent of total billed charges,All Other,1057.7,70,,1057.7,percent of total billed charges,All Other,88.87,,,88.87,Fee Schedule,,75.41,,,75.41,Fee Schedule,,22.37,,,22.37,Fee Schedule,,22.37,,,22.37,Fee Schedule,,22.37,,,22.37,Fee Schedule,,22.37,,,22.37,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1359.9,
DRUG ASSAY SALICYLATE           ,80179,CPT,,40173080,CDM,300,RC,,,both,,,60,30.65,,,30.65,Other,150% of Medicare + 9.63% HCRA Surcharge,18.64,,,18.64,Fee Schedule,Mediare Clinical Lab,35.98,,,35.98,Fee Schedule,,32.43,,,32.43,Fee Schedule,,14.91,,,14.91,Fee Schedule,,14.91,,,14.91,Fee Schedule,,14.91,,,14.91,Fee Schedule,,30,50,,30,percent of total billed charges,All Other,39.39,,,39.39,Fee Schedule,,58.72,,,58.72,Fee Schedule,,79.59,,,79.59,Other,186% Medicaid methodology,69.15,,,69.15,Fee Schedule,,37.2,,,37.2,Fee Schedule,,39.14,,,39.14,Fee Schedule,,69.15,,,69.15,Fee Schedule,,37.2,,,37.2,Fee Schedule,,73.63,,,73.63,Fee Schedule,,42,70,,42,percent of total billed charges,All Other,88.87,,,88.87,Fee Schedule,,75.41,,,75.41,Fee Schedule,,22.37,,,22.37,Fee Schedule,,22.37,,,22.37,Fee Schedule,,22.37,,,22.37,Fee Schedule,,22.37,,,22.37,Fee Schedule,,42.79,,,42.79,Other,New York Medicaid APG methodology,42.79,,,42.79,Other,100% Medicaid APG methodology,42.79,,,42.79,Other,100% Medicaid APG methodology,42.79,,,42.79,Other,100% Medicaid APG methodology,96.28,,,96.28,Other,225% Medicaid APG methodology,96.28,,,96.28,Other,225% Medicaid APG methodology,65.47,,,65.47,Other,153% Medicaid APG methodology,96.28,,,96.28,Other,225% Medicaid APG methodology,59.91,,,59.91,Other,140% Medicaid APG methodology,96.28,,,96.28,Other,225% Medicaid APG methodology,111.26,,,111.26,Other,260% Medicaid APG methodology,138.64,,,138.64,Other,324% Medicaid APG methodology,92,,,92,Other,215% Medicaid APG methodology,92,,,92,Other,215% Medicaid APG methodology,53.49,,,53.49,Other,125% Medicaid APG methodology,14.91,138.64,
ROUTINE VENIPUNCTURE            ,36415,CPT,,40191504,CDM,300,RC,,,both,,,45,14.52,,,14.52,Other,150% of Medicare + 9.63% HCRA Surcharge,8.83,,,8.83,Fee Schedule,Mediare Clinical Lab,17.04,,,17.04,Fee Schedule,,15.36,,,15.36,Fee Schedule,,21.54,,,21.54,Fee Schedule,,19.38,,,19.38,Fee Schedule,,18.3,,,18.3,Fee Schedule,,22.5,50,,22.5,percent of total billed charges,All Other,0.01,,,0.01,Fee Schedule,,27.81,,,27.81,Fee Schedule,,120.43,,,120.43,Other,186% Medicaid methodology,32.76,,,32.76,Fee Schedule,,27.9,,,27.9,Fee Schedule,,18.54,,,18.54,Fee Schedule,,32.76,,,32.76,Fee Schedule,,27.9,,,27.9,Fee Schedule,,34.88,,,34.88,Fee Schedule,,31.5,70,,31.5,percent of total billed charges,All Other,14.3,,,14.3,Fee Schedule,,12.14,,,12.14,Fee Schedule,,3.6,,,3.6,Fee Schedule,,3.6,,,3.6,Fee Schedule,,3.6,,,3.6,Fee Schedule,,3.6,,,3.6,Fee Schedule,,64.75,,,64.75,Other,New York Medicaid APG methodology,64.75,,,64.75,Other,100% Medicaid APG methodology,64.75,,,64.75,Other,100% Medicaid APG methodology,64.75,,,64.75,Other,100% Medicaid APG methodology,145.69,,,145.69,Other,225% Medicaid APG methodology,145.69,,,145.69,Other,225% Medicaid APG methodology,99.07,,,99.07,Other,153% Medicaid APG methodology,145.69,,,145.69,Other,225% Medicaid APG methodology,90.65,,,90.65,Other,140% Medicaid APG methodology,145.69,,,145.69,Other,225% Medicaid APG methodology,168.35,,,168.35,Other,260% Medicaid APG methodology,209.79,,,209.79,Other,324% Medicaid APG methodology,139.21,,,139.21,Other,215% Medicaid APG methodology,139.21,,,139.21,Other,215% Medicaid APG methodology,80.94,,,80.94,Other,125% Medicaid APG methodology,0.01,209.79,
ACUTE HEPATITIS PANEL           ,80074,CPT,,40194185,CDM,300,RC,,,both,,,757,78.33,,,78.33,Other,150% of Medicare + 9.63% HCRA Surcharge,47.63,,,47.63,Fee Schedule,Mediare Clinical Lab,91.93,,,91.93,Fee Schedule,,82.88,,,82.88,Fee Schedule,,481.13,,,481.13,Fee Schedule,,432.88,,,432.88,Fee Schedule,,408.76,,,408.76,Fee Schedule,,378.5,50,,378.5,percent of total billed charges,All Other,100.62,,,100.62,Fee Schedule,,150.03,,,150.03,Fee Schedule,,99.94,,,99.94,Other,186% Medicaid methodology,176.71,,,176.71,Fee Schedule,,469.34,,,469.34,Fee Schedule,,100.02,,,100.02,Fee Schedule,,176.71,,,176.71,Fee Schedule,,469.34,,,469.34,Fee Schedule,,188.14,,,188.14,Fee Schedule,,529.9,70,,529.9,percent of total billed charges,All Other,227.1,,,227.1,Fee Schedule,,192.69,,,192.69,Fee Schedule,,57.16,,,57.16,Fee Schedule,,57.16,,,57.16,Fee Schedule,,57.16,,,57.16,Fee Schedule,,57.16,,,57.16,Fee Schedule,,53.73,,,53.73,Other,New York Medicaid APG methodology,53.73,,,53.73,Other,100% Medicaid APG methodology,53.73,,,53.73,Other,100% Medicaid APG methodology,53.73,,,53.73,Other,100% Medicaid APG methodology,120.9,,,120.9,Other,225% Medicaid APG methodology,120.9,,,120.9,Other,225% Medicaid APG methodology,82.21,,,82.21,Other,153% Medicaid APG methodology,120.9,,,120.9,Other,225% Medicaid APG methodology,75.23,,,75.23,Other,140% Medicaid APG methodology,120.9,,,120.9,Other,225% Medicaid APG methodology,139.7,,,139.7,Other,260% Medicaid APG methodology,174.09,,,174.09,Other,324% Medicaid APG methodology,115.52,,,115.52,Other,215% Medicaid APG methodology,115.52,,,115.52,Other,215% Medicaid APG methodology,67.17,,,67.17,Other,125% Medicaid APG methodology,47.63,529.9,
BLOOD TYPING SEROLOGIC ABO      ,86900,CPT,,40211005,CDM,300,RC,,,both,,,2033,4.92,,,4.92,Other,150% of Medicare + 9.63% HCRA Surcharge,2.99,,,2.99,Fee Schedule,Mediare Clinical Lab,5.77,,,5.77,Fee Schedule,,5.2,,,5.2,Fee Schedule,,30.16,,,30.16,Fee Schedule,,27.13,,,27.13,Fee Schedule,,25.62,,,25.62,Fee Schedule,,1016.5,50,,1016.5,percent of total billed charges,All Other,6.31,,,6.31,Fee Schedule,,9.42,,,9.42,Fee Schedule,,5.56,,,5.56,Other,186% Medicaid methodology,11.09,,,11.09,Fee Schedule,,1260.46,,,1260.46,Fee Schedule,,6.28,,,6.28,Fee Schedule,,11.09,,,11.09,Fee Schedule,,1260.46,,,1260.46,Fee Schedule,,11.81,,,11.81,Fee Schedule,,1423.1,70,,1423.1,percent of total billed charges,All Other,14.26,,,14.26,Fee Schedule,,12.1,,,12.1,Fee Schedule,,3.59,,,3.59,Fee Schedule,,3.59,,,3.59,Fee Schedule,,3.59,,,3.59,Fee Schedule,,3.59,,,3.59,Fee Schedule,,2.99,,,2.99,Fee Schedule,Medicaid Laboratory Fee Schedule,2.99,,,2.99,Fee Schedule,100% Medicaid Laboratory Fee Schedule,2.99,,,2.99,Fee Schedule,100% Medicaid Laboratory Fee Schedule,2.99,,,2.99,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.73,,,6.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,6.73,,,6.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,4.57,,,4.57,Fee Schedule,153% Medicaid Laboratory Fee Schedule,6.73,,,6.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,4.19,,,4.19,Fee Schedule,140% Medicaid Laboratory Fee Schedule,6.73,,,6.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.77,,,7.77,Fee Schedule,260% Medicaid Laboratory Fee Schedule,9.69,,,9.69,Fee Schedule,324% Medicaid Laboratory Fee Schedule,6.43,,,6.43,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.43,,,6.43,Fee Schedule,215% Medicaid Laboratory Fee Schedule,3.74,,,3.74,Fee Schedule,125% Medicaid Laboratory Fee Schedule,2.99,1423.1,
BLOOD TYPING SEROLOGIC RH(D)    ,86901,CPT,,40211351,CDM,300,RC,,,both,,,624,4.92,,,4.92,Other,150% of Medicare + 9.63% HCRA Surcharge,2.99,,,2.99,Fee Schedule,Mediare Clinical Lab,5.77,,,5.77,Fee Schedule,,5.2,,,5.2,Fee Schedule,,30.16,,,30.16,Fee Schedule,,27.13,,,27.13,Fee Schedule,,25.62,,,25.62,Fee Schedule,,312,50,,312,percent of total billed charges,All Other,6.31,,,6.31,Fee Schedule,,9.42,,,9.42,Fee Schedule,,5.56,,,5.56,Other,186% Medicaid methodology,11.09,,,11.09,Fee Schedule,,386.88,,,386.88,Fee Schedule,,6.28,,,6.28,Fee Schedule,,11.09,,,11.09,Fee Schedule,,386.88,,,386.88,Fee Schedule,,11.81,,,11.81,Fee Schedule,,436.8,70,,436.8,percent of total billed charges,All Other,14.26,,,14.26,Fee Schedule,,12.1,,,12.1,Fee Schedule,,3.59,,,3.59,Fee Schedule,,3.59,,,3.59,Fee Schedule,,3.59,,,3.59,Fee Schedule,,3.59,,,3.59,Fee Schedule,,2.99,,,2.99,Fee Schedule,Medicaid Laboratory Fee Schedule,2.99,,,2.99,Fee Schedule,100% Medicaid Laboratory Fee Schedule,2.99,,,2.99,Fee Schedule,100% Medicaid Laboratory Fee Schedule,2.99,,,2.99,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.73,,,6.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,6.73,,,6.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,4.57,,,4.57,Fee Schedule,153% Medicaid Laboratory Fee Schedule,6.73,,,6.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,4.19,,,4.19,Fee Schedule,140% Medicaid Laboratory Fee Schedule,6.73,,,6.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.77,,,7.77,Fee Schedule,260% Medicaid Laboratory Fee Schedule,9.69,,,9.69,Fee Schedule,324% Medicaid Laboratory Fee Schedule,6.43,,,6.43,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.43,,,6.43,Fee Schedule,215% Medicaid Laboratory Fee Schedule,3.74,,,3.74,Fee Schedule,125% Medicaid Laboratory Fee Schedule,2.99,436.8,
RBC ANTIBODY SCREEN EA TCHNQ    ,86850,CPT,,40211369,CDM,300,RC,,,both,,,923,16.07,,,16.07,Other,150% of Medicare + 9.63% HCRA Surcharge,9.77,,,9.77,Fee Schedule,Mediare Clinical Lab,18.86,,,18.86,Fee Schedule,,17,,,17,Fee Schedule,,6.54,,,6.54,Fee Schedule,,6.54,,,6.54,Fee Schedule,,6.54,,,6.54,Fee Schedule,,461.5,50,,461.5,percent of total billed charges,All Other,20.64,,,20.64,Fee Schedule,,30.78,,,30.78,Fee Schedule,,10.43,,,10.43,Other,186% Medicaid methodology,36.25,,,36.25,Fee Schedule,,572.26,,,572.26,Fee Schedule,,20.52,,,20.52,Fee Schedule,,36.25,,,36.25,Fee Schedule,,572.26,,,572.26,Fee Schedule,,38.59,,,38.59,Fee Schedule,,646.1,70,,646.1,percent of total billed charges,All Other,46.58,,,46.58,Fee Schedule,,39.52,,,39.52,Fee Schedule,,11.72,,,11.72,Fee Schedule,,11.72,,,11.72,Fee Schedule,,11.72,,,11.72,Fee Schedule,,11.72,,,11.72,Fee Schedule,,5.61,,,5.61,Fee Schedule,Medicaid Laboratory Fee Schedule,5.61,,,5.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.61,,,5.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.61,,,5.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.61,,,12.61,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.61,,,12.61,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.58,,,8.58,Fee Schedule,153% Medicaid Laboratory Fee Schedule,12.61,,,12.61,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.85,,,7.85,Fee Schedule,140% Medicaid Laboratory Fee Schedule,12.61,,,12.61,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.57,,,14.57,Fee Schedule,260% Medicaid Laboratory Fee Schedule,18.16,,,18.16,Fee Schedule,324% Medicaid Laboratory Fee Schedule,12.05,,,12.05,Fee Schedule,215% Medicaid Laboratory Fee Schedule,12.05,,,12.05,Fee Schedule,215% Medicaid Laboratory Fee Schedule,7.01,,,7.01,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.61,646.1,
RBC ANTIBODY ELUTION EA         ,86860,CPT,,40211377,CDM,300,RC,,,both,,,2675,324.81,,,324.81,Other,150% of Medicare + 9.63% HCRA Surcharge,197.52,,,197.52,Other,Medicare OPPS methodology,1337.5,50,,1337.5,percent of total billed charges,All Other Outpatient,1203.75,45,,1203.75,percent of total billed charges,All Other Outpatient,8.44,,,8.44,Fee Schedule,,8.44,,,8.44,Fee Schedule,,8.44,,,8.44,Fee Schedule,,1337.5,50,,1337.5,percent of total billed charges,All Other,69.29,,,69.29,Fee Schedule,,1819,68,,1819,percent of total billed charges,All Other Outpatient,21.98,,,21.98,Other,186% Medicaid methodology,2140,80,,2140,percent of total billed charges,All Other Outpatient,2220.25,83,,2220.25,percent of total billed charges,All Other Outpatient,2220.25,83,,2220.25,percent of total billed charges,All Other Outpatient,2140,80,,2140,percent of total billed charges,All Other Outpatient,2220.25,83,,2220.25,percent of total billed charges,All Other Outpatient,2407.5,90,,2407.5,percent of total billed charges,All Other,1872.5,70,,1872.5,percent of total billed charges,All Other,1337.5,50,,1337.5,percent of total billed charges,All Other,1337.5,50,,1337.5,percent of total billed charges,All Other,172.2,,,172.2,Fee Schedule,,172.2,,,172.2,Fee Schedule,,172.2,,,172.2,Fee Schedule,,172.2,,,172.2,Fee Schedule,,11.82,,,11.82,Fee Schedule,Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,100% Medicaid Laboratory Fee Schedule,26.59,,,26.59,Fee Schedule,225% Medicaid Laboratory Fee Schedule,26.59,,,26.59,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.08,,,18.08,Fee Schedule,153% Medicaid Laboratory Fee Schedule,26.59,,,26.59,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.54,,,16.54,Fee Schedule,140% Medicaid Laboratory Fee Schedule,26.59,,,26.59,Fee Schedule,225% Medicaid Laboratory Fee Schedule,30.72,,,30.72,Fee Schedule,260% Medicaid Laboratory Fee Schedule,38.29,,,38.29,Fee Schedule,324% Medicaid Laboratory Fee Schedule,25.41,,,25.41,Fee Schedule,215% Medicaid Laboratory Fee Schedule,25.41,,,25.41,Fee Schedule,215% Medicaid Laboratory Fee Schedule,14.77,,,14.77,Fee Schedule,125% Medicaid Laboratory Fee Schedule,8.44,2407.5,
RBC ANTIBODY ID EA TCHNQ        ,86870,CPT,,40211450,CDM,300,RC,,,both,,,5281,683.55,,,683.55,Other,150% of Medicare + 9.63% HCRA Surcharge,415.67,,,415.67,Other,Medicare OPPS methodology,2640.5,50,,2640.5,percent of total billed charges,All Other Outpatient,2376.45,45,,2376.45,percent of total billed charges,All Other Outpatient,11.57,,,11.57,Fee Schedule,,11.57,,,11.57,Fee Schedule,,11.57,,,11.57,Fee Schedule,,2640.5,50,,2640.5,percent of total billed charges,All Other,94.35,,,94.35,Fee Schedule,,3591.08,68,,3591.08,percent of total billed charges,All Other Outpatient,26.49,,,26.49,Other,186% Medicaid methodology,4224.8,80,,4224.8,percent of total billed charges,All Other Outpatient,4383.23,83,,4383.23,percent of total billed charges,All Other Outpatient,4383.23,83,,4383.23,percent of total billed charges,All Other Outpatient,4224.8,80,,4224.8,percent of total billed charges,All Other Outpatient,4383.23,83,,4383.23,percent of total billed charges,All Other Outpatient,4752.9,90,,4752.9,percent of total billed charges,All Other,3696.7,70,,3696.7,percent of total billed charges,All Other,2640.5,50,,2640.5,percent of total billed charges,All Other,2640.5,50,,2640.5,percent of total billed charges,All Other,340.09,,,340.09,Fee Schedule,,340.09,,,340.09,Fee Schedule,,340.09,,,340.09,Fee Schedule,,340.09,,,340.09,Fee Schedule,,14.24,,,14.24,Fee Schedule,Medicaid Laboratory Fee Schedule,14.24,,,14.24,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.24,,,14.24,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.24,,,14.24,Fee Schedule,100% Medicaid Laboratory Fee Schedule,32.04,,,32.04,Fee Schedule,225% Medicaid Laboratory Fee Schedule,32.04,,,32.04,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.79,,,21.79,Fee Schedule,153% Medicaid Laboratory Fee Schedule,32.04,,,32.04,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.94,,,19.94,Fee Schedule,140% Medicaid Laboratory Fee Schedule,32.04,,,32.04,Fee Schedule,225% Medicaid Laboratory Fee Schedule,37.03,,,37.03,Fee Schedule,260% Medicaid Laboratory Fee Schedule,46.14,,,46.14,Fee Schedule,324% Medicaid Laboratory Fee Schedule,30.62,,,30.62,Fee Schedule,215% Medicaid Laboratory Fee Schedule,30.62,,,30.62,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.8,,,17.8,Fee Schedule,125% Medicaid Laboratory Fee Schedule,11.57,4752.9,
COMPATIBILITY TEST INCUBATE     ,86921,CPT,,40211591,CDM,300,RC,,,both,,,2675,324.81,,,324.81,Other,150% of Medicare + 9.63% HCRA Surcharge,197.52,,,197.52,Other,Medicare OPPS methodology,1337.5,50,,1337.5,percent of total billed charges,All Other Outpatient,1203.75,45,,1203.75,percent of total billed charges,All Other Outpatient,8.44,,,8.44,Fee Schedule,,8.44,,,8.44,Fee Schedule,,8.44,,,8.44,Fee Schedule,,1337.5,50,,1337.5,percent of total billed charges,All Other,69.29,,,69.29,Fee Schedule,,1819,68,,1819,percent of total billed charges,All Other Outpatient,134.94,,,134.94,Other,186% Medicaid methodology,2140,80,,2140,percent of total billed charges,All Other Outpatient,2220.25,83,,2220.25,percent of total billed charges,All Other Outpatient,2220.25,83,,2220.25,percent of total billed charges,All Other Outpatient,2140,80,,2140,percent of total billed charges,All Other Outpatient,2220.25,83,,2220.25,percent of total billed charges,All Other Outpatient,2407.5,90,,2407.5,percent of total billed charges,All Other,1872.5,70,,1872.5,percent of total billed charges,All Other,1337.5,50,,1337.5,percent of total billed charges,All Other,1337.5,50,,1337.5,percent of total billed charges,All Other,172.2,,,172.2,Fee Schedule,,172.2,,,172.2,Fee Schedule,,172.2,,,172.2,Fee Schedule,,172.2,,,172.2,Fee Schedule,,72.55,,,72.55,Other,New York Medicaid APG methodology,72.55,,,72.55,Other,100% Medicaid APG methodology,72.55,,,72.55,Other,100% Medicaid APG methodology,72.55,,,72.55,Other,100% Medicaid APG methodology,163.23,,,163.23,Other,225% Medicaid APG methodology,163.23,,,163.23,Other,225% Medicaid APG methodology,111,,,111,Other,153% Medicaid APG methodology,163.23,,,163.23,Other,225% Medicaid APG methodology,101.57,,,101.57,Other,140% Medicaid APG methodology,163.23,,,163.23,Other,225% Medicaid APG methodology,188.62,,,188.62,Other,260% Medicaid APG methodology,235.05,,,235.05,Other,324% Medicaid APG methodology,155.98,,,155.98,Other,215% Medicaid APG methodology,155.98,,,155.98,Other,215% Medicaid APG methodology,90.68,,,90.68,Other,125% Medicaid APG methodology,8.44,2407.5,
COOMBS TEST DIRECT              ,86880,CPT,,40211641,CDM,300,RC,,,both,,,624,8.86,,,8.86,Other,150% of Medicare + 9.63% HCRA Surcharge,5.39,,,5.39,Fee Schedule,Mediare Clinical Lab,10.4,,,10.4,Fee Schedule,,9.38,,,9.38,Fee Schedule,,54.28,,,54.28,Fee Schedule,,48.84,,,48.84,Fee Schedule,,46.12,,,46.12,Fee Schedule,,312,50,,312,percent of total billed charges,All Other,11.38,,,11.38,Fee Schedule,,16.98,,,16.98,Fee Schedule,,8.81,,,8.81,Other,186% Medicaid methodology,20,,,20,Fee Schedule,,386.88,,,386.88,Fee Schedule,,11.32,,,11.32,Fee Schedule,,20,,,20,Fee Schedule,,386.88,,,386.88,Fee Schedule,,21.29,,,21.29,Fee Schedule,,436.8,70,,436.8,percent of total billed charges,All Other,25.7,,,25.7,Fee Schedule,,21.81,,,21.81,Fee Schedule,,6.47,,,6.47,Fee Schedule,,6.47,,,6.47,Fee Schedule,,6.47,,,6.47,Fee Schedule,,6.47,,,6.47,Fee Schedule,,4.74,,,4.74,Fee Schedule,Medicaid Laboratory Fee Schedule,4.74,,,4.74,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.74,,,4.74,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.74,,,4.74,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.66,,,10.66,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.66,,,10.66,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.25,,,7.25,Fee Schedule,153% Medicaid Laboratory Fee Schedule,10.66,,,10.66,Fee Schedule,225% Medicaid Laboratory Fee Schedule,6.63,,,6.63,Fee Schedule,140% Medicaid Laboratory Fee Schedule,10.66,,,10.66,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.32,,,12.32,Fee Schedule,260% Medicaid Laboratory Fee Schedule,15.35,,,15.35,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.18,,,10.18,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.18,,,10.18,Fee Schedule,215% Medicaid Laboratory Fee Schedule,5.92,,,5.92,Fee Schedule,125% Medicaid Laboratory Fee Schedule,4.74,436.8,
BLOOD TYPING RBC ANTIGENS       ,86905,CPT,,40211708,CDM,300,RC,,,both,,,5281,6.3,,,6.3,Other,150% of Medicare + 9.63% HCRA Surcharge,3.83,,,3.83,Fee Schedule,Mediare Clinical Lab,7.39,,,7.39,Fee Schedule,,6.66,,,6.66,Fee Schedule,,38.63,,,38.63,Fee Schedule,,34.75,,,34.75,Fee Schedule,,32.82,,,32.82,Fee Schedule,,2640.5,50,,2640.5,percent of total billed charges,All Other,8.09,,,8.09,Fee Schedule,,12.06,,,12.06,Fee Schedule,,7.12,,,7.12,Other,186% Medicaid methodology,14.21,,,14.21,Fee Schedule,,3274.22,,,3274.22,Fee Schedule,,8.04,,,8.04,Fee Schedule,,14.21,,,14.21,Fee Schedule,,3274.22,,,3274.22,Fee Schedule,,15.13,,,15.13,Fee Schedule,,3696.7,70,,3696.7,percent of total billed charges,All Other,18.26,,,18.26,Fee Schedule,,15.49,,,15.49,Fee Schedule,,4.6,,,4.6,Fee Schedule,,4.6,,,4.6,Fee Schedule,,4.6,,,4.6,Fee Schedule,,4.6,,,4.6,Fee Schedule,,3.83,,,3.83,Fee Schedule,Medicaid Laboratory Fee Schedule,3.83,,,3.83,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.83,,,3.83,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.83,,,3.83,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.62,,,8.62,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.62,,,8.62,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.86,,,5.86,Fee Schedule,153% Medicaid Laboratory Fee Schedule,8.62,,,8.62,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.36,,,5.36,Fee Schedule,140% Medicaid Laboratory Fee Schedule,8.62,,,8.62,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.96,,,9.96,Fee Schedule,260% Medicaid Laboratory Fee Schedule,12.41,,,12.41,Fee Schedule,324% Medicaid Laboratory Fee Schedule,8.23,,,8.23,Fee Schedule,215% Medicaid Laboratory Fee Schedule,8.23,,,8.23,Fee Schedule,215% Medicaid Laboratory Fee Schedule,4.79,,,4.79,Fee Schedule,125% Medicaid Laboratory Fee Schedule,3.83,3696.7,
MOPATH PROCEDURE LEVEL 4        ,81403,CPT,,40212813,CDM,300,RC,,,both,,,875,304.55,,,304.55,Other,150% of Medicare + 9.63% HCRA Surcharge,185.2,,,185.2,Fee Schedule,Mediare Clinical Lab,357.44,,,357.44,Fee Schedule,,322.25,,,322.25,Fee Schedule,,67.55,,,67.55,Fee Schedule,,67.55,,,67.55,Fee Schedule,,67.55,,,67.55,Fee Schedule,,437.5,50,,437.5,percent of total billed charges,All Other,391.24,,,391.24,Fee Schedule,,583.38,,,583.38,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,687.09,,,687.09,Fee Schedule,,542.5,,,542.5,Fee Schedule,,388.92,,,388.92,Fee Schedule,,687.09,,,687.09,Fee Schedule,,542.5,,,542.5,Fee Schedule,,731.54,,,731.54,Fee Schedule,,612.5,70,,612.5,percent of total billed charges,All Other,883.02,,,883.02,Fee Schedule,,749.23,,,749.23,Fee Schedule,,222.24,,,222.24,Fee Schedule,,222.24,,,222.24,Fee Schedule,,222.24,,,222.24,Fee Schedule,,222.24,,,222.24,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,883.02,
ROUTINE VENIPUNCTURE            ,36415,CPT,,40800005,CDM,300,RC,,,both,,,45,14.52,,,14.52,Other,150% of Medicare + 9.63% HCRA Surcharge,8.83,,,8.83,Fee Schedule,Mediare Clinical Lab,17.04,,,17.04,Fee Schedule,,15.36,,,15.36,Fee Schedule,,21.54,,,21.54,Fee Schedule,,19.38,,,19.38,Fee Schedule,,18.3,,,18.3,Fee Schedule,,22.5,50,,22.5,percent of total billed charges,All Other,0.01,,,0.01,Fee Schedule,,27.81,,,27.81,Fee Schedule,,120.43,,,120.43,Other,186% Medicaid methodology,32.76,,,32.76,Fee Schedule,,27.9,,,27.9,Fee Schedule,,18.54,,,18.54,Fee Schedule,,32.76,,,32.76,Fee Schedule,,27.9,,,27.9,Fee Schedule,,34.88,,,34.88,Fee Schedule,,31.5,70,,31.5,percent of total billed charges,All Other,14.3,,,14.3,Fee Schedule,,12.14,,,12.14,Fee Schedule,,3.6,,,3.6,Fee Schedule,,3.6,,,3.6,Fee Schedule,,3.6,,,3.6,Fee Schedule,,3.6,,,3.6,Fee Schedule,,64.75,,,64.75,Other,New York Medicaid APG methodology,64.75,,,64.75,Other,100% Medicaid APG methodology,64.75,,,64.75,Other,100% Medicaid APG methodology,64.75,,,64.75,Other,100% Medicaid APG methodology,145.69,,,145.69,Other,225% Medicaid APG methodology,145.69,,,145.69,Other,225% Medicaid APG methodology,99.07,,,99.07,Other,153% Medicaid APG methodology,145.69,,,145.69,Other,225% Medicaid APG methodology,90.65,,,90.65,Other,140% Medicaid APG methodology,145.69,,,145.69,Other,225% Medicaid APG methodology,168.35,,,168.35,Other,260% Medicaid APG methodology,209.79,,,209.79,Other,324% Medicaid APG methodology,139.21,,,139.21,Other,215% Medicaid APG methodology,139.21,,,139.21,Other,215% Medicaid APG methodology,80.94,,,80.94,Other,125% Medicaid APG methodology,0.01,209.79,
CAPILLARY BLOOD DRAW            ,36416,CPT,,40800336,CDM,300,RC,,,both,,,76,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1.22,,,1.22,Fee Schedule,,1.22,,,1.22,Fee Schedule,,1.22,,,1.22,Fee Schedule,,38,50,,38,percent of total billed charges,All Other,6.63,,,6.63,Fee Schedule,,51.68,68,,51.68,percent of total billed charges,All Other Outpatient,120.43,,,120.43,Other,186% Medicaid methodology,60.8,80,,60.8,percent of total billed charges,All Other Outpatient,63.08,83,,63.08,percent of total billed charges,All Other Outpatient,63.08,83,,63.08,percent of total billed charges,All Other Outpatient,60.8,80,,60.8,percent of total billed charges,All Other Outpatient,63.08,83,,63.08,percent of total billed charges,All Other Outpatient,68.4,90,,68.4,percent of total billed charges,All Other,53.2,70,,53.2,percent of total billed charges,All Other,38,50,,38,percent of total billed charges,All Other,38,50,,38,percent of total billed charges,All Other,3.47,,,3.47,Fee Schedule,,3.47,,,3.47,Fee Schedule,,3.47,,,3.47,Fee Schedule,,3.47,,,3.47,Fee Schedule,,64.75,,,64.75,Other,New York Medicaid APG methodology,64.75,,,64.75,Other,100% Medicaid APG methodology,64.75,,,64.75,Other,100% Medicaid APG methodology,64.75,,,64.75,Other,100% Medicaid APG methodology,145.69,,,145.69,Other,225% Medicaid APG methodology,145.69,,,145.69,Other,225% Medicaid APG methodology,99.07,,,99.07,Other,153% Medicaid APG methodology,145.69,,,145.69,Other,225% Medicaid APG methodology,90.65,,,90.65,Other,140% Medicaid APG methodology,145.69,,,145.69,Other,225% Medicaid APG methodology,168.35,,,168.35,Other,260% Medicaid APG methodology,209.79,,,209.79,Other,324% Medicaid APG methodology,139.21,,,139.21,Other,215% Medicaid APG methodology,139.21,,,139.21,Other,215% Medicaid APG methodology,80.94,,,80.94,Other,125% Medicaid APG methodology,0.01,209.79,
INSITU HYBRIDIZATION (FISH)ADD  ,88364,CPT,,43503440,CDM,300,RC,,,both,,,686,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,229.48,,,229.48,Fee Schedule,,206.89,,,206.89,Fee Schedule,,28.03,,,28.03,Fee Schedule,,28.03,,,28.03,Fee Schedule,,28.03,,,28.03,Fee Schedule,,343,50,,343,percent of total billed charges,All Other,231.47,,,231.47,Fee Schedule,,450.63,,,450.63,Fee Schedule,,333.65,,,333.65,Other,186% Medicaid methodology,530.29,,,530.29,Fee Schedule,,425.32,,,425.32,Fee Schedule,,249.69,,,249.69,Fee Schedule,,530.29,,,530.29,Fee Schedule,,425.32,,,425.32,Fee Schedule,,469.66,,,469.66,Fee Schedule,,480.2,70,,480.2,percent of total billed charges,All Other,504.9,,,504.9,Fee Schedule,,428.4,,,428.4,Fee Schedule,,125.16,,,125.16,Fee Schedule,,125.16,,,125.16,Fee Schedule,,125.16,,,125.16,Fee Schedule,,125.16,,,125.16,Fee Schedule,,179.38,,,179.38,Fee Schedule,Medicaid Laboratory Fee Schedule,179.38,,,179.38,Fee Schedule,100% Medicaid Laboratory Fee Schedule,179.38,,,179.38,Fee Schedule,100% Medicaid Laboratory Fee Schedule,179.38,,,179.38,Fee Schedule,100% Medicaid Laboratory Fee Schedule,403.61,,,403.61,Fee Schedule,225% Medicaid Laboratory Fee Schedule,403.61,,,403.61,Fee Schedule,225% Medicaid Laboratory Fee Schedule,274.45,,,274.45,Fee Schedule,153% Medicaid Laboratory Fee Schedule,403.61,,,403.61,Fee Schedule,225% Medicaid Laboratory Fee Schedule,251.13,,,251.13,Fee Schedule,140% Medicaid Laboratory Fee Schedule,403.61,,,403.61,Fee Schedule,225% Medicaid Laboratory Fee Schedule,466.39,,,466.39,Fee Schedule,260% Medicaid Laboratory Fee Schedule,581.19,,,581.19,Fee Schedule,324% Medicaid Laboratory Fee Schedule,385.67,,,385.67,Fee Schedule,215% Medicaid Laboratory Fee Schedule,385.67,,,385.67,Fee Schedule,215% Medicaid Laboratory Fee Schedule,224.23,,,224.23,Fee Schedule,125% Medicaid Laboratory Fee Schedule,0.01,581.19,
ROUTINE VENIPUNCTURE            ,36415,CPT,,48400220,CDM,300,RC,,,both,,,45,14.52,,,14.52,Other,150% of Medicare + 9.63% HCRA Surcharge,8.83,,,8.83,Fee Schedule,Mediare Clinical Lab,17.04,,,17.04,Fee Schedule,,15.36,,,15.36,Fee Schedule,,21.54,,,21.54,Fee Schedule,,19.38,,,19.38,Fee Schedule,,18.3,,,18.3,Fee Schedule,,22.5,50,,22.5,percent of total billed charges,All Other,0.01,,,0.01,Fee Schedule,,27.81,,,27.81,Fee Schedule,,120.43,,,120.43,Other,186% Medicaid methodology,32.76,,,32.76,Fee Schedule,,27.9,,,27.9,Fee Schedule,,18.54,,,18.54,Fee Schedule,,32.76,,,32.76,Fee Schedule,,27.9,,,27.9,Fee Schedule,,34.88,,,34.88,Fee Schedule,,31.5,70,,31.5,percent of total billed charges,All Other,14.3,,,14.3,Fee Schedule,,12.14,,,12.14,Fee Schedule,,3.6,,,3.6,Fee Schedule,,3.6,,,3.6,Fee Schedule,,3.6,,,3.6,Fee Schedule,,3.6,,,3.6,Fee Schedule,,64.75,,,64.75,Other,New York Medicaid APG methodology,64.75,,,64.75,Other,100% Medicaid APG methodology,64.75,,,64.75,Other,100% Medicaid APG methodology,64.75,,,64.75,Other,100% Medicaid APG methodology,145.69,,,145.69,Other,225% Medicaid APG methodology,145.69,,,145.69,Other,225% Medicaid APG methodology,99.07,,,99.07,Other,153% Medicaid APG methodology,145.69,,,145.69,Other,225% Medicaid APG methodology,90.65,,,90.65,Other,140% Medicaid APG methodology,145.69,,,145.69,Other,225% Medicaid APG methodology,168.35,,,168.35,Other,260% Medicaid APG methodology,209.79,,,209.79,Other,324% Medicaid APG methodology,139.21,,,139.21,Other,215% Medicaid APG methodology,139.21,,,139.21,Other,215% Medicaid APG methodology,80.94,,,80.94,Other,125% Medicaid APG methodology,0.01,209.79,
DRAW BLOOD OFF VENOUS DEVICE    ,36591,CPT,,48401988,CDM,300,RC,,,both,,,2033,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,57.16,,,57.16,Fee Schedule,,51.57,,,51.57,Fee Schedule,,212.17,,,212.17,Fee Schedule,,190.89,,,190.89,Fee Schedule,,180.26,,,180.26,Fee Schedule,,1016.5,50,,1016.5,percent of total billed charges,All Other,1423.1,70,,1423.1,percent of total billed charges,All Other,124.5,,,124.5,Fee Schedule,,104.72,,,104.72,Other,186% Medicaid methodology,146.51,,,146.51,Fee Schedule,,1260.46,,,1260.46,Fee Schedule,,68.99,,,68.99,Fee Schedule,,146.51,,,146.51,Fee Schedule,,1260.46,,,1260.46,Fee Schedule,,129.76,,,129.76,Fee Schedule,,1423.1,70,,1423.1,percent of total billed charges,All Other,130.35,,,130.35,Fee Schedule,,110.6,,,110.6,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,56.3,,,56.3,Other,New York Medicaid APG methodology,56.3,,,56.3,Other,100% Medicaid APG methodology,56.3,,,56.3,Other,100% Medicaid APG methodology,56.3,,,56.3,Other,100% Medicaid APG methodology,126.68,,,126.68,Other,225% Medicaid APG methodology,126.68,,,126.68,Other,225% Medicaid APG methodology,86.14,,,86.14,Other,153% Medicaid APG methodology,126.68,,,126.68,Other,225% Medicaid APG methodology,78.82,,,78.82,Other,140% Medicaid APG methodology,126.68,,,126.68,Other,225% Medicaid APG methodology,146.38,,,146.38,Other,260% Medicaid APG methodology,182.41,,,182.41,Other,324% Medicaid APG methodology,121.05,,,121.05,Other,215% Medicaid APG methodology,121.05,,,121.05,Other,215% Medicaid APG methodology,70.38,,,70.38,Other,125% Medicaid APG methodology,0.01,1423.1,
ASSAY OTHER FLUID CHLORIDES     ,82438,CPT,,40110165,CDM,301,RC,,,both,,,80,8.22,,,8.22,Other,150% of Medicare + 9.63% HCRA Surcharge,5,,,5,Fee Schedule,Mediare Clinical Lab,9.65,,,9.65,Fee Schedule,,8.7,,,8.7,Fee Schedule,,24.41,,,24.41,Fee Schedule,,21.96,,,21.96,Fee Schedule,,20.74,,,20.74,Fee Schedule,,40,50,,40,percent of total billed charges,All Other,10.56,,,10.56,Fee Schedule,,15.75,,,15.75,Fee Schedule,,9.3,,,9.3,Other,186% Medicaid methodology,18.55,,,18.55,Fee Schedule,,49.6,,,49.6,Fee Schedule,,10.5,,,10.5,Fee Schedule,,18.55,,,18.55,Fee Schedule,,49.6,,,49.6,Fee Schedule,,19.75,,,19.75,Fee Schedule,,56,70,,56,percent of total billed charges,All Other,23.84,,,23.84,Fee Schedule,,20.23,,,20.23,Fee Schedule,,6,,,6,Fee Schedule,,6,,,6,Fee Schedule,,6,,,6,Fee Schedule,,6,,,6,Fee Schedule,,5,,,5,Fee Schedule,Medicaid Laboratory Fee Schedule,5,,,5,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5,,,5,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5,,,5,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.25,,,11.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.25,,,11.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.65,,,7.65,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.25,,,11.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7,,,7,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.25,,,11.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13,,,13,Fee Schedule,260% Medicaid Laboratory Fee Schedule,16.2,,,16.2,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.75,,,10.75,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.75,,,10.75,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.25,,,6.25,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5,56,
GLUCOSE OTHER FLUID             ,82945,CPT,,40110389,CDM,301,RC,,,both,,,63,6.46,,,6.46,Other,150% of Medicare + 9.63% HCRA Surcharge,3.93,,,3.93,Fee Schedule,Mediare Clinical Lab,7.58,,,7.58,Fee Schedule,,6.84,,,6.84,Fee Schedule,,39.63,,,39.63,Fee Schedule,,35.66,,,35.66,Fee Schedule,,33.67,,,33.67,Fee Schedule,,31.5,50,,31.5,percent of total billed charges,All Other,8.29,,,8.29,Fee Schedule,,12.38,,,12.38,Fee Schedule,,7.31,,,7.31,Other,186% Medicaid methodology,14.58,,,14.58,Fee Schedule,,39.06,,,39.06,Fee Schedule,,8.25,,,8.25,Fee Schedule,,14.58,,,14.58,Fee Schedule,,39.06,,,39.06,Fee Schedule,,15.52,,,15.52,Fee Schedule,,44.1,70,,44.1,percent of total billed charges,All Other,18.74,,,18.74,Fee Schedule,,15.9,,,15.9,Fee Schedule,,4.72,,,4.72,Fee Schedule,,4.72,,,4.72,Fee Schedule,,4.72,,,4.72,Fee Schedule,,4.72,,,4.72,Fee Schedule,,3.93,,,3.93,Fee Schedule,Medicaid Laboratory Fee Schedule,3.93,,,3.93,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.93,,,3.93,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.93,,,3.93,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.84,,,8.84,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.84,,,8.84,Fee Schedule,225% Medicaid Laboratory Fee Schedule,6.01,,,6.01,Fee Schedule,153% Medicaid Laboratory Fee Schedule,8.84,,,8.84,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.5,,,5.5,Fee Schedule,140% Medicaid Laboratory Fee Schedule,8.84,,,8.84,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.22,,,10.22,Fee Schedule,260% Medicaid Laboratory Fee Schedule,12.73,,,12.73,Fee Schedule,324% Medicaid Laboratory Fee Schedule,8.45,,,8.45,Fee Schedule,215% Medicaid Laboratory Fee Schedule,8.45,,,8.45,Fee Schedule,215% Medicaid Laboratory Fee Schedule,4.91,,,4.91,Fee Schedule,125% Medicaid Laboratory Fee Schedule,3.93,44.1,
ASSAY PH BODY FLUID NOS         ,83986,CPT,,40110520,CDM,301,RC,,,both,,,58,5.89,,,5.89,Other,150% of Medicare + 9.63% HCRA Surcharge,3.58,,,3.58,Fee Schedule,Mediare Clinical Lab,6.91,,,6.91,Fee Schedule,,6.23,,,6.23,Fee Schedule,,33.82,,,33.82,Fee Schedule,,30.43,,,30.43,Fee Schedule,,28.73,,,28.73,Fee Schedule,,29,50,,29,percent of total billed charges,All Other,7.57,,,7.57,Fee Schedule,,11.28,,,11.28,Fee Schedule,,56.01,,,56.01,Other,186% Medicaid methodology,13.28,,,13.28,Fee Schedule,,35.96,,,35.96,Fee Schedule,,7.52,,,7.52,Fee Schedule,,13.28,,,13.28,Fee Schedule,,35.96,,,35.96,Fee Schedule,,14.14,,,14.14,Fee Schedule,,40.6,70,,40.6,percent of total billed charges,All Other,17.07,,,17.07,Fee Schedule,,14.48,,,14.48,Fee Schedule,,4.3,,,4.3,Fee Schedule,,4.3,,,4.3,Fee Schedule,,4.3,,,4.3,Fee Schedule,,4.3,,,4.3,Fee Schedule,,30.11,,,30.11,Other,New York Medicaid APG methodology,30.11,,,30.11,Other,100% Medicaid APG methodology,30.11,,,30.11,Other,100% Medicaid APG methodology,30.11,,,30.11,Other,100% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,46.07,,,46.07,Other,153% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,42.16,,,42.16,Other,140% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,78.29,,,78.29,Other,260% Medicaid APG methodology,97.56,,,97.56,Other,324% Medicaid APG methodology,64.74,,,64.74,Other,215% Medicaid APG methodology,64.74,,,64.74,Other,215% Medicaid APG methodology,37.64,,,37.64,Other,125% Medicaid APG methodology,3.58,97.56,
UNLISTED CHEMISTRY TEST         ,84999,CPT,,40110546,CDM,301,RC,,,both,,,269,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,134.5,50,,134.5,percent of total billed charges,All Other Outpatient,121.05,45,,121.05,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,134.5,50,,134.5,percent of total billed charges,All Other,74.72,,,74.72,Fee Schedule,,182.92,68,,182.92,percent of total billed charges,All Other Outpatient,65.35,,,65.35,Other,186% Medicaid methodology,215.2,80,,215.2,percent of total billed charges,All Other Outpatient,223.27,83,,223.27,percent of total billed charges,All Other Outpatient,223.27,83,,223.27,percent of total billed charges,All Other Outpatient,215.2,80,,215.2,percent of total billed charges,All Other Outpatient,223.27,83,,223.27,percent of total billed charges,All Other Outpatient,242.1,90,,242.1,percent of total billed charges,All Other,188.3,70,,188.3,percent of total billed charges,All Other,134.5,50,,134.5,percent of total billed charges,All Other,134.5,50,,134.5,percent of total billed charges,All Other,188.3,70,,188.3,percent of total billed charges,All Other,188.3,70,,188.3,percent of total billed charges,All Other,188.3,70,,188.3,percent of total billed charges,All Other,188.3,70,,188.3,percent of total billed charges,All Other,35.13,,,35.13,Other,New York Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,53.75,,,53.75,Other,153% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,49.19,,,49.19,Other,140% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,91.35,,,91.35,Other,260% Medicaid APG methodology,113.83,,,113.83,Other,324% Medicaid APG methodology,75.54,,,75.54,Other,215% Medicaid APG methodology,75.54,,,75.54,Other,215% Medicaid APG methodology,43.92,,,43.92,Other,125% Medicaid APG methodology,0.01,242.1,
ASSAY OF PROTEIN OTHER          ,84157,CPT,,40110587,CDM,301,RC,,,both,,,64,6.58,,,6.58,Other,150% of Medicare + 9.63% HCRA Surcharge,4,,,4,Fee Schedule,Mediare Clinical Lab,7.72,,,7.72,Fee Schedule,,6.96,,,6.96,Fee Schedule,,37.05,,,37.05,Fee Schedule,,33.33,,,33.33,Fee Schedule,,31.48,,,31.48,Fee Schedule,,32,50,,32,percent of total billed charges,All Other,8.45,,,8.45,Fee Schedule,,12.6,,,12.6,Fee Schedule,,7.44,,,7.44,Other,186% Medicaid methodology,14.84,,,14.84,Fee Schedule,,39.68,,,39.68,Fee Schedule,,8.4,,,8.4,Fee Schedule,,14.84,,,14.84,Fee Schedule,,39.68,,,39.68,Fee Schedule,,15.8,,,15.8,Fee Schedule,,44.8,70,,44.8,percent of total billed charges,All Other,19.07,,,19.07,Fee Schedule,,16.18,,,16.18,Fee Schedule,,4.8,,,4.8,Fee Schedule,,4.8,,,4.8,Fee Schedule,,4.8,,,4.8,Fee Schedule,,4.8,,,4.8,Fee Schedule,,4,,,4,Fee Schedule,Medicaid Laboratory Fee Schedule,4,,,4,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4,,,4,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4,,,4,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9,,,9,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9,,,9,Fee Schedule,225% Medicaid Laboratory Fee Schedule,6.12,,,6.12,Fee Schedule,153% Medicaid Laboratory Fee Schedule,9,,,9,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.6,,,5.6,Fee Schedule,140% Medicaid Laboratory Fee Schedule,9,,,9,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.4,,,10.4,Fee Schedule,260% Medicaid Laboratory Fee Schedule,12.96,,,12.96,Fee Schedule,324% Medicaid Laboratory Fee Schedule,8.6,,,8.6,Fee Schedule,215% Medicaid Laboratory Fee Schedule,8.6,,,8.6,Fee Schedule,215% Medicaid Laboratory Fee Schedule,5,,,5,Fee Schedule,125% Medicaid Laboratory Fee Schedule,4,44.8,
EVAL CV AMNI FL PROTEIN QUAL E  ,84112,CPT,,40110637,CDM,301,RC,,,both,,,1561,161.34,,,161.34,Other,150% of Medicare + 9.63% HCRA Surcharge,98.11,,,98.11,Fee Schedule,Mediare Clinical Lab,189.35,,,189.35,Fee Schedule,,170.71,,,170.71,Fee Schedule,,635.65,,,635.65,Fee Schedule,,571.9,,,571.9,Fee Schedule,,540.03,,,540.03,Fee Schedule,,780.5,50,,780.5,percent of total billed charges,All Other,207.25,,,207.25,Fee Schedule,,309.05,,,309.05,Fee Schedule,,133.76,,,133.76,Other,186% Medicaid methodology,363.99,,,363.99,Fee Schedule,,967.82,,,967.82,Fee Schedule,,206.03,,,206.03,Fee Schedule,,363.99,,,363.99,Fee Schedule,,967.82,,,967.82,Fee Schedule,,387.53,,,387.53,Fee Schedule,,1092.7,70,,1092.7,percent of total billed charges,All Other,467.78,,,467.78,Fee Schedule,,396.91,,,396.91,Fee Schedule,,117.73,,,117.73,Fee Schedule,,117.73,,,117.73,Fee Schedule,,117.73,,,117.73,Fee Schedule,,117.73,,,117.73,Fee Schedule,,71.91,,,71.91,Fee Schedule,Medicaid Laboratory Fee Schedule,71.91,,,71.91,Fee Schedule,100% Medicaid Laboratory Fee Schedule,71.91,,,71.91,Fee Schedule,100% Medicaid Laboratory Fee Schedule,71.91,,,71.91,Fee Schedule,100% Medicaid Laboratory Fee Schedule,161.8,,,161.8,Fee Schedule,225% Medicaid Laboratory Fee Schedule,161.8,,,161.8,Fee Schedule,225% Medicaid Laboratory Fee Schedule,110.03,,,110.03,Fee Schedule,153% Medicaid Laboratory Fee Schedule,161.8,,,161.8,Fee Schedule,225% Medicaid Laboratory Fee Schedule,100.68,,,100.68,Fee Schedule,140% Medicaid Laboratory Fee Schedule,161.8,,,161.8,Fee Schedule,225% Medicaid Laboratory Fee Schedule,186.97,,,186.97,Fee Schedule,260% Medicaid Laboratory Fee Schedule,232.99,,,232.99,Fee Schedule,324% Medicaid Laboratory Fee Schedule,154.61,,,154.61,Fee Schedule,215% Medicaid Laboratory Fee Schedule,154.61,,,154.61,Fee Schedule,215% Medicaid Laboratory Fee Schedule,89.89,,,89.89,Fee Schedule,125% Medicaid Laboratory Fee Schedule,71.91,1092.7,
OLIGOCLONAL BANDS               ,83916,CPT,,40110785,CDM,301,RC,,,both,,,436,45.04,,,45.04,Other,150% of Medicare + 9.63% HCRA Surcharge,27.39,,,27.39,Fee Schedule,Mediare Clinical Lab,52.86,,,52.86,Fee Schedule,,47.66,,,47.66,Fee Schedule,,203.19,,,203.19,Fee Schedule,,182.82,,,182.82,Fee Schedule,,172.63,,,172.63,Fee Schedule,,218,50,,218,percent of total billed charges,All Other,57.85,,,57.85,Fee Schedule,,86.28,,,86.28,Fee Schedule,,117.69,,,117.69,Other,186% Medicaid methodology,101.62,,,101.62,Fee Schedule,,270.32,,,270.32,Fee Schedule,,57.52,,,57.52,Fee Schedule,,101.62,,,101.62,Fee Schedule,,270.32,,,270.32,Fee Schedule,,108.19,,,108.19,Fee Schedule,,305.2,70,,305.2,percent of total billed charges,All Other,130.59,,,130.59,Fee Schedule,,110.81,,,110.81,Fee Schedule,,32.87,,,32.87,Fee Schedule,,32.87,,,32.87,Fee Schedule,,32.87,,,32.87,Fee Schedule,,32.87,,,32.87,Fee Schedule,,63.28,,,63.28,Other,New York Medicaid APG methodology,63.28,,,63.28,Other,100% Medicaid APG methodology,63.28,,,63.28,Other,100% Medicaid APG methodology,63.28,,,63.28,Other,100% Medicaid APG methodology,142.37,,,142.37,Other,225% Medicaid APG methodology,142.37,,,142.37,Other,225% Medicaid APG methodology,96.81,,,96.81,Other,153% Medicaid APG methodology,142.37,,,142.37,Other,225% Medicaid APG methodology,88.59,,,88.59,Other,140% Medicaid APG methodology,142.37,,,142.37,Other,225% Medicaid APG methodology,164.52,,,164.52,Other,260% Medicaid APG methodology,205.01,,,205.01,Other,324% Medicaid APG methodology,136.04,,,136.04,Other,215% Medicaid APG methodology,136.04,,,136.04,Other,215% Medicaid APG methodology,79.09,,,79.09,Other,125% Medicaid APG methodology,27.39,305.2,
OTHER SOURCE ALBUMIN QUAN EA    ,82042,CPT,,40110843,CDM,301,RC,,,both,,,582,12.79,,,12.79,Other,150% of Medicare + 9.63% HCRA Surcharge,7.78,,,7.78,Fee Schedule,Mediare Clinical Lab,15.02,,,15.02,Fee Schedule,,13.54,,,13.54,Fee Schedule,,29.08,,,29.08,Fee Schedule,,26.16,,,26.16,Fee Schedule,,24.71,,,24.71,Fee Schedule,,291,50,,291,percent of total billed charges,All Other,16.45,,,16.45,Fee Schedule,,24.51,,,24.51,Fee Schedule,,9.45,,,9.45,Other,186% Medicaid methodology,28.86,,,28.86,Fee Schedule,,360.84,,,360.84,Fee Schedule,,16.34,,,16.34,Fee Schedule,,28.86,,,28.86,Fee Schedule,,360.84,,,360.84,Fee Schedule,,30.73,,,30.73,Fee Schedule,,407.4,70,,407.4,percent of total billed charges,All Other,37.09,,,37.09,Fee Schedule,,31.47,,,31.47,Fee Schedule,,9.34,,,9.34,Fee Schedule,,9.34,,,9.34,Fee Schedule,,9.34,,,9.34,Fee Schedule,,9.34,,,9.34,Fee Schedule,,5.08,,,5.08,Fee Schedule,Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.77,,,7.77,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.11,,,7.11,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.21,,,13.21,Fee Schedule,260% Medicaid Laboratory Fee Schedule,16.46,,,16.46,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.35,,,6.35,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.08,407.4,
ASSAY OF SWEAT SODIUM           ,84302,CPT,,40111049,CDM,301,RC,,,both,,,78,7.99,,,7.99,Other,150% of Medicare + 9.63% HCRA Surcharge,4.86,,,4.86,Fee Schedule,Mediare Clinical Lab,9.38,,,9.38,Fee Schedule,,8.46,,,8.46,Fee Schedule,,49.18,,,49.18,Fee Schedule,,44.25,,,44.25,Fee Schedule,,41.79,,,41.79,Fee Schedule,,39,50,,39,percent of total billed charges,All Other,10.27,,,10.27,Fee Schedule,,15.31,,,15.31,Fee Schedule,,9.04,,,9.04,Other,186% Medicaid methodology,18.03,,,18.03,Fee Schedule,,48.36,,,48.36,Fee Schedule,,10.21,,,10.21,Fee Schedule,,18.03,,,18.03,Fee Schedule,,48.36,,,48.36,Fee Schedule,,19.2,,,19.2,Fee Schedule,,54.6,70,,54.6,percent of total billed charges,All Other,23.17,,,23.17,Fee Schedule,,19.66,,,19.66,Fee Schedule,,5.83,,,5.83,Fee Schedule,,5.83,,,5.83,Fee Schedule,,5.83,,,5.83,Fee Schedule,,5.83,,,5.83,Fee Schedule,,4.86,,,4.86,Fee Schedule,Medicaid Laboratory Fee Schedule,4.86,,,4.86,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.86,,,4.86,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.86,,,4.86,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.94,,,10.94,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.94,,,10.94,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.44,,,7.44,Fee Schedule,153% Medicaid Laboratory Fee Schedule,10.94,,,10.94,Fee Schedule,225% Medicaid Laboratory Fee Schedule,6.8,,,6.8,Fee Schedule,140% Medicaid Laboratory Fee Schedule,10.94,,,10.94,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.64,,,12.64,Fee Schedule,260% Medicaid Laboratory Fee Schedule,15.75,,,15.75,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.45,,,10.45,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.45,,,10.45,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.08,,,6.08,Fee Schedule,125% Medicaid Laboratory Fee Schedule,4.86,54.6,
OCCULT BLOOD OTHER SOURCES      ,82271,CPT,,40112260,CDM,301,RC,,,both,,,85,8.75,,,8.75,Other,150% of Medicare + 9.63% HCRA Surcharge,5.32,,,5.32,Fee Schedule,Mediare Clinical Lab,10.27,,,10.27,Fee Schedule,,9.26,,,9.26,Fee Schedule,,32.88,,,32.88,Fee Schedule,,29.59,,,29.59,Fee Schedule,,27.94,,,27.94,Fee Schedule,,42.5,50,,42.5,percent of total billed charges,All Other,11.25,,,11.25,Fee Schedule,,16.76,,,16.76,Fee Schedule,,56.01,,,56.01,Other,186% Medicaid methodology,19.74,,,19.74,Fee Schedule,,52.7,,,52.7,Fee Schedule,,11.17,,,11.17,Fee Schedule,,19.74,,,19.74,Fee Schedule,,52.7,,,52.7,Fee Schedule,,21.01,,,21.01,Fee Schedule,,59.5,70,,59.5,percent of total billed charges,All Other,25.37,,,25.37,Fee Schedule,,21.52,,,21.52,Fee Schedule,,6.38,,,6.38,Fee Schedule,,6.38,,,6.38,Fee Schedule,,6.38,,,6.38,Fee Schedule,,6.38,,,6.38,Fee Schedule,,30.11,,,30.11,Other,New York Medicaid APG methodology,30.11,,,30.11,Other,100% Medicaid APG methodology,30.11,,,30.11,Other,100% Medicaid APG methodology,30.11,,,30.11,Other,100% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,46.07,,,46.07,Other,153% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,42.16,,,42.16,Other,140% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,78.29,,,78.29,Other,260% Medicaid APG methodology,97.56,,,97.56,Other,324% Medicaid APG methodology,64.74,,,64.74,Other,215% Medicaid APG methodology,64.74,,,64.74,Other,215% Medicaid APG methodology,37.64,,,37.64,Other,125% Medicaid APG methodology,5.32,97.56,
ASSAY OF FETAL FIBRONECTIN      ,82731,CPT,,40112427,CDM,301,RC,,,both,,,1024,105.92,,,105.92,Other,150% of Medicare + 9.63% HCRA Surcharge,64.41,,,64.41,Fee Schedule,Mediare Clinical Lab,124.31,,,124.31,Fee Schedule,,112.07,,,112.07,Fee Schedule,,635.65,,,635.65,Fee Schedule,,571.9,,,571.9,Fee Schedule,,540.03,,,540.03,Fee Schedule,,512,50,,512,percent of total billed charges,All Other,136.08,,,136.08,Fee Schedule,,202.89,,,202.89,Fee Schedule,,119.8,,,119.8,Other,186% Medicaid methodology,238.96,,,238.96,Fee Schedule,,634.88,,,634.88,Fee Schedule,,135.26,,,135.26,Fee Schedule,,238.96,,,238.96,Fee Schedule,,634.88,,,634.88,Fee Schedule,,254.42,,,254.42,Fee Schedule,,716.8,70,,716.8,percent of total billed charges,All Other,307.1,,,307.1,Fee Schedule,,260.57,,,260.57,Fee Schedule,,77.29,,,77.29,Fee Schedule,,77.29,,,77.29,Fee Schedule,,77.29,,,77.29,Fee Schedule,,77.29,,,77.29,Fee Schedule,,64.41,,,64.41,Fee Schedule,Medicaid Laboratory Fee Schedule,64.41,,,64.41,Fee Schedule,100% Medicaid Laboratory Fee Schedule,64.41,,,64.41,Fee Schedule,100% Medicaid Laboratory Fee Schedule,64.41,,,64.41,Fee Schedule,100% Medicaid Laboratory Fee Schedule,144.92,,,144.92,Fee Schedule,225% Medicaid Laboratory Fee Schedule,144.92,,,144.92,Fee Schedule,225% Medicaid Laboratory Fee Schedule,98.55,,,98.55,Fee Schedule,153% Medicaid Laboratory Fee Schedule,144.92,,,144.92,Fee Schedule,225% Medicaid Laboratory Fee Schedule,90.17,,,90.17,Fee Schedule,140% Medicaid Laboratory Fee Schedule,144.92,,,144.92,Fee Schedule,225% Medicaid Laboratory Fee Schedule,167.47,,,167.47,Fee Schedule,260% Medicaid Laboratory Fee Schedule,208.69,,,208.69,Fee Schedule,324% Medicaid Laboratory Fee Schedule,138.48,,,138.48,Fee Schedule,215% Medicaid Laboratory Fee Schedule,138.48,,,138.48,Fee Schedule,215% Medicaid Laboratory Fee Schedule,80.51,,,80.51,Fee Schedule,125% Medicaid Laboratory Fee Schedule,64.41,716.8,
OCCULT BLD FECES 1-3 TESTS      ,82272,CPT,,40112500,CDM,301,RC,,,both,,,67,6.96,,,6.96,Other,150% of Medicare + 9.63% HCRA Surcharge,4.23,,,4.23,Fee Schedule,Mediare Clinical Lab,8.16,,,8.16,Fee Schedule,,7.36,,,7.36,Fee Schedule,,32.88,,,32.88,Fee Schedule,,29.59,,,29.59,Fee Schedule,,27.94,,,27.94,Fee Schedule,,33.5,50,,33.5,percent of total billed charges,All Other,8.94,,,8.94,Fee Schedule,,13.32,,,13.32,Fee Schedule,,56.01,,,56.01,Other,186% Medicaid methodology,15.69,,,15.69,Fee Schedule,,41.54,,,41.54,Fee Schedule,,8.88,,,8.88,Fee Schedule,,15.69,,,15.69,Fee Schedule,,41.54,,,41.54,Fee Schedule,,16.71,,,16.71,Fee Schedule,,46.9,70,,46.9,percent of total billed charges,All Other,20.17,,,20.17,Fee Schedule,,17.11,,,17.11,Fee Schedule,,5.08,,,5.08,Fee Schedule,,5.08,,,5.08,Fee Schedule,,5.08,,,5.08,Fee Schedule,,5.08,,,5.08,Fee Schedule,,30.11,,,30.11,Other,New York Medicaid APG methodology,30.11,,,30.11,Other,100% Medicaid APG methodology,30.11,,,30.11,Other,100% Medicaid APG methodology,30.11,,,30.11,Other,100% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,46.07,,,46.07,Other,153% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,42.16,,,42.16,Other,140% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,78.29,,,78.29,Other,260% Medicaid APG methodology,97.56,,,97.56,Other,324% Medicaid APG methodology,64.74,,,64.74,Other,215% Medicaid APG methodology,64.74,,,64.74,Other,215% Medicaid APG methodology,37.64,,,37.64,Other,125% Medicaid APG methodology,4.23,97.56,
FATS/LIPIDS FECES QUAL          ,82705,CPT,,40112849,CDM,301,RC,,,both,,,82,8.39,,,8.39,Other,150% of Medicare + 9.63% HCRA Surcharge,5.1,,,5.1,Fee Schedule,Mediare Clinical Lab,9.84,,,9.84,Fee Schedule,,8.87,,,8.87,Fee Schedule,,51.41,,,51.41,Fee Schedule,,46.25,,,46.25,Fee Schedule,,43.68,,,43.68,Fee Schedule,,41,50,,41,percent of total billed charges,All Other,10.79,,,10.79,Fee Schedule,,16.07,,,16.07,Fee Schedule,,9.49,,,9.49,Other,186% Medicaid methodology,18.92,,,18.92,Fee Schedule,,50.84,,,50.84,Fee Schedule,,10.71,,,10.71,Fee Schedule,,18.92,,,18.92,Fee Schedule,,50.84,,,50.84,Fee Schedule,,20.15,,,20.15,Fee Schedule,,57.4,70,,57.4,percent of total billed charges,All Other,24.32,,,24.32,Fee Schedule,,20.63,,,20.63,Fee Schedule,,6.12,,,6.12,Fee Schedule,,6.12,,,6.12,Fee Schedule,,6.12,,,6.12,Fee Schedule,,6.12,,,6.12,Fee Schedule,,5.1,,,5.1,Fee Schedule,Medicaid Laboratory Fee Schedule,5.1,,,5.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.1,,,5.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.1,,,5.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.48,,,11.48,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.48,,,11.48,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.8,,,7.8,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.48,,,11.48,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.14,,,7.14,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.48,,,11.48,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.26,,,13.26,Fee Schedule,260% Medicaid Laboratory Fee Schedule,16.52,,,16.52,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.97,,,10.97,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.97,,,10.97,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.38,,,6.38,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.1,57.4,
APT DOWNEY,83033,CPT,,40113003,CDM,301,RC,,,both,,,46,13.16,,,13.16,Other,150% of Medicare + 9.63% HCRA Surcharge,8,,,8,Fee Schedule,Mediare Clinical Lab,15.44,,,15.44,Fee Schedule,,13.92,,,13.92,Fee Schedule,,35.25,,,35.25,Fee Schedule,,31.72,,,31.72,Fee Schedule,,29.95,,,29.95,Fee Schedule,,23,50,,23,percent of total billed charges,All Other,16.9,,,16.9,Fee Schedule,,25.2,,,25.2,Fee Schedule,,56.01,,,56.01,Other,186% Medicaid methodology,29.68,,,29.68,Fee Schedule,,28.52,,,28.52,Fee Schedule,,16.8,,,16.8,Fee Schedule,,29.68,,,29.68,Fee Schedule,,28.52,,,28.52,Fee Schedule,,31.6,,,31.6,Fee Schedule,,32.2,70,,32.2,percent of total billed charges,All Other,38.14,,,38.14,Fee Schedule,,32.36,,,32.36,Fee Schedule,,9.6,,,9.6,Fee Schedule,,9.6,,,9.6,Fee Schedule,,9.6,,,9.6,Fee Schedule,,9.6,,,9.6,Fee Schedule,,30.11,,,30.11,Other,New York Medicaid APG methodology,30.11,,,30.11,Other,100% Medicaid APG methodology,30.11,,,30.11,Other,100% Medicaid APG methodology,30.11,,,30.11,Other,100% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,46.07,,,46.07,Other,153% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,42.16,,,42.16,Other,140% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,78.29,,,78.29,Other,260% Medicaid APG methodology,97.56,,,97.56,Other,324% Medicaid APG methodology,64.74,,,64.74,Other,215% Medicaid APG methodology,64.74,,,64.74,Other,215% Medicaid APG methodology,37.64,,,37.64,Other,125% Medicaid APG methodology,8,97.56,
CHEMILUMINESCENT ASSAY          ,82397,CPT,,40120032,CDM,301,RC,,,both,,,225,23.22,,,23.22,Other,150% of Medicare + 9.63% HCRA Surcharge,14.12,,,14.12,Fee Schedule,Mediare Clinical Lab,27.25,,,27.25,Fee Schedule,,24.57,,,24.57,Fee Schedule,,107.99,,,107.99,Fee Schedule,,97.16,,,97.16,Fee Schedule,,91.74,,,91.74,Fee Schedule,,112.5,50,,112.5,percent of total billed charges,All Other,29.84,,,29.84,Fee Schedule,,44.48,,,44.48,Fee Schedule,,65.35,,,65.35,Other,186% Medicaid methodology,52.39,,,52.39,Fee Schedule,,139.5,,,139.5,Fee Schedule,,29.65,,,29.65,Fee Schedule,,52.39,,,52.39,Fee Schedule,,139.5,,,139.5,Fee Schedule,,55.77,,,55.77,Fee Schedule,,157.5,70,,157.5,percent of total billed charges,All Other,67.32,,,67.32,Fee Schedule,,57.12,,,57.12,Fee Schedule,,16.94,,,16.94,Fee Schedule,,16.94,,,16.94,Fee Schedule,,16.94,,,16.94,Fee Schedule,,16.94,,,16.94,Fee Schedule,,35.13,,,35.13,Other,New York Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,53.75,,,53.75,Other,153% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,49.19,,,49.19,Other,140% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,91.35,,,91.35,Other,260% Medicaid APG methodology,113.83,,,113.83,Other,324% Medicaid APG methodology,75.54,,,75.54,Other,215% Medicaid APG methodology,75.54,,,75.54,Other,215% Medicaid APG methodology,43.92,,,43.92,Other,125% Medicaid APG methodology,14.12,157.5,
METABOLIC PANEL TOTAL CA        ,80048,CPT,,40120040,CDM,301,RC,,,both,,,135,13.91,,,13.91,Other,150% of Medicare + 9.63% HCRA Surcharge,8.46,,,8.46,Fee Schedule,Mediare Clinical Lab,16.33,,,16.33,Fee Schedule,,14.72,,,14.72,Fee Schedule,,64.55,,,64.55,Fee Schedule,,58.08,,,58.08,Fee Schedule,,54.84,,,54.84,Fee Schedule,,67.5,50,,67.5,percent of total billed charges,All Other,17.88,,,17.88,Fee Schedule,,26.65,,,26.65,Fee Schedule,,13.62,,,13.62,Other,186% Medicaid methodology,31.39,,,31.39,Fee Schedule,,83.7,,,83.7,Fee Schedule,,17.77,,,17.77,Fee Schedule,,31.39,,,31.39,Fee Schedule,,83.7,,,83.7,Fee Schedule,,33.42,,,33.42,Fee Schedule,,94.5,70,,94.5,percent of total billed charges,All Other,40.34,,,40.34,Fee Schedule,,34.23,,,34.23,Fee Schedule,,10.15,,,10.15,Fee Schedule,,10.15,,,10.15,Fee Schedule,,10.15,,,10.15,Fee Schedule,,10.15,,,10.15,Fee Schedule,,7.32,,,7.32,Fee Schedule,Medicaid Laboratory Fee Schedule,7.32,,,7.32,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.32,,,7.32,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.32,,,7.32,Fee Schedule,100% Medicaid Laboratory Fee Schedule,16.48,,,16.48,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.48,,,16.48,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.2,,,11.2,Fee Schedule,153% Medicaid Laboratory Fee Schedule,16.48,,,16.48,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.25,,,10.25,Fee Schedule,140% Medicaid Laboratory Fee Schedule,16.48,,,16.48,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.04,,,19.04,Fee Schedule,260% Medicaid Laboratory Fee Schedule,23.72,,,23.72,Fee Schedule,324% Medicaid Laboratory Fee Schedule,15.74,,,15.74,Fee Schedule,215% Medicaid Laboratory Fee Schedule,15.74,,,15.74,Fee Schedule,215% Medicaid Laboratory Fee Schedule,9.15,,,9.15,Fee Schedule,125% Medicaid Laboratory Fee Schedule,7.32,94.5,
BCR/ABL1 GENE MAJOR BP          ,81206,CPT,,40120099,CDM,301,RC,,,both,,,2607,269.62,,,269.62,Other,150% of Medicare + 9.63% HCRA Surcharge,163.96,,,163.96,Fee Schedule,Mediare Clinical Lab,316.44,,,316.44,Fee Schedule,,285.29,,,285.29,Fee Schedule,,24.24,,,24.24,Fee Schedule,,24.24,,,24.24,Fee Schedule,,24.24,,,24.24,Fee Schedule,,1303.5,50,,1303.5,percent of total billed charges,All Other,346.35,,,346.35,Fee Schedule,,516.47,,,516.47,Fee Schedule,,304.97,,,304.97,Other,186% Medicaid methodology,608.29,,,608.29,Fee Schedule,,1616.34,,,1616.34,Fee Schedule,,344.32,,,344.32,Fee Schedule,,608.29,,,608.29,Fee Schedule,,1616.34,,,1616.34,Fee Schedule,,647.64,,,647.64,Fee Schedule,,1824.9,70,,1824.9,percent of total billed charges,All Other,781.75,,,781.75,Fee Schedule,,663.3,,,663.3,Fee Schedule,,196.75,,,196.75,Fee Schedule,,196.75,,,196.75,Fee Schedule,,196.75,,,196.75,Fee Schedule,,196.75,,,196.75,Fee Schedule,,163.96,,,163.96,Fee Schedule,Medicaid Laboratory Fee Schedule,163.96,,,163.96,Fee Schedule,100% Medicaid Laboratory Fee Schedule,163.96,,,163.96,Fee Schedule,100% Medicaid Laboratory Fee Schedule,163.96,,,163.96,Fee Schedule,100% Medicaid Laboratory Fee Schedule,368.91,,,368.91,Fee Schedule,225% Medicaid Laboratory Fee Schedule,368.91,,,368.91,Fee Schedule,225% Medicaid Laboratory Fee Schedule,250.86,,,250.86,Fee Schedule,153% Medicaid Laboratory Fee Schedule,368.91,,,368.91,Fee Schedule,225% Medicaid Laboratory Fee Schedule,229.54,,,229.54,Fee Schedule,140% Medicaid Laboratory Fee Schedule,368.91,,,368.91,Fee Schedule,225% Medicaid Laboratory Fee Schedule,426.3,,,426.3,Fee Schedule,260% Medicaid Laboratory Fee Schedule,531.23,,,531.23,Fee Schedule,324% Medicaid Laboratory Fee Schedule,352.51,,,352.51,Fee Schedule,215% Medicaid Laboratory Fee Schedule,352.51,,,352.51,Fee Schedule,215% Medicaid Laboratory Fee Schedule,204.95,,,204.95,Fee Schedule,125% Medicaid Laboratory Fee Schedule,24.24,1824.9,
LIPID PANEL                     ,80061,CPT,,40120107,CDM,301,RC,,,both,,,214,22.02,,,22.02,Other,150% of Medicare + 9.63% HCRA Surcharge,13.39,,,13.39,Fee Schedule,Mediare Clinical Lab,25.84,,,25.84,Fee Schedule,,23.3,,,23.3,Fee Schedule,,135.34,,,135.34,Fee Schedule,,121.77,,,121.77,Fee Schedule,,114.99,,,114.99,Fee Schedule,,107,50,,107,percent of total billed charges,All Other,28.28,,,28.28,Fee Schedule,,42.18,,,42.18,Fee Schedule,,11.35,,,11.35,Other,186% Medicaid methodology,49.68,,,49.68,Fee Schedule,,132.68,,,132.68,Fee Schedule,,28.12,,,28.12,Fee Schedule,,49.68,,,49.68,Fee Schedule,,132.68,,,132.68,Fee Schedule,,52.89,,,52.89,Fee Schedule,,149.8,70,,149.8,percent of total billed charges,All Other,63.84,,,63.84,Fee Schedule,,54.17,,,54.17,Fee Schedule,,16.07,,,16.07,Fee Schedule,,16.07,,,16.07,Fee Schedule,,16.07,,,16.07,Fee Schedule,,16.07,,,16.07,Fee Schedule,,6.1,,,6.1,Fee Schedule,Medicaid Laboratory Fee Schedule,6.1,,,6.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.1,,,6.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.1,,,6.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.73,,,13.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.73,,,13.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.33,,,9.33,Fee Schedule,153% Medicaid Laboratory Fee Schedule,13.73,,,13.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.54,,,8.54,Fee Schedule,140% Medicaid Laboratory Fee Schedule,13.73,,,13.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.86,,,15.86,Fee Schedule,260% Medicaid Laboratory Fee Schedule,19.77,,,19.77,Fee Schedule,324% Medicaid Laboratory Fee Schedule,13.12,,,13.12,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.12,,,13.12,Fee Schedule,215% Medicaid Laboratory Fee Schedule,7.63,,,7.63,Fee Schedule,125% Medicaid Laboratory Fee Schedule,6.1,149.8,
ASSAY OF AMYLASE                ,82150,CPT,,40120149,CDM,301,RC,,,both,,,103,10.66,,,10.66,Other,150% of Medicare + 9.63% HCRA Surcharge,6.48,,,6.48,Fee Schedule,Mediare Clinical Lab,12.51,,,12.51,Fee Schedule,,11.28,,,11.28,Fee Schedule,,65.48,,,65.48,Fee Schedule,,58.92,,,58.92,Fee Schedule,,55.63,,,55.63,Fee Schedule,,51.5,50,,51.5,percent of total billed charges,All Other,13.68,,,13.68,Fee Schedule,,20.41,,,20.41,Fee Schedule,,9.45,,,9.45,Other,186% Medicaid methodology,24.04,,,24.04,Fee Schedule,,63.86,,,63.86,Fee Schedule,,13.61,,,13.61,Fee Schedule,,24.04,,,24.04,Fee Schedule,,63.86,,,63.86,Fee Schedule,,25.6,,,25.6,Fee Schedule,,72.1,70,,72.1,percent of total billed charges,All Other,30.9,,,30.9,Fee Schedule,,26.21,,,26.21,Fee Schedule,,7.78,,,7.78,Fee Schedule,,7.78,,,7.78,Fee Schedule,,7.78,,,7.78,Fee Schedule,,7.78,,,7.78,Fee Schedule,,5.08,,,5.08,Fee Schedule,Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.77,,,7.77,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.11,,,7.11,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.21,,,13.21,Fee Schedule,260% Medicaid Laboratory Fee Schedule,16.46,,,16.46,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.35,,,6.35,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.08,72.1,
ASSAY OF LIPASE                 ,83690,CPT,,40120164,CDM,301,RC,,,both,,,110,11.33,,,11.33,Other,150% of Medicare + 9.63% HCRA Surcharge,6.89,,,6.89,Fee Schedule,Mediare Clinical Lab,13.3,,,13.3,Fee Schedule,,11.99,,,11.99,Fee Schedule,,58.73,,,58.73,Fee Schedule,,52.84,,,52.84,Fee Schedule,,49.9,,,49.9,Fee Schedule,,55,50,,55,percent of total billed charges,All Other,14.56,,,14.56,Fee Schedule,,21.7,,,21.7,Fee Schedule,,10.8,,,10.8,Other,186% Medicaid methodology,25.56,,,25.56,Fee Schedule,,68.2,,,68.2,Fee Schedule,,14.47,,,14.47,Fee Schedule,,25.56,,,25.56,Fee Schedule,,68.2,,,68.2,Fee Schedule,,27.22,,,27.22,Fee Schedule,,77,70,,77,percent of total billed charges,All Other,32.85,,,32.85,Fee Schedule,,27.87,,,27.87,Fee Schedule,,8.27,,,8.27,Fee Schedule,,8.27,,,8.27,Fee Schedule,,8.27,,,8.27,Fee Schedule,,8.27,,,8.27,Fee Schedule,,5.81,,,5.81,Fee Schedule,Medicaid Laboratory Fee Schedule,5.81,,,5.81,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.81,,,5.81,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.81,,,5.81,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.07,,,13.07,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.07,,,13.07,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.89,,,8.89,Fee Schedule,153% Medicaid Laboratory Fee Schedule,13.07,,,13.07,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.13,,,8.13,Fee Schedule,140% Medicaid Laboratory Fee Schedule,13.07,,,13.07,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.1,,,15.1,Fee Schedule,260% Medicaid Laboratory Fee Schedule,18.82,,,18.82,Fee Schedule,324% Medicaid Laboratory Fee Schedule,12.49,,,12.49,Fee Schedule,215% Medicaid Laboratory Fee Schedule,12.49,,,12.49,Fee Schedule,215% Medicaid Laboratory Fee Schedule,7.26,,,7.26,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.81,77,
BRAF GENE                       ,81210,CPT,,40120172,CDM,301,RC,,,both,,,2789,288.44,,,288.44,Other,150% of Medicare + 9.63% HCRA Surcharge,175.4,,,175.4,Fee Schedule,Mediare Clinical Lab,338.52,,,338.52,Fee Schedule,,305.2,,,305.2,Fee Schedule,,35.94,,,35.94,Fee Schedule,,35.94,,,35.94,Fee Schedule,,35.94,,,35.94,Fee Schedule,,1394.5,50,,1394.5,percent of total billed charges,All Other,370.53,,,370.53,Fee Schedule,,552.51,,,552.51,Fee Schedule,,326.24,,,326.24,Other,186% Medicaid methodology,650.73,,,650.73,Fee Schedule,,1729.18,,,1729.18,Fee Schedule,,368.34,,,368.34,Fee Schedule,,650.73,,,650.73,Fee Schedule,,1729.18,,,1729.18,Fee Schedule,,692.83,,,692.83,Fee Schedule,,1952.3,70,,1952.3,percent of total billed charges,All Other,836.3,,,836.3,Fee Schedule,,709.58,,,709.58,Fee Schedule,,210.48,,,210.48,Fee Schedule,,210.48,,,210.48,Fee Schedule,,210.48,,,210.48,Fee Schedule,,210.48,,,210.48,Fee Schedule,,175.4,,,175.4,Fee Schedule,Medicaid Laboratory Fee Schedule,175.4,,,175.4,Fee Schedule,100% Medicaid Laboratory Fee Schedule,175.4,,,175.4,Fee Schedule,100% Medicaid Laboratory Fee Schedule,175.4,,,175.4,Fee Schedule,100% Medicaid Laboratory Fee Schedule,394.65,,,394.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,394.65,,,394.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,268.36,,,268.36,Fee Schedule,153% Medicaid Laboratory Fee Schedule,394.65,,,394.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,245.56,,,245.56,Fee Schedule,140% Medicaid Laboratory Fee Schedule,394.65,,,394.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,456.04,,,456.04,Fee Schedule,260% Medicaid Laboratory Fee Schedule,568.3,,,568.3,Fee Schedule,324% Medicaid Laboratory Fee Schedule,377.11,,,377.11,Fee Schedule,215% Medicaid Laboratory Fee Schedule,377.11,,,377.11,Fee Schedule,215% Medicaid Laboratory Fee Schedule,219.25,,,219.25,Fee Schedule,125% Medicaid Laboratory Fee Schedule,35.94,1952.3,
ASSAY OF CALCIUM TOTAL          ,82310,CPT,,40120180,CDM,301,RC,,,both,,,82,8.49,,,8.49,Other,150% of Medicare + 9.63% HCRA Surcharge,5.16,,,5.16,Fee Schedule,Mediare Clinical Lab,9.96,,,9.96,Fee Schedule,,8.98,,,8.98,Fee Schedule,,52.13,,,52.13,Fee Schedule,,46.9,,,46.9,Fee Schedule,,44.29,,,44.29,Fee Schedule,,41,50,,41,percent of total billed charges,All Other,10.89,,,10.89,Fee Schedule,,16.25,,,16.25,Fee Schedule,,9.45,,,9.45,Other,186% Medicaid methodology,19.14,,,19.14,Fee Schedule,,50.84,,,50.84,Fee Schedule,,10.84,,,10.84,Fee Schedule,,19.14,,,19.14,Fee Schedule,,50.84,,,50.84,Fee Schedule,,20.38,,,20.38,Fee Schedule,,57.4,70,,57.4,percent of total billed charges,All Other,24.6,,,24.6,Fee Schedule,,20.87,,,20.87,Fee Schedule,,6.19,,,6.19,Fee Schedule,,6.19,,,6.19,Fee Schedule,,6.19,,,6.19,Fee Schedule,,6.19,,,6.19,Fee Schedule,,5.08,,,5.08,Fee Schedule,Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.77,,,7.77,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.11,,,7.11,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.21,,,13.21,Fee Schedule,260% Medicaid Laboratory Fee Schedule,16.46,,,16.46,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.35,,,6.35,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.08,57.4,
ASSAY OF BLOOD LIPOPROTEIN      ,83721,CPT,,40120198,CDM,301,RC,,,both,,,168,17.27,,,17.27,Other,150% of Medicare + 9.63% HCRA Surcharge,10.5,,,10.5,Fee Schedule,Mediare Clinical Lab,20.27,,,20.27,Fee Schedule,,18.27,,,18.27,Fee Schedule,,96.36,,,96.36,Fee Schedule,,86.69,,,86.69,Fee Schedule,,81.86,,,81.86,Fee Schedule,,84,50,,84,percent of total billed charges,All Other,22.2,,,22.2,Fee Schedule,,33.08,,,33.08,Fee Schedule,,56.01,,,56.01,Other,186% Medicaid methodology,38.96,,,38.96,Fee Schedule,,104.16,,,104.16,Fee Schedule,,22.05,,,22.05,Fee Schedule,,38.96,,,38.96,Fee Schedule,,104.16,,,104.16,Fee Schedule,,41.48,,,41.48,Fee Schedule,,117.6,70,,117.6,percent of total billed charges,All Other,50.06,,,50.06,Fee Schedule,,42.48,,,42.48,Fee Schedule,,12.6,,,12.6,Fee Schedule,,12.6,,,12.6,Fee Schedule,,12.6,,,12.6,Fee Schedule,,12.6,,,12.6,Fee Schedule,,30.11,,,30.11,Other,New York Medicaid APG methodology,30.11,,,30.11,Other,100% Medicaid APG methodology,30.11,,,30.11,Other,100% Medicaid APG methodology,30.11,,,30.11,Other,100% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,46.07,,,46.07,Other,153% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,42.16,,,42.16,Other,140% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,78.29,,,78.29,Other,260% Medicaid APG methodology,97.56,,,97.56,Other,324% Medicaid APG methodology,64.74,,,64.74,Other,215% Medicaid APG methodology,64.74,,,64.74,Other,215% Medicaid APG methodology,37.64,,,37.64,Other,125% Medicaid APG methodology,10.5,117.6,
ASSAY OF PHOSPHORUS             ,84100,CPT,,40120206,CDM,301,RC,,,both,,,76,7.79,,,7.79,Other,150% of Medicare + 9.63% HCRA Surcharge,4.74,,,4.74,Fee Schedule,Mediare Clinical Lab,9.15,,,9.15,Fee Schedule,,8.25,,,8.25,Fee Schedule,,47.89,,,47.89,Fee Schedule,,43.09,,,43.09,Fee Schedule,,40.69,,,40.69,Fee Schedule,,38,50,,38,percent of total billed charges,All Other,10.01,,,10.01,Fee Schedule,,14.93,,,14.93,Fee Schedule,,8.82,,,8.82,Other,186% Medicaid methodology,17.59,,,17.59,Fee Schedule,,47.12,,,47.12,Fee Schedule,,9.95,,,9.95,Fee Schedule,,17.59,,,17.59,Fee Schedule,,47.12,,,47.12,Fee Schedule,,18.72,,,18.72,Fee Schedule,,53.2,70,,53.2,percent of total billed charges,All Other,22.6,,,22.6,Fee Schedule,,19.18,,,19.18,Fee Schedule,,5.69,,,5.69,Fee Schedule,,5.69,,,5.69,Fee Schedule,,5.69,,,5.69,Fee Schedule,,5.69,,,5.69,Fee Schedule,,4.74,,,4.74,Fee Schedule,Medicaid Laboratory Fee Schedule,4.74,,,4.74,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.74,,,4.74,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.74,,,4.74,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.67,,,10.67,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.67,,,10.67,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.25,,,7.25,Fee Schedule,153% Medicaid Laboratory Fee Schedule,10.67,,,10.67,Fee Schedule,225% Medicaid Laboratory Fee Schedule,6.64,,,6.64,Fee Schedule,140% Medicaid Laboratory Fee Schedule,10.67,,,10.67,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.32,,,12.32,Fee Schedule,260% Medicaid Laboratory Fee Schedule,15.36,,,15.36,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.19,,,10.19,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.19,,,10.19,Fee Schedule,215% Medicaid Laboratory Fee Schedule,5.93,,,5.93,Fee Schedule,125% Medicaid Laboratory Fee Schedule,4.74,53.2,
ASSAY OF MAGNESIUM              ,83735,CPT,,40120222,CDM,301,RC,,,both,,,108,11.02,,,11.02,Other,150% of Medicare + 9.63% HCRA Surcharge,6.7,,,6.7,Fee Schedule,Mediare Clinical Lab,12.93,,,12.93,Fee Schedule,,11.66,,,11.66,Fee Schedule,,67.71,,,67.71,Fee Schedule,,60.92,,,60.92,Fee Schedule,,57.52,,,57.52,Fee Schedule,,54,50,,54,percent of total billed charges,All Other,14.17,,,14.17,Fee Schedule,,21.11,,,21.11,Fee Schedule,,9.45,,,9.45,Other,186% Medicaid methodology,24.86,,,24.86,Fee Schedule,,66.96,,,66.96,Fee Schedule,,14.07,,,14.07,Fee Schedule,,24.86,,,24.86,Fee Schedule,,66.96,,,66.96,Fee Schedule,,26.47,,,26.47,Fee Schedule,,75.6,70,,75.6,percent of total billed charges,All Other,31.95,,,31.95,Fee Schedule,,27.1,,,27.1,Fee Schedule,,8.04,,,8.04,Fee Schedule,,8.04,,,8.04,Fee Schedule,,8.04,,,8.04,Fee Schedule,,8.04,,,8.04,Fee Schedule,,5.08,,,5.08,Fee Schedule,Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.77,,,7.77,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.11,,,7.11,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.21,,,13.21,Fee Schedule,260% Medicaid Laboratory Fee Schedule,16.46,,,16.46,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.35,,,6.35,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.08,75.6,
ASSAY OF BLOOD OSMOLALITY       ,83930,CPT,,40120248,CDM,301,RC,,,both,,,105,10.87,,,10.87,Other,150% of Medicare + 9.63% HCRA Surcharge,6.61,,,6.61,Fee Schedule,Mediare Clinical Lab,12.76,,,12.76,Fee Schedule,,11.5,,,11.5,Fee Schedule,,66.77,,,66.77,Fee Schedule,,60.08,,,60.08,Fee Schedule,,56.73,,,56.73,Fee Schedule,,52.5,50,,52.5,percent of total billed charges,All Other,13.98,,,13.98,Fee Schedule,,20.82,,,20.82,Fee Schedule,,11.35,,,11.35,Other,186% Medicaid methodology,24.52,,,24.52,Fee Schedule,,65.1,,,65.1,Fee Schedule,,13.88,,,13.88,Fee Schedule,,24.52,,,24.52,Fee Schedule,,65.1,,,65.1,Fee Schedule,,26.11,,,26.11,Fee Schedule,,73.5,70,,73.5,percent of total billed charges,All Other,31.52,,,31.52,Fee Schedule,,26.74,,,26.74,Fee Schedule,,7.93,,,7.93,Fee Schedule,,7.93,,,7.93,Fee Schedule,,7.93,,,7.93,Fee Schedule,,7.93,,,7.93,Fee Schedule,,6.1,,,6.1,Fee Schedule,Medicaid Laboratory Fee Schedule,6.1,,,6.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.1,,,6.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.1,,,6.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.73,,,13.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.73,,,13.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.33,,,9.33,Fee Schedule,153% Medicaid Laboratory Fee Schedule,13.73,,,13.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.54,,,8.54,Fee Schedule,140% Medicaid Laboratory Fee Schedule,13.73,,,13.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.86,,,15.86,Fee Schedule,260% Medicaid Laboratory Fee Schedule,19.77,,,19.77,Fee Schedule,324% Medicaid Laboratory Fee Schedule,13.12,,,13.12,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.12,,,13.12,Fee Schedule,215% Medicaid Laboratory Fee Schedule,7.63,,,7.63,Fee Schedule,125% Medicaid Laboratory Fee Schedule,6.1,73.5,
ACETONE ASSAY                   ,82010,CPT,,40120255,CDM,301,RC,,,both,,,131,13.44,,,13.44,Other,150% of Medicare + 9.63% HCRA Surcharge,8.17,,,8.17,Fee Schedule,Mediare Clinical Lab,15.77,,,15.77,Fee Schedule,,14.22,,,14.22,Fee Schedule,,82.57,,,82.57,Fee Schedule,,74.29,,,74.29,Fee Schedule,,70.15,,,70.15,Fee Schedule,,65.5,50,,65.5,percent of total billed charges,All Other,17.26,,,17.26,Fee Schedule,,25.74,,,25.74,Fee Schedule,,56.01,,,56.01,Other,186% Medicaid methodology,30.31,,,30.31,Fee Schedule,,81.22,,,81.22,Fee Schedule,,17.16,,,17.16,Fee Schedule,,30.31,,,30.31,Fee Schedule,,81.22,,,81.22,Fee Schedule,,32.27,,,32.27,Fee Schedule,,91.7,70,,91.7,percent of total billed charges,All Other,38.95,,,38.95,Fee Schedule,,33.05,,,33.05,Fee Schedule,,9.8,,,9.8,Fee Schedule,,9.8,,,9.8,Fee Schedule,,9.8,,,9.8,Fee Schedule,,9.8,,,9.8,Fee Schedule,,30.11,,,30.11,Other,New York Medicaid APG methodology,30.11,,,30.11,Other,100% Medicaid APG methodology,30.11,,,30.11,Other,100% Medicaid APG methodology,30.11,,,30.11,Other,100% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,46.07,,,46.07,Other,153% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,42.16,,,42.16,Other,140% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,78.29,,,78.29,Other,260% Medicaid APG methodology,97.56,,,97.56,Other,324% Medicaid APG methodology,64.74,,,64.74,Other,215% Medicaid APG methodology,64.74,,,64.74,Other,215% Medicaid APG methodology,37.64,,,37.64,Other,125% Medicaid APG methodology,8.17,97.56,
ASSAY OF PROTEIN SERUM          ,84155,CPT,,40120263,CDM,301,RC,,,both,,,59,6.04,,,6.04,Other,150% of Medicare + 9.63% HCRA Surcharge,3.67,,,3.67,Fee Schedule,Mediare Clinical Lab,7.08,,,7.08,Fee Schedule,,6.39,,,6.39,Fee Schedule,,37.05,,,37.05,Fee Schedule,,33.33,,,33.33,Fee Schedule,,31.48,,,31.48,Fee Schedule,,29.5,50,,29.5,percent of total billed charges,All Other,7.77,,,7.77,Fee Schedule,,11.56,,,11.56,Fee Schedule,,6.83,,,6.83,Other,186% Medicaid methodology,13.62,,,13.62,Fee Schedule,,36.58,,,36.58,Fee Schedule,,7.71,,,7.71,Fee Schedule,,13.62,,,13.62,Fee Schedule,,36.58,,,36.58,Fee Schedule,,14.5,,,14.5,Fee Schedule,,41.3,70,,41.3,percent of total billed charges,All Other,17.5,,,17.5,Fee Schedule,,14.85,,,14.85,Fee Schedule,,4.4,,,4.4,Fee Schedule,,4.4,,,4.4,Fee Schedule,,4.4,,,4.4,Fee Schedule,,4.4,,,4.4,Fee Schedule,,3.67,,,3.67,Fee Schedule,Medicaid Laboratory Fee Schedule,3.67,,,3.67,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.67,,,3.67,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.67,,,3.67,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.26,,,8.26,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.26,,,8.26,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.62,,,5.62,Fee Schedule,153% Medicaid Laboratory Fee Schedule,8.26,,,8.26,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.14,,,5.14,Fee Schedule,140% Medicaid Laboratory Fee Schedule,8.26,,,8.26,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.54,,,9.54,Fee Schedule,260% Medicaid Laboratory Fee Schedule,11.89,,,11.89,Fee Schedule,324% Medicaid Laboratory Fee Schedule,7.89,,,7.89,Fee Schedule,215% Medicaid Laboratory Fee Schedule,7.89,,,7.89,Fee Schedule,215% Medicaid Laboratory Fee Schedule,4.59,,,4.59,Fee Schedule,125% Medicaid Laboratory Fee Schedule,3.67,41.3,
ASSAY OF LDH ENZYMES            ,83625,CPT,,40120271,CDM,301,RC,,,both,,,204,21.03,,,21.03,Other,150% of Medicare + 9.63% HCRA Surcharge,12.79,,,12.79,Fee Schedule,Mediare Clinical Lab,24.68,,,24.68,Fee Schedule,,22.25,,,22.25,Fee Schedule,,88.39,,,88.39,Fee Schedule,,79.52,,,79.52,Fee Schedule,,75.09,,,75.09,Fee Schedule,,102,50,,102,percent of total billed charges,All Other,27.01,,,27.01,Fee Schedule,,40.29,,,40.29,Fee Schedule,,17.66,,,17.66,Other,186% Medicaid methodology,47.45,,,47.45,Fee Schedule,,126.48,,,126.48,Fee Schedule,,26.86,,,26.86,Fee Schedule,,47.45,,,47.45,Fee Schedule,,126.48,,,126.48,Fee Schedule,,50.52,,,50.52,Fee Schedule,,142.8,70,,142.8,percent of total billed charges,All Other,60.98,,,60.98,Fee Schedule,,51.74,,,51.74,Fee Schedule,,15.35,,,15.35,Fee Schedule,,15.35,,,15.35,Fee Schedule,,15.35,,,15.35,Fee Schedule,,15.35,,,15.35,Fee Schedule,,9.49,,,9.49,Fee Schedule,Medicaid Laboratory Fee Schedule,9.49,,,9.49,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.49,,,9.49,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.49,,,9.49,Fee Schedule,100% Medicaid Laboratory Fee Schedule,21.36,,,21.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.36,,,21.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.53,,,14.53,Fee Schedule,153% Medicaid Laboratory Fee Schedule,21.36,,,21.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.29,,,13.29,Fee Schedule,140% Medicaid Laboratory Fee Schedule,21.36,,,21.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,24.68,,,24.68,Fee Schedule,260% Medicaid Laboratory Fee Schedule,30.76,,,30.76,Fee Schedule,324% Medicaid Laboratory Fee Schedule,20.41,,,20.41,Fee Schedule,215% Medicaid Laboratory Fee Schedule,20.41,,,20.41,Fee Schedule,215% Medicaid Laboratory Fee Schedule,11.87,,,11.87,Fee Schedule,125% Medicaid Laboratory Fee Schedule,9.49,142.8,
ASSAY OF SERUM ALBUMIN          ,82040,CPT,,40120289,CDM,301,RC,,,both,,,79,8.14,,,8.14,Other,150% of Medicare + 9.63% HCRA Surcharge,4.95,,,4.95,Fee Schedule,Mediare Clinical Lab,9.55,,,9.55,Fee Schedule,,8.61,,,8.61,Fee Schedule,,49.97,,,49.97,Fee Schedule,,44.96,,,44.96,Fee Schedule,,42.46,,,42.46,Fee Schedule,,39.5,50,,39.5,percent of total billed charges,All Other,10.47,,,10.47,Fee Schedule,,15.59,,,15.59,Fee Schedule,,9.21,,,9.21,Other,186% Medicaid methodology,18.36,,,18.36,Fee Schedule,,48.98,,,48.98,Fee Schedule,,10.4,,,10.4,Fee Schedule,,18.36,,,18.36,Fee Schedule,,48.98,,,48.98,Fee Schedule,,19.55,,,19.55,Fee Schedule,,55.3,70,,55.3,percent of total billed charges,All Other,23.6,,,23.6,Fee Schedule,,20.03,,,20.03,Fee Schedule,,5.94,,,5.94,Fee Schedule,,5.94,,,5.94,Fee Schedule,,5.94,,,5.94,Fee Schedule,,5.94,,,5.94,Fee Schedule,,4.95,,,4.95,Fee Schedule,Medicaid Laboratory Fee Schedule,4.95,,,4.95,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.95,,,4.95,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.95,,,4.95,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.14,,,11.14,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.14,,,11.14,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.57,,,7.57,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.14,,,11.14,Fee Schedule,225% Medicaid Laboratory Fee Schedule,6.93,,,6.93,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.14,,,11.14,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.87,,,12.87,Fee Schedule,260% Medicaid Laboratory Fee Schedule,16.04,,,16.04,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.64,,,10.64,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.64,,,10.64,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.19,,,6.19,Fee Schedule,125% Medicaid Laboratory Fee Schedule,4.95,55.3,
BILIRUBIN TOTAL                 ,82247,CPT,,40120305,CDM,301,RC,,,both,,,80,8.26,,,8.26,Other,150% of Medicare + 9.63% HCRA Surcharge,5.02,,,5.02,Fee Schedule,Mediare Clinical Lab,9.69,,,9.69,Fee Schedule,,8.73,,,8.73,Fee Schedule,,50.69,,,50.69,Fee Schedule,,45.61,,,45.61,Fee Schedule,,43.07,,,43.07,Fee Schedule,,40,50,,40,percent of total billed charges,All Other,10.6,,,10.6,Fee Schedule,,15.81,,,15.81,Fee Schedule,,9.34,,,9.34,Other,186% Medicaid methodology,18.62,,,18.62,Fee Schedule,,49.6,,,49.6,Fee Schedule,,10.54,,,10.54,Fee Schedule,,18.62,,,18.62,Fee Schedule,,49.6,,,49.6,Fee Schedule,,19.83,,,19.83,Fee Schedule,,56,70,,56,percent of total billed charges,All Other,23.94,,,23.94,Fee Schedule,,20.31,,,20.31,Fee Schedule,,6.02,,,6.02,Fee Schedule,,6.02,,,6.02,Fee Schedule,,6.02,,,6.02,Fee Schedule,,6.02,,,6.02,Fee Schedule,,5.02,,,5.02,Fee Schedule,Medicaid Laboratory Fee Schedule,5.02,,,5.02,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.02,,,5.02,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.02,,,5.02,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.3,,,11.3,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.3,,,11.3,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.68,,,7.68,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.3,,,11.3,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.03,,,7.03,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.3,,,11.3,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.05,,,13.05,Fee Schedule,260% Medicaid Laboratory Fee Schedule,16.26,,,16.26,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.79,,,10.79,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.79,,,10.79,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.28,,,6.28,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.02,56,
BILIRUBIN DIRECT                ,82248,CPT,,40120321,CDM,301,RC,,,both,,,80,8.26,,,8.26,Other,150% of Medicare + 9.63% HCRA Surcharge,5.02,,,5.02,Fee Schedule,Mediare Clinical Lab,9.69,,,9.69,Fee Schedule,,8.73,,,8.73,Fee Schedule,,50.69,,,50.69,Fee Schedule,,45.61,,,45.61,Fee Schedule,,43.07,,,43.07,Fee Schedule,,40,50,,40,percent of total billed charges,All Other,10.6,,,10.6,Fee Schedule,,15.81,,,15.81,Fee Schedule,,9.34,,,9.34,Other,186% Medicaid methodology,18.62,,,18.62,Fee Schedule,,49.6,,,49.6,Fee Schedule,,10.54,,,10.54,Fee Schedule,,18.62,,,18.62,Fee Schedule,,49.6,,,49.6,Fee Schedule,,19.83,,,19.83,Fee Schedule,,56,70,,56,percent of total billed charges,All Other,23.94,,,23.94,Fee Schedule,,20.31,,,20.31,Fee Schedule,,6.02,,,6.02,Fee Schedule,,6.02,,,6.02,Fee Schedule,,6.02,,,6.02,Fee Schedule,,6.02,,,6.02,Fee Schedule,,5.02,,,5.02,Fee Schedule,Medicaid Laboratory Fee Schedule,5.02,,,5.02,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.02,,,5.02,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.02,,,5.02,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.3,,,11.3,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.3,,,11.3,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.68,,,7.68,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.3,,,11.3,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.03,,,7.03,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.3,,,11.3,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.05,,,13.05,Fee Schedule,260% Medicaid Laboratory Fee Schedule,16.26,,,16.26,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.79,,,10.79,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.79,,,10.79,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.28,,,6.28,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.02,56,
CFTR GENE COM VARIANTS          ,81220,CPT,,40120339,CDM,301,RC,,,both,,,8850,915.3,,,915.3,Other,150% of Medicare + 9.63% HCRA Surcharge,556.6,,,556.6,Fee Schedule,Mediare Clinical Lab,1074.24,,,1074.24,Fee Schedule,,968.48,,,968.48,Fee Schedule,,179.18,,,179.18,Fee Schedule,,179.18,,,179.18,Fee Schedule,,179.18,,,179.18,Fee Schedule,,4425,50,,4425,percent of total billed charges,All Other,1175.82,,,1175.82,Fee Schedule,,1753.29,,,1753.29,Fee Schedule,,610.55,,,610.55,Other,186% Medicaid methodology,2064.99,,,2064.99,Fee Schedule,,5487,,,5487,Fee Schedule,,1168.86,,,1168.86,Fee Schedule,,2064.99,,,2064.99,Fee Schedule,,5487,,,5487,Fee Schedule,,2198.57,,,2198.57,Fee Schedule,,6195,70,,6195,percent of total billed charges,All Other,2653.83,,,2653.83,Fee Schedule,,2251.74,,,2251.74,Fee Schedule,,667.92,,,667.92,Fee Schedule,,667.92,,,667.92,Fee Schedule,,667.92,,,667.92,Fee Schedule,,667.92,,,667.92,Fee Schedule,,328.25,,,328.25,Fee Schedule,Medicaid Laboratory Fee Schedule,328.25,,,328.25,Fee Schedule,100% Medicaid Laboratory Fee Schedule,328.25,,,328.25,Fee Schedule,100% Medicaid Laboratory Fee Schedule,328.25,,,328.25,Fee Schedule,100% Medicaid Laboratory Fee Schedule,738.56,,,738.56,Fee Schedule,225% Medicaid Laboratory Fee Schedule,738.56,,,738.56,Fee Schedule,225% Medicaid Laboratory Fee Schedule,502.22,,,502.22,Fee Schedule,153% Medicaid Laboratory Fee Schedule,738.56,,,738.56,Fee Schedule,225% Medicaid Laboratory Fee Schedule,459.55,,,459.55,Fee Schedule,140% Medicaid Laboratory Fee Schedule,738.56,,,738.56,Fee Schedule,225% Medicaid Laboratory Fee Schedule,853.45,,,853.45,Fee Schedule,260% Medicaid Laboratory Fee Schedule,1063.53,,,1063.53,Fee Schedule,324% Medicaid Laboratory Fee Schedule,705.74,,,705.74,Fee Schedule,215% Medicaid Laboratory Fee Schedule,705.74,,,705.74,Fee Schedule,215% Medicaid Laboratory Fee Schedule,410.31,,,410.31,Fee Schedule,125% Medicaid Laboratory Fee Schedule,179.18,6195,
ASSAY ALKALINE PHOSPHATASE      ,84075,CPT,,40120347,CDM,301,RC,,,both,,,83,8.52,,,8.52,Other,150% of Medicare + 9.63% HCRA Surcharge,5.18,,,5.18,Fee Schedule,Mediare Clinical Lab,10,,,10,Fee Schedule,,9.01,,,9.01,Fee Schedule,,52.27,,,52.27,Fee Schedule,,47.03,,,47.03,Fee Schedule,,44.41,,,44.41,Fee Schedule,,41.5,50,,41.5,percent of total billed charges,All Other,10.95,,,10.95,Fee Schedule,,16.32,,,16.32,Fee Schedule,,9.45,,,9.45,Other,186% Medicaid methodology,19.22,,,19.22,Fee Schedule,,51.46,,,51.46,Fee Schedule,,10.88,,,10.88,Fee Schedule,,19.22,,,19.22,Fee Schedule,,51.46,,,51.46,Fee Schedule,,20.46,,,20.46,Fee Schedule,,58.1,70,,58.1,percent of total billed charges,All Other,24.7,,,24.7,Fee Schedule,,20.96,,,20.96,Fee Schedule,,6.22,,,6.22,Fee Schedule,,6.22,,,6.22,Fee Schedule,,6.22,,,6.22,Fee Schedule,,6.22,,,6.22,Fee Schedule,,5.08,,,5.08,Fee Schedule,Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.77,,,7.77,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.11,,,7.11,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.21,,,13.21,Fee Schedule,260% Medicaid Laboratory Fee Schedule,16.46,,,16.46,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.35,,,6.35,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.08,58.1,
ASSAY OF AMMONIA                ,82140,CPT,,40120362,CDM,301,RC,,,both,,,233,23.96,,,23.96,Other,150% of Medicare + 9.63% HCRA Surcharge,14.57,,,14.57,Fee Schedule,Mediare Clinical Lab,28.12,,,28.12,Fee Schedule,,25.35,,,25.35,Fee Schedule,,147.26,,,147.26,Fee Schedule,,132.49,,,132.49,Fee Schedule,,125.11,,,125.11,Fee Schedule,,116.5,50,,116.5,percent of total billed charges,All Other,30.78,,,30.78,Fee Schedule,,45.9,,,45.9,Fee Schedule,,27.1,,,27.1,Other,186% Medicaid methodology,54.05,,,54.05,Fee Schedule,,144.46,,,144.46,Fee Schedule,,30.6,,,30.6,Fee Schedule,,54.05,,,54.05,Fee Schedule,,144.46,,,144.46,Fee Schedule,,57.55,,,57.55,Fee Schedule,,163.1,70,,163.1,percent of total billed charges,All Other,69.47,,,69.47,Fee Schedule,,58.94,,,58.94,Fee Schedule,,17.48,,,17.48,Fee Schedule,,17.48,,,17.48,Fee Schedule,,17.48,,,17.48,Fee Schedule,,17.48,,,17.48,Fee Schedule,,14.57,,,14.57,Fee Schedule,Medicaid Laboratory Fee Schedule,14.57,,,14.57,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.57,,,14.57,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.57,,,14.57,Fee Schedule,100% Medicaid Laboratory Fee Schedule,32.78,,,32.78,Fee Schedule,225% Medicaid Laboratory Fee Schedule,32.78,,,32.78,Fee Schedule,225% Medicaid Laboratory Fee Schedule,22.29,,,22.29,Fee Schedule,153% Medicaid Laboratory Fee Schedule,32.78,,,32.78,Fee Schedule,225% Medicaid Laboratory Fee Schedule,20.4,,,20.4,Fee Schedule,140% Medicaid Laboratory Fee Schedule,32.78,,,32.78,Fee Schedule,225% Medicaid Laboratory Fee Schedule,37.88,,,37.88,Fee Schedule,260% Medicaid Laboratory Fee Schedule,47.21,,,47.21,Fee Schedule,324% Medicaid Laboratory Fee Schedule,31.33,,,31.33,Fee Schedule,215% Medicaid Laboratory Fee Schedule,31.33,,,31.33,Fee Schedule,215% Medicaid Laboratory Fee Schedule,18.21,,,18.21,Fee Schedule,125% Medicaid Laboratory Fee Schedule,14.57,163.1,
ASSAY OF CREATININE             ,82565,CPT,,40120388,CDM,301,RC,,,both,,,82,8.42,,,8.42,Other,150% of Medicare + 9.63% HCRA Surcharge,5.12,,,5.12,Fee Schedule,Mediare Clinical Lab,9.88,,,9.88,Fee Schedule,,8.91,,,8.91,Fee Schedule,,51.84,,,51.84,Fee Schedule,,46.64,,,46.64,Fee Schedule,,44.04,,,44.04,Fee Schedule,,41,50,,41,percent of total billed charges,All Other,10.82,,,10.82,Fee Schedule,,16.13,,,16.13,Fee Schedule,,9.45,,,9.45,Other,186% Medicaid methodology,19,,,19,Fee Schedule,,50.84,,,50.84,Fee Schedule,,10.75,,,10.75,Fee Schedule,,19,,,19,Fee Schedule,,50.84,,,50.84,Fee Schedule,,20.22,,,20.22,Fee Schedule,,57.4,70,,57.4,percent of total billed charges,All Other,24.41,,,24.41,Fee Schedule,,20.71,,,20.71,Fee Schedule,,6.14,,,6.14,Fee Schedule,,6.14,,,6.14,Fee Schedule,,6.14,,,6.14,Fee Schedule,,6.14,,,6.14,Fee Schedule,,5.08,,,5.08,Fee Schedule,Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.77,,,7.77,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.11,,,7.11,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.21,,,13.21,Fee Schedule,260% Medicaid Laboratory Fee Schedule,16.46,,,16.46,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.35,,,6.35,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.08,57.4,
ASSAY OF CK (CPK)               ,82550,CPT,,40120404,CDM,301,RC,,,both,,,104,10.71,,,10.71,Other,150% of Medicare + 9.63% HCRA Surcharge,6.51,,,6.51,Fee Schedule,Mediare Clinical Lab,12.56,,,12.56,Fee Schedule,,11.33,,,11.33,Fee Schedule,,65.84,,,65.84,Fee Schedule,,59.24,,,59.24,Fee Schedule,,55.94,,,55.94,Fee Schedule,,52,50,,52,percent of total billed charges,All Other,13.75,,,13.75,Fee Schedule,,20.51,,,20.51,Fee Schedule,,9.45,,,9.45,Other,186% Medicaid methodology,24.15,,,24.15,Fee Schedule,,64.48,,,64.48,Fee Schedule,,13.67,,,13.67,Fee Schedule,,24.15,,,24.15,Fee Schedule,,64.48,,,64.48,Fee Schedule,,25.71,,,25.71,Fee Schedule,,72.8,70,,72.8,percent of total billed charges,All Other,31.04,,,31.04,Fee Schedule,,26.34,,,26.34,Fee Schedule,,7.81,,,7.81,Fee Schedule,,7.81,,,7.81,Fee Schedule,,7.81,,,7.81,Fee Schedule,,7.81,,,7.81,Fee Schedule,,5.08,,,5.08,Fee Schedule,Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.77,,,7.77,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.11,,,7.11,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.21,,,13.21,Fee Schedule,260% Medicaid Laboratory Fee Schedule,16.46,,,16.46,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.35,,,6.35,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.08,72.8,
ASSAY BLD/SERUM CHOLESTEROL     ,82465,CPT,,40120420,CDM,301,RC,,,both,,,69,7.15,,,7.15,Other,150% of Medicare + 9.63% HCRA Surcharge,4.35,,,4.35,Fee Schedule,Mediare Clinical Lab,8.4,,,8.4,Fee Schedule,,7.57,,,7.57,Fee Schedule,,44.01,,,44.01,Fee Schedule,,39.6,,,39.6,Fee Schedule,,37.39,,,37.39,Fee Schedule,,34.5,50,,34.5,percent of total billed charges,All Other,9.2,,,9.2,Fee Schedule,,13.7,,,13.7,Fee Schedule,,8.09,,,8.09,Other,186% Medicaid methodology,16.14,,,16.14,Fee Schedule,,42.78,,,42.78,Fee Schedule,,9.14,,,9.14,Fee Schedule,,16.14,,,16.14,Fee Schedule,,42.78,,,42.78,Fee Schedule,,17.18,,,17.18,Fee Schedule,,48.3,70,,48.3,percent of total billed charges,All Other,20.74,,,20.74,Fee Schedule,,17.6,,,17.6,Fee Schedule,,5.22,,,5.22,Fee Schedule,,5.22,,,5.22,Fee Schedule,,5.22,,,5.22,Fee Schedule,,5.22,,,5.22,Fee Schedule,,4.35,,,4.35,Fee Schedule,Medicaid Laboratory Fee Schedule,4.35,,,4.35,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.35,,,4.35,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.35,,,4.35,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.79,,,9.79,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.79,,,9.79,Fee Schedule,225% Medicaid Laboratory Fee Schedule,6.66,,,6.66,Fee Schedule,153% Medicaid Laboratory Fee Schedule,9.79,,,9.79,Fee Schedule,225% Medicaid Laboratory Fee Schedule,6.09,,,6.09,Fee Schedule,140% Medicaid Laboratory Fee Schedule,9.79,,,9.79,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.31,,,11.31,Fee Schedule,260% Medicaid Laboratory Fee Schedule,14.09,,,14.09,Fee Schedule,324% Medicaid Laboratory Fee Schedule,9.35,,,9.35,Fee Schedule,215% Medicaid Laboratory Fee Schedule,9.35,,,9.35,Fee Schedule,215% Medicaid Laboratory Fee Schedule,5.44,,,5.44,Fee Schedule,125% Medicaid Laboratory Fee Schedule,4.35,48.3,
ASSAY OF GGT                    ,82977,CPT,,40120461,CDM,301,RC,,,both,,,115,11.84,,,11.84,Other,150% of Medicare + 9.63% HCRA Surcharge,7.2,,,7.2,Fee Schedule,Mediare Clinical Lab,13.9,,,13.9,Fee Schedule,,12.53,,,12.53,Fee Schedule,,72.73,,,72.73,Fee Schedule,,65.44,,,65.44,Fee Schedule,,61.79,,,61.79,Fee Schedule,,57.5,50,,57.5,percent of total billed charges,All Other,15.21,,,15.21,Fee Schedule,,22.68,,,22.68,Fee Schedule,,9.45,,,9.45,Other,186% Medicaid methodology,26.71,,,26.71,Fee Schedule,,71.3,,,71.3,Fee Schedule,,15.12,,,15.12,Fee Schedule,,26.71,,,26.71,Fee Schedule,,71.3,,,71.3,Fee Schedule,,28.44,,,28.44,Fee Schedule,,80.5,70,,80.5,percent of total billed charges,All Other,34.33,,,34.33,Fee Schedule,,29.13,,,29.13,Fee Schedule,,8.64,,,8.64,Fee Schedule,,8.64,,,8.64,Fee Schedule,,8.64,,,8.64,Fee Schedule,,8.64,,,8.64,Fee Schedule,,5.08,,,5.08,Fee Schedule,Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.77,,,7.77,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.11,,,7.11,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.21,,,13.21,Fee Schedule,260% Medicaid Laboratory Fee Schedule,16.46,,,16.46,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.35,,,6.35,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.08,80.5,
ASSAY OF LACTIC ACID            ,83605,CPT,,40120487,CDM,301,RC,,,both,,,185,19.03,,,19.03,Other,150% of Medicare + 9.63% HCRA Surcharge,11.57,,,11.57,Fee Schedule,Mediare Clinical Lab,22.33,,,22.33,Fee Schedule,,20.13,,,20.13,Fee Schedule,,87.31,,,87.31,Fee Schedule,,78.55,,,78.55,Fee Schedule,,74.18,,,74.18,Fee Schedule,,92.5,50,,92.5,percent of total billed charges,All Other,24.44,,,24.44,Fee Schedule,,36.45,,,36.45,Fee Schedule,,17.47,,,17.47,Other,186% Medicaid methodology,42.92,,,42.92,Fee Schedule,,114.7,,,114.7,Fee Schedule,,24.3,,,24.3,Fee Schedule,,42.92,,,42.92,Fee Schedule,,114.7,,,114.7,Fee Schedule,,45.7,,,45.7,Fee Schedule,,129.5,70,,129.5,percent of total billed charges,All Other,55.16,,,55.16,Fee Schedule,,46.81,,,46.81,Fee Schedule,,13.88,,,13.88,Fee Schedule,,13.88,,,13.88,Fee Schedule,,13.88,,,13.88,Fee Schedule,,13.88,,,13.88,Fee Schedule,,9.39,,,9.39,Fee Schedule,Medicaid Laboratory Fee Schedule,9.39,,,9.39,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.39,,,9.39,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.39,,,9.39,Fee Schedule,100% Medicaid Laboratory Fee Schedule,21.13,,,21.13,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.13,,,21.13,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.37,,,14.37,Fee Schedule,153% Medicaid Laboratory Fee Schedule,21.13,,,21.13,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.15,,,13.15,Fee Schedule,140% Medicaid Laboratory Fee Schedule,21.13,,,21.13,Fee Schedule,225% Medicaid Laboratory Fee Schedule,24.42,,,24.42,Fee Schedule,260% Medicaid Laboratory Fee Schedule,30.43,,,30.43,Fee Schedule,324% Medicaid Laboratory Fee Schedule,20.19,,,20.19,Fee Schedule,215% Medicaid Laboratory Fee Schedule,20.19,,,20.19,Fee Schedule,215% Medicaid Laboratory Fee Schedule,11.74,,,11.74,Fee Schedule,125% Medicaid Laboratory Fee Schedule,9.39,129.5,
LACTATE (LD) (LDH) ENZYME       ,83615,CPT,,40120503,CDM,301,RC,,,both,,,97,9.93,,,9.93,Other,150% of Medicare + 9.63% HCRA Surcharge,6.04,,,6.04,Fee Schedule,Mediare Clinical Lab,11.66,,,11.66,Fee Schedule,,10.51,,,10.51,Fee Schedule,,61.03,,,61.03,Fee Schedule,,54.91,,,54.91,Fee Schedule,,51.85,,,51.85,Fee Schedule,,48.5,50,,48.5,percent of total billed charges,All Other,12.77,,,12.77,Fee Schedule,,19.03,,,19.03,Fee Schedule,,9.45,,,9.45,Other,186% Medicaid methodology,22.41,,,22.41,Fee Schedule,,60.14,,,60.14,Fee Schedule,,12.68,,,12.68,Fee Schedule,,22.41,,,22.41,Fee Schedule,,60.14,,,60.14,Fee Schedule,,23.86,,,23.86,Fee Schedule,,67.9,70,,67.9,percent of total billed charges,All Other,28.8,,,28.8,Fee Schedule,,24.43,,,24.43,Fee Schedule,,7.25,,,7.25,Fee Schedule,,7.25,,,7.25,Fee Schedule,,7.25,,,7.25,Fee Schedule,,7.25,,,7.25,Fee Schedule,,5.08,,,5.08,Fee Schedule,Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.77,,,7.77,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.11,,,7.11,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.21,,,13.21,Fee Schedule,260% Medicaid Laboratory Fee Schedule,16.46,,,16.46,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.35,,,6.35,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.08,67.9,
F2 GENE                         ,81240,CPT,,40120511,CDM,301,RC,,,both,,,1045,108.02,,,108.02,Other,150% of Medicare + 9.63% HCRA Surcharge,65.69,,,65.69,Fee Schedule,Mediare Clinical Lab,126.78,,,126.78,Fee Schedule,,114.3,,,114.3,Fee Schedule,,20.27,,,20.27,Fee Schedule,,20.27,,,20.27,Fee Schedule,,20.27,,,20.27,Fee Schedule,,522.5,50,,522.5,percent of total billed charges,All Other,138.78,,,138.78,Fee Schedule,,206.92,,,206.92,Fee Schedule,,122.18,,,122.18,Other,186% Medicaid methodology,243.71,,,243.71,Fee Schedule,,647.9,,,647.9,Fee Schedule,,137.95,,,137.95,Fee Schedule,,243.71,,,243.71,Fee Schedule,,647.9,,,647.9,Fee Schedule,,259.48,,,259.48,Fee Schedule,,731.5,70,,731.5,percent of total billed charges,All Other,313.21,,,313.21,Fee Schedule,,265.75,,,265.75,Fee Schedule,,78.83,,,78.83,Fee Schedule,,78.83,,,78.83,Fee Schedule,,78.83,,,78.83,Fee Schedule,,78.83,,,78.83,Fee Schedule,,65.69,,,65.69,Fee Schedule,Medicaid Laboratory Fee Schedule,65.69,,,65.69,Fee Schedule,100% Medicaid Laboratory Fee Schedule,65.69,,,65.69,Fee Schedule,100% Medicaid Laboratory Fee Schedule,65.69,,,65.69,Fee Schedule,100% Medicaid Laboratory Fee Schedule,147.8,,,147.8,Fee Schedule,225% Medicaid Laboratory Fee Schedule,147.8,,,147.8,Fee Schedule,225% Medicaid Laboratory Fee Schedule,100.51,,,100.51,Fee Schedule,153% Medicaid Laboratory Fee Schedule,147.8,,,147.8,Fee Schedule,225% Medicaid Laboratory Fee Schedule,91.97,,,91.97,Fee Schedule,140% Medicaid Laboratory Fee Schedule,147.8,,,147.8,Fee Schedule,225% Medicaid Laboratory Fee Schedule,170.79,,,170.79,Fee Schedule,260% Medicaid Laboratory Fee Schedule,212.84,,,212.84,Fee Schedule,324% Medicaid Laboratory Fee Schedule,141.23,,,141.23,Fee Schedule,215% Medicaid Laboratory Fee Schedule,141.23,,,141.23,Fee Schedule,215% Medicaid Laboratory Fee Schedule,82.11,,,82.11,Fee Schedule,125% Medicaid Laboratory Fee Schedule,20.27,731.5,
TRANSFERASE (AST) (SGOT)        ,84450,CPT,,40120529,CDM,301,RC,,,both,,,83,8.52,,,8.52,Other,150% of Medicare + 9.63% HCRA Surcharge,5.18,,,5.18,Fee Schedule,Mediare Clinical Lab,10,,,10,Fee Schedule,,9.01,,,9.01,Fee Schedule,,52.27,,,52.27,Fee Schedule,,47.03,,,47.03,Fee Schedule,,44.41,,,44.41,Fee Schedule,,41.5,50,,41.5,percent of total billed charges,All Other,10.95,,,10.95,Fee Schedule,,16.32,,,16.32,Fee Schedule,,9.45,,,9.45,Other,186% Medicaid methodology,19.22,,,19.22,Fee Schedule,,51.46,,,51.46,Fee Schedule,,10.88,,,10.88,Fee Schedule,,19.22,,,19.22,Fee Schedule,,51.46,,,51.46,Fee Schedule,,20.46,,,20.46,Fee Schedule,,58.1,70,,58.1,percent of total billed charges,All Other,24.7,,,24.7,Fee Schedule,,20.96,,,20.96,Fee Schedule,,6.22,,,6.22,Fee Schedule,,6.22,,,6.22,Fee Schedule,,6.22,,,6.22,Fee Schedule,,6.22,,,6.22,Fee Schedule,,5.08,,,5.08,Fee Schedule,Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.77,,,7.77,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.11,,,7.11,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.21,,,13.21,Fee Schedule,260% Medicaid Laboratory Fee Schedule,16.46,,,16.46,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.35,,,6.35,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.08,58.1,
F5 GENE                         ,81241,CPT,,40120537,CDM,301,RC,,,both,,,1168,120.65,,,120.65,Other,150% of Medicare + 9.63% HCRA Surcharge,73.37,,,73.37,Fee Schedule,Mediare Clinical Lab,141.6,,,141.6,Fee Schedule,,127.66,,,127.66,Fee Schedule,,21.16,,,21.16,Fee Schedule,,21.16,,,21.16,Fee Schedule,,21.16,,,21.16,Fee Schedule,,584,50,,584,percent of total billed charges,All Other,154.99,,,154.99,Fee Schedule,,231.12,,,231.12,Fee Schedule,,136.47,,,136.47,Other,186% Medicaid methodology,272.2,,,272.2,Fee Schedule,,724.16,,,724.16,Fee Schedule,,154.08,,,154.08,Fee Schedule,,272.2,,,272.2,Fee Schedule,,724.16,,,724.16,Fee Schedule,,289.81,,,289.81,Fee Schedule,,817.6,70,,817.6,percent of total billed charges,All Other,349.82,,,349.82,Fee Schedule,,296.82,,,296.82,Fee Schedule,,88.04,,,88.04,Fee Schedule,,88.04,,,88.04,Fee Schedule,,88.04,,,88.04,Fee Schedule,,88.04,,,88.04,Fee Schedule,,73.37,,,73.37,Fee Schedule,Medicaid Laboratory Fee Schedule,73.37,,,73.37,Fee Schedule,100% Medicaid Laboratory Fee Schedule,73.37,,,73.37,Fee Schedule,100% Medicaid Laboratory Fee Schedule,73.37,,,73.37,Fee Schedule,100% Medicaid Laboratory Fee Schedule,165.08,,,165.08,Fee Schedule,225% Medicaid Laboratory Fee Schedule,165.08,,,165.08,Fee Schedule,225% Medicaid Laboratory Fee Schedule,112.26,,,112.26,Fee Schedule,153% Medicaid Laboratory Fee Schedule,165.08,,,165.08,Fee Schedule,225% Medicaid Laboratory Fee Schedule,102.72,,,102.72,Fee Schedule,140% Medicaid Laboratory Fee Schedule,165.08,,,165.08,Fee Schedule,225% Medicaid Laboratory Fee Schedule,190.76,,,190.76,Fee Schedule,260% Medicaid Laboratory Fee Schedule,237.72,,,237.72,Fee Schedule,324% Medicaid Laboratory Fee Schedule,157.75,,,157.75,Fee Schedule,215% Medicaid Laboratory Fee Schedule,157.75,,,157.75,Fee Schedule,215% Medicaid Laboratory Fee Schedule,91.71,,,91.71,Fee Schedule,125% Medicaid Laboratory Fee Schedule,21.16,817.6,
ALANINE AMINO (ALT) (SGPT)      ,84460,CPT,,40120545,CDM,301,RC,,,both,,,85,8.72,,,8.72,Other,150% of Medicare + 9.63% HCRA Surcharge,5.3,,,5.3,Fee Schedule,Mediare Clinical Lab,10.23,,,10.23,Fee Schedule,,9.22,,,9.22,Fee Schedule,,53.42,,,53.42,Fee Schedule,,48.06,,,48.06,Fee Schedule,,45.38,,,45.38,Fee Schedule,,42.5,50,,42.5,percent of total billed charges,All Other,11.21,,,11.21,Fee Schedule,,16.7,,,16.7,Fee Schedule,,9.45,,,9.45,Other,186% Medicaid methodology,19.66,,,19.66,Fee Schedule,,52.7,,,52.7,Fee Schedule,,11.13,,,11.13,Fee Schedule,,19.66,,,19.66,Fee Schedule,,52.7,,,52.7,Fee Schedule,,20.94,,,20.94,Fee Schedule,,59.5,70,,59.5,percent of total billed charges,All Other,25.27,,,25.27,Fee Schedule,,21.44,,,21.44,Fee Schedule,,6.36,,,6.36,Fee Schedule,,6.36,,,6.36,Fee Schedule,,6.36,,,6.36,Fee Schedule,,6.36,,,6.36,Fee Schedule,,5.08,,,5.08,Fee Schedule,Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.77,,,7.77,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.11,,,7.11,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.21,,,13.21,Fee Schedule,260% Medicaid Laboratory Fee Schedule,16.46,,,16.46,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.35,,,6.35,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.08,59.5,
FLT3 GENE                       ,81245,CPT,,40120610,CDM,301,RC,,,both,,,1164,272.17,,,272.17,Other,150% of Medicare + 9.63% HCRA Surcharge,165.51,,,165.51,Fee Schedule,Mediare Clinical Lab,319.43,,,319.43,Fee Schedule,,287.99,,,287.99,Fee Schedule,,31.12,,,31.12,Fee Schedule,,31.12,,,31.12,Fee Schedule,,31.12,,,31.12,Fee Schedule,,582,50,,582,percent of total billed charges,All Other,349.64,,,349.64,Fee Schedule,,521.36,,,521.36,Fee Schedule,,307.85,,,307.85,Other,186% Medicaid methodology,614.04,,,614.04,Fee Schedule,,721.68,,,721.68,Fee Schedule,,347.57,,,347.57,Fee Schedule,,614.04,,,614.04,Fee Schedule,,721.68,,,721.68,Fee Schedule,,653.76,,,653.76,Fee Schedule,,814.8,70,,814.8,percent of total billed charges,All Other,789.14,,,789.14,Fee Schedule,,669.57,,,669.57,Fee Schedule,,198.61,,,198.61,Fee Schedule,,198.61,,,198.61,Fee Schedule,,198.61,,,198.61,Fee Schedule,,198.61,,,198.61,Fee Schedule,,165.51,,,165.51,Fee Schedule,Medicaid Laboratory Fee Schedule,165.51,,,165.51,Fee Schedule,100% Medicaid Laboratory Fee Schedule,165.51,,,165.51,Fee Schedule,100% Medicaid Laboratory Fee Schedule,165.51,,,165.51,Fee Schedule,100% Medicaid Laboratory Fee Schedule,372.4,,,372.4,Fee Schedule,225% Medicaid Laboratory Fee Schedule,372.4,,,372.4,Fee Schedule,225% Medicaid Laboratory Fee Schedule,253.23,,,253.23,Fee Schedule,153% Medicaid Laboratory Fee Schedule,372.4,,,372.4,Fee Schedule,225% Medicaid Laboratory Fee Schedule,231.71,,,231.71,Fee Schedule,140% Medicaid Laboratory Fee Schedule,372.4,,,372.4,Fee Schedule,225% Medicaid Laboratory Fee Schedule,430.33,,,430.33,Fee Schedule,260% Medicaid Laboratory Fee Schedule,536.25,,,536.25,Fee Schedule,324% Medicaid Laboratory Fee Schedule,355.85,,,355.85,Fee Schedule,215% Medicaid Laboratory Fee Schedule,355.85,,,355.85,Fee Schedule,215% Medicaid Laboratory Fee Schedule,206.89,,,206.89,Fee Schedule,125% Medicaid Laboratory Fee Schedule,31.12,814.8,
PROTEIN E-PHORESIS SERUM        ,84165,CPT,,40120628,CDM,301,RC,,,both,,,171,17.66,,,17.66,Other,150% of Medicare + 9.63% HCRA Surcharge,10.74,,,10.74,Fee Schedule,Mediare Clinical Lab,20.73,,,20.73,Fee Schedule,,18.69,,,18.69,Fee Schedule,,108.56,,,108.56,Fee Schedule,,97.68,,,97.68,Fee Schedule,,92.23,,,92.23,Fee Schedule,,85.5,50,,85.5,percent of total billed charges,All Other,22.69,,,22.69,Fee Schedule,,33.83,,,33.83,Fee Schedule,,15.03,,,15.03,Other,186% Medicaid methodology,39.85,,,39.85,Fee Schedule,,106.02,,,106.02,Fee Schedule,,22.55,,,22.55,Fee Schedule,,39.85,,,39.85,Fee Schedule,,106.02,,,106.02,Fee Schedule,,42.42,,,42.42,Fee Schedule,,119.7,70,,119.7,percent of total billed charges,All Other,51.21,,,51.21,Fee Schedule,,43.45,,,43.45,Fee Schedule,,12.89,,,12.89,Fee Schedule,,12.89,,,12.89,Fee Schedule,,12.89,,,12.89,Fee Schedule,,12.89,,,12.89,Fee Schedule,,8.08,,,8.08,Fee Schedule,Medicaid Laboratory Fee Schedule,8.08,,,8.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.08,,,8.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.08,,,8.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.18,,,18.18,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.18,,,18.18,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.36,,,12.36,Fee Schedule,153% Medicaid Laboratory Fee Schedule,18.18,,,18.18,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.31,,,11.31,Fee Schedule,140% Medicaid Laboratory Fee Schedule,18.18,,,18.18,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.01,,,21.01,Fee Schedule,260% Medicaid Laboratory Fee Schedule,26.18,,,26.18,Fee Schedule,324% Medicaid Laboratory Fee Schedule,17.37,,,17.37,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.37,,,17.37,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.1,,,10.1,Fee Schedule,125% Medicaid Laboratory Fee Schedule,8.08,119.7,
GTT-ADDED SAMPLES               ,82952,CPT,,40120685,CDM,301,RC,,,both,,,63,6.45,,,6.45,Other,150% of Medicare + 9.63% HCRA Surcharge,3.92,,,3.92,Fee Schedule,Mediare Clinical Lab,7.57,,,7.57,Fee Schedule,,6.82,,,6.82,Fee Schedule,,29.08,,,29.08,Fee Schedule,,26.16,,,26.16,Fee Schedule,,24.71,,,24.71,Fee Schedule,,31.5,50,,31.5,percent of total billed charges,All Other,8.29,,,8.29,Fee Schedule,,12.35,,,12.35,Fee Schedule,,2.63,,,2.63,Other,186% Medicaid methodology,14.54,,,14.54,Fee Schedule,,39.06,,,39.06,Fee Schedule,,8.23,,,8.23,Fee Schedule,,14.54,,,14.54,Fee Schedule,,39.06,,,39.06,Fee Schedule,,15.48,,,15.48,Fee Schedule,,44.1,70,,44.1,percent of total billed charges,All Other,18.69,,,18.69,Fee Schedule,,15.86,,,15.86,Fee Schedule,,4.7,,,4.7,Fee Schedule,,4.7,,,4.7,Fee Schedule,,4.7,,,4.7,Fee Schedule,,4.7,,,4.7,Fee Schedule,,1.41,,,1.41,Fee Schedule,Medicaid Laboratory Fee Schedule,1.41,,,1.41,Fee Schedule,100% Medicaid Laboratory Fee Schedule,1.41,,,1.41,Fee Schedule,100% Medicaid Laboratory Fee Schedule,1.41,,,1.41,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.18,,,3.18,Fee Schedule,225% Medicaid Laboratory Fee Schedule,3.18,,,3.18,Fee Schedule,225% Medicaid Laboratory Fee Schedule,2.16,,,2.16,Fee Schedule,153% Medicaid Laboratory Fee Schedule,3.18,,,3.18,Fee Schedule,225% Medicaid Laboratory Fee Schedule,1.98,,,1.98,Fee Schedule,140% Medicaid Laboratory Fee Schedule,3.18,,,3.18,Fee Schedule,225% Medicaid Laboratory Fee Schedule,3.68,,,3.68,Fee Schedule,260% Medicaid Laboratory Fee Schedule,4.58,,,4.58,Fee Schedule,324% Medicaid Laboratory Fee Schedule,3.04,,,3.04,Fee Schedule,215% Medicaid Laboratory Fee Schedule,3.04,,,3.04,Fee Schedule,215% Medicaid Laboratory Fee Schedule,1.77,,,1.77,Fee Schedule,125% Medicaid Laboratory Fee Schedule,1.41,44.1,
HFE GENE                        ,81256,CPT,,40120693,CDM,301,RC,,,both,,,1039,107.48,,,107.48,Other,150% of Medicare + 9.63% HCRA Surcharge,65.36,,,65.36,Fee Schedule,Mediare Clinical Lab,126.14,,,126.14,Fee Schedule,,113.73,,,113.73,Fee Schedule,,25.42,,,25.42,Fee Schedule,,25.42,,,25.42,Fee Schedule,,25.42,,,25.42,Fee Schedule,,519.5,50,,519.5,percent of total billed charges,All Other,138.06,,,138.06,Fee Schedule,,205.88,,,205.88,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,242.49,,,242.49,Fee Schedule,,644.18,,,644.18,Fee Schedule,,137.26,,,137.26,Fee Schedule,,242.49,,,242.49,Fee Schedule,,644.18,,,644.18,Fee Schedule,,258.17,,,258.17,Fee Schedule,,727.3,70,,727.3,percent of total billed charges,All Other,311.63,,,311.63,Fee Schedule,,264.42,,,264.42,Fee Schedule,,78.43,,,78.43,Fee Schedule,,78.43,,,78.43,Fee Schedule,,78.43,,,78.43,Fee Schedule,,78.43,,,78.43,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,727.3,
IGH GENE REARRANGE AMP METH     ,81261,CPT,,40120750,CDM,301,RC,,,both,,,990,325.58,,,325.58,Other,150% of Medicare + 9.63% HCRA Surcharge,197.99,,,197.99,Fee Schedule,Mediare Clinical Lab,382.12,,,382.12,Fee Schedule,,344.5,,,344.5,Fee Schedule,,28.82,,,28.82,Fee Schedule,,28.82,,,28.82,Fee Schedule,,28.82,,,28.82,Fee Schedule,,495,50,,495,percent of total billed charges,All Other,418.24,,,418.24,Fee Schedule,,623.67,,,623.67,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,734.54,,,734.54,Fee Schedule,,613.8,,,613.8,Fee Schedule,,415.78,,,415.78,Fee Schedule,,734.54,,,734.54,Fee Schedule,,613.8,,,613.8,Fee Schedule,,782.06,,,782.06,Fee Schedule,,693,70,,693,percent of total billed charges,All Other,944,,,944,Fee Schedule,,800.97,,,800.97,Fee Schedule,,237.59,,,237.59,Fee Schedule,,237.59,,,237.59,Fee Schedule,,237.59,,,237.59,Fee Schedule,,237.59,,,237.59,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,944,
ASSAY OF SERUM POTASSIUM        ,84132,CPT,,40120768,CDM,301,RC,,,both,,,76,7.83,,,7.83,Other,150% of Medicare + 9.63% HCRA Surcharge,4.76,,,4.76,Fee Schedule,Mediare Clinical Lab,9.19,,,9.19,Fee Schedule,,8.28,,,8.28,Fee Schedule,,46.45,,,46.45,Fee Schedule,,41.8,,,41.8,Fee Schedule,,39.47,,,39.47,Fee Schedule,,38,50,,38,percent of total billed charges,All Other,10.04,,,10.04,Fee Schedule,,14.99,,,14.99,Fee Schedule,,8.85,,,8.85,Other,186% Medicaid methodology,17.66,,,17.66,Fee Schedule,,47.12,,,47.12,Fee Schedule,,10,,,10,Fee Schedule,,17.66,,,17.66,Fee Schedule,,47.12,,,47.12,Fee Schedule,,18.8,,,18.8,Fee Schedule,,53.2,70,,53.2,percent of total billed charges,All Other,22.7,,,22.7,Fee Schedule,,19.26,,,19.26,Fee Schedule,,5.71,,,5.71,Fee Schedule,,5.71,,,5.71,Fee Schedule,,5.71,,,5.71,Fee Schedule,,5.71,,,5.71,Fee Schedule,,4.76,,,4.76,Fee Schedule,Medicaid Laboratory Fee Schedule,4.76,,,4.76,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.76,,,4.76,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.76,,,4.76,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.71,,,10.71,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.71,,,10.71,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.28,,,7.28,Fee Schedule,153% Medicaid Laboratory Fee Schedule,10.71,,,10.71,Fee Schedule,225% Medicaid Laboratory Fee Schedule,6.66,,,6.66,Fee Schedule,140% Medicaid Laboratory Fee Schedule,10.71,,,10.71,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.38,,,12.38,Fee Schedule,260% Medicaid Laboratory Fee Schedule,15.42,,,15.42,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.23,,,10.23,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.23,,,10.23,Fee Schedule,215% Medicaid Laboratory Fee Schedule,5.95,,,5.95,Fee Schedule,125% Medicaid Laboratory Fee Schedule,4.76,53.2,
ASSAY OF SERUM SODIUM           ,84295,CPT,,40120784,CDM,301,RC,,,both,,,77,7.91,,,7.91,Other,150% of Medicare + 9.63% HCRA Surcharge,4.81,,,4.81,Fee Schedule,Mediare Clinical Lab,9.28,,,9.28,Fee Schedule,,8.37,,,8.37,Fee Schedule,,48.61,,,48.61,Fee Schedule,,43.73,,,43.73,Fee Schedule,,41.3,,,41.3,Fee Schedule,,38.5,50,,38.5,percent of total billed charges,All Other,10.17,,,10.17,Fee Schedule,,15.15,,,15.15,Fee Schedule,,8.95,,,8.95,Other,186% Medicaid methodology,17.85,,,17.85,Fee Schedule,,47.74,,,47.74,Fee Schedule,,10.1,,,10.1,Fee Schedule,,17.85,,,17.85,Fee Schedule,,47.74,,,47.74,Fee Schedule,,19,,,19,Fee Schedule,,53.9,70,,53.9,percent of total billed charges,All Other,22.93,,,22.93,Fee Schedule,,19.46,,,19.46,Fee Schedule,,5.77,,,5.77,Fee Schedule,,5.77,,,5.77,Fee Schedule,,5.77,,,5.77,Fee Schedule,,5.77,,,5.77,Fee Schedule,,4.81,,,4.81,Fee Schedule,Medicaid Laboratory Fee Schedule,4.81,,,4.81,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.81,,,4.81,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.81,,,4.81,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.82,,,10.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.82,,,10.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.36,,,7.36,Fee Schedule,153% Medicaid Laboratory Fee Schedule,10.82,,,10.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,6.73,,,6.73,Fee Schedule,140% Medicaid Laboratory Fee Schedule,10.82,,,10.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.51,,,12.51,Fee Schedule,260% Medicaid Laboratory Fee Schedule,15.58,,,15.58,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.34,,,10.34,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.34,,,10.34,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.01,,,6.01,Fee Schedule,125% Medicaid Laboratory Fee Schedule,4.81,53.9,
CHLORIDE; BLOOD                 ,82435,CPT,,40120800,CDM,301,RC,,,both,,,74,7.56,,,7.56,Other,150% of Medicare + 9.63% HCRA Surcharge,4.6,,,4.6,Fee Schedule,Mediare Clinical Lab,8.88,,,8.88,Fee Schedule,,8,,,8,Fee Schedule,,46.45,,,46.45,Fee Schedule,,41.8,,,41.8,Fee Schedule,,39.47,,,39.47,Fee Schedule,,37,50,,37,percent of total billed charges,All Other,9.72,,,9.72,Fee Schedule,,14.49,,,14.49,Fee Schedule,,8.56,,,8.56,Other,186% Medicaid methodology,17.07,,,17.07,Fee Schedule,,45.88,,,45.88,Fee Schedule,,9.66,,,9.66,Fee Schedule,,17.07,,,17.07,Fee Schedule,,45.88,,,45.88,Fee Schedule,,18.17,,,18.17,Fee Schedule,,51.8,70,,51.8,percent of total billed charges,All Other,21.93,,,21.93,Fee Schedule,,18.61,,,18.61,Fee Schedule,,5.52,,,5.52,Fee Schedule,,5.52,,,5.52,Fee Schedule,,5.52,,,5.52,Fee Schedule,,5.52,,,5.52,Fee Schedule,,4.6,,,4.6,Fee Schedule,Medicaid Laboratory Fee Schedule,4.6,,,4.6,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.6,,,4.6,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.6,,,4.6,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.35,,,10.35,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.35,,,10.35,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.04,,,7.04,Fee Schedule,153% Medicaid Laboratory Fee Schedule,10.35,,,10.35,Fee Schedule,225% Medicaid Laboratory Fee Schedule,6.44,,,6.44,Fee Schedule,140% Medicaid Laboratory Fee Schedule,10.35,,,10.35,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.96,,,11.96,Fee Schedule,260% Medicaid Laboratory Fee Schedule,14.9,,,14.9,Fee Schedule,324% Medicaid Laboratory Fee Schedule,9.89,,,9.89,Fee Schedule,215% Medicaid Laboratory Fee Schedule,9.89,,,9.89,Fee Schedule,215% Medicaid Laboratory Fee Schedule,5.75,,,5.75,Fee Schedule,125% Medicaid Laboratory Fee Schedule,4.6,51.8,
ASSAY BLOOD CARBON DIOXIDE      ,82374,CPT,,40120826,CDM,301,RC,,,both,,,138,8.02,,,8.02,Other,150% of Medicare + 9.63% HCRA Surcharge,4.88,,,4.88,Fee Schedule,Mediare Clinical Lab,9.42,,,9.42,Fee Schedule,,8.49,,,8.49,Fee Schedule,,49.4,,,49.4,Fee Schedule,,44.44,,,44.44,Fee Schedule,,41.97,,,41.97,Fee Schedule,,69,50,,69,percent of total billed charges,All Other,10.3,,,10.3,Fee Schedule,,15.37,,,15.37,Fee Schedule,,9.08,,,9.08,Other,186% Medicaid methodology,18.1,,,18.1,Fee Schedule,,85.56,,,85.56,Fee Schedule,,10.25,,,10.25,Fee Schedule,,18.1,,,18.1,Fee Schedule,,85.56,,,85.56,Fee Schedule,,19.28,,,19.28,Fee Schedule,,96.6,70,,96.6,percent of total billed charges,All Other,23.27,,,23.27,Fee Schedule,,19.74,,,19.74,Fee Schedule,,5.86,,,5.86,Fee Schedule,,5.86,,,5.86,Fee Schedule,,5.86,,,5.86,Fee Schedule,,5.86,,,5.86,Fee Schedule,,4.88,,,4.88,Fee Schedule,Medicaid Laboratory Fee Schedule,4.88,,,4.88,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.88,,,4.88,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.88,,,4.88,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.98,,,10.98,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.98,,,10.98,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.47,,,7.47,Fee Schedule,153% Medicaid Laboratory Fee Schedule,10.98,,,10.98,Fee Schedule,225% Medicaid Laboratory Fee Schedule,6.83,,,6.83,Fee Schedule,140% Medicaid Laboratory Fee Schedule,10.98,,,10.98,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.69,,,12.69,Fee Schedule,260% Medicaid Laboratory Fee Schedule,15.81,,,15.81,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.49,,,10.49,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.49,,,10.49,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.1,,,6.1,Fee Schedule,125% Medicaid Laboratory Fee Schedule,4.88,96.6,
JAK2 GENE                       ,81270,CPT,,40120917,CDM,301,RC,,,both,,,1458,150.73,,,150.73,Other,150% of Medicare + 9.63% HCRA Surcharge,91.66,,,91.66,Fee Schedule,Mediare Clinical Lab,176.9,,,176.9,Fee Schedule,,159.49,,,159.49,Fee Schedule,,21.53,,,21.53,Fee Schedule,,21.53,,,21.53,Fee Schedule,,21.53,,,21.53,Fee Schedule,,729,50,,729,percent of total billed charges,All Other,193.64,,,193.64,Fee Schedule,,288.73,,,288.73,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,340.06,,,340.06,Fee Schedule,,903.96,,,903.96,Fee Schedule,,192.49,,,192.49,Fee Schedule,,340.06,,,340.06,Fee Schedule,,903.96,,,903.96,Fee Schedule,,362.06,,,362.06,Fee Schedule,,1020.6,70,,1020.6,percent of total billed charges,All Other,437.03,,,437.03,Fee Schedule,,370.81,,,370.81,Fee Schedule,,109.99,,,109.99,Fee Schedule,,109.99,,,109.99,Fee Schedule,,109.99,,,109.99,Fee Schedule,,109.99,,,109.99,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1020.6,
ASSAY OF ALDOLASE               ,82085,CPT,,40120925,CDM,301,RC,,,both,,,155,15.97,,,15.97,Other,150% of Medicare + 9.63% HCRA Surcharge,9.71,,,9.71,Fee Schedule,Mediare Clinical Lab,18.74,,,18.74,Fee Schedule,,16.9,,,16.9,Fee Schedule,,98.08,,,98.08,Fee Schedule,,88.24,,,88.24,Fee Schedule,,83.33,,,83.33,Fee Schedule,,77.5,50,,77.5,percent of total billed charges,All Other,20.51,,,20.51,Fee Schedule,,30.59,,,30.59,Fee Schedule,,56.01,,,56.01,Other,186% Medicaid methodology,36.02,,,36.02,Fee Schedule,,96.1,,,96.1,Fee Schedule,,20.39,,,20.39,Fee Schedule,,36.02,,,36.02,Fee Schedule,,96.1,,,96.1,Fee Schedule,,38.35,,,38.35,Fee Schedule,,108.5,70,,108.5,percent of total billed charges,All Other,46.3,,,46.3,Fee Schedule,,39.28,,,39.28,Fee Schedule,,11.65,,,11.65,Fee Schedule,,11.65,,,11.65,Fee Schedule,,11.65,,,11.65,Fee Schedule,,11.65,,,11.65,Fee Schedule,,30.11,,,30.11,Other,New York Medicaid APG methodology,30.11,,,30.11,Other,100% Medicaid APG methodology,30.11,,,30.11,Other,100% Medicaid APG methodology,30.11,,,30.11,Other,100% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,46.07,,,46.07,Other,153% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,42.16,,,42.16,Other,140% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,78.29,,,78.29,Other,260% Medicaid APG methodology,97.56,,,97.56,Other,324% Medicaid APG methodology,64.74,,,64.74,Other,215% Medicaid APG methodology,64.74,,,64.74,Other,215% Medicaid APG methodology,37.64,,,37.64,Other,125% Medicaid APG methodology,9.71,108.5,
KRAS GENE VARIANTS EXON 2       ,81275,CPT,,40120933,CDM,301,RC,,,both,,,2041,317.79,,,317.79,Other,150% of Medicare + 9.63% HCRA Surcharge,193.25,,,193.25,Fee Schedule,Mediare Clinical Lab,372.97,,,372.97,Fee Schedule,,336.26,,,336.26,Fee Schedule,,43.32,,,43.32,Fee Schedule,,43.32,,,43.32,Fee Schedule,,43.32,,,43.32,Fee Schedule,,1020.5,50,,1020.5,percent of total billed charges,All Other,408.23,,,408.23,Fee Schedule,,608.74,,,608.74,Fee Schedule,,359.45,,,359.45,Other,186% Medicaid methodology,716.96,,,716.96,Fee Schedule,,1265.42,,,1265.42,Fee Schedule,,405.83,,,405.83,Fee Schedule,,716.96,,,716.96,Fee Schedule,,1265.42,,,1265.42,Fee Schedule,,763.34,,,763.34,Fee Schedule,,1428.7,70,,1428.7,percent of total billed charges,All Other,921.4,,,921.4,Fee Schedule,,781.8,,,781.8,Fee Schedule,,231.9,,,231.9,Fee Schedule,,231.9,,,231.9,Fee Schedule,,231.9,,,231.9,Fee Schedule,,231.9,,,231.9,Fee Schedule,,193.25,,,193.25,Fee Schedule,Medicaid Laboratory Fee Schedule,193.25,,,193.25,Fee Schedule,100% Medicaid Laboratory Fee Schedule,193.25,,,193.25,Fee Schedule,100% Medicaid Laboratory Fee Schedule,193.25,,,193.25,Fee Schedule,100% Medicaid Laboratory Fee Schedule,434.81,,,434.81,Fee Schedule,225% Medicaid Laboratory Fee Schedule,434.81,,,434.81,Fee Schedule,225% Medicaid Laboratory Fee Schedule,295.67,,,295.67,Fee Schedule,153% Medicaid Laboratory Fee Schedule,434.81,,,434.81,Fee Schedule,225% Medicaid Laboratory Fee Schedule,270.55,,,270.55,Fee Schedule,140% Medicaid Laboratory Fee Schedule,434.81,,,434.81,Fee Schedule,225% Medicaid Laboratory Fee Schedule,502.45,,,502.45,Fee Schedule,260% Medicaid Laboratory Fee Schedule,626.13,,,626.13,Fee Schedule,324% Medicaid Laboratory Fee Schedule,415.49,,,415.49,Fee Schedule,215% Medicaid Laboratory Fee Schedule,415.49,,,415.49,Fee Schedule,215% Medicaid Laboratory Fee Schedule,241.56,,,241.56,Fee Schedule,125% Medicaid Laboratory Fee Schedule,43.32,1428.7,
AMINO ACIDS QUAN 6 OR MORE      ,82139,CPT,,40121022,CDM,301,RC,,,both,,,269,27.74,,,27.74,Other,150% of Medicare + 9.63% HCRA Surcharge,16.87,,,16.87,Fee Schedule,Mediare Clinical Lab,32.56,,,32.56,Fee Schedule,,29.35,,,29.35,Fee Schedule,,145.61,,,145.61,Fee Schedule,,131.01,,,131.01,Fee Schedule,,123.71,,,123.71,Fee Schedule,,134.5,50,,134.5,percent of total billed charges,All Other,35.65,,,35.65,Fee Schedule,,53.14,,,53.14,Fee Schedule,,26.3,,,26.3,Other,186% Medicaid methodology,62.59,,,62.59,Fee Schedule,,166.78,,,166.78,Fee Schedule,,35.43,,,35.43,Fee Schedule,,62.59,,,62.59,Fee Schedule,,166.78,,,166.78,Fee Schedule,,66.64,,,66.64,Fee Schedule,,188.3,70,,188.3,percent of total billed charges,All Other,80.44,,,80.44,Fee Schedule,,68.25,,,68.25,Fee Schedule,,20.24,,,20.24,Fee Schedule,,20.24,,,20.24,Fee Schedule,,20.24,,,20.24,Fee Schedule,,20.24,,,20.24,Fee Schedule,,14.14,,,14.14,Fee Schedule,Medicaid Laboratory Fee Schedule,14.14,,,14.14,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.14,,,14.14,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.14,,,14.14,Fee Schedule,100% Medicaid Laboratory Fee Schedule,31.82,,,31.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,31.82,,,31.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.63,,,21.63,Fee Schedule,153% Medicaid Laboratory Fee Schedule,31.82,,,31.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.8,,,19.8,Fee Schedule,140% Medicaid Laboratory Fee Schedule,31.82,,,31.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,36.76,,,36.76,Fee Schedule,260% Medicaid Laboratory Fee Schedule,45.81,,,45.81,Fee Schedule,324% Medicaid Laboratory Fee Schedule,30.4,,,30.4,Fee Schedule,215% Medicaid Laboratory Fee Schedule,30.4,,,30.4,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.68,,,17.68,Fee Schedule,125% Medicaid Laboratory Fee Schedule,14.14,188.3,
MTHFR GENE                      ,81291,CPT,,40121030,CDM,301,RC,,,both,,,1039,107.45,,,107.45,Other,150% of Medicare + 9.63% HCRA Surcharge,65.34,,,65.34,Fee Schedule,Mediare Clinical Lab,126.11,,,126.11,Fee Schedule,,113.69,,,113.69,Fee Schedule,,24.37,,,24.37,Fee Schedule,,24.37,,,24.37,Fee Schedule,,24.37,,,24.37,Fee Schedule,,519.5,50,,519.5,percent of total billed charges,All Other,138.03,,,138.03,Fee Schedule,,205.82,,,205.82,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,242.41,,,242.41,Fee Schedule,,644.18,,,644.18,Fee Schedule,,137.21,,,137.21,Fee Schedule,,242.41,,,242.41,Fee Schedule,,644.18,,,644.18,Fee Schedule,,258.09,,,258.09,Fee Schedule,,727.3,70,,727.3,percent of total billed charges,All Other,311.54,,,311.54,Fee Schedule,,264.33,,,264.33,Fee Schedule,,78.41,,,78.41,Fee Schedule,,78.41,,,78.41,Fee Schedule,,78.41,,,78.41,Fee Schedule,,78.41,,,78.41,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,727.3,
ASSAY OF UREA NITROGEN QUAN     ,84520,CPT,,40121063,CDM,301,RC,,,both,,,63,6.5,,,6.5,Other,150% of Medicare + 9.63% HCRA Surcharge,3.95,,,3.95,Fee Schedule,Mediare Clinical Lab,7.62,,,7.62,Fee Schedule,,6.87,,,6.87,Fee Schedule,,39.92,,,39.92,Fee Schedule,,35.92,,,35.92,Fee Schedule,,33.92,,,33.92,Fee Schedule,,31.5,50,,31.5,percent of total billed charges,All Other,8.35,,,8.35,Fee Schedule,,12.44,,,12.44,Fee Schedule,,7.35,,,7.35,Other,186% Medicaid methodology,14.65,,,14.65,Fee Schedule,,39.06,,,39.06,Fee Schedule,,8.3,,,8.3,Fee Schedule,,14.65,,,14.65,Fee Schedule,,39.06,,,39.06,Fee Schedule,,15.6,,,15.6,Fee Schedule,,44.1,70,,44.1,percent of total billed charges,All Other,18.83,,,18.83,Fee Schedule,,15.98,,,15.98,Fee Schedule,,4.74,,,4.74,Fee Schedule,,4.74,,,4.74,Fee Schedule,,4.74,,,4.74,Fee Schedule,,4.74,,,4.74,Fee Schedule,,3.95,,,3.95,Fee Schedule,Medicaid Laboratory Fee Schedule,3.95,,,3.95,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.95,,,3.95,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.95,,,3.95,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.89,,,8.89,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.89,,,8.89,Fee Schedule,225% Medicaid Laboratory Fee Schedule,6.04,,,6.04,Fee Schedule,153% Medicaid Laboratory Fee Schedule,8.89,,,8.89,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.53,,,5.53,Fee Schedule,140% Medicaid Laboratory Fee Schedule,8.89,,,8.89,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.27,,,10.27,Fee Schedule,260% Medicaid Laboratory Fee Schedule,12.8,,,12.8,Fee Schedule,324% Medicaid Laboratory Fee Schedule,8.49,,,8.49,Fee Schedule,215% Medicaid Laboratory Fee Schedule,8.49,,,8.49,Fee Schedule,215% Medicaid Laboratory Fee Schedule,4.94,,,4.94,Fee Schedule,125% Medicaid Laboratory Fee Schedule,3.95,44.1,
ASSAY OF COPPER                 ,82525,CPT,,40121121,CDM,301,RC,,,both,,,198,20.41,,,20.41,Other,150% of Medicare + 9.63% HCRA Surcharge,12.41,,,12.41,Fee Schedule,Mediare Clinical Lab,23.95,,,23.95,Fee Schedule,,21.59,,,21.59,Fee Schedule,,125.36,,,125.36,Fee Schedule,,112.79,,,112.79,Fee Schedule,,106.51,,,106.51,Fee Schedule,,99,50,,99,percent of total billed charges,All Other,26.23,,,26.23,Fee Schedule,,39.09,,,39.09,Fee Schedule,,23.08,,,23.08,Other,186% Medicaid methodology,46.04,,,46.04,Fee Schedule,,122.76,,,122.76,Fee Schedule,,26.06,,,26.06,Fee Schedule,,46.04,,,46.04,Fee Schedule,,122.76,,,122.76,Fee Schedule,,49.02,,,49.02,Fee Schedule,,138.6,70,,138.6,percent of total billed charges,All Other,59.17,,,59.17,Fee Schedule,,50.2,,,50.2,Fee Schedule,,14.89,,,14.89,Fee Schedule,,14.89,,,14.89,Fee Schedule,,14.89,,,14.89,Fee Schedule,,14.89,,,14.89,Fee Schedule,,12.41,,,12.41,Fee Schedule,Medicaid Laboratory Fee Schedule,12.41,,,12.41,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.41,,,12.41,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.41,,,12.41,Fee Schedule,100% Medicaid Laboratory Fee Schedule,27.92,,,27.92,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.92,,,27.92,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.99,,,18.99,Fee Schedule,153% Medicaid Laboratory Fee Schedule,27.92,,,27.92,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.37,,,17.37,Fee Schedule,140% Medicaid Laboratory Fee Schedule,27.92,,,27.92,Fee Schedule,225% Medicaid Laboratory Fee Schedule,32.27,,,32.27,Fee Schedule,260% Medicaid Laboratory Fee Schedule,40.21,,,40.21,Fee Schedule,324% Medicaid Laboratory Fee Schedule,26.68,,,26.68,Fee Schedule,215% Medicaid Laboratory Fee Schedule,26.68,,,26.68,Fee Schedule,215% Medicaid Laboratory Fee Schedule,15.51,,,15.51,Fee Schedule,125% Medicaid Laboratory Fee Schedule,12.41,138.6,
ALPHA-1-ANTITRYPSIN TOTAL       ,82103,CPT,,40121162,CDM,301,RC,,,both,,,215,22.1,,,22.1,Other,150% of Medicare + 9.63% HCRA Surcharge,13.44,,,13.44,Fee Schedule,Mediare Clinical Lab,25.94,,,25.94,Fee Schedule,,23.39,,,23.39,Fee Schedule,,135.77,,,135.77,Fee Schedule,,122.16,,,122.16,Fee Schedule,,115.35,,,115.35,Fee Schedule,,107.5,50,,107.5,percent of total billed charges,All Other,28.41,,,28.41,Fee Schedule,,42.34,,,42.34,Fee Schedule,,23.48,,,23.48,Other,186% Medicaid methodology,49.86,,,49.86,Fee Schedule,,133.3,,,133.3,Fee Schedule,,28.22,,,28.22,Fee Schedule,,49.86,,,49.86,Fee Schedule,,133.3,,,133.3,Fee Schedule,,53.09,,,53.09,Fee Schedule,,150.5,70,,150.5,percent of total billed charges,All Other,64.08,,,64.08,Fee Schedule,,54.37,,,54.37,Fee Schedule,,16.13,,,16.13,Fee Schedule,,16.13,,,16.13,Fee Schedule,,16.13,,,16.13,Fee Schedule,,16.13,,,16.13,Fee Schedule,,12.63,,,12.63,Fee Schedule,Medicaid Laboratory Fee Schedule,12.63,,,12.63,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.63,,,12.63,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.63,,,12.63,Fee Schedule,100% Medicaid Laboratory Fee Schedule,28.41,,,28.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,28.41,,,28.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.32,,,19.32,Fee Schedule,153% Medicaid Laboratory Fee Schedule,28.41,,,28.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.68,,,17.68,Fee Schedule,140% Medicaid Laboratory Fee Schedule,28.41,,,28.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,32.83,,,32.83,Fee Schedule,260% Medicaid Laboratory Fee Schedule,40.91,,,40.91,Fee Schedule,324% Medicaid Laboratory Fee Schedule,27.14,,,27.14,Fee Schedule,215% Medicaid Laboratory Fee Schedule,27.14,,,27.14,Fee Schedule,215% Medicaid Laboratory Fee Schedule,15.78,,,15.78,Fee Schedule,125% Medicaid Laboratory Fee Schedule,12.63,150.5,
ANGIOTENSIN I ENZYME TEST       ,82164,CPT,,40121204,CDM,301,RC,,,both,,,233,24.01,,,24.01,Other,150% of Medicare + 9.63% HCRA Surcharge,14.6,,,14.6,Fee Schedule,Mediare Clinical Lab,28.18,,,28.18,Fee Schedule,,25.4,,,25.4,Fee Schedule,,147.48,,,147.48,Fee Schedule,,132.69,,,132.69,Fee Schedule,,125.29,,,125.29,Fee Schedule,,116.5,50,,116.5,percent of total billed charges,All Other,30.84,,,30.84,Fee Schedule,,45.99,,,45.99,Fee Schedule,,65.35,,,65.35,Other,186% Medicaid methodology,54.17,,,54.17,Fee Schedule,,144.46,,,144.46,Fee Schedule,,30.66,,,30.66,Fee Schedule,,54.17,,,54.17,Fee Schedule,,144.46,,,144.46,Fee Schedule,,57.67,,,57.67,Fee Schedule,,163.1,70,,163.1,percent of total billed charges,All Other,69.61,,,69.61,Fee Schedule,,59.06,,,59.06,Fee Schedule,,17.52,,,17.52,Fee Schedule,,17.52,,,17.52,Fee Schedule,,17.52,,,17.52,Fee Schedule,,17.52,,,17.52,Fee Schedule,,35.13,,,35.13,Other,New York Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,53.75,,,53.75,Other,153% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,49.19,,,49.19,Other,140% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,91.35,,,91.35,Other,260% Medicaid APG methodology,113.83,,,113.83,Other,324% Medicaid APG methodology,75.54,,,75.54,Other,215% Medicaid APG methodology,75.54,,,75.54,Other,215% Medicaid APG methodology,43.92,,,43.92,Other,125% Medicaid APG methodology,14.6,163.1,
ASSAY OF BETA-2 PROTEIN         ,82232,CPT,,40121246,CDM,301,RC,,,both,,,258,26.61,,,26.61,Other,150% of Medicare + 9.63% HCRA Surcharge,16.18,,,16.18,Fee Schedule,Mediare Clinical Lab,31.23,,,31.23,Fee Schedule,,28.15,,,28.15,Fee Schedule,,163.42,,,163.42,Fee Schedule,,147.03,,,147.03,Fee Schedule,,138.84,,,138.84,Fee Schedule,,129,50,,129,percent of total billed charges,All Other,34.19,,,34.19,Fee Schedule,,50.97,,,50.97,Fee Schedule,,23.48,,,23.48,Other,186% Medicaid methodology,60.03,,,60.03,Fee Schedule,,159.96,,,159.96,Fee Schedule,,33.98,,,33.98,Fee Schedule,,60.03,,,60.03,Fee Schedule,,159.96,,,159.96,Fee Schedule,,63.91,,,63.91,Fee Schedule,,180.6,70,,180.6,percent of total billed charges,All Other,77.15,,,77.15,Fee Schedule,,65.46,,,65.46,Fee Schedule,,19.42,,,19.42,Fee Schedule,,19.42,,,19.42,Fee Schedule,,19.42,,,19.42,Fee Schedule,,19.42,,,19.42,Fee Schedule,,12.63,,,12.63,Fee Schedule,Medicaid Laboratory Fee Schedule,12.63,,,12.63,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.63,,,12.63,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.63,,,12.63,Fee Schedule,100% Medicaid Laboratory Fee Schedule,28.41,,,28.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,28.41,,,28.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.32,,,19.32,Fee Schedule,153% Medicaid Laboratory Fee Schedule,28.41,,,28.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.68,,,17.68,Fee Schedule,140% Medicaid Laboratory Fee Schedule,28.41,,,28.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,32.83,,,32.83,Fee Schedule,260% Medicaid Laboratory Fee Schedule,40.91,,,40.91,Fee Schedule,324% Medicaid Laboratory Fee Schedule,27.14,,,27.14,Fee Schedule,215% Medicaid Laboratory Fee Schedule,27.14,,,27.14,Fee Schedule,215% Medicaid Laboratory Fee Schedule,15.78,,,15.78,Fee Schedule,125% Medicaid Laboratory Fee Schedule,12.63,180.6,
NPM1 GENE                       ,81310,CPT,,40121311,CDM,301,RC,,,both,,,1734,405.39,,,405.39,Other,150% of Medicare + 9.63% HCRA Surcharge,246.52,,,246.52,Fee Schedule,Mediare Clinical Lab,475.78,,,475.78,Fee Schedule,,428.94,,,428.94,Fee Schedule,,14.5,,,14.5,Fee Schedule,,14.5,,,14.5,Fee Schedule,,14.5,,,14.5,Fee Schedule,,867,50,,867,percent of total billed charges,All Other,520.78,,,520.78,Fee Schedule,,776.54,,,776.54,Fee Schedule,,458.53,,,458.53,Other,186% Medicaid methodology,914.59,,,914.59,Fee Schedule,,1075.08,,,1075.08,Fee Schedule,,517.69,,,517.69,Fee Schedule,,914.59,,,914.59,Fee Schedule,,1075.08,,,1075.08,Fee Schedule,,973.75,,,973.75,Fee Schedule,,1213.8,70,,1213.8,percent of total billed charges,All Other,1175.39,,,1175.39,Fee Schedule,,997.3,,,997.3,Fee Schedule,,295.82,,,295.82,Fee Schedule,,295.82,,,295.82,Fee Schedule,,295.82,,,295.82,Fee Schedule,,295.82,,,295.82,Fee Schedule,,246.52,,,246.52,Fee Schedule,Medicaid Laboratory Fee Schedule,246.52,,,246.52,Fee Schedule,100% Medicaid Laboratory Fee Schedule,246.52,,,246.52,Fee Schedule,100% Medicaid Laboratory Fee Schedule,246.52,,,246.52,Fee Schedule,100% Medicaid Laboratory Fee Schedule,554.67,,,554.67,Fee Schedule,225% Medicaid Laboratory Fee Schedule,554.67,,,554.67,Fee Schedule,225% Medicaid Laboratory Fee Schedule,377.18,,,377.18,Fee Schedule,153% Medicaid Laboratory Fee Schedule,554.67,,,554.67,Fee Schedule,225% Medicaid Laboratory Fee Schedule,345.13,,,345.13,Fee Schedule,140% Medicaid Laboratory Fee Schedule,554.67,,,554.67,Fee Schedule,225% Medicaid Laboratory Fee Schedule,640.95,,,640.95,Fee Schedule,260% Medicaid Laboratory Fee Schedule,798.72,,,798.72,Fee Schedule,324% Medicaid Laboratory Fee Schedule,530.02,,,530.02,Fee Schedule,215% Medicaid Laboratory Fee Schedule,530.02,,,530.02,Fee Schedule,215% Medicaid Laboratory Fee Schedule,308.15,,,308.15,Fee Schedule,125% Medicaid Laboratory Fee Schedule,14.5,1213.8,
ASSAY OF CALCITONIN             ,82308,CPT,,40121329,CDM,301,RC,,,both,,,427,44.05,,,44.05,Other,150% of Medicare + 9.63% HCRA Surcharge,26.79,,,26.79,Fee Schedule,Mediare Clinical Lab,51.7,,,51.7,Fee Schedule,,46.61,,,46.61,Fee Schedule,,270.61,,,270.61,Fee Schedule,,243.48,,,243.48,Fee Schedule,,229.91,,,229.91,Fee Schedule,,213.5,50,,213.5,percent of total billed charges,All Other,56.58,,,56.58,Fee Schedule,,84.39,,,84.39,Fee Schedule,,49.83,,,49.83,Other,186% Medicaid methodology,99.39,,,99.39,Fee Schedule,,264.74,,,264.74,Fee Schedule,,56.26,,,56.26,Fee Schedule,,99.39,,,99.39,Fee Schedule,,264.74,,,264.74,Fee Schedule,,105.82,,,105.82,Fee Schedule,,298.9,70,,298.9,percent of total billed charges,All Other,127.73,,,127.73,Fee Schedule,,108.38,,,108.38,Fee Schedule,,32.15,,,32.15,Fee Schedule,,32.15,,,32.15,Fee Schedule,,32.15,,,32.15,Fee Schedule,,32.15,,,32.15,Fee Schedule,,26.79,,,26.79,Fee Schedule,Medicaid Laboratory Fee Schedule,26.79,,,26.79,Fee Schedule,100% Medicaid Laboratory Fee Schedule,26.79,,,26.79,Fee Schedule,100% Medicaid Laboratory Fee Schedule,26.79,,,26.79,Fee Schedule,100% Medicaid Laboratory Fee Schedule,60.28,,,60.28,Fee Schedule,225% Medicaid Laboratory Fee Schedule,60.28,,,60.28,Fee Schedule,225% Medicaid Laboratory Fee Schedule,40.99,,,40.99,Fee Schedule,153% Medicaid Laboratory Fee Schedule,60.28,,,60.28,Fee Schedule,225% Medicaid Laboratory Fee Schedule,37.51,,,37.51,Fee Schedule,140% Medicaid Laboratory Fee Schedule,60.28,,,60.28,Fee Schedule,225% Medicaid Laboratory Fee Schedule,69.65,,,69.65,Fee Schedule,260% Medicaid Laboratory Fee Schedule,86.8,,,86.8,Fee Schedule,324% Medicaid Laboratory Fee Schedule,57.6,,,57.6,Fee Schedule,215% Medicaid Laboratory Fee Schedule,57.6,,,57.6,Fee Schedule,215% Medicaid Laboratory Fee Schedule,33.49,,,33.49,Fee Schedule,125% Medicaid Laboratory Fee Schedule,26.79,298.9,
PML/RARALPHA COM BREAKPOINTS    ,81315,CPT,,40121337,CDM,301,RC,,,both,,,1984,340.91,,,340.91,Other,150% of Medicare + 9.63% HCRA Surcharge,207.31,,,207.31,Fee Schedule,Mediare Clinical Lab,400.11,,,400.11,Fee Schedule,,360.72,,,360.72,Fee Schedule,,39.53,,,39.53,Fee Schedule,,39.53,,,39.53,Fee Schedule,,39.53,,,39.53,Fee Schedule,,992,50,,992,percent of total billed charges,All Other,437.94,,,437.94,Fee Schedule,,653.03,,,653.03,Fee Schedule,,385.6,,,385.6,Other,186% Medicaid methodology,769.12,,,769.12,Fee Schedule,,1230.08,,,1230.08,Fee Schedule,,435.35,,,435.35,Fee Schedule,,769.12,,,769.12,Fee Schedule,,1230.08,,,1230.08,Fee Schedule,,818.87,,,818.87,Fee Schedule,,1388.8,70,,1388.8,percent of total billed charges,All Other,988.44,,,988.44,Fee Schedule,,838.68,,,838.68,Fee Schedule,,248.77,,,248.77,Fee Schedule,,248.77,,,248.77,Fee Schedule,,248.77,,,248.77,Fee Schedule,,248.77,,,248.77,Fee Schedule,,207.31,,,207.31,Fee Schedule,Medicaid Laboratory Fee Schedule,207.31,,,207.31,Fee Schedule,100% Medicaid Laboratory Fee Schedule,207.31,,,207.31,Fee Schedule,100% Medicaid Laboratory Fee Schedule,207.31,,,207.31,Fee Schedule,100% Medicaid Laboratory Fee Schedule,466.45,,,466.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,466.45,,,466.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,317.18,,,317.18,Fee Schedule,153% Medicaid Laboratory Fee Schedule,466.45,,,466.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,290.23,,,290.23,Fee Schedule,140% Medicaid Laboratory Fee Schedule,466.45,,,466.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,539.01,,,539.01,Fee Schedule,260% Medicaid Laboratory Fee Schedule,671.68,,,671.68,Fee Schedule,324% Medicaid Laboratory Fee Schedule,445.72,,,445.72,Fee Schedule,215% Medicaid Laboratory Fee Schedule,445.72,,,445.72,Fee Schedule,215% Medicaid Laboratory Fee Schedule,259.14,,,259.14,Fee Schedule,125% Medicaid Laboratory Fee Schedule,39.53,1388.8,
ASSAY CARBOXYHB QUANT           ,82375,CPT,,40121345,CDM,301,RC,,,both,,,197,20.26,,,20.26,Other,150% of Medicare + 9.63% HCRA Surcharge,12.32,,,12.32,Fee Schedule,Mediare Clinical Lab,23.78,,,23.78,Fee Schedule,,21.44,,,21.44,Fee Schedule,,124.57,,,124.57,Fee Schedule,,112.08,,,112.08,Fee Schedule,,105.84,,,105.84,Fee Schedule,,98.5,50,,98.5,percent of total billed charges,All Other,26.03,,,26.03,Fee Schedule,,38.81,,,38.81,Fee Schedule,,20.66,,,20.66,Other,186% Medicaid methodology,45.71,,,45.71,Fee Schedule,,122.14,,,122.14,Fee Schedule,,25.87,,,25.87,Fee Schedule,,45.71,,,45.71,Fee Schedule,,122.14,,,122.14,Fee Schedule,,48.66,,,48.66,Fee Schedule,,137.9,70,,137.9,percent of total billed charges,All Other,58.74,,,58.74,Fee Schedule,,49.84,,,49.84,Fee Schedule,,14.78,,,14.78,Fee Schedule,,14.78,,,14.78,Fee Schedule,,14.78,,,14.78,Fee Schedule,,14.78,,,14.78,Fee Schedule,,11.11,,,11.11,Fee Schedule,Medicaid Laboratory Fee Schedule,11.11,,,11.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.11,,,11.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.11,,,11.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,25,,,25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,25,,,25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17,,,17,Fee Schedule,153% Medicaid Laboratory Fee Schedule,25,,,25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.55,,,15.55,Fee Schedule,140% Medicaid Laboratory Fee Schedule,25,,,25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,28.89,,,28.89,Fee Schedule,260% Medicaid Laboratory Fee Schedule,36,,,36,Fee Schedule,324% Medicaid Laboratory Fee Schedule,23.89,,,23.89,Fee Schedule,215% Medicaid Laboratory Fee Schedule,23.89,,,23.89,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.89,,,13.89,Fee Schedule,125% Medicaid Laboratory Fee Schedule,11.11,137.9,
ASSAY OF CARNITINE              ,82379,CPT,,40121360,CDM,301,RC,,,both,,,170,27.74,,,27.74,Other,150% of Medicare + 9.63% HCRA Surcharge,16.87,,,16.87,Fee Schedule,Mediare Clinical Lab,32.56,,,32.56,Fee Schedule,,29.35,,,29.35,Fee Schedule,,145.61,,,145.61,Fee Schedule,,131.01,,,131.01,Fee Schedule,,123.71,,,123.71,Fee Schedule,,85,50,,85,percent of total billed charges,All Other,35.65,,,35.65,Fee Schedule,,53.14,,,53.14,Fee Schedule,,19.73,,,19.73,Other,186% Medicaid methodology,62.59,,,62.59,Fee Schedule,,105.4,,,105.4,Fee Schedule,,35.43,,,35.43,Fee Schedule,,62.59,,,62.59,Fee Schedule,,105.4,,,105.4,Fee Schedule,,66.64,,,66.64,Fee Schedule,,119,70,,119,percent of total billed charges,All Other,80.44,,,80.44,Fee Schedule,,68.25,,,68.25,Fee Schedule,,20.24,,,20.24,Fee Schedule,,20.24,,,20.24,Fee Schedule,,20.24,,,20.24,Fee Schedule,,20.24,,,20.24,Fee Schedule,,10.61,,,10.61,Fee Schedule,Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.23,,,16.23,Fee Schedule,153% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.85,,,14.85,Fee Schedule,140% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.57,,,27.57,Fee Schedule,260% Medicaid Laboratory Fee Schedule,34.36,,,34.36,Fee Schedule,324% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.26,,,13.26,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.61,145.61,
CARCINOEMBRYONIC ANTIGEN        ,82378,CPT,,40121402,CDM,301,RC,,,both,,,302,31.18,,,31.18,Other,150% of Medicare + 9.63% HCRA Surcharge,18.96,,,18.96,Fee Schedule,Mediare Clinical Lab,36.59,,,36.59,Fee Schedule,,32.99,,,32.99,Fee Schedule,,191.71,,,191.71,Fee Schedule,,172.48,,,172.48,Fee Schedule,,162.87,,,162.87,Fee Schedule,,151,50,,151,percent of total billed charges,All Other,40.04,,,40.04,Fee Schedule,,59.72,,,59.72,Fee Schedule,,35.27,,,35.27,Other,186% Medicaid methodology,70.34,,,70.34,Fee Schedule,,187.24,,,187.24,Fee Schedule,,39.82,,,39.82,Fee Schedule,,70.34,,,70.34,Fee Schedule,,187.24,,,187.24,Fee Schedule,,74.89,,,74.89,Fee Schedule,,211.4,70,,211.4,percent of total billed charges,All Other,90.4,,,90.4,Fee Schedule,,76.7,,,76.7,Fee Schedule,,22.75,,,22.75,Fee Schedule,,22.75,,,22.75,Fee Schedule,,22.75,,,22.75,Fee Schedule,,22.75,,,22.75,Fee Schedule,,18.96,,,18.96,Fee Schedule,Medicaid Laboratory Fee Schedule,18.96,,,18.96,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.96,,,18.96,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.96,,,18.96,Fee Schedule,100% Medicaid Laboratory Fee Schedule,42.66,,,42.66,Fee Schedule,225% Medicaid Laboratory Fee Schedule,42.66,,,42.66,Fee Schedule,225% Medicaid Laboratory Fee Schedule,29.01,,,29.01,Fee Schedule,153% Medicaid Laboratory Fee Schedule,42.66,,,42.66,Fee Schedule,225% Medicaid Laboratory Fee Schedule,26.54,,,26.54,Fee Schedule,140% Medicaid Laboratory Fee Schedule,42.66,,,42.66,Fee Schedule,225% Medicaid Laboratory Fee Schedule,49.3,,,49.3,Fee Schedule,260% Medicaid Laboratory Fee Schedule,61.43,,,61.43,Fee Schedule,324% Medicaid Laboratory Fee Schedule,40.76,,,40.76,Fee Schedule,215% Medicaid Laboratory Fee Schedule,40.76,,,40.76,Fee Schedule,215% Medicaid Laboratory Fee Schedule,23.7,,,23.7,Fee Schedule,125% Medicaid Laboratory Fee Schedule,18.96,211.4,
ASSAY OF CERULOPLASMIN          ,82390,CPT,,40121428,CDM,301,RC,,,both,,,171,17.66,,,17.66,Other,150% of Medicare + 9.63% HCRA Surcharge,10.74,,,10.74,Fee Schedule,Mediare Clinical Lab,20.73,,,20.73,Fee Schedule,,18.69,,,18.69,Fee Schedule,,76.11,,,76.11,Fee Schedule,,68.48,,,68.48,Fee Schedule,,64.66,,,64.66,Fee Schedule,,85.5,50,,85.5,percent of total billed charges,All Other,22.69,,,22.69,Fee Schedule,,33.83,,,33.83,Fee Schedule,,15.22,,,15.22,Other,186% Medicaid methodology,39.85,,,39.85,Fee Schedule,,106.02,,,106.02,Fee Schedule,,22.55,,,22.55,Fee Schedule,,39.85,,,39.85,Fee Schedule,,106.02,,,106.02,Fee Schedule,,42.42,,,42.42,Fee Schedule,,119.7,70,,119.7,percent of total billed charges,All Other,51.21,,,51.21,Fee Schedule,,43.45,,,43.45,Fee Schedule,,12.89,,,12.89,Fee Schedule,,12.89,,,12.89,Fee Schedule,,12.89,,,12.89,Fee Schedule,,12.89,,,12.89,Fee Schedule,,8.18,,,8.18,Fee Schedule,Medicaid Laboratory Fee Schedule,8.18,,,8.18,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.18,,,8.18,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.18,,,8.18,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.41,,,18.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.41,,,18.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.52,,,12.52,Fee Schedule,153% Medicaid Laboratory Fee Schedule,18.41,,,18.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.45,,,11.45,Fee Schedule,140% Medicaid Laboratory Fee Schedule,18.41,,,18.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.27,,,21.27,Fee Schedule,260% Medicaid Laboratory Fee Schedule,26.51,,,26.51,Fee Schedule,324% Medicaid Laboratory Fee Schedule,17.59,,,17.59,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.59,,,17.59,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.23,,,10.23,Fee Schedule,125% Medicaid Laboratory Fee Schedule,8.18,119.7,
ASSAY OF GASTRIN                ,82941,CPT,,40121543,CDM,301,RC,,,both,,,280,28.99,,,28.99,Other,150% of Medicare + 9.63% HCRA Surcharge,17.63,,,17.63,Fee Schedule,Mediare Clinical Lab,34.03,,,34.03,Fee Schedule,,30.68,,,30.68,Fee Schedule,,178.21,,,178.21,Fee Schedule,,160.34,,,160.34,Fee Schedule,,151.4,,,151.4,Fee Schedule,,140,50,,140,percent of total billed charges,All Other,37.25,,,37.25,Fee Schedule,,55.53,,,55.53,Fee Schedule,,32.79,,,32.79,Other,186% Medicaid methodology,65.41,,,65.41,Fee Schedule,,173.6,,,173.6,Fee Schedule,,37.02,,,37.02,Fee Schedule,,65.41,,,65.41,Fee Schedule,,173.6,,,173.6,Fee Schedule,,69.64,,,69.64,Fee Schedule,,196,70,,196,percent of total billed charges,All Other,84.06,,,84.06,Fee Schedule,,71.32,,,71.32,Fee Schedule,,21.16,,,21.16,Fee Schedule,,21.16,,,21.16,Fee Schedule,,21.16,,,21.16,Fee Schedule,,21.16,,,21.16,Fee Schedule,,17.63,,,17.63,Fee Schedule,Medicaid Laboratory Fee Schedule,17.63,,,17.63,Fee Schedule,100% Medicaid Laboratory Fee Schedule,17.63,,,17.63,Fee Schedule,100% Medicaid Laboratory Fee Schedule,17.63,,,17.63,Fee Schedule,100% Medicaid Laboratory Fee Schedule,39.67,,,39.67,Fee Schedule,225% Medicaid Laboratory Fee Schedule,39.67,,,39.67,Fee Schedule,225% Medicaid Laboratory Fee Schedule,26.97,,,26.97,Fee Schedule,153% Medicaid Laboratory Fee Schedule,39.67,,,39.67,Fee Schedule,225% Medicaid Laboratory Fee Schedule,24.68,,,24.68,Fee Schedule,140% Medicaid Laboratory Fee Schedule,39.67,,,39.67,Fee Schedule,225% Medicaid Laboratory Fee Schedule,45.84,,,45.84,Fee Schedule,260% Medicaid Laboratory Fee Schedule,57.12,,,57.12,Fee Schedule,324% Medicaid Laboratory Fee Schedule,37.9,,,37.9,Fee Schedule,215% Medicaid Laboratory Fee Schedule,37.9,,,37.9,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.04,,,22.04,Fee Schedule,125% Medicaid Laboratory Fee Schedule,17.63,196,
ELASTASE PANCREATIC FECAL QUAN  ,82653,CPT,,40121592,CDM,301,RC,,,both,,,366,37.77,,,37.77,Other,150% of Medicare + 9.63% HCRA Surcharge,22.97,,,22.97,Fee Schedule,Mediare Clinical Lab,44.33,,,44.33,Fee Schedule,,39.97,,,39.97,Fee Schedule,,22.97,,,22.97,Fee Schedule,,22.97,,,22.97,Fee Schedule,,22.97,,,22.97,Fee Schedule,,183,50,,183,percent of total billed charges,All Other,256.2,70,,256.2,percent of total billed charges,All Other,72.36,,,72.36,Fee Schedule,,25.89,,,25.89,Other,186% Medicaid methodology,85.22,,,85.22,Fee Schedule,,226.92,,,226.92,Fee Schedule,,48.24,,,48.24,Fee Schedule,,85.22,,,85.22,Fee Schedule,,226.92,,,226.92,Fee Schedule,,90.73,,,90.73,Fee Schedule,,256.2,70,,256.2,percent of total billed charges,All Other,109.52,,,109.52,Fee Schedule,,92.93,,,92.93,Fee Schedule,,27.56,,,27.56,Fee Schedule,,27.56,,,27.56,Fee Schedule,,27.56,,,27.56,Fee Schedule,,27.56,,,27.56,Fee Schedule,,13.92,,,13.92,Fee Schedule,Medicaid Laboratory Fee Schedule,13.92,,,13.92,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.92,,,13.92,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.92,,,13.92,Fee Schedule,100% Medicaid Laboratory Fee Schedule,31.32,,,31.32,Fee Schedule,225% Medicaid Laboratory Fee Schedule,31.32,,,31.32,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.29,,,21.29,Fee Schedule,153% Medicaid Laboratory Fee Schedule,31.32,,,31.32,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.48,,,19.48,Fee Schedule,140% Medicaid Laboratory Fee Schedule,31.32,,,31.32,Fee Schedule,225% Medicaid Laboratory Fee Schedule,36.19,,,36.19,Fee Schedule,260% Medicaid Laboratory Fee Schedule,45.09,,,45.09,Fee Schedule,324% Medicaid Laboratory Fee Schedule,29.92,,,29.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,29.92,,,29.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.4,,,17.4,Fee Schedule,125% Medicaid Laboratory Fee Schedule,13.92,256.2,
ASSAY OF INTERLEUKIN 6          ,83529,CPT,,40121618,CDM,301,RC,,,both,,,275,28.4,,,28.4,Other,150% of Medicare + 9.63% HCRA Surcharge,17.27,,,17.27,Fee Schedule,Mediare Clinical Lab,33.33,,,33.33,Fee Schedule,,30.05,,,30.05,Fee Schedule,,17.27,,,17.27,Fee Schedule,,17.27,,,17.27,Fee Schedule,,17.27,,,17.27,Fee Schedule,,137.5,50,,137.5,percent of total billed charges,All Other,192.5,70,,192.5,percent of total billed charges,All Other,54.4,,,54.4,Fee Schedule,,19.46,,,19.46,Other,186% Medicaid methodology,64.07,,,64.07,Fee Schedule,,170.5,,,170.5,Fee Schedule,,36.27,,,36.27,Fee Schedule,,64.07,,,64.07,Fee Schedule,,170.5,,,170.5,Fee Schedule,,68.22,,,68.22,Fee Schedule,,192.5,70,,192.5,percent of total billed charges,All Other,82.34,,,82.34,Fee Schedule,,69.87,,,69.87,Fee Schedule,,20.72,,,20.72,Fee Schedule,,20.72,,,20.72,Fee Schedule,,20.72,,,20.72,Fee Schedule,,20.72,,,20.72,Fee Schedule,,10.46,,,10.46,Fee Schedule,Medicaid Laboratory Fee Schedule,10.46,,,10.46,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.46,,,10.46,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.46,,,10.46,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.54,,,23.54,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.54,,,23.54,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.01,,,16.01,Fee Schedule,153% Medicaid Laboratory Fee Schedule,23.54,,,23.54,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.65,,,14.65,Fee Schedule,140% Medicaid Laboratory Fee Schedule,23.54,,,23.54,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.21,,,27.21,Fee Schedule,260% Medicaid Laboratory Fee Schedule,33.9,,,33.9,Fee Schedule,324% Medicaid Laboratory Fee Schedule,22.5,,,22.5,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.5,,,22.5,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.08,,,13.08,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.46,192.5,
ASSAY OF LEAD                   ,83655,CPT,,40121626,CDM,301,RC,,,both,,,193,19.91,,,19.91,Other,150% of Medicare + 9.63% HCRA Surcharge,12.11,,,12.11,Fee Schedule,Mediare Clinical Lab,23.37,,,23.37,Fee Schedule,,21.07,,,21.07,Fee Schedule,,122.28,,,122.28,Fee Schedule,,110.01,,,110.01,Fee Schedule,,103.88,,,103.88,Fee Schedule,,96.5,50,,96.5,percent of total billed charges,All Other,25.58,,,25.58,Fee Schedule,,38.15,,,38.15,Fee Schedule,,22.52,,,22.52,Other,186% Medicaid methodology,44.93,,,44.93,Fee Schedule,,119.66,,,119.66,Fee Schedule,,25.43,,,25.43,Fee Schedule,,44.93,,,44.93,Fee Schedule,,119.66,,,119.66,Fee Schedule,,47.83,,,47.83,Fee Schedule,,135.1,70,,135.1,percent of total billed charges,All Other,57.74,,,57.74,Fee Schedule,,48.99,,,48.99,Fee Schedule,,14.53,,,14.53,Fee Schedule,,14.53,,,14.53,Fee Schedule,,14.53,,,14.53,Fee Schedule,,14.53,,,14.53,Fee Schedule,,12.11,,,12.11,Fee Schedule,Medicaid Laboratory Fee Schedule,12.11,,,12.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.11,,,12.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.11,,,12.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,27.25,,,27.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.25,,,27.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.53,,,18.53,Fee Schedule,153% Medicaid Laboratory Fee Schedule,27.25,,,27.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.95,,,16.95,Fee Schedule,140% Medicaid Laboratory Fee Schedule,27.25,,,27.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,31.49,,,31.49,Fee Schedule,260% Medicaid Laboratory Fee Schedule,39.24,,,39.24,Fee Schedule,324% Medicaid Laboratory Fee Schedule,26.04,,,26.04,Fee Schedule,215% Medicaid Laboratory Fee Schedule,26.04,,,26.04,Fee Schedule,215% Medicaid Laboratory Fee Schedule,15.14,,,15.14,Fee Schedule,125% Medicaid Laboratory Fee Schedule,12.11,135.1,
ASSAY OF MYOGLOBIN              ,83874,CPT,,40121667,CDM,301,RC,,,both,,,206,21.25,,,21.25,Other,150% of Medicare + 9.63% HCRA Surcharge,12.92,,,12.92,Fee Schedule,Mediare Clinical Lab,24.94,,,24.94,Fee Schedule,,22.48,,,22.48,Fee Schedule,,120.34,,,120.34,Fee Schedule,,108.27,,,108.27,Fee Schedule,,102.24,,,102.24,Fee Schedule,,103,50,,103,percent of total billed charges,All Other,27.3,,,27.3,Fee Schedule,,40.7,,,40.7,Fee Schedule,,65.35,,,65.35,Other,186% Medicaid methodology,47.93,,,47.93,Fee Schedule,,127.72,,,127.72,Fee Schedule,,27.13,,,27.13,Fee Schedule,,47.93,,,47.93,Fee Schedule,,127.72,,,127.72,Fee Schedule,,51.03,,,51.03,Fee Schedule,,144.2,70,,144.2,percent of total billed charges,All Other,61.6,,,61.6,Fee Schedule,,52.27,,,52.27,Fee Schedule,,15.5,,,15.5,Fee Schedule,,15.5,,,15.5,Fee Schedule,,15.5,,,15.5,Fee Schedule,,15.5,,,15.5,Fee Schedule,,35.13,,,35.13,Other,New York Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,53.75,,,53.75,Other,153% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,49.19,,,49.19,Other,140% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,91.35,,,91.35,Other,260% Medicaid APG methodology,113.83,,,113.83,Other,324% Medicaid APG methodology,75.54,,,75.54,Other,215% Medicaid APG methodology,75.54,,,75.54,Other,215% Medicaid APG methodology,43.92,,,43.92,Other,125% Medicaid APG methodology,12.92,144.2,
HLA I TYPING 1 ANTIGEN LR       ,81374,CPT,,40121675,CDM,301,RC,,,both,,,1182,122.23,,,122.23,Other,150% of Medicare + 9.63% HCRA Surcharge,74.33,,,74.33,Fee Schedule,Mediare Clinical Lab,143.46,,,143.46,Fee Schedule,,129.33,,,129.33,Fee Schedule,,124.6,,,124.6,Fee Schedule,,124.6,,,124.6,Fee Schedule,,124.6,,,124.6,Fee Schedule,,591,50,,591,percent of total billed charges,All Other,157.01,,,157.01,Fee Schedule,,234.14,,,234.14,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,275.76,,,275.76,Fee Schedule,,732.84,,,732.84,Fee Schedule,,156.09,,,156.09,Fee Schedule,,275.76,,,275.76,Fee Schedule,,732.84,,,732.84,Fee Schedule,,293.6,,,293.6,Fee Schedule,,827.4,70,,827.4,percent of total billed charges,All Other,354.4,,,354.4,Fee Schedule,,300.7,,,300.7,Fee Schedule,,89.2,,,89.2,Fee Schedule,,89.2,,,89.2,Fee Schedule,,89.2,,,89.2,Fee Schedule,,89.2,,,89.2,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,827.4,
ASSAY OF OSTEOCALCIN            ,83937,CPT,,40121725,CDM,301,RC,,,both,,,475,49.09,,,49.09,Other,150% of Medicare + 9.63% HCRA Surcharge,29.85,,,29.85,Fee Schedule,Mediare Clinical Lab,57.61,,,57.61,Fee Schedule,,51.94,,,51.94,Fee Schedule,,301.63,,,301.63,Fee Schedule,,271.38,,,271.38,Fee Schedule,,256.26,,,256.26,Fee Schedule,,237.5,50,,237.5,percent of total billed charges,All Other,63.05,,,63.05,Fee Schedule,,94.03,,,94.03,Fee Schedule,,122.22,,,122.22,Other,186% Medicaid methodology,110.74,,,110.74,Fee Schedule,,294.5,,,294.5,Fee Schedule,,62.69,,,62.69,Fee Schedule,,110.74,,,110.74,Fee Schedule,,294.5,,,294.5,Fee Schedule,,117.91,,,117.91,Fee Schedule,,332.5,70,,332.5,percent of total billed charges,All Other,142.32,,,142.32,Fee Schedule,,120.76,,,120.76,Fee Schedule,,35.82,,,35.82,Fee Schedule,,35.82,,,35.82,Fee Schedule,,35.82,,,35.82,Fee Schedule,,35.82,,,35.82,Fee Schedule,,65.71,,,65.71,Other,New York Medicaid APG methodology,65.71,,,65.71,Other,100% Medicaid APG methodology,65.71,,,65.71,Other,100% Medicaid APG methodology,65.71,,,65.71,Other,100% Medicaid APG methodology,147.85,,,147.85,Other,225% Medicaid APG methodology,147.85,,,147.85,Other,225% Medicaid APG methodology,100.54,,,100.54,Other,153% Medicaid APG methodology,147.85,,,147.85,Other,225% Medicaid APG methodology,92,,,92,Other,140% Medicaid APG methodology,147.85,,,147.85,Other,225% Medicaid APG methodology,170.85,,,170.85,Other,260% Medicaid APG methodology,212.9,,,212.9,Other,324% Medicaid APG methodology,141.28,,,141.28,Other,215% Medicaid APG methodology,141.28,,,141.28,Other,215% Medicaid APG methodology,82.14,,,82.14,Other,125% Medicaid APG methodology,29.85,332.5,
ASSAY OF PREALBUMIN             ,84134,CPT,,40121741,CDM,301,RC,,,both,,,233,23.99,,,23.99,Other,150% of Medicare + 9.63% HCRA Surcharge,14.59,,,14.59,Fee Schedule,Mediare Clinical Lab,28.16,,,28.16,Fee Schedule,,25.39,,,25.39,Fee Schedule,,56.43,,,56.43,Fee Schedule,,50.78,,,50.78,Fee Schedule,,47.95,,,47.95,Fee Schedule,,116.5,50,,116.5,percent of total billed charges,All Other,30.81,,,30.81,Fee Schedule,,45.96,,,45.96,Fee Schedule,,13.75,,,13.75,Other,186% Medicaid methodology,54.13,,,54.13,Fee Schedule,,144.46,,,144.46,Fee Schedule,,30.64,,,30.64,Fee Schedule,,54.13,,,54.13,Fee Schedule,,144.46,,,144.46,Fee Schedule,,57.63,,,57.63,Fee Schedule,,163.1,70,,163.1,percent of total billed charges,All Other,69.56,,,69.56,Fee Schedule,,59.02,,,59.02,Fee Schedule,,17.51,,,17.51,Fee Schedule,,17.51,,,17.51,Fee Schedule,,17.51,,,17.51,Fee Schedule,,17.51,,,17.51,Fee Schedule,,7.39,,,7.39,Fee Schedule,Medicaid Laboratory Fee Schedule,7.39,,,7.39,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.39,,,7.39,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.39,,,7.39,Fee Schedule,100% Medicaid Laboratory Fee Schedule,16.63,,,16.63,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.63,,,16.63,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.31,,,11.31,Fee Schedule,153% Medicaid Laboratory Fee Schedule,16.63,,,16.63,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.35,,,10.35,Fee Schedule,140% Medicaid Laboratory Fee Schedule,16.63,,,16.63,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.22,,,19.22,Fee Schedule,260% Medicaid Laboratory Fee Schedule,23.95,,,23.95,Fee Schedule,324% Medicaid Laboratory Fee Schedule,15.9,,,15.9,Fee Schedule,215% Medicaid Laboratory Fee Schedule,15.9,,,15.9,Fee Schedule,215% Medicaid Laboratory Fee Schedule,9.24,,,9.24,Fee Schedule,125% Medicaid Laboratory Fee Schedule,7.39,163.1,
KAPPA FREE LIGHT CHAINS         ,83521,CPT,,40121758,CDM,301,RC,,,both,,,275,28.4,,,28.4,Other,150% of Medicare + 9.63% HCRA Surcharge,17.27,,,17.27,Fee Schedule,Mediare Clinical Lab,33.33,,,33.33,Fee Schedule,,30.05,,,30.05,Fee Schedule,,17.27,,,17.27,Fee Schedule,,17.27,,,17.27,Fee Schedule,,17.27,,,17.27,Fee Schedule,,137.5,50,,137.5,percent of total billed charges,All Other,192.5,70,,192.5,percent of total billed charges,All Other,54.4,,,54.4,Fee Schedule,,19.46,,,19.46,Other,186% Medicaid methodology,64.07,,,64.07,Fee Schedule,,170.5,,,170.5,Fee Schedule,,36.27,,,36.27,Fee Schedule,,64.07,,,64.07,Fee Schedule,,170.5,,,170.5,Fee Schedule,,68.22,,,68.22,Fee Schedule,,192.5,70,,192.5,percent of total billed charges,All Other,82.34,,,82.34,Fee Schedule,,69.87,,,69.87,Fee Schedule,,20.72,,,20.72,Fee Schedule,,20.72,,,20.72,Fee Schedule,,20.72,,,20.72,Fee Schedule,,20.72,,,20.72,Fee Schedule,,10.46,,,10.46,Fee Schedule,Medicaid Laboratory Fee Schedule,10.46,,,10.46,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.46,,,10.46,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.46,,,10.46,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.54,,,23.54,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.54,,,23.54,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.01,,,16.01,Fee Schedule,153% Medicaid Laboratory Fee Schedule,23.54,,,23.54,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.65,,,14.65,Fee Schedule,140% Medicaid Laboratory Fee Schedule,23.54,,,23.54,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.21,,,27.21,Fee Schedule,260% Medicaid Laboratory Fee Schedule,33.9,,,33.9,Fee Schedule,324% Medicaid Laboratory Fee Schedule,22.5,,,22.5,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.5,,,22.5,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.08,,,13.08,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.46,192.5,
ASSAY OF PSA TOTAL              ,84153,CPT,,40121766,CDM,301,RC,,,both,,,293,30.24,,,30.24,Other,150% of Medicare + 9.63% HCRA Surcharge,18.39,,,18.39,Fee Schedule,Mediare Clinical Lab,35.49,,,35.49,Fee Schedule,,32,,,32,Fee Schedule,,185.89,,,185.89,Fee Schedule,,167.25,,,167.25,Fee Schedule,,157.93,,,157.93,Fee Schedule,,146.5,50,,146.5,percent of total billed charges,All Other,38.84,,,38.84,Fee Schedule,,57.93,,,57.93,Fee Schedule,,34.21,,,34.21,Other,186% Medicaid methodology,68.23,,,68.23,Fee Schedule,,181.66,,,181.66,Fee Schedule,,38.62,,,38.62,Fee Schedule,,68.23,,,68.23,Fee Schedule,,181.66,,,181.66,Fee Schedule,,72.64,,,72.64,Fee Schedule,,205.1,70,,205.1,percent of total billed charges,All Other,87.68,,,87.68,Fee Schedule,,74.4,,,74.4,Fee Schedule,,22.07,,,22.07,Fee Schedule,,22.07,,,22.07,Fee Schedule,,22.07,,,22.07,Fee Schedule,,22.07,,,22.07,Fee Schedule,,18.39,,,18.39,Fee Schedule,Medicaid Laboratory Fee Schedule,18.39,,,18.39,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.39,,,18.39,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.39,,,18.39,Fee Schedule,100% Medicaid Laboratory Fee Schedule,41.38,,,41.38,Fee Schedule,225% Medicaid Laboratory Fee Schedule,41.38,,,41.38,Fee Schedule,225% Medicaid Laboratory Fee Schedule,28.14,,,28.14,Fee Schedule,153% Medicaid Laboratory Fee Schedule,41.38,,,41.38,Fee Schedule,225% Medicaid Laboratory Fee Schedule,25.75,,,25.75,Fee Schedule,140% Medicaid Laboratory Fee Schedule,41.38,,,41.38,Fee Schedule,225% Medicaid Laboratory Fee Schedule,47.81,,,47.81,Fee Schedule,260% Medicaid Laboratory Fee Schedule,59.58,,,59.58,Fee Schedule,324% Medicaid Laboratory Fee Schedule,39.54,,,39.54,Fee Schedule,215% Medicaid Laboratory Fee Schedule,39.54,,,39.54,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.99,,,22.99,Fee Schedule,125% Medicaid Laboratory Fee Schedule,18.39,205.1,
ASSAY OF SELENIUM               ,84255,CPT,,40121782,CDM,301,RC,,,both,,,245,41.98,,,41.98,Other,150% of Medicare + 9.63% HCRA Surcharge,25.53,,,25.53,Fee Schedule,Mediare Clinical Lab,49.27,,,49.27,Fee Schedule,,44.42,,,44.42,Fee Schedule,,257.98,,,257.98,Fee Schedule,,232.11,,,232.11,Fee Schedule,,219.17,,,219.17,Fee Schedule,,122.5,50,,122.5,percent of total billed charges,All Other,53.92,,,53.92,Fee Schedule,,80.42,,,80.42,Fee Schedule,,84.07,,,84.07,Other,186% Medicaid methodology,94.72,,,94.72,Fee Schedule,,151.9,,,151.9,Fee Schedule,,53.61,,,53.61,Fee Schedule,,94.72,,,94.72,Fee Schedule,,151.9,,,151.9,Fee Schedule,,100.84,,,100.84,Fee Schedule,,171.5,70,,171.5,percent of total billed charges,All Other,121.73,,,121.73,Fee Schedule,,103.28,,,103.28,Fee Schedule,,30.64,,,30.64,Fee Schedule,,30.64,,,30.64,Fee Schedule,,30.64,,,30.64,Fee Schedule,,30.64,,,30.64,Fee Schedule,,45.2,,,45.2,Other,New York Medicaid APG methodology,45.2,,,45.2,Other,100% Medicaid APG methodology,45.2,,,45.2,Other,100% Medicaid APG methodology,45.2,,,45.2,Other,100% Medicaid APG methodology,101.7,,,101.7,Other,225% Medicaid APG methodology,101.7,,,101.7,Other,225% Medicaid APG methodology,69.16,,,69.16,Other,153% Medicaid APG methodology,101.7,,,101.7,Other,225% Medicaid APG methodology,63.28,,,63.28,Other,140% Medicaid APG methodology,101.7,,,101.7,Other,225% Medicaid APG methodology,117.52,,,117.52,Other,260% Medicaid APG methodology,146.45,,,146.45,Other,324% Medicaid APG methodology,97.18,,,97.18,Other,215% Medicaid APG methodology,97.18,,,97.18,Other,215% Medicaid APG methodology,56.5,,,56.5,Other,125% Medicaid APG methodology,25.53,257.98,
ASSAY OF SEROTONIN              ,84260,CPT,,40121808,CDM,301,RC,,,both,,,493,50.95,,,50.95,Other,150% of Medicare + 9.63% HCRA Surcharge,30.98,,,30.98,Fee Schedule,Mediare Clinical Lab,59.79,,,59.79,Fee Schedule,,53.91,,,53.91,Fee Schedule,,173.04,,,173.04,Fee Schedule,,155.69,,,155.69,Fee Schedule,,147.01,,,147.01,Fee Schedule,,246.5,50,,246.5,percent of total billed charges,All Other,65.46,,,65.46,Fee Schedule,,97.59,,,97.59,Fee Schedule,,122.22,,,122.22,Other,186% Medicaid methodology,114.94,,,114.94,Fee Schedule,,305.66,,,305.66,Fee Schedule,,65.06,,,65.06,Fee Schedule,,114.94,,,114.94,Fee Schedule,,305.66,,,305.66,Fee Schedule,,122.37,,,122.37,Fee Schedule,,345.1,70,,345.1,percent of total billed charges,All Other,147.71,,,147.71,Fee Schedule,,125.33,,,125.33,Fee Schedule,,37.18,,,37.18,Fee Schedule,,37.18,,,37.18,Fee Schedule,,37.18,,,37.18,Fee Schedule,,37.18,,,37.18,Fee Schedule,,65.71,,,65.71,Other,New York Medicaid APG methodology,65.71,,,65.71,Other,100% Medicaid APG methodology,65.71,,,65.71,Other,100% Medicaid APG methodology,65.71,,,65.71,Other,100% Medicaid APG methodology,147.85,,,147.85,Other,225% Medicaid APG methodology,147.85,,,147.85,Other,225% Medicaid APG methodology,100.54,,,100.54,Other,153% Medicaid APG methodology,147.85,,,147.85,Other,225% Medicaid APG methodology,92,,,92,Other,140% Medicaid APG methodology,147.85,,,147.85,Other,225% Medicaid APG methodology,170.85,,,170.85,Other,260% Medicaid APG methodology,212.9,,,212.9,Other,324% Medicaid APG methodology,141.28,,,141.28,Other,215% Medicaid APG methodology,141.28,,,141.28,Other,215% Medicaid APG methodology,82.14,,,82.14,Other,125% Medicaid APG methodology,30.98,345.1,
CALCULUS SPECTROSCOPY           ,82365,CPT,,40121840,CDM,301,RC,,,both,,,65,21.21,,,21.21,Other,150% of Medicare + 9.63% HCRA Surcharge,12.9,,,12.9,Fee Schedule,Mediare Clinical Lab,24.9,,,24.9,Fee Schedule,,22.45,,,22.45,Fee Schedule,,130.25,,,130.25,Fee Schedule,,117.18,,,117.18,Fee Schedule,,110.65,,,110.65,Fee Schedule,,32.5,50,,32.5,percent of total billed charges,All Other,27.27,,,27.27,Fee Schedule,,40.64,,,40.64,Fee Schedule,,23.28,,,23.28,Other,186% Medicaid methodology,47.86,,,47.86,Fee Schedule,,40.3,,,40.3,Fee Schedule,,27.09,,,27.09,Fee Schedule,,47.86,,,47.86,Fee Schedule,,40.3,,,40.3,Fee Schedule,,50.96,,,50.96,Fee Schedule,,45.5,70,,45.5,percent of total billed charges,All Other,61.51,,,61.51,Fee Schedule,,52.19,,,52.19,Fee Schedule,,15.48,,,15.48,Fee Schedule,,15.48,,,15.48,Fee Schedule,,15.48,,,15.48,Fee Schedule,,15.48,,,15.48,Fee Schedule,,12.51,,,12.51,Fee Schedule,Medicaid Laboratory Fee Schedule,12.51,,,12.51,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.51,,,12.51,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.51,,,12.51,Fee Schedule,100% Medicaid Laboratory Fee Schedule,28.16,,,28.16,Fee Schedule,225% Medicaid Laboratory Fee Schedule,28.16,,,28.16,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.15,,,19.15,Fee Schedule,153% Medicaid Laboratory Fee Schedule,28.16,,,28.16,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.52,,,17.52,Fee Schedule,140% Medicaid Laboratory Fee Schedule,28.16,,,28.16,Fee Schedule,225% Medicaid Laboratory Fee Schedule,32.54,,,32.54,Fee Schedule,260% Medicaid Laboratory Fee Schedule,40.55,,,40.55,Fee Schedule,324% Medicaid Laboratory Fee Schedule,26.9,,,26.9,Fee Schedule,215% Medicaid Laboratory Fee Schedule,26.9,,,26.9,Fee Schedule,215% Medicaid Laboratory Fee Schedule,15.64,,,15.64,Fee Schedule,125% Medicaid Laboratory Fee Schedule,12.51,130.25,
HLA II TYPING 1 ALLELE HR       ,81383,CPT,,40121857,CDM,301,RC,,,both,,,1736,179.46,,,179.46,Other,150% of Medicare + 9.63% HCRA Surcharge,109.13,,,109.13,Fee Schedule,Mediare Clinical Lab,210.62,,,210.62,Fee Schedule,,189.89,,,189.89,Fee Schedule,,45.74,,,45.74,Fee Schedule,,45.74,,,45.74,Fee Schedule,,45.74,,,45.74,Fee Schedule,,868,50,,868,percent of total billed charges,All Other,230.52,,,230.52,Fee Schedule,,343.76,,,343.76,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,404.87,,,404.87,Fee Schedule,,1076.32,,,1076.32,Fee Schedule,,229.17,,,229.17,Fee Schedule,,404.87,,,404.87,Fee Schedule,,1076.32,,,1076.32,Fee Schedule,,431.06,,,431.06,Fee Schedule,,1215.2,70,,1215.2,percent of total billed charges,All Other,520.32,,,520.32,Fee Schedule,,441.49,,,441.49,Fee Schedule,,130.96,,,130.96,Fee Schedule,,130.96,,,130.96,Fee Schedule,,130.96,,,130.96,Fee Schedule,,130.96,,,130.96,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1215.2,
ASSAY OF TRIGLYCERIDES          ,84478,CPT,,40121907,CDM,301,RC,,,both,,,92,9.44,,,9.44,Other,150% of Medicare + 9.63% HCRA Surcharge,5.74,,,5.74,Fee Schedule,Mediare Clinical Lab,11.08,,,11.08,Fee Schedule,,9.99,,,9.99,Fee Schedule,,58.16,,,58.16,Fee Schedule,,52.33,,,52.33,Fee Schedule,,49.41,,,49.41,Fee Schedule,,46,50,,46,percent of total billed charges,All Other,12.12,,,12.12,Fee Schedule,,18.08,,,18.08,Fee Schedule,,9.45,,,9.45,Other,186% Medicaid methodology,21.3,,,21.3,Fee Schedule,,57.04,,,57.04,Fee Schedule,,12.05,,,12.05,Fee Schedule,,21.3,,,21.3,Fee Schedule,,57.04,,,57.04,Fee Schedule,,22.67,,,22.67,Fee Schedule,,64.4,70,,64.4,percent of total billed charges,All Other,27.37,,,27.37,Fee Schedule,,23.22,,,23.22,Fee Schedule,,6.89,,,6.89,Fee Schedule,,6.89,,,6.89,Fee Schedule,,6.89,,,6.89,Fee Schedule,,6.89,,,6.89,Fee Schedule,,5.08,,,5.08,Fee Schedule,Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.77,,,7.77,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.11,,,7.11,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.21,,,13.21,Fee Schedule,260% Medicaid Laboratory Fee Schedule,16.46,,,16.46,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.35,,,6.35,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.08,64.4,
ASSAY OF BLOOD/URIC ACID        ,84550,CPT,,40121923,CDM,301,RC,,,both,,,73,7.43,,,7.43,Other,150% of Medicare + 9.63% HCRA Surcharge,4.52,,,4.52,Fee Schedule,Mediare Clinical Lab,8.72,,,8.72,Fee Schedule,,7.86,,,7.86,Fee Schedule,,45.66,,,45.66,Fee Schedule,,41.09,,,41.09,Fee Schedule,,38.8,,,38.8,Fee Schedule,,36.5,50,,36.5,percent of total billed charges,All Other,9.56,,,9.56,Fee Schedule,,14.24,,,14.24,Fee Schedule,,8.41,,,8.41,Other,186% Medicaid methodology,16.77,,,16.77,Fee Schedule,,45.26,,,45.26,Fee Schedule,,9.49,,,9.49,Fee Schedule,,16.77,,,16.77,Fee Schedule,,45.26,,,45.26,Fee Schedule,,17.85,,,17.85,Fee Schedule,,51.1,70,,51.1,percent of total billed charges,All Other,21.55,,,21.55,Fee Schedule,,18.29,,,18.29,Fee Schedule,,5.42,,,5.42,Fee Schedule,,5.42,,,5.42,Fee Schedule,,5.42,,,5.42,Fee Schedule,,5.42,,,5.42,Fee Schedule,,4.52,,,4.52,Fee Schedule,Medicaid Laboratory Fee Schedule,4.52,,,4.52,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.52,,,4.52,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.52,,,4.52,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.17,,,10.17,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.17,,,10.17,Fee Schedule,225% Medicaid Laboratory Fee Schedule,6.92,,,6.92,Fee Schedule,153% Medicaid Laboratory Fee Schedule,10.17,,,10.17,Fee Schedule,225% Medicaid Laboratory Fee Schedule,6.33,,,6.33,Fee Schedule,140% Medicaid Laboratory Fee Schedule,10.17,,,10.17,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.75,,,11.75,Fee Schedule,260% Medicaid Laboratory Fee Schedule,14.64,,,14.64,Fee Schedule,324% Medicaid Laboratory Fee Schedule,9.72,,,9.72,Fee Schedule,215% Medicaid Laboratory Fee Schedule,9.72,,,9.72,Fee Schedule,215% Medicaid Laboratory Fee Schedule,5.65,,,5.65,Fee Schedule,125% Medicaid Laboratory Fee Schedule,4.52,51.1,
MOPATH PROCEDURE LEVEL 4        ,81403,CPT,,40121931,CDM,301,RC,,,both,,,875,304.55,,,304.55,Other,150% of Medicare + 9.63% HCRA Surcharge,185.2,,,185.2,Fee Schedule,Mediare Clinical Lab,357.44,,,357.44,Fee Schedule,,322.25,,,322.25,Fee Schedule,,67.55,,,67.55,Fee Schedule,,67.55,,,67.55,Fee Schedule,,67.55,,,67.55,Fee Schedule,,437.5,50,,437.5,percent of total billed charges,All Other,391.24,,,391.24,Fee Schedule,,583.38,,,583.38,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,687.09,,,687.09,Fee Schedule,,542.5,,,542.5,Fee Schedule,,388.92,,,388.92,Fee Schedule,,687.09,,,687.09,Fee Schedule,,542.5,,,542.5,Fee Schedule,,731.54,,,731.54,Fee Schedule,,612.5,70,,612.5,percent of total billed charges,All Other,883.02,,,883.02,Fee Schedule,,749.23,,,749.23,Fee Schedule,,222.24,,,222.24,Fee Schedule,,222.24,,,222.24,Fee Schedule,,222.24,,,222.24,Fee Schedule,,222.24,,,222.24,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,883.02,
MOPATH PROCEDURE LEVEL 6        ,81405,CPT,,40121972,CDM,301,RC,,,both,,,2411,495.56,,,495.56,Other,150% of Medicare + 9.63% HCRA Surcharge,301.35,,,301.35,Fee Schedule,Mediare Clinical Lab,581.61,,,581.61,Fee Schedule,,524.35,,,524.35,Fee Schedule,,87.56,,,87.56,Fee Schedule,,87.56,,,87.56,Fee Schedule,,87.56,,,87.56,Fee Schedule,,1205.5,50,,1205.5,percent of total billed charges,All Other,636.61,,,636.61,Fee Schedule,,949.25,,,949.25,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,1118.01,,,1118.01,Fee Schedule,,1494.82,,,1494.82,Fee Schedule,,632.84,,,632.84,Fee Schedule,,1118.01,,,1118.01,Fee Schedule,,1494.82,,,1494.82,Fee Schedule,,1190.33,,,1190.33,Fee Schedule,,1687.7,70,,1687.7,percent of total billed charges,All Other,1436.82,,,1436.82,Fee Schedule,,1219.12,,,1219.12,Fee Schedule,,361.62,,,361.62,Fee Schedule,,361.62,,,361.62,Fee Schedule,,361.62,,,361.62,Fee Schedule,,361.62,,,361.62,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1687.7,
VIT D 1 25-DIHYDROXY            ,82652,CPT,,40121980,CDM,301,RC,,,both,,,613,63.31,,,63.31,Other,150% of Medicare + 9.63% HCRA Surcharge,38.5,,,38.5,Fee Schedule,Mediare Clinical Lab,74.31,,,74.31,Fee Schedule,,66.99,,,66.99,Fee Schedule,,389.01,,,389.01,Fee Schedule,,350,,,350,Fee Schedule,,330.5,,,330.5,Fee Schedule,,306.5,50,,306.5,percent of total billed charges,All Other,81.35,,,81.35,Fee Schedule,,121.28,,,121.28,Fee Schedule,,117.69,,,117.69,Other,186% Medicaid methodology,142.84,,,142.84,Fee Schedule,,380.06,,,380.06,Fee Schedule,,80.85,,,80.85,Fee Schedule,,142.84,,,142.84,Fee Schedule,,380.06,,,380.06,Fee Schedule,,152.08,,,152.08,Fee Schedule,,429.1,70,,429.1,percent of total billed charges,All Other,183.57,,,183.57,Fee Schedule,,155.75,,,155.75,Fee Schedule,,46.2,,,46.2,Fee Schedule,,46.2,,,46.2,Fee Schedule,,46.2,,,46.2,Fee Schedule,,46.2,,,46.2,Fee Schedule,,63.28,,,63.28,Other,New York Medicaid APG methodology,63.28,,,63.28,Other,100% Medicaid APG methodology,63.28,,,63.28,Other,100% Medicaid APG methodology,63.28,,,63.28,Other,100% Medicaid APG methodology,142.37,,,142.37,Other,225% Medicaid APG methodology,142.37,,,142.37,Other,225% Medicaid APG methodology,96.81,,,96.81,Other,153% Medicaid APG methodology,142.37,,,142.37,Other,225% Medicaid APG methodology,88.59,,,88.59,Other,140% Medicaid APG methodology,142.37,,,142.37,Other,225% Medicaid APG methodology,164.52,,,164.52,Other,260% Medicaid APG methodology,205.01,,,205.01,Other,324% Medicaid APG methodology,136.04,,,136.04,Other,215% Medicaid APG methodology,136.04,,,136.04,Other,215% Medicaid APG methodology,79.09,,,79.09,Other,125% Medicaid APG methodology,38.5,429.1,
VITAMIN D 25 HYDROXY            ,82306,CPT,,40122004,CDM,301,RC,,,both,,,471,48.68,,,48.68,Other,150% of Medicare + 9.63% HCRA Surcharge,29.6,,,29.6,Fee Schedule,Mediare Clinical Lab,57.13,,,57.13,Fee Schedule,,51.5,,,51.5,Fee Schedule,,299.12,,,299.12,Fee Schedule,,269.12,,,269.12,Fee Schedule,,254.13,,,254.13,Fee Schedule,,235.5,50,,235.5,percent of total billed charges,All Other,62.53,,,62.53,Fee Schedule,,93.24,,,93.24,Fee Schedule,,55.06,,,55.06,Other,186% Medicaid methodology,109.82,,,109.82,Fee Schedule,,292.02,,,292.02,Fee Schedule,,62.16,,,62.16,Fee Schedule,,109.82,,,109.82,Fee Schedule,,292.02,,,292.02,Fee Schedule,,116.92,,,116.92,Fee Schedule,,329.7,70,,329.7,percent of total billed charges,All Other,141.13,,,141.13,Fee Schedule,,119.75,,,119.75,Fee Schedule,,35.52,,,35.52,Fee Schedule,,35.52,,,35.52,Fee Schedule,,35.52,,,35.52,Fee Schedule,,35.52,,,35.52,Fee Schedule,,29.6,,,29.6,Fee Schedule,Medicaid Laboratory Fee Schedule,29.6,,,29.6,Fee Schedule,100% Medicaid Laboratory Fee Schedule,29.6,,,29.6,Fee Schedule,100% Medicaid Laboratory Fee Schedule,29.6,,,29.6,Fee Schedule,100% Medicaid Laboratory Fee Schedule,66.6,,,66.6,Fee Schedule,225% Medicaid Laboratory Fee Schedule,66.6,,,66.6,Fee Schedule,225% Medicaid Laboratory Fee Schedule,45.29,,,45.29,Fee Schedule,153% Medicaid Laboratory Fee Schedule,66.6,,,66.6,Fee Schedule,225% Medicaid Laboratory Fee Schedule,41.44,,,41.44,Fee Schedule,140% Medicaid Laboratory Fee Schedule,66.6,,,66.6,Fee Schedule,225% Medicaid Laboratory Fee Schedule,76.96,,,76.96,Fee Schedule,260% Medicaid Laboratory Fee Schedule,95.9,,,95.9,Fee Schedule,324% Medicaid Laboratory Fee Schedule,63.64,,,63.64,Fee Schedule,215% Medicaid Laboratory Fee Schedule,63.64,,,63.64,Fee Schedule,215% Medicaid Laboratory Fee Schedule,37,,,37,Fee Schedule,125% Medicaid Laboratory Fee Schedule,29.6,329.7,
ASSAY OF VITAMIN A              ,84590,CPT,,40122020,CDM,301,RC,,,both,,,185,19.09,,,19.09,Other,150% of Medicare + 9.63% HCRA Surcharge,11.61,,,11.61,Fee Schedule,Mediare Clinical Lab,22.41,,,22.41,Fee Schedule,,20.2,,,20.2,Fee Schedule,,117.18,,,117.18,Fee Schedule,,105.43,,,105.43,Fee Schedule,,99.55,,,99.55,Fee Schedule,,92.5,50,,92.5,percent of total billed charges,All Other,24.54,,,24.54,Fee Schedule,,36.57,,,36.57,Fee Schedule,,21.59,,,21.59,Other,186% Medicaid methodology,43.07,,,43.07,Fee Schedule,,114.7,,,114.7,Fee Schedule,,24.38,,,24.38,Fee Schedule,,43.07,,,43.07,Fee Schedule,,114.7,,,114.7,Fee Schedule,,45.86,,,45.86,Fee Schedule,,129.5,70,,129.5,percent of total billed charges,All Other,55.36,,,55.36,Fee Schedule,,46.97,,,46.97,Fee Schedule,,13.93,,,13.93,Fee Schedule,,13.93,,,13.93,Fee Schedule,,13.93,,,13.93,Fee Schedule,,13.93,,,13.93,Fee Schedule,,11.61,,,11.61,Fee Schedule,Medicaid Laboratory Fee Schedule,11.61,,,11.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.61,,,11.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.61,,,11.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,26.12,,,26.12,Fee Schedule,225% Medicaid Laboratory Fee Schedule,26.12,,,26.12,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.76,,,17.76,Fee Schedule,153% Medicaid Laboratory Fee Schedule,26.12,,,26.12,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.25,,,16.25,Fee Schedule,140% Medicaid Laboratory Fee Schedule,26.12,,,26.12,Fee Schedule,225% Medicaid Laboratory Fee Schedule,30.19,,,30.19,Fee Schedule,260% Medicaid Laboratory Fee Schedule,37.62,,,37.62,Fee Schedule,324% Medicaid Laboratory Fee Schedule,24.96,,,24.96,Fee Schedule,215% Medicaid Laboratory Fee Schedule,24.96,,,24.96,Fee Schedule,215% Medicaid Laboratory Fee Schedule,14.51,,,14.51,Fee Schedule,125% Medicaid Laboratory Fee Schedule,11.61,129.5,
ASSAY OF VITAMIN B-1            ,84425,CPT,,40122046,CDM,301,RC,,,both,,,338,34.91,,,34.91,Other,150% of Medicare + 9.63% HCRA Surcharge,21.23,,,21.23,Fee Schedule,Mediare Clinical Lab,40.97,,,40.97,Fee Schedule,,36.94,,,36.94,Fee Schedule,,214.54,,,214.54,Fee Schedule,,193.02,,,193.02,Fee Schedule,,182.27,,,182.27,Fee Schedule,,169,50,,169,percent of total billed charges,All Other,44.85,,,44.85,Fee Schedule,,66.87,,,66.87,Fee Schedule,,28.18,,,28.18,Other,186% Medicaid methodology,78.76,,,78.76,Fee Schedule,,209.56,,,209.56,Fee Schedule,,44.58,,,44.58,Fee Schedule,,78.76,,,78.76,Fee Schedule,,209.56,,,209.56,Fee Schedule,,83.86,,,83.86,Fee Schedule,,236.6,70,,236.6,percent of total billed charges,All Other,101.22,,,101.22,Fee Schedule,,85.89,,,85.89,Fee Schedule,,25.48,,,25.48,Fee Schedule,,25.48,,,25.48,Fee Schedule,,25.48,,,25.48,Fee Schedule,,25.48,,,25.48,Fee Schedule,,15.15,,,15.15,Fee Schedule,Medicaid Laboratory Fee Schedule,15.15,,,15.15,Fee Schedule,100% Medicaid Laboratory Fee Schedule,15.15,,,15.15,Fee Schedule,100% Medicaid Laboratory Fee Schedule,15.15,,,15.15,Fee Schedule,100% Medicaid Laboratory Fee Schedule,34.09,,,34.09,Fee Schedule,225% Medicaid Laboratory Fee Schedule,34.09,,,34.09,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.18,,,23.18,Fee Schedule,153% Medicaid Laboratory Fee Schedule,34.09,,,34.09,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.21,,,21.21,Fee Schedule,140% Medicaid Laboratory Fee Schedule,34.09,,,34.09,Fee Schedule,225% Medicaid Laboratory Fee Schedule,39.39,,,39.39,Fee Schedule,260% Medicaid Laboratory Fee Schedule,49.09,,,49.09,Fee Schedule,324% Medicaid Laboratory Fee Schedule,32.57,,,32.57,Fee Schedule,215% Medicaid Laboratory Fee Schedule,32.57,,,32.57,Fee Schedule,215% Medicaid Laboratory Fee Schedule,18.94,,,18.94,Fee Schedule,125% Medicaid Laboratory Fee Schedule,15.15,236.6,
ASSAY OF ASCORBIC ACID          ,82180,CPT,,40122061,CDM,301,RC,,,both,,,157,16.26,,,16.26,Other,150% of Medicare + 9.63% HCRA Surcharge,9.89,,,9.89,Fee Schedule,Mediare Clinical Lab,19.09,,,19.09,Fee Schedule,,17.21,,,17.21,Fee Schedule,,93.05,,,93.05,Fee Schedule,,83.72,,,83.72,Fee Schedule,,79.06,,,79.06,Fee Schedule,,78.5,50,,78.5,percent of total billed charges,All Other,20.9,,,20.9,Fee Schedule,,31.15,,,31.15,Fee Schedule,,18.4,,,18.4,Other,186% Medicaid methodology,36.69,,,36.69,Fee Schedule,,97.34,,,97.34,Fee Schedule,,20.77,,,20.77,Fee Schedule,,36.69,,,36.69,Fee Schedule,,97.34,,,97.34,Fee Schedule,,39.07,,,39.07,Fee Schedule,,109.9,70,,109.9,percent of total billed charges,All Other,47.15,,,47.15,Fee Schedule,,40.01,,,40.01,Fee Schedule,,11.87,,,11.87,Fee Schedule,,11.87,,,11.87,Fee Schedule,,11.87,,,11.87,Fee Schedule,,11.87,,,11.87,Fee Schedule,,9.89,,,9.89,Fee Schedule,Medicaid Laboratory Fee Schedule,9.89,,,9.89,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.89,,,9.89,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.89,,,9.89,Fee Schedule,100% Medicaid Laboratory Fee Schedule,22.25,,,22.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,22.25,,,22.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.13,,,15.13,Fee Schedule,153% Medicaid Laboratory Fee Schedule,22.25,,,22.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.85,,,13.85,Fee Schedule,140% Medicaid Laboratory Fee Schedule,22.25,,,22.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,25.71,,,25.71,Fee Schedule,260% Medicaid Laboratory Fee Schedule,32.04,,,32.04,Fee Schedule,324% Medicaid Laboratory Fee Schedule,21.26,,,21.26,Fee Schedule,215% Medicaid Laboratory Fee Schedule,21.26,,,21.26,Fee Schedule,215% Medicaid Laboratory Fee Schedule,12.36,,,12.36,Fee Schedule,125% Medicaid Laboratory Fee Schedule,9.89,109.9,
ASSAY OF VITAMIN E              ,84446,CPT,,40122087,CDM,301,RC,,,both,,,226,23.32,,,23.32,Other,150% of Medicare + 9.63% HCRA Surcharge,14.18,,,14.18,Fee Schedule,Mediare Clinical Lab,27.37,,,27.37,Fee Schedule,,24.67,,,24.67,Fee Schedule,,143.24,,,143.24,Fee Schedule,,128.88,,,128.88,Fee Schedule,,121.7,,,121.7,Fee Schedule,,113,50,,113,percent of total billed charges,All Other,29.97,,,29.97,Fee Schedule,,44.67,,,44.67,Fee Schedule,,26.37,,,26.37,Other,186% Medicaid methodology,52.61,,,52.61,Fee Schedule,,140.12,,,140.12,Fee Schedule,,29.78,,,29.78,Fee Schedule,,52.61,,,52.61,Fee Schedule,,140.12,,,140.12,Fee Schedule,,56.01,,,56.01,Fee Schedule,,158.2,70,,158.2,percent of total billed charges,All Other,67.61,,,67.61,Fee Schedule,,57.37,,,57.37,Fee Schedule,,17.02,,,17.02,Fee Schedule,,17.02,,,17.02,Fee Schedule,,17.02,,,17.02,Fee Schedule,,17.02,,,17.02,Fee Schedule,,14.18,,,14.18,Fee Schedule,Medicaid Laboratory Fee Schedule,14.18,,,14.18,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.18,,,14.18,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.18,,,14.18,Fee Schedule,100% Medicaid Laboratory Fee Schedule,31.91,,,31.91,Fee Schedule,225% Medicaid Laboratory Fee Schedule,31.91,,,31.91,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.7,,,21.7,Fee Schedule,153% Medicaid Laboratory Fee Schedule,31.91,,,31.91,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.85,,,19.85,Fee Schedule,140% Medicaid Laboratory Fee Schedule,31.91,,,31.91,Fee Schedule,225% Medicaid Laboratory Fee Schedule,36.87,,,36.87,Fee Schedule,260% Medicaid Laboratory Fee Schedule,45.94,,,45.94,Fee Schedule,324% Medicaid Laboratory Fee Schedule,30.49,,,30.49,Fee Schedule,215% Medicaid Laboratory Fee Schedule,30.49,,,30.49,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.73,,,17.73,Fee Schedule,125% Medicaid Laboratory Fee Schedule,14.18,158.2,
ASSAY OF VITAMIN B-6            ,84207,CPT,,40122103,CDM,301,RC,,,both,,,448,46.21,,,46.21,Other,150% of Medicare + 9.63% HCRA Surcharge,28.1,,,28.1,Fee Schedule,Mediare Clinical Lab,54.23,,,54.23,Fee Schedule,,48.89,,,48.89,Fee Schedule,,283.9,,,283.9,Fee Schedule,,255.43,,,255.43,Fee Schedule,,241.19,,,241.19,Fee Schedule,,224,50,,224,percent of total billed charges,All Other,59.38,,,59.38,Fee Schedule,,88.52,,,88.52,Fee Schedule,,52.27,,,52.27,Other,186% Medicaid methodology,104.25,,,104.25,Fee Schedule,,277.76,,,277.76,Fee Schedule,,59.01,,,59.01,Fee Schedule,,104.25,,,104.25,Fee Schedule,,277.76,,,277.76,Fee Schedule,,111,,,111,Fee Schedule,,313.6,70,,313.6,percent of total billed charges,All Other,133.98,,,133.98,Fee Schedule,,113.68,,,113.68,Fee Schedule,,33.72,,,33.72,Fee Schedule,,33.72,,,33.72,Fee Schedule,,33.72,,,33.72,Fee Schedule,,33.72,,,33.72,Fee Schedule,,28.1,,,28.1,Fee Schedule,Medicaid Laboratory Fee Schedule,28.1,,,28.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,28.1,,,28.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,28.1,,,28.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,63.23,,,63.23,Fee Schedule,225% Medicaid Laboratory Fee Schedule,63.23,,,63.23,Fee Schedule,225% Medicaid Laboratory Fee Schedule,42.99,,,42.99,Fee Schedule,153% Medicaid Laboratory Fee Schedule,63.23,,,63.23,Fee Schedule,225% Medicaid Laboratory Fee Schedule,39.34,,,39.34,Fee Schedule,140% Medicaid Laboratory Fee Schedule,63.23,,,63.23,Fee Schedule,225% Medicaid Laboratory Fee Schedule,73.06,,,73.06,Fee Schedule,260% Medicaid Laboratory Fee Schedule,91.04,,,91.04,Fee Schedule,324% Medicaid Laboratory Fee Schedule,60.42,,,60.42,Fee Schedule,215% Medicaid Laboratory Fee Schedule,60.42,,,60.42,Fee Schedule,215% Medicaid Laboratory Fee Schedule,35.13,,,35.13,Fee Schedule,125% Medicaid Laboratory Fee Schedule,28.1,313.6,
ALPHA-FETOPROTEIN SERUM         ,82105,CPT,,40122160,CDM,301,RC,,,both,,,268,27.58,,,27.58,Other,150% of Medicare + 9.63% HCRA Surcharge,16.77,,,16.77,Fee Schedule,Mediare Clinical Lab,32.37,,,32.37,Fee Schedule,,29.18,,,29.18,Fee Schedule,,169.52,,,169.52,Fee Schedule,,152.52,,,152.52,Fee Schedule,,144.02,,,144.02,Fee Schedule,,134,50,,134,percent of total billed charges,All Other,35.43,,,35.43,Fee Schedule,,52.83,,,52.83,Fee Schedule,,12.21,,,12.21,Other,186% Medicaid methodology,62.22,,,62.22,Fee Schedule,,166.16,,,166.16,Fee Schedule,,35.22,,,35.22,Fee Schedule,,62.22,,,62.22,Fee Schedule,,166.16,,,166.16,Fee Schedule,,66.24,,,66.24,Fee Schedule,,187.6,70,,187.6,percent of total billed charges,All Other,79.96,,,79.96,Fee Schedule,,67.84,,,67.84,Fee Schedule,,20.12,,,20.12,Fee Schedule,,20.12,,,20.12,Fee Schedule,,20.12,,,20.12,Fee Schedule,,20.12,,,20.12,Fee Schedule,,6.57,,,6.57,Fee Schedule,Medicaid Laboratory Fee Schedule,6.57,,,6.57,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.57,,,6.57,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.57,,,6.57,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.77,,,14.77,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.77,,,14.77,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.04,,,10.04,Fee Schedule,153% Medicaid Laboratory Fee Schedule,14.77,,,14.77,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.19,,,9.19,Fee Schedule,140% Medicaid Laboratory Fee Schedule,14.77,,,14.77,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.07,,,17.07,Fee Schedule,260% Medicaid Laboratory Fee Schedule,21.27,,,21.27,Fee Schedule,324% Medicaid Laboratory Fee Schedule,14.11,,,14.11,Fee Schedule,215% Medicaid Laboratory Fee Schedule,14.11,,,14.11,Fee Schedule,215% Medicaid Laboratory Fee Schedule,8.21,,,8.21,Fee Schedule,125% Medicaid Laboratory Fee Schedule,6.57,187.6,
GLUCOSE TOLERANCE TEST (GTT)    ,82951,CPT,,40122244,CDM,301,RC,,,both,,,205,21.16,,,21.16,Other,150% of Medicare + 9.63% HCRA Surcharge,12.87,,,12.87,Fee Schedule,Mediare Clinical Lab,24.84,,,24.84,Fee Schedule,,22.39,,,22.39,Fee Schedule,,130.1,,,130.1,Fee Schedule,,117.06,,,117.06,Fee Schedule,,110.53,,,110.53,Fee Schedule,,102.5,50,,102.5,percent of total billed charges,All Other,27.2,,,27.2,Fee Schedule,,40.54,,,40.54,Fee Schedule,,12.85,,,12.85,Other,186% Medicaid methodology,47.75,,,47.75,Fee Schedule,,127.1,,,127.1,Fee Schedule,,27.03,,,27.03,Fee Schedule,,47.75,,,47.75,Fee Schedule,,127.1,,,127.1,Fee Schedule,,50.84,,,50.84,Fee Schedule,,143.5,70,,143.5,percent of total billed charges,All Other,61.36,,,61.36,Fee Schedule,,52.07,,,52.07,Fee Schedule,,15.44,,,15.44,Fee Schedule,,15.44,,,15.44,Fee Schedule,,15.44,,,15.44,Fee Schedule,,15.44,,,15.44,Fee Schedule,,6.91,,,6.91,Fee Schedule,Medicaid Laboratory Fee Schedule,6.91,,,6.91,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.91,,,6.91,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.91,,,6.91,Fee Schedule,100% Medicaid Laboratory Fee Schedule,15.54,,,15.54,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.54,,,15.54,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.57,,,10.57,Fee Schedule,153% Medicaid Laboratory Fee Schedule,15.54,,,15.54,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.67,,,9.67,Fee Schedule,140% Medicaid Laboratory Fee Schedule,15.54,,,15.54,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.96,,,17.96,Fee Schedule,260% Medicaid Laboratory Fee Schedule,22.38,,,22.38,Fee Schedule,324% Medicaid Laboratory Fee Schedule,14.85,,,14.85,Fee Schedule,215% Medicaid Laboratory Fee Schedule,14.85,,,14.85,Fee Schedule,215% Medicaid Laboratory Fee Schedule,8.64,,,8.64,Fee Schedule,125% Medicaid Laboratory Fee Schedule,6.91,143.5,
PAI-1 4G/5G POLYMORPHISM        ,81400,CPT,,40122350,CDM,301,RC,,,both,,,969,105.18,,,105.18,Other,150% of Medicare + 9.63% HCRA Surcharge,63.96,,,63.96,Fee Schedule,Mediare Clinical Lab,123.44,,,123.44,Fee Schedule,,111.29,,,111.29,Fee Schedule,,20.51,,,20.51,Fee Schedule,,20.51,,,20.51,Fee Schedule,,20.51,,,20.51,Fee Schedule,,484.5,50,,484.5,percent of total billed charges,All Other,135.1,,,135.1,Fee Schedule,,201.47,,,201.47,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,237.29,,,237.29,Fee Schedule,,600.78,,,600.78,Fee Schedule,,134.32,,,134.32,Fee Schedule,,237.29,,,237.29,Fee Schedule,,600.78,,,600.78,Fee Schedule,,252.64,,,252.64,Fee Schedule,,678.3,70,,678.3,percent of total billed charges,All Other,304.96,,,304.96,Fee Schedule,,258.75,,,258.75,Fee Schedule,,76.75,,,76.75,Fee Schedule,,76.75,,,76.75,Fee Schedule,,76.75,,,76.75,Fee Schedule,,76.75,,,76.75,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,678.3,
ASSAY OF TROPONIN QUANT         ,84484,CPT,,40122400,CDM,301,RC,,,both,,,199,20.51,,,20.51,Other,150% of Medicare + 9.63% HCRA Surcharge,12.47,,,12.47,Fee Schedule,Mediare Clinical Lab,24.07,,,24.07,Fee Schedule,,21.7,,,21.7,Fee Schedule,,62.18,,,62.18,Fee Schedule,,55.94,,,55.94,Fee Schedule,,52.83,,,52.83,Fee Schedule,,99.5,50,,99.5,percent of total billed charges,All Other,26.36,,,26.36,Fee Schedule,,39.28,,,39.28,Fee Schedule,,15.12,,,15.12,Other,186% Medicaid methodology,46.26,,,46.26,Fee Schedule,,123.38,,,123.38,Fee Schedule,,26.19,,,26.19,Fee Schedule,,46.26,,,46.26,Fee Schedule,,123.38,,,123.38,Fee Schedule,,49.26,,,49.26,Fee Schedule,,139.3,70,,139.3,percent of total billed charges,All Other,59.46,,,59.46,Fee Schedule,,50.45,,,50.45,Fee Schedule,,14.96,,,14.96,Fee Schedule,,14.96,,,14.96,Fee Schedule,,14.96,,,14.96,Fee Schedule,,14.96,,,14.96,Fee Schedule,,8.13,,,8.13,Fee Schedule,Medicaid Laboratory Fee Schedule,8.13,,,8.13,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.13,,,8.13,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.13,,,8.13,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.29,,,18.29,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.29,,,18.29,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.44,,,12.44,Fee Schedule,153% Medicaid Laboratory Fee Schedule,18.29,,,18.29,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.38,,,11.38,Fee Schedule,140% Medicaid Laboratory Fee Schedule,18.29,,,18.29,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.14,,,21.14,Fee Schedule,260% Medicaid Laboratory Fee Schedule,26.34,,,26.34,Fee Schedule,324% Medicaid Laboratory Fee Schedule,17.48,,,17.48,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.48,,,17.48,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.16,,,10.16,Fee Schedule,125% Medicaid Laboratory Fee Schedule,8.13,139.3,
MOPATH PROCEDURE LEVEL 2        ,81401,CPT,,40122459,CDM,301,RC,,,both,,,1639,225.29,,,225.29,Other,150% of Medicare + 9.63% HCRA Surcharge,137,,,137,Fee Schedule,Mediare Clinical Lab,264.41,,,264.41,Fee Schedule,,238.38,,,238.38,Fee Schedule,,20.51,,,20.51,Fee Schedule,,20.51,,,20.51,Fee Schedule,,20.51,,,20.51,Fee Schedule,,819.5,50,,819.5,percent of total billed charges,All Other,289.41,,,289.41,Fee Schedule,,431.55,,,431.55,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,508.27,,,508.27,Fee Schedule,,1016.18,,,1016.18,Fee Schedule,,287.7,,,287.7,Fee Schedule,,508.27,,,508.27,Fee Schedule,,1016.18,,,1016.18,Fee Schedule,,541.15,,,541.15,Fee Schedule,,1147.3,70,,1147.3,percent of total billed charges,All Other,653.21,,,653.21,Fee Schedule,,554.24,,,554.24,Fee Schedule,,164.4,,,164.4,Fee Schedule,,164.4,,,164.4,Fee Schedule,,164.4,,,164.4,Fee Schedule,,164.4,,,164.4,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1147.3,
UNLISTED MOLECULAR PATHOLOGY    ,81479,CPT,,40122517,CDM,301,RC,,,both,,,5379,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,2689.5,50,,2689.5,percent of total billed charges,All Other Outpatient,2420.55,45,,2420.55,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,2689.5,50,,2689.5,percent of total billed charges,All Other,355,,,355,Fee Schedule,,3657.72,68,,3657.72,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,4303.2,80,,4303.2,percent of total billed charges,All Other Outpatient,4464.57,83,,4464.57,percent of total billed charges,All Other Outpatient,4464.57,83,,4464.57,percent of total billed charges,All Other Outpatient,4303.2,80,,4303.2,percent of total billed charges,All Other Outpatient,4464.57,83,,4464.57,percent of total billed charges,All Other Outpatient,4841.1,90,,4841.1,percent of total billed charges,All Other,3765.3,70,,3765.3,percent of total billed charges,All Other,2689.5,50,,2689.5,percent of total billed charges,All Other,2689.5,50,,2689.5,percent of total billed charges,All Other,3765.3,70,,3765.3,percent of total billed charges,All Other,3765.3,70,,3765.3,percent of total billed charges,All Other,3765.3,70,,3765.3,percent of total billed charges,All Other,3765.3,70,,3765.3,percent of total billed charges,All Other,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,4841.1,
ORGANIC ACID SINGLE QUANT       ,83921,CPT,,40122608,CDM,301,RC,,,both,,,338,34.88,,,34.88,Other,150% of Medicare + 9.63% HCRA Surcharge,21.21,,,21.21,Fee Schedule,Mediare Clinical Lab,40.94,,,40.94,Fee Schedule,,36.91,,,36.91,Fee Schedule,,166.29,,,166.29,Fee Schedule,,149.61,,,149.61,Fee Schedule,,141.28,,,141.28,Fee Schedule,,169,50,,169,percent of total billed charges,All Other,44.82,,,44.82,Fee Schedule,,66.81,,,66.81,Fee Schedule,,39.45,,,39.45,Other,186% Medicaid methodology,78.69,,,78.69,Fee Schedule,,209.56,,,209.56,Fee Schedule,,44.54,,,44.54,Fee Schedule,,78.69,,,78.69,Fee Schedule,,209.56,,,209.56,Fee Schedule,,83.78,,,83.78,Fee Schedule,,236.6,70,,236.6,percent of total billed charges,All Other,101.13,,,101.13,Fee Schedule,,85.81,,,85.81,Fee Schedule,,25.45,,,25.45,Fee Schedule,,25.45,,,25.45,Fee Schedule,,25.45,,,25.45,Fee Schedule,,25.45,,,25.45,Fee Schedule,,21.21,,,21.21,Fee Schedule,Medicaid Laboratory Fee Schedule,21.21,,,21.21,Fee Schedule,100% Medicaid Laboratory Fee Schedule,21.21,,,21.21,Fee Schedule,100% Medicaid Laboratory Fee Schedule,21.21,,,21.21,Fee Schedule,100% Medicaid Laboratory Fee Schedule,47.72,,,47.72,Fee Schedule,225% Medicaid Laboratory Fee Schedule,47.72,,,47.72,Fee Schedule,225% Medicaid Laboratory Fee Schedule,32.45,,,32.45,Fee Schedule,153% Medicaid Laboratory Fee Schedule,47.72,,,47.72,Fee Schedule,225% Medicaid Laboratory Fee Schedule,29.69,,,29.69,Fee Schedule,140% Medicaid Laboratory Fee Schedule,47.72,,,47.72,Fee Schedule,225% Medicaid Laboratory Fee Schedule,55.15,,,55.15,Fee Schedule,260% Medicaid Laboratory Fee Schedule,68.72,,,68.72,Fee Schedule,324% Medicaid Laboratory Fee Schedule,45.6,,,45.6,Fee Schedule,215% Medicaid Laboratory Fee Schedule,45.6,,,45.6,Fee Schedule,215% Medicaid Laboratory Fee Schedule,26.51,,,26.51,Fee Schedule,125% Medicaid Laboratory Fee Schedule,21.21,236.6,
ASSAY OF ZINC                   ,84630,CPT,,40122665,CDM,301,RC,,,both,,,182,18.73,,,18.73,Other,150% of Medicare + 9.63% HCRA Surcharge,11.39,,,11.39,Fee Schedule,Mediare Clinical Lab,21.98,,,21.98,Fee Schedule,,19.82,,,19.82,Fee Schedule,,74.38,,,74.38,Fee Schedule,,66.93,,,66.93,Fee Schedule,,63.2,,,63.2,Fee Schedule,,91,50,,91,percent of total billed charges,All Other,24.05,,,24.05,Fee Schedule,,35.88,,,35.88,Fee Schedule,,14.84,,,14.84,Other,186% Medicaid methodology,42.26,,,42.26,Fee Schedule,,112.84,,,112.84,Fee Schedule,,23.92,,,23.92,Fee Schedule,,42.26,,,42.26,Fee Schedule,,112.84,,,112.84,Fee Schedule,,44.99,,,44.99,Fee Schedule,,127.4,70,,127.4,percent of total billed charges,All Other,54.31,,,54.31,Fee Schedule,,46.08,,,46.08,Fee Schedule,,13.67,,,13.67,Fee Schedule,,13.67,,,13.67,Fee Schedule,,13.67,,,13.67,Fee Schedule,,13.67,,,13.67,Fee Schedule,,7.98,,,7.98,Fee Schedule,Medicaid Laboratory Fee Schedule,7.98,,,7.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.98,,,7.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.98,,,7.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,17.95,,,17.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.95,,,17.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.21,,,12.21,Fee Schedule,153% Medicaid Laboratory Fee Schedule,17.95,,,17.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.17,,,11.17,Fee Schedule,140% Medicaid Laboratory Fee Schedule,17.95,,,17.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,20.75,,,20.75,Fee Schedule,260% Medicaid Laboratory Fee Schedule,25.85,,,25.85,Fee Schedule,324% Medicaid Laboratory Fee Schedule,17.15,,,17.15,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.15,,,17.15,Fee Schedule,215% Medicaid Laboratory Fee Schedule,9.97,,,9.97,Fee Schedule,125% Medicaid Laboratory Fee Schedule,7.98,127.4,
ASSAY GLUCOSE BLOOD QUANT       ,82947,CPT,,40122756,CDM,301,RC,,,both,,,63,6.46,,,6.46,Other,150% of Medicare + 9.63% HCRA Surcharge,3.93,,,3.93,Fee Schedule,Mediare Clinical Lab,7.58,,,7.58,Fee Schedule,,6.84,,,6.84,Fee Schedule,,39.63,,,39.63,Fee Schedule,,35.66,,,35.66,Fee Schedule,,33.67,,,33.67,Fee Schedule,,31.5,50,,31.5,percent of total billed charges,All Other,8.29,,,8.29,Fee Schedule,,12.38,,,12.38,Fee Schedule,,7.31,,,7.31,Other,186% Medicaid methodology,14.58,,,14.58,Fee Schedule,,39.06,,,39.06,Fee Schedule,,8.25,,,8.25,Fee Schedule,,14.58,,,14.58,Fee Schedule,,39.06,,,39.06,Fee Schedule,,15.52,,,15.52,Fee Schedule,,44.1,70,,44.1,percent of total billed charges,All Other,18.74,,,18.74,Fee Schedule,,15.9,,,15.9,Fee Schedule,,4.72,,,4.72,Fee Schedule,,4.72,,,4.72,Fee Schedule,,4.72,,,4.72,Fee Schedule,,4.72,,,4.72,Fee Schedule,,3.93,,,3.93,Fee Schedule,Medicaid Laboratory Fee Schedule,3.93,,,3.93,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.93,,,3.93,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.93,,,3.93,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.84,,,8.84,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.84,,,8.84,Fee Schedule,225% Medicaid Laboratory Fee Schedule,6.01,,,6.01,Fee Schedule,153% Medicaid Laboratory Fee Schedule,8.84,,,8.84,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.5,,,5.5,Fee Schedule,140% Medicaid Laboratory Fee Schedule,8.84,,,8.84,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.22,,,10.22,Fee Schedule,260% Medicaid Laboratory Fee Schedule,12.73,,,12.73,Fee Schedule,324% Medicaid Laboratory Fee Schedule,8.45,,,8.45,Fee Schedule,215% Medicaid Laboratory Fee Schedule,8.45,,,8.45,Fee Schedule,215% Medicaid Laboratory Fee Schedule,4.91,,,4.91,Fee Schedule,125% Medicaid Laboratory Fee Schedule,3.93,44.1,
DRUG SCREEN QUAN LAMOTRIGINE    ,80175,CPT,,40122780,CDM,301,RC,,,both,,,211,21.79,,,21.79,Other,150% of Medicare + 9.63% HCRA Surcharge,13.25,,,13.25,Fee Schedule,Mediare Clinical Lab,25.57,,,25.57,Fee Schedule,,23.06,,,23.06,Fee Schedule,,7.24,,,7.24,Fee Schedule,,7.24,,,7.24,Fee Schedule,,7.24,,,7.24,Fee Schedule,,105.5,50,,105.5,percent of total billed charges,All Other,27.98,,,27.98,Fee Schedule,,41.74,,,41.74,Fee Schedule,,19.73,,,19.73,Other,186% Medicaid methodology,49.16,,,49.16,Fee Schedule,,130.82,,,130.82,Fee Schedule,,27.83,,,27.83,Fee Schedule,,49.16,,,49.16,Fee Schedule,,130.82,,,130.82,Fee Schedule,,52.34,,,52.34,Fee Schedule,,147.7,70,,147.7,percent of total billed charges,All Other,63.18,,,63.18,Fee Schedule,,53.6,,,53.6,Fee Schedule,,15.9,,,15.9,Fee Schedule,,15.9,,,15.9,Fee Schedule,,15.9,,,15.9,Fee Schedule,,15.9,,,15.9,Fee Schedule,,10.61,,,10.61,Fee Schedule,Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.23,,,16.23,Fee Schedule,153% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.85,,,14.85,Fee Schedule,140% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.57,,,27.57,Fee Schedule,260% Medicaid Laboratory Fee Schedule,34.36,,,34.36,Fee Schedule,324% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.26,,,13.26,Fee Schedule,125% Medicaid Laboratory Fee Schedule,7.24,147.7,
DRUG SCREEN QUANT GABAPENTIN    ,80171,CPT,,40122863,CDM,301,RC,,,both,,,345,35.64,,,35.64,Other,150% of Medicare + 9.63% HCRA Surcharge,21.67,,,21.67,Fee Schedule,Mediare Clinical Lab,41.82,,,41.82,Fee Schedule,,37.71,,,37.71,Fee Schedule,,7.24,,,7.24,Fee Schedule,,7.24,,,7.24,Fee Schedule,,7.24,,,7.24,Fee Schedule,,172.5,50,,172.5,percent of total billed charges,All Other,45.79,,,45.79,Fee Schedule,,68.26,,,68.26,Fee Schedule,,19.73,,,19.73,Other,186% Medicaid methodology,80.4,,,80.4,Fee Schedule,,213.9,,,213.9,Fee Schedule,,45.51,,,45.51,Fee Schedule,,80.4,,,80.4,Fee Schedule,,213.9,,,213.9,Fee Schedule,,85.6,,,85.6,Fee Schedule,,241.5,70,,241.5,percent of total billed charges,All Other,103.32,,,103.32,Fee Schedule,,87.67,,,87.67,Fee Schedule,,26,,,26,Fee Schedule,,26,,,26,Fee Schedule,,26,,,26,Fee Schedule,,26,,,26,Fee Schedule,,10.61,,,10.61,Fee Schedule,Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.23,,,16.23,Fee Schedule,153% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.85,,,14.85,Fee Schedule,140% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.57,,,27.57,Fee Schedule,260% Medicaid Laboratory Fee Schedule,34.36,,,34.36,Fee Schedule,324% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.26,,,13.26,Fee Schedule,125% Medicaid Laboratory Fee Schedule,7.24,241.5,
ASSAY OF SEX HORMONE GLOBUL     ,84270,CPT,,40122947,CDM,301,RC,,,both,,,346,35.73,,,35.73,Other,150% of Medicare + 9.63% HCRA Surcharge,21.73,,,21.73,Fee Schedule,Mediare Clinical Lab,41.94,,,41.94,Fee Schedule,,37.81,,,37.81,Fee Schedule,,219.56,,,219.56,Fee Schedule,,197.55,,,197.55,Fee Schedule,,186.54,,,186.54,Fee Schedule,,173,50,,173,percent of total billed charges,All Other,45.89,,,45.89,Fee Schedule,,68.45,,,68.45,Fee Schedule,,65.35,,,65.35,Other,186% Medicaid methodology,80.62,,,80.62,Fee Schedule,,214.52,,,214.52,Fee Schedule,,45.63,,,45.63,Fee Schedule,,80.62,,,80.62,Fee Schedule,,214.52,,,214.52,Fee Schedule,,85.83,,,85.83,Fee Schedule,,242.2,70,,242.2,percent of total billed charges,All Other,103.61,,,103.61,Fee Schedule,,87.91,,,87.91,Fee Schedule,,26.08,,,26.08,Fee Schedule,,26.08,,,26.08,Fee Schedule,,26.08,,,26.08,Fee Schedule,,26.08,,,26.08,Fee Schedule,,35.13,,,35.13,Other,New York Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,53.75,,,53.75,Other,153% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,49.19,,,49.19,Other,140% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,91.35,,,91.35,Other,260% Medicaid APG methodology,113.83,,,113.83,Other,324% Medicaid APG methodology,75.54,,,75.54,Other,215% Medicaid APG methodology,75.54,,,75.54,Other,215% Medicaid APG methodology,43.92,,,43.92,Other,125% Medicaid APG methodology,21.73,242.2,
HEPATIC FUNCTION PANEL          ,80076,CPT,,40123028,CDM,301,RC,,,both,,,131,13.44,,,13.44,Other,150% of Medicare + 9.63% HCRA Surcharge,8.17,,,8.17,Fee Schedule,Mediare Clinical Lab,15.77,,,15.77,Fee Schedule,,14.22,,,14.22,Fee Schedule,,64.55,,,64.55,Fee Schedule,,58.08,,,58.08,Fee Schedule,,54.84,,,54.84,Fee Schedule,,65.5,50,,65.5,percent of total billed charges,All Other,17.26,,,17.26,Fee Schedule,,25.74,,,25.74,Fee Schedule,,13.62,,,13.62,Other,186% Medicaid methodology,30.31,,,30.31,Fee Schedule,,81.22,,,81.22,Fee Schedule,,17.16,,,17.16,Fee Schedule,,30.31,,,30.31,Fee Schedule,,81.22,,,81.22,Fee Schedule,,32.27,,,32.27,Fee Schedule,,91.7,70,,91.7,percent of total billed charges,All Other,38.95,,,38.95,Fee Schedule,,33.05,,,33.05,Fee Schedule,,9.8,,,9.8,Fee Schedule,,9.8,,,9.8,Fee Schedule,,9.8,,,9.8,Fee Schedule,,9.8,,,9.8,Fee Schedule,,7.32,,,7.32,Fee Schedule,Medicaid Laboratory Fee Schedule,7.32,,,7.32,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.32,,,7.32,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.32,,,7.32,Fee Schedule,100% Medicaid Laboratory Fee Schedule,16.48,,,16.48,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.48,,,16.48,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.2,,,11.2,Fee Schedule,153% Medicaid Laboratory Fee Schedule,16.48,,,16.48,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.25,,,10.25,Fee Schedule,140% Medicaid Laboratory Fee Schedule,16.48,,,16.48,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.04,,,19.04,Fee Schedule,260% Medicaid Laboratory Fee Schedule,23.72,,,23.72,Fee Schedule,324% Medicaid Laboratory Fee Schedule,15.74,,,15.74,Fee Schedule,215% Medicaid Laboratory Fee Schedule,15.74,,,15.74,Fee Schedule,215% Medicaid Laboratory Fee Schedule,9.15,,,9.15,Fee Schedule,125% Medicaid Laboratory Fee Schedule,7.32,91.7,
COMPREHEN METABOLIC PANEL       ,80053,CPT,,40123069,CDM,301,RC,,,both,,,168,17.37,,,17.37,Other,150% of Medicare + 9.63% HCRA Surcharge,10.56,,,10.56,Fee Schedule,Mediare Clinical Lab,20.38,,,20.38,Fee Schedule,,18.37,,,18.37,Fee Schedule,,96.57,,,96.57,Fee Schedule,,86.89,,,86.89,Fee Schedule,,82.05,,,82.05,Fee Schedule,,84,50,,84,percent of total billed charges,All Other,22.3,,,22.3,Fee Schedule,,33.26,,,33.26,Fee Schedule,,18.79,,,18.79,Other,186% Medicaid methodology,39.18,,,39.18,Fee Schedule,,104.16,,,104.16,Fee Schedule,,22.18,,,22.18,Fee Schedule,,39.18,,,39.18,Fee Schedule,,104.16,,,104.16,Fee Schedule,,41.71,,,41.71,Fee Schedule,,117.6,70,,117.6,percent of total billed charges,All Other,50.35,,,50.35,Fee Schedule,,42.72,,,42.72,Fee Schedule,,12.67,,,12.67,Fee Schedule,,12.67,,,12.67,Fee Schedule,,12.67,,,12.67,Fee Schedule,,12.67,,,12.67,Fee Schedule,,10.1,,,10.1,Fee Schedule,Medicaid Laboratory Fee Schedule,10.1,,,10.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.1,,,10.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.1,,,10.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,22.73,,,22.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,22.73,,,22.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.45,,,15.45,Fee Schedule,153% Medicaid Laboratory Fee Schedule,22.73,,,22.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.14,,,14.14,Fee Schedule,140% Medicaid Laboratory Fee Schedule,22.73,,,22.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,26.26,,,26.26,Fee Schedule,260% Medicaid Laboratory Fee Schedule,32.72,,,32.72,Fee Schedule,324% Medicaid Laboratory Fee Schedule,21.72,,,21.72,Fee Schedule,215% Medicaid Laboratory Fee Schedule,21.72,,,21.72,Fee Schedule,215% Medicaid Laboratory Fee Schedule,12.63,,,12.63,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.1,117.6,
ELECTROLYTE PANEL               ,80051,CPT,,40123085,CDM,301,RC,,,both,,,112,11.53,,,11.53,Other,150% of Medicare + 9.63% HCRA Surcharge,7.01,,,7.01,Fee Schedule,Mediare Clinical Lab,13.53,,,13.53,Fee Schedule,,12.2,,,12.2,Fee Schedule,,53.92,,,53.92,Fee Schedule,,48.51,,,48.51,Fee Schedule,,45.81,,,45.81,Fee Schedule,,56,50,,56,percent of total billed charges,All Other,14.82,,,14.82,Fee Schedule,,22.08,,,22.08,Fee Schedule,,11.35,,,11.35,Other,186% Medicaid methodology,26.01,,,26.01,Fee Schedule,,69.44,,,69.44,Fee Schedule,,14.72,,,14.72,Fee Schedule,,26.01,,,26.01,Fee Schedule,,69.44,,,69.44,Fee Schedule,,27.69,,,27.69,Fee Schedule,,78.4,70,,78.4,percent of total billed charges,All Other,33.42,,,33.42,Fee Schedule,,28.36,,,28.36,Fee Schedule,,8.41,,,8.41,Fee Schedule,,8.41,,,8.41,Fee Schedule,,8.41,,,8.41,Fee Schedule,,8.41,,,8.41,Fee Schedule,,6.1,,,6.1,Fee Schedule,Medicaid Laboratory Fee Schedule,6.1,,,6.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.1,,,6.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.1,,,6.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.73,,,13.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.73,,,13.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.33,,,9.33,Fee Schedule,153% Medicaid Laboratory Fee Schedule,13.73,,,13.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.54,,,8.54,Fee Schedule,140% Medicaid Laboratory Fee Schedule,13.73,,,13.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.86,,,15.86,Fee Schedule,260% Medicaid Laboratory Fee Schedule,19.77,,,19.77,Fee Schedule,324% Medicaid Laboratory Fee Schedule,13.12,,,13.12,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.12,,,13.12,Fee Schedule,215% Medicaid Laboratory Fee Schedule,7.63,,,7.63,Fee Schedule,125% Medicaid Laboratory Fee Schedule,6.1,78.4,
PROCALCITONIN (PCT)             ,84145,CPT,,40123093,CDM,301,RC,,,both,,,433,44.76,,,44.76,Other,150% of Medicare + 9.63% HCRA Surcharge,27.22,,,27.22,Fee Schedule,Mediare Clinical Lab,52.53,,,52.53,Fee Schedule,,47.36,,,47.36,Fee Schedule,,270.61,,,270.61,Fee Schedule,,243.48,,,243.48,Fee Schedule,,229.91,,,229.91,Fee Schedule,,216.5,50,,216.5,percent of total billed charges,All Other,57.49,,,57.49,Fee Schedule,,85.74,,,85.74,Fee Schedule,,98.59,,,98.59,Other,186% Medicaid methodology,100.99,,,100.99,Fee Schedule,,268.46,,,268.46,Fee Schedule,,57.16,,,57.16,Fee Schedule,,100.99,,,100.99,Fee Schedule,,268.46,,,268.46,Fee Schedule,,107.52,,,107.52,Fee Schedule,,303.1,70,,303.1,percent of total billed charges,All Other,129.78,,,129.78,Fee Schedule,,110.12,,,110.12,Fee Schedule,,32.66,,,32.66,Fee Schedule,,32.66,,,32.66,Fee Schedule,,32.66,,,32.66,Fee Schedule,,32.66,,,32.66,Fee Schedule,,53,,,53,Other,New York Medicaid APG methodology,53,,,53,Other,100% Medicaid APG methodology,53,,,53,Other,100% Medicaid APG methodology,53,,,53,Other,100% Medicaid APG methodology,119.26,,,119.26,Other,225% Medicaid APG methodology,119.26,,,119.26,Other,225% Medicaid APG methodology,81.1,,,81.1,Other,153% Medicaid APG methodology,119.26,,,119.26,Other,225% Medicaid APG methodology,74.21,,,74.21,Other,140% Medicaid APG methodology,119.26,,,119.26,Other,225% Medicaid APG methodology,137.81,,,137.81,Other,260% Medicaid APG methodology,171.73,,,171.73,Other,324% Medicaid APG methodology,113.96,,,113.96,Other,215% Medicaid APG methodology,113.96,,,113.96,Other,215% Medicaid APG methodology,66.26,,,66.26,Other,125% Medicaid APG methodology,27.22,303.1,
RENAL FUNCTION PANEL            ,80069,CPT,,40123101,CDM,301,RC,,,both,,,138,14.27,,,14.27,Other,150% of Medicare + 9.63% HCRA Surcharge,8.68,,,8.68,Fee Schedule,Mediare Clinical Lab,16.75,,,16.75,Fee Schedule,,15.1,,,15.1,Fee Schedule,,80.99,,,80.99,Fee Schedule,,72.87,,,72.87,Fee Schedule,,68.81,,,68.81,Fee Schedule,,69,50,,69,percent of total billed charges,All Other,18.33,,,18.33,Fee Schedule,,27.34,,,27.34,Fee Schedule,,16.14,,,16.14,Other,186% Medicaid methodology,32.2,,,32.2,Fee Schedule,,85.56,,,85.56,Fee Schedule,,18.23,,,18.23,Fee Schedule,,32.2,,,32.2,Fee Schedule,,85.56,,,85.56,Fee Schedule,,34.29,,,34.29,Fee Schedule,,96.6,70,,96.6,percent of total billed charges,All Other,41.39,,,41.39,Fee Schedule,,35.12,,,35.12,Fee Schedule,,10.42,,,10.42,Fee Schedule,,10.42,,,10.42,Fee Schedule,,10.42,,,10.42,Fee Schedule,,10.42,,,10.42,Fee Schedule,,8.68,,,8.68,Fee Schedule,Medicaid Laboratory Fee Schedule,8.68,,,8.68,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.68,,,8.68,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.68,,,8.68,Fee Schedule,100% Medicaid Laboratory Fee Schedule,19.53,,,19.53,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.53,,,19.53,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.28,,,13.28,Fee Schedule,153% Medicaid Laboratory Fee Schedule,19.53,,,19.53,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.15,,,12.15,Fee Schedule,140% Medicaid Laboratory Fee Schedule,19.53,,,19.53,Fee Schedule,225% Medicaid Laboratory Fee Schedule,22.57,,,22.57,Fee Schedule,260% Medicaid Laboratory Fee Schedule,28.12,,,28.12,Fee Schedule,324% Medicaid Laboratory Fee Schedule,18.66,,,18.66,Fee Schedule,215% Medicaid Laboratory Fee Schedule,18.66,,,18.66,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.85,,,10.85,Fee Schedule,125% Medicaid Laboratory Fee Schedule,8.68,96.6,
Hemoglobin A1c LC,83036,CPT,,40123119,CDM,301,RC,,,both,,,155,15.97,,,15.97,Other,150% of Medicare + 9.63% HCRA Surcharge,9.71,,,9.71,Fee Schedule,Mediare Clinical Lab,18.74,,,18.74,Fee Schedule,,16.9,,,16.9,Fee Schedule,,98.08,,,98.08,Fee Schedule,,88.24,,,88.24,Fee Schedule,,83.33,,,83.33,Fee Schedule,,77.5,50,,77.5,percent of total billed charges,All Other,20.51,,,20.51,Fee Schedule,,30.59,,,30.59,Fee Schedule,,56.01,,,56.01,Other,186% Medicaid methodology,36.02,,,36.02,Fee Schedule,,96.1,,,96.1,Fee Schedule,,20.39,,,20.39,Fee Schedule,,36.02,,,36.02,Fee Schedule,,96.1,,,96.1,Fee Schedule,,38.35,,,38.35,Fee Schedule,,108.5,70,,108.5,percent of total billed charges,All Other,46.3,,,46.3,Fee Schedule,,39.28,,,39.28,Fee Schedule,,11.65,,,11.65,Fee Schedule,,11.65,,,11.65,Fee Schedule,,11.65,,,11.65,Fee Schedule,,11.65,,,11.65,Fee Schedule,,30.11,,,30.11,Other,New York Medicaid APG methodology,30.11,,,30.11,Other,100% Medicaid APG methodology,30.11,,,30.11,Other,100% Medicaid APG methodology,30.11,,,30.11,Other,100% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,46.07,,,46.07,Other,153% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,42.16,,,42.16,Other,140% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,78.29,,,78.29,Other,260% Medicaid APG methodology,97.56,,,97.56,Other,324% Medicaid APG methodology,64.74,,,64.74,Other,215% Medicaid APG methodology,64.74,,,64.74,Other,215% Medicaid APG methodology,37.64,,,37.64,Other,125% Medicaid APG methodology,9.71,108.5,
ASSAY OF INSULIN TOTAL          ,83525,CPT,,40123267,CDM,301,RC,,,both,,,182,18.8,,,18.8,Other,150% of Medicare + 9.63% HCRA Surcharge,11.43,,,11.43,Fee Schedule,Mediare Clinical Lab,22.06,,,22.06,Fee Schedule,,19.89,,,19.89,Fee Schedule,,115.53,,,115.53,Fee Schedule,,103.94,,,103.94,Fee Schedule,,98.15,,,98.15,Fee Schedule,,91,50,,91,percent of total billed charges,All Other,24.15,,,24.15,Fee Schedule,,36,,,36,Fee Schedule,,21.26,,,21.26,Other,186% Medicaid methodology,42.41,,,42.41,Fee Schedule,,112.84,,,112.84,Fee Schedule,,24,,,24,Fee Schedule,,42.41,,,42.41,Fee Schedule,,112.84,,,112.84,Fee Schedule,,45.15,,,45.15,Fee Schedule,,127.4,70,,127.4,percent of total billed charges,All Other,54.5,,,54.5,Fee Schedule,,46.24,,,46.24,Fee Schedule,,13.72,,,13.72,Fee Schedule,,13.72,,,13.72,Fee Schedule,,13.72,,,13.72,Fee Schedule,,13.72,,,13.72,Fee Schedule,,11.43,,,11.43,Fee Schedule,Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,100% Medicaid Laboratory Fee Schedule,25.72,,,25.72,Fee Schedule,225% Medicaid Laboratory Fee Schedule,25.72,,,25.72,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.49,,,17.49,Fee Schedule,153% Medicaid Laboratory Fee Schedule,25.72,,,25.72,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16,,,16,Fee Schedule,140% Medicaid Laboratory Fee Schedule,25.72,,,25.72,Fee Schedule,225% Medicaid Laboratory Fee Schedule,29.72,,,29.72,Fee Schedule,260% Medicaid Laboratory Fee Schedule,37.03,,,37.03,Fee Schedule,324% Medicaid Laboratory Fee Schedule,24.57,,,24.57,Fee Schedule,215% Medicaid Laboratory Fee Schedule,24.57,,,24.57,Fee Schedule,215% Medicaid Laboratory Fee Schedule,14.29,,,14.29,Fee Schedule,125% Medicaid Laboratory Fee Schedule,11.43,127.4,
ASSAY OF HOMOCYSTINE            ,83090,CPT,,40123481,CDM,301,RC,,,both,,,286,29.47,,,29.47,Other,150% of Medicare + 9.63% HCRA Surcharge,17.92,,,17.92,Fee Schedule,Mediare Clinical Lab,34.59,,,34.59,Fee Schedule,,31.18,,,31.18,Fee Schedule,,170.45,,,170.45,Fee Schedule,,153.36,,,153.36,Fee Schedule,,144.81,,,144.81,Fee Schedule,,143,50,,143,percent of total billed charges,All Other,37.86,,,37.86,Fee Schedule,,56.45,,,56.45,Fee Schedule,,33.33,,,33.33,Other,186% Medicaid methodology,66.48,,,66.48,Fee Schedule,,177.32,,,177.32,Fee Schedule,,37.63,,,37.63,Fee Schedule,,66.48,,,66.48,Fee Schedule,,177.32,,,177.32,Fee Schedule,,70.78,,,70.78,Fee Schedule,,200.2,70,,200.2,percent of total billed charges,All Other,85.44,,,85.44,Fee Schedule,,72.5,,,72.5,Fee Schedule,,21.5,,,21.5,Fee Schedule,,21.5,,,21.5,Fee Schedule,,21.5,,,21.5,Fee Schedule,,21.5,,,21.5,Fee Schedule,,17.92,,,17.92,Fee Schedule,Medicaid Laboratory Fee Schedule,17.92,,,17.92,Fee Schedule,100% Medicaid Laboratory Fee Schedule,17.92,,,17.92,Fee Schedule,100% Medicaid Laboratory Fee Schedule,17.92,,,17.92,Fee Schedule,100% Medicaid Laboratory Fee Schedule,40.32,,,40.32,Fee Schedule,225% Medicaid Laboratory Fee Schedule,40.32,,,40.32,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.42,,,27.42,Fee Schedule,153% Medicaid Laboratory Fee Schedule,40.32,,,40.32,Fee Schedule,225% Medicaid Laboratory Fee Schedule,25.09,,,25.09,Fee Schedule,140% Medicaid Laboratory Fee Schedule,40.32,,,40.32,Fee Schedule,225% Medicaid Laboratory Fee Schedule,46.59,,,46.59,Fee Schedule,260% Medicaid Laboratory Fee Schedule,58.06,,,58.06,Fee Schedule,324% Medicaid Laboratory Fee Schedule,38.53,,,38.53,Fee Schedule,215% Medicaid Laboratory Fee Schedule,38.53,,,38.53,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.4,,,22.4,Fee Schedule,125% Medicaid Laboratory Fee Schedule,17.92,200.2,
DRUG SCRN QUAN LEVETIRACETAM    ,80177,CPT,,40123606,CDM,301,RC,,,both,,,211,21.79,,,21.79,Other,150% of Medicare + 9.63% HCRA Surcharge,13.25,,,13.25,Fee Schedule,Mediare Clinical Lab,25.57,,,25.57,Fee Schedule,,23.06,,,23.06,Fee Schedule,,7.24,,,7.24,Fee Schedule,,7.24,,,7.24,Fee Schedule,,7.24,,,7.24,Fee Schedule,,105.5,50,,105.5,percent of total billed charges,All Other,27.98,,,27.98,Fee Schedule,,41.74,,,41.74,Fee Schedule,,19.73,,,19.73,Other,186% Medicaid methodology,49.16,,,49.16,Fee Schedule,,130.82,,,130.82,Fee Schedule,,27.83,,,27.83,Fee Schedule,,49.16,,,49.16,Fee Schedule,,130.82,,,130.82,Fee Schedule,,52.34,,,52.34,Fee Schedule,,147.7,70,,147.7,percent of total billed charges,All Other,63.18,,,63.18,Fee Schedule,,53.6,,,53.6,Fee Schedule,,15.9,,,15.9,Fee Schedule,,15.9,,,15.9,Fee Schedule,,15.9,,,15.9,Fee Schedule,,15.9,,,15.9,Fee Schedule,,10.61,,,10.61,Fee Schedule,Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.23,,,16.23,Fee Schedule,153% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.85,,,14.85,Fee Schedule,140% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.57,,,27.57,Fee Schedule,260% Medicaid Laboratory Fee Schedule,34.36,,,34.36,Fee Schedule,324% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.26,,,13.26,Fee Schedule,125% Medicaid Laboratory Fee Schedule,7.24,147.7,
ASSAY OF MERCURY                ,83825,CPT,,40123820,CDM,301,RC,,,both,,,259,26.74,,,26.74,Other,150% of Medicare + 9.63% HCRA Surcharge,16.26,,,16.26,Fee Schedule,Mediare Clinical Lab,31.38,,,31.38,Fee Schedule,,28.29,,,28.29,Fee Schedule,,164.28,,,164.28,Fee Schedule,,147.8,,,147.8,Fee Schedule,,139.57,,,139.57,Fee Schedule,,129.5,50,,129.5,percent of total billed charges,All Other,34.35,,,34.35,Fee Schedule,,51.22,,,51.22,Fee Schedule,,30.24,,,30.24,Other,186% Medicaid methodology,60.32,,,60.32,Fee Schedule,,160.58,,,160.58,Fee Schedule,,34.15,,,34.15,Fee Schedule,,60.32,,,60.32,Fee Schedule,,160.58,,,160.58,Fee Schedule,,64.23,,,64.23,Fee Schedule,,181.3,70,,181.3,percent of total billed charges,All Other,77.53,,,77.53,Fee Schedule,,65.78,,,65.78,Fee Schedule,,19.51,,,19.51,Fee Schedule,,19.51,,,19.51,Fee Schedule,,19.51,,,19.51,Fee Schedule,,19.51,,,19.51,Fee Schedule,,16.26,,,16.26,Fee Schedule,Medicaid Laboratory Fee Schedule,16.26,,,16.26,Fee Schedule,100% Medicaid Laboratory Fee Schedule,16.26,,,16.26,Fee Schedule,100% Medicaid Laboratory Fee Schedule,16.26,,,16.26,Fee Schedule,100% Medicaid Laboratory Fee Schedule,36.59,,,36.59,Fee Schedule,225% Medicaid Laboratory Fee Schedule,36.59,,,36.59,Fee Schedule,225% Medicaid Laboratory Fee Schedule,24.88,,,24.88,Fee Schedule,153% Medicaid Laboratory Fee Schedule,36.59,,,36.59,Fee Schedule,225% Medicaid Laboratory Fee Schedule,22.76,,,22.76,Fee Schedule,140% Medicaid Laboratory Fee Schedule,36.59,,,36.59,Fee Schedule,225% Medicaid Laboratory Fee Schedule,42.28,,,42.28,Fee Schedule,260% Medicaid Laboratory Fee Schedule,52.68,,,52.68,Fee Schedule,324% Medicaid Laboratory Fee Schedule,34.96,,,34.96,Fee Schedule,215% Medicaid Laboratory Fee Schedule,34.96,,,34.96,Fee Schedule,215% Medicaid Laboratory Fee Schedule,20.33,,,20.33,Fee Schedule,125% Medicaid Laboratory Fee Schedule,16.26,181.3,
DRUG SCREEN QUANT ZONISAMIDE    ,80203,CPT,,40123960,CDM,301,RC,,,both,,,211,21.79,,,21.79,Other,150% of Medicare + 9.63% HCRA Surcharge,13.25,,,13.25,Fee Schedule,Mediare Clinical Lab,25.57,,,25.57,Fee Schedule,,23.06,,,23.06,Fee Schedule,,7.24,,,7.24,Fee Schedule,,7.24,,,7.24,Fee Schedule,,7.24,,,7.24,Fee Schedule,,105.5,50,,105.5,percent of total billed charges,All Other,27.98,,,27.98,Fee Schedule,,41.74,,,41.74,Fee Schedule,,19.73,,,19.73,Other,186% Medicaid methodology,49.16,,,49.16,Fee Schedule,,130.82,,,130.82,Fee Schedule,,27.83,,,27.83,Fee Schedule,,49.16,,,49.16,Fee Schedule,,130.82,,,130.82,Fee Schedule,,52.34,,,52.34,Fee Schedule,,147.7,70,,147.7,percent of total billed charges,All Other,63.18,,,63.18,Fee Schedule,,53.6,,,53.6,Fee Schedule,,15.9,,,15.9,Fee Schedule,,15.9,,,15.9,Fee Schedule,,15.9,,,15.9,Fee Schedule,,15.9,,,15.9,Fee Schedule,,10.61,,,10.61,Fee Schedule,Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.23,,,16.23,Fee Schedule,153% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.85,,,14.85,Fee Schedule,140% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.57,,,27.57,Fee Schedule,260% Medicaid Laboratory Fee Schedule,34.36,,,34.36,Fee Schedule,324% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.26,,,13.26,Fee Schedule,125% Medicaid Laboratory Fee Schedule,7.24,147.7,
ASSAY OF TRANSFERRIN            ,84466,CPT,,40123986,CDM,301,RC,,,both,,,203,20.98,,,20.98,Other,150% of Medicare + 9.63% HCRA Surcharge,12.76,,,12.76,Fee Schedule,Mediare Clinical Lab,24.63,,,24.63,Fee Schedule,,22.2,,,22.2,Fee Schedule,,129.02,,,129.02,Fee Schedule,,116.09,,,116.09,Fee Schedule,,109.62,,,109.62,Fee Schedule,,101.5,50,,101.5,percent of total billed charges,All Other,26.94,,,26.94,Fee Schedule,,40.19,,,40.19,Fee Schedule,,23.48,,,23.48,Other,186% Medicaid methodology,47.34,,,47.34,Fee Schedule,,125.86,,,125.86,Fee Schedule,,26.8,,,26.8,Fee Schedule,,47.34,,,47.34,Fee Schedule,,125.86,,,125.86,Fee Schedule,,50.4,,,50.4,Fee Schedule,,142.1,70,,142.1,percent of total billed charges,All Other,60.84,,,60.84,Fee Schedule,,51.62,,,51.62,Fee Schedule,,15.31,,,15.31,Fee Schedule,,15.31,,,15.31,Fee Schedule,,15.31,,,15.31,Fee Schedule,,15.31,,,15.31,Fee Schedule,,12.63,,,12.63,Fee Schedule,Medicaid Laboratory Fee Schedule,12.63,,,12.63,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.63,,,12.63,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.63,,,12.63,Fee Schedule,100% Medicaid Laboratory Fee Schedule,28.41,,,28.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,28.41,,,28.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.32,,,19.32,Fee Schedule,153% Medicaid Laboratory Fee Schedule,28.41,,,28.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.68,,,17.68,Fee Schedule,140% Medicaid Laboratory Fee Schedule,28.41,,,28.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,32.83,,,32.83,Fee Schedule,260% Medicaid Laboratory Fee Schedule,40.91,,,40.91,Fee Schedule,324% Medicaid Laboratory Fee Schedule,27.14,,,27.14,Fee Schedule,215% Medicaid Laboratory Fee Schedule,27.14,,,27.14,Fee Schedule,215% Medicaid Laboratory Fee Schedule,15.78,,,15.78,Fee Schedule,125% Medicaid Laboratory Fee Schedule,12.63,142.1,
ASSAY OF NATRIURETIC PEPTIDE    ,83880,CPT,,40124349,CDM,301,RC,,,both,,,625,64.56,,,64.56,Other,150% of Medicare + 9.63% HCRA Surcharge,39.26,,,39.26,Fee Schedule,Mediare Clinical Lab,75.77,,,75.77,Fee Schedule,,68.31,,,68.31,Fee Schedule,,342.99,,,342.99,Fee Schedule,,308.59,,,308.59,Fee Schedule,,291.4,,,291.4,Fee Schedule,,312.5,50,,312.5,percent of total billed charges,All Other,82.94,,,82.94,Fee Schedule,,123.67,,,123.67,Fee Schedule,,64,,,64,Other,186% Medicaid methodology,145.65,,,145.65,Fee Schedule,,387.5,,,387.5,Fee Schedule,,82.45,,,82.45,Fee Schedule,,145.65,,,145.65,Fee Schedule,,387.5,,,387.5,Fee Schedule,,155.08,,,155.08,Fee Schedule,,437.5,70,,437.5,percent of total billed charges,All Other,187.19,,,187.19,Fee Schedule,,158.83,,,158.83,Fee Schedule,,47.11,,,47.11,Fee Schedule,,47.11,,,47.11,Fee Schedule,,47.11,,,47.11,Fee Schedule,,47.11,,,47.11,Fee Schedule,,34.41,,,34.41,Fee Schedule,Medicaid Laboratory Fee Schedule,34.41,,,34.41,Fee Schedule,100% Medicaid Laboratory Fee Schedule,34.41,,,34.41,Fee Schedule,100% Medicaid Laboratory Fee Schedule,34.41,,,34.41,Fee Schedule,100% Medicaid Laboratory Fee Schedule,77.42,,,77.42,Fee Schedule,225% Medicaid Laboratory Fee Schedule,77.42,,,77.42,Fee Schedule,225% Medicaid Laboratory Fee Schedule,52.65,,,52.65,Fee Schedule,153% Medicaid Laboratory Fee Schedule,77.42,,,77.42,Fee Schedule,225% Medicaid Laboratory Fee Schedule,48.17,,,48.17,Fee Schedule,140% Medicaid Laboratory Fee Schedule,77.42,,,77.42,Fee Schedule,225% Medicaid Laboratory Fee Schedule,89.47,,,89.47,Fee Schedule,260% Medicaid Laboratory Fee Schedule,111.49,,,111.49,Fee Schedule,324% Medicaid Laboratory Fee Schedule,73.98,,,73.98,Fee Schedule,215% Medicaid Laboratory Fee Schedule,73.98,,,73.98,Fee Schedule,215% Medicaid Laboratory Fee Schedule,43.01,,,43.01,Fee Schedule,125% Medicaid Laboratory Fee Schedule,34.41,437.5,
ASSAY NONENDOCRINE RECEPTOR     ,86041,CPT,,40124604,CDM,301,RC,,,both,,,582,30.26,,,30.26,Other,150% of Medicare + 9.63% HCRA Surcharge,18.4,,,18.4,Fee Schedule,Mediare Clinical Lab,35.51,,,35.51,Fee Schedule,,32.02,,,32.02,Fee Schedule,,291,50,,291,percent of total billed charges,All Other Outpatient,261.9,45,,261.9,percent of total billed charges,All Other Outpatient,250.26,43,,250.26,percent of total billed charges,All Other Outpatient,291,50,,291,percent of total billed charges,All Other,407.4,70,,407.4,percent of total billed charges,All Other,57.96,,,57.96,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,68.26,,,68.26,Fee Schedule,,360.84,,,360.84,Fee Schedule,,38.64,,,38.64,Fee Schedule,,68.26,,,68.26,Fee Schedule,,360.84,,,360.84,Fee Schedule,,72.68,,,72.68,Fee Schedule,,407.4,70,,407.4,percent of total billed charges,All Other,291,50,,291,percent of total billed charges,All Other,291,50,,291,percent of total billed charges,All Other,22.08,,,22.08,Fee Schedule,,22.08,,,22.08,Fee Schedule,,22.08,,,22.08,Fee Schedule,,22.08,,,22.08,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,407.4,
RIA NONANTIBODY                 ,83519,CPT,,40124901,CDM,301,RC,,,both,,,293,30.26,,,30.26,Other,150% of Medicare + 9.63% HCRA Surcharge,18.4,,,18.4,Fee Schedule,Mediare Clinical Lab,35.51,,,35.51,Fee Schedule,,32.02,,,32.02,Fee Schedule,,136.49,,,136.49,Fee Schedule,,122.8,,,122.8,Fee Schedule,,115.96,,,115.96,Fee Schedule,,146.5,50,,146.5,percent of total billed charges,All Other,38.87,,,38.87,Fee Schedule,,57.96,,,57.96,Fee Schedule,,65.35,,,65.35,Other,186% Medicaid methodology,68.26,,,68.26,Fee Schedule,,181.66,,,181.66,Fee Schedule,,38.64,,,38.64,Fee Schedule,,68.26,,,68.26,Fee Schedule,,181.66,,,181.66,Fee Schedule,,72.68,,,72.68,Fee Schedule,,205.1,70,,205.1,percent of total billed charges,All Other,87.73,,,87.73,Fee Schedule,,74.44,,,74.44,Fee Schedule,,22.08,,,22.08,Fee Schedule,,22.08,,,22.08,Fee Schedule,,22.08,,,22.08,Fee Schedule,,22.08,,,22.08,Fee Schedule,,35.13,,,35.13,Other,New York Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,53.75,,,53.75,Other,153% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,49.19,,,49.19,Other,140% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,91.35,,,91.35,Other,260% Medicaid APG methodology,113.83,,,113.83,Other,324% Medicaid APG methodology,75.54,,,75.54,Other,215% Medicaid APG methodology,75.54,,,75.54,Other,215% Medicaid APG methodology,43.92,,,43.92,Other,125% Medicaid APG methodology,18.4,205.1,
IMMUNOASSAY QUANT NOS NONAB     ,83520,CPT,,40124968,CDM,301,RC,,,both,,,275,28.4,,,28.4,Other,150% of Medicare + 9.63% HCRA Surcharge,17.27,,,17.27,Fee Schedule,Mediare Clinical Lab,33.33,,,33.33,Fee Schedule,,30.05,,,30.05,Fee Schedule,,130.82,,,130.82,Fee Schedule,,117.7,,,117.7,Fee Schedule,,111.14,,,111.14,Fee Schedule,,137.5,50,,137.5,percent of total billed charges,All Other,36.5,,,36.5,Fee Schedule,,54.4,,,54.4,Fee Schedule,,65.35,,,65.35,Other,186% Medicaid methodology,64.07,,,64.07,Fee Schedule,,170.5,,,170.5,Fee Schedule,,36.27,,,36.27,Fee Schedule,,64.07,,,64.07,Fee Schedule,,170.5,,,170.5,Fee Schedule,,68.22,,,68.22,Fee Schedule,,192.5,70,,192.5,percent of total billed charges,All Other,82.34,,,82.34,Fee Schedule,,69.87,,,69.87,Fee Schedule,,20.72,,,20.72,Fee Schedule,,20.72,,,20.72,Fee Schedule,,20.72,,,20.72,Fee Schedule,,20.72,,,20.72,Fee Schedule,,35.13,,,35.13,Other,New York Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,53.75,,,53.75,Other,153% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,49.19,,,49.19,Other,140% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,91.35,,,91.35,Other,260% Medicaid APG methodology,113.83,,,113.83,Other,324% Medicaid APG methodology,75.54,,,75.54,Other,215% Medicaid APG methodology,75.54,,,75.54,Other,215% Medicaid APG methodology,43.92,,,43.92,Other,125% Medicaid APG methodology,17.27,192.5,
IMMUNOASSAY QUANT NOS NONAB     ,83520,CPT,,40125080,CDM,301,RC,,,both,,,275,28.4,,,28.4,Other,150% of Medicare + 9.63% HCRA Surcharge,17.27,,,17.27,Fee Schedule,Mediare Clinical Lab,33.33,,,33.33,Fee Schedule,,30.05,,,30.05,Fee Schedule,,130.82,,,130.82,Fee Schedule,,117.7,,,117.7,Fee Schedule,,111.14,,,111.14,Fee Schedule,,137.5,50,,137.5,percent of total billed charges,All Other,36.5,,,36.5,Fee Schedule,,54.4,,,54.4,Fee Schedule,,65.35,,,65.35,Other,186% Medicaid methodology,64.07,,,64.07,Fee Schedule,,170.5,,,170.5,Fee Schedule,,36.27,,,36.27,Fee Schedule,,64.07,,,64.07,Fee Schedule,,170.5,,,170.5,Fee Schedule,,68.22,,,68.22,Fee Schedule,,192.5,70,,192.5,percent of total billed charges,All Other,82.34,,,82.34,Fee Schedule,,69.87,,,69.87,Fee Schedule,,20.72,,,20.72,Fee Schedule,,20.72,,,20.72,Fee Schedule,,20.72,,,20.72,Fee Schedule,,20.72,,,20.72,Fee Schedule,,35.13,,,35.13,Other,New York Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,53.75,,,53.75,Other,153% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,49.19,,,49.19,Other,140% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,91.35,,,91.35,Other,260% Medicaid APG methodology,113.83,,,113.83,Other,324% Medicaid APG methodology,75.54,,,75.54,Other,215% Medicaid APG methodology,75.54,,,75.54,Other,215% Medicaid APG methodology,43.92,,,43.92,Other,125% Medicaid APG methodology,17.27,192.5,
GLUCOSE; POST GLUCOSE DOSE      ,82950,CPT,,40125445,CDM,301,RC,,,both,,,76,7.81,,,7.81,Other,150% of Medicare + 9.63% HCRA Surcharge,4.75,,,4.75,Fee Schedule,Mediare Clinical Lab,9.17,,,9.17,Fee Schedule,,8.27,,,8.27,Fee Schedule,,47.96,,,47.96,Fee Schedule,,43.15,,,43.15,Fee Schedule,,40.75,,,40.75,Fee Schedule,,38,50,,38,percent of total billed charges,All Other,10.04,,,10.04,Fee Schedule,,14.96,,,14.96,Fee Schedule,,8.84,,,8.84,Other,186% Medicaid methodology,17.62,,,17.62,Fee Schedule,,47.12,,,47.12,Fee Schedule,,9.98,,,9.98,Fee Schedule,,17.62,,,17.62,Fee Schedule,,47.12,,,47.12,Fee Schedule,,18.76,,,18.76,Fee Schedule,,53.2,70,,53.2,percent of total billed charges,All Other,22.65,,,22.65,Fee Schedule,,19.22,,,19.22,Fee Schedule,,5.7,,,5.7,Fee Schedule,,5.7,,,5.7,Fee Schedule,,5.7,,,5.7,Fee Schedule,,5.7,,,5.7,Fee Schedule,,4.75,,,4.75,Fee Schedule,Medicaid Laboratory Fee Schedule,4.75,,,4.75,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.75,,,4.75,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.75,,,4.75,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.69,,,10.69,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.69,,,10.69,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.27,,,7.27,Fee Schedule,153% Medicaid Laboratory Fee Schedule,10.69,,,10.69,Fee Schedule,225% Medicaid Laboratory Fee Schedule,6.65,,,6.65,Fee Schedule,140% Medicaid Laboratory Fee Schedule,10.69,,,10.69,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.35,,,12.35,Fee Schedule,260% Medicaid Laboratory Fee Schedule,15.39,,,15.39,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.21,,,10.21,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.21,,,10.21,Fee Schedule,215% Medicaid Laboratory Fee Schedule,5.94,,,5.94,Fee Schedule,125% Medicaid Laboratory Fee Schedule,4.75,53.2,
COL CHROMOTOGRAPHY QUAL/QUAN    ,82542,CPT,,40125569,CDM,301,RC,,,both,,,383,39.61,,,39.61,Other,150% of Medicare + 9.63% HCRA Surcharge,24.09,,,24.09,Fee Schedule,Mediare Clinical Lab,46.49,,,46.49,Fee Schedule,,41.92,,,41.92,Fee Schedule,,182.44,,,182.44,Fee Schedule,,164.15,,,164.15,Fee Schedule,,155,,,155,Fee Schedule,,191.5,50,,191.5,percent of total billed charges,All Other,50.9,,,50.9,Fee Schedule,,75.88,,,75.88,Fee Schedule,,65.35,,,65.35,Other,186% Medicaid methodology,89.37,,,89.37,Fee Schedule,,237.46,,,237.46,Fee Schedule,,50.59,,,50.59,Fee Schedule,,89.37,,,89.37,Fee Schedule,,237.46,,,237.46,Fee Schedule,,95.16,,,95.16,Fee Schedule,,268.1,70,,268.1,percent of total billed charges,All Other,114.86,,,114.86,Fee Schedule,,97.46,,,97.46,Fee Schedule,,28.91,,,28.91,Fee Schedule,,28.91,,,28.91,Fee Schedule,,28.91,,,28.91,Fee Schedule,,28.91,,,28.91,Fee Schedule,,35.13,,,35.13,Other,New York Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,53.75,,,53.75,Other,153% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,49.19,,,49.19,Other,140% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,91.35,,,91.35,Other,260% Medicaid APG methodology,113.83,,,113.83,Other,324% Medicaid APG methodology,75.54,,,75.54,Other,215% Medicaid APG methodology,75.54,,,75.54,Other,215% Medicaid APG methodology,43.92,,,43.92,Other,125% Medicaid APG methodology,24.09,268.1,
ASSAY OF PSA FREE               ,84154,CPT,,40125684,CDM,301,RC,,,both,,,293,30.24,,,30.24,Other,150% of Medicare + 9.63% HCRA Surcharge,18.39,,,18.39,Fee Schedule,Mediare Clinical Lab,35.49,,,35.49,Fee Schedule,,32,,,32,Fee Schedule,,185.89,,,185.89,Fee Schedule,,167.25,,,167.25,Fee Schedule,,157.93,,,157.93,Fee Schedule,,146.5,50,,146.5,percent of total billed charges,All Other,38.84,,,38.84,Fee Schedule,,57.93,,,57.93,Fee Schedule,,34.21,,,34.21,Other,186% Medicaid methodology,68.23,,,68.23,Fee Schedule,,181.66,,,181.66,Fee Schedule,,38.62,,,38.62,Fee Schedule,,68.23,,,68.23,Fee Schedule,,181.66,,,181.66,Fee Schedule,,72.64,,,72.64,Fee Schedule,,205.1,70,,205.1,percent of total billed charges,All Other,87.68,,,87.68,Fee Schedule,,74.4,,,74.4,Fee Schedule,,22.07,,,22.07,Fee Schedule,,22.07,,,22.07,Fee Schedule,,22.07,,,22.07,Fee Schedule,,22.07,,,22.07,Fee Schedule,,18.39,,,18.39,Fee Schedule,Medicaid Laboratory Fee Schedule,18.39,,,18.39,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.39,,,18.39,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.39,,,18.39,Fee Schedule,100% Medicaid Laboratory Fee Schedule,41.38,,,41.38,Fee Schedule,225% Medicaid Laboratory Fee Schedule,41.38,,,41.38,Fee Schedule,225% Medicaid Laboratory Fee Schedule,28.14,,,28.14,Fee Schedule,153% Medicaid Laboratory Fee Schedule,41.38,,,41.38,Fee Schedule,225% Medicaid Laboratory Fee Schedule,25.75,,,25.75,Fee Schedule,140% Medicaid Laboratory Fee Schedule,41.38,,,41.38,Fee Schedule,225% Medicaid Laboratory Fee Schedule,47.81,,,47.81,Fee Schedule,260% Medicaid Laboratory Fee Schedule,59.58,,,59.58,Fee Schedule,324% Medicaid Laboratory Fee Schedule,39.54,,,39.54,Fee Schedule,215% Medicaid Laboratory Fee Schedule,39.54,,,39.54,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.99,,,22.99,Fee Schedule,125% Medicaid Laboratory Fee Schedule,18.39,205.1,
ASSAY OF METANEPHRINES          ,83835,CPT,,40125726,CDM,301,RC,,,both,,,270,27.86,,,27.86,Other,150% of Medicare + 9.63% HCRA Surcharge,16.94,,,16.94,Fee Schedule,Mediare Clinical Lab,32.69,,,32.69,Fee Schedule,,29.48,,,29.48,Fee Schedule,,171.17,,,171.17,Fee Schedule,,154.01,,,154.01,Fee Schedule,,145.42,,,145.42,Fee Schedule,,135,50,,135,percent of total billed charges,All Other,35.78,,,35.78,Fee Schedule,,53.36,,,53.36,Fee Schedule,,31.51,,,31.51,Other,186% Medicaid methodology,62.85,,,62.85,Fee Schedule,,167.4,,,167.4,Fee Schedule,,35.57,,,35.57,Fee Schedule,,62.85,,,62.85,Fee Schedule,,167.4,,,167.4,Fee Schedule,,66.91,,,66.91,Fee Schedule,,189,70,,189,percent of total billed charges,All Other,80.77,,,80.77,Fee Schedule,,68.53,,,68.53,Fee Schedule,,20.33,,,20.33,Fee Schedule,,20.33,,,20.33,Fee Schedule,,20.33,,,20.33,Fee Schedule,,20.33,,,20.33,Fee Schedule,,16.94,,,16.94,Fee Schedule,Medicaid Laboratory Fee Schedule,16.94,,,16.94,Fee Schedule,100% Medicaid Laboratory Fee Schedule,16.94,,,16.94,Fee Schedule,100% Medicaid Laboratory Fee Schedule,16.94,,,16.94,Fee Schedule,100% Medicaid Laboratory Fee Schedule,38.12,,,38.12,Fee Schedule,225% Medicaid Laboratory Fee Schedule,38.12,,,38.12,Fee Schedule,225% Medicaid Laboratory Fee Schedule,25.92,,,25.92,Fee Schedule,153% Medicaid Laboratory Fee Schedule,38.12,,,38.12,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.72,,,23.72,Fee Schedule,140% Medicaid Laboratory Fee Schedule,38.12,,,38.12,Fee Schedule,225% Medicaid Laboratory Fee Schedule,44.04,,,44.04,Fee Schedule,260% Medicaid Laboratory Fee Schedule,54.89,,,54.89,Fee Schedule,324% Medicaid Laboratory Fee Schedule,36.42,,,36.42,Fee Schedule,215% Medicaid Laboratory Fee Schedule,36.42,,,36.42,Fee Schedule,215% Medicaid Laboratory Fee Schedule,21.18,,,21.18,Fee Schedule,125% Medicaid Laboratory Fee Schedule,16.94,189,
ALKALINE PHOSPHATASE ISOENZYM   ,84080,CPT,,40125783,CDM,301,RC,,,both,,,236,24.3,,,24.3,Other,150% of Medicare + 9.63% HCRA Surcharge,14.78,,,14.78,Fee Schedule,Mediare Clinical Lab,28.53,,,28.53,Fee Schedule,,25.72,,,25.72,Fee Schedule,,88.39,,,88.39,Fee Schedule,,79.52,,,79.52,Fee Schedule,,75.09,,,75.09,Fee Schedule,,118,50,,118,percent of total billed charges,All Other,31.23,,,31.23,Fee Schedule,,46.56,,,46.56,Fee Schedule,,18.62,,,18.62,Other,186% Medicaid methodology,54.83,,,54.83,Fee Schedule,,146.32,,,146.32,Fee Schedule,,31.04,,,31.04,Fee Schedule,,54.83,,,54.83,Fee Schedule,,146.32,,,146.32,Fee Schedule,,58.38,,,58.38,Fee Schedule,,165.2,70,,165.2,percent of total billed charges,All Other,70.47,,,70.47,Fee Schedule,,59.79,,,59.79,Fee Schedule,,17.74,,,17.74,Fee Schedule,,17.74,,,17.74,Fee Schedule,,17.74,,,17.74,Fee Schedule,,17.74,,,17.74,Fee Schedule,,10.01,,,10.01,Fee Schedule,Medicaid Laboratory Fee Schedule,10.01,,,10.01,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.01,,,10.01,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.01,,,10.01,Fee Schedule,100% Medicaid Laboratory Fee Schedule,22.52,,,22.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,22.52,,,22.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.31,,,15.31,Fee Schedule,153% Medicaid Laboratory Fee Schedule,22.52,,,22.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.01,,,14.01,Fee Schedule,140% Medicaid Laboratory Fee Schedule,22.52,,,22.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,26.02,,,26.02,Fee Schedule,260% Medicaid Laboratory Fee Schedule,32.43,,,32.43,Fee Schedule,324% Medicaid Laboratory Fee Schedule,21.52,,,21.52,Fee Schedule,215% Medicaid Laboratory Fee Schedule,21.52,,,21.52,Fee Schedule,215% Medicaid Laboratory Fee Schedule,12.51,,,12.51,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.01,165.2,
MASS SPECTROMETRY QUAL/QUAN     ,83789,CPT,,40125908,CDM,301,RC,,,both,,,384,39.65,,,39.65,Other,150% of Medicare + 9.63% HCRA Surcharge,24.11,,,24.11,Fee Schedule,Mediare Clinical Lab,46.53,,,46.53,Fee Schedule,,41.95,,,41.95,Fee Schedule,,182.44,,,182.44,Fee Schedule,,164.15,,,164.15,Fee Schedule,,155,,,155,Fee Schedule,,192,50,,192,percent of total billed charges,All Other,50.93,,,50.93,Fee Schedule,,75.95,,,75.95,Fee Schedule,,65.35,,,65.35,Other,186% Medicaid methodology,89.45,,,89.45,Fee Schedule,,238.08,,,238.08,Fee Schedule,,50.63,,,50.63,Fee Schedule,,89.45,,,89.45,Fee Schedule,,238.08,,,238.08,Fee Schedule,,95.23,,,95.23,Fee Schedule,,268.8,70,,268.8,percent of total billed charges,All Other,114.95,,,114.95,Fee Schedule,,97.54,,,97.54,Fee Schedule,,28.93,,,28.93,Fee Schedule,,28.93,,,28.93,Fee Schedule,,28.93,,,28.93,Fee Schedule,,28.93,,,28.93,Fee Schedule,,35.13,,,35.13,Other,New York Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,53.75,,,53.75,Other,153% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,49.19,,,49.19,Other,140% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,91.35,,,91.35,Other,260% Medicaid APG methodology,113.83,,,113.83,Other,324% Medicaid APG methodology,75.54,,,75.54,Other,215% Medicaid APG methodology,75.54,,,75.54,Other,215% Medicaid APG methodology,43.92,,,43.92,Other,125% Medicaid APG methodology,24.11,268.8,
CYSTATIN C                      ,82610,CPT,,40126641,CDM,301,RC,,,both,,,295,30.46,,,30.46,Other,150% of Medicare + 9.63% HCRA Surcharge,18.52,,,18.52,Fee Schedule,Mediare Clinical Lab,35.74,,,35.74,Fee Schedule,,32.22,,,32.22,Fee Schedule,,114.74,,,114.74,Fee Schedule,,103.23,,,103.23,Fee Schedule,,97.48,,,97.48,Fee Schedule,,147.5,50,,147.5,percent of total billed charges,All Other,39.13,,,39.13,Fee Schedule,,58.34,,,58.34,Fee Schedule,,65.35,,,65.35,Other,186% Medicaid methodology,68.71,,,68.71,Fee Schedule,,182.9,,,182.9,Fee Schedule,,38.89,,,38.89,Fee Schedule,,68.71,,,68.71,Fee Schedule,,182.9,,,182.9,Fee Schedule,,73.15,,,73.15,Fee Schedule,,206.5,70,,206.5,percent of total billed charges,All Other,88.3,,,88.3,Fee Schedule,,74.92,,,74.92,Fee Schedule,,22.22,,,22.22,Fee Schedule,,22.22,,,22.22,Fee Schedule,,22.22,,,22.22,Fee Schedule,,22.22,,,22.22,Fee Schedule,,35.13,,,35.13,Other,New York Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,53.75,,,53.75,Other,153% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,49.19,,,49.19,Other,140% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,91.35,,,91.35,Other,260% Medicaid APG methodology,113.83,,,113.83,Other,324% Medicaid APG methodology,75.54,,,75.54,Other,215% Medicaid APG methodology,75.54,,,75.54,Other,215% Medicaid APG methodology,43.92,,,43.92,Other,125% Medicaid APG methodology,18.52,206.5,
IGG 1 2 3 OR 4 EACH             ,82787,CPT,,40127888,CDM,301,RC,,,both,,,128,13.19,,,13.19,Other,150% of Medicare + 9.63% HCRA Surcharge,8.02,,,8.02,Fee Schedule,Mediare Clinical Lab,15.48,,,15.48,Fee Schedule,,13.95,,,13.95,Fee Schedule,,42.29,,,42.29,Fee Schedule,,38.05,,,38.05,Fee Schedule,,35.93,,,35.93,Fee Schedule,,64,50,,64,percent of total billed charges,All Other,16.93,,,16.93,Fee Schedule,,25.26,,,25.26,Fee Schedule,,11.08,,,11.08,Other,186% Medicaid methodology,29.75,,,29.75,Fee Schedule,,79.36,,,79.36,Fee Schedule,,16.84,,,16.84,Fee Schedule,,29.75,,,29.75,Fee Schedule,,79.36,,,79.36,Fee Schedule,,31.68,,,31.68,Fee Schedule,,89.6,70,,89.6,percent of total billed charges,All Other,38.24,,,38.24,Fee Schedule,,32.45,,,32.45,Fee Schedule,,9.62,,,9.62,Fee Schedule,,9.62,,,9.62,Fee Schedule,,9.62,,,9.62,Fee Schedule,,9.62,,,9.62,Fee Schedule,,5.96,,,5.96,Fee Schedule,Medicaid Laboratory Fee Schedule,5.96,,,5.96,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.96,,,5.96,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.96,,,5.96,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.41,,,13.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.41,,,13.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.12,,,9.12,Fee Schedule,153% Medicaid Laboratory Fee Schedule,13.41,,,13.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.34,,,8.34,Fee Schedule,140% Medicaid Laboratory Fee Schedule,13.41,,,13.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.49,,,15.49,Fee Schedule,260% Medicaid Laboratory Fee Schedule,19.31,,,19.31,Fee Schedule,324% Medicaid Laboratory Fee Schedule,12.81,,,12.81,Fee Schedule,215% Medicaid Laboratory Fee Schedule,12.81,,,12.81,Fee Schedule,215% Medicaid Laboratory Fee Schedule,7.45,,,7.45,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.96,89.6,
ASSAY OF THYROGLOBULIN          ,84432,CPT,,40128449,CDM,301,RC,,,both,,,256,26.41,,,26.41,Other,150% of Medicare + 9.63% HCRA Surcharge,16.06,,,16.06,Fee Schedule,Mediare Clinical Lab,31,,,31,Fee Schedule,,27.94,,,27.94,Fee Schedule,,162.34,,,162.34,Fee Schedule,,146.06,,,146.06,Fee Schedule,,137.92,,,137.92,Fee Schedule,,128,50,,128,percent of total billed charges,All Other,33.93,,,33.93,Fee Schedule,,50.59,,,50.59,Fee Schedule,,98.59,,,98.59,Other,186% Medicaid methodology,59.58,,,59.58,Fee Schedule,,158.72,,,158.72,Fee Schedule,,33.73,,,33.73,Fee Schedule,,59.58,,,59.58,Fee Schedule,,158.72,,,158.72,Fee Schedule,,63.44,,,63.44,Fee Schedule,,179.2,70,,179.2,percent of total billed charges,All Other,76.57,,,76.57,Fee Schedule,,64.97,,,64.97,Fee Schedule,,19.27,,,19.27,Fee Schedule,,19.27,,,19.27,Fee Schedule,,19.27,,,19.27,Fee Schedule,,19.27,,,19.27,Fee Schedule,,53,,,53,Other,New York Medicaid APG methodology,53,,,53,Other,100% Medicaid APG methodology,53,,,53,Other,100% Medicaid APG methodology,53,,,53,Other,100% Medicaid APG methodology,119.26,,,119.26,Other,225% Medicaid APG methodology,119.26,,,119.26,Other,225% Medicaid APG methodology,81.1,,,81.1,Other,153% Medicaid APG methodology,119.26,,,119.26,Other,225% Medicaid APG methodology,74.21,,,74.21,Other,140% Medicaid APG methodology,119.26,,,119.26,Other,225% Medicaid APG methodology,137.81,,,137.81,Other,260% Medicaid APG methodology,171.73,,,171.73,Other,324% Medicaid APG methodology,113.96,,,113.96,Other,215% Medicaid APG methodology,113.96,,,113.96,Other,215% Medicaid APG methodology,66.26,,,66.26,Other,125% Medicaid APG methodology,16.06,179.2,
COLLAGEN CROSSLINKS             ,82523,CPT,,40128464,CDM,301,RC,,,both,,,297,30.72,,,30.72,Other,150% of Medicare + 9.63% HCRA Surcharge,18.68,,,18.68,Fee Schedule,Mediare Clinical Lab,36.05,,,36.05,Fee Schedule,,32.5,,,32.5,Fee Schedule,,188.91,,,188.91,Fee Schedule,,169.96,,,169.96,Fee Schedule,,160.49,,,160.49,Fee Schedule,,148.5,50,,148.5,percent of total billed charges,All Other,39.46,,,39.46,Fee Schedule,,58.84,,,58.84,Fee Schedule,,34.74,,,34.74,Other,186% Medicaid methodology,69.3,,,69.3,Fee Schedule,,184.14,,,184.14,Fee Schedule,,39.23,,,39.23,Fee Schedule,,69.3,,,69.3,Fee Schedule,,184.14,,,184.14,Fee Schedule,,73.79,,,73.79,Fee Schedule,,207.9,70,,207.9,percent of total billed charges,All Other,89.06,,,89.06,Fee Schedule,,75.57,,,75.57,Fee Schedule,,22.42,,,22.42,Fee Schedule,,22.42,,,22.42,Fee Schedule,,22.42,,,22.42,Fee Schedule,,22.42,,,22.42,Fee Schedule,,18.68,,,18.68,Fee Schedule,Medicaid Laboratory Fee Schedule,18.68,,,18.68,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.68,,,18.68,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.68,,,18.68,Fee Schedule,100% Medicaid Laboratory Fee Schedule,42.03,,,42.03,Fee Schedule,225% Medicaid Laboratory Fee Schedule,42.03,,,42.03,Fee Schedule,225% Medicaid Laboratory Fee Schedule,28.58,,,28.58,Fee Schedule,153% Medicaid Laboratory Fee Schedule,42.03,,,42.03,Fee Schedule,225% Medicaid Laboratory Fee Schedule,26.15,,,26.15,Fee Schedule,140% Medicaid Laboratory Fee Schedule,42.03,,,42.03,Fee Schedule,225% Medicaid Laboratory Fee Schedule,48.57,,,48.57,Fee Schedule,260% Medicaid Laboratory Fee Schedule,60.52,,,60.52,Fee Schedule,324% Medicaid Laboratory Fee Schedule,40.16,,,40.16,Fee Schedule,215% Medicaid Laboratory Fee Schedule,40.16,,,40.16,Fee Schedule,215% Medicaid Laboratory Fee Schedule,23.35,,,23.35,Fee Schedule,125% Medicaid Laboratory Fee Schedule,18.68,207.9,
ASSAY OF LIPOPROTEIN            ,83718,CPT,,40128480,CDM,301,RC,,,both,,,131,13.47,,,13.47,Other,150% of Medicare + 9.63% HCRA Surcharge,8.19,,,8.19,Fee Schedule,Mediare Clinical Lab,15.81,,,15.81,Fee Schedule,,14.25,,,14.25,Fee Schedule,,82.71,,,82.71,Fee Schedule,,74.42,,,74.42,Fee Schedule,,70.27,,,70.27,Fee Schedule,,65.5,50,,65.5,percent of total billed charges,All Other,17.29,,,17.29,Fee Schedule,,25.8,,,25.8,Fee Schedule,,9.45,,,9.45,Other,186% Medicaid methodology,30.38,,,30.38,Fee Schedule,,81.22,,,81.22,Fee Schedule,,17.2,,,17.2,Fee Schedule,,30.38,,,30.38,Fee Schedule,,81.22,,,81.22,Fee Schedule,,32.35,,,32.35,Fee Schedule,,91.7,70,,91.7,percent of total billed charges,All Other,39.05,,,39.05,Fee Schedule,,33.13,,,33.13,Fee Schedule,,9.83,,,9.83,Fee Schedule,,9.83,,,9.83,Fee Schedule,,9.83,,,9.83,Fee Schedule,,9.83,,,9.83,Fee Schedule,,5.08,,,5.08,Fee Schedule,Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.77,,,7.77,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.11,,,7.11,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.21,,,13.21,Fee Schedule,260% Medicaid Laboratory Fee Schedule,16.46,,,16.46,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.35,,,6.35,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.08,91.7,
ASSAY NEPHELOMETRY NOT SPEC     ,83883,CPT,,40128563,CDM,301,RC,,,both,,,217,22.36,,,22.36,Other,150% of Medicare + 9.63% HCRA Surcharge,13.6,,,13.6,Fee Schedule,Mediare Clinical Lab,26.25,,,26.25,Fee Schedule,,23.66,,,23.66,Fee Schedule,,114.74,,,114.74,Fee Schedule,,103.23,,,103.23,Fee Schedule,,97.48,,,97.48,Fee Schedule,,108.5,50,,108.5,percent of total billed charges,All Other,28.73,,,28.73,Fee Schedule,,42.84,,,42.84,Fee Schedule,,64.67,,,64.67,Other,186% Medicaid methodology,50.46,,,50.46,Fee Schedule,,134.54,,,134.54,Fee Schedule,,28.56,,,28.56,Fee Schedule,,50.46,,,50.46,Fee Schedule,,134.54,,,134.54,Fee Schedule,,53.72,,,53.72,Fee Schedule,,151.9,70,,151.9,percent of total billed charges,All Other,64.84,,,64.84,Fee Schedule,,55.02,,,55.02,Fee Schedule,,16.32,,,16.32,Fee Schedule,,16.32,,,16.32,Fee Schedule,,16.32,,,16.32,Fee Schedule,,16.32,,,16.32,Fee Schedule,,34.77,,,34.77,Other,New York Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,53.2,,,53.2,Other,153% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,48.68,,,48.68,Other,140% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,90.41,,,90.41,Other,260% Medicaid APG methodology,112.66,,,112.66,Other,324% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,43.46,,,43.46,Other,125% Medicaid APG methodology,13.6,151.9,
SPECTROPHOTOMETRY               ,84311,CPT,,40128928,CDM,301,RC,,,both,,,445,13.32,,,13.32,Other,150% of Medicare + 9.63% HCRA Surcharge,8.1,,,8.1,Fee Schedule,Mediare Clinical Lab,15.63,,,15.63,Fee Schedule,,14.09,,,14.09,Fee Schedule,,70.58,,,70.58,Fee Schedule,,63.5,,,63.5,Fee Schedule,,59.96,,,59.96,Fee Schedule,,222.5,50,,222.5,percent of total billed charges,All Other,17.13,,,17.13,Fee Schedule,,25.52,,,25.52,Fee Schedule,,56.01,,,56.01,Other,186% Medicaid methodology,30.05,,,30.05,Fee Schedule,,275.9,,,275.9,Fee Schedule,,17.01,,,17.01,Fee Schedule,,30.05,,,30.05,Fee Schedule,,275.9,,,275.9,Fee Schedule,,32,,,32,Fee Schedule,,311.5,70,,311.5,percent of total billed charges,All Other,38.62,,,38.62,Fee Schedule,,32.77,,,32.77,Fee Schedule,,9.72,,,9.72,Fee Schedule,,9.72,,,9.72,Fee Schedule,,9.72,,,9.72,Fee Schedule,,9.72,,,9.72,Fee Schedule,,30.11,,,30.11,Other,New York Medicaid APG methodology,30.11,,,30.11,Other,100% Medicaid APG methodology,30.11,,,30.11,Other,100% Medicaid APG methodology,30.11,,,30.11,Other,100% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,46.07,,,46.07,Other,153% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,42.16,,,42.16,Other,140% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,78.29,,,78.29,Other,260% Medicaid APG methodology,97.56,,,97.56,Other,324% Medicaid APG methodology,64.74,,,64.74,Other,215% Medicaid APG methodology,64.74,,,64.74,Other,215% Medicaid APG methodology,37.64,,,37.64,Other,125% Medicaid APG methodology,8.1,311.5,
ASSAY OF ARSENIC                ,82175,CPT,,40129249,CDM,301,RC,,,both,,,303,31.2,,,31.2,Other,150% of Medicare + 9.63% HCRA Surcharge,18.97,,,18.97,Fee Schedule,Mediare Clinical Lab,36.61,,,36.61,Fee Schedule,,33.01,,,33.01,Fee Schedule,,191.71,,,191.71,Fee Schedule,,172.48,,,172.48,Fee Schedule,,162.87,,,162.87,Fee Schedule,,151.5,50,,151.5,percent of total billed charges,All Other,40.07,,,40.07,Fee Schedule,,59.76,,,59.76,Fee Schedule,,35.28,,,35.28,Other,186% Medicaid methodology,70.38,,,70.38,Fee Schedule,,187.86,,,187.86,Fee Schedule,,39.84,,,39.84,Fee Schedule,,70.38,,,70.38,Fee Schedule,,187.86,,,187.86,Fee Schedule,,74.93,,,74.93,Fee Schedule,,212.1,70,,212.1,percent of total billed charges,All Other,90.45,,,90.45,Fee Schedule,,76.74,,,76.74,Fee Schedule,,22.76,,,22.76,Fee Schedule,,22.76,,,22.76,Fee Schedule,,22.76,,,22.76,Fee Schedule,,22.76,,,22.76,Fee Schedule,,18.97,,,18.97,Fee Schedule,Medicaid Laboratory Fee Schedule,18.97,,,18.97,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.97,,,18.97,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.97,,,18.97,Fee Schedule,100% Medicaid Laboratory Fee Schedule,42.68,,,42.68,Fee Schedule,225% Medicaid Laboratory Fee Schedule,42.68,,,42.68,Fee Schedule,225% Medicaid Laboratory Fee Schedule,29.02,,,29.02,Fee Schedule,153% Medicaid Laboratory Fee Schedule,42.68,,,42.68,Fee Schedule,225% Medicaid Laboratory Fee Schedule,26.56,,,26.56,Fee Schedule,140% Medicaid Laboratory Fee Schedule,42.68,,,42.68,Fee Schedule,225% Medicaid Laboratory Fee Schedule,49.32,,,49.32,Fee Schedule,260% Medicaid Laboratory Fee Schedule,61.46,,,61.46,Fee Schedule,324% Medicaid Laboratory Fee Schedule,40.79,,,40.79,Fee Schedule,215% Medicaid Laboratory Fee Schedule,40.79,,,40.79,Fee Schedule,215% Medicaid Laboratory Fee Schedule,23.71,,,23.71,Fee Schedule,125% Medicaid Laboratory Fee Schedule,18.97,212.1,
ASSAY FOR CALPROTECTIN FECAL    ,83993,CPT,,40129322,CDM,301,RC,,,both,,,312,32.28,,,32.28,Other,150% of Medicare + 9.63% HCRA Surcharge,19.63,,,19.63,Fee Schedule,Mediare Clinical Lab,37.89,,,37.89,Fee Schedule,,34.16,,,34.16,Fee Schedule,,198.31,,,198.31,Fee Schedule,,178.43,,,178.43,Fee Schedule,,168.48,,,168.48,Fee Schedule,,156,50,,156,percent of total billed charges,All Other,41.47,,,41.47,Fee Schedule,,61.83,,,61.83,Fee Schedule,,21.19,,,21.19,Other,186% Medicaid methodology,72.83,,,72.83,Fee Schedule,,193.44,,,193.44,Fee Schedule,,41.22,,,41.22,Fee Schedule,,72.83,,,72.83,Fee Schedule,,193.44,,,193.44,Fee Schedule,,77.54,,,77.54,Fee Schedule,,218.4,70,,218.4,percent of total billed charges,All Other,93.59,,,93.59,Fee Schedule,,79.41,,,79.41,Fee Schedule,,23.56,,,23.56,Fee Schedule,,23.56,,,23.56,Fee Schedule,,23.56,,,23.56,Fee Schedule,,23.56,,,23.56,Fee Schedule,,11.39,,,11.39,Fee Schedule,Medicaid Laboratory Fee Schedule,11.39,,,11.39,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.39,,,11.39,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.39,,,11.39,Fee Schedule,100% Medicaid Laboratory Fee Schedule,25.63,,,25.63,Fee Schedule,225% Medicaid Laboratory Fee Schedule,25.63,,,25.63,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.43,,,17.43,Fee Schedule,153% Medicaid Laboratory Fee Schedule,25.63,,,25.63,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.95,,,15.95,Fee Schedule,140% Medicaid Laboratory Fee Schedule,25.63,,,25.63,Fee Schedule,225% Medicaid Laboratory Fee Schedule,29.62,,,29.62,Fee Schedule,260% Medicaid Laboratory Fee Schedule,36.91,,,36.91,Fee Schedule,324% Medicaid Laboratory Fee Schedule,24.49,,,24.49,Fee Schedule,215% Medicaid Laboratory Fee Schedule,24.49,,,24.49,Fee Schedule,215% Medicaid Laboratory Fee Schedule,14.24,,,14.24,Fee Schedule,125% Medicaid Laboratory Fee Schedule,11.39,218.4,
EGFR GENE COM VARIANTS          ,81235,CPT,,40129363,CDM,301,RC,,,both,,,5162,533.76,,,533.76,Other,150% of Medicare + 9.63% HCRA Surcharge,324.58,,,324.58,Fee Schedule,Mediare Clinical Lab,626.44,,,626.44,Fee Schedule,,564.77,,,564.77,Fee Schedule,,20.27,,,20.27,Fee Schedule,,20.27,,,20.27,Fee Schedule,,20.27,,,20.27,Fee Schedule,,2581,50,,2581,percent of total billed charges,All Other,685.69,,,685.69,Fee Schedule,,1022.43,,,1022.43,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,1204.19,,,1204.19,Fee Schedule,,3200.44,,,3200.44,Fee Schedule,,681.62,,,681.62,Fee Schedule,,1204.19,,,1204.19,Fee Schedule,,3200.44,,,3200.44,Fee Schedule,,1282.09,,,1282.09,Fee Schedule,,3613.4,70,,3613.4,percent of total billed charges,All Other,1547.58,,,1547.58,Fee Schedule,,1313.09,,,1313.09,Fee Schedule,,389.5,,,389.5,Fee Schedule,,389.5,,,389.5,Fee Schedule,,389.5,,,389.5,Fee Schedule,,389.5,,,389.5,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,3613.4,
PROTEIN WESTERN BLOT TEST       ,84182,CPT,,40129488,CDM,301,RC,,,both,,,313,48.03,,,48.03,Other,150% of Medicare + 9.63% HCRA Surcharge,29.21,,,29.21,Fee Schedule,Mediare Clinical Lab,56.38,,,56.38,Fee Schedule,,50.83,,,50.83,Fee Schedule,,181.87,,,181.87,Fee Schedule,,163.63,,,163.63,Fee Schedule,,154.51,,,154.51,Fee Schedule,,156.5,50,,156.5,percent of total billed charges,All Other,61.72,,,61.72,Fee Schedule,,92.01,,,92.01,Fee Schedule,,126.53,,,126.53,Other,186% Medicaid methodology,108.37,,,108.37,Fee Schedule,,194.06,,,194.06,Fee Schedule,,61.34,,,61.34,Fee Schedule,,108.37,,,108.37,Fee Schedule,,194.06,,,194.06,Fee Schedule,,115.38,,,115.38,Fee Schedule,,219.1,70,,219.1,percent of total billed charges,All Other,139.27,,,139.27,Fee Schedule,,118.17,,,118.17,Fee Schedule,,35.05,,,35.05,Fee Schedule,,35.05,,,35.05,Fee Schedule,,35.05,,,35.05,Fee Schedule,,35.05,,,35.05,Fee Schedule,,68.03,,,68.03,Other,New York Medicaid APG methodology,68.03,,,68.03,Other,100% Medicaid APG methodology,68.03,,,68.03,Other,100% Medicaid APG methodology,68.03,,,68.03,Other,100% Medicaid APG methodology,153.06,,,153.06,Other,225% Medicaid APG methodology,153.06,,,153.06,Other,225% Medicaid APG methodology,104.08,,,104.08,Other,153% Medicaid APG methodology,153.06,,,153.06,Other,225% Medicaid APG methodology,95.24,,,95.24,Other,140% Medicaid APG methodology,153.06,,,153.06,Other,225% Medicaid APG methodology,176.87,,,176.87,Other,260% Medicaid APG methodology,220.41,,,220.41,Other,324% Medicaid APG methodology,146.26,,,146.26,Other,215% Medicaid APG methodology,146.26,,,146.26,Other,215% Medicaid APG methodology,85.03,,,85.03,Other,125% Medicaid APG methodology,29.21,220.41,
TARGETED GENOMIC SEQ ANALYS     ,81445,CPT,,40129769,CDM,301,RC,,,both,,,5979,983.23,,,983.23,Other,150% of Medicare + 9.63% HCRA Surcharge,597.91,,,597.91,Fee Schedule,Mediare Clinical Lab,1153.97,,,1153.97,Fee Schedule,,1040.36,,,1040.36,Fee Schedule,,846.27,,,846.27,Fee Schedule,,846.27,,,846.27,Fee Schedule,,846.27,,,846.27,Fee Schedule,,2989.5,50,,2989.5,percent of total billed charges,All Other,1263.08,,,1263.08,Fee Schedule,,1883.42,,,1883.42,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,2218.25,,,2218.25,Fee Schedule,,3706.98,,,3706.98,Fee Schedule,,1255.61,,,1255.61,Fee Schedule,,2218.25,,,2218.25,Fee Schedule,,3706.98,,,3706.98,Fee Schedule,,2361.74,,,2361.74,Fee Schedule,,4185.3,70,,4185.3,percent of total billed charges,All Other,2850.79,,,2850.79,Fee Schedule,,2418.86,,,2418.86,Fee Schedule,,717.49,,,717.49,Fee Schedule,,717.49,,,717.49,Fee Schedule,,717.49,,,717.49,Fee Schedule,,717.49,,,717.49,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,4185.3,
TARGETED GENOMIC SEQ ANALYS     ,81450,CPT,,40129777,CDM,301,RC,,,both,,,5317,1249.01,,,1249.01,Other,150% of Medicare + 9.63% HCRA Surcharge,759.53,,,759.53,Fee Schedule,Mediare Clinical Lab,1465.89,,,1465.89,Fee Schedule,,1321.58,,,1321.58,Fee Schedule,,846.27,,,846.27,Fee Schedule,,846.27,,,846.27,Fee Schedule,,846.27,,,846.27,Fee Schedule,,2658.5,50,,2658.5,percent of total billed charges,All Other,1604.49,,,1604.49,Fee Schedule,,2392.52,,,2392.52,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,2817.86,,,2817.86,Fee Schedule,,3296.54,,,3296.54,Fee Schedule,,1595.01,,,1595.01,Fee Schedule,,2817.86,,,2817.86,Fee Schedule,,3296.54,,,3296.54,Fee Schedule,,3000.14,,,3000.14,Fee Schedule,,3721.9,70,,3721.9,percent of total billed charges,All Other,3621.39,,,3621.39,Fee Schedule,,3072.69,,,3072.69,Fee Schedule,,911.44,,,911.44,Fee Schedule,,911.44,,,911.44,Fee Schedule,,911.44,,,911.44,Fee Schedule,,911.44,,,911.44,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,3721.9,
FLT3 GENE ANALYSIS              ,81246,CPT,,40129926,CDM,301,RC,,,both,,,830,136.49,,,136.49,Other,150% of Medicare + 9.63% HCRA Surcharge,83,,,83,Fee Schedule,Mediare Clinical Lab,160.19,,,160.19,Fee Schedule,,144.42,,,144.42,Fee Schedule,,31.12,,,31.12,Fee Schedule,,31.12,,,31.12,Fee Schedule,,31.12,,,31.12,Fee Schedule,,415,50,,415,percent of total billed charges,All Other,175.34,,,175.34,Fee Schedule,,261.45,,,261.45,Fee Schedule,,154.38,,,154.38,Other,186% Medicaid methodology,307.93,,,307.93,Fee Schedule,,514.6,,,514.6,Fee Schedule,,174.3,,,174.3,Fee Schedule,,307.93,,,307.93,Fee Schedule,,514.6,,,514.6,Fee Schedule,,327.85,,,327.85,Fee Schedule,,581,70,,581,percent of total billed charges,All Other,395.74,,,395.74,Fee Schedule,,335.78,,,335.78,Fee Schedule,,99.6,,,99.6,Fee Schedule,,99.6,,,99.6,Fee Schedule,,99.6,,,99.6,Fee Schedule,,99.6,,,99.6,Fee Schedule,,83,,,83,Fee Schedule,Medicaid Laboratory Fee Schedule,83,,,83,Fee Schedule,100% Medicaid Laboratory Fee Schedule,83,,,83,Fee Schedule,100% Medicaid Laboratory Fee Schedule,83,,,83,Fee Schedule,100% Medicaid Laboratory Fee Schedule,186.75,,,186.75,Fee Schedule,225% Medicaid Laboratory Fee Schedule,186.75,,,186.75,Fee Schedule,225% Medicaid Laboratory Fee Schedule,126.99,,,126.99,Fee Schedule,153% Medicaid Laboratory Fee Schedule,186.75,,,186.75,Fee Schedule,225% Medicaid Laboratory Fee Schedule,116.2,,,116.2,Fee Schedule,140% Medicaid Laboratory Fee Schedule,186.75,,,186.75,Fee Schedule,225% Medicaid Laboratory Fee Schedule,215.8,,,215.8,Fee Schedule,260% Medicaid Laboratory Fee Schedule,268.92,,,268.92,Fee Schedule,324% Medicaid Laboratory Fee Schedule,178.45,,,178.45,Fee Schedule,215% Medicaid Laboratory Fee Schedule,178.45,,,178.45,Fee Schedule,215% Medicaid Laboratory Fee Schedule,103.75,,,103.75,Fee Schedule,125% Medicaid Laboratory Fee Schedule,31.12,581,
ASSAY OF URINE CHLORIDE         ,82436,CPT,,40130122,CDM,301,RC,,,both,,,92,9.46,,,9.46,Other,150% of Medicare + 9.63% HCRA Surcharge,5.75,,,5.75,Fee Schedule,Mediare Clinical Lab,11.1,,,11.1,Fee Schedule,,10.01,,,10.01,Fee Schedule,,24.41,,,24.41,Fee Schedule,,21.96,,,21.96,Fee Schedule,,20.74,,,20.74,Fee Schedule,,46,50,,46,percent of total billed charges,All Other,12.16,,,12.16,Fee Schedule,,18.11,,,18.11,Fee Schedule,,9.45,,,9.45,Other,186% Medicaid methodology,21.33,,,21.33,Fee Schedule,,57.04,,,57.04,Fee Schedule,,12.08,,,12.08,Fee Schedule,,21.33,,,21.33,Fee Schedule,,57.04,,,57.04,Fee Schedule,,22.71,,,22.71,Fee Schedule,,64.4,70,,64.4,percent of total billed charges,All Other,27.42,,,27.42,Fee Schedule,,23.26,,,23.26,Fee Schedule,,6.9,,,6.9,Fee Schedule,,6.9,,,6.9,Fee Schedule,,6.9,,,6.9,Fee Schedule,,6.9,,,6.9,Fee Schedule,,5.08,,,5.08,Fee Schedule,Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.77,,,7.77,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.11,,,7.11,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.21,,,13.21,Fee Schedule,260% Medicaid Laboratory Fee Schedule,16.46,,,16.46,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.35,,,6.35,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.08,64.4,
ASSAY OF URINE OSMOLALITY       ,83935,CPT,,40130148,CDM,301,RC,,,both,,,109,11.22,,,11.22,Other,150% of Medicare + 9.63% HCRA Surcharge,6.82,,,6.82,Fee Schedule,Mediare Clinical Lab,13.16,,,13.16,Fee Schedule,,11.87,,,11.87,Fee Schedule,,68.86,,,68.86,Fee Schedule,,61.95,,,61.95,Fee Schedule,,58.5,,,58.5,Fee Schedule,,54.5,50,,54.5,percent of total billed charges,All Other,14.4,,,14.4,Fee Schedule,,21.48,,,21.48,Fee Schedule,,11.35,,,11.35,Other,186% Medicaid methodology,25.3,,,25.3,Fee Schedule,,67.58,,,67.58,Fee Schedule,,14.32,,,14.32,Fee Schedule,,25.3,,,25.3,Fee Schedule,,67.58,,,67.58,Fee Schedule,,26.94,,,26.94,Fee Schedule,,76.3,70,,76.3,percent of total billed charges,All Other,32.52,,,32.52,Fee Schedule,,27.59,,,27.59,Fee Schedule,,8.18,,,8.18,Fee Schedule,,8.18,,,8.18,Fee Schedule,,8.18,,,8.18,Fee Schedule,,8.18,,,8.18,Fee Schedule,,6.1,,,6.1,Fee Schedule,Medicaid Laboratory Fee Schedule,6.1,,,6.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.1,,,6.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.1,,,6.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.73,,,13.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.73,,,13.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.33,,,9.33,Fee Schedule,153% Medicaid Laboratory Fee Schedule,13.73,,,13.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.54,,,8.54,Fee Schedule,140% Medicaid Laboratory Fee Schedule,13.73,,,13.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.86,,,15.86,Fee Schedule,260% Medicaid Laboratory Fee Schedule,19.77,,,19.77,Fee Schedule,324% Medicaid Laboratory Fee Schedule,13.12,,,13.12,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.12,,,13.12,Fee Schedule,215% Medicaid Laboratory Fee Schedule,7.63,,,7.63,Fee Schedule,125% Medicaid Laboratory Fee Schedule,6.1,76.3,
PROTEIN E-PHORESIS/URINE/CSF    ,84166,CPT,,40130320,CDM,301,RC,,,both,,,284,29.32,,,29.32,Other,150% of Medicare + 9.63% HCRA Surcharge,17.83,,,17.83,Fee Schedule,Mediare Clinical Lab,34.41,,,34.41,Fee Schedule,,31.02,,,31.02,Fee Schedule,,180.15,,,180.15,Fee Schedule,,162.08,,,162.08,Fee Schedule,,153.05,,,153.05,Fee Schedule,,142,50,,142,percent of total billed charges,All Other,37.67,,,37.67,Fee Schedule,,56.16,,,56.16,Fee Schedule,,15.03,,,15.03,Other,186% Medicaid methodology,66.15,,,66.15,Fee Schedule,,176.08,,,176.08,Fee Schedule,,37.44,,,37.44,Fee Schedule,,66.15,,,66.15,Fee Schedule,,176.08,,,176.08,Fee Schedule,,70.43,,,70.43,Fee Schedule,,198.8,70,,198.8,percent of total billed charges,All Other,85.01,,,85.01,Fee Schedule,,72.13,,,72.13,Fee Schedule,,21.4,,,21.4,Fee Schedule,,21.4,,,21.4,Fee Schedule,,21.4,,,21.4,Fee Schedule,,21.4,,,21.4,Fee Schedule,,8.08,,,8.08,Fee Schedule,Medicaid Laboratory Fee Schedule,8.08,,,8.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.08,,,8.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.08,,,8.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.18,,,18.18,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.18,,,18.18,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.36,,,12.36,Fee Schedule,153% Medicaid Laboratory Fee Schedule,18.18,,,18.18,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.31,,,11.31,Fee Schedule,140% Medicaid Laboratory Fee Schedule,18.18,,,18.18,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.01,,,21.01,Fee Schedule,260% Medicaid Laboratory Fee Schedule,26.18,,,26.18,Fee Schedule,324% Medicaid Laboratory Fee Schedule,17.37,,,17.37,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.37,,,17.37,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.1,,,10.1,Fee Schedule,125% Medicaid Laboratory Fee Schedule,8.08,198.8,
CREATININE CLEARANCE TEST       ,82575,CPT,,40130528,CDM,301,RC,,,both,,,151,15.56,,,15.56,Other,150% of Medicare + 9.63% HCRA Surcharge,9.46,,,9.46,Fee Schedule,Mediare Clinical Lab,18.26,,,18.26,Fee Schedule,,16.46,,,16.46,Fee Schedule,,95.49,,,95.49,Fee Schedule,,85.92,,,85.92,Fee Schedule,,81.13,,,81.13,Fee Schedule,,75.5,50,,75.5,percent of total billed charges,All Other,19.99,,,19.99,Fee Schedule,,29.8,,,29.8,Fee Schedule,,10.95,,,10.95,Other,186% Medicaid methodology,35.1,,,35.1,Fee Schedule,,93.62,,,93.62,Fee Schedule,,19.87,,,19.87,Fee Schedule,,35.1,,,35.1,Fee Schedule,,93.62,,,93.62,Fee Schedule,,37.37,,,37.37,Fee Schedule,,105.7,70,,105.7,percent of total billed charges,All Other,45.1,,,45.1,Fee Schedule,,38.27,,,38.27,Fee Schedule,,11.35,,,11.35,Fee Schedule,,11.35,,,11.35,Fee Schedule,,11.35,,,11.35,Fee Schedule,,11.35,,,11.35,Fee Schedule,,5.89,,,5.89,Fee Schedule,Medicaid Laboratory Fee Schedule,5.89,,,5.89,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.89,,,5.89,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.89,,,5.89,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.25,,,13.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.25,,,13.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.01,,,9.01,Fee Schedule,153% Medicaid Laboratory Fee Schedule,13.25,,,13.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.24,,,8.24,Fee Schedule,140% Medicaid Laboratory Fee Schedule,13.25,,,13.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.31,,,15.31,Fee Schedule,260% Medicaid Laboratory Fee Schedule,19.08,,,19.08,Fee Schedule,324% Medicaid Laboratory Fee Schedule,12.66,,,12.66,Fee Schedule,215% Medicaid Laboratory Fee Schedule,12.66,,,12.66,Fee Schedule,215% Medicaid Laboratory Fee Schedule,7.36,,,7.36,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.89,105.7,
ASSAY OF CALCIUM IN URINE       ,82340,CPT,,40130940,CDM,301,RC,,,both,,,96,9.92,,,9.92,Other,150% of Medicare + 9.63% HCRA Surcharge,6.03,,,6.03,Fee Schedule,Mediare Clinical Lab,11.64,,,11.64,Fee Schedule,,10.49,,,10.49,Fee Schedule,,60.96,,,60.96,Fee Schedule,,54.85,,,54.85,Fee Schedule,,51.79,,,51.79,Fee Schedule,,48,50,,48,percent of total billed charges,All Other,12.74,,,12.74,Fee Schedule,,18.99,,,18.99,Fee Schedule,,11.22,,,11.22,Other,186% Medicaid methodology,22.37,,,22.37,Fee Schedule,,59.52,,,59.52,Fee Schedule,,12.66,,,12.66,Fee Schedule,,22.37,,,22.37,Fee Schedule,,59.52,,,59.52,Fee Schedule,,23.82,,,23.82,Fee Schedule,,67.2,70,,67.2,percent of total billed charges,All Other,28.75,,,28.75,Fee Schedule,,24.39,,,24.39,Fee Schedule,,7.24,,,7.24,Fee Schedule,,7.24,,,7.24,Fee Schedule,,7.24,,,7.24,Fee Schedule,,7.24,,,7.24,Fee Schedule,,6.03,,,6.03,Fee Schedule,Medicaid Laboratory Fee Schedule,6.03,,,6.03,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.03,,,6.03,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.03,,,6.03,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.57,,,13.57,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.57,,,13.57,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.23,,,9.23,Fee Schedule,153% Medicaid Laboratory Fee Schedule,13.57,,,13.57,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.44,,,8.44,Fee Schedule,140% Medicaid Laboratory Fee Schedule,13.57,,,13.57,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.68,,,15.68,Fee Schedule,260% Medicaid Laboratory Fee Schedule,19.54,,,19.54,Fee Schedule,324% Medicaid Laboratory Fee Schedule,12.96,,,12.96,Fee Schedule,215% Medicaid Laboratory Fee Schedule,12.96,,,12.96,Fee Schedule,215% Medicaid Laboratory Fee Schedule,7.54,,,7.54,Fee Schedule,125% Medicaid Laboratory Fee Schedule,6.03,67.2,
ASSAY OF URINE PHOSPHORUS       ,84105,CPT,,40131468,CDM,301,RC,,,both,,,147,9.5,,,9.5,Other,150% of Medicare + 9.63% HCRA Surcharge,5.78,,,5.78,Fee Schedule,Mediare Clinical Lab,11.16,,,11.16,Fee Schedule,,10.06,,,10.06,Fee Schedule,,52.27,,,52.27,Fee Schedule,,47.03,,,47.03,Fee Schedule,,44.41,,,44.41,Fee Schedule,,73.5,50,,73.5,percent of total billed charges,All Other,12.22,,,12.22,Fee Schedule,,18.21,,,18.21,Fee Schedule,,9.45,,,9.45,Other,186% Medicaid methodology,21.44,,,21.44,Fee Schedule,,91.14,,,91.14,Fee Schedule,,12.14,,,12.14,Fee Schedule,,21.44,,,21.44,Fee Schedule,,91.14,,,91.14,Fee Schedule,,22.83,,,22.83,Fee Schedule,,102.9,70,,102.9,percent of total billed charges,All Other,27.56,,,27.56,Fee Schedule,,23.38,,,23.38,Fee Schedule,,6.94,,,6.94,Fee Schedule,,6.94,,,6.94,Fee Schedule,,6.94,,,6.94,Fee Schedule,,6.94,,,6.94,Fee Schedule,,5.08,,,5.08,Fee Schedule,Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.77,,,7.77,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.11,,,7.11,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.21,,,13.21,Fee Schedule,260% Medicaid Laboratory Fee Schedule,16.46,,,16.46,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.35,,,6.35,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.08,102.9,
ASSAY OF URINE POTASSIUM        ,84133,CPT,,40131500,CDM,301,RC,,,both,,,76,7.78,,,7.78,Other,150% of Medicare + 9.63% HCRA Surcharge,4.73,,,4.73,Fee Schedule,Mediare Clinical Lab,9.13,,,9.13,Fee Schedule,,8.23,,,8.23,Fee Schedule,,43.44,,,43.44,Fee Schedule,,39.08,,,39.08,Fee Schedule,,36.91,,,36.91,Fee Schedule,,38,50,,38,percent of total billed charges,All Other,9.98,,,9.98,Fee Schedule,,14.9,,,14.9,Fee Schedule,,8.8,,,8.8,Other,186% Medicaid methodology,17.55,,,17.55,Fee Schedule,,47.12,,,47.12,Fee Schedule,,9.93,,,9.93,Fee Schedule,,17.55,,,17.55,Fee Schedule,,47.12,,,47.12,Fee Schedule,,18.68,,,18.68,Fee Schedule,,53.2,70,,53.2,percent of total billed charges,All Other,22.55,,,22.55,Fee Schedule,,19.14,,,19.14,Fee Schedule,,5.68,,,5.68,Fee Schedule,,5.68,,,5.68,Fee Schedule,,5.68,,,5.68,Fee Schedule,,5.68,,,5.68,Fee Schedule,,4.73,,,4.73,Fee Schedule,Medicaid Laboratory Fee Schedule,4.73,,,4.73,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.73,,,4.73,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.73,,,4.73,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.64,,,10.64,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.64,,,10.64,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.24,,,7.24,Fee Schedule,153% Medicaid Laboratory Fee Schedule,10.64,,,10.64,Fee Schedule,225% Medicaid Laboratory Fee Schedule,6.62,,,6.62,Fee Schedule,140% Medicaid Laboratory Fee Schedule,10.64,,,10.64,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.3,,,12.3,Fee Schedule,260% Medicaid Laboratory Fee Schedule,15.33,,,15.33,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.17,,,10.17,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.17,,,10.17,Fee Schedule,215% Medicaid Laboratory Fee Schedule,5.91,,,5.91,Fee Schedule,125% Medicaid Laboratory Fee Schedule,4.73,53.2,
ASSAY OF URINE SODIUM           ,84300,CPT,,40131567,CDM,301,RC,,,both,,,81,8.32,,,8.32,Other,150% of Medicare + 9.63% HCRA Surcharge,5.06,,,5.06,Fee Schedule,Mediare Clinical Lab,9.77,,,9.77,Fee Schedule,,8.8,,,8.8,Fee Schedule,,49.18,,,49.18,Fee Schedule,,44.25,,,44.25,Fee Schedule,,41.79,,,41.79,Fee Schedule,,40.5,50,,40.5,percent of total billed charges,All Other,10.69,,,10.69,Fee Schedule,,15.94,,,15.94,Fee Schedule,,9.36,,,9.36,Other,186% Medicaid methodology,18.77,,,18.77,Fee Schedule,,50.22,,,50.22,Fee Schedule,,10.63,,,10.63,Fee Schedule,,18.77,,,18.77,Fee Schedule,,50.22,,,50.22,Fee Schedule,,19.99,,,19.99,Fee Schedule,,56.7,70,,56.7,percent of total billed charges,All Other,24.13,,,24.13,Fee Schedule,,20.47,,,20.47,Fee Schedule,,6.07,,,6.07,Fee Schedule,,6.07,,,6.07,Fee Schedule,,6.07,,,6.07,Fee Schedule,,6.07,,,6.07,Fee Schedule,,5.03,,,5.03,Fee Schedule,Medicaid Laboratory Fee Schedule,5.03,,,5.03,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.03,,,5.03,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.03,,,5.03,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.32,,,11.32,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.32,,,11.32,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.7,,,7.7,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.32,,,11.32,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.04,,,7.04,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.32,,,11.32,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.08,,,13.08,Fee Schedule,260% Medicaid Laboratory Fee Schedule,16.3,,,16.3,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.81,,,10.81,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.81,,,10.81,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.29,,,6.29,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.03,56.7,
ASSAY OF URINE/UREA-N           ,84540,CPT,,40131625,CDM,301,RC,,,both,,,88,9.14,,,9.14,Other,150% of Medicare + 9.63% HCRA Surcharge,5.56,,,5.56,Fee Schedule,Mediare Clinical Lab,10.73,,,10.73,Fee Schedule,,9.67,,,9.67,Fee Schedule,,47.96,,,47.96,Fee Schedule,,43.15,,,43.15,Fee Schedule,,40.75,,,40.75,Fee Schedule,,44,50,,44,percent of total billed charges,All Other,11.73,,,11.73,Fee Schedule,,17.51,,,17.51,Fee Schedule,,9.45,,,9.45,Other,186% Medicaid methodology,20.63,,,20.63,Fee Schedule,,54.56,,,54.56,Fee Schedule,,11.68,,,11.68,Fee Schedule,,20.63,,,20.63,Fee Schedule,,54.56,,,54.56,Fee Schedule,,21.96,,,21.96,Fee Schedule,,61.6,70,,61.6,percent of total billed charges,All Other,26.51,,,26.51,Fee Schedule,,22.49,,,22.49,Fee Schedule,,6.67,,,6.67,Fee Schedule,,6.67,,,6.67,Fee Schedule,,6.67,,,6.67,Fee Schedule,,6.67,,,6.67,Fee Schedule,,5.08,,,5.08,Fee Schedule,Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.77,,,7.77,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.11,,,7.11,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.21,,,13.21,Fee Schedule,260% Medicaid Laboratory Fee Schedule,16.46,,,16.46,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.35,,,6.35,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.08,61.6,
ASSAY OF URINE/URIC ACID        ,84560,CPT,,40131641,CDM,301,RC,,,both,,,81,8.35,,,8.35,Other,150% of Medicare + 9.63% HCRA Surcharge,5.08,,,5.08,Fee Schedule,Mediare Clinical Lab,9.8,,,9.8,Fee Schedule,,8.84,,,8.84,Fee Schedule,,47.96,,,47.96,Fee Schedule,,43.15,,,43.15,Fee Schedule,,40.75,,,40.75,Fee Schedule,,40.5,50,,40.5,percent of total billed charges,All Other,10.73,,,10.73,Fee Schedule,,16,,,16,Fee Schedule,,9.45,,,9.45,Other,186% Medicaid methodology,18.85,,,18.85,Fee Schedule,,50.22,,,50.22,Fee Schedule,,10.67,,,10.67,Fee Schedule,,18.85,,,18.85,Fee Schedule,,50.22,,,50.22,Fee Schedule,,20.07,,,20.07,Fee Schedule,,56.7,70,,56.7,percent of total billed charges,All Other,24.22,,,24.22,Fee Schedule,,20.55,,,20.55,Fee Schedule,,6.1,,,6.1,Fee Schedule,,6.1,,,6.1,Fee Schedule,,6.1,,,6.1,Fee Schedule,,6.1,,,6.1,Fee Schedule,,5.08,,,5.08,Fee Schedule,Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.77,,,7.77,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.11,,,7.11,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.21,,,13.21,Fee Schedule,260% Medicaid Laboratory Fee Schedule,16.46,,,16.46,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.35,,,6.35,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.08,56.7,
ASSAY OF 5-HIAA                 ,83497,CPT,,40131781,CDM,301,RC,,,both,,,206,21.21,,,21.21,Other,150% of Medicare + 9.63% HCRA Surcharge,12.9,,,12.9,Fee Schedule,Mediare Clinical Lab,24.9,,,24.9,Fee Schedule,,22.45,,,22.45,Fee Schedule,,130.25,,,130.25,Fee Schedule,,117.18,,,117.18,Fee Schedule,,110.65,,,110.65,Fee Schedule,,103,50,,103,percent of total billed charges,All Other,27.27,,,27.27,Fee Schedule,,40.64,,,40.64,Fee Schedule,,23.99,,,23.99,Other,186% Medicaid methodology,47.86,,,47.86,Fee Schedule,,127.72,,,127.72,Fee Schedule,,27.09,,,27.09,Fee Schedule,,47.86,,,47.86,Fee Schedule,,127.72,,,127.72,Fee Schedule,,50.96,,,50.96,Fee Schedule,,144.2,70,,144.2,percent of total billed charges,All Other,61.51,,,61.51,Fee Schedule,,52.19,,,52.19,Fee Schedule,,15.48,,,15.48,Fee Schedule,,15.48,,,15.48,Fee Schedule,,15.48,,,15.48,Fee Schedule,,15.48,,,15.48,Fee Schedule,,12.9,,,12.9,Fee Schedule,Medicaid Laboratory Fee Schedule,12.9,,,12.9,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.9,,,12.9,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.9,,,12.9,Fee Schedule,100% Medicaid Laboratory Fee Schedule,29.03,,,29.03,Fee Schedule,225% Medicaid Laboratory Fee Schedule,29.03,,,29.03,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.74,,,19.74,Fee Schedule,153% Medicaid Laboratory Fee Schedule,29.03,,,29.03,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.06,,,18.06,Fee Schedule,140% Medicaid Laboratory Fee Schedule,29.03,,,29.03,Fee Schedule,225% Medicaid Laboratory Fee Schedule,33.54,,,33.54,Fee Schedule,260% Medicaid Laboratory Fee Schedule,41.8,,,41.8,Fee Schedule,324% Medicaid Laboratory Fee Schedule,27.74,,,27.74,Fee Schedule,215% Medicaid Laboratory Fee Schedule,27.74,,,27.74,Fee Schedule,215% Medicaid Laboratory Fee Schedule,16.13,,,16.13,Fee Schedule,125% Medicaid Laboratory Fee Schedule,12.9,144.2,
ASSAY OF URINE CREATININE       ,82570,CPT,,40131906,CDM,301,RC,,,both,,,83,8.52,,,8.52,Other,150% of Medicare + 9.63% HCRA Surcharge,5.18,,,5.18,Fee Schedule,Mediare Clinical Lab,10,,,10,Fee Schedule,,9.01,,,9.01,Fee Schedule,,52.27,,,52.27,Fee Schedule,,47.03,,,47.03,Fee Schedule,,44.41,,,44.41,Fee Schedule,,41.5,50,,41.5,percent of total billed charges,All Other,10.95,,,10.95,Fee Schedule,,16.32,,,16.32,Fee Schedule,,9.45,,,9.45,Other,186% Medicaid methodology,19.22,,,19.22,Fee Schedule,,51.46,,,51.46,Fee Schedule,,10.88,,,10.88,Fee Schedule,,19.22,,,19.22,Fee Schedule,,51.46,,,51.46,Fee Schedule,,20.46,,,20.46,Fee Schedule,,58.1,70,,58.1,percent of total billed charges,All Other,24.7,,,24.7,Fee Schedule,,20.96,,,20.96,Fee Schedule,,6.22,,,6.22,Fee Schedule,,6.22,,,6.22,Fee Schedule,,6.22,,,6.22,Fee Schedule,,6.22,,,6.22,Fee Schedule,,5.08,,,5.08,Fee Schedule,Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.77,,,7.77,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.11,,,7.11,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.21,,,13.21,Fee Schedule,260% Medicaid Laboratory Fee Schedule,16.46,,,16.46,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.35,,,6.35,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.08,58.1,
UR ALBUMIN QUANTITATIVE         ,82043,CPT,,40131989,CDM,301,RC,,,both,,,93,9.5,,,9.5,Other,150% of Medicare + 9.63% HCRA Surcharge,5.78,,,5.78,Fee Schedule,Mediare Clinical Lab,11.16,,,11.16,Fee Schedule,,10.06,,,10.06,Fee Schedule,,58.45,,,58.45,Fee Schedule,,52.58,,,52.58,Fee Schedule,,49.65,,,49.65,Fee Schedule,,46.5,50,,46.5,percent of total billed charges,All Other,12.22,,,12.22,Fee Schedule,,18.21,,,18.21,Fee Schedule,,9.45,,,9.45,Other,186% Medicaid methodology,21.44,,,21.44,Fee Schedule,,57.66,,,57.66,Fee Schedule,,12.14,,,12.14,Fee Schedule,,21.44,,,21.44,Fee Schedule,,57.66,,,57.66,Fee Schedule,,22.83,,,22.83,Fee Schedule,,65.1,70,,65.1,percent of total billed charges,All Other,27.56,,,27.56,Fee Schedule,,23.38,,,23.38,Fee Schedule,,6.94,,,6.94,Fee Schedule,,6.94,,,6.94,Fee Schedule,,6.94,,,6.94,Fee Schedule,,6.94,,,6.94,Fee Schedule,,5.08,,,5.08,Fee Schedule,Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.77,,,7.77,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.11,,,7.11,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.21,,,13.21,Fee Schedule,260% Medicaid Laboratory Fee Schedule,16.46,,,16.46,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.35,,,6.35,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.08,65.1,
ASSAY OF PROTEIN URINE          ,84156,CPT,,40132565,CDM,301,RC,,,both,,,59,6.04,,,6.04,Other,150% of Medicare + 9.63% HCRA Surcharge,3.67,,,3.67,Fee Schedule,Mediare Clinical Lab,7.08,,,7.08,Fee Schedule,,6.39,,,6.39,Fee Schedule,,37.05,,,37.05,Fee Schedule,,33.33,,,33.33,Fee Schedule,,31.48,,,31.48,Fee Schedule,,29.5,50,,29.5,percent of total billed charges,All Other,7.77,,,7.77,Fee Schedule,,11.56,,,11.56,Fee Schedule,,6.83,,,6.83,Other,186% Medicaid methodology,13.62,,,13.62,Fee Schedule,,36.58,,,36.58,Fee Schedule,,7.71,,,7.71,Fee Schedule,,13.62,,,13.62,Fee Schedule,,36.58,,,36.58,Fee Schedule,,14.5,,,14.5,Fee Schedule,,41.3,70,,41.3,percent of total billed charges,All Other,17.5,,,17.5,Fee Schedule,,14.85,,,14.85,Fee Schedule,,4.4,,,4.4,Fee Schedule,,4.4,,,4.4,Fee Schedule,,4.4,,,4.4,Fee Schedule,,4.4,,,4.4,Fee Schedule,,3.67,,,3.67,Fee Schedule,Medicaid Laboratory Fee Schedule,3.67,,,3.67,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.67,,,3.67,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.67,,,3.67,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.26,,,8.26,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.26,,,8.26,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.62,,,5.62,Fee Schedule,153% Medicaid Laboratory Fee Schedule,8.26,,,8.26,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.14,,,5.14,Fee Schedule,140% Medicaid Laboratory Fee Schedule,8.26,,,8.26,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.54,,,9.54,Fee Schedule,260% Medicaid Laboratory Fee Schedule,11.89,,,11.89,Fee Schedule,324% Medicaid Laboratory Fee Schedule,7.89,,,7.89,Fee Schedule,215% Medicaid Laboratory Fee Schedule,7.89,,,7.89,Fee Schedule,215% Medicaid Laboratory Fee Schedule,4.59,,,4.59,Fee Schedule,125% Medicaid Laboratory Fee Schedule,3.67,41.3,
DRUG SCREENING FENTANYL         ,80354,CPT,,40134322,CDM,301,RC,,,both,,,140,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,70,50,,70,percent of total billed charges,All Other Outpatient,63,45,,63,percent of total billed charges,All Other Outpatient,11.02,,,11.02,Fee Schedule,,11.02,,,11.02,Fee Schedule,,11.02,,,11.02,Fee Schedule,,70,50,,70,percent of total billed charges,All Other,98,70,,98,percent of total billed charges,All Other,95.2,68,,95.2,percent of total billed charges,All Other Outpatient,9.39,,,9.39,Other,186% Medicaid methodology,112,80,,112,percent of total billed charges,All Other Outpatient,116.2,83,,116.2,percent of total billed charges,All Other Outpatient,116.2,83,,116.2,percent of total billed charges,All Other Outpatient,112,80,,112,percent of total billed charges,All Other Outpatient,116.2,83,,116.2,percent of total billed charges,All Other Outpatient,126,90,,126,percent of total billed charges,All Other,98,70,,98,percent of total billed charges,All Other,70,50,,70,percent of total billed charges,All Other,70,50,,70,percent of total billed charges,All Other,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,5.05,,,5.05,Fee Schedule,Medicaid Laboratory Fee Schedule,5.05,,,5.05,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.05,,,5.05,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.05,,,5.05,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.36,,,11.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.36,,,11.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.73,,,7.73,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.36,,,11.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.07,,,7.07,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.36,,,11.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.13,,,13.13,Fee Schedule,260% Medicaid Laboratory Fee Schedule,16.36,,,16.36,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.86,,,10.86,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.86,,,10.86,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.31,,,6.31,Fee Schedule,125% Medicaid Laboratory Fee Schedule,0.01,126,
ASSAY OF IRON                   ,83540,CPT,,40140162,CDM,301,RC,,,both,,,103,10.64,,,10.64,Other,150% of Medicare + 9.63% HCRA Surcharge,6.47,,,6.47,Fee Schedule,Mediare Clinical Lab,12.49,,,12.49,Fee Schedule,,11.26,,,11.26,Fee Schedule,,65.48,,,65.48,Fee Schedule,,58.92,,,58.92,Fee Schedule,,55.63,,,55.63,Fee Schedule,,51.5,50,,51.5,percent of total billed charges,All Other,13.68,,,13.68,Fee Schedule,,20.38,,,20.38,Fee Schedule,,9.45,,,9.45,Other,186% Medicaid methodology,24,,,24,Fee Schedule,,63.86,,,63.86,Fee Schedule,,13.59,,,13.59,Fee Schedule,,24,,,24,Fee Schedule,,63.86,,,63.86,Fee Schedule,,25.56,,,25.56,Fee Schedule,,72.1,70,,72.1,percent of total billed charges,All Other,30.85,,,30.85,Fee Schedule,,26.17,,,26.17,Fee Schedule,,7.76,,,7.76,Fee Schedule,,7.76,,,7.76,Fee Schedule,,7.76,,,7.76,Fee Schedule,,7.76,,,7.76,Fee Schedule,,5.08,,,5.08,Fee Schedule,Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.77,,,7.77,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.11,,,7.11,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.21,,,13.21,Fee Schedule,260% Medicaid Laboratory Fee Schedule,16.46,,,16.46,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.35,,,6.35,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.08,72.1,
VITAMIN B-12                    ,82607,CPT,,40140188,CDM,301,RC,,,both,,,240,24.8,,,24.8,Other,150% of Medicare + 9.63% HCRA Surcharge,15.08,,,15.08,Fee Schedule,Mediare Clinical Lab,29.1,,,29.1,Fee Schedule,,26.24,,,26.24,Fee Schedule,,152.29,,,152.29,Fee Schedule,,137.02,,,137.02,Fee Schedule,,129.38,,,129.38,Fee Schedule,,120,50,,120,percent of total billed charges,All Other,31.85,,,31.85,Fee Schedule,,47.5,,,47.5,Fee Schedule,,23.48,,,23.48,Other,186% Medicaid methodology,55.95,,,55.95,Fee Schedule,,148.8,,,148.8,Fee Schedule,,31.67,,,31.67,Fee Schedule,,55.95,,,55.95,Fee Schedule,,148.8,,,148.8,Fee Schedule,,59.57,,,59.57,Fee Schedule,,168,70,,168,percent of total billed charges,All Other,71.9,,,71.9,Fee Schedule,,61.01,,,61.01,Fee Schedule,,18.1,,,18.1,Fee Schedule,,18.1,,,18.1,Fee Schedule,,18.1,,,18.1,Fee Schedule,,18.1,,,18.1,Fee Schedule,,12.63,,,12.63,Fee Schedule,Medicaid Laboratory Fee Schedule,12.63,,,12.63,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.63,,,12.63,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.63,,,12.63,Fee Schedule,100% Medicaid Laboratory Fee Schedule,28.41,,,28.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,28.41,,,28.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.32,,,19.32,Fee Schedule,153% Medicaid Laboratory Fee Schedule,28.41,,,28.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.68,,,17.68,Fee Schedule,140% Medicaid Laboratory Fee Schedule,28.41,,,28.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,32.83,,,32.83,Fee Schedule,260% Medicaid Laboratory Fee Schedule,40.91,,,40.91,Fee Schedule,324% Medicaid Laboratory Fee Schedule,27.14,,,27.14,Fee Schedule,215% Medicaid Laboratory Fee Schedule,27.14,,,27.14,Fee Schedule,215% Medicaid Laboratory Fee Schedule,15.78,,,15.78,Fee Schedule,125% Medicaid Laboratory Fee Schedule,12.63,168,
ASSAY OF FOLIC ACID RBC         ,82747,CPT,,40140220,CDM,301,RC,,,both,,,281,29.02,,,29.02,Other,150% of Medicare + 9.63% HCRA Surcharge,17.65,,,17.65,Fee Schedule,Mediare Clinical Lab,34.06,,,34.06,Fee Schedule,,30.71,,,30.71,Fee Schedule,,117.61,,,117.61,Fee Schedule,,105.81,,,105.81,Fee Schedule,,99.92,,,99.92,Fee Schedule,,140.5,50,,140.5,percent of total billed charges,All Other,37.28,,,37.28,Fee Schedule,,55.6,,,55.6,Fee Schedule,,23.48,,,23.48,Other,186% Medicaid methodology,65.48,,,65.48,Fee Schedule,,174.22,,,174.22,Fee Schedule,,37.07,,,37.07,Fee Schedule,,65.48,,,65.48,Fee Schedule,,174.22,,,174.22,Fee Schedule,,69.72,,,69.72,Fee Schedule,,196.7,70,,196.7,percent of total billed charges,All Other,84.15,,,84.15,Fee Schedule,,71.4,,,71.4,Fee Schedule,,21.18,,,21.18,Fee Schedule,,21.18,,,21.18,Fee Schedule,,21.18,,,21.18,Fee Schedule,,21.18,,,21.18,Fee Schedule,,12.63,,,12.63,Fee Schedule,Medicaid Laboratory Fee Schedule,12.63,,,12.63,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.63,,,12.63,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.63,,,12.63,Fee Schedule,100% Medicaid Laboratory Fee Schedule,28.41,,,28.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,28.41,,,28.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.32,,,19.32,Fee Schedule,153% Medicaid Laboratory Fee Schedule,28.41,,,28.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.68,,,17.68,Fee Schedule,140% Medicaid Laboratory Fee Schedule,28.41,,,28.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,32.83,,,32.83,Fee Schedule,260% Medicaid Laboratory Fee Schedule,40.91,,,40.91,Fee Schedule,324% Medicaid Laboratory Fee Schedule,27.14,,,27.14,Fee Schedule,215% Medicaid Laboratory Fee Schedule,27.14,,,27.14,Fee Schedule,215% Medicaid Laboratory Fee Schedule,15.78,,,15.78,Fee Schedule,125% Medicaid Laboratory Fee Schedule,12.63,196.7,
ASSAY OF FERRITIN               ,82728,CPT,,40140246,CDM,301,RC,,,both,,,217,22.41,,,22.41,Other,150% of Medicare + 9.63% HCRA Surcharge,13.63,,,13.63,Fee Schedule,Mediare Clinical Lab,26.31,,,26.31,Fee Schedule,,23.72,,,23.72,Fee Schedule,,137.64,,,137.64,Fee Schedule,,123.84,,,123.84,Fee Schedule,,116.94,,,116.94,Fee Schedule,,108.5,50,,108.5,percent of total billed charges,All Other,28.8,,,28.8,Fee Schedule,,42.93,,,42.93,Fee Schedule,,25.35,,,25.35,Other,186% Medicaid methodology,50.57,,,50.57,Fee Schedule,,134.54,,,134.54,Fee Schedule,,28.62,,,28.62,Fee Schedule,,50.57,,,50.57,Fee Schedule,,134.54,,,134.54,Fee Schedule,,53.84,,,53.84,Fee Schedule,,151.9,70,,151.9,percent of total billed charges,All Other,64.99,,,64.99,Fee Schedule,,55.14,,,55.14,Fee Schedule,,16.36,,,16.36,Fee Schedule,,16.36,,,16.36,Fee Schedule,,16.36,,,16.36,Fee Schedule,,16.36,,,16.36,Fee Schedule,,13.63,,,13.63,Fee Schedule,Medicaid Laboratory Fee Schedule,13.63,,,13.63,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.63,,,13.63,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.63,,,13.63,Fee Schedule,100% Medicaid Laboratory Fee Schedule,30.67,,,30.67,Fee Schedule,225% Medicaid Laboratory Fee Schedule,30.67,,,30.67,Fee Schedule,225% Medicaid Laboratory Fee Schedule,20.85,,,20.85,Fee Schedule,153% Medicaid Laboratory Fee Schedule,30.67,,,30.67,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.08,,,19.08,Fee Schedule,140% Medicaid Laboratory Fee Schedule,30.67,,,30.67,Fee Schedule,225% Medicaid Laboratory Fee Schedule,35.44,,,35.44,Fee Schedule,260% Medicaid Laboratory Fee Schedule,44.16,,,44.16,Fee Schedule,324% Medicaid Laboratory Fee Schedule,29.3,,,29.3,Fee Schedule,215% Medicaid Laboratory Fee Schedule,29.3,,,29.3,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.04,,,17.04,Fee Schedule,125% Medicaid Laboratory Fee Schedule,13.63,151.9,
HEMOGLOBIN CHROMOTOGRAPHY       ,83021,CPT,,40140261,CDM,301,RC,,,both,,,288,29.7,,,29.7,Other,150% of Medicare + 9.63% HCRA Surcharge,18.06,,,18.06,Fee Schedule,Mediare Clinical Lab,34.86,,,34.86,Fee Schedule,,31.42,,,31.42,Fee Schedule,,182.44,,,182.44,Fee Schedule,,164.15,,,164.15,Fee Schedule,,155,,,155,Fee Schedule,,144,50,,144,percent of total billed charges,All Other,38.16,,,38.16,Fee Schedule,,56.89,,,56.89,Fee Schedule,,33.59,,,33.59,Other,186% Medicaid methodology,67,,,67,Fee Schedule,,178.56,,,178.56,Fee Schedule,,37.93,,,37.93,Fee Schedule,,67,,,67,Fee Schedule,,178.56,,,178.56,Fee Schedule,,71.34,,,71.34,Fee Schedule,,201.6,70,,201.6,percent of total billed charges,All Other,86.11,,,86.11,Fee Schedule,,73.06,,,73.06,Fee Schedule,,21.67,,,21.67,Fee Schedule,,21.67,,,21.67,Fee Schedule,,21.67,,,21.67,Fee Schedule,,21.67,,,21.67,Fee Schedule,,18.06,,,18.06,Fee Schedule,Medicaid Laboratory Fee Schedule,18.06,,,18.06,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.06,,,18.06,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.06,,,18.06,Fee Schedule,100% Medicaid Laboratory Fee Schedule,40.64,,,40.64,Fee Schedule,225% Medicaid Laboratory Fee Schedule,40.64,,,40.64,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.63,,,27.63,Fee Schedule,153% Medicaid Laboratory Fee Schedule,40.64,,,40.64,Fee Schedule,225% Medicaid Laboratory Fee Schedule,25.28,,,25.28,Fee Schedule,140% Medicaid Laboratory Fee Schedule,40.64,,,40.64,Fee Schedule,225% Medicaid Laboratory Fee Schedule,46.96,,,46.96,Fee Schedule,260% Medicaid Laboratory Fee Schedule,58.51,,,58.51,Fee Schedule,324% Medicaid Laboratory Fee Schedule,38.83,,,38.83,Fee Schedule,215% Medicaid Laboratory Fee Schedule,38.83,,,38.83,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.58,,,22.58,Fee Schedule,125% Medicaid Laboratory Fee Schedule,18.06,201.6,
HEMOGLOBIN ELECTROPHORESIS      ,83020,CPT,,40140287,CDM,301,RC,,,both,,,42,21.16,,,21.16,Other,150% of Medicare + 9.63% HCRA Surcharge,12.87,,,12.87,Fee Schedule,Mediare Clinical Lab,24.84,,,24.84,Fee Schedule,,22.39,,,22.39,Fee Schedule,,130.1,,,130.1,Fee Schedule,,117.06,,,117.06,Fee Schedule,,110.53,,,110.53,Fee Schedule,,21,50,,21,percent of total billed charges,All Other,27.2,,,27.2,Fee Schedule,,40.54,,,40.54,Fee Schedule,,23.94,,,23.94,Other,186% Medicaid methodology,47.75,,,47.75,Fee Schedule,,26.04,,,26.04,Fee Schedule,,27.03,,,27.03,Fee Schedule,,47.75,,,47.75,Fee Schedule,,26.04,,,26.04,Fee Schedule,,50.84,,,50.84,Fee Schedule,,29.4,70,,29.4,percent of total billed charges,All Other,61.36,,,61.36,Fee Schedule,,52.07,,,52.07,Fee Schedule,,15.44,,,15.44,Fee Schedule,,15.44,,,15.44,Fee Schedule,,15.44,,,15.44,Fee Schedule,,15.44,,,15.44,Fee Schedule,,12.87,,,12.87,Fee Schedule,Medicaid Laboratory Fee Schedule,12.87,,,12.87,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.87,,,12.87,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.87,,,12.87,Fee Schedule,100% Medicaid Laboratory Fee Schedule,28.96,,,28.96,Fee Schedule,225% Medicaid Laboratory Fee Schedule,28.96,,,28.96,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.69,,,19.69,Fee Schedule,153% Medicaid Laboratory Fee Schedule,28.96,,,28.96,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.02,,,18.02,Fee Schedule,140% Medicaid Laboratory Fee Schedule,28.96,,,28.96,Fee Schedule,225% Medicaid Laboratory Fee Schedule,33.46,,,33.46,Fee Schedule,260% Medicaid Laboratory Fee Schedule,41.7,,,41.7,Fee Schedule,324% Medicaid Laboratory Fee Schedule,27.67,,,27.67,Fee Schedule,215% Medicaid Laboratory Fee Schedule,27.67,,,27.67,Fee Schedule,215% Medicaid Laboratory Fee Schedule,16.09,,,16.09,Fee Schedule,125% Medicaid Laboratory Fee Schedule,12.87,130.1,
ASSAY OF HAPTOGLOBIN QUANT      ,83010,CPT,,40140329,CDM,301,RC,,,both,,,201,20.69,,,20.69,Other,150% of Medicare + 9.63% HCRA Surcharge,12.58,,,12.58,Fee Schedule,Mediare Clinical Lab,24.28,,,24.28,Fee Schedule,,21.89,,,21.89,Fee Schedule,,127.09,,,127.09,Fee Schedule,,114.34,,,114.34,Fee Schedule,,107.97,,,107.97,Fee Schedule,,100.5,50,,100.5,percent of total billed charges,All Other,26.59,,,26.59,Fee Schedule,,39.63,,,39.63,Fee Schedule,,23.4,,,23.4,Other,186% Medicaid methodology,46.67,,,46.67,Fee Schedule,,124.62,,,124.62,Fee Schedule,,26.42,,,26.42,Fee Schedule,,46.67,,,46.67,Fee Schedule,,124.62,,,124.62,Fee Schedule,,49.69,,,49.69,Fee Schedule,,140.7,70,,140.7,percent of total billed charges,All Other,59.98,,,59.98,Fee Schedule,,50.89,,,50.89,Fee Schedule,,15.1,,,15.1,Fee Schedule,,15.1,,,15.1,Fee Schedule,,15.1,,,15.1,Fee Schedule,,15.1,,,15.1,Fee Schedule,,12.58,,,12.58,Fee Schedule,Medicaid Laboratory Fee Schedule,12.58,,,12.58,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.58,,,12.58,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.58,,,12.58,Fee Schedule,100% Medicaid Laboratory Fee Schedule,28.31,,,28.31,Fee Schedule,225% Medicaid Laboratory Fee Schedule,28.31,,,28.31,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.25,,,19.25,Fee Schedule,153% Medicaid Laboratory Fee Schedule,28.31,,,28.31,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.61,,,17.61,Fee Schedule,140% Medicaid Laboratory Fee Schedule,28.31,,,28.31,Fee Schedule,225% Medicaid Laboratory Fee Schedule,32.71,,,32.71,Fee Schedule,260% Medicaid Laboratory Fee Schedule,40.76,,,40.76,Fee Schedule,324% Medicaid Laboratory Fee Schedule,27.05,,,27.05,Fee Schedule,215% Medicaid Laboratory Fee Schedule,27.05,,,27.05,Fee Schedule,215% Medicaid Laboratory Fee Schedule,15.73,,,15.73,Fee Schedule,125% Medicaid Laboratory Fee Schedule,12.58,140.7,
GLYCOSYLATED HEMOGLOBIN TEST    ,83036,CPT,,40140709,CDM,301,RC,,,both,,,331,15.97,,,15.97,Other,150% of Medicare + 9.63% HCRA Surcharge,9.71,,,9.71,Fee Schedule,Mediare Clinical Lab,18.74,,,18.74,Fee Schedule,,16.9,,,16.9,Fee Schedule,,98.08,,,98.08,Fee Schedule,,88.24,,,88.24,Fee Schedule,,83.33,,,83.33,Fee Schedule,,165.5,50,,165.5,percent of total billed charges,All Other,20.51,,,20.51,Fee Schedule,,30.59,,,30.59,Fee Schedule,,18.06,,,18.06,Other,186% Medicaid methodology,36.02,,,36.02,Fee Schedule,,205.22,,,205.22,Fee Schedule,,20.39,,,20.39,Fee Schedule,,36.02,,,36.02,Fee Schedule,,205.22,,,205.22,Fee Schedule,,38.35,,,38.35,Fee Schedule,,231.7,70,,231.7,percent of total billed charges,All Other,46.3,,,46.3,Fee Schedule,,39.28,,,39.28,Fee Schedule,,11.65,,,11.65,Fee Schedule,,11.65,,,11.65,Fee Schedule,,11.65,,,11.65,Fee Schedule,,11.65,,,11.65,Fee Schedule,,9.71,,,9.71,Fee Schedule,Medicaid Laboratory Fee Schedule,9.71,,,9.71,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.71,,,9.71,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.71,,,9.71,Fee Schedule,100% Medicaid Laboratory Fee Schedule,21.85,,,21.85,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.85,,,21.85,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.86,,,14.86,Fee Schedule,153% Medicaid Laboratory Fee Schedule,21.85,,,21.85,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.59,,,13.59,Fee Schedule,140% Medicaid Laboratory Fee Schedule,21.85,,,21.85,Fee Schedule,225% Medicaid Laboratory Fee Schedule,25.25,,,25.25,Fee Schedule,260% Medicaid Laboratory Fee Schedule,31.46,,,31.46,Fee Schedule,324% Medicaid Laboratory Fee Schedule,20.88,,,20.88,Fee Schedule,215% Medicaid Laboratory Fee Schedule,20.88,,,20.88,Fee Schedule,215% Medicaid Laboratory Fee Schedule,12.14,,,12.14,Fee Schedule,125% Medicaid Laboratory Fee Schedule,9.71,231.7,
ASSAY OF PLASMA HEMOGLOBIN      ,83051,CPT,,40141202,CDM,301,RC,,,both,,,85,12.02,,,12.02,Other,150% of Medicare + 9.63% HCRA Surcharge,7.31,,,7.31,Fee Schedule,Mediare Clinical Lab,14.11,,,14.11,Fee Schedule,,12.72,,,12.72,Fee Schedule,,35.25,,,35.25,Fee Schedule,,31.72,,,31.72,Fee Schedule,,29.95,,,29.95,Fee Schedule,,42.5,50,,42.5,percent of total billed charges,All Other,15.44,,,15.44,Fee Schedule,,23.03,,,23.03,Fee Schedule,,7.04,,,7.04,Other,186% Medicaid methodology,27.12,,,27.12,Fee Schedule,,52.7,,,52.7,Fee Schedule,,15.35,,,15.35,Fee Schedule,,27.12,,,27.12,Fee Schedule,,52.7,,,52.7,Fee Schedule,,28.87,,,28.87,Fee Schedule,,59.5,70,,59.5,percent of total billed charges,All Other,34.85,,,34.85,Fee Schedule,,29.57,,,29.57,Fee Schedule,,8.77,,,8.77,Fee Schedule,,8.77,,,8.77,Fee Schedule,,8.77,,,8.77,Fee Schedule,,8.77,,,8.77,Fee Schedule,,3.79,,,3.79,Fee Schedule,Medicaid Laboratory Fee Schedule,3.79,,,3.79,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.79,,,3.79,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.79,,,3.79,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.52,,,8.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.52,,,8.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.79,,,5.79,Fee Schedule,153% Medicaid Laboratory Fee Schedule,8.52,,,8.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.3,,,5.3,Fee Schedule,140% Medicaid Laboratory Fee Schedule,8.52,,,8.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.85,,,9.85,Fee Schedule,260% Medicaid Laboratory Fee Schedule,12.27,,,12.27,Fee Schedule,324% Medicaid Laboratory Fee Schedule,8.14,,,8.14,Fee Schedule,215% Medicaid Laboratory Fee Schedule,8.14,,,8.14,Fee Schedule,215% Medicaid Laboratory Fee Schedule,4.73,,,4.73,Fee Schedule,125% Medicaid Laboratory Fee Schedule,3.79,59.5,
ASSAY OF IGE                    ,82785,CPT,,40141400,CDM,301,RC,,,both,,,262,27.07,,,27.07,Other,150% of Medicare + 9.63% HCRA Surcharge,16.46,,,16.46,Fee Schedule,Mediare Clinical Lab,31.77,,,31.77,Fee Schedule,,28.64,,,28.64,Fee Schedule,,166.43,,,166.43,Fee Schedule,,149.74,,,149.74,Fee Schedule,,141.4,,,141.4,Fee Schedule,,131,50,,131,percent of total billed charges,All Other,34.78,,,34.78,Fee Schedule,,51.85,,,51.85,Fee Schedule,,23.48,,,23.48,Other,186% Medicaid methodology,61.07,,,61.07,Fee Schedule,,162.44,,,162.44,Fee Schedule,,34.57,,,34.57,Fee Schedule,,61.07,,,61.07,Fee Schedule,,162.44,,,162.44,Fee Schedule,,65.02,,,65.02,Fee Schedule,,183.4,70,,183.4,percent of total billed charges,All Other,78.48,,,78.48,Fee Schedule,,66.59,,,66.59,Fee Schedule,,19.75,,,19.75,Fee Schedule,,19.75,,,19.75,Fee Schedule,,19.75,,,19.75,Fee Schedule,,19.75,,,19.75,Fee Schedule,,12.63,,,12.63,Fee Schedule,Medicaid Laboratory Fee Schedule,12.63,,,12.63,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.63,,,12.63,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.63,,,12.63,Fee Schedule,100% Medicaid Laboratory Fee Schedule,28.41,,,28.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,28.41,,,28.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.32,,,19.32,Fee Schedule,153% Medicaid Laboratory Fee Schedule,28.41,,,28.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.68,,,17.68,Fee Schedule,140% Medicaid Laboratory Fee Schedule,28.41,,,28.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,32.83,,,32.83,Fee Schedule,260% Medicaid Laboratory Fee Schedule,40.91,,,40.91,Fee Schedule,324% Medicaid Laboratory Fee Schedule,27.14,,,27.14,Fee Schedule,215% Medicaid Laboratory Fee Schedule,27.14,,,27.14,Fee Schedule,215% Medicaid Laboratory Fee Schedule,15.78,,,15.78,Fee Schedule,125% Medicaid Laboratory Fee Schedule,12.63,183.4,
ASSAY OF ERYTHROPOIETIN         ,82668,CPT,,40141483,CDM,301,RC,,,both,,,299,30.9,,,30.9,Other,150% of Medicare + 9.63% HCRA Surcharge,18.79,,,18.79,Fee Schedule,Mediare Clinical Lab,36.26,,,36.26,Fee Schedule,,32.69,,,32.69,Fee Schedule,,189.98,,,189.98,Fee Schedule,,170.93,,,170.93,Fee Schedule,,161.41,,,161.41,Fee Schedule,,149.5,50,,149.5,percent of total billed charges,All Other,39.68,,,39.68,Fee Schedule,,59.19,,,59.19,Fee Schedule,,32.05,,,32.05,Other,186% Medicaid methodology,69.71,,,69.71,Fee Schedule,,185.38,,,185.38,Fee Schedule,,39.46,,,39.46,Fee Schedule,,69.71,,,69.71,Fee Schedule,,185.38,,,185.38,Fee Schedule,,74.22,,,74.22,Fee Schedule,,209.3,70,,209.3,percent of total billed charges,All Other,89.59,,,89.59,Fee Schedule,,76.02,,,76.02,Fee Schedule,,22.55,,,22.55,Fee Schedule,,22.55,,,22.55,Fee Schedule,,22.55,,,22.55,Fee Schedule,,22.55,,,22.55,Fee Schedule,,17.23,,,17.23,Fee Schedule,Medicaid Laboratory Fee Schedule,17.23,,,17.23,Fee Schedule,100% Medicaid Laboratory Fee Schedule,17.23,,,17.23,Fee Schedule,100% Medicaid Laboratory Fee Schedule,17.23,,,17.23,Fee Schedule,100% Medicaid Laboratory Fee Schedule,38.77,,,38.77,Fee Schedule,225% Medicaid Laboratory Fee Schedule,38.77,,,38.77,Fee Schedule,225% Medicaid Laboratory Fee Schedule,26.36,,,26.36,Fee Schedule,153% Medicaid Laboratory Fee Schedule,38.77,,,38.77,Fee Schedule,225% Medicaid Laboratory Fee Schedule,24.12,,,24.12,Fee Schedule,140% Medicaid Laboratory Fee Schedule,38.77,,,38.77,Fee Schedule,225% Medicaid Laboratory Fee Schedule,44.8,,,44.8,Fee Schedule,260% Medicaid Laboratory Fee Schedule,55.83,,,55.83,Fee Schedule,324% Medicaid Laboratory Fee Schedule,37.05,,,37.05,Fee Schedule,215% Medicaid Laboratory Fee Schedule,37.05,,,37.05,Fee Schedule,215% Medicaid Laboratory Fee Schedule,21.54,,,21.54,Fee Schedule,125% Medicaid Laboratory Fee Schedule,17.23,209.3,
BILE ACIDS TOTAL                ,82239,CPT,,40141681,CDM,301,RC,,,both,,,273,28.15,,,28.15,Other,150% of Medicare + 9.63% HCRA Surcharge,17.12,,,17.12,Fee Schedule,Mediare Clinical Lab,33.04,,,33.04,Fee Schedule,,29.79,,,29.79,Fee Schedule,,142.88,,,142.88,Fee Schedule,,128.55,,,128.55,Fee Schedule,,121.39,,,121.39,Fee Schedule,,136.5,50,,136.5,percent of total billed charges,All Other,36.17,,,36.17,Fee Schedule,,53.93,,,53.93,Fee Schedule,,24.52,,,24.52,Other,186% Medicaid methodology,63.52,,,63.52,Fee Schedule,,169.26,,,169.26,Fee Schedule,,35.95,,,35.95,Fee Schedule,,63.52,,,63.52,Fee Schedule,,169.26,,,169.26,Fee Schedule,,67.62,,,67.62,Fee Schedule,,191.1,70,,191.1,percent of total billed charges,All Other,81.63,,,81.63,Fee Schedule,,69.26,,,69.26,Fee Schedule,,20.54,,,20.54,Fee Schedule,,20.54,,,20.54,Fee Schedule,,20.54,,,20.54,Fee Schedule,,20.54,,,20.54,Fee Schedule,,13.18,,,13.18,Fee Schedule,Medicaid Laboratory Fee Schedule,13.18,,,13.18,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.18,,,13.18,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.18,,,13.18,Fee Schedule,100% Medicaid Laboratory Fee Schedule,29.66,,,29.66,Fee Schedule,225% Medicaid Laboratory Fee Schedule,29.66,,,29.66,Fee Schedule,225% Medicaid Laboratory Fee Schedule,20.17,,,20.17,Fee Schedule,153% Medicaid Laboratory Fee Schedule,29.66,,,29.66,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.45,,,18.45,Fee Schedule,140% Medicaid Laboratory Fee Schedule,29.66,,,29.66,Fee Schedule,225% Medicaid Laboratory Fee Schedule,34.27,,,34.27,Fee Schedule,260% Medicaid Laboratory Fee Schedule,42.7,,,42.7,Fee Schedule,324% Medicaid Laboratory Fee Schedule,28.34,,,28.34,Fee Schedule,215% Medicaid Laboratory Fee Schedule,28.34,,,28.34,Fee Schedule,215% Medicaid Laboratory Fee Schedule,16.48,,,16.48,Fee Schedule,125% Medicaid Laboratory Fee Schedule,13.18,191.1,
ASSAY OF GLYCATED PROTEIN       ,82985,CPT,,40142085,CDM,301,RC,,,both,,,267,27.56,,,27.56,Other,150% of Medicare + 9.63% HCRA Surcharge,16.76,,,16.76,Fee Schedule,Mediare Clinical Lab,32.35,,,32.35,Fee Schedule,,29.16,,,29.16,Fee Schedule,,152.29,,,152.29,Fee Schedule,,137.02,,,137.02,Fee Schedule,,129.38,,,129.38,Fee Schedule,,133.5,50,,133.5,percent of total billed charges,All Other,35.39,,,35.39,Fee Schedule,,52.79,,,52.79,Fee Schedule,,19.99,,,19.99,Other,186% Medicaid methodology,62.18,,,62.18,Fee Schedule,,165.54,,,165.54,Fee Schedule,,35.2,,,35.2,Fee Schedule,,62.18,,,62.18,Fee Schedule,,165.54,,,165.54,Fee Schedule,,66.2,,,66.2,Fee Schedule,,186.9,70,,186.9,percent of total billed charges,All Other,79.91,,,79.91,Fee Schedule,,67.8,,,67.8,Fee Schedule,,20.11,,,20.11,Fee Schedule,,20.11,,,20.11,Fee Schedule,,20.11,,,20.11,Fee Schedule,,20.11,,,20.11,Fee Schedule,,10.75,,,10.75,Fee Schedule,Medicaid Laboratory Fee Schedule,10.75,,,10.75,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.75,,,10.75,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.75,,,10.75,Fee Schedule,100% Medicaid Laboratory Fee Schedule,24.18,,,24.18,Fee Schedule,225% Medicaid Laboratory Fee Schedule,24.18,,,24.18,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.44,,,16.44,Fee Schedule,153% Medicaid Laboratory Fee Schedule,24.18,,,24.18,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.04,,,15.04,Fee Schedule,140% Medicaid Laboratory Fee Schedule,24.18,,,24.18,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.94,,,27.94,Fee Schedule,260% Medicaid Laboratory Fee Schedule,34.82,,,34.82,Fee Schedule,324% Medicaid Laboratory Fee Schedule,23.1,,,23.1,Fee Schedule,215% Medicaid Laboratory Fee Schedule,23.1,,,23.1,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.43,,,13.43,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.75,186.9,
ASSAY OF G6PD ENZYME            ,82955,CPT,,40143281,CDM,301,RC,,,both,,,155,15.95,,,15.95,Other,150% of Medicare + 9.63% HCRA Surcharge,9.7,,,9.7,Fee Schedule,Mediare Clinical Lab,18.72,,,18.72,Fee Schedule,,16.88,,,16.88,Fee Schedule,,98.01,,,98.01,Fee Schedule,,88.18,,,88.18,Fee Schedule,,83.27,,,83.27,Fee Schedule,,77.5,50,,77.5,percent of total billed charges,All Other,20.51,,,20.51,Fee Schedule,,30.56,,,30.56,Fee Schedule,,18.04,,,18.04,Other,186% Medicaid methodology,35.99,,,35.99,Fee Schedule,,96.1,,,96.1,Fee Schedule,,20.37,,,20.37,Fee Schedule,,35.99,,,35.99,Fee Schedule,,96.1,,,96.1,Fee Schedule,,38.32,,,38.32,Fee Schedule,,108.5,70,,108.5,percent of total billed charges,All Other,46.25,,,46.25,Fee Schedule,,39.24,,,39.24,Fee Schedule,,11.64,,,11.64,Fee Schedule,,11.64,,,11.64,Fee Schedule,,11.64,,,11.64,Fee Schedule,,11.64,,,11.64,Fee Schedule,,9.7,,,9.7,Fee Schedule,Medicaid Laboratory Fee Schedule,9.7,,,9.7,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.7,,,9.7,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.7,,,9.7,Fee Schedule,100% Medicaid Laboratory Fee Schedule,21.83,,,21.83,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.83,,,21.83,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.84,,,14.84,Fee Schedule,153% Medicaid Laboratory Fee Schedule,21.83,,,21.83,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.58,,,13.58,Fee Schedule,140% Medicaid Laboratory Fee Schedule,21.83,,,21.83,Fee Schedule,225% Medicaid Laboratory Fee Schedule,25.22,,,25.22,Fee Schedule,260% Medicaid Laboratory Fee Schedule,31.43,,,31.43,Fee Schedule,324% Medicaid Laboratory Fee Schedule,20.86,,,20.86,Fee Schedule,215% Medicaid Laboratory Fee Schedule,20.86,,,20.86,Fee Schedule,215% Medicaid Laboratory Fee Schedule,12.13,,,12.13,Fee Schedule,125% Medicaid Laboratory Fee Schedule,9.7,108.5,
ASSAY IGA/IGD/IGG/IGM EACH      ,82784,CPT,,40161341,CDM,301,RC,,,both,,,149,15.29,,,15.29,Other,150% of Medicare + 9.63% HCRA Surcharge,9.3,,,9.3,Fee Schedule,Mediare Clinical Lab,17.95,,,17.95,Fee Schedule,,16.18,,,16.18,Fee Schedule,,93.99,,,93.99,Fee Schedule,,84.56,,,84.56,Fee Schedule,,79.85,,,79.85,Fee Schedule,,74.5,50,,74.5,percent of total billed charges,All Other,19.66,,,19.66,Fee Schedule,,29.3,,,29.3,Fee Schedule,,17.3,,,17.3,Other,186% Medicaid methodology,34.5,,,34.5,Fee Schedule,,92.38,,,92.38,Fee Schedule,,19.53,,,19.53,Fee Schedule,,34.5,,,34.5,Fee Schedule,,92.38,,,92.38,Fee Schedule,,36.74,,,36.74,Fee Schedule,,104.3,70,,104.3,percent of total billed charges,All Other,44.34,,,44.34,Fee Schedule,,37.62,,,37.62,Fee Schedule,,11.16,,,11.16,Fee Schedule,,11.16,,,11.16,Fee Schedule,,11.16,,,11.16,Fee Schedule,,11.16,,,11.16,Fee Schedule,,9.3,,,9.3,Fee Schedule,Medicaid Laboratory Fee Schedule,9.3,,,9.3,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.3,,,9.3,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.3,,,9.3,Fee Schedule,100% Medicaid Laboratory Fee Schedule,20.93,,,20.93,Fee Schedule,225% Medicaid Laboratory Fee Schedule,20.93,,,20.93,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.23,,,14.23,Fee Schedule,153% Medicaid Laboratory Fee Schedule,20.93,,,20.93,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.02,,,13.02,Fee Schedule,140% Medicaid Laboratory Fee Schedule,20.93,,,20.93,Fee Schedule,225% Medicaid Laboratory Fee Schedule,24.18,,,24.18,Fee Schedule,260% Medicaid Laboratory Fee Schedule,30.13,,,30.13,Fee Schedule,324% Medicaid Laboratory Fee Schedule,20,,,20,Fee Schedule,215% Medicaid Laboratory Fee Schedule,20,,,20,Fee Schedule,215% Medicaid Laboratory Fee Schedule,11.63,,,11.63,Fee Schedule,125% Medicaid Laboratory Fee Schedule,9.3,104.3,
DRUG TEST PRSMV CHEM ANLYZR     ,80307,CPT,,40170300,CDM,301,RC,,,both,,,988,102.19,,,102.19,Other,150% of Medicare + 9.63% HCRA Surcharge,62.14,,,62.14,Fee Schedule,Mediare Clinical Lab,119.93,,,119.93,Fee Schedule,,108.12,,,108.12,Fee Schedule,,31.92,,,31.92,Fee Schedule,,31.92,,,31.92,Fee Schedule,,31.92,,,31.92,Fee Schedule,,494,50,,494,percent of total billed charges,All Other,131.27,,,131.27,Fee Schedule,,195.74,,,195.74,Fee Schedule,,14.09,,,14.09,Other,186% Medicaid methodology,230.54,,,230.54,Fee Schedule,,612.56,,,612.56,Fee Schedule,,130.49,,,130.49,Fee Schedule,,230.54,,,230.54,Fee Schedule,,612.56,,,612.56,Fee Schedule,,245.45,,,245.45,Fee Schedule,,691.6,70,,691.6,percent of total billed charges,All Other,296.28,,,296.28,Fee Schedule,,251.39,,,251.39,Fee Schedule,,74.57,,,74.57,Fee Schedule,,74.57,,,74.57,Fee Schedule,,74.57,,,74.57,Fee Schedule,,74.57,,,74.57,Fee Schedule,,7.58,,,7.58,Fee Schedule,Medicaid Laboratory Fee Schedule,7.58,,,7.58,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.58,,,7.58,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.58,,,7.58,Fee Schedule,100% Medicaid Laboratory Fee Schedule,17.04,,,17.04,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.04,,,17.04,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.59,,,11.59,Fee Schedule,153% Medicaid Laboratory Fee Schedule,17.04,,,17.04,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,140% Medicaid Laboratory Fee Schedule,17.04,,,17.04,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.7,,,19.7,Fee Schedule,260% Medicaid Laboratory Fee Schedule,24.54,,,24.54,Fee Schedule,324% Medicaid Laboratory Fee Schedule,16.29,,,16.29,Fee Schedule,215% Medicaid Laboratory Fee Schedule,16.29,,,16.29,Fee Schedule,215% Medicaid Laboratory Fee Schedule,9.47,,,9.47,Fee Schedule,125% Medicaid Laboratory Fee Schedule,7.58,691.6,
ASSAY OF THEOPHYLLINE           ,80198,CPT,,40170367,CDM,301,RC,,,both,,,225,23.25,,,23.25,Other,150% of Medicare + 9.63% HCRA Surcharge,14.14,,,14.14,Fee Schedule,Mediare Clinical Lab,27.29,,,27.29,Fee Schedule,,24.6,,,24.6,Fee Schedule,,142.95,,,142.95,Fee Schedule,,128.62,,,128.62,Fee Schedule,,121.45,,,121.45,Fee Schedule,,112.5,50,,112.5,percent of total billed charges,All Other,29.87,,,29.87,Fee Schedule,,44.54,,,44.54,Fee Schedule,,15.03,,,15.03,Other,186% Medicaid methodology,52.46,,,52.46,Fee Schedule,,139.5,,,139.5,Fee Schedule,,29.69,,,29.69,Fee Schedule,,52.46,,,52.46,Fee Schedule,,139.5,,,139.5,Fee Schedule,,55.85,,,55.85,Fee Schedule,,157.5,70,,157.5,percent of total billed charges,All Other,67.42,,,67.42,Fee Schedule,,57.2,,,57.2,Fee Schedule,,16.97,,,16.97,Fee Schedule,,16.97,,,16.97,Fee Schedule,,16.97,,,16.97,Fee Schedule,,16.97,,,16.97,Fee Schedule,,8.08,,,8.08,Fee Schedule,Medicaid Laboratory Fee Schedule,8.08,,,8.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.08,,,8.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.08,,,8.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.18,,,18.18,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.18,,,18.18,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.36,,,12.36,Fee Schedule,153% Medicaid Laboratory Fee Schedule,18.18,,,18.18,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.31,,,11.31,Fee Schedule,140% Medicaid Laboratory Fee Schedule,18.18,,,18.18,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.01,,,21.01,Fee Schedule,260% Medicaid Laboratory Fee Schedule,26.18,,,26.18,Fee Schedule,324% Medicaid Laboratory Fee Schedule,17.37,,,17.37,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.37,,,17.37,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.1,,,10.1,Fee Schedule,125% Medicaid Laboratory Fee Schedule,8.08,157.5,
ASSAY OF DIGOXIN TOTAL          ,80162,CPT,,40170383,CDM,301,RC,,,both,,,211,21.84,,,21.84,Other,150% of Medicare + 9.63% HCRA Surcharge,13.28,,,13.28,Fee Schedule,Mediare Clinical Lab,25.63,,,25.63,Fee Schedule,,23.11,,,23.11,Fee Schedule,,134.19,,,134.19,Fee Schedule,,120.74,,,120.74,Fee Schedule,,114.01,,,114.01,Fee Schedule,,105.5,50,,105.5,percent of total billed charges,All Other,28.05,,,28.05,Fee Schedule,,41.83,,,41.83,Fee Schedule,,19.73,,,19.73,Other,186% Medicaid methodology,49.27,,,49.27,Fee Schedule,,130.82,,,130.82,Fee Schedule,,27.89,,,27.89,Fee Schedule,,49.27,,,49.27,Fee Schedule,,130.82,,,130.82,Fee Schedule,,52.46,,,52.46,Fee Schedule,,147.7,70,,147.7,percent of total billed charges,All Other,63.32,,,63.32,Fee Schedule,,53.72,,,53.72,Fee Schedule,,15.94,,,15.94,Fee Schedule,,15.94,,,15.94,Fee Schedule,,15.94,,,15.94,Fee Schedule,,15.94,,,15.94,Fee Schedule,,10.61,,,10.61,Fee Schedule,Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.23,,,16.23,Fee Schedule,153% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.85,,,14.85,Fee Schedule,140% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.57,,,27.57,Fee Schedule,260% Medicaid Laboratory Fee Schedule,34.36,,,34.36,Fee Schedule,324% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.26,,,13.26,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.61,147.7,
ASSAY CARBAMAZEPINE TOTAL       ,80156,CPT,,40170466,CDM,301,RC,,,both,,,233,23.96,,,23.96,Other,150% of Medicare + 9.63% HCRA Surcharge,14.57,,,14.57,Fee Schedule,Mediare Clinical Lab,28.12,,,28.12,Fee Schedule,,25.35,,,25.35,Fee Schedule,,118.54,,,118.54,Fee Schedule,,106.65,,,106.65,Fee Schedule,,100.71,,,100.71,Fee Schedule,,116.5,50,,116.5,percent of total billed charges,All Other,30.78,,,30.78,Fee Schedule,,45.9,,,45.9,Fee Schedule,,19.73,,,19.73,Other,186% Medicaid methodology,54.05,,,54.05,Fee Schedule,,144.46,,,144.46,Fee Schedule,,30.6,,,30.6,Fee Schedule,,54.05,,,54.05,Fee Schedule,,144.46,,,144.46,Fee Schedule,,57.55,,,57.55,Fee Schedule,,163.1,70,,163.1,percent of total billed charges,All Other,69.47,,,69.47,Fee Schedule,,58.94,,,58.94,Fee Schedule,,17.48,,,17.48,Fee Schedule,,17.48,,,17.48,Fee Schedule,,17.48,,,17.48,Fee Schedule,,17.48,,,17.48,Fee Schedule,,10.61,,,10.61,Fee Schedule,Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.23,,,16.23,Fee Schedule,153% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.85,,,14.85,Fee Schedule,140% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.57,,,27.57,Fee Schedule,260% Medicaid Laboratory Fee Schedule,34.36,,,34.36,Fee Schedule,324% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.26,,,13.26,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.61,163.1,
ASSAY OF PHENYTOIN TOTAL        ,80185,CPT,,40170482,CDM,301,RC,,,both,,,211,21.79,,,21.79,Other,150% of Medicare + 9.63% HCRA Surcharge,13.25,,,13.25,Fee Schedule,Mediare Clinical Lab,25.57,,,25.57,Fee Schedule,,23.06,,,23.06,Fee Schedule,,133.98,,,133.98,Fee Schedule,,120.54,,,120.54,Fee Schedule,,113.83,,,113.83,Fee Schedule,,105.5,50,,105.5,percent of total billed charges,All Other,27.98,,,27.98,Fee Schedule,,41.74,,,41.74,Fee Schedule,,19.73,,,19.73,Other,186% Medicaid methodology,49.16,,,49.16,Fee Schedule,,130.82,,,130.82,Fee Schedule,,27.83,,,27.83,Fee Schedule,,49.16,,,49.16,Fee Schedule,,130.82,,,130.82,Fee Schedule,,52.34,,,52.34,Fee Schedule,,147.7,70,,147.7,percent of total billed charges,All Other,63.18,,,63.18,Fee Schedule,,53.6,,,53.6,Fee Schedule,,15.9,,,15.9,Fee Schedule,,15.9,,,15.9,Fee Schedule,,15.9,,,15.9,Fee Schedule,,15.9,,,15.9,Fee Schedule,,10.61,,,10.61,Fee Schedule,Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.23,,,16.23,Fee Schedule,153% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.85,,,14.85,Fee Schedule,140% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.57,,,27.57,Fee Schedule,260% Medicaid Laboratory Fee Schedule,34.36,,,34.36,Fee Schedule,324% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.26,,,13.26,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.61,147.7,
ASSAY OF PHENOBARBITAL          ,80184,CPT,,40170508,CDM,301,RC,,,both,,,244,25.16,,,25.16,Other,150% of Medicare + 9.63% HCRA Surcharge,15.3,,,15.3,Fee Schedule,Mediare Clinical Lab,29.53,,,29.53,Fee Schedule,,26.62,,,26.62,Fee Schedule,,115.74,,,115.74,Fee Schedule,,104.14,,,104.14,Fee Schedule,,98.33,,,98.33,Fee Schedule,,122,50,,122,percent of total billed charges,All Other,32.34,,,32.34,Fee Schedule,,48.2,,,48.2,Fee Schedule,,19.73,,,19.73,Other,186% Medicaid methodology,56.76,,,56.76,Fee Schedule,,151.28,,,151.28,Fee Schedule,,32.13,,,32.13,Fee Schedule,,56.76,,,56.76,Fee Schedule,,151.28,,,151.28,Fee Schedule,,60.44,,,60.44,Fee Schedule,,170.8,70,,170.8,percent of total billed charges,All Other,72.95,,,72.95,Fee Schedule,,61.9,,,61.9,Fee Schedule,,18.36,,,18.36,Fee Schedule,,18.36,,,18.36,Fee Schedule,,18.36,,,18.36,Fee Schedule,,18.36,,,18.36,Fee Schedule,,10.61,,,10.61,Fee Schedule,Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.23,,,16.23,Fee Schedule,153% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.85,,,14.85,Fee Schedule,140% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.57,,,27.57,Fee Schedule,260% Medicaid Laboratory Fee Schedule,34.36,,,34.36,Fee Schedule,324% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.26,,,13.26,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.61,170.8,
ASSAY DIPROPYLACETIC ACD TOT    ,80164,CPT,,40170540,CDM,301,RC,,,both,,,216,22.27,,,22.27,Other,150% of Medicare + 9.63% HCRA Surcharge,13.54,,,13.54,Fee Schedule,Mediare Clinical Lab,26.13,,,26.13,Fee Schedule,,23.56,,,23.56,Fee Schedule,,136.85,,,136.85,Fee Schedule,,123.13,,,123.13,Fee Schedule,,116.27,,,116.27,Fee Schedule,,108,50,,108,percent of total billed charges,All Other,28.6,,,28.6,Fee Schedule,,42.65,,,42.65,Fee Schedule,,19.73,,,19.73,Other,186% Medicaid methodology,50.23,,,50.23,Fee Schedule,,133.92,,,133.92,Fee Schedule,,28.43,,,28.43,Fee Schedule,,50.23,,,50.23,Fee Schedule,,133.92,,,133.92,Fee Schedule,,53.48,,,53.48,Fee Schedule,,151.2,70,,151.2,percent of total billed charges,All Other,64.56,,,64.56,Fee Schedule,,54.78,,,54.78,Fee Schedule,,16.25,,,16.25,Fee Schedule,,16.25,,,16.25,Fee Schedule,,16.25,,,16.25,Fee Schedule,,16.25,,,16.25,Fee Schedule,,10.61,,,10.61,Fee Schedule,Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.23,,,16.23,Fee Schedule,153% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.85,,,14.85,Fee Schedule,140% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.57,,,27.57,Fee Schedule,260% Medicaid Laboratory Fee Schedule,34.36,,,34.36,Fee Schedule,324% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.26,,,13.26,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.61,151.2,
ASSAY OF LITHIUM                ,80178,CPT,,40170565,CDM,301,RC,,,both,,,105,10.87,,,10.87,Other,150% of Medicare + 9.63% HCRA Surcharge,6.61,,,6.61,Fee Schedule,Mediare Clinical Lab,12.76,,,12.76,Fee Schedule,,11.5,,,11.5,Fee Schedule,,66.77,,,66.77,Fee Schedule,,60.08,,,60.08,Fee Schedule,,56.73,,,56.73,Fee Schedule,,52.5,50,,52.5,percent of total billed charges,All Other,13.98,,,13.98,Fee Schedule,,20.82,,,20.82,Fee Schedule,,12.29,,,12.29,Other,186% Medicaid methodology,24.52,,,24.52,Fee Schedule,,65.1,,,65.1,Fee Schedule,,13.88,,,13.88,Fee Schedule,,24.52,,,24.52,Fee Schedule,,65.1,,,65.1,Fee Schedule,,26.11,,,26.11,Fee Schedule,,73.5,70,,73.5,percent of total billed charges,All Other,31.52,,,31.52,Fee Schedule,,26.74,,,26.74,Fee Schedule,,7.93,,,7.93,Fee Schedule,,7.93,,,7.93,Fee Schedule,,7.93,,,7.93,Fee Schedule,,7.93,,,7.93,Fee Schedule,,6.61,,,6.61,Fee Schedule,Medicaid Laboratory Fee Schedule,6.61,,,6.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.61,,,6.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.61,,,6.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.87,,,14.87,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.87,,,14.87,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.11,,,10.11,Fee Schedule,153% Medicaid Laboratory Fee Schedule,14.87,,,14.87,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.25,,,9.25,Fee Schedule,140% Medicaid Laboratory Fee Schedule,14.87,,,14.87,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.19,,,17.19,Fee Schedule,260% Medicaid Laboratory Fee Schedule,21.42,,,21.42,Fee Schedule,324% Medicaid Laboratory Fee Schedule,14.21,,,14.21,Fee Schedule,215% Medicaid Laboratory Fee Schedule,14.21,,,14.21,Fee Schedule,215% Medicaid Laboratory Fee Schedule,8.26,,,8.26,Fee Schedule,125% Medicaid Laboratory Fee Schedule,6.61,73.5,
DRUG ASSAY CYCLOSPORINE         ,80158,CPT,,40170581,CDM,301,RC,,,both,,,288,29.68,,,29.68,Other,150% of Medicare + 9.63% HCRA Surcharge,18.05,,,18.05,Fee Schedule,Mediare Clinical Lab,34.84,,,34.84,Fee Schedule,,31.41,,,31.41,Fee Schedule,,182.37,,,182.37,Fee Schedule,,164.08,,,164.08,Fee Schedule,,154.94,,,154.94,Fee Schedule,,144,50,,144,percent of total billed charges,All Other,38.12,,,38.12,Fee Schedule,,56.86,,,56.86,Fee Schedule,,19.73,,,19.73,Other,186% Medicaid methodology,66.97,,,66.97,Fee Schedule,,178.56,,,178.56,Fee Schedule,,37.91,,,37.91,Fee Schedule,,66.97,,,66.97,Fee Schedule,,178.56,,,178.56,Fee Schedule,,71.3,,,71.3,Fee Schedule,,201.6,70,,201.6,percent of total billed charges,All Other,86.06,,,86.06,Fee Schedule,,73.02,,,73.02,Fee Schedule,,21.66,,,21.66,Fee Schedule,,21.66,,,21.66,Fee Schedule,,21.66,,,21.66,Fee Schedule,,21.66,,,21.66,Fee Schedule,,10.61,,,10.61,Fee Schedule,Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.23,,,16.23,Fee Schedule,153% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.85,,,14.85,Fee Schedule,140% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.57,,,27.57,Fee Schedule,260% Medicaid Laboratory Fee Schedule,34.36,,,34.36,Fee Schedule,324% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.26,,,13.26,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.61,201.6,
ASSAY OF GENTAMICIN             ,80170,CPT,,40170664,CDM,301,RC,,,both,,,261,26.94,,,26.94,Other,150% of Medicare + 9.63% HCRA Surcharge,16.38,,,16.38,Fee Schedule,Mediare Clinical Lab,31.61,,,31.61,Fee Schedule,,28.5,,,28.5,Fee Schedule,,165.64,,,165.64,Fee Schedule,,149.03,,,149.03,Fee Schedule,,140.73,,,140.73,Fee Schedule,,130.5,50,,130.5,percent of total billed charges,All Other,34.61,,,34.61,Fee Schedule,,51.6,,,51.6,Fee Schedule,,19.73,,,19.73,Other,186% Medicaid methodology,60.77,,,60.77,Fee Schedule,,161.82,,,161.82,Fee Schedule,,34.4,,,34.4,Fee Schedule,,60.77,,,60.77,Fee Schedule,,161.82,,,161.82,Fee Schedule,,64.7,,,64.7,Fee Schedule,,182.7,70,,182.7,percent of total billed charges,All Other,78.1,,,78.1,Fee Schedule,,66.27,,,66.27,Fee Schedule,,19.66,,,19.66,Fee Schedule,,19.66,,,19.66,Fee Schedule,,19.66,,,19.66,Fee Schedule,,19.66,,,19.66,Fee Schedule,,10.61,,,10.61,Fee Schedule,Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.23,,,16.23,Fee Schedule,153% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.85,,,14.85,Fee Schedule,140% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.57,,,27.57,Fee Schedule,260% Medicaid Laboratory Fee Schedule,34.36,,,34.36,Fee Schedule,324% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.26,,,13.26,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.61,182.7,
ASSAY OF GENTAMICIN             ,80170,CPT,,40170680,CDM,301,RC,,,both,,,261,26.94,,,26.94,Other,150% of Medicare + 9.63% HCRA Surcharge,16.38,,,16.38,Fee Schedule,Mediare Clinical Lab,31.61,,,31.61,Fee Schedule,,28.5,,,28.5,Fee Schedule,,165.64,,,165.64,Fee Schedule,,149.03,,,149.03,Fee Schedule,,140.73,,,140.73,Fee Schedule,,130.5,50,,130.5,percent of total billed charges,All Other,34.61,,,34.61,Fee Schedule,,51.6,,,51.6,Fee Schedule,,19.73,,,19.73,Other,186% Medicaid methodology,60.77,,,60.77,Fee Schedule,,161.82,,,161.82,Fee Schedule,,34.4,,,34.4,Fee Schedule,,60.77,,,60.77,Fee Schedule,,161.82,,,161.82,Fee Schedule,,64.7,,,64.7,Fee Schedule,,182.7,70,,182.7,percent of total billed charges,All Other,78.1,,,78.1,Fee Schedule,,66.27,,,66.27,Fee Schedule,,19.66,,,19.66,Fee Schedule,,19.66,,,19.66,Fee Schedule,,19.66,,,19.66,Fee Schedule,,19.66,,,19.66,Fee Schedule,,10.61,,,10.61,Fee Schedule,Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.23,,,16.23,Fee Schedule,153% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.85,,,14.85,Fee Schedule,140% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.57,,,27.57,Fee Schedule,260% Medicaid Laboratory Fee Schedule,34.36,,,34.36,Fee Schedule,324% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.26,,,13.26,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.61,182.7,
ASSAY OF VANCOMYCIN             ,80202,CPT,,40170763,CDM,301,RC,,,both,,,216,22.27,,,22.27,Other,150% of Medicare + 9.63% HCRA Surcharge,13.54,,,13.54,Fee Schedule,Mediare Clinical Lab,26.13,,,26.13,Fee Schedule,,23.56,,,23.56,Fee Schedule,,136.85,,,136.85,Fee Schedule,,123.13,,,123.13,Fee Schedule,,116.27,,,116.27,Fee Schedule,,108,50,,108,percent of total billed charges,All Other,28.6,,,28.6,Fee Schedule,,42.65,,,42.65,Fee Schedule,,19.73,,,19.73,Other,186% Medicaid methodology,50.23,,,50.23,Fee Schedule,,133.92,,,133.92,Fee Schedule,,28.43,,,28.43,Fee Schedule,,50.23,,,50.23,Fee Schedule,,133.92,,,133.92,Fee Schedule,,53.48,,,53.48,Fee Schedule,,151.2,70,,151.2,percent of total billed charges,All Other,64.56,,,64.56,Fee Schedule,,54.78,,,54.78,Fee Schedule,,16.25,,,16.25,Fee Schedule,,16.25,,,16.25,Fee Schedule,,16.25,,,16.25,Fee Schedule,,16.25,,,16.25,Fee Schedule,,10.61,,,10.61,Fee Schedule,Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.23,,,16.23,Fee Schedule,153% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.85,,,14.85,Fee Schedule,140% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.57,,,27.57,Fee Schedule,260% Medicaid Laboratory Fee Schedule,34.36,,,34.36,Fee Schedule,324% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.26,,,13.26,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.61,151.2,
ASSAY OF VANCOMYCIN             ,80202,CPT,,40170789,CDM,301,RC,,,both,,,216,22.27,,,22.27,Other,150% of Medicare + 9.63% HCRA Surcharge,13.54,,,13.54,Fee Schedule,Mediare Clinical Lab,26.13,,,26.13,Fee Schedule,,23.56,,,23.56,Fee Schedule,,136.85,,,136.85,Fee Schedule,,123.13,,,123.13,Fee Schedule,,116.27,,,116.27,Fee Schedule,,108,50,,108,percent of total billed charges,All Other,28.6,,,28.6,Fee Schedule,,42.65,,,42.65,Fee Schedule,,19.73,,,19.73,Other,186% Medicaid methodology,50.23,,,50.23,Fee Schedule,,133.92,,,133.92,Fee Schedule,,28.43,,,28.43,Fee Schedule,,50.23,,,50.23,Fee Schedule,,133.92,,,133.92,Fee Schedule,,53.48,,,53.48,Fee Schedule,,151.2,70,,151.2,percent of total billed charges,All Other,64.56,,,64.56,Fee Schedule,,54.78,,,54.78,Fee Schedule,,16.25,,,16.25,Fee Schedule,,16.25,,,16.25,Fee Schedule,,16.25,,,16.25,Fee Schedule,,16.25,,,16.25,Fee Schedule,,10.61,,,10.61,Fee Schedule,Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.23,,,16.23,Fee Schedule,153% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.85,,,14.85,Fee Schedule,140% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.57,,,27.57,Fee Schedule,260% Medicaid Laboratory Fee Schedule,34.36,,,34.36,Fee Schedule,324% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.26,,,13.26,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.61,151.2,
ASSAY OF VANCOMYCIN             ,80202,CPT,,40170821,CDM,301,RC,,,both,,,216,22.27,,,22.27,Other,150% of Medicare + 9.63% HCRA Surcharge,13.54,,,13.54,Fee Schedule,Mediare Clinical Lab,26.13,,,26.13,Fee Schedule,,23.56,,,23.56,Fee Schedule,,136.85,,,136.85,Fee Schedule,,123.13,,,123.13,Fee Schedule,,116.27,,,116.27,Fee Schedule,,108,50,,108,percent of total billed charges,All Other,28.6,,,28.6,Fee Schedule,,42.65,,,42.65,Fee Schedule,,19.73,,,19.73,Other,186% Medicaid methodology,50.23,,,50.23,Fee Schedule,,133.92,,,133.92,Fee Schedule,,28.43,,,28.43,Fee Schedule,,50.23,,,50.23,Fee Schedule,,133.92,,,133.92,Fee Schedule,,53.48,,,53.48,Fee Schedule,,151.2,70,,151.2,percent of total billed charges,All Other,64.56,,,64.56,Fee Schedule,,54.78,,,54.78,Fee Schedule,,16.25,,,16.25,Fee Schedule,,16.25,,,16.25,Fee Schedule,,16.25,,,16.25,Fee Schedule,,16.25,,,16.25,Fee Schedule,,10.61,,,10.61,Fee Schedule,Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.23,,,16.23,Fee Schedule,153% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.85,,,14.85,Fee Schedule,140% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.57,,,27.57,Fee Schedule,260% Medicaid Laboratory Fee Schedule,34.36,,,34.36,Fee Schedule,324% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.26,,,13.26,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.61,151.2,
ASSAY OF PREGNENOLONE           ,84140,CPT,,40171480,CDM,301,RC,,,both,,,329,33.99,,,33.99,Other,150% of Medicare + 9.63% HCRA Surcharge,20.67,,,20.67,Fee Schedule,Mediare Clinical Lab,39.89,,,39.89,Fee Schedule,,35.97,,,35.97,Fee Schedule,,208.94,,,208.94,Fee Schedule,,187.99,,,187.99,Fee Schedule,,177.51,,,177.51,Fee Schedule,,164.5,50,,164.5,percent of total billed charges,All Other,43.68,,,43.68,Fee Schedule,,65.11,,,65.11,Fee Schedule,,38.45,,,38.45,Other,186% Medicaid methodology,76.69,,,76.69,Fee Schedule,,203.98,,,203.98,Fee Schedule,,43.41,,,43.41,Fee Schedule,,76.69,,,76.69,Fee Schedule,,203.98,,,203.98,Fee Schedule,,81.65,,,81.65,Fee Schedule,,230.3,70,,230.3,percent of total billed charges,All Other,98.55,,,98.55,Fee Schedule,,83.62,,,83.62,Fee Schedule,,24.8,,,24.8,Fee Schedule,,24.8,,,24.8,Fee Schedule,,24.8,,,24.8,Fee Schedule,,24.8,,,24.8,Fee Schedule,,20.67,,,20.67,Fee Schedule,Medicaid Laboratory Fee Schedule,20.67,,,20.67,Fee Schedule,100% Medicaid Laboratory Fee Schedule,20.67,,,20.67,Fee Schedule,100% Medicaid Laboratory Fee Schedule,20.67,,,20.67,Fee Schedule,100% Medicaid Laboratory Fee Schedule,46.51,,,46.51,Fee Schedule,225% Medicaid Laboratory Fee Schedule,46.51,,,46.51,Fee Schedule,225% Medicaid Laboratory Fee Schedule,31.63,,,31.63,Fee Schedule,153% Medicaid Laboratory Fee Schedule,46.51,,,46.51,Fee Schedule,225% Medicaid Laboratory Fee Schedule,28.94,,,28.94,Fee Schedule,140% Medicaid Laboratory Fee Schedule,46.51,,,46.51,Fee Schedule,225% Medicaid Laboratory Fee Schedule,53.74,,,53.74,Fee Schedule,260% Medicaid Laboratory Fee Schedule,66.97,,,66.97,Fee Schedule,324% Medicaid Laboratory Fee Schedule,44.44,,,44.44,Fee Schedule,215% Medicaid Laboratory Fee Schedule,44.44,,,44.44,Fee Schedule,215% Medicaid Laboratory Fee Schedule,25.84,,,25.84,Fee Schedule,125% Medicaid Laboratory Fee Schedule,20.67,230.3,
ASSAY OF TACROLIMUS             ,80197,CPT,,40171688,CDM,301,RC,,,both,,,219,22.58,,,22.58,Other,150% of Medicare + 9.63% HCRA Surcharge,13.73,,,13.73,Fee Schedule,Mediare Clinical Lab,26.5,,,26.5,Fee Schedule,,23.89,,,23.89,Fee Schedule,,138.72,,,138.72,Fee Schedule,,124.81,,,124.81,Fee Schedule,,117.85,,,117.85,Fee Schedule,,109.5,50,,109.5,percent of total billed charges,All Other,28.99,,,28.99,Fee Schedule,,43.25,,,43.25,Fee Schedule,,19.73,,,19.73,Other,186% Medicaid methodology,50.94,,,50.94,Fee Schedule,,135.78,,,135.78,Fee Schedule,,28.83,,,28.83,Fee Schedule,,50.94,,,50.94,Fee Schedule,,135.78,,,135.78,Fee Schedule,,54.23,,,54.23,Fee Schedule,,153.3,70,,153.3,percent of total billed charges,All Other,65.46,,,65.46,Fee Schedule,,55.54,,,55.54,Fee Schedule,,16.48,,,16.48,Fee Schedule,,16.48,,,16.48,Fee Schedule,,16.48,,,16.48,Fee Schedule,,16.48,,,16.48,Fee Schedule,,10.61,,,10.61,Fee Schedule,Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.23,,,16.23,Fee Schedule,153% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.85,,,14.85,Fee Schedule,140% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.57,,,27.57,Fee Schedule,260% Medicaid Laboratory Fee Schedule,34.36,,,34.36,Fee Schedule,324% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.26,,,13.26,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.61,153.3,
ASSAY OF SIROLIMUS              ,80195,CPT,,40171720,CDM,301,RC,,,both,,,219,22.58,,,22.58,Other,150% of Medicare + 9.63% HCRA Surcharge,13.73,,,13.73,Fee Schedule,Mediare Clinical Lab,26.5,,,26.5,Fee Schedule,,23.89,,,23.89,Fee Schedule,,138.72,,,138.72,Fee Schedule,,124.81,,,124.81,Fee Schedule,,117.85,,,117.85,Fee Schedule,,109.5,50,,109.5,percent of total billed charges,All Other,28.99,,,28.99,Fee Schedule,,43.25,,,43.25,Fee Schedule,,19.73,,,19.73,Other,186% Medicaid methodology,50.94,,,50.94,Fee Schedule,,135.78,,,135.78,Fee Schedule,,28.83,,,28.83,Fee Schedule,,50.94,,,50.94,Fee Schedule,,135.78,,,135.78,Fee Schedule,,54.23,,,54.23,Fee Schedule,,153.3,70,,153.3,percent of total billed charges,All Other,65.46,,,65.46,Fee Schedule,,55.54,,,55.54,Fee Schedule,,16.48,,,16.48,Fee Schedule,,16.48,,,16.48,Fee Schedule,,16.48,,,16.48,Fee Schedule,,16.48,,,16.48,Fee Schedule,,10.61,,,10.61,Fee Schedule,Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.23,,,16.23,Fee Schedule,153% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.85,,,14.85,Fee Schedule,140% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.57,,,27.57,Fee Schedule,260% Medicaid Laboratory Fee Schedule,34.36,,,34.36,Fee Schedule,324% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.26,,,13.26,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.61,153.3,
DRUG SCRN QUANT OXCARBAZEPIN    ,80183,CPT,,40171761,CDM,301,RC,,,both,,,211,21.79,,,21.79,Other,150% of Medicare + 9.63% HCRA Surcharge,13.25,,,13.25,Fee Schedule,Mediare Clinical Lab,25.57,,,25.57,Fee Schedule,,23.06,,,23.06,Fee Schedule,,7.24,,,7.24,Fee Schedule,,7.24,,,7.24,Fee Schedule,,7.24,,,7.24,Fee Schedule,,105.5,50,,105.5,percent of total billed charges,All Other,27.98,,,27.98,Fee Schedule,,41.74,,,41.74,Fee Schedule,,19.73,,,19.73,Other,186% Medicaid methodology,49.16,,,49.16,Fee Schedule,,130.82,,,130.82,Fee Schedule,,27.83,,,27.83,Fee Schedule,,49.16,,,49.16,Fee Schedule,,130.82,,,130.82,Fee Schedule,,52.34,,,52.34,Fee Schedule,,147.7,70,,147.7,percent of total billed charges,All Other,63.18,,,63.18,Fee Schedule,,53.6,,,53.6,Fee Schedule,,15.9,,,15.9,Fee Schedule,,15.9,,,15.9,Fee Schedule,,15.9,,,15.9,Fee Schedule,,15.9,,,15.9,Fee Schedule,,10.61,,,10.61,Fee Schedule,Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.23,,,16.23,Fee Schedule,153% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.85,,,14.85,Fee Schedule,140% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.57,,,27.57,Fee Schedule,260% Medicaid Laboratory Fee Schedule,34.36,,,34.36,Fee Schedule,324% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.26,,,13.26,Fee Schedule,125% Medicaid Laboratory Fee Schedule,7.24,147.7,
ASSAY OF TOPIRAMATE             ,80201,CPT,,40171829,CDM,301,RC,,,both,,,190,19.6,,,19.6,Other,150% of Medicare + 9.63% HCRA Surcharge,11.92,,,11.92,Fee Schedule,Mediare Clinical Lab,23.01,,,23.01,Fee Schedule,,20.74,,,20.74,Fee Schedule,,120.48,,,120.48,Fee Schedule,,108.4,,,108.4,Fee Schedule,,102.36,,,102.36,Fee Schedule,,95,50,,95,percent of total billed charges,All Other,25.19,,,25.19,Fee Schedule,,37.55,,,37.55,Fee Schedule,,79.59,,,79.59,Other,186% Medicaid methodology,44.22,,,44.22,Fee Schedule,,117.8,,,117.8,Fee Schedule,,25.03,,,25.03,Fee Schedule,,44.22,,,44.22,Fee Schedule,,117.8,,,117.8,Fee Schedule,,47.08,,,47.08,Fee Schedule,,133,70,,133,percent of total billed charges,All Other,56.83,,,56.83,Fee Schedule,,48.22,,,48.22,Fee Schedule,,14.3,,,14.3,Fee Schedule,,14.3,,,14.3,Fee Schedule,,14.3,,,14.3,Fee Schedule,,14.3,,,14.3,Fee Schedule,,42.79,,,42.79,Other,New York Medicaid APG methodology,42.79,,,42.79,Other,100% Medicaid APG methodology,42.79,,,42.79,Other,100% Medicaid APG methodology,42.79,,,42.79,Other,100% Medicaid APG methodology,96.28,,,96.28,Other,225% Medicaid APG methodology,96.28,,,96.28,Other,225% Medicaid APG methodology,65.47,,,65.47,Other,153% Medicaid APG methodology,96.28,,,96.28,Other,225% Medicaid APG methodology,59.91,,,59.91,Other,140% Medicaid APG methodology,96.28,,,96.28,Other,225% Medicaid APG methodology,111.26,,,111.26,Other,260% Medicaid APG methodology,138.64,,,138.64,Other,324% Medicaid APG methodology,92,,,92,Other,215% Medicaid APG methodology,92,,,92,Other,215% Medicaid APG methodology,53.49,,,53.49,Other,125% Medicaid APG methodology,11.92,138.64,
DRUG TEST PRSMV CHEM ANLYZR     ,80307,CPT,,40172165,CDM,301,RC,,,both,,,988,102.19,,,102.19,Other,150% of Medicare + 9.63% HCRA Surcharge,62.14,,,62.14,Fee Schedule,Mediare Clinical Lab,119.93,,,119.93,Fee Schedule,,108.12,,,108.12,Fee Schedule,,31.92,,,31.92,Fee Schedule,,31.92,,,31.92,Fee Schedule,,31.92,,,31.92,Fee Schedule,,494,50,,494,percent of total billed charges,All Other,131.27,,,131.27,Fee Schedule,,195.74,,,195.74,Fee Schedule,,14.09,,,14.09,Other,186% Medicaid methodology,230.54,,,230.54,Fee Schedule,,612.56,,,612.56,Fee Schedule,,130.49,,,130.49,Fee Schedule,,230.54,,,230.54,Fee Schedule,,612.56,,,612.56,Fee Schedule,,245.45,,,245.45,Fee Schedule,,691.6,70,,691.6,percent of total billed charges,All Other,296.28,,,296.28,Fee Schedule,,251.39,,,251.39,Fee Schedule,,74.57,,,74.57,Fee Schedule,,74.57,,,74.57,Fee Schedule,,74.57,,,74.57,Fee Schedule,,74.57,,,74.57,Fee Schedule,,7.58,,,7.58,Fee Schedule,Medicaid Laboratory Fee Schedule,7.58,,,7.58,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.58,,,7.58,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.58,,,7.58,Fee Schedule,100% Medicaid Laboratory Fee Schedule,17.04,,,17.04,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.04,,,17.04,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.59,,,11.59,Fee Schedule,153% Medicaid Laboratory Fee Schedule,17.04,,,17.04,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,140% Medicaid Laboratory Fee Schedule,17.04,,,17.04,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.7,,,19.7,Fee Schedule,260% Medicaid Laboratory Fee Schedule,24.54,,,24.54,Fee Schedule,324% Medicaid Laboratory Fee Schedule,16.29,,,16.29,Fee Schedule,215% Medicaid Laboratory Fee Schedule,16.29,,,16.29,Fee Schedule,215% Medicaid Laboratory Fee Schedule,9.47,,,9.47,Fee Schedule,125% Medicaid Laboratory Fee Schedule,7.58,691.6,
DRUG ASSAY CLOZAPINE            ,80159,CPT,,40172348,CDM,301,RC,,,both,,,321,33.14,,,33.14,Other,150% of Medicare + 9.63% HCRA Surcharge,20.15,,,20.15,Fee Schedule,Mediare Clinical Lab,38.89,,,38.89,Fee Schedule,,35.06,,,35.06,Fee Schedule,,10.09,,,10.09,Fee Schedule,,10.09,,,10.09,Fee Schedule,,10.09,,,10.09,Fee Schedule,,160.5,50,,160.5,percent of total billed charges,All Other,42.58,,,42.58,Fee Schedule,,63.47,,,63.47,Fee Schedule,,19.73,,,19.73,Other,186% Medicaid methodology,74.76,,,74.76,Fee Schedule,,199.02,,,199.02,Fee Schedule,,42.32,,,42.32,Fee Schedule,,74.76,,,74.76,Fee Schedule,,199.02,,,199.02,Fee Schedule,,79.59,,,79.59,Fee Schedule,,224.7,70,,224.7,percent of total billed charges,All Other,96.07,,,96.07,Fee Schedule,,81.52,,,81.52,Fee Schedule,,24.18,,,24.18,Fee Schedule,,24.18,,,24.18,Fee Schedule,,24.18,,,24.18,Fee Schedule,,24.18,,,24.18,Fee Schedule,,10.61,,,10.61,Fee Schedule,Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.23,,,16.23,Fee Schedule,153% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.85,,,14.85,Fee Schedule,140% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.57,,,27.57,Fee Schedule,260% Medicaid Laboratory Fee Schedule,34.36,,,34.36,Fee Schedule,324% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.26,,,13.26,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.09,224.7,
DRUG ASSAY INFLIXIMAB           ,80230,CPT,,40173023,CDM,301,RC,,,both,,,614,63.43,,,63.43,Other,150% of Medicare + 9.63% HCRA Surcharge,38.57,,,38.57,Fee Schedule,Mediare Clinical Lab,74.44,,,74.44,Fee Schedule,,67.11,,,67.11,Fee Schedule,,7.39,,,7.39,Fee Schedule,,7.39,,,7.39,Fee Schedule,,7.39,,,7.39,Fee Schedule,,307,50,,307,percent of total billed charges,All Other,81.48,,,81.48,Fee Schedule,,121.5,,,121.5,Fee Schedule,,19.73,,,19.73,Other,186% Medicaid methodology,143.09,,,143.09,Fee Schedule,,380.68,,,380.68,Fee Schedule,,81,,,81,Fee Schedule,,143.09,,,143.09,Fee Schedule,,380.68,,,380.68,Fee Schedule,,152.35,,,152.35,Fee Schedule,,429.8,70,,429.8,percent of total billed charges,All Other,183.9,,,183.9,Fee Schedule,,156.04,,,156.04,Fee Schedule,,46.28,,,46.28,Fee Schedule,,46.28,,,46.28,Fee Schedule,,46.28,,,46.28,Fee Schedule,,46.28,,,46.28,Fee Schedule,,10.61,,,10.61,Fee Schedule,Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.23,,,16.23,Fee Schedule,153% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.85,,,14.85,Fee Schedule,140% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.57,,,27.57,Fee Schedule,260% Medicaid Laboratory Fee Schedule,34.36,,,34.36,Fee Schedule,324% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.26,,,13.26,Fee Schedule,125% Medicaid Laboratory Fee Schedule,7.39,429.8,
DRUG ASSAY LACOSAMIDE           ,80235,CPT,,40173049,CDM,301,RC,,,both,,,432,44.58,,,44.58,Other,150% of Medicare + 9.63% HCRA Surcharge,27.11,,,27.11,Fee Schedule,Mediare Clinical Lab,52.32,,,52.32,Fee Schedule,,47.17,,,47.17,Fee Schedule,,21.69,,,21.69,Fee Schedule,,21.69,,,21.69,Fee Schedule,,21.69,,,21.69,Fee Schedule,,216,50,,216,percent of total billed charges,All Other,57.27,,,57.27,Fee Schedule,,85.4,,,85.4,Fee Schedule,,19.73,,,19.73,Other,186% Medicaid methodology,100.58,,,100.58,Fee Schedule,,267.84,,,267.84,Fee Schedule,,56.93,,,56.93,Fee Schedule,,100.58,,,100.58,Fee Schedule,,267.84,,,267.84,Fee Schedule,,107.08,,,107.08,Fee Schedule,,302.4,70,,302.4,percent of total billed charges,All Other,129.26,,,129.26,Fee Schedule,,109.67,,,109.67,Fee Schedule,,32.53,,,32.53,Fee Schedule,,32.53,,,32.53,Fee Schedule,,32.53,,,32.53,Fee Schedule,,32.53,,,32.53,Fee Schedule,,10.61,,,10.61,Fee Schedule,Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.23,,,16.23,Fee Schedule,153% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.85,,,14.85,Fee Schedule,140% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.57,,,27.57,Fee Schedule,260% Medicaid Laboratory Fee Schedule,34.36,,,34.36,Fee Schedule,324% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.26,,,13.26,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.61,302.4,
DRUG ASSAY ACETAMINOPHEN        ,80143,CPT,,40173106,CDM,301,RC,,,both,,,60,30.65,,,30.65,Other,150% of Medicare + 9.63% HCRA Surcharge,18.64,,,18.64,Fee Schedule,Mediare Clinical Lab,35.98,,,35.98,Fee Schedule,,32.43,,,32.43,Fee Schedule,,14.91,,,14.91,Fee Schedule,,14.91,,,14.91,Fee Schedule,,14.91,,,14.91,Fee Schedule,,30,50,,30,percent of total billed charges,All Other,39.39,,,39.39,Fee Schedule,,58.72,,,58.72,Fee Schedule,,79.59,,,79.59,Other,186% Medicaid methodology,69.15,,,69.15,Fee Schedule,,37.2,,,37.2,Fee Schedule,,39.14,,,39.14,Fee Schedule,,69.15,,,69.15,Fee Schedule,,37.2,,,37.2,Fee Schedule,,73.63,,,73.63,Fee Schedule,,42,70,,42,percent of total billed charges,All Other,88.87,,,88.87,Fee Schedule,,75.41,,,75.41,Fee Schedule,,22.37,,,22.37,Fee Schedule,,22.37,,,22.37,Fee Schedule,,22.37,,,22.37,Fee Schedule,,22.37,,,22.37,Fee Schedule,,42.79,,,42.79,Other,New York Medicaid APG methodology,42.79,,,42.79,Other,100% Medicaid APG methodology,42.79,,,42.79,Other,100% Medicaid APG methodology,42.79,,,42.79,Other,100% Medicaid APG methodology,96.28,,,96.28,Other,225% Medicaid APG methodology,96.28,,,96.28,Other,225% Medicaid APG methodology,65.47,,,65.47,Other,153% Medicaid APG methodology,96.28,,,96.28,Other,225% Medicaid APG methodology,59.91,,,59.91,Other,140% Medicaid APG methodology,96.28,,,96.28,Other,225% Medicaid APG methodology,111.26,,,111.26,Other,260% Medicaid APG methodology,138.64,,,138.64,Other,324% Medicaid APG methodology,92,,,92,Other,215% Medicaid APG methodology,92,,,92,Other,215% Medicaid APG methodology,53.49,,,53.49,Other,125% Medicaid APG methodology,14.91,138.64,
ASSAY OF CRYOGLOBULIN           ,82595,CPT,,40180226,CDM,301,RC,,,both,,,103,10.64,,,10.64,Other,150% of Medicare + 9.63% HCRA Surcharge,6.47,,,6.47,Fee Schedule,Mediare Clinical Lab,12.49,,,12.49,Fee Schedule,,11.26,,,11.26,Fee Schedule,,65.41,,,65.41,Fee Schedule,,58.85,,,58.85,Fee Schedule,,55.57,,,55.57,Fee Schedule,,51.5,50,,51.5,percent of total billed charges,All Other,13.68,,,13.68,Fee Schedule,,20.38,,,20.38,Fee Schedule,,10.29,,,10.29,Other,186% Medicaid methodology,24,,,24,Fee Schedule,,63.86,,,63.86,Fee Schedule,,13.59,,,13.59,Fee Schedule,,24,,,24,Fee Schedule,,63.86,,,63.86,Fee Schedule,,25.56,,,25.56,Fee Schedule,,72.1,70,,72.1,percent of total billed charges,All Other,30.85,,,30.85,Fee Schedule,,26.17,,,26.17,Fee Schedule,,7.76,,,7.76,Fee Schedule,,7.76,,,7.76,Fee Schedule,,7.76,,,7.76,Fee Schedule,,7.76,,,7.76,Fee Schedule,,5.53,,,5.53,Fee Schedule,Medicaid Laboratory Fee Schedule,5.53,,,5.53,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.53,,,5.53,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.53,,,5.53,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.45,,,12.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.45,,,12.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.47,,,8.47,Fee Schedule,153% Medicaid Laboratory Fee Schedule,12.45,,,12.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.75,,,7.75,Fee Schedule,140% Medicaid Laboratory Fee Schedule,12.45,,,12.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.39,,,14.39,Fee Schedule,260% Medicaid Laboratory Fee Schedule,17.93,,,17.93,Fee Schedule,324% Medicaid Laboratory Fee Schedule,11.9,,,11.9,Fee Schedule,215% Medicaid Laboratory Fee Schedule,11.9,,,11.9,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.92,,,6.92,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.53,72.1,
ALPHA-1-ANTITRYPSIN PHENO       ,82104,CPT,,40181026,CDM,301,RC,,,both,,,231,23.78,,,23.78,Other,150% of Medicare + 9.63% HCRA Surcharge,14.46,,,14.46,Fee Schedule,Mediare Clinical Lab,27.91,,,27.91,Fee Schedule,,25.16,,,25.16,Fee Schedule,,146.11,,,146.11,Fee Schedule,,131.46,,,131.46,Fee Schedule,,124.14,,,124.14,Fee Schedule,,115.5,50,,115.5,percent of total billed charges,All Other,30.55,,,30.55,Fee Schedule,,45.55,,,45.55,Fee Schedule,,25.77,,,25.77,Other,186% Medicaid methodology,53.65,,,53.65,Fee Schedule,,143.22,,,143.22,Fee Schedule,,30.37,,,30.37,Fee Schedule,,53.65,,,53.65,Fee Schedule,,143.22,,,143.22,Fee Schedule,,57.12,,,57.12,Fee Schedule,,161.7,70,,161.7,percent of total billed charges,All Other,68.94,,,68.94,Fee Schedule,,58.5,,,58.5,Fee Schedule,,17.35,,,17.35,Fee Schedule,,17.35,,,17.35,Fee Schedule,,17.35,,,17.35,Fee Schedule,,17.35,,,17.35,Fee Schedule,,13.86,,,13.86,Fee Schedule,Medicaid Laboratory Fee Schedule,13.86,,,13.86,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.86,,,13.86,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.86,,,13.86,Fee Schedule,100% Medicaid Laboratory Fee Schedule,31.18,,,31.18,Fee Schedule,225% Medicaid Laboratory Fee Schedule,31.18,,,31.18,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.2,,,21.2,Fee Schedule,153% Medicaid Laboratory Fee Schedule,31.18,,,31.18,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.4,,,19.4,Fee Schedule,140% Medicaid Laboratory Fee Schedule,31.18,,,31.18,Fee Schedule,225% Medicaid Laboratory Fee Schedule,36.03,,,36.03,Fee Schedule,260% Medicaid Laboratory Fee Schedule,44.9,,,44.9,Fee Schedule,324% Medicaid Laboratory Fee Schedule,29.79,,,29.79,Fee Schedule,215% Medicaid Laboratory Fee Schedule,29.79,,,29.79,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.32,,,17.32,Fee Schedule,125% Medicaid Laboratory Fee Schedule,13.86,161.7,
ASSAY OF LIPOPROTEIN(A)         ,83695,CPT,,40181448,CDM,301,RC,,,both,,,228,23.55,,,23.55,Other,150% of Medicare + 9.63% HCRA Surcharge,14.32,,,14.32,Fee Schedule,Mediare Clinical Lab,27.64,,,27.64,Fee Schedule,,24.92,,,24.92,Fee Schedule,,130.82,,,130.82,Fee Schedule,,117.7,,,117.7,Fee Schedule,,111.14,,,111.14,Fee Schedule,,114,50,,114,percent of total billed charges,All Other,30.26,,,30.26,Fee Schedule,,45.11,,,45.11,Fee Schedule,,65.35,,,65.35,Other,186% Medicaid methodology,53.13,,,53.13,Fee Schedule,,141.36,,,141.36,Fee Schedule,,30.07,,,30.07,Fee Schedule,,53.13,,,53.13,Fee Schedule,,141.36,,,141.36,Fee Schedule,,56.56,,,56.56,Fee Schedule,,159.6,70,,159.6,percent of total billed charges,All Other,68.28,,,68.28,Fee Schedule,,57.93,,,57.93,Fee Schedule,,17.18,,,17.18,Fee Schedule,,17.18,,,17.18,Fee Schedule,,17.18,,,17.18,Fee Schedule,,17.18,,,17.18,Fee Schedule,,35.13,,,35.13,Other,New York Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,53.75,,,53.75,Other,153% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,49.19,,,49.19,Other,140% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,91.35,,,91.35,Other,260% Medicaid APG methodology,113.83,,,113.83,Other,324% Medicaid APG methodology,75.54,,,75.54,Other,215% Medicaid APG methodology,75.54,,,75.54,Other,215% Medicaid APG methodology,43.92,,,43.92,Other,125% Medicaid APG methodology,14.32,159.6,
IMMUNOASSAY NONANTIBODY         ,83516,CPT,,40181844,CDM,301,RC,,,both,,,184,18.96,,,18.96,Other,150% of Medicare + 9.63% HCRA Surcharge,11.53,,,11.53,Fee Schedule,Mediare Clinical Lab,22.25,,,22.25,Fee Schedule,,20.06,,,20.06,Fee Schedule,,88.39,,,88.39,Fee Schedule,,79.52,,,79.52,Fee Schedule,,75.09,,,75.09,Fee Schedule,,92,50,,92,percent of total billed charges,All Other,24.34,,,24.34,Fee Schedule,,36.32,,,36.32,Fee Schedule,,65.35,,,65.35,Other,186% Medicaid methodology,42.78,,,42.78,Fee Schedule,,114.08,,,114.08,Fee Schedule,,24.21,,,24.21,Fee Schedule,,42.78,,,42.78,Fee Schedule,,114.08,,,114.08,Fee Schedule,,45.54,,,45.54,Fee Schedule,,128.8,70,,128.8,percent of total billed charges,All Other,54.97,,,54.97,Fee Schedule,,46.64,,,46.64,Fee Schedule,,13.84,,,13.84,Fee Schedule,,13.84,,,13.84,Fee Schedule,,13.84,,,13.84,Fee Schedule,,13.84,,,13.84,Fee Schedule,,35.13,,,35.13,Other,New York Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,35.13,,,35.13,Other,100% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,53.75,,,53.75,Other,153% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,49.19,,,49.19,Other,140% Medicaid APG methodology,79.05,,,79.05,Other,225% Medicaid APG methodology,91.35,,,91.35,Other,260% Medicaid APG methodology,113.83,,,113.83,Other,324% Medicaid APG methodology,75.54,,,75.54,Other,215% Medicaid APG methodology,75.54,,,75.54,Other,215% Medicaid APG methodology,43.92,,,43.92,Other,125% Medicaid APG methodology,11.53,128.8,
ASSAY OF PARATHORMONE           ,83970,CPT,,40182222,CDM,301,RC,,,both,,,657,67.88,,,67.88,Other,150% of Medicare + 9.63% HCRA Surcharge,41.28,,,41.28,Fee Schedule,Mediare Clinical Lab,79.67,,,79.67,Fee Schedule,,71.83,,,71.83,Fee Schedule,,417.01,,,417.01,Fee Schedule,,375.2,,,375.2,Fee Schedule,,354.29,,,354.29,Fee Schedule,,328.5,50,,328.5,percent of total billed charges,All Other,87.2,,,87.2,Fee Schedule,,130.03,,,130.03,Fee Schedule,,76.78,,,76.78,Other,186% Medicaid methodology,153.15,,,153.15,Fee Schedule,,407.34,,,407.34,Fee Schedule,,86.69,,,86.69,Fee Schedule,,153.15,,,153.15,Fee Schedule,,407.34,,,407.34,Fee Schedule,,163.06,,,163.06,Fee Schedule,,459.9,70,,459.9,percent of total billed charges,All Other,196.82,,,196.82,Fee Schedule,,167,,,167,Fee Schedule,,49.54,,,49.54,Fee Schedule,,49.54,,,49.54,Fee Schedule,,49.54,,,49.54,Fee Schedule,,49.54,,,49.54,Fee Schedule,,41.28,,,41.28,Fee Schedule,Medicaid Laboratory Fee Schedule,41.28,,,41.28,Fee Schedule,100% Medicaid Laboratory Fee Schedule,41.28,,,41.28,Fee Schedule,100% Medicaid Laboratory Fee Schedule,41.28,,,41.28,Fee Schedule,100% Medicaid Laboratory Fee Schedule,92.88,,,92.88,Fee Schedule,225% Medicaid Laboratory Fee Schedule,92.88,,,92.88,Fee Schedule,225% Medicaid Laboratory Fee Schedule,63.16,,,63.16,Fee Schedule,153% Medicaid Laboratory Fee Schedule,92.88,,,92.88,Fee Schedule,225% Medicaid Laboratory Fee Schedule,57.79,,,57.79,Fee Schedule,140% Medicaid Laboratory Fee Schedule,92.88,,,92.88,Fee Schedule,225% Medicaid Laboratory Fee Schedule,107.33,,,107.33,Fee Schedule,260% Medicaid Laboratory Fee Schedule,133.75,,,133.75,Fee Schedule,324% Medicaid Laboratory Fee Schedule,88.75,,,88.75,Fee Schedule,215% Medicaid Laboratory Fee Schedule,88.75,,,88.75,Fee Schedule,215% Medicaid Laboratory Fee Schedule,51.6,,,51.6,Fee Schedule,125% Medicaid Laboratory Fee Schedule,41.28,459.9,
81218 CEBPA,81218,CPT,,40187007,CDM,301,RC,,,both,,,500,397.79,,,397.79,Other,150% of Medicare + 9.63% HCRA Surcharge,241.9,,,241.9,Fee Schedule,Mediare Clinical Lab,466.87,,,466.87,Fee Schedule,,420.91,,,420.91,Fee Schedule,,131.8,,,131.8,Fee Schedule,,131.8,,,131.8,Fee Schedule,,131.8,,,131.8,Fee Schedule,,250,50,,250,percent of total billed charges,All Other,511.03,,,511.03,Fee Schedule,,761.99,,,761.99,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,897.45,,,897.45,Fee Schedule,,310,,,310,Fee Schedule,,507.99,,,507.99,Fee Schedule,,897.45,,,897.45,Fee Schedule,,310,,,310,Fee Schedule,,955.51,,,955.51,Fee Schedule,,350,70,,350,percent of total billed charges,All Other,1153.36,,,1153.36,Fee Schedule,,978.61,,,978.61,Fee Schedule,,290.28,,,290.28,Fee Schedule,,290.28,,,290.28,Fee Schedule,,290.28,,,290.28,Fee Schedule,,290.28,,,290.28,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1153.36,
81272 KIT,81272,CPT,,40187387,CDM,301,RC,,,both,,,500,541.86,,,541.86,Other,150% of Medicare + 9.63% HCRA Surcharge,329.51,,,329.51,Fee Schedule,Mediare Clinical Lab,635.95,,,635.95,Fee Schedule,,573.35,,,573.35,Fee Schedule,,131.8,,,131.8,Fee Schedule,,131.8,,,131.8,Fee Schedule,,131.8,,,131.8,Fee Schedule,,250,50,,250,percent of total billed charges,All Other,696.09,,,696.09,Fee Schedule,,1037.96,,,1037.96,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,1222.48,,,1222.48,Fee Schedule,,310,,,310,Fee Schedule,,691.97,,,691.97,Fee Schedule,,1222.48,,,1222.48,Fee Schedule,,310,,,310,Fee Schedule,,1301.56,,,1301.56,Fee Schedule,,350,70,,350,percent of total billed charges,All Other,1571.08,,,1571.08,Fee Schedule,,1333.04,,,1333.04,Fee Schedule,,395.41,,,395.41,Fee Schedule,,395.41,,,395.41,Fee Schedule,,395.41,,,395.41,Fee Schedule,,395.41,,,395.41,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1571.08,
ASSAY OF APOLIPOPROTEIN         ,82172,CPT,,40188187,CDM,301,RC,,,both,,,335,34.68,,,34.68,Other,150% of Medicare + 9.63% HCRA Surcharge,21.09,,,21.09,Fee Schedule,Mediare Clinical Lab,40.7,,,40.7,Fee Schedule,,36.7,,,36.7,Fee Schedule,,156.6,,,156.6,Fee Schedule,,140.89,,,140.89,Fee Schedule,,133.04,,,133.04,Fee Schedule,,167.5,50,,167.5,percent of total billed charges,All Other,44.56,,,44.56,Fee Schedule,,66.43,,,66.43,Fee Schedule,,29.93,,,29.93,Other,186% Medicaid methodology,78.24,,,78.24,Fee Schedule,,207.7,,,207.7,Fee Schedule,,44.29,,,44.29,Fee Schedule,,78.24,,,78.24,Fee Schedule,,207.7,,,207.7,Fee Schedule,,83.31,,,83.31,Fee Schedule,,234.5,70,,234.5,percent of total billed charges,All Other,100.56,,,100.56,Fee Schedule,,85.32,,,85.32,Fee Schedule,,25.31,,,25.31,Fee Schedule,,25.31,,,25.31,Fee Schedule,,25.31,,,25.31,Fee Schedule,,25.31,,,25.31,Fee Schedule,,16.09,,,16.09,Fee Schedule,Medicaid Laboratory Fee Schedule,16.09,,,16.09,Fee Schedule,100% Medicaid Laboratory Fee Schedule,16.09,,,16.09,Fee Schedule,100% Medicaid Laboratory Fee Schedule,16.09,,,16.09,Fee Schedule,100% Medicaid Laboratory Fee Schedule,36.2,,,36.2,Fee Schedule,225% Medicaid Laboratory Fee Schedule,36.2,,,36.2,Fee Schedule,225% Medicaid Laboratory Fee Schedule,24.62,,,24.62,Fee Schedule,153% Medicaid Laboratory Fee Schedule,36.2,,,36.2,Fee Schedule,225% Medicaid Laboratory Fee Schedule,22.53,,,22.53,Fee Schedule,140% Medicaid Laboratory Fee Schedule,36.2,,,36.2,Fee Schedule,225% Medicaid Laboratory Fee Schedule,41.83,,,41.83,Fee Schedule,260% Medicaid Laboratory Fee Schedule,52.13,,,52.13,Fee Schedule,324% Medicaid Laboratory Fee Schedule,34.59,,,34.59,Fee Schedule,215% Medicaid Laboratory Fee Schedule,34.59,,,34.59,Fee Schedule,215% Medicaid Laboratory Fee Schedule,20.11,,,20.11,Fee Schedule,125% Medicaid Laboratory Fee Schedule,16.09,234.5,
ASSAY OF ACTH                   ,82024,CPT,,40190001,CDM,301,RC,,,both,,,614,63.51,,,63.51,Other,150% of Medicare + 9.63% HCRA Surcharge,38.62,,,38.62,Fee Schedule,Mediare Clinical Lab,74.54,,,74.54,Fee Schedule,,67.2,,,67.2,Fee Schedule,,390.23,,,390.23,Fee Schedule,,351.1,,,351.1,Fee Schedule,,331.54,,,331.54,Fee Schedule,,307,50,,307,percent of total billed charges,All Other,81.58,,,81.58,Fee Schedule,,121.65,,,121.65,Fee Schedule,,71.83,,,71.83,Other,186% Medicaid methodology,143.28,,,143.28,Fee Schedule,,380.68,,,380.68,Fee Schedule,,81.1,,,81.1,Fee Schedule,,143.28,,,143.28,Fee Schedule,,380.68,,,380.68,Fee Schedule,,152.55,,,152.55,Fee Schedule,,429.8,70,,429.8,percent of total billed charges,All Other,184.14,,,184.14,Fee Schedule,,156.24,,,156.24,Fee Schedule,,46.34,,,46.34,Fee Schedule,,46.34,,,46.34,Fee Schedule,,46.34,,,46.34,Fee Schedule,,46.34,,,46.34,Fee Schedule,,38.62,,,38.62,Fee Schedule,Medicaid Laboratory Fee Schedule,38.62,,,38.62,Fee Schedule,100% Medicaid Laboratory Fee Schedule,38.62,,,38.62,Fee Schedule,100% Medicaid Laboratory Fee Schedule,38.62,,,38.62,Fee Schedule,100% Medicaid Laboratory Fee Schedule,86.9,,,86.9,Fee Schedule,225% Medicaid Laboratory Fee Schedule,86.9,,,86.9,Fee Schedule,225% Medicaid Laboratory Fee Schedule,59.09,,,59.09,Fee Schedule,153% Medicaid Laboratory Fee Schedule,86.9,,,86.9,Fee Schedule,225% Medicaid Laboratory Fee Schedule,54.07,,,54.07,Fee Schedule,140% Medicaid Laboratory Fee Schedule,86.9,,,86.9,Fee Schedule,225% Medicaid Laboratory Fee Schedule,100.41,,,100.41,Fee Schedule,260% Medicaid Laboratory Fee Schedule,125.13,,,125.13,Fee Schedule,324% Medicaid Laboratory Fee Schedule,83.03,,,83.03,Fee Schedule,215% Medicaid Laboratory Fee Schedule,83.03,,,83.03,Fee Schedule,215% Medicaid Laboratory Fee Schedule,48.28,,,48.28,Fee Schedule,125% Medicaid Laboratory Fee Schedule,38.62,429.8,
TOTAL CORTISOL                  ,82533,CPT,,40190084,CDM,301,RC,,,both,,,260,26.8,,,26.8,Other,150% of Medicare + 9.63% HCRA Surcharge,16.3,,,16.3,Fee Schedule,Mediare Clinical Lab,31.46,,,31.46,Fee Schedule,,28.36,,,28.36,Fee Schedule,,164.78,,,164.78,Fee Schedule,,148.26,,,148.26,Fee Schedule,,140,,,140,Fee Schedule,,130,50,,130,percent of total billed charges,All Other,34.45,,,34.45,Fee Schedule,,51.35,,,51.35,Fee Schedule,,30.32,,,30.32,Other,186% Medicaid methodology,60.47,,,60.47,Fee Schedule,,161.2,,,161.2,Fee Schedule,,34.23,,,34.23,Fee Schedule,,60.47,,,60.47,Fee Schedule,,161.2,,,161.2,Fee Schedule,,64.39,,,64.39,Fee Schedule,,182,70,,182,percent of total billed charges,All Other,77.72,,,77.72,Fee Schedule,,65.94,,,65.94,Fee Schedule,,19.56,,,19.56,Fee Schedule,,19.56,,,19.56,Fee Schedule,,19.56,,,19.56,Fee Schedule,,19.56,,,19.56,Fee Schedule,,16.3,,,16.3,Fee Schedule,Medicaid Laboratory Fee Schedule,16.3,,,16.3,Fee Schedule,100% Medicaid Laboratory Fee Schedule,16.3,,,16.3,Fee Schedule,100% Medicaid Laboratory Fee Schedule,16.3,,,16.3,Fee Schedule,100% Medicaid Laboratory Fee Schedule,36.68,,,36.68,Fee Schedule,225% Medicaid Laboratory Fee Schedule,36.68,,,36.68,Fee Schedule,225% Medicaid Laboratory Fee Schedule,24.94,,,24.94,Fee Schedule,153% Medicaid Laboratory Fee Schedule,36.68,,,36.68,Fee Schedule,225% Medicaid Laboratory Fee Schedule,22.82,,,22.82,Fee Schedule,140% Medicaid Laboratory Fee Schedule,36.68,,,36.68,Fee Schedule,225% Medicaid Laboratory Fee Schedule,42.38,,,42.38,Fee Schedule,260% Medicaid Laboratory Fee Schedule,52.81,,,52.81,Fee Schedule,324% Medicaid Laboratory Fee Schedule,35.05,,,35.05,Fee Schedule,215% Medicaid Laboratory Fee Schedule,35.05,,,35.05,Fee Schedule,215% Medicaid Laboratory Fee Schedule,20.38,,,20.38,Fee Schedule,125% Medicaid Laboratory Fee Schedule,16.3,182,
CORTISOL FREE                   ,82530,CPT,,40190100,CDM,301,RC,,,both,,,267,27.48,,,27.48,Other,150% of Medicare + 9.63% HCRA Surcharge,16.71,,,16.71,Fee Schedule,Mediare Clinical Lab,32.25,,,32.25,Fee Schedule,,29.08,,,29.08,Fee Schedule,,168.87,,,168.87,Fee Schedule,,151.94,,,151.94,Fee Schedule,,143.47,,,143.47,Fee Schedule,,133.5,50,,133.5,percent of total billed charges,All Other,35.3,,,35.3,Fee Schedule,,52.64,,,52.64,Fee Schedule,,31.08,,,31.08,Other,186% Medicaid methodology,61.99,,,61.99,Fee Schedule,,165.54,,,165.54,Fee Schedule,,35.09,,,35.09,Fee Schedule,,61.99,,,61.99,Fee Schedule,,165.54,,,165.54,Fee Schedule,,66,,,66,Fee Schedule,,186.9,70,,186.9,percent of total billed charges,All Other,79.67,,,79.67,Fee Schedule,,67.6,,,67.6,Fee Schedule,,20.05,,,20.05,Fee Schedule,,20.05,,,20.05,Fee Schedule,,20.05,,,20.05,Fee Schedule,,20.05,,,20.05,Fee Schedule,,16.71,,,16.71,Fee Schedule,Medicaid Laboratory Fee Schedule,16.71,,,16.71,Fee Schedule,100% Medicaid Laboratory Fee Schedule,16.71,,,16.71,Fee Schedule,100% Medicaid Laboratory Fee Schedule,16.71,,,16.71,Fee Schedule,100% Medicaid Laboratory Fee Schedule,37.6,,,37.6,Fee Schedule,225% Medicaid Laboratory Fee Schedule,37.6,,,37.6,Fee Schedule,225% Medicaid Laboratory Fee Schedule,25.57,,,25.57,Fee Schedule,153% Medicaid Laboratory Fee Schedule,37.6,,,37.6,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.39,,,23.39,Fee Schedule,140% Medicaid Laboratory Fee Schedule,37.6,,,37.6,Fee Schedule,225% Medicaid Laboratory Fee Schedule,43.45,,,43.45,Fee Schedule,260% Medicaid Laboratory Fee Schedule,54.14,,,54.14,Fee Schedule,324% Medicaid Laboratory Fee Schedule,35.93,,,35.93,Fee Schedule,215% Medicaid Laboratory Fee Schedule,35.93,,,35.93,Fee Schedule,215% Medicaid Laboratory Fee Schedule,20.89,,,20.89,Fee Schedule,125% Medicaid Laboratory Fee Schedule,16.71,186.9,
ASSAY OF GONADOTROPIN (FSH)     ,83001,CPT,,40190126,CDM,301,RC,,,both,,,296,30.55,,,30.55,Other,150% of Medicare + 9.63% HCRA Surcharge,18.58,,,18.58,Fee Schedule,Mediare Clinical Lab,35.86,,,35.86,Fee Schedule,,32.33,,,32.33,Fee Schedule,,187.76,,,187.76,Fee Schedule,,168.93,,,168.93,Fee Schedule,,159.52,,,159.52,Fee Schedule,,148,50,,148,percent of total billed charges,All Other,39.26,,,39.26,Fee Schedule,,58.53,,,58.53,Fee Schedule,,34.56,,,34.56,Other,186% Medicaid methodology,68.93,,,68.93,Fee Schedule,,183.52,,,183.52,Fee Schedule,,39.02,,,39.02,Fee Schedule,,68.93,,,68.93,Fee Schedule,,183.52,,,183.52,Fee Schedule,,73.39,,,73.39,Fee Schedule,,207.2,70,,207.2,percent of total billed charges,All Other,88.59,,,88.59,Fee Schedule,,75.17,,,75.17,Fee Schedule,,22.3,,,22.3,Fee Schedule,,22.3,,,22.3,Fee Schedule,,22.3,,,22.3,Fee Schedule,,22.3,,,22.3,Fee Schedule,,18.58,,,18.58,Fee Schedule,Medicaid Laboratory Fee Schedule,18.58,,,18.58,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.58,,,18.58,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.58,,,18.58,Fee Schedule,100% Medicaid Laboratory Fee Schedule,41.81,,,41.81,Fee Schedule,225% Medicaid Laboratory Fee Schedule,41.81,,,41.81,Fee Schedule,225% Medicaid Laboratory Fee Schedule,28.43,,,28.43,Fee Schedule,153% Medicaid Laboratory Fee Schedule,41.81,,,41.81,Fee Schedule,225% Medicaid Laboratory Fee Schedule,26.01,,,26.01,Fee Schedule,140% Medicaid Laboratory Fee Schedule,41.81,,,41.81,Fee Schedule,225% Medicaid Laboratory Fee Schedule,48.31,,,48.31,Fee Schedule,260% Medicaid Laboratory Fee Schedule,60.2,,,60.2,Fee Schedule,324% Medicaid Laboratory Fee Schedule,39.95,,,39.95,Fee Schedule,215% Medicaid Laboratory Fee Schedule,39.95,,,39.95,Fee Schedule,215% Medicaid Laboratory Fee Schedule,23.23,,,23.23,Fee Schedule,125% Medicaid Laboratory Fee Schedule,18.58,207.2,
CHORIONIC GONADOTROPIN ASSAY    ,84703,CPT,,40190142,CDM,301,RC,,,both,,,120,12.37,,,12.37,Other,150% of Medicare + 9.63% HCRA Surcharge,7.52,,,7.52,Fee Schedule,Mediare Clinical Lab,14.51,,,14.51,Fee Schedule,,13.08,,,13.08,Fee Schedule,,75.89,,,75.89,Fee Schedule,,68.28,,,68.28,Fee Schedule,,64.48,,,64.48,Fee Schedule,,60,50,,60,percent of total billed charges,All Other,15.89,,,15.89,Fee Schedule,,23.69,,,23.69,Fee Schedule,,3.76,,,3.76,Other,186% Medicaid methodology,27.9,,,27.9,Fee Schedule,,74.4,,,74.4,Fee Schedule,,15.79,,,15.79,Fee Schedule,,27.9,,,27.9,Fee Schedule,,74.4,,,74.4,Fee Schedule,,29.7,,,29.7,Fee Schedule,,84,70,,84,percent of total billed charges,All Other,35.85,,,35.85,Fee Schedule,,30.42,,,30.42,Fee Schedule,,9.02,,,9.02,Fee Schedule,,9.02,,,9.02,Fee Schedule,,9.02,,,9.02,Fee Schedule,,9.02,,,9.02,Fee Schedule,,2.02,,,2.02,Fee Schedule,Medicaid Laboratory Fee Schedule,2.02,,,2.02,Fee Schedule,100% Medicaid Laboratory Fee Schedule,2.02,,,2.02,Fee Schedule,100% Medicaid Laboratory Fee Schedule,2.02,,,2.02,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,225% Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,225% Medicaid Laboratory Fee Schedule,3.09,,,3.09,Fee Schedule,153% Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,225% Medicaid Laboratory Fee Schedule,2.83,,,2.83,Fee Schedule,140% Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,260% Medicaid Laboratory Fee Schedule,6.54,,,6.54,Fee Schedule,324% Medicaid Laboratory Fee Schedule,4.34,,,4.34,Fee Schedule,215% Medicaid Laboratory Fee Schedule,4.34,,,4.34,Fee Schedule,215% Medicaid Laboratory Fee Schedule,2.53,,,2.53,Fee Schedule,125% Medicaid Laboratory Fee Schedule,2.02,84,
CHORIONIC GONADOTROPIN TEST     ,84702,CPT,,40190167,CDM,301,RC,,,both,,,240,24.75,,,24.75,Other,150% of Medicare + 9.63% HCRA Surcharge,15.05,,,15.05,Fee Schedule,Mediare Clinical Lab,29.05,,,29.05,Fee Schedule,,26.19,,,26.19,Fee Schedule,,152.14,,,152.14,Fee Schedule,,136.89,,,136.89,Fee Schedule,,129.26,,,129.26,Fee Schedule,,120,50,,120,percent of total billed charges,All Other,31.79,,,31.79,Fee Schedule,,47.41,,,47.41,Fee Schedule,,23.24,,,23.24,Other,186% Medicaid methodology,55.84,,,55.84,Fee Schedule,,148.8,,,148.8,Fee Schedule,,31.61,,,31.61,Fee Schedule,,55.84,,,55.84,Fee Schedule,,148.8,,,148.8,Fee Schedule,,59.45,,,59.45,Fee Schedule,,168,70,,168,percent of total billed charges,All Other,71.76,,,71.76,Fee Schedule,,60.89,,,60.89,Fee Schedule,,18.06,,,18.06,Fee Schedule,,18.06,,,18.06,Fee Schedule,,18.06,,,18.06,Fee Schedule,,18.06,,,18.06,Fee Schedule,,12.49,,,12.49,Fee Schedule,Medicaid Laboratory Fee Schedule,12.49,,,12.49,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.49,,,12.49,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.49,,,12.49,Fee Schedule,100% Medicaid Laboratory Fee Schedule,28.11,,,28.11,Fee Schedule,225% Medicaid Laboratory Fee Schedule,28.11,,,28.11,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.12,,,19.12,Fee Schedule,153% Medicaid Laboratory Fee Schedule,28.11,,,28.11,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.49,,,17.49,Fee Schedule,140% Medicaid Laboratory Fee Schedule,28.11,,,28.11,Fee Schedule,225% Medicaid Laboratory Fee Schedule,32.48,,,32.48,Fee Schedule,260% Medicaid Laboratory Fee Schedule,40.48,,,40.48,Fee Schedule,324% Medicaid Laboratory Fee Schedule,26.86,,,26.86,Fee Schedule,215% Medicaid Laboratory Fee Schedule,26.86,,,26.86,Fee Schedule,215% Medicaid Laboratory Fee Schedule,15.62,,,15.62,Fee Schedule,125% Medicaid Laboratory Fee Schedule,12.49,168,
ASSAY OF CALCIUM IONIZED        ,82330,CPT,,40190209,CDM,301,RC,,,both,,,218,22.5,,,22.5,Other,150% of Medicare + 9.63% HCRA Surcharge,13.68,,,13.68,Fee Schedule,Mediare Clinical Lab,26.4,,,26.4,Fee Schedule,,23.8,,,23.8,Fee Schedule,,70.65,,,70.65,Fee Schedule,,63.57,,,63.57,Fee Schedule,,60.02,,,60.02,Fee Schedule,,109,50,,109,percent of total billed charges,All Other,28.89,,,28.89,Fee Schedule,,43.09,,,43.09,Fee Schedule,,9.45,,,9.45,Other,186% Medicaid methodology,50.75,,,50.75,Fee Schedule,,135.16,,,135.16,Fee Schedule,,28.73,,,28.73,Fee Schedule,,50.75,,,50.75,Fee Schedule,,135.16,,,135.16,Fee Schedule,,54.04,,,54.04,Fee Schedule,,152.6,70,,152.6,percent of total billed charges,All Other,65.23,,,65.23,Fee Schedule,,55.34,,,55.34,Fee Schedule,,16.42,,,16.42,Fee Schedule,,16.42,,,16.42,Fee Schedule,,16.42,,,16.42,Fee Schedule,,16.42,,,16.42,Fee Schedule,,5.08,,,5.08,Fee Schedule,Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.77,,,7.77,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.11,,,7.11,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.21,,,13.21,Fee Schedule,260% Medicaid Laboratory Fee Schedule,16.46,,,16.46,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.35,,,6.35,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.08,152.6,
ASSAY OF TOTAL THYROXINE        ,84436,CPT,,40190324,CDM,301,RC,,,both,,,110,11.3,,,11.3,Other,150% of Medicare + 9.63% HCRA Surcharge,6.87,,,6.87,Fee Schedule,Mediare Clinical Lab,13.26,,,13.26,Fee Schedule,,11.95,,,11.95,Fee Schedule,,69.43,,,69.43,Fee Schedule,,62.47,,,62.47,Fee Schedule,,58.99,,,58.99,Fee Schedule,,55,50,,55,percent of total billed charges,All Other,14.53,,,14.53,Fee Schedule,,21.64,,,21.64,Fee Schedule,,10.71,,,10.71,Other,186% Medicaid methodology,25.49,,,25.49,Fee Schedule,,68.2,,,68.2,Fee Schedule,,14.43,,,14.43,Fee Schedule,,25.49,,,25.49,Fee Schedule,,68.2,,,68.2,Fee Schedule,,27.14,,,27.14,Fee Schedule,,77,70,,77,percent of total billed charges,All Other,32.76,,,32.76,Fee Schedule,,27.79,,,27.79,Fee Schedule,,8.24,,,8.24,Fee Schedule,,8.24,,,8.24,Fee Schedule,,8.24,,,8.24,Fee Schedule,,8.24,,,8.24,Fee Schedule,,5.76,,,5.76,Fee Schedule,Medicaid Laboratory Fee Schedule,5.76,,,5.76,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.76,,,5.76,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.76,,,5.76,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.95,,,12.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.95,,,12.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.81,,,8.81,Fee Schedule,153% Medicaid Laboratory Fee Schedule,12.95,,,12.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.06,,,8.06,Fee Schedule,140% Medicaid Laboratory Fee Schedule,12.95,,,12.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.97,,,14.97,Fee Schedule,260% Medicaid Laboratory Fee Schedule,18.65,,,18.65,Fee Schedule,324% Medicaid Laboratory Fee Schedule,12.38,,,12.38,Fee Schedule,215% Medicaid Laboratory Fee Schedule,12.38,,,12.38,Fee Schedule,215% Medicaid Laboratory Fee Schedule,7.2,,,7.2,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.76,77,
FREE ASSAY (FT-3)               ,84481,CPT,,40190365,CDM,301,RC,,,both,,,226,27.86,,,27.86,Other,150% of Medicare + 9.63% HCRA Surcharge,16.94,,,16.94,Fee Schedule,Mediare Clinical Lab,32.69,,,32.69,Fee Schedule,,29.48,,,29.48,Fee Schedule,,171.17,,,171.17,Fee Schedule,,154.01,,,154.01,Fee Schedule,,145.42,,,145.42,Fee Schedule,,113,50,,113,percent of total billed charges,All Other,35.78,,,35.78,Fee Schedule,,53.36,,,53.36,Fee Schedule,,16.91,,,16.91,Other,186% Medicaid methodology,62.85,,,62.85,Fee Schedule,,140.12,,,140.12,Fee Schedule,,35.57,,,35.57,Fee Schedule,,62.85,,,62.85,Fee Schedule,,140.12,,,140.12,Fee Schedule,,66.91,,,66.91,Fee Schedule,,158.2,70,,158.2,percent of total billed charges,All Other,80.77,,,80.77,Fee Schedule,,68.53,,,68.53,Fee Schedule,,20.33,,,20.33,Fee Schedule,,20.33,,,20.33,Fee Schedule,,20.33,,,20.33,Fee Schedule,,20.33,,,20.33,Fee Schedule,,9.09,,,9.09,Fee Schedule,Medicaid Laboratory Fee Schedule,9.09,,,9.09,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.09,,,9.09,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.09,,,9.09,Fee Schedule,100% Medicaid Laboratory Fee Schedule,20.45,,,20.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,20.45,,,20.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.91,,,13.91,Fee Schedule,153% Medicaid Laboratory Fee Schedule,20.45,,,20.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.73,,,12.73,Fee Schedule,140% Medicaid Laboratory Fee Schedule,20.45,,,20.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.63,,,23.63,Fee Schedule,260% Medicaid Laboratory Fee Schedule,29.45,,,29.45,Fee Schedule,324% Medicaid Laboratory Fee Schedule,19.54,,,19.54,Fee Schedule,215% Medicaid Laboratory Fee Schedule,19.54,,,19.54,Fee Schedule,215% Medicaid Laboratory Fee Schedule,11.36,,,11.36,Fee Schedule,125% Medicaid Laboratory Fee Schedule,9.09,171.17,
T3 REVERSE                      ,84482,CPT,,40190381,CDM,301,RC,,,both,,,251,25.92,,,25.92,Other,150% of Medicare + 9.63% HCRA Surcharge,15.76,,,15.76,Fee Schedule,Mediare Clinical Lab,30.42,,,30.42,Fee Schedule,,27.42,,,27.42,Fee Schedule,,77.76,,,77.76,Fee Schedule,,69.96,,,69.96,Fee Schedule,,66.06,,,66.06,Fee Schedule,,125.5,50,,125.5,percent of total billed charges,All Other,33.28,,,33.28,Fee Schedule,,49.64,,,49.64,Fee Schedule,,10.71,,,10.71,Other,186% Medicaid methodology,58.47,,,58.47,Fee Schedule,,155.62,,,155.62,Fee Schedule,,33.1,,,33.1,Fee Schedule,,58.47,,,58.47,Fee Schedule,,155.62,,,155.62,Fee Schedule,,62.25,,,62.25,Fee Schedule,,175.7,70,,175.7,percent of total billed charges,All Other,75.14,,,75.14,Fee Schedule,,63.76,,,63.76,Fee Schedule,,18.91,,,18.91,Fee Schedule,,18.91,,,18.91,Fee Schedule,,18.91,,,18.91,Fee Schedule,,18.91,,,18.91,Fee Schedule,,5.76,,,5.76,Fee Schedule,Medicaid Laboratory Fee Schedule,5.76,,,5.76,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.76,,,5.76,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.76,,,5.76,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.95,,,12.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.95,,,12.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.81,,,8.81,Fee Schedule,153% Medicaid Laboratory Fee Schedule,12.95,,,12.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.06,,,8.06,Fee Schedule,140% Medicaid Laboratory Fee Schedule,12.95,,,12.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.97,,,14.97,Fee Schedule,260% Medicaid Laboratory Fee Schedule,18.65,,,18.65,Fee Schedule,324% Medicaid Laboratory Fee Schedule,12.38,,,12.38,Fee Schedule,215% Medicaid Laboratory Fee Schedule,12.38,,,12.38,Fee Schedule,215% Medicaid Laboratory Fee Schedule,7.2,,,7.2,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.76,175.7,
ASSAY OF THYROID ACTIVITY       ,84442,CPT,,40190423,CDM,301,RC,,,both,,,143,24.3,,,24.3,Other,150% of Medicare + 9.63% HCRA Surcharge,14.78,,,14.78,Fee Schedule,Mediare Clinical Lab,28.53,,,28.53,Fee Schedule,,25.72,,,25.72,Fee Schedule,,149.49,,,149.49,Fee Schedule,,134.5,,,134.5,Fee Schedule,,127,,,127,Fee Schedule,,71.5,50,,71.5,percent of total billed charges,All Other,31.23,,,31.23,Fee Schedule,,46.56,,,46.56,Fee Schedule,,16.91,,,16.91,Other,186% Medicaid methodology,54.83,,,54.83,Fee Schedule,,88.66,,,88.66,Fee Schedule,,31.04,,,31.04,Fee Schedule,,54.83,,,54.83,Fee Schedule,,88.66,,,88.66,Fee Schedule,,58.38,,,58.38,Fee Schedule,,100.1,70,,100.1,percent of total billed charges,All Other,70.47,,,70.47,Fee Schedule,,59.79,,,59.79,Fee Schedule,,17.74,,,17.74,Fee Schedule,,17.74,,,17.74,Fee Schedule,,17.74,,,17.74,Fee Schedule,,17.74,,,17.74,Fee Schedule,,9.09,,,9.09,Fee Schedule,Medicaid Laboratory Fee Schedule,9.09,,,9.09,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.09,,,9.09,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.09,,,9.09,Fee Schedule,100% Medicaid Laboratory Fee Schedule,20.45,,,20.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,20.45,,,20.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.91,,,13.91,Fee Schedule,153% Medicaid Laboratory Fee Schedule,20.45,,,20.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.73,,,12.73,Fee Schedule,140% Medicaid Laboratory Fee Schedule,20.45,,,20.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.63,,,23.63,Fee Schedule,260% Medicaid Laboratory Fee Schedule,29.45,,,29.45,Fee Schedule,324% Medicaid Laboratory Fee Schedule,19.54,,,19.54,Fee Schedule,215% Medicaid Laboratory Fee Schedule,19.54,,,19.54,Fee Schedule,215% Medicaid Laboratory Fee Schedule,11.36,,,11.36,Fee Schedule,125% Medicaid Laboratory Fee Schedule,9.09,149.49,
ASSAY THYROID STIM HORMONE      ,84443,CPT,,40190480,CDM,301,RC,,,both,,,268,27.63,,,27.63,Other,150% of Medicare + 9.63% HCRA Surcharge,16.8,,,16.8,Fee Schedule,Mediare Clinical Lab,32.42,,,32.42,Fee Schedule,,29.23,,,29.23,Fee Schedule,,169.74,,,169.74,Fee Schedule,,152.71,,,152.71,Fee Schedule,,144.2,,,144.2,Fee Schedule,,134,50,,134,percent of total billed charges,All Other,35.49,,,35.49,Fee Schedule,,52.92,,,52.92,Fee Schedule,,16.91,,,16.91,Other,186% Medicaid methodology,62.33,,,62.33,Fee Schedule,,166.16,,,166.16,Fee Schedule,,35.28,,,35.28,Fee Schedule,,62.33,,,62.33,Fee Schedule,,166.16,,,166.16,Fee Schedule,,66.36,,,66.36,Fee Schedule,,187.6,70,,187.6,percent of total billed charges,All Other,80.1,,,80.1,Fee Schedule,,67.96,,,67.96,Fee Schedule,,20.16,,,20.16,Fee Schedule,,20.16,,,20.16,Fee Schedule,,20.16,,,20.16,Fee Schedule,,20.16,,,20.16,Fee Schedule,,9.09,,,9.09,Fee Schedule,Medicaid Laboratory Fee Schedule,9.09,,,9.09,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.09,,,9.09,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.09,,,9.09,Fee Schedule,100% Medicaid Laboratory Fee Schedule,20.45,,,20.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,20.45,,,20.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.91,,,13.91,Fee Schedule,153% Medicaid Laboratory Fee Schedule,20.45,,,20.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.73,,,12.73,Fee Schedule,140% Medicaid Laboratory Fee Schedule,20.45,,,20.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.63,,,23.63,Fee Schedule,260% Medicaid Laboratory Fee Schedule,29.45,,,29.45,Fee Schedule,324% Medicaid Laboratory Fee Schedule,19.54,,,19.54,Fee Schedule,215% Medicaid Laboratory Fee Schedule,19.54,,,19.54,Fee Schedule,215% Medicaid Laboratory Fee Schedule,11.36,,,11.36,Fee Schedule,125% Medicaid Laboratory Fee Schedule,9.09,187.6,
ASSAY OF TSI GLOBULIN           ,84445,CPT,,40190506,CDM,301,RC,,,both,,,809,83.64,,,83.64,Other,150% of Medicare + 9.63% HCRA Surcharge,50.86,,,50.86,Fee Schedule,Mediare Clinical Lab,98.16,,,98.16,Fee Schedule,,88.5,,,88.5,Fee Schedule,,513.8,,,513.8,Fee Schedule,,462.28,,,462.28,Fee Schedule,,436.52,,,436.52,Fee Schedule,,404.5,50,,404.5,percent of total billed charges,All Other,107.45,,,107.45,Fee Schedule,,160.21,,,160.21,Fee Schedule,,122.22,,,122.22,Other,186% Medicaid methodology,188.69,,,188.69,Fee Schedule,,501.58,,,501.58,Fee Schedule,,106.81,,,106.81,Fee Schedule,,188.69,,,188.69,Fee Schedule,,501.58,,,501.58,Fee Schedule,,200.9,,,200.9,Fee Schedule,,566.3,70,,566.3,percent of total billed charges,All Other,242.5,,,242.5,Fee Schedule,,205.76,,,205.76,Fee Schedule,,61.03,,,61.03,Fee Schedule,,61.03,,,61.03,Fee Schedule,,61.03,,,61.03,Fee Schedule,,61.03,,,61.03,Fee Schedule,,65.71,,,65.71,Other,New York Medicaid APG methodology,65.71,,,65.71,Other,100% Medicaid APG methodology,65.71,,,65.71,Other,100% Medicaid APG methodology,65.71,,,65.71,Other,100% Medicaid APG methodology,147.85,,,147.85,Other,225% Medicaid APG methodology,147.85,,,147.85,Other,225% Medicaid APG methodology,100.54,,,100.54,Other,153% Medicaid APG methodology,147.85,,,147.85,Other,225% Medicaid APG methodology,92,,,92,Other,140% Medicaid APG methodology,147.85,,,147.85,Other,225% Medicaid APG methodology,170.85,,,170.85,Other,260% Medicaid APG methodology,212.9,,,212.9,Other,324% Medicaid APG methodology,141.28,,,141.28,Other,215% Medicaid APG methodology,141.28,,,141.28,Other,215% Medicaid APG methodology,82.14,,,82.14,Other,125% Medicaid APG methodology,50.86,566.3,
ASSAY OF C-PEPTIDE              ,84681,CPT,,40190522,CDM,301,RC,,,both,,,331,34.22,,,34.22,Other,150% of Medicare + 9.63% HCRA Surcharge,20.81,,,20.81,Fee Schedule,Mediare Clinical Lab,40.16,,,40.16,Fee Schedule,,36.21,,,36.21,Fee Schedule,,210.23,,,210.23,Fee Schedule,,189.15,,,189.15,Fee Schedule,,178.61,,,178.61,Fee Schedule,,165.5,50,,165.5,percent of total billed charges,All Other,43.97,,,43.97,Fee Schedule,,65.55,,,65.55,Fee Schedule,,38.71,,,38.71,Other,186% Medicaid methodology,77.21,,,77.21,Fee Schedule,,205.22,,,205.22,Fee Schedule,,43.7,,,43.7,Fee Schedule,,77.21,,,77.21,Fee Schedule,,205.22,,,205.22,Fee Schedule,,82.2,,,82.2,Fee Schedule,,231.7,70,,231.7,percent of total billed charges,All Other,99.22,,,99.22,Fee Schedule,,84.19,,,84.19,Fee Schedule,,24.97,,,24.97,Fee Schedule,,24.97,,,24.97,Fee Schedule,,24.97,,,24.97,Fee Schedule,,24.97,,,24.97,Fee Schedule,,20.81,,,20.81,Fee Schedule,Medicaid Laboratory Fee Schedule,20.81,,,20.81,Fee Schedule,100% Medicaid Laboratory Fee Schedule,20.81,,,20.81,Fee Schedule,100% Medicaid Laboratory Fee Schedule,20.81,,,20.81,Fee Schedule,100% Medicaid Laboratory Fee Schedule,46.82,,,46.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,46.82,,,46.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,31.84,,,31.84,Fee Schedule,153% Medicaid Laboratory Fee Schedule,46.82,,,46.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,29.13,,,29.13,Fee Schedule,140% Medicaid Laboratory Fee Schedule,46.82,,,46.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,54.11,,,54.11,Fee Schedule,260% Medicaid Laboratory Fee Schedule,67.42,,,67.42,Fee Schedule,324% Medicaid Laboratory Fee Schedule,44.74,,,44.74,Fee Schedule,215% Medicaid Laboratory Fee Schedule,44.74,,,44.74,Fee Schedule,215% Medicaid Laboratory Fee Schedule,26.01,,,26.01,Fee Schedule,125% Medicaid Laboratory Fee Schedule,20.81,231.7,
ASSAY THREE CATECHOLAMINES      ,82384,CPT,,40190605,CDM,301,RC,,,both,,,402,41.52,,,41.52,Other,150% of Medicare + 9.63% HCRA Surcharge,25.25,,,25.25,Fee Schedule,Mediare Clinical Lab,48.73,,,48.73,Fee Schedule,,43.94,,,43.94,Fee Schedule,,173.04,,,173.04,Fee Schedule,,155.69,,,155.69,Fee Schedule,,147.01,,,147.01,Fee Schedule,,201,50,,201,percent of total billed charges,All Other,53.33,,,53.33,Fee Schedule,,79.54,,,79.54,Fee Schedule,,34.57,,,34.57,Other,186% Medicaid methodology,93.68,,,93.68,Fee Schedule,,249.24,,,249.24,Fee Schedule,,53.03,,,53.03,Fee Schedule,,93.68,,,93.68,Fee Schedule,,249.24,,,249.24,Fee Schedule,,99.74,,,99.74,Fee Schedule,,281.4,70,,281.4,percent of total billed charges,All Other,120.39,,,120.39,Fee Schedule,,102.15,,,102.15,Fee Schedule,,30.3,,,30.3,Fee Schedule,,30.3,,,30.3,Fee Schedule,,30.3,,,30.3,Fee Schedule,,30.3,,,30.3,Fee Schedule,,18.58,,,18.58,Fee Schedule,Medicaid Laboratory Fee Schedule,18.58,,,18.58,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.58,,,18.58,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.58,,,18.58,Fee Schedule,100% Medicaid Laboratory Fee Schedule,41.81,,,41.81,Fee Schedule,225% Medicaid Laboratory Fee Schedule,41.81,,,41.81,Fee Schedule,225% Medicaid Laboratory Fee Schedule,28.43,,,28.43,Fee Schedule,153% Medicaid Laboratory Fee Schedule,41.81,,,41.81,Fee Schedule,225% Medicaid Laboratory Fee Schedule,26.02,,,26.02,Fee Schedule,140% Medicaid Laboratory Fee Schedule,41.81,,,41.81,Fee Schedule,225% Medicaid Laboratory Fee Schedule,48.32,,,48.32,Fee Schedule,260% Medicaid Laboratory Fee Schedule,60.21,,,60.21,Fee Schedule,324% Medicaid Laboratory Fee Schedule,39.96,,,39.96,Fee Schedule,215% Medicaid Laboratory Fee Schedule,39.96,,,39.96,Fee Schedule,215% Medicaid Laboratory Fee Schedule,23.23,,,23.23,Fee Schedule,125% Medicaid Laboratory Fee Schedule,18.58,281.4,
ASSAY OF PROGESTERONE 17-D      ,83498,CPT,,40190688,CDM,301,RC,,,both,,,433,44.68,,,44.68,Other,150% of Medicare + 9.63% HCRA Surcharge,27.17,,,27.17,Fee Schedule,Mediare Clinical Lab,52.44,,,52.44,Fee Schedule,,47.28,,,47.28,Fee Schedule,,274.49,,,274.49,Fee Schedule,,246.97,,,246.97,Fee Schedule,,233.2,,,233.2,Fee Schedule,,216.5,50,,216.5,percent of total billed charges,All Other,57.4,,,57.4,Fee Schedule,,85.59,,,85.59,Fee Schedule,,50.54,,,50.54,Other,186% Medicaid methodology,100.8,,,100.8,Fee Schedule,,268.46,,,268.46,Fee Schedule,,57.06,,,57.06,Fee Schedule,,100.8,,,100.8,Fee Schedule,,268.46,,,268.46,Fee Schedule,,107.32,,,107.32,Fee Schedule,,303.1,70,,303.1,percent of total billed charges,All Other,129.54,,,129.54,Fee Schedule,,109.92,,,109.92,Fee Schedule,,32.6,,,32.6,Fee Schedule,,32.6,,,32.6,Fee Schedule,,32.6,,,32.6,Fee Schedule,,32.6,,,32.6,Fee Schedule,,27.17,,,27.17,Fee Schedule,Medicaid Laboratory Fee Schedule,27.17,,,27.17,Fee Schedule,100% Medicaid Laboratory Fee Schedule,27.17,,,27.17,Fee Schedule,100% Medicaid Laboratory Fee Schedule,27.17,,,27.17,Fee Schedule,100% Medicaid Laboratory Fee Schedule,61.13,,,61.13,Fee Schedule,225% Medicaid Laboratory Fee Schedule,61.13,,,61.13,Fee Schedule,225% Medicaid Laboratory Fee Schedule,41.57,,,41.57,Fee Schedule,153% Medicaid Laboratory Fee Schedule,61.13,,,61.13,Fee Schedule,225% Medicaid Laboratory Fee Schedule,38.04,,,38.04,Fee Schedule,140% Medicaid Laboratory Fee Schedule,61.13,,,61.13,Fee Schedule,225% Medicaid Laboratory Fee Schedule,70.64,,,70.64,Fee Schedule,260% Medicaid Laboratory Fee Schedule,88.03,,,88.03,Fee Schedule,324% Medicaid Laboratory Fee Schedule,58.42,,,58.42,Fee Schedule,215% Medicaid Laboratory Fee Schedule,58.42,,,58.42,Fee Schedule,215% Medicaid Laboratory Fee Schedule,33.96,,,33.96,Fee Schedule,125% Medicaid Laboratory Fee Schedule,27.17,303.1,
ASSAY OF GONADOTROPIN (LH)      ,83002,CPT,,40190746,CDM,301,RC,,,both,,,295,30.46,,,30.46,Other,150% of Medicare + 9.63% HCRA Surcharge,18.52,,,18.52,Fee Schedule,Mediare Clinical Lab,35.74,,,35.74,Fee Schedule,,32.22,,,32.22,Fee Schedule,,187.11,,,187.11,Fee Schedule,,168.35,,,168.35,Fee Schedule,,158.97,,,158.97,Fee Schedule,,147.5,50,,147.5,percent of total billed charges,All Other,39.13,,,39.13,Fee Schedule,,58.34,,,58.34,Fee Schedule,,34.45,,,34.45,Other,186% Medicaid methodology,68.71,,,68.71,Fee Schedule,,182.9,,,182.9,Fee Schedule,,38.89,,,38.89,Fee Schedule,,68.71,,,68.71,Fee Schedule,,182.9,,,182.9,Fee Schedule,,73.15,,,73.15,Fee Schedule,,206.5,70,,206.5,percent of total billed charges,All Other,88.3,,,88.3,Fee Schedule,,74.92,,,74.92,Fee Schedule,,22.22,,,22.22,Fee Schedule,,22.22,,,22.22,Fee Schedule,,22.22,,,22.22,Fee Schedule,,22.22,,,22.22,Fee Schedule,,18.52,,,18.52,Fee Schedule,Medicaid Laboratory Fee Schedule,18.52,,,18.52,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.52,,,18.52,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.52,,,18.52,Fee Schedule,100% Medicaid Laboratory Fee Schedule,41.67,,,41.67,Fee Schedule,225% Medicaid Laboratory Fee Schedule,41.67,,,41.67,Fee Schedule,225% Medicaid Laboratory Fee Schedule,28.34,,,28.34,Fee Schedule,153% Medicaid Laboratory Fee Schedule,41.67,,,41.67,Fee Schedule,225% Medicaid Laboratory Fee Schedule,25.93,,,25.93,Fee Schedule,140% Medicaid Laboratory Fee Schedule,41.67,,,41.67,Fee Schedule,225% Medicaid Laboratory Fee Schedule,48.15,,,48.15,Fee Schedule,260% Medicaid Laboratory Fee Schedule,60,,,60,Fee Schedule,324% Medicaid Laboratory Fee Schedule,39.82,,,39.82,Fee Schedule,215% Medicaid Laboratory Fee Schedule,39.82,,,39.82,Fee Schedule,215% Medicaid Laboratory Fee Schedule,23.15,,,23.15,Fee Schedule,125% Medicaid Laboratory Fee Schedule,18.52,206.5,
ASSAY OF ALDOSTERONE            ,82088,CPT,,40190761,CDM,301,RC,,,both,,,648,67.01,,,67.01,Other,150% of Medicare + 9.63% HCRA Surcharge,40.75,,,40.75,Fee Schedule,Mediare Clinical Lab,78.65,,,78.65,Fee Schedule,,70.91,,,70.91,Fee Schedule,,411.77,,,411.77,Fee Schedule,,370.48,,,370.48,Fee Schedule,,349.84,,,349.84,Fee Schedule,,324,50,,324,percent of total billed charges,All Other,86.09,,,86.09,Fee Schedule,,128.36,,,128.36,Fee Schedule,,75.8,,,75.8,Other,186% Medicaid methodology,151.18,,,151.18,Fee Schedule,,401.76,,,401.76,Fee Schedule,,85.58,,,85.58,Fee Schedule,,151.18,,,151.18,Fee Schedule,,401.76,,,401.76,Fee Schedule,,160.96,,,160.96,Fee Schedule,,453.6,70,,453.6,percent of total billed charges,All Other,194.29,,,194.29,Fee Schedule,,164.85,,,164.85,Fee Schedule,,48.9,,,48.9,Fee Schedule,,48.9,,,48.9,Fee Schedule,,48.9,,,48.9,Fee Schedule,,48.9,,,48.9,Fee Schedule,,40.75,,,40.75,Fee Schedule,Medicaid Laboratory Fee Schedule,40.75,,,40.75,Fee Schedule,100% Medicaid Laboratory Fee Schedule,40.75,,,40.75,Fee Schedule,100% Medicaid Laboratory Fee Schedule,40.75,,,40.75,Fee Schedule,100% Medicaid Laboratory Fee Schedule,91.69,,,91.69,Fee Schedule,225% Medicaid Laboratory Fee Schedule,91.69,,,91.69,Fee Schedule,225% Medicaid Laboratory Fee Schedule,62.35,,,62.35,Fee Schedule,153% Medicaid Laboratory Fee Schedule,91.69,,,91.69,Fee Schedule,225% Medicaid Laboratory Fee Schedule,57.05,,,57.05,Fee Schedule,140% Medicaid Laboratory Fee Schedule,91.69,,,91.69,Fee Schedule,225% Medicaid Laboratory Fee Schedule,105.95,,,105.95,Fee Schedule,260% Medicaid Laboratory Fee Schedule,132.03,,,132.03,Fee Schedule,324% Medicaid Laboratory Fee Schedule,87.61,,,87.61,Fee Schedule,215% Medicaid Laboratory Fee Schedule,87.61,,,87.61,Fee Schedule,215% Medicaid Laboratory Fee Schedule,50.94,,,50.94,Fee Schedule,125% Medicaid Laboratory Fee Schedule,40.75,453.6,
ASSAY OF ANDROSTENEDIONE        ,82157,CPT,,40190845,CDM,301,RC,,,both,,,466,48.15,,,48.15,Other,150% of Medicare + 9.63% HCRA Surcharge,29.28,,,29.28,Fee Schedule,Mediare Clinical Lab,56.51,,,56.51,Fee Schedule,,50.95,,,50.95,Fee Schedule,,295.82,,,295.82,Fee Schedule,,266.15,,,266.15,Fee Schedule,,251.32,,,251.32,Fee Schedule,,233,50,,233,percent of total billed charges,All Other,61.85,,,61.85,Fee Schedule,,92.23,,,92.23,Fee Schedule,,54.46,,,54.46,Other,186% Medicaid methodology,108.63,,,108.63,Fee Schedule,,288.92,,,288.92,Fee Schedule,,61.49,,,61.49,Fee Schedule,,108.63,,,108.63,Fee Schedule,,288.92,,,288.92,Fee Schedule,,115.66,,,115.66,Fee Schedule,,326.2,70,,326.2,percent of total billed charges,All Other,139.61,,,139.61,Fee Schedule,,118.45,,,118.45,Fee Schedule,,35.14,,,35.14,Fee Schedule,,35.14,,,35.14,Fee Schedule,,35.14,,,35.14,Fee Schedule,,35.14,,,35.14,Fee Schedule,,29.28,,,29.28,Fee Schedule,Medicaid Laboratory Fee Schedule,29.28,,,29.28,Fee Schedule,100% Medicaid Laboratory Fee Schedule,29.28,,,29.28,Fee Schedule,100% Medicaid Laboratory Fee Schedule,29.28,,,29.28,Fee Schedule,100% Medicaid Laboratory Fee Schedule,65.88,,,65.88,Fee Schedule,225% Medicaid Laboratory Fee Schedule,65.88,,,65.88,Fee Schedule,225% Medicaid Laboratory Fee Schedule,44.8,,,44.8,Fee Schedule,153% Medicaid Laboratory Fee Schedule,65.88,,,65.88,Fee Schedule,225% Medicaid Laboratory Fee Schedule,40.99,,,40.99,Fee Schedule,140% Medicaid Laboratory Fee Schedule,65.88,,,65.88,Fee Schedule,225% Medicaid Laboratory Fee Schedule,76.13,,,76.13,Fee Schedule,260% Medicaid Laboratory Fee Schedule,94.87,,,94.87,Fee Schedule,324% Medicaid Laboratory Fee Schedule,62.95,,,62.95,Fee Schedule,215% Medicaid Laboratory Fee Schedule,62.95,,,62.95,Fee Schedule,215% Medicaid Laboratory Fee Schedule,36.6,,,36.6,Fee Schedule,125% Medicaid Laboratory Fee Schedule,29.28,326.2,
DEHYDROEPIANDROSTERONE          ,82626,CPT,,40190860,CDM,301,RC,,,both,,,402,41.56,,,41.56,Other,150% of Medicare + 9.63% HCRA Surcharge,25.27,,,25.27,Fee Schedule,Mediare Clinical Lab,48.77,,,48.77,Fee Schedule,,43.97,,,43.97,Fee Schedule,,255.32,,,255.32,Fee Schedule,,229.72,,,229.72,Fee Schedule,,216.92,,,216.92,Fee Schedule,,201,50,,201,percent of total billed charges,All Other,53.4,,,53.4,Fee Schedule,,79.6,,,79.6,Fee Schedule,,44.75,,,44.75,Other,186% Medicaid methodology,93.75,,,93.75,Fee Schedule,,249.24,,,249.24,Fee Schedule,,53.07,,,53.07,Fee Schedule,,93.75,,,93.75,Fee Schedule,,249.24,,,249.24,Fee Schedule,,99.82,,,99.82,Fee Schedule,,281.4,70,,281.4,percent of total billed charges,All Other,120.49,,,120.49,Fee Schedule,,102.23,,,102.23,Fee Schedule,,30.32,,,30.32,Fee Schedule,,30.32,,,30.32,Fee Schedule,,30.32,,,30.32,Fee Schedule,,30.32,,,30.32,Fee Schedule,,24.06,,,24.06,Fee Schedule,Medicaid Laboratory Fee Schedule,24.06,,,24.06,Fee Schedule,100% Medicaid Laboratory Fee Schedule,24.06,,,24.06,Fee Schedule,100% Medicaid Laboratory Fee Schedule,24.06,,,24.06,Fee Schedule,100% Medicaid Laboratory Fee Schedule,54.13,,,54.13,Fee Schedule,225% Medicaid Laboratory Fee Schedule,54.13,,,54.13,Fee Schedule,225% Medicaid Laboratory Fee Schedule,36.81,,,36.81,Fee Schedule,153% Medicaid Laboratory Fee Schedule,54.13,,,54.13,Fee Schedule,225% Medicaid Laboratory Fee Schedule,33.68,,,33.68,Fee Schedule,140% Medicaid Laboratory Fee Schedule,54.13,,,54.13,Fee Schedule,225% Medicaid Laboratory Fee Schedule,62.55,,,62.55,Fee Schedule,260% Medicaid Laboratory Fee Schedule,77.95,,,77.95,Fee Schedule,324% Medicaid Laboratory Fee Schedule,51.73,,,51.73,Fee Schedule,215% Medicaid Laboratory Fee Schedule,51.73,,,51.73,Fee Schedule,215% Medicaid Laboratory Fee Schedule,30.07,,,30.07,Fee Schedule,125% Medicaid Laboratory Fee Schedule,24.06,281.4,
DEHYDROEPIANDROSTERONE          ,82627,CPT,,40190886,CDM,301,RC,,,both,,,353,36.56,,,36.56,Other,150% of Medicare + 9.63% HCRA Surcharge,22.23,,,22.23,Fee Schedule,Mediare Clinical Lab,42.9,,,42.9,Fee Schedule,,38.68,,,38.68,Fee Schedule,,224.66,,,224.66,Fee Schedule,,202.13,,,202.13,Fee Schedule,,190.87,,,190.87,Fee Schedule,,176.5,50,,176.5,percent of total billed charges,All Other,46.96,,,46.96,Fee Schedule,,70.02,,,70.02,Fee Schedule,,41.35,,,41.35,Other,186% Medicaid methodology,82.47,,,82.47,Fee Schedule,,218.86,,,218.86,Fee Schedule,,46.68,,,46.68,Fee Schedule,,82.47,,,82.47,Fee Schedule,,218.86,,,218.86,Fee Schedule,,87.81,,,87.81,Fee Schedule,,247.1,70,,247.1,percent of total billed charges,All Other,105.99,,,105.99,Fee Schedule,,89.93,,,89.93,Fee Schedule,,26.68,,,26.68,Fee Schedule,,26.68,,,26.68,Fee Schedule,,26.68,,,26.68,Fee Schedule,,26.68,,,26.68,Fee Schedule,,22.23,,,22.23,Fee Schedule,Medicaid Laboratory Fee Schedule,22.23,,,22.23,Fee Schedule,100% Medicaid Laboratory Fee Schedule,22.23,,,22.23,Fee Schedule,100% Medicaid Laboratory Fee Schedule,22.23,,,22.23,Fee Schedule,100% Medicaid Laboratory Fee Schedule,50.02,,,50.02,Fee Schedule,225% Medicaid Laboratory Fee Schedule,50.02,,,50.02,Fee Schedule,225% Medicaid Laboratory Fee Schedule,34.01,,,34.01,Fee Schedule,153% Medicaid Laboratory Fee Schedule,50.02,,,50.02,Fee Schedule,225% Medicaid Laboratory Fee Schedule,31.12,,,31.12,Fee Schedule,140% Medicaid Laboratory Fee Schedule,50.02,,,50.02,Fee Schedule,225% Medicaid Laboratory Fee Schedule,57.8,,,57.8,Fee Schedule,260% Medicaid Laboratory Fee Schedule,72.03,,,72.03,Fee Schedule,324% Medicaid Laboratory Fee Schedule,47.79,,,47.79,Fee Schedule,215% Medicaid Laboratory Fee Schedule,47.79,,,47.79,Fee Schedule,215% Medicaid Laboratory Fee Schedule,27.79,,,27.79,Fee Schedule,125% Medicaid Laboratory Fee Schedule,22.23,247.1,
DIHYDROTESTOSTERONE             ,82642,CPT,,40190902,CDM,301,RC,,,both,,,466,48.15,,,48.15,Other,150% of Medicare + 9.63% HCRA Surcharge,29.28,,,29.28,Fee Schedule,Mediare Clinical Lab,56.51,,,56.51,Fee Schedule,,50.95,,,50.95,Fee Schedule,,32.53,,,32.53,Fee Schedule,,32.53,,,32.53,Fee Schedule,,32.53,,,32.53,Fee Schedule,,233,50,,233,percent of total billed charges,All Other,61.85,,,61.85,Fee Schedule,,92.23,,,92.23,Fee Schedule,,98.59,,,98.59,Other,186% Medicaid methodology,108.63,,,108.63,Fee Schedule,,288.92,,,288.92,Fee Schedule,,61.49,,,61.49,Fee Schedule,,108.63,,,108.63,Fee Schedule,,288.92,,,288.92,Fee Schedule,,115.66,,,115.66,Fee Schedule,,326.2,70,,326.2,percent of total billed charges,All Other,139.61,,,139.61,Fee Schedule,,118.45,,,118.45,Fee Schedule,,35.14,,,35.14,Fee Schedule,,35.14,,,35.14,Fee Schedule,,35.14,,,35.14,Fee Schedule,,35.14,,,35.14,Fee Schedule,,53,,,53,Other,New York Medicaid APG methodology,53,,,53,Other,100% Medicaid APG methodology,53,,,53,Other,100% Medicaid APG methodology,53,,,53,Other,100% Medicaid APG methodology,119.26,,,119.26,Other,225% Medicaid APG methodology,119.26,,,119.26,Other,225% Medicaid APG methodology,81.1,,,81.1,Other,153% Medicaid APG methodology,119.26,,,119.26,Other,225% Medicaid APG methodology,74.21,,,74.21,Other,140% Medicaid APG methodology,119.26,,,119.26,Other,225% Medicaid APG methodology,137.81,,,137.81,Other,260% Medicaid APG methodology,171.73,,,171.73,Other,324% Medicaid APG methodology,113.96,,,113.96,Other,215% Medicaid APG methodology,113.96,,,113.96,Other,215% Medicaid APG methodology,66.26,,,66.26,Other,125% Medicaid APG methodology,29.28,326.2,
ASSAY GROWTH HORMONE (HGH)      ,83003,CPT,,40190944,CDM,301,RC,,,both,,,265,27.41,,,27.41,Other,150% of Medicare + 9.63% HCRA Surcharge,16.67,,,16.67,Fee Schedule,Mediare Clinical Lab,32.17,,,32.17,Fee Schedule,,29.01,,,29.01,Fee Schedule,,168.51,,,168.51,Fee Schedule,,151.62,,,151.62,Fee Schedule,,143.17,,,143.17,Fee Schedule,,132.5,50,,132.5,percent of total billed charges,All Other,35.23,,,35.23,Fee Schedule,,52.51,,,52.51,Fee Schedule,,31.01,,,31.01,Other,186% Medicaid methodology,61.85,,,61.85,Fee Schedule,,164.3,,,164.3,Fee Schedule,,35.01,,,35.01,Fee Schedule,,61.85,,,61.85,Fee Schedule,,164.3,,,164.3,Fee Schedule,,65.85,,,65.85,Fee Schedule,,185.5,70,,185.5,percent of total billed charges,All Other,79.48,,,79.48,Fee Schedule,,67.44,,,67.44,Fee Schedule,,20,,,20,Fee Schedule,,20,,,20,Fee Schedule,,20,,,20,Fee Schedule,,20,,,20,Fee Schedule,,16.67,,,16.67,Fee Schedule,Medicaid Laboratory Fee Schedule,16.67,,,16.67,Fee Schedule,100% Medicaid Laboratory Fee Schedule,16.67,,,16.67,Fee Schedule,100% Medicaid Laboratory Fee Schedule,16.67,,,16.67,Fee Schedule,100% Medicaid Laboratory Fee Schedule,37.51,,,37.51,Fee Schedule,225% Medicaid Laboratory Fee Schedule,37.51,,,37.51,Fee Schedule,225% Medicaid Laboratory Fee Schedule,25.51,,,25.51,Fee Schedule,153% Medicaid Laboratory Fee Schedule,37.51,,,37.51,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.34,,,23.34,Fee Schedule,140% Medicaid Laboratory Fee Schedule,37.51,,,37.51,Fee Schedule,225% Medicaid Laboratory Fee Schedule,43.34,,,43.34,Fee Schedule,260% Medicaid Laboratory Fee Schedule,54.01,,,54.01,Fee Schedule,324% Medicaid Laboratory Fee Schedule,35.84,,,35.84,Fee Schedule,215% Medicaid Laboratory Fee Schedule,35.84,,,35.84,Fee Schedule,215% Medicaid Laboratory Fee Schedule,20.84,,,20.84,Fee Schedule,125% Medicaid Laboratory Fee Schedule,16.67,185.5,
ASSAY OF PROGESTERONE           ,84144,CPT,,40190985,CDM,301,RC,,,both,,,332,34.3,,,34.3,Other,150% of Medicare + 9.63% HCRA Surcharge,20.86,,,20.86,Fee Schedule,Mediare Clinical Lab,40.26,,,40.26,Fee Schedule,,36.3,,,36.3,Fee Schedule,,210.8,,,210.8,Fee Schedule,,189.67,,,189.67,Fee Schedule,,179.1,,,179.1,Fee Schedule,,166,50,,166,percent of total billed charges,All Other,44.07,,,44.07,Fee Schedule,,65.71,,,65.71,Fee Schedule,,38.8,,,38.8,Other,186% Medicaid methodology,77.39,,,77.39,Fee Schedule,,205.84,,,205.84,Fee Schedule,,43.81,,,43.81,Fee Schedule,,77.39,,,77.39,Fee Schedule,,205.84,,,205.84,Fee Schedule,,82.4,,,82.4,Fee Schedule,,232.4,70,,232.4,percent of total billed charges,All Other,99.46,,,99.46,Fee Schedule,,84.39,,,84.39,Fee Schedule,,25.03,,,25.03,Fee Schedule,,25.03,,,25.03,Fee Schedule,,25.03,,,25.03,Fee Schedule,,25.03,,,25.03,Fee Schedule,,20.86,,,20.86,Fee Schedule,Medicaid Laboratory Fee Schedule,20.86,,,20.86,Fee Schedule,100% Medicaid Laboratory Fee Schedule,20.86,,,20.86,Fee Schedule,100% Medicaid Laboratory Fee Schedule,20.86,,,20.86,Fee Schedule,100% Medicaid Laboratory Fee Schedule,46.94,,,46.94,Fee Schedule,225% Medicaid Laboratory Fee Schedule,46.94,,,46.94,Fee Schedule,225% Medicaid Laboratory Fee Schedule,31.92,,,31.92,Fee Schedule,153% Medicaid Laboratory Fee Schedule,46.94,,,46.94,Fee Schedule,225% Medicaid Laboratory Fee Schedule,29.2,,,29.2,Fee Schedule,140% Medicaid Laboratory Fee Schedule,46.94,,,46.94,Fee Schedule,225% Medicaid Laboratory Fee Schedule,54.24,,,54.24,Fee Schedule,260% Medicaid Laboratory Fee Schedule,67.59,,,67.59,Fee Schedule,324% Medicaid Laboratory Fee Schedule,44.85,,,44.85,Fee Schedule,215% Medicaid Laboratory Fee Schedule,44.85,,,44.85,Fee Schedule,215% Medicaid Laboratory Fee Schedule,26.08,,,26.08,Fee Schedule,125% Medicaid Laboratory Fee Schedule,20.86,232.4,
ASSAY OF PROLACTIN              ,84146,CPT,,40191009,CDM,301,RC,,,both,,,309,31.87,,,31.87,Other,150% of Medicare + 9.63% HCRA Surcharge,19.38,,,19.38,Fee Schedule,Mediare Clinical Lab,37.4,,,37.4,Fee Schedule,,33.72,,,33.72,Fee Schedule,,195.8,,,195.8,Fee Schedule,,176.16,,,176.16,Fee Schedule,,166.35,,,166.35,Fee Schedule,,154.5,50,,154.5,percent of total billed charges,All Other,40.95,,,40.95,Fee Schedule,,61.05,,,61.05,Fee Schedule,,36.05,,,36.05,Other,186% Medicaid methodology,71.9,,,71.9,Fee Schedule,,191.58,,,191.58,Fee Schedule,,40.7,,,40.7,Fee Schedule,,71.9,,,71.9,Fee Schedule,,191.58,,,191.58,Fee Schedule,,76.55,,,76.55,Fee Schedule,,216.3,70,,216.3,percent of total billed charges,All Other,92.4,,,92.4,Fee Schedule,,78.4,,,78.4,Fee Schedule,,23.26,,,23.26,Fee Schedule,,23.26,,,23.26,Fee Schedule,,23.26,,,23.26,Fee Schedule,,23.26,,,23.26,Fee Schedule,,19.38,,,19.38,Fee Schedule,Medicaid Laboratory Fee Schedule,19.38,,,19.38,Fee Schedule,100% Medicaid Laboratory Fee Schedule,19.38,,,19.38,Fee Schedule,100% Medicaid Laboratory Fee Schedule,19.38,,,19.38,Fee Schedule,100% Medicaid Laboratory Fee Schedule,43.61,,,43.61,Fee Schedule,225% Medicaid Laboratory Fee Schedule,43.61,,,43.61,Fee Schedule,225% Medicaid Laboratory Fee Schedule,29.65,,,29.65,Fee Schedule,153% Medicaid Laboratory Fee Schedule,43.61,,,43.61,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.13,,,27.13,Fee Schedule,140% Medicaid Laboratory Fee Schedule,43.61,,,43.61,Fee Schedule,225% Medicaid Laboratory Fee Schedule,50.39,,,50.39,Fee Schedule,260% Medicaid Laboratory Fee Schedule,62.79,,,62.79,Fee Schedule,324% Medicaid Laboratory Fee Schedule,41.67,,,41.67,Fee Schedule,215% Medicaid Laboratory Fee Schedule,41.67,,,41.67,Fee Schedule,215% Medicaid Laboratory Fee Schedule,24.23,,,24.23,Fee Schedule,125% Medicaid Laboratory Fee Schedule,19.38,216.3,
ASSAY OF RENIN                  ,84244,CPT,,40191025,CDM,301,RC,,,both,,,350,36.16,,,36.16,Other,150% of Medicare + 9.63% HCRA Surcharge,21.99,,,21.99,Fee Schedule,Mediare Clinical Lab,42.44,,,42.44,Fee Schedule,,38.26,,,38.26,Fee Schedule,,222.22,,,222.22,Fee Schedule,,199.94,,,199.94,Fee Schedule,,188.8,,,188.8,Fee Schedule,,175,50,,175,percent of total billed charges,All Other,46.44,,,46.44,Fee Schedule,,69.27,,,69.27,Fee Schedule,,98.59,,,98.59,Other,186% Medicaid methodology,81.58,,,81.58,Fee Schedule,,217,,,217,Fee Schedule,,46.18,,,46.18,Fee Schedule,,81.58,,,81.58,Fee Schedule,,217,,,217,Fee Schedule,,86.86,,,86.86,Fee Schedule,,245,70,,245,percent of total billed charges,All Other,104.85,,,104.85,Fee Schedule,,88.96,,,88.96,Fee Schedule,,26.39,,,26.39,Fee Schedule,,26.39,,,26.39,Fee Schedule,,26.39,,,26.39,Fee Schedule,,26.39,,,26.39,Fee Schedule,,53,,,53,Other,New York Medicaid APG methodology,53,,,53,Other,100% Medicaid APG methodology,53,,,53,Other,100% Medicaid APG methodology,53,,,53,Other,100% Medicaid APG methodology,119.26,,,119.26,Other,225% Medicaid APG methodology,119.26,,,119.26,Other,225% Medicaid APG methodology,81.1,,,81.1,Other,153% Medicaid APG methodology,119.26,,,119.26,Other,225% Medicaid APG methodology,74.21,,,74.21,Other,140% Medicaid APG methodology,119.26,,,119.26,Other,225% Medicaid APG methodology,137.81,,,137.81,Other,260% Medicaid APG methodology,171.73,,,171.73,Other,324% Medicaid APG methodology,113.96,,,113.96,Other,215% Medicaid APG methodology,113.96,,,113.96,Other,215% Medicaid APG methodology,66.26,,,66.26,Other,125% Medicaid APG methodology,21.99,245,
ASSAY OF SOMATOMEDIN            ,84305,CPT,,40191041,CDM,301,RC,,,both,,,339,34.96,,,34.96,Other,150% of Medicare + 9.63% HCRA Surcharge,21.26,,,21.26,Fee Schedule,Mediare Clinical Lab,41.03,,,41.03,Fee Schedule,,36.99,,,36.99,Fee Schedule,,214.83,,,214.83,Fee Schedule,,193.28,,,193.28,Fee Schedule,,182.51,,,182.51,Fee Schedule,,169.5,50,,169.5,percent of total billed charges,All Other,44.92,,,44.92,Fee Schedule,,66.97,,,66.97,Fee Schedule,,38.51,,,38.51,Other,186% Medicaid methodology,78.87,,,78.87,Fee Schedule,,210.18,,,210.18,Fee Schedule,,44.65,,,44.65,Fee Schedule,,78.87,,,78.87,Fee Schedule,,210.18,,,210.18,Fee Schedule,,83.98,,,83.98,Fee Schedule,,237.3,70,,237.3,percent of total billed charges,All Other,101.37,,,101.37,Fee Schedule,,86.01,,,86.01,Fee Schedule,,25.51,,,25.51,Fee Schedule,,25.51,,,25.51,Fee Schedule,,25.51,,,25.51,Fee Schedule,,25.51,,,25.51,Fee Schedule,,20.71,,,20.71,Fee Schedule,Medicaid Laboratory Fee Schedule,20.71,,,20.71,Fee Schedule,100% Medicaid Laboratory Fee Schedule,20.71,,,20.71,Fee Schedule,100% Medicaid Laboratory Fee Schedule,20.71,,,20.71,Fee Schedule,100% Medicaid Laboratory Fee Schedule,46.59,,,46.59,Fee Schedule,225% Medicaid Laboratory Fee Schedule,46.59,,,46.59,Fee Schedule,225% Medicaid Laboratory Fee Schedule,31.68,,,31.68,Fee Schedule,153% Medicaid Laboratory Fee Schedule,46.59,,,46.59,Fee Schedule,225% Medicaid Laboratory Fee Schedule,28.99,,,28.99,Fee Schedule,140% Medicaid Laboratory Fee Schedule,46.59,,,46.59,Fee Schedule,225% Medicaid Laboratory Fee Schedule,53.83,,,53.83,Fee Schedule,260% Medicaid Laboratory Fee Schedule,67.08,,,67.08,Fee Schedule,324% Medicaid Laboratory Fee Schedule,44.52,,,44.52,Fee Schedule,215% Medicaid Laboratory Fee Schedule,44.52,,,44.52,Fee Schedule,215% Medicaid Laboratory Fee Schedule,25.88,,,25.88,Fee Schedule,125% Medicaid Laboratory Fee Schedule,20.71,237.3,
ASSAY OF TOTAL TESTOSTERONE     ,84403,CPT,,40191066,CDM,301,RC,,,both,,,411,42.44,,,42.44,Other,150% of Medicare + 9.63% HCRA Surcharge,25.81,,,25.81,Fee Schedule,Mediare Clinical Lab,49.81,,,49.81,Fee Schedule,,44.91,,,44.91,Fee Schedule,,260.85,,,260.85,Fee Schedule,,234.69,,,234.69,Fee Schedule,,221.61,,,221.61,Fee Schedule,,205.5,50,,205.5,percent of total billed charges,All Other,54.54,,,54.54,Fee Schedule,,81.3,,,81.3,Fee Schedule,,48.01,,,48.01,Other,186% Medicaid methodology,95.76,,,95.76,Fee Schedule,,254.82,,,254.82,Fee Schedule,,54.2,,,54.2,Fee Schedule,,95.76,,,95.76,Fee Schedule,,254.82,,,254.82,Fee Schedule,,101.95,,,101.95,Fee Schedule,,287.7,70,,287.7,percent of total billed charges,All Other,123.06,,,123.06,Fee Schedule,,104.41,,,104.41,Fee Schedule,,30.97,,,30.97,Fee Schedule,,30.97,,,30.97,Fee Schedule,,30.97,,,30.97,Fee Schedule,,30.97,,,30.97,Fee Schedule,,25.81,,,25.81,Fee Schedule,Medicaid Laboratory Fee Schedule,25.81,,,25.81,Fee Schedule,100% Medicaid Laboratory Fee Schedule,25.81,,,25.81,Fee Schedule,100% Medicaid Laboratory Fee Schedule,25.81,,,25.81,Fee Schedule,100% Medicaid Laboratory Fee Schedule,58.07,,,58.07,Fee Schedule,225% Medicaid Laboratory Fee Schedule,58.07,,,58.07,Fee Schedule,225% Medicaid Laboratory Fee Schedule,39.49,,,39.49,Fee Schedule,153% Medicaid Laboratory Fee Schedule,58.07,,,58.07,Fee Schedule,225% Medicaid Laboratory Fee Schedule,36.13,,,36.13,Fee Schedule,140% Medicaid Laboratory Fee Schedule,58.07,,,58.07,Fee Schedule,225% Medicaid Laboratory Fee Schedule,67.11,,,67.11,Fee Schedule,260% Medicaid Laboratory Fee Schedule,83.62,,,83.62,Fee Schedule,324% Medicaid Laboratory Fee Schedule,55.49,,,55.49,Fee Schedule,215% Medicaid Laboratory Fee Schedule,55.49,,,55.49,Fee Schedule,215% Medicaid Laboratory Fee Schedule,32.26,,,32.26,Fee Schedule,125% Medicaid Laboratory Fee Schedule,25.81,287.7,
ASSAY OF FREE TESTOSTERONE      ,84402,CPT,,40191082,CDM,301,RC,,,both,,,405,41.88,,,41.88,Other,150% of Medicare + 9.63% HCRA Surcharge,25.47,,,25.47,Fee Schedule,Mediare Clinical Lab,49.16,,,49.16,Fee Schedule,,44.32,,,44.32,Fee Schedule,,257.33,,,257.33,Fee Schedule,,231.53,,,231.53,Fee Schedule,,218.62,,,218.62,Fee Schedule,,202.5,50,,202.5,percent of total billed charges,All Other,53.82,,,53.82,Fee Schedule,,80.23,,,80.23,Fee Schedule,,47.37,,,47.37,Other,186% Medicaid methodology,94.49,,,94.49,Fee Schedule,,251.1,,,251.1,Fee Schedule,,53.49,,,53.49,Fee Schedule,,94.49,,,94.49,Fee Schedule,,251.1,,,251.1,Fee Schedule,,100.61,,,100.61,Fee Schedule,,283.5,70,,283.5,percent of total billed charges,All Other,121.44,,,121.44,Fee Schedule,,103.04,,,103.04,Fee Schedule,,30.56,,,30.56,Fee Schedule,,30.56,,,30.56,Fee Schedule,,30.56,,,30.56,Fee Schedule,,30.56,,,30.56,Fee Schedule,,25.47,,,25.47,Fee Schedule,Medicaid Laboratory Fee Schedule,25.47,,,25.47,Fee Schedule,100% Medicaid Laboratory Fee Schedule,25.47,,,25.47,Fee Schedule,100% Medicaid Laboratory Fee Schedule,25.47,,,25.47,Fee Schedule,100% Medicaid Laboratory Fee Schedule,57.31,,,57.31,Fee Schedule,225% Medicaid Laboratory Fee Schedule,57.31,,,57.31,Fee Schedule,225% Medicaid Laboratory Fee Schedule,38.97,,,38.97,Fee Schedule,153% Medicaid Laboratory Fee Schedule,57.31,,,57.31,Fee Schedule,225% Medicaid Laboratory Fee Schedule,35.66,,,35.66,Fee Schedule,140% Medicaid Laboratory Fee Schedule,57.31,,,57.31,Fee Schedule,225% Medicaid Laboratory Fee Schedule,66.22,,,66.22,Fee Schedule,260% Medicaid Laboratory Fee Schedule,82.52,,,82.52,Fee Schedule,324% Medicaid Laboratory Fee Schedule,54.76,,,54.76,Fee Schedule,215% Medicaid Laboratory Fee Schedule,54.76,,,54.76,Fee Schedule,215% Medicaid Laboratory Fee Schedule,31.84,,,31.84,Fee Schedule,125% Medicaid Laboratory Fee Schedule,25.47,283.5,
ASSAY OF TOTAL ESTRADIOL        ,82670,CPT,,40191181,CDM,301,RC,,,both,,,445,45.95,,,45.95,Other,150% of Medicare + 9.63% HCRA Surcharge,27.94,,,27.94,Fee Schedule,Mediare Clinical Lab,53.92,,,53.92,Fee Schedule,,48.62,,,48.62,Fee Schedule,,282.32,,,282.32,Fee Schedule,,254.01,,,254.01,Fee Schedule,,239.85,,,239.85,Fee Schedule,,222.5,50,,222.5,percent of total billed charges,All Other,59.02,,,59.02,Fee Schedule,,88.01,,,88.01,Fee Schedule,,51.97,,,51.97,Other,186% Medicaid methodology,103.66,,,103.66,Fee Schedule,,275.9,,,275.9,Fee Schedule,,58.67,,,58.67,Fee Schedule,,103.66,,,103.66,Fee Schedule,,275.9,,,275.9,Fee Schedule,,110.36,,,110.36,Fee Schedule,,311.5,70,,311.5,percent of total billed charges,All Other,133.22,,,133.22,Fee Schedule,,113.03,,,113.03,Fee Schedule,,33.53,,,33.53,Fee Schedule,,33.53,,,33.53,Fee Schedule,,33.53,,,33.53,Fee Schedule,,33.53,,,33.53,Fee Schedule,,27.94,,,27.94,Fee Schedule,Medicaid Laboratory Fee Schedule,27.94,,,27.94,Fee Schedule,100% Medicaid Laboratory Fee Schedule,27.94,,,27.94,Fee Schedule,100% Medicaid Laboratory Fee Schedule,27.94,,,27.94,Fee Schedule,100% Medicaid Laboratory Fee Schedule,62.87,,,62.87,Fee Schedule,225% Medicaid Laboratory Fee Schedule,62.87,,,62.87,Fee Schedule,225% Medicaid Laboratory Fee Schedule,42.75,,,42.75,Fee Schedule,153% Medicaid Laboratory Fee Schedule,62.87,,,62.87,Fee Schedule,225% Medicaid Laboratory Fee Schedule,39.12,,,39.12,Fee Schedule,140% Medicaid Laboratory Fee Schedule,62.87,,,62.87,Fee Schedule,225% Medicaid Laboratory Fee Schedule,72.64,,,72.64,Fee Schedule,260% Medicaid Laboratory Fee Schedule,90.53,,,90.53,Fee Schedule,324% Medicaid Laboratory Fee Schedule,60.07,,,60.07,Fee Schedule,215% Medicaid Laboratory Fee Schedule,60.07,,,60.07,Fee Schedule,215% Medicaid Laboratory Fee Schedule,34.93,,,34.93,Fee Schedule,125% Medicaid Laboratory Fee Schedule,27.94,311.5,
ASSAY OF ESTRONE                ,82679,CPT,,40191207,CDM,301,RC,,,both,,,397,41.03,,,41.03,Other,150% of Medicare + 9.63% HCRA Surcharge,24.95,,,24.95,Fee Schedule,Mediare Clinical Lab,48.15,,,48.15,Fee Schedule,,43.41,,,43.41,Fee Schedule,,252.16,,,252.16,Fee Schedule,,226.88,,,226.88,Fee Schedule,,214.23,,,214.23,Fee Schedule,,198.5,50,,198.5,percent of total billed charges,All Other,52.72,,,52.72,Fee Schedule,,78.59,,,78.59,Fee Schedule,,46.41,,,46.41,Other,186% Medicaid methodology,92.56,,,92.56,Fee Schedule,,246.14,,,246.14,Fee Schedule,,52.4,,,52.4,Fee Schedule,,92.56,,,92.56,Fee Schedule,,246.14,,,246.14,Fee Schedule,,98.55,,,98.55,Fee Schedule,,277.9,70,,277.9,percent of total billed charges,All Other,118.96,,,118.96,Fee Schedule,,100.94,,,100.94,Fee Schedule,,29.94,,,29.94,Fee Schedule,,29.94,,,29.94,Fee Schedule,,29.94,,,29.94,Fee Schedule,,29.94,,,29.94,Fee Schedule,,24.95,,,24.95,Fee Schedule,Medicaid Laboratory Fee Schedule,24.95,,,24.95,Fee Schedule,100% Medicaid Laboratory Fee Schedule,24.95,,,24.95,Fee Schedule,100% Medicaid Laboratory Fee Schedule,24.95,,,24.95,Fee Schedule,100% Medicaid Laboratory Fee Schedule,56.14,,,56.14,Fee Schedule,225% Medicaid Laboratory Fee Schedule,56.14,,,56.14,Fee Schedule,225% Medicaid Laboratory Fee Schedule,38.17,,,38.17,Fee Schedule,153% Medicaid Laboratory Fee Schedule,56.14,,,56.14,Fee Schedule,225% Medicaid Laboratory Fee Schedule,34.93,,,34.93,Fee Schedule,140% Medicaid Laboratory Fee Schedule,56.14,,,56.14,Fee Schedule,225% Medicaid Laboratory Fee Schedule,64.87,,,64.87,Fee Schedule,260% Medicaid Laboratory Fee Schedule,80.84,,,80.84,Fee Schedule,324% Medicaid Laboratory Fee Schedule,53.64,,,53.64,Fee Schedule,215% Medicaid Laboratory Fee Schedule,53.64,,,53.64,Fee Schedule,215% Medicaid Laboratory Fee Schedule,31.19,,,31.19,Fee Schedule,125% Medicaid Laboratory Fee Schedule,24.95,277.9,
ASSAY OF FREE THYROXINE         ,84439,CPT,,40191264,CDM,301,RC,,,both,,,144,14.83,,,14.83,Other,150% of Medicare + 9.63% HCRA Surcharge,9.02,,,9.02,Fee Schedule,Mediare Clinical Lab,17.41,,,17.41,Fee Schedule,,15.69,,,15.69,Fee Schedule,,91.11,,,91.11,Fee Schedule,,81.98,,,81.98,Fee Schedule,,77.41,,,77.41,Fee Schedule,,72,50,,72,percent of total billed charges,All Other,19.05,,,19.05,Fee Schedule,,28.41,,,28.41,Fee Schedule,,16.74,,,16.74,Other,186% Medicaid methodology,33.46,,,33.46,Fee Schedule,,89.28,,,89.28,Fee Schedule,,18.94,,,18.94,Fee Schedule,,33.46,,,33.46,Fee Schedule,,89.28,,,89.28,Fee Schedule,,35.63,,,35.63,Fee Schedule,,100.8,70,,100.8,percent of total billed charges,All Other,43.01,,,43.01,Fee Schedule,,36.49,,,36.49,Fee Schedule,,10.82,,,10.82,Fee Schedule,,10.82,,,10.82,Fee Schedule,,10.82,,,10.82,Fee Schedule,,10.82,,,10.82,Fee Schedule,,9,,,9,Fee Schedule,Medicaid Laboratory Fee Schedule,9,,,9,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9,,,9,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9,,,9,Fee Schedule,100% Medicaid Laboratory Fee Schedule,20.25,,,20.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,20.25,,,20.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.77,,,13.77,Fee Schedule,153% Medicaid Laboratory Fee Schedule,20.25,,,20.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.6,,,12.6,Fee Schedule,140% Medicaid Laboratory Fee Schedule,20.25,,,20.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.4,,,23.4,Fee Schedule,260% Medicaid Laboratory Fee Schedule,29.16,,,29.16,Fee Schedule,324% Medicaid Laboratory Fee Schedule,19.35,,,19.35,Fee Schedule,215% Medicaid Laboratory Fee Schedule,19.35,,,19.35,Fee Schedule,215% Medicaid Laboratory Fee Schedule,11.25,,,11.25,Fee Schedule,125% Medicaid Laboratory Fee Schedule,9,100.8,
81347 -SF3B1,81347,CPT,,40193203,CDM,301,RC,,,both,,,500,317.79,,,317.79,Other,150% of Medicare + 9.63% HCRA Surcharge,193.25,,,193.25,Fee Schedule,Mediare Clinical Lab,372.97,,,372.97,Fee Schedule,,336.26,,,336.26,Fee Schedule,,73.44,,,73.44,Fee Schedule,,73.44,,,73.44,Fee Schedule,,73.44,,,73.44,Fee Schedule,,250,50,,250,percent of total billed charges,All Other,408.23,,,408.23,Fee Schedule,,608.74,,,608.74,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,716.96,,,716.96,Fee Schedule,,310,,,310,Fee Schedule,,405.83,,,405.83,Fee Schedule,,716.96,,,716.96,Fee Schedule,,310,,,310,Fee Schedule,,763.34,,,763.34,Fee Schedule,,350,70,,350,percent of total billed charges,All Other,921.4,,,921.4,Fee Schedule,,781.8,,,781.8,Fee Schedule,,231.9,,,231.9,Fee Schedule,,231.9,,,231.9,Fee Schedule,,231.9,,,231.9,Fee Schedule,,231.9,,,231.9,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,921.4,
IRON BINDING TEST               ,83550,CPT,,40196081,CDM,301,RC,,,both,,,139,14.37,,,14.37,Other,150% of Medicare + 9.63% HCRA Surcharge,8.74,,,8.74,Fee Schedule,Mediare Clinical Lab,16.87,,,16.87,Fee Schedule,,15.21,,,15.21,Fee Schedule,,88.31,,,88.31,Fee Schedule,,79.46,,,79.46,Fee Schedule,,75.03,,,75.03,Fee Schedule,,69.5,50,,69.5,percent of total billed charges,All Other,18.46,,,18.46,Fee Schedule,,27.53,,,27.53,Fee Schedule,,9.45,,,9.45,Other,186% Medicaid methodology,32.43,,,32.43,Fee Schedule,,86.18,,,86.18,Fee Schedule,,18.35,,,18.35,Fee Schedule,,32.43,,,32.43,Fee Schedule,,86.18,,,86.18,Fee Schedule,,34.52,,,34.52,Fee Schedule,,97.3,70,,97.3,percent of total billed charges,All Other,41.67,,,41.67,Fee Schedule,,35.36,,,35.36,Fee Schedule,,10.49,,,10.49,Fee Schedule,,10.49,,,10.49,Fee Schedule,,10.49,,,10.49,Fee Schedule,,10.49,,,10.49,Fee Schedule,,5.08,,,5.08,Fee Schedule,Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.08,,,5.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.77,,,7.77,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.11,,,7.11,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.43,,,11.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.21,,,13.21,Fee Schedule,260% Medicaid Laboratory Fee Schedule,16.46,,,16.46,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.92,,,10.92,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.35,,,6.35,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.08,97.3,
81352 -TP53,81352,CPT,,40198988,CDM,301,RC,,,both,,,500,541.86,,,541.86,Other,150% of Medicare + 9.63% HCRA Surcharge,329.51,,,329.51,Fee Schedule,Mediare Clinical Lab,635.95,,,635.95,Fee Schedule,,573.35,,,573.35,Fee Schedule,,57.48,,,57.48,Fee Schedule,,57.48,,,57.48,Fee Schedule,,57.48,,,57.48,Fee Schedule,,250,50,,250,percent of total billed charges,All Other,696.09,,,696.09,Fee Schedule,,1037.96,,,1037.96,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,1222.48,,,1222.48,Fee Schedule,,310,,,310,Fee Schedule,,691.97,,,691.97,Fee Schedule,,1222.48,,,1222.48,Fee Schedule,,310,,,310,Fee Schedule,,1301.56,,,1301.56,Fee Schedule,,350,70,,350,percent of total billed charges,All Other,1571.08,,,1571.08,Fee Schedule,,1333.04,,,1333.04,Fee Schedule,,395.41,,,395.41,Fee Schedule,,395.41,,,395.41,Fee Schedule,,395.41,,,395.41,Fee Schedule,,395.41,,,395.41,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1571.08,
ASSAY TRIIODOTHYRONINE (T3)     ,84480,CPT,,40199218,CDM,301,RC,,,both,,,226,23.32,,,23.32,Other,150% of Medicare + 9.63% HCRA Surcharge,14.18,,,14.18,Fee Schedule,Mediare Clinical Lab,27.37,,,27.37,Fee Schedule,,24.67,,,24.67,Fee Schedule,,143.24,,,143.24,Fee Schedule,,128.88,,,128.88,Fee Schedule,,121.7,,,121.7,Fee Schedule,,113,50,,113,percent of total billed charges,All Other,29.97,,,29.97,Fee Schedule,,44.67,,,44.67,Fee Schedule,,10.71,,,10.71,Other,186% Medicaid methodology,52.61,,,52.61,Fee Schedule,,140.12,,,140.12,Fee Schedule,,29.78,,,29.78,Fee Schedule,,52.61,,,52.61,Fee Schedule,,140.12,,,140.12,Fee Schedule,,56.01,,,56.01,Fee Schedule,,158.2,70,,158.2,percent of total billed charges,All Other,67.61,,,67.61,Fee Schedule,,57.37,,,57.37,Fee Schedule,,17.02,,,17.02,Fee Schedule,,17.02,,,17.02,Fee Schedule,,17.02,,,17.02,Fee Schedule,,17.02,,,17.02,Fee Schedule,,5.76,,,5.76,Fee Schedule,Medicaid Laboratory Fee Schedule,5.76,,,5.76,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.76,,,5.76,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.76,,,5.76,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.95,,,12.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.95,,,12.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.81,,,8.81,Fee Schedule,153% Medicaid Laboratory Fee Schedule,12.95,,,12.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.06,,,8.06,Fee Schedule,140% Medicaid Laboratory Fee Schedule,12.95,,,12.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.97,,,14.97,Fee Schedule,260% Medicaid Laboratory Fee Schedule,18.65,,,18.65,Fee Schedule,324% Medicaid Laboratory Fee Schedule,12.38,,,12.38,Fee Schedule,215% Medicaid Laboratory Fee Schedule,12.38,,,12.38,Fee Schedule,215% Medicaid Laboratory Fee Schedule,7.2,,,7.2,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.76,158.2,
ASSAY SPEC XCP UR&BREATH IA     ,82077,CPT,,40199812,CDM,301,RC,,,both,,,686,28.4,,,28.4,Other,150% of Medicare + 9.63% HCRA Surcharge,17.27,,,17.27,Fee Schedule,Mediare Clinical Lab,33.33,,,33.33,Fee Schedule,,30.05,,,30.05,Fee Schedule,,13.82,,,13.82,Fee Schedule,,13.82,,,13.82,Fee Schedule,,13.82,,,13.82,Fee Schedule,,343,50,,343,percent of total billed charges,All Other,36.5,,,36.5,Fee Schedule,,54.4,,,54.4,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,64.07,,,64.07,Fee Schedule,,425.32,,,425.32,Fee Schedule,,36.27,,,36.27,Fee Schedule,,64.07,,,64.07,Fee Schedule,,425.32,,,425.32,Fee Schedule,,68.22,,,68.22,Fee Schedule,,480.2,70,,480.2,percent of total billed charges,All Other,82.34,,,82.34,Fee Schedule,,69.87,,,69.87,Fee Schedule,,20.72,,,20.72,Fee Schedule,,20.72,,,20.72,Fee Schedule,,20.72,,,20.72,Fee Schedule,,20.72,,,20.72,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,480.2,
BLOOD GAS MIXED WO O2 SAT       ,82803,CPT,,46500005,CDM,301,RC,,,both,,,415,42.87,,,42.87,Other,150% of Medicare + 9.63% HCRA Surcharge,26.07,,,26.07,Fee Schedule,Mediare Clinical Lab,50.32,,,50.32,Fee Schedule,,45.36,,,45.36,Fee Schedule,,195.44,,,195.44,Fee Schedule,,175.84,,,175.84,Fee Schedule,,166.04,,,166.04,Fee Schedule,,207.5,50,,207.5,percent of total billed charges,All Other,55.09,,,55.09,Fee Schedule,,82.12,,,82.12,Fee Schedule,,30.43,,,30.43,Other,186% Medicaid methodology,96.72,,,96.72,Fee Schedule,,257.3,,,257.3,Fee Schedule,,54.75,,,54.75,Fee Schedule,,96.72,,,96.72,Fee Schedule,,257.3,,,257.3,Fee Schedule,,102.98,,,102.98,Fee Schedule,,290.5,70,,290.5,percent of total billed charges,All Other,124.3,,,124.3,Fee Schedule,,105.47,,,105.47,Fee Schedule,,31.28,,,31.28,Fee Schedule,,31.28,,,31.28,Fee Schedule,,31.28,,,31.28,Fee Schedule,,31.28,,,31.28,Fee Schedule,,16.36,,,16.36,Fee Schedule,Medicaid Laboratory Fee Schedule,16.36,,,16.36,Fee Schedule,100% Medicaid Laboratory Fee Schedule,16.36,,,16.36,Fee Schedule,100% Medicaid Laboratory Fee Schedule,16.36,,,16.36,Fee Schedule,100% Medicaid Laboratory Fee Schedule,36.81,,,36.81,Fee Schedule,225% Medicaid Laboratory Fee Schedule,36.81,,,36.81,Fee Schedule,225% Medicaid Laboratory Fee Schedule,25.03,,,25.03,Fee Schedule,153% Medicaid Laboratory Fee Schedule,36.81,,,36.81,Fee Schedule,225% Medicaid Laboratory Fee Schedule,22.91,,,22.91,Fee Schedule,140% Medicaid Laboratory Fee Schedule,36.81,,,36.81,Fee Schedule,225% Medicaid Laboratory Fee Schedule,42.54,,,42.54,Fee Schedule,260% Medicaid Laboratory Fee Schedule,53.01,,,53.01,Fee Schedule,324% Medicaid Laboratory Fee Schedule,35.18,,,35.18,Fee Schedule,215% Medicaid Laboratory Fee Schedule,35.18,,,35.18,Fee Schedule,215% Medicaid Laboratory Fee Schedule,20.45,,,20.45,Fee Schedule,125% Medicaid Laboratory Fee Schedule,16.36,290.5,
BLOOD GAS MIXED WO O2 SAT       ,82803,CPT,,46600565,CDM,301,RC,,,both,,,415,42.87,,,42.87,Other,150% of Medicare + 9.63% HCRA Surcharge,26.07,,,26.07,Fee Schedule,Mediare Clinical Lab,50.32,,,50.32,Fee Schedule,,45.36,,,45.36,Fee Schedule,,195.44,,,195.44,Fee Schedule,,175.84,,,175.84,Fee Schedule,,166.04,,,166.04,Fee Schedule,,207.5,50,,207.5,percent of total billed charges,All Other,55.09,,,55.09,Fee Schedule,,82.12,,,82.12,Fee Schedule,,30.43,,,30.43,Other,186% Medicaid methodology,96.72,,,96.72,Fee Schedule,,257.3,,,257.3,Fee Schedule,,54.75,,,54.75,Fee Schedule,,96.72,,,96.72,Fee Schedule,,257.3,,,257.3,Fee Schedule,,102.98,,,102.98,Fee Schedule,,290.5,70,,290.5,percent of total billed charges,All Other,124.3,,,124.3,Fee Schedule,,105.47,,,105.47,Fee Schedule,,31.28,,,31.28,Fee Schedule,,31.28,,,31.28,Fee Schedule,,31.28,,,31.28,Fee Schedule,,31.28,,,31.28,Fee Schedule,,16.36,,,16.36,Fee Schedule,Medicaid Laboratory Fee Schedule,16.36,,,16.36,Fee Schedule,100% Medicaid Laboratory Fee Schedule,16.36,,,16.36,Fee Schedule,100% Medicaid Laboratory Fee Schedule,16.36,,,16.36,Fee Schedule,100% Medicaid Laboratory Fee Schedule,36.81,,,36.81,Fee Schedule,225% Medicaid Laboratory Fee Schedule,36.81,,,36.81,Fee Schedule,225% Medicaid Laboratory Fee Schedule,25.03,,,25.03,Fee Schedule,153% Medicaid Laboratory Fee Schedule,36.81,,,36.81,Fee Schedule,225% Medicaid Laboratory Fee Schedule,22.91,,,22.91,Fee Schedule,140% Medicaid Laboratory Fee Schedule,36.81,,,36.81,Fee Schedule,225% Medicaid Laboratory Fee Schedule,42.54,,,42.54,Fee Schedule,260% Medicaid Laboratory Fee Schedule,53.01,,,53.01,Fee Schedule,324% Medicaid Laboratory Fee Schedule,35.18,,,35.18,Fee Schedule,215% Medicaid Laboratory Fee Schedule,35.18,,,35.18,Fee Schedule,215% Medicaid Laboratory Fee Schedule,20.45,,,20.45,Fee Schedule,125% Medicaid Laboratory Fee Schedule,16.36,290.5,
GLUCOSE BLOOD TEST              ,82962,CPT,,47900436,CDM,301,RC,,,both,,,52,5.39,,,5.39,Other,150% of Medicare + 9.63% HCRA Surcharge,3.28,,,3.28,Fee Schedule,Mediare Clinical Lab,6.33,,,6.33,Fee Schedule,,5.71,,,5.71,Fee Schedule,,21.97,,,21.97,Fee Schedule,,19.77,,,19.77,Fee Schedule,,18.67,,,18.67,Fee Schedule,,26,50,,26,percent of total billed charges,All Other,6.92,,,6.92,Fee Schedule,,10.33,,,10.33,Fee Schedule,,56.01,,,56.01,Other,186% Medicaid methodology,12.17,,,12.17,Fee Schedule,,32.24,,,32.24,Fee Schedule,,6.89,,,6.89,Fee Schedule,,12.17,,,12.17,Fee Schedule,,32.24,,,32.24,Fee Schedule,,12.96,,,12.96,Fee Schedule,,36.4,70,,36.4,percent of total billed charges,All Other,15.64,,,15.64,Fee Schedule,,13.27,,,13.27,Fee Schedule,,3.94,,,3.94,Fee Schedule,,3.94,,,3.94,Fee Schedule,,3.94,,,3.94,Fee Schedule,,3.94,,,3.94,Fee Schedule,,30.11,,,30.11,Other,New York Medicaid APG methodology,30.11,,,30.11,Other,100% Medicaid APG methodology,30.11,,,30.11,Other,100% Medicaid APG methodology,30.11,,,30.11,Other,100% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,46.07,,,46.07,Other,153% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,42.16,,,42.16,Other,140% Medicaid APG methodology,67.75,,,67.75,Other,225% Medicaid APG methodology,78.29,,,78.29,Other,260% Medicaid APG methodology,97.56,,,97.56,Other,324% Medicaid APG methodology,64.74,,,64.74,Other,215% Medicaid APG methodology,64.74,,,64.74,Other,215% Medicaid APG methodology,37.64,,,37.64,Other,125% Medicaid APG methodology,3.28,97.56,
SYPHILIS TEST NON-TREP QUAL     ,86592,CPT,,40110744,CDM,302,RC,,,both,,,68,7.02,,,7.02,Other,150% of Medicare + 9.63% HCRA Surcharge,4.27,,,4.27,Fee Schedule,Mediare Clinical Lab,8.24,,,8.24,Fee Schedule,,7.43,,,7.43,Fee Schedule,,43.15,,,43.15,Fee Schedule,,38.82,,,38.82,Fee Schedule,,36.66,,,36.66,Fee Schedule,,34,50,,34,percent of total billed charges,All Other,9.04,,,9.04,Fee Schedule,,13.45,,,13.45,Fee Schedule,,6.14,,,6.14,Other,186% Medicaid methodology,15.84,,,15.84,Fee Schedule,,42.16,,,42.16,Fee Schedule,,8.97,,,8.97,Fee Schedule,,15.84,,,15.84,Fee Schedule,,42.16,,,42.16,Fee Schedule,,16.87,,,16.87,Fee Schedule,,47.6,70,,47.6,percent of total billed charges,All Other,20.36,,,20.36,Fee Schedule,,17.27,,,17.27,Fee Schedule,,5.12,,,5.12,Fee Schedule,,5.12,,,5.12,Fee Schedule,,5.12,,,5.12,Fee Schedule,,5.12,,,5.12,Fee Schedule,,3.3,,,3.3,Fee Schedule,Medicaid Laboratory Fee Schedule,3.3,,,3.3,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.3,,,3.3,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.3,,,3.3,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.43,,,7.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.43,,,7.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.05,,,5.05,Fee Schedule,153% Medicaid Laboratory Fee Schedule,7.43,,,7.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,4.62,,,4.62,Fee Schedule,140% Medicaid Laboratory Fee Schedule,7.43,,,7.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.59,,,8.59,Fee Schedule,260% Medicaid Laboratory Fee Schedule,10.7,,,10.7,Fee Schedule,324% Medicaid Laboratory Fee Schedule,7.1,,,7.1,Fee Schedule,215% Medicaid Laboratory Fee Schedule,7.1,,,7.1,Fee Schedule,215% Medicaid Laboratory Fee Schedule,4.13,,,4.13,Fee Schedule,125% Medicaid Laboratory Fee Schedule,3.3,47.6,
EPSTEIN-BARR NUCLEAR ANTIGEN    ,86664,CPT,,40112708,CDM,302,RC,,,both,,,243,25.14,,,25.14,Other,150% of Medicare + 9.63% HCRA Surcharge,15.29,,,15.29,Fee Schedule,Mediare Clinical Lab,29.51,,,29.51,Fee Schedule,,26.6,,,26.6,Fee Schedule,,154.59,,,154.59,Fee Schedule,,139.08,,,139.08,Fee Schedule,,131.33,,,131.33,Fee Schedule,,121.5,50,,121.5,percent of total billed charges,All Other,32.31,,,32.31,Fee Schedule,,48.16,,,48.16,Fee Schedule,,28.44,,,28.44,Other,186% Medicaid methodology,56.73,,,56.73,Fee Schedule,,150.66,,,150.66,Fee Schedule,,32.11,,,32.11,Fee Schedule,,56.73,,,56.73,Fee Schedule,,150.66,,,150.66,Fee Schedule,,60.4,,,60.4,Fee Schedule,,170.1,70,,170.1,percent of total billed charges,All Other,72.9,,,72.9,Fee Schedule,,61.86,,,61.86,Fee Schedule,,18.35,,,18.35,Fee Schedule,,18.35,,,18.35,Fee Schedule,,18.35,,,18.35,Fee Schedule,,18.35,,,18.35,Fee Schedule,,15.29,,,15.29,Fee Schedule,Medicaid Laboratory Fee Schedule,15.29,,,15.29,Fee Schedule,100% Medicaid Laboratory Fee Schedule,15.29,,,15.29,Fee Schedule,100% Medicaid Laboratory Fee Schedule,15.29,,,15.29,Fee Schedule,100% Medicaid Laboratory Fee Schedule,34.4,,,34.4,Fee Schedule,225% Medicaid Laboratory Fee Schedule,34.4,,,34.4,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.39,,,23.39,Fee Schedule,153% Medicaid Laboratory Fee Schedule,34.4,,,34.4,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.41,,,21.41,Fee Schedule,140% Medicaid Laboratory Fee Schedule,34.4,,,34.4,Fee Schedule,225% Medicaid Laboratory Fee Schedule,39.75,,,39.75,Fee Schedule,260% Medicaid Laboratory Fee Schedule,49.54,,,49.54,Fee Schedule,324% Medicaid Laboratory Fee Schedule,32.87,,,32.87,Fee Schedule,215% Medicaid Laboratory Fee Schedule,32.87,,,32.87,Fee Schedule,215% Medicaid Laboratory Fee Schedule,19.11,,,19.11,Fee Schedule,125% Medicaid Laboratory Fee Schedule,15.29,170.1,
WEST NILE VIRUS ANTIBODY        ,86789,CPT,,40112740,CDM,302,RC,,,both,,,229,23.66,,,23.66,Other,150% of Medicare + 9.63% HCRA Surcharge,14.39,,,14.39,Fee Schedule,Mediare Clinical Lab,27.77,,,27.77,Fee Schedule,,25.04,,,25.04,Fee Schedule,,145.4,,,145.4,Fee Schedule,,130.82,,,130.82,Fee Schedule,,123.53,,,123.53,Fee Schedule,,114.5,50,,114.5,percent of total billed charges,All Other,30.39,,,30.39,Fee Schedule,,45.33,,,45.33,Fee Schedule,,26.77,,,26.77,Other,186% Medicaid methodology,53.39,,,53.39,Fee Schedule,,141.98,,,141.98,Fee Schedule,,30.22,,,30.22,Fee Schedule,,53.39,,,53.39,Fee Schedule,,141.98,,,141.98,Fee Schedule,,56.84,,,56.84,Fee Schedule,,160.3,70,,160.3,percent of total billed charges,All Other,68.61,,,68.61,Fee Schedule,,58.22,,,58.22,Fee Schedule,,17.27,,,17.27,Fee Schedule,,17.27,,,17.27,Fee Schedule,,17.27,,,17.27,Fee Schedule,,17.27,,,17.27,Fee Schedule,,14.39,,,14.39,Fee Schedule,Medicaid Laboratory Fee Schedule,14.39,,,14.39,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.39,,,14.39,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.39,,,14.39,Fee Schedule,100% Medicaid Laboratory Fee Schedule,32.38,,,32.38,Fee Schedule,225% Medicaid Laboratory Fee Schedule,32.38,,,32.38,Fee Schedule,225% Medicaid Laboratory Fee Schedule,22.02,,,22.02,Fee Schedule,153% Medicaid Laboratory Fee Schedule,32.38,,,32.38,Fee Schedule,225% Medicaid Laboratory Fee Schedule,20.15,,,20.15,Fee Schedule,140% Medicaid Laboratory Fee Schedule,32.38,,,32.38,Fee Schedule,225% Medicaid Laboratory Fee Schedule,37.41,,,37.41,Fee Schedule,260% Medicaid Laboratory Fee Schedule,46.62,,,46.62,Fee Schedule,324% Medicaid Laboratory Fee Schedule,30.94,,,30.94,Fee Schedule,215% Medicaid Laboratory Fee Schedule,30.94,,,30.94,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.99,,,17.99,Fee Schedule,125% Medicaid Laboratory Fee Schedule,14.39,160.3,
WEST NILE VIRUS AB IGM          ,86788,CPT,,40112765,CDM,302,RC,,,both,,,269,27.71,,,27.71,Other,150% of Medicare + 9.63% HCRA Surcharge,16.85,,,16.85,Fee Schedule,Mediare Clinical Lab,32.52,,,32.52,Fee Schedule,,29.32,,,29.32,Fee Schedule,,58.73,,,58.73,Fee Schedule,,52.84,,,52.84,Fee Schedule,,49.9,,,49.9,Fee Schedule,,134.5,50,,134.5,percent of total billed charges,All Other,35.59,,,35.59,Fee Schedule,,53.08,,,53.08,Fee Schedule,,15.09,,,15.09,Other,186% Medicaid methodology,62.51,,,62.51,Fee Schedule,,166.78,,,166.78,Fee Schedule,,35.39,,,35.39,Fee Schedule,,62.51,,,62.51,Fee Schedule,,166.78,,,166.78,Fee Schedule,,66.56,,,66.56,Fee Schedule,,188.3,70,,188.3,percent of total billed charges,All Other,80.34,,,80.34,Fee Schedule,,68.17,,,68.17,Fee Schedule,,20.22,,,20.22,Fee Schedule,,20.22,,,20.22,Fee Schedule,,20.22,,,20.22,Fee Schedule,,20.22,,,20.22,Fee Schedule,,8.11,,,8.11,Fee Schedule,Medicaid Laboratory Fee Schedule,8.11,,,8.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.11,,,8.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.11,,,8.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.41,,,12.41,Fee Schedule,153% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.35,,,11.35,Fee Schedule,140% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.09,,,21.09,Fee Schedule,260% Medicaid Laboratory Fee Schedule,26.28,,,26.28,Fee Schedule,324% Medicaid Laboratory Fee Schedule,17.44,,,17.44,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.44,,,17.44,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.14,,,10.14,Fee Schedule,125% Medicaid Laboratory Fee Schedule,8.11,188.3,
C-REACTIVE PROTEIN              ,86140,CPT,,40121089,CDM,302,RC,,,both,,,83,8.52,,,8.52,Other,150% of Medicare + 9.63% HCRA Surcharge,5.18,,,5.18,Fee Schedule,Mediare Clinical Lab,10,,,10,Fee Schedule,,9.01,,,9.01,Fee Schedule,,52.27,,,52.27,Fee Schedule,,47.03,,,47.03,Fee Schedule,,44.41,,,44.41,Fee Schedule,,41.5,50,,41.5,percent of total billed charges,All Other,10.95,,,10.95,Fee Schedule,,16.32,,,16.32,Fee Schedule,,7.7,,,7.7,Other,186% Medicaid methodology,19.22,,,19.22,Fee Schedule,,51.46,,,51.46,Fee Schedule,,10.88,,,10.88,Fee Schedule,,19.22,,,19.22,Fee Schedule,,51.46,,,51.46,Fee Schedule,,20.46,,,20.46,Fee Schedule,,58.1,70,,58.1,percent of total billed charges,All Other,24.7,,,24.7,Fee Schedule,,20.96,,,20.96,Fee Schedule,,6.22,,,6.22,Fee Schedule,,6.22,,,6.22,Fee Schedule,,6.22,,,6.22,Fee Schedule,,6.22,,,6.22,Fee Schedule,,4.14,,,4.14,Fee Schedule,Medicaid Laboratory Fee Schedule,4.14,,,4.14,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.14,,,4.14,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.14,,,4.14,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.32,,,9.32,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.32,,,9.32,Fee Schedule,225% Medicaid Laboratory Fee Schedule,6.34,,,6.34,Fee Schedule,153% Medicaid Laboratory Fee Schedule,9.32,,,9.32,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.8,,,5.8,Fee Schedule,140% Medicaid Laboratory Fee Schedule,9.32,,,9.32,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.77,,,10.77,Fee Schedule,260% Medicaid Laboratory Fee Schedule,13.42,,,13.42,Fee Schedule,324% Medicaid Laboratory Fee Schedule,8.9,,,8.9,Fee Schedule,215% Medicaid Laboratory Fee Schedule,8.9,,,8.9,Fee Schedule,215% Medicaid Laboratory Fee Schedule,5.18,,,5.18,Fee Schedule,125% Medicaid Laboratory Fee Schedule,4.14,58.1,
IMMUNOASSAY TUMOR CA 19-9       ,86301,CPT,,40121287,CDM,302,RC,,,both,,,331,34.22,,,34.22,Other,150% of Medicare + 9.63% HCRA Surcharge,20.81,,,20.81,Fee Schedule,Mediare Clinical Lab,40.16,,,40.16,Fee Schedule,,36.21,,,36.21,Fee Schedule,,210.3,,,210.3,Fee Schedule,,189.21,,,189.21,Fee Schedule,,178.67,,,178.67,Fee Schedule,,165.5,50,,165.5,percent of total billed charges,All Other,43.97,,,43.97,Fee Schedule,,65.55,,,65.55,Fee Schedule,,38.71,,,38.71,Other,186% Medicaid methodology,77.21,,,77.21,Fee Schedule,,205.22,,,205.22,Fee Schedule,,43.7,,,43.7,Fee Schedule,,77.21,,,77.21,Fee Schedule,,205.22,,,205.22,Fee Schedule,,82.2,,,82.2,Fee Schedule,,231.7,70,,231.7,percent of total billed charges,All Other,99.22,,,99.22,Fee Schedule,,84.19,,,84.19,Fee Schedule,,24.97,,,24.97,Fee Schedule,,24.97,,,24.97,Fee Schedule,,24.97,,,24.97,Fee Schedule,,24.97,,,24.97,Fee Schedule,,20.81,,,20.81,Fee Schedule,Medicaid Laboratory Fee Schedule,20.81,,,20.81,Fee Schedule,100% Medicaid Laboratory Fee Schedule,20.81,,,20.81,Fee Schedule,100% Medicaid Laboratory Fee Schedule,20.81,,,20.81,Fee Schedule,100% Medicaid Laboratory Fee Schedule,46.82,,,46.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,46.82,,,46.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,31.84,,,31.84,Fee Schedule,153% Medicaid Laboratory Fee Schedule,46.82,,,46.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,29.13,,,29.13,Fee Schedule,140% Medicaid Laboratory Fee Schedule,46.82,,,46.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,54.11,,,54.11,Fee Schedule,260% Medicaid Laboratory Fee Schedule,67.42,,,67.42,Fee Schedule,324% Medicaid Laboratory Fee Schedule,44.74,,,44.74,Fee Schedule,215% Medicaid Laboratory Fee Schedule,44.74,,,44.74,Fee Schedule,215% Medicaid Laboratory Fee Schedule,26.01,,,26.01,Fee Schedule,125% Medicaid Laboratory Fee Schedule,20.81,231.7,
IMMUNOASSAY TUMOR CA 125        ,86304,CPT,,40121303,CDM,302,RC,,,both,,,331,34.22,,,34.22,Other,150% of Medicare + 9.63% HCRA Surcharge,20.81,,,20.81,Fee Schedule,Mediare Clinical Lab,40.16,,,40.16,Fee Schedule,,36.21,,,36.21,Fee Schedule,,210.3,,,210.3,Fee Schedule,,189.21,,,189.21,Fee Schedule,,178.67,,,178.67,Fee Schedule,,165.5,50,,165.5,percent of total billed charges,All Other,43.97,,,43.97,Fee Schedule,,65.55,,,65.55,Fee Schedule,,38.71,,,38.71,Other,186% Medicaid methodology,77.21,,,77.21,Fee Schedule,,205.22,,,205.22,Fee Schedule,,43.7,,,43.7,Fee Schedule,,77.21,,,77.21,Fee Schedule,,205.22,,,205.22,Fee Schedule,,82.2,,,82.2,Fee Schedule,,231.7,70,,231.7,percent of total billed charges,All Other,99.22,,,99.22,Fee Schedule,,84.19,,,84.19,Fee Schedule,,24.97,,,24.97,Fee Schedule,,24.97,,,24.97,Fee Schedule,,24.97,,,24.97,Fee Schedule,,24.97,,,24.97,Fee Schedule,,20.81,,,20.81,Fee Schedule,Medicaid Laboratory Fee Schedule,20.81,,,20.81,Fee Schedule,100% Medicaid Laboratory Fee Schedule,20.81,,,20.81,Fee Schedule,100% Medicaid Laboratory Fee Schedule,20.81,,,20.81,Fee Schedule,100% Medicaid Laboratory Fee Schedule,46.82,,,46.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,46.82,,,46.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,31.84,,,31.84,Fee Schedule,153% Medicaid Laboratory Fee Schedule,46.82,,,46.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,29.13,,,29.13,Fee Schedule,140% Medicaid Laboratory Fee Schedule,46.82,,,46.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,54.11,,,54.11,Fee Schedule,260% Medicaid Laboratory Fee Schedule,67.42,,,67.42,Fee Schedule,324% Medicaid Laboratory Fee Schedule,44.74,,,44.74,Fee Schedule,215% Medicaid Laboratory Fee Schedule,44.74,,,44.74,Fee Schedule,215% Medicaid Laboratory Fee Schedule,26.01,,,26.01,Fee Schedule,125% Medicaid Laboratory Fee Schedule,20.81,231.7,
Inflammatory Bowel Disease (Ref Lab Only),86671,CPT,,40123440,CDM,302,RC,,,both,,,196,20.14,,,20.14,Other,150% of Medicare + 9.63% HCRA Surcharge,12.25,,,12.25,Fee Schedule,Mediare Clinical Lab,23.64,,,23.64,Fee Schedule,,21.32,,,21.32,Fee Schedule,,51.34,,,51.34,Fee Schedule,,46.19,,,46.19,Fee Schedule,,43.62,,,43.62,Fee Schedule,,98,50,,98,percent of total billed charges,All Other,25.87,,,25.87,Fee Schedule,,38.59,,,38.59,Fee Schedule,,64.67,,,64.67,Other,186% Medicaid methodology,45.45,,,45.45,Fee Schedule,,121.52,,,121.52,Fee Schedule,,25.73,,,25.73,Fee Schedule,,45.45,,,45.45,Fee Schedule,,121.52,,,121.52,Fee Schedule,,48.39,,,48.39,Fee Schedule,,137.2,70,,137.2,percent of total billed charges,All Other,58.41,,,58.41,Fee Schedule,,49.56,,,49.56,Fee Schedule,,14.7,,,14.7,Fee Schedule,,14.7,,,14.7,Fee Schedule,,14.7,,,14.7,Fee Schedule,,14.7,,,14.7,Fee Schedule,,34.77,,,34.77,Other,New York Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,53.2,,,53.2,Other,153% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,48.68,,,48.68,Other,140% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,90.41,,,90.41,Other,260% Medicaid APG methodology,112.66,,,112.66,Other,324% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,43.46,,,43.46,Other,125% Medicaid APG methodology,12.25,137.2,
C-REACTIVE PROTEIN HS           ,86141,CPT,,40123861,CDM,302,RC,,,both,,,206,21.3,,,21.3,Other,150% of Medicare + 9.63% HCRA Surcharge,12.95,,,12.95,Fee Schedule,Mediare Clinical Lab,24.99,,,24.99,Fee Schedule,,22.53,,,22.53,Fee Schedule,,130.82,,,130.82,Fee Schedule,,117.7,,,117.7,Fee Schedule,,111.14,,,111.14,Fee Schedule,,103,50,,103,percent of total billed charges,All Other,27.37,,,27.37,Fee Schedule,,40.79,,,40.79,Fee Schedule,,19.26,,,19.26,Other,186% Medicaid methodology,48.04,,,48.04,Fee Schedule,,127.72,,,127.72,Fee Schedule,,27.2,,,27.2,Fee Schedule,,48.04,,,48.04,Fee Schedule,,127.72,,,127.72,Fee Schedule,,51.15,,,51.15,Fee Schedule,,144.2,70,,144.2,percent of total billed charges,All Other,61.74,,,61.74,Fee Schedule,,52.39,,,52.39,Fee Schedule,,15.54,,,15.54,Fee Schedule,,15.54,,,15.54,Fee Schedule,,15.54,,,15.54,Fee Schedule,,15.54,,,15.54,Fee Schedule,,10.35,,,10.35,Fee Schedule,Medicaid Laboratory Fee Schedule,10.35,,,10.35,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.35,,,10.35,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.35,,,10.35,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.29,,,23.29,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.29,,,23.29,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.84,,,15.84,Fee Schedule,153% Medicaid Laboratory Fee Schedule,23.29,,,23.29,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.49,,,14.49,Fee Schedule,140% Medicaid Laboratory Fee Schedule,23.29,,,23.29,Fee Schedule,225% Medicaid Laboratory Fee Schedule,26.92,,,26.92,Fee Schedule,260% Medicaid Laboratory Fee Schedule,33.54,,,33.54,Fee Schedule,324% Medicaid Laboratory Fee Schedule,22.26,,,22.26,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.26,,,22.26,Fee Schedule,215% Medicaid Laboratory Fee Schedule,12.94,,,12.94,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.35,144.2,
CCP ANTIBODY                    ,86200,CPT,,40124745,CDM,302,RC,,,both,,,206,21.3,,,21.3,Other,150% of Medicare + 9.63% HCRA Surcharge,12.95,,,12.95,Fee Schedule,Mediare Clinical Lab,24.99,,,24.99,Fee Schedule,,22.53,,,22.53,Fee Schedule,,130.82,,,130.82,Fee Schedule,,117.7,,,117.7,Fee Schedule,,111.14,,,111.14,Fee Schedule,,103,50,,103,percent of total billed charges,All Other,27.37,,,27.37,Fee Schedule,,40.79,,,40.79,Fee Schedule,,64.67,,,64.67,Other,186% Medicaid methodology,48.04,,,48.04,Fee Schedule,,127.72,,,127.72,Fee Schedule,,27.2,,,27.2,Fee Schedule,,48.04,,,48.04,Fee Schedule,,127.72,,,127.72,Fee Schedule,,51.15,,,51.15,Fee Schedule,,144.2,70,,144.2,percent of total billed charges,All Other,61.74,,,61.74,Fee Schedule,,52.39,,,52.39,Fee Schedule,,15.54,,,15.54,Fee Schedule,,15.54,,,15.54,Fee Schedule,,15.54,,,15.54,Fee Schedule,,15.54,,,15.54,Fee Schedule,,34.77,,,34.77,Other,New York Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,53.2,,,53.2,Other,153% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,48.68,,,48.68,Other,140% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,90.41,,,90.41,Other,260% Medicaid APG methodology,112.66,,,112.66,Other,324% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,43.46,,,43.46,Other,125% Medicaid APG methodology,12.95,144.2,
BETA-2 GLYCOPROTEIN ANTIBDY EA  ,86146,CPT,,40125882,CDM,302,RC,,,both,,,405,41.85,,,41.85,Other,150% of Medicare + 9.63% HCRA Surcharge,25.45,,,25.45,Fee Schedule,Mediare Clinical Lab,49.12,,,49.12,Fee Schedule,,44.28,,,44.28,Fee Schedule,,58.73,,,58.73,Fee Schedule,,52.84,,,52.84,Fee Schedule,,49.9,,,49.9,Fee Schedule,,202.5,50,,202.5,percent of total billed charges,All Other,53.76,,,53.76,Fee Schedule,,80.17,,,80.17,Fee Schedule,,14.69,,,14.69,Other,186% Medicaid methodology,94.42,,,94.42,Fee Schedule,,251.1,,,251.1,Fee Schedule,,53.45,,,53.45,Fee Schedule,,94.42,,,94.42,Fee Schedule,,251.1,,,251.1,Fee Schedule,,100.53,,,100.53,Fee Schedule,,283.5,70,,283.5,percent of total billed charges,All Other,121.34,,,121.34,Fee Schedule,,102.96,,,102.96,Fee Schedule,,30.54,,,30.54,Fee Schedule,,30.54,,,30.54,Fee Schedule,,30.54,,,30.54,Fee Schedule,,30.54,,,30.54,Fee Schedule,,7.9,,,7.9,Fee Schedule,Medicaid Laboratory Fee Schedule,7.9,,,7.9,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.9,,,7.9,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.9,,,7.9,Fee Schedule,100% Medicaid Laboratory Fee Schedule,17.77,,,17.77,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.77,,,17.77,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.08,,,12.08,Fee Schedule,153% Medicaid Laboratory Fee Schedule,17.77,,,17.77,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.06,,,11.06,Fee Schedule,140% Medicaid Laboratory Fee Schedule,17.77,,,17.77,Fee Schedule,225% Medicaid Laboratory Fee Schedule,20.54,,,20.54,Fee Schedule,260% Medicaid Laboratory Fee Schedule,25.59,,,25.59,Fee Schedule,324% Medicaid Laboratory Fee Schedule,16.98,,,16.98,Fee Schedule,215% Medicaid Laboratory Fee Schedule,16.98,,,16.98,Fee Schedule,215% Medicaid Laboratory Fee Schedule,9.87,,,9.87,Fee Schedule,125% Medicaid Laboratory Fee Schedule,7.9,283.5,
HELMINTH ANTIBODY               ,86682,CPT,,40127524,CDM,302,RC,,,both,,,322,21.39,,,21.39,Other,150% of Medicare + 9.63% HCRA Surcharge,13.01,,,13.01,Fee Schedule,Mediare Clinical Lab,25.11,,,25.11,Fee Schedule,,22.64,,,22.64,Fee Schedule,,58.73,,,58.73,Fee Schedule,,52.84,,,52.84,Fee Schedule,,49.9,,,49.9,Fee Schedule,,161,50,,161,percent of total billed charges,All Other,27.5,,,27.5,Fee Schedule,,40.98,,,40.98,Fee Schedule,,64.67,,,64.67,Other,186% Medicaid methodology,48.27,,,48.27,Fee Schedule,,199.64,,,199.64,Fee Schedule,,27.32,,,27.32,Fee Schedule,,48.27,,,48.27,Fee Schedule,,199.64,,,199.64,Fee Schedule,,51.39,,,51.39,Fee Schedule,,225.4,70,,225.4,percent of total billed charges,All Other,62.03,,,62.03,Fee Schedule,,52.63,,,52.63,Fee Schedule,,15.61,,,15.61,Fee Schedule,,15.61,,,15.61,Fee Schedule,,15.61,,,15.61,Fee Schedule,,15.61,,,15.61,Fee Schedule,,34.77,,,34.77,Other,New York Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,53.2,,,53.2,Other,153% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,48.68,,,48.68,Other,140% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,90.41,,,90.41,Other,260% Medicaid APG methodology,112.66,,,112.66,Other,324% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,43.46,,,43.46,Other,125% Medicaid APG methodology,13.01,225.4,
ANTI-PHOSPHOLIPID ANTIBODY      ,86148,CPT,,40127946,CDM,302,RC,,,both,,,256,26.43,,,26.43,Other,150% of Medicare + 9.63% HCRA Surcharge,16.07,,,16.07,Fee Schedule,Mediare Clinical Lab,31.02,,,31.02,Fee Schedule,,27.96,,,27.96,Fee Schedule,,162.34,,,162.34,Fee Schedule,,146.06,,,146.06,Fee Schedule,,137.92,,,137.92,Fee Schedule,,128,50,,128,percent of total billed charges,All Other,33.96,,,33.96,Fee Schedule,,50.62,,,50.62,Fee Schedule,,14.69,,,14.69,Other,186% Medicaid methodology,59.62,,,59.62,Fee Schedule,,158.72,,,158.72,Fee Schedule,,33.75,,,33.75,Fee Schedule,,59.62,,,59.62,Fee Schedule,,158.72,,,158.72,Fee Schedule,,63.48,,,63.48,Fee Schedule,,179.2,70,,179.2,percent of total billed charges,All Other,76.62,,,76.62,Fee Schedule,,65.01,,,65.01,Fee Schedule,,19.28,,,19.28,Fee Schedule,,19.28,,,19.28,Fee Schedule,,19.28,,,19.28,Fee Schedule,,19.28,,,19.28,Fee Schedule,,7.9,,,7.9,Fee Schedule,Medicaid Laboratory Fee Schedule,7.9,,,7.9,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.9,,,7.9,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.9,,,7.9,Fee Schedule,100% Medicaid Laboratory Fee Schedule,17.77,,,17.77,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.77,,,17.77,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.08,,,12.08,Fee Schedule,153% Medicaid Laboratory Fee Schedule,17.77,,,17.77,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.06,,,11.06,Fee Schedule,140% Medicaid Laboratory Fee Schedule,17.77,,,17.77,Fee Schedule,225% Medicaid Laboratory Fee Schedule,20.54,,,20.54,Fee Schedule,260% Medicaid Laboratory Fee Schedule,25.59,,,25.59,Fee Schedule,324% Medicaid Laboratory Fee Schedule,16.98,,,16.98,Fee Schedule,215% Medicaid Laboratory Fee Schedule,16.98,,,16.98,Fee Schedule,215% Medicaid Laboratory Fee Schedule,9.87,,,9.87,Fee Schedule,125% Medicaid Laboratory Fee Schedule,7.9,179.2,
TB TEST CELL IMMUN MEASURE      ,86480,CPT,,40128340,CDM,302,RC,,,both,,,986,101.92,,,101.92,Other,150% of Medicare + 9.63% HCRA Surcharge,61.98,,,61.98,Fee Schedule,Mediare Clinical Lab,119.62,,,119.62,Fee Schedule,,107.85,,,107.85,Fee Schedule,,626.24,,,626.24,Fee Schedule,,563.44,,,563.44,Fee Schedule,,532.04,,,532.04,Fee Schedule,,493,50,,493,percent of total billed charges,All Other,130.94,,,130.94,Fee Schedule,,195.24,,,195.24,Fee Schedule,,93.93,,,93.93,Other,186% Medicaid methodology,229.95,,,229.95,Fee Schedule,,611.32,,,611.32,Fee Schedule,,130.16,,,130.16,Fee Schedule,,229.95,,,229.95,Fee Schedule,,611.32,,,611.32,Fee Schedule,,244.82,,,244.82,Fee Schedule,,690.2,70,,690.2,percent of total billed charges,All Other,295.52,,,295.52,Fee Schedule,,250.74,,,250.74,Fee Schedule,,74.38,,,74.38,Fee Schedule,,74.38,,,74.38,Fee Schedule,,74.38,,,74.38,Fee Schedule,,74.38,,,74.38,Fee Schedule,,50.5,,,50.5,Fee Schedule,Medicaid Laboratory Fee Schedule,50.5,,,50.5,Fee Schedule,100% Medicaid Laboratory Fee Schedule,50.5,,,50.5,Fee Schedule,100% Medicaid Laboratory Fee Schedule,50.5,,,50.5,Fee Schedule,100% Medicaid Laboratory Fee Schedule,113.63,,,113.63,Fee Schedule,225% Medicaid Laboratory Fee Schedule,113.63,,,113.63,Fee Schedule,225% Medicaid Laboratory Fee Schedule,77.27,,,77.27,Fee Schedule,153% Medicaid Laboratory Fee Schedule,113.63,,,113.63,Fee Schedule,225% Medicaid Laboratory Fee Schedule,70.7,,,70.7,Fee Schedule,140% Medicaid Laboratory Fee Schedule,113.63,,,113.63,Fee Schedule,225% Medicaid Laboratory Fee Schedule,131.3,,,131.3,Fee Schedule,260% Medicaid Laboratory Fee Schedule,163.62,,,163.62,Fee Schedule,324% Medicaid Laboratory Fee Schedule,108.58,,,108.58,Fee Schedule,215% Medicaid Laboratory Fee Schedule,108.58,,,108.58,Fee Schedule,215% Medicaid Laboratory Fee Schedule,63.13,,,63.13,Fee Schedule,125% Medicaid Laboratory Fee Schedule,50.5,690.2,
IMMUNFIX E-PHORSIS/URINE/CSF    ,86335,CPT,,40131823,CDM,302,RC,,,both,,,467,48.26,,,48.26,Other,150% of Medicare + 9.63% HCRA Surcharge,29.35,,,29.35,Fee Schedule,Mediare Clinical Lab,56.65,,,56.65,Fee Schedule,,51.07,,,51.07,Fee Schedule,,296.53,,,296.53,Fee Schedule,,266.8,,,266.8,Fee Schedule,,251.93,,,251.93,Fee Schedule,,233.5,50,,233.5,percent of total billed charges,All Other,62.01,,,62.01,Fee Schedule,,92.45,,,92.45,Fee Schedule,,54.59,,,54.59,Other,186% Medicaid methodology,108.89,,,108.89,Fee Schedule,,289.54,,,289.54,Fee Schedule,,61.64,,,61.64,Fee Schedule,,108.89,,,108.89,Fee Schedule,,289.54,,,289.54,Fee Schedule,,115.93,,,115.93,Fee Schedule,,326.9,70,,326.9,percent of total billed charges,All Other,139.94,,,139.94,Fee Schedule,,118.74,,,118.74,Fee Schedule,,35.22,,,35.22,Fee Schedule,,35.22,,,35.22,Fee Schedule,,35.22,,,35.22,Fee Schedule,,35.22,,,35.22,Fee Schedule,,29.35,,,29.35,Fee Schedule,Medicaid Laboratory Fee Schedule,29.35,,,29.35,Fee Schedule,100% Medicaid Laboratory Fee Schedule,29.35,,,29.35,Fee Schedule,100% Medicaid Laboratory Fee Schedule,29.35,,,29.35,Fee Schedule,100% Medicaid Laboratory Fee Schedule,66.04,,,66.04,Fee Schedule,225% Medicaid Laboratory Fee Schedule,66.04,,,66.04,Fee Schedule,225% Medicaid Laboratory Fee Schedule,44.91,,,44.91,Fee Schedule,153% Medicaid Laboratory Fee Schedule,66.04,,,66.04,Fee Schedule,225% Medicaid Laboratory Fee Schedule,41.09,,,41.09,Fee Schedule,140% Medicaid Laboratory Fee Schedule,66.04,,,66.04,Fee Schedule,225% Medicaid Laboratory Fee Schedule,76.31,,,76.31,Fee Schedule,260% Medicaid Laboratory Fee Schedule,95.09,,,95.09,Fee Schedule,324% Medicaid Laboratory Fee Schedule,63.1,,,63.1,Fee Schedule,215% Medicaid Laboratory Fee Schedule,63.1,,,63.1,Fee Schedule,215% Medicaid Laboratory Fee Schedule,36.69,,,36.69,Fee Schedule,125% Medicaid Laboratory Fee Schedule,29.35,326.9,
AGENT NOS ASSAY W/OPTIC         ,87899,CPT,,40132425,CDM,302,RC,,,both,,,224,26.43,,,26.43,Other,150% of Medicare + 9.63% HCRA Surcharge,16.07,,,16.07,Fee Schedule,Mediare Clinical Lab,31.02,,,31.02,Fee Schedule,,27.96,,,27.96,Fee Schedule,,88.39,,,88.39,Fee Schedule,,79.52,,,79.52,Fee Schedule,,75.09,,,75.09,Fee Schedule,,112,50,,112,percent of total billed charges,All Other,33.96,,,33.96,Fee Schedule,,50.62,,,50.62,Fee Schedule,,15.09,,,15.09,Other,186% Medicaid methodology,59.62,,,59.62,Fee Schedule,,138.88,,,138.88,Fee Schedule,,33.75,,,33.75,Fee Schedule,,59.62,,,59.62,Fee Schedule,,138.88,,,138.88,Fee Schedule,,63.48,,,63.48,Fee Schedule,,156.8,70,,156.8,percent of total billed charges,All Other,76.62,,,76.62,Fee Schedule,,65.01,,,65.01,Fee Schedule,,19.28,,,19.28,Fee Schedule,,19.28,,,19.28,Fee Schedule,,19.28,,,19.28,Fee Schedule,,19.28,,,19.28,Fee Schedule,,8.11,,,8.11,Fee Schedule,Medicaid Laboratory Fee Schedule,8.11,,,8.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.11,,,8.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.11,,,8.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.41,,,12.41,Fee Schedule,153% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.35,,,11.35,Fee Schedule,140% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.09,,,21.09,Fee Schedule,260% Medicaid Laboratory Fee Schedule,26.28,,,26.28,Fee Schedule,324% Medicaid Laboratory Fee Schedule,17.44,,,17.44,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.44,,,17.44,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.14,,,10.14,Fee Schedule,125% Medicaid Laboratory Fee Schedule,8.11,156.8,
THYROGLOBULIN ANTIBODY          ,86800,CPT,,40136426,CDM,302,RC,,,both,,,254,26.16,,,26.16,Other,150% of Medicare + 9.63% HCRA Surcharge,15.91,,,15.91,Fee Schedule,Mediare Clinical Lab,30.71,,,30.71,Fee Schedule,,27.68,,,27.68,Fee Schedule,,160.69,,,160.69,Fee Schedule,,144.57,,,144.57,Fee Schedule,,136.52,,,136.52,Fee Schedule,,127,50,,127,percent of total billed charges,All Other,33.61,,,33.61,Fee Schedule,,50.12,,,50.12,Fee Schedule,,25.08,,,25.08,Other,186% Medicaid methodology,59.03,,,59.03,Fee Schedule,,157.48,,,157.48,Fee Schedule,,33.41,,,33.41,Fee Schedule,,59.03,,,59.03,Fee Schedule,,157.48,,,157.48,Fee Schedule,,62.84,,,62.84,Fee Schedule,,177.8,70,,177.8,percent of total billed charges,All Other,75.86,,,75.86,Fee Schedule,,64.36,,,64.36,Fee Schedule,,19.09,,,19.09,Fee Schedule,,19.09,,,19.09,Fee Schedule,,19.09,,,19.09,Fee Schedule,,19.09,,,19.09,Fee Schedule,,13.48,,,13.48,Fee Schedule,Medicaid Laboratory Fee Schedule,13.48,,,13.48,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.48,,,13.48,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.48,,,13.48,Fee Schedule,100% Medicaid Laboratory Fee Schedule,30.34,,,30.34,Fee Schedule,225% Medicaid Laboratory Fee Schedule,30.34,,,30.34,Fee Schedule,225% Medicaid Laboratory Fee Schedule,20.63,,,20.63,Fee Schedule,153% Medicaid Laboratory Fee Schedule,30.34,,,30.34,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.88,,,18.88,Fee Schedule,140% Medicaid Laboratory Fee Schedule,30.34,,,30.34,Fee Schedule,225% Medicaid Laboratory Fee Schedule,35.06,,,35.06,Fee Schedule,260% Medicaid Laboratory Fee Schedule,43.69,,,43.69,Fee Schedule,324% Medicaid Laboratory Fee Schedule,28.99,,,28.99,Fee Schedule,215% Medicaid Laboratory Fee Schedule,28.99,,,28.99,Fee Schedule,215% Medicaid Laboratory Fee Schedule,16.85,,,16.85,Fee Schedule,125% Medicaid Laboratory Fee Schedule,13.48,177.8,
ANTIBODY HELICOBACTER PYLORI,86677,CPT,,40141822,CDM,302,RC,,,both,,,269,27.71,,,27.71,Other,150% of Medicare + 9.63% HCRA Surcharge,16.85,,,16.85,Fee Schedule,Mediare Clinical Lab,32.52,,,32.52,Fee Schedule,,29.32,,,29.32,Fee Schedule,,58.73,,,58.73,Fee Schedule,,52.84,,,52.84,Fee Schedule,,49.9,,,49.9,Fee Schedule,,134.5,50,,134.5,percent of total billed charges,All Other,35.59,,,35.59,Fee Schedule,,53.08,,,53.08,Fee Schedule,,64.67,,,64.67,Other,186% Medicaid methodology,62.51,,,62.51,Fee Schedule,,166.78,,,166.78,Fee Schedule,,35.39,,,35.39,Fee Schedule,,62.51,,,62.51,Fee Schedule,,166.78,,,166.78,Fee Schedule,,66.56,,,66.56,Fee Schedule,,188.3,70,,188.3,percent of total billed charges,All Other,80.34,,,80.34,Fee Schedule,,68.17,,,68.17,Fee Schedule,,20.22,,,20.22,Fee Schedule,,20.22,,,20.22,Fee Schedule,,20.22,,,20.22,Fee Schedule,,20.22,,,20.22,Fee Schedule,,34.77,,,34.77,Other,New York Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,53.2,,,53.2,Other,153% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,48.68,,,48.68,Other,140% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,90.41,,,90.41,Other,260% Medicaid APG methodology,112.66,,,112.66,Other,324% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,43.46,,,43.46,Other,125% Medicaid APG methodology,16.85,188.3,
PLATELET ANTIBODIES             ,86022,CPT,,40142267,CDM,302,RC,,,both,,,293,30.21,,,30.21,Other,150% of Medicare + 9.63% HCRA Surcharge,18.37,,,18.37,Fee Schedule,Mediare Clinical Lab,35.45,,,35.45,Fee Schedule,,31.96,,,31.96,Fee Schedule,,185.6,,,185.6,Fee Schedule,,166.99,,,166.99,Fee Schedule,,157.69,,,157.69,Fee Schedule,,146.5,50,,146.5,percent of total billed charges,All Other,38.81,,,38.81,Fee Schedule,,57.87,,,57.87,Fee Schedule,,64.67,,,64.67,Other,186% Medicaid methodology,68.15,,,68.15,Fee Schedule,,181.66,,,181.66,Fee Schedule,,38.58,,,38.58,Fee Schedule,,68.15,,,68.15,Fee Schedule,,181.66,,,181.66,Fee Schedule,,72.56,,,72.56,Fee Schedule,,205.1,70,,205.1,percent of total billed charges,All Other,87.59,,,87.59,Fee Schedule,,74.32,,,74.32,Fee Schedule,,22.04,,,22.04,Fee Schedule,,22.04,,,22.04,Fee Schedule,,22.04,,,22.04,Fee Schedule,,22.04,,,22.04,Fee Schedule,,34.77,,,34.77,Other,New York Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,53.2,,,53.2,Other,153% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,48.68,,,48.68,Other,140% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,90.41,,,90.41,Other,260% Medicaid APG methodology,112.66,,,112.66,Other,324% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,43.46,,,43.46,Other,125% Medicaid APG methodology,18.37,205.1,
LYME DISEASE ANTIBODY           ,86618,CPT,,40164105,CDM,302,RC,,,both,,,271,28,,,28,Other,150% of Medicare + 9.63% HCRA Surcharge,17.03,,,17.03,Fee Schedule,Mediare Clinical Lab,32.87,,,32.87,Fee Schedule,,29.63,,,29.63,Fee Schedule,,172.1,,,172.1,Fee Schedule,,154.85,,,154.85,Fee Schedule,,146.22,,,146.22,Fee Schedule,,135.5,50,,135.5,percent of total billed charges,All Other,35.98,,,35.98,Fee Schedule,,53.64,,,53.64,Fee Schedule,,31.68,,,31.68,Other,186% Medicaid methodology,63.18,,,63.18,Fee Schedule,,168.02,,,168.02,Fee Schedule,,35.76,,,35.76,Fee Schedule,,63.18,,,63.18,Fee Schedule,,168.02,,,168.02,Fee Schedule,,67.27,,,67.27,Fee Schedule,,189.7,70,,189.7,percent of total billed charges,All Other,81.2,,,81.2,Fee Schedule,,68.9,,,68.9,Fee Schedule,,20.44,,,20.44,Fee Schedule,,20.44,,,20.44,Fee Schedule,,20.44,,,20.44,Fee Schedule,,20.44,,,20.44,Fee Schedule,,17.03,,,17.03,Fee Schedule,Medicaid Laboratory Fee Schedule,17.03,,,17.03,Fee Schedule,100% Medicaid Laboratory Fee Schedule,17.03,,,17.03,Fee Schedule,100% Medicaid Laboratory Fee Schedule,17.03,,,17.03,Fee Schedule,100% Medicaid Laboratory Fee Schedule,38.32,,,38.32,Fee Schedule,225% Medicaid Laboratory Fee Schedule,38.32,,,38.32,Fee Schedule,225% Medicaid Laboratory Fee Schedule,26.06,,,26.06,Fee Schedule,153% Medicaid Laboratory Fee Schedule,38.32,,,38.32,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.84,,,23.84,Fee Schedule,140% Medicaid Laboratory Fee Schedule,38.32,,,38.32,Fee Schedule,225% Medicaid Laboratory Fee Schedule,44.28,,,44.28,Fee Schedule,260% Medicaid Laboratory Fee Schedule,55.18,,,55.18,Fee Schedule,324% Medicaid Laboratory Fee Schedule,36.61,,,36.61,Fee Schedule,215% Medicaid Laboratory Fee Schedule,36.61,,,36.61,Fee Schedule,215% Medicaid Laboratory Fee Schedule,21.29,,,21.29,Fee Schedule,125% Medicaid Laboratory Fee Schedule,17.03,189.7,
LYME DISEASE ANTIBODY           ,86618,CPT,,40164113,CDM,302,RC,,,both,,,271,28,,,28,Other,150% of Medicare + 9.63% HCRA Surcharge,17.03,,,17.03,Fee Schedule,Mediare Clinical Lab,32.87,,,32.87,Fee Schedule,,29.63,,,29.63,Fee Schedule,,172.1,,,172.1,Fee Schedule,,154.85,,,154.85,Fee Schedule,,146.22,,,146.22,Fee Schedule,,135.5,50,,135.5,percent of total billed charges,All Other,35.98,,,35.98,Fee Schedule,,53.64,,,53.64,Fee Schedule,,31.68,,,31.68,Other,186% Medicaid methodology,63.18,,,63.18,Fee Schedule,,168.02,,,168.02,Fee Schedule,,35.76,,,35.76,Fee Schedule,,63.18,,,63.18,Fee Schedule,,168.02,,,168.02,Fee Schedule,,67.27,,,67.27,Fee Schedule,,189.7,70,,189.7,percent of total billed charges,All Other,81.2,,,81.2,Fee Schedule,,68.9,,,68.9,Fee Schedule,,20.44,,,20.44,Fee Schedule,,20.44,,,20.44,Fee Schedule,,20.44,,,20.44,Fee Schedule,,20.44,,,20.44,Fee Schedule,,17.03,,,17.03,Fee Schedule,Medicaid Laboratory Fee Schedule,17.03,,,17.03,Fee Schedule,100% Medicaid Laboratory Fee Schedule,17.03,,,17.03,Fee Schedule,100% Medicaid Laboratory Fee Schedule,17.03,,,17.03,Fee Schedule,100% Medicaid Laboratory Fee Schedule,38.32,,,38.32,Fee Schedule,225% Medicaid Laboratory Fee Schedule,38.32,,,38.32,Fee Schedule,225% Medicaid Laboratory Fee Schedule,26.06,,,26.06,Fee Schedule,153% Medicaid Laboratory Fee Schedule,38.32,,,38.32,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.84,,,23.84,Fee Schedule,140% Medicaid Laboratory Fee Schedule,38.32,,,38.32,Fee Schedule,225% Medicaid Laboratory Fee Schedule,44.28,,,44.28,Fee Schedule,260% Medicaid Laboratory Fee Schedule,55.18,,,55.18,Fee Schedule,324% Medicaid Laboratory Fee Schedule,36.61,,,36.61,Fee Schedule,215% Medicaid Laboratory Fee Schedule,36.61,,,36.61,Fee Schedule,215% Medicaid Laboratory Fee Schedule,21.29,,,21.29,Fee Schedule,125% Medicaid Laboratory Fee Schedule,17.03,189.7,
ANTISTREPTOLYSIN O TITER        ,86060,CPT,,40165003,CDM,302,RC,,,both,,,117,12,,,12,Other,150% of Medicare + 9.63% HCRA Surcharge,7.3,,,7.3,Fee Schedule,Mediare Clinical Lab,14.09,,,14.09,Fee Schedule,,12.7,,,12.7,Fee Schedule,,73.74,,,73.74,Fee Schedule,,66.34,,,66.34,Fee Schedule,,62.65,,,62.65,Fee Schedule,,58.5,50,,58.5,percent of total billed charges,All Other,15.44,,,15.44,Fee Schedule,,23,,,23,Fee Schedule,,9.77,,,9.77,Other,186% Medicaid methodology,27.08,,,27.08,Fee Schedule,,72.54,,,72.54,Fee Schedule,,15.33,,,15.33,Fee Schedule,,27.08,,,27.08,Fee Schedule,,72.54,,,72.54,Fee Schedule,,28.84,,,28.84,Fee Schedule,,81.9,70,,81.9,percent of total billed charges,All Other,34.81,,,34.81,Fee Schedule,,29.53,,,29.53,Fee Schedule,,8.76,,,8.76,Fee Schedule,,8.76,,,8.76,Fee Schedule,,8.76,,,8.76,Fee Schedule,,8.76,,,8.76,Fee Schedule,,5.25,,,5.25,Fee Schedule,Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.04,,,8.04,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.35,,,7.35,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.66,,,13.66,Fee Schedule,260% Medicaid Laboratory Fee Schedule,17.02,,,17.02,Fee Schedule,324% Medicaid Laboratory Fee Schedule,11.29,,,11.29,Fee Schedule,215% Medicaid Laboratory Fee Schedule,11.29,,,11.29,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.57,,,6.57,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.25,81.9,
CMV ANTIBODY                    ,86644,CPT,,40165045,CDM,302,RC,,,both,,,229,23.66,,,23.66,Other,150% of Medicare + 9.63% HCRA Surcharge,14.39,,,14.39,Fee Schedule,Mediare Clinical Lab,27.77,,,27.77,Fee Schedule,,25.04,,,25.04,Fee Schedule,,145.4,,,145.4,Fee Schedule,,130.82,,,130.82,Fee Schedule,,123.53,,,123.53,Fee Schedule,,114.5,50,,114.5,percent of total billed charges,All Other,30.39,,,30.39,Fee Schedule,,45.33,,,45.33,Fee Schedule,,26.77,,,26.77,Other,186% Medicaid methodology,53.39,,,53.39,Fee Schedule,,141.98,,,141.98,Fee Schedule,,30.22,,,30.22,Fee Schedule,,53.39,,,53.39,Fee Schedule,,141.98,,,141.98,Fee Schedule,,56.84,,,56.84,Fee Schedule,,160.3,70,,160.3,percent of total billed charges,All Other,68.61,,,68.61,Fee Schedule,,58.22,,,58.22,Fee Schedule,,17.27,,,17.27,Fee Schedule,,17.27,,,17.27,Fee Schedule,,17.27,,,17.27,Fee Schedule,,17.27,,,17.27,Fee Schedule,,14.39,,,14.39,Fee Schedule,Medicaid Laboratory Fee Schedule,14.39,,,14.39,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.39,,,14.39,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.39,,,14.39,Fee Schedule,100% Medicaid Laboratory Fee Schedule,32.38,,,32.38,Fee Schedule,225% Medicaid Laboratory Fee Schedule,32.38,,,32.38,Fee Schedule,225% Medicaid Laboratory Fee Schedule,22.02,,,22.02,Fee Schedule,153% Medicaid Laboratory Fee Schedule,32.38,,,32.38,Fee Schedule,225% Medicaid Laboratory Fee Schedule,20.15,,,20.15,Fee Schedule,140% Medicaid Laboratory Fee Schedule,32.38,,,32.38,Fee Schedule,225% Medicaid Laboratory Fee Schedule,37.41,,,37.41,Fee Schedule,260% Medicaid Laboratory Fee Schedule,46.62,,,46.62,Fee Schedule,324% Medicaid Laboratory Fee Schedule,30.94,,,30.94,Fee Schedule,215% Medicaid Laboratory Fee Schedule,30.94,,,30.94,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.99,,,17.99,Fee Schedule,125% Medicaid Laboratory Fee Schedule,14.39,160.3,
CMV ANTIBODY IGM                ,86645,CPT,,40165060,CDM,302,RC,,,both,,,269,27.71,,,27.71,Other,150% of Medicare + 9.63% HCRA Surcharge,16.85,,,16.85,Fee Schedule,Mediare Clinical Lab,32.52,,,32.52,Fee Schedule,,29.32,,,29.32,Fee Schedule,,58.73,,,58.73,Fee Schedule,,52.84,,,52.84,Fee Schedule,,49.9,,,49.9,Fee Schedule,,134.5,50,,134.5,percent of total billed charges,All Other,35.59,,,35.59,Fee Schedule,,53.08,,,53.08,Fee Schedule,,15.09,,,15.09,Other,186% Medicaid methodology,62.51,,,62.51,Fee Schedule,,166.78,,,166.78,Fee Schedule,,35.39,,,35.39,Fee Schedule,,62.51,,,62.51,Fee Schedule,,166.78,,,166.78,Fee Schedule,,66.56,,,66.56,Fee Schedule,,188.3,70,,188.3,percent of total billed charges,All Other,80.34,,,80.34,Fee Schedule,,68.17,,,68.17,Fee Schedule,,20.22,,,20.22,Fee Schedule,,20.22,,,20.22,Fee Schedule,,20.22,,,20.22,Fee Schedule,,20.22,,,20.22,Fee Schedule,,8.11,,,8.11,Fee Schedule,Medicaid Laboratory Fee Schedule,8.11,,,8.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.11,,,8.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.11,,,8.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.41,,,12.41,Fee Schedule,153% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.35,,,11.35,Fee Schedule,140% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.09,,,21.09,Fee Schedule,260% Medicaid Laboratory Fee Schedule,26.28,,,26.28,Fee Schedule,324% Medicaid Laboratory Fee Schedule,17.44,,,17.44,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.44,,,17.44,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.14,,,10.14,Fee Schedule,125% Medicaid Laboratory Fee Schedule,8.11,188.3,
LYME DISEASE ANTIBODY           ,86618,CPT,,40165128,CDM,302,RC,,,both,,,271,28,,,28,Other,150% of Medicare + 9.63% HCRA Surcharge,17.03,,,17.03,Fee Schedule,Mediare Clinical Lab,32.87,,,32.87,Fee Schedule,,29.63,,,29.63,Fee Schedule,,172.1,,,172.1,Fee Schedule,,154.85,,,154.85,Fee Schedule,,146.22,,,146.22,Fee Schedule,,135.5,50,,135.5,percent of total billed charges,All Other,35.98,,,35.98,Fee Schedule,,53.64,,,53.64,Fee Schedule,,31.68,,,31.68,Other,186% Medicaid methodology,63.18,,,63.18,Fee Schedule,,168.02,,,168.02,Fee Schedule,,35.76,,,35.76,Fee Schedule,,63.18,,,63.18,Fee Schedule,,168.02,,,168.02,Fee Schedule,,67.27,,,67.27,Fee Schedule,,189.7,70,,189.7,percent of total billed charges,All Other,81.2,,,81.2,Fee Schedule,,68.9,,,68.9,Fee Schedule,,20.44,,,20.44,Fee Schedule,,20.44,,,20.44,Fee Schedule,,20.44,,,20.44,Fee Schedule,,20.44,,,20.44,Fee Schedule,,17.03,,,17.03,Fee Schedule,Medicaid Laboratory Fee Schedule,17.03,,,17.03,Fee Schedule,100% Medicaid Laboratory Fee Schedule,17.03,,,17.03,Fee Schedule,100% Medicaid Laboratory Fee Schedule,17.03,,,17.03,Fee Schedule,100% Medicaid Laboratory Fee Schedule,38.32,,,38.32,Fee Schedule,225% Medicaid Laboratory Fee Schedule,38.32,,,38.32,Fee Schedule,225% Medicaid Laboratory Fee Schedule,26.06,,,26.06,Fee Schedule,153% Medicaid Laboratory Fee Schedule,38.32,,,38.32,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.84,,,23.84,Fee Schedule,140% Medicaid Laboratory Fee Schedule,38.32,,,38.32,Fee Schedule,225% Medicaid Laboratory Fee Schedule,44.28,,,44.28,Fee Schedule,260% Medicaid Laboratory Fee Schedule,55.18,,,55.18,Fee Schedule,324% Medicaid Laboratory Fee Schedule,36.61,,,36.61,Fee Schedule,215% Medicaid Laboratory Fee Schedule,36.61,,,36.61,Fee Schedule,215% Medicaid Laboratory Fee Schedule,21.29,,,21.29,Fee Schedule,125% Medicaid Laboratory Fee Schedule,17.03,189.7,
HETEROPHILE ANTIBODY SCREEN     ,86308,CPT,,40165144,CDM,302,RC,,,both,,,83,8.52,,,8.52,Other,150% of Medicare + 9.63% HCRA Surcharge,5.18,,,5.18,Fee Schedule,Mediare Clinical Lab,10,,,10,Fee Schedule,,9.01,,,9.01,Fee Schedule,,52.27,,,52.27,Fee Schedule,,47.03,,,47.03,Fee Schedule,,44.41,,,44.41,Fee Schedule,,41.5,50,,41.5,percent of total billed charges,All Other,10.95,,,10.95,Fee Schedule,,16.32,,,16.32,Fee Schedule,,8.89,,,8.89,Other,186% Medicaid methodology,19.22,,,19.22,Fee Schedule,,51.46,,,51.46,Fee Schedule,,10.88,,,10.88,Fee Schedule,,19.22,,,19.22,Fee Schedule,,51.46,,,51.46,Fee Schedule,,20.46,,,20.46,Fee Schedule,,58.1,70,,58.1,percent of total billed charges,All Other,24.7,,,24.7,Fee Schedule,,20.96,,,20.96,Fee Schedule,,6.22,,,6.22,Fee Schedule,,6.22,,,6.22,Fee Schedule,,6.22,,,6.22,Fee Schedule,,6.22,,,6.22,Fee Schedule,,4.78,,,4.78,Fee Schedule,Medicaid Laboratory Fee Schedule,4.78,,,4.78,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.78,,,4.78,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.78,,,4.78,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.75,,,10.75,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.75,,,10.75,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.31,,,7.31,Fee Schedule,153% Medicaid Laboratory Fee Schedule,10.75,,,10.75,Fee Schedule,225% Medicaid Laboratory Fee Schedule,6.69,,,6.69,Fee Schedule,140% Medicaid Laboratory Fee Schedule,10.75,,,10.75,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.42,,,12.42,Fee Schedule,260% Medicaid Laboratory Fee Schedule,15.48,,,15.48,Fee Schedule,324% Medicaid Laboratory Fee Schedule,10.27,,,10.27,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.27,,,10.27,Fee Schedule,215% Medicaid Laboratory Fee Schedule,5.97,,,5.97,Fee Schedule,125% Medicaid Laboratory Fee Schedule,4.78,58.1,
MYCOPLASMA ANTIBODY             ,86738,CPT,,40165169,CDM,302,RC,,,both,,,211,21.77,,,21.77,Other,150% of Medicare + 9.63% HCRA Surcharge,13.24,,,13.24,Fee Schedule,Mediare Clinical Lab,25.55,,,25.55,Fee Schedule,,23.04,,,23.04,Fee Schedule,,133.84,,,133.84,Fee Schedule,,120.41,,,120.41,Fee Schedule,,113.7,,,113.7,Fee Schedule,,105.5,50,,105.5,percent of total billed charges,All Other,27.98,,,27.98,Fee Schedule,,41.71,,,41.71,Fee Schedule,,24.63,,,24.63,Other,186% Medicaid methodology,49.12,,,49.12,Fee Schedule,,130.82,,,130.82,Fee Schedule,,27.8,,,27.8,Fee Schedule,,49.12,,,49.12,Fee Schedule,,130.82,,,130.82,Fee Schedule,,52.3,,,52.3,Fee Schedule,,147.7,70,,147.7,percent of total billed charges,All Other,63.13,,,63.13,Fee Schedule,,53.56,,,53.56,Fee Schedule,,15.89,,,15.89,Fee Schedule,,15.89,,,15.89,Fee Schedule,,15.89,,,15.89,Fee Schedule,,15.89,,,15.89,Fee Schedule,,13.24,,,13.24,Fee Schedule,Medicaid Laboratory Fee Schedule,13.24,,,13.24,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.24,,,13.24,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.24,,,13.24,Fee Schedule,100% Medicaid Laboratory Fee Schedule,29.79,,,29.79,Fee Schedule,225% Medicaid Laboratory Fee Schedule,29.79,,,29.79,Fee Schedule,225% Medicaid Laboratory Fee Schedule,20.26,,,20.26,Fee Schedule,153% Medicaid Laboratory Fee Schedule,29.79,,,29.79,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.54,,,18.54,Fee Schedule,140% Medicaid Laboratory Fee Schedule,29.79,,,29.79,Fee Schedule,225% Medicaid Laboratory Fee Schedule,34.42,,,34.42,Fee Schedule,260% Medicaid Laboratory Fee Schedule,42.9,,,42.9,Fee Schedule,324% Medicaid Laboratory Fee Schedule,28.47,,,28.47,Fee Schedule,215% Medicaid Laboratory Fee Schedule,28.47,,,28.47,Fee Schedule,215% Medicaid Laboratory Fee Schedule,16.55,,,16.55,Fee Schedule,125% Medicaid Laboratory Fee Schedule,13.24,147.7,
RUBEOLA ANTIBODY                ,86765,CPT,,40165201,CDM,302,RC,,,both,,,205,21.18,,,21.18,Other,150% of Medicare + 9.63% HCRA Surcharge,12.88,,,12.88,Fee Schedule,Mediare Clinical Lab,24.86,,,24.86,Fee Schedule,,22.41,,,22.41,Fee Schedule,,130.17,,,130.17,Fee Schedule,,117.12,,,117.12,Fee Schedule,,110.59,,,110.59,Fee Schedule,,102.5,50,,102.5,percent of total billed charges,All Other,27.2,,,27.2,Fee Schedule,,40.57,,,40.57,Fee Schedule,,23.96,,,23.96,Other,186% Medicaid methodology,47.78,,,47.78,Fee Schedule,,127.1,,,127.1,Fee Schedule,,27.05,,,27.05,Fee Schedule,,47.78,,,47.78,Fee Schedule,,127.1,,,127.1,Fee Schedule,,50.88,,,50.88,Fee Schedule,,143.5,70,,143.5,percent of total billed charges,All Other,61.41,,,61.41,Fee Schedule,,52.11,,,52.11,Fee Schedule,,15.46,,,15.46,Fee Schedule,,15.46,,,15.46,Fee Schedule,,15.46,,,15.46,Fee Schedule,,15.46,,,15.46,Fee Schedule,,12.88,,,12.88,Fee Schedule,Medicaid Laboratory Fee Schedule,12.88,,,12.88,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.88,,,12.88,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.88,,,12.88,Fee Schedule,100% Medicaid Laboratory Fee Schedule,28.98,,,28.98,Fee Schedule,225% Medicaid Laboratory Fee Schedule,28.98,,,28.98,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.71,,,19.71,Fee Schedule,153% Medicaid Laboratory Fee Schedule,28.98,,,28.98,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.03,,,18.03,Fee Schedule,140% Medicaid Laboratory Fee Schedule,28.98,,,28.98,Fee Schedule,225% Medicaid Laboratory Fee Schedule,33.49,,,33.49,Fee Schedule,260% Medicaid Laboratory Fee Schedule,41.73,,,41.73,Fee Schedule,324% Medicaid Laboratory Fee Schedule,27.69,,,27.69,Fee Schedule,215% Medicaid Laboratory Fee Schedule,27.69,,,27.69,Fee Schedule,215% Medicaid Laboratory Fee Schedule,16.1,,,16.1,Fee Schedule,125% Medicaid Laboratory Fee Schedule,12.88,143.5,
MUMPS ANTIBODY                  ,86735,CPT,,40165227,CDM,302,RC,,,both,,,208,21.46,,,21.46,Other,150% of Medicare + 9.63% HCRA Surcharge,13.05,,,13.05,Fee Schedule,Mediare Clinical Lab,25.19,,,25.19,Fee Schedule,,22.71,,,22.71,Fee Schedule,,58.73,,,58.73,Fee Schedule,,52.84,,,52.84,Fee Schedule,,49.9,,,49.9,Fee Schedule,,104,50,,104,percent of total billed charges,All Other,27.56,,,27.56,Fee Schedule,,41.11,,,41.11,Fee Schedule,,15.09,,,15.09,Other,186% Medicaid methodology,48.42,,,48.42,Fee Schedule,,128.96,,,128.96,Fee Schedule,,27.41,,,27.41,Fee Schedule,,48.42,,,48.42,Fee Schedule,,128.96,,,128.96,Fee Schedule,,51.55,,,51.55,Fee Schedule,,145.6,70,,145.6,percent of total billed charges,All Other,62.22,,,62.22,Fee Schedule,,52.79,,,52.79,Fee Schedule,,15.66,,,15.66,Fee Schedule,,15.66,,,15.66,Fee Schedule,,15.66,,,15.66,Fee Schedule,,15.66,,,15.66,Fee Schedule,,8.11,,,8.11,Fee Schedule,Medicaid Laboratory Fee Schedule,8.11,,,8.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.11,,,8.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.11,,,8.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.41,,,12.41,Fee Schedule,153% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.35,,,11.35,Fee Schedule,140% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.09,,,21.09,Fee Schedule,260% Medicaid Laboratory Fee Schedule,26.28,,,26.28,Fee Schedule,324% Medicaid Laboratory Fee Schedule,17.44,,,17.44,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.44,,,17.44,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.14,,,10.14,Fee Schedule,125% Medicaid Laboratory Fee Schedule,8.11,145.6,
TOXOPLASMA ANTIBODY             ,86777,CPT,,40165243,CDM,302,RC,,,both,,,229,23.66,,,23.66,Other,150% of Medicare + 9.63% HCRA Surcharge,14.39,,,14.39,Fee Schedule,Mediare Clinical Lab,27.77,,,27.77,Fee Schedule,,25.04,,,25.04,Fee Schedule,,145.4,,,145.4,Fee Schedule,,130.82,,,130.82,Fee Schedule,,123.53,,,123.53,Fee Schedule,,114.5,50,,114.5,percent of total billed charges,All Other,30.39,,,30.39,Fee Schedule,,45.33,,,45.33,Fee Schedule,,26.77,,,26.77,Other,186% Medicaid methodology,53.39,,,53.39,Fee Schedule,,141.98,,,141.98,Fee Schedule,,30.22,,,30.22,Fee Schedule,,53.39,,,53.39,Fee Schedule,,141.98,,,141.98,Fee Schedule,,56.84,,,56.84,Fee Schedule,,160.3,70,,160.3,percent of total billed charges,All Other,68.61,,,68.61,Fee Schedule,,58.22,,,58.22,Fee Schedule,,17.27,,,17.27,Fee Schedule,,17.27,,,17.27,Fee Schedule,,17.27,,,17.27,Fee Schedule,,17.27,,,17.27,Fee Schedule,,14.39,,,14.39,Fee Schedule,Medicaid Laboratory Fee Schedule,14.39,,,14.39,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.39,,,14.39,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.39,,,14.39,Fee Schedule,100% Medicaid Laboratory Fee Schedule,32.38,,,32.38,Fee Schedule,225% Medicaid Laboratory Fee Schedule,32.38,,,32.38,Fee Schedule,225% Medicaid Laboratory Fee Schedule,22.02,,,22.02,Fee Schedule,153% Medicaid Laboratory Fee Schedule,32.38,,,32.38,Fee Schedule,225% Medicaid Laboratory Fee Schedule,20.15,,,20.15,Fee Schedule,140% Medicaid Laboratory Fee Schedule,32.38,,,32.38,Fee Schedule,225% Medicaid Laboratory Fee Schedule,37.41,,,37.41,Fee Schedule,260% Medicaid Laboratory Fee Schedule,46.62,,,46.62,Fee Schedule,324% Medicaid Laboratory Fee Schedule,30.94,,,30.94,Fee Schedule,215% Medicaid Laboratory Fee Schedule,30.94,,,30.94,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.99,,,17.99,Fee Schedule,125% Medicaid Laboratory Fee Schedule,14.39,160.3,
TOXOPLASMA ANTIBODY IGM         ,86778,CPT,,40165268,CDM,302,RC,,,both,,,229,23.7,,,23.7,Other,150% of Medicare + 9.63% HCRA Surcharge,14.41,,,14.41,Fee Schedule,Mediare Clinical Lab,27.81,,,27.81,Fee Schedule,,25.07,,,25.07,Fee Schedule,,129.02,,,129.02,Fee Schedule,,116.09,,,116.09,Fee Schedule,,109.62,,,109.62,Fee Schedule,,114.5,50,,114.5,percent of total billed charges,All Other,30.45,,,30.45,Fee Schedule,,45.39,,,45.39,Fee Schedule,,26.53,,,26.53,Other,186% Medicaid methodology,53.46,,,53.46,Fee Schedule,,141.98,,,141.98,Fee Schedule,,30.26,,,30.26,Fee Schedule,,53.46,,,53.46,Fee Schedule,,141.98,,,141.98,Fee Schedule,,56.92,,,56.92,Fee Schedule,,160.3,70,,160.3,percent of total billed charges,All Other,68.71,,,68.71,Fee Schedule,,58.3,,,58.3,Fee Schedule,,17.29,,,17.29,Fee Schedule,,17.29,,,17.29,Fee Schedule,,17.29,,,17.29,Fee Schedule,,17.29,,,17.29,Fee Schedule,,14.26,,,14.26,Fee Schedule,Medicaid Laboratory Fee Schedule,14.26,,,14.26,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.26,,,14.26,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.26,,,14.26,Fee Schedule,100% Medicaid Laboratory Fee Schedule,32.09,,,32.09,Fee Schedule,225% Medicaid Laboratory Fee Schedule,32.09,,,32.09,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.82,,,21.82,Fee Schedule,153% Medicaid Laboratory Fee Schedule,32.09,,,32.09,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.97,,,19.97,Fee Schedule,140% Medicaid Laboratory Fee Schedule,32.09,,,32.09,Fee Schedule,225% Medicaid Laboratory Fee Schedule,37.08,,,37.08,Fee Schedule,260% Medicaid Laboratory Fee Schedule,46.21,,,46.21,Fee Schedule,324% Medicaid Laboratory Fee Schedule,30.66,,,30.66,Fee Schedule,215% Medicaid Laboratory Fee Schedule,30.66,,,30.66,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.83,,,17.83,Fee Schedule,125% Medicaid Laboratory Fee Schedule,14.26,160.3,
RUBELLA ANTIBODY                ,86762,CPT,,40165284,CDM,302,RC,,,both,,,229,23.66,,,23.66,Other,150% of Medicare + 9.63% HCRA Surcharge,14.39,,,14.39,Fee Schedule,Mediare Clinical Lab,27.77,,,27.77,Fee Schedule,,25.04,,,25.04,Fee Schedule,,145.4,,,145.4,Fee Schedule,,130.82,,,130.82,Fee Schedule,,123.53,,,123.53,Fee Schedule,,114.5,50,,114.5,percent of total billed charges,All Other,30.39,,,30.39,Fee Schedule,,45.33,,,45.33,Fee Schedule,,26.77,,,26.77,Other,186% Medicaid methodology,53.39,,,53.39,Fee Schedule,,141.98,,,141.98,Fee Schedule,,30.22,,,30.22,Fee Schedule,,53.39,,,53.39,Fee Schedule,,141.98,,,141.98,Fee Schedule,,56.84,,,56.84,Fee Schedule,,160.3,70,,160.3,percent of total billed charges,All Other,68.61,,,68.61,Fee Schedule,,58.22,,,58.22,Fee Schedule,,17.27,,,17.27,Fee Schedule,,17.27,,,17.27,Fee Schedule,,17.27,,,17.27,Fee Schedule,,17.27,,,17.27,Fee Schedule,,14.39,,,14.39,Fee Schedule,Medicaid Laboratory Fee Schedule,14.39,,,14.39,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.39,,,14.39,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.39,,,14.39,Fee Schedule,100% Medicaid Laboratory Fee Schedule,32.38,,,32.38,Fee Schedule,225% Medicaid Laboratory Fee Schedule,32.38,,,32.38,Fee Schedule,225% Medicaid Laboratory Fee Schedule,22.02,,,22.02,Fee Schedule,153% Medicaid Laboratory Fee Schedule,32.38,,,32.38,Fee Schedule,225% Medicaid Laboratory Fee Schedule,20.15,,,20.15,Fee Schedule,140% Medicaid Laboratory Fee Schedule,32.38,,,32.38,Fee Schedule,225% Medicaid Laboratory Fee Schedule,37.41,,,37.41,Fee Schedule,260% Medicaid Laboratory Fee Schedule,46.62,,,46.62,Fee Schedule,324% Medicaid Laboratory Fee Schedule,30.94,,,30.94,Fee Schedule,215% Medicaid Laboratory Fee Schedule,30.94,,,30.94,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.99,,,17.99,Fee Schedule,125% Medicaid Laboratory Fee Schedule,14.39,160.3,
SYPHILIS TEST NON-TREP QUANT    ,86593,CPT,,40165342,CDM,302,RC,,,both,,,70,7.24,,,7.24,Other,150% of Medicare + 9.63% HCRA Surcharge,4.4,,,4.4,Fee Schedule,Mediare Clinical Lab,8.49,,,8.49,Fee Schedule,,7.66,,,7.66,Fee Schedule,,44.44,,,44.44,Fee Schedule,,39.99,,,39.99,Fee Schedule,,37.76,,,37.76,Fee Schedule,,35,50,,35,percent of total billed charges,All Other,9.3,,,9.3,Fee Schedule,,13.86,,,13.86,Fee Schedule,,6.95,,,6.95,Other,186% Medicaid methodology,16.32,,,16.32,Fee Schedule,,43.4,,,43.4,Fee Schedule,,9.24,,,9.24,Fee Schedule,,16.32,,,16.32,Fee Schedule,,43.4,,,43.4,Fee Schedule,,17.38,,,17.38,Fee Schedule,,49,70,,49,percent of total billed charges,All Other,20.98,,,20.98,Fee Schedule,,17.8,,,17.8,Fee Schedule,,5.28,,,5.28,Fee Schedule,,5.28,,,5.28,Fee Schedule,,5.28,,,5.28,Fee Schedule,,5.28,,,5.28,Fee Schedule,,3.74,,,3.74,Fee Schedule,Medicaid Laboratory Fee Schedule,3.74,,,3.74,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.74,,,3.74,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.74,,,3.74,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.41,,,8.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.41,,,8.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.72,,,5.72,Fee Schedule,153% Medicaid Laboratory Fee Schedule,8.41,,,8.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.23,,,5.23,Fee Schedule,140% Medicaid Laboratory Fee Schedule,8.41,,,8.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.72,,,9.72,Fee Schedule,260% Medicaid Laboratory Fee Schedule,12.11,,,12.11,Fee Schedule,324% Medicaid Laboratory Fee Schedule,8.03,,,8.03,Fee Schedule,215% Medicaid Laboratory Fee Schedule,8.03,,,8.03,Fee Schedule,215% Medicaid Laboratory Fee Schedule,4.67,,,4.67,Fee Schedule,125% Medicaid Laboratory Fee Schedule,3.74,49,
HEP B SURFACE ANTIBODY          ,86706,CPT,,40165409,CDM,302,RC,,,both,,,171,17.66,,,17.66,Other,150% of Medicare + 9.63% HCRA Surcharge,10.74,,,10.74,Fee Schedule,Mediare Clinical Lab,20.73,,,20.73,Fee Schedule,,18.69,,,18.69,Fee Schedule,,108.56,,,108.56,Fee Schedule,,97.68,,,97.68,Fee Schedule,,92.23,,,92.23,Fee Schedule,,85.5,50,,85.5,percent of total billed charges,All Other,22.69,,,22.69,Fee Schedule,,33.83,,,33.83,Fee Schedule,,18.97,,,18.97,Other,186% Medicaid methodology,39.85,,,39.85,Fee Schedule,,106.02,,,106.02,Fee Schedule,,22.55,,,22.55,Fee Schedule,,39.85,,,39.85,Fee Schedule,,106.02,,,106.02,Fee Schedule,,42.42,,,42.42,Fee Schedule,,119.7,70,,119.7,percent of total billed charges,All Other,51.21,,,51.21,Fee Schedule,,43.45,,,43.45,Fee Schedule,,12.89,,,12.89,Fee Schedule,,12.89,,,12.89,Fee Schedule,,12.89,,,12.89,Fee Schedule,,12.89,,,12.89,Fee Schedule,,10.2,,,10.2,Fee Schedule,Medicaid Laboratory Fee Schedule,10.2,,,10.2,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.2,,,10.2,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.2,,,10.2,Fee Schedule,100% Medicaid Laboratory Fee Schedule,22.95,,,22.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,22.95,,,22.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.61,,,15.61,Fee Schedule,153% Medicaid Laboratory Fee Schedule,22.95,,,22.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.28,,,14.28,Fee Schedule,140% Medicaid Laboratory Fee Schedule,22.95,,,22.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,26.52,,,26.52,Fee Schedule,260% Medicaid Laboratory Fee Schedule,33.05,,,33.05,Fee Schedule,324% Medicaid Laboratory Fee Schedule,21.93,,,21.93,Fee Schedule,215% Medicaid Laboratory Fee Schedule,21.93,,,21.93,Fee Schedule,215% Medicaid Laboratory Fee Schedule,12.75,,,12.75,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.2,119.7,
HEP B CORE ANTIBODY TOTAL       ,86704,CPT,,40165425,CDM,302,RC,,,both,,,192,19.82,,,19.82,Other,150% of Medicare + 9.63% HCRA Surcharge,12.05,,,12.05,Fee Schedule,Mediare Clinical Lab,23.26,,,23.26,Fee Schedule,,20.97,,,20.97,Fee Schedule,,121.77,,,121.77,Fee Schedule,,109.56,,,109.56,Fee Schedule,,103.46,,,103.46,Fee Schedule,,96,50,,96,percent of total billed charges,All Other,25.45,,,25.45,Fee Schedule,,37.96,,,37.96,Fee Schedule,,18.97,,,18.97,Other,186% Medicaid methodology,44.71,,,44.71,Fee Schedule,,119.04,,,119.04,Fee Schedule,,25.31,,,25.31,Fee Schedule,,44.71,,,44.71,Fee Schedule,,119.04,,,119.04,Fee Schedule,,47.6,,,47.6,Fee Schedule,,134.4,70,,134.4,percent of total billed charges,All Other,57.45,,,57.45,Fee Schedule,,48.75,,,48.75,Fee Schedule,,14.46,,,14.46,Fee Schedule,,14.46,,,14.46,Fee Schedule,,14.46,,,14.46,Fee Schedule,,14.46,,,14.46,Fee Schedule,,10.2,,,10.2,Fee Schedule,Medicaid Laboratory Fee Schedule,10.2,,,10.2,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.2,,,10.2,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.2,,,10.2,Fee Schedule,100% Medicaid Laboratory Fee Schedule,22.95,,,22.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,22.95,,,22.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.61,,,15.61,Fee Schedule,153% Medicaid Laboratory Fee Schedule,22.95,,,22.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.28,,,14.28,Fee Schedule,140% Medicaid Laboratory Fee Schedule,22.95,,,22.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,26.52,,,26.52,Fee Schedule,260% Medicaid Laboratory Fee Schedule,33.05,,,33.05,Fee Schedule,324% Medicaid Laboratory Fee Schedule,21.93,,,21.93,Fee Schedule,215% Medicaid Laboratory Fee Schedule,21.93,,,21.93,Fee Schedule,215% Medicaid Laboratory Fee Schedule,12.75,,,12.75,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.2,134.4,
HEPATITIS BE ANTIBODY           ,86707,CPT,,40165441,CDM,302,RC,,,both,,,185,19.03,,,19.03,Other,150% of Medicare + 9.63% HCRA Surcharge,11.57,,,11.57,Fee Schedule,Mediare Clinical Lab,22.33,,,22.33,Fee Schedule,,20.13,,,20.13,Fee Schedule,,116.89,,,116.89,Fee Schedule,,105.17,,,105.17,Fee Schedule,,99.31,,,99.31,Fee Schedule,,92.5,50,,92.5,percent of total billed charges,All Other,24.44,,,24.44,Fee Schedule,,36.45,,,36.45,Fee Schedule,,18.97,,,18.97,Other,186% Medicaid methodology,42.92,,,42.92,Fee Schedule,,114.7,,,114.7,Fee Schedule,,24.3,,,24.3,Fee Schedule,,42.92,,,42.92,Fee Schedule,,114.7,,,114.7,Fee Schedule,,45.7,,,45.7,Fee Schedule,,129.5,70,,129.5,percent of total billed charges,All Other,55.16,,,55.16,Fee Schedule,,46.81,,,46.81,Fee Schedule,,13.88,,,13.88,Fee Schedule,,13.88,,,13.88,Fee Schedule,,13.88,,,13.88,Fee Schedule,,13.88,,,13.88,Fee Schedule,,10.2,,,10.2,Fee Schedule,Medicaid Laboratory Fee Schedule,10.2,,,10.2,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.2,,,10.2,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.2,,,10.2,Fee Schedule,100% Medicaid Laboratory Fee Schedule,22.95,,,22.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,22.95,,,22.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.61,,,15.61,Fee Schedule,153% Medicaid Laboratory Fee Schedule,22.95,,,22.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.28,,,14.28,Fee Schedule,140% Medicaid Laboratory Fee Schedule,22.95,,,22.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,26.52,,,26.52,Fee Schedule,260% Medicaid Laboratory Fee Schedule,33.05,,,33.05,Fee Schedule,324% Medicaid Laboratory Fee Schedule,21.93,,,21.93,Fee Schedule,215% Medicaid Laboratory Fee Schedule,21.93,,,21.93,Fee Schedule,215% Medicaid Laboratory Fee Schedule,12.75,,,12.75,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.2,129.5,
HEPATITIS C AB TEST             ,86803,CPT,,40165466,CDM,302,RC,,,both,,,227,23.47,,,23.47,Other,150% of Medicare + 9.63% HCRA Surcharge,14.27,,,14.27,Fee Schedule,Mediare Clinical Lab,27.54,,,27.54,Fee Schedule,,24.83,,,24.83,Fee Schedule,,144.17,,,144.17,Fee Schedule,,129.72,,,129.72,Fee Schedule,,122.49,,,122.49,Fee Schedule,,113.5,50,,113.5,percent of total billed charges,All Other,30.16,,,30.16,Fee Schedule,,44.95,,,44.95,Fee Schedule,,18.79,,,18.79,Other,186% Medicaid methodology,52.94,,,52.94,Fee Schedule,,140.74,,,140.74,Fee Schedule,,29.97,,,29.97,Fee Schedule,,52.94,,,52.94,Fee Schedule,,140.74,,,140.74,Fee Schedule,,56.37,,,56.37,Fee Schedule,,158.9,70,,158.9,percent of total billed charges,All Other,68.04,,,68.04,Fee Schedule,,57.73,,,57.73,Fee Schedule,,17.12,,,17.12,Fee Schedule,,17.12,,,17.12,Fee Schedule,,17.12,,,17.12,Fee Schedule,,17.12,,,17.12,Fee Schedule,,10.1,,,10.1,Fee Schedule,Medicaid Laboratory Fee Schedule,10.1,,,10.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.1,,,10.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.1,,,10.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,22.73,,,22.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,22.73,,,22.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.45,,,15.45,Fee Schedule,153% Medicaid Laboratory Fee Schedule,22.73,,,22.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.14,,,14.14,Fee Schedule,140% Medicaid Laboratory Fee Schedule,22.73,,,22.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,26.26,,,26.26,Fee Schedule,260% Medicaid Laboratory Fee Schedule,32.72,,,32.72,Fee Schedule,324% Medicaid Laboratory Fee Schedule,21.72,,,21.72,Fee Schedule,215% Medicaid Laboratory Fee Schedule,21.72,,,21.72,Fee Schedule,215% Medicaid Laboratory Fee Schedule,12.63,,,12.63,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.1,158.9,
HEPATITIS A IGM ANTIBODY        ,86709,CPT,,40165482,CDM,302,RC,,,both,,,180,18.52,,,18.52,Other,150% of Medicare + 9.63% HCRA Surcharge,11.26,,,11.26,Fee Schedule,Mediare Clinical Lab,21.73,,,21.73,Fee Schedule,,19.59,,,19.59,Fee Schedule,,113.73,,,113.73,Fee Schedule,,102.33,,,102.33,Fee Schedule,,96.62,,,96.62,Fee Schedule,,90,50,,90,percent of total billed charges,All Other,23.79,,,23.79,Fee Schedule,,35.47,,,35.47,Fee Schedule,,18.79,,,18.79,Other,186% Medicaid methodology,41.77,,,41.77,Fee Schedule,,111.6,,,111.6,Fee Schedule,,23.65,,,23.65,Fee Schedule,,41.77,,,41.77,Fee Schedule,,111.6,,,111.6,Fee Schedule,,44.48,,,44.48,Fee Schedule,,126,70,,126,percent of total billed charges,All Other,53.69,,,53.69,Fee Schedule,,45.55,,,45.55,Fee Schedule,,13.51,,,13.51,Fee Schedule,,13.51,,,13.51,Fee Schedule,,13.51,,,13.51,Fee Schedule,,13.51,,,13.51,Fee Schedule,,10.1,,,10.1,Fee Schedule,Medicaid Laboratory Fee Schedule,10.1,,,10.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.1,,,10.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.1,,,10.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,22.73,,,22.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,22.73,,,22.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.45,,,15.45,Fee Schedule,153% Medicaid Laboratory Fee Schedule,22.73,,,22.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.14,,,14.14,Fee Schedule,140% Medicaid Laboratory Fee Schedule,22.73,,,22.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,26.26,,,26.26,Fee Schedule,260% Medicaid Laboratory Fee Schedule,32.72,,,32.72,Fee Schedule,324% Medicaid Laboratory Fee Schedule,21.72,,,21.72,Fee Schedule,215% Medicaid Laboratory Fee Schedule,21.72,,,21.72,Fee Schedule,215% Medicaid Laboratory Fee Schedule,12.63,,,12.63,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.1,126,
HEPATITIS A ANTIBODY            ,86708,CPT,,40165508,CDM,302,RC,,,both,,,198,20.37,,,20.37,Other,150% of Medicare + 9.63% HCRA Surcharge,12.39,,,12.39,Fee Schedule,Mediare Clinical Lab,23.91,,,23.91,Fee Schedule,,21.56,,,21.56,Fee Schedule,,125.15,,,125.15,Fee Schedule,,112.6,,,112.6,Fee Schedule,,106.32,,,106.32,Fee Schedule,,99,50,,99,percent of total billed charges,All Other,26.16,,,26.16,Fee Schedule,,39.03,,,39.03,Fee Schedule,,18.79,,,18.79,Other,186% Medicaid methodology,45.97,,,45.97,Fee Schedule,,122.76,,,122.76,Fee Schedule,,26.02,,,26.02,Fee Schedule,,45.97,,,45.97,Fee Schedule,,122.76,,,122.76,Fee Schedule,,48.94,,,48.94,Fee Schedule,,138.6,70,,138.6,percent of total billed charges,All Other,59.07,,,59.07,Fee Schedule,,50.12,,,50.12,Fee Schedule,,14.87,,,14.87,Fee Schedule,,14.87,,,14.87,Fee Schedule,,14.87,,,14.87,Fee Schedule,,14.87,,,14.87,Fee Schedule,,10.1,,,10.1,Fee Schedule,Medicaid Laboratory Fee Schedule,10.1,,,10.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.1,,,10.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.1,,,10.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,22.73,,,22.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,22.73,,,22.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.45,,,15.45,Fee Schedule,153% Medicaid Laboratory Fee Schedule,22.73,,,22.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.14,,,14.14,Fee Schedule,140% Medicaid Laboratory Fee Schedule,22.73,,,22.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,26.26,,,26.26,Fee Schedule,260% Medicaid Laboratory Fee Schedule,32.72,,,32.72,Fee Schedule,324% Medicaid Laboratory Fee Schedule,21.72,,,21.72,Fee Schedule,215% Medicaid Laboratory Fee Schedule,21.72,,,21.72,Fee Schedule,215% Medicaid Laboratory Fee Schedule,12.63,,,12.63,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.1,138.6,
ASPERGILLUS ANTIBODY            ,86606,CPT,,40165862,CDM,302,RC,,,both,,,240,24.75,,,24.75,Other,150% of Medicare + 9.63% HCRA Surcharge,15.05,,,15.05,Fee Schedule,Mediare Clinical Lab,29.05,,,29.05,Fee Schedule,,26.19,,,26.19,Fee Schedule,,58.73,,,58.73,Fee Schedule,,52.84,,,52.84,Fee Schedule,,49.9,,,49.9,Fee Schedule,,120,50,,120,percent of total billed charges,All Other,31.79,,,31.79,Fee Schedule,,47.41,,,47.41,Fee Schedule,,15.09,,,15.09,Other,186% Medicaid methodology,55.84,,,55.84,Fee Schedule,,148.8,,,148.8,Fee Schedule,,31.61,,,31.61,Fee Schedule,,55.84,,,55.84,Fee Schedule,,148.8,,,148.8,Fee Schedule,,59.45,,,59.45,Fee Schedule,,168,70,,168,percent of total billed charges,All Other,71.76,,,71.76,Fee Schedule,,60.89,,,60.89,Fee Schedule,,18.06,,,18.06,Fee Schedule,,18.06,,,18.06,Fee Schedule,,18.06,,,18.06,Fee Schedule,,18.06,,,18.06,Fee Schedule,,8.11,,,8.11,Fee Schedule,Medicaid Laboratory Fee Schedule,8.11,,,8.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.11,,,8.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.11,,,8.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.41,,,12.41,Fee Schedule,153% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.35,,,11.35,Fee Schedule,140% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.09,,,21.09,Fee Schedule,260% Medicaid Laboratory Fee Schedule,26.28,,,26.28,Fee Schedule,324% Medicaid Laboratory Fee Schedule,17.44,,,17.44,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.44,,,17.44,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.14,,,10.14,Fee Schedule,125% Medicaid Laboratory Fee Schedule,8.11,168,
ENTEROVIRUS ANTIBODY            ,86658,CPT,,40166027,CDM,302,RC,,,both,,,207,21.43,,,21.43,Other,150% of Medicare + 9.63% HCRA Surcharge,13.03,,,13.03,Fee Schedule,Mediare Clinical Lab,25.15,,,25.15,Fee Schedule,,22.67,,,22.67,Fee Schedule,,58.73,,,58.73,Fee Schedule,,52.84,,,52.84,Fee Schedule,,49.9,,,49.9,Fee Schedule,,103.5,50,,103.5,percent of total billed charges,All Other,27.53,,,27.53,Fee Schedule,,41.04,,,41.04,Fee Schedule,,15.09,,,15.09,Other,186% Medicaid methodology,48.34,,,48.34,Fee Schedule,,128.34,,,128.34,Fee Schedule,,27.36,,,27.36,Fee Schedule,,48.34,,,48.34,Fee Schedule,,128.34,,,128.34,Fee Schedule,,51.47,,,51.47,Fee Schedule,,144.9,70,,144.9,percent of total billed charges,All Other,62.13,,,62.13,Fee Schedule,,52.71,,,52.71,Fee Schedule,,15.64,,,15.64,Fee Schedule,,15.64,,,15.64,Fee Schedule,,15.64,,,15.64,Fee Schedule,,15.64,,,15.64,Fee Schedule,,8.11,,,8.11,Fee Schedule,Medicaid Laboratory Fee Schedule,8.11,,,8.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.11,,,8.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.11,,,8.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.41,,,12.41,Fee Schedule,153% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.35,,,11.35,Fee Schedule,140% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.09,,,21.09,Fee Schedule,260% Medicaid Laboratory Fee Schedule,26.28,,,26.28,Fee Schedule,324% Medicaid Laboratory Fee Schedule,17.44,,,17.44,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.44,,,17.44,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.14,,,10.14,Fee Schedule,125% Medicaid Laboratory Fee Schedule,8.11,144.9,
HEP B CORE ANTIBODY IGM         ,86705,CPT,,40166241,CDM,302,RC,,,both,,,188,19.36,,,19.36,Other,150% of Medicare + 9.63% HCRA Surcharge,11.77,,,11.77,Fee Schedule,Mediare Clinical Lab,22.72,,,22.72,Fee Schedule,,20.48,,,20.48,Fee Schedule,,118.9,,,118.9,Fee Schedule,,106.98,,,106.98,Fee Schedule,,101.02,,,101.02,Fee Schedule,,94,50,,94,percent of total billed charges,All Other,24.86,,,24.86,Fee Schedule,,37.08,,,37.08,Fee Schedule,,18.97,,,18.97,Other,186% Medicaid methodology,43.67,,,43.67,Fee Schedule,,116.56,,,116.56,Fee Schedule,,24.72,,,24.72,Fee Schedule,,43.67,,,43.67,Fee Schedule,,116.56,,,116.56,Fee Schedule,,46.49,,,46.49,Fee Schedule,,131.6,70,,131.6,percent of total billed charges,All Other,56.12,,,56.12,Fee Schedule,,47.62,,,47.62,Fee Schedule,,14.12,,,14.12,Fee Schedule,,14.12,,,14.12,Fee Schedule,,14.12,,,14.12,Fee Schedule,,14.12,,,14.12,Fee Schedule,,10.2,,,10.2,Fee Schedule,Medicaid Laboratory Fee Schedule,10.2,,,10.2,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.2,,,10.2,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.2,,,10.2,Fee Schedule,100% Medicaid Laboratory Fee Schedule,22.95,,,22.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,22.95,,,22.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.61,,,15.61,Fee Schedule,153% Medicaid Laboratory Fee Schedule,22.95,,,22.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.28,,,14.28,Fee Schedule,140% Medicaid Laboratory Fee Schedule,22.95,,,22.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,26.52,,,26.52,Fee Schedule,260% Medicaid Laboratory Fee Schedule,33.05,,,33.05,Fee Schedule,324% Medicaid Laboratory Fee Schedule,21.93,,,21.93,Fee Schedule,215% Medicaid Laboratory Fee Schedule,21.93,,,21.93,Fee Schedule,215% Medicaid Laboratory Fee Schedule,12.75,,,12.75,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.2,131.6,
INTRINSIC FACTOR ANTIBODY       ,86340,CPT,,40166548,CDM,302,RC,,,both,,,240,24.8,,,24.8,Other,150% of Medicare + 9.63% HCRA Surcharge,15.08,,,15.08,Fee Schedule,Mediare Clinical Lab,29.1,,,29.1,Fee Schedule,,26.24,,,26.24,Fee Schedule,,152.29,,,152.29,Fee Schedule,,137.02,,,137.02,Fee Schedule,,129.38,,,129.38,Fee Schedule,,120,50,,120,percent of total billed charges,All Other,31.85,,,31.85,Fee Schedule,,47.5,,,47.5,Fee Schedule,,21.34,,,21.34,Other,186% Medicaid methodology,55.95,,,55.95,Fee Schedule,,148.8,,,148.8,Fee Schedule,,31.67,,,31.67,Fee Schedule,,55.95,,,55.95,Fee Schedule,,148.8,,,148.8,Fee Schedule,,59.57,,,59.57,Fee Schedule,,168,70,,168,percent of total billed charges,All Other,71.9,,,71.9,Fee Schedule,,61.01,,,61.01,Fee Schedule,,18.1,,,18.1,Fee Schedule,,18.1,,,18.1,Fee Schedule,,18.1,,,18.1,Fee Schedule,,18.1,,,18.1,Fee Schedule,,11.47,,,11.47,Fee Schedule,Medicaid Laboratory Fee Schedule,11.47,,,11.47,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.47,,,11.47,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.47,,,11.47,Fee Schedule,100% Medicaid Laboratory Fee Schedule,25.82,,,25.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,25.82,,,25.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.55,,,17.55,Fee Schedule,153% Medicaid Laboratory Fee Schedule,25.82,,,25.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.06,,,16.06,Fee Schedule,140% Medicaid Laboratory Fee Schedule,25.82,,,25.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,29.83,,,29.83,Fee Schedule,260% Medicaid Laboratory Fee Schedule,37.17,,,37.17,Fee Schedule,324% Medicaid Laboratory Fee Schedule,24.67,,,24.67,Fee Schedule,215% Medicaid Laboratory Fee Schedule,24.67,,,24.67,Fee Schedule,215% Medicaid Laboratory Fee Schedule,14.34,,,14.34,Fee Schedule,125% Medicaid Laboratory Fee Schedule,11.47,168,
LEGIONELLA ANTIBODY             ,86713,CPT,,40166589,CDM,302,RC,,,both,,,244,25.16,,,25.16,Other,150% of Medicare + 9.63% HCRA Surcharge,15.3,,,15.3,Fee Schedule,Mediare Clinical Lab,29.53,,,29.53,Fee Schedule,,26.62,,,26.62,Fee Schedule,,154.59,,,154.59,Fee Schedule,,139.08,,,139.08,Fee Schedule,,131.33,,,131.33,Fee Schedule,,122,50,,122,percent of total billed charges,All Other,32.34,,,32.34,Fee Schedule,,48.2,,,48.2,Fee Schedule,,28.46,,,28.46,Other,186% Medicaid methodology,56.76,,,56.76,Fee Schedule,,151.28,,,151.28,Fee Schedule,,32.13,,,32.13,Fee Schedule,,56.76,,,56.76,Fee Schedule,,151.28,,,151.28,Fee Schedule,,60.44,,,60.44,Fee Schedule,,170.8,70,,170.8,percent of total billed charges,All Other,72.95,,,72.95,Fee Schedule,,61.9,,,61.9,Fee Schedule,,18.36,,,18.36,Fee Schedule,,18.36,,,18.36,Fee Schedule,,18.36,,,18.36,Fee Schedule,,18.36,,,18.36,Fee Schedule,,15.3,,,15.3,Fee Schedule,Medicaid Laboratory Fee Schedule,15.3,,,15.3,Fee Schedule,100% Medicaid Laboratory Fee Schedule,15.3,,,15.3,Fee Schedule,100% Medicaid Laboratory Fee Schedule,15.3,,,15.3,Fee Schedule,100% Medicaid Laboratory Fee Schedule,34.43,,,34.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,34.43,,,34.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.41,,,23.41,Fee Schedule,153% Medicaid Laboratory Fee Schedule,34.43,,,34.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.42,,,21.42,Fee Schedule,140% Medicaid Laboratory Fee Schedule,34.43,,,34.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,39.78,,,39.78,Fee Schedule,260% Medicaid Laboratory Fee Schedule,49.57,,,49.57,Fee Schedule,324% Medicaid Laboratory Fee Schedule,32.9,,,32.9,Fee Schedule,215% Medicaid Laboratory Fee Schedule,32.9,,,32.9,Fee Schedule,215% Medicaid Laboratory Fee Schedule,19.13,,,19.13,Fee Schedule,125% Medicaid Laboratory Fee Schedule,15.3,170.8,
VARICELLA-ZOSTER ANTIBODY       ,86787,CPT,,40166886,CDM,302,RC,,,both,,,205,21.18,,,21.18,Other,150% of Medicare + 9.63% HCRA Surcharge,12.88,,,12.88,Fee Schedule,Mediare Clinical Lab,24.86,,,24.86,Fee Schedule,,22.41,,,22.41,Fee Schedule,,58.73,,,58.73,Fee Schedule,,52.84,,,52.84,Fee Schedule,,49.9,,,49.9,Fee Schedule,,102.5,50,,102.5,percent of total billed charges,All Other,27.2,,,27.2,Fee Schedule,,40.57,,,40.57,Fee Schedule,,15.09,,,15.09,Other,186% Medicaid methodology,47.78,,,47.78,Fee Schedule,,127.1,,,127.1,Fee Schedule,,27.05,,,27.05,Fee Schedule,,47.78,,,47.78,Fee Schedule,,127.1,,,127.1,Fee Schedule,,50.88,,,50.88,Fee Schedule,,143.5,70,,143.5,percent of total billed charges,All Other,61.41,,,61.41,Fee Schedule,,52.11,,,52.11,Fee Schedule,,15.46,,,15.46,Fee Schedule,,15.46,,,15.46,Fee Schedule,,15.46,,,15.46,Fee Schedule,,15.46,,,15.46,Fee Schedule,,8.11,,,8.11,Fee Schedule,Medicaid Laboratory Fee Schedule,8.11,,,8.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.11,,,8.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.11,,,8.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.41,,,12.41,Fee Schedule,153% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.35,,,11.35,Fee Schedule,140% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.09,,,21.09,Fee Schedule,260% Medicaid Laboratory Fee Schedule,26.28,,,26.28,Fee Schedule,324% Medicaid Laboratory Fee Schedule,17.44,,,17.44,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.44,,,17.44,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.14,,,10.14,Fee Schedule,125% Medicaid Laboratory Fee Schedule,8.11,143.5,
SYPHILIS TEST NON-TREP QUAL     ,86592,CPT,,40167082,CDM,302,RC,,,both,,,68,7.02,,,7.02,Other,150% of Medicare + 9.63% HCRA Surcharge,4.27,,,4.27,Fee Schedule,Mediare Clinical Lab,8.24,,,8.24,Fee Schedule,,7.43,,,7.43,Fee Schedule,,43.15,,,43.15,Fee Schedule,,38.82,,,38.82,Fee Schedule,,36.66,,,36.66,Fee Schedule,,34,50,,34,percent of total billed charges,All Other,9.04,,,9.04,Fee Schedule,,13.45,,,13.45,Fee Schedule,,6.14,,,6.14,Other,186% Medicaid methodology,15.84,,,15.84,Fee Schedule,,42.16,,,42.16,Fee Schedule,,8.97,,,8.97,Fee Schedule,,15.84,,,15.84,Fee Schedule,,42.16,,,42.16,Fee Schedule,,16.87,,,16.87,Fee Schedule,,47.6,70,,47.6,percent of total billed charges,All Other,20.36,,,20.36,Fee Schedule,,17.27,,,17.27,Fee Schedule,,5.12,,,5.12,Fee Schedule,,5.12,,,5.12,Fee Schedule,,5.12,,,5.12,Fee Schedule,,5.12,,,5.12,Fee Schedule,,3.3,,,3.3,Fee Schedule,Medicaid Laboratory Fee Schedule,3.3,,,3.3,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.3,,,3.3,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.3,,,3.3,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.43,,,7.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.43,,,7.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.05,,,5.05,Fee Schedule,153% Medicaid Laboratory Fee Schedule,7.43,,,7.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,4.62,,,4.62,Fee Schedule,140% Medicaid Laboratory Fee Schedule,7.43,,,7.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.59,,,8.59,Fee Schedule,260% Medicaid Laboratory Fee Schedule,10.7,,,10.7,Fee Schedule,324% Medicaid Laboratory Fee Schedule,7.1,,,7.1,Fee Schedule,215% Medicaid Laboratory Fee Schedule,7.1,,,7.1,Fee Schedule,215% Medicaid Laboratory Fee Schedule,4.13,,,4.13,Fee Schedule,125% Medicaid Laboratory Fee Schedule,3.3,47.6,
EPSTEIN-BARR CAPSID VCA         ,86665,CPT,,40167207,CDM,302,RC,,,both,,,289,29.83,,,29.83,Other,150% of Medicare + 9.63% HCRA Surcharge,18.14,,,18.14,Fee Schedule,Mediare Clinical Lab,35.01,,,35.01,Fee Schedule,,31.56,,,31.56,Fee Schedule,,183.31,,,183.31,Fee Schedule,,164.92,,,164.92,Fee Schedule,,155.73,,,155.73,Fee Schedule,,144.5,50,,144.5,percent of total billed charges,All Other,38.32,,,38.32,Fee Schedule,,57.14,,,57.14,Fee Schedule,,33.74,,,33.74,Other,186% Medicaid methodology,67.3,,,67.3,Fee Schedule,,179.18,,,179.18,Fee Schedule,,38.09,,,38.09,Fee Schedule,,67.3,,,67.3,Fee Schedule,,179.18,,,179.18,Fee Schedule,,71.65,,,71.65,Fee Schedule,,202.3,70,,202.3,percent of total billed charges,All Other,86.49,,,86.49,Fee Schedule,,73.39,,,73.39,Fee Schedule,,21.77,,,21.77,Fee Schedule,,21.77,,,21.77,Fee Schedule,,21.77,,,21.77,Fee Schedule,,21.77,,,21.77,Fee Schedule,,18.14,,,18.14,Fee Schedule,Medicaid Laboratory Fee Schedule,18.14,,,18.14,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.14,,,18.14,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.14,,,18.14,Fee Schedule,100% Medicaid Laboratory Fee Schedule,40.82,,,40.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,40.82,,,40.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.75,,,27.75,Fee Schedule,153% Medicaid Laboratory Fee Schedule,40.82,,,40.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,25.4,,,25.4,Fee Schedule,140% Medicaid Laboratory Fee Schedule,40.82,,,40.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,47.16,,,47.16,Fee Schedule,260% Medicaid Laboratory Fee Schedule,58.77,,,58.77,Fee Schedule,324% Medicaid Laboratory Fee Schedule,39,,,39,Fee Schedule,215% Medicaid Laboratory Fee Schedule,39,,,39,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.68,,,22.68,Fee Schedule,125% Medicaid Laboratory Fee Schedule,18.14,202.3,
HERPES SIMPLEX NES ANTBDY       ,86694,CPT,,40167744,CDM,302,RC,,,both,,,229,23.66,,,23.66,Other,150% of Medicare + 9.63% HCRA Surcharge,14.39,,,14.39,Fee Schedule,Mediare Clinical Lab,27.77,,,27.77,Fee Schedule,,25.04,,,25.04,Fee Schedule,,145.4,,,145.4,Fee Schedule,,130.82,,,130.82,Fee Schedule,,123.53,,,123.53,Fee Schedule,,114.5,50,,114.5,percent of total billed charges,All Other,30.39,,,30.39,Fee Schedule,,45.33,,,45.33,Fee Schedule,,64.67,,,64.67,Other,186% Medicaid methodology,53.39,,,53.39,Fee Schedule,,141.98,,,141.98,Fee Schedule,,30.22,,,30.22,Fee Schedule,,53.39,,,53.39,Fee Schedule,,141.98,,,141.98,Fee Schedule,,56.84,,,56.84,Fee Schedule,,160.3,70,,160.3,percent of total billed charges,All Other,68.61,,,68.61,Fee Schedule,,58.22,,,58.22,Fee Schedule,,17.27,,,17.27,Fee Schedule,,17.27,,,17.27,Fee Schedule,,17.27,,,17.27,Fee Schedule,,17.27,,,17.27,Fee Schedule,,34.77,,,34.77,Other,New York Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,53.2,,,53.2,Other,153% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,48.68,,,48.68,Other,140% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,90.41,,,90.41,Other,260% Medicaid APG methodology,112.66,,,112.66,Other,324% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,43.46,,,43.46,Other,125% Medicaid APG methodology,14.39,160.3,
DNA ANTIBODY NATIVE             ,86225,CPT,,40180044,CDM,302,RC,,,both,,,219,22.59,,,22.59,Other,150% of Medicare + 9.63% HCRA Surcharge,13.74,,,13.74,Fee Schedule,Mediare Clinical Lab,26.52,,,26.52,Fee Schedule,,23.91,,,23.91,Fee Schedule,,138.79,,,138.79,Fee Schedule,,124.87,,,124.87,Fee Schedule,,117.91,,,117.91,Fee Schedule,,109.5,50,,109.5,percent of total billed charges,All Other,29.02,,,29.02,Fee Schedule,,43.28,,,43.28,Fee Schedule,,9.77,,,9.77,Other,186% Medicaid methodology,50.98,,,50.98,Fee Schedule,,135.78,,,135.78,Fee Schedule,,28.85,,,28.85,Fee Schedule,,50.98,,,50.98,Fee Schedule,,135.78,,,135.78,Fee Schedule,,54.27,,,54.27,Fee Schedule,,153.3,70,,153.3,percent of total billed charges,All Other,65.51,,,65.51,Fee Schedule,,55.59,,,55.59,Fee Schedule,,16.49,,,16.49,Fee Schedule,,16.49,,,16.49,Fee Schedule,,16.49,,,16.49,Fee Schedule,,16.49,,,16.49,Fee Schedule,,5.25,,,5.25,Fee Schedule,Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.04,,,8.04,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.35,,,7.35,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.66,,,13.66,Fee Schedule,260% Medicaid Laboratory Fee Schedule,17.02,,,17.02,Fee Schedule,324% Medicaid Laboratory Fee Schedule,11.29,,,11.29,Fee Schedule,215% Medicaid Laboratory Fee Schedule,11.29,,,11.29,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.57,,,6.57,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.25,153.3,
COMPLEMENT ANTIGEN EA           ,86160,CPT,,40180168,CDM,302,RC,,,both,,,191,19.73,,,19.73,Other,150% of Medicare + 9.63% HCRA Surcharge,12,,,12,Fee Schedule,Mediare Clinical Lab,23.16,,,23.16,Fee Schedule,,20.88,,,20.88,Fee Schedule,,121.27,,,121.27,Fee Schedule,,109.11,,,109.11,Fee Schedule,,103.03,,,103.03,Fee Schedule,,95.5,50,,95.5,percent of total billed charges,All Other,25.35,,,25.35,Fee Schedule,,37.8,,,37.8,Fee Schedule,,19.73,,,19.73,Other,186% Medicaid methodology,44.52,,,44.52,Fee Schedule,,118.42,,,118.42,Fee Schedule,,25.2,,,25.2,Fee Schedule,,44.52,,,44.52,Fee Schedule,,118.42,,,118.42,Fee Schedule,,47.4,,,47.4,Fee Schedule,,133.7,70,,133.7,percent of total billed charges,All Other,57.22,,,57.22,Fee Schedule,,48.55,,,48.55,Fee Schedule,,14.4,,,14.4,Fee Schedule,,14.4,,,14.4,Fee Schedule,,14.4,,,14.4,Fee Schedule,,14.4,,,14.4,Fee Schedule,,10.61,,,10.61,Fee Schedule,Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.61,,,10.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.23,,,16.23,Fee Schedule,153% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.85,,,14.85,Fee Schedule,140% Medicaid Laboratory Fee Schedule,23.86,,,23.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.57,,,27.57,Fee Schedule,260% Medicaid Laboratory Fee Schedule,34.36,,,34.36,Fee Schedule,324% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.8,,,22.8,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.26,,,13.26,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.61,133.7,
COMPLEMENT TOTAL (CH50)         ,86162,CPT,,40180184,CDM,302,RC,,,both,,,324,33.42,,,33.42,Other,150% of Medicare + 9.63% HCRA Surcharge,20.32,,,20.32,Fee Schedule,Mediare Clinical Lab,39.22,,,39.22,Fee Schedule,,35.36,,,35.36,Fee Schedule,,205.28,,,205.28,Fee Schedule,,184.69,,,184.69,Fee Schedule,,174.4,,,174.4,Fee Schedule,,162,50,,162,percent of total billed charges,All Other,42.93,,,42.93,Fee Schedule,,64.01,,,64.01,Fee Schedule,,36.43,,,36.43,Other,186% Medicaid methodology,75.39,,,75.39,Fee Schedule,,200.88,,,200.88,Fee Schedule,,42.67,,,42.67,Fee Schedule,,75.39,,,75.39,Fee Schedule,,200.88,,,200.88,Fee Schedule,,80.26,,,80.26,Fee Schedule,,226.8,70,,226.8,percent of total billed charges,All Other,96.88,,,96.88,Fee Schedule,,82.2,,,82.2,Fee Schedule,,24.38,,,24.38,Fee Schedule,,24.38,,,24.38,Fee Schedule,,24.38,,,24.38,Fee Schedule,,24.38,,,24.38,Fee Schedule,,19.58,,,19.58,Fee Schedule,Medicaid Laboratory Fee Schedule,19.58,,,19.58,Fee Schedule,100% Medicaid Laboratory Fee Schedule,19.58,,,19.58,Fee Schedule,100% Medicaid Laboratory Fee Schedule,19.58,,,19.58,Fee Schedule,100% Medicaid Laboratory Fee Schedule,44.06,,,44.06,Fee Schedule,225% Medicaid Laboratory Fee Schedule,44.06,,,44.06,Fee Schedule,225% Medicaid Laboratory Fee Schedule,29.96,,,29.96,Fee Schedule,153% Medicaid Laboratory Fee Schedule,44.06,,,44.06,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.42,,,27.42,Fee Schedule,140% Medicaid Laboratory Fee Schedule,44.06,,,44.06,Fee Schedule,225% Medicaid Laboratory Fee Schedule,50.92,,,50.92,Fee Schedule,260% Medicaid Laboratory Fee Schedule,63.45,,,63.45,Fee Schedule,324% Medicaid Laboratory Fee Schedule,42.11,,,42.11,Fee Schedule,215% Medicaid Laboratory Fee Schedule,42.11,,,42.11,Fee Schedule,215% Medicaid Laboratory Fee Schedule,24.48,,,24.48,Fee Schedule,125% Medicaid Laboratory Fee Schedule,19.58,226.8,
RHEUMATOID FACTOR QUANT         ,86431,CPT,,40180283,CDM,302,RC,,,both,,,91,9.32,,,9.32,Other,150% of Medicare + 9.63% HCRA Surcharge,5.67,,,5.67,Fee Schedule,Mediare Clinical Lab,10.94,,,10.94,Fee Schedule,,9.87,,,9.87,Fee Schedule,,57.3,,,57.3,Fee Schedule,,51.55,,,51.55,Fee Schedule,,48.68,,,48.68,Fee Schedule,,45.5,50,,45.5,percent of total billed charges,All Other,11.99,,,11.99,Fee Schedule,,17.86,,,17.86,Fee Schedule,,9.77,,,9.77,Other,186% Medicaid methodology,21.04,,,21.04,Fee Schedule,,56.42,,,56.42,Fee Schedule,,11.91,,,11.91,Fee Schedule,,21.04,,,21.04,Fee Schedule,,56.42,,,56.42,Fee Schedule,,22.4,,,22.4,Fee Schedule,,63.7,70,,63.7,percent of total billed charges,All Other,27.03,,,27.03,Fee Schedule,,22.94,,,22.94,Fee Schedule,,6.8,,,6.8,Fee Schedule,,6.8,,,6.8,Fee Schedule,,6.8,,,6.8,Fee Schedule,,6.8,,,6.8,Fee Schedule,,5.25,,,5.25,Fee Schedule,Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.04,,,8.04,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.35,,,7.35,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.66,,,13.66,Fee Schedule,260% Medicaid Laboratory Fee Schedule,17.02,,,17.02,Fee Schedule,324% Medicaid Laboratory Fee Schedule,11.29,,,11.29,Fee Schedule,215% Medicaid Laboratory Fee Schedule,11.29,,,11.29,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.57,,,6.57,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.25,63.7,
ALLG SPEC IGE CRUDE XTRC EA     ,86003,CPT,,40180440,CDM,302,RC,,,both,,,83,8.58,,,8.58,Other,150% of Medicare + 9.63% HCRA Surcharge,5.22,,,5.22,Fee Schedule,Mediare Clinical Lab,10.07,,,10.07,Fee Schedule,,9.08,,,9.08,Fee Schedule,,50.4,,,50.4,Fee Schedule,,45.35,,,45.35,Fee Schedule,,42.82,,,42.82,Fee Schedule,,41.5,50,,41.5,percent of total billed charges,All Other,11.02,,,11.02,Fee Schedule,,16.44,,,16.44,Fee Schedule,,6.86,,,6.86,Other,186% Medicaid methodology,19.37,,,19.37,Fee Schedule,,51.46,,,51.46,Fee Schedule,,10.96,,,10.96,Fee Schedule,,19.37,,,19.37,Fee Schedule,,51.46,,,51.46,Fee Schedule,,20.62,,,20.62,Fee Schedule,,58.1,70,,58.1,percent of total billed charges,All Other,24.89,,,24.89,Fee Schedule,,21.12,,,21.12,Fee Schedule,,6.26,,,6.26,Fee Schedule,,6.26,,,6.26,Fee Schedule,,6.26,,,6.26,Fee Schedule,,6.26,,,6.26,Fee Schedule,,3.69,,,3.69,Fee Schedule,Medicaid Laboratory Fee Schedule,3.69,,,3.69,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.69,,,3.69,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.69,,,3.69,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.29,,,8.29,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.29,,,8.29,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.64,,,5.64,Fee Schedule,153% Medicaid Laboratory Fee Schedule,8.29,,,8.29,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.16,,,5.16,Fee Schedule,140% Medicaid Laboratory Fee Schedule,8.29,,,8.29,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.58,,,9.58,Fee Schedule,260% Medicaid Laboratory Fee Schedule,11.94,,,11.94,Fee Schedule,324% Medicaid Laboratory Fee Schedule,7.93,,,7.93,Fee Schedule,215% Medicaid Laboratory Fee Schedule,7.93,,,7.93,Fee Schedule,215% Medicaid Laboratory Fee Schedule,4.61,,,4.61,Fee Schedule,125% Medicaid Laboratory Fee Schedule,3.69,58.1,
T CELL ABSOLUTE COUNT/RATIO     ,86360,CPT,,40180663,CDM,302,RC,,,both,,,748,77.26,,,77.26,Other,150% of Medicare + 9.63% HCRA Surcharge,46.98,,,46.98,Fee Schedule,Mediare Clinical Lab,90.67,,,90.67,Fee Schedule,,81.75,,,81.75,Fee Schedule,,474.74,,,474.74,Fee Schedule,,427.14,,,427.14,Fee Schedule,,403.33,,,403.33,Fee Schedule,,374,50,,374,percent of total billed charges,All Other,99.26,,,99.26,Fee Schedule,,147.99,,,147.99,Fee Schedule,,87.38,,,87.38,Other,186% Medicaid methodology,174.3,,,174.3,Fee Schedule,,463.76,,,463.76,Fee Schedule,,98.66,,,98.66,Fee Schedule,,174.3,,,174.3,Fee Schedule,,463.76,,,463.76,Fee Schedule,,185.57,,,185.57,Fee Schedule,,523.6,70,,523.6,percent of total billed charges,All Other,224,,,224,Fee Schedule,,190.06,,,190.06,Fee Schedule,,56.38,,,56.38,Fee Schedule,,56.38,,,56.38,Fee Schedule,,56.38,,,56.38,Fee Schedule,,56.38,,,56.38,Fee Schedule,,46.98,,,46.98,Fee Schedule,Medicaid Laboratory Fee Schedule,46.98,,,46.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,46.98,,,46.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,46.98,,,46.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,105.71,,,105.71,Fee Schedule,225% Medicaid Laboratory Fee Schedule,105.71,,,105.71,Fee Schedule,225% Medicaid Laboratory Fee Schedule,71.88,,,71.88,Fee Schedule,153% Medicaid Laboratory Fee Schedule,105.71,,,105.71,Fee Schedule,225% Medicaid Laboratory Fee Schedule,65.77,,,65.77,Fee Schedule,140% Medicaid Laboratory Fee Schedule,105.71,,,105.71,Fee Schedule,225% Medicaid Laboratory Fee Schedule,122.15,,,122.15,Fee Schedule,260% Medicaid Laboratory Fee Schedule,152.22,,,152.22,Fee Schedule,324% Medicaid Laboratory Fee Schedule,101.01,,,101.01,Fee Schedule,215% Medicaid Laboratory Fee Schedule,101.01,,,101.01,Fee Schedule,215% Medicaid Laboratory Fee Schedule,58.73,,,58.73,Fee Schedule,125% Medicaid Laboratory Fee Schedule,46.98,523.6,
IMMUNOFIX E-PHORESIS SERUM      ,86334,CPT,,40180721,CDM,302,RC,,,both,,,356,36.74,,,36.74,Other,150% of Medicare + 9.63% HCRA Surcharge,22.34,,,22.34,Fee Schedule,Mediare Clinical Lab,43.12,,,43.12,Fee Schedule,,38.87,,,38.87,Fee Schedule,,225.74,,,225.74,Fee Schedule,,203.1,,,203.1,Fee Schedule,,191.78,,,191.78,Fee Schedule,,178,50,,178,percent of total billed charges,All Other,47.19,,,47.19,Fee Schedule,,70.37,,,70.37,Fee Schedule,,41.55,,,41.55,Other,186% Medicaid methodology,82.88,,,82.88,Fee Schedule,,220.72,,,220.72,Fee Schedule,,46.91,,,46.91,Fee Schedule,,82.88,,,82.88,Fee Schedule,,220.72,,,220.72,Fee Schedule,,88.24,,,88.24,Fee Schedule,,249.2,70,,249.2,percent of total billed charges,All Other,106.52,,,106.52,Fee Schedule,,90.38,,,90.38,Fee Schedule,,26.81,,,26.81,Fee Schedule,,26.81,,,26.81,Fee Schedule,,26.81,,,26.81,Fee Schedule,,26.81,,,26.81,Fee Schedule,,22.34,,,22.34,Fee Schedule,Medicaid Laboratory Fee Schedule,22.34,,,22.34,Fee Schedule,100% Medicaid Laboratory Fee Schedule,22.34,,,22.34,Fee Schedule,100% Medicaid Laboratory Fee Schedule,22.34,,,22.34,Fee Schedule,100% Medicaid Laboratory Fee Schedule,50.27,,,50.27,Fee Schedule,225% Medicaid Laboratory Fee Schedule,50.27,,,50.27,Fee Schedule,225% Medicaid Laboratory Fee Schedule,34.18,,,34.18,Fee Schedule,153% Medicaid Laboratory Fee Schedule,50.27,,,50.27,Fee Schedule,225% Medicaid Laboratory Fee Schedule,31.28,,,31.28,Fee Schedule,140% Medicaid Laboratory Fee Schedule,50.27,,,50.27,Fee Schedule,225% Medicaid Laboratory Fee Schedule,58.08,,,58.08,Fee Schedule,260% Medicaid Laboratory Fee Schedule,72.38,,,72.38,Fee Schedule,324% Medicaid Laboratory Fee Schedule,48.03,,,48.03,Fee Schedule,215% Medicaid Laboratory Fee Schedule,48.03,,,48.03,Fee Schedule,215% Medicaid Laboratory Fee Schedule,27.93,,,27.93,Fee Schedule,125% Medicaid Laboratory Fee Schedule,22.34,249.2,
FLUORESCENT ANTIBODY SCREEN EA  ,86255,CPT,,40180945,CDM,302,RC,,,both,,,192,19.82,,,19.82,Other,150% of Medicare + 9.63% HCRA Surcharge,12.05,,,12.05,Fee Schedule,Mediare Clinical Lab,23.26,,,23.26,Fee Schedule,,20.97,,,20.97,Fee Schedule,,121.77,,,121.77,Fee Schedule,,109.56,,,109.56,Fee Schedule,,103.46,,,103.46,Fee Schedule,,96,50,,96,percent of total billed charges,All Other,25.45,,,25.45,Fee Schedule,,37.96,,,37.96,Fee Schedule,,9.77,,,9.77,Other,186% Medicaid methodology,44.71,,,44.71,Fee Schedule,,119.04,,,119.04,Fee Schedule,,25.31,,,25.31,Fee Schedule,,44.71,,,44.71,Fee Schedule,,119.04,,,119.04,Fee Schedule,,47.6,,,47.6,Fee Schedule,,134.4,70,,134.4,percent of total billed charges,All Other,57.45,,,57.45,Fee Schedule,,48.75,,,48.75,Fee Schedule,,14.46,,,14.46,Fee Schedule,,14.46,,,14.46,Fee Schedule,,14.46,,,14.46,Fee Schedule,,14.46,,,14.46,Fee Schedule,,5.25,,,5.25,Fee Schedule,Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.04,,,8.04,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.35,,,7.35,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.66,,,13.66,Fee Schedule,260% Medicaid Laboratory Fee Schedule,17.02,,,17.02,Fee Schedule,324% Medicaid Laboratory Fee Schedule,11.29,,,11.29,Fee Schedule,215% Medicaid Laboratory Fee Schedule,11.29,,,11.29,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.57,,,6.57,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.25,134.4,
MICROSOMAL ANTIBODY EACH        ,86376,CPT,,40181109,CDM,302,RC,,,both,,,232,23.93,,,23.93,Other,150% of Medicare + 9.63% HCRA Surcharge,14.55,,,14.55,Fee Schedule,Mediare Clinical Lab,28.08,,,28.08,Fee Schedule,,25.32,,,25.32,Fee Schedule,,147.05,,,147.05,Fee Schedule,,132.3,,,132.3,Fee Schedule,,124.93,,,124.93,Fee Schedule,,116,50,,116,percent of total billed charges,All Other,30.75,,,30.75,Fee Schedule,,45.83,,,45.83,Fee Schedule,,27.06,,,27.06,Other,186% Medicaid methodology,53.98,,,53.98,Fee Schedule,,143.84,,,143.84,Fee Schedule,,30.56,,,30.56,Fee Schedule,,53.98,,,53.98,Fee Schedule,,143.84,,,143.84,Fee Schedule,,57.47,,,57.47,Fee Schedule,,162.4,70,,162.4,percent of total billed charges,All Other,69.37,,,69.37,Fee Schedule,,58.86,,,58.86,Fee Schedule,,17.46,,,17.46,Fee Schedule,,17.46,,,17.46,Fee Schedule,,17.46,,,17.46,Fee Schedule,,17.46,,,17.46,Fee Schedule,,14.55,,,14.55,Fee Schedule,Medicaid Laboratory Fee Schedule,14.55,,,14.55,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.55,,,14.55,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.55,,,14.55,Fee Schedule,100% Medicaid Laboratory Fee Schedule,32.74,,,32.74,Fee Schedule,225% Medicaid Laboratory Fee Schedule,32.74,,,32.74,Fee Schedule,225% Medicaid Laboratory Fee Schedule,22.26,,,22.26,Fee Schedule,153% Medicaid Laboratory Fee Schedule,32.74,,,32.74,Fee Schedule,225% Medicaid Laboratory Fee Schedule,20.37,,,20.37,Fee Schedule,140% Medicaid Laboratory Fee Schedule,32.74,,,32.74,Fee Schedule,225% Medicaid Laboratory Fee Schedule,37.83,,,37.83,Fee Schedule,260% Medicaid Laboratory Fee Schedule,47.14,,,47.14,Fee Schedule,324% Medicaid Laboratory Fee Schedule,31.28,,,31.28,Fee Schedule,215% Medicaid Laboratory Fee Schedule,31.28,,,31.28,Fee Schedule,215% Medicaid Laboratory Fee Schedule,18.19,,,18.19,Fee Schedule,125% Medicaid Laboratory Fee Schedule,14.55,162.4,
ANTINUCLEAR ANTIBODIES          ,86038,CPT,,40181125,CDM,302,RC,,,both,,,192,19.88,,,19.88,Other,150% of Medicare + 9.63% HCRA Surcharge,12.09,,,12.09,Fee Schedule,Mediare Clinical Lab,23.33,,,23.33,Fee Schedule,,21.04,,,21.04,Fee Schedule,,122.13,,,122.13,Fee Schedule,,109.88,,,109.88,Fee Schedule,,103.76,,,103.76,Fee Schedule,,96,50,,96,percent of total billed charges,All Other,25.55,,,25.55,Fee Schedule,,38.08,,,38.08,Fee Schedule,,9.77,,,9.77,Other,186% Medicaid methodology,44.85,,,44.85,Fee Schedule,,119.04,,,119.04,Fee Schedule,,25.39,,,25.39,Fee Schedule,,44.85,,,44.85,Fee Schedule,,119.04,,,119.04,Fee Schedule,,47.76,,,47.76,Fee Schedule,,134.4,70,,134.4,percent of total billed charges,All Other,57.64,,,57.64,Fee Schedule,,48.91,,,48.91,Fee Schedule,,14.51,,,14.51,Fee Schedule,,14.51,,,14.51,Fee Schedule,,14.51,,,14.51,Fee Schedule,,14.51,,,14.51,Fee Schedule,,5.25,,,5.25,Fee Schedule,Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.04,,,8.04,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.35,,,7.35,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.66,,,13.66,Fee Schedule,260% Medicaid Laboratory Fee Schedule,17.02,,,17.02,Fee Schedule,324% Medicaid Laboratory Fee Schedule,11.29,,,11.29,Fee Schedule,215% Medicaid Laboratory Fee Schedule,11.29,,,11.29,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.57,,,6.57,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.25,134.4,
Hypersensitivity Pneumonitis LC,86331,CPT,,40181380,CDM,302,RC,,,both,,,116,19.7,,,19.7,Other,150% of Medicare + 9.63% HCRA Surcharge,11.98,,,11.98,Fee Schedule,Mediare Clinical Lab,23.12,,,23.12,Fee Schedule,,20.85,,,20.85,Fee Schedule,,121.05,,,121.05,Fee Schedule,,108.92,,,108.92,Fee Schedule,,102.85,,,102.85,Fee Schedule,,58,50,,58,percent of total billed charges,All Other,25.32,,,25.32,Fee Schedule,,37.74,,,37.74,Fee Schedule,,64.67,,,64.67,Other,186% Medicaid methodology,44.45,,,44.45,Fee Schedule,,71.92,,,71.92,Fee Schedule,,25.16,,,25.16,Fee Schedule,,44.45,,,44.45,Fee Schedule,,71.92,,,71.92,Fee Schedule,,47.32,,,47.32,Fee Schedule,,81.2,70,,81.2,percent of total billed charges,All Other,57.12,,,57.12,Fee Schedule,,48.47,,,48.47,Fee Schedule,,14.38,,,14.38,Fee Schedule,,14.38,,,14.38,Fee Schedule,,14.38,,,14.38,Fee Schedule,,14.38,,,14.38,Fee Schedule,,34.77,,,34.77,Other,New York Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,53.2,,,53.2,Other,153% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,48.68,,,48.68,Other,140% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,90.41,,,90.41,Other,260% Medicaid APG methodology,112.66,,,112.66,Other,324% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,43.46,,,43.46,Other,125% Medicaid APG methodology,11.98,121.05,
ISLET CELL ANTIBODY             ,86341,CPT,,40182008,CDM,302,RC,,,both,,,376,38.76,,,38.76,Other,150% of Medicare + 9.63% HCRA Surcharge,23.57,,,23.57,Fee Schedule,Mediare Clinical Lab,45.49,,,45.49,Fee Schedule,,41.01,,,41.01,Fee Schedule,,199.96,,,199.96,Fee Schedule,,179.91,,,179.91,Fee Schedule,,169.89,,,169.89,Fee Schedule,,188,50,,188,percent of total billed charges,All Other,49.79,,,49.79,Fee Schedule,,74.25,,,74.25,Fee Schedule,,23.48,,,23.48,Other,186% Medicaid methodology,87.44,,,87.44,Fee Schedule,,233.12,,,233.12,Fee Schedule,,49.5,,,49.5,Fee Schedule,,87.44,,,87.44,Fee Schedule,,233.12,,,233.12,Fee Schedule,,93.1,,,93.1,Fee Schedule,,263.2,70,,263.2,percent of total billed charges,All Other,112.38,,,112.38,Fee Schedule,,95.35,,,95.35,Fee Schedule,,28.28,,,28.28,Fee Schedule,,28.28,,,28.28,Fee Schedule,,28.28,,,28.28,Fee Schedule,,28.28,,,28.28,Fee Schedule,,12.63,,,12.63,Fee Schedule,Medicaid Laboratory Fee Schedule,12.63,,,12.63,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.63,,,12.63,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.63,,,12.63,Fee Schedule,100% Medicaid Laboratory Fee Schedule,28.41,,,28.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,28.41,,,28.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.32,,,19.32,Fee Schedule,153% Medicaid Laboratory Fee Schedule,28.41,,,28.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.68,,,17.68,Fee Schedule,140% Medicaid Laboratory Fee Schedule,28.41,,,28.41,Fee Schedule,225% Medicaid Laboratory Fee Schedule,32.83,,,32.83,Fee Schedule,260% Medicaid Laboratory Fee Schedule,40.91,,,40.91,Fee Schedule,324% Medicaid Laboratory Fee Schedule,27.14,,,27.14,Fee Schedule,215% Medicaid Laboratory Fee Schedule,27.14,,,27.14,Fee Schedule,215% Medicaid Laboratory Fee Schedule,15.78,,,15.78,Fee Schedule,125% Medicaid Laboratory Fee Schedule,12.63,263.2,
LYME DISEASE ANTIBODY           ,86617,CPT,,40182164,CDM,302,RC,,,both,,,246,25.47,,,25.47,Other,150% of Medicare + 9.63% HCRA Surcharge,15.49,,,15.49,Fee Schedule,Mediare Clinical Lab,29.9,,,29.9,Fee Schedule,,26.95,,,26.95,Fee Schedule,,156.52,,,156.52,Fee Schedule,,140.83,,,140.83,Fee Schedule,,132.98,,,132.98,Fee Schedule,,123,50,,123,percent of total billed charges,All Other,32.73,,,32.73,Fee Schedule,,48.79,,,48.79,Fee Schedule,,28.81,,,28.81,Other,186% Medicaid methodology,57.47,,,57.47,Fee Schedule,,152.52,,,152.52,Fee Schedule,,32.53,,,32.53,Fee Schedule,,57.47,,,57.47,Fee Schedule,,152.52,,,152.52,Fee Schedule,,61.19,,,61.19,Fee Schedule,,172.2,70,,172.2,percent of total billed charges,All Other,73.86,,,73.86,Fee Schedule,,62.67,,,62.67,Fee Schedule,,18.59,,,18.59,Fee Schedule,,18.59,,,18.59,Fee Schedule,,18.59,,,18.59,Fee Schedule,,18.59,,,18.59,Fee Schedule,,15.49,,,15.49,Fee Schedule,Medicaid Laboratory Fee Schedule,15.49,,,15.49,Fee Schedule,100% Medicaid Laboratory Fee Schedule,15.49,,,15.49,Fee Schedule,100% Medicaid Laboratory Fee Schedule,15.49,,,15.49,Fee Schedule,100% Medicaid Laboratory Fee Schedule,34.85,,,34.85,Fee Schedule,225% Medicaid Laboratory Fee Schedule,34.85,,,34.85,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.7,,,23.7,Fee Schedule,153% Medicaid Laboratory Fee Schedule,34.85,,,34.85,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.69,,,21.69,Fee Schedule,140% Medicaid Laboratory Fee Schedule,34.85,,,34.85,Fee Schedule,225% Medicaid Laboratory Fee Schedule,40.27,,,40.27,Fee Schedule,260% Medicaid Laboratory Fee Schedule,50.19,,,50.19,Fee Schedule,324% Medicaid Laboratory Fee Schedule,33.3,,,33.3,Fee Schedule,215% Medicaid Laboratory Fee Schedule,33.3,,,33.3,Fee Schedule,215% Medicaid Laboratory Fee Schedule,19.36,,,19.36,Fee Schedule,125% Medicaid Laboratory Fee Schedule,15.49,172.2,
CARDIOLIPIN ANTIBODY EA IG      ,86147,CPT,,40182263,CDM,302,RC,,,both,,,405,41.85,,,41.85,Other,150% of Medicare + 9.63% HCRA Surcharge,25.45,,,25.45,Fee Schedule,Mediare Clinical Lab,49.12,,,49.12,Fee Schedule,,44.28,,,44.28,Fee Schedule,,58.73,,,58.73,Fee Schedule,,52.84,,,52.84,Fee Schedule,,49.9,,,49.9,Fee Schedule,,202.5,50,,202.5,percent of total billed charges,All Other,53.76,,,53.76,Fee Schedule,,80.17,,,80.17,Fee Schedule,,14.69,,,14.69,Other,186% Medicaid methodology,94.42,,,94.42,Fee Schedule,,251.1,,,251.1,Fee Schedule,,53.45,,,53.45,Fee Schedule,,94.42,,,94.42,Fee Schedule,,251.1,,,251.1,Fee Schedule,,100.53,,,100.53,Fee Schedule,,283.5,70,,283.5,percent of total billed charges,All Other,121.34,,,121.34,Fee Schedule,,102.96,,,102.96,Fee Schedule,,30.54,,,30.54,Fee Schedule,,30.54,,,30.54,Fee Schedule,,30.54,,,30.54,Fee Schedule,,30.54,,,30.54,Fee Schedule,,7.9,,,7.9,Fee Schedule,Medicaid Laboratory Fee Schedule,7.9,,,7.9,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.9,,,7.9,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.9,,,7.9,Fee Schedule,100% Medicaid Laboratory Fee Schedule,17.77,,,17.77,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.77,,,17.77,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.08,,,12.08,Fee Schedule,153% Medicaid Laboratory Fee Schedule,17.77,,,17.77,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.06,,,11.06,Fee Schedule,140% Medicaid Laboratory Fee Schedule,17.77,,,17.77,Fee Schedule,225% Medicaid Laboratory Fee Schedule,20.54,,,20.54,Fee Schedule,260% Medicaid Laboratory Fee Schedule,25.59,,,25.59,Fee Schedule,324% Medicaid Laboratory Fee Schedule,16.98,,,16.98,Fee Schedule,215% Medicaid Laboratory Fee Schedule,16.98,,,16.98,Fee Schedule,215% Medicaid Laboratory Fee Schedule,9.87,,,9.87,Fee Schedule,125% Medicaid Laboratory Fee Schedule,7.9,283.5,
NUCLEAR ANTIGEN ANTIBODY EA     ,86235,CPT,,40182362,CDM,302,RC,,,both,,,286,29.48,,,29.48,Other,150% of Medicare + 9.63% HCRA Surcharge,17.93,,,17.93,Fee Schedule,Mediare Clinical Lab,34.6,,,34.6,Fee Schedule,,31.2,,,31.2,Fee Schedule,,181.15,,,181.15,Fee Schedule,,162.99,,,162.99,Fee Schedule,,153.9,,,153.9,Fee Schedule,,143,50,,143,percent of total billed charges,All Other,37.86,,,37.86,Fee Schedule,,56.48,,,56.48,Fee Schedule,,9.77,,,9.77,Other,186% Medicaid methodology,66.52,,,66.52,Fee Schedule,,177.32,,,177.32,Fee Schedule,,37.65,,,37.65,Fee Schedule,,66.52,,,66.52,Fee Schedule,,177.32,,,177.32,Fee Schedule,,70.82,,,70.82,Fee Schedule,,200.2,70,,200.2,percent of total billed charges,All Other,85.49,,,85.49,Fee Schedule,,72.54,,,72.54,Fee Schedule,,21.52,,,21.52,Fee Schedule,,21.52,,,21.52,Fee Schedule,,21.52,,,21.52,Fee Schedule,,21.52,,,21.52,Fee Schedule,,5.25,,,5.25,Fee Schedule,Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.04,,,8.04,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.35,,,7.35,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.66,,,13.66,Fee Schedule,260% Medicaid Laboratory Fee Schedule,17.02,,,17.02,Fee Schedule,324% Medicaid Laboratory Fee Schedule,11.29,,,11.29,Fee Schedule,215% Medicaid Laboratory Fee Schedule,11.29,,,11.29,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.57,,,6.57,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.25,200.2,
IMMUNOASSAY TUMOR OTHER EA      ,86316,CPT,,40182768,CDM,302,RC,,,both,,,331,34.22,,,34.22,Other,150% of Medicare + 9.63% HCRA Surcharge,20.81,,,20.81,Fee Schedule,Mediare Clinical Lab,40.16,,,40.16,Fee Schedule,,36.21,,,36.21,Fee Schedule,,210.3,,,210.3,Fee Schedule,,189.21,,,189.21,Fee Schedule,,178.67,,,178.67,Fee Schedule,,165.5,50,,165.5,percent of total billed charges,All Other,43.97,,,43.97,Fee Schedule,,65.55,,,65.55,Fee Schedule,,64.67,,,64.67,Other,186% Medicaid methodology,77.21,,,77.21,Fee Schedule,,205.22,,,205.22,Fee Schedule,,43.7,,,43.7,Fee Schedule,,77.21,,,77.21,Fee Schedule,,205.22,,,205.22,Fee Schedule,,82.2,,,82.2,Fee Schedule,,231.7,70,,231.7,percent of total billed charges,All Other,99.22,,,99.22,Fee Schedule,,84.19,,,84.19,Fee Schedule,,24.97,,,24.97,Fee Schedule,,24.97,,,24.97,Fee Schedule,,24.97,,,24.97,Fee Schedule,,24.97,,,24.97,Fee Schedule,,34.77,,,34.77,Other,New York Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,53.2,,,53.2,Other,153% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,48.68,,,48.68,Other,140% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,90.41,,,90.41,Other,260% Medicaid APG methodology,112.66,,,112.66,Other,324% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,43.46,,,43.46,Other,125% Medicaid APG methodology,20.81,231.7,
ANTISTREPTOLYSIN O SCREEN       ,86063,CPT,,40182842,CDM,302,RC,,,both,,,93,9.49,,,9.49,Other,150% of Medicare + 9.63% HCRA Surcharge,5.77,,,5.77,Fee Schedule,Mediare Clinical Lab,11.14,,,11.14,Fee Schedule,,10.04,,,10.04,Fee Schedule,,51.77,,,51.77,Fee Schedule,,46.58,,,46.58,Fee Schedule,,43.98,,,43.98,Fee Schedule,,46.5,50,,46.5,percent of total billed charges,All Other,12.19,,,12.19,Fee Schedule,,18.18,,,18.18,Fee Schedule,,7.04,,,7.04,Other,186% Medicaid methodology,21.41,,,21.41,Fee Schedule,,57.66,,,57.66,Fee Schedule,,12.12,,,12.12,Fee Schedule,,21.41,,,21.41,Fee Schedule,,57.66,,,57.66,Fee Schedule,,22.79,,,22.79,Fee Schedule,,65.1,70,,65.1,percent of total billed charges,All Other,27.51,,,27.51,Fee Schedule,,23.34,,,23.34,Fee Schedule,,6.92,,,6.92,Fee Schedule,,6.92,,,6.92,Fee Schedule,,6.92,,,6.92,Fee Schedule,,6.92,,,6.92,Fee Schedule,,3.79,,,3.79,Fee Schedule,Medicaid Laboratory Fee Schedule,3.79,,,3.79,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.79,,,3.79,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.79,,,3.79,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.52,,,8.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.52,,,8.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.79,,,5.79,Fee Schedule,153% Medicaid Laboratory Fee Schedule,8.52,,,8.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.3,,,5.3,Fee Schedule,140% Medicaid Laboratory Fee Schedule,8.52,,,8.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.85,,,9.85,Fee Schedule,260% Medicaid Laboratory Fee Schedule,12.27,,,12.27,Fee Schedule,324% Medicaid Laboratory Fee Schedule,8.14,,,8.14,Fee Schedule,215% Medicaid Laboratory Fee Schedule,8.14,,,8.14,Fee Schedule,215% Medicaid Laboratory Fee Schedule,4.73,,,4.73,Fee Schedule,125% Medicaid Laboratory Fee Schedule,3.79,65.1,
HERPES SIMPLEX TYPE 1 TEST      ,86695,CPT,,40185282,CDM,302,RC,,,both,,,210,21.69,,,21.69,Other,150% of Medicare + 9.63% HCRA Surcharge,13.19,,,13.19,Fee Schedule,Mediare Clinical Lab,25.46,,,25.46,Fee Schedule,,22.95,,,22.95,Fee Schedule,,133.26,,,133.26,Fee Schedule,,119.9,,,119.9,Fee Schedule,,113.22,,,113.22,Fee Schedule,,105,50,,105,percent of total billed charges,All Other,27.85,,,27.85,Fee Schedule,,41.55,,,41.55,Fee Schedule,,64.67,,,64.67,Other,186% Medicaid methodology,48.93,,,48.93,Fee Schedule,,130.2,,,130.2,Fee Schedule,,27.7,,,27.7,Fee Schedule,,48.93,,,48.93,Fee Schedule,,130.2,,,130.2,Fee Schedule,,52.1,,,52.1,Fee Schedule,,147,70,,147,percent of total billed charges,All Other,62.89,,,62.89,Fee Schedule,,53.36,,,53.36,Fee Schedule,,15.83,,,15.83,Fee Schedule,,15.83,,,15.83,Fee Schedule,,15.83,,,15.83,Fee Schedule,,15.83,,,15.83,Fee Schedule,,34.77,,,34.77,Other,New York Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,53.2,,,53.2,Other,153% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,48.68,,,48.68,Other,140% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,90.41,,,90.41,Other,260% Medicaid APG methodology,112.66,,,112.66,Other,324% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,43.46,,,43.46,Other,125% Medicaid APG methodology,13.19,147,
PARVOVIRUS ANTIBODY             ,86747,CPT,,40185480,CDM,302,RC,,,both,,,239,24.72,,,24.72,Other,150% of Medicare + 9.63% HCRA Surcharge,15.03,,,15.03,Fee Schedule,Mediare Clinical Lab,29.01,,,29.01,Fee Schedule,,26.15,,,26.15,Fee Schedule,,151.93,,,151.93,Fee Schedule,,136.69,,,136.69,Fee Schedule,,129.08,,,129.08,Fee Schedule,,119.5,50,,119.5,percent of total billed charges,All Other,31.75,,,31.75,Fee Schedule,,47.34,,,47.34,Fee Schedule,,27.96,,,27.96,Other,186% Medicaid methodology,55.76,,,55.76,Fee Schedule,,148.18,,,148.18,Fee Schedule,,31.56,,,31.56,Fee Schedule,,55.76,,,55.76,Fee Schedule,,148.18,,,148.18,Fee Schedule,,59.37,,,59.37,Fee Schedule,,167.3,70,,167.3,percent of total billed charges,All Other,71.66,,,71.66,Fee Schedule,,60.8,,,60.8,Fee Schedule,,18.04,,,18.04,Fee Schedule,,18.04,,,18.04,Fee Schedule,,18.04,,,18.04,Fee Schedule,,18.04,,,18.04,Fee Schedule,,15.03,,,15.03,Fee Schedule,Medicaid Laboratory Fee Schedule,15.03,,,15.03,Fee Schedule,100% Medicaid Laboratory Fee Schedule,15.03,,,15.03,Fee Schedule,100% Medicaid Laboratory Fee Schedule,15.03,,,15.03,Fee Schedule,100% Medicaid Laboratory Fee Schedule,33.82,,,33.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,33.82,,,33.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23,,,23,Fee Schedule,153% Medicaid Laboratory Fee Schedule,33.82,,,33.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.04,,,21.04,Fee Schedule,140% Medicaid Laboratory Fee Schedule,33.82,,,33.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,39.08,,,39.08,Fee Schedule,260% Medicaid Laboratory Fee Schedule,48.7,,,48.7,Fee Schedule,324% Medicaid Laboratory Fee Schedule,32.31,,,32.31,Fee Schedule,215% Medicaid Laboratory Fee Schedule,32.31,,,32.31,Fee Schedule,215% Medicaid Laboratory Fee Schedule,18.79,,,18.79,Fee Schedule,125% Medicaid Laboratory Fee Schedule,15.03,167.3,
Anti-DNase B Strep Antibodies  LC,86215,CPT,,40185647,CDM,302,RC,,,both,,,211,21.79,,,21.79,Other,150% of Medicare + 9.63% HCRA Surcharge,13.25,,,13.25,Fee Schedule,Mediare Clinical Lab,25.57,,,25.57,Fee Schedule,,23.06,,,23.06,Fee Schedule,,133.91,,,133.91,Fee Schedule,,120.48,,,120.48,Fee Schedule,,113.77,,,113.77,Fee Schedule,,105.5,50,,105.5,percent of total billed charges,All Other,27.98,,,27.98,Fee Schedule,,41.74,,,41.74,Fee Schedule,,64.67,,,64.67,Other,186% Medicaid methodology,49.16,,,49.16,Fee Schedule,,130.82,,,130.82,Fee Schedule,,27.83,,,27.83,Fee Schedule,,49.16,,,49.16,Fee Schedule,,130.82,,,130.82,Fee Schedule,,52.34,,,52.34,Fee Schedule,,147.7,70,,147.7,percent of total billed charges,All Other,63.18,,,63.18,Fee Schedule,,53.6,,,53.6,Fee Schedule,,15.9,,,15.9,Fee Schedule,,15.9,,,15.9,Fee Schedule,,15.9,,,15.9,Fee Schedule,,15.9,,,15.9,Fee Schedule,,34.77,,,34.77,Other,New York Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,53.2,,,53.2,Other,153% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,48.68,,,48.68,Other,140% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,90.41,,,90.41,Other,260% Medicaid APG methodology,112.66,,,112.66,Other,324% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,43.46,,,43.46,Other,125% Medicaid APG methodology,13.25,147.7,
BARTONELLA ANTIBODY             ,86611,CPT,,40185969,CDM,302,RC,,,both,,,163,16.74,,,16.74,Other,150% of Medicare + 9.63% HCRA Surcharge,10.18,,,10.18,Fee Schedule,Mediare Clinical Lab,19.65,,,19.65,Fee Schedule,,17.71,,,17.71,Fee Schedule,,58.73,,,58.73,Fee Schedule,,52.84,,,52.84,Fee Schedule,,49.9,,,49.9,Fee Schedule,,81.5,50,,81.5,percent of total billed charges,All Other,21.52,,,21.52,Fee Schedule,,32.07,,,32.07,Fee Schedule,,15.09,,,15.09,Other,186% Medicaid methodology,37.77,,,37.77,Fee Schedule,,101.06,,,101.06,Fee Schedule,,21.38,,,21.38,Fee Schedule,,37.77,,,37.77,Fee Schedule,,101.06,,,101.06,Fee Schedule,,40.21,,,40.21,Fee Schedule,,114.1,70,,114.1,percent of total billed charges,All Other,48.54,,,48.54,Fee Schedule,,41.18,,,41.18,Fee Schedule,,12.22,,,12.22,Fee Schedule,,12.22,,,12.22,Fee Schedule,,12.22,,,12.22,Fee Schedule,,12.22,,,12.22,Fee Schedule,,8.11,,,8.11,Fee Schedule,Medicaid Laboratory Fee Schedule,8.11,,,8.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.11,,,8.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.11,,,8.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.41,,,12.41,Fee Schedule,153% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.35,,,11.35,Fee Schedule,140% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.09,,,21.09,Fee Schedule,260% Medicaid Laboratory Fee Schedule,26.28,,,26.28,Fee Schedule,324% Medicaid Laboratory Fee Schedule,17.44,,,17.44,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.44,,,17.44,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.14,,,10.14,Fee Schedule,125% Medicaid Laboratory Fee Schedule,8.11,114.1,
PROTOZOA ANTIBODY NOS           ,86753,CPT,,40185985,CDM,302,RC,,,both,,,198,20.37,,,20.37,Other,150% of Medicare + 9.63% HCRA Surcharge,12.39,,,12.39,Fee Schedule,Mediare Clinical Lab,23.91,,,23.91,Fee Schedule,,21.56,,,21.56,Fee Schedule,,58.73,,,58.73,Fee Schedule,,52.84,,,52.84,Fee Schedule,,49.9,,,49.9,Fee Schedule,,99,50,,99,percent of total billed charges,All Other,26.16,,,26.16,Fee Schedule,,39.03,,,39.03,Fee Schedule,,64.67,,,64.67,Other,186% Medicaid methodology,45.97,,,45.97,Fee Schedule,,122.76,,,122.76,Fee Schedule,,26.02,,,26.02,Fee Schedule,,45.97,,,45.97,Fee Schedule,,122.76,,,122.76,Fee Schedule,,48.94,,,48.94,Fee Schedule,,138.6,70,,138.6,percent of total billed charges,All Other,59.07,,,59.07,Fee Schedule,,50.12,,,50.12,Fee Schedule,,14.87,,,14.87,Fee Schedule,,14.87,,,14.87,Fee Schedule,,14.87,,,14.87,Fee Schedule,,14.87,,,14.87,Fee Schedule,,34.77,,,34.77,Other,New York Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,53.2,,,53.2,Other,153% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,48.68,,,48.68,Other,140% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,90.41,,,90.41,Other,260% Medicaid APG methodology,112.66,,,112.66,Other,324% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,43.46,,,43.46,Other,125% Medicaid APG methodology,12.39,138.6,
EHRLICHIA ANTIBODY              ,86666,CPT,,40186207,CDM,302,RC,,,both,,,163,16.74,,,16.74,Other,150% of Medicare + 9.63% HCRA Surcharge,10.18,,,10.18,Fee Schedule,Mediare Clinical Lab,19.65,,,19.65,Fee Schedule,,17.71,,,17.71,Fee Schedule,,58.73,,,58.73,Fee Schedule,,52.84,,,52.84,Fee Schedule,,49.9,,,49.9,Fee Schedule,,81.5,50,,81.5,percent of total billed charges,All Other,21.52,,,21.52,Fee Schedule,,32.07,,,32.07,Fee Schedule,,15.09,,,15.09,Other,186% Medicaid methodology,37.77,,,37.77,Fee Schedule,,101.06,,,101.06,Fee Schedule,,21.38,,,21.38,Fee Schedule,,37.77,,,37.77,Fee Schedule,,101.06,,,101.06,Fee Schedule,,40.21,,,40.21,Fee Schedule,,114.1,70,,114.1,percent of total billed charges,All Other,48.54,,,48.54,Fee Schedule,,41.18,,,41.18,Fee Schedule,,12.22,,,12.22,Fee Schedule,,12.22,,,12.22,Fee Schedule,,12.22,,,12.22,Fee Schedule,,12.22,,,12.22,Fee Schedule,,8.11,,,8.11,Fee Schedule,Medicaid Laboratory Fee Schedule,8.11,,,8.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.11,,,8.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.11,,,8.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.41,,,12.41,Fee Schedule,153% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.35,,,11.35,Fee Schedule,140% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.09,,,21.09,Fee Schedule,260% Medicaid Laboratory Fee Schedule,26.28,,,26.28,Fee Schedule,324% Medicaid Laboratory Fee Schedule,17.44,,,17.44,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.44,,,17.44,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.14,,,10.14,Fee Schedule,125% Medicaid Laboratory Fee Schedule,8.11,114.1,
HERPES SIMPLEX TYPE 2 TEST      ,86696,CPT,,40186983,CDM,302,RC,,,both,,,308,31.82,,,31.82,Other,150% of Medicare + 9.63% HCRA Surcharge,19.35,,,19.35,Fee Schedule,Mediare Clinical Lab,37.35,,,37.35,Fee Schedule,,33.67,,,33.67,Fee Schedule,,195.51,,,195.51,Fee Schedule,,175.91,,,175.91,Fee Schedule,,166.1,,,166.1,Fee Schedule,,154,50,,154,percent of total billed charges,All Other,40.89,,,40.89,Fee Schedule,,60.95,,,60.95,Fee Schedule,,27.24,,,27.24,Other,186% Medicaid methodology,71.79,,,71.79,Fee Schedule,,190.96,,,190.96,Fee Schedule,,40.64,,,40.64,Fee Schedule,,71.79,,,71.79,Fee Schedule,,190.96,,,190.96,Fee Schedule,,76.43,,,76.43,Fee Schedule,,215.6,70,,215.6,percent of total billed charges,All Other,92.26,,,92.26,Fee Schedule,,78.28,,,78.28,Fee Schedule,,23.22,,,23.22,Fee Schedule,,23.22,,,23.22,Fee Schedule,,23.22,,,23.22,Fee Schedule,,23.22,,,23.22,Fee Schedule,,14.65,,,14.65,Fee Schedule,Medicaid Laboratory Fee Schedule,14.65,,,14.65,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.65,,,14.65,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.65,,,14.65,Fee Schedule,100% Medicaid Laboratory Fee Schedule,32.95,,,32.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,32.95,,,32.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,22.41,,,22.41,Fee Schedule,153% Medicaid Laboratory Fee Schedule,32.95,,,32.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,20.5,,,20.5,Fee Schedule,140% Medicaid Laboratory Fee Schedule,32.95,,,32.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,38.08,,,38.08,Fee Schedule,260% Medicaid Laboratory Fee Schedule,47.45,,,47.45,Fee Schedule,324% Medicaid Laboratory Fee Schedule,31.49,,,31.49,Fee Schedule,215% Medicaid Laboratory Fee Schedule,31.49,,,31.49,Fee Schedule,215% Medicaid Laboratory Fee Schedule,18.31,,,18.31,Fee Schedule,125% Medicaid Laboratory Fee Schedule,14.65,215.6,
FLUORESCENT ANTIBODY TITER EA   ,86256,CPT,,40187445,CDM,302,RC,,,both,,,192,19.82,,,19.82,Other,150% of Medicare + 9.63% HCRA Surcharge,12.05,,,12.05,Fee Schedule,Mediare Clinical Lab,23.26,,,23.26,Fee Schedule,,20.97,,,20.97,Fee Schedule,,121.77,,,121.77,Fee Schedule,,109.56,,,109.56,Fee Schedule,,103.46,,,103.46,Fee Schedule,,96,50,,96,percent of total billed charges,All Other,25.45,,,25.45,Fee Schedule,,37.96,,,37.96,Fee Schedule,,64.67,,,64.67,Other,186% Medicaid methodology,44.71,,,44.71,Fee Schedule,,119.04,,,119.04,Fee Schedule,,25.31,,,25.31,Fee Schedule,,44.71,,,44.71,Fee Schedule,,119.04,,,119.04,Fee Schedule,,47.6,,,47.6,Fee Schedule,,134.4,70,,134.4,percent of total billed charges,All Other,57.45,,,57.45,Fee Schedule,,48.75,,,48.75,Fee Schedule,,14.46,,,14.46,Fee Schedule,,14.46,,,14.46,Fee Schedule,,14.46,,,14.46,Fee Schedule,,14.46,,,14.46,Fee Schedule,,34.77,,,34.77,Other,New York Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,53.2,,,53.2,Other,153% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,48.68,,,48.68,Other,140% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,90.41,,,90.41,Other,260% Medicaid APG methodology,112.66,,,112.66,Other,324% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,43.46,,,43.46,Other,125% Medicaid APG methodology,12.05,134.4,
B CELLS TOTAL COUNT             ,86355,CPT,,40187460,CDM,302,RC,,,both,,,600,62.05,,,62.05,Other,150% of Medicare + 9.63% HCRA Surcharge,37.73,,,37.73,Fee Schedule,Mediare Clinical Lab,72.82,,,72.82,Fee Schedule,,65.65,,,65.65,Fee Schedule,,381.11,,,381.11,Fee Schedule,,342.9,,,342.9,Fee Schedule,,323.79,,,323.79,Fee Schedule,,300,50,,300,percent of total billed charges,All Other,79.69,,,79.69,Fee Schedule,,118.85,,,118.85,Fee Schedule,,43.53,,,43.53,Other,186% Medicaid methodology,139.98,,,139.98,Fee Schedule,,372,,,372,Fee Schedule,,79.23,,,79.23,Fee Schedule,,139.98,,,139.98,Fee Schedule,,372,,,372,Fee Schedule,,149.03,,,149.03,Fee Schedule,,420,70,,420,percent of total billed charges,All Other,179.89,,,179.89,Fee Schedule,,152.64,,,152.64,Fee Schedule,,45.28,,,45.28,Fee Schedule,,45.28,,,45.28,Fee Schedule,,45.28,,,45.28,Fee Schedule,,45.28,,,45.28,Fee Schedule,,23.4,,,23.4,Fee Schedule,Medicaid Laboratory Fee Schedule,23.4,,,23.4,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.4,,,23.4,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.4,,,23.4,Fee Schedule,100% Medicaid Laboratory Fee Schedule,52.65,,,52.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,52.65,,,52.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,35.8,,,35.8,Fee Schedule,153% Medicaid Laboratory Fee Schedule,52.65,,,52.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,32.76,,,32.76,Fee Schedule,140% Medicaid Laboratory Fee Schedule,52.65,,,52.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,60.84,,,60.84,Fee Schedule,260% Medicaid Laboratory Fee Schedule,75.82,,,75.82,Fee Schedule,324% Medicaid Laboratory Fee Schedule,50.31,,,50.31,Fee Schedule,215% Medicaid Laboratory Fee Schedule,50.31,,,50.31,Fee Schedule,215% Medicaid Laboratory Fee Schedule,29.25,,,29.25,Fee Schedule,125% Medicaid Laboratory Fee Schedule,23.4,420,
NK CELLS TOTAL COUNT            ,86357,CPT,,40187486,CDM,302,RC,,,both,,,600,62.05,,,62.05,Other,150% of Medicare + 9.63% HCRA Surcharge,37.73,,,37.73,Fee Schedule,Mediare Clinical Lab,72.82,,,72.82,Fee Schedule,,65.65,,,65.65,Fee Schedule,,381.11,,,381.11,Fee Schedule,,342.9,,,342.9,Fee Schedule,,323.79,,,323.79,Fee Schedule,,300,50,,300,percent of total billed charges,All Other,79.69,,,79.69,Fee Schedule,,118.85,,,118.85,Fee Schedule,,43.53,,,43.53,Other,186% Medicaid methodology,139.98,,,139.98,Fee Schedule,,372,,,372,Fee Schedule,,79.23,,,79.23,Fee Schedule,,139.98,,,139.98,Fee Schedule,,372,,,372,Fee Schedule,,149.03,,,149.03,Fee Schedule,,420,70,,420,percent of total billed charges,All Other,179.89,,,179.89,Fee Schedule,,152.64,,,152.64,Fee Schedule,,45.28,,,45.28,Fee Schedule,,45.28,,,45.28,Fee Schedule,,45.28,,,45.28,Fee Schedule,,45.28,,,45.28,Fee Schedule,,23.4,,,23.4,Fee Schedule,Medicaid Laboratory Fee Schedule,23.4,,,23.4,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.4,,,23.4,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.4,,,23.4,Fee Schedule,100% Medicaid Laboratory Fee Schedule,52.65,,,52.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,52.65,,,52.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,35.8,,,35.8,Fee Schedule,153% Medicaid Laboratory Fee Schedule,52.65,,,52.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,32.76,,,32.76,Fee Schedule,140% Medicaid Laboratory Fee Schedule,52.65,,,52.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,60.84,,,60.84,Fee Schedule,260% Medicaid Laboratory Fee Schedule,75.82,,,75.82,Fee Schedule,324% Medicaid Laboratory Fee Schedule,50.31,,,50.31,Fee Schedule,215% Medicaid Laboratory Fee Schedule,50.31,,,50.31,Fee Schedule,215% Medicaid Laboratory Fee Schedule,29.25,,,29.25,Fee Schedule,125% Medicaid Laboratory Fee Schedule,23.4,420,
T CELLS TOTAL COUNT             ,86359,CPT,,40187544,CDM,302,RC,,,both,,,600,62.05,,,62.05,Other,150% of Medicare + 9.63% HCRA Surcharge,37.73,,,37.73,Fee Schedule,Mediare Clinical Lab,72.82,,,72.82,Fee Schedule,,65.65,,,65.65,Fee Schedule,,381.11,,,381.11,Fee Schedule,,342.9,,,342.9,Fee Schedule,,323.79,,,323.79,Fee Schedule,,300,50,,300,percent of total billed charges,All Other,79.69,,,79.69,Fee Schedule,,118.85,,,118.85,Fee Schedule,,43.53,,,43.53,Other,186% Medicaid methodology,139.98,,,139.98,Fee Schedule,,372,,,372,Fee Schedule,,79.23,,,79.23,Fee Schedule,,139.98,,,139.98,Fee Schedule,,372,,,372,Fee Schedule,,149.03,,,149.03,Fee Schedule,,420,70,,420,percent of total billed charges,All Other,179.89,,,179.89,Fee Schedule,,152.64,,,152.64,Fee Schedule,,45.28,,,45.28,Fee Schedule,,45.28,,,45.28,Fee Schedule,,45.28,,,45.28,Fee Schedule,,45.28,,,45.28,Fee Schedule,,23.4,,,23.4,Fee Schedule,Medicaid Laboratory Fee Schedule,23.4,,,23.4,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.4,,,23.4,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.4,,,23.4,Fee Schedule,100% Medicaid Laboratory Fee Schedule,52.65,,,52.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,52.65,,,52.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,35.8,,,35.8,Fee Schedule,153% Medicaid Laboratory Fee Schedule,52.65,,,52.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,32.76,,,32.76,Fee Schedule,140% Medicaid Laboratory Fee Schedule,52.65,,,52.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,60.84,,,60.84,Fee Schedule,260% Medicaid Laboratory Fee Schedule,75.82,,,75.82,Fee Schedule,324% Medicaid Laboratory Fee Schedule,50.31,,,50.31,Fee Schedule,215% Medicaid Laboratory Fee Schedule,50.31,,,50.31,Fee Schedule,215% Medicaid Laboratory Fee Schedule,29.25,,,29.25,Fee Schedule,125% Medicaid Laboratory Fee Schedule,23.4,420,
HIV-1/HIV-2 1 RESULT ANTBDY     ,86703,CPT,,40188005,CDM,302,RC,,,both,,,219,22.55,,,22.55,Other,150% of Medicare + 9.63% HCRA Surcharge,13.71,,,13.71,Fee Schedule,Mediare Clinical Lab,26.46,,,26.46,Fee Schedule,,23.86,,,23.86,Fee Schedule,,138.57,,,138.57,Fee Schedule,,124.68,,,124.68,Fee Schedule,,117.73,,,117.73,Fee Schedule,,109.5,50,,109.5,percent of total billed charges,All Other,28.96,,,28.96,Fee Schedule,,43.19,,,43.19,Fee Schedule,,25.5,,,25.5,Other,186% Medicaid methodology,50.86,,,50.86,Fee Schedule,,135.78,,,135.78,Fee Schedule,,28.79,,,28.79,Fee Schedule,,50.86,,,50.86,Fee Schedule,,135.78,,,135.78,Fee Schedule,,54.15,,,54.15,Fee Schedule,,153.3,70,,153.3,percent of total billed charges,All Other,65.37,,,65.37,Fee Schedule,,55.46,,,55.46,Fee Schedule,,16.45,,,16.45,Fee Schedule,,16.45,,,16.45,Fee Schedule,,16.45,,,16.45,Fee Schedule,,16.45,,,16.45,Fee Schedule,,13.71,,,13.71,Fee Schedule,Medicaid Laboratory Fee Schedule,13.71,,,13.71,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.71,,,13.71,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.71,,,13.71,Fee Schedule,100% Medicaid Laboratory Fee Schedule,30.85,,,30.85,Fee Schedule,225% Medicaid Laboratory Fee Schedule,30.85,,,30.85,Fee Schedule,225% Medicaid Laboratory Fee Schedule,20.98,,,20.98,Fee Schedule,153% Medicaid Laboratory Fee Schedule,30.85,,,30.85,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.19,,,19.19,Fee Schedule,140% Medicaid Laboratory Fee Schedule,30.85,,,30.85,Fee Schedule,225% Medicaid Laboratory Fee Schedule,35.65,,,35.65,Fee Schedule,260% Medicaid Laboratory Fee Schedule,44.42,,,44.42,Fee Schedule,324% Medicaid Laboratory Fee Schedule,29.48,,,29.48,Fee Schedule,215% Medicaid Laboratory Fee Schedule,29.48,,,29.48,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.14,,,17.14,Fee Schedule,125% Medicaid Laboratory Fee Schedule,13.71,153.3,
RICKETTSIA ANTIBODY             ,86757,CPT,,40188021,CDM,302,RC,,,both,,,308,31.82,,,31.82,Other,150% of Medicare + 9.63% HCRA Surcharge,19.35,,,19.35,Fee Schedule,Mediare Clinical Lab,37.35,,,37.35,Fee Schedule,,33.67,,,33.67,Fee Schedule,,195.51,,,195.51,Fee Schedule,,175.91,,,175.91,Fee Schedule,,166.1,,,166.1,Fee Schedule,,154,50,,154,percent of total billed charges,All Other,40.89,,,40.89,Fee Schedule,,60.95,,,60.95,Fee Schedule,,35.99,,,35.99,Other,186% Medicaid methodology,71.79,,,71.79,Fee Schedule,,190.96,,,190.96,Fee Schedule,,40.64,,,40.64,Fee Schedule,,71.79,,,71.79,Fee Schedule,,190.96,,,190.96,Fee Schedule,,76.43,,,76.43,Fee Schedule,,215.6,70,,215.6,percent of total billed charges,All Other,92.26,,,92.26,Fee Schedule,,78.28,,,78.28,Fee Schedule,,23.22,,,23.22,Fee Schedule,,23.22,,,23.22,Fee Schedule,,23.22,,,23.22,Fee Schedule,,23.22,,,23.22,Fee Schedule,,19.35,,,19.35,Fee Schedule,Medicaid Laboratory Fee Schedule,19.35,,,19.35,Fee Schedule,100% Medicaid Laboratory Fee Schedule,19.35,,,19.35,Fee Schedule,100% Medicaid Laboratory Fee Schedule,19.35,,,19.35,Fee Schedule,100% Medicaid Laboratory Fee Schedule,43.54,,,43.54,Fee Schedule,225% Medicaid Laboratory Fee Schedule,43.54,,,43.54,Fee Schedule,225% Medicaid Laboratory Fee Schedule,29.61,,,29.61,Fee Schedule,153% Medicaid Laboratory Fee Schedule,43.54,,,43.54,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.09,,,27.09,Fee Schedule,140% Medicaid Laboratory Fee Schedule,43.54,,,43.54,Fee Schedule,225% Medicaid Laboratory Fee Schedule,50.31,,,50.31,Fee Schedule,260% Medicaid Laboratory Fee Schedule,62.69,,,62.69,Fee Schedule,324% Medicaid Laboratory Fee Schedule,41.6,,,41.6,Fee Schedule,215% Medicaid Laboratory Fee Schedule,41.6,,,41.6,Fee Schedule,215% Medicaid Laboratory Fee Schedule,24.19,,,24.19,Fee Schedule,125% Medicaid Laboratory Fee Schedule,19.35,215.6,
HIV-1 AG W/HIV-1&2 AB AG IA     ,87389,CPT,,40188674,CDM,302,RC,,,both,,,383,39.6,,,39.6,Other,150% of Medicare + 9.63% HCRA Surcharge,24.08,,,24.08,Fee Schedule,Mediare Clinical Lab,46.47,,,46.47,Fee Schedule,,41.9,,,41.9,Fee Schedule,,13.65,,,13.65,Fee Schedule,,13.65,,,13.65,Fee Schedule,,13.65,,,13.65,Fee Schedule,,191.5,50,,191.5,percent of total billed charges,All Other,50.86,,,50.86,Fee Schedule,,75.85,,,75.85,Fee Schedule,,34.74,,,34.74,Other,186% Medicaid methodology,89.34,,,89.34,Fee Schedule,,237.46,,,237.46,Fee Schedule,,50.57,,,50.57,Fee Schedule,,89.34,,,89.34,Fee Schedule,,237.46,,,237.46,Fee Schedule,,95.12,,,95.12,Fee Schedule,,268.1,70,,268.1,percent of total billed charges,All Other,114.81,,,114.81,Fee Schedule,,97.42,,,97.42,Fee Schedule,,28.9,,,28.9,Fee Schedule,,28.9,,,28.9,Fee Schedule,,28.9,,,28.9,Fee Schedule,,28.9,,,28.9,Fee Schedule,,18.67,,,18.67,Fee Schedule,Medicaid Laboratory Fee Schedule,18.67,,,18.67,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.67,,,18.67,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.67,,,18.67,Fee Schedule,100% Medicaid Laboratory Fee Schedule,42.02,,,42.02,Fee Schedule,225% Medicaid Laboratory Fee Schedule,42.02,,,42.02,Fee Schedule,225% Medicaid Laboratory Fee Schedule,28.57,,,28.57,Fee Schedule,153% Medicaid Laboratory Fee Schedule,42.02,,,42.02,Fee Schedule,225% Medicaid Laboratory Fee Schedule,26.14,,,26.14,Fee Schedule,140% Medicaid Laboratory Fee Schedule,42.02,,,42.02,Fee Schedule,225% Medicaid Laboratory Fee Schedule,48.55,,,48.55,Fee Schedule,260% Medicaid Laboratory Fee Schedule,60.51,,,60.51,Fee Schedule,324% Medicaid Laboratory Fee Schedule,40.15,,,40.15,Fee Schedule,215% Medicaid Laboratory Fee Schedule,40.15,,,40.15,Fee Schedule,215% Medicaid Laboratory Fee Schedule,23.34,,,23.34,Fee Schedule,125% Medicaid Laboratory Fee Schedule,13.65,268.1,
TREPONEMA PALLIDUM              ,86780,CPT,,40189052,CDM,302,RC,,,both,,,211,21.77,,,21.77,Other,150% of Medicare + 9.63% HCRA Surcharge,13.24,,,13.24,Fee Schedule,Mediare Clinical Lab,25.55,,,25.55,Fee Schedule,,23.04,,,23.04,Fee Schedule,,133.76,,,133.76,Fee Schedule,,120.35,,,120.35,Fee Schedule,,113.64,,,113.64,Fee Schedule,,105.5,50,,105.5,percent of total billed charges,All Other,27.98,,,27.98,Fee Schedule,,41.71,,,41.71,Fee Schedule,,23.73,,,23.73,Other,186% Medicaid methodology,49.12,,,49.12,Fee Schedule,,130.82,,,130.82,Fee Schedule,,27.8,,,27.8,Fee Schedule,,49.12,,,49.12,Fee Schedule,,130.82,,,130.82,Fee Schedule,,52.3,,,52.3,Fee Schedule,,147.7,70,,147.7,percent of total billed charges,All Other,63.13,,,63.13,Fee Schedule,,53.56,,,53.56,Fee Schedule,,15.89,,,15.89,Fee Schedule,,15.89,,,15.89,Fee Schedule,,15.89,,,15.89,Fee Schedule,,15.89,,,15.89,Fee Schedule,,12.76,,,12.76,Fee Schedule,Medicaid Laboratory Fee Schedule,12.76,,,12.76,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.76,,,12.76,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.76,,,12.76,Fee Schedule,100% Medicaid Laboratory Fee Schedule,28.7,,,28.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,28.7,,,28.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.52,,,19.52,Fee Schedule,153% Medicaid Laboratory Fee Schedule,28.7,,,28.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.86,,,17.86,Fee Schedule,140% Medicaid Laboratory Fee Schedule,28.7,,,28.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,33.17,,,33.17,Fee Schedule,260% Medicaid Laboratory Fee Schedule,41.33,,,41.33,Fee Schedule,324% Medicaid Laboratory Fee Schedule,27.43,,,27.43,Fee Schedule,215% Medicaid Laboratory Fee Schedule,27.43,,,27.43,Fee Schedule,215% Medicaid Laboratory Fee Schedule,15.95,,,15.95,Fee Schedule,125% Medicaid Laboratory Fee Schedule,12.76,147.7,
HUMAN EPIDIDYMIS PROTEIN 4      ,86305,CPT,,40189128,CDM,302,RC,,,both,,,331,34.22,,,34.22,Other,150% of Medicare + 9.63% HCRA Surcharge,20.81,,,20.81,Fee Schedule,Mediare Clinical Lab,40.16,,,40.16,Fee Schedule,,36.21,,,36.21,Fee Schedule,,210.3,,,210.3,Fee Schedule,,189.21,,,189.21,Fee Schedule,,178.67,,,178.67,Fee Schedule,,165.5,50,,165.5,percent of total billed charges,All Other,43.97,,,43.97,Fee Schedule,,65.55,,,65.55,Fee Schedule,,38.71,,,38.71,Other,186% Medicaid methodology,77.21,,,77.21,Fee Schedule,,205.22,,,205.22,Fee Schedule,,43.7,,,43.7,Fee Schedule,,77.21,,,77.21,Fee Schedule,,205.22,,,205.22,Fee Schedule,,82.2,,,82.2,Fee Schedule,,231.7,70,,231.7,percent of total billed charges,All Other,99.22,,,99.22,Fee Schedule,,84.19,,,84.19,Fee Schedule,,24.97,,,24.97,Fee Schedule,,24.97,,,24.97,Fee Schedule,,24.97,,,24.97,Fee Schedule,,24.97,,,24.97,Fee Schedule,,20.81,,,20.81,Fee Schedule,Medicaid Laboratory Fee Schedule,20.81,,,20.81,Fee Schedule,100% Medicaid Laboratory Fee Schedule,20.81,,,20.81,Fee Schedule,100% Medicaid Laboratory Fee Schedule,20.81,,,20.81,Fee Schedule,100% Medicaid Laboratory Fee Schedule,46.82,,,46.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,46.82,,,46.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,31.84,,,31.84,Fee Schedule,153% Medicaid Laboratory Fee Schedule,46.82,,,46.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,29.13,,,29.13,Fee Schedule,140% Medicaid Laboratory Fee Schedule,46.82,,,46.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,54.11,,,54.11,Fee Schedule,260% Medicaid Laboratory Fee Schedule,67.42,,,67.42,Fee Schedule,324% Medicaid Laboratory Fee Schedule,44.74,,,44.74,Fee Schedule,215% Medicaid Laboratory Fee Schedule,44.74,,,44.74,Fee Schedule,215% Medicaid Laboratory Fee Schedule,26.01,,,26.01,Fee Schedule,125% Medicaid Laboratory Fee Schedule,20.81,231.7,
HIV-1 ANTIBODY                  ,86701,CPT,,40190357,CDM,302,RC,,,both,,,141,14.62,,,14.62,Other,150% of Medicare + 9.63% HCRA Surcharge,8.89,,,8.89,Fee Schedule,Mediare Clinical Lab,17.16,,,17.16,Fee Schedule,,15.47,,,15.47,Fee Schedule,,89.75,,,89.75,Fee Schedule,,80.75,,,80.75,Fee Schedule,,76.25,,,76.25,Fee Schedule,,70.5,50,,70.5,percent of total billed charges,All Other,18.79,,,18.79,Fee Schedule,,28,,,28,Fee Schedule,,16.54,,,16.54,Other,186% Medicaid methodology,32.98,,,32.98,Fee Schedule,,87.42,,,87.42,Fee Schedule,,18.67,,,18.67,Fee Schedule,,32.98,,,32.98,Fee Schedule,,87.42,,,87.42,Fee Schedule,,35.12,,,35.12,Fee Schedule,,98.7,70,,98.7,percent of total billed charges,All Other,42.39,,,42.39,Fee Schedule,,35.96,,,35.96,Fee Schedule,,10.67,,,10.67,Fee Schedule,,10.67,,,10.67,Fee Schedule,,10.67,,,10.67,Fee Schedule,,10.67,,,10.67,Fee Schedule,,8.89,,,8.89,Fee Schedule,Medicaid Laboratory Fee Schedule,8.89,,,8.89,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.89,,,8.89,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.89,,,8.89,Fee Schedule,100% Medicaid Laboratory Fee Schedule,20,,,20,Fee Schedule,225% Medicaid Laboratory Fee Schedule,20,,,20,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.6,,,13.6,Fee Schedule,153% Medicaid Laboratory Fee Schedule,20,,,20,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.45,,,12.45,Fee Schedule,140% Medicaid Laboratory Fee Schedule,20,,,20,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.11,,,23.11,Fee Schedule,260% Medicaid Laboratory Fee Schedule,28.8,,,28.8,Fee Schedule,324% Medicaid Laboratory Fee Schedule,19.11,,,19.11,Fee Schedule,215% Medicaid Laboratory Fee Schedule,19.11,,,19.11,Fee Schedule,215% Medicaid Laboratory Fee Schedule,11.11,,,11.11,Fee Schedule,125% Medicaid Laboratory Fee Schedule,8.89,98.7,
HIV-2 ANTIBODY                  ,86702,CPT,,40190373,CDM,302,RC,,,both,,,216,22.23,,,22.23,Other,150% of Medicare + 9.63% HCRA Surcharge,13.52,,,13.52,Fee Schedule,Mediare Clinical Lab,26.09,,,26.09,Fee Schedule,,23.52,,,23.52,Fee Schedule,,136.64,,,136.64,Fee Schedule,,122.93,,,122.93,Fee Schedule,,116.08,,,116.08,Fee Schedule,,108,50,,108,percent of total billed charges,All Other,28.57,,,28.57,Fee Schedule,,42.59,,,42.59,Fee Schedule,,25.15,,,25.15,Other,186% Medicaid methodology,50.16,,,50.16,Fee Schedule,,133.92,,,133.92,Fee Schedule,,28.39,,,28.39,Fee Schedule,,50.16,,,50.16,Fee Schedule,,133.92,,,133.92,Fee Schedule,,53.4,,,53.4,Fee Schedule,,151.2,70,,151.2,percent of total billed charges,All Other,64.46,,,64.46,Fee Schedule,,54.7,,,54.7,Fee Schedule,,16.22,,,16.22,Fee Schedule,,16.22,,,16.22,Fee Schedule,,16.22,,,16.22,Fee Schedule,,16.22,,,16.22,Fee Schedule,,13.52,,,13.52,Fee Schedule,Medicaid Laboratory Fee Schedule,13.52,,,13.52,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.52,,,13.52,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.52,,,13.52,Fee Schedule,100% Medicaid Laboratory Fee Schedule,30.42,,,30.42,Fee Schedule,225% Medicaid Laboratory Fee Schedule,30.42,,,30.42,Fee Schedule,225% Medicaid Laboratory Fee Schedule,20.69,,,20.69,Fee Schedule,153% Medicaid Laboratory Fee Schedule,30.42,,,30.42,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.93,,,18.93,Fee Schedule,140% Medicaid Laboratory Fee Schedule,30.42,,,30.42,Fee Schedule,225% Medicaid Laboratory Fee Schedule,35.15,,,35.15,Fee Schedule,260% Medicaid Laboratory Fee Schedule,43.8,,,43.8,Fee Schedule,324% Medicaid Laboratory Fee Schedule,29.07,,,29.07,Fee Schedule,215% Medicaid Laboratory Fee Schedule,29.07,,,29.07,Fee Schedule,215% Medicaid Laboratory Fee Schedule,16.9,,,16.9,Fee Schedule,125% Medicaid Laboratory Fee Schedule,13.52,151.2,
SARS-COV-2 COVID-19 ANTIBODY    ,86769,CPT,,40199036,CDM,302,RC,,,both,,,159,69.28,,,69.28,Other,150% of Medicare + 9.63% HCRA Surcharge,42.13,,,42.13,Fee Schedule,Mediare Clinical Lab,81.31,,,81.31,Fee Schedule,,73.31,,,73.31,Fee Schedule,,19.38,,,19.38,Fee Schedule,,19.38,,,19.38,Fee Schedule,,19.38,,,19.38,Fee Schedule,,79.5,50,,79.5,percent of total billed charges,All Other,42.13,,,42.13,Fee Schedule,,132.71,,,132.71,Fee Schedule,,47.02,,,47.02,Other,186% Medicaid methodology,156.3,,,156.3,Fee Schedule,,98.58,,,98.58,Fee Schedule,,88.47,,,88.47,Fee Schedule,,156.3,,,156.3,Fee Schedule,,98.58,,,98.58,Fee Schedule,,166.41,,,166.41,Fee Schedule,,111.3,70,,111.3,percent of total billed charges,All Other,200.87,,,200.87,Fee Schedule,,170.44,,,170.44,Fee Schedule,,50.56,,,50.56,Fee Schedule,,50.56,,,50.56,Fee Schedule,,50.56,,,50.56,Fee Schedule,,50.56,,,50.56,Fee Schedule,,25.28,,,25.28,Fee Schedule,Medicaid Laboratory Fee Schedule,25.28,,,25.28,Fee Schedule,100% Medicaid Laboratory Fee Schedule,25.28,,,25.28,Fee Schedule,100% Medicaid Laboratory Fee Schedule,25.28,,,25.28,Fee Schedule,100% Medicaid Laboratory Fee Schedule,56.88,,,56.88,Fee Schedule,225% Medicaid Laboratory Fee Schedule,56.88,,,56.88,Fee Schedule,225% Medicaid Laboratory Fee Schedule,38.68,,,38.68,Fee Schedule,153% Medicaid Laboratory Fee Schedule,56.88,,,56.88,Fee Schedule,225% Medicaid Laboratory Fee Schedule,35.39,,,35.39,Fee Schedule,140% Medicaid Laboratory Fee Schedule,56.88,,,56.88,Fee Schedule,225% Medicaid Laboratory Fee Schedule,65.73,,,65.73,Fee Schedule,260% Medicaid Laboratory Fee Schedule,81.91,,,81.91,Fee Schedule,324% Medicaid Laboratory Fee Schedule,54.35,,,54.35,Fee Schedule,215% Medicaid Laboratory Fee Schedule,54.35,,,54.35,Fee Schedule,215% Medicaid Laboratory Fee Schedule,31.6,,,31.6,Fee Schedule,125% Medicaid Laboratory Fee Schedule,19.38,200.87,
IMMUNOASSAY INFECTIOUS AGENT    ,86317,CPT,,40199069,CDM,302,RC,,,both,,,239,24.65,,,24.65,Other,150% of Medicare + 9.63% HCRA Surcharge,14.99,,,14.99,Fee Schedule,Mediare Clinical Lab,28.93,,,28.93,Fee Schedule,,26.08,,,26.08,Fee Schedule,,151.5,,,151.5,Fee Schedule,,136.31,,,136.31,Fee Schedule,,128.71,,,128.71,Fee Schedule,,119.5,50,,119.5,percent of total billed charges,All Other,31.66,,,31.66,Fee Schedule,,47.22,,,47.22,Fee Schedule,,64.67,,,64.67,Other,186% Medicaid methodology,55.61,,,55.61,Fee Schedule,,148.18,,,148.18,Fee Schedule,,31.48,,,31.48,Fee Schedule,,55.61,,,55.61,Fee Schedule,,148.18,,,148.18,Fee Schedule,,59.21,,,59.21,Fee Schedule,,167.3,70,,167.3,percent of total billed charges,All Other,71.47,,,71.47,Fee Schedule,,60.64,,,60.64,Fee Schedule,,17.99,,,17.99,Fee Schedule,,17.99,,,17.99,Fee Schedule,,17.99,,,17.99,Fee Schedule,,17.99,,,17.99,Fee Schedule,,34.77,,,34.77,Other,New York Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,53.2,,,53.2,Other,153% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,48.68,,,48.68,Other,140% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,90.41,,,90.41,Other,260% Medicaid APG methodology,112.66,,,112.66,Other,324% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,43.46,,,43.46,Other,125% Medicaid APG methodology,14.99,167.3,
IMMUNOASSAY TUMOR CA 15-3       ,86300,CPT,,40199119,CDM,302,RC,,,both,,,331,34.22,,,34.22,Other,150% of Medicare + 9.63% HCRA Surcharge,20.81,,,20.81,Fee Schedule,Mediare Clinical Lab,40.16,,,40.16,Fee Schedule,,36.21,,,36.21,Fee Schedule,,210.3,,,210.3,Fee Schedule,,189.21,,,189.21,Fee Schedule,,178.67,,,178.67,Fee Schedule,,165.5,50,,165.5,percent of total billed charges,All Other,43.97,,,43.97,Fee Schedule,,65.55,,,65.55,Fee Schedule,,38.71,,,38.71,Other,186% Medicaid methodology,77.21,,,77.21,Fee Schedule,,205.22,,,205.22,Fee Schedule,,43.7,,,43.7,Fee Schedule,,77.21,,,77.21,Fee Schedule,,205.22,,,205.22,Fee Schedule,,82.2,,,82.2,Fee Schedule,,231.7,70,,231.7,percent of total billed charges,All Other,99.22,,,99.22,Fee Schedule,,84.19,,,84.19,Fee Schedule,,24.97,,,24.97,Fee Schedule,,24.97,,,24.97,Fee Schedule,,24.97,,,24.97,Fee Schedule,,24.97,,,24.97,Fee Schedule,,20.81,,,20.81,Fee Schedule,Medicaid Laboratory Fee Schedule,20.81,,,20.81,Fee Schedule,100% Medicaid Laboratory Fee Schedule,20.81,,,20.81,Fee Schedule,100% Medicaid Laboratory Fee Schedule,20.81,,,20.81,Fee Schedule,100% Medicaid Laboratory Fee Schedule,46.82,,,46.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,46.82,,,46.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,31.84,,,31.84,Fee Schedule,153% Medicaid Laboratory Fee Schedule,46.82,,,46.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,29.13,,,29.13,Fee Schedule,140% Medicaid Laboratory Fee Schedule,46.82,,,46.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,54.11,,,54.11,Fee Schedule,260% Medicaid Laboratory Fee Schedule,67.42,,,67.42,Fee Schedule,324% Medicaid Laboratory Fee Schedule,44.74,,,44.74,Fee Schedule,215% Medicaid Laboratory Fee Schedule,44.74,,,44.74,Fee Schedule,215% Medicaid Laboratory Fee Schedule,26.01,,,26.01,Fee Schedule,125% Medicaid Laboratory Fee Schedule,20.81,231.7,
ACTIN ANTIBODY EACH             ,86015,CPT,,40199556,CDM,302,RC,,,both,,,184,19.82,,,19.82,Other,150% of Medicare + 9.63% HCRA Surcharge,12.05,,,12.05,Fee Schedule,Mediare Clinical Lab,23.26,,,23.26,Fee Schedule,,20.97,,,20.97,Fee Schedule,,11.53,,,11.53,Fee Schedule,,11.53,,,11.53,Fee Schedule,,11.53,,,11.53,Fee Schedule,,92,50,,92,percent of total billed charges,All Other,128.8,70,,128.8,percent of total billed charges,All Other,37.96,,,37.96,Fee Schedule,,12.98,,,12.98,Other,186% Medicaid methodology,44.71,,,44.71,Fee Schedule,,114.08,,,114.08,Fee Schedule,,25.31,,,25.31,Fee Schedule,,44.71,,,44.71,Fee Schedule,,114.08,,,114.08,Fee Schedule,,47.6,,,47.6,Fee Schedule,,128.8,70,,128.8,percent of total billed charges,All Other,54.97,,,54.97,Fee Schedule,,46.64,,,46.64,Fee Schedule,,13.84,,,13.84,Fee Schedule,,13.84,,,13.84,Fee Schedule,,13.84,,,13.84,Fee Schedule,,13.84,,,13.84,Fee Schedule,,6.98,,,6.98,Fee Schedule,Medicaid Laboratory Fee Schedule,6.98,,,6.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.98,,,6.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.98,,,6.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,15.7,,,15.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.7,,,15.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.68,,,10.68,Fee Schedule,153% Medicaid Laboratory Fee Schedule,15.7,,,15.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.77,,,9.77,Fee Schedule,140% Medicaid Laboratory Fee Schedule,15.7,,,15.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.15,,,18.15,Fee Schedule,260% Medicaid Laboratory Fee Schedule,22.61,,,22.61,Fee Schedule,324% Medicaid Laboratory Fee Schedule,15.01,,,15.01,Fee Schedule,215% Medicaid Laboratory Fee Schedule,15.01,,,15.01,Fee Schedule,215% Medicaid Laboratory Fee Schedule,8.72,,,8.72,Fee Schedule,125% Medicaid Laboratory Fee Schedule,6.98,128.8,
C ANCA TITER                    ,86037,CPT,,40199572,CDM,302,RC,,,both,,,192,19.82,,,19.82,Other,150% of Medicare + 9.63% HCRA Surcharge,12.05,,,12.05,Fee Schedule,Mediare Clinical Lab,23.26,,,23.26,Fee Schedule,,20.97,,,20.97,Fee Schedule,,12.05,,,12.05,Fee Schedule,,12.05,,,12.05,Fee Schedule,,12.05,,,12.05,Fee Schedule,,96,50,,96,percent of total billed charges,All Other,134.4,70,,134.4,percent of total billed charges,All Other,37.96,,,37.96,Fee Schedule,,13.58,,,13.58,Other,186% Medicaid methodology,44.71,,,44.71,Fee Schedule,,119.04,,,119.04,Fee Schedule,,25.31,,,25.31,Fee Schedule,,44.71,,,44.71,Fee Schedule,,119.04,,,119.04,Fee Schedule,,47.6,,,47.6,Fee Schedule,,134.4,70,,134.4,percent of total billed charges,All Other,57.45,,,57.45,Fee Schedule,,48.75,,,48.75,Fee Schedule,,14.46,,,14.46,Fee Schedule,,14.46,,,14.46,Fee Schedule,,14.46,,,14.46,Fee Schedule,,14.46,,,14.46,Fee Schedule,,7.3,,,7.3,Fee Schedule,Medicaid Laboratory Fee Schedule,7.3,,,7.3,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.3,,,7.3,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.3,,,7.3,Fee Schedule,100% Medicaid Laboratory Fee Schedule,16.43,,,16.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.43,,,16.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.17,,,11.17,Fee Schedule,153% Medicaid Laboratory Fee Schedule,16.43,,,16.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.22,,,10.22,Fee Schedule,140% Medicaid Laboratory Fee Schedule,16.43,,,16.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.99,,,18.99,Fee Schedule,260% Medicaid Laboratory Fee Schedule,23.66,,,23.66,Fee Schedule,324% Medicaid Laboratory Fee Schedule,15.7,,,15.7,Fee Schedule,215% Medicaid Laboratory Fee Schedule,15.7,,,15.7,Fee Schedule,215% Medicaid Laboratory Fee Schedule,9.13,,,9.13,Fee Schedule,125% Medicaid Laboratory Fee Schedule,7.3,134.4,
AQUAPORIN 4 AB ELISA            ,86051,CPT,,40199606,CDM,302,RC,,,both,,,184,18.96,,,18.96,Other,150% of Medicare + 9.63% HCRA Surcharge,11.53,,,11.53,Fee Schedule,Mediare Clinical Lab,22.25,,,22.25,Fee Schedule,,20.06,,,20.06,Fee Schedule,,11.53,,,11.53,Fee Schedule,,11.53,,,11.53,Fee Schedule,,11.53,,,11.53,Fee Schedule,,92,50,,92,percent of total billed charges,All Other,128.8,70,,128.8,percent of total billed charges,All Other,36.32,,,36.32,Fee Schedule,,12.98,,,12.98,Other,186% Medicaid methodology,42.78,,,42.78,Fee Schedule,,114.08,,,114.08,Fee Schedule,,24.21,,,24.21,Fee Schedule,,42.78,,,42.78,Fee Schedule,,114.08,,,114.08,Fee Schedule,,45.54,,,45.54,Fee Schedule,,128.8,70,,128.8,percent of total billed charges,All Other,54.97,,,54.97,Fee Schedule,,46.64,,,46.64,Fee Schedule,,13.84,,,13.84,Fee Schedule,,13.84,,,13.84,Fee Schedule,,13.84,,,13.84,Fee Schedule,,13.84,,,13.84,Fee Schedule,,6.98,,,6.98,Fee Schedule,Medicaid Laboratory Fee Schedule,6.98,,,6.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.98,,,6.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.98,,,6.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,15.7,,,15.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.7,,,15.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.68,,,10.68,Fee Schedule,153% Medicaid Laboratory Fee Schedule,15.7,,,15.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.77,,,9.77,Fee Schedule,140% Medicaid Laboratory Fee Schedule,15.7,,,15.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.15,,,18.15,Fee Schedule,260% Medicaid Laboratory Fee Schedule,22.61,,,22.61,Fee Schedule,324% Medicaid Laboratory Fee Schedule,15.01,,,15.01,Fee Schedule,215% Medicaid Laboratory Fee Schedule,15.01,,,15.01,Fee Schedule,215% Medicaid Laboratory Fee Schedule,8.72,,,8.72,Fee Schedule,125% Medicaid Laboratory Fee Schedule,6.98,128.8,
ENDOMYSIAL AB IGA               ,86231,CPT,,40199630,CDM,302,RC,,,both,,,192,19.88,,,19.88,Other,150% of Medicare + 9.63% HCRA Surcharge,12.09,,,12.09,Fee Schedule,Mediare Clinical Lab,23.33,,,23.33,Fee Schedule,,21.04,,,21.04,Fee Schedule,,12.09,,,12.09,Fee Schedule,,12.09,,,12.09,Fee Schedule,,12.09,,,12.09,Fee Schedule,,96,50,,96,percent of total billed charges,All Other,134.4,70,,134.4,percent of total billed charges,All Other,38.08,,,38.08,Fee Schedule,,13.62,,,13.62,Other,186% Medicaid methodology,44.85,,,44.85,Fee Schedule,,119.04,,,119.04,Fee Schedule,,25.39,,,25.39,Fee Schedule,,44.85,,,44.85,Fee Schedule,,119.04,,,119.04,Fee Schedule,,47.76,,,47.76,Fee Schedule,,134.4,70,,134.4,percent of total billed charges,All Other,57.64,,,57.64,Fee Schedule,,48.91,,,48.91,Fee Schedule,,14.51,,,14.51,Fee Schedule,,14.51,,,14.51,Fee Schedule,,14.51,,,14.51,Fee Schedule,,14.51,,,14.51,Fee Schedule,,7.32,,,7.32,Fee Schedule,Medicaid Laboratory Fee Schedule,7.32,,,7.32,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.32,,,7.32,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.32,,,7.32,Fee Schedule,100% Medicaid Laboratory Fee Schedule,16.48,,,16.48,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.48,,,16.48,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.2,,,11.2,Fee Schedule,153% Medicaid Laboratory Fee Schedule,16.48,,,16.48,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.25,,,10.25,Fee Schedule,140% Medicaid Laboratory Fee Schedule,16.48,,,16.48,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.04,,,19.04,Fee Schedule,260% Medicaid Laboratory Fee Schedule,23.72,,,23.72,Fee Schedule,324% Medicaid Laboratory Fee Schedule,15.74,,,15.74,Fee Schedule,215% Medicaid Laboratory Fee Schedule,15.74,,,15.74,Fee Schedule,215% Medicaid Laboratory Fee Schedule,9.15,,,9.15,Fee Schedule,125% Medicaid Laboratory Fee Schedule,7.32,134.4,
GLIADIN AB IGA                  ,86258,CPT,,40199655,CDM,302,RC,,,both,,,184,19.82,,,19.82,Other,150% of Medicare + 9.63% HCRA Surcharge,12.05,,,12.05,Fee Schedule,Mediare Clinical Lab,23.26,,,23.26,Fee Schedule,,20.97,,,20.97,Fee Schedule,,11.53,,,11.53,Fee Schedule,,11.53,,,11.53,Fee Schedule,,11.53,,,11.53,Fee Schedule,,92,50,,92,percent of total billed charges,All Other,128.8,70,,128.8,percent of total billed charges,All Other,37.96,,,37.96,Fee Schedule,,12.98,,,12.98,Other,186% Medicaid methodology,44.71,,,44.71,Fee Schedule,,114.08,,,114.08,Fee Schedule,,25.31,,,25.31,Fee Schedule,,44.71,,,44.71,Fee Schedule,,114.08,,,114.08,Fee Schedule,,47.6,,,47.6,Fee Schedule,,128.8,70,,128.8,percent of total billed charges,All Other,54.97,,,54.97,Fee Schedule,,46.64,,,46.64,Fee Schedule,,13.84,,,13.84,Fee Schedule,,13.84,,,13.84,Fee Schedule,,13.84,,,13.84,Fee Schedule,,13.84,,,13.84,Fee Schedule,,6.98,,,6.98,Fee Schedule,Medicaid Laboratory Fee Schedule,6.98,,,6.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.98,,,6.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.98,,,6.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,15.7,,,15.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.7,,,15.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.68,,,10.68,Fee Schedule,153% Medicaid Laboratory Fee Schedule,15.7,,,15.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.77,,,9.77,Fee Schedule,140% Medicaid Laboratory Fee Schedule,15.7,,,15.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.15,,,18.15,Fee Schedule,260% Medicaid Laboratory Fee Schedule,22.61,,,22.61,Fee Schedule,324% Medicaid Laboratory Fee Schedule,15.01,,,15.01,Fee Schedule,215% Medicaid Laboratory Fee Schedule,15.01,,,15.01,Fee Schedule,215% Medicaid Laboratory Fee Schedule,8.72,,,8.72,Fee Schedule,125% Medicaid Laboratory Fee Schedule,6.98,128.8,
GLIADIN AB IGG                  ,86258,CPT,,40199663,CDM,302,RC,,,both,,,184,19.82,,,19.82,Other,150% of Medicare + 9.63% HCRA Surcharge,12.05,,,12.05,Fee Schedule,Mediare Clinical Lab,23.26,,,23.26,Fee Schedule,,20.97,,,20.97,Fee Schedule,,11.53,,,11.53,Fee Schedule,,11.53,,,11.53,Fee Schedule,,11.53,,,11.53,Fee Schedule,,92,50,,92,percent of total billed charges,All Other,128.8,70,,128.8,percent of total billed charges,All Other,37.96,,,37.96,Fee Schedule,,12.98,,,12.98,Other,186% Medicaid methodology,44.71,,,44.71,Fee Schedule,,114.08,,,114.08,Fee Schedule,,25.31,,,25.31,Fee Schedule,,44.71,,,44.71,Fee Schedule,,114.08,,,114.08,Fee Schedule,,47.6,,,47.6,Fee Schedule,,128.8,70,,128.8,percent of total billed charges,All Other,54.97,,,54.97,Fee Schedule,,46.64,,,46.64,Fee Schedule,,13.84,,,13.84,Fee Schedule,,13.84,,,13.84,Fee Schedule,,13.84,,,13.84,Fee Schedule,,13.84,,,13.84,Fee Schedule,,6.98,,,6.98,Fee Schedule,Medicaid Laboratory Fee Schedule,6.98,,,6.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.98,,,6.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.98,,,6.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,15.7,,,15.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.7,,,15.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.68,,,10.68,Fee Schedule,153% Medicaid Laboratory Fee Schedule,15.7,,,15.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.77,,,9.77,Fee Schedule,140% Medicaid Laboratory Fee Schedule,15.7,,,15.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.15,,,18.15,Fee Schedule,260% Medicaid Laboratory Fee Schedule,22.61,,,22.61,Fee Schedule,324% Medicaid Laboratory Fee Schedule,15.01,,,15.01,Fee Schedule,215% Medicaid Laboratory Fee Schedule,15.01,,,15.01,Fee Schedule,215% Medicaid Laboratory Fee Schedule,8.72,,,8.72,Fee Schedule,125% Medicaid Laboratory Fee Schedule,6.98,128.8,
TISSUE TRANSGLUTAMINSE IGA      ,86364,CPT,,40199697,CDM,302,RC,,,both,,,184,18.96,,,18.96,Other,150% of Medicare + 9.63% HCRA Surcharge,11.53,,,11.53,Fee Schedule,Mediare Clinical Lab,22.25,,,22.25,Fee Schedule,,20.06,,,20.06,Fee Schedule,,11.53,,,11.53,Fee Schedule,,11.53,,,11.53,Fee Schedule,,11.53,,,11.53,Fee Schedule,,92,50,,92,percent of total billed charges,All Other,128.8,70,,128.8,percent of total billed charges,All Other,36.32,,,36.32,Fee Schedule,,12.98,,,12.98,Other,186% Medicaid methodology,42.78,,,42.78,Fee Schedule,,114.08,,,114.08,Fee Schedule,,24.21,,,24.21,Fee Schedule,,42.78,,,42.78,Fee Schedule,,114.08,,,114.08,Fee Schedule,,45.54,,,45.54,Fee Schedule,,128.8,70,,128.8,percent of total billed charges,All Other,54.97,,,54.97,Fee Schedule,,46.64,,,46.64,Fee Schedule,,13.84,,,13.84,Fee Schedule,,13.84,,,13.84,Fee Schedule,,13.84,,,13.84,Fee Schedule,,13.84,,,13.84,Fee Schedule,,6.98,,,6.98,Fee Schedule,Medicaid Laboratory Fee Schedule,6.98,,,6.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.98,,,6.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.98,,,6.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,15.7,,,15.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.7,,,15.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.68,,,10.68,Fee Schedule,153% Medicaid Laboratory Fee Schedule,15.7,,,15.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.77,,,9.77,Fee Schedule,140% Medicaid Laboratory Fee Schedule,15.7,,,15.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.15,,,18.15,Fee Schedule,260% Medicaid Laboratory Fee Schedule,22.61,,,22.61,Fee Schedule,324% Medicaid Laboratory Fee Schedule,15.01,,,15.01,Fee Schedule,215% Medicaid Laboratory Fee Schedule,15.01,,,15.01,Fee Schedule,215% Medicaid Laboratory Fee Schedule,8.72,,,8.72,Fee Schedule,125% Medicaid Laboratory Fee Schedule,6.98,128.8,
TISSUE TRANSGLUTAMINSE IGG      ,86364,CPT,,40199705,CDM,302,RC,,,both,,,184,18.96,,,18.96,Other,150% of Medicare + 9.63% HCRA Surcharge,11.53,,,11.53,Fee Schedule,Mediare Clinical Lab,22.25,,,22.25,Fee Schedule,,20.06,,,20.06,Fee Schedule,,11.53,,,11.53,Fee Schedule,,11.53,,,11.53,Fee Schedule,,11.53,,,11.53,Fee Schedule,,92,50,,92,percent of total billed charges,All Other,128.8,70,,128.8,percent of total billed charges,All Other,36.32,,,36.32,Fee Schedule,,12.98,,,12.98,Other,186% Medicaid methodology,42.78,,,42.78,Fee Schedule,,114.08,,,114.08,Fee Schedule,,24.21,,,24.21,Fee Schedule,,42.78,,,42.78,Fee Schedule,,114.08,,,114.08,Fee Schedule,,45.54,,,45.54,Fee Schedule,,128.8,70,,128.8,percent of total billed charges,All Other,54.97,,,54.97,Fee Schedule,,46.64,,,46.64,Fee Schedule,,13.84,,,13.84,Fee Schedule,,13.84,,,13.84,Fee Schedule,,13.84,,,13.84,Fee Schedule,,13.84,,,13.84,Fee Schedule,,6.98,,,6.98,Fee Schedule,Medicaid Laboratory Fee Schedule,6.98,,,6.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.98,,,6.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.98,,,6.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,15.7,,,15.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.7,,,15.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.68,,,10.68,Fee Schedule,153% Medicaid Laboratory Fee Schedule,15.7,,,15.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.77,,,9.77,Fee Schedule,140% Medicaid Laboratory Fee Schedule,15.7,,,15.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.15,,,18.15,Fee Schedule,260% Medicaid Laboratory Fee Schedule,22.61,,,22.61,Fee Schedule,324% Medicaid Laboratory Fee Schedule,15.01,,,15.01,Fee Schedule,215% Medicaid Laboratory Fee Schedule,15.01,,,15.01,Fee Schedule,215% Medicaid Laboratory Fee Schedule,8.72,,,8.72,Fee Schedule,125% Medicaid Laboratory Fee Schedule,6.98,128.8,
MITOCHONDRIAL AB EA             ,86381,CPT,,40199713,CDM,302,RC,,,both,,,405,41.85,,,41.85,Other,150% of Medicare + 9.63% HCRA Surcharge,25.45,,,25.45,Fee Schedule,Mediare Clinical Lab,49.12,,,49.12,Fee Schedule,,44.28,,,44.28,Fee Schedule,,25.45,,,25.45,Fee Schedule,,25.45,,,25.45,Fee Schedule,,25.45,,,25.45,Fee Schedule,,202.5,50,,202.5,percent of total billed charges,All Other,283.5,70,,283.5,percent of total billed charges,All Other,80.17,,,80.17,Fee Schedule,,28.69,,,28.69,Other,186% Medicaid methodology,94.42,,,94.42,Fee Schedule,,251.1,,,251.1,Fee Schedule,,53.45,,,53.45,Fee Schedule,,94.42,,,94.42,Fee Schedule,,251.1,,,251.1,Fee Schedule,,100.53,,,100.53,Fee Schedule,,283.5,70,,283.5,percent of total billed charges,All Other,121.34,,,121.34,Fee Schedule,,102.96,,,102.96,Fee Schedule,,30.54,,,30.54,Fee Schedule,,30.54,,,30.54,Fee Schedule,,30.54,,,30.54,Fee Schedule,,30.54,,,30.54,Fee Schedule,,15.42,,,15.42,Fee Schedule,Medicaid Laboratory Fee Schedule,15.42,,,15.42,Fee Schedule,100% Medicaid Laboratory Fee Schedule,15.42,,,15.42,Fee Schedule,100% Medicaid Laboratory Fee Schedule,15.42,,,15.42,Fee Schedule,100% Medicaid Laboratory Fee Schedule,34.7,,,34.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,34.7,,,34.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.6,,,23.6,Fee Schedule,153% Medicaid Laboratory Fee Schedule,34.7,,,34.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.59,,,21.59,Fee Schedule,140% Medicaid Laboratory Fee Schedule,34.7,,,34.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,40.1,,,40.1,Fee Schedule,260% Medicaid Laboratory Fee Schedule,49.97,,,49.97,Fee Schedule,324% Medicaid Laboratory Fee Schedule,33.16,,,33.16,Fee Schedule,215% Medicaid Laboratory Fee Schedule,33.16,,,33.16,Fee Schedule,215% Medicaid Laboratory Fee Schedule,19.28,,,19.28,Fee Schedule,125% Medicaid Laboratory Fee Schedule,15.42,283.5,
PQ TYPE VOLTAGE GATED CALCIUM   ,86596,CPT,,40199739,CDM,302,RC,,,both,,,293,19.82,,,19.82,Other,150% of Medicare + 9.63% HCRA Surcharge,12.05,,,12.05,Fee Schedule,Mediare Clinical Lab,23.26,,,23.26,Fee Schedule,,20.97,,,20.97,Fee Schedule,,18.4,,,18.4,Fee Schedule,,18.4,,,18.4,Fee Schedule,,18.4,,,18.4,Fee Schedule,,146.5,50,,146.5,percent of total billed charges,All Other,205.1,70,,205.1,percent of total billed charges,All Other,37.96,,,37.96,Fee Schedule,,20.74,,,20.74,Other,186% Medicaid methodology,44.71,,,44.71,Fee Schedule,,181.66,,,181.66,Fee Schedule,,25.31,,,25.31,Fee Schedule,,44.71,,,44.71,Fee Schedule,,181.66,,,181.66,Fee Schedule,,47.6,,,47.6,Fee Schedule,,205.1,70,,205.1,percent of total billed charges,All Other,87.73,,,87.73,Fee Schedule,,74.44,,,74.44,Fee Schedule,,22.08,,,22.08,Fee Schedule,,22.08,,,22.08,Fee Schedule,,22.08,,,22.08,Fee Schedule,,22.08,,,22.08,Fee Schedule,,11.15,,,11.15,Fee Schedule,Medicaid Laboratory Fee Schedule,11.15,,,11.15,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.15,,,11.15,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.15,,,11.15,Fee Schedule,100% Medicaid Laboratory Fee Schedule,25.09,,,25.09,Fee Schedule,225% Medicaid Laboratory Fee Schedule,25.09,,,25.09,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.06,,,17.06,Fee Schedule,153% Medicaid Laboratory Fee Schedule,25.09,,,25.09,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.61,,,15.61,Fee Schedule,140% Medicaid Laboratory Fee Schedule,25.09,,,25.09,Fee Schedule,225% Medicaid Laboratory Fee Schedule,28.99,,,28.99,Fee Schedule,260% Medicaid Laboratory Fee Schedule,36.13,,,36.13,Fee Schedule,324% Medicaid Laboratory Fee Schedule,23.97,,,23.97,Fee Schedule,215% Medicaid Laboratory Fee Schedule,23.97,,,23.97,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.94,,,13.94,Fee Schedule,125% Medicaid Laboratory Fee Schedule,11.15,205.1,
COOMBS TEST INDIRECT TITER      ,86886,CPT,,40211948,CDM,302,RC,,,both,,,853,8.52,,,8.52,Other,150% of Medicare + 9.63% HCRA Surcharge,5.18,,,5.18,Fee Schedule,Mediare Clinical Lab,10,,,10,Fee Schedule,,9.01,,,9.01,Fee Schedule,,52.27,,,52.27,Fee Schedule,,47.03,,,47.03,Fee Schedule,,44.41,,,44.41,Fee Schedule,,426.5,50,,426.5,percent of total billed charges,All Other,10.95,,,10.95,Fee Schedule,,16.32,,,16.32,Fee Schedule,,134.95,,,134.95,Other,186% Medicaid methodology,19.22,,,19.22,Fee Schedule,,528.86,,,528.86,Fee Schedule,,10.88,,,10.88,Fee Schedule,,19.22,,,19.22,Fee Schedule,,528.86,,,528.86,Fee Schedule,,20.46,,,20.46,Fee Schedule,,597.1,70,,597.1,percent of total billed charges,All Other,24.7,,,24.7,Fee Schedule,,20.96,,,20.96,Fee Schedule,,6.22,,,6.22,Fee Schedule,,6.22,,,6.22,Fee Schedule,,6.22,,,6.22,Fee Schedule,,6.22,,,6.22,Fee Schedule,,72.55,,,72.55,Other,New York Medicaid APG methodology,72.55,,,72.55,Other,100% Medicaid APG methodology,72.55,,,72.55,Other,100% Medicaid APG methodology,72.55,,,72.55,Other,100% Medicaid APG methodology,163.24,,,163.24,Other,225% Medicaid APG methodology,163.24,,,163.24,Other,225% Medicaid APG methodology,111.01,,,111.01,Other,153% Medicaid APG methodology,163.24,,,163.24,Other,225% Medicaid APG methodology,101.57,,,101.57,Other,140% Medicaid APG methodology,163.24,,,163.24,Other,225% Medicaid APG methodology,188.64,,,188.64,Other,260% Medicaid APG methodology,235.07,,,235.07,Other,324% Medicaid APG methodology,155.99,,,155.99,Other,215% Medicaid APG methodology,155.99,,,155.99,Other,215% Medicaid APG methodology,90.69,,,90.69,Other,125% Medicaid APG methodology,5.18,597.1,
IMMUNOLOGY PROCEDURE            ,86849,CPT,,40400467,CDM,302,RC,,,both,,,904,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,452,50,,452,percent of total billed charges,All Other Outpatient,406.8,45,,406.8,percent of total billed charges,All Other Outpatient,7.5,,,7.5,Fee Schedule,,7.5,,,7.5,Fee Schedule,,7.5,,,7.5,Fee Schedule,,452,50,,452,percent of total billed charges,All Other,74.72,,,74.72,Fee Schedule,,614.72,68,,614.72,percent of total billed charges,All Other Outpatient,64.67,,,64.67,Other,186% Medicaid methodology,723.2,80,,723.2,percent of total billed charges,All Other Outpatient,750.32,83,,750.32,percent of total billed charges,All Other Outpatient,750.32,83,,750.32,percent of total billed charges,All Other Outpatient,723.2,80,,723.2,percent of total billed charges,All Other Outpatient,750.32,83,,750.32,percent of total billed charges,All Other Outpatient,813.6,90,,813.6,percent of total billed charges,All Other,632.8,70,,632.8,percent of total billed charges,All Other,452,50,,452,percent of total billed charges,All Other,452,50,,452,percent of total billed charges,All Other,632.8,70,,632.8,percent of total billed charges,All Other,632.8,70,,632.8,percent of total billed charges,All Other,632.8,70,,632.8,percent of total billed charges,All Other,632.8,70,,632.8,percent of total billed charges,All Other,34.77,,,34.77,Other,New York Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,53.2,,,53.2,Other,153% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,48.68,,,48.68,Other,140% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,90.41,,,90.41,Other,260% Medicaid APG methodology,112.66,,,112.66,Other,324% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,43.46,,,43.46,Other,125% Medicaid APG methodology,0.01,813.6,
TB INTRADERMAL TEST             ,86580,CPT,,40800914,CDM,302,RC,,,both,,,229,56.62,,,56.62,Other,150% of Medicare + 9.63% HCRA Surcharge,34.43,,,34.43,Other,Medicare OPPS methodology,23.95,,,23.95,Fee Schedule,,21.59,,,21.59,Fee Schedule,,68.71,,,68.71,Fee Schedule,,61.82,,,61.82,Fee Schedule,,58.38,,,58.38,Fee Schedule,,114.5,50,,114.5,percent of total billed charges,All Other,21.39,,,21.39,Fee Schedule,,47.03,,,47.03,Fee Schedule,,64.67,,,64.67,Other,186% Medicaid methodology,55.35,,,55.35,Fee Schedule,,141.98,,,141.98,Fee Schedule,,26.06,,,26.06,Fee Schedule,,55.35,,,55.35,Fee Schedule,,141.98,,,141.98,Fee Schedule,,49.02,,,49.02,Fee Schedule,,160.3,70,,160.3,percent of total billed charges,All Other,51.15,,,51.15,Fee Schedule,,43.4,,,43.4,Fee Schedule,,27.59,,,27.59,Fee Schedule,,27.59,,,27.59,Fee Schedule,,27.59,,,27.59,Fee Schedule,,27.59,,,27.59,Fee Schedule,,34.77,,,34.77,Other,New York Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,34.77,,,34.77,Other,100% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,53.2,,,53.2,Other,153% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,48.68,,,48.68,Other,140% Medicaid APG methodology,78.24,,,78.24,Other,225% Medicaid APG methodology,90.41,,,90.41,Other,260% Medicaid APG methodology,112.66,,,112.66,Other,324% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,74.76,,,74.76,Other,215% Medicaid APG methodology,43.46,,,43.46,Other,125% Medicaid APG methodology,21.39,160.3,
HEMATOCRIT                      ,85014,CPT,,40110405,CDM,305,RC,,,both,,,39,3.9,,,3.9,Other,150% of Medicare + 9.63% HCRA Surcharge,2.37,,,2.37,Fee Schedule,Mediare Clinical Lab,4.57,,,4.57,Fee Schedule,,4.12,,,4.12,Fee Schedule,,23.91,,,23.91,Fee Schedule,,21.51,,,21.51,Fee Schedule,,20.31,,,20.31,Fee Schedule,,19.5,50,,19.5,percent of total billed charges,All Other,5.01,,,5.01,Fee Schedule,,7.47,,,7.47,Fee Schedule,,3.76,,,3.76,Other,186% Medicaid methodology,8.79,,,8.79,Fee Schedule,,24.18,,,24.18,Fee Schedule,,4.98,,,4.98,Fee Schedule,,8.79,,,8.79,Fee Schedule,,24.18,,,24.18,Fee Schedule,,9.36,,,9.36,Fee Schedule,,27.3,70,,27.3,percent of total billed charges,All Other,11.3,,,11.3,Fee Schedule,,9.59,,,9.59,Fee Schedule,,2.84,,,2.84,Fee Schedule,,2.84,,,2.84,Fee Schedule,,2.84,,,2.84,Fee Schedule,,2.84,,,2.84,Fee Schedule,,2.02,,,2.02,Fee Schedule,Medicaid Laboratory Fee Schedule,2.02,,,2.02,Fee Schedule,100% Medicaid Laboratory Fee Schedule,2.02,,,2.02,Fee Schedule,100% Medicaid Laboratory Fee Schedule,2.02,,,2.02,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,225% Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,225% Medicaid Laboratory Fee Schedule,3.09,,,3.09,Fee Schedule,153% Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,225% Medicaid Laboratory Fee Schedule,2.83,,,2.83,Fee Schedule,140% Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,260% Medicaid Laboratory Fee Schedule,6.54,,,6.54,Fee Schedule,324% Medicaid Laboratory Fee Schedule,4.34,,,4.34,Fee Schedule,215% Medicaid Laboratory Fee Schedule,4.34,,,4.34,Fee Schedule,215% Medicaid Laboratory Fee Schedule,2.53,,,2.53,Fee Schedule,125% Medicaid Laboratory Fee Schedule,2.02,27.3,
Factor XIII LC,85291,CPT,,40125981,CDM,305,RC,,,both,,,146,14.98,,,14.98,Other,150% of Medicare + 9.63% HCRA Surcharge,9.11,,,9.11,Fee Schedule,Mediare Clinical Lab,17.58,,,17.58,Fee Schedule,,15.85,,,15.85,Fee Schedule,,74.38,,,74.38,Fee Schedule,,66.93,,,66.93,Fee Schedule,,63.2,,,63.2,Fee Schedule,,73,50,,73,percent of total billed charges,All Other,19.24,,,19.24,Fee Schedule,,28.7,,,28.7,Fee Schedule,,13.34,,,13.34,Other,186% Medicaid methodology,33.8,,,33.8,Fee Schedule,,90.52,,,90.52,Fee Schedule,,19.13,,,19.13,Fee Schedule,,33.8,,,33.8,Fee Schedule,,90.52,,,90.52,Fee Schedule,,35.98,,,35.98,Fee Schedule,,102.2,70,,102.2,percent of total billed charges,All Other,43.44,,,43.44,Fee Schedule,,36.85,,,36.85,Fee Schedule,,10.93,,,10.93,Fee Schedule,,10.93,,,10.93,Fee Schedule,,10.93,,,10.93,Fee Schedule,,10.93,,,10.93,Fee Schedule,,7.17,,,7.17,Fee Schedule,Medicaid Laboratory Fee Schedule,7.17,,,7.17,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.17,,,7.17,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.17,,,7.17,Fee Schedule,100% Medicaid Laboratory Fee Schedule,16.13,,,16.13,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.13,,,16.13,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.97,,,10.97,Fee Schedule,153% Medicaid Laboratory Fee Schedule,16.13,,,16.13,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.04,,,10.04,Fee Schedule,140% Medicaid Laboratory Fee Schedule,16.13,,,16.13,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.64,,,18.64,Fee Schedule,260% Medicaid Laboratory Fee Schedule,23.23,,,23.23,Fee Schedule,324% Medicaid Laboratory Fee Schedule,15.42,,,15.42,Fee Schedule,215% Medicaid Laboratory Fee Schedule,15.42,,,15.42,Fee Schedule,215% Medicaid Laboratory Fee Schedule,8.96,,,8.96,Fee Schedule,125% Medicaid Laboratory Fee Schedule,7.17,102.2,
BODY FLUID CELL COUNT           ,89050,CPT,,40130288,CDM,305,RC,,,both,,,76,7.76,,,7.76,Other,150% of Medicare + 9.63% HCRA Surcharge,4.72,,,4.72,Fee Schedule,Mediare Clinical Lab,9.11,,,9.11,Fee Schedule,,8.21,,,8.21,Fee Schedule,,43.37,,,43.37,Fee Schedule,,39.02,,,39.02,Fee Schedule,,36.84,,,36.84,Fee Schedule,,38,50,,38,percent of total billed charges,All Other,9.98,,,9.98,Fee Schedule,,14.87,,,14.87,Fee Schedule,,5.26,,,5.26,Other,186% Medicaid methodology,17.51,,,17.51,Fee Schedule,,47.12,,,47.12,Fee Schedule,,9.91,,,9.91,Fee Schedule,,17.51,,,17.51,Fee Schedule,,47.12,,,47.12,Fee Schedule,,18.64,,,18.64,Fee Schedule,,53.2,70,,53.2,percent of total billed charges,All Other,22.5,,,22.5,Fee Schedule,,19.09,,,19.09,Fee Schedule,,5.66,,,5.66,Fee Schedule,,5.66,,,5.66,Fee Schedule,,5.66,,,5.66,Fee Schedule,,5.66,,,5.66,Fee Schedule,,2.83,,,2.83,Fee Schedule,Medicaid Laboratory Fee Schedule,2.83,,,2.83,Fee Schedule,100% Medicaid Laboratory Fee Schedule,2.83,,,2.83,Fee Schedule,100% Medicaid Laboratory Fee Schedule,2.83,,,2.83,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.36,,,6.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,6.36,,,6.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,4.33,,,4.33,Fee Schedule,153% Medicaid Laboratory Fee Schedule,6.36,,,6.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,3.96,,,3.96,Fee Schedule,140% Medicaid Laboratory Fee Schedule,6.36,,,6.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.35,,,7.35,Fee Schedule,260% Medicaid Laboratory Fee Schedule,9.16,,,9.16,Fee Schedule,324% Medicaid Laboratory Fee Schedule,6.08,,,6.08,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.08,,,6.08,Fee Schedule,215% Medicaid Laboratory Fee Schedule,3.54,,,3.54,Fee Schedule,125% Medicaid Laboratory Fee Schedule,2.83,53.2,
COMPLETE CBC AUTOMATED          ,85027,CPT,,40140022,CDM,305,RC,,,both,,,103,10.64,,,10.64,Other,150% of Medicare + 9.63% HCRA Surcharge,6.47,,,6.47,Fee Schedule,Mediare Clinical Lab,12.49,,,12.49,Fee Schedule,,11.26,,,11.26,Fee Schedule,,58.73,,,58.73,Fee Schedule,,52.84,,,52.84,Fee Schedule,,49.9,,,49.9,Fee Schedule,,51.5,50,,51.5,percent of total billed charges,All Other,13.68,,,13.68,Fee Schedule,,20.38,,,20.38,Fee Schedule,,5.96,,,5.96,Other,186% Medicaid methodology,24,,,24,Fee Schedule,,63.86,,,63.86,Fee Schedule,,13.59,,,13.59,Fee Schedule,,24,,,24,Fee Schedule,,63.86,,,63.86,Fee Schedule,,25.56,,,25.56,Fee Schedule,,72.1,70,,72.1,percent of total billed charges,All Other,30.85,,,30.85,Fee Schedule,,26.17,,,26.17,Fee Schedule,,7.76,,,7.76,Fee Schedule,,7.76,,,7.76,Fee Schedule,,7.76,,,7.76,Fee Schedule,,7.76,,,7.76,Fee Schedule,,3.2,,,3.2,Fee Schedule,Medicaid Laboratory Fee Schedule,3.2,,,3.2,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.2,,,3.2,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.2,,,3.2,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.2,,,7.2,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.2,,,7.2,Fee Schedule,225% Medicaid Laboratory Fee Schedule,4.9,,,4.9,Fee Schedule,153% Medicaid Laboratory Fee Schedule,7.2,,,7.2,Fee Schedule,225% Medicaid Laboratory Fee Schedule,4.48,,,4.48,Fee Schedule,140% Medicaid Laboratory Fee Schedule,7.2,,,7.2,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.32,,,8.32,Fee Schedule,260% Medicaid Laboratory Fee Schedule,10.37,,,10.37,Fee Schedule,324% Medicaid Laboratory Fee Schedule,6.88,,,6.88,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.88,,,6.88,Fee Schedule,215% Medicaid Laboratory Fee Schedule,4,,,4,Fee Schedule,125% Medicaid Laboratory Fee Schedule,3.2,72.1,
BL SMEAR W/DIFF WBC COUNT       ,85007,CPT,,40140048,CDM,305,RC,,,both,,,61,6.25,,,6.25,Other,150% of Medicare + 9.63% HCRA Surcharge,3.8,,,3.8,Fee Schedule,Mediare Clinical Lab,7.33,,,7.33,Fee Schedule,,6.61,,,6.61,Fee Schedule,,34.75,,,34.75,Fee Schedule,,31.27,,,31.27,Fee Schedule,,29.52,,,29.52,Fee Schedule,,30.5,50,,30.5,percent of total billed charges,All Other,8.03,,,8.03,Fee Schedule,,11.97,,,11.97,Fee Schedule,,2.69,,,2.69,Other,186% Medicaid methodology,14.1,,,14.1,Fee Schedule,,37.82,,,37.82,Fee Schedule,,7.98,,,7.98,Fee Schedule,,14.1,,,14.1,Fee Schedule,,37.82,,,37.82,Fee Schedule,,15.01,,,15.01,Fee Schedule,,42.7,70,,42.7,percent of total billed charges,All Other,18.12,,,18.12,Fee Schedule,,15.37,,,15.37,Fee Schedule,,4.56,,,4.56,Fee Schedule,,4.56,,,4.56,Fee Schedule,,4.56,,,4.56,Fee Schedule,,4.56,,,4.56,Fee Schedule,,1.44,,,1.44,Fee Schedule,Medicaid Laboratory Fee Schedule,1.44,,,1.44,Fee Schedule,100% Medicaid Laboratory Fee Schedule,1.44,,,1.44,Fee Schedule,100% Medicaid Laboratory Fee Schedule,1.44,,,1.44,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.25,,,3.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,3.25,,,3.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,2.21,,,2.21,Fee Schedule,153% Medicaid Laboratory Fee Schedule,3.25,,,3.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,2.02,,,2.02,Fee Schedule,140% Medicaid Laboratory Fee Schedule,3.25,,,3.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,3.76,,,3.76,Fee Schedule,260% Medicaid Laboratory Fee Schedule,4.68,,,4.68,Fee Schedule,324% Medicaid Laboratory Fee Schedule,3.11,,,3.11,Fee Schedule,215% Medicaid Laboratory Fee Schedule,3.11,,,3.11,Fee Schedule,215% Medicaid Laboratory Fee Schedule,1.81,,,1.81,Fee Schedule,125% Medicaid Laboratory Fee Schedule,1.44,42.7,
COMPLETE CBC W/AUTO DIFF WBC    ,85025,CPT,,40140063,CDM,305,RC,,,both,,,125,12.78,,,12.78,Other,150% of Medicare + 9.63% HCRA Surcharge,7.77,,,7.77,Fee Schedule,Mediare Clinical Lab,15,,,15,Fee Schedule,,13.52,,,13.52,Fee Schedule,,78.55,,,78.55,Fee Schedule,,70.67,,,70.67,Fee Schedule,,66.73,,,66.73,Fee Schedule,,62.5,50,,62.5,percent of total billed charges,All Other,16.41,,,16.41,Fee Schedule,,24.48,,,24.48,Fee Schedule,,5.96,,,5.96,Other,186% Medicaid methodology,28.83,,,28.83,Fee Schedule,,77.5,,,77.5,Fee Schedule,,16.32,,,16.32,Fee Schedule,,28.83,,,28.83,Fee Schedule,,77.5,,,77.5,Fee Schedule,,30.69,,,30.69,Fee Schedule,,87.5,70,,87.5,percent of total billed charges,All Other,37.05,,,37.05,Fee Schedule,,31.43,,,31.43,Fee Schedule,,9.32,,,9.32,Fee Schedule,,9.32,,,9.32,Fee Schedule,,9.32,,,9.32,Fee Schedule,,9.32,,,9.32,Fee Schedule,,3.2,,,3.2,Fee Schedule,Medicaid Laboratory Fee Schedule,3.2,,,3.2,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.2,,,3.2,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.2,,,3.2,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.2,,,7.2,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.2,,,7.2,Fee Schedule,225% Medicaid Laboratory Fee Schedule,4.9,,,4.9,Fee Schedule,153% Medicaid Laboratory Fee Schedule,7.2,,,7.2,Fee Schedule,225% Medicaid Laboratory Fee Schedule,4.48,,,4.48,Fee Schedule,140% Medicaid Laboratory Fee Schedule,7.2,,,7.2,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.32,,,8.32,Fee Schedule,260% Medicaid Laboratory Fee Schedule,10.37,,,10.37,Fee Schedule,324% Medicaid Laboratory Fee Schedule,6.88,,,6.88,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.88,,,6.88,Fee Schedule,215% Medicaid Laboratory Fee Schedule,4,,,4,Fee Schedule,125% Medicaid Laboratory Fee Schedule,3.2,87.5,
AUTOMATED RETICULOCYTE COUNT    ,85045,CPT,,40140089,CDM,305,RC,,,both,,,64,6.56,,,6.56,Other,150% of Medicare + 9.63% HCRA Surcharge,3.99,,,3.99,Fee Schedule,Mediare Clinical Lab,7.7,,,7.7,Fee Schedule,,6.94,,,6.94,Fee Schedule,,40.42,,,40.42,Fee Schedule,,36.37,,,36.37,Fee Schedule,,34.34,,,34.34,Fee Schedule,,32,50,,32,percent of total billed charges,All Other,8.42,,,8.42,Fee Schedule,,12.57,,,12.57,Fee Schedule,,5.96,,,5.96,Other,186% Medicaid methodology,14.8,,,14.8,Fee Schedule,,39.68,,,39.68,Fee Schedule,,8.38,,,8.38,Fee Schedule,,14.8,,,14.8,Fee Schedule,,39.68,,,39.68,Fee Schedule,,15.76,,,15.76,Fee Schedule,,44.8,70,,44.8,percent of total billed charges,All Other,19.02,,,19.02,Fee Schedule,,16.14,,,16.14,Fee Schedule,,4.79,,,4.79,Fee Schedule,,4.79,,,4.79,Fee Schedule,,4.79,,,4.79,Fee Schedule,,4.79,,,4.79,Fee Schedule,,3.2,,,3.2,Fee Schedule,Medicaid Laboratory Fee Schedule,3.2,,,3.2,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.2,,,3.2,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.2,,,3.2,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.2,,,7.2,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.2,,,7.2,Fee Schedule,225% Medicaid Laboratory Fee Schedule,4.9,,,4.9,Fee Schedule,153% Medicaid Laboratory Fee Schedule,7.2,,,7.2,Fee Schedule,225% Medicaid Laboratory Fee Schedule,4.48,,,4.48,Fee Schedule,140% Medicaid Laboratory Fee Schedule,7.2,,,7.2,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.32,,,8.32,Fee Schedule,260% Medicaid Laboratory Fee Schedule,10.37,,,10.37,Fee Schedule,324% Medicaid Laboratory Fee Schedule,6.88,,,6.88,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.88,,,6.88,Fee Schedule,215% Medicaid Laboratory Fee Schedule,4,,,4,Fee Schedule,125% Medicaid Laboratory Fee Schedule,3.2,44.8,
RBC SED RATE NONAUTOMATED       ,85651,CPT,,40140105,CDM,305,RC,,,both,,,115,7.02,,,7.02,Other,150% of Medicare + 9.63% HCRA Surcharge,4.27,,,4.27,Fee Schedule,Mediare Clinical Lab,8.24,,,8.24,Fee Schedule,,7.43,,,7.43,Fee Schedule,,35.9,,,35.9,Fee Schedule,,32.3,,,32.3,Fee Schedule,,30.5,,,30.5,Fee Schedule,,57.5,50,,57.5,percent of total billed charges,All Other,9.04,,,9.04,Fee Schedule,,13.45,,,13.45,Fee Schedule,,3.76,,,3.76,Other,186% Medicaid methodology,15.84,,,15.84,Fee Schedule,,71.3,,,71.3,Fee Schedule,,8.97,,,8.97,Fee Schedule,,15.84,,,15.84,Fee Schedule,,71.3,,,71.3,Fee Schedule,,16.87,,,16.87,Fee Schedule,,80.5,70,,80.5,percent of total billed charges,All Other,20.36,,,20.36,Fee Schedule,,17.27,,,17.27,Fee Schedule,,5.12,,,5.12,Fee Schedule,,5.12,,,5.12,Fee Schedule,,5.12,,,5.12,Fee Schedule,,5.12,,,5.12,Fee Schedule,,2.02,,,2.02,Fee Schedule,Medicaid Laboratory Fee Schedule,2.02,,,2.02,Fee Schedule,100% Medicaid Laboratory Fee Schedule,2.02,,,2.02,Fee Schedule,100% Medicaid Laboratory Fee Schedule,2.02,,,2.02,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,225% Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,225% Medicaid Laboratory Fee Schedule,3.09,,,3.09,Fee Schedule,153% Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,225% Medicaid Laboratory Fee Schedule,2.83,,,2.83,Fee Schedule,140% Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,260% Medicaid Laboratory Fee Schedule,6.54,,,6.54,Fee Schedule,324% Medicaid Laboratory Fee Schedule,4.34,,,4.34,Fee Schedule,215% Medicaid Laboratory Fee Schedule,4.34,,,4.34,Fee Schedule,215% Medicaid Laboratory Fee Schedule,2.53,,,2.53,Fee Schedule,125% Medicaid Laboratory Fee Schedule,2.02,80.5,
RBC SICKLE CELL TEST            ,85660,CPT,,40140121,CDM,305,RC,,,both,,,88,9.06,,,9.06,Other,150% of Medicare + 9.63% HCRA Surcharge,5.51,,,5.51,Fee Schedule,Mediare Clinical Lab,10.63,,,10.63,Fee Schedule,,9.59,,,9.59,Fee Schedule,,41.29,,,41.29,Fee Schedule,,37.15,,,37.15,Fee Schedule,,35.08,,,35.08,Fee Schedule,,44,50,,44,percent of total billed charges,All Other,11.64,,,11.64,Fee Schedule,,17.36,,,17.36,Fee Schedule,,66.06,,,66.06,Other,186% Medicaid methodology,20.44,,,20.44,Fee Schedule,,54.56,,,54.56,Fee Schedule,,11.57,,,11.57,Fee Schedule,,20.44,,,20.44,Fee Schedule,,54.56,,,54.56,Fee Schedule,,21.76,,,21.76,Fee Schedule,,61.6,70,,61.6,percent of total billed charges,All Other,26.27,,,26.27,Fee Schedule,,22.29,,,22.29,Fee Schedule,,6.61,,,6.61,Fee Schedule,,6.61,,,6.61,Fee Schedule,,6.61,,,6.61,Fee Schedule,,6.61,,,6.61,Fee Schedule,,35.52,,,35.52,Other,New York Medicaid APG methodology,35.52,,,35.52,Other,100% Medicaid APG methodology,35.52,,,35.52,Other,100% Medicaid APG methodology,35.52,,,35.52,Other,100% Medicaid APG methodology,79.91,,,79.91,Other,225% Medicaid APG methodology,79.91,,,79.91,Other,225% Medicaid APG methodology,54.34,,,54.34,Other,153% Medicaid APG methodology,79.91,,,79.91,Other,225% Medicaid APG methodology,49.72,,,49.72,Other,140% Medicaid APG methodology,79.91,,,79.91,Other,225% Medicaid APG methodology,92.34,,,92.34,Other,260% Medicaid APG methodology,115.07,,,115.07,Other,324% Medicaid APG methodology,76.36,,,76.36,Other,215% Medicaid APG methodology,76.36,,,76.36,Other,215% Medicaid APG methodology,44.39,,,44.39,Other,125% Medicaid APG methodology,5.51,115.07,
HEMOGLOBIN                      ,85018,CPT,,40140147,CDM,305,RC,,,both,,,39,3.9,,,3.9,Other,150% of Medicare + 9.63% HCRA Surcharge,2.37,,,2.37,Fee Schedule,Mediare Clinical Lab,4.57,,,4.57,Fee Schedule,,4.12,,,4.12,Fee Schedule,,23.91,,,23.91,Fee Schedule,,21.51,,,21.51,Fee Schedule,,20.31,,,20.31,Fee Schedule,,19.5,50,,19.5,percent of total billed charges,All Other,5.01,,,5.01,Fee Schedule,,7.47,,,7.47,Fee Schedule,,3.76,,,3.76,Other,186% Medicaid methodology,8.79,,,8.79,Fee Schedule,,24.18,,,24.18,Fee Schedule,,4.98,,,4.98,Fee Schedule,,8.79,,,8.79,Fee Schedule,,24.18,,,24.18,Fee Schedule,,9.36,,,9.36,Fee Schedule,,27.3,70,,27.3,percent of total billed charges,All Other,11.3,,,11.3,Fee Schedule,,9.59,,,9.59,Fee Schedule,,2.84,,,2.84,Fee Schedule,,2.84,,,2.84,Fee Schedule,,2.84,,,2.84,Fee Schedule,,2.84,,,2.84,Fee Schedule,,2.02,,,2.02,Fee Schedule,Medicaid Laboratory Fee Schedule,2.02,,,2.02,Fee Schedule,100% Medicaid Laboratory Fee Schedule,2.02,,,2.02,Fee Schedule,100% Medicaid Laboratory Fee Schedule,2.02,,,2.02,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,225% Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,225% Medicaid Laboratory Fee Schedule,3.09,,,3.09,Fee Schedule,153% Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,225% Medicaid Laboratory Fee Schedule,2.83,,,2.83,Fee Schedule,140% Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,260% Medicaid Laboratory Fee Schedule,6.54,,,6.54,Fee Schedule,324% Medicaid Laboratory Fee Schedule,4.34,,,4.34,Fee Schedule,215% Medicaid Laboratory Fee Schedule,4.34,,,4.34,Fee Schedule,215% Medicaid Laboratory Fee Schedule,2.53,,,2.53,Fee Schedule,125% Medicaid Laboratory Fee Schedule,2.02,27.3,
PROTHROMBIN TIME                ,85610,CPT,,40140428,CDM,305,RC,,,both,,,68,7.05,,,7.05,Other,150% of Medicare + 9.63% HCRA Surcharge,4.29,,,4.29,Fee Schedule,Mediare Clinical Lab,8.28,,,8.28,Fee Schedule,,7.46,,,7.46,Fee Schedule,,39.71,,,39.71,Fee Schedule,,35.72,,,35.72,Fee Schedule,,33.73,,,33.73,Fee Schedule,,34,50,,34,percent of total billed charges,All Other,9.07,,,9.07,Fee Schedule,,13.51,,,13.51,Fee Schedule,,7.35,,,7.35,Other,186% Medicaid methodology,15.92,,,15.92,Fee Schedule,,42.16,,,42.16,Fee Schedule,,9.01,,,9.01,Fee Schedule,,15.92,,,15.92,Fee Schedule,,42.16,,,42.16,Fee Schedule,,16.95,,,16.95,Fee Schedule,,47.6,70,,47.6,percent of total billed charges,All Other,20.45,,,20.45,Fee Schedule,,17.36,,,17.36,Fee Schedule,,5.15,,,5.15,Fee Schedule,,5.15,,,5.15,Fee Schedule,,5.15,,,5.15,Fee Schedule,,5.15,,,5.15,Fee Schedule,,3.95,,,3.95,Fee Schedule,Medicaid Laboratory Fee Schedule,3.95,,,3.95,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.95,,,3.95,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.95,,,3.95,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.89,,,8.89,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.89,,,8.89,Fee Schedule,225% Medicaid Laboratory Fee Schedule,6.04,,,6.04,Fee Schedule,153% Medicaid Laboratory Fee Schedule,8.89,,,8.89,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.53,,,5.53,Fee Schedule,140% Medicaid Laboratory Fee Schedule,8.89,,,8.89,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.27,,,10.27,Fee Schedule,260% Medicaid Laboratory Fee Schedule,12.8,,,12.8,Fee Schedule,324% Medicaid Laboratory Fee Schedule,8.49,,,8.49,Fee Schedule,215% Medicaid Laboratory Fee Schedule,8.49,,,8.49,Fee Schedule,215% Medicaid Laboratory Fee Schedule,4.94,,,4.94,Fee Schedule,125% Medicaid Laboratory Fee Schedule,3.95,47.6,
FIBRINOGEN ACTIVITY             ,85384,CPT,,40140485,CDM,305,RC,,,both,,,155,15.98,,,15.98,Other,150% of Medicare + 9.63% HCRA Surcharge,9.72,,,9.72,Fee Schedule,Mediare Clinical Lab,18.76,,,18.76,Fee Schedule,,16.91,,,16.91,Fee Schedule,,85.8,,,85.8,Fee Schedule,,77.2,,,77.2,Fee Schedule,,72.9,,,72.9,Fee Schedule,,77.5,50,,77.5,percent of total billed charges,All Other,20.54,,,20.54,Fee Schedule,,30.62,,,30.62,Fee Schedule,,12.96,,,12.96,Other,186% Medicaid methodology,36.06,,,36.06,Fee Schedule,,96.1,,,96.1,Fee Schedule,,20.41,,,20.41,Fee Schedule,,36.06,,,36.06,Fee Schedule,,96.1,,,96.1,Fee Schedule,,38.39,,,38.39,Fee Schedule,,108.5,70,,108.5,percent of total billed charges,All Other,46.34,,,46.34,Fee Schedule,,39.32,,,39.32,Fee Schedule,,11.66,,,11.66,Fee Schedule,,11.66,,,11.66,Fee Schedule,,11.66,,,11.66,Fee Schedule,,11.66,,,11.66,Fee Schedule,,6.97,,,6.97,Fee Schedule,Medicaid Laboratory Fee Schedule,6.97,,,6.97,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.97,,,6.97,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.97,,,6.97,Fee Schedule,100% Medicaid Laboratory Fee Schedule,15.68,,,15.68,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.68,,,15.68,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.66,,,10.66,Fee Schedule,153% Medicaid Laboratory Fee Schedule,15.68,,,15.68,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.76,,,9.76,Fee Schedule,140% Medicaid Laboratory Fee Schedule,15.68,,,15.68,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.12,,,18.12,Fee Schedule,260% Medicaid Laboratory Fee Schedule,22.58,,,22.58,Fee Schedule,324% Medicaid Laboratory Fee Schedule,14.98,,,14.98,Fee Schedule,215% Medicaid Laboratory Fee Schedule,14.98,,,14.98,Fee Schedule,215% Medicaid Laboratory Fee Schedule,8.71,,,8.71,Fee Schedule,125% Medicaid Laboratory Fee Schedule,6.97,108.5,
FIBRIN DEGRADATION PRODUCTS     ,85362,CPT,,40140501,CDM,305,RC,,,both,,,110,11.33,,,11.33,Other,150% of Medicare + 9.63% HCRA Surcharge,6.89,,,6.89,Fee Schedule,Mediare Clinical Lab,13.3,,,13.3,Fee Schedule,,11.99,,,11.99,Fee Schedule,,69.57,,,69.57,Fee Schedule,,62.6,,,62.6,Fee Schedule,,59.11,,,59.11,Fee Schedule,,55,50,,55,percent of total billed charges,All Other,14.56,,,14.56,Fee Schedule,,21.7,,,21.7,Fee Schedule,,12.82,,,12.82,Other,186% Medicaid methodology,25.56,,,25.56,Fee Schedule,,68.2,,,68.2,Fee Schedule,,14.47,,,14.47,Fee Schedule,,25.56,,,25.56,Fee Schedule,,68.2,,,68.2,Fee Schedule,,27.22,,,27.22,Fee Schedule,,77,70,,77,percent of total billed charges,All Other,32.85,,,32.85,Fee Schedule,,27.87,,,27.87,Fee Schedule,,8.27,,,8.27,Fee Schedule,,8.27,,,8.27,Fee Schedule,,8.27,,,8.27,Fee Schedule,,8.27,,,8.27,Fee Schedule,,6.89,,,6.89,Fee Schedule,Medicaid Laboratory Fee Schedule,6.89,,,6.89,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.89,,,6.89,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.89,,,6.89,Fee Schedule,100% Medicaid Laboratory Fee Schedule,15.5,,,15.5,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.5,,,15.5,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.54,,,10.54,Fee Schedule,153% Medicaid Laboratory Fee Schedule,15.5,,,15.5,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.65,,,9.65,Fee Schedule,140% Medicaid Laboratory Fee Schedule,15.5,,,15.5,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.91,,,17.91,Fee Schedule,260% Medicaid Laboratory Fee Schedule,22.32,,,22.32,Fee Schedule,324% Medicaid Laboratory Fee Schedule,14.81,,,14.81,Fee Schedule,215% Medicaid Laboratory Fee Schedule,14.81,,,14.81,Fee Schedule,215% Medicaid Laboratory Fee Schedule,8.61,,,8.61,Fee Schedule,125% Medicaid Laboratory Fee Schedule,6.89,77,
THROMBOPLASTIN TIME PARTIAL     ,85732,CPT,,40140543,CDM,305,RC,,,both,,,103,10.64,,,10.64,Other,150% of Medicare + 9.63% HCRA Surcharge,6.47,,,6.47,Fee Schedule,Mediare Clinical Lab,12.49,,,12.49,Fee Schedule,,11.26,,,11.26,Fee Schedule,,65.41,,,65.41,Fee Schedule,,58.85,,,58.85,Fee Schedule,,55.57,,,55.57,Fee Schedule,,51.5,50,,51.5,percent of total billed charges,All Other,13.68,,,13.68,Fee Schedule,,20.38,,,20.38,Fee Schedule,,11.63,,,11.63,Other,186% Medicaid methodology,24,,,24,Fee Schedule,,63.86,,,63.86,Fee Schedule,,13.59,,,13.59,Fee Schedule,,24,,,24,Fee Schedule,,63.86,,,63.86,Fee Schedule,,25.56,,,25.56,Fee Schedule,,72.1,70,,72.1,percent of total billed charges,All Other,30.85,,,30.85,Fee Schedule,,26.17,,,26.17,Fee Schedule,,7.76,,,7.76,Fee Schedule,,7.76,,,7.76,Fee Schedule,,7.76,,,7.76,Fee Schedule,,7.76,,,7.76,Fee Schedule,,6.25,,,6.25,Fee Schedule,Medicaid Laboratory Fee Schedule,6.25,,,6.25,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.25,,,6.25,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.25,,,6.25,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.07,,,14.07,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.07,,,14.07,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.57,,,9.57,Fee Schedule,153% Medicaid Laboratory Fee Schedule,14.07,,,14.07,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.75,,,8.75,Fee Schedule,140% Medicaid Laboratory Fee Schedule,14.07,,,14.07,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.25,,,16.25,Fee Schedule,260% Medicaid Laboratory Fee Schedule,20.26,,,20.26,Fee Schedule,324% Medicaid Laboratory Fee Schedule,13.44,,,13.44,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.44,,,13.44,Fee Schedule,215% Medicaid Laboratory Fee Schedule,7.81,,,7.81,Fee Schedule,125% Medicaid Laboratory Fee Schedule,6.25,72.1,
FIBRIN DEGRADATION QUANT        ,85379,CPT,,40140568,CDM,305,RC,,,both,,,163,16.74,,,16.74,Other,150% of Medicare + 9.63% HCRA Surcharge,10.18,,,10.18,Fee Schedule,Mediare Clinical Lab,19.65,,,19.65,Fee Schedule,,17.71,,,17.71,Fee Schedule,,81.92,,,81.92,Fee Schedule,,73.71,,,73.71,Fee Schedule,,69.6,,,69.6,Fee Schedule,,81.5,50,,81.5,percent of total billed charges,All Other,21.52,,,21.52,Fee Schedule,,32.07,,,32.07,Fee Schedule,,18.93,,,18.93,Other,186% Medicaid methodology,37.77,,,37.77,Fee Schedule,,101.06,,,101.06,Fee Schedule,,21.38,,,21.38,Fee Schedule,,37.77,,,37.77,Fee Schedule,,101.06,,,101.06,Fee Schedule,,40.21,,,40.21,Fee Schedule,,114.1,70,,114.1,percent of total billed charges,All Other,48.54,,,48.54,Fee Schedule,,41.18,,,41.18,Fee Schedule,,12.22,,,12.22,Fee Schedule,,12.22,,,12.22,Fee Schedule,,12.22,,,12.22,Fee Schedule,,12.22,,,12.22,Fee Schedule,,10.18,,,10.18,Fee Schedule,Medicaid Laboratory Fee Schedule,10.18,,,10.18,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.18,,,10.18,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.18,,,10.18,Fee Schedule,100% Medicaid Laboratory Fee Schedule,22.91,,,22.91,Fee Schedule,225% Medicaid Laboratory Fee Schedule,22.91,,,22.91,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.58,,,15.58,Fee Schedule,153% Medicaid Laboratory Fee Schedule,22.91,,,22.91,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.25,,,14.25,Fee Schedule,140% Medicaid Laboratory Fee Schedule,22.91,,,22.91,Fee Schedule,225% Medicaid Laboratory Fee Schedule,26.47,,,26.47,Fee Schedule,260% Medicaid Laboratory Fee Schedule,32.98,,,32.98,Fee Schedule,324% Medicaid Laboratory Fee Schedule,21.89,,,21.89,Fee Schedule,215% Medicaid Laboratory Fee Schedule,21.89,,,21.89,Fee Schedule,215% Medicaid Laboratory Fee Schedule,12.73,,,12.73,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.18,114.1,
RUSSELL VIPER VENOM DILUTED     ,85613,CPT,,40140634,CDM,305,RC,,,both,,,153,15.75,,,15.75,Other,150% of Medicare + 9.63% HCRA Surcharge,9.58,,,9.58,Fee Schedule,Mediare Clinical Lab,18.49,,,18.49,Fee Schedule,,16.67,,,16.67,Fee Schedule,,58.73,,,58.73,Fee Schedule,,52.84,,,52.84,Fee Schedule,,49.9,,,49.9,Fee Schedule,,76.5,50,,76.5,percent of total billed charges,All Other,20.25,,,20.25,Fee Schedule,,30.18,,,30.18,Fee Schedule,,14.69,,,14.69,Other,186% Medicaid methodology,35.54,,,35.54,Fee Schedule,,94.86,,,94.86,Fee Schedule,,20.12,,,20.12,Fee Schedule,,35.54,,,35.54,Fee Schedule,,94.86,,,94.86,Fee Schedule,,37.84,,,37.84,Fee Schedule,,107.1,70,,107.1,percent of total billed charges,All Other,45.68,,,45.68,Fee Schedule,,38.76,,,38.76,Fee Schedule,,11.5,,,11.5,Fee Schedule,,11.5,,,11.5,Fee Schedule,,11.5,,,11.5,Fee Schedule,,11.5,,,11.5,Fee Schedule,,7.9,,,7.9,Fee Schedule,Medicaid Laboratory Fee Schedule,7.9,,,7.9,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.9,,,7.9,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.9,,,7.9,Fee Schedule,100% Medicaid Laboratory Fee Schedule,17.77,,,17.77,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.77,,,17.77,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.08,,,12.08,Fee Schedule,153% Medicaid Laboratory Fee Schedule,17.77,,,17.77,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.06,,,11.06,Fee Schedule,140% Medicaid Laboratory Fee Schedule,17.77,,,17.77,Fee Schedule,225% Medicaid Laboratory Fee Schedule,20.54,,,20.54,Fee Schedule,260% Medicaid Laboratory Fee Schedule,25.59,,,25.59,Fee Schedule,324% Medicaid Laboratory Fee Schedule,16.98,,,16.98,Fee Schedule,215% Medicaid Laboratory Fee Schedule,16.98,,,16.98,Fee Schedule,215% Medicaid Laboratory Fee Schedule,9.87,,,9.87,Fee Schedule,125% Medicaid Laboratory Fee Schedule,7.9,107.1,
ANTITHROMBIN III ACTIVITY       ,85300,CPT,,40140642,CDM,305,RC,,,both,,,189,19.49,,,19.49,Other,150% of Medicare + 9.63% HCRA Surcharge,11.85,,,11.85,Fee Schedule,Mediare Clinical Lab,22.87,,,22.87,Fee Schedule,,20.62,,,20.62,Fee Schedule,,88.39,,,88.39,Fee Schedule,,79.52,,,79.52,Fee Schedule,,75.09,,,75.09,Fee Schedule,,94.5,50,,94.5,percent of total billed charges,All Other,25.03,,,25.03,Fee Schedule,,37.33,,,37.33,Fee Schedule,,17.72,,,17.72,Other,186% Medicaid methodology,43.96,,,43.96,Fee Schedule,,117.18,,,117.18,Fee Schedule,,24.89,,,24.89,Fee Schedule,,43.96,,,43.96,Fee Schedule,,117.18,,,117.18,Fee Schedule,,46.81,,,46.81,Fee Schedule,,132.3,70,,132.3,percent of total billed charges,All Other,56.5,,,56.5,Fee Schedule,,47.94,,,47.94,Fee Schedule,,14.22,,,14.22,Fee Schedule,,14.22,,,14.22,Fee Schedule,,14.22,,,14.22,Fee Schedule,,14.22,,,14.22,Fee Schedule,,9.52,,,9.52,Fee Schedule,Medicaid Laboratory Fee Schedule,9.52,,,9.52,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.52,,,9.52,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.52,,,9.52,Fee Schedule,100% Medicaid Laboratory Fee Schedule,21.43,,,21.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.43,,,21.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.57,,,14.57,Fee Schedule,153% Medicaid Laboratory Fee Schedule,21.43,,,21.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.33,,,13.33,Fee Schedule,140% Medicaid Laboratory Fee Schedule,21.43,,,21.43,Fee Schedule,225% Medicaid Laboratory Fee Schedule,24.76,,,24.76,Fee Schedule,260% Medicaid Laboratory Fee Schedule,30.86,,,30.86,Fee Schedule,324% Medicaid Laboratory Fee Schedule,20.48,,,20.48,Fee Schedule,215% Medicaid Laboratory Fee Schedule,20.48,,,20.48,Fee Schedule,215% Medicaid Laboratory Fee Schedule,11.91,,,11.91,Fee Schedule,125% Medicaid Laboratory Fee Schedule,9.52,132.3,
AUTOMATED PLATELET COUNT        ,85049,CPT,,40140741,CDM,305,RC,,,both,,,72,7.37,,,7.37,Other,150% of Medicare + 9.63% HCRA Surcharge,4.48,,,4.48,Fee Schedule,Mediare Clinical Lab,8.65,,,8.65,Fee Schedule,,7.8,,,7.8,Fee Schedule,,45.16,,,45.16,Fee Schedule,,40.63,,,40.63,Fee Schedule,,38.37,,,38.37,Fee Schedule,,36,50,,36,percent of total billed charges,All Other,9.46,,,9.46,Fee Schedule,,14.11,,,14.11,Fee Schedule,,5.96,,,5.96,Other,186% Medicaid methodology,16.62,,,16.62,Fee Schedule,,44.64,,,44.64,Fee Schedule,,9.41,,,9.41,Fee Schedule,,16.62,,,16.62,Fee Schedule,,44.64,,,44.64,Fee Schedule,,17.7,,,17.7,Fee Schedule,,50.4,70,,50.4,percent of total billed charges,All Other,21.36,,,21.36,Fee Schedule,,18.12,,,18.12,Fee Schedule,,5.38,,,5.38,Fee Schedule,,5.38,,,5.38,Fee Schedule,,5.38,,,5.38,Fee Schedule,,5.38,,,5.38,Fee Schedule,,3.2,,,3.2,Fee Schedule,Medicaid Laboratory Fee Schedule,3.2,,,3.2,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.2,,,3.2,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.2,,,3.2,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.2,,,7.2,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.2,,,7.2,Fee Schedule,225% Medicaid Laboratory Fee Schedule,4.9,,,4.9,Fee Schedule,153% Medicaid Laboratory Fee Schedule,7.2,,,7.2,Fee Schedule,225% Medicaid Laboratory Fee Schedule,4.48,,,4.48,Fee Schedule,140% Medicaid Laboratory Fee Schedule,7.2,,,7.2,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.32,,,8.32,Fee Schedule,260% Medicaid Laboratory Fee Schedule,10.37,,,10.37,Fee Schedule,324% Medicaid Laboratory Fee Schedule,6.88,,,6.88,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.88,,,6.88,Fee Schedule,215% Medicaid Laboratory Fee Schedule,4,,,4,Fee Schedule,125% Medicaid Laboratory Fee Schedule,3.2,50.4,
CLOT FACTOR VIII VW ANTIGEN     ,85246,CPT,,40140865,CDM,305,RC,,,both,,,365,37.72,,,37.72,Other,150% of Medicare + 9.63% HCRA Surcharge,22.94,,,22.94,Fee Schedule,Mediare Clinical Lab,44.27,,,44.27,Fee Schedule,,39.92,,,39.92,Fee Schedule,,88.39,,,88.39,Fee Schedule,,79.52,,,79.52,Fee Schedule,,75.09,,,75.09,Fee Schedule,,182.5,50,,182.5,percent of total billed charges,All Other,48.46,,,48.46,Fee Schedule,,72.26,,,72.26,Fee Schedule,,17.66,,,17.66,Other,186% Medicaid methodology,85.11,,,85.11,Fee Schedule,,226.3,,,226.3,Fee Schedule,,48.17,,,48.17,Fee Schedule,,85.11,,,85.11,Fee Schedule,,226.3,,,226.3,Fee Schedule,,90.61,,,90.61,Fee Schedule,,255.5,70,,255.5,percent of total billed charges,All Other,109.38,,,109.38,Fee Schedule,,92.8,,,92.8,Fee Schedule,,27.53,,,27.53,Fee Schedule,,27.53,,,27.53,Fee Schedule,,27.53,,,27.53,Fee Schedule,,27.53,,,27.53,Fee Schedule,,9.49,,,9.49,Fee Schedule,Medicaid Laboratory Fee Schedule,9.49,,,9.49,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.49,,,9.49,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.49,,,9.49,Fee Schedule,100% Medicaid Laboratory Fee Schedule,21.36,,,21.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.36,,,21.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.53,,,14.53,Fee Schedule,153% Medicaid Laboratory Fee Schedule,21.36,,,21.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.29,,,13.29,Fee Schedule,140% Medicaid Laboratory Fee Schedule,21.36,,,21.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,24.68,,,24.68,Fee Schedule,260% Medicaid Laboratory Fee Schedule,30.76,,,30.76,Fee Schedule,324% Medicaid Laboratory Fee Schedule,20.41,,,20.41,Fee Schedule,215% Medicaid Laboratory Fee Schedule,20.41,,,20.41,Fee Schedule,215% Medicaid Laboratory Fee Schedule,11.87,,,11.87,Fee Schedule,125% Medicaid Laboratory Fee Schedule,9.49,255.5,
CLOT FACTOR II PROTHROM SPEC    ,85210,CPT,,40140881,CDM,305,RC,,,both,,,207,21.34,,,21.34,Other,150% of Medicare + 9.63% HCRA Surcharge,12.98,,,12.98,Fee Schedule,Mediare Clinical Lab,25.05,,,25.05,Fee Schedule,,22.59,,,22.59,Fee Schedule,,131.18,,,131.18,Fee Schedule,,118.02,,,118.02,Fee Schedule,,111.45,,,111.45,Fee Schedule,,103.5,50,,103.5,percent of total billed charges,All Other,27.43,,,27.43,Fee Schedule,,40.89,,,40.89,Fee Schedule,,24.14,,,24.14,Other,186% Medicaid methodology,48.16,,,48.16,Fee Schedule,,128.34,,,128.34,Fee Schedule,,27.26,,,27.26,Fee Schedule,,48.16,,,48.16,Fee Schedule,,128.34,,,128.34,Fee Schedule,,51.27,,,51.27,Fee Schedule,,144.9,70,,144.9,percent of total billed charges,All Other,61.89,,,61.89,Fee Schedule,,52.51,,,52.51,Fee Schedule,,15.58,,,15.58,Fee Schedule,,15.58,,,15.58,Fee Schedule,,15.58,,,15.58,Fee Schedule,,15.58,,,15.58,Fee Schedule,,12.98,,,12.98,Fee Schedule,Medicaid Laboratory Fee Schedule,12.98,,,12.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.98,,,12.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.98,,,12.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,29.21,,,29.21,Fee Schedule,225% Medicaid Laboratory Fee Schedule,29.21,,,29.21,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.86,,,19.86,Fee Schedule,153% Medicaid Laboratory Fee Schedule,29.21,,,29.21,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.17,,,18.17,Fee Schedule,140% Medicaid Laboratory Fee Schedule,29.21,,,29.21,Fee Schedule,225% Medicaid Laboratory Fee Schedule,33.75,,,33.75,Fee Schedule,260% Medicaid Laboratory Fee Schedule,42.06,,,42.06,Fee Schedule,324% Medicaid Laboratory Fee Schedule,27.91,,,27.91,Fee Schedule,215% Medicaid Laboratory Fee Schedule,27.91,,,27.91,Fee Schedule,215% Medicaid Laboratory Fee Schedule,16.23,,,16.23,Fee Schedule,125% Medicaid Laboratory Fee Schedule,12.98,144.9,
CLOT FACTOR IX PTC/CHRSTMAS     ,85250,CPT,,40140907,CDM,305,RC,,,both,,,304,31.31,,,31.31,Other,150% of Medicare + 9.63% HCRA Surcharge,19.04,,,19.04,Fee Schedule,Mediare Clinical Lab,36.75,,,36.75,Fee Schedule,,33.13,,,33.13,Fee Schedule,,187.18,,,187.18,Fee Schedule,,168.41,,,168.41,Fee Schedule,,159.03,,,159.03,Fee Schedule,,152,50,,152,percent of total billed charges,All Other,40.24,,,40.24,Fee Schedule,,59.98,,,59.98,Fee Schedule,,35.41,,,35.41,Other,186% Medicaid methodology,70.64,,,70.64,Fee Schedule,,188.48,,,188.48,Fee Schedule,,39.98,,,39.98,Fee Schedule,,70.64,,,70.64,Fee Schedule,,188.48,,,188.48,Fee Schedule,,75.21,,,75.21,Fee Schedule,,212.8,70,,212.8,percent of total billed charges,All Other,90.78,,,90.78,Fee Schedule,,77.03,,,77.03,Fee Schedule,,22.85,,,22.85,Fee Schedule,,22.85,,,22.85,Fee Schedule,,22.85,,,22.85,Fee Schedule,,22.85,,,22.85,Fee Schedule,,19.04,,,19.04,Fee Schedule,Medicaid Laboratory Fee Schedule,19.04,,,19.04,Fee Schedule,100% Medicaid Laboratory Fee Schedule,19.04,,,19.04,Fee Schedule,100% Medicaid Laboratory Fee Schedule,19.04,,,19.04,Fee Schedule,100% Medicaid Laboratory Fee Schedule,42.84,,,42.84,Fee Schedule,225% Medicaid Laboratory Fee Schedule,42.84,,,42.84,Fee Schedule,225% Medicaid Laboratory Fee Schedule,29.13,,,29.13,Fee Schedule,153% Medicaid Laboratory Fee Schedule,42.84,,,42.84,Fee Schedule,225% Medicaid Laboratory Fee Schedule,26.66,,,26.66,Fee Schedule,140% Medicaid Laboratory Fee Schedule,42.84,,,42.84,Fee Schedule,225% Medicaid Laboratory Fee Schedule,49.5,,,49.5,Fee Schedule,260% Medicaid Laboratory Fee Schedule,61.69,,,61.69,Fee Schedule,324% Medicaid Laboratory Fee Schedule,40.94,,,40.94,Fee Schedule,215% Medicaid Laboratory Fee Schedule,40.94,,,40.94,Fee Schedule,215% Medicaid Laboratory Fee Schedule,23.8,,,23.8,Fee Schedule,125% Medicaid Laboratory Fee Schedule,19.04,212.8,
BLOOC CLOT FACTOR V TEST        ,85220,CPT,,40140923,CDM,305,RC,,,both,,,281,29.02,,,29.02,Other,150% of Medicare + 9.63% HCRA Surcharge,17.65,,,17.65,Fee Schedule,Mediare Clinical Lab,34.06,,,34.06,Fee Schedule,,30.71,,,30.71,Fee Schedule,,178.28,,,178.28,Fee Schedule,,160.4,,,160.4,Fee Schedule,,151.46,,,151.46,Fee Schedule,,140.5,50,,140.5,percent of total billed charges,All Other,37.28,,,37.28,Fee Schedule,,55.6,,,55.6,Fee Schedule,,32.83,,,32.83,Other,186% Medicaid methodology,65.48,,,65.48,Fee Schedule,,174.22,,,174.22,Fee Schedule,,37.07,,,37.07,Fee Schedule,,65.48,,,65.48,Fee Schedule,,174.22,,,174.22,Fee Schedule,,69.72,,,69.72,Fee Schedule,,196.7,70,,196.7,percent of total billed charges,All Other,84.15,,,84.15,Fee Schedule,,71.4,,,71.4,Fee Schedule,,21.18,,,21.18,Fee Schedule,,21.18,,,21.18,Fee Schedule,,21.18,,,21.18,Fee Schedule,,21.18,,,21.18,Fee Schedule,,17.65,,,17.65,Fee Schedule,Medicaid Laboratory Fee Schedule,17.65,,,17.65,Fee Schedule,100% Medicaid Laboratory Fee Schedule,17.65,,,17.65,Fee Schedule,100% Medicaid Laboratory Fee Schedule,17.65,,,17.65,Fee Schedule,100% Medicaid Laboratory Fee Schedule,39.71,,,39.71,Fee Schedule,225% Medicaid Laboratory Fee Schedule,39.71,,,39.71,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27,,,27,Fee Schedule,153% Medicaid Laboratory Fee Schedule,39.71,,,39.71,Fee Schedule,225% Medicaid Laboratory Fee Schedule,24.71,,,24.71,Fee Schedule,140% Medicaid Laboratory Fee Schedule,39.71,,,39.71,Fee Schedule,225% Medicaid Laboratory Fee Schedule,45.89,,,45.89,Fee Schedule,260% Medicaid Laboratory Fee Schedule,57.19,,,57.19,Fee Schedule,324% Medicaid Laboratory Fee Schedule,37.95,,,37.95,Fee Schedule,215% Medicaid Laboratory Fee Schedule,37.95,,,37.95,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.06,,,22.06,Fee Schedule,125% Medicaid Laboratory Fee Schedule,17.65,196.7,
CLOT FACTOR VII PROCONVERTIN    ,85230,CPT,,40140949,CDM,305,RC,,,both,,,286,29.44,,,29.44,Other,150% of Medicare + 9.63% HCRA Surcharge,17.9,,,17.9,Fee Schedule,Mediare Clinical Lab,34.55,,,34.55,Fee Schedule,,31.15,,,31.15,Fee Schedule,,180.94,,,180.94,Fee Schedule,,162.79,,,162.79,Fee Schedule,,153.72,,,153.72,Fee Schedule,,143,50,,143,percent of total billed charges,All Other,37.83,,,37.83,Fee Schedule,,56.39,,,56.39,Fee Schedule,,33.29,,,33.29,Other,186% Medicaid methodology,66.41,,,66.41,Fee Schedule,,177.32,,,177.32,Fee Schedule,,37.59,,,37.59,Fee Schedule,,66.41,,,66.41,Fee Schedule,,177.32,,,177.32,Fee Schedule,,70.71,,,70.71,Fee Schedule,,200.2,70,,200.2,percent of total billed charges,All Other,85.35,,,85.35,Fee Schedule,,72.41,,,72.41,Fee Schedule,,21.48,,,21.48,Fee Schedule,,21.48,,,21.48,Fee Schedule,,21.48,,,21.48,Fee Schedule,,21.48,,,21.48,Fee Schedule,,17.9,,,17.9,Fee Schedule,Medicaid Laboratory Fee Schedule,17.9,,,17.9,Fee Schedule,100% Medicaid Laboratory Fee Schedule,17.9,,,17.9,Fee Schedule,100% Medicaid Laboratory Fee Schedule,17.9,,,17.9,Fee Schedule,100% Medicaid Laboratory Fee Schedule,40.28,,,40.28,Fee Schedule,225% Medicaid Laboratory Fee Schedule,40.28,,,40.28,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.39,,,27.39,Fee Schedule,153% Medicaid Laboratory Fee Schedule,40.28,,,40.28,Fee Schedule,225% Medicaid Laboratory Fee Schedule,25.06,,,25.06,Fee Schedule,140% Medicaid Laboratory Fee Schedule,40.28,,,40.28,Fee Schedule,225% Medicaid Laboratory Fee Schedule,46.54,,,46.54,Fee Schedule,260% Medicaid Laboratory Fee Schedule,58,,,58,Fee Schedule,324% Medicaid Laboratory Fee Schedule,38.49,,,38.49,Fee Schedule,215% Medicaid Laboratory Fee Schedule,38.49,,,38.49,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.38,,,22.38,Fee Schedule,125% Medicaid Laboratory Fee Schedule,17.9,200.2,
CLOT FACTOR VIII AHG 1 STAGE    ,85240,CPT,,40140964,CDM,305,RC,,,both,,,286,29.44,,,29.44,Other,150% of Medicare + 9.63% HCRA Surcharge,17.9,,,17.9,Fee Schedule,Mediare Clinical Lab,34.55,,,34.55,Fee Schedule,,31.15,,,31.15,Fee Schedule,,88.39,,,88.39,Fee Schedule,,79.52,,,79.52,Fee Schedule,,75.09,,,75.09,Fee Schedule,,143,50,,143,percent of total billed charges,All Other,37.83,,,37.83,Fee Schedule,,56.39,,,56.39,Fee Schedule,,17.66,,,17.66,Other,186% Medicaid methodology,66.41,,,66.41,Fee Schedule,,177.32,,,177.32,Fee Schedule,,37.59,,,37.59,Fee Schedule,,66.41,,,66.41,Fee Schedule,,177.32,,,177.32,Fee Schedule,,70.71,,,70.71,Fee Schedule,,200.2,70,,200.2,percent of total billed charges,All Other,85.35,,,85.35,Fee Schedule,,72.41,,,72.41,Fee Schedule,,21.48,,,21.48,Fee Schedule,,21.48,,,21.48,Fee Schedule,,21.48,,,21.48,Fee Schedule,,21.48,,,21.48,Fee Schedule,,9.49,,,9.49,Fee Schedule,Medicaid Laboratory Fee Schedule,9.49,,,9.49,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.49,,,9.49,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.49,,,9.49,Fee Schedule,100% Medicaid Laboratory Fee Schedule,21.36,,,21.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.36,,,21.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.53,,,14.53,Fee Schedule,153% Medicaid Laboratory Fee Schedule,21.36,,,21.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.29,,,13.29,Fee Schedule,140% Medicaid Laboratory Fee Schedule,21.36,,,21.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,24.68,,,24.68,Fee Schedule,260% Medicaid Laboratory Fee Schedule,30.76,,,30.76,Fee Schedule,324% Medicaid Laboratory Fee Schedule,20.41,,,20.41,Fee Schedule,215% Medicaid Laboratory Fee Schedule,20.41,,,20.41,Fee Schedule,215% Medicaid Laboratory Fee Schedule,11.87,,,11.87,Fee Schedule,125% Medicaid Laboratory Fee Schedule,9.49,200.2,
CLOT FACTOR XI PTA              ,85270,CPT,,40141004,CDM,305,RC,,,both,,,286,29.44,,,29.44,Other,150% of Medicare + 9.63% HCRA Surcharge,17.9,,,17.9,Fee Schedule,Mediare Clinical Lab,34.55,,,34.55,Fee Schedule,,31.15,,,31.15,Fee Schedule,,180.94,,,180.94,Fee Schedule,,162.79,,,162.79,Fee Schedule,,153.72,,,153.72,Fee Schedule,,143,50,,143,percent of total billed charges,All Other,37.83,,,37.83,Fee Schedule,,56.39,,,56.39,Fee Schedule,,33.29,,,33.29,Other,186% Medicaid methodology,66.41,,,66.41,Fee Schedule,,177.32,,,177.32,Fee Schedule,,37.59,,,37.59,Fee Schedule,,66.41,,,66.41,Fee Schedule,,177.32,,,177.32,Fee Schedule,,70.71,,,70.71,Fee Schedule,,200.2,70,,200.2,percent of total billed charges,All Other,85.35,,,85.35,Fee Schedule,,72.41,,,72.41,Fee Schedule,,21.48,,,21.48,Fee Schedule,,21.48,,,21.48,Fee Schedule,,21.48,,,21.48,Fee Schedule,,21.48,,,21.48,Fee Schedule,,17.9,,,17.9,Fee Schedule,Medicaid Laboratory Fee Schedule,17.9,,,17.9,Fee Schedule,100% Medicaid Laboratory Fee Schedule,17.9,,,17.9,Fee Schedule,100% Medicaid Laboratory Fee Schedule,17.9,,,17.9,Fee Schedule,100% Medicaid Laboratory Fee Schedule,40.28,,,40.28,Fee Schedule,225% Medicaid Laboratory Fee Schedule,40.28,,,40.28,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.39,,,27.39,Fee Schedule,153% Medicaid Laboratory Fee Schedule,40.28,,,40.28,Fee Schedule,225% Medicaid Laboratory Fee Schedule,25.06,,,25.06,Fee Schedule,140% Medicaid Laboratory Fee Schedule,40.28,,,40.28,Fee Schedule,225% Medicaid Laboratory Fee Schedule,46.54,,,46.54,Fee Schedule,260% Medicaid Laboratory Fee Schedule,58,,,58,Fee Schedule,324% Medicaid Laboratory Fee Schedule,38.49,,,38.49,Fee Schedule,215% Medicaid Laboratory Fee Schedule,38.49,,,38.49,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.38,,,22.38,Fee Schedule,125% Medicaid Laboratory Fee Schedule,17.9,200.2,
CLOT FACTOR XII HAGEMAN         ,85280,CPT,,40141020,CDM,305,RC,,,both,,,308,31.82,,,31.82,Other,150% of Medicare + 9.63% HCRA Surcharge,19.35,,,19.35,Fee Schedule,Mediare Clinical Lab,37.35,,,37.35,Fee Schedule,,33.67,,,33.67,Fee Schedule,,187.18,,,187.18,Fee Schedule,,168.41,,,168.41,Fee Schedule,,159.03,,,159.03,Fee Schedule,,154,50,,154,percent of total billed charges,All Other,40.89,,,40.89,Fee Schedule,,60.95,,,60.95,Fee Schedule,,35.99,,,35.99,Other,186% Medicaid methodology,71.79,,,71.79,Fee Schedule,,190.96,,,190.96,Fee Schedule,,40.64,,,40.64,Fee Schedule,,71.79,,,71.79,Fee Schedule,,190.96,,,190.96,Fee Schedule,,76.43,,,76.43,Fee Schedule,,215.6,70,,215.6,percent of total billed charges,All Other,92.26,,,92.26,Fee Schedule,,78.28,,,78.28,Fee Schedule,,23.22,,,23.22,Fee Schedule,,23.22,,,23.22,Fee Schedule,,23.22,,,23.22,Fee Schedule,,23.22,,,23.22,Fee Schedule,,19.35,,,19.35,Fee Schedule,Medicaid Laboratory Fee Schedule,19.35,,,19.35,Fee Schedule,100% Medicaid Laboratory Fee Schedule,19.35,,,19.35,Fee Schedule,100% Medicaid Laboratory Fee Schedule,19.35,,,19.35,Fee Schedule,100% Medicaid Laboratory Fee Schedule,43.54,,,43.54,Fee Schedule,225% Medicaid Laboratory Fee Schedule,43.54,,,43.54,Fee Schedule,225% Medicaid Laboratory Fee Schedule,29.61,,,29.61,Fee Schedule,153% Medicaid Laboratory Fee Schedule,43.54,,,43.54,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.09,,,27.09,Fee Schedule,140% Medicaid Laboratory Fee Schedule,43.54,,,43.54,Fee Schedule,225% Medicaid Laboratory Fee Schedule,50.31,,,50.31,Fee Schedule,260% Medicaid Laboratory Fee Schedule,62.69,,,62.69,Fee Schedule,324% Medicaid Laboratory Fee Schedule,41.6,,,41.6,Fee Schedule,215% Medicaid Laboratory Fee Schedule,41.6,,,41.6,Fee Schedule,215% Medicaid Laboratory Fee Schedule,24.19,,,24.19,Fee Schedule,125% Medicaid Laboratory Fee Schedule,19.35,215.6,
CLOT INHIBIT PROT C ACTIVITY    ,85303,CPT,,40141301,CDM,305,RC,,,both,,,221,22.76,,,22.76,Other,150% of Medicare + 9.63% HCRA Surcharge,13.84,,,13.84,Fee Schedule,Mediare Clinical Lab,26.71,,,26.71,Fee Schedule,,24.08,,,24.08,Fee Schedule,,139.72,,,139.72,Fee Schedule,,125.71,,,125.71,Fee Schedule,,118.71,,,118.71,Fee Schedule,,110.5,50,,110.5,percent of total billed charges,All Other,29.25,,,29.25,Fee Schedule,,43.6,,,43.6,Fee Schedule,,25.74,,,25.74,Other,186% Medicaid methodology,51.35,,,51.35,Fee Schedule,,137.02,,,137.02,Fee Schedule,,29.06,,,29.06,Fee Schedule,,51.35,,,51.35,Fee Schedule,,137.02,,,137.02,Fee Schedule,,54.67,,,54.67,Fee Schedule,,154.7,70,,154.7,percent of total billed charges,All Other,65.99,,,65.99,Fee Schedule,,55.99,,,55.99,Fee Schedule,,16.61,,,16.61,Fee Schedule,,16.61,,,16.61,Fee Schedule,,16.61,,,16.61,Fee Schedule,,16.61,,,16.61,Fee Schedule,,13.84,,,13.84,Fee Schedule,Medicaid Laboratory Fee Schedule,13.84,,,13.84,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.84,,,13.84,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.84,,,13.84,Fee Schedule,100% Medicaid Laboratory Fee Schedule,31.14,,,31.14,Fee Schedule,225% Medicaid Laboratory Fee Schedule,31.14,,,31.14,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.18,,,21.18,Fee Schedule,153% Medicaid Laboratory Fee Schedule,31.14,,,31.14,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.38,,,19.38,Fee Schedule,140% Medicaid Laboratory Fee Schedule,31.14,,,31.14,Fee Schedule,225% Medicaid Laboratory Fee Schedule,35.98,,,35.98,Fee Schedule,260% Medicaid Laboratory Fee Schedule,44.84,,,44.84,Fee Schedule,324% Medicaid Laboratory Fee Schedule,29.76,,,29.76,Fee Schedule,215% Medicaid Laboratory Fee Schedule,29.76,,,29.76,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.3,,,17.3,Fee Schedule,125% Medicaid Laboratory Fee Schedule,13.84,154.7,
CLOT INHIBIT PROT S FREE        ,85306,CPT,,40141327,CDM,305,RC,,,both,,,244,25.19,,,25.19,Other,150% of Medicare + 9.63% HCRA Surcharge,15.32,,,15.32,Fee Schedule,Mediare Clinical Lab,29.57,,,29.57,Fee Schedule,,26.66,,,26.66,Fee Schedule,,144.39,,,144.39,Fee Schedule,,129.91,,,129.91,Fee Schedule,,122.67,,,122.67,Fee Schedule,,122,50,,122,percent of total billed charges,All Other,32.37,,,32.37,Fee Schedule,,48.26,,,48.26,Fee Schedule,,28.5,,,28.5,Other,186% Medicaid methodology,56.84,,,56.84,Fee Schedule,,151.28,,,151.28,Fee Schedule,,32.17,,,32.17,Fee Schedule,,56.84,,,56.84,Fee Schedule,,151.28,,,151.28,Fee Schedule,,60.51,,,60.51,Fee Schedule,,170.8,70,,170.8,percent of total billed charges,All Other,73.04,,,73.04,Fee Schedule,,61.98,,,61.98,Fee Schedule,,18.38,,,18.38,Fee Schedule,,18.38,,,18.38,Fee Schedule,,18.38,,,18.38,Fee Schedule,,18.38,,,18.38,Fee Schedule,,15.32,,,15.32,Fee Schedule,Medicaid Laboratory Fee Schedule,15.32,,,15.32,Fee Schedule,100% Medicaid Laboratory Fee Schedule,15.32,,,15.32,Fee Schedule,100% Medicaid Laboratory Fee Schedule,15.32,,,15.32,Fee Schedule,100% Medicaid Laboratory Fee Schedule,34.47,,,34.47,Fee Schedule,225% Medicaid Laboratory Fee Schedule,34.47,,,34.47,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.44,,,23.44,Fee Schedule,153% Medicaid Laboratory Fee Schedule,34.47,,,34.47,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.45,,,21.45,Fee Schedule,140% Medicaid Laboratory Fee Schedule,34.47,,,34.47,Fee Schedule,225% Medicaid Laboratory Fee Schedule,39.83,,,39.83,Fee Schedule,260% Medicaid Laboratory Fee Schedule,49.64,,,49.64,Fee Schedule,324% Medicaid Laboratory Fee Schedule,32.94,,,32.94,Fee Schedule,215% Medicaid Laboratory Fee Schedule,32.94,,,32.94,Fee Schedule,215% Medicaid Laboratory Fee Schedule,19.15,,,19.15,Fee Schedule,125% Medicaid Laboratory Fee Schedule,15.32,170.8,
BLOOD VISCOSITY EXAMINATION     ,85810,CPT,,40141384,CDM,305,RC,,,both,,,186,19.19,,,19.19,Other,150% of Medicare + 9.63% HCRA Surcharge,11.67,,,11.67,Fee Schedule,Mediare Clinical Lab,22.52,,,22.52,Fee Schedule,,20.31,,,20.31,Fee Schedule,,117.97,,,117.97,Fee Schedule,,106.14,,,106.14,Fee Schedule,,100.22,,,100.22,Fee Schedule,,93,50,,93,percent of total billed charges,All Other,24.67,,,24.67,Fee Schedule,,36.76,,,36.76,Fee Schedule,,21.71,,,21.71,Other,186% Medicaid methodology,43.3,,,43.3,Fee Schedule,,115.32,,,115.32,Fee Schedule,,24.51,,,24.51,Fee Schedule,,43.3,,,43.3,Fee Schedule,,115.32,,,115.32,Fee Schedule,,46.1,,,46.1,Fee Schedule,,130.2,70,,130.2,percent of total billed charges,All Other,55.64,,,55.64,Fee Schedule,,47.21,,,47.21,Fee Schedule,,14,,,14,Fee Schedule,,14,,,14,Fee Schedule,,14,,,14,Fee Schedule,,14,,,14,Fee Schedule,,11.67,,,11.67,Fee Schedule,Medicaid Laboratory Fee Schedule,11.67,,,11.67,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.67,,,11.67,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.67,,,11.67,Fee Schedule,100% Medicaid Laboratory Fee Schedule,26.26,,,26.26,Fee Schedule,225% Medicaid Laboratory Fee Schedule,26.26,,,26.26,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.86,,,17.86,Fee Schedule,153% Medicaid Laboratory Fee Schedule,26.26,,,26.26,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.34,,,16.34,Fee Schedule,140% Medicaid Laboratory Fee Schedule,26.26,,,26.26,Fee Schedule,225% Medicaid Laboratory Fee Schedule,30.34,,,30.34,Fee Schedule,260% Medicaid Laboratory Fee Schedule,37.81,,,37.81,Fee Schedule,324% Medicaid Laboratory Fee Schedule,25.09,,,25.09,Fee Schedule,215% Medicaid Laboratory Fee Schedule,25.09,,,25.09,Fee Schedule,215% Medicaid Laboratory Fee Schedule,14.59,,,14.59,Fee Schedule,125% Medicaid Laboratory Fee Schedule,11.67,130.2,
CLOT FACTOR VIII VW RISTOCTN    ,85245,CPT,,40142622,CDM,305,RC,,,both,,,365,37.72,,,37.72,Other,150% of Medicare + 9.63% HCRA Surcharge,22.94,,,22.94,Fee Schedule,Mediare Clinical Lab,44.27,,,44.27,Fee Schedule,,39.92,,,39.92,Fee Schedule,,88.39,,,88.39,Fee Schedule,,79.52,,,79.52,Fee Schedule,,75.09,,,75.09,Fee Schedule,,182.5,50,,182.5,percent of total billed charges,All Other,48.46,,,48.46,Fee Schedule,,72.26,,,72.26,Fee Schedule,,17.66,,,17.66,Other,186% Medicaid methodology,85.11,,,85.11,Fee Schedule,,226.3,,,226.3,Fee Schedule,,48.17,,,48.17,Fee Schedule,,85.11,,,85.11,Fee Schedule,,226.3,,,226.3,Fee Schedule,,90.61,,,90.61,Fee Schedule,,255.5,70,,255.5,percent of total billed charges,All Other,109.38,,,109.38,Fee Schedule,,92.8,,,92.8,Fee Schedule,,27.53,,,27.53,Fee Schedule,,27.53,,,27.53,Fee Schedule,,27.53,,,27.53,Fee Schedule,,27.53,,,27.53,Fee Schedule,,9.49,,,9.49,Fee Schedule,Medicaid Laboratory Fee Schedule,9.49,,,9.49,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.49,,,9.49,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.49,,,9.49,Fee Schedule,100% Medicaid Laboratory Fee Schedule,21.36,,,21.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.36,,,21.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.53,,,14.53,Fee Schedule,153% Medicaid Laboratory Fee Schedule,21.36,,,21.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.29,,,13.29,Fee Schedule,140% Medicaid Laboratory Fee Schedule,21.36,,,21.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,24.68,,,24.68,Fee Schedule,260% Medicaid Laboratory Fee Schedule,30.76,,,30.76,Fee Schedule,324% Medicaid Laboratory Fee Schedule,20.41,,,20.41,Fee Schedule,215% Medicaid Laboratory Fee Schedule,20.41,,,20.41,Fee Schedule,215% Medicaid Laboratory Fee Schedule,11.87,,,11.87,Fee Schedule,125% Medicaid Laboratory Fee Schedule,9.49,255.5,
CLOT FACTOR VIII MULTIMETRIC    ,85247,CPT,,40143109,CDM,305,RC,,,both,,,365,37.72,,,37.72,Other,150% of Medicare + 9.63% HCRA Surcharge,22.94,,,22.94,Fee Schedule,Mediare Clinical Lab,44.27,,,44.27,Fee Schedule,,39.92,,,39.92,Fee Schedule,,88.39,,,88.39,Fee Schedule,,79.52,,,79.52,Fee Schedule,,75.09,,,75.09,Fee Schedule,,182.5,50,,182.5,percent of total billed charges,All Other,48.46,,,48.46,Fee Schedule,,72.26,,,72.26,Fee Schedule,,22.11,,,22.11,Other,186% Medicaid methodology,85.11,,,85.11,Fee Schedule,,226.3,,,226.3,Fee Schedule,,48.17,,,48.17,Fee Schedule,,85.11,,,85.11,Fee Schedule,,226.3,,,226.3,Fee Schedule,,90.61,,,90.61,Fee Schedule,,255.5,70,,255.5,percent of total billed charges,All Other,109.38,,,109.38,Fee Schedule,,92.8,,,92.8,Fee Schedule,,27.53,,,27.53,Fee Schedule,,27.53,,,27.53,Fee Schedule,,27.53,,,27.53,Fee Schedule,,27.53,,,27.53,Fee Schedule,,11.89,,,11.89,Fee Schedule,Medicaid Laboratory Fee Schedule,11.89,,,11.89,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.89,,,11.89,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.89,,,11.89,Fee Schedule,100% Medicaid Laboratory Fee Schedule,26.75,,,26.75,Fee Schedule,225% Medicaid Laboratory Fee Schedule,26.75,,,26.75,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.19,,,18.19,Fee Schedule,153% Medicaid Laboratory Fee Schedule,26.75,,,26.75,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.64,,,16.64,Fee Schedule,140% Medicaid Laboratory Fee Schedule,26.75,,,26.75,Fee Schedule,225% Medicaid Laboratory Fee Schedule,30.91,,,30.91,Fee Schedule,260% Medicaid Laboratory Fee Schedule,38.52,,,38.52,Fee Schedule,324% Medicaid Laboratory Fee Schedule,25.56,,,25.56,Fee Schedule,215% Medicaid Laboratory Fee Schedule,25.56,,,25.56,Fee Schedule,215% Medicaid Laboratory Fee Schedule,14.86,,,14.86,Fee Schedule,125% Medicaid Laboratory Fee Schedule,11.89,255.5,
BLOOD PLATELET AGGREGATION EA   ,85576,CPT,,40143687,CDM,305,RC,,,both,,,397,40.96,,,40.96,Other,150% of Medicare + 9.63% HCRA Surcharge,24.91,,,24.91,Fee Schedule,Mediare Clinical Lab,48.08,,,48.08,Fee Schedule,,43.34,,,43.34,Fee Schedule,,217.05,,,217.05,Fee Schedule,,195.29,,,195.29,Fee Schedule,,184.4,,,184.4,Fee Schedule,,198.5,50,,198.5,percent of total billed charges,All Other,52.62,,,52.62,Fee Schedule,,78.47,,,78.47,Fee Schedule,,20.12,,,20.12,Other,186% Medicaid methodology,92.42,,,92.42,Fee Schedule,,246.14,,,246.14,Fee Schedule,,52.31,,,52.31,Fee Schedule,,92.42,,,92.42,Fee Schedule,,246.14,,,246.14,Fee Schedule,,98.39,,,98.39,Fee Schedule,,277.9,70,,277.9,percent of total billed charges,All Other,118.77,,,118.77,Fee Schedule,,100.77,,,100.77,Fee Schedule,,29.89,,,29.89,Fee Schedule,,29.89,,,29.89,Fee Schedule,,29.89,,,29.89,Fee Schedule,,29.89,,,29.89,Fee Schedule,,10.82,,,10.82,Fee Schedule,Medicaid Laboratory Fee Schedule,10.82,,,10.82,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.82,,,10.82,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.82,,,10.82,Fee Schedule,100% Medicaid Laboratory Fee Schedule,24.34,,,24.34,Fee Schedule,225% Medicaid Laboratory Fee Schedule,24.34,,,24.34,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.55,,,16.55,Fee Schedule,153% Medicaid Laboratory Fee Schedule,24.34,,,24.34,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.14,,,15.14,Fee Schedule,140% Medicaid Laboratory Fee Schedule,24.34,,,24.34,Fee Schedule,225% Medicaid Laboratory Fee Schedule,28.12,,,28.12,Fee Schedule,260% Medicaid Laboratory Fee Schedule,35.05,,,35.05,Fee Schedule,324% Medicaid Laboratory Fee Schedule,23.26,,,23.26,Fee Schedule,215% Medicaid Laboratory Fee Schedule,23.26,,,23.26,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.52,,,13.52,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.82,277.9,
COAGULATION TIME ACTIVATED      ,85347,CPT,,40143828,CDM,305,RC,,,both,,,81,7.04,,,7.04,Other,150% of Medicare + 9.63% HCRA Surcharge,4.28,,,4.28,Fee Schedule,Mediare Clinical Lab,8.26,,,8.26,Fee Schedule,,7.45,,,7.45,Fee Schedule,,43.01,,,43.01,Fee Schedule,,38.7,,,38.7,Fee Schedule,,36.54,,,36.54,Fee Schedule,,40.5,50,,40.5,percent of total billed charges,All Other,9.04,,,9.04,Fee Schedule,,13.48,,,13.48,Fee Schedule,,7.96,,,7.96,Other,186% Medicaid methodology,15.88,,,15.88,Fee Schedule,,50.22,,,50.22,Fee Schedule,,8.99,,,8.99,Fee Schedule,,15.88,,,15.88,Fee Schedule,,50.22,,,50.22,Fee Schedule,,16.91,,,16.91,Fee Schedule,,56.7,70,,56.7,percent of total billed charges,All Other,20.41,,,20.41,Fee Schedule,,17.31,,,17.31,Fee Schedule,,5.14,,,5.14,Fee Schedule,,5.14,,,5.14,Fee Schedule,,5.14,,,5.14,Fee Schedule,,5.14,,,5.14,Fee Schedule,,4.28,,,4.28,Fee Schedule,Medicaid Laboratory Fee Schedule,4.28,,,4.28,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.28,,,4.28,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.28,,,4.28,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.63,,,9.63,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.63,,,9.63,Fee Schedule,225% Medicaid Laboratory Fee Schedule,6.55,,,6.55,Fee Schedule,153% Medicaid Laboratory Fee Schedule,9.63,,,9.63,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.99,,,5.99,Fee Schedule,140% Medicaid Laboratory Fee Schedule,9.63,,,9.63,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.13,,,11.13,Fee Schedule,260% Medicaid Laboratory Fee Schedule,13.87,,,13.87,Fee Schedule,324% Medicaid Laboratory Fee Schedule,9.2,,,9.2,Fee Schedule,215% Medicaid Laboratory Fee Schedule,9.2,,,9.2,Fee Schedule,215% Medicaid Laboratory Fee Schedule,5.35,,,5.35,Fee Schedule,125% Medicaid Laboratory Fee Schedule,4.28,56.7,
CLOTTING FUNCT ACTIVITY         ,85397,CPT,,40143885,CDM,305,RC,,,both,,,491,50.75,,,50.75,Other,150% of Medicare + 9.63% HCRA Surcharge,30.86,,,30.86,Fee Schedule,Mediare Clinical Lab,59.56,,,59.56,Fee Schedule,,53.7,,,53.7,Fee Schedule,,88.39,,,88.39,Fee Schedule,,79.52,,,79.52,Fee Schedule,,75.09,,,75.09,Fee Schedule,,245.5,50,,245.5,percent of total billed charges,All Other,65.2,,,65.2,Fee Schedule,,97.21,,,97.21,Fee Schedule,,17.66,,,17.66,Other,186% Medicaid methodology,114.49,,,114.49,Fee Schedule,,304.42,,,304.42,Fee Schedule,,64.81,,,64.81,Fee Schedule,,114.49,,,114.49,Fee Schedule,,304.42,,,304.42,Fee Schedule,,121.9,,,121.9,Fee Schedule,,343.7,70,,343.7,percent of total billed charges,All Other,147.14,,,147.14,Fee Schedule,,124.84,,,124.84,Fee Schedule,,37.03,,,37.03,Fee Schedule,,37.03,,,37.03,Fee Schedule,,37.03,,,37.03,Fee Schedule,,37.03,,,37.03,Fee Schedule,,9.49,,,9.49,Fee Schedule,Medicaid Laboratory Fee Schedule,9.49,,,9.49,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.49,,,9.49,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.49,,,9.49,Fee Schedule,100% Medicaid Laboratory Fee Schedule,21.36,,,21.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.36,,,21.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.53,,,14.53,Fee Schedule,153% Medicaid Laboratory Fee Schedule,21.36,,,21.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.29,,,13.29,Fee Schedule,140% Medicaid Laboratory Fee Schedule,21.36,,,21.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,24.68,,,24.68,Fee Schedule,260% Medicaid Laboratory Fee Schedule,30.76,,,30.76,Fee Schedule,324% Medicaid Laboratory Fee Schedule,20.41,,,20.41,Fee Schedule,215% Medicaid Laboratory Fee Schedule,20.41,,,20.41,Fee Schedule,215% Medicaid Laboratory Fee Schedule,11.87,,,11.87,Fee Schedule,125% Medicaid Laboratory Fee Schedule,9.49,343.7,
AUTOMATED RBC COUNT             ,85041,CPT,,40144123,CDM,305,RC,,,both,,,48,4.97,,,4.97,Other,150% of Medicare + 9.63% HCRA Surcharge,3.02,,,3.02,Fee Schedule,Mediare Clinical Lab,5.83,,,5.83,Fee Schedule,,5.25,,,5.25,Fee Schedule,,30.44,,,30.44,Fee Schedule,,27.39,,,27.39,Fee Schedule,,25.86,,,25.86,Fee Schedule,,24,50,,24,percent of total billed charges,All Other,6.37,,,6.37,Fee Schedule,,9.51,,,9.51,Fee Schedule,,5.62,,,5.62,Other,186% Medicaid methodology,11.2,,,11.2,Fee Schedule,,29.76,,,29.76,Fee Schedule,,6.34,,,6.34,Fee Schedule,,11.2,,,11.2,Fee Schedule,,29.76,,,29.76,Fee Schedule,,11.93,,,11.93,Fee Schedule,,33.6,70,,33.6,percent of total billed charges,All Other,14.4,,,14.4,Fee Schedule,,12.22,,,12.22,Fee Schedule,,3.62,,,3.62,Fee Schedule,,3.62,,,3.62,Fee Schedule,,3.62,,,3.62,Fee Schedule,,3.62,,,3.62,Fee Schedule,,3.02,,,3.02,Fee Schedule,Medicaid Laboratory Fee Schedule,3.02,,,3.02,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.02,,,3.02,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.02,,,3.02,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.8,,,6.8,Fee Schedule,225% Medicaid Laboratory Fee Schedule,6.8,,,6.8,Fee Schedule,225% Medicaid Laboratory Fee Schedule,4.62,,,4.62,Fee Schedule,153% Medicaid Laboratory Fee Schedule,6.8,,,6.8,Fee Schedule,225% Medicaid Laboratory Fee Schedule,4.23,,,4.23,Fee Schedule,140% Medicaid Laboratory Fee Schedule,6.8,,,6.8,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.85,,,7.85,Fee Schedule,260% Medicaid Laboratory Fee Schedule,9.78,,,9.78,Fee Schedule,324% Medicaid Laboratory Fee Schedule,6.49,,,6.49,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.49,,,6.49,Fee Schedule,215% Medicaid Laboratory Fee Schedule,3.78,,,3.78,Fee Schedule,125% Medicaid Laboratory Fee Schedule,3.02,33.6,
PHOSPHOLIPID PLTLT NEUTRALIZ    ,85597,CPT,,40144149,CDM,305,RC,,,both,,,287,29.57,,,29.57,Other,150% of Medicare + 9.63% HCRA Surcharge,17.98,,,17.98,Fee Schedule,Mediare Clinical Lab,34.7,,,34.7,Fee Schedule,,31.29,,,31.29,Fee Schedule,,136.42,,,136.42,Fee Schedule,,122.74,,,122.74,Fee Schedule,,115.9,,,115.9,Fee Schedule,,143.5,50,,143.5,percent of total billed charges,All Other,37.99,,,37.99,Fee Schedule,,56.64,,,56.64,Fee Schedule,,71.2,,,71.2,Other,186% Medicaid methodology,66.71,,,66.71,Fee Schedule,,177.94,,,177.94,Fee Schedule,,37.76,,,37.76,Fee Schedule,,66.71,,,66.71,Fee Schedule,,177.94,,,177.94,Fee Schedule,,71.02,,,71.02,Fee Schedule,,200.9,70,,200.9,percent of total billed charges,All Other,85.73,,,85.73,Fee Schedule,,72.74,,,72.74,Fee Schedule,,21.58,,,21.58,Fee Schedule,,21.58,,,21.58,Fee Schedule,,21.58,,,21.58,Fee Schedule,,21.58,,,21.58,Fee Schedule,,38.28,,,38.28,Other,New York Medicaid APG methodology,38.28,,,38.28,Other,100% Medicaid APG methodology,38.28,,,38.28,Other,100% Medicaid APG methodology,38.28,,,38.28,Other,100% Medicaid APG methodology,86.13,,,86.13,Other,225% Medicaid APG methodology,86.13,,,86.13,Other,225% Medicaid APG methodology,58.57,,,58.57,Other,153% Medicaid APG methodology,86.13,,,86.13,Other,225% Medicaid APG methodology,53.59,,,53.59,Other,140% Medicaid APG methodology,86.13,,,86.13,Other,225% Medicaid APG methodology,99.52,,,99.52,Other,260% Medicaid APG methodology,124.02,,,124.02,Other,324% Medicaid APG methodology,82.3,,,82.3,Other,215% Medicaid APG methodology,82.3,,,82.3,Other,215% Medicaid APG methodology,47.85,,,47.85,Other,125% Medicaid APG methodology,17.98,200.9,
HEXAGNAL PHOSPH PLTLT NEUTRL    ,85598,CPT,,40144164,CDM,305,RC,,,both,,,287,29.57,,,29.57,Other,150% of Medicare + 9.63% HCRA Surcharge,17.98,,,17.98,Fee Schedule,Mediare Clinical Lab,34.7,,,34.7,Fee Schedule,,31.29,,,31.29,Fee Schedule,,136.42,,,136.42,Fee Schedule,,122.74,,,122.74,Fee Schedule,,115.9,,,115.9,Fee Schedule,,143.5,50,,143.5,percent of total billed charges,All Other,37.99,,,37.99,Fee Schedule,,56.64,,,56.64,Fee Schedule,,71.2,,,71.2,Other,186% Medicaid methodology,66.71,,,66.71,Fee Schedule,,177.94,,,177.94,Fee Schedule,,37.76,,,37.76,Fee Schedule,,66.71,,,66.71,Fee Schedule,,177.94,,,177.94,Fee Schedule,,71.02,,,71.02,Fee Schedule,,200.9,70,,200.9,percent of total billed charges,All Other,85.73,,,85.73,Fee Schedule,,72.74,,,72.74,Fee Schedule,,21.58,,,21.58,Fee Schedule,,21.58,,,21.58,Fee Schedule,,21.58,,,21.58,Fee Schedule,,21.58,,,21.58,Fee Schedule,,38.28,,,38.28,Other,New York Medicaid APG methodology,38.28,,,38.28,Other,100% Medicaid APG methodology,38.28,,,38.28,Other,100% Medicaid APG methodology,38.28,,,38.28,Other,100% Medicaid APG methodology,86.13,,,86.13,Other,225% Medicaid APG methodology,86.13,,,86.13,Other,225% Medicaid APG methodology,58.57,,,58.57,Other,153% Medicaid APG methodology,86.13,,,86.13,Other,225% Medicaid APG methodology,53.59,,,53.59,Other,140% Medicaid APG methodology,86.13,,,86.13,Other,225% Medicaid APG methodology,99.52,,,99.52,Other,260% Medicaid APG methodology,124.02,,,124.02,Other,324% Medicaid APG methodology,82.3,,,82.3,Other,215% Medicaid APG methodology,82.3,,,82.3,Other,215% Medicaid APG methodology,47.85,,,47.85,Other,125% Medicaid APG methodology,17.98,200.9,
CLOT INHIBIT PROT C ANTIGEN     ,85302,CPT,,40144180,CDM,305,RC,,,both,,,191,19.75,,,19.75,Other,150% of Medicare + 9.63% HCRA Surcharge,12.01,,,12.01,Fee Schedule,Mediare Clinical Lab,23.18,,,23.18,Fee Schedule,,20.9,,,20.9,Fee Schedule,,121.49,,,121.49,Fee Schedule,,109.3,,,109.3,Fee Schedule,,103.21,,,103.21,Fee Schedule,,95.5,50,,95.5,percent of total billed charges,All Other,25.38,,,25.38,Fee Schedule,,37.83,,,37.83,Fee Schedule,,22.34,,,22.34,Other,186% Medicaid methodology,44.56,,,44.56,Fee Schedule,,118.42,,,118.42,Fee Schedule,,25.22,,,25.22,Fee Schedule,,44.56,,,44.56,Fee Schedule,,118.42,,,118.42,Fee Schedule,,47.44,,,47.44,Fee Schedule,,133.7,70,,133.7,percent of total billed charges,All Other,57.26,,,57.26,Fee Schedule,,48.59,,,48.59,Fee Schedule,,14.41,,,14.41,Fee Schedule,,14.41,,,14.41,Fee Schedule,,14.41,,,14.41,Fee Schedule,,14.41,,,14.41,Fee Schedule,,12.01,,,12.01,Fee Schedule,Medicaid Laboratory Fee Schedule,12.01,,,12.01,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.01,,,12.01,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.01,,,12.01,Fee Schedule,100% Medicaid Laboratory Fee Schedule,27.02,,,27.02,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.02,,,27.02,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.38,,,18.38,Fee Schedule,153% Medicaid Laboratory Fee Schedule,27.02,,,27.02,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.81,,,16.81,Fee Schedule,140% Medicaid Laboratory Fee Schedule,27.02,,,27.02,Fee Schedule,225% Medicaid Laboratory Fee Schedule,31.23,,,31.23,Fee Schedule,260% Medicaid Laboratory Fee Schedule,38.91,,,38.91,Fee Schedule,324% Medicaid Laboratory Fee Schedule,25.82,,,25.82,Fee Schedule,215% Medicaid Laboratory Fee Schedule,25.82,,,25.82,Fee Schedule,215% Medicaid Laboratory Fee Schedule,15.01,,,15.01,Fee Schedule,125% Medicaid Laboratory Fee Schedule,12.01,133.7,
CLOT INHIBIT PROT S TOTAL       ,85305,CPT,,40144347,CDM,305,RC,,,both,,,185,19.09,,,19.09,Other,150% of Medicare + 9.63% HCRA Surcharge,11.61,,,11.61,Fee Schedule,Mediare Clinical Lab,22.41,,,22.41,Fee Schedule,,20.2,,,20.2,Fee Schedule,,117.18,,,117.18,Fee Schedule,,105.43,,,105.43,Fee Schedule,,99.55,,,99.55,Fee Schedule,,92.5,50,,92.5,percent of total billed charges,All Other,24.54,,,24.54,Fee Schedule,,36.57,,,36.57,Fee Schedule,,21.59,,,21.59,Other,186% Medicaid methodology,43.07,,,43.07,Fee Schedule,,114.7,,,114.7,Fee Schedule,,24.38,,,24.38,Fee Schedule,,43.07,,,43.07,Fee Schedule,,114.7,,,114.7,Fee Schedule,,45.86,,,45.86,Fee Schedule,,129.5,70,,129.5,percent of total billed charges,All Other,55.36,,,55.36,Fee Schedule,,46.97,,,46.97,Fee Schedule,,13.93,,,13.93,Fee Schedule,,13.93,,,13.93,Fee Schedule,,13.93,,,13.93,Fee Schedule,,13.93,,,13.93,Fee Schedule,,11.61,,,11.61,Fee Schedule,Medicaid Laboratory Fee Schedule,11.61,,,11.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.61,,,11.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.61,,,11.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,26.12,,,26.12,Fee Schedule,225% Medicaid Laboratory Fee Schedule,26.12,,,26.12,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.76,,,17.76,Fee Schedule,153% Medicaid Laboratory Fee Schedule,26.12,,,26.12,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.25,,,16.25,Fee Schedule,140% Medicaid Laboratory Fee Schedule,26.12,,,26.12,Fee Schedule,225% Medicaid Laboratory Fee Schedule,30.19,,,30.19,Fee Schedule,260% Medicaid Laboratory Fee Schedule,37.62,,,37.62,Fee Schedule,324% Medicaid Laboratory Fee Schedule,24.96,,,24.96,Fee Schedule,215% Medicaid Laboratory Fee Schedule,24.96,,,24.96,Fee Schedule,215% Medicaid Laboratory Fee Schedule,14.51,,,14.51,Fee Schedule,125% Medicaid Laboratory Fee Schedule,11.61,129.5,
PROTHROMBIN TEST                ,85611,CPT,,40144354,CDM,305,RC,,,both,,,63,6.48,,,6.48,Other,150% of Medicare + 9.63% HCRA Surcharge,3.94,,,3.94,Fee Schedule,Mediare Clinical Lab,7.6,,,7.6,Fee Schedule,,6.86,,,6.86,Fee Schedule,,39.78,,,39.78,Fee Schedule,,35.79,,,35.79,Fee Schedule,,33.79,,,33.79,Fee Schedule,,31.5,50,,31.5,percent of total billed charges,All Other,8.32,,,8.32,Fee Schedule,,12.41,,,12.41,Fee Schedule,,71.2,,,71.2,Other,186% Medicaid methodology,14.62,,,14.62,Fee Schedule,,39.06,,,39.06,Fee Schedule,,8.27,,,8.27,Fee Schedule,,14.62,,,14.62,Fee Schedule,,39.06,,,39.06,Fee Schedule,,15.56,,,15.56,Fee Schedule,,44.1,70,,44.1,percent of total billed charges,All Other,18.79,,,18.79,Fee Schedule,,15.94,,,15.94,Fee Schedule,,4.73,,,4.73,Fee Schedule,,4.73,,,4.73,Fee Schedule,,4.73,,,4.73,Fee Schedule,,4.73,,,4.73,Fee Schedule,,38.28,,,38.28,Other,New York Medicaid APG methodology,38.28,,,38.28,Other,100% Medicaid APG methodology,38.28,,,38.28,Other,100% Medicaid APG methodology,38.28,,,38.28,Other,100% Medicaid APG methodology,86.13,,,86.13,Other,225% Medicaid APG methodology,86.13,,,86.13,Other,225% Medicaid APG methodology,58.57,,,58.57,Other,153% Medicaid APG methodology,86.13,,,86.13,Other,225% Medicaid APG methodology,53.59,,,53.59,Other,140% Medicaid APG methodology,86.13,,,86.13,Other,225% Medicaid APG methodology,99.52,,,99.52,Other,260% Medicaid APG methodology,124.02,,,124.02,Other,324% Medicaid APG methodology,82.3,,,82.3,Other,215% Medicaid APG methodology,82.3,,,82.3,Other,215% Medicaid APG methodology,47.85,,,47.85,Other,125% Medicaid APG methodology,3.94,124.02,
BLOOD SMEAR INTERPRETATION      ,85060,CPT,,40144370,CDM,305,RC,,,both,,,474,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,50.59,,,50.59,Fee Schedule,,45.61,,,45.61,Fee Schedule,,187.4,,,187.4,Fee Schedule,,168.61,,,168.61,Fee Schedule,,159.21,,,159.21,Fee Schedule,,237,50,,237,percent of total billed charges,All Other,52.33,,,52.33,Fee Schedule,,99.34,,,99.34,Fee Schedule,,37.99,,,37.99,Other,186% Medicaid methodology,116.9,,,116.9,Fee Schedule,,293.88,,,293.88,Fee Schedule,,55.04,,,55.04,Fee Schedule,,116.9,,,116.9,Fee Schedule,,293.88,,,293.88,Fee Schedule,,103.53,,,103.53,Fee Schedule,,331.8,70,,331.8,percent of total billed charges,All Other,117.15,,,117.15,Fee Schedule,,99.4,,,99.4,Fee Schedule,,30.31,,,30.31,Fee Schedule,,30.31,,,30.31,Fee Schedule,,30.31,,,30.31,Fee Schedule,,30.31,,,30.31,Fee Schedule,,20.42,,,20.42,Fee Schedule,Medicaid Laboratory Fee Schedule,20.42,,,20.42,Fee Schedule,100% Medicaid Laboratory Fee Schedule,20.42,,,20.42,Fee Schedule,100% Medicaid Laboratory Fee Schedule,20.42,,,20.42,Fee Schedule,100% Medicaid Laboratory Fee Schedule,45.95,,,45.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,45.95,,,45.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,31.25,,,31.25,Fee Schedule,153% Medicaid Laboratory Fee Schedule,45.95,,,45.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,28.59,,,28.59,Fee Schedule,140% Medicaid Laboratory Fee Schedule,45.95,,,45.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,53.1,,,53.1,Fee Schedule,260% Medicaid Laboratory Fee Schedule,66.17,,,66.17,Fee Schedule,324% Medicaid Laboratory Fee Schedule,43.91,,,43.91,Fee Schedule,215% Medicaid Laboratory Fee Schedule,43.91,,,43.91,Fee Schedule,215% Medicaid Laboratory Fee Schedule,25.53,,,25.53,Fee Schedule,125% Medicaid Laboratory Fee Schedule,0.01,331.8,
KLEIHAUER-BETKE TEST            ,85460,CPT,,40211906,CDM,305,RC,,,both,,,123,12.71,,,12.71,Other,150% of Medicare + 9.63% HCRA Surcharge,7.73,,,7.73,Fee Schedule,Mediare Clinical Lab,14.92,,,14.92,Fee Schedule,,13.45,,,13.45,Fee Schedule,,78.19,,,78.19,Fee Schedule,,70.35,,,70.35,Fee Schedule,,66.43,,,66.43,Fee Schedule,,61.5,50,,61.5,percent of total billed charges,All Other,16.32,,,16.32,Fee Schedule,,24.35,,,24.35,Fee Schedule,,14.38,,,14.38,Other,186% Medicaid methodology,28.68,,,28.68,Fee Schedule,,76.26,,,76.26,Fee Schedule,,16.23,,,16.23,Fee Schedule,,28.68,,,28.68,Fee Schedule,,76.26,,,76.26,Fee Schedule,,30.53,,,30.53,Fee Schedule,,86.1,70,,86.1,percent of total billed charges,All Other,36.86,,,36.86,Fee Schedule,,31.27,,,31.27,Fee Schedule,,9.28,,,9.28,Fee Schedule,,9.28,,,9.28,Fee Schedule,,9.28,,,9.28,Fee Schedule,,9.28,,,9.28,Fee Schedule,,7.73,,,7.73,Fee Schedule,Medicaid Laboratory Fee Schedule,7.73,,,7.73,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.73,,,7.73,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.73,,,7.73,Fee Schedule,100% Medicaid Laboratory Fee Schedule,17.39,,,17.39,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.39,,,17.39,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.83,,,11.83,Fee Schedule,153% Medicaid Laboratory Fee Schedule,17.39,,,17.39,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.82,,,10.82,Fee Schedule,140% Medicaid Laboratory Fee Schedule,17.39,,,17.39,Fee Schedule,225% Medicaid Laboratory Fee Schedule,20.1,,,20.1,Fee Schedule,260% Medicaid Laboratory Fee Schedule,25.05,,,25.05,Fee Schedule,324% Medicaid Laboratory Fee Schedule,16.62,,,16.62,Fee Schedule,215% Medicaid Laboratory Fee Schedule,16.62,,,16.62,Fee Schedule,215% Medicaid Laboratory Fee Schedule,9.66,,,9.66,Fee Schedule,125% Medicaid Laboratory Fee Schedule,7.73,86.1,
HEMOGLOBIN FETAL                ,85461,CPT,,40211914,CDM,305,RC,,,both,,,149,15.39,,,15.39,Other,150% of Medicare + 9.63% HCRA Surcharge,9.36,,,9.36,Fee Schedule,Mediare Clinical Lab,18.06,,,18.06,Fee Schedule,,16.29,,,16.29,Fee Schedule,,67.06,,,67.06,Fee Schedule,,60.34,,,60.34,Fee Schedule,,56.97,,,56.97,Fee Schedule,,74.5,50,,74.5,percent of total billed charges,All Other,19.76,,,19.76,Fee Schedule,,29.48,,,29.48,Fee Schedule,,17.41,,,17.41,Other,186% Medicaid methodology,34.73,,,34.73,Fee Schedule,,92.38,,,92.38,Fee Schedule,,19.66,,,19.66,Fee Schedule,,34.73,,,34.73,Fee Schedule,,92.38,,,92.38,Fee Schedule,,36.97,,,36.97,Fee Schedule,,104.3,70,,104.3,percent of total billed charges,All Other,44.63,,,44.63,Fee Schedule,,37.87,,,37.87,Fee Schedule,,11.23,,,11.23,Fee Schedule,,11.23,,,11.23,Fee Schedule,,11.23,,,11.23,Fee Schedule,,11.23,,,11.23,Fee Schedule,,9.36,,,9.36,Fee Schedule,Medicaid Laboratory Fee Schedule,9.36,,,9.36,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.36,,,9.36,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.36,,,9.36,Fee Schedule,100% Medicaid Laboratory Fee Schedule,21.06,,,21.06,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.06,,,21.06,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.32,,,14.32,Fee Schedule,153% Medicaid Laboratory Fee Schedule,21.06,,,21.06,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.1,,,13.1,Fee Schedule,140% Medicaid Laboratory Fee Schedule,21.06,,,21.06,Fee Schedule,225% Medicaid Laboratory Fee Schedule,24.34,,,24.34,Fee Schedule,260% Medicaid Laboratory Fee Schedule,30.33,,,30.33,Fee Schedule,324% Medicaid Laboratory Fee Schedule,20.12,,,20.12,Fee Schedule,215% Medicaid Laboratory Fee Schedule,20.12,,,20.12,Fee Schedule,215% Medicaid Laboratory Fee Schedule,11.7,,,11.7,Fee Schedule,125% Medicaid Laboratory Fee Schedule,9.36,104.3,
SARS-COV-2 COVID-19 AMP PRB     ,87635,CPT,,40100687,CDM,306,RC,,,both,,,159,84.38,,,84.38,Other,150% of Medicare + 9.63% HCRA Surcharge,51.31,,,51.31,Fee Schedule,Mediare Clinical Lab,99.03,,,99.03,Fee Schedule,,89.28,,,89.28,Fee Schedule,,61.57,,,61.57,Fee Schedule,,61.57,,,61.57,Fee Schedule,,61.57,,,61.57,Fee Schedule,,79.5,50,,79.5,percent of total billed charges,All Other,51.31,,,51.31,Fee Schedule,,161.63,,,161.63,Fee Schedule,,57.27,,,57.27,Other,186% Medicaid methodology,190.36,,,190.36,Fee Schedule,,98.58,,,98.58,Fee Schedule,,107.75,,,107.75,Fee Schedule,,190.36,,,190.36,Fee Schedule,,98.58,,,98.58,Fee Schedule,,202.67,,,202.67,Fee Schedule,,111.3,70,,111.3,percent of total billed charges,All Other,244.64,,,244.64,Fee Schedule,,207.58,,,207.58,Fee Schedule,,61.57,,,61.57,Fee Schedule,,61.57,,,61.57,Fee Schedule,,61.57,,,61.57,Fee Schedule,,61.57,,,61.57,Fee Schedule,,30.79,,,30.79,Fee Schedule,Medicaid Laboratory Fee Schedule,30.79,,,30.79,Fee Schedule,100% Medicaid Laboratory Fee Schedule,30.79,,,30.79,Fee Schedule,100% Medicaid Laboratory Fee Schedule,30.79,,,30.79,Fee Schedule,100% Medicaid Laboratory Fee Schedule,69.28,,,69.28,Fee Schedule,225% Medicaid Laboratory Fee Schedule,69.28,,,69.28,Fee Schedule,225% Medicaid Laboratory Fee Schedule,47.11,,,47.11,Fee Schedule,153% Medicaid Laboratory Fee Schedule,69.28,,,69.28,Fee Schedule,225% Medicaid Laboratory Fee Schedule,43.11,,,43.11,Fee Schedule,140% Medicaid Laboratory Fee Schedule,69.28,,,69.28,Fee Schedule,225% Medicaid Laboratory Fee Schedule,80.05,,,80.05,Fee Schedule,260% Medicaid Laboratory Fee Schedule,99.76,,,99.76,Fee Schedule,324% Medicaid Laboratory Fee Schedule,66.2,,,66.2,Fee Schedule,215% Medicaid Laboratory Fee Schedule,66.2,,,66.2,Fee Schedule,215% Medicaid Laboratory Fee Schedule,38.49,,,38.49,Fee Schedule,125% Medicaid Laboratory Fee Schedule,30.79,244.64,
LYME DIS DNA AMP PROBE          ,87476,CPT,,40111601,CDM,306,RC,,,both,,,558,57.7,,,57.7,Other,150% of Medicare + 9.63% HCRA Surcharge,35.09,,,35.09,Fee Schedule,Mediare Clinical Lab,67.72,,,67.72,Fee Schedule,,61.06,,,61.06,Fee Schedule,,354.62,,,354.62,Fee Schedule,,319.06,,,319.06,Fee Schedule,,301.28,,,301.28,Fee Schedule,,279,50,,279,percent of total billed charges,All Other,74.13,,,74.13,Fee Schedule,,110.53,,,110.53,Fee Schedule,,40.26,,,40.26,Other,186% Medicaid methodology,130.18,,,130.18,Fee Schedule,,345.96,,,345.96,Fee Schedule,,73.69,,,73.69,Fee Schedule,,130.18,,,130.18,Fee Schedule,,345.96,,,345.96,Fee Schedule,,138.61,,,138.61,Fee Schedule,,390.6,70,,390.6,percent of total billed charges,All Other,167.31,,,167.31,Fee Schedule,,141.96,,,141.96,Fee Schedule,,42.11,,,42.11,Fee Schedule,,42.11,,,42.11,Fee Schedule,,42.11,,,42.11,Fee Schedule,,42.11,,,42.11,Fee Schedule,,21.64,,,21.64,Fee Schedule,Medicaid Laboratory Fee Schedule,21.64,,,21.64,Fee Schedule,100% Medicaid Laboratory Fee Schedule,21.64,,,21.64,Fee Schedule,100% Medicaid Laboratory Fee Schedule,21.64,,,21.64,Fee Schedule,100% Medicaid Laboratory Fee Schedule,48.7,,,48.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,48.7,,,48.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,33.12,,,33.12,Fee Schedule,153% Medicaid Laboratory Fee Schedule,48.7,,,48.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,30.3,,,30.3,Fee Schedule,140% Medicaid Laboratory Fee Schedule,48.7,,,48.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,56.28,,,56.28,Fee Schedule,260% Medicaid Laboratory Fee Schedule,70.13,,,70.13,Fee Schedule,324% Medicaid Laboratory Fee Schedule,46.54,,,46.54,Fee Schedule,215% Medicaid Laboratory Fee Schedule,46.54,,,46.54,Fee Schedule,215% Medicaid Laboratory Fee Schedule,27.06,,,27.06,Fee Schedule,125% Medicaid Laboratory Fee Schedule,21.64,390.6,
HPYLORI STOOL AG IA             ,87338,CPT,,40112286,CDM,306,RC,,,both,,,229,23.65,,,23.65,Other,150% of Medicare + 9.63% HCRA Surcharge,14.38,,,14.38,Fee Schedule,Mediare Clinical Lab,27.75,,,27.75,Fee Schedule,,25.02,,,25.02,Fee Schedule,,145.32,,,145.32,Fee Schedule,,130.75,,,130.75,Fee Schedule,,123.46,,,123.46,Fee Schedule,,114.5,50,,114.5,percent of total billed charges,All Other,30.39,,,30.39,Fee Schedule,,45.3,,,45.3,Fee Schedule,,15.09,,,15.09,Other,186% Medicaid methodology,53.35,,,53.35,Fee Schedule,,141.98,,,141.98,Fee Schedule,,30.2,,,30.2,Fee Schedule,,53.35,,,53.35,Fee Schedule,,141.98,,,141.98,Fee Schedule,,56.8,,,56.8,Fee Schedule,,160.3,70,,160.3,percent of total billed charges,All Other,68.56,,,68.56,Fee Schedule,,58.17,,,58.17,Fee Schedule,,17.26,,,17.26,Fee Schedule,,17.26,,,17.26,Fee Schedule,,17.26,,,17.26,Fee Schedule,,17.26,,,17.26,Fee Schedule,,8.11,,,8.11,Fee Schedule,Medicaid Laboratory Fee Schedule,8.11,,,8.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.11,,,8.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.11,,,8.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.41,,,12.41,Fee Schedule,153% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.35,,,11.35,Fee Schedule,140% Medicaid Laboratory Fee Schedule,18.25,,,18.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.09,,,21.09,Fee Schedule,260% Medicaid Laboratory Fee Schedule,26.28,,,26.28,Fee Schedule,324% Medicaid Laboratory Fee Schedule,17.44,,,17.44,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.44,,,17.44,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.14,,,10.14,Fee Schedule,125% Medicaid Laboratory Fee Schedule,8.11,160.3,
HIV-1 QUANT&REVRSE TRNSCRPJ     ,87536,CPT,,40123721,CDM,306,RC,,,both,,,1354,139.94,,,139.94,Other,150% of Medicare + 9.63% HCRA Surcharge,85.1,,,85.1,Fee Schedule,Mediare Clinical Lab,164.24,,,164.24,Fee Schedule,,148.07,,,148.07,Fee Schedule,,859.81,,,859.81,Fee Schedule,,773.59,,,773.59,Fee Schedule,,730.48,,,730.48,Fee Schedule,,677,50,,677,percent of total billed charges,All Other,179.79,,,179.79,Fee Schedule,,268.07,,,268.07,Fee Schedule,,158.29,,,158.29,Other,186% Medicaid methodology,315.72,,,315.72,Fee Schedule,,839.48,,,839.48,Fee Schedule,,178.71,,,178.71,Fee Schedule,,315.72,,,315.72,Fee Schedule,,839.48,,,839.48,Fee Schedule,,336.15,,,336.15,Fee Schedule,,947.8,70,,947.8,percent of total billed charges,All Other,405.75,,,405.75,Fee Schedule,,344.27,,,344.27,Fee Schedule,,102.12,,,102.12,Fee Schedule,,102.12,,,102.12,Fee Schedule,,102.12,,,102.12,Fee Schedule,,102.12,,,102.12,Fee Schedule,,85.1,,,85.1,Fee Schedule,Medicaid Laboratory Fee Schedule,85.1,,,85.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,85.1,,,85.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,85.1,,,85.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,191.48,,,191.48,Fee Schedule,225% Medicaid Laboratory Fee Schedule,191.48,,,191.48,Fee Schedule,225% Medicaid Laboratory Fee Schedule,130.2,,,130.2,Fee Schedule,153% Medicaid Laboratory Fee Schedule,191.48,,,191.48,Fee Schedule,225% Medicaid Laboratory Fee Schedule,119.14,,,119.14,Fee Schedule,140% Medicaid Laboratory Fee Schedule,191.48,,,191.48,Fee Schedule,225% Medicaid Laboratory Fee Schedule,221.26,,,221.26,Fee Schedule,260% Medicaid Laboratory Fee Schedule,275.72,,,275.72,Fee Schedule,324% Medicaid Laboratory Fee Schedule,182.97,,,182.97,Fee Schedule,215% Medicaid Laboratory Fee Schedule,182.97,,,182.97,Fee Schedule,215% Medicaid Laboratory Fee Schedule,106.38,,,106.38,Fee Schedule,125% Medicaid Laboratory Fee Schedule,85.1,947.8,
URINE CULTURE/COLONY COUNT      ,87086,CPT,,40130049,CDM,306,RC,,,both,,,129,13.27,,,13.27,Other,150% of Medicare + 9.63% HCRA Surcharge,8.07,,,8.07,Fee Schedule,Mediare Clinical Lab,15.58,,,15.58,Fee Schedule,,14.04,,,14.04,Fee Schedule,,81.56,,,81.56,Fee Schedule,,73.39,,,73.39,Fee Schedule,,69.3,,,69.3,Fee Schedule,,64.5,50,,64.5,percent of total billed charges,All Other,17.06,,,17.06,Fee Schedule,,25.42,,,25.42,Fee Schedule,,15.01,,,15.01,Other,186% Medicaid methodology,29.94,,,29.94,Fee Schedule,,79.98,,,79.98,Fee Schedule,,16.95,,,16.95,Fee Schedule,,29.94,,,29.94,Fee Schedule,,79.98,,,79.98,Fee Schedule,,31.88,,,31.88,Fee Schedule,,90.3,70,,90.3,percent of total billed charges,All Other,38.48,,,38.48,Fee Schedule,,32.65,,,32.65,Fee Schedule,,9.68,,,9.68,Fee Schedule,,9.68,,,9.68,Fee Schedule,,9.68,,,9.68,Fee Schedule,,9.68,,,9.68,Fee Schedule,,8.07,,,8.07,Fee Schedule,Medicaid Laboratory Fee Schedule,8.07,,,8.07,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.07,,,8.07,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.07,,,8.07,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.16,,,18.16,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.16,,,18.16,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.35,,,12.35,Fee Schedule,153% Medicaid Laboratory Fee Schedule,18.16,,,18.16,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.3,,,11.3,Fee Schedule,140% Medicaid Laboratory Fee Schedule,18.16,,,18.16,Fee Schedule,225% Medicaid Laboratory Fee Schedule,20.98,,,20.98,Fee Schedule,260% Medicaid Laboratory Fee Schedule,26.15,,,26.15,Fee Schedule,324% Medicaid Laboratory Fee Schedule,17.35,,,17.35,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.35,,,17.35,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.09,,,10.09,Fee Schedule,125% Medicaid Laboratory Fee Schedule,8.07,90.3,
BLOOD CULTURE FOR BACTERIA      ,87040,CPT,,40160046,CDM,306,RC,,,both,,,165,16.97,,,16.97,Other,150% of Medicare + 9.63% HCRA Surcharge,10.32,,,10.32,Fee Schedule,Mediare Clinical Lab,19.92,,,19.92,Fee Schedule,,17.96,,,17.96,Fee Schedule,,88.39,,,88.39,Fee Schedule,,79.52,,,79.52,Fee Schedule,,75.09,,,75.09,Fee Schedule,,82.5,50,,82.5,percent of total billed charges,All Other,21.81,,,21.81,Fee Schedule,,32.51,,,32.51,Fee Schedule,,15.31,,,15.31,Other,186% Medicaid methodology,38.29,,,38.29,Fee Schedule,,102.3,,,102.3,Fee Schedule,,21.67,,,21.67,Fee Schedule,,38.29,,,38.29,Fee Schedule,,102.3,,,102.3,Fee Schedule,,40.76,,,40.76,Fee Schedule,,115.5,70,,115.5,percent of total billed charges,All Other,49.21,,,49.21,Fee Schedule,,41.75,,,41.75,Fee Schedule,,12.38,,,12.38,Fee Schedule,,12.38,,,12.38,Fee Schedule,,12.38,,,12.38,Fee Schedule,,12.38,,,12.38,Fee Schedule,,8.23,,,8.23,Fee Schedule,Medicaid Laboratory Fee Schedule,8.23,,,8.23,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.23,,,8.23,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.23,,,8.23,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.52,,,18.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.52,,,18.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.59,,,12.59,Fee Schedule,153% Medicaid Laboratory Fee Schedule,18.52,,,18.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.52,,,11.52,Fee Schedule,140% Medicaid Laboratory Fee Schedule,18.52,,,18.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.4,,,21.4,Fee Schedule,260% Medicaid Laboratory Fee Schedule,26.67,,,26.67,Fee Schedule,324% Medicaid Laboratory Fee Schedule,17.7,,,17.7,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.7,,,17.7,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.29,,,10.29,Fee Schedule,125% Medicaid Laboratory Fee Schedule,8.23,115.5,
FUNGUS ISOLATION CULTURE        ,87102,CPT,,40160228,CDM,306,RC,,,both,,,134,13.83,,,13.83,Other,150% of Medicare + 9.63% HCRA Surcharge,8.41,,,8.41,Fee Schedule,Mediare Clinical Lab,16.23,,,16.23,Fee Schedule,,14.63,,,14.63,Fee Schedule,,84.94,,,84.94,Fee Schedule,,76.42,,,76.42,Fee Schedule,,72.16,,,72.16,Fee Schedule,,67,50,,67,percent of total billed charges,All Other,17.78,,,17.78,Fee Schedule,,26.49,,,26.49,Fee Schedule,,15.64,,,15.64,Other,186% Medicaid methodology,31.2,,,31.2,Fee Schedule,,83.08,,,83.08,Fee Schedule,,17.66,,,17.66,Fee Schedule,,31.2,,,31.2,Fee Schedule,,83.08,,,83.08,Fee Schedule,,33.22,,,33.22,Fee Schedule,,93.8,70,,93.8,percent of total billed charges,All Other,40.1,,,40.1,Fee Schedule,,34.02,,,34.02,Fee Schedule,,10.09,,,10.09,Fee Schedule,,10.09,,,10.09,Fee Schedule,,10.09,,,10.09,Fee Schedule,,10.09,,,10.09,Fee Schedule,,8.41,,,8.41,Fee Schedule,Medicaid Laboratory Fee Schedule,8.41,,,8.41,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.41,,,8.41,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.41,,,8.41,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.92,,,18.92,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.92,,,18.92,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.87,,,12.87,Fee Schedule,153% Medicaid Laboratory Fee Schedule,18.92,,,18.92,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.77,,,11.77,Fee Schedule,140% Medicaid Laboratory Fee Schedule,18.92,,,18.92,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.87,,,21.87,Fee Schedule,260% Medicaid Laboratory Fee Schedule,27.25,,,27.25,Fee Schedule,324% Medicaid Laboratory Fee Schedule,18.08,,,18.08,Fee Schedule,215% Medicaid Laboratory Fee Schedule,18.08,,,18.08,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.51,,,10.51,Fee Schedule,125% Medicaid Laboratory Fee Schedule,8.41,93.8,
SMEAR GRAM STAIN                ,87205,CPT,,40160285,CDM,306,RC,,,both,,,68,7.02,,,7.02,Other,150% of Medicare + 9.63% HCRA Surcharge,4.27,,,4.27,Fee Schedule,Mediare Clinical Lab,8.24,,,8.24,Fee Schedule,,7.43,,,7.43,Fee Schedule,,43.15,,,43.15,Fee Schedule,,38.82,,,38.82,Fee Schedule,,36.66,,,36.66,Fee Schedule,,34,50,,34,percent of total billed charges,All Other,9.04,,,9.04,Fee Schedule,,13.45,,,13.45,Fee Schedule,,6.39,,,6.39,Other,186% Medicaid methodology,15.84,,,15.84,Fee Schedule,,42.16,,,42.16,Fee Schedule,,8.97,,,8.97,Fee Schedule,,15.84,,,15.84,Fee Schedule,,42.16,,,42.16,Fee Schedule,,16.87,,,16.87,Fee Schedule,,47.6,70,,47.6,percent of total billed charges,All Other,20.36,,,20.36,Fee Schedule,,17.27,,,17.27,Fee Schedule,,5.12,,,5.12,Fee Schedule,,5.12,,,5.12,Fee Schedule,,5.12,,,5.12,Fee Schedule,,5.12,,,5.12,Fee Schedule,,3.43,,,3.43,Fee Schedule,Medicaid Laboratory Fee Schedule,3.43,,,3.43,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.43,,,3.43,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.43,,,3.43,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.73,,,7.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.73,,,7.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,153% Medicaid Laboratory Fee Schedule,7.73,,,7.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,4.81,,,4.81,Fee Schedule,140% Medicaid Laboratory Fee Schedule,7.73,,,7.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.93,,,8.93,Fee Schedule,260% Medicaid Laboratory Fee Schedule,11.13,,,11.13,Fee Schedule,324% Medicaid Laboratory Fee Schedule,7.38,,,7.38,Fee Schedule,215% Medicaid Laboratory Fee Schedule,7.38,,,7.38,Fee Schedule,215% Medicaid Laboratory Fee Schedule,4.29,,,4.29,Fee Schedule,125% Medicaid Laboratory Fee Schedule,3.43,47.6,
VIRUS INOCULATION TISSUE        ,87252,CPT,,40160384,CDM,306,RC,,,both,,,415,42.87,,,42.87,Other,150% of Medicare + 9.63% HCRA Surcharge,26.07,,,26.07,Fee Schedule,Mediare Clinical Lab,50.32,,,50.32,Fee Schedule,,45.36,,,45.36,Fee Schedule,,263.36,,,263.36,Fee Schedule,,236.95,,,236.95,Fee Schedule,,223.75,,,223.75,Fee Schedule,,207.5,50,,207.5,percent of total billed charges,All Other,55.09,,,55.09,Fee Schedule,,82.12,,,82.12,Fee Schedule,,48.49,,,48.49,Other,186% Medicaid methodology,96.72,,,96.72,Fee Schedule,,257.3,,,257.3,Fee Schedule,,54.75,,,54.75,Fee Schedule,,96.72,,,96.72,Fee Schedule,,257.3,,,257.3,Fee Schedule,,102.98,,,102.98,Fee Schedule,,290.5,70,,290.5,percent of total billed charges,All Other,124.3,,,124.3,Fee Schedule,,105.47,,,105.47,Fee Schedule,,31.28,,,31.28,Fee Schedule,,31.28,,,31.28,Fee Schedule,,31.28,,,31.28,Fee Schedule,,31.28,,,31.28,Fee Schedule,,26.07,,,26.07,Fee Schedule,Medicaid Laboratory Fee Schedule,26.07,,,26.07,Fee Schedule,100% Medicaid Laboratory Fee Schedule,26.07,,,26.07,Fee Schedule,100% Medicaid Laboratory Fee Schedule,26.07,,,26.07,Fee Schedule,100% Medicaid Laboratory Fee Schedule,58.66,,,58.66,Fee Schedule,225% Medicaid Laboratory Fee Schedule,58.66,,,58.66,Fee Schedule,225% Medicaid Laboratory Fee Schedule,39.89,,,39.89,Fee Schedule,153% Medicaid Laboratory Fee Schedule,58.66,,,58.66,Fee Schedule,225% Medicaid Laboratory Fee Schedule,36.5,,,36.5,Fee Schedule,140% Medicaid Laboratory Fee Schedule,58.66,,,58.66,Fee Schedule,225% Medicaid Laboratory Fee Schedule,67.78,,,67.78,Fee Schedule,260% Medicaid Laboratory Fee Schedule,84.47,,,84.47,Fee Schedule,324% Medicaid Laboratory Fee Schedule,56.05,,,56.05,Fee Schedule,215% Medicaid Laboratory Fee Schedule,56.05,,,56.05,Fee Schedule,215% Medicaid Laboratory Fee Schedule,32.59,,,32.59,Fee Schedule,125% Medicaid Laboratory Fee Schedule,26.07,290.5,
OVA AND PARASITES SMEARS        ,87177,CPT,,40160509,CDM,306,RC,,,both,,,143,14.64,,,14.64,Other,150% of Medicare + 9.63% HCRA Surcharge,8.9,,,8.9,Fee Schedule,Mediare Clinical Lab,17.18,,,17.18,Fee Schedule,,15.49,,,15.49,Fee Schedule,,89.89,,,89.89,Fee Schedule,,80.88,,,80.88,Fee Schedule,,76.37,,,76.37,Fee Schedule,,71.5,50,,71.5,percent of total billed charges,All Other,18.82,,,18.82,Fee Schedule,,28.04,,,28.04,Fee Schedule,,16.55,,,16.55,Other,186% Medicaid methodology,33.02,,,33.02,Fee Schedule,,88.66,,,88.66,Fee Schedule,,18.69,,,18.69,Fee Schedule,,33.02,,,33.02,Fee Schedule,,88.66,,,88.66,Fee Schedule,,35.16,,,35.16,Fee Schedule,,100.1,70,,100.1,percent of total billed charges,All Other,42.43,,,42.43,Fee Schedule,,36.01,,,36.01,Fee Schedule,,10.68,,,10.68,Fee Schedule,,10.68,,,10.68,Fee Schedule,,10.68,,,10.68,Fee Schedule,,10.68,,,10.68,Fee Schedule,,8.9,,,8.9,Fee Schedule,Medicaid Laboratory Fee Schedule,8.9,,,8.9,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.9,,,8.9,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.9,,,8.9,Fee Schedule,100% Medicaid Laboratory Fee Schedule,20.03,,,20.03,Fee Schedule,225% Medicaid Laboratory Fee Schedule,20.03,,,20.03,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.62,,,13.62,Fee Schedule,153% Medicaid Laboratory Fee Schedule,20.03,,,20.03,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.46,,,12.46,Fee Schedule,140% Medicaid Laboratory Fee Schedule,20.03,,,20.03,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.14,,,23.14,Fee Schedule,260% Medicaid Laboratory Fee Schedule,28.84,,,28.84,Fee Schedule,324% Medicaid Laboratory Fee Schedule,19.14,,,19.14,Fee Schedule,215% Medicaid Laboratory Fee Schedule,19.14,,,19.14,Fee Schedule,215% Medicaid Laboratory Fee Schedule,11.13,,,11.13,Fee Schedule,125% Medicaid Laboratory Fee Schedule,8.9,100.1,
MYCOBACTERIA CULTURE            ,87116,CPT,,40160988,CDM,306,RC,,,both,,,172,17.76,,,17.76,Other,150% of Medicare + 9.63% HCRA Surcharge,10.8,,,10.8,Fee Schedule,Mediare Clinical Lab,20.84,,,20.84,Fee Schedule,,18.79,,,18.79,Fee Schedule,,109.21,,,109.21,Fee Schedule,,98.26,,,98.26,Fee Schedule,,92.78,,,92.78,Fee Schedule,,86,50,,86,percent of total billed charges,All Other,22.82,,,22.82,Fee Schedule,,34.02,,,34.02,Fee Schedule,,15.31,,,15.31,Other,186% Medicaid methodology,40.07,,,40.07,Fee Schedule,,106.64,,,106.64,Fee Schedule,,22.68,,,22.68,Fee Schedule,,40.07,,,40.07,Fee Schedule,,106.64,,,106.64,Fee Schedule,,42.66,,,42.66,Fee Schedule,,120.4,70,,120.4,percent of total billed charges,All Other,51.49,,,51.49,Fee Schedule,,43.69,,,43.69,Fee Schedule,,12.96,,,12.96,Fee Schedule,,12.96,,,12.96,Fee Schedule,,12.96,,,12.96,Fee Schedule,,12.96,,,12.96,Fee Schedule,,8.23,,,8.23,Fee Schedule,Medicaid Laboratory Fee Schedule,8.23,,,8.23,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.23,,,8.23,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.23,,,8.23,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.52,,,18.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.52,,,18.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.59,,,12.59,Fee Schedule,153% Medicaid Laboratory Fee Schedule,18.52,,,18.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.52,,,11.52,Fee Schedule,140% Medicaid Laboratory Fee Schedule,18.52,,,18.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.4,,,21.4,Fee Schedule,260% Medicaid Laboratory Fee Schedule,26.67,,,26.67,Fee Schedule,324% Medicaid Laboratory Fee Schedule,17.7,,,17.7,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.7,,,17.7,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.29,,,10.29,Fee Schedule,125% Medicaid Laboratory Fee Schedule,8.23,120.4,
SMEAR FLUORESCENT/ACID STAI     ,87206,CPT,,40161028,CDM,306,RC,,,both,,,86,8.86,,,8.86,Other,150% of Medicare + 9.63% HCRA Surcharge,5.39,,,5.39,Fee Schedule,Mediare Clinical Lab,10.4,,,10.4,Fee Schedule,,9.38,,,9.38,Fee Schedule,,54.28,,,54.28,Fee Schedule,,48.84,,,48.84,Fee Schedule,,46.12,,,46.12,Fee Schedule,,43,50,,43,percent of total billed charges,All Other,11.38,,,11.38,Fee Schedule,,16.98,,,16.98,Fee Schedule,,10.03,,,10.03,Other,186% Medicaid methodology,20,,,20,Fee Schedule,,53.32,,,53.32,Fee Schedule,,11.32,,,11.32,Fee Schedule,,20,,,20,Fee Schedule,,53.32,,,53.32,Fee Schedule,,21.29,,,21.29,Fee Schedule,,60.2,70,,60.2,percent of total billed charges,All Other,25.7,,,25.7,Fee Schedule,,21.81,,,21.81,Fee Schedule,,6.47,,,6.47,Fee Schedule,,6.47,,,6.47,Fee Schedule,,6.47,,,6.47,Fee Schedule,,6.47,,,6.47,Fee Schedule,,5.39,,,5.39,Fee Schedule,Medicaid Laboratory Fee Schedule,5.39,,,5.39,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.39,,,5.39,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.39,,,5.39,Fee Schedule,100% Medicaid Laboratory Fee Schedule,12.13,,,12.13,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.13,,,12.13,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.25,,,8.25,Fee Schedule,153% Medicaid Laboratory Fee Schedule,12.13,,,12.13,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.55,,,7.55,Fee Schedule,140% Medicaid Laboratory Fee Schedule,12.13,,,12.13,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.01,,,14.01,Fee Schedule,260% Medicaid Laboratory Fee Schedule,17.46,,,17.46,Fee Schedule,324% Medicaid Laboratory Fee Schedule,11.59,,,11.59,Fee Schedule,215% Medicaid Laboratory Fee Schedule,11.59,,,11.59,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.74,,,6.74,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.39,60.2,
CULTURE OTHR SPECIMN AEROBIC    ,87070,CPT,,40161069,CDM,306,RC,,,both,,,151,14.18,,,14.18,Other,150% of Medicare + 9.63% HCRA Surcharge,8.62,,,8.62,Fee Schedule,Mediare Clinical Lab,16.64,,,16.64,Fee Schedule,,15,,,15,Fee Schedule,,87.02,,,87.02,Fee Schedule,,78.3,,,78.3,Fee Schedule,,73.93,,,73.93,Fee Schedule,,75.5,50,,75.5,percent of total billed charges,All Other,18.2,,,18.2,Fee Schedule,,27.15,,,27.15,Fee Schedule,,15.31,,,15.31,Other,186% Medicaid methodology,31.98,,,31.98,Fee Schedule,,93.62,,,93.62,Fee Schedule,,18.1,,,18.1,Fee Schedule,,31.98,,,31.98,Fee Schedule,,93.62,,,93.62,Fee Schedule,,34.05,,,34.05,Fee Schedule,,105.7,70,,105.7,percent of total billed charges,All Other,41.1,,,41.1,Fee Schedule,,34.87,,,34.87,Fee Schedule,,10.34,,,10.34,Fee Schedule,,10.34,,,10.34,Fee Schedule,,10.34,,,10.34,Fee Schedule,,10.34,,,10.34,Fee Schedule,,8.23,,,8.23,Fee Schedule,Medicaid Laboratory Fee Schedule,8.23,,,8.23,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.23,,,8.23,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.23,,,8.23,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.52,,,18.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.52,,,18.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.59,,,12.59,Fee Schedule,153% Medicaid Laboratory Fee Schedule,18.52,,,18.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.52,,,11.52,Fee Schedule,140% Medicaid Laboratory Fee Schedule,18.52,,,18.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.4,,,21.4,Fee Schedule,260% Medicaid Laboratory Fee Schedule,26.67,,,26.67,Fee Schedule,324% Medicaid Laboratory Fee Schedule,17.7,,,17.7,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.7,,,17.7,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.29,,,10.29,Fee Schedule,125% Medicaid Laboratory Fee Schedule,8.23,105.7,
MACROSCOPIC EXAM ARTHROPOD      ,87168,CPT,,40161168,CDM,306,RC,,,both,,,68,7.02,,,7.02,Other,150% of Medicare + 9.63% HCRA Surcharge,4.27,,,4.27,Fee Schedule,Mediare Clinical Lab,8.24,,,8.24,Fee Schedule,,7.43,,,7.43,Fee Schedule,,43.15,,,43.15,Fee Schedule,,38.82,,,38.82,Fee Schedule,,36.66,,,36.66,Fee Schedule,,34,50,,34,percent of total billed charges,All Other,9.04,,,9.04,Fee Schedule,,13.45,,,13.45,Fee Schedule,,62.87,,,62.87,Other,186% Medicaid methodology,15.84,,,15.84,Fee Schedule,,42.16,,,42.16,Fee Schedule,,8.97,,,8.97,Fee Schedule,,15.84,,,15.84,Fee Schedule,,42.16,,,42.16,Fee Schedule,,16.87,,,16.87,Fee Schedule,,47.6,70,,47.6,percent of total billed charges,All Other,20.36,,,20.36,Fee Schedule,,17.27,,,17.27,Fee Schedule,,5.12,,,5.12,Fee Schedule,,5.12,,,5.12,Fee Schedule,,5.12,,,5.12,Fee Schedule,,5.12,,,5.12,Fee Schedule,,33.8,,,33.8,Other,New York Medicaid APG methodology,33.8,,,33.8,Other,100% Medicaid APG methodology,33.8,,,33.8,Other,100% Medicaid APG methodology,33.8,,,33.8,Other,100% Medicaid APG methodology,76.06,,,76.06,Other,225% Medicaid APG methodology,76.06,,,76.06,Other,225% Medicaid APG methodology,51.72,,,51.72,Other,153% Medicaid APG methodology,76.06,,,76.06,Other,225% Medicaid APG methodology,47.32,,,47.32,Other,140% Medicaid APG methodology,76.06,,,76.06,Other,225% Medicaid APG methodology,87.89,,,87.89,Other,260% Medicaid APG methodology,109.52,,,109.52,Other,324% Medicaid APG methodology,72.68,,,72.68,Other,215% Medicaid APG methodology,72.68,,,72.68,Other,215% Medicaid APG methodology,42.25,,,42.25,Other,125% Medicaid APG methodology,4.27,109.52,
SMEAR SPECIAL STAIN             ,87207,CPT,,40161200,CDM,306,RC,,,both,,,128,9.85,,,9.85,Other,150% of Medicare + 9.63% HCRA Surcharge,5.99,,,5.99,Fee Schedule,Mediare Clinical Lab,11.56,,,11.56,Fee Schedule,,10.42,,,10.42,Fee Schedule,,60.6,,,60.6,Fee Schedule,,54.52,,,54.52,Fee Schedule,,51.48,,,51.48,Fee Schedule,,64,50,,64,percent of total billed charges,All Other,12.64,,,12.64,Fee Schedule,,18.87,,,18.87,Fee Schedule,,11.14,,,11.14,Other,186% Medicaid methodology,22.22,,,22.22,Fee Schedule,,79.36,,,79.36,Fee Schedule,,12.58,,,12.58,Fee Schedule,,22.22,,,22.22,Fee Schedule,,79.36,,,79.36,Fee Schedule,,23.66,,,23.66,Fee Schedule,,89.6,70,,89.6,percent of total billed charges,All Other,28.56,,,28.56,Fee Schedule,,24.23,,,24.23,Fee Schedule,,7.19,,,7.19,Fee Schedule,,7.19,,,7.19,Fee Schedule,,7.19,,,7.19,Fee Schedule,,7.19,,,7.19,Fee Schedule,,5.99,,,5.99,Fee Schedule,Medicaid Laboratory Fee Schedule,5.99,,,5.99,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.99,,,5.99,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.99,,,5.99,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.48,,,13.48,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.48,,,13.48,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.16,,,9.16,Fee Schedule,153% Medicaid Laboratory Fee Schedule,13.48,,,13.48,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.39,,,8.39,Fee Schedule,140% Medicaid Laboratory Fee Schedule,13.48,,,13.48,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.57,,,15.57,Fee Schedule,260% Medicaid Laboratory Fee Schedule,19.41,,,19.41,Fee Schedule,324% Medicaid Laboratory Fee Schedule,12.88,,,12.88,Fee Schedule,215% Medicaid Laboratory Fee Schedule,12.88,,,12.88,Fee Schedule,215% Medicaid Laboratory Fee Schedule,7.49,,,7.49,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.99,89.6,
FUNGI IDENTIFICATION YEAST      ,87106,CPT,,40162141,CDM,306,RC,,,both,,,165,16.97,,,16.97,Other,150% of Medicare + 9.63% HCRA Surcharge,10.32,,,10.32,Fee Schedule,Mediare Clinical Lab,19.92,,,19.92,Fee Schedule,,17.96,,,17.96,Fee Schedule,,104.33,,,104.33,Fee Schedule,,93.86,,,93.86,Fee Schedule,,88.63,,,88.63,Fee Schedule,,82.5,50,,82.5,percent of total billed charges,All Other,21.81,,,21.81,Fee Schedule,,32.51,,,32.51,Fee Schedule,,18.22,,,18.22,Other,186% Medicaid methodology,38.29,,,38.29,Fee Schedule,,102.3,,,102.3,Fee Schedule,,21.67,,,21.67,Fee Schedule,,38.29,,,38.29,Fee Schedule,,102.3,,,102.3,Fee Schedule,,40.76,,,40.76,Fee Schedule,,115.5,70,,115.5,percent of total billed charges,All Other,49.21,,,49.21,Fee Schedule,,41.75,,,41.75,Fee Schedule,,12.38,,,12.38,Fee Schedule,,12.38,,,12.38,Fee Schedule,,12.38,,,12.38,Fee Schedule,,12.38,,,12.38,Fee Schedule,,9.8,,,9.8,Fee Schedule,Medicaid Laboratory Fee Schedule,9.8,,,9.8,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.8,,,9.8,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.8,,,9.8,Fee Schedule,100% Medicaid Laboratory Fee Schedule,22.04,,,22.04,Fee Schedule,225% Medicaid Laboratory Fee Schedule,22.04,,,22.04,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.99,,,14.99,Fee Schedule,153% Medicaid Laboratory Fee Schedule,22.04,,,22.04,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.72,,,13.72,Fee Schedule,140% Medicaid Laboratory Fee Schedule,22.04,,,22.04,Fee Schedule,225% Medicaid Laboratory Fee Schedule,25.47,,,25.47,Fee Schedule,260% Medicaid Laboratory Fee Schedule,31.74,,,31.74,Fee Schedule,324% Medicaid Laboratory Fee Schedule,21.06,,,21.06,Fee Schedule,215% Medicaid Laboratory Fee Schedule,21.06,,,21.06,Fee Schedule,215% Medicaid Laboratory Fee Schedule,12.25,,,12.25,Fee Schedule,125% Medicaid Laboratory Fee Schedule,9.8,115.5,
MICROBE SUSCEPTIBLE MIC         ,87186,CPT,,40162182,CDM,306,RC,,,both,,,138,14.22,,,14.22,Other,150% of Medicare + 9.63% HCRA Surcharge,8.65,,,8.65,Fee Schedule,Mediare Clinical Lab,16.69,,,16.69,Fee Schedule,,15.05,,,15.05,Fee Schedule,,58.73,,,58.73,Fee Schedule,,52.84,,,52.84,Fee Schedule,,49.9,,,49.9,Fee Schedule,,69,50,,69,percent of total billed charges,All Other,18.27,,,18.27,Fee Schedule,,27.25,,,27.25,Fee Schedule,,12.38,,,12.38,Other,186% Medicaid methodology,32.09,,,32.09,Fee Schedule,,85.56,,,85.56,Fee Schedule,,18.17,,,18.17,Fee Schedule,,32.09,,,32.09,Fee Schedule,,85.56,,,85.56,Fee Schedule,,34.17,,,34.17,Fee Schedule,,96.6,70,,96.6,percent of total billed charges,All Other,41.24,,,41.24,Fee Schedule,,34.99,,,34.99,Fee Schedule,,10.38,,,10.38,Fee Schedule,,10.38,,,10.38,Fee Schedule,,10.38,,,10.38,Fee Schedule,,10.38,,,10.38,Fee Schedule,,6.66,,,6.66,Fee Schedule,Medicaid Laboratory Fee Schedule,6.66,,,6.66,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.66,,,6.66,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.66,,,6.66,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.98,,,14.98,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.98,,,14.98,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.18,,,10.18,Fee Schedule,153% Medicaid Laboratory Fee Schedule,14.98,,,14.98,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.32,,,9.32,Fee Schedule,140% Medicaid Laboratory Fee Schedule,14.98,,,14.98,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.31,,,17.31,Fee Schedule,260% Medicaid Laboratory Fee Schedule,21.57,,,21.57,Fee Schedule,324% Medicaid Laboratory Fee Schedule,14.31,,,14.31,Fee Schedule,215% Medicaid Laboratory Fee Schedule,14.31,,,14.31,Fee Schedule,215% Medicaid Laboratory Fee Schedule,8.32,,,8.32,Fee Schedule,125% Medicaid Laboratory Fee Schedule,6.66,96.6,
C DIFF AMPLIFIED PROBE          ,87493,CPT,,40162265,CDM,306,RC,,,both,,,593,61.29,,,61.29,Other,150% of Medicare + 9.63% HCRA Surcharge,37.27,,,37.27,Fee Schedule,Mediare Clinical Lab,71.93,,,71.93,Fee Schedule,,64.85,,,64.85,Fee Schedule,,354.62,,,354.62,Fee Schedule,,319.06,,,319.06,Fee Schedule,,301.28,,,301.28,Fee Schedule,,296.5,50,,296.5,percent of total billed charges,All Other,78.75,,,78.75,Fee Schedule,,117.4,,,117.4,Fee Schedule,,128.55,,,128.55,Other,186% Medicaid methodology,138.27,,,138.27,Fee Schedule,,367.66,,,367.66,Fee Schedule,,78.27,,,78.27,Fee Schedule,,138.27,,,138.27,Fee Schedule,,367.66,,,367.66,Fee Schedule,,147.22,,,147.22,Fee Schedule,,415.1,70,,415.1,percent of total billed charges,All Other,177.7,,,177.7,Fee Schedule,,150.78,,,150.78,Fee Schedule,,44.72,,,44.72,Fee Schedule,,44.72,,,44.72,Fee Schedule,,44.72,,,44.72,Fee Schedule,,44.72,,,44.72,Fee Schedule,,69.11,,,69.11,Other,New York Medicaid APG methodology,69.11,,,69.11,Other,100% Medicaid APG methodology,69.11,,,69.11,Other,100% Medicaid APG methodology,69.11,,,69.11,Other,100% Medicaid APG methodology,155.5,,,155.5,Other,225% Medicaid APG methodology,155.5,,,155.5,Other,225% Medicaid APG methodology,105.74,,,105.74,Other,153% Medicaid APG methodology,155.5,,,155.5,Other,225% Medicaid APG methodology,96.75,,,96.75,Other,140% Medicaid APG methodology,155.5,,,155.5,Other,225% Medicaid APG methodology,179.69,,,179.69,Other,260% Medicaid APG methodology,223.92,,,223.92,Other,324% Medicaid APG methodology,148.59,,,148.59,Other,215% Medicaid APG methodology,148.59,,,148.59,Other,215% Medicaid APG methodology,86.39,,,86.39,Other,125% Medicaid APG methodology,37.27,415.1,
GENET VIRUS ISOLATE HSV         ,87255,CPT,,40162323,CDM,306,RC,,,both,,,539,55.68,,,55.68,Other,150% of Medicare + 9.63% HCRA Surcharge,33.86,,,33.86,Fee Schedule,Mediare Clinical Lab,65.35,,,65.35,Fee Schedule,,58.92,,,58.92,Fee Schedule,,342.2,,,342.2,Fee Schedule,,307.88,,,307.88,Fee Schedule,,290.73,,,290.73,Fee Schedule,,269.5,50,,269.5,percent of total billed charges,All Other,71.53,,,71.53,Fee Schedule,,106.66,,,106.66,Fee Schedule,,12.7,,,12.7,Other,186% Medicaid methodology,125.62,,,125.62,Fee Schedule,,334.18,,,334.18,Fee Schedule,,71.11,,,71.11,Fee Schedule,,125.62,,,125.62,Fee Schedule,,334.18,,,334.18,Fee Schedule,,133.75,,,133.75,Fee Schedule,,377.3,70,,377.3,percent of total billed charges,All Other,161.44,,,161.44,Fee Schedule,,136.98,,,136.98,Fee Schedule,,40.63,,,40.63,Fee Schedule,,40.63,,,40.63,Fee Schedule,,40.63,,,40.63,Fee Schedule,,40.63,,,40.63,Fee Schedule,,6.83,,,6.83,Fee Schedule,Medicaid Laboratory Fee Schedule,6.83,,,6.83,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.83,,,6.83,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.83,,,6.83,Fee Schedule,100% Medicaid Laboratory Fee Schedule,15.36,,,15.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.36,,,15.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.45,,,10.45,Fee Schedule,153% Medicaid Laboratory Fee Schedule,15.36,,,15.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.56,,,9.56,Fee Schedule,140% Medicaid Laboratory Fee Schedule,15.36,,,15.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,17.75,,,17.75,Fee Schedule,260% Medicaid Laboratory Fee Schedule,22.12,,,22.12,Fee Schedule,324% Medicaid Laboratory Fee Schedule,14.68,,,14.68,Fee Schedule,215% Medicaid Laboratory Fee Schedule,14.68,,,14.68,Fee Schedule,215% Medicaid Laboratory Fee Schedule,8.53,,,8.53,Fee Schedule,125% Medicaid Laboratory Fee Schedule,6.83,377.3,
CHYLMD TRACH DNA AMP PROBE      ,87491,CPT,,40162661,CDM,306,RC,,,both,,,558,57.7,,,57.7,Other,150% of Medicare + 9.63% HCRA Surcharge,35.09,,,35.09,Fee Schedule,Mediare Clinical Lab,67.72,,,67.72,Fee Schedule,,61.06,,,61.06,Fee Schedule,,354.62,,,354.62,Fee Schedule,,319.06,,,319.06,Fee Schedule,,301.28,,,301.28,Fee Schedule,,279,50,,279,percent of total billed charges,All Other,74.13,,,74.13,Fee Schedule,,110.53,,,110.53,Fee Schedule,,40.26,,,40.26,Other,186% Medicaid methodology,130.18,,,130.18,Fee Schedule,,345.96,,,345.96,Fee Schedule,,73.69,,,73.69,Fee Schedule,,130.18,,,130.18,Fee Schedule,,345.96,,,345.96,Fee Schedule,,138.61,,,138.61,Fee Schedule,,390.6,70,,390.6,percent of total billed charges,All Other,167.31,,,167.31,Fee Schedule,,141.96,,,141.96,Fee Schedule,,42.11,,,42.11,Fee Schedule,,42.11,,,42.11,Fee Schedule,,42.11,,,42.11,Fee Schedule,,42.11,,,42.11,Fee Schedule,,21.64,,,21.64,Fee Schedule,Medicaid Laboratory Fee Schedule,21.64,,,21.64,Fee Schedule,100% Medicaid Laboratory Fee Schedule,21.64,,,21.64,Fee Schedule,100% Medicaid Laboratory Fee Schedule,21.64,,,21.64,Fee Schedule,100% Medicaid Laboratory Fee Schedule,48.7,,,48.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,48.7,,,48.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,33.12,,,33.12,Fee Schedule,153% Medicaid Laboratory Fee Schedule,48.7,,,48.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,30.3,,,30.3,Fee Schedule,140% Medicaid Laboratory Fee Schedule,48.7,,,48.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,56.28,,,56.28,Fee Schedule,260% Medicaid Laboratory Fee Schedule,70.13,,,70.13,Fee Schedule,324% Medicaid Laboratory Fee Schedule,46.54,,,46.54,Fee Schedule,215% Medicaid Laboratory Fee Schedule,46.54,,,46.54,Fee Schedule,215% Medicaid Laboratory Fee Schedule,27.06,,,27.06,Fee Schedule,125% Medicaid Laboratory Fee Schedule,21.64,390.6,
N.GONORRHOEAE DNA AMP PROB      ,87591,CPT,,40162687,CDM,306,RC,,,both,,,558,57.7,,,57.7,Other,150% of Medicare + 9.63% HCRA Surcharge,35.09,,,35.09,Fee Schedule,Mediare Clinical Lab,67.72,,,67.72,Fee Schedule,,61.06,,,61.06,Fee Schedule,,354.62,,,354.62,Fee Schedule,,319.06,,,319.06,Fee Schedule,,301.28,,,301.28,Fee Schedule,,279,50,,279,percent of total billed charges,All Other,74.13,,,74.13,Fee Schedule,,110.53,,,110.53,Fee Schedule,,40.26,,,40.26,Other,186% Medicaid methodology,130.18,,,130.18,Fee Schedule,,345.96,,,345.96,Fee Schedule,,73.69,,,73.69,Fee Schedule,,130.18,,,130.18,Fee Schedule,,345.96,,,345.96,Fee Schedule,,138.61,,,138.61,Fee Schedule,,390.6,70,,390.6,percent of total billed charges,All Other,167.31,,,167.31,Fee Schedule,,141.96,,,141.96,Fee Schedule,,42.11,,,42.11,Fee Schedule,,42.11,,,42.11,Fee Schedule,,42.11,,,42.11,Fee Schedule,,42.11,,,42.11,Fee Schedule,,21.64,,,21.64,Fee Schedule,Medicaid Laboratory Fee Schedule,21.64,,,21.64,Fee Schedule,100% Medicaid Laboratory Fee Schedule,21.64,,,21.64,Fee Schedule,100% Medicaid Laboratory Fee Schedule,21.64,,,21.64,Fee Schedule,100% Medicaid Laboratory Fee Schedule,48.7,,,48.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,48.7,,,48.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,33.12,,,33.12,Fee Schedule,153% Medicaid Laboratory Fee Schedule,48.7,,,48.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,30.3,,,30.3,Fee Schedule,140% Medicaid Laboratory Fee Schedule,48.7,,,48.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,56.28,,,56.28,Fee Schedule,260% Medicaid Laboratory Fee Schedule,70.13,,,70.13,Fee Schedule,324% Medicaid Laboratory Fee Schedule,46.54,,,46.54,Fee Schedule,215% Medicaid Laboratory Fee Schedule,46.54,,,46.54,Fee Schedule,215% Medicaid Laboratory Fee Schedule,27.06,,,27.06,Fee Schedule,125% Medicaid Laboratory Fee Schedule,21.64,390.6,
NOS EACH ORGANISM AG IA         ,87449,CPT,,40162703,CDM,306,RC,,,both,,,191,19.7,,,19.7,Other,150% of Medicare + 9.63% HCRA Surcharge,11.98,,,11.98,Fee Schedule,Mediare Clinical Lab,23.12,,,23.12,Fee Schedule,,20.85,,,20.85,Fee Schedule,,88.39,,,88.39,Fee Schedule,,79.52,,,79.52,Fee Schedule,,75.09,,,75.09,Fee Schedule,,95.5,50,,95.5,percent of total billed charges,All Other,25.32,,,25.32,Fee Schedule,,37.74,,,37.74,Fee Schedule,,9.77,,,9.77,Other,186% Medicaid methodology,44.45,,,44.45,Fee Schedule,,118.42,,,118.42,Fee Schedule,,25.16,,,25.16,Fee Schedule,,44.45,,,44.45,Fee Schedule,,118.42,,,118.42,Fee Schedule,,47.32,,,47.32,Fee Schedule,,133.7,70,,133.7,percent of total billed charges,All Other,57.12,,,57.12,Fee Schedule,,48.47,,,48.47,Fee Schedule,,14.38,,,14.38,Fee Schedule,,14.38,,,14.38,Fee Schedule,,14.38,,,14.38,Fee Schedule,,14.38,,,14.38,Fee Schedule,,5.25,,,5.25,Fee Schedule,Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.04,,,8.04,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.35,,,7.35,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.66,,,13.66,Fee Schedule,260% Medicaid Laboratory Fee Schedule,17.02,,,17.02,Fee Schedule,324% Medicaid Laboratory Fee Schedule,11.29,,,11.29,Fee Schedule,215% Medicaid Laboratory Fee Schedule,11.29,,,11.29,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.57,,,6.57,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.25,133.7,
DETECT AGENT NOS DNA QUANT      ,87799,CPT,,40162729,CDM,306,RC,,,both,,,682,70.45,,,70.45,Other,150% of Medicare + 9.63% HCRA Surcharge,42.84,,,42.84,Fee Schedule,Mediare Clinical Lab,82.68,,,82.68,Fee Schedule,,74.54,,,74.54,Fee Schedule,,432.81,,,432.81,Fee Schedule,,389.41,,,389.41,Fee Schedule,,367.71,,,367.71,Fee Schedule,,341,50,,341,percent of total billed charges,All Other,90.51,,,90.51,Fee Schedule,,134.95,,,134.95,Fee Schedule,,128.55,,,128.55,Other,186% Medicaid methodology,158.94,,,158.94,Fee Schedule,,422.84,,,422.84,Fee Schedule,,89.96,,,89.96,Fee Schedule,,158.94,,,158.94,Fee Schedule,,422.84,,,422.84,Fee Schedule,,169.22,,,169.22,Fee Schedule,,477.4,70,,477.4,percent of total billed charges,All Other,204.26,,,204.26,Fee Schedule,,173.31,,,173.31,Fee Schedule,,51.41,,,51.41,Fee Schedule,,51.41,,,51.41,Fee Schedule,,51.41,,,51.41,Fee Schedule,,51.41,,,51.41,Fee Schedule,,69.11,,,69.11,Other,New York Medicaid APG methodology,69.11,,,69.11,Other,100% Medicaid APG methodology,69.11,,,69.11,Other,100% Medicaid APG methodology,69.11,,,69.11,Other,100% Medicaid APG methodology,155.5,,,155.5,Other,225% Medicaid APG methodology,155.5,,,155.5,Other,225% Medicaid APG methodology,105.74,,,105.74,Other,153% Medicaid APG methodology,155.5,,,155.5,Other,225% Medicaid APG methodology,96.75,,,96.75,Other,140% Medicaid APG methodology,155.5,,,155.5,Other,225% Medicaid APG methodology,179.69,,,179.69,Other,260% Medicaid APG methodology,223.92,,,223.92,Other,324% Medicaid APG methodology,148.59,,,148.59,Other,215% Medicaid APG methodology,148.59,,,148.59,Other,215% Medicaid APG methodology,86.39,,,86.39,Other,125% Medicaid APG methodology,42.84,477.4,
SMEAR COMPLEX STAIN             ,87209,CPT,,40163123,CDM,306,RC,,,both,,,287,29.57,,,29.57,Other,150% of Medicare + 9.63% HCRA Surcharge,17.98,,,17.98,Fee Schedule,Mediare Clinical Lab,34.7,,,34.7,Fee Schedule,,31.29,,,31.29,Fee Schedule,,181.58,,,181.58,Fee Schedule,,163.37,,,163.37,Fee Schedule,,154.27,,,154.27,Fee Schedule,,143.5,50,,143.5,percent of total billed charges,All Other,37.99,,,37.99,Fee Schedule,,56.64,,,56.64,Fee Schedule,,10.99,,,10.99,Other,186% Medicaid methodology,66.71,,,66.71,Fee Schedule,,177.94,,,177.94,Fee Schedule,,37.76,,,37.76,Fee Schedule,,66.71,,,66.71,Fee Schedule,,177.94,,,177.94,Fee Schedule,,71.02,,,71.02,Fee Schedule,,200.9,70,,200.9,percent of total billed charges,All Other,85.73,,,85.73,Fee Schedule,,72.74,,,72.74,Fee Schedule,,21.58,,,21.58,Fee Schedule,,21.58,,,21.58,Fee Schedule,,21.58,,,21.58,Fee Schedule,,21.58,,,21.58,Fee Schedule,,5.91,,,5.91,Fee Schedule,Medicaid Laboratory Fee Schedule,5.91,,,5.91,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.91,,,5.91,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.91,,,5.91,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.29,,,13.29,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.29,,,13.29,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.04,,,9.04,Fee Schedule,153% Medicaid Laboratory Fee Schedule,13.29,,,13.29,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.27,,,8.27,Fee Schedule,140% Medicaid Laboratory Fee Schedule,13.29,,,13.29,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.36,,,15.36,Fee Schedule,260% Medicaid Laboratory Fee Schedule,19.14,,,19.14,Fee Schedule,324% Medicaid Laboratory Fee Schedule,12.7,,,12.7,Fee Schedule,215% Medicaid Laboratory Fee Schedule,12.7,,,12.7,Fee Schedule,215% Medicaid Laboratory Fee Schedule,7.39,,,7.39,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.91,200.9,
Flu A+B NAA LC,87502,CPT,,40163263,CDM,306,RC,,,both,,,1524,157.54,,,157.54,Other,150% of Medicare + 9.63% HCRA Surcharge,95.8,,,95.8,Fee Schedule,Mediare Clinical Lab,184.89,,,184.89,Fee Schedule,,166.69,,,166.69,Fee Schedule,,859.81,,,859.81,Fee Schedule,,773.59,,,773.59,Fee Schedule,,730.48,,,730.48,Fee Schedule,,762,50,,762,percent of total billed charges,All Other,202.38,,,202.38,Fee Schedule,,301.77,,,301.77,Fee Schedule,,100.41,,,100.41,Other,186% Medicaid methodology,355.42,,,355.42,Fee Schedule,,944.88,,,944.88,Fee Schedule,,201.18,,,201.18,Fee Schedule,,355.42,,,355.42,Fee Schedule,,944.88,,,944.88,Fee Schedule,,378.41,,,378.41,Fee Schedule,,1066.8,70,,1066.8,percent of total billed charges,All Other,456.77,,,456.77,Fee Schedule,,387.56,,,387.56,Fee Schedule,,114.96,,,114.96,Fee Schedule,,114.96,,,114.96,Fee Schedule,,114.96,,,114.96,Fee Schedule,,114.96,,,114.96,Fee Schedule,,53.98,,,53.98,Fee Schedule,Medicaid Laboratory Fee Schedule,53.98,,,53.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,53.98,,,53.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,53.98,,,53.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,121.47,,,121.47,Fee Schedule,225% Medicaid Laboratory Fee Schedule,121.47,,,121.47,Fee Schedule,225% Medicaid Laboratory Fee Schedule,82.6,,,82.6,Fee Schedule,153% Medicaid Laboratory Fee Schedule,121.47,,,121.47,Fee Schedule,225% Medicaid Laboratory Fee Schedule,75.58,,,75.58,Fee Schedule,140% Medicaid Laboratory Fee Schedule,121.47,,,121.47,Fee Schedule,225% Medicaid Laboratory Fee Schedule,140.36,,,140.36,Fee Schedule,260% Medicaid Laboratory Fee Schedule,174.91,,,174.91,Fee Schedule,324% Medicaid Laboratory Fee Schedule,116.07,,,116.07,Fee Schedule,215% Medicaid Laboratory Fee Schedule,116.07,,,116.07,Fee Schedule,215% Medicaid Laboratory Fee Schedule,67.48,,,67.48,Fee Schedule,125% Medicaid Laboratory Fee Schedule,53.98,1066.8,
DETECT AGENT NOS DNA AMP        ,87798,CPT,,40163370,CDM,306,RC,,,both,,,558,57.7,,,57.7,Other,150% of Medicare + 9.63% HCRA Surcharge,35.09,,,35.09,Fee Schedule,Mediare Clinical Lab,67.72,,,67.72,Fee Schedule,,61.06,,,61.06,Fee Schedule,,354.62,,,354.62,Fee Schedule,,319.06,,,319.06,Fee Schedule,,301.28,,,301.28,Fee Schedule,,279,50,,279,percent of total billed charges,All Other,74.13,,,74.13,Fee Schedule,,110.53,,,110.53,Fee Schedule,,128.55,,,128.55,Other,186% Medicaid methodology,130.18,,,130.18,Fee Schedule,,345.96,,,345.96,Fee Schedule,,73.69,,,73.69,Fee Schedule,,130.18,,,130.18,Fee Schedule,,345.96,,,345.96,Fee Schedule,,138.61,,,138.61,Fee Schedule,,390.6,70,,390.6,percent of total billed charges,All Other,167.31,,,167.31,Fee Schedule,,141.96,,,141.96,Fee Schedule,,42.11,,,42.11,Fee Schedule,,42.11,,,42.11,Fee Schedule,,42.11,,,42.11,Fee Schedule,,42.11,,,42.11,Fee Schedule,,69.11,,,69.11,Other,New York Medicaid APG methodology,69.11,,,69.11,Other,100% Medicaid APG methodology,69.11,,,69.11,Other,100% Medicaid APG methodology,69.11,,,69.11,Other,100% Medicaid APG methodology,155.5,,,155.5,Other,225% Medicaid APG methodology,155.5,,,155.5,Other,225% Medicaid APG methodology,105.74,,,105.74,Other,153% Medicaid APG methodology,155.5,,,155.5,Other,225% Medicaid APG methodology,96.75,,,96.75,Other,140% Medicaid APG methodology,155.5,,,155.5,Other,225% Medicaid APG methodology,179.69,,,179.69,Other,260% Medicaid APG methodology,223.92,,,223.92,Other,324% Medicaid APG methodology,148.59,,,148.59,Other,215% Medicaid APG methodology,148.59,,,148.59,Other,215% Medicaid APG methodology,86.39,,,86.39,Other,125% Medicaid APG methodology,35.09,390.6,
CHYLMD PNEUM DNA AMP PROBE      ,87486,CPT,,40163388,CDM,306,RC,,,both,,,865,57.7,,,57.7,Other,150% of Medicare + 9.63% HCRA Surcharge,35.09,,,35.09,Fee Schedule,Mediare Clinical Lab,67.72,,,67.72,Fee Schedule,,61.06,,,61.06,Fee Schedule,,354.62,,,354.62,Fee Schedule,,319.06,,,319.06,Fee Schedule,,301.28,,,301.28,Fee Schedule,,432.5,50,,432.5,percent of total billed charges,All Other,74.13,,,74.13,Fee Schedule,,110.53,,,110.53,Fee Schedule,,40.26,,,40.26,Other,186% Medicaid methodology,130.18,,,130.18,Fee Schedule,,536.3,,,536.3,Fee Schedule,,73.69,,,73.69,Fee Schedule,,130.18,,,130.18,Fee Schedule,,536.3,,,536.3,Fee Schedule,,138.61,,,138.61,Fee Schedule,,605.5,70,,605.5,percent of total billed charges,All Other,167.31,,,167.31,Fee Schedule,,141.96,,,141.96,Fee Schedule,,42.11,,,42.11,Fee Schedule,,42.11,,,42.11,Fee Schedule,,42.11,,,42.11,Fee Schedule,,42.11,,,42.11,Fee Schedule,,21.64,,,21.64,Fee Schedule,Medicaid Laboratory Fee Schedule,21.64,,,21.64,Fee Schedule,100% Medicaid Laboratory Fee Schedule,21.64,,,21.64,Fee Schedule,100% Medicaid Laboratory Fee Schedule,21.64,,,21.64,Fee Schedule,100% Medicaid Laboratory Fee Schedule,48.7,,,48.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,48.7,,,48.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,33.12,,,33.12,Fee Schedule,153% Medicaid Laboratory Fee Schedule,48.7,,,48.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,30.3,,,30.3,Fee Schedule,140% Medicaid Laboratory Fee Schedule,48.7,,,48.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,56.28,,,56.28,Fee Schedule,260% Medicaid Laboratory Fee Schedule,70.13,,,70.13,Fee Schedule,324% Medicaid Laboratory Fee Schedule,46.54,,,46.54,Fee Schedule,215% Medicaid Laboratory Fee Schedule,46.54,,,46.54,Fee Schedule,215% Medicaid Laboratory Fee Schedule,27.06,,,27.06,Fee Schedule,125% Medicaid Laboratory Fee Schedule,21.64,605.5,
M.PNEUMON DNA AMP PROBE         ,87581,CPT,,40163396,CDM,306,RC,,,both,,,558,57.7,,,57.7,Other,150% of Medicare + 9.63% HCRA Surcharge,35.09,,,35.09,Fee Schedule,Mediare Clinical Lab,67.72,,,67.72,Fee Schedule,,61.06,,,61.06,Fee Schedule,,354.62,,,354.62,Fee Schedule,,319.06,,,319.06,Fee Schedule,,301.28,,,301.28,Fee Schedule,,279,50,,279,percent of total billed charges,All Other,74.13,,,74.13,Fee Schedule,,110.53,,,110.53,Fee Schedule,,40.26,,,40.26,Other,186% Medicaid methodology,130.18,,,130.18,Fee Schedule,,345.96,,,345.96,Fee Schedule,,73.69,,,73.69,Fee Schedule,,130.18,,,130.18,Fee Schedule,,345.96,,,345.96,Fee Schedule,,138.61,,,138.61,Fee Schedule,,390.6,70,,390.6,percent of total billed charges,All Other,167.31,,,167.31,Fee Schedule,,141.96,,,141.96,Fee Schedule,,42.11,,,42.11,Fee Schedule,,42.11,,,42.11,Fee Schedule,,42.11,,,42.11,Fee Schedule,,42.11,,,42.11,Fee Schedule,,21.64,,,21.64,Fee Schedule,Medicaid Laboratory Fee Schedule,21.64,,,21.64,Fee Schedule,100% Medicaid Laboratory Fee Schedule,21.64,,,21.64,Fee Schedule,100% Medicaid Laboratory Fee Schedule,21.64,,,21.64,Fee Schedule,100% Medicaid Laboratory Fee Schedule,48.7,,,48.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,48.7,,,48.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,33.12,,,33.12,Fee Schedule,153% Medicaid Laboratory Fee Schedule,48.7,,,48.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,30.3,,,30.3,Fee Schedule,140% Medicaid Laboratory Fee Schedule,48.7,,,48.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,56.28,,,56.28,Fee Schedule,260% Medicaid Laboratory Fee Schedule,70.13,,,70.13,Fee Schedule,324% Medicaid Laboratory Fee Schedule,46.54,,,46.54,Fee Schedule,215% Medicaid Laboratory Fee Schedule,46.54,,,46.54,Fee Schedule,215% Medicaid Laboratory Fee Schedule,27.06,,,27.06,Fee Schedule,125% Medicaid Laboratory Fee Schedule,21.64,390.6,
RSV ASSAY W/OPTIC               ,87807,CPT,,40163669,CDM,306,RC,,,both,,,209,21.54,,,21.54,Other,150% of Medicare + 9.63% HCRA Surcharge,13.1,,,13.1,Fee Schedule,Mediare Clinical Lab,25.28,,,25.28,Fee Schedule,,22.79,,,22.79,Fee Schedule,,88.39,,,88.39,Fee Schedule,,79.52,,,79.52,Fee Schedule,,75.09,,,75.09,Fee Schedule,,104.5,50,,104.5,percent of total billed charges,All Other,27.69,,,27.69,Fee Schedule,,41.27,,,41.27,Fee Schedule,,24.37,,,24.37,Other,186% Medicaid methodology,48.6,,,48.6,Fee Schedule,,129.58,,,129.58,Fee Schedule,,27.51,,,27.51,Fee Schedule,,48.6,,,48.6,Fee Schedule,,129.58,,,129.58,Fee Schedule,,51.75,,,51.75,Fee Schedule,,146.3,70,,146.3,percent of total billed charges,All Other,62.46,,,62.46,Fee Schedule,,53,,,53,Fee Schedule,,15.72,,,15.72,Fee Schedule,,15.72,,,15.72,Fee Schedule,,15.72,,,15.72,Fee Schedule,,15.72,,,15.72,Fee Schedule,,13.1,,,13.1,Fee Schedule,Medicaid Laboratory Fee Schedule,13.1,,,13.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.1,,,13.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.1,,,13.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,29.48,,,29.48,Fee Schedule,225% Medicaid Laboratory Fee Schedule,29.48,,,29.48,Fee Schedule,225% Medicaid Laboratory Fee Schedule,20.04,,,20.04,Fee Schedule,153% Medicaid Laboratory Fee Schedule,29.48,,,29.48,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.34,,,18.34,Fee Schedule,140% Medicaid Laboratory Fee Schedule,29.48,,,29.48,Fee Schedule,225% Medicaid Laboratory Fee Schedule,34.06,,,34.06,Fee Schedule,260% Medicaid Laboratory Fee Schedule,42.44,,,42.44,Fee Schedule,324% Medicaid Laboratory Fee Schedule,28.17,,,28.17,Fee Schedule,215% Medicaid Laboratory Fee Schedule,28.17,,,28.17,Fee Schedule,215% Medicaid Laboratory Fee Schedule,16.38,,,16.38,Fee Schedule,125% Medicaid Laboratory Fee Schedule,13.1,146.3,
STREP A ASSAY W/OPTIC           ,87880,CPT,,40163677,CDM,306,RC,,,both,,,263,27.18,,,27.18,Other,150% of Medicare + 9.63% HCRA Surcharge,16.53,,,16.53,Fee Schedule,Mediare Clinical Lab,31.9,,,31.9,Fee Schedule,,28.76,,,28.76,Fee Schedule,,88.39,,,88.39,Fee Schedule,,79.52,,,79.52,Fee Schedule,,75.09,,,75.09,Fee Schedule,,131.5,50,,131.5,percent of total billed charges,All Other,34.91,,,34.91,Fee Schedule,,52.07,,,52.07,Fee Schedule,,7.04,,,7.04,Other,186% Medicaid methodology,61.33,,,61.33,Fee Schedule,,163.06,,,163.06,Fee Schedule,,34.71,,,34.71,Fee Schedule,,61.33,,,61.33,Fee Schedule,,163.06,,,163.06,Fee Schedule,,65.29,,,65.29,Fee Schedule,,184.1,70,,184.1,percent of total billed charges,All Other,78.81,,,78.81,Fee Schedule,,66.87,,,66.87,Fee Schedule,,19.84,,,19.84,Fee Schedule,,19.84,,,19.84,Fee Schedule,,19.84,,,19.84,Fee Schedule,,19.84,,,19.84,Fee Schedule,,3.79,,,3.79,Fee Schedule,Medicaid Laboratory Fee Schedule,3.79,,,3.79,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.79,,,3.79,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.79,,,3.79,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.52,,,8.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.52,,,8.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.79,,,5.79,Fee Schedule,153% Medicaid Laboratory Fee Schedule,8.52,,,8.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.3,,,5.3,Fee Schedule,140% Medicaid Laboratory Fee Schedule,8.52,,,8.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.85,,,9.85,Fee Schedule,260% Medicaid Laboratory Fee Schedule,12.27,,,12.27,Fee Schedule,324% Medicaid Laboratory Fee Schedule,8.14,,,8.14,Fee Schedule,215% Medicaid Laboratory Fee Schedule,8.14,,,8.14,Fee Schedule,215% Medicaid Laboratory Fee Schedule,4.73,,,4.73,Fee Schedule,125% Medicaid Laboratory Fee Schedule,3.79,184.1,
INFLUENZA ASSAY W/OPTIC         ,87804,CPT,,40163693,CDM,306,RC,,,both,,,263,27.22,,,27.22,Other,150% of Medicare + 9.63% HCRA Surcharge,16.55,,,16.55,Fee Schedule,Mediare Clinical Lab,31.94,,,31.94,Fee Schedule,,28.8,,,28.8,Fee Schedule,,88.39,,,88.39,Fee Schedule,,79.52,,,79.52,Fee Schedule,,75.09,,,75.09,Fee Schedule,,131.5,50,,131.5,percent of total billed charges,All Other,34.97,,,34.97,Fee Schedule,,52.13,,,52.13,Fee Schedule,,27.24,,,27.24,Other,186% Medicaid methodology,61.4,,,61.4,Fee Schedule,,163.06,,,163.06,Fee Schedule,,34.76,,,34.76,Fee Schedule,,61.4,,,61.4,Fee Schedule,,163.06,,,163.06,Fee Schedule,,65.37,,,65.37,Fee Schedule,,184.1,70,,184.1,percent of total billed charges,All Other,78.91,,,78.91,Fee Schedule,,66.95,,,66.95,Fee Schedule,,19.86,,,19.86,Fee Schedule,,19.86,,,19.86,Fee Schedule,,19.86,,,19.86,Fee Schedule,,19.86,,,19.86,Fee Schedule,,14.65,,,14.65,Fee Schedule,Medicaid Laboratory Fee Schedule,14.65,,,14.65,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.65,,,14.65,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.65,,,14.65,Fee Schedule,100% Medicaid Laboratory Fee Schedule,32.95,,,32.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,32.95,,,32.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,22.41,,,22.41,Fee Schedule,153% Medicaid Laboratory Fee Schedule,32.95,,,32.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,20.5,,,20.5,Fee Schedule,140% Medicaid Laboratory Fee Schedule,32.95,,,32.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,38.08,,,38.08,Fee Schedule,260% Medicaid Laboratory Fee Schedule,47.45,,,47.45,Fee Schedule,324% Medicaid Laboratory Fee Schedule,31.49,,,31.49,Fee Schedule,215% Medicaid Laboratory Fee Schedule,31.49,,,31.49,Fee Schedule,215% Medicaid Laboratory Fee Schedule,18.31,,,18.31,Fee Schedule,125% Medicaid Laboratory Fee Schedule,14.65,184.1,
DNA/RNA SEQUENCING              ,87153,CPT,,40163818,CDM,306,RC,,,both,,,1834,189.7,,,189.7,Other,150% of Medicare + 9.63% HCRA Surcharge,115.36,,,115.36,Fee Schedule,Mediare Clinical Lab,222.64,,,222.64,Fee Schedule,,200.73,,,200.73,Fee Schedule,,1165.53,,,1165.53,Fee Schedule,,1048.65,,,1048.65,Fee Schedule,,990.21,,,990.21,Fee Schedule,,917,50,,917,percent of total billed charges,All Other,243.69,,,243.69,Fee Schedule,,363.38,,,363.38,Fee Schedule,,163.03,,,163.03,Other,186% Medicaid methodology,427.99,,,427.99,Fee Schedule,,1137.08,,,1137.08,Fee Schedule,,242.26,,,242.26,Fee Schedule,,427.99,,,427.99,Fee Schedule,,1137.08,,,1137.08,Fee Schedule,,455.67,,,455.67,Fee Schedule,,1283.8,70,,1283.8,percent of total billed charges,All Other,550.03,,,550.03,Fee Schedule,,466.69,,,466.69,Fee Schedule,,138.43,,,138.43,Fee Schedule,,138.43,,,138.43,Fee Schedule,,138.43,,,138.43,Fee Schedule,,138.43,,,138.43,Fee Schedule,,87.65,,,87.65,Other,New York Medicaid APG methodology,87.65,,,87.65,Other,100% Medicaid APG methodology,87.65,,,87.65,Other,100% Medicaid APG methodology,87.65,,,87.65,Other,100% Medicaid APG methodology,197.21,,,197.21,Other,225% Medicaid APG methodology,197.21,,,197.21,Other,225% Medicaid APG methodology,134.11,,,134.11,Other,153% Medicaid APG methodology,197.21,,,197.21,Other,225% Medicaid APG methodology,122.71,,,122.71,Other,140% Medicaid APG methodology,197.21,,,197.21,Other,225% Medicaid APG methodology,227.89,,,227.89,Other,260% Medicaid APG methodology,283.99,,,283.99,Other,324% Medicaid APG methodology,188.45,,,188.45,Other,215% Medicaid APG methodology,188.45,,,188.45,Other,215% Medicaid APG methodology,109.56,,,109.56,Other,125% Medicaid APG methodology,87.65,1283.8,
RSV PCR,87634,CPT,,40163966,CDM,306,RC,,,both,,,1117,115.44,,,115.44,Other,150% of Medicare + 9.63% HCRA Surcharge,70.2,,,70.2,Fee Schedule,Mediare Clinical Lab,135.49,,,135.49,Fee Schedule,,122.15,,,122.15,Fee Schedule,,558.5,,,558.5,Fee Schedule,,502.65,,,502.65,Fee Schedule,,480.31,,,480.31,Fee Schedule,,558.5,50,,558.5,percent of total billed charges,All Other,148.3,,,148.3,Fee Schedule,,221.13,,,221.13,Fee Schedule,,40.26,,,40.26,Other,186% Medicaid methodology,260.44,,,260.44,Fee Schedule,,692.54,,,692.54,Fee Schedule,,147.42,,,147.42,Fee Schedule,,260.44,,,260.44,Fee Schedule,,692.54,,,692.54,Fee Schedule,,277.29,,,277.29,Fee Schedule,,781.9,70,,781.9,percent of total billed charges,All Other,334.71,,,334.71,Fee Schedule,,284,,,284,Fee Schedule,,84.24,,,84.24,Fee Schedule,,84.24,,,84.24,Fee Schedule,,84.24,,,84.24,Fee Schedule,,84.24,,,84.24,Fee Schedule,,21.64,,,21.64,Fee Schedule,Medicaid Laboratory Fee Schedule,21.64,,,21.64,Fee Schedule,100% Medicaid Laboratory Fee Schedule,21.64,,,21.64,Fee Schedule,100% Medicaid Laboratory Fee Schedule,21.64,,,21.64,Fee Schedule,100% Medicaid Laboratory Fee Schedule,48.7,,,48.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,48.7,,,48.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,33.12,,,33.12,Fee Schedule,153% Medicaid Laboratory Fee Schedule,48.7,,,48.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,30.3,,,30.3,Fee Schedule,140% Medicaid Laboratory Fee Schedule,48.7,,,48.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,56.28,,,56.28,Fee Schedule,260% Medicaid Laboratory Fee Schedule,70.13,,,70.13,Fee Schedule,324% Medicaid Laboratory Fee Schedule,46.54,,,46.54,Fee Schedule,215% Medicaid Laboratory Fee Schedule,46.54,,,46.54,Fee Schedule,215% Medicaid Laboratory Fee Schedule,27.06,,,27.06,Fee Schedule,125% Medicaid Laboratory Fee Schedule,21.64,781.9,
TRICHOMONAS VAGIN DIR PROBE     ,87660,CPT,,40164014,CDM,306,RC,,,both,,,320,32.97,,,32.97,Other,150% of Medicare + 9.63% HCRA Surcharge,20.05,,,20.05,Fee Schedule,Mediare Clinical Lab,38.7,,,38.7,Fee Schedule,,34.89,,,34.89,Fee Schedule,,202.62,,,202.62,Fee Schedule,,182.3,,,182.3,Fee Schedule,,172.14,,,172.14,Fee Schedule,,160,50,,160,percent of total billed charges,All Other,42.35,,,42.35,Fee Schedule,,63.16,,,63.16,Fee Schedule,,26.21,,,26.21,Other,186% Medicaid methodology,74.39,,,74.39,Fee Schedule,,198.4,,,198.4,Fee Schedule,,42.11,,,42.11,Fee Schedule,,74.39,,,74.39,Fee Schedule,,198.4,,,198.4,Fee Schedule,,79.2,,,79.2,Fee Schedule,,224,70,,224,percent of total billed charges,All Other,95.6,,,95.6,Fee Schedule,,81.11,,,81.11,Fee Schedule,,24.06,,,24.06,Fee Schedule,,24.06,,,24.06,Fee Schedule,,24.06,,,24.06,Fee Schedule,,24.06,,,24.06,Fee Schedule,,14.09,,,14.09,Fee Schedule,Medicaid Laboratory Fee Schedule,14.09,,,14.09,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.09,,,14.09,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.09,,,14.09,Fee Schedule,100% Medicaid Laboratory Fee Schedule,31.7,,,31.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,31.7,,,31.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.56,,,21.56,Fee Schedule,153% Medicaid Laboratory Fee Schedule,31.7,,,31.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.73,,,19.73,Fee Schedule,140% Medicaid Laboratory Fee Schedule,31.7,,,31.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,36.63,,,36.63,Fee Schedule,260% Medicaid Laboratory Fee Schedule,45.65,,,45.65,Fee Schedule,324% Medicaid Laboratory Fee Schedule,30.29,,,30.29,Fee Schedule,215% Medicaid Laboratory Fee Schedule,30.29,,,30.29,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.61,,,17.61,Fee Schedule,125% Medicaid Laboratory Fee Schedule,14.09,224,
GARDNER VAG DNA DIR PROBE       ,87510,CPT,,40164022,CDM,306,RC,,,both,,,320,32.97,,,32.97,Other,150% of Medicare + 9.63% HCRA Surcharge,20.05,,,20.05,Fee Schedule,Mediare Clinical Lab,38.7,,,38.7,Fee Schedule,,34.89,,,34.89,Fee Schedule,,202.62,,,202.62,Fee Schedule,,182.3,,,182.3,Fee Schedule,,172.14,,,172.14,Fee Schedule,,160,50,,160,percent of total billed charges,All Other,42.35,,,42.35,Fee Schedule,,63.16,,,63.16,Fee Schedule,,26.21,,,26.21,Other,186% Medicaid methodology,74.39,,,74.39,Fee Schedule,,198.4,,,198.4,Fee Schedule,,42.11,,,42.11,Fee Schedule,,74.39,,,74.39,Fee Schedule,,198.4,,,198.4,Fee Schedule,,79.2,,,79.2,Fee Schedule,,224,70,,224,percent of total billed charges,All Other,95.6,,,95.6,Fee Schedule,,81.11,,,81.11,Fee Schedule,,24.06,,,24.06,Fee Schedule,,24.06,,,24.06,Fee Schedule,,24.06,,,24.06,Fee Schedule,,24.06,,,24.06,Fee Schedule,,14.09,,,14.09,Fee Schedule,Medicaid Laboratory Fee Schedule,14.09,,,14.09,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.09,,,14.09,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.09,,,14.09,Fee Schedule,100% Medicaid Laboratory Fee Schedule,31.7,,,31.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,31.7,,,31.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.56,,,21.56,Fee Schedule,153% Medicaid Laboratory Fee Schedule,31.7,,,31.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.73,,,19.73,Fee Schedule,140% Medicaid Laboratory Fee Schedule,31.7,,,31.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,36.63,,,36.63,Fee Schedule,260% Medicaid Laboratory Fee Schedule,45.65,,,45.65,Fee Schedule,324% Medicaid Laboratory Fee Schedule,30.29,,,30.29,Fee Schedule,215% Medicaid Laboratory Fee Schedule,30.29,,,30.29,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.61,,,17.61,Fee Schedule,125% Medicaid Laboratory Fee Schedule,14.09,224,
HIV-1 PROBE&REVERSE TRNSCRPJ    ,87535,CPT,,40164030,CDM,306,RC,,,both,,,558,57.7,,,57.7,Other,150% of Medicare + 9.63% HCRA Surcharge,35.09,,,35.09,Fee Schedule,Mediare Clinical Lab,67.72,,,67.72,Fee Schedule,,61.06,,,61.06,Fee Schedule,,354.62,,,354.62,Fee Schedule,,319.06,,,319.06,Fee Schedule,,301.28,,,301.28,Fee Schedule,,279,50,,279,percent of total billed charges,All Other,74.13,,,74.13,Fee Schedule,,110.53,,,110.53,Fee Schedule,,40.26,,,40.26,Other,186% Medicaid methodology,130.18,,,130.18,Fee Schedule,,345.96,,,345.96,Fee Schedule,,73.69,,,73.69,Fee Schedule,,130.18,,,130.18,Fee Schedule,,345.96,,,345.96,Fee Schedule,,138.61,,,138.61,Fee Schedule,,390.6,70,,390.6,percent of total billed charges,All Other,167.31,,,167.31,Fee Schedule,,141.96,,,141.96,Fee Schedule,,42.11,,,42.11,Fee Schedule,,42.11,,,42.11,Fee Schedule,,42.11,,,42.11,Fee Schedule,,42.11,,,42.11,Fee Schedule,,21.64,,,21.64,Fee Schedule,Medicaid Laboratory Fee Schedule,21.64,,,21.64,Fee Schedule,100% Medicaid Laboratory Fee Schedule,21.64,,,21.64,Fee Schedule,100% Medicaid Laboratory Fee Schedule,21.64,,,21.64,Fee Schedule,100% Medicaid Laboratory Fee Schedule,48.7,,,48.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,48.7,,,48.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,33.12,,,33.12,Fee Schedule,153% Medicaid Laboratory Fee Schedule,48.7,,,48.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,30.3,,,30.3,Fee Schedule,140% Medicaid Laboratory Fee Schedule,48.7,,,48.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,56.28,,,56.28,Fee Schedule,260% Medicaid Laboratory Fee Schedule,70.13,,,70.13,Fee Schedule,324% Medicaid Laboratory Fee Schedule,46.54,,,46.54,Fee Schedule,215% Medicaid Laboratory Fee Schedule,46.54,,,46.54,Fee Schedule,215% Medicaid Laboratory Fee Schedule,27.06,,,27.06,Fee Schedule,125% Medicaid Laboratory Fee Schedule,21.64,390.6,
CULTURE SCREEN ONLY             ,87081,CPT,,40164089,CDM,306,RC,,,both,,,105,10.9,,,10.9,Other,150% of Medicare + 9.63% HCRA Surcharge,6.63,,,6.63,Fee Schedule,Mediare Clinical Lab,12.8,,,12.8,Fee Schedule,,11.54,,,11.54,Fee Schedule,,66.99,,,66.99,Fee Schedule,,60.27,,,60.27,Fee Schedule,,56.91,,,56.91,Fee Schedule,,52.5,50,,52.5,percent of total billed charges,All Other,14.01,,,14.01,Fee Schedule,,20.88,,,20.88,Fee Schedule,,9.77,,,9.77,Other,186% Medicaid methodology,24.6,,,24.6,Fee Schedule,,65.1,,,65.1,Fee Schedule,,13.92,,,13.92,Fee Schedule,,24.6,,,24.6,Fee Schedule,,65.1,,,65.1,Fee Schedule,,26.19,,,26.19,Fee Schedule,,73.5,70,,73.5,percent of total billed charges,All Other,31.61,,,31.61,Fee Schedule,,26.82,,,26.82,Fee Schedule,,7.96,,,7.96,Fee Schedule,,7.96,,,7.96,Fee Schedule,,7.96,,,7.96,Fee Schedule,,7.96,,,7.96,Fee Schedule,,5.25,,,5.25,Fee Schedule,Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,100% Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.04,,,8.04,Fee Schedule,153% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.35,,,7.35,Fee Schedule,140% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.66,,,13.66,Fee Schedule,260% Medicaid Laboratory Fee Schedule,17.02,,,17.02,Fee Schedule,324% Medicaid Laboratory Fee Schedule,11.29,,,11.29,Fee Schedule,215% Medicaid Laboratory Fee Schedule,11.29,,,11.29,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.57,,,6.57,Fee Schedule,125% Medicaid Laboratory Fee Schedule,5.25,73.5,
SARSCOV2 & INF A&B AMP PRB      ,87636,CPT,,40164238,CDM,306,RC,,,both,,,159,234.55,,,234.55,Other,150% of Medicare + 9.63% HCRA Surcharge,142.63,,,142.63,Fee Schedule,Mediare Clinical Lab,275.28,,,275.28,Fee Schedule,,248.18,,,248.18,Fee Schedule,,142.63,,,142.63,Fee Schedule,,142.63,,,142.63,Fee Schedule,,142.63,,,142.63,Fee Schedule,,79.5,50,,79.5,percent of total billed charges,All Other,142.63,,,142.63,Fee Schedule,,449.28,,,449.28,Fee Schedule,,159.2,,,159.2,Other,186% Medicaid methodology,529.16,,,529.16,Fee Schedule,,98.58,,,98.58,Fee Schedule,,299.52,,,299.52,Fee Schedule,,529.16,,,529.16,Fee Schedule,,98.58,,,98.58,Fee Schedule,,563.39,,,563.39,Fee Schedule,,111.3,70,,111.3,percent of total billed charges,All Other,680.05,,,680.05,Fee Schedule,,577.01,,,577.01,Fee Schedule,,171.12,,,171.12,Fee Schedule,,171.12,,,171.12,Fee Schedule,,171.12,,,171.12,Fee Schedule,,171.12,,,171.12,Fee Schedule,,85.59,,,85.59,Fee Schedule,Medicaid Laboratory Fee Schedule,85.59,,,85.59,Fee Schedule,100% Medicaid Laboratory Fee Schedule,85.59,,,85.59,Fee Schedule,100% Medicaid Laboratory Fee Schedule,85.59,,,85.59,Fee Schedule,100% Medicaid Laboratory Fee Schedule,192.58,,,192.58,Fee Schedule,225% Medicaid Laboratory Fee Schedule,192.58,,,192.58,Fee Schedule,225% Medicaid Laboratory Fee Schedule,130.95,,,130.95,Fee Schedule,153% Medicaid Laboratory Fee Schedule,192.58,,,192.58,Fee Schedule,225% Medicaid Laboratory Fee Schedule,119.83,,,119.83,Fee Schedule,140% Medicaid Laboratory Fee Schedule,192.58,,,192.58,Fee Schedule,225% Medicaid Laboratory Fee Schedule,222.53,,,222.53,Fee Schedule,260% Medicaid Laboratory Fee Schedule,277.31,,,277.31,Fee Schedule,324% Medicaid Laboratory Fee Schedule,184.02,,,184.02,Fee Schedule,215% Medicaid Laboratory Fee Schedule,184.02,,,184.02,Fee Schedule,215% Medicaid Laboratory Fee Schedule,106.99,,,106.99,Fee Schedule,125% Medicaid Laboratory Fee Schedule,79.5,680.05,
CANDIDA DNA DIR PROBE           ,87480,CPT,,40164477,CDM,306,RC,,,both,,,320,32.97,,,32.97,Other,150% of Medicare + 9.63% HCRA Surcharge,20.05,,,20.05,Fee Schedule,Mediare Clinical Lab,38.7,,,38.7,Fee Schedule,,34.89,,,34.89,Fee Schedule,,202.62,,,202.62,Fee Schedule,,182.3,,,182.3,Fee Schedule,,172.14,,,172.14,Fee Schedule,,160,50,,160,percent of total billed charges,All Other,42.35,,,42.35,Fee Schedule,,63.16,,,63.16,Fee Schedule,,26.21,,,26.21,Other,186% Medicaid methodology,74.39,,,74.39,Fee Schedule,,198.4,,,198.4,Fee Schedule,,42.11,,,42.11,Fee Schedule,,74.39,,,74.39,Fee Schedule,,198.4,,,198.4,Fee Schedule,,79.2,,,79.2,Fee Schedule,,224,70,,224,percent of total billed charges,All Other,95.6,,,95.6,Fee Schedule,,81.11,,,81.11,Fee Schedule,,24.06,,,24.06,Fee Schedule,,24.06,,,24.06,Fee Schedule,,24.06,,,24.06,Fee Schedule,,24.06,,,24.06,Fee Schedule,,14.09,,,14.09,Fee Schedule,Medicaid Laboratory Fee Schedule,14.09,,,14.09,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.09,,,14.09,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.09,,,14.09,Fee Schedule,100% Medicaid Laboratory Fee Schedule,31.7,,,31.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,31.7,,,31.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.56,,,21.56,Fee Schedule,153% Medicaid Laboratory Fee Schedule,31.7,,,31.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.73,,,19.73,Fee Schedule,140% Medicaid Laboratory Fee Schedule,31.7,,,31.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,36.63,,,36.63,Fee Schedule,260% Medicaid Laboratory Fee Schedule,45.65,,,45.65,Fee Schedule,324% Medicaid Laboratory Fee Schedule,30.29,,,30.29,Fee Schedule,215% Medicaid Laboratory Fee Schedule,30.29,,,30.29,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.61,,,17.61,Fee Schedule,125% Medicaid Laboratory Fee Schedule,14.09,224,
ORTHOPOXVIRUS MOLEC DETECT PCR  ,87593,CPT,,40164659,CDM,306,RC,,,both,,,159,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,79.5,50,,79.5,percent of total billed charges,All Other Outpatient,71.55,45,,71.55,percent of total billed charges,All Other Outpatient,68.37,43,,68.37,percent of total billed charges,All Other Outpatient,79.5,50,,79.5,percent of total billed charges,All Other,111.3,70,,111.3,percent of total billed charges,All Other,0.01,,,0.01,Fee Schedule,,96.39,,,96.39,Other,186% Medicaid methodology,0.01,,,0.01,Fee Schedule,,98.58,,,98.58,Fee Schedule,,0.01,,,0.01,Fee Schedule,,0.01,,,0.01,Fee Schedule,,98.58,,,98.58,Fee Schedule,,0.01,,,0.01,Fee Schedule,,111.3,70,,111.3,percent of total billed charges,All Other,79.5,50,,79.5,percent of total billed charges,All Other,79.5,50,,79.5,percent of total billed charges,All Other,61.4,,,61.4,Fee Schedule,,61.4,,,61.4,Fee Schedule,,61.4,,,61.4,Fee Schedule,,61.4,,,61.4,Fee Schedule,,51.82,,,51.82,Fee Schedule,Medicaid Laboratory Fee Schedule,51.82,,,51.82,Fee Schedule,100% Medicaid Laboratory Fee Schedule,51.82,,,51.82,Fee Schedule,100% Medicaid Laboratory Fee Schedule,51.82,,,51.82,Fee Schedule,100% Medicaid Laboratory Fee Schedule,116.6,,,116.6,Fee Schedule,225% Medicaid Laboratory Fee Schedule,116.6,,,116.6,Fee Schedule,225% Medicaid Laboratory Fee Schedule,79.29,,,79.29,Fee Schedule,153% Medicaid Laboratory Fee Schedule,116.6,,,116.6,Fee Schedule,225% Medicaid Laboratory Fee Schedule,72.55,,,72.55,Fee Schedule,140% Medicaid Laboratory Fee Schedule,116.6,,,116.6,Fee Schedule,225% Medicaid Laboratory Fee Schedule,134.74,,,134.74,Fee Schedule,260% Medicaid Laboratory Fee Schedule,167.91,,,167.91,Fee Schedule,324% Medicaid Laboratory Fee Schedule,111.42,,,111.42,Fee Schedule,215% Medicaid Laboratory Fee Schedule,111.42,,,111.42,Fee Schedule,215% Medicaid Laboratory Fee Schedule,64.78,,,64.78,Fee Schedule,125% Medicaid Laboratory Fee Schedule,0.01,167.91,
CULTURE TYPING OTHER METHODS    ,87158,CPT,,40164709,CDM,306,RC,,,both,,,78,12.73,,,12.73,Other,150% of Medicare + 9.63% HCRA Surcharge,7.74,,,7.74,Fee Schedule,Mediare Clinical Lab,14.94,,,14.94,Fee Schedule,,13.47,,,13.47,Fee Schedule,,52.84,,,52.84,Fee Schedule,,47.55,,,47.55,Fee Schedule,,44.9,,,44.9,Fee Schedule,,39,50,,39,percent of total billed charges,All Other,16.35,,,16.35,Fee Schedule,,24.38,,,24.38,Fee Schedule,,62.87,,,62.87,Other,186% Medicaid methodology,28.72,,,28.72,Fee Schedule,,48.36,,,48.36,Fee Schedule,,16.25,,,16.25,Fee Schedule,,28.72,,,28.72,Fee Schedule,,48.36,,,48.36,Fee Schedule,,30.57,,,30.57,Fee Schedule,,54.6,70,,54.6,percent of total billed charges,All Other,36.9,,,36.9,Fee Schedule,,31.31,,,31.31,Fee Schedule,,9.29,,,9.29,Fee Schedule,,9.29,,,9.29,Fee Schedule,,9.29,,,9.29,Fee Schedule,,9.29,,,9.29,Fee Schedule,,33.8,,,33.8,Other,New York Medicaid APG methodology,33.8,,,33.8,Other,100% Medicaid APG methodology,33.8,,,33.8,Other,100% Medicaid APG methodology,33.8,,,33.8,Other,100% Medicaid APG methodology,76.06,,,76.06,Other,225% Medicaid APG methodology,76.06,,,76.06,Other,225% Medicaid APG methodology,51.72,,,51.72,Other,153% Medicaid APG methodology,76.06,,,76.06,Other,225% Medicaid APG methodology,47.32,,,47.32,Other,140% Medicaid APG methodology,76.06,,,76.06,Other,225% Medicaid APG methodology,87.89,,,87.89,Other,260% Medicaid APG methodology,109.52,,,109.52,Other,324% Medicaid APG methodology,72.68,,,72.68,Other,215% Medicaid APG methodology,72.68,,,72.68,Other,215% Medicaid APG methodology,42.25,,,42.25,Other,125% Medicaid APG methodology,7.74,109.52,
RSV DNA/RNA AMP PROBE           ,87634,CPT,,40164725,CDM,306,RC,,,both,,,1117,115.44,,,115.44,Other,150% of Medicare + 9.63% HCRA Surcharge,70.2,,,70.2,Fee Schedule,Mediare Clinical Lab,135.49,,,135.49,Fee Schedule,,122.15,,,122.15,Fee Schedule,,558.5,50,,558.5,percent of total billed charges,All Other Outpatient,502.65,45,,502.65,percent of total billed charges,All Other Outpatient,480.31,43,,480.31,percent of total billed charges,All Other Outpatient,558.5,50,,558.5,percent of total billed charges,All Other,148.3,,,148.3,Fee Schedule,,221.13,,,221.13,Fee Schedule,,40.26,,,40.26,Other,186% Medicaid methodology,260.44,,,260.44,Fee Schedule,,692.54,,,692.54,Fee Schedule,,147.42,,,147.42,Fee Schedule,,260.44,,,260.44,Fee Schedule,,692.54,,,692.54,Fee Schedule,,277.29,,,277.29,Fee Schedule,,781.9,70,,781.9,percent of total billed charges,All Other,334.71,,,334.71,Fee Schedule,,284,,,284,Fee Schedule,,84.24,,,84.24,Fee Schedule,,84.24,,,84.24,Fee Schedule,,84.24,,,84.24,Fee Schedule,,84.24,,,84.24,Fee Schedule,,21.64,,,21.64,Fee Schedule,Medicaid Laboratory Fee Schedule,21.64,,,21.64,Fee Schedule,100% Medicaid Laboratory Fee Schedule,21.64,,,21.64,Fee Schedule,100% Medicaid Laboratory Fee Schedule,21.64,,,21.64,Fee Schedule,100% Medicaid Laboratory Fee Schedule,48.7,,,48.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,48.7,,,48.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,33.12,,,33.12,Fee Schedule,153% Medicaid Laboratory Fee Schedule,48.7,,,48.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,30.3,,,30.3,Fee Schedule,140% Medicaid Laboratory Fee Schedule,48.7,,,48.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,56.28,,,56.28,Fee Schedule,260% Medicaid Laboratory Fee Schedule,70.13,,,70.13,Fee Schedule,324% Medicaid Laboratory Fee Schedule,46.54,,,46.54,Fee Schedule,215% Medicaid Laboratory Fee Schedule,46.54,,,46.54,Fee Schedule,215% Medicaid Laboratory Fee Schedule,27.06,,,27.06,Fee Schedule,125% Medicaid Laboratory Fee Schedule,21.64,781.9,
DNA/RNA DIRECT PROBE            ,87149,CPT,,40164733,CDM,306,RC,,,both,,,320,32.97,,,32.97,Other,150% of Medicare + 9.63% HCRA Surcharge,20.05,,,20.05,Fee Schedule,Mediare Clinical Lab,38.7,,,38.7,Fee Schedule,,34.89,,,34.89,Fee Schedule,,202.62,,,202.62,Fee Schedule,,182.3,,,182.3,Fee Schedule,,172.14,,,172.14,Fee Schedule,,160,50,,160,percent of total billed charges,All Other,42.35,,,42.35,Fee Schedule,,63.16,,,63.16,Fee Schedule,,62.87,,,62.87,Other,186% Medicaid methodology,74.39,,,74.39,Fee Schedule,,198.4,,,198.4,Fee Schedule,,42.11,,,42.11,Fee Schedule,,74.39,,,74.39,Fee Schedule,,198.4,,,198.4,Fee Schedule,,79.2,,,79.2,Fee Schedule,,224,70,,224,percent of total billed charges,All Other,95.6,,,95.6,Fee Schedule,,81.11,,,81.11,Fee Schedule,,24.06,,,24.06,Fee Schedule,,24.06,,,24.06,Fee Schedule,,24.06,,,24.06,Fee Schedule,,24.06,,,24.06,Fee Schedule,,33.8,,,33.8,Other,New York Medicaid APG methodology,33.8,,,33.8,Other,100% Medicaid APG methodology,33.8,,,33.8,Other,100% Medicaid APG methodology,33.8,,,33.8,Other,100% Medicaid APG methodology,76.06,,,76.06,Other,225% Medicaid APG methodology,76.06,,,76.06,Other,225% Medicaid APG methodology,51.72,,,51.72,Other,153% Medicaid APG methodology,76.06,,,76.06,Other,225% Medicaid APG methodology,47.32,,,47.32,Other,140% Medicaid APG methodology,76.06,,,76.06,Other,225% Medicaid APG methodology,87.89,,,87.89,Other,260% Medicaid APG methodology,109.52,,,109.52,Other,324% Medicaid APG methodology,72.68,,,72.68,Other,215% Medicaid APG methodology,72.68,,,72.68,Other,215% Medicaid APG methodology,42.25,,,42.25,Other,125% Medicaid APG methodology,20.05,224,
HIV-2 PROBE&REVRSE TRNSCRIPJ    ,87538,CPT,,40164741,CDM,306,RC,,,both,,,557,57.7,,,57.7,Other,150% of Medicare + 9.63% HCRA Surcharge,35.09,,,35.09,Fee Schedule,Mediare Clinical Lab,67.72,,,67.72,Fee Schedule,,61.06,,,61.06,Fee Schedule,,354.62,,,354.62,Fee Schedule,,319.06,,,319.06,Fee Schedule,,301.28,,,301.28,Fee Schedule,,278.5,50,,278.5,percent of total billed charges,All Other,74.13,,,74.13,Fee Schedule,,110.53,,,110.53,Fee Schedule,,128.55,,,128.55,Other,186% Medicaid methodology,130.18,,,130.18,Fee Schedule,,345.34,,,345.34,Fee Schedule,,73.69,,,73.69,Fee Schedule,,130.18,,,130.18,Fee Schedule,,345.34,,,345.34,Fee Schedule,,138.61,,,138.61,Fee Schedule,,389.9,70,,389.9,percent of total billed charges,All Other,167.31,,,167.31,Fee Schedule,,141.96,,,141.96,Fee Schedule,,42.11,,,42.11,Fee Schedule,,42.11,,,42.11,Fee Schedule,,42.11,,,42.11,Fee Schedule,,42.11,,,42.11,Fee Schedule,,69.11,,,69.11,Other,New York Medicaid APG methodology,69.11,,,69.11,Other,100% Medicaid APG methodology,69.11,,,69.11,Other,100% Medicaid APG methodology,69.11,,,69.11,Other,100% Medicaid APG methodology,155.5,,,155.5,Other,225% Medicaid APG methodology,155.5,,,155.5,Other,225% Medicaid APG methodology,105.74,,,105.74,Other,153% Medicaid APG methodology,155.5,,,155.5,Other,225% Medicaid APG methodology,96.75,,,96.75,Other,140% Medicaid APG methodology,155.5,,,155.5,Other,225% Medicaid APG methodology,179.69,,,179.69,Other,260% Medicaid APG methodology,223.92,,,223.92,Other,324% Medicaid APG methodology,148.59,,,148.59,Other,215% Medicaid APG methodology,148.59,,,148.59,Other,215% Medicaid APG methodology,86.39,,,86.39,Other,125% Medicaid APG methodology,35.09,389.9,
MICROBE SUSCEPT MACROBROTH      ,87188,CPT,,40164758,CDM,306,RC,,,both,,,349,10.92,,,10.92,Other,150% of Medicare + 9.63% HCRA Surcharge,6.64,,,6.64,Fee Schedule,Mediare Clinical Lab,12.82,,,12.82,Fee Schedule,,11.55,,,11.55,Fee Schedule,,58.73,,,58.73,Fee Schedule,,52.84,,,52.84,Fee Schedule,,49.9,,,49.9,Fee Schedule,,174.5,50,,174.5,percent of total billed charges,All Other,14.04,,,14.04,Fee Schedule,,20.92,,,20.92,Fee Schedule,,8.45,,,8.45,Other,186% Medicaid methodology,24.63,,,24.63,Fee Schedule,,216.38,,,216.38,Fee Schedule,,13.94,,,13.94,Fee Schedule,,24.63,,,24.63,Fee Schedule,,216.38,,,216.38,Fee Schedule,,26.23,,,26.23,Fee Schedule,,244.3,70,,244.3,percent of total billed charges,All Other,31.66,,,31.66,Fee Schedule,,26.86,,,26.86,Fee Schedule,,7.97,,,7.97,Fee Schedule,,7.97,,,7.97,Fee Schedule,,7.97,,,7.97,Fee Schedule,,7.97,,,7.97,Fee Schedule,,4.55,,,4.55,Fee Schedule,Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.23,,,10.23,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.23,,,10.23,Fee Schedule,225% Medicaid Laboratory Fee Schedule,6.95,,,6.95,Fee Schedule,153% Medicaid Laboratory Fee Schedule,10.23,,,10.23,Fee Schedule,225% Medicaid Laboratory Fee Schedule,6.36,,,6.36,Fee Schedule,140% Medicaid Laboratory Fee Schedule,10.23,,,10.23,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,260% Medicaid Laboratory Fee Schedule,14.73,,,14.73,Fee Schedule,324% Medicaid Laboratory Fee Schedule,9.77,,,9.77,Fee Schedule,215% Medicaid Laboratory Fee Schedule,9.77,,,9.77,Fee Schedule,215% Medicaid Laboratory Fee Schedule,5.68,,,5.68,Fee Schedule,125% Medicaid Laboratory Fee Schedule,4.55,244.3,
MICROBE SUSCEPT MYCOBACTERI     ,87190,CPT,,40164766,CDM,306,RC,,,both,,,55,12.02,,,12.02,Other,150% of Medicare + 9.63% HCRA Surcharge,7.31,,,7.31,Fee Schedule,Mediare Clinical Lab,14.11,,,14.11,Fee Schedule,,12.72,,,12.72,Fee Schedule,,57.15,,,57.15,Fee Schedule,,51.42,,,51.42,Fee Schedule,,48.56,,,48.56,Fee Schedule,,27.5,50,,27.5,percent of total billed charges,All Other,15.44,,,15.44,Fee Schedule,,23.03,,,23.03,Fee Schedule,,13.6,,,13.6,Other,186% Medicaid methodology,27.12,,,27.12,Fee Schedule,,34.1,,,34.1,Fee Schedule,,15.35,,,15.35,Fee Schedule,,27.12,,,27.12,Fee Schedule,,34.1,,,34.1,Fee Schedule,,28.87,,,28.87,Fee Schedule,,38.5,70,,38.5,percent of total billed charges,All Other,34.85,,,34.85,Fee Schedule,,29.57,,,29.57,Fee Schedule,,8.77,,,8.77,Fee Schedule,,8.77,,,8.77,Fee Schedule,,8.77,,,8.77,Fee Schedule,,8.77,,,8.77,Fee Schedule,,7.31,,,7.31,Fee Schedule,Medicaid Laboratory Fee Schedule,7.31,,,7.31,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.31,,,7.31,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.31,,,7.31,Fee Schedule,100% Medicaid Laboratory Fee Schedule,16.45,,,16.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.45,,,16.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.18,,,11.18,Fee Schedule,153% Medicaid Laboratory Fee Schedule,16.45,,,16.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.23,,,10.23,Fee Schedule,140% Medicaid Laboratory Fee Schedule,16.45,,,16.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,19.01,,,19.01,Fee Schedule,260% Medicaid Laboratory Fee Schedule,23.68,,,23.68,Fee Schedule,324% Medicaid Laboratory Fee Schedule,15.72,,,15.72,Fee Schedule,215% Medicaid Laboratory Fee Schedule,15.72,,,15.72,Fee Schedule,215% Medicaid Laboratory Fee Schedule,9.14,,,9.14,Fee Schedule,125% Medicaid Laboratory Fee Schedule,7.31,57.15,
MYCOBACTERIC IDENTIFICATION     ,87118,CPT,,40164774,CDM,306,RC,,,both,,,74,24.03,,,24.03,Other,150% of Medicare + 9.63% HCRA Surcharge,14.61,,,14.61,Fee Schedule,Mediare Clinical Lab,28.2,,,28.2,Fee Schedule,,25.42,,,25.42,Fee Schedule,,110.57,,,110.57,Fee Schedule,,99.48,,,99.48,Fee Schedule,,93.94,,,93.94,Fee Schedule,,37,50,,37,percent of total billed charges,All Other,30.88,,,30.88,Fee Schedule,,46.02,,,46.02,Fee Schedule,,27.17,,,27.17,Other,186% Medicaid methodology,54.2,,,54.2,Fee Schedule,,45.88,,,45.88,Fee Schedule,,30.68,,,30.68,Fee Schedule,,54.2,,,54.2,Fee Schedule,,45.88,,,45.88,Fee Schedule,,57.71,,,57.71,Fee Schedule,,51.8,70,,51.8,percent of total billed charges,All Other,69.66,,,69.66,Fee Schedule,,59.11,,,59.11,Fee Schedule,,17.53,,,17.53,Fee Schedule,,17.53,,,17.53,Fee Schedule,,17.53,,,17.53,Fee Schedule,,17.53,,,17.53,Fee Schedule,,14.61,,,14.61,Fee Schedule,Medicaid Laboratory Fee Schedule,14.61,,,14.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.61,,,14.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,14.61,,,14.61,Fee Schedule,100% Medicaid Laboratory Fee Schedule,32.87,,,32.87,Fee Schedule,225% Medicaid Laboratory Fee Schedule,32.87,,,32.87,Fee Schedule,225% Medicaid Laboratory Fee Schedule,22.35,,,22.35,Fee Schedule,153% Medicaid Laboratory Fee Schedule,32.87,,,32.87,Fee Schedule,225% Medicaid Laboratory Fee Schedule,20.45,,,20.45,Fee Schedule,140% Medicaid Laboratory Fee Schedule,32.87,,,32.87,Fee Schedule,225% Medicaid Laboratory Fee Schedule,37.99,,,37.99,Fee Schedule,260% Medicaid Laboratory Fee Schedule,47.34,,,47.34,Fee Schedule,324% Medicaid Laboratory Fee Schedule,31.41,,,31.41,Fee Schedule,215% Medicaid Laboratory Fee Schedule,31.41,,,31.41,Fee Schedule,215% Medicaid Laboratory Fee Schedule,18.26,,,18.26,Fee Schedule,125% Medicaid Laboratory Fee Schedule,14.61,110.57,
HEPATITIS B SURFACE AG IA       ,87340,CPT,,40165607,CDM,306,RC,,,both,,,165,16.99,,,16.99,Other,150% of Medicare + 9.63% HCRA Surcharge,10.33,,,10.33,Fee Schedule,Mediare Clinical Lab,19.94,,,19.94,Fee Schedule,,17.97,,,17.97,Fee Schedule,,104.33,,,104.33,Fee Schedule,,93.86,,,93.86,Fee Schedule,,88.63,,,88.63,Fee Schedule,,82.5,50,,82.5,percent of total billed charges,All Other,21.81,,,21.81,Fee Schedule,,32.54,,,32.54,Fee Schedule,,19.21,,,19.21,Other,186% Medicaid methodology,38.32,,,38.32,Fee Schedule,,102.3,,,102.3,Fee Schedule,,21.69,,,21.69,Fee Schedule,,38.32,,,38.32,Fee Schedule,,102.3,,,102.3,Fee Schedule,,40.8,,,40.8,Fee Schedule,,115.5,70,,115.5,percent of total billed charges,All Other,49.25,,,49.25,Fee Schedule,,41.79,,,41.79,Fee Schedule,,12.4,,,12.4,Fee Schedule,,12.4,,,12.4,Fee Schedule,,12.4,,,12.4,Fee Schedule,,12.4,,,12.4,Fee Schedule,,10.33,,,10.33,Fee Schedule,Medicaid Laboratory Fee Schedule,10.33,,,10.33,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.33,,,10.33,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.33,,,10.33,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.24,,,23.24,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.24,,,23.24,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.8,,,15.8,Fee Schedule,153% Medicaid Laboratory Fee Schedule,23.24,,,23.24,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.46,,,14.46,Fee Schedule,140% Medicaid Laboratory Fee Schedule,23.24,,,23.24,Fee Schedule,225% Medicaid Laboratory Fee Schedule,26.86,,,26.86,Fee Schedule,260% Medicaid Laboratory Fee Schedule,33.47,,,33.47,Fee Schedule,324% Medicaid Laboratory Fee Schedule,22.21,,,22.21,Fee Schedule,215% Medicaid Laboratory Fee Schedule,22.21,,,22.21,Fee Schedule,215% Medicaid Laboratory Fee Schedule,12.91,,,12.91,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.33,115.5,
HEPATITIS BE AG IA              ,87350,CPT,,40165623,CDM,306,RC,,,both,,,184,18.96,,,18.96,Other,150% of Medicare + 9.63% HCRA Surcharge,11.53,,,11.53,Fee Schedule,Mediare Clinical Lab,22.25,,,22.25,Fee Schedule,,20.06,,,20.06,Fee Schedule,,116.46,,,116.46,Fee Schedule,,104.78,,,104.78,Fee Schedule,,98.94,,,98.94,Fee Schedule,,92,50,,92,percent of total billed charges,All Other,24.34,,,24.34,Fee Schedule,,36.32,,,36.32,Fee Schedule,,18.97,,,18.97,Other,186% Medicaid methodology,42.78,,,42.78,Fee Schedule,,114.08,,,114.08,Fee Schedule,,24.21,,,24.21,Fee Schedule,,42.78,,,42.78,Fee Schedule,,114.08,,,114.08,Fee Schedule,,45.54,,,45.54,Fee Schedule,,128.8,70,,128.8,percent of total billed charges,All Other,54.97,,,54.97,Fee Schedule,,46.64,,,46.64,Fee Schedule,,13.84,,,13.84,Fee Schedule,,13.84,,,13.84,Fee Schedule,,13.84,,,13.84,Fee Schedule,,13.84,,,13.84,Fee Schedule,,10.2,,,10.2,Fee Schedule,Medicaid Laboratory Fee Schedule,10.2,,,10.2,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.2,,,10.2,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.2,,,10.2,Fee Schedule,100% Medicaid Laboratory Fee Schedule,22.95,,,22.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,22.95,,,22.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.61,,,15.61,Fee Schedule,153% Medicaid Laboratory Fee Schedule,22.95,,,22.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.28,,,14.28,Fee Schedule,140% Medicaid Laboratory Fee Schedule,22.95,,,22.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,26.52,,,26.52,Fee Schedule,260% Medicaid Laboratory Fee Schedule,33.05,,,33.05,Fee Schedule,324% Medicaid Laboratory Fee Schedule,21.93,,,21.93,Fee Schedule,215% Medicaid Laboratory Fee Schedule,21.93,,,21.93,Fee Schedule,215% Medicaid Laboratory Fee Schedule,12.75,,,12.75,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.2,128.8,
GIARDIA AG IA                   ,87329,CPT,,40166225,CDM,306,RC,,,both,,,191,19.7,,,19.7,Other,150% of Medicare + 9.63% HCRA Surcharge,11.98,,,11.98,Fee Schedule,Mediare Clinical Lab,23.12,,,23.12,Fee Schedule,,20.85,,,20.85,Fee Schedule,,88.39,,,88.39,Fee Schedule,,79.52,,,79.52,Fee Schedule,,75.09,,,75.09,Fee Schedule,,95.5,50,,95.5,percent of total billed charges,All Other,25.32,,,25.32,Fee Schedule,,37.74,,,37.74,Fee Schedule,,22.28,,,22.28,Other,186% Medicaid methodology,44.45,,,44.45,Fee Schedule,,118.42,,,118.42,Fee Schedule,,25.16,,,25.16,Fee Schedule,,44.45,,,44.45,Fee Schedule,,118.42,,,118.42,Fee Schedule,,47.32,,,47.32,Fee Schedule,,133.7,70,,133.7,percent of total billed charges,All Other,57.12,,,57.12,Fee Schedule,,48.47,,,48.47,Fee Schedule,,14.38,,,14.38,Fee Schedule,,14.38,,,14.38,Fee Schedule,,14.38,,,14.38,Fee Schedule,,14.38,,,14.38,Fee Schedule,,11.98,,,11.98,Fee Schedule,Medicaid Laboratory Fee Schedule,11.98,,,11.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.98,,,11.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,11.98,,,11.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,26.96,,,26.96,Fee Schedule,225% Medicaid Laboratory Fee Schedule,26.96,,,26.96,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.33,,,18.33,Fee Schedule,153% Medicaid Laboratory Fee Schedule,26.96,,,26.96,Fee Schedule,225% Medicaid Laboratory Fee Schedule,16.77,,,16.77,Fee Schedule,140% Medicaid Laboratory Fee Schedule,26.96,,,26.96,Fee Schedule,225% Medicaid Laboratory Fee Schedule,31.15,,,31.15,Fee Schedule,260% Medicaid Laboratory Fee Schedule,38.82,,,38.82,Fee Schedule,324% Medicaid Laboratory Fee Schedule,25.76,,,25.76,Fee Schedule,215% Medicaid Laboratory Fee Schedule,25.76,,,25.76,Fee Schedule,215% Medicaid Laboratory Fee Schedule,14.98,,,14.98,Fee Schedule,125% Medicaid Laboratory Fee Schedule,11.98,133.7,
CYTOMEG DNA AMP PROBE           ,87496,CPT,,40169005,CDM,306,RC,,,both,,,558,57.7,,,57.7,Other,150% of Medicare + 9.63% HCRA Surcharge,35.09,,,35.09,Fee Schedule,Mediare Clinical Lab,67.72,,,67.72,Fee Schedule,,61.06,,,61.06,Fee Schedule,,354.62,,,354.62,Fee Schedule,,319.06,,,319.06,Fee Schedule,,301.28,,,301.28,Fee Schedule,,279,50,,279,percent of total billed charges,All Other,74.13,,,74.13,Fee Schedule,,110.53,,,110.53,Fee Schedule,,43.94,,,43.94,Other,186% Medicaid methodology,130.18,,,130.18,Fee Schedule,,345.96,,,345.96,Fee Schedule,,73.69,,,73.69,Fee Schedule,,130.18,,,130.18,Fee Schedule,,345.96,,,345.96,Fee Schedule,,138.61,,,138.61,Fee Schedule,,390.6,70,,390.6,percent of total billed charges,All Other,167.31,,,167.31,Fee Schedule,,141.96,,,141.96,Fee Schedule,,42.11,,,42.11,Fee Schedule,,42.11,,,42.11,Fee Schedule,,42.11,,,42.11,Fee Schedule,,42.11,,,42.11,Fee Schedule,,23.62,,,23.62,Fee Schedule,Medicaid Laboratory Fee Schedule,23.62,,,23.62,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.62,,,23.62,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.62,,,23.62,Fee Schedule,100% Medicaid Laboratory Fee Schedule,53.15,,,53.15,Fee Schedule,225% Medicaid Laboratory Fee Schedule,53.15,,,53.15,Fee Schedule,225% Medicaid Laboratory Fee Schedule,36.14,,,36.14,Fee Schedule,153% Medicaid Laboratory Fee Schedule,53.15,,,53.15,Fee Schedule,225% Medicaid Laboratory Fee Schedule,33.07,,,33.07,Fee Schedule,140% Medicaid Laboratory Fee Schedule,53.15,,,53.15,Fee Schedule,225% Medicaid Laboratory Fee Schedule,61.42,,,61.42,Fee Schedule,260% Medicaid Laboratory Fee Schedule,76.54,,,76.54,Fee Schedule,324% Medicaid Laboratory Fee Schedule,50.79,,,50.79,Fee Schedule,215% Medicaid Laboratory Fee Schedule,50.79,,,50.79,Fee Schedule,215% Medicaid Laboratory Fee Schedule,29.53,,,29.53,Fee Schedule,125% Medicaid Laboratory Fee Schedule,23.62,390.6,
CYTOMEG DNA QUANT               ,87497,CPT,,40169021,CDM,306,RC,,,both,,,682,70.45,,,70.45,Other,150% of Medicare + 9.63% HCRA Surcharge,42.84,,,42.84,Fee Schedule,Mediare Clinical Lab,82.68,,,82.68,Fee Schedule,,74.54,,,74.54,Fee Schedule,,432.81,,,432.81,Fee Schedule,,389.41,,,389.41,Fee Schedule,,367.71,,,367.71,Fee Schedule,,341,50,,341,percent of total billed charges,All Other,90.51,,,90.51,Fee Schedule,,134.95,,,134.95,Fee Schedule,,53.65,,,53.65,Other,186% Medicaid methodology,158.94,,,158.94,Fee Schedule,,422.84,,,422.84,Fee Schedule,,89.96,,,89.96,Fee Schedule,,158.94,,,158.94,Fee Schedule,,422.84,,,422.84,Fee Schedule,,169.22,,,169.22,Fee Schedule,,477.4,70,,477.4,percent of total billed charges,All Other,204.26,,,204.26,Fee Schedule,,173.31,,,173.31,Fee Schedule,,51.41,,,51.41,Fee Schedule,,51.41,,,51.41,Fee Schedule,,51.41,,,51.41,Fee Schedule,,51.41,,,51.41,Fee Schedule,,28.85,,,28.85,Fee Schedule,Medicaid Laboratory Fee Schedule,28.85,,,28.85,Fee Schedule,100% Medicaid Laboratory Fee Schedule,28.85,,,28.85,Fee Schedule,100% Medicaid Laboratory Fee Schedule,28.85,,,28.85,Fee Schedule,100% Medicaid Laboratory Fee Schedule,64.9,,,64.9,Fee Schedule,225% Medicaid Laboratory Fee Schedule,64.9,,,64.9,Fee Schedule,225% Medicaid Laboratory Fee Schedule,44.13,,,44.13,Fee Schedule,153% Medicaid Laboratory Fee Schedule,64.9,,,64.9,Fee Schedule,225% Medicaid Laboratory Fee Schedule,40.38,,,40.38,Fee Schedule,140% Medicaid Laboratory Fee Schedule,64.9,,,64.9,Fee Schedule,225% Medicaid Laboratory Fee Schedule,75,,,75,Fee Schedule,260% Medicaid Laboratory Fee Schedule,93.46,,,93.46,Fee Schedule,324% Medicaid Laboratory Fee Schedule,62.02,,,62.02,Fee Schedule,215% Medicaid Laboratory Fee Schedule,62.02,,,62.02,Fee Schedule,215% Medicaid Laboratory Fee Schedule,36.06,,,36.06,Fee Schedule,125% Medicaid Laboratory Fee Schedule,28.85,477.4,
STOOL CULTR AEROBIC BACT EA     ,87046,CPT,,40169146,CDM,306,RC,,,both,,,151,15.52,,,15.52,Other,150% of Medicare + 9.63% HCRA Surcharge,9.44,,,9.44,Fee Schedule,Mediare Clinical Lab,18.22,,,18.22,Fee Schedule,,16.43,,,16.43,Fee Schedule,,95.35,,,95.35,Fee Schedule,,85.79,,,85.79,Fee Schedule,,81.01,,,81.01,Fee Schedule,,75.5,50,,75.5,percent of total billed charges,All Other,19.96,,,19.96,Fee Schedule,,29.74,,,29.74,Fee Schedule,,5.54,,,5.54,Other,186% Medicaid methodology,35.02,,,35.02,Fee Schedule,,93.62,,,93.62,Fee Schedule,,19.82,,,19.82,Fee Schedule,,35.02,,,35.02,Fee Schedule,,93.62,,,93.62,Fee Schedule,,37.29,,,37.29,Fee Schedule,,105.7,70,,105.7,percent of total billed charges,All Other,45.01,,,45.01,Fee Schedule,,38.19,,,38.19,Fee Schedule,,11.33,,,11.33,Fee Schedule,,11.33,,,11.33,Fee Schedule,,11.33,,,11.33,Fee Schedule,,11.33,,,11.33,Fee Schedule,,2.98,,,2.98,Fee Schedule,Medicaid Laboratory Fee Schedule,2.98,,,2.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,2.98,,,2.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,2.98,,,2.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.7,,,6.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,6.7,,,6.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,4.56,,,4.56,Fee Schedule,153% Medicaid Laboratory Fee Schedule,6.7,,,6.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,4.17,,,4.17,Fee Schedule,140% Medicaid Laboratory Fee Schedule,6.7,,,6.7,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.75,,,7.75,Fee Schedule,260% Medicaid Laboratory Fee Schedule,9.65,,,9.65,Fee Schedule,324% Medicaid Laboratory Fee Schedule,6.41,,,6.41,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.41,,,6.41,Fee Schedule,215% Medicaid Laboratory Fee Schedule,3.72,,,3.72,Fee Schedule,125% Medicaid Laboratory Fee Schedule,2.98,105.7,
MICROBE SUSCEPTIBLE DIFFUSE     ,87181,CPT,,40169229,CDM,306,RC,,,both,,,46,7.81,,,7.81,Other,150% of Medicare + 9.63% HCRA Surcharge,4.75,,,4.75,Fee Schedule,Mediare Clinical Lab,9.17,,,9.17,Fee Schedule,,8.27,,,8.27,Fee Schedule,,47.96,,,47.96,Fee Schedule,,43.15,,,43.15,Fee Schedule,,40.75,,,40.75,Fee Schedule,,23,50,,23,percent of total billed charges,All Other,10.04,,,10.04,Fee Schedule,,14.96,,,14.96,Fee Schedule,,8.45,,,8.45,Other,186% Medicaid methodology,17.62,,,17.62,Fee Schedule,,28.52,,,28.52,Fee Schedule,,9.98,,,9.98,Fee Schedule,,17.62,,,17.62,Fee Schedule,,28.52,,,28.52,Fee Schedule,,18.76,,,18.76,Fee Schedule,,32.2,70,,32.2,percent of total billed charges,All Other,22.65,,,22.65,Fee Schedule,,19.22,,,19.22,Fee Schedule,,5.7,,,5.7,Fee Schedule,,5.7,,,5.7,Fee Schedule,,5.7,,,5.7,Fee Schedule,,5.7,,,5.7,Fee Schedule,,4.55,,,4.55,Fee Schedule,Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.23,,,10.23,Fee Schedule,225% Medicaid Laboratory Fee Schedule,10.23,,,10.23,Fee Schedule,225% Medicaid Laboratory Fee Schedule,6.95,,,6.95,Fee Schedule,153% Medicaid Laboratory Fee Schedule,10.23,,,10.23,Fee Schedule,225% Medicaid Laboratory Fee Schedule,6.36,,,6.36,Fee Schedule,140% Medicaid Laboratory Fee Schedule,10.23,,,10.23,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.82,,,11.82,Fee Schedule,260% Medicaid Laboratory Fee Schedule,14.73,,,14.73,Fee Schedule,324% Medicaid Laboratory Fee Schedule,9.77,,,9.77,Fee Schedule,215% Medicaid Laboratory Fee Schedule,9.77,,,9.77,Fee Schedule,215% Medicaid Laboratory Fee Schedule,5.68,,,5.68,Fee Schedule,125% Medicaid Laboratory Fee Schedule,4.55,47.96,
CULTURE TYPE IMMUNOLOGIC        ,87147,CPT,,40169385,CDM,306,RC,,,both,,,50,8.52,,,8.52,Other,150% of Medicare + 9.63% HCRA Surcharge,5.18,,,5.18,Fee Schedule,Mediare Clinical Lab,10,,,10,Fee Schedule,,9.01,,,9.01,Fee Schedule,,52.27,,,52.27,Fee Schedule,,47.03,,,47.03,Fee Schedule,,44.41,,,44.41,Fee Schedule,,25,50,,25,percent of total billed charges,All Other,10.95,,,10.95,Fee Schedule,,16.32,,,16.32,Fee Schedule,,62.87,,,62.87,Other,186% Medicaid methodology,19.22,,,19.22,Fee Schedule,,31,,,31,Fee Schedule,,10.88,,,10.88,Fee Schedule,,19.22,,,19.22,Fee Schedule,,31,,,31,Fee Schedule,,20.46,,,20.46,Fee Schedule,,35,70,,35,percent of total billed charges,All Other,24.7,,,24.7,Fee Schedule,,20.96,,,20.96,Fee Schedule,,6.22,,,6.22,Fee Schedule,,6.22,,,6.22,Fee Schedule,,6.22,,,6.22,Fee Schedule,,6.22,,,6.22,Fee Schedule,,33.8,,,33.8,Other,New York Medicaid APG methodology,33.8,,,33.8,Other,100% Medicaid APG methodology,33.8,,,33.8,Other,100% Medicaid APG methodology,33.8,,,33.8,Other,100% Medicaid APG methodology,76.06,,,76.06,Other,225% Medicaid APG methodology,76.06,,,76.06,Other,225% Medicaid APG methodology,51.72,,,51.72,Other,153% Medicaid APG methodology,76.06,,,76.06,Other,225% Medicaid APG methodology,47.32,,,47.32,Other,140% Medicaid APG methodology,76.06,,,76.06,Other,225% Medicaid APG methodology,87.89,,,87.89,Other,260% Medicaid APG methodology,109.52,,,109.52,Other,324% Medicaid APG methodology,72.68,,,72.68,Other,215% Medicaid APG methodology,72.68,,,72.68,Other,215% Medicaid APG methodology,42.25,,,42.25,Other,125% Medicaid APG methodology,5.18,109.52,
SMEAR WET MOUNT SALINE/INK      ,87210,CPT,,40169765,CDM,306,RC,,,both,,,93,9.57,,,9.57,Other,150% of Medicare + 9.63% HCRA Surcharge,5.82,,,5.82,Fee Schedule,Mediare Clinical Lab,11.23,,,11.23,Fee Schedule,,10.13,,,10.13,Fee Schedule,,43.15,,,43.15,Fee Schedule,,38.82,,,38.82,Fee Schedule,,36.66,,,36.66,Fee Schedule,,46.5,50,,46.5,percent of total billed charges,All Other,12.29,,,12.29,Fee Schedule,,18.33,,,18.33,Fee Schedule,,6.39,,,6.39,Other,186% Medicaid methodology,21.59,,,21.59,Fee Schedule,,57.66,,,57.66,Fee Schedule,,12.22,,,12.22,Fee Schedule,,21.59,,,21.59,Fee Schedule,,57.66,,,57.66,Fee Schedule,,22.99,,,22.99,Fee Schedule,,65.1,70,,65.1,percent of total billed charges,All Other,27.75,,,27.75,Fee Schedule,,23.54,,,23.54,Fee Schedule,,6.98,,,6.98,Fee Schedule,,6.98,,,6.98,Fee Schedule,,6.98,,,6.98,Fee Schedule,,6.98,,,6.98,Fee Schedule,,3.43,,,3.43,Fee Schedule,Medicaid Laboratory Fee Schedule,3.43,,,3.43,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.43,,,3.43,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.43,,,3.43,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.73,,,7.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.73,,,7.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,153% Medicaid Laboratory Fee Schedule,7.73,,,7.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,4.81,,,4.81,Fee Schedule,140% Medicaid Laboratory Fee Schedule,7.73,,,7.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.93,,,8.93,Fee Schedule,260% Medicaid Laboratory Fee Schedule,11.13,,,11.13,Fee Schedule,324% Medicaid Laboratory Fee Schedule,7.38,,,7.38,Fee Schedule,215% Medicaid Laboratory Fee Schedule,7.38,,,7.38,Fee Schedule,215% Medicaid Laboratory Fee Schedule,4.29,,,4.29,Fee Schedule,125% Medicaid Laboratory Fee Schedule,3.43,65.1,
CULTURE ANAEROBE IDENT EACH     ,87076,CPT,,40169781,CDM,306,RC,,,both,,,129,13.29,,,13.29,Other,150% of Medicare + 9.63% HCRA Surcharge,8.08,,,8.08,Fee Schedule,Mediare Clinical Lab,15.59,,,15.59,Fee Schedule,,14.06,,,14.06,Fee Schedule,,81.64,,,81.64,Fee Schedule,,73.45,,,73.45,Fee Schedule,,69.36,,,69.36,Fee Schedule,,64.5,50,,64.5,percent of total billed charges,All Other,17.06,,,17.06,Fee Schedule,,25.45,,,25.45,Fee Schedule,,15.03,,,15.03,Other,186% Medicaid methodology,29.98,,,29.98,Fee Schedule,,79.98,,,79.98,Fee Schedule,,16.97,,,16.97,Fee Schedule,,29.98,,,29.98,Fee Schedule,,79.98,,,79.98,Fee Schedule,,31.92,,,31.92,Fee Schedule,,90.3,70,,90.3,percent of total billed charges,All Other,38.52,,,38.52,Fee Schedule,,32.69,,,32.69,Fee Schedule,,9.7,,,9.7,Fee Schedule,,9.7,,,9.7,Fee Schedule,,9.7,,,9.7,Fee Schedule,,9.7,,,9.7,Fee Schedule,,8.08,,,8.08,Fee Schedule,Medicaid Laboratory Fee Schedule,8.08,,,8.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.08,,,8.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.08,,,8.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.18,,,18.18,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.18,,,18.18,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.36,,,12.36,Fee Schedule,153% Medicaid Laboratory Fee Schedule,18.18,,,18.18,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.31,,,11.31,Fee Schedule,140% Medicaid Laboratory Fee Schedule,18.18,,,18.18,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.01,,,21.01,Fee Schedule,260% Medicaid Laboratory Fee Schedule,26.18,,,26.18,Fee Schedule,324% Medicaid Laboratory Fee Schedule,17.37,,,17.37,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.37,,,17.37,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.1,,,10.1,Fee Schedule,125% Medicaid Laboratory Fee Schedule,8.08,90.3,
SPECIMEN INFECT AGNT CONCNTJ    ,87015,CPT,,40169807,CDM,306,RC,,,both,,,106,10.98,,,10.98,Other,150% of Medicare + 9.63% HCRA Surcharge,6.68,,,6.68,Fee Schedule,Mediare Clinical Lab,12.89,,,12.89,Fee Schedule,,11.62,,,11.62,Fee Schedule,,67.49,,,67.49,Fee Schedule,,60.72,,,60.72,Fee Schedule,,57.34,,,57.34,Fee Schedule,,53,50,,53,percent of total billed charges,All Other,14.11,,,14.11,Fee Schedule,,21.04,,,21.04,Fee Schedule,,6.11,,,6.11,Other,186% Medicaid methodology,24.78,,,24.78,Fee Schedule,,65.72,,,65.72,Fee Schedule,,14.03,,,14.03,Fee Schedule,,24.78,,,24.78,Fee Schedule,,65.72,,,65.72,Fee Schedule,,26.39,,,26.39,Fee Schedule,,74.2,70,,74.2,percent of total billed charges,All Other,31.85,,,31.85,Fee Schedule,,27.02,,,27.02,Fee Schedule,,8.02,,,8.02,Fee Schedule,,8.02,,,8.02,Fee Schedule,,8.02,,,8.02,Fee Schedule,,8.02,,,8.02,Fee Schedule,,3.28,,,3.28,Fee Schedule,Medicaid Laboratory Fee Schedule,3.28,,,3.28,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.28,,,3.28,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.28,,,3.28,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.39,,,7.39,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.39,,,7.39,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.02,,,5.02,Fee Schedule,153% Medicaid Laboratory Fee Schedule,7.39,,,7.39,Fee Schedule,225% Medicaid Laboratory Fee Schedule,4.6,,,4.6,Fee Schedule,140% Medicaid Laboratory Fee Schedule,7.39,,,7.39,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.53,,,8.53,Fee Schedule,260% Medicaid Laboratory Fee Schedule,10.64,,,10.64,Fee Schedule,324% Medicaid Laboratory Fee Schedule,7.06,,,7.06,Fee Schedule,215% Medicaid Laboratory Fee Schedule,7.06,,,7.06,Fee Schedule,215% Medicaid Laboratory Fee Schedule,4.1,,,4.1,Fee Schedule,125% Medicaid Laboratory Fee Schedule,3.28,74.2,
CULTURE AEROBIC IDENTIFY        ,87077,CPT,,40169880,CDM,306,RC,,,both,,,129,13.29,,,13.29,Other,150% of Medicare + 9.63% HCRA Surcharge,8.08,,,8.08,Fee Schedule,Mediare Clinical Lab,15.59,,,15.59,Fee Schedule,,14.06,,,14.06,Fee Schedule,,81.64,,,81.64,Fee Schedule,,73.45,,,73.45,Fee Schedule,,69.36,,,69.36,Fee Schedule,,64.5,50,,64.5,percent of total billed charges,All Other,17.06,,,17.06,Fee Schedule,,25.45,,,25.45,Fee Schedule,,15.03,,,15.03,Other,186% Medicaid methodology,29.98,,,29.98,Fee Schedule,,79.98,,,79.98,Fee Schedule,,16.97,,,16.97,Fee Schedule,,29.98,,,29.98,Fee Schedule,,79.98,,,79.98,Fee Schedule,,31.92,,,31.92,Fee Schedule,,90.3,70,,90.3,percent of total billed charges,All Other,38.52,,,38.52,Fee Schedule,,32.69,,,32.69,Fee Schedule,,9.7,,,9.7,Fee Schedule,,9.7,,,9.7,Fee Schedule,,9.7,,,9.7,Fee Schedule,,9.7,,,9.7,Fee Schedule,,8.08,,,8.08,Fee Schedule,Medicaid Laboratory Fee Schedule,8.08,,,8.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.08,,,8.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,8.08,,,8.08,Fee Schedule,100% Medicaid Laboratory Fee Schedule,18.18,,,18.18,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.18,,,18.18,Fee Schedule,225% Medicaid Laboratory Fee Schedule,12.36,,,12.36,Fee Schedule,153% Medicaid Laboratory Fee Schedule,18.18,,,18.18,Fee Schedule,225% Medicaid Laboratory Fee Schedule,11.31,,,11.31,Fee Schedule,140% Medicaid Laboratory Fee Schedule,18.18,,,18.18,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.01,,,21.01,Fee Schedule,260% Medicaid Laboratory Fee Schedule,26.18,,,26.18,Fee Schedule,324% Medicaid Laboratory Fee Schedule,17.37,,,17.37,Fee Schedule,215% Medicaid Laboratory Fee Schedule,17.37,,,17.37,Fee Schedule,215% Medicaid Laboratory Fee Schedule,10.1,,,10.1,Fee Schedule,125% Medicaid Laboratory Fee Schedule,8.08,90.3,
FUNGI IDENTIFICATION MOLD       ,87107,CPT,,40169906,CDM,306,RC,,,both,,,165,16.97,,,16.97,Other,150% of Medicare + 9.63% HCRA Surcharge,10.32,,,10.32,Fee Schedule,Mediare Clinical Lab,19.92,,,19.92,Fee Schedule,,17.96,,,17.96,Fee Schedule,,104.33,,,104.33,Fee Schedule,,93.86,,,93.86,Fee Schedule,,88.63,,,88.63,Fee Schedule,,82.5,50,,82.5,percent of total billed charges,All Other,21.81,,,21.81,Fee Schedule,,32.51,,,32.51,Fee Schedule,,18.22,,,18.22,Other,186% Medicaid methodology,38.29,,,38.29,Fee Schedule,,102.3,,,102.3,Fee Schedule,,21.67,,,21.67,Fee Schedule,,38.29,,,38.29,Fee Schedule,,102.3,,,102.3,Fee Schedule,,40.76,,,40.76,Fee Schedule,,115.5,70,,115.5,percent of total billed charges,All Other,49.21,,,49.21,Fee Schedule,,41.75,,,41.75,Fee Schedule,,12.38,,,12.38,Fee Schedule,,12.38,,,12.38,Fee Schedule,,12.38,,,12.38,Fee Schedule,,12.38,,,12.38,Fee Schedule,,9.8,,,9.8,Fee Schedule,Medicaid Laboratory Fee Schedule,9.8,,,9.8,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.8,,,9.8,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.8,,,9.8,Fee Schedule,100% Medicaid Laboratory Fee Schedule,22.04,,,22.04,Fee Schedule,225% Medicaid Laboratory Fee Schedule,22.04,,,22.04,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.99,,,14.99,Fee Schedule,153% Medicaid Laboratory Fee Schedule,22.04,,,22.04,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.72,,,13.72,Fee Schedule,140% Medicaid Laboratory Fee Schedule,22.04,,,22.04,Fee Schedule,225% Medicaid Laboratory Fee Schedule,25.47,,,25.47,Fee Schedule,260% Medicaid Laboratory Fee Schedule,31.74,,,31.74,Fee Schedule,324% Medicaid Laboratory Fee Schedule,21.06,,,21.06,Fee Schedule,215% Medicaid Laboratory Fee Schedule,21.06,,,21.06,Fee Schedule,215% Medicaid Laboratory Fee Schedule,12.25,,,12.25,Fee Schedule,125% Medicaid Laboratory Fee Schedule,9.8,115.5,
CULTR BACTERIA EXCEPT BLOOD     ,87075,CPT,,40172520,CDM,306,RC,,,both,,,151,15.57,,,15.57,Other,150% of Medicare + 9.63% HCRA Surcharge,9.47,,,9.47,Fee Schedule,Mediare Clinical Lab,18.28,,,18.28,Fee Schedule,,16.48,,,16.48,Fee Schedule,,95.57,,,95.57,Fee Schedule,,85.98,,,85.98,Fee Schedule,,81.19,,,81.19,Fee Schedule,,75.5,50,,75.5,percent of total billed charges,All Other,20.02,,,20.02,Fee Schedule,,29.83,,,29.83,Fee Schedule,,17.61,,,17.61,Other,186% Medicaid methodology,35.13,,,35.13,Fee Schedule,,93.62,,,93.62,Fee Schedule,,19.89,,,19.89,Fee Schedule,,35.13,,,35.13,Fee Schedule,,93.62,,,93.62,Fee Schedule,,37.41,,,37.41,Fee Schedule,,105.7,70,,105.7,percent of total billed charges,All Other,45.15,,,45.15,Fee Schedule,,38.31,,,38.31,Fee Schedule,,11.36,,,11.36,Fee Schedule,,11.36,,,11.36,Fee Schedule,,11.36,,,11.36,Fee Schedule,,11.36,,,11.36,Fee Schedule,,9.47,,,9.47,Fee Schedule,Medicaid Laboratory Fee Schedule,9.47,,,9.47,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.47,,,9.47,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.47,,,9.47,Fee Schedule,100% Medicaid Laboratory Fee Schedule,21.31,,,21.31,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.31,,,21.31,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.49,,,14.49,Fee Schedule,153% Medicaid Laboratory Fee Schedule,21.31,,,21.31,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.26,,,13.26,Fee Schedule,140% Medicaid Laboratory Fee Schedule,21.31,,,21.31,Fee Schedule,225% Medicaid Laboratory Fee Schedule,24.62,,,24.62,Fee Schedule,260% Medicaid Laboratory Fee Schedule,30.68,,,30.68,Fee Schedule,324% Medicaid Laboratory Fee Schedule,20.36,,,20.36,Fee Schedule,215% Medicaid Laboratory Fee Schedule,20.36,,,20.36,Fee Schedule,215% Medicaid Laboratory Fee Schedule,11.84,,,11.84,Fee Schedule,125% Medicaid Laboratory Fee Schedule,9.47,105.7,
HSV DNA AMP PROBE               ,87529,CPT,,40181349,CDM,306,RC,,,both,,,558,57.7,,,57.7,Other,150% of Medicare + 9.63% HCRA Surcharge,35.09,,,35.09,Fee Schedule,Mediare Clinical Lab,67.72,,,67.72,Fee Schedule,,61.06,,,61.06,Fee Schedule,,354.62,,,354.62,Fee Schedule,,319.06,,,319.06,Fee Schedule,,301.28,,,301.28,Fee Schedule,,279,50,,279,percent of total billed charges,All Other,74.13,,,74.13,Fee Schedule,,110.53,,,110.53,Fee Schedule,,60.4,,,60.4,Other,186% Medicaid methodology,130.18,,,130.18,Fee Schedule,,345.96,,,345.96,Fee Schedule,,73.69,,,73.69,Fee Schedule,,130.18,,,130.18,Fee Schedule,,345.96,,,345.96,Fee Schedule,,138.61,,,138.61,Fee Schedule,,390.6,70,,390.6,percent of total billed charges,All Other,167.31,,,167.31,Fee Schedule,,141.96,,,141.96,Fee Schedule,,42.11,,,42.11,Fee Schedule,,42.11,,,42.11,Fee Schedule,,42.11,,,42.11,Fee Schedule,,42.11,,,42.11,Fee Schedule,,32.47,,,32.47,Fee Schedule,Medicaid Laboratory Fee Schedule,32.47,,,32.47,Fee Schedule,100% Medicaid Laboratory Fee Schedule,32.47,,,32.47,Fee Schedule,100% Medicaid Laboratory Fee Schedule,32.47,,,32.47,Fee Schedule,100% Medicaid Laboratory Fee Schedule,73.06,,,73.06,Fee Schedule,225% Medicaid Laboratory Fee Schedule,73.06,,,73.06,Fee Schedule,225% Medicaid Laboratory Fee Schedule,49.68,,,49.68,Fee Schedule,153% Medicaid Laboratory Fee Schedule,73.06,,,73.06,Fee Schedule,225% Medicaid Laboratory Fee Schedule,45.46,,,45.46,Fee Schedule,140% Medicaid Laboratory Fee Schedule,73.06,,,73.06,Fee Schedule,225% Medicaid Laboratory Fee Schedule,84.43,,,84.43,Fee Schedule,260% Medicaid Laboratory Fee Schedule,105.21,,,105.21,Fee Schedule,324% Medicaid Laboratory Fee Schedule,69.81,,,69.81,Fee Schedule,215% Medicaid Laboratory Fee Schedule,69.81,,,69.81,Fee Schedule,215% Medicaid Laboratory Fee Schedule,40.59,,,40.59,Fee Schedule,125% Medicaid Laboratory Fee Schedule,32.47,390.6,
HEPATITIS C REVRS TRNSCRPJ      ,87522,CPT,,40181984,CDM,306,RC,,,both,,,682,70.45,,,70.45,Other,150% of Medicare + 9.63% HCRA Surcharge,42.84,,,42.84,Fee Schedule,Mediare Clinical Lab,82.68,,,82.68,Fee Schedule,,74.54,,,74.54,Fee Schedule,,432.81,,,432.81,Fee Schedule,,389.41,,,389.41,Fee Schedule,,367.71,,,367.71,Fee Schedule,,341,50,,341,percent of total billed charges,All Other,90.51,,,90.51,Fee Schedule,,134.95,,,134.95,Fee Schedule,,79.68,,,79.68,Other,186% Medicaid methodology,158.94,,,158.94,Fee Schedule,,422.84,,,422.84,Fee Schedule,,89.96,,,89.96,Fee Schedule,,158.94,,,158.94,Fee Schedule,,422.84,,,422.84,Fee Schedule,,169.22,,,169.22,Fee Schedule,,477.4,70,,477.4,percent of total billed charges,All Other,204.26,,,204.26,Fee Schedule,,173.31,,,173.31,Fee Schedule,,51.41,,,51.41,Fee Schedule,,51.41,,,51.41,Fee Schedule,,51.41,,,51.41,Fee Schedule,,51.41,,,51.41,Fee Schedule,,42.84,,,42.84,Fee Schedule,Medicaid Laboratory Fee Schedule,42.84,,,42.84,Fee Schedule,100% Medicaid Laboratory Fee Schedule,42.84,,,42.84,Fee Schedule,100% Medicaid Laboratory Fee Schedule,42.84,,,42.84,Fee Schedule,100% Medicaid Laboratory Fee Schedule,96.39,,,96.39,Fee Schedule,225% Medicaid Laboratory Fee Schedule,96.39,,,96.39,Fee Schedule,225% Medicaid Laboratory Fee Schedule,65.55,,,65.55,Fee Schedule,153% Medicaid Laboratory Fee Schedule,96.39,,,96.39,Fee Schedule,225% Medicaid Laboratory Fee Schedule,59.98,,,59.98,Fee Schedule,140% Medicaid Laboratory Fee Schedule,96.39,,,96.39,Fee Schedule,225% Medicaid Laboratory Fee Schedule,111.38,,,111.38,Fee Schedule,260% Medicaid Laboratory Fee Schedule,138.8,,,138.8,Fee Schedule,324% Medicaid Laboratory Fee Schedule,92.11,,,92.11,Fee Schedule,215% Medicaid Laboratory Fee Schedule,92.11,,,92.11,Fee Schedule,215% Medicaid Laboratory Fee Schedule,53.55,,,53.55,Fee Schedule,125% Medicaid Laboratory Fee Schedule,42.84,477.4,
HEPATITIS B DNA QUANT           ,87517,CPT,,40182149,CDM,306,RC,,,both,,,682,70.45,,,70.45,Other,150% of Medicare + 9.63% HCRA Surcharge,42.84,,,42.84,Fee Schedule,Mediare Clinical Lab,82.68,,,82.68,Fee Schedule,,74.54,,,74.54,Fee Schedule,,432.81,,,432.81,Fee Schedule,,389.41,,,389.41,Fee Schedule,,367.71,,,367.71,Fee Schedule,,341,50,,341,percent of total billed charges,All Other,90.51,,,90.51,Fee Schedule,,134.95,,,134.95,Fee Schedule,,128.55,,,128.55,Other,186% Medicaid methodology,158.94,,,158.94,Fee Schedule,,422.84,,,422.84,Fee Schedule,,89.96,,,89.96,Fee Schedule,,158.94,,,158.94,Fee Schedule,,422.84,,,422.84,Fee Schedule,,169.22,,,169.22,Fee Schedule,,477.4,70,,477.4,percent of total billed charges,All Other,204.26,,,204.26,Fee Schedule,,173.31,,,173.31,Fee Schedule,,51.41,,,51.41,Fee Schedule,,51.41,,,51.41,Fee Schedule,,51.41,,,51.41,Fee Schedule,,51.41,,,51.41,Fee Schedule,,69.11,,,69.11,Other,New York Medicaid APG methodology,69.11,,,69.11,Other,100% Medicaid APG methodology,69.11,,,69.11,Other,100% Medicaid APG methodology,69.11,,,69.11,Other,100% Medicaid APG methodology,155.5,,,155.5,Other,225% Medicaid APG methodology,155.5,,,155.5,Other,225% Medicaid APG methodology,105.74,,,105.74,Other,153% Medicaid APG methodology,155.5,,,155.5,Other,225% Medicaid APG methodology,96.75,,,96.75,Other,140% Medicaid APG methodology,155.5,,,155.5,Other,225% Medicaid APG methodology,179.69,,,179.69,Other,260% Medicaid APG methodology,223.92,,,223.92,Other,324% Medicaid APG methodology,148.59,,,148.59,Other,215% Medicaid APG methodology,148.59,,,148.59,Other,215% Medicaid APG methodology,86.39,,,86.39,Other,125% Medicaid APG methodology,42.84,477.4,
GENOTYPE DNA/RNA HEP C          ,87902,CPT,,40185506,CDM,306,RC,,,both,,,4094,423.36,,,423.36,Other,150% of Medicare + 9.63% HCRA Surcharge,257.45,,,257.45,Fee Schedule,Mediare Clinical Lab,496.88,,,496.88,Fee Schedule,,447.96,,,447.96,Fee Schedule,,2601.17,,,2601.17,Fee Schedule,,2340.33,,,2340.33,Fee Schedule,,2209.91,,,2209.91,Fee Schedule,,2047,50,,2047,percent of total billed charges,All Other,543.86,,,543.86,Fee Schedule,,810.97,,,810.97,Fee Schedule,,478.86,,,478.86,Other,186% Medicaid methodology,955.14,,,955.14,Fee Schedule,,2538.28,,,2538.28,Fee Schedule,,540.65,,,540.65,Fee Schedule,,955.14,,,955.14,Fee Schedule,,2538.28,,,2538.28,Fee Schedule,,1016.93,,,1016.93,Fee Schedule,,2865.8,70,,2865.8,percent of total billed charges,All Other,1227.5,,,1227.5,Fee Schedule,,1041.52,,,1041.52,Fee Schedule,,308.94,,,308.94,Fee Schedule,,308.94,,,308.94,Fee Schedule,,308.94,,,308.94,Fee Schedule,,308.94,,,308.94,Fee Schedule,,257.45,,,257.45,Fee Schedule,Medicaid Laboratory Fee Schedule,257.45,,,257.45,Fee Schedule,100% Medicaid Laboratory Fee Schedule,257.45,,,257.45,Fee Schedule,100% Medicaid Laboratory Fee Schedule,257.45,,,257.45,Fee Schedule,100% Medicaid Laboratory Fee Schedule,579.26,,,579.26,Fee Schedule,225% Medicaid Laboratory Fee Schedule,579.26,,,579.26,Fee Schedule,225% Medicaid Laboratory Fee Schedule,393.9,,,393.9,Fee Schedule,153% Medicaid Laboratory Fee Schedule,579.26,,,579.26,Fee Schedule,225% Medicaid Laboratory Fee Schedule,360.43,,,360.43,Fee Schedule,140% Medicaid Laboratory Fee Schedule,579.26,,,579.26,Fee Schedule,225% Medicaid Laboratory Fee Schedule,669.37,,,669.37,Fee Schedule,260% Medicaid Laboratory Fee Schedule,834.14,,,834.14,Fee Schedule,324% Medicaid Laboratory Fee Schedule,553.52,,,553.52,Fee Schedule,215% Medicaid Laboratory Fee Schedule,553.52,,,553.52,Fee Schedule,215% Medicaid Laboratory Fee Schedule,321.81,,,321.81,Fee Schedule,125% Medicaid Laboratory Fee Schedule,257.45,2865.8,
SARS-COV-2 COVID-19 AMP PRB     ,87635,CPT,,40199051,CDM,306,RC,,,both,,,159,84.38,,,84.38,Other,150% of Medicare + 9.63% HCRA Surcharge,51.31,,,51.31,Fee Schedule,Mediare Clinical Lab,99.03,,,99.03,Fee Schedule,,89.28,,,89.28,Fee Schedule,,61.57,,,61.57,Fee Schedule,,61.57,,,61.57,Fee Schedule,,61.57,,,61.57,Fee Schedule,,79.5,50,,79.5,percent of total billed charges,All Other,51.31,,,51.31,Fee Schedule,,161.63,,,161.63,Fee Schedule,,57.27,,,57.27,Other,186% Medicaid methodology,190.36,,,190.36,Fee Schedule,,98.58,,,98.58,Fee Schedule,,107.75,,,107.75,Fee Schedule,,190.36,,,190.36,Fee Schedule,,98.58,,,98.58,Fee Schedule,,202.67,,,202.67,Fee Schedule,,111.3,70,,111.3,percent of total billed charges,All Other,244.64,,,244.64,Fee Schedule,,207.58,,,207.58,Fee Schedule,,61.57,,,61.57,Fee Schedule,,61.57,,,61.57,Fee Schedule,,61.57,,,61.57,Fee Schedule,,61.57,,,61.57,Fee Schedule,,30.79,,,30.79,Fee Schedule,Medicaid Laboratory Fee Schedule,30.79,,,30.79,Fee Schedule,100% Medicaid Laboratory Fee Schedule,30.79,,,30.79,Fee Schedule,100% Medicaid Laboratory Fee Schedule,30.79,,,30.79,Fee Schedule,100% Medicaid Laboratory Fee Schedule,69.28,,,69.28,Fee Schedule,225% Medicaid Laboratory Fee Schedule,69.28,,,69.28,Fee Schedule,225% Medicaid Laboratory Fee Schedule,47.11,,,47.11,Fee Schedule,153% Medicaid Laboratory Fee Schedule,69.28,,,69.28,Fee Schedule,225% Medicaid Laboratory Fee Schedule,43.11,,,43.11,Fee Schedule,140% Medicaid Laboratory Fee Schedule,69.28,,,69.28,Fee Schedule,225% Medicaid Laboratory Fee Schedule,80.05,,,80.05,Fee Schedule,260% Medicaid Laboratory Fee Schedule,99.76,,,99.76,Fee Schedule,324% Medicaid Laboratory Fee Schedule,66.2,,,66.2,Fee Schedule,215% Medicaid Laboratory Fee Schedule,66.2,,,66.2,Fee Schedule,215% Medicaid Laboratory Fee Schedule,38.49,,,38.49,Fee Schedule,125% Medicaid Laboratory Fee Schedule,30.79,244.64,
URINALYSIS VOLUME MEASURE       ,81050,CPT,,40100109,CDM,307,RC,,,both,,,59,5.99,,,5.99,Other,150% of Medicare + 9.63% HCRA Surcharge,3.64,,,3.64,Fee Schedule,Mediare Clinical Lab,7.03,,,7.03,Fee Schedule,,6.33,,,6.33,Fee Schedule,,30.3,,,30.3,Fee Schedule,,27.26,,,27.26,Fee Schedule,,25.74,,,25.74,Fee Schedule,,29.5,50,,29.5,percent of total billed charges,All Other,7.7,,,7.7,Fee Schedule,,11.47,,,11.47,Fee Schedule,,64.86,,,64.86,Other,186% Medicaid methodology,13.5,,,13.5,Fee Schedule,,36.58,,,36.58,Fee Schedule,,7.64,,,7.64,Fee Schedule,,13.5,,,13.5,Fee Schedule,,36.58,,,36.58,Fee Schedule,,14.38,,,14.38,Fee Schedule,,41.3,70,,41.3,percent of total billed charges,All Other,17.36,,,17.36,Fee Schedule,,14.73,,,14.73,Fee Schedule,,4.37,,,4.37,Fee Schedule,,4.37,,,4.37,Fee Schedule,,4.37,,,4.37,Fee Schedule,,4.37,,,4.37,Fee Schedule,,34.87,,,34.87,Other,New York Medicaid APG methodology,34.87,,,34.87,Other,100% Medicaid APG methodology,34.87,,,34.87,Other,100% Medicaid APG methodology,34.87,,,34.87,Other,100% Medicaid APG methodology,78.46,,,78.46,Other,225% Medicaid APG methodology,78.46,,,78.46,Other,225% Medicaid APG methodology,53.35,,,53.35,Other,153% Medicaid APG methodology,78.46,,,78.46,Other,225% Medicaid APG methodology,48.82,,,48.82,Other,140% Medicaid APG methodology,78.46,,,78.46,Other,225% Medicaid APG methodology,90.67,,,90.67,Other,260% Medicaid APG methodology,112.98,,,112.98,Other,324% Medicaid APG methodology,74.97,,,74.97,Other,215% Medicaid APG methodology,74.97,,,74.97,Other,215% Medicaid APG methodology,43.59,,,43.59,Other,125% Medicaid APG methodology,3.64,112.98,
URINALYSIS AUTO W/SCOPE         ,81001,CPT,,40130007,CDM,307,RC,,,both,,,51,5.21,,,5.21,Other,150% of Medicare + 9.63% HCRA Surcharge,3.17,,,3.17,Fee Schedule,Mediare Clinical Lab,6.12,,,6.12,Fee Schedule,,5.52,,,5.52,Fee Schedule,,31.95,,,31.95,Fee Schedule,,28.75,,,28.75,Fee Schedule,,27.15,,,27.15,Fee Schedule,,25.5,50,,25.5,percent of total billed charges,All Other,6.7,,,6.7,Fee Schedule,,9.99,,,9.99,Fee Schedule,,5.9,,,5.9,Other,186% Medicaid methodology,11.76,,,11.76,Fee Schedule,,31.62,,,31.62,Fee Schedule,,6.66,,,6.66,Fee Schedule,,11.76,,,11.76,Fee Schedule,,31.62,,,31.62,Fee Schedule,,12.52,,,12.52,Fee Schedule,,35.7,70,,35.7,percent of total billed charges,All Other,15.11,,,15.11,Fee Schedule,,12.82,,,12.82,Fee Schedule,,3.8,,,3.8,Fee Schedule,,3.8,,,3.8,Fee Schedule,,3.8,,,3.8,Fee Schedule,,3.8,,,3.8,Fee Schedule,,3.17,,,3.17,Fee Schedule,Medicaid Laboratory Fee Schedule,3.17,,,3.17,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.17,,,3.17,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.17,,,3.17,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.13,,,7.13,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.13,,,7.13,Fee Schedule,225% Medicaid Laboratory Fee Schedule,4.85,,,4.85,Fee Schedule,153% Medicaid Laboratory Fee Schedule,7.13,,,7.13,Fee Schedule,225% Medicaid Laboratory Fee Schedule,4.44,,,4.44,Fee Schedule,140% Medicaid Laboratory Fee Schedule,7.13,,,7.13,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.24,,,8.24,Fee Schedule,260% Medicaid Laboratory Fee Schedule,10.27,,,10.27,Fee Schedule,324% Medicaid Laboratory Fee Schedule,6.82,,,6.82,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.82,,,6.82,Fee Schedule,215% Medicaid Laboratory Fee Schedule,3.96,,,3.96,Fee Schedule,125% Medicaid Laboratory Fee Schedule,3.17,35.7,
URINALYSIS AUTO W/O SCOPE       ,81003,CPT,,40130023,CDM,307,RC,,,both,,,37,3.7,,,3.7,Other,150% of Medicare + 9.63% HCRA Surcharge,2.25,,,2.25,Fee Schedule,Mediare Clinical Lab,4.34,,,4.34,Fee Schedule,,3.92,,,3.92,Fee Schedule,,22.69,,,22.69,Fee Schedule,,20.41,,,20.41,Fee Schedule,,19.28,,,19.28,Fee Schedule,,18.5,50,,18.5,percent of total billed charges,All Other,4.75,,,4.75,Fee Schedule,,7.09,,,7.09,Fee Schedule,,3.76,,,3.76,Other,186% Medicaid methodology,8.35,,,8.35,Fee Schedule,,22.94,,,22.94,Fee Schedule,,4.73,,,4.73,Fee Schedule,,8.35,,,8.35,Fee Schedule,,22.94,,,22.94,Fee Schedule,,8.89,,,8.89,Fee Schedule,,25.9,70,,25.9,percent of total billed charges,All Other,10.73,,,10.73,Fee Schedule,,9.1,,,9.1,Fee Schedule,,2.7,,,2.7,Fee Schedule,,2.7,,,2.7,Fee Schedule,,2.7,,,2.7,Fee Schedule,,2.7,,,2.7,Fee Schedule,,2.02,,,2.02,Fee Schedule,Medicaid Laboratory Fee Schedule,2.02,,,2.02,Fee Schedule,100% Medicaid Laboratory Fee Schedule,2.02,,,2.02,Fee Schedule,100% Medicaid Laboratory Fee Schedule,2.02,,,2.02,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,225% Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,225% Medicaid Laboratory Fee Schedule,3.09,,,3.09,Fee Schedule,153% Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,225% Medicaid Laboratory Fee Schedule,2.83,,,2.83,Fee Schedule,140% Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,260% Medicaid Laboratory Fee Schedule,6.54,,,6.54,Fee Schedule,324% Medicaid Laboratory Fee Schedule,4.34,,,4.34,Fee Schedule,215% Medicaid Laboratory Fee Schedule,4.34,,,4.34,Fee Schedule,215% Medicaid Laboratory Fee Schedule,2.53,,,2.53,Fee Schedule,125% Medicaid Laboratory Fee Schedule,2.02,25.9,
PREGNANCY TEST URINE            ,81025,CPT,,40130080,CDM,307,RC,,,both,,,137,14.16,,,14.16,Other,150% of Medicare + 9.63% HCRA Surcharge,8.61,,,8.61,Fee Schedule,Mediare Clinical Lab,16.62,,,16.62,Fee Schedule,,14.98,,,14.98,Fee Schedule,,63.9,,,63.9,Fee Schedule,,57.49,,,57.49,Fee Schedule,,54.29,,,54.29,Fee Schedule,,68.5,50,,68.5,percent of total billed charges,All Other,18.2,,,18.2,Fee Schedule,,27.12,,,27.12,Fee Schedule,,3.76,,,3.76,Other,186% Medicaid methodology,31.94,,,31.94,Fee Schedule,,84.94,,,84.94,Fee Schedule,,18.08,,,18.08,Fee Schedule,,31.94,,,31.94,Fee Schedule,,84.94,,,84.94,Fee Schedule,,34.01,,,34.01,Fee Schedule,,95.9,70,,95.9,percent of total billed charges,All Other,41.05,,,41.05,Fee Schedule,,34.83,,,34.83,Fee Schedule,,10.33,,,10.33,Fee Schedule,,10.33,,,10.33,Fee Schedule,,10.33,,,10.33,Fee Schedule,,10.33,,,10.33,Fee Schedule,,2.02,,,2.02,Fee Schedule,Medicaid Laboratory Fee Schedule,2.02,,,2.02,Fee Schedule,100% Medicaid Laboratory Fee Schedule,2.02,,,2.02,Fee Schedule,100% Medicaid Laboratory Fee Schedule,2.02,,,2.02,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,225% Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,225% Medicaid Laboratory Fee Schedule,3.09,,,3.09,Fee Schedule,153% Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,225% Medicaid Laboratory Fee Schedule,2.83,,,2.83,Fee Schedule,140% Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,260% Medicaid Laboratory Fee Schedule,6.54,,,6.54,Fee Schedule,324% Medicaid Laboratory Fee Schedule,4.34,,,4.34,Fee Schedule,215% Medicaid Laboratory Fee Schedule,4.34,,,4.34,Fee Schedule,215% Medicaid Laboratory Fee Schedule,2.53,,,2.53,Fee Schedule,125% Medicaid Laboratory Fee Schedule,2.02,95.9,
UA Microscopic,81015,CPT,,40133126,CDM,307,RC,,,both,,,49,5.02,,,5.02,Other,150% of Medicare + 9.63% HCRA Surcharge,3.05,,,3.05,Fee Schedule,Mediare Clinical Lab,5.89,,,5.89,Fee Schedule,,5.31,,,5.31,Fee Schedule,,30.73,,,30.73,Fee Schedule,,27.65,,,27.65,Fee Schedule,,26.11,,,26.11,Fee Schedule,,24.5,50,,24.5,percent of total billed charges,All Other,6.44,,,6.44,Fee Schedule,,9.61,,,9.61,Fee Schedule,,3.76,,,3.76,Other,186% Medicaid methodology,11.32,,,11.32,Fee Schedule,,30.38,,,30.38,Fee Schedule,,6.41,,,6.41,Fee Schedule,,11.32,,,11.32,Fee Schedule,,30.38,,,30.38,Fee Schedule,,12.05,,,12.05,Fee Schedule,,34.3,70,,34.3,percent of total billed charges,All Other,14.54,,,14.54,Fee Schedule,,12.34,,,12.34,Fee Schedule,,3.66,,,3.66,Fee Schedule,,3.66,,,3.66,Fee Schedule,,3.66,,,3.66,Fee Schedule,,3.66,,,3.66,Fee Schedule,,2.02,,,2.02,Fee Schedule,Medicaid Laboratory Fee Schedule,2.02,,,2.02,Fee Schedule,100% Medicaid Laboratory Fee Schedule,2.02,,,2.02,Fee Schedule,100% Medicaid Laboratory Fee Schedule,2.02,,,2.02,Fee Schedule,100% Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,225% Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,225% Medicaid Laboratory Fee Schedule,3.09,,,3.09,Fee Schedule,153% Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,225% Medicaid Laboratory Fee Schedule,2.83,,,2.83,Fee Schedule,140% Medicaid Laboratory Fee Schedule,4.55,,,4.55,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,260% Medicaid Laboratory Fee Schedule,6.54,,,6.54,Fee Schedule,324% Medicaid Laboratory Fee Schedule,4.34,,,4.34,Fee Schedule,215% Medicaid Laboratory Fee Schedule,4.34,,,4.34,Fee Schedule,215% Medicaid Laboratory Fee Schedule,2.53,,,2.53,Fee Schedule,125% Medicaid Laboratory Fee Schedule,2.02,34.3,
EXAM SYNOVIAL FLUID CRYSTALS    ,89060,CPT,,40110280,CDM,309,RC,,,both,,,134,12.05,,,12.05,Other,150% of Medicare + 9.63% HCRA Surcharge,7.33,,,7.33,Fee Schedule,Mediare Clinical Lab,14.15,,,14.15,Fee Schedule,,12.75,,,12.75,Fee Schedule,,72.23,,,72.23,Fee Schedule,,64.99,,,64.99,Fee Schedule,,61.37,,,61.37,Fee Schedule,,67,50,,67,percent of total billed charges,All Other,15.47,,,15.47,Fee Schedule,,23.09,,,23.09,Fee Schedule,,11.27,,,11.27,Other,186% Medicaid methodology,27.19,,,27.19,Fee Schedule,,83.08,,,83.08,Fee Schedule,,15.39,,,15.39,Fee Schedule,,27.19,,,27.19,Fee Schedule,,83.08,,,83.08,Fee Schedule,,28.95,,,28.95,Fee Schedule,,93.8,70,,93.8,percent of total billed charges,All Other,34.95,,,34.95,Fee Schedule,,29.65,,,29.65,Fee Schedule,,8.8,,,8.8,Fee Schedule,,8.8,,,8.8,Fee Schedule,,8.8,,,8.8,Fee Schedule,,8.8,,,8.8,Fee Schedule,,6.06,,,6.06,Fee Schedule,Medicaid Laboratory Fee Schedule,6.06,,,6.06,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.06,,,6.06,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.06,,,6.06,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.64,,,13.64,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.64,,,13.64,Fee Schedule,225% Medicaid Laboratory Fee Schedule,9.27,,,9.27,Fee Schedule,153% Medicaid Laboratory Fee Schedule,13.64,,,13.64,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.48,,,8.48,Fee Schedule,140% Medicaid Laboratory Fee Schedule,13.64,,,13.64,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.76,,,15.76,Fee Schedule,260% Medicaid Laboratory Fee Schedule,19.63,,,19.63,Fee Schedule,324% Medicaid Laboratory Fee Schedule,13.03,,,13.03,Fee Schedule,215% Medicaid Laboratory Fee Schedule,13.03,,,13.03,Fee Schedule,215% Medicaid Laboratory Fee Schedule,7.58,,,7.58,Fee Schedule,125% Medicaid Laboratory Fee Schedule,6.06,93.8,
BODY FLUID CELL COUNT           ,89051,CPT,,40110306,CDM,309,RC,,,both,,,196,9.21,,,9.21,Other,150% of Medicare + 9.63% HCRA Surcharge,5.6,,,5.6,Fee Schedule,Mediare Clinical Lab,10.81,,,10.81,Fee Schedule,,9.74,,,9.74,Fee Schedule,,43.37,,,43.37,Fee Schedule,,39.02,,,39.02,Fee Schedule,,36.84,,,36.84,Fee Schedule,,98,50,,98,percent of total billed charges,All Other,11.83,,,11.83,Fee Schedule,,17.64,,,17.64,Fee Schedule,,5.26,,,5.26,Other,186% Medicaid methodology,20.78,,,20.78,Fee Schedule,,121.52,,,121.52,Fee Schedule,,11.76,,,11.76,Fee Schedule,,20.78,,,20.78,Fee Schedule,,121.52,,,121.52,Fee Schedule,,22.12,,,22.12,Fee Schedule,,137.2,70,,137.2,percent of total billed charges,All Other,26.7,,,26.7,Fee Schedule,,22.65,,,22.65,Fee Schedule,,6.72,,,6.72,Fee Schedule,,6.72,,,6.72,Fee Schedule,,6.72,,,6.72,Fee Schedule,,6.72,,,6.72,Fee Schedule,,2.83,,,2.83,Fee Schedule,Medicaid Laboratory Fee Schedule,2.83,,,2.83,Fee Schedule,100% Medicaid Laboratory Fee Schedule,2.83,,,2.83,Fee Schedule,100% Medicaid Laboratory Fee Schedule,2.83,,,2.83,Fee Schedule,100% Medicaid Laboratory Fee Schedule,6.36,,,6.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,6.36,,,6.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,4.33,,,4.33,Fee Schedule,153% Medicaid Laboratory Fee Schedule,6.36,,,6.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,3.96,,,3.96,Fee Schedule,140% Medicaid Laboratory Fee Schedule,6.36,,,6.36,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.35,,,7.35,Fee Schedule,260% Medicaid Laboratory Fee Schedule,9.16,,,9.16,Fee Schedule,324% Medicaid Laboratory Fee Schedule,6.08,,,6.08,Fee Schedule,215% Medicaid Laboratory Fee Schedule,6.08,,,6.08,Fee Schedule,215% Medicaid Laboratory Fee Schedule,3.54,,,3.54,Fee Schedule,125% Medicaid Laboratory Fee Schedule,2.83,137.2,
LEUKOCYTE ASSESSMENT FECAL      ,89055,CPT,,40160525,CDM,309,RC,,,both,,,68,7.02,,,7.02,Other,150% of Medicare + 9.63% HCRA Surcharge,4.27,,,4.27,Fee Schedule,Mediare Clinical Lab,8.24,,,8.24,Fee Schedule,,7.43,,,7.43,Fee Schedule,,43.15,,,43.15,Fee Schedule,,38.82,,,38.82,Fee Schedule,,36.66,,,36.66,Fee Schedule,,34,50,,34,percent of total billed charges,All Other,9.04,,,9.04,Fee Schedule,,13.45,,,13.45,Fee Schedule,,6.39,,,6.39,Other,186% Medicaid methodology,15.84,,,15.84,Fee Schedule,,42.16,,,42.16,Fee Schedule,,8.97,,,8.97,Fee Schedule,,15.84,,,15.84,Fee Schedule,,42.16,,,42.16,Fee Schedule,,16.87,,,16.87,Fee Schedule,,47.6,70,,47.6,percent of total billed charges,All Other,20.36,,,20.36,Fee Schedule,,17.27,,,17.27,Fee Schedule,,5.12,,,5.12,Fee Schedule,,5.12,,,5.12,Fee Schedule,,5.12,,,5.12,Fee Schedule,,5.12,,,5.12,Fee Schedule,,3.43,,,3.43,Fee Schedule,Medicaid Laboratory Fee Schedule,3.43,,,3.43,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.43,,,3.43,Fee Schedule,100% Medicaid Laboratory Fee Schedule,3.43,,,3.43,Fee Schedule,100% Medicaid Laboratory Fee Schedule,7.73,,,7.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,7.73,,,7.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,5.25,,,5.25,Fee Schedule,153% Medicaid Laboratory Fee Schedule,7.73,,,7.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,4.81,,,4.81,Fee Schedule,140% Medicaid Laboratory Fee Schedule,7.73,,,7.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,8.93,,,8.93,Fee Schedule,260% Medicaid Laboratory Fee Schedule,11.13,,,11.13,Fee Schedule,324% Medicaid Laboratory Fee Schedule,7.38,,,7.38,Fee Schedule,215% Medicaid Laboratory Fee Schedule,7.38,,,7.38,Fee Schedule,215% Medicaid Laboratory Fee Schedule,4.29,,,4.29,Fee Schedule,125% Medicaid Laboratory Fee Schedule,3.43,47.6,
COMPATIBILITY TEST SPIN         ,86920,CPT,,40211385,CDM,309,RC,,,both,,,2675,324.81,,,324.81,Other,150% of Medicare + 9.63% HCRA Surcharge,197.52,,,197.52,Other,Medicare OPPS methodology,1337.5,50,,1337.5,percent of total billed charges,All Other Outpatient,1203.75,45,,1203.75,percent of total billed charges,All Other Outpatient,9.4,,,9.4,Fee Schedule,,9.4,,,9.4,Fee Schedule,,9.4,,,9.4,Fee Schedule,,1337.5,50,,1337.5,percent of total billed charges,All Other,76.67,,,76.67,Fee Schedule,,1819,68,,1819,percent of total billed charges,All Other Outpatient,134.94,,,134.94,Other,186% Medicaid methodology,2140,80,,2140,percent of total billed charges,All Other Outpatient,2220.25,83,,2220.25,percent of total billed charges,All Other Outpatient,2220.25,83,,2220.25,percent of total billed charges,All Other Outpatient,2140,80,,2140,percent of total billed charges,All Other Outpatient,2220.25,83,,2220.25,percent of total billed charges,All Other Outpatient,2407.5,90,,2407.5,percent of total billed charges,All Other,1872.5,70,,1872.5,percent of total billed charges,All Other,1337.5,50,,1337.5,percent of total billed charges,All Other,1337.5,50,,1337.5,percent of total billed charges,All Other,172.2,,,172.2,Fee Schedule,,172.2,,,172.2,Fee Schedule,,172.2,,,172.2,Fee Schedule,,172.2,,,172.2,Fee Schedule,,72.55,,,72.55,Other,New York Medicaid APG methodology,72.55,,,72.55,Other,100% Medicaid APG methodology,72.55,,,72.55,Other,100% Medicaid APG methodology,72.55,,,72.55,Other,100% Medicaid APG methodology,163.23,,,163.23,Other,225% Medicaid APG methodology,163.23,,,163.23,Other,225% Medicaid APG methodology,111,,,111,Other,153% Medicaid APG methodology,163.23,,,163.23,Other,225% Medicaid APG methodology,101.57,,,101.57,Other,140% Medicaid APG methodology,163.23,,,163.23,Other,225% Medicaid APG methodology,188.62,,,188.62,Other,260% Medicaid APG methodology,235.05,,,235.05,Other,324% Medicaid APG methodology,155.98,,,155.98,Other,215% Medicaid APG methodology,155.98,,,155.98,Other,215% Medicaid APG methodology,90.68,,,90.68,Other,125% Medicaid APG methodology,9.4,2407.5,
COMPATIBILITY TEST ANTIGLOB     ,86922,CPT,,40211393,CDM,309,RC,,,both,,,2675,324.81,,,324.81,Other,150% of Medicare + 9.63% HCRA Surcharge,197.52,,,197.52,Other,Medicare OPPS methodology,1337.5,50,,1337.5,percent of total billed charges,All Other Outpatient,1203.75,45,,1203.75,percent of total billed charges,All Other Outpatient,10.08,,,10.08,Fee Schedule,,10.08,,,10.08,Fee Schedule,,10.08,,,10.08,Fee Schedule,,1337.5,50,,1337.5,percent of total billed charges,All Other,81.84,,,81.84,Fee Schedule,,1819,68,,1819,percent of total billed charges,All Other Outpatient,134.94,,,134.94,Other,186% Medicaid methodology,2140,80,,2140,percent of total billed charges,All Other Outpatient,2220.25,83,,2220.25,percent of total billed charges,All Other Outpatient,2220.25,83,,2220.25,percent of total billed charges,All Other Outpatient,2140,80,,2140,percent of total billed charges,All Other Outpatient,2220.25,83,,2220.25,percent of total billed charges,All Other Outpatient,2407.5,90,,2407.5,percent of total billed charges,All Other,1872.5,70,,1872.5,percent of total billed charges,All Other,1337.5,50,,1337.5,percent of total billed charges,All Other,1337.5,50,,1337.5,percent of total billed charges,All Other,172.2,,,172.2,Fee Schedule,,172.2,,,172.2,Fee Schedule,,172.2,,,172.2,Fee Schedule,,172.2,,,172.2,Fee Schedule,,72.55,,,72.55,Other,New York Medicaid APG methodology,72.55,,,72.55,Other,100% Medicaid APG methodology,72.55,,,72.55,Other,100% Medicaid APG methodology,72.55,,,72.55,Other,100% Medicaid APG methodology,163.23,,,163.23,Other,225% Medicaid APG methodology,163.23,,,163.23,Other,225% Medicaid APG methodology,111,,,111,Other,153% Medicaid APG methodology,163.23,,,163.23,Other,225% Medicaid APG methodology,101.57,,,101.57,Other,140% Medicaid APG methodology,163.23,,,163.23,Other,225% Medicaid APG methodology,188.62,,,188.62,Other,260% Medicaid APG methodology,235.05,,,235.05,Other,324% Medicaid APG methodology,155.98,,,155.98,Other,215% Medicaid APG methodology,155.98,,,155.98,Other,215% Medicaid APG methodology,90.68,,,90.68,Other,125% Medicaid APG methodology,10.08,2407.5,
81292 MIH1 GENE FULL SEQ,81292,CPT,,40121055,CDM,310,RC,,,both,,,2702,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,1351,50,,1351,percent of total billed charges,All Other Outpatient,1215.9,45,,1215.9,percent of total billed charges,All Other Outpatient,1351,50,,1351,percent of total billed charges,All Other Outpatient,1215.9,45,,1215.9,percent of total billed charges,All Other Outpatient,1161.86,43,,1161.86,percent of total billed charges,All Other Outpatient,1351,50,,1351,percent of total billed charges,All Other,1426.78,,,1426.78,Fee Schedule,,1837.36,68,,1837.36,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,2161.6,80,,2161.6,percent of total billed charges,All Other Outpatient,2242.66,83,,2242.66,percent of total billed charges,All Other Outpatient,2242.66,83,,2242.66,percent of total billed charges,All Other Outpatient,2161.6,80,,2161.6,percent of total billed charges,All Other Outpatient,2242.66,83,,2242.66,percent of total billed charges,All Other Outpatient,2431.8,90,,2431.8,percent of total billed charges,All Other,1891.4,70,,1891.4,percent of total billed charges,All Other,1351,50,,1351,percent of total billed charges,All Other,1351,50,,1351,percent of total billed charges,All Other,810.48,,,810.48,Fee Schedule,,810.48,,,810.48,Fee Schedule,,810.48,,,810.48,Fee Schedule,,810.48,,,810.48,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,2431.8,
81301 REF LAB MICROSATELLITE INSTABILITY,81301,CPT,,40121238,CDM,310,RC,,,both,,,1395,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,697.5,50,,697.5,percent of total billed charges,All Other Outpatient,627.75,45,,627.75,percent of total billed charges,All Other Outpatient,697.5,50,,697.5,percent of total billed charges,All Other Outpatient,627.75,45,,627.75,percent of total billed charges,All Other Outpatient,599.85,43,,599.85,percent of total billed charges,All Other Outpatient,697.5,50,,697.5,percent of total billed charges,All Other,736.32,,,736.32,Fee Schedule,,948.6,68,,948.6,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,1116,80,,1116,percent of total billed charges,All Other Outpatient,1157.85,83,,1157.85,percent of total billed charges,All Other Outpatient,1157.85,83,,1157.85,percent of total billed charges,All Other Outpatient,1116,80,,1116,percent of total billed charges,All Other Outpatient,1157.85,83,,1157.85,percent of total billed charges,All Other Outpatient,1255.5,90,,1255.5,percent of total billed charges,All Other,976.5,70,,976.5,percent of total billed charges,All Other,697.5,50,,697.5,percent of total billed charges,All Other,697.5,50,,697.5,percent of total billed charges,All Other,418.27,,,418.27,Fee Schedule,,418.27,,,418.27,Fee Schedule,,418.27,,,418.27,Fee Schedule,,418.27,,,418.27,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1255.5,
81402 REF LAB T CELL REARRANGEMENT / MPL,81402,CPT,,40121915,CDM,310,RC,,,both,,,451,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,225.5,50,,225.5,percent of total billed charges,All Other Outpatient,202.95,45,,202.95,percent of total billed charges,All Other Outpatient,225.5,50,,225.5,percent of total billed charges,All Other Outpatient,202.95,45,,202.95,percent of total billed charges,All Other Outpatient,193.93,43,,193.93,percent of total billed charges,All Other Outpatient,225.5,50,,225.5,percent of total billed charges,All Other,317.56,,,317.56,Fee Schedule,,306.68,68,,306.68,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,360.8,80,,360.8,percent of total billed charges,All Other Outpatient,374.33,83,,374.33,percent of total billed charges,All Other Outpatient,374.33,83,,374.33,percent of total billed charges,All Other Outpatient,360.8,80,,360.8,percent of total billed charges,All Other Outpatient,374.33,83,,374.33,percent of total billed charges,All Other Outpatient,405.9,90,,405.9,percent of total billed charges,All Other,315.7,70,,315.7,percent of total billed charges,All Other,225.5,50,,225.5,percent of total billed charges,All Other,225.5,50,,225.5,percent of total billed charges,All Other,180.4,,,180.4,Fee Schedule,,180.4,,,180.4,Fee Schedule,,180.4,,,180.4,Fee Schedule,,180.4,,,180.4,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,405.9,
81340 REF T-CELL RECEPTOR BETA,81340,CPT,,40129819,CDM,310,RC,,,both,,,836,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,418,50,,418,percent of total billed charges,All Other Outpatient,376.2,45,,376.2,percent of total billed charges,All Other Outpatient,418,50,,418,percent of total billed charges,All Other Outpatient,376.2,45,,376.2,percent of total billed charges,All Other Outpatient,359.48,43,,359.48,percent of total billed charges,All Other Outpatient,418,50,,418,percent of total billed charges,All Other,441.35,,,441.35,Fee Schedule,,568.48,68,,568.48,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,668.8,80,,668.8,percent of total billed charges,All Other Outpatient,693.88,83,,693.88,percent of total billed charges,All Other Outpatient,693.88,83,,693.88,percent of total billed charges,All Other Outpatient,668.8,80,,668.8,percent of total billed charges,All Other Outpatient,693.88,83,,693.88,percent of total billed charges,All Other Outpatient,752.4,90,,752.4,percent of total billed charges,All Other,585.2,70,,585.2,percent of total billed charges,All Other,418,50,,418,percent of total billed charges,All Other,418,50,,418,percent of total billed charges,All Other,250.7,,,250.7,Fee Schedule,,250.7,,,250.7,Fee Schedule,,250.7,,,250.7,Fee Schedule,,250.7,,,250.7,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,752.4,
81342 REF LAB P TCELL RECEPTOR,81342,CPT,,40129827,CDM,310,RC,,,both,,,806,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,403,50,,403,percent of total billed charges,All Other Outpatient,362.7,45,,362.7,percent of total billed charges,All Other Outpatient,403,50,,403,percent of total billed charges,All Other Outpatient,362.7,45,,362.7,percent of total billed charges,All Other Outpatient,346.58,43,,346.58,percent of total billed charges,All Other Outpatient,403,50,,403,percent of total billed charges,All Other,425.69,,,425.69,Fee Schedule,,548.08,68,,548.08,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,644.8,80,,644.8,percent of total billed charges,All Other Outpatient,668.98,83,,668.98,percent of total billed charges,All Other Outpatient,668.98,83,,668.98,percent of total billed charges,All Other Outpatient,644.8,80,,644.8,percent of total billed charges,All Other Outpatient,668.98,83,,668.98,percent of total billed charges,All Other Outpatient,725.4,90,,725.4,percent of total billed charges,All Other,564.2,70,,564.2,percent of total billed charges,All Other,403,50,,403,percent of total billed charges,All Other,403,50,,403,percent of total billed charges,All Other,241.8,,,241.8,Fee Schedule,,241.8,,,241.8,Fee Schedule,,241.8,,,241.8,Fee Schedule,,241.8,,,241.8,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,725.4,
81207 REF LAB BCR-ABL1 PCR Minor QT,81207,CPT,,40129918,CDM,310,RC,,,both,,,2304,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,1152,50,,1152,percent of total billed charges,All Other Outpatient,1036.8,45,,1036.8,percent of total billed charges,All Other Outpatient,1152,50,,1152,percent of total billed charges,All Other Outpatient,1036.8,45,,1036.8,percent of total billed charges,All Other Outpatient,990.72,43,,990.72,percent of total billed charges,All Other Outpatient,1152,50,,1152,percent of total billed charges,All Other,305.99,,,305.99,Fee Schedule,,1566.72,68,,1566.72,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,1843.2,80,,1843.2,percent of total billed charges,All Other Outpatient,1912.32,83,,1912.32,percent of total billed charges,All Other Outpatient,1912.32,83,,1912.32,percent of total billed charges,All Other Outpatient,1843.2,80,,1843.2,percent of total billed charges,All Other Outpatient,1912.32,83,,1912.32,percent of total billed charges,All Other Outpatient,2073.6,90,,2073.6,percent of total billed charges,All Other,1612.8,70,,1612.8,percent of total billed charges,All Other,1152,50,,1152,percent of total billed charges,All Other,1152,50,,1152,percent of total billed charges,All Other,173.81,,,173.81,Fee Schedule,,173.81,,,173.81,Fee Schedule,,173.81,,,173.81,Fee Schedule,,173.81,,,173.81,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,2073.6,
SURGICAL PATH GROSS LV 1        ,88300,CPT,,43500107,CDM,310,RC,,,both,,,429,56.62,,,56.62,Other,150% of Medicare + 9.63% HCRA Surcharge,34.43,,,34.43,Other,Medicare OPPS methodology,27.75,,,27.75,Fee Schedule,,25.02,,,25.02,Fee Schedule,,205.92,,,205.92,Fee Schedule,,185.27,,,185.27,Fee Schedule,,174.95,,,174.95,Fee Schedule,,214.5,50,,214.5,percent of total billed charges,All Other,23.6,,,23.6,Fee Schedule,,54.5,,,54.5,Fee Schedule,,154.29,,,154.29,Other,186% Medicaid methodology,64.13,,,64.13,Fee Schedule,,265.98,,,265.98,Fee Schedule,,30.2,,,30.2,Fee Schedule,,64.13,,,64.13,Fee Schedule,,265.98,,,265.98,Fee Schedule,,56.8,,,56.8,Fee Schedule,,300.3,70,,300.3,percent of total billed charges,All Other,52.8,,,52.8,Fee Schedule,,44.8,,,44.8,Fee Schedule,,27.59,,,27.59,Fee Schedule,,27.59,,,27.59,Fee Schedule,,27.59,,,27.59,Fee Schedule,,27.59,,,27.59,Fee Schedule,,82.95,,,82.95,Other,New York Medicaid APG methodology,82.95,,,82.95,Other,100% Medicaid APG methodology,82.95,,,82.95,Other,100% Medicaid APG methodology,82.95,,,82.95,Other,100% Medicaid APG methodology,186.64,,,186.64,Other,225% Medicaid APG methodology,186.64,,,186.64,Other,225% Medicaid APG methodology,126.92,,,126.92,Other,153% Medicaid APG methodology,186.64,,,186.64,Other,225% Medicaid APG methodology,116.13,,,116.13,Other,140% Medicaid APG methodology,186.64,,,186.64,Other,225% Medicaid APG methodology,215.67,,,215.67,Other,260% Medicaid APG methodology,268.76,,,268.76,Other,324% Medicaid APG methodology,178.35,,,178.35,Other,215% Medicaid APG methodology,178.35,,,178.35,Other,215% Medicaid APG methodology,103.69,,,103.69,Other,125% Medicaid APG methodology,23.6,300.3,
TISSUE EX BY PATHOLOGIST LV 2   ,88302,CPT,,43500115,CDM,310,RC,,,both,,,490,56.62,,,56.62,Other,150% of Medicare + 9.63% HCRA Surcharge,34.43,,,34.43,Other,Medicare OPPS methodology,61.12,,,61.12,Fee Schedule,,55.11,,,55.11,Fee Schedule,,430.37,,,430.37,Fee Schedule,,387.21,,,387.21,Fee Schedule,,365.63,,,365.63,Fee Schedule,,245,50,,245,percent of total billed charges,All Other,53.07,,,53.07,Fee Schedule,,120.03,,,120.03,Fee Schedule,,36.28,,,36.28,Other,186% Medicaid methodology,141.25,,,141.25,Fee Schedule,,303.8,,,303.8,Fee Schedule,,66.51,,,66.51,Fee Schedule,,141.25,,,141.25,Fee Schedule,,303.8,,,303.8,Fee Schedule,,125.1,,,125.1,Fee Schedule,,343,70,,343,percent of total billed charges,All Other,120.45,,,120.45,Fee Schedule,,102.2,,,102.2,Fee Schedule,,27.59,,,27.59,Fee Schedule,,27.59,,,27.59,Fee Schedule,,27.59,,,27.59,Fee Schedule,,27.59,,,27.59,Fee Schedule,,19.5,,,19.5,Fee Schedule,Medicaid Laboratory Fee Schedule,19.5,,,19.5,Fee Schedule,100% Medicaid Laboratory Fee Schedule,19.5,,,19.5,Fee Schedule,100% Medicaid Laboratory Fee Schedule,19.5,,,19.5,Fee Schedule,100% Medicaid Laboratory Fee Schedule,43.88,,,43.88,Fee Schedule,225% Medicaid Laboratory Fee Schedule,43.88,,,43.88,Fee Schedule,225% Medicaid Laboratory Fee Schedule,29.84,,,29.84,Fee Schedule,153% Medicaid Laboratory Fee Schedule,43.88,,,43.88,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.3,,,27.3,Fee Schedule,140% Medicaid Laboratory Fee Schedule,43.88,,,43.88,Fee Schedule,225% Medicaid Laboratory Fee Schedule,50.71,,,50.71,Fee Schedule,260% Medicaid Laboratory Fee Schedule,63.19,,,63.19,Fee Schedule,324% Medicaid Laboratory Fee Schedule,41.93,,,41.93,Fee Schedule,215% Medicaid Laboratory Fee Schedule,41.93,,,41.93,Fee Schedule,215% Medicaid Laboratory Fee Schedule,24.38,,,24.38,Fee Schedule,125% Medicaid Laboratory Fee Schedule,19.5,430.37,
TISSUE EX BY PATHOLOGIST LV 3   ,88304,CPT,,43500123,CDM,310,RC,,,both,,,923,103.05,,,103.05,Other,150% of Medicare + 9.63% HCRA Surcharge,62.66,,,62.66,Other,Medicare OPPS methodology,73.24,,,73.24,Fee Schedule,,66.03,,,66.03,Fee Schedule,,474.02,,,474.02,Fee Schedule,,426.49,,,426.49,Fee Schedule,,402.72,,,402.72,Fee Schedule,,461.5,50,,461.5,percent of total billed charges,All Other,64.87,,,64.87,Fee Schedule,,143.83,,,143.83,Fee Schedule,,47.58,,,47.58,Other,186% Medicaid methodology,169.26,,,169.26,Fee Schedule,,572.26,,,572.26,Fee Schedule,,79.7,,,79.7,Fee Schedule,,169.26,,,169.26,Fee Schedule,,572.26,,,572.26,Fee Schedule,,149.9,,,149.9,Fee Schedule,,646.1,70,,646.1,percent of total billed charges,All Other,146.85,,,146.85,Fee Schedule,,124.6,,,124.6,Fee Schedule,,59.36,,,59.36,Fee Schedule,,59.36,,,59.36,Fee Schedule,,59.36,,,59.36,Fee Schedule,,59.36,,,59.36,Fee Schedule,,25.58,,,25.58,Fee Schedule,Medicaid Laboratory Fee Schedule,25.58,,,25.58,Fee Schedule,100% Medicaid Laboratory Fee Schedule,25.58,,,25.58,Fee Schedule,100% Medicaid Laboratory Fee Schedule,25.58,,,25.58,Fee Schedule,100% Medicaid Laboratory Fee Schedule,57.56,,,57.56,Fee Schedule,225% Medicaid Laboratory Fee Schedule,57.56,,,57.56,Fee Schedule,225% Medicaid Laboratory Fee Schedule,39.14,,,39.14,Fee Schedule,153% Medicaid Laboratory Fee Schedule,57.56,,,57.56,Fee Schedule,225% Medicaid Laboratory Fee Schedule,35.82,,,35.82,Fee Schedule,140% Medicaid Laboratory Fee Schedule,57.56,,,57.56,Fee Schedule,225% Medicaid Laboratory Fee Schedule,66.52,,,66.52,Fee Schedule,260% Medicaid Laboratory Fee Schedule,82.89,,,82.89,Fee Schedule,324% Medicaid Laboratory Fee Schedule,55,,,55,Fee Schedule,215% Medicaid Laboratory Fee Schedule,55,,,55,Fee Schedule,215% Medicaid Laboratory Fee Schedule,31.98,,,31.98,Fee Schedule,125% Medicaid Laboratory Fee Schedule,25.58,646.1,
TISSUE EX BY PATHOLOGIST LV 4   ,88305,CPT,,43500131,CDM,310,RC,,,both,,,923,103.05,,,103.05,Other,150% of Medicare + 9.63% HCRA Surcharge,62.66,,,62.66,Other,Medicare OPPS methodology,81.6,,,81.6,Fee Schedule,,73.57,,,73.57,Fee Schedule,,639.24,,,639.24,Fee Schedule,,575.13,,,575.13,Fee Schedule,,543.08,,,543.08,Fee Schedule,,461.5,50,,461.5,percent of total billed charges,All Other,71.5,,,71.5,Fee Schedule,,160.24,,,160.24,Fee Schedule,,81.14,,,81.14,Other,186% Medicaid methodology,188.57,,,188.57,Fee Schedule,,572.26,,,572.26,Fee Schedule,,88.79,,,88.79,Fee Schedule,,188.57,,,188.57,Fee Schedule,,572.26,,,572.26,Fee Schedule,,167.01,,,167.01,Fee Schedule,,646.1,70,,646.1,percent of total billed charges,All Other,165,,,165,Fee Schedule,,140,,,140,Fee Schedule,,59.36,,,59.36,Fee Schedule,,59.36,,,59.36,Fee Schedule,,59.36,,,59.36,Fee Schedule,,59.36,,,59.36,Fee Schedule,,43.62,,,43.62,Fee Schedule,Medicaid Laboratory Fee Schedule,43.62,,,43.62,Fee Schedule,100% Medicaid Laboratory Fee Schedule,43.62,,,43.62,Fee Schedule,100% Medicaid Laboratory Fee Schedule,43.62,,,43.62,Fee Schedule,100% Medicaid Laboratory Fee Schedule,98.15,,,98.15,Fee Schedule,225% Medicaid Laboratory Fee Schedule,98.15,,,98.15,Fee Schedule,225% Medicaid Laboratory Fee Schedule,66.74,,,66.74,Fee Schedule,153% Medicaid Laboratory Fee Schedule,98.15,,,98.15,Fee Schedule,225% Medicaid Laboratory Fee Schedule,61.07,,,61.07,Fee Schedule,140% Medicaid Laboratory Fee Schedule,98.15,,,98.15,Fee Schedule,225% Medicaid Laboratory Fee Schedule,113.42,,,113.42,Fee Schedule,260% Medicaid Laboratory Fee Schedule,141.33,,,141.33,Fee Schedule,324% Medicaid Laboratory Fee Schedule,93.79,,,93.79,Fee Schedule,215% Medicaid Laboratory Fee Schedule,93.79,,,93.79,Fee Schedule,215% Medicaid Laboratory Fee Schedule,54.53,,,54.53,Fee Schedule,125% Medicaid Laboratory Fee Schedule,43.62,646.1,
TISSUE EX BY PATHOLOGIST LV 5   ,88307,CPT,,43500149,CDM,310,RC,,,both,,,5281,683.55,,,683.55,Other,150% of Medicare + 9.63% HCRA Surcharge,415.67,,,415.67,Other,Medicare OPPS methodology,477.29,,,477.29,Fee Schedule,,430.3,,,430.3,Fee Schedule,,1346.97,,,1346.97,Fee Schedule,,1211.9,,,1211.9,Fee Schedule,,1144.36,,,1144.36,Fee Schedule,,2640.5,50,,2640.5,percent of total billed charges,All Other,437.13,,,437.13,Fee Schedule,,937.27,,,937.27,Fee Schedule,,327.65,,,327.65,Other,186% Medicaid methodology,1102.96,,,1102.96,Fee Schedule,,3274.22,,,3274.22,Fee Schedule,,519.33,,,519.33,Fee Schedule,,1102.96,,,1102.96,Fee Schedule,,3274.22,,,3274.22,Fee Schedule,,976.84,,,976.84,Fee Schedule,,3696.7,70,,3696.7,percent of total billed charges,All Other,993.3,,,993.3,Fee Schedule,,842.8,,,842.8,Fee Schedule,,340.09,,,340.09,Fee Schedule,,340.09,,,340.09,Fee Schedule,,340.09,,,340.09,Fee Schedule,,340.09,,,340.09,Fee Schedule,,176.15,,,176.15,Fee Schedule,Medicaid Laboratory Fee Schedule,176.15,,,176.15,Fee Schedule,100% Medicaid Laboratory Fee Schedule,176.15,,,176.15,Fee Schedule,100% Medicaid Laboratory Fee Schedule,176.15,,,176.15,Fee Schedule,100% Medicaid Laboratory Fee Schedule,396.35,,,396.35,Fee Schedule,225% Medicaid Laboratory Fee Schedule,396.35,,,396.35,Fee Schedule,225% Medicaid Laboratory Fee Schedule,269.52,,,269.52,Fee Schedule,153% Medicaid Laboratory Fee Schedule,396.35,,,396.35,Fee Schedule,225% Medicaid Laboratory Fee Schedule,246.62,,,246.62,Fee Schedule,140% Medicaid Laboratory Fee Schedule,396.35,,,396.35,Fee Schedule,225% Medicaid Laboratory Fee Schedule,458,,,458,Fee Schedule,260% Medicaid Laboratory Fee Schedule,570.74,,,570.74,Fee Schedule,324% Medicaid Laboratory Fee Schedule,378.73,,,378.73,Fee Schedule,215% Medicaid Laboratory Fee Schedule,378.73,,,378.73,Fee Schedule,215% Medicaid Laboratory Fee Schedule,220.19,,,220.19,Fee Schedule,125% Medicaid Laboratory Fee Schedule,176.15,3696.7,
TISSUE EX BY PATHOLOGIST LV 6   ,88309,CPT,,43500156,CDM,310,RC,,,both,,,11706,1635.2,,,1635.2,Other,150% of Medicare + 9.63% HCRA Surcharge,994.37,,,994.37,Other,Medicare OPPS methodology,669.15,,,669.15,Fee Schedule,,603.28,,,603.28,Fee Schedule,,1871.04,,,1871.04,Fee Schedule,,1683.41,,,1683.41,Fee Schedule,,1589.6,,,1589.6,Fee Schedule,,5853,50,,5853,percent of total billed charges,All Other,622.86,,,622.86,Fee Schedule,,1314.03,,,1314.03,Fee Schedule,,497.81,,,497.81,Other,186% Medicaid methodology,1546.33,,,1546.33,Fee Schedule,,7257.72,,,7257.72,Fee Schedule,,728.09,,,728.09,Fee Schedule,,1546.33,,,1546.33,Fee Schedule,,7257.72,,,7257.72,Fee Schedule,,1369.5,,,1369.5,Fee Schedule,,8194.2,70,,8194.2,percent of total billed charges,All Other,1415.7,,,1415.7,Fee Schedule,,1201.2,,,1201.2,Fee Schedule,,753.84,,,753.84,Fee Schedule,,753.84,,,753.84,Fee Schedule,,753.84,,,753.84,Fee Schedule,,753.84,,,753.84,Fee Schedule,,267.64,,,267.64,Fee Schedule,Medicaid Laboratory Fee Schedule,267.64,,,267.64,Fee Schedule,100% Medicaid Laboratory Fee Schedule,267.64,,,267.64,Fee Schedule,100% Medicaid Laboratory Fee Schedule,267.64,,,267.64,Fee Schedule,100% Medicaid Laboratory Fee Schedule,602.19,,,602.19,Fee Schedule,225% Medicaid Laboratory Fee Schedule,602.19,,,602.19,Fee Schedule,225% Medicaid Laboratory Fee Schedule,409.49,,,409.49,Fee Schedule,153% Medicaid Laboratory Fee Schedule,602.19,,,602.19,Fee Schedule,225% Medicaid Laboratory Fee Schedule,374.7,,,374.7,Fee Schedule,140% Medicaid Laboratory Fee Schedule,602.19,,,602.19,Fee Schedule,225% Medicaid Laboratory Fee Schedule,695.86,,,695.86,Fee Schedule,260% Medicaid Laboratory Fee Schedule,867.15,,,867.15,Fee Schedule,324% Medicaid Laboratory Fee Schedule,575.43,,,575.43,Fee Schedule,215% Medicaid Laboratory Fee Schedule,575.43,,,575.43,Fee Schedule,215% Medicaid Laboratory Fee Schedule,334.55,,,334.55,Fee Schedule,125% Medicaid Laboratory Fee Schedule,267.64,8194.2,
DECALCIFY TISSUE                ,88311,CPT,,43500164,CDM,310,RC,,,both,,,331,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,20.17,,,20.17,Fee Schedule,,18.18,,,18.18,Fee Schedule,,62.47,,,62.47,Fee Schedule,,56.2,,,56.2,Fee Schedule,,53.07,,,53.07,Fee Schedule,,165.5,50,,165.5,percent of total billed charges,All Other,18.43,,,18.43,Fee Schedule,,39.61,,,39.61,Fee Schedule,,154.29,,,154.29,Other,186% Medicaid methodology,46.61,,,46.61,Fee Schedule,,205.22,,,205.22,Fee Schedule,,21.95,,,21.95,Fee Schedule,,46.61,,,46.61,Fee Schedule,,205.22,,,205.22,Fee Schedule,,41.28,,,41.28,Fee Schedule,,231.7,70,,231.7,percent of total billed charges,All Other,41.25,,,41.25,Fee Schedule,,35,,,35,Fee Schedule,,10.82,,,10.82,Fee Schedule,,10.82,,,10.82,Fee Schedule,,10.82,,,10.82,Fee Schedule,,10.82,,,10.82,Fee Schedule,,82.95,,,82.95,Other,New York Medicaid APG methodology,82.95,,,82.95,Other,100% Medicaid APG methodology,82.95,,,82.95,Other,100% Medicaid APG methodology,82.95,,,82.95,Other,100% Medicaid APG methodology,186.64,,,186.64,Other,225% Medicaid APG methodology,186.64,,,186.64,Other,225% Medicaid APG methodology,126.92,,,126.92,Other,153% Medicaid APG methodology,186.64,,,186.64,Other,225% Medicaid APG methodology,116.13,,,116.13,Other,140% Medicaid APG methodology,186.64,,,186.64,Other,225% Medicaid APG methodology,215.67,,,215.67,Other,260% Medicaid APG methodology,268.76,,,268.76,Other,324% Medicaid APG methodology,178.35,,,178.35,Other,215% Medicaid APG methodology,178.35,,,178.35,Other,215% Medicaid APG methodology,103.69,,,103.69,Other,125% Medicaid APG methodology,0.01,268.76,
SPECIAL STAINS GROUP 1          ,88312,CPT,,43500172,CDM,310,RC,,,both,,,923,103.05,,,103.05,Other,150% of Medicare + 9.63% HCRA Surcharge,62.66,,,62.66,Other,Medicare OPPS methodology,198.38,,,198.38,Fee Schedule,,178.85,,,178.85,Fee Schedule,,739.04,,,739.04,Fee Schedule,,664.93,,,664.93,Fee Schedule,,627.87,,,627.87,Fee Schedule,,461.5,50,,461.5,percent of total billed charges,All Other,182.07,,,182.07,Fee Schedule,,389.57,,,389.57,Fee Schedule,,24.76,,,24.76,Other,186% Medicaid methodology,458.44,,,458.44,Fee Schedule,,572.26,,,572.26,Fee Schedule,,215.86,,,215.86,Fee Schedule,,458.44,,,458.44,Fee Schedule,,572.26,,,572.26,Fee Schedule,,406.02,,,406.02,Fee Schedule,,646.1,70,,646.1,percent of total billed charges,All Other,420.75,,,420.75,Fee Schedule,,357,,,357,Fee Schedule,,59.36,,,59.36,Fee Schedule,,59.36,,,59.36,Fee Schedule,,59.36,,,59.36,Fee Schedule,,59.36,,,59.36,Fee Schedule,,13.31,,,13.31,Fee Schedule,Medicaid Laboratory Fee Schedule,13.31,,,13.31,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.31,,,13.31,Fee Schedule,100% Medicaid Laboratory Fee Schedule,13.31,,,13.31,Fee Schedule,100% Medicaid Laboratory Fee Schedule,29.95,,,29.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,29.95,,,29.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,20.37,,,20.37,Fee Schedule,153% Medicaid Laboratory Fee Schedule,29.95,,,29.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,18.64,,,18.64,Fee Schedule,140% Medicaid Laboratory Fee Schedule,29.95,,,29.95,Fee Schedule,225% Medicaid Laboratory Fee Schedule,34.61,,,34.61,Fee Schedule,260% Medicaid Laboratory Fee Schedule,43.13,,,43.13,Fee Schedule,324% Medicaid Laboratory Fee Schedule,28.62,,,28.62,Fee Schedule,215% Medicaid Laboratory Fee Schedule,28.62,,,28.62,Fee Schedule,215% Medicaid Laboratory Fee Schedule,16.64,,,16.64,Fee Schedule,125% Medicaid Laboratory Fee Schedule,13.31,739.04,
SPECIAL STAINS GROUP 2          ,88313,CPT,,43500180,CDM,310,RC,,,both,,,691,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,162.74,,,162.74,Fee Schedule,,146.72,,,146.72,Fee Schedule,,608.07,,,608.07,Fee Schedule,,547.1,,,547.1,Fee Schedule,,516.61,,,516.61,Fee Schedule,,345.5,50,,345.5,percent of total billed charges,All Other,146.67,,,146.67,Fee Schedule,,319.57,,,319.57,Fee Schedule,,18.56,,,18.56,Other,186% Medicaid methodology,376.07,,,376.07,Fee Schedule,,428.42,,,428.42,Fee Schedule,,177.07,,,177.07,Fee Schedule,,376.07,,,376.07,Fee Schedule,,428.42,,,428.42,Fee Schedule,,333.06,,,333.06,Fee Schedule,,483.7,70,,483.7,percent of total billed charges,All Other,334.95,,,334.95,Fee Schedule,,284.2,,,284.2,Fee Schedule,,40.12,,,40.12,Fee Schedule,,40.12,,,40.12,Fee Schedule,,40.12,,,40.12,Fee Schedule,,40.12,,,40.12,Fee Schedule,,9.98,,,9.98,Fee Schedule,Medicaid Laboratory Fee Schedule,9.98,,,9.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.98,,,9.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,9.98,,,9.98,Fee Schedule,100% Medicaid Laboratory Fee Schedule,22.45,,,22.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,22.45,,,22.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.27,,,15.27,Fee Schedule,153% Medicaid Laboratory Fee Schedule,22.45,,,22.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,13.97,,,13.97,Fee Schedule,140% Medicaid Laboratory Fee Schedule,22.45,,,22.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,25.94,,,25.94,Fee Schedule,260% Medicaid Laboratory Fee Schedule,32.33,,,32.33,Fee Schedule,324% Medicaid Laboratory Fee Schedule,21.45,,,21.45,Fee Schedule,215% Medicaid Laboratory Fee Schedule,21.45,,,21.45,Fee Schedule,215% Medicaid Laboratory Fee Schedule,12.47,,,12.47,Fee Schedule,125% Medicaid Laboratory Fee Schedule,9.98,608.07,
PATH CONSULT INTRAOP 1 BLOC     ,88331,CPT,,43500214,CDM,310,RC,,,both,,,2675,324.81,,,324.81,Other,150% of Medicare + 9.63% HCRA Surcharge,197.52,,,197.52,Other,Medicare OPPS methodology,94.49,,,94.49,Fee Schedule,,85.19,,,85.19,Fee Schedule,,293.23,,,293.23,Fee Schedule,,263.83,,,263.83,Fee Schedule,,249.12,,,249.12,Fee Schedule,,1337.5,50,,1337.5,percent of total billed charges,All Other,89.18,,,89.18,Fee Schedule,,185.56,,,185.56,Fee Schedule,,175.77,,,175.77,Other,186% Medicaid methodology,218.36,,,218.36,Fee Schedule,,1658.5,,,1658.5,Fee Schedule,,102.82,,,102.82,Fee Schedule,,218.36,,,218.36,Fee Schedule,,1658.5,,,1658.5,Fee Schedule,,193.39,,,193.39,Fee Schedule,,1872.5,70,,1872.5,percent of total billed charges,All Other,198,,,198,Fee Schedule,,168,,,168,Fee Schedule,,172.2,,,172.2,Fee Schedule,,172.2,,,172.2,Fee Schedule,,172.2,,,172.2,Fee Schedule,,172.2,,,172.2,Fee Schedule,,94.5,,,94.5,Other,New York Medicaid APG methodology,94.5,,,94.5,Other,100% Medicaid APG methodology,94.5,,,94.5,Other,100% Medicaid APG methodology,94.5,,,94.5,Other,100% Medicaid APG methodology,212.63,,,212.63,Other,225% Medicaid APG methodology,212.63,,,212.63,Other,225% Medicaid APG methodology,144.59,,,144.59,Other,153% Medicaid APG methodology,212.63,,,212.63,Other,225% Medicaid APG methodology,132.3,,,132.3,Other,140% Medicaid APG methodology,212.63,,,212.63,Other,225% Medicaid APG methodology,245.7,,,245.7,Other,260% Medicaid APG methodology,306.18,,,306.18,Other,324% Medicaid APG methodology,203.18,,,203.18,Other,215% Medicaid APG methodology,203.18,,,203.18,Other,215% Medicaid APG methodology,118.13,,,118.13,Other,125% Medicaid APG methodology,85.19,1872.5,
PATH CONSULT INTRAOP ADDL       ,88332,CPT,,43500222,CDM,310,RC,,,both,,,317,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,57.32,,,57.32,Fee Schedule,,51.68,,,51.68,Fee Schedule,,103.03,,,103.03,Fee Schedule,,92.7,,,92.7,Fee Schedule,,87.54,,,87.54,Fee Schedule,,158.5,50,,158.5,percent of total billed charges,All Other,50.86,,,50.86,Fee Schedule,,112.56,,,112.56,Fee Schedule,,175.77,,,175.77,Other,186% Medicaid methodology,132.46,,,132.46,Fee Schedule,,196.54,,,196.54,Fee Schedule,,62.37,,,62.37,Fee Schedule,,132.46,,,132.46,Fee Schedule,,196.54,,,196.54,Fee Schedule,,117.32,,,117.32,Fee Schedule,,221.9,70,,221.9,percent of total billed charges,All Other,117.15,,,117.15,Fee Schedule,,99.4,,,99.4,Fee Schedule,,27.72,,,27.72,Fee Schedule,,27.72,,,27.72,Fee Schedule,,27.72,,,27.72,Fee Schedule,,27.72,,,27.72,Fee Schedule,,94.5,,,94.5,Other,New York Medicaid APG methodology,94.5,,,94.5,Other,100% Medicaid APG methodology,94.5,,,94.5,Other,100% Medicaid APG methodology,94.5,,,94.5,Other,100% Medicaid APG methodology,212.63,,,212.63,Other,225% Medicaid APG methodology,212.63,,,212.63,Other,225% Medicaid APG methodology,144.59,,,144.59,Other,153% Medicaid APG methodology,212.63,,,212.63,Other,225% Medicaid APG methodology,132.3,,,132.3,Other,140% Medicaid APG methodology,212.63,,,212.63,Other,225% Medicaid APG methodology,245.7,,,245.7,Other,260% Medicaid APG methodology,306.18,,,306.18,Other,324% Medicaid APG methodology,203.18,,,203.18,Other,215% Medicaid APG methodology,203.18,,,203.18,Other,215% Medicaid APG methodology,118.13,,,118.13,Other,125% Medicaid APG methodology,0.01,306.18,
IMMUNOHISTO ANTB 1ST STAIN      ,88342,CPT,,43500230,CDM,310,RC,,,both,,,2675,324.81,,,324.81,Other,150% of Medicare + 9.63% HCRA Surcharge,197.52,,,197.52,Other,Medicare OPPS methodology,165.02,,,165.02,Fee Schedule,,148.77,,,148.77,Fee Schedule,,576.91,,,576.91,Fee Schedule,,519.06,,,519.06,Fee Schedule,,490.14,,,490.14,Fee Schedule,,1337.5,50,,1337.5,percent of total billed charges,All Other,149.63,,,149.63,Fee Schedule,,324.05,,,324.05,Fee Schedule,,47.66,,,47.66,Other,186% Medicaid methodology,381.33,,,381.33,Fee Schedule,,1658.5,,,1658.5,Fee Schedule,,179.55,,,179.55,Fee Schedule,,381.33,,,381.33,Fee Schedule,,1658.5,,,1658.5,Fee Schedule,,337.73,,,337.73,Fee Schedule,,1872.5,70,,1872.5,percent of total billed charges,All Other,323.4,,,323.4,Fee Schedule,,274.4,,,274.4,Fee Schedule,,172.2,,,172.2,Fee Schedule,,172.2,,,172.2,Fee Schedule,,172.2,,,172.2,Fee Schedule,,172.2,,,172.2,Fee Schedule,,25.62,,,25.62,Fee Schedule,Medicaid Laboratory Fee Schedule,25.62,,,25.62,Fee Schedule,100% Medicaid Laboratory Fee Schedule,25.62,,,25.62,Fee Schedule,100% Medicaid Laboratory Fee Schedule,25.62,,,25.62,Fee Schedule,100% Medicaid Laboratory Fee Schedule,57.65,,,57.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,57.65,,,57.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,39.2,,,39.2,Fee Schedule,153% Medicaid Laboratory Fee Schedule,57.65,,,57.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,35.87,,,35.87,Fee Schedule,140% Medicaid Laboratory Fee Schedule,57.65,,,57.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,66.62,,,66.62,Fee Schedule,260% Medicaid Laboratory Fee Schedule,83.02,,,83.02,Fee Schedule,324% Medicaid Laboratory Fee Schedule,55.09,,,55.09,Fee Schedule,215% Medicaid Laboratory Fee Schedule,55.09,,,55.09,Fee Schedule,215% Medicaid Laboratory Fee Schedule,32.03,,,32.03,Fee Schedule,125% Medicaid Laboratory Fee Schedule,25.62,1872.5,
CYTP DX EVAL FNA 1ST EA SITE    ,88172,CPT,,43500560,CDM,310,RC,,,both,,,2675,324.81,,,324.81,Other,150% of Medicare + 9.63% HCRA Surcharge,197.52,,,197.52,Other,Medicare OPPS methodology,49.74,,,49.74,Fee Schedule,,44.84,,,44.84,Fee Schedule,,190.34,,,190.34,Fee Schedule,,171.25,,,171.25,Fee Schedule,,161.71,,,161.71,Fee Schedule,,1337.5,50,,1337.5,percent of total billed charges,All Other,42.02,,,42.02,Fee Schedule,,97.67,,,97.67,Fee Schedule,,211.57,,,211.57,Other,186% Medicaid methodology,114.93,,,114.93,Fee Schedule,,1658.5,,,1658.5,Fee Schedule,,54.12,,,54.12,Fee Schedule,,114.93,,,114.93,Fee Schedule,,1658.5,,,1658.5,Fee Schedule,,101.79,,,101.79,Fee Schedule,,1872.5,70,,1872.5,percent of total billed charges,All Other,94.05,,,94.05,Fee Schedule,,79.8,,,79.8,Fee Schedule,,172.2,,,172.2,Fee Schedule,,172.2,,,172.2,Fee Schedule,,172.2,,,172.2,Fee Schedule,,172.2,,,172.2,Fee Schedule,,113.75,,,113.75,Other,New York Medicaid APG methodology,113.75,,,113.75,Other,100% Medicaid APG methodology,113.75,,,113.75,Other,100% Medicaid APG methodology,113.75,,,113.75,Other,100% Medicaid APG methodology,255.94,,,255.94,Other,225% Medicaid APG methodology,255.94,,,255.94,Other,225% Medicaid APG methodology,174.04,,,174.04,Other,153% Medicaid APG methodology,255.94,,,255.94,Other,225% Medicaid APG methodology,159.25,,,159.25,Other,140% Medicaid APG methodology,255.94,,,255.94,Other,225% Medicaid APG methodology,295.75,,,295.75,Other,260% Medicaid APG methodology,368.55,,,368.55,Other,324% Medicaid APG methodology,244.56,,,244.56,Other,215% Medicaid APG methodology,244.56,,,244.56,Other,215% Medicaid APG methodology,142.19,,,142.19,Other,125% Medicaid APG methodology,42.02,1872.5,
CYTOPATH CELL ENHANCE TECH      ,88112,CPT,,43500669,CDM,310,RC,,,both,,,327,103.05,,,103.05,Other,150% of Medicare + 9.63% HCRA Surcharge,62.66,,,62.66,Other,Medicare OPPS methodology,94.49,,,94.49,Fee Schedule,,85.19,,,85.19,Fee Schedule,,424.12,,,424.12,Fee Schedule,,381.59,,,381.59,Fee Schedule,,360.33,,,360.33,Fee Schedule,,163.5,50,,163.5,percent of total billed charges,All Other,84.05,,,84.05,Fee Schedule,,185.56,,,185.56,Fee Schedule,,54.14,,,54.14,Other,186% Medicaid methodology,218.36,,,218.36,Fee Schedule,,202.74,,,202.74,Fee Schedule,,102.82,,,102.82,Fee Schedule,,218.36,,,218.36,Fee Schedule,,202.74,,,202.74,Fee Schedule,,193.39,,,193.39,Fee Schedule,,228.9,70,,228.9,percent of total billed charges,All Other,189.75,,,189.75,Fee Schedule,,161,,,161,Fee Schedule,,59.36,,,59.36,Fee Schedule,,59.36,,,59.36,Fee Schedule,,59.36,,,59.36,Fee Schedule,,59.36,,,59.36,Fee Schedule,,29.11,,,29.11,Fee Schedule,Medicaid Laboratory Fee Schedule,29.11,,,29.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,29.11,,,29.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,29.11,,,29.11,Fee Schedule,100% Medicaid Laboratory Fee Schedule,65.49,,,65.49,Fee Schedule,225% Medicaid Laboratory Fee Schedule,65.49,,,65.49,Fee Schedule,225% Medicaid Laboratory Fee Schedule,44.54,,,44.54,Fee Schedule,153% Medicaid Laboratory Fee Schedule,65.49,,,65.49,Fee Schedule,225% Medicaid Laboratory Fee Schedule,40.75,,,40.75,Fee Schedule,140% Medicaid Laboratory Fee Schedule,65.49,,,65.49,Fee Schedule,225% Medicaid Laboratory Fee Schedule,75.68,,,75.68,Fee Schedule,260% Medicaid Laboratory Fee Schedule,94.31,,,94.31,Fee Schedule,324% Medicaid Laboratory Fee Schedule,62.58,,,62.58,Fee Schedule,215% Medicaid Laboratory Fee Schedule,62.58,,,62.58,Fee Schedule,215% Medicaid Laboratory Fee Schedule,36.39,,,36.39,Fee Schedule,125% Medicaid Laboratory Fee Schedule,29.11,424.12,
TUMOR IMMUNOHISTOCHEM/MANUAL    ,88360,CPT,,43501667,CDM,310,RC,,,both,,,2675,324.81,,,324.81,Other,150% of Medicare + 9.63% HCRA Surcharge,197.52,,,197.52,Other,Medicare OPPS methodology,183.21,,,183.21,Fee Schedule,,165.18,,,165.18,Fee Schedule,,651.73,,,651.73,Fee Schedule,,586.37,,,586.37,Fee Schedule,,553.7,,,553.7,Fee Schedule,,1337.5,50,,1337.5,percent of total billed charges,All Other,174.69,,,174.69,Fee Schedule,,359.78,,,359.78,Fee Schedule,,47.66,,,47.66,Other,186% Medicaid methodology,423.39,,,423.39,Fee Schedule,,1658.5,,,1658.5,Fee Schedule,,199.35,,,199.35,Fee Schedule,,423.39,,,423.39,Fee Schedule,,1658.5,,,1658.5,Fee Schedule,,374.97,,,374.97,Fee Schedule,,1872.5,70,,1872.5,percent of total billed charges,All Other,386.1,,,386.1,Fee Schedule,,327.6,,,327.6,Fee Schedule,,172.2,,,172.2,Fee Schedule,,172.2,,,172.2,Fee Schedule,,172.2,,,172.2,Fee Schedule,,172.2,,,172.2,Fee Schedule,,25.62,,,25.62,Fee Schedule,Medicaid Laboratory Fee Schedule,25.62,,,25.62,Fee Schedule,100% Medicaid Laboratory Fee Schedule,25.62,,,25.62,Fee Schedule,100% Medicaid Laboratory Fee Schedule,25.62,,,25.62,Fee Schedule,100% Medicaid Laboratory Fee Schedule,57.65,,,57.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,57.65,,,57.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,39.2,,,39.2,Fee Schedule,153% Medicaid Laboratory Fee Schedule,57.65,,,57.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,35.87,,,35.87,Fee Schedule,140% Medicaid Laboratory Fee Schedule,57.65,,,57.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,66.62,,,66.62,Fee Schedule,260% Medicaid Laboratory Fee Schedule,83.02,,,83.02,Fee Schedule,324% Medicaid Laboratory Fee Schedule,55.09,,,55.09,Fee Schedule,215% Medicaid Laboratory Fee Schedule,55.09,,,55.09,Fee Schedule,215% Medicaid Laboratory Fee Schedule,32.03,,,32.03,Fee Schedule,125% Medicaid Laboratory Fee Schedule,25.62,1872.5,
INSITU HYBRIDIZATION MANUAL     ,88368,CPT,,43501717,CDM,310,RC,,,both,,,5281,683.55,,,683.55,Other,150% of Medicare + 9.63% HCRA Surcharge,415.67,,,415.67,Other,Medicare OPPS methodology,245.09,,,245.09,Fee Schedule,,220.96,,,220.96,Fee Schedule,,1446.77,,,1446.77,Fee Schedule,,1301.69,,,1301.69,Fee Schedule,,1229.15,,,1229.15,Fee Schedule,,2640.5,50,,2640.5,percent of total billed charges,All Other,201.96,,,201.96,Fee Schedule,,481.29,,,481.29,Fee Schedule,,333.65,,,333.65,Other,186% Medicaid methodology,566.38,,,566.38,Fee Schedule,,3274.22,,,3274.22,Fee Schedule,,266.68,,,266.68,Fee Schedule,,566.38,,,566.38,Fee Schedule,,3274.22,,,3274.22,Fee Schedule,,501.61,,,501.61,Fee Schedule,,3696.7,70,,3696.7,percent of total billed charges,All Other,462,,,462,Fee Schedule,,392,,,392,Fee Schedule,,340.09,,,340.09,Fee Schedule,,340.09,,,340.09,Fee Schedule,,340.09,,,340.09,Fee Schedule,,340.09,,,340.09,Fee Schedule,,179.38,,,179.38,Fee Schedule,Medicaid Laboratory Fee Schedule,179.38,,,179.38,Fee Schedule,100% Medicaid Laboratory Fee Schedule,179.38,,,179.38,Fee Schedule,100% Medicaid Laboratory Fee Schedule,179.38,,,179.38,Fee Schedule,100% Medicaid Laboratory Fee Schedule,403.61,,,403.61,Fee Schedule,225% Medicaid Laboratory Fee Schedule,403.61,,,403.61,Fee Schedule,225% Medicaid Laboratory Fee Schedule,274.45,,,274.45,Fee Schedule,153% Medicaid Laboratory Fee Schedule,403.61,,,403.61,Fee Schedule,225% Medicaid Laboratory Fee Schedule,251.13,,,251.13,Fee Schedule,140% Medicaid Laboratory Fee Schedule,403.61,,,403.61,Fee Schedule,225% Medicaid Laboratory Fee Schedule,466.39,,,466.39,Fee Schedule,260% Medicaid Laboratory Fee Schedule,581.19,,,581.19,Fee Schedule,324% Medicaid Laboratory Fee Schedule,385.67,,,385.67,Fee Schedule,215% Medicaid Laboratory Fee Schedule,385.67,,,385.67,Fee Schedule,215% Medicaid Laboratory Fee Schedule,224.23,,,224.23,Fee Schedule,125% Medicaid Laboratory Fee Schedule,179.38,3696.7,
CYTP URNE 3-5 PROBES EA SPEC    ,88120,CPT,,43502558,CDM,310,RC,,,both,,,4177,324.81,,,324.81,Other,150% of Medicare + 9.63% HCRA Surcharge,197.52,,,197.52,Other,Medicare OPPS methodology,1192.72,,,1192.72,Fee Schedule,,1075.3,,,1075.3,Fee Schedule,,3707.32,,,3707.32,Fee Schedule,,3335.56,,,3335.56,Fee Schedule,,3149.67,,,3149.67,Fee Schedule,,2088.5,50,,2088.5,percent of total billed charges,All Other,1214.04,,,1214.04,Fee Schedule,,2342.18,,,2342.18,Fee Schedule,,333.64,,,333.64,Other,186% Medicaid methodology,2756.24,,,2756.24,Fee Schedule,,2589.74,,,2589.74,Fee Schedule,,1297.78,,,1297.78,Fee Schedule,,2756.24,,,2756.24,Fee Schedule,,2589.74,,,2589.74,Fee Schedule,,2441.06,,,2441.06,Fee Schedule,,2923.9,70,,2923.9,percent of total billed charges,All Other,2729.1,,,2729.1,Fee Schedule,,2315.6,,,2315.6,Fee Schedule,,172.2,,,172.2,Fee Schedule,,172.2,,,172.2,Fee Schedule,,172.2,,,172.2,Fee Schedule,,172.2,,,172.2,Fee Schedule,,179.38,,,179.38,Fee Schedule,Medicaid Laboratory Fee Schedule,179.38,,,179.38,Fee Schedule,100% Medicaid Laboratory Fee Schedule,179.38,,,179.38,Fee Schedule,100% Medicaid Laboratory Fee Schedule,179.38,,,179.38,Fee Schedule,100% Medicaid Laboratory Fee Schedule,403.6,,,403.6,Fee Schedule,225% Medicaid Laboratory Fee Schedule,403.6,,,403.6,Fee Schedule,225% Medicaid Laboratory Fee Schedule,274.45,,,274.45,Fee Schedule,153% Medicaid Laboratory Fee Schedule,403.6,,,403.6,Fee Schedule,225% Medicaid Laboratory Fee Schedule,251.13,,,251.13,Fee Schedule,140% Medicaid Laboratory Fee Schedule,403.6,,,403.6,Fee Schedule,225% Medicaid Laboratory Fee Schedule,466.38,,,466.38,Fee Schedule,260% Medicaid Laboratory Fee Schedule,581.18,,,581.18,Fee Schedule,324% Medicaid Laboratory Fee Schedule,385.66,,,385.66,Fee Schedule,215% Medicaid Laboratory Fee Schedule,385.66,,,385.66,Fee Schedule,215% Medicaid Laboratory Fee Schedule,224.22,,,224.22,Fee Schedule,125% Medicaid Laboratory Fee Schedule,172.2,3707.32,
IMMUNOHISTO ANTB ADDL SLIDE     ,88341,CPT,,43502798,CDM,310,RC,,,both,,,463,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,144.85,,,144.85,Fee Schedule,,130.59,,,130.59,Fee Schedule,,18.31,,,18.31,Fee Schedule,,18.31,,,18.31,Fee Schedule,,18.31,,,18.31,Fee Schedule,,231.5,50,,231.5,percent of total billed charges,All Other,137.83,,,137.83,Fee Schedule,,284.44,,,284.44,Fee Schedule,,47.66,,,47.66,Other,186% Medicaid methodology,334.72,,,334.72,Fee Schedule,,287.06,,,287.06,Fee Schedule,,157.61,,,157.61,Fee Schedule,,334.72,,,334.72,Fee Schedule,,287.06,,,287.06,Fee Schedule,,296.45,,,296.45,Fee Schedule,,324.1,70,,324.1,percent of total billed charges,All Other,293.7,,,293.7,Fee Schedule,,249.2,,,249.2,Fee Schedule,,77.52,,,77.52,Fee Schedule,,77.52,,,77.52,Fee Schedule,,77.52,,,77.52,Fee Schedule,,77.52,,,77.52,Fee Schedule,,25.62,,,25.62,Fee Schedule,Medicaid Laboratory Fee Schedule,25.62,,,25.62,Fee Schedule,100% Medicaid Laboratory Fee Schedule,25.62,,,25.62,Fee Schedule,100% Medicaid Laboratory Fee Schedule,25.62,,,25.62,Fee Schedule,100% Medicaid Laboratory Fee Schedule,57.65,,,57.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,57.65,,,57.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,39.2,,,39.2,Fee Schedule,153% Medicaid Laboratory Fee Schedule,57.65,,,57.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,35.87,,,35.87,Fee Schedule,140% Medicaid Laboratory Fee Schedule,57.65,,,57.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,66.62,,,66.62,Fee Schedule,260% Medicaid Laboratory Fee Schedule,83.02,,,83.02,Fee Schedule,324% Medicaid Laboratory Fee Schedule,55.09,,,55.09,Fee Schedule,215% Medicaid Laboratory Fee Schedule,55.09,,,55.09,Fee Schedule,215% Medicaid Laboratory Fee Schedule,32.03,,,32.03,Fee Schedule,125% Medicaid Laboratory Fee Schedule,0.01,334.72,
IMMUNOHISTO ANTIBODY SLIDE      ,88344,CPT,,43502806,CDM,310,RC,,,both,,,1281,683.55,,,683.55,Other,150% of Medicare + 9.63% HCRA Surcharge,415.67,,,415.67,Other,Medicare OPPS methodology,309.86,,,309.86,Fee Schedule,,279.36,,,279.36,Fee Schedule,,30.75,,,30.75,Fee Schedule,,30.75,,,30.75,Fee Schedule,,30.75,,,30.75,Fee Schedule,,640.5,50,,640.5,percent of total billed charges,All Other,295.59,,,295.59,Fee Schedule,,608.48,,,608.48,Fee Schedule,,47.66,,,47.66,Other,186% Medicaid methodology,716.05,,,716.05,Fee Schedule,,794.22,,,794.22,Fee Schedule,,337.16,,,337.16,Fee Schedule,,716.05,,,716.05,Fee Schedule,,794.22,,,794.22,Fee Schedule,,634.17,,,634.17,Fee Schedule,,896.7,70,,896.7,percent of total billed charges,All Other,643.5,,,643.5,Fee Schedule,,546,,,546,Fee Schedule,,340.09,,,340.09,Fee Schedule,,340.09,,,340.09,Fee Schedule,,340.09,,,340.09,Fee Schedule,,340.09,,,340.09,Fee Schedule,,25.62,,,25.62,Fee Schedule,Medicaid Laboratory Fee Schedule,25.62,,,25.62,Fee Schedule,100% Medicaid Laboratory Fee Schedule,25.62,,,25.62,Fee Schedule,100% Medicaid Laboratory Fee Schedule,25.62,,,25.62,Fee Schedule,100% Medicaid Laboratory Fee Schedule,57.65,,,57.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,57.65,,,57.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,39.2,,,39.2,Fee Schedule,153% Medicaid Laboratory Fee Schedule,57.65,,,57.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,35.87,,,35.87,Fee Schedule,140% Medicaid Laboratory Fee Schedule,57.65,,,57.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,66.62,,,66.62,Fee Schedule,260% Medicaid Laboratory Fee Schedule,83.02,,,83.02,Fee Schedule,324% Medicaid Laboratory Fee Schedule,55.09,,,55.09,Fee Schedule,215% Medicaid Laboratory Fee Schedule,55.09,,,55.09,Fee Schedule,215% Medicaid Laboratory Fee Schedule,32.03,,,32.03,Fee Schedule,125% Medicaid Laboratory Fee Schedule,25.62,896.7,
M/PHMTRC ALYS ISHQUANT/SEMIQ    ,88377,CPT,,43502848,CDM,310,RC,,,both,,,2675,324.81,,,324.81,Other,150% of Medicare + 9.63% HCRA Surcharge,197.52,,,197.52,Other,Medicare OPPS methodology,760.46,,,760.46,Fee Schedule,,685.59,,,685.59,Fee Schedule,,59.35,,,59.35,Fee Schedule,,59.35,,,59.35,Fee Schedule,,59.35,,,59.35,Fee Schedule,,1337.5,50,,1337.5,percent of total billed charges,All Other,760.7,,,760.7,Fee Schedule,,1493.34,,,1493.34,Fee Schedule,,333.65,,,333.65,Other,186% Medicaid methodology,1757.33,,,1757.33,Fee Schedule,,1658.5,,,1658.5,Fee Schedule,,827.44,,,827.44,Fee Schedule,,1757.33,,,1757.33,Fee Schedule,,1658.5,,,1658.5,Fee Schedule,,1556.38,,,1556.38,Fee Schedule,,1872.5,70,,1872.5,percent of total billed charges,All Other,1659.9,,,1659.9,Fee Schedule,,1408.4,,,1408.4,Fee Schedule,,172.2,,,172.2,Fee Schedule,,172.2,,,172.2,Fee Schedule,,172.2,,,172.2,Fee Schedule,,172.2,,,172.2,Fee Schedule,,179.38,,,179.38,Fee Schedule,Medicaid Laboratory Fee Schedule,179.38,,,179.38,Fee Schedule,100% Medicaid Laboratory Fee Schedule,179.38,,,179.38,Fee Schedule,100% Medicaid Laboratory Fee Schedule,179.38,,,179.38,Fee Schedule,100% Medicaid Laboratory Fee Schedule,403.61,,,403.61,Fee Schedule,225% Medicaid Laboratory Fee Schedule,403.61,,,403.61,Fee Schedule,225% Medicaid Laboratory Fee Schedule,274.45,,,274.45,Fee Schedule,153% Medicaid Laboratory Fee Schedule,403.61,,,403.61,Fee Schedule,225% Medicaid Laboratory Fee Schedule,251.13,,,251.13,Fee Schedule,140% Medicaid Laboratory Fee Schedule,403.61,,,403.61,Fee Schedule,225% Medicaid Laboratory Fee Schedule,466.39,,,466.39,Fee Schedule,260% Medicaid Laboratory Fee Schedule,581.19,,,581.19,Fee Schedule,324% Medicaid Laboratory Fee Schedule,385.67,,,385.67,Fee Schedule,215% Medicaid Laboratory Fee Schedule,385.67,,,385.67,Fee Schedule,215% Medicaid Laboratory Fee Schedule,224.23,,,224.23,Fee Schedule,125% Medicaid Laboratory Fee Schedule,59.35,1872.5,
MICRODISSECTION MANUAL          ,88381,CPT,,43502855,CDM,310,RC,,,both,,,819,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,408.27,,,408.27,Fee Schedule,,368.08,,,368.08,Fee Schedule,,1200.42,,,1200.42,Fee Schedule,,1080.05,,,1080.05,Fee Schedule,,1019.86,,,1019.86,Fee Schedule,,409.5,50,,409.5,percent of total billed charges,All Other,380.35,,,380.35,Fee Schedule,,801.74,,,801.74,Fee Schedule,,154.29,,,154.29,Other,186% Medicaid methodology,943.47,,,943.47,Fee Schedule,,507.78,,,507.78,Fee Schedule,,444.23,,,444.23,Fee Schedule,,943.47,,,943.47,Fee Schedule,,507.78,,,507.78,Fee Schedule,,835.58,,,835.58,Fee Schedule,,573.3,70,,573.3,percent of total billed charges,All Other,905.85,,,905.85,Fee Schedule,,768.6,,,768.6,Fee Schedule,,188.39,,,188.39,Fee Schedule,,188.39,,,188.39,Fee Schedule,,188.39,,,188.39,Fee Schedule,,188.39,,,188.39,Fee Schedule,,82.95,,,82.95,Other,New York Medicaid APG methodology,82.95,,,82.95,Other,100% Medicaid APG methodology,82.95,,,82.95,Other,100% Medicaid APG methodology,82.95,,,82.95,Other,100% Medicaid APG methodology,186.64,,,186.64,Other,225% Medicaid APG methodology,186.64,,,186.64,Other,225% Medicaid APG methodology,126.92,,,126.92,Other,153% Medicaid APG methodology,186.64,,,186.64,Other,225% Medicaid APG methodology,116.13,,,116.13,Other,140% Medicaid APG methodology,186.64,,,186.64,Other,225% Medicaid APG methodology,215.67,,,215.67,Other,260% Medicaid APG methodology,268.76,,,268.76,Other,324% Medicaid APG methodology,178.35,,,178.35,Other,215% Medicaid APG methodology,178.35,,,178.35,Other,215% Medicaid APG methodology,103.69,,,103.69,Other,125% Medicaid APG methodology,0.01,1200.42,
NFCT DS CHRNC HCV 6 ASSAYS      ,81596,CPT,,43503101,CDM,310,RC,,,both,,,1148,118.71,,,118.71,Other,150% of Medicare + 9.63% HCRA Surcharge,72.19,,,72.19,Fee Schedule,Mediare Clinical Lab,139.33,,,139.33,Fee Schedule,,125.61,,,125.61,Fee Schedule,,72.19,,,72.19,Fee Schedule,,72.19,,,72.19,Fee Schedule,,72.19,,,72.19,Fee Schedule,,574,50,,574,percent of total billed charges,All Other,152.49,,,152.49,Fee Schedule,,227.4,,,227.4,Fee Schedule,,108.49,,,108.49,Other,186% Medicaid methodology,267.82,,,267.82,Fee Schedule,,711.76,,,711.76,Fee Schedule,,151.6,,,151.6,Fee Schedule,,267.82,,,267.82,Fee Schedule,,711.76,,,711.76,Fee Schedule,,285.15,,,285.15,Fee Schedule,,803.6,70,,803.6,percent of total billed charges,All Other,344.2,,,344.2,Fee Schedule,,292.05,,,292.05,Fee Schedule,,86.63,,,86.63,Fee Schedule,,86.63,,,86.63,Fee Schedule,,86.63,,,86.63,Fee Schedule,,86.63,,,86.63,Fee Schedule,,58.33,,,58.33,Fee Schedule,Medicaid Laboratory Fee Schedule,58.33,,,58.33,Fee Schedule,100% Medicaid Laboratory Fee Schedule,58.33,,,58.33,Fee Schedule,100% Medicaid Laboratory Fee Schedule,58.33,,,58.33,Fee Schedule,100% Medicaid Laboratory Fee Schedule,131.24,,,131.24,Fee Schedule,225% Medicaid Laboratory Fee Schedule,131.24,,,131.24,Fee Schedule,225% Medicaid Laboratory Fee Schedule,89.24,,,89.24,Fee Schedule,153% Medicaid Laboratory Fee Schedule,131.24,,,131.24,Fee Schedule,225% Medicaid Laboratory Fee Schedule,81.66,,,81.66,Fee Schedule,140% Medicaid Laboratory Fee Schedule,131.24,,,131.24,Fee Schedule,225% Medicaid Laboratory Fee Schedule,151.65,,,151.65,Fee Schedule,260% Medicaid Laboratory Fee Schedule,188.98,,,188.98,Fee Schedule,324% Medicaid Laboratory Fee Schedule,125.4,,,125.4,Fee Schedule,215% Medicaid Laboratory Fee Schedule,125.4,,,125.4,Fee Schedule,215% Medicaid Laboratory Fee Schedule,72.91,,,72.91,Fee Schedule,125% Medicaid Laboratory Fee Schedule,58.33,803.6,
BCR/ABL1 GENE OTHER BP          ,81208,CPT,,43503176,CDM,310,RC,,,both,,,580,352.93,,,352.93,Other,150% of Medicare + 9.63% HCRA Surcharge,214.62,,,214.62,Fee Schedule,Mediare Clinical Lab,414.22,,,414.22,Fee Schedule,,373.44,,,373.44,Fee Schedule,,47.77,,,47.77,Fee Schedule,,47.77,,,47.77,Fee Schedule,,47.77,,,47.77,Fee Schedule,,290,50,,290,percent of total billed charges,All Other,453.38,,,453.38,Fee Schedule,,676.05,,,676.05,Fee Schedule,,399.19,,,399.19,Other,186% Medicaid methodology,796.24,,,796.24,Fee Schedule,,359.6,,,359.6,Fee Schedule,,450.7,,,450.7,Fee Schedule,,796.24,,,796.24,Fee Schedule,,359.6,,,359.6,Fee Schedule,,847.75,,,847.75,Fee Schedule,,406,70,,406,percent of total billed charges,All Other,1023.29,,,1023.29,Fee Schedule,,868.25,,,868.25,Fee Schedule,,257.54,,,257.54,Fee Schedule,,257.54,,,257.54,Fee Schedule,,257.54,,,257.54,Fee Schedule,,257.54,,,257.54,Fee Schedule,,214.62,,,214.62,Fee Schedule,Medicaid Laboratory Fee Schedule,214.62,,,214.62,Fee Schedule,100% Medicaid Laboratory Fee Schedule,214.62,,,214.62,Fee Schedule,100% Medicaid Laboratory Fee Schedule,214.62,,,214.62,Fee Schedule,100% Medicaid Laboratory Fee Schedule,482.9,,,482.9,Fee Schedule,225% Medicaid Laboratory Fee Schedule,482.9,,,482.9,Fee Schedule,225% Medicaid Laboratory Fee Schedule,328.37,,,328.37,Fee Schedule,153% Medicaid Laboratory Fee Schedule,482.9,,,482.9,Fee Schedule,225% Medicaid Laboratory Fee Schedule,300.47,,,300.47,Fee Schedule,140% Medicaid Laboratory Fee Schedule,482.9,,,482.9,Fee Schedule,225% Medicaid Laboratory Fee Schedule,558.01,,,558.01,Fee Schedule,260% Medicaid Laboratory Fee Schedule,695.37,,,695.37,Fee Schedule,324% Medicaid Laboratory Fee Schedule,461.43,,,461.43,Fee Schedule,215% Medicaid Laboratory Fee Schedule,461.43,,,461.43,Fee Schedule,215% Medicaid Laboratory Fee Schedule,268.28,,,268.28,Fee Schedule,125% Medicaid Laboratory Fee Schedule,47.77,1023.29,
81479 ALK,81479,CPT,,43503218,CDM,310,RC,,,both,,,5379,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,2689.5,50,,2689.5,percent of total billed charges,All Other Outpatient,2420.55,45,,2420.55,percent of total billed charges,All Other Outpatient,2689.5,50,,2689.5,percent of total billed charges,All Other Outpatient,2420.55,45,,2420.55,percent of total billed charges,All Other Outpatient,2312.97,43,,2312.97,percent of total billed charges,All Other Outpatient,2689.5,50,,2689.5,percent of total billed charges,All Other,355,,,355,Fee Schedule,,3657.72,68,,3657.72,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,4303.2,80,,4303.2,percent of total billed charges,All Other Outpatient,4464.57,83,,4464.57,percent of total billed charges,All Other Outpatient,4464.57,83,,4464.57,percent of total billed charges,All Other Outpatient,4303.2,80,,4303.2,percent of total billed charges,All Other Outpatient,4464.57,83,,4464.57,percent of total billed charges,All Other Outpatient,4841.1,90,,4841.1,percent of total billed charges,All Other,3765.3,70,,3765.3,percent of total billed charges,All Other,2689.5,50,,2689.5,percent of total billed charges,All Other,2689.5,50,,2689.5,percent of total billed charges,All Other,3765.3,70,,3765.3,percent of total billed charges,All Other,3765.3,70,,3765.3,percent of total billed charges,All Other,3765.3,70,,3765.3,percent of total billed charges,All Other,3765.3,70,,3765.3,percent of total billed charges,All Other,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,4841.1,
MOPATH PROCEDURE LEVEL 8        ,81407,CPT,,43503234,CDM,310,RC,,,both,,,4740,1391.65,,,1391.65,Other,150% of Medicare + 9.63% HCRA Surcharge,846.27,,,846.27,Fee Schedule,Mediare Clinical Lab,1633.3,,,1633.3,Fee Schedule,,1472.51,,,1472.51,Fee Schedule,,846.27,,,846.27,Fee Schedule,,846.27,,,846.27,Fee Schedule,,846.27,,,846.27,Fee Schedule,,2370,50,,2370,percent of total billed charges,All Other,1787.76,,,1787.76,Fee Schedule,,2665.75,,,2665.75,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,3139.66,,,3139.66,Fee Schedule,,2938.8,,,2938.8,Fee Schedule,,1777.17,,,1777.17,Fee Schedule,,3139.66,,,3139.66,Fee Schedule,,2938.8,,,2938.8,Fee Schedule,,3342.77,,,3342.77,Fee Schedule,,3318,70,,3318,percent of total billed charges,All Other,4034.96,,,4034.96,Fee Schedule,,3423.6,,,3423.6,Fee Schedule,,1015.52,,,1015.52,Fee Schedule,,1015.52,,,1015.52,Fee Schedule,,1015.52,,,1015.52,Fee Schedule,,1015.52,,,1015.52,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,4034.96,
81404 REF LAB MOL PATH LEVEL V/ PIK3CA,81404,CPT,,43503259,CDM,310,RC,,,both,,,825,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,412.5,50,,412.5,percent of total billed charges,All Other Outpatient,371.25,45,,371.25,percent of total billed charges,All Other Outpatient,412.5,50,,412.5,percent of total billed charges,All Other Outpatient,371.25,45,,371.25,percent of total billed charges,All Other Outpatient,354.75,43,,354.75,percent of total billed charges,All Other Outpatient,412.5,50,,412.5,percent of total billed charges,All Other,580.58,,,580.58,Fee Schedule,,561,68,,561,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,660,80,,660,percent of total billed charges,All Other Outpatient,684.75,83,,684.75,percent of total billed charges,All Other Outpatient,684.75,83,,684.75,percent of total billed charges,All Other Outpatient,660,80,,660,percent of total billed charges,All Other Outpatient,684.75,83,,684.75,percent of total billed charges,All Other Outpatient,742.5,90,,742.5,percent of total billed charges,All Other,577.5,70,,577.5,percent of total billed charges,All Other,412.5,50,,412.5,percent of total billed charges,All Other,412.5,50,,412.5,percent of total billed charges,All Other,329.8,,,329.8,Fee Schedule,,329.8,,,329.8,Fee Schedule,,329.8,,,329.8,Fee Schedule,,329.8,,,329.8,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,742.5,
BRCA1&2 GEN FULL SEQ DUP/DEL    ,81162,CPT,,43503317,CDM,310,RC,,,both,,,4380,3000.92,,,3000.92,Other,150% of Medicare + 9.63% HCRA Surcharge,1824.88,,,1824.88,Fee Schedule,Mediare Clinical Lab,3522.02,,,3522.02,Fee Schedule,,3175.29,,,3175.29,Fee Schedule,,994.34,,,994.34,Fee Schedule,,994.34,,,994.34,Fee Schedule,,994.34,,,994.34,Fee Schedule,,2190,50,,2190,percent of total billed charges,All Other,3855.05,,,3855.05,Fee Schedule,,5748.37,,,5748.37,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,6770.3,,,6770.3,Fee Schedule,,2715.6,,,2715.6,Fee Schedule,,3832.25,,,3832.25,Fee Schedule,,6770.3,,,6770.3,Fee Schedule,,2715.6,,,2715.6,Fee Schedule,,7208.28,,,7208.28,Fee Schedule,,3066,70,,3066,percent of total billed charges,All Other,8700.9,,,8700.9,Fee Schedule,,7382.58,,,7382.58,Fee Schedule,,2189.86,,,2189.86,Fee Schedule,,2189.86,,,2189.86,Fee Schedule,,2189.86,,,2189.86,Fee Schedule,,2189.86,,,2189.86,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,8700.9,
NF1 FULL GENE ANALYSIS          ,81408,CPT,,43503432,CDM,310,RC,,,both,,,2560,3288.9,,,3288.9,Other,150% of Medicare + 9.63% HCRA Surcharge,2000,,,2000,Fee Schedule,Mediare Clinical Lab,3860,,,3860,Fee Schedule,,3480,,,3480,Fee Schedule,,964.59,,,964.59,Fee Schedule,,964.59,,,964.59,Fee Schedule,,964.59,,,964.59,Fee Schedule,,1280,50,,1280,percent of total billed charges,All Other,4225,,,4225,Fee Schedule,,6300,,,6300,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,7420,,,7420,Fee Schedule,,1587.2,,,1587.2,Fee Schedule,,4200,,,4200,Fee Schedule,,7420,,,7420,Fee Schedule,,1587.2,,,1587.2,Fee Schedule,,7900,,,7900,Fee Schedule,,1792,70,,1792,percent of total billed charges,All Other,9535.86,,,9535.86,Fee Schedule,,8091.04,,,8091.04,Fee Schedule,,2400,,,2400,Fee Schedule,,2400,,,2400,Fee Schedule,,2400,,,2400,Fee Schedule,,2400,,,2400,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,9535.86,
BRAF GENE                       ,81210,CPT,,43503457,CDM,310,RC,,,both,,,2789,288.44,,,288.44,Other,150% of Medicare + 9.63% HCRA Surcharge,175.4,,,175.4,Fee Schedule,Mediare Clinical Lab,338.52,,,338.52,Fee Schedule,,305.2,,,305.2,Fee Schedule,,35.94,,,35.94,Fee Schedule,,35.94,,,35.94,Fee Schedule,,35.94,,,35.94,Fee Schedule,,1394.5,50,,1394.5,percent of total billed charges,All Other,370.53,,,370.53,Fee Schedule,,552.51,,,552.51,Fee Schedule,,326.24,,,326.24,Other,186% Medicaid methodology,650.73,,,650.73,Fee Schedule,,1729.18,,,1729.18,Fee Schedule,,368.34,,,368.34,Fee Schedule,,650.73,,,650.73,Fee Schedule,,1729.18,,,1729.18,Fee Schedule,,692.83,,,692.83,Fee Schedule,,1952.3,70,,1952.3,percent of total billed charges,All Other,836.3,,,836.3,Fee Schedule,,709.58,,,709.58,Fee Schedule,,210.48,,,210.48,Fee Schedule,,210.48,,,210.48,Fee Schedule,,210.48,,,210.48,Fee Schedule,,210.48,,,210.48,Fee Schedule,,175.4,,,175.4,Fee Schedule,Medicaid Laboratory Fee Schedule,175.4,,,175.4,Fee Schedule,100% Medicaid Laboratory Fee Schedule,175.4,,,175.4,Fee Schedule,100% Medicaid Laboratory Fee Schedule,175.4,,,175.4,Fee Schedule,100% Medicaid Laboratory Fee Schedule,394.65,,,394.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,394.65,,,394.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,268.36,,,268.36,Fee Schedule,153% Medicaid Laboratory Fee Schedule,394.65,,,394.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,245.56,,,245.56,Fee Schedule,140% Medicaid Laboratory Fee Schedule,394.65,,,394.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,456.04,,,456.04,Fee Schedule,260% Medicaid Laboratory Fee Schedule,568.3,,,568.3,Fee Schedule,324% Medicaid Laboratory Fee Schedule,377.11,,,377.11,Fee Schedule,215% Medicaid Laboratory Fee Schedule,377.11,,,377.11,Fee Schedule,215% Medicaid Laboratory Fee Schedule,219.25,,,219.25,Fee Schedule,125% Medicaid Laboratory Fee Schedule,35.94,1952.3,
CALR GENE COM VARIANTS          ,81219,CPT,,43503465,CDM,310,RC,,,both,,,329,200.01,,,200.01,Other,150% of Medicare + 9.63% HCRA Surcharge,121.63,,,121.63,Fee Schedule,Mediare Clinical Lab,234.75,,,234.75,Fee Schedule,,211.64,,,211.64,Fee Schedule,,66.27,,,66.27,Fee Schedule,,66.27,,,66.27,Fee Schedule,,66.27,,,66.27,Fee Schedule,,164.5,50,,164.5,percent of total billed charges,All Other,256.95,,,256.95,Fee Schedule,,383.13,,,383.13,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,451.25,,,451.25,Fee Schedule,,203.98,,,203.98,Fee Schedule,,255.42,,,255.42,Fee Schedule,,451.25,,,451.25,Fee Schedule,,203.98,,,203.98,Fee Schedule,,480.44,,,480.44,Fee Schedule,,230.3,70,,230.3,percent of total billed charges,All Other,579.92,,,579.92,Fee Schedule,,492.06,,,492.06,Fee Schedule,,145.96,,,145.96,Fee Schedule,,145.96,,,145.96,Fee Schedule,,145.96,,,145.96,Fee Schedule,,145.96,,,145.96,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,579.92,
FANCC GENE                      ,81242,CPT,,43503473,CDM,310,RC,,,both,,,569,60.22,,,60.22,Other,150% of Medicare + 9.63% HCRA Surcharge,36.62,,,36.62,Fee Schedule,Mediare Clinical Lab,70.68,,,70.68,Fee Schedule,,63.72,,,63.72,Fee Schedule,,24.37,,,24.37,Fee Schedule,,24.37,,,24.37,Fee Schedule,,24.37,,,24.37,Fee Schedule,,284.5,50,,284.5,percent of total billed charges,All Other,77.35,,,77.35,Fee Schedule,,115.35,,,115.35,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,135.86,,,135.86,Fee Schedule,,352.78,,,352.78,Fee Schedule,,76.9,,,76.9,Fee Schedule,,135.86,,,135.86,Fee Schedule,,352.78,,,352.78,Fee Schedule,,144.65,,,144.65,Fee Schedule,,398.3,70,,398.3,percent of total billed charges,All Other,174.6,,,174.6,Fee Schedule,,148.15,,,148.15,Fee Schedule,,43.94,,,43.94,Fee Schedule,,43.94,,,43.94,Fee Schedule,,43.94,,,43.94,Fee Schedule,,43.94,,,43.94,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,398.3,
FLT3 GENE                       ,81245,CPT,,43503481,CDM,310,RC,,,both,,,1164,272.17,,,272.17,Other,150% of Medicare + 9.63% HCRA Surcharge,165.51,,,165.51,Fee Schedule,Mediare Clinical Lab,319.43,,,319.43,Fee Schedule,,287.99,,,287.99,Fee Schedule,,31.12,,,31.12,Fee Schedule,,31.12,,,31.12,Fee Schedule,,31.12,,,31.12,Fee Schedule,,582,50,,582,percent of total billed charges,All Other,349.64,,,349.64,Fee Schedule,,521.36,,,521.36,Fee Schedule,,307.85,,,307.85,Other,186% Medicaid methodology,614.04,,,614.04,Fee Schedule,,721.68,,,721.68,Fee Schedule,,347.57,,,347.57,Fee Schedule,,614.04,,,614.04,Fee Schedule,,721.68,,,721.68,Fee Schedule,,653.76,,,653.76,Fee Schedule,,814.8,70,,814.8,percent of total billed charges,All Other,789.14,,,789.14,Fee Schedule,,669.57,,,669.57,Fee Schedule,,198.61,,,198.61,Fee Schedule,,198.61,,,198.61,Fee Schedule,,198.61,,,198.61,Fee Schedule,,198.61,,,198.61,Fee Schedule,,165.51,,,165.51,Fee Schedule,Medicaid Laboratory Fee Schedule,165.51,,,165.51,Fee Schedule,100% Medicaid Laboratory Fee Schedule,165.51,,,165.51,Fee Schedule,100% Medicaid Laboratory Fee Schedule,165.51,,,165.51,Fee Schedule,100% Medicaid Laboratory Fee Schedule,372.4,,,372.4,Fee Schedule,225% Medicaid Laboratory Fee Schedule,372.4,,,372.4,Fee Schedule,225% Medicaid Laboratory Fee Schedule,253.23,,,253.23,Fee Schedule,153% Medicaid Laboratory Fee Schedule,372.4,,,372.4,Fee Schedule,225% Medicaid Laboratory Fee Schedule,231.71,,,231.71,Fee Schedule,140% Medicaid Laboratory Fee Schedule,372.4,,,372.4,Fee Schedule,225% Medicaid Laboratory Fee Schedule,430.33,,,430.33,Fee Schedule,260% Medicaid Laboratory Fee Schedule,536.25,,,536.25,Fee Schedule,324% Medicaid Laboratory Fee Schedule,355.85,,,355.85,Fee Schedule,215% Medicaid Laboratory Fee Schedule,355.85,,,355.85,Fee Schedule,215% Medicaid Laboratory Fee Schedule,206.89,,,206.89,Fee Schedule,125% Medicaid Laboratory Fee Schedule,31.12,814.8,
FLT3 GENE ANALYSIS              ,81246,CPT,,43503499,CDM,310,RC,,,both,,,415,136.49,,,136.49,Other,150% of Medicare + 9.63% HCRA Surcharge,83,,,83,Fee Schedule,Mediare Clinical Lab,160.19,,,160.19,Fee Schedule,,144.42,,,144.42,Fee Schedule,,31.12,,,31.12,Fee Schedule,,31.12,,,31.12,Fee Schedule,,31.12,,,31.12,Fee Schedule,,207.5,50,,207.5,percent of total billed charges,All Other,175.34,,,175.34,Fee Schedule,,261.45,,,261.45,Fee Schedule,,154.38,,,154.38,Other,186% Medicaid methodology,307.93,,,307.93,Fee Schedule,,257.3,,,257.3,Fee Schedule,,174.3,,,174.3,Fee Schedule,,307.93,,,307.93,Fee Schedule,,257.3,,,257.3,Fee Schedule,,327.85,,,327.85,Fee Schedule,,290.5,70,,290.5,percent of total billed charges,All Other,395.74,,,395.74,Fee Schedule,,335.78,,,335.78,Fee Schedule,,99.6,,,99.6,Fee Schedule,,99.6,,,99.6,Fee Schedule,,99.6,,,99.6,Fee Schedule,,99.6,,,99.6,Fee Schedule,,83,,,83,Fee Schedule,Medicaid Laboratory Fee Schedule,83,,,83,Fee Schedule,100% Medicaid Laboratory Fee Schedule,83,,,83,Fee Schedule,100% Medicaid Laboratory Fee Schedule,83,,,83,Fee Schedule,100% Medicaid Laboratory Fee Schedule,186.75,,,186.75,Fee Schedule,225% Medicaid Laboratory Fee Schedule,186.75,,,186.75,Fee Schedule,225% Medicaid Laboratory Fee Schedule,126.99,,,126.99,Fee Schedule,153% Medicaid Laboratory Fee Schedule,186.75,,,186.75,Fee Schedule,225% Medicaid Laboratory Fee Schedule,116.2,,,116.2,Fee Schedule,140% Medicaid Laboratory Fee Schedule,186.75,,,186.75,Fee Schedule,225% Medicaid Laboratory Fee Schedule,215.8,,,215.8,Fee Schedule,260% Medicaid Laboratory Fee Schedule,268.92,,,268.92,Fee Schedule,324% Medicaid Laboratory Fee Schedule,178.45,,,178.45,Fee Schedule,215% Medicaid Laboratory Fee Schedule,178.45,,,178.45,Fee Schedule,215% Medicaid Laboratory Fee Schedule,103.75,,,103.75,Fee Schedule,125% Medicaid Laboratory Fee Schedule,31.12,395.74,
IGH VARI REGIONAL MUTATION      ,81263,CPT,,43503507,CDM,310,RC,,,both,,,4684,484.32,,,484.32,Other,150% of Medicare + 9.63% HCRA Surcharge,294.52,,,294.52,Fee Schedule,Mediare Clinical Lab,568.42,,,568.42,Fee Schedule,,512.46,,,512.46,Fee Schedule,,51.44,,,51.44,Fee Schedule,,51.44,,,51.44,Fee Schedule,,51.44,,,51.44,Fee Schedule,,2342,50,,2342,percent of total billed charges,All Other,622.18,,,622.18,Fee Schedule,,927.74,,,927.74,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,1092.67,,,1092.67,Fee Schedule,,2904.08,,,2904.08,Fee Schedule,,618.49,,,618.49,Fee Schedule,,1092.67,,,1092.67,Fee Schedule,,2904.08,,,2904.08,Fee Schedule,,1163.35,,,1163.35,Fee Schedule,,3278.8,70,,3278.8,percent of total billed charges,All Other,1404.25,,,1404.25,Fee Schedule,,1191.49,,,1191.49,Fee Schedule,,353.42,,,353.42,Fee Schedule,,353.42,,,353.42,Fee Schedule,,353.42,,,353.42,Fee Schedule,,353.42,,,353.42,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,3278.8,
MCOLN1 GENE                     ,81290,CPT,,43503515,CDM,310,RC,,,both,,,107,64.64,,,64.64,Other,150% of Medicare + 9.63% HCRA Surcharge,39.31,,,39.31,Fee Schedule,Mediare Clinical Lab,75.87,,,75.87,Fee Schedule,,68.4,,,68.4,Fee Schedule,,24.24,,,24.24,Fee Schedule,,24.24,,,24.24,Fee Schedule,,24.24,,,24.24,Fee Schedule,,53.5,50,,53.5,percent of total billed charges,All Other,83.04,,,83.04,Fee Schedule,,123.83,,,123.83,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,145.84,,,145.84,Fee Schedule,,66.34,,,66.34,Fee Schedule,,82.55,,,82.55,Fee Schedule,,145.84,,,145.84,Fee Schedule,,66.34,,,66.34,Fee Schedule,,155.27,,,155.27,Fee Schedule,,74.9,70,,74.9,percent of total billed charges,All Other,187.43,,,187.43,Fee Schedule,,159.03,,,159.03,Fee Schedule,,47.17,,,47.17,Fee Schedule,,47.17,,,47.17,Fee Schedule,,47.17,,,47.17,Fee Schedule,,47.17,,,47.17,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,187.43,
HBA1 HBA2 GENE                  ,81257,CPT,,43503549,CDM,310,RC,,,both,,,2373,168.16,,,168.16,Other,150% of Medicare + 9.63% HCRA Surcharge,102.26,,,102.26,Fee Schedule,Mediare Clinical Lab,197.36,,,197.36,Fee Schedule,,177.93,,,177.93,Fee Schedule,,36.07,,,36.07,Fee Schedule,,36.07,,,36.07,Fee Schedule,,36.07,,,36.07,Fee Schedule,,1186.5,50,,1186.5,percent of total billed charges,All Other,216.03,,,216.03,Fee Schedule,,322.12,,,322.12,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,379.38,,,379.38,Fee Schedule,,1471.26,,,1471.26,Fee Schedule,,214.75,,,214.75,Fee Schedule,,379.38,,,379.38,Fee Schedule,,1471.26,,,1471.26,Fee Schedule,,403.93,,,403.93,Fee Schedule,,1661.1,70,,1661.1,percent of total billed charges,All Other,487.57,,,487.57,Fee Schedule,,413.69,,,413.69,Fee Schedule,,122.71,,,122.71,Fee Schedule,,122.71,,,122.71,Fee Schedule,,122.71,,,122.71,Fee Schedule,,122.71,,,122.71,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1661.1,
KRAS GENE ADDL VARIANTS         ,81276,CPT,,43503556,CDM,310,RC,,,both,,,580,317.79,,,317.79,Other,150% of Medicare + 9.63% HCRA Surcharge,193.25,,,193.25,Fee Schedule,Mediare Clinical Lab,372.97,,,372.97,Fee Schedule,,336.26,,,336.26,Fee Schedule,,78.88,,,78.88,Fee Schedule,,78.88,,,78.88,Fee Schedule,,78.88,,,78.88,Fee Schedule,,290,50,,290,percent of total billed charges,All Other,408.23,,,408.23,Fee Schedule,,608.74,,,608.74,Fee Schedule,,222.26,,,222.26,Other,186% Medicaid methodology,716.96,,,716.96,Fee Schedule,,359.6,,,359.6,Fee Schedule,,405.83,,,405.83,Fee Schedule,,716.96,,,716.96,Fee Schedule,,359.6,,,359.6,Fee Schedule,,763.34,,,763.34,Fee Schedule,,406,70,,406,percent of total billed charges,All Other,921.4,,,921.4,Fee Schedule,,781.8,,,781.8,Fee Schedule,,231.9,,,231.9,Fee Schedule,,231.9,,,231.9,Fee Schedule,,231.9,,,231.9,Fee Schedule,,231.9,,,231.9,Fee Schedule,,119.49,,,119.49,Fee Schedule,Medicaid Laboratory Fee Schedule,119.49,,,119.49,Fee Schedule,100% Medicaid Laboratory Fee Schedule,119.49,,,119.49,Fee Schedule,100% Medicaid Laboratory Fee Schedule,119.49,,,119.49,Fee Schedule,100% Medicaid Laboratory Fee Schedule,268.86,,,268.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,268.86,,,268.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,182.82,,,182.82,Fee Schedule,153% Medicaid Laboratory Fee Schedule,268.86,,,268.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,167.29,,,167.29,Fee Schedule,140% Medicaid Laboratory Fee Schedule,268.86,,,268.86,Fee Schedule,225% Medicaid Laboratory Fee Schedule,310.68,,,310.68,Fee Schedule,260% Medicaid Laboratory Fee Schedule,387.16,,,387.16,Fee Schedule,324% Medicaid Laboratory Fee Schedule,256.91,,,256.91,Fee Schedule,215% Medicaid Laboratory Fee Schedule,256.91,,,256.91,Fee Schedule,215% Medicaid Laboratory Fee Schedule,149.37,,,149.37,Fee Schedule,125% Medicaid Laboratory Fee Schedule,78.88,921.4,
JAK2 GENE TRGT SEQUENCE ALYS    ,81279,CPT,,43503564,CDM,310,RC,,,both,,,500,304.55,,,304.55,Other,150% of Medicare + 9.63% HCRA Surcharge,185.2,,,185.2,Fee Schedule,Mediare Clinical Lab,357.44,,,357.44,Fee Schedule,,322.25,,,322.25,Fee Schedule,,148.16,,,148.16,Fee Schedule,,148.16,,,148.16,Fee Schedule,,148.16,,,148.16,Fee Schedule,,250,50,,250,percent of total billed charges,All Other,391.24,,,391.24,Fee Schedule,,583.38,,,583.38,Fee Schedule,,208.75,,,208.75,Other,186% Medicaid methodology,687.09,,,687.09,Fee Schedule,,310,,,310,Fee Schedule,,388.92,,,388.92,Fee Schedule,,687.09,,,687.09,Fee Schedule,,310,,,310,Fee Schedule,,731.54,,,731.54,Fee Schedule,,350,70,,350,percent of total billed charges,All Other,883.02,,,883.02,Fee Schedule,,749.23,,,749.23,Fee Schedule,,222.24,,,222.24,Fee Schedule,,222.24,,,222.24,Fee Schedule,,222.24,,,222.24,Fee Schedule,,222.24,,,222.24,Fee Schedule,,112.23,,,112.23,Fee Schedule,Medicaid Laboratory Fee Schedule,112.23,,,112.23,Fee Schedule,100% Medicaid Laboratory Fee Schedule,112.23,,,112.23,Fee Schedule,100% Medicaid Laboratory Fee Schedule,112.23,,,112.23,Fee Schedule,100% Medicaid Laboratory Fee Schedule,252.52,,,252.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,252.52,,,252.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,171.71,,,171.71,Fee Schedule,153% Medicaid Laboratory Fee Schedule,252.52,,,252.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,157.12,,,157.12,Fee Schedule,140% Medicaid Laboratory Fee Schedule,252.52,,,252.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,291.8,,,291.8,Fee Schedule,260% Medicaid Laboratory Fee Schedule,363.63,,,363.63,Fee Schedule,324% Medicaid Laboratory Fee Schedule,241.3,,,241.3,Fee Schedule,215% Medicaid Laboratory Fee Schedule,241.3,,,241.3,Fee Schedule,215% Medicaid Laboratory Fee Schedule,140.29,,,140.29,Fee Schedule,125% Medicaid Laboratory Fee Schedule,112.23,883.02,
NRAS GENE VARIANTS EXON 2&3     ,81311,CPT,,43503572,CDM,310,RC,,,both,,,888,486.41,,,486.41,Other,150% of Medicare + 9.63% HCRA Surcharge,295.79,,,295.79,Fee Schedule,Mediare Clinical Lab,570.87,,,570.87,Fee Schedule,,514.67,,,514.67,Fee Schedule,,118.32,,,118.32,Fee Schedule,,118.32,,,118.32,Fee Schedule,,118.32,,,118.32,Fee Schedule,,444,50,,444,percent of total billed charges,All Other,624.85,,,624.85,Fee Schedule,,931.74,,,931.74,Fee Schedule,,333.4,,,333.4,Other,186% Medicaid methodology,1097.38,,,1097.38,Fee Schedule,,550.56,,,550.56,Fee Schedule,,621.16,,,621.16,Fee Schedule,,1097.38,,,1097.38,Fee Schedule,,550.56,,,550.56,Fee Schedule,,1168.37,,,1168.37,Fee Schedule,,621.6,70,,621.6,percent of total billed charges,All Other,1410.31,,,1410.31,Fee Schedule,,1196.62,,,1196.62,Fee Schedule,,354.95,,,354.95,Fee Schedule,,354.95,,,354.95,Fee Schedule,,354.95,,,354.95,Fee Schedule,,354.95,,,354.95,Fee Schedule,,179.24,,,179.24,Fee Schedule,Medicaid Laboratory Fee Schedule,179.24,,,179.24,Fee Schedule,100% Medicaid Laboratory Fee Schedule,179.24,,,179.24,Fee Schedule,100% Medicaid Laboratory Fee Schedule,179.24,,,179.24,Fee Schedule,100% Medicaid Laboratory Fee Schedule,403.3,,,403.3,Fee Schedule,225% Medicaid Laboratory Fee Schedule,403.3,,,403.3,Fee Schedule,225% Medicaid Laboratory Fee Schedule,274.24,,,274.24,Fee Schedule,153% Medicaid Laboratory Fee Schedule,403.3,,,403.3,Fee Schedule,225% Medicaid Laboratory Fee Schedule,250.94,,,250.94,Fee Schedule,140% Medicaid Laboratory Fee Schedule,403.3,,,403.3,Fee Schedule,225% Medicaid Laboratory Fee Schedule,466.04,,,466.04,Fee Schedule,260% Medicaid Laboratory Fee Schedule,580.75,,,580.75,Fee Schedule,324% Medicaid Laboratory Fee Schedule,385.38,,,385.38,Fee Schedule,215% Medicaid Laboratory Fee Schedule,385.38,,,385.38,Fee Schedule,215% Medicaid Laboratory Fee Schedule,224.06,,,224.06,Fee Schedule,125% Medicaid Laboratory Fee Schedule,118.32,1410.31,
MPL GENE SEQ ALYS EXON 10       ,81339,CPT,,43503580,CDM,310,RC,,,both,,,500,304.55,,,304.55,Other,150% of Medicare + 9.63% HCRA Surcharge,185.2,,,185.2,Fee Schedule,Mediare Clinical Lab,357.44,,,357.44,Fee Schedule,,322.25,,,322.25,Fee Schedule,,148.16,,,148.16,Fee Schedule,,148.16,,,148.16,Fee Schedule,,148.16,,,148.16,Fee Schedule,,250,50,,250,percent of total billed charges,All Other,391.24,,,391.24,Fee Schedule,,583.38,,,583.38,Fee Schedule,,208.75,,,208.75,Other,186% Medicaid methodology,687.09,,,687.09,Fee Schedule,,310,,,310,Fee Schedule,,388.92,,,388.92,Fee Schedule,,687.09,,,687.09,Fee Schedule,,310,,,310,Fee Schedule,,731.54,,,731.54,Fee Schedule,,350,70,,350,percent of total billed charges,All Other,883.02,,,883.02,Fee Schedule,,749.23,,,749.23,Fee Schedule,,222.24,,,222.24,Fee Schedule,,222.24,,,222.24,Fee Schedule,,222.24,,,222.24,Fee Schedule,,222.24,,,222.24,Fee Schedule,,112.23,,,112.23,Fee Schedule,Medicaid Laboratory Fee Schedule,112.23,,,112.23,Fee Schedule,100% Medicaid Laboratory Fee Schedule,112.23,,,112.23,Fee Schedule,100% Medicaid Laboratory Fee Schedule,112.23,,,112.23,Fee Schedule,100% Medicaid Laboratory Fee Schedule,252.52,,,252.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,252.52,,,252.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,171.71,,,171.71,Fee Schedule,153% Medicaid Laboratory Fee Schedule,252.52,,,252.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,157.12,,,157.12,Fee Schedule,140% Medicaid Laboratory Fee Schedule,252.52,,,252.52,Fee Schedule,225% Medicaid Laboratory Fee Schedule,291.8,,,291.8,Fee Schedule,260% Medicaid Laboratory Fee Schedule,363.63,,,363.63,Fee Schedule,324% Medicaid Laboratory Fee Schedule,241.3,,,241.3,Fee Schedule,215% Medicaid Laboratory Fee Schedule,241.3,,,241.3,Fee Schedule,215% Medicaid Laboratory Fee Schedule,140.29,,,140.29,Fee Schedule,125% Medicaid Laboratory Fee Schedule,112.23,883.02,
"88160 Cytology, Other Source , screen and Interp",88160,CPT,,43500297,CDM,311,RC,,,both,,,429,56.62,,,56.62,Other,150% of Medicare + 9.63% HCRA Surcharge,34.43,,,34.43,Other,Medicare OPPS methodology,126.03,,,126.03,Fee Schedule,,113.62,,,113.62,Fee Schedule,,274.49,,,274.49,Fee Schedule,,246.97,,,246.97,Fee Schedule,,233.2,,,233.2,Fee Schedule,,214.5,50,,214.5,percent of total billed charges,All Other,97.31,,,97.31,Fee Schedule,,247.49,,,247.49,Fee Schedule,,199.49,,,199.49,Other,186% Medicaid methodology,291.24,,,291.24,Fee Schedule,,265.98,,,265.98,Fee Schedule,,137.13,,,137.13,Fee Schedule,,291.24,,,291.24,Fee Schedule,,265.98,,,265.98,Fee Schedule,,257.94,,,257.94,Fee Schedule,,300.3,70,,300.3,percent of total billed charges,All Other,224.4,,,224.4,Fee Schedule,,190.4,,,190.4,Fee Schedule,,27.59,,,27.59,Fee Schedule,,27.59,,,27.59,Fee Schedule,,27.59,,,27.59,Fee Schedule,,27.59,,,27.59,Fee Schedule,,107.25,,,107.25,Other,New York Medicaid APG methodology,107.25,,,107.25,Other,100% Medicaid APG methodology,107.25,,,107.25,Other,100% Medicaid APG methodology,107.25,,,107.25,Other,100% Medicaid APG methodology,241.31,,,241.31,Other,225% Medicaid APG methodology,241.31,,,241.31,Other,225% Medicaid APG methodology,164.09,,,164.09,Other,153% Medicaid APG methodology,241.31,,,241.31,Other,225% Medicaid APG methodology,150.15,,,150.15,Other,140% Medicaid APG methodology,241.31,,,241.31,Other,225% Medicaid APG methodology,278.85,,,278.85,Other,260% Medicaid APG methodology,347.49,,,347.49,Other,324% Medicaid APG methodology,230.59,,,230.59,Other,215% Medicaid APG methodology,230.59,,,230.59,Other,215% Medicaid APG methodology,134.06,,,134.06,Other,125% Medicaid APG methodology,27.59,347.49,
CYTOPATH EVAL FNA REPORT        ,88173,CPT,,43500354,CDM,311,RC,,,both,,,923,103.05,,,103.05,Other,150% of Medicare + 9.63% HCRA Surcharge,62.66,,,62.66,Other,Medicare OPPS methodology,228.86,,,228.86,Fee Schedule,,206.33,,,206.33,Fee Schedule,,636.15,,,636.15,Fee Schedule,,572.36,,,572.36,Fee Schedule,,540.46,,,540.46,Fee Schedule,,461.5,50,,461.5,percent of total billed charges,All Other,180.6,,,180.6,Fee Schedule,,449.42,,,449.42,Fee Schedule,,35.92,,,35.92,Other,186% Medicaid methodology,528.87,,,528.87,Fee Schedule,,572.26,,,572.26,Fee Schedule,,249.02,,,249.02,Fee Schedule,,528.87,,,528.87,Fee Schedule,,572.26,,,572.26,Fee Schedule,,468.39,,,468.39,Fee Schedule,,646.1,70,,646.1,percent of total billed charges,All Other,425.7,,,425.7,Fee Schedule,,361.2,,,361.2,Fee Schedule,,59.36,,,59.36,Fee Schedule,,59.36,,,59.36,Fee Schedule,,59.36,,,59.36,Fee Schedule,,59.36,,,59.36,Fee Schedule,,19.31,,,19.31,Fee Schedule,Medicaid Laboratory Fee Schedule,19.31,,,19.31,Fee Schedule,100% Medicaid Laboratory Fee Schedule,19.31,,,19.31,Fee Schedule,100% Medicaid Laboratory Fee Schedule,19.31,,,19.31,Fee Schedule,100% Medicaid Laboratory Fee Schedule,43.45,,,43.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,43.45,,,43.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,29.55,,,29.55,Fee Schedule,153% Medicaid Laboratory Fee Schedule,43.45,,,43.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.04,,,27.04,Fee Schedule,140% Medicaid Laboratory Fee Schedule,43.45,,,43.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,50.21,,,50.21,Fee Schedule,260% Medicaid Laboratory Fee Schedule,62.57,,,62.57,Fee Schedule,324% Medicaid Laboratory Fee Schedule,41.52,,,41.52,Fee Schedule,215% Medicaid Laboratory Fee Schedule,41.52,,,41.52,Fee Schedule,215% Medicaid Laboratory Fee Schedule,24.14,,,24.14,Fee Schedule,125% Medicaid Laboratory Fee Schedule,19.31,646.1,
CYTOPATH FL NONGYN SMEARS       ,88104,CPT,,43500578,CDM,311,RC,,,both,,,624,76.26,,,76.26,Other,150% of Medicare + 9.63% HCRA Surcharge,46.38,,,46.38,Other,Medicare OPPS methodology,112.38,,,112.38,Fee Schedule,,101.32,,,101.32,Fee Schedule,,346.22,,,346.22,Fee Schedule,,311.5,,,311.5,Fee Schedule,,294.14,,,294.14,Fee Schedule,,312,50,,312,percent of total billed charges,All Other,84.05,,,84.05,Fee Schedule,,220.69,,,220.69,Fee Schedule,,35.92,,,35.92,Other,186% Medicaid methodology,259.71,,,259.71,Fee Schedule,,386.88,,,386.88,Fee Schedule,,122.28,,,122.28,Fee Schedule,,259.71,,,259.71,Fee Schedule,,386.88,,,386.88,Fee Schedule,,230.01,,,230.01,Fee Schedule,,436.8,70,,436.8,percent of total billed charges,All Other,194.7,,,194.7,Fee Schedule,,165.2,,,165.2,Fee Schedule,,40.12,,,40.12,Fee Schedule,,40.12,,,40.12,Fee Schedule,,40.12,,,40.12,Fee Schedule,,40.12,,,40.12,Fee Schedule,,19.31,,,19.31,Fee Schedule,Medicaid Laboratory Fee Schedule,19.31,,,19.31,Fee Schedule,100% Medicaid Laboratory Fee Schedule,19.31,,,19.31,Fee Schedule,100% Medicaid Laboratory Fee Schedule,19.31,,,19.31,Fee Schedule,100% Medicaid Laboratory Fee Schedule,43.45,,,43.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,43.45,,,43.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,29.55,,,29.55,Fee Schedule,153% Medicaid Laboratory Fee Schedule,43.45,,,43.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.04,,,27.04,Fee Schedule,140% Medicaid Laboratory Fee Schedule,43.45,,,43.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,50.21,,,50.21,Fee Schedule,260% Medicaid Laboratory Fee Schedule,62.57,,,62.57,Fee Schedule,324% Medicaid Laboratory Fee Schedule,41.52,,,41.52,Fee Schedule,215% Medicaid Laboratory Fee Schedule,41.52,,,41.52,Fee Schedule,215% Medicaid Laboratory Fee Schedule,24.14,,,24.14,Fee Schedule,125% Medicaid Laboratory Fee Schedule,19.31,436.8,
FLOWCYTOMETRY/ TC 1 MARKER      ,88184,CPT,,43501105,CDM,311,RC,,,both,,,5281,683.55,,,683.55,Other,150% of Medicare + 9.63% HCRA Surcharge,415.67,,,415.67,Other,Medicare OPPS methodology,178.35,,,178.35,Fee Schedule,,160.79,,,160.79,Fee Schedule,,770.2,,,770.2,Fee Schedule,,692.96,,,692.96,Fee Schedule,,654.35,,,654.35,Fee Schedule,,2640.5,50,,2640.5,percent of total billed charges,All Other,147.42,,,147.42,Fee Schedule,,350.23,,,350.23,Fee Schedule,,43.53,,,43.53,Other,186% Medicaid methodology,412.15,,,412.15,Fee Schedule,,3274.22,,,3274.22,Fee Schedule,,194.06,,,194.06,Fee Schedule,,412.15,,,412.15,Fee Schedule,,3274.22,,,3274.22,Fee Schedule,,365.02,,,365.02,Fee Schedule,,3696.7,70,,3696.7,percent of total billed charges,All Other,330,,,330,Fee Schedule,,280,,,280,Fee Schedule,,340.09,,,340.09,Fee Schedule,,340.09,,,340.09,Fee Schedule,,340.09,,,340.09,Fee Schedule,,340.09,,,340.09,Fee Schedule,,23.4,,,23.4,Fee Schedule,Medicaid Laboratory Fee Schedule,23.4,,,23.4,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.4,,,23.4,Fee Schedule,100% Medicaid Laboratory Fee Schedule,23.4,,,23.4,Fee Schedule,100% Medicaid Laboratory Fee Schedule,52.65,,,52.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,52.65,,,52.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,35.8,,,35.8,Fee Schedule,153% Medicaid Laboratory Fee Schedule,52.65,,,52.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,32.76,,,32.76,Fee Schedule,140% Medicaid Laboratory Fee Schedule,52.65,,,52.65,Fee Schedule,225% Medicaid Laboratory Fee Schedule,60.84,,,60.84,Fee Schedule,260% Medicaid Laboratory Fee Schedule,75.82,,,75.82,Fee Schedule,324% Medicaid Laboratory Fee Schedule,50.31,,,50.31,Fee Schedule,215% Medicaid Laboratory Fee Schedule,50.31,,,50.31,Fee Schedule,215% Medicaid Laboratory Fee Schedule,29.25,,,29.25,Fee Schedule,125% Medicaid Laboratory Fee Schedule,23.4,3696.7,
FLOWCYTOMETRY/TC ADD-ON         ,88185,CPT,,43501121,CDM,311,RC,,,both,,,525,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,53.85,,,53.85,Fee Schedule,,48.55,,,48.55,Fee Schedule,,461.53,,,461.53,Fee Schedule,,415.25,,,415.25,Fee Schedule,,392.11,,,392.11,Fee Schedule,,262.5,50,,262.5,percent of total billed charges,All Other,48.65,,,48.65,Fee Schedule,,105.74,,,105.74,Fee Schedule,,29.02,,,29.02,Other,186% Medicaid methodology,124.43,,,124.43,Fee Schedule,,325.5,,,325.5,Fee Schedule,,58.59,,,58.59,Fee Schedule,,124.43,,,124.43,Fee Schedule,,325.5,,,325.5,Fee Schedule,,110.21,,,110.21,Fee Schedule,,367.5,70,,367.5,percent of total billed charges,All Other,105.6,,,105.6,Fee Schedule,,89.6,,,89.6,Fee Schedule,,26.86,,,26.86,Fee Schedule,,26.86,,,26.86,Fee Schedule,,26.86,,,26.86,Fee Schedule,,26.86,,,26.86,Fee Schedule,,15.6,,,15.6,Fee Schedule,Medicaid Laboratory Fee Schedule,15.6,,,15.6,Fee Schedule,100% Medicaid Laboratory Fee Schedule,15.6,,,15.6,Fee Schedule,100% Medicaid Laboratory Fee Schedule,15.6,,,15.6,Fee Schedule,100% Medicaid Laboratory Fee Schedule,35.11,,,35.11,Fee Schedule,225% Medicaid Laboratory Fee Schedule,35.11,,,35.11,Fee Schedule,225% Medicaid Laboratory Fee Schedule,23.87,,,23.87,Fee Schedule,153% Medicaid Laboratory Fee Schedule,35.11,,,35.11,Fee Schedule,225% Medicaid Laboratory Fee Schedule,21.85,,,21.85,Fee Schedule,140% Medicaid Laboratory Fee Schedule,35.11,,,35.11,Fee Schedule,225% Medicaid Laboratory Fee Schedule,40.57,,,40.57,Fee Schedule,260% Medicaid Laboratory Fee Schedule,50.56,,,50.56,Fee Schedule,324% Medicaid Laboratory Fee Schedule,33.55,,,33.55,Fee Schedule,215% Medicaid Laboratory Fee Schedule,33.55,,,33.55,Fee Schedule,215% Medicaid Laboratory Fee Schedule,19.51,,,19.51,Fee Schedule,125% Medicaid Laboratory Fee Schedule,0.01,461.53,
CYTOPATH C/V THIN LAYER         ,88142,CPT,,43501501,CDM,311,RC,,,both,,,222,33.32,,,33.32,Other,150% of Medicare + 9.63% HCRA Surcharge,20.26,,,20.26,Fee Schedule,Mediare Clinical Lab,39.1,,,39.1,Fee Schedule,,35.25,,,35.25,Fee Schedule,,204.7,,,204.7,Fee Schedule,,184.17,,,184.17,Fee Schedule,,173.91,,,173.91,Fee Schedule,,111,50,,111,percent of total billed charges,All Other,42.8,,,42.8,Fee Schedule,,63.82,,,63.82,Fee Schedule,,37.68,,,37.68,Other,186% Medicaid methodology,75.16,,,75.16,Fee Schedule,,137.64,,,137.64,Fee Schedule,,42.55,,,42.55,Fee Schedule,,75.16,,,75.16,Fee Schedule,,137.64,,,137.64,Fee Schedule,,80.03,,,80.03,Fee Schedule,,155.4,70,,155.4,percent of total billed charges,All Other,96.6,,,96.6,Fee Schedule,,81.96,,,81.96,Fee Schedule,,24.31,,,24.31,Fee Schedule,,24.31,,,24.31,Fee Schedule,,24.31,,,24.31,Fee Schedule,,24.31,,,24.31,Fee Schedule,,20.26,,,20.26,Fee Schedule,Medicaid Laboratory Fee Schedule,20.26,,,20.26,Fee Schedule,100% Medicaid Laboratory Fee Schedule,20.26,,,20.26,Fee Schedule,100% Medicaid Laboratory Fee Schedule,20.26,,,20.26,Fee Schedule,100% Medicaid Laboratory Fee Schedule,45.59,,,45.59,Fee Schedule,225% Medicaid Laboratory Fee Schedule,45.59,,,45.59,Fee Schedule,225% Medicaid Laboratory Fee Schedule,31,,,31,Fee Schedule,153% Medicaid Laboratory Fee Schedule,45.59,,,45.59,Fee Schedule,225% Medicaid Laboratory Fee Schedule,28.36,,,28.36,Fee Schedule,140% Medicaid Laboratory Fee Schedule,45.59,,,45.59,Fee Schedule,225% Medicaid Laboratory Fee Schedule,52.68,,,52.68,Fee Schedule,260% Medicaid Laboratory Fee Schedule,65.64,,,65.64,Fee Schedule,324% Medicaid Laboratory Fee Schedule,43.56,,,43.56,Fee Schedule,215% Medicaid Laboratory Fee Schedule,43.56,,,43.56,Fee Schedule,215% Medicaid Laboratory Fee Schedule,25.33,,,25.33,Fee Schedule,125% Medicaid Laboratory Fee Schedule,20.26,204.7,
FLOWCYTOMETRY/READ 2-8          ,88187,CPT,,43501709,CDM,311,RC,,,both,,,374,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,74.65,,,74.65,Fee Schedule,,67.3,,,67.3,Fee Schedule,,545.9,,,545.9,Fee Schedule,,491.15,,,491.15,Fee Schedule,,463.78,,,463.78,Fee Schedule,,187,50,,187,percent of total billed charges,All Other,77.38,,,77.38,Fee Schedule,,146.6,,,146.6,Fee Schedule,,37.57,,,37.57,Other,186% Medicaid methodology,172.51,,,172.51,Fee Schedule,,231.88,,,231.88,Fee Schedule,,81.23,,,81.23,Fee Schedule,,172.51,,,172.51,Fee Schedule,,231.88,,,231.88,Fee Schedule,,152.79,,,152.79,Fee Schedule,,261.8,70,,261.8,percent of total billed charges,All Other,171.6,,,171.6,Fee Schedule,,145.6,,,145.6,Fee Schedule,,47.21,,,47.21,Fee Schedule,,47.21,,,47.21,Fee Schedule,,47.21,,,47.21,Fee Schedule,,47.21,,,47.21,Fee Schedule,,20.2,,,20.2,Fee Schedule,Medicaid Laboratory Fee Schedule,20.2,,,20.2,Fee Schedule,100% Medicaid Laboratory Fee Schedule,20.2,,,20.2,Fee Schedule,100% Medicaid Laboratory Fee Schedule,20.2,,,20.2,Fee Schedule,100% Medicaid Laboratory Fee Schedule,45.45,,,45.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,45.45,,,45.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,30.91,,,30.91,Fee Schedule,153% Medicaid Laboratory Fee Schedule,45.45,,,45.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,28.28,,,28.28,Fee Schedule,140% Medicaid Laboratory Fee Schedule,45.45,,,45.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,52.52,,,52.52,Fee Schedule,260% Medicaid Laboratory Fee Schedule,65.45,,,65.45,Fee Schedule,324% Medicaid Laboratory Fee Schedule,43.43,,,43.43,Fee Schedule,215% Medicaid Laboratory Fee Schedule,43.43,,,43.43,Fee Schedule,215% Medicaid Laboratory Fee Schedule,25.25,,,25.25,Fee Schedule,125% Medicaid Laboratory Fee Schedule,0.01,545.9,
CHROMOSOME KARYOTYPE STDY EA +  ,88280,CPT,,43502020,CDM,311,RC,,,both,,,533,55.04,,,55.04,Other,150% of Medicare + 9.63% HCRA Surcharge,33.47,,,33.47,Fee Schedule,Mediare Clinical Lab,64.6,,,64.6,Fee Schedule,,58.24,,,58.24,Fee Schedule,,253.6,,,253.6,Fee Schedule,,228.17,,,228.17,Fee Schedule,,215.45,,,215.45,Fee Schedule,,266.5,50,,266.5,percent of total billed charges,All Other,70.72,,,70.72,Fee Schedule,,105.43,,,105.43,Fee Schedule,,18.79,,,18.79,Other,186% Medicaid methodology,124.17,,,124.17,Fee Schedule,,330.46,,,330.46,Fee Schedule,,70.29,,,70.29,Fee Schedule,,124.17,,,124.17,Fee Schedule,,330.46,,,330.46,Fee Schedule,,132.21,,,132.21,Fee Schedule,,373.1,70,,373.1,percent of total billed charges,All Other,159.58,,,159.58,Fee Schedule,,135.4,,,135.4,Fee Schedule,,40.16,,,40.16,Fee Schedule,,40.16,,,40.16,Fee Schedule,,40.16,,,40.16,Fee Schedule,,40.16,,,40.16,Fee Schedule,,10.1,,,10.1,Fee Schedule,Medicaid Laboratory Fee Schedule,10.1,,,10.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.1,,,10.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,10.1,,,10.1,Fee Schedule,100% Medicaid Laboratory Fee Schedule,22.73,,,22.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,22.73,,,22.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,15.45,,,15.45,Fee Schedule,153% Medicaid Laboratory Fee Schedule,22.73,,,22.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,14.14,,,14.14,Fee Schedule,140% Medicaid Laboratory Fee Schedule,22.73,,,22.73,Fee Schedule,225% Medicaid Laboratory Fee Schedule,26.26,,,26.26,Fee Schedule,260% Medicaid Laboratory Fee Schedule,32.72,,,32.72,Fee Schedule,324% Medicaid Laboratory Fee Schedule,21.72,,,21.72,Fee Schedule,215% Medicaid Laboratory Fee Schedule,21.72,,,21.72,Fee Schedule,215% Medicaid Laboratory Fee Schedule,12.63,,,12.63,Fee Schedule,125% Medicaid Laboratory Fee Schedule,10.1,373.1,
TISSUE CULTURE LYMPHOCYTE       ,88230,CPT,,43502046,CDM,311,RC,,,both,,,1852,191.56,,,191.56,Other,150% of Medicare + 9.63% HCRA Surcharge,116.49,,,116.49,Fee Schedule,Mediare Clinical Lab,224.83,,,224.83,Fee Schedule,,202.69,,,202.69,Fee Schedule,,207.57,,,207.57,Fee Schedule,,186.76,,,186.76,Fee Schedule,,176.35,,,176.35,Fee Schedule,,926,50,,926,percent of total billed charges,All Other,246.09,,,246.09,Fee Schedule,,366.94,,,366.94,Fee Schedule,,75.14,,,75.14,Other,186% Medicaid methodology,432.18,,,432.18,Fee Schedule,,1148.24,,,1148.24,Fee Schedule,,244.63,,,244.63,Fee Schedule,,432.18,,,432.18,Fee Schedule,,1148.24,,,1148.24,Fee Schedule,,460.14,,,460.14,Fee Schedule,,1296.4,70,,1296.4,percent of total billed charges,All Other,555.42,,,555.42,Fee Schedule,,471.26,,,471.26,Fee Schedule,,139.79,,,139.79,Fee Schedule,,139.79,,,139.79,Fee Schedule,,139.79,,,139.79,Fee Schedule,,139.79,,,139.79,Fee Schedule,,40.4,,,40.4,Fee Schedule,Medicaid Laboratory Fee Schedule,40.4,,,40.4,Fee Schedule,100% Medicaid Laboratory Fee Schedule,40.4,,,40.4,Fee Schedule,100% Medicaid Laboratory Fee Schedule,40.4,,,40.4,Fee Schedule,100% Medicaid Laboratory Fee Schedule,90.9,,,90.9,Fee Schedule,225% Medicaid Laboratory Fee Schedule,90.9,,,90.9,Fee Schedule,225% Medicaid Laboratory Fee Schedule,61.81,,,61.81,Fee Schedule,153% Medicaid Laboratory Fee Schedule,90.9,,,90.9,Fee Schedule,225% Medicaid Laboratory Fee Schedule,56.56,,,56.56,Fee Schedule,140% Medicaid Laboratory Fee Schedule,90.9,,,90.9,Fee Schedule,225% Medicaid Laboratory Fee Schedule,105.04,,,105.04,Fee Schedule,260% Medicaid Laboratory Fee Schedule,130.9,,,130.9,Fee Schedule,324% Medicaid Laboratory Fee Schedule,86.86,,,86.86,Fee Schedule,215% Medicaid Laboratory Fee Schedule,86.86,,,86.86,Fee Schedule,215% Medicaid Laboratory Fee Schedule,50.5,,,50.5,Fee Schedule,125% Medicaid Laboratory Fee Schedule,40.4,1296.4,
CHROMOSOME ANALYSIS 15-20       ,88262,CPT,,43502053,CDM,311,RC,,,both,,,1995,206.36,,,206.36,Other,150% of Medicare + 9.63% HCRA Surcharge,125.49,,,125.49,Fee Schedule,Mediare Clinical Lab,242.2,,,242.2,Fee Schedule,,218.35,,,218.35,Fee Schedule,,1259.37,,,1259.37,Fee Schedule,,1133.08,,,1133.08,Fee Schedule,,1069.94,,,1069.94,Fee Schedule,,997.5,50,,997.5,percent of total billed charges,All Other,265.1,,,265.1,Fee Schedule,,395.29,,,395.29,Fee Schedule,,187.86,,,187.86,Other,186% Medicaid methodology,465.57,,,465.57,Fee Schedule,,1236.9,,,1236.9,Fee Schedule,,263.53,,,263.53,Fee Schedule,,465.57,,,465.57,Fee Schedule,,1236.9,,,1236.9,Fee Schedule,,495.69,,,495.69,Fee Schedule,,1396.5,70,,1396.5,percent of total billed charges,All Other,598.33,,,598.33,Fee Schedule,,507.67,,,507.67,Fee Schedule,,150.59,,,150.59,Fee Schedule,,150.59,,,150.59,Fee Schedule,,150.59,,,150.59,Fee Schedule,,150.59,,,150.59,Fee Schedule,,101,,,101,Fee Schedule,Medicaid Laboratory Fee Schedule,101,,,101,Fee Schedule,100% Medicaid Laboratory Fee Schedule,101,,,101,Fee Schedule,100% Medicaid Laboratory Fee Schedule,101,,,101,Fee Schedule,100% Medicaid Laboratory Fee Schedule,227.25,,,227.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,227.25,,,227.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,154.53,,,154.53,Fee Schedule,153% Medicaid Laboratory Fee Schedule,227.25,,,227.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,141.4,,,141.4,Fee Schedule,140% Medicaid Laboratory Fee Schedule,227.25,,,227.25,Fee Schedule,225% Medicaid Laboratory Fee Schedule,262.6,,,262.6,Fee Schedule,260% Medicaid Laboratory Fee Schedule,327.24,,,327.24,Fee Schedule,324% Medicaid Laboratory Fee Schedule,217.15,,,217.15,Fee Schedule,215% Medicaid Laboratory Fee Schedule,217.15,,,217.15,Fee Schedule,215% Medicaid Laboratory Fee Schedule,126.25,,,126.25,Fee Schedule,125% Medicaid Laboratory Fee Schedule,101,1396.5,
TISSUE CULTURE BONE MARROW      ,88237,CPT,,43502129,CDM,311,RC,,,both,,,2286,236.39,,,236.39,Other,150% of Medicare + 9.63% HCRA Surcharge,143.75,,,143.75,Fee Schedule,Mediare Clinical Lab,277.44,,,277.44,Fee Schedule,,250.13,,,250.13,Fee Schedule,,259.84,,,259.84,Fee Schedule,,233.79,,,233.79,Fee Schedule,,220.76,,,220.76,Fee Schedule,,1143,50,,1143,percent of total billed charges,All Other,303.68,,,303.68,Fee Schedule,,452.81,,,452.81,Fee Schedule,,187.92,,,187.92,Other,186% Medicaid methodology,533.31,,,533.31,Fee Schedule,,1417.32,,,1417.32,Fee Schedule,,301.88,,,301.88,Fee Schedule,,533.31,,,533.31,Fee Schedule,,1417.32,,,1417.32,Fee Schedule,,567.81,,,567.81,Fee Schedule,,1600.2,70,,1600.2,percent of total billed charges,All Other,685.39,,,685.39,Fee Schedule,,581.54,,,581.54,Fee Schedule,,172.5,,,172.5,Fee Schedule,,172.5,,,172.5,Fee Schedule,,172.5,,,172.5,Fee Schedule,,172.5,,,172.5,Fee Schedule,,101.03,,,101.03,Fee Schedule,Medicaid Laboratory Fee Schedule,101.03,,,101.03,Fee Schedule,100% Medicaid Laboratory Fee Schedule,101.03,,,101.03,Fee Schedule,100% Medicaid Laboratory Fee Schedule,101.03,,,101.03,Fee Schedule,100% Medicaid Laboratory Fee Schedule,227.32,,,227.32,Fee Schedule,225% Medicaid Laboratory Fee Schedule,227.32,,,227.32,Fee Schedule,225% Medicaid Laboratory Fee Schedule,154.58,,,154.58,Fee Schedule,153% Medicaid Laboratory Fee Schedule,227.32,,,227.32,Fee Schedule,225% Medicaid Laboratory Fee Schedule,141.44,,,141.44,Fee Schedule,140% Medicaid Laboratory Fee Schedule,227.32,,,227.32,Fee Schedule,225% Medicaid Laboratory Fee Schedule,262.68,,,262.68,Fee Schedule,260% Medicaid Laboratory Fee Schedule,327.34,,,327.34,Fee Schedule,324% Medicaid Laboratory Fee Schedule,217.22,,,217.22,Fee Schedule,215% Medicaid Laboratory Fee Schedule,217.22,,,217.22,Fee Schedule,215% Medicaid Laboratory Fee Schedule,126.29,,,126.29,Fee Schedule,125% Medicaid Laboratory Fee Schedule,101.03,1600.2,
CHROMOSOME ANALYSIS 20-25       ,88264,CPT,,43502517,CDM,311,RC,,,both,,,1193,237.8,,,237.8,Other,150% of Medicare + 9.63% HCRA Surcharge,144.61,,,144.61,Fee Schedule,Mediare Clinical Lab,279.1,,,279.1,Fee Schedule,,251.62,,,251.62,Fee Schedule,,1259.37,,,1259.37,Fee Schedule,,1133.08,,,1133.08,Fee Schedule,,1069.94,,,1069.94,Fee Schedule,,596.5,50,,596.5,percent of total billed charges,All Other,305.5,,,305.5,Fee Schedule,,455.52,,,455.52,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,536.5,,,536.5,Fee Schedule,,739.66,,,739.66,Fee Schedule,,303.68,,,303.68,Fee Schedule,,536.5,,,536.5,Fee Schedule,,739.66,,,739.66,Fee Schedule,,571.21,,,571.21,Fee Schedule,,835.1,70,,835.1,percent of total billed charges,All Other,689.49,,,689.49,Fee Schedule,,585.02,,,585.02,Fee Schedule,,173.53,,,173.53,Fee Schedule,,173.53,,,173.53,Fee Schedule,,173.53,,,173.53,Fee Schedule,,173.53,,,173.53,Fee Schedule,,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1259.37,
CYTP FNA EVAL EA ADDL           ,88177,CPT,,43502756,CDM,311,RC,,,both,,,191,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,18.95,,,18.95,Fee Schedule,,17.09,,,17.09,Fee Schedule,,59.38,,,59.38,Fee Schedule,,53.42,,,53.42,Fee Schedule,,50.45,,,50.45,Fee Schedule,,95.5,50,,95.5,percent of total billed charges,All Other,15.47,,,15.47,Fee Schedule,,37.22,,,37.22,Fee Schedule,,199.49,,,199.49,Other,186% Medicaid methodology,43.8,,,43.8,Fee Schedule,,118.42,,,118.42,Fee Schedule,,20.62,,,20.62,Fee Schedule,,43.8,,,43.8,Fee Schedule,,118.42,,,118.42,Fee Schedule,,38.79,,,38.79,Fee Schedule,,133.7,70,,133.7,percent of total billed charges,All Other,34.65,,,34.65,Fee Schedule,,29.4,,,29.4,Fee Schedule,,8.66,,,8.66,Fee Schedule,,8.66,,,8.66,Fee Schedule,,8.66,,,8.66,Fee Schedule,,8.66,,,8.66,Fee Schedule,,107.25,,,107.25,Other,New York Medicaid APG methodology,107.25,,,107.25,Other,100% Medicaid APG methodology,107.25,,,107.25,Other,100% Medicaid APG methodology,107.25,,,107.25,Other,100% Medicaid APG methodology,241.31,,,241.31,Other,225% Medicaid APG methodology,241.31,,,241.31,Other,225% Medicaid APG methodology,164.09,,,164.09,Other,153% Medicaid APG methodology,241.31,,,241.31,Other,225% Medicaid APG methodology,150.15,,,150.15,Other,140% Medicaid APG methodology,241.31,,,241.31,Other,225% Medicaid APG methodology,278.85,,,278.85,Other,260% Medicaid APG methodology,347.49,,,347.49,Other,324% Medicaid APG methodology,230.59,,,230.59,Other,215% Medicaid APG methodology,230.59,,,230.59,Other,215% Medicaid APG methodology,134.06,,,134.06,Other,125% Medicaid APG methodology,0.01,347.49,
CYTOPATH CONCENTRATE TECH?      ,88108,CPT,,43503606,CDM,311,RC,,,both,,,624,76.26,,,76.26,Other,150% of Medicare + 9.63% HCRA Surcharge,46.38,,,46.38,Other,Medicare OPPS methodology,107.39,,,107.39,Fee Schedule,,96.81,,,96.81,Fee Schedule,,442.86,,,442.86,Fee Schedule,,398.45,,,398.45,Fee Schedule,,376.25,,,376.25,Fee Schedule,,312,50,,312,percent of total billed charges,All Other,86.97,,,86.97,Fee Schedule,,210.88,,,210.88,Fee Schedule,,35.92,,,35.92,Other,186% Medicaid methodology,248.15,,,248.15,Fee Schedule,,386.88,,,386.88,Fee Schedule,,116.84,,,116.84,Fee Schedule,,248.15,,,248.15,Fee Schedule,,386.88,,,386.88,Fee Schedule,,219.78,,,219.78,Fee Schedule,,436.8,70,,436.8,percent of total billed charges,All Other,204.6,,,204.6,Fee Schedule,,173.6,,,173.6,Fee Schedule,,40.12,,,40.12,Fee Schedule,,40.12,,,40.12,Fee Schedule,,40.12,,,40.12,Fee Schedule,,40.12,,,40.12,Fee Schedule,,19.31,,,19.31,Fee Schedule,Medicaid Laboratory Fee Schedule,19.31,,,19.31,Fee Schedule,100% Medicaid Laboratory Fee Schedule,19.31,,,19.31,Fee Schedule,100% Medicaid Laboratory Fee Schedule,19.31,,,19.31,Fee Schedule,100% Medicaid Laboratory Fee Schedule,43.45,,,43.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,43.45,,,43.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,29.55,,,29.55,Fee Schedule,153% Medicaid Laboratory Fee Schedule,43.45,,,43.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,27.04,,,27.04,Fee Schedule,140% Medicaid Laboratory Fee Schedule,43.45,,,43.45,Fee Schedule,225% Medicaid Laboratory Fee Schedule,50.21,,,50.21,Fee Schedule,260% Medicaid Laboratory Fee Schedule,62.57,,,62.57,Fee Schedule,324% Medicaid Laboratory Fee Schedule,41.52,,,41.52,Fee Schedule,215% Medicaid Laboratory Fee Schedule,41.52,,,41.52,Fee Schedule,215% Medicaid Laboratory Fee Schedule,24.14,,,24.14,Fee Schedule,125% Medicaid Laboratory Fee Schedule,19.31,442.86,
88329 AP Bill Surgical Gross Consult,88329,CPT,,43500511,CDM,312,RC,,,both,,,624,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,74.19,,,74.19,Fee Schedule,,66.89,,,66.89,Fee Schedule,,440.28,,,440.28,Fee Schedule,,396.13,,,396.13,Fee Schedule,,374.05,,,374.05,Fee Schedule,,312,50,,312,percent of total billed charges,All Other,75.92,,,75.92,Fee Schedule,,145.69,,,145.69,Fee Schedule,,175.77,,,175.77,Other,186% Medicaid methodology,171.44,,,171.44,Fee Schedule,,386.88,,,386.88,Fee Schedule,,80.72,,,80.72,Fee Schedule,,171.44,,,171.44,Fee Schedule,,386.88,,,386.88,Fee Schedule,,151.84,,,151.84,Fee Schedule,,436.8,70,,436.8,percent of total billed charges,All Other,169.95,,,169.95,Fee Schedule,,144.2,,,144.2,Fee Schedule,,40.12,,,40.12,Fee Schedule,,40.12,,,40.12,Fee Schedule,,40.12,,,40.12,Fee Schedule,,40.12,,,40.12,Fee Schedule,,94.5,,,94.5,Fee Schedule,Medicaid Laboratory Fee Schedule,94.5,,,94.5,Fee Schedule,100% Medicaid Laboratory Fee Schedule,94.5,,,94.5,Fee Schedule,100% Medicaid Laboratory Fee Schedule,94.5,,,94.5,Fee Schedule,100% Medicaid Laboratory Fee Schedule,212.63,,,212.63,Fee Schedule,225% Medicaid Laboratory Fee Schedule,212.63,,,212.63,Fee Schedule,225% Medicaid Laboratory Fee Schedule,144.59,,,144.59,Fee Schedule,153% Medicaid Laboratory Fee Schedule,212.63,,,212.63,Fee Schedule,225% Medicaid Laboratory Fee Schedule,132.3,,,132.3,Fee Schedule,140% Medicaid Laboratory Fee Schedule,212.63,,,212.63,Fee Schedule,225% Medicaid Laboratory Fee Schedule,245.7,,,245.7,Fee Schedule,260% Medicaid Laboratory Fee Schedule,306.18,,,306.18,Fee Schedule,324% Medicaid Laboratory Fee Schedule,203.18,,,203.18,Fee Schedule,215% Medicaid Laboratory Fee Schedule,203.18,,,203.18,Fee Schedule,215% Medicaid Laboratory Fee Schedule,118.13,,,118.13,Fee Schedule,125% Medicaid Laboratory Fee Schedule,40.12,440.28,
INTRAOP CYTO PATH CONSULT 1     ,88333,CPT,,43501402,CDM,312,RC,,,both,,,11706,1635.2,,,1635.2,Other,150% of Medicare + 9.63% HCRA Surcharge,994.37,,,994.37,Other,Medicare OPPS methodology,73.24,,,73.24,Fee Schedule,,66.03,,,66.03,Fee Schedule,,321.23,,,321.23,Fee Schedule,,289.02,,,289.02,Fee Schedule,,272.91,,,272.91,Fee Schedule,,5853,50,,5853,percent of total billed charges,All Other,71.5,,,71.5,Fee Schedule,,143.83,,,143.83,Fee Schedule,,175.77,,,175.77,Other,186% Medicaid methodology,169.26,,,169.26,Fee Schedule,,7257.72,,,7257.72,Fee Schedule,,79.7,,,79.7,Fee Schedule,,169.26,,,169.26,Fee Schedule,,7257.72,,,7257.72,Fee Schedule,,149.9,,,149.9,Fee Schedule,,8194.2,70,,8194.2,percent of total billed charges,All Other,156.75,,,156.75,Fee Schedule,,133,,,133,Fee Schedule,,753.84,,,753.84,Fee Schedule,,753.84,,,753.84,Fee Schedule,,753.84,,,753.84,Fee Schedule,,753.84,,,753.84,Fee Schedule,,94.5,,,94.5,Other,New York Medicaid APG methodology,94.5,,,94.5,Other,100% Medicaid APG methodology,94.5,,,94.5,Other,100% Medicaid APG methodology,94.5,,,94.5,Other,100% Medicaid APG methodology,212.63,,,212.63,Other,225% Medicaid APG methodology,212.63,,,212.63,Other,225% Medicaid APG methodology,144.59,,,144.59,Other,153% Medicaid APG methodology,212.63,,,212.63,Other,225% Medicaid APG methodology,132.3,,,132.3,Other,140% Medicaid APG methodology,212.63,,,212.63,Other,225% Medicaid APG methodology,245.7,,,245.7,Other,260% Medicaid APG methodology,306.18,,,306.18,Other,324% Medicaid APG methodology,203.18,,,203.18,Other,215% Medicaid APG methodology,203.18,,,203.18,Other,215% Medicaid APG methodology,118.13,,,118.13,Other,125% Medicaid APG methodology,66.03,8194.2,
INTRAOP CYTO PATH CONSULT 2     ,88334,CPT,,43501428,CDM,312,RC,,,both,,,286,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,43.98,,,43.98,Fee Schedule,,39.65,,,39.65,Fee Schedule,,202.76,,,202.76,Fee Schedule,,182.43,,,182.43,Fee Schedule,,172.26,,,172.26,Fee Schedule,,143,50,,143,percent of total billed charges,All Other,40.53,,,40.53,Fee Schedule,,86.37,,,86.37,Fee Schedule,,175.77,,,175.77,Other,186% Medicaid methodology,101.64,,,101.64,Fee Schedule,,177.32,,,177.32,Fee Schedule,,47.86,,,47.86,Fee Schedule,,101.64,,,101.64,Fee Schedule,,177.32,,,177.32,Fee Schedule,,90.02,,,90.02,Fee Schedule,,200.2,70,,200.2,percent of total billed charges,All Other,92.4,,,92.4,Fee Schedule,,78.4,,,78.4,Fee Schedule,,21.65,,,21.65,Fee Schedule,,21.65,,,21.65,Fee Schedule,,21.65,,,21.65,Fee Schedule,,21.65,,,21.65,Fee Schedule,,94.5,,,94.5,Other,New York Medicaid APG methodology,94.5,,,94.5,Other,100% Medicaid APG methodology,94.5,,,94.5,Other,100% Medicaid APG methodology,94.5,,,94.5,Other,100% Medicaid APG methodology,212.63,,,212.63,Other,225% Medicaid APG methodology,212.63,,,212.63,Other,225% Medicaid APG methodology,144.59,,,144.59,Other,153% Medicaid APG methodology,212.63,,,212.63,Other,225% Medicaid APG methodology,132.3,,,132.3,Other,140% Medicaid APG methodology,212.63,,,212.63,Other,225% Medicaid APG methodology,245.7,,,245.7,Other,260% Medicaid APG methodology,306.18,,,306.18,Other,324% Medicaid APG methodology,203.18,,,203.18,Other,215% Medicaid APG methodology,203.18,,,203.18,Other,215% Medicaid APG methodology,118.13,,,118.13,Other,125% Medicaid APG methodology,0.01,306.18,
"88365 REF LAB Tissue Insitu Hybridization,single probe stain",88365,CPT,,43503192,CDM,312,RC,,,both,,,2675,324.81,,,324.81,Other,150% of Medicare + 9.63% HCRA Surcharge,197.52,,,197.52,Other,Medicare OPPS methodology,310.31,,,310.31,Fee Schedule,,279.76,,,279.76,Fee Schedule,,994.72,,,994.72,Fee Schedule,,894.97,,,894.97,Fee Schedule,,845.09,,,845.09,Fee Schedule,,1337.5,50,,1337.5,percent of total billed charges,All Other,300.01,,,300.01,Fee Schedule,,609.36,,,609.36,Fee Schedule,,333.65,,,333.65,Other,186% Medicaid methodology,717.08,,,717.08,Fee Schedule,,1658.5,,,1658.5,Fee Schedule,,337.64,,,337.64,Fee Schedule,,717.08,,,717.08,Fee Schedule,,1658.5,,,1658.5,Fee Schedule,,635.08,,,635.08,Fee Schedule,,1872.5,70,,1872.5,percent of total billed charges,All Other,663.3,,,663.3,Fee Schedule,,562.8,,,562.8,Fee Schedule,,172.2,,,172.2,Fee Schedule,,172.2,,,172.2,Fee Schedule,,172.2,,,172.2,Fee Schedule,,172.2,,,172.2,Fee Schedule,,179.38,,,179.38,Fee Schedule,Medicaid Laboratory Fee Schedule,179.38,,,179.38,Fee Schedule,100% Medicaid Laboratory Fee Schedule,179.38,,,179.38,Fee Schedule,100% Medicaid Laboratory Fee Schedule,179.38,,,179.38,Fee Schedule,100% Medicaid Laboratory Fee Schedule,403.61,,,403.61,Fee Schedule,225% Medicaid Laboratory Fee Schedule,403.61,,,403.61,Fee Schedule,225% Medicaid Laboratory Fee Schedule,274.45,,,274.45,Fee Schedule,153% Medicaid Laboratory Fee Schedule,403.61,,,403.61,Fee Schedule,225% Medicaid Laboratory Fee Schedule,251.13,,,251.13,Fee Schedule,140% Medicaid Laboratory Fee Schedule,403.61,,,403.61,Fee Schedule,225% Medicaid Laboratory Fee Schedule,466.39,,,466.39,Fee Schedule,260% Medicaid Laboratory Fee Schedule,581.19,,,581.19,Fee Schedule,324% Medicaid Laboratory Fee Schedule,385.67,,,385.67,Fee Schedule,215% Medicaid Laboratory Fee Schedule,385.67,,,385.67,Fee Schedule,215% Medicaid Laboratory Fee Schedule,224.23,,,224.23,Fee Schedule,125% Medicaid Laboratory Fee Schedule,172.2,1872.5,
"G0416 Prostate, SAT Bx any number",G0416,HCPCS,,43501618,CDM,314,RC,,,both,,,5281,683.55,,,683.55,Other,150% of Medicare + 9.63% HCRA Surcharge,415.67,,,415.67,Other,Medicare OPPS methodology,717.64,,,717.64,Fee Schedule,,644.96,,,644.96,Fee Schedule,,3788.1,,,3788.1,Fee Schedule,,3408.23,,,3408.23,Fee Schedule,,3218.3,,,3218.3,Fee Schedule,,2640.5,50,,2640.5,percent of total billed charges,All Other,370.76,,,370.76,Fee Schedule,,860.71,,,860.71,Fee Schedule,,200.78,,,200.78,Other,186% Medicaid methodology,1012.87,,,1012.87,Fee Schedule,,3274.22,,,3274.22,Fee Schedule,,476.91,,,476.91,Fee Schedule,,1012.87,,,1012.87,Fee Schedule,,3274.22,,,3274.22,Fee Schedule,,897.05,,,897.05,Fee Schedule,,3696.7,70,,3696.7,percent of total billed charges,All Other,862.95,,,862.95,Fee Schedule,,732.2,,,732.2,Fee Schedule,,340.09,,,340.09,Fee Schedule,,340.09,,,340.09,Fee Schedule,,340.09,,,340.09,Fee Schedule,,340.09,,,340.09,Fee Schedule,,107.95,,,107.95,Other,New York Medicaid APG methodology,107.95,,,107.95,Other,100% Medicaid APG methodology,107.95,,,107.95,Other,100% Medicaid APG methodology,107.95,,,107.95,Other,100% Medicaid APG methodology,242.88,,,242.88,Other,225% Medicaid APG methodology,242.88,,,242.88,Other,225% Medicaid APG methodology,165.16,,,165.16,Other,153% Medicaid APG methodology,242.88,,,242.88,Other,225% Medicaid APG methodology,151.12,,,151.12,Other,140% Medicaid APG methodology,242.88,,,242.88,Other,225% Medicaid APG methodology,280.66,,,280.66,Other,260% Medicaid APG methodology,349.74,,,349.74,Other,324% Medicaid APG methodology,232.08,,,232.08,Other,215% Medicaid APG methodology,232.08,,,232.08,Other,215% Medicaid APG methodology,134.93,,,134.93,Other,125% Medicaid APG methodology,107.95,3788.1,
LAB - REFER MATER W PREP SLIDE  ,88323,CPT,,43500396,CDM,319,RC,,,both,,,923,103.05,,,103.05,Other,150% of Medicare + 9.63% HCRA Surcharge,62.66,,,62.66,Other,Medicare OPPS methodology,67.94,,,67.94,Fee Schedule,,61.25,,,61.25,Fee Schedule,,539.51,,,539.51,Fee Schedule,,485.4,,,485.4,Fee Schedule,,458.35,,,458.35,Fee Schedule,,461.5,50,,461.5,percent of total billed charges,All Other,57.49,,,57.49,Fee Schedule,,133.41,,,133.41,Fee Schedule,,175.77,,,175.77,Other,186% Medicaid methodology,156.99,,,156.99,Fee Schedule,,572.26,,,572.26,Fee Schedule,,73.92,,,73.92,Fee Schedule,,156.99,,,156.99,Fee Schedule,,572.26,,,572.26,Fee Schedule,,139.04,,,139.04,Fee Schedule,,646.1,70,,646.1,percent of total billed charges,All Other,130.35,,,130.35,Fee Schedule,,110.6,,,110.6,Fee Schedule,,59.36,,,59.36,Fee Schedule,,59.36,,,59.36,Fee Schedule,,59.36,,,59.36,Fee Schedule,,59.36,,,59.36,Fee Schedule,,94.5,,,94.5,Other,New York Medicaid APG methodology,94.5,,,94.5,Other,100% Medicaid APG methodology,94.5,,,94.5,Other,100% Medicaid APG methodology,94.5,,,94.5,Other,100% Medicaid APG methodology,212.63,,,212.63,Other,225% Medicaid APG methodology,212.63,,,212.63,Other,225% Medicaid APG methodology,144.59,,,144.59,Other,153% Medicaid APG methodology,212.63,,,212.63,Other,225% Medicaid APG methodology,132.3,,,132.3,Other,140% Medicaid APG methodology,212.63,,,212.63,Other,225% Medicaid APG methodology,245.7,,,245.7,Other,260% Medicaid APG methodology,306.18,,,306.18,Other,324% Medicaid APG methodology,203.18,,,203.18,Other,215% Medicaid APG methodology,203.18,,,203.18,Other,215% Medicaid APG methodology,118.13,,,118.13,Other,125% Medicaid APG methodology,57.49,646.1,
XR Fluoroscopy w/ Result >1 HR,76000,CPT,TC,44000982,CDM,320,RC,,,both,,,4342,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,103.71,,,103.71,Fee Schedule,,93.4,,,93.4,Fee Schedule,,2171,50,,2171,percent of total billed charges,All Other Outpatient,1953.9,45,,1953.9,percent of total billed charges,All Other Outpatient,1867.06,43,,1867.06,percent of total billed charges,All Other Outpatient,2171,50,,2171,percent of total billed charges,All Other,3039.4,70,,3039.4,percent of total billed charges,All Other,125.98,,,125.98,Fee Schedule,,552.19,,,552.19,Other,186% Medicaid methodology,148.25,,,148.25,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,69.8,,,69.8,Fee Schedule,,148.25,,,148.25,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,131.3,,,131.3,Fee Schedule,,3039.4,70,,3039.4,percent of total billed charges,All Other,136.95,,,136.95,Fee Schedule,,116.2,,,116.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,296.88,,,296.88,Other,New York Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,454.22,,,454.22,Other,153% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,415.63,,,415.63,Other,140% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,771.88,,,771.88,Other,260% Medicaid APG methodology,961.88,,,961.88,Other,324% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,371.1,,,371.1,Other,125% Medicaid APG methodology,69.8,3039.4,
DUP-SCAN HEMO COMPL BI STD      ,93985,CPT,,44401313,CDM,320,RC,,,both,,,794,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,1049.38,,,1049.38,Fee Schedule,,944.7,,,944.7,Fee Schedule,,226.42,,,226.42,Fee Schedule,,226.42,,,226.42,Fee Schedule,,226.42,,,226.42,Fee Schedule,,397,50,,397,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,944.7,,,944.7,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,1111.7,,,1111.7,Fee Schedule,,492.28,,,492.28,Fee Schedule,,523.45,,,523.45,Fee Schedule,,1111.7,,,1111.7,Fee Schedule,,492.28,,,492.28,Fee Schedule,,984.58,,,984.58,Fee Schedule,,555.8,70,,555.8,percent of total billed charges,All Other,1060.95,,,1060.95,Fee Schedule,,900.2,,,900.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,180.79,1388,
DUP-SCAN HEMO COMPL UNI STD     ,93986,CPT,,44401321,CDM,320,RC,,,both,,,383,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,532.31,,,532.31,Fee Schedule,,479.21,,,479.21,Fee Schedule,,109.7,,,109.7,Fee Schedule,,109.7,,,109.7,Fee Schedule,,109.7,,,109.7,Fee Schedule,,191.5,50,,191.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,479.21,,,479.21,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,563.92,,,563.92,Fee Schedule,,237.46,,,237.46,Fee Schedule,,265.52,,,265.52,Fee Schedule,,563.92,,,563.92,Fee Schedule,,237.46,,,237.46,Fee Schedule,,499.44,,,499.44,Fee Schedule,,268.1,70,,268.1,percent of total billed charges,All Other,623.7,,,623.7,Fee Schedule,,529.2,,,529.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,109.7,1388,
X-RAY EXAM OF SKULL <4V         ,70250,CPT,,45000015,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,103.81,,,103.81,Fee Schedule,,93.29,,,93.29,Fee Schedule,,230.84,,,230.84,Fee Schedule,,207.69,,,207.69,Fee Schedule,,196.12,,,196.12,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,124.5,,,124.5,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,146.51,,,146.51,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,68.99,,,68.99,Fee Schedule,,146.51,,,146.51,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,129.76,,,129.76,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,133.65,,,133.65,Fee Schedule,,113.4,,,113.4,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1462.3,
X-RAY EXAM RIBS UNI 2 VIEWS     ,71100,CPT,,45000148,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,98.81,,,98.81,Fee Schedule,,88.81,,,88.81,Fee Schedule,,199.68,,,199.68,Fee Schedule,,179.65,,,179.65,Fee Schedule,,169.64,,,169.64,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,118.51,,,118.51,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,139.46,,,139.46,Fee Schedule,,922.56,,,922.56,Fee Schedule,,65.67,,,65.67,Fee Schedule,,139.46,,,139.46,Fee Schedule,,922.56,,,922.56,Fee Schedule,,123.52,,,123.52,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,128.7,,,128.7,Fee Schedule,,109.2,,,109.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM RIBS BIL 3 VIEWS     ,71110,CPT,,45000155,CDM,320,RC,,,both,,,1384,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,113.73,,,113.73,Fee Schedule,,102.21,,,102.21,Fee Schedule,,255.82,,,255.82,Fee Schedule,,230.17,,,230.17,Fee Schedule,,217.34,,,217.34,Fee Schedule,,692,50,,692,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,136.4,,,136.4,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,160.52,,,160.52,Fee Schedule,,858.08,,,858.08,Fee Schedule,,75.58,,,75.58,Fee Schedule,,160.52,,,160.52,Fee Schedule,,858.08,,,858.08,Fee Schedule,,142.16,,,142.16,Fee Schedule,,968.8,70,,968.8,percent of total billed charges,All Other,148.5,,,148.5,Fee Schedule,,126,,,126,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM BREASTBONE 2/>VWS    ,71120,CPT,,45000163,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,91.39,,,91.39,Fee Schedule,,82.13,,,82.13,Fee Schedule,,205.92,,,205.92,Fee Schedule,,185.27,,,185.27,Fee Schedule,,174.95,,,174.95,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,109.61,,,109.61,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,128.98,,,128.98,Fee Schedule,,922.56,,,922.56,Fee Schedule,,60.73,,,60.73,Fee Schedule,,128.98,,,128.98,Fee Schedule,,922.56,,,922.56,Fee Schedule,,114.23,,,114.23,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,120.45,,,120.45,Fee Schedule,,102.2,,,102.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY STRENOCLAVIC JT 3/>VWS    ,71130,CPT,,45000171,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,116.22,,,116.22,Fee Schedule,,104.46,,,104.46,Fee Schedule,,246.42,,,246.42,Fee Schedule,,221.71,,,221.71,Fee Schedule,,209.35,,,209.35,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,139.4,,,139.4,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,164.04,,,164.04,Fee Schedule,,922.56,,,922.56,Fee Schedule,,77.24,,,77.24,Fee Schedule,,164.04,,,164.04,Fee Schedule,,922.56,,,922.56,Fee Schedule,,145.28,,,145.28,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,153.45,,,153.45,Fee Schedule,,130.2,,,130.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM OF COLLAR BONE RT    ,73000,CPT,RT       ,45000189,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,92.62,,,92.62,Fee Schedule,,83.24,,,83.24,Fee Schedule,,190.34,,,190.34,Fee Schedule,,171.25,,,171.25,Fee Schedule,,161.71,,,161.71,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,111.08,,,111.08,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,130.72,,,130.72,Fee Schedule,,922.56,,,922.56,Fee Schedule,,61.55,,,61.55,Fee Schedule,,130.72,,,130.72,Fee Schedule,,922.56,,,922.56,Fee Schedule,,115.77,,,115.77,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,118.8,,,118.8,Fee Schedule,,100.8,,,100.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM SHOULDER BLADE RT    ,73010,CPT,RT       ,45000197,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,57.86,,,57.86,Fee Schedule,,52,,,52,Fee Schedule,,196.59,,,196.59,Fee Schedule,,176.87,,,176.87,Fee Schedule,,167.02,,,167.02,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,69.39,,,69.39,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,81.66,,,81.66,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,38.45,,,38.45,Fee Schedule,,81.66,,,81.66,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,72.32,,,72.32,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,74.25,,,74.25,Fee Schedule,,63,,,63,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,38.45,1462.3,
X-RAY EXAM OF SHOULDER +2V RT   ,73030,CPT,RT       ,45000205,CDM,320,RC,,,both,,,2089,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,97.58,,,97.58,Fee Schedule,,87.7,,,87.7,Fee Schedule,,193.43,,,193.43,Fee Schedule,,174.03,,,174.03,Fee Schedule,,164.33,,,164.33,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,117.04,,,117.04,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,137.72,,,137.72,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,64.85,,,64.85,Fee Schedule,,137.72,,,137.72,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,121.98,,,121.98,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,125.4,,,125.4,Fee Schedule,,106.4,,,106.4,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1462.3,
CONTRAST X-RAY OF HIP RT        ,73525,CPT,RT       ,45000213,CDM,320,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,376.96,,,376.96,Fee Schedule,,338.78,,,338.78,Fee Schedule,,667.31,,,667.31,Fee Schedule,,600.39,,,600.39,Fee Schedule,,566.93,,,566.93,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,452.11,,,452.11,Fee Schedule,,552.19,,,552.19,Other,186% Medicaid methodology,532.03,,,532.03,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,250.51,,,250.51,Fee Schedule,,532.03,,,532.03,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,471.2,,,471.2,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,529.65,,,529.65,Fee Schedule,,449.4,,,449.4,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,296.88,,,296.88,Other,New York Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,454.22,,,454.22,Other,153% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,415.63,,,415.63,Other,140% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,771.88,,,771.88,Other,260% Medicaid APG methodology,961.88,,,961.88,Other,324% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,371.1,,,371.1,Other,125% Medicaid APG methodology,250.51,4980.5,
X-RAY EXAM SHLDRS W/WO WGTS BI  ,73050,CPT,,45000221,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,75.24,,,75.24,Fee Schedule,,67.62,,,67.62,Fee Schedule,,252.66,,,252.66,Fee Schedule,,227.33,,,227.33,Fee Schedule,,214.66,,,214.66,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,90.24,,,90.24,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,106.19,,,106.19,Fee Schedule,,922.56,,,922.56,Fee Schedule,,50,,,50,Fee Schedule,,106.19,,,106.19,Fee Schedule,,922.56,,,922.56,Fee Schedule,,94.05,,,94.05,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,95.7,,,95.7,Fee Schedule,,81.2,,,81.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,50,1388,
X-RAY EXAM OF HUMERUS RT        ,73060,CPT,RT       ,45000239,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,91.39,,,91.39,Fee Schedule,,82.13,,,82.13,Fee Schedule,,190.34,,,190.34,Fee Schedule,,171.25,,,171.25,Fee Schedule,,161.71,,,161.71,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,109.61,,,109.61,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,128.98,,,128.98,Fee Schedule,,922.56,,,922.56,Fee Schedule,,60.73,,,60.73,Fee Schedule,,128.98,,,128.98,Fee Schedule,,922.56,,,922.56,Fee Schedule,,114.23,,,114.23,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,118.8,,,118.8,Fee Schedule,,100.8,,,100.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM OF FOREARM RT        ,73090,CPT,RT       ,45000254,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,81.43,,,81.43,Fee Schedule,,73.19,,,73.19,Fee Schedule,,184.1,,,184.1,Fee Schedule,,165.63,,,165.63,Fee Schedule,,156.4,,,156.4,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,97.67,,,97.67,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,114.93,,,114.93,Fee Schedule,,922.56,,,922.56,Fee Schedule,,54.12,,,54.12,Fee Schedule,,114.93,,,114.93,Fee Schedule,,922.56,,,922.56,Fee Schedule,,101.79,,,101.79,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,105.6,,,105.6,Fee Schedule,,89.6,,,89.6,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,54.12,1388,
X-RAY EXAM OF ARM INFANT RT     ,73092,CPT,RT       ,45000262,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,90.12,,,90.12,Fee Schedule,,81,,,81,Fee Schedule,,209.01,,,209.01,Fee Schedule,,188.05,,,188.05,Fee Schedule,,177.57,,,177.57,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,108.09,,,108.09,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,127.2,,,127.2,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,59.89,,,59.89,Fee Schedule,,127.2,,,127.2,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,112.65,,,112.65,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,118.8,,,118.8,Fee Schedule,,100.8,,,100.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1462.3,
X-RAY EXAM OF WRIST +3V RT      ,73110,CPT,RT       ,45000270,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,123.65,,,123.65,Fee Schedule,,111.13,,,111.13,Fee Schedule,,255.82,,,255.82,Fee Schedule,,230.17,,,230.17,Fee Schedule,,217.34,,,217.34,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,148.3,,,148.3,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,174.52,,,174.52,Fee Schedule,,922.56,,,922.56,Fee Schedule,,82.17,,,82.17,Fee Schedule,,174.52,,,174.52,Fee Schedule,,922.56,,,922.56,Fee Schedule,,154.56,,,154.56,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,160.05,,,160.05,Fee Schedule,,135.8,,,135.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM OF HAND +3V RT       ,73130,CPT,RT       ,45000288,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,108.77,,,108.77,Fee Schedule,,97.75,,,97.75,Fee Schedule,,218.34,,,218.34,Fee Schedule,,196.45,,,196.45,Fee Schedule,,185.5,,,185.5,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,130.45,,,130.45,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,153.51,,,153.51,Fee Schedule,,922.56,,,922.56,Fee Schedule,,72.28,,,72.28,Fee Schedule,,153.51,,,153.51,Fee Schedule,,922.56,,,922.56,Fee Schedule,,135.96,,,135.96,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,138.6,,,138.6,Fee Schedule,,117.6,,,117.6,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM NECK SPINE 2-3 VW    ,72040,CPT,,45000304,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,108.77,,,108.77,Fee Schedule,,97.75,,,97.75,Fee Schedule,,252.66,,,252.66,Fee Schedule,,227.33,,,227.33,Fee Schedule,,214.66,,,214.66,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,130.45,,,130.45,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,153.51,,,153.51,Fee Schedule,,922.56,,,922.56,Fee Schedule,,72.28,,,72.28,Fee Schedule,,153.51,,,153.51,Fee Schedule,,922.56,,,922.56,Fee Schedule,,135.96,,,135.96,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,141.9,,,141.9,Fee Schedule,,120.4,,,120.4,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM NECK SPINE 6/>VWS    ,72052,CPT,,45000312,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,180.78,,,180.78,Fee Schedule,,162.48,,,162.48,Fee Schedule,,452.2,,,452.2,Fee Schedule,,406.85,,,406.85,Fee Schedule,,384.18,,,384.18,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,216.83,,,216.83,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,255.16,,,255.16,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,120.14,,,120.14,Fee Schedule,,255.16,,,255.16,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,225.98,,,225.98,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,235.95,,,235.95,Fee Schedule,,200.2,,,200.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1462.3,
X-RAY EXAM THORAC SPINE 2VWS    ,72070,CPT,,45000320,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,87.66,,,87.66,Fee Schedule,,78.78,,,78.78,Fee Schedule,,212.17,,,212.17,Fee Schedule,,190.89,,,190.89,Fee Schedule,,180.26,,,180.26,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,105.13,,,105.13,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,123.72,,,123.72,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,58.25,,,58.25,Fee Schedule,,123.72,,,123.72,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,109.57,,,109.57,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,113.85,,,113.85,Fee Schedule,,96.6,,,96.6,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,58.25,1462.3,
X-RAY EXAM L-S SPINE 2/3 VWS    ,72100,CPT,,45000346,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,110,,,110,Fee Schedule,,98.86,,,98.86,Fee Schedule,,268.24,,,268.24,Fee Schedule,,241.35,,,241.35,Fee Schedule,,227.9,,,227.9,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,131.93,,,131.93,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,155.25,,,155.25,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,73.1,,,73.1,Fee Schedule,,155.25,,,155.25,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,137.5,,,137.5,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,143.55,,,143.55,Fee Schedule,,121.8,,,121.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1462.3,
X-RAY EXAM L-2 SPINE 4/>VWS     ,72110,CPT,,45000353,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,148.49,,,148.49,Fee Schedule,,133.45,,,133.45,Fee Schedule,,368.05,,,368.05,Fee Schedule,,331.14,,,331.14,Fee Schedule,,312.69,,,312.69,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,178.09,,,178.09,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,209.58,,,209.58,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,98.68,,,98.68,Fee Schedule,,209.58,,,209.58,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,185.61,,,185.61,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,191.4,,,191.4,Fee Schedule,,162.4,,,162.4,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1462.3,
X-RAY EXAM OF PELVIS +3V        ,72190,CPT,,45000361,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,113.73,,,113.73,Fee Schedule,,102.21,,,102.21,Fee Schedule,,283.83,,,283.83,Fee Schedule,,255.36,,,255.36,Fee Schedule,,241.13,,,241.13,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,136.4,,,136.4,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,160.52,,,160.52,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,75.58,,,75.58,Fee Schedule,,160.52,,,160.52,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,142.16,,,142.16,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,148.5,,,148.5,Fee Schedule,,126,,,126,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1462.3,
X-RAY EXAM SACRUM TAILBONE      ,72220,CPT,,45000387,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,91.39,,,91.39,Fee Schedule,,82.13,,,82.13,Fee Schedule,,193.43,,,193.43,Fee Schedule,,174.03,,,174.03,Fee Schedule,,164.33,,,164.33,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,109.61,,,109.61,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,128.98,,,128.98,Fee Schedule,,922.56,,,922.56,Fee Schedule,,60.73,,,60.73,Fee Schedule,,128.98,,,128.98,Fee Schedule,,922.56,,,922.56,Fee Schedule,,114.23,,,114.23,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,118.8,,,118.8,Fee Schedule,,100.8,,,100.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM HIP UNI 1 VIEW RT    ,73501,CPT,RT       ,45000403,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,90.12,,,90.12,Fee Schedule,,81,,,81,Fee Schedule,,20.07,,,20.07,Fee Schedule,,20.07,,,20.07,Fee Schedule,,20.07,,,20.07,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,108.09,,,108.09,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,127.2,,,127.2,Fee Schedule,,922.56,,,922.56,Fee Schedule,,59.89,,,59.89,Fee Schedule,,127.2,,,127.2,Fee Schedule,,922.56,,,922.56,Fee Schedule,,112.65,,,112.65,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,115.5,,,115.5,Fee Schedule,,98,,,98,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,20.07,1388,
X-RAY EXAM HIP UNI 2-3 VWS RT   ,73502,CPT,RT       ,45000411,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,138.57,,,138.57,Fee Schedule,,124.53,,,124.53,Fee Schedule,,29.42,,,29.42,Fee Schedule,,29.42,,,29.42,Fee Schedule,,29.42,,,29.42,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,166.19,,,166.19,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,195.57,,,195.57,Fee Schedule,,922.56,,,922.56,Fee Schedule,,92.09,,,92.09,Fee Schedule,,195.57,,,195.57,Fee Schedule,,922.56,,,922.56,Fee Schedule,,173.21,,,173.21,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,178.2,,,178.2,Fee Schedule,,151.2,,,151.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,29.42,1388,
X-RAY EXAM HIPS BI 2 VIEWS BI   ,73521,CPT,,45000429,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,114.96,,,114.96,Fee Schedule,,103.32,,,103.32,Fee Schedule,,25.61,,,25.61,Fee Schedule,,25.61,,,25.61,Fee Schedule,,25.61,,,25.61,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,137.88,,,137.88,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,162.25,,,162.25,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,76.4,,,76.4,Fee Schedule,,162.25,,,162.25,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,143.7,,,143.7,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,150.15,,,150.15,Fee Schedule,,127.4,,,127.4,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,25.61,1462.3,
X-RAY EXAM OF FEMUR 2/> RT      ,73552,CPT,RT       ,45000445,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,101.31,,,101.31,Fee Schedule,,91.05,,,91.05,Fee Schedule,,22.84,,,22.84,Fee Schedule,,22.84,,,22.84,Fee Schedule,,22.84,,,22.84,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,121.51,,,121.51,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,142.99,,,142.99,Fee Schedule,,922.56,,,922.56,Fee Schedule,,67.33,,,67.33,Fee Schedule,,142.99,,,142.99,Fee Schedule,,922.56,,,922.56,Fee Schedule,,126.64,,,126.64,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,130.35,,,130.35,Fee Schedule,,110.6,,,110.6,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,22.84,1388,
X-RAY EXAM OF KNEE 1 OR 2 RT    ,73560,CPT,RT       ,45000452,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,98.81,,,98.81,Fee Schedule,,88.81,,,88.81,Fee Schedule,,196.59,,,196.59,Fee Schedule,,176.87,,,176.87,Fee Schedule,,167.02,,,167.02,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,118.51,,,118.51,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,139.46,,,139.46,Fee Schedule,,922.56,,,922.56,Fee Schedule,,65.67,,,65.67,Fee Schedule,,139.46,,,139.46,Fee Schedule,,922.56,,,922.56,Fee Schedule,,123.52,,,123.52,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,128.7,,,128.7,Fee Schedule,,109.2,,,109.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM KNEE 4 OR MORE RT    ,73564,CPT,RT       ,45000460,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,136.07,,,136.07,Fee Schedule,,122.29,,,122.29,Fee Schedule,,280.74,,,280.74,Fee Schedule,,252.59,,,252.59,Fee Schedule,,238.51,,,238.51,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,163.2,,,163.2,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,192.05,,,192.05,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,90.43,,,90.43,Fee Schedule,,192.05,,,192.05,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,170.09,,,170.09,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,174.9,,,174.9,Fee Schedule,,148.4,,,148.4,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1462.3,
XR ARTHRO KNEE SI RT            ,73580,CPT,RT       ,45000478,CDM,320,RC,,,both,,,946,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,299.98,,,299.98,Fee Schedule,,269.6,,,269.6,Fee Schedule,,947.9,,,947.9,Fee Schedule,,852.85,,,852.85,Fee Schedule,,805.32,,,805.32,Fee Schedule,,473,50,,473,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,359.78,,,359.78,Fee Schedule,,552.19,,,552.19,Other,186% Medicaid methodology,423.39,,,423.39,Fee Schedule,,586.52,,,586.52,Fee Schedule,,199.35,,,199.35,Fee Schedule,,423.39,,,423.39,Fee Schedule,,586.52,,,586.52,Fee Schedule,,374.97,,,374.97,Fee Schedule,,662.2,70,,662.2,percent of total billed charges,All Other,598.95,,,598.95,Fee Schedule,,508.2,,,508.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,296.88,,,296.88,Other,New York Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,454.22,,,454.22,Other,153% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,415.63,,,415.63,Other,140% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,771.88,,,771.88,Other,260% Medicaid APG methodology,961.88,,,961.88,Other,324% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,371.1,,,371.1,Other,125% Medicaid APG methodology,199.35,1388,
X-RAY EXAM OF LOWER LEG RT      ,73590,CPT,RT       ,45000486,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,90.12,,,90.12,Fee Schedule,,81,,,81,Fee Schedule,,177.85,,,177.85,Fee Schedule,,160.01,,,160.01,Fee Schedule,,151.1,,,151.1,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,108.09,,,108.09,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,127.2,,,127.2,Fee Schedule,,922.56,,,922.56,Fee Schedule,,59.89,,,59.89,Fee Schedule,,127.2,,,127.2,Fee Schedule,,922.56,,,922.56,Fee Schedule,,112.65,,,112.65,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,117.15,,,117.15,Fee Schedule,,99.4,,,99.4,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM OF LEG INFANT RT     ,73592,CPT,RT       ,45000494,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,90.12,,,90.12,Fee Schedule,,81,,,81,Fee Schedule,,212.17,,,212.17,Fee Schedule,,190.89,,,190.89,Fee Schedule,,180.26,,,180.26,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,108.09,,,108.09,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,127.2,,,127.2,Fee Schedule,,922.56,,,922.56,Fee Schedule,,59.89,,,59.89,Fee Schedule,,127.2,,,127.2,Fee Schedule,,922.56,,,922.56,Fee Schedule,,112.65,,,112.65,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,118.8,,,118.8,Fee Schedule,,100.8,,,100.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM OF ANKLE +3V RT      ,73610,CPT,RT       ,45000502,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,106.27,,,106.27,Fee Schedule,,95.51,,,95.51,Fee Schedule,,221.5,,,221.5,Fee Schedule,,199.29,,,199.29,Fee Schedule,,188.19,,,188.19,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,127.46,,,127.46,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,149.99,,,149.99,Fee Schedule,,922.56,,,922.56,Fee Schedule,,70.62,,,70.62,Fee Schedule,,149.99,,,149.99,Fee Schedule,,922.56,,,922.56,Fee Schedule,,132.84,,,132.84,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,140.25,,,140.25,Fee Schedule,,119,,,119,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM OF FOOT +3V RT       ,73630,CPT,RT       ,45000510,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,98.81,,,98.81,Fee Schedule,,88.81,,,88.81,Fee Schedule,,215.26,,,215.26,Fee Schedule,,193.67,,,193.67,Fee Schedule,,182.88,,,182.88,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,118.51,,,118.51,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,139.46,,,139.46,Fee Schedule,,922.56,,,922.56,Fee Schedule,,65.67,,,65.67,Fee Schedule,,139.46,,,139.46,Fee Schedule,,922.56,,,922.56,Fee Schedule,,123.52,,,123.52,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,130.35,,,130.35,Fee Schedule,,110.6,,,110.6,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM OF HEEL RT           ,73650,CPT,RT       ,45000528,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,78.97,,,78.97,Fee Schedule,,70.97,,,70.97,Fee Schedule,,184.1,,,184.1,Fee Schedule,,165.63,,,165.63,Fee Schedule,,156.4,,,156.4,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,94.71,,,94.71,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,111.46,,,111.46,Fee Schedule,,922.56,,,922.56,Fee Schedule,,52.48,,,52.48,Fee Schedule,,111.46,,,111.46,Fee Schedule,,922.56,,,922.56,Fee Schedule,,98.71,,,98.71,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,103.95,,,103.95,Fee Schedule,,88.2,,,88.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,52.48,1388,
X-RAY EXAM ABDOMEN 1 VIEW       ,74018,CPT,,45000536,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,81.43,,,81.43,Fee Schedule,,73.19,,,73.19,Fee Schedule,,17.12,,,17.12,Fee Schedule,,17.12,,,17.12,Fee Schedule,,17.12,,,17.12,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,97.67,,,97.67,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,114.93,,,114.93,Fee Schedule,,922.56,,,922.56,Fee Schedule,,54.12,,,54.12,Fee Schedule,,114.93,,,114.93,Fee Schedule,,922.56,,,922.56,Fee Schedule,,101.79,,,101.79,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,105.6,,,105.6,Fee Schedule,,89.6,,,89.6,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,17.12,1388,
X-RAY EXAM ABDOMEN 3+ VIEWS     ,74021,CPT,,45000544,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,113.73,,,113.73,Fee Schedule,,102.21,,,102.21,Fee Schedule,,23.83,,,23.83,Fee Schedule,,23.83,,,23.83,Fee Schedule,,23.83,,,23.83,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,136.4,,,136.4,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,160.52,,,160.52,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,75.58,,,75.58,Fee Schedule,,160.52,,,160.52,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,142.16,,,142.16,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,150.15,,,150.15,Fee Schedule,,127.4,,,127.4,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,23.83,1462.3,
X-RAY XM ESOPHAGUS 1CNTRST      ,74220,CPT,,45000569,CDM,320,RC,,,both,,,3396,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,258.99,,,258.99,Fee Schedule,,232.77,,,232.77,Fee Schedule,,620.57,,,620.57,Fee Schedule,,558.34,,,558.34,Fee Schedule,,527.22,,,527.22,Fee Schedule,,1698,50,,1698,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,310.63,,,310.63,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,365.54,,,365.54,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,172.12,,,172.12,Fee Schedule,,365.54,,,365.54,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,323.74,,,323.74,Fee Schedule,,2377.2,70,,2377.2,percent of total billed charges,All Other,356.4,,,356.4,Fee Schedule,,302.4,,,302.4,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,2377.2,
X-RAY XM UPR GI TRC 1CNTRST     ,74240,CPT,,45000585,CDM,320,RC,,,both,,,3396,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,317.36,,,317.36,Fee Schedule,,285.22,,,285.22,Fee Schedule,,714.12,,,714.12,Fee Schedule,,642.51,,,642.51,Fee Schedule,,606.71,,,606.71,Fee Schedule,,1698,50,,1698,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,380.63,,,380.63,Fee Schedule,,552.19,,,552.19,Other,186% Medicaid methodology,447.92,,,447.92,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,210.9,,,210.9,Fee Schedule,,447.92,,,447.92,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,396.7,,,396.7,Fee Schedule,,2377.2,70,,2377.2,percent of total billed charges,All Other,435.6,,,435.6,Fee Schedule,,369.6,,,369.6,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,296.88,,,296.88,Other,New York Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,454.22,,,454.22,Other,153% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,415.63,,,415.63,Other,140% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,771.88,,,771.88,Other,260% Medicaid APG methodology,961.88,,,961.88,Other,324% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,371.1,,,371.1,Other,125% Medicaid APG methodology,210.9,2377.2,
X-RAY XM SM INT 1CNTRST STD     ,74250,CPT,,45000601,CDM,320,RC,,,both,,,3396,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,313.63,,,313.63,Fee Schedule,,281.87,,,281.87,Fee Schedule,,767.11,,,767.11,Fee Schedule,,690.19,,,690.19,Fee Schedule,,651.72,,,651.72,Fee Schedule,,1698,50,,1698,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,376.16,,,376.16,Fee Schedule,,552.19,,,552.19,Other,186% Medicaid methodology,442.66,,,442.66,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,208.43,,,208.43,Fee Schedule,,442.66,,,442.66,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,392.04,,,392.04,Fee Schedule,,2377.2,70,,2377.2,percent of total billed charges,All Other,432.3,,,432.3,Fee Schedule,,366.8,,,366.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,296.88,,,296.88,Other,New York Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,454.22,,,454.22,Other,153% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,415.63,,,415.63,Other,140% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,771.88,,,771.88,Other,260% Medicaid APG methodology,961.88,,,961.88,Other,324% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,371.1,,,371.1,Other,125% Medicaid APG methodology,208.43,2377.2,
X-RAY XM COLON 1CNTRST STD      ,74270,CPT,,45000627,CDM,320,RC,,,both,,,3396,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,391.87,,,391.87,Fee Schedule,,352.19,,,352.19,Fee Schedule,,798.27,,,798.27,Fee Schedule,,718.22,,,718.22,Fee Schedule,,678.2,,,678.2,Fee Schedule,,1698,50,,1698,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,470,,,470,Fee Schedule,,552.19,,,552.19,Other,186% Medicaid methodology,553.08,,,553.08,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,260.42,,,260.42,Fee Schedule,,553.08,,,553.08,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,489.84,,,489.84,Fee Schedule,,2377.2,70,,2377.2,percent of total billed charges,All Other,539.55,,,539.55,Fee Schedule,,457.8,,,457.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,296.88,,,296.88,Other,New York Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,454.22,,,454.22,Other,153% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,415.63,,,415.63,Other,140% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,771.88,,,771.88,Other,260% Medicaid APG methodology,961.88,,,961.88,Other,324% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,371.1,,,371.1,Other,125% Medicaid APG methodology,212.47,2377.2,
X-RAY XM COLON 2CNTRST STD      ,74280,CPT,,45000635,CDM,320,RC,,,both,,,2849,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,599.96,,,599.96,Fee Schedule,,539.2,,,539.2,Fee Schedule,,1303.31,,,1303.31,Fee Schedule,,1172.62,,,1172.62,Fee Schedule,,1107.27,,,1107.27,Fee Schedule,,1424.5,50,,1424.5,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,719.57,,,719.57,Fee Schedule,,552.19,,,552.19,Other,186% Medicaid methodology,846.78,,,846.78,Fee Schedule,,1766.38,,,1766.38,Fee Schedule,,398.71,,,398.71,Fee Schedule,,846.78,,,846.78,Fee Schedule,,1766.38,,,1766.38,Fee Schedule,,749.95,,,749.95,Fee Schedule,,1994.3,70,,1994.3,percent of total billed charges,All Other,831.6,,,831.6,Fee Schedule,,705.6,,,705.6,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,296.88,,,296.88,Other,New York Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,454.22,,,454.22,Other,153% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,415.63,,,415.63,Other,140% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,771.88,,,771.88,Other,260% Medicaid APG methodology,961.88,,,961.88,Other,324% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,371.1,,,371.1,Other,125% Medicaid APG methodology,212.47,1994.3,
CONTRAST X-RAY BLADDER          ,74430,CPT,,45000718,CDM,320,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,98.81,,,98.81,Fee Schedule,,88.81,,,88.81,Fee Schedule,,417.88,,,417.88,Fee Schedule,,375.97,,,375.97,Fee Schedule,,355.02,,,355.02,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,118.51,,,118.51,Fee Schedule,,552.19,,,552.19,Other,186% Medicaid methodology,139.46,,,139.46,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,65.67,,,65.67,Fee Schedule,,139.46,,,139.46,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,123.52,,,123.52,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,127.05,,,127.05,Fee Schedule,,107.8,,,107.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,296.88,,,296.88,Other,New York Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,454.22,,,454.22,Other,153% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,415.63,,,415.63,Other,140% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,771.88,,,771.88,Other,260% Medicaid APG methodology,961.88,,,961.88,Other,324% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,371.1,,,371.1,Other,125% Medicaid APG methodology,65.67,4980.5,
X-RAY URETHRA/BLADDER VOIDING   ,74455,CPT,,45000734,CDM,320,RC,,,both,,,4342,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,331.01,,,331.01,Fee Schedule,,297.49,,,297.49,Fee Schedule,,676.64,,,676.64,Fee Schedule,,608.79,,,608.79,Fee Schedule,,574.86,,,574.86,Fee Schedule,,2171,50,,2171,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,397,,,397,Fee Schedule,,552.19,,,552.19,Other,186% Medicaid methodology,467.19,,,467.19,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,219.98,,,219.98,Fee Schedule,,467.19,,,467.19,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,413.76,,,413.76,Fee Schedule,,3039.4,70,,3039.4,percent of total billed charges,All Other,450.45,,,450.45,Fee Schedule,,382.2,,,382.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,296.88,,,296.88,Other,New York Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,454.22,,,454.22,Other,153% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,415.63,,,415.63,Other,140% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,771.88,,,771.88,Other,260% Medicaid APG methodology,961.88,,,961.88,Other,324% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,371.1,,,371.1,Other,125% Medicaid APG methodology,219.98,3039.4,
X-RAY FEMALE GENITAL TRACT      ,74740,CPT,,45000767,CDM,320,RC,,,both,,,4342,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,282.6,,,282.6,Fee Schedule,,253.98,,,253.98,Fee Schedule,,558.17,,,558.17,Fee Schedule,,502.2,,,502.2,Fee Schedule,,474.21,,,474.21,Fee Schedule,,2171,50,,2171,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,338.94,,,338.94,Fee Schedule,,552.19,,,552.19,Other,186% Medicaid methodology,398.86,,,398.86,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,187.8,,,187.8,Fee Schedule,,398.86,,,398.86,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,353.25,,,353.25,Fee Schedule,,3039.4,70,,3039.4,percent of total billed charges,All Other,396,,,396,Fee Schedule,,336,,,336,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,296.88,,,296.88,Other,New York Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,454.22,,,454.22,Other,153% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,415.63,,,415.63,Other,140% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,771.88,,,771.88,Other,260% Medicaid APG methodology,961.88,,,961.88,Other,324% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,371.1,,,371.1,Other,125% Medicaid APG methodology,187.8,3039.4,
X-RAY EXAM OF SKULL +4V         ,70260,CPT,,45000866,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,117.46,,,117.46,Fee Schedule,,105.56,,,105.56,Fee Schedule,,283.83,,,283.83,Fee Schedule,,255.36,,,255.36,Fee Schedule,,241.13,,,241.13,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,140.87,,,140.87,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,165.78,,,165.78,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,78.06,,,78.06,Fee Schedule,,165.78,,,165.78,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,146.82,,,146.82,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,155.1,,,155.1,Fee Schedule,,131.6,,,131.6,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1462.3,
X-RAY EXAM ENTIRE SPI 1 VW      ,72081,CPT,,45000874,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,113.73,,,113.73,Fee Schedule,,102.21,,,102.21,Fee Schedule,,24.57,,,24.57,Fee Schedule,,24.57,,,24.57,Fee Schedule,,24.57,,,24.57,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,136.4,,,136.4,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,160.52,,,160.52,Fee Schedule,,922.56,,,922.56,Fee Schedule,,75.58,,,75.58,Fee Schedule,,160.52,,,160.52,Fee Schedule,,922.56,,,922.56,Fee Schedule,,142.16,,,142.16,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,148.5,,,148.5,Fee Schedule,,126,,,126,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,24.57,1388,
ELBOW ARTHROGRAPHY RT           ,73085,CPT,,45001054,CDM,320,RC,,,both,,,1327,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,278.87,,,278.87,Fee Schedule,,250.63,,,250.63,Fee Schedule,,648.64,,,648.64,Fee Schedule,,583.6,,,583.6,Fee Schedule,,551.07,,,551.07,Fee Schedule,,663.5,50,,663.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,334.47,,,334.47,Fee Schedule,,552.19,,,552.19,Other,186% Medicaid methodology,393.6,,,393.6,Fee Schedule,,822.74,,,822.74,Fee Schedule,,185.33,,,185.33,Fee Schedule,,393.6,,,393.6,Fee Schedule,,822.74,,,822.74,Fee Schedule,,348.59,,,348.59,Fee Schedule,,928.9,70,,928.9,percent of total billed charges,All Other,427.35,,,427.35,Fee Schedule,,362.6,,,362.6,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,296.88,,,296.88,Other,New York Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,454.22,,,454.22,Other,153% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,415.63,,,415.63,Other,140% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,771.88,,,771.88,Other,260% Medicaid APG methodology,961.88,,,961.88,Other,324% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,371.1,,,371.1,Other,125% Medicaid APG methodology,185.33,1388,
X-RAY EXAM OF JAW <4VIEWS       ,70100,CPT,,45001260,CDM,320,RC,,,both,,,1392,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,113.73,,,113.73,Fee Schedule,,102.21,,,102.21,Fee Schedule,,221.5,,,221.5,Fee Schedule,,199.29,,,199.29,Fee Schedule,,188.19,,,188.19,Fee Schedule,,696,50,,696,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,136.4,,,136.4,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,160.52,,,160.52,Fee Schedule,,863.04,,,863.04,Fee Schedule,,75.58,,,75.58,Fee Schedule,,160.52,,,160.52,Fee Schedule,,863.04,,,863.04,Fee Schedule,,142.16,,,142.16,Fee Schedule,,974.4,70,,974.4,percent of total billed charges,All Other,146.85,,,146.85,Fee Schedule,,124.6,,,124.6,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM OF JAW 4/> VIEWS     ,70110,CPT,,45001278,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,119.92,,,119.92,Fee Schedule,,107.78,,,107.78,Fee Schedule,,252.66,,,252.66,Fee Schedule,,227.33,,,227.33,Fee Schedule,,214.66,,,214.66,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,143.83,,,143.83,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,169.26,,,169.26,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,79.7,,,79.7,Fee Schedule,,169.26,,,169.26,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,149.9,,,149.9,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,158.4,,,158.4,Fee Schedule,,134.4,,,134.4,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1462.3,
X-RAY EXAM FACIAL BONES +3V FY  ,70150,CPT,,45001294,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,131.11,,,131.11,Fee Schedule,,117.83,,,117.83,Fee Schedule,,277.58,,,277.58,Fee Schedule,,249.74,,,249.74,Fee Schedule,,235.83,,,235.83,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,157.25,,,157.25,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,185.05,,,185.05,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,87.13,,,87.13,Fee Schedule,,185.05,,,185.05,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,163.89,,,163.89,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,173.25,,,173.25,Fee Schedule,,147,,,147,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1462.3,
X-RAY EXAM OF NASAL BONES +3V   ,70160,CPT,,45001302,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,111.23,,,111.23,Fee Schedule,,99.97,,,99.97,Fee Schedule,,227.75,,,227.75,Fee Schedule,,204.91,,,204.91,Fee Schedule,,193.49,,,193.49,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,133.41,,,133.41,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,156.99,,,156.99,Fee Schedule,,922.56,,,922.56,Fee Schedule,,73.92,,,73.92,Fee Schedule,,156.99,,,156.99,Fee Schedule,,922.56,,,922.56,Fee Schedule,,139.04,,,139.04,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,146.85,,,146.85,Fee Schedule,,124.6,,,124.6,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
XR Optic Foramina Right,70190,CPT,TCRT,45001328,CDM,320,RC,,,both,,,399,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,100.03,,,100.03,Fee Schedule,,90.09,,,90.09,Fee Schedule,,199.5,50,,199.5,percent of total billed charges,All Other Outpatient,179.55,45,,179.55,percent of total billed charges,All Other Outpatient,171.57,43,,171.57,percent of total billed charges,All Other Outpatient,199.5,50,,199.5,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,121.51,,,121.51,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,142.99,,,142.99,Fee Schedule,,247.38,,,247.38,Fee Schedule,,67.33,,,67.33,Fee Schedule,,142.99,,,142.99,Fee Schedule,,247.38,,,247.38,Fee Schedule,,126.64,,,126.64,Fee Schedule,,279.3,70,,279.3,percent of total billed charges,All Other,135.3,,,135.3,Fee Schedule,,114.8,,,114.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM OF EYE SOCKETS +4V   ,70200,CPT,,45001336,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,129.88,,,129.88,Fee Schedule,,116.72,,,116.72,Fee Schedule,,280.74,,,280.74,Fee Schedule,,252.59,,,252.59,Fee Schedule,,238.51,,,238.51,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,155.77,,,155.77,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,183.31,,,183.31,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,86.31,,,86.31,Fee Schedule,,183.31,,,183.31,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,162.35,,,162.35,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,173.25,,,173.25,Fee Schedule,,147,,,147,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1462.3,
X-RAY EXAM OF SINUSES +3V       ,70220,CPT,,45001344,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,102.54,,,102.54,Fee Schedule,,92.16,,,92.16,Fee Schedule,,246.42,,,246.42,Fee Schedule,,221.71,,,221.71,Fee Schedule,,209.35,,,209.35,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,122.99,,,122.99,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,144.73,,,144.73,Fee Schedule,,922.56,,,922.56,Fee Schedule,,68.15,,,68.15,Fee Schedule,,144.73,,,144.73,Fee Schedule,,922.56,,,922.56,Fee Schedule,,128.18,,,128.18,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,135.3,,,135.3,Fee Schedule,,114.8,,,114.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
CONTRAST X-RAY OF SHOULDER RT   ,73040,CPT,RT       ,45001369,CDM,320,RC,,,both,,,1217,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,393.1,,,393.1,Fee Schedule,,353.3,,,353.3,Fee Schedule,,742.12,,,742.12,Fee Schedule,,667.71,,,667.71,Fee Schedule,,630.5,,,630.5,Fee Schedule,,608.5,50,,608.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,471.48,,,471.48,Fee Schedule,,552.19,,,552.19,Other,186% Medicaid methodology,554.82,,,554.82,Fee Schedule,,754.54,,,754.54,Fee Schedule,,261.24,,,261.24,Fee Schedule,,554.82,,,554.82,Fee Schedule,,754.54,,,754.54,Fee Schedule,,491.38,,,491.38,Fee Schedule,,851.9,70,,851.9,percent of total billed charges,All Other,524.7,,,524.7,Fee Schedule,,445.2,,,445.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,296.88,,,296.88,Other,New York Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,454.22,,,454.22,Other,153% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,415.63,,,415.63,Other,140% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,771.88,,,771.88,Other,260% Medicaid APG methodology,961.88,,,961.88,Other,324% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,371.1,,,371.1,Other,125% Medicaid APG methodology,261.24,1388,
X-RAY EXAM OF FACIAL BONES <3V  ,70140,CPT,,45001443,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,85.16,,,85.16,Fee Schedule,,76.54,,,76.54,Fee Schedule,,190.34,,,190.34,Fee Schedule,,171.25,,,171.25,Fee Schedule,,161.71,,,161.71,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,102.14,,,102.14,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,120.2,,,120.2,Fee Schedule,,922.56,,,922.56,Fee Schedule,,56.6,,,56.6,Fee Schedule,,120.2,,,120.2,Fee Schedule,,922.56,,,922.56,Fee Schedule,,106.45,,,106.45,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,110.55,,,110.55,Fee Schedule,,93.8,,,93.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,56.6,1388,
X-RAY EXAM OF SINUSES <3V       ,70210,CPT,,45001450,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,90.12,,,90.12,Fee Schedule,,81,,,81,Fee Schedule,,205.92,,,205.92,Fee Schedule,,185.27,,,185.27,Fee Schedule,,174.95,,,174.95,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,108.09,,,108.09,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,127.2,,,127.2,Fee Schedule,,922.56,,,922.56,Fee Schedule,,59.89,,,59.89,Fee Schedule,,127.2,,,127.2,Fee Schedule,,922.56,,,922.56,Fee Schedule,,112.65,,,112.65,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,118.8,,,118.8,Fee Schedule,,100.8,,,100.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM OF JAW JOINTS BI     ,70330,CPT,,45001468,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,155.95,,,155.95,Fee Schedule,,140.15,,,140.15,Fee Schedule,,333.73,,,333.73,Fee Schedule,,300.26,,,300.26,Fee Schedule,,283.53,,,283.53,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,187.04,,,187.04,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,220.1,,,220.1,Fee Schedule,,922.56,,,922.56,Fee Schedule,,103.64,,,103.64,Fee Schedule,,220.1,,,220.1,Fee Schedule,,922.56,,,922.56,Fee Schedule,,194.93,,,194.93,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,207.9,,,207.9,Fee Schedule,,176.4,,,176.4,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM UNILAT RIBS/CHEST    ,71101,CPT,,45001492,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,111.23,,,111.23,Fee Schedule,,99.97,,,99.97,Fee Schedule,,243.33,,,243.33,Fee Schedule,,218.93,,,218.93,Fee Schedule,,206.73,,,206.73,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,133.41,,,133.41,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,156.99,,,156.99,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,73.92,,,73.92,Fee Schedule,,156.99,,,156.99,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,139.04,,,139.04,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,145.2,,,145.2,Fee Schedule,,123.2,,,123.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1462.3,
X-RAY EXAM RIBS/CHEST4/>VWS BI  ,71111,CPT,,45001518,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,139.8,,,139.8,Fee Schedule,,125.64,,,125.64,Fee Schedule,,343.06,,,343.06,Fee Schedule,,308.66,,,308.66,Fee Schedule,,291.46,,,291.46,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,167.67,,,167.67,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,197.31,,,197.31,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,92.9,,,92.9,Fee Schedule,,197.31,,,197.31,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,174.75,,,174.75,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,184.8,,,184.8,Fee Schedule,,156.8,,,156.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1462.3,
X-RAY EXAM OF SPINE 1 VIEW      ,72020,CPT,,45001542,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,62.82,,,62.82,Fee Schedule,,56.46,,,56.46,Fee Schedule,,149.77,,,149.77,Fee Schedule,,134.76,,,134.76,Fee Schedule,,127.25,,,127.25,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,75.35,,,75.35,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,88.66,,,88.66,Fee Schedule,,922.56,,,922.56,Fee Schedule,,41.75,,,41.75,Fee Schedule,,88.66,,,88.66,Fee Schedule,,922.56,,,922.56,Fee Schedule,,78.53,,,78.53,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,82.5,,,82.5,Fee Schedule,,70,,,70,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,41.75,1388,
X-RAY EXAM NECK SPINE 4/5VWS    ,72050,CPT,,45001567,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,153.45,,,153.45,Fee Schedule,,137.91,,,137.91,Fee Schedule,,343.06,,,343.06,Fee Schedule,,308.66,,,308.66,Fee Schedule,,291.46,,,291.46,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,184.04,,,184.04,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,216.58,,,216.58,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,101.98,,,101.98,Fee Schedule,,216.58,,,216.58,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,191.81,,,191.81,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,198,,,198,Fee Schedule,,168,,,168,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1462.3,
X-RAY EXAM OF PELVIS 1-2V       ,72170,CPT,,45001583,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,74.01,,,74.01,Fee Schedule,,66.51,,,66.51,Fee Schedule,,165.36,,,165.36,Fee Schedule,,148.77,,,148.77,Fee Schedule,,140.48,,,140.48,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,88.76,,,88.76,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,104.45,,,104.45,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,49.18,,,49.18,Fee Schedule,,104.45,,,104.45,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,92.51,,,92.51,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,95.7,,,95.7,Fee Schedule,,81.2,,,81.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,49.18,1462.3,
MYELOGRAM - CERVICAL            ,72240,CPT,,45001609,CDM,320,RC,,,both,,,2667,1522.61,,,1522.61,Other,150% of Medicare + 9.63% HCRA Surcharge,925.91,,,925.91,Other,Medicare OPPS methodology,257.76,,,257.76,Fee Schedule,,231.66,,,231.66,Fee Schedule,,916.74,,,916.74,Fee Schedule,,824.81,,,824.81,Fee Schedule,,778.85,,,778.85,Fee Schedule,,1333.5,50,,1333.5,percent of total billed charges,All Other,2097.16,,,2097.16,Fee Schedule,,309.15,,,309.15,Fee Schedule,,1235,,,1235,Other,186% Medicaid methodology,363.8,,,363.8,Fee Schedule,,1653.54,,,1653.54,Fee Schedule,,171.3,,,171.3,Fee Schedule,,363.8,,,363.8,Fee Schedule,,1653.54,,,1653.54,Fee Schedule,,322.2,,,322.2,Fee Schedule,,1866.9,70,,1866.9,percent of total billed charges,All Other,356.4,,,356.4,Fee Schedule,,302.4,,,302.4,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,663.98,,,663.98,Other,New York Medicaid APG methodology,663.98,,,663.98,Other,100% Medicaid APG methodology,663.98,,,663.98,Other,100% Medicaid APG methodology,663.98,,,663.98,Other,100% Medicaid APG methodology,1493.95,,,1493.95,Other,225% Medicaid APG methodology,1493.95,,,1493.95,Other,225% Medicaid APG methodology,1015.89,,,1015.89,Other,153% Medicaid APG methodology,1493.95,,,1493.95,Other,225% Medicaid APG methodology,929.57,,,929.57,Other,140% Medicaid APG methodology,1493.95,,,1493.95,Other,225% Medicaid APG methodology,1726.34,,,1726.34,Other,260% Medicaid APG methodology,2151.29,,,2151.29,Other,324% Medicaid APG methodology,1427.55,,,1427.55,Other,215% Medicaid APG methodology,1427.55,,,1427.55,Other,215% Medicaid APG methodology,829.97,,,829.97,Other,125% Medicaid APG methodology,171.3,2151.29,
MYELOGRAM-LUMBOSACRAL           ,72265,CPT,,45001625,CDM,320,RC,,,both,,,2667,1522.61,,,1522.61,Other,150% of Medicare + 9.63% HCRA Surcharge,925.91,,,925.91,Other,Medicare OPPS methodology,260.26,,,260.26,Fee Schedule,,233.9,,,233.9,Fee Schedule,,891.83,,,891.83,Fee Schedule,,802.4,,,802.4,Fee Schedule,,757.68,,,757.68,Fee Schedule,,1333.5,50,,1333.5,percent of total billed charges,All Other,2097.16,,,2097.16,Fee Schedule,,312.14,,,312.14,Fee Schedule,,1235,,,1235,Other,186% Medicaid methodology,367.33,,,367.33,Fee Schedule,,1653.54,,,1653.54,Fee Schedule,,172.96,,,172.96,Fee Schedule,,367.33,,,367.33,Fee Schedule,,1653.54,,,1653.54,Fee Schedule,,325.32,,,325.32,Fee Schedule,,1866.9,70,,1866.9,percent of total billed charges,All Other,348.15,,,348.15,Fee Schedule,,295.4,,,295.4,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,663.98,,,663.98,Other,New York Medicaid APG methodology,663.98,,,663.98,Other,100% Medicaid APG methodology,663.98,,,663.98,Other,100% Medicaid APG methodology,663.98,,,663.98,Other,100% Medicaid APG methodology,1493.95,,,1493.95,Other,225% Medicaid APG methodology,1493.95,,,1493.95,Other,225% Medicaid APG methodology,1015.89,,,1015.89,Other,153% Medicaid APG methodology,1493.95,,,1493.95,Other,225% Medicaid APG methodology,929.57,,,929.57,Other,140% Medicaid APG methodology,1493.95,,,1493.95,Other,225% Medicaid APG methodology,1726.34,,,1726.34,Other,260% Medicaid APG methodology,2151.29,,,2151.29,Other,324% Medicaid APG methodology,1427.55,,,1427.55,Other,215% Medicaid APG methodology,1427.55,,,1427.55,Other,215% Medicaid APG methodology,829.97,,,829.97,Other,125% Medicaid APG methodology,172.96,2151.29,
X-RAY EXAM OF SHOULDER 1V RT    ,73020,CPT,RT       ,45001641,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,54.13,,,54.13,Fee Schedule,,48.65,,,48.65,Fee Schedule,,149.77,,,149.77,Fee Schedule,,134.76,,,134.76,Fee Schedule,,127.25,,,127.25,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,64.92,,,64.92,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,76.4,,,76.4,Fee Schedule,,922.56,,,922.56,Fee Schedule,,35.97,,,35.97,Fee Schedule,,76.4,,,76.4,Fee Schedule,,922.56,,,922.56,Fee Schedule,,67.66,,,67.66,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,69.3,,,69.3,Fee Schedule,,58.8,,,58.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,35.97,1388,
X-RAY EXAM OF SHOULDER 1V LT    ,73020,CPT,LT       ,45001658,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,54.13,,,54.13,Fee Schedule,,48.65,,,48.65,Fee Schedule,,149.77,,,149.77,Fee Schedule,,134.76,,,134.76,Fee Schedule,,127.25,,,127.25,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,64.92,,,64.92,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,76.4,,,76.4,Fee Schedule,,922.56,,,922.56,Fee Schedule,,35.97,,,35.97,Fee Schedule,,76.4,,,76.4,Fee Schedule,,922.56,,,922.56,Fee Schedule,,67.66,,,67.66,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,69.3,,,69.3,Fee Schedule,,58.8,,,58.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,35.97,1388,
X-RAY EXAM OF WRIST 2V RT       ,73100,CPT,RT       ,45001666,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,97.58,,,97.58,Fee Schedule,,87.7,,,87.7,Fee Schedule,,202.76,,,202.76,Fee Schedule,,182.43,,,182.43,Fee Schedule,,172.26,,,172.26,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,117.04,,,117.04,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,137.72,,,137.72,Fee Schedule,,922.56,,,922.56,Fee Schedule,,64.85,,,64.85,Fee Schedule,,137.72,,,137.72,Fee Schedule,,922.56,,,922.56,Fee Schedule,,121.98,,,121.98,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,127.05,,,127.05,Fee Schedule,,107.8,,,107.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM OF WRIST 2V LT       ,73100,CPT,LT       ,45001674,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,97.58,,,97.58,Fee Schedule,,87.7,,,87.7,Fee Schedule,,202.76,,,202.76,Fee Schedule,,182.43,,,182.43,Fee Schedule,,172.26,,,172.26,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,117.04,,,117.04,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,137.72,,,137.72,Fee Schedule,,922.56,,,922.56,Fee Schedule,,64.85,,,64.85,Fee Schedule,,137.72,,,137.72,Fee Schedule,,922.56,,,922.56,Fee Schedule,,121.98,,,121.98,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,127.05,,,127.05,Fee Schedule,,107.8,,,107.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM OF HAND 2V RT        ,73120,CPT,RT       ,45001682,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,88.89,,,88.89,Fee Schedule,,79.89,,,79.89,Fee Schedule,,180.94,,,180.94,Fee Schedule,,162.79,,,162.79,Fee Schedule,,153.72,,,153.72,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,106.61,,,106.61,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,125.46,,,125.46,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,59.07,,,59.07,Fee Schedule,,125.46,,,125.46,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,111.11,,,111.11,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,113.85,,,113.85,Fee Schedule,,96.6,,,96.6,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.07,1462.3,
X-RAY EXAM OF KNEE 3 RT         ,73562,CPT,RT       ,45001690,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,119.92,,,119.92,Fee Schedule,,107.78,,,107.78,Fee Schedule,,246.42,,,246.42,Fee Schedule,,221.71,,,221.71,Fee Schedule,,209.35,,,209.35,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,143.83,,,143.83,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,169.26,,,169.26,Fee Schedule,,922.56,,,922.56,Fee Schedule,,79.7,,,79.7,Fee Schedule,,169.26,,,169.26,Fee Schedule,,922.56,,,922.56,Fee Schedule,,149.9,,,149.9,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,156.75,,,156.75,Fee Schedule,,133,,,133,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM OF KNEE 3 LT         ,73562,CPT,LT       ,45001708,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,119.92,,,119.92,Fee Schedule,,107.78,,,107.78,Fee Schedule,,246.42,,,246.42,Fee Schedule,,221.71,,,221.71,Fee Schedule,,209.35,,,209.35,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,143.83,,,143.83,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,169.26,,,169.26,Fee Schedule,,922.56,,,922.56,Fee Schedule,,79.7,,,79.7,Fee Schedule,,169.26,,,169.26,Fee Schedule,,922.56,,,922.56,Fee Schedule,,149.9,,,149.9,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,156.75,,,156.75,Fee Schedule,,133,,,133,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM OF KNEES             ,73565,CPT,,45001716,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,119.92,,,119.92,Fee Schedule,,107.78,,,107.78,Fee Schedule,,224.59,,,224.59,Fee Schedule,,202.07,,,202.07,Fee Schedule,,190.81,,,190.81,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,143.83,,,143.83,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,169.26,,,169.26,Fee Schedule,,922.56,,,922.56,Fee Schedule,,79.7,,,79.7,Fee Schedule,,169.26,,,169.26,Fee Schedule,,922.56,,,922.56,Fee Schedule,,149.9,,,149.9,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,158.4,,,158.4,Fee Schedule,,134.4,,,134.4,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM OF ANKLE 2V RT       ,73600,CPT,RT       ,45001724,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,92.62,,,92.62,Fee Schedule,,83.24,,,83.24,Fee Schedule,,187.18,,,187.18,Fee Schedule,,168.41,,,168.41,Fee Schedule,,159.03,,,159.03,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,111.08,,,111.08,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,130.72,,,130.72,Fee Schedule,,922.56,,,922.56,Fee Schedule,,61.55,,,61.55,Fee Schedule,,130.72,,,130.72,Fee Schedule,,922.56,,,922.56,Fee Schedule,,115.77,,,115.77,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,120.45,,,120.45,Fee Schedule,,102.2,,,102.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM OF ANKLE 2V LT       ,73600,CPT,LT       ,45001732,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,92.62,,,92.62,Fee Schedule,,83.24,,,83.24,Fee Schedule,,187.18,,,187.18,Fee Schedule,,168.41,,,168.41,Fee Schedule,,159.03,,,159.03,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,111.08,,,111.08,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,130.72,,,130.72,Fee Schedule,,922.56,,,922.56,Fee Schedule,,61.55,,,61.55,Fee Schedule,,130.72,,,130.72,Fee Schedule,,922.56,,,922.56,Fee Schedule,,115.77,,,115.77,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,120.45,,,120.45,Fee Schedule,,102.2,,,102.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAYS FOR BONE AGE             ,77072,CPT,,45002250,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,64.05,,,64.05,Fee Schedule,,57.57,,,57.57,Fee Schedule,,131.11,,,131.11,Fee Schedule,,117.96,,,117.96,Fee Schedule,,111.39,,,111.39,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,76.82,,,76.82,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,90.4,,,90.4,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,42.57,,,42.57,Fee Schedule,,90.4,,,90.4,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,80.07,,,80.07,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,84.15,,,84.15,Fee Schedule,,71.4,,,71.4,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,42.57,1462.3,
X-RAYS BONE SURVEY COMPLETE     ,77075,CPT,,45002284,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,275.87,,,275.87,Fee Schedule,,247.93,,,247.93,Fee Schedule,,695.38,,,695.38,Fee Schedule,,625.65,,,625.65,Fee Schedule,,590.79,,,590.79,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,330.87,,,330.87,Fee Schedule,,552.19,,,552.19,Other,186% Medicaid methodology,389.36,,,389.36,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,183.33,,,183.33,Fee Schedule,,389.36,,,389.36,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,344.84,,,344.84,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,361.35,,,361.35,Fee Schedule,,306.6,,,306.6,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,296.88,,,296.88,Other,New York Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,454.22,,,454.22,Other,153% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,415.63,,,415.63,Other,140% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,771.88,,,771.88,Other,260% Medicaid APG methodology,961.88,,,961.88,Other,324% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,371.1,,,371.1,Other,125% Medicaid APG methodology,127.14,1462.3,
X-RAYS BONE SURVEY INFANT       ,77076,CPT,,45002300,CDM,320,RC,,,both,,,1178,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,278.36,,,278.36,Fee Schedule,,250.18,,,250.18,Fee Schedule,,611.23,,,611.23,Fee Schedule,,549.94,,,549.94,Fee Schedule,,519.29,,,519.29,Fee Schedule,,589,50,,589,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,333.86,,,333.86,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,392.88,,,392.88,Fee Schedule,,730.36,,,730.36,Fee Schedule,,184.99,,,184.99,Fee Schedule,,392.88,,,392.88,Fee Schedule,,730.36,,,730.36,Fee Schedule,,347.96,,,347.96,Fee Schedule,,824.6,70,,824.6,percent of total billed charges,All Other,364.65,,,364.65,Fee Schedule,,309.4,,,309.4,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM OF FOOT 2V RT        ,73620,CPT,RT       ,45002532,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,80.2,,,80.2,Fee Schedule,,72.08,,,72.08,Fee Schedule,,180.94,,,180.94,Fee Schedule,,162.79,,,162.79,Fee Schedule,,153.72,,,153.72,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,96.19,,,96.19,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,113.19,,,113.19,Fee Schedule,,922.56,,,922.56,Fee Schedule,,53.3,,,53.3,Fee Schedule,,113.19,,,113.19,Fee Schedule,,922.56,,,922.56,Fee Schedule,,100.25,,,100.25,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,102.3,,,102.3,Fee Schedule,,86.8,,,86.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,53.3,1388,
X-RAY EXAM OF ELBOW 2V RT       ,73070,CPT,RT       ,45002540,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,80.2,,,80.2,Fee Schedule,,72.08,,,72.08,Fee Schedule,,190.34,,,190.34,Fee Schedule,,171.25,,,171.25,Fee Schedule,,161.71,,,161.71,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,96.19,,,96.19,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,113.19,,,113.19,Fee Schedule,,922.56,,,922.56,Fee Schedule,,53.3,,,53.3,Fee Schedule,,113.19,,,113.19,Fee Schedule,,922.56,,,922.56,Fee Schedule,,100.25,,,100.25,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,103.95,,,103.95,Fee Schedule,,88.2,,,88.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,53.3,1388,
X-RAY EXAM SI JOINTS 3/> VWS    ,72202,CPT,,45002557,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,107.5,,,107.5,Fee Schedule,,96.62,,,96.62,Fee Schedule,,234,,,234,Fee Schedule,,210.53,,,210.53,Fee Schedule,,198.8,,,198.8,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,128.94,,,128.94,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,151.73,,,151.73,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,71.44,,,71.44,Fee Schedule,,151.73,,,151.73,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,134.38,,,134.38,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,140.25,,,140.25,Fee Schedule,,119,,,119,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1462.3,
XR Fluoroscopy w/ Result <1 HR,76000,CPT,TC,45002615,CDM,320,RC,,,both,,,4342,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,103.71,,,103.71,Fee Schedule,,93.4,,,93.4,Fee Schedule,,2171,50,,2171,percent of total billed charges,All Other Outpatient,1953.9,45,,1953.9,percent of total billed charges,All Other Outpatient,1867.06,43,,1867.06,percent of total billed charges,All Other Outpatient,2171,50,,2171,percent of total billed charges,All Other,3039.4,70,,3039.4,percent of total billed charges,All Other,125.98,,,125.98,Fee Schedule,,552.19,,,552.19,Other,186% Medicaid methodology,148.25,,,148.25,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,69.8,,,69.8,Fee Schedule,,148.25,,,148.25,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,131.3,,,131.3,Fee Schedule,,3039.4,70,,3039.4,percent of total billed charges,All Other,136.95,,,136.95,Fee Schedule,,116.2,,,116.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,296.88,,,296.88,Other,New York Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,454.22,,,454.22,Other,153% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,415.63,,,415.63,Other,140% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,771.88,,,771.88,Other,260% Medicaid APG methodology,961.88,,,961.88,Other,324% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,371.1,,,371.1,Other,125% Medicaid APG methodology,69.8,3039.4,
XR Orbits Foreign Body Right,70030,CPT,TCRT,45002631,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,90.23,,,90.23,Fee Schedule,,81.27,,,81.27,Fee Schedule,,744,50,,744,percent of total billed charges,All Other Outpatient,669.6,45,,669.6,percent of total billed charges,All Other Outpatient,639.84,43,,639.84,percent of total billed charges,All Other Outpatient,744,50,,744,percent of total billed charges,All Other,1041.6,70,,1041.6,percent of total billed charges,All Other,109.61,,,109.61,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,128.98,,,128.98,Fee Schedule,,922.56,,,922.56,Fee Schedule,,60.73,,,60.73,Fee Schedule,,128.98,,,128.98,Fee Schedule,,922.56,,,922.56,Fee Schedule,,114.23,,,114.23,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,117.15,,,117.15,Fee Schedule,,99.4,,,99.4,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM OF ARM INFANT LT     ,73092,CPT,LT       ,45002730,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,90.12,,,90.12,Fee Schedule,,81,,,81,Fee Schedule,,209.01,,,209.01,Fee Schedule,,188.05,,,188.05,Fee Schedule,,177.57,,,177.57,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,108.09,,,108.09,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,127.2,,,127.2,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,59.89,,,59.89,Fee Schedule,,127.2,,,127.2,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,112.65,,,112.65,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,118.8,,,118.8,Fee Schedule,,100.8,,,100.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1462.3,
X-RAY EXAM OF ELBOW +3V LT      ,73080,CPT,LT       ,45002748,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,92.62,,,92.62,Fee Schedule,,83.24,,,83.24,Fee Schedule,,237.08,,,237.08,Fee Schedule,,213.31,,,213.31,Fee Schedule,,201.42,,,201.42,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,111.08,,,111.08,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,130.72,,,130.72,Fee Schedule,,922.56,,,922.56,Fee Schedule,,61.55,,,61.55,Fee Schedule,,130.72,,,130.72,Fee Schedule,,922.56,,,922.56,Fee Schedule,,115.77,,,115.77,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,118.8,,,118.8,Fee Schedule,,100.8,,,100.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
CONTRAST X-RAY OF HIP LT        ,73525,CPT,LT       ,45002755,CDM,320,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,376.96,,,376.96,Fee Schedule,,338.78,,,338.78,Fee Schedule,,667.31,,,667.31,Fee Schedule,,600.39,,,600.39,Fee Schedule,,566.93,,,566.93,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,452.11,,,452.11,Fee Schedule,,552.19,,,552.19,Other,186% Medicaid methodology,532.03,,,532.03,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,250.51,,,250.51,Fee Schedule,,532.03,,,532.03,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,471.2,,,471.2,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,529.65,,,529.65,Fee Schedule,,449.4,,,449.4,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,296.88,,,296.88,Other,New York Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,454.22,,,454.22,Other,153% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,415.63,,,415.63,Other,140% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,771.88,,,771.88,Other,260% Medicaid APG methodology,961.88,,,961.88,Other,324% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,371.1,,,371.1,Other,125% Medicaid APG methodology,250.51,4980.5,
KNEE ARTHOGRAPHY LT             ,73580,CPT,LT       ,45002771,CDM,320,RC,,,both,,,946,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,299.98,,,299.98,Fee Schedule,,269.6,,,269.6,Fee Schedule,,947.9,,,947.9,Fee Schedule,,852.85,,,852.85,Fee Schedule,,805.32,,,805.32,Fee Schedule,,473,50,,473,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,359.78,,,359.78,Fee Schedule,,552.19,,,552.19,Other,186% Medicaid methodology,423.39,,,423.39,Fee Schedule,,586.52,,,586.52,Fee Schedule,,199.35,,,199.35,Fee Schedule,,423.39,,,423.39,Fee Schedule,,586.52,,,586.52,Fee Schedule,,374.97,,,374.97,Fee Schedule,,662.2,70,,662.2,percent of total billed charges,All Other,598.95,,,598.95,Fee Schedule,,508.2,,,508.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,296.88,,,296.88,Other,New York Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,454.22,,,454.22,Other,153% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,415.63,,,415.63,Other,140% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,771.88,,,771.88,Other,260% Medicaid APG methodology,961.88,,,961.88,Other,324% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,371.1,,,371.1,Other,125% Medicaid APG methodology,199.35,1388,
X-RAY EXAM OF ELBOW 2V LT       ,73070,CPT,LT       ,45002789,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,80.2,,,80.2,Fee Schedule,,72.08,,,72.08,Fee Schedule,,190.34,,,190.34,Fee Schedule,,171.25,,,171.25,Fee Schedule,,161.71,,,161.71,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,96.19,,,96.19,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,113.19,,,113.19,Fee Schedule,,922.56,,,922.56,Fee Schedule,,53.3,,,53.3,Fee Schedule,,113.19,,,113.19,Fee Schedule,,922.56,,,922.56,Fee Schedule,,100.25,,,100.25,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,103.95,,,103.95,Fee Schedule,,88.2,,,88.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,53.3,1388,
X-RAY EXAM OF KNEE 1 OR 2 LT    ,73560,CPT,LT       ,45002797,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,98.81,,,98.81,Fee Schedule,,88.81,,,88.81,Fee Schedule,,196.59,,,196.59,Fee Schedule,,176.87,,,176.87,Fee Schedule,,167.02,,,167.02,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,118.51,,,118.51,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,139.46,,,139.46,Fee Schedule,,922.56,,,922.56,Fee Schedule,,65.67,,,65.67,Fee Schedule,,139.46,,,139.46,Fee Schedule,,922.56,,,922.56,Fee Schedule,,123.52,,,123.52,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,128.7,,,128.7,Fee Schedule,,109.2,,,109.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM OF ANKLE +3V LT      ,73610,CPT,LT       ,45002805,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,106.27,,,106.27,Fee Schedule,,95.51,,,95.51,Fee Schedule,,221.5,,,221.5,Fee Schedule,,199.29,,,199.29,Fee Schedule,,188.19,,,188.19,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,127.46,,,127.46,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,149.99,,,149.99,Fee Schedule,,922.56,,,922.56,Fee Schedule,,70.62,,,70.62,Fee Schedule,,149.99,,,149.99,Fee Schedule,,922.56,,,922.56,Fee Schedule,,132.84,,,132.84,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,140.25,,,140.25,Fee Schedule,,119,,,119,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM OF HUMERUS LT        ,73060,CPT,LT       ,45002821,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,91.39,,,91.39,Fee Schedule,,82.13,,,82.13,Fee Schedule,,190.34,,,190.34,Fee Schedule,,171.25,,,171.25,Fee Schedule,,161.71,,,161.71,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,109.61,,,109.61,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,128.98,,,128.98,Fee Schedule,,922.56,,,922.56,Fee Schedule,,60.73,,,60.73,Fee Schedule,,128.98,,,128.98,Fee Schedule,,922.56,,,922.56,Fee Schedule,,114.23,,,114.23,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,118.8,,,118.8,Fee Schedule,,100.8,,,100.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
CONTRAST X-RAY OF SHOULDER LT   ,73040,CPT,LT       ,45002839,CDM,320,RC,,,both,,,1217,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,393.1,,,393.1,Fee Schedule,,353.3,,,353.3,Fee Schedule,,742.12,,,742.12,Fee Schedule,,667.71,,,667.71,Fee Schedule,,630.5,,,630.5,Fee Schedule,,608.5,50,,608.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,471.48,,,471.48,Fee Schedule,,552.19,,,552.19,Other,186% Medicaid methodology,554.82,,,554.82,Fee Schedule,,754.54,,,754.54,Fee Schedule,,261.24,,,261.24,Fee Schedule,,554.82,,,554.82,Fee Schedule,,754.54,,,754.54,Fee Schedule,,491.38,,,491.38,Fee Schedule,,851.9,70,,851.9,percent of total billed charges,All Other,524.7,,,524.7,Fee Schedule,,445.2,,,445.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,296.88,,,296.88,Other,New York Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,454.22,,,454.22,Other,153% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,415.63,,,415.63,Other,140% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,771.88,,,771.88,Other,260% Medicaid APG methodology,961.88,,,961.88,Other,324% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,371.1,,,371.1,Other,125% Medicaid APG methodology,261.24,1388,
X-RAY EXAM OF FOREARM LT        ,73090,CPT,LT       ,45002847,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,81.43,,,81.43,Fee Schedule,,73.19,,,73.19,Fee Schedule,,184.1,,,184.1,Fee Schedule,,165.63,,,165.63,Fee Schedule,,156.4,,,156.4,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,97.67,,,97.67,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,114.93,,,114.93,Fee Schedule,,922.56,,,922.56,Fee Schedule,,54.12,,,54.12,Fee Schedule,,114.93,,,114.93,Fee Schedule,,922.56,,,922.56,Fee Schedule,,101.79,,,101.79,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,105.6,,,105.6,Fee Schedule,,89.6,,,89.6,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,54.12,1388,
X-RAY EXAM HIP UNI 2-3 VWS LT   ,73502,CPT,LT       ,45002854,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,138.57,,,138.57,Fee Schedule,,124.53,,,124.53,Fee Schedule,,29.42,,,29.42,Fee Schedule,,29.42,,,29.42,Fee Schedule,,29.42,,,29.42,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,166.19,,,166.19,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,195.57,,,195.57,Fee Schedule,,922.56,,,922.56,Fee Schedule,,92.09,,,92.09,Fee Schedule,,195.57,,,195.57,Fee Schedule,,922.56,,,922.56,Fee Schedule,,173.21,,,173.21,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,178.2,,,178.2,Fee Schedule,,151.2,,,151.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,29.42,1388,
X-RAY EXAM OF HEEL LT           ,73650,CPT,LT       ,45002862,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,78.97,,,78.97,Fee Schedule,,70.97,,,70.97,Fee Schedule,,184.1,,,184.1,Fee Schedule,,165.63,,,165.63,Fee Schedule,,156.4,,,156.4,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,94.71,,,94.71,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,111.46,,,111.46,Fee Schedule,,922.56,,,922.56,Fee Schedule,,52.48,,,52.48,Fee Schedule,,111.46,,,111.46,Fee Schedule,,922.56,,,922.56,Fee Schedule,,98.71,,,98.71,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,103.95,,,103.95,Fee Schedule,,88.2,,,88.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,52.48,1388,
X-RAY EXAM OF HAND +3V LT       ,73130,CPT,LT       ,45002912,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,108.77,,,108.77,Fee Schedule,,97.75,,,97.75,Fee Schedule,,218.34,,,218.34,Fee Schedule,,196.45,,,196.45,Fee Schedule,,185.5,,,185.5,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,130.45,,,130.45,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,153.51,,,153.51,Fee Schedule,,922.56,,,922.56,Fee Schedule,,72.28,,,72.28,Fee Schedule,,153.51,,,153.51,Fee Schedule,,922.56,,,922.56,Fee Schedule,,135.96,,,135.96,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,138.6,,,138.6,Fee Schedule,,117.6,,,117.6,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM OF FOOT +3V LT       ,73630,CPT,LT       ,45002920,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,98.81,,,98.81,Fee Schedule,,88.81,,,88.81,Fee Schedule,,215.26,,,215.26,Fee Schedule,,193.67,,,193.67,Fee Schedule,,182.88,,,182.88,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,118.51,,,118.51,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,139.46,,,139.46,Fee Schedule,,922.56,,,922.56,Fee Schedule,,65.67,,,65.67,Fee Schedule,,139.46,,,139.46,Fee Schedule,,922.56,,,922.56,Fee Schedule,,123.52,,,123.52,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,130.35,,,130.35,Fee Schedule,,110.6,,,110.6,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM OF HAND 2V LT        ,73120,CPT,LT       ,45002938,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,88.89,,,88.89,Fee Schedule,,79.89,,,79.89,Fee Schedule,,180.94,,,180.94,Fee Schedule,,162.79,,,162.79,Fee Schedule,,153.72,,,153.72,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,106.61,,,106.61,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,125.46,,,125.46,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,59.07,,,59.07,Fee Schedule,,125.46,,,125.46,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,111.11,,,111.11,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,113.85,,,113.85,Fee Schedule,,96.6,,,96.6,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.07,1462.3,
X-RAY EXAM KNEE 4 OR MORE LT    ,73564,CPT,LT       ,45002961,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,136.07,,,136.07,Fee Schedule,,122.29,,,122.29,Fee Schedule,,280.74,,,280.74,Fee Schedule,,252.59,,,252.59,Fee Schedule,,238.51,,,238.51,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,163.2,,,163.2,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,192.05,,,192.05,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,90.43,,,90.43,Fee Schedule,,192.05,,,192.05,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,170.09,,,170.09,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,174.9,,,174.9,Fee Schedule,,148.4,,,148.4,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1462.3,
X-RAY EXAM OF WRIST +3V LT      ,73110,CPT,LT       ,45002979,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,123.65,,,123.65,Fee Schedule,,111.13,,,111.13,Fee Schedule,,255.82,,,255.82,Fee Schedule,,230.17,,,230.17,Fee Schedule,,217.34,,,217.34,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,148.3,,,148.3,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,174.52,,,174.52,Fee Schedule,,922.56,,,922.56,Fee Schedule,,82.17,,,82.17,Fee Schedule,,174.52,,,174.52,Fee Schedule,,922.56,,,922.56,Fee Schedule,,154.56,,,154.56,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,160.05,,,160.05,Fee Schedule,,135.8,,,135.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM OF SHOULDER +2V LT   ,73030,CPT,LT       ,45002995,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,97.58,,,97.58,Fee Schedule,,87.7,,,87.7,Fee Schedule,,193.43,,,193.43,Fee Schedule,,174.03,,,174.03,Fee Schedule,,164.33,,,164.33,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,117.04,,,117.04,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,137.72,,,137.72,Fee Schedule,,922.56,,,922.56,Fee Schedule,,64.85,,,64.85,Fee Schedule,,137.72,,,137.72,Fee Schedule,,922.56,,,922.56,Fee Schedule,,121.98,,,121.98,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,125.4,,,125.4,Fee Schedule,,106.4,,,106.4,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM OF FOOT 2V LT        ,73620,CPT,LT       ,45003001,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,80.2,,,80.2,Fee Schedule,,72.08,,,72.08,Fee Schedule,,180.94,,,180.94,Fee Schedule,,162.79,,,162.79,Fee Schedule,,153.72,,,153.72,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,96.19,,,96.19,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,113.19,,,113.19,Fee Schedule,,922.56,,,922.56,Fee Schedule,,53.3,,,53.3,Fee Schedule,,113.19,,,113.19,Fee Schedule,,922.56,,,922.56,Fee Schedule,,100.25,,,100.25,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,102.3,,,102.3,Fee Schedule,,86.8,,,86.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,53.3,1388,
X-RAY EXAM OF LOWER LEG LT      ,73590,CPT,LT       ,45003027,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,90.12,,,90.12,Fee Schedule,,81,,,81,Fee Schedule,,177.85,,,177.85,Fee Schedule,,160.01,,,160.01,Fee Schedule,,151.1,,,151.1,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,108.09,,,108.09,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,127.2,,,127.2,Fee Schedule,,922.56,,,922.56,Fee Schedule,,59.89,,,59.89,Fee Schedule,,127.2,,,127.2,Fee Schedule,,922.56,,,922.56,Fee Schedule,,112.65,,,112.65,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,117.15,,,117.15,Fee Schedule,,99.4,,,99.4,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM OF FEMUR 2/> LT      ,73552,CPT,LT       ,45003035,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,101.31,,,101.31,Fee Schedule,,91.05,,,91.05,Fee Schedule,,22.84,,,22.84,Fee Schedule,,22.84,,,22.84,Fee Schedule,,22.84,,,22.84,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,121.51,,,121.51,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,142.99,,,142.99,Fee Schedule,,922.56,,,922.56,Fee Schedule,,67.33,,,67.33,Fee Schedule,,142.99,,,142.99,Fee Schedule,,922.56,,,922.56,Fee Schedule,,126.64,,,126.64,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,130.35,,,130.35,Fee Schedule,,110.6,,,110.6,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,22.84,1388,
X-RAY EXAM OF NECK              ,70360,CPT,,45003043,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,85.16,,,85.16,Fee Schedule,,76.54,,,76.54,Fee Schedule,,177.85,,,177.85,Fee Schedule,,160.01,,,160.01,Fee Schedule,,151.1,,,151.1,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,102.14,,,102.14,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,120.2,,,120.2,Fee Schedule,,922.56,,,922.56,Fee Schedule,,56.6,,,56.6,Fee Schedule,,120.2,,,120.2,Fee Schedule,,922.56,,,922.56,Fee Schedule,,106.45,,,106.45,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,112.2,,,112.2,Fee Schedule,,95.2,,,95.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,56.6,1388,
X-RAY EXAM OF LEG INFANT LT     ,73592,CPT,LT       ,45003050,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,90.12,,,90.12,Fee Schedule,,81,,,81,Fee Schedule,,212.17,,,212.17,Fee Schedule,,190.89,,,190.89,Fee Schedule,,180.26,,,180.26,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,108.09,,,108.09,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,127.2,,,127.2,Fee Schedule,,922.56,,,922.56,Fee Schedule,,59.89,,,59.89,Fee Schedule,,127.2,,,127.2,Fee Schedule,,922.56,,,922.56,Fee Schedule,,112.65,,,112.65,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,118.8,,,118.8,Fee Schedule,,100.8,,,100.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM SHOULDER BLADE LT    ,73010,CPT,LT       ,45003126,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,57.86,,,57.86,Fee Schedule,,52,,,52,Fee Schedule,,196.59,,,196.59,Fee Schedule,,176.87,,,176.87,Fee Schedule,,167.02,,,167.02,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,69.39,,,69.39,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,81.66,,,81.66,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,38.45,,,38.45,Fee Schedule,,81.66,,,81.66,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,72.32,,,72.32,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,74.25,,,74.25,Fee Schedule,,63,,,63,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,38.45,1462.3,
X-RAY EXAM SURGICAL SPECIMEN    ,76098,CPT,,45003555,CDM,320,RC,,,both,,,8973,1049.09,,,1049.09,Other,150% of Medicare + 9.63% HCRA Surcharge,637.96,,,637.96,Other,Medicare OPPS methodology,103.81,,,103.81,Fee Schedule,,93.29,,,93.29,Fee Schedule,,103.03,,,103.03,Fee Schedule,,92.7,,,92.7,Fee Schedule,,87.54,,,87.54,Fee Schedule,,4486.5,50,,4486.5,percent of total billed charges,All Other,1415.99,,,1415.99,Fee Schedule,,124.5,,,124.5,Fee Schedule,,552.19,,,552.19,Other,186% Medicaid methodology,146.51,,,146.51,Fee Schedule,,5563.26,,,5563.26,Fee Schedule,,68.99,,,68.99,Fee Schedule,,146.51,,,146.51,Fee Schedule,,5563.26,,,5563.26,Fee Schedule,,129.76,,,129.76,Fee Schedule,,6281.1,70,,6281.1,percent of total billed charges,All Other,125.4,,,125.4,Fee Schedule,,106.4,,,106.4,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,296.88,,,296.88,Other,New York Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,454.22,,,454.22,Other,153% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,415.63,,,415.63,Other,140% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,771.88,,,771.88,Other,260% Medicaid APG methodology,961.88,,,961.88,Other,324% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,371.1,,,371.1,Other,125% Medicaid APG methodology,68.99,6281.1,
XR Fluoro For Pain Management Special,77003,CPT,TC,45003746,CDM,320,RC,,,both,,,1993,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,283.92,,,283.92,Fee Schedule,,255.71,,,255.71,Fee Schedule,,996.5,50,,996.5,percent of total billed charges,All Other Outpatient,896.85,45,,896.85,percent of total billed charges,All Other Outpatient,856.99,43,,856.99,percent of total billed charges,All Other Outpatient,996.5,50,,996.5,percent of total billed charges,All Other,1395.1,70,,1395.1,percent of total billed charges,All Other,344.89,,,344.89,Fee Schedule,,751.06,,,751.06,Other,186% Medicaid methodology,405.86,,,405.86,Fee Schedule,,1235.66,,,1235.66,Fee Schedule,,191.1,,,191.1,Fee Schedule,,405.86,,,405.86,Fee Schedule,,1235.66,,,1235.66,Fee Schedule,,359.45,,,359.45,Fee Schedule,,1395.1,70,,1395.1,percent of total billed charges,All Other,381.15,,,381.15,Fee Schedule,,323.4,,,323.4,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,403.79,,,403.79,Other,New York Medicaid APG methodology,403.79,,,403.79,Other,100% Medicaid APG methodology,403.79,,,403.79,Other,100% Medicaid APG methodology,403.79,,,403.79,Other,100% Medicaid APG methodology,908.54,,,908.54,Other,225% Medicaid APG methodology,908.54,,,908.54,Other,225% Medicaid APG methodology,617.81,,,617.81,Other,153% Medicaid APG methodology,908.54,,,908.54,Other,225% Medicaid APG methodology,565.31,,,565.31,Other,140% Medicaid APG methodology,908.54,,,908.54,Other,225% Medicaid APG methodology,1049.87,,,1049.87,Other,260% Medicaid APG methodology,1308.29,,,1308.29,Other,324% Medicaid APG methodology,868.16,,,868.16,Other,215% Medicaid APG methodology,868.16,,,868.16,Other,215% Medicaid APG methodology,504.74,,,504.74,Other,125% Medicaid APG methodology,0.01,1395.1,
XR Spine Thoracic 3 Views,72072,CPT,TC,45004017,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,107.39,,,107.39,Fee Schedule,,96.72,,,96.72,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other Outpatient,940.05,45,,940.05,percent of total billed charges,All Other Outpatient,898.27,43,,898.27,percent of total billed charges,All Other Outpatient,1044.5,50,,1044.5,percent of total billed charges,All Other,1462.3,70,,1462.3,percent of total billed charges,All Other,130.45,,,130.45,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,153.51,,,153.51,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,72.28,,,72.28,Fee Schedule,,153.51,,,153.51,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,135.96,,,135.96,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,140.25,,,140.25,Fee Schedule,,119,,,119,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1462.3,
X-RAY EXAM COMPLETE ABDOMEN     ,74022,CPT,,45004181,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,131.11,,,131.11,Fee Schedule,,117.83,,,117.83,Fee Schedule,,302.57,,,302.57,Fee Schedule,,272.22,,,272.22,Fee Schedule,,257.05,,,257.05,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,157.25,,,157.25,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,185.05,,,185.05,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,87.13,,,87.13,Fee Schedule,,185.05,,,185.05,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,163.89,,,163.89,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,171.6,,,171.6,Fee Schedule,,145.6,,,145.6,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1462.3,
X-RAY EXAM OF FINGER(S) RT FY   ,73140,CPT,,45004355,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,118.69,,,118.69,Fee Schedule,,106.67,,,106.67,Fee Schedule,,227.75,,,227.75,Fee Schedule,,204.91,,,204.91,Fee Schedule,,193.49,,,193.49,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,142.35,,,142.35,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,167.52,,,167.52,Fee Schedule,,922.56,,,922.56,Fee Schedule,,78.88,,,78.88,Fee Schedule,,167.52,,,167.52,Fee Schedule,,922.56,,,922.56,Fee Schedule,,148.36,,,148.36,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,151.8,,,151.8,Fee Schedule,,128.8,,,128.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM OF TOE(S)            ,73660,CPT,,45004512,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,86.43,,,86.43,Fee Schedule,,77.67,,,77.67,Fee Schedule,,212.17,,,212.17,Fee Schedule,,190.89,,,190.89,Fee Schedule,,180.26,,,180.26,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,103.66,,,103.66,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,121.98,,,121.98,Fee Schedule,,922.56,,,922.56,Fee Schedule,,57.44,,,57.44,Fee Schedule,,121.98,,,121.98,Fee Schedule,,922.56,,,922.56,Fee Schedule,,108.03,,,108.03,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,112.2,,,112.2,Fee Schedule,,95.2,,,95.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,57.44,1388,
XR Orbits Foreign Body Left,70030,CPT,TCLT,45004678,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,90.23,,,90.23,Fee Schedule,,81.27,,,81.27,Fee Schedule,,744,50,,744,percent of total billed charges,All Other Outpatient,669.6,45,,669.6,percent of total billed charges,All Other Outpatient,639.84,43,,639.84,percent of total billed charges,All Other Outpatient,744,50,,744,percent of total billed charges,All Other,1041.6,70,,1041.6,percent of total billed charges,All Other,109.61,,,109.61,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,128.98,,,128.98,Fee Schedule,,922.56,,,922.56,Fee Schedule,,60.73,,,60.73,Fee Schedule,,128.98,,,128.98,Fee Schedule,,922.56,,,922.56,Fee Schedule,,114.23,,,114.23,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,117.15,,,117.15,Fee Schedule,,99.4,,,99.4,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
XR Mastoids Complete,70130,CPT,TC,45004710,CDM,320,RC,,,both,,,1178,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,169.92,,,169.92,Fee Schedule,,153.03,,,153.03,Fee Schedule,,589,50,,589,percent of total billed charges,All Other Outpatient,530.1,45,,530.1,percent of total billed charges,All Other Outpatient,506.54,43,,506.54,percent of total billed charges,All Other Outpatient,589,50,,589,percent of total billed charges,All Other,824.6,70,,824.6,percent of total billed charges,All Other,206.4,,,206.4,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,242.89,,,242.89,Fee Schedule,,730.36,,,730.36,Fee Schedule,,114.37,,,114.37,Fee Schedule,,242.89,,,242.89,Fee Schedule,,730.36,,,730.36,Fee Schedule,,215.12,,,215.12,Fee Schedule,,824.6,70,,824.6,percent of total billed charges,All Other,229.35,,,229.35,Fee Schedule,,194.6,,,194.6,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
XR Optic Foramina Left,70190,CPT,TCLT,45004736,CDM,320,RC,,,both,,,399,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,100.03,,,100.03,Fee Schedule,,90.09,,,90.09,Fee Schedule,,199.5,50,,199.5,percent of total billed charges,All Other Outpatient,179.55,45,,179.55,percent of total billed charges,All Other Outpatient,171.57,43,,171.57,percent of total billed charges,All Other Outpatient,199.5,50,,199.5,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,121.51,,,121.51,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,142.99,,,142.99,Fee Schedule,,247.38,,,247.38,Fee Schedule,,67.33,,,67.33,Fee Schedule,,142.99,,,142.99,Fee Schedule,,247.38,,,247.38,Fee Schedule,,126.64,,,126.64,Fee Schedule,,279.3,70,,279.3,percent of total billed charges,All Other,135.3,,,135.3,Fee Schedule,,114.8,,,114.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
XR Optic Foramina Bilateral,70190,CPT,TC50,45004744,CDM,320,RC,,,both,,,399,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,100.03,,,100.03,Fee Schedule,,90.09,,,90.09,Fee Schedule,,199.5,50,,199.5,percent of total billed charges,All Other Outpatient,179.55,45,,179.55,percent of total billed charges,All Other Outpatient,171.57,43,,171.57,percent of total billed charges,All Other Outpatient,199.5,50,,199.5,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,121.51,,,121.51,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,142.99,,,142.99,Fee Schedule,,247.38,,,247.38,Fee Schedule,,67.33,,,67.33,Fee Schedule,,142.99,,,142.99,Fee Schedule,,247.38,,,247.38,Fee Schedule,,126.64,,,126.64,Fee Schedule,,279.3,70,,279.3,percent of total billed charges,All Other,135.3,,,135.3,Fee Schedule,,114.8,,,114.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAYS BONE LENGTH STUDIES      ,77073,CPT,,45005279,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,121.19,,,121.19,Fee Schedule,,108.91,,,108.91,Fee Schedule,,224.59,,,224.59,Fee Schedule,,202.07,,,202.07,Fee Schedule,,190.81,,,190.81,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,145.35,,,145.35,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,171.04,,,171.04,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,80.54,,,80.54,Fee Schedule,,171.04,,,171.04,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,151.48,,,151.48,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,158.4,,,158.4,Fee Schedule,,134.4,,,134.4,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1462.3,
X-RAY BEND ONLY L-S SPINE       ,72120,CPT,,45005469,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,112.5,,,112.5,Fee Schedule,,101.1,,,101.1,Fee Schedule,,368.05,,,368.05,Fee Schedule,,331.14,,,331.14,Fee Schedule,,312.69,,,312.69,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,134.92,,,134.92,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,158.78,,,158.78,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,74.76,,,74.76,Fee Schedule,,158.78,,,158.78,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,140.62,,,140.62,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,148.5,,,148.5,Fee Schedule,,126,,,126,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1462.3,
DXA BONE DENSITY AXIAL          ,77080,CPT,,45005568,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,111.23,,,111.23,Fee Schedule,,99.97,,,99.97,Fee Schedule,,796.84,,,796.84,Fee Schedule,,716.93,,,716.93,Fee Schedule,,676.98,,,676.98,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,133.41,,,133.41,Fee Schedule,,370.65,,,370.65,Other,186% Medicaid methodology,156.99,,,156.99,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,73.92,,,73.92,Fee Schedule,,156.99,,,156.99,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,139.04,,,139.04,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,135.3,,,135.3,Fee Schedule,,114.8,,,114.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,199.27,,,199.27,Other,New York Medicaid APG methodology,199.27,,,199.27,Other,100% Medicaid APG methodology,199.27,,,199.27,Other,100% Medicaid APG methodology,199.27,,,199.27,Other,100% Medicaid APG methodology,448.36,,,448.36,Other,225% Medicaid APG methodology,448.36,,,448.36,Other,225% Medicaid APG methodology,304.89,,,304.89,Other,153% Medicaid APG methodology,448.36,,,448.36,Other,225% Medicaid APG methodology,278.98,,,278.98,Other,140% Medicaid APG methodology,448.36,,,448.36,Other,225% Medicaid APG methodology,518.11,,,518.11,Other,260% Medicaid APG methodology,645.64,,,645.64,Other,324% Medicaid APG methodology,428.43,,,428.43,Other,215% Medicaid APG methodology,428.43,,,428.43,Other,215% Medicaid APG methodology,249.09,,,249.09,Other,125% Medicaid APG methodology,73.92,1462.3,
X-RAY EXAM OF FEMUR 1 RT        ,73551,CPT,RT       ,45005592,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,80.2,,,80.2,Fee Schedule,,72.08,,,72.08,Fee Schedule,,19.04,,,19.04,Fee Schedule,,19.04,,,19.04,Fee Schedule,,19.04,,,19.04,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,96.19,,,96.19,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,113.19,,,113.19,Fee Schedule,,922.56,,,922.56,Fee Schedule,,53.3,,,53.3,Fee Schedule,,113.19,,,113.19,Fee Schedule,,922.56,,,922.56,Fee Schedule,,100.25,,,100.25,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,103.95,,,103.95,Fee Schedule,,88.2,,,88.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,19.04,1388,
X-RAY EXAM OF FEMUR 1 LT        ,73551,CPT,LT       ,45005600,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,80.2,,,80.2,Fee Schedule,,72.08,,,72.08,Fee Schedule,,19.04,,,19.04,Fee Schedule,,19.04,,,19.04,Fee Schedule,,19.04,,,19.04,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,96.19,,,96.19,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,113.19,,,113.19,Fee Schedule,,922.56,,,922.56,Fee Schedule,,53.3,,,53.3,Fee Schedule,,113.19,,,113.19,Fee Schedule,,922.56,,,922.56,Fee Schedule,,100.25,,,100.25,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,103.95,,,103.95,Fee Schedule,,88.2,,,88.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,19.04,1388,
X-RAY EXAM HIP UNI 4/> VWS RT   ,73503,CPT,RT       ,45005642,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,175.82,,,175.82,Fee Schedule,,158.02,,,158.02,Fee Schedule,,36.34,,,36.34,Fee Schedule,,36.34,,,36.34,Fee Schedule,,36.34,,,36.34,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,210.88,,,210.88,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,248.15,,,248.15,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,116.84,,,116.84,Fee Schedule,,248.15,,,248.15,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,219.78,,,219.78,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,226.05,,,226.05,Fee Schedule,,191.8,,,191.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,36.34,1462.3,
X-RAY EXAM HIP UNI 4/> VWS LT   ,73503,CPT,LT       ,45005667,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,175.82,,,175.82,Fee Schedule,,158.02,,,158.02,Fee Schedule,,36.34,,,36.34,Fee Schedule,,36.34,,,36.34,Fee Schedule,,36.34,,,36.34,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,210.88,,,210.88,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,248.15,,,248.15,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,116.84,,,116.84,Fee Schedule,,248.15,,,248.15,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,219.78,,,219.78,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,226.05,,,226.05,Fee Schedule,,191.8,,,191.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,36.34,1462.3,
XR Orbits Foreign Body Bilateral,70030,CPT,TC50,45005686,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,90.23,,,90.23,Fee Schedule,,81.27,,,81.27,Fee Schedule,,744,50,,744,percent of total billed charges,All Other Outpatient,669.6,45,,669.6,percent of total billed charges,All Other Outpatient,639.84,43,,639.84,percent of total billed charges,All Other Outpatient,744,50,,744,percent of total billed charges,All Other,1041.6,70,,1041.6,percent of total billed charges,All Other,109.61,,,109.61,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,128.98,,,128.98,Fee Schedule,,922.56,,,922.56,Fee Schedule,,60.73,,,60.73,Fee Schedule,,128.98,,,128.98,Fee Schedule,,922.56,,,922.56,Fee Schedule,,114.23,,,114.23,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,117.15,,,117.15,Fee Schedule,,99.4,,,99.4,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
X-RAY EXAM HIP UNI 1 VIEW LT    ,73501,CPT,LT       ,45005717,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,90.12,,,90.12,Fee Schedule,,81,,,81,Fee Schedule,,20.07,,,20.07,Fee Schedule,,20.07,,,20.07,Fee Schedule,,20.07,,,20.07,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,108.09,,,108.09,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,127.2,,,127.2,Fee Schedule,,922.56,,,922.56,Fee Schedule,,59.89,,,59.89,Fee Schedule,,127.2,,,127.2,Fee Schedule,,922.56,,,922.56,Fee Schedule,,112.65,,,112.65,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,115.5,,,115.5,Fee Schedule,,98,,,98,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,20.07,1388,
X-RAY EXAM ENTIRE SPI 2/3 VW    ,72082,CPT,,45005741,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,206.85,,,206.85,Fee Schedule,,185.91,,,185.91,Fee Schedule,,44.99,,,44.99,Fee Schedule,,44.99,,,44.99,Fee Schedule,,44.99,,,44.99,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,248.09,,,248.09,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,291.95,,,291.95,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,137.47,,,137.47,Fee Schedule,,291.95,,,291.95,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,258.57,,,258.57,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,272.25,,,272.25,Fee Schedule,,231,,,231,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,44.99,1462.3,
X-RAY EXAM ABDOMEN 2 VIEWS      ,74019,CPT,,45005808,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,97.58,,,97.58,Fee Schedule,,87.7,,,87.7,Fee Schedule,,20.47,,,20.47,Fee Schedule,,20.47,,,20.47,Fee Schedule,,20.47,,,20.47,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,117.04,,,117.04,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,137.72,,,137.72,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,64.85,,,64.85,Fee Schedule,,137.72,,,137.72,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,121.98,,,121.98,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,127.05,,,127.05,Fee Schedule,,107.8,,,107.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,20.47,1462.3,
MYELOGRAPHY LUMBAR INJ 2+ REG   ,62305,CPT,,45005907,CDM,320,RC,,,both,,,9142,1522.61,,,1522.61,Other,150% of Medicare + 9.63% HCRA Surcharge,925.91,,,925.91,Other,Medicare OPPS methodology,424.91,,,424.91,Fee Schedule,,382.69,,,382.69,Fee Schedule,,4571,50,,4571,percent of total billed charges,All Other Outpatient,4113.9,45,,4113.9,percent of total billed charges,All Other Outpatient,3931.06,43,,3931.06,percent of total billed charges,All Other Outpatient,4571,50,,4571,percent of total billed charges,All Other,6399.4,70,,6399.4,percent of total billed charges,All Other,516.16,,,516.16,Fee Schedule,,1235,,,1235,Other,186% Medicaid methodology,607.41,,,607.41,Fee Schedule,,5668.04,,,5668.04,Fee Schedule,,286,,,286,Fee Schedule,,607.41,,,607.41,Fee Schedule,,5668.04,,,5668.04,Fee Schedule,,537.95,,,537.95,Fee Schedule,,6399.4,70,,6399.4,percent of total billed charges,All Other,592.35,,,592.35,Fee Schedule,,502.6,,,502.6,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,663.98,,,663.98,Other,New York Medicaid APG methodology,663.98,,,663.98,Other,100% Medicaid APG methodology,663.98,,,663.98,Other,100% Medicaid APG methodology,663.98,,,663.98,Other,100% Medicaid APG methodology,1493.95,,,1493.95,Other,225% Medicaid APG methodology,1493.95,,,1493.95,Other,225% Medicaid APG methodology,1015.89,,,1015.89,Other,153% Medicaid APG methodology,1493.95,,,1493.95,Other,225% Medicaid APG methodology,929.57,,,929.57,Other,140% Medicaid APG methodology,1493.95,,,1493.95,Other,225% Medicaid APG methodology,1726.34,,,1726.34,Other,260% Medicaid APG methodology,2151.29,,,2151.29,Other,324% Medicaid APG methodology,1427.55,,,1427.55,Other,215% Medicaid APG methodology,1427.55,,,1427.55,Other,215% Medicaid APG methodology,829.97,,,829.97,Other,125% Medicaid APG methodology,286,6399.4,
MYELOGRAPHY LUMBAR INJ LMBSCRL  ,62304,CPT,,45005915,CDM,320,RC,,,both,,,9872,1522.61,,,1522.61,Other,150% of Medicare + 9.63% HCRA Surcharge,925.91,,,925.91,Other,Medicare OPPS methodology,410.34,,,410.34,Fee Schedule,,369.57,,,369.57,Fee Schedule,,4936,50,,4936,percent of total billed charges,All Other Outpatient,4442.4,45,,4442.4,percent of total billed charges,All Other Outpatient,4244.96,43,,4244.96,percent of total billed charges,All Other Outpatient,4936,50,,4936,percent of total billed charges,All Other,6910.4,70,,6910.4,percent of total billed charges,All Other,498.46,,,498.46,Fee Schedule,,1235,,,1235,Other,186% Medicaid methodology,586.58,,,586.58,Fee Schedule,,6120.64,,,6120.64,Fee Schedule,,276.19,,,276.19,Fee Schedule,,586.58,,,586.58,Fee Schedule,,6120.64,,,6120.64,Fee Schedule,,519.5,,,519.5,Fee Schedule,,6910.4,70,,6910.4,percent of total billed charges,All Other,567.6,,,567.6,Fee Schedule,,481.6,,,481.6,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,663.98,,,663.98,Other,New York Medicaid APG methodology,663.98,,,663.98,Other,100% Medicaid APG methodology,663.98,,,663.98,Other,100% Medicaid APG methodology,663.98,,,663.98,Other,100% Medicaid APG methodology,1493.95,,,1493.95,Other,225% Medicaid APG methodology,1493.95,,,1493.95,Other,225% Medicaid APG methodology,1015.89,,,1015.89,Other,153% Medicaid APG methodology,1493.95,,,1493.95,Other,225% Medicaid APG methodology,929.57,,,929.57,Other,140% Medicaid APG methodology,1493.95,,,1493.95,Other,225% Medicaid APG methodology,1726.34,,,1726.34,Other,260% Medicaid APG methodology,2151.29,,,2151.29,Other,324% Medicaid APG methodology,1427.55,,,1427.55,Other,215% Medicaid APG methodology,1427.55,,,1427.55,Other,215% Medicaid APG methodology,829.97,,,829.97,Other,125% Medicaid APG methodology,276.19,6910.4,
MYELOGRAPHY LUMBAR INJECTION    ,62303,CPT,,45005923,CDM,320,RC,,,both,,,8310,1522.61,,,1522.61,Other,150% of Medicare + 9.63% HCRA Surcharge,925.91,,,925.91,Other,Medicare OPPS methodology,413.96,,,413.96,Fee Schedule,,372.83,,,372.83,Fee Schedule,,4155,50,,4155,percent of total billed charges,All Other Outpatient,3739.5,45,,3739.5,percent of total billed charges,All Other Outpatient,3573.3,43,,3573.3,percent of total billed charges,All Other Outpatient,4155,50,,4155,percent of total billed charges,All Other,5817,70,,5817,percent of total billed charges,All Other,502.86,,,502.86,Fee Schedule,,1235,,,1235,Other,186% Medicaid methodology,591.75,,,591.75,Fee Schedule,,5152.2,,,5152.2,Fee Schedule,,278.63,,,278.63,Fee Schedule,,591.75,,,591.75,Fee Schedule,,5152.2,,,5152.2,Fee Schedule,,524.09,,,524.09,Fee Schedule,,5817,70,,5817,percent of total billed charges,All Other,577.5,,,577.5,Fee Schedule,,490,,,490,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,663.98,,,663.98,Other,New York Medicaid APG methodology,663.98,,,663.98,Other,100% Medicaid APG methodology,663.98,,,663.98,Other,100% Medicaid APG methodology,663.98,,,663.98,Other,100% Medicaid APG methodology,1493.95,,,1493.95,Other,225% Medicaid APG methodology,1493.95,,,1493.95,Other,225% Medicaid APG methodology,1015.89,,,1015.89,Other,153% Medicaid APG methodology,1493.95,,,1493.95,Other,225% Medicaid APG methodology,929.57,,,929.57,Other,140% Medicaid APG methodology,1493.95,,,1493.95,Other,225% Medicaid APG methodology,1726.34,,,1726.34,Other,260% Medicaid APG methodology,2151.29,,,2151.29,Other,324% Medicaid APG methodology,1427.55,,,1427.55,Other,215% Medicaid APG methodology,1427.55,,,1427.55,Other,215% Medicaid APG methodology,829.97,,,829.97,Other,125% Medicaid APG methodology,278.63,5817,
MYELOGRAPHY LUMBAR INJECTION    ,62302,CPT,,45005931,CDM,320,RC,,,both,,,9058,1522.61,,,1522.61,Other,150% of Medicare + 9.63% HCRA Surcharge,925.91,,,925.91,Other,Medicare OPPS methodology,414.71,,,414.71,Fee Schedule,,373.51,,,373.51,Fee Schedule,,4529,50,,4529,percent of total billed charges,All Other Outpatient,4076.1,45,,4076.1,percent of total billed charges,All Other Outpatient,3894.94,43,,3894.94,percent of total billed charges,All Other Outpatient,4529,50,,4529,percent of total billed charges,All Other,6340.6,70,,6340.6,percent of total billed charges,All Other,503.77,,,503.77,Fee Schedule,,1235,,,1235,Other,186% Medicaid methodology,592.82,,,592.82,Fee Schedule,,5615.96,,,5615.96,Fee Schedule,,279.13,,,279.13,Fee Schedule,,592.82,,,592.82,Fee Schedule,,5615.96,,,5615.96,Fee Schedule,,525.03,,,525.03,Fee Schedule,,6340.6,70,,6340.6,percent of total billed charges,All Other,575.85,,,575.85,Fee Schedule,,488.6,,,488.6,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,663.98,,,663.98,Other,New York Medicaid APG methodology,663.98,,,663.98,Other,100% Medicaid APG methodology,663.98,,,663.98,Other,100% Medicaid APG methodology,663.98,,,663.98,Other,100% Medicaid APG methodology,1493.95,,,1493.95,Other,225% Medicaid APG methodology,1493.95,,,1493.95,Other,225% Medicaid APG methodology,1015.89,,,1015.89,Other,153% Medicaid APG methodology,1493.95,,,1493.95,Other,225% Medicaid APG methodology,929.57,,,929.57,Other,140% Medicaid APG methodology,1493.95,,,1493.95,Other,225% Medicaid APG methodology,1726.34,,,1726.34,Other,260% Medicaid APG methodology,2151.29,,,2151.29,Other,324% Medicaid APG methodology,1427.55,,,1427.55,Other,215% Medicaid APG methodology,1427.55,,,1427.55,Other,215% Medicaid APG methodology,829.97,,,829.97,Other,125% Medicaid APG methodology,279.13,6340.6,
XR Ankle 1 View Left,73600,CPT,TC52,45006236,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,91.45,,,91.45,Fee Schedule,,82.36,,,82.36,Fee Schedule,,744,50,,744,percent of total billed charges,All Other Outpatient,669.6,45,,669.6,percent of total billed charges,All Other Outpatient,639.84,43,,639.84,percent of total billed charges,All Other Outpatient,744,50,,744,percent of total billed charges,All Other,1041.6,70,,1041.6,percent of total billed charges,All Other,111.08,,,111.08,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,130.72,,,130.72,Fee Schedule,,922.56,,,922.56,Fee Schedule,,61.55,,,61.55,Fee Schedule,,130.72,,,130.72,Fee Schedule,,922.56,,,922.56,Fee Schedule,,115.77,,,115.77,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,120.45,,,120.45,Fee Schedule,,102.2,,,102.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
XR Ankle 1 View Right,73600,CPT,TC52,45006244,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,91.45,,,91.45,Fee Schedule,,82.36,,,82.36,Fee Schedule,,744,50,,744,percent of total billed charges,All Other Outpatient,669.6,45,,669.6,percent of total billed charges,All Other Outpatient,639.84,43,,639.84,percent of total billed charges,All Other Outpatient,744,50,,744,percent of total billed charges,All Other,1041.6,70,,1041.6,percent of total billed charges,All Other,111.08,,,111.08,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,130.72,,,130.72,Fee Schedule,,922.56,,,922.56,Fee Schedule,,61.55,,,61.55,Fee Schedule,,130.72,,,130.72,Fee Schedule,,922.56,,,922.56,Fee Schedule,,115.77,,,115.77,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,120.45,,,120.45,Fee Schedule,,102.2,,,102.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
XR Elbow 1 View Left,73070,CPT,TC52,45006277,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,79.19,,,79.19,Fee Schedule,,71.32,,,71.32,Fee Schedule,,744,50,,744,percent of total billed charges,All Other Outpatient,669.6,45,,669.6,percent of total billed charges,All Other Outpatient,639.84,43,,639.84,percent of total billed charges,All Other Outpatient,744,50,,744,percent of total billed charges,All Other,1041.6,70,,1041.6,percent of total billed charges,All Other,96.19,,,96.19,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,113.19,,,113.19,Fee Schedule,,922.56,,,922.56,Fee Schedule,,53.3,,,53.3,Fee Schedule,,113.19,,,113.19,Fee Schedule,,922.56,,,922.56,Fee Schedule,,100.25,,,100.25,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,103.95,,,103.95,Fee Schedule,,88.2,,,88.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,53.3,1388,
XR Elbow 1 View Right,73070,CPT,TC52,45006285,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,79.19,,,79.19,Fee Schedule,,71.32,,,71.32,Fee Schedule,,744,50,,744,percent of total billed charges,All Other Outpatient,669.6,45,,669.6,percent of total billed charges,All Other Outpatient,639.84,43,,639.84,percent of total billed charges,All Other Outpatient,744,50,,744,percent of total billed charges,All Other,1041.6,70,,1041.6,percent of total billed charges,All Other,96.19,,,96.19,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,113.19,,,113.19,Fee Schedule,,922.56,,,922.56,Fee Schedule,,53.3,,,53.3,Fee Schedule,,113.19,,,113.19,Fee Schedule,,922.56,,,922.56,Fee Schedule,,100.25,,,100.25,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,103.95,,,103.95,Fee Schedule,,88.2,,,88.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,53.3,1388,
XR Finger(2nd Digit) 2+ Views Left,73140,CPT,TCLT,45006293,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,117.19,,,117.19,Fee Schedule,,105.54,,,105.54,Fee Schedule,,744,50,,744,percent of total billed charges,All Other Outpatient,669.6,45,,669.6,percent of total billed charges,All Other Outpatient,639.84,43,,639.84,percent of total billed charges,All Other Outpatient,744,50,,744,percent of total billed charges,All Other,1041.6,70,,1041.6,percent of total billed charges,All Other,142.35,,,142.35,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,167.52,,,167.52,Fee Schedule,,922.56,,,922.56,Fee Schedule,,78.88,,,78.88,Fee Schedule,,167.52,,,167.52,Fee Schedule,,922.56,,,922.56,Fee Schedule,,148.36,,,148.36,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,151.8,,,151.8,Fee Schedule,,128.8,,,128.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
XR Finger(3rd Digit) 2+ Views Left,73140,CPT,TCLT,45006301,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,117.19,,,117.19,Fee Schedule,,105.54,,,105.54,Fee Schedule,,744,50,,744,percent of total billed charges,All Other Outpatient,669.6,45,,669.6,percent of total billed charges,All Other Outpatient,639.84,43,,639.84,percent of total billed charges,All Other Outpatient,744,50,,744,percent of total billed charges,All Other,1041.6,70,,1041.6,percent of total billed charges,All Other,142.35,,,142.35,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,167.52,,,167.52,Fee Schedule,,922.56,,,922.56,Fee Schedule,,78.88,,,78.88,Fee Schedule,,167.52,,,167.52,Fee Schedule,,922.56,,,922.56,Fee Schedule,,148.36,,,148.36,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,151.8,,,151.8,Fee Schedule,,128.8,,,128.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
XR Finger(4th Digit) 2+ Views Left,73140,CPT,TCLT,45006319,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,117.19,,,117.19,Fee Schedule,,105.54,,,105.54,Fee Schedule,,744,50,,744,percent of total billed charges,All Other Outpatient,669.6,45,,669.6,percent of total billed charges,All Other Outpatient,639.84,43,,639.84,percent of total billed charges,All Other Outpatient,744,50,,744,percent of total billed charges,All Other,1041.6,70,,1041.6,percent of total billed charges,All Other,142.35,,,142.35,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,167.52,,,167.52,Fee Schedule,,922.56,,,922.56,Fee Schedule,,78.88,,,78.88,Fee Schedule,,167.52,,,167.52,Fee Schedule,,922.56,,,922.56,Fee Schedule,,148.36,,,148.36,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,151.8,,,151.8,Fee Schedule,,128.8,,,128.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
XR Finger(5th Digit) 2+ Views Left,73140,CPT,TCLT,45006327,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,117.19,,,117.19,Fee Schedule,,105.54,,,105.54,Fee Schedule,,744,50,,744,percent of total billed charges,All Other Outpatient,669.6,45,,669.6,percent of total billed charges,All Other Outpatient,639.84,43,,639.84,percent of total billed charges,All Other Outpatient,744,50,,744,percent of total billed charges,All Other,1041.6,70,,1041.6,percent of total billed charges,All Other,142.35,,,142.35,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,167.52,,,167.52,Fee Schedule,,922.56,,,922.56,Fee Schedule,,78.88,,,78.88,Fee Schedule,,167.52,,,167.52,Fee Schedule,,922.56,,,922.56,Fee Schedule,,148.36,,,148.36,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,151.8,,,151.8,Fee Schedule,,128.8,,,128.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
XR Forearm 1 View Left,73090,CPT,TC52,45006335,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,80.4,,,80.4,Fee Schedule,,72.41,,,72.41,Fee Schedule,,744,50,,744,percent of total billed charges,All Other Outpatient,669.6,45,,669.6,percent of total billed charges,All Other Outpatient,639.84,43,,639.84,percent of total billed charges,All Other Outpatient,744,50,,744,percent of total billed charges,All Other,1041.6,70,,1041.6,percent of total billed charges,All Other,97.67,,,97.67,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,114.93,,,114.93,Fee Schedule,,922.56,,,922.56,Fee Schedule,,54.12,,,54.12,Fee Schedule,,114.93,,,114.93,Fee Schedule,,922.56,,,922.56,Fee Schedule,,101.79,,,101.79,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,105.6,,,105.6,Fee Schedule,,89.6,,,89.6,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,54.12,1388,
XR Forearm 1 View Right,73090,CPT,TC52,45006343,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,80.4,,,80.4,Fee Schedule,,72.41,,,72.41,Fee Schedule,,744,50,,744,percent of total billed charges,All Other Outpatient,669.6,45,,669.6,percent of total billed charges,All Other Outpatient,639.84,43,,639.84,percent of total billed charges,All Other Outpatient,744,50,,744,percent of total billed charges,All Other,1041.6,70,,1041.6,percent of total billed charges,All Other,97.67,,,97.67,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,114.93,,,114.93,Fee Schedule,,922.56,,,922.56,Fee Schedule,,54.12,,,54.12,Fee Schedule,,114.93,,,114.93,Fee Schedule,,922.56,,,922.56,Fee Schedule,,101.79,,,101.79,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,105.6,,,105.6,Fee Schedule,,89.6,,,89.6,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,54.12,1388,
X-RAY EXAM OF HAND 1V LT RED    ,73120,CPT,LT52     ,45006350,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,88.89,,,88.89,Fee Schedule,,79.89,,,79.89,Fee Schedule,,180.94,,,180.94,Fee Schedule,,162.79,,,162.79,Fee Schedule,,153.72,,,153.72,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,106.61,,,106.61,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,125.46,,,125.46,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,59.07,,,59.07,Fee Schedule,,125.46,,,125.46,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,111.11,,,111.11,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,113.85,,,113.85,Fee Schedule,,96.6,,,96.6,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.07,1462.3,
X-RAY EXAM OF HAND 1V RT RED    ,73120,CPT,RT52     ,45006368,CDM,320,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,88.89,,,88.89,Fee Schedule,,79.89,,,79.89,Fee Schedule,,180.94,,,180.94,Fee Schedule,,162.79,,,162.79,Fee Schedule,,153.72,,,153.72,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,106.61,,,106.61,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,125.46,,,125.46,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,59.07,,,59.07,Fee Schedule,,125.46,,,125.46,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,111.11,,,111.11,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,113.85,,,113.85,Fee Schedule,,96.6,,,96.6,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.07,1462.3,
XR Humerus 1 View Left,73060,CPT,TC52,45006376,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,90.23,,,90.23,Fee Schedule,,81.27,,,81.27,Fee Schedule,,744,50,,744,percent of total billed charges,All Other Outpatient,669.6,45,,669.6,percent of total billed charges,All Other Outpatient,639.84,43,,639.84,percent of total billed charges,All Other Outpatient,744,50,,744,percent of total billed charges,All Other,1041.6,70,,1041.6,percent of total billed charges,All Other,109.61,,,109.61,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,128.98,,,128.98,Fee Schedule,,922.56,,,922.56,Fee Schedule,,60.73,,,60.73,Fee Schedule,,128.98,,,128.98,Fee Schedule,,922.56,,,922.56,Fee Schedule,,114.23,,,114.23,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,118.8,,,118.8,Fee Schedule,,100.8,,,100.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
XR Humerus 1 View Right,73060,CPT,TC52,45006384,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,90.23,,,90.23,Fee Schedule,,81.27,,,81.27,Fee Schedule,,744,50,,744,percent of total billed charges,All Other Outpatient,669.6,45,,669.6,percent of total billed charges,All Other Outpatient,639.84,43,,639.84,percent of total billed charges,All Other Outpatient,744,50,,744,percent of total billed charges,All Other,1041.6,70,,1041.6,percent of total billed charges,All Other,109.61,,,109.61,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,128.98,,,128.98,Fee Schedule,,922.56,,,922.56,Fee Schedule,,60.73,,,60.73,Fee Schedule,,128.98,,,128.98,Fee Schedule,,922.56,,,922.56,Fee Schedule,,114.23,,,114.23,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,118.8,,,118.8,Fee Schedule,,100.8,,,100.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
XR Orthopantogram/Panorex,70355,CPT,TC,45006392,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,32.6,,,32.6,Fee Schedule,,29.36,,,29.36,Fee Schedule,,744,50,,744,percent of total billed charges,All Other Outpatient,669.6,45,,669.6,percent of total billed charges,All Other Outpatient,639.84,43,,639.84,percent of total billed charges,All Other Outpatient,744,50,,744,percent of total billed charges,All Other,1041.6,70,,1041.6,percent of total billed charges,All Other,39.61,,,39.61,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,46.61,,,46.61,Fee Schedule,,922.56,,,922.56,Fee Schedule,,21.95,,,21.95,Fee Schedule,,46.61,,,46.61,Fee Schedule,,922.56,,,922.56,Fee Schedule,,41.28,,,41.28,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,39.6,,,39.6,Fee Schedule,,33.6,,,33.6,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,21.95,1388,
XR Tibia/Fibula 1 View Left,73590,CPT,TC52,45006400,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,88.98,,,88.98,Fee Schedule,,80.14,,,80.14,Fee Schedule,,744,50,,744,percent of total billed charges,All Other Outpatient,669.6,45,,669.6,percent of total billed charges,All Other Outpatient,639.84,43,,639.84,percent of total billed charges,All Other Outpatient,744,50,,744,percent of total billed charges,All Other,1041.6,70,,1041.6,percent of total billed charges,All Other,108.09,,,108.09,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,127.2,,,127.2,Fee Schedule,,922.56,,,922.56,Fee Schedule,,59.89,,,59.89,Fee Schedule,,127.2,,,127.2,Fee Schedule,,922.56,,,922.56,Fee Schedule,,112.65,,,112.65,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,117.15,,,117.15,Fee Schedule,,99.4,,,99.4,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
XR Tibia/Fibula 1 View Right,73590,CPT,TC52,45006418,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,88.98,,,88.98,Fee Schedule,,80.14,,,80.14,Fee Schedule,,744,50,,744,percent of total billed charges,All Other Outpatient,669.6,45,,669.6,percent of total billed charges,All Other Outpatient,639.84,43,,639.84,percent of total billed charges,All Other Outpatient,744,50,,744,percent of total billed charges,All Other,1041.6,70,,1041.6,percent of total billed charges,All Other,108.09,,,108.09,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,127.2,,,127.2,Fee Schedule,,922.56,,,922.56,Fee Schedule,,59.89,,,59.89,Fee Schedule,,127.2,,,127.2,Fee Schedule,,922.56,,,922.56,Fee Schedule,,112.65,,,112.65,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,117.15,,,117.15,Fee Schedule,,99.4,,,99.4,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
XR Wrist 1 View Left,73100,CPT,TC52,45006426,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,96.35,,,96.35,Fee Schedule,,86.77,,,86.77,Fee Schedule,,744,50,,744,percent of total billed charges,All Other Outpatient,669.6,45,,669.6,percent of total billed charges,All Other Outpatient,639.84,43,,639.84,percent of total billed charges,All Other Outpatient,744,50,,744,percent of total billed charges,All Other,1041.6,70,,1041.6,percent of total billed charges,All Other,117.04,,,117.04,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,137.72,,,137.72,Fee Schedule,,922.56,,,922.56,Fee Schedule,,64.85,,,64.85,Fee Schedule,,137.72,,,137.72,Fee Schedule,,922.56,,,922.56,Fee Schedule,,121.98,,,121.98,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,127.05,,,127.05,Fee Schedule,,107.8,,,107.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
XR Wrist 1 View Right,73100,CPT,TC52,45006434,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,96.35,,,96.35,Fee Schedule,,86.77,,,86.77,Fee Schedule,,744,50,,744,percent of total billed charges,All Other Outpatient,669.6,45,,669.6,percent of total billed charges,All Other Outpatient,639.84,43,,639.84,percent of total billed charges,All Other Outpatient,744,50,,744,percent of total billed charges,All Other,1041.6,70,,1041.6,percent of total billed charges,All Other,117.04,,,117.04,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,137.72,,,137.72,Fee Schedule,,922.56,,,922.56,Fee Schedule,,64.85,,,64.85,Fee Schedule,,137.72,,,137.72,Fee Schedule,,922.56,,,922.56,Fee Schedule,,121.98,,,121.98,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,127.05,,,127.05,Fee Schedule,,107.8,,,107.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,59.31,1388,
XR Injection Ileal Conduit,50690,CPT,TC,45006541,CDM,320,RC,,,both,,,1581,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,246.48,,,246.48,Fee Schedule,,221.99,,,221.99,Fee Schedule,,790.5,50,,790.5,percent of total billed charges,All Other Outpatient,711.45,45,,711.45,percent of total billed charges,All Other Outpatient,679.83,43,,679.83,percent of total billed charges,All Other Outpatient,790.5,50,,790.5,percent of total billed charges,All Other,1106.7,70,,1106.7,percent of total billed charges,All Other,299.41,,,299.41,Fee Schedule,,969.7,,,969.7,Other,186% Medicaid methodology,352.34,,,352.34,Fee Schedule,,980.22,,,980.22,Fee Schedule,,165.9,,,165.9,Fee Schedule,,352.34,,,352.34,Fee Schedule,,980.22,,,980.22,Fee Schedule,,312.05,,,312.05,Fee Schedule,,1106.7,70,,1106.7,percent of total billed charges,All Other,333.3,,,333.3,Fee Schedule,,282.8,,,282.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,521.34,,,521.34,Other,New York Medicaid APG methodology,521.34,,,521.34,Other,100% Medicaid APG methodology,521.34,,,521.34,Other,100% Medicaid APG methodology,521.34,,,521.34,Other,100% Medicaid APG methodology,1173.02,,,1173.02,Other,225% Medicaid APG methodology,1173.02,,,1173.02,Other,225% Medicaid APG methodology,797.65,,,797.65,Other,153% Medicaid APG methodology,1173.02,,,1173.02,Other,225% Medicaid APG methodology,729.88,,,729.88,Other,140% Medicaid APG methodology,1173.02,,,1173.02,Other,225% Medicaid APG methodology,1355.49,,,1355.49,Other,260% Medicaid APG methodology,1689.15,,,1689.15,Other,324% Medicaid APG methodology,1120.89,,,1120.89,Other,215% Medicaid APG methodology,1120.89,,,1120.89,Other,215% Medicaid APG methodology,651.68,,,651.68,Other,125% Medicaid APG methodology,0.01,1689.15,
XR Sinogram,20501,CPT,TC,45006558,CDM,320,RC,,,both,,,2475,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,125.77,,,125.77,Fee Schedule,,113.27,,,113.27,Fee Schedule,,1237.5,50,,1237.5,percent of total billed charges,All Other Outpatient,1113.75,45,,1113.75,percent of total billed charges,All Other Outpatient,1064.25,43,,1064.25,percent of total billed charges,All Other Outpatient,1237.5,50,,1237.5,percent of total billed charges,All Other,1732.5,70,,1732.5,percent of total billed charges,All Other,152.77,,,152.77,Fee Schedule,,969.7,,,969.7,Other,186% Medicaid methodology,179.78,,,179.78,Fee Schedule,,1534.5,,,1534.5,Fee Schedule,,84.65,,,84.65,Fee Schedule,,179.78,,,179.78,Fee Schedule,,1534.5,,,1534.5,Fee Schedule,,159.22,,,159.22,Fee Schedule,,1732.5,70,,1732.5,percent of total billed charges,All Other,179.85,,,179.85,Fee Schedule,,152.6,,,152.6,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,521.34,,,521.34,Other,New York Medicaid APG methodology,521.34,,,521.34,Other,100% Medicaid APG methodology,521.34,,,521.34,Other,100% Medicaid APG methodology,521.34,,,521.34,Other,100% Medicaid APG methodology,1173.02,,,1173.02,Other,225% Medicaid APG methodology,1173.02,,,1173.02,Other,225% Medicaid APG methodology,797.65,,,797.65,Other,153% Medicaid APG methodology,1173.02,,,1173.02,Other,225% Medicaid APG methodology,729.88,,,729.88,Other,140% Medicaid APG methodology,1173.02,,,1173.02,Other,225% Medicaid APG methodology,1355.49,,,1355.49,Other,260% Medicaid APG methodology,1689.15,,,1689.15,Other,324% Medicaid APG methodology,1120.89,,,1120.89,Other,215% Medicaid APG methodology,1120.89,,,1120.89,Other,215% Medicaid APG methodology,651.68,,,651.68,Other,125% Medicaid APG methodology,0.01,1732.5,
XR Injection Hypogastric Plexus Anesthet,64517,CPT,TC,45006566,CDM,320,RC,,,both,,,3032,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,444.41,,,444.41,Fee Schedule,,400.26,,,400.26,Fee Schedule,,1516,50,,1516,percent of total billed charges,All Other Outpatient,1364.4,45,,1364.4,percent of total billed charges,All Other Outpatient,1303.76,43,,1303.76,percent of total billed charges,All Other Outpatient,1516,50,,1516,percent of total billed charges,All Other,2122.4,70,,2122.4,percent of total billed charges,All Other,539.85,,,539.85,Fee Schedule,,1155.44,,,1155.44,Other,186% Medicaid methodology,635.28,,,635.28,Fee Schedule,,1879.84,,,1879.84,Fee Schedule,,299.12,,,299.12,Fee Schedule,,635.28,,,635.28,Fee Schedule,,1879.84,,,1879.84,Fee Schedule,,562.64,,,562.64,Fee Schedule,,2122.4,70,,2122.4,percent of total billed charges,All Other,610.5,,,610.5,Fee Schedule,,518,,,518,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,621.21,,,621.21,Other,New York Medicaid APG methodology,621.21,,,621.21,Other,100% Medicaid APG methodology,621.21,,,621.21,Other,100% Medicaid APG methodology,621.21,,,621.21,Other,100% Medicaid APG methodology,1397.71,,,1397.71,Other,225% Medicaid APG methodology,1397.71,,,1397.71,Other,225% Medicaid APG methodology,950.45,,,950.45,Other,153% Medicaid APG methodology,1397.71,,,1397.71,Other,225% Medicaid APG methodology,869.69,,,869.69,Other,140% Medicaid APG methodology,1397.71,,,1397.71,Other,225% Medicaid APG methodology,1615.14,,,1615.14,Other,260% Medicaid APG methodology,2012.71,,,2012.71,Other,324% Medicaid APG methodology,1335.59,,,1335.59,Other,215% Medicaid APG methodology,1335.59,,,1335.59,Other,215% Medicaid APG methodology,776.51,,,776.51,Other,125% Medicaid APG methodology,299.12,2122.4,
ULTRASOUND BREAST LIMITED RT    ,76642,CPT,RT       ,47101340,CDM,320,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,198.16,,,198.16,Fee Schedule,,178.1,,,178.1,Fee Schedule,,57.01,,,57.01,Fee Schedule,,57.01,,,57.01,Fee Schedule,,57.01,,,57.01,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,237.67,,,237.67,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,279.69,,,279.69,Fee Schedule,,922.56,,,922.56,Fee Schedule,,131.69,,,131.69,Fee Schedule,,279.69,,,279.69,Fee Schedule,,922.56,,,922.56,Fee Schedule,,247.7,,,247.7,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,260.7,,,260.7,Fee Schedule,,221.2,,,221.2,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,57.01,1388,
CONTRAST X-RAY GALLBLADDER      ,74290,CPT,,47800933,CDM,320,RC,,,both,,,3203,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,261.49,,,261.49,Fee Schedule,,235.01,,,235.01,Fee Schedule,,486.52,,,486.52,Fee Schedule,,437.73,,,437.73,Fee Schedule,,413.34,,,413.34,Fee Schedule,,1601.5,50,,1601.5,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,313.62,,,313.62,Fee Schedule,,552.19,,,552.19,Other,186% Medicaid methodology,369.07,,,369.07,Fee Schedule,,1985.86,,,1985.86,Fee Schedule,,173.78,,,173.78,Fee Schedule,,369.07,,,369.07,Fee Schedule,,1985.86,,,1985.86,Fee Schedule,,326.86,,,326.86,Fee Schedule,,2242.1,70,,2242.1,percent of total billed charges,All Other,363,,,363,Fee Schedule,,308,,,308,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,296.88,,,296.88,Other,New York Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,454.22,,,454.22,Other,153% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,415.63,,,415.63,Other,140% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,771.88,,,771.88,Other,260% Medicaid APG methodology,961.88,,,961.88,Other,324% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,371.1,,,371.1,Other,125% Medicaid APG methodology,173.78,2242.1,
PLMT NEPHROSTOMY CATHETER       ,50432,CPT,,47839287,CDM,320,RC,,,both,,,13500,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,704.56,,,704.56,Fee Schedule,,634.55,,,634.55,Fee Schedule,,6750,50,,6750,percent of total billed charges,All Other Outpatient,6075,45,,6075,percent of total billed charges,All Other Outpatient,5805,43,,5805,percent of total billed charges,All Other Outpatient,6750,50,,6750,percent of total billed charges,All Other,9450,70,,9450,percent of total billed charges,All Other,855.86,,,855.86,Fee Schedule,,2238.19,,,2238.19,Other,186% Medicaid methodology,1007.16,,,1007.16,Fee Schedule,,8370,,,8370,Fee Schedule,,474.22,,,474.22,Fee Schedule,,1007.16,,,1007.16,Fee Schedule,,8370,,,8370,Fee Schedule,,891.99,,,891.99,Fee Schedule,,9450,70,,9450,percent of total billed charges,All Other,975.15,,,975.15,Fee Schedule,,827.4,,,827.4,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,1203.33,,,1203.33,Other,New York Medicaid APG methodology,1203.33,,,1203.33,Other,100% Medicaid APG methodology,1203.33,,,1203.33,Other,100% Medicaid APG methodology,1203.33,,,1203.33,Other,100% Medicaid APG methodology,2707.49,,,2707.49,Other,225% Medicaid APG methodology,2707.49,,,2707.49,Other,225% Medicaid APG methodology,1841.09,,,1841.09,Other,153% Medicaid APG methodology,2707.49,,,2707.49,Other,225% Medicaid APG methodology,1684.66,,,1684.66,Other,140% Medicaid APG methodology,2707.49,,,2707.49,Other,225% Medicaid APG methodology,3128.66,,,3128.66,Other,260% Medicaid APG methodology,3898.79,,,3898.79,Other,324% Medicaid APG methodology,2587.16,,,2587.16,Other,215% Medicaid APG methodology,2587.16,,,2587.16,Other,215% Medicaid APG methodology,1504.16,,,1504.16,Other,125% Medicaid APG methodology,474.22,9450,
MOTION FLUOROSCOPY/SWALLOW      ,92611,CPT,GN       ,48800106,CDM,320,RC,,,both,,,1213,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,324.98,,,324.98,Fee Schedule,,292.69,,,292.69,Fee Schedule,,967.86,,,967.86,Fee Schedule,,870.81,,,870.81,Fee Schedule,,822.28,,,822.28,Fee Schedule,,606.5,50,,606.5,percent of total billed charges,All Other,849.1,70,,849.1,percent of total billed charges,All Other,394.77,,,394.77,Fee Schedule,,552.19,,,552.19,Other,186% Medicaid methodology,464.55,,,464.55,Fee Schedule,,752.06,,,752.06,Fee Schedule,,218.74,,,218.74,Fee Schedule,,464.55,,,464.55,Fee Schedule,,752.06,,,752.06,Fee Schedule,,411.43,,,411.43,Fee Schedule,,849.1,70,,849.1,percent of total billed charges,All Other,447.15,,,447.15,Fee Schedule,,379.4,,,379.4,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,296.88,,,296.88,Other,New York Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,454.22,,,454.22,Other,153% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,415.63,,,415.63,Other,140% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,771.88,,,771.88,Other,260% Medicaid APG methodology,961.88,,,961.88,Other,324% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,371.1,,,371.1,Other,125% Medicaid APG methodology,0.01,1388,
XR Arthrogram Ankle Left,73615,CPT,TCLT,45001047,CDM,322,RC,,,both,,,1320,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,376.96,,,376.96,Fee Schedule,,338.78,,,338.78,Fee Schedule,,701.63,,,701.63,Fee Schedule,,631.27,,,631.27,Fee Schedule,,596.09,,,596.09,Fee Schedule,,660,50,,660,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,452.11,,,452.11,Fee Schedule,,552.19,,,552.19,Other,186% Medicaid methodology,532.03,,,532.03,Fee Schedule,,818.4,,,818.4,Fee Schedule,,250.51,,,250.51,Fee Schedule,,532.03,,,532.03,Fee Schedule,,818.4,,,818.4,Fee Schedule,,471.2,,,471.2,Fee Schedule,,924,70,,924,percent of total billed charges,All Other,528,,,528,Fee Schedule,,448,,,448,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,296.88,,,296.88,Other,New York Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,454.22,,,454.22,Other,153% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,415.63,,,415.63,Other,140% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,771.88,,,771.88,Other,260% Medicaid APG methodology,961.88,,,961.88,Other,324% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,371.1,,,371.1,Other,125% Medicaid APG methodology,250.51,1388,
IR Arthrogram Wrist Right,73115,CPT,TCRT,45001062,CDM,322,RC,,,both,,,806,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,404.29,,,404.29,Fee Schedule,,363.35,,,363.35,Fee Schedule,,748.37,,,748.37,Fee Schedule,,673.33,,,673.33,Fee Schedule,,635.8,,,635.8,Fee Schedule,,403,50,,403,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,484.89,,,484.89,Fee Schedule,,552.19,,,552.19,Other,186% Medicaid methodology,570.61,,,570.61,Fee Schedule,,499.72,,,499.72,Fee Schedule,,268.67,,,268.67,Fee Schedule,,570.61,,,570.61,Fee Schedule,,499.72,,,499.72,Fee Schedule,,505.36,,,505.36,Fee Schedule,,564.2,70,,564.2,percent of total billed charges,All Other,547.8,,,547.8,Fee Schedule,,464.8,,,464.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,296.88,,,296.88,Other,New York Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,454.22,,,454.22,Other,153% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,415.63,,,415.63,Other,140% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,771.88,,,771.88,Other,260% Medicaid APG methodology,961.88,,,961.88,Other,324% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,371.1,,,371.1,Other,125% Medicaid APG methodology,268.67,1388,
IR Arthrogram Elbow Left,73085,CPT,TCLT,45002763,CDM,322,RC,,,both,,,895,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,278.87,,,278.87,Fee Schedule,,250.63,,,250.63,Fee Schedule,,648.64,,,648.64,Fee Schedule,,583.6,,,583.6,Fee Schedule,,551.07,,,551.07,Fee Schedule,,447.5,50,,447.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,334.47,,,334.47,Fee Schedule,,552.19,,,552.19,Other,186% Medicaid methodology,393.6,,,393.6,Fee Schedule,,554.9,,,554.9,Fee Schedule,,185.33,,,185.33,Fee Schedule,,393.6,,,393.6,Fee Schedule,,554.9,,,554.9,Fee Schedule,,348.59,,,348.59,Fee Schedule,,626.5,70,,626.5,percent of total billed charges,All Other,427.35,,,427.35,Fee Schedule,,362.6,,,362.6,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,296.88,,,296.88,Other,New York Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,454.22,,,454.22,Other,153% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,415.63,,,415.63,Other,140% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,771.88,,,771.88,Other,260% Medicaid APG methodology,961.88,,,961.88,Other,324% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,371.1,,,371.1,Other,125% Medicaid APG methodology,185.33,1388,
IR Arthrogram Wrist Left,73115,CPT,TCLT,45002953,CDM,322,RC,,,both,,,806,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,404.29,,,404.29,Fee Schedule,,363.35,,,363.35,Fee Schedule,,748.37,,,748.37,Fee Schedule,,673.33,,,673.33,Fee Schedule,,635.8,,,635.8,Fee Schedule,,403,50,,403,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,484.89,,,484.89,Fee Schedule,,552.19,,,552.19,Other,186% Medicaid methodology,570.61,,,570.61,Fee Schedule,,499.72,,,499.72,Fee Schedule,,268.67,,,268.67,Fee Schedule,,570.61,,,570.61,Fee Schedule,,499.72,,,499.72,Fee Schedule,,505.36,,,505.36,Fee Schedule,,564.2,70,,564.2,percent of total billed charges,All Other,547.8,,,547.8,Fee Schedule,,464.8,,,464.8,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,296.88,,,296.88,Other,New York Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,454.22,,,454.22,Other,153% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,415.63,,,415.63,Other,140% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,771.88,,,771.88,Other,260% Medicaid APG methodology,961.88,,,961.88,Other,324% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,371.1,,,371.1,Other,125% Medicaid APG methodology,268.67,1388,
IR Arthrogram Ankle Left,73615,CPT,TCLT,45003142,CDM,322,RC,,,both,,,1320,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,376.96,,,376.96,Fee Schedule,,338.78,,,338.78,Fee Schedule,,701.63,,,701.63,Fee Schedule,,631.27,,,631.27,Fee Schedule,,596.09,,,596.09,Fee Schedule,,660,50,,660,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,452.11,,,452.11,Fee Schedule,,552.19,,,552.19,Other,186% Medicaid methodology,532.03,,,532.03,Fee Schedule,,818.4,,,818.4,Fee Schedule,,250.51,,,250.51,Fee Schedule,,532.03,,,532.03,Fee Schedule,,818.4,,,818.4,Fee Schedule,,471.2,,,471.2,Fee Schedule,,924,70,,924,percent of total billed charges,All Other,528,,,528,Fee Schedule,,448,,,448,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,296.88,,,296.88,Other,New York Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,296.88,,,296.88,Other,100% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,454.22,,,454.22,Other,153% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,415.63,,,415.63,Other,140% Medicaid APG methodology,667.97,,,667.97,Other,225% Medicaid APG methodology,771.88,,,771.88,Other,260% Medicaid APG methodology,961.88,,,961.88,Other,324% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,638.28,,,638.28,Other,215% Medicaid APG methodology,371.1,,,371.1,Other,125% Medicaid APG methodology,250.51,1388,
X-RAY EXAM CHEST 1 VIEW         ,71045,CPT,,45000080,CDM,324,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,65.32,,,65.32,Fee Schedule,,58.7,,,58.7,Fee Schedule,,10.16,,,10.16,Fee Schedule,,10.16,,,10.16,Fee Schedule,,10.16,,,10.16,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,78.34,,,78.34,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,92.19,,,92.19,Fee Schedule,,922.56,,,922.56,Fee Schedule,,43.41,,,43.41,Fee Schedule,,92.19,,,92.19,Fee Schedule,,922.56,,,922.56,Fee Schedule,,81.65,,,81.65,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,84.15,,,84.15,Fee Schedule,,71.4,,,71.4,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,10.16,1388,
X-RAY EXAM CHEST 2 VIEWS        ,71046,CPT,,45000098,CDM,324,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,87.66,,,87.66,Fee Schedule,,78.78,,,78.78,Fee Schedule,,18.62,,,18.62,Fee Schedule,,18.62,,,18.62,Fee Schedule,,18.62,,,18.62,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,105.13,,,105.13,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,123.72,,,123.72,Fee Schedule,,922.56,,,922.56,Fee Schedule,,58.25,,,58.25,Fee Schedule,,123.72,,,123.72,Fee Schedule,,922.56,,,922.56,Fee Schedule,,109.57,,,109.57,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,113.85,,,113.85,Fee Schedule,,96.6,,,96.6,Fee Schedule,,1087,,,1087,Case Rate,Other Diag Rad Per Visit,1249,,,1249,Case Rate,Other Diag Rad Per Visit,1388,,,1388,Case Rate,Other Diag Rad Per Visit,1179,,,1179,Case Rate,Other Diag Rad Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,18.62,1388,
CHEMO ANTI-NEOPL SQ/IM          ,96401,CPT,,40800484,CDM,331,RC,,,both,,,812,133.96,,,133.96,Other,150% of Medicare + 9.63% HCRA Surcharge,81.46,,,81.46,Other,Medicare OPPS methodology,581,,,581,Case Rate,Chemotherapy Per Visit,523,,,523,Case Rate,Chemotherapy Per Visit,5902,,,5902,Case Rate,Chemotherapy Per Visit,5312,,,5312,Case Rate,Chemotherapy Per Visit,5017,,,5017,Case Rate,Chemotherapy Per Visit,406,50,,406,percent of total billed charges,All Other,785,,,785,Case Rate,Chemotherapy Per Visit,552.16,68,,552.16,percent of total billed charges,All Other,116.47,,,116.47,Other,186% Medicaid methodology,649.6,80,,649.6,percent of total billed charges,All Other,673.96,83,,673.96,percent of total billed charges,All Other,673.96,83,,673.96,percent of total billed charges,All Other,649.6,80,,649.6,percent of total billed charges,All Other,673.96,83,,673.96,percent of total billed charges,All Other,1735,,,1735,Case Rate,Chemotherapy Per Visit,568.4,70,,568.4,percent of total billed charges,All Other,371.25,,,371.25,Fee Schedule,,315,,,315,Fee Schedule,,2307,,,2307,Case Rate,Chemotherapy Per Visit,1983,,,1983,Case Rate,Chemotherapy Per Visit,2203,,,2203,Case Rate,Chemotherapy Per Visit,1873,,,1873,Case Rate,Chemotherapy Per Visit,62.62,,,62.62,Other,New York Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,95.8,,,95.8,Other,153% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,87.66,,,87.66,Other,140% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,162.81,,,162.81,Other,260% Medicaid APG methodology,202.88,,,202.88,Other,324% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,78.27,,,78.27,Other,125% Medicaid APG methodology,62.62,5902,
CHEMOTHERAPY INJECTION          ,96542,CPT,,40800583,CDM,331,RC,,,both,,,1005,644.03,,,644.03,Other,150% of Medicare + 9.63% HCRA Surcharge,391.64,,,391.64,Other,Medicare OPPS methodology,581,,,581,Fee Schedule,,523,,,523,Fee Schedule,,502.5,50,,502.5,percent of total billed charges,All Other Outpatient,452.25,45,,452.25,percent of total billed charges,All Other Outpatient,432.15,43,,432.15,percent of total billed charges,All Other Outpatient,502.5,50,,502.5,percent of total billed charges,All Other,703.5,70,,703.5,percent of total billed charges,All Other,683.4,68,,683.4,percent of total billed charges,All Other,116.47,,,116.47,Other,186% Medicaid methodology,804,80,,804,percent of total billed charges,All Other,834.15,83,,834.15,percent of total billed charges,All Other,834.15,83,,834.15,percent of total billed charges,All Other,804,80,,804,percent of total billed charges,All Other,834.15,83,,834.15,percent of total billed charges,All Other,186.44,,,186.44,Fee Schedule,,703.5,70,,703.5,percent of total billed charges,All Other,204.6,,,204.6,Fee Schedule,,173.6,,,173.6,Fee Schedule,,2307,,,2307,Case Rate,Chemotherapy Per Visit,1983,,,1983,Case Rate,Chemotherapy Per Visit,2203,,,2203,Case Rate,Chemotherapy Per Visit,1873,,,1873,Case Rate,Chemotherapy Per Visit,62.62,,,62.62,Other,New York Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,95.8,,,95.8,Other,153% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,87.66,,,87.66,Other,140% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,162.81,,,162.81,Other,260% Medicaid APG methodology,202.88,,,202.88,Other,324% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,78.27,,,78.27,Other,125% Medicaid APG methodology,62.62,2307,
CHEMO IA PUSH TECNIQUE          ,96420,CPT,,40800765,CDM,331,RC,,,both,,,1419,644.03,,,644.03,Other,150% of Medicare + 9.63% HCRA Surcharge,391.64,,,391.64,Other,Medicare OPPS methodology,581,,,581,Case Rate,Chemotherapy Per Visit,523,,,523,Case Rate,Chemotherapy Per Visit,5902,,,5902,Case Rate,Chemotherapy Per Visit,5312,,,5312,Case Rate,Chemotherapy Per Visit,5017,,,5017,Case Rate,Chemotherapy Per Visit,709.5,50,,709.5,percent of total billed charges,All Other,785,,,785,Case Rate,Chemotherapy Per Visit,964.92,68,,964.92,percent of total billed charges,All Other,116.47,,,116.47,Other,186% Medicaid methodology,1135.2,80,,1135.2,percent of total billed charges,All Other,1177.77,83,,1177.77,percent of total billed charges,All Other,1177.77,83,,1177.77,percent of total billed charges,All Other,1135.2,80,,1135.2,percent of total billed charges,All Other,1177.77,83,,1177.77,percent of total billed charges,All Other,1735,,,1735,Case Rate,Chemotherapy Per Visit,993.3,70,,993.3,percent of total billed charges,All Other,528,,,528,Fee Schedule,,448,,,448,Fee Schedule,,2307,,,2307,Case Rate,Chemotherapy Per Visit,1983,,,1983,Case Rate,Chemotherapy Per Visit,2203,,,2203,Case Rate,Chemotherapy Per Visit,1873,,,1873,Case Rate,Chemotherapy Per Visit,62.62,,,62.62,Other,New York Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,95.8,,,95.8,Other,153% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,87.66,,,87.66,Other,140% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,162.81,,,162.81,Other,260% Medicaid APG methodology,202.88,,,202.88,Other,324% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,78.27,,,78.27,Other,125% Medicaid APG methodology,62.62,5902,
CHEMO INTRALESIONAL UP TO 7     ,96405,CPT,,40800831,CDM,331,RC,,,both,,,594,133.96,,,133.96,Other,150% of Medicare + 9.63% HCRA Surcharge,81.46,,,81.46,Other,Medicare OPPS methodology,581,,,581,Case Rate,Chemotherapy Per Visit,523,,,523,Case Rate,Chemotherapy Per Visit,5902,,,5902,Case Rate,Chemotherapy Per Visit,5312,,,5312,Case Rate,Chemotherapy Per Visit,5017,,,5017,Case Rate,Chemotherapy Per Visit,297,50,,297,percent of total billed charges,All Other,785,,,785,Case Rate,Chemotherapy Per Visit,403.92,68,,403.92,percent of total billed charges,All Other,116.47,,,116.47,Other,186% Medicaid methodology,475.2,80,,475.2,percent of total billed charges,All Other,493.02,83,,493.02,percent of total billed charges,All Other,493.02,83,,493.02,percent of total billed charges,All Other,475.2,80,,475.2,percent of total billed charges,All Other,493.02,83,,493.02,percent of total billed charges,All Other,1735,,,1735,Case Rate,Chemotherapy Per Visit,415.8,70,,415.8,percent of total billed charges,All Other,138.6,,,138.6,Fee Schedule,,117.6,,,117.6,Fee Schedule,,2307,,,2307,Case Rate,Chemotherapy Per Visit,1983,,,1983,Case Rate,Chemotherapy Per Visit,2203,,,2203,Case Rate,Chemotherapy Per Visit,1873,,,1873,Case Rate,Chemotherapy Per Visit,62.62,,,62.62,Other,New York Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,95.8,,,95.8,Other,153% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,87.66,,,87.66,Other,140% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,162.81,,,162.81,Other,260% Medicaid APG methodology,202.88,,,202.88,Other,324% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,78.27,,,78.27,Other,125% Medicaid APG methodology,62.62,5902,
SET RADIATION THERAPY FLD CPLX  ,77290,CPT,,44000073,CDM,333,RC,,,both,,,6683,702.65,,,702.65,Other,150% of Medicare + 9.63% HCRA Surcharge,427.28,,,427.28,Other,Medicare OPPS methodology,1365.56,,,1365.56,Fee Schedule,,1227.28,,,1227.28,Fee Schedule,,4146.67,,,4146.67,Fee Schedule,,3730.84,,,3730.84,Fee Schedule,,3522.93,,,3522.93,Fee Schedule,,3341.5,50,,3341.5,percent of total billed charges,All Other,993.14,,,993.14,Fee Schedule,,1637.81,,,1637.81,Fee Schedule,,925.03,,,925.03,Other,186% Medicaid methodology,1927.34,,,1927.34,Fee Schedule,,4143.46,,,4143.46,Fee Schedule,,907.49,,,907.49,Fee Schedule,,1927.34,,,1927.34,Fee Schedule,,4143.46,,,4143.46,Fee Schedule,,1706.95,,,1706.95,Fee Schedule,,4678.1,70,,4678.1,percent of total billed charges,All Other,1839.75,,,1839.75,Fee Schedule,,1561,,,1561,Fee Schedule,,7413,,,7413,Case Rate,Rad Therapy Per Visit,7152,,,7152,Case Rate,Rad Therapy Per Visit,7947,,,7947,Case Rate,Rad Therapy Per Visit,6755,,,6755,Case Rate,Rad Therapy Per Visit,497.33,,,497.33,Other,New York Medicaid APG methodology,497.33,,,497.33,Other,100% Medicaid APG methodology,497.33,,,497.33,Other,100% Medicaid APG methodology,497.33,,,497.33,Other,100% Medicaid APG methodology,1118.99,,,1118.99,Other,225% Medicaid APG methodology,1118.99,,,1118.99,Other,225% Medicaid APG methodology,760.91,,,760.91,Other,153% Medicaid APG methodology,1118.99,,,1118.99,Other,225% Medicaid APG methodology,696.26,,,696.26,Other,140% Medicaid APG methodology,1118.99,,,1118.99,Other,225% Medicaid APG methodology,1293.05,,,1293.05,Other,260% Medicaid APG methodology,1611.34,,,1611.34,Other,324% Medicaid APG methodology,1069.26,,,1069.26,Other,215% Medicaid APG methodology,1069.26,,,1069.26,Other,215% Medicaid APG methodology,621.66,,,621.66,Other,125% Medicaid APG methodology,427.28,7947,
SET RADIATION THERAPY FLD SMPL  ,77280,CPT,,44000099,CDM,333,RC,,,both,,,2524,258.03,,,258.03,Other,150% of Medicare + 9.63% HCRA Surcharge,156.91,,,156.91,Other,Medicare OPPS methodology,864.92,,,864.92,Fee Schedule,,777.34,,,777.34,Fee Schedule,,1412.45,,,1412.45,Fee Schedule,,1270.81,,,1270.81,Fee Schedule,,1199.99,,,1199.99,Fee Schedule,,1262,50,,1262,percent of total billed charges,All Other,372.03,,,372.03,Fee Schedule,,1037.36,,,1037.36,Fee Schedule,,977.09,,,977.09,Other,186% Medicaid methodology,1220.75,,,1220.75,Fee Schedule,,1564.88,,,1564.88,Fee Schedule,,574.79,,,574.79,Fee Schedule,,1220.75,,,1220.75,Fee Schedule,,1564.88,,,1564.88,Fee Schedule,,1081.15,,,1081.15,Fee Schedule,,1766.8,70,,1766.8,percent of total billed charges,All Other,1130.25,,,1130.25,Fee Schedule,,959,,,959,Fee Schedule,,7413,,,7413,Case Rate,Rad Therapy Per Visit,7152,,,7152,Case Rate,Rad Therapy Per Visit,7947,,,7947,Case Rate,Rad Therapy Per Visit,6755,,,6755,Case Rate,Rad Therapy Per Visit,525.32,,,525.32,Other,New York Medicaid APG methodology,525.32,,,525.32,Other,100% Medicaid APG methodology,525.32,,,525.32,Other,100% Medicaid APG methodology,525.32,,,525.32,Other,100% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,803.73,,,803.73,Other,153% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,735.44,,,735.44,Other,140% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,1365.82,,,1365.82,Other,260% Medicaid APG methodology,1702.02,,,1702.02,Other,324% Medicaid APG methodology,1129.43,,,1129.43,Other,215% Medicaid APG methodology,1129.43,,,1129.43,Other,215% Medicaid APG methodology,656.64,,,656.64,Other,125% Medicaid APG methodology,156.91,7947,
RADIATION TREATMENT DLVRY SMPL  ,77402,CPT,,44000198,CDM,333,RC,,,both,,,3073,228.03,,,228.03,Other,150% of Medicare + 9.63% HCRA Surcharge,138.67,,,138.67,Other,Medicare OPPS methodology,1536.5,50,,1536.5,percent of total billed charges,All Other Outpatient,1382.85,45,,1382.85,percent of total billed charges,All Other Outpatient,1618.23,,,1618.23,Fee Schedule,,1455.95,,,1455.95,Fee Schedule,,1374.82,,,1374.82,Fee Schedule,,1536.5,50,,1536.5,percent of total billed charges,All Other,353.47,,,353.47,Fee Schedule,,2089.64,68,,2089.64,percent of total billed charges,All Other Outpatient,739.39,,,739.39,Other,186% Medicaid methodology,2458.4,80,,2458.4,percent of total billed charges,All Other Outpatient,2550.59,83,,2550.59,percent of total billed charges,All Other Outpatient,2550.59,83,,2550.59,percent of total billed charges,All Other Outpatient,2458.4,80,,2458.4,percent of total billed charges,All Other Outpatient,2550.59,83,,2550.59,percent of total billed charges,All Other Outpatient,2765.7,90,,2765.7,percent of total billed charges,All Other,2151.1,70,,2151.1,percent of total billed charges,All Other,1536.5,50,,1536.5,percent of total billed charges,All Other,1536.5,50,,1536.5,percent of total billed charges,All Other,7413,,,7413,Case Rate,Rad Therapy Per Visit,7152,,,7152,Case Rate,Rad Therapy Per Visit,7947,,,7947,Case Rate,Rad Therapy Per Visit,6755,,,6755,Case Rate,Rad Therapy Per Visit,397.52,,,397.52,Other,New York Medicaid APG methodology,397.52,,,397.52,Other,100% Medicaid APG methodology,397.52,,,397.52,Other,100% Medicaid APG methodology,397.52,,,397.52,Other,100% Medicaid APG methodology,894.42,,,894.42,Other,225% Medicaid APG methodology,894.42,,,894.42,Other,225% Medicaid APG methodology,608.21,,,608.21,Other,153% Medicaid APG methodology,894.42,,,894.42,Other,225% Medicaid APG methodology,556.53,,,556.53,Other,140% Medicaid APG methodology,894.42,,,894.42,Other,225% Medicaid APG methodology,1033.56,,,1033.56,Other,260% Medicaid APG methodology,1287.97,,,1287.97,Other,324% Medicaid APG methodology,854.67,,,854.67,Other,215% Medicaid APG methodology,854.67,,,854.67,Other,215% Medicaid APG methodology,496.9,,,496.9,Other,125% Medicaid APG methodology,138.67,7947,
RAD TX DELIVERY = or >1 MEV INTERMED 77407,77407,CPT,TC,44000230,CDM,333,RC,,,both,,,4986,511.06,,,511.06,Other,150% of Medicare + 9.63% HCRA Surcharge,310.78,,,310.78,Other,Medicare OPPS methodology,2493,,,2493,Fee Schedule,,2493,,,2493,Fee Schedule,,2344.63,,,2344.63,Fee Schedule,,2109.51,,,2109.51,Fee Schedule,,1991.96,,,1991.96,Fee Schedule,,2493,50,,2493,percent of total billed charges,All Other,3490.2,70,,3490.2,percent of total billed charges,All Other,2143.98,43,,2143.98,percent of total billed charges,All Other,739.39,,,739.39,Other,186% Medicaid methodology,2493,50,,2493,percent of total billed charges,All Other,2742.3,55,,2742.3,percent of total billed charges,All Other,2742.3,55,,2742.3,percent of total billed charges,All Other,2493,50,,2493,percent of total billed charges,All Other,2742.3,55,,2742.3,percent of total billed charges,All Other,4487.4,90,,4487.4,percent of total billed charges,All Other,3490.2,70,,3490.2,percent of total billed charges,All Other,2493,50,,2493,percent of total billed charges,All Other,2493,50,,2493,percent of total billed charges,All Other,7413,,,7413,Case Rate,Rad Therapy Per Visit,7152,,,7152,Case Rate,Rad Therapy Per Visit,7947,,,7947,Case Rate,Rad Therapy Per Visit,6755,,,6755,Case Rate,Rad Therapy Per Visit,397.52,,,397.52,Other,New York Medicaid APG methodology,397.52,,,397.52,Other,100% Medicaid APG methodology,397.52,,,397.52,Other,100% Medicaid APG methodology,397.52,,,397.52,Other,100% Medicaid APG methodology,894.42,,,894.42,Other,225% Medicaid APG methodology,894.42,,,894.42,Other,225% Medicaid APG methodology,608.21,,,608.21,Other,153% Medicaid APG methodology,894.42,,,894.42,Other,225% Medicaid APG methodology,556.53,,,556.53,Other,140% Medicaid APG methodology,894.42,,,894.42,Other,225% Medicaid APG methodology,1033.56,,,1033.56,Other,260% Medicaid APG methodology,1287.97,,,1287.97,Other,324% Medicaid APG methodology,854.67,,,854.67,Other,215% Medicaid APG methodology,854.67,,,854.67,Other,215% Medicaid APG methodology,496.9,,,496.9,Other,125% Medicaid APG methodology,310.78,7947,
RADIATION TREATMENT DLVRY CMPX  ,77412,CPT,TC       ,44000271,CDM,333,RC,,,both,,,4713,511.06,,,511.06,Other,150% of Medicare + 9.63% HCRA Surcharge,310.78,,,310.78,Other,Medicare OPPS methodology,2356.5,50,,2356.5,percent of total billed charges,All Other Outpatient,2120.85,45,,2120.85,percent of total billed charges,All Other Outpatient,2135.76,,,2135.76,Fee Schedule,,1921.59,,,1921.59,Fee Schedule,,1814.51,,,1814.51,Fee Schedule,,2356.5,50,,2356.5,percent of total billed charges,All Other,708.7,,,708.7,Fee Schedule,,3204.84,68,,3204.84,percent of total billed charges,All Other Outpatient,739.39,,,739.39,Other,186% Medicaid methodology,3770.4,80,,3770.4,percent of total billed charges,All Other Outpatient,3911.79,83,,3911.79,percent of total billed charges,All Other Outpatient,3911.79,83,,3911.79,percent of total billed charges,All Other Outpatient,3770.4,80,,3770.4,percent of total billed charges,All Other Outpatient,3911.79,83,,3911.79,percent of total billed charges,All Other Outpatient,4241.7,90,,4241.7,percent of total billed charges,All Other,3299.1,70,,3299.1,percent of total billed charges,All Other,2356.5,50,,2356.5,percent of total billed charges,All Other,2356.5,50,,2356.5,percent of total billed charges,All Other,7413,,,7413,Case Rate,Rad Therapy Per Visit,7152,,,7152,Case Rate,Rad Therapy Per Visit,7947,,,7947,Case Rate,Rad Therapy Per Visit,6755,,,6755,Case Rate,Rad Therapy Per Visit,397.52,,,397.52,Other,New York Medicaid APG methodology,397.52,,,397.52,Other,100% Medicaid APG methodology,397.52,,,397.52,Other,100% Medicaid APG methodology,397.52,,,397.52,Other,100% Medicaid APG methodology,894.42,,,894.42,Other,225% Medicaid APG methodology,894.42,,,894.42,Other,225% Medicaid APG methodology,608.21,,,608.21,Other,153% Medicaid APG methodology,894.42,,,894.42,Other,225% Medicaid APG methodology,556.53,,,556.53,Other,140% Medicaid APG methodology,894.42,,,894.42,Other,225% Medicaid APG methodology,1033.56,,,1033.56,Other,260% Medicaid APG methodology,1287.97,,,1287.97,Other,324% Medicaid APG methodology,854.67,,,854.67,Other,215% Medicaid APG methodology,854.67,,,854.67,Other,215% Medicaid APG methodology,496.9,,,496.9,Other,125% Medicaid APG methodology,310.78,7947,
RADIATION THERAPY DOSE PLAN     ,77300,CPT,,44000305,CDM,333,RC,,,both,,,2524,258.03,,,258.03,Other,150% of Medicare + 9.63% HCRA Surcharge,156.91,,,156.91,Other,Medicare OPPS methodology,126.15,,,126.15,Fee Schedule,,113.37,,,113.37,Fee Schedule,,355.55,,,355.55,Fee Schedule,,319.9,,,319.9,Fee Schedule,,302.07,,,302.07,Fee Schedule,,1262,50,,1262,percent of total billed charges,All Other,372.03,,,372.03,Fee Schedule,,151.3,,,151.3,Fee Schedule,,925.03,,,925.03,Other,186% Medicaid methodology,178.04,,,178.04,Fee Schedule,,1564.88,,,1564.88,Fee Schedule,,83.83,,,83.83,Fee Schedule,,178.04,,,178.04,Fee Schedule,,1564.88,,,1564.88,Fee Schedule,,157.68,,,157.68,Fee Schedule,,1766.8,70,,1766.8,percent of total billed charges,All Other,158.4,,,158.4,Fee Schedule,,134.4,,,134.4,Fee Schedule,,7413,,,7413,Case Rate,Rad Therapy Per Visit,7152,,,7152,Case Rate,Rad Therapy Per Visit,7947,,,7947,Case Rate,Rad Therapy Per Visit,6755,,,6755,Case Rate,Rad Therapy Per Visit,497.33,,,497.33,Other,New York Medicaid APG methodology,497.33,,,497.33,Other,100% Medicaid APG methodology,497.33,,,497.33,Other,100% Medicaid APG methodology,497.33,,,497.33,Other,100% Medicaid APG methodology,1118.99,,,1118.99,Other,225% Medicaid APG methodology,1118.99,,,1118.99,Other,225% Medicaid APG methodology,760.91,,,760.91,Other,153% Medicaid APG methodology,1118.99,,,1118.99,Other,225% Medicaid APG methodology,696.26,,,696.26,Other,140% Medicaid APG methodology,1118.99,,,1118.99,Other,225% Medicaid APG methodology,1293.05,,,1293.05,Other,260% Medicaid APG methodology,1611.34,,,1611.34,Other,324% Medicaid APG methodology,1069.26,,,1069.26,Other,215% Medicaid APG methodology,1069.26,,,1069.26,Other,215% Medicaid APG methodology,621.66,,,621.66,Other,125% Medicaid APG methodology,83.83,7947,
SPECIAL RADIATION DOSIMETRY     ,77331,CPT,,44000321,CDM,333,RC,,,both,,,2524,258.03,,,258.03,Other,150% of Medicare + 9.63% HCRA Surcharge,156.91,,,156.91,Other,Medicare OPPS methodology,72.74,,,72.74,Fee Schedule,,65.38,,,65.38,Fee Schedule,,177.85,,,177.85,Fee Schedule,,160.01,,,160.01,Fee Schedule,,151.1,,,151.1,Fee Schedule,,1262,50,,1262,percent of total billed charges,All Other,372.03,,,372.03,Fee Schedule,,87.25,,,87.25,Fee Schedule,,977.09,,,977.09,Other,186% Medicaid methodology,102.67,,,102.67,Fee Schedule,,1564.88,,,1564.88,Fee Schedule,,48.34,,,48.34,Fee Schedule,,102.67,,,102.67,Fee Schedule,,1564.88,,,1564.88,Fee Schedule,,90.93,,,90.93,Fee Schedule,,1766.8,70,,1766.8,percent of total billed charges,All Other,90.75,,,90.75,Fee Schedule,,77,,,77,Fee Schedule,,7413,,,7413,Case Rate,Rad Therapy Per Visit,7152,,,7152,Case Rate,Rad Therapy Per Visit,7947,,,7947,Case Rate,Rad Therapy Per Visit,6755,,,6755,Case Rate,Rad Therapy Per Visit,525.32,,,525.32,Other,New York Medicaid APG methodology,525.32,,,525.32,Other,100% Medicaid APG methodology,525.32,,,525.32,Other,100% Medicaid APG methodology,525.32,,,525.32,Other,100% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,803.73,,,803.73,Other,153% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,735.44,,,735.44,Other,140% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,1365.82,,,1365.82,Other,260% Medicaid APG methodology,1702.02,,,1702.02,Other,324% Medicaid APG methodology,1129.43,,,1129.43,Other,215% Medicaid APG methodology,1129.43,,,1129.43,Other,215% Medicaid APG methodology,656.64,,,656.64,Other,125% Medicaid APG methodology,48.34,7947,
3-D RADIOTHERAPY PLAN           ,77295,CPT,,44000354,CDM,333,RC,,,both,,,8466,2634.97,,,2634.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1602.34,,,1602.34,Other,Medicare OPPS methodology,963.71,,,963.71,Fee Schedule,,866.11,,,866.11,Fee Schedule,,3077.71,,,3077.71,Fee Schedule,,2769.08,,,2769.08,Fee Schedule,,2614.77,,,2614.77,Fee Schedule,,4233,50,,4233,percent of total billed charges,All Other,3701.17,,,3701.17,Fee Schedule,,1155.84,,,1155.84,Fee Schedule,,377.79,,,377.79,Other,186% Medicaid methodology,1360.17,,,1360.17,Fee Schedule,,5248.92,,,5248.92,Fee Schedule,,640.44,,,640.44,Fee Schedule,,1360.17,,,1360.17,Fee Schedule,,5248.92,,,5248.92,Fee Schedule,,1204.63,,,1204.63,Fee Schedule,,5926.2,70,,5926.2,percent of total billed charges,All Other,1216.05,,,1216.05,Fee Schedule,,1031.8,,,1031.8,Fee Schedule,,7413,,,7413,Case Rate,Rad Therapy Per Visit,7152,,,7152,Case Rate,Rad Therapy Per Visit,7947,,,7947,Case Rate,Rad Therapy Per Visit,6755,,,6755,Case Rate,Rad Therapy Per Visit,203.11,,,203.11,Other,New York Medicaid APG methodology,203.11,,,203.11,Other,100% Medicaid APG methodology,203.11,,,203.11,Other,100% Medicaid APG methodology,203.11,,,203.11,Other,100% Medicaid APG methodology,457,,,457,Other,225% Medicaid APG methodology,457,,,457,Other,225% Medicaid APG methodology,310.76,,,310.76,Other,153% Medicaid APG methodology,457,,,457,Other,225% Medicaid APG methodology,284.36,,,284.36,Other,140% Medicaid APG methodology,457,,,457,Other,225% Medicaid APG methodology,528.09,,,528.09,Other,260% Medicaid APG methodology,658.08,,,658.08,Other,324% Medicaid APG methodology,436.69,,,436.69,Other,215% Medicaid APG methodology,436.69,,,436.69,Other,215% Medicaid APG methodology,253.89,,,253.89,Other,125% Medicaid APG methodology,203.11,7947,
RADIATION PHYSICS CONSULT       ,77336,CPT,,44000362,CDM,333,RC,,,both,,,2524,258.03,,,258.03,Other,150% of Medicare + 9.63% HCRA Surcharge,156.91,,,156.91,Other,Medicare OPPS methodology,337.39,,,337.39,Fee Schedule,,303.23,,,303.23,Fee Schedule,,480.27,,,480.27,Fee Schedule,,432.11,,,432.11,Fee Schedule,,408.03,,,408.03,Fee Schedule,,1262,50,,1262,percent of total billed charges,All Other,372.03,,,372.03,Fee Schedule,,404.66,,,404.66,Fee Schedule,,977.09,,,977.09,Other,186% Medicaid methodology,476.19,,,476.19,Fee Schedule,,1564.88,,,1564.88,Fee Schedule,,224.22,,,224.22,Fee Schedule,,476.19,,,476.19,Fee Schedule,,1564.88,,,1564.88,Fee Schedule,,421.74,,,421.74,Fee Schedule,,1766.8,70,,1766.8,percent of total billed charges,All Other,400.95,,,400.95,Fee Schedule,,340.2,,,340.2,Fee Schedule,,7413,,,7413,Case Rate,Rad Therapy Per Visit,7152,,,7152,Case Rate,Rad Therapy Per Visit,7947,,,7947,Case Rate,Rad Therapy Per Visit,6755,,,6755,Case Rate,Rad Therapy Per Visit,525.32,,,525.32,Other,New York Medicaid APG methodology,525.32,,,525.32,Other,100% Medicaid APG methodology,525.32,,,525.32,Other,100% Medicaid APG methodology,525.32,,,525.32,Other,100% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,803.73,,,803.73,Other,153% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,735.44,,,735.44,Other,140% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,1365.82,,,1365.82,Other,260% Medicaid APG methodology,1702.02,,,1702.02,Other,324% Medicaid APG methodology,1129.43,,,1129.43,Other,215% Medicaid APG methodology,1129.43,,,1129.43,Other,215% Medicaid APG methodology,656.64,,,656.64,Other,125% Medicaid APG methodology,156.91,7947,
RADIATION TREATMNT AID(S) CPLX  ,77334,CPT,,44000388,CDM,333,RC,,,both,,,6683,702.65,,,702.65,Other,150% of Medicare + 9.63% HCRA Surcharge,427.28,,,427.28,Other,Medicare OPPS methodology,245.34,,,245.34,Fee Schedule,,220.5,,,220.5,Fee Schedule,,841.93,,,841.93,Fee Schedule,,757.5,,,757.5,Fee Schedule,,715.29,,,715.29,Fee Schedule,,3341.5,50,,3341.5,percent of total billed charges,All Other,993.14,,,993.14,Fee Schedule,,294.26,,,294.26,Fee Schedule,,925.03,,,925.03,Other,186% Medicaid methodology,346.27,,,346.27,Fee Schedule,,4143.46,,,4143.46,Fee Schedule,,163.04,,,163.04,Fee Schedule,,346.27,,,346.27,Fee Schedule,,4143.46,,,4143.46,Fee Schedule,,306.68,,,306.68,Fee Schedule,,4678.1,70,,4678.1,percent of total billed charges,All Other,310.2,,,310.2,Fee Schedule,,263.2,,,263.2,Fee Schedule,,7413,,,7413,Case Rate,Rad Therapy Per Visit,7152,,,7152,Case Rate,Rad Therapy Per Visit,7947,,,7947,Case Rate,Rad Therapy Per Visit,6755,,,6755,Case Rate,Rad Therapy Per Visit,497.33,,,497.33,Other,New York Medicaid APG methodology,497.33,,,497.33,Other,100% Medicaid APG methodology,497.33,,,497.33,Other,100% Medicaid APG methodology,497.33,,,497.33,Other,100% Medicaid APG methodology,1118.99,,,1118.99,Other,225% Medicaid APG methodology,1118.99,,,1118.99,Other,225% Medicaid APG methodology,760.91,,,760.91,Other,153% Medicaid APG methodology,1118.99,,,1118.99,Other,225% Medicaid APG methodology,696.26,,,696.26,Other,140% Medicaid APG methodology,1118.99,,,1118.99,Other,225% Medicaid APG methodology,1293.05,,,1293.05,Other,260% Medicaid APG methodology,1611.34,,,1611.34,Other,324% Medicaid APG methodology,1069.26,,,1069.26,Other,215% Medicaid APG methodology,1069.26,,,1069.26,Other,215% Medicaid APG methodology,621.66,,,621.66,Other,125% Medicaid APG methodology,163.04,7947,
RADIATION TREATMNT AID(S) SMPL  ,77332,CPT,,44000438,CDM,333,RC,,,both,,,2524,258.03,,,258.03,Other,150% of Medicare + 9.63% HCRA Surcharge,156.91,,,156.91,Other,Medicare OPPS methodology,59.09,,,59.09,Fee Schedule,,53.11,,,53.11,Fee Schedule,,474.02,,,474.02,Fee Schedule,,426.49,,,426.49,Fee Schedule,,402.72,,,402.72,Fee Schedule,,1262,50,,1262,percent of total billed charges,All Other,372.03,,,372.03,Fee Schedule,,70.87,,,70.87,Fee Schedule,,977.09,,,977.09,Other,186% Medicaid methodology,83.4,,,83.4,Fee Schedule,,1564.88,,,1564.88,Fee Schedule,,39.27,,,39.27,Fee Schedule,,83.4,,,83.4,Fee Schedule,,1564.88,,,1564.88,Fee Schedule,,73.87,,,73.87,Fee Schedule,,1766.8,70,,1766.8,percent of total billed charges,All Other,70.95,,,70.95,Fee Schedule,,60.2,,,60.2,Fee Schedule,,7413,,,7413,Case Rate,Rad Therapy Per Visit,7152,,,7152,Case Rate,Rad Therapy Per Visit,7947,,,7947,Case Rate,Rad Therapy Per Visit,6755,,,6755,Case Rate,Rad Therapy Per Visit,525.32,,,525.32,Other,New York Medicaid APG methodology,525.32,,,525.32,Other,100% Medicaid APG methodology,525.32,,,525.32,Other,100% Medicaid APG methodology,525.32,,,525.32,Other,100% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,803.73,,,803.73,Other,153% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,735.44,,,735.44,Other,140% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,1365.82,,,1365.82,Other,260% Medicaid APG methodology,1702.02,,,1702.02,Other,324% Medicaid APG methodology,1129.43,,,1129.43,Other,215% Medicaid APG methodology,1129.43,,,1129.43,Other,215% Medicaid APG methodology,656.64,,,656.64,Other,125% Medicaid APG methodology,39.27,7947,
TX DEVICES; INTERMED            ,77333,CPT,,44000446,CDM,333,RC,,,both,,,891,258.03,,,258.03,Other,150% of Medicare + 9.63% HCRA Surcharge,156.91,,,156.91,Other,Medicare OPPS methodology,365.77,,,365.77,Fee Schedule,,328.73,,,328.73,Fee Schedule,,162.27,,,162.27,Fee Schedule,,146,,,146,Fee Schedule,,137.86,,,137.86,Fee Schedule,,445.5,50,,445.5,percent of total billed charges,All Other,372.03,,,372.03,Fee Schedule,,438.69,,,438.69,Fee Schedule,,977.09,,,977.09,Other,186% Medicaid methodology,516.25,,,516.25,Fee Schedule,,552.42,,,552.42,Fee Schedule,,243.08,,,243.08,Fee Schedule,,516.25,,,516.25,Fee Schedule,,552.42,,,552.42,Fee Schedule,,457.21,,,457.21,Fee Schedule,,623.7,70,,623.7,percent of total billed charges,All Other,486.75,,,486.75,Fee Schedule,,413,,,413,Fee Schedule,,7413,,,7413,Case Rate,Rad Therapy Per Visit,7152,,,7152,Case Rate,Rad Therapy Per Visit,7947,,,7947,Case Rate,Rad Therapy Per Visit,6755,,,6755,Case Rate,Rad Therapy Per Visit,525.32,,,525.32,Other,New York Medicaid APG methodology,525.32,,,525.32,Other,100% Medicaid APG methodology,525.32,,,525.32,Other,100% Medicaid APG methodology,525.32,,,525.32,Other,100% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,803.73,,,803.73,Other,153% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,735.44,,,735.44,Other,140% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,1365.82,,,1365.82,Other,260% Medicaid APG methodology,1702.02,,,1702.02,Other,324% Medicaid APG methodology,1129.43,,,1129.43,Other,215% Medicaid APG methodology,1129.43,,,1129.43,Other,215% Medicaid APG methodology,656.64,,,656.64,Other,125% Medicaid APG methodology,137.86,7947,
"TX ISODOSE PLAN, INTERMEDIATE   ",77306,CPT,,44000495,CDM,333,RC,,,both,,,2494,702.65,,,702.65,Other,150% of Medicare + 9.63% HCRA Surcharge,427.28,,,427.28,Other,Medicare OPPS methodology,282.09,,,282.09,Fee Schedule,,253.53,,,253.53,Fee Schedule,,76.09,,,76.09,Fee Schedule,,76.09,,,76.09,Fee Schedule,,76.09,,,76.09,Fee Schedule,,1247,50,,1247,percent of total billed charges,All Other,993.14,,,993.14,Fee Schedule,,338.33,,,338.33,Fee Schedule,,977.09,,,977.09,Other,186% Medicaid methodology,398.14,,,398.14,Fee Schedule,,1546.28,,,1546.28,Fee Schedule,,187.47,,,187.47,Fee Schedule,,398.14,,,398.14,Fee Schedule,,1546.28,,,1546.28,Fee Schedule,,352.62,,,352.62,Fee Schedule,,1745.8,70,,1745.8,percent of total billed charges,All Other,353.1,,,353.1,Fee Schedule,,299.6,,,299.6,Fee Schedule,,7413,,,7413,Case Rate,Rad Therapy Per Visit,7152,,,7152,Case Rate,Rad Therapy Per Visit,7947,,,7947,Case Rate,Rad Therapy Per Visit,6755,,,6755,Case Rate,Rad Therapy Per Visit,525.32,,,525.32,Other,New York Medicaid APG methodology,525.32,,,525.32,Other,100% Medicaid APG methodology,525.32,,,525.32,Other,100% Medicaid APG methodology,525.32,,,525.32,Other,100% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,803.73,,,803.73,Other,153% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,735.44,,,735.44,Other,140% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,1365.82,,,1365.82,Other,260% Medicaid APG methodology,1702.02,,,1702.02,Other,324% Medicaid APG methodology,1129.43,,,1129.43,Other,215% Medicaid APG methodology,1129.43,,,1129.43,Other,215% Medicaid APG methodology,656.64,,,656.64,Other,125% Medicaid APG methodology,76.09,7947,
TELETHX ISODOSE PLAN CPLX       ,77307,CPT,,44000503,CDM,333,RC,,,both,,,6683,702.65,,,702.65,Other,150% of Medicare + 9.63% HCRA Surcharge,427.28,,,427.28,Other,Medicare OPPS methodology,510.78,,,510.78,Fee Schedule,,459.06,,,459.06,Fee Schedule,,137.5,,,137.5,Fee Schedule,,137.5,,,137.5,Fee Schedule,,137.5,,,137.5,Fee Schedule,,3341.5,50,,3341.5,percent of total billed charges,All Other,993.14,,,993.14,Fee Schedule,,612.62,,,612.62,Fee Schedule,,925.03,,,925.03,Other,186% Medicaid methodology,720.91,,,720.91,Fee Schedule,,4143.46,,,4143.46,Fee Schedule,,339.44,,,339.44,Fee Schedule,,720.91,,,720.91,Fee Schedule,,4143.46,,,4143.46,Fee Schedule,,638.48,,,638.48,Fee Schedule,,4678.1,70,,4678.1,percent of total billed charges,All Other,640.2,,,640.2,Fee Schedule,,543.2,,,543.2,Fee Schedule,,7413,,,7413,Case Rate,Rad Therapy Per Visit,7152,,,7152,Case Rate,Rad Therapy Per Visit,7947,,,7947,Case Rate,Rad Therapy Per Visit,6755,,,6755,Case Rate,Rad Therapy Per Visit,497.33,,,497.33,Other,New York Medicaid APG methodology,497.33,,,497.33,Other,100% Medicaid APG methodology,497.33,,,497.33,Other,100% Medicaid APG methodology,497.33,,,497.33,Other,100% Medicaid APG methodology,1118.99,,,1118.99,Other,225% Medicaid APG methodology,1118.99,,,1118.99,Other,225% Medicaid APG methodology,760.91,,,760.91,Other,153% Medicaid APG methodology,1118.99,,,1118.99,Other,225% Medicaid APG methodology,696.26,,,696.26,Other,140% Medicaid APG methodology,1118.99,,,1118.99,Other,225% Medicaid APG methodology,1293.05,,,1293.05,Other,260% Medicaid APG methodology,1611.34,,,1611.34,Other,324% Medicaid APG methodology,1069.26,,,1069.26,Other,215% Medicaid APG methodology,1069.26,,,1069.26,Other,215% Medicaid APG methodology,621.66,,,621.66,Other,125% Medicaid APG methodology,137.5,7947,
SPECIAL TELETX PORT PLAN        ,77321,CPT,,44000511,CDM,333,RC,,,both,,,2265,702.65,,,702.65,Other,150% of Medicare + 9.63% HCRA Surcharge,427.28,,,427.28,Other,Medicare OPPS methodology,167.13,,,167.13,Fee Schedule,,150.21,,,150.21,Fee Schedule,,548.84,,,548.84,Fee Schedule,,493.8,,,493.8,Fee Schedule,,466.28,,,466.28,Fee Schedule,,1132.5,50,,1132.5,percent of total billed charges,All Other,993.14,,,993.14,Fee Schedule,,200.45,,,200.45,Fee Schedule,,925.03,,,925.03,Other,186% Medicaid methodology,235.89,,,235.89,Fee Schedule,,1404.3,,,1404.3,Fee Schedule,,111.07,,,111.07,Fee Schedule,,235.89,,,235.89,Fee Schedule,,1404.3,,,1404.3,Fee Schedule,,208.92,,,208.92,Fee Schedule,,1585.5,70,,1585.5,percent of total billed charges,All Other,211.2,,,211.2,Fee Schedule,,179.2,,,179.2,Fee Schedule,,7413,,,7413,Case Rate,Rad Therapy Per Visit,7152,,,7152,Case Rate,Rad Therapy Per Visit,7947,,,7947,Case Rate,Rad Therapy Per Visit,6755,,,6755,Case Rate,Rad Therapy Per Visit,497.33,,,497.33,Other,New York Medicaid APG methodology,497.33,,,497.33,Other,100% Medicaid APG methodology,497.33,,,497.33,Other,100% Medicaid APG methodology,497.33,,,497.33,Other,100% Medicaid APG methodology,1118.99,,,1118.99,Other,225% Medicaid APG methodology,1118.99,,,1118.99,Other,225% Medicaid APG methodology,760.91,,,760.91,Other,153% Medicaid APG methodology,1118.99,,,1118.99,Other,225% Medicaid APG methodology,696.26,,,696.26,Other,140% Medicaid APG methodology,1118.99,,,1118.99,Other,225% Medicaid APG methodology,1293.05,,,1293.05,Other,260% Medicaid APG methodology,1611.34,,,1611.34,Other,324% Medicaid APG methodology,1069.26,,,1069.26,Other,215% Medicaid APG methodology,1069.26,,,1069.26,Other,215% Medicaid APG methodology,621.66,,,621.66,Other,125% Medicaid APG methodology,111.07,7947,
RADIATION PHYSICS CONSULT       ,77370,CPT,,44000560,CDM,333,RC,,,both,,,6683,258.03,,,258.03,Other,150% of Medicare + 9.63% HCRA Surcharge,156.91,,,156.91,Other,Medicare OPPS methodology,549.9,,,549.9,Fee Schedule,,494.22,,,494.22,Fee Schedule,,1069.89,,,1069.89,Fee Schedule,,962.6,,,962.6,Fee Schedule,,908.96,,,908.96,Fee Schedule,,3341.5,50,,3341.5,percent of total billed charges,All Other,372.03,,,372.03,Fee Schedule,,659.54,,,659.54,Fee Schedule,,977.09,,,977.09,Other,186% Medicaid methodology,776.13,,,776.13,Fee Schedule,,4143.46,,,4143.46,Fee Schedule,,365.44,,,365.44,Fee Schedule,,776.13,,,776.13,Fee Schedule,,4143.46,,,4143.46,Fee Schedule,,687.38,,,687.38,Fee Schedule,,4678.1,70,,4678.1,percent of total billed charges,All Other,638.55,,,638.55,Fee Schedule,,541.8,,,541.8,Fee Schedule,,7413,,,7413,Case Rate,Rad Therapy Per Visit,7152,,,7152,Case Rate,Rad Therapy Per Visit,7947,,,7947,Case Rate,Rad Therapy Per Visit,6755,,,6755,Case Rate,Rad Therapy Per Visit,525.32,,,525.32,Other,New York Medicaid APG methodology,525.32,,,525.32,Other,100% Medicaid APG methodology,525.32,,,525.32,Other,100% Medicaid APG methodology,525.32,,,525.32,Other,100% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,803.73,,,803.73,Other,153% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,735.44,,,735.44,Other,140% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,1365.82,,,1365.82,Other,260% Medicaid APG methodology,1702.02,,,1702.02,Other,324% Medicaid APG methodology,1129.43,,,1129.43,Other,215% Medicaid APG methodology,1129.43,,,1129.43,Other,215% Medicaid APG methodology,656.64,,,656.64,Other,125% Medicaid APG methodology,156.91,7947,
RADIOLOGY PORT IMAGES(S)        ,77417,CPT,,44000578,CDM,333,RC,,,both,,,486,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,56.6,,,56.6,Fee Schedule,,50.86,,,50.86,Fee Schedule,,137.28,,,137.28,Fee Schedule,,123.52,,,123.52,Fee Schedule,,116.63,,,116.63,Fee Schedule,,243,50,,243,percent of total billed charges,All Other,340.2,70,,340.2,percent of total billed charges,All Other,67.88,,,67.88,Fee Schedule,,110.32,,,110.32,Other,186% Medicaid methodology,79.88,,,79.88,Fee Schedule,,301.32,,,301.32,Fee Schedule,,37.61,,,37.61,Fee Schedule,,79.88,,,79.88,Fee Schedule,,301.32,,,301.32,Fee Schedule,,70.74,,,70.74,Fee Schedule,,340.2,70,,340.2,percent of total billed charges,All Other,61.05,,,61.05,Fee Schedule,,51.8,,,51.8,Fee Schedule,,7413,,,7413,Case Rate,Rad Therapy Per Visit,7152,,,7152,Case Rate,Rad Therapy Per Visit,7947,,,7947,Case Rate,Rad Therapy Per Visit,6755,,,6755,Case Rate,Rad Therapy Per Visit,59.31,,,59.31,Other,New York Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,59.31,,,59.31,Other,100% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,90.75,,,90.75,Other,153% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,83.03,,,83.03,Other,140% Medicaid APG methodology,133.45,,,133.45,Other,225% Medicaid APG methodology,154.21,,,154.21,Other,260% Medicaid APG methodology,192.17,,,192.17,Other,324% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,127.52,,,127.52,Other,215% Medicaid APG methodology,74.14,,,74.14,Other,125% Medicaid APG methodology,0.01,7947,
RADIOTHERAPY DOSE PLAN IMRT     ,77301,CPT,,44000933,CDM,333,RC,,,both,,,31664,2634.97,,,2634.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1602.34,,,1602.34,Other,Medicare OPPS methodology,5348.74,,,5348.74,Fee Schedule,,4807.1,,,4807.1,Fee Schedule,,15479.29,,,15479.29,Fee Schedule,,13927.05,,,13927.05,Fee Schedule,,13150.93,,,13150.93,Fee Schedule,,15832,50,,15832,percent of total billed charges,All Other,3701.17,,,3701.17,Fee Schedule,,6415.11,,,6415.11,Fee Schedule,,377.79,,,377.79,Other,186% Medicaid methodology,7549.17,,,7549.17,Fee Schedule,,19631.68,,,19631.68,Fee Schedule,,3554.54,,,3554.54,Fee Schedule,,7549.17,,,7549.17,Fee Schedule,,19631.68,,,19631.68,Fee Schedule,,6685.93,,,6685.93,Fee Schedule,,22164.8,70,,22164.8,percent of total billed charges,All Other,6868.95,,,6868.95,Fee Schedule,,5828.2,,,5828.2,Fee Schedule,,7413,,,7413,Case Rate,Rad Therapy Per Visit,7152,,,7152,Case Rate,Rad Therapy Per Visit,7947,,,7947,Case Rate,Rad Therapy Per Visit,6755,,,6755,Case Rate,Rad Therapy Per Visit,203.11,,,203.11,Other,New York Medicaid APG methodology,203.11,,,203.11,Other,100% Medicaid APG methodology,203.11,,,203.11,Other,100% Medicaid APG methodology,203.11,,,203.11,Other,100% Medicaid APG methodology,457,,,457,Other,225% Medicaid APG methodology,457,,,457,Other,225% Medicaid APG methodology,310.76,,,310.76,Other,153% Medicaid APG methodology,457,,,457,Other,225% Medicaid APG methodology,284.36,,,284.36,Other,140% Medicaid APG methodology,457,,,457,Other,225% Medicaid APG methodology,528.09,,,528.09,Other,260% Medicaid APG methodology,658.08,,,658.08,Other,324% Medicaid APG methodology,436.69,,,436.69,Other,215% Medicaid APG methodology,436.69,,,436.69,Other,215% Medicaid APG methodology,253.89,,,253.89,Other,125% Medicaid APG methodology,203.11,22164.8,
INTSTY MODUL RAD TX DLVR CPLX   ,77386,CPT,,44000941,CDM,333,RC,,,both,,,10744,1119.42,,,1119.42,Other,150% of Medicare + 9.63% HCRA Surcharge,680.73,,,680.73,Other,Medicare OPPS methodology,5372,50,,5372,percent of total billed charges,All Other Outpatient,4834.8,45,,4834.8,percent of total billed charges,All Other Outpatient,366.63,,,366.63,Fee Schedule,,366.63,,,366.63,Fee Schedule,,366.63,,,366.63,Fee Schedule,,5372,50,,5372,percent of total billed charges,All Other,1590.94,,,1590.94,Fee Schedule,,7305.92,68,,7305.92,percent of total billed charges,All Other Outpatient,362.27,,,362.27,Other,186% Medicaid methodology,8595.2,80,,8595.2,percent of total billed charges,All Other Outpatient,8917.52,83,,8917.52,percent of total billed charges,All Other Outpatient,8917.52,83,,8917.52,percent of total billed charges,All Other Outpatient,8595.2,80,,8595.2,percent of total billed charges,All Other Outpatient,8917.52,83,,8917.52,percent of total billed charges,All Other Outpatient,9669.6,90,,9669.6,percent of total billed charges,All Other,7520.8,70,,7520.8,percent of total billed charges,All Other,5372,50,,5372,percent of total billed charges,All Other,5372,50,,5372,percent of total billed charges,All Other,7413,,,7413,Case Rate,Rad Therapy Per Visit,7152,,,7152,Case Rate,Rad Therapy Per Visit,7947,,,7947,Case Rate,Rad Therapy Per Visit,6755,,,6755,Case Rate,Rad Therapy Per Visit,194.77,,,194.77,Other,New York Medicaid APG methodology,194.77,,,194.77,Other,100% Medicaid APG methodology,194.77,,,194.77,Other,100% Medicaid APG methodology,194.77,,,194.77,Other,100% Medicaid APG methodology,438.23,,,438.23,Other,225% Medicaid APG methodology,438.23,,,438.23,Other,225% Medicaid APG methodology,298,,,298,Other,153% Medicaid APG methodology,438.23,,,438.23,Other,225% Medicaid APG methodology,272.68,,,272.68,Other,140% Medicaid APG methodology,438.23,,,438.23,Other,225% Medicaid APG methodology,506.4,,,506.4,Other,260% Medicaid APG methodology,631.05,,,631.05,Other,324% Medicaid APG methodology,418.75,,,418.75,Other,215% Medicaid APG methodology,418.75,,,418.75,Other,215% Medicaid APG methodology,243.46,,,243.46,Other,125% Medicaid APG methodology,194.77,9669.6,
SBRT DELIVERY                   ,77373,CPT,,44000958,CDM,333,RC,,,both,,,2316,3393.22,,,3393.22,Other,150% of Medicare + 9.63% HCRA Surcharge,2063.44,,,2063.44,Other,Medicare OPPS methodology,3724.76,,,3724.76,Fee Schedule,,3347.56,,,3347.56,Fee Schedule,,14594.86,,,14594.86,Fee Schedule,,13131.31,,,13131.31,Fee Schedule,,12399.53,,,12399.53,Fee Schedule,,1158,50,,1158,percent of total billed charges,All Other,5083.94,,,5083.94,Fee Schedule,,4467.35,,,4467.35,Fee Schedule,,1586.64,,,1586.64,Other,186% Medicaid methodology,5257.09,,,5257.09,Fee Schedule,,1435.92,,,1435.92,Fee Schedule,,2475.31,,,2475.31,Fee Schedule,,5257.09,,,5257.09,Fee Schedule,,1435.92,,,1435.92,Fee Schedule,,4655.94,,,4655.94,Fee Schedule,,1621.2,70,,1621.2,percent of total billed charges,All Other,4958.25,,,4958.25,Fee Schedule,,4207,,,4207,Fee Schedule,,6233,,,6233,Case Rate,Stereotactic Radio Case Rate,5610,,,5610,Case Rate,Stereotactic Radio Case Rate,6233,,,6233,Case Rate,Stereotactic Radio Case Rate,5298,,,5298,Case Rate,Stereotactic Radio Case Rate,853.03,,,853.03,Other,New York Medicaid APG methodology,853.03,,,853.03,Other,100% Medicaid APG methodology,853.03,,,853.03,Other,100% Medicaid APG methodology,853.03,,,853.03,Other,100% Medicaid APG methodology,1919.32,,,1919.32,Other,225% Medicaid APG methodology,1919.32,,,1919.32,Other,225% Medicaid APG methodology,1305.14,,,1305.14,Other,153% Medicaid APG methodology,1919.32,,,1919.32,Other,225% Medicaid APG methodology,1194.25,,,1194.25,Other,140% Medicaid APG methodology,1919.32,,,1919.32,Other,225% Medicaid APG methodology,2217.89,,,2217.89,Other,260% Medicaid APG methodology,2763.83,,,2763.83,Other,324% Medicaid APG methodology,1834.02,,,1834.02,Other,215% Medicaid APG methodology,1834.02,,,1834.02,Other,215% Medicaid APG methodology,1066.29,,,1066.29,Other,125% Medicaid APG methodology,853.03,14594.86,
GUIDANCE FOR RADJ TX DLVR       ,77387,CPT,,44001121,CDM,333,RC,,,both,,,10744,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,5372,50,,5372,percent of total billed charges,All Other Outpatient,4834.8,45,,4834.8,percent of total billed charges,All Other Outpatient,63.46,,,63.46,Fee Schedule,,63.46,,,63.46,Fee Schedule,,63.46,,,63.46,Fee Schedule,,5372,50,,5372,percent of total billed charges,All Other,281.16,,,281.16,Fee Schedule,,7305.92,68,,7305.92,percent of total billed charges,All Other Outpatient,977.09,,,977.09,Other,186% Medicaid methodology,8595.2,80,,8595.2,percent of total billed charges,All Other Outpatient,8917.52,83,,8917.52,percent of total billed charges,All Other Outpatient,8917.52,83,,8917.52,percent of total billed charges,All Other Outpatient,8595.2,80,,8595.2,percent of total billed charges,All Other Outpatient,8917.52,83,,8917.52,percent of total billed charges,All Other Outpatient,9669.6,90,,9669.6,percent of total billed charges,All Other,7520.8,70,,7520.8,percent of total billed charges,All Other,5372,50,,5372,percent of total billed charges,All Other,5372,50,,5372,percent of total billed charges,All Other,7413,,,7413,Case Rate,Rad Therapy Per Visit,7152,,,7152,Case Rate,Rad Therapy Per Visit,7947,,,7947,Case Rate,Rad Therapy Per Visit,6755,,,6755,Case Rate,Rad Therapy Per Visit,525.32,,,525.32,Other,New York Medicaid APG methodology,525.32,,,525.32,Other,100% Medicaid APG methodology,525.32,,,525.32,Other,100% Medicaid APG methodology,525.32,,,525.32,Other,100% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,803.73,,,803.73,Other,153% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,735.44,,,735.44,Other,140% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,1365.82,,,1365.82,Other,260% Medicaid APG methodology,1702.02,,,1702.02,Other,324% Medicaid APG methodology,1129.43,,,1129.43,Other,215% Medicaid APG methodology,1129.43,,,1129.43,Other,215% Medicaid APG methodology,656.64,,,656.64,Other,125% Medicaid APG methodology,0.01,9669.6,
IMAGE FUSION 77387,77387,CPT,TC,44001238,CDM,333,RC,,,both,,,14477,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,7238.5,,,7238.5,Fee Schedule,,7238.5,,,7238.5,Fee Schedule,,63.46,,,63.46,Fee Schedule,,63.46,,,63.46,Fee Schedule,,63.46,,,63.46,Fee Schedule,,7238.5,50,,7238.5,percent of total billed charges,All Other,10133.9,70,,10133.9,percent of total billed charges,All Other,6225.11,43,,6225.11,percent of total billed charges,All Other,977.09,,,977.09,Other,186% Medicaid methodology,7238.5,50,,7238.5,percent of total billed charges,All Other,7962.35,55,,7962.35,percent of total billed charges,All Other,7962.35,55,,7962.35,percent of total billed charges,All Other,7238.5,50,,7238.5,percent of total billed charges,All Other,7962.35,55,,7962.35,percent of total billed charges,All Other,13029.3,90,,13029.3,percent of total billed charges,All Other,10133.9,70,,10133.9,percent of total billed charges,All Other,7238.5,50,,7238.5,percent of total billed charges,All Other,7238.5,50,,7238.5,percent of total billed charges,All Other,7413,,,7413,Case Rate,Rad Therapy Per Visit,7152,,,7152,Case Rate,Rad Therapy Per Visit,7947,,,7947,Case Rate,Rad Therapy Per Visit,6755,,,6755,Case Rate,Rad Therapy Per Visit,525.32,,,525.32,Other,New York Medicaid APG methodology,525.32,,,525.32,Other,100% Medicaid APG methodology,525.32,,,525.32,Other,100% Medicaid APG methodology,525.32,,,525.32,Other,100% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,803.73,,,803.73,Other,153% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,735.44,,,735.44,Other,140% Medicaid APG methodology,1181.96,,,1181.96,Other,225% Medicaid APG methodology,1365.82,,,1365.82,Other,260% Medicaid APG methodology,1702.02,,,1702.02,Other,324% Medicaid APG methodology,1129.43,,,1129.43,Other,215% Medicaid APG methodology,1129.43,,,1129.43,Other,215% Medicaid APG methodology,656.64,,,656.64,Other,125% Medicaid APG methodology,0.01,13029.3,
INTSTY MODUL RAD TX DLVR SMPL   ,77385,CPT,,44050177,CDM,333,RC,,,both,,,30800,1119.42,,,1119.42,Other,150% of Medicare + 9.63% HCRA Surcharge,680.73,,,680.73,Other,Medicare OPPS methodology,15400,50,,15400,percent of total billed charges,All Other Outpatient,13860,45,,13860,percent of total billed charges,All Other Outpatient,365.52,,,365.52,Fee Schedule,,365.52,,,365.52,Fee Schedule,,365.52,,,365.52,Fee Schedule,,15400,50,,15400,percent of total billed charges,All Other,1590.94,,,1590.94,Fee Schedule,,20944,68,,20944,percent of total billed charges,All Other Outpatient,362.27,,,362.27,Other,186% Medicaid methodology,24640,80,,24640,percent of total billed charges,All Other Outpatient,25564,83,,25564,percent of total billed charges,All Other Outpatient,25564,83,,25564,percent of total billed charges,All Other Outpatient,24640,80,,24640,percent of total billed charges,All Other Outpatient,25564,83,,25564,percent of total billed charges,All Other Outpatient,27720,90,,27720,percent of total billed charges,All Other,21560,70,,21560,percent of total billed charges,All Other,15400,50,,15400,percent of total billed charges,All Other,15400,50,,15400,percent of total billed charges,All Other,7413,,,7413,Case Rate,Rad Therapy Per Visit,7152,,,7152,Case Rate,Rad Therapy Per Visit,7947,,,7947,Case Rate,Rad Therapy Per Visit,6755,,,6755,Case Rate,Rad Therapy Per Visit,194.77,,,194.77,Other,New York Medicaid APG methodology,194.77,,,194.77,Other,100% Medicaid APG methodology,194.77,,,194.77,Other,100% Medicaid APG methodology,194.77,,,194.77,Other,100% Medicaid APG methodology,438.23,,,438.23,Other,225% Medicaid APG methodology,438.23,,,438.23,Other,225% Medicaid APG methodology,298,,,298,Other,153% Medicaid APG methodology,438.23,,,438.23,Other,225% Medicaid APG methodology,272.68,,,272.68,Other,140% Medicaid APG methodology,438.23,,,438.23,Other,225% Medicaid APG methodology,506.4,,,506.4,Other,260% Medicaid APG methodology,631.05,,,631.05,Other,324% Medicaid APG methodology,418.75,,,418.75,Other,215% Medicaid APG methodology,418.75,,,418.75,Other,215% Medicaid APG methodology,243.46,,,243.46,Other,125% Medicaid APG methodology,194.77,27720,
CHEMO HORMON ANTINEOPL SQ/IM    ,96402,CPT,,40800492,CDM,335,RC,,,both,,,829,133.96,,,133.96,Other,150% of Medicare + 9.63% HCRA Surcharge,81.46,,,81.46,Other,Medicare OPPS methodology,581,,,581,Case Rate,Chemotherapy Per Visit,523,,,523,Case Rate,Chemotherapy Per Visit,5902,,,5902,Case Rate,Chemotherapy Per Visit,5312,,,5312,Case Rate,Chemotherapy Per Visit,5017,,,5017,Case Rate,Chemotherapy Per Visit,414.5,50,,414.5,percent of total billed charges,All Other,785,,,785,Case Rate,Chemotherapy Per Visit,563.72,68,,563.72,percent of total billed charges,All Other,116.47,,,116.47,Other,186% Medicaid methodology,663.2,80,,663.2,percent of total billed charges,All Other,688.07,83,,688.07,percent of total billed charges,All Other,688.07,83,,688.07,percent of total billed charges,All Other,663.2,80,,663.2,percent of total billed charges,All Other,688.07,83,,688.07,percent of total billed charges,All Other,1735,,,1735,Case Rate,Chemotherapy Per Visit,580.3,70,,580.3,percent of total billed charges,All Other,161.7,,,161.7,Fee Schedule,,137.2,,,137.2,Fee Schedule,,2307,,,2307,Case Rate,Chemotherapy Per Visit,1983,,,1983,Case Rate,Chemotherapy Per Visit,2203,,,2203,Case Rate,Chemotherapy Per Visit,1873,,,1873,Case Rate,Chemotherapy Per Visit,62.62,,,62.62,Other,New York Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,95.8,,,95.8,Other,153% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,87.66,,,87.66,Other,140% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,162.81,,,162.81,Other,260% Medicaid APG methodology,202.88,,,202.88,Other,324% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,78.27,,,78.27,Other,125% Medicaid APG methodology,62.62,5902,
CHEMO IV PUSH SNGL DRUG         ,96409,CPT,,40800500,CDM,335,RC,,,both,,,744,644.03,,,644.03,Other,150% of Medicare + 9.63% HCRA Surcharge,391.64,,,391.64,Other,Medicare OPPS methodology,581,,,581,Case Rate,Chemotherapy Per Visit,523,,,523,Case Rate,Chemotherapy Per Visit,5902,,,5902,Case Rate,Chemotherapy Per Visit,5312,,,5312,Case Rate,Chemotherapy Per Visit,5017,,,5017,Case Rate,Chemotherapy Per Visit,372,50,,372,percent of total billed charges,All Other,785,,,785,Case Rate,Chemotherapy Per Visit,505.92,68,,505.92,percent of total billed charges,All Other,116.47,,,116.47,Other,186% Medicaid methodology,595.2,80,,595.2,percent of total billed charges,All Other,617.52,83,,617.52,percent of total billed charges,All Other,617.52,83,,617.52,percent of total billed charges,All Other,595.2,80,,595.2,percent of total billed charges,All Other,617.52,83,,617.52,percent of total billed charges,All Other,1735,,,1735,Case Rate,Chemotherapy Per Visit,520.8,70,,520.8,percent of total billed charges,All Other,514.8,,,514.8,Fee Schedule,,436.8,,,436.8,Fee Schedule,,2307,,,2307,Case Rate,Chemotherapy Per Visit,1983,,,1983,Case Rate,Chemotherapy Per Visit,2203,,,2203,Case Rate,Chemotherapy Per Visit,1873,,,1873,Case Rate,Chemotherapy Per Visit,62.62,,,62.62,Other,New York Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,95.8,,,95.8,Other,153% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,87.66,,,87.66,Other,140% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,162.81,,,162.81,Other,260% Medicaid APG methodology,202.88,,,202.88,Other,324% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,78.27,,,78.27,Other,125% Medicaid APG methodology,62.62,5902,
CHEMO IV PUSH ADDL DRUG         ,96411,CPT,,40800518,CDM,335,RC,,,both,,,654,133.96,,,133.96,Other,150% of Medicare + 9.63% HCRA Surcharge,81.46,,,81.46,Other,Medicare OPPS methodology,581,,,581,Case Rate,Chemotherapy Per Visit,523,,,523,Case Rate,Chemotherapy Per Visit,5902,,,5902,Case Rate,Chemotherapy Per Visit,5312,,,5312,Case Rate,Chemotherapy Per Visit,5017,,,5017,Case Rate,Chemotherapy Per Visit,327,50,,327,percent of total billed charges,All Other,785,,,785,Case Rate,Chemotherapy Per Visit,444.72,68,,444.72,percent of total billed charges,All Other,116.47,,,116.47,Other,186% Medicaid methodology,523.2,80,,523.2,percent of total billed charges,All Other,542.82,83,,542.82,percent of total billed charges,All Other,542.82,83,,542.82,percent of total billed charges,All Other,523.2,80,,523.2,percent of total billed charges,All Other,542.82,83,,542.82,percent of total billed charges,All Other,1735,,,1735,Case Rate,Chemotherapy Per Visit,457.8,70,,457.8,percent of total billed charges,All Other,280.5,,,280.5,Fee Schedule,,238,,,238,Fee Schedule,,2307,,,2307,Case Rate,Chemotherapy Per Visit,1983,,,1983,Case Rate,Chemotherapy Per Visit,2203,,,2203,Case Rate,Chemotherapy Per Visit,1873,,,1873,Case Rate,Chemotherapy Per Visit,62.62,,,62.62,Other,New York Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,95.8,,,95.8,Other,153% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,87.66,,,87.66,Other,140% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,162.81,,,162.81,Other,260% Medicaid APG methodology,202.88,,,202.88,Other,324% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,78.27,,,78.27,Other,125% Medicaid APG methodology,62.62,5902,
CHEMO IV INFUSION 1 HR          ,96413,CPT,,40800526,CDM,335,RC,,,both,,,1620,644.03,,,644.03,Other,150% of Medicare + 9.63% HCRA Surcharge,391.64,,,391.64,Other,Medicare OPPS methodology,581,,,581,Case Rate,Chemotherapy Per Visit,523,,,523,Case Rate,Chemotherapy Per Visit,5902,,,5902,Case Rate,Chemotherapy Per Visit,5312,,,5312,Case Rate,Chemotherapy Per Visit,5017,,,5017,Case Rate,Chemotherapy Per Visit,810,50,,810,percent of total billed charges,All Other,785,,,785,Case Rate,Chemotherapy Per Visit,1101.6,68,,1101.6,percent of total billed charges,All Other,577.69,,,577.69,Other,186% Medicaid methodology,1296,80,,1296,percent of total billed charges,All Other,1344.6,83,,1344.6,percent of total billed charges,All Other,1344.6,83,,1344.6,percent of total billed charges,All Other,1296,80,,1296,percent of total billed charges,All Other,1344.6,83,,1344.6,percent of total billed charges,All Other,1735,,,1735,Case Rate,Chemotherapy Per Visit,1134,70,,1134,percent of total billed charges,All Other,668.25,,,668.25,Fee Schedule,,567,,,567,Fee Schedule,,2307,,,2307,Case Rate,Chemotherapy Per Visit,1983,,,1983,Case Rate,Chemotherapy Per Visit,2203,,,2203,Case Rate,Chemotherapy Per Visit,1873,,,1873,Case Rate,Chemotherapy Per Visit,310.58,,,310.58,Other,New York Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,475.19,,,475.19,Other,153% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,434.82,,,434.82,Other,140% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,807.52,,,807.52,Other,260% Medicaid APG methodology,1006.29,,,1006.29,Other,324% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,388.23,,,388.23,Other,125% Medicaid APG methodology,310.58,5902,
CHEMO IV INFUSION ADDL HR       ,96415,CPT,,40800534,CDM,335,RC,,,both,,,777,133.96,,,133.96,Other,150% of Medicare + 9.63% HCRA Surcharge,81.46,,,81.46,Other,Medicare OPPS methodology,581,,,581,Case Rate,Chemotherapy Per Visit,523,,,523,Case Rate,Chemotherapy Per Visit,5902,,,5902,Case Rate,Chemotherapy Per Visit,5312,,,5312,Case Rate,Chemotherapy Per Visit,5017,,,5017,Case Rate,Chemotherapy Per Visit,388.5,50,,388.5,percent of total billed charges,All Other,785,,,785,Case Rate,Chemotherapy Per Visit,528.36,68,,528.36,percent of total billed charges,All Other,1474.51,,,1474.51,Other,186% Medicaid methodology,621.6,80,,621.6,percent of total billed charges,All Other,644.91,83,,644.91,percent of total billed charges,All Other,644.91,83,,644.91,percent of total billed charges,All Other,621.6,80,,621.6,percent of total billed charges,All Other,644.91,83,,644.91,percent of total billed charges,All Other,1735,,,1735,Case Rate,Chemotherapy Per Visit,543.9,70,,543.9,percent of total billed charges,All Other,141.9,,,141.9,Fee Schedule,,120.4,,,120.4,Fee Schedule,,2307,,,2307,Case Rate,Chemotherapy Per Visit,1983,,,1983,Case Rate,Chemotherapy Per Visit,2203,,,2203,Case Rate,Chemotherapy Per Visit,1873,,,1873,Case Rate,Chemotherapy Per Visit,792.75,,,792.75,Other,New York Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1212.91,,,1212.91,Other,153% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1109.85,,,1109.85,Other,140% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,2061.15,,,2061.15,Other,260% Medicaid APG methodology,2568.51,,,2568.51,Other,324% Medicaid APG methodology,1704.41,,,1704.41,Other,215% Medicaid APG methodology,1704.41,,,1704.41,Other,215% Medicaid APG methodology,990.94,,,990.94,Other,125% Medicaid APG methodology,81.46,5902,
CHEMO IV INFUS EACH ADDL SEQ    ,96417,CPT,,40800542,CDM,335,RC,,,both,,,1586,133.96,,,133.96,Other,150% of Medicare + 9.63% HCRA Surcharge,81.46,,,81.46,Other,Medicare OPPS methodology,581,,,581,Case Rate,Chemotherapy Per Visit,523,,,523,Case Rate,Chemotherapy Per Visit,5902,,,5902,Case Rate,Chemotherapy Per Visit,5312,,,5312,Case Rate,Chemotherapy Per Visit,5017,,,5017,Case Rate,Chemotherapy Per Visit,793,50,,793,percent of total billed charges,All Other,785,,,785,Case Rate,Chemotherapy Per Visit,1078.48,68,,1078.48,percent of total billed charges,All Other,577.69,,,577.69,Other,186% Medicaid methodology,1268.8,80,,1268.8,percent of total billed charges,All Other,1316.38,83,,1316.38,percent of total billed charges,All Other,1316.38,83,,1316.38,percent of total billed charges,All Other,1268.8,80,,1268.8,percent of total billed charges,All Other,1316.38,83,,1316.38,percent of total billed charges,All Other,1735,,,1735,Case Rate,Chemotherapy Per Visit,1110.2,70,,1110.2,percent of total billed charges,All Other,325.05,,,325.05,Fee Schedule,,275.8,,,275.8,Fee Schedule,,2307,,,2307,Case Rate,Chemotherapy Per Visit,1983,,,1983,Case Rate,Chemotherapy Per Visit,2203,,,2203,Case Rate,Chemotherapy Per Visit,1873,,,1873,Case Rate,Chemotherapy Per Visit,310.58,,,310.58,Other,New York Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,475.19,,,475.19,Other,153% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,434.82,,,434.82,Other,140% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,807.52,,,807.52,Other,260% Medicaid APG methodology,1006.29,,,1006.29,Other,324% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,388.23,,,388.23,Other,125% Medicaid APG methodology,81.46,5902,
CHEMOTX ADMN PRTL CAVITY        ,96446,CPT,,40800559,CDM,335,RC,,,both,,,1419,644.03,,,644.03,Other,150% of Medicare + 9.63% HCRA Surcharge,391.64,,,391.64,Other,Medicare OPPS methodology,581,,,581,Case Rate,Chemotherapy Per Visit,523,,,523,Case Rate,Chemotherapy Per Visit,5902,,,5902,Case Rate,Chemotherapy Per Visit,5312,,,5312,Case Rate,Chemotherapy Per Visit,5017,,,5017,Case Rate,Chemotherapy Per Visit,709.5,50,,709.5,percent of total billed charges,All Other,785,,,785,Case Rate,Chemotherapy Per Visit,964.92,68,,964.92,percent of total billed charges,All Other,577.69,,,577.69,Other,186% Medicaid methodology,1135.2,80,,1135.2,percent of total billed charges,All Other,1177.77,83,,1177.77,percent of total billed charges,All Other,1177.77,83,,1177.77,percent of total billed charges,All Other,1135.2,80,,1135.2,percent of total billed charges,All Other,1177.77,83,,1177.77,percent of total billed charges,All Other,1735,,,1735,Case Rate,Chemotherapy Per Visit,993.3,70,,993.3,percent of total billed charges,All Other,130.35,,,130.35,Fee Schedule,,110.6,,,110.6,Fee Schedule,,2307,,,2307,Case Rate,Chemotherapy Per Visit,1983,,,1983,Case Rate,Chemotherapy Per Visit,2203,,,2203,Case Rate,Chemotherapy Per Visit,1873,,,1873,Case Rate,Chemotherapy Per Visit,310.58,,,310.58,Other,New York Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,475.19,,,475.19,Other,153% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,434.82,,,434.82,Other,140% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,807.52,,,807.52,Other,260% Medicaid APG methodology,1006.29,,,1006.29,Other,324% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,388.23,,,388.23,Other,125% Medicaid APG methodology,110.6,5902,
CHEMOTHERAPY INTO CNS           ,96450,CPT,,40800567,CDM,335,RC,,,both,,,1419,644.03,,,644.03,Other,150% of Medicare + 9.63% HCRA Surcharge,391.64,,,391.64,Other,Medicare OPPS methodology,581,,,581,Case Rate,Chemotherapy Per Visit,523,,,523,Case Rate,Chemotherapy Per Visit,5902,,,5902,Case Rate,Chemotherapy Per Visit,5312,,,5312,Case Rate,Chemotherapy Per Visit,5017,,,5017,Case Rate,Chemotherapy Per Visit,709.5,50,,709.5,percent of total billed charges,All Other,785,,,785,Case Rate,Chemotherapy Per Visit,964.92,68,,964.92,percent of total billed charges,All Other,1474.51,,,1474.51,Other,186% Medicaid methodology,1135.2,80,,1135.2,percent of total billed charges,All Other,1177.77,83,,1177.77,percent of total billed charges,All Other,1177.77,83,,1177.77,percent of total billed charges,All Other,1135.2,80,,1135.2,percent of total billed charges,All Other,1177.77,83,,1177.77,percent of total billed charges,All Other,1735,,,1735,Case Rate,Chemotherapy Per Visit,993.3,70,,993.3,percent of total billed charges,All Other,369.6,,,369.6,Fee Schedule,,313.6,,,313.6,Fee Schedule,,2307,,,2307,Case Rate,Chemotherapy Per Visit,1983,,,1983,Case Rate,Chemotherapy Per Visit,2203,,,2203,Case Rate,Chemotherapy Per Visit,1873,,,1873,Case Rate,Chemotherapy Per Visit,792.75,,,792.75,Other,New York Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1212.91,,,1212.91,Other,153% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1109.85,,,1109.85,Other,140% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,2061.15,,,2061.15,Other,260% Medicaid APG methodology,2568.51,,,2568.51,Other,324% Medicaid APG methodology,1704.41,,,1704.41,Other,215% Medicaid APG methodology,1704.41,,,1704.41,Other,215% Medicaid APG methodology,990.94,,,990.94,Other,125% Medicaid APG methodology,313.6,5902,
CHEMO PROLONG INFUSE W/PUMP     ,96416,CPT,,40800757,CDM,335,RC,,,both,,,1561,644.03,,,644.03,Other,150% of Medicare + 9.63% HCRA Surcharge,391.64,,,391.64,Other,Medicare OPPS methodology,581,,,581,Case Rate,Chemotherapy Per Visit,523,,,523,Case Rate,Chemotherapy Per Visit,5902,,,5902,Case Rate,Chemotherapy Per Visit,5312,,,5312,Case Rate,Chemotherapy Per Visit,5017,,,5017,Case Rate,Chemotherapy Per Visit,780.5,50,,780.5,percent of total billed charges,All Other,785,,,785,Case Rate,Chemotherapy Per Visit,1061.48,68,,1061.48,percent of total billed charges,All Other,1474.51,,,1474.51,Other,186% Medicaid methodology,1248.8,80,,1248.8,percent of total billed charges,All Other,1295.63,83,,1295.63,percent of total billed charges,All Other,1295.63,83,,1295.63,percent of total billed charges,All Other,1248.8,80,,1248.8,percent of total billed charges,All Other,1295.63,83,,1295.63,percent of total billed charges,All Other,1735,,,1735,Case Rate,Chemotherapy Per Visit,1092.7,70,,1092.7,percent of total billed charges,All Other,655.05,,,655.05,Fee Schedule,,555.8,,,555.8,Fee Schedule,,2307,,,2307,Case Rate,Chemotherapy Per Visit,1983,,,1983,Case Rate,Chemotherapy Per Visit,2203,,,2203,Case Rate,Chemotherapy Per Visit,1873,,,1873,Case Rate,Chemotherapy Per Visit,792.75,,,792.75,Other,New York Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1212.91,,,1212.91,Other,153% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1109.85,,,1109.85,Other,140% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,2061.15,,,2061.15,Other,260% Medicaid APG methodology,2568.51,,,2568.51,Other,324% Medicaid APG methodology,1704.41,,,1704.41,Other,215% Medicaid APG methodology,1704.41,,,1704.41,Other,215% Medicaid APG methodology,990.94,,,990.94,Other,125% Medicaid APG methodology,391.64,5902,
CHEMO IA INFUSION UP TO 1 HR    ,96422,CPT,,40800773,CDM,335,RC,,,both,,,1005,644.03,,,644.03,Other,150% of Medicare + 9.63% HCRA Surcharge,391.64,,,391.64,Other,Medicare OPPS methodology,581,,,581,Case Rate,Chemotherapy Per Visit,523,,,523,Case Rate,Chemotherapy Per Visit,5902,,,5902,Case Rate,Chemotherapy Per Visit,5312,,,5312,Case Rate,Chemotherapy Per Visit,5017,,,5017,Case Rate,Chemotherapy Per Visit,502.5,50,,502.5,percent of total billed charges,All Other,785,,,785,Case Rate,Chemotherapy Per Visit,683.4,68,,683.4,percent of total billed charges,All Other,577.69,,,577.69,Other,186% Medicaid methodology,804,80,,804,percent of total billed charges,All Other,834.15,83,,834.15,percent of total billed charges,All Other,834.15,83,,834.15,percent of total billed charges,All Other,804,80,,804,percent of total billed charges,All Other,834.15,83,,834.15,percent of total billed charges,All Other,1735,,,1735,Case Rate,Chemotherapy Per Visit,703.5,70,,703.5,percent of total billed charges,All Other,803.55,,,803.55,Fee Schedule,,681.8,,,681.8,Fee Schedule,,2307,,,2307,Case Rate,Chemotherapy Per Visit,1983,,,1983,Case Rate,Chemotherapy Per Visit,2203,,,2203,Case Rate,Chemotherapy Per Visit,1873,,,1873,Case Rate,Chemotherapy Per Visit,310.58,,,310.58,Other,New York Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,475.19,,,475.19,Other,153% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,434.82,,,434.82,Other,140% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,807.52,,,807.52,Other,260% Medicaid APG methodology,1006.29,,,1006.29,Other,324% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,388.23,,,388.23,Other,125% Medicaid APG methodology,310.58,5902,
CHEMO IA INFUSE EACH ADDL HR    ,96423,CPT,,40800781,CDM,335,RC,,,both,,,418,90.33,,,90.33,Other,150% of Medicare + 9.63% HCRA Surcharge,54.93,,,54.93,Other,Medicare OPPS methodology,581,,,581,Case Rate,Chemotherapy Per Visit,523,,,523,Case Rate,Chemotherapy Per Visit,5902,,,5902,Case Rate,Chemotherapy Per Visit,5312,,,5312,Case Rate,Chemotherapy Per Visit,5017,,,5017,Case Rate,Chemotherapy Per Visit,209,50,,209,percent of total billed charges,All Other,785,,,785,Case Rate,Chemotherapy Per Visit,284.24,68,,284.24,percent of total billed charges,All Other,1474.51,,,1474.51,Other,186% Medicaid methodology,334.4,80,,334.4,percent of total billed charges,All Other,346.94,83,,346.94,percent of total billed charges,All Other,346.94,83,,346.94,percent of total billed charges,All Other,334.4,80,,334.4,percent of total billed charges,All Other,346.94,83,,346.94,percent of total billed charges,All Other,1735,,,1735,Case Rate,Chemotherapy Per Visit,292.6,70,,292.6,percent of total billed charges,All Other,371.25,,,371.25,Fee Schedule,,315,,,315,Fee Schedule,,2307,,,2307,Case Rate,Chemotherapy Per Visit,1983,,,1983,Case Rate,Chemotherapy Per Visit,2203,,,2203,Case Rate,Chemotherapy Per Visit,1873,,,1873,Case Rate,Chemotherapy Per Visit,792.75,,,792.75,Other,New York Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1212.91,,,1212.91,Other,153% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1109.85,,,1109.85,Other,140% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,2061.15,,,2061.15,Other,260% Medicaid APG methodology,2568.51,,,2568.51,Other,324% Medicaid APG methodology,1704.41,,,1704.41,Other,215% Medicaid APG methodology,1704.41,,,1704.41,Other,215% Medicaid APG methodology,990.94,,,990.94,Other,125% Medicaid APG methodology,54.93,5902,
CHEMO IA; INFUSION; > 8 HRS     ,96425,CPT,,40800799,CDM,335,RC,,,both,,,1419,644.03,,,644.03,Other,150% of Medicare + 9.63% HCRA Surcharge,391.64,,,391.64,Other,Medicare OPPS methodology,581,,,581,Case Rate,Chemotherapy Per Visit,523,,,523,Case Rate,Chemotherapy Per Visit,5902,,,5902,Case Rate,Chemotherapy Per Visit,5312,,,5312,Case Rate,Chemotherapy Per Visit,5017,,,5017,Case Rate,Chemotherapy Per Visit,709.5,50,,709.5,percent of total billed charges,All Other,785,,,785,Case Rate,Chemotherapy Per Visit,964.92,68,,964.92,percent of total billed charges,All Other,1474.51,,,1474.51,Other,186% Medicaid methodology,1135.2,80,,1135.2,percent of total billed charges,All Other,1177.77,83,,1177.77,percent of total billed charges,All Other,1177.77,83,,1177.77,percent of total billed charges,All Other,1135.2,80,,1135.2,percent of total billed charges,All Other,1177.77,83,,1177.77,percent of total billed charges,All Other,1735,,,1735,Case Rate,Chemotherapy Per Visit,993.3,70,,993.3,percent of total billed charges,All Other,864.6,,,864.6,Fee Schedule,,733.6,,,733.6,Fee Schedule,,2307,,,2307,Case Rate,Chemotherapy Per Visit,1983,,,1983,Case Rate,Chemotherapy Per Visit,2203,,,2203,Case Rate,Chemotherapy Per Visit,1873,,,1873,Case Rate,Chemotherapy Per Visit,792.75,,,792.75,Other,New York Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1212.91,,,1212.91,Other,153% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1109.85,,,1109.85,Other,140% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,2061.15,,,2061.15,Other,260% Medicaid APG methodology,2568.51,,,2568.51,Other,324% Medicaid APG methodology,1704.41,,,1704.41,Other,215% Medicaid APG methodology,1704.41,,,1704.41,Other,215% Medicaid APG methodology,990.94,,,990.94,Other,125% Medicaid APG methodology,391.64,5902,
CHEMO INTRALESIONAL OVER 7      ,96406,CPT,,40800997,CDM,335,RC,,,both,,,1005,407.6,,,407.6,Other,150% of Medicare + 9.63% HCRA Surcharge,247.86,,,247.86,Other,Medicare OPPS methodology,581,,,581,Case Rate,Chemotherapy Per Visit,523,,,523,Case Rate,Chemotherapy Per Visit,5902,,,5902,Case Rate,Chemotherapy Per Visit,5312,,,5312,Case Rate,Chemotherapy Per Visit,5017,,,5017,Case Rate,Chemotherapy Per Visit,502.5,50,,502.5,percent of total billed charges,All Other,785,,,785,Case Rate,Chemotherapy Per Visit,683.4,68,,683.4,percent of total billed charges,All Other,116.47,,,116.47,Other,186% Medicaid methodology,804,80,,804,percent of total billed charges,All Other,834.15,83,,834.15,percent of total billed charges,All Other,834.15,83,,834.15,percent of total billed charges,All Other,804,80,,804,percent of total billed charges,All Other,834.15,83,,834.15,percent of total billed charges,All Other,1735,,,1735,Case Rate,Chemotherapy Per Visit,703.5,70,,703.5,percent of total billed charges,All Other,216.15,,,216.15,Fee Schedule,,183.4,,,183.4,Fee Schedule,,2307,,,2307,Case Rate,Chemotherapy Per Visit,1983,,,1983,Case Rate,Chemotherapy Per Visit,2203,,,2203,Case Rate,Chemotherapy Per Visit,1873,,,1873,Case Rate,Chemotherapy Per Visit,62.62,,,62.62,Other,New York Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,95.8,,,95.8,Other,153% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,87.66,,,87.66,Other,140% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,162.81,,,162.81,Other,260% Medicaid APG methodology,202.88,,,202.88,Other,324% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,78.27,,,78.27,Other,125% Medicaid APG methodology,62.62,5902,
CHEMOTHERAPY UNSPECIFIED        ,96549,CPT,,40801003,CDM,335,RC,,,both,,,418,90.33,,,90.33,Other,150% of Medicare + 9.63% HCRA Surcharge,54.93,,,54.93,Other,Medicare OPPS methodology,209,50,,209,percent of total billed charges,All Other Outpatient,188.1,45,,188.1,percent of total billed charges,All Other Outpatient,209,50,,209,percent of total billed charges,All Other Outpatient,188.1,45,,188.1,percent of total billed charges,All Other Outpatient,179.74,43,,179.74,percent of total billed charges,All Other Outpatient,209,50,,209,percent of total billed charges,All Other,292.6,70,,292.6,percent of total billed charges,All Other,284.24,68,,284.24,percent of total billed charges,All Other Outpatient,577.69,,,577.69,Other,186% Medicaid methodology,334.4,80,,334.4,percent of total billed charges,All Other Outpatient,346.94,83,,346.94,percent of total billed charges,All Other Outpatient,346.94,83,,346.94,percent of total billed charges,All Other Outpatient,334.4,80,,334.4,percent of total billed charges,All Other Outpatient,346.94,83,,346.94,percent of total billed charges,All Other Outpatient,376.2,90,,376.2,percent of total billed charges,All Other,292.6,70,,292.6,percent of total billed charges,All Other,209,50,,209,percent of total billed charges,All Other,209,50,,209,percent of total billed charges,All Other,2307,,,2307,Case Rate,Chemotherapy Per Visit,1983,,,1983,Case Rate,Chemotherapy Per Visit,2203,,,2203,Case Rate,Chemotherapy Per Visit,1873,,,1873,Case Rate,Chemotherapy Per Visit,310.58,,,310.58,Other,New York Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,475.19,,,475.19,Other,153% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,434.82,,,434.82,Other,140% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,807.52,,,807.52,Other,260% Medicaid APG methodology,1006.29,,,1006.29,Other,324% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,388.23,,,388.23,Other,125% Medicaid APG methodology,54.93,2307,
GATED HEART PLANAR SINGLE       ,78472,CPT,,44400471,CDM,341,RC,,,both,,,6860,784.32,,,784.32,Other,150% of Medicare + 9.63% HCRA Surcharge,476.95,,,476.95,Other,Medicare OPPS methodology,618.79,,,618.79,Fee Schedule,,556.13,,,556.13,Fee Schedule,,1861.7,,,1861.7,Fee Schedule,,1675.01,,,1675.01,Fee Schedule,,1581.67,,,1581.67,Fee Schedule,,3430,50,,3430,percent of total billed charges,All Other,1105.85,,,1105.85,Fee Schedule,,742.16,,,742.16,Fee Schedule,,725.43,,,725.43,Other,186% Medicaid methodology,873.36,,,873.36,Fee Schedule,,4253.2,,,4253.2,Fee Schedule,,411.22,,,411.22,Fee Schedule,,873.36,,,873.36,Fee Schedule,,4253.2,,,4253.2,Fee Schedule,,773.49,,,773.49,Fee Schedule,,4802,70,,4802,percent of total billed charges,All Other,844.8,,,844.8,Fee Schedule,,716.8,,,716.8,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,390.01,,,390.01,Other,New York Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,596.72,,,596.72,Other,153% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,546.02,,,546.02,Other,140% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,1014.04,,,1014.04,Other,260% Medicaid APG methodology,1263.65,,,1263.65,Other,324% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,487.52,,,487.52,Other,125% Medicaid APG methodology,390.01,4802,
HT MUSCLE IMAGE SPECT MULT      ,78452,CPT,,44400489,CDM,341,RC,,,both,,,24380,2700.27,,,2700.27,Other,150% of Medicare + 9.63% HCRA Surcharge,1642.05,,,1642.05,Other,Medicare OPPS methodology,1343.16,,,1343.16,Fee Schedule,,1207.14,,,1207.14,Fee Schedule,,3670.06,,,3670.06,Fee Schedule,,3302.03,,,3302.03,Fee Schedule,,3118.02,,,3118.02,Fee Schedule,,12190,50,,12190,percent of total billed charges,All Other,3829.48,,,3829.48,Fee Schedule,,1610.94,,,1610.94,Fee Schedule,,1535.06,,,1535.06,Other,186% Medicaid methodology,1895.72,,,1895.72,Fee Schedule,,15115.6,,,15115.6,Fee Schedule,,892.61,,,892.61,Fee Schedule,,1895.72,,,1895.72,Fee Schedule,,15115.6,,,15115.6,Fee Schedule,,1678.95,,,1678.95,Fee Schedule,,17066,70,,17066,percent of total billed charges,All Other,1843.05,,,1843.05,Fee Schedule,,1563.8,,,1563.8,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,825.3,,,825.3,Other,New York Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1262.71,,,1262.71,Other,153% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1155.42,,,1155.42,Other,140% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,2145.79,,,2145.79,Other,260% Medicaid APG methodology,2673.98,,,2673.98,Other,324% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1031.63,,,1031.63,Other,125% Medicaid APG methodology,825.3,17066,
HT MUSCLE IMAGE SPECT SING      ,78451,CPT,,44400547,CDM,341,RC,,,both,,,23705,2700.27,,,2700.27,Other,150% of Medicare + 9.63% HCRA Surcharge,1642.05,,,1642.05,Other,Medicare OPPS methodology,934.92,,,934.92,Fee Schedule,,840.24,,,840.24,Fee Schedule,,2525.71,,,2525.71,Fee Schedule,,2272.43,,,2272.43,Fee Schedule,,2145.8,,,2145.8,Fee Schedule,,11852.5,50,,11852.5,percent of total billed charges,All Other,3829.48,,,3829.48,Fee Schedule,,1121.31,,,1121.31,Fee Schedule,,1535.06,,,1535.06,Other,186% Medicaid methodology,1319.54,,,1319.54,Fee Schedule,,14697.1,,,14697.1,Fee Schedule,,621.31,,,621.31,Fee Schedule,,1319.54,,,1319.54,Fee Schedule,,14697.1,,,14697.1,Fee Schedule,,1168.65,,,1168.65,Fee Schedule,,16593.5,70,,16593.5,percent of total billed charges,All Other,1275.45,,,1275.45,Fee Schedule,,1082.2,,,1082.2,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,825.3,,,825.3,Other,New York Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1262.71,,,1262.71,Other,153% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1155.42,,,1155.42,Other,140% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,2145.79,,,2145.79,Other,260% Medicaid APG methodology,2673.98,,,2673.98,Other,324% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1031.63,,,1031.63,Other,125% Medicaid APG methodology,621.31,16593.5,
BONE IMAGING MULTIPLE AREAS     ,78305,CPT,,47500004,CDM,341,RC,,,both,,,2616,784.32,,,784.32,Other,150% of Medicare + 9.63% HCRA Surcharge,476.95,,,476.95,Other,Medicare OPPS methodology,790.16,,,790.16,Fee Schedule,,710.14,,,710.14,Fee Schedule,,1761.9,,,1761.9,Fee Schedule,,1585.22,,,1585.22,Fee Schedule,,1496.88,,,1496.88,Fee Schedule,,1308,50,,1308,percent of total billed charges,All Other,1105.85,,,1105.85,Fee Schedule,,947.69,,,947.69,Fee Schedule,,725.43,,,725.43,Other,186% Medicaid methodology,1115.22,,,1115.22,Fee Schedule,,1621.92,,,1621.92,Fee Schedule,,525.11,,,525.11,Fee Schedule,,1115.22,,,1115.22,Fee Schedule,,1621.92,,,1621.92,Fee Schedule,,987.7,,,987.7,Fee Schedule,,1831.2,70,,1831.2,percent of total billed charges,All Other,1097.25,,,1097.25,Fee Schedule,,931,,,931,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,390.01,,,390.01,Other,New York Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,596.72,,,596.72,Other,153% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,546.02,,,546.02,Other,140% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,1014.04,,,1014.04,Other,260% Medicaid APG methodology,1263.65,,,1263.65,Other,324% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,487.52,,,487.52,Other,125% Medicaid APG methodology,390.01,3642,
BONE IMAGING WHOLE BODY         ,78306,CPT,,47500012,CDM,341,RC,,,both,,,6860,784.32,,,784.32,Other,150% of Medicare + 9.63% HCRA Surcharge,476.95,,,476.95,Other,Medicare OPPS methodology,859.68,,,859.68,Fee Schedule,,772.62,,,772.62,Fee Schedule,,1936.52,,,1936.52,Fee Schedule,,1742.33,,,1742.33,Fee Schedule,,1645.23,,,1645.23,Fee Schedule,,3430,50,,3430,percent of total billed charges,All Other,1105.85,,,1105.85,Fee Schedule,,1031.07,,,1031.07,Fee Schedule,,725.43,,,725.43,Other,186% Medicaid methodology,1213.34,,,1213.34,Fee Schedule,,4253.2,,,4253.2,Fee Schedule,,571.31,,,571.31,Fee Schedule,,1213.34,,,1213.34,Fee Schedule,,4253.2,,,4253.2,Fee Schedule,,1074.6,,,1074.6,Fee Schedule,,4802,70,,4802,percent of total billed charges,All Other,1189.65,,,1189.65,Fee Schedule,,1009.4,,,1009.4,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,390.01,,,390.01,Other,New York Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,596.72,,,596.72,Other,153% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,546.02,,,546.02,Other,140% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,1014.04,,,1014.04,Other,260% Medicaid APG methodology,1263.65,,,1263.65,Other,324% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,487.52,,,487.52,Other,125% Medicaid APG methodology,390.01,4802,
BONE IMAGING LIMITED AREA       ,78300,CPT,,47500020,CDM,341,RC,,,both,,,6860,784.32,,,784.32,Other,150% of Medicare + 9.63% HCRA Surcharge,476.95,,,476.95,Other,Medicare OPPS methodology,665.24,,,665.24,Fee Schedule,,597.88,,,597.88,Fee Schedule,,1334.76,,,1334.76,Fee Schedule,,1200.91,,,1200.91,Fee Schedule,,1133.99,,,1133.99,Fee Schedule,,3430,50,,3430,percent of total billed charges,All Other,1105.85,,,1105.85,Fee Schedule,,797.87,,,797.87,Fee Schedule,,725.43,,,725.43,Other,186% Medicaid methodology,938.92,,,938.92,Fee Schedule,,4253.2,,,4253.2,Fee Schedule,,442.09,,,442.09,Fee Schedule,,938.92,,,938.92,Fee Schedule,,4253.2,,,4253.2,Fee Schedule,,831.55,,,831.55,Fee Schedule,,4802,70,,4802,percent of total billed charges,All Other,922.35,,,922.35,Fee Schedule,,782.6,,,782.6,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,390.01,,,390.01,Other,New York Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,596.72,,,596.72,Other,153% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,546.02,,,546.02,Other,140% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,1014.04,,,1014.04,Other,260% Medicaid APG methodology,1263.65,,,1263.65,Other,324% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,487.52,,,487.52,Other,125% Medicaid APG methodology,390.01,4802,
BRAIN IMAGE W/FLOW 4 + VIEWS    ,78606,CPT,,47500038,CDM,341,RC,,,both,,,6374,1027.85,,,1027.85,Other,150% of Medicare + 9.63% HCRA Surcharge,625.04,,,625.04,Other,Medicare OPPS methodology,1017.61,,,1017.61,Fee Schedule,,914.57,,,914.57,Fee Schedule,,2687.83,,,2687.83,Fee Schedule,,2418.3,,,2418.3,Fee Schedule,,2283.54,,,2283.54,Fee Schedule,,3187,50,,3187,percent of total billed charges,All Other,1435.1,,,1435.1,Fee Schedule,,1220.49,,,1220.49,Fee Schedule,,725.43,,,725.43,Other,186% Medicaid methodology,1436.25,,,1436.25,Fee Schedule,,3951.88,,,3951.88,Fee Schedule,,676.26,,,676.26,Fee Schedule,,1436.25,,,1436.25,Fee Schedule,,3951.88,,,3951.88,Fee Schedule,,1272.02,,,1272.02,Fee Schedule,,4461.8,70,,4461.8,percent of total billed charges,All Other,1384.35,,,1384.35,Fee Schedule,,1174.6,,,1174.6,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,390.01,,,390.01,Other,New York Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,596.72,,,596.72,Other,153% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,546.02,,,546.02,Other,140% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,1014.04,,,1014.04,Other,260% Medicaid APG methodology,1263.65,,,1263.65,Other,324% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,487.52,,,487.52,Other,125% Medicaid APG methodology,390.01,4461.8,
GASTRIC EMPTYING IMAG STUDY     ,78264,CPT,,47500095,CDM,341,RC,,,both,,,6860,784.32,,,784.32,Other,150% of Medicare + 9.63% HCRA Surcharge,476.95,,,476.95,Other,Medicare OPPS methodology,994.01,,,994.01,Fee Schedule,,893.35,,,893.35,Fee Schedule,,2195.29,,,2195.29,Fee Schedule,,1975.15,,,1975.15,Fee Schedule,,1865.08,,,1865.08,Fee Schedule,,3430,50,,3430,percent of total billed charges,All Other,1105.85,,,1105.85,Fee Schedule,,1192.18,,,1192.18,Fee Schedule,,725.43,,,725.43,Other,186% Medicaid methodology,1402.94,,,1402.94,Fee Schedule,,4253.2,,,4253.2,Fee Schedule,,660.58,,,660.58,Fee Schedule,,1402.94,,,1402.94,Fee Schedule,,4253.2,,,4253.2,Fee Schedule,,1242.51,,,1242.51,Fee Schedule,,4802,70,,4802,percent of total billed charges,All Other,1362.9,,,1362.9,Fee Schedule,,1156.4,,,1156.4,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,390.01,,,390.01,Other,New York Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,596.72,,,596.72,Other,153% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,546.02,,,546.02,Other,140% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,1014.04,,,1014.04,Other,260% Medicaid APG methodology,1263.65,,,1263.65,Other,324% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,487.52,,,487.52,Other,125% Medicaid APG methodology,390.01,4802,
ACUTE GI BLOOD LOSS IMAGING     ,78278,CPT,,47500103,CDM,341,RC,,,both,,,6860,784.32,,,784.32,Other,150% of Medicare + 9.63% HCRA Surcharge,476.95,,,476.95,Other,Medicare OPPS methodology,1021.34,,,1021.34,Fee Schedule,,917.92,,,917.92,Fee Schedule,,2195.14,,,2195.14,Fee Schedule,,1975.02,,,1975.02,Fee Schedule,,1864.95,,,1864.95,Fee Schedule,,3430,50,,3430,percent of total billed charges,All Other,1105.85,,,1105.85,Fee Schedule,,1224.97,,,1224.97,Fee Schedule,,1535.06,,,1535.06,Other,186% Medicaid methodology,1441.52,,,1441.52,Fee Schedule,,4253.2,,,4253.2,Fee Schedule,,678.74,,,678.74,Fee Schedule,,1441.52,,,1441.52,Fee Schedule,,4253.2,,,4253.2,Fee Schedule,,1276.68,,,1276.68,Fee Schedule,,4802,70,,4802,percent of total billed charges,All Other,1400.85,,,1400.85,Fee Schedule,,1188.6,,,1188.6,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,825.3,,,825.3,Other,New York Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1262.71,,,1262.71,Other,153% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1155.42,,,1155.42,Other,140% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,2145.79,,,2145.79,Other,260% Medicaid APG methodology,2673.98,,,2673.98,Other,324% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1031.63,,,1031.63,Other,125% Medicaid APG methodology,476.95,4802,
HEPATOBILIARY SYSTEM IMAGING    ,78226,CPT,,47500111,CDM,341,RC,,,both,,,6860,784.32,,,784.32,Other,150% of Medicare + 9.63% HCRA Surcharge,476.95,,,476.95,Other,Medicare OPPS methodology,980.86,,,980.86,Fee Schedule,,881.54,,,881.54,Fee Schedule,,282.47,,,282.47,Fee Schedule,,282.47,,,282.47,Fee Schedule,,282.47,,,282.47,Fee Schedule,,3430,50,,3430,percent of total billed charges,All Other,1105.85,,,1105.85,Fee Schedule,,1176.42,,,1176.42,Fee Schedule,,725.43,,,725.43,Other,186% Medicaid methodology,1384.38,,,1384.38,Fee Schedule,,4253.2,,,4253.2,Fee Schedule,,651.84,,,651.84,Fee Schedule,,1384.38,,,1384.38,Fee Schedule,,4253.2,,,4253.2,Fee Schedule,,1226.08,,,1226.08,Fee Schedule,,4802,70,,4802,percent of total billed charges,All Other,1349.7,,,1349.7,Fee Schedule,,1145.2,,,1145.2,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,390.01,,,390.01,Other,New York Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,596.72,,,596.72,Other,153% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,546.02,,,546.02,Other,140% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,1014.04,,,1014.04,Other,260% Medicaid APG methodology,1263.65,,,1263.65,Other,324% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,487.52,,,487.52,Other,125% Medicaid APG methodology,282.47,4802,
LIVER AND SPLEEN IMAGING        ,78215,CPT,,47500129,CDM,341,RC,,,both,,,2838,784.32,,,784.32,Other,150% of Medicare + 9.63% HCRA Surcharge,476.95,,,476.95,Other,Medicare OPPS methodology,597.68,,,597.68,Fee Schedule,,537.16,,,537.16,Fee Schedule,,1540.54,,,1540.54,Fee Schedule,,1386.06,,,1386.06,Fee Schedule,,1308.82,,,1308.82,Fee Schedule,,1419,50,,1419,percent of total billed charges,All Other,1105.85,,,1105.85,Fee Schedule,,716.84,,,716.84,Fee Schedule,,1535.06,,,1535.06,Other,186% Medicaid methodology,843.56,,,843.56,Fee Schedule,,1759.56,,,1759.56,Fee Schedule,,397.19,,,397.19,Fee Schedule,,843.56,,,843.56,Fee Schedule,,1759.56,,,1759.56,Fee Schedule,,747.1,,,747.1,Fee Schedule,,1986.6,70,,1986.6,percent of total billed charges,All Other,806.85,,,806.85,Fee Schedule,,684.6,,,684.6,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,825.3,,,825.3,Other,New York Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1262.71,,,1262.71,Other,153% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1155.42,,,1155.42,Other,140% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,2145.79,,,2145.79,Other,260% Medicaid APG methodology,2673.98,,,2673.98,Other,324% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1031.63,,,1031.63,Other,125% Medicaid APG methodology,397.19,3642,
LUNG PERFUSION IMAGING          ,78580,CPT,,47500137,CDM,341,RC,,,both,,,6860,784.32,,,784.32,Other,150% of Medicare + 9.63% HCRA Surcharge,476.95,,,476.95,Other,Medicare OPPS methodology,683.38,,,683.38,Fee Schedule,,614.18,,,614.18,Fee Schedule,,1618.52,,,1618.52,Fee Schedule,,1456.21,,,1456.21,Fee Schedule,,1375.06,,,1375.06,Fee Schedule,,3430,50,,3430,percent of total billed charges,All Other,1105.85,,,1105.85,Fee Schedule,,819.63,,,819.63,Fee Schedule,,1535.06,,,1535.06,Other,186% Medicaid methodology,964.52,,,964.52,Fee Schedule,,4253.2,,,4253.2,Fee Schedule,,454.15,,,454.15,Fee Schedule,,964.52,,,964.52,Fee Schedule,,4253.2,,,4253.2,Fee Schedule,,854.23,,,854.23,Fee Schedule,,4802,70,,4802,percent of total billed charges,All Other,935.55,,,935.55,Fee Schedule,,793.8,,,793.8,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,825.3,,,825.3,Other,New York Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1262.71,,,1262.71,Other,153% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1155.42,,,1155.42,Other,140% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,2145.79,,,2145.79,Other,260% Medicaid APG methodology,2673.98,,,2673.98,Other,324% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1031.63,,,1031.63,Other,125% Medicaid APG methodology,454.15,4802,
MECKELS DIVERT EXAM             ,78290,CPT,,47500152,CDM,341,RC,,,both,,,2561,784.32,,,784.32,Other,150% of Medicare + 9.63% HCRA Surcharge,476.95,,,476.95,Other,Medicare OPPS methodology,1007.66,,,1007.66,Fee Schedule,,905.62,,,905.62,Fee Schedule,,2198.37,,,2198.37,Fee Schedule,,1977.92,,,1977.92,Fee Schedule,,1867.7,,,1867.7,Fee Schedule,,1280.5,50,,1280.5,percent of total billed charges,All Other,1105.85,,,1105.85,Fee Schedule,,1208.56,,,1208.56,Fee Schedule,,725.43,,,725.43,Other,186% Medicaid methodology,1422.2,,,1422.2,Fee Schedule,,1587.82,,,1587.82,Fee Schedule,,669.65,,,669.65,Fee Schedule,,1422.2,,,1422.2,Fee Schedule,,1587.82,,,1587.82,Fee Schedule,,1259.58,,,1259.58,Fee Schedule,,1792.7,70,,1792.7,percent of total billed charges,All Other,1384.35,,,1384.35,Fee Schedule,,1174.6,,,1174.6,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,390.01,,,390.01,Other,New York Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,596.72,,,596.72,Other,153% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,546.02,,,546.02,Other,140% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,1014.04,,,1014.04,Other,260% Medicaid APG methodology,1263.65,,,1263.65,Other,324% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,487.52,,,487.52,Other,125% Medicaid APG methodology,390.01,3642,
THYROID IMAGING W/BLOOD FLOW    ,78014,CPT,,47500269,CDM,341,RC,,,both,,,6860,784.32,,,784.32,Other,150% of Medicare + 9.63% HCRA Surcharge,476.95,,,476.95,Other,Medicare OPPS methodology,729.33,,,729.33,Fee Schedule,,655.47,,,655.47,Fee Schedule,,219.34,,,219.34,Fee Schedule,,219.34,,,219.34,Fee Schedule,,219.34,,,219.34,Fee Schedule,,3430,50,,3430,percent of total billed charges,All Other,1105.85,,,1105.85,Fee Schedule,,874.73,,,874.73,Fee Schedule,,725.43,,,725.43,Other,186% Medicaid methodology,1029.37,,,1029.37,Fee Schedule,,4253.2,,,4253.2,Fee Schedule,,484.68,,,484.68,Fee Schedule,,1029.37,,,1029.37,Fee Schedule,,4253.2,,,4253.2,Fee Schedule,,911.66,,,911.66,Fee Schedule,,4802,70,,4802,percent of total billed charges,All Other,999.9,,,999.9,Fee Schedule,,848.4,,,848.4,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,390.01,,,390.01,Other,New York Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,596.72,,,596.72,Other,153% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,546.02,,,546.02,Other,140% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,1014.04,,,1014.04,Other,260% Medicaid APG methodology,1263.65,,,1263.65,Other,324% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,487.52,,,487.52,Other,125% Medicaid APG methodology,219.34,4802,
K FLOW/FUNCT IMAGE W/DRUG       ,78708,CPT,,47500285,CDM,341,RC,,,both,,,8795,1027.85,,,1027.85,Other,150% of Medicare + 9.63% HCRA Surcharge,625.04,,,625.04,Other,Medicare OPPS methodology,450.68,,,450.68,Fee Schedule,,405.04,,,405.04,Fee Schedule,,1113.4,,,1113.4,Fee Schedule,,1001.75,,,1001.75,Fee Schedule,,945.93,,,945.93,Fee Schedule,,4397.5,50,,4397.5,percent of total billed charges,All Other,1435.1,,,1435.1,Fee Schedule,,540.53,,,540.53,Fee Schedule,,725.43,,,725.43,Other,186% Medicaid methodology,636.09,,,636.09,Fee Schedule,,5452.9,,,5452.9,Fee Schedule,,299.5,,,299.5,Fee Schedule,,636.09,,,636.09,Fee Schedule,,5452.9,,,5452.9,Fee Schedule,,563.35,,,563.35,Fee Schedule,,6156.5,70,,6156.5,percent of total billed charges,All Other,580.8,,,580.8,Fee Schedule,,492.8,,,492.8,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,390.01,,,390.01,Other,New York Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,596.72,,,596.72,Other,153% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,546.02,,,546.02,Other,140% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,1014.04,,,1014.04,Other,260% Medicaid APG methodology,1263.65,,,1263.65,Other,324% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,487.52,,,487.52,Other,125% Medicaid APG methodology,299.5,6156.5,
RP LOCLZJ TUM SPECT 1 AREA      ,78803,CPT,,47500301,CDM,341,RC,,,both,,,23705,2700.27,,,2700.27,Other,150% of Medicare + 9.63% HCRA Surcharge,1642.05,,,1642.05,Other,Medicare OPPS methodology,1113.71,,,1113.71,Fee Schedule,,1000.93,,,1000.93,Fee Schedule,,2737.73,,,2737.73,Fee Schedule,,2463.2,,,2463.2,Fee Schedule,,2325.93,,,2325.93,Fee Schedule,,11852.5,50,,11852.5,percent of total billed charges,All Other,3829.48,,,3829.48,Fee Schedule,,1335.75,,,1335.75,Fee Schedule,,1535.06,,,1535.06,Other,186% Medicaid methodology,1571.88,,,1571.88,Fee Schedule,,14697.1,,,14697.1,Fee Schedule,,740.12,,,740.12,Fee Schedule,,1571.88,,,1571.88,Fee Schedule,,14697.1,,,14697.1,Fee Schedule,,1392.14,,,1392.14,Fee Schedule,,16593.5,70,,16593.5,percent of total billed charges,All Other,1549.35,,,1549.35,Fee Schedule,,1314.6,,,1314.6,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,825.3,,,825.3,Other,New York Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1262.71,,,1262.71,Other,153% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1155.42,,,1155.42,Other,140% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,2145.79,,,2145.79,Other,260% Medicaid APG methodology,2673.98,,,2673.98,Other,324% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1031.63,,,1031.63,Other,125% Medicaid APG methodology,740.12,16593.5,
RP LOCLZJ TUM WHBDY 1 D IMG     ,78802,CPT,,47500335,CDM,341,RC,,,both,,,23705,2700.27,,,2700.27,Other,150% of Medicare + 9.63% HCRA Surcharge,1642.05,,,1642.05,Other,Medicare OPPS methodology,915.58,,,915.58,Fee Schedule,,822.86,,,822.86,Fee Schedule,,2613.02,,,2613.02,Fee Schedule,,2350.99,,,2350.99,Fee Schedule,,2219.97,,,2219.97,Fee Schedule,,11852.5,50,,11852.5,percent of total billed charges,All Other,3829.48,,,3829.48,Fee Schedule,,1098.11,,,1098.11,Fee Schedule,,1535.06,,,1535.06,Other,186% Medicaid methodology,1292.24,,,1292.24,Fee Schedule,,14697.1,,,14697.1,Fee Schedule,,608.45,,,608.45,Fee Schedule,,1292.24,,,1292.24,Fee Schedule,,14697.1,,,14697.1,Fee Schedule,,1144.47,,,1144.47,Fee Schedule,,16593.5,70,,16593.5,percent of total billed charges,All Other,1268.85,,,1268.85,Fee Schedule,,1076.6,,,1076.6,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,825.3,,,825.3,Other,New York Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1262.71,,,1262.71,Other,153% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1155.42,,,1155.42,Other,140% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,2145.79,,,2145.79,Other,260% Medicaid APG methodology,2673.98,,,2673.98,Other,324% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1031.63,,,1031.63,Other,125% Medicaid APG methodology,608.45,16593.5,
THYROID MET IMAGING BODY        ,78018,CPT,,47500418,CDM,341,RC,,,both,,,8795,1027.85,,,1027.85,Other,150% of Medicare + 9.63% HCRA Surcharge,625.04,,,625.04,Other,Medicare OPPS methodology,920.03,,,920.03,Fee Schedule,,826.87,,,826.87,Fee Schedule,,2541.36,,,2541.36,Fee Schedule,,2286.52,,,2286.52,Fee Schedule,,2159.1,,,2159.1,Fee Schedule,,4397.5,50,,4397.5,percent of total billed charges,All Other,1435.1,,,1435.1,Fee Schedule,,1103.46,,,1103.46,Fee Schedule,,725.43,,,725.43,Other,186% Medicaid methodology,1298.53,,,1298.53,Fee Schedule,,5452.9,,,5452.9,Fee Schedule,,611.42,,,611.42,Fee Schedule,,1298.53,,,1298.53,Fee Schedule,,5452.9,,,5452.9,Fee Schedule,,1150.04,,,1150.04,Fee Schedule,,6156.5,70,,6156.5,percent of total billed charges,All Other,1272.15,,,1272.15,Fee Schedule,,1079.4,,,1079.4,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,390.01,,,390.01,Other,New York Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,596.72,,,596.72,Other,153% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,546.02,,,546.02,Other,140% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,1014.04,,,1014.04,Other,260% Medicaid APG methodology,1263.65,,,1263.65,Other,324% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,487.52,,,487.52,Other,125% Medicaid APG methodology,390.01,6156.5,
PARATHYROID PLANAR IMAGING      ,78070,CPT,,47500426,CDM,341,RC,,,both,,,6860,784.32,,,784.32,Other,150% of Medicare + 9.63% HCRA Surcharge,476.95,,,476.95,Other,Medicare OPPS methodology,869.13,,,869.13,Fee Schedule,,781.11,,,781.11,Fee Schedule,,1150.81,,,1150.81,Fee Schedule,,1035.41,,,1035.41,Fee Schedule,,977.71,,,977.71,Fee Schedule,,3430,50,,3430,percent of total billed charges,All Other,1105.85,,,1105.85,Fee Schedule,,1042.4,,,1042.4,Fee Schedule,,1535.06,,,1535.06,Other,186% Medicaid methodology,1226.68,,,1226.68,Fee Schedule,,4253.2,,,4253.2,Fee Schedule,,577.58,,,577.58,Fee Schedule,,1226.68,,,1226.68,Fee Schedule,,4253.2,,,4253.2,Fee Schedule,,1086.41,,,1086.41,Fee Schedule,,4802,70,,4802,percent of total billed charges,All Other,1186.35,,,1186.35,Fee Schedule,,1006.6,,,1006.6,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,825.3,,,825.3,Other,New York Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1262.71,,,1262.71,Other,153% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1155.42,,,1155.42,Other,140% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,2145.79,,,2145.79,Other,260% Medicaid APG methodology,2673.98,,,2673.98,Other,324% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1031.63,,,1031.63,Other,125% Medicaid APG methodology,476.95,4802,
BONE MARROW IMAGING LTD         ,78102,CPT,,47500442,CDM,341,RC,,,both,,,1857,784.32,,,784.32,Other,150% of Medicare + 9.63% HCRA Surcharge,476.95,,,476.95,Other,Medicare OPPS methodology,509.55,,,509.55,Fee Schedule,,457.95,,,457.95,Fee Schedule,,1281.77,,,1281.77,Fee Schedule,,1153.24,,,1153.24,Fee Schedule,,1088.97,,,1088.97,Fee Schedule,,928.5,50,,928.5,percent of total billed charges,All Other,1105.85,,,1105.85,Fee Schedule,,611.14,,,611.14,Fee Schedule,,725.43,,,725.43,Other,186% Medicaid methodology,719.18,,,719.18,Fee Schedule,,1151.34,,,1151.34,Fee Schedule,,338.63,,,338.63,Fee Schedule,,719.18,,,719.18,Fee Schedule,,1151.34,,,1151.34,Fee Schedule,,636.94,,,636.94,Fee Schedule,,1299.9,70,,1299.9,percent of total billed charges,All Other,684.75,,,684.75,Fee Schedule,,581,,,581,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,390.01,,,390.01,Other,New York Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,596.72,,,596.72,Other,153% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,546.02,,,546.02,Other,140% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,1014.04,,,1014.04,Other,260% Medicaid APG methodology,1263.65,,,1263.65,Other,324% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,487.52,,,487.52,Other,125% Medicaid APG methodology,338.63,3642,
NM BONE MARROW IMG MULT AREAS   ,78103,CPT,,47500459,CDM,341,RC,,,both,,,2747,784.32,,,784.32,Other,150% of Medicare + 9.63% HCRA Surcharge,476.95,,,476.95,Other,Medicare OPPS methodology,530.66,,,530.66,Fee Schedule,,476.92,,,476.92,Fee Schedule,,1680.84,,,1680.84,Fee Schedule,,1512.29,,,1512.29,Fee Schedule,,1428.01,,,1428.01,Fee Schedule,,1373.5,50,,1373.5,percent of total billed charges,All Other,1105.85,,,1105.85,Fee Schedule,,636.45,,,636.45,Fee Schedule,,725.43,,,725.43,Other,186% Medicaid methodology,748.97,,,748.97,Fee Schedule,,1703.14,,,1703.14,Fee Schedule,,352.65,,,352.65,Fee Schedule,,748.97,,,748.97,Fee Schedule,,1703.14,,,1703.14,Fee Schedule,,663.32,,,663.32,Fee Schedule,,1922.9,70,,1922.9,percent of total billed charges,All Other,740.85,,,740.85,Fee Schedule,,628.6,,,628.6,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,390.01,,,390.01,Other,New York Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,596.72,,,596.72,Other,153% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,546.02,,,546.02,Other,140% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,1014.04,,,1014.04,Other,260% Medicaid APG methodology,1263.65,,,1263.65,Other,324% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,487.52,,,487.52,Other,125% Medicaid APG methodology,352.65,3642,
NM Bone Marrow Imaging Whole Body Scan,78104,CPT,TC,47500467,CDM,341,RC,,,both,,,1857,784.32,,,784.32,Other,150% of Medicare + 9.63% HCRA Surcharge,476.95,,,476.95,Other,Medicare OPPS methodology,725.09,,,725.09,Fee Schedule,,651.67,,,651.67,Fee Schedule,,1930.27,,,1930.27,Fee Schedule,,1736.71,,,1736.71,Fee Schedule,,1639.92,,,1639.92,Fee Schedule,,928.5,50,,928.5,percent of total billed charges,All Other,1105.85,,,1105.85,Fee Schedule,,869.65,,,869.65,Fee Schedule,,725.43,,,725.43,Other,186% Medicaid methodology,1023.39,,,1023.39,Fee Schedule,,1151.34,,,1151.34,Fee Schedule,,481.87,,,481.87,Fee Schedule,,1023.39,,,1023.39,Fee Schedule,,1151.34,,,1151.34,Fee Schedule,,906.37,,,906.37,Fee Schedule,,1299.9,70,,1299.9,percent of total billed charges,All Other,988.35,,,988.35,Fee Schedule,,838.6,,,838.6,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,390.01,,,390.01,Other,New York Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,596.72,,,596.72,Other,153% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,546.02,,,546.02,Other,140% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,1014.04,,,1014.04,Other,260% Medicaid APG methodology,1263.65,,,1263.65,Other,324% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,487.52,,,487.52,Other,125% Medicaid APG methodology,390.01,3642,
LYMPH SYSTEM IMAGING            ,78195,CPT,,47500525,CDM,341,RC,,,both,,,8795,1027.85,,,1027.85,Other,150% of Medicare + 9.63% HCRA Surcharge,625.04,,,625.04,Other,Medicare OPPS methodology,1006.43,,,1006.43,Fee Schedule,,904.51,,,904.51,Fee Schedule,,2360.5,,,2360.5,Fee Schedule,,2123.79,,,2123.79,Fee Schedule,,2005.44,,,2005.44,Fee Schedule,,4397.5,50,,4397.5,percent of total billed charges,All Other,1435.1,,,1435.1,Fee Schedule,,1207.08,,,1207.08,Fee Schedule,,1535.06,,,1535.06,Other,186% Medicaid methodology,1420.47,,,1420.47,Fee Schedule,,5452.9,,,5452.9,Fee Schedule,,668.83,,,668.83,Fee Schedule,,1420.47,,,1420.47,Fee Schedule,,5452.9,,,5452.9,Fee Schedule,,1258.04,,,1258.04,Fee Schedule,,6156.5,70,,6156.5,percent of total billed charges,All Other,1382.7,,,1382.7,Fee Schedule,,1173.2,,,1173.2,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,825.3,,,825.3,Other,New York Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1262.71,,,1262.71,Other,153% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1155.42,,,1155.42,Other,140% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,2145.79,,,2145.79,Other,260% Medicaid APG methodology,2673.98,,,2673.98,Other,324% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1031.63,,,1031.63,Other,125% Medicaid APG methodology,625.04,6156.5,
BONE IMAGING 3 PHASE            ,78315,CPT,,47500624,CDM,341,RC,,,both,,,6860,784.32,,,784.32,Other,150% of Medicare + 9.63% HCRA Surcharge,476.95,,,476.95,Other,Medicare OPPS methodology,1008.92,,,1008.92,Fee Schedule,,906.76,,,906.76,Fee Schedule,,2245.04,,,2245.04,Fee Schedule,,2019.91,,,2019.91,Fee Schedule,,1907.35,,,1907.35,Fee Schedule,,3430,50,,3430,percent of total billed charges,All Other,1105.85,,,1105.85,Fee Schedule,,1210.07,,,1210.07,Fee Schedule,,725.43,,,725.43,Other,186% Medicaid methodology,1423.99,,,1423.99,Fee Schedule,,4253.2,,,4253.2,Fee Schedule,,670.49,,,670.49,Fee Schedule,,1423.99,,,1423.99,Fee Schedule,,4253.2,,,4253.2,Fee Schedule,,1261.16,,,1261.16,Fee Schedule,,4802,70,,4802,percent of total billed charges,All Other,1384.35,,,1384.35,Fee Schedule,,1174.6,,,1174.6,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,390.01,,,390.01,Other,New York Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,596.72,,,596.72,Other,153% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,546.02,,,546.02,Other,140% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,1014.04,,,1014.04,Other,260% Medicaid APG methodology,1263.65,,,1263.65,Other,324% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,487.52,,,487.52,Other,125% Medicaid APG methodology,390.01,4802,
NM LUNG VENTILATION IMAGING     ,78579,CPT,,47500715,CDM,341,RC,,,both,,,1808,784.32,,,784.32,Other,150% of Medicare + 9.63% HCRA Surcharge,476.95,,,476.95,Other,Medicare OPPS methodology,560.96,,,560.96,Fee Schedule,,504.16,,,504.16,Fee Schedule,,156.38,,,156.38,Fee Schedule,,156.38,,,156.38,Fee Schedule,,156.38,,,156.38,Fee Schedule,,904,50,,904,percent of total billed charges,All Other,1105.85,,,1105.85,Fee Schedule,,672.8,,,672.8,Fee Schedule,,1535.06,,,1535.06,Other,186% Medicaid methodology,791.74,,,791.74,Fee Schedule,,1120.96,,,1120.96,Fee Schedule,,372.79,,,372.79,Fee Schedule,,791.74,,,791.74,Fee Schedule,,1120.96,,,1120.96,Fee Schedule,,701.2,,,701.2,Fee Schedule,,1265.6,70,,1265.6,percent of total billed charges,All Other,763.95,,,763.95,Fee Schedule,,648.2,,,648.2,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,825.3,,,825.3,Other,New York Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1262.71,,,1262.71,Other,153% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1155.42,,,1155.42,Other,140% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,2145.79,,,2145.79,Other,260% Medicaid APG methodology,2673.98,,,2673.98,Other,324% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1031.63,,,1031.63,Other,125% Medicaid APG methodology,156.38,3642,
LUNG PERFUSION DIFFERENTIAL     ,78597,CPT,,47500756,CDM,341,RC,,,both,,,6860,784.32,,,784.32,Other,150% of Medicare + 9.63% HCRA Surcharge,476.95,,,476.95,Other,Medicare OPPS methodology,563.43,,,563.43,Fee Schedule,,506.37,,,506.37,Fee Schedule,,160.95,,,160.95,Fee Schedule,,160.95,,,160.95,Fee Schedule,,160.95,,,160.95,Fee Schedule,,3430,50,,3430,percent of total billed charges,All Other,1105.85,,,1105.85,Fee Schedule,,675.76,,,675.76,Fee Schedule,,1535.06,,,1535.06,Other,186% Medicaid methodology,795.22,,,795.22,Fee Schedule,,4253.2,,,4253.2,Fee Schedule,,374.43,,,374.43,Fee Schedule,,795.22,,,795.22,Fee Schedule,,4253.2,,,4253.2,Fee Schedule,,704.29,,,704.29,Fee Schedule,,4802,70,,4802,percent of total billed charges,All Other,778.8,,,778.8,Fee Schedule,,660.8,,,660.8,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,825.3,,,825.3,Other,New York Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1262.71,,,1262.71,Other,153% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1155.42,,,1155.42,Other,140% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,2145.79,,,2145.79,Other,260% Medicaid APG methodology,2673.98,,,2673.98,Other,324% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1031.63,,,1031.63,Other,125% Medicaid APG methodology,160.95,4802,
NM Cisternography Scan Day 3,78630,CPT,TC,47500798,CDM,341,RC,,,both,,,8795,1027.85,,,1027.85,Other,150% of Medicare + 9.63% HCRA Surcharge,625.04,,,625.04,Other,Medicare OPPS methodology,1034.99,,,1034.99,Fee Schedule,,930.19,,,930.19,Fee Schedule,,2778.3,,,2778.3,Fee Schedule,,2499.7,,,2499.7,Fee Schedule,,2360.4,,,2360.4,Fee Schedule,,4397.5,50,,4397.5,percent of total billed charges,All Other,1435.1,,,1435.1,Fee Schedule,,1241.34,,,1241.34,Fee Schedule,,1535.06,,,1535.06,Other,186% Medicaid methodology,1460.78,,,1460.78,Fee Schedule,,5452.9,,,5452.9,Fee Schedule,,687.81,,,687.81,Fee Schedule,,1460.78,,,1460.78,Fee Schedule,,5452.9,,,5452.9,Fee Schedule,,1293.74,,,1293.74,Fee Schedule,,6156.5,70,,6156.5,percent of total billed charges,All Other,1422.3,,,1422.3,Fee Schedule,,1206.8,,,1206.8,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,825.3,,,825.3,Other,New York Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1262.71,,,1262.71,Other,153% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1155.42,,,1155.42,Other,140% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,2145.79,,,2145.79,Other,260% Medicaid APG methodology,2673.98,,,2673.98,Other,324% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1031.63,,,1031.63,Other,125% Medicaid APG methodology,625.04,6156.5,
NM Cerebrospinal Fluid Leak Detec Scan 3,78650,CPT,TC,47500806,CDM,341,RC,,,both,,,7000,2700.27,,,2700.27,Other,150% of Medicare + 9.63% HCRA Surcharge,1642.05,,,1642.05,Other,Medicare OPPS methodology,837.56,,,837.56,Fee Schedule,,752.74,,,752.74,Fee Schedule,,2747.07,,,2747.07,Fee Schedule,,2471.6,,,2471.6,Fee Schedule,,2333.86,,,2333.86,Fee Schedule,,3500,50,,3500,percent of total billed charges,All Other,3829.48,,,3829.48,Fee Schedule,,1004.54,,,1004.54,Fee Schedule,,1535.06,,,1535.06,Other,186% Medicaid methodology,1182.12,,,1182.12,Fee Schedule,,4340,,,4340,Fee Schedule,,556.61,,,556.61,Fee Schedule,,1182.12,,,1182.12,Fee Schedule,,4340,,,4340,Fee Schedule,,1046.95,,,1046.95,Fee Schedule,,4900,70,,4900,percent of total billed charges,All Other,1176.45,,,1176.45,Fee Schedule,,998.2,,,998.2,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,825.3,,,825.3,Other,New York Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1262.71,,,1262.71,Other,153% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1155.42,,,1155.42,Other,140% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,2145.79,,,2145.79,Other,260% Medicaid APG methodology,2673.98,,,2673.98,Other,324% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1031.63,,,1031.63,Other,125% Medicaid APG methodology,556.61,4900,
K FLOW/FUNCT IMAGE W/O DRUG     ,78707,CPT,,47500830,CDM,341,RC,,,both,,,3437,1027.85,,,1027.85,Other,150% of Medicare + 9.63% HCRA Surcharge,625.04,,,625.04,Other,Medicare OPPS methodology,642.4,,,642.4,Fee Schedule,,577.34,,,577.34,Fee Schedule,,1752.57,,,1752.57,Fee Schedule,,1576.82,,,1576.82,Fee Schedule,,1488.95,,,1488.95,Fee Schedule,,1718.5,50,,1718.5,percent of total billed charges,All Other,1435.1,,,1435.1,Fee Schedule,,770.47,,,770.47,Fee Schedule,,725.43,,,725.43,Other,186% Medicaid methodology,906.67,,,906.67,Fee Schedule,,2130.94,,,2130.94,Fee Schedule,,426.91,,,426.91,Fee Schedule,,906.67,,,906.67,Fee Schedule,,2130.94,,,2130.94,Fee Schedule,,803,,,803,Fee Schedule,,2405.9,70,,2405.9,percent of total billed charges,All Other,871.2,,,871.2,Fee Schedule,,739.2,,,739.2,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,390.01,,,390.01,Other,New York Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,596.72,,,596.72,Other,153% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,546.02,,,546.02,Other,140% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,1014.04,,,1014.04,Other,260% Medicaid APG methodology,1263.65,,,1263.65,Other,324% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,487.52,,,487.52,Other,125% Medicaid APG methodology,390.01,3642,
NCR TESTICULAR W FLOW           ,78761,CPT,,47500863,CDM,341,RC,,,both,,,1672,784.32,,,784.32,Other,150% of Medicare + 9.63% HCRA Surcharge,476.95,,,476.95,Other,Medicare OPPS methodology,612.6,,,612.6,Fee Schedule,,550.56,,,550.56,Fee Schedule,,1624.76,,,1624.76,Fee Schedule,,1461.83,,,1461.83,Fee Schedule,,1380.37,,,1380.37,Fee Schedule,,836,50,,836,percent of total billed charges,All Other,1105.85,,,1105.85,Fee Schedule,,734.73,,,734.73,Fee Schedule,,725.43,,,725.43,Other,186% Medicaid methodology,864.62,,,864.62,Fee Schedule,,1036.64,,,1036.64,Fee Schedule,,407.11,,,407.11,Fee Schedule,,864.62,,,864.62,Fee Schedule,,1036.64,,,1036.64,Fee Schedule,,765.75,,,765.75,Fee Schedule,,1170.4,70,,1170.4,percent of total billed charges,All Other,828.3,,,828.3,Fee Schedule,,702.8,,,702.8,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,390.01,,,390.01,Other,New York Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,596.72,,,596.72,Other,153% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,546.02,,,546.02,Other,140% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,1014.04,,,1014.04,Other,260% Medicaid APG methodology,1263.65,,,1263.65,Other,324% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,487.52,,,487.52,Other,125% Medicaid APG methodology,390.01,3642,
RP LOCLZJ TUM 1 AREA 1 D IMG    ,78800,CPT,,47500905,CDM,341,RC,,,both,,,2709,784.32,,,784.32,Other,150% of Medicare + 9.63% HCRA Surcharge,476.95,,,476.95,Other,Medicare OPPS methodology,755.4,,,755.4,Fee Schedule,,678.9,,,678.9,Fee Schedule,,1418.98,,,1418.98,Fee Schedule,,1276.69,,,1276.69,Fee Schedule,,1205.54,,,1205.54,Fee Schedule,,1354.5,50,,1354.5,percent of total billed charges,All Other,1105.85,,,1105.85,Fee Schedule,,906,,,906,Fee Schedule,,1535.06,,,1535.06,Other,186% Medicaid methodology,1066.16,,,1066.16,Fee Schedule,,1679.58,,,1679.58,Fee Schedule,,502.01,,,502.01,Fee Schedule,,1066.16,,,1066.16,Fee Schedule,,1679.58,,,1679.58,Fee Schedule,,944.25,,,944.25,Fee Schedule,,1896.3,70,,1896.3,percent of total billed charges,All Other,1036.2,,,1036.2,Fee Schedule,,879.2,,,879.2,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,825.3,,,825.3,Other,New York Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1262.71,,,1262.71,Other,153% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1155.42,,,1155.42,Other,140% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,2145.79,,,2145.79,Other,260% Medicaid APG methodology,2673.98,,,2673.98,Other,324% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1031.63,,,1031.63,Other,125% Medicaid APG methodology,476.95,3642,
NCR GALLIUM-TUMOR MULTIPLE      ,78801,CPT,,47500913,CDM,341,RC,,,both,,,2709,784.32,,,784.32,Other,150% of Medicare + 9.63% HCRA Surcharge,476.95,,,476.95,Other,Medicare OPPS methodology,806.31,,,806.31,Fee Schedule,,724.65,,,724.65,Fee Schedule,,1961.43,,,1961.43,Fee Schedule,,1764.74,,,1764.74,Fee Schedule,,1666.4,,,1666.4,Fee Schedule,,1354.5,50,,1354.5,percent of total billed charges,All Other,1105.85,,,1105.85,Fee Schedule,,967.06,,,967.06,Fee Schedule,,1535.06,,,1535.06,Other,186% Medicaid methodology,1138.01,,,1138.01,Fee Schedule,,1679.58,,,1679.58,Fee Schedule,,535.84,,,535.84,Fee Schedule,,1138.01,,,1138.01,Fee Schedule,,1679.58,,,1679.58,Fee Schedule,,1007.88,,,1007.88,Fee Schedule,,1896.3,70,,1896.3,percent of total billed charges,All Other,1122,,,1122,Fee Schedule,,952,,,952,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,825.3,,,825.3,Other,New York Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1262.71,,,1262.71,Other,153% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1155.42,,,1155.42,Other,140% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,2145.79,,,2145.79,Other,260% Medicaid APG methodology,2673.98,,,2673.98,Other,324% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1031.63,,,1031.63,Other,125% Medicaid APG methodology,476.95,3642,
NM LIVER SCAN                   ,78201,CPT,,47501093,CDM,341,RC,,,both,,,4533,1027.85,,,1027.85,Other,150% of Medicare + 9.63% HCRA Surcharge,625.04,,,625.04,Other,Medicare OPPS methodology,587.76,,,587.76,Fee Schedule,,528.24,,,528.24,Fee Schedule,,1506.29,,,1506.29,Fee Schedule,,1355.24,,,1355.24,Fee Schedule,,1279.72,,,1279.72,Fee Schedule,,2266.5,50,,2266.5,percent of total billed charges,All Other,1435.1,,,1435.1,Fee Schedule,,704.94,,,704.94,Fee Schedule,,1535.06,,,1535.06,Other,186% Medicaid methodology,829.56,,,829.56,Fee Schedule,,2810.46,,,2810.46,Fee Schedule,,390.6,,,390.6,Fee Schedule,,829.56,,,829.56,Fee Schedule,,2810.46,,,2810.46,Fee Schedule,,734.7,,,734.7,Fee Schedule,,3173.1,70,,3173.1,percent of total billed charges,All Other,793.65,,,793.65,Fee Schedule,,673.4,,,673.4,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,825.3,,,825.3,Other,New York Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1262.71,,,1262.71,Other,153% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1155.42,,,1155.42,Other,140% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,2145.79,,,2145.79,Other,260% Medicaid APG methodology,2673.98,,,2673.98,Other,324% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1031.63,,,1031.63,Other,125% Medicaid APG methodology,390.6,3642,
LUNG VENTILAT&PERFUS IMAGING    ,78582,CPT,,47501101,CDM,341,RC,,,both,,,8795,1027.85,,,1027.85,Other,150% of Medicare + 9.63% HCRA Surcharge,625.04,,,625.04,Other,Medicare OPPS methodology,951.07,,,951.07,Fee Schedule,,854.75,,,854.75,Fee Schedule,,270.41,,,270.41,Fee Schedule,,270.41,,,270.41,Fee Schedule,,270.41,,,270.41,Fee Schedule,,4397.5,50,,4397.5,percent of total billed charges,All Other,1435.1,,,1435.1,Fee Schedule,,1140.68,,,1140.68,Fee Schedule,,1535.06,,,1535.06,Other,186% Medicaid methodology,1342.33,,,1342.33,Fee Schedule,,5452.9,,,5452.9,Fee Schedule,,632.04,,,632.04,Fee Schedule,,1342.33,,,1342.33,Fee Schedule,,5452.9,,,5452.9,Fee Schedule,,1188.83,,,1188.83,Fee Schedule,,6156.5,70,,6156.5,percent of total billed charges,All Other,1310.1,,,1310.1,Fee Schedule,,1111.6,,,1111.6,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,825.3,,,825.3,Other,New York Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1262.71,,,1262.71,Other,153% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1155.42,,,1155.42,Other,140% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,2145.79,,,2145.79,Other,260% Medicaid APG methodology,2673.98,,,2673.98,Other,324% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1031.63,,,1031.63,Other,125% Medicaid APG methodology,270.41,6156.5,
RP LOCLZJ TUM WHBDY 2+D IMG     ,78804,CPT,,47501127,CDM,341,RC,,,both,,,23705,2700.27,,,2700.27,Other,150% of Medicare + 9.63% HCRA Surcharge,1642.05,,,1642.05,Other,Medicare OPPS methodology,2018.1,,,2018.1,Fee Schedule,,1813.74,,,1813.74,Fee Schedule,,4848.73,,,4848.73,Fee Schedule,,4362.5,,,4362.5,Fee Schedule,,4119.39,,,4119.39,Fee Schedule,,11852.5,50,,11852.5,percent of total billed charges,All Other,3829.48,,,3829.48,Fee Schedule,,2420.45,,,2420.45,Fee Schedule,,1535.06,,,1535.06,Other,186% Medicaid methodology,2848.33,,,2848.33,Fee Schedule,,14697.1,,,14697.1,Fee Schedule,,1341.14,,,1341.14,Fee Schedule,,2848.33,,,2848.33,Fee Schedule,,14697.1,,,14697.1,Fee Schedule,,2522.63,,,2522.63,Fee Schedule,,16593.5,70,,16593.5,percent of total billed charges,All Other,2823.15,,,2823.15,Fee Schedule,,2395.4,,,2395.4,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,825.3,,,825.3,Other,New York Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1262.71,,,1262.71,Other,153% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1155.42,,,1155.42,Other,140% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,2145.79,,,2145.79,Other,260% Medicaid APG methodology,2673.98,,,2673.98,Other,324% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1031.63,,,1031.63,Other,125% Medicaid APG methodology,825.3,16593.5,
HEPATOBIL SYST IMAGE W/DRUG     ,78227,CPT,,47502018,CDM,341,RC,,,both,,,8795,1027.85,,,1027.85,Other,150% of Medicare + 9.63% HCRA Surcharge,625.04,,,625.04,Other,Medicare OPPS methodology,1333.74,,,1333.74,Fee Schedule,,1198.68,,,1198.68,Fee Schedule,,387.38,,,387.38,Fee Schedule,,387.38,,,387.38,Fee Schedule,,387.38,,,387.38,Fee Schedule,,4397.5,50,,4397.5,percent of total billed charges,All Other,1435.1,,,1435.1,Fee Schedule,,1599.65,,,1599.65,Fee Schedule,,725.43,,,725.43,Other,186% Medicaid methodology,1882.43,,,1882.43,Fee Schedule,,5452.9,,,5452.9,Fee Schedule,,886.35,,,886.35,Fee Schedule,,1882.43,,,1882.43,Fee Schedule,,5452.9,,,5452.9,Fee Schedule,,1667.18,,,1667.18,Fee Schedule,,6156.5,70,,6156.5,percent of total billed charges,All Other,1838.1,,,1838.1,Fee Schedule,,1559.6,,,1559.6,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,390.01,,,390.01,Other,New York Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,596.72,,,596.72,Other,153% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,546.02,,,546.02,Other,140% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,1014.04,,,1014.04,Other,260% Medicaid APG methodology,1263.65,,,1263.65,Other,324% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,487.52,,,487.52,Other,125% Medicaid APG methodology,387.38,6156.5,
RP LOCLZJ TUM SPECT 2 AREAS     ,78831,CPT,,47502125,CDM,341,RC,,,both,,,23705,2700.27,,,2700.27,Other,150% of Medicare + 9.63% HCRA Surcharge,1642.05,,,1642.05,Other,Medicare OPPS methodology,2119.92,,,2119.92,Fee Schedule,,1905.24,,,1905.24,Fee Schedule,,629.14,,,629.14,Fee Schedule,,629.14,,,629.14,Fee Schedule,,629.14,,,629.14,Fee Schedule,,11852.5,50,,11852.5,percent of total billed charges,All Other,3829.48,,,3829.48,Fee Schedule,,2542.56,,,2542.56,Fee Schedule,,1535.06,,,1535.06,Other,186% Medicaid methodology,2992.04,,,2992.04,Fee Schedule,,14697.1,,,14697.1,Fee Schedule,,1408.81,,,1408.81,Fee Schedule,,2992.04,,,2992.04,Fee Schedule,,14697.1,,,14697.1,Fee Schedule,,2649.9,,,2649.9,Fee Schedule,,16593.5,70,,16593.5,percent of total billed charges,All Other,2890.8,,,2890.8,Fee Schedule,,2452.8,,,2452.8,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,825.3,,,825.3,Other,New York Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1262.71,,,1262.71,Other,153% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1155.42,,,1155.42,Other,140% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,2145.79,,,2145.79,Other,260% Medicaid APG methodology,2673.98,,,2673.98,Other,324% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1031.63,,,1031.63,Other,125% Medicaid APG methodology,629.14,16593.5,
NM CARDIAC BP MUGA REST/STRS I  ,78472,CPT,,47502307,CDM,341,RC,,,both,,,6860,784.32,,,784.32,Other,150% of Medicare + 9.63% HCRA Surcharge,476.95,,,476.95,Other,Medicare OPPS methodology,618.79,,,618.79,Fee Schedule,,556.13,,,556.13,Fee Schedule,,1861.7,,,1861.7,Fee Schedule,,1675.01,,,1675.01,Fee Schedule,,1581.67,,,1581.67,Fee Schedule,,3430,50,,3430,percent of total billed charges,All Other,1105.85,,,1105.85,Fee Schedule,,742.16,,,742.16,Fee Schedule,,725.43,,,725.43,Other,186% Medicaid methodology,873.36,,,873.36,Fee Schedule,,4253.2,,,4253.2,Fee Schedule,,411.22,,,411.22,Fee Schedule,,873.36,,,873.36,Fee Schedule,,4253.2,,,4253.2,Fee Schedule,,773.49,,,773.49,Fee Schedule,,4802,70,,4802,percent of total billed charges,All Other,844.8,,,844.8,Fee Schedule,,716.8,,,716.8,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,390.01,,,390.01,Other,New York Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,596.72,,,596.72,Other,153% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,546.02,,,546.02,Other,140% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,1014.04,,,1014.04,Other,260% Medicaid APG methodology,1263.65,,,1263.65,Other,324% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,487.52,,,487.52,Other,125% Medicaid APG methodology,390.01,4802,
NM Cardiac SPECT Rest Only,78451,CPT,TC,47502315,CDM,341,RC,,,both,,,23705,2700.27,,,2700.27,Other,150% of Medicare + 9.63% HCRA Surcharge,1642.05,,,1642.05,Other,Medicare OPPS methodology,934.92,,,934.92,Fee Schedule,,840.24,,,840.24,Fee Schedule,,2525.71,,,2525.71,Fee Schedule,,2272.43,,,2272.43,Fee Schedule,,2145.8,,,2145.8,Fee Schedule,,11852.5,50,,11852.5,percent of total billed charges,All Other,3829.48,,,3829.48,Fee Schedule,,1121.31,,,1121.31,Fee Schedule,,1535.06,,,1535.06,Other,186% Medicaid methodology,1319.54,,,1319.54,Fee Schedule,,14697.1,,,14697.1,Fee Schedule,,621.31,,,621.31,Fee Schedule,,1319.54,,,1319.54,Fee Schedule,,14697.1,,,14697.1,Fee Schedule,,1168.65,,,1168.65,Fee Schedule,,16593.5,70,,16593.5,percent of total billed charges,All Other,1275.45,,,1275.45,Fee Schedule,,1082.2,,,1082.2,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,825.3,,,825.3,Other,New York Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1262.71,,,1262.71,Other,153% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1155.42,,,1155.42,Other,140% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,2145.79,,,2145.79,Other,260% Medicaid APG methodology,2673.98,,,2673.98,Other,324% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1031.63,,,1031.63,Other,125% Medicaid APG methodology,621.31,16593.5,
NM Cardiac SPECT Stress Only,78451,CPT,TC,47502323,CDM,341,RC,,,both,,,23705,2700.27,,,2700.27,Other,150% of Medicare + 9.63% HCRA Surcharge,1642.05,,,1642.05,Other,Medicare OPPS methodology,934.92,,,934.92,Fee Schedule,,840.24,,,840.24,Fee Schedule,,2525.71,,,2525.71,Fee Schedule,,2272.43,,,2272.43,Fee Schedule,,2145.8,,,2145.8,Fee Schedule,,11852.5,50,,11852.5,percent of total billed charges,All Other,3829.48,,,3829.48,Fee Schedule,,1121.31,,,1121.31,Fee Schedule,,1535.06,,,1535.06,Other,186% Medicaid methodology,1319.54,,,1319.54,Fee Schedule,,14697.1,,,14697.1,Fee Schedule,,621.31,,,621.31,Fee Schedule,,1319.54,,,1319.54,Fee Schedule,,14697.1,,,14697.1,Fee Schedule,,1168.65,,,1168.65,Fee Schedule,,16593.5,70,,16593.5,percent of total billed charges,All Other,1275.45,,,1275.45,Fee Schedule,,1082.2,,,1082.2,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,825.3,,,825.3,Other,New York Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1262.71,,,1262.71,Other,153% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1155.42,,,1155.42,Other,140% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,2145.79,,,2145.79,Other,260% Medicaid APG methodology,2673.98,,,2673.98,Other,324% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1031.63,,,1031.63,Other,125% Medicaid APG methodology,621.31,16593.5,
NM Cardiac Stress Test 2nd Scan,78452,CPT,TC,47502349,CDM,341,RC,,,both,,,24380,2700.27,,,2700.27,Other,150% of Medicare + 9.63% HCRA Surcharge,1642.05,,,1642.05,Other,Medicare OPPS methodology,1343.16,,,1343.16,Fee Schedule,,1207.14,,,1207.14,Fee Schedule,,3670.06,,,3670.06,Fee Schedule,,3302.03,,,3302.03,Fee Schedule,,3118.02,,,3118.02,Fee Schedule,,12190,50,,12190,percent of total billed charges,All Other,3829.48,,,3829.48,Fee Schedule,,1610.94,,,1610.94,Fee Schedule,,1535.06,,,1535.06,Other,186% Medicaid methodology,1895.72,,,1895.72,Fee Schedule,,15115.6,,,15115.6,Fee Schedule,,892.61,,,892.61,Fee Schedule,,1895.72,,,1895.72,Fee Schedule,,15115.6,,,15115.6,Fee Schedule,,1678.95,,,1678.95,Fee Schedule,,17066,70,,17066,percent of total billed charges,All Other,1843.05,,,1843.05,Fee Schedule,,1563.8,,,1563.8,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,825.3,,,825.3,Other,New York Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1262.71,,,1262.71,Other,153% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1155.42,,,1155.42,Other,140% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,2145.79,,,2145.79,Other,260% Medicaid APG methodology,2673.98,,,2673.98,Other,324% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1031.63,,,1031.63,Other,125% Medicaid APG methodology,825.3,17066,
NM Lung Vent/Perf Differential Imaging,78598,CPT,TC,47502356,CDM,341,RC,,,both,,,8795,1027.85,,,1027.85,Other,150% of Medicare + 9.63% HCRA Surcharge,625.04,,,625.04,Other,Medicare OPPS methodology,887.74,,,887.74,Fee Schedule,,797.84,,,797.84,Fee Schedule,,253.15,,,253.15,Fee Schedule,,253.15,,,253.15,Fee Schedule,,253.15,,,253.15,Fee Schedule,,4397.5,50,,4397.5,percent of total billed charges,All Other,1435.1,,,1435.1,Fee Schedule,,1064.72,,,1064.72,Fee Schedule,,1535.06,,,1535.06,Other,186% Medicaid methodology,1252.95,,,1252.95,Fee Schedule,,5452.9,,,5452.9,Fee Schedule,,589.95,,,589.95,Fee Schedule,,1252.95,,,1252.95,Fee Schedule,,5452.9,,,5452.9,Fee Schedule,,1109.67,,,1109.67,Fee Schedule,,6156.5,70,,6156.5,percent of total billed charges,All Other,1227.6,,,1227.6,Fee Schedule,,1041.6,,,1041.6,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,825.3,,,825.3,Other,New York Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1262.71,,,1262.71,Other,153% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1155.42,,,1155.42,Other,140% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,2145.79,,,2145.79,Other,260% Medicaid APG methodology,2673.98,,,2673.98,Other,324% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1031.63,,,1031.63,Other,125% Medicaid APG methodology,253.15,6156.5,
NM Parathyroid Img w/Spect Scan Delayed,78071,CPT,TC,47502364,CDM,341,RC,,,both,,,6860,784.32,,,784.32,Other,150% of Medicare + 9.63% HCRA Surcharge,476.95,,,476.95,Other,Medicare OPPS methodology,992.05,,,992.05,Fee Schedule,,891.59,,,891.59,Fee Schedule,,295.66,,,295.66,Fee Schedule,,295.66,,,295.66,Fee Schedule,,295.66,,,295.66,Fee Schedule,,3430,50,,3430,percent of total billed charges,All Other,1105.85,,,1105.85,Fee Schedule,,1189.83,,,1189.83,Fee Schedule,,725.43,,,725.43,Other,186% Medicaid methodology,1400.17,,,1400.17,Fee Schedule,,4253.2,,,4253.2,Fee Schedule,,659.27,,,659.27,Fee Schedule,,1400.17,,,1400.17,Fee Schedule,,4253.2,,,4253.2,Fee Schedule,,1240.06,,,1240.06,Fee Schedule,,4802,70,,4802,percent of total billed charges,All Other,1362.9,,,1362.9,Fee Schedule,,1156.4,,,1156.4,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,390.01,,,390.01,Other,New York Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,596.72,,,596.72,Other,153% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,546.02,,,546.02,Other,140% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,1014.04,,,1014.04,Other,260% Medicaid APG methodology,1263.65,,,1263.65,Other,324% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,487.52,,,487.52,Other,125% Medicaid APG methodology,295.66,4802,
NM Sentinel Node Injection,38792,CPT,,47502372,CDM,341,RC,,,both,,,1808,784.32,,,784.32,Other,150% of Medicare + 9.63% HCRA Surcharge,476.95,,,476.95,Other,Medicare OPPS methodology,114.77,,,114.77,Fee Schedule,,103.15,,,103.15,Fee Schedule,,904,,,904,Fee Schedule,,813.6,,,813.6,Fee Schedule,,777.44,,,777.44,Fee Schedule,,904,50,,904,percent of total billed charges,All Other,1265.6,70,,1265.6,percent of total billed charges,All Other,137.65,,,137.65,Fee Schedule,,1535.06,,,1535.06,Other,186% Medicaid methodology,161.99,,,161.99,Fee Schedule,,1120.96,,,1120.96,Fee Schedule,,76.27,,,76.27,Fee Schedule,,161.99,,,161.99,Fee Schedule,,1120.96,,,1120.96,Fee Schedule,,143.46,,,143.46,Fee Schedule,,1265.6,70,,1265.6,percent of total billed charges,All Other,160.05,,,160.05,Fee Schedule,,135.8,,,135.8,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,825.3,,,825.3,Other,New York Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,825.3,,,825.3,Other,100% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1262.71,,,1262.71,Other,153% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,1155.42,,,1155.42,Other,140% Medicaid APG methodology,1856.93,,,1856.93,Other,225% Medicaid APG methodology,2145.79,,,2145.79,Other,260% Medicaid APG methodology,2673.98,,,2673.98,Other,324% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1774.4,,,1774.4,Other,215% Medicaid APG methodology,1031.63,,,1031.63,Other,125% Medicaid APG methodology,76.27,3642,
NM Thyroid Cancer Uptake Perf & Cal,78020,CPT,TC,47502380,CDM,341,RC,,,both,,,616,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,196.43,,,196.43,Fee Schedule,,176.53,,,176.53,Fee Schedule,,527.01,,,527.01,Fee Schedule,,474.16,,,474.16,Fee Schedule,,447.74,,,447.74,Fee Schedule,,308,50,,308,percent of total billed charges,All Other,431.2,70,,431.2,percent of total billed charges,All Other,235.59,,,235.59,Fee Schedule,,725.43,,,725.43,Other,186% Medicaid methodology,277.23,,,277.23,Fee Schedule,,381.92,,,381.92,Fee Schedule,,130.54,,,130.54,Fee Schedule,,277.23,,,277.23,Fee Schedule,,381.92,,,381.92,Fee Schedule,,245.53,,,245.53,Fee Schedule,,431.2,70,,431.2,percent of total billed charges,All Other,259.05,,,259.05,Fee Schedule,,219.8,,,219.8,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,390.01,,,390.01,Other,New York Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,390.01,,,390.01,Other,100% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,596.72,,,596.72,Other,153% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,546.02,,,546.02,Other,140% Medicaid APG methodology,877.53,,,877.53,Other,225% Medicaid APG methodology,1014.04,,,1014.04,Other,260% Medicaid APG methodology,1263.65,,,1263.65,Other,324% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,838.53,,,838.53,Other,215% Medicaid APG methodology,487.52,,,487.52,Other,125% Medicaid APG methodology,0.01,3642,
NUCLEAR RX IV ADMIN             ,79101,CPT,,47500350,CDM,342,RC,,,both,,,4424,473.1,,,473.1,Other,150% of Medicare + 9.63% HCRA Surcharge,287.7,,,287.7,Other,Medicare OPPS methodology,201.39,,,201.39,Fee Schedule,,180.99,,,180.99,Fee Schedule,,545.75,,,545.75,Fee Schedule,,491.02,,,491.02,Fee Schedule,,463.66,,,463.66,Fee Schedule,,2212,50,,2212,percent of total billed charges,All Other,731.97,,,731.97,Fee Schedule,,241.54,,,241.54,Fee Schedule,,820.22,,,820.22,Other,186% Medicaid methodology,284.24,,,284.24,Fee Schedule,,2742.88,,,2742.88,Fee Schedule,,133.83,,,133.83,Fee Schedule,,284.24,,,284.24,Fee Schedule,,2742.88,,,2742.88,Fee Schedule,,251.73,,,251.73,Fee Schedule,,3096.8,70,,3096.8,percent of total billed charges,All Other,259.05,,,259.05,Fee Schedule,,219.8,,,219.8,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,440.98,,,440.98,Other,New York Medicaid APG methodology,440.98,,,440.98,Other,100% Medicaid APG methodology,440.98,,,440.98,Other,100% Medicaid APG methodology,440.98,,,440.98,Other,100% Medicaid APG methodology,992.2,,,992.2,Other,225% Medicaid APG methodology,992.2,,,992.2,Other,225% Medicaid APG methodology,674.7,,,674.7,Other,153% Medicaid APG methodology,992.2,,,992.2,Other,225% Medicaid APG methodology,617.37,,,617.37,Other,140% Medicaid APG methodology,992.2,,,992.2,Other,225% Medicaid APG methodology,1146.55,,,1146.55,Other,260% Medicaid APG methodology,1428.77,,,1428.77,Other,324% Medicaid APG methodology,948.1,,,948.1,Other,215% Medicaid APG methodology,948.1,,,948.1,Other,215% Medicaid APG methodology,551.22,,,551.22,Other,125% Medicaid APG methodology,133.83,3642,
NUCLEAR RX ORAL ADMIN           ,79005,CPT,,47501002,CDM,342,RC,,,both,,,4424,473.1,,,473.1,Other,150% of Medicare + 9.63% HCRA Surcharge,287.7,,,287.7,Other,Medicare OPPS methodology,192.7,,,192.7,Fee Schedule,,173.18,,,173.18,Fee Schedule,,502.1,,,502.1,Fee Schedule,,451.75,,,451.75,Fee Schedule,,426.57,,,426.57,Fee Schedule,,2212,50,,2212,percent of total billed charges,All Other,731.97,,,731.97,Fee Schedule,,231.11,,,231.11,Fee Schedule,,820.22,,,820.22,Other,186% Medicaid methodology,271.97,,,271.97,Fee Schedule,,2742.88,,,2742.88,Fee Schedule,,128.06,,,128.06,Fee Schedule,,271.97,,,271.97,Fee Schedule,,2742.88,,,2742.88,Fee Schedule,,240.87,,,240.87,Fee Schedule,,3096.8,70,,3096.8,percent of total billed charges,All Other,249.15,,,249.15,Fee Schedule,,211.4,,,211.4,Fee Schedule,,2307,,,2307,Case Rate,Nuclear Medicine Per Visit,3277,,,3277,Case Rate,Nuclear Medicine Per Visit,3642,,,3642,Case Rate,Nuclear Medicine Per Visit,3096,,,3096,Case Rate,Nuclear Medicine Per Visit,440.98,,,440.98,Other,New York Medicaid APG methodology,440.98,,,440.98,Other,100% Medicaid APG methodology,440.98,,,440.98,Other,100% Medicaid APG methodology,440.98,,,440.98,Other,100% Medicaid APG methodology,992.2,,,992.2,Other,225% Medicaid APG methodology,992.2,,,992.2,Other,225% Medicaid APG methodology,674.7,,,674.7,Other,153% Medicaid APG methodology,992.2,,,992.2,Other,225% Medicaid APG methodology,617.37,,,617.37,Other,140% Medicaid APG methodology,992.2,,,992.2,Other,225% Medicaid APG methodology,1146.55,,,1146.55,Other,260% Medicaid APG methodology,1428.77,,,1428.77,Other,324% Medicaid APG methodology,948.1,,,948.1,Other,215% Medicaid APG methodology,948.1,,,948.1,Other,215% Medicaid APG methodology,551.22,,,551.22,Other,125% Medicaid APG methodology,128.06,3642,
TC99M SESTAMIBI DX PER DOSE     ,A9500,HCPCS,,47501234,CDM,343,RC,,,both,,,123,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,36.9,30,,36.9,percent of total billed charges,Drugs,36.9,30,,36.9,percent of total billed charges,Drugs,36.9,30,,36.9,percent of total billed charges,Drugs,61.5,50,,61.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,36.9,30,,36.9,percent of total billed charges,Drugs,0.02,,,0.02,Other,186% Medicaid methodology,36.9,30,,36.9,percent of total billed charges,Drugs,36.9,30,,36.9,percent of total billed charges,Drugs,36.9,30,,36.9,percent of total billed charges,Drugs,36.9,30,,36.9,percent of total billed charges,Drugs,36.9,30,,36.9,percent of total billed charges,Drugs,0.01,,,0.01,Other,Non-covered service,86.1,70,,86.1,percent of total billed charges,All Other,86.1,70,,86.1,percent of total billed charges,Radiopharmaceuticals,86.1,70,,86.1,percent of total billed charges,Radiopharmaceuticals,36.9,30,,36.9,percent of total billed charges,Drugs,36.9,30,,36.9,percent of total billed charges,Drugs,36.9,30,,36.9,percent of total billed charges,Drugs,36.9,30,,36.9,percent of total billed charges,Drugs,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,86.1,
TC99M MDP PER DOSE              ,A9503,HCPCS,,47501259,CDM,343,RC,,,both,,,126,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,37.8,30,,37.8,percent of total billed charges,Drugs,37.8,30,,37.8,percent of total billed charges,Drugs,37.8,30,,37.8,percent of total billed charges,Drugs,63,50,,63,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,37.8,30,,37.8,percent of total billed charges,Drugs,0.02,,,0.02,Other,186% Medicaid methodology,37.8,30,,37.8,percent of total billed charges,Drugs,37.8,30,,37.8,percent of total billed charges,Drugs,37.8,30,,37.8,percent of total billed charges,Drugs,37.8,30,,37.8,percent of total billed charges,Drugs,37.8,30,,37.8,percent of total billed charges,Drugs,0.01,,,0.01,Other,Non-covered service,88.2,70,,88.2,percent of total billed charges,All Other,88.2,70,,88.2,percent of total billed charges,Radiopharmaceuticals,88.2,70,,88.2,percent of total billed charges,Radiopharmaceuticals,37.8,30,,37.8,percent of total billed charges,Drugs,37.8,30,,37.8,percent of total billed charges,Drugs,37.8,30,,37.8,percent of total billed charges,Drugs,37.8,30,,37.8,percent of total billed charges,Drugs,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,88.2,
Tl-201 (4mCi),A9505,HCPCS,,47501275,CDM,343,RC,,,both,,,60,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,18,30,,18,percent of total billed charges,Drugs,18,30,,18,percent of total billed charges,Drugs,18,30,,18,percent of total billed charges,Drugs,30,50,,30,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,18,30,,18,percent of total billed charges,Drugs,0.02,,,0.02,Other,186% Medicaid methodology,18,30,,18,percent of total billed charges,Drugs,18,30,,18,percent of total billed charges,Drugs,18,30,,18,percent of total billed charges,Drugs,18,30,,18,percent of total billed charges,Drugs,18,30,,18,percent of total billed charges,Drugs,0.01,,,0.01,Other,Non-covered service,42,70,,42,percent of total billed charges,All Other,42,70,,42,percent of total billed charges,Radiopharmaceuticals,42,70,,42,percent of total billed charges,Radiopharmaceuticals,18,30,,18,percent of total billed charges,Drugs,18,30,,18,percent of total billed charges,Drugs,18,30,,18,percent of total billed charges,Drugs,18,30,,18,percent of total billed charges,Drugs,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,42,
PERTECHNETATE PER MCI           ,A9512,HCPCS,,47501325,CDM,343,RC,,,both,,,3,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,1.5,50,,1.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.9,30,,0.9,percent of total billed charges,Drugs,0.02,,,0.02,Other,186% Medicaid methodology,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.01,,,0.01,Other,Non-covered service,2.1,70,,2.1,percent of total billed charges,All Other,2.1,70,,2.1,percent of total billed charges,Radiopharmaceuticals,2.1,70,,2.1,percent of total billed charges,Radiopharmaceuticals,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,2.1,
TC99 MEBROFENIN PER DOSE        ,A9537,HCPCS,,47501333,CDM,343,RC,,,both,,,142,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,42.6,30,,42.6,percent of total billed charges,Drugs,42.6,30,,42.6,percent of total billed charges,Drugs,42.6,30,,42.6,percent of total billed charges,Drugs,71,50,,71,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,42.6,30,,42.6,percent of total billed charges,Drugs,0.02,,,0.02,Other,186% Medicaid methodology,42.6,30,,42.6,percent of total billed charges,Drugs,42.6,30,,42.6,percent of total billed charges,Drugs,42.6,30,,42.6,percent of total billed charges,Drugs,42.6,30,,42.6,percent of total billed charges,Drugs,42.6,30,,42.6,percent of total billed charges,Drugs,0.01,,,0.01,Other,Non-covered service,99.4,70,,99.4,percent of total billed charges,All Other,99.4,70,,99.4,percent of total billed charges,Radiopharmaceuticals,99.4,70,,99.4,percent of total billed charges,Radiopharmaceuticals,42.6,30,,42.6,percent of total billed charges,Drugs,42.6,30,,42.6,percent of total billed charges,Drugs,42.6,30,,42.6,percent of total billed charges,Drugs,42.6,30,,42.6,percent of total billed charges,Drugs,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,99.4,
TC99M PENTETATE PER DOSE DTPA   ,A9539,HCPCS,,47501358,CDM,343,RC,,,both,,,338,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,101.4,30,,101.4,percent of total billed charges,Drugs,101.4,30,,101.4,percent of total billed charges,Drugs,101.4,30,,101.4,percent of total billed charges,Drugs,169,50,,169,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,101.4,30,,101.4,percent of total billed charges,Drugs,0.02,,,0.02,Other,186% Medicaid methodology,101.4,30,,101.4,percent of total billed charges,Drugs,101.4,30,,101.4,percent of total billed charges,Drugs,101.4,30,,101.4,percent of total billed charges,Drugs,101.4,30,,101.4,percent of total billed charges,Drugs,101.4,30,,101.4,percent of total billed charges,Drugs,0.01,,,0.01,Other,Non-covered service,236.6,70,,236.6,percent of total billed charges,All Other,236.6,70,,236.6,percent of total billed charges,Radiopharmaceuticals,236.6,70,,236.6,percent of total billed charges,Radiopharmaceuticals,101.4,30,,101.4,percent of total billed charges,Drugs,101.4,30,,101.4,percent of total billed charges,Drugs,101.4,30,,101.4,percent of total billed charges,Drugs,101.4,30,,101.4,percent of total billed charges,Drugs,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,236.6,
I-123 SI CAPSULE 100 UCI        ,A9516,HCPCS,,47501366,CDM,343,RC,,,both,,,229,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,68.7,30,,68.7,percent of total billed charges,Drugs,68.7,30,,68.7,percent of total billed charges,Drugs,68.7,30,,68.7,percent of total billed charges,Drugs,114.5,50,,114.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,68.7,30,,68.7,percent of total billed charges,Drugs,0.02,,,0.02,Other,186% Medicaid methodology,68.7,30,,68.7,percent of total billed charges,Drugs,68.7,30,,68.7,percent of total billed charges,Drugs,68.7,30,,68.7,percent of total billed charges,Drugs,68.7,30,,68.7,percent of total billed charges,Drugs,68.7,30,,68.7,percent of total billed charges,Drugs,0.01,,,0.01,Other,Non-covered service,160.3,70,,160.3,percent of total billed charges,All Other,160.3,70,,160.3,percent of total billed charges,Radiopharmaceuticals,160.3,70,,160.3,percent of total billed charges,Radiopharmaceuticals,68.7,30,,68.7,percent of total billed charges,Drugs,68.7,30,,68.7,percent of total billed charges,Drugs,68.7,30,,68.7,percent of total billed charges,Drugs,68.7,30,,68.7,percent of total billed charges,Drugs,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,160.3,
TC99M MAA PER DOSE              ,A9540,HCPCS,,47501382,CDM,343,RC,,,both,,,516,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,154.8,30,,154.8,percent of total billed charges,Drugs,154.8,30,,154.8,percent of total billed charges,Drugs,154.8,30,,154.8,percent of total billed charges,Drugs,258,50,,258,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,154.8,30,,154.8,percent of total billed charges,Drugs,0.02,,,0.02,Other,186% Medicaid methodology,154.8,30,,154.8,percent of total billed charges,Drugs,154.8,30,,154.8,percent of total billed charges,Drugs,154.8,30,,154.8,percent of total billed charges,Drugs,154.8,30,,154.8,percent of total billed charges,Drugs,154.8,30,,154.8,percent of total billed charges,Drugs,0.01,,,0.01,Other,Non-covered service,361.2,70,,361.2,percent of total billed charges,All Other,361.2,70,,361.2,percent of total billed charges,Radiopharmaceuticals,361.2,70,,361.2,percent of total billed charges,Radiopharmaceuticals,154.8,30,,154.8,percent of total billed charges,Drugs,154.8,30,,154.8,percent of total billed charges,Drugs,154.8,30,,154.8,percent of total billed charges,Drugs,154.8,30,,154.8,percent of total billed charges,Drugs,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,361.2,
TC99M SULFUR COLLOID PER DOSE   ,A9541,HCPCS,,47501390,CDM,343,RC,,,both,,,651,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,195.3,30,,195.3,percent of total billed charges,Drugs,195.3,30,,195.3,percent of total billed charges,Drugs,195.3,30,,195.3,percent of total billed charges,Drugs,325.5,50,,325.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,195.3,30,,195.3,percent of total billed charges,Drugs,0.02,,,0.02,Other,186% Medicaid methodology,195.3,30,,195.3,percent of total billed charges,Drugs,195.3,30,,195.3,percent of total billed charges,Drugs,195.3,30,,195.3,percent of total billed charges,Drugs,195.3,30,,195.3,percent of total billed charges,Drugs,195.3,30,,195.3,percent of total billed charges,Drugs,0.01,,,0.01,Other,Non-covered service,455.7,70,,455.7,percent of total billed charges,All Other,455.7,70,,455.7,percent of total billed charges,Radiopharmaceuticals,455.7,70,,455.7,percent of total billed charges,Radiopharmaceuticals,195.3,30,,195.3,percent of total billed charges,Drugs,195.3,30,,195.3,percent of total billed charges,Drugs,195.3,30,,195.3,percent of total billed charges,Drugs,195.3,30,,195.3,percent of total billed charges,Drugs,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,455.7,
I-131 DX CAPSULE PER MCI        ,A9528,HCPCS,,47501457,CDM,343,RC,,,both,,,52,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,15.6,30,,15.6,percent of total billed charges,Drugs,15.6,30,,15.6,percent of total billed charges,Drugs,15.6,30,,15.6,percent of total billed charges,Drugs,26,50,,26,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,15.6,30,,15.6,percent of total billed charges,Drugs,0.02,,,0.02,Other,186% Medicaid methodology,15.6,30,,15.6,percent of total billed charges,Drugs,15.6,30,,15.6,percent of total billed charges,Drugs,15.6,30,,15.6,percent of total billed charges,Drugs,15.6,30,,15.6,percent of total billed charges,Drugs,15.6,30,,15.6,percent of total billed charges,Drugs,0.01,,,0.01,Other,Non-covered service,36.4,70,,36.4,percent of total billed charges,All Other,36.4,70,,36.4,percent of total billed charges,Radiopharmaceuticals,36.4,70,,36.4,percent of total billed charges,Radiopharmaceuticals,15.6,30,,15.6,percent of total billed charges,Drugs,15.6,30,,15.6,percent of total billed charges,Drugs,15.6,30,,15.6,percent of total billed charges,Drugs,15.6,30,,15.6,percent of total billed charges,Drugs,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,36.4,
IN-111 OXYQUINOLINE PER 0.5MCI  ,A9547,HCPCS,,47501606,CDM,343,RC,,,both,,,6865,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2059.5,30,,2059.5,percent of total billed charges,Drugs,2059.5,30,,2059.5,percent of total billed charges,Drugs,2059.5,30,,2059.5,percent of total billed charges,Drugs,3432.5,50,,3432.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,2059.5,30,,2059.5,percent of total billed charges,Drugs,0.02,,,0.02,Other,186% Medicaid methodology,2059.5,30,,2059.5,percent of total billed charges,Drugs,2059.5,30,,2059.5,percent of total billed charges,Drugs,2059.5,30,,2059.5,percent of total billed charges,Drugs,2059.5,30,,2059.5,percent of total billed charges,Drugs,2059.5,30,,2059.5,percent of total billed charges,Drugs,0.01,,,0.01,Other,Non-covered service,4805.5,70,,4805.5,percent of total billed charges,All Other,4805.5,70,,4805.5,percent of total billed charges,Radiopharmaceuticals,4805.5,70,,4805.5,percent of total billed charges,Radiopharmaceuticals,2059.5,30,,2059.5,percent of total billed charges,Drugs,2059.5,30,,2059.5,percent of total billed charges,Drugs,2059.5,30,,2059.5,percent of total billed charges,Drugs,2059.5,30,,2059.5,percent of total billed charges,Drugs,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,4805.5,
IN-111 PENTETATE PER 0.5 MCI    ,A9548,HCPCS,,47501614,CDM,343,RC,,,both,,,8797,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2639.1,30,,2639.1,percent of total billed charges,Drugs,2639.1,30,,2639.1,percent of total billed charges,Drugs,2639.1,30,,2639.1,percent of total billed charges,Drugs,4398.5,50,,4398.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,2639.1,30,,2639.1,percent of total billed charges,Drugs,0.02,,,0.02,Other,186% Medicaid methodology,2639.1,30,,2639.1,percent of total billed charges,Drugs,2639.1,30,,2639.1,percent of total billed charges,Drugs,2639.1,30,,2639.1,percent of total billed charges,Drugs,2639.1,30,,2639.1,percent of total billed charges,Drugs,2639.1,30,,2639.1,percent of total billed charges,Drugs,0.01,,,0.01,Other,Non-covered service,6157.9,70,,6157.9,percent of total billed charges,All Other,6157.9,70,,6157.9,percent of total billed charges,Radiopharmaceuticals,6157.9,70,,6157.9,percent of total billed charges,Radiopharmaceuticals,2639.1,30,,2639.1,percent of total billed charges,Drugs,2639.1,30,,2639.1,percent of total billed charges,Drugs,2639.1,30,,2639.1,percent of total billed charges,Drugs,2639.1,30,,2639.1,percent of total billed charges,Drugs,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,6157.9,
GA67 GALLIUM CITRATE PER MCI    ,A9556,HCPCS,,47501713,CDM,343,RC,,,both,,,161,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,48.3,30,,48.3,percent of total billed charges,Drugs,48.3,30,,48.3,percent of total billed charges,Drugs,48.3,30,,48.3,percent of total billed charges,Drugs,80.5,50,,80.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,48.3,30,,48.3,percent of total billed charges,Drugs,0.02,,,0.02,Other,186% Medicaid methodology,48.3,30,,48.3,percent of total billed charges,Drugs,48.3,30,,48.3,percent of total billed charges,Drugs,48.3,30,,48.3,percent of total billed charges,Drugs,48.3,30,,48.3,percent of total billed charges,Drugs,48.3,30,,48.3,percent of total billed charges,Drugs,0.01,,,0.01,Other,Non-covered service,112.7,70,,112.7,percent of total billed charges,All Other,112.7,70,,112.7,percent of total billed charges,Radiopharmaceuticals,112.7,70,,112.7,percent of total billed charges,Radiopharmaceuticals,48.3,30,,48.3,percent of total billed charges,Drugs,48.3,30,,48.3,percent of total billed charges,Drugs,48.3,30,,48.3,percent of total billed charges,Drugs,48.3,30,,48.3,percent of total billed charges,Drugs,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,112.7,
TC99M MERTIATIDE PER DOSE MAG3  ,A9562,HCPCS,,47501747,CDM,343,RC,,,both,,,1262,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,378.6,30,,378.6,percent of total billed charges,Drugs,378.6,30,,378.6,percent of total billed charges,Drugs,378.6,30,,378.6,percent of total billed charges,Drugs,631,50,,631,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,378.6,30,,378.6,percent of total billed charges,Drugs,0.02,,,0.02,Other,186% Medicaid methodology,378.6,30,,378.6,percent of total billed charges,Drugs,378.6,30,,378.6,percent of total billed charges,Drugs,378.6,30,,378.6,percent of total billed charges,Drugs,378.6,30,,378.6,percent of total billed charges,Drugs,378.6,30,,378.6,percent of total billed charges,Drugs,0.01,,,0.01,Other,Non-covered service,883.4,70,,883.4,percent of total billed charges,All Other,883.4,70,,883.4,percent of total billed charges,Radiopharmaceuticals,883.4,70,,883.4,percent of total billed charges,Radiopharmaceuticals,378.6,30,,378.6,percent of total billed charges,Drugs,378.6,30,,378.6,percent of total billed charges,Drugs,378.6,30,,378.6,percent of total billed charges,Drugs,378.6,30,,378.6,percent of total billed charges,Drugs,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,883.4,
IN-111 PENTETREOTIDE PER DOSE   ,A9572,HCPCS,,47501770,CDM,343,RC,,,both,,,12436,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3730.8,30,,3730.8,percent of total billed charges,Drugs,3730.8,30,,3730.8,percent of total billed charges,Drugs,3730.8,30,,3730.8,percent of total billed charges,Drugs,6218,50,,6218,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,3730.8,30,,3730.8,percent of total billed charges,Drugs,0.02,,,0.02,Other,186% Medicaid methodology,3730.8,30,,3730.8,percent of total billed charges,Drugs,3730.8,30,,3730.8,percent of total billed charges,Drugs,3730.8,30,,3730.8,percent of total billed charges,Drugs,3730.8,30,,3730.8,percent of total billed charges,Drugs,3730.8,30,,3730.8,percent of total billed charges,Drugs,0.01,,,0.01,Other,Non-covered service,8705.2,70,,8705.2,percent of total billed charges,All Other,8705.2,70,,8705.2,percent of total billed charges,Radiopharmaceuticals,8705.2,70,,8705.2,percent of total billed charges,Radiopharmaceuticals,3730.8,30,,3730.8,percent of total billed charges,Drugs,3730.8,30,,3730.8,percent of total billed charges,Drugs,3730.8,30,,3730.8,percent of total billed charges,Drugs,3730.8,30,,3730.8,percent of total billed charges,Drugs,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,8705.2,
TC99M LABELED RBC PER DOSE      ,A9560,HCPCS,,47501796,CDM,343,RC,,,both,,,484,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,145.2,30,,145.2,percent of total billed charges,Drugs,145.2,30,,145.2,percent of total billed charges,Drugs,145.2,30,,145.2,percent of total billed charges,Drugs,242,50,,242,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,145.2,30,,145.2,percent of total billed charges,Drugs,0.02,,,0.02,Other,186% Medicaid methodology,145.2,30,,145.2,percent of total billed charges,Drugs,145.2,30,,145.2,percent of total billed charges,Drugs,145.2,30,,145.2,percent of total billed charges,Drugs,145.2,30,,145.2,percent of total billed charges,Drugs,145.2,30,,145.2,percent of total billed charges,Drugs,0.01,,,0.01,Other,Non-covered service,338.8,70,,338.8,percent of total billed charges,All Other,338.8,70,,338.8,percent of total billed charges,Radiopharmaceuticals,338.8,70,,338.8,percent of total billed charges,Radiopharmaceuticals,145.2,30,,145.2,percent of total billed charges,Drugs,145.2,30,,145.2,percent of total billed charges,Drugs,145.2,30,,145.2,percent of total billed charges,Drugs,145.2,30,,145.2,percent of total billed charges,Drugs,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,338.8,
TC99M EXAMETAZIME PER DOSE      ,A9521,HCPCS,,47501986,CDM,343,RC,,,both,,,5457,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1637.1,30,,1637.1,percent of total billed charges,Drugs,1637.1,30,,1637.1,percent of total billed charges,Drugs,1637.1,30,,1637.1,percent of total billed charges,Drugs,2728.5,50,,2728.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,1637.1,30,,1637.1,percent of total billed charges,Drugs,0.02,,,0.02,Other,186% Medicaid methodology,1637.1,30,,1637.1,percent of total billed charges,Drugs,1637.1,30,,1637.1,percent of total billed charges,Drugs,1637.1,30,,1637.1,percent of total billed charges,Drugs,1637.1,30,,1637.1,percent of total billed charges,Drugs,1637.1,30,,1637.1,percent of total billed charges,Drugs,0.01,,,0.01,Other,Non-covered service,3819.9,70,,3819.9,percent of total billed charges,All Other,3819.9,70,,3819.9,percent of total billed charges,Radiopharmaceuticals,3819.9,70,,3819.9,percent of total billed charges,Radiopharmaceuticals,1637.1,30,,1637.1,percent of total billed charges,Drugs,1637.1,30,,1637.1,percent of total billed charges,Drugs,1637.1,30,,1637.1,percent of total billed charges,Drugs,1637.1,30,,1637.1,percent of total billed charges,Drugs,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,3819.9,
IODINE 1 123 IOFLUPANE =< 5MCI  ,A9584,HCPCS,,47502034,CDM,343,RC,,,both,,,6825,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2047.5,30,,2047.5,percent of total billed charges,Drugs,2047.5,30,,2047.5,percent of total billed charges,Drugs,2047.5,30,,2047.5,percent of total billed charges,Drugs,3412.5,50,,3412.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,2047.5,30,,2047.5,percent of total billed charges,Drugs,0.02,,,0.02,Other,186% Medicaid methodology,2047.5,30,,2047.5,percent of total billed charges,Drugs,2047.5,30,,2047.5,percent of total billed charges,Drugs,2047.5,30,,2047.5,percent of total billed charges,Drugs,2047.5,30,,2047.5,percent of total billed charges,Drugs,2047.5,30,,2047.5,percent of total billed charges,Drugs,0.01,,,0.01,Other,Non-covered service,4777.5,70,,4777.5,percent of total billed charges,All Other,4777.5,70,,4777.5,percent of total billed charges,Radiopharmaceuticals,4777.5,70,,4777.5,percent of total billed charges,Radiopharmaceuticals,2047.5,30,,2047.5,percent of total billed charges,Drugs,2047.5,30,,2047.5,percent of total billed charges,Drugs,2047.5,30,,2047.5,percent of total billed charges,Drugs,2047.5,30,,2047.5,percent of total billed charges,Drugs,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,4777.5,
TC 99M DTPA AEROSOL 1 UNIT DOS  ,A9567,HCPCS,,47502406,CDM,343,RC,,,both,,,338,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,101.4,30,,101.4,percent of total billed charges,Drugs,101.4,30,,101.4,percent of total billed charges,Drugs,101.4,30,,101.4,percent of total billed charges,Drugs,169,50,,169,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,101.4,30,,101.4,percent of total billed charges,Drugs,0.02,,,0.02,Other,186% Medicaid methodology,101.4,30,,101.4,percent of total billed charges,Drugs,101.4,30,,101.4,percent of total billed charges,Drugs,101.4,30,,101.4,percent of total billed charges,Drugs,101.4,30,,101.4,percent of total billed charges,Drugs,101.4,30,,101.4,percent of total billed charges,Drugs,0.01,,,0.01,Other,Non-covered service,236.6,70,,236.6,percent of total billed charges,All Other,236.6,70,,236.6,percent of total billed charges,Radiopharmaceuticals,236.6,70,,236.6,percent of total billed charges,Radiopharmaceuticals,101.4,30,,101.4,percent of total billed charges,Drugs,101.4,30,,101.4,percent of total billed charges,Drugs,101.4,30,,101.4,percent of total billed charges,Drugs,101.4,30,,101.4,percent of total billed charges,Drugs,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,236.6,
GALLIUM ILLUCCIX 1 MILL         ,A9596,HCPCS,,47502505,CDM,343,RC,,,both,,,1410,1630.77,,,1630.77,Other,150% of Medicare + 9.63% HCRA Surcharge,991.68,,,991.68,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,423,30,,423,percent of total billed charges,Drugs,423,30,,423,percent of total billed charges,Drugs,423,30,,423,percent of total billed charges,Drugs,705,50,,705,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,423,30,,423,percent of total billed charges,Drugs,0.02,,,0.02,Other,186% Medicaid methodology,423,30,,423,percent of total billed charges,Drugs,423,30,,423,percent of total billed charges,Drugs,423,30,,423,percent of total billed charges,Drugs,423,30,,423,percent of total billed charges,Drugs,423,30,,423,percent of total billed charges,Drugs,0.01,,,0.01,Other,Non-covered service,987,70,,987,percent of total billed charges,All Other,987,70,,987,percent of total billed charges,Radiopharmaceuticals,987,70,,987,percent of total billed charges,Radiopharmaceuticals,423,30,,423,percent of total billed charges,Drugs,423,30,,423,percent of total billed charges,Drugs,423,30,,423,percent of total billed charges,Drugs,423,30,,423,percent of total billed charges,Drugs,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1630.77,
XOFIGO PER MICROCURIE           ,A9606,HCPCS,,47502059,CDM,344,RC,,,both,,,267,265.02,,,265.02,Other,150% of Medicare + 9.63% HCRA Surcharge,161.16,,,161.16,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,80.1,30,,80.1,percent of total billed charges,Drugs,80.1,30,,80.1,percent of total billed charges,Drugs,80.1,30,,80.1,percent of total billed charges,Drugs,133.5,50,,133.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,80.1,30,,80.1,percent of total billed charges,Drugs,2366.27,,,2366.27,Other,186% Medicaid methodology,80.1,30,,80.1,percent of total billed charges,Drugs,80.1,30,,80.1,percent of total billed charges,Drugs,80.1,30,,80.1,percent of total billed charges,Drugs,80.1,30,,80.1,percent of total billed charges,Drugs,80.1,30,,80.1,percent of total billed charges,Drugs,0.01,,,0.01,Other,Non-covered service,186.9,70,,186.9,percent of total billed charges,All Other,186.9,70,,186.9,percent of total billed charges,Radiopharmaceuticals,186.9,70,,186.9,percent of total billed charges,Radiopharmaceuticals,80.1,30,,80.1,percent of total billed charges,Drugs,80.1,30,,80.1,percent of total billed charges,Drugs,80.1,30,,80.1,percent of total billed charges,Drugs,80.1,30,,80.1,percent of total billed charges,Drugs,1272.19,,,1272.19,Other,New York Medicaid APG methodology,1272.19,,,1272.19,Other,100% Medicaid APG methodology,1272.19,,,1272.19,Other,100% Medicaid APG methodology,1272.19,,,1272.19,Other,100% Medicaid APG methodology,2862.43,,,2862.43,Other,225% Medicaid APG methodology,2862.43,,,2862.43,Other,225% Medicaid APG methodology,1946.45,,,1946.45,Other,153% Medicaid APG methodology,2862.43,,,2862.43,Other,225% Medicaid APG methodology,1781.07,,,1781.07,Other,140% Medicaid APG methodology,2862.43,,,2862.43,Other,225% Medicaid APG methodology,3307.69,,,3307.69,Other,260% Medicaid APG methodology,4121.9,,,4121.9,Other,324% Medicaid APG methodology,2735.21,,,2735.21,Other,215% Medicaid APG methodology,2735.21,,,2735.21,Other,215% Medicaid APG methodology,1590.24,,,1590.24,Other,125% Medicaid APG methodology,0.01,4121.9,
CT SCAN FOR NEEDLE BIOPSY       ,77012,CPT,,47200423,CDM,350,RC,,,both,,,4204,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,263.95,,,263.95,Fee Schedule,,237.23,,,237.23,Fee Schedule,,979.06,,,979.06,Fee Schedule,,880.89,,,880.89,Fee Schedule,,831.8,,,831.8,Fee Schedule,,2102,50,,2102,percent of total billed charges,All Other,2942.8,70,,2942.8,percent of total billed charges,All Other,316.58,,,316.58,Fee Schedule,,431.43,,,431.43,Other,186% Medicaid methodology,372.54,,,372.54,Fee Schedule,,2606.48,,,2606.48,Fee Schedule,,175.41,,,175.41,Fee Schedule,,372.54,,,372.54,Fee Schedule,,2606.48,,,2606.48,Fee Schedule,,329.94,,,329.94,Fee Schedule,,2942.8,70,,2942.8,percent of total billed charges,All Other,359.7,,,359.7,Fee Schedule,,305.2,,,305.2,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,231.95,,,231.95,Other,New York Medicaid APG methodology,231.95,,,231.95,Other,100% Medicaid APG methodology,231.95,,,231.95,Other,100% Medicaid APG methodology,231.95,,,231.95,Other,100% Medicaid APG methodology,521.89,,,521.89,Other,225% Medicaid APG methodology,521.89,,,521.89,Other,225% Medicaid APG methodology,354.88,,,354.88,Other,153% Medicaid APG methodology,521.89,,,521.89,Other,225% Medicaid APG methodology,324.73,,,324.73,Other,140% Medicaid APG methodology,521.89,,,521.89,Other,225% Medicaid APG methodology,603.07,,,603.07,Other,260% Medicaid APG methodology,751.52,,,751.52,Other,324% Medicaid APG methodology,498.69,,,498.69,Other,215% Medicaid APG methodology,498.69,,,498.69,Other,215% Medicaid APG methodology,289.94,,,289.94,Other,125% Medicaid APG methodology,0.01,2942.8,
CAT SCAN FOLLOW-UP STUDY        ,76380,CPT,,47200498,CDM,350,RC,,,both,,,2484,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,328.55,,,328.55,Fee Schedule,,295.27,,,295.27,Fee Schedule,,1041.46,,,1041.46,Fee Schedule,,937.02,,,937.02,Fee Schedule,,884.81,,,884.81,Fee Schedule,,1242,50,,1242,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,394.05,,,394.05,Fee Schedule,,638.26,,,638.26,Other,186% Medicaid methodology,463.71,,,463.71,Fee Schedule,,1540.08,,,1540.08,Fee Schedule,,218.34,,,218.34,Fee Schedule,,463.71,,,463.71,Fee Schedule,,1540.08,,,1540.08,Fee Schedule,,410.68,,,410.68,Fee Schedule,,1738.8,70,,1738.8,percent of total billed charges,All Other,453.75,,,453.75,Fee Schedule,,385,,,385,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,343.15,,,343.15,Other,New York Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,525.02,,,525.02,Other,153% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,480.41,,,480.41,Other,140% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,892.19,,,892.19,Other,260% Medicaid APG methodology,1111.8,,,1111.8,Other,324% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,428.94,,,428.94,Other,125% Medicaid APG methodology,105.08,2602,
ABSCESS DRAINAGE UNDER X-RAY    ,75989,CPT,,47200910,CDM,350,RC,,,both,,,4065,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,213.05,,,213.05,Fee Schedule,,191.47,,,191.47,Fee Schedule,,710.96,,,710.96,Fee Schedule,,639.67,,,639.67,Fee Schedule,,604.02,,,604.02,Fee Schedule,,2032.5,50,,2032.5,percent of total billed charges,All Other,2845.5,70,,2845.5,percent of total billed charges,All Other,255.52,,,255.52,Fee Schedule,,751.06,,,751.06,Other,186% Medicaid methodology,300.69,,,300.69,Fee Schedule,,2520.3,,,2520.3,Fee Schedule,,141.58,,,141.58,Fee Schedule,,300.69,,,300.69,Fee Schedule,,2520.3,,,2520.3,Fee Schedule,,266.31,,,266.31,Fee Schedule,,2845.5,70,,2845.5,percent of total billed charges,All Other,293.7,,,293.7,Fee Schedule,,249.2,,,249.2,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,403.79,,,403.79,Other,New York Medicaid APG methodology,403.79,,,403.79,Other,100% Medicaid APG methodology,403.79,,,403.79,Other,100% Medicaid APG methodology,403.79,,,403.79,Other,100% Medicaid APG methodology,908.54,,,908.54,Other,225% Medicaid APG methodology,908.54,,,908.54,Other,225% Medicaid APG methodology,617.81,,,617.81,Other,153% Medicaid APG methodology,908.54,,,908.54,Other,225% Medicaid APG methodology,565.31,,,565.31,Other,140% Medicaid APG methodology,908.54,,,908.54,Other,225% Medicaid APG methodology,1049.87,,,1049.87,Other,260% Medicaid APG methodology,1308.29,,,1308.29,Other,324% Medicaid APG methodology,868.16,,,868.16,Other,215% Medicaid APG methodology,868.16,,,868.16,Other,215% Medicaid APG methodology,504.74,,,504.74,Other,125% Medicaid APG methodology,0.01,2845.5,
CT HRT W/O DYE W/CA TEST        ,75571,CPT,,47201132,CDM,350,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,282.09,,,282.09,Fee Schedule,,253.53,,,253.53,Fee Schedule,,427.28,,,427.28,Fee Schedule,,384.43,,,384.43,Fee Schedule,,363.01,,,363.01,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,338.33,,,338.33,Fee Schedule,,638.26,,,638.26,Other,186% Medicaid methodology,398.14,,,398.14,Fee Schedule,,922.56,,,922.56,Fee Schedule,,187.47,,,187.47,Fee Schedule,,398.14,,,398.14,Fee Schedule,,922.56,,,922.56,Fee Schedule,,352.62,,,352.62,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,369.6,,,369.6,Fee Schedule,,313.6,,,313.6,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,343.15,,,343.15,Other,New York Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,525.02,,,525.02,Other,153% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,480.41,,,480.41,Other,140% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,892.19,,,892.19,Other,260% Medicaid APG methodology,1111.8,,,1111.8,Other,324% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,428.94,,,428.94,Other,125% Medicaid APG methodology,105.08,2602,
CT HRT W/3D IMAGE               ,75572,CPT,,47201157,CDM,350,RC,,,both,,,3396,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,569.65,,,569.65,Fee Schedule,,511.97,,,511.97,Fee Schedule,,1920.65,,,1920.65,Fee Schedule,,1728.05,,,1728.05,Fee Schedule,,1631.75,,,1631.75,Fee Schedule,,1698,50,,1698,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,683.22,,,683.22,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,804,,,804,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,378.57,,,378.57,Fee Schedule,,804,,,804,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,712.07,,,712.07,Fee Schedule,,2377.2,70,,2377.2,percent of total billed charges,All Other,757.35,,,757.35,Fee Schedule,,642.6,,,642.6,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,212.47,2602,
CT ANGIO HRT W/3D IMAGE         ,75574,CPT,,47201173,CDM,350,RC,,,both,,,3396,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,665.24,,,665.24,Fee Schedule,,597.88,,,597.88,Fee Schedule,,2357.12,,,2357.12,Fee Schedule,,2120.75,,,2120.75,Fee Schedule,,2002.57,,,2002.57,Fee Schedule,,1698,50,,1698,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,797.87,,,797.87,Fee Schedule,,798.43,,,798.43,Other,186% Medicaid methodology,938.92,,,938.92,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,442.09,,,442.09,Fee Schedule,,938.92,,,938.92,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,831.55,,,831.55,Fee Schedule,,2377.2,70,,2377.2,percent of total billed charges,All Other,1107.15,,,1107.15,Fee Schedule,,939.4,,,939.4,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,429.26,,,429.26,Other,New York Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,656.77,,,656.77,Other,153% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,600.97,,,600.97,Other,140% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,1116.09,,,1116.09,Other,260% Medicaid APG methodology,1390.82,,,1390.82,Other,324% Medicaid APG methodology,922.92,,,922.92,Other,215% Medicaid APG methodology,922.92,,,922.92,Other,215% Medicaid APG methodology,536.58,,,536.58,Other,125% Medicaid APG methodology,212.47,2602,
CT HRT W/3D IMAGE CONGEN        ,75573,CPT,,47201199,CDM,350,RC,,,both,,,3498,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,667.23,,,667.23,Fee Schedule,,599.67,,,599.67,Fee Schedule,,2357.12,,,2357.12,Fee Schedule,,2120.75,,,2120.75,Fee Schedule,,2002.57,,,2002.57,Fee Schedule,,1749,50,,1749,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,800.26,,,800.26,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,941.73,,,941.73,Fee Schedule,,2168.76,,,2168.76,Fee Schedule,,443.42,,,443.42,Fee Schedule,,941.73,,,941.73,Fee Schedule,,2168.76,,,2168.76,Fee Schedule,,834.04,,,834.04,Fee Schedule,,2448.6,70,,2448.6,percent of total billed charges,All Other,970.2,,,970.2,Fee Schedule,,823.2,,,823.2,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,212.47,2602,
CT MAXILLOFACIAL W/DYE          ,70487,CPT,,47200001,CDM,351,RC,,,both,,,3396,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,386.37,,,386.37,Fee Schedule,,347.25,,,347.25,Fee Schedule,,2316.56,,,2316.56,Fee Schedule,,2084.25,,,2084.25,Fee Schedule,,1968.1,,,1968.1,Fee Schedule,,1698,50,,1698,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,463.4,,,463.4,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,545.32,,,545.32,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,256.77,,,256.77,Fee Schedule,,545.32,,,545.32,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,482.97,,,482.97,Fee Schedule,,2377.2,70,,2377.2,percent of total billed charges,All Other,518.1,,,518.1,Fee Schedule,,439.6,,,439.6,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,212.47,2602,
CT MAXILLOFACIAL W/O & W/DYE    ,70488,CPT,,47200019,CDM,351,RC,,,both,,,3396,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,484.49,,,484.49,Fee Schedule,,435.43,,,435.43,Fee Schedule,,2890.24,,,2890.24,Fee Schedule,,2600.41,,,2600.41,Fee Schedule,,2455.49,,,2455.49,Fee Schedule,,1698,50,,1698,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,581.08,,,581.08,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,683.81,,,683.81,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,321.97,,,321.97,Fee Schedule,,683.81,,,683.81,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,605.61,,,605.61,Fee Schedule,,2377.2,70,,2377.2,percent of total billed charges,All Other,656.7,,,656.7,Fee Schedule,,557.2,,,557.2,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,212.47,2890.24,
CT SOFT TISSUE NECK W/O DYE     ,70490,CPT,,47200027,CDM,351,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,349.65,,,349.65,Fee Schedule,,314.25,,,314.25,Fee Schedule,,1780.35,,,1780.35,Fee Schedule,,1601.82,,,1601.82,Fee Schedule,,1512.56,,,1512.56,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,419.36,,,419.36,Fee Schedule,,638.26,,,638.26,Other,186% Medicaid methodology,493.5,,,493.5,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,232.37,,,232.37,Fee Schedule,,493.5,,,493.5,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,437.07,,,437.07,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,470.25,,,470.25,Fee Schedule,,399,,,399,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,343.15,,,343.15,Other,New York Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,525.02,,,525.02,Other,153% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,480.41,,,480.41,Other,140% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,892.19,,,892.19,Other,260% Medicaid APG methodology,1111.8,,,1111.8,Other,324% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,428.94,,,428.94,Other,125% Medicaid APG methodology,127.14,2602,
CT SOFT TISSUE NECK W/DYE       ,70491,CPT,,47200035,CDM,351,RC,,,both,,,3396,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,464.61,,,464.61,Fee Schedule,,417.57,,,417.57,Fee Schedule,,2223.07,,,2223.07,Fee Schedule,,2000.15,,,2000.15,Fee Schedule,,1888.68,,,1888.68,Fee Schedule,,1698,50,,1698,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,557.24,,,557.24,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,655.75,,,655.75,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,308.76,,,308.76,Fee Schedule,,655.75,,,655.75,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,580.77,,,580.77,Fee Schedule,,2377.2,70,,2377.2,percent of total billed charges,All Other,627,,,627,Fee Schedule,,532,,,532,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,212.47,2602,
CT ANGIOGRAPHY NECK             ,70498,CPT,,47200050,CDM,351,RC,,,both,,,3503,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,666.51,,,666.51,Fee Schedule,,599.01,,,599.01,Fee Schedule,,3108.51,,,3108.51,Fee Schedule,,2796.79,,,2796.79,Fee Schedule,,2640.93,,,2640.93,Fee Schedule,,1751.5,50,,1751.5,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,799.39,,,799.39,Fee Schedule,,798.43,,,798.43,Other,186% Medicaid methodology,940.7,,,940.7,Fee Schedule,,2171.86,,,2171.86,Fee Schedule,,442.93,,,442.93,Fee Schedule,,940.7,,,940.7,Fee Schedule,,2171.86,,,2171.86,Fee Schedule,,833.13,,,833.13,Fee Schedule,,2452.1,70,,2452.1,percent of total billed charges,All Other,1008.15,,,1008.15,Fee Schedule,,855.4,,,855.4,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,429.26,,,429.26,Other,New York Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,656.77,,,656.77,Other,153% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,600.97,,,600.97,Other,140% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,1116.09,,,1116.09,Other,260% Medicaid APG methodology,1390.82,,,1390.82,Other,324% Medicaid APG methodology,922.92,,,922.92,Other,215% Medicaid APG methodology,922.92,,,922.92,Other,215% Medicaid APG methodology,536.58,,,536.58,Other,125% Medicaid APG methodology,212.47,3108.51,
CT ORBIT/EAR/FOSSA W/O&W/DYE    ,70482,CPT,,47200134,CDM,351,RC,,,both,,,3457,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,586.31,,,586.31,Fee Schedule,,526.93,,,526.93,Fee Schedule,,3067.94,,,3067.94,Fee Schedule,,2760.29,,,2760.29,Fee Schedule,,2606.47,,,2606.47,Fee Schedule,,1728.5,50,,1728.5,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,703.2,,,703.2,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,827.51,,,827.51,Fee Schedule,,2143.34,,,2143.34,Fee Schedule,,389.63,,,389.63,Fee Schedule,,827.51,,,827.51,Fee Schedule,,2143.34,,,2143.34,Fee Schedule,,732.88,,,732.88,Fee Schedule,,2419.9,70,,2419.9,percent of total billed charges,All Other,795.3,,,795.3,Fee Schedule,,674.8,,,674.8,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,212.47,3067.94,
CT ORBIT/EAR/FOSSA W/O DYE      ,70480,CPT,,47200142,CDM,351,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,383.91,,,383.91,Fee Schedule,,345.03,,,345.03,Fee Schedule,,1780.35,,,1780.35,Fee Schedule,,1601.82,,,1601.82,Fee Schedule,,1512.56,,,1512.56,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,460.45,,,460.45,Fee Schedule,,638.26,,,638.26,Other,186% Medicaid methodology,541.85,,,541.85,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,255.13,,,255.13,Fee Schedule,,541.85,,,541.85,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,479.89,,,479.89,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,513.15,,,513.15,Fee Schedule,,435.4,,,435.4,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,343.15,,,343.15,Other,New York Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,525.02,,,525.02,Other,153% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,480.41,,,480.41,Other,140% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,892.19,,,892.19,Other,260% Medicaid APG methodology,1111.8,,,1111.8,Other,324% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,428.94,,,428.94,Other,125% Medicaid APG methodology,127.14,2602,
CT ORBIT/EAR/FOSSA W/DYE        ,70481,CPT,,47200159,CDM,351,RC,,,both,,,3396,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,494.41,,,494.41,Fee Schedule,,444.35,,,444.35,Fee Schedule,,2734.36,,,2734.36,Fee Schedule,,2460.16,,,2460.16,Fee Schedule,,2323.06,,,2323.06,Fee Schedule,,1698,50,,1698,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,592.98,,,592.98,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,697.81,,,697.81,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,328.57,,,328.57,Fee Schedule,,697.81,,,697.81,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,618.02,,,618.02,Fee Schedule,,2377.2,70,,2377.2,percent of total billed charges,All Other,666.6,,,666.6,Fee Schedule,,565.6,,,565.6,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,212.47,2734.36,
CT HEAD/BRAIN W/DYE             ,70460,CPT,,47200720,CDM,351,RC,,,both,,,3396,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,369.5,,,369.5,Fee Schedule,,332.08,,,332.08,Fee Schedule,,1845.83,,,1845.83,Fee Schedule,,1660.74,,,1660.74,Fee Schedule,,1568.19,,,1568.19,Fee Schedule,,1698,50,,1698,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,443.16,,,443.16,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,521.51,,,521.51,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,245.55,,,245.55,Fee Schedule,,521.51,,,521.51,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,461.87,,,461.87,Fee Schedule,,2377.2,70,,2377.2,percent of total billed charges,All Other,496.65,,,496.65,Fee Schedule,,421.4,,,421.4,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,212.47,2602,
CT HEAD/BRAIN W/O DYE           ,70450,CPT,,47200738,CDM,351,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,257.76,,,257.76,Fee Schedule,,231.66,,,231.66,Fee Schedule,,1424.94,,,1424.94,Fee Schedule,,1282.05,,,1282.05,Fee Schedule,,1210.61,,,1210.61,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,309.15,,,309.15,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,363.8,,,363.8,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,171.3,,,171.3,Fee Schedule,,363.8,,,363.8,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,322.2,,,322.2,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,343.2,,,343.2,Fee Schedule,,291.2,,,291.2,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,127.14,2602,
CT ANGIOGRAPHY HEAD             ,70496,CPT,,47200753,CDM,351,RC,,,both,,,3503,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,666.51,,,666.51,Fee Schedule,,599.01,,,599.01,Fee Schedule,,3108.51,,,3108.51,Fee Schedule,,2796.79,,,2796.79,Fee Schedule,,2640.93,,,2640.93,Fee Schedule,,1751.5,50,,1751.5,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,799.39,,,799.39,Fee Schedule,,798.43,,,798.43,Other,186% Medicaid methodology,940.7,,,940.7,Fee Schedule,,2171.86,,,2171.86,Fee Schedule,,442.93,,,442.93,Fee Schedule,,940.7,,,940.7,Fee Schedule,,2171.86,,,2171.86,Fee Schedule,,833.13,,,833.13,Fee Schedule,,2452.1,70,,2452.1,percent of total billed charges,All Other,1009.8,,,1009.8,Fee Schedule,,856.8,,,856.8,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,429.26,,,429.26,Other,New York Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,656.77,,,656.77,Other,153% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,600.97,,,600.97,Other,140% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,1116.09,,,1116.09,Other,260% Medicaid APG methodology,1390.82,,,1390.82,Other,324% Medicaid APG methodology,922.92,,,922.92,Other,215% Medicaid APG methodology,922.92,,,922.92,Other,215% Medicaid APG methodology,536.58,,,536.58,Other,125% Medicaid APG methodology,212.47,3108.51,
CT MAXILLOFACIAL W/O DYE        ,70486,CPT,,47200761,CDM,351,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,340.96,,,340.96,Fee Schedule,,306.44,,,306.44,Fee Schedule,,1780.35,,,1780.35,Fee Schedule,,1601.82,,,1601.82,Fee Schedule,,1512.56,,,1512.56,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,408.94,,,408.94,Fee Schedule,,638.26,,,638.26,Other,186% Medicaid methodology,481.23,,,481.23,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,226.59,,,226.59,Fee Schedule,,481.23,,,481.23,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,426.21,,,426.21,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,455.4,,,455.4,Fee Schedule,,386.4,,,386.4,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,343.15,,,343.15,Other,New York Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,525.02,,,525.02,Other,153% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,480.41,,,480.41,Other,140% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,892.19,,,892.19,Other,260% Medicaid APG methodology,1111.8,,,1111.8,Other,324% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,428.94,,,428.94,Other,125% Medicaid APG methodology,127.14,2602,
CT HEAD/BRAIN W/O & W/DYE       ,70470,CPT,,47200795,CDM,351,RC,,,both,,,3396,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,442.27,,,442.27,Fee Schedule,,397.49,,,397.49,Fee Schedule,,2272.9,,,2272.9,Fee Schedule,,2044.98,,,2044.98,Fee Schedule,,1931.02,,,1931.02,Fee Schedule,,1698,50,,1698,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,530.45,,,530.45,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,624.22,,,624.22,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,293.92,,,293.92,Fee Schedule,,624.22,,,624.22,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,552.84,,,552.84,Fee Schedule,,2377.2,70,,2377.2,percent of total billed charges,All Other,595.65,,,595.65,Fee Schedule,,505.4,,,505.4,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,212.47,2602,
CT SFT TSUE NCK W/O & W/DYE     ,70492,CPT,,47200803,CDM,351,RC,,,both,,,3396,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,565.2,,,565.2,Fee Schedule,,507.96,,,507.96,Fee Schedule,,2784.26,,,2784.26,Fee Schedule,,2505.06,,,2505.06,Fee Schedule,,2365.46,,,2365.46,Fee Schedule,,1698,50,,1698,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,677.88,,,677.88,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,797.72,,,797.72,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,375.61,,,375.61,Fee Schedule,,797.72,,,797.72,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,706.5,,,706.5,Fee Schedule,,2377.2,70,,2377.2,percent of total billed charges,All Other,765.6,,,765.6,Fee Schedule,,649.6,,,649.6,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,212.47,2784.26,
CT PERFUSION W/CONTRAST CBF     ,0042T,HCPCS,,47201116,CDM,351,RC,,,both,,,966,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,483,50,,483,percent of total billed charges,All Other Outpatient,434.7,45,,434.7,percent of total billed charges,All Other Outpatient,168.77,,,168.77,Fee Schedule,,168.77,,,168.77,Fee Schedule,,168.77,,,168.77,Fee Schedule,,483,50,,483,percent of total billed charges,All Other,676.2,70,,676.2,percent of total billed charges,All Other,656.88,68,,656.88,percent of total billed charges,All Other Outpatient,754.86,,,754.86,Other,186% Medicaid methodology,772.8,80,,772.8,percent of total billed charges,All Other Outpatient,801.78,83,,801.78,percent of total billed charges,All Other Outpatient,801.78,83,,801.78,percent of total billed charges,All Other Outpatient,772.8,80,,772.8,percent of total billed charges,All Other Outpatient,801.78,83,,801.78,percent of total billed charges,All Other Outpatient,869.4,90,,869.4,percent of total billed charges,All Other,676.2,70,,676.2,percent of total billed charges,All Other,483,50,,483,percent of total billed charges,All Other,483,50,,483,percent of total billed charges,All Other,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,0.01,2602,
CT THORAX DX C-                 ,71250,CPT,,47200068,CDM,352,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,319.86,,,319.86,Fee Schedule,,287.46,,,287.46,Fee Schedule,,1780.35,,,1780.35,Fee Schedule,,1601.82,,,1601.82,Fee Schedule,,1512.56,,,1512.56,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,383.62,,,383.62,Fee Schedule,,638.26,,,638.26,Other,186% Medicaid methodology,451.44,,,451.44,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,212.56,,,212.56,Fee Schedule,,451.44,,,451.44,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,399.82,,,399.82,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,427.35,,,427.35,Fee Schedule,,362.6,,,362.6,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,343.15,,,343.15,Other,New York Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,525.02,,,525.02,Other,153% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,480.41,,,480.41,Other,140% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,892.19,,,892.19,Other,260% Medicaid APG methodology,1111.8,,,1111.8,Other,324% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,428.94,,,428.94,Other,125% Medicaid APG methodology,127.14,2602,
CT THORAX DX C+                 ,71260,CPT,,47200076,CDM,352,RC,,,both,,,3396,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,436.05,,,436.05,Fee Schedule,,391.89,,,391.89,Fee Schedule,,2294.73,,,2294.73,Fee Schedule,,2064.62,,,2064.62,Fee Schedule,,1949.56,,,1949.56,Fee Schedule,,1698,50,,1698,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,522.98,,,522.98,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,615.44,,,615.44,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,289.78,,,289.78,Fee Schedule,,615.44,,,615.44,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,545.06,,,545.06,Fee Schedule,,2377.2,70,,2377.2,percent of total billed charges,All Other,584.1,,,584.1,Fee Schedule,,495.6,,,495.6,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,212.47,2602,
CT THORAX DX C-/C+              ,71270,CPT,,47200084,CDM,352,RC,,,both,,,3396,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,534.13,,,534.13,Fee Schedule,,480.05,,,480.05,Fee Schedule,,2887.15,,,2887.15,Fee Schedule,,2597.63,,,2597.63,Fee Schedule,,2452.87,,,2452.87,Fee Schedule,,1698,50,,1698,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,640.62,,,640.62,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,753.87,,,753.87,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,354.96,,,354.96,Fee Schedule,,753.87,,,753.87,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,667.67,,,667.67,Fee Schedule,,2377.2,70,,2377.2,percent of total billed charges,All Other,722.7,,,722.7,Fee Schedule,,613.2,,,613.2,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,212.47,2887.15,
CT NECK SPINE W/O DYE           ,72125,CPT,,47200092,CDM,352,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,323.55,,,323.55,Fee Schedule,,290.79,,,290.79,Fee Schedule,,1780.35,,,1780.35,Fee Schedule,,1601.82,,,1601.82,Fee Schedule,,1512.56,,,1512.56,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,388.06,,,388.06,Fee Schedule,,638.26,,,638.26,Other,186% Medicaid methodology,456.66,,,456.66,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,215.02,,,215.02,Fee Schedule,,456.66,,,456.66,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,404.44,,,404.44,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,432.3,,,432.3,Fee Schedule,,366.8,,,366.8,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,343.15,,,343.15,Other,New York Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,525.02,,,525.02,Other,153% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,480.41,,,480.41,Other,140% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,892.19,,,892.19,Other,260% Medicaid APG methodology,1111.8,,,1111.8,Other,324% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,428.94,,,428.94,Other,125% Medicaid APG methodology,127.14,2602,
CT NECK SPINE W/DYE             ,72126,CPT,,47200100,CDM,352,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,433.58,,,433.58,Fee Schedule,,389.68,,,389.68,Fee Schedule,,2300.97,,,2300.97,Fee Schedule,,2070.24,,,2070.24,Fee Schedule,,1954.87,,,1954.87,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,520.03,,,520.03,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,611.96,,,611.96,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,288.14,,,288.14,Fee Schedule,,611.96,,,611.96,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,541.98,,,541.98,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,582.45,,,582.45,Fee Schedule,,494.2,,,494.2,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,288.14,4980.5,
CT CHEST SPINE W/O DYE          ,72128,CPT,,47200167,CDM,352,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,322.32,,,322.32,Fee Schedule,,289.68,,,289.68,Fee Schedule,,1780.35,,,1780.35,Fee Schedule,,1601.82,,,1601.82,Fee Schedule,,1512.56,,,1512.56,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,386.58,,,386.58,Fee Schedule,,638.26,,,638.26,Other,186% Medicaid methodology,454.92,,,454.92,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,214.2,,,214.2,Fee Schedule,,454.92,,,454.92,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,402.9,,,402.9,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,430.65,,,430.65,Fee Schedule,,365.4,,,365.4,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,343.15,,,343.15,Other,New York Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,525.02,,,525.02,Other,153% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,480.41,,,480.41,Other,140% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,892.19,,,892.19,Other,260% Medicaid APG methodology,1111.8,,,1111.8,Other,324% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,428.94,,,428.94,Other,125% Medicaid APG methodology,127.14,2602,
CT CHEST SPINE W/DYE            ,72129,CPT,,47200175,CDM,352,RC,,,both,,,3396,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,437.28,,,437.28,Fee Schedule,,393,,,393,Fee Schedule,,2304.13,,,2304.13,Fee Schedule,,2073.08,,,2073.08,Fee Schedule,,1957.55,,,1957.55,Fee Schedule,,1698,50,,1698,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,524.46,,,524.46,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,617.17,,,617.17,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,290.6,,,290.6,Fee Schedule,,617.17,,,617.17,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,546.6,,,546.6,Fee Schedule,,2377.2,70,,2377.2,percent of total billed charges,All Other,587.4,,,587.4,Fee Schedule,,498.4,,,498.4,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,212.47,2602,
CT CHEST SPINE W/O & W/DYE      ,72130,CPT,,47200191,CDM,352,RC,,,both,,,4378,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,539.1,,,539.1,Fee Schedule,,484.5,,,484.5,Fee Schedule,,2887.15,,,2887.15,Fee Schedule,,2597.63,,,2597.63,Fee Schedule,,2452.87,,,2452.87,Fee Schedule,,2189,50,,2189,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,646.57,,,646.57,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,760.88,,,760.88,Fee Schedule,,2714.36,,,2714.36,Fee Schedule,,358.26,,,358.26,Fee Schedule,,760.88,,,760.88,Fee Schedule,,2714.36,,,2714.36,Fee Schedule,,673.87,,,673.87,Fee Schedule,,3064.6,70,,3064.6,percent of total billed charges,All Other,727.65,,,727.65,Fee Schedule,,617.4,,,617.4,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,212.47,3064.6,
CT LUMBAR SPINE W/O DYE         ,72131,CPT,,47200209,CDM,352,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,319.86,,,319.86,Fee Schedule,,287.46,,,287.46,Fee Schedule,,1780.35,,,1780.35,Fee Schedule,,1601.82,,,1601.82,Fee Schedule,,1512.56,,,1512.56,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,383.62,,,383.62,Fee Schedule,,638.26,,,638.26,Other,186% Medicaid methodology,451.44,,,451.44,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,212.56,,,212.56,Fee Schedule,,451.44,,,451.44,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,399.82,,,399.82,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,429,,,429,Fee Schedule,,364,,,364,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,343.15,,,343.15,Other,New York Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,525.02,,,525.02,Other,153% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,480.41,,,480.41,Other,140% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,892.19,,,892.19,Other,260% Medicaid APG methodology,1111.8,,,1111.8,Other,324% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,428.94,,,428.94,Other,125% Medicaid APG methodology,127.14,2602,
CT LUMBAR SPINE W/DYE           ,72132,CPT,,47200217,CDM,352,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,434.82,,,434.82,Fee Schedule,,390.78,,,390.78,Fee Schedule,,2297.89,,,2297.89,Fee Schedule,,2067.46,,,2067.46,Fee Schedule,,1952.24,,,1952.24,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,521.5,,,521.5,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,613.7,,,613.7,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,288.96,,,288.96,Fee Schedule,,613.7,,,613.7,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,543.52,,,543.52,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,582.45,,,582.45,Fee Schedule,,494.2,,,494.2,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,288.96,4980.5,
CT LUMBAR SPINE W/O & W/DYE     ,72133,CPT,,47200225,CDM,352,RC,,,both,,,3396,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,536.63,,,536.63,Fee Schedule,,482.29,,,482.29,Fee Schedule,,2883.99,,,2883.99,Fee Schedule,,2594.79,,,2594.79,Fee Schedule,,2450.19,,,2450.19,Fee Schedule,,1698,50,,1698,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,643.62,,,643.62,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,757.4,,,757.4,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,356.62,,,356.62,Fee Schedule,,757.4,,,757.4,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,670.79,,,670.79,Fee Schedule,,2377.2,70,,2377.2,percent of total billed charges,All Other,721.05,,,721.05,Fee Schedule,,611.8,,,611.8,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,212.47,2883.99,
CT PELVIS W/O DYE               ,72192,CPT,,47200233,CDM,352,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,318.59,,,318.59,Fee Schedule,,286.33,,,286.33,Fee Schedule,,1742.95,,,1742.95,Fee Schedule,,1568.17,,,1568.17,Fee Schedule,,1480.78,,,1480.78,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,382.11,,,382.11,Fee Schedule,,638.26,,,638.26,Other,186% Medicaid methodology,449.66,,,449.66,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,211.72,,,211.72,Fee Schedule,,449.66,,,449.66,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,398.24,,,398.24,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,427.35,,,427.35,Fee Schedule,,362.6,,,362.6,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,343.15,,,343.15,Other,New York Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,525.02,,,525.02,Other,153% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,480.41,,,480.41,Other,140% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,892.19,,,892.19,Other,260% Medicaid APG methodology,1111.8,,,1111.8,Other,324% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,428.94,,,428.94,Other,125% Medicaid APG methodology,127.14,2602,
CT PELVIS W/DYE                 ,72193,CPT,,47200241,CDM,352,RC,,,both,,,3396,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,665.75,,,665.75,Fee Schedule,,598.33,,,598.33,Fee Schedule,,2179.42,,,2179.42,Fee Schedule,,1960.87,,,1960.87,Fee Schedule,,1851.59,,,1851.59,Fee Schedule,,1698,50,,1698,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,798.48,,,798.48,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,939.63,,,939.63,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,442.43,,,442.43,Fee Schedule,,939.63,,,939.63,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,832.19,,,832.19,Fee Schedule,,2377.2,70,,2377.2,percent of total billed charges,All Other,930.6,,,930.6,Fee Schedule,,789.6,,,789.6,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,212.47,2602,
CT PELVIS W/O & W/DYE           ,72194,CPT,,47200266,CDM,352,RC,,,both,,,4139,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,665.75,,,665.75,Fee Schedule,,598.33,,,598.33,Fee Schedule,,2915.15,,,2915.15,Fee Schedule,,2622.82,,,2622.82,Fee Schedule,,2476.66,,,2476.66,Fee Schedule,,2069.5,50,,2069.5,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,798.48,,,798.48,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,939.63,,,939.63,Fee Schedule,,2566.18,,,2566.18,Fee Schedule,,442.43,,,442.43,Fee Schedule,,939.63,,,939.63,Fee Schedule,,2566.18,,,2566.18,Fee Schedule,,832.19,,,832.19,Fee Schedule,,2897.3,70,,2897.3,percent of total billed charges,All Other,1039.5,,,1039.5,Fee Schedule,,882,,,882,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,212.47,2915.15,
CT UPPER EXTREMITY W/O DYE RT   ,73200,CPT,,47200274,CDM,352,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,398.07,,,398.07,Fee Schedule,,357.75,,,357.75,Fee Schedule,,1780.35,,,1780.35,Fee Schedule,,1601.82,,,1601.82,Fee Schedule,,1512.56,,,1512.56,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,477.43,,,477.43,Fee Schedule,,638.26,,,638.26,Other,186% Medicaid methodology,561.83,,,561.83,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,264.54,,,264.54,Fee Schedule,,561.83,,,561.83,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,497.58,,,497.58,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,605.55,,,605.55,Fee Schedule,,513.8,,,513.8,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,343.15,,,343.15,Other,New York Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,525.02,,,525.02,Other,153% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,480.41,,,480.41,Other,140% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,892.19,,,892.19,Other,260% Medicaid APG methodology,1111.8,,,1111.8,Other,324% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,428.94,,,428.94,Other,125% Medicaid APG methodology,127.14,2602,
CT UPPER EXTREMITY W/DYE RT     ,73201,CPT,,47200282,CDM,352,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,566.43,,,566.43,Fee Schedule,,509.07,,,509.07,Fee Schedule,,2226.16,,,2226.16,Fee Schedule,,2002.92,,,2002.92,Fee Schedule,,1891.31,,,1891.31,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,679.36,,,679.36,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,799.46,,,799.46,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,376.43,,,376.43,Fee Schedule,,799.46,,,799.46,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,708.04,,,708.04,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,770.55,,,770.55,Fee Schedule,,653.8,,,653.8,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,376.43,4980.5,
UP EXT W & W/O CNT RIGHT        ,73202,CPT,,47200290,CDM,352,RC,,,both,,,4815,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,665.75,,,665.75,Fee Schedule,,598.33,,,598.33,Fee Schedule,,2971.3,,,2971.3,Fee Schedule,,2673.34,,,2673.34,Fee Schedule,,2524.36,,,2524.36,Fee Schedule,,2407.5,50,,2407.5,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,798.48,,,798.48,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,939.63,,,939.63,Fee Schedule,,2985.3,,,2985.3,Fee Schedule,,442.43,,,442.43,Fee Schedule,,939.63,,,939.63,Fee Schedule,,2985.3,,,2985.3,Fee Schedule,,832.19,,,832.19,Fee Schedule,,3370.5,70,,3370.5,percent of total billed charges,All Other,1018.05,,,1018.05,Fee Schedule,,863.8,,,863.8,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,212.47,3370.5,
CT LOWER EXTREMITY W/O DYE RT   ,73700,CPT,RT       ,47200308,CDM,352,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,321.09,,,321.09,Fee Schedule,,288.57,,,288.57,Fee Schedule,,1780.35,,,1780.35,Fee Schedule,,1601.82,,,1601.82,Fee Schedule,,1512.56,,,1512.56,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,385.1,,,385.1,Fee Schedule,,638.26,,,638.26,Other,186% Medicaid methodology,453.18,,,453.18,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,213.38,,,213.38,Fee Schedule,,453.18,,,453.18,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,401.36,,,401.36,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,429,,,429,Fee Schedule,,364,,,364,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,343.15,,,343.15,Other,New York Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,525.02,,,525.02,Other,153% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,480.41,,,480.41,Other,140% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,892.19,,,892.19,Other,260% Medicaid APG methodology,1111.8,,,1111.8,Other,324% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,428.94,,,428.94,Other,125% Medicaid APG methodology,127.14,2602,
CT LOWER EXTREMITY W/DYE RT     ,73701,CPT,,47200316,CDM,352,RC,,,both,,,3396,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,436.05,,,436.05,Fee Schedule,,391.89,,,391.89,Fee Schedule,,2251.15,,,2251.15,Fee Schedule,,2025.4,,,2025.4,Fee Schedule,,1912.53,,,1912.53,Fee Schedule,,1698,50,,1698,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,522.98,,,522.98,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,615.44,,,615.44,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,289.78,,,289.78,Fee Schedule,,615.44,,,615.44,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,545.06,,,545.06,Fee Schedule,,2377.2,70,,2377.2,percent of total billed charges,All Other,585.75,,,585.75,Fee Schedule,,497,,,497,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,212.47,2602,
CT LWR EXTREMITY W/O&W/DYE RT   ,73702,CPT,,47200332,CDM,352,RC,,,both,,,3396,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,536.63,,,536.63,Fee Schedule,,482.29,,,482.29,Fee Schedule,,2986.88,,,2986.88,Fee Schedule,,2687.36,,,2687.36,Fee Schedule,,2537.6,,,2537.6,Fee Schedule,,1698,50,,1698,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,643.62,,,643.62,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,757.4,,,757.4,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,356.62,,,356.62,Fee Schedule,,757.4,,,757.4,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,670.79,,,670.79,Fee Schedule,,2377.2,70,,2377.2,percent of total billed charges,All Other,719.4,,,719.4,Fee Schedule,,610.4,,,610.4,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,212.47,2986.88,
CT ABDOMEN W/O DYE              ,74150,CPT,,47200340,CDM,352,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,314.86,,,314.86,Fee Schedule,,282.98,,,282.98,Fee Schedule,,1730.45,,,1730.45,Fee Schedule,,1556.92,,,1556.92,Fee Schedule,,1470.16,,,1470.16,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,377.64,,,377.64,Fee Schedule,,638.26,,,638.26,Other,186% Medicaid methodology,444.39,,,444.39,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,209.24,,,209.24,Fee Schedule,,444.39,,,444.39,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,393.58,,,393.58,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,422.4,,,422.4,Fee Schedule,,358.4,,,358.4,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,343.15,,,343.15,Other,New York Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,525.02,,,525.02,Other,153% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,480.41,,,480.41,Other,140% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,892.19,,,892.19,Other,260% Medicaid APG methodology,1111.8,,,1111.8,Other,324% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,428.94,,,428.94,Other,125% Medicaid APG methodology,127.14,2602,
CT ABDOMEN W/DYE                ,74160,CPT,,47200357,CDM,352,RC,,,both,,,3396,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,665.75,,,665.75,Fee Schedule,,598.33,,,598.33,Fee Schedule,,2494.26,,,2494.26,Fee Schedule,,2244.14,,,2244.14,Fee Schedule,,2119.08,,,2119.08,Fee Schedule,,1698,50,,1698,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,798.48,,,798.48,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,939.63,,,939.63,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,442.43,,,442.43,Fee Schedule,,939.63,,,939.63,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,832.19,,,832.19,Fee Schedule,,2377.2,70,,2377.2,percent of total billed charges,All Other,927.3,,,927.3,Fee Schedule,,786.8,,,786.8,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,212.47,2602,
CT ANGIO ABDOM W/O & W/DYE      ,74175,CPT,,47200365,CDM,352,RC,,,both,,,3503,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,664.52,,,664.52,Fee Schedule,,597.22,,,597.22,Fee Schedule,,3108.51,,,3108.51,Fee Schedule,,2796.79,,,2796.79,Fee Schedule,,2640.93,,,2640.93,Fee Schedule,,1751.5,50,,1751.5,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,797,,,797,Fee Schedule,,798.43,,,798.43,Other,186% Medicaid methodology,937.89,,,937.89,Fee Schedule,,2171.86,,,2171.86,Fee Schedule,,441.61,,,441.61,Fee Schedule,,937.89,,,937.89,Fee Schedule,,2171.86,,,2171.86,Fee Schedule,,830.65,,,830.65,Fee Schedule,,2452.1,70,,2452.1,percent of total billed charges,All Other,1161.6,,,1161.6,Fee Schedule,,985.6,,,985.6,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,429.26,,,429.26,Other,New York Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,656.77,,,656.77,Other,153% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,600.97,,,600.97,Other,140% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,1116.09,,,1116.09,Other,260% Medicaid APG methodology,1390.82,,,1390.82,Other,324% Medicaid APG methodology,922.92,,,922.92,Other,215% Medicaid APG methodology,922.92,,,922.92,Other,215% Medicaid APG methodology,536.58,,,536.58,Other,125% Medicaid APG methodology,212.47,3108.51,
CT NECK SPINE W/O & W/DYE       ,72127,CPT,,47200373,CDM,352,RC,,,both,,,3396,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,535.4,,,535.4,Fee Schedule,,481.18,,,481.18,Fee Schedule,,2883.99,,,2883.99,Fee Schedule,,2594.79,,,2594.79,Fee Schedule,,2450.19,,,2450.19,Fee Schedule,,1698,50,,1698,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,642.14,,,642.14,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,755.66,,,755.66,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,355.8,,,355.8,Fee Schedule,,755.66,,,755.66,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,669.25,,,669.25,Fee Schedule,,2377.2,70,,2377.2,percent of total billed charges,All Other,722.7,,,722.7,Fee Schedule,,613.2,,,613.2,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,212.47,2883.99,
CT UPPER EXTREMITY W/DYE LT     ,73201,CPT,,47200506,CDM,352,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,566.43,,,566.43,Fee Schedule,,509.07,,,509.07,Fee Schedule,,2226.16,,,2226.16,Fee Schedule,,2002.92,,,2002.92,Fee Schedule,,1891.31,,,1891.31,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,679.36,,,679.36,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,799.46,,,799.46,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,376.43,,,376.43,Fee Schedule,,799.46,,,799.46,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,708.04,,,708.04,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,770.55,,,770.55,Fee Schedule,,653.8,,,653.8,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,376.43,4980.5,
CT UPPR EXTREMITY W/O&W/DYE LT  ,73202,CPT,,47200514,CDM,352,RC,,,both,,,4815,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,665.75,,,665.75,Fee Schedule,,598.33,,,598.33,Fee Schedule,,2971.3,,,2971.3,Fee Schedule,,2673.34,,,2673.34,Fee Schedule,,2524.36,,,2524.36,Fee Schedule,,2407.5,50,,2407.5,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,798.48,,,798.48,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,939.63,,,939.63,Fee Schedule,,2985.3,,,2985.3,Fee Schedule,,442.43,,,442.43,Fee Schedule,,939.63,,,939.63,Fee Schedule,,2985.3,,,2985.3,Fee Schedule,,832.19,,,832.19,Fee Schedule,,3370.5,70,,3370.5,percent of total billed charges,All Other,1018.05,,,1018.05,Fee Schedule,,863.8,,,863.8,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,212.47,3370.5,
CT UPPER EXTREMITY W/O DYE LT   ,73200,CPT,,47200522,CDM,352,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,398.07,,,398.07,Fee Schedule,,357.75,,,357.75,Fee Schedule,,1780.35,,,1780.35,Fee Schedule,,1601.82,,,1601.82,Fee Schedule,,1512.56,,,1512.56,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,477.43,,,477.43,Fee Schedule,,638.26,,,638.26,Other,186% Medicaid methodology,561.83,,,561.83,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,264.54,,,264.54,Fee Schedule,,561.83,,,561.83,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,497.58,,,497.58,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,605.55,,,605.55,Fee Schedule,,513.8,,,513.8,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,343.15,,,343.15,Other,New York Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,525.02,,,525.02,Other,153% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,480.41,,,480.41,Other,140% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,892.19,,,892.19,Other,260% Medicaid APG methodology,1111.8,,,1111.8,Other,324% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,428.94,,,428.94,Other,125% Medicaid APG methodology,127.14,2602,
CT LOWER EXTREMITY W/O DYE LT   ,73700,CPT,LT       ,47200548,CDM,352,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,321.09,,,321.09,Fee Schedule,,288.57,,,288.57,Fee Schedule,,1780.35,,,1780.35,Fee Schedule,,1601.82,,,1601.82,Fee Schedule,,1512.56,,,1512.56,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,385.1,,,385.1,Fee Schedule,,638.26,,,638.26,Other,186% Medicaid methodology,453.18,,,453.18,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,213.38,,,213.38,Fee Schedule,,453.18,,,453.18,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,401.36,,,401.36,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,429,,,429,Fee Schedule,,364,,,364,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,343.15,,,343.15,Other,New York Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,525.02,,,525.02,Other,153% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,480.41,,,480.41,Other,140% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,892.19,,,892.19,Other,260% Medicaid APG methodology,1111.8,,,1111.8,Other,324% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,428.94,,,428.94,Other,125% Medicaid APG methodology,127.14,2602,
CT LWR EXTREMITY W/O&W/DYELT    ,73702,CPT,,47200555,CDM,352,RC,,,both,,,3396,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,536.63,,,536.63,Fee Schedule,,482.29,,,482.29,Fee Schedule,,2986.88,,,2986.88,Fee Schedule,,2687.36,,,2687.36,Fee Schedule,,2537.6,,,2537.6,Fee Schedule,,1698,50,,1698,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,643.62,,,643.62,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,757.4,,,757.4,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,356.62,,,356.62,Fee Schedule,,757.4,,,757.4,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,670.79,,,670.79,Fee Schedule,,2377.2,70,,2377.2,percent of total billed charges,All Other,719.4,,,719.4,Fee Schedule,,610.4,,,610.4,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,212.47,2986.88,
CT LOWER EXTREMITY W/DYE LT     ,73701,CPT,,47200589,CDM,352,RC,,,both,,,3396,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,436.05,,,436.05,Fee Schedule,,391.89,,,391.89,Fee Schedule,,2251.15,,,2251.15,Fee Schedule,,2025.4,,,2025.4,Fee Schedule,,1912.53,,,1912.53,Fee Schedule,,1698,50,,1698,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,522.98,,,522.98,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,615.44,,,615.44,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,289.78,,,289.78,Fee Schedule,,615.44,,,615.44,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,545.06,,,545.06,Fee Schedule,,2377.2,70,,2377.2,percent of total billed charges,All Other,585.75,,,585.75,Fee Schedule,,497,,,497,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,212.47,2602,
CT ANGIO ABDOMINAL ARTERIES     ,75635,CPT,,47200779,CDM,352,RC,,,both,,,3500,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,666.51,,,666.51,Fee Schedule,,599.01,,,599.01,Fee Schedule,,3105.49,,,3105.49,Fee Schedule,,2794.08,,,2794.08,Fee Schedule,,2638.37,,,2638.37,Fee Schedule,,1750,50,,1750,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,799.39,,,799.39,Fee Schedule,,798.43,,,798.43,Other,186% Medicaid methodology,940.7,,,940.7,Fee Schedule,,2170,,,2170,Fee Schedule,,442.93,,,442.93,Fee Schedule,,940.7,,,940.7,Fee Schedule,,2170,,,2170,Fee Schedule,,833.13,,,833.13,Fee Schedule,,2450,70,,2450,percent of total billed charges,All Other,1555.95,,,1555.95,Fee Schedule,,1320.2,,,1320.2,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,429.26,,,429.26,Other,New York Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,656.77,,,656.77,Other,153% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,600.97,,,600.97,Other,140% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,1116.09,,,1116.09,Other,260% Medicaid APG methodology,1390.82,,,1390.82,Other,324% Medicaid APG methodology,922.92,,,922.92,Other,215% Medicaid APG methodology,922.92,,,922.92,Other,215% Medicaid APG methodology,536.58,,,536.58,Other,125% Medicaid APG methodology,212.47,3105.49,
CT ABDOMEN W/O & W/DYE          ,74170,CPT,,47200787,CDM,352,RC,,,both,,,3457,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,665.75,,,665.75,Fee Schedule,,598.33,,,598.33,Fee Schedule,,3067.94,,,3067.94,Fee Schedule,,2760.29,,,2760.29,Fee Schedule,,2606.47,,,2606.47,Fee Schedule,,1728.5,50,,1728.5,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,798.48,,,798.48,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,939.63,,,939.63,Fee Schedule,,2143.34,,,2143.34,Fee Schedule,,442.43,,,442.43,Fee Schedule,,939.63,,,939.63,Fee Schedule,,2143.34,,,2143.34,Fee Schedule,,832.19,,,832.19,Fee Schedule,,2419.9,70,,2419.9,percent of total billed charges,All Other,1044.45,,,1044.45,Fee Schedule,,886.2,,,886.2,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,212.47,3067.94,
CT UPPER EXTREMITY W/O DYE BI   ,73200,CPT,50,47200811,CDM,352,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,398.07,,,398.07,Fee Schedule,,357.75,,,357.75,Fee Schedule,,1780.35,,,1780.35,Fee Schedule,,1601.82,,,1601.82,Fee Schedule,,1512.56,,,1512.56,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,477.43,,,477.43,Fee Schedule,,638.26,,,638.26,Other,186% Medicaid methodology,561.83,,,561.83,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,264.54,,,264.54,Fee Schedule,,561.83,,,561.83,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,497.58,,,497.58,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,605.55,,,605.55,Fee Schedule,,513.8,,,513.8,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,343.15,,,343.15,Other,New York Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,525.02,,,525.02,Other,153% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,480.41,,,480.41,Other,140% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,892.19,,,892.19,Other,260% Medicaid APG methodology,1111.8,,,1111.8,Other,324% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,428.94,,,428.94,Other,125% Medicaid APG methodology,127.14,2602,
CT UPPER EXTREMITY W/DYE BI     ,73201,CPT,50,47200829,CDM,352,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,566.43,,,566.43,Fee Schedule,,509.07,,,509.07,Fee Schedule,,2226.16,,,2226.16,Fee Schedule,,2002.92,,,2002.92,Fee Schedule,,1891.31,,,1891.31,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,679.36,,,679.36,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,799.46,,,799.46,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,376.43,,,376.43,Fee Schedule,,799.46,,,799.46,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,708.04,,,708.04,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,770.55,,,770.55,Fee Schedule,,653.8,,,653.8,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,376.43,4980.5,
CT UPPR EXTREMITY W/O&W/DYE BI  ,73202,CPT,50,47200837,CDM,352,RC,,,both,,,4815,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,665.75,,,665.75,Fee Schedule,,598.33,,,598.33,Fee Schedule,,2971.3,,,2971.3,Fee Schedule,,2673.34,,,2673.34,Fee Schedule,,2524.36,,,2524.36,Fee Schedule,,2407.5,50,,2407.5,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,798.48,,,798.48,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,939.63,,,939.63,Fee Schedule,,2985.3,,,2985.3,Fee Schedule,,442.43,,,442.43,Fee Schedule,,939.63,,,939.63,Fee Schedule,,2985.3,,,2985.3,Fee Schedule,,832.19,,,832.19,Fee Schedule,,3370.5,70,,3370.5,percent of total billed charges,All Other,1018.05,,,1018.05,Fee Schedule,,863.8,,,863.8,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,212.47,3370.5,
CT LOWER EXTREMITY W/O DYE BI   ,73700,CPT,,47200845,CDM,352,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,321.09,,,321.09,Fee Schedule,,288.57,,,288.57,Fee Schedule,,1780.35,,,1780.35,Fee Schedule,,1601.82,,,1601.82,Fee Schedule,,1512.56,,,1512.56,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,385.1,,,385.1,Fee Schedule,,638.26,,,638.26,Other,186% Medicaid methodology,453.18,,,453.18,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,213.38,,,213.38,Fee Schedule,,453.18,,,453.18,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,401.36,,,401.36,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,429,,,429,Fee Schedule,,364,,,364,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,343.15,,,343.15,Other,New York Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,525.02,,,525.02,Other,153% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,480.41,,,480.41,Other,140% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,892.19,,,892.19,Other,260% Medicaid APG methodology,1111.8,,,1111.8,Other,324% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,428.94,,,428.94,Other,125% Medicaid APG methodology,127.14,2602,
CT LOWER EXTREMITY W/DYE BI     ,73701,CPT,50,47200852,CDM,352,RC,,,both,,,3396,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,436.05,,,436.05,Fee Schedule,,391.89,,,391.89,Fee Schedule,,2251.15,,,2251.15,Fee Schedule,,2025.4,,,2025.4,Fee Schedule,,1912.53,,,1912.53,Fee Schedule,,1698,50,,1698,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,522.98,,,522.98,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,615.44,,,615.44,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,289.78,,,289.78,Fee Schedule,,615.44,,,615.44,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,545.06,,,545.06,Fee Schedule,,2377.2,70,,2377.2,percent of total billed charges,All Other,585.75,,,585.75,Fee Schedule,,497,,,497,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,212.47,2602,
CT LWR EXTREMITY W/O&W/DYE BI   ,73702,CPT,50,47200860,CDM,352,RC,,,both,,,3396,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,536.63,,,536.63,Fee Schedule,,482.29,,,482.29,Fee Schedule,,2986.88,,,2986.88,Fee Schedule,,2687.36,,,2687.36,Fee Schedule,,2537.6,,,2537.6,Fee Schedule,,1698,50,,1698,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,643.62,,,643.62,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,757.4,,,757.4,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,356.62,,,356.62,Fee Schedule,,757.4,,,757.4,Fee Schedule,,2105.52,,,2105.52,Fee Schedule,,670.79,,,670.79,Fee Schedule,,2377.2,70,,2377.2,percent of total billed charges,All Other,719.4,,,719.4,Fee Schedule,,610.4,,,610.4,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,212.47,2986.88,
CT ANGIOGRAPH PELV W/O&W/DYE    ,72191,CPT,,47201009,CDM,352,RC,,,both,,,3500,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,664.52,,,664.52,Fee Schedule,,597.22,,,597.22,Fee Schedule,,3105.35,,,3105.35,Fee Schedule,,2793.95,,,2793.95,Fee Schedule,,2638.25,,,2638.25,Fee Schedule,,1750,50,,1750,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,797,,,797,Fee Schedule,,798.43,,,798.43,Other,186% Medicaid methodology,937.89,,,937.89,Fee Schedule,,2170,,,2170,Fee Schedule,,441.61,,,441.61,Fee Schedule,,937.89,,,937.89,Fee Schedule,,2170,,,2170,Fee Schedule,,830.65,,,830.65,Fee Schedule,,2450,70,,2450,percent of total billed charges,All Other,1163.25,,,1163.25,Fee Schedule,,987,,,987,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,429.26,,,429.26,Other,New York Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,656.77,,,656.77,Other,153% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,600.97,,,600.97,Other,140% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,1116.09,,,1116.09,Other,260% Medicaid APG methodology,1390.82,,,1390.82,Other,324% Medicaid APG methodology,922.92,,,922.92,Other,215% Medicaid APG methodology,922.92,,,922.92,Other,215% Medicaid APG methodology,536.58,,,536.58,Other,125% Medicaid APG methodology,212.47,3105.35,
CT ANGIOGRAPHY CHEST            ,71275,CPT,,47201017,CDM,352,RC,,,both,,,3500,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,666.51,,,666.51,Fee Schedule,,599.01,,,599.01,Fee Schedule,,3105.35,,,3105.35,Fee Schedule,,2793.95,,,2793.95,Fee Schedule,,2638.25,,,2638.25,Fee Schedule,,1750,50,,1750,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,799.39,,,799.39,Fee Schedule,,798.43,,,798.43,Other,186% Medicaid methodology,940.7,,,940.7,Fee Schedule,,2170,,,2170,Fee Schedule,,442.93,,,442.93,Fee Schedule,,940.7,,,940.7,Fee Schedule,,2170,,,2170,Fee Schedule,,833.13,,,833.13,Fee Schedule,,2450,70,,2450,percent of total billed charges,All Other,1023,,,1023,Fee Schedule,,868,,,868,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,429.26,,,429.26,Other,New York Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,656.77,,,656.77,Other,153% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,600.97,,,600.97,Other,140% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,1116.09,,,1116.09,Other,260% Medicaid APG methodology,1390.82,,,1390.82,Other,324% Medicaid APG methodology,922.92,,,922.92,Other,215% Medicaid APG methodology,922.92,,,922.92,Other,215% Medicaid APG methodology,536.58,,,536.58,Other,125% Medicaid APG methodology,212.47,3105.35,
CT ANGIO UPR EXTRM W/O&W/DYE    ,73206,CPT,,47201058,CDM,352,RC,,,both,,,3500,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,664.52,,,664.52,Fee Schedule,,597.22,,,597.22,Fee Schedule,,3105.35,,,3105.35,Fee Schedule,,2793.95,,,2793.95,Fee Schedule,,2638.25,,,2638.25,Fee Schedule,,1750,50,,1750,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,797,,,797,Fee Schedule,,798.43,,,798.43,Other,186% Medicaid methodology,937.89,,,937.89,Fee Schedule,,2170,,,2170,Fee Schedule,,441.61,,,441.61,Fee Schedule,,937.89,,,937.89,Fee Schedule,,2170,,,2170,Fee Schedule,,830.65,,,830.65,Fee Schedule,,2450,70,,2450,percent of total billed charges,All Other,1123.65,,,1123.65,Fee Schedule,,953.4,,,953.4,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,429.26,,,429.26,Other,New York Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,656.77,,,656.77,Other,153% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,600.97,,,600.97,Other,140% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,1116.09,,,1116.09,Other,260% Medicaid APG methodology,1390.82,,,1390.82,Other,324% Medicaid APG methodology,922.92,,,922.92,Other,215% Medicaid APG methodology,922.92,,,922.92,Other,215% Medicaid APG methodology,536.58,,,536.58,Other,125% Medicaid APG methodology,212.47,3105.35,
CT ANGIO UPR EXTRM W/O&W/DYE    ,73206,CPT,,47201066,CDM,352,RC,,,both,,,3500,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,664.52,,,664.52,Fee Schedule,,597.22,,,597.22,Fee Schedule,,3105.35,,,3105.35,Fee Schedule,,2793.95,,,2793.95,Fee Schedule,,2638.25,,,2638.25,Fee Schedule,,1750,50,,1750,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,797,,,797,Fee Schedule,,798.43,,,798.43,Other,186% Medicaid methodology,937.89,,,937.89,Fee Schedule,,2170,,,2170,Fee Schedule,,441.61,,,441.61,Fee Schedule,,937.89,,,937.89,Fee Schedule,,2170,,,2170,Fee Schedule,,830.65,,,830.65,Fee Schedule,,2450,70,,2450,percent of total billed charges,All Other,1123.65,,,1123.65,Fee Schedule,,953.4,,,953.4,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,429.26,,,429.26,Other,New York Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,656.77,,,656.77,Other,153% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,600.97,,,600.97,Other,140% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,1116.09,,,1116.09,Other,260% Medicaid APG methodology,1390.82,,,1390.82,Other,324% Medicaid APG methodology,922.92,,,922.92,Other,215% Medicaid APG methodology,922.92,,,922.92,Other,215% Medicaid APG methodology,536.58,,,536.58,Other,125% Medicaid APG methodology,212.47,3105.35,
CT ANGIO LWR EXTR W/O&W/DYE     ,73706,CPT,,47201082,CDM,352,RC,,,both,,,3500,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,666.51,,,666.51,Fee Schedule,,599.01,,,599.01,Fee Schedule,,3105.35,,,3105.35,Fee Schedule,,2793.95,,,2793.95,Fee Schedule,,2638.25,,,2638.25,Fee Schedule,,1750,50,,1750,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,799.39,,,799.39,Fee Schedule,,798.43,,,798.43,Other,186% Medicaid methodology,940.7,,,940.7,Fee Schedule,,2170,,,2170,Fee Schedule,,442.93,,,442.93,Fee Schedule,,940.7,,,940.7,Fee Schedule,,2170,,,2170,Fee Schedule,,833.13,,,833.13,Fee Schedule,,2450,70,,2450,percent of total billed charges,All Other,1234.2,,,1234.2,Fee Schedule,,1047.2,,,1047.2,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,429.26,,,429.26,Other,New York Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,656.77,,,656.77,Other,153% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,600.97,,,600.97,Other,140% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,1116.09,,,1116.09,Other,260% Medicaid APG methodology,1390.82,,,1390.82,Other,324% Medicaid APG methodology,922.92,,,922.92,Other,215% Medicaid APG methodology,922.92,,,922.92,Other,215% Medicaid APG methodology,536.58,,,536.58,Other,125% Medicaid APG methodology,212.47,3105.35,
CT ANGIO LWR EXTR W/O&W/DYE     ,73706,CPT,,47201090,CDM,352,RC,,,both,,,3500,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,666.51,,,666.51,Fee Schedule,,599.01,,,599.01,Fee Schedule,,3105.35,,,3105.35,Fee Schedule,,2793.95,,,2793.95,Fee Schedule,,2638.25,,,2638.25,Fee Schedule,,1750,50,,1750,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,799.39,,,799.39,Fee Schedule,,798.43,,,798.43,Other,186% Medicaid methodology,940.7,,,940.7,Fee Schedule,,2170,,,2170,Fee Schedule,,442.93,,,442.93,Fee Schedule,,940.7,,,940.7,Fee Schedule,,2170,,,2170,Fee Schedule,,833.13,,,833.13,Fee Schedule,,2450,70,,2450,percent of total billed charges,All Other,1234.2,,,1234.2,Fee Schedule,,1047.2,,,1047.2,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,429.26,,,429.26,Other,New York Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,656.77,,,656.77,Other,153% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,600.97,,,600.97,Other,140% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,1116.09,,,1116.09,Other,260% Medicaid APG methodology,1390.82,,,1390.82,Other,324% Medicaid APG methodology,922.92,,,922.92,Other,215% Medicaid APG methodology,922.92,,,922.92,Other,215% Medicaid APG methodology,536.58,,,536.58,Other,125% Medicaid APG methodology,212.47,3105.35,
CT ANGIO LWR EXTR W/O&W/DYE     ,73706,CPT,,47201108,CDM,352,RC,,,both,,,3500,349.4,,,349.4,Other,150% of Medicare + 9.63% HCRA Surcharge,212.47,,,212.47,Other,Medicare OPPS methodology,666.51,,,666.51,Fee Schedule,,599.01,,,599.01,Fee Schedule,,3105.35,,,3105.35,Fee Schedule,,2793.95,,,2793.95,Fee Schedule,,2638.25,,,2638.25,Fee Schedule,,1750,50,,1750,percent of total billed charges,All Other,523.58,,,523.58,Fee Schedule,,799.39,,,799.39,Fee Schedule,,798.43,,,798.43,Other,186% Medicaid methodology,940.7,,,940.7,Fee Schedule,,2170,,,2170,Fee Schedule,,442.93,,,442.93,Fee Schedule,,940.7,,,940.7,Fee Schedule,,2170,,,2170,Fee Schedule,,833.13,,,833.13,Fee Schedule,,2450,70,,2450,percent of total billed charges,All Other,1234.2,,,1234.2,Fee Schedule,,1047.2,,,1047.2,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,429.26,,,429.26,Other,New York Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,656.77,,,656.77,Other,153% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,600.97,,,600.97,Other,140% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,1116.09,,,1116.09,Other,260% Medicaid APG methodology,1390.82,,,1390.82,Other,324% Medicaid APG methodology,922.92,,,922.92,Other,215% Medicaid APG methodology,922.92,,,922.92,Other,215% Medicaid APG methodology,536.58,,,536.58,Other,125% Medicaid APG methodology,212.47,3105.35,
CT ABD & PELV W/CONTRAST        ,74177,CPT,,47201249,CDM,352,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,844.57,,,844.57,Fee Schedule,,759.05,,,759.05,Fee Schedule,,2307.22,,,2307.22,Fee Schedule,,2075.86,,,2075.86,Fee Schedule,,1960.17,,,1960.17,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,1012.95,,,1012.95,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,1192.02,,,1192.02,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,561.27,,,561.27,Fee Schedule,,1192.02,,,1192.02,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,1055.72,,,1055.72,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,1164.9,,,1164.9,Fee Schedule,,988.4,,,988.4,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,405.84,4980.5,
CT ABD & PELVIS W/O CONTRAST    ,74176,CPT,,47201256,CDM,352,RC,,,both,,,4342,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,397.56,,,397.56,Fee Schedule,,357.3,,,357.3,Fee Schedule,,1209.83,,,1209.83,Fee Schedule,,1088.51,,,1088.51,Fee Schedule,,1027.85,,,1027.85,Fee Schedule,,2171,50,,2171,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,476.82,,,476.82,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,561.11,,,561.11,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,264.2,,,264.2,Fee Schedule,,561.11,,,561.11,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,496.95,,,496.95,Fee Schedule,,3039.4,70,,3039.4,percent of total billed charges,All Other,529.65,,,529.65,Fee Schedule,,449.4,,,449.4,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,264.2,3039.4,
CT ABD & PELV 1/> REGNS W&WO    ,74178,CPT,,47201264,CDM,352,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,954.57,,,954.57,Fee Schedule,,857.91,,,857.91,Fee Schedule,,3049.2,,,3049.2,Fee Schedule,,2743.43,,,2743.43,Fee Schedule,,2590.55,,,2590.55,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,1144.88,,,1144.88,Fee Schedule,,754.86,,,754.86,Other,186% Medicaid methodology,1347.28,,,1347.28,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,634.37,,,634.37,Fee Schedule,,1347.28,,,1347.28,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,1193.22,,,1193.22,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,1313.4,,,1313.4,Fee Schedule,,1114.4,,,1114.4,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,405.84,,,405.84,Other,New York Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,405.84,,,405.84,Other,100% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,620.93,,,620.93,Other,153% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,568.17,,,568.17,Other,140% Medicaid APG methodology,913.13,,,913.13,Other,225% Medicaid APG methodology,1055.18,,,1055.18,Other,260% Medicaid APG methodology,1314.91,,,1314.91,Other,324% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,872.55,,,872.55,Other,215% Medicaid APG methodology,507.3,,,507.3,Other,125% Medicaid APG methodology,405.84,4980.5,
CT ANGIO ABD&PELV W/O&W/DYE     ,74174,CPT,,47201280,CDM,352,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,1075.73,,,1075.73,Fee Schedule,,966.79,,,966.79,Fee Schedule,,246.54,,,246.54,Fee Schedule,,246.54,,,246.54,Fee Schedule,,246.54,,,246.54,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,1290.19,,,1290.19,Fee Schedule,,798.43,,,798.43,Other,186% Medicaid methodology,1518.27,,,1518.27,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,714.88,,,714.88,Fee Schedule,,1518.27,,,1518.27,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,1344.66,,,1344.66,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,1461.9,,,1461.9,Fee Schedule,,1240.4,,,1240.4,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,429.26,,,429.26,Other,New York Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,429.26,,,429.26,Other,100% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,656.77,,,656.77,Other,153% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,600.97,,,600.97,Other,140% Medicaid APG methodology,965.84,,,965.84,Other,225% Medicaid APG methodology,1116.09,,,1116.09,Other,260% Medicaid APG methodology,1390.82,,,1390.82,Other,324% Medicaid APG methodology,922.92,,,922.92,Other,215% Medicaid APG methodology,922.92,,,922.92,Other,215% Medicaid APG methodology,536.58,,,536.58,Other,125% Medicaid APG methodology,246.54,4980.5,
CT THORAX LUNG CANCER SCR C-    ,71271,CPT,,47201355,CDM,352,RC,,,both,,,1488,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,337.96,,,337.96,Fee Schedule,,303.74,,,303.74,Fee Schedule,,96,,,96,Fee Schedule,,96,,,96,Fee Schedule,,96,,,96,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,405.34,,,405.34,Fee Schedule,,638.26,,,638.26,Other,186% Medicaid methodology,477,,,477,Fee Schedule,,922.56,,,922.56,Fee Schedule,,224.6,,,224.6,Fee Schedule,,477,,,477,Fee Schedule,,922.56,,,922.56,Fee Schedule,,422.45,,,422.45,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,450.45,,,450.45,Fee Schedule,,382.2,,,382.2,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,343.15,,,343.15,Other,New York Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,343.15,,,343.15,Other,100% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,525.02,,,525.02,Other,153% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,480.41,,,480.41,Other,140% Medicaid APG methodology,772.09,,,772.09,Other,225% Medicaid APG methodology,892.19,,,892.19,Other,260% Medicaid APG methodology,1111.8,,,1111.8,Other,324% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,737.77,,,737.77,Other,215% Medicaid APG methodology,428.94,,,428.94,Other,125% Medicaid APG methodology,96,2602,
CT Bone Dens Axial Skel,77078,CPT,TC,47201454,CDM,352,RC,,,both,,,2484,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,328.55,,,328.55,Fee Schedule,,295.27,,,295.27,Fee Schedule,,645.34,,,645.34,Fee Schedule,,580.62,,,580.62,Fee Schedule,,548.27,,,548.27,Fee Schedule,,1242,50,,1242,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,394.05,,,394.05,Fee Schedule,,370.65,,,370.65,Other,186% Medicaid methodology,463.71,,,463.71,Fee Schedule,,1540.08,,,1540.08,Fee Schedule,,218.34,,,218.34,Fee Schedule,,463.71,,,463.71,Fee Schedule,,1540.08,,,1540.08,Fee Schedule,,410.68,,,410.68,Fee Schedule,,1738.8,70,,1738.8,percent of total billed charges,All Other,471.9,,,471.9,Fee Schedule,,400.4,,,400.4,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,199.27,,,199.27,Other,New York Medicaid APG methodology,199.27,,,199.27,Other,100% Medicaid APG methodology,199.27,,,199.27,Other,100% Medicaid APG methodology,199.27,,,199.27,Other,100% Medicaid APG methodology,448.36,,,448.36,Other,225% Medicaid APG methodology,448.36,,,448.36,Other,225% Medicaid APG methodology,304.89,,,304.89,Other,153% Medicaid APG methodology,448.36,,,448.36,Other,225% Medicaid APG methodology,278.98,,,278.98,Other,140% Medicaid APG methodology,448.36,,,448.36,Other,225% Medicaid APG methodology,518.11,,,518.11,Other,260% Medicaid APG methodology,645.64,,,645.64,Other,324% Medicaid APG methodology,428.43,,,428.43,Other,215% Medicaid APG methodology,428.43,,,428.43,Other,215% Medicaid APG methodology,249.09,,,249.09,Other,125% Medicaid APG methodology,105.08,2602,
CT SCAN FOR LOCALIZATION        ,77011,CPT,,47200415,CDM,359,RC,,,both,,,4373,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,599.23,,,599.23,Fee Schedule,,538.55,,,538.55,Fee Schedule,,3881.65,,,3881.65,Fee Schedule,,3492.41,,,3492.41,Fee Schedule,,3297.78,,,3297.78,Fee Schedule,,2186.5,50,,2186.5,percent of total billed charges,All Other,3061.1,70,,3061.1,percent of total billed charges,All Other,718.7,,,718.7,Fee Schedule,,431.43,,,431.43,Other,186% Medicaid methodology,845.75,,,845.75,Fee Schedule,,2711.26,,,2711.26,Fee Schedule,,398.22,,,398.22,Fee Schedule,,845.75,,,845.75,Fee Schedule,,2711.26,,,2711.26,Fee Schedule,,749.04,,,749.04,Fee Schedule,,3061.1,70,,3061.1,percent of total billed charges,All Other,816.75,,,816.75,Fee Schedule,,693,,,693,Fee Schedule,,1687,,,1687,Case Rate,CT Scan,2341,,,2341,Case Rate,CT Scan,2602,,,2602,Case Rate,CT Scan,2212,,,2212,Case Rate,CT Scan,231.95,,,231.95,Other,New York Medicaid APG methodology,231.95,,,231.95,Other,100% Medicaid APG methodology,231.95,,,231.95,Other,100% Medicaid APG methodology,231.95,,,231.95,Other,100% Medicaid APG methodology,521.89,,,521.89,Other,225% Medicaid APG methodology,521.89,,,521.89,Other,225% Medicaid APG methodology,354.88,,,354.88,Other,153% Medicaid APG methodology,521.89,,,521.89,Other,225% Medicaid APG methodology,324.73,,,324.73,Other,140% Medicaid APG methodology,521.89,,,521.89,Other,225% Medicaid APG methodology,603.07,,,603.07,Other,260% Medicaid APG methodology,751.52,,,751.52,Other,324% Medicaid APG methodology,498.69,,,498.69,Other,215% Medicaid APG methodology,498.69,,,498.69,Other,215% Medicaid APG methodology,289.94,,,289.94,Other,125% Medicaid APG methodology,0.01,3881.65,
ILR Insertion Charge -> Yes,33285,CPT,,44621076,CDM,360,RC,,,both,,,29379,16155.78,,,16155.78,Other,150% of Medicare + 9.63% HCRA Surcharge,9824.43,,,9824.43,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,14198,,,14198,Fee Schedule,,12778,,,12778,Fee Schedule,,12068,,,12068,Fee Schedule,,14689.5,50,,14689.5,percent of total billed charges,All Other,20565.3,70,,20565.3,percent of total billed charges,All Other,19977.72,68,,19977.72,percent of total billed charges,All Other Outpatient,13784.15,,,13784.15,Other,186% Medicaid methodology,23503.2,80,,23503.2,percent of total billed charges,All Other Outpatient,24384.57,83,,24384.57,percent of total billed charges,All Other Outpatient,24384.57,83,,24384.57,percent of total billed charges,All Other Outpatient,23503.2,80,,23503.2,percent of total billed charges,All Other Outpatient,24384.57,83,,24384.57,percent of total billed charges,All Other Outpatient,26441.1,90,,26441.1,percent of total billed charges,All Other,20565.3,70,,20565.3,percent of total billed charges,All Other,425.7,,,425.7,Fee Schedule,,361.2,,,361.2,Fee Schedule,,14938,,"100% primary, 50% secondary, 25% tertiary procedure",14938,Other,United Healthcare ASC Grouper,13443,,"100% primary, 50% secondary, 25% tertiary procedure",13443,Other,United Healthcare ASC Grouper,14938,,"100% primary, 50% secondary, 25% tertiary procedure",14938,Other,United Healthcare ASC Grouper,12698,,"100% primary, 50% secondary, 25% tertiary procedure",12698,Other,United Healthcare ASC Grouper,7410.83,,,7410.83,Other,New York Medicaid APG methodology,7410.83,,,7410.83,Other,100% Medicaid APG methodology,7410.83,,,7410.83,Other,100% Medicaid APG methodology,7410.83,,,7410.83,Other,100% Medicaid APG methodology,16674.38,,,16674.38,Other,225% Medicaid APG methodology,16674.38,,,16674.38,Other,225% Medicaid APG methodology,11338.58,,,11338.58,Other,153% Medicaid APG methodology,16674.38,,,16674.38,Other,225% Medicaid APG methodology,10375.17,,,10375.17,Other,140% Medicaid APG methodology,16674.38,,,16674.38,Other,225% Medicaid APG methodology,19268.17,,,19268.17,Other,260% Medicaid APG methodology,24011.11,,,24011.11,Other,324% Medicaid APG methodology,15933.3,,,15933.3,Other,215% Medicaid APG methodology,15933.3,,,15933.3,Other,215% Medicaid APG methodology,9263.54,,,9263.54,Other,125% Medicaid APG methodology,361.2,26441.1,
ILR Explant Charge -> Yes,33286,CPT,,44621084,CDM,360,RC,,,both,,,11159,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,,4343,Fee Schedule,,3909,,,3909,Fee Schedule,,3692,,,3692,Fee Schedule,,5579.5,50,,5579.5,percent of total billed charges,All Other,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,7588.12,68,,7588.12,percent of total billed charges,All Other Outpatient,5826.77,,,5826.77,Other,186% Medicaid methodology,8927.2,80,,8927.2,percent of total billed charges,All Other Outpatient,9261.97,83,,9261.97,percent of total billed charges,All Other Outpatient,9261.97,83,,9261.97,percent of total billed charges,All Other Outpatient,8927.2,80,,8927.2,percent of total billed charges,All Other Outpatient,9261.97,83,,9261.97,percent of total billed charges,All Other Outpatient,10043.1,90,,10043.1,percent of total billed charges,All Other,7811.3,70,,7811.3,percent of total billed charges,All Other,420.75,,,420.75,Fee Schedule,,357,,,357,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,3132.67,,,3132.67,Other,New York Medicaid APG methodology,3132.67,,,3132.67,Other,100% Medicaid APG methodology,3132.67,,,3132.67,Other,100% Medicaid APG methodology,3132.67,,,3132.67,Other,100% Medicaid APG methodology,7048.51,,,7048.51,Other,225% Medicaid APG methodology,7048.51,,,7048.51,Other,225% Medicaid APG methodology,4792.99,,,4792.99,Other,153% Medicaid APG methodology,7048.51,,,7048.51,Other,225% Medicaid APG methodology,4385.74,,,4385.74,Other,140% Medicaid APG methodology,7048.51,,,7048.51,Other,225% Medicaid APG methodology,8144.95,,,8144.95,Other,260% Medicaid APG methodology,10149.86,,,10149.86,Other,324% Medicaid APG methodology,6735.24,,,6735.24,Other,215% Medicaid APG methodology,6735.24,,,6735.24,Other,215% Medicaid APG methodology,3915.84,,,3915.84,Other,125% Medicaid APG methodology,357,10149.86,
SPL AVULSE NP; EA ADDTL 11732,11732,CPT,,47901988,CDM,361,RC,,,both,,,229,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,114.5,50,,114.5,percent of total billed charges,All Other,160.3,70,,160.3,percent of total billed charges,All Other,155.72,68,,155.72,percent of total billed charges,All Other Outpatient,411.2,,,411.2,Other,186% Medicaid methodology,183.2,80,,183.2,percent of total billed charges,All Other Outpatient,190.07,83,,190.07,percent of total billed charges,All Other Outpatient,190.07,83,,190.07,percent of total billed charges,All Other Outpatient,183.2,80,,183.2,percent of total billed charges,All Other Outpatient,190.07,83,,190.07,percent of total billed charges,All Other Outpatient,206.1,90,,206.1,percent of total billed charges,All Other,160.3,70,,160.3,percent of total billed charges,All Other,84.15,,,84.15,Fee Schedule,,71.4,,,71.4,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,221.08,,,221.08,Other,New York Medicaid APG methodology,221.08,,,221.08,Other,100% Medicaid APG methodology,221.08,,,221.08,Other,100% Medicaid APG methodology,221.08,,,221.08,Other,100% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,338.25,,,338.25,Other,153% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,309.51,,,309.51,Other,140% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,574.8,,,574.8,Other,260% Medicaid APG methodology,716.29,,,716.29,Other,324% Medicaid APG methodology,475.32,,,475.32,Other,215% Medicaid APG methodology,475.32,,,475.32,Other,215% Medicaid APG methodology,276.35,,,276.35,Other,125% Medicaid APG methodology,0.01,4343,
LOW COST SKIN SUBSTITUTE APP C5272,C5272,HCPCS,,47902051,CDM,361,RC,,,both,,,3368,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1684,50,,1684,percent of total billed charges,All Other,2357.6,70,,2357.6,percent of total billed charges,All Other,2290.24,68,,2290.24,percent of total billed charges,All Other Outpatient,2945.61,,,2945.61,Other,186% Medicaid methodology,2694.4,80,,2694.4,percent of total billed charges,All Other Outpatient,2795.44,83,,2795.44,percent of total billed charges,All Other Outpatient,2795.44,83,,2795.44,percent of total billed charges,All Other Outpatient,2694.4,80,,2694.4,percent of total billed charges,All Other Outpatient,2795.44,83,,2795.44,percent of total billed charges,All Other Outpatient,3031.2,90,,3031.2,percent of total billed charges,All Other,2357.6,70,,2357.6,percent of total billed charges,All Other,1684,50,,1684,percent of total billed charges,All Other,1684,50,,1684,percent of total billed charges,All Other,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1583.66,,,1583.66,Other,New York Medicaid APG methodology,1583.66,,,1583.66,Other,100% Medicaid APG methodology,1583.66,,,1583.66,Other,100% Medicaid APG methodology,1583.66,,,1583.66,Other,100% Medicaid APG methodology,3563.23,,,3563.23,Other,225% Medicaid APG methodology,3563.23,,,3563.23,Other,225% Medicaid APG methodology,2423,,,2423,Other,153% Medicaid APG methodology,3563.23,,,3563.23,Other,225% Medicaid APG methodology,2217.12,,,2217.12,Other,140% Medicaid APG methodology,3563.23,,,3563.23,Other,225% Medicaid APG methodology,4117.52,,,4117.52,Other,260% Medicaid APG methodology,5131.06,,,5131.06,Other,324% Medicaid APG methodology,3404.87,,,3404.87,Other,215% Medicaid APG methodology,3404.87,,,3404.87,Other,215% Medicaid APG methodology,1979.57,,,1979.57,Other,125% Medicaid APG methodology,0.01,5131.06,
LOW COST SKIN SUBSTITUTE APP C5278,C5278,HCPCS,,47902077,CDM,361,RC,,,both,,,965,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,482.5,50,,482.5,percent of total billed charges,All Other,675.5,70,,675.5,percent of total billed charges,All Other,656.2,68,,656.2,percent of total billed charges,All Other Outpatient,2945.61,,,2945.61,Other,186% Medicaid methodology,772,80,,772,percent of total billed charges,All Other Outpatient,800.95,83,,800.95,percent of total billed charges,All Other Outpatient,800.95,83,,800.95,percent of total billed charges,All Other Outpatient,772,80,,772,percent of total billed charges,All Other Outpatient,800.95,83,,800.95,percent of total billed charges,All Other Outpatient,868.5,90,,868.5,percent of total billed charges,All Other,675.5,70,,675.5,percent of total billed charges,All Other,482.5,50,,482.5,percent of total billed charges,All Other,482.5,50,,482.5,percent of total billed charges,All Other,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1583.66,,,1583.66,Other,New York Medicaid APG methodology,1583.66,,,1583.66,Other,100% Medicaid APG methodology,1583.66,,,1583.66,Other,100% Medicaid APG methodology,1583.66,,,1583.66,Other,100% Medicaid APG methodology,3563.23,,,3563.23,Other,225% Medicaid APG methodology,3563.23,,,3563.23,Other,225% Medicaid APG methodology,2423,,,2423,Other,153% Medicaid APG methodology,3563.23,,,3563.23,Other,225% Medicaid APG methodology,2217.12,,,2217.12,Other,140% Medicaid APG methodology,3563.23,,,3563.23,Other,225% Medicaid APG methodology,4117.52,,,4117.52,Other,260% Medicaid APG methodology,5131.06,,,5131.06,Other,324% Medicaid APG methodology,3404.87,,,3404.87,Other,215% Medicaid APG methodology,3404.87,,,3404.87,Other,215% Medicaid APG methodology,1979.57,,,1979.57,Other,125% Medicaid APG methodology,0.01,5131.06,
TRANSPLT ALLO HCT/DONOR         ,38240,CPT,,40700023,CDM,362,RC,,,both,,,150254,103917.25,,,103917.25,Other,150% of Medicare + 9.63% HCRA Surcharge,63192.71,,,63192.71,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,75127,50,,75127,percent of total billed charges,All Other,105177.8,70,,105177.8,percent of total billed charges,All Other,102172.72,68,,102172.72,percent of total billed charges,All Other Outpatient,4136.44,,,4136.44,Other,186% Medicaid methodology,120203.2,80,,120203.2,percent of total billed charges,All Other Outpatient,124710.82,83,,124710.82,percent of total billed charges,All Other Outpatient,124710.82,83,,124710.82,percent of total billed charges,All Other Outpatient,120203.2,80,,120203.2,percent of total billed charges,All Other Outpatient,124710.82,83,,124710.82,percent of total billed charges,All Other Outpatient,135228.6,90,,135228.6,percent of total billed charges,All Other,105177.8,70,,105177.8,percent of total billed charges,All Other,1173.15,,,1173.15,Fee Schedule,,995.4,,,995.4,Fee Schedule,,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2223.89,,,2223.89,Other,New York Medicaid APG methodology,2223.89,,,2223.89,Other,100% Medicaid APG methodology,2223.89,,,2223.89,Other,100% Medicaid APG methodology,2223.89,,,2223.89,Other,100% Medicaid APG methodology,5003.76,,,5003.76,Other,225% Medicaid APG methodology,5003.76,,,5003.76,Other,225% Medicaid APG methodology,3402.56,,,3402.56,Other,153% Medicaid APG methodology,5003.76,,,5003.76,Other,225% Medicaid APG methodology,3113.45,,,3113.45,Other,140% Medicaid APG methodology,5003.76,,,5003.76,Other,225% Medicaid APG methodology,5782.12,,,5782.12,Other,260% Medicaid APG methodology,7205.41,,,7205.41,Other,324% Medicaid APG methodology,4781.37,,,4781.37,Other,215% Medicaid APG methodology,4781.37,,,4781.37,Other,215% Medicaid APG methodology,2779.87,,,2779.87,Other,125% Medicaid APG methodology,995.4,135228.6,
TRANSPLT AUTOL HCT/DONOR        ,38241,CPT,,40700031,CDM,362,RC,,,both,,,4838,2917.74,,,2917.74,Other,150% of Medicare + 9.63% HCRA Surcharge,1774.3,,,1774.3,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,2419,50,,2419,percent of total billed charges,All Other,3386.6,70,,3386.6,percent of total billed charges,All Other,3289.84,68,,3289.84,percent of total billed charges,All Other Outpatient,4136.45,,,4136.45,Other,186% Medicaid methodology,3870.4,80,,3870.4,percent of total billed charges,All Other Outpatient,4015.54,83,,4015.54,percent of total billed charges,All Other Outpatient,4015.54,83,,4015.54,percent of total billed charges,All Other Outpatient,3870.4,80,,3870.4,percent of total billed charges,All Other Outpatient,4015.54,83,,4015.54,percent of total billed charges,All Other Outpatient,4354.2,90,,4354.2,percent of total billed charges,All Other,3386.6,70,,3386.6,percent of total billed charges,All Other,864.6,,,864.6,Fee Schedule,,733.6,,,733.6,Fee Schedule,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2223.9,,,2223.9,Other,New York Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,3402.56,,,3402.56,Other,153% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,3113.46,,,3113.46,Other,140% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,5782.13,,,5782.13,Other,260% Medicaid APG methodology,7205.43,,,7205.43,Other,324% Medicaid APG methodology,4781.38,,,4781.38,Other,215% Medicaid APG methodology,4781.38,,,4781.38,Other,215% Medicaid APG methodology,2779.87,,,2779.87,Other,125% Medicaid APG methodology,733.6,9999,
TRANSPLT ALLO LYMPHOCYTES       ,38242,CPT,,40700049,CDM,362,RC,,,both,,,4838,2917.74,,,2917.74,Other,150% of Medicare + 9.63% HCRA Surcharge,1774.3,,,1774.3,Other,Medicare OPPS methodology,2419,50,,2419,percent of total billed charges,All Other Outpatient,2177.1,45,,2177.1,percent of total billed charges,All Other Outpatient,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,2419,50,,2419,percent of total billed charges,All Other,3386.6,70,,3386.6,percent of total billed charges,All Other,3289.84,68,,3289.84,percent of total billed charges,All Other Outpatient,4580.06,,,4580.06,Other,186% Medicaid methodology,3870.4,80,,3870.4,percent of total billed charges,All Other Outpatient,4015.54,83,,4015.54,percent of total billed charges,All Other Outpatient,4015.54,83,,4015.54,percent of total billed charges,All Other Outpatient,3870.4,80,,3870.4,percent of total billed charges,All Other Outpatient,4015.54,83,,4015.54,percent of total billed charges,All Other Outpatient,4354.2,90,,4354.2,percent of total billed charges,All Other,3386.6,70,,3386.6,percent of total billed charges,All Other,610.5,,,610.5,Fee Schedule,,518,,,518,Fee Schedule,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2462.4,,,2462.4,Other,New York Medicaid APG methodology,2462.4,,,2462.4,Other,100% Medicaid APG methodology,2462.4,,,2462.4,Other,100% Medicaid APG methodology,2462.4,,,2462.4,Other,100% Medicaid APG methodology,5540.39,,,5540.39,Other,225% Medicaid APG methodology,5540.39,,,5540.39,Other,225% Medicaid APG methodology,3767.47,,,3767.47,Other,153% Medicaid APG methodology,5540.39,,,5540.39,Other,225% Medicaid APG methodology,3447.35,,,3447.35,Other,140% Medicaid APG methodology,5540.39,,,5540.39,Other,225% Medicaid APG methodology,6402.23,,,6402.23,Other,260% Medicaid APG methodology,7978.16,,,7978.16,Other,324% Medicaid APG methodology,5294.15,,,5294.15,Other,215% Medicaid APG methodology,5294.15,,,5294.15,Other,215% Medicaid APG methodology,3077.99,,,3077.99,Other,125% Medicaid APG methodology,518,7978.16,
TRANSPLJ HEMATOPOIETIC BOOST    ,38243,CPT,,40700270,CDM,362,RC,,,both,,,4838,2917.74,,,2917.74,Other,150% of Medicare + 9.63% HCRA Surcharge,1774.3,,,1774.3,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,2419,50,,2419,percent of total billed charges,All Other,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper,3289.84,68,,3289.84,percent of total billed charges,All Other Outpatient,4136.45,,,4136.45,Other,186% Medicaid methodology,3870.4,80,,3870.4,percent of total billed charges,All Other Outpatient,4015.54,83,,4015.54,percent of total billed charges,All Other Outpatient,4015.54,83,,4015.54,percent of total billed charges,All Other Outpatient,3870.4,80,,3870.4,percent of total billed charges,All Other Outpatient,4015.54,83,,4015.54,percent of total billed charges,All Other Outpatient,4354.2,90,,4354.2,percent of total billed charges,All Other,3386.6,70,,3386.6,percent of total billed charges,All Other,594,,,594,Fee Schedule,,504,,,504,Fee Schedule,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2223.9,,,2223.9,Other,New York Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,3402.56,,,3402.56,Other,153% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,3113.46,,,3113.46,Other,140% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,5782.13,,,5782.13,Other,260% Medicaid APG methodology,7205.43,,,7205.43,Other,324% Medicaid APG methodology,4781.38,,,4781.38,Other,215% Medicaid APG methodology,4781.38,,,4781.38,Other,215% Medicaid APG methodology,2779.87,,,2779.87,Other,125% Medicaid APG methodology,0.01,7205.43,
TRANSPLJ HEMATOPOIETIC BOOST    ,38243,CPT,,48403232,CDM,362,RC,,,both,,,4838,2917.74,,,2917.74,Other,150% of Medicare + 9.63% HCRA Surcharge,1774.3,,,1774.3,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,2419,50,,2419,percent of total billed charges,All Other,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper,3289.84,68,,3289.84,percent of total billed charges,All Other Outpatient,4136.45,,,4136.45,Other,186% Medicaid methodology,3870.4,80,,3870.4,percent of total billed charges,All Other Outpatient,4015.54,83,,4015.54,percent of total billed charges,All Other Outpatient,4015.54,83,,4015.54,percent of total billed charges,All Other Outpatient,3870.4,80,,3870.4,percent of total billed charges,All Other Outpatient,4015.54,83,,4015.54,percent of total billed charges,All Other Outpatient,4354.2,90,,4354.2,percent of total billed charges,All Other,3386.6,70,,3386.6,percent of total billed charges,All Other,594,,,594,Fee Schedule,,504,,,504,Fee Schedule,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2223.9,,,2223.9,Other,New York Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,3402.56,,,3402.56,Other,153% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,3113.46,,,3113.46,Other,140% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,5782.13,,,5782.13,Other,260% Medicaid APG methodology,7205.43,,,7205.43,Other,324% Medicaid APG methodology,4781.38,,,4781.38,Other,215% Medicaid APG methodology,4781.38,,,4781.38,Other,215% Medicaid APG methodology,2779.87,,,2779.87,Other,125% Medicaid APG methodology,0.01,7205.43,
PLASMA CRYO-DEPLETED EA UNIT    ,P9044,HCPCS,,40211021,CDM,390,RC,,,both,,,1380,113.71,,,113.71,Other,150% of Medicare + 9.63% HCRA Surcharge,69.15,,,69.15,Other,Medicare OPPS methodology,966,70,,966,percent of total billed charges,Blood Products,966,70,,966,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,690,50,,690,percent of total billed charges,All Other,924.6,67,,924.6,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,966,70,"If Charge > 500, then 70 percent",966,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,966,70,,966,percent of total billed charges,Blood Products,966,70,,966,percent of total billed charges,Blood Products,966,70,,966,percent of total billed charges,Blood Products,966,70,,966,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,606.19,,,606.19,Other,New York Medicaid APG methodology,606.19,,,606.19,Other,100% Medicaid APG methodology,606.19,,,606.19,Other,100% Medicaid APG methodology,606.19,,,606.19,Other,100% Medicaid APG methodology,1363.94,,,1363.94,Other,225% Medicaid APG methodology,1363.94,,,1363.94,Other,225% Medicaid APG methodology,927.48,,,927.48,Other,153% Medicaid APG methodology,1363.94,,,1363.94,Other,225% Medicaid APG methodology,848.67,,,848.67,Other,140% Medicaid APG methodology,0.01,70,"If Charge > 2,000, then 70 percent",0.01,percent of total billed charges,Blood Products,1576.1,,,1576.1,Other,260% Medicaid APG methodology,1964.07,,,1964.07,Other,324% Medicaid APG methodology,1303.32,,,1303.32,Other,215% Medicaid APG methodology,1303.32,,,1303.32,Other,215% Medicaid APG methodology,757.74,,,757.74,Other,125% Medicaid APG methodology,0.01,1964.07,
CRYOPRECIPITATE EA UNIT         ,P9012,HCPCS,,40211039,CDM,390,RC,,,both,,,200,98.45,,,98.45,Other,150% of Medicare + 9.63% HCRA Surcharge,59.87,,,59.87,Other,Medicare OPPS methodology,140,70,,140,percent of total billed charges,Blood Products,140,70,,140,percent of total billed charges,Blood Products,134,67,,134,percent of total billed charges,Blood Products,134,67,,134,percent of total billed charges,Blood Products,134,67,,134,percent of total billed charges,Blood Products,100,50,,100,percent of total billed charges,All Other,134,67,,134,percent of total billed charges,Blood Products,134,67,,134,percent of total billed charges,Blood Products,0.01,70,"If Charge > 500, then 70 percent",0.01,percent of total billed charges,Blood Products,134,67,,134,percent of total billed charges,Blood Products,134,67,,134,percent of total billed charges,Blood Products,134,67,,134,percent of total billed charges,Blood Products,134,67,,134,percent of total billed charges,Blood Products,134,67,,134,percent of total billed charges,Blood Products,140,70,,140,percent of total billed charges,Blood Products,140,70,,140,percent of total billed charges,Blood Products,140,70,,140,percent of total billed charges,Blood Products,140,70,,140,percent of total billed charges,Blood Products,134,67,,134,percent of total billed charges,Blood Products,134,67,,134,percent of total billed charges,Blood Products,134,67,,134,percent of total billed charges,Blood Products,134,67,,134,percent of total billed charges,Blood Products,740.99,,,740.99,Other,New York Medicaid APG methodology,740.99,,,740.99,Other,100% Medicaid APG methodology,740.99,,,740.99,Other,100% Medicaid APG methodology,740.99,,,740.99,Other,100% Medicaid APG methodology,1667.23,,,1667.23,Other,225% Medicaid APG methodology,1667.23,,,1667.23,Other,225% Medicaid APG methodology,1133.72,,,1133.72,Other,153% Medicaid APG methodology,1667.23,,,1667.23,Other,225% Medicaid APG methodology,1037.39,,,1037.39,Other,140% Medicaid APG methodology,0.01,70,"If Charge > 2,000, then 70 percent",0.01,percent of total billed charges,Blood Products,1926.58,,,1926.58,Other,260% Medicaid APG methodology,2400.81,,,2400.81,Other,324% Medicaid APG methodology,1593.13,,,1593.13,Other,215% Medicaid APG methodology,1593.13,,,1593.13,Other,215% Medicaid APG methodology,926.24,,,926.24,Other,125% Medicaid APG methodology,0.01,2400.81,
FFP FRZ W/IN 8HR DIR EA UNIT    ,P9017,HCPCS,,40211054,CDM,390,RC,,,both,,,250,131.49,,,131.49,Other,150% of Medicare + 9.63% HCRA Surcharge,79.96,,,79.96,Other,Medicare OPPS methodology,175,70,,175,percent of total billed charges,Blood Products,175,70,,175,percent of total billed charges,Blood Products,167.5,67,,167.5,percent of total billed charges,Blood Products,167.5,67,,167.5,percent of total billed charges,Blood Products,167.5,67,,167.5,percent of total billed charges,Blood Products,125,50,,125,percent of total billed charges,All Other,167.5,67,,167.5,percent of total billed charges,Blood Products,167.5,67,,167.5,percent of total billed charges,Blood Products,0.01,70,"If Charge > 500, then 70 percent",0.01,percent of total billed charges,Blood Products,167.5,67,,167.5,percent of total billed charges,Blood Products,167.5,67,,167.5,percent of total billed charges,Blood Products,167.5,67,,167.5,percent of total billed charges,Blood Products,167.5,67,,167.5,percent of total billed charges,Blood Products,167.5,67,,167.5,percent of total billed charges,Blood Products,175,70,,175,percent of total billed charges,Blood Products,175,70,,175,percent of total billed charges,Blood Products,175,70,,175,percent of total billed charges,Blood Products,175,70,,175,percent of total billed charges,Blood Products,167.5,67,,167.5,percent of total billed charges,Blood Products,167.5,67,,167.5,percent of total billed charges,Blood Products,167.5,67,,167.5,percent of total billed charges,Blood Products,167.5,67,,167.5,percent of total billed charges,Blood Products,606.19,,,606.19,Other,New York Medicaid APG methodology,606.19,,,606.19,Other,100% Medicaid APG methodology,606.19,,,606.19,Other,100% Medicaid APG methodology,606.19,,,606.19,Other,100% Medicaid APG methodology,1363.94,,,1363.94,Other,225% Medicaid APG methodology,1363.94,,,1363.94,Other,225% Medicaid APG methodology,927.48,,,927.48,Other,153% Medicaid APG methodology,1363.94,,,1363.94,Other,225% Medicaid APG methodology,848.67,,,848.67,Other,140% Medicaid APG methodology,0.01,70,"If Charge > 2,000, then 70 percent",0.01,percent of total billed charges,Blood Products,1576.1,,,1576.1,Other,260% Medicaid APG methodology,1964.07,,,1964.07,Other,324% Medicaid APG methodology,1303.32,,,1303.32,Other,215% Medicaid APG methodology,1303.32,,,1303.32,Other,215% Medicaid APG methodology,757.74,,,757.74,Other,125% Medicaid APG methodology,0.01,1964.07,
"RBC, LR, EA UNIT                ",P9016,HCPCS,,40211153,CDM,390,RC,,,both,,,1030,297.35,,,297.35,Other,150% of Medicare + 9.63% HCRA Surcharge,180.82,,,180.82,Other,Medicare OPPS methodology,721,70,,721,percent of total billed charges,Blood Products,721,70,,721,percent of total billed charges,Blood Products,690.1,67,,690.1,percent of total billed charges,Blood Products,690.1,67,,690.1,percent of total billed charges,Blood Products,690.1,67,,690.1,percent of total billed charges,Blood Products,515,50,,515,percent of total billed charges,All Other,690.1,67,,690.1,percent of total billed charges,Blood Products,690.1,67,,690.1,percent of total billed charges,Blood Products,721,70,"If Charge > 500, then 70 percent",721,percent of total billed charges,Blood Products,690.1,67,,690.1,percent of total billed charges,Blood Products,690.1,67,,690.1,percent of total billed charges,Blood Products,690.1,67,,690.1,percent of total billed charges,Blood Products,690.1,67,,690.1,percent of total billed charges,Blood Products,690.1,67,,690.1,percent of total billed charges,Blood Products,721,70,,721,percent of total billed charges,Blood Products,721,70,,721,percent of total billed charges,Blood Products,721,70,,721,percent of total billed charges,Blood Products,721,70,,721,percent of total billed charges,Blood Products,690.1,67,,690.1,percent of total billed charges,Blood Products,690.1,67,,690.1,percent of total billed charges,Blood Products,690.1,67,,690.1,percent of total billed charges,Blood Products,690.1,67,,690.1,percent of total billed charges,Blood Products,606.19,,,606.19,Other,New York Medicaid APG methodology,606.19,,,606.19,Other,100% Medicaid APG methodology,606.19,,,606.19,Other,100% Medicaid APG methodology,606.19,,,606.19,Other,100% Medicaid APG methodology,1363.94,,,1363.94,Other,225% Medicaid APG methodology,1363.94,,,1363.94,Other,225% Medicaid APG methodology,927.48,,,927.48,Other,153% Medicaid APG methodology,1363.94,,,1363.94,Other,225% Medicaid APG methodology,848.67,,,848.67,Other,140% Medicaid APG methodology,0.01,70,"If Charge > 2,000, then 70 percent",0.01,percent of total billed charges,Blood Products,1576.1,,,1576.1,Other,260% Medicaid APG methodology,1964.07,,,1964.07,Other,324% Medicaid APG methodology,1303.32,,,1303.32,Other,215% Medicaid APG methodology,1303.32,,,1303.32,Other,215% Medicaid APG methodology,757.74,,,757.74,Other,125% Medicaid APG methodology,0.01,1964.07,
PLTS SING DNR LR NO IRR EA UN   ,P9035,HCPCS,,40211161,CDM,390,RC,,,both,,,1030,776.72,,,776.72,Other,150% of Medicare + 9.63% HCRA Surcharge,472.33,,,472.33,Other,Medicare OPPS methodology,721,70,,721,percent of total billed charges,Blood Products,721,70,,721,percent of total billed charges,Blood Products,690.1,67,,690.1,percent of total billed charges,Blood Products,690.1,67,,690.1,percent of total billed charges,Blood Products,690.1,67,,690.1,percent of total billed charges,Blood Products,515,50,,515,percent of total billed charges,All Other,690.1,67,,690.1,percent of total billed charges,Blood Products,690.1,67,,690.1,percent of total billed charges,Blood Products,721,70,"If Charge > 500, then 70 percent",721,percent of total billed charges,Blood Products,690.1,67,,690.1,percent of total billed charges,Blood Products,690.1,67,,690.1,percent of total billed charges,Blood Products,690.1,67,,690.1,percent of total billed charges,Blood Products,690.1,67,,690.1,percent of total billed charges,Blood Products,690.1,67,,690.1,percent of total billed charges,Blood Products,721,70,,721,percent of total billed charges,Blood Products,721,70,,721,percent of total billed charges,Blood Products,721,70,,721,percent of total billed charges,Blood Products,721,70,,721,percent of total billed charges,Blood Products,690.1,67,,690.1,percent of total billed charges,Blood Products,690.1,67,,690.1,percent of total billed charges,Blood Products,690.1,67,,690.1,percent of total billed charges,Blood Products,690.1,67,,690.1,percent of total billed charges,Blood Products,740.99,,,740.99,Other,New York Medicaid APG methodology,740.99,,,740.99,Other,100% Medicaid APG methodology,740.99,,,740.99,Other,100% Medicaid APG methodology,740.99,,,740.99,Other,100% Medicaid APG methodology,1667.23,,,1667.23,Other,225% Medicaid APG methodology,1667.23,,,1667.23,Other,225% Medicaid APG methodology,1133.72,,,1133.72,Other,153% Medicaid APG methodology,1667.23,,,1667.23,Other,225% Medicaid APG methodology,1037.39,,,1037.39,Other,140% Medicaid APG methodology,0.01,70,"If Charge > 2,000, then 70 percent",0.01,percent of total billed charges,Blood Products,1926.58,,,1926.58,Other,260% Medicaid APG methodology,2400.81,,,2400.81,Other,324% Medicaid APG methodology,1593.13,,,1593.13,Other,215% Medicaid APG methodology,1593.13,,,1593.13,Other,215% Medicaid APG methodology,926.24,,,926.24,Other,125% Medicaid APG methodology,0.01,2400.81,
PLTS SINGLE DONOR EA UNIT       ,P9034,HCPCS,,40211203,CDM,390,RC,,,both,,,2640,529.28,,,529.28,Other,150% of Medicare + 9.63% HCRA Surcharge,321.86,,,321.86,Other,Medicare OPPS methodology,1848,70,,1848,percent of total billed charges,Blood Products,1848,70,,1848,percent of total billed charges,Blood Products,1768.8,67,,1768.8,percent of total billed charges,Blood Products,1768.8,67,,1768.8,percent of total billed charges,Blood Products,1768.8,67,,1768.8,percent of total billed charges,Blood Products,1320,50,,1320,percent of total billed charges,All Other,1768.8,67,,1768.8,percent of total billed charges,Blood Products,1768.8,67,,1768.8,percent of total billed charges,Blood Products,1848,70,"If Charge > 500, then 70 percent",1848,percent of total billed charges,Blood Products,1768.8,67,,1768.8,percent of total billed charges,Blood Products,1768.8,67,,1768.8,percent of total billed charges,Blood Products,1768.8,67,,1768.8,percent of total billed charges,Blood Products,1768.8,67,,1768.8,percent of total billed charges,Blood Products,1768.8,67,,1768.8,percent of total billed charges,Blood Products,1848,70,,1848,percent of total billed charges,Blood Products,1848,70,,1848,percent of total billed charges,Blood Products,1848,70,,1848,percent of total billed charges,Blood Products,1848,70,,1848,percent of total billed charges,Blood Products,1768.8,67,,1768.8,percent of total billed charges,Blood Products,1768.8,67,,1768.8,percent of total billed charges,Blood Products,1768.8,67,,1768.8,percent of total billed charges,Blood Products,1768.8,67,,1768.8,percent of total billed charges,Blood Products,740.99,,,740.99,Other,New York Medicaid APG methodology,740.99,,,740.99,Other,100% Medicaid APG methodology,740.99,,,740.99,Other,100% Medicaid APG methodology,740.99,,,740.99,Other,100% Medicaid APG methodology,1667.23,,,1667.23,Other,225% Medicaid APG methodology,1667.23,,,1667.23,Other,225% Medicaid APG methodology,1133.72,,,1133.72,Other,153% Medicaid APG methodology,1667.23,,,1667.23,Other,225% Medicaid APG methodology,1037.39,,,1037.39,Other,140% Medicaid APG methodology,1848,70,"If Charge > 2,000, then 70 percent",1848,percent of total billed charges,Blood Products,1926.58,,,1926.58,Other,260% Medicaid APG methodology,2400.81,,,2400.81,Other,324% Medicaid APG methodology,1593.13,,,1593.13,Other,215% Medicaid APG methodology,1593.13,,,1593.13,Other,215% Medicaid APG methodology,926.24,,,926.24,Other,125% Medicaid APG methodology,321.86,2400.81,
WASHED LR RBC EA UNIT           ,P9054,HCPCS,,40211229,CDM,390,RC,,,both,,,1247,353.9,,,353.9,Other,150% of Medicare + 9.63% HCRA Surcharge,215.21,,,215.21,Other,Medicare OPPS methodology,872.9,70,,872.9,percent of total billed charges,Blood Products,872.9,70,,872.9,percent of total billed charges,Blood Products,835.49,67,,835.49,percent of total billed charges,Blood Products,835.49,67,,835.49,percent of total billed charges,Blood Products,835.49,67,,835.49,percent of total billed charges,Blood Products,623.5,50,,623.5,percent of total billed charges,All Other,835.49,67,,835.49,percent of total billed charges,Blood Products,835.49,67,,835.49,percent of total billed charges,Blood Products,872.9,70,"If Charge > 500, then 70 percent",872.9,percent of total billed charges,Blood Products,835.49,67,,835.49,percent of total billed charges,Blood Products,835.49,67,,835.49,percent of total billed charges,Blood Products,835.49,67,,835.49,percent of total billed charges,Blood Products,835.49,67,,835.49,percent of total billed charges,Blood Products,835.49,67,,835.49,percent of total billed charges,Blood Products,872.9,70,,872.9,percent of total billed charges,Blood Products,872.9,70,,872.9,percent of total billed charges,Blood Products,872.9,70,,872.9,percent of total billed charges,Blood Products,872.9,70,,872.9,percent of total billed charges,Blood Products,835.49,67,,835.49,percent of total billed charges,Blood Products,835.49,67,,835.49,percent of total billed charges,Blood Products,835.49,67,,835.49,percent of total billed charges,Blood Products,835.49,67,,835.49,percent of total billed charges,Blood Products,606.19,,,606.19,Other,New York Medicaid APG methodology,606.19,,,606.19,Other,100% Medicaid APG methodology,606.19,,,606.19,Other,100% Medicaid APG methodology,606.19,,,606.19,Other,100% Medicaid APG methodology,1363.94,,,1363.94,Other,225% Medicaid APG methodology,1363.94,,,1363.94,Other,225% Medicaid APG methodology,927.48,,,927.48,Other,153% Medicaid APG methodology,1363.94,,,1363.94,Other,225% Medicaid APG methodology,848.67,,,848.67,Other,140% Medicaid APG methodology,0.01,70,"If Charge > 2,000, then 70 percent",0.01,percent of total billed charges,Blood Products,1576.1,,,1576.1,Other,260% Medicaid APG methodology,1964.07,,,1964.07,Other,324% Medicaid APG methodology,1303.32,,,1303.32,Other,215% Medicaid APG methodology,1303.32,,,1303.32,Other,215% Medicaid APG methodology,757.74,,,757.74,Other,125% Medicaid APG methodology,0.01,1964.07,
E4145 Aph ARBC Washed LR Irr Open,P9057,HCPCS,,40211526,CDM,390,RC,,,both,,,1005,810.22,,,810.22,Other,150% of Medicare + 9.63% HCRA Surcharge,492.7,,,492.7,Other,Medicare OPPS methodology,703.5,70,,703.5,percent of total billed charges,Blood Products,703.5,70,,703.5,percent of total billed charges,Blood Products,673.35,67,,673.35,percent of total billed charges,Blood Products,673.35,67,,673.35,percent of total billed charges,Blood Products,673.35,67,,673.35,percent of total billed charges,Blood Products,502.5,50,,502.5,percent of total billed charges,All Other,673.35,67,,673.35,percent of total billed charges,Blood Products,673.35,67,,673.35,percent of total billed charges,Blood Products,703.5,70,"If Charge > 500, then 70 percent",703.5,percent of total billed charges,Blood Products,673.35,67,,673.35,percent of total billed charges,Blood Products,673.35,67,,673.35,percent of total billed charges,Blood Products,673.35,67,,673.35,percent of total billed charges,Blood Products,673.35,67,,673.35,percent of total billed charges,Blood Products,673.35,67,,673.35,percent of total billed charges,Blood Products,703.5,70,,703.5,percent of total billed charges,Blood Products,703.5,70,,703.5,percent of total billed charges,Blood Products,703.5,70,,703.5,percent of total billed charges,Blood Products,703.5,70,,703.5,percent of total billed charges,Blood Products,673.35,67,,673.35,percent of total billed charges,Blood Products,673.35,67,,673.35,percent of total billed charges,Blood Products,673.35,67,,673.35,percent of total billed charges,Blood Products,673.35,67,,673.35,percent of total billed charges,Blood Products,606.19,,,606.19,Other,New York Medicaid APG methodology,606.19,,,606.19,Other,100% Medicaid APG methodology,606.19,,,606.19,Other,100% Medicaid APG methodology,606.19,,,606.19,Other,100% Medicaid APG methodology,1363.94,,,1363.94,Other,225% Medicaid APG methodology,1363.94,,,1363.94,Other,225% Medicaid APG methodology,927.48,,,927.48,Other,153% Medicaid APG methodology,1363.94,,,1363.94,Other,225% Medicaid APG methodology,848.67,,,848.67,Other,140% Medicaid APG methodology,0.01,70,"If Charge > 2,000, then 70 percent",0.01,percent of total billed charges,Blood Products,1576.1,,,1576.1,Other,260% Medicaid APG methodology,1964.07,,,1964.07,Other,324% Medicaid APG methodology,1303.32,,,1303.32,Other,215% Medicaid APG methodology,1303.32,,,1303.32,Other,215% Medicaid APG methodology,757.74,,,757.74,Other,125% Medicaid APG methodology,0.01,1964.07,
"FFP, FROZ 8-24 HRS, EA UN       ",P9059,HCPCS,,40211542,CDM,390,RC,,,both,,,426,119.34,,,119.34,Other,150% of Medicare + 9.63% HCRA Surcharge,72.57,,,72.57,Other,Medicare OPPS methodology,298.2,70,,298.2,percent of total billed charges,Blood Products,298.2,70,,298.2,percent of total billed charges,Blood Products,285.42,67,,285.42,percent of total billed charges,Blood Products,285.42,67,,285.42,percent of total billed charges,Blood Products,285.42,67,,285.42,percent of total billed charges,Blood Products,213,50,,213,percent of total billed charges,All Other,285.42,67,,285.42,percent of total billed charges,Blood Products,285.42,67,,285.42,percent of total billed charges,Blood Products,0.01,70,"If Charge > 500, then 70 percent",0.01,percent of total billed charges,Blood Products,285.42,67,,285.42,percent of total billed charges,Blood Products,285.42,67,,285.42,percent of total billed charges,Blood Products,285.42,67,,285.42,percent of total billed charges,Blood Products,285.42,67,,285.42,percent of total billed charges,Blood Products,285.42,67,,285.42,percent of total billed charges,Blood Products,298.2,70,,298.2,percent of total billed charges,Blood Products,298.2,70,,298.2,percent of total billed charges,Blood Products,298.2,70,,298.2,percent of total billed charges,Blood Products,298.2,70,,298.2,percent of total billed charges,Blood Products,285.42,67,,285.42,percent of total billed charges,Blood Products,285.42,67,,285.42,percent of total billed charges,Blood Products,285.42,67,,285.42,percent of total billed charges,Blood Products,285.42,67,,285.42,percent of total billed charges,Blood Products,606.19,,,606.19,Other,New York Medicaid APG methodology,606.19,,,606.19,Other,100% Medicaid APG methodology,606.19,,,606.19,Other,100% Medicaid APG methodology,606.19,,,606.19,Other,100% Medicaid APG methodology,1363.94,,,1363.94,Other,225% Medicaid APG methodology,1363.94,,,1363.94,Other,225% Medicaid APG methodology,927.48,,,927.48,Other,153% Medicaid APG methodology,1363.94,,,1363.94,Other,225% Medicaid APG methodology,848.67,,,848.67,Other,140% Medicaid APG methodology,0.01,70,"If Charge > 2,000, then 70 percent",0.01,percent of total billed charges,Blood Products,1576.1,,,1576.1,Other,260% Medicaid APG methodology,1964.07,,,1964.07,Other,324% Medicaid APG methodology,1303.32,,,1303.32,Other,215% Medicaid APG methodology,1303.32,,,1303.32,Other,215% Medicaid APG methodology,757.74,,,757.74,Other,125% Medicaid APG methodology,0.01,1964.07,
E3045 Aph Plt ACDA Irr,P9036,HCPCS,,40211856,CDM,390,RC,,,both,,,3003,920.79,,,920.79,Other,150% of Medicare + 9.63% HCRA Surcharge,559.94,,,559.94,Other,Medicare OPPS methodology,2102.1,70,,2102.1,percent of total billed charges,Blood Products,2102.1,70,,2102.1,percent of total billed charges,Blood Products,2012.01,67,,2012.01,percent of total billed charges,Blood Products,2012.01,67,,2012.01,percent of total billed charges,Blood Products,2012.01,67,,2012.01,percent of total billed charges,Blood Products,1501.5,50,,1501.5,percent of total billed charges,All Other,2012.01,67,,2012.01,percent of total billed charges,Blood Products,2012.01,67,,2012.01,percent of total billed charges,Blood Products,2102.1,70,"If Charge > 500, then 70 percent",2102.1,percent of total billed charges,Blood Products,2012.01,67,,2012.01,percent of total billed charges,Blood Products,2012.01,67,,2012.01,percent of total billed charges,Blood Products,2012.01,67,,2012.01,percent of total billed charges,Blood Products,2012.01,67,,2012.01,percent of total billed charges,Blood Products,2012.01,67,,2012.01,percent of total billed charges,Blood Products,2102.1,70,,2102.1,percent of total billed charges,Blood Products,2102.1,70,,2102.1,percent of total billed charges,Blood Products,2102.1,70,,2102.1,percent of total billed charges,Blood Products,2102.1,70,,2102.1,percent of total billed charges,Blood Products,2012.01,67,,2012.01,percent of total billed charges,Blood Products,2012.01,67,,2012.01,percent of total billed charges,Blood Products,2012.01,67,,2012.01,percent of total billed charges,Blood Products,2012.01,67,,2012.01,percent of total billed charges,Blood Products,740.99,,,740.99,Other,New York Medicaid APG methodology,740.99,,,740.99,Other,100% Medicaid APG methodology,740.99,,,740.99,Other,100% Medicaid APG methodology,740.99,,,740.99,Other,100% Medicaid APG methodology,1667.23,,,1667.23,Other,225% Medicaid APG methodology,1667.23,,,1667.23,Other,225% Medicaid APG methodology,1133.72,,,1133.72,Other,153% Medicaid APG methodology,1667.23,,,1667.23,Other,225% Medicaid APG methodology,1037.39,,,1037.39,Other,140% Medicaid APG methodology,2102.1,70,"If Charge > 2,000, then 70 percent",2102.1,percent of total billed charges,Blood Products,1926.58,,,1926.58,Other,260% Medicaid APG methodology,2400.81,,,2400.81,Other,324% Medicaid APG methodology,1593.13,,,1593.13,Other,215% Medicaid APG methodology,1593.13,,,1593.13,Other,215% Medicaid APG methodology,926.24,,,926.24,Other,125% Medicaid APG methodology,559.94,2400.81,
"SD PLTS, PHERESIS, LR,IRR, EA   ",P9037,HCPCS,,40211864,CDM,390,RC,,,both,,,1380,1105.86,,,1105.86,Other,150% of Medicare + 9.63% HCRA Surcharge,672.48,,,672.48,Other,Medicare OPPS methodology,966,70,,966,percent of total billed charges,Blood Products,966,70,,966,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,690,50,,690,percent of total billed charges,All Other,924.6,67,,924.6,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,966,70,"If Charge > 500, then 70 percent",966,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,966,70,,966,percent of total billed charges,Blood Products,966,70,,966,percent of total billed charges,Blood Products,966,70,,966,percent of total billed charges,Blood Products,966,70,,966,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,740.99,,,740.99,Other,New York Medicaid APG methodology,740.99,,,740.99,Other,100% Medicaid APG methodology,740.99,,,740.99,Other,100% Medicaid APG methodology,740.99,,,740.99,Other,100% Medicaid APG methodology,1667.23,,,1667.23,Other,225% Medicaid APG methodology,1667.23,,,1667.23,Other,225% Medicaid APG methodology,1133.72,,,1133.72,Other,153% Medicaid APG methodology,1667.23,,,1667.23,Other,225% Medicaid APG methodology,1037.39,,,1037.39,Other,140% Medicaid APG methodology,0.01,70,"If Charge > 2,000, then 70 percent",0.01,percent of total billed charges,Blood Products,1926.58,,,1926.58,Other,260% Medicaid APG methodology,2400.81,,,2400.81,Other,324% Medicaid APG methodology,1593.13,,,1593.13,Other,215% Medicaid APG methodology,1593.13,,,1593.13,Other,215% Medicaid APG methodology,926.24,,,926.24,Other,125% Medicaid APG methodology,0.01,2400.81,
"RBC,LR,IRRAD,EACH UNIT          ",P9040,HCPCS,,40211955,CDM,390,RC,,,both,,,1380,415.19,,,415.19,Other,150% of Medicare + 9.63% HCRA Surcharge,252.48,,,252.48,Other,Medicare OPPS methodology,966,70,,966,percent of total billed charges,Blood Products,966,70,,966,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,690,50,,690,percent of total billed charges,All Other,924.6,67,,924.6,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,966,70,"If Charge > 500, then 70 percent",966,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,966,70,,966,percent of total billed charges,Blood Products,966,70,,966,percent of total billed charges,Blood Products,966,70,,966,percent of total billed charges,Blood Products,966,70,,966,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,924.6,67,,924.6,percent of total billed charges,Blood Products,606.19,,,606.19,Other,New York Medicaid APG methodology,606.19,,,606.19,Other,100% Medicaid APG methodology,606.19,,,606.19,Other,100% Medicaid APG methodology,606.19,,,606.19,Other,100% Medicaid APG methodology,1363.94,,,1363.94,Other,225% Medicaid APG methodology,1363.94,,,1363.94,Other,225% Medicaid APG methodology,927.48,,,927.48,Other,153% Medicaid APG methodology,1363.94,,,1363.94,Other,225% Medicaid APG methodology,848.67,,,848.67,Other,140% Medicaid APG methodology,0.01,70,"If Charge > 2,000, then 70 percent",0.01,percent of total billed charges,Blood Products,1576.1,,,1576.1,Other,260% Medicaid APG methodology,1964.07,,,1964.07,Other,324% Medicaid APG methodology,1303.32,,,1303.32,Other,215% Medicaid APG methodology,1303.32,,,1303.32,Other,215% Medicaid APG methodology,757.74,,,757.74,Other,125% Medicaid APG methodology,0.01,1964.07,
PLATELETS PHERESIS PATH RED EA  ,P9073,HCPCS,,40212920,CDM,390,RC,,,both,,,3000,906.55,,,906.55,Other,150% of Medicare + 9.63% HCRA Surcharge,551.28,,,551.28,Other,Medicare OPPS methodology,2100,70,,2100,percent of total billed charges,Blood Products,2100,70,,2100,percent of total billed charges,Blood Products,2010,67,,2010,percent of total billed charges,Blood Products,2010,67,,2010,percent of total billed charges,Blood Products,2010,67,,2010,percent of total billed charges,Blood Products,1500,50,,1500,percent of total billed charges,All Other,2010,67,,2010,percent of total billed charges,Blood Products,2010,67,,2010,percent of total billed charges,Blood Products,2100,70,"If Charge > 500, then 70 percent",2100,percent of total billed charges,Blood Products,2010,67,,2010,percent of total billed charges,Blood Products,2010,67,,2010,percent of total billed charges,Blood Products,2010,67,,2010,percent of total billed charges,Blood Products,2010,67,,2010,percent of total billed charges,Blood Products,2010,67,,2010,percent of total billed charges,Blood Products,2100,70,,2100,percent of total billed charges,Blood Products,2100,70,,2100,percent of total billed charges,Blood Products,2100,70,,2100,percent of total billed charges,Blood Products,2100,70,,2100,percent of total billed charges,Blood Products,2010,67,,2010,percent of total billed charges,Blood Products,2010,67,,2010,percent of total billed charges,Blood Products,2010,67,,2010,percent of total billed charges,Blood Products,2010,67,,2010,percent of total billed charges,Blood Products,740.99,,,740.99,Other,New York Medicaid APG methodology,740.99,,,740.99,Other,100% Medicaid APG methodology,740.99,,,740.99,Other,100% Medicaid APG methodology,740.99,,,740.99,Other,100% Medicaid APG methodology,1667.23,,,1667.23,Other,225% Medicaid APG methodology,1667.23,,,1667.23,Other,225% Medicaid APG methodology,1133.72,,,1133.72,Other,153% Medicaid APG methodology,1667.23,,,1667.23,Other,225% Medicaid APG methodology,1037.39,,,1037.39,Other,140% Medicaid APG methodology,2100,70,"If Charge > 2,000, then 70 percent",2100,percent of total billed charges,Blood Products,1926.58,,,1926.58,Other,260% Medicaid APG methodology,2400.81,,,2400.81,Other,324% Medicaid APG methodology,1593.13,,,1593.13,Other,215% Medicaid APG methodology,1593.13,,,1593.13,Other,215% Medicaid APG methodology,926.24,,,926.24,Other,125% Medicaid APG methodology,551.28,2400.81,
LEUKACYTE TRANSFUSION           ,86950,CPT,,48401400,CDM,391,RC,,,both,,,853,324.81,,,324.81,Other,150% of Medicare + 9.63% HCRA Surcharge,197.52,,,197.52,Other,Medicare OPPS methodology,597.1,70,,597.1,percent of total billed charges,Blood Products,597.1,70,,597.1,percent of total billed charges,Blood Products,571.51,67,,571.51,percent of total billed charges,Blood Products,571.51,67,,571.51,percent of total billed charges,Blood Products,571.51,67,,571.51,percent of total billed charges,Blood Products,426.5,50,,426.5,percent of total billed charges,All Other,571.51,67,,571.51,percent of total billed charges,Blood Products,571.51,67,,571.51,percent of total billed charges,Blood Products,597.1,70,"If Charge > 500, then 70 percent",597.1,percent of total billed charges,Blood Products,571.51,67,,571.51,percent of total billed charges,Blood Products,571.51,67,,571.51,percent of total billed charges,Blood Products,571.51,67,,571.51,percent of total billed charges,Blood Products,571.51,67,,571.51,percent of total billed charges,Blood Products,571.51,67,,571.51,percent of total billed charges,Blood Products,597.1,70,,597.1,percent of total billed charges,Blood Products,597.1,70,,597.1,percent of total billed charges,Blood Products,597.1,70,,597.1,percent of total billed charges,Blood Products,597.1,70,,597.1,percent of total billed charges,Blood Products,571.51,67,,571.51,percent of total billed charges,Blood Products,571.51,67,,571.51,percent of total billed charges,Blood Products,571.51,67,,571.51,percent of total billed charges,Blood Products,571.51,67,,571.51,percent of total billed charges,Blood Products,71.88,,,71.88,Other,New York Medicaid APG methodology,71.88,,,71.88,Other,100% Medicaid APG methodology,71.88,,,71.88,Other,100% Medicaid APG methodology,71.88,,,71.88,Other,100% Medicaid APG methodology,161.72,,,161.72,Other,225% Medicaid APG methodology,161.72,,,161.72,Other,225% Medicaid APG methodology,109.97,,,109.97,Other,153% Medicaid APG methodology,161.72,,,161.72,Other,225% Medicaid APG methodology,100.63,,,100.63,Other,140% Medicaid APG methodology,0.01,70,"If Charge > 2,000, then 70 percent",0.01,percent of total billed charges,Blood Products,186.88,,,186.88,Other,260% Medicaid APG methodology,232.88,,,232.88,Other,324% Medicaid APG methodology,154.53,,,154.53,Other,215% Medicaid APG methodology,154.53,,,154.53,Other,215% Medicaid APG methodology,89.85,,,89.85,Other,125% Medicaid APG methodology,0.01,597.1,
DX MAMMO INCL CAD UNI RT        ,77065,CPT,RT       ,45004777,CDM,401,RC,,,both,,,727,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,326.05,,,326.05,Fee Schedule,,293.03,,,293.03,Fee Schedule,,72.65,,,72.65,Fee Schedule,,72.65,,,72.65,Fee Schedule,,72.65,,,72.65,Fee Schedule,,363.5,50,,363.5,percent of total billed charges,All Other,283.34,,,283.34,Fee Schedule,,391.05,,,391.05,Fee Schedule,,286.25,,,286.25,Other,186% Medicaid methodology,460.18,,,460.18,Fee Schedule,,450.74,,,450.74,Fee Schedule,,216.68,,,216.68,Fee Schedule,,460.18,,,460.18,Fee Schedule,,450.74,,,450.74,Fee Schedule,,407.56,,,407.56,Fee Schedule,,508.9,70,,508.9,percent of total billed charges,All Other,432.3,,,432.3,Fee Schedule,,366.8,,,366.8,Fee Schedule,,659,,,659,Case Rate,Mammography Per Visit,649,,,649,Case Rate,Mammography Per Visit,722,,,722,Case Rate,Mammography Per Visit,614,,,614,Case Rate,Mammography Per Visit,153.9,,,153.9,Other,New York Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,235.47,,,235.47,Other,153% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,215.46,,,215.46,Other,140% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,400.14,,,400.14,Other,260% Medicaid APG methodology,498.64,,,498.64,Other,324% Medicaid APG methodology,330.89,,,330.89,Other,215% Medicaid APG methodology,330.89,,,330.89,Other,215% Medicaid APG methodology,192.38,,,192.38,Other,125% Medicaid APG methodology,0.01,722,
DX MAMMO INCL CAD UNI LT        ,77065,CPT,LT       ,45004785,CDM,401,RC,,,both,,,727,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,326.05,,,326.05,Fee Schedule,,293.03,,,293.03,Fee Schedule,,72.65,,,72.65,Fee Schedule,,72.65,,,72.65,Fee Schedule,,72.65,,,72.65,Fee Schedule,,363.5,50,,363.5,percent of total billed charges,All Other,283.34,,,283.34,Fee Schedule,,391.05,,,391.05,Fee Schedule,,286.25,,,286.25,Other,186% Medicaid methodology,460.18,,,460.18,Fee Schedule,,450.74,,,450.74,Fee Schedule,,216.68,,,216.68,Fee Schedule,,460.18,,,460.18,Fee Schedule,,450.74,,,450.74,Fee Schedule,,407.56,,,407.56,Fee Schedule,,508.9,70,,508.9,percent of total billed charges,All Other,432.3,,,432.3,Fee Schedule,,366.8,,,366.8,Fee Schedule,,659,,,659,Case Rate,Mammography Per Visit,649,,,649,Case Rate,Mammography Per Visit,722,,,722,Case Rate,Mammography Per Visit,614,,,614,Case Rate,Mammography Per Visit,153.9,,,153.9,Other,New York Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,235.47,,,235.47,Other,153% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,215.46,,,215.46,Other,140% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,400.14,,,400.14,Other,260% Medicaid APG methodology,498.64,,,498.64,Other,324% Medicaid APG methodology,330.89,,,330.89,Other,215% Medicaid APG methodology,330.89,,,330.89,Other,215% Medicaid APG methodology,192.38,,,192.38,Other,125% Medicaid APG methodology,0.01,722,
DX MAMMO INCL CAD BI            ,77066,CPT,,45004793,CDM,401,RC,,,both,,,915,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,418.67,,,418.67,Fee Schedule,,376.27,,,376.27,Fee Schedule,,92.79,,,92.79,Fee Schedule,,92.79,,,92.79,Fee Schedule,,92.79,,,92.79,Fee Schedule,,457.5,50,,457.5,percent of total billed charges,All Other,362.38,,,362.38,Fee Schedule,,502.14,,,502.14,Fee Schedule,,286.25,,,286.25,Other,186% Medicaid methodology,590.91,,,590.91,Fee Schedule,,567.3,,,567.3,Fee Schedule,,278.23,,,278.23,Fee Schedule,,590.91,,,590.91,Fee Schedule,,567.3,,,567.3,Fee Schedule,,523.34,,,523.34,Fee Schedule,,640.5,70,,640.5,percent of total billed charges,All Other,551.1,,,551.1,Fee Schedule,,467.6,,,467.6,Fee Schedule,,659,,,659,Case Rate,Mammography Per Visit,649,,,649,Case Rate,Mammography Per Visit,722,,,722,Case Rate,Mammography Per Visit,614,,,614,Case Rate,Mammography Per Visit,153.9,,,153.9,Other,New York Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,235.47,,,235.47,Other,153% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,215.46,,,215.46,Other,140% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,400.14,,,400.14,Other,260% Medicaid APG methodology,498.64,,,498.64,Other,324% Medicaid APG methodology,330.89,,,330.89,Other,215% Medicaid APG methodology,330.89,,,330.89,Other,215% Medicaid APG methodology,192.38,,,192.38,Other,125% Medicaid APG methodology,0.01,722,
"TOMOSYNTHESIS, MAMMO RT         ",G0279,HCPCS,RT       ,45005477,CDM,401,RC,,,both,,,183,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,72.02,,,72.02,Fee Schedule,,64.72,,,64.72,Fee Schedule,,24.15,,,24.15,Fee Schedule,,24.15,,,24.15,Fee Schedule,,24.15,,,24.15,Fee Schedule,,91.5,50,,91.5,percent of total billed charges,All Other,79.07,,,79.07,Fee Schedule,,86.37,,,86.37,Fee Schedule,,286.25,,,286.25,Other,186% Medicaid methodology,101.64,,,101.64,Fee Schedule,,113.46,,,113.46,Fee Schedule,,47.86,,,47.86,Fee Schedule,,101.64,,,101.64,Fee Schedule,,113.46,,,113.46,Fee Schedule,,90.02,,,90.02,Fee Schedule,,128.1,70,,128.1,percent of total billed charges,All Other,115.5,,,115.5,Fee Schedule,,98,,,98,Fee Schedule,,659,,,659,Case Rate,Mammography Per Visit,649,,,649,Case Rate,Mammography Per Visit,722,,,722,Case Rate,Mammography Per Visit,614,,,614,Case Rate,Mammography Per Visit,153.9,,,153.9,Other,New York Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,235.47,,,235.47,Other,153% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,215.46,,,215.46,Other,140% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,400.14,,,400.14,Other,260% Medicaid APG methodology,498.64,,,498.64,Other,324% Medicaid APG methodology,330.89,,,330.89,Other,215% Medicaid APG methodology,330.89,,,330.89,Other,215% Medicaid APG methodology,192.38,,,192.38,Other,125% Medicaid APG methodology,0.01,722,
"TOMOSYNTHESIS, MAMMO LT         ",G0279,HCPCS,LT       ,45005543,CDM,401,RC,,,both,,,183,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,72.02,,,72.02,Fee Schedule,,64.72,,,64.72,Fee Schedule,,24.15,,,24.15,Fee Schedule,,24.15,,,24.15,Fee Schedule,,24.15,,,24.15,Fee Schedule,,91.5,50,,91.5,percent of total billed charges,All Other,79.07,,,79.07,Fee Schedule,,86.37,,,86.37,Fee Schedule,,286.25,,,286.25,Other,186% Medicaid methodology,101.64,,,101.64,Fee Schedule,,113.46,,,113.46,Fee Schedule,,47.86,,,47.86,Fee Schedule,,101.64,,,101.64,Fee Schedule,,113.46,,,113.46,Fee Schedule,,90.02,,,90.02,Fee Schedule,,128.1,70,,128.1,percent of total billed charges,All Other,115.5,,,115.5,Fee Schedule,,98,,,98,Fee Schedule,,659,,,659,Case Rate,Mammography Per Visit,649,,,649,Case Rate,Mammography Per Visit,722,,,722,Case Rate,Mammography Per Visit,614,,,614,Case Rate,Mammography Per Visit,153.9,,,153.9,Other,New York Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,235.47,,,235.47,Other,153% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,215.46,,,215.46,Other,140% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,400.14,,,400.14,Other,260% Medicaid APG methodology,498.64,,,498.64,Other,324% Medicaid APG methodology,330.89,,,330.89,Other,215% Medicaid APG methodology,330.89,,,330.89,Other,215% Medicaid APG methodology,192.38,,,192.38,Other,125% Medicaid APG methodology,0.01,722,
MG Mammo CAD Bilat Add on 77062,77062,CPT,TC50,45006442,CDM,401,RC,,,both,,,183,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,91.5,,,91.5,Fee Schedule,,91.5,,,91.5,Fee Schedule,,89.45,,,89.45,Fee Schedule,,89.45,,,89.45,Fee Schedule,,89.45,,,89.45,Fee Schedule,,91.5,50,,91.5,percent of total billed charges,All Other,362.38,,,362.38,Fee Schedule,,78.69,43,,78.69,percent of total billed charges,All Other,286.25,,,286.25,Other,186% Medicaid methodology,91.5,50,,91.5,percent of total billed charges,All Other,100.65,55,,100.65,percent of total billed charges,All Other,100.65,55,,100.65,percent of total billed charges,All Other,91.5,50,,91.5,percent of total billed charges,All Other,100.65,55,,100.65,percent of total billed charges,All Other,164.7,90,,164.7,percent of total billed charges,All Other,128.1,70,,128.1,percent of total billed charges,All Other,91.5,50,,91.5,percent of total billed charges,All Other,91.5,50,,91.5,percent of total billed charges,All Other,659,,,659,Case Rate,Mammography Per Visit,649,,,649,Case Rate,Mammography Per Visit,722,,,722,Case Rate,Mammography Per Visit,614,,,614,Case Rate,Mammography Per Visit,153.9,,,153.9,Other,New York Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,235.47,,,235.47,Other,153% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,215.46,,,215.46,Other,140% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,400.14,,,400.14,Other,260% Medicaid APG methodology,498.64,,,498.64,Other,324% Medicaid APG methodology,330.89,,,330.89,Other,215% Medicaid APG methodology,330.89,,,330.89,Other,215% Medicaid APG methodology,192.38,,,192.38,Other,125% Medicaid APG methodology,0.01,722,
MG Mammo w CAD 3D Left add on 77061,77061,CPT,TCLT,45006459,CDM,401,RC,,,both,,,183,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,91.5,,,91.5,Fee Schedule,,91.5,,,91.5,Fee Schedule,,113.93,,,113.93,Fee Schedule,,113.93,,,113.93,Fee Schedule,,113.93,,,113.93,Fee Schedule,,91.5,50,,91.5,percent of total billed charges,All Other,283.34,,,283.34,Fee Schedule,,78.69,43,,78.69,percent of total billed charges,All Other,286.25,,,286.25,Other,186% Medicaid methodology,91.5,50,,91.5,percent of total billed charges,All Other,100.65,55,,100.65,percent of total billed charges,All Other,100.65,55,,100.65,percent of total billed charges,All Other,91.5,50,,91.5,percent of total billed charges,All Other,100.65,55,,100.65,percent of total billed charges,All Other,164.7,90,,164.7,percent of total billed charges,All Other,128.1,70,,128.1,percent of total billed charges,All Other,91.5,50,,91.5,percent of total billed charges,All Other,91.5,50,,91.5,percent of total billed charges,All Other,659,,,659,Case Rate,Mammography Per Visit,649,,,649,Case Rate,Mammography Per Visit,722,,,722,Case Rate,Mammography Per Visit,614,,,614,Case Rate,Mammography Per Visit,153.9,,,153.9,Other,New York Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,235.47,,,235.47,Other,153% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,215.46,,,215.46,Other,140% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,400.14,,,400.14,Other,260% Medicaid APG methodology,498.64,,,498.64,Other,324% Medicaid APG methodology,330.89,,,330.89,Other,215% Medicaid APG methodology,330.89,,,330.89,Other,215% Medicaid APG methodology,192.38,,,192.38,Other,125% Medicaid APG methodology,0.01,722,
MG Mammo w CAD 3D Right add on 77061,77061,CPT,TCRT,45006467,CDM,401,RC,,,both,,,183,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,91.5,,,91.5,Fee Schedule,,91.5,,,91.5,Fee Schedule,,113.93,,,113.93,Fee Schedule,,113.93,,,113.93,Fee Schedule,,113.93,,,113.93,Fee Schedule,,91.5,50,,91.5,percent of total billed charges,All Other,283.34,,,283.34,Fee Schedule,,78.69,43,,78.69,percent of total billed charges,All Other,286.25,,,286.25,Other,186% Medicaid methodology,91.5,50,,91.5,percent of total billed charges,All Other,100.65,55,,100.65,percent of total billed charges,All Other,100.65,55,,100.65,percent of total billed charges,All Other,91.5,50,,91.5,percent of total billed charges,All Other,100.65,55,,100.65,percent of total billed charges,All Other,164.7,90,,164.7,percent of total billed charges,All Other,128.1,70,,128.1,percent of total billed charges,All Other,91.5,50,,91.5,percent of total billed charges,All Other,91.5,50,,91.5,percent of total billed charges,All Other,659,,,659,Case Rate,Mammography Per Visit,649,,,649,Case Rate,Mammography Per Visit,722,,,722,Case Rate,Mammography Per Visit,614,,,614,Case Rate,Mammography Per Visit,153.9,,,153.9,Other,New York Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,235.47,,,235.47,Other,153% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,215.46,,,215.46,Other,140% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,400.14,,,400.14,Other,260% Medicaid APG methodology,498.64,,,498.64,Other,324% Medicaid APG methodology,330.89,,,330.89,Other,215% Medicaid APG methodology,330.89,,,330.89,Other,215% Medicaid APG methodology,192.38,,,192.38,Other,125% Medicaid APG methodology,0.01,722,
ECHO EXAM OF FETAL HEART 2D     ,76825,CPT,,44401453,CDM,402,RC,,,both,,,1798,1049.09,,,1049.09,Other,150% of Medicare + 9.63% HCRA Surcharge,637.96,,,637.96,Other,Medicare OPPS methodology,686.35,,,686.35,Fee Schedule,,616.85,,,616.85,Fee Schedule,,1250.33,,,1250.33,Fee Schedule,,1124.94,,,1124.94,Fee Schedule,,1062.25,,,1062.25,Fee Schedule,,899,50,,899,percent of total billed charges,All Other,1415.99,,,1415.99,Fee Schedule,,823.19,,,823.19,Fee Schedule,,296.12,,,296.12,Other,186% Medicaid methodology,968.71,,,968.71,Fee Schedule,,1114.76,,,1114.76,Fee Schedule,,456.12,,,456.12,Fee Schedule,,968.71,,,968.71,Fee Schedule,,1114.76,,,1114.76,Fee Schedule,,857.94,,,857.94,Fee Schedule,,1258.6,70,,1258.6,percent of total billed charges,All Other,920.7,,,920.7,Fee Schedule,,781.2,,,781.2,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,159.2,,,159.2,Other,New York Medicaid APG methodology,159.2,,,159.2,Other,100% Medicaid APG methodology,159.2,,,159.2,Other,100% Medicaid APG methodology,159.2,,,159.2,Other,100% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,243.58,,,243.58,Other,153% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,222.89,,,222.89,Other,140% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,413.93,,,413.93,Other,260% Medicaid APG methodology,515.82,,,515.82,Other,324% Medicaid APG methodology,342.29,,,342.29,Other,215% Medicaid APG methodology,342.29,,,342.29,Other,215% Medicaid APG methodology,199.01,,,199.01,Other,125% Medicaid APG methodology,159.2,1734,
US EXAM SPINAL CANAL            ,76800,CPT,,47100136,CDM,402,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,398.07,,,398.07,Fee Schedule,,357.75,,,357.75,Fee Schedule,,723.46,,,723.46,Fee Schedule,,650.91,,,650.91,Fee Schedule,,614.64,,,614.64,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,477.43,,,477.43,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,561.83,,,561.83,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,264.54,,,264.54,Fee Schedule,,561.83,,,561.83,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,497.58,,,497.58,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,433.95,,,433.95,Fee Schedule,,368.2,,,368.2,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,127.14,1734,
US EXAM CHEST                   ,76604,CPT,,47100193,CDM,402,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,113.73,,,113.73,Fee Schedule,,102.21,,,102.21,Fee Schedule,,561.33,,,561.33,Fee Schedule,,505.04,,,505.04,Fee Schedule,,476.9,,,476.9,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,136.4,,,136.4,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,160.52,,,160.52,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,75.58,,,75.58,Fee Schedule,,160.52,,,160.52,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,142.16,,,142.16,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,151.8,,,151.8,Fee Schedule,,128.8,,,128.8,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,75.58,1734,
US EXAM ABDOM COMPLETE          ,76700,CPT,,47100201,CDM,402,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,294.51,,,294.51,Fee Schedule,,264.69,,,264.69,Fee Schedule,,882.42,,,882.42,Fee Schedule,,793.93,,,793.93,Fee Schedule,,749.69,,,749.69,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,353.23,,,353.23,Fee Schedule,,1322.89,,,1322.89,Other,186% Medicaid methodology,415.67,,,415.67,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,195.72,,,195.72,Fee Schedule,,415.67,,,415.67,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,368.14,,,368.14,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,394.35,,,394.35,Fee Schedule,,334.6,,,334.6,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,711.23,,,711.23,Other,New York Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1088.18,,,1088.18,Other,153% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,995.72,,,995.72,Other,140% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1849.2,,,1849.2,Other,260% Medicaid APG methodology,2304.38,,,2304.38,Other,324% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,889.04,,,889.04,Other,125% Medicaid APG methodology,127.14,2304.38,
ECHO EXAM OF ABDOMEN            ,76705,CPT,,47100219,CDM,402,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,223,,,223,Fee Schedule,,200.42,,,200.42,Fee Schedule,,717.21,,,717.21,Fee Schedule,,645.29,,,645.29,Fee Schedule,,609.33,,,609.33,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,267.46,,,267.46,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,314.74,,,314.74,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,148.2,,,148.2,Fee Schedule,,314.74,,,314.74,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,278.75,,,278.75,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,297,,,297,Fee Schedule,,252,,,252,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,127.14,1734,
US EXAM ABDO BACK WALL COMP     ,76770,CPT,,47100235,CDM,402,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,275.14,,,275.14,Fee Schedule,,247.28,,,247.28,Fee Schedule,,882.42,,,882.42,Fee Schedule,,793.93,,,793.93,Fee Schedule,,749.69,,,749.69,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,330,,,330,Fee Schedule,,1322.89,,,1322.89,Other,186% Medicaid methodology,388.33,,,388.33,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,182.85,,,182.85,Fee Schedule,,388.33,,,388.33,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,343.93,,,343.93,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,367.95,,,367.95,Fee Schedule,,312.2,,,312.2,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,711.23,,,711.23,Other,New York Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1088.18,,,1088.18,Other,153% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,995.72,,,995.72,Other,140% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1849.2,,,1849.2,Other,260% Medicaid APG methodology,2304.38,,,2304.38,Other,324% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,889.04,,,889.04,Other,125% Medicaid APG methodology,127.14,2304.38,
ECHO GUIDE FOR BIOPSY           ,76942,CPT,,47100284,CDM,402,RC,,,both,,,2971,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,106.27,,,106.27,Fee Schedule,,95.51,,,95.51,Fee Schedule,,1509.09,,,1509.09,Fee Schedule,,1357.76,,,1357.76,Fee Schedule,,1282.1,,,1282.1,Fee Schedule,,1485.5,50,,1485.5,percent of total billed charges,All Other,2079.7,70,,2079.7,percent of total billed charges,All Other,127.46,,,127.46,Fee Schedule,,464.97,,,464.97,Other,186% Medicaid methodology,149.99,,,149.99,Fee Schedule,,1842.02,,,1842.02,Fee Schedule,,70.62,,,70.62,Fee Schedule,,149.99,,,149.99,Fee Schedule,,1842.02,,,1842.02,Fee Schedule,,132.84,,,132.84,Fee Schedule,,2079.7,70,,2079.7,percent of total billed charges,All Other,135.3,,,135.3,Fee Schedule,,114.8,,,114.8,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,249.98,,,249.98,Other,New York Medicaid APG methodology,249.98,,,249.98,Other,100% Medicaid APG methodology,249.98,,,249.98,Other,100% Medicaid APG methodology,249.98,,,249.98,Other,100% Medicaid APG methodology,562.46,,,562.46,Other,225% Medicaid APG methodology,562.46,,,562.46,Other,225% Medicaid APG methodology,382.47,,,382.47,Other,153% Medicaid APG methodology,562.46,,,562.46,Other,225% Medicaid APG methodology,349.97,,,349.97,Other,140% Medicaid APG methodology,562.46,,,562.46,Other,225% Medicaid APG methodology,649.95,,,649.95,Other,260% Medicaid APG methodology,809.94,,,809.94,Other,324% Medicaid APG methodology,537.46,,,537.46,Other,215% Medicaid APG methodology,537.46,,,537.46,Other,215% Medicaid APG methodology,312.48,,,312.48,Other,125% Medicaid APG methodology,0.01,2079.7,
US EXAM PELVIC LIMITED          ,76857,CPT,,47100300,CDM,402,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,98.81,,,98.81,Fee Schedule,,88.81,,,88.81,Fee Schedule,,570.67,,,570.67,Fee Schedule,,513.44,,,513.44,Fee Schedule,,484.83,,,484.83,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,118.51,,,118.51,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,139.46,,,139.46,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,65.67,,,65.67,Fee Schedule,,139.46,,,139.46,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,123.52,,,123.52,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,120.45,,,120.45,Fee Schedule,,102.2,,,102.2,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,65.67,1734,
US EXAM PELVIC COMPLETE         ,76856,CPT,,47100318,CDM,402,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,273.91,,,273.91,Fee Schedule,,246.17,,,246.17,Fee Schedule,,835.68,,,835.68,Fee Schedule,,751.88,,,751.88,Fee Schedule,,709.98,,,709.98,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,328.52,,,328.52,Fee Schedule,,1322.89,,,1322.89,Other,186% Medicaid methodology,386.59,,,386.59,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,182.03,,,182.03,Fee Schedule,,386.59,,,386.59,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,342.39,,,342.39,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,364.65,,,364.65,Fee Schedule,,309.4,,,309.4,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,711.23,,,711.23,Other,New York Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1088.18,,,1088.18,Other,153% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,995.72,,,995.72,Other,140% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1849.2,,,1849.2,Other,260% Medicaid APG methodology,2304.38,,,2304.38,Other,324% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,889.04,,,889.04,Other,125% Medicaid APG methodology,127.14,2304.38,
US Intraluminal Transrectal,76872,CPT,TC,47100326,CDM,402,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,393.03,,,393.03,Fee Schedule,,353.98,,,353.98,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other Outpatient,940.05,45,,940.05,percent of total billed charges,All Other Outpatient,898.27,43,,898.27,percent of total billed charges,All Other Outpatient,1044.5,50,,1044.5,percent of total billed charges,All Other,1462.3,70,,1462.3,percent of total billed charges,All Other,477.43,,,477.43,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,561.83,,,561.83,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,264.54,,,264.54,Fee Schedule,,561.83,,,561.83,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,497.58,,,497.58,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,851.4,,,851.4,Fee Schedule,,722.4,,,722.4,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,127.14,1734,
ECHO EXAM OF HEAD               ,76506,CPT,,47100334,CDM,402,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,307.44,,,307.44,Fee Schedule,,276.3,,,276.3,Fee Schedule,,573.83,,,573.83,Fee Schedule,,516.28,,,516.28,Fee Schedule,,487.51,,,487.51,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,368.73,,,368.73,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,433.91,,,433.91,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,204.31,,,204.31,Fee Schedule,,433.91,,,433.91,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,384.3,,,384.3,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,422.4,,,422.4,Fee Schedule,,358.4,,,358.4,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,127.14,1734,
US EXAM OF HEAD AND NECK        ,76536,CPT,,47100342,CDM,402,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,313.63,,,313.63,Fee Schedule,,281.87,,,281.87,Fee Schedule,,835.68,,,835.68,Fee Schedule,,751.88,,,751.88,Fee Schedule,,709.98,,,709.98,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,376.16,,,376.16,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,442.66,,,442.66,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,208.43,,,208.43,Fee Schedule,,442.66,,,442.66,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,392.04,,,392.04,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,422.4,,,422.4,Fee Schedule,,358.4,,,358.4,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,127.14,1734,
ULTRASOUND BREAST COMPLETE RT   ,76641,CPT,RT       ,47100367,CDM,402,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,255.26,,,255.26,Fee Schedule,,229.42,,,229.42,Fee Schedule,,74.78,,,74.78,Fee Schedule,,74.78,,,74.78,Fee Schedule,,74.78,,,74.78,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,306.16,,,306.16,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,360.28,,,360.28,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,169.64,,,169.64,Fee Schedule,,360.28,,,360.28,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,319.08,,,319.08,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,341.55,,,341.55,Fee Schedule,,289.8,,,289.8,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,74.78,1734,
US EXAM SCROTUM                 ,76870,CPT,,47100375,CDM,402,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,262.72,,,262.72,Fee Schedule,,236.12,,,236.12,Fee Schedule,,848.17,,,848.17,Fee Schedule,,763.12,,,763.12,Fee Schedule,,720.59,,,720.59,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,315.1,,,315.1,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,370.8,,,370.8,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,174.59,,,174.59,Fee Schedule,,370.8,,,370.8,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,328.4,,,328.4,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,351.45,,,351.45,Fee Schedule,,298.2,,,298.2,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,127.14,1734,
OB US >= 14 WKS SNGL FETUS      ,76805,CPT,,47100383,CDM,402,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,333,,,333,Fee Schedule,,299.28,,,299.28,Fee Schedule,,882.42,,,882.42,Fee Schedule,,793.93,,,793.93,Fee Schedule,,749.69,,,749.69,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,399.39,,,399.39,Fee Schedule,,296.12,,,296.12,Other,186% Medicaid methodology,469.99,,,469.99,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,221.3,,,221.3,Fee Schedule,,469.99,,,469.99,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,416.25,,,416.25,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,437.25,,,437.25,Fee Schedule,,371,,,371,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,159.2,,,159.2,Other,New York Medicaid APG methodology,159.2,,,159.2,Other,100% Medicaid APG methodology,159.2,,,159.2,Other,100% Medicaid APG methodology,159.2,,,159.2,Other,100% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,243.58,,,243.58,Other,153% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,222.89,,,222.89,Other,140% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,413.93,,,413.93,Other,260% Medicaid APG methodology,515.82,,,515.82,Other,324% Medicaid APG methodology,342.29,,,342.29,Other,215% Medicaid APG methodology,342.29,,,342.29,Other,215% Medicaid APG methodology,199.01,,,199.01,Other,125% Medicaid APG methodology,127.14,1734,
TRANSVAGINAL US NON-OB          ,76830,CPT,,47100425,CDM,402,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,325.54,,,325.54,Fee Schedule,,292.58,,,292.58,Fee Schedule,,838.77,,,838.77,Fee Schedule,,754.66,,,754.66,Fee Schedule,,712.6,,,712.6,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,390.45,,,390.45,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,459.47,,,459.47,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,216.34,,,216.34,Fee Schedule,,459.47,,,459.47,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,406.93,,,406.93,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,433.95,,,433.95,Fee Schedule,,368.2,,,368.2,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,127.14,1734,
US EXAM INFANT HIPS DYNAMIC     ,76885,CPT,,47100508,CDM,402,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,330.5,,,330.5,Fee Schedule,,297.04,,,297.04,Fee Schedule,,573.83,,,573.83,Fee Schedule,,516.28,,,516.28,Fee Schedule,,487.51,,,487.51,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,396.4,,,396.4,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,466.47,,,466.47,Fee Schedule,,922.56,,,922.56,Fee Schedule,,219.64,,,219.64,Fee Schedule,,466.47,,,466.47,Fee Schedule,,922.56,,,922.56,Fee Schedule,,413.13,,,413.13,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,509.85,,,509.85,Fee Schedule,,432.6,,,432.6,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,105.08,1734,
US Guided Prostate Vol Study,76873,CPT,TC,47100524,CDM,402,RC,,,both,,,662,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,370.47,,,370.47,Fee Schedule,,333.66,,,333.66,Fee Schedule,,331,50,,331,percent of total billed charges,All Other Outpatient,297.9,45,,297.9,percent of total billed charges,All Other Outpatient,284.66,43,,284.66,percent of total billed charges,All Other Outpatient,331,50,,331,percent of total billed charges,All Other,463.4,70,,463.4,percent of total billed charges,All Other,450.02,,,450.02,Fee Schedule,,1322.89,,,1322.89,Other,186% Medicaid methodology,529.58,,,529.58,Fee Schedule,,410.44,,,410.44,Fee Schedule,,249.35,,,249.35,Fee Schedule,,529.58,,,529.58,Fee Schedule,,410.44,,,410.44,Fee Schedule,,469.02,,,469.02,Fee Schedule,,463.4,70,,463.4,percent of total billed charges,All Other,486.75,,,486.75,Fee Schedule,,413,,,413,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,711.23,,,711.23,Other,New York Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1088.18,,,1088.18,Other,153% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,995.72,,,995.72,Other,140% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1849.2,,,1849.2,Other,260% Medicaid APG methodology,2304.38,,,2304.38,Other,324% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,889.04,,,889.04,Other,125% Medicaid APG methodology,127.14,2304.38,
US Pre/Post Void Bladder,51798,CPT,TC,47100557,CDM,402,RC,,,both,,,1129,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,42.4,,,42.4,Fee Schedule,,38.19,,,38.19,Fee Schedule,,564.5,50,,564.5,percent of total billed charges,All Other Outpatient,508.05,45,,508.05,percent of total billed charges,All Other Outpatient,485.47,43,,485.47,percent of total billed charges,All Other Outpatient,564.5,50,,564.5,percent of total billed charges,All Other,790.3,70,,790.3,percent of total billed charges,All Other,51.51,,,51.51,Fee Schedule,,1051.03,,,1051.03,Other,186% Medicaid methodology,60.61,,,60.61,Fee Schedule,,699.98,,,699.98,Fee Schedule,,28.54,,,28.54,Fee Schedule,,60.61,,,60.61,Fee Schedule,,699.98,,,699.98,Fee Schedule,,53.68,,,53.68,Fee Schedule,,790.3,70,,790.3,percent of total billed charges,All Other,51.15,,,51.15,Fee Schedule,,43.4,,,43.4,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,565.07,,,565.07,Other,New York Medicaid APG methodology,565.07,,,565.07,Other,100% Medicaid APG methodology,565.07,,,565.07,Other,100% Medicaid APG methodology,565.07,,,565.07,Other,100% Medicaid APG methodology,1271.41,,,1271.41,Other,225% Medicaid APG methodology,1271.41,,,1271.41,Other,225% Medicaid APG methodology,864.56,,,864.56,Other,153% Medicaid APG methodology,1271.41,,,1271.41,Other,225% Medicaid APG methodology,791.1,,,791.1,Other,140% Medicaid APG methodology,1271.41,,,1271.41,Other,225% Medicaid APG methodology,1469.19,,,1469.19,Other,260% Medicaid APG methodology,1830.83,,,1830.83,Other,324% Medicaid APG methodology,1214.9,,,1214.9,Other,215% Medicaid APG methodology,1214.9,,,1214.9,Other,215% Medicaid APG methodology,706.34,,,706.34,Other,125% Medicaid APG methodology,28.54,1830.83,
US Pseudoaneurysm Compression,76936,CPT,TC,47100631,CDM,402,RC,,,both,,,1129,596.88,,,596.88,Other,150% of Medicare + 9.63% HCRA Surcharge,362.97,,,362.97,Other,Medicare OPPS methodology,621.29,,,621.29,Fee Schedule,,559.56,,,559.56,Fee Schedule,,564.5,50,,564.5,percent of total billed charges,All Other Outpatient,508.05,45,,508.05,percent of total billed charges,All Other Outpatient,485.47,43,,485.47,percent of total billed charges,All Other Outpatient,564.5,50,,564.5,percent of total billed charges,All Other,790.3,70,,790.3,percent of total billed charges,All Other,754.7,,,754.7,Fee Schedule,,751.06,,,751.06,Other,186% Medicaid methodology,888.12,,,888.12,Fee Schedule,,699.98,,,699.98,Fee Schedule,,418.17,,,418.17,Fee Schedule,,888.12,,,888.12,Fee Schedule,,699.98,,,699.98,Fee Schedule,,786.56,,,786.56,Fee Schedule,,790.3,70,,790.3,percent of total billed charges,All Other,834.9,,,834.9,Fee Schedule,,708.4,,,708.4,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,403.79,,,403.79,Other,New York Medicaid APG methodology,403.79,,,403.79,Other,100% Medicaid APG methodology,403.79,,,403.79,Other,100% Medicaid APG methodology,403.79,,,403.79,Other,100% Medicaid APG methodology,908.54,,,908.54,Other,225% Medicaid APG methodology,908.54,,,908.54,Other,225% Medicaid APG methodology,617.81,,,617.81,Other,153% Medicaid APG methodology,908.54,,,908.54,Other,225% Medicaid APG methodology,565.31,,,565.31,Other,140% Medicaid APG methodology,908.54,,,908.54,Other,225% Medicaid APG methodology,1049.87,,,1049.87,Other,260% Medicaid APG methodology,1308.29,,,1308.29,Other,324% Medicaid APG methodology,868.16,,,868.16,Other,215% Medicaid APG methodology,868.16,,,868.16,Other,215% Medicaid APG methodology,504.74,,,504.74,Other,125% Medicaid APG methodology,362.97,1734,
US GUIDE INTRAOP                ,76998,CPT,,47100649,CDM,402,RC,,,both,,,1977,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,988.5,50,,988.5,percent of total billed charges,All Other Outpatient,889.65,45,,889.65,percent of total billed charges,All Other Outpatient,70.21,,,70.21,Fee Schedule,,70.21,,,70.21,Fee Schedule,,70.21,,,70.21,Fee Schedule,,988.5,50,,988.5,percent of total billed charges,All Other,1383.9,70,,1383.9,percent of total billed charges,All Other,1344.36,68,,1344.36,percent of total billed charges,All Other Outpatient,464.97,,,464.97,Other,186% Medicaid methodology,1581.6,80,,1581.6,percent of total billed charges,All Other Outpatient,1640.91,83,,1640.91,percent of total billed charges,All Other Outpatient,1640.91,83,,1640.91,percent of total billed charges,All Other Outpatient,1581.6,80,,1581.6,percent of total billed charges,All Other Outpatient,1640.91,83,,1640.91,percent of total billed charges,All Other Outpatient,1779.3,90,,1779.3,percent of total billed charges,All Other,1383.9,70,,1383.9,percent of total billed charges,All Other,988.5,50,,988.5,percent of total billed charges,All Other,988.5,50,,988.5,percent of total billed charges,All Other,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,249.98,,,249.98,Other,New York Medicaid APG methodology,249.98,,,249.98,Other,100% Medicaid APG methodology,249.98,,,249.98,Other,100% Medicaid APG methodology,249.98,,,249.98,Other,100% Medicaid APG methodology,562.46,,,562.46,Other,225% Medicaid APG methodology,562.46,,,562.46,Other,225% Medicaid APG methodology,382.47,,,382.47,Other,153% Medicaid APG methodology,562.46,,,562.46,Other,225% Medicaid APG methodology,349.97,,,349.97,Other,140% Medicaid APG methodology,562.46,,,562.46,Other,225% Medicaid APG methodology,649.95,,,649.95,Other,260% Medicaid APG methodology,809.94,,,809.94,Other,324% Medicaid APG methodology,537.46,,,537.46,Other,215% Medicaid APG methodology,537.46,,,537.46,Other,215% Medicaid APG methodology,312.48,,,312.48,Other,125% Medicaid APG methodology,0.01,1779.3,
OB US < 14 WKS SINGLE FETUS     ,76801,CPT,,47100656,CDM,402,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,265.22,,,265.22,Fee Schedule,,238.36,,,238.36,Fee Schedule,,751.53,,,751.53,Fee Schedule,,676.17,,,676.17,Fee Schedule,,638.49,,,638.49,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,318.09,,,318.09,Fee Schedule,,296.12,,,296.12,Other,186% Medicaid methodology,374.33,,,374.33,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,176.25,,,176.25,Fee Schedule,,374.33,,,374.33,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,331.52,,,331.52,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,351.45,,,351.45,Fee Schedule,,298.2,,,298.2,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,159.2,,,159.2,Other,New York Medicaid APG methodology,159.2,,,159.2,Other,100% Medicaid APG methodology,159.2,,,159.2,Other,100% Medicaid APG methodology,159.2,,,159.2,Other,100% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,243.58,,,243.58,Other,153% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,222.89,,,222.89,Other,140% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,413.93,,,413.93,Other,260% Medicaid APG methodology,515.82,,,515.82,Other,324% Medicaid APG methodology,342.29,,,342.29,Other,215% Medicaid APG methodology,342.29,,,342.29,Other,215% Medicaid APG methodology,199.01,,,199.01,Other,125% Medicaid APG methodology,127.14,1734,
TRANSVAGINAL US OBSTETRIC       ,76817,CPT,,47100672,CDM,402,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,214.31,,,214.31,Fee Schedule,,192.61,,,192.61,Fee Schedule,,570.67,,,570.67,Fee Schedule,,513.44,,,513.44,Fee Schedule,,484.83,,,484.83,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,257.04,,,257.04,Fee Schedule,,296.12,,,296.12,Other,186% Medicaid methodology,302.48,,,302.48,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,142.42,,,142.42,Fee Schedule,,302.48,,,302.48,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,267.89,,,267.89,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,283.8,,,283.8,Fee Schedule,,240.8,,,240.8,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,159.2,,,159.2,Other,New York Medicaid APG methodology,159.2,,,159.2,Other,100% Medicaid APG methodology,159.2,,,159.2,Other,100% Medicaid APG methodology,159.2,,,159.2,Other,100% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,243.58,,,243.58,Other,153% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,222.89,,,222.89,Other,140% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,413.93,,,413.93,Other,260% Medicaid APG methodology,515.82,,,515.82,Other,324% Medicaid APG methodology,342.29,,,342.29,Other,215% Medicaid APG methodology,342.29,,,342.29,Other,215% Medicaid APG methodology,199.01,,,199.01,Other,125% Medicaid APG methodology,127.14,1734,
OB US < 14 WKS ADDL FETUS       ,76802,CPT,,47100797,CDM,402,RC,,,both,,,998,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,78.21,,,78.21,Fee Schedule,,70.29,,,70.29,Fee Schedule,,268.24,,,268.24,Fee Schedule,,241.35,,,241.35,Fee Schedule,,227.9,,,227.9,Fee Schedule,,499,50,,499,percent of total billed charges,All Other,698.6,70,,698.6,percent of total billed charges,All Other,93.8,,,93.8,Fee Schedule,,296.12,,,296.12,Other,186% Medicaid methodology,110.39,,,110.39,Fee Schedule,,618.76,,,618.76,Fee Schedule,,51.98,,,51.98,Fee Schedule,,110.39,,,110.39,Fee Schedule,,618.76,,,618.76,Fee Schedule,,97.76,,,97.76,Fee Schedule,,698.6,70,,698.6,percent of total billed charges,All Other,105.6,,,105.6,Fee Schedule,,89.6,,,89.6,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,159.2,,,159.2,Other,New York Medicaid APG methodology,159.2,,,159.2,Other,100% Medicaid APG methodology,159.2,,,159.2,Other,100% Medicaid APG methodology,159.2,,,159.2,Other,100% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,243.58,,,243.58,Other,153% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,222.89,,,222.89,Other,140% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,413.93,,,413.93,Other,260% Medicaid APG methodology,515.82,,,515.82,Other,324% Medicaid APG methodology,342.29,,,342.29,Other,215% Medicaid APG methodology,342.29,,,342.29,Other,215% Medicaid APG methodology,199.01,,,199.01,Other,125% Medicaid APG methodology,0.01,1734,
OB US LIMITED FETUS(S)          ,76815,CPT,,47100805,CDM,402,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,189.47,,,189.47,Fee Schedule,,170.29,,,170.29,Fee Schedule,,552,,,552,Fee Schedule,,496.64,,,496.64,Fee Schedule,,468.97,,,468.97,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,227.25,,,227.25,Fee Schedule,,296.12,,,296.12,Other,186% Medicaid methodology,267.42,,,267.42,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,125.92,,,125.92,Fee Schedule,,267.42,,,267.42,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,236.84,,,236.84,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,250.8,,,250.8,Fee Schedule,,212.8,,,212.8,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,159.2,,,159.2,Other,New York Medicaid APG methodology,159.2,,,159.2,Other,100% Medicaid APG methodology,159.2,,,159.2,Other,100% Medicaid APG methodology,159.2,,,159.2,Other,100% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,243.58,,,243.58,Other,153% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,222.89,,,222.89,Other,140% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,413.93,,,413.93,Other,260% Medicaid APG methodology,515.82,,,515.82,Other,324% Medicaid APG methodology,342.29,,,342.29,Other,215% Medicaid APG methodology,342.29,,,342.29,Other,215% Medicaid APG methodology,199.01,,,199.01,Other,125% Medicaid APG methodology,125.92,1734,
ECHO EXAM UTERUS                ,76831,CPT,,47100813,CDM,402,RC,,,both,,,2463,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,307.44,,,307.44,Fee Schedule,,276.3,,,276.3,Fee Schedule,,829.43,,,829.43,Fee Schedule,,746.26,,,746.26,Fee Schedule,,704.67,,,704.67,Fee Schedule,,1231.5,50,,1231.5,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,368.73,,,368.73,Fee Schedule,,1322.89,,,1322.89,Other,186% Medicaid methodology,433.91,,,433.91,Fee Schedule,,1527.06,,,1527.06,Fee Schedule,,204.31,,,204.31,Fee Schedule,,433.91,,,433.91,Fee Schedule,,1527.06,,,1527.06,Fee Schedule,,384.3,,,384.3,Fee Schedule,,1724.1,70,,1724.1,percent of total billed charges,All Other,409.2,,,409.2,Fee Schedule,,347.2,,,347.2,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,711.23,,,711.23,Other,New York Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1088.18,,,1088.18,Other,153% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,995.72,,,995.72,Other,140% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1849.2,,,1849.2,Other,260% Medicaid APG methodology,2304.38,,,2304.38,Other,324% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,889.04,,,889.04,Other,125% Medicaid APG methodology,204.31,2304.38,
US EXAM ABDO BACK WALL LIM      ,76775,CPT,,47101027,CDM,402,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,122.42,,,122.42,Fee Schedule,,110.02,,,110.02,Fee Schedule,,760.86,,,760.86,Fee Schedule,,684.57,,,684.57,Fee Schedule,,646.42,,,646.42,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,146.82,,,146.82,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,172.78,,,172.78,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,81.35,,,81.35,Fee Schedule,,172.78,,,172.78,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,153.02,,,153.02,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,150.15,,,150.15,Fee Schedule,,127.4,,,127.4,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,81.35,1734,
US COMPL JOINT R-T W/IMG        ,76881,CPT,RT       ,47101233,CDM,402,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,41.71,,,41.71,Fee Schedule,,37.49,,,37.49,Fee Schedule,,792.03,,,792.03,Fee Schedule,,712.6,,,712.6,Fee Schedule,,672.89,,,672.89,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,50.03,,,50.03,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,58.87,,,58.87,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,27.72,,,27.72,Fee Schedule,,58.87,,,58.87,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,52.14,,,52.14,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,140.25,,,140.25,Fee Schedule,,119,,,119,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,27.72,1734,
US LMTD JT/NONVASC XTR STRUX    ,76882,CPT,RT       ,47101241,CDM,402,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,116.22,,,116.22,Fee Schedule,,104.46,,,104.46,Fee Schedule,,93.7,,,93.7,Fee Schedule,,84.3,,,84.3,Fee Schedule,,79.61,,,79.61,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,139.4,,,139.4,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,164.04,,,164.04,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,77.24,,,77.24,Fee Schedule,,164.04,,,164.04,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,145.28,,,145.28,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,163.35,,,163.35,Fee Schedule,,138.6,,,138.6,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,77.24,1734,
US COMPL JOINT R-T W/IMG        ,76881,CPT,LT       ,47101258,CDM,402,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,41.71,,,41.71,Fee Schedule,,37.49,,,37.49,Fee Schedule,,792.03,,,792.03,Fee Schedule,,712.6,,,712.6,Fee Schedule,,672.89,,,672.89,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,50.03,,,50.03,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,58.87,,,58.87,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,27.72,,,27.72,Fee Schedule,,58.87,,,58.87,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,52.14,,,52.14,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,140.25,,,140.25,Fee Schedule,,119,,,119,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,27.72,1734,
US LMTD JT/NONVASC XTR STRUX    ,76882,CPT,LT       ,47101266,CDM,402,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,116.22,,,116.22,Fee Schedule,,104.46,,,104.46,Fee Schedule,,93.7,,,93.7,Fee Schedule,,84.3,,,84.3,Fee Schedule,,79.61,,,79.61,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,139.4,,,139.4,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,164.04,,,164.04,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,77.24,,,77.24,Fee Schedule,,164.04,,,164.04,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,145.28,,,145.28,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,163.35,,,163.35,Fee Schedule,,138.6,,,138.6,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,77.24,1734,
OB ULTRASOUND DETAILED SNGL     ,76811,CPT,,47101308,CDM,402,RC,,,both,,,4342,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,331.23,,,331.23,Fee Schedule,,297.69,,,297.69,Fee Schedule,,919.83,,,919.83,Fee Schedule,,827.59,,,827.59,Fee Schedule,,781.47,,,781.47,Fee Schedule,,2171,50,,2171,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,397.27,,,397.27,Fee Schedule,,296.12,,,296.12,Other,186% Medicaid methodology,467.5,,,467.5,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,220.12,,,220.12,Fee Schedule,,467.5,,,467.5,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,414.04,,,414.04,Fee Schedule,,3039.4,70,,3039.4,percent of total billed charges,All Other,412.5,,,412.5,Fee Schedule,,350,,,350,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,159.2,,,159.2,Other,New York Medicaid APG methodology,159.2,,,159.2,Other,100% Medicaid APG methodology,159.2,,,159.2,Other,100% Medicaid APG methodology,159.2,,,159.2,Other,100% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,243.58,,,243.58,Other,153% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,222.89,,,222.89,Other,140% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,413.93,,,413.93,Other,260% Medicaid APG methodology,515.82,,,515.82,Other,324% Medicaid APG methodology,342.29,,,342.29,Other,215% Medicaid APG methodology,342.29,,,342.29,Other,215% Medicaid APG methodology,199.01,,,199.01,Other,125% Medicaid APG methodology,159.2,3039.4,
US EXAM K TRANSPL W/DOPPLER     ,76776,CPT,,47101316,CDM,402,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,418.67,,,418.67,Fee Schedule,,376.27,,,376.27,Fee Schedule,,1050.79,,,1050.79,Fee Schedule,,945.42,,,945.42,Fee Schedule,,892.74,,,892.74,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,502.14,,,502.14,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,590.91,,,590.91,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,278.23,,,278.23,Fee Schedule,,590.91,,,590.91,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,523.34,,,523.34,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,564.3,,,564.3,Fee Schedule,,478.8,,,478.8,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,127.14,1734,
ULTRASOUND BREAST COMPLETE LT   ,76641,CPT,LT       ,47101357,CDM,402,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,255.26,,,255.26,Fee Schedule,,229.42,,,229.42,Fee Schedule,,74.78,,,74.78,Fee Schedule,,74.78,,,74.78,Fee Schedule,,74.78,,,74.78,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,306.16,,,306.16,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,360.28,,,360.28,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,169.64,,,169.64,Fee Schedule,,360.28,,,360.28,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,319.08,,,319.08,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,341.55,,,341.55,Fee Schedule,,289.8,,,289.8,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,74.78,1734,
ULTRASOUND BREAST LIMITED LT    ,76642,CPT,LT       ,47101365,CDM,402,RC,,,both,,,1488,172.8,,,172.8,Other,150% of Medicare + 9.63% HCRA Surcharge,105.08,,,105.08,Other,Medicare OPPS methodology,198.16,,,198.16,Fee Schedule,,178.1,,,178.1,Fee Schedule,,57.01,,,57.01,Fee Schedule,,57.01,,,57.01,Fee Schedule,,57.01,,,57.01,Fee Schedule,,744,50,,744,percent of total billed charges,All Other,237.22,,,237.22,Fee Schedule,,237.67,,,237.67,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,279.69,,,279.69,Fee Schedule,,922.56,,,922.56,Fee Schedule,,131.69,,,131.69,Fee Schedule,,279.69,,,279.69,Fee Schedule,,922.56,,,922.56,Fee Schedule,,247.7,,,247.7,Fee Schedule,,1041.6,70,,1041.6,percent of total billed charges,All Other,260.7,,,260.7,Fee Schedule,,221.2,,,221.2,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,57.01,1734,
ULTRASOUND BREAST COMPLETE BI   ,76641,CPT,TC50     ,47101506,CDM,402,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,255.26,,,255.26,Fee Schedule,,229.42,,,229.42,Fee Schedule,,74.78,,,74.78,Fee Schedule,,74.78,,,74.78,Fee Schedule,,74.78,,,74.78,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,306.16,,,306.16,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,360.28,,,360.28,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,169.64,,,169.64,Fee Schedule,,360.28,,,360.28,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,319.08,,,319.08,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,341.55,,,341.55,Fee Schedule,,289.8,,,289.8,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,74.78,1734,
US AAA Screening,76706,CPT,TC,47101555,CDM,402,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,298.62,,,298.62,Fee Schedule,,268.95,,,268.95,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other Outpatient,940.05,45,,940.05,percent of total billed charges,All Other Outpatient,898.27,43,,898.27,percent of total billed charges,All Other Outpatient,1044.5,50,,1044.5,percent of total billed charges,All Other,1462.3,70,,1462.3,percent of total billed charges,All Other,362.74,,,362.74,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,426.87,,,426.87,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,200.99,,,200.99,Fee Schedule,,426.87,,,426.87,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,378.05,,,378.05,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,400.95,,,400.95,Fee Schedule,,340.2,,,340.2,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,127.14,1734,
FETAL BIOPHYS PROFIL W/O NST    ,76819,CPT,,48300131,CDM,402,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,186.47,,,186.47,Fee Schedule,,167.59,,,167.59,Fee Schedule,,495.85,,,495.85,Fee Schedule,,446.13,,,446.13,Fee Schedule,,421.27,,,421.27,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,223.65,,,223.65,Fee Schedule,,296.12,,,296.12,Other,186% Medicaid methodology,263.18,,,263.18,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,123.92,,,123.92,Fee Schedule,,263.18,,,263.18,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,233.09,,,233.09,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,231,,,231,Fee Schedule,,196,,,196,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,159.2,,,159.2,Other,New York Medicaid APG methodology,159.2,,,159.2,Other,100% Medicaid APG methodology,159.2,,,159.2,Other,100% Medicaid APG methodology,159.2,,,159.2,Other,100% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,243.58,,,243.58,Other,153% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,222.89,,,222.89,Other,140% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,413.93,,,413.93,Other,260% Medicaid APG methodology,515.82,,,515.82,Other,324% Medicaid APG methodology,342.29,,,342.29,Other,215% Medicaid APG methodology,342.29,,,342.29,Other,215% Medicaid APG methodology,199.01,,,199.01,Other,125% Medicaid APG methodology,123.92,1734,
ECHO GUIDE FOR TRANSFUSION      ,76941,CPT,,48301220,CDM,402,RC,,,both,,,1340,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,670,50,,670,percent of total billed charges,All Other Outpatient,603,45,,603,percent of total billed charges,All Other Outpatient,56.36,,,56.36,Fee Schedule,,56.36,,,56.36,Fee Schedule,,56.36,,,56.36,Fee Schedule,,670,50,,670,percent of total billed charges,All Other,938,70,,938,percent of total billed charges,All Other,911.2,68,,911.2,percent of total billed charges,All Other Outpatient,464.97,,,464.97,Other,186% Medicaid methodology,1072,80,,1072,percent of total billed charges,All Other Outpatient,1112.2,83,,1112.2,percent of total billed charges,All Other Outpatient,1112.2,83,,1112.2,percent of total billed charges,All Other Outpatient,1072,80,,1072,percent of total billed charges,All Other Outpatient,1112.2,83,,1112.2,percent of total billed charges,All Other Outpatient,1206,90,,1206,percent of total billed charges,All Other,938,70,,938,percent of total billed charges,All Other,670,50,,670,percent of total billed charges,All Other,670,50,,670,percent of total billed charges,All Other,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,249.98,,,249.98,Other,New York Medicaid APG methodology,249.98,,,249.98,Other,100% Medicaid APG methodology,249.98,,,249.98,Other,100% Medicaid APG methodology,249.98,,,249.98,Other,100% Medicaid APG methodology,562.46,,,562.46,Other,225% Medicaid APG methodology,562.46,,,562.46,Other,225% Medicaid APG methodology,382.47,,,382.47,Other,153% Medicaid APG methodology,562.46,,,562.46,Other,225% Medicaid APG methodology,349.97,,,349.97,Other,140% Medicaid APG methodology,562.46,,,562.46,Other,225% Medicaid APG methodology,649.95,,,649.95,Other,260% Medicaid APG methodology,809.94,,,809.94,Other,324% Medicaid APG methodology,537.46,,,537.46,Other,215% Medicaid APG methodology,537.46,,,537.46,Other,215% Medicaid APG methodology,312.48,,,312.48,Other,125% Medicaid APG methodology,0.01,1734,
FETAL BIOPHYS PROF WO NST +FET  ,76819,CPT,59,48301295,CDM,402,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,186.47,,,186.47,Fee Schedule,,167.59,,,167.59,Fee Schedule,,495.85,,,495.85,Fee Schedule,,446.13,,,446.13,Fee Schedule,,421.27,,,421.27,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,223.65,,,223.65,Fee Schedule,,296.12,,,296.12,Other,186% Medicaid methodology,263.18,,,263.18,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,123.92,,,123.92,Fee Schedule,,263.18,,,263.18,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,233.09,,,233.09,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,231,,,231,Fee Schedule,,196,,,196,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,159.2,,,159.2,Other,New York Medicaid APG methodology,159.2,,,159.2,Other,100% Medicaid APG methodology,159.2,,,159.2,Other,100% Medicaid APG methodology,159.2,,,159.2,Other,100% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,243.58,,,243.58,Other,153% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,222.89,,,222.89,Other,140% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,413.93,,,413.93,Other,260% Medicaid APG methodology,515.82,,,515.82,Other,324% Medicaid APG methodology,342.29,,,342.29,Other,215% Medicaid APG methodology,342.29,,,342.29,Other,215% Medicaid APG methodology,199.01,,,199.01,Other,125% Medicaid APG methodology,123.92,1734,
OB US FOLLOW-UP PER FETUS       ,76816,CPT,,48301303,CDM,402,RC,,,both,,,2089,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,261.49,,,261.49,Fee Schedule,,235.01,,,235.01,Fee Schedule,,570.67,,,570.67,Fee Schedule,,513.44,,,513.44,Fee Schedule,,484.83,,,484.83,Fee Schedule,,1044.5,50,,1044.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,313.62,,,313.62,Fee Schedule,,296.12,,,296.12,Other,186% Medicaid methodology,369.07,,,369.07,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,173.78,,,173.78,Fee Schedule,,369.07,,,369.07,Fee Schedule,,1295.18,,,1295.18,Fee Schedule,,326.86,,,326.86,Fee Schedule,,1462.3,70,,1462.3,percent of total billed charges,All Other,343.2,,,343.2,Fee Schedule,,291.2,,,291.2,Fee Schedule,,1152,,,1152,Case Rate,Ultrasound Per Visit,1562,,,1562,Case Rate,Ultrasound Per Visit,1734,,,1734,Case Rate,Ultrasound Per Visit,1474,,,1474,Case Rate,Ultrasound Per Visit,159.2,,,159.2,Other,New York Medicaid APG methodology,159.2,,,159.2,Other,100% Medicaid APG methodology,159.2,,,159.2,Other,100% Medicaid APG methodology,159.2,,,159.2,Other,100% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,243.58,,,243.58,Other,153% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,222.89,,,222.89,Other,140% Medicaid APG methodology,358.21,,,358.21,Other,225% Medicaid APG methodology,413.93,,,413.93,Other,260% Medicaid APG methodology,515.82,,,515.82,Other,324% Medicaid APG methodology,342.29,,,342.29,Other,215% Medicaid APG methodology,342.29,,,342.29,Other,215% Medicaid APG methodology,199.01,,,199.01,Other,125% Medicaid APG methodology,127.14,1734,
SCR MAMMO BI INCL CAD           ,77067,CPT,,45004819,CDM,403,RC,,,both,,,771,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,344.66,,,344.66,Fee Schedule,,309.76,,,309.76,Fee Schedule,,76.73,,,76.73,Fee Schedule,,76.73,,,76.73,Fee Schedule,,76.73,,,76.73,Fee Schedule,,385.5,50,,385.5,percent of total billed charges,All Other,299.59,,,299.59,Fee Schedule,,413.38,,,413.38,Fee Schedule,,286.25,,,286.25,Other,186% Medicaid methodology,486.45,,,486.45,Fee Schedule,,478.02,,,478.02,Fee Schedule,,229.05,,,229.05,Fee Schedule,,486.45,,,486.45,Fee Schedule,,478.02,,,478.02,Fee Schedule,,430.83,,,430.83,Fee Schedule,,539.7,70,,539.7,percent of total billed charges,All Other,455.4,,,455.4,Fee Schedule,,386.4,,,386.4,Fee Schedule,,659,,,659,Case Rate,Mammography Per Visit,649,,,649,Case Rate,Mammography Per Visit,722,,,722,Case Rate,Mammography Per Visit,614,,,614,Case Rate,Mammography Per Visit,153.9,,,153.9,Other,New York Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,235.47,,,235.47,Other,153% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,215.46,,,215.46,Other,140% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,400.14,,,400.14,Other,260% Medicaid APG methodology,498.64,,,498.64,Other,324% Medicaid APG methodology,330.89,,,330.89,Other,215% Medicaid APG methodology,330.89,,,330.89,Other,215% Medicaid APG methodology,192.38,,,192.38,Other,125% Medicaid APG methodology,0.01,722,
BREAST TOMOSYNTHESIS BI         ,77063,CPT,,45005493,CDM,403,RC,,,both,,,151,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,89.4,,,89.4,Fee Schedule,,80.34,,,80.34,Fee Schedule,,24.15,,,24.15,Fee Schedule,,24.15,,,24.15,Fee Schedule,,24.15,,,24.15,Fee Schedule,,75.5,50,,75.5,percent of total billed charges,All Other,79.07,,,79.07,Fee Schedule,,107.22,,,107.22,Fee Schedule,,286.25,,,286.25,Other,186% Medicaid methodology,126.17,,,126.17,Fee Schedule,,93.62,,,93.62,Fee Schedule,,59.41,,,59.41,Fee Schedule,,126.17,,,126.17,Fee Schedule,,93.62,,,93.62,Fee Schedule,,111.75,,,111.75,Fee Schedule,,105.7,70,,105.7,percent of total billed charges,All Other,115.5,,,115.5,Fee Schedule,,98,,,98,Fee Schedule,,659,,,659,Case Rate,Mammography Per Visit,649,,,649,Case Rate,Mammography Per Visit,722,,,722,Case Rate,Mammography Per Visit,614,,,614,Case Rate,Mammography Per Visit,153.9,,,153.9,Other,New York Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,235.47,,,235.47,Other,153% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,215.46,,,215.46,Other,140% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,400.14,,,400.14,Other,260% Medicaid APG methodology,498.64,,,498.64,Other,324% Medicaid APG methodology,330.89,,,330.89,Other,215% Medicaid APG methodology,330.89,,,330.89,Other,215% Medicaid APG methodology,192.38,,,192.38,Other,125% Medicaid APG methodology,0.01,722,
BREAST TOMOSYNTHESIS SCREEN RT  ,77063,CPT,RT52     ,45006723,CDM,403,RC,,,both,,,151,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,89.4,,,89.4,Fee Schedule,,80.34,,,80.34,Fee Schedule,,24.15,,,24.15,Fee Schedule,,24.15,,,24.15,Fee Schedule,,24.15,,,24.15,Fee Schedule,,75.5,50,,75.5,percent of total billed charges,All Other,79.07,,,79.07,Fee Schedule,,107.22,,,107.22,Fee Schedule,,286.25,,,286.25,Other,186% Medicaid methodology,126.17,,,126.17,Fee Schedule,,93.62,,,93.62,Fee Schedule,,59.41,,,59.41,Fee Schedule,,126.17,,,126.17,Fee Schedule,,93.62,,,93.62,Fee Schedule,,111.75,,,111.75,Fee Schedule,,105.7,70,,105.7,percent of total billed charges,All Other,115.5,,,115.5,Fee Schedule,,98,,,98,Fee Schedule,,659,,,659,Case Rate,Mammography Per Visit,649,,,649,Case Rate,Mammography Per Visit,722,,,722,Case Rate,Mammography Per Visit,614,,,614,Case Rate,Mammography Per Visit,153.9,,,153.9,Other,New York Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,235.47,,,235.47,Other,153% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,215.46,,,215.46,Other,140% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,400.14,,,400.14,Other,260% Medicaid APG methodology,498.64,,,498.64,Other,324% Medicaid APG methodology,330.89,,,330.89,Other,215% Medicaid APG methodology,330.89,,,330.89,Other,215% Medicaid APG methodology,192.38,,,192.38,Other,125% Medicaid APG methodology,0.01,722,
BREAST TOMOSYNTHESIS SCREEN LT  ,77063,CPT,LT52     ,45006764,CDM,403,RC,,,both,,,151,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,89.4,,,89.4,Fee Schedule,,80.34,,,80.34,Fee Schedule,,24.15,,,24.15,Fee Schedule,,24.15,,,24.15,Fee Schedule,,24.15,,,24.15,Fee Schedule,,75.5,50,,75.5,percent of total billed charges,All Other,79.07,,,79.07,Fee Schedule,,107.22,,,107.22,Fee Schedule,,286.25,,,286.25,Other,186% Medicaid methodology,126.17,,,126.17,Fee Schedule,,93.62,,,93.62,Fee Schedule,,59.41,,,59.41,Fee Schedule,,126.17,,,126.17,Fee Schedule,,93.62,,,93.62,Fee Schedule,,111.75,,,111.75,Fee Schedule,,105.7,70,,105.7,percent of total billed charges,All Other,115.5,,,115.5,Fee Schedule,,98,,,98,Fee Schedule,,659,,,659,Case Rate,Mammography Per Visit,649,,,649,Case Rate,Mammography Per Visit,722,,,722,Case Rate,Mammography Per Visit,614,,,614,Case Rate,Mammography Per Visit,153.9,,,153.9,Other,New York Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,153.9,,,153.9,Other,100% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,235.47,,,235.47,Other,153% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,215.46,,,215.46,Other,140% Medicaid APG methodology,346.28,,,346.28,Other,225% Medicaid APG methodology,400.14,,,400.14,Other,260% Medicaid APG methodology,498.64,,,498.64,Other,324% Medicaid APG methodology,330.89,,,330.89,Other,215% Medicaid APG methodology,330.89,,,330.89,Other,215% Medicaid APG methodology,192.38,,,192.38,Other,125% Medicaid APG methodology,0.01,722,
PET IMAGE W/CT SKULL-THIGH PI   ,78815,CPT,,47300041,CDM,404,RC,,,both,,,8831,2975.04,,,2975.04,Other,150% of Medicare + 9.63% HCRA Surcharge,1809.14,,,1809.14,Other,Medicare OPPS methodology,4415.5,50,,4415.5,percent of total billed charges,All Other Outpatient,3973.95,45,,3973.95,percent of total billed charges,All Other Outpatient,9562.11,,,9562.11,Fee Schedule,,8603.23,,,8603.23,Fee Schedule,,8123.8,,,8123.8,Fee Schedule,,4415.5,50,,4415.5,percent of total billed charges,All Other,4340.86,,,4340.86,Fee Schedule,,6005.08,68,,6005.08,percent of total billed charges,All Other Outpatient,3087.39,,,3087.39,Other,186% Medicaid methodology,7064.8,80,,7064.8,percent of total billed charges,All Other Outpatient,7329.73,83,,7329.73,percent of total billed charges,All Other Outpatient,7329.73,83,,7329.73,percent of total billed charges,All Other Outpatient,7064.8,80,,7064.8,percent of total billed charges,All Other Outpatient,7329.73,83,,7329.73,percent of total billed charges,All Other Outpatient,7947.9,90,,7947.9,percent of total billed charges,All Other,6181.7,70,,6181.7,percent of total billed charges,All Other,4415.5,50,,4415.5,percent of total billed charges,All Other,4415.5,50,,4415.5,percent of total billed charges,All Other,3296,,,3296,Case Rate,PET Scan Per Visit,2965,,,2965,Case Rate,PET Scan Per Visit,3293,,,3293,Case Rate,PET Scan Per Visit,2799,,,2799,Case Rate,PET Scan Per Visit,1659.89,,,1659.89,Other,New York Medicaid APG methodology,1659.89,,,1659.89,Other,100% Medicaid APG methodology,1659.89,,,1659.89,Other,100% Medicaid APG methodology,1659.89,,,1659.89,Other,100% Medicaid APG methodology,3734.75,,,3734.75,Other,225% Medicaid APG methodology,3734.75,,,3734.75,Other,225% Medicaid APG methodology,2539.63,,,2539.63,Other,153% Medicaid APG methodology,3734.75,,,3734.75,Other,225% Medicaid APG methodology,2323.84,,,2323.84,Other,140% Medicaid APG methodology,3734.75,,,3734.75,Other,225% Medicaid APG methodology,4315.71,,,4315.71,Other,260% Medicaid APG methodology,5378.04,,,5378.04,Other,324% Medicaid APG methodology,3568.76,,,3568.76,Other,215% Medicaid APG methodology,3568.76,,,3568.76,Other,215% Medicaid APG methodology,2074.86,,,2074.86,Other,125% Medicaid APG methodology,1659.89,9562.11,
PET IMAGE W/CT FULL BODY PI     ,78816,CPT,,47300058,CDM,404,RC,,,both,,,8831,2975.04,,,2975.04,Other,150% of Medicare + 9.63% HCRA Surcharge,1809.14,,,1809.14,Other,Medicare OPPS methodology,4415.5,50,,4415.5,percent of total billed charges,All Other Outpatient,3973.95,45,,3973.95,percent of total billed charges,All Other Outpatient,9562.11,,,9562.11,Fee Schedule,,8603.23,,,8603.23,Fee Schedule,,8123.8,,,8123.8,Fee Schedule,,4415.5,50,,4415.5,percent of total billed charges,All Other,4340.86,,,4340.86,Fee Schedule,,6005.08,68,,6005.08,percent of total billed charges,All Other Outpatient,3087.39,,,3087.39,Other,186% Medicaid methodology,7064.8,80,,7064.8,percent of total billed charges,All Other Outpatient,7329.73,83,,7329.73,percent of total billed charges,All Other Outpatient,7329.73,83,,7329.73,percent of total billed charges,All Other Outpatient,7064.8,80,,7064.8,percent of total billed charges,All Other Outpatient,7329.73,83,,7329.73,percent of total billed charges,All Other Outpatient,7947.9,90,,7947.9,percent of total billed charges,All Other,6181.7,70,,6181.7,percent of total billed charges,All Other,4415.5,50,,4415.5,percent of total billed charges,All Other,4415.5,50,,4415.5,percent of total billed charges,All Other,3296,,,3296,Case Rate,PET Scan Per Visit,2965,,,2965,Case Rate,PET Scan Per Visit,3293,,,3293,Case Rate,PET Scan Per Visit,2799,,,2799,Case Rate,PET Scan Per Visit,1659.89,,,1659.89,Other,New York Medicaid APG methodology,1659.89,,,1659.89,Other,100% Medicaid APG methodology,1659.89,,,1659.89,Other,100% Medicaid APG methodology,1659.89,,,1659.89,Other,100% Medicaid APG methodology,3734.75,,,3734.75,Other,225% Medicaid APG methodology,3734.75,,,3734.75,Other,225% Medicaid APG methodology,2539.63,,,2539.63,Other,153% Medicaid APG methodology,3734.75,,,3734.75,Other,225% Medicaid APG methodology,2323.84,,,2323.84,Other,140% Medicaid APG methodology,3734.75,,,3734.75,Other,225% Medicaid APG methodology,4315.71,,,4315.71,Other,260% Medicaid APG methodology,5378.04,,,5378.04,Other,324% Medicaid APG methodology,3568.76,,,3568.76,Other,215% Medicaid APG methodology,3568.76,,,3568.76,Other,215% Medicaid APG methodology,2074.86,,,2074.86,Other,125% Medicaid APG methodology,1659.89,9562.11,
PET IMAGE W/CT SKULL-THIGH PS   ,78815,CPT,,47300132,CDM,404,RC,,,both,,,8831,2975.04,,,2975.04,Other,150% of Medicare + 9.63% HCRA Surcharge,1809.14,,,1809.14,Other,Medicare OPPS methodology,4415.5,50,,4415.5,percent of total billed charges,All Other Outpatient,3973.95,45,,3973.95,percent of total billed charges,All Other Outpatient,9562.11,,,9562.11,Fee Schedule,,8603.23,,,8603.23,Fee Schedule,,8123.8,,,8123.8,Fee Schedule,,4415.5,50,,4415.5,percent of total billed charges,All Other,4340.86,,,4340.86,Fee Schedule,,6005.08,68,,6005.08,percent of total billed charges,All Other Outpatient,3087.39,,,3087.39,Other,186% Medicaid methodology,7064.8,80,,7064.8,percent of total billed charges,All Other Outpatient,7329.73,83,,7329.73,percent of total billed charges,All Other Outpatient,7329.73,83,,7329.73,percent of total billed charges,All Other Outpatient,7064.8,80,,7064.8,percent of total billed charges,All Other Outpatient,7329.73,83,,7329.73,percent of total billed charges,All Other Outpatient,7947.9,90,,7947.9,percent of total billed charges,All Other,6181.7,70,,6181.7,percent of total billed charges,All Other,4415.5,50,,4415.5,percent of total billed charges,All Other,4415.5,50,,4415.5,percent of total billed charges,All Other,3296,,,3296,Case Rate,PET Scan Per Visit,2965,,,2965,Case Rate,PET Scan Per Visit,3293,,,3293,Case Rate,PET Scan Per Visit,2799,,,2799,Case Rate,PET Scan Per Visit,1659.89,,,1659.89,Other,New York Medicaid APG methodology,1659.89,,,1659.89,Other,100% Medicaid APG methodology,1659.89,,,1659.89,Other,100% Medicaid APG methodology,1659.89,,,1659.89,Other,100% Medicaid APG methodology,3734.75,,,3734.75,Other,225% Medicaid APG methodology,3734.75,,,3734.75,Other,225% Medicaid APG methodology,2539.63,,,2539.63,Other,153% Medicaid APG methodology,3734.75,,,3734.75,Other,225% Medicaid APG methodology,2323.84,,,2323.84,Other,140% Medicaid APG methodology,3734.75,,,3734.75,Other,225% Medicaid APG methodology,4315.71,,,4315.71,Other,260% Medicaid APG methodology,5378.04,,,5378.04,Other,324% Medicaid APG methodology,3568.76,,,3568.76,Other,215% Medicaid APG methodology,3568.76,,,3568.76,Other,215% Medicaid APG methodology,2074.86,,,2074.86,Other,125% Medicaid APG methodology,1659.89,9562.11,
PET IMAGE W/CT FULL BODY PS     ,78816,CPT,,47300140,CDM,404,RC,,,both,,,8831,2975.04,,,2975.04,Other,150% of Medicare + 9.63% HCRA Surcharge,1809.14,,,1809.14,Other,Medicare OPPS methodology,4415.5,50,,4415.5,percent of total billed charges,All Other Outpatient,3973.95,45,,3973.95,percent of total billed charges,All Other Outpatient,9562.11,,,9562.11,Fee Schedule,,8603.23,,,8603.23,Fee Schedule,,8123.8,,,8123.8,Fee Schedule,,4415.5,50,,4415.5,percent of total billed charges,All Other,4340.86,,,4340.86,Fee Schedule,,6005.08,68,,6005.08,percent of total billed charges,All Other Outpatient,3087.39,,,3087.39,Other,186% Medicaid methodology,7064.8,80,,7064.8,percent of total billed charges,All Other Outpatient,7329.73,83,,7329.73,percent of total billed charges,All Other Outpatient,7329.73,83,,7329.73,percent of total billed charges,All Other Outpatient,7064.8,80,,7064.8,percent of total billed charges,All Other Outpatient,7329.73,83,,7329.73,percent of total billed charges,All Other Outpatient,7947.9,90,,7947.9,percent of total billed charges,All Other,6181.7,70,,6181.7,percent of total billed charges,All Other,4415.5,50,,4415.5,percent of total billed charges,All Other,4415.5,50,,4415.5,percent of total billed charges,All Other,3296,,,3296,Case Rate,PET Scan Per Visit,2965,,,2965,Case Rate,PET Scan Per Visit,3293,,,3293,Case Rate,PET Scan Per Visit,2799,,,2799,Case Rate,PET Scan Per Visit,1659.89,,,1659.89,Other,New York Medicaid APG methodology,1659.89,,,1659.89,Other,100% Medicaid APG methodology,1659.89,,,1659.89,Other,100% Medicaid APG methodology,1659.89,,,1659.89,Other,100% Medicaid APG methodology,3734.75,,,3734.75,Other,225% Medicaid APG methodology,3734.75,,,3734.75,Other,225% Medicaid APG methodology,2539.63,,,2539.63,Other,153% Medicaid APG methodology,3734.75,,,3734.75,Other,225% Medicaid APG methodology,2323.84,,,2323.84,Other,140% Medicaid APG methodology,3734.75,,,3734.75,Other,225% Medicaid APG methodology,4315.71,,,4315.71,Other,260% Medicaid APG methodology,5378.04,,,5378.04,Other,324% Medicaid APG methodology,3568.76,,,3568.76,Other,215% Medicaid APG methodology,3568.76,,,3568.76,Other,215% Medicaid APG methodology,2074.86,,,2074.86,Other,125% Medicaid APG methodology,1659.89,9562.11,
WITHDRAWAL OF ARTERIAL BLOOD    ,36600,CPT,,46500013,CDM,410,RC,,,both,,,418,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,209,50,,209,percent of total billed charges,All Other Outpatient,188.1,45,,188.1,percent of total billed charges,All Other Outpatient,209,50,,209,percent of total billed charges,All Other Outpatient,188.1,45,,188.1,percent of total billed charges,All Other Outpatient,179.74,43,,179.74,percent of total billed charges,All Other Outpatient,209,50,,209,percent of total billed charges,All Other,292.6,70,,292.6,percent of total billed charges,All Other,61.93,,,61.93,Fee Schedule,,104.72,,,104.72,Other,186% Medicaid methodology,72.88,,,72.88,Fee Schedule,,259.16,,,259.16,Fee Schedule,,34.31,,,34.31,Fee Schedule,,72.88,,,72.88,Fee Schedule,,259.16,,,259.16,Fee Schedule,,376.2,90,,376.2,percent of total billed charges,All Other,292.6,70,,292.6,percent of total billed charges,All Other,75.9,,,75.9,Fee Schedule,,64.4,,,64.4,Fee Schedule,,248,,,248,Case Rate,Respiratory Per Visit,223,,,223,Case Rate,Respiratory Per Visit,247,,,247,Case Rate,Respiratory Per Visit,210,,,210,Case Rate,Respiratory Per Visit,56.3,,,56.3,Other,New York Medicaid APG methodology,56.3,,,56.3,Other,100% Medicaid APG methodology,56.3,,,56.3,Other,100% Medicaid APG methodology,56.3,,,56.3,Other,100% Medicaid APG methodology,126.68,,,126.68,Other,225% Medicaid APG methodology,126.68,,,126.68,Other,225% Medicaid APG methodology,86.14,,,86.14,Other,153% Medicaid APG methodology,126.68,,,126.68,Other,225% Medicaid APG methodology,78.82,,,78.82,Other,140% Medicaid APG methodology,126.68,,,126.68,Other,225% Medicaid APG methodology,146.38,,,146.38,Other,260% Medicaid APG methodology,182.41,,,182.41,Other,324% Medicaid APG methodology,121.05,,,121.05,Other,215% Medicaid APG methodology,121.05,,,121.05,Other,215% Medicaid APG methodology,70.38,,,70.38,Other,125% Medicaid APG methodology,34.31,376.2,
EVALUATE PT USE OF INHALER      ,94664,CPT,,46500310,CDM,410,RC,,,both,,,690,405.6,,,405.6,Other,150% of Medicare + 9.63% HCRA Surcharge,246.65,,,246.65,Other,Medicare OPPS methodology,345,50,,345,percent of total billed charges,All Other Outpatient,310.5,45,,310.5,percent of total billed charges,All Other Outpatient,146.69,,,146.69,Fee Schedule,,131.98,,,131.98,Fee Schedule,,124.62,,,124.62,Fee Schedule,,345,50,,345,percent of total billed charges,All Other,483,70,,483,percent of total billed charges,All Other,82.17,,,82.17,Fee Schedule,,188.85,,,188.85,Other,186% Medicaid methodology,96.69,,,96.69,Fee Schedule,,427.8,,,427.8,Fee Schedule,,45.53,,,45.53,Fee Schedule,,96.69,,,96.69,Fee Schedule,,427.8,,,427.8,Fee Schedule,,621,90,,621,percent of total billed charges,All Other,483,70,,483,percent of total billed charges,All Other,82.5,,,82.5,Fee Schedule,,70,,,70,Fee Schedule,,248,,,248,Case Rate,Respiratory Per Visit,223,,,223,Case Rate,Respiratory Per Visit,247,,,247,Case Rate,Respiratory Per Visit,210,,,210,Case Rate,Respiratory Per Visit,101.53,,,101.53,Other,New York Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,155.34,,,155.34,Other,153% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,142.14,,,142.14,Other,140% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,263.98,,,263.98,Other,260% Medicaid APG methodology,328.96,,,328.96,Other,324% Medicaid APG methodology,218.29,,,218.29,Other,215% Medicaid APG methodology,218.29,,,218.29,Other,215% Medicaid APG methodology,126.92,,,126.92,Other,125% Medicaid APG methodology,45.53,621,
INSERT EMERGENCY AIRWAY         ,31500,CPT,,46600003,CDM,410,RC,,,both,,,2283,464.5,,,464.5,Other,150% of Medicare + 9.63% HCRA Surcharge,282.46,,,282.46,Other,Medicare OPPS methodology,1141.5,50,,1141.5,percent of total billed charges,All Other Outpatient,1027.35,45,,1027.35,percent of total billed charges,All Other Outpatient,1141.5,50,,1141.5,percent of total billed charges,All Other Outpatient,1027.35,45,,1027.35,percent of total billed charges,All Other Outpatient,981.69,43,,981.69,percent of total billed charges,All Other Outpatient,1141.5,50,,1141.5,percent of total billed charges,All Other,1598.1,70,,1598.1,percent of total billed charges,All Other,608.67,,,608.67,Fee Schedule,,1189.48,,,1189.48,Other,186% Medicaid methodology,716.28,,,716.28,Fee Schedule,,1415.46,,,1415.46,Fee Schedule,,337.26,,,337.26,Fee Schedule,,716.28,,,716.28,Fee Schedule,,1415.46,,,1415.46,Fee Schedule,,2054.7,90,,2054.7,percent of total billed charges,All Other,1598.1,70,,1598.1,percent of total billed charges,All Other,684.75,,,684.75,Fee Schedule,,581,,,581,Fee Schedule,,248,,,248,Case Rate,Respiratory Per Visit,223,,,223,Case Rate,Respiratory Per Visit,247,,,247,Case Rate,Respiratory Per Visit,210,,,210,Case Rate,Respiratory Per Visit,639.51,,,639.51,Other,New York Medicaid APG methodology,639.51,,,639.51,Other,100% Medicaid APG methodology,639.51,,,639.51,Other,100% Medicaid APG methodology,639.51,,,639.51,Other,100% Medicaid APG methodology,1438.89,,,1438.89,Other,225% Medicaid APG methodology,1438.89,,,1438.89,Other,225% Medicaid APG methodology,978.45,,,978.45,Other,153% Medicaid APG methodology,1438.89,,,1438.89,Other,225% Medicaid APG methodology,895.31,,,895.31,Other,140% Medicaid APG methodology,1438.89,,,1438.89,Other,225% Medicaid APG methodology,1662.72,,,1662.72,Other,260% Medicaid APG methodology,2072,,,2072,Other,324% Medicaid APG methodology,1374.94,,,1374.94,Other,215% Medicaid APG methodology,1374.94,,,1374.94,Other,215% Medicaid APG methodology,799.38,,,799.38,Other,125% Medicaid APG methodology,210,2072,
VENT MGMT INPAT INIT DAY        ,94002,CPT,,46600110,CDM,410,RC,,,both,,,2009,1191.69,,,1191.69,Other,150% of Medicare + 9.63% HCRA Surcharge,724.68,,,724.68,Other,Medicare OPPS methodology,1004.5,50,,1004.5,percent of total billed charges,All Other Outpatient,904.05,45,,904.05,percent of total billed charges,All Other Outpatient,1004.5,50,,1004.5,percent of total billed charges,All Other Outpatient,904.05,45,,904.05,percent of total billed charges,All Other Outpatient,863.87,43,,863.87,percent of total billed charges,All Other Outpatient,1004.5,50,,1004.5,percent of total billed charges,All Other,1406.3,70,,1406.3,percent of total billed charges,All Other,382.87,,,382.87,Fee Schedule,,417.67,,,417.67,Other,186% Medicaid methodology,450.55,,,450.55,Fee Schedule,,1245.58,,,1245.58,Fee Schedule,,212.14,,,212.14,Fee Schedule,,450.55,,,450.55,Fee Schedule,,1245.58,,,1245.58,Fee Schedule,,1808.1,90,,1808.1,percent of total billed charges,All Other,1406.3,70,,1406.3,percent of total billed charges,All Other,445.5,,,445.5,Fee Schedule,,378,,,378,Fee Schedule,,248,,,248,Case Rate,Respiratory Per Visit,223,,,223,Case Rate,Respiratory Per Visit,247,,,247,Case Rate,Respiratory Per Visit,210,,,210,Case Rate,Respiratory Per Visit,224.55,,,224.55,Other,New York Medicaid APG methodology,224.55,,,224.55,Other,100% Medicaid APG methodology,224.55,,,224.55,Other,100% Medicaid APG methodology,224.55,,,224.55,Other,100% Medicaid APG methodology,505.25,,,505.25,Other,225% Medicaid APG methodology,505.25,,,505.25,Other,225% Medicaid APG methodology,343.57,,,343.57,Other,153% Medicaid APG methodology,505.25,,,505.25,Other,225% Medicaid APG methodology,314.38,,,314.38,Other,140% Medicaid APG methodology,505.25,,,505.25,Other,225% Medicaid APG methodology,583.84,,,583.84,Other,260% Medicaid APG methodology,727.56,,,727.56,Other,324% Medicaid APG methodology,482.79,,,482.79,Other,215% Medicaid APG methodology,482.79,,,482.79,Other,215% Medicaid APG methodology,280.69,,,280.69,Other,125% Medicaid APG methodology,210,1808.1,
VENT MGMT INPAT SUBQ DAY        ,94003,CPT,,46600128,CDM,410,RC,,,both,,,2004,1191.69,,,1191.69,Other,150% of Medicare + 9.63% HCRA Surcharge,724.68,,,724.68,Other,Medicare OPPS methodology,1002,50,,1002,percent of total billed charges,All Other Outpatient,901.8,45,,901.8,percent of total billed charges,All Other Outpatient,1002,50,,1002,percent of total billed charges,All Other Outpatient,901.8,45,,901.8,percent of total billed charges,All Other Outpatient,861.72,43,,861.72,percent of total billed charges,All Other Outpatient,1002,50,,1002,percent of total billed charges,All Other,1402.8,70,,1402.8,percent of total billed charges,All Other,269.7,,,269.7,Fee Schedule,,417.67,,,417.67,Other,186% Medicaid methodology,317.37,,,317.37,Fee Schedule,,1242.48,,,1242.48,Fee Schedule,,149.44,,,149.44,Fee Schedule,,317.37,,,317.37,Fee Schedule,,1242.48,,,1242.48,Fee Schedule,,1803.6,90,,1803.6,percent of total billed charges,All Other,1402.8,70,,1402.8,percent of total billed charges,All Other,313.5,,,313.5,Fee Schedule,,266,,,266,Fee Schedule,,248,,,248,Case Rate,Respiratory Per Visit,223,,,223,Case Rate,Respiratory Per Visit,247,,,247,Case Rate,Respiratory Per Visit,210,,,210,Case Rate,Respiratory Per Visit,224.55,,,224.55,Other,New York Medicaid APG methodology,224.55,,,224.55,Other,100% Medicaid APG methodology,224.55,,,224.55,Other,100% Medicaid APG methodology,224.55,,,224.55,Other,100% Medicaid APG methodology,505.25,,,505.25,Other,225% Medicaid APG methodology,505.25,,,505.25,Other,225% Medicaid APG methodology,343.57,,,343.57,Other,153% Medicaid APG methodology,505.25,,,505.25,Other,225% Medicaid APG methodology,314.38,,,314.38,Other,140% Medicaid APG methodology,505.25,,,505.25,Other,225% Medicaid APG methodology,583.84,,,583.84,Other,260% Medicaid APG methodology,727.56,,,727.56,Other,324% Medicaid APG methodology,482.79,,,482.79,Other,215% Medicaid APG methodology,482.79,,,482.79,Other,215% Medicaid APG methodology,280.69,,,280.69,Other,125% Medicaid APG methodology,149.44,1803.6,
POS AIRWAY PRESSURE CPAP        ,94660,CPT,,46600136,CDM,410,RC,,,both,,,1469,405.6,,,405.6,Other,150% of Medicare + 9.63% HCRA Surcharge,246.65,,,246.65,Other,Medicare OPPS methodology,734.5,50,,734.5,percent of total billed charges,All Other Outpatient,661.05,45,,661.05,percent of total billed charges,All Other Outpatient,734.5,50,,734.5,percent of total billed charges,All Other Outpatient,661.05,45,,661.05,percent of total billed charges,All Other Outpatient,631.67,43,,631.67,percent of total billed charges,All Other Outpatient,734.5,50,,734.5,percent of total billed charges,All Other,1028.3,70,,1028.3,percent of total billed charges,All Other,156.38,,,156.38,Fee Schedule,,417.68,,,417.68,Other,186% Medicaid methodology,184.02,,,184.02,Fee Schedule,,910.78,,,910.78,Fee Schedule,,86.65,,,86.65,Fee Schedule,,184.02,,,184.02,Fee Schedule,,910.78,,,910.78,Fee Schedule,,1322.1,90,,1322.1,percent of total billed charges,All Other,1028.3,70,,1028.3,percent of total billed charges,All Other,183.15,,,183.15,Fee Schedule,,155.4,,,155.4,Fee Schedule,,248,,,248,Case Rate,Respiratory Per Visit,223,,,223,Case Rate,Respiratory Per Visit,247,,,247,Case Rate,Respiratory Per Visit,210,,,210,Case Rate,Respiratory Per Visit,224.56,,,224.56,Other,New York Medicaid APG methodology,224.56,,,224.56,Other,100% Medicaid APG methodology,224.56,,,224.56,Other,100% Medicaid APG methodology,224.56,,,224.56,Other,100% Medicaid APG methodology,505.26,,,505.26,Other,225% Medicaid APG methodology,505.26,,,505.26,Other,225% Medicaid APG methodology,343.58,,,343.58,Other,153% Medicaid APG methodology,505.26,,,505.26,Other,225% Medicaid APG methodology,314.39,,,314.39,Other,140% Medicaid APG methodology,505.26,,,505.26,Other,225% Medicaid APG methodology,583.86,,,583.86,Other,260% Medicaid APG methodology,727.58,,,727.58,Other,324% Medicaid APG methodology,482.81,,,482.81,Other,215% Medicaid APG methodology,482.81,,,482.81,Other,215% Medicaid APG methodology,280.7,,,280.7,Other,125% Medicaid APG methodology,86.65,1322.1,
CHEST WALL MANIPULATION INIT    ,94667,CPT,,46600151,CDM,410,RC,,,both,,,418,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,209,50,,209,percent of total billed charges,All Other Outpatient,188.1,45,,188.1,percent of total billed charges,All Other Outpatient,205.92,,,205.92,Fee Schedule,,185.27,,,185.27,Fee Schedule,,174.95,,,174.95,Fee Schedule,,209,50,,209,percent of total billed charges,All Other,292.6,70,,292.6,percent of total billed charges,All Other,113.47,,,113.47,Fee Schedule,,188.85,,,188.85,Other,186% Medicaid methodology,133.53,,,133.53,Fee Schedule,,259.16,,,259.16,Fee Schedule,,62.87,,,62.87,Fee Schedule,,133.53,,,133.53,Fee Schedule,,259.16,,,259.16,Fee Schedule,,376.2,90,,376.2,percent of total billed charges,All Other,292.6,70,,292.6,percent of total billed charges,All Other,110.55,,,110.55,Fee Schedule,,93.8,,,93.8,Fee Schedule,,248,,,248,Case Rate,Respiratory Per Visit,223,,,223,Case Rate,Respiratory Per Visit,247,,,247,Case Rate,Respiratory Per Visit,210,,,210,Case Rate,Respiratory Per Visit,101.53,,,101.53,Other,New York Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,155.34,,,155.34,Other,153% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,142.14,,,142.14,Other,140% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,263.98,,,263.98,Other,260% Medicaid APG methodology,328.96,,,328.96,Other,324% Medicaid APG methodology,218.29,,,218.29,Other,215% Medicaid APG methodology,218.29,,,218.29,Other,215% Medicaid APG methodology,126.92,,,126.92,Other,125% Medicaid APG methodology,62.87,376.2,
CHEST WALL MANIPULATION SUBSQ   ,94668,CPT,,46600169,CDM,410,RC,,,both,,,418,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,209,50,,209,percent of total billed charges,All Other Outpatient,188.1,45,,188.1,percent of total billed charges,All Other Outpatient,199.68,,,199.68,Fee Schedule,,179.65,,,179.65,Fee Schedule,,169.64,,,169.64,Fee Schedule,,209,50,,209,percent of total billed charges,All Other,292.6,70,,292.6,percent of total billed charges,All Other,178.36,,,178.36,Fee Schedule,,188.85,,,188.85,Other,186% Medicaid methodology,209.89,,,209.89,Fee Schedule,,259.16,,,259.16,Fee Schedule,,98.83,,,98.83,Fee Schedule,,209.89,,,209.89,Fee Schedule,,259.16,,,259.16,Fee Schedule,,376.2,90,,376.2,percent of total billed charges,All Other,292.6,70,,292.6,percent of total billed charges,All Other,171.6,,,171.6,Fee Schedule,,145.6,,,145.6,Fee Schedule,,248,,,248,Case Rate,Respiratory Per Visit,223,,,223,Case Rate,Respiratory Per Visit,247,,,247,Case Rate,Respiratory Per Visit,210,,,210,Case Rate,Respiratory Per Visit,101.53,,,101.53,Other,New York Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,155.34,,,155.34,Other,153% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,142.14,,,142.14,Other,140% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,263.98,,,263.98,Other,260% Medicaid APG methodology,328.96,,,328.96,Other,324% Medicaid APG methodology,218.29,,,218.29,Other,215% Medicaid APG methodology,218.29,,,218.29,Other,215% Medicaid APG methodology,126.92,,,126.92,Other,125% Medicaid APG methodology,98.83,376.2,
HEART/LUNG RESUSCITATION CPR    ,92950,CPT,,46600326,CDM,410,RC,,,both,,,9801,596.88,,,596.88,Other,150% of Medicare + 9.63% HCRA Surcharge,362.97,,,362.97,Other,Medicare OPPS methodology,4900.5,50,,4900.5,percent of total billed charges,All Other Outpatient,4410.45,45,,4410.45,percent of total billed charges,All Other Outpatient,4900.5,50,,4900.5,percent of total billed charges,All Other Outpatient,4410.45,45,,4410.45,percent of total billed charges,All Other Outpatient,4214.43,43,,4214.43,percent of total billed charges,All Other Outpatient,4900.5,50,,4900.5,percent of total billed charges,All Other,6860.7,70,,6860.7,percent of total billed charges,All Other,773.96,,,773.96,Fee Schedule,,1189.48,,,1189.48,Other,186% Medicaid methodology,910.78,,,910.78,Fee Schedule,,6076.62,,,6076.62,Fee Schedule,,428.84,,,428.84,Fee Schedule,,910.78,,,910.78,Fee Schedule,,6076.62,,,6076.62,Fee Schedule,,8820.9,90,,8820.9,percent of total billed charges,All Other,6860.7,70,,6860.7,percent of total billed charges,All Other,889.35,,,889.35,Fee Schedule,,754.6,,,754.6,Fee Schedule,,248,,,248,Case Rate,Respiratory Per Visit,223,,,223,Case Rate,Respiratory Per Visit,247,,,247,Case Rate,Respiratory Per Visit,210,,,210,Case Rate,Respiratory Per Visit,639.51,,,639.51,Other,New York Medicaid APG methodology,639.51,,,639.51,Other,100% Medicaid APG methodology,639.51,,,639.51,Other,100% Medicaid APG methodology,639.51,,,639.51,Other,100% Medicaid APG methodology,1438.89,,,1438.89,Other,225% Medicaid APG methodology,1438.89,,,1438.89,Other,225% Medicaid APG methodology,978.45,,,978.45,Other,153% Medicaid APG methodology,1438.89,,,1438.89,Other,225% Medicaid APG methodology,895.31,,,895.31,Other,140% Medicaid APG methodology,1438.89,,,1438.89,Other,225% Medicaid APG methodology,1662.72,,,1662.72,Other,260% Medicaid APG methodology,2072,,,2072,Other,324% Medicaid APG methodology,1374.94,,,1374.94,Other,215% Medicaid APG methodology,1374.94,,,1374.94,Other,215% Medicaid APG methodology,799.38,,,799.38,Other,125% Medicaid APG methodology,210,8820.9,
POS AIRWAY PRESSURE CPAP SUBQ   ,94660,CPT,,46600334,CDM,410,RC,,,both,,,1469,405.6,,,405.6,Other,150% of Medicare + 9.63% HCRA Surcharge,246.65,,,246.65,Other,Medicare OPPS methodology,734.5,50,,734.5,percent of total billed charges,All Other Outpatient,661.05,45,,661.05,percent of total billed charges,All Other Outpatient,734.5,50,,734.5,percent of total billed charges,All Other Outpatient,661.05,45,,661.05,percent of total billed charges,All Other Outpatient,631.67,43,,631.67,percent of total billed charges,All Other Outpatient,734.5,50,,734.5,percent of total billed charges,All Other,1028.3,70,,1028.3,percent of total billed charges,All Other,156.38,,,156.38,Fee Schedule,,417.68,,,417.68,Other,186% Medicaid methodology,184.02,,,184.02,Fee Schedule,,910.78,,,910.78,Fee Schedule,,86.65,,,86.65,Fee Schedule,,184.02,,,184.02,Fee Schedule,,910.78,,,910.78,Fee Schedule,,1322.1,90,,1322.1,percent of total billed charges,All Other,1028.3,70,,1028.3,percent of total billed charges,All Other,183.15,,,183.15,Fee Schedule,,155.4,,,155.4,Fee Schedule,,248,,,248,Case Rate,Respiratory Per Visit,223,,,223,Case Rate,Respiratory Per Visit,247,,,247,Case Rate,Respiratory Per Visit,210,,,210,Case Rate,Respiratory Per Visit,224.56,,,224.56,Other,New York Medicaid APG methodology,224.56,,,224.56,Other,100% Medicaid APG methodology,224.56,,,224.56,Other,100% Medicaid APG methodology,224.56,,,224.56,Other,100% Medicaid APG methodology,505.26,,,505.26,Other,225% Medicaid APG methodology,505.26,,,505.26,Other,225% Medicaid APG methodology,343.58,,,343.58,Other,153% Medicaid APG methodology,505.26,,,505.26,Other,225% Medicaid APG methodology,314.39,,,314.39,Other,140% Medicaid APG methodology,505.26,,,505.26,Other,225% Medicaid APG methodology,583.86,,,583.86,Other,260% Medicaid APG methodology,727.58,,,727.58,Other,324% Medicaid APG methodology,482.81,,,482.81,Other,215% Medicaid APG methodology,482.81,,,482.81,Other,215% Medicaid APG methodology,280.7,,,280.7,Other,125% Medicaid APG methodology,86.65,1322.1,
CHANGE OF WINDPIPE AIRWAY       ,31502,CPT,,46600409,CDM,410,RC,,,both,,,663,464.5,,,464.5,Other,150% of Medicare + 9.63% HCRA Surcharge,282.46,,,282.46,Other,Medicare OPPS methodology,331.5,50,,331.5,percent of total billed charges,All Other Outpatient,298.35,45,,298.35,percent of total billed charges,All Other Outpatient,331.5,50,,331.5,percent of total billed charges,All Other Outpatient,298.35,45,,298.35,percent of total billed charges,All Other Outpatient,285.09,43,,285.09,percent of total billed charges,All Other Outpatient,331.5,50,,331.5,percent of total billed charges,All Other,464.1,70,,464.1,percent of total billed charges,All Other,151.94,,,151.94,Fee Schedule,,309.03,,,309.03,Other,186% Medicaid methodology,178.8,,,178.8,Fee Schedule,,411.06,,,411.06,Fee Schedule,,84.19,,,84.19,Fee Schedule,,178.8,,,178.8,Fee Schedule,,411.06,,,411.06,Fee Schedule,,596.7,90,,596.7,percent of total billed charges,All Other,464.1,70,,464.1,percent of total billed charges,All Other,169.95,,,169.95,Fee Schedule,,144.2,,,144.2,Fee Schedule,,248,,,248,Case Rate,Respiratory Per Visit,223,,,223,Case Rate,Respiratory Per Visit,247,,,247,Case Rate,Respiratory Per Visit,210,,,210,Case Rate,Respiratory Per Visit,166.14,,,166.14,Other,New York Medicaid APG methodology,166.14,,,166.14,Other,100% Medicaid APG methodology,166.14,,,166.14,Other,100% Medicaid APG methodology,166.14,,,166.14,Other,100% Medicaid APG methodology,373.83,,,373.83,Other,225% Medicaid APG methodology,373.83,,,373.83,Other,225% Medicaid APG methodology,254.2,,,254.2,Other,153% Medicaid APG methodology,373.83,,,373.83,Other,225% Medicaid APG methodology,232.6,,,232.6,Other,140% Medicaid APG methodology,373.83,,,373.83,Other,225% Medicaid APG methodology,431.98,,,431.98,Other,260% Medicaid APG methodology,538.31,,,538.31,Other,324% Medicaid APG methodology,357.21,,,357.21,Other,215% Medicaid APG methodology,357.21,,,357.21,Other,215% Medicaid APG methodology,207.68,,,207.68,Other,125% Medicaid APG methodology,84.19,596.7,
MECHANICAL CHEST WALL OSCILL    ,94669,CPT,,46600755,CDM,410,RC,,,both,,,541,405.6,,,405.6,Other,150% of Medicare + 9.63% HCRA Surcharge,246.65,,,246.65,Other,Medicare OPPS methodology,270.5,50,,270.5,percent of total billed charges,All Other Outpatient,243.45,45,,243.45,percent of total billed charges,All Other Outpatient,270.5,50,,270.5,percent of total billed charges,All Other Outpatient,243.45,45,,243.45,percent of total billed charges,All Other Outpatient,232.63,43,,232.63,percent of total billed charges,All Other Outpatient,270.5,50,,270.5,percent of total billed charges,All Other,378.7,70,,378.7,percent of total billed charges,All Other,94.11,,,94.11,Fee Schedule,,188.85,,,188.85,Other,186% Medicaid methodology,110.74,,,110.74,Fee Schedule,,335.42,,,335.42,Fee Schedule,,52.14,,,52.14,Fee Schedule,,110.74,,,110.74,Fee Schedule,,335.42,,,335.42,Fee Schedule,,486.9,90,,486.9,percent of total billed charges,All Other,378.7,70,,378.7,percent of total billed charges,All Other,90.75,,,90.75,Fee Schedule,,77,,,77,Fee Schedule,,248,,,248,Case Rate,Respiratory Per Visit,223,,,223,Case Rate,Respiratory Per Visit,247,,,247,Case Rate,Respiratory Per Visit,210,,,210,Case Rate,Respiratory Per Visit,101.53,,,101.53,Other,New York Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,155.34,,,155.34,Other,153% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,142.14,,,142.14,Other,140% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,263.98,,,263.98,Other,260% Medicaid APG methodology,328.96,,,328.96,Other,324% Medicaid APG methodology,218.29,,,218.29,Other,215% Medicaid APG methodology,218.29,,,218.29,Other,215% Medicaid APG methodology,126.92,,,126.92,Other,125% Medicaid APG methodology,52.14,486.9,
AIRWAY INHALATION TREATMENT     ,94640,CPT,,46600243,CDM,412,RC,,,both,,,888,405.6,,,405.6,Other,150% of Medicare + 9.63% HCRA Surcharge,246.65,,,246.65,Other,Medicare OPPS methodology,444,50,,444,percent of total billed charges,All Other Outpatient,399.6,45,,399.6,percent of total billed charges,All Other Outpatient,146.69,,,146.69,Fee Schedule,,131.98,,,131.98,Fee Schedule,,124.62,,,124.62,Fee Schedule,,444,50,,444,percent of total billed charges,All Other,621.6,70,,621.6,percent of total billed charges,All Other,36.61,,,36.61,Fee Schedule,,188.85,,,188.85,Other,186% Medicaid methodology,43.08,,,43.08,Fee Schedule,,550.56,,,550.56,Fee Schedule,,20.29,,,20.29,Fee Schedule,,43.08,,,43.08,Fee Schedule,,550.56,,,550.56,Fee Schedule,,799.2,90,,799.2,percent of total billed charges,All Other,621.6,70,,621.6,percent of total billed charges,All Other,54.45,,,54.45,Fee Schedule,,46.2,,,46.2,Fee Schedule,,248,,,248,Case Rate,Respiratory Per Visit,223,,,223,Case Rate,Respiratory Per Visit,247,,,247,Case Rate,Respiratory Per Visit,210,,,210,Case Rate,Respiratory Per Visit,101.53,,,101.53,Other,New York Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,155.34,,,155.34,Other,153% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,142.14,,,142.14,Other,140% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,263.98,,,263.98,Other,260% Medicaid APG methodology,328.96,,,328.96,Other,324% Medicaid APG methodology,218.29,,,218.29,Other,215% Medicaid APG methodology,218.29,,,218.29,Other,215% Medicaid APG methodology,126.92,,,126.92,Other,125% Medicaid APG methodology,20.29,799.2,
AIRWAY INHALATION TREATMENT     ,94640,CPT,,46600250,CDM,412,RC,,,both,,,888,405.6,,,405.6,Other,150% of Medicare + 9.63% HCRA Surcharge,246.65,,,246.65,Other,Medicare OPPS methodology,444,50,,444,percent of total billed charges,All Other Outpatient,399.6,45,,399.6,percent of total billed charges,All Other Outpatient,146.69,,,146.69,Fee Schedule,,131.98,,,131.98,Fee Schedule,,124.62,,,124.62,Fee Schedule,,444,50,,444,percent of total billed charges,All Other,621.6,70,,621.6,percent of total billed charges,All Other,36.61,,,36.61,Fee Schedule,,188.85,,,188.85,Other,186% Medicaid methodology,43.08,,,43.08,Fee Schedule,,550.56,,,550.56,Fee Schedule,,20.29,,,20.29,Fee Schedule,,43.08,,,43.08,Fee Schedule,,550.56,,,550.56,Fee Schedule,,799.2,90,,799.2,percent of total billed charges,All Other,621.6,70,,621.6,percent of total billed charges,All Other,54.45,,,54.45,Fee Schedule,,46.2,,,46.2,Fee Schedule,,248,,,248,Case Rate,Respiratory Per Visit,223,,,223,Case Rate,Respiratory Per Visit,247,,,247,Case Rate,Respiratory Per Visit,210,,,210,Case Rate,Respiratory Per Visit,101.53,,,101.53,Other,New York Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,155.34,,,155.34,Other,153% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,142.14,,,142.14,Other,140% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,263.98,,,263.98,Other,260% Medicaid APG methodology,328.96,,,328.96,Other,324% Medicaid APG methodology,218.29,,,218.29,Other,215% Medicaid APG methodology,218.29,,,218.29,Other,215% Medicaid APG methodology,126.92,,,126.92,Other,125% Medicaid APG methodology,20.29,799.2,
"HBOT, FULL BODY CHAMBER, 30M    ",G0277,HCPCS,,47900014,CDM,413,RC,,,both,,,977,263.87,,,263.87,Other,150% of Medicare + 9.63% HCRA Surcharge,160.46,,,160.46,Other,Medicare OPPS methodology,1991,,,1991,Case Rate,Hyperbaric Therapy Per Visit,1792,,,1792,Case Rate,Hyperbaric Therapy Per Visit,488.5,50,,488.5,percent of total billed charges,All Other Outpatient,439.65,45,,439.65,percent of total billed charges,All Other Outpatient,420.11,43,,420.11,percent of total billed charges,All Other Outpatient,488.5,50,,488.5,percent of total billed charges,All Other,683.9,70,,683.9,percent of total billed charges,All Other,664.36,68,,664.36,percent of total billed charges,All Other Outpatient,1438.1,,,1438.1,Other,186% Medicaid methodology,781.6,80,,781.6,percent of total billed charges,All Other Outpatient,810.91,83,,810.91,percent of total billed charges,All Other Outpatient,810.91,83,,810.91,percent of total billed charges,All Other Outpatient,781.6,80,,781.6,percent of total billed charges,All Other Outpatient,810.91,83,,810.91,percent of total billed charges,All Other Outpatient,879.3,90,,879.3,percent of total billed charges,All Other,683.9,70,,683.9,percent of total billed charges,All Other,1817,,,1817,Case Rate,Hyperbaric Therapy Per Visit,1544,,,1544,Case Rate,Hyperbaric Therapy Per Visit,1812,,,1812,Case Rate,Hyperbaric Therapy Per Visit,1791,,,1791,Case Rate,Hyperbaric Therapy Per Visit,1990,,,1990,Case Rate,Hyperbaric Therapy Per Visit,1692,,,1692,Case Rate,Hyperbaric Therapy Per Visit,773.17,,,773.17,Other,New York Medicaid APG methodology,773.17,,,773.17,Other,100% Medicaid APG methodology,773.17,,,773.17,Other,100% Medicaid APG methodology,773.17,,,773.17,Other,100% Medicaid APG methodology,1739.64,,,1739.64,Other,225% Medicaid APG methodology,1739.64,,,1739.64,Other,225% Medicaid APG methodology,1182.95,,,1182.95,Other,153% Medicaid APG methodology,1739.64,,,1739.64,Other,225% Medicaid APG methodology,1082.44,,,1082.44,Other,140% Medicaid APG methodology,1739.64,,,1739.64,Other,225% Medicaid APG methodology,2010.25,,,2010.25,Other,260% Medicaid APG methodology,2505.08,,,2505.08,Other,324% Medicaid APG methodology,1662.32,,,1662.32,Other,215% Medicaid APG methodology,1662.32,,,1662.32,Other,215% Medicaid APG methodology,966.46,,,966.46,Other,125% Medicaid APG methodology,160.46,2505.08,
HOT OR COLD PACKS THERAPY       ,97010,CPT,GP       ,48600035,CDM,420,RC,,,both,,,384,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,3.82,,,3.82,Fee Schedule,,3.82,,,3.82,Fee Schedule,,3.82,,,3.82,Fee Schedule,,192,50,,192,percent of total billed charges,All Other,268.8,70,,268.8,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,91.32,,,91.32,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,211.2,55,,211.2,percent of total billed charges,All Other,211.2,55,,211.2,percent of total billed charges,All Other,257,,,257,Case Rate,PT OT ST Per Visit,211.2,55,,211.2,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,268.8,70,,268.8,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,49.09,,,49.09,Other,New York Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,75.11,,,75.11,Other,153% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,68.73,,,68.73,Other,140% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,127.64,,,127.64,Other,260% Medicaid APG methodology,159.07,,,159.07,Other,324% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,61.37,,,61.37,Other,125% Medicaid APG methodology,0.01,368,
MECHANICAL TRACTION THERAPY     ,97012,CPT,GP       ,48600043,CDM,420,RC,,,both,,,493,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,126.51,,,126.51,Fee Schedule,,113.83,,,113.83,Fee Schedule,,107.48,,,107.48,Fee Schedule,,246.5,50,,246.5,percent of total billed charges,All Other,345.1,70,,345.1,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,91.32,,,91.32,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,409.19,83,,409.19,percent of total billed charges,All Other,32.82,,,32.82,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,409.19,83,,409.19,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,345.1,70,,345.1,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,49.09,,,49.09,Other,New York Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,75.11,,,75.11,Other,153% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,68.73,,,68.73,Other,140% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,127.64,,,127.64,Other,260% Medicaid APG methodology,159.07,,,159.07,Other,324% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,61.37,,,61.37,Other,125% Medicaid APG methodology,0.01,409.19,
PARAFFIN BATH THERAPY           ,97018,CPT,GP       ,48600050,CDM,420,RC,,,both,,,262,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,84.08,,,84.08,Fee Schedule,,75.65,,,75.65,Fee Schedule,,71.43,,,71.43,Fee Schedule,,131,50,,131,percent of total billed charges,All Other,183.4,70,,183.4,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,91.32,,,91.32,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,217.46,83,,217.46,percent of total billed charges,All Other,13.97,,,13.97,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,217.46,83,,217.46,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,183.4,70,,183.4,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,49.09,,,49.09,Other,New York Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,75.11,,,75.11,Other,153% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,68.73,,,68.73,Other,140% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,127.64,,,127.64,Other,260% Medicaid APG methodology,159.07,,,159.07,Other,324% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,61.37,,,61.37,Other,125% Medicaid APG methodology,0.01,368,
WHIRLPOOL THERAPY               ,97022,CPT,GP       ,48600068,CDM,420,RC,,,both,,,558,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,177.78,,,177.78,Fee Schedule,,159.95,,,159.95,Fee Schedule,,151.04,,,151.04,Fee Schedule,,279,50,,279,percent of total billed charges,All Other,390.6,70,,390.6,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,91.32,,,91.32,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,463.14,83,,463.14,percent of total billed charges,All Other,40.99,,,40.99,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,463.14,83,,463.14,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,390.6,70,,390.6,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,49.09,,,49.09,Other,New York Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,75.11,,,75.11,Other,153% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,68.73,,,68.73,Other,140% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,127.64,,,127.64,Other,260% Medicaid APG methodology,159.07,,,159.07,Other,324% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,61.37,,,61.37,Other,125% Medicaid APG methodology,0.01,463.14,
ULTRASOUND THERAPY EA 15        ,97035,CPT,GP       ,48600084,CDM,420,RC,,,both,,,704,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,97.58,,,97.58,Fee Schedule,,87.79,,,87.79,Fee Schedule,,82.9,,,82.9,Fee Schedule,,352,50,,352,percent of total billed charges,All Other,492.8,70,,492.8,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,91.32,,,91.32,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,584.32,83,,584.32,percent of total billed charges,All Other,33.2,,,33.2,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,584.32,83,,584.32,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,492.8,70,,492.8,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,49.09,,,49.09,Other,New York Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,75.11,,,75.11,Other,153% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,68.73,,,68.73,Other,140% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,127.64,,,127.64,Other,260% Medicaid APG methodology,159.07,,,159.07,Other,324% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,61.37,,,61.37,Other,125% Medicaid APG methodology,0.01,584.32,
THERAPEUTIC EXERCISES EA 15     ,97110,CPT,GP       ,48600100,CDM,420,RC,,,both,,,596,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,246.35,,,246.35,Fee Schedule,,221.64,,,221.64,Fee Schedule,,209.29,,,209.29,Fee Schedule,,298,50,,298,percent of total billed charges,All Other,417.2,70,,417.2,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,494.68,83,,494.68,percent of total billed charges,All Other,68.92,,,68.92,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,494.68,83,,494.68,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,417.2,70,,417.2,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,494.68,
NEUROMUSCULAR RE-ED EA 15       ,97112,CPT,GP       ,48600118,CDM,420,RC,,,both,,,398,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,258.84,,,258.84,Fee Schedule,,232.88,,,232.88,Fee Schedule,,219.91,,,219.91,Fee Schedule,,199,50,,199,percent of total billed charges,All Other,278.6,70,,278.6,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,330.34,83,,330.34,percent of total billed charges,All Other,79.19,,,79.19,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,330.34,83,,330.34,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,278.6,70,,278.6,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,368,
GAIT TRAINING THERAPY EA 15     ,97116,CPT,GP       ,48600134,CDM,420,RC,,,both,,,507,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,217.98,,,217.98,Fee Schedule,,196.13,,,196.13,Fee Schedule,,185.2,,,185.2,Fee Schedule,,253.5,50,,253.5,percent of total billed charges,All Other,354.9,70,,354.9,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,91.32,,,91.32,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,420.81,83,,420.81,percent of total billed charges,All Other,68.92,,,68.92,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,420.81,83,,420.81,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,354.9,70,,354.9,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,49.09,,,49.09,Other,New York Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,75.11,,,75.11,Other,153% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,68.73,,,68.73,Other,140% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,127.64,,,127.64,Other,260% Medicaid APG methodology,159.07,,,159.07,Other,324% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,61.37,,,61.37,Other,125% Medicaid APG methodology,0.01,420.81,
MASSAGE THERAPY EA 15           ,97124,CPT,GP       ,48600159,CDM,420,RC,,,both,,,311,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,202.05,,,202.05,Fee Schedule,,181.78,,,181.78,Fee Schedule,,171.65,,,171.65,Fee Schedule,,155.5,50,,155.5,percent of total billed charges,All Other,217.7,70,,217.7,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,91.32,,,91.32,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,258.13,83,,258.13,percent of total billed charges,All Other,72.32,,,72.32,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,258.13,83,,258.13,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,217.7,70,,217.7,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,49.09,,,49.09,Other,New York Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,75.11,,,75.11,Other,153% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,68.73,,,68.73,Other,140% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,127.64,,,127.64,Other,260% Medicaid APG methodology,159.07,,,159.07,Other,324% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,61.37,,,61.37,Other,125% Medicaid APG methodology,0.01,368,
PROSTHETIC TRAING 1ST EA 15     ,97761,CPT,GP       ,48600209,CDM,420,RC,,,both,,,245,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,259.13,,,259.13,Fee Schedule,,233.14,,,233.14,Fee Schedule,,220.15,,,220.15,Fee Schedule,,122.5,50,,122.5,percent of total billed charges,All Other,171.5,70,,171.5,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,203.35,83,,203.35,percent of total billed charges,All Other,98.99,,,98.99,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,203.35,83,,203.35,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,171.5,70,,171.5,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,368,
ELECTRIC STIMULATION THERAPY    ,97014,CPT,GP       ,48600324,CDM,420,RC,,,both,,,822,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,10.38,,,10.38,Fee Schedule,,10.38,,,10.38,Fee Schedule,,10.38,,,10.38,Fee Schedule,,411,50,,411,percent of total billed charges,All Other,575.4,70,,575.4,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,91.32,,,91.32,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,452.1,55,,452.1,percent of total billed charges,All Other,452.1,55,,452.1,percent of total billed charges,All Other,257,,,257,Case Rate,PT OT ST Per Visit,452.1,55,,452.1,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,575.4,70,,575.4,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,49.09,,,49.09,Other,New York Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,75.11,,,75.11,Other,153% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,68.73,,,68.73,Other,140% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,127.64,,,127.64,Other,260% Medicaid APG methodology,159.07,,,159.07,Other,324% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,61.37,,,61.37,Other,125% Medicaid APG methodology,0.01,575.4,
VASOPNEUMATIC DEVICE THERAPY    ,97016,CPT,GP       ,48600332,CDM,420,RC,,,both,,,265,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,149.13,,,149.13,Fee Schedule,,134.17,,,134.17,Fee Schedule,,126.7,,,126.7,Fee Schedule,,132.5,50,,132.5,percent of total billed charges,All Other,185.5,70,,185.5,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,91.32,,,91.32,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,219.95,83,,219.95,percent of total billed charges,All Other,27.7,,,27.7,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,219.95,83,,219.95,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,185.5,70,,185.5,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,49.09,,,49.09,Other,New York Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,75.11,,,75.11,Other,153% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,68.73,,,68.73,Other,140% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,127.64,,,127.64,Other,260% Medicaid APG methodology,159.07,,,159.07,Other,324% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,61.37,,,61.37,Other,125% Medicaid APG methodology,0.01,368,
ELECTRIC CURRENT THERAPY EA 15  ,97033,CPT,GP       ,48600340,CDM,420,RC,,,both,,,234,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,244.48,,,244.48,Fee Schedule,,219.96,,,219.96,Fee Schedule,,207.71,,,207.71,Fee Schedule,,117,50,,117,percent of total billed charges,All Other,163.8,70,,163.8,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,91.32,,,91.32,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,194.22,83,,194.22,percent of total billed charges,All Other,45.93,,,45.93,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,194.22,83,,194.22,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,163.8,70,,163.8,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,49.09,,,49.09,Other,New York Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,75.11,,,75.11,Other,153% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,68.73,,,68.73,Other,140% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,127.64,,,127.64,Other,260% Medicaid APG methodology,159.07,,,159.07,Other,324% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,61.37,,,61.37,Other,125% Medicaid APG methodology,0.01,368,
ORTHOTIC MGMT&TRAING 1ST ENC    ,97760,CPT,GP       ,48600381,CDM,420,RC,,,both,,,340,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,296.53,,,296.53,Fee Schedule,,266.8,,,266.8,Fee Schedule,,251.93,,,251.93,Fee Schedule,,170,50,,170,percent of total billed charges,All Other,238,70,,238,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,282.2,83,,282.2,percent of total billed charges,All Other,113.84,,,113.84,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,282.2,83,,282.2,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,238,70,,238,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,368,
MANUAL THERAPY 1/> REG EA 15    ,97140,CPT,GP       ,48600415,CDM,420,RC,,,both,,,501,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,231.84,,,231.84,Fee Schedule,,208.59,,,208.59,Fee Schedule,,196.97,,,196.97,Fee Schedule,,250.5,50,,250.5,percent of total billed charges,All Other,350.7,70,,350.7,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,415.83,83,,415.83,percent of total billed charges,All Other,63.34,,,63.34,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,415.83,83,,415.83,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,350.7,70,,350.7,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,415.83,
THERAPEUTIC ACTIVITIES          ,97530,CPT,GP       ,48600423,CDM,420,RC,,,both,,,465,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,271.83,,,271.83,Fee Schedule,,244.58,,,244.58,Fee Schedule,,230.95,,,230.95,Fee Schedule,,232.5,50,,232.5,percent of total billed charges,All Other,325.5,70,,325.5,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,385.95,83,,385.95,percent of total billed charges,All Other,87.17,,,87.17,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,385.95,83,,385.95,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,325.5,70,,325.5,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,385.95,
SELF CARE MNGMENT TRAINING      ,97535,CPT,GP       ,48600431,CDM,420,RC,,,both,,,314,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,271.26,,,271.26,Fee Schedule,,244.06,,,244.06,Fee Schedule,,230.46,,,230.46,Fee Schedule,,157,50,,157,percent of total billed charges,All Other,219.8,70,,219.8,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,91.32,,,91.32,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,260.62,83,,260.62,percent of total billed charges,All Other,77.18,,,77.18,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,260.62,83,,260.62,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,219.8,70,,219.8,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,49.09,,,49.09,Other,New York Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,75.11,,,75.11,Other,153% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,68.73,,,68.73,Other,140% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,127.64,,,127.64,Other,260% Medicaid APG methodology,159.07,,,159.07,Other,324% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,61.37,,,61.37,Other,125% Medicaid APG methodology,0.01,368,
WHEELCHAIR MNG TRAINING EA 15   ,97542,CPT,GP       ,48600456,CDM,420,RC,,,both,,,216,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,237.01,,,237.01,Fee Schedule,,213.24,,,213.24,Fee Schedule,,201.36,,,201.36,Fee Schedule,,108,50,,108,percent of total billed charges,All Other,151.2,70,,151.2,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,179.28,83,,179.28,percent of total billed charges,All Other,74.42,,,74.42,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,179.28,83,,179.28,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,151.2,70,,151.2,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,368,
ORTHC/PROSTC MGMT SBSQ ENC      ,97763,CPT,GP       ,48600498,CDM,420,RC,,,both,,,210,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,45.82,,,45.82,Fee Schedule,,45.82,,,45.82,Fee Schedule,,45.82,,,45.82,Fee Schedule,,105,50,,105,percent of total billed charges,All Other,147,70,,147,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,174.3,83,,174.3,percent of total billed charges,All Other,125.58,,,125.58,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,174.3,83,,174.3,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,147,70,,147,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,368,
THER IVNTJ 1ST 15 MIN           ,97129,CPT,GP       ,48600522,CDM,420,RC,,,both,,,302,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,22.08,,,22.08,Fee Schedule,,22.08,,,22.08,Fee Schedule,,22.08,,,22.08,Fee Schedule,,151,50,,151,percent of total billed charges,All Other,211.4,70,,211.4,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,250.66,83,,250.66,percent of total billed charges,All Other,50.32,,,50.32,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,250.66,83,,250.66,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,211.4,70,,211.4,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,368,
PHYSICAL PERFORM TEST EA 15     ,97750,CPT,GP       ,48601207,CDM,420,RC,,,both,,,376,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,262.21,,,262.21,Fee Schedule,,235.92,,,235.92,Fee Schedule,,222.77,,,222.77,Fee Schedule,,188,50,,188,percent of total billed charges,All Other,263.2,70,,263.2,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,312.08,83,,312.08,percent of total billed charges,All Other,80.47,,,80.47,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,312.08,83,,312.08,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,263.2,70,,263.2,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,368,
CANALITH REPOSITIONING PROC     ,95992,CPT,GP       ,48601223,CDM,420,RC,,,both,,,399,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,348.66,,,348.66,Fee Schedule,,313.7,,,313.7,Fee Schedule,,296.22,,,296.22,Fee Schedule,,199.5,50,,199.5,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,331.17,83,,331.17,percent of total billed charges,All Other,81.96,,,81.96,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,331.17,83,,331.17,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,279.3,70,,279.3,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,368,
HOT OR COLD PACKS THERAPY PTA   ,97010,CPT,GP       ,48602908,CDM,420,RC,,,both,,,384,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,3.82,,,3.82,Fee Schedule,,3.82,,,3.82,Fee Schedule,,3.82,,,3.82,Fee Schedule,,192,50,,192,percent of total billed charges,All Other,268.8,70,,268.8,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,91.32,,,91.32,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,211.2,55,,211.2,percent of total billed charges,All Other,211.2,55,,211.2,percent of total billed charges,All Other,257,,,257,Case Rate,PT OT ST Per Visit,211.2,55,,211.2,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,268.8,70,,268.8,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,49.09,,,49.09,Other,New York Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,75.11,,,75.11,Other,153% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,68.73,,,68.73,Other,140% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,127.64,,,127.64,Other,260% Medicaid APG methodology,159.07,,,159.07,Other,324% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,61.37,,,61.37,Other,125% Medicaid APG methodology,0.01,368,
MECHANICAL TRACTION THER PTA    ,97012,CPT,GP       ,48602916,CDM,420,RC,,,both,,,493,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,126.51,,,126.51,Fee Schedule,,113.83,,,113.83,Fee Schedule,,107.48,,,107.48,Fee Schedule,,246.5,50,,246.5,percent of total billed charges,All Other,345.1,70,,345.1,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,91.32,,,91.32,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,409.19,83,,409.19,percent of total billed charges,All Other,32.82,,,32.82,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,409.19,83,,409.19,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,345.1,70,,345.1,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,49.09,,,49.09,Other,New York Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,75.11,,,75.11,Other,153% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,68.73,,,68.73,Other,140% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,127.64,,,127.64,Other,260% Medicaid APG methodology,159.07,,,159.07,Other,324% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,61.37,,,61.37,Other,125% Medicaid APG methodology,0.01,409.19,
ELECTRIC STIMULATION THER PTA   ,97014,CPT,GP       ,48602924,CDM,420,RC,,,both,,,822,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,10.38,,,10.38,Fee Schedule,,10.38,,,10.38,Fee Schedule,,10.38,,,10.38,Fee Schedule,,411,50,,411,percent of total billed charges,All Other,575.4,70,,575.4,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,91.32,,,91.32,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,452.1,55,,452.1,percent of total billed charges,All Other,452.1,55,,452.1,percent of total billed charges,All Other,257,,,257,Case Rate,PT OT ST Per Visit,452.1,55,,452.1,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,575.4,70,,575.4,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,49.09,,,49.09,Other,New York Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,75.11,,,75.11,Other,153% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,68.73,,,68.73,Other,140% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,127.64,,,127.64,Other,260% Medicaid APG methodology,159.07,,,159.07,Other,324% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,61.37,,,61.37,Other,125% Medicaid APG methodology,0.01,575.4,
PARAFFIN BATH THERAPY PTA       ,97018,CPT,GP       ,48602940,CDM,420,RC,,,both,,,262,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,84.08,,,84.08,Fee Schedule,,75.65,,,75.65,Fee Schedule,,71.43,,,71.43,Fee Schedule,,131,50,,131,percent of total billed charges,All Other,183.4,70,,183.4,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,91.32,,,91.32,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,217.46,83,,217.46,percent of total billed charges,All Other,13.97,,,13.97,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,217.46,83,,217.46,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,183.4,70,,183.4,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,49.09,,,49.09,Other,New York Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,75.11,,,75.11,Other,153% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,68.73,,,68.73,Other,140% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,127.64,,,127.64,Other,260% Medicaid APG methodology,159.07,,,159.07,Other,324% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,61.37,,,61.37,Other,125% Medicaid APG methodology,0.01,368,
ULTRASOUND THERAPY EA 15 PTA    ,97035,CPT,GP       ,48602981,CDM,420,RC,,,both,,,704,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,97.58,,,97.58,Fee Schedule,,87.79,,,87.79,Fee Schedule,,82.9,,,82.9,Fee Schedule,,352,50,,352,percent of total billed charges,All Other,492.8,70,,492.8,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,91.32,,,91.32,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,584.32,83,,584.32,percent of total billed charges,All Other,33.2,,,33.2,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,584.32,83,,584.32,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,492.8,70,,492.8,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,49.09,,,49.09,Other,New York Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,75.11,,,75.11,Other,153% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,68.73,,,68.73,Other,140% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,127.64,,,127.64,Other,260% Medicaid APG methodology,159.07,,,159.07,Other,324% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,61.37,,,61.37,Other,125% Medicaid APG methodology,0.01,584.32,
THERAPEUTIC EXERCISE EA 15 PTA  ,97110,CPT,GP       ,48602999,CDM,420,RC,,,both,,,596,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,246.35,,,246.35,Fee Schedule,,221.64,,,221.64,Fee Schedule,,209.29,,,209.29,Fee Schedule,,298,50,,298,percent of total billed charges,All Other,417.2,70,,417.2,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,494.68,83,,494.68,percent of total billed charges,All Other,68.92,,,68.92,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,494.68,83,,494.68,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,417.2,70,,417.2,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,494.68,
NEUROMUSCULAR RE-ED EA 15 PTA   ,97112,CPT,GP       ,48603005,CDM,420,RC,,,both,,,398,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,258.84,,,258.84,Fee Schedule,,232.88,,,232.88,Fee Schedule,,219.91,,,219.91,Fee Schedule,,199,50,,199,percent of total billed charges,All Other,278.6,70,,278.6,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,330.34,83,,330.34,percent of total billed charges,All Other,79.19,,,79.19,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,330.34,83,,330.34,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,278.6,70,,278.6,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,368,
GAIT TRAINING THER EA 15 PTA    ,97116,CPT,GP       ,48603021,CDM,420,RC,,,both,,,507,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,217.98,,,217.98,Fee Schedule,,196.13,,,196.13,Fee Schedule,,185.2,,,185.2,Fee Schedule,,253.5,50,,253.5,percent of total billed charges,All Other,354.9,70,,354.9,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,91.32,,,91.32,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,420.81,83,,420.81,percent of total billed charges,All Other,68.92,,,68.92,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,420.81,83,,420.81,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,354.9,70,,354.9,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,49.09,,,49.09,Other,New York Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,75.11,,,75.11,Other,153% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,68.73,,,68.73,Other,140% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,127.64,,,127.64,Other,260% Medicaid APG methodology,159.07,,,159.07,Other,324% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,61.37,,,61.37,Other,125% Medicaid APG methodology,0.01,420.81,
MASSAGE THERAPY EA 15 PTA       ,97124,CPT,GP       ,48603039,CDM,420,RC,,,both,,,311,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,202.05,,,202.05,Fee Schedule,,181.78,,,181.78,Fee Schedule,,171.65,,,171.65,Fee Schedule,,155.5,50,,155.5,percent of total billed charges,All Other,217.7,70,,217.7,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,91.32,,,91.32,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,258.13,83,,258.13,percent of total billed charges,All Other,72.32,,,72.32,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,258.13,83,,258.13,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,217.7,70,,217.7,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,49.09,,,49.09,Other,New York Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,75.11,,,75.11,Other,153% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,68.73,,,68.73,Other,140% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,127.64,,,127.64,Other,260% Medicaid APG methodology,159.07,,,159.07,Other,324% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,61.37,,,61.37,Other,125% Medicaid APG methodology,0.01,368,
MANUAL THER 1/> REG EA 15 PTA   ,97140,CPT,GP       ,48603070,CDM,420,RC,,,both,,,501,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,231.84,,,231.84,Fee Schedule,,208.59,,,208.59,Fee Schedule,,196.97,,,196.97,Fee Schedule,,250.5,50,,250.5,percent of total billed charges,All Other,350.7,70,,350.7,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,415.83,83,,415.83,percent of total billed charges,All Other,63.34,,,63.34,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,415.83,83,,415.83,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,350.7,70,,350.7,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,415.83,
THERAPEUTIC ACTIVITIES PTA      ,97530,CPT,GP       ,48603138,CDM,420,RC,,,both,,,465,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,271.83,,,271.83,Fee Schedule,,244.58,,,244.58,Fee Schedule,,230.95,,,230.95,Fee Schedule,,232.5,50,,232.5,percent of total billed charges,All Other,325.5,70,,325.5,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,385.95,83,,385.95,percent of total billed charges,All Other,87.17,,,87.17,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,385.95,83,,385.95,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,325.5,70,,325.5,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,385.95,
WHEELCHAIR MNG TRNG EA 15 PTA   ,97542,CPT,GP       ,48603161,CDM,420,RC,,,both,,,216,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,237.01,,,237.01,Fee Schedule,,213.24,,,213.24,Fee Schedule,,201.36,,,201.36,Fee Schedule,,108,50,,108,percent of total billed charges,All Other,151.2,70,,151.2,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,179.28,83,,179.28,percent of total billed charges,All Other,74.42,,,74.42,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,179.28,83,,179.28,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,151.2,70,,151.2,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,368,
BIOFEEDBACK TRAIN ANY METH PTA  ,90901,CPT,GP       ,48603179,CDM,420,RC,,,both,,,145,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,72.5,50,,72.5,percent of total billed charges,All Other Outpatient,65.25,45,,65.25,percent of total billed charges,All Other Outpatient,62.35,43,,62.35,percent of total billed charges,All Other Outpatient,72.5,50,,72.5,percent of total billed charges,All Other,101.5,70,,101.5,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,0.02,,,0.02,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,120.35,83,,120.35,percent of total billed charges,All Other,44.21,,,44.21,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,120.35,83,,120.35,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,101.5,70,,101.5,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,368,
PHYSICAL PERFORM TST EA 15 PTA  ,97750,CPT,GP       ,48603187,CDM,420,RC,,,both,,,376,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,262.21,,,262.21,Fee Schedule,,235.92,,,235.92,Fee Schedule,,222.77,,,222.77,Fee Schedule,,188,50,,188,percent of total billed charges,All Other,263.2,70,,263.2,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,312.08,83,,312.08,percent of total billed charges,All Other,80.47,,,80.47,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,312.08,83,,312.08,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,263.2,70,,263.2,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,368,
ORTHOTIC MGMT&TRNG 1ST ENC PTA  ,97760,CPT,GP       ,48603195,CDM,420,RC,,,both,,,340,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,296.53,,,296.53,Fee Schedule,,266.8,,,266.8,Fee Schedule,,251.93,,,251.93,Fee Schedule,,170,50,,170,percent of total billed charges,All Other,238,70,,238,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,282.2,83,,282.2,percent of total billed charges,All Other,113.84,,,113.84,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,282.2,83,,282.2,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,238,70,,238,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,368,
PROSTHETIC TRNG 1ST EA 15 PTA   ,97761,CPT,GP       ,48603203,CDM,420,RC,,,both,,,245,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,259.13,,,259.13,Fee Schedule,,233.14,,,233.14,Fee Schedule,,220.15,,,220.15,Fee Schedule,,122.5,50,,122.5,percent of total billed charges,All Other,171.5,70,,171.5,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,203.35,83,,203.35,percent of total billed charges,All Other,98.99,,,98.99,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,203.35,83,,203.35,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,171.5,70,,171.5,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,368,
ORTHC/PROSTC MGMT SBSQ ENC PTA  ,97763,CPT,GP       ,48603211,CDM,420,RC,,,both,,,190,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,45.82,,,45.82,Fee Schedule,,45.82,,,45.82,Fee Schedule,,45.82,,,45.82,Fee Schedule,,95,50,,95,percent of total billed charges,All Other,133,70,,133,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,157.7,83,,157.7,percent of total billed charges,All Other,125.58,,,125.58,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,157.7,83,,157.7,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,133,70,,133,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,368,
"PT Biofdbk Peri,Urethral,Rectal,First 15 Min Assistant Units",90912,CPT,,48603310,CDM,420,RC,,,both,,,286,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,143,50,,143,percent of total billed charges,All Other Outpatient,128.7,45,,128.7,percent of total billed charges,All Other Outpatient,122.98,43,,122.98,percent of total billed charges,All Other Outpatient,143,50,,143,percent of total billed charges,All Other,200.2,70,,200.2,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,0.02,,,0.02,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,237.38,83,,237.38,percent of total billed charges,All Other,98.05,,,98.05,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,237.38,83,,237.38,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,200.2,70,,200.2,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,368,
"PT Biofdbk Peri,Urethral,Rectal,First 15 Min Units",90912,CPT,,48603328,CDM,420,RC,,,both,,,286,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,143,50,,143,percent of total billed charges,All Other Outpatient,128.7,45,,128.7,percent of total billed charges,All Other Outpatient,122.98,43,,122.98,percent of total billed charges,All Other Outpatient,143,50,,143,percent of total billed charges,All Other,200.2,70,,200.2,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,0.02,,,0.02,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,237.38,83,,237.38,percent of total billed charges,All Other,98.05,,,98.05,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,237.38,83,,237.38,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,200.2,70,,200.2,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,368,
"PT Biofdbk Peri,Urethral,Rectal, Addl 15 Min Assistant Units",90913,CPT,,48603336,CDM,420,RC,,,both,,,115,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,57.5,50,,57.5,percent of total billed charges,All Other Outpatient,51.75,45,,51.75,percent of total billed charges,All Other Outpatient,49.45,43,,49.45,percent of total billed charges,All Other Outpatient,57.5,50,,57.5,percent of total billed charges,All Other,80.5,70,,80.5,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,0.02,,,0.02,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,95.45,83,,95.45,percent of total billed charges,All Other,55.42,,,55.42,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,95.45,83,,95.45,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,80.5,70,,80.5,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,368,
"PT Biofdbk Peri,Urethral,Rectal, Addl 15 Min Units",90913,CPT,,48603344,CDM,420,RC,,,both,,,115,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,57.5,50,,57.5,percent of total billed charges,All Other Outpatient,51.75,45,,51.75,percent of total billed charges,All Other Outpatient,49.45,43,,49.45,percent of total billed charges,All Other Outpatient,57.5,50,,57.5,percent of total billed charges,All Other,80.5,70,,80.5,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,0.02,,,0.02,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,95.45,83,,95.45,percent of total billed charges,All Other,55.42,,,55.42,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,95.45,83,,95.45,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,80.5,70,,80.5,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,368,
PT BIOFEEDBACK ASSISTANT UNITS  ,90901,CPT,GP       ,48603351,CDM,420,RC,,,both,,,145,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,72.5,50,,72.5,percent of total billed charges,All Other Outpatient,65.25,45,,65.25,percent of total billed charges,All Other Outpatient,62.35,43,,62.35,percent of total billed charges,All Other Outpatient,72.5,50,,72.5,percent of total billed charges,All Other,101.5,70,,101.5,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,0.02,,,0.02,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,120.35,83,,120.35,percent of total billed charges,All Other,44.21,,,44.21,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,120.35,83,,120.35,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,101.5,70,,101.5,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,368,
ORTHC/PROSTC MGMT SBSQ ENC      ,97763,CPT,GP       ,48603369,CDM,420,RC,,,both,,,190,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,45.82,,,45.82,Fee Schedule,,45.82,,,45.82,Fee Schedule,,45.82,,,45.82,Fee Schedule,,95,50,,95,percent of total billed charges,All Other,133,70,,133,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,157.7,83,,157.7,percent of total billed charges,All Other,125.58,,,125.58,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,157.7,83,,157.7,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,133,70,,133,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,368,
STRAPPING OF ANKLE AND/OR FT    ,29540,CPT,GP       ,48601264,CDM,421,RC,,,both,,,570,299.64,,,299.64,Other,150% of Medicare + 9.63% HCRA Surcharge,182.21,,,182.21,Other,Medicare OPPS methodology,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,285,50,,285,percent of total billed charges,All Other Outpatient,256.5,45,,256.5,percent of total billed charges,All Other Outpatient,245.1,43,,245.1,percent of total billed charges,All Other Outpatient,285,50,,285,percent of total billed charges,All Other,399,70,,399,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,465.59,,,465.59,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,473.1,83,,473.1,percent of total billed charges,All Other,39.92,,,39.92,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,473.1,83,,473.1,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,399,70,,399,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,250.32,,,250.32,Other,New York Medicaid APG methodology,250.32,,,250.32,Other,100% Medicaid APG methodology,250.32,,,250.32,Other,100% Medicaid APG methodology,250.32,,,250.32,Other,100% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,382.99,,,382.99,Other,153% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,350.45,,,350.45,Other,140% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,650.83,,,650.83,Other,260% Medicaid APG methodology,811.03,,,811.03,Other,324% Medicaid APG methodology,538.19,,,538.19,Other,215% Medicaid APG methodology,538.19,,,538.19,Other,215% Medicaid APG methodology,312.9,,,312.9,Other,125% Medicaid APG methodology,39.92,811.03,
ELECTRICAL STIMULATION EA 15    ,97032,CPT,GP       ,48601322,CDM,421,RC,,,both,,,561,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,148.34,,,148.34,Fee Schedule,,133.46,,,133.46,Fee Schedule,,126.03,,,126.03,Fee Schedule,,280.5,50,,280.5,percent of total billed charges,All Other,392.7,70,,392.7,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,91.32,,,91.32,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,465.63,83,,465.63,percent of total billed charges,All Other,33.64,,,33.64,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,465.63,83,,465.63,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,392.7,70,,392.7,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,49.09,,,49.09,Other,New York Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,75.11,,,75.11,Other,153% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,68.73,,,68.73,Other,140% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,127.64,,,127.64,Other,260% Medicaid APG methodology,159.07,,,159.07,Other,324% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,61.37,,,61.37,Other,125% Medicaid APG methodology,0.01,465.63,
ELECTRICAL STIM EA 15 PTA       ,97032,CPT,GP       ,48602965,CDM,421,RC,,,both,,,561,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,148.34,,,148.34,Fee Schedule,,133.46,,,133.46,Fee Schedule,,126.03,,,126.03,Fee Schedule,,280.5,50,,280.5,percent of total billed charges,All Other,392.7,70,,392.7,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,91.32,,,91.32,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,465.63,83,,465.63,percent of total billed charges,All Other,33.64,,,33.64,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,465.63,83,,465.63,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,392.7,70,,392.7,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,49.09,,,49.09,Other,New York Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,75.11,,,75.11,Other,153% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,68.73,,,68.73,Other,140% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,127.64,,,127.64,Other,260% Medicaid APG methodology,159.07,,,159.07,Other,324% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,61.37,,,61.37,Other,125% Medicaid APG methodology,0.01,465.63,
SELF CARE MNGMENT TRAINING PTA  ,97535,CPT,GP       ,48603278,CDM,421,RC,,,both,,,314,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,271.26,,,271.26,Fee Schedule,,244.06,,,244.06,Fee Schedule,,230.46,,,230.46,Fee Schedule,,157,50,,157,percent of total billed charges,All Other,219.8,70,,219.8,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,91.32,,,91.32,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,260.62,83,,260.62,percent of total billed charges,All Other,77.18,,,77.18,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,260.62,83,,260.62,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,219.8,70,,219.8,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,49.09,,,49.09,Other,New York Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,75.11,,,75.11,Other,153% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,68.73,,,68.73,Other,140% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,127.64,,,127.64,Other,260% Medicaid APG methodology,159.07,,,159.07,Other,324% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,61.37,,,61.37,Other,125% Medicaid APG methodology,0.01,368,
GROUP THERAPEUTIC PROCEDURES    ,97150,CPT,GP       ,48600027,CDM,423,RC,,,both,,,146,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,159.68,,,159.68,Fee Schedule,,143.67,,,143.67,Fee Schedule,,135.66,,,135.66,Fee Schedule,,73,50,,73,percent of total billed charges,All Other,102.2,70,,102.2,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,121.18,83,,121.18,percent of total billed charges,All Other,42.36,,,42.36,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,121.18,83,,121.18,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,102.2,70,,102.2,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,368,
PT EVAL LOW COMPLEX 20 MIN      ,97161,CPT,GP       ,48600001,CDM,424,RC,,,both,,,1098,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,549,50,,549,percent of total billed charges,All Other,768.6,70,,768.6,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,291.37,,,291.37,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,911.34,83,,911.34,percent of total billed charges,All Other,236.04,,,236.04,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,911.34,83,,911.34,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,768.6,70,,768.6,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,156.65,,,156.65,Other,New York Medicaid APG methodology,156.65,,,156.65,Other,100% Medicaid APG methodology,156.65,,,156.65,Other,100% Medicaid APG methodology,156.65,,,156.65,Other,100% Medicaid APG methodology,352.46,,,352.46,Other,225% Medicaid APG methodology,352.46,,,352.46,Other,225% Medicaid APG methodology,239.68,,,239.68,Other,153% Medicaid APG methodology,352.46,,,352.46,Other,225% Medicaid APG methodology,219.31,,,219.31,Other,140% Medicaid APG methodology,352.46,,,352.46,Other,225% Medicaid APG methodology,407.29,,,407.29,Other,260% Medicaid APG methodology,507.55,,,507.55,Other,324% Medicaid APG methodology,336.8,,,336.8,Other,215% Medicaid APG methodology,336.8,,,336.8,Other,215% Medicaid APG methodology,195.81,,,195.81,Other,125% Medicaid APG methodology,0.01,911.34,
PT RE-EVAL EST PLAN CARE        ,97164,CPT,GP       ,48600019,CDM,424,RC,,,both,,,1092,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,52.16,,,52.16,Fee Schedule,,52.16,,,52.16,Fee Schedule,,52.16,,,52.16,Fee Schedule,,546,50,,546,percent of total billed charges,All Other,764.4,70,,764.4,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,291.37,,,291.37,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,906.36,83,,906.36,percent of total billed charges,All Other,165.02,,,165.02,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,906.36,83,,906.36,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,764.4,70,,764.4,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,156.65,,,156.65,Other,New York Medicaid APG methodology,156.65,,,156.65,Other,100% Medicaid APG methodology,156.65,,,156.65,Other,100% Medicaid APG methodology,156.65,,,156.65,Other,100% Medicaid APG methodology,352.46,,,352.46,Other,225% Medicaid APG methodology,352.46,,,352.46,Other,225% Medicaid APG methodology,239.68,,,239.68,Other,153% Medicaid APG methodology,352.46,,,352.46,Other,225% Medicaid APG methodology,219.31,,,219.31,Other,140% Medicaid APG methodology,352.46,,,352.46,Other,225% Medicaid APG methodology,407.29,,,407.29,Other,260% Medicaid APG methodology,507.55,,,507.55,Other,324% Medicaid APG methodology,336.8,,,336.8,Other,215% Medicaid APG methodology,336.8,,,336.8,Other,215% Medicaid APG methodology,195.81,,,195.81,Other,125% Medicaid APG methodology,0.01,906.36,
PT EVAL MOD COMPLEX 30 MIN      ,97162,CPT,GP       ,48601165,CDM,424,RC,,,both,,,1098,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,549,50,,549,percent of total billed charges,All Other,768.6,70,,768.6,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,291.37,,,291.37,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,911.34,83,,911.34,percent of total billed charges,All Other,236.04,,,236.04,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,911.34,83,,911.34,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,768.6,70,,768.6,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,156.65,,,156.65,Other,New York Medicaid APG methodology,156.65,,,156.65,Other,100% Medicaid APG methodology,156.65,,,156.65,Other,100% Medicaid APG methodology,156.65,,,156.65,Other,100% Medicaid APG methodology,352.46,,,352.46,Other,225% Medicaid APG methodology,352.46,,,352.46,Other,225% Medicaid APG methodology,239.68,,,239.68,Other,153% Medicaid APG methodology,352.46,,,352.46,Other,225% Medicaid APG methodology,219.31,,,219.31,Other,140% Medicaid APG methodology,352.46,,,352.46,Other,225% Medicaid APG methodology,407.29,,,407.29,Other,260% Medicaid APG methodology,507.55,,,507.55,Other,324% Medicaid APG methodology,336.8,,,336.8,Other,215% Medicaid APG methodology,336.8,,,336.8,Other,215% Medicaid APG methodology,195.81,,,195.81,Other,125% Medicaid APG methodology,0.01,911.34,
PT EVAL HIGH COMPLEX 45 MIN     ,97163,CPT,GP       ,48601173,CDM,424,RC,,,both,,,1098,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,76.19,,,76.19,Fee Schedule,,549,50,,549,percent of total billed charges,All Other,768.6,70,,768.6,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,291.37,,,291.37,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,911.34,83,,911.34,percent of total billed charges,All Other,236.04,,,236.04,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,911.34,83,,911.34,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,768.6,70,,768.6,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,156.65,,,156.65,Other,New York Medicaid APG methodology,156.65,,,156.65,Other,100% Medicaid APG methodology,156.65,,,156.65,Other,100% Medicaid APG methodology,156.65,,,156.65,Other,100% Medicaid APG methodology,352.46,,,352.46,Other,225% Medicaid APG methodology,352.46,,,352.46,Other,225% Medicaid APG methodology,239.68,,,239.68,Other,153% Medicaid APG methodology,352.46,,,352.46,Other,225% Medicaid APG methodology,219.31,,,219.31,Other,140% Medicaid APG methodology,352.46,,,352.46,Other,225% Medicaid APG methodology,407.29,,,407.29,Other,260% Medicaid APG methodology,507.55,,,507.55,Other,324% Medicaid APG methodology,336.8,,,336.8,Other,215% Medicaid APG methodology,336.8,,,336.8,Other,215% Medicaid APG methodology,195.81,,,195.81,Other,125% Medicaid APG methodology,0.01,911.34,
THER IVNTJ EA ADDL 15 MIN       ,97130,CPT,,48602619,CDM,430,RC,,,both,,,218,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,21.13,,,21.13,Fee Schedule,,21.13,,,21.13,Fee Schedule,,21.13,,,21.13,Fee Schedule,,109,50,,109,percent of total billed charges,All Other,152.6,70,,152.6,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,180.94,83,,180.94,percent of total billed charges,All Other,48.03,,,48.03,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,180.94,83,,180.94,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,152.6,70,,152.6,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,368,
HOT OR COLD PACKS THERAPY       ,97010,CPT,GO       ,48700033,CDM,430,RC,,,both,,,384,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,3.82,,,3.82,Fee Schedule,,3.82,,,3.82,Fee Schedule,,3.82,,,3.82,Fee Schedule,,192,50,,192,percent of total billed charges,All Other,268.8,70,,268.8,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,91.32,,,91.32,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,211.2,55,,211.2,percent of total billed charges,All Other,211.2,55,,211.2,percent of total billed charges,All Other,257,,,257,Case Rate,PT OT ST Per Visit,211.2,55,,211.2,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,268.8,70,,268.8,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,49.09,,,49.09,Other,New York Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,75.11,,,75.11,Other,153% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,68.73,,,68.73,Other,140% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,127.64,,,127.64,Other,260% Medicaid APG methodology,159.07,,,159.07,Other,324% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,61.37,,,61.37,Other,125% Medicaid APG methodology,0.01,368,
THERAPEUTIC EXERCISES EA 15     ,97110,CPT,GO       ,48700108,CDM,430,RC,,,both,,,596,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,246.35,,,246.35,Fee Schedule,,221.64,,,221.64,Fee Schedule,,209.29,,,209.29,Fee Schedule,,298,50,,298,percent of total billed charges,All Other,417.2,70,,417.2,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,494.68,83,,494.68,percent of total billed charges,All Other,68.92,,,68.92,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,494.68,83,,494.68,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,417.2,70,,417.2,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,494.68,
NEUROMUSCULAR RE-ED EA 15       ,97112,CPT,GO       ,48700132,CDM,430,RC,,,both,,,398,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,258.84,,,258.84,Fee Schedule,,232.88,,,232.88,Fee Schedule,,219.91,,,219.91,Fee Schedule,,199,50,,199,percent of total billed charges,All Other,278.6,70,,278.6,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,330.34,83,,330.34,percent of total billed charges,All Other,79.19,,,79.19,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,330.34,83,,330.34,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,278.6,70,,278.6,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,368,
PHYSICAL PERFORM TEST EA 15     ,97750,CPT,GO       ,48700223,CDM,430,RC,,,both,,,376,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,262.21,,,262.21,Fee Schedule,,235.92,,,235.92,Fee Schedule,,222.77,,,222.77,Fee Schedule,,188,50,,188,percent of total billed charges,All Other,263.2,70,,263.2,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,312.08,83,,312.08,percent of total billed charges,All Other,80.47,,,80.47,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,312.08,83,,312.08,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,263.2,70,,263.2,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,368,
ORTHOTIC MGMT&TRAING 1ST ENC    ,97760,CPT,GO       ,48700256,CDM,430,RC,,,both,,,340,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,296.53,,,296.53,Fee Schedule,,266.8,,,266.8,Fee Schedule,,251.93,,,251.93,Fee Schedule,,170,50,,170,percent of total billed charges,All Other,238,70,,238,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,282.2,83,,282.2,percent of total billed charges,All Other,113.84,,,113.84,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,282.2,83,,282.2,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,238,70,,238,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,368,
THERAPEUTIC ACTVTY EA 15 MIN    ,97530,CPT,GO       ,48700264,CDM,430,RC,,,both,,,465,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,271.83,,,271.83,Fee Schedule,,244.58,,,244.58,Fee Schedule,,230.95,,,230.95,Fee Schedule,,232.5,50,,232.5,percent of total billed charges,All Other,325.5,70,,325.5,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,385.95,83,,385.95,percent of total billed charges,All Other,87.17,,,87.17,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,385.95,83,,385.95,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,325.5,70,,325.5,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,385.95,
SELF CARE MNG TRNG EA 15 MIN    ,97535,CPT,GO       ,48700272,CDM,430,RC,,,both,,,314,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,271.26,,,271.26,Fee Schedule,,244.06,,,244.06,Fee Schedule,,230.46,,,230.46,Fee Schedule,,157,50,,157,percent of total billed charges,All Other,219.8,70,,219.8,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,91.32,,,91.32,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,260.62,83,,260.62,percent of total billed charges,All Other,77.18,,,77.18,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,260.62,83,,260.62,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,219.8,70,,219.8,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,49.09,,,49.09,Other,New York Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,75.11,,,75.11,Other,153% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,68.73,,,68.73,Other,140% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,127.64,,,127.64,Other,260% Medicaid APG methodology,159.07,,,159.07,Other,324% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,61.37,,,61.37,Other,125% Medicaid APG methodology,0.01,368,
COMMUNITY/WORK REINTEGRATION    ,97537,CPT,GO       ,48700280,CDM,430,RC,,,both,,,232,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,233.85,,,233.85,Fee Schedule,,210.4,,,210.4,Fee Schedule,,198.68,,,198.68,Fee Schedule,,116,50,,116,percent of total billed charges,All Other,162.4,70,,162.4,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,192.56,83,,192.56,percent of total billed charges,All Other,74.42,,,74.42,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,192.56,83,,192.56,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,162.4,70,,162.4,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,368,
WHEELCHAIR MNG TRAINING EA 15   ,97542,CPT,GO       ,48700298,CDM,430,RC,,,both,,,216,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,237.01,,,237.01,Fee Schedule,,213.24,,,213.24,Fee Schedule,,201.36,,,201.36,Fee Schedule,,108,50,,108,percent of total billed charges,All Other,151.2,70,,151.2,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,179.28,83,,179.28,percent of total billed charges,All Other,74.42,,,74.42,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,179.28,83,,179.28,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,151.2,70,,151.2,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,368,
ORTHC/PROSTC MGMT SBSQ ENC      ,97763,CPT,GO       ,48700348,CDM,430,RC,,,both,,,210,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,45.82,,,45.82,Fee Schedule,,45.82,,,45.82,Fee Schedule,,45.82,,,45.82,Fee Schedule,,105,50,,105,percent of total billed charges,All Other,147,70,,147,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,174.3,83,,174.3,percent of total billed charges,All Other,125.58,,,125.58,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,174.3,83,,174.3,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,147,70,,147,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,368,
MANUAL THERAPY 1/> REG EA 15    ,97140,CPT,GO       ,48700413,CDM,430,RC,,,both,,,501,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,231.84,,,231.84,Fee Schedule,,208.59,,,208.59,Fee Schedule,,196.97,,,196.97,Fee Schedule,,250.5,50,,250.5,percent of total billed charges,All Other,350.7,70,,350.7,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,415.83,83,,415.83,percent of total billed charges,All Other,63.34,,,63.34,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,415.83,83,,415.83,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,350.7,70,,350.7,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,415.83,
ELECTRIC CURRENT THERAPY EA 15  ,97033,CPT,GO       ,48700538,CDM,430,RC,,,both,,,234,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,244.48,,,244.48,Fee Schedule,,219.96,,,219.96,Fee Schedule,,207.71,,,207.71,Fee Schedule,,117,50,,117,percent of total billed charges,All Other,163.8,70,,163.8,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,91.32,,,91.32,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,194.22,83,,194.22,percent of total billed charges,All Other,45.93,,,45.93,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,194.22,83,,194.22,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,163.8,70,,163.8,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,49.09,,,49.09,Other,New York Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,75.11,,,75.11,Other,153% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,68.73,,,68.73,Other,140% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,127.64,,,127.64,Other,260% Medicaid APG methodology,159.07,,,159.07,Other,324% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,61.37,,,61.37,Other,125% Medicaid APG methodology,0.01,368,
ELECTRIC STIMULATION THERAPY    ,97014,CPT,GO       ,48700546,CDM,430,RC,,,both,,,822,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,10.38,,,10.38,Fee Schedule,,10.38,,,10.38,Fee Schedule,,10.38,,,10.38,Fee Schedule,,411,50,,411,percent of total billed charges,All Other,575.4,70,,575.4,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,91.32,,,91.32,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,452.1,55,,452.1,percent of total billed charges,All Other,452.1,55,,452.1,percent of total billed charges,All Other,257,,,257,Case Rate,PT OT ST Per Visit,452.1,55,,452.1,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,575.4,70,,575.4,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,49.09,,,49.09,Other,New York Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,75.11,,,75.11,Other,153% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,68.73,,,68.73,Other,140% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,127.64,,,127.64,Other,260% Medicaid APG methodology,159.07,,,159.07,Other,324% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,61.37,,,61.37,Other,125% Medicaid APG methodology,0.01,575.4,
THER IVNTJ 1ST 15 MIN           ,97129,CPT,,48700561,CDM,430,RC,,,both,,,302,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,22.08,,,22.08,Fee Schedule,,22.08,,,22.08,Fee Schedule,,22.08,,,22.08,Fee Schedule,,151,50,,151,percent of total billed charges,All Other,211.4,70,,211.4,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,250.66,83,,250.66,percent of total billed charges,All Other,50.32,,,50.32,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,250.66,83,,250.66,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,211.4,70,,211.4,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,368,
SENSORY INTEGRATION EA 15 MIN   ,97533,CPT,GO       ,48700579,CDM,430,RC,,,both,,,246,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,228.18,,,228.18,Fee Schedule,,205.3,,,205.3,Fee Schedule,,193.86,,,193.86,Fee Schedule,,123,50,,123,percent of total billed charges,All Other,172.2,70,,172.2,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,204.18,83,,204.18,percent of total billed charges,All Other,150.34,,,150.34,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,204.18,83,,204.18,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,172.2,70,,172.2,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,368,
ELECTRICAL STIMULATION EA 15    ,97032,CPT,GO       ,48700850,CDM,430,RC,,,both,,,561,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,148.34,,,148.34,Fee Schedule,,133.46,,,133.46,Fee Schedule,,126.03,,,126.03,Fee Schedule,,280.5,50,,280.5,percent of total billed charges,All Other,392.7,70,,392.7,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,91.32,,,91.32,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,465.63,83,,465.63,percent of total billed charges,All Other,33.64,,,33.64,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,465.63,83,,465.63,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,392.7,70,,392.7,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,49.09,,,49.09,Other,New York Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,75.11,,,75.11,Other,153% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,68.73,,,68.73,Other,140% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,127.64,,,127.64,Other,260% Medicaid APG methodology,159.07,,,159.07,Other,324% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,61.37,,,61.37,Other,125% Medicaid APG methodology,0.01,465.63,
ASSISTIVE TECH ASSESS EA 15 MN  ,97755,CPT,GO       ,48700884,CDM,430,RC,,,both,,,434,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,280.81,,,280.81,Fee Schedule,,252.65,,,252.65,Fee Schedule,,238.57,,,238.57,Fee Schedule,,217,50,,217,percent of total billed charges,All Other,303.8,70,,303.8,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,291.37,,,291.37,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,360.22,83,,360.22,percent of total billed charges,All Other,90.11,,,90.11,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,360.22,83,,360.22,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,303.8,70,,303.8,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,156.65,,,156.65,Other,New York Medicaid APG methodology,156.65,,,156.65,Other,100% Medicaid APG methodology,156.65,,,156.65,Other,100% Medicaid APG methodology,156.65,,,156.65,Other,100% Medicaid APG methodology,352.46,,,352.46,Other,225% Medicaid APG methodology,352.46,,,352.46,Other,225% Medicaid APG methodology,239.68,,,239.68,Other,153% Medicaid APG methodology,352.46,,,352.46,Other,225% Medicaid APG methodology,219.31,,,219.31,Other,140% Medicaid APG methodology,352.46,,,352.46,Other,225% Medicaid APG methodology,407.29,,,407.29,Other,260% Medicaid APG methodology,507.55,,,507.55,Other,324% Medicaid APG methodology,336.8,,,336.8,Other,215% Medicaid APG methodology,336.8,,,336.8,Other,215% Medicaid APG methodology,195.81,,,195.81,Other,125% Medicaid APG methodology,0.01,507.55,
MASSAGE THERAPY EA 15 MIN       ,97124,CPT,59GO     ,48701411,CDM,430,RC,,,both,,,311,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,202.05,,,202.05,Fee Schedule,,181.78,,,181.78,Fee Schedule,,171.65,,,171.65,Fee Schedule,,155.5,50,,155.5,percent of total billed charges,All Other,217.7,70,,217.7,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,91.32,,,91.32,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,258.13,83,,258.13,percent of total billed charges,All Other,72.32,,,72.32,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,258.13,83,,258.13,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,217.7,70,,217.7,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,49.09,,,49.09,Other,New York Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,75.11,,,75.11,Other,153% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,68.73,,,68.73,Other,140% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,127.64,,,127.64,Other,260% Medicaid APG methodology,159.07,,,159.07,Other,324% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,61.37,,,61.37,Other,125% Medicaid APG methodology,0.01,368,
THER IVNTJ EA ADDL 15 MIN       ,97130,CPT,,48701601,CDM,430,RC,,,both,,,218,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,21.13,,,21.13,Fee Schedule,,21.13,,,21.13,Fee Schedule,,21.13,,,21.13,Fee Schedule,,109,50,,109,percent of total billed charges,All Other,152.6,70,,152.6,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,180.94,83,,180.94,percent of total billed charges,All Other,48.03,,,48.03,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,180.94,83,,180.94,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,152.6,70,,152.6,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,368,
"OT Cog Funct Ther Interventions, Addl 15 Min Assistant Units",97130,CPT,,48701809,CDM,430,RC,,,both,,,218,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,109,50,,109,percent of total billed charges,All Other Outpatient,98.1,45,,98.1,percent of total billed charges,All Other Outpatient,93.74,43,,93.74,percent of total billed charges,All Other Outpatient,109,50,,109,percent of total billed charges,All Other,152.6,70,,152.6,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,180.94,83,,180.94,percent of total billed charges,All Other,48.03,,,48.03,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,180.94,83,,180.94,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,152.6,70,,152.6,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,368,
"OT Orthotic/Prosthetic Manage,Train Assistant Units",97763,CPT,,48701817,CDM,430,RC,,,both,,,210,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,105,50,,105,percent of total billed charges,All Other Outpatient,94.5,45,,94.5,percent of total billed charges,All Other Outpatient,90.3,43,,90.3,percent of total billed charges,All Other Outpatient,105,50,,105,percent of total billed charges,All Other,147,70,,147,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,174.3,83,,174.3,percent of total billed charges,All Other,125.58,,,125.58,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,174.3,83,,174.3,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,147,70,,147,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,368,
SELF CARE MANGMENT TRAINING     ,97535,CPT,GO       ,48701825,CDM,430,RC,,,both,,,314,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,271.26,,,271.26,Fee Schedule,,244.06,,,244.06,Fee Schedule,,230.46,,,230.46,Fee Schedule,,157,50,,157,percent of total billed charges,All Other,219.8,70,,219.8,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,91.32,,,91.32,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,260.62,83,,260.62,percent of total billed charges,All Other,77.18,,,77.18,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,260.62,83,,260.62,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,219.8,70,,219.8,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,49.09,,,49.09,Other,New York Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,75.11,,,75.11,Other,153% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,68.73,,,68.73,Other,140% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,127.64,,,127.64,Other,260% Medicaid APG methodology,159.07,,,159.07,Other,324% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,61.37,,,61.37,Other,125% Medicaid APG methodology,0.01,368,
"OT Self Care, Home Mgmt Assistant Units",97535,CPT,,48701833,CDM,430,RC,,,both,,,314,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,157,50,,157,percent of total billed charges,All Other Outpatient,141.3,45,,141.3,percent of total billed charges,All Other Outpatient,135.02,43,,135.02,percent of total billed charges,All Other Outpatient,157,50,,157,percent of total billed charges,All Other,219.8,70,,219.8,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,91.32,,,91.32,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,260.62,83,,260.62,percent of total billed charges,All Other,77.18,,,77.18,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,260.62,83,,260.62,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,219.8,70,,219.8,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,49.09,,,49.09,Other,New York Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,75.11,,,75.11,Other,153% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,68.73,,,68.73,Other,140% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,127.64,,,127.64,Other,260% Medicaid APG methodology,159.07,,,159.07,Other,324% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,61.37,,,61.37,Other,125% Medicaid APG methodology,0.01,368,
OT Std Cog Perform Test Assist,96125,CPT,,48701841,CDM,430,RC,,,both,,,869,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,434.5,50,,434.5,percent of total billed charges,All Other Outpatient,391.05,45,,391.05,percent of total billed charges,All Other Outpatient,373.67,43,,373.67,percent of total billed charges,All Other Outpatient,434.5,50,,434.5,percent of total billed charges,All Other,608.3,70,,608.3,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,344.55,,,344.55,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,721.27,83,,721.27,percent of total billed charges,All Other,240.47,,,240.47,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,721.27,83,,721.27,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,608.3,70,,608.3,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,185.24,,,185.24,Other,New York Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,283.42,,,283.42,Other,153% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,259.34,,,259.34,Other,140% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,481.63,,,481.63,Other,260% Medicaid APG methodology,600.18,,,600.18,Other,324% Medicaid APG methodology,398.27,,,398.27,Other,215% Medicaid APG methodology,398.27,,,398.27,Other,215% Medicaid APG methodology,231.55,,,231.55,Other,125% Medicaid APG methodology,0.01,721.27,
WHIRLPOOL THERAPY               ,97022,CPT,GO       ,48701395,CDM,431,RC,,,both,,,558,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,177.78,,,177.78,Fee Schedule,,159.95,,,159.95,Fee Schedule,,151.04,,,151.04,Fee Schedule,,279,50,,279,percent of total billed charges,All Other,390.6,70,,390.6,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,91.32,,,91.32,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,463.14,83,,463.14,percent of total billed charges,All Other,40.99,,,40.99,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,463.14,83,,463.14,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,390.6,70,,390.6,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,49.09,,,49.09,Other,New York Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,75.11,,,75.11,Other,153% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,68.73,,,68.73,Other,140% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,127.64,,,127.64,Other,260% Medicaid APG methodology,159.07,,,159.07,Other,324% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,61.37,,,61.37,Other,125% Medicaid APG methodology,0.01,463.14,
ULTRASOUND THERAPY EA 15        ,97035,CPT,GO       ,48701403,CDM,431,RC,,,both,,,704,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,97.58,,,97.58,Fee Schedule,,87.79,,,87.79,Fee Schedule,,82.9,,,82.9,Fee Schedule,,352,50,,352,percent of total billed charges,All Other,492.8,70,,492.8,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,91.32,,,91.32,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,584.32,83,,584.32,percent of total billed charges,All Other,33.2,,,33.2,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,584.32,83,,584.32,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,492.8,70,,492.8,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,49.09,,,49.09,Other,New York Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,75.11,,,75.11,Other,153% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,68.73,,,68.73,Other,140% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,127.64,,,127.64,Other,260% Medicaid APG methodology,159.07,,,159.07,Other,324% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,61.37,,,61.37,Other,125% Medicaid APG methodology,0.01,584.32,
PARAFFIN BATH THERAPY           ,97018,CPT,GO       ,48701478,CDM,431,RC,,,both,,,262,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,84.08,,,84.08,Fee Schedule,,75.65,,,75.65,Fee Schedule,,71.43,,,71.43,Fee Schedule,,131,50,,131,percent of total billed charges,All Other,183.4,70,,183.4,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,91.32,,,91.32,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,217.46,83,,217.46,percent of total billed charges,All Other,13.97,,,13.97,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,217.46,83,,217.46,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,183.4,70,,183.4,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,49.09,,,49.09,Other,New York Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,75.11,,,75.11,Other,153% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,68.73,,,68.73,Other,140% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,127.64,,,127.64,Other,260% Medicaid APG methodology,159.07,,,159.07,Other,324% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,61.37,,,61.37,Other,125% Medicaid APG methodology,0.01,368,
PROSTHETIC TRNG 1ST ENC EA 15   ,97761,CPT,GO       ,48701486,CDM,431,RC,,,both,,,245,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,259.13,,,259.13,Fee Schedule,,233.14,,,233.14,Fee Schedule,,220.15,,,220.15,Fee Schedule,,122.5,50,,122.5,percent of total billed charges,All Other,171.5,70,,171.5,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,203.35,83,,203.35,percent of total billed charges,All Other,98.99,,,98.99,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,203.35,83,,203.35,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,171.5,70,,171.5,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,368,
OT EVAL LOW COMPLEX 30 MIN      ,97165,CPT,GO       ,48700009,CDM,434,RC,,,both,,,1271,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,635.5,50,,635.5,percent of total billed charges,All Other,889.7,70,,889.7,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,306.56,,,306.56,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,1054.93,83,,1054.93,percent of total billed charges,All Other,238.5,,,238.5,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,1054.93,83,,1054.93,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,889.7,70,,889.7,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,164.82,,,164.82,Other,New York Medicaid APG methodology,164.82,,,164.82,Other,100% Medicaid APG methodology,164.82,,,164.82,Other,100% Medicaid APG methodology,164.82,,,164.82,Other,100% Medicaid APG methodology,370.84,,,370.84,Other,225% Medicaid APG methodology,370.84,,,370.84,Other,225% Medicaid APG methodology,252.17,,,252.17,Other,153% Medicaid APG methodology,370.84,,,370.84,Other,225% Medicaid APG methodology,230.75,,,230.75,Other,140% Medicaid APG methodology,370.84,,,370.84,Other,225% Medicaid APG methodology,428.53,,,428.53,Other,260% Medicaid APG methodology,534.02,,,534.02,Other,324% Medicaid APG methodology,354.36,,,354.36,Other,215% Medicaid APG methodology,354.36,,,354.36,Other,215% Medicaid APG methodology,206.02,,,206.02,Other,125% Medicaid APG methodology,0.01,1054.93,
OT RE-EVAL EST PLAN CARE        ,97168,CPT,GO       ,48700017,CDM,434,RC,,,both,,,740,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,48.77,,,48.77,Fee Schedule,,48.77,,,48.77,Fee Schedule,,48.77,,,48.77,Fee Schedule,,370,50,,370,percent of total billed charges,All Other,518,70,,518,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,306.56,,,306.56,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,614.2,83,,614.2,percent of total billed charges,All Other,165.84,,,165.84,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,614.2,83,,614.2,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,518,70,,518,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,164.82,,,164.82,Other,New York Medicaid APG methodology,164.82,,,164.82,Other,100% Medicaid APG methodology,164.82,,,164.82,Other,100% Medicaid APG methodology,164.82,,,164.82,Other,100% Medicaid APG methodology,370.84,,,370.84,Other,225% Medicaid APG methodology,370.84,,,370.84,Other,225% Medicaid APG methodology,252.17,,,252.17,Other,153% Medicaid APG methodology,370.84,,,370.84,Other,225% Medicaid APG methodology,230.75,,,230.75,Other,140% Medicaid APG methodology,370.84,,,370.84,Other,225% Medicaid APG methodology,428.53,,,428.53,Other,260% Medicaid APG methodology,534.02,,,534.02,Other,324% Medicaid APG methodology,354.36,,,354.36,Other,215% Medicaid APG methodology,354.36,,,354.36,Other,215% Medicaid APG methodology,206.02,,,206.02,Other,125% Medicaid APG methodology,0.01,614.2,
OT EVAL MOD COMPLEX 45 MIN      ,97166,CPT,GO       ,48701353,CDM,434,RC,,,both,,,1271,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,635.5,50,,635.5,percent of total billed charges,All Other,889.7,70,,889.7,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,306.56,,,306.56,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,1054.93,83,,1054.93,percent of total billed charges,All Other,238.5,,,238.5,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,1054.93,83,,1054.93,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,889.7,70,,889.7,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,164.82,,,164.82,Other,New York Medicaid APG methodology,164.82,,,164.82,Other,100% Medicaid APG methodology,164.82,,,164.82,Other,100% Medicaid APG methodology,164.82,,,164.82,Other,100% Medicaid APG methodology,370.84,,,370.84,Other,225% Medicaid APG methodology,370.84,,,370.84,Other,225% Medicaid APG methodology,252.17,,,252.17,Other,153% Medicaid APG methodology,370.84,,,370.84,Other,225% Medicaid APG methodology,230.75,,,230.75,Other,140% Medicaid APG methodology,370.84,,,370.84,Other,225% Medicaid APG methodology,428.53,,,428.53,Other,260% Medicaid APG methodology,534.02,,,534.02,Other,324% Medicaid APG methodology,354.36,,,354.36,Other,215% Medicaid APG methodology,354.36,,,354.36,Other,215% Medicaid APG methodology,206.02,,,206.02,Other,125% Medicaid APG methodology,0.01,1054.93,
OT EVAL HIGH COMPLEX 60 MIN     ,97167,CPT,GO       ,48701361,CDM,434,RC,,,both,,,1271,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,73.77,,,73.77,Fee Schedule,,635.5,50,,635.5,percent of total billed charges,All Other,889.7,70,,889.7,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,306.56,,,306.56,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,1054.93,83,,1054.93,percent of total billed charges,All Other,238.5,,,238.5,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,1054.93,83,,1054.93,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,889.7,70,,889.7,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,164.82,,,164.82,Other,New York Medicaid APG methodology,164.82,,,164.82,Other,100% Medicaid APG methodology,164.82,,,164.82,Other,100% Medicaid APG methodology,164.82,,,164.82,Other,100% Medicaid APG methodology,370.84,,,370.84,Other,225% Medicaid APG methodology,370.84,,,370.84,Other,225% Medicaid APG methodology,252.17,,,252.17,Other,153% Medicaid APG methodology,370.84,,,370.84,Other,225% Medicaid APG methodology,230.75,,,230.75,Other,140% Medicaid APG methodology,370.84,,,370.84,Other,225% Medicaid APG methodology,428.53,,,428.53,Other,260% Medicaid APG methodology,534.02,,,534.02,Other,324% Medicaid APG methodology,354.36,,,354.36,Other,215% Medicaid APG methodology,354.36,,,354.36,Other,215% Medicaid APG methodology,206.02,,,206.02,Other,125% Medicaid APG methodology,0.01,1054.93,
COGNITIVE TEST BY HC PRO        ,96125,CPT,GO       ,48701791,CDM,434,RC,,,both,,,869,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,766.9,,,766.9,Fee Schedule,,689.99,,,689.99,Fee Schedule,,651.54,,,651.54,Fee Schedule,,434.5,50,,434.5,percent of total billed charges,All Other,608.3,70,,608.3,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,344.55,,,344.55,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,721.27,83,,721.27,percent of total billed charges,All Other,240.47,,,240.47,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,721.27,83,,721.27,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,608.3,70,,608.3,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,185.24,,,185.24,Other,New York Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,283.42,,,283.42,Other,153% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,259.34,,,259.34,Other,140% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,481.63,,,481.63,Other,260% Medicaid APG methodology,600.18,,,600.18,Other,324% Medicaid APG methodology,398.27,,,398.27,Other,215% Medicaid APG methodology,398.27,,,398.27,Other,215% Medicaid APG methodology,231.55,,,231.55,Other,125% Medicaid APG methodology,0.01,766.9,
SPEECH SOUND LANG COMPREHEN     ,92523,CPT,GN       ,48800049,CDM,440,RC,,,both,,,1372,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,190.46,,,190.46,Fee Schedule,,190.46,,,190.46,Fee Schedule,,190.46,,,190.46,Fee Schedule,,686,50,,686,percent of total billed charges,All Other,960.4,70,,960.4,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,283.77,,,283.77,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,1138.76,83,,1138.76,percent of total billed charges,All Other,533.65,,,533.65,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,1138.76,83,,1138.76,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,960.4,70,,960.4,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,152.57,,,152.57,Other,New York Medicaid APG methodology,152.57,,,152.57,Other,100% Medicaid APG methodology,152.57,,,152.57,Other,100% Medicaid APG methodology,152.57,,,152.57,Other,100% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,233.43,,,233.43,Other,153% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,213.59,,,213.59,Other,140% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,396.67,,,396.67,Other,260% Medicaid APG methodology,494.32,,,494.32,Other,324% Medicaid APG methodology,328.02,,,328.02,Other,215% Medicaid APG methodology,328.02,,,328.02,Other,215% Medicaid APG methodology,190.71,,,190.71,Other,125% Medicaid APG methodology,0.01,1138.76,
EVALUATE SWALLOWING FUNCTION    ,92610,CPT,GN       ,48800056,CDM,440,RC,,,both,,,1123,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,892.04,,,892.04,Fee Schedule,,802.59,,,802.59,Fee Schedule,,757.86,,,757.86,Fee Schedule,,561.5,50,,561.5,percent of total billed charges,All Other,786.1,70,,786.1,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,283.77,,,283.77,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,932.09,83,,932.09,percent of total billed charges,All Other,163.17,,,163.17,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,932.09,83,,932.09,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,786.1,70,,786.1,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,152.57,,,152.57,Other,New York Medicaid APG methodology,152.57,,,152.57,Other,100% Medicaid APG methodology,152.57,,,152.57,Other,100% Medicaid APG methodology,152.57,,,152.57,Other,100% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,233.43,,,233.43,Other,153% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,213.59,,,213.59,Other,140% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,396.67,,,396.67,Other,260% Medicaid APG methodology,494.32,,,494.32,Other,324% Medicaid APG methodology,328.02,,,328.02,Other,215% Medicaid APG methodology,328.02,,,328.02,Other,215% Medicaid APG methodology,190.71,,,190.71,Other,125% Medicaid APG methodology,0.01,932.09,
SPEECH/HEARING THERAPY INDV     ,92507,CPT,GN       ,48800130,CDM,440,RC,,,both,,,1000,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,683.18,,,683.18,Fee Schedule,,614.67,,,614.67,Fee Schedule,,580.42,,,580.42,Fee Schedule,,500,50,,500,percent of total billed charges,All Other,700,70,,700,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,283.77,,,283.77,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,830,83,,830,percent of total billed charges,All Other,178.35,,,178.35,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,830,83,,830,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,700,70,,700,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,152.57,,,152.57,Other,New York Medicaid APG methodology,152.57,,,152.57,Other,100% Medicaid APG methodology,152.57,,,152.57,Other,100% Medicaid APG methodology,152.57,,,152.57,Other,100% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,233.43,,,233.43,Other,153% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,213.59,,,213.59,Other,140% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,396.67,,,396.67,Other,260% Medicaid APG methodology,494.32,,,494.32,Other,324% Medicaid APG methodology,328.02,,,328.02,Other,215% Medicaid APG methodology,328.02,,,328.02,Other,215% Medicaid APG methodology,190.71,,,190.71,Other,125% Medicaid APG methodology,0.01,830,
SPEECH/HEARING THERAPY GRP      ,92508,CPT,GN       ,48800171,CDM,440,RC,,,both,,,208,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,228.11,,,228.11,Fee Schedule,,205.23,,,205.23,Fee Schedule,,193.8,,,193.8,Fee Schedule,,104,50,,104,percent of total billed charges,All Other,145.6,70,,145.6,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,172.64,83,,172.64,percent of total billed charges,All Other,57.67,,,57.67,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,172.64,83,,172.64,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,145.6,70,,145.6,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,368,
ORAL FUNCTION THERAPY           ,92526,CPT,GN       ,48800205,CDM,440,RC,,,both,,,895,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,790.02,,,790.02,Fee Schedule,,710.79,,,710.79,Fee Schedule,,671.18,,,671.18,Fee Schedule,,447.5,50,,447.5,percent of total billed charges,All Other,626.5,70,,626.5,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,742.85,83,,742.85,percent of total billed charges,All Other,198.62,,,198.62,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,742.85,83,,742.85,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,626.5,70,,626.5,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,790.02,
ORAL SPEECH DEVICE EVAL         ,92597,CPT,GN       ,48800213,CDM,440,RC,,,both,,,939,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,828.79,,,828.79,Fee Schedule,,745.68,,,745.68,Fee Schedule,,704.12,,,704.12,Fee Schedule,,469.5,50,,469.5,percent of total billed charges,All Other,657.3,70,,657.3,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,283.77,,,283.77,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,779.37,83,,779.37,percent of total billed charges,All Other,169.32,,,169.32,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,779.37,83,,779.37,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,657.3,70,,657.3,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,152.57,,,152.57,Other,New York Medicaid APG methodology,152.57,,,152.57,Other,100% Medicaid APG methodology,152.57,,,152.57,Other,100% Medicaid APG methodology,152.57,,,152.57,Other,100% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,233.43,,,233.43,Other,153% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,213.59,,,213.59,Other,140% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,396.67,,,396.67,Other,260% Medicaid APG methodology,494.32,,,494.32,Other,324% Medicaid APG methodology,328.02,,,328.02,Other,215% Medicaid APG methodology,328.02,,,328.02,Other,215% Medicaid APG methodology,190.71,,,190.71,Other,125% Medicaid APG methodology,0.01,828.79,
NON-SPEECH DEVICE SERVICE       ,92606,CPT,GN       ,48800296,CDM,440,RC,,,both,,,155,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,77.6,,,77.6,Fee Schedule,,77.6,,,77.6,Fee Schedule,,77.6,,,77.6,Fee Schedule,,77.5,50,,77.5,percent of total billed charges,All Other,108.5,70,,108.5,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,91.32,,,91.32,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,85.25,55,,85.25,percent of total billed charges,All Other,85.25,55,,85.25,percent of total billed charges,All Other,257,,,257,Case Rate,PT OT ST Per Visit,85.25,55,,85.25,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,108.5,70,,108.5,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,49.09,,,49.09,Other,New York Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,49.09,,,49.09,Other,100% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,75.11,,,75.11,Other,153% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,68.73,,,68.73,Other,140% Medicaid APG methodology,110.46,,,110.46,Other,225% Medicaid APG methodology,127.64,,,127.64,Other,260% Medicaid APG methodology,159.07,,,159.07,Other,324% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,105.55,,,105.55,Other,215% Medicaid APG methodology,61.37,,,61.37,Other,125% Medicaid APG methodology,0.01,368,
USE OF SPEECH DEVICE SERVICE    ,92609,CPT,GN       ,48800304,CDM,440,RC,,,both,,,882,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,980.64,,,980.64,Fee Schedule,,882.31,,,882.31,Fee Schedule,,833.14,,,833.14,Fee Schedule,,441,50,,441,percent of total billed charges,All Other,617.4,70,,617.4,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,732.06,83,,732.06,percent of total billed charges,All Other,243.83,,,243.83,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,732.06,83,,732.06,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,617.4,70,,617.4,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,980.64,
ENDOSCOPY SWALLOW (FEES) VID    ,92612,CPT,GN       ,48800312,CDM,440,RC,,,both,,,550,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,1461.13,,,1461.13,Fee Schedule,,1314.61,,,1314.61,Fee Schedule,,1241.35,,,1241.35,Fee Schedule,,275,50,,275,percent of total billed charges,All Other,385,70,,385,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,309.03,,,309.03,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,456.5,83,,456.5,percent of total billed charges,All Other,153.7,,,153.7,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,456.5,83,,456.5,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,385,70,,385,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,166.14,,,166.14,Other,New York Medicaid APG methodology,166.14,,,166.14,Other,100% Medicaid APG methodology,166.14,,,166.14,Other,100% Medicaid APG methodology,166.14,,,166.14,Other,100% Medicaid APG methodology,373.83,,,373.83,Other,225% Medicaid APG methodology,373.83,,,373.83,Other,225% Medicaid APG methodology,254.2,,,254.2,Other,153% Medicaid APG methodology,373.83,,,373.83,Other,225% Medicaid APG methodology,232.6,,,232.6,Other,140% Medicaid APG methodology,373.83,,,373.83,Other,225% Medicaid APG methodology,431.98,,,431.98,Other,260% Medicaid APG methodology,538.31,,,538.31,Other,324% Medicaid APG methodology,357.21,,,357.21,Other,215% Medicaid APG methodology,357.21,,,357.21,Other,215% Medicaid APG methodology,207.68,,,207.68,Other,125% Medicaid APG methodology,0.01,1461.13,
NASOPHARYNGOSCOPY               ,92511,CPT,GN       ,48800460,CDM,440,RC,,,both,,,733,376.68,,,376.68,Other,150% of Medicare + 9.63% HCRA Surcharge,229.06,,,229.06,Other,Medicare OPPS methodology,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,366.5,50,,366.5,percent of total billed charges,All Other Outpatient,329.85,45,,329.85,percent of total billed charges,All Other Outpatient,315.19,43,,315.19,percent of total billed charges,All Other Outpatient,366.5,50,,366.5,percent of total billed charges,All Other,513.1,70,,513.1,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,309.03,,,309.03,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,608.39,83,,608.39,percent of total billed charges,All Other,89.54,,,89.54,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,608.39,83,,608.39,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,513.1,70,,513.1,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,166.14,,,166.14,Other,New York Medicaid APG methodology,166.14,,,166.14,Other,100% Medicaid APG methodology,166.14,,,166.14,Other,100% Medicaid APG methodology,166.14,,,166.14,Other,100% Medicaid APG methodology,373.83,,,373.83,Other,225% Medicaid APG methodology,373.83,,,373.83,Other,225% Medicaid APG methodology,254.2,,,254.2,Other,153% Medicaid APG methodology,373.83,,,373.83,Other,225% Medicaid APG methodology,232.6,,,232.6,Other,140% Medicaid APG methodology,373.83,,,373.83,Other,225% Medicaid APG methodology,431.98,,,431.98,Other,260% Medicaid APG methodology,538.31,,,538.31,Other,324% Medicaid APG methodology,357.21,,,357.21,Other,215% Medicaid APG methodology,357.21,,,357.21,Other,215% Medicaid APG methodology,207.68,,,207.68,Other,125% Medicaid APG methodology,89.54,608.39,
EVALUATION OF SPEECH FLUENCY    ,92521,CPT,GN       ,48800486,CDM,440,RC,,,both,,,815,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,109.85,,,109.85,Fee Schedule,,109.85,,,109.85,Fee Schedule,,109.85,,,109.85,Fee Schedule,,407.5,50,,407.5,percent of total billed charges,All Other,570.5,70,,570.5,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,283.77,,,283.77,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,676.45,83,,676.45,percent of total billed charges,All Other,311.37,,,311.37,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,676.45,83,,676.45,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,570.5,70,,570.5,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,152.57,,,152.57,Other,New York Medicaid APG methodology,152.57,,,152.57,Other,100% Medicaid APG methodology,152.57,,,152.57,Other,100% Medicaid APG methodology,152.57,,,152.57,Other,100% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,233.43,,,233.43,Other,153% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,213.59,,,213.59,Other,140% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,396.67,,,396.67,Other,260% Medicaid APG methodology,494.32,,,494.32,Other,324% Medicaid APG methodology,328.02,,,328.02,Other,215% Medicaid APG methodology,328.02,,,328.02,Other,215% Medicaid APG methodology,190.71,,,190.71,Other,125% Medicaid APG methodology,0.01,676.45,
EVALUATE SPEECH PRODUCTION      ,92522,CPT,GN       ,48800494,CDM,440,RC,,,both,,,659,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,88.43,,,88.43,Fee Schedule,,88.43,,,88.43,Fee Schedule,,88.43,,,88.43,Fee Schedule,,329.5,50,,329.5,percent of total billed charges,All Other,461.3,70,,461.3,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,283.77,,,283.77,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,546.97,83,,546.97,percent of total billed charges,All Other,261.2,,,261.2,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,546.97,83,,546.97,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,461.3,70,,461.3,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,152.57,,,152.57,Other,New York Medicaid APG methodology,152.57,,,152.57,Other,100% Medicaid APG methodology,152.57,,,152.57,Other,100% Medicaid APG methodology,152.57,,,152.57,Other,100% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,233.43,,,233.43,Other,153% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,213.59,,,213.59,Other,140% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,396.67,,,396.67,Other,260% Medicaid APG methodology,494.32,,,494.32,Other,324% Medicaid APG methodology,328.02,,,328.02,Other,215% Medicaid APG methodology,328.02,,,328.02,Other,215% Medicaid APG methodology,190.71,,,190.71,Other,125% Medicaid APG methodology,0.01,546.97,
BEHAVRAL QUALIT ANALYS VOICE    ,92524,CPT,GN       ,48800502,CDM,440,RC,,,both,,,659,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,84.68,,,84.68,Fee Schedule,,84.68,,,84.68,Fee Schedule,,84.68,,,84.68,Fee Schedule,,329.5,50,,329.5,percent of total billed charges,All Other,461.3,70,,461.3,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,283.77,,,283.77,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,546.97,83,,546.97,percent of total billed charges,All Other,257.08,,,257.08,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,546.97,83,,546.97,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,461.3,70,,461.3,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,152.57,,,152.57,Other,New York Medicaid APG methodology,152.57,,,152.57,Other,100% Medicaid APG methodology,152.57,,,152.57,Other,100% Medicaid APG methodology,152.57,,,152.57,Other,100% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,233.43,,,233.43,Other,153% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,213.59,,,213.59,Other,140% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,396.67,,,396.67,Other,260% Medicaid APG methodology,494.32,,,494.32,Other,324% Medicaid APG methodology,328.02,,,328.02,Other,215% Medicaid APG methodology,328.02,,,328.02,Other,215% Medicaid APG methodology,190.71,,,190.71,Other,125% Medicaid APG methodology,0.01,546.97,
THER IVNTJ 1ST 15 MIN           ,97129,CPT,GN       ,48800981,CDM,440,RC,,,both,,,302,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,22.08,,,22.08,Fee Schedule,,22.08,,,22.08,Fee Schedule,,22.08,,,22.08,Fee Schedule,,151,50,,151,percent of total billed charges,All Other,211.4,70,,211.4,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,250.66,83,,250.66,percent of total billed charges,All Other,50.32,,,50.32,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,250.66,83,,250.66,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,211.4,70,,211.4,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,368,
SENSORY INTEGRATION             ,97533,CPT,GN       ,48801013,CDM,440,RC,,,both,,,246,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,228.18,,,228.18,Fee Schedule,,205.3,,,205.3,Fee Schedule,,193.86,,,193.86,Fee Schedule,,123,50,,123,percent of total billed charges,All Other,172.2,70,,172.2,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,204.18,83,,204.18,percent of total billed charges,All Other,150.34,,,150.34,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,204.18,83,,204.18,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,172.2,70,,172.2,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,368,
COGNITIVE TEST BY HC PRO        ,96125,CPT,GN       ,48801187,CDM,440,RC,,,both,,,869,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,766.9,,,766.9,Fee Schedule,,689.99,,,689.99,Fee Schedule,,651.54,,,651.54,Fee Schedule,,434.5,50,,434.5,percent of total billed charges,All Other,608.3,70,,608.3,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,344.55,,,344.55,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,721.27,83,,721.27,percent of total billed charges,All Other,240.47,,,240.47,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,721.27,83,,721.27,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,608.3,70,,608.3,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,185.24,,,185.24,Other,New York Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,283.42,,,283.42,Other,153% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,259.34,,,259.34,Other,140% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,481.63,,,481.63,Other,260% Medicaid APG methodology,600.18,,,600.18,Other,324% Medicaid APG methodology,398.27,,,398.27,Other,215% Medicaid APG methodology,398.27,,,398.27,Other,215% Medicaid APG methodology,231.55,,,231.55,Other,125% Medicaid APG methodology,0.01,766.9,
THER IVNTJ EA ADDL 15 MIN       ,97130,CPT,GN       ,48801195,CDM,440,RC,,,both,,,218,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,21.13,,,21.13,Fee Schedule,,21.13,,,21.13,Fee Schedule,,21.13,,,21.13,Fee Schedule,,109,50,,109,percent of total billed charges,All Other,152.6,70,,152.6,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,183.45,,,183.45,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,180.94,83,,180.94,percent of total billed charges,All Other,48.03,,,48.03,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,180.94,83,,180.94,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,152.6,70,,152.6,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,368,
SPEECH/HEARING THERAPY INDV CC  ,92507,CPT,GTGN     ,48901516,CDM,441,RC,,,both,,,1000,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,683.18,,,683.18,Fee Schedule,,614.67,,,614.67,Fee Schedule,,580.42,,,580.42,Fee Schedule,,500,50,,500,percent of total billed charges,All Other,700,70,,700,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,283.77,,,283.77,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,830,83,,830,percent of total billed charges,All Other,178.35,,,178.35,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,830,83,,830,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,700,70,,700,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,152.57,,,152.57,Other,New York Medicaid APG methodology,152.57,,,152.57,Other,100% Medicaid APG methodology,152.57,,,152.57,Other,100% Medicaid APG methodology,152.57,,,152.57,Other,100% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,233.43,,,233.43,Other,153% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,213.59,,,213.59,Other,140% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,396.67,,,396.67,Other,260% Medicaid APG methodology,494.32,,,494.32,Other,324% Medicaid APG methodology,328.02,,,328.02,Other,215% Medicaid APG methodology,328.02,,,328.02,Other,215% Medicaid APG methodology,190.71,,,190.71,Other,125% Medicaid APG methodology,0.01,830,
EX FOR SPEECH DEVICE RX 1HR     ,92607,CPT,GN       ,48800437,CDM,444,RC,,,both,,,1364,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,1516.56,,,1516.56,Fee Schedule,,1364.48,,,1364.48,Fee Schedule,,1288.44,,,1288.44,Fee Schedule,,682,50,,682,percent of total billed charges,All Other,954.8,70,,954.8,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,283.77,,,283.77,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,1132.12,83,,1132.12,percent of total billed charges,All Other,292.24,,,292.24,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,1132.12,83,,1132.12,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,954.8,70,,954.8,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,152.57,,,152.57,Other,New York Medicaid APG methodology,152.57,,,152.57,Other,100% Medicaid APG methodology,152.57,,,152.57,Other,100% Medicaid APG methodology,152.57,,,152.57,Other,100% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,233.43,,,233.43,Other,153% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,213.59,,,213.59,Other,140% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,396.67,,,396.67,Other,260% Medicaid APG methodology,494.32,,,494.32,Other,324% Medicaid APG methodology,328.02,,,328.02,Other,215% Medicaid APG methodology,328.02,,,328.02,Other,215% Medicaid APG methodology,190.71,,,190.71,Other,125% Medicaid APG methodology,0.01,1516.56,
EX FOR SPEECH DEVICE RX ADD 30  ,92608,CPT,GN       ,48800940,CDM,444,RC,,,both,,,399,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,441.71,,,441.71,Fee Schedule,,397.42,,,397.42,Fee Schedule,,375.27,,,375.27,Fee Schedule,,199.5,50,,199.5,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,283.77,,,283.77,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,331.17,83,,331.17,percent of total billed charges,All Other,114.95,,,114.95,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,331.17,83,,331.17,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,279.3,70,,279.3,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,152.57,,,152.57,Other,New York Medicaid APG methodology,152.57,,,152.57,Other,100% Medicaid APG methodology,152.57,,,152.57,Other,100% Medicaid APG methodology,152.57,,,152.57,Other,100% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,233.43,,,233.43,Other,153% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,213.59,,,213.59,Other,140% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,396.67,,,396.67,Other,260% Medicaid APG methodology,494.32,,,494.32,Other,324% Medicaid APG methodology,328.02,,,328.02,Other,215% Medicaid APG methodology,328.02,,,328.02,Other,215% Medicaid APG methodology,190.71,,,190.71,Other,125% Medicaid APG methodology,0.01,494.32,
ASSESSMENT OF APHASIA EA 1HR    ,96105,CPT,GN       ,48800965,CDM,444,RC,,,both,,,999,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,341,,,341,Case Rate,PT OT ST Per Visit,307,,,307,Case Rate,PT OT ST Per Visit,882.21,,,882.21,Fee Schedule,,793.74,,,793.74,Fee Schedule,,749.51,,,749.51,Fee Schedule,,499.5,50,,499.5,percent of total billed charges,All Other,699.3,70,,699.3,percent of total billed charges,All Other,219,,,219,Case Rate,PT OT ST Per Visit,344.55,,,344.55,Other,186% Medicaid methodology,257,,,257,Case Rate,PT OT ST Per Visit,829.17,83,,829.17,percent of total billed charges,All Other,224.83,,,224.83,Fee Schedule,,257,,,257,Case Rate,PT OT ST Per Visit,829.17,83,,829.17,percent of total billed charges,All Other,368,,,368,Case Rate,PT OT ST Per Visit,699.3,70,,699.3,percent of total billed charges,All Other,272,,,272,Case Rate,PT OT ST Per Visit,231,,,231,Case Rate,PT OT ST Per Visit,208,,,208,Case Rate,PT OT ST Per Visit,192,,,192,Case Rate,PT OT ST Per Visit,213,,,213,Case Rate,PT OT ST Per Visit,181,,,181,Case Rate,PT OT ST Per Visit,185.24,,,185.24,Other,New York Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,283.42,,,283.42,Other,153% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,259.34,,,259.34,Other,140% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,481.63,,,481.63,Other,260% Medicaid APG methodology,600.18,,,600.18,Other,324% Medicaid APG methodology,398.27,,,398.27,Other,215% Medicaid APG methodology,398.27,,,398.27,Other,215% Medicaid APG methodology,231.55,,,231.55,Other,125% Medicaid APG methodology,0.01,882.21,
96373- Intra-Arterial Injection OBED,96373,CPT,,48300883,CDM,450,RC,,,both,,,1005,407.6,,,407.6,Other,150% of Medicare + 9.63% HCRA Surcharge,247.86,,,247.86,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,116.47,,,116.47,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,703.5,70,,703.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,62.62,,,62.62,Other,New York Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,95.8,,,95.8,Other,153% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,87.66,,,87.66,Other,140% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,162.81,,,162.81,Other,260% Medicaid APG methodology,202.88,,,202.88,Other,324% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,78.27,,,78.27,Other,125% Medicaid APG methodology,0.01,703.5,
EMERGENCY DEPT VISIT LEVEL 1    ,99281,CPT,,50000058,CDM,450,RC,,,both,,,2970,168.83,,,168.83,Other,150% of Medicare + 9.63% HCRA Surcharge,102.67,,,102.67,Other,Medicare OPPS methodology,2672,,,2672,Case Rate,ED Visit,2405,,,2405,Case Rate,ED Visit,1512,,,1512,Case Rate,ED Visit,1361,,,1361,Case Rate,ED Visit,1285,,,1285,Case Rate,ED Visit,2414,,,2414,Case Rate,ED Visit,2423,,,2423,Case Rate,ED Visit,412,,,412,Case Rate,ED Visit,0.02,,,0.02,Other,186% Medicaid methodology,485,,,485,Case Rate,ED Visit,2160,,,2160,Case Rate,ED Visit,2160,,,2160,Case Rate,ED Visit,485,,,485,Case Rate,ED Visit,2160,,,2160,Case Rate,ED Visit,2166,,,2166,Case Rate,ED Visit,2079,70,,2079,percent of total billed charges,All Other,2631,,,2631,Case Rate,ED Visit,2236,,,2236,Case Rate,ED Visit,1501,,,1501,Case Rate,ED Visit,1416,,,1416,Case Rate,ED Visit,1573,,,1573,Case Rate,ED Visit,1338,,,1338,Case Rate,ED Visit,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,2672,
EMERGENCY DEPT VISIT LEVEL 2    ,99282,CPT,,50000082,CDM,450,RC,,,both,,,3713,311.02,,,311.02,Other,150% of Medicare + 9.63% HCRA Surcharge,189.13,,,189.13,Other,Medicare OPPS methodology,2672,,,2672,Case Rate,ED Visit,2405,,,2405,Case Rate,ED Visit,1512,,,1512,Case Rate,ED Visit,1361,,,1361,Case Rate,ED Visit,1285,,,1285,Case Rate,ED Visit,2414,,,2414,Case Rate,ED Visit,2423,,,2423,Case Rate,ED Visit,569,,,569,Case Rate,ED Visit,0.02,,,0.02,Other,186% Medicaid methodology,670,,,670,Case Rate,ED Visit,2160,,,2160,Case Rate,ED Visit,2160,,,2160,Case Rate,ED Visit,670,,,670,Case Rate,ED Visit,2160,,,2160,Case Rate,ED Visit,2166,,,2166,Case Rate,ED Visit,2599.1,70,,2599.1,percent of total billed charges,All Other,2631,,,2631,Case Rate,ED Visit,2236,,,2236,Case Rate,ED Visit,1501,,,1501,Case Rate,ED Visit,1416,,,1416,Case Rate,ED Visit,1573,,,1573,Case Rate,ED Visit,1338,,,1338,Case Rate,ED Visit,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,2672,
EMERGENCY DEPT VISIT LEVEL 3    ,99283,CPT,,50000108,CDM,450,RC,,,both,,,5199,542.58,,,542.58,Other,150% of Medicare + 9.63% HCRA Surcharge,329.94,,,329.94,Other,Medicare OPPS methodology,2672,,,2672,Case Rate,ED Visit,2405,,,2405,Case Rate,ED Visit,2292,,,2292,Case Rate,ED Visit,2063,,,2063,Case Rate,ED Visit,1948,,,1948,Case Rate,ED Visit,2414,,,2414,Case Rate,ED Visit,2423,,,2423,Case Rate,ED Visit,1754,,,1754,Case Rate,ED Visit,0.02,,,0.02,Other,186% Medicaid methodology,2064,,,2064,Case Rate,ED Visit,2160,,,2160,Case Rate,ED Visit,2160,,,2160,Case Rate,ED Visit,2064,,,2064,Case Rate,ED Visit,2160,,,2160,Case Rate,ED Visit,2166,,,2166,Case Rate,ED Visit,3639.3,70,,3639.3,percent of total billed charges,All Other,2631,,,2631,Case Rate,ED Visit,2236,,,2236,Case Rate,ED Visit,1501,,,1501,Case Rate,ED Visit,1416,,,1416,Case Rate,ED Visit,1573,,,1573,Case Rate,ED Visit,1338,,,1338,Case Rate,ED Visit,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,3639.3,
EMERGENCY DEPT VISIT LEVEL 4    ,99284,CPT,,50000116,CDM,450,RC,,,both,,,6239,842.26,,,842.26,Other,150% of Medicare + 9.63% HCRA Surcharge,512.18,,,512.18,Other,Medicare OPPS methodology,2672,,,2672,Case Rate,ED Visit,2405,,,2405,Case Rate,ED Visit,5633,,,5633,Case Rate,ED Visit,5070,,,5070,Case Rate,ED Visit,4788,,,4788,Case Rate,ED Visit,2414,,,2414,Case Rate,ED Visit,2423,,,2423,Case Rate,ED Visit,1754,,,1754,Case Rate,ED Visit,0.02,,,0.02,Other,186% Medicaid methodology,2064,,,2064,Case Rate,ED Visit,2160,,,2160,Case Rate,ED Visit,2160,,,2160,Case Rate,ED Visit,2064,,,2064,Case Rate,ED Visit,2160,,,2160,Case Rate,ED Visit,2166,,,2166,Case Rate,ED Visit,4367.3,70,,4367.3,percent of total billed charges,All Other,2631,,,2631,Case Rate,ED Visit,2236,,,2236,Case Rate,ED Visit,1501,,,1501,Case Rate,ED Visit,1416,,,1416,Case Rate,ED Visit,1573,,,1573,Case Rate,ED Visit,1338,,,1338,Case Rate,ED Visit,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,5633,
EMERGENCY DEPT VISIT LEVEL 5    ,99285,CPT,,50000124,CDM,450,RC,,,both,,,9530,1221.45,,,1221.45,Other,150% of Medicare + 9.63% HCRA Surcharge,742.77,,,742.77,Other,Medicare OPPS methodology,2672,,,2672,Case Rate,ED Visit,2405,,,2405,Case Rate,ED Visit,5633,,,5633,Case Rate,ED Visit,5070,,,5070,Case Rate,ED Visit,4788,,,4788,Case Rate,ED Visit,2414,,,2414,Case Rate,ED Visit,3566,,,3566,Case Rate,ED Visit,1754,,,1754,Case Rate,ED Visit,0.02,,,0.02,Other,186% Medicaid methodology,2064,,,2064,Case Rate,ED Visit,2160,,,2160,Case Rate,ED Visit,2160,,,2160,Case Rate,ED Visit,2064,,,2064,Case Rate,ED Visit,2160,,,2160,Case Rate,ED Visit,2166,,,2166,Case Rate,ED Visit,6671,70,,6671,percent of total billed charges,All Other,2631,,,2631,Case Rate,ED Visit,2236,,,2236,Case Rate,ED Visit,1501,,,1501,Case Rate,ED Visit,1416,,,1416,Case Rate,ED Visit,1573,,,1573,Case Rate,ED Visit,1338,,,1338,Case Rate,ED Visit,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,6671,
DRAINAGE OF SKIN ABSCESS SMPL   ,10060,CPT,,50000140,CDM,450,RC,,,both,,,2125,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,902.56,,,902.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1487.5,70,,1487.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,742.43,,,742.43,Other,153% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,679.35,,,679.35,Other,140% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,1261.65,,,1261.65,Other,260% Medicaid APG methodology,1572.2,,,1572.2,Other,324% Medicaid APG methodology,1043.28,,,1043.28,Other,215% Medicaid APG methodology,1043.28,,,1043.28,Other,215% Medicaid APG methodology,606.56,,,606.56,Other,125% Medicaid APG methodology,0.01,1572.2,
REMOVE FOREIGN BODY SMPL        ,10120,CPT,,50000157,CDM,450,RC,,,both,,,2132,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,902.56,,,902.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1492.4,70,,1492.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,742.43,,,742.43,Other,153% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,679.35,,,679.35,Other,140% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,1261.65,,,1261.65,Other,260% Medicaid APG methodology,1572.2,,,1572.2,Other,324% Medicaid APG methodology,1043.28,,,1043.28,Other,215% Medicaid APG methodology,1043.28,,,1043.28,Other,215% Medicaid APG methodology,606.56,,,606.56,Other,125% Medicaid APG methodology,0.01,1572.2,
DRAINAGE OF HEMATOMA/FLUID      ,10140,CPT,,50000165,CDM,450,RC,,,both,,,6422,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1516.17,,,1516.17,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,4495.4,70,,4495.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,815.14,,,815.14,Other,New York Medicaid APG methodology,815.14,,,815.14,Other,100% Medicaid APG methodology,815.14,,,815.14,Other,100% Medicaid APG methodology,815.14,,,815.14,Other,100% Medicaid APG methodology,1834.07,,,1834.07,Other,225% Medicaid APG methodology,1834.07,,,1834.07,Other,225% Medicaid APG methodology,1247.17,,,1247.17,Other,153% Medicaid APG methodology,1834.07,,,1834.07,Other,225% Medicaid APG methodology,1141.2,,,1141.2,Other,140% Medicaid APG methodology,1834.07,,,1834.07,Other,225% Medicaid APG methodology,2119.37,,,2119.37,Other,260% Medicaid APG methodology,2641.06,,,2641.06,Other,324% Medicaid APG methodology,1752.56,,,1752.56,Other,215% Medicaid APG methodology,1752.56,,,1752.56,Other,215% Medicaid APG methodology,1018.93,,,1018.93,Other,125% Medicaid APG methodology,0.01,4495.4,
DEB BONE 20 SQ CM/<             ,11044,CPT,,50000181,CDM,450,RC,,,both,,,4888,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,3180.63,,,3180.63,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3421.6,70,,3421.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% Medicaid APG methodology,1710.01,,,1710.01,Other,100% Medicaid APG methodology,1710.01,,,1710.01,Other,100% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,2616.32,,,2616.32,Other,153% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,2394.02,,,2394.02,Other,140% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,4446.04,,,4446.04,Other,260% Medicaid APG methodology,5540.45,,,5540.45,Other,324% Medicaid APG methodology,3676.53,,,3676.53,Other,215% Medicaid APG methodology,3676.53,,,3676.53,Other,215% Medicaid APG methodology,2137.52,,,2137.52,Other,125% Medicaid APG methodology,0.01,5540.45,
RPR S/N/A/GEN/TRK12.6-20.0CM    ,12005,CPT,,50000207,CDM,450,RC,,,both,,,1533,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1193.32,,,1193.32,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1073.1,70,,1073.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,981.6,,,981.6,Other,153% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,898.2,,,898.2,Other,140% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1668.08,,,1668.08,Other,260% Medicaid APG methodology,2078.69,,,2078.69,Other,324% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,801.96,,,801.96,Other,125% Medicaid APG methodology,0.01,2078.69,
INTMD RPR S/A/T/EXT 2.5 CM/<    ,12031,CPT,,50000215,CDM,450,RC,,,both,,,3117,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1704.43,,,1704.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2181.9,70,,2181.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1402.03,,,1402.03,Other,153% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1282.9,,,1282.9,Other,140% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2382.54,,,2382.54,Other,260% Medicaid APG methodology,2969.01,,,2969.01,Other,324% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1145.45,,,1145.45,Other,125% Medicaid APG methodology,0.01,2969.01,
INTMD RPR S/A/T/EXT 2.6-7.5     ,12032,CPT,,50000223,CDM,450,RC,,,both,,,3429,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1704.43,,,1704.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2400.3,70,,2400.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1402.03,,,1402.03,Other,153% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1282.9,,,1282.9,Other,140% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2382.54,,,2382.54,Other,260% Medicaid APG methodology,2969.01,,,2969.01,Other,324% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1145.45,,,1145.45,Other,125% Medicaid APG methodology,0.01,2969.01,
INTMD RPR FACE/MM 2.5 CM/<      ,12051,CPT,,50000231,CDM,450,RC,,,both,,,3429,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1704.43,,,1704.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2400.3,70,,2400.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1402.03,,,1402.03,Other,153% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1282.9,,,1282.9,Other,140% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2382.54,,,2382.54,Other,260% Medicaid APG methodology,2969.01,,,2969.01,Other,324% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1145.45,,,1145.45,Other,125% Medicaid APG methodology,0.01,2969.01,
INTMD RPR FACE/MM 2.6-5.0 CM    ,12052,CPT,,50000249,CDM,450,RC,,,both,,,3429,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1704.43,,,1704.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2400.3,70,,2400.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1402.03,,,1402.03,Other,153% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1282.9,,,1282.9,Other,140% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2382.54,,,2382.54,Other,260% Medicaid APG methodology,2969.01,,,2969.01,Other,324% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1145.45,,,1145.45,Other,125% Medicaid APG methodology,0.01,2969.01,
CMPLX RPR S/A/L 2.6-7.5 CM      ,13121,CPT,,50000256,CDM,450,RC,,,both,,,2175,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1559.83,,,1559.83,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1522.5,70,,1522.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1283.09,,,1283.09,Other,153% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1174.07,,,1174.07,Other,140% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,2180.41,,,2180.41,Other,260% Medicaid APG methodology,2717.12,,,2717.12,Other,324% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1048.27,,,1048.27,Other,125% Medicaid APG methodology,0.01,2717.12,
TIS TRNFR F/C/C/M/N/A/G/H/F     ,14040,CPT,,50000272,CDM,450,RC,,,both,,,6223,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,3310.98,,,3310.98,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,4356.1,70,,4356.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,2723.55,,,2723.55,Other,153% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,2492.13,,,2492.13,Other,140% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,4628.25,,,4628.25,Other,260% Medicaid APG methodology,5767.51,,,5767.51,Other,324% Medicaid APG methodology,3827.2,,,3827.2,Other,215% Medicaid APG methodology,3827.2,,,3827.2,Other,215% Medicaid APG methodology,2225.12,,,2225.12,Other,125% Medicaid APG methodology,0.01,5767.51,
SKIN FULL GRFT FACE/GENIT/HF    ,15240,CPT,,50000306,CDM,450,RC,,,both,,,6223,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,3310.98,,,3310.98,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,4356.1,70,,4356.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,2723.55,,,2723.55,Other,153% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,2492.13,,,2492.13,Other,140% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,4628.25,,,4628.25,Other,260% Medicaid APG methodology,5767.51,,,5767.51,Other,324% Medicaid APG methodology,3827.2,,,3827.2,Other,215% Medicaid APG methodology,3827.2,,,3827.2,Other,215% Medicaid APG methodology,2225.12,,,2225.12,Other,125% Medicaid APG methodology,0.01,5767.51,
CHEM CAUT OF GRANLTJ TISSUE     ,17250,CPT,,50000322,CDM,450,RC,,,both,,,924,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,902.56,,,902.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,646.8,70,,646.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,742.43,,,742.43,Other,153% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,679.35,,,679.35,Other,140% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,1261.65,,,1261.65,Other,260% Medicaid APG methodology,1572.2,,,1572.2,Other,324% Medicaid APG methodology,1043.28,,,1043.28,Other,215% Medicaid APG methodology,1043.28,,,1043.28,Other,215% Medicaid APG methodology,606.56,,,606.56,Other,125% Medicaid APG methodology,0.01,1572.2,
EXPLORE WOUND EXTREMITY         ,20103,CPT,,50000330,CDM,450,RC,,,both,,,8245,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1704.43,,,1704.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,5771.5,70,,5771.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1402.03,,,1402.03,Other,153% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1282.9,,,1282.9,Other,140% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2382.54,,,2382.54,Other,260% Medicaid APG methodology,2969.01,,,2969.01,Other,324% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1145.45,,,1145.45,Other,125% Medicaid APG methodology,0.01,5771.5,
DRAIN/INJ INT JNT/BURSA W/O US  ,20605,CPT,,50000355,CDM,450,RC,,,both,,,1344,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,841.15,,,841.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,940.8,70,,940.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,452.23,,,452.23,Other,New York Medicaid APG methodology,452.23,,,452.23,Other,100% Medicaid APG methodology,452.23,,,452.23,Other,100% Medicaid APG methodology,452.23,,,452.23,Other,100% Medicaid APG methodology,1017.52,,,1017.52,Other,225% Medicaid APG methodology,1017.52,,,1017.52,Other,225% Medicaid APG methodology,691.91,,,691.91,Other,153% Medicaid APG methodology,1017.52,,,1017.52,Other,225% Medicaid APG methodology,633.12,,,633.12,Other,140% Medicaid APG methodology,1017.52,,,1017.52,Other,225% Medicaid APG methodology,1175.8,,,1175.8,Other,260% Medicaid APG methodology,1465.23,,,1465.23,Other,324% Medicaid APG methodology,972.3,,,972.3,Other,215% Medicaid APG methodology,972.3,,,972.3,Other,215% Medicaid APG methodology,565.29,,,565.29,Other,125% Medicaid APG methodology,0.01,1465.23,
DRAIN/INJ MJR JNT/BURSA W/O US  ,20610,CPT,,50000363,CDM,450,RC,,,both,,,1616,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,841.15,,,841.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1131.2,70,,1131.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,452.23,,,452.23,Other,New York Medicaid APG methodology,452.23,,,452.23,Other,100% Medicaid APG methodology,452.23,,,452.23,Other,100% Medicaid APG methodology,452.23,,,452.23,Other,100% Medicaid APG methodology,1017.52,,,1017.52,Other,225% Medicaid APG methodology,1017.52,,,1017.52,Other,225% Medicaid APG methodology,691.91,,,691.91,Other,153% Medicaid APG methodology,1017.52,,,1017.52,Other,225% Medicaid APG methodology,633.12,,,633.12,Other,140% Medicaid APG methodology,1017.52,,,1017.52,Other,225% Medicaid APG methodology,1175.8,,,1175.8,Other,260% Medicaid APG methodology,1465.23,,,1465.23,Other,324% Medicaid APG methodology,972.3,,,972.3,Other,215% Medicaid APG methodology,972.3,,,972.3,Other,215% Medicaid APG methodology,565.29,,,565.29,Other,125% Medicaid APG methodology,0.01,1465.23,
DRAINAGE FINGER ABSCESS SMPL    ,26010,CPT,,50000371,CDM,450,RC,,,both,,,979,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,902.56,,,902.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,685.3,70,,685.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,742.43,,,742.43,Other,153% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,679.35,,,679.35,Other,140% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,1261.65,,,1261.65,Other,260% Medicaid APG methodology,1572.2,,,1572.2,Other,324% Medicaid APG methodology,1043.28,,,1043.28,Other,215% Medicaid APG methodology,1043.28,,,1043.28,Other,215% Medicaid APG methodology,606.56,,,606.56,Other,125% Medicaid APG methodology,0.01,1572.2,
REPAIR HAND TENDON EA           ,26410,CPT,,50000397,CDM,450,RC,,,both,,,5309,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2917.58,,,2917.58,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3716.3,70,,3716.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% Medicaid APG methodology,1568.59,,,1568.59,Other,100% Medicaid APG methodology,1568.59,,,1568.59,Other,100% Medicaid APG methodology,3529.33,,,3529.33,Other,225% Medicaid APG methodology,3529.33,,,3529.33,Other,225% Medicaid APG methodology,2399.94,,,2399.94,Other,153% Medicaid APG methodology,3529.33,,,3529.33,Other,225% Medicaid APG methodology,2196.03,,,2196.03,Other,140% Medicaid APG methodology,3529.33,,,3529.33,Other,225% Medicaid APG methodology,4078.34,,,4078.34,Other,260% Medicaid APG methodology,5082.24,,,5082.24,Other,324% Medicaid APG methodology,3372.47,,,3372.47,Other,215% Medicaid APG methodology,3372.47,,,3372.47,Other,215% Medicaid APG methodology,1960.74,,,1960.74,Other,125% Medicaid APG methodology,0.01,5082.24,
REPAIR FINGER TENDON EA         ,26418,CPT,,50000405,CDM,450,RC,,,both,,,5309,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2917.58,,,2917.58,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3716.3,70,,3716.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% Medicaid APG methodology,1568.59,,,1568.59,Other,100% Medicaid APG methodology,1568.59,,,1568.59,Other,100% Medicaid APG methodology,3529.33,,,3529.33,Other,225% Medicaid APG methodology,3529.33,,,3529.33,Other,225% Medicaid APG methodology,2399.94,,,2399.94,Other,153% Medicaid APG methodology,3529.33,,,3529.33,Other,225% Medicaid APG methodology,2196.03,,,2196.03,Other,140% Medicaid APG methodology,3529.33,,,3529.33,Other,225% Medicaid APG methodology,4078.34,,,4078.34,Other,260% Medicaid APG methodology,5082.24,,,5082.24,Other,324% Medicaid APG methodology,3372.47,,,3372.47,Other,215% Medicaid APG methodology,3372.47,,,3372.47,Other,215% Medicaid APG methodology,1960.74,,,1960.74,Other,125% Medicaid APG methodology,0.01,5082.24,
CONTROL OF NOSEBLEED SMPL       ,30901,CPT,,50000421,CDM,450,RC,,,both,,,1038,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,501.18,,,501.18,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,726.6,70,,726.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,412.26,,,412.26,Other,153% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,377.23,,,377.23,Other,140% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,700.58,,,700.58,Other,260% Medicaid APG methodology,873.03,,,873.03,Other,324% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,336.82,,,336.82,Other,125% Medicaid APG methodology,0.01,873.03,
NASAL SURGERY PROCEDURE         ,30999,CPT,,50000439,CDM,450,RC,,,both,,,740,464.5,,,464.5,Other,150% of Medicare + 9.63% HCRA Surcharge,282.46,,,282.46,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2536.27,,,2536.27,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,518,70,,518,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1363.59,,,1363.59,Other,New York Medicaid APG methodology,1363.59,,,1363.59,Other,100% Medicaid APG methodology,1363.59,,,1363.59,Other,100% Medicaid APG methodology,1363.59,,,1363.59,Other,100% Medicaid APG methodology,3068.07,,,3068.07,Other,225% Medicaid APG methodology,3068.07,,,3068.07,Other,225% Medicaid APG methodology,2086.29,,,2086.29,Other,153% Medicaid APG methodology,3068.07,,,3068.07,Other,225% Medicaid APG methodology,1909.02,,,1909.02,Other,140% Medicaid APG methodology,3068.07,,,3068.07,Other,225% Medicaid APG methodology,3545.33,,,3545.33,Other,260% Medicaid APG methodology,4418.02,,,4418.02,Other,324% Medicaid APG methodology,2931.71,,,2931.71,Other,215% Medicaid APG methodology,2931.71,,,2931.71,Other,215% Medicaid APG methodology,1704.48,,,1704.48,Other,125% Medicaid APG methodology,0.01,4418.02,
DRAINAGE OF GUM LESION          ,41800,CPT,,50000603,CDM,450,RC,,,both,,,476,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,501.18,,,501.18,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,333.2,70,,333.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,412.26,,,412.26,Other,153% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,377.23,,,377.23,Other,140% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,700.58,,,700.58,Other,260% Medicaid APG methodology,873.03,,,873.03,Other,324% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,336.82,,,336.82,Other,125% Medicaid APG methodology,0.01,873.03,
RPLC GTUBE NO REVJ TRC          ,43762,CPT,,50000645,CDM,450,RC,,,both,,,1918,469.99,,,469.99,Other,150% of Medicare + 9.63% HCRA Surcharge,285.8,,,285.8,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1287.38,,,1287.38,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1342.6,70,,1342.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.14,,,692.14,Other,New York Medicaid APG methodology,692.14,,,692.14,Other,100% Medicaid APG methodology,692.14,,,692.14,Other,100% Medicaid APG methodology,692.14,,,692.14,Other,100% Medicaid APG methodology,1557.31,,,1557.31,Other,225% Medicaid APG methodology,1557.31,,,1557.31,Other,225% Medicaid APG methodology,1058.97,,,1058.97,Other,153% Medicaid APG methodology,1557.31,,,1557.31,Other,225% Medicaid APG methodology,968.99,,,968.99,Other,140% Medicaid APG methodology,1557.31,,,1557.31,Other,225% Medicaid APG methodology,1799.56,,,1799.56,Other,260% Medicaid APG methodology,2242.53,,,2242.53,Other,324% Medicaid APG methodology,1488.1,,,1488.1,Other,215% Medicaid APG methodology,1488.1,,,1488.1,Other,215% Medicaid APG methodology,865.17,,,865.17,Other,125% Medicaid APG methodology,0.01,2242.53,
DX LMBR SPI PNXR                ,62270,CPT,,50000710,CDM,450,RC,,,both,,,4209,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1398.69,,,1398.69,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2946.3,70,,2946.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% Medicaid APG methodology,751.98,,,751.98,Other,100% Medicaid APG methodology,751.98,,,751.98,Other,100% Medicaid APG methodology,1691.96,,,1691.96,Other,225% Medicaid APG methodology,1691.96,,,1691.96,Other,225% Medicaid APG methodology,1150.53,,,1150.53,Other,153% Medicaid APG methodology,1691.96,,,1691.96,Other,225% Medicaid APG methodology,1052.78,,,1052.78,Other,140% Medicaid APG methodology,1691.96,,,1691.96,Other,225% Medicaid APG methodology,1955.15,,,1955.15,Other,260% Medicaid APG methodology,2436.42,,,2436.42,Other,324% Medicaid APG methodology,1616.76,,,1616.76,Other,215% Medicaid APG methodology,1616.76,,,1616.76,Other,215% Medicaid APG methodology,939.98,,,939.98,Other,125% Medicaid APG methodology,0.01,2946.3,
NJX AA&/STRD OTHER PN/BRANCH    ,64450,CPT,,50000728,CDM,450,RC,,,both,,,3633,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,968.7,,,968.7,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2543.1,70,,2543.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,520.81,,,520.81,Other,New York Medicaid APG methodology,520.81,,,520.81,Other,100% Medicaid APG methodology,520.81,,,520.81,Other,100% Medicaid APG methodology,520.81,,,520.81,Other,100% Medicaid APG methodology,1171.82,,,1171.82,Other,225% Medicaid APG methodology,1171.82,,,1171.82,Other,225% Medicaid APG methodology,796.84,,,796.84,Other,153% Medicaid APG methodology,1171.82,,,1171.82,Other,225% Medicaid APG methodology,729.13,,,729.13,Other,140% Medicaid APG methodology,1171.82,,,1171.82,Other,225% Medicaid APG methodology,1354.1,,,1354.1,Other,260% Medicaid APG methodology,1687.42,,,1687.42,Other,324% Medicaid APG methodology,1119.74,,,1119.74,Other,215% Medicaid APG methodology,1119.74,,,1119.74,Other,215% Medicaid APG methodology,651.01,,,651.01,Other,125% Medicaid APG methodology,0.01,2543.1,
REMOVAL FB FROM EYE EXT WO SLT  ,65220,CPT,,50000736,CDM,450,RC,,,both,,,1359,757.69,,,757.69,Other,150% of Medicare + 9.63% HCRA Surcharge,460.76,,,460.76,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,408.99,,,408.99,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,951.3,70,,951.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,219.89,,,219.89,Other,New York Medicaid APG methodology,219.89,,,219.89,Other,100% Medicaid APG methodology,219.89,,,219.89,Other,100% Medicaid APG methodology,219.89,,,219.89,Other,100% Medicaid APG methodology,494.75,,,494.75,Other,225% Medicaid APG methodology,494.75,,,494.75,Other,225% Medicaid APG methodology,336.43,,,336.43,Other,153% Medicaid APG methodology,494.75,,,494.75,Other,225% Medicaid APG methodology,307.84,,,307.84,Other,140% Medicaid APG methodology,494.75,,,494.75,Other,225% Medicaid APG methodology,571.71,,,571.71,Other,260% Medicaid APG methodology,712.44,,,712.44,Other,324% Medicaid APG methodology,472.76,,,472.76,Other,215% Medicaid APG methodology,472.76,,,472.76,Other,215% Medicaid APG methodology,274.86,,,274.86,Other,125% Medicaid APG methodology,0.01,951.3,
REMOVE IMPACTED EAR WAX UNI     ,69210,CPT,,50000751,CDM,450,RC,,,both,,,678,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,474.6,70,,474.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,474.6,
DRAINAGE OF SKIN ABSCESS COMPL  ,10061,CPT,,50000819,CDM,450,RC,,,both,,,1993,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,902.56,,,902.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1395.1,70,,1395.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,742.43,,,742.43,Other,153% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,679.35,,,679.35,Other,140% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,1261.65,,,1261.65,Other,260% Medicaid APG methodology,1572.2,,,1572.2,Other,324% Medicaid APG methodology,1043.28,,,1043.28,Other,215% Medicaid APG methodology,1043.28,,,1043.28,Other,215% Medicaid APG methodology,606.56,,,606.56,Other,125% Medicaid APG methodology,0.01,1572.2,
DEB SKIN BONE AT FX SITE        ,11012,CPT,,50000835,CDM,450,RC,,,both,,,9375,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,3180.63,,,3180.63,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,6562.5,70,,6562.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% Medicaid APG methodology,1710.01,,,1710.01,Other,100% Medicaid APG methodology,1710.01,,,1710.01,Other,100% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,2616.32,,,2616.32,Other,153% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,2394.02,,,2394.02,Other,140% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,4446.04,,,4446.04,Other,260% Medicaid APG methodology,5540.45,,,5540.45,Other,324% Medicaid APG methodology,3676.53,,,3676.53,Other,215% Medicaid APG methodology,3676.53,,,3676.53,Other,215% Medicaid APG methodology,2137.52,,,2137.52,Other,125% Medicaid APG methodology,0.01,6562.5,
TRIM NAIL(S) ANY NUMBER         ,11719,CPT,,50000843,CDM,450,RC,,,both,,,269,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,411.2,,,411.2,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,188.3,70,,188.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,221.08,,,221.08,Other,New York Medicaid APG methodology,221.08,,,221.08,Other,100% Medicaid APG methodology,221.08,,,221.08,Other,100% Medicaid APG methodology,221.08,,,221.08,Other,100% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,338.25,,,338.25,Other,153% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,309.51,,,309.51,Other,140% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,574.8,,,574.8,Other,260% Medicaid APG methodology,716.29,,,716.29,Other,324% Medicaid APG methodology,475.32,,,475.32,Other,215% Medicaid APG methodology,475.32,,,475.32,Other,215% Medicaid APG methodology,276.35,,,276.35,Other,125% Medicaid APG methodology,0.01,716.29,
DRAIN BLOOD FROM UNDER NAIL     ,11740,CPT,,50000850,CDM,450,RC,,,both,,,418,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,411.2,,,411.2,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,292.6,70,,292.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,221.08,,,221.08,Other,New York Medicaid APG methodology,221.08,,,221.08,Other,100% Medicaid APG methodology,221.08,,,221.08,Other,100% Medicaid APG methodology,221.08,,,221.08,Other,100% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,338.25,,,338.25,Other,153% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,309.51,,,309.51,Other,140% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,574.8,,,574.8,Other,260% Medicaid APG methodology,716.29,,,716.29,Other,324% Medicaid APG methodology,475.32,,,475.32,Other,215% Medicaid APG methodology,475.32,,,475.32,Other,215% Medicaid APG methodology,276.35,,,276.35,Other,125% Medicaid APG methodology,0.01,716.29,
REPAIR OF NAIL BED              ,11760,CPT,,50000868,CDM,450,RC,,,both,,,2455,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,411.2,,,411.2,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1718.5,70,,1718.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,221.08,,,221.08,Other,New York Medicaid APG methodology,221.08,,,221.08,Other,100% Medicaid APG methodology,221.08,,,221.08,Other,100% Medicaid APG methodology,221.08,,,221.08,Other,100% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,338.25,,,338.25,Other,153% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,309.51,,,309.51,Other,140% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,574.8,,,574.8,Other,260% Medicaid APG methodology,716.29,,,716.29,Other,324% Medicaid APG methodology,475.32,,,475.32,Other,215% Medicaid APG methodology,475.32,,,475.32,Other,215% Medicaid APG methodology,276.35,,,276.35,Other,125% Medicaid APG methodology,0.01,1718.5,
RPR S/N/AX/GEN/TRNK 2.5CM/<     ,12001,CPT,,50000876,CDM,450,RC,,,both,,,1129,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1193.32,,,1193.32,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,790.3,70,,790.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,981.6,,,981.6,Other,153% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,898.2,,,898.2,Other,140% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1668.08,,,1668.08,Other,260% Medicaid APG methodology,2078.69,,,2078.69,Other,324% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,801.96,,,801.96,Other,125% Medicaid APG methodology,0.01,2078.69,
RPR S/N/AX/GEN/TRNK2.6-7.5CM    ,12002,CPT,,50000884,CDM,450,RC,,,both,,,1157,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1193.32,,,1193.32,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,809.9,70,,809.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,981.6,,,981.6,Other,153% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,898.2,,,898.2,Other,140% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1668.08,,,1668.08,Other,260% Medicaid APG methodology,2078.69,,,2078.69,Other,324% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,801.96,,,801.96,Other,125% Medicaid APG methodology,0.01,2078.69,
RPR S/N/AX/GEN/TRK7.6-12.5CM    ,12004,CPT,,50000892,CDM,450,RC,,,both,,,1152,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1193.32,,,1193.32,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,806.4,70,,806.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,981.6,,,981.6,Other,153% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,898.2,,,898.2,Other,140% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1668.08,,,1668.08,Other,260% Medicaid APG methodology,2078.69,,,2078.69,Other,324% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,801.96,,,801.96,Other,125% Medicaid APG methodology,0.01,2078.69,
RPR S/N/A/GEN/TRK20.1-30.0CM    ,12006,CPT,,50000900,CDM,450,RC,,,both,,,1343,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1193.32,,,1193.32,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,940.1,70,,940.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,981.6,,,981.6,Other,153% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,898.2,,,898.2,Other,140% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1668.08,,,1668.08,Other,260% Medicaid APG methodology,2078.69,,,2078.69,Other,324% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,801.96,,,801.96,Other,125% Medicaid APG methodology,0.01,2078.69,
RPR F/E/E/N/L/M 2.5 CM/<        ,12011,CPT,,50000918,CDM,450,RC,,,both,,,1230,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1193.32,,,1193.32,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,861,70,,861,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,981.6,,,981.6,Other,153% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,898.2,,,898.2,Other,140% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1668.08,,,1668.08,Other,260% Medicaid APG methodology,2078.69,,,2078.69,Other,324% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,801.96,,,801.96,Other,125% Medicaid APG methodology,0.01,2078.69,
RPR F/E/E/N/L/M 2.6-5.0 CM      ,12013,CPT,,50000926,CDM,450,RC,,,both,,,1232,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1193.32,,,1193.32,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,862.4,70,,862.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,981.6,,,981.6,Other,153% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,898.2,,,898.2,Other,140% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1668.08,,,1668.08,Other,260% Medicaid APG methodology,2078.69,,,2078.69,Other,324% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,801.96,,,801.96,Other,125% Medicaid APG methodology,0.01,2078.69,
RPR F/E/E/N/L/M 5.1-7.5 CM      ,12014,CPT,,50000934,CDM,450,RC,,,both,,,1152,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1193.32,,,1193.32,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,806.4,70,,806.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,981.6,,,981.6,Other,153% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,898.2,,,898.2,Other,140% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1668.08,,,1668.08,Other,260% Medicaid APG methodology,2078.69,,,2078.69,Other,324% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,801.96,,,801.96,Other,125% Medicaid APG methodology,0.01,2078.69,
RPR FE/E/EN/L/M 12.6-20.0 CM    ,12016,CPT,,50000942,CDM,450,RC,,,both,,,1047,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1193.32,,,1193.32,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,732.9,70,,732.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,981.6,,,981.6,Other,153% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,898.2,,,898.2,Other,140% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1668.08,,,1668.08,Other,260% Medicaid APG methodology,2078.69,,,2078.69,Other,324% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,801.96,,,801.96,Other,125% Medicaid APG methodology,0.01,2078.69,
CMPLX RPR S/A/L ADDL 5 CM/>     ,13122,CPT,,50000959,CDM,450,RC,,,both,,,989,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1559.83,,,1559.83,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,692.3,70,,692.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1283.09,,,1283.09,Other,153% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1174.07,,,1174.07,Other,140% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,2180.41,,,2180.41,Other,260% Medicaid APG methodology,2717.12,,,2717.12,Other,324% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1048.27,,,1048.27,Other,125% Medicaid APG methodology,0.01,2717.12,
CMPLX RPR F/C/C/M/N/AX/G/H/F    ,13131,CPT,,50000967,CDM,450,RC,,,both,,,4873,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1559.83,,,1559.83,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3411.1,70,,3411.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1283.09,,,1283.09,Other,153% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1174.07,,,1174.07,Other,140% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,2180.41,,,2180.41,Other,260% Medicaid APG methodology,2717.12,,,2717.12,Other,324% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1048.27,,,1048.27,Other,125% Medicaid APG methodology,0.01,3411.1,
CMPLX RPR F/C/C/M/N/AX/G/H/F    ,13132,CPT,,50000975,CDM,450,RC,,,both,,,5361,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1559.83,,,1559.83,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3752.7,70,,3752.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1283.09,,,1283.09,Other,153% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1174.07,,,1174.07,Other,140% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,2180.41,,,2180.41,Other,260% Medicaid APG methodology,2717.12,,,2717.12,Other,324% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1048.27,,,1048.27,Other,125% Medicaid APG methodology,0.01,3752.7,
CMPLX RPR E/N/E/L 1.1-2.5 CM    ,13151,CPT,,50000991,CDM,450,RC,,,both,,,4873,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1559.83,,,1559.83,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3411.1,70,,3411.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1283.09,,,1283.09,Other,153% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1174.07,,,1174.07,Other,140% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,2180.41,,,2180.41,Other,260% Medicaid APG methodology,2717.12,,,2717.12,Other,324% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1048.27,,,1048.27,Other,125% Medicaid APG methodology,0.01,3411.1,
DRESS/DEBRID P-THICK BURN SM    ,16020,CPT,,50001007,CDM,450,RC,,,both,,,650,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1193.32,,,1193.32,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,455,70,,455,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,981.6,,,981.6,Other,153% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,898.2,,,898.2,Other,140% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1668.08,,,1668.08,Other,260% Medicaid APG methodology,2078.69,,,2078.69,Other,324% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,801.96,,,801.96,Other,125% Medicaid APG methodology,0.01,2078.69,
DRESS/DEBRID P-THICK BURN MD    ,16025,CPT,,50001015,CDM,450,RC,,,both,,,747,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1193.32,,,1193.32,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,522.9,70,,522.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,981.6,,,981.6,Other,153% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,898.2,,,898.2,Other,140% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1668.08,,,1668.08,Other,260% Medicaid APG methodology,2078.69,,,2078.69,Other,324% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,801.96,,,801.96,Other,125% Medicaid APG methodology,0.01,2078.69,
INCISION OF BREAST LESION       ,19020,CPT,,50001031,CDM,450,RC,,,both,,,7842,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,3569.69,,,3569.69,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,5489.4,70,,5489.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1919.19,,,1919.19,Other,New York Medicaid APG methodology,1919.19,,,1919.19,Other,100% Medicaid APG methodology,1919.19,,,1919.19,Other,100% Medicaid APG methodology,1919.19,,,1919.19,Other,100% Medicaid APG methodology,4318.17,,,4318.17,Other,225% Medicaid APG methodology,4318.17,,,4318.17,Other,225% Medicaid APG methodology,2936.36,,,2936.36,Other,153% Medicaid APG methodology,4318.17,,,4318.17,Other,225% Medicaid APG methodology,2686.86,,,2686.86,Other,140% Medicaid APG methodology,4318.17,,,4318.17,Other,225% Medicaid APG methodology,4989.89,,,4989.89,Other,260% Medicaid APG methodology,6218.17,,,6218.17,Other,324% Medicaid APG methodology,4126.25,,,4126.25,Other,215% Medicaid APG methodology,4126.25,,,4126.25,Other,215% Medicaid APG methodology,2398.98,,,2398.98,Other,125% Medicaid APG methodology,0.01,6218.17,
RESET DISLOCATED JAW INIT       ,21480,CPT,,50001056,CDM,450,RC,,,both,,,1018,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,501.18,,,501.18,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,712.6,70,,712.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,412.26,,,412.26,Other,153% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,377.23,,,377.23,Other,140% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,700.58,,,700.58,Other,260% Medicaid APG methodology,873.03,,,873.03,Other,324% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,336.82,,,336.82,Other,125% Medicaid APG methodology,0.01,873.03,
INTERDENTAL WIRING              ,21497,CPT,,50001064,CDM,450,RC,,,both,,,4939,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,508.35,,,508.35,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3457.3,70,,3457.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,273.31,,,273.31,Other,New York Medicaid APG methodology,273.31,,,273.31,Other,100% Medicaid APG methodology,273.31,,,273.31,Other,100% Medicaid APG methodology,273.31,,,273.31,Other,100% Medicaid APG methodology,614.94,,,614.94,Other,225% Medicaid APG methodology,614.94,,,614.94,Other,225% Medicaid APG methodology,418.16,,,418.16,Other,153% Medicaid APG methodology,614.94,,,614.94,Other,225% Medicaid APG methodology,382.63,,,382.63,Other,140% Medicaid APG methodology,614.94,,,614.94,Other,225% Medicaid APG methodology,710.6,,,710.6,Other,260% Medicaid APG methodology,885.52,,,885.52,Other,324% Medicaid APG methodology,587.61,,,587.61,Other,215% Medicaid APG methodology,587.61,,,587.61,Other,215% Medicaid APG methodology,341.64,,,341.64,Other,125% Medicaid APG methodology,0.01,3457.3,
TREAT SHOULDER DISLOC WO ANES   ,23650,CPT,,50001080,CDM,450,RC,,,both,,,1952,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1366.4,70,,1366.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,2244.92,
TREAT SHOULDER DISLOC W ANES    ,23655,CPT,,50001098,CDM,450,RC,,,both,,,3578,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2193.58,,,2193.58,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2504.6,70,,2504.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% Medicaid APG methodology,1179.35,,,1179.35,Other,100% Medicaid APG methodology,1179.35,,,1179.35,Other,100% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,1804.4,,,1804.4,Other,153% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,1651.08,,,1651.08,Other,140% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,3066.3,,,3066.3,Other,260% Medicaid APG methodology,3821.08,,,3821.08,Other,324% Medicaid APG methodology,2535.59,,,2535.59,Other,215% Medicaid APG methodology,2535.59,,,2535.59,Other,215% Medicaid APG methodology,1474.18,,,1474.18,Other,125% Medicaid APG methodology,0.01,3821.08,
CL TX SHDR DISLC & FX GT W MAN  ,23665,CPT,,50001106,CDM,450,RC,,,both,,,6368,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,4457.6,70,,4457.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,4457.6,
RX CL ELBOW DISLOC WO ANESTH    ,24600,CPT,,50001114,CDM,450,RC,,,both,,,951,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,665.7,70,,665.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,2244.92,
TREAT ELBOW DISLOCATION         ,24640,CPT,,50001122,CDM,450,RC,,,both,,,1952,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1366.4,70,,1366.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,2244.92,
REPAIR FOREARM TENDON/MSC XTSR  ,25270,CPT,,50001130,CDM,450,RC,,,both,,,10637,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,4458.03,,,4458.03,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,7445.9,70,,7445.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% Medicaid APG methodology,2396.79,,,2396.79,Other,100% Medicaid APG methodology,2396.79,,,2396.79,Other,100% Medicaid APG methodology,5392.78,,,5392.78,Other,225% Medicaid APG methodology,5392.78,,,5392.78,Other,225% Medicaid APG methodology,3667.09,,,3667.09,Other,153% Medicaid APG methodology,5392.78,,,5392.78,Other,225% Medicaid APG methodology,3355.51,,,3355.51,Other,140% Medicaid APG methodology,5392.78,,,5392.78,Other,225% Medicaid APG methodology,6231.66,,,6231.66,Other,260% Medicaid APG methodology,7765.6,,,7765.6,Other,324% Medicaid APG methodology,5153.1,,,5153.1,Other,215% Medicaid APG methodology,5153.1,,,5153.1,Other,215% Medicaid APG methodology,2995.99,,,2995.99,Other,125% Medicaid APG methodology,0.01,7765.6,
TREAT FX RADIUS/ULNA W MNP      ,25605,CPT,,50001148,CDM,450,RC,,,both,,,6814,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,4769.8,70,,4769.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,4769.8,
TREAT METACARPAL FX W MNP       ,26605,CPT,,50001163,CDM,450,RC,,,both,,,936,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,655.2,70,,655.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,2244.92,
CL TX PHALANG SHFT FX; W MANIP  ,26725,CPT,,50001189,CDM,450,RC,,,both,,,936,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,655.2,70,,655.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,2244.92,
TREAT FINGER DISLOC WO ANES     ,26770,CPT,,50001205,CDM,450,RC,,,both,,,1120,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,784,70,,784,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,2244.92,
TREAT HIP DISLOC WO ANES PST    ,27265,CPT,,50001213,CDM,450,RC,,,both,,,1030,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,721,70,,721,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,2244.92,
CL TX DSTL FIB FX WO MANIP      ,27786,CPT,,50001221,CDM,450,RC,,,both,,,961,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,672.7,70,,672.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,2244.92,
TREAT LOWER LEG FRACTURE W MNP  ,27825,CPT,,50001239,CDM,450,RC,,,both,,,5309,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3716.3,70,,3716.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,3716.3,
APPLICATION OF LONG ARM CAST    ,29065,CPT,,50001247,CDM,450,RC,,,both,,,1124,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,621.41,,,621.41,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,786.8,70,,786.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,334.09,,,334.09,Other,New York Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,511.16,,,511.16,Other,153% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,467.73,,,467.73,Other,140% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,868.64,,,868.64,Other,260% Medicaid APG methodology,1082.45,,,1082.45,Other,324% Medicaid APG methodology,718.29,,,718.29,Other,215% Medicaid APG methodology,718.29,,,718.29,Other,215% Medicaid APG methodology,417.61,,,417.61,Other,125% Medicaid APG methodology,0.01,1082.45,
APPLICATION OF FOREARM CAST     ,29075,CPT,,50001254,CDM,450,RC,,,both,,,1124,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,621.41,,,621.41,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,786.8,70,,786.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,334.09,,,334.09,Other,New York Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,511.16,,,511.16,Other,153% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,467.73,,,467.73,Other,140% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,868.64,,,868.64,Other,260% Medicaid APG methodology,1082.45,,,1082.45,Other,324% Medicaid APG methodology,718.29,,,718.29,Other,215% Medicaid APG methodology,718.29,,,718.29,Other,215% Medicaid APG methodology,417.61,,,417.61,Other,125% Medicaid APG methodology,0.01,1082.45,
APPLY LONG ARM SPLINT           ,29105,CPT,,50001262,CDM,450,RC,,,both,,,1238,299.64,,,299.64,Other,150% of Medicare + 9.63% HCRA Surcharge,182.21,,,182.21,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,465.59,,,465.59,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,866.6,70,,866.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,250.32,,,250.32,Other,New York Medicaid APG methodology,250.32,,,250.32,Other,100% Medicaid APG methodology,250.32,,,250.32,Other,100% Medicaid APG methodology,250.32,,,250.32,Other,100% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,382.99,,,382.99,Other,153% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,350.45,,,350.45,Other,140% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,650.83,,,650.83,Other,260% Medicaid APG methodology,811.03,,,811.03,Other,324% Medicaid APG methodology,538.19,,,538.19,Other,215% Medicaid APG methodology,538.19,,,538.19,Other,215% Medicaid APG methodology,312.9,,,312.9,Other,125% Medicaid APG methodology,0.01,866.6,
APPLY FOREARM SPLINT            ,29125,CPT,,50001270,CDM,450,RC,,,both,,,1236,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,465.59,,,465.59,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,865.2,70,,865.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,250.32,,,250.32,Other,New York Medicaid APG methodology,250.32,,,250.32,Other,100% Medicaid APG methodology,250.32,,,250.32,Other,100% Medicaid APG methodology,250.32,,,250.32,Other,100% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,382.99,,,382.99,Other,153% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,350.45,,,350.45,Other,140% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,650.83,,,650.83,Other,260% Medicaid APG methodology,811.03,,,811.03,Other,324% Medicaid APG methodology,538.19,,,538.19,Other,215% Medicaid APG methodology,538.19,,,538.19,Other,215% Medicaid APG methodology,312.9,,,312.9,Other,125% Medicaid APG methodology,0.01,865.2,
APPLICATION OF FINGER SPLINT    ,29130,CPT,,50001288,CDM,450,RC,,,both,,,1158,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,465.59,,,465.59,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,810.6,70,,810.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,250.32,,,250.32,Other,New York Medicaid APG methodology,250.32,,,250.32,Other,100% Medicaid APG methodology,250.32,,,250.32,Other,100% Medicaid APG methodology,250.32,,,250.32,Other,100% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,382.99,,,382.99,Other,153% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,350.45,,,350.45,Other,140% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,650.83,,,650.83,Other,260% Medicaid APG methodology,811.03,,,811.03,Other,324% Medicaid APG methodology,538.19,,,538.19,Other,215% Medicaid APG methodology,538.19,,,538.19,Other,215% Medicaid APG methodology,312.9,,,312.9,Other,125% Medicaid APG methodology,0.01,811.03,
STRAPPING OF ELBOW OR WRIST     ,29260,CPT,,50001296,CDM,450,RC,,,both,,,966,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,465.59,,,465.59,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,676.2,70,,676.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,250.32,,,250.32,Other,New York Medicaid APG methodology,250.32,,,250.32,Other,100% Medicaid APG methodology,250.32,,,250.32,Other,100% Medicaid APG methodology,250.32,,,250.32,Other,100% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,382.99,,,382.99,Other,153% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,350.45,,,350.45,Other,140% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,650.83,,,650.83,Other,260% Medicaid APG methodology,811.03,,,811.03,Other,324% Medicaid APG methodology,538.19,,,538.19,Other,215% Medicaid APG methodology,538.19,,,538.19,Other,215% Medicaid APG methodology,312.9,,,312.9,Other,125% Medicaid APG methodology,0.01,811.03,
APPLICATION OF HIP CAST         ,29305,CPT,,50001312,CDM,450,RC,,,both,,,1124,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,834.08,,,834.08,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,786.8,70,,786.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% Medicaid APG methodology,448.43,,,448.43,Other,100% Medicaid APG methodology,448.43,,,448.43,Other,100% Medicaid APG methodology,1008.97,,,1008.97,Other,225% Medicaid APG methodology,1008.97,,,1008.97,Other,225% Medicaid APG methodology,686.1,,,686.1,Other,153% Medicaid APG methodology,1008.97,,,1008.97,Other,225% Medicaid APG methodology,627.81,,,627.81,Other,140% Medicaid APG methodology,1008.97,,,1008.97,Other,225% Medicaid APG methodology,1165.92,,,1165.92,Other,260% Medicaid APG methodology,1452.92,,,1452.92,Other,324% Medicaid APG methodology,964.13,,,964.13,Other,215% Medicaid APG methodology,964.13,,,964.13,Other,215% Medicaid APG methodology,560.54,,,560.54,Other,125% Medicaid APG methodology,0.01,1452.92,
APPLY LONG LEG CAST             ,29345,CPT,,50001320,CDM,450,RC,,,both,,,1124,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,621.41,,,621.41,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,786.8,70,,786.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,334.09,,,334.09,Other,New York Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,511.16,,,511.16,Other,153% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,467.73,,,467.73,Other,140% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,868.64,,,868.64,Other,260% Medicaid APG methodology,1082.45,,,1082.45,Other,324% Medicaid APG methodology,718.29,,,718.29,Other,215% Medicaid APG methodology,718.29,,,718.29,Other,215% Medicaid APG methodology,417.61,,,417.61,Other,125% Medicaid APG methodology,0.01,1082.45,
APLY SHORT LEG CAST BLW KN      ,29405,CPT,,50001338,CDM,450,RC,,,both,,,1124,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,621.41,,,621.41,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,786.8,70,,786.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,334.09,,,334.09,Other,New York Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,511.16,,,511.16,Other,153% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,467.73,,,467.73,Other,140% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,868.64,,,868.64,Other,260% Medicaid APG methodology,1082.45,,,1082.45,Other,324% Medicaid APG methodology,718.29,,,718.29,Other,215% Medicaid APG methodology,718.29,,,718.29,Other,215% Medicaid APG methodology,417.61,,,417.61,Other,125% Medicaid APG methodology,0.01,1082.45,
APPLICATION LONG LEG SPLINT     ,29505,CPT,,50001346,CDM,450,RC,,,both,,,1158,299.64,,,299.64,Other,150% of Medicare + 9.63% HCRA Surcharge,182.21,,,182.21,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,465.59,,,465.59,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,810.6,70,,810.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,250.32,,,250.32,Other,New York Medicaid APG methodology,250.32,,,250.32,Other,100% Medicaid APG methodology,250.32,,,250.32,Other,100% Medicaid APG methodology,250.32,,,250.32,Other,100% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,382.99,,,382.99,Other,153% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,350.45,,,350.45,Other,140% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,650.83,,,650.83,Other,260% Medicaid APG methodology,811.03,,,811.03,Other,324% Medicaid APG methodology,538.19,,,538.19,Other,215% Medicaid APG methodology,538.19,,,538.19,Other,215% Medicaid APG methodology,312.9,,,312.9,Other,125% Medicaid APG methodology,0.01,811.03,
APPLICATION LOWER LEG SPLINT    ,29515,CPT,,50001353,CDM,450,RC,,,both,,,761,299.64,,,299.64,Other,150% of Medicare + 9.63% HCRA Surcharge,182.21,,,182.21,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,465.59,,,465.59,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,532.7,70,,532.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,250.32,,,250.32,Other,New York Medicaid APG methodology,250.32,,,250.32,Other,100% Medicaid APG methodology,250.32,,,250.32,Other,100% Medicaid APG methodology,250.32,,,250.32,Other,100% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,382.99,,,382.99,Other,153% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,350.45,,,350.45,Other,140% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,650.83,,,650.83,Other,260% Medicaid APG methodology,811.03,,,811.03,Other,324% Medicaid APG methodology,538.19,,,538.19,Other,215% Medicaid APG methodology,538.19,,,538.19,Other,215% Medicaid APG methodology,312.9,,,312.9,Other,125% Medicaid APG methodology,0.01,811.03,
STRAPPING OF KNEE               ,29530,CPT,,50001361,CDM,450,RC,,,both,,,476,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,465.59,,,465.59,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,333.2,70,,333.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,250.32,,,250.32,Other,New York Medicaid APG methodology,250.32,,,250.32,Other,100% Medicaid APG methodology,250.32,,,250.32,Other,100% Medicaid APG methodology,250.32,,,250.32,Other,100% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,382.99,,,382.99,Other,153% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,350.45,,,350.45,Other,140% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,650.83,,,650.83,Other,260% Medicaid APG methodology,811.03,,,811.03,Other,324% Medicaid APG methodology,538.19,,,538.19,Other,215% Medicaid APG methodology,538.19,,,538.19,Other,215% Medicaid APG methodology,312.9,,,312.9,Other,125% Medicaid APG methodology,0.01,811.03,
STRAPPING OF ANKLE AND/OR FT    ,29540,CPT,,50001379,CDM,450,RC,,,both,,,570,299.64,,,299.64,Other,150% of Medicare + 9.63% HCRA Surcharge,182.21,,,182.21,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,465.59,,,465.59,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,399,70,,399,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,250.32,,,250.32,Other,New York Medicaid APG methodology,250.32,,,250.32,Other,100% Medicaid APG methodology,250.32,,,250.32,Other,100% Medicaid APG methodology,250.32,,,250.32,Other,100% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,382.99,,,382.99,Other,153% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,350.45,,,350.45,Other,140% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,650.83,,,650.83,Other,260% Medicaid APG methodology,811.03,,,811.03,Other,324% Medicaid APG methodology,538.19,,,538.19,Other,215% Medicaid APG methodology,538.19,,,538.19,Other,215% Medicaid APG methodology,312.9,,,312.9,Other,125% Medicaid APG methodology,0.01,811.03,
STRAPPING OF TOES               ,29550,CPT,,50001387,CDM,450,RC,,,both,,,1052,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,465.59,,,465.59,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,736.4,70,,736.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,250.32,,,250.32,Other,New York Medicaid APG methodology,250.32,,,250.32,Other,100% Medicaid APG methodology,250.32,,,250.32,Other,100% Medicaid APG methodology,250.32,,,250.32,Other,100% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,382.99,,,382.99,Other,153% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,350.45,,,350.45,Other,140% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,650.83,,,650.83,Other,260% Medicaid APG methodology,811.03,,,811.03,Other,324% Medicaid APG methodology,538.19,,,538.19,Other,215% Medicaid APG methodology,538.19,,,538.19,Other,215% Medicaid APG methodology,312.9,,,312.9,Other,125% Medicaid APG methodology,0.01,811.03,
INSERT EMERGENCY AIRWAY         ,31500,CPT,,50001403,CDM,450,RC,,,both,,,2283,464.5,,,464.5,Other,150% of Medicare + 9.63% HCRA Surcharge,282.46,,,282.46,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1189.48,,,1189.48,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1598.1,70,,1598.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,639.51,,,639.51,Other,New York Medicaid APG methodology,639.51,,,639.51,Other,100% Medicaid APG methodology,639.51,,,639.51,Other,100% Medicaid APG methodology,639.51,,,639.51,Other,100% Medicaid APG methodology,1438.89,,,1438.89,Other,225% Medicaid APG methodology,1438.89,,,1438.89,Other,225% Medicaid APG methodology,978.45,,,978.45,Other,153% Medicaid APG methodology,1438.89,,,1438.89,Other,225% Medicaid APG methodology,895.31,,,895.31,Other,140% Medicaid APG methodology,1438.89,,,1438.89,Other,225% Medicaid APG methodology,1662.72,,,1662.72,Other,260% Medicaid APG methodology,2072,,,2072,Other,324% Medicaid APG methodology,1374.94,,,1374.94,Other,215% Medicaid APG methodology,1374.94,,,1374.94,Other,215% Medicaid APG methodology,799.38,,,799.38,Other,125% Medicaid APG methodology,0.01,2072,
DIAGNOSTIC LARYNGOSCOPY         ,31505,CPT,,50001411,CDM,450,RC,,,both,,,733,376.68,,,376.68,Other,150% of Medicare + 9.63% HCRA Surcharge,229.06,,,229.06,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,501.18,,,501.18,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,513.1,70,,513.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,412.26,,,412.26,Other,153% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,377.23,,,377.23,Other,140% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,700.58,,,700.58,Other,260% Medicaid APG methodology,873.03,,,873.03,Other,324% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,336.82,,,336.82,Other,125% Medicaid APG methodology,0.01,873.03,
DIAGNOSTIC LARYNGOSCOPY         ,31575,CPT,,50001429,CDM,450,RC,,,both,,,733,376.68,,,376.68,Other,150% of Medicare + 9.63% HCRA Surcharge,229.06,,,229.06,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,501.18,,,501.18,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,513.1,70,,513.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,412.26,,,412.26,Other,153% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,377.23,,,377.23,Other,140% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,700.58,,,700.58,Other,260% Medicaid APG methodology,873.03,,,873.03,Other,324% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,336.82,,,336.82,Other,125% Medicaid APG methodology,0.01,873.03,
INSERTION OF CHEST TUBE         ,32551,CPT,,50001437,CDM,450,RC,,,both,,,1870,3045.56,,,3045.56,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.02,,,1852.02,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1502.62,,,1502.62,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1309,70,,1309,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% Medicaid APG methodology,807.86,,,807.86,Other,100% Medicaid APG methodology,807.86,,,807.86,Other,100% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,1236.03,,,1236.03,Other,153% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,1131.01,,,1131.01,Other,140% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,2100.44,,,2100.44,Other,260% Medicaid APG methodology,2617.47,,,2617.47,Other,324% Medicaid APG methodology,1736.9,,,1736.9,Other,215% Medicaid APG methodology,1736.9,,,1736.9,Other,215% Medicaid APG methodology,1009.83,,,1009.83,Other,125% Medicaid APG methodology,0.01,3045.56,
DRAINAGE OF MOUTH LESION SMPL   ,40800,CPT,,50001452,CDM,450,RC,,,both,,,2335,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,508.35,,,508.35,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1634.5,70,,1634.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,273.31,,,273.31,Other,New York Medicaid APG methodology,273.31,,,273.31,Other,100% Medicaid APG methodology,273.31,,,273.31,Other,100% Medicaid APG methodology,273.31,,,273.31,Other,100% Medicaid APG methodology,614.94,,,614.94,Other,225% Medicaid APG methodology,614.94,,,614.94,Other,225% Medicaid APG methodology,418.16,,,418.16,Other,153% Medicaid APG methodology,614.94,,,614.94,Other,225% Medicaid APG methodology,382.63,,,382.63,Other,140% Medicaid APG methodology,614.94,,,614.94,Other,225% Medicaid APG methodology,710.6,,,710.6,Other,260% Medicaid APG methodology,885.52,,,885.52,Other,324% Medicaid APG methodology,587.61,,,587.61,Other,215% Medicaid APG methodology,587.61,,,587.61,Other,215% Medicaid APG methodology,341.64,,,341.64,Other,125% Medicaid APG methodology,0.01,1634.5,
REMOVE PHARYNX FOREIGN BODY     ,42809,CPT,,50001478,CDM,450,RC,,,both,,,2086,757.69,,,757.69,Other,150% of Medicare + 9.63% HCRA Surcharge,460.76,,,460.76,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,501.18,,,501.18,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1460.2,70,,1460.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,412.26,,,412.26,Other,153% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,377.23,,,377.23,Other,140% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,700.58,,,700.58,Other,260% Medicaid APG methodology,873.03,,,873.03,Other,324% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,336.82,,,336.82,Other,125% Medicaid APG methodology,0.01,1460.2,
RECTUM SURGERY PROCEDURE        ,45999,CPT,,50001486,CDM,450,RC,,,both,,,3176,1738.02,,,1738.02,Other,150% of Medicare + 9.63% HCRA Surcharge,1056.9,,,1056.9,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2224.8,,,2224.8,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2223.2,70,,2223.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1196.13,,,1196.13,Other,New York Medicaid APG methodology,1196.13,,,1196.13,Other,100% Medicaid APG methodology,1196.13,,,1196.13,Other,100% Medicaid APG methodology,1196.13,,,1196.13,Other,100% Medicaid APG methodology,2691.29,,,2691.29,Other,225% Medicaid APG methodology,2691.29,,,2691.29,Other,225% Medicaid APG methodology,1830.08,,,1830.08,Other,153% Medicaid APG methodology,2691.29,,,2691.29,Other,225% Medicaid APG methodology,1674.58,,,1674.58,Other,140% Medicaid APG methodology,2691.29,,,2691.29,Other,225% Medicaid APG methodology,3109.94,,,3109.94,Other,260% Medicaid APG methodology,3875.46,,,3875.46,Other,324% Medicaid APG methodology,2571.68,,,2571.68,Other,215% Medicaid APG methodology,2571.68,,,2571.68,Other,215% Medicaid APG methodology,1495.16,,,1495.16,Other,125% Medicaid APG methodology,0.01,3875.46,
INCISION OF ANAL ABSCESS        ,46050,CPT,,50001494,CDM,450,RC,,,both,,,3494,1738.02,,,1738.02,Other,150% of Medicare + 9.63% HCRA Surcharge,1056.9,,,1056.9,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2542.82,,,2542.82,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2445.8,70,,2445.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% Medicaid APG methodology,1367.11,,,1367.11,Other,100% Medicaid APG methodology,1367.11,,,1367.11,Other,100% Medicaid APG methodology,3075.99,,,3075.99,Other,225% Medicaid APG methodology,3075.99,,,3075.99,Other,225% Medicaid APG methodology,2091.67,,,2091.67,Other,153% Medicaid APG methodology,3075.99,,,3075.99,Other,225% Medicaid APG methodology,1913.95,,,1913.95,Other,140% Medicaid APG methodology,3075.99,,,3075.99,Other,225% Medicaid APG methodology,3554.48,,,3554.48,Other,260% Medicaid APG methodology,4429.43,,,4429.43,Other,324% Medicaid APG methodology,2939.28,,,2939.28,Other,215% Medicaid APG methodology,2939.28,,,2939.28,Other,215% Medicaid APG methodology,1708.88,,,1708.88,Other,125% Medicaid APG methodology,0.01,4429.43,
DRAINAGE OF SCROTUM ABSCESS     ,55100,CPT,,50001528,CDM,450,RC,,,both,,,5335,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2992,,,2992,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3734.5,70,,3734.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1608.6,,,1608.6,Other,New York Medicaid APG methodology,1608.6,,,1608.6,Other,100% Medicaid APG methodology,1608.6,,,1608.6,Other,100% Medicaid APG methodology,1608.6,,,1608.6,Other,100% Medicaid APG methodology,3619.35,,,3619.35,Other,225% Medicaid APG methodology,3619.35,,,3619.35,Other,225% Medicaid APG methodology,2461.16,,,2461.16,Other,153% Medicaid APG methodology,3619.35,,,3619.35,Other,225% Medicaid APG methodology,2252.04,,,2252.04,Other,140% Medicaid APG methodology,3619.35,,,3619.35,Other,225% Medicaid APG methodology,4182.36,,,4182.36,Other,260% Medicaid APG methodology,5211.87,,,5211.87,Other,324% Medicaid APG methodology,3458.49,,,3458.49,Other,215% Medicaid APG methodology,3458.49,,,3458.49,Other,215% Medicaid APG methodology,2010.75,,,2010.75,Other,125% Medicaid APG methodology,0.01,5211.87,
DRAINAGE OF GLAND ABSCESS       ,56420,CPT,,50001536,CDM,450,RC,,,both,,,797,378.94,,,378.94,Other,150% of Medicare + 9.63% HCRA Surcharge,230.43,,,230.43,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,529.85,,,529.85,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,557.9,70,,557.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,284.87,,,284.87,Other,New York Medicaid APG methodology,284.87,,,284.87,Other,100% Medicaid APG methodology,284.87,,,284.87,Other,100% Medicaid APG methodology,284.87,,,284.87,Other,100% Medicaid APG methodology,640.95,,,640.95,Other,225% Medicaid APG methodology,640.95,,,640.95,Other,225% Medicaid APG methodology,435.85,,,435.85,Other,153% Medicaid APG methodology,640.95,,,640.95,Other,225% Medicaid APG methodology,398.81,,,398.81,Other,140% Medicaid APG methodology,640.95,,,640.95,Other,225% Medicaid APG methodology,740.65,,,740.65,Other,260% Medicaid APG methodology,922.97,,,922.97,Other,324% Medicaid APG methodology,612.46,,,612.46,Other,215% Medicaid APG methodology,612.46,,,612.46,Other,215% Medicaid APG methodology,356.08,,,356.08,Other,125% Medicaid APG methodology,0.01,922.97,
TREAT VAGINAL BLEEDING          ,57180,CPT,,50001544,CDM,450,RC,,,both,,,724,378.94,,,378.94,Other,150% of Medicare + 9.63% HCRA Surcharge,230.43,,,230.43,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1419.19,,,1419.19,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,506.8,70,,506.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,763.01,,,763.01,Other,New York Medicaid APG methodology,763.01,,,763.01,Other,100% Medicaid APG methodology,763.01,,,763.01,Other,100% Medicaid APG methodology,763.01,,,763.01,Other,100% Medicaid APG methodology,1716.77,,,1716.77,Other,225% Medicaid APG methodology,1716.77,,,1716.77,Other,225% Medicaid APG methodology,1167.4,,,1167.4,Other,153% Medicaid APG methodology,1716.77,,,1716.77,Other,225% Medicaid APG methodology,1068.21,,,1068.21,Other,140% Medicaid APG methodology,1716.77,,,1716.77,Other,225% Medicaid APG methodology,1983.82,,,1983.82,Other,260% Medicaid APG methodology,2472.14,,,2472.14,Other,324% Medicaid APG methodology,1640.46,,,1640.46,Other,215% Medicaid APG methodology,1640.46,,,1640.46,Other,215% Medicaid APG methodology,953.76,,,953.76,Other,125% Medicaid APG methodology,0.01,2472.14,
BRAIN CANAL SHUNT PROCEDURE     ,61070,CPT,,50001551,CDM,450,RC,,,both,,,2354,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1204.2,,,1204.2,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1647.8,70,,1647.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% Medicaid APG methodology,647.42,,,647.42,Other,100% Medicaid APG methodology,647.42,,,647.42,Other,100% Medicaid APG methodology,1456.69,,,1456.69,Other,225% Medicaid APG methodology,1456.69,,,1456.69,Other,225% Medicaid APG methodology,990.55,,,990.55,Other,153% Medicaid APG methodology,1456.69,,,1456.69,Other,225% Medicaid APG methodology,906.38,,,906.38,Other,140% Medicaid APG methodology,1456.69,,,1456.69,Other,225% Medicaid APG methodology,1683.28,,,1683.28,Other,260% Medicaid APG methodology,2097.63,,,2097.63,Other,324% Medicaid APG methodology,1391.95,,,1391.95,Other,215% Medicaid APG methodology,1391.95,,,1391.95,Other,215% Medicaid APG methodology,809.27,,,809.27,Other,125% Medicaid APG methodology,0.01,2097.63,
REMOVAL FB FROM EYE SPRFCL      ,65205,CPT,,50001569,CDM,450,RC,,,both,,,1066,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,408.99,,,408.99,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,746.2,70,,746.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,219.89,,,219.89,Other,New York Medicaid APG methodology,219.89,,,219.89,Other,100% Medicaid APG methodology,219.89,,,219.89,Other,100% Medicaid APG methodology,219.89,,,219.89,Other,100% Medicaid APG methodology,494.75,,,494.75,Other,225% Medicaid APG methodology,494.75,,,494.75,Other,225% Medicaid APG methodology,336.43,,,336.43,Other,153% Medicaid APG methodology,494.75,,,494.75,Other,225% Medicaid APG methodology,307.84,,,307.84,Other,140% Medicaid APG methodology,494.75,,,494.75,Other,225% Medicaid APG methodology,571.71,,,571.71,Other,260% Medicaid APG methodology,712.44,,,712.44,Other,324% Medicaid APG methodology,472.76,,,472.76,Other,215% Medicaid APG methodology,472.76,,,472.76,Other,215% Medicaid APG methodology,274.86,,,274.86,Other,125% Medicaid APG methodology,0.01,746.2,
CLEAR OUTER EAR CANAL           ,69200,CPT,,50001577,CDM,450,RC,,,both,,,722,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,505.4,70,,505.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,505.4,
DENTAL SURGERY PROCEDURE        ,41899,CPT,,50001585,CDM,450,RC,,,both,,,740,464.5,,,464.5,Other,150% of Medicare + 9.63% HCRA Surcharge,282.46,,,282.46,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,315.76,,,315.76,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,518,70,,518,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,169.76,,,169.76,Other,New York Medicaid APG methodology,169.76,,,169.76,Other,100% Medicaid APG methodology,169.76,,,169.76,Other,100% Medicaid APG methodology,169.76,,,169.76,Other,100% Medicaid APG methodology,381.97,,,381.97,Other,225% Medicaid APG methodology,381.97,,,381.97,Other,225% Medicaid APG methodology,259.74,,,259.74,Other,153% Medicaid APG methodology,381.97,,,381.97,Other,225% Medicaid APG methodology,237.67,,,237.67,Other,140% Medicaid APG methodology,381.97,,,381.97,Other,225% Medicaid APG methodology,441.38,,,441.38,Other,260% Medicaid APG methodology,550.03,,,550.03,Other,324% Medicaid APG methodology,364.99,,,364.99,Other,215% Medicaid APG methodology,364.99,,,364.99,Other,215% Medicaid APG methodology,212.2,,,212.2,Other,125% Medicaid APG methodology,0.01,550.03,
DEBRIDE INFECTED SKIN           ,11000,CPT,,50001676,CDM,450,RC,,,both,,,2231,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1704.43,,,1704.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1561.7,70,,1561.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1402.03,,,1402.03,Other,153% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1282.9,,,1282.9,Other,140% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2382.54,,,2382.54,Other,260% Medicaid APG methodology,2969.01,,,2969.01,Other,324% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1145.45,,,1145.45,Other,125% Medicaid APG methodology,0.01,2969.01,
DEBRIDE SKIN AT FX SITE         ,11010,CPT,,50001684,CDM,450,RC,,,both,,,2335,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1704.43,,,1704.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1634.5,70,,1634.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1402.03,,,1402.03,Other,153% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1282.9,,,1282.9,Other,140% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2382.54,,,2382.54,Other,260% Medicaid APG methodology,2969.01,,,2969.01,Other,324% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1145.45,,,1145.45,Other,125% Medicaid APG methodology,0.01,2969.01,
DEB SUBQ TISSUE 20 SQ CM/<      ,11042,CPT,,50001700,CDM,450,RC,,,both,,,2132,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1704.43,,,1704.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1492.4,70,,1492.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1402.03,,,1402.03,Other,153% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1282.9,,,1282.9,Other,140% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2382.54,,,2382.54,Other,260% Medicaid APG methodology,2969.01,,,2969.01,Other,324% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1145.45,,,1145.45,Other,125% Medicaid APG methodology,0.01,2969.01,
REMOVAL OF SKIN TAGS <W/15      ,11200,CPT,,50001742,CDM,450,RC,,,both,,,651,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,902.56,,,902.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,455.7,70,,455.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,742.43,,,742.43,Other,153% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,679.35,,,679.35,Other,140% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,1261.65,,,1261.65,Other,260% Medicaid APG methodology,1572.2,,,1572.2,Other,324% Medicaid APG methodology,1043.28,,,1043.28,Other,215% Medicaid APG methodology,1043.28,,,1043.28,Other,215% Medicaid APG methodology,606.56,,,606.56,Other,125% Medicaid APG methodology,0.01,1572.2,
EXC H-F-NK-SP B9+MARG 0.6-1     ,11421,CPT,,50001825,CDM,450,RC,,,both,,,2335,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1559.83,,,1559.83,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1634.5,70,,1634.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1283.09,,,1283.09,Other,153% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1174.07,,,1174.07,Other,140% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,2180.41,,,2180.41,Other,260% Medicaid APG methodology,2717.12,,,2717.12,Other,324% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1048.27,,,1048.27,Other,125% Medicaid APG methodology,0.01,2717.12,
EXC FACE-MM B9+MARG 0.5 CM/<    ,11440,CPT,,50001882,CDM,450,RC,,,both,,,3333,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1559.83,,,1559.83,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2333.1,70,,2333.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1283.09,,,1283.09,Other,153% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1174.07,,,1174.07,Other,140% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,2180.41,,,2180.41,Other,260% Medicaid APG methodology,2717.12,,,2717.12,Other,324% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1048.27,,,1048.27,Other,125% Medicaid APG methodology,0.01,2717.12,
REMOVAL OF NAIL BED             ,11750,CPT,,50002062,CDM,450,RC,,,both,,,1343,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1559.83,,,1559.83,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,940.1,70,,940.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1283.09,,,1283.09,Other,153% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1174.07,,,1174.07,Other,140% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,2180.41,,,2180.41,Other,260% Medicaid APG methodology,2717.12,,,2717.12,Other,324% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1048.27,,,1048.27,Other,125% Medicaid APG methodology,0.01,2717.12,
CLOSURE OF SPLIT WOUND          ,12020,CPT,,50002146,CDM,450,RC,,,both,,,2484,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1704.43,,,1704.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1738.8,70,,1738.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1402.03,,,1402.03,Other,153% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1282.9,,,1282.9,Other,140% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2382.54,,,2382.54,Other,260% Medicaid APG methodology,2969.01,,,2969.01,Other,324% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1145.45,,,1145.45,Other,125% Medicaid APG methodology,0.01,2969.01,
INTMD RPR S/TR/EXT 7.6-12.5     ,12034,CPT,,50002179,CDM,450,RC,,,both,,,3669,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1704.43,,,1704.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2568.3,70,,2568.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1402.03,,,1402.03,Other,153% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1282.9,,,1282.9,Other,140% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2382.54,,,2382.54,Other,260% Medicaid APG methodology,2969.01,,,2969.01,Other,324% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1145.45,,,1145.45,Other,125% Medicaid APG methodology,0.01,2969.01,
INTMD RPR N-HF/GENIT2.6-7.5     ,12042,CPT,,50002187,CDM,450,RC,,,both,,,3117,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1704.43,,,1704.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2181.9,70,,2181.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1402.03,,,1402.03,Other,153% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1282.9,,,1282.9,Other,140% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2382.54,,,2382.54,Other,260% Medicaid APG methodology,2969.01,,,2969.01,Other,324% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1145.45,,,1145.45,Other,125% Medicaid APG methodology,0.01,2969.01,
INTMD RPR FACE/MM 5.1-7.5 CM    ,12053,CPT,,50002211,CDM,450,RC,,,both,,,3117,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1704.43,,,1704.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2181.9,70,,2181.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1402.03,,,1402.03,Other,153% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1282.9,,,1282.9,Other,140% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2382.54,,,2382.54,Other,260% Medicaid APG methodology,2969.01,,,2969.01,Other,324% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1145.45,,,1145.45,Other,125% Medicaid APG methodology,0.01,2969.01,
REMOVAL OF SUPPORT IMPLANT      ,20670,CPT,,50003102,CDM,450,RC,,,both,,,5335,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,3873.59,,,3873.59,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3734.5,70,,3734.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,2082.57,,,2082.57,Other,New York Medicaid APG methodology,2082.57,,,2082.57,Other,100% Medicaid APG methodology,2082.57,,,2082.57,Other,100% Medicaid APG methodology,2082.57,,,2082.57,Other,100% Medicaid APG methodology,4685.79,,,4685.79,Other,225% Medicaid APG methodology,4685.79,,,4685.79,Other,225% Medicaid APG methodology,3186.34,,,3186.34,Other,153% Medicaid APG methodology,4685.79,,,4685.79,Other,225% Medicaid APG methodology,2915.6,,,2915.6,Other,140% Medicaid APG methodology,4685.79,,,4685.79,Other,225% Medicaid APG methodology,5414.69,,,5414.69,Other,260% Medicaid APG methodology,6747.54,,,6747.54,Other,324% Medicaid APG methodology,4477.53,,,4477.53,Other,215% Medicaid APG methodology,4477.53,,,4477.53,Other,215% Medicaid APG methodology,2603.22,,,2603.22,Other,125% Medicaid APG methodology,0.01,6747.54,
EXCISE MANDIBLE LESION          ,21040,CPT,,50003185,CDM,450,RC,,,both,,,10122,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,5647.23,,,5647.23,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,7085.4,70,,7085.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% Medicaid APG methodology,3036.14,,,3036.14,Other,100% Medicaid APG methodology,3036.14,,,3036.14,Other,100% Medicaid APG methodology,6831.33,,,6831.33,Other,225% Medicaid APG methodology,6831.33,,,6831.33,Other,225% Medicaid APG methodology,4645.3,,,4645.3,Other,153% Medicaid APG methodology,6831.33,,,6831.33,Other,225% Medicaid APG methodology,4250.6,,,4250.6,Other,140% Medicaid APG methodology,6831.33,,,6831.33,Other,225% Medicaid APG methodology,7893.98,,,7893.98,Other,260% Medicaid APG methodology,9837.11,,,9837.11,Other,324% Medicaid APG methodology,6527.71,,,6527.71,Other,215% Medicaid APG methodology,6527.71,,,6527.71,Other,215% Medicaid APG methodology,3795.18,,,3795.18,Other,125% Medicaid APG methodology,0.01,9837.11,
FACE BONE GRAFT                 ,21210,CPT,,50003235,CDM,450,RC,,,both,,,18997,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,7051.19,,,7051.19,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,13297.9,70,,13297.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% Medicaid APG methodology,3790.96,,,3790.96,Other,100% Medicaid APG methodology,3790.96,,,3790.96,Other,100% Medicaid APG methodology,8529.66,,,8529.66,Other,225% Medicaid APG methodology,8529.66,,,8529.66,Other,225% Medicaid APG methodology,5800.17,,,5800.17,Other,153% Medicaid APG methodology,8529.66,,,8529.66,Other,225% Medicaid APG methodology,5307.35,,,5307.35,Other,140% Medicaid APG methodology,8529.66,,,8529.66,Other,225% Medicaid APG methodology,9856.5,,,9856.5,Other,260% Medicaid APG methodology,12282.71,,,12282.71,Other,324% Medicaid APG methodology,8150.57,,,8150.57,Other,215% Medicaid APG methodology,8150.57,,,8150.57,Other,215% Medicaid APG methodology,4738.7,,,4738.7,Other,125% Medicaid APG methodology,0.01,13297.9,
EAR CARTILAGE GRAFT             ,21235,CPT,,50003243,CDM,450,RC,,,both,,,18997,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,5647.23,,,5647.23,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,13297.9,70,,13297.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% Medicaid APG methodology,3036.14,,,3036.14,Other,100% Medicaid APG methodology,3036.14,,,3036.14,Other,100% Medicaid APG methodology,6831.33,,,6831.33,Other,225% Medicaid APG methodology,6831.33,,,6831.33,Other,225% Medicaid APG methodology,4645.3,,,4645.3,Other,153% Medicaid APG methodology,6831.33,,,6831.33,Other,225% Medicaid APG methodology,4250.6,,,4250.6,Other,140% Medicaid APG methodology,6831.33,,,6831.33,Other,225% Medicaid APG methodology,7893.98,,,7893.98,Other,260% Medicaid APG methodology,9837.11,,,9837.11,Other,324% Medicaid APG methodology,6527.71,,,6527.71,Other,215% Medicaid APG methodology,6527.71,,,6527.71,Other,215% Medicaid APG methodology,3795.18,,,3795.18,Other,125% Medicaid APG methodology,0.01,13297.9,
CLOSED TX NOSE FX W/O STABLJ    ,21315,CPT,,50003276,CDM,450,RC,,,both,,,966,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,676.2,70,,676.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,2900.1,
CLOSED TX NOSE FX W/ STABLJ     ,21320,CPT,,50003284,CDM,450,RC,,,both,,,966,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,676.2,70,,676.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,6122.57,
TREAT CLAVICLE DISLOCATION      ,23545,CPT,,50003482,CDM,450,RC,,,both,,,961,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,672.7,70,,672.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,2244.92,
UPPER ARM/ELBOW SURGERY         ,24999,CPT,,50003615,CDM,450,RC,,,both,,,873,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1048.04,,,1048.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,611.1,70,,611.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,563.46,,,563.46,Other,New York Medicaid APG methodology,563.46,,,563.46,Other,100% Medicaid APG methodology,563.46,,,563.46,Other,100% Medicaid APG methodology,563.46,,,563.46,Other,100% Medicaid APG methodology,1267.79,,,1267.79,Other,225% Medicaid APG methodology,1267.79,,,1267.79,Other,225% Medicaid APG methodology,862.1,,,862.1,Other,153% Medicaid APG methodology,1267.79,,,1267.79,Other,225% Medicaid APG methodology,788.85,,,788.85,Other,140% Medicaid APG methodology,1267.79,,,1267.79,Other,225% Medicaid APG methodology,1465.01,,,1465.01,Other,260% Medicaid APG methodology,1825.62,,,1825.62,Other,324% Medicaid APG methodology,1211.45,,,1211.45,Other,215% Medicaid APG methodology,1211.45,,,1211.45,Other,215% Medicaid APG methodology,704.33,,,704.33,Other,125% Medicaid APG methodology,0.01,1825.62,
REPAIR FOREARM TENDON/MSC FLXR  ,25260,CPT,,50003755,CDM,450,RC,,,both,,,10637,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,4458.03,,,4458.03,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,7445.9,70,,7445.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% Medicaid APG methodology,2396.79,,,2396.79,Other,100% Medicaid APG methodology,2396.79,,,2396.79,Other,100% Medicaid APG methodology,5392.78,,,5392.78,Other,225% Medicaid APG methodology,5392.78,,,5392.78,Other,225% Medicaid APG methodology,3667.09,,,3667.09,Other,153% Medicaid APG methodology,5392.78,,,5392.78,Other,225% Medicaid APG methodology,3355.51,,,3355.51,Other,140% Medicaid APG methodology,5392.78,,,5392.78,Other,225% Medicaid APG methodology,6231.66,,,6231.66,Other,260% Medicaid APG methodology,7765.6,,,7765.6,Other,324% Medicaid APG methodology,5153.1,,,5153.1,Other,215% Medicaid APG methodology,5153.1,,,5153.1,Other,215% Medicaid APG methodology,2995.99,,,2995.99,Other,125% Medicaid APG methodology,0.01,7765.6,
REPAIR FINGER/HAND TENDON       ,26350,CPT,,50004035,CDM,450,RC,,,both,,,10637,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2917.58,,,2917.58,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,7445.9,70,,7445.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% Medicaid APG methodology,1568.59,,,1568.59,Other,100% Medicaid APG methodology,1568.59,,,1568.59,Other,100% Medicaid APG methodology,3529.33,,,3529.33,Other,225% Medicaid APG methodology,3529.33,,,3529.33,Other,225% Medicaid APG methodology,2399.94,,,2399.94,Other,153% Medicaid APG methodology,3529.33,,,3529.33,Other,225% Medicaid APG methodology,2196.03,,,2196.03,Other,140% Medicaid APG methodology,3529.33,,,3529.33,Other,225% Medicaid APG methodology,4078.34,,,4078.34,Other,260% Medicaid APG methodology,5082.24,,,5082.24,Other,324% Medicaid APG methodology,3372.47,,,3372.47,Other,215% Medicaid APG methodology,3372.47,,,3372.47,Other,215% Medicaid APG methodology,1960.74,,,1960.74,Other,125% Medicaid APG methodology,0.01,7445.9,
REPAIR FINGER TENDON            ,26433,CPT,,50004118,CDM,450,RC,,,both,,,10637,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2917.58,,,2917.58,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,7445.9,70,,7445.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% Medicaid APG methodology,1568.59,,,1568.59,Other,100% Medicaid APG methodology,1568.59,,,1568.59,Other,100% Medicaid APG methodology,3529.33,,,3529.33,Other,225% Medicaid APG methodology,3529.33,,,3529.33,Other,225% Medicaid APG methodology,2399.94,,,2399.94,Other,153% Medicaid APG methodology,3529.33,,,3529.33,Other,225% Medicaid APG methodology,2196.03,,,2196.03,Other,140% Medicaid APG methodology,3529.33,,,3529.33,Other,225% Medicaid APG methodology,4078.34,,,4078.34,Other,260% Medicaid APG methodology,5082.24,,,5082.24,Other,324% Medicaid APG methodology,3372.47,,,3372.47,Other,215% Medicaid APG methodology,3372.47,,,3372.47,Other,215% Medicaid APG methodology,1960.74,,,1960.74,Other,125% Medicaid APG methodology,0.01,7445.9,
REPAIR HAND JOINT               ,26540,CPT,,50004266,CDM,450,RC,,,both,,,10637,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2917.58,,,2917.58,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,7445.9,70,,7445.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% Medicaid APG methodology,1568.59,,,1568.59,Other,100% Medicaid APG methodology,1568.59,,,1568.59,Other,100% Medicaid APG methodology,3529.33,,,3529.33,Other,225% Medicaid APG methodology,3529.33,,,3529.33,Other,225% Medicaid APG methodology,2399.94,,,2399.94,Other,153% Medicaid APG methodology,3529.33,,,3529.33,Other,225% Medicaid APG methodology,2196.03,,,2196.03,Other,140% Medicaid APG methodology,3529.33,,,3529.33,Other,225% Medicaid APG methodology,4078.34,,,4078.34,Other,260% Medicaid APG methodology,5082.24,,,5082.24,Other,324% Medicaid APG methodology,3372.47,,,3372.47,Other,215% Medicaid APG methodology,3372.47,,,3372.47,Other,215% Medicaid APG methodology,1960.74,,,1960.74,Other,125% Medicaid APG methodology,0.01,7445.9,
OPEN TX DISTAL PHALANG FX EA    ,26765,CPT,,50004415,CDM,450,RC,,,both,,,10637,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,6546.01,,,6546.01,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,7445.9,70,,7445.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% Medicaid APG methodology,3519.36,,,3519.36,Other,100% Medicaid APG methodology,3519.36,,,3519.36,Other,100% Medicaid APG methodology,7918.56,,,7918.56,Other,225% Medicaid APG methodology,7918.56,,,7918.56,Other,225% Medicaid APG methodology,5384.62,,,5384.62,Other,153% Medicaid APG methodology,7918.56,,,7918.56,Other,225% Medicaid APG methodology,4927.1,,,4927.1,Other,140% Medicaid APG methodology,7918.56,,,7918.56,Other,225% Medicaid APG methodology,9150.34,,,9150.34,Other,260% Medicaid APG methodology,11402.73,,,11402.73,Other,324% Medicaid APG methodology,7566.62,,,7566.62,Other,215% Medicaid APG methodology,7566.62,,,7566.62,Other,215% Medicaid APG methodology,4399.2,,,4399.2,Other,125% Medicaid APG methodology,0.01,11402.73,
AMPUTATE METACARPAL BONE        ,26910,CPT,,50004464,CDM,450,RC,,,both,,,10637,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,4684.96,,,4684.96,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,7445.9,70,,7445.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% Medicaid APG methodology,2518.8,,,2518.8,Other,100% Medicaid APG methodology,2518.8,,,2518.8,Other,100% Medicaid APG methodology,5667.29,,,5667.29,Other,225% Medicaid APG methodology,5667.29,,,5667.29,Other,225% Medicaid APG methodology,3853.76,,,3853.76,Other,153% Medicaid APG methodology,5667.29,,,5667.29,Other,225% Medicaid APG methodology,3526.31,,,3526.31,Other,140% Medicaid APG methodology,5667.29,,,5667.29,Other,225% Medicaid APG methodology,6548.87,,,6548.87,Other,260% Medicaid APG methodology,8160.9,,,8160.9,Other,324% Medicaid APG methodology,5415.41,,,5415.41,Other,215% Medicaid APG methodology,5415.41,,,5415.41,Other,215% Medicaid APG methodology,3148.49,,,3148.49,Other,125% Medicaid APG methodology,0.01,8160.9,
AMPUTATION OF FNGR/THMB DIR CL  ,26951,CPT,,50004472,CDM,450,RC,,,both,,,11701,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2917.58,,,2917.58,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,8190.7,70,,8190.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% Medicaid APG methodology,1568.59,,,1568.59,Other,100% Medicaid APG methodology,1568.59,,,1568.59,Other,100% Medicaid APG methodology,3529.33,,,3529.33,Other,225% Medicaid APG methodology,3529.33,,,3529.33,Other,225% Medicaid APG methodology,2399.94,,,2399.94,Other,153% Medicaid APG methodology,3529.33,,,3529.33,Other,225% Medicaid APG methodology,2196.03,,,2196.03,Other,140% Medicaid APG methodology,3529.33,,,3529.33,Other,225% Medicaid APG methodology,4078.34,,,4078.34,Other,260% Medicaid APG methodology,5082.24,,,5082.24,Other,324% Medicaid APG methodology,3372.47,,,3372.47,Other,215% Medicaid APG methodology,3372.47,,,3372.47,Other,215% Medicaid APG methodology,1960.74,,,1960.74,Other,125% Medicaid APG methodology,0.01,8190.7,
AMPUTATION OF FNGR/THMB LOC FL  ,26952,CPT,,50004480,CDM,450,RC,,,both,,,10637,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,4684.96,,,4684.96,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,7445.9,70,,7445.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% Medicaid APG methodology,2518.8,,,2518.8,Other,100% Medicaid APG methodology,2518.8,,,2518.8,Other,100% Medicaid APG methodology,5667.29,,,5667.29,Other,225% Medicaid APG methodology,5667.29,,,5667.29,Other,225% Medicaid APG methodology,3853.76,,,3853.76,Other,153% Medicaid APG methodology,5667.29,,,5667.29,Other,225% Medicaid APG methodology,3526.31,,,3526.31,Other,140% Medicaid APG methodology,5667.29,,,5667.29,Other,225% Medicaid APG methodology,6548.87,,,6548.87,Other,260% Medicaid APG methodology,8160.9,,,8160.9,Other,324% Medicaid APG methodology,5415.41,,,5415.41,Other,215% Medicaid APG methodology,5415.41,,,5415.41,Other,215% Medicaid APG methodology,3148.49,,,3148.49,Other,125% Medicaid APG methodology,0.01,8160.9,
LEG/ANKLE SURGERY PROCEDURE     ,27899,CPT,,50004837,CDM,450,RC,,,both,,,873,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1048.04,,,1048.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,611.1,70,,611.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,563.46,,,563.46,Other,New York Medicaid APG methodology,563.46,,,563.46,Other,100% Medicaid APG methodology,563.46,,,563.46,Other,100% Medicaid APG methodology,563.46,,,563.46,Other,100% Medicaid APG methodology,1267.79,,,1267.79,Other,225% Medicaid APG methodology,1267.79,,,1267.79,Other,225% Medicaid APG methodology,862.1,,,862.1,Other,153% Medicaid APG methodology,1267.79,,,1267.79,Other,225% Medicaid APG methodology,788.85,,,788.85,Other,140% Medicaid APG methodology,1267.79,,,1267.79,Other,225% Medicaid APG methodology,1465.01,,,1465.01,Other,260% Medicaid APG methodology,1825.62,,,1825.62,Other,324% Medicaid APG methodology,1211.45,,,1211.45,Other,215% Medicaid APG methodology,1211.45,,,1211.45,Other,215% Medicaid APG methodology,704.33,,,704.33,Other,125% Medicaid APG methodology,0.01,1825.62,
DX LARYNGOSCOPY EXCL NB         ,31525,CPT,,50005792,CDM,450,RC,,,both,,,4480,3227.6,,,3227.6,Other,150% of Medicare + 9.63% HCRA Surcharge,1962.72,,,1962.72,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1030.04,,,1030.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3136,70,,3136,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,553.79,,,553.79,Other,New York Medicaid APG methodology,553.79,,,553.79,Other,100% Medicaid APG methodology,553.79,,,553.79,Other,100% Medicaid APG methodology,553.79,,,553.79,Other,100% Medicaid APG methodology,1246.02,,,1246.02,Other,225% Medicaid APG methodology,1246.02,,,1246.02,Other,225% Medicaid APG methodology,847.29,,,847.29,Other,153% Medicaid APG methodology,1246.02,,,1246.02,Other,225% Medicaid APG methodology,775.3,,,775.3,Other,140% Medicaid APG methodology,1246.02,,,1246.02,Other,225% Medicaid APG methodology,1439.85,,,1439.85,Other,260% Medicaid APG methodology,1794.27,,,1794.27,Other,324% Medicaid APG methodology,1190.64,,,1190.64,Other,215% Medicaid APG methodology,1190.64,,,1190.64,Other,215% Medicaid APG methodology,692.23,,,692.23,Other,125% Medicaid APG methodology,0.01,3227.6,
LARYNGOSCOPY W/FB REMOVAL       ,31530,CPT,,50005818,CDM,450,RC,,,both,,,5689,3227.6,,,3227.6,Other,150% of Medicare + 9.63% HCRA Surcharge,1962.72,,,1962.72,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1030.04,,,1030.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3982.3,70,,3982.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,553.79,,,553.79,Other,New York Medicaid APG methodology,553.79,,,553.79,Other,100% Medicaid APG methodology,553.79,,,553.79,Other,100% Medicaid APG methodology,553.79,,,553.79,Other,100% Medicaid APG methodology,1246.02,,,1246.02,Other,225% Medicaid APG methodology,1246.02,,,1246.02,Other,225% Medicaid APG methodology,847.29,,,847.29,Other,153% Medicaid APG methodology,1246.02,,,1246.02,Other,225% Medicaid APG methodology,775.3,,,775.3,Other,140% Medicaid APG methodology,1246.02,,,1246.02,Other,225% Medicaid APG methodology,1439.85,,,1439.85,Other,260% Medicaid APG methodology,1794.27,,,1794.27,Other,324% Medicaid APG methodology,1190.64,,,1190.64,Other,215% Medicaid APG methodology,1190.64,,,1190.64,Other,215% Medicaid APG methodology,692.23,,,692.23,Other,125% Medicaid APG methodology,0.01,3982.3,
LARYNX SURGERY PROCEDURE        ,31599,CPT,,50005875,CDM,450,RC,,,both,,,740,464.5,,,464.5,Other,150% of Medicare + 9.63% HCRA Surcharge,282.46,,,282.46,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2536.27,,,2536.27,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,518,70,,518,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1363.59,,,1363.59,Other,New York Medicaid APG methodology,1363.59,,,1363.59,Other,100% Medicaid APG methodology,1363.59,,,1363.59,Other,100% Medicaid APG methodology,1363.59,,,1363.59,Other,100% Medicaid APG methodology,3068.07,,,3068.07,Other,225% Medicaid APG methodology,3068.07,,,3068.07,Other,225% Medicaid APG methodology,2086.29,,,2086.29,Other,153% Medicaid APG methodology,3068.07,,,3068.07,Other,225% Medicaid APG methodology,1909.02,,,1909.02,Other,140% Medicaid APG methodology,3068.07,,,3068.07,Other,225% Medicaid APG methodology,3545.33,,,3545.33,Other,260% Medicaid APG methodology,4418.02,,,4418.02,Other,324% Medicaid APG methodology,2931.71,,,2931.71,Other,215% Medicaid APG methodology,2931.71,,,2931.71,Other,215% Medicaid APG methodology,1704.48,,,1704.48,Other,125% Medicaid APG methodology,0.01,4418.02,
DX BRONCHOSCOPE/WASH            ,31622,CPT,,50005909,CDM,450,RC,,,both,,,5997,3227.6,,,3227.6,Other,150% of Medicare + 9.63% HCRA Surcharge,1962.72,,,1962.72,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2717.57,,,2717.57,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,4197.9,70,,4197.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1461.06,,,1461.06,Other,New York Medicaid APG methodology,1461.06,,,1461.06,Other,100% Medicaid APG methodology,1461.06,,,1461.06,Other,100% Medicaid APG methodology,1461.06,,,1461.06,Other,100% Medicaid APG methodology,3287.38,,,3287.38,Other,225% Medicaid APG methodology,3287.38,,,3287.38,Other,225% Medicaid APG methodology,2235.42,,,2235.42,Other,153% Medicaid APG methodology,3287.38,,,3287.38,Other,225% Medicaid APG methodology,2045.48,,,2045.48,Other,140% Medicaid APG methodology,3287.38,,,3287.38,Other,225% Medicaid APG methodology,3798.75,,,3798.75,Other,260% Medicaid APG methodology,4733.83,,,4733.83,Other,324% Medicaid APG methodology,3141.28,,,3141.28,Other,215% Medicaid APG methodology,3141.28,,,3141.28,Other,215% Medicaid APG methodology,1826.32,,,1826.32,Other,125% Medicaid APG methodology,0.01,4733.83,
ASPIRATE PLEURA W/O IMAGING     ,32554,CPT,,50006006,CDM,450,RC,,,both,,,4918,1194.63,,,1194.63,Other,150% of Medicare + 9.63% HCRA Surcharge,726.46,,,726.46,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1502.62,,,1502.62,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3442.6,70,,3442.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% Medicaid APG methodology,807.86,,,807.86,Other,100% Medicaid APG methodology,807.86,,,807.86,Other,100% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,1236.03,,,1236.03,Other,153% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,1131.01,,,1131.01,Other,140% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,2100.44,,,2100.44,Other,260% Medicaid APG methodology,2617.47,,,2617.47,Other,324% Medicaid APG methodology,1736.9,,,1736.9,Other,215% Medicaid APG methodology,1736.9,,,1736.9,Other,215% Medicaid APG methodology,1009.83,,,1009.83,Other,125% Medicaid APG methodology,0.01,3442.6,
TEMPORAL ARTERY PROCEDURE       ,37609,CPT,,50006717,CDM,450,RC,,,both,,,5335,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,5673.29,,,5673.29,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3734.5,70,,3734.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% Medicaid APG methodology,3050.16,,,3050.16,Other,100% Medicaid APG methodology,3050.16,,,3050.16,Other,100% Medicaid APG methodology,6862.85,,,6862.85,Other,225% Medicaid APG methodology,6862.85,,,6862.85,Other,225% Medicaid APG methodology,4666.74,,,4666.74,Other,153% Medicaid APG methodology,6862.85,,,6862.85,Other,225% Medicaid APG methodology,4270.22,,,4270.22,Other,140% Medicaid APG methodology,6862.85,,,6862.85,Other,225% Medicaid APG methodology,7930.41,,,7930.41,Other,260% Medicaid APG methodology,9882.51,,,9882.51,Other,324% Medicaid APG methodology,6557.84,,,6557.84,Other,215% Medicaid APG methodology,6557.84,,,6557.84,Other,215% Medicaid APG methodology,3812.7,,,3812.7,Other,125% Medicaid APG methodology,0.01,9882.51,
LIGATION OF EXTREMITY ARTERY    ,37618,CPT,,50006725,CDM,450,RC,,,both,,,9784,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,5162.29,,,5162.29,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,6848.8,70,,6848.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,2775.42,,,2775.42,Other,New York Medicaid APG methodology,2775.42,,,2775.42,Other,100% Medicaid APG methodology,2775.42,,,2775.42,Other,100% Medicaid APG methodology,2775.42,,,2775.42,Other,100% Medicaid APG methodology,6244.71,,,6244.71,Other,225% Medicaid APG methodology,6244.71,,,6244.71,Other,225% Medicaid APG methodology,4246.4,,,4246.4,Other,153% Medicaid APG methodology,6244.71,,,6244.71,Other,225% Medicaid APG methodology,3885.59,,,3885.59,Other,140% Medicaid APG methodology,6244.71,,,6244.71,Other,225% Medicaid APG methodology,7216.1,,,7216.1,Other,260% Medicaid APG methodology,8992.38,,,8992.38,Other,324% Medicaid APG methodology,5967.16,,,5967.16,Other,215% Medicaid APG methodology,5967.16,,,5967.16,Other,215% Medicaid APG methodology,3469.28,,,3469.28,Other,125% Medicaid APG methodology,0.01,8992.38,
VASCULAR SURGERY PROCEDURE      ,37799,CPT,,50006790,CDM,450,RC,,,both,,,2128,1194.63,,,1194.63,Other,150% of Medicare + 9.63% HCRA Surcharge,726.46,,,726.46,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,5162.29,,,5162.29,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1489.6,70,,1489.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,2775.42,,,2775.42,Other,New York Medicaid APG methodology,2775.42,,,2775.42,Other,100% Medicaid APG methodology,2775.42,,,2775.42,Other,100% Medicaid APG methodology,2775.42,,,2775.42,Other,100% Medicaid APG methodology,6244.71,,,6244.71,Other,225% Medicaid APG methodology,6244.71,,,6244.71,Other,225% Medicaid APG methodology,4246.4,,,4246.4,Other,153% Medicaid APG methodology,6244.71,,,6244.71,Other,225% Medicaid APG methodology,3885.59,,,3885.59,Other,140% Medicaid APG methodology,6244.71,,,6244.71,Other,225% Medicaid APG methodology,7216.1,,,7216.1,Other,260% Medicaid APG methodology,8992.38,,,8992.38,Other,324% Medicaid APG methodology,5967.16,,,5967.16,Other,215% Medicaid APG methodology,5967.16,,,5967.16,Other,215% Medicaid APG methodology,3469.28,,,3469.28,Other,125% Medicaid APG methodology,0.01,8992.38,
INCISION OF TONGUE FOLD         ,41010,CPT,,50007053,CDM,450,RC,,,both,,,4939,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2874.75,,,2874.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3457.3,70,,3457.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% Medicaid APG methodology,1545.56,,,1545.56,Other,100% Medicaid APG methodology,1545.56,,,1545.56,Other,100% Medicaid APG methodology,3477.52,,,3477.52,Other,225% Medicaid APG methodology,3477.52,,,3477.52,Other,225% Medicaid APG methodology,2364.71,,,2364.71,Other,153% Medicaid APG methodology,3477.52,,,3477.52,Other,225% Medicaid APG methodology,2163.79,,,2163.79,Other,140% Medicaid APG methodology,3477.52,,,3477.52,Other,225% Medicaid APG methodology,4018.47,,,4018.47,Other,260% Medicaid APG methodology,5007.63,,,5007.63,Other,324% Medicaid APG methodology,3322.96,,,3322.96,Other,215% Medicaid APG methodology,3322.96,,,3322.96,Other,215% Medicaid APG methodology,1931.96,,,1931.96,Other,125% Medicaid APG methodology,0.01,5007.63,
TONGUE AND MOUTH SURGERY        ,41599,CPT,,50007129,CDM,450,RC,,,both,,,740,464.5,,,464.5,Other,150% of Medicare + 9.63% HCRA Surcharge,282.46,,,282.46,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2536.27,,,2536.27,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,518,70,,518,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1363.59,,,1363.59,Other,New York Medicaid APG methodology,1363.59,,,1363.59,Other,100% Medicaid APG methodology,1363.59,,,1363.59,Other,100% Medicaid APG methodology,1363.59,,,1363.59,Other,100% Medicaid APG methodology,3068.07,,,3068.07,Other,225% Medicaid APG methodology,3068.07,,,3068.07,Other,225% Medicaid APG methodology,2086.29,,,2086.29,Other,153% Medicaid APG methodology,3068.07,,,3068.07,Other,225% Medicaid APG methodology,1909.02,,,1909.02,Other,140% Medicaid APG methodology,3068.07,,,3068.07,Other,225% Medicaid APG methodology,3545.33,,,3545.33,Other,260% Medicaid APG methodology,4418.02,,,4418.02,Other,324% Medicaid APG methodology,2931.71,,,2931.71,Other,215% Medicaid APG methodology,2931.71,,,2931.71,Other,215% Medicaid APG methodology,1704.48,,,1704.48,Other,125% Medicaid APG methodology,0.01,4418.02,
EXCISION OF GUM LESION          ,41825,CPT,,50007152,CDM,450,RC,,,both,,,10122,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1027.22,,,1027.22,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,7085.4,70,,7085.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% Medicaid APG methodology,552.27,,,552.27,Other,100% Medicaid APG methodology,552.27,,,552.27,Other,100% Medicaid APG methodology,1242.61,,,1242.61,Other,225% Medicaid APG methodology,1242.61,,,1242.61,Other,225% Medicaid APG methodology,844.98,,,844.98,Other,153% Medicaid APG methodology,1242.61,,,1242.61,Other,225% Medicaid APG methodology,773.18,,,773.18,Other,140% Medicaid APG methodology,1242.61,,,1242.61,Other,225% Medicaid APG methodology,1435.91,,,1435.91,Other,260% Medicaid APG methodology,1789.36,,,1789.36,Other,324% Medicaid APG methodology,1187.38,,,1187.38,Other,215% Medicaid APG methodology,1187.38,,,1187.38,Other,215% Medicaid APG methodology,690.34,,,690.34,Other,125% Medicaid APG methodology,0.01,7085.4,
DRAINAGE SALIVARY GLAND SMPL    ,42300,CPT,,50007244,CDM,450,RC,,,both,,,4939,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,508.35,,,508.35,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3457.3,70,,3457.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,273.31,,,273.31,Other,New York Medicaid APG methodology,273.31,,,273.31,Other,100% Medicaid APG methodology,273.31,,,273.31,Other,100% Medicaid APG methodology,273.31,,,273.31,Other,100% Medicaid APG methodology,614.94,,,614.94,Other,225% Medicaid APG methodology,614.94,,,614.94,Other,225% Medicaid APG methodology,418.16,,,418.16,Other,153% Medicaid APG methodology,614.94,,,614.94,Other,225% Medicaid APG methodology,382.63,,,382.63,Other,140% Medicaid APG methodology,614.94,,,614.94,Other,225% Medicaid APG methodology,710.6,,,710.6,Other,260% Medicaid APG methodology,885.52,,,885.52,Other,324% Medicaid APG methodology,587.61,,,587.61,Other,215% Medicaid APG methodology,587.61,,,587.61,Other,215% Medicaid APG methodology,341.64,,,341.64,Other,125% Medicaid APG methodology,0.01,3457.3,
SALIVARY SURGERY PROCED         ,42699,CPT,,50007293,CDM,450,RC,,,both,,,740,464.5,,,464.5,Other,150% of Medicare + 9.63% HCRA Surcharge,282.46,,,282.46,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,315.76,,,315.76,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,518,70,,518,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,169.76,,,169.76,Other,New York Medicaid APG methodology,169.76,,,169.76,Other,100% Medicaid APG methodology,169.76,,,169.76,Other,100% Medicaid APG methodology,169.76,,,169.76,Other,100% Medicaid APG methodology,381.97,,,381.97,Other,225% Medicaid APG methodology,381.97,,,381.97,Other,225% Medicaid APG methodology,259.74,,,259.74,Other,153% Medicaid APG methodology,381.97,,,381.97,Other,225% Medicaid APG methodology,237.67,,,237.67,Other,140% Medicaid APG methodology,381.97,,,381.97,Other,225% Medicaid APG methodology,441.38,,,441.38,Other,260% Medicaid APG methodology,550.03,,,550.03,Other,324% Medicaid APG methodology,364.99,,,364.99,Other,215% Medicaid APG methodology,364.99,,,364.99,Other,215% Medicaid APG methodology,212.2,,,212.2,Other,125% Medicaid APG methodology,0.01,550.03,
EGD DIAGNOSTIC BRUSH WASH       ,43235,CPT,,50007475,CDM,450,RC,,,both,,,3610,1723.81,,,1723.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.26,,,1048.26,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1935.29,,,1935.29,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2527,70,,2527,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% Medicaid APG methodology,1040.48,,,1040.48,Other,100% Medicaid APG methodology,1040.48,,,1040.48,Other,100% Medicaid APG methodology,2341.08,,,2341.08,Other,225% Medicaid APG methodology,2341.08,,,2341.08,Other,225% Medicaid APG methodology,1591.93,,,1591.93,Other,153% Medicaid APG methodology,2341.08,,,2341.08,Other,225% Medicaid APG methodology,1456.67,,,1456.67,Other,140% Medicaid APG methodology,2341.08,,,2341.08,Other,225% Medicaid APG methodology,2705.25,,,2705.25,Other,260% Medicaid APG methodology,3371.15,,,3371.15,Other,324% Medicaid APG methodology,2237.03,,,2237.03,Other,215% Medicaid APG methodology,2237.03,,,2237.03,Other,215% Medicaid APG methodology,1300.6,,,1300.6,Other,125% Medicaid APG methodology,0.01,3371.15,
STOMACH SURGERY PROCEDURE       ,43999,CPT,,50007814,CDM,450,RC,,,both,,,3610,1723.81,,,1723.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.26,,,1048.26,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,3630.47,,,3630.47,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2527,70,,2527,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1951.87,,,1951.87,Other,New York Medicaid APG methodology,1951.87,,,1951.87,Other,100% Medicaid APG methodology,1951.87,,,1951.87,Other,100% Medicaid APG methodology,1951.87,,,1951.87,Other,100% Medicaid APG methodology,4391.7,,,4391.7,Other,225% Medicaid APG methodology,4391.7,,,4391.7,Other,225% Medicaid APG methodology,2986.36,,,2986.36,Other,153% Medicaid APG methodology,4391.7,,,4391.7,Other,225% Medicaid APG methodology,2732.61,,,2732.61,Other,140% Medicaid APG methodology,4391.7,,,4391.7,Other,225% Medicaid APG methodology,5074.86,,,5074.86,Other,260% Medicaid APG methodology,6324.05,,,6324.05,Other,324% Medicaid APG methodology,4196.52,,,4196.52,Other,215% Medicaid APG methodology,4196.52,,,4196.52,Other,215% Medicaid APG methodology,2439.83,,,2439.83,Other,125% Medicaid APG methodology,0.01,6324.05,
UNLISTED PX SMALL INTESTINE     ,44799,CPT,,50007954,CDM,450,RC,,,both,,,3610,1723.81,,,1723.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.26,,,1048.26,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,4648.17,,,4648.17,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2527,70,,2527,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,2499.02,,,2499.02,Other,New York Medicaid APG methodology,2499.02,,,2499.02,Other,100% Medicaid APG methodology,2499.02,,,2499.02,Other,100% Medicaid APG methodology,2499.02,,,2499.02,Other,100% Medicaid APG methodology,5622.79,,,5622.79,Other,225% Medicaid APG methodology,5622.79,,,5622.79,Other,225% Medicaid APG methodology,3823.5,,,3823.5,Other,153% Medicaid APG methodology,5622.79,,,5622.79,Other,225% Medicaid APG methodology,3498.62,,,3498.62,Other,140% Medicaid APG methodology,5622.79,,,5622.79,Other,225% Medicaid APG methodology,6497.44,,,6497.44,Other,260% Medicaid APG methodology,8096.82,,,8096.82,Other,324% Medicaid APG methodology,5372.89,,,5372.89,Other,215% Medicaid APG methodology,5372.89,,,5372.89,Other,215% Medicaid APG methodology,3123.77,,,3123.77,Other,125% Medicaid APG methodology,0.01,8096.82,
BIOPSY OF RECTUM                ,45100,CPT,,50007970,CDM,450,RC,,,both,,,9142,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2542.82,,,2542.82,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,6399.4,70,,6399.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% Medicaid APG methodology,1367.11,,,1367.11,Other,100% Medicaid APG methodology,1367.11,,,1367.11,Other,100% Medicaid APG methodology,3075.99,,,3075.99,Other,225% Medicaid APG methodology,3075.99,,,3075.99,Other,225% Medicaid APG methodology,2091.67,,,2091.67,Other,153% Medicaid APG methodology,3075.99,,,3075.99,Other,225% Medicaid APG methodology,1913.95,,,1913.95,Other,140% Medicaid APG methodology,3075.99,,,3075.99,Other,225% Medicaid APG methodology,3554.48,,,3554.48,Other,260% Medicaid APG methodology,4429.43,,,4429.43,Other,324% Medicaid APG methodology,2939.28,,,2939.28,Other,215% Medicaid APG methodology,2939.28,,,2939.28,Other,215% Medicaid APG methodology,1708.88,,,1708.88,Other,125% Medicaid APG methodology,0.01,6399.4,
REMOVE RECTAL OBSTRUCTION       ,45915,CPT,,50008135,CDM,450,RC,,,both,,,3853,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2542.82,,,2542.82,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2697.1,70,,2697.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% Medicaid APG methodology,1367.11,,,1367.11,Other,100% Medicaid APG methodology,1367.11,,,1367.11,Other,100% Medicaid APG methodology,3075.99,,,3075.99,Other,225% Medicaid APG methodology,3075.99,,,3075.99,Other,225% Medicaid APG methodology,2091.67,,,2091.67,Other,153% Medicaid APG methodology,3075.99,,,3075.99,Other,225% Medicaid APG methodology,1913.95,,,1913.95,Other,140% Medicaid APG methodology,3075.99,,,3075.99,Other,225% Medicaid APG methodology,3554.48,,,3554.48,Other,260% Medicaid APG methodology,4429.43,,,4429.43,Other,324% Medicaid APG methodology,2939.28,,,2939.28,Other,215% Medicaid APG methodology,2939.28,,,2939.28,Other,215% Medicaid APG methodology,1708.88,,,1708.88,Other,125% Medicaid APG methodology,0.01,4429.43,
INCISION OF RECTAL ABSCESS      ,46040,CPT,,50008143,CDM,450,RC,,,both,,,3853,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2542.82,,,2542.82,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2697.1,70,,2697.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% Medicaid APG methodology,1367.11,,,1367.11,Other,100% Medicaid APG methodology,1367.11,,,1367.11,Other,100% Medicaid APG methodology,3075.99,,,3075.99,Other,225% Medicaid APG methodology,3075.99,,,3075.99,Other,225% Medicaid APG methodology,2091.67,,,2091.67,Other,153% Medicaid APG methodology,3075.99,,,3075.99,Other,225% Medicaid APG methodology,1913.95,,,1913.95,Other,140% Medicaid APG methodology,3075.99,,,3075.99,Other,225% Medicaid APG methodology,3554.48,,,3554.48,Other,260% Medicaid APG methodology,4429.43,,,4429.43,Other,324% Medicaid APG methodology,2939.28,,,2939.28,Other,215% Medicaid APG methodology,2939.28,,,2939.28,Other,215% Medicaid APG methodology,1708.88,,,1708.88,Other,125% Medicaid APG methodology,0.01,4429.43,
ANUS SURGERY PROCEDURE          ,46999,CPT,,50008291,CDM,450,RC,,,both,,,3176,1738.02,,,1738.02,Other,150% of Medicare + 9.63% HCRA Surcharge,1056.9,,,1056.9,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2224.8,,,2224.8,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2223.2,70,,2223.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1196.13,,,1196.13,Other,New York Medicaid APG methodology,1196.13,,,1196.13,Other,100% Medicaid APG methodology,1196.13,,,1196.13,Other,100% Medicaid APG methodology,1196.13,,,1196.13,Other,100% Medicaid APG methodology,2691.29,,,2691.29,Other,225% Medicaid APG methodology,2691.29,,,2691.29,Other,225% Medicaid APG methodology,1830.08,,,1830.08,Other,153% Medicaid APG methodology,2691.29,,,2691.29,Other,225% Medicaid APG methodology,1674.58,,,1674.58,Other,140% Medicaid APG methodology,2691.29,,,2691.29,Other,225% Medicaid APG methodology,3109.94,,,3109.94,Other,260% Medicaid APG methodology,3875.46,,,3875.46,Other,324% Medicaid APG methodology,2571.68,,,2571.68,Other,215% Medicaid APG methodology,2571.68,,,2571.68,Other,215% Medicaid APG methodology,1495.16,,,1495.16,Other,125% Medicaid APG methodology,0.01,3875.46,
INJECTION FOR CHOLANGIOGRAM     ,47531,CPT,,50008358,CDM,450,RC,,,both,,,15349,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,751.07,,,751.07,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,10744.3,70,,10744.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,403.8,,,403.8,Other,New York Medicaid APG methodology,403.8,,,403.8,Other,100% Medicaid APG methodology,403.8,,,403.8,Other,100% Medicaid APG methodology,403.8,,,403.8,Other,100% Medicaid APG methodology,908.55,,,908.55,Other,225% Medicaid APG methodology,908.55,,,908.55,Other,225% Medicaid APG methodology,617.81,,,617.81,Other,153% Medicaid APG methodology,908.55,,,908.55,Other,225% Medicaid APG methodology,565.32,,,565.32,Other,140% Medicaid APG methodology,908.55,,,908.55,Other,225% Medicaid APG methodology,1049.88,,,1049.88,Other,260% Medicaid APG methodology,1308.31,,,1308.31,Other,324% Medicaid APG methodology,868.17,,,868.17,Other,215% Medicaid APG methodology,868.17,,,868.17,Other,215% Medicaid APG methodology,504.75,,,504.75,Other,125% Medicaid APG methodology,0.01,10744.3,
CYSTOSCOPY AND TREATMENT        ,52310,CPT,,50009018,CDM,450,RC,,,both,,,6600,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,3289.6,,,3289.6,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,4620,70,,4620,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1768.6,,,1768.6,Other,New York Medicaid APG methodology,1768.6,,,1768.6,Other,100% Medicaid APG methodology,1768.6,,,1768.6,Other,100% Medicaid APG methodology,1768.6,,,1768.6,Other,100% Medicaid APG methodology,3979.36,,,3979.36,Other,225% Medicaid APG methodology,3979.36,,,3979.36,Other,225% Medicaid APG methodology,2705.96,,,2705.96,Other,153% Medicaid APG methodology,3979.36,,,3979.36,Other,225% Medicaid APG methodology,2476.04,,,2476.04,Other,140% Medicaid APG methodology,3979.36,,,3979.36,Other,225% Medicaid APG methodology,4598.37,,,4598.37,Other,260% Medicaid APG methodology,5730.27,,,5730.27,Other,324% Medicaid APG methodology,3802.5,,,3802.5,Other,215% Medicaid APG methodology,3802.5,,,3802.5,Other,215% Medicaid APG methodology,2210.75,,,2210.75,Other,125% Medicaid APG methodology,0.01,5730.27,
PREPUTIAL STRETCHING            ,54450,CPT,,50009455,CDM,450,RC,,,both,,,943,469.99,,,469.99,Other,150% of Medicare + 9.63% HCRA Surcharge,285.8,,,285.8,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1123.05,,,1123.05,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,660.1,70,,660.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,603.79,,,603.79,Other,New York Medicaid APG methodology,603.79,,,603.79,Other,100% Medicaid APG methodology,603.79,,,603.79,Other,100% Medicaid APG methodology,603.79,,,603.79,Other,100% Medicaid APG methodology,1358.53,,,1358.53,Other,225% Medicaid APG methodology,1358.53,,,1358.53,Other,225% Medicaid APG methodology,923.8,,,923.8,Other,153% Medicaid APG methodology,1358.53,,,1358.53,Other,225% Medicaid APG methodology,845.31,,,845.31,Other,140% Medicaid APG methodology,1358.53,,,1358.53,Other,225% Medicaid APG methodology,1569.85,,,1569.85,Other,260% Medicaid APG methodology,1956.28,,,1956.28,Other,324% Medicaid APG methodology,1298.15,,,1298.15,Other,215% Medicaid APG methodology,1298.15,,,1298.15,Other,215% Medicaid APG methodology,754.74,,,754.74,Other,125% Medicaid APG methodology,0.01,1956.28,
GENITAL SURGERY PROCEDURE       ,55899,CPT,,50009687,CDM,450,RC,,,both,,,943,469.99,,,469.99,Other,150% of Medicare + 9.63% HCRA Surcharge,285.8,,,285.8,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2646.29,,,2646.29,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,660.1,70,,660.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1422.74,,,1422.74,Other,New York Medicaid APG methodology,1422.74,,,1422.74,Other,100% Medicaid APG methodology,1422.74,,,1422.74,Other,100% Medicaid APG methodology,1422.74,,,1422.74,Other,100% Medicaid APG methodology,3201.16,,,3201.16,Other,225% Medicaid APG methodology,3201.16,,,3201.16,Other,225% Medicaid APG methodology,2176.79,,,2176.79,Other,153% Medicaid APG methodology,3201.16,,,3201.16,Other,225% Medicaid APG methodology,1991.83,,,1991.83,Other,140% Medicaid APG methodology,3201.16,,,3201.16,Other,225% Medicaid APG methodology,3699.12,,,3699.12,Other,260% Medicaid APG methodology,4609.67,,,4609.67,Other,324% Medicaid APG methodology,3058.88,,,3058.88,Other,215% Medicaid APG methodology,3058.88,,,3058.88,Other,215% Medicaid APG methodology,1778.42,,,1778.42,Other,125% Medicaid APG methodology,0.01,4609.67,
BIOPSY OF VULVA/PERINEUM        ,56605,CPT,,50009927,CDM,450,RC,,,both,,,2503,1528.76,,,1528.76,Other,150% of Medicare + 9.63% HCRA Surcharge,929.65,,,929.65,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1419.19,,,1419.19,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1752.1,70,,1752.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,763.01,,,763.01,Other,New York Medicaid APG methodology,763.01,,,763.01,Other,100% Medicaid APG methodology,763.01,,,763.01,Other,100% Medicaid APG methodology,763.01,,,763.01,Other,100% Medicaid APG methodology,1716.77,,,1716.77,Other,225% Medicaid APG methodology,1716.77,,,1716.77,Other,225% Medicaid APG methodology,1167.4,,,1167.4,Other,153% Medicaid APG methodology,1716.77,,,1716.77,Other,225% Medicaid APG methodology,1068.21,,,1068.21,Other,140% Medicaid APG methodology,1716.77,,,1716.77,Other,225% Medicaid APG methodology,1983.82,,,1983.82,Other,260% Medicaid APG methodology,2472.14,,,2472.14,Other,324% Medicaid APG methodology,1640.46,,,1640.46,Other,215% Medicaid APG methodology,1640.46,,,1640.46,Other,215% Medicaid APG methodology,953.76,,,953.76,Other,125% Medicaid APG methodology,0.01,2472.14,
BIOPSY OF CERVIX                ,57500,CPT,,50010115,CDM,450,RC,,,both,,,2503,1528.76,,,1528.76,Other,150% of Medicare + 9.63% HCRA Surcharge,929.65,,,929.65,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1170.45,,,1170.45,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1752.1,70,,1752.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,629.27,,,629.27,Other,New York Medicaid APG methodology,629.27,,,629.27,Other,100% Medicaid APG methodology,629.27,,,629.27,Other,100% Medicaid APG methodology,629.27,,,629.27,Other,100% Medicaid APG methodology,1415.86,,,1415.86,Other,225% Medicaid APG methodology,1415.86,,,1415.86,Other,225% Medicaid APG methodology,962.79,,,962.79,Other,153% Medicaid APG methodology,1415.86,,,1415.86,Other,225% Medicaid APG methodology,880.98,,,880.98,Other,140% Medicaid APG methodology,1415.86,,,1415.86,Other,225% Medicaid APG methodology,1636.11,,,1636.11,Other,260% Medicaid APG methodology,2038.84,,,2038.84,Other,324% Medicaid APG methodology,1352.94,,,1352.94,Other,215% Medicaid APG methodology,1352.94,,,1352.94,Other,215% Medicaid APG methodology,786.59,,,786.59,Other,125% Medicaid APG methodology,0.01,2038.84,
BIOPSY OF UTERUS LINING         ,58100,CPT,,50010180,CDM,450,RC,,,both,,,724,378.94,,,378.94,Other,150% of Medicare + 9.63% HCRA Surcharge,230.43,,,230.43,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1419.19,,,1419.19,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,506.8,70,,506.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,763.01,,,763.01,Other,New York Medicaid APG methodology,763.01,,,763.01,Other,100% Medicaid APG methodology,763.01,,,763.01,Other,100% Medicaid APG methodology,763.01,,,763.01,Other,100% Medicaid APG methodology,1716.77,,,1716.77,Other,225% Medicaid APG methodology,1716.77,,,1716.77,Other,225% Medicaid APG methodology,1167.4,,,1167.4,Other,153% Medicaid APG methodology,1716.77,,,1716.77,Other,225% Medicaid APG methodology,1068.21,,,1068.21,Other,140% Medicaid APG methodology,1716.77,,,1716.77,Other,225% Medicaid APG methodology,1983.82,,,1983.82,Other,260% Medicaid APG methodology,2472.14,,,2472.14,Other,324% Medicaid APG methodology,1640.46,,,1640.46,Other,215% Medicaid APG methodology,1640.46,,,1640.46,Other,215% Medicaid APG methodology,953.76,,,953.76,Other,125% Medicaid APG methodology,0.01,2472.14,
REMOVE INTRAUTERINE DEVICE      ,58301,CPT,,50010222,CDM,450,RC,,,both,,,1313,610.06,,,610.06,Other,150% of Medicare + 9.63% HCRA Surcharge,370.98,,,370.98,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,335.93,,,335.93,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,919.1,70,,919.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,180.61,,,180.61,Other,New York Medicaid APG methodology,180.61,,,180.61,Other,100% Medicaid APG methodology,180.61,,,180.61,Other,100% Medicaid APG methodology,180.61,,,180.61,Other,100% Medicaid APG methodology,406.37,,,406.37,Other,225% Medicaid APG methodology,406.37,,,406.37,Other,225% Medicaid APG methodology,276.33,,,276.33,Other,153% Medicaid APG methodology,406.37,,,406.37,Other,225% Medicaid APG methodology,252.85,,,252.85,Other,140% Medicaid APG methodology,406.37,,,406.37,Other,225% Medicaid APG methodology,469.58,,,469.58,Other,260% Medicaid APG methodology,585.17,,,585.17,Other,324% Medicaid APG methodology,388.31,,,388.31,Other,215% Medicaid APG methodology,388.31,,,388.31,Other,215% Medicaid APG methodology,225.76,,,225.76,Other,125% Medicaid APG methodology,0.01,919.1,
CARE OF MISCARRIAGE             ,59820,CPT,,50010388,CDM,450,RC,,,both,,,11066,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1838.27,,,1838.27,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,7746.2,70,,7746.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,988.32,,,988.32,Other,New York Medicaid APG methodology,988.32,,,988.32,Other,100% Medicaid APG methodology,988.32,,,988.32,Other,100% Medicaid APG methodology,988.32,,,988.32,Other,100% Medicaid APG methodology,2223.72,,,2223.72,Other,225% Medicaid APG methodology,2223.72,,,2223.72,Other,225% Medicaid APG methodology,1512.13,,,1512.13,Other,153% Medicaid APG methodology,2223.72,,,2223.72,Other,225% Medicaid APG methodology,1383.65,,,1383.65,Other,140% Medicaid APG methodology,2223.72,,,2223.72,Other,225% Medicaid APG methodology,2569.63,,,2569.63,Other,260% Medicaid APG methodology,3202.16,,,3202.16,Other,324% Medicaid APG methodology,2124.89,,,2124.89,Other,215% Medicaid APG methodology,2124.89,,,2124.89,Other,215% Medicaid APG methodology,1235.4,,,1235.4,Other,125% Medicaid APG methodology,0.01,7746.2,
ENDOCRINE SURGERY PROCEDURE     ,60699,CPT,,50010461,CDM,450,RC,,,both,,,18544,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2920.1,,,2920.1,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,12980.8,70,,12980.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1569.95,,,1569.95,Other,New York Medicaid APG methodology,1569.95,,,1569.95,Other,100% Medicaid APG methodology,1569.95,,,1569.95,Other,100% Medicaid APG methodology,1569.95,,,1569.95,Other,100% Medicaid APG methodology,3532.38,,,3532.38,Other,225% Medicaid APG methodology,3532.38,,,3532.38,Other,225% Medicaid APG methodology,2402.02,,,2402.02,Other,153% Medicaid APG methodology,3532.38,,,3532.38,Other,225% Medicaid APG methodology,2197.93,,,2197.93,Other,140% Medicaid APG methodology,3532.38,,,3532.38,Other,225% Medicaid APG methodology,4081.87,,,4081.87,Other,260% Medicaid APG methodology,5086.63,,,5086.63,Other,324% Medicaid APG methodology,3375.39,,,3375.39,Other,215% Medicaid APG methodology,3375.39,,,3375.39,Other,215% Medicaid APG methodology,1962.44,,,1962.44,Other,125% Medicaid APG methodology,0.01,12980.8,
THER SPI PNXR DRG CSF           ,62272,CPT,,50010511,CDM,450,RC,,,both,,,2354,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1398.69,,,1398.69,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1647.8,70,,1647.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% Medicaid APG methodology,751.98,,,751.98,Other,100% Medicaid APG methodology,751.98,,,751.98,Other,100% Medicaid APG methodology,1691.96,,,1691.96,Other,225% Medicaid APG methodology,1691.96,,,1691.96,Other,225% Medicaid APG methodology,1150.53,,,1150.53,Other,153% Medicaid APG methodology,1691.96,,,1691.96,Other,225% Medicaid APG methodology,1052.78,,,1052.78,Other,140% Medicaid APG methodology,1691.96,,,1691.96,Other,225% Medicaid APG methodology,1955.15,,,1955.15,Other,260% Medicaid APG methodology,2436.42,,,2436.42,Other,324% Medicaid APG methodology,1616.76,,,1616.76,Other,215% Medicaid APG methodology,1616.76,,,1616.76,Other,215% Medicaid APG methodology,939.98,,,939.98,Other,125% Medicaid APG methodology,0.01,2436.42,
NJX AA&/STRD TRIGEMINAL NRV     ,64400,CPT,,50010701,CDM,450,RC,,,both,,,1968,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1204.2,,,1204.2,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1377.6,70,,1377.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% Medicaid APG methodology,647.42,,,647.42,Other,100% Medicaid APG methodology,647.42,,,647.42,Other,100% Medicaid APG methodology,1456.69,,,1456.69,Other,225% Medicaid APG methodology,1456.69,,,1456.69,Other,225% Medicaid APG methodology,990.55,,,990.55,Other,153% Medicaid APG methodology,1456.69,,,1456.69,Other,225% Medicaid APG methodology,906.38,,,906.38,Other,140% Medicaid APG methodology,1456.69,,,1456.69,Other,225% Medicaid APG methodology,1683.28,,,1683.28,Other,260% Medicaid APG methodology,2097.63,,,2097.63,Other,324% Medicaid APG methodology,1391.95,,,1391.95,Other,215% Medicaid APG methodology,1391.95,,,1391.95,Other,215% Medicaid APG methodology,809.27,,,809.27,Other,125% Medicaid APG methodology,0.01,2097.63,
REPAIR OF HAND OR FOOT NERVE    ,64836,CPT,,50011162,CDM,450,RC,,,both,,,21982,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,7783.74,,,7783.74,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,15387.4,70,,15387.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% Medicaid APG methodology,4184.81,,,4184.81,Other,100% Medicaid APG methodology,4184.81,,,4184.81,Other,100% Medicaid APG methodology,9415.82,,,9415.82,Other,225% Medicaid APG methodology,9415.82,,,9415.82,Other,225% Medicaid APG methodology,6402.75,,,6402.75,Other,153% Medicaid APG methodology,9415.82,,,9415.82,Other,225% Medicaid APG methodology,5858.73,,,5858.73,Other,140% Medicaid APG methodology,9415.82,,,9415.82,Other,225% Medicaid APG methodology,10880.5,,,10880.5,Other,260% Medicaid APG methodology,13558.78,,,13558.78,Other,324% Medicaid APG methodology,8997.34,,,8997.34,Other,215% Medicaid APG methodology,8997.34,,,8997.34,Other,215% Medicaid APG methodology,5231.01,,,5231.01,Other,125% Medicaid APG methodology,0.01,15387.4,
REPAIR OF EYE WOUND DIR CLSR    ,65270,CPT,,50011253,CDM,450,RC,,,both,,,7522,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,4056.18,,,4056.18,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,5265.4,70,,5265.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% Medicaid APG methodology,2180.74,,,2180.74,Other,100% Medicaid APG methodology,2180.74,,,2180.74,Other,100% Medicaid APG methodology,4906.67,,,4906.67,Other,225% Medicaid APG methodology,4906.67,,,4906.67,Other,225% Medicaid APG methodology,3336.53,,,3336.53,Other,153% Medicaid APG methodology,4906.67,,,4906.67,Other,225% Medicaid APG methodology,3053.04,,,3053.04,Other,140% Medicaid APG methodology,4906.67,,,4906.67,Other,225% Medicaid APG methodology,5669.93,,,5669.93,Other,260% Medicaid APG methodology,7065.6,,,7065.6,Other,324% Medicaid APG methodology,4688.59,,,4688.59,Other,215% Medicaid APG methodology,4688.59,,,4688.59,Other,215% Medicaid APG methodology,2725.93,,,2725.93,Other,125% Medicaid APG methodology,0.01,7065.6,
INCISION OF IRIS                ,66500,CPT,,50011444,CDM,450,RC,,,both,,,8355,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,3710.11,,,3710.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,5848.5,70,,5848.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% Medicaid APG methodology,1994.68,,,1994.68,Other,100% Medicaid APG methodology,1994.68,,,1994.68,Other,100% Medicaid APG methodology,4488.04,,,4488.04,Other,225% Medicaid APG methodology,4488.04,,,4488.04,Other,225% Medicaid APG methodology,3051.87,,,3051.87,Other,153% Medicaid APG methodology,4488.04,,,4488.04,Other,225% Medicaid APG methodology,2792.56,,,2792.56,Other,140% Medicaid APG methodology,4488.04,,,4488.04,Other,225% Medicaid APG methodology,5186.18,,,5186.18,Other,260% Medicaid APG methodology,6462.78,,,6462.78,Other,324% Medicaid APG methodology,4288.57,,,4288.57,Other,215% Medicaid APG methodology,4288.57,,,4288.57,Other,215% Medicaid APG methodology,2493.36,,,2493.36,Other,125% Medicaid APG methodology,0.01,6462.78,
INCISION OF EYELID FOLD         ,67715,CPT,,50011832,CDM,450,RC,,,both,,,7522,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2759.56,,,2759.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,5265.4,70,,5265.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% Medicaid APG methodology,1483.63,,,1483.63,Other,100% Medicaid APG methodology,1483.63,,,1483.63,Other,100% Medicaid APG methodology,3338.18,,,3338.18,Other,225% Medicaid APG methodology,3338.18,,,3338.18,Other,225% Medicaid APG methodology,2269.96,,,2269.96,Other,153% Medicaid APG methodology,3338.18,,,3338.18,Other,225% Medicaid APG methodology,2077.09,,,2077.09,Other,140% Medicaid APG methodology,3338.18,,,3338.18,Other,225% Medicaid APG methodology,3857.45,,,3857.45,Other,260% Medicaid APG methodology,4806.98,,,4806.98,Other,324% Medicaid APG methodology,3189.81,,,3189.81,Other,215% Medicaid APG methodology,3189.81,,,3189.81,Other,215% Medicaid APG methodology,1854.54,,,1854.54,Other,125% Medicaid APG methodology,0.01,5265.4,
REMOVE EYELID FOREIGN BODY      ,67938,CPT,,50012020,CDM,450,RC,,,both,,,1406,553.97,,,553.97,Other,150% of Medicare + 9.63% HCRA Surcharge,336.87,,,336.87,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,634.14,,,634.14,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,984.2,70,,984.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,340.93,,,340.93,Other,New York Medicaid APG methodology,340.93,,,340.93,Other,100% Medicaid APG methodology,340.93,,,340.93,Other,100% Medicaid APG methodology,340.93,,,340.93,Other,100% Medicaid APG methodology,767.1,,,767.1,Other,225% Medicaid APG methodology,767.1,,,767.1,Other,225% Medicaid APG methodology,521.63,,,521.63,Other,153% Medicaid APG methodology,767.1,,,767.1,Other,225% Medicaid APG methodology,477.31,,,477.31,Other,140% Medicaid APG methodology,767.1,,,767.1,Other,225% Medicaid APG methodology,886.43,,,886.43,Other,260% Medicaid APG methodology,1104.63,,,1104.63,Other,324% Medicaid APG methodology,733.01,,,733.01,Other,215% Medicaid APG methodology,733.01,,,733.01,Other,215% Medicaid APG methodology,426.17,,,426.17,Other,125% Medicaid APG methodology,0.01,1104.63,
PROBE NASOLACRIMAL DUCT         ,68810,CPT,,50012269,CDM,450,RC,,,both,,,1278,553.97,,,553.97,Other,150% of Medicare + 9.63% HCRA Surcharge,336.87,,,336.87,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,634.14,,,634.14,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,894.6,70,,894.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,340.93,,,340.93,Other,New York Medicaid APG methodology,340.93,,,340.93,Other,100% Medicaid APG methodology,340.93,,,340.93,Other,100% Medicaid APG methodology,340.93,,,340.93,Other,100% Medicaid APG methodology,767.1,,,767.1,Other,225% Medicaid APG methodology,767.1,,,767.1,Other,225% Medicaid APG methodology,521.63,,,521.63,Other,153% Medicaid APG methodology,767.1,,,767.1,Other,225% Medicaid APG methodology,477.31,,,477.31,Other,140% Medicaid APG methodology,767.1,,,767.1,Other,225% Medicaid APG methodology,886.43,,,886.43,Other,260% Medicaid APG methodology,1104.63,,,1104.63,Other,324% Medicaid APG methodology,733.01,,,733.01,Other,215% Medicaid APG methodology,733.01,,,733.01,Other,215% Medicaid APG methodology,426.17,,,426.17,Other,125% Medicaid APG methodology,0.01,1104.63,
CARDIOVERSION ELECTRIC EXT      ,92960,CPT,,50012921,CDM,450,RC,,,both,,,6121,1237.64,,,1237.64,Other,150% of Medicare + 9.63% HCRA Surcharge,752.62,,,752.62,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1106.33,,,1106.33,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,4284.7,70,,4284.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,594.8,,,594.8,Other,New York Medicaid APG methodology,594.8,,,594.8,Other,100% Medicaid APG methodology,594.8,,,594.8,Other,100% Medicaid APG methodology,594.8,,,594.8,Other,100% Medicaid APG methodology,1338.31,,,1338.31,Other,225% Medicaid APG methodology,1338.31,,,1338.31,Other,225% Medicaid APG methodology,910.05,,,910.05,Other,153% Medicaid APG methodology,1338.31,,,1338.31,Other,225% Medicaid APG methodology,832.72,,,832.72,Other,140% Medicaid APG methodology,1338.31,,,1338.31,Other,225% Medicaid APG methodology,1546.49,,,1546.49,Other,260% Medicaid APG methodology,1927.16,,,1927.16,Other,324% Medicaid APG methodology,1278.83,,,1278.83,Other,215% Medicaid APG methodology,1278.83,,,1278.83,Other,215% Medicaid APG methodology,743.5,,,743.5,Other,125% Medicaid APG methodology,0.01,4284.7,
DRAINAGE PILONIDAL CYST SMPL    ,10080,CPT,,50013515,CDM,450,RC,,,both,,,2286,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,902.56,,,902.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1600.2,70,,1600.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,742.43,,,742.43,Other,153% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,679.35,,,679.35,Other,140% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,1261.65,,,1261.65,Other,260% Medicaid APG methodology,1572.2,,,1572.2,Other,324% Medicaid APG methodology,1043.28,,,1043.28,Other,215% Medicaid APG methodology,1043.28,,,1043.28,Other,215% Medicaid APG methodology,606.56,,,606.56,Other,125% Medicaid APG methodology,0.01,1600.2,
REMOVE FOREIGN BODY COMPL       ,10121,CPT,,50013531,CDM,450,RC,,,both,,,5169,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2855.7,,,2855.7,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3618.3,70,,3618.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1535.32,,,1535.32,Other,New York Medicaid APG methodology,1535.32,,,1535.32,Other,100% Medicaid APG methodology,1535.32,,,1535.32,Other,100% Medicaid APG methodology,1535.32,,,1535.32,Other,100% Medicaid APG methodology,3454.48,,,3454.48,Other,225% Medicaid APG methodology,3454.48,,,3454.48,Other,225% Medicaid APG methodology,2349.04,,,2349.04,Other,153% Medicaid APG methodology,3454.48,,,3454.48,Other,225% Medicaid APG methodology,2149.45,,,2149.45,Other,140% Medicaid APG methodology,3454.48,,,3454.48,Other,225% Medicaid APG methodology,3991.84,,,3991.84,Other,260% Medicaid APG methodology,4974.44,,,4974.44,Other,324% Medicaid APG methodology,3300.94,,,3300.94,Other,215% Medicaid APG methodology,3300.94,,,3300.94,Other,215% Medicaid APG methodology,1919.15,,,1919.15,Other,125% Medicaid APG methodology,0.01,4974.44,
PUNCTURE DRAINAGE OF LESION     ,10160,CPT,,50013549,CDM,450,RC,,,both,,,1343,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,902.56,,,902.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,940.1,70,,940.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,742.43,,,742.43,Other,153% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,679.35,,,679.35,Other,140% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,1261.65,,,1261.65,Other,260% Medicaid APG methodology,1572.2,,,1572.2,Other,324% Medicaid APG methodology,1043.28,,,1043.28,Other,215% Medicaid APG methodology,1043.28,,,1043.28,Other,215% Medicaid APG methodology,606.56,,,606.56,Other,125% Medicaid APG methodology,0.01,1572.2,
COMPLEX DRAINAGE WOUND          ,10180,CPT,,50013556,CDM,450,RC,,,both,,,3776,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,3180.63,,,3180.63,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2643.2,70,,2643.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% Medicaid APG methodology,1710.01,,,1710.01,Other,100% Medicaid APG methodology,1710.01,,,1710.01,Other,100% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,2616.32,,,2616.32,Other,153% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,2394.02,,,2394.02,Other,140% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,4446.04,,,4446.04,Other,260% Medicaid APG methodology,5540.45,,,5540.45,Other,324% Medicaid APG methodology,3676.53,,,3676.53,Other,215% Medicaid APG methodology,3676.53,,,3676.53,Other,215% Medicaid APG methodology,2137.52,,,2137.52,Other,125% Medicaid APG methodology,0.01,5540.45,
DEB MUSC/FASCIA 20 SQ CM/<      ,11043,CPT,,50013606,CDM,450,RC,,,both,,,1938,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1704.43,,,1704.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1356.6,70,,1356.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1402.03,,,1402.03,Other,153% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1282.9,,,1282.9,Other,140% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2382.54,,,2382.54,Other,260% Medicaid APG methodology,2969.01,,,2969.01,Other,324% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1145.45,,,1145.45,Other,125% Medicaid APG methodology,0.01,2969.01,
DEBRIDE NAIL 1-5                ,11720,CPT,,50013903,CDM,450,RC,,,both,,,602,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,411.2,,,411.2,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,421.4,70,,421.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,221.08,,,221.08,Other,New York Medicaid APG methodology,221.08,,,221.08,Other,100% Medicaid APG methodology,221.08,,,221.08,Other,100% Medicaid APG methodology,221.08,,,221.08,Other,100% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,338.25,,,338.25,Other,153% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,309.51,,,309.51,Other,140% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,574.8,,,574.8,Other,260% Medicaid APG methodology,716.29,,,716.29,Other,324% Medicaid APG methodology,475.32,,,475.32,Other,215% Medicaid APG methodology,475.32,,,475.32,Other,215% Medicaid APG methodology,276.35,,,276.35,Other,125% Medicaid APG methodology,0.01,716.29,
REMOVAL OF NAIL PLATE           ,11730,CPT,,50013929,CDM,450,RC,,,both,,,1570,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,411.2,,,411.2,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1099,70,,1099,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,221.08,,,221.08,Other,New York Medicaid APG methodology,221.08,,,221.08,Other,100% Medicaid APG methodology,221.08,,,221.08,Other,100% Medicaid APG methodology,221.08,,,221.08,Other,100% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,338.25,,,338.25,Other,153% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,309.51,,,309.51,Other,140% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,574.8,,,574.8,Other,260% Medicaid APG methodology,716.29,,,716.29,Other,324% Medicaid APG methodology,475.32,,,475.32,Other,215% Medicaid APG methodology,475.32,,,475.32,Other,215% Medicaid APG methodology,276.35,,,276.35,Other,125% Medicaid APG methodology,0.01,1099,
EXCISION OF NAIL FOLD TOE       ,11765,CPT,,50013986,CDM,450,RC,,,both,,,1144,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,411.2,,,411.2,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,800.8,70,,800.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,221.08,,,221.08,Other,New York Medicaid APG methodology,221.08,,,221.08,Other,100% Medicaid APG methodology,221.08,,,221.08,Other,100% Medicaid APG methodology,221.08,,,221.08,Other,100% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,338.25,,,338.25,Other,153% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,309.51,,,309.51,Other,140% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,574.8,,,574.8,Other,260% Medicaid APG methodology,716.29,,,716.29,Other,324% Medicaid APG methodology,475.32,,,475.32,Other,215% Medicaid APG methodology,475.32,,,475.32,Other,215% Medicaid APG methodology,276.35,,,276.35,Other,125% Medicaid APG methodology,0.01,800.8,
RPR S/N/AX/GEN/TRNK >30.0 CM    ,12007,CPT,,50014174,CDM,450,RC,,,both,,,651,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1193.32,,,1193.32,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,455.7,70,,455.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,981.6,,,981.6,Other,153% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,898.2,,,898.2,Other,140% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1668.08,,,1668.08,Other,260% Medicaid APG methodology,2078.69,,,2078.69,Other,324% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,801.96,,,801.96,Other,125% Medicaid APG methodology,0.01,2078.69,
RPR F/E/E/N/L/M 7.6-12.5 CM     ,12015,CPT,,50014216,CDM,450,RC,,,both,,,1152,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1193.32,,,1193.32,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,806.4,70,,806.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,981.6,,,981.6,Other,153% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,898.2,,,898.2,Other,140% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1668.08,,,1668.08,Other,260% Medicaid APG methodology,2078.69,,,2078.69,Other,324% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,801.96,,,801.96,Other,125% Medicaid APG methodology,0.01,2078.69,
RPR F/E/E/N/L/M >30.0 CM        ,12018,CPT,,50014240,CDM,450,RC,,,both,,,651,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1193.32,,,1193.32,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,455.7,70,,455.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,981.6,,,981.6,Other,153% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,898.2,,,898.2,Other,140% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1668.08,,,1668.08,Other,260% Medicaid APG methodology,2078.69,,,2078.69,Other,324% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,801.96,,,801.96,Other,125% Medicaid APG methodology,0.01,2078.69,
CLOSURE OF SPLIT WOUND          ,12021,CPT,,50014257,CDM,450,RC,,,both,,,1765,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1704.43,,,1704.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1235.5,70,,1235.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1402.03,,,1402.03,Other,153% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1282.9,,,1282.9,Other,140% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2382.54,,,2382.54,Other,260% Medicaid APG methodology,2969.01,,,2969.01,Other,324% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1145.45,,,1145.45,Other,125% Medicaid APG methodology,0.01,2969.01,
INTMD RPR S/A/T/EXT 12.6-20     ,12035,CPT,,50014265,CDM,450,RC,,,both,,,3429,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1704.43,,,1704.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2400.3,70,,2400.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1402.03,,,1402.03,Other,153% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1282.9,,,1282.9,Other,140% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2382.54,,,2382.54,Other,260% Medicaid APG methodology,2969.01,,,2969.01,Other,324% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1145.45,,,1145.45,Other,125% Medicaid APG methodology,0.01,2969.01,
INTMD RPR S/A/T/EXT 20.1-30     ,12036,CPT,,50014273,CDM,450,RC,,,both,,,1977,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1704.43,,,1704.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1383.9,70,,1383.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1402.03,,,1402.03,Other,153% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1282.9,,,1282.9,Other,140% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2382.54,,,2382.54,Other,260% Medicaid APG methodology,2969.01,,,2969.01,Other,324% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1145.45,,,1145.45,Other,125% Medicaid APG methodology,0.01,2969.01,
INTMD RPR N-HF/GENIT 2.5CM/<    ,12041,CPT,,50014299,CDM,450,RC,,,both,,,3117,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1704.43,,,1704.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2181.9,70,,2181.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1402.03,,,1402.03,Other,153% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1282.9,,,1282.9,Other,140% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2382.54,,,2382.54,Other,260% Medicaid APG methodology,2969.01,,,2969.01,Other,324% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1145.45,,,1145.45,Other,125% Medicaid APG methodology,0.01,2969.01,
INTMD RPR N-HF/GENIT7.6-12.5    ,12044,CPT,,50014307,CDM,450,RC,,,both,,,3117,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1704.43,,,1704.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2181.9,70,,2181.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1402.03,,,1402.03,Other,153% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1282.9,,,1282.9,Other,140% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2382.54,,,2382.54,Other,260% Medicaid APG methodology,2969.01,,,2969.01,Other,324% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1145.45,,,1145.45,Other,125% Medicaid APG methodology,0.01,2969.01,
INTMD RPR N-HF/GENIT12.6-20     ,12045,CPT,,50014315,CDM,450,RC,,,both,,,2231,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1704.43,,,1704.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1561.7,70,,1561.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1402.03,,,1402.03,Other,153% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1282.9,,,1282.9,Other,140% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2382.54,,,2382.54,Other,260% Medicaid APG methodology,2969.01,,,2969.01,Other,324% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1145.45,,,1145.45,Other,125% Medicaid APG methodology,0.01,2969.01,
INTMD RPR FACE/MM 7.6-12.5CM    ,12054,CPT,,50014349,CDM,450,RC,,,both,,,3117,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1704.43,,,1704.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2181.9,70,,2181.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1402.03,,,1402.03,Other,153% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1282.9,,,1282.9,Other,140% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2382.54,,,2382.54,Other,260% Medicaid APG methodology,2969.01,,,2969.01,Other,324% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1145.45,,,1145.45,Other,125% Medicaid APG methodology,0.01,2969.01,
INTMD RPR FACE/MM 12.6-20 CM    ,12055,CPT,,50014356,CDM,450,RC,,,both,,,1339,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1704.43,,,1704.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,937.3,70,,937.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1402.03,,,1402.03,Other,153% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1282.9,,,1282.9,Other,140% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2382.54,,,2382.54,Other,260% Medicaid APG methodology,2969.01,,,2969.01,Other,324% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1145.45,,,1145.45,Other,125% Medicaid APG methodology,0.01,2969.01,
INTMD RPR FACE/MM 20.1-30.0     ,12056,CPT,,50014364,CDM,450,RC,,,both,,,2861,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1704.43,,,1704.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2002.7,70,,2002.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1402.03,,,1402.03,Other,153% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1282.9,,,1282.9,Other,140% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2382.54,,,2382.54,Other,260% Medicaid APG methodology,2969.01,,,2969.01,Other,324% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1145.45,,,1145.45,Other,125% Medicaid APG methodology,0.01,2969.01,
CMPLX RPR TRUNK 2.6-7.5 CM      ,13101,CPT,,50014398,CDM,450,RC,,,both,,,2455,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1559.83,,,1559.83,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1718.5,70,,1718.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1283.09,,,1283.09,Other,153% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1174.07,,,1174.07,Other,140% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,2180.41,,,2180.41,Other,260% Medicaid APG methodology,2717.12,,,2717.12,Other,324% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1048.27,,,1048.27,Other,125% Medicaid APG methodology,0.01,2717.12,
CMPLX RPR E/N/E/L 2.6-7.5 CM    ,13152,CPT,,50014489,CDM,450,RC,,,both,,,4873,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1559.83,,,1559.83,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3411.1,70,,3411.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1283.09,,,1283.09,Other,153% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1174.07,,,1174.07,Other,140% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,2180.41,,,2180.41,Other,260% Medicaid APG methodology,2717.12,,,2717.12,Other,324% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1048.27,,,1048.27,Other,125% Medicaid APG methodology,0.01,3411.1,
CMPLX RPR E/N/E/L ADDL 5CM/<    ,13153,CPT,,50014497,CDM,450,RC,,,both,,,247,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2855.7,,,2855.7,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,172.9,70,,172.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1535.32,,,1535.32,Other,New York Medicaid APG methodology,1535.32,,,1535.32,Other,100% Medicaid APG methodology,1535.32,,,1535.32,Other,100% Medicaid APG methodology,1535.32,,,1535.32,Other,100% Medicaid APG methodology,3454.48,,,3454.48,Other,225% Medicaid APG methodology,3454.48,,,3454.48,Other,225% Medicaid APG methodology,2349.04,,,2349.04,Other,153% Medicaid APG methodology,3454.48,,,3454.48,Other,225% Medicaid APG methodology,2149.45,,,2149.45,Other,140% Medicaid APG methodology,3454.48,,,3454.48,Other,225% Medicaid APG methodology,3991.84,,,3991.84,Other,260% Medicaid APG methodology,4974.44,,,4974.44,Other,324% Medicaid APG methodology,3300.94,,,3300.94,Other,215% Medicaid APG methodology,3300.94,,,3300.94,Other,215% Medicaid APG methodology,1919.15,,,1919.15,Other,125% Medicaid APG methodology,0.01,4974.44,
COMPOSITE SKIN GRAFT            ,15760,CPT,,50014703,CDM,450,RC,,,both,,,6223,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,3310.98,,,3310.98,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,4356.1,70,,4356.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,2723.55,,,2723.55,Other,153% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,2492.13,,,2492.13,Other,140% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,4628.25,,,4628.25,Other,260% Medicaid APG methodology,5767.51,,,5767.51,Other,324% Medicaid APG methodology,3827.2,,,3827.2,Other,215% Medicaid APG methodology,3827.2,,,3827.2,Other,215% Medicaid APG methodology,2225.12,,,2225.12,Other,125% Medicaid APG methodology,0.01,5767.51,
INCISION OF BURN SCAB INITI     ,16035,CPT,,50015296,CDM,450,RC,,,both,,,1339,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1704.43,,,1704.43,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,937.3,70,,937.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1402.03,,,1402.03,Other,153% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1282.9,,,1282.9,Other,140% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2382.54,,,2382.54,Other,260% Medicaid APG methodology,2969.01,,,2969.01,Other,324% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1145.45,,,1145.45,Other,125% Medicaid APG methodology,0.01,2969.01,
EXPLORE WOUND ABDOMEN           ,20102,CPT,,50015882,CDM,450,RC,,,both,,,5335,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,3180.63,,,3180.63,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3734.5,70,,3734.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% Medicaid APG methodology,1710.01,,,1710.01,Other,100% Medicaid APG methodology,1710.01,,,1710.01,Other,100% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,2616.32,,,2616.32,Other,153% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,2394.02,,,2394.02,Other,140% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,4446.04,,,4446.04,Other,260% Medicaid APG methodology,5540.45,,,5540.45,Other,324% Medicaid APG methodology,3676.53,,,3676.53,Other,215% Medicaid APG methodology,3676.53,,,3676.53,Other,215% Medicaid APG methodology,2137.52,,,2137.52,Other,125% Medicaid APG methodology,0.01,5540.45,
REMOVE EXOSTOSIS MAXILLA        ,21032,CPT,,50016344,CDM,450,RC,,,both,,,10122,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,5647.23,,,5647.23,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,7085.4,70,,7085.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% Medicaid APG methodology,3036.14,,,3036.14,Other,100% Medicaid APG methodology,3036.14,,,3036.14,Other,100% Medicaid APG methodology,6831.33,,,6831.33,Other,225% Medicaid APG methodology,6831.33,,,6831.33,Other,225% Medicaid APG methodology,4645.3,,,4645.3,Other,153% Medicaid APG methodology,6831.33,,,6831.33,Other,225% Medicaid APG methodology,4250.6,,,4250.6,Other,140% Medicaid APG methodology,6831.33,,,6831.33,Other,225% Medicaid APG methodology,7893.98,,,7893.98,Other,260% Medicaid APG methodology,9837.11,,,9837.11,Other,324% Medicaid APG methodology,6527.71,,,6527.71,Other,215% Medicaid APG methodology,6527.71,,,6527.71,Other,215% Medicaid APG methodology,3795.18,,,3795.18,Other,125% Medicaid APG methodology,0.01,9837.11,
INTERDENTAL FIXATION            ,21110,CPT,,50016575,CDM,450,RC,,,both,,,4939,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,508.35,,,508.35,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3457.3,70,,3457.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,273.31,,,273.31,Other,New York Medicaid APG methodology,273.31,,,273.31,Other,100% Medicaid APG methodology,273.31,,,273.31,Other,100% Medicaid APG methodology,273.31,,,273.31,Other,100% Medicaid APG methodology,614.94,,,614.94,Other,225% Medicaid APG methodology,614.94,,,614.94,Other,225% Medicaid APG methodology,418.16,,,418.16,Other,153% Medicaid APG methodology,614.94,,,614.94,Other,225% Medicaid APG methodology,382.63,,,382.63,Other,140% Medicaid APG methodology,614.94,,,614.94,Other,225% Medicaid APG methodology,710.6,,,710.6,Other,260% Medicaid APG methodology,885.52,,,885.52,Other,324% Medicaid APG methodology,587.61,,,587.61,Other,215% Medicaid APG methodology,587.61,,,587.61,Other,215% Medicaid APG methodology,341.64,,,341.64,Other,125% Medicaid APG methodology,0.01,3457.3,
OP TX PALATE OR MAXILLARY FX    ,21422,CPT,,50017433,CDM,450,RC,,,both,,,18997,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,6455.24,,,6455.24,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,13297.9,70,,13297.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,3470.56,,,3470.56,Other,New York Medicaid APG methodology,3470.56,,,3470.56,Other,100% Medicaid APG methodology,3470.56,,,3470.56,Other,100% Medicaid APG methodology,3470.56,,,3470.56,Other,100% Medicaid APG methodology,7808.76,,,7808.76,Other,225% Medicaid APG methodology,7808.76,,,7808.76,Other,225% Medicaid APG methodology,5309.96,,,5309.96,Other,153% Medicaid APG methodology,7808.76,,,7808.76,Other,225% Medicaid APG methodology,4858.78,,,4858.78,Other,140% Medicaid APG methodology,7808.76,,,7808.76,Other,225% Medicaid APG methodology,9023.46,,,9023.46,Other,260% Medicaid APG methodology,11244.62,,,11244.62,Other,324% Medicaid APG methodology,7461.71,,,7461.71,Other,215% Medicaid APG methodology,7461.71,,,7461.71,Other,215% Medicaid APG methodology,4338.2,,,4338.2,Other,125% Medicaid APG methodology,0.01,13297.9,
CL TX MAND/MAXIALVEOLAR RDG FX  ,21440,CPT,,50017508,CDM,450,RC,,,both,,,10122,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,5647.23,,,5647.23,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,7085.4,70,,7085.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% Medicaid APG methodology,3036.14,,,3036.14,Other,100% Medicaid APG methodology,3036.14,,,3036.14,Other,100% Medicaid APG methodology,6831.33,,,6831.33,Other,225% Medicaid APG methodology,6831.33,,,6831.33,Other,225% Medicaid APG methodology,4645.3,,,4645.3,Other,153% Medicaid APG methodology,6831.33,,,6831.33,Other,225% Medicaid APG methodology,4250.6,,,4250.6,Other,140% Medicaid APG methodology,6831.33,,,6831.33,Other,225% Medicaid APG methodology,7893.98,,,7893.98,Other,260% Medicaid APG methodology,9837.11,,,9837.11,Other,324% Medicaid APG methodology,6527.71,,,6527.71,Other,215% Medicaid APG methodology,6527.71,,,6527.71,Other,215% Medicaid APG methodology,3795.18,,,3795.18,Other,125% Medicaid APG methodology,0.01,9837.11,
CL TX MANDIBULAR FX; WO MANIP   ,21450,CPT,,50017524,CDM,450,RC,,,both,,,740,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,518,70,,518,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,2244.92,
PERC TX OF MAND FX W EXT FIX    ,21452,CPT,,50017540,CDM,450,RC,,,both,,,18997,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,7051.19,,,7051.19,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,13297.9,70,,13297.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% Medicaid APG methodology,3790.96,,,3790.96,Other,100% Medicaid APG methodology,3790.96,,,3790.96,Other,100% Medicaid APG methodology,8529.66,,,8529.66,Other,225% Medicaid APG methodology,8529.66,,,8529.66,Other,225% Medicaid APG methodology,5800.17,,,5800.17,Other,153% Medicaid APG methodology,8529.66,,,8529.66,Other,225% Medicaid APG methodology,5307.35,,,5307.35,Other,140% Medicaid APG methodology,8529.66,,,8529.66,Other,225% Medicaid APG methodology,9856.5,,,9856.5,Other,260% Medicaid APG methodology,12282.71,,,12282.71,Other,324% Medicaid APG methodology,8150.57,,,8150.57,Other,215% Medicaid APG methodology,8150.57,,,8150.57,Other,215% Medicaid APG methodology,4738.7,,,4738.7,Other,125% Medicaid APG methodology,0.01,13297.9,
CL TX OF MAND FX W ID FIX       ,21453,CPT,,50017557,CDM,450,RC,,,both,,,18997,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,7051.19,,,7051.19,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,13297.9,70,,13297.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% Medicaid APG methodology,3790.96,,,3790.96,Other,100% Medicaid APG methodology,3790.96,,,3790.96,Other,100% Medicaid APG methodology,8529.66,,,8529.66,Other,225% Medicaid APG methodology,8529.66,,,8529.66,Other,225% Medicaid APG methodology,5800.17,,,5800.17,Other,153% Medicaid APG methodology,8529.66,,,8529.66,Other,225% Medicaid APG methodology,5307.35,,,5307.35,Other,140% Medicaid APG methodology,8529.66,,,8529.66,Other,225% Medicaid APG methodology,9856.5,,,9856.5,Other,260% Medicaid APG methodology,12282.71,,,12282.71,Other,324% Medicaid APG methodology,8150.57,,,8150.57,Other,215% Medicaid APG methodology,8150.57,,,8150.57,Other,215% Medicaid APG methodology,4738.7,,,4738.7,Other,125% Medicaid APG methodology,0.01,13297.9,
RESET DISLOCATED JAW            ,21485,CPT,,50017623,CDM,450,RC,,,both,,,4939,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2193.58,,,2193.58,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3457.3,70,,3457.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% Medicaid APG methodology,1179.35,,,1179.35,Other,100% Medicaid APG methodology,1179.35,,,1179.35,Other,100% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,1804.4,,,1804.4,Other,153% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,1651.08,,,1651.08,Other,140% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,3066.3,,,3066.3,Other,260% Medicaid APG methodology,3821.08,,,3821.08,Other,324% Medicaid APG methodology,2535.59,,,2535.59,Other,215% Medicaid APG methodology,2535.59,,,2535.59,Other,215% Medicaid APG methodology,1474.18,,,1474.18,Other,125% Medicaid APG methodology,0.01,3821.08,
TREAT CLAVICLE FRACTURE         ,23505,CPT,,50018720,CDM,450,RC,,,both,,,5309,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3716.3,70,,3716.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,3716.3,
TREAT HUMERUS FRACTURE          ,23605,CPT,,50018852,CDM,450,RC,,,both,,,5309,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3716.3,70,,3716.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,3716.3,
TREAT HUMERUS FRACTURE          ,23625,CPT,,50018894,CDM,450,RC,,,both,,,5386,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3770.2,70,,3770.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,3770.2,
CL TX SHDR DISLC W NK FX W MAN  ,23675,CPT,,50018969,CDM,450,RC,,,both,,,5309,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3716.3,70,,3716.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,3716.3,
CL TX HUMERUS FX W MANIP        ,24505,CPT,,50019637,CDM,450,RC,,,both,,,5309,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3716.3,70,,3716.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,3716.3,
TREAT HUMERUS FRACTURE          ,24535,CPT,,50019678,CDM,450,RC,,,both,,,5309,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3716.3,70,,3716.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,3716.3,
TREAT HUMERUS FRACTURE          ,24545,CPT,,50019694,CDM,450,RC,,,both,,,10637,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,6546.01,,,6546.01,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,7445.9,70,,7445.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% Medicaid APG methodology,3519.36,,,3519.36,Other,100% Medicaid APG methodology,3519.36,,,3519.36,Other,100% Medicaid APG methodology,7918.56,,,7918.56,Other,225% Medicaid APG methodology,7918.56,,,7918.56,Other,225% Medicaid APG methodology,5384.62,,,5384.62,Other,153% Medicaid APG methodology,7918.56,,,7918.56,Other,225% Medicaid APG methodology,4927.1,,,4927.1,Other,140% Medicaid APG methodology,7918.56,,,7918.56,Other,225% Medicaid APG methodology,9150.34,,,9150.34,Other,260% Medicaid APG methodology,11402.73,,,11402.73,Other,324% Medicaid APG methodology,7566.62,,,7566.62,Other,215% Medicaid APG methodology,7566.62,,,7566.62,Other,215% Medicaid APG methodology,4399.2,,,4399.2,Other,125% Medicaid APG methodology,0.01,25027.84,
TREAT HUMERUS FRACTURE          ,24565,CPT,,50019728,CDM,450,RC,,,both,,,5309,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3716.3,70,,3716.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,3716.3,
CL TX C HUMERUS FX W MANIP      ,24577,CPT,,50019751,CDM,450,RC,,,both,,,5309,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3716.3,70,,3716.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,3716.3,
TREAT ELBOW DISLOCATION         ,24605,CPT,,50019819,CDM,450,RC,,,both,,,5790,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2193.58,,,2193.58,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,4053,70,,4053,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% Medicaid APG methodology,1179.35,,,1179.35,Other,100% Medicaid APG methodology,1179.35,,,1179.35,Other,100% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,1804.4,,,1804.4,Other,153% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,1651.08,,,1651.08,Other,140% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,3066.3,,,3066.3,Other,260% Medicaid APG methodology,3821.08,,,3821.08,Other,324% Medicaid APG methodology,2535.59,,,2535.59,Other,215% Medicaid APG methodology,2535.59,,,2535.59,Other,215% Medicaid APG methodology,1474.18,,,1474.18,Other,125% Medicaid APG methodology,0.01,4053,
TREAT ELBOW FRACTURE            ,24620,CPT,,50019835,CDM,450,RC,,,both,,,5871,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,4109.7,70,,4109.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,4109.7,
TREAT RADIUS FRACTURE           ,24655,CPT,,50019876,CDM,450,RC,,,both,,,5309,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3716.3,70,,3716.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,3716.3,
TREAT ULNAR FRACTURE            ,24675,CPT,,50019918,CDM,450,RC,,,both,,,5840,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,4088,70,,4088,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,4088,
CL TX RADIAL SHFT FX W MANIP    ,25505,CPT,,50020734,CDM,450,RC,,,both,,,5309,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3716.3,70,,3716.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,3716.3,
GALEAZZI FX/DISLOC              ,25520,CPT,,50020759,CDM,450,RC,,,both,,,5309,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3716.3,70,,3716.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,3716.3,
TREAT FRACTURE OF ULNA          ,25535,CPT,,50020791,CDM,450,RC,,,both,,,873,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,611.1,70,,611.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,2244.92,
CL TX RADIAL & ULNA FX W MANIP  ,25565,CPT,,50020825,CDM,450,RC,,,both,,,6459,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,4521.3,70,,4521.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,4521.3,
TREAT WRIST BONE FX W MNP       ,25624,CPT,,50020890,CDM,450,RC,,,both,,,5309,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3716.3,70,,3716.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,3716.3,
TREAT WRIST FX W MNP EA BONE    ,25635,CPT,,50020916,CDM,450,RC,,,both,,,5309,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3716.3,70,,3716.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,3716.3,
TREAT WRIST BONE FRACTURE CLSD  ,25650,CPT,,50020924,CDM,450,RC,,,both,,,873,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,611.1,70,,611.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,2244.92,
TREAT WRIST DISLOCATION         ,25675,CPT,,50020957,CDM,450,RC,,,both,,,966,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,676.2,70,,676.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,2244.92,
TREAT WRIST DISLOCATION         ,25690,CPT,,50020999,CDM,450,RC,,,both,,,5309,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3716.3,70,,3716.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,3716.3,
DRAINAGE FINGER ABSCESS COMPL   ,26011,CPT,,50021187,CDM,450,RC,,,both,,,5335,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1516.17,,,1516.17,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3734.5,70,,3734.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,815.14,,,815.14,Other,New York Medicaid APG methodology,815.14,,,815.14,Other,100% Medicaid APG methodology,815.14,,,815.14,Other,100% Medicaid APG methodology,815.14,,,815.14,Other,100% Medicaid APG methodology,1834.07,,,1834.07,Other,225% Medicaid APG methodology,1834.07,,,1834.07,Other,225% Medicaid APG methodology,1247.17,,,1247.17,Other,153% Medicaid APG methodology,1834.07,,,1834.07,Other,225% Medicaid APG methodology,1141.2,,,1141.2,Other,140% Medicaid APG methodology,1834.07,,,1834.07,Other,225% Medicaid APG methodology,2119.37,,,2119.37,Other,260% Medicaid APG methodology,2641.06,,,2641.06,Other,324% Medicaid APG methodology,1752.56,,,1752.56,Other,215% Medicaid APG methodology,1752.56,,,1752.56,Other,215% Medicaid APG methodology,1018.93,,,1018.93,Other,125% Medicaid APG methodology,0.01,3734.5,
TREAT THUMB DISLOCATION W MNP   ,26641,CPT,,50022052,CDM,450,RC,,,both,,,873,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,611.1,70,,611.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,2244.92,
TREAT THUMB FRACTURE            ,26645,CPT,,50022060,CDM,450,RC,,,both,,,5309,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3716.3,70,,3716.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,3716.3,
TREAT KNUCKLE DISLOC WO ANES    ,26700,CPT,,50022136,CDM,450,RC,,,both,,,1047,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,732.9,70,,732.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,2244.92,
CL TX ART FX MCP/IP JNT WO MNP  ,26740,CPT,,50022201,CDM,450,RC,,,both,,,873,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,611.1,70,,611.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,2244.92,
CL TX ARTFX MCP/IP JNT W MANIP  ,26742,CPT,,50022219,CDM,450,RC,,,both,,,5309,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3716.3,70,,3716.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,3716.3,
CL TX D PHAL FX FNG/THMB W MNP  ,26755,CPT,,50022235,CDM,450,RC,,,both,,,961,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,672.7,70,,672.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,2244.92,
TREAT FINGER DISLOC W ANES      ,26775,CPT,,50022276,CDM,450,RC,,,both,,,1124,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2193.58,,,2193.58,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,786.8,70,,786.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% Medicaid APG methodology,1179.35,,,1179.35,Other,100% Medicaid APG methodology,1179.35,,,1179.35,Other,100% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,1804.4,,,1804.4,Other,153% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,1651.08,,,1651.08,Other,140% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,3066.3,,,3066.3,Other,260% Medicaid APG methodology,3821.08,,,3821.08,Other,324% Medicaid APG methodology,2535.59,,,2535.59,Other,215% Medicaid APG methodology,2535.59,,,2535.59,Other,215% Medicaid APG methodology,1474.18,,,1474.18,Other,125% Medicaid APG methodology,0.01,3821.08,
TREAT FINGER DISLOCATION        ,26785,CPT,,50022292,CDM,450,RC,,,both,,,10637,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,6546.01,,,6546.01,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,7445.9,70,,7445.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% Medicaid APG methodology,3519.36,,,3519.36,Other,100% Medicaid APG methodology,3519.36,,,3519.36,Other,100% Medicaid APG methodology,7918.56,,,7918.56,Other,225% Medicaid APG methodology,7918.56,,,7918.56,Other,225% Medicaid APG methodology,5384.62,,,5384.62,Other,153% Medicaid APG methodology,7918.56,,,7918.56,Other,225% Medicaid APG methodology,4927.1,,,4927.1,Other,140% Medicaid APG methodology,7918.56,,,7918.56,Other,225% Medicaid APG methodology,9150.34,,,9150.34,Other,260% Medicaid APG methodology,11402.73,,,11402.73,Other,324% Medicaid APG methodology,7566.62,,,7566.62,Other,215% Medicaid APG methodology,7566.62,,,7566.62,Other,215% Medicaid APG methodology,4399.2,,,4399.2,Other,125% Medicaid APG methodology,0.01,11402.73,
TREAT HIP DISLOC WO ANES TR     ,27250,CPT,,50023050,CDM,450,RC,,,both,,,951,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,665.7,70,,665.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,2244.92,
TREAT HIP DISLOC W ANES TR      ,27252,CPT,,50023068,CDM,450,RC,,,both,,,5312,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2193.58,,,2193.58,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3718.4,70,,3718.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% Medicaid APG methodology,1179.35,,,1179.35,Other,100% Medicaid APG methodology,1179.35,,,1179.35,Other,100% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,1804.4,,,1804.4,Other,153% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,1651.08,,,1651.08,Other,140% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,3066.3,,,3066.3,Other,260% Medicaid APG methodology,3821.08,,,3821.08,Other,324% Medicaid APG methodology,2535.59,,,2535.59,Other,215% Medicaid APG methodology,2535.59,,,2535.59,Other,215% Medicaid APG methodology,1474.18,,,1474.18,Other,125% Medicaid APG methodology,0.01,3821.08,
TREAT HIP DISLOC W ANES PST     ,27266,CPT,,50023142,CDM,450,RC,,,both,,,6368,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2193.58,,,2193.58,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,4457.6,70,,4457.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% Medicaid APG methodology,1179.35,,,1179.35,Other,100% Medicaid APG methodology,1179.35,,,1179.35,Other,100% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,1804.4,,,1804.4,Other,153% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,1651.08,,,1651.08,Other,140% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,3066.3,,,3066.3,Other,260% Medicaid APG methodology,3821.08,,,3821.08,Other,324% Medicaid APG methodology,2535.59,,,2535.59,Other,215% Medicaid APG methodology,2535.59,,,2535.59,Other,215% Medicaid APG methodology,1474.18,,,1474.18,Other,125% Medicaid APG methodology,0.01,4457.6,
CL TX FEMORAL SHAFT FX W MANIP  ,27502,CPT,,50023860,CDM,450,RC,,,both,,,5309,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3716.3,70,,3716.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,3716.3,
CL TX FEMUR FX OR EPIPHYS SEP   ,27510,CPT,,50023928,CDM,450,RC,,,both,,,5309,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3716.3,70,,3716.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,3716.3,
TREAT KNEE FRACTURE             ,27532,CPT,,50024017,CDM,450,RC,,,both,,,10637,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,7445.9,70,,7445.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,7445.9,
TREAT KNEE FRACTURE(S)          ,27538,CPT,,50024041,CDM,450,RC,,,both,,,873,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,611.1,70,,611.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,2244.92,
TREAT KNEE DISLOCATION          ,27550,CPT,,50024066,CDM,450,RC,,,both,,,961,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,672.7,70,,672.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,2244.92,
TREAT KNEE DISLOCATION          ,27552,CPT,,50024074,CDM,450,RC,,,both,,,5309,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2193.58,,,2193.58,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3716.3,70,,3716.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% Medicaid APG methodology,1179.35,,,1179.35,Other,100% Medicaid APG methodology,1179.35,,,1179.35,Other,100% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,1804.4,,,1804.4,Other,153% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,1651.08,,,1651.08,Other,140% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,3066.3,,,3066.3,Other,260% Medicaid APG methodology,3821.08,,,3821.08,Other,324% Medicaid APG methodology,2535.59,,,2535.59,Other,215% Medicaid APG methodology,2535.59,,,2535.59,Other,215% Medicaid APG methodology,1474.18,,,1474.18,Other,125% Medicaid APG methodology,0.01,3821.08,
TREAT KNEECAP DISLOC WO ANES    ,27560,CPT,,50024116,CDM,450,RC,,,both,,,1047,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,732.9,70,,732.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,2244.92,
TREAT KNEECAP DISLOC W ANES     ,27562,CPT,,50024124,CDM,450,RC,,,both,,,873,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2193.58,,,2193.58,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,611.1,70,,611.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% Medicaid APG methodology,1179.35,,,1179.35,Other,100% Medicaid APG methodology,1179.35,,,1179.35,Other,100% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,1804.4,,,1804.4,Other,153% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,1651.08,,,1651.08,Other,140% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,3066.3,,,3066.3,Other,260% Medicaid APG methodology,3821.08,,,3821.08,Other,324% Medicaid APG methodology,2535.59,,,2535.59,Other,215% Medicaid APG methodology,2535.59,,,2535.59,Other,215% Medicaid APG methodology,1474.18,,,1474.18,Other,125% Medicaid APG methodology,0.01,3821.08,
REPAIR ACHILLES TENDON          ,27650,CPT,,50024439,CDM,450,RC,,,both,,,10637,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,3963.08,,,3963.08,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,7445.9,70,,7445.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% Medicaid APG methodology,2130.69,,,2130.69,Other,100% Medicaid APG methodology,2130.69,,,2130.69,Other,100% Medicaid APG methodology,4794.05,,,4794.05,Other,225% Medicaid APG methodology,4794.05,,,4794.05,Other,225% Medicaid APG methodology,3259.95,,,3259.95,Other,153% Medicaid APG methodology,4794.05,,,4794.05,Other,225% Medicaid APG methodology,2982.96,,,2982.96,Other,140% Medicaid APG methodology,4794.05,,,4794.05,Other,225% Medicaid APG methodology,5539.79,,,5539.79,Other,260% Medicaid APG methodology,6903.43,,,6903.43,Other,324% Medicaid APG methodology,4580.98,,,4580.98,Other,215% Medicaid APG methodology,4580.98,,,4580.98,Other,215% Medicaid APG methodology,2663.36,,,2663.36,Other,125% Medicaid APG methodology,0.01,13604.5,
TREATMENT OF TIBIA FX WO MNP    ,27750,CPT,,50024819,CDM,450,RC,,,both,,,961,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,672.7,70,,672.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,2244.92,
TREATMENT OF TIBIA FX W MNP     ,27752,CPT,,50024827,CDM,450,RC,,,both,,,5309,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3716.3,70,,3716.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,3716.3,
CLTX MED ANKLE FX W/MNPJ        ,27762,CPT,,50024876,CDM,450,RC,,,both,,,5309,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3716.3,70,,3716.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,3716.3,
TREATMENT OF FIBULA FRACTURE    ,27781,CPT,,50024900,CDM,450,RC,,,both,,,5309,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3716.3,70,,3716.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,3716.3,
CL TX DISTL FIB FX W MANIP      ,27788,CPT,,50024934,CDM,450,RC,,,both,,,1030,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,721,70,,721,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,2244.92,
CLTX BIMALLEOLAR ANKL FX W MNP  ,27810,CPT,,50024967,CDM,450,RC,,,both,,,6369,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,4458.3,70,,4458.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,4458.3,
CL TX TRIMALL ANKLE FX W MANIP  ,27818,CPT,,50024991,CDM,450,RC,,,both,,,6194,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,4335.8,70,,4335.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,4335.8,
TREAT ANKLE DISLOC WO ANES      ,27840,CPT,,50025113,CDM,450,RC,,,both,,,951,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,665.7,70,,665.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,2244.92,
TREAT ANKLE DISLOCATION         ,27842,CPT,,50025121,CDM,450,RC,,,both,,,5311,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2193.58,,,2193.58,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3717.7,70,,3717.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% Medicaid APG methodology,1179.35,,,1179.35,Other,100% Medicaid APG methodology,1179.35,,,1179.35,Other,100% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,1804.4,,,1804.4,Other,153% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,1651.08,,,1651.08,Other,140% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,3066.3,,,3066.3,Other,260% Medicaid APG methodology,3821.08,,,3821.08,Other,324% Medicaid APG methodology,2535.59,,,2535.59,Other,215% Medicaid APG methodology,2535.59,,,2535.59,Other,215% Medicaid APG methodology,1474.18,,,1474.18,Other,125% Medicaid APG methodology,0.01,3821.08,
REMOVAL FOOT FOREIGN BODY SQ    ,28190,CPT,,50025741,CDM,450,RC,,,both,,,3863,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1559.83,,,1559.83,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2704.1,70,,2704.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1283.09,,,1283.09,Other,153% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1174.07,,,1174.07,Other,140% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,2180.41,,,2180.41,Other,260% Medicaid APG methodology,2717.12,,,2717.12,Other,324% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1048.27,,,1048.27,Other,125% Medicaid APG methodology,0.01,2717.12,
REPAIR OF FOOT TENDON EA        ,28208,CPT,,50025790,CDM,450,RC,,,both,,,11701,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,3696.26,,,3696.26,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,8190.7,70,,8190.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% Medicaid APG methodology,1987.23,,,1987.23,Other,100% Medicaid APG methodology,1987.23,,,1987.23,Other,100% Medicaid APG methodology,4471.28,,,4471.28,Other,225% Medicaid APG methodology,4471.28,,,4471.28,Other,225% Medicaid APG methodology,3040.47,,,3040.47,Other,153% Medicaid APG methodology,4471.28,,,4471.28,Other,225% Medicaid APG methodology,2782.13,,,2782.13,Other,140% Medicaid APG methodology,4471.28,,,4471.28,Other,225% Medicaid APG methodology,5166.81,,,5166.81,Other,260% Medicaid APG methodology,6438.64,,,6438.64,Other,324% Medicaid APG methodology,4272.55,,,4272.55,Other,215% Medicaid APG methodology,4272.55,,,4272.55,Other,215% Medicaid APG methodology,2484.04,,,2484.04,Other,125% Medicaid APG methodology,0.01,8190.7,
TREATMENT OF HEEL FRACTURE      ,28405,CPT,,50026251,CDM,450,RC,,,both,,,873,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,611.1,70,,611.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,2244.92,
TREATMENT OF ANKLE FRACTURE     ,28435,CPT,,50026301,CDM,450,RC,,,both,,,5309,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3716.3,70,,3716.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,3716.3,
TREAT METATARSAL FRACTURE       ,28475,CPT,,50026384,CDM,450,RC,,,both,,,873,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,611.1,70,,611.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,2244.92,
CL TX FX GT PHALANX(S) W MANIP  ,28495,CPT,,50026418,CDM,450,RC,,,both,,,873,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,611.1,70,,611.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,2244.92,
TREATMENT OF TOE FRACTURE       ,28515,CPT,,50026442,CDM,450,RC,,,both,,,873,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,611.1,70,,611.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,2244.92,
TREAT TOE DISLOCATION           ,28630,CPT,,50026608,CDM,450,RC,,,both,,,873,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,611.1,70,,611.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,2244.92,
TREAT TOE DISLOCATION           ,28635,CPT,,50026616,CDM,450,RC,,,both,,,5309,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2193.58,,,2193.58,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3716.3,70,,3716.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% Medicaid APG methodology,1179.35,,,1179.35,Other,100% Medicaid APG methodology,1179.35,,,1179.35,Other,100% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,1804.4,,,1804.4,Other,153% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,1651.08,,,1651.08,Other,140% Medicaid APG methodology,2653.53,,,2653.53,Other,225% Medicaid APG methodology,3066.3,,,3066.3,Other,260% Medicaid APG methodology,3821.08,,,3821.08,Other,324% Medicaid APG methodology,2535.59,,,2535.59,Other,215% Medicaid APG methodology,2535.59,,,2535.59,Other,215% Medicaid APG methodology,1474.18,,,1474.18,Other,125% Medicaid APG methodology,0.01,3821.08,
TREAT TOE DISLOCATION           ,28660,CPT,,50026657,CDM,450,RC,,,both,,,951,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,665.7,70,,665.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,2244.92,
APPLY HAND/WRIST CAST           ,29085,CPT,,50026970,CDM,450,RC,,,both,,,570,299.64,,,299.64,Other,150% of Medicare + 9.63% HCRA Surcharge,182.21,,,182.21,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,621.41,,,621.41,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,399,70,,399,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,334.09,,,334.09,Other,New York Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,511.16,,,511.16,Other,153% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,467.73,,,467.73,Other,140% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,868.64,,,868.64,Other,260% Medicaid APG methodology,1082.45,,,1082.45,Other,324% Medicaid APG methodology,718.29,,,718.29,Other,215% Medicaid APG methodology,718.29,,,718.29,Other,215% Medicaid APG methodology,417.61,,,417.61,Other,125% Medicaid APG methodology,0.01,1082.45,
APPLICATION OF HIP CASTS        ,29325,CPT,,50027085,CDM,450,RC,,,both,,,1124,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,834.08,,,834.08,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,786.8,70,,786.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% Medicaid APG methodology,448.43,,,448.43,Other,100% Medicaid APG methodology,448.43,,,448.43,Other,100% Medicaid APG methodology,1008.97,,,1008.97,Other,225% Medicaid APG methodology,1008.97,,,1008.97,Other,225% Medicaid APG methodology,686.1,,,686.1,Other,153% Medicaid APG methodology,1008.97,,,1008.97,Other,225% Medicaid APG methodology,627.81,,,627.81,Other,140% Medicaid APG methodology,1008.97,,,1008.97,Other,225% Medicaid APG methodology,1165.92,,,1165.92,Other,260% Medicaid APG methodology,1452.92,,,1452.92,Other,324% Medicaid APG methodology,964.13,,,964.13,Other,215% Medicaid APG methodology,964.13,,,964.13,Other,215% Medicaid APG methodology,560.54,,,560.54,Other,125% Medicaid APG methodology,0.01,1452.92,
APPLY CYLINDER CAST             ,29365,CPT,,50027127,CDM,450,RC,,,both,,,1124,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,621.41,,,621.41,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,786.8,70,,786.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,334.09,,,334.09,Other,New York Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,511.16,,,511.16,Other,153% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,467.73,,,467.73,Other,140% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,868.64,,,868.64,Other,260% Medicaid APG methodology,1082.45,,,1082.45,Other,324% Medicaid APG methodology,718.29,,,718.29,Other,215% Medicaid APG methodology,718.29,,,718.29,Other,215% Medicaid APG methodology,417.61,,,417.61,Other,125% Medicaid APG methodology,0.01,1082.45,
APLY SHRT LEG CAST WALK/AMB     ,29425,CPT,,50027143,CDM,450,RC,,,both,,,1124,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,834.08,,,834.08,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,786.8,70,,786.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% Medicaid APG methodology,448.43,,,448.43,Other,100% Medicaid APG methodology,448.43,,,448.43,Other,100% Medicaid APG methodology,1008.97,,,1008.97,Other,225% Medicaid APG methodology,1008.97,,,1008.97,Other,225% Medicaid APG methodology,686.1,,,686.1,Other,153% Medicaid APG methodology,1008.97,,,1008.97,Other,225% Medicaid APG methodology,627.81,,,627.81,Other,140% Medicaid APG methodology,1008.97,,,1008.97,Other,225% Medicaid APG methodology,1165.92,,,1165.92,Other,260% Medicaid APG methodology,1452.92,,,1452.92,Other,324% Medicaid APG methodology,964.13,,,964.13,Other,215% Medicaid APG methodology,964.13,,,964.13,Other,215% Medicaid APG methodology,560.54,,,560.54,Other,125% Medicaid APG methodology,0.01,1452.92,
APPLICATION OF LEG CAST         ,29450,CPT,,50027184,CDM,450,RC,,,both,,,570,299.64,,,299.64,Other,150% of Medicare + 9.63% HCRA Surcharge,182.21,,,182.21,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,834.08,,,834.08,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,399,70,,399,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% Medicaid APG methodology,448.43,,,448.43,Other,100% Medicaid APG methodology,448.43,,,448.43,Other,100% Medicaid APG methodology,1008.97,,,1008.97,Other,225% Medicaid APG methodology,1008.97,,,1008.97,Other,225% Medicaid APG methodology,686.1,,,686.1,Other,153% Medicaid APG methodology,1008.97,,,1008.97,Other,225% Medicaid APG methodology,627.81,,,627.81,Other,140% Medicaid APG methodology,1008.97,,,1008.97,Other,225% Medicaid APG methodology,1165.92,,,1165.92,Other,260% Medicaid APG methodology,1452.92,,,1452.92,Other,324% Medicaid APG methodology,964.13,,,964.13,Other,215% Medicaid APG methodology,964.13,,,964.13,Other,215% Medicaid APG methodology,560.54,,,560.54,Other,125% Medicaid APG methodology,0.01,1452.92,
REMOVAL/REVISION CAST ARM/LEG   ,29705,CPT,,50027283,CDM,450,RC,,,both,,,1124,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,834.08,,,834.08,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,786.8,70,,786.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% Medicaid APG methodology,448.43,,,448.43,Other,100% Medicaid APG methodology,448.43,,,448.43,Other,100% Medicaid APG methodology,1008.97,,,1008.97,Other,225% Medicaid APG methodology,1008.97,,,1008.97,Other,225% Medicaid APG methodology,686.1,,,686.1,Other,153% Medicaid APG methodology,1008.97,,,1008.97,Other,225% Medicaid APG methodology,627.81,,,627.81,Other,140% Medicaid APG methodology,1008.97,,,1008.97,Other,225% Medicaid APG methodology,1165.92,,,1165.92,Other,260% Medicaid APG methodology,1452.92,,,1452.92,Other,324% Medicaid APG methodology,964.13,,,964.13,Other,215% Medicaid APG methodology,964.13,,,964.13,Other,215% Medicaid APG methodology,560.54,,,560.54,Other,125% Medicaid APG methodology,0.01,1452.92,
DRAINAGE NOSE LESION INT APP    ,30000,CPT,,50027572,CDM,450,RC,,,both,,,740,464.5,,,464.5,Other,150% of Medicare + 9.63% HCRA Surcharge,282.46,,,282.46,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,501.18,,,501.18,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,518,70,,518,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,412.26,,,412.26,Other,153% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,377.23,,,377.23,Other,140% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,700.58,,,700.58,Other,260% Medicaid APG methodology,873.03,,,873.03,Other,324% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,336.82,,,336.82,Other,125% Medicaid APG methodology,0.01,873.03,
DRAINAGE OF NOSE LESION SEPT    ,30020,CPT,,50027580,CDM,450,RC,,,both,,,740,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2874.75,,,2874.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,518,70,,518,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% Medicaid APG methodology,1545.56,,,1545.56,Other,100% Medicaid APG methodology,1545.56,,,1545.56,Other,100% Medicaid APG methodology,3477.52,,,3477.52,Other,225% Medicaid APG methodology,3477.52,,,3477.52,Other,225% Medicaid APG methodology,2364.71,,,2364.71,Other,153% Medicaid APG methodology,3477.52,,,3477.52,Other,225% Medicaid APG methodology,2163.79,,,2163.79,Other,140% Medicaid APG methodology,3477.52,,,3477.52,Other,225% Medicaid APG methodology,4018.47,,,4018.47,Other,260% Medicaid APG methodology,5007.63,,,5007.63,Other,324% Medicaid APG methodology,3322.96,,,3322.96,Other,215% Medicaid APG methodology,3322.96,,,3322.96,Other,215% Medicaid APG methodology,1931.96,,,1931.96,Other,125% Medicaid APG methodology,0.01,5007.63,
REMOVE NASAL FOREIGN BODY       ,30300,CPT,,50027697,CDM,450,RC,,,both,,,647,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,501.18,,,501.18,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,452.9,70,,452.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,412.26,,,412.26,Other,153% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,377.23,,,377.23,Other,140% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,700.58,,,700.58,Other,260% Medicaid APG methodology,873.03,,,873.03,Other,324% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,336.82,,,336.82,Other,125% Medicaid APG methodology,0.01,873.03,
CONTROL OF NOSEBLEED CPLX       ,30905,CPT,,50027804,CDM,450,RC,,,both,,,1038,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,501.18,,,501.18,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,726.6,70,,726.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,412.26,,,412.26,Other,153% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,377.23,,,377.23,Other,140% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,700.58,,,700.58,Other,260% Medicaid APG methodology,873.03,,,873.03,Other,324% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,336.82,,,336.82,Other,125% Medicaid APG methodology,0.01,873.03,
NASAL/SINUS ENDOSCOPY SURG      ,31238,CPT,,50028000,CDM,450,RC,,,both,,,7369,3227.6,,,3227.6,Other,150% of Medicare + 9.63% HCRA Surcharge,1962.72,,,1962.72,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,3814.26,,,3814.26,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,5158.3,70,,5158.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,2050.68,,,2050.68,Other,New York Medicaid APG methodology,2050.68,,,2050.68,Other,100% Medicaid APG methodology,2050.68,,,2050.68,Other,100% Medicaid APG methodology,2050.68,,,2050.68,Other,100% Medicaid APG methodology,4614.03,,,4614.03,Other,225% Medicaid APG methodology,4614.03,,,4614.03,Other,225% Medicaid APG methodology,3137.54,,,3137.54,Other,153% Medicaid APG methodology,4614.03,,,4614.03,Other,225% Medicaid APG methodology,2870.95,,,2870.95,Other,140% Medicaid APG methodology,4614.03,,,4614.03,Other,225% Medicaid APG methodology,5331.77,,,5331.77,Other,260% Medicaid APG methodology,6644.2,,,6644.2,Other,324% Medicaid APG methodology,4408.96,,,4408.96,Other,215% Medicaid APG methodology,4408.96,,,4408.96,Other,215% Medicaid APG methodology,2563.35,,,2563.35,Other,125% Medicaid APG methodology,0.01,6644.2,
REPAIR BLD VESSEL LESION U EXT  ,35206,CPT,,50029727,CDM,450,RC,,,both,,,10599,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,5673.29,,,5673.29,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,7419.3,70,,7419.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% Medicaid APG methodology,3050.16,,,3050.16,Other,100% Medicaid APG methodology,3050.16,,,3050.16,Other,100% Medicaid APG methodology,6862.85,,,6862.85,Other,225% Medicaid APG methodology,6862.85,,,6862.85,Other,225% Medicaid APG methodology,4666.74,,,4666.74,Other,153% Medicaid APG methodology,6862.85,,,6862.85,Other,225% Medicaid APG methodology,4270.22,,,4270.22,Other,140% Medicaid APG methodology,6862.85,,,6862.85,Other,225% Medicaid APG methodology,7930.41,,,7930.41,Other,260% Medicaid APG methodology,9882.51,,,9882.51,Other,324% Medicaid APG methodology,6557.84,,,6557.84,Other,215% Medicaid APG methodology,6557.84,,,6557.84,Other,215% Medicaid APG methodology,3812.7,,,3812.7,Other,125% Medicaid APG methodology,0.01,9882.51,
REPAIR BLD VESSEL LSN HND/FNG   ,35207,CPT,,50029735,CDM,450,RC,,,both,,,10599,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,5673.29,,,5673.29,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,7419.3,70,,7419.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% Medicaid APG methodology,3050.16,,,3050.16,Other,100% Medicaid APG methodology,3050.16,,,3050.16,Other,100% Medicaid APG methodology,6862.85,,,6862.85,Other,225% Medicaid APG methodology,6862.85,,,6862.85,Other,225% Medicaid APG methodology,4666.74,,,4666.74,Other,153% Medicaid APG methodology,6862.85,,,6862.85,Other,225% Medicaid APG methodology,4270.22,,,4270.22,Other,140% Medicaid APG methodology,6862.85,,,6862.85,Other,225% Medicaid APG methodology,7930.41,,,7930.41,Other,260% Medicaid APG methodology,9882.51,,,9882.51,Other,324% Medicaid APG methodology,6557.84,,,6557.84,Other,215% Medicaid APG methodology,6557.84,,,6557.84,Other,215% Medicaid APG methodology,3812.7,,,3812.7,Other,125% Medicaid APG methodology,0.01,9882.51,
REPAIR BLD VESSEL LESION L EXT  ,35226,CPT,,50029768,CDM,450,RC,,,both,,,2335,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,5673.29,,,5673.29,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1634.5,70,,1634.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% Medicaid APG methodology,3050.16,,,3050.16,Other,100% Medicaid APG methodology,3050.16,,,3050.16,Other,100% Medicaid APG methodology,6862.85,,,6862.85,Other,225% Medicaid APG methodology,6862.85,,,6862.85,Other,225% Medicaid APG methodology,4666.74,,,4666.74,Other,153% Medicaid APG methodology,6862.85,,,6862.85,Other,225% Medicaid APG methodology,4270.22,,,4270.22,Other,140% Medicaid APG methodology,6862.85,,,6862.85,Other,225% Medicaid APG methodology,7930.41,,,7930.41,Other,260% Medicaid APG methodology,9882.51,,,9882.51,Other,324% Medicaid APG methodology,6557.84,,,6557.84,Other,215% Medicaid APG methodology,6557.84,,,6557.84,Other,215% Medicaid APG methodology,3812.7,,,3812.7,Other,125% Medicaid APG methodology,0.01,9882.51,
INSERTION CATHETER ARTERY       ,36620,CPT,,50030451,CDM,450,RC,,,both,,,270,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,421.95,,,421.95,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,189,70,,189,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,226.86,,,226.86,Other,New York Medicaid APG methodology,226.86,,,226.86,Other,100% Medicaid APG methodology,226.86,,,226.86,Other,100% Medicaid APG methodology,226.86,,,226.86,Other,100% Medicaid APG methodology,510.43,,,510.43,Other,225% Medicaid APG methodology,510.43,,,510.43,Other,225% Medicaid APG methodology,347.09,,,347.09,Other,153% Medicaid APG methodology,510.43,,,510.43,Other,225% Medicaid APG methodology,317.6,,,317.6,Other,140% Medicaid APG methodology,510.43,,,510.43,Other,225% Medicaid APG methodology,589.83,,,589.83,Other,260% Medicaid APG methodology,735.01,,,735.01,Other,324% Medicaid APG methodology,487.74,,,487.74,Other,215% Medicaid APG methodology,487.74,,,487.74,Other,215% Medicaid APG methodology,283.57,,,283.57,Other,125% Medicaid APG methodology,0.01,735.01,
INSERT NEEDLE BONE CAVITY       ,36680,CPT,,50030493,CDM,450,RC,,,both,,,1581,757.69,,,757.69,Other,150% of Medicare + 9.63% HCRA Surcharge,460.76,,,460.76,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,841.15,,,841.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1106.7,70,,1106.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,452.23,,,452.23,Other,New York Medicaid APG methodology,452.23,,,452.23,Other,100% Medicaid APG methodology,452.23,,,452.23,Other,100% Medicaid APG methodology,452.23,,,452.23,Other,100% Medicaid APG methodology,1017.52,,,1017.52,Other,225% Medicaid APG methodology,1017.52,,,1017.52,Other,225% Medicaid APG methodology,691.91,,,691.91,Other,153% Medicaid APG methodology,1017.52,,,1017.52,Other,225% Medicaid APG methodology,633.12,,,633.12,Other,140% Medicaid APG methodology,1017.52,,,1017.52,Other,225% Medicaid APG methodology,1175.8,,,1175.8,Other,260% Medicaid APG methodology,1465.23,,,1465.23,Other,324% Medicaid APG methodology,972.3,,,972.3,Other,215% Medicaid APG methodology,972.3,,,972.3,Other,215% Medicaid APG methodology,565.29,,,565.29,Other,125% Medicaid APG methodology,0.01,1465.23,
LIGATION OF NECK ARTERY         ,37615,CPT,,50030659,CDM,450,RC,,,both,,,10599,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,5673.29,,,5673.29,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,7419.3,70,,7419.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% Medicaid APG methodology,3050.16,,,3050.16,Other,100% Medicaid APG methodology,3050.16,,,3050.16,Other,100% Medicaid APG methodology,6862.85,,,6862.85,Other,225% Medicaid APG methodology,6862.85,,,6862.85,Other,225% Medicaid APG methodology,4666.74,,,4666.74,Other,153% Medicaid APG methodology,6862.85,,,6862.85,Other,225% Medicaid APG methodology,4270.22,,,4270.22,Other,140% Medicaid APG methodology,6862.85,,,6862.85,Other,225% Medicaid APG methodology,7930.41,,,7930.41,Other,260% Medicaid APG methodology,9882.51,,,9882.51,Other,324% Medicaid APG methodology,6557.84,,,6557.84,Other,215% Medicaid APG methodology,6557.84,,,6557.84,Other,215% Medicaid APG methodology,3812.7,,,3812.7,Other,125% Medicaid APG methodology,0.01,9882.51,
NEEDLE BIOPSY LYMPH NODES       ,38505,CPT,,50030782,CDM,450,RC,,,both,,,3628,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2855.7,,,2855.7,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2539.6,70,,2539.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1535.32,,,1535.32,Other,New York Medicaid APG methodology,1535.32,,,1535.32,Other,100% Medicaid APG methodology,1535.32,,,1535.32,Other,100% Medicaid APG methodology,1535.32,,,1535.32,Other,100% Medicaid APG methodology,3454.48,,,3454.48,Other,225% Medicaid APG methodology,3454.48,,,3454.48,Other,225% Medicaid APG methodology,2349.04,,,2349.04,Other,153% Medicaid APG methodology,3454.48,,,3454.48,Other,225% Medicaid APG methodology,2149.45,,,2149.45,Other,140% Medicaid APG methodology,3454.48,,,3454.48,Other,225% Medicaid APG methodology,3991.84,,,3991.84,Other,260% Medicaid APG methodology,4974.44,,,4974.44,Other,324% Medicaid APG methodology,3300.94,,,3300.94,Other,215% Medicaid APG methodology,3300.94,,,3300.94,Other,215% Medicaid APG methodology,1919.15,,,1919.15,Other,125% Medicaid APG methodology,0.01,4974.44,
EXCISION OF MOUTH LESION        ,40810,CPT,,50031236,CDM,450,RC,,,both,,,10122,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1027.22,,,1027.22,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,7085.4,70,,7085.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% Medicaid APG methodology,552.27,,,552.27,Other,100% Medicaid APG methodology,552.27,,,552.27,Other,100% Medicaid APG methodology,1242.61,,,1242.61,Other,225% Medicaid APG methodology,1242.61,,,1242.61,Other,225% Medicaid APG methodology,844.98,,,844.98,Other,153% Medicaid APG methodology,1242.61,,,1242.61,Other,225% Medicaid APG methodology,773.18,,,773.18,Other,140% Medicaid APG methodology,1242.61,,,1242.61,Other,225% Medicaid APG methodology,1435.91,,,1435.91,Other,260% Medicaid APG methodology,1789.36,,,1789.36,Other,324% Medicaid APG methodology,1187.38,,,1187.38,Other,215% Medicaid APG methodology,1187.38,,,1187.38,Other,215% Medicaid APG methodology,690.34,,,690.34,Other,125% Medicaid APG methodology,0.01,7085.4,
EXCISE LIP OR CHEEK FOLD        ,40819,CPT,,50031285,CDM,450,RC,,,both,,,4939,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2874.75,,,2874.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3457.3,70,,3457.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% Medicaid APG methodology,1545.56,,,1545.56,Other,100% Medicaid APG methodology,1545.56,,,1545.56,Other,100% Medicaid APG methodology,3477.52,,,3477.52,Other,225% Medicaid APG methodology,3477.52,,,3477.52,Other,225% Medicaid APG methodology,2364.71,,,2364.71,Other,153% Medicaid APG methodology,3477.52,,,3477.52,Other,225% Medicaid APG methodology,2163.79,,,2163.79,Other,140% Medicaid APG methodology,3477.52,,,3477.52,Other,225% Medicaid APG methodology,4018.47,,,4018.47,Other,260% Medicaid APG methodology,5007.63,,,5007.63,Other,324% Medicaid APG methodology,3322.96,,,3322.96,Other,215% Medicaid APG methodology,3322.96,,,3322.96,Other,215% Medicaid APG methodology,1931.96,,,1931.96,Other,125% Medicaid APG methodology,0.01,5007.63,
REPAIR MOUTH LAC =<2.5CM        ,40830,CPT,,50031301,CDM,450,RC,,,both,,,740,464.5,,,464.5,Other,150% of Medicare + 9.63% HCRA Surcharge,282.46,,,282.46,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,501.18,,,501.18,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,518,70,,518,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,412.26,,,412.26,Other,153% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,377.23,,,377.23,Other,140% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,700.58,,,700.58,Other,260% Medicaid APG methodology,873.03,,,873.03,Other,324% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,336.82,,,336.82,Other,125% Medicaid APG methodology,0.01,873.03,
DRAINAGE MOUTH LESION SUBMNTL   ,41007,CPT,,50031418,CDM,450,RC,,,both,,,4939,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2874.75,,,2874.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3457.3,70,,3457.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% Medicaid APG methodology,1545.56,,,1545.56,Other,100% Medicaid APG methodology,1545.56,,,1545.56,Other,100% Medicaid APG methodology,3477.52,,,3477.52,Other,225% Medicaid APG methodology,3477.52,,,3477.52,Other,225% Medicaid APG methodology,2364.71,,,2364.71,Other,153% Medicaid APG methodology,3477.52,,,3477.52,Other,225% Medicaid APG methodology,2163.79,,,2163.79,Other,140% Medicaid APG methodology,3477.52,,,3477.52,Other,225% Medicaid APG methodology,4018.47,,,4018.47,Other,260% Medicaid APG methodology,5007.63,,,5007.63,Other,324% Medicaid APG methodology,3322.96,,,3322.96,Other,215% Medicaid APG methodology,3322.96,,,3322.96,Other,215% Medicaid APG methodology,1931.96,,,1931.96,Other,125% Medicaid APG methodology,0.01,5007.63,
DRAINAGE MOUTH LESION SUBMAND   ,41008,CPT,,50031426,CDM,450,RC,,,both,,,10122,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2874.75,,,2874.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,7085.4,70,,7085.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% Medicaid APG methodology,1545.56,,,1545.56,Other,100% Medicaid APG methodology,1545.56,,,1545.56,Other,100% Medicaid APG methodology,3477.52,,,3477.52,Other,225% Medicaid APG methodology,3477.52,,,3477.52,Other,225% Medicaid APG methodology,2364.71,,,2364.71,Other,153% Medicaid APG methodology,3477.52,,,3477.52,Other,225% Medicaid APG methodology,2163.79,,,2163.79,Other,140% Medicaid APG methodology,3477.52,,,3477.52,Other,225% Medicaid APG methodology,4018.47,,,4018.47,Other,260% Medicaid APG methodology,5007.63,,,5007.63,Other,324% Medicaid APG methodology,3322.96,,,3322.96,Other,215% Medicaid APG methodology,3322.96,,,3322.96,Other,215% Medicaid APG methodology,1931.96,,,1931.96,Other,125% Medicaid APG methodology,0.01,7085.4,
DRAINAGE MOUTH LESN SUBMAND EO  ,41017,CPT,,50031475,CDM,450,RC,,,both,,,10122,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1027.22,,,1027.22,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,7085.4,70,,7085.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% Medicaid APG methodology,552.27,,,552.27,Other,100% Medicaid APG methodology,552.27,,,552.27,Other,100% Medicaid APG methodology,1242.61,,,1242.61,Other,225% Medicaid APG methodology,1242.61,,,1242.61,Other,225% Medicaid APG methodology,844.98,,,844.98,Other,153% Medicaid APG methodology,1242.61,,,1242.61,Other,225% Medicaid APG methodology,773.18,,,773.18,Other,140% Medicaid APG methodology,1242.61,,,1242.61,Other,225% Medicaid APG methodology,1435.91,,,1435.91,Other,260% Medicaid APG methodology,1789.36,,,1789.36,Other,324% Medicaid APG methodology,1187.38,,,1187.38,Other,215% Medicaid APG methodology,1187.38,,,1187.38,Other,215% Medicaid APG methodology,690.34,,,690.34,Other,125% Medicaid APG methodology,0.01,7085.4,
REP LAC 2.5 CM/< FLR-MTH /ANT   ,41250,CPT,,50031574,CDM,450,RC,,,both,,,1380,757.69,,,757.69,Other,150% of Medicare + 9.63% HCRA Surcharge,460.76,,,460.76,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,501.18,,,501.18,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,966,70,,966,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,412.26,,,412.26,Other,153% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,377.23,,,377.23,Other,140% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,700.58,,,700.58,Other,260% Medicaid APG methodology,873.03,,,873.03,Other,324% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,336.82,,,336.82,Other,125% Medicaid APG methodology,0.01,966,
REP LAC TNG FLR-MTH > 2.6/CMPL  ,41252,CPT,,50031590,CDM,450,RC,,,both,,,740,464.5,,,464.5,Other,150% of Medicare + 9.63% HCRA Surcharge,282.46,,,282.46,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,501.18,,,501.18,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,518,70,,518,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,412.26,,,412.26,Other,153% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,377.23,,,377.23,Other,140% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,700.58,,,700.58,Other,260% Medicaid APG methodology,873.03,,,873.03,Other,324% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,336.82,,,336.82,Other,125% Medicaid APG methodology,0.01,873.03,
DRAINAGE MOUTH ROOF LESION      ,42000,CPT,,50031723,CDM,450,RC,,,both,,,740,464.5,,,464.5,Other,150% of Medicare + 9.63% HCRA Surcharge,282.46,,,282.46,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,501.18,,,501.18,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,518,70,,518,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,412.26,,,412.26,Other,153% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,377.23,,,377.23,Other,140% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,700.58,,,700.58,Other,260% Medicaid APG methodology,873.03,,,873.03,Other,324% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,336.82,,,336.82,Other,125% Medicaid APG methodology,0.01,873.03,
BIOPSY ROOF OF MOUTH            ,42100,CPT,,50031731,CDM,450,RC,,,both,,,4939,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2874.75,,,2874.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3457.3,70,,3457.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% Medicaid APG methodology,1545.56,,,1545.56,Other,100% Medicaid APG methodology,1545.56,,,1545.56,Other,100% Medicaid APG methodology,3477.52,,,3477.52,Other,225% Medicaid APG methodology,3477.52,,,3477.52,Other,225% Medicaid APG methodology,2364.71,,,2364.71,Other,153% Medicaid APG methodology,3477.52,,,3477.52,Other,225% Medicaid APG methodology,2163.79,,,2163.79,Other,140% Medicaid APG methodology,3477.52,,,3477.52,Other,225% Medicaid APG methodology,4018.47,,,4018.47,Other,260% Medicaid APG methodology,5007.63,,,5007.63,Other,324% Medicaid APG methodology,3322.96,,,3322.96,Other,215% Medicaid APG methodology,3322.96,,,3322.96,Other,215% Medicaid APG methodology,1931.96,,,1931.96,Other,125% Medicaid APG methodology,0.01,5007.63,
EXCISION LESION MOUTH ROOF      ,42104,CPT,,50031749,CDM,450,RC,,,both,,,10122,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,3792.93,,,3792.93,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,7085.4,70,,7085.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,2039.21,,,2039.21,Other,New York Medicaid APG methodology,2039.21,,,2039.21,Other,100% Medicaid APG methodology,2039.21,,,2039.21,Other,100% Medicaid APG methodology,2039.21,,,2039.21,Other,100% Medicaid APG methodology,4588.22,,,4588.22,Other,225% Medicaid APG methodology,4588.22,,,4588.22,Other,225% Medicaid APG methodology,3119.99,,,3119.99,Other,153% Medicaid APG methodology,4588.22,,,4588.22,Other,225% Medicaid APG methodology,2854.89,,,2854.89,Other,140% Medicaid APG methodology,4588.22,,,4588.22,Other,225% Medicaid APG methodology,5301.94,,,5301.94,Other,260% Medicaid APG methodology,6607.03,,,6607.03,Other,324% Medicaid APG methodology,4384.3,,,4384.3,Other,215% Medicaid APG methodology,4384.3,,,4384.3,Other,215% Medicaid APG methodology,2549.01,,,2549.01,Other,125% Medicaid APG methodology,0.01,7085.4,
REPAIR PALATE                   ,42182,CPT,,50031814,CDM,450,RC,,,both,,,18997,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1027.22,,,1027.22,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,13297.9,70,,13297.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% Medicaid APG methodology,552.27,,,552.27,Other,100% Medicaid APG methodology,552.27,,,552.27,Other,100% Medicaid APG methodology,1242.61,,,1242.61,Other,225% Medicaid APG methodology,1242.61,,,1242.61,Other,225% Medicaid APG methodology,844.98,,,844.98,Other,153% Medicaid APG methodology,1242.61,,,1242.61,Other,225% Medicaid APG methodology,773.18,,,773.18,Other,140% Medicaid APG methodology,1242.61,,,1242.61,Other,225% Medicaid APG methodology,1435.91,,,1435.91,Other,260% Medicaid APG methodology,1789.36,,,1789.36,Other,324% Medicaid APG methodology,1187.38,,,1187.38,Other,215% Medicaid APG methodology,1187.38,,,1187.38,Other,215% Medicaid APG methodology,690.34,,,690.34,Other,125% Medicaid APG methodology,0.01,13297.9,
DRAINAGE SALIVARY GLAND INOR    ,42310,CPT,,50031939,CDM,450,RC,,,both,,,740,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,508.35,,,508.35,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,518,70,,518,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,273.31,,,273.31,Other,New York Medicaid APG methodology,273.31,,,273.31,Other,100% Medicaid APG methodology,273.31,,,273.31,Other,100% Medicaid APG methodology,273.31,,,273.31,Other,100% Medicaid APG methodology,614.94,,,614.94,Other,225% Medicaid APG methodology,614.94,,,614.94,Other,225% Medicaid APG methodology,418.16,,,418.16,Other,153% Medicaid APG methodology,614.94,,,614.94,Other,225% Medicaid APG methodology,382.63,,,382.63,Other,140% Medicaid APG methodology,614.94,,,614.94,Other,225% Medicaid APG methodology,710.6,,,710.6,Other,260% Medicaid APG methodology,885.52,,,885.52,Other,324% Medicaid APG methodology,587.61,,,587.61,Other,215% Medicaid APG methodology,587.61,,,587.61,Other,215% Medicaid APG methodology,341.64,,,341.64,Other,125% Medicaid APG methodology,0.01,1046.29,
DRAINAGE OF TONSIL ABSCESS      ,42700,CPT,,50032176,CDM,450,RC,,,both,,,2850,464.5,,,464.5,Other,150% of Medicare + 9.63% HCRA Surcharge,282.46,,,282.46,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,501.18,,,501.18,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1995,70,,1995,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,412.26,,,412.26,Other,153% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,377.23,,,377.23,Other,140% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,700.58,,,700.58,Other,260% Medicaid APG methodology,873.03,,,873.03,Other,324% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,336.82,,,336.82,Other,125% Medicaid APG methodology,0.01,1995,
DRAINAGE OF THROAT ABSCESS      ,42720,CPT,,50032184,CDM,450,RC,,,both,,,10122,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2874.75,,,2874.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,7085.4,70,,7085.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% Medicaid APG methodology,1545.56,,,1545.56,Other,100% Medicaid APG methodology,1545.56,,,1545.56,Other,100% Medicaid APG methodology,3477.52,,,3477.52,Other,225% Medicaid APG methodology,3477.52,,,3477.52,Other,225% Medicaid APG methodology,2364.71,,,2364.71,Other,153% Medicaid APG methodology,3477.52,,,3477.52,Other,225% Medicaid APG methodology,2163.79,,,2163.79,Other,140% Medicaid APG methodology,3477.52,,,3477.52,Other,225% Medicaid APG methodology,4018.47,,,4018.47,Other,260% Medicaid APG methodology,5007.63,,,5007.63,Other,324% Medicaid APG methodology,3322.96,,,3322.96,Other,215% Medicaid APG methodology,3322.96,,,3322.96,Other,215% Medicaid APG methodology,1931.96,,,1931.96,Other,125% Medicaid APG methodology,0.01,7085.4,
CONTROL THROAT BLEEDING         ,42960,CPT,,50032374,CDM,450,RC,,,both,,,740,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2874.75,,,2874.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,518,70,,518,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% Medicaid APG methodology,1545.56,,,1545.56,Other,100% Medicaid APG methodology,1545.56,,,1545.56,Other,100% Medicaid APG methodology,3477.52,,,3477.52,Other,225% Medicaid APG methodology,3477.52,,,3477.52,Other,225% Medicaid APG methodology,2364.71,,,2364.71,Other,153% Medicaid APG methodology,3477.52,,,3477.52,Other,225% Medicaid APG methodology,2163.79,,,2163.79,Other,140% Medicaid APG methodology,3477.52,,,3477.52,Other,225% Medicaid APG methodology,4018.47,,,4018.47,Other,260% Medicaid APG methodology,5007.63,,,5007.63,Other,324% Medicaid APG methodology,3322.96,,,3322.96,Other,215% Medicaid APG methodology,3322.96,,,3322.96,Other,215% Medicaid APG methodology,1931.96,,,1931.96,Other,125% Medicaid APG methodology,0.01,5007.63,
THROAT SURGERY PROCEDURE        ,42999,CPT,,50032432,CDM,450,RC,,,both,,,740,464.5,,,464.5,Other,150% of Medicare + 9.63% HCRA Surcharge,282.46,,,282.46,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2931.1,,,2931.1,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,518,70,,518,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1575.86,,,1575.86,Other,New York Medicaid APG methodology,1575.86,,,1575.86,Other,100% Medicaid APG methodology,1575.86,,,1575.86,Other,100% Medicaid APG methodology,1575.86,,,1575.86,Other,100% Medicaid APG methodology,3545.69,,,3545.69,Other,225% Medicaid APG methodology,3545.69,,,3545.69,Other,225% Medicaid APG methodology,2411.07,,,2411.07,Other,153% Medicaid APG methodology,3545.69,,,3545.69,Other,225% Medicaid APG methodology,2206.21,,,2206.21,Other,140% Medicaid APG methodology,3545.69,,,3545.69,Other,225% Medicaid APG methodology,4097.24,,,4097.24,Other,260% Medicaid APG methodology,5105.79,,,5105.79,Other,324% Medicaid APG methodology,3388.1,,,3388.1,Other,215% Medicaid APG methodology,3388.1,,,3388.1,Other,215% Medicaid APG methodology,1969.83,,,1969.83,Other,125% Medicaid APG methodology,0.01,5105.79,
LAPAROSCOPY APPENDECTOMY        ,44970,CPT,,50032671,CDM,450,RC,,,both,,,18544,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,5601.44,,,5601.44,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,12980.8,70,,12980.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,3011.53,,,3011.53,Other,New York Medicaid APG methodology,3011.53,,,3011.53,Other,100% Medicaid APG methodology,3011.53,,,3011.53,Other,100% Medicaid APG methodology,3011.53,,,3011.53,Other,100% Medicaid APG methodology,6775.94,,,6775.94,Other,225% Medicaid APG methodology,6775.94,,,6775.94,Other,225% Medicaid APG methodology,4607.64,,,4607.64,Other,153% Medicaid APG methodology,6775.94,,,6775.94,Other,225% Medicaid APG methodology,4216.14,,,4216.14,Other,140% Medicaid APG methodology,6775.94,,,6775.94,Other,225% Medicaid APG methodology,7829.98,,,7829.98,Other,260% Medicaid APG methodology,9757.35,,,9757.35,Other,324% Medicaid APG methodology,6474.79,,,6474.79,Other,215% Medicaid APG methodology,6474.79,,,6474.79,Other,215% Medicaid APG methodology,3764.41,,,3764.41,Other,125% Medicaid APG methodology,0.01,12980.8,
REDUCTION OF RECTAL PROLAPSE    ,45900,CPT,,50032960,CDM,450,RC,,,both,,,2914,1738.02,,,1738.02,Other,150% of Medicare + 9.63% HCRA Surcharge,1056.9,,,1056.9,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2542.82,,,2542.82,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2039.8,70,,2039.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% Medicaid APG methodology,1367.11,,,1367.11,Other,100% Medicaid APG methodology,1367.11,,,1367.11,Other,100% Medicaid APG methodology,3075.99,,,3075.99,Other,225% Medicaid APG methodology,3075.99,,,3075.99,Other,225% Medicaid APG methodology,2091.67,,,2091.67,Other,153% Medicaid APG methodology,3075.99,,,3075.99,Other,225% Medicaid APG methodology,1913.95,,,1913.95,Other,140% Medicaid APG methodology,3075.99,,,3075.99,Other,225% Medicaid APG methodology,3554.48,,,3554.48,Other,260% Medicaid APG methodology,4429.43,,,4429.43,Other,324% Medicaid APG methodology,2939.28,,,2939.28,Other,215% Medicaid APG methodology,2939.28,,,2939.28,Other,215% Medicaid APG methodology,1708.88,,,1708.88,Other,125% Medicaid APG methodology,0.01,4429.43,
INCISION RECTAL ABSCESS W ANES  ,46045,CPT,,50032994,CDM,450,RC,,,both,,,9142,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,3491.2,,,3491.2,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,6399.4,70,,6399.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% Medicaid APG methodology,1876.99,,,1876.99,Other,100% Medicaid APG methodology,1876.99,,,1876.99,Other,100% Medicaid APG methodology,4223.23,,,4223.23,Other,225% Medicaid APG methodology,4223.23,,,4223.23,Other,225% Medicaid APG methodology,2871.8,,,2871.8,Other,153% Medicaid APG methodology,4223.23,,,4223.23,Other,225% Medicaid APG methodology,2627.79,,,2627.79,Other,140% Medicaid APG methodology,4223.23,,,4223.23,Other,225% Medicaid APG methodology,4880.18,,,4880.18,Other,260% Medicaid APG methodology,6081.45,,,6081.45,Other,324% Medicaid APG methodology,4035.53,,,4035.53,Other,215% Medicaid APG methodology,4035.53,,,4035.53,Other,215% Medicaid APG methodology,2346.24,,,2346.24,Other,125% Medicaid APG methodology,0.01,6399.4,
INCISE EXTERNAL HEMORRHOID      ,46083,CPT,,50033034,CDM,450,RC,,,both,,,943,469.99,,,469.99,Other,150% of Medicare + 9.63% HCRA Surcharge,285.8,,,285.8,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2542.82,,,2542.82,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,660.1,70,,660.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% Medicaid APG methodology,1367.11,,,1367.11,Other,100% Medicaid APG methodology,1367.11,,,1367.11,Other,100% Medicaid APG methodology,3075.99,,,3075.99,Other,225% Medicaid APG methodology,3075.99,,,3075.99,Other,225% Medicaid APG methodology,2091.67,,,2091.67,Other,153% Medicaid APG methodology,3075.99,,,3075.99,Other,225% Medicaid APG methodology,1913.95,,,1913.95,Other,140% Medicaid APG methodology,3075.99,,,3075.99,Other,225% Medicaid APG methodology,3554.48,,,3554.48,Other,260% Medicaid APG methodology,4429.43,,,4429.43,Other,324% Medicaid APG methodology,2939.28,,,2939.28,Other,215% Medicaid APG methodology,2939.28,,,2939.28,Other,215% Medicaid APG methodology,1708.88,,,1708.88,Other,125% Medicaid APG methodology,0.01,4429.43,
EXCHANGE DRAINAGE CATHETER      ,49423,CPT,,50034230,CDM,450,RC,,,both,,,6946,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1502.62,,,1502.62,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,4862.2,70,,4862.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% Medicaid APG methodology,807.86,,,807.86,Other,100% Medicaid APG methodology,807.86,,,807.86,Other,100% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,1236.03,,,1236.03,Other,153% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,1131.01,,,1131.01,Other,140% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,2100.44,,,2100.44,Other,260% Medicaid APG methodology,2617.47,,,2617.47,Other,324% Medicaid APG methodology,1736.9,,,1736.9,Other,215% Medicaid APG methodology,1736.9,,,1736.9,Other,215% Medicaid APG methodology,1009.83,,,1009.83,Other,125% Medicaid APG methodology,0.01,4862.2,
INJECTION FOR BLADDER X-RAY     ,51610,CPT,,50035088,CDM,450,RC,,,both,,,3238,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1205.26,,,1205.26,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2266.6,70,,2266.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,647.99,,,647.99,Other,New York Medicaid APG methodology,647.99,,,647.99,Other,100% Medicaid APG methodology,647.99,,,647.99,Other,100% Medicaid APG methodology,647.99,,,647.99,Other,100% Medicaid APG methodology,1457.97,,,1457.97,Other,225% Medicaid APG methodology,1457.97,,,1457.97,Other,225% Medicaid APG methodology,991.42,,,991.42,Other,153% Medicaid APG methodology,1457.97,,,1457.97,Other,225% Medicaid APG methodology,907.18,,,907.18,Other,140% Medicaid APG methodology,1457.97,,,1457.97,Other,225% Medicaid APG methodology,1684.77,,,1684.77,Other,260% Medicaid APG methodology,2099.48,,,2099.48,Other,324% Medicaid APG methodology,1393.17,,,1393.17,Other,215% Medicaid APG methodology,1393.17,,,1393.17,Other,215% Medicaid APG methodology,809.98,,,809.98,Other,125% Medicaid APG methodology,0.01,2266.6,
DILATE URETHRA STRICTURE        ,53600,CPT,,50035732,CDM,450,RC,,,both,,,541,469.99,,,469.99,Other,150% of Medicare + 9.63% HCRA Surcharge,285.8,,,285.8,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1051.03,,,1051.03,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,378.7,70,,378.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,565.07,,,565.07,Other,New York Medicaid APG methodology,565.07,,,565.07,Other,100% Medicaid APG methodology,565.07,,,565.07,Other,100% Medicaid APG methodology,565.07,,,565.07,Other,100% Medicaid APG methodology,1271.41,,,1271.41,Other,225% Medicaid APG methodology,1271.41,,,1271.41,Other,225% Medicaid APG methodology,864.56,,,864.56,Other,153% Medicaid APG methodology,1271.41,,,1271.41,Other,225% Medicaid APG methodology,791.1,,,791.1,Other,140% Medicaid APG methodology,1271.41,,,1271.41,Other,225% Medicaid APG methodology,1469.19,,,1469.19,Other,260% Medicaid APG methodology,1830.83,,,1830.83,Other,324% Medicaid APG methodology,1214.9,,,1214.9,Other,215% Medicaid APG methodology,1214.9,,,1214.9,Other,215% Medicaid APG methodology,706.34,,,706.34,Other,125% Medicaid APG methodology,0.01,1830.83,
TREATMENT OF PENIS LESION       ,54220,CPT,,50036045,CDM,450,RC,,,both,,,1859,469.99,,,469.99,Other,150% of Medicare + 9.63% HCRA Surcharge,285.8,,,285.8,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1051.03,,,1051.03,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1301.3,70,,1301.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,565.07,,,565.07,Other,New York Medicaid APG methodology,565.07,,,565.07,Other,100% Medicaid APG methodology,565.07,,,565.07,Other,100% Medicaid APG methodology,565.07,,,565.07,Other,100% Medicaid APG methodology,1271.41,,,1271.41,Other,225% Medicaid APG methodology,1271.41,,,1271.41,Other,225% Medicaid APG methodology,864.56,,,864.56,Other,153% Medicaid APG methodology,1271.41,,,1271.41,Other,225% Medicaid APG methodology,791.1,,,791.1,Other,140% Medicaid APG methodology,1271.41,,,1271.41,Other,225% Medicaid APG methodology,1469.19,,,1469.19,Other,260% Medicaid APG methodology,1830.83,,,1830.83,Other,324% Medicaid APG methodology,1214.9,,,1214.9,Other,215% Medicaid APG methodology,1214.9,,,1214.9,Other,215% Medicaid APG methodology,706.34,,,706.34,Other,125% Medicaid APG methodology,0.01,1830.83,
PENILE INJECTION                ,54235,CPT,,50036078,CDM,450,RC,,,both,,,943,469.99,,,469.99,Other,150% of Medicare + 9.63% HCRA Surcharge,285.8,,,285.8,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1051.03,,,1051.03,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,660.1,70,,660.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,565.07,,,565.07,Other,New York Medicaid APG methodology,565.07,,,565.07,Other,100% Medicaid APG methodology,565.07,,,565.07,Other,100% Medicaid APG methodology,565.07,,,565.07,Other,100% Medicaid APG methodology,1271.41,,,1271.41,Other,225% Medicaid APG methodology,1271.41,,,1271.41,Other,225% Medicaid APG methodology,864.56,,,864.56,Other,153% Medicaid APG methodology,1271.41,,,1271.41,Other,225% Medicaid APG methodology,791.1,,,791.1,Other,140% Medicaid APG methodology,1271.41,,,1271.41,Other,225% Medicaid APG methodology,1469.19,,,1469.19,Other,260% Medicaid APG methodology,1830.83,,,1830.83,Other,324% Medicaid APG methodology,1214.9,,,1214.9,Other,215% Medicaid APG methodology,1214.9,,,1214.9,Other,215% Medicaid APG methodology,706.34,,,706.34,Other,125% Medicaid APG methodology,0.01,1830.83,
I & D OF VULVA/PERINEUM         ,56405,CPT,,50036573,CDM,450,RC,,,both,,,1313,610.06,,,610.06,Other,150% of Medicare + 9.63% HCRA Surcharge,370.98,,,370.98,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,529.85,,,529.85,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,919.1,70,,919.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,284.87,,,284.87,Other,New York Medicaid APG methodology,284.87,,,284.87,Other,100% Medicaid APG methodology,284.87,,,284.87,Other,100% Medicaid APG methodology,284.87,,,284.87,Other,100% Medicaid APG methodology,640.95,,,640.95,Other,225% Medicaid APG methodology,640.95,,,640.95,Other,225% Medicaid APG methodology,435.85,,,435.85,Other,153% Medicaid APG methodology,640.95,,,640.95,Other,225% Medicaid APG methodology,398.81,,,398.81,Other,140% Medicaid APG methodology,640.95,,,640.95,Other,225% Medicaid APG methodology,740.65,,,740.65,Other,260% Medicaid APG methodology,922.97,,,922.97,Other,324% Medicaid APG methodology,612.46,,,612.46,Other,215% Medicaid APG methodology,612.46,,,612.46,Other,215% Medicaid APG methodology,356.08,,,356.08,Other,125% Medicaid APG methodology,0.01,922.97,
SURGERY FOR VULVA LESION        ,56440,CPT,,50036599,CDM,450,RC,,,both,,,10060,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2981.36,,,2981.36,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,7042,70,,7042,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1602.88,,,1602.88,Other,New York Medicaid APG methodology,1602.88,,,1602.88,Other,100% Medicaid APG methodology,1602.88,,,1602.88,Other,100% Medicaid APG methodology,1602.88,,,1602.88,Other,100% Medicaid APG methodology,3606.49,,,3606.49,Other,225% Medicaid APG methodology,3606.49,,,3606.49,Other,225% Medicaid APG methodology,2452.41,,,2452.41,Other,153% Medicaid APG methodology,3606.49,,,3606.49,Other,225% Medicaid APG methodology,2244.04,,,2244.04,Other,140% Medicaid APG methodology,3606.49,,,3606.49,Other,225% Medicaid APG methodology,4167.5,,,4167.5,Other,260% Medicaid APG methodology,5193.34,,,5193.34,Other,324% Medicaid APG methodology,3446.2,,,3446.2,Other,215% Medicaid APG methodology,3446.2,,,3446.2,Other,215% Medicaid APG methodology,2003.6,,,2003.6,Other,125% Medicaid APG methodology,0.01,7042,
MATERNITY CARE PROCEDURE        ,59899,CPT,,50037985,CDM,450,RC,,,both,,,1237,378.94,,,378.94,Other,150% of Medicare + 9.63% HCRA Surcharge,230.43,,,230.43,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1560.74,,,1560.74,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,865.9,70,,865.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,839.11,,,839.11,Other,New York Medicaid APG methodology,839.11,,,839.11,Other,100% Medicaid APG methodology,839.11,,,839.11,Other,100% Medicaid APG methodology,839.11,,,839.11,Other,100% Medicaid APG methodology,1888,,,1888,Other,225% Medicaid APG methodology,1888,,,1888,Other,225% Medicaid APG methodology,1283.84,,,1283.84,Other,153% Medicaid APG methodology,1888,,,1888,Other,225% Medicaid APG methodology,1174.75,,,1174.75,Other,140% Medicaid APG methodology,1888,,,1888,Other,225% Medicaid APG methodology,2181.69,,,2181.69,Other,260% Medicaid APG methodology,2718.72,,,2718.72,Other,324% Medicaid APG methodology,1804.09,,,1804.09,Other,215% Medicaid APG methodology,1804.09,,,1804.09,Other,215% Medicaid APG methodology,1048.89,,,1048.89,Other,125% Medicaid APG methodology,0.01,2718.72,
ASPIR/INJ THYROID CYST          ,60300,CPT,,50038009,CDM,450,RC,,,both,,,2187,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1296.67,,,1296.67,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1530.9,70,,1530.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,697.14,,,697.14,Other,New York Medicaid APG methodology,697.14,,,697.14,Other,100% Medicaid APG methodology,697.14,,,697.14,Other,100% Medicaid APG methodology,697.14,,,697.14,Other,100% Medicaid APG methodology,1568.56,,,1568.56,Other,225% Medicaid APG methodology,1568.56,,,1568.56,Other,225% Medicaid APG methodology,1066.62,,,1066.62,Other,153% Medicaid APG methodology,1568.56,,,1568.56,Other,225% Medicaid APG methodology,975.99,,,975.99,Other,140% Medicaid APG methodology,1568.56,,,1568.56,Other,225% Medicaid APG methodology,1812.56,,,1812.56,Other,260% Medicaid APG methodology,2258.72,,,2258.72,Other,324% Medicaid APG methodology,1498.84,,,1498.84,Other,215% Medicaid APG methodology,1498.84,,,1498.84,Other,215% Medicaid APG methodology,871.42,,,871.42,Other,125% Medicaid APG methodology,0.01,2258.72,
REMOVE BRAIN CAVITY FLUID       ,61020,CPT,,50038207,CDM,450,RC,,,both,,,3032,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1403.21,,,1403.21,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2122.4,70,,2122.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,754.41,,,754.41,Other,New York Medicaid APG methodology,754.41,,,754.41,Other,100% Medicaid APG methodology,754.41,,,754.41,Other,100% Medicaid APG methodology,754.41,,,754.41,Other,100% Medicaid APG methodology,1697.43,,,1697.43,Other,225% Medicaid APG methodology,1697.43,,,1697.43,Other,225% Medicaid APG methodology,1154.25,,,1154.25,Other,153% Medicaid APG methodology,1697.43,,,1697.43,Other,225% Medicaid APG methodology,1056.18,,,1056.18,Other,140% Medicaid APG methodology,1697.43,,,1697.43,Other,225% Medicaid APG methodology,1961.47,,,1961.47,Other,260% Medicaid APG methodology,2444.29,,,2444.29,Other,324% Medicaid APG methodology,1621.98,,,1621.98,Other,215% Medicaid APG methodology,1621.98,,,1621.98,Other,215% Medicaid APG methodology,943.01,,,943.01,Other,125% Medicaid APG methodology,0.01,2444.29,
INJECT EPIDURAL PATCH           ,62273,CPT,,50038504,CDM,450,RC,,,both,,,2565,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1398.69,,,1398.69,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1795.5,70,,1795.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% Medicaid APG methodology,751.98,,,751.98,Other,100% Medicaid APG methodology,751.98,,,751.98,Other,100% Medicaid APG methodology,1691.96,,,1691.96,Other,225% Medicaid APG methodology,1691.96,,,1691.96,Other,225% Medicaid APG methodology,1150.53,,,1150.53,Other,153% Medicaid APG methodology,1691.96,,,1691.96,Other,225% Medicaid APG methodology,1052.78,,,1052.78,Other,140% Medicaid APG methodology,1691.96,,,1691.96,Other,225% Medicaid APG methodology,1955.15,,,1955.15,Other,260% Medicaid APG methodology,2436.42,,,2436.42,Other,324% Medicaid APG methodology,1616.76,,,1616.76,Other,215% Medicaid APG methodology,1616.76,,,1616.76,Other,215% Medicaid APG methodology,939.98,,,939.98,Other,125% Medicaid APG methodology,0.01,2436.42,
REMOVAL FB FROM EYE EMBD        ,65210,CPT,,50039924,CDM,450,RC,,,both,,,1437,757.69,,,757.69,Other,150% of Medicare + 9.63% HCRA Surcharge,460.76,,,460.76,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,408.99,,,408.99,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1005.9,70,,1005.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,219.89,,,219.89,Other,New York Medicaid APG methodology,219.89,,,219.89,Other,100% Medicaid APG methodology,219.89,,,219.89,Other,100% Medicaid APG methodology,219.89,,,219.89,Other,100% Medicaid APG methodology,494.75,,,494.75,Other,225% Medicaid APG methodology,494.75,,,494.75,Other,225% Medicaid APG methodology,336.43,,,336.43,Other,153% Medicaid APG methodology,494.75,,,494.75,Other,225% Medicaid APG methodology,307.84,,,307.84,Other,140% Medicaid APG methodology,494.75,,,494.75,Other,225% Medicaid APG methodology,571.71,,,571.71,Other,260% Medicaid APG methodology,712.44,,,712.44,Other,324% Medicaid APG methodology,472.76,,,472.76,Other,215% Medicaid APG methodology,472.76,,,472.76,Other,215% Medicaid APG methodology,274.86,,,274.86,Other,125% Medicaid APG methodology,0.01,1005.9,
REMOVAL FB FROM EYE EXT W SLT   ,65222,CPT,,50039932,CDM,450,RC,,,both,,,1066,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,408.99,,,408.99,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,746.2,70,,746.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,219.89,,,219.89,Other,New York Medicaid APG methodology,219.89,,,219.89,Other,100% Medicaid APG methodology,219.89,,,219.89,Other,100% Medicaid APG methodology,219.89,,,219.89,Other,100% Medicaid APG methodology,494.75,,,494.75,Other,225% Medicaid APG methodology,494.75,,,494.75,Other,225% Medicaid APG methodology,336.43,,,336.43,Other,153% Medicaid APG methodology,494.75,,,494.75,Other,225% Medicaid APG methodology,307.84,,,307.84,Other,140% Medicaid APG methodology,494.75,,,494.75,Other,225% Medicaid APG methodology,571.71,,,571.71,Other,260% Medicaid APG methodology,712.44,,,712.44,Other,324% Medicaid APG methodology,472.76,,,472.76,Other,215% Medicaid APG methodology,472.76,,,472.76,Other,215% Medicaid APG methodology,274.86,,,274.86,Other,125% Medicaid APG methodology,0.01,746.2,
REPAIR EYE WOUND W TISS GLUE    ,65286,CPT,,50040021,CDM,450,RC,,,both,,,8355,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,3655.3,,,3655.3,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,5848.5,70,,5848.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1965.22,,,1965.22,Other,New York Medicaid APG methodology,1965.22,,,1965.22,Other,100% Medicaid APG methodology,1965.22,,,1965.22,Other,100% Medicaid APG methodology,1965.22,,,1965.22,Other,100% Medicaid APG methodology,4421.74,,,4421.74,Other,225% Medicaid APG methodology,4421.74,,,4421.74,Other,225% Medicaid APG methodology,3006.78,,,3006.78,Other,153% Medicaid APG methodology,4421.74,,,4421.74,Other,225% Medicaid APG methodology,2751.3,,,2751.3,Other,140% Medicaid APG methodology,4421.74,,,4421.74,Other,225% Medicaid APG methodology,5109.57,,,5109.57,Other,260% Medicaid APG methodology,6367.3,,,6367.3,Other,324% Medicaid APG methodology,4225.22,,,4225.22,Other,215% Medicaid APG methodology,4225.22,,,4225.22,Other,215% Medicaid APG methodology,2456.52,,,2456.52,Other,125% Medicaid APG methodology,0.01,6367.3,
DRAINAGE OF EYE                 ,65800,CPT,,50040161,CDM,450,RC,,,both,,,8355,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,3710.11,,,3710.11,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,5848.5,70,,5848.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% Medicaid APG methodology,1994.68,,,1994.68,Other,100% Medicaid APG methodology,1994.68,,,1994.68,Other,100% Medicaid APG methodology,4488.04,,,4488.04,Other,225% Medicaid APG methodology,4488.04,,,4488.04,Other,225% Medicaid APG methodology,3051.87,,,3051.87,Other,153% Medicaid APG methodology,4488.04,,,4488.04,Other,225% Medicaid APG methodology,2792.56,,,2792.56,Other,140% Medicaid APG methodology,4488.04,,,4488.04,Other,225% Medicaid APG methodology,5186.18,,,5186.18,Other,260% Medicaid APG methodology,6462.78,,,6462.78,Other,324% Medicaid APG methodology,4288.57,,,4288.57,Other,215% Medicaid APG methodology,4288.57,,,4288.57,Other,215% Medicaid APG methodology,2493.36,,,2493.36,Other,125% Medicaid APG methodology,0.01,6462.78,
INJECTION EYE DRUG              ,67028,CPT,,50040526,CDM,450,RC,,,both,,,1419,644.03,,,644.03,Other,150% of Medicare + 9.63% HCRA Surcharge,391.64,,,391.64,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,433.79,,,433.79,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,993.3,70,,993.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,233.22,,,233.22,Other,New York Medicaid APG methodology,233.22,,,233.22,Other,100% Medicaid APG methodology,233.22,,,233.22,Other,100% Medicaid APG methodology,233.22,,,233.22,Other,100% Medicaid APG methodology,524.74,,,524.74,Other,225% Medicaid APG methodology,524.74,,,524.74,Other,225% Medicaid APG methodology,356.83,,,356.83,Other,153% Medicaid APG methodology,524.74,,,524.74,Other,225% Medicaid APG methodology,326.51,,,326.51,Other,140% Medicaid APG methodology,524.74,,,524.74,Other,225% Medicaid APG methodology,606.37,,,606.37,Other,260% Medicaid APG methodology,755.63,,,755.63,Other,324% Medicaid APG methodology,501.42,,,501.42,Other,215% Medicaid APG methodology,501.42,,,501.42,Other,215% Medicaid APG methodology,291.52,,,291.52,Other,125% Medicaid APG methodology,0.01,993.3,
DRAINAGE OF EYELID ABSCESS      ,67700,CPT,,50040880,CDM,450,RC,,,both,,,1278,553.97,,,553.97,Other,150% of Medicare + 9.63% HCRA Surcharge,336.87,,,336.87,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,634.14,,,634.14,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,894.6,70,,894.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,340.93,,,340.93,Other,New York Medicaid APG methodology,340.93,,,340.93,Other,100% Medicaid APG methodology,340.93,,,340.93,Other,100% Medicaid APG methodology,340.93,,,340.93,Other,100% Medicaid APG methodology,767.1,,,767.1,Other,225% Medicaid APG methodology,767.1,,,767.1,Other,225% Medicaid APG methodology,521.63,,,521.63,Other,153% Medicaid APG methodology,767.1,,,767.1,Other,225% Medicaid APG methodology,477.31,,,477.31,Other,140% Medicaid APG methodology,767.1,,,767.1,Other,225% Medicaid APG methodology,886.43,,,886.43,Other,260% Medicaid APG methodology,1104.63,,,1104.63,Other,324% Medicaid APG methodology,733.01,,,733.01,Other,215% Medicaid APG methodology,733.01,,,733.01,Other,215% Medicaid APG methodology,426.17,,,426.17,Other,125% Medicaid APG methodology,0.01,1104.63,
CLOSURE OF EYELID BY SUTURE     ,67875,CPT,,50040963,CDM,450,RC,,,both,,,3102,1925.3,,,1925.3,Other,150% of Medicare + 9.63% HCRA Surcharge,1170.78,,,1170.78,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2759.56,,,2759.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2171.4,70,,2171.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% Medicaid APG methodology,1483.63,,,1483.63,Other,100% Medicaid APG methodology,1483.63,,,1483.63,Other,100% Medicaid APG methodology,3338.18,,,3338.18,Other,225% Medicaid APG methodology,3338.18,,,3338.18,Other,225% Medicaid APG methodology,2269.96,,,2269.96,Other,153% Medicaid APG methodology,3338.18,,,3338.18,Other,225% Medicaid APG methodology,2077.09,,,2077.09,Other,140% Medicaid APG methodology,3338.18,,,3338.18,Other,225% Medicaid APG methodology,3857.45,,,3857.45,Other,260% Medicaid APG methodology,4806.98,,,4806.98,Other,324% Medicaid APG methodology,3189.81,,,3189.81,Other,215% Medicaid APG methodology,3189.81,,,3189.81,Other,215% Medicaid APG methodology,1854.54,,,1854.54,Other,125% Medicaid APG methodology,0.01,4806.98,
TREAT EYELID BY INJECTION       ,68200,CPT,,50041136,CDM,450,RC,,,both,,,1437,757.69,,,757.69,Other,150% of Medicare + 9.63% HCRA Surcharge,460.76,,,460.76,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,408.99,,,408.99,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1005.9,70,,1005.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,219.89,,,219.89,Other,New York Medicaid APG methodology,219.89,,,219.89,Other,100% Medicaid APG methodology,219.89,,,219.89,Other,100% Medicaid APG methodology,219.89,,,219.89,Other,100% Medicaid APG methodology,494.75,,,494.75,Other,225% Medicaid APG methodology,494.75,,,494.75,Other,225% Medicaid APG methodology,336.43,,,336.43,Other,153% Medicaid APG methodology,494.75,,,494.75,Other,225% Medicaid APG methodology,307.84,,,307.84,Other,140% Medicaid APG methodology,494.75,,,494.75,Other,225% Medicaid APG methodology,571.71,,,571.71,Other,260% Medicaid APG methodology,712.44,,,712.44,Other,324% Medicaid APG methodology,472.76,,,472.76,Other,215% Medicaid APG methodology,472.76,,,472.76,Other,215% Medicaid APG methodology,274.86,,,274.86,Other,125% Medicaid APG methodology,0.01,1005.9,
DRAIN EXTERNAL EAR LESION SMPL  ,69000,CPT,,50041318,CDM,450,RC,,,both,,,2589,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,501.18,,,501.18,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1812.3,70,,1812.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,412.26,,,412.26,Other,153% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,377.23,,,377.23,Other,140% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,700.58,,,700.58,Other,260% Medicaid APG methodology,873.03,,,873.03,Other,324% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,336.82,,,336.82,Other,125% Medicaid APG methodology,0.01,1812.3,
DRAIN OUTER EAR CANAL LESION    ,69020,CPT,,50041334,CDM,450,RC,,,both,,,2564,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,501.18,,,501.18,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1794.8,70,,1794.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,412.26,,,412.26,Other,153% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,377.23,,,377.23,Other,140% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,700.58,,,700.58,Other,260% Medicaid APG methodology,873.03,,,873.03,Other,324% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,336.82,,,336.82,Other,125% Medicaid APG methodology,0.01,1794.8,
INTRODUC NEED IN VEIN           ,36000,CPT,,50042084,CDM,450,RC,,,both,,,697,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,104.72,,,104.72,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,487.9,70,,487.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,56.3,,,56.3,Other,New York Medicaid APG methodology,56.3,,,56.3,Other,100% Medicaid APG methodology,56.3,,,56.3,Other,100% Medicaid APG methodology,56.3,,,56.3,Other,100% Medicaid APG methodology,126.68,,,126.68,Other,225% Medicaid APG methodology,126.68,,,126.68,Other,225% Medicaid APG methodology,86.14,,,86.14,Other,153% Medicaid APG methodology,126.68,,,126.68,Other,225% Medicaid APG methodology,78.82,,,78.82,Other,140% Medicaid APG methodology,126.68,,,126.68,Other,225% Medicaid APG methodology,146.38,,,146.38,Other,260% Medicaid APG methodology,182.41,,,182.41,Other,324% Medicaid APG methodology,121.05,,,121.05,Other,215% Medicaid APG methodology,121.05,,,121.05,Other,215% Medicaid APG methodology,70.38,,,70.38,Other,125% Medicaid APG methodology,0.01,487.9,
BLOOD TRANSFUSION SERVICE       ,36430,CPT,,50042159,CDM,450,RC,,,both,,,3124,825.51,,,825.51,Other,150% of Medicare + 9.63% HCRA Surcharge,502,,,502,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1373.44,,,1373.44,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2186.8,70,,2186.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,738.41,,,738.41,Other,New York Medicaid APG methodology,738.41,,,738.41,Other,100% Medicaid APG methodology,738.41,,,738.41,Other,100% Medicaid APG methodology,738.41,,,738.41,Other,100% Medicaid APG methodology,1661.41,,,1661.41,Other,225% Medicaid APG methodology,1661.41,,,1661.41,Other,225% Medicaid APG methodology,1129.76,,,1129.76,Other,153% Medicaid APG methodology,1661.41,,,1661.41,Other,225% Medicaid APG methodology,1033.77,,,1033.77,Other,140% Medicaid APG methodology,1661.41,,,1661.41,Other,225% Medicaid APG methodology,1919.86,,,1919.86,Other,260% Medicaid APG methodology,2392.44,,,2392.44,Other,324% Medicaid APG methodology,1587.57,,,1587.57,Other,215% Medicaid APG methodology,1587.57,,,1587.57,Other,215% Medicaid APG methodology,923.01,,,923.01,Other,125% Medicaid APG methodology,0.01,2392.44,
REPOSITION GASTROSTOMY TUBE     ,43761,CPT,,50042449,CDM,450,RC,,,both,,,943,469.99,,,469.99,Other,150% of Medicare + 9.63% HCRA Surcharge,285.8,,,285.8,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1287.38,,,1287.38,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,660.1,70,,660.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.14,,,692.14,Other,New York Medicaid APG methodology,692.14,,,692.14,Other,100% Medicaid APG methodology,692.14,,,692.14,Other,100% Medicaid APG methodology,692.14,,,692.14,Other,100% Medicaid APG methodology,1557.31,,,1557.31,Other,225% Medicaid APG methodology,1557.31,,,1557.31,Other,225% Medicaid APG methodology,1058.97,,,1058.97,Other,153% Medicaid APG methodology,1557.31,,,1557.31,Other,225% Medicaid APG methodology,968.99,,,968.99,Other,140% Medicaid APG methodology,1557.31,,,1557.31,Other,225% Medicaid APG methodology,1799.56,,,1799.56,Other,260% Medicaid APG methodology,2242.53,,,2242.53,Other,324% Medicaid APG methodology,1488.1,,,1488.1,Other,215% Medicaid APG methodology,1488.1,,,1488.1,Other,215% Medicaid APG methodology,865.17,,,865.17,Other,125% Medicaid APG methodology,0.01,2242.53,
EXCHANGE NEPHROSTOMY CATH       ,50435,CPT,,50042696,CDM,450,RC,,,both,,,11721,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2238.19,,,2238.19,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,8204.7,70,,8204.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1203.33,,,1203.33,Other,New York Medicaid APG methodology,1203.33,,,1203.33,Other,100% Medicaid APG methodology,1203.33,,,1203.33,Other,100% Medicaid APG methodology,1203.33,,,1203.33,Other,100% Medicaid APG methodology,2707.49,,,2707.49,Other,225% Medicaid APG methodology,2707.49,,,2707.49,Other,225% Medicaid APG methodology,1841.09,,,1841.09,Other,153% Medicaid APG methodology,2707.49,,,2707.49,Other,225% Medicaid APG methodology,1684.66,,,1684.66,Other,140% Medicaid APG methodology,2707.49,,,2707.49,Other,225% Medicaid APG methodology,3128.66,,,3128.66,Other,260% Medicaid APG methodology,3898.79,,,3898.79,Other,324% Medicaid APG methodology,2587.16,,,2587.16,Other,215% Medicaid APG methodology,2587.16,,,2587.16,Other,215% Medicaid APG methodology,1504.16,,,1504.16,Other,125% Medicaid APG methodology,0.01,8204.7,
CHANGE OF BLADDER TUBE SMPL     ,51705,CPT,,50042746,CDM,450,RC,,,both,,,1921,469.99,,,469.99,Other,150% of Medicare + 9.63% HCRA Surcharge,285.8,,,285.8,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,824.98,,,824.98,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1344.7,70,,1344.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,443.54,,,443.54,Other,New York Medicaid APG methodology,443.54,,,443.54,Other,100% Medicaid APG methodology,443.54,,,443.54,Other,100% Medicaid APG methodology,443.54,,,443.54,Other,100% Medicaid APG methodology,997.96,,,997.96,Other,225% Medicaid APG methodology,997.96,,,997.96,Other,225% Medicaid APG methodology,678.62,,,678.62,Other,153% Medicaid APG methodology,997.96,,,997.96,Other,225% Medicaid APG methodology,620.96,,,620.96,Other,140% Medicaid APG methodology,997.96,,,997.96,Other,225% Medicaid APG methodology,1153.2,,,1153.2,Other,260% Medicaid APG methodology,1437.07,,,1437.07,Other,324% Medicaid APG methodology,953.61,,,953.61,Other,215% Medicaid APG methodology,953.61,,,953.61,Other,215% Medicaid APG methodology,554.42,,,554.42,Other,125% Medicaid APG methodology,0.01,1437.07,
CYSTOSCOPY                      ,52000,CPT,,50042860,CDM,450,RC,,,both,,,2252,1299.03,,,1299.03,Other,150% of Medicare + 9.63% HCRA Surcharge,789.95,,,789.95,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,3289.6,,,3289.6,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1576.4,70,,1576.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1768.6,,,1768.6,Other,New York Medicaid APG methodology,1768.6,,,1768.6,Other,100% Medicaid APG methodology,1768.6,,,1768.6,Other,100% Medicaid APG methodology,1768.6,,,1768.6,Other,100% Medicaid APG methodology,3979.36,,,3979.36,Other,225% Medicaid APG methodology,3979.36,,,3979.36,Other,225% Medicaid APG methodology,2705.96,,,2705.96,Other,153% Medicaid APG methodology,3979.36,,,3979.36,Other,225% Medicaid APG methodology,2476.04,,,2476.04,Other,140% Medicaid APG methodology,3979.36,,,3979.36,Other,225% Medicaid APG methodology,4598.37,,,4598.37,Other,260% Medicaid APG methodology,5730.27,,,5730.27,Other,324% Medicaid APG methodology,3802.5,,,3802.5,Other,215% Medicaid APG methodology,3802.5,,,3802.5,Other,215% Medicaid APG methodology,2210.75,,,2210.75,Other,125% Medicaid APG methodology,0.01,5730.27,
CYSTOSCOPY & URETER CATHETER    ,52005,CPT,,50042878,CDM,450,RC,,,both,,,6600,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,3677.57,,,3677.57,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,4620,70,,4620,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% Medicaid APG methodology,1977.19,,,1977.19,Other,100% Medicaid APG methodology,1977.19,,,1977.19,Other,100% Medicaid APG methodology,4448.67,,,4448.67,Other,225% Medicaid APG methodology,4448.67,,,4448.67,Other,225% Medicaid APG methodology,3025.1,,,3025.1,Other,153% Medicaid APG methodology,4448.67,,,4448.67,Other,225% Medicaid APG methodology,2768.06,,,2768.06,Other,140% Medicaid APG methodology,4448.67,,,4448.67,Other,225% Medicaid APG methodology,5140.69,,,5140.69,Other,260% Medicaid APG methodology,6406.09,,,6406.09,Other,324% Medicaid APG methodology,4250.96,,,4250.96,Other,215% Medicaid APG methodology,4250.96,,,4250.96,Other,215% Medicaid APG methodology,2471.49,,,2471.49,Other,125% Medicaid APG methodology,0.01,6406.09,
DRAINAGE OF HYDROCELE           ,55000,CPT,,50042969,CDM,450,RC,,,both,,,2335,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1051.03,,,1051.03,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1634.5,70,,1634.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,565.07,,,565.07,Other,New York Medicaid APG methodology,565.07,,,565.07,Other,100% Medicaid APG methodology,565.07,,,565.07,Other,100% Medicaid APG methodology,565.07,,,565.07,Other,100% Medicaid APG methodology,1271.41,,,1271.41,Other,225% Medicaid APG methodology,1271.41,,,1271.41,Other,225% Medicaid APG methodology,864.56,,,864.56,Other,153% Medicaid APG methodology,1271.41,,,1271.41,Other,225% Medicaid APG methodology,791.1,,,791.1,Other,140% Medicaid APG methodology,1271.41,,,1271.41,Other,225% Medicaid APG methodology,1469.19,,,1469.19,Other,260% Medicaid APG methodology,1830.83,,,1830.83,Other,324% Medicaid APG methodology,1214.9,,,1214.9,Other,215% Medicaid APG methodology,1214.9,,,1214.9,Other,215% Medicaid APG methodology,706.34,,,706.34,Other,125% Medicaid APG methodology,0.01,1830.83,
EXAM OF CERVIX W/SCOPE          ,57452,CPT,,50043017,CDM,450,RC,,,both,,,724,378.94,,,378.94,Other,150% of Medicare + 9.63% HCRA Surcharge,230.43,,,230.43,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1419.19,,,1419.19,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,506.8,70,,506.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,763.01,,,763.01,Other,New York Medicaid APG methodology,763.01,,,763.01,Other,100% Medicaid APG methodology,763.01,,,763.01,Other,100% Medicaid APG methodology,763.01,,,763.01,Other,100% Medicaid APG methodology,1716.77,,,1716.77,Other,225% Medicaid APG methodology,1716.77,,,1716.77,Other,225% Medicaid APG methodology,1167.4,,,1167.4,Other,153% Medicaid APG methodology,1716.77,,,1716.77,Other,225% Medicaid APG methodology,1068.21,,,1068.21,Other,140% Medicaid APG methodology,1716.77,,,1716.77,Other,225% Medicaid APG methodology,1983.82,,,1983.82,Other,260% Medicaid APG methodology,2472.14,,,2472.14,Other,324% Medicaid APG methodology,1640.46,,,1640.46,Other,215% Medicaid APG methodology,1640.46,,,1640.46,Other,215% Medicaid APG methodology,953.76,,,953.76,Other,125% Medicaid APG methodology,0.01,2472.14,
REVISION OF IRIS                ,66761,CPT,,50043041,CDM,450,RC,,,both,,,1889,1105.37,,,1105.37,Other,150% of Medicare + 9.63% HCRA Surcharge,672.18,,,672.18,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,3320.14,,,3320.14,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1322.3,70,,1322.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1785.02,,,1785.02,Other,New York Medicaid APG methodology,1785.02,,,1785.02,Other,100% Medicaid APG methodology,1785.02,,,1785.02,Other,100% Medicaid APG methodology,1785.02,,,1785.02,Other,100% Medicaid APG methodology,4016.29,,,4016.29,Other,225% Medicaid APG methodology,4016.29,,,4016.29,Other,225% Medicaid APG methodology,2731.08,,,2731.08,Other,153% Medicaid APG methodology,4016.29,,,4016.29,Other,225% Medicaid APG methodology,2499.03,,,2499.03,Other,140% Medicaid APG methodology,4016.29,,,4016.29,Other,225% Medicaid APG methodology,4641.05,,,4641.05,Other,260% Medicaid APG methodology,5783.46,,,5783.46,Other,324% Medicaid APG methodology,3837.79,,,3837.79,Other,215% Medicaid APG methodology,3837.79,,,3837.79,Other,215% Medicaid APG methodology,2231.27,,,2231.27,Other,125% Medicaid APG methodology,0.01,5783.46,
TX GASTRO INTUB W/ASP           ,43753,CPT,,50053446,CDM,450,RC,,,both,,,345,596.88,,,596.88,Other,150% of Medicare + 9.63% HCRA Surcharge,362.97,,,362.97,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,241.5,70,,241.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,596.88,
TX/PROPH/DG ADDL SEQ IV INF     ,96367,CPT,,50053453,CDM,450,RC,,,both,,,722,133.96,,,133.96,Other,150% of Medicare + 9.63% HCRA Surcharge,81.46,,,81.46,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,577.69,,,577.69,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,505.4,70,,505.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,310.58,,,310.58,Other,New York Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,475.19,,,475.19,Other,153% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,434.82,,,434.82,Other,140% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,807.52,,,807.52,Other,260% Medicaid APG methodology,1006.29,,,1006.29,Other,324% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,388.23,,,388.23,Other,125% Medicaid APG methodology,0.01,1006.29,
THER/PROPH/DIAG INJ IA          ,96373,CPT,,50053701,CDM,450,RC,,,both,,,1005,407.6,,,407.6,Other,150% of Medicare + 9.63% HCRA Surcharge,247.86,,,247.86,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,116.47,,,116.47,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,703.5,70,,703.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,62.62,,,62.62,Other,New York Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,95.8,,,95.8,Other,153% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,87.66,,,87.66,Other,140% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,162.81,,,162.81,Other,260% Medicaid APG methodology,202.88,,,202.88,Other,324% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,78.27,,,78.27,Other,125% Medicaid APG methodology,0.01,703.5,
APPLY FINGER CAST               ,29086,CPT,,50053768,CDM,450,RC,,,both,,,570,299.64,,,299.64,Other,150% of Medicare + 9.63% HCRA Surcharge,182.21,,,182.21,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,834.08,,,834.08,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,399,70,,399,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% Medicaid APG methodology,448.43,,,448.43,Other,100% Medicaid APG methodology,448.43,,,448.43,Other,100% Medicaid APG methodology,1008.97,,,1008.97,Other,225% Medicaid APG methodology,1008.97,,,1008.97,Other,225% Medicaid APG methodology,686.1,,,686.1,Other,153% Medicaid APG methodology,1008.97,,,1008.97,Other,225% Medicaid APG methodology,627.81,,,627.81,Other,140% Medicaid APG methodology,1008.97,,,1008.97,Other,225% Medicaid APG methodology,1165.92,,,1165.92,Other,260% Medicaid APG methodology,1452.92,,,1452.92,Other,324% Medicaid APG methodology,964.13,,,964.13,Other,215% Medicaid APG methodology,964.13,,,964.13,Other,215% Medicaid APG methodology,560.54,,,560.54,Other,125% Medicaid APG methodology,0.01,1452.92,
HEART/LUNG RESUSCITATION CPR    ,92950,CPT,,50053784,CDM,450,RC,,,both,,,9801,596.88,,,596.88,Other,150% of Medicare + 9.63% HCRA Surcharge,362.97,,,362.97,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1189.48,,,1189.48,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,6860.7,70,,6860.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,639.51,,,639.51,Other,New York Medicaid APG methodology,639.51,,,639.51,Other,100% Medicaid APG methodology,639.51,,,639.51,Other,100% Medicaid APG methodology,639.51,,,639.51,Other,100% Medicaid APG methodology,1438.89,,,1438.89,Other,225% Medicaid APG methodology,1438.89,,,1438.89,Other,225% Medicaid APG methodology,978.45,,,978.45,Other,153% Medicaid APG methodology,1438.89,,,1438.89,Other,225% Medicaid APG methodology,895.31,,,895.31,Other,140% Medicaid APG methodology,1438.89,,,1438.89,Other,225% Medicaid APG methodology,1662.72,,,1662.72,Other,260% Medicaid APG methodology,2072,,,2072,Other,324% Medicaid APG methodology,1374.94,,,1374.94,Other,215% Medicaid APG methodology,1374.94,,,1374.94,Other,215% Medicaid APG methodology,799.38,,,799.38,Other,125% Medicaid APG methodology,0.01,6860.7,
CRITICAL CARE ADDL 30 MIN       ,99292,CPT,,50053818,CDM,450,RC,,,both,,,919,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,643.3,70,,643.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,643.3,
INJ TRIGGER POINT 1/2 MUSCL     ,20552,CPT,,50053842,CDM,450,RC,,,both,,,5335,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,841.15,,,841.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3734.5,70,,3734.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,452.23,,,452.23,Other,New York Medicaid APG methodology,452.23,,,452.23,Other,100% Medicaid APG methodology,452.23,,,452.23,Other,100% Medicaid APG methodology,452.23,,,452.23,Other,100% Medicaid APG methodology,1017.52,,,1017.52,Other,225% Medicaid APG methodology,1017.52,,,1017.52,Other,225% Medicaid APG methodology,691.91,,,691.91,Other,153% Medicaid APG methodology,1017.52,,,1017.52,Other,225% Medicaid APG methodology,633.12,,,633.12,Other,140% Medicaid APG methodology,1017.52,,,1017.52,Other,225% Medicaid APG methodology,1175.8,,,1175.8,Other,260% Medicaid APG methodology,1465.23,,,1465.23,Other,324% Medicaid APG methodology,972.3,,,972.3,Other,215% Medicaid APG methodology,972.3,,,972.3,Other,215% Medicaid APG methodology,565.29,,,565.29,Other,125% Medicaid APG methodology,0.01,3734.5,
OPEN CHEST HEART MASSAGE        ,32160,CPT,CA       ,50053867,CDM,450,RC,,,both,,,4562,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,4710.85,,,4710.85,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3193.4,70,,3193.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,2532.72,,,2532.72,Other,New York Medicaid APG methodology,2532.72,,,2532.72,Other,100% Medicaid APG methodology,2532.72,,,2532.72,Other,100% Medicaid APG methodology,2532.72,,,2532.72,Other,100% Medicaid APG methodology,5698.61,,,5698.61,Other,225% Medicaid APG methodology,5698.61,,,5698.61,Other,225% Medicaid APG methodology,3875.06,,,3875.06,Other,153% Medicaid APG methodology,5698.61,,,5698.61,Other,225% Medicaid APG methodology,3545.8,,,3545.8,Other,140% Medicaid APG methodology,5698.61,,,5698.61,Other,225% Medicaid APG methodology,6585.06,,,6585.06,Other,260% Medicaid APG methodology,8206,,,8206,Other,324% Medicaid APG methodology,5445.34,,,5445.34,Other,215% Medicaid APG methodology,5445.34,,,5445.34,Other,215% Medicaid APG methodology,3165.9,,,3165.9,Other,125% Medicaid APG methodology,0.01,8206,
TX/PRO/DX INJ NEW DRUG ADDON    ,96375,CPT,,50053909,CDM,450,RC,,,both,,,742,90.33,,,90.33,Other,150% of Medicare + 9.63% HCRA Surcharge,54.93,,,54.93,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,116.47,,,116.47,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,519.4,70,,519.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,62.62,,,62.62,Other,New York Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,95.8,,,95.8,Other,153% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,87.66,,,87.66,Other,140% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,162.81,,,162.81,Other,260% Medicaid APG methodology,202.88,,,202.88,Other,324% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,78.27,,,78.27,Other,125% Medicaid APG methodology,0.01,519.4,
REPLANTATION DIGIT COMPLETE     ,20822,CPT,,50053958,CDM,450,RC,,,both,,,5309,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,4684.96,,,4684.96,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3716.3,70,,3716.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% Medicaid APG methodology,2518.8,,,2518.8,Other,100% Medicaid APG methodology,2518.8,,,2518.8,Other,100% Medicaid APG methodology,5667.29,,,5667.29,Other,225% Medicaid APG methodology,5667.29,,,5667.29,Other,225% Medicaid APG methodology,3853.76,,,3853.76,Other,153% Medicaid APG methodology,5667.29,,,5667.29,Other,225% Medicaid APG methodology,3526.31,,,3526.31,Other,140% Medicaid APG methodology,5667.29,,,5667.29,Other,225% Medicaid APG methodology,6548.87,,,6548.87,Other,260% Medicaid APG methodology,8160.9,,,8160.9,Other,324% Medicaid APG methodology,5415.41,,,5415.41,Other,215% Medicaid APG methodology,5415.41,,,5415.41,Other,215% Medicaid APG methodology,3148.49,,,3148.49,Other,125% Medicaid APG methodology,0.01,8160.9,
DECLOT VASCULAR DEVICE          ,36593,CPT,,50053966,CDM,450,RC,,,both,,,1198,644.03,,,644.03,Other,150% of Medicare + 9.63% HCRA Surcharge,391.64,,,391.64,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,577.69,,,577.69,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,838.6,70,,838.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,310.58,,,310.58,Other,New York Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,475.19,,,475.19,Other,153% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,434.82,,,434.82,Other,140% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,807.52,,,807.52,Other,260% Medicaid APG methodology,1006.29,,,1006.29,Other,324% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,388.23,,,388.23,Other,125% Medicaid APG methodology,0.01,1006.29,
NASAL/OROGASTRIC W/TUBE PLMT    ,43752,CPT,,50053974,CDM,450,RC,,,both,,,1437,757.69,,,757.69,Other,150% of Medicare + 9.63% HCRA Surcharge,460.76,,,460.76,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1287.38,,,1287.38,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1005.9,70,,1005.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.14,,,692.14,Other,New York Medicaid APG methodology,692.14,,,692.14,Other,100% Medicaid APG methodology,692.14,,,692.14,Other,100% Medicaid APG methodology,692.14,,,692.14,Other,100% Medicaid APG methodology,1557.31,,,1557.31,Other,225% Medicaid APG methodology,1557.31,,,1557.31,Other,225% Medicaid APG methodology,1058.97,,,1058.97,Other,153% Medicaid APG methodology,1557.31,,,1557.31,Other,225% Medicaid APG methodology,968.99,,,968.99,Other,140% Medicaid APG methodology,1557.31,,,1557.31,Other,225% Medicaid APG methodology,1799.56,,,1799.56,Other,260% Medicaid APG methodology,2242.53,,,2242.53,Other,324% Medicaid APG methodology,1488.1,,,1488.1,Other,215% Medicaid APG methodology,1488.1,,,1488.1,Other,215% Medicaid APG methodology,865.17,,,865.17,Other,125% Medicaid APG methodology,0.01,2242.53,
INSERT TEMP BLADDER CATH        ,51702,CPT,,50053982,CDM,450,RC,,,both,,,578,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,824.98,,,824.98,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,404.6,70,,404.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,443.54,,,443.54,Other,New York Medicaid APG methodology,443.54,,,443.54,Other,100% Medicaid APG methodology,443.54,,,443.54,Other,100% Medicaid APG methodology,443.54,,,443.54,Other,100% Medicaid APG methodology,997.96,,,997.96,Other,225% Medicaid APG methodology,997.96,,,997.96,Other,225% Medicaid APG methodology,678.62,,,678.62,Other,153% Medicaid APG methodology,997.96,,,997.96,Other,225% Medicaid APG methodology,620.96,,,620.96,Other,140% Medicaid APG methodology,997.96,,,997.96,Other,225% Medicaid APG methodology,1153.2,,,1153.2,Other,260% Medicaid APG methodology,1437.07,,,1437.07,Other,324% Medicaid APG methodology,953.61,,,953.61,Other,215% Medicaid APG methodology,953.61,,,953.61,Other,215% Medicaid APG methodology,554.42,,,554.42,Other,125% Medicaid APG methodology,0.01,1437.07,
FNA BX W/O IMG GDN 1ST LES      ,10021,CPT,,50054071,CDM,450,RC,,,both,,,3879,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1296.67,,,1296.67,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2715.3,70,,2715.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,697.14,,,697.14,Other,New York Medicaid APG methodology,697.14,,,697.14,Other,100% Medicaid APG methodology,697.14,,,697.14,Other,100% Medicaid APG methodology,697.14,,,697.14,Other,100% Medicaid APG methodology,1568.56,,,1568.56,Other,225% Medicaid APG methodology,1568.56,,,1568.56,Other,225% Medicaid APG methodology,1066.62,,,1066.62,Other,153% Medicaid APG methodology,1568.56,,,1568.56,Other,225% Medicaid APG methodology,975.99,,,975.99,Other,140% Medicaid APG methodology,1568.56,,,1568.56,Other,225% Medicaid APG methodology,1812.56,,,1812.56,Other,260% Medicaid APG methodology,2258.72,,,2258.72,Other,324% Medicaid APG methodology,1498.84,,,1498.84,Other,215% Medicaid APG methodology,1498.84,,,1498.84,Other,215% Medicaid APG methodology,871.42,,,871.42,Other,125% Medicaid APG methodology,0.01,2715.3,
THER/PROPH/DIAG INJ SC/IM       ,96372,CPT,,50054188,CDM,450,RC,,,both,,,725,133.96,,,133.96,Other,150% of Medicare + 9.63% HCRA Surcharge,81.46,,,81.46,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,116.47,,,116.47,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,507.5,70,,507.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,62.62,,,62.62,Other,New York Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,95.8,,,95.8,Other,153% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,87.66,,,87.66,Other,140% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,162.81,,,162.81,Other,260% Medicaid APG methodology,202.88,,,202.88,Other,324% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,78.27,,,78.27,Other,125% Medicaid APG methodology,0.01,507.5,
HYDRATION IV INFUSION INIT      ,96360,CPT,,50054196,CDM,450,RC,,,both,,,1946,407.6,,,407.6,Other,150% of Medicare + 9.63% HCRA Surcharge,247.86,,,247.86,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,577.69,,,577.69,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1362.2,70,,1362.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,310.58,,,310.58,Other,New York Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,475.19,,,475.19,Other,153% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,434.82,,,434.82,Other,140% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,807.52,,,807.52,Other,260% Medicaid APG methodology,1006.29,,,1006.29,Other,324% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,388.23,,,388.23,Other,125% Medicaid APG methodology,0.01,1362.2,
HYDRATE IV INFUSION ADD-ON      ,96361,CPT,,50054212,CDM,450,RC,,,both,,,465,90.33,,,90.33,Other,150% of Medicare + 9.63% HCRA Surcharge,54.93,,,54.93,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1474.51,,,1474.51,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,325.5,70,,325.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,792.75,,,792.75,Other,New York Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1212.91,,,1212.91,Other,153% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1109.85,,,1109.85,Other,140% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,2061.15,,,2061.15,Other,260% Medicaid APG methodology,2568.51,,,2568.51,Other,324% Medicaid APG methodology,1704.41,,,1704.41,Other,215% Medicaid APG methodology,1704.41,,,1704.41,Other,215% Medicaid APG methodology,990.94,,,990.94,Other,125% Medicaid APG methodology,0.01,2568.51,
NASOPHARYNGOSCOPY               ,92511,CPT,,50054253,CDM,450,RC,,,both,,,733,376.68,,,376.68,Other,150% of Medicare + 9.63% HCRA Surcharge,229.06,,,229.06,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,309.03,,,309.03,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,513.1,70,,513.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,166.14,,,166.14,Other,New York Medicaid APG methodology,166.14,,,166.14,Other,100% Medicaid APG methodology,166.14,,,166.14,Other,100% Medicaid APG methodology,166.14,,,166.14,Other,100% Medicaid APG methodology,373.83,,,373.83,Other,225% Medicaid APG methodology,373.83,,,373.83,Other,225% Medicaid APG methodology,254.2,,,254.2,Other,153% Medicaid APG methodology,373.83,,,373.83,Other,225% Medicaid APG methodology,232.6,,,232.6,Other,140% Medicaid APG methodology,373.83,,,373.83,Other,225% Medicaid APG methodology,431.98,,,431.98,Other,260% Medicaid APG methodology,538.31,,,538.31,Other,324% Medicaid APG methodology,357.21,,,357.21,Other,215% Medicaid APG methodology,357.21,,,357.21,Other,215% Medicaid APG methodology,207.68,,,207.68,Other,125% Medicaid APG methodology,0.01,538.31,
STRAPPING OF SHOULDER           ,29240,CPT,,50054303,CDM,450,RC,,,both,,,966,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,465.59,,,465.59,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,676.2,70,,676.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,250.32,,,250.32,Other,New York Medicaid APG methodology,250.32,,,250.32,Other,100% Medicaid APG methodology,250.32,,,250.32,Other,100% Medicaid APG methodology,250.32,,,250.32,Other,100% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,382.99,,,382.99,Other,153% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,350.45,,,350.45,Other,140% Medicaid APG methodology,563.22,,,563.22,Other,225% Medicaid APG methodology,650.83,,,650.83,Other,260% Medicaid APG methodology,811.03,,,811.03,Other,324% Medicaid APG methodology,538.19,,,538.19,Other,215% Medicaid APG methodology,538.19,,,538.19,Other,215% Medicaid APG methodology,312.9,,,312.9,Other,125% Medicaid APG methodology,0.01,811.03,
INSERT BLADDER CATHETER         ,51701,CPT,,50054311,CDM,450,RC,,,both,,,625,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,824.98,,,824.98,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,437.5,70,,437.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,443.54,,,443.54,Other,New York Medicaid APG methodology,443.54,,,443.54,Other,100% Medicaid APG methodology,443.54,,,443.54,Other,100% Medicaid APG methodology,443.54,,,443.54,Other,100% Medicaid APG methodology,997.96,,,997.96,Other,225% Medicaid APG methodology,997.96,,,997.96,Other,225% Medicaid APG methodology,678.62,,,678.62,Other,153% Medicaid APG methodology,997.96,,,997.96,Other,225% Medicaid APG methodology,620.96,,,620.96,Other,140% Medicaid APG methodology,997.96,,,997.96,Other,225% Medicaid APG methodology,1153.2,,,1153.2,Other,260% Medicaid APG methodology,1437.07,,,1437.07,Other,324% Medicaid APG methodology,953.61,,,953.61,Other,215% Medicaid APG methodology,953.61,,,953.61,Other,215% Medicaid APG methodology,554.42,,,554.42,Other,125% Medicaid APG methodology,0.01,1437.07,
REPAIR CVA CATHETER             ,36575,CPT,,50054345,CDM,450,RC,,,both,,,2128,1194.63,,,1194.63,Other,150% of Medicare + 9.63% HCRA Surcharge,726.46,,,726.46,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1968.77,,,1968.77,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1489.6,70,,1489.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1058.48,,,1058.48,Other,New York Medicaid APG methodology,1058.48,,,1058.48,Other,100% Medicaid APG methodology,1058.48,,,1058.48,Other,100% Medicaid APG methodology,1058.48,,,1058.48,Other,100% Medicaid APG methodology,2381.58,,,2381.58,Other,225% Medicaid APG methodology,2381.58,,,2381.58,Other,225% Medicaid APG methodology,1619.47,,,1619.47,Other,153% Medicaid APG methodology,2381.58,,,2381.58,Other,225% Medicaid APG methodology,1481.87,,,1481.87,Other,140% Medicaid APG methodology,2381.58,,,2381.58,Other,225% Medicaid APG methodology,2752.04,,,2752.04,Other,260% Medicaid APG methodology,3429.47,,,3429.47,Other,324% Medicaid APG methodology,2275.73,,,2275.73,Other,215% Medicaid APG methodology,2275.73,,,2275.73,Other,215% Medicaid APG methodology,1323.1,,,1323.1,Other,125% Medicaid APG methodology,0.01,3429.47,
IMMUNIZATION ADMIN EACH ADD     ,90472,CPT,,50054352,CDM,450,RC,,,both,,,140,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,71.04,,,71.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,98,70,,98,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,38.19,,,38.19,Other,New York Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,58.44,,,58.44,Other,153% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,53.47,,,53.47,Other,140% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,99.3,,,99.3,Other,260% Medicaid APG methodology,123.75,,,123.75,Other,324% Medicaid APG methodology,82.12,,,82.12,Other,215% Medicaid APG methodology,82.12,,,82.12,Other,215% Medicaid APG methodology,47.74,,,47.74,Other,125% Medicaid APG methodology,0.01,123.75,
REMOVAL TUNNELED CV CATH        ,36589,CPT,,50054394,CDM,450,RC,,,both,,,3047,1194.63,,,1194.63,Other,150% of Medicare + 9.63% HCRA Surcharge,726.46,,,726.46,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1686.14,,,1686.14,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2132.9,70,,2132.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,906.53,,,906.53,Other,New York Medicaid APG methodology,906.53,,,906.53,Other,100% Medicaid APG methodology,906.53,,,906.53,Other,100% Medicaid APG methodology,906.53,,,906.53,Other,100% Medicaid APG methodology,2039.69,,,2039.69,Other,225% Medicaid APG methodology,2039.69,,,2039.69,Other,225% Medicaid APG methodology,1386.99,,,1386.99,Other,153% Medicaid APG methodology,2039.69,,,2039.69,Other,225% Medicaid APG methodology,1269.14,,,1269.14,Other,140% Medicaid APG methodology,2039.69,,,2039.69,Other,225% Medicaid APG methodology,2356.97,,,2356.97,Other,260% Medicaid APG methodology,2937.15,,,2937.15,Other,324% Medicaid APG methodology,1949.04,,,1949.04,Other,215% Medicaid APG methodology,1949.04,,,1949.04,Other,215% Medicaid APG methodology,1133.16,,,1133.16,Other,125% Medicaid APG methodology,0.01,2937.15,
INSERT NON-TUNNEL CV CATH <5Y   ,36555,CPT,,50054444,CDM,450,RC,,,both,,,10599,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,713.01,,,713.01,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,7419.3,70,,7419.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,383.34,,,383.34,Other,New York Medicaid APG methodology,383.34,,,383.34,Other,100% Medicaid APG methodology,383.34,,,383.34,Other,100% Medicaid APG methodology,383.34,,,383.34,Other,100% Medicaid APG methodology,862.51,,,862.51,Other,225% Medicaid APG methodology,862.51,,,862.51,Other,225% Medicaid APG methodology,586.51,,,586.51,Other,153% Medicaid APG methodology,862.51,,,862.51,Other,225% Medicaid APG methodology,536.67,,,536.67,Other,140% Medicaid APG methodology,862.51,,,862.51,Other,225% Medicaid APG methodology,996.68,,,996.68,Other,260% Medicaid APG methodology,1242.01,,,1242.01,Other,324% Medicaid APG methodology,824.17,,,824.17,Other,215% Medicaid APG methodology,824.17,,,824.17,Other,215% Medicaid APG methodology,479.17,,,479.17,Other,125% Medicaid APG methodology,0.01,7419.3,
INSERT NON-TUNNEL CV CATH 5+Y   ,36556,CPT,,50054451,CDM,450,RC,,,both,,,8005,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,713.01,,,713.01,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,5603.5,70,,5603.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,383.34,,,383.34,Other,New York Medicaid APG methodology,383.34,,,383.34,Other,100% Medicaid APG methodology,383.34,,,383.34,Other,100% Medicaid APG methodology,383.34,,,383.34,Other,100% Medicaid APG methodology,862.51,,,862.51,Other,225% Medicaid APG methodology,862.51,,,862.51,Other,225% Medicaid APG methodology,586.51,,,586.51,Other,153% Medicaid APG methodology,862.51,,,862.51,Other,225% Medicaid APG methodology,536.67,,,536.67,Other,140% Medicaid APG methodology,862.51,,,862.51,Other,225% Medicaid APG methodology,996.68,,,996.68,Other,260% Medicaid APG methodology,1242.01,,,1242.01,Other,324% Medicaid APG methodology,824.17,,,824.17,Other,215% Medicaid APG methodology,824.17,,,824.17,Other,215% Medicaid APG methodology,479.17,,,479.17,Other,125% Medicaid APG methodology,0.01,6061.47,
RH IG FULL-DOSE IM              ,90384,CPT,,50054469,CDM,450,RC,,,both,,,658,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,247.65,,,247.65,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,460.6,70,,460.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,133.14,,,133.14,Other,New York Medicaid APG methodology,133.14,,,133.14,Other,100% Medicaid APG methodology,133.14,,,133.14,Other,100% Medicaid APG methodology,133.14,,,133.14,Other,100% Medicaid APG methodology,299.57,,,299.57,Other,225% Medicaid APG methodology,299.57,,,299.57,Other,225% Medicaid APG methodology,203.71,,,203.71,Other,153% Medicaid APG methodology,299.57,,,299.57,Other,225% Medicaid APG methodology,186.4,,,186.4,Other,140% Medicaid APG methodology,299.57,,,299.57,Other,225% Medicaid APG methodology,346.17,,,346.17,Other,260% Medicaid APG methodology,431.38,,,431.38,Other,324% Medicaid APG methodology,286.26,,,286.26,Other,215% Medicaid APG methodology,286.26,,,286.26,Other,215% Medicaid APG methodology,166.43,,,166.43,Other,125% Medicaid APG methodology,0.01,460.6,
CL TX LEFORT I  FX; W ID W FIX  ,21421,CPT,,50054956,CDM,450,RC,,,both,,,10122,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,5647.23,,,5647.23,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,7085.4,70,,7085.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% Medicaid APG methodology,3036.14,,,3036.14,Other,100% Medicaid APG methodology,3036.14,,,3036.14,Other,100% Medicaid APG methodology,6831.33,,,6831.33,Other,225% Medicaid APG methodology,6831.33,,,6831.33,Other,225% Medicaid APG methodology,4645.3,,,4645.3,Other,153% Medicaid APG methodology,6831.33,,,6831.33,Other,225% Medicaid APG methodology,4250.6,,,4250.6,Other,140% Medicaid APG methodology,6831.33,,,6831.33,Other,225% Medicaid APG methodology,7893.98,,,7893.98,Other,260% Medicaid APG methodology,9837.11,,,9837.11,Other,324% Medicaid APG methodology,6527.71,,,6527.71,Other,215% Medicaid APG methodology,6527.71,,,6527.71,Other,215% Medicaid APG methodology,3795.18,,,3795.18,Other,125% Medicaid APG methodology,0.01,9837.11,
NASAL ENDOSCOPY DX              ,31231,CPT,,50054972,CDM,450,RC,,,both,,,733,376.68,,,376.68,Other,150% of Medicare + 9.63% HCRA Surcharge,229.06,,,229.06,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,501.18,,,501.18,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,513.1,70,,513.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,269.45,,,269.45,Other,100% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,412.26,,,412.26,Other,153% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,377.23,,,377.23,Other,140% Medicaid APG methodology,606.27,,,606.27,Other,225% Medicaid APG methodology,700.58,,,700.58,Other,260% Medicaid APG methodology,873.03,,,873.03,Other,324% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,579.32,,,579.32,Other,215% Medicaid APG methodology,336.82,,,336.82,Other,125% Medicaid APG methodology,0.01,873.03,
CRITICAL CARE FIRST HOUR        ,99291,CPT,,50055060,CDM,450,RC,,,both,,,11013,1687.47,,,1687.47,Other,150% of Medicare + 9.63% HCRA Surcharge,1026.16,,,1026.16,Other,Medicare OPPS methodology,2672,,,2672,Case Rate,ED Visit,2405,,,2405,Case Rate,ED Visit,5633,,,5633,Case Rate,ED Visit,5070,,,5070,Case Rate,ED Visit,4788,,,4788,Case Rate,ED Visit,2414,,,2414,Case Rate,ED Visit,3566,,,3566,Case Rate,ED Visit,1754,,,1754,Case Rate,ED Visit,0.02,,,0.02,Other,186% Medicaid methodology,2064,,,2064,Case Rate,ED Visit,2160,,,2160,Case Rate,ED Visit,2160,,,2160,Case Rate,ED Visit,2064,,,2064,Case Rate,ED Visit,2160,,,2160,Case Rate,ED Visit,2166,,,2166,Case Rate,ED Visit,7709.1,70,,7709.1,percent of total billed charges,All Other,2631,,,2631,Case Rate,ED Visit,2236,,,2236,Case Rate,ED Visit,1501,,,1501,Case Rate,ED Visit,1416,,,1416,Case Rate,ED Visit,1573,,,1573,Case Rate,ED Visit,1338,,,1338,Case Rate,ED Visit,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,7709.1,
TX/PRO/DX INJ SAME DRUG ADON    ,96376,CPT,,50055086,CDM,450,RC,,,both,,,742,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,116.47,,,116.47,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,519.4,70,,519.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,62.62,,,62.62,Other,New York Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,95.8,,,95.8,Other,153% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,87.66,,,87.66,Other,140% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,162.81,,,162.81,Other,260% Medicaid APG methodology,202.88,,,202.88,Other,324% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,78.27,,,78.27,Other,125% Medicaid APG methodology,0.01,519.4,
INSERT BLADDER CATH COMPLEX     ,51703,CPT,,50055235,CDM,450,RC,,,both,,,664,297.05,,,297.05,Other,150% of Medicare + 9.63% HCRA Surcharge,180.63,,,180.63,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1051.03,,,1051.03,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,464.8,70,,464.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,565.07,,,565.07,Other,New York Medicaid APG methodology,565.07,,,565.07,Other,100% Medicaid APG methodology,565.07,,,565.07,Other,100% Medicaid APG methodology,565.07,,,565.07,Other,100% Medicaid APG methodology,1271.41,,,1271.41,Other,225% Medicaid APG methodology,1271.41,,,1271.41,Other,225% Medicaid APG methodology,864.56,,,864.56,Other,153% Medicaid APG methodology,1271.41,,,1271.41,Other,225% Medicaid APG methodology,791.1,,,791.1,Other,140% Medicaid APG methodology,1271.41,,,1271.41,Other,225% Medicaid APG methodology,1469.19,,,1469.19,Other,260% Medicaid APG methodology,1830.83,,,1830.83,Other,324% Medicaid APG methodology,1214.9,,,1214.9,Other,215% Medicaid APG methodology,1214.9,,,1214.9,Other,215% Medicaid APG methodology,706.34,,,706.34,Other,125% Medicaid APG methodology,0.01,1830.83,
INSERT TUNNELED CV CATH 5+Y     ,36558,CPT,,50055276,CDM,450,RC,,,both,,,14148,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,3177.13,,,3177.13,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,9903.6,70,,9903.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1708.14,,,1708.14,Other,New York Medicaid APG methodology,1708.14,,,1708.14,Other,100% Medicaid APG methodology,1708.14,,,1708.14,Other,100% Medicaid APG methodology,1708.14,,,1708.14,Other,100% Medicaid APG methodology,3843.31,,,3843.31,Other,225% Medicaid APG methodology,3843.31,,,3843.31,Other,225% Medicaid APG methodology,2613.45,,,2613.45,Other,153% Medicaid APG methodology,3843.31,,,3843.31,Other,225% Medicaid APG methodology,2391.39,,,2391.39,Other,140% Medicaid APG methodology,3843.31,,,3843.31,Other,225% Medicaid APG methodology,4441.15,,,4441.15,Other,260% Medicaid APG methodology,5534.36,,,5534.36,Other,324% Medicaid APG methodology,3672.49,,,3672.49,Other,215% Medicaid APG methodology,3672.49,,,3672.49,Other,215% Medicaid APG methodology,2135.17,,,2135.17,Other,125% Medicaid APG methodology,0.01,9903.6,
CMPLX RPR TRUNK ADDL 5CM/<      ,13102,CPT,,50055391,CDM,450,RC,,,both,,,1846,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1559.83,,,1559.83,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1292.2,70,,1292.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1283.09,,,1283.09,Other,153% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1174.07,,,1174.07,Other,140% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,2180.41,,,2180.41,Other,260% Medicaid APG methodology,2717.12,,,2717.12,Other,324% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1048.27,,,1048.27,Other,125% Medicaid APG methodology,0.01,2717.12,
CMPLX RPR S/A/L 1.1-2.5 CM      ,13120,CPT,,50055409,CDM,450,RC,,,both,,,2455,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1559.83,,,1559.83,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1718.5,70,,1718.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1283.09,,,1283.09,Other,153% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1174.07,,,1174.07,Other,140% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,2180.41,,,2180.41,Other,260% Medicaid APG methodology,2717.12,,,2717.12,Other,324% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1048.27,,,1048.27,Other,125% Medicaid APG methodology,0.01,2717.12,
CMPLX RPR F/C/C/M/N/AX/G/H/F    ,13133,CPT,,50055417,CDM,450,RC,,,both,,,4873,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1559.83,,,1559.83,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3411.1,70,,3411.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1283.09,,,1283.09,Other,153% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1174.07,,,1174.07,Other,140% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,2180.41,,,2180.41,Other,260% Medicaid APG methodology,2717.12,,,2717.12,Other,324% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1048.27,,,1048.27,Other,125% Medicaid APG methodology,0.01,3411.1,
TIS TRNFR E/N/E/L 10 SQ CM/<    ,14060,CPT,,50055425,CDM,450,RC,,,both,,,6822,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,3310.98,,,3310.98,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,4775.4,70,,4775.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,2723.55,,,2723.55,Other,153% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,2492.13,,,2492.13,Other,140% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,4628.25,,,4628.25,Other,260% Medicaid APG methodology,5767.51,,,5767.51,Other,324% Medicaid APG methodology,3827.2,,,3827.2,Other,215% Medicaid APG methodology,3827.2,,,3827.2,Other,215% Medicaid APG methodology,2225.12,,,2225.12,Other,125% Medicaid APG methodology,0.01,5767.51,
WOUND PREP F/N/HF/G             ,15004,CPT,,50055433,CDM,450,RC,,,both,,,2231,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,3180.63,,,3180.63,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1561.7,70,,1561.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% Medicaid APG methodology,1710.01,,,1710.01,Other,100% Medicaid APG methodology,1710.01,,,1710.01,Other,100% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,2616.32,,,2616.32,Other,153% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,2394.02,,,2394.02,Other,140% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,4446.04,,,4446.04,Other,260% Medicaid APG methodology,5540.45,,,5540.45,Other,324% Medicaid APG methodology,3676.53,,,3676.53,Other,215% Medicaid APG methodology,3676.53,,,3676.53,Other,215% Medicaid APG methodology,2137.52,,,2137.52,Other,125% Medicaid APG methodology,0.01,5540.45,
INITIAL TREATMENT OF BURN(S)    ,16000,CPT,,50055441,CDM,450,RC,,,both,,,651,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1193.32,,,1193.32,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,455.7,70,,455.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,981.6,,,981.6,Other,153% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,898.2,,,898.2,Other,140% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1668.08,,,1668.08,Other,260% Medicaid APG methodology,2078.69,,,2078.69,Other,324% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,801.96,,,801.96,Other,125% Medicaid APG methodology,0.01,2078.69,
REMOVAL OF FOREIGN BODY         ,20520,CPT,,50055458,CDM,450,RC,,,both,,,8245,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2507.74,,,2507.74,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,5771.5,70,,5771.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% Medicaid APG methodology,1348.25,,,1348.25,Other,100% Medicaid APG methodology,1348.25,,,1348.25,Other,100% Medicaid APG methodology,3033.56,,,3033.56,Other,225% Medicaid APG methodology,3033.56,,,3033.56,Other,225% Medicaid APG methodology,2062.82,,,2062.82,Other,153% Medicaid APG methodology,3033.56,,,3033.56,Other,225% Medicaid APG methodology,1887.55,,,1887.55,Other,140% Medicaid APG methodology,3033.56,,,3033.56,Other,225% Medicaid APG methodology,3505.45,,,3505.45,Other,260% Medicaid APG methodology,4368.33,,,4368.33,Other,324% Medicaid APG methodology,2898.73,,,2898.73,Other,215% Medicaid APG methodology,2898.73,,,2898.73,Other,215% Medicaid APG methodology,1685.31,,,1685.31,Other,125% Medicaid APG methodology,0.01,5771.5,
DRAIN/INJ SML JNT/BURSA W/O US  ,20600,CPT,,50055474,CDM,450,RC,,,both,,,1344,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,841.15,,,841.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,940.8,70,,940.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,452.23,,,452.23,Other,New York Medicaid APG methodology,452.23,,,452.23,Other,100% Medicaid APG methodology,452.23,,,452.23,Other,100% Medicaid APG methodology,452.23,,,452.23,Other,100% Medicaid APG methodology,1017.52,,,1017.52,Other,225% Medicaid APG methodology,1017.52,,,1017.52,Other,225% Medicaid APG methodology,691.91,,,691.91,Other,153% Medicaid APG methodology,1017.52,,,1017.52,Other,225% Medicaid APG methodology,633.12,,,633.12,Other,140% Medicaid APG methodology,1017.52,,,1017.52,Other,225% Medicaid APG methodology,1175.8,,,1175.8,Other,260% Medicaid APG methodology,1465.23,,,1465.23,Other,324% Medicaid APG methodology,972.3,,,972.3,Other,215% Medicaid APG methodology,972.3,,,972.3,Other,215% Medicaid APG methodology,565.29,,,565.29,Other,125% Medicaid APG methodology,0.01,1465.23,
LARYNGOSCOPY FOR ASPIRATION     ,31515,CPT,,50055847,CDM,450,RC,,,both,,,733,776.49,,,776.49,Other,150% of Medicare + 9.63% HCRA Surcharge,472.19,,,472.19,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1030.04,,,1030.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,513.1,70,,513.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,553.79,,,553.79,Other,New York Medicaid APG methodology,553.79,,,553.79,Other,100% Medicaid APG methodology,553.79,,,553.79,Other,100% Medicaid APG methodology,553.79,,,553.79,Other,100% Medicaid APG methodology,1246.02,,,1246.02,Other,225% Medicaid APG methodology,1246.02,,,1246.02,Other,225% Medicaid APG methodology,847.29,,,847.29,Other,153% Medicaid APG methodology,1246.02,,,1246.02,Other,225% Medicaid APG methodology,775.3,,,775.3,Other,140% Medicaid APG methodology,1246.02,,,1246.02,Other,225% Medicaid APG methodology,1439.85,,,1439.85,Other,260% Medicaid APG methodology,1794.27,,,1794.27,Other,324% Medicaid APG methodology,1190.64,,,1190.64,Other,215% Medicaid APG methodology,1190.64,,,1190.64,Other,215% Medicaid APG methodology,692.23,,,692.23,Other,125% Medicaid APG methodology,0.01,1794.27,
DRAINAGE OF MOUTH LESION COMPL  ,40801,CPT,,50055912,CDM,450,RC,,,both,,,740,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,508.35,,,508.35,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,518,70,,518,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,273.31,,,273.31,Other,New York Medicaid APG methodology,273.31,,,273.31,Other,100% Medicaid APG methodology,273.31,,,273.31,Other,100% Medicaid APG methodology,273.31,,,273.31,Other,100% Medicaid APG methodology,614.94,,,614.94,Other,225% Medicaid APG methodology,614.94,,,614.94,Other,225% Medicaid APG methodology,418.16,,,418.16,Other,153% Medicaid APG methodology,614.94,,,614.94,Other,225% Medicaid APG methodology,382.63,,,382.63,Other,140% Medicaid APG methodology,614.94,,,614.94,Other,225% Medicaid APG methodology,710.6,,,710.6,Other,260% Medicaid APG methodology,885.52,,,885.52,Other,324% Medicaid APG methodology,587.61,,,587.61,Other,215% Medicaid APG methodology,587.61,,,587.61,Other,215% Medicaid APG methodology,341.64,,,341.64,Other,125% Medicaid APG methodology,0.01,1046.29,
REPAIR MOUTH LACERATION >2.5CM  ,40831,CPT,,50055946,CDM,450,RC,,,both,,,740,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,508.35,,,508.35,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,518,70,,518,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,273.31,,,273.31,Other,New York Medicaid APG methodology,273.31,,,273.31,Other,100% Medicaid APG methodology,273.31,,,273.31,Other,100% Medicaid APG methodology,273.31,,,273.31,Other,100% Medicaid APG methodology,614.94,,,614.94,Other,225% Medicaid APG methodology,614.94,,,614.94,Other,225% Medicaid APG methodology,418.16,,,418.16,Other,153% Medicaid APG methodology,614.94,,,614.94,Other,225% Medicaid APG methodology,382.63,,,382.63,Other,140% Medicaid APG methodology,614.94,,,614.94,Other,225% Medicaid APG methodology,710.6,,,710.6,Other,260% Medicaid APG methodology,885.52,,,885.52,Other,324% Medicaid APG methodology,587.61,,,587.61,Other,215% Medicaid APG methodology,587.61,,,587.61,Other,215% Medicaid APG methodology,341.64,,,341.64,Other,125% Medicaid APG methodology,0.01,1046.29,
IRRIGATION OF BLADDER           ,51700,CPT,,50055995,CDM,450,RC,,,both,,,1336,469.99,,,469.99,Other,150% of Medicare + 9.63% HCRA Surcharge,285.8,,,285.8,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1051.03,,,1051.03,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,935.2,70,,935.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,565.07,,,565.07,Other,New York Medicaid APG methodology,565.07,,,565.07,Other,100% Medicaid APG methodology,565.07,,,565.07,Other,100% Medicaid APG methodology,565.07,,,565.07,Other,100% Medicaid APG methodology,1271.41,,,1271.41,Other,225% Medicaid APG methodology,1271.41,,,1271.41,Other,225% Medicaid APG methodology,864.56,,,864.56,Other,153% Medicaid APG methodology,1271.41,,,1271.41,Other,225% Medicaid APG methodology,791.1,,,791.1,Other,140% Medicaid APG methodology,1271.41,,,1271.41,Other,225% Medicaid APG methodology,1469.19,,,1469.19,Other,260% Medicaid APG methodology,1830.83,,,1830.83,Other,324% Medicaid APG methodology,1214.9,,,1214.9,Other,215% Medicaid APG methodology,1214.9,,,1214.9,Other,215% Medicaid APG methodology,706.34,,,706.34,Other,125% Medicaid APG methodology,0.01,1830.83,
REPAIR EYELID WOUND PART THICK  ,67930,CPT,,50056035,CDM,450,RC,,,both,,,7522,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2759.56,,,2759.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,5265.4,70,,5265.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% Medicaid APG methodology,1483.63,,,1483.63,Other,100% Medicaid APG methodology,1483.63,,,1483.63,Other,100% Medicaid APG methodology,3338.18,,,3338.18,Other,225% Medicaid APG methodology,3338.18,,,3338.18,Other,225% Medicaid APG methodology,2269.96,,,2269.96,Other,153% Medicaid APG methodology,3338.18,,,3338.18,Other,225% Medicaid APG methodology,2077.09,,,2077.09,Other,140% Medicaid APG methodology,3338.18,,,3338.18,Other,225% Medicaid APG methodology,3857.45,,,3857.45,Other,260% Medicaid APG methodology,4806.98,,,4806.98,Other,324% Medicaid APG methodology,3189.81,,,3189.81,Other,215% Medicaid APG methodology,3189.81,,,3189.81,Other,215% Medicaid APG methodology,1854.54,,,1854.54,Other,125% Medicaid APG methodology,0.01,5265.4,
REPAIR EYELID WOUND FULL THICK  ,67935,CPT,,50056043,CDM,450,RC,,,both,,,7522,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2759.56,,,2759.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,5265.4,70,,5265.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% Medicaid APG methodology,1483.63,,,1483.63,Other,100% Medicaid APG methodology,1483.63,,,1483.63,Other,100% Medicaid APG methodology,3338.18,,,3338.18,Other,225% Medicaid APG methodology,3338.18,,,3338.18,Other,225% Medicaid APG methodology,2269.96,,,2269.96,Other,153% Medicaid APG methodology,3338.18,,,3338.18,Other,225% Medicaid APG methodology,2077.09,,,2077.09,Other,140% Medicaid APG methodology,3338.18,,,3338.18,Other,225% Medicaid APG methodology,3857.45,,,3857.45,Other,260% Medicaid APG methodology,4806.98,,,4806.98,Other,324% Medicaid APG methodology,3189.81,,,3189.81,Other,215% Medicaid APG methodology,3189.81,,,3189.81,Other,215% Medicaid APG methodology,1854.54,,,1854.54,Other,125% Medicaid APG methodology,0.01,5265.4,
SC THER INFUSION RESET PUMP     ,96371,CPT,,50056100,CDM,450,RC,,,both,,,594,133.96,,,133.96,Other,150% of Medicare + 9.63% HCRA Surcharge,81.46,,,81.46,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,577.69,,,577.69,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,415.8,70,,415.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,310.58,,,310.58,Other,New York Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,475.19,,,475.19,Other,153% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,434.82,,,434.82,Other,140% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,807.52,,,807.52,Other,260% Medicaid APG methodology,1006.29,,,1006.29,Other,324% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,388.23,,,388.23,Other,125% Medicaid APG methodology,0.01,1006.29,
EMERGENCY DEPT VISIT LEV 1 TG   ,99281,CPT,,50056217,CDM,450,RC,,,both,,,2700,168.83,,,168.83,Other,150% of Medicare + 9.63% HCRA Surcharge,102.67,,,102.67,Other,Medicare OPPS methodology,2672,,,2672,Case Rate,ED Visit,2405,,,2405,Case Rate,ED Visit,1512,,,1512,Case Rate,ED Visit,1361,,,1361,Case Rate,ED Visit,1285,,,1285,Case Rate,ED Visit,2414,,,2414,Case Rate,ED Visit,2423,,,2423,Case Rate,ED Visit,412,,,412,Case Rate,ED Visit,0.02,,,0.02,Other,186% Medicaid methodology,485,,,485,Case Rate,ED Visit,2160,,,2160,Case Rate,ED Visit,2160,,,2160,Case Rate,ED Visit,485,,,485,Case Rate,ED Visit,2160,,,2160,Case Rate,ED Visit,2166,,,2166,Case Rate,ED Visit,1890,70,,1890,percent of total billed charges,All Other,2631,,,2631,Case Rate,ED Visit,2236,,,2236,Case Rate,ED Visit,1501,,,1501,Case Rate,ED Visit,1416,,,1416,Case Rate,ED Visit,1573,,,1573,Case Rate,ED Visit,1338,,,1338,Case Rate,ED Visit,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,2672,
INJECT TRIGGER POINTS 3/>       ,20553,CPT,,50056290,CDM,450,RC,,,both,,,1344,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,841.15,,,841.15,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,940.8,70,,940.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,452.23,,,452.23,Other,New York Medicaid APG methodology,452.23,,,452.23,Other,100% Medicaid APG methodology,452.23,,,452.23,Other,100% Medicaid APG methodology,452.23,,,452.23,Other,100% Medicaid APG methodology,1017.52,,,1017.52,Other,225% Medicaid APG methodology,1017.52,,,1017.52,Other,225% Medicaid APG methodology,691.91,,,691.91,Other,153% Medicaid APG methodology,1017.52,,,1017.52,Other,225% Medicaid APG methodology,633.12,,,633.12,Other,140% Medicaid APG methodology,1017.52,,,1017.52,Other,225% Medicaid APG methodology,1175.8,,,1175.8,Other,260% Medicaid APG methodology,1465.23,,,1465.23,Other,324% Medicaid APG methodology,972.3,,,972.3,Other,215% Medicaid APG methodology,972.3,,,972.3,Other,215% Medicaid APG methodology,565.29,,,565.29,Other,125% Medicaid APG methodology,0.01,1465.23,
REPAIR PALATE                   ,42180,CPT,,50056316,CDM,450,RC,,,both,,,740,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,508.35,,,508.35,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,518,70,,518,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,273.31,,,273.31,Other,New York Medicaid APG methodology,273.31,,,273.31,Other,100% Medicaid APG methodology,273.31,,,273.31,Other,100% Medicaid APG methodology,273.31,,,273.31,Other,100% Medicaid APG methodology,614.94,,,614.94,Other,225% Medicaid APG methodology,614.94,,,614.94,Other,225% Medicaid APG methodology,418.16,,,418.16,Other,153% Medicaid APG methodology,614.94,,,614.94,Other,225% Medicaid APG methodology,382.63,,,382.63,Other,140% Medicaid APG methodology,614.94,,,614.94,Other,225% Medicaid APG methodology,710.6,,,710.6,Other,260% Medicaid APG methodology,885.52,,,885.52,Other,324% Medicaid APG methodology,587.61,,,587.61,Other,215% Medicaid APG methodology,587.61,,,587.61,Other,215% Medicaid APG methodology,341.64,,,341.64,Other,125% Medicaid APG methodology,0.01,1046.29,
WCD DEVICE INTERROGATE          ,93292,CPT,,50056332,CDM,450,RC,,,both,,,880,71.71,,,71.71,Other,150% of Medicare + 9.63% HCRA Surcharge,43.61,,,43.61,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,207.55,,,207.55,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,616,70,,616,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,111.58,,,111.58,Other,New York Medicaid APG methodology,111.58,,,111.58,Other,100% Medicaid APG methodology,111.58,,,111.58,Other,100% Medicaid APG methodology,111.58,,,111.58,Other,100% Medicaid APG methodology,251.06,,,251.06,Other,225% Medicaid APG methodology,251.06,,,251.06,Other,225% Medicaid APG methodology,170.72,,,170.72,Other,153% Medicaid APG methodology,251.06,,,251.06,Other,225% Medicaid APG methodology,156.22,,,156.22,Other,140% Medicaid APG methodology,251.06,,,251.06,Other,225% Medicaid APG methodology,290.12,,,290.12,Other,260% Medicaid APG methodology,361.53,,,361.53,Other,324% Medicaid APG methodology,239.91,,,239.91,Other,215% Medicaid APG methodology,239.91,,,239.91,Other,215% Medicaid APG methodology,139.48,,,139.48,Other,125% Medicaid APG methodology,0.01,616,
INSJ PICC <5 YR W/O IMAGING     ,36568,CPT,,50056381,CDM,450,RC,,,both,,,5339,3045.56,,,3045.56,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.02,,,1852.02,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,507.79,,,507.79,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3737.3,70,,3737.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,273.01,,,273.01,Other,New York Medicaid APG methodology,273.01,,,273.01,Other,100% Medicaid APG methodology,273.01,,,273.01,Other,100% Medicaid APG methodology,273.01,,,273.01,Other,100% Medicaid APG methodology,614.27,,,614.27,Other,225% Medicaid APG methodology,614.27,,,614.27,Other,225% Medicaid APG methodology,417.7,,,417.7,Other,153% Medicaid APG methodology,614.27,,,614.27,Other,225% Medicaid APG methodology,382.21,,,382.21,Other,140% Medicaid APG methodology,614.27,,,614.27,Other,225% Medicaid APG methodology,709.82,,,709.82,Other,260% Medicaid APG methodology,884.55,,,884.55,Other,324% Medicaid APG methodology,586.97,,,586.97,Other,215% Medicaid APG methodology,586.97,,,586.97,Other,215% Medicaid APG methodology,341.26,,,341.26,Other,125% Medicaid APG methodology,0.01,3737.3,
ABD PARACENTESIS                ,49082,CPT,,50056399,CDM,450,RC,,,both,,,3610,1723.81,,,1723.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.26,,,1048.26,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1502.62,,,1502.62,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2527,70,,2527,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% Medicaid APG methodology,807.86,,,807.86,Other,100% Medicaid APG methodology,807.86,,,807.86,Other,100% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,1236.03,,,1236.03,Other,153% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,1131.01,,,1131.01,Other,140% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,2100.44,,,2100.44,Other,260% Medicaid APG methodology,2617.47,,,2617.47,Other,324% Medicaid APG methodology,1736.9,,,1736.9,Other,215% Medicaid APG methodology,1736.9,,,1736.9,Other,215% Medicaid APG methodology,1009.83,,,1009.83,Other,125% Medicaid APG methodology,0.01,2617.47,
ABD PARACENTESIS W/IMAGING      ,49083,CPT,,50056407,CDM,450,RC,,,both,,,3121,1723.81,,,1723.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.26,,,1048.26,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1502.62,,,1502.62,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2184.7,70,,2184.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% Medicaid APG methodology,807.86,,,807.86,Other,100% Medicaid APG methodology,807.86,,,807.86,Other,100% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,1236.03,,,1236.03,Other,153% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,1131.01,,,1131.01,Other,140% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,2100.44,,,2100.44,Other,260% Medicaid APG methodology,2617.47,,,2617.47,Other,324% Medicaid APG methodology,1736.9,,,1736.9,Other,215% Medicaid APG methodology,1736.9,,,1736.9,Other,215% Medicaid APG methodology,1009.83,,,1009.83,Other,125% Medicaid APG methodology,0.01,2617.47,
PERITONEAL LAVAGE               ,49084,CPT,,50056415,CDM,450,RC,,,both,,,3610,1723.81,,,1723.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.26,,,1048.26,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1502.62,,,1502.62,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2527,70,,2527,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% Medicaid APG methodology,807.86,,,807.86,Other,100% Medicaid APG methodology,807.86,,,807.86,Other,100% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,1236.03,,,1236.03,Other,153% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,1131.01,,,1131.01,Other,140% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,2100.44,,,2100.44,Other,260% Medicaid APG methodology,2617.47,,,2617.47,Other,324% Medicaid APG methodology,1736.9,,,1736.9,Other,215% Medicaid APG methodology,1736.9,,,1736.9,Other,215% Medicaid APG methodology,1009.83,,,1009.83,Other,125% Medicaid APG methodology,0.01,2617.47,
INSJ PICC 5 YR+ W/O IMAGING     ,36569,CPT,,50056464,CDM,450,RC,,,both,,,6724,3045.56,,,3045.56,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.02,,,1852.02,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,507.79,,,507.79,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,4706.8,70,,4706.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,273.01,,,273.01,Other,New York Medicaid APG methodology,273.01,,,273.01,Other,100% Medicaid APG methodology,273.01,,,273.01,Other,100% Medicaid APG methodology,273.01,,,273.01,Other,100% Medicaid APG methodology,614.27,,,614.27,Other,225% Medicaid APG methodology,614.27,,,614.27,Other,225% Medicaid APG methodology,417.7,,,417.7,Other,153% Medicaid APG methodology,614.27,,,614.27,Other,225% Medicaid APG methodology,382.21,,,382.21,Other,140% Medicaid APG methodology,614.27,,,614.27,Other,225% Medicaid APG methodology,709.82,,,709.82,Other,260% Medicaid APG methodology,884.55,,,884.55,Other,324% Medicaid APG methodology,586.97,,,586.97,Other,215% Medicaid APG methodology,586.97,,,586.97,Other,215% Medicaid APG methodology,341.26,,,341.26,Other,125% Medicaid APG methodology,0.01,4706.8,
REM TUNNELED CV CATH W PRT/PMP  ,36590,CPT,,50056472,CDM,450,RC,,,both,,,5389,3045.56,,,3045.56,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.02,,,1852.02,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1968.77,,,1968.77,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3772.3,70,,3772.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1058.48,,,1058.48,Other,New York Medicaid APG methodology,1058.48,,,1058.48,Other,100% Medicaid APG methodology,1058.48,,,1058.48,Other,100% Medicaid APG methodology,1058.48,,,1058.48,Other,100% Medicaid APG methodology,2381.58,,,2381.58,Other,225% Medicaid APG methodology,2381.58,,,2381.58,Other,225% Medicaid APG methodology,1619.47,,,1619.47,Other,153% Medicaid APG methodology,2381.58,,,2381.58,Other,225% Medicaid APG methodology,1481.87,,,1481.87,Other,140% Medicaid APG methodology,2381.58,,,2381.58,Other,225% Medicaid APG methodology,2752.04,,,2752.04,Other,260% Medicaid APG methodology,3429.47,,,3429.47,Other,324% Medicaid APG methodology,2275.73,,,2275.73,Other,215% Medicaid APG methodology,2275.73,,,2275.73,Other,215% Medicaid APG methodology,1323.1,,,1323.1,Other,125% Medicaid APG methodology,0.01,3772.3,
CLTX POST ANKLE FX W/MNPJ       ,27768,CPT,,50056514,CDM,450,RC,,,both,,,5309,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3716.3,70,,3716.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,3716.3,
ASPIRATE PLEURA W/ IMAGING      ,32555,CPT,,50056613,CDM,450,RC,,,both,,,10048,1194.63,,,1194.63,Other,150% of Medicare + 9.63% HCRA Surcharge,726.46,,,726.46,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1502.62,,,1502.62,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,7033.6,70,,7033.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% Medicaid APG methodology,807.86,,,807.86,Other,100% Medicaid APG methodology,807.86,,,807.86,Other,100% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,1236.03,,,1236.03,Other,153% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,1131.01,,,1131.01,Other,140% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,2100.44,,,2100.44,Other,260% Medicaid APG methodology,2617.47,,,2617.47,Other,324% Medicaid APG methodology,1736.9,,,1736.9,Other,215% Medicaid APG methodology,1736.9,,,1736.9,Other,215% Medicaid APG methodology,1009.83,,,1009.83,Other,125% Medicaid APG methodology,0.01,7033.6,
REPAIR CVA DEVICE W PORT/PUMP   ,36576,CPT,,50056621,CDM,450,RC,,,both,,,5339,3045.56,,,3045.56,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.02,,,1852.02,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1968.77,,,1968.77,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3737.3,70,,3737.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1058.48,,,1058.48,Other,New York Medicaid APG methodology,1058.48,,,1058.48,Other,100% Medicaid APG methodology,1058.48,,,1058.48,Other,100% Medicaid APG methodology,1058.48,,,1058.48,Other,100% Medicaid APG methodology,2381.58,,,2381.58,Other,225% Medicaid APG methodology,2381.58,,,2381.58,Other,225% Medicaid APG methodology,1619.47,,,1619.47,Other,153% Medicaid APG methodology,2381.58,,,2381.58,Other,225% Medicaid APG methodology,1481.87,,,1481.87,Other,140% Medicaid APG methodology,2381.58,,,2381.58,Other,225% Medicaid APG methodology,2752.04,,,2752.04,Other,260% Medicaid APG methodology,3429.47,,,3429.47,Other,324% Medicaid APG methodology,2275.73,,,2275.73,Other,215% Medicaid APG methodology,2275.73,,,2275.73,Other,215% Medicaid APG methodology,1323.1,,,1323.1,Other,125% Medicaid APG methodology,0.01,3737.3,
INSERT CATH PLEURA W/O IMAGE    ,32556,CPT,,50056639,CDM,450,RC,,,both,,,7641,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1502.62,,,1502.62,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,5348.7,70,,5348.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% Medicaid APG methodology,807.86,,,807.86,Other,100% Medicaid APG methodology,807.86,,,807.86,Other,100% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,1236.03,,,1236.03,Other,153% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,1131.01,,,1131.01,Other,140% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,2100.44,,,2100.44,Other,260% Medicaid APG methodology,2617.47,,,2617.47,Other,324% Medicaid APG methodology,1736.9,,,1736.9,Other,215% Medicaid APG methodology,1736.9,,,1736.9,Other,215% Medicaid APG methodology,1009.83,,,1009.83,Other,125% Medicaid APG methodology,0.01,5348.7,
CL TX SC/TC FEMUR FX W MANIP    ,27503,CPT,,50056647,CDM,450,RC,,,both,,,3898,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1288.75,,,1288.75,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2728.6,70,,2728.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,692.88,,,692.88,Other,100% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1060.1,,,1060.1,Other,153% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,970.03,,,970.03,Other,140% Medicaid APG methodology,1558.97,,,1558.97,Other,225% Medicaid APG methodology,1801.48,,,1801.48,Other,260% Medicaid APG methodology,2244.92,,,2244.92,Other,324% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,1489.68,,,1489.68,Other,215% Medicaid APG methodology,866.09,,,866.09,Other,125% Medicaid APG methodology,0.01,3056.33,
SKIN SUB GRAFT TRNK/ARM/LEG     ,15271,CPT,,50056670,CDM,450,RC,,,both,,,5203,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,3310.98,,,3310.98,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3642.1,70,,3642.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,2723.55,,,2723.55,Other,153% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,2492.13,,,2492.13,Other,140% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,4628.25,,,4628.25,Other,260% Medicaid APG methodology,5767.51,,,5767.51,Other,324% Medicaid APG methodology,3827.2,,,3827.2,Other,215% Medicaid APG methodology,3827.2,,,3827.2,Other,215% Medicaid APG methodology,2225.12,,,2225.12,Other,125% Medicaid APG methodology,0.01,5767.51,
ESCHAROTOMY ADDL INCISION       ,16036,CPT,,50056696,CDM,450,RC,,,both,,,4,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1438.1,,,1438.1,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2.8,70,,2.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,773.17,,,773.17,Other,New York Medicaid APG methodology,773.17,,,773.17,Other,100% Medicaid APG methodology,773.17,,,773.17,Other,100% Medicaid APG methodology,773.17,,,773.17,Other,100% Medicaid APG methodology,1739.64,,,1739.64,Other,225% Medicaid APG methodology,1739.64,,,1739.64,Other,225% Medicaid APG methodology,1182.95,,,1182.95,Other,153% Medicaid APG methodology,1739.64,,,1739.64,Other,225% Medicaid APG methodology,1082.44,,,1082.44,Other,140% Medicaid APG methodology,1739.64,,,1739.64,Other,225% Medicaid APG methodology,2010.25,,,2010.25,Other,260% Medicaid APG methodology,2505.08,,,2505.08,Other,324% Medicaid APG methodology,1662.32,,,1662.32,Other,215% Medicaid APG methodology,1662.32,,,1662.32,Other,215% Medicaid APG methodology,966.46,,,966.46,Other,125% Medicaid APG methodology,0.01,2505.08,
SKIN SUB GRAFT FACE/NK/HF/G     ,15275,CPT,,50056779,CDM,450,RC,,,both,,,5671,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,3310.98,,,3310.98,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,3969.7,70,,3969.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,2723.55,,,2723.55,Other,153% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,2492.13,,,2492.13,Other,140% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,4628.25,,,4628.25,Other,260% Medicaid APG methodology,5767.51,,,5767.51,Other,324% Medicaid APG methodology,3827.2,,,3827.2,Other,215% Medicaid APG methodology,3827.2,,,3827.2,Other,215% Medicaid APG methodology,2225.12,,,2225.12,Other,125% Medicaid APG methodology,0.01,5767.51,
PERC FIX SC/TC HUMERUS FX       ,24538,CPT,,50056787,CDM,450,RC,,,both,,,10637,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,6546.01,,,6546.01,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,7445.9,70,,7445.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% Medicaid APG methodology,3519.36,,,3519.36,Other,100% Medicaid APG methodology,3519.36,,,3519.36,Other,100% Medicaid APG methodology,7918.56,,,7918.56,Other,225% Medicaid APG methodology,7918.56,,,7918.56,Other,225% Medicaid APG methodology,5384.62,,,5384.62,Other,153% Medicaid APG methodology,7918.56,,,7918.56,Other,225% Medicaid APG methodology,4927.1,,,4927.1,Other,140% Medicaid APG methodology,7918.56,,,7918.56,Other,225% Medicaid APG methodology,9150.34,,,9150.34,Other,260% Medicaid APG methodology,11402.73,,,11402.73,Other,324% Medicaid APG methodology,7566.62,,,7566.62,Other,215% Medicaid APG methodology,7566.62,,,7566.62,Other,215% Medicaid APG methodology,4399.2,,,4399.2,Other,125% Medicaid APG methodology,0.01,13604.5,
DRAIN/INJ JOINT/BURSA W/US MAJ  ,20611,CPT,,50056860,CDM,450,RC,,,both,,,2768,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1351.14,,,1351.14,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1937.6,70,,1937.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,726.42,,,726.42,Other,New York Medicaid APG methodology,726.42,,,726.42,Other,100% Medicaid APG methodology,726.42,,,726.42,Other,100% Medicaid APG methodology,726.42,,,726.42,Other,100% Medicaid APG methodology,1634.45,,,1634.45,Other,225% Medicaid APG methodology,1634.45,,,1634.45,Other,225% Medicaid APG methodology,1111.42,,,1111.42,Other,153% Medicaid APG methodology,1634.45,,,1634.45,Other,225% Medicaid APG methodology,1016.99,,,1016.99,Other,140% Medicaid APG methodology,1634.45,,,1634.45,Other,225% Medicaid APG methodology,1888.69,,,1888.69,Other,260% Medicaid APG methodology,2353.6,,,2353.6,Other,324% Medicaid APG methodology,1561.8,,,1561.8,Other,215% Medicaid APG methodology,1561.8,,,1561.8,Other,215% Medicaid APG methodology,908.03,,,908.03,Other,125% Medicaid APG methodology,0.01,2353.6,
ANALYZE SPINE INFUS PUMP        ,62367,CPT,,50056878,CDM,450,RC,,,both,,,1724,568,,,568,Other,150% of Medicare + 9.63% HCRA Surcharge,345.41,,,345.41,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,393.03,,,393.03,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1206.8,70,,1206.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,211.31,,,211.31,Other,New York Medicaid APG methodology,211.31,,,211.31,Other,100% Medicaid APG methodology,211.31,,,211.31,Other,100% Medicaid APG methodology,211.31,,,211.31,Other,100% Medicaid APG methodology,475.44,,,475.44,Other,225% Medicaid APG methodology,475.44,,,475.44,Other,225% Medicaid APG methodology,323.3,,,323.3,Other,153% Medicaid APG methodology,475.44,,,475.44,Other,225% Medicaid APG methodology,295.83,,,295.83,Other,140% Medicaid APG methodology,475.44,,,475.44,Other,225% Medicaid APG methodology,549.4,,,549.4,Other,260% Medicaid APG methodology,684.64,,,684.64,Other,324% Medicaid APG methodology,454.31,,,454.31,Other,215% Medicaid APG methodology,454.31,,,454.31,Other,215% Medicaid APG methodology,264.14,,,264.14,Other,125% Medicaid APG methodology,0.01,1206.8,
REMOVE DRUG IMPLANT DEVICE      ,11982,CPT,,50056886,CDM,450,RC,,,both,,,1437,757.69,,,757.69,Other,150% of Medicare + 9.63% HCRA Surcharge,460.76,,,460.76,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,902.56,,,902.56,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1005.9,70,,1005.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,742.43,,,742.43,Other,153% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,679.35,,,679.35,Other,140% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,1261.65,,,1261.65,Other,260% Medicaid APG methodology,1572.2,,,1572.2,Other,324% Medicaid APG methodology,1043.28,,,1043.28,Other,215% Medicaid APG methodology,1043.28,,,1043.28,Other,215% Medicaid APG methodology,606.56,,,606.56,Other,125% Medicaid APG methodology,0.01,1572.2,
CLTX THIGH FX W/MNPJ            ,27268,CPT,,50056894,CDM,450,RC,,,both,,,10525,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1048.04,,,1048.04,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,7367.5,70,,7367.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,563.46,,,563.46,Other,New York Medicaid APG methodology,563.46,,,563.46,Other,100% Medicaid APG methodology,563.46,,,563.46,Other,100% Medicaid APG methodology,563.46,,,563.46,Other,100% Medicaid APG methodology,1267.79,,,1267.79,Other,225% Medicaid APG methodology,1267.79,,,1267.79,Other,225% Medicaid APG methodology,862.1,,,862.1,Other,153% Medicaid APG methodology,1267.79,,,1267.79,Other,225% Medicaid APG methodology,788.85,,,788.85,Other,140% Medicaid APG methodology,1267.79,,,1267.79,Other,225% Medicaid APG methodology,1465.01,,,1465.01,Other,260% Medicaid APG methodology,1825.62,,,1825.62,Other,324% Medicaid APG methodology,1211.45,,,1211.45,Other,215% Medicaid APG methodology,1211.45,,,1211.45,Other,215% Medicaid APG methodology,704.33,,,704.33,Other,125% Medicaid APG methodology,0.01,7367.5,
REMOVE IMPACTED EAR WAX UNI     ,69209,CPT,,50056902,CDM,450,RC,,,both,,,236,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,0.02,,,0.02,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,165.2,70,,165.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,165.2,
INTERROG EVL PM/LDLS PM IP      ,93288,CPT,,50056910,CDM,450,RC,,,both,,,805,71.71,,,71.71,Other,150% of Medicare + 9.63% HCRA Surcharge,43.61,,,43.61,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,207.55,,,207.55,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,563.5,70,,563.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,111.58,,,111.58,Other,New York Medicaid APG methodology,111.58,,,111.58,Other,100% Medicaid APG methodology,111.58,,,111.58,Other,100% Medicaid APG methodology,111.58,,,111.58,Other,100% Medicaid APG methodology,251.06,,,251.06,Other,225% Medicaid APG methodology,251.06,,,251.06,Other,225% Medicaid APG methodology,170.72,,,170.72,Other,153% Medicaid APG methodology,251.06,,,251.06,Other,225% Medicaid APG methodology,156.22,,,156.22,Other,140% Medicaid APG methodology,251.06,,,251.06,Other,225% Medicaid APG methodology,290.12,,,290.12,Other,260% Medicaid APG methodology,361.53,,,361.53,Other,324% Medicaid APG methodology,239.91,,,239.91,Other,215% Medicaid APG methodology,239.91,,,239.91,Other,215% Medicaid APG methodology,139.48,,,139.48,Other,125% Medicaid APG methodology,0.01,563.5,
DRILL SKULL FOR IMPLANTATION    ,61107,CPT,,50056936,CDM,450,RC,,,both,,,1409,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,5454.84,,,5454.84,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,986.3,70,,986.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,2932.71,,,2932.71,Other,New York Medicaid APG methodology,2932.71,,,2932.71,Other,100% Medicaid APG methodology,2932.71,,,2932.71,Other,100% Medicaid APG methodology,2932.71,,,2932.71,Other,100% Medicaid APG methodology,6598.6,,,6598.6,Other,225% Medicaid APG methodology,6598.6,,,6598.6,Other,225% Medicaid APG methodology,4487.05,,,4487.05,Other,153% Medicaid APG methodology,6598.6,,,6598.6,Other,225% Medicaid APG methodology,4105.79,,,4105.79,Other,140% Medicaid APG methodology,6598.6,,,6598.6,Other,225% Medicaid APG methodology,7625.04,,,7625.04,Other,260% Medicaid APG methodology,9501.98,,,9501.98,Other,324% Medicaid APG methodology,6305.33,,,6305.33,Other,215% Medicaid APG methodology,6305.33,,,6305.33,Other,215% Medicaid APG methodology,3665.89,,,3665.89,Other,125% Medicaid APG methodology,0.01,9501.98,
INTERROG DEVICE EVAL HEART      ,93289,CPT,,50056944,CDM,450,RC,,,both,,,910,71.71,,,71.71,Other,150% of Medicare + 9.63% HCRA Surcharge,43.61,,,43.61,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,207.55,,,207.55,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,637,70,,637,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,111.58,,,111.58,Other,New York Medicaid APG methodology,111.58,,,111.58,Other,100% Medicaid APG methodology,111.58,,,111.58,Other,100% Medicaid APG methodology,111.58,,,111.58,Other,100% Medicaid APG methodology,251.06,,,251.06,Other,225% Medicaid APG methodology,251.06,,,251.06,Other,225% Medicaid APG methodology,170.72,,,170.72,Other,153% Medicaid APG methodology,251.06,,,251.06,Other,225% Medicaid APG methodology,156.22,,,156.22,Other,140% Medicaid APG methodology,251.06,,,251.06,Other,225% Medicaid APG methodology,290.12,,,290.12,Other,260% Medicaid APG methodology,361.53,,,361.53,Other,324% Medicaid APG methodology,239.91,,,239.91,Other,215% Medicaid APG methodology,239.91,,,239.91,Other,215% Medicaid APG methodology,139.48,,,139.48,Other,125% Medicaid APG methodology,0.01,637,
COVER EYE W/MEMBRANE            ,65778,CPT,,50057009,CDM,450,RC,,,both,,,3105,1925.3,,,1925.3,Other,150% of Medicare + 9.63% HCRA Surcharge,1170.78,,,1170.78,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,3655.3,,,3655.3,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2173.5,70,,2173.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1965.22,,,1965.22,Other,New York Medicaid APG methodology,1965.22,,,1965.22,Other,100% Medicaid APG methodology,1965.22,,,1965.22,Other,100% Medicaid APG methodology,1965.22,,,1965.22,Other,100% Medicaid APG methodology,4421.74,,,4421.74,Other,225% Medicaid APG methodology,4421.74,,,4421.74,Other,225% Medicaid APG methodology,3006.78,,,3006.78,Other,153% Medicaid APG methodology,4421.74,,,4421.74,Other,225% Medicaid APG methodology,2751.3,,,2751.3,Other,140% Medicaid APG methodology,4421.74,,,4421.74,Other,225% Medicaid APG methodology,5109.57,,,5109.57,Other,260% Medicaid APG methodology,6367.3,,,6367.3,Other,324% Medicaid APG methodology,4225.22,,,4225.22,Other,215% Medicaid APG methodology,4225.22,,,4225.22,Other,215% Medicaid APG methodology,2456.52,,,2456.52,Other,125% Medicaid APG methodology,0.01,6367.3,
INTERROG DEV EVAL SCRMS IP      ,93291,CPT,,50057017,CDM,450,RC,,,both,,,229,56.62,,,56.62,Other,150% of Medicare + 9.63% HCRA Surcharge,34.43,,,34.43,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,207.55,,,207.55,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,160.3,70,,160.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,111.58,,,111.58,Other,New York Medicaid APG methodology,111.58,,,111.58,Other,100% Medicaid APG methodology,111.58,,,111.58,Other,100% Medicaid APG methodology,111.58,,,111.58,Other,100% Medicaid APG methodology,251.06,,,251.06,Other,225% Medicaid APG methodology,251.06,,,251.06,Other,225% Medicaid APG methodology,170.72,,,170.72,Other,153% Medicaid APG methodology,251.06,,,251.06,Other,225% Medicaid APG methodology,156.22,,,156.22,Other,140% Medicaid APG methodology,251.06,,,251.06,Other,225% Medicaid APG methodology,290.12,,,290.12,Other,260% Medicaid APG methodology,361.53,,,361.53,Other,324% Medicaid APG methodology,239.91,,,239.91,Other,215% Medicaid APG methodology,239.91,,,239.91,Other,215% Medicaid APG methodology,139.48,,,139.48,Other,125% Medicaid APG methodology,0.01,361.53,
EXAM OF VAGINA W/SCOPE          ,57420,CPT,,50057025,CDM,450,RC,,,both,,,1313,610.06,,,610.06,Other,150% of Medicare + 9.63% HCRA Surcharge,370.98,,,370.98,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1170.45,,,1170.45,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,919.1,70,,919.1,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,629.27,,,629.27,Other,New York Medicaid APG methodology,629.27,,,629.27,Other,100% Medicaid APG methodology,629.27,,,629.27,Other,100% Medicaid APG methodology,629.27,,,629.27,Other,100% Medicaid APG methodology,1415.86,,,1415.86,Other,225% Medicaid APG methodology,1415.86,,,1415.86,Other,225% Medicaid APG methodology,962.79,,,962.79,Other,153% Medicaid APG methodology,1415.86,,,1415.86,Other,225% Medicaid APG methodology,880.98,,,880.98,Other,140% Medicaid APG methodology,1415.86,,,1415.86,Other,225% Medicaid APG methodology,1636.11,,,1636.11,Other,260% Medicaid APG methodology,2038.84,,,2038.84,Other,324% Medicaid APG methodology,1352.94,,,1352.94,Other,215% Medicaid APG methodology,1352.94,,,1352.94,Other,215% Medicaid APG methodology,786.59,,,786.59,Other,125% Medicaid APG methodology,0.01,2038.84,
INSJ PICC RS&I <5 YR            ,36572,CPT,,50057033,CDM,450,RC,,,both,,,9232,1194.63,,,1194.63,Other,150% of Medicare + 9.63% HCRA Surcharge,726.46,,,726.46,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,713.01,,,713.01,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,6462.4,70,,6462.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,383.34,,,383.34,Other,New York Medicaid APG methodology,383.34,,,383.34,Other,100% Medicaid APG methodology,383.34,,,383.34,Other,100% Medicaid APG methodology,383.34,,,383.34,Other,100% Medicaid APG methodology,862.51,,,862.51,Other,225% Medicaid APG methodology,862.51,,,862.51,Other,225% Medicaid APG methodology,586.51,,,586.51,Other,153% Medicaid APG methodology,862.51,,,862.51,Other,225% Medicaid APG methodology,536.67,,,536.67,Other,140% Medicaid APG methodology,862.51,,,862.51,Other,225% Medicaid APG methodology,996.68,,,996.68,Other,260% Medicaid APG methodology,1242.01,,,1242.01,Other,324% Medicaid APG methodology,824.17,,,824.17,Other,215% Medicaid APG methodology,824.17,,,824.17,Other,215% Medicaid APG methodology,479.17,,,479.17,Other,125% Medicaid APG methodology,0.01,6462.4,
INSJ PICC RS&I 5 YR+            ,36573,CPT,,50057041,CDM,450,RC,,,both,,,9705,3045.56,,,3045.56,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.02,,,1852.02,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,713.01,,,713.01,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,6793.5,70,,6793.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,383.34,,,383.34,Other,New York Medicaid APG methodology,383.34,,,383.34,Other,100% Medicaid APG methodology,383.34,,,383.34,Other,100% Medicaid APG methodology,383.34,,,383.34,Other,100% Medicaid APG methodology,862.51,,,862.51,Other,225% Medicaid APG methodology,862.51,,,862.51,Other,225% Medicaid APG methodology,586.51,,,586.51,Other,153% Medicaid APG methodology,862.51,,,862.51,Other,225% Medicaid APG methodology,536.67,,,536.67,Other,140% Medicaid APG methodology,862.51,,,862.51,Other,225% Medicaid APG methodology,996.68,,,996.68,Other,260% Medicaid APG methodology,1242.01,,,1242.01,Other,324% Medicaid APG methodology,824.17,,,824.17,Other,215% Medicaid APG methodology,824.17,,,824.17,Other,215% Medicaid APG methodology,479.17,,,479.17,Other,125% Medicaid APG methodology,0.01,6793.5,
IMAGE CATH FLUID TRNS/VGNL      ,49407,CPT,,50057058,CDM,450,RC,,,both,,,6361,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1502.62,,,1502.62,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,4452.7,70,,4452.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% Medicaid APG methodology,807.86,,,807.86,Other,100% Medicaid APG methodology,807.86,,,807.86,Other,100% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,1236.03,,,1236.03,Other,153% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,1131.01,,,1131.01,Other,140% Medicaid APG methodology,1817.69,,,1817.69,Other,225% Medicaid APG methodology,2100.44,,,2100.44,Other,260% Medicaid APG methodology,2617.47,,,2617.47,Other,324% Medicaid APG methodology,1736.9,,,1736.9,Other,215% Medicaid APG methodology,1736.9,,,1736.9,Other,215% Medicaid APG methodology,1009.83,,,1009.83,Other,125% Medicaid APG methodology,0.01,4452.7,
NJX AA&/STRD GR OCPL NRV        ,64405,CPT,,50057066,CDM,450,RC,,,both,,,3440,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1204.2,,,1204.2,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,2408,70,,2408,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% Medicaid APG methodology,647.42,,,647.42,Other,100% Medicaid APG methodology,647.42,,,647.42,Other,100% Medicaid APG methodology,1456.69,,,1456.69,Other,225% Medicaid APG methodology,1456.69,,,1456.69,Other,225% Medicaid APG methodology,990.55,,,990.55,Other,153% Medicaid APG methodology,1456.69,,,1456.69,Other,225% Medicaid APG methodology,906.38,,,906.38,Other,140% Medicaid APG methodology,1456.69,,,1456.69,Other,225% Medicaid APG methodology,1683.28,,,1683.28,Other,260% Medicaid APG methodology,2097.63,,,2097.63,Other,324% Medicaid APG methodology,1391.95,,,1391.95,Other,215% Medicaid APG methodology,1391.95,,,1391.95,Other,215% Medicaid APG methodology,809.27,,,809.27,Other,125% Medicaid APG methodology,0.01,2408,
PSEUDOANEURYSM INJECTION TRT    ,36002,CPT,,50057074,CDM,450,RC,,,both,,,2128,1194.63,,,1194.63,Other,150% of Medicare + 9.63% HCRA Surcharge,726.46,,,726.46,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,896.55,,,896.55,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1489.6,70,,1489.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,482.02,,,482.02,Other,New York Medicaid APG methodology,482.02,,,482.02,Other,100% Medicaid APG methodology,482.02,,,482.02,Other,100% Medicaid APG methodology,482.02,,,482.02,Other,100% Medicaid APG methodology,1084.54,,,1084.54,Other,225% Medicaid APG methodology,1084.54,,,1084.54,Other,225% Medicaid APG methodology,737.49,,,737.49,Other,153% Medicaid APG methodology,1084.54,,,1084.54,Other,225% Medicaid APG methodology,674.83,,,674.83,Other,140% Medicaid APG methodology,1084.54,,,1084.54,Other,225% Medicaid APG methodology,1253.25,,,1253.25,Other,260% Medicaid APG methodology,1561.74,,,1561.74,Other,324% Medicaid APG methodology,1036.34,,,1036.34,Other,215% Medicaid APG methodology,1036.34,,,1036.34,Other,215% Medicaid APG methodology,602.52,,,602.52,Other,125% Medicaid APG methodology,0.01,1561.74,
INTERROGATE SUBQ DEFIB          ,93261,CPT,,50057751,CDM,450,RC,,,both,,,205,71.71,,,71.71,Other,150% of Medicare + 9.63% HCRA Surcharge,43.61,,,43.61,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,207.55,,,207.55,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,143.5,70,,143.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,111.58,,,111.58,Other,New York Medicaid APG methodology,111.58,,,111.58,Other,100% Medicaid APG methodology,111.58,,,111.58,Other,100% Medicaid APG methodology,111.58,,,111.58,Other,100% Medicaid APG methodology,251.06,,,251.06,Other,225% Medicaid APG methodology,251.06,,,251.06,Other,225% Medicaid APG methodology,170.72,,,170.72,Other,153% Medicaid APG methodology,251.06,,,251.06,Other,225% Medicaid APG methodology,156.22,,,156.22,Other,140% Medicaid APG methodology,251.06,,,251.06,Other,225% Medicaid APG methodology,290.12,,,290.12,Other,260% Medicaid APG methodology,361.53,,,361.53,Other,324% Medicaid APG methodology,239.91,,,239.91,Other,215% Medicaid APG methodology,239.91,,,239.91,Other,215% Medicaid APG methodology,139.48,,,139.48,Other,125% Medicaid APG methodology,0.01,361.53,
US URINE CAPACITY MEASURE       ,51798,CPT,,50057769,CDM,450,RC,,,both,,,1129,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,824.98,,,824.98,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,790.3,70,,790.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,443.54,,,443.54,Other,New York Medicaid APG methodology,443.54,,,443.54,Other,100% Medicaid APG methodology,443.54,,,443.54,Other,100% Medicaid APG methodology,443.54,,,443.54,Other,100% Medicaid APG methodology,997.96,,,997.96,Other,225% Medicaid APG methodology,997.96,,,997.96,Other,225% Medicaid APG methodology,678.62,,,678.62,Other,153% Medicaid APG methodology,997.96,,,997.96,Other,225% Medicaid APG methodology,620.96,,,620.96,Other,140% Medicaid APG methodology,997.96,,,997.96,Other,225% Medicaid APG methodology,1153.2,,,1153.2,Other,260% Medicaid APG methodology,1437.07,,,1437.07,Other,324% Medicaid APG methodology,953.61,,,953.61,Other,215% Medicaid APG methodology,953.61,,,953.61,Other,215% Medicaid APG methodology,554.42,,,554.42,Other,125% Medicaid APG methodology,0.01,1437.07,
DRAIN INJ INTER JOINT BURSAWUS  ,20606,CPT,,50057934,CDM,450,RC,,,both,,,2516,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,1351.14,,,1351.14,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Inclusive of Other Service,1761.2,70,,1761.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,726.42,,,726.42,Other,New York Medicaid APG methodology,726.42,,,726.42,Other,100% Medicaid APG methodology,726.42,,,726.42,Other,100% Medicaid APG methodology,726.42,,,726.42,Other,100% Medicaid APG methodology,1634.45,,,1634.45,Other,225% Medicaid APG methodology,1634.45,,,1634.45,Other,225% Medicaid APG methodology,1111.42,,,1111.42,Other,153% Medicaid APG methodology,1634.45,,,1634.45,Other,225% Medicaid APG methodology,1016.99,,,1016.99,Other,140% Medicaid APG methodology,1634.45,,,1634.45,Other,225% Medicaid APG methodology,1888.69,,,1888.69,Other,260% Medicaid APG methodology,2353.6,,,2353.6,Other,324% Medicaid APG methodology,1561.8,,,1561.8,Other,215% Medicaid APG methodology,1561.8,,,1561.8,Other,215% Medicaid APG methodology,908.03,,,908.03,Other,125% Medicaid APG methodology,0.01,2353.6,
BREATHING CAPACITY TEST         ,94010,CPT,,46400008,CDM,460,RC,,,both,,,1287,297.05,,,297.05,Other,150% of Medicare + 9.63% HCRA Surcharge,180.63,,,180.63,Other,Medicare OPPS methodology,643.5,50,,643.5,percent of total billed charges,All Other Outpatient,579.15,45,,579.15,percent of total billed charges,All Other Outpatient,246.42,,,246.42,Fee Schedule,,221.71,,,221.71,Fee Schedule,,209.35,,,209.35,Fee Schedule,,643.5,50,,643.5,percent of total billed charges,All Other,900.9,70,,900.9,percent of total billed charges,All Other,87.25,,,87.25,Fee Schedule,,188.85,,,188.85,Other,186% Medicaid methodology,102.67,,,102.67,Fee Schedule,,797.94,,,797.94,Fee Schedule,,48.34,,,48.34,Fee Schedule,,102.67,,,102.67,Fee Schedule,,797.94,,,797.94,Fee Schedule,,1158.3,90,,1158.3,percent of total billed charges,All Other,900.9,70,,900.9,percent of total billed charges,All Other,90.75,,,90.75,Fee Schedule,,77,,,77,Fee Schedule,,1441,,,1441,Case Rate,Pulm Function Per Visit,1791,,,1791,Case Rate,Pulm Function Per Visit,1990,,,1990,Case Rate,Pulm Function Per Visit,1692,,,1692,Case Rate,Pulm Function Per Visit,101.53,,,101.53,Other,New York Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,155.34,,,155.34,Other,153% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,142.14,,,142.14,Other,140% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,263.98,,,263.98,Other,260% Medicaid APG methodology,328.96,,,328.96,Other,324% Medicaid APG methodology,218.29,,,218.29,Other,215% Medicaid APG methodology,218.29,,,218.29,Other,215% Medicaid APG methodology,126.92,,,126.92,Other,125% Medicaid APG methodology,48.34,1990,
EVALUATION OF WHEEZING          ,94060,CPT,,46400016,CDM,460,RC,,,both,,,3204,596.88,,,596.88,Other,150% of Medicare + 9.63% HCRA Surcharge,362.97,,,362.97,Other,Medicare OPPS methodology,1602,50,,1602,percent of total billed charges,All Other Outpatient,1441.8,45,,1441.8,percent of total billed charges,All Other Outpatient,424.12,,,424.12,Fee Schedule,,381.59,,,381.59,Fee Schedule,,360.33,,,360.33,Fee Schedule,,1602,50,,1602,percent of total billed charges,All Other,2242.8,70,,2242.8,percent of total billed charges,All Other,130.45,,,130.45,Fee Schedule,,588.26,,,588.26,Other,186% Medicaid methodology,153.51,,,153.51,Fee Schedule,,1986.48,,,1986.48,Fee Schedule,,72.28,,,72.28,Fee Schedule,,153.51,,,153.51,Fee Schedule,,1986.48,,,1986.48,Fee Schedule,,2883.6,90,,2883.6,percent of total billed charges,All Other,2242.8,70,,2242.8,percent of total billed charges,All Other,140.25,,,140.25,Fee Schedule,,119,,,119,Fee Schedule,,1441,,,1441,Case Rate,Pulm Function Per Visit,1791,,,1791,Case Rate,Pulm Function Per Visit,1990,,,1990,Case Rate,Pulm Function Per Visit,1692,,,1692,Case Rate,Pulm Function Per Visit,316.27,,,316.27,Other,New York Medicaid APG methodology,316.27,,,316.27,Other,100% Medicaid APG methodology,316.27,,,316.27,Other,100% Medicaid APG methodology,316.27,,,316.27,Other,100% Medicaid APG methodology,711.61,,,711.61,Other,225% Medicaid APG methodology,711.61,,,711.61,Other,225% Medicaid APG methodology,483.89,,,483.89,Other,153% Medicaid APG methodology,711.61,,,711.61,Other,225% Medicaid APG methodology,442.78,,,442.78,Other,140% Medicaid APG methodology,711.61,,,711.61,Other,225% Medicaid APG methodology,822.3,,,822.3,Other,260% Medicaid APG methodology,1024.72,,,1024.72,Other,324% Medicaid APG methodology,679.98,,,679.98,Other,215% Medicaid APG methodology,679.98,,,679.98,Other,215% Medicaid APG methodology,395.34,,,395.34,Other,125% Medicaid APG methodology,72.28,2883.6,
RESPIRATORY FLOW VOLUME LOOP    ,94375,CPT,,46400040,CDM,460,RC,,,both,,,1031,596.88,,,596.88,Other,150% of Medicare + 9.63% HCRA Surcharge,362.97,,,362.97,Other,Medicare OPPS methodology,515.5,50,,515.5,percent of total billed charges,All Other Outpatient,463.95,45,,463.95,percent of total billed charges,All Other Outpatient,218.34,,,218.34,Fee Schedule,,196.45,,,196.45,Fee Schedule,,185.5,,,185.5,Fee Schedule,,515.5,50,,515.5,percent of total billed charges,All Other,721.7,70,,721.7,percent of total billed charges,All Other,112.56,,,112.56,Fee Schedule,,588.26,,,588.26,Other,186% Medicaid methodology,132.46,,,132.46,Fee Schedule,,639.22,,,639.22,Fee Schedule,,62.37,,,62.37,Fee Schedule,,132.46,,,132.46,Fee Schedule,,639.22,,,639.22,Fee Schedule,,927.9,90,,927.9,percent of total billed charges,All Other,721.7,70,,721.7,percent of total billed charges,All Other,117.15,,,117.15,Fee Schedule,,99.4,,,99.4,Fee Schedule,,1441,,,1441,Case Rate,Pulm Function Per Visit,1791,,,1791,Case Rate,Pulm Function Per Visit,1990,,,1990,Case Rate,Pulm Function Per Visit,1692,,,1692,Case Rate,Pulm Function Per Visit,316.27,,,316.27,Other,New York Medicaid APG methodology,316.27,,,316.27,Other,100% Medicaid APG methodology,316.27,,,316.27,Other,100% Medicaid APG methodology,316.27,,,316.27,Other,100% Medicaid APG methodology,711.61,,,711.61,Other,225% Medicaid APG methodology,711.61,,,711.61,Other,225% Medicaid APG methodology,483.89,,,483.89,Other,153% Medicaid APG methodology,711.61,,,711.61,Other,225% Medicaid APG methodology,442.78,,,442.78,Other,140% Medicaid APG methodology,711.61,,,711.61,Other,225% Medicaid APG methodology,822.3,,,822.3,Other,260% Medicaid APG methodology,1024.72,,,1024.72,Other,324% Medicaid APG methodology,679.98,,,679.98,Other,215% Medicaid APG methodology,679.98,,,679.98,Other,215% Medicaid APG methodology,395.34,,,395.34,Other,125% Medicaid APG methodology,62.37,1990,
MEASURE BLOOD OXYGEN LVL MULT   ,94761,CPT,,46400164,CDM,460,RC,,,both,,,380,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,190,50,,190,percent of total billed charges,All Other Outpatient,171,45,,171,percent of total billed charges,All Other Outpatient,40.64,,,40.64,Fee Schedule,,36.56,,,36.56,Fee Schedule,,34.53,,,34.53,Fee Schedule,,190,50,,190,percent of total billed charges,All Other,266,70,,266,percent of total billed charges,All Other,18.76,,,18.76,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,22.08,,,22.08,Fee Schedule,,235.6,,,235.6,Fee Schedule,,10.4,,,10.4,Fee Schedule,,22.08,,,22.08,Fee Schedule,,235.6,,,235.6,Fee Schedule,,342,90,,342,percent of total billed charges,All Other,266,70,,266,percent of total billed charges,All Other,16.5,,,16.5,Fee Schedule,,14,,,14,Fee Schedule,,1441,,,1441,Case Rate,Pulm Function Per Visit,1791,,,1791,Case Rate,Pulm Function Per Visit,1990,,,1990,Case Rate,Pulm Function Per Visit,1692,,,1692,Case Rate,Pulm Function Per Visit,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1990,
MEASURE BLOOD OXYGEN LVL SNGL   ,94760,CPT,,46400180,CDM,460,RC,,,both,,,260,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,130,50,,130,percent of total billed charges,All Other Outpatient,117,45,,117,percent of total billed charges,All Other Outpatient,25.06,,,25.06,Fee Schedule,,22.55,,,22.55,Fee Schedule,,21.29,,,21.29,Fee Schedule,,130,50,,130,percent of total billed charges,All Other,182,70,,182,percent of total billed charges,All Other,12.81,,,12.81,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,15.07,,,15.07,Fee Schedule,,161.2,,,161.2,Fee Schedule,,7.1,,,7.1,Fee Schedule,,15.07,,,15.07,Fee Schedule,,161.2,,,161.2,Fee Schedule,,234,90,,234,percent of total billed charges,All Other,182,70,,182,percent of total billed charges,All Other,11.55,,,11.55,Fee Schedule,,9.8,,,9.8,Fee Schedule,,1441,,,1441,Case Rate,Pulm Function Per Visit,1791,,,1791,Case Rate,Pulm Function Per Visit,1990,,,1990,Case Rate,Pulm Function Per Visit,1692,,,1692,Case Rate,Pulm Function Per Visit,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1990,
PULM FUNCT TST PLETHYSMOGRAP    ,94726,CPT,,46400412,CDM,460,RC,,,both,,,965,596.88,,,596.88,Other,150% of Medicare + 9.63% HCRA Surcharge,362.97,,,362.97,Other,Medicare OPPS methodology,482.5,50,,482.5,percent of total billed charges,All Other Outpatient,434.25,45,,434.25,percent of total billed charges,All Other Outpatient,41.15,,,41.15,Fee Schedule,,41.15,,,41.15,Fee Schedule,,41.15,,,41.15,Fee Schedule,,482.5,50,,482.5,percent of total billed charges,All Other,675.5,70,,675.5,percent of total billed charges,All Other,199.85,,,199.85,Fee Schedule,,588.26,,,588.26,Other,186% Medicaid methodology,235.18,,,235.18,Fee Schedule,,598.3,,,598.3,Fee Schedule,,110.73,,,110.73,Fee Schedule,,235.18,,,235.18,Fee Schedule,,598.3,,,598.3,Fee Schedule,,868.5,90,,868.5,percent of total billed charges,All Other,675.5,70,,675.5,percent of total billed charges,All Other,207.9,,,207.9,Fee Schedule,,176.4,,,176.4,Fee Schedule,,1441,,,1441,Case Rate,Pulm Function Per Visit,1791,,,1791,Case Rate,Pulm Function Per Visit,1990,,,1990,Case Rate,Pulm Function Per Visit,1692,,,1692,Case Rate,Pulm Function Per Visit,316.27,,,316.27,Other,New York Medicaid APG methodology,316.27,,,316.27,Other,100% Medicaid APG methodology,316.27,,,316.27,Other,100% Medicaid APG methodology,316.27,,,316.27,Other,100% Medicaid APG methodology,711.61,,,711.61,Other,225% Medicaid APG methodology,711.61,,,711.61,Other,225% Medicaid APG methodology,483.89,,,483.89,Other,153% Medicaid APG methodology,711.61,,,711.61,Other,225% Medicaid APG methodology,442.78,,,442.78,Other,140% Medicaid APG methodology,711.61,,,711.61,Other,225% Medicaid APG methodology,822.3,,,822.3,Other,260% Medicaid APG methodology,1024.72,,,1024.72,Other,324% Medicaid APG methodology,679.98,,,679.98,Other,215% Medicaid APG methodology,679.98,,,679.98,Other,215% Medicaid APG methodology,395.34,,,395.34,Other,125% Medicaid APG methodology,41.15,1990,
PULM FUNCTION TEST BY GAS       ,94727,CPT,,46400438,CDM,460,RC,,,both,,,745,297.05,,,297.05,Other,150% of Medicare + 9.63% HCRA Surcharge,180.63,,,180.63,Other,Medicare OPPS methodology,372.5,50,,372.5,percent of total billed charges,All Other Outpatient,335.25,45,,335.25,percent of total billed charges,All Other Outpatient,30.61,,,30.61,Fee Schedule,,30.61,,,30.61,Fee Schedule,,30.61,,,30.61,Fee Schedule,,372.5,50,,372.5,percent of total billed charges,All Other,521.5,70,,521.5,percent of total billed charges,All Other,148.3,,,148.3,Fee Schedule,,188.85,,,188.85,Other,186% Medicaid methodology,174.52,,,174.52,Fee Schedule,,461.9,,,461.9,Fee Schedule,,82.17,,,82.17,Fee Schedule,,174.52,,,174.52,Fee Schedule,,461.9,,,461.9,Fee Schedule,,670.5,90,,670.5,percent of total billed charges,All Other,521.5,70,,521.5,percent of total billed charges,All Other,155.1,,,155.1,Fee Schedule,,131.6,,,131.6,Fee Schedule,,1441,,,1441,Case Rate,Pulm Function Per Visit,1791,,,1791,Case Rate,Pulm Function Per Visit,1990,,,1990,Case Rate,Pulm Function Per Visit,1692,,,1692,Case Rate,Pulm Function Per Visit,101.53,,,101.53,Other,New York Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,155.34,,,155.34,Other,153% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,142.14,,,142.14,Other,140% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,263.98,,,263.98,Other,260% Medicaid APG methodology,328.96,,,328.96,Other,324% Medicaid APG methodology,218.29,,,218.29,Other,215% Medicaid APG methodology,218.29,,,218.29,Other,215% Medicaid APG methodology,126.92,,,126.92,Other,125% Medicaid APG methodology,30.61,1990,
CO/MEMBANE DIFFUSE CAPACITY     ,94729,CPT,,46400446,CDM,460,RC,,,both,,,1541,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,770.5,50,,770.5,percent of total billed charges,All Other Outpatient,693.45,45,,693.45,percent of total billed charges,All Other Outpatient,43.87,,,43.87,Fee Schedule,,43.87,,,43.87,Fee Schedule,,43.87,,,43.87,Fee Schedule,,770.5,50,,770.5,percent of total billed charges,All Other,1078.7,70,,1078.7,percent of total billed charges,All Other,215.31,,,215.31,Fee Schedule,,188.85,,,188.85,Other,186% Medicaid methodology,253.37,,,253.37,Fee Schedule,,955.42,,,955.42,Fee Schedule,,119.3,,,119.3,Fee Schedule,,253.37,,,253.37,Fee Schedule,,955.42,,,955.42,Fee Schedule,,1386.9,90,,1386.9,percent of total billed charges,All Other,1078.7,70,,1078.7,percent of total billed charges,All Other,242.55,,,242.55,Fee Schedule,,205.8,,,205.8,Fee Schedule,,1441,,,1441,Case Rate,Pulm Function Per Visit,1791,,,1791,Case Rate,Pulm Function Per Visit,1990,,,1990,Case Rate,Pulm Function Per Visit,1692,,,1692,Case Rate,Pulm Function Per Visit,101.53,,,101.53,Other,New York Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,155.34,,,155.34,Other,153% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,142.14,,,142.14,Other,140% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,263.98,,,263.98,Other,260% Medicaid APG methodology,328.96,,,328.96,Other,324% Medicaid APG methodology,218.29,,,218.29,Other,215% Medicaid APG methodology,218.29,,,218.29,Other,215% Medicaid APG methodology,126.92,,,126.92,Other,125% Medicaid APG methodology,0.01,1990,
EVALUATION OF WHEEZING          ,94060,CPT,,46500039,CDM,460,RC,,,both,,,3204,596.88,,,596.88,Other,150% of Medicare + 9.63% HCRA Surcharge,362.97,,,362.97,Other,Medicare OPPS methodology,1602,50,,1602,percent of total billed charges,All Other Outpatient,1441.8,45,,1441.8,percent of total billed charges,All Other Outpatient,424.12,,,424.12,Fee Schedule,,381.59,,,381.59,Fee Schedule,,360.33,,,360.33,Fee Schedule,,1602,50,,1602,percent of total billed charges,All Other,2242.8,70,,2242.8,percent of total billed charges,All Other,130.45,,,130.45,Fee Schedule,,588.26,,,588.26,Other,186% Medicaid methodology,153.51,,,153.51,Fee Schedule,,1986.48,,,1986.48,Fee Schedule,,72.28,,,72.28,Fee Schedule,,153.51,,,153.51,Fee Schedule,,1986.48,,,1986.48,Fee Schedule,,2883.6,90,,2883.6,percent of total billed charges,All Other,2242.8,70,,2242.8,percent of total billed charges,All Other,140.25,,,140.25,Fee Schedule,,119,,,119,Fee Schedule,,1441,,,1441,Case Rate,Pulm Function Per Visit,1791,,,1791,Case Rate,Pulm Function Per Visit,1990,,,1990,Case Rate,Pulm Function Per Visit,1692,,,1692,Case Rate,Pulm Function Per Visit,316.27,,,316.27,Other,New York Medicaid APG methodology,316.27,,,316.27,Other,100% Medicaid APG methodology,316.27,,,316.27,Other,100% Medicaid APG methodology,316.27,,,316.27,Other,100% Medicaid APG methodology,711.61,,,711.61,Other,225% Medicaid APG methodology,711.61,,,711.61,Other,225% Medicaid APG methodology,483.89,,,483.89,Other,153% Medicaid APG methodology,711.61,,,711.61,Other,225% Medicaid APG methodology,442.78,,,442.78,Other,140% Medicaid APG methodology,711.61,,,711.61,Other,225% Medicaid APG methodology,822.3,,,822.3,Other,260% Medicaid APG methodology,1024.72,,,1024.72,Other,324% Medicaid APG methodology,679.98,,,679.98,Other,215% Medicaid APG methodology,679.98,,,679.98,Other,215% Medicaid APG methodology,395.34,,,395.34,Other,125% Medicaid APG methodology,72.28,2883.6,
LUNG FUNCTION TEST (MBC/MVV)    ,94200,CPT,,46500096,CDM,460,RC,,,both,,,288,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,144,50,,144,percent of total billed charges,All Other Outpatient,129.6,45,,129.6,percent of total billed charges,All Other Outpatient,171.6,,,171.6,Fee Schedule,,154.39,,,154.39,Fee Schedule,,145.79,,,145.79,Fee Schedule,,144,50,,144,percent of total billed charges,All Other,201.6,70,,201.6,percent of total billed charges,All Other,55.98,,,55.98,Fee Schedule,,188.85,,,188.85,Other,186% Medicaid methodology,65.87,,,65.87,Fee Schedule,,178.56,,,178.56,Fee Schedule,,31.02,,,31.02,Fee Schedule,,65.87,,,65.87,Fee Schedule,,178.56,,,178.56,Fee Schedule,,259.2,90,,259.2,percent of total billed charges,All Other,201.6,70,,201.6,percent of total billed charges,All Other,59.4,,,59.4,Fee Schedule,,50.4,,,50.4,Fee Schedule,,1441,,,1441,Case Rate,Pulm Function Per Visit,1791,,,1791,Case Rate,Pulm Function Per Visit,1990,,,1990,Case Rate,Pulm Function Per Visit,1692,,,1692,Case Rate,Pulm Function Per Visit,101.53,,,101.53,Other,New York Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,155.34,,,155.34,Other,153% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,142.14,,,142.14,Other,140% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,263.98,,,263.98,Other,260% Medicaid APG methodology,328.96,,,328.96,Other,324% Medicaid APG methodology,218.29,,,218.29,Other,215% Medicaid APG methodology,218.29,,,218.29,Other,215% Medicaid APG methodology,126.92,,,126.92,Other,125% Medicaid APG methodology,31.02,1990,
BREATHING CAPACITY TEST         ,94010,CPT,,46500146,CDM,460,RC,,,both,,,1287,297.05,,,297.05,Other,150% of Medicare + 9.63% HCRA Surcharge,180.63,,,180.63,Other,Medicare OPPS methodology,643.5,50,,643.5,percent of total billed charges,All Other Outpatient,579.15,45,,579.15,percent of total billed charges,All Other Outpatient,246.42,,,246.42,Fee Schedule,,221.71,,,221.71,Fee Schedule,,209.35,,,209.35,Fee Schedule,,643.5,50,,643.5,percent of total billed charges,All Other,900.9,70,,900.9,percent of total billed charges,All Other,87.25,,,87.25,Fee Schedule,,188.85,,,188.85,Other,186% Medicaid methodology,102.67,,,102.67,Fee Schedule,,797.94,,,797.94,Fee Schedule,,48.34,,,48.34,Fee Schedule,,102.67,,,102.67,Fee Schedule,,797.94,,,797.94,Fee Schedule,,1158.3,90,,1158.3,percent of total billed charges,All Other,900.9,70,,900.9,percent of total billed charges,All Other,90.75,,,90.75,Fee Schedule,,77,,,77,Fee Schedule,,1441,,,1441,Case Rate,Pulm Function Per Visit,1791,,,1791,Case Rate,Pulm Function Per Visit,1990,,,1990,Case Rate,Pulm Function Per Visit,1692,,,1692,Case Rate,Pulm Function Per Visit,101.53,,,101.53,Other,New York Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,155.34,,,155.34,Other,153% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,142.14,,,142.14,Other,140% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,263.98,,,263.98,Other,260% Medicaid APG methodology,328.96,,,328.96,Other,324% Medicaid APG methodology,218.29,,,218.29,Other,215% Medicaid APG methodology,218.29,,,218.29,Other,215% Medicaid APG methodology,126.92,,,126.92,Other,125% Medicaid APG methodology,48.34,1990,
MEASURE BLOOD OXYGEN LVL SNGL   ,94760,CPT,,46500229,CDM,460,RC,,,both,,,260,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,130,50,,130,percent of total billed charges,All Other Outpatient,117,45,,117,percent of total billed charges,All Other Outpatient,25.06,,,25.06,Fee Schedule,,22.55,,,22.55,Fee Schedule,,21.29,,,21.29,Fee Schedule,,130,50,,130,percent of total billed charges,All Other,182,70,,182,percent of total billed charges,All Other,12.81,,,12.81,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,15.07,,,15.07,Fee Schedule,,161.2,,,161.2,Fee Schedule,,7.1,,,7.1,Fee Schedule,,15.07,,,15.07,Fee Schedule,,161.2,,,161.2,Fee Schedule,,234,90,,234,percent of total billed charges,All Other,182,70,,182,percent of total billed charges,All Other,11.55,,,11.55,Fee Schedule,,9.8,,,9.8,Fee Schedule,,1441,,,1441,Case Rate,Pulm Function Per Visit,1791,,,1791,Case Rate,Pulm Function Per Visit,1990,,,1990,Case Rate,Pulm Function Per Visit,1692,,,1692,Case Rate,Pulm Function Per Visit,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1990,
MEASURE BLOOD OXYGEN LVL MULT   ,94761,CPT,,46500237,CDM,460,RC,,,both,,,380,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,190,50,,190,percent of total billed charges,All Other Outpatient,171,45,,171,percent of total billed charges,All Other Outpatient,40.64,,,40.64,Fee Schedule,,36.56,,,36.56,Fee Schedule,,34.53,,,34.53,Fee Schedule,,190,50,,190,percent of total billed charges,All Other,266,70,,266,percent of total billed charges,All Other,18.76,,,18.76,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,22.08,,,22.08,Fee Schedule,,235.6,,,235.6,Fee Schedule,,10.4,,,10.4,Fee Schedule,,22.08,,,22.08,Fee Schedule,,235.6,,,235.6,Fee Schedule,,342,90,,342,percent of total billed charges,All Other,266,70,,266,percent of total billed charges,All Other,16.5,,,16.5,Fee Schedule,,14,,,14,Fee Schedule,,1441,,,1441,Case Rate,Pulm Function Per Visit,1791,,,1791,Case Rate,Pulm Function Per Visit,1990,,,1990,Case Rate,Pulm Function Per Visit,1692,,,1692,Case Rate,Pulm Function Per Visit,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1990,
PULM FUNCT TST PLETHYSMOGRAP    ,94726,CPT,,46500641,CDM,460,RC,,,both,,,1008,596.88,,,596.88,Other,150% of Medicare + 9.63% HCRA Surcharge,362.97,,,362.97,Other,Medicare OPPS methodology,504,50,,504,percent of total billed charges,All Other Outpatient,453.6,45,,453.6,percent of total billed charges,All Other Outpatient,41.15,,,41.15,Fee Schedule,,41.15,,,41.15,Fee Schedule,,41.15,,,41.15,Fee Schedule,,504,50,,504,percent of total billed charges,All Other,705.6,70,,705.6,percent of total billed charges,All Other,199.85,,,199.85,Fee Schedule,,588.26,,,588.26,Other,186% Medicaid methodology,235.18,,,235.18,Fee Schedule,,624.96,,,624.96,Fee Schedule,,110.73,,,110.73,Fee Schedule,,235.18,,,235.18,Fee Schedule,,624.96,,,624.96,Fee Schedule,,907.2,90,,907.2,percent of total billed charges,All Other,705.6,70,,705.6,percent of total billed charges,All Other,207.9,,,207.9,Fee Schedule,,176.4,,,176.4,Fee Schedule,,1441,,,1441,Case Rate,Pulm Function Per Visit,1791,,,1791,Case Rate,Pulm Function Per Visit,1990,,,1990,Case Rate,Pulm Function Per Visit,1692,,,1692,Case Rate,Pulm Function Per Visit,316.27,,,316.27,Other,New York Medicaid APG methodology,316.27,,,316.27,Other,100% Medicaid APG methodology,316.27,,,316.27,Other,100% Medicaid APG methodology,316.27,,,316.27,Other,100% Medicaid APG methodology,711.61,,,711.61,Other,225% Medicaid APG methodology,711.61,,,711.61,Other,225% Medicaid APG methodology,483.89,,,483.89,Other,153% Medicaid APG methodology,711.61,,,711.61,Other,225% Medicaid APG methodology,442.78,,,442.78,Other,140% Medicaid APG methodology,711.61,,,711.61,Other,225% Medicaid APG methodology,822.3,,,822.3,Other,260% Medicaid APG methodology,1024.72,,,1024.72,Other,324% Medicaid APG methodology,679.98,,,679.98,Other,215% Medicaid APG methodology,679.98,,,679.98,Other,215% Medicaid APG methodology,395.34,,,395.34,Other,125% Medicaid APG methodology,41.15,1990,
PULM FUNCTION TEST BY GAS       ,94727,CPT,,46500666,CDM,460,RC,,,both,,,745,297.05,,,297.05,Other,150% of Medicare + 9.63% HCRA Surcharge,180.63,,,180.63,Other,Medicare OPPS methodology,372.5,50,,372.5,percent of total billed charges,All Other Outpatient,335.25,45,,335.25,percent of total billed charges,All Other Outpatient,30.61,,,30.61,Fee Schedule,,30.61,,,30.61,Fee Schedule,,30.61,,,30.61,Fee Schedule,,372.5,50,,372.5,percent of total billed charges,All Other,521.5,70,,521.5,percent of total billed charges,All Other,148.3,,,148.3,Fee Schedule,,188.85,,,188.85,Other,186% Medicaid methodology,174.52,,,174.52,Fee Schedule,,461.9,,,461.9,Fee Schedule,,82.17,,,82.17,Fee Schedule,,174.52,,,174.52,Fee Schedule,,461.9,,,461.9,Fee Schedule,,670.5,90,,670.5,percent of total billed charges,All Other,521.5,70,,521.5,percent of total billed charges,All Other,155.1,,,155.1,Fee Schedule,,131.6,,,131.6,Fee Schedule,,1441,,,1441,Case Rate,Pulm Function Per Visit,1791,,,1791,Case Rate,Pulm Function Per Visit,1990,,,1990,Case Rate,Pulm Function Per Visit,1692,,,1692,Case Rate,Pulm Function Per Visit,101.53,,,101.53,Other,New York Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,155.34,,,155.34,Other,153% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,142.14,,,142.14,Other,140% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,263.98,,,263.98,Other,260% Medicaid APG methodology,328.96,,,328.96,Other,324% Medicaid APG methodology,218.29,,,218.29,Other,215% Medicaid APG methodology,218.29,,,218.29,Other,215% Medicaid APG methodology,126.92,,,126.92,Other,125% Medicaid APG methodology,30.61,1990,
CO/MEMBANE DIFFUSE CAPACITY     ,94729,CPT,,46500674,CDM,460,RC,,,both,,,1541,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,770.5,50,,770.5,percent of total billed charges,All Other Outpatient,693.45,45,,693.45,percent of total billed charges,All Other Outpatient,43.87,,,43.87,Fee Schedule,,43.87,,,43.87,Fee Schedule,,43.87,,,43.87,Fee Schedule,,770.5,50,,770.5,percent of total billed charges,All Other,1078.7,70,,1078.7,percent of total billed charges,All Other,215.31,,,215.31,Fee Schedule,,188.85,,,188.85,Other,186% Medicaid methodology,253.37,,,253.37,Fee Schedule,,955.42,,,955.42,Fee Schedule,,119.3,,,119.3,Fee Schedule,,253.37,,,253.37,Fee Schedule,,955.42,,,955.42,Fee Schedule,,1386.9,90,,1386.9,percent of total billed charges,All Other,1078.7,70,,1078.7,percent of total billed charges,All Other,242.55,,,242.55,Fee Schedule,,205.8,,,205.8,Fee Schedule,,1441,,,1441,Case Rate,Pulm Function Per Visit,1791,,,1791,Case Rate,Pulm Function Per Visit,1990,,,1990,Case Rate,Pulm Function Per Visit,1692,,,1692,Case Rate,Pulm Function Per Visit,101.53,,,101.53,Other,New York Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,101.53,,,101.53,Other,100% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,155.34,,,155.34,Other,153% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,142.14,,,142.14,Other,140% Medicaid APG methodology,228.45,,,228.45,Other,225% Medicaid APG methodology,263.98,,,263.98,Other,260% Medicaid APG methodology,328.96,,,328.96,Other,324% Medicaid APG methodology,218.29,,,218.29,Other,215% Medicaid APG methodology,218.29,,,218.29,Other,215% Medicaid APG methodology,126.92,,,126.92,Other,125% Medicaid APG methodology,0.01,1990,
EVAL AUD FUNCJ 1ST HOUR         ,92626,CPT,,48801104,CDM,471,RC,,,both,,,570,297.05,,,297.05,Other,150% of Medicare + 9.63% HCRA Surcharge,180.63,,,180.63,Other,Medicare OPPS methodology,285,50,,285,percent of total billed charges,All Other Outpatient,256.5,45,,256.5,percent of total billed charges,All Other Outpatient,693.16,,,693.16,Fee Schedule,,623.65,,,623.65,Fee Schedule,,588.89,,,588.89,Fee Schedule,,285,50,,285,percent of total billed charges,All Other,399,70,,399,percent of total billed charges,All Other,307.71,,,307.71,Fee Schedule,,283.77,,,283.77,Other,186% Medicaid methodology,362.11,,,362.11,Fee Schedule,,353.4,,,353.4,Fee Schedule,,170.5,,,170.5,Fee Schedule,,362.11,,,362.11,Fee Schedule,,353.4,,,353.4,Fee Schedule,,513,90,,513,percent of total billed charges,All Other,399,70,,399,percent of total billed charges,All Other,361.35,,,361.35,Fee Schedule,,306.6,,,306.6,Fee Schedule,,458,,,458,Case Rate,Audiology Per Visit,363,,,363,Case Rate,Audiology Per Visit,401,,,401,Case Rate,Audiology Per Visit,341,,,341,Case Rate,Audiology Per Visit,152.57,,,152.57,Other,New York Medicaid APG methodology,152.57,,,152.57,Other,100% Medicaid APG methodology,152.57,,,152.57,Other,100% Medicaid APG methodology,152.57,,,152.57,Other,100% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,233.43,,,233.43,Other,153% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,213.59,,,213.59,Other,140% Medicaid APG methodology,343.27,,,343.27,Other,225% Medicaid APG methodology,396.67,,,396.67,Other,260% Medicaid APG methodology,494.32,,,494.32,Other,324% Medicaid APG methodology,328.02,,,328.02,Other,215% Medicaid APG methodology,328.02,,,328.02,Other,215% Medicaid APG methodology,190.71,,,190.71,Other,125% Medicaid APG methodology,152.57,693.16,
CARDIOVERSION ELECTRIC EXT      ,92960,CPT,,44401412,CDM,480,RC,,,both,,,6121,1237.64,,,1237.64,Other,150% of Medicare + 9.63% HCRA Surcharge,752.62,,,752.62,Other,Medicare OPPS methodology,246.38,,,246.38,Fee Schedule,,221.26,,,221.26,Fee Schedule,,2087.23,,,2087.23,Fee Schedule,,1877.92,,,1877.92,Fee Schedule,,1773.27,,,1773.27,Fee Schedule,,3060.5,50,,3060.5,percent of total billed charges,All Other,4284.7,70,,4284.7,percent of total billed charges,All Other,453.28,,,453.28,Fee Schedule,,1106.33,,,1106.33,Other,186% Medicaid methodology,533.42,,,533.42,Fee Schedule,,3795.02,,,3795.02,Fee Schedule,,251.16,,,251.16,Fee Schedule,,533.42,,,533.42,Fee Schedule,,3795.02,,,3795.02,Fee Schedule,,5508.9,90,,5508.9,percent of total billed charges,All Other,4284.7,70,,4284.7,percent of total billed charges,All Other,521.4,,,521.4,Fee Schedule,,442.4,,,442.4,Fee Schedule,,906,,,906,Case Rate,Cardiology Per Visit,780,,,780,Case Rate,Cardiology Per Visit,867,,,867,Case Rate,Cardiology Per Visit,736,,,736,Case Rate,Cardiology Per Visit,594.8,,,594.8,Other,New York Medicaid APG methodology,594.8,,,594.8,Other,100% Medicaid APG methodology,594.8,,,594.8,Other,100% Medicaid APG methodology,594.8,,,594.8,Other,100% Medicaid APG methodology,1338.31,,,1338.31,Other,225% Medicaid APG methodology,1338.31,,,1338.31,Other,225% Medicaid APG methodology,910.05,,,910.05,Other,153% Medicaid APG methodology,1338.31,,,1338.31,Other,225% Medicaid APG methodology,832.72,,,832.72,Other,140% Medicaid APG methodology,1338.31,,,1338.31,Other,225% Medicaid APG methodology,1546.49,,,1546.49,Other,260% Medicaid APG methodology,1927.16,,,1927.16,Other,324% Medicaid APG methodology,1278.83,,,1278.83,Other,215% Medicaid APG methodology,1278.83,,,1278.83,Other,215% Medicaid APG methodology,743.5,,,743.5,Other,125% Medicaid APG methodology,221.26,5508.9,
REM INTERROG EVL PM/IDS         ,93296,CPT,,44401511,CDM,480,RC,,,both,,,942,71.71,,,71.71,Other,150% of Medicare + 9.63% HCRA Surcharge,43.61,,,43.61,Other,Medicare OPPS methodology,106.85,,,106.85,Fee Schedule,,96.19,,,96.19,Fee Schedule,,299.41,,,299.41,Fee Schedule,,269.38,,,269.38,Fee Schedule,,254.37,,,254.37,Fee Schedule,,471,50,,471,percent of total billed charges,All Other,659.4,70,,659.4,percent of total billed charges,All Other,96.19,,,96.19,Fee Schedule,,207.55,,,207.55,Other,186% Medicaid methodology,113.19,,,113.19,Fee Schedule,,584.04,,,584.04,Fee Schedule,,53.3,,,53.3,Fee Schedule,,113.19,,,113.19,Fee Schedule,,584.04,,,584.04,Fee Schedule,,847.8,90,,847.8,percent of total billed charges,All Other,659.4,70,,659.4,percent of total billed charges,All Other,113.85,,,113.85,Fee Schedule,,96.6,,,96.6,Fee Schedule,,906,,,906,Case Rate,Cardiology Per Visit,780,,,780,Case Rate,Cardiology Per Visit,867,,,867,Case Rate,Cardiology Per Visit,736,,,736,Case Rate,Cardiology Per Visit,111.58,,,111.58,Other,New York Medicaid APG methodology,111.58,,,111.58,Other,100% Medicaid APG methodology,111.58,,,111.58,Other,100% Medicaid APG methodology,111.58,,,111.58,Other,100% Medicaid APG methodology,251.06,,,251.06,Other,225% Medicaid APG methodology,251.06,,,251.06,Other,225% Medicaid APG methodology,170.72,,,170.72,Other,153% Medicaid APG methodology,251.06,,,251.06,Other,225% Medicaid APG methodology,156.22,,,156.22,Other,140% Medicaid APG methodology,251.06,,,251.06,Other,225% Medicaid APG methodology,290.12,,,290.12,Other,260% Medicaid APG methodology,361.53,,,361.53,Other,324% Medicaid APG methodology,239.91,,,239.91,Other,215% Medicaid APG methodology,239.91,,,239.91,Other,215% Medicaid APG methodology,139.48,,,139.48,Other,125% Medicaid APG methodology,43.61,906,
HC INTER DEVC REMOTE 30D G2066,93297,CPT,,44401529,CDM,480,RC,,,both,,,56,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,87.9,,,87.9,Fee Schedule,,78.94,,,78.94,Fee Schedule,,208.44,,,208.44,Fee Schedule,,187.53,,,187.53,Fee Schedule,,177.08,,,177.08,Fee Schedule,,28,50,,28,percent of total billed charges,All Other,39.2,70,,39.2,percent of total billed charges,All Other,161.72,,,161.72,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,190.31,,,190.31,Fee Schedule,,34.72,,,34.72,Fee Schedule,,89.61,,,89.61,Fee Schedule,,190.31,,,190.31,Fee Schedule,,34.72,,,34.72,Fee Schedule,,50.4,90,,50.4,percent of total billed charges,All Other,39.2,70,,39.2,percent of total billed charges,All Other,127.05,,,127.05,Fee Schedule,,107.8,,,107.8,Fee Schedule,,906,,,906,Case Rate,Cardiology Per Visit,780,,,780,Case Rate,Cardiology Per Visit,867,,,867,Case Rate,Cardiology Per Visit,736,,,736,Case Rate,Cardiology Per Visit,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,906,
CARDIOVASCULAR STRESS TEST      ,93017,CPT,,44400000,CDM,482,RC,,,both,,,3726,596.88,,,596.88,Other,150% of Medicare + 9.63% HCRA Surcharge,362.97,,,362.97,Other,Medicare OPPS methodology,188.9,,,188.9,Fee Schedule,,170.06,,,170.06,Fee Schedule,,495.85,,,495.85,Fee Schedule,,446.13,,,446.13,Fee Schedule,,421.27,,,421.27,Fee Schedule,,1863,50,,1863,percent of total billed charges,All Other,2608.2,70,,2608.2,percent of total billed charges,All Other,170.06,,,170.06,Fee Schedule,,374.3,,,374.3,Other,186% Medicaid methodology,200.12,,,200.12,Fee Schedule,,2310.12,,,2310.12,Fee Schedule,,94.23,,,94.23,Fee Schedule,,200.12,,,200.12,Fee Schedule,,2310.12,,,2310.12,Fee Schedule,,3353.4,90,,3353.4,percent of total billed charges,All Other,2608.2,70,,2608.2,percent of total billed charges,All Other,171.6,,,171.6,Fee Schedule,,145.6,,,145.6,Fee Schedule,,1977,,,1977,Case Rate,Stress Test Per Visit,1755,,,1755,Case Rate,Stress Test Per Visit,1950,,,1950,Case Rate,Stress Test Per Visit,1657,,,1657,Case Rate,Stress Test Per Visit,201.24,,,201.24,Other,New York Medicaid APG methodology,201.24,,,201.24,Other,100% Medicaid APG methodology,201.24,,,201.24,Other,100% Medicaid APG methodology,201.24,,,201.24,Other,100% Medicaid APG methodology,452.78,,,452.78,Other,225% Medicaid APG methodology,452.78,,,452.78,Other,225% Medicaid APG methodology,307.89,,,307.89,Other,153% Medicaid APG methodology,452.78,,,452.78,Other,225% Medicaid APG methodology,281.73,,,281.73,Other,140% Medicaid APG methodology,452.78,,,452.78,Other,225% Medicaid APG methodology,523.21,,,523.21,Other,260% Medicaid APG methodology,652,,,652,Other,324% Medicaid APG methodology,432.66,,,432.66,Other,215% Medicaid APG methodology,432.66,,,432.66,Other,215% Medicaid APG methodology,251.54,,,251.54,Other,125% Medicaid APG methodology,94.23,3353.4,
TILT TABLE EVALUATION           ,93660,CPT,,44400091,CDM,482,RC,,,both,,,4843,1019.25,,,1019.25,Other,150% of Medicare + 9.63% HCRA Surcharge,619.81,,,619.81,Other,Medicare OPPS methodology,178.71,,,178.71,Fee Schedule,,160.49,,,160.49,Fee Schedule,,604.99,,,604.99,Fee Schedule,,544.32,,,544.32,Fee Schedule,,513.99,,,513.99,Fee Schedule,,2421.5,50,,2421.5,percent of total billed charges,All Other,3390.1,70,,3390.1,percent of total billed charges,All Other,328.78,,,328.78,Fee Schedule,,374.3,,,374.3,Other,186% Medicaid methodology,386.91,,,386.91,Fee Schedule,,3002.66,,,3002.66,Fee Schedule,,182.18,,,182.18,Fee Schedule,,386.91,,,386.91,Fee Schedule,,3002.66,,,3002.66,Fee Schedule,,4358.7,90,,4358.7,percent of total billed charges,All Other,3390.1,70,,3390.1,percent of total billed charges,All Other,330,,,330,Fee Schedule,,280,,,280,Fee Schedule,,1977,,,1977,Case Rate,Stress Test Per Visit,1755,,,1755,Case Rate,Stress Test Per Visit,1950,,,1950,Case Rate,Stress Test Per Visit,1657,,,1657,Case Rate,Stress Test Per Visit,201.24,,,201.24,Other,New York Medicaid APG methodology,201.24,,,201.24,Other,100% Medicaid APG methodology,201.24,,,201.24,Other,100% Medicaid APG methodology,201.24,,,201.24,Other,100% Medicaid APG methodology,452.78,,,452.78,Other,225% Medicaid APG methodology,452.78,,,452.78,Other,225% Medicaid APG methodology,307.89,,,307.89,Other,153% Medicaid APG methodology,452.78,,,452.78,Other,225% Medicaid APG methodology,281.73,,,281.73,Other,140% Medicaid APG methodology,452.78,,,452.78,Other,225% Medicaid APG methodology,523.21,,,523.21,Other,260% Medicaid APG methodology,652,,,652,Other,324% Medicaid APG methodology,432.66,,,432.66,Other,215% Medicaid APG methodology,432.66,,,432.66,Other,215% Medicaid APG methodology,251.54,,,251.54,Other,125% Medicaid APG methodology,160.49,4358.7,
CARDIOVASCULAR STRESS TEST      ,93017,CPT,,44400463,CDM,482,RC,,,both,,,3726,596.88,,,596.88,Other,150% of Medicare + 9.63% HCRA Surcharge,362.97,,,362.97,Other,Medicare OPPS methodology,188.9,,,188.9,Fee Schedule,,170.06,,,170.06,Fee Schedule,,495.85,,,495.85,Fee Schedule,,446.13,,,446.13,Fee Schedule,,421.27,,,421.27,Fee Schedule,,1863,50,,1863,percent of total billed charges,All Other,2608.2,70,,2608.2,percent of total billed charges,All Other,170.06,,,170.06,Fee Schedule,,374.3,,,374.3,Other,186% Medicaid methodology,200.12,,,200.12,Fee Schedule,,2310.12,,,2310.12,Fee Schedule,,94.23,,,94.23,Fee Schedule,,200.12,,,200.12,Fee Schedule,,2310.12,,,2310.12,Fee Schedule,,3353.4,90,,3353.4,percent of total billed charges,All Other,2608.2,70,,2608.2,percent of total billed charges,All Other,171.6,,,171.6,Fee Schedule,,145.6,,,145.6,Fee Schedule,,1977,,,1977,Case Rate,Stress Test Per Visit,1755,,,1755,Case Rate,Stress Test Per Visit,1950,,,1950,Case Rate,Stress Test Per Visit,1657,,,1657,Case Rate,Stress Test Per Visit,201.24,,,201.24,Other,New York Medicaid APG methodology,201.24,,,201.24,Other,100% Medicaid APG methodology,201.24,,,201.24,Other,100% Medicaid APG methodology,201.24,,,201.24,Other,100% Medicaid APG methodology,452.78,,,452.78,Other,225% Medicaid APG methodology,452.78,,,452.78,Other,225% Medicaid APG methodology,307.89,,,307.89,Other,153% Medicaid APG methodology,452.78,,,452.78,Other,225% Medicaid APG methodology,281.73,,,281.73,Other,140% Medicaid APG methodology,452.78,,,452.78,Other,225% Medicaid APG methodology,523.21,,,523.21,Other,260% Medicaid APG methodology,652,,,652,Other,324% Medicaid APG methodology,432.66,,,432.66,Other,215% Medicaid APG methodology,432.66,,,432.66,Other,215% Medicaid APG methodology,251.54,,,251.54,Other,125% Medicaid APG methodology,94.23,3353.4,
CARDIOVASCULAR STRESS TEST      ,93017,CPT,,44401305,CDM,482,RC,,,both,,,3726,596.88,,,596.88,Other,150% of Medicare + 9.63% HCRA Surcharge,362.97,,,362.97,Other,Medicare OPPS methodology,188.9,,,188.9,Fee Schedule,,170.06,,,170.06,Fee Schedule,,495.85,,,495.85,Fee Schedule,,446.13,,,446.13,Fee Schedule,,421.27,,,421.27,Fee Schedule,,1863,50,,1863,percent of total billed charges,All Other,2608.2,70,,2608.2,percent of total billed charges,All Other,170.06,,,170.06,Fee Schedule,,374.3,,,374.3,Other,186% Medicaid methodology,200.12,,,200.12,Fee Schedule,,2310.12,,,2310.12,Fee Schedule,,94.23,,,94.23,Fee Schedule,,200.12,,,200.12,Fee Schedule,,2310.12,,,2310.12,Fee Schedule,,3353.4,90,,3353.4,percent of total billed charges,All Other,2608.2,70,,2608.2,percent of total billed charges,All Other,171.6,,,171.6,Fee Schedule,,145.6,,,145.6,Fee Schedule,,1977,,,1977,Case Rate,Stress Test Per Visit,1755,,,1755,Case Rate,Stress Test Per Visit,1950,,,1950,Case Rate,Stress Test Per Visit,1657,,,1657,Case Rate,Stress Test Per Visit,201.24,,,201.24,Other,New York Medicaid APG methodology,201.24,,,201.24,Other,100% Medicaid APG methodology,201.24,,,201.24,Other,100% Medicaid APG methodology,201.24,,,201.24,Other,100% Medicaid APG methodology,452.78,,,452.78,Other,225% Medicaid APG methodology,452.78,,,452.78,Other,225% Medicaid APG methodology,307.89,,,307.89,Other,153% Medicaid APG methodology,452.78,,,452.78,Other,225% Medicaid APG methodology,281.73,,,281.73,Other,140% Medicaid APG methodology,452.78,,,452.78,Other,225% Medicaid APG methodology,523.21,,,523.21,Other,260% Medicaid APG methodology,652,,,652,Other,324% Medicaid APG methodology,432.66,,,432.66,Other,215% Medicaid APG methodology,432.66,,,432.66,Other,215% Medicaid APG methodology,251.54,,,251.54,Other,125% Medicaid APG methodology,94.23,3353.4,
TTE W/DOPPLER COMPLETE          ,93306,CPT,,44400018,CDM,483,RC,,,both,,,7826,1049.09,,,1049.09,Other,150% of Medicare + 9.63% HCRA Surcharge,637.96,,,637.96,Other,Medicare OPPS methodology,643.12,,,643.12,Fee Schedule,,578.96,,,578.96,Fee Schedule,,1515.34,,,1515.34,Fee Schedule,,1363.38,,,1363.38,Fee Schedule,,1287.41,,,1287.41,Fee Schedule,,3913,50,,3913,percent of total billed charges,All Other,5478.2,70,,5478.2,percent of total billed charges,All Other,578.96,,,578.96,Fee Schedule,,690.16,,,690.16,Other,186% Medicaid methodology,681.31,,,681.31,Fee Schedule,,4852.12,,,4852.12,Fee Schedule,,320.8,,,320.8,Fee Schedule,,681.31,,,681.31,Fee Schedule,,4852.12,,,4852.12,Fee Schedule,,7043.4,90,,7043.4,percent of total billed charges,All Other,5478.2,70,,5478.2,percent of total billed charges,All Other,641.85,,,641.85,Fee Schedule,,544.6,,,544.6,Fee Schedule,,1648,,,1648,Case Rate,Echo Per Visit,1924,,,1924,Case Rate,Echo Per Visit,2139,,,2139,Case Rate,Echo Per Visit,1818,,,1818,Case Rate,Echo Per Visit,371.05,,,371.05,Other,New York Medicaid APG methodology,371.05,,,371.05,Other,100% Medicaid APG methodology,371.05,,,371.05,Other,100% Medicaid APG methodology,371.05,,,371.05,Other,100% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,567.71,,,567.71,Other,153% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,519.47,,,519.47,Other,140% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,964.73,,,964.73,Other,260% Medicaid APG methodology,1202.21,,,1202.21,Other,324% Medicaid APG methodology,797.76,,,797.76,Other,215% Medicaid APG methodology,797.76,,,797.76,Other,215% Medicaid APG methodology,463.81,,,463.81,Other,125% Medicaid APG methodology,320.8,7043.4,
TTE F-UP OR LMTD                ,93308,CPT,,44400034,CDM,483,RC,,,both,,,2347,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,370.86,,,370.86,Fee Schedule,,333.86,,,333.86,Fee Schedule,,717.21,,,717.21,Fee Schedule,,645.29,,,645.29,Fee Schedule,,609.33,,,609.33,Fee Schedule,,1173.5,50,,1173.5,percent of total billed charges,All Other,1642.9,70,,1642.9,percent of total billed charges,All Other,333.86,,,333.86,Fee Schedule,,690.16,,,690.16,Other,186% Medicaid methodology,392.88,,,392.88,Fee Schedule,,1455.14,,,1455.14,Fee Schedule,,184.99,,,184.99,Fee Schedule,,392.88,,,392.88,Fee Schedule,,1455.14,,,1455.14,Fee Schedule,,2112.3,90,,2112.3,percent of total billed charges,All Other,1642.9,70,,1642.9,percent of total billed charges,All Other,364.65,,,364.65,Fee Schedule,,309.4,,,309.4,Fee Schedule,,1648,,,1648,Case Rate,Echo Per Visit,1924,,,1924,Case Rate,Echo Per Visit,2139,,,2139,Case Rate,Echo Per Visit,1818,,,1818,Case Rate,Echo Per Visit,371.05,,,371.05,Other,New York Medicaid APG methodology,371.05,,,371.05,Other,100% Medicaid APG methodology,371.05,,,371.05,Other,100% Medicaid APG methodology,371.05,,,371.05,Other,100% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,567.71,,,567.71,Other,153% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,519.47,,,519.47,Other,140% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,964.73,,,964.73,Other,260% Medicaid APG methodology,1202.21,,,1202.21,Other,324% Medicaid APG methodology,797.76,,,797.76,Other,215% Medicaid APG methodology,797.76,,,797.76,Other,215% Medicaid APG methodology,463.81,,,463.81,Other,125% Medicaid APG methodology,184.99,2139,
STRESS TTE COMPLETE             ,93351,CPT,,44400158,CDM,483,RC,,,both,,,7125,1049.09,,,1049.09,Other,150% of Medicare + 9.63% HCRA Surcharge,637.96,,,637.96,Other,Medicare OPPS methodology,754.94,,,754.94,Fee Schedule,,679.62,,,679.62,Fee Schedule,,1431.4,,,1431.4,Fee Schedule,,1287.87,,,1287.87,Fee Schedule,,1216.1,,,1216.1,Fee Schedule,,3562.5,50,,3562.5,percent of total billed charges,All Other,4987.5,70,,4987.5,percent of total billed charges,All Other,679.62,,,679.62,Fee Schedule,,690.16,,,690.16,Other,186% Medicaid methodology,799.77,,,799.77,Fee Schedule,,4417.5,,,4417.5,Fee Schedule,,376.57,,,376.57,Fee Schedule,,799.77,,,799.77,Fee Schedule,,4417.5,,,4417.5,Fee Schedule,,6412.5,90,,6412.5,percent of total billed charges,All Other,4987.5,70,,4987.5,percent of total billed charges,All Other,749.1,,,749.1,Fee Schedule,,635.6,,,635.6,Fee Schedule,,1648,,,1648,Case Rate,Echo Per Visit,1924,,,1924,Case Rate,Echo Per Visit,2139,,,2139,Case Rate,Echo Per Visit,1818,,,1818,Case Rate,Echo Per Visit,371.05,,,371.05,Other,New York Medicaid APG methodology,371.05,,,371.05,Other,100% Medicaid APG methodology,371.05,,,371.05,Other,100% Medicaid APG methodology,371.05,,,371.05,Other,100% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,567.71,,,567.71,Other,153% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,519.47,,,519.47,Other,140% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,964.73,,,964.73,Other,260% Medicaid APG methodology,1202.21,,,1202.21,Other,324% Medicaid APG methodology,797.76,,,797.76,Other,215% Medicaid APG methodology,797.76,,,797.76,Other,215% Medicaid APG methodology,463.81,,,463.81,Other,125% Medicaid APG methodology,371.05,6412.5,
TTE CONG ABN; COMPLETE          ,93303,CPT,,44400166,CDM,483,RC,,,both,,,4903,1049.09,,,1049.09,Other,150% of Medicare + 9.63% HCRA Surcharge,637.96,,,637.96,Other,Medicare OPPS methodology,793.67,,,793.67,Fee Schedule,,714.49,,,714.49,Fee Schedule,,1322.05,,,1322.05,Fee Schedule,,1189.48,,,1189.48,Fee Schedule,,1123.19,,,1123.19,Fee Schedule,,2451.5,50,,2451.5,percent of total billed charges,All Other,3432.1,70,,3432.1,percent of total billed charges,All Other,714.49,,,714.49,Fee Schedule,,690.16,,,690.16,Other,186% Medicaid methodology,840.8,,,840.8,Fee Schedule,,3039.86,,,3039.86,Fee Schedule,,395.89,,,395.89,Fee Schedule,,840.8,,,840.8,Fee Schedule,,3039.86,,,3039.86,Fee Schedule,,4412.7,90,,4412.7,percent of total billed charges,All Other,3432.1,70,,3432.1,percent of total billed charges,All Other,803.55,,,803.55,Fee Schedule,,681.8,,,681.8,Fee Schedule,,1648,,,1648,Case Rate,Echo Per Visit,1924,,,1924,Case Rate,Echo Per Visit,2139,,,2139,Case Rate,Echo Per Visit,1818,,,1818,Case Rate,Echo Per Visit,371.05,,,371.05,Other,New York Medicaid APG methodology,371.05,,,371.05,Other,100% Medicaid APG methodology,371.05,,,371.05,Other,100% Medicaid APG methodology,371.05,,,371.05,Other,100% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,567.71,,,567.71,Other,153% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,519.47,,,519.47,Other,140% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,964.73,,,964.73,Other,260% Medicaid APG methodology,1202.21,,,1202.21,Other,324% Medicaid APG methodology,797.76,,,797.76,Other,215% Medicaid APG methodology,797.76,,,797.76,Other,215% Medicaid APG methodology,463.81,,,463.81,Other,125% Medicaid APG methodology,371.05,4412.7,
TTE CONG ABN; LIMITED/F-UP      ,93304,CPT,,44400174,CDM,483,RC,,,both,,,3467,1049.09,,,1049.09,Other,150% of Medicare + 9.63% HCRA Surcharge,637.96,,,637.96,Other,Medicare OPPS methodology,599.13,,,599.13,Fee Schedule,,539.35,,,539.35,Fee Schedule,,882.42,,,882.42,Fee Schedule,,793.93,,,793.93,Fee Schedule,,749.69,,,749.69,Fee Schedule,,1733.5,50,,1733.5,percent of total billed charges,All Other,2426.9,70,,2426.9,percent of total billed charges,All Other,539.35,,,539.35,Fee Schedule,,690.16,,,690.16,Other,186% Medicaid methodology,634.7,,,634.7,Fee Schedule,,2149.54,,,2149.54,Fee Schedule,,298.85,,,298.85,Fee Schedule,,634.7,,,634.7,Fee Schedule,,2149.54,,,2149.54,Fee Schedule,,3120.3,90,,3120.3,percent of total billed charges,All Other,2426.9,70,,2426.9,percent of total billed charges,All Other,602.25,,,602.25,Fee Schedule,,511,,,511,Fee Schedule,,1648,,,1648,Case Rate,Echo Per Visit,1924,,,1924,Case Rate,Echo Per Visit,2139,,,2139,Case Rate,Echo Per Visit,1818,,,1818,Case Rate,Echo Per Visit,371.05,,,371.05,Other,New York Medicaid APG methodology,371.05,,,371.05,Other,100% Medicaid APG methodology,371.05,,,371.05,Other,100% Medicaid APG methodology,371.05,,,371.05,Other,100% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,567.71,,,567.71,Other,153% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,519.47,,,519.47,Other,140% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,964.73,,,964.73,Other,260% Medicaid APG methodology,1202.21,,,1202.21,Other,324% Medicaid APG methodology,797.76,,,797.76,Other,215% Medicaid APG methodology,797.76,,,797.76,Other,215% Medicaid APG methodology,463.81,,,463.81,Other,125% Medicaid APG methodology,298.85,3120.3,
MYOCRD STRAIN IMG SPCKL TRCK    ,93356,CPT,,44400604,CDM,483,RC,,,both,,,607,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,26.29,,,26.29,Fee Schedule,,23.61,,,23.61,Fee Schedule,,39.13,,,39.13,Fee Schedule,,39.13,,,39.13,Fee Schedule,,39.13,,,39.13,Fee Schedule,,303.5,50,,303.5,percent of total billed charges,All Other,424.9,70,,424.9,percent of total billed charges,All Other,48.36,,,48.36,Fee Schedule,,690.16,,,690.16,Other,186% Medicaid methodology,56.91,,,56.91,Fee Schedule,,376.34,,,376.34,Fee Schedule,,26.8,,,26.8,Fee Schedule,,56.91,,,56.91,Fee Schedule,,376.34,,,376.34,Fee Schedule,,546.3,90,,546.3,percent of total billed charges,All Other,424.9,70,,424.9,percent of total billed charges,All Other,57.75,,,57.75,Fee Schedule,,49,,,49,Fee Schedule,,1648,,,1648,Case Rate,Echo Per Visit,1924,,,1924,Case Rate,Echo Per Visit,2139,,,2139,Case Rate,Echo Per Visit,1818,,,1818,Case Rate,Echo Per Visit,371.05,,,371.05,Other,New York Medicaid APG methodology,371.05,,,371.05,Other,100% Medicaid APG methodology,371.05,,,371.05,Other,100% Medicaid APG methodology,371.05,,,371.05,Other,100% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,567.71,,,567.71,Other,153% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,519.47,,,519.47,Other,140% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,964.73,,,964.73,Other,260% Medicaid APG methodology,1202.21,,,1202.21,Other,324% Medicaid APG methodology,797.76,,,797.76,Other,215% Medicaid APG methodology,797.76,,,797.76,Other,215% Medicaid APG methodology,463.81,,,463.81,Other,125% Medicaid APG methodology,0.01,2139,
ECHO TRANSESOPHAGEAL            ,93312,CPT,,44401396,CDM,483,RC,,,both,,,6138,1049.09,,,1049.09,Other,150% of Medicare + 9.63% HCRA Surcharge,637.96,,,637.96,Other,Medicare OPPS methodology,656.38,,,656.38,Fee Schedule,,590.9,,,590.9,Fee Schedule,,1961.43,,,1961.43,Fee Schedule,,1764.74,,,1764.74,Fee Schedule,,1666.4,,,1666.4,Fee Schedule,,3069,50,,3069,percent of total billed charges,All Other,4296.6,70,,4296.6,percent of total billed charges,All Other,590.9,,,590.9,Fee Schedule,,690.16,,,690.16,Other,186% Medicaid methodology,695.36,,,695.36,Fee Schedule,,3805.56,,,3805.56,Fee Schedule,,327.41,,,327.41,Fee Schedule,,695.36,,,695.36,Fee Schedule,,3805.56,,,3805.56,Fee Schedule,,5524.2,90,,5524.2,percent of total billed charges,All Other,4296.6,70,,4296.6,percent of total billed charges,All Other,660,,,660,Fee Schedule,,560,,,560,Fee Schedule,,1648,,,1648,Case Rate,Echo Per Visit,1924,,,1924,Case Rate,Echo Per Visit,2139,,,2139,Case Rate,Echo Per Visit,1818,,,1818,Case Rate,Echo Per Visit,371.05,,,371.05,Other,New York Medicaid APG methodology,371.05,,,371.05,Other,100% Medicaid APG methodology,371.05,,,371.05,Other,100% Medicaid APG methodology,371.05,,,371.05,Other,100% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,567.71,,,567.71,Other,153% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,519.47,,,519.47,Other,140% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,964.73,,,964.73,Other,260% Medicaid APG methodology,1202.21,,,1202.21,Other,324% Medicaid APG methodology,797.76,,,797.76,Other,215% Medicaid APG methodology,797.76,,,797.76,Other,215% Medicaid APG methodology,463.81,,,463.81,Other,125% Medicaid APG methodology,327.41,5524.2,
TEE CONGENITAL GLOBAL           ,93315,CPT,,44401461,CDM,483,RC,,,both,,,1798,1049.09,,,1049.09,Other,150% of Medicare + 9.63% HCRA Surcharge,637.96,,,637.96,Other,Medicare OPPS methodology,899,50,,899,percent of total billed charges,All Other Outpatient,809.1,45,,809.1,percent of total billed charges,All Other Outpatient,5159.91,,,5159.91,Fee Schedule,,4642.48,,,4642.48,Fee Schedule,,4383.77,,,4383.77,Fee Schedule,,899,50,,899,percent of total billed charges,All Other,1258.6,70,,1258.6,percent of total billed charges,All Other,1222.64,68,,1222.64,percent of total billed charges,All Other Outpatient,690.16,,,690.16,Other,186% Medicaid methodology,1438.4,80,,1438.4,percent of total billed charges,All Other Outpatient,1492.34,83,,1492.34,percent of total billed charges,All Other Outpatient,1492.34,83,,1492.34,percent of total billed charges,All Other Outpatient,1438.4,80,,1438.4,percent of total billed charges,All Other Outpatient,1492.34,83,,1492.34,percent of total billed charges,All Other Outpatient,1618.2,90,,1618.2,percent of total billed charges,All Other,1258.6,70,,1258.6,percent of total billed charges,All Other,899,50,,899,percent of total billed charges,All Other,899,50,,899,percent of total billed charges,All Other,1648,,,1648,Case Rate,Echo Per Visit,1924,,,1924,Case Rate,Echo Per Visit,2139,,,2139,Case Rate,Echo Per Visit,1818,,,1818,Case Rate,Echo Per Visit,371.05,,,371.05,Other,New York Medicaid APG methodology,371.05,,,371.05,Other,100% Medicaid APG methodology,371.05,,,371.05,Other,100% Medicaid APG methodology,371.05,,,371.05,Other,100% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,567.71,,,567.71,Other,153% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,519.47,,,519.47,Other,140% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,964.73,,,964.73,Other,260% Medicaid APG methodology,1202.21,,,1202.21,Other,324% Medicaid APG methodology,797.76,,,797.76,Other,215% Medicaid APG methodology,797.76,,,797.76,Other,215% Medicaid APG methodology,463.81,,,463.81,Other,125% Medicaid APG methodology,371.05,5159.91,
ECHO TRANSESOPHAGEAL            ,93312,CPT,,44500304,CDM,483,RC,,,both,,,6138,1049.09,,,1049.09,Other,150% of Medicare + 9.63% HCRA Surcharge,637.96,,,637.96,Other,Medicare OPPS methodology,656.38,,,656.38,Fee Schedule,,590.9,,,590.9,Fee Schedule,,1961.43,,,1961.43,Fee Schedule,,1764.74,,,1764.74,Fee Schedule,,1666.4,,,1666.4,Fee Schedule,,3069,50,,3069,percent of total billed charges,All Other,4296.6,70,,4296.6,percent of total billed charges,All Other,590.9,,,590.9,Fee Schedule,,690.16,,,690.16,Other,186% Medicaid methodology,695.36,,,695.36,Fee Schedule,,3805.56,,,3805.56,Fee Schedule,,327.41,,,327.41,Fee Schedule,,695.36,,,695.36,Fee Schedule,,3805.56,,,3805.56,Fee Schedule,,5524.2,90,,5524.2,percent of total billed charges,All Other,4296.6,70,,4296.6,percent of total billed charges,All Other,660,,,660,Fee Schedule,,560,,,560,Fee Schedule,,1648,,,1648,Case Rate,Echo Per Visit,1924,,,1924,Case Rate,Echo Per Visit,2139,,,2139,Case Rate,Echo Per Visit,1818,,,1818,Case Rate,Echo Per Visit,371.05,,,371.05,Other,New York Medicaid APG methodology,371.05,,,371.05,Other,100% Medicaid APG methodology,371.05,,,371.05,Other,100% Medicaid APG methodology,371.05,,,371.05,Other,100% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,567.71,,,567.71,Other,153% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,519.47,,,519.47,Other,140% Medicaid APG methodology,834.87,,,834.87,Other,225% Medicaid APG methodology,964.73,,,964.73,Other,260% Medicaid APG methodology,1202.21,,,1202.21,Other,324% Medicaid APG methodology,797.76,,,797.76,Other,215% Medicaid APG methodology,797.76,,,797.76,Other,215% Medicaid APG methodology,463.81,,,463.81,Other,125% Medicaid APG methodology,327.41,5524.2,
CANALITH REPOSITIONING PROC     ,95992,CPT,GP       ,48602890,CDM,510,RC,,,both,,,399,157.47,,,157.47,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,199.5,50,,199.5,percent of total billed charges,All Other Outpatient,179.55,45,,179.55,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,199.5,50,,199.5,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,122.94,,,122.94,Fee Schedule,,183.45,,,183.45,Other,186% Medicaid methodology,144.8,,,144.8,Fee Schedule,,247.38,62,,247.38,percent of total billed charges,All Other Outpatient,81.96,,,81.96,Fee Schedule,,144.8,,,144.8,Fee Schedule,,247.38,62,,247.38,percent of total billed charges,All Other Outpatient,620,,,620,Case Rate,Clinic Visit,279.3,70,,279.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,279.3,70,,279.3,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,279.3,70,,279.3,percent of total billed charges,All Other,98.63,,,98.63,Other,New York Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,98.63,,,98.63,Other,100% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,150.9,,,150.9,Other,153% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,138.08,,,138.08,Other,140% Medicaid APG methodology,221.91,,,221.91,Other,225% Medicaid APG methodology,256.43,,,256.43,Other,260% Medicaid APG methodology,319.55,,,319.55,Other,324% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,212.05,,,212.05,Other,215% Medicaid APG methodology,123.28,,,123.28,Other,125% Medicaid APG methodology,0.01,620,
OFFICE O/P EST LOW 20-29 MIN    ,99213,CPT,,50107523,CDM,510,RC,,,both,,,371,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,185.5,50,,185.5,percent of total billed charges,All Other Outpatient,166.95,45,,166.95,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,185.5,50,,185.5,percent of total billed charges,All Other,259.7,70,,259.7,percent of total billed charges,All Other,231.84,,,231.84,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,273.06,,,273.06,Fee Schedule,,230.02,62,,230.02,percent of total billed charges,All Other Outpatient,154.56,,,154.56,Fee Schedule,,273.06,,,273.06,Fee Schedule,,230.02,62,,230.02,percent of total billed charges,All Other Outpatient,620,,,620,Case Rate,Clinic Visit,259.7,70,,259.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,259.7,70,,259.7,percent of total billed charges,All Other,259.7,70,,259.7,percent of total billed charges,All Other,259.7,70,,259.7,percent of total billed charges,All Other,259.7,70,,259.7,percent of total billed charges,All Other,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,620,
OFFICE O/P NEW SF 15-29 MIN     ,99202,CPT,,50118322,CDM,510,RC,,,both,,,477,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,238.5,50,,238.5,percent of total billed charges,All Other Outpatient,214.65,45,,214.65,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,238.5,50,,238.5,percent of total billed charges,All Other,333.9,70,,333.9,percent of total billed charges,All Other,167.42,,,167.42,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,197.19,,,197.19,Fee Schedule,,295.74,62,,295.74,percent of total billed charges,All Other Outpatient,111.62,,,111.62,Fee Schedule,,197.19,,,197.19,Fee Schedule,,295.74,62,,295.74,percent of total billed charges,All Other Outpatient,620,,,620,Case Rate,Clinic Visit,333.9,70,,333.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,333.9,70,,333.9,percent of total billed charges,All Other,333.9,70,,333.9,percent of total billed charges,All Other,333.9,70,,333.9,percent of total billed charges,All Other,333.9,70,,333.9,percent of total billed charges,All Other,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,620,
OFFICE O/P NEW LOW 30-44 MIN    ,99203,CPT,,50118330,CDM,510,RC,,,both,,,634,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,317,50,,317,percent of total billed charges,All Other Outpatient,285.3,45,,285.3,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,317,50,,317,percent of total billed charges,All Other,443.8,70,,443.8,percent of total billed charges,All Other,291.47,,,291.47,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,343.29,,,343.29,Fee Schedule,,393.08,62,,393.08,percent of total billed charges,All Other Outpatient,194.31,,,194.31,Fee Schedule,,343.29,,,343.29,Fee Schedule,,393.08,62,,393.08,percent of total billed charges,All Other Outpatient,620,,,620,Case Rate,Clinic Visit,443.8,70,,443.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,443.8,70,,443.8,percent of total billed charges,All Other,443.8,70,,443.8,percent of total billed charges,All Other,443.8,70,,443.8,percent of total billed charges,All Other,443.8,70,,443.8,percent of total billed charges,All Other,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,620,
OFFICE O/P NEW MOD 45-59 MIN    ,99204,CPT,,50118348,CDM,510,RC,,,both,,,870,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,435,50,,435,percent of total billed charges,All Other Outpatient,391.5,45,,391.5,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,435,50,,435,percent of total billed charges,All Other,609,70,,609,percent of total billed charges,All Other,472.78,,,472.78,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,556.83,,,556.83,Fee Schedule,,539.4,62,,539.4,percent of total billed charges,All Other Outpatient,315.19,,,315.19,Fee Schedule,,556.83,,,556.83,Fee Schedule,,539.4,62,,539.4,percent of total billed charges,All Other Outpatient,620,,,620,Case Rate,Clinic Visit,609,70,,609,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,609,70,,609,percent of total billed charges,All Other,609,70,,609,percent of total billed charges,All Other,609,70,,609,percent of total billed charges,All Other,609,70,,609,percent of total billed charges,All Other,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,620,
OFFICE O/P NEW HI 60-74 MIN     ,99205,CPT,,50118355,CDM,510,RC,,,both,,,1042,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,521,50,,521,percent of total billed charges,All Other Outpatient,468.9,45,,468.9,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,521,50,,521,percent of total billed charges,All Other,729.4,70,,729.4,percent of total billed charges,All Other,643.83,,,643.83,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,758.29,,,758.29,Fee Schedule,,646.04,62,,646.04,percent of total billed charges,All Other Outpatient,429.22,,,429.22,Fee Schedule,,758.29,,,758.29,Fee Schedule,,646.04,62,,646.04,percent of total billed charges,All Other Outpatient,620,,,620,Case Rate,Clinic Visit,729.4,70,,729.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,729.4,70,,729.4,percent of total billed charges,All Other,729.4,70,,729.4,percent of total billed charges,All Other,729.4,70,,729.4,percent of total billed charges,All Other,729.4,70,,729.4,percent of total billed charges,All Other,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,758.29,
OFFICE O/P EST MINIMAL PROB     ,99211,CPT,,50118363,CDM,510,RC,,,both,,,218,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,109,50,,109,percent of total billed charges,All Other Outpatient,98.1,45,,98.1,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,109,50,,109,percent of total billed charges,All Other,152.6,70,,152.6,percent of total billed charges,All Other,30.4,,,30.4,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,35.8,,,35.8,Fee Schedule,,135.16,62,,135.16,percent of total billed charges,All Other Outpatient,20.27,,,20.27,Fee Schedule,,35.8,,,35.8,Fee Schedule,,135.16,62,,135.16,percent of total billed charges,All Other Outpatient,620,,,620,Case Rate,Clinic Visit,152.6,70,,152.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,152.6,70,,152.6,percent of total billed charges,All Other,152.6,70,,152.6,percent of total billed charges,All Other,152.6,70,,152.6,percent of total billed charges,All Other,152.6,70,,152.6,percent of total billed charges,All Other,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,620,
OFFICE O/P EST SF 10-19 MIN     ,99212,CPT,,50118371,CDM,510,RC,,,both,,,329,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,164.5,50,,164.5,percent of total billed charges,All Other Outpatient,148.05,45,,148.05,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,164.5,50,,164.5,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,124.61,,,124.61,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,146.77,,,146.77,Fee Schedule,,203.98,62,,203.98,percent of total billed charges,All Other Outpatient,83.08,,,83.08,Fee Schedule,,146.77,,,146.77,Fee Schedule,,203.98,62,,203.98,percent of total billed charges,All Other Outpatient,620,,,620,Case Rate,Clinic Visit,230.3,70,,230.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,230.3,70,,230.3,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,620,
OFFICE O/P EST MOD 30-39 MIN    ,99214,CPT,,50118397,CDM,510,RC,,,both,,,581,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,290.5,50,,290.5,percent of total billed charges,All Other Outpatient,261.45,45,,261.45,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,290.5,50,,290.5,percent of total billed charges,All Other,406.7,70,,406.7,percent of total billed charges,All Other,341.24,,,341.24,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,401.9,,,401.9,Fee Schedule,,360.22,62,,360.22,percent of total billed charges,All Other Outpatient,227.49,,,227.49,Fee Schedule,,401.9,,,401.9,Fee Schedule,,360.22,62,,360.22,percent of total billed charges,All Other Outpatient,620,,,620,Case Rate,Clinic Visit,406.7,70,,406.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,406.7,70,,406.7,percent of total billed charges,All Other,406.7,70,,406.7,percent of total billed charges,All Other,406.7,70,,406.7,percent of total billed charges,All Other,406.7,70,,406.7,percent of total billed charges,All Other,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,620,
OFFICE O/P EST HI 40-54 MIN     ,99215,CPT,,50118405,CDM,510,RC,,,both,,,787,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,393.5,50,,393.5,percent of total billed charges,All Other Outpatient,354.15,45,,354.15,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,393.5,50,,393.5,percent of total billed charges,All Other,550.9,70,,550.9,percent of total billed charges,All Other,508.13,,,508.13,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,598.46,,,598.46,Fee Schedule,,487.94,62,,487.94,percent of total billed charges,All Other Outpatient,338.75,,,338.75,Fee Schedule,,598.46,,,598.46,Fee Schedule,,487.94,62,,487.94,percent of total billed charges,All Other Outpatient,620,,,620,Case Rate,Clinic Visit,550.9,70,,550.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,550.9,70,,550.9,percent of total billed charges,All Other,550.9,70,,550.9,percent of total billed charges,All Other,550.9,70,,550.9,percent of total billed charges,All Other,550.9,70,,550.9,percent of total billed charges,All Other,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,620,
OFFICE O/P NEW LOW 30-44 MIN    ,99203,CPT,,50720432,CDM,513,RC,,,both,,,634,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,317,50,,317,percent of total billed charges,All Other Outpatient,285.3,45,,285.3,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,317,50,,317,percent of total billed charges,All Other,443.8,70,,443.8,percent of total billed charges,All Other,291.47,,,291.47,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,343.29,,,343.29,Fee Schedule,,393.08,62,,393.08,percent of total billed charges,All Other Outpatient,194.31,,,194.31,Fee Schedule,,343.29,,,343.29,Fee Schedule,,393.08,62,,393.08,percent of total billed charges,All Other Outpatient,620,,,620,Case Rate,Clinic Visit,443.8,70,,443.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,443.8,70,,443.8,percent of total billed charges,All Other,443.8,70,,443.8,percent of total billed charges,All Other,443.8,70,,443.8,percent of total billed charges,All Other,443.8,70,,443.8,percent of total billed charges,All Other,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,620,
OFFICE O/P NEW MOD 45-59 MIN    ,99204,CPT,,50720457,CDM,513,RC,,,both,,,870,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,435,50,,435,percent of total billed charges,All Other Outpatient,391.5,45,,391.5,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,435,50,,435,percent of total billed charges,All Other,609,70,,609,percent of total billed charges,All Other,472.78,,,472.78,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,556.83,,,556.83,Fee Schedule,,539.4,62,,539.4,percent of total billed charges,All Other Outpatient,315.19,,,315.19,Fee Schedule,,556.83,,,556.83,Fee Schedule,,539.4,62,,539.4,percent of total billed charges,All Other Outpatient,620,,,620,Case Rate,Clinic Visit,609,70,,609,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,609,70,,609,percent of total billed charges,All Other,609,70,,609,percent of total billed charges,All Other,609,70,,609,percent of total billed charges,All Other,609,70,,609,percent of total billed charges,All Other,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,620,
OFFICE O/P NEW HI 60-74 MIN     ,99205,CPT,,50720465,CDM,513,RC,,,both,,,1042,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,521,50,,521,percent of total billed charges,All Other Outpatient,468.9,45,,468.9,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,521,50,,521,percent of total billed charges,All Other,729.4,70,,729.4,percent of total billed charges,All Other,643.83,,,643.83,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,758.29,,,758.29,Fee Schedule,,646.04,62,,646.04,percent of total billed charges,All Other Outpatient,429.22,,,429.22,Fee Schedule,,758.29,,,758.29,Fee Schedule,,646.04,62,,646.04,percent of total billed charges,All Other Outpatient,620,,,620,Case Rate,Clinic Visit,729.4,70,,729.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,729.4,70,,729.4,percent of total billed charges,All Other,729.4,70,,729.4,percent of total billed charges,All Other,729.4,70,,729.4,percent of total billed charges,All Other,729.4,70,,729.4,percent of total billed charges,All Other,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,758.29,
OFFICE O/P EST SF 10-19 MIN     ,99212,CPT,,50720507,CDM,513,RC,,,both,,,329,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,164.5,50,,164.5,percent of total billed charges,All Other Outpatient,148.05,45,,148.05,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,164.5,50,,164.5,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,124.61,,,124.61,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,146.77,,,146.77,Fee Schedule,,203.98,62,,203.98,percent of total billed charges,All Other Outpatient,83.08,,,83.08,Fee Schedule,,146.77,,,146.77,Fee Schedule,,203.98,62,,203.98,percent of total billed charges,All Other Outpatient,620,,,620,Case Rate,Clinic Visit,230.3,70,,230.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,230.3,70,,230.3,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,620,
OFFICE O/P EST LOW 20-29 MIN    ,99213,CPT,,50720515,CDM,513,RC,,,both,,,371,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,185.5,50,,185.5,percent of total billed charges,All Other Outpatient,166.95,45,,166.95,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,185.5,50,,185.5,percent of total billed charges,All Other,259.7,70,,259.7,percent of total billed charges,All Other,231.84,,,231.84,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,273.06,,,273.06,Fee Schedule,,230.02,62,,230.02,percent of total billed charges,All Other Outpatient,154.56,,,154.56,Fee Schedule,,273.06,,,273.06,Fee Schedule,,230.02,62,,230.02,percent of total billed charges,All Other Outpatient,620,,,620,Case Rate,Clinic Visit,259.7,70,,259.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,259.7,70,,259.7,percent of total billed charges,All Other,259.7,70,,259.7,percent of total billed charges,All Other,259.7,70,,259.7,percent of total billed charges,All Other,259.7,70,,259.7,percent of total billed charges,All Other,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,620,
OFFICE O/P EST MOD 30-39 MIN    ,99214,CPT,,50720523,CDM,513,RC,,,both,,,581,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,290.5,50,,290.5,percent of total billed charges,All Other Outpatient,261.45,45,,261.45,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,290.5,50,,290.5,percent of total billed charges,All Other,406.7,70,,406.7,percent of total billed charges,All Other,341.24,,,341.24,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,401.9,,,401.9,Fee Schedule,,360.22,62,,360.22,percent of total billed charges,All Other Outpatient,227.49,,,227.49,Fee Schedule,,401.9,,,401.9,Fee Schedule,,360.22,62,,360.22,percent of total billed charges,All Other Outpatient,620,,,620,Case Rate,Clinic Visit,406.7,70,,406.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,406.7,70,,406.7,percent of total billed charges,All Other,406.7,70,,406.7,percent of total billed charges,All Other,406.7,70,,406.7,percent of total billed charges,All Other,406.7,70,,406.7,percent of total billed charges,All Other,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,620,
OFFICE O/P EST HI 40-54 MIN     ,99215,CPT,,50720531,CDM,513,RC,,,both,,,787,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,393.5,50,,393.5,percent of total billed charges,All Other Outpatient,354.15,45,,354.15,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,393.5,50,,393.5,percent of total billed charges,All Other,550.9,70,,550.9,percent of total billed charges,All Other,508.13,,,508.13,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,598.46,,,598.46,Fee Schedule,,487.94,62,,487.94,percent of total billed charges,All Other Outpatient,338.75,,,338.75,Fee Schedule,,598.46,,,598.46,Fee Schedule,,487.94,62,,487.94,percent of total billed charges,All Other Outpatient,620,,,620,Case Rate,Clinic Visit,550.9,70,,550.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,550.9,70,,550.9,percent of total billed charges,All Other,550.9,70,,550.9,percent of total billed charges,All Other,550.9,70,,550.9,percent of total billed charges,All Other,550.9,70,,550.9,percent of total billed charges,All Other,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,620,
OFFICE O/P EST MINIMAL PROB     ,99211,CPT,,50790757,CDM,513,RC,,,both,,,218,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,109,50,,109,percent of total billed charges,All Other Outpatient,98.1,45,,98.1,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,109,50,,109,percent of total billed charges,All Other,152.6,70,,152.6,percent of total billed charges,All Other,30.4,,,30.4,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,35.8,,,35.8,Fee Schedule,,135.16,62,,135.16,percent of total billed charges,All Other Outpatient,20.27,,,20.27,Fee Schedule,,35.8,,,35.8,Fee Schedule,,135.16,62,,135.16,percent of total billed charges,All Other Outpatient,620,,,620,Case Rate,Clinic Visit,152.6,70,,152.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,152.6,70,,152.6,percent of total billed charges,All Other,152.6,70,,152.6,percent of total billed charges,All Other,152.6,70,,152.6,percent of total billed charges,All Other,152.6,70,,152.6,percent of total billed charges,All Other,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,620,
OFFICE O/P NEW SF 15-29 MIN     ,99202,CPT,,50790765,CDM,513,RC,,,both,,,477,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,238.5,50,,238.5,percent of total billed charges,All Other Outpatient,214.65,45,,214.65,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,238.5,50,,238.5,percent of total billed charges,All Other,333.9,70,,333.9,percent of total billed charges,All Other,167.42,,,167.42,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,197.19,,,197.19,Fee Schedule,,295.74,62,,295.74,percent of total billed charges,All Other Outpatient,111.62,,,111.62,Fee Schedule,,197.19,,,197.19,Fee Schedule,,295.74,62,,295.74,percent of total billed charges,All Other Outpatient,620,,,620,Case Rate,Clinic Visit,333.9,70,,333.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,333.9,70,,333.9,percent of total billed charges,All Other,333.9,70,,333.9,percent of total billed charges,All Other,333.9,70,,333.9,percent of total billed charges,All Other,333.9,70,,333.9,percent of total billed charges,All Other,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,620,
HOPD MNTL HLT 15-29 MIN         ,C7900,HCPCS,,50791318,CDM,513,RC,,,both,,,495,54.57,,,54.57,Other,150% of Medicare + 9.63% HCRA Surcharge,33.18,,,33.18,Other,Medicare OPPS methodology,247.5,50,,247.5,percent of total billed charges,All Other Outpatient,222.75,45,,222.75,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,247.5,50,,247.5,percent of total billed charges,All Other,346.5,70,,346.5,percent of total billed charges,All Other,336.6,68,,336.6,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,396,80,,396,percent of total billed charges,All Other Outpatient,410.85,83,,410.85,percent of total billed charges,All Other Outpatient,410.85,83,,410.85,percent of total billed charges,All Other Outpatient,396,80,,396,percent of total billed charges,All Other Outpatient,410.85,83,,410.85,percent of total billed charges,All Other Outpatient,620,,,620,Case Rate,Clinic Visit,346.5,70,,346.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,346.5,70,,346.5,percent of total billed charges,All Other,346.5,70,,346.5,percent of total billed charges,All Other,346.5,70,,346.5,percent of total billed charges,All Other,346.5,70,,346.5,percent of total billed charges,All Other,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,620,
HOPD MNTL HLT 30-60 MIN         ,C7901,HCPCS,,50791326,CDM,513,RC,,,both,,,546,169.51,,,169.51,Other,150% of Medicare + 9.63% HCRA Surcharge,103.08,,,103.08,Other,Medicare OPPS methodology,273,50,,273,percent of total billed charges,All Other Outpatient,245.7,45,,245.7,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,273,50,,273,percent of total billed charges,All Other,382.2,70,,382.2,percent of total billed charges,All Other,371.28,68,,371.28,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,436.8,80,,436.8,percent of total billed charges,All Other Outpatient,453.18,83,,453.18,percent of total billed charges,All Other Outpatient,453.18,83,,453.18,percent of total billed charges,All Other Outpatient,436.8,80,,436.8,percent of total billed charges,All Other Outpatient,453.18,83,,453.18,percent of total billed charges,All Other Outpatient,620,,,620,Case Rate,Clinic Visit,382.2,70,,382.2,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,382.2,70,,382.2,percent of total billed charges,All Other,382.2,70,,382.2,percent of total billed charges,All Other,382.2,70,,382.2,percent of total billed charges,All Other,382.2,70,,382.2,percent of total billed charges,All Other,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,620,
HOPD MNTL HLT EA ADDL 15 MIN    ,C7902,HCPCS,,50791334,CDM,513,RC,,,both,,,137,54.07,,,54.07,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,68.5,50,,68.5,percent of total billed charges,All Other Outpatient,61.65,45,,61.65,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,68.5,50,,68.5,percent of total billed charges,All Other,95.9,70,,95.9,percent of total billed charges,All Other,93.16,68,,93.16,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,109.6,80,,109.6,percent of total billed charges,All Other Outpatient,113.71,83,,113.71,percent of total billed charges,All Other Outpatient,113.71,83,,113.71,percent of total billed charges,All Other Outpatient,109.6,80,,109.6,percent of total billed charges,All Other Outpatient,113.71,83,,113.71,percent of total billed charges,All Other Outpatient,620,,,620,Case Rate,Clinic Visit,95.9,70,,95.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,95.9,70,,95.9,percent of total billed charges,All Other,95.9,70,,95.9,percent of total billed charges,All Other,95.9,70,,95.9,percent of total billed charges,All Other,95.9,70,,95.9,percent of total billed charges,All Other,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,620,
OFFICE O/P NEW LOW 30-44 MIN    ,99203,CPT,,50820539,CDM,513,RC,,,both,,,634,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,317,50,,317,percent of total billed charges,All Other Outpatient,285.3,45,,285.3,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,317,50,,317,percent of total billed charges,All Other,443.8,70,,443.8,percent of total billed charges,All Other,291.47,,,291.47,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,343.29,,,343.29,Fee Schedule,,393.08,62,,393.08,percent of total billed charges,All Other Outpatient,194.31,,,194.31,Fee Schedule,,343.29,,,343.29,Fee Schedule,,393.08,62,,393.08,percent of total billed charges,All Other Outpatient,620,,,620,Case Rate,Clinic Visit,443.8,70,,443.8,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,443.8,70,,443.8,percent of total billed charges,All Other,443.8,70,,443.8,percent of total billed charges,All Other,443.8,70,,443.8,percent of total billed charges,All Other,443.8,70,,443.8,percent of total billed charges,All Other,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,620,
OFFICE O/P EST SF 10-19 MIN     ,99212,CPT,,50820562,CDM,513,RC,,,both,,,329,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,164.5,50,,164.5,percent of total billed charges,All Other Outpatient,148.05,45,,148.05,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,164.5,50,,164.5,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,124.61,,,124.61,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,146.77,,,146.77,Fee Schedule,,203.98,62,,203.98,percent of total billed charges,All Other Outpatient,83.08,,,83.08,Fee Schedule,,146.77,,,146.77,Fee Schedule,,203.98,62,,203.98,percent of total billed charges,All Other Outpatient,620,,,620,Case Rate,Clinic Visit,230.3,70,,230.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,230.3,70,,230.3,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,620,
OFFICE O/P EST LOW 20-29 MIN    ,99213,CPT,,50820570,CDM,513,RC,,,both,,,371,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,185.5,50,,185.5,percent of total billed charges,All Other Outpatient,166.95,45,,166.95,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,185.5,50,,185.5,percent of total billed charges,All Other,259.7,70,,259.7,percent of total billed charges,All Other,231.84,,,231.84,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,273.06,,,273.06,Fee Schedule,,230.02,62,,230.02,percent of total billed charges,All Other Outpatient,154.56,,,154.56,Fee Schedule,,273.06,,,273.06,Fee Schedule,,230.02,62,,230.02,percent of total billed charges,All Other Outpatient,620,,,620,Case Rate,Clinic Visit,259.7,70,,259.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,259.7,70,,259.7,percent of total billed charges,All Other,259.7,70,,259.7,percent of total billed charges,All Other,259.7,70,,259.7,percent of total billed charges,All Other,259.7,70,,259.7,percent of total billed charges,All Other,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,620,
OFFICE O/P EST MOD 30-39 MIN    ,99214,CPT,,50820588,CDM,513,RC,,,both,,,581,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,290.5,50,,290.5,percent of total billed charges,All Other Outpatient,261.45,45,,261.45,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,290.5,50,,290.5,percent of total billed charges,All Other,406.7,70,,406.7,percent of total billed charges,All Other,341.24,,,341.24,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,401.9,,,401.9,Fee Schedule,,360.22,62,,360.22,percent of total billed charges,All Other Outpatient,227.49,,,227.49,Fee Schedule,,401.9,,,401.9,Fee Schedule,,360.22,62,,360.22,percent of total billed charges,All Other Outpatient,620,,,620,Case Rate,Clinic Visit,406.7,70,,406.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,406.7,70,,406.7,percent of total billed charges,All Other,406.7,70,,406.7,percent of total billed charges,All Other,406.7,70,,406.7,percent of total billed charges,All Other,406.7,70,,406.7,percent of total billed charges,All Other,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,620,
OFFICE O/P EST HI 40-54 MIN     ,99215,CPT,,50820596,CDM,513,RC,,,both,,,787,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,393.5,50,,393.5,percent of total billed charges,All Other Outpatient,354.15,45,,354.15,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,393.5,50,,393.5,percent of total billed charges,All Other,550.9,70,,550.9,percent of total billed charges,All Other,508.13,,,508.13,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,598.46,,,598.46,Fee Schedule,,487.94,62,,487.94,percent of total billed charges,All Other Outpatient,338.75,,,338.75,Fee Schedule,,598.46,,,598.46,Fee Schedule,,487.94,62,,487.94,percent of total billed charges,All Other Outpatient,620,,,620,Case Rate,Clinic Visit,550.9,70,,550.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,550.9,70,,550.9,percent of total billed charges,All Other,550.9,70,,550.9,percent of total billed charges,All Other,550.9,70,,550.9,percent of total billed charges,All Other,550.9,70,,550.9,percent of total billed charges,All Other,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,620,
OFFICE O/P EST MINIMAL PROB     ,99211,CPT,,50891159,CDM,513,RC,,,both,,,218,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,109,50,,109,percent of total billed charges,All Other Outpatient,98.1,45,,98.1,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,109,50,,109,percent of total billed charges,All Other,152.6,70,,152.6,percent of total billed charges,All Other,30.4,,,30.4,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,35.8,,,35.8,Fee Schedule,,135.16,62,,135.16,percent of total billed charges,All Other Outpatient,20.27,,,20.27,Fee Schedule,,35.8,,,35.8,Fee Schedule,,135.16,62,,135.16,percent of total billed charges,All Other Outpatient,620,,,620,Case Rate,Clinic Visit,152.6,70,,152.6,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,152.6,70,,152.6,percent of total billed charges,All Other,152.6,70,,152.6,percent of total billed charges,All Other,152.6,70,,152.6,percent of total billed charges,All Other,152.6,70,,152.6,percent of total billed charges,All Other,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,620,
OFFICE O/P NEW SF 15-29 MIN     ,99202,CPT,,50891175,CDM,513,RC,,,both,,,477,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,238.5,50,,238.5,percent of total billed charges,All Other Outpatient,214.65,45,,214.65,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,238.5,50,,238.5,percent of total billed charges,All Other,333.9,70,,333.9,percent of total billed charges,All Other,167.42,,,167.42,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,197.19,,,197.19,Fee Schedule,,295.74,62,,295.74,percent of total billed charges,All Other Outpatient,111.62,,,111.62,Fee Schedule,,197.19,,,197.19,Fee Schedule,,295.74,62,,295.74,percent of total billed charges,All Other Outpatient,620,,,620,Case Rate,Clinic Visit,333.9,70,,333.9,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,333.9,70,,333.9,percent of total billed charges,All Other,333.9,70,,333.9,percent of total billed charges,All Other,333.9,70,,333.9,percent of total billed charges,All Other,333.9,70,,333.9,percent of total billed charges,All Other,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,620,
OFFICE O/P NEW MOD 45-59 MIN    ,99204,CPT,,50891209,CDM,513,RC,,,both,,,870,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,435,50,,435,percent of total billed charges,All Other Outpatient,391.5,45,,391.5,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,435,50,,435,percent of total billed charges,All Other,609,70,,609,percent of total billed charges,All Other,472.78,,,472.78,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,556.83,,,556.83,Fee Schedule,,539.4,62,,539.4,percent of total billed charges,All Other Outpatient,315.19,,,315.19,Fee Schedule,,556.83,,,556.83,Fee Schedule,,539.4,62,,539.4,percent of total billed charges,All Other Outpatient,620,,,620,Case Rate,Clinic Visit,609,70,,609,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,609,70,,609,percent of total billed charges,All Other,609,70,,609,percent of total billed charges,All Other,609,70,,609,percent of total billed charges,All Other,609,70,,609,percent of total billed charges,All Other,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,620,
OFFICE O/P NEW HI 60-74 MIN     ,99205,CPT,,50891225,CDM,513,RC,,,both,,,1042,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,521,50,,521,percent of total billed charges,All Other Outpatient,468.9,45,,468.9,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,521,50,,521,percent of total billed charges,All Other,729.4,70,,729.4,percent of total billed charges,All Other,643.83,,,643.83,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,758.29,,,758.29,Fee Schedule,,646.04,62,,646.04,percent of total billed charges,All Other Outpatient,429.22,,,429.22,Fee Schedule,,758.29,,,758.29,Fee Schedule,,646.04,62,,646.04,percent of total billed charges,All Other Outpatient,620,,,620,Case Rate,Clinic Visit,729.4,70,,729.4,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,729.4,70,,729.4,percent of total billed charges,All Other,729.4,70,,729.4,percent of total billed charges,All Other,729.4,70,,729.4,percent of total billed charges,All Other,729.4,70,,729.4,percent of total billed charges,All Other,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,758.29,
THER/PROPH/DIAG INJ SC/IM       ,96372,CPT,,50720200,CDM,519,RC,,,both,,,659,133.96,,,133.96,Other,150% of Medicare + 9.63% HCRA Surcharge,81.46,,,81.46,Other,Medicare OPPS methodology,329.5,50,,329.5,percent of total billed charges,All Other Outpatient,296.55,45,,296.55,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,329.5,50,,329.5,percent of total billed charges,All Other,461.3,70,,461.3,percent of total billed charges,All Other,51.6,,,51.6,Fee Schedule,,116.47,,,116.47,Other,186% Medicaid methodology,60.77,,,60.77,Fee Schedule,,408.58,62,,408.58,percent of total billed charges,All Other Outpatient,34.4,,,34.4,Fee Schedule,,60.77,,,60.77,Fee Schedule,,408.58,62,,408.58,percent of total billed charges,All Other Outpatient,620,,,620,Case Rate,Clinic Visit,461.3,70,,461.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,461.3,70,,461.3,percent of total billed charges,All Other,461.3,70,,461.3,percent of total billed charges,All Other,461.3,70,,461.3,percent of total billed charges,All Other,461.3,70,,461.3,percent of total billed charges,All Other,62.62,,,62.62,Other,New York Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,95.8,,,95.8,Other,153% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,87.66,,,87.66,Other,140% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,162.81,,,162.81,Other,260% Medicaid APG methodology,202.88,,,202.88,Other,324% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,78.27,,,78.27,Other,125% Medicaid APG methodology,0.01,620,
MAGNETIC IMAGE JAW JOINT        ,70336,CPT,,47600010,CDM,610,RC,,,both,,,4342,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,756.41,,,756.41,Fee Schedule,,679.81,,,679.81,Fee Schedule,,3145.92,,,3145.92,Fee Schedule,,2830.45,,,2830.45,Fee Schedule,,2672.72,,,2672.72,Fee Schedule,,2171,50,,2171,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,907.21,,,907.21,Fee Schedule,,915.24,,,915.24,Other,186% Medicaid methodology,1067.59,,,1067.59,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,502.68,,,502.68,Fee Schedule,,1067.59,,,1067.59,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,945.51,,,945.51,Fee Schedule,,3039.4,70,,3039.4,percent of total billed charges,All Other,1046.1,,,1046.1,Fee Schedule,,887.6,,,887.6,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,492.06,,,492.06,Other,New York Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,752.86,,,752.86,Other,153% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,688.89,,,688.89,Other,140% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1279.36,,,1279.36,Other,260% Medicaid APG methodology,1594.29,,,1594.29,Other,324% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,615.08,,,615.08,Other,125% Medicaid APG methodology,283.36,6501,
MRI CHEST W/O DYE               ,71550,CPT,,47600069,CDM,610,RC,,,both,,,4342,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,887.52,,,887.52,Fee Schedule,,797.64,,,797.64,Fee Schedule,,3149,,,3149,Fee Schedule,,2833.23,,,2833.23,Fee Schedule,,2675.34,,,2675.34,Fee Schedule,,2171,50,,2171,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,1064.46,,,1064.46,Fee Schedule,,915.24,,,915.24,Other,186% Medicaid methodology,1252.64,,,1252.64,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,589.81,,,589.81,Fee Schedule,,1252.64,,,1252.64,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,1109.4,,,1109.4,Fee Schedule,,3039.4,70,,3039.4,percent of total billed charges,All Other,1438.8,,,1438.8,Fee Schedule,,1220.8,,,1220.8,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,492.06,,,492.06,Other,New York Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,752.86,,,752.86,Other,153% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,688.89,,,688.89,Other,140% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1279.36,,,1279.36,Other,260% Medicaid APG methodology,1594.29,,,1594.29,Other,324% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,615.08,,,615.08,Other,125% Medicaid APG methodology,283.36,6501,
MRI ABDOMEN W/O DYE             ,74181,CPT,,47600085,CDM,610,RC,,,both,,,4342,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,496.88,,,496.88,Fee Schedule,,446.56,,,446.56,Fee Schedule,,3145.92,,,3145.92,Fee Schedule,,2830.45,,,2830.45,Fee Schedule,,2672.72,,,2672.72,Fee Schedule,,2171,50,,2171,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,595.94,,,595.94,Fee Schedule,,915.24,,,915.24,Other,186% Medicaid methodology,701.29,,,701.29,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,330.2,,,330.2,Fee Schedule,,701.29,,,701.29,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,621.1,,,621.1,Fee Schedule,,3039.4,70,,3039.4,percent of total billed charges,All Other,674.85,,,674.85,Fee Schedule,,572.6,,,572.6,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,492.06,,,492.06,Other,New York Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,752.86,,,752.86,Other,153% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,688.89,,,688.89,Other,140% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1279.36,,,1279.36,Other,260% Medicaid APG methodology,1594.29,,,1594.29,Other,324% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,615.08,,,615.08,Other,125% Medicaid APG methodology,283.36,6501,
MRI UPR EXTREMITY W/O&W/DYE LT  ,73220,CPT,LT       ,47600200,CDM,610,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,1197.92,,,1197.92,Fee Schedule,,1076.62,,,1076.62,Fee Schedule,,4898.05,,,4898.05,Fee Schedule,,4406.88,,,4406.88,Fee Schedule,,4161.3,,,4161.3,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,1436.75,,,1436.75,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1690.74,,,1690.74,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,796.09,,,796.09,Fee Schedule,,1690.74,,,1690.74,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,1497.41,,,1497.41,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,1654.95,,,1654.95,Fee Schedule,,1404.2,,,1404.2,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,444.72,6501,
MRI LWR EXTREMITY W/O&W/DYE LT  ,73720,CPT,LT       ,47600218,CDM,610,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,919.78,,,919.78,Fee Schedule,,826.64,,,826.64,Fee Schedule,,4898.05,,,4898.05,Fee Schedule,,4406.88,,,4406.88,Fee Schedule,,4161.3,,,4161.3,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,1103.16,,,1103.16,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1298.17,,,1298.17,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,611.25,,,611.25,Fee Schedule,,1298.17,,,1298.17,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,1149.73,,,1149.73,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,1263.9,,,1263.9,Fee Schedule,,1072.4,,,1072.4,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,444.72,6501,
MRI JOINT UPR EXTM W/O DYE RT   ,73221,CPT,RT       ,47600226,CDM,610,RC,,,both,,,4342,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,541.59,,,541.59,Fee Schedule,,486.75,,,486.75,Fee Schedule,,3149,,,3149,Fee Schedule,,2833.23,,,2833.23,Fee Schedule,,2675.34,,,2675.34,Fee Schedule,,2171,50,,2171,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,649.57,,,649.57,Fee Schedule,,915.24,,,915.24,Other,186% Medicaid methodology,764.4,,,764.4,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,359.92,,,359.92,Fee Schedule,,764.4,,,764.4,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,676.99,,,676.99,Fee Schedule,,3039.4,70,,3039.4,percent of total billed charges,All Other,727.65,,,727.65,Fee Schedule,,617.4,,,617.4,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,492.06,,,492.06,Other,New York Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,752.86,,,752.86,Other,153% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,688.89,,,688.89,Other,140% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1279.36,,,1279.36,Other,260% Medicaid APG methodology,1594.29,,,1594.29,Other,324% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,615.08,,,615.08,Other,125% Medicaid APG methodology,283.36,6501,
MRI JNT OF LWR EXTR W/O DYE RT  ,73721,CPT,RT       ,47600234,CDM,610,RC,,,both,,,4342,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,540.36,,,540.36,Fee Schedule,,485.64,,,485.64,Fee Schedule,,3149,,,3149,Fee Schedule,,2833.23,,,2833.23,Fee Schedule,,2675.34,,,2675.34,Fee Schedule,,2171,50,,2171,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,648.09,,,648.09,Fee Schedule,,915.24,,,915.24,Other,186% Medicaid methodology,762.66,,,762.66,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,359.1,,,359.1,Fee Schedule,,762.66,,,762.66,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,675.45,,,675.45,Fee Schedule,,3039.4,70,,3039.4,percent of total billed charges,All Other,726,,,726,Fee Schedule,,616,,,616,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,492.06,,,492.06,Other,New York Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,752.86,,,752.86,Other,153% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,688.89,,,688.89,Other,140% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1279.36,,,1279.36,Other,260% Medicaid APG methodology,1594.29,,,1594.29,Other,324% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,615.08,,,615.08,Other,125% Medicaid APG methodology,283.36,6501,
MRI LWR EXTREMITY W/O&W/DYE RT  ,73720,CPT,RT       ,47600663,CDM,610,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,919.78,,,919.78,Fee Schedule,,826.64,,,826.64,Fee Schedule,,4898.05,,,4898.05,Fee Schedule,,4406.88,,,4406.88,Fee Schedule,,4161.3,,,4161.3,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,1103.16,,,1103.16,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1298.17,,,1298.17,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,611.25,,,611.25,Fee Schedule,,1298.17,,,1298.17,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,1149.73,,,1149.73,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,1263.9,,,1263.9,Fee Schedule,,1072.4,,,1072.4,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,444.72,6501,
MRI JOINT OF LWR EXTR W/DYE RT  ,73722,CPT,RT       ,47600713,CDM,610,RC,,,both,,,12687,1522.61,,,1522.61,Other,150% of Medicare + 9.63% HCRA Surcharge,925.91,,,925.91,Other,Medicare OPPS methodology,921.05,,,921.05,Fee Schedule,,827.77,,,827.77,Fee Schedule,,4009.46,,,4009.46,Fee Schedule,,3607.39,,,3607.39,Fee Schedule,,3406.36,,,3406.36,Fee Schedule,,6343.5,50,,6343.5,percent of total billed charges,All Other,2097.16,,,2097.16,Fee Schedule,,1104.67,,,1104.67,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1299.96,,,1299.96,Fee Schedule,,7865.94,,,7865.94,Fee Schedule,,612.09,,,612.09,Fee Schedule,,1299.96,,,1299.96,Fee Schedule,,7865.94,,,7865.94,Fee Schedule,,1151.31,,,1151.31,Fee Schedule,,8880.9,70,,8880.9,percent of total billed charges,All Other,1267.2,,,1267.2,Fee Schedule,,1075.2,,,1075.2,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,612.09,8880.9,
MRI ABDOMEN W/O & W/DYE         ,74183,CPT,,47600721,CDM,610,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,914.82,,,914.82,Fee Schedule,,822.18,,,822.18,Fee Schedule,,4898.05,,,4898.05,Fee Schedule,,4406.88,,,4406.88,Fee Schedule,,4161.3,,,4161.3,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,1097.21,,,1097.21,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1291.17,,,1291.17,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,607.95,,,607.95,Fee Schedule,,1291.17,,,1291.17,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,1143.53,,,1143.53,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,1257.3,,,1257.3,Fee Schedule,,1066.8,,,1066.8,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,444.72,6501,
MR ANGIOGRAPH NECK W/O&W/DYE    ,70549,CPT,,47600739,CDM,610,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,1013.66,,,1013.66,Fee Schedule,,911.02,,,911.02,Fee Schedule,,4898.05,,,4898.05,Fee Schedule,,4406.88,,,4406.88,Fee Schedule,,4161.3,,,4161.3,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,1215.76,,,1215.76,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,1430.68,,,1430.68,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,673.64,,,673.64,Fee Schedule,,1430.68,,,1430.68,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,1267.08,,,1267.08,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,1367.85,,,1367.85,Fee Schedule,,1160.6,,,1160.6,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,444.72,6501,
MR ANGIOGRAPH HEAD W/O&W/DYE    ,70546,CPT,,47600754,CDM,610,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,1009.94,,,1009.94,Fee Schedule,,907.66,,,907.66,Fee Schedule,,4898.05,,,4898.05,Fee Schedule,,4406.88,,,4406.88,Fee Schedule,,4161.3,,,4161.3,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,1211.28,,,1211.28,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,1425.42,,,1425.42,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,671.16,,,671.16,Fee Schedule,,1425.42,,,1425.42,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,1262.42,,,1262.42,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,1359.6,,,1359.6,Fee Schedule,,1153.6,,,1153.6,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,444.72,6501,
MRI LOWER EXTREMITY W/O DYE RT  ,73718,CPT,RT       ,47600762,CDM,610,RC,,,both,,,4342,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,622.3,,,622.3,Fee Schedule,,559.28,,,559.28,Fee Schedule,,3149,,,3149,Fee Schedule,,2833.23,,,2833.23,Fee Schedule,,2675.34,,,2675.34,Fee Schedule,,2171,50,,2171,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,746.36,,,746.36,Fee Schedule,,915.24,,,915.24,Other,186% Medicaid methodology,878.31,,,878.31,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,413.55,,,413.55,Fee Schedule,,878.31,,,878.31,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,777.87,,,777.87,Fee Schedule,,3039.4,70,,3039.4,percent of total billed charges,All Other,849.75,,,849.75,Fee Schedule,,721,,,721,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,492.06,,,492.06,Other,New York Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,752.86,,,752.86,Other,153% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,688.89,,,688.89,Other,140% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1279.36,,,1279.36,Other,260% Medicaid APG methodology,1594.29,,,1594.29,Other,324% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,615.08,,,615.08,Other,125% Medicaid APG methodology,283.36,6501,
MRI ORBT/FAC/NCK W/O &W/DYE     ,70543,CPT,,47600770,CDM,610,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,926.01,,,926.01,Fee Schedule,,832.23,,,832.23,Fee Schedule,,4898.05,,,4898.05,Fee Schedule,,4406.88,,,4406.88,Fee Schedule,,4161.3,,,4161.3,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,1110.62,,,1110.62,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1306.96,,,1306.96,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,615.38,,,615.38,Fee Schedule,,1306.96,,,1306.96,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,1157.51,,,1157.51,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,1268.85,,,1268.85,Fee Schedule,,1076.6,,,1076.6,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,444.72,6501,
MR ANGIOGRAPHY HEAD W/DYE       ,70545,CPT,,47600788,CDM,610,RC,,,both,,,5588,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,664.01,,,664.01,Fee Schedule,,596.77,,,596.77,Fee Schedule,,4009.46,,,4009.46,Fee Schedule,,3607.39,,,3607.39,Fee Schedule,,3406.36,,,3406.36,Fee Schedule,,2794,50,,2794,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,796.39,,,796.39,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,937.18,,,937.18,Fee Schedule,,3464.56,,,3464.56,Fee Schedule,,441.27,,,441.27,Fee Schedule,,937.18,,,937.18,Fee Schedule,,3464.56,,,3464.56,Fee Schedule,,830.01,,,830.01,Fee Schedule,,3911.6,70,,3911.6,percent of total billed charges,All Other,895.95,,,895.95,Fee Schedule,,760.2,,,760.2,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,441.27,6501,
MRI Chest w/ Contrast,71551,CPT,TC,47600804,CDM,610,RC,,,both,,,5204,1522.61,,,1522.61,Other,150% of Medicare + 9.63% HCRA Surcharge,925.91,,,925.91,Other,Medicare OPPS methodology,1132.13,,,1132.13,Fee Schedule,,1017.49,,,1017.49,Fee Schedule,,4009.46,,,4009.46,Fee Schedule,,3607.39,,,3607.39,Fee Schedule,,3406.36,,,3406.36,Fee Schedule,,2602,50,,2602,percent of total billed charges,All Other,2097.16,,,2097.16,Fee Schedule,,1357.84,,,1357.84,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1597.88,,,1597.88,Fee Schedule,,3226.48,,,3226.48,Fee Schedule,,752.37,,,752.37,Fee Schedule,,1597.88,,,1597.88,Fee Schedule,,3226.48,,,3226.48,Fee Schedule,,1415.17,,,1415.17,Fee Schedule,,3642.8,70,,3642.8,percent of total billed charges,All Other,1564.2,,,1564.2,Fee Schedule,,1327.2,,,1327.2,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,731.03,6501,
MRI CHEST W/O & W/DYE           ,71552,CPT,,47600812,CDM,610,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,1392.36,,,1392.36,Fee Schedule,,1251.36,,,1251.36,Fee Schedule,,4898.05,,,4898.05,Fee Schedule,,4406.88,,,4406.88,Fee Schedule,,4161.3,,,4161.3,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,1669.95,,,1669.95,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1965.17,,,1965.17,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,925.3,,,925.3,Fee Schedule,,1965.17,,,1965.17,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,1740.45,,,1740.45,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,1960.2,,,1960.2,Fee Schedule,,1663.2,,,1663.2,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,444.72,6501,
MRI PELVIS W/O DYE              ,72195,CPT,,47600820,CDM,610,RC,,,both,,,4342,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,623.53,,,623.53,Fee Schedule,,560.39,,,560.39,Fee Schedule,,3149,,,3149,Fee Schedule,,2833.23,,,2833.23,Fee Schedule,,2675.34,,,2675.34,Fee Schedule,,2171,50,,2171,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,747.84,,,747.84,Fee Schedule,,915.24,,,915.24,Other,186% Medicaid methodology,880.05,,,880.05,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,414.37,,,414.37,Fee Schedule,,880.05,,,880.05,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,779.41,,,779.41,Fee Schedule,,3039.4,70,,3039.4,percent of total billed charges,All Other,856.35,,,856.35,Fee Schedule,,726.6,,,726.6,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,492.06,,,492.06,Other,New York Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,752.86,,,752.86,Other,153% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,688.89,,,688.89,Other,140% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1279.36,,,1279.36,Other,260% Medicaid APG methodology,1594.29,,,1594.29,Other,324% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,615.08,,,615.08,Other,125% Medicaid APG methodology,283.36,6501,
MRI PELVIS W/O & W/DYE          ,72197,CPT,,47600838,CDM,610,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,909.86,,,909.86,Fee Schedule,,817.72,,,817.72,Fee Schedule,,4898.05,,,4898.05,Fee Schedule,,4406.88,,,4406.88,Fee Schedule,,4161.3,,,4161.3,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,1091.25,,,1091.25,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1284.17,,,1284.17,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,604.65,,,604.65,Fee Schedule,,1284.17,,,1284.17,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,1137.32,,,1137.32,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,1252.35,,,1252.35,Fee Schedule,,1062.6,,,1062.6,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,444.72,6501,
MRI UPPER EXTREMITY W/O DYE RT  ,73218,CPT,RT       ,47600846,CDM,610,RC,,,both,,,4342,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,887.52,,,887.52,Fee Schedule,,797.64,,,797.64,Fee Schedule,,3149,,,3149,Fee Schedule,,2833.23,,,2833.23,Fee Schedule,,2675.34,,,2675.34,Fee Schedule,,2171,50,,2171,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,1064.46,,,1064.46,Fee Schedule,,915.24,,,915.24,Other,186% Medicaid methodology,1252.64,,,1252.64,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,589.81,,,589.81,Fee Schedule,,1252.64,,,1252.64,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,1109.4,,,1109.4,Fee Schedule,,3039.4,70,,3039.4,percent of total billed charges,All Other,1275.45,,,1275.45,Fee Schedule,,1082.2,,,1082.2,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,492.06,,,492.06,Other,New York Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,752.86,,,752.86,Other,153% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,688.89,,,688.89,Other,140% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1279.36,,,1279.36,Other,260% Medicaid APG methodology,1594.29,,,1594.29,Other,324% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,615.08,,,615.08,Other,125% Medicaid APG methodology,283.36,6501,
MRI UP EXT W CONT RT            ,73219,CPT,RT       ,47600853,CDM,610,RC,,,both,,,4776,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,989.33,,,989.33,Fee Schedule,,889.15,,,889.15,Fee Schedule,,4009.46,,,4009.46,Fee Schedule,,3607.39,,,3607.39,Fee Schedule,,3406.36,,,3406.36,Fee Schedule,,2388,50,,2388,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,1186.57,,,1186.57,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1396.34,,,1396.34,Fee Schedule,,2961.12,,,2961.12,Fee Schedule,,657.47,,,657.47,Fee Schedule,,1396.34,,,1396.34,Fee Schedule,,2961.12,,,2961.12,Fee Schedule,,1236.67,,,1236.67,Fee Schedule,,3343.2,70,,3343.2,percent of total billed charges,All Other,1356.3,,,1356.3,Fee Schedule,,1150.8,,,1150.8,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,444.72,6501,
MRI JOINT UPR EXTREM W/DYE RT   ,73222,CPT,RT       ,47600861,CDM,610,RC,,,both,,,12687,1522.61,,,1522.61,Other,150% of Medicare + 9.63% HCRA Surcharge,925.91,,,925.91,Other,Medicare OPPS methodology,918.55,,,918.55,Fee Schedule,,825.53,,,825.53,Fee Schedule,,4009.46,,,4009.46,Fee Schedule,,3607.39,,,3607.39,Fee Schedule,,3406.36,,,3406.36,Fee Schedule,,6343.5,50,,6343.5,percent of total billed charges,All Other,2097.16,,,2097.16,Fee Schedule,,1101.68,,,1101.68,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1296.43,,,1296.43,Fee Schedule,,7865.94,,,7865.94,Fee Schedule,,610.43,,,610.43,Fee Schedule,,1296.43,,,1296.43,Fee Schedule,,7865.94,,,7865.94,Fee Schedule,,1148.19,,,1148.19,Fee Schedule,,8880.9,70,,8880.9,percent of total billed charges,All Other,1263.9,,,1263.9,Fee Schedule,,1072.4,,,1072.4,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,610.43,8880.9,
MRI JOINT UPR EXT W/O&W/DYE RT  ,73223,CPT,RT       ,47600879,CDM,610,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,1109.76,,,1109.76,Fee Schedule,,997.38,,,997.38,Fee Schedule,,4898.05,,,4898.05,Fee Schedule,,4406.88,,,4406.88,Fee Schedule,,4161.3,,,4161.3,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,1331.01,,,1331.01,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1566.31,,,1566.31,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,737.5,,,737.5,Fee Schedule,,1566.31,,,1566.31,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,1387.2,,,1387.2,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,1536.15,,,1536.15,Fee Schedule,,1303.4,,,1303.4,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,444.72,6501,
MRI LW EXT W CONT RT            ,73719,CPT,RT       ,47600887,CDM,610,RC,,,both,,,6125,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,728.57,,,728.57,Fee Schedule,,654.79,,,654.79,Fee Schedule,,4009.46,,,4009.46,Fee Schedule,,3607.39,,,3607.39,Fee Schedule,,3406.36,,,3406.36,Fee Schedule,,3062.5,50,,3062.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,873.82,,,873.82,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1028.3,,,1028.3,Fee Schedule,,3797.5,,,3797.5,Fee Schedule,,484.18,,,484.18,Fee Schedule,,1028.3,,,1028.3,Fee Schedule,,3797.5,,,3797.5,Fee Schedule,,910.71,,,910.71,Fee Schedule,,4287.5,70,,4287.5,percent of total billed charges,All Other,991.65,,,991.65,Fee Schedule,,841.4,,,841.4,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,444.72,6501,
MRI JOINT LWR EXT W/O&W/DYE RT  ,73723,CPT,RT       ,47600895,CDM,610,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,1104.8,,,1104.8,Fee Schedule,,992.92,,,992.92,Fee Schedule,,4898.05,,,4898.05,Fee Schedule,,4406.88,,,4406.88,Fee Schedule,,4161.3,,,4161.3,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,1325.06,,,1325.06,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1559.31,,,1559.31,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,734.2,,,734.2,Fee Schedule,,1559.31,,,1559.31,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,1381,,,1381,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,1531.2,,,1531.2,Fee Schedule,,1299.2,,,1299.2,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,444.72,6501,
MRI ABDOMEN W/DYE               ,74182,CPT,,47600903,CDM,610,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,860.18,,,860.18,Fee Schedule,,773.08,,,773.08,Fee Schedule,,4009.46,,,4009.46,Fee Schedule,,3607.39,,,3607.39,Fee Schedule,,3406.36,,,3406.36,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,1031.68,,,1031.68,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1214.06,,,1214.06,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,571.64,,,571.64,Fee Schedule,,1214.06,,,1214.06,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,1075.23,,,1075.23,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,1176.45,,,1176.45,Fee Schedule,,998.2,,,998.2,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,444.72,6501,
MRI UPPER EXTREMITY W/O DYE LT  ,73218,CPT,LT       ,47600952,CDM,610,RC,,,both,,,4342,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,887.52,,,887.52,Fee Schedule,,797.64,,,797.64,Fee Schedule,,3149,,,3149,Fee Schedule,,2833.23,,,2833.23,Fee Schedule,,2675.34,,,2675.34,Fee Schedule,,2171,50,,2171,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,1064.46,,,1064.46,Fee Schedule,,915.24,,,915.24,Other,186% Medicaid methodology,1252.64,,,1252.64,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,589.81,,,589.81,Fee Schedule,,1252.64,,,1252.64,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,1109.4,,,1109.4,Fee Schedule,,3039.4,70,,3039.4,percent of total billed charges,All Other,1275.45,,,1275.45,Fee Schedule,,1082.2,,,1082.2,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,492.06,,,492.06,Other,New York Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,752.86,,,752.86,Other,153% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,688.89,,,688.89,Other,140% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1279.36,,,1279.36,Other,260% Medicaid APG methodology,1594.29,,,1594.29,Other,324% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,615.08,,,615.08,Other,125% Medicaid APG methodology,283.36,6501,
MRI Forearm w/ Contrast Left,73219,CPT,TCLT,47600960,CDM,610,RC,,,both,,,4776,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,989.33,,,989.33,Fee Schedule,,889.15,,,889.15,Fee Schedule,,4009.46,,,4009.46,Fee Schedule,,3607.39,,,3607.39,Fee Schedule,,3406.36,,,3406.36,Fee Schedule,,2388,50,,2388,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,1186.57,,,1186.57,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1396.34,,,1396.34,Fee Schedule,,2961.12,,,2961.12,Fee Schedule,,657.47,,,657.47,Fee Schedule,,1396.34,,,1396.34,Fee Schedule,,2961.12,,,2961.12,Fee Schedule,,1236.67,,,1236.67,Fee Schedule,,3343.2,70,,3343.2,percent of total billed charges,All Other,1356.3,,,1356.3,Fee Schedule,,1150.8,,,1150.8,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,444.72,6501,
MRI UPR EXTREMITY W/O&W/DYE RT  ,73220,CPT,RT       ,47600978,CDM,610,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,1197.92,,,1197.92,Fee Schedule,,1076.62,,,1076.62,Fee Schedule,,4898.05,,,4898.05,Fee Schedule,,4406.88,,,4406.88,Fee Schedule,,4161.3,,,4161.3,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,1436.75,,,1436.75,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1690.74,,,1690.74,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,796.09,,,796.09,Fee Schedule,,1690.74,,,1690.74,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,1497.41,,,1497.41,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,1654.95,,,1654.95,Fee Schedule,,1404.2,,,1404.2,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,444.72,6501,
MRI JOINT UPR EXTRM W/O DYE LT  ,73221,CPT,LT       ,47600986,CDM,610,RC,,,both,,,4342,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,541.59,,,541.59,Fee Schedule,,486.75,,,486.75,Fee Schedule,,3149,,,3149,Fee Schedule,,2833.23,,,2833.23,Fee Schedule,,2675.34,,,2675.34,Fee Schedule,,2171,50,,2171,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,649.57,,,649.57,Fee Schedule,,915.24,,,915.24,Other,186% Medicaid methodology,764.4,,,764.4,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,359.92,,,359.92,Fee Schedule,,764.4,,,764.4,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,676.99,,,676.99,Fee Schedule,,3039.4,70,,3039.4,percent of total billed charges,All Other,727.65,,,727.65,Fee Schedule,,617.4,,,617.4,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,492.06,,,492.06,Other,New York Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,752.86,,,752.86,Other,153% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,688.89,,,688.89,Other,140% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1279.36,,,1279.36,Other,260% Medicaid APG methodology,1594.29,,,1594.29,Other,324% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,615.08,,,615.08,Other,125% Medicaid APG methodology,283.36,6501,
MRI JOINT UPR EXTREM W/DYE LT   ,73222,CPT,LT       ,47600994,CDM,610,RC,,,both,,,12687,1522.61,,,1522.61,Other,150% of Medicare + 9.63% HCRA Surcharge,925.91,,,925.91,Other,Medicare OPPS methodology,918.55,,,918.55,Fee Schedule,,825.53,,,825.53,Fee Schedule,,4009.46,,,4009.46,Fee Schedule,,3607.39,,,3607.39,Fee Schedule,,3406.36,,,3406.36,Fee Schedule,,6343.5,50,,6343.5,percent of total billed charges,All Other,2097.16,,,2097.16,Fee Schedule,,1101.68,,,1101.68,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1296.43,,,1296.43,Fee Schedule,,7865.94,,,7865.94,Fee Schedule,,610.43,,,610.43,Fee Schedule,,1296.43,,,1296.43,Fee Schedule,,7865.94,,,7865.94,Fee Schedule,,1148.19,,,1148.19,Fee Schedule,,8880.9,70,,8880.9,percent of total billed charges,All Other,1263.9,,,1263.9,Fee Schedule,,1072.4,,,1072.4,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,610.43,8880.9,
MRI JOINT UPR EXT W/O&W/DYE LT  ,73223,CPT,LT       ,47601000,CDM,610,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,1109.76,,,1109.76,Fee Schedule,,997.38,,,997.38,Fee Schedule,,4898.05,,,4898.05,Fee Schedule,,4406.88,,,4406.88,Fee Schedule,,4161.3,,,4161.3,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,1331.01,,,1331.01,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1566.31,,,1566.31,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,737.5,,,737.5,Fee Schedule,,1566.31,,,1566.31,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,1387.2,,,1387.2,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,1536.15,,,1536.15,Fee Schedule,,1303.4,,,1303.4,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,444.72,6501,
MRI LOWER EXTREMITY W/O DYE LT  ,73718,CPT,LT       ,47601018,CDM,610,RC,,,both,,,4342,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,622.3,,,622.3,Fee Schedule,,559.28,,,559.28,Fee Schedule,,3149,,,3149,Fee Schedule,,2833.23,,,2833.23,Fee Schedule,,2675.34,,,2675.34,Fee Schedule,,2171,50,,2171,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,746.36,,,746.36,Fee Schedule,,915.24,,,915.24,Other,186% Medicaid methodology,878.31,,,878.31,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,413.55,,,413.55,Fee Schedule,,878.31,,,878.31,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,777.87,,,777.87,Fee Schedule,,3039.4,70,,3039.4,percent of total billed charges,All Other,849.75,,,849.75,Fee Schedule,,721,,,721,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,492.06,,,492.06,Other,New York Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,752.86,,,752.86,Other,153% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,688.89,,,688.89,Other,140% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1279.36,,,1279.36,Other,260% Medicaid APG methodology,1594.29,,,1594.29,Other,324% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,615.08,,,615.08,Other,125% Medicaid APG methodology,283.36,6501,
MRI LW EXT W CONT LT            ,73719,CPT,LT       ,47601026,CDM,610,RC,,,both,,,6125,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,728.57,,,728.57,Fee Schedule,,654.79,,,654.79,Fee Schedule,,4009.46,,,4009.46,Fee Schedule,,3607.39,,,3607.39,Fee Schedule,,3406.36,,,3406.36,Fee Schedule,,3062.5,50,,3062.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,873.82,,,873.82,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1028.3,,,1028.3,Fee Schedule,,3797.5,,,3797.5,Fee Schedule,,484.18,,,484.18,Fee Schedule,,1028.3,,,1028.3,Fee Schedule,,3797.5,,,3797.5,Fee Schedule,,910.71,,,910.71,Fee Schedule,,4287.5,70,,4287.5,percent of total billed charges,All Other,991.65,,,991.65,Fee Schedule,,841.4,,,841.4,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,444.72,6501,
MRI JNT OF LWR EXTR W/O DYE LT  ,73721,CPT,LT       ,47601034,CDM,610,RC,,,both,,,4342,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,540.36,,,540.36,Fee Schedule,,485.64,,,485.64,Fee Schedule,,3149,,,3149,Fee Schedule,,2833.23,,,2833.23,Fee Schedule,,2675.34,,,2675.34,Fee Schedule,,2171,50,,2171,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,648.09,,,648.09,Fee Schedule,,915.24,,,915.24,Other,186% Medicaid methodology,762.66,,,762.66,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,359.1,,,359.1,Fee Schedule,,762.66,,,762.66,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,675.45,,,675.45,Fee Schedule,,3039.4,70,,3039.4,percent of total billed charges,All Other,726,,,726,Fee Schedule,,616,,,616,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,492.06,,,492.06,Other,New York Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,752.86,,,752.86,Other,153% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,688.89,,,688.89,Other,140% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1279.36,,,1279.36,Other,260% Medicaid APG methodology,1594.29,,,1594.29,Other,324% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,615.08,,,615.08,Other,125% Medicaid APG methodology,283.36,6501,
MRI JOINT OF LWR EXTR W/DYE LT  ,73722,CPT,LT       ,47601042,CDM,610,RC,,,both,,,12687,1522.61,,,1522.61,Other,150% of Medicare + 9.63% HCRA Surcharge,925.91,,,925.91,Other,Medicare OPPS methodology,921.05,,,921.05,Fee Schedule,,827.77,,,827.77,Fee Schedule,,4009.46,,,4009.46,Fee Schedule,,3607.39,,,3607.39,Fee Schedule,,3406.36,,,3406.36,Fee Schedule,,6343.5,50,,6343.5,percent of total billed charges,All Other,2097.16,,,2097.16,Fee Schedule,,1104.67,,,1104.67,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1299.96,,,1299.96,Fee Schedule,,7865.94,,,7865.94,Fee Schedule,,612.09,,,612.09,Fee Schedule,,1299.96,,,1299.96,Fee Schedule,,7865.94,,,7865.94,Fee Schedule,,1151.31,,,1151.31,Fee Schedule,,8880.9,70,,8880.9,percent of total billed charges,All Other,1267.2,,,1267.2,Fee Schedule,,1075.2,,,1075.2,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,612.09,8880.9,
MRI JOINT LWR EXT W/O&W/DYE LT  ,73723,CPT,LT       ,47601059,CDM,610,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,1104.8,,,1104.8,Fee Schedule,,992.92,,,992.92,Fee Schedule,,4898.05,,,4898.05,Fee Schedule,,4406.88,,,4406.88,Fee Schedule,,4161.3,,,4161.3,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,1325.06,,,1325.06,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1559.31,,,1559.31,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,734.2,,,734.2,Fee Schedule,,1559.31,,,1559.31,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,1381,,,1381,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,1531.2,,,1531.2,Fee Schedule,,1299.2,,,1299.2,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,444.72,6501,
MRA Lower Extremity w/ Contrast Right,73725,CPT,TCRT,47601083,CDM,610,RC,,,both,,,6593,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,976.41,,,976.41,Fee Schedule,,877.53,,,877.53,Fee Schedule,,4268.22,,,4268.22,Fee Schedule,,3840.21,,,3840.21,Fee Schedule,,3626.21,,,3626.21,Fee Schedule,,3296.5,50,,3296.5,percent of total billed charges,All Other,919.95,,,919.95,Fee Schedule,,1171.07,,,1171.07,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,1378.1,,,1378.1,Fee Schedule,,4087.66,,,4087.66,Fee Schedule,,648.88,,,648.88,Fee Schedule,,1378.1,,,1378.1,Fee Schedule,,4087.66,,,4087.66,Fee Schedule,,1220.51,,,1220.51,Fee Schedule,,4615.1,70,,4615.1,percent of total billed charges,All Other,1324.95,,,1324.95,Fee Schedule,,1124.2,,,1124.2,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,444.72,6501,
MR ANGIOGRAPHY HEAD W/O DYE     ,70544,CPT,,47601125,CDM,610,RC,,,both,,,4342,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,619.3,,,619.3,Fee Schedule,,556.58,,,556.58,Fee Schedule,,3149,,,3149,Fee Schedule,,2833.23,,,2833.23,Fee Schedule,,2675.34,,,2675.34,Fee Schedule,,2171,50,,2171,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,742.76,,,742.76,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,874.07,,,874.07,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,411.56,,,411.56,Fee Schedule,,874.07,,,874.07,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,774.12,,,774.12,Fee Schedule,,3039.4,70,,3039.4,percent of total billed charges,All Other,833.25,,,833.25,Fee Schedule,,707,,,707,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,283.36,6501,
MR ANGIOGRAPHY NECK W/DYE       ,70548,CPT,,47601133,CDM,610,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,683.89,,,683.89,Fee Schedule,,614.63,,,614.63,Fee Schedule,,4009.46,,,4009.46,Fee Schedule,,3607.39,,,3607.39,Fee Schedule,,3406.36,,,3406.36,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,820.23,,,820.23,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,965.23,,,965.23,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,454.48,,,454.48,Fee Schedule,,965.23,,,965.23,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,854.86,,,854.86,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,922.35,,,922.35,Fee Schedule,,782.6,,,782.6,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,444.72,6501,
MR ANGIOGRAPHY NECK W/O DYE     ,70547,CPT,,47601141,CDM,610,RC,,,both,,,4342,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,620.56,,,620.56,Fee Schedule,,557.72,,,557.72,Fee Schedule,,3149,,,3149,Fee Schedule,,2833.23,,,2833.23,Fee Schedule,,2675.34,,,2675.34,Fee Schedule,,2171,50,,2171,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,744.28,,,744.28,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,875.85,,,875.85,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,412.4,,,412.4,Fee Schedule,,875.85,,,875.85,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,775.7,,,775.7,Fee Schedule,,3039.4,70,,3039.4,percent of total billed charges,All Other,836.55,,,836.55,Fee Schedule,,709.8,,,709.8,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,283.36,6501,
MRI Breast BX Vac Assist Left,77021,CPT,TCLT,47601190,CDM,610,RC,,,both,,,2241,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,1327.58,,,1327.58,Fee Schedule,,1193.14,,,1193.14,Fee Schedule,,3289.3,,,3289.3,Fee Schedule,,2959.46,,,2959.46,Fee Schedule,,2794.53,,,2794.53,Fee Schedule,,1120.5,50,,1120.5,percent of total billed charges,All Other,1568.7,,,1568.7,Fee Schedule,,1592.25,,,1592.25,Fee Schedule,,565.84,,,565.84,Other,186% Medicaid methodology,1873.74,,,1873.74,Fee Schedule,,1389.42,,,1389.42,Fee Schedule,,882.25,,,882.25,Fee Schedule,,1873.74,,,1873.74,Fee Schedule,,1389.42,,,1389.42,Fee Schedule,,1659.47,,,1659.47,Fee Schedule,,1568.7,70,,1568.7,percent of total billed charges,All Other,1777.05,,,1777.05,Fee Schedule,,1507.8,,,1507.8,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,304.21,,,304.21,Other,New York Medicaid APG methodology,304.21,,,304.21,Other,100% Medicaid APG methodology,304.21,,,304.21,Other,100% Medicaid APG methodology,304.21,,,304.21,Other,100% Medicaid APG methodology,684.48,,,684.48,Other,225% Medicaid APG methodology,684.48,,,684.48,Other,225% Medicaid APG methodology,465.45,,,465.45,Other,153% Medicaid APG methodology,684.48,,,684.48,Other,225% Medicaid APG methodology,425.9,,,425.9,Other,140% Medicaid APG methodology,684.48,,,684.48,Other,225% Medicaid APG methodology,790.95,,,790.95,Other,260% Medicaid APG methodology,985.65,,,985.65,Other,324% Medicaid APG methodology,654.06,,,654.06,Other,215% Medicaid APG methodology,654.06,,,654.06,Other,215% Medicaid APG methodology,380.27,,,380.27,Other,125% Medicaid APG methodology,0.01,6501,
CARDIAC MRI FOR MORPH W/O DYE   ,75557,CPT,,47601240,CDM,610,RC,,,both,,,4342,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,662.02,,,662.02,Fee Schedule,,594.98,,,594.98,Fee Schedule,,3030.53,,,3030.53,Fee Schedule,,2726.64,,,2726.64,Fee Schedule,,2574.69,,,2574.69,Fee Schedule,,2171,50,,2171,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,794.01,,,794.01,Fee Schedule,,915.24,,,915.24,Other,186% Medicaid methodology,934.37,,,934.37,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,439.95,,,439.95,Fee Schedule,,934.37,,,934.37,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,827.53,,,827.53,Fee Schedule,,3039.4,70,,3039.4,percent of total billed charges,All Other,917.4,,,917.4,Fee Schedule,,778.4,,,778.4,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,492.06,,,492.06,Other,New York Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,752.86,,,752.86,Other,153% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,688.89,,,688.89,Other,140% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1279.36,,,1279.36,Other,260% Medicaid APG methodology,1594.29,,,1594.29,Other,324% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,615.08,,,615.08,Other,125% Medicaid APG methodology,283.36,6501,
CARDIAC MRI FOR MORPH W/DYE     ,75561,CPT,,47601257,CDM,610,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,945.88,,,945.88,Fee Schedule,,850.1,,,850.1,Fee Schedule,,4371.11,,,4371.11,Fee Schedule,,3932.78,,,3932.78,Fee Schedule,,3713.62,,,3713.62,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,1134.46,,,1134.46,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1335.01,,,1335.01,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,628.59,,,628.59,Fee Schedule,,1335.01,,,1335.01,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,1182.35,,,1182.35,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,1315.05,,,1315.05,Fee Schedule,,1115.8,,,1115.8,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,444.72,6501,
MRI ANGIO ABDOM W ORW/O DYE     ,74185,CPT,,47601265,CDM,610,RC,,,both,,,9890,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,982.6,,,982.6,Fee Schedule,,883.1,,,883.1,Fee Schedule,,4255.8,,,4255.8,Fee Schedule,,3829.04,,,3829.04,Fee Schedule,,3615.65,,,3615.65,Fee Schedule,,4945,50,,4945,percent of total billed charges,All Other,926.45,,,926.45,Fee Schedule,,1178.5,,,1178.5,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,1386.84,,,1386.84,Fee Schedule,,6131.8,,,6131.8,Fee Schedule,,653,,,653,Fee Schedule,,1386.84,,,1386.84,Fee Schedule,,6131.8,,,6131.8,Fee Schedule,,1228.25,,,1228.25,Fee Schedule,,6923,70,,6923,percent of total billed charges,All Other,1336.5,,,1336.5,Fee Schedule,,1134,,,1134,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,444.72,6923,
MRI ANGIO ABDOM W ORW/O DYE     ,74185,CPT,,47601273,CDM,610,RC,,,both,,,9890,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,982.6,,,982.6,Fee Schedule,,883.1,,,883.1,Fee Schedule,,4255.8,,,4255.8,Fee Schedule,,3829.04,,,3829.04,Fee Schedule,,3615.65,,,3615.65,Fee Schedule,,4945,50,,4945,percent of total billed charges,All Other,926.45,,,926.45,Fee Schedule,,1178.5,,,1178.5,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,1386.84,,,1386.84,Fee Schedule,,6131.8,,,6131.8,Fee Schedule,,653,,,653,Fee Schedule,,1386.84,,,1386.84,Fee Schedule,,6131.8,,,6131.8,Fee Schedule,,1228.25,,,1228.25,Fee Schedule,,6923,70,,6923,percent of total billed charges,All Other,1336.5,,,1336.5,Fee Schedule,,1134,,,1134,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,283.36,6923,
MRI ANGIO ABDOM W ORW/O DYE     ,74185,CPT,,47601281,CDM,610,RC,,,both,,,9890,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,982.6,,,982.6,Fee Schedule,,883.1,,,883.1,Fee Schedule,,4255.8,,,4255.8,Fee Schedule,,3829.04,,,3829.04,Fee Schedule,,3615.65,,,3615.65,Fee Schedule,,4945,50,,4945,percent of total billed charges,All Other,926.45,,,926.45,Fee Schedule,,1178.5,,,1178.5,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,1386.84,,,1386.84,Fee Schedule,,6131.8,,,6131.8,Fee Schedule,,653,,,653,Fee Schedule,,1386.84,,,1386.84,Fee Schedule,,6131.8,,,6131.8,Fee Schedule,,1228.25,,,1228.25,Fee Schedule,,6923,70,,6923,percent of total billed charges,All Other,1336.5,,,1336.5,Fee Schedule,,1134,,,1134,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,444.72,6923,
MRI ANGIO CHEST W OR W/O DYE    ,71555,CPT,,47601299,CDM,610,RC,,,both,,,7041,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,970.18,,,970.18,Fee Schedule,,871.94,,,871.94,Fee Schedule,,4277.63,,,4277.63,Fee Schedule,,3848.67,,,3848.67,Fee Schedule,,3634.2,,,3634.2,Fee Schedule,,3520.5,50,,3520.5,percent of total billed charges,All Other,916.7,,,916.7,Fee Schedule,,1163.61,,,1163.61,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,1369.31,,,1369.31,Fee Schedule,,4365.42,,,4365.42,Fee Schedule,,644.74,,,644.74,Fee Schedule,,1369.31,,,1369.31,Fee Schedule,,4365.42,,,4365.42,Fee Schedule,,1212.73,,,1212.73,Fee Schedule,,4928.7,70,,4928.7,percent of total billed charges,All Other,1321.65,,,1321.65,Fee Schedule,,1121.4,,,1121.4,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,444.72,6501,
MRI ANGIO CHEST W OR W/O DYE    ,71555,CPT,,47601307,CDM,610,RC,,,both,,,7041,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,970.18,,,970.18,Fee Schedule,,871.94,,,871.94,Fee Schedule,,4277.63,,,4277.63,Fee Schedule,,3848.67,,,3848.67,Fee Schedule,,3634.2,,,3634.2,Fee Schedule,,3520.5,50,,3520.5,percent of total billed charges,All Other,916.7,,,916.7,Fee Schedule,,1163.61,,,1163.61,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,1369.31,,,1369.31,Fee Schedule,,4365.42,,,4365.42,Fee Schedule,,644.74,,,644.74,Fee Schedule,,1369.31,,,1369.31,Fee Schedule,,4365.42,,,4365.42,Fee Schedule,,1212.73,,,1212.73,Fee Schedule,,4928.7,70,,4928.7,percent of total billed charges,All Other,1321.65,,,1321.65,Fee Schedule,,1121.4,,,1121.4,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,283.36,6501,
MRI ANGIO CHEST W OR W/O DYE    ,71555,CPT,,47601315,CDM,610,RC,,,both,,,7041,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,970.18,,,970.18,Fee Schedule,,871.94,,,871.94,Fee Schedule,,4277.63,,,4277.63,Fee Schedule,,3848.67,,,3848.67,Fee Schedule,,3634.2,,,3634.2,Fee Schedule,,3520.5,50,,3520.5,percent of total billed charges,All Other,916.7,,,916.7,Fee Schedule,,1163.61,,,1163.61,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,1369.31,,,1369.31,Fee Schedule,,4365.42,,,4365.42,Fee Schedule,,644.74,,,644.74,Fee Schedule,,1369.31,,,1369.31,Fee Schedule,,4365.42,,,4365.42,Fee Schedule,,1212.73,,,1212.73,Fee Schedule,,4928.7,70,,4928.7,percent of total billed charges,All Other,1321.65,,,1321.65,Fee Schedule,,1121.4,,,1121.4,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,444.72,6501,
MR ANG LWR EXT W OR W/O DYE RT  ,73725,CPT,RT       ,47601331,CDM,610,RC,,,both,,,6593,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,976.41,,,976.41,Fee Schedule,,877.53,,,877.53,Fee Schedule,,4268.22,,,4268.22,Fee Schedule,,3840.21,,,3840.21,Fee Schedule,,3626.21,,,3626.21,Fee Schedule,,3296.5,50,,3296.5,percent of total billed charges,All Other,919.95,,,919.95,Fee Schedule,,1171.07,,,1171.07,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,1378.1,,,1378.1,Fee Schedule,,4087.66,,,4087.66,Fee Schedule,,648.88,,,648.88,Fee Schedule,,1378.1,,,1378.1,Fee Schedule,,4087.66,,,4087.66,Fee Schedule,,1220.51,,,1220.51,Fee Schedule,,4615.1,70,,4615.1,percent of total billed charges,All Other,1324.95,,,1324.95,Fee Schedule,,1124.2,,,1124.2,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,283.36,6501,
MR ANG LWR EXT W OR W/O DYE RT  ,73725,CPT,RT       ,47601349,CDM,610,RC,,,both,,,6593,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,976.41,,,976.41,Fee Schedule,,877.53,,,877.53,Fee Schedule,,4268.22,,,4268.22,Fee Schedule,,3840.21,,,3840.21,Fee Schedule,,3626.21,,,3626.21,Fee Schedule,,3296.5,50,,3296.5,percent of total billed charges,All Other,919.95,,,919.95,Fee Schedule,,1171.07,,,1171.07,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,1378.1,,,1378.1,Fee Schedule,,4087.66,,,4087.66,Fee Schedule,,648.88,,,648.88,Fee Schedule,,1378.1,,,1378.1,Fee Schedule,,4087.66,,,4087.66,Fee Schedule,,1220.51,,,1220.51,Fee Schedule,,4615.1,70,,4615.1,percent of total billed charges,All Other,1324.95,,,1324.95,Fee Schedule,,1124.2,,,1124.2,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,444.72,6501,
MR ANG LWR EXT W OR W/O DYE LT  ,73725,CPT,LT       ,47601356,CDM,610,RC,,,both,,,6593,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,976.41,,,976.41,Fee Schedule,,877.53,,,877.53,Fee Schedule,,4268.22,,,4268.22,Fee Schedule,,3840.21,,,3840.21,Fee Schedule,,3626.21,,,3626.21,Fee Schedule,,3296.5,50,,3296.5,percent of total billed charges,All Other,919.95,,,919.95,Fee Schedule,,1171.07,,,1171.07,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,1378.1,,,1378.1,Fee Schedule,,4087.66,,,4087.66,Fee Schedule,,648.88,,,648.88,Fee Schedule,,1378.1,,,1378.1,Fee Schedule,,4087.66,,,4087.66,Fee Schedule,,1220.51,,,1220.51,Fee Schedule,,4615.1,70,,4615.1,percent of total billed charges,All Other,1324.95,,,1324.95,Fee Schedule,,1124.2,,,1124.2,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,444.72,6501,
MR ANG LWR EXT W OR W/O DYE LT  ,73725,CPT,LT       ,47601364,CDM,610,RC,,,both,,,6593,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,976.41,,,976.41,Fee Schedule,,877.53,,,877.53,Fee Schedule,,4268.22,,,4268.22,Fee Schedule,,3840.21,,,3840.21,Fee Schedule,,3626.21,,,3626.21,Fee Schedule,,3296.5,50,,3296.5,percent of total billed charges,All Other,919.95,,,919.95,Fee Schedule,,1171.07,,,1171.07,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,1378.1,,,1378.1,Fee Schedule,,4087.66,,,4087.66,Fee Schedule,,648.88,,,648.88,Fee Schedule,,1378.1,,,1378.1,Fee Schedule,,4087.66,,,4087.66,Fee Schedule,,1220.51,,,1220.51,Fee Schedule,,4615.1,70,,4615.1,percent of total billed charges,All Other,1324.95,,,1324.95,Fee Schedule,,1124.2,,,1124.2,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,283.36,6501,
MR ANG LWR EXT W OR W/O DYE LT  ,73725,CPT,LT       ,47601372,CDM,610,RC,,,both,,,6593,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,976.41,,,976.41,Fee Schedule,,877.53,,,877.53,Fee Schedule,,4268.22,,,4268.22,Fee Schedule,,3840.21,,,3840.21,Fee Schedule,,3626.21,,,3626.21,Fee Schedule,,3296.5,50,,3296.5,percent of total billed charges,All Other,919.95,,,919.95,Fee Schedule,,1171.07,,,1171.07,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,1378.1,,,1378.1,Fee Schedule,,4087.66,,,4087.66,Fee Schedule,,648.88,,,648.88,Fee Schedule,,1378.1,,,1378.1,Fee Schedule,,4087.66,,,4087.66,Fee Schedule,,1220.51,,,1220.51,Fee Schedule,,4615.1,70,,4615.1,percent of total billed charges,All Other,1324.95,,,1324.95,Fee Schedule,,1124.2,,,1124.2,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,444.72,6501,
MRI BREAST C-+ W/CAD BI         ,77049,CPT,,47601497,CDM,610,RC,,,both,,,7306,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,913.59,,,913.59,Fee Schedule,,821.07,,,821.07,Fee Schedule,,353.74,,,353.74,Fee Schedule,,353.74,,,353.74,Fee Schedule,,353.74,,,353.74,Fee Schedule,,3653,50,,3653,percent of total billed charges,All Other,876.4,,,876.4,Fee Schedule,,1095.73,,,1095.73,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1289.43,,,1289.43,Fee Schedule,,4529.72,,,4529.72,Fee Schedule,,607.13,,,607.13,Fee Schedule,,1289.43,,,1289.43,Fee Schedule,,4529.72,,,4529.72,Fee Schedule,,1141.98,,,1141.98,Fee Schedule,,5114.2,70,,5114.2,percent of total billed charges,All Other,1255.65,,,1255.65,Fee Schedule,,1065.4,,,1065.4,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,353.74,6501,
MRI BREAST C- BILATERAL         ,77047,CPT,,47601505,CDM,610,RC,,,both,,,4813,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,561.47,,,561.47,Fee Schedule,,504.61,,,504.61,Fee Schedule,,214.44,,,214.44,Fee Schedule,,214.44,,,214.44,Fee Schedule,,214.44,,,214.44,Fee Schedule,,2406.5,50,,2406.5,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,673.41,,,673.41,Fee Schedule,,915.24,,,915.24,Other,186% Medicaid methodology,792.45,,,792.45,Fee Schedule,,2984.06,,,2984.06,Fee Schedule,,373.13,,,373.13,Fee Schedule,,792.45,,,792.45,Fee Schedule,,2984.06,,,2984.06,Fee Schedule,,701.84,,,701.84,Fee Schedule,,3369.1,70,,3369.1,percent of total billed charges,All Other,765.6,,,765.6,Fee Schedule,,649.6,,,649.6,Fee Schedule,,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,492.06,,,492.06,Other,New York Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,752.86,,,752.86,Other,153% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,688.89,,,688.89,Other,140% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1279.36,,,1279.36,Other,260% Medicaid APG methodology,1594.29,,,1594.29,Other,324% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,615.08,,,615.08,Other,125% Medicaid APG methodology,214.44,6501,
MRI Guidance Tissue Ablation,77022,CPT,TC,47601901,CDM,610,RC,,,both,,,594,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,297,,,297,Fee Schedule,,297,,,297,Fee Schedule,,480.79,,,480.79,Fee Schedule,,480.79,,,480.79,Fee Schedule,,480.79,,,480.79,Fee Schedule,,297,50,,297,percent of total billed charges,All Other,415.8,,,415.8,Fee Schedule,,255.42,43,,255.42,percent of total billed charges,All Other,565.84,,,565.84,Other,186% Medicaid methodology,297,50,,297,percent of total billed charges,All Other,326.7,55,,326.7,percent of total billed charges,All Other,326.7,55,,326.7,percent of total billed charges,All Other,297,50,,297,percent of total billed charges,All Other,326.7,55,,326.7,percent of total billed charges,All Other,534.6,90,,534.6,percent of total billed charges,All Other,415.8,70,,415.8,percent of total billed charges,All Other,297,50,,297,percent of total billed charges,All Other,297,50,,297,percent of total billed charges,All Other,3253,,,3253,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,304.21,,,304.21,Other,New York Medicaid APG methodology,304.21,,,304.21,Other,100% Medicaid APG methodology,304.21,,,304.21,Other,100% Medicaid APG methodology,304.21,,,304.21,Other,100% Medicaid APG methodology,684.48,,,684.48,Other,225% Medicaid APG methodology,684.48,,,684.48,Other,225% Medicaid APG methodology,465.45,,,465.45,Other,153% Medicaid APG methodology,684.48,,,684.48,Other,225% Medicaid APG methodology,425.9,,,425.9,Other,140% Medicaid APG methodology,684.48,,,684.48,Other,225% Medicaid APG methodology,790.95,,,790.95,Other,260% Medicaid APG methodology,985.65,,,985.65,Other,324% Medicaid APG methodology,654.06,,,654.06,Other,215% Medicaid APG methodology,654.06,,,654.06,Other,215% Medicaid APG methodology,380.27,,,380.27,Other,125% Medicaid APG methodology,0.01,6501,
MRI ORBIT/FACE/NECK W/O DYE     ,70540,CPT,,47600028,CDM,611,RC,,,both,,,4342,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,633.49,,,633.49,Fee Schedule,,569.33,,,569.33,Fee Schedule,,3149,,,3149,Fee Schedule,,2833.23,,,2833.23,Fee Schedule,,2675.34,,,2675.34,Fee Schedule,,2171,50,,2171,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,759.78,,,759.78,Fee Schedule,,915.24,,,915.24,Other,186% Medicaid methodology,894.1,,,894.1,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,420.99,,,420.99,Fee Schedule,,894.1,,,894.1,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,791.86,,,791.86,Fee Schedule,,3039.4,70,,3039.4,percent of total billed charges,All Other,864.6,,,864.6,Fee Schedule,,733.6,,,733.6,Fee Schedule,,6501,,,6501,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,492.06,,,492.06,Other,New York Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,752.86,,,752.86,Other,153% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,688.89,,,688.89,Other,140% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1279.36,,,1279.36,Other,260% Medicaid APG methodology,1594.29,,,1594.29,Other,324% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,615.08,,,615.08,Other,125% Medicaid APG methodology,283.36,6501,
MRI BRAIN STEM W/O DYE          ,70551,CPT,,47600036,CDM,611,RC,,,both,,,4342,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,494.41,,,494.41,Fee Schedule,,444.35,,,444.35,Fee Schedule,,3149,,,3149,Fee Schedule,,2833.23,,,2833.23,Fee Schedule,,2675.34,,,2675.34,Fee Schedule,,2171,50,,2171,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,592.98,,,592.98,Fee Schedule,,915.24,,,915.24,Other,186% Medicaid methodology,697.81,,,697.81,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,328.57,,,328.57,Fee Schedule,,697.81,,,697.81,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,618.02,,,618.02,Fee Schedule,,3039.4,70,,3039.4,percent of total billed charges,All Other,666.6,,,666.6,Fee Schedule,,565.6,,,565.6,Fee Schedule,,6501,,,6501,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,492.06,,,492.06,Other,New York Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,752.86,,,752.86,Other,153% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,688.89,,,688.89,Other,140% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1279.36,,,1279.36,Other,260% Medicaid APG methodology,1594.29,,,1594.29,Other,324% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,615.08,,,615.08,Other,125% Medicaid APG methodology,283.36,6501,
MRI BRAIN STEM W/DYE            ,70552,CPT,,47600044,CDM,611,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,727.34,,,727.34,Fee Schedule,,653.68,,,653.68,Fee Schedule,,4009.46,,,4009.46,Fee Schedule,,3607.39,,,3607.39,Fee Schedule,,3406.36,,,3406.36,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,872.34,,,872.34,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1026.56,,,1026.56,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,483.36,,,483.36,Fee Schedule,,1026.56,,,1026.56,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,909.17,,,909.17,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,985.05,,,985.05,Fee Schedule,,835.8,,,835.8,Fee Schedule,,6501,,,6501,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,444.72,6501,
MRI BRAIN STEM W/O & W/DYE      ,70553,CPT,,47600051,CDM,611,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,822.96,,,822.96,Fee Schedule,,739.62,,,739.62,Fee Schedule,,4898.05,,,4898.05,Fee Schedule,,4406.88,,,4406.88,Fee Schedule,,4161.3,,,4161.3,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,987.03,,,987.03,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1161.52,,,1161.52,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,546.9,,,546.9,Fee Schedule,,1161.52,,,1161.52,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,1028.7,,,1028.7,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,1120.35,,,1120.35,Fee Schedule,,950.6,,,950.6,Fee Schedule,,6501,,,6501,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,444.72,6501,
MRI ORBIT/FACE/NECK W/DYE       ,70542,CPT,,47600796,CDM,611,RC,,,both,,,7160,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,748.45,,,748.45,Fee Schedule,,672.65,,,672.65,Fee Schedule,,4009.46,,,4009.46,Fee Schedule,,3607.39,,,3607.39,Fee Schedule,,3406.36,,,3406.36,Fee Schedule,,3580,50,,3580,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,897.66,,,897.66,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1056.35,,,1056.35,Fee Schedule,,4439.2,,,4439.2,Fee Schedule,,497.39,,,497.39,Fee Schedule,,1056.35,,,1056.35,Fee Schedule,,4439.2,,,4439.2,Fee Schedule,,935.56,,,935.56,Fee Schedule,,5012,70,,5012,percent of total billed charges,All Other,1023,,,1023,Fee Schedule,,868,,,868,Fee Schedule,,6501,,,6501,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,444.72,6501,
MRI PELVIS W/DYE                ,72196,CPT,,47600077,CDM,612,RC,,,both,,,5065,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,729.83,,,729.83,Fee Schedule,,655.93,,,655.93,Fee Schedule,,4009.46,,,4009.46,Fee Schedule,,3607.39,,,3607.39,Fee Schedule,,3406.36,,,3406.36,Fee Schedule,,2532.5,50,,2532.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,875.34,,,875.34,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1030.08,,,1030.08,Fee Schedule,,3140.3,,,3140.3,Fee Schedule,,485.02,,,485.02,Fee Schedule,,1030.08,,,1030.08,Fee Schedule,,3140.3,,,3140.3,Fee Schedule,,912.29,,,912.29,Fee Schedule,,3545.5,70,,3545.5,percent of total billed charges,All Other,999.9,,,999.9,Fee Schedule,,848.4,,,848.4,Fee Schedule,,6501,,,6501,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,444.72,6501,
MRI NECK SPINE W/O DYE          ,72141,CPT,,47600093,CDM,612,RC,,,both,,,4342,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,473.3,,,473.3,Fee Schedule,,425.38,,,425.38,Fee Schedule,,3145.92,,,3145.92,Fee Schedule,,2830.45,,,2830.45,Fee Schedule,,2672.72,,,2672.72,Fee Schedule,,2171,50,,2171,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,567.67,,,567.67,Fee Schedule,,915.24,,,915.24,Other,186% Medicaid methodology,668.02,,,668.02,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,314.54,,,314.54,Fee Schedule,,668.02,,,668.02,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,591.63,,,591.63,Fee Schedule,,3039.4,70,,3039.4,percent of total billed charges,All Other,641.85,,,641.85,Fee Schedule,,544.6,,,544.6,Fee Schedule,,6501,,,6501,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,492.06,,,492.06,Other,New York Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,752.86,,,752.86,Other,153% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,688.89,,,688.89,Other,140% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1279.36,,,1279.36,Other,260% Medicaid APG methodology,1594.29,,,1594.29,Other,324% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,615.08,,,615.08,Other,125% Medicaid APG methodology,283.36,6501,
MRI NECK SPINE W/DYE            ,72142,CPT,,47600101,CDM,612,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,744.72,,,744.72,Fee Schedule,,669.3,,,669.3,Fee Schedule,,4009.46,,,4009.46,Fee Schedule,,3607.39,,,3607.39,Fee Schedule,,3406.36,,,3406.36,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,893.19,,,893.19,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1051.09,,,1051.09,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,494.91,,,494.91,Fee Schedule,,1051.09,,,1051.09,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,930.9,,,930.9,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,1016.4,,,1016.4,Fee Schedule,,862.4,,,862.4,Fee Schedule,,6501,,,6501,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,444.72,6501,
MRI NECK SPINE W/O & W/DYE      ,72156,CPT,,47600119,CDM,612,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,827.92,,,827.92,Fee Schedule,,744.08,,,744.08,Fee Schedule,,4898.05,,,4898.05,Fee Schedule,,4406.88,,,4406.88,Fee Schedule,,4161.3,,,4161.3,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,992.98,,,992.98,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1168.52,,,1168.52,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,550.2,,,550.2,Fee Schedule,,1168.52,,,1168.52,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,1034.9,,,1034.9,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,1130.25,,,1130.25,Fee Schedule,,959,,,959,Fee Schedule,,6501,,,6501,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,444.72,6501,
MRI CHEST SPINE W/O DYE         ,72146,CPT,,47600127,CDM,612,RC,,,both,,,4342,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,472.07,,,472.07,Fee Schedule,,424.27,,,424.27,Fee Schedule,,3145.92,,,3145.92,Fee Schedule,,2830.45,,,2830.45,Fee Schedule,,2672.72,,,2672.72,Fee Schedule,,2171,50,,2171,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,566.19,,,566.19,Fee Schedule,,915.24,,,915.24,Other,186% Medicaid methodology,666.28,,,666.28,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,313.72,,,313.72,Fee Schedule,,666.28,,,666.28,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,590.09,,,590.09,Fee Schedule,,3039.4,70,,3039.4,percent of total billed charges,All Other,641.85,,,641.85,Fee Schedule,,544.6,,,544.6,Fee Schedule,,6501,,,6501,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,492.06,,,492.06,Other,New York Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,752.86,,,752.86,Other,153% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,688.89,,,688.89,Other,140% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1279.36,,,1279.36,Other,260% Medicaid APG methodology,1594.29,,,1594.29,Other,324% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,615.08,,,615.08,Other,125% Medicaid APG methodology,283.36,6501,
MRI CHEST SPINE W/DYE           ,72147,CPT,,47600135,CDM,612,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,737.26,,,737.26,Fee Schedule,,662.6,,,662.6,Fee Schedule,,3968.96,,,3968.96,Fee Schedule,,3570.96,,,3570.96,Fee Schedule,,3371.96,,,3371.96,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,884.24,,,884.24,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1040.56,,,1040.56,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,489.95,,,489.95,Fee Schedule,,1040.56,,,1040.56,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,921.57,,,921.57,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,1003.2,,,1003.2,Fee Schedule,,851.2,,,851.2,Fee Schedule,,6501,,,6501,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,444.72,6501,
MRI CHEST SPINE W/O & W/DYE     ,72157,CPT,,47600143,CDM,612,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,830.38,,,830.38,Fee Schedule,,746.3,,,746.3,Fee Schedule,,4898.05,,,4898.05,Fee Schedule,,4406.88,,,4406.88,Fee Schedule,,4161.3,,,4161.3,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,995.94,,,995.94,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1172,,,1172,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,551.84,,,551.84,Fee Schedule,,1172,,,1172,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,1037.98,,,1037.98,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,1131.9,,,1131.9,Fee Schedule,,960.4,,,960.4,Fee Schedule,,6501,,,6501,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,444.72,6501,
MRI LUMBAR SPINE W/O DYE        ,72148,CPT,,47600150,CDM,612,RC,,,both,,,4342,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,474.54,,,474.54,Fee Schedule,,426.48,,,426.48,Fee Schedule,,3145.92,,,3145.92,Fee Schedule,,2830.45,,,2830.45,Fee Schedule,,2672.72,,,2672.72,Fee Schedule,,2171,50,,2171,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,569.14,,,569.14,Fee Schedule,,915.24,,,915.24,Other,186% Medicaid methodology,669.76,,,669.76,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,315.36,,,315.36,Fee Schedule,,669.76,,,669.76,Fee Schedule,,2692.04,,,2692.04,Fee Schedule,,593.17,,,593.17,Fee Schedule,,3039.4,70,,3039.4,percent of total billed charges,All Other,643.5,,,643.5,Fee Schedule,,546,,,546,Fee Schedule,,6501,,,6501,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,492.06,,,492.06,Other,New York Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,492.06,,,492.06,Other,100% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,752.86,,,752.86,Other,153% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,688.89,,,688.89,Other,140% Medicaid APG methodology,1107.14,,,1107.14,Other,225% Medicaid APG methodology,1279.36,,,1279.36,Other,260% Medicaid APG methodology,1594.29,,,1594.29,Other,324% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,1057.94,,,1057.94,Other,215% Medicaid APG methodology,615.08,,,615.08,Other,125% Medicaid APG methodology,283.36,6501,
MRI LUMBAR SPINE W/DYE          ,72149,CPT,,47600168,CDM,612,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,727.34,,,727.34,Fee Schedule,,653.68,,,653.68,Fee Schedule,,4009.46,,,4009.46,Fee Schedule,,3607.39,,,3607.39,Fee Schedule,,3406.36,,,3406.36,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,872.34,,,872.34,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1026.56,,,1026.56,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,483.36,,,483.36,Fee Schedule,,1026.56,,,1026.56,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,909.17,,,909.17,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,991.65,,,991.65,Fee Schedule,,841.4,,,841.4,Fee Schedule,,6501,,,6501,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,444.72,6501,
MRI LUMBAR SPINE W/O & W/DYE    ,72158,CPT,,47600176,CDM,612,RC,,,both,,,7115,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,825.42,,,825.42,Fee Schedule,,741.84,,,741.84,Fee Schedule,,4898.05,,,4898.05,Fee Schedule,,4406.88,,,4406.88,Fee Schedule,,4161.3,,,4161.3,Fee Schedule,,3557.5,50,,3557.5,percent of total billed charges,All Other,1079.46,,,1079.46,Fee Schedule,,989.99,,,989.99,Fee Schedule,,1359.71,,,1359.71,Other,186% Medicaid methodology,1165,,,1165,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,548.54,,,548.54,Fee Schedule,,1165,,,1165,Fee Schedule,,4411.3,,,4411.3,Fee Schedule,,1031.78,,,1031.78,Fee Schedule,,4980.5,70,,4980.5,percent of total billed charges,All Other,1125.3,,,1125.3,Fee Schedule,,954.8,,,954.8,Fee Schedule,,6501,,,6501,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,731.03,,,731.03,Other,New York Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,731.03,,,731.03,Other,100% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1118.47,,,1118.47,Other,153% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1023.44,,,1023.44,Other,140% Medicaid APG methodology,1644.81,,,1644.81,Other,225% Medicaid APG methodology,1900.67,,,1900.67,Other,260% Medicaid APG methodology,2368.53,,,2368.53,Other,324% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,1571.71,,,1571.71,Other,215% Medicaid APG methodology,913.78,,,913.78,Other,125% Medicaid APG methodology,444.72,6501,
MR ANGIO SPINE W/O&W/DYE        ,72159,CPT,,47600267,CDM,612,RC,,,both,,,9067,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,1012.4,,,1012.4,Fee Schedule,,909.88,,,909.88,Fee Schedule,,4820.08,,,4820.08,Fee Schedule,,4336.73,,,4336.73,Fee Schedule,,4095.05,,,4095.05,Fee Schedule,,4533.5,50,,4533.5,percent of total billed charges,All Other,954.59,,,954.59,Fee Schedule,,1214.24,,,1214.24,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,1428.89,,,1428.89,Fee Schedule,,5621.54,,,5621.54,Fee Schedule,,672.8,,,672.8,Fee Schedule,,1428.89,,,1428.89,Fee Schedule,,5621.54,,,5621.54,Fee Schedule,,1265.5,,,1265.5,Fee Schedule,,6346.9,70,,6346.9,percent of total billed charges,All Other,1377.75,,,1377.75,Fee Schedule,,1169,,,1169,Fee Schedule,,6501,,,6501,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,0.01,6501,
MR ANGIO PELVIS W/O & W/DYE     ,72198,CPT,,47601398,CDM,612,RC,,,both,,,8655,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,987.59,,,987.59,Fee Schedule,,887.59,,,887.59,Fee Schedule,,4265.14,,,4265.14,Fee Schedule,,3837.43,,,3837.43,Fee Schedule,,3623.58,,,3623.58,Fee Schedule,,4327.5,50,,4327.5,percent of total billed charges,All Other,925.37,,,925.37,Fee Schedule,,1184.49,,,1184.49,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,1393.88,,,1393.88,Fee Schedule,,5366.1,,,5366.1,Fee Schedule,,656.31,,,656.31,Fee Schedule,,1393.88,,,1393.88,Fee Schedule,,5366.1,,,5366.1,Fee Schedule,,1234.49,,,1234.49,Fee Schedule,,6058.5,70,,6058.5,percent of total billed charges,All Other,1333.2,,,1333.2,Fee Schedule,,1131.2,,,1131.2,Fee Schedule,,6501,,,6501,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,283.36,6501,
MR ANGIO PELVIS W/O & W/DYE     ,72198,CPT,,47601406,CDM,612,RC,,,both,,,8655,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,987.59,,,987.59,Fee Schedule,,887.59,,,887.59,Fee Schedule,,4265.14,,,4265.14,Fee Schedule,,3837.43,,,3837.43,Fee Schedule,,3623.58,,,3623.58,Fee Schedule,,4327.5,50,,4327.5,percent of total billed charges,All Other,925.37,,,925.37,Fee Schedule,,1184.49,,,1184.49,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,1393.88,,,1393.88,Fee Schedule,,5366.1,,,5366.1,Fee Schedule,,656.31,,,656.31,Fee Schedule,,1393.88,,,1393.88,Fee Schedule,,5366.1,,,5366.1,Fee Schedule,,1234.49,,,1234.49,Fee Schedule,,6058.5,70,,6058.5,percent of total billed charges,All Other,1333.2,,,1333.2,Fee Schedule,,1131.2,,,1131.2,Fee Schedule,,6501,,,6501,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,444.72,6501,
MRA Lower Extremity w/ Contrast Bilat,73725,CPT,50,47601836,CDM,616,RC,,,both,,,6593,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,976.41,,,976.41,Fee Schedule,,877.53,,,877.53,Fee Schedule,,4268.22,,,4268.22,Fee Schedule,,3840.21,,,3840.21,Fee Schedule,,3626.21,,,3626.21,Fee Schedule,,3296.5,50,,3296.5,percent of total billed charges,All Other,919.95,,,919.95,Fee Schedule,,1171.07,,,1171.07,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,1378.1,,,1378.1,Fee Schedule,,4087.66,,,4087.66,Fee Schedule,,648.88,,,648.88,Fee Schedule,,1378.1,,,1378.1,Fee Schedule,,4087.66,,,4087.66,Fee Schedule,,1220.51,,,1220.51,Fee Schedule,,4615.1,70,,4615.1,percent of total billed charges,All Other,1324.95,,,1324.95,Fee Schedule,,1124.2,,,1124.2,Fee Schedule,,6501,,,6501,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,444.72,6501,
MRA Lower Extremity w/o Contrast Bilat,73725,CPT,50,47601844,CDM,616,RC,,,both,,,6593,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,976.41,,,976.41,Fee Schedule,,877.53,,,877.53,Fee Schedule,,4268.22,,,4268.22,Fee Schedule,,3840.21,,,3840.21,Fee Schedule,,3626.21,,,3626.21,Fee Schedule,,3296.5,50,,3296.5,percent of total billed charges,All Other,919.95,,,919.95,Fee Schedule,,1171.07,,,1171.07,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,1378.1,,,1378.1,Fee Schedule,,4087.66,,,4087.66,Fee Schedule,,648.88,,,648.88,Fee Schedule,,1378.1,,,1378.1,Fee Schedule,,4087.66,,,4087.66,Fee Schedule,,1220.51,,,1220.51,Fee Schedule,,4615.1,70,,4615.1,percent of total billed charges,All Other,1324.95,,,1324.95,Fee Schedule,,1124.2,,,1124.2,Fee Schedule,,6501,,,6501,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,283.36,6501,
MRA Lower Extremity w/ or w/o Cnt Bilat,73725,CPT,50,47601851,CDM,616,RC,,,both,,,6593,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,976.41,,,976.41,Fee Schedule,,877.53,,,877.53,Fee Schedule,,4268.22,,,4268.22,Fee Schedule,,3840.21,,,3840.21,Fee Schedule,,3626.21,,,3626.21,Fee Schedule,,3296.5,50,,3296.5,percent of total billed charges,All Other,919.95,,,919.95,Fee Schedule,,1171.07,,,1171.07,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,1378.1,,,1378.1,Fee Schedule,,4087.66,,,4087.66,Fee Schedule,,648.88,,,648.88,Fee Schedule,,1378.1,,,1378.1,Fee Schedule,,4087.66,,,4087.66,Fee Schedule,,1220.51,,,1220.51,Fee Schedule,,4615.1,70,,4615.1,percent of total billed charges,All Other,1324.95,,,1324.95,Fee Schedule,,1124.2,,,1124.2,Fee Schedule,,6501,,,6501,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,444.72,6501,
MRA Runoff Lower Extremity w/ + w/o Bil,73725,CPT,50,47601869,CDM,616,RC,,,both,,,6593,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,976.41,,,976.41,Fee Schedule,,877.53,,,877.53,Fee Schedule,,4268.22,,,4268.22,Fee Schedule,,3840.21,,,3840.21,Fee Schedule,,3626.21,,,3626.21,Fee Schedule,,3296.5,50,,3296.5,percent of total billed charges,All Other,919.95,,,919.95,Fee Schedule,,1171.07,,,1171.07,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,1378.1,,,1378.1,Fee Schedule,,4087.66,,,4087.66,Fee Schedule,,648.88,,,648.88,Fee Schedule,,1378.1,,,1378.1,Fee Schedule,,4087.66,,,4087.66,Fee Schedule,,1220.51,,,1220.51,Fee Schedule,,4615.1,70,,4615.1,percent of total billed charges,All Other,1324.95,,,1324.95,Fee Schedule,,1124.2,,,1124.2,Fee Schedule,,6501,,,6501,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,444.72,6501,
MRA RUNOFF LOWER EXTREM W CONT  ,73725,CPT,,47601943,CDM,616,RC,,,both,,,6593,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,976.41,,,976.41,Fee Schedule,,877.53,,,877.53,Fee Schedule,,4268.22,,,4268.22,Fee Schedule,,3840.21,,,3840.21,Fee Schedule,,3626.21,,,3626.21,Fee Schedule,,3296.5,50,,3296.5,percent of total billed charges,All Other,919.95,,,919.95,Fee Schedule,,1171.07,,,1171.07,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,1378.1,,,1378.1,Fee Schedule,,4087.66,,,4087.66,Fee Schedule,,648.88,,,648.88,Fee Schedule,,1378.1,,,1378.1,Fee Schedule,,4087.66,,,4087.66,Fee Schedule,,1220.51,,,1220.51,Fee Schedule,,4615.1,70,,4615.1,percent of total billed charges,All Other,1324.95,,,1324.95,Fee Schedule,,1124.2,,,1124.2,Fee Schedule,,6501,,,6501,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,0.01,6501,
MRA Pelvis w/ Contrast,72198,CPT,TC,47601380,CDM,618,RC,,,both,,,8655,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,987.59,,,987.59,Fee Schedule,,887.59,,,887.59,Fee Schedule,,4265.14,,,4265.14,Fee Schedule,,3837.43,,,3837.43,Fee Schedule,,3623.58,,,3623.58,Fee Schedule,,4327.5,50,,4327.5,percent of total billed charges,All Other,925.37,,,925.37,Fee Schedule,,1184.49,,,1184.49,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,1393.88,,,1393.88,Fee Schedule,,5366.1,,,5366.1,Fee Schedule,,656.31,,,656.31,Fee Schedule,,1393.88,,,1393.88,Fee Schedule,,5366.1,,,5366.1,Fee Schedule,,1234.49,,,1234.49,Fee Schedule,,6058.5,70,,6058.5,percent of total billed charges,All Other,1333.2,,,1333.2,Fee Schedule,,1131.2,,,1131.2,Fee Schedule,,6501,,,6501,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,444.72,6501,
MRA Upper Extremity w/o Contrast Left,73225,CPT,TC,47601711,CDM,618,RC,,,both,,,4303,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,1012.4,,,1012.4,Fee Schedule,,909.88,,,909.88,Fee Schedule,,4760.84,,,4760.84,Fee Schedule,,4283.43,,,4283.43,Fee Schedule,,4044.73,,,4044.73,Fee Schedule,,2151.5,50,,2151.5,percent of total billed charges,All Other,954.59,,,954.59,Fee Schedule,,1214.24,,,1214.24,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,1428.89,,,1428.89,Fee Schedule,,2667.86,,,2667.86,Fee Schedule,,672.8,,,672.8,Fee Schedule,,1428.89,,,1428.89,Fee Schedule,,2667.86,,,2667.86,Fee Schedule,,1265.5,,,1265.5,Fee Schedule,,3012.1,70,,3012.1,percent of total billed charges,All Other,1377.75,,,1377.75,Fee Schedule,,1169,,,1169,Fee Schedule,,6501,,,6501,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,444.72,6501,
MRA Upper Extremity w/ Contrast Left,73225,CPT,TC,47601729,CDM,618,RC,,,both,,,6423,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,1012.4,,,1012.4,Fee Schedule,,909.88,,,909.88,Fee Schedule,,4760.84,,,4760.84,Fee Schedule,,4283.43,,,4283.43,Fee Schedule,,4044.73,,,4044.73,Fee Schedule,,3211.5,50,,3211.5,percent of total billed charges,All Other,954.59,,,954.59,Fee Schedule,,1214.24,,,1214.24,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,1428.89,,,1428.89,Fee Schedule,,3982.26,,,3982.26,Fee Schedule,,672.8,,,672.8,Fee Schedule,,1428.89,,,1428.89,Fee Schedule,,3982.26,,,3982.26,Fee Schedule,,1265.5,,,1265.5,Fee Schedule,,4496.1,70,,4496.1,percent of total billed charges,All Other,1377.75,,,1377.75,Fee Schedule,,1169,,,1169,Fee Schedule,,6501,,,6501,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,444.72,6501,
MRA Upper Extremity w/o Contrast Right,73225,CPT,TC,47601745,CDM,618,RC,,,both,,,4303,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,1012.4,,,1012.4,Fee Schedule,,909.88,,,909.88,Fee Schedule,,4760.84,,,4760.84,Fee Schedule,,4283.43,,,4283.43,Fee Schedule,,4044.73,,,4044.73,Fee Schedule,,2151.5,50,,2151.5,percent of total billed charges,All Other,954.59,,,954.59,Fee Schedule,,1214.24,,,1214.24,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,1428.89,,,1428.89,Fee Schedule,,2667.86,,,2667.86,Fee Schedule,,672.8,,,672.8,Fee Schedule,,1428.89,,,1428.89,Fee Schedule,,2667.86,,,2667.86,Fee Schedule,,1265.5,,,1265.5,Fee Schedule,,3012.1,70,,3012.1,percent of total billed charges,All Other,1377.75,,,1377.75,Fee Schedule,,1169,,,1169,Fee Schedule,,6501,,,6501,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,444.72,6501,
MRA Upper Extremity w/ Contrast Right,73225,CPT,TC,47601752,CDM,618,RC,,,both,,,6423,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,1012.4,,,1012.4,Fee Schedule,,909.88,,,909.88,Fee Schedule,,4760.84,,,4760.84,Fee Schedule,,4283.43,,,4283.43,Fee Schedule,,4044.73,,,4044.73,Fee Schedule,,3211.5,50,,3211.5,percent of total billed charges,All Other,954.59,,,954.59,Fee Schedule,,1214.24,,,1214.24,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,1428.89,,,1428.89,Fee Schedule,,3982.26,,,3982.26,Fee Schedule,,672.8,,,672.8,Fee Schedule,,1428.89,,,1428.89,Fee Schedule,,3982.26,,,3982.26,Fee Schedule,,1265.5,,,1265.5,Fee Schedule,,4496.1,70,,4496.1,percent of total billed charges,All Other,1377.75,,,1377.75,Fee Schedule,,1169,,,1169,Fee Schedule,,6501,,,6501,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,444.72,6501,
MRA Upper Extremity w/ Contrast Bilat,73225,CPT,50,47601877,CDM,618,RC,,,both,,,9635,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,1012.4,,,1012.4,Fee Schedule,,909.88,,,909.88,Fee Schedule,,4760.84,,,4760.84,Fee Schedule,,4283.43,,,4283.43,Fee Schedule,,4044.73,,,4044.73,Fee Schedule,,4817.5,50,,4817.5,percent of total billed charges,All Other,954.59,,,954.59,Fee Schedule,,1214.24,,,1214.24,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,1428.89,,,1428.89,Fee Schedule,,5973.7,,,5973.7,Fee Schedule,,672.8,,,672.8,Fee Schedule,,1428.89,,,1428.89,Fee Schedule,,5973.7,,,5973.7,Fee Schedule,,1265.5,,,1265.5,Fee Schedule,,6744.5,70,,6744.5,percent of total billed charges,All Other,1377.75,,,1377.75,Fee Schedule,,1169,,,1169,Fee Schedule,,6501,,,6501,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,444.72,6744.5,
MRA Upper Extremity w/ or w/o Cnt Bilat,73225,CPT,50,47601885,CDM,618,RC,,,both,,,9635,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,1012.4,,,1012.4,Fee Schedule,,909.88,,,909.88,Fee Schedule,,4760.84,,,4760.84,Fee Schedule,,4283.43,,,4283.43,Fee Schedule,,4044.73,,,4044.73,Fee Schedule,,4817.5,50,,4817.5,percent of total billed charges,All Other,954.59,,,954.59,Fee Schedule,,1214.24,,,1214.24,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,1428.89,,,1428.89,Fee Schedule,,5973.7,,,5973.7,Fee Schedule,,672.8,,,672.8,Fee Schedule,,1428.89,,,1428.89,Fee Schedule,,5973.7,,,5973.7,Fee Schedule,,1265.5,,,1265.5,Fee Schedule,,6744.5,70,,6744.5,percent of total billed charges,All Other,1377.75,,,1377.75,Fee Schedule,,1169,,,1169,Fee Schedule,,6501,,,6501,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,444.72,6744.5,
MRA Upper Extremity w/o Contrast Bilat,73225,CPT,50,47601893,CDM,618,RC,,,both,,,6455,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,1012.4,,,1012.4,Fee Schedule,,909.88,,,909.88,Fee Schedule,,4760.84,,,4760.84,Fee Schedule,,4283.43,,,4283.43,Fee Schedule,,4044.73,,,4044.73,Fee Schedule,,3227.5,50,,3227.5,percent of total billed charges,All Other,954.59,,,954.59,Fee Schedule,,1214.24,,,1214.24,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,1428.89,,,1428.89,Fee Schedule,,4002.1,,,4002.1,Fee Schedule,,672.8,,,672.8,Fee Schedule,,1428.89,,,1428.89,Fee Schedule,,4002.1,,,4002.1,Fee Schedule,,1265.5,,,1265.5,Fee Schedule,,4518.5,70,,4518.5,percent of total billed charges,All Other,1377.75,,,1377.75,Fee Schedule,,1169,,,1169,Fee Schedule,,6501,,,6501,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,444.72,6501,
MR ANGIO UPR EXTR W/O&W/DYE LT  ,73225,CPT,,47601737,CDM,619,RC,,,both,,,9635,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,1012.4,,,1012.4,Fee Schedule,,909.88,,,909.88,Fee Schedule,,4760.84,,,4760.84,Fee Schedule,,4283.43,,,4283.43,Fee Schedule,,4044.73,,,4044.73,Fee Schedule,,4817.5,50,,4817.5,percent of total billed charges,All Other,954.59,,,954.59,Fee Schedule,,1214.24,,,1214.24,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,1428.89,,,1428.89,Fee Schedule,,5973.7,,,5973.7,Fee Schedule,,672.8,,,672.8,Fee Schedule,,1428.89,,,1428.89,Fee Schedule,,5973.7,,,5973.7,Fee Schedule,,1265.5,,,1265.5,Fee Schedule,,6744.5,70,,6744.5,percent of total billed charges,All Other,1377.75,,,1377.75,Fee Schedule,,1169,,,1169,Fee Schedule,,6501,,,6501,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,444.72,6744.5,
MR ANGIO UPR EXTR W/O&W/DYE RT  ,73225,CPT,,47601760,CDM,619,RC,,,both,,,9635,731.33,,,731.33,Other,150% of Medicare + 9.63% HCRA Surcharge,444.72,,,444.72,Other,Medicare OPPS methodology,1012.4,,,1012.4,Fee Schedule,,909.88,,,909.88,Fee Schedule,,4760.84,,,4760.84,Fee Schedule,,4283.43,,,4283.43,Fee Schedule,,4044.73,,,4044.73,Fee Schedule,,4817.5,50,,4817.5,percent of total billed charges,All Other,954.59,,,954.59,Fee Schedule,,1214.24,,,1214.24,Fee Schedule,,1160.61,,,1160.61,Other,186% Medicaid methodology,1428.89,,,1428.89,Fee Schedule,,5973.7,,,5973.7,Fee Schedule,,672.8,,,672.8,Fee Schedule,,1428.89,,,1428.89,Fee Schedule,,5973.7,,,5973.7,Fee Schedule,,1265.5,,,1265.5,Fee Schedule,,6744.5,70,,6744.5,percent of total billed charges,All Other,1377.75,,,1377.75,Fee Schedule,,1169,,,1169,Fee Schedule,,6501,,,6501,Case Rate,MRI Per Visit,5851,,,5851,Case Rate,MRI Per Visit,6501,,,6501,Case Rate,MRI Per Visit,5527,,,5527,Case Rate,MRI Per Visit,623.98,,,623.98,Other,New York Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,623.98,,,623.98,Other,100% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,954.7,,,954.7,Other,153% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,873.58,,,873.58,Other,140% Medicaid APG methodology,1403.96,,,1403.96,Other,225% Medicaid APG methodology,1622.36,,,1622.36,Other,260% Medicaid APG methodology,2021.71,,,2021.71,Other,324% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,1341.57,,,1341.57,Other,215% Medicaid APG methodology,779.98,,,779.98,Other,125% Medicaid APG methodology,444.72,6744.5,
DALBAVANCIN 500 MG IV INJ       ,J0875,HCPCS,,40500373,CDM,636,RC,57970-0100-01,NDC,both,1,EA,3250.1,150.89,,,150.89,Other,150% of Medicare + 9.63% HCRA Surcharge,91.76,,,91.76,Fee Schedule,Average Sale Price (ASP) x 6,975.03,30,,975.03,percent of total billed charges,Drugs,975.03,30,,975.03,percent of total billed charges,Drugs,975.03,30,,975.03,percent of total billed charges,Drugs,975.03,30,,975.03,percent of total billed charges,Drugs,975.03,30,,975.03,percent of total billed charges,Drugs,1625.05,50,,1625.05,percent of total billed charges,All Other,975.03,30,,975.03,percent of total billed charges,Drugs,975.03,30,,975.03,percent of total billed charges,Drugs,1105.03,34,"If Charge > 500, then 34 percent",1105.03,percent of total billed charges,Drugs,975.03,30,,975.03,percent of total billed charges,Drugs,975.03,30,,975.03,percent of total billed charges,Drugs,975.03,30,,975.03,percent of total billed charges,Drugs,975.03,30,,975.03,percent of total billed charges,Drugs,975.03,30,,975.03,percent of total billed charges,Drugs,975.03,30,,975.03,percent of total billed charges,Drugs,975.03,30,,975.03,percent of total billed charges,Drugs,975.03,30,,975.03,percent of total billed charges,Drugs,975.03,30,,975.03,percent of total billed charges,Drugs,975.03,30,,975.03,percent of total billed charges,Drugs,975.03,30,,975.03,percent of total billed charges,Drugs,975.03,30,,975.03,percent of total billed charges,Drugs,975.03,30,,975.03,percent of total billed charges,Drugs,636.72,,,636.72,Other,Drug Cost,636.72,,,636.72,Other,Drug Cost,636.72,,,636.72,Other,Drug Cost,636.72,,,636.72,Other,Drug Cost,636.72,,,636.72,Other,Drug Cost,1105.03,34,,1105.03,percent of total billed charges,Drugs,636.72,,,636.72,Other,Drug Cost,1432.62,,,1432.62,Other,225% Medicaid APG methodology,891.41,,,891.41,Other,140% Medicaid APG methodology,1105.03,34,"If Charge > 2,000, then 34 percent",1105.03,percent of total billed charges,Drugs,146.81,,,146.81,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",636.72,,,636.72,Other,Drug Cost,636.72,,,636.72,Other,Drug Cost,795.9,,,795.9,Other,125% Medicaid APG methodology,0.01,1625.05,
TRASTUZUMAB-DKST 150 MG IV INJ  ,Q5114,HCPCS,,40500423,CDM,636,RC,67457-0991-15,NDC,both,1,EA,2945.01,438.36,,,438.36,Other,150% of Medicare + 9.63% HCRA Surcharge,266.57,,,266.57,Fee Schedule,Average Sale Price (ASP) x 6,883.5,30,,883.5,percent of total billed charges,Drugs,883.5,30,,883.5,percent of total billed charges,Drugs,883.5,30,,883.5,percent of total billed charges,Drugs,883.5,30,,883.5,percent of total billed charges,Drugs,883.5,30,,883.5,percent of total billed charges,Drugs,1472.51,50,,1472.51,percent of total billed charges,All Other,883.5,30,,883.5,percent of total billed charges,Drugs,883.5,30,,883.5,percent of total billed charges,Drugs,1001.3,34,"If Charge > 500, then 34 percent",1001.3,percent of total billed charges,Drugs,883.5,30,,883.5,percent of total billed charges,Drugs,883.5,30,,883.5,percent of total billed charges,Drugs,883.5,30,,883.5,percent of total billed charges,Drugs,883.5,30,,883.5,percent of total billed charges,Drugs,883.5,30,,883.5,percent of total billed charges,Drugs,883.5,30,,883.5,percent of total billed charges,Drugs,883.5,30,,883.5,percent of total billed charges,Drugs,883.5,30,,883.5,percent of total billed charges,Drugs,883.5,30,,883.5,percent of total billed charges,Drugs,883.5,30,,883.5,percent of total billed charges,Drugs,883.5,30,,883.5,percent of total billed charges,Drugs,883.5,30,,883.5,percent of total billed charges,Drugs,883.5,30,,883.5,percent of total billed charges,Drugs,385.58,,,385.58,Other,Drug Cost,385.58,,,385.58,Other,Drug Cost,385.58,,,385.58,Other,Drug Cost,385.58,,,385.58,Other,Drug Cost,385.58,,,385.58,Other,Drug Cost,1001.3,34,,1001.3,percent of total billed charges,Drugs,385.58,,,385.58,Other,Drug Cost,867.56,,,867.56,Other,225% Medicaid APG methodology,539.81,,,539.81,Other,140% Medicaid APG methodology,1001.3,34,"If Charge > 2,000, then 34 percent",1001.3,percent of total billed charges,Drugs,426.51,,,426.51,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",385.58,,,385.58,Other,Drug Cost,385.58,,,385.58,Other,Drug Cost,481.98,,,481.98,Other,125% Medicaid APG methodology,0.01,1472.51,
FERRIC CARBOXYMALTOSE IV        ,J1439,HCPCS,,40500472,CDM,636,RC,00517-0650-01,NDC,both,15,ML,3068.63,11.32,,,11.32,Other,150% of Medicare + 9.63% HCRA Surcharge,6.88,,,6.88,Fee Schedule,Average Sale Price (ASP) x 6,920.59,30,,920.59,percent of total billed charges,Drugs,920.59,30,,920.59,percent of total billed charges,Drugs,920.59,30,,920.59,percent of total billed charges,Drugs,920.59,30,,920.59,percent of total billed charges,Drugs,920.59,30,,920.59,percent of total billed charges,Drugs,1534.32,50,,1534.32,percent of total billed charges,All Other,920.59,30,,920.59,percent of total billed charges,Drugs,920.59,30,,920.59,percent of total billed charges,Drugs,1043.33,34,"If Charge > 500, then 34 percent",1043.33,percent of total billed charges,Drugs,920.59,30,,920.59,percent of total billed charges,Drugs,920.59,30,,920.59,percent of total billed charges,Drugs,920.59,30,,920.59,percent of total billed charges,Drugs,920.59,30,,920.59,percent of total billed charges,Drugs,920.59,30,,920.59,percent of total billed charges,Drugs,920.59,30,,920.59,percent of total billed charges,Drugs,920.59,30,,920.59,percent of total billed charges,Drugs,920.59,30,,920.59,percent of total billed charges,Drugs,920.59,30,,920.59,percent of total billed charges,Drugs,920.59,30,,920.59,percent of total billed charges,Drugs,920.59,30,,920.59,percent of total billed charges,Drugs,920.59,30,,920.59,percent of total billed charges,Drugs,920.59,30,,920.59,percent of total billed charges,Drugs,586.11,,,586.11,Other,Drug Cost,586.11,,,586.11,Other,Drug Cost,586.11,,,586.11,Other,Drug Cost,586.11,,,586.11,Other,Drug Cost,586.11,,,586.11,Other,Drug Cost,1043.33,34,,1043.33,percent of total billed charges,Drugs,586.11,,,586.11,Other,Drug Cost,1318.75,,,1318.75,Other,225% Medicaid APG methodology,820.55,,,820.55,Other,140% Medicaid APG methodology,1043.33,34,"If Charge > 2,000, then 34 percent",1043.33,percent of total billed charges,Drugs,11.01,,,11.01,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",586.11,,,586.11,Other,Drug Cost,586.11,,,586.11,Other,Drug Cost,732.64,,,732.64,Other,125% Medicaid APG methodology,0.01,1534.32,
COPANLISIB 60 MG IV INJ         ,J9057,HCPCS,,40500480,CDM,636,RC,50419-0385-01,NDC,both,1,EA,16986.9,6704.19,39.4668,,6704.19,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,5096.07,30,,5096.07,percent of total billed charges,Drugs,5096.07,30,,5096.07,percent of total billed charges,Drugs,5096.07,30,,5096.07,percent of total billed charges,Drugs,5096.07,30,,5096.07,percent of total billed charges,Drugs,5096.07,30,,5096.07,percent of total billed charges,Drugs,8493.45,50,,8493.45,percent of total billed charges,All Other,5096.07,30,,5096.07,percent of total billed charges,Drugs,5096.07,30,,5096.07,percent of total billed charges,Drugs,5775.55,34,"If Charge > 500, then 34 percent",5775.55,percent of total billed charges,Drugs,5096.07,30,,5096.07,percent of total billed charges,Drugs,5096.07,30,,5096.07,percent of total billed charges,Drugs,5096.07,30,,5096.07,percent of total billed charges,Drugs,5096.07,30,,5096.07,percent of total billed charges,Drugs,5096.07,30,,5096.07,percent of total billed charges,Drugs,5096.07,30,,5096.07,percent of total billed charges,Drugs,5096.07,30,,5096.07,percent of total billed charges,Drugs,5096.07,30,,5096.07,percent of total billed charges,Drugs,5096.07,30,,5096.07,percent of total billed charges,Drugs,5096.07,30,,5096.07,percent of total billed charges,Drugs,5096.07,30,,5096.07,percent of total billed charges,Drugs,5096.07,30,,5096.07,percent of total billed charges,Drugs,5096.07,30,,5096.07,percent of total billed charges,Drugs,3569.63,,,3569.63,Other,Drug Cost,3569.63,,,3569.63,Other,Drug Cost,3569.63,,,3569.63,Other,Drug Cost,3569.63,,,3569.63,Other,Drug Cost,3569.63,,,3569.63,Other,Drug Cost,5775.55,34,,5775.55,percent of total billed charges,Drugs,3569.63,,,3569.63,Other,Drug Cost,8031.67,,,8031.67,Other,225% Medicaid APG methodology,4997.48,,,4997.48,Other,140% Medicaid APG methodology,5775.55,34,"If Charge > 2,000, then 34 percent",5775.55,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3569.63,,,3569.63,Other,Drug Cost,3569.63,,,3569.63,Other,Drug Cost,4462.04,,,4462.04,Other,125% Medicaid APG methodology,0.01,8493.45,
FAM-TRASTUZU DERUX-NXKI 100MG   ,J9358,HCPCS,,40500548,CDM,636,RC,65597-0406-01,NDC,both,1,EA,9235.87,268.77,,,268.77,Other,150% of Medicare + 9.63% HCRA Surcharge,163.44,,,163.44,Fee Schedule,Average Sale Price (ASP) x 6,2770.76,30,,2770.76,percent of total billed charges,Drugs,2770.76,30,,2770.76,percent of total billed charges,Drugs,2770.76,30,,2770.76,percent of total billed charges,Drugs,2770.76,30,,2770.76,percent of total billed charges,Drugs,2770.76,30,,2770.76,percent of total billed charges,Drugs,4617.94,50,,4617.94,percent of total billed charges,All Other,2770.76,30,,2770.76,percent of total billed charges,Drugs,2770.76,30,,2770.76,percent of total billed charges,Drugs,3140.2,34,"If Charge > 500, then 34 percent",3140.2,percent of total billed charges,Drugs,2770.76,30,,2770.76,percent of total billed charges,Drugs,2770.76,30,,2770.76,percent of total billed charges,Drugs,2770.76,30,,2770.76,percent of total billed charges,Drugs,2770.76,30,,2770.76,percent of total billed charges,Drugs,2770.76,30,,2770.76,percent of total billed charges,Drugs,2770.76,30,,2770.76,percent of total billed charges,Drugs,2770.76,30,,2770.76,percent of total billed charges,Drugs,2770.76,30,,2770.76,percent of total billed charges,Drugs,2770.76,30,,2770.76,percent of total billed charges,Drugs,2770.76,30,,2770.76,percent of total billed charges,Drugs,2770.76,30,,2770.76,percent of total billed charges,Drugs,2770.76,30,,2770.76,percent of total billed charges,Drugs,2770.76,30,,2770.76,percent of total billed charges,Drugs,1835.36,,,1835.36,Other,Drug Cost,1835.36,,,1835.36,Other,Drug Cost,1835.36,,,1835.36,Other,Drug Cost,1835.36,,,1835.36,Other,Drug Cost,1835.36,,,1835.36,Other,Drug Cost,3140.2,34,,3140.2,percent of total billed charges,Drugs,1835.36,,,1835.36,Other,Drug Cost,4129.56,,,4129.56,Other,225% Medicaid APG methodology,2569.5,,,2569.5,Other,140% Medicaid APG methodology,3140.2,34,"If Charge > 2,000, then 34 percent",3140.2,percent of total billed charges,Drugs,261.5,,,261.5,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1835.36,,,1835.36,Other,Drug Cost,1835.36,,,1835.36,Other,Drug Cost,2294.2,,,2294.2,Other,125% Medicaid APG methodology,0.01,4617.94,
VEDOLIZUMAB 300 MG IV INJ       ,J3380,HCPCS,,40500779,CDM,636,RC,64764-0300-20,NDC,both,1,EA,30202.59,217.69,,,217.69,Other,150% of Medicare + 9.63% HCRA Surcharge,132.38,,,132.38,Fee Schedule,Average Sale Price (ASP) x 6,9060.78,30,,9060.78,percent of total billed charges,Drugs,9060.78,30,,9060.78,percent of total billed charges,Drugs,9060.78,30,,9060.78,percent of total billed charges,Drugs,9060.78,30,,9060.78,percent of total billed charges,Drugs,9060.78,30,,9060.78,percent of total billed charges,Drugs,15101.3,50,,15101.3,percent of total billed charges,All Other,9060.78,30,,9060.78,percent of total billed charges,Drugs,9060.78,30,,9060.78,percent of total billed charges,Drugs,10268.88,34,"If Charge > 500, then 34 percent",10268.88,percent of total billed charges,Drugs,9060.78,30,,9060.78,percent of total billed charges,Drugs,9060.78,30,,9060.78,percent of total billed charges,Drugs,9060.78,30,,9060.78,percent of total billed charges,Drugs,9060.78,30,,9060.78,percent of total billed charges,Drugs,9060.78,30,,9060.78,percent of total billed charges,Drugs,9060.78,30,,9060.78,percent of total billed charges,Drugs,9060.78,30,,9060.78,percent of total billed charges,Drugs,9060.78,30,,9060.78,percent of total billed charges,Drugs,9060.78,30,,9060.78,percent of total billed charges,Drugs,9060.78,30,,9060.78,percent of total billed charges,Drugs,9060.78,30,,9060.78,percent of total billed charges,Drugs,9060.78,30,,9060.78,percent of total billed charges,Drugs,9060.78,30,,9060.78,percent of total billed charges,Drugs,4691.58,,,4691.58,Other,Drug Cost,4691.58,,,4691.58,Other,Drug Cost,4691.58,,,4691.58,Other,Drug Cost,4691.58,,,4691.58,Other,Drug Cost,4691.58,,,4691.58,Other,Drug Cost,10268.88,34,,10268.88,percent of total billed charges,Drugs,4691.58,,,4691.58,Other,Drug Cost,10556.06,,,10556.06,Other,225% Medicaid APG methodology,6568.21,,,6568.21,Other,140% Medicaid APG methodology,10268.88,34,"If Charge > 2,000, then 34 percent",10268.88,percent of total billed charges,Drugs,211.8,,,211.8,Other,160% Medicare Fee Schedule,10268.88,34,,10268.88,Other,"Drug Charges > 20,000, then 34% of Charges",4691.58,,,4691.58,Other,Drug Cost,4691.58,,,4691.58,Other,Drug Cost,5864.48,,,5864.48,Other,125% Medicaid APG methodology,132.38,15101.3,
RITUXIMAB 10MG/ML IV SOLN 50ML  ,J9312,HCPCS,,40500936,CDM,636,RC,50242-0053-06,NDC,both,50,ML,16370.9,781.42,,,781.42,Other,150% of Medicare + 9.63% HCRA Surcharge,475.19,,,475.19,Fee Schedule,Average Sale Price (ASP) x 6,4911.27,30,,4911.27,percent of total billed charges,Drugs,4911.27,30,,4911.27,percent of total billed charges,Drugs,4911.27,30,,4911.27,percent of total billed charges,Drugs,4911.27,30,,4911.27,percent of total billed charges,Drugs,4911.27,30,,4911.27,percent of total billed charges,Drugs,8185.45,50,,8185.45,percent of total billed charges,All Other,4911.27,30,,4911.27,percent of total billed charges,Drugs,4911.27,30,,4911.27,percent of total billed charges,Drugs,5566.11,34,"If Charge > 500, then 34 percent",5566.11,percent of total billed charges,Drugs,4911.27,30,,4911.27,percent of total billed charges,Drugs,4911.27,30,,4911.27,percent of total billed charges,Drugs,4911.27,30,,4911.27,percent of total billed charges,Drugs,4911.27,30,,4911.27,percent of total billed charges,Drugs,4911.27,30,,4911.27,percent of total billed charges,Drugs,4911.27,30,,4911.27,percent of total billed charges,Drugs,4911.27,30,,4911.27,percent of total billed charges,Drugs,4911.27,30,,4911.27,percent of total billed charges,Drugs,4911.27,30,,4911.27,percent of total billed charges,Drugs,4911.27,30,,4911.27,percent of total billed charges,Drugs,4911.27,30,,4911.27,percent of total billed charges,Drugs,4911.27,30,,4911.27,percent of total billed charges,Drugs,4911.27,30,,4911.27,percent of total billed charges,Drugs,2076.33,,,2076.33,Other,Drug Cost,2076.33,,,2076.33,Other,Drug Cost,2076.33,,,2076.33,Other,Drug Cost,2076.33,,,2076.33,Other,Drug Cost,2076.33,,,2076.33,Other,Drug Cost,5566.11,34,,5566.11,percent of total billed charges,Drugs,2076.33,,,2076.33,Other,Drug Cost,4671.74,,,4671.74,Other,225% Medicaid APG methodology,2906.86,,,2906.86,Other,140% Medicaid APG methodology,5566.11,34,"If Charge > 2,000, then 34 percent",5566.11,percent of total billed charges,Drugs,760.3,,,760.3,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2076.33,,,2076.33,Other,Drug Cost,2076.33,,,2076.33,Other,Drug Cost,2595.41,,,2595.41,Other,125% Medicaid APG methodology,0.01,8185.45,
AMIFOSTINE 500 MG IV INJ        ,J0207,HCPCS,,40500977,CDM,636,RC,47335-0581-40,NDC,both,1,EA,1581.86,624.31,39.4668,,624.31,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,474.56,30,,474.56,percent of total billed charges,Drugs,474.56,30,,474.56,percent of total billed charges,Drugs,474.56,30,,474.56,percent of total billed charges,Drugs,474.56,30,,474.56,percent of total billed charges,Drugs,474.56,30,,474.56,percent of total billed charges,Drugs,790.93,50,,790.93,percent of total billed charges,All Other,474.56,30,,474.56,percent of total billed charges,Drugs,474.56,30,,474.56,percent of total billed charges,Drugs,537.83,34,"If Charge > 500, then 34 percent",537.83,percent of total billed charges,Drugs,474.56,30,,474.56,percent of total billed charges,Drugs,474.56,30,,474.56,percent of total billed charges,Drugs,474.56,30,,474.56,percent of total billed charges,Drugs,474.56,30,,474.56,percent of total billed charges,Drugs,474.56,30,,474.56,percent of total billed charges,Drugs,474.56,30,,474.56,percent of total billed charges,Drugs,474.56,30,,474.56,percent of total billed charges,Drugs,474.56,30,,474.56,percent of total billed charges,Drugs,474.56,30,,474.56,percent of total billed charges,Drugs,474.56,30,,474.56,percent of total billed charges,Drugs,474.56,30,,474.56,percent of total billed charges,Drugs,474.56,30,,474.56,percent of total billed charges,Drugs,474.56,30,,474.56,percent of total billed charges,Drugs,451.96,,,451.96,Other,Drug Cost,451.96,,,451.96,Other,Drug Cost,451.96,,,451.96,Other,Drug Cost,451.96,,,451.96,Other,Drug Cost,451.96,,,451.96,Other,Drug Cost,537.83,34,,537.83,percent of total billed charges,Drugs,451.96,,,451.96,Other,Drug Cost,1016.91,,,1016.91,Other,225% Medicaid APG methodology,632.74,,,632.74,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",451.96,,,451.96,Other,Drug Cost,451.96,,,451.96,Other,Drug Cost,564.95,,,564.95,Other,125% Medicaid APG methodology,0.01,1016.91,
BLEOMYCIN 15 UNITS INJ          ,J9040,HCPCS,,40501033,CDM,636,RC,61703-0332-18,NDC,both,1,EA,79.73,207.44,,,207.44,Other,150% of Medicare + 9.63% HCRA Surcharge,126.14,,,126.14,Fee Schedule,Average Sale Price (ASP) x 6,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,39.87,50,,39.87,percent of total billed charges,All Other,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,19.67,,,19.67,Other,Drug Cost,19.67,,,19.67,Other,Drug Cost,19.67,,,19.67,Other,Drug Cost,19.67,,,19.67,Other,Drug Cost,19.67,,,19.67,Other,Drug Cost,27.11,34,,27.11,percent of total billed charges,Drugs,19.67,,,19.67,Other,Drug Cost,44.26,,,44.26,Other,225% Medicaid APG methodology,27.54,,,27.54,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,201.83,,,201.83,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",19.67,,,19.67,Other,Drug Cost,19.67,,,19.67,Other,Drug Cost,24.59,,,24.59,Other,125% Medicaid APG methodology,0.01,207.44,
FILGRASTIM 480 MCG/1.6ML INJ    ,J1442,HCPCS,,40501058,CDM,636,RC,55513-0546-10,NDC,both,1.6,ML,1709.09,9.72,,,9.72,Other,150% of Medicare + 9.63% HCRA Surcharge,5.91,,,5.91,Fee Schedule,Average Sale Price (ASP) x 6,512.73,30,,512.73,percent of total billed charges,Drugs,512.73,30,,512.73,percent of total billed charges,Drugs,512.73,30,,512.73,percent of total billed charges,Drugs,512.73,30,,512.73,percent of total billed charges,Drugs,512.73,30,,512.73,percent of total billed charges,Drugs,854.55,50,,854.55,percent of total billed charges,All Other,512.73,30,,512.73,percent of total billed charges,Drugs,512.73,30,,512.73,percent of total billed charges,Drugs,581.09,34,"If Charge > 500, then 34 percent",581.09,percent of total billed charges,Drugs,512.73,30,,512.73,percent of total billed charges,Drugs,512.73,30,,512.73,percent of total billed charges,Drugs,512.73,30,,512.73,percent of total billed charges,Drugs,512.73,30,,512.73,percent of total billed charges,Drugs,512.73,30,,512.73,percent of total billed charges,Drugs,512.73,30,,512.73,percent of total billed charges,Drugs,512.73,30,,512.73,percent of total billed charges,Drugs,512.73,30,,512.73,percent of total billed charges,Drugs,512.73,30,,512.73,percent of total billed charges,Drugs,512.73,30,,512.73,percent of total billed charges,Drugs,512.73,30,,512.73,percent of total billed charges,Drugs,512.73,30,,512.73,percent of total billed charges,Drugs,512.73,30,,512.73,percent of total billed charges,Drugs,135.34,,,135.34,Other,Drug Cost,135.34,,,135.34,Other,Drug Cost,135.34,,,135.34,Other,Drug Cost,135.34,,,135.34,Other,Drug Cost,135.34,,,135.34,Other,Drug Cost,581.09,34,,581.09,percent of total billed charges,Drugs,135.34,,,135.34,Other,Drug Cost,304.52,,,304.52,Other,225% Medicaid APG methodology,189.48,,,189.48,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,9.46,,,9.46,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",135.34,,,135.34,Other,Drug Cost,135.34,,,135.34,Other,Drug Cost,169.18,,,169.18,Other,125% Medicaid APG methodology,0.01,854.55,
FLUDARABINE 50 MG IV INJ        ,J9185,HCPCS,,40501066,CDM,636,RC,25021-0242-02,NDC,both,2,ML,125.27,1716.5,,,1716.5,Other,150% of Medicare + 9.63% HCRA Surcharge,1043.81,,,1043.81,Fee Schedule,Average Sale Price (ASP) x 6,37.58,30,,37.58,percent of total billed charges,Drugs,37.58,30,,37.58,percent of total billed charges,Drugs,37.58,30,,37.58,percent of total billed charges,Drugs,37.58,30,,37.58,percent of total billed charges,Drugs,37.58,30,,37.58,percent of total billed charges,Drugs,62.64,50,,62.64,percent of total billed charges,All Other,37.58,30,,37.58,percent of total billed charges,Drugs,37.58,30,,37.58,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,37.58,30,,37.58,percent of total billed charges,Drugs,37.58,30,,37.58,percent of total billed charges,Drugs,37.58,30,,37.58,percent of total billed charges,Drugs,37.58,30,,37.58,percent of total billed charges,Drugs,37.58,30,,37.58,percent of total billed charges,Drugs,37.58,30,,37.58,percent of total billed charges,Drugs,37.58,30,,37.58,percent of total billed charges,Drugs,37.58,30,,37.58,percent of total billed charges,Drugs,37.58,30,,37.58,percent of total billed charges,Drugs,37.58,30,,37.58,percent of total billed charges,Drugs,37.58,30,,37.58,percent of total billed charges,Drugs,37.58,30,,37.58,percent of total billed charges,Drugs,37.58,30,,37.58,percent of total billed charges,Drugs,67.87,,,67.87,Other,Drug Cost,67.87,,,67.87,Other,Drug Cost,67.87,,,67.87,Other,Drug Cost,67.87,,,67.87,Other,Drug Cost,67.87,,,67.87,Other,Drug Cost,42.59,34,,42.59,percent of total billed charges,Drugs,67.87,,,67.87,Other,Drug Cost,152.71,,,152.71,Other,225% Medicaid APG methodology,95.02,,,95.02,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1670.1,,,1670.1,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",67.87,,,67.87,Other,Drug Cost,67.87,,,67.87,Other,Drug Cost,84.84,,,84.84,Other,125% Medicaid APG methodology,0.01,1716.5,
FILGRASTIM 300 MCG/ML INJ 1ML   ,J1442,HCPCS,,40501132,CDM,636,RC,55513-0530-10,NDC,both,1,ML,1074.36,9.72,,,9.72,Other,150% of Medicare + 9.63% HCRA Surcharge,5.91,,,5.91,Fee Schedule,Average Sale Price (ASP) x 6,322.31,30,,322.31,percent of total billed charges,Drugs,322.31,30,,322.31,percent of total billed charges,Drugs,322.31,30,,322.31,percent of total billed charges,Drugs,322.31,30,,322.31,percent of total billed charges,Drugs,322.31,30,,322.31,percent of total billed charges,Drugs,537.18,50,,537.18,percent of total billed charges,All Other,322.31,30,,322.31,percent of total billed charges,Drugs,322.31,30,,322.31,percent of total billed charges,Drugs,365.28,34,"If Charge > 500, then 34 percent",365.28,percent of total billed charges,Drugs,322.31,30,,322.31,percent of total billed charges,Drugs,322.31,30,,322.31,percent of total billed charges,Drugs,322.31,30,,322.31,percent of total billed charges,Drugs,322.31,30,,322.31,percent of total billed charges,Drugs,322.31,30,,322.31,percent of total billed charges,Drugs,322.31,30,,322.31,percent of total billed charges,Drugs,322.31,30,,322.31,percent of total billed charges,Drugs,322.31,30,,322.31,percent of total billed charges,Drugs,322.31,30,,322.31,percent of total billed charges,Drugs,322.31,30,,322.31,percent of total billed charges,Drugs,322.31,30,,322.31,percent of total billed charges,Drugs,322.31,30,,322.31,percent of total billed charges,Drugs,322.31,30,,322.31,percent of total billed charges,Drugs,46.52,,,46.52,Other,Drug Cost,46.52,,,46.52,Other,Drug Cost,46.52,,,46.52,Other,Drug Cost,46.52,,,46.52,Other,Drug Cost,46.52,,,46.52,Other,Drug Cost,365.28,34,,365.28,percent of total billed charges,Drugs,46.52,,,46.52,Other,Drug Cost,104.67,,,104.67,Other,225% Medicaid APG methodology,65.13,,,65.13,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,9.46,,,9.46,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",46.52,,,46.52,Other,Drug Cost,46.52,,,46.52,Other,Drug Cost,58.15,,,58.15,Other,125% Medicaid APG methodology,0.01,537.18,
PACLITAXEL 6MG/ML IV SOLN 50ML  ,J9267,HCPCS,,40501157,CDM,636,RC,61703-0342-50,NDC,both,50,ML,231.98,1.07,,,1.07,Other,150% of Medicare + 9.63% HCRA Surcharge,0.65,,,0.65,Fee Schedule,Average Sale Price (ASP) x 6,69.59,30,,69.59,percent of total billed charges,Drugs,69.59,30,,69.59,percent of total billed charges,Drugs,69.59,30,,69.59,percent of total billed charges,Drugs,69.59,30,,69.59,percent of total billed charges,Drugs,69.59,30,,69.59,percent of total billed charges,Drugs,115.99,50,,115.99,percent of total billed charges,All Other,69.59,30,,69.59,percent of total billed charges,Drugs,69.59,30,,69.59,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,69.59,30,,69.59,percent of total billed charges,Drugs,69.59,30,,69.59,percent of total billed charges,Drugs,69.59,30,,69.59,percent of total billed charges,Drugs,69.59,30,,69.59,percent of total billed charges,Drugs,69.59,30,,69.59,percent of total billed charges,Drugs,69.59,30,,69.59,percent of total billed charges,Drugs,69.59,30,,69.59,percent of total billed charges,Drugs,69.59,30,,69.59,percent of total billed charges,Drugs,69.59,30,,69.59,percent of total billed charges,Drugs,69.59,30,,69.59,percent of total billed charges,Drugs,69.59,30,,69.59,percent of total billed charges,Drugs,69.59,30,,69.59,percent of total billed charges,Drugs,69.59,30,,69.59,percent of total billed charges,Drugs,30.93,,,30.93,Other,Drug Cost,30.93,,,30.93,Other,Drug Cost,30.93,,,30.93,Other,Drug Cost,30.93,,,30.93,Other,Drug Cost,30.93,,,30.93,Other,Drug Cost,78.87,34,,78.87,percent of total billed charges,Drugs,30.93,,,30.93,Other,Drug Cost,69.59,,,69.59,Other,225% Medicaid APG methodology,43.3,,,43.3,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.04,,,1.04,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",30.93,,,30.93,Other,Drug Cost,30.93,,,30.93,Other,Drug Cost,38.66,,,38.66,Other,125% Medicaid APG methodology,0.01,115.99,
IRINOTECAN 20MG/ML IV SOLN 5ML  ,J9206,HCPCS,,40501231,CDM,636,RC,00143-9701-01,NDC,both,5,ML,40.53,19.19,,,19.19,Other,150% of Medicare + 9.63% HCRA Surcharge,11.67,,,11.67,Fee Schedule,Average Sale Price (ASP) x 6,12.16,30,,12.16,percent of total billed charges,Drugs,12.16,30,,12.16,percent of total billed charges,Drugs,12.16,30,,12.16,percent of total billed charges,Drugs,12.16,30,,12.16,percent of total billed charges,Drugs,12.16,30,,12.16,percent of total billed charges,Drugs,20.27,50,,20.27,percent of total billed charges,All Other,12.16,30,,12.16,percent of total billed charges,Drugs,12.16,30,,12.16,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,12.16,30,,12.16,percent of total billed charges,Drugs,12.16,30,,12.16,percent of total billed charges,Drugs,12.16,30,,12.16,percent of total billed charges,Drugs,12.16,30,,12.16,percent of total billed charges,Drugs,12.16,30,,12.16,percent of total billed charges,Drugs,12.16,30,,12.16,percent of total billed charges,Drugs,12.16,30,,12.16,percent of total billed charges,Drugs,12.16,30,,12.16,percent of total billed charges,Drugs,12.16,30,,12.16,percent of total billed charges,Drugs,12.16,30,,12.16,percent of total billed charges,Drugs,12.16,30,,12.16,percent of total billed charges,Drugs,12.16,30,,12.16,percent of total billed charges,Drugs,12.16,30,,12.16,percent of total billed charges,Drugs,8.33,,,8.33,Other,Drug Cost,8.33,,,8.33,Other,Drug Cost,8.33,,,8.33,Other,Drug Cost,8.33,,,8.33,Other,Drug Cost,8.33,,,8.33,Other,Drug Cost,13.78,34,,13.78,percent of total billed charges,Drugs,8.33,,,8.33,Other,Drug Cost,18.74,,,18.74,Other,225% Medicaid APG methodology,11.66,,,11.66,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,18.67,,,18.67,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",8.33,,,8.33,Other,Drug Cost,8.33,,,8.33,Other,Drug Cost,10.41,,,10.41,Other,125% Medicaid APG methodology,0.01,20.27,
MITOMYCIN 5 MG IV INJ           ,J9280,HCPCS,,40501249,CDM,636,RC,16729-0246-05,NDC,both,1,EA,791.49,625.04,,,625.04,Other,150% of Medicare + 9.63% HCRA Surcharge,380.09,,,380.09,Fee Schedule,Average Sale Price (ASP) x 6,237.45,30,,237.45,percent of total billed charges,Drugs,237.45,30,,237.45,percent of total billed charges,Drugs,237.45,30,,237.45,percent of total billed charges,Drugs,237.45,30,,237.45,percent of total billed charges,Drugs,237.45,30,,237.45,percent of total billed charges,Drugs,395.75,50,,395.75,percent of total billed charges,All Other,237.45,30,,237.45,percent of total billed charges,Drugs,237.45,30,,237.45,percent of total billed charges,Drugs,269.11,34,"If Charge > 500, then 34 percent",269.11,percent of total billed charges,Drugs,237.45,30,,237.45,percent of total billed charges,Drugs,237.45,30,,237.45,percent of total billed charges,Drugs,237.45,30,,237.45,percent of total billed charges,Drugs,237.45,30,,237.45,percent of total billed charges,Drugs,237.45,30,,237.45,percent of total billed charges,Drugs,237.45,30,,237.45,percent of total billed charges,Drugs,237.45,30,,237.45,percent of total billed charges,Drugs,237.45,30,,237.45,percent of total billed charges,Drugs,237.45,30,,237.45,percent of total billed charges,Drugs,237.45,30,,237.45,percent of total billed charges,Drugs,237.45,30,,237.45,percent of total billed charges,Drugs,237.45,30,,237.45,percent of total billed charges,Drugs,237.45,30,,237.45,percent of total billed charges,Drugs,243.27,,,243.27,Other,Drug Cost,243.27,,,243.27,Other,Drug Cost,243.27,,,243.27,Other,Drug Cost,243.27,,,243.27,Other,Drug Cost,243.27,,,243.27,Other,Drug Cost,269.11,34,,269.11,percent of total billed charges,Drugs,243.27,,,243.27,Other,Drug Cost,547.36,,,547.36,Other,225% Medicaid APG methodology,340.58,,,340.58,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,608.14,,,608.14,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",243.27,,,243.27,Other,Drug Cost,243.27,,,243.27,Other,Drug Cost,304.09,,,304.09,Other,125% Medicaid APG methodology,0.01,625.04,
THIOTEPA 15 MG INJ              ,J9340,HCPCS,,40501264,CDM,636,RC,43598-0650-11,NDC,both,1,EA,694.33,2478.56,,,2478.56,Other,150% of Medicare + 9.63% HCRA Surcharge,1507.23,,,1507.23,Fee Schedule,Average Sale Price (ASP) x 6,208.3,30,,208.3,percent of total billed charges,Drugs,208.3,30,,208.3,percent of total billed charges,Drugs,208.3,30,,208.3,percent of total billed charges,Drugs,208.3,30,,208.3,percent of total billed charges,Drugs,208.3,30,,208.3,percent of total billed charges,Drugs,347.17,50,,347.17,percent of total billed charges,All Other,208.3,30,,208.3,percent of total billed charges,Drugs,208.3,30,,208.3,percent of total billed charges,Drugs,236.07,34,"If Charge > 500, then 34 percent",236.07,percent of total billed charges,Drugs,208.3,30,,208.3,percent of total billed charges,Drugs,208.3,30,,208.3,percent of total billed charges,Drugs,208.3,30,,208.3,percent of total billed charges,Drugs,208.3,30,,208.3,percent of total billed charges,Drugs,208.3,30,,208.3,percent of total billed charges,Drugs,208.3,30,,208.3,percent of total billed charges,Drugs,208.3,30,,208.3,percent of total billed charges,Drugs,208.3,30,,208.3,percent of total billed charges,Drugs,208.3,30,,208.3,percent of total billed charges,Drugs,208.3,30,,208.3,percent of total billed charges,Drugs,208.3,30,,208.3,percent of total billed charges,Drugs,208.3,30,,208.3,percent of total billed charges,Drugs,208.3,30,,208.3,percent of total billed charges,Drugs,137.35,,,137.35,Other,Drug Cost,137.35,,,137.35,Other,Drug Cost,137.35,,,137.35,Other,Drug Cost,137.35,,,137.35,Other,Drug Cost,137.35,,,137.35,Other,Drug Cost,236.07,34,,236.07,percent of total billed charges,Drugs,137.35,,,137.35,Other,Drug Cost,309.04,,,309.04,Other,225% Medicaid APG methodology,192.29,,,192.29,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2411.57,,,2411.57,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",137.35,,,137.35,Other,Drug Cost,137.35,,,137.35,Other,Drug Cost,171.69,,,171.69,Other,125% Medicaid APG methodology,0.01,2478.56,
AMPHOTERICIN B 50 MG IV INJ     ,J0285,HCPCS,,40501306,CDM,636,RC,39822-1055-05,NDC,both,1,EA,116.97,94.09,,,94.09,Other,150% of Medicare + 9.63% HCRA Surcharge,57.22,,,57.22,Fee Schedule,Average Sale Price (ASP) x 6,35.09,30,,35.09,percent of total billed charges,Drugs,35.09,30,,35.09,percent of total billed charges,Drugs,35.09,30,,35.09,percent of total billed charges,Drugs,35.09,30,,35.09,percent of total billed charges,Drugs,35.09,30,,35.09,percent of total billed charges,Drugs,58.49,50,,58.49,percent of total billed charges,All Other,35.09,30,,35.09,percent of total billed charges,Drugs,35.09,30,,35.09,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,35.09,30,,35.09,percent of total billed charges,Drugs,35.09,30,,35.09,percent of total billed charges,Drugs,35.09,30,,35.09,percent of total billed charges,Drugs,35.09,30,,35.09,percent of total billed charges,Drugs,35.09,30,,35.09,percent of total billed charges,Drugs,35.09,30,,35.09,percent of total billed charges,Drugs,35.09,30,,35.09,percent of total billed charges,Drugs,35.09,30,,35.09,percent of total billed charges,Drugs,35.09,30,,35.09,percent of total billed charges,Drugs,35.09,30,,35.09,percent of total billed charges,Drugs,35.09,30,,35.09,percent of total billed charges,Drugs,35.09,30,,35.09,percent of total billed charges,Drugs,35.09,30,,35.09,percent of total billed charges,Drugs,11.57,,,11.57,Other,Drug Cost,11.57,,,11.57,Other,Drug Cost,11.57,,,11.57,Other,Drug Cost,11.57,,,11.57,Other,Drug Cost,11.57,,,11.57,Other,Drug Cost,39.77,34,,39.77,percent of total billed charges,Drugs,11.57,,,11.57,Other,Drug Cost,26.03,,,26.03,Other,225% Medicaid APG methodology,16.2,,,16.2,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,91.55,,,91.55,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",11.57,,,11.57,Other,Drug Cost,11.57,,,11.57,Other,Drug Cost,14.46,,,14.46,Other,125% Medicaid APG methodology,0.01,94.09,
LEUPROLIDE 3.75MG DEPOT IM INJ  ,J1950,HCPCS,,40501330,CDM,636,RC,00074-3641-03,NDC,both,1,EA,4825.7,15437.48,,,15437.48,Other,150% of Medicare + 9.63% HCRA Surcharge,9387.62,,,9387.62,Fee Schedule,Average Sale Price (ASP) x 6,1447.71,30,,1447.71,percent of total billed charges,Drugs,1447.71,30,,1447.71,percent of total billed charges,Drugs,1447.71,30,,1447.71,percent of total billed charges,Drugs,1447.71,30,,1447.71,percent of total billed charges,Drugs,1447.71,30,,1447.71,percent of total billed charges,Drugs,2412.85,50,,2412.85,percent of total billed charges,All Other,1447.71,30,,1447.71,percent of total billed charges,Drugs,1447.71,30,,1447.71,percent of total billed charges,Drugs,1640.74,34,"If Charge > 500, then 34 percent",1640.74,percent of total billed charges,Drugs,1447.71,30,,1447.71,percent of total billed charges,Drugs,1447.71,30,,1447.71,percent of total billed charges,Drugs,1447.71,30,,1447.71,percent of total billed charges,Drugs,1447.71,30,,1447.71,percent of total billed charges,Drugs,1447.71,30,,1447.71,percent of total billed charges,Drugs,1447.71,30,,1447.71,percent of total billed charges,Drugs,1447.71,30,,1447.71,percent of total billed charges,Drugs,1447.71,30,,1447.71,percent of total billed charges,Drugs,1447.71,30,,1447.71,percent of total billed charges,Drugs,1447.71,30,,1447.71,percent of total billed charges,Drugs,1447.71,30,,1447.71,percent of total billed charges,Drugs,1447.71,30,,1447.71,percent of total billed charges,Drugs,1447.71,30,,1447.71,percent of total billed charges,Drugs,8.53,,,8.53,Other,Drug Cost,8.53,,,8.53,Other,Drug Cost,8.53,,,8.53,Other,Drug Cost,8.53,,,8.53,Other,Drug Cost,8.53,,,8.53,Other,Drug Cost,1640.74,34,,1640.74,percent of total billed charges,Drugs,8.53,,,8.53,Other,Drug Cost,19.19,,,19.19,Other,225% Medicaid APG methodology,11.94,,,11.94,Other,140% Medicaid APG methodology,1640.74,34,"If Charge > 2,000, then 34 percent",1640.74,percent of total billed charges,Drugs,15020.2,,,15020.2,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",8.53,,,8.53,Other,Drug Cost,8.53,,,8.53,Other,Drug Cost,10.66,,,10.66,Other,125% Medicaid APG methodology,0.01,15437.48,
CLADRIBINE 1MG/ML IV SOLN 10ML  ,J9065,HCPCS,,40501405,CDM,636,RC,63323-0140-10,NDC,both,10,ML,396.03,155.63,,,155.63,Other,150% of Medicare + 9.63% HCRA Surcharge,94.64,,,94.64,Fee Schedule,Average Sale Price (ASP) x 6,118.81,30,,118.81,percent of total billed charges,Drugs,118.81,30,,118.81,percent of total billed charges,Drugs,118.81,30,,118.81,percent of total billed charges,Drugs,118.81,30,,118.81,percent of total billed charges,Drugs,118.81,30,,118.81,percent of total billed charges,Drugs,198.02,50,,198.02,percent of total billed charges,All Other,118.81,30,,118.81,percent of total billed charges,Drugs,118.81,30,,118.81,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,118.81,30,,118.81,percent of total billed charges,Drugs,118.81,30,,118.81,percent of total billed charges,Drugs,118.81,30,,118.81,percent of total billed charges,Drugs,118.81,30,,118.81,percent of total billed charges,Drugs,118.81,30,,118.81,percent of total billed charges,Drugs,118.81,30,,118.81,percent of total billed charges,Drugs,118.81,30,,118.81,percent of total billed charges,Drugs,118.81,30,,118.81,percent of total billed charges,Drugs,118.81,30,,118.81,percent of total billed charges,Drugs,118.81,30,,118.81,percent of total billed charges,Drugs,118.81,30,,118.81,percent of total billed charges,Drugs,118.81,30,,118.81,percent of total billed charges,Drugs,118.81,30,,118.81,percent of total billed charges,Drugs,97.7,,,97.7,Other,Drug Cost,97.7,,,97.7,Other,Drug Cost,97.7,,,97.7,Other,Drug Cost,97.7,,,97.7,Other,Drug Cost,97.7,,,97.7,Other,Drug Cost,134.65,34,,134.65,percent of total billed charges,Drugs,97.7,,,97.7,Other,Drug Cost,219.83,,,219.83,Other,225% Medicaid APG methodology,136.78,,,136.78,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,151.42,,,151.42,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",97.7,,,97.7,Other,Drug Cost,97.7,,,97.7,Other,Drug Cost,122.13,,,122.13,Other,125% Medicaid APG methodology,0.01,219.83,
CISPLATIN 1MG/ML IV SOLN 100ML  ,J9060,HCPCS,,40501439,CDM,636,RC,63323-0103-65,NDC,both,100,ML,54.6,39.85,,,39.85,Other,150% of Medicare + 9.63% HCRA Surcharge,24.23,,,24.23,Fee Schedule,Average Sale Price (ASP) x 6,16.38,30,,16.38,percent of total billed charges,Drugs,16.38,30,,16.38,percent of total billed charges,Drugs,16.38,30,,16.38,percent of total billed charges,Drugs,16.38,30,,16.38,percent of total billed charges,Drugs,16.38,30,,16.38,percent of total billed charges,Drugs,27.3,50,,27.3,percent of total billed charges,All Other,16.38,30,,16.38,percent of total billed charges,Drugs,16.38,30,,16.38,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,16.38,30,,16.38,percent of total billed charges,Drugs,16.38,30,,16.38,percent of total billed charges,Drugs,16.38,30,,16.38,percent of total billed charges,Drugs,16.38,30,,16.38,percent of total billed charges,Drugs,16.38,30,,16.38,percent of total billed charges,Drugs,16.38,30,,16.38,percent of total billed charges,Drugs,16.38,30,,16.38,percent of total billed charges,Drugs,16.38,30,,16.38,percent of total billed charges,Drugs,16.38,30,,16.38,percent of total billed charges,Drugs,16.38,30,,16.38,percent of total billed charges,Drugs,16.38,30,,16.38,percent of total billed charges,Drugs,16.38,30,,16.38,percent of total billed charges,Drugs,16.38,30,,16.38,percent of total billed charges,Drugs,12.53,,,12.53,Other,Drug Cost,12.53,,,12.53,Other,Drug Cost,12.53,,,12.53,Other,Drug Cost,12.53,,,12.53,Other,Drug Cost,12.53,,,12.53,Other,Drug Cost,18.56,34,,18.56,percent of total billed charges,Drugs,12.53,,,12.53,Other,Drug Cost,28.19,,,28.19,Other,225% Medicaid APG methodology,17.54,,,17.54,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,38.77,,,38.77,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",12.53,,,12.53,Other,Drug Cost,12.53,,,12.53,Other,Drug Cost,15.66,,,15.66,Other,125% Medicaid APG methodology,0.01,39.85,
GRANISETRON 1MG/ML IV SOLN 1ML  ,J1626,HCPCS,,40501587,CDM,636,RC,67457-0863-01,NDC,both,1,ML,10.57,3.76,,,3.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2.29,,,2.29,Fee Schedule,Average Sale Price (ASP) x 6,3.17,30,,3.17,percent of total billed charges,Drugs,3.17,30,,3.17,percent of total billed charges,Drugs,3.17,30,,3.17,percent of total billed charges,Drugs,3.17,30,,3.17,percent of total billed charges,Drugs,3.17,30,,3.17,percent of total billed charges,Drugs,5.29,50,,5.29,percent of total billed charges,All Other,3.17,30,,3.17,percent of total billed charges,Drugs,3.17,30,,3.17,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.17,30,,3.17,percent of total billed charges,Drugs,3.17,30,,3.17,percent of total billed charges,Drugs,3.17,30,,3.17,percent of total billed charges,Drugs,3.17,30,,3.17,percent of total billed charges,Drugs,3.17,30,,3.17,percent of total billed charges,Drugs,3.17,30,,3.17,percent of total billed charges,Drugs,3.17,30,,3.17,percent of total billed charges,Drugs,3.17,30,,3.17,percent of total billed charges,Drugs,3.17,30,,3.17,percent of total billed charges,Drugs,3.17,30,,3.17,percent of total billed charges,Drugs,3.17,30,,3.17,percent of total billed charges,Drugs,3.17,30,,3.17,percent of total billed charges,Drugs,3.17,30,,3.17,percent of total billed charges,Drugs,3.06,,,3.06,Other,Drug Cost,3.06,,,3.06,Other,Drug Cost,3.06,,,3.06,Other,Drug Cost,3.06,,,3.06,Other,Drug Cost,3.06,,,3.06,Other,Drug Cost,3.59,34,,3.59,percent of total billed charges,Drugs,3.06,,,3.06,Other,Drug Cost,6.89,,,6.89,Other,225% Medicaid APG methodology,4.28,,,4.28,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,3.66,,,3.66,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.06,,,3.06,Other,Drug Cost,3.06,,,3.06,Other,Drug Cost,3.83,,,3.83,Other,125% Medicaid APG methodology,0.01,6.89,
MORPHINE 10MG/ML PF IV SLN 1ML  ,J2270,HCPCS,,40501702,CDM,636,RC,00641-6127-25,NDC,both,1,ML,7.53,46.03,,,46.03,Other,150% of Medicare + 9.63% HCRA Surcharge,27.99,,,27.99,Fee Schedule,Average Sale Price (ASP) x 6,2.26,30,,2.26,percent of total billed charges,Drugs,2.26,30,,2.26,percent of total billed charges,Drugs,2.26,30,,2.26,percent of total billed charges,Drugs,2.26,30,,2.26,percent of total billed charges,Drugs,2.26,30,,2.26,percent of total billed charges,Drugs,3.77,50,,3.77,percent of total billed charges,All Other,2.26,30,,2.26,percent of total billed charges,Drugs,2.26,30,,2.26,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.26,30,,2.26,percent of total billed charges,Drugs,2.26,30,,2.26,percent of total billed charges,Drugs,2.26,30,,2.26,percent of total billed charges,Drugs,2.26,30,,2.26,percent of total billed charges,Drugs,2.26,30,,2.26,percent of total billed charges,Drugs,2.26,30,,2.26,percent of total billed charges,Drugs,2.26,30,,2.26,percent of total billed charges,Drugs,2.26,30,,2.26,percent of total billed charges,Drugs,2.26,30,,2.26,percent of total billed charges,Drugs,2.26,30,,2.26,percent of total billed charges,Drugs,2.26,30,,2.26,percent of total billed charges,Drugs,2.26,30,,2.26,percent of total billed charges,Drugs,2.26,30,,2.26,percent of total billed charges,Drugs,0.72,,,0.72,Other,Drug Cost,0.72,,,0.72,Other,Drug Cost,0.72,,,0.72,Other,Drug Cost,0.72,,,0.72,Other,Drug Cost,0.72,,,0.72,Other,Drug Cost,2.56,34,,2.56,percent of total billed charges,Drugs,0.72,,,0.72,Other,Drug Cost,1.62,,,1.62,Other,225% Medicaid APG methodology,1.01,,,1.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,44.78,,,44.78,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.72,,,0.72,Other,Drug Cost,0.72,,,0.72,Other,Drug Cost,0.9,,,0.9,Other,125% Medicaid APG methodology,0.01,46.03,
LEUCOVORIN 50 MG INJ            ,J0640,HCPCS,,40501751,CDM,636,RC,25021-0813-10,NDC,both,1,EA,32.55,44.1,,,44.1,Other,150% of Medicare + 9.63% HCRA Surcharge,26.82,,,26.82,Fee Schedule,Average Sale Price (ASP) x 6,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,16.28,50,,16.28,percent of total billed charges,All Other,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,11.07,34,,11.07,percent of total billed charges,Drugs,2.4,,,2.4,Other,Drug Cost,5.4,,,5.4,Other,225% Medicaid APG methodology,3.36,,,3.36,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,42.91,,,42.91,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.4,,,2.4,Other,Drug Cost,2.4,,,2.4,Other,Drug Cost,3,,,3,Other,125% Medicaid APG methodology,0.01,44.1,
VINBLASTINE 1MG/ML IV SLN 10ML  ,J9360,HCPCS,,40501777,CDM,636,RC,63323-0278-10,NDC,both,10,ML,128.21,41.6,,,41.6,Other,150% of Medicare + 9.63% HCRA Surcharge,25.3,,,25.3,Fee Schedule,Average Sale Price (ASP) x 6,38.46,30,,38.46,percent of total billed charges,Drugs,38.46,30,,38.46,percent of total billed charges,Drugs,38.46,30,,38.46,percent of total billed charges,Drugs,38.46,30,,38.46,percent of total billed charges,Drugs,38.46,30,,38.46,percent of total billed charges,Drugs,64.11,50,,64.11,percent of total billed charges,All Other,38.46,30,,38.46,percent of total billed charges,Drugs,38.46,30,,38.46,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,38.46,30,,38.46,percent of total billed charges,Drugs,38.46,30,,38.46,percent of total billed charges,Drugs,38.46,30,,38.46,percent of total billed charges,Drugs,38.46,30,,38.46,percent of total billed charges,Drugs,38.46,30,,38.46,percent of total billed charges,Drugs,38.46,30,,38.46,percent of total billed charges,Drugs,38.46,30,,38.46,percent of total billed charges,Drugs,38.46,30,,38.46,percent of total billed charges,Drugs,38.46,30,,38.46,percent of total billed charges,Drugs,38.46,30,,38.46,percent of total billed charges,Drugs,38.46,30,,38.46,percent of total billed charges,Drugs,38.46,30,,38.46,percent of total billed charges,Drugs,38.46,30,,38.46,percent of total billed charges,Drugs,18.42,,,18.42,Other,Drug Cost,18.42,,,18.42,Other,Drug Cost,18.42,,,18.42,Other,Drug Cost,18.42,,,18.42,Other,Drug Cost,18.42,,,18.42,Other,Drug Cost,43.59,34,,43.59,percent of total billed charges,Drugs,18.42,,,18.42,Other,Drug Cost,41.45,,,41.45,Other,225% Medicaid APG methodology,25.79,,,25.79,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,40.47,,,40.47,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",18.42,,,18.42,Other,Drug Cost,18.42,,,18.42,Other,Drug Cost,23.03,,,23.03,Other,125% Medicaid APG methodology,0.01,64.11,
ETOPOSIDE 20MG/ML IV SOLN 5ML   ,J9181,HCPCS,,40501819,CDM,636,RC,16729-0114-31,NDC,both,5,ML,17.15,9.8,,,9.8,Other,150% of Medicare + 9.63% HCRA Surcharge,5.96,,,5.96,Fee Schedule,Average Sale Price (ASP) x 6,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,8.58,50,,8.58,percent of total billed charges,All Other,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,3.84,,,3.84,Other,Drug Cost,3.84,,,3.84,Other,Drug Cost,3.84,,,3.84,Other,Drug Cost,3.84,,,3.84,Other,Drug Cost,3.84,,,3.84,Other,Drug Cost,5.83,34,,5.83,percent of total billed charges,Drugs,3.84,,,3.84,Other,Drug Cost,8.64,,,8.64,Other,225% Medicaid APG methodology,5.38,,,5.38,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,9.53,,,9.53,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.84,,,3.84,Other,Drug Cost,3.84,,,3.84,Other,Drug Cost,4.8,,,4.8,Other,125% Medicaid APG methodology,0.01,9.8,
DRONABINOL 2.5 MG CAP           ,Q0167,HCPCS,,40501835,CDM,636,RC,42858-0867-06,NDC,both,1,EA,4.48,8,,,8,Other,150% of Medicare + 9.63% HCRA Surcharge,4.87,,,4.87,Fee Schedule,Average Sale Price (ASP) x 6,1.34,30,,1.34,percent of total billed charges,Drugs,1.34,30,,1.34,percent of total billed charges,Drugs,1.34,30,,1.34,percent of total billed charges,Drugs,1.34,30,,1.34,percent of total billed charges,Drugs,1.34,30,,1.34,percent of total billed charges,Drugs,2.24,50,,2.24,percent of total billed charges,All Other,1.34,30,,1.34,percent of total billed charges,Drugs,1.34,30,,1.34,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.34,30,,1.34,percent of total billed charges,Drugs,1.34,30,,1.34,percent of total billed charges,Drugs,1.34,30,,1.34,percent of total billed charges,Drugs,1.34,30,,1.34,percent of total billed charges,Drugs,1.34,30,,1.34,percent of total billed charges,Drugs,1.34,30,,1.34,percent of total billed charges,Drugs,1.34,30,,1.34,percent of total billed charges,Drugs,1.34,30,,1.34,percent of total billed charges,Drugs,1.34,30,,1.34,percent of total billed charges,Drugs,1.34,30,,1.34,percent of total billed charges,Drugs,1.34,30,,1.34,percent of total billed charges,Drugs,1.34,30,,1.34,percent of total billed charges,Drugs,1.34,30,,1.34,percent of total billed charges,Drugs,0.67,,,0.67,Other,Drug Cost,0.67,,,0.67,Other,Drug Cost,0.67,,,0.67,Other,Drug Cost,0.67,,,0.67,Other,Drug Cost,0.67,,,0.67,Other,Drug Cost,1.52,34,,1.52,percent of total billed charges,Drugs,0.67,,,0.67,Other,Drug Cost,1.51,,,1.51,Other,225% Medicaid APG methodology,0.94,,,0.94,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.79,,,7.79,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.67,,,0.67,Other,Drug Cost,0.67,,,0.67,Other,Drug Cost,0.84,,,0.84,Other,125% Medicaid APG methodology,0.01,8,
METHOTREXATE 2.5 MG TAB         ,J8610,HCPCS,,40501843,CDM,636,RC,50268-0527-15,NDC,both,1,EA,2.91,2.63,,,2.63,Other,150% of Medicare + 9.63% HCRA Surcharge,1.6,,,1.6,Fee Schedule,Average Sale Price (ASP) x 6,0.87,30,,0.87,percent of total billed charges,Drugs,0.87,30,,0.87,percent of total billed charges,Drugs,0.87,30,,0.87,percent of total billed charges,Drugs,0.87,30,,0.87,percent of total billed charges,Drugs,0.87,30,,0.87,percent of total billed charges,Drugs,1.46,50,,1.46,percent of total billed charges,All Other,0.87,30,,0.87,percent of total billed charges,Drugs,0.87,30,,0.87,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.87,30,,0.87,percent of total billed charges,Drugs,0.87,30,,0.87,percent of total billed charges,Drugs,0.87,30,,0.87,percent of total billed charges,Drugs,0.87,30,,0.87,percent of total billed charges,Drugs,0.87,30,,0.87,percent of total billed charges,Drugs,0.87,30,,0.87,percent of total billed charges,Drugs,0.87,30,,0.87,percent of total billed charges,Drugs,0.87,30,,0.87,percent of total billed charges,Drugs,0.87,30,,0.87,percent of total billed charges,Drugs,0.87,30,,0.87,percent of total billed charges,Drugs,0.87,30,,0.87,percent of total billed charges,Drugs,0.87,30,,0.87,percent of total billed charges,Drugs,0.87,30,,0.87,percent of total billed charges,Drugs,0.79,,,0.79,Other,Drug Cost,0.79,,,0.79,Other,Drug Cost,0.79,,,0.79,Other,Drug Cost,0.79,,,0.79,Other,Drug Cost,0.79,,,0.79,Other,Drug Cost,0.99,34,,0.99,percent of total billed charges,Drugs,0.79,,,0.79,Other,Drug Cost,1.78,,,1.78,Other,225% Medicaid APG methodology,1.11,,,1.11,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.56,,,2.56,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.79,,,0.79,Other,Drug Cost,0.79,,,0.79,Other,Drug Cost,0.99,,,0.99,Other,125% Medicaid APG methodology,0.01,2.63,
CYCLOPHOSPHAMIDE 25 MG CAP      ,J8530,HCPCS,,40501868,CDM,636,RC,00054-0382-25,NDC,both,1,EA,17.15,6.1,,,6.1,Other,150% of Medicare + 9.63% HCRA Surcharge,3.71,,,3.71,Fee Schedule,Average Sale Price (ASP) x 6,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,8.58,50,,8.58,percent of total billed charges,All Other,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,0.79,,,0.79,Other,Drug Cost,0.79,,,0.79,Other,Drug Cost,0.79,,,0.79,Other,Drug Cost,0.79,,,0.79,Other,Drug Cost,0.79,,,0.79,Other,Drug Cost,5.83,34,,5.83,percent of total billed charges,Drugs,0.79,,,0.79,Other,Drug Cost,1.78,,,1.78,Other,225% Medicaid APG methodology,1.11,,,1.11,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,5.93,,,5.93,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.79,,,0.79,Other,Drug Cost,0.79,,,0.79,Other,Drug Cost,0.99,,,0.99,Other,125% Medicaid APG methodology,0.01,8.58,
FLUOROURACIL 50MG/ML SLN 10ML   ,J9190,HCPCS,,40501900,CDM,636,RC,00703-3015-13,NDC,both,10,ML,19.43,31.72,,,31.72,Other,150% of Medicare + 9.63% HCRA Surcharge,19.29,,,19.29,Fee Schedule,Average Sale Price (ASP) x 6,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,9.72,50,,9.72,percent of total billed charges,All Other,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,5.55,,,5.55,Other,Drug Cost,5.55,,,5.55,Other,Drug Cost,5.55,,,5.55,Other,Drug Cost,5.55,,,5.55,Other,Drug Cost,5.55,,,5.55,Other,Drug Cost,6.61,34,,6.61,percent of total billed charges,Drugs,5.55,,,5.55,Other,Drug Cost,12.49,,,12.49,Other,225% Medicaid APG methodology,7.77,,,7.77,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,30.86,,,30.86,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.55,,,5.55,Other,Drug Cost,5.55,,,5.55,Other,Drug Cost,6.94,,,6.94,Other,125% Medicaid APG methodology,0.01,31.72,
BACLOFEN 0.5MG/ML INTRATH 20ML  ,J0475,HCPCS,,40501983,CDM,636,RC,70121-2501-01,NDC,both,20,ML,827.02,1754.34,,,1754.34,Other,150% of Medicare + 9.63% HCRA Surcharge,1066.82,,,1066.82,Fee Schedule,Average Sale Price (ASP) x 6,248.11,30,,248.11,percent of total billed charges,Drugs,248.11,30,,248.11,percent of total billed charges,Drugs,248.11,30,,248.11,percent of total billed charges,Drugs,248.11,30,,248.11,percent of total billed charges,Drugs,248.11,30,,248.11,percent of total billed charges,Drugs,413.51,50,,413.51,percent of total billed charges,All Other,248.11,30,,248.11,percent of total billed charges,Drugs,248.11,30,,248.11,percent of total billed charges,Drugs,281.19,34,"If Charge > 500, then 34 percent",281.19,percent of total billed charges,Drugs,248.11,30,,248.11,percent of total billed charges,Drugs,248.11,30,,248.11,percent of total billed charges,Drugs,248.11,30,,248.11,percent of total billed charges,Drugs,248.11,30,,248.11,percent of total billed charges,Drugs,248.11,30,,248.11,percent of total billed charges,Drugs,248.11,30,,248.11,percent of total billed charges,Drugs,248.11,30,,248.11,percent of total billed charges,Drugs,248.11,30,,248.11,percent of total billed charges,Drugs,248.11,30,,248.11,percent of total billed charges,Drugs,248.11,30,,248.11,percent of total billed charges,Drugs,248.11,30,,248.11,percent of total billed charges,Drugs,248.11,30,,248.11,percent of total billed charges,Drugs,248.11,30,,248.11,percent of total billed charges,Drugs,124,,,124,Other,Drug Cost,124,,,124,Other,Drug Cost,124,,,124,Other,Drug Cost,124,,,124,Other,Drug Cost,124,,,124,Other,Drug Cost,281.19,34,,281.19,percent of total billed charges,Drugs,124,,,124,Other,Drug Cost,279,,,279,Other,225% Medicaid APG methodology,173.6,,,173.6,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1706.92,,,1706.92,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",124,,,124,Other,Drug Cost,124,,,124,Other,Drug Cost,155,,,155,Other,125% Medicaid APG methodology,0.01,1754.34,
FOSPHENYTOIN 100MG (AS PE)/2ML  ,Q2009,HCPCS,,40502015,CDM,636,RC,63323-0403-02,NDC,both,2,ML,15.61,6.16,39.4668,,6.16,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,7.81,50,,7.81,percent of total billed charges,All Other,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,1.57,,,1.57,Other,Drug Cost,1.57,,,1.57,Other,Drug Cost,1.57,,,1.57,Other,Drug Cost,1.57,,,1.57,Other,Drug Cost,1.57,,,1.57,Other,Drug Cost,5.31,34,,5.31,percent of total billed charges,Drugs,1.57,,,1.57,Other,Drug Cost,3.53,,,3.53,Other,225% Medicaid APG methodology,2.2,,,2.2,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.57,,,1.57,Other,Drug Cost,1.57,,,1.57,Other,Drug Cost,1.96,,,1.96,Other,125% Medicaid APG methodology,0.01,7.81,
ERTAPENEM 1000 MG INJ           ,J1335,HCPCS,,40502148,CDM,636,RC,43598-0901-58,NDC,both,1,EA,109.69,127.92,,,127.92,Other,150% of Medicare + 9.63% HCRA Surcharge,77.79,,,77.79,Fee Schedule,Average Sale Price (ASP) x 6,32.91,30,,32.91,percent of total billed charges,Drugs,32.91,30,,32.91,percent of total billed charges,Drugs,32.91,30,,32.91,percent of total billed charges,Drugs,32.91,30,,32.91,percent of total billed charges,Drugs,32.91,30,,32.91,percent of total billed charges,Drugs,54.85,50,,54.85,percent of total billed charges,All Other,32.91,30,,32.91,percent of total billed charges,Drugs,32.91,30,,32.91,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,32.91,30,,32.91,percent of total billed charges,Drugs,32.91,30,,32.91,percent of total billed charges,Drugs,32.91,30,,32.91,percent of total billed charges,Drugs,32.91,30,,32.91,percent of total billed charges,Drugs,32.91,30,,32.91,percent of total billed charges,Drugs,32.91,30,,32.91,percent of total billed charges,Drugs,32.91,30,,32.91,percent of total billed charges,Drugs,32.91,30,,32.91,percent of total billed charges,Drugs,32.91,30,,32.91,percent of total billed charges,Drugs,32.91,30,,32.91,percent of total billed charges,Drugs,32.91,30,,32.91,percent of total billed charges,Drugs,32.91,30,,32.91,percent of total billed charges,Drugs,32.91,30,,32.91,percent of total billed charges,Drugs,12.48,,,12.48,Other,Drug Cost,12.48,,,12.48,Other,Drug Cost,12.48,,,12.48,Other,Drug Cost,12.48,,,12.48,Other,Drug Cost,12.48,,,12.48,Other,Drug Cost,37.29,34,,37.29,percent of total billed charges,Drugs,12.48,,,12.48,Other,Drug Cost,28.08,,,28.08,Other,225% Medicaid APG methodology,17.47,,,17.47,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,124.46,,,124.46,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",12.48,,,12.48,Other,Drug Cost,12.48,,,12.48,Other,Drug Cost,15.6,,,15.6,Other,125% Medicaid APG methodology,0.01,127.92,
PANTOPRAZOLE 40 MG IV INJ       ,C9113,HCPCS,,40502189,CDM,636,RC,00143-9284-10,NDC,both,1,EA,8.86,3.5,39.4668,,3.5,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,2.66,30,,2.66,percent of total billed charges,Drugs,2.66,30,,2.66,percent of total billed charges,Drugs,2.66,30,,2.66,percent of total billed charges,Drugs,2.66,30,,2.66,percent of total billed charges,Drugs,2.66,30,,2.66,percent of total billed charges,Drugs,4.43,50,,4.43,percent of total billed charges,All Other,2.66,30,,2.66,percent of total billed charges,Drugs,2.66,30,,2.66,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.66,30,,2.66,percent of total billed charges,Drugs,2.66,30,,2.66,percent of total billed charges,Drugs,2.66,30,,2.66,percent of total billed charges,Drugs,2.66,30,,2.66,percent of total billed charges,Drugs,2.66,30,,2.66,percent of total billed charges,Drugs,2.66,30,,2.66,percent of total billed charges,Drugs,2.66,30,,2.66,percent of total billed charges,Drugs,2.66,30,,2.66,percent of total billed charges,Drugs,2.66,30,,2.66,percent of total billed charges,Drugs,2.66,30,,2.66,percent of total billed charges,Drugs,2.66,30,,2.66,percent of total billed charges,Drugs,2.66,30,,2.66,percent of total billed charges,Drugs,2.66,30,,2.66,percent of total billed charges,Drugs,1.79,,,1.79,Other,Drug Cost,1.79,,,1.79,Other,Drug Cost,1.79,,,1.79,Other,Drug Cost,1.79,,,1.79,Other,Drug Cost,1.79,,,1.79,Other,Drug Cost,3.01,34,,3.01,percent of total billed charges,Drugs,1.79,,,1.79,Other,Drug Cost,4.03,,,4.03,Other,225% Medicaid APG methodology,2.51,,,2.51,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.79,,,1.79,Other,Drug Cost,1.79,,,1.79,Other,Drug Cost,2.24,,,2.24,Other,125% Medicaid APG methodology,0.01,4.43,
BIVALIRUDIN 250 MG IV INJ       ,J0583,HCPCS,,40502205,CDM,636,RC,00781-3158-95,NDC,both,1,EA,243.92,2.11,,,2.11,Other,150% of Medicare + 9.63% HCRA Surcharge,1.28,,,1.28,Fee Schedule,Average Sale Price (ASP) x 6,73.18,30,,73.18,percent of total billed charges,Drugs,73.18,30,,73.18,percent of total billed charges,Drugs,73.18,30,,73.18,percent of total billed charges,Drugs,73.18,30,,73.18,percent of total billed charges,Drugs,73.18,30,,73.18,percent of total billed charges,Drugs,121.96,50,,121.96,percent of total billed charges,All Other,73.18,30,,73.18,percent of total billed charges,Drugs,73.18,30,,73.18,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,73.18,30,,73.18,percent of total billed charges,Drugs,73.18,30,,73.18,percent of total billed charges,Drugs,73.18,30,,73.18,percent of total billed charges,Drugs,73.18,30,,73.18,percent of total billed charges,Drugs,73.18,30,,73.18,percent of total billed charges,Drugs,73.18,30,,73.18,percent of total billed charges,Drugs,73.18,30,,73.18,percent of total billed charges,Drugs,73.18,30,,73.18,percent of total billed charges,Drugs,73.18,30,,73.18,percent of total billed charges,Drugs,73.18,30,,73.18,percent of total billed charges,Drugs,73.18,30,,73.18,percent of total billed charges,Drugs,73.18,30,,73.18,percent of total billed charges,Drugs,73.18,30,,73.18,percent of total billed charges,Drugs,16.64,,,16.64,Other,Drug Cost,16.64,,,16.64,Other,Drug Cost,16.64,,,16.64,Other,Drug Cost,16.64,,,16.64,Other,Drug Cost,16.64,,,16.64,Other,Drug Cost,82.93,34,,82.93,percent of total billed charges,Drugs,16.64,,,16.64,Other,Drug Cost,37.44,,,37.44,Other,225% Medicaid APG methodology,23.3,,,23.3,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.05,,,2.05,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",16.64,,,16.64,Other,Drug Cost,16.64,,,16.64,Other,Drug Cost,20.8,,,20.8,Other,125% Medicaid APG methodology,0.01,121.96,
ARGATROBAN 250MG/2.5ML INJ      ,J0883,HCPCS,,40502304,CDM,636,RC,63323-0526-03,NDC,both,2.5,ML,670.22,264.51,39.4668,,264.51,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,201.07,30,,201.07,percent of total billed charges,Drugs,201.07,30,,201.07,percent of total billed charges,Drugs,201.07,30,,201.07,percent of total billed charges,Drugs,201.07,30,,201.07,percent of total billed charges,Drugs,201.07,30,,201.07,percent of total billed charges,Drugs,335.11,50,,335.11,percent of total billed charges,All Other,201.07,30,,201.07,percent of total billed charges,Drugs,201.07,30,,201.07,percent of total billed charges,Drugs,227.87,34,"If Charge > 500, then 34 percent",227.87,percent of total billed charges,Drugs,201.07,30,,201.07,percent of total billed charges,Drugs,201.07,30,,201.07,percent of total billed charges,Drugs,201.07,30,,201.07,percent of total billed charges,Drugs,201.07,30,,201.07,percent of total billed charges,Drugs,201.07,30,,201.07,percent of total billed charges,Drugs,201.07,30,,201.07,percent of total billed charges,Drugs,201.07,30,,201.07,percent of total billed charges,Drugs,201.07,30,,201.07,percent of total billed charges,Drugs,201.07,30,,201.07,percent of total billed charges,Drugs,201.07,30,,201.07,percent of total billed charges,Drugs,201.07,30,,201.07,percent of total billed charges,Drugs,201.07,30,,201.07,percent of total billed charges,Drugs,201.07,30,,201.07,percent of total billed charges,Drugs,100.74,,,100.74,Other,Drug Cost,100.74,,,100.74,Other,Drug Cost,100.74,,,100.74,Other,Drug Cost,100.74,,,100.74,Other,Drug Cost,100.74,,,100.74,Other,Drug Cost,227.87,34,,227.87,percent of total billed charges,Drugs,100.74,,,100.74,Other,Drug Cost,226.67,,,226.67,Other,225% Medicaid APG methodology,141.04,,,141.04,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",100.74,,,100.74,Other,Drug Cost,100.74,,,100.74,Other,Drug Cost,125.93,,,125.93,Other,125% Medicaid APG methodology,0.01,335.11,
ALBUMIN HUMAN 25% IV SOLN 50ML  ,P9047,HCPCS,,40502361,CDM,636,RC,00944-0493-01,NDC,both,50,ML,116.03,523.69,,,523.69,Other,150% of Medicare + 9.63% HCRA Surcharge,318.46,,,318.46,Fee Schedule,Average Sale Price (ASP) x 6,34.81,30,,34.81,percent of total billed charges,Drugs,34.81,30,,34.81,percent of total billed charges,Drugs,34.81,30,,34.81,percent of total billed charges,Drugs,34.81,30,,34.81,percent of total billed charges,Drugs,34.81,30,,34.81,percent of total billed charges,Drugs,58.02,50,,58.02,percent of total billed charges,All Other,34.81,30,,34.81,percent of total billed charges,Drugs,34.81,30,,34.81,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,34.81,30,,34.81,percent of total billed charges,Drugs,34.81,30,,34.81,percent of total billed charges,Drugs,34.81,30,,34.81,percent of total billed charges,Drugs,34.81,30,,34.81,percent of total billed charges,Drugs,34.81,30,,34.81,percent of total billed charges,Drugs,34.81,30,,34.81,percent of total billed charges,Drugs,34.81,30,,34.81,percent of total billed charges,Drugs,34.81,30,,34.81,percent of total billed charges,Drugs,34.81,30,,34.81,percent of total billed charges,Drugs,34.81,30,,34.81,percent of total billed charges,Drugs,34.81,30,,34.81,percent of total billed charges,Drugs,34.81,30,,34.81,percent of total billed charges,Drugs,34.81,30,,34.81,percent of total billed charges,Drugs,26.41,,,26.41,Other,Drug Cost,26.41,,,26.41,Other,Drug Cost,26.41,,,26.41,Other,Drug Cost,26.41,,,26.41,Other,Drug Cost,26.41,,,26.41,Other,Drug Cost,39.45,34,,39.45,percent of total billed charges,Drugs,26.41,,,26.41,Other,Drug Cost,59.42,,,59.42,Other,225% Medicaid APG methodology,36.97,,,36.97,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,509.54,,,509.54,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",26.41,,,26.41,Other,Drug Cost,26.41,,,26.41,Other,Drug Cost,33.01,,,33.01,Other,125% Medicaid APG methodology,0.01,523.69,
ALBUMIN HUMAN 5% IV SOLN 250ML  ,P9045,HCPCS,,40502379,CDM,636,RC,00944-0495-05,NDC,both,250,ML,102.38,523.69,,,523.69,Other,150% of Medicare + 9.63% HCRA Surcharge,318.46,,,318.46,Fee Schedule,Average Sale Price (ASP) x 6,30.71,30,,30.71,percent of total billed charges,Drugs,30.71,30,,30.71,percent of total billed charges,Drugs,30.71,30,,30.71,percent of total billed charges,Drugs,30.71,30,,30.71,percent of total billed charges,Drugs,30.71,30,,30.71,percent of total billed charges,Drugs,51.19,50,,51.19,percent of total billed charges,All Other,30.71,30,,30.71,percent of total billed charges,Drugs,30.71,30,,30.71,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,30.71,30,,30.71,percent of total billed charges,Drugs,30.71,30,,30.71,percent of total billed charges,Drugs,30.71,30,,30.71,percent of total billed charges,Drugs,30.71,30,,30.71,percent of total billed charges,Drugs,30.71,30,,30.71,percent of total billed charges,Drugs,30.71,30,,30.71,percent of total billed charges,Drugs,30.71,30,,30.71,percent of total billed charges,Drugs,30.71,30,,30.71,percent of total billed charges,Drugs,30.71,30,,30.71,percent of total billed charges,Drugs,30.71,30,,30.71,percent of total billed charges,Drugs,30.71,30,,30.71,percent of total billed charges,Drugs,30.71,30,,30.71,percent of total billed charges,Drugs,30.71,30,,30.71,percent of total billed charges,Drugs,26.68,,,26.68,Other,Drug Cost,26.68,,,26.68,Other,Drug Cost,26.68,,,26.68,Other,Drug Cost,26.68,,,26.68,Other,Drug Cost,26.68,,,26.68,Other,Drug Cost,34.81,34,,34.81,percent of total billed charges,Drugs,26.68,,,26.68,Other,Drug Cost,60.03,,,60.03,Other,225% Medicaid APG methodology,37.35,,,37.35,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,509.54,,,509.54,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",26.68,,,26.68,Other,Drug Cost,26.68,,,26.68,Other,Drug Cost,33.35,,,33.35,Other,125% Medicaid APG methodology,0.01,523.69,
LEUPROLIDE 7.5MG/MONTH IM KIT   ,J9217,HCPCS,,40502437,CDM,636,RC,00074-3642-03,NDC,both,1,EA,6327.16,1788.85,,,1788.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1087.81,,,1087.81,Fee Schedule,Average Sale Price (ASP) x 6,1898.15,30,,1898.15,percent of total billed charges,Drugs,1898.15,30,,1898.15,percent of total billed charges,Drugs,1898.15,30,,1898.15,percent of total billed charges,Drugs,1898.15,30,,1898.15,percent of total billed charges,Drugs,1898.15,30,,1898.15,percent of total billed charges,Drugs,3163.58,50,,3163.58,percent of total billed charges,All Other,1898.15,30,,1898.15,percent of total billed charges,Drugs,1898.15,30,,1898.15,percent of total billed charges,Drugs,2151.23,34,"If Charge > 500, then 34 percent",2151.23,percent of total billed charges,Drugs,1898.15,30,,1898.15,percent of total billed charges,Drugs,1898.15,30,,1898.15,percent of total billed charges,Drugs,1898.15,30,,1898.15,percent of total billed charges,Drugs,1898.15,30,,1898.15,percent of total billed charges,Drugs,1898.15,30,,1898.15,percent of total billed charges,Drugs,1898.15,30,,1898.15,percent of total billed charges,Drugs,1898.15,30,,1898.15,percent of total billed charges,Drugs,1898.15,30,,1898.15,percent of total billed charges,Drugs,1898.15,30,,1898.15,percent of total billed charges,Drugs,1898.15,30,,1898.15,percent of total billed charges,Drugs,1898.15,30,,1898.15,percent of total billed charges,Drugs,1898.15,30,,1898.15,percent of total billed charges,Drugs,1898.15,30,,1898.15,percent of total billed charges,Drugs,99.67,,,99.67,Other,Drug Cost,99.67,,,99.67,Other,Drug Cost,99.67,,,99.67,Other,Drug Cost,99.67,,,99.67,Other,Drug Cost,99.67,,,99.67,Other,Drug Cost,2151.23,34,,2151.23,percent of total billed charges,Drugs,99.67,,,99.67,Other,Drug Cost,224.26,,,224.26,Other,225% Medicaid APG methodology,139.54,,,139.54,Other,140% Medicaid APG methodology,2151.23,34,"If Charge > 2,000, then 34 percent",2151.23,percent of total billed charges,Drugs,1740.5,,,1740.5,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",99.67,,,99.67,Other,Drug Cost,99.67,,,99.67,Other,Drug Cost,124.59,,,124.59,Other,125% Medicaid APG methodology,0.01,3163.58,
SIROLIMUS 1 MG TAB              ,J7520,HCPCS,,40502460,CDM,636,RC,68084-0915-25,NDC,both,1,EA,25.73,26.36,,,26.36,Other,150% of Medicare + 9.63% HCRA Surcharge,16.03,,,16.03,Fee Schedule,Average Sale Price (ASP) x 6,7.72,30,,7.72,percent of total billed charges,Drugs,7.72,30,,7.72,percent of total billed charges,Drugs,7.72,30,,7.72,percent of total billed charges,Drugs,7.72,30,,7.72,percent of total billed charges,Drugs,7.72,30,,7.72,percent of total billed charges,Drugs,12.87,50,,12.87,percent of total billed charges,All Other,7.72,30,,7.72,percent of total billed charges,Drugs,7.72,30,,7.72,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,7.72,30,,7.72,percent of total billed charges,Drugs,7.72,30,,7.72,percent of total billed charges,Drugs,7.72,30,,7.72,percent of total billed charges,Drugs,7.72,30,,7.72,percent of total billed charges,Drugs,7.72,30,,7.72,percent of total billed charges,Drugs,7.72,30,,7.72,percent of total billed charges,Drugs,7.72,30,,7.72,percent of total billed charges,Drugs,7.72,30,,7.72,percent of total billed charges,Drugs,7.72,30,,7.72,percent of total billed charges,Drugs,7.72,30,,7.72,percent of total billed charges,Drugs,7.72,30,,7.72,percent of total billed charges,Drugs,7.72,30,,7.72,percent of total billed charges,Drugs,7.72,30,,7.72,percent of total billed charges,Drugs,10.25,,,10.25,Other,Drug Cost,10.25,,,10.25,Other,Drug Cost,10.25,,,10.25,Other,Drug Cost,10.25,,,10.25,Other,Drug Cost,10.25,,,10.25,Other,Drug Cost,8.75,34,,8.75,percent of total billed charges,Drugs,10.25,,,10.25,Other,Drug Cost,23.06,,,23.06,Other,225% Medicaid APG methodology,14.35,,,14.35,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,25.65,,,25.65,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",10.25,,,10.25,Other,Drug Cost,10.25,,,10.25,Other,Drug Cost,12.81,,,12.81,Other,125% Medicaid APG methodology,0.01,26.36,
VINCRISTINE 1MG/ML IV SOLN 2ML  ,J9370,HCPCS,,40502536,CDM,636,RC,61703-0309-16,NDC,both,2,ML,32.55,76.22,,,76.22,Other,150% of Medicare + 9.63% HCRA Surcharge,46.35,,,46.35,Fee Schedule,Average Sale Price (ASP) x 6,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,16.28,50,,16.28,percent of total billed charges,All Other,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,9.77,30,,9.77,percent of total billed charges,Drugs,10.58,,,10.58,Other,Drug Cost,10.58,,,10.58,Other,Drug Cost,10.58,,,10.58,Other,Drug Cost,10.58,,,10.58,Other,Drug Cost,10.58,,,10.58,Other,Drug Cost,11.07,34,,11.07,percent of total billed charges,Drugs,10.58,,,10.58,Other,Drug Cost,23.81,,,23.81,Other,225% Medicaid APG methodology,14.81,,,14.81,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,74.16,,,74.16,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",10.58,,,10.58,Other,Drug Cost,10.58,,,10.58,Other,Drug Cost,13.23,,,13.23,Other,125% Medicaid APG methodology,0.01,76.22,
NF - BUDESONIDE-FORMOTEROL 160  ,J3535,HCPCS,,40502585,CDM,636,RC,00186-0370-20,NDC,both,10.2,GM,1220.94,481.87,39.4668,,481.87,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,366.28,30,,366.28,percent of total billed charges,Drugs,366.28,30,,366.28,percent of total billed charges,Drugs,366.28,30,,366.28,percent of total billed charges,Drugs,366.28,30,,366.28,percent of total billed charges,Drugs,366.28,30,,366.28,percent of total billed charges,Drugs,610.47,50,,610.47,percent of total billed charges,All Other,366.28,30,,366.28,percent of total billed charges,Drugs,366.28,30,,366.28,percent of total billed charges,Drugs,415.12,34,"If Charge > 500, then 34 percent",415.12,percent of total billed charges,Drugs,366.28,30,,366.28,percent of total billed charges,Drugs,366.28,30,,366.28,percent of total billed charges,Drugs,366.28,30,,366.28,percent of total billed charges,Drugs,366.28,30,,366.28,percent of total billed charges,Drugs,366.28,30,,366.28,percent of total billed charges,Drugs,366.28,30,,366.28,percent of total billed charges,Drugs,366.28,30,,366.28,percent of total billed charges,Drugs,366.28,30,,366.28,percent of total billed charges,Drugs,366.28,30,,366.28,percent of total billed charges,Drugs,366.28,30,,366.28,percent of total billed charges,Drugs,366.28,30,,366.28,percent of total billed charges,Drugs,366.28,30,,366.28,percent of total billed charges,Drugs,366.28,30,,366.28,percent of total billed charges,Drugs,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,415.12,34,,415.12,percent of total billed charges,Drugs,0.09,,,0.09,Other,Drug Cost,0.2,,,0.2,Other,225% Medicaid APG methodology,0.13,,,0.13,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,610.47,
DOXORUBICIN 2MG/ML IV SLN 10ML  ,J9000,HCPCS,,40502668,CDM,636,RC,00069-3031-20,NDC,both,10,ML,68.6,32.35,,,32.35,Other,150% of Medicare + 9.63% HCRA Surcharge,19.67,,,19.67,Fee Schedule,Average Sale Price (ASP) x 6,20.58,30,,20.58,percent of total billed charges,Drugs,20.58,30,,20.58,percent of total billed charges,Drugs,20.58,30,,20.58,percent of total billed charges,Drugs,20.58,30,,20.58,percent of total billed charges,Drugs,20.58,30,,20.58,percent of total billed charges,Drugs,34.3,50,,34.3,percent of total billed charges,All Other,20.58,30,,20.58,percent of total billed charges,Drugs,20.58,30,,20.58,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,20.58,30,,20.58,percent of total billed charges,Drugs,20.58,30,,20.58,percent of total billed charges,Drugs,20.58,30,,20.58,percent of total billed charges,Drugs,20.58,30,,20.58,percent of total billed charges,Drugs,20.58,30,,20.58,percent of total billed charges,Drugs,20.58,30,,20.58,percent of total billed charges,Drugs,20.58,30,,20.58,percent of total billed charges,Drugs,20.58,30,,20.58,percent of total billed charges,Drugs,20.58,30,,20.58,percent of total billed charges,Drugs,20.58,30,,20.58,percent of total billed charges,Drugs,20.58,30,,20.58,percent of total billed charges,Drugs,20.58,30,,20.58,percent of total billed charges,Drugs,20.58,30,,20.58,percent of total billed charges,Drugs,3,,,3,Other,Drug Cost,3,,,3,Other,Drug Cost,3,,,3,Other,Drug Cost,3,,,3,Other,Drug Cost,3,,,3,Other,Drug Cost,23.32,34,,23.32,percent of total billed charges,Drugs,3,,,3,Other,Drug Cost,6.75,,,6.75,Other,225% Medicaid APG methodology,4.2,,,4.2,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,31.48,,,31.48,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3,,,3,Other,Drug Cost,3,,,3,Other,Drug Cost,3.75,,,3.75,Other,125% Medicaid APG methodology,0.01,34.3,
CYCLOPHOSPHAMIDE 500 MG IV INJ  ,J9070,HCPCS,,40502759,CDM,636,RC,00781-3233-94,NDC,both,1,EA,358.72,198.84,,,198.84,Other,150% of Medicare + 9.63% HCRA Surcharge,120.92,,,120.92,Fee Schedule,Average Sale Price (ASP) x 6,107.62,30,,107.62,percent of total billed charges,Drugs,107.62,30,,107.62,percent of total billed charges,Drugs,107.62,30,,107.62,percent of total billed charges,Drugs,107.62,30,,107.62,percent of total billed charges,Drugs,107.62,30,,107.62,percent of total billed charges,Drugs,179.36,50,,179.36,percent of total billed charges,All Other,107.62,30,,107.62,percent of total billed charges,Drugs,107.62,30,,107.62,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,107.62,30,,107.62,percent of total billed charges,Drugs,107.62,30,,107.62,percent of total billed charges,Drugs,107.62,30,,107.62,percent of total billed charges,Drugs,107.62,30,,107.62,percent of total billed charges,Drugs,107.62,30,,107.62,percent of total billed charges,Drugs,107.62,30,,107.62,percent of total billed charges,Drugs,107.62,30,,107.62,percent of total billed charges,Drugs,107.62,30,,107.62,percent of total billed charges,Drugs,107.62,30,,107.62,percent of total billed charges,Drugs,107.62,30,,107.62,percent of total billed charges,Drugs,107.62,30,,107.62,percent of total billed charges,Drugs,107.62,30,,107.62,percent of total billed charges,Drugs,107.62,30,,107.62,percent of total billed charges,Drugs,106.96,,,106.96,Other,Drug Cost,106.96,,,106.96,Other,Drug Cost,106.96,,,106.96,Other,Drug Cost,106.96,,,106.96,Other,Drug Cost,106.96,,,106.96,Other,Drug Cost,121.96,34,,121.96,percent of total billed charges,Drugs,106.96,,,106.96,Other,Drug Cost,240.66,,,240.66,Other,225% Medicaid APG methodology,149.74,,,149.74,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,193.47,,,193.47,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",106.96,,,106.96,Other,Drug Cost,106.96,,,106.96,Other,Drug Cost,133.7,,,133.7,Other,125% Medicaid APG methodology,0.01,240.66,
CYCLOPHOSPHAMIDE 1000MG IV INJ  ,J9070,HCPCS,,40502767,CDM,636,RC,10019-0956-01,NDC,both,1,EA,773.22,198.84,,,198.84,Other,150% of Medicare + 9.63% HCRA Surcharge,120.92,,,120.92,Fee Schedule,Average Sale Price (ASP) x 6,231.97,30,,231.97,percent of total billed charges,Drugs,231.97,30,,231.97,percent of total billed charges,Drugs,231.97,30,,231.97,percent of total billed charges,Drugs,231.97,30,,231.97,percent of total billed charges,Drugs,231.97,30,,231.97,percent of total billed charges,Drugs,386.61,50,,386.61,percent of total billed charges,All Other,231.97,30,,231.97,percent of total billed charges,Drugs,231.97,30,,231.97,percent of total billed charges,Drugs,262.89,34,"If Charge > 500, then 34 percent",262.89,percent of total billed charges,Drugs,231.97,30,,231.97,percent of total billed charges,Drugs,231.97,30,,231.97,percent of total billed charges,Drugs,231.97,30,,231.97,percent of total billed charges,Drugs,231.97,30,,231.97,percent of total billed charges,Drugs,231.97,30,,231.97,percent of total billed charges,Drugs,231.97,30,,231.97,percent of total billed charges,Drugs,231.97,30,,231.97,percent of total billed charges,Drugs,231.97,30,,231.97,percent of total billed charges,Drugs,231.97,30,,231.97,percent of total billed charges,Drugs,231.97,30,,231.97,percent of total billed charges,Drugs,231.97,30,,231.97,percent of total billed charges,Drugs,231.97,30,,231.97,percent of total billed charges,Drugs,231.97,30,,231.97,percent of total billed charges,Drugs,109.6,,,109.6,Other,Drug Cost,109.6,,,109.6,Other,Drug Cost,109.6,,,109.6,Other,Drug Cost,109.6,,,109.6,Other,Drug Cost,109.6,,,109.6,Other,Drug Cost,262.89,34,,262.89,percent of total billed charges,Drugs,109.6,,,109.6,Other,Drug Cost,246.6,,,246.6,Other,225% Medicaid APG methodology,153.44,,,153.44,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,193.47,,,193.47,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",109.6,,,109.6,Other,Drug Cost,109.6,,,109.6,Other,Drug Cost,137,,,137,Other,125% Medicaid APG methodology,0.01,386.61,
DIPHENHYDRAMINE 50MG/ML INJ1ML  ,J1200,HCPCS,,40502817,CDM,636,RC,00641-0376-25,NDC,both,1,ML,1.89,7.93,,,7.93,Other,150% of Medicare + 9.63% HCRA Surcharge,4.82,,,4.82,Fee Schedule,Average Sale Price (ASP) x 6,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.95,50,,0.95,percent of total billed charges,All Other,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.58,,,0.58,Other,Drug Cost,0.58,,,0.58,Other,Drug Cost,0.58,,,0.58,Other,Drug Cost,0.58,,,0.58,Other,Drug Cost,0.58,,,0.58,Other,Drug Cost,0.64,34,,0.64,percent of total billed charges,Drugs,0.58,,,0.58,Other,Drug Cost,1.31,,,1.31,Other,225% Medicaid APG methodology,0.81,,,0.81,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.72,,,7.72,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.58,,,0.58,Other,Drug Cost,0.58,,,0.58,Other,Drug Cost,0.73,,,0.73,Other,125% Medicaid APG methodology,0.01,7.93,
HYDROCORTISONE 100 MG PF INJ    ,J1720,HCPCS,,40502841,CDM,636,RC,00009-0825-01,NDC,both,1,EA,36.3,176.07,,,176.07,Other,150% of Medicare + 9.63% HCRA Surcharge,107.07,,,107.07,Fee Schedule,Average Sale Price (ASP) x 6,10.89,30,,10.89,percent of total billed charges,Drugs,10.89,30,,10.89,percent of total billed charges,Drugs,10.89,30,,10.89,percent of total billed charges,Drugs,10.89,30,,10.89,percent of total billed charges,Drugs,10.89,30,,10.89,percent of total billed charges,Drugs,18.15,50,,18.15,percent of total billed charges,All Other,10.89,30,,10.89,percent of total billed charges,Drugs,10.89,30,,10.89,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,10.89,30,,10.89,percent of total billed charges,Drugs,10.89,30,,10.89,percent of total billed charges,Drugs,10.89,30,,10.89,percent of total billed charges,Drugs,10.89,30,,10.89,percent of total billed charges,Drugs,10.89,30,,10.89,percent of total billed charges,Drugs,10.89,30,,10.89,percent of total billed charges,Drugs,10.89,30,,10.89,percent of total billed charges,Drugs,10.89,30,,10.89,percent of total billed charges,Drugs,10.89,30,,10.89,percent of total billed charges,Drugs,10.89,30,,10.89,percent of total billed charges,Drugs,10.89,30,,10.89,percent of total billed charges,Drugs,10.89,30,,10.89,percent of total billed charges,Drugs,10.89,30,,10.89,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,12.34,34,,12.34,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,171.31,,,171.31,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,176.07,
INFLIXIMAB 100 MG IV INJ        ,J1745,HCPCS,,40502882,CDM,636,RC,57894-0030-01,NDC,both,1,EA,3983.21,317.32,,,317.32,Other,150% of Medicare + 9.63% HCRA Surcharge,192.97,,,192.97,Fee Schedule,Average Sale Price (ASP) x 6,1194.96,30,,1194.96,percent of total billed charges,Drugs,1194.96,30,,1194.96,percent of total billed charges,Drugs,1194.96,30,,1194.96,percent of total billed charges,Drugs,1194.96,30,,1194.96,percent of total billed charges,Drugs,1194.96,30,,1194.96,percent of total billed charges,Drugs,1991.61,50,,1991.61,percent of total billed charges,All Other,1194.96,30,,1194.96,percent of total billed charges,Drugs,1194.96,30,,1194.96,percent of total billed charges,Drugs,1354.29,34,"If Charge > 500, then 34 percent",1354.29,percent of total billed charges,Drugs,1194.96,30,,1194.96,percent of total billed charges,Drugs,1194.96,30,,1194.96,percent of total billed charges,Drugs,1194.96,30,,1194.96,percent of total billed charges,Drugs,1194.96,30,,1194.96,percent of total billed charges,Drugs,1194.96,30,,1194.96,percent of total billed charges,Drugs,1194.96,30,,1194.96,percent of total billed charges,Drugs,1194.96,30,,1194.96,percent of total billed charges,Drugs,1194.96,30,,1194.96,percent of total billed charges,Drugs,1194.96,30,,1194.96,percent of total billed charges,Drugs,1194.96,30,,1194.96,percent of total billed charges,Drugs,1194.96,30,,1194.96,percent of total billed charges,Drugs,1194.96,30,,1194.96,percent of total billed charges,Drugs,1194.96,30,,1194.96,percent of total billed charges,Drugs,227.14,,,227.14,Other,Drug Cost,227.14,,,227.14,Other,Drug Cost,227.14,,,227.14,Other,Drug Cost,227.14,,,227.14,Other,Drug Cost,227.14,,,227.14,Other,Drug Cost,1354.29,34,,1354.29,percent of total billed charges,Drugs,227.14,,,227.14,Other,Drug Cost,511.07,,,511.07,Other,225% Medicaid APG methodology,318,,,318,Other,140% Medicaid APG methodology,1354.29,34,"If Charge > 2,000, then 34 percent",1354.29,percent of total billed charges,Drugs,308.75,,,308.75,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",227.14,,,227.14,Other,Drug Cost,227.14,,,227.14,Other,Drug Cost,283.93,,,283.93,Other,125% Medicaid APG methodology,0.01,1991.61,
ONABOTULNUMTOXINA 100UNITS INJ  ,J0585,HCPCS,,40503039,CDM,636,RC,00023-1145-01,NDC,both,1,EA,2219,62.43,,,62.43,Other,150% of Medicare + 9.63% HCRA Surcharge,37.96,,,37.96,Fee Schedule,Average Sale Price (ASP) x 6,665.7,30,,665.7,percent of total billed charges,Drugs,665.7,30,,665.7,percent of total billed charges,Drugs,665.7,30,,665.7,percent of total billed charges,Drugs,665.7,30,,665.7,percent of total billed charges,Drugs,665.7,30,,665.7,percent of total billed charges,Drugs,1109.5,50,,1109.5,percent of total billed charges,All Other,665.7,30,,665.7,percent of total billed charges,Drugs,665.7,30,,665.7,percent of total billed charges,Drugs,754.46,34,"If Charge > 500, then 34 percent",754.46,percent of total billed charges,Drugs,665.7,30,,665.7,percent of total billed charges,Drugs,665.7,30,,665.7,percent of total billed charges,Drugs,665.7,30,,665.7,percent of total billed charges,Drugs,665.7,30,,665.7,percent of total billed charges,Drugs,665.7,30,,665.7,percent of total billed charges,Drugs,665.7,30,,665.7,percent of total billed charges,Drugs,665.7,30,,665.7,percent of total billed charges,Drugs,665.7,30,,665.7,percent of total billed charges,Drugs,665.7,30,,665.7,percent of total billed charges,Drugs,665.7,30,,665.7,percent of total billed charges,Drugs,665.7,30,,665.7,percent of total billed charges,Drugs,665.7,30,,665.7,percent of total billed charges,Drugs,665.7,30,,665.7,percent of total billed charges,Drugs,461.62,,,461.62,Other,Drug Cost,461.62,,,461.62,Other,Drug Cost,461.62,,,461.62,Other,Drug Cost,461.62,,,461.62,Other,Drug Cost,461.62,,,461.62,Other,Drug Cost,754.46,34,,754.46,percent of total billed charges,Drugs,461.62,,,461.62,Other,Drug Cost,1038.65,,,1038.65,Other,225% Medicaid APG methodology,646.27,,,646.27,Other,140% Medicaid APG methodology,754.46,34,"If Charge > 2,000, then 34 percent",754.46,percent of total billed charges,Drugs,60.74,,,60.74,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",461.62,,,461.62,Other,Drug Cost,461.62,,,461.62,Other,Drug Cost,577.03,,,577.03,Other,125% Medicaid APG methodology,0.01,1109.5,
LORAZEPAM 2MG/ML INJ SOLN 1ML   ,J2060,HCPCS,,40503187,CDM,636,RC,00409-6778-02,NDC,both,1,ML,5.5,11.07,,,11.07,Other,150% of Medicare + 9.63% HCRA Surcharge,6.73,,,6.73,Fee Schedule,Average Sale Price (ASP) x 6,1.65,30,,1.65,percent of total billed charges,Drugs,1.65,30,,1.65,percent of total billed charges,Drugs,1.65,30,,1.65,percent of total billed charges,Drugs,1.65,30,,1.65,percent of total billed charges,Drugs,1.65,30,,1.65,percent of total billed charges,Drugs,2.75,50,,2.75,percent of total billed charges,All Other,1.65,30,,1.65,percent of total billed charges,Drugs,1.65,30,,1.65,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.65,30,,1.65,percent of total billed charges,Drugs,1.65,30,,1.65,percent of total billed charges,Drugs,1.65,30,,1.65,percent of total billed charges,Drugs,1.65,30,,1.65,percent of total billed charges,Drugs,1.65,30,,1.65,percent of total billed charges,Drugs,1.65,30,,1.65,percent of total billed charges,Drugs,1.65,30,,1.65,percent of total billed charges,Drugs,1.65,30,,1.65,percent of total billed charges,Drugs,1.65,30,,1.65,percent of total billed charges,Drugs,1.65,30,,1.65,percent of total billed charges,Drugs,1.65,30,,1.65,percent of total billed charges,Drugs,1.65,30,,1.65,percent of total billed charges,Drugs,1.65,30,,1.65,percent of total billed charges,Drugs,0.68,,,0.68,Other,Drug Cost,0.68,,,0.68,Other,Drug Cost,0.68,,,0.68,Other,Drug Cost,0.68,,,0.68,Other,Drug Cost,0.68,,,0.68,Other,Drug Cost,1.87,34,,1.87,percent of total billed charges,Drugs,0.68,,,0.68,Other,Drug Cost,1.53,,,1.53,Other,225% Medicaid APG methodology,0.95,,,0.95,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,10.77,,,10.77,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.68,,,0.68,Other,Drug Cost,0.68,,,0.68,Other,Drug Cost,0.85,,,0.85,Other,125% Medicaid APG methodology,0.01,11.07,
EPINEPH 1MG/ML 1ML (SULFIT/PF)  ,J0171,HCPCS,,40503203,CDM,636,RC,54288-0103-10,NDC,both,1,ML,28.46,7.38,,,7.38,Other,150% of Medicare + 9.63% HCRA Surcharge,4.49,,,4.49,Fee Schedule,Average Sale Price (ASP) x 6,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,14.23,50,,14.23,percent of total billed charges,All Other,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,9.23,,,9.23,Other,Drug Cost,9.23,,,9.23,Other,Drug Cost,9.23,,,9.23,Other,Drug Cost,9.23,,,9.23,Other,Drug Cost,9.23,,,9.23,Other,Drug Cost,9.68,34,,9.68,percent of total billed charges,Drugs,9.23,,,9.23,Other,Drug Cost,20.77,,,20.77,Other,225% Medicaid APG methodology,12.92,,,12.92,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.18,,,7.18,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",9.23,,,9.23,Other,Drug Cost,9.23,,,9.23,Other,Drug Cost,11.54,,,11.54,Other,125% Medicaid APG methodology,0.01,20.77,
VANCOMYCIN 500 MG IV INJ        ,J3370,HCPCS,,40503252,CDM,636,RC,25021-0150-10,NDC,both,1,EA,6.16,22.76,,,22.76,Other,150% of Medicare + 9.63% HCRA Surcharge,13.84,,,13.84,Fee Schedule,Average Sale Price (ASP) x 6,1.85,30,,1.85,percent of total billed charges,Drugs,1.85,30,,1.85,percent of total billed charges,Drugs,1.85,30,,1.85,percent of total billed charges,Drugs,1.85,30,,1.85,percent of total billed charges,Drugs,1.85,30,,1.85,percent of total billed charges,Drugs,3.08,50,,3.08,percent of total billed charges,All Other,1.85,30,,1.85,percent of total billed charges,Drugs,1.85,30,,1.85,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.85,30,,1.85,percent of total billed charges,Drugs,1.85,30,,1.85,percent of total billed charges,Drugs,1.85,30,,1.85,percent of total billed charges,Drugs,1.85,30,,1.85,percent of total billed charges,Drugs,1.85,30,,1.85,percent of total billed charges,Drugs,1.85,30,,1.85,percent of total billed charges,Drugs,1.85,30,,1.85,percent of total billed charges,Drugs,1.85,30,,1.85,percent of total billed charges,Drugs,1.85,30,,1.85,percent of total billed charges,Drugs,1.85,30,,1.85,percent of total billed charges,Drugs,1.85,30,,1.85,percent of total billed charges,Drugs,1.85,30,,1.85,percent of total billed charges,Drugs,1.85,30,,1.85,percent of total billed charges,Drugs,2.26,,,2.26,Other,Drug Cost,2.26,,,2.26,Other,Drug Cost,2.26,,,2.26,Other,Drug Cost,2.26,,,2.26,Other,Drug Cost,2.26,,,2.26,Other,Drug Cost,2.09,34,,2.09,percent of total billed charges,Drugs,2.26,,,2.26,Other,Drug Cost,5.09,,,5.09,Other,225% Medicaid APG methodology,3.16,,,3.16,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,22.15,,,22.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.26,,,2.26,Other,Drug Cost,2.26,,,2.26,Other,Drug Cost,2.83,,,2.83,Other,125% Medicaid APG methodology,0.01,22.76,
VORICONAZOLE 200 MG IV INJ      ,J3465,HCPCS,,40503393,CDM,636,RC,00049-3190-28,NDC,both,1,EA,69.86,11.43,,,11.43,Other,150% of Medicare + 9.63% HCRA Surcharge,6.95,,,6.95,Fee Schedule,Average Sale Price (ASP) x 6,20.96,30,,20.96,percent of total billed charges,Drugs,20.96,30,,20.96,percent of total billed charges,Drugs,20.96,30,,20.96,percent of total billed charges,Drugs,20.96,30,,20.96,percent of total billed charges,Drugs,20.96,30,,20.96,percent of total billed charges,Drugs,34.93,50,,34.93,percent of total billed charges,All Other,20.96,30,,20.96,percent of total billed charges,Drugs,20.96,30,,20.96,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,20.96,30,,20.96,percent of total billed charges,Drugs,20.96,30,,20.96,percent of total billed charges,Drugs,20.96,30,,20.96,percent of total billed charges,Drugs,20.96,30,,20.96,percent of total billed charges,Drugs,20.96,30,,20.96,percent of total billed charges,Drugs,20.96,30,,20.96,percent of total billed charges,Drugs,20.96,30,,20.96,percent of total billed charges,Drugs,20.96,30,,20.96,percent of total billed charges,Drugs,20.96,30,,20.96,percent of total billed charges,Drugs,20.96,30,,20.96,percent of total billed charges,Drugs,20.96,30,,20.96,percent of total billed charges,Drugs,20.96,30,,20.96,percent of total billed charges,Drugs,20.96,30,,20.96,percent of total billed charges,Drugs,21.12,,,21.12,Other,Drug Cost,21.12,,,21.12,Other,Drug Cost,21.12,,,21.12,Other,Drug Cost,21.12,,,21.12,Other,Drug Cost,21.12,,,21.12,Other,Drug Cost,23.75,34,,23.75,percent of total billed charges,Drugs,21.12,,,21.12,Other,Drug Cost,47.52,,,47.52,Other,225% Medicaid APG methodology,29.57,,,29.57,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,11.12,,,11.12,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",21.12,,,21.12,Other,Drug Cost,21.12,,,21.12,Other,Drug Cost,26.4,,,26.4,Other,125% Medicaid APG methodology,0.01,47.52,
AMIODARONE 50MG/ML IV SOLN 3ML  ,J0282,HCPCS,,40503419,CDM,636,RC,55150-0180-03,NDC,both,3,ML,7,2.76,39.4668,,2.76,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,3.5,50,,3.5,percent of total billed charges,All Other,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,2.38,34,,2.38,percent of total billed charges,Drugs,2,,,2,Other,Drug Cost,4.5,,,4.5,Other,225% Medicaid APG methodology,2.8,,,2.8,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,2.5,,,2.5,Other,125% Medicaid APG methodology,0.01,4.5,
AMPICILLIN 500 MG INJ           ,J0290,HCPCS,,40503427,CDM,636,RC,55150-0112-10,NDC,both,1,EA,2.7,9.98,,,9.98,Other,150% of Medicare + 9.63% HCRA Surcharge,6.07,,,6.07,Fee Schedule,Average Sale Price (ASP) x 6,0.81,30,,0.81,percent of total billed charges,Drugs,0.81,30,,0.81,percent of total billed charges,Drugs,0.81,30,,0.81,percent of total billed charges,Drugs,0.81,30,,0.81,percent of total billed charges,Drugs,0.81,30,,0.81,percent of total billed charges,Drugs,1.35,50,,1.35,percent of total billed charges,All Other,0.81,30,,0.81,percent of total billed charges,Drugs,0.81,30,,0.81,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.81,30,,0.81,percent of total billed charges,Drugs,0.81,30,,0.81,percent of total billed charges,Drugs,0.81,30,,0.81,percent of total billed charges,Drugs,0.81,30,,0.81,percent of total billed charges,Drugs,0.81,30,,0.81,percent of total billed charges,Drugs,0.81,30,,0.81,percent of total billed charges,Drugs,0.81,30,,0.81,percent of total billed charges,Drugs,0.81,30,,0.81,percent of total billed charges,Drugs,0.81,30,,0.81,percent of total billed charges,Drugs,0.81,30,,0.81,percent of total billed charges,Drugs,0.81,30,,0.81,percent of total billed charges,Drugs,0.81,30,,0.81,percent of total billed charges,Drugs,0.81,30,,0.81,percent of total billed charges,Drugs,0.57,,,0.57,Other,Drug Cost,0.57,,,0.57,Other,Drug Cost,0.57,,,0.57,Other,Drug Cost,0.57,,,0.57,Other,Drug Cost,0.57,,,0.57,Other,Drug Cost,0.92,34,,0.92,percent of total billed charges,Drugs,0.57,,,0.57,Other,Drug Cost,1.28,,,1.28,Other,225% Medicaid APG methodology,0.8,,,0.8,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,9.71,,,9.71,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.57,,,0.57,Other,Drug Cost,0.57,,,0.57,Other,Drug Cost,0.71,,,0.71,Other,125% Medicaid APG methodology,0.01,9.98,
AMPICILLIN-SULBACTAM 1.5 G INJ  ,J0295,HCPCS,,40503435,CDM,636,RC,71288-0031-21,NDC,both,1,EA,7.98,17.45,,,17.45,Other,150% of Medicare + 9.63% HCRA Surcharge,10.61,,,10.61,Fee Schedule,Average Sale Price (ASP) x 6,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,3.99,50,,3.99,percent of total billed charges,All Other,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,3.71,,,3.71,Other,Drug Cost,3.71,,,3.71,Other,Drug Cost,3.71,,,3.71,Other,Drug Cost,3.71,,,3.71,Other,Drug Cost,3.71,,,3.71,Other,Drug Cost,2.71,34,,2.71,percent of total billed charges,Drugs,3.71,,,3.71,Other,Drug Cost,8.35,,,8.35,Other,225% Medicaid APG methodology,5.19,,,5.19,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,16.98,,,16.98,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.71,,,3.71,Other,Drug Cost,3.71,,,3.71,Other,Drug Cost,4.64,,,4.64,Other,125% Medicaid APG methodology,0.01,17.45,
AZITHROMYCIN 500 MG IV INJ      ,J0456,HCPCS,,40503443,CDM,636,RC,63323-0398-10,NDC,both,1,EA,24.15,25.65,,,25.65,Other,150% of Medicare + 9.63% HCRA Surcharge,15.6,,,15.6,Fee Schedule,Average Sale Price (ASP) x 6,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,12.08,50,,12.08,percent of total billed charges,All Other,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,1.46,,,1.46,Other,Drug Cost,1.46,,,1.46,Other,Drug Cost,1.46,,,1.46,Other,Drug Cost,1.46,,,1.46,Other,Drug Cost,1.46,,,1.46,Other,Drug Cost,8.21,34,,8.21,percent of total billed charges,Drugs,1.46,,,1.46,Other,Drug Cost,3.29,,,3.29,Other,225% Medicaid APG methodology,2.04,,,2.04,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,24.96,,,24.96,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.46,,,1.46,Other,Drug Cost,1.46,,,1.46,Other,Drug Cost,1.83,,,1.83,Other,125% Medicaid APG methodology,0.01,25.65,
"NAFCILLIN SOD 2GM VL, P2GM      ",J3490,HCPCS,,40503500,CDM,636,RC,63323-0328-20,NDC,both,1,EA,93.84,37.04,39.4668,,37.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,28.15,30,,28.15,percent of total billed charges,Drugs,28.15,30,,28.15,percent of total billed charges,Drugs,28.15,30,,28.15,percent of total billed charges,Drugs,28.15,30,,28.15,percent of total billed charges,Drugs,28.15,30,,28.15,percent of total billed charges,Drugs,46.92,50,,46.92,percent of total billed charges,All Other,28.15,30,,28.15,percent of total billed charges,Drugs,28.15,30,,28.15,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,28.15,30,,28.15,percent of total billed charges,Drugs,28.15,30,,28.15,percent of total billed charges,Drugs,28.15,30,,28.15,percent of total billed charges,Drugs,28.15,30,,28.15,percent of total billed charges,Drugs,28.15,30,,28.15,percent of total billed charges,Drugs,28.15,30,,28.15,percent of total billed charges,Drugs,28.15,30,,28.15,percent of total billed charges,Drugs,28.15,30,,28.15,percent of total billed charges,Drugs,28.15,30,,28.15,percent of total billed charges,Drugs,28.15,30,,28.15,percent of total billed charges,Drugs,28.15,30,,28.15,percent of total billed charges,Drugs,28.15,30,,28.15,percent of total billed charges,Drugs,28.15,30,,28.15,percent of total billed charges,Drugs,9.6,,,9.6,Other,Drug Cost,9.6,,,9.6,Other,Drug Cost,9.6,,,9.6,Other,Drug Cost,9.6,,,9.6,Other,Drug Cost,9.6,,,9.6,Other,Drug Cost,31.91,34,,31.91,percent of total billed charges,Drugs,9.6,,,9.6,Other,Drug Cost,21.6,,,21.6,Other,225% Medicaid APG methodology,13.44,,,13.44,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",9.6,,,9.6,Other,Drug Cost,9.6,,,9.6,Other,Drug Cost,12,,,12,Other,125% Medicaid APG methodology,0.01,46.92,
TERBUTALINE 1MG/ML INJ SLN 1ML  ,J3105,HCPCS,,40503526,CDM,636,RC,63323-0665-01,NDC,both,1,ML,5.15,76.9,,,76.9,Other,150% of Medicare + 9.63% HCRA Surcharge,46.76,,,46.76,Fee Schedule,Average Sale Price (ASP) x 6,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,2.58,50,,2.58,percent of total billed charges,All Other,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,4.04,,,4.04,Other,Drug Cost,4.04,,,4.04,Other,Drug Cost,4.04,,,4.04,Other,Drug Cost,4.04,,,4.04,Other,Drug Cost,4.04,,,4.04,Other,Drug Cost,1.75,34,,1.75,percent of total billed charges,Drugs,4.04,,,4.04,Other,Drug Cost,9.09,,,9.09,Other,225% Medicaid APG methodology,5.66,,,5.66,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,74.82,,,74.82,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.04,,,4.04,Other,Drug Cost,4.04,,,4.04,Other,Drug Cost,5.05,,,5.05,Other,125% Medicaid APG methodology,0.01,76.9,
HYDROXYUREA 500 MG CAP          ,J8999,HCPCS,,40503542,CDM,636,RC,00003-0830-50,NDC,both,1,EA,4.66,1.84,39.4668,,1.84,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,1.4,30,,1.4,percent of total billed charges,Drugs,1.4,30,,1.4,percent of total billed charges,Drugs,1.4,30,,1.4,percent of total billed charges,Drugs,1.4,30,,1.4,percent of total billed charges,Drugs,1.4,30,,1.4,percent of total billed charges,Drugs,2.33,50,,2.33,percent of total billed charges,All Other,1.4,30,,1.4,percent of total billed charges,Drugs,1.4,30,,1.4,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.4,30,,1.4,percent of total billed charges,Drugs,1.4,30,,1.4,percent of total billed charges,Drugs,1.4,30,,1.4,percent of total billed charges,Drugs,1.4,30,,1.4,percent of total billed charges,Drugs,1.4,30,,1.4,percent of total billed charges,Drugs,1.4,30,,1.4,percent of total billed charges,Drugs,1.4,30,,1.4,percent of total billed charges,Drugs,1.4,30,,1.4,percent of total billed charges,Drugs,1.4,30,,1.4,percent of total billed charges,Drugs,1.4,30,,1.4,percent of total billed charges,Drugs,1.4,30,,1.4,percent of total billed charges,Drugs,1.4,30,,1.4,percent of total billed charges,Drugs,1.4,30,,1.4,percent of total billed charges,Drugs,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1.58,34,,1.58,percent of total billed charges,Drugs,1,,,1,Other,Drug Cost,2.25,,,2.25,Other,225% Medicaid APG methodology,1.4,,,1.4,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1.25,,,1.25,Other,125% Medicaid APG methodology,0.01,2.33,
PROPOFOL 10MG/ML IV EMUL 20ML   ,J2704,HCPCS,,40503583,CDM,636,RC,63323-0269-29,NDC,both,20,ML,7.25,1.26,,,1.26,Other,150% of Medicare + 9.63% HCRA Surcharge,0.77,,,0.77,Fee Schedule,Average Sale Price (ASP) x 6,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,3.63,50,,3.63,percent of total billed charges,All Other,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,1.61,,,1.61,Other,Drug Cost,1.61,,,1.61,Other,Drug Cost,1.61,,,1.61,Other,Drug Cost,1.61,,,1.61,Other,Drug Cost,1.61,,,1.61,Other,Drug Cost,2.47,34,,2.47,percent of total billed charges,Drugs,1.61,,,1.61,Other,Drug Cost,3.62,,,3.62,Other,225% Medicaid APG methodology,2.25,,,2.25,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.23,,,1.23,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.61,,,1.61,Other,Drug Cost,1.61,,,1.61,Other,Drug Cost,2.01,,,2.01,Other,125% Medicaid APG methodology,0.01,3.63,
PNEUMOCOC 23-POLYVAL VAC 0.5ML  ,90732,CPT,,40503658,CDM,636,RC,00006-4837-03,NDC,both,0.5,ML,337.72,1316.93,,,1316.93,Other,150% of Medicare + 9.63% HCRA Surcharge,800.83,,,800.83,Fee Schedule,Average Sale Price (ASP) x 6,101.32,30,,101.32,percent of total billed charges,Drugs,101.32,30,,101.32,percent of total billed charges,Drugs,101.32,30,,101.32,percent of total billed charges,Drugs,101.32,30,,101.32,percent of total billed charges,Drugs,101.32,30,,101.32,percent of total billed charges,Drugs,168.86,50,,168.86,percent of total billed charges,All Other,101.32,30,,101.32,percent of total billed charges,Drugs,101.32,30,,101.32,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,101.32,30,,101.32,percent of total billed charges,Drugs,101.32,30,,101.32,percent of total billed charges,Drugs,101.32,30,,101.32,percent of total billed charges,Drugs,101.32,30,,101.32,percent of total billed charges,Drugs,101.32,30,,101.32,percent of total billed charges,Drugs,101.32,30,,101.32,percent of total billed charges,Drugs,101.32,30,,101.32,percent of total billed charges,Drugs,101.32,30,,101.32,percent of total billed charges,Drugs,101.32,30,,101.32,percent of total billed charges,Drugs,101.32,30,,101.32,percent of total billed charges,Drugs,101.32,30,,101.32,percent of total billed charges,Drugs,101.32,30,,101.32,percent of total billed charges,Drugs,101.32,30,,101.32,percent of total billed charges,Drugs,99.16,,,99.16,Other,Drug Cost,99.16,,,99.16,Other,Drug Cost,99.16,,,99.16,Other,Drug Cost,99.16,,,99.16,Other,Drug Cost,99.16,,,99.16,Other,Drug Cost,114.82,34,,114.82,percent of total billed charges,Drugs,99.16,,,99.16,Other,Drug Cost,223.11,,,223.11,Other,225% Medicaid APG methodology,138.82,,,138.82,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1281.33,,,1281.33,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",99.16,,,99.16,Other,Drug Cost,99.16,,,99.16,Other,Drug Cost,123.95,,,123.95,Other,125% Medicaid APG methodology,0.01,1316.93,
DAPTOMYCIN 500 MG IV INJ        ,J0878,HCPCS,,40503666,CDM,636,RC,71288-0016-15,NDC,both,1,EA,55.83,0.37,,,0.37,Other,150% of Medicare + 9.63% HCRA Surcharge,0.23,,,0.23,Fee Schedule,Average Sale Price (ASP) x 6,16.75,30,,16.75,percent of total billed charges,Drugs,16.75,30,,16.75,percent of total billed charges,Drugs,16.75,30,,16.75,percent of total billed charges,Drugs,16.75,30,,16.75,percent of total billed charges,Drugs,16.75,30,,16.75,percent of total billed charges,Drugs,27.92,50,,27.92,percent of total billed charges,All Other,16.75,30,,16.75,percent of total billed charges,Drugs,16.75,30,,16.75,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,16.75,30,,16.75,percent of total billed charges,Drugs,16.75,30,,16.75,percent of total billed charges,Drugs,16.75,30,,16.75,percent of total billed charges,Drugs,16.75,30,,16.75,percent of total billed charges,Drugs,16.75,30,,16.75,percent of total billed charges,Drugs,16.75,30,,16.75,percent of total billed charges,Drugs,16.75,30,,16.75,percent of total billed charges,Drugs,16.75,30,,16.75,percent of total billed charges,Drugs,16.75,30,,16.75,percent of total billed charges,Drugs,16.75,30,,16.75,percent of total billed charges,Drugs,16.75,30,,16.75,percent of total billed charges,Drugs,16.75,30,,16.75,percent of total billed charges,Drugs,16.75,30,,16.75,percent of total billed charges,Drugs,16.43,,,16.43,Other,Drug Cost,16.43,,,16.43,Other,Drug Cost,16.43,,,16.43,Other,Drug Cost,16.43,,,16.43,Other,Drug Cost,16.43,,,16.43,Other,Drug Cost,18.98,34,,18.98,percent of total billed charges,Drugs,16.43,,,16.43,Other,Drug Cost,36.97,,,36.97,Other,225% Medicaid APG methodology,23,,,23,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.36,,,0.36,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",16.43,,,16.43,Other,Drug Cost,16.43,,,16.43,Other,Drug Cost,20.54,,,20.54,Other,125% Medicaid APG methodology,0.01,36.97,
BEVACIZUMAB 25MG/ML IV SLN 4ML  ,J9035,HCPCS,,40503690,CDM,636,RC,50242-0060-01,NDC,both,4,ML,2222.96,730.86,,,730.86,Other,150% of Medicare + 9.63% HCRA Surcharge,444.44,,,444.44,Fee Schedule,Average Sale Price (ASP) x 6,666.89,30,,666.89,percent of total billed charges,Drugs,666.89,30,,666.89,percent of total billed charges,Drugs,666.89,30,,666.89,percent of total billed charges,Drugs,666.89,30,,666.89,percent of total billed charges,Drugs,666.89,30,,666.89,percent of total billed charges,Drugs,1111.48,50,,1111.48,percent of total billed charges,All Other,666.89,30,,666.89,percent of total billed charges,Drugs,666.89,30,,666.89,percent of total billed charges,Drugs,755.81,34,"If Charge > 500, then 34 percent",755.81,percent of total billed charges,Drugs,666.89,30,,666.89,percent of total billed charges,Drugs,666.89,30,,666.89,percent of total billed charges,Drugs,666.89,30,,666.89,percent of total billed charges,Drugs,666.89,30,,666.89,percent of total billed charges,Drugs,666.89,30,,666.89,percent of total billed charges,Drugs,666.89,30,,666.89,percent of total billed charges,Drugs,666.89,30,,666.89,percent of total billed charges,Drugs,666.89,30,,666.89,percent of total billed charges,Drugs,666.89,30,,666.89,percent of total billed charges,Drugs,666.89,30,,666.89,percent of total billed charges,Drugs,666.89,30,,666.89,percent of total billed charges,Drugs,666.89,30,,666.89,percent of total billed charges,Drugs,666.89,30,,666.89,percent of total billed charges,Drugs,572.5,,,572.5,Other,Drug Cost,572.5,,,572.5,Other,Drug Cost,572.5,,,572.5,Other,Drug Cost,572.5,,,572.5,Other,Drug Cost,572.5,,,572.5,Other,Drug Cost,755.81,34,,755.81,percent of total billed charges,Drugs,572.5,,,572.5,Other,Drug Cost,1288.13,,,1288.13,Other,225% Medicaid APG methodology,801.5,,,801.5,Other,140% Medicaid APG methodology,755.81,34,"If Charge > 2,000, then 34 percent",755.81,percent of total billed charges,Drugs,711.1,,,711.1,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",572.5,,,572.5,Other,Drug Cost,572.5,,,572.5,Other,Drug Cost,715.63,,,715.63,Other,125% Medicaid APG methodology,0.01,1288.13,
CETUXIMAB 2MG/ML IV SOLN 50ML   ,J9055,HCPCS,,40503708,CDM,636,RC,66733-0948-23,NDC,both,50,ML,2366.25,727.37,,,727.37,Other,150% of Medicare + 9.63% HCRA Surcharge,442.32,,,442.32,Fee Schedule,Average Sale Price (ASP) x 6,709.88,30,,709.88,percent of total billed charges,Drugs,709.88,30,,709.88,percent of total billed charges,Drugs,709.88,30,,709.88,percent of total billed charges,Drugs,709.88,30,,709.88,percent of total billed charges,Drugs,709.88,30,,709.88,percent of total billed charges,Drugs,1183.13,50,,1183.13,percent of total billed charges,All Other,709.88,30,,709.88,percent of total billed charges,Drugs,709.88,30,,709.88,percent of total billed charges,Drugs,804.53,34,"If Charge > 500, then 34 percent",804.53,percent of total billed charges,Drugs,709.88,30,,709.88,percent of total billed charges,Drugs,709.88,30,,709.88,percent of total billed charges,Drugs,709.88,30,,709.88,percent of total billed charges,Drugs,709.88,30,,709.88,percent of total billed charges,Drugs,709.88,30,,709.88,percent of total billed charges,Drugs,709.88,30,,709.88,percent of total billed charges,Drugs,709.88,30,,709.88,percent of total billed charges,Drugs,709.88,30,,709.88,percent of total billed charges,Drugs,709.88,30,,709.88,percent of total billed charges,Drugs,709.88,30,,709.88,percent of total billed charges,Drugs,709.88,30,,709.88,percent of total billed charges,Drugs,709.88,30,,709.88,percent of total billed charges,Drugs,709.88,30,,709.88,percent of total billed charges,Drugs,468.09,,,468.09,Other,Drug Cost,468.09,,,468.09,Other,Drug Cost,468.09,,,468.09,Other,Drug Cost,468.09,,,468.09,Other,Drug Cost,468.09,,,468.09,Other,Drug Cost,804.53,34,,804.53,percent of total billed charges,Drugs,468.09,,,468.09,Other,Drug Cost,1053.2,,,1053.2,Other,225% Medicaid APG methodology,655.33,,,655.33,Other,140% Medicaid APG methodology,804.53,34,"If Charge > 2,000, then 34 percent",804.53,percent of total billed charges,Drugs,707.71,,,707.71,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",468.09,,,468.09,Other,Drug Cost,468.09,,,468.09,Other,Drug Cost,585.11,,,585.11,Other,125% Medicaid APG methodology,0.01,1183.13,
RASBURICASE 1.5 MG IV INJ       ,J2783,HCPCS,,40503773,CDM,636,RC,00024-5150-10,NDC,both,1,EA,3636.68,3623.72,,,3623.72,Other,150% of Medicare + 9.63% HCRA Surcharge,2203.61,,,2203.61,Fee Schedule,Average Sale Price (ASP) x 6,1091,30,,1091,percent of total billed charges,Drugs,1091,30,,1091,percent of total billed charges,Drugs,1091,30,,1091,percent of total billed charges,Drugs,1091,30,,1091,percent of total billed charges,Drugs,1091,30,,1091,percent of total billed charges,Drugs,1818.34,50,,1818.34,percent of total billed charges,All Other,1091,30,,1091,percent of total billed charges,Drugs,1091,30,,1091,percent of total billed charges,Drugs,1236.47,34,"If Charge > 500, then 34 percent",1236.47,percent of total billed charges,Drugs,1091,30,,1091,percent of total billed charges,Drugs,1091,30,,1091,percent of total billed charges,Drugs,1091,30,,1091,percent of total billed charges,Drugs,1091,30,,1091,percent of total billed charges,Drugs,1091,30,,1091,percent of total billed charges,Drugs,1091,30,,1091,percent of total billed charges,Drugs,1091,30,,1091,percent of total billed charges,Drugs,1091,30,,1091,percent of total billed charges,Drugs,1091,30,,1091,percent of total billed charges,Drugs,1091,30,,1091,percent of total billed charges,Drugs,1091,30,,1091,percent of total billed charges,Drugs,1091,30,,1091,percent of total billed charges,Drugs,1091,30,,1091,percent of total billed charges,Drugs,245.63,,,245.63,Other,Drug Cost,245.63,,,245.63,Other,Drug Cost,245.63,,,245.63,Other,Drug Cost,245.63,,,245.63,Other,Drug Cost,245.63,,,245.63,Other,Drug Cost,1236.47,34,,1236.47,percent of total billed charges,Drugs,245.63,,,245.63,Other,Drug Cost,552.67,,,552.67,Other,225% Medicaid APG methodology,343.88,,,343.88,Other,140% Medicaid APG methodology,1236.47,34,"If Charge > 2,000, then 34 percent",1236.47,percent of total billed charges,Drugs,3525.77,,,3525.77,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",245.63,,,245.63,Other,Drug Cost,245.63,,,245.63,Other,Drug Cost,307.04,,,307.04,Other,125% Medicaid APG methodology,0.01,3623.72,
IRON SUCROSE 20MG/ML IV  5ML    ,J1756,HCPCS,,40503914,CDM,636,RC,00517-2340-25,NDC,both,5,ML,107.38,2.18,,,2.18,Other,150% of Medicare + 9.63% HCRA Surcharge,1.33,,,1.33,Fee Schedule,Average Sale Price (ASP) x 6,32.21,30,,32.21,percent of total billed charges,Drugs,32.21,30,,32.21,percent of total billed charges,Drugs,32.21,30,,32.21,percent of total billed charges,Drugs,32.21,30,,32.21,percent of total billed charges,Drugs,32.21,30,,32.21,percent of total billed charges,Drugs,53.69,50,,53.69,percent of total billed charges,All Other,32.21,30,,32.21,percent of total billed charges,Drugs,32.21,30,,32.21,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,32.21,30,,32.21,percent of total billed charges,Drugs,32.21,30,,32.21,percent of total billed charges,Drugs,32.21,30,,32.21,percent of total billed charges,Drugs,32.21,30,,32.21,percent of total billed charges,Drugs,32.21,30,,32.21,percent of total billed charges,Drugs,32.21,30,,32.21,percent of total billed charges,Drugs,32.21,30,,32.21,percent of total billed charges,Drugs,32.21,30,,32.21,percent of total billed charges,Drugs,32.21,30,,32.21,percent of total billed charges,Drugs,32.21,30,,32.21,percent of total billed charges,Drugs,32.21,30,,32.21,percent of total billed charges,Drugs,32.21,30,,32.21,percent of total billed charges,Drugs,32.21,30,,32.21,percent of total billed charges,Drugs,22.74,,,22.74,Other,Drug Cost,22.74,,,22.74,Other,Drug Cost,22.74,,,22.74,Other,Drug Cost,22.74,,,22.74,Other,Drug Cost,22.74,,,22.74,Other,Drug Cost,36.51,34,,36.51,percent of total billed charges,Drugs,22.74,,,22.74,Other,Drug Cost,51.17,,,51.17,Other,225% Medicaid APG methodology,31.84,,,31.84,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.12,,,2.12,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",22.74,,,22.74,Other,Drug Cost,22.74,,,22.74,Other,Drug Cost,28.43,,,28.43,Other,125% Medicaid APG methodology,0.01,53.69,
RABIE VAC EMBRY CELL 2.5UN INJ  ,90675,CPT,,40503955,CDM,636,RC,50632-0010-01,NDC,both,1,EA,1003.98,3204.15,,,3204.15,Other,150% of Medicare + 9.63% HCRA Surcharge,1948.46,,,1948.46,Fee Schedule,Average Sale Price (ASP) x 6,301.19,30,,301.19,percent of total billed charges,Drugs,301.19,30,,301.19,percent of total billed charges,Drugs,301.19,30,,301.19,percent of total billed charges,Drugs,301.19,30,,301.19,percent of total billed charges,Drugs,301.19,30,,301.19,percent of total billed charges,Drugs,501.99,50,,501.99,percent of total billed charges,All Other,301.19,30,,301.19,percent of total billed charges,Drugs,301.19,30,,301.19,percent of total billed charges,Drugs,341.35,34,"If Charge > 500, then 34 percent",341.35,percent of total billed charges,Drugs,301.19,30,,301.19,percent of total billed charges,Drugs,301.19,30,,301.19,percent of total billed charges,Drugs,301.19,30,,301.19,percent of total billed charges,Drugs,301.19,30,,301.19,percent of total billed charges,Drugs,301.19,30,,301.19,percent of total billed charges,Drugs,301.19,30,,301.19,percent of total billed charges,Drugs,301.19,30,,301.19,percent of total billed charges,Drugs,301.19,30,,301.19,percent of total billed charges,Drugs,301.19,30,,301.19,percent of total billed charges,Drugs,301.19,30,,301.19,percent of total billed charges,Drugs,301.19,30,,301.19,percent of total billed charges,Drugs,301.19,30,,301.19,percent of total billed charges,Drugs,301.19,30,,301.19,percent of total billed charges,Drugs,293.05,,,293.05,Other,Drug Cost,293.05,,,293.05,Other,Drug Cost,293.05,,,293.05,Other,Drug Cost,293.05,,,293.05,Other,Drug Cost,293.05,,,293.05,Other,Drug Cost,341.35,34,,341.35,percent of total billed charges,Drugs,293.05,,,293.05,Other,Drug Cost,659.36,,,659.36,Other,225% Medicaid APG methodology,410.27,,,410.27,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,3117.54,,,3117.54,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",293.05,,,293.05,Other,Drug Cost,293.05,,,293.05,Other,Drug Cost,366.31,,,366.31,Other,125% Medicaid APG methodology,0.01,3204.15,
SUCCINYLCHOLINE 20MG/ML  10ML   ,J0330,HCPCS,,40504052,CDM,636,RC,70069-0301-25,NDC,both,1,ML,1.93,0.76,39.4668,,0.76,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.97,50,,0.97,percent of total billed charges,All Other,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.4,,,0.4,Other,Drug Cost,0.4,,,0.4,Other,Drug Cost,0.4,,,0.4,Other,Drug Cost,0.4,,,0.4,Other,Drug Cost,0.4,,,0.4,Other,Drug Cost,0.66,34,,0.66,percent of total billed charges,Drugs,0.4,,,0.4,Other,Drug Cost,0.9,,,0.9,Other,225% Medicaid APG methodology,0.56,,,0.56,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.4,,,0.4,Other,Drug Cost,0.4,,,0.4,Other,Drug Cost,0.5,,,0.5,Other,125% Medicaid APG methodology,0.01,0.97,
HYDRALAZINE 20MG/ML INJ  1ML    ,J0360,HCPCS,,40504060,CDM,636,RC,63323-0614-01,NDC,both,1,ML,10.99,55.13,,,55.13,Other,150% of Medicare + 9.63% HCRA Surcharge,33.52,,,33.52,Fee Schedule,Average Sale Price (ASP) x 6,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,5.5,50,,5.5,percent of total billed charges,All Other,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,3.87,,,3.87,Other,Drug Cost,3.87,,,3.87,Other,Drug Cost,3.87,,,3.87,Other,Drug Cost,3.87,,,3.87,Other,Drug Cost,3.87,,,3.87,Other,Drug Cost,3.74,34,,3.74,percent of total billed charges,Drugs,3.87,,,3.87,Other,Drug Cost,8.71,,,8.71,Other,225% Medicaid APG methodology,5.42,,,5.42,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,53.64,,,53.64,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.87,,,3.87,Other,Drug Cost,3.87,,,3.87,Other,Drug Cost,4.84,,,4.84,Other,125% Medicaid APG methodology,0.01,55.13,
PENG BENZ 1.2 MIL UN/2ML 2ML    ,J0561,HCPCS,,40504102,CDM,636,RC,60793-0701-10,NDC,both,2,ML,560.07,214.4,,,214.4,Other,150% of Medicare + 9.63% HCRA Surcharge,130.38,,,130.38,Fee Schedule,Average Sale Price (ASP) x 6,168.02,30,,168.02,percent of total billed charges,Drugs,168.02,30,,168.02,percent of total billed charges,Drugs,168.02,30,,168.02,percent of total billed charges,Drugs,168.02,30,,168.02,percent of total billed charges,Drugs,168.02,30,,168.02,percent of total billed charges,Drugs,280.04,50,,280.04,percent of total billed charges,All Other,168.02,30,,168.02,percent of total billed charges,Drugs,168.02,30,,168.02,percent of total billed charges,Drugs,190.42,34,"If Charge > 500, then 34 percent",190.42,percent of total billed charges,Drugs,168.02,30,,168.02,percent of total billed charges,Drugs,168.02,30,,168.02,percent of total billed charges,Drugs,168.02,30,,168.02,percent of total billed charges,Drugs,168.02,30,,168.02,percent of total billed charges,Drugs,168.02,30,,168.02,percent of total billed charges,Drugs,168.02,30,,168.02,percent of total billed charges,Drugs,168.02,30,,168.02,percent of total billed charges,Drugs,168.02,30,,168.02,percent of total billed charges,Drugs,168.02,30,,168.02,percent of total billed charges,Drugs,168.02,30,,168.02,percent of total billed charges,Drugs,168.02,30,,168.02,percent of total billed charges,Drugs,168.02,30,,168.02,percent of total billed charges,Drugs,168.02,30,,168.02,percent of total billed charges,Drugs,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,190.42,34,,190.42,percent of total billed charges,Drugs,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,208.61,,,208.61,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,280.04,
PENG BENZ 2.4 MIL UN/4ML 4ML    ,J0561,HCPCS,,40504110,CDM,636,RC,60793-0702-10,NDC,both,4,ML,1262.52,214.4,,,214.4,Other,150% of Medicare + 9.63% HCRA Surcharge,130.38,,,130.38,Fee Schedule,Average Sale Price (ASP) x 6,378.76,30,,378.76,percent of total billed charges,Drugs,378.76,30,,378.76,percent of total billed charges,Drugs,378.76,30,,378.76,percent of total billed charges,Drugs,378.76,30,,378.76,percent of total billed charges,Drugs,378.76,30,,378.76,percent of total billed charges,Drugs,631.26,50,,631.26,percent of total billed charges,All Other,378.76,30,,378.76,percent of total billed charges,Drugs,378.76,30,,378.76,percent of total billed charges,Drugs,429.26,34,"If Charge > 500, then 34 percent",429.26,percent of total billed charges,Drugs,378.76,30,,378.76,percent of total billed charges,Drugs,378.76,30,,378.76,percent of total billed charges,Drugs,378.76,30,,378.76,percent of total billed charges,Drugs,378.76,30,,378.76,percent of total billed charges,Drugs,378.76,30,,378.76,percent of total billed charges,Drugs,378.76,30,,378.76,percent of total billed charges,Drugs,378.76,30,,378.76,percent of total billed charges,Drugs,378.76,30,,378.76,percent of total billed charges,Drugs,378.76,30,,378.76,percent of total billed charges,Drugs,378.76,30,,378.76,percent of total billed charges,Drugs,378.76,30,,378.76,percent of total billed charges,Drugs,378.76,30,,378.76,percent of total billed charges,Drugs,378.76,30,,378.76,percent of total billed charges,Drugs,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,429.26,34,,429.26,percent of total billed charges,Drugs,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,208.61,,,208.61,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,631.26,
MEPIVACAINE 1% PF INJ SLN 30ML  ,J0670,HCPCS,,40504128,CDM,636,RC,63323-0260-37,NDC,both,30,ML,19.71,32.46,,,32.46,Other,150% of Medicare + 9.63% HCRA Surcharge,19.74,,,19.74,Fee Schedule,Average Sale Price (ASP) x 6,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,9.86,50,,9.86,percent of total billed charges,All Other,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,3.48,,,3.48,Other,Drug Cost,3.48,,,3.48,Other,Drug Cost,3.48,,,3.48,Other,Drug Cost,3.48,,,3.48,Other,Drug Cost,3.48,,,3.48,Other,Drug Cost,6.7,34,,6.7,percent of total billed charges,Drugs,3.48,,,3.48,Other,Drug Cost,7.83,,,7.83,Other,225% Medicaid APG methodology,4.87,,,4.87,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,31.58,,,31.58,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.48,,,3.48,Other,Drug Cost,3.48,,,3.48,Other,Drug Cost,4.35,,,4.35,Other,125% Medicaid APG methodology,0.01,32.46,
COLISTIMETHATE 150MG INJ        ,J0770,HCPCS,,40504201,CDM,636,RC,70594-0023-01,NDC,both,1,EA,33.36,137.3,,,137.3,Other,150% of Medicare + 9.63% HCRA Surcharge,83.5,,,83.5,Fee Schedule,Average Sale Price (ASP) x 6,10.01,30,,10.01,percent of total billed charges,Drugs,10.01,30,,10.01,percent of total billed charges,Drugs,10.01,30,,10.01,percent of total billed charges,Drugs,10.01,30,,10.01,percent of total billed charges,Drugs,10.01,30,,10.01,percent of total billed charges,Drugs,16.68,50,,16.68,percent of total billed charges,All Other,10.01,30,,10.01,percent of total billed charges,Drugs,10.01,30,,10.01,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,10.01,30,,10.01,percent of total billed charges,Drugs,10.01,30,,10.01,percent of total billed charges,Drugs,10.01,30,,10.01,percent of total billed charges,Drugs,10.01,30,,10.01,percent of total billed charges,Drugs,10.01,30,,10.01,percent of total billed charges,Drugs,10.01,30,,10.01,percent of total billed charges,Drugs,10.01,30,,10.01,percent of total billed charges,Drugs,10.01,30,,10.01,percent of total billed charges,Drugs,10.01,30,,10.01,percent of total billed charges,Drugs,10.01,30,,10.01,percent of total billed charges,Drugs,10.01,30,,10.01,percent of total billed charges,Drugs,10.01,30,,10.01,percent of total billed charges,Drugs,10.01,30,,10.01,percent of total billed charges,Drugs,10.83,,,10.83,Other,Drug Cost,10.83,,,10.83,Other,Drug Cost,10.83,,,10.83,Other,Drug Cost,10.83,,,10.83,Other,Drug Cost,10.83,,,10.83,Other,Drug Cost,11.34,34,,11.34,percent of total billed charges,Drugs,10.83,,,10.83,Other,Drug Cost,24.37,,,24.37,Other,225% Medicaid APG methodology,15.16,,,15.16,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,133.59,,,133.59,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",10.83,,,10.83,Other,Drug Cost,10.83,,,10.83,Other,Drug Cost,13.54,,,13.54,Other,125% Medicaid APG methodology,0.01,137.3,
DIGOXIN 250 MCG/ML INJ SLN 2ML  ,J1160,HCPCS,,40504243,CDM,636,RC,00641-1410-35,NDC,both,2,ML,9.98,92.83,,,92.83,Other,150% of Medicare + 9.63% HCRA Surcharge,56.45,,,56.45,Fee Schedule,Average Sale Price (ASP) x 6,2.99,30,,2.99,percent of total billed charges,Drugs,2.99,30,,2.99,percent of total billed charges,Drugs,2.99,30,,2.99,percent of total billed charges,Drugs,2.99,30,,2.99,percent of total billed charges,Drugs,2.99,30,,2.99,percent of total billed charges,Drugs,4.99,50,,4.99,percent of total billed charges,All Other,2.99,30,,2.99,percent of total billed charges,Drugs,2.99,30,,2.99,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.99,30,,2.99,percent of total billed charges,Drugs,2.99,30,,2.99,percent of total billed charges,Drugs,2.99,30,,2.99,percent of total billed charges,Drugs,2.99,30,,2.99,percent of total billed charges,Drugs,2.99,30,,2.99,percent of total billed charges,Drugs,2.99,30,,2.99,percent of total billed charges,Drugs,2.99,30,,2.99,percent of total billed charges,Drugs,2.99,30,,2.99,percent of total billed charges,Drugs,2.99,30,,2.99,percent of total billed charges,Drugs,2.99,30,,2.99,percent of total billed charges,Drugs,2.99,30,,2.99,percent of total billed charges,Drugs,2.99,30,,2.99,percent of total billed charges,Drugs,2.99,30,,2.99,percent of total billed charges,Drugs,2.44,,,2.44,Other,Drug Cost,2.44,,,2.44,Other,Drug Cost,2.44,,,2.44,Other,Drug Cost,2.44,,,2.44,Other,Drug Cost,2.44,,,2.44,Other,Drug Cost,3.39,34,,3.39,percent of total billed charges,Drugs,2.44,,,2.44,Other,Drug Cost,5.49,,,5.49,Other,225% Medicaid APG methodology,3.42,,,3.42,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,90.32,,,90.32,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.44,,,2.44,Other,Drug Cost,2.44,,,2.44,Other,Drug Cost,3.05,,,3.05,Other,125% Medicaid APG methodology,0.01,92.83,
CONJUGATED ESTROGENS 25 MG INJ  ,J1410,HCPCS,,40504342,CDM,636,RC,00046-0749-05,NDC,both,1,EA,1064.63,3671.85,,,3671.85,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.88,,,2232.88,Fee Schedule,Average Sale Price (ASP) x 6,319.39,30,,319.39,percent of total billed charges,Drugs,319.39,30,,319.39,percent of total billed charges,Drugs,319.39,30,,319.39,percent of total billed charges,Drugs,319.39,30,,319.39,percent of total billed charges,Drugs,319.39,30,,319.39,percent of total billed charges,Drugs,532.32,50,,532.32,percent of total billed charges,All Other,319.39,30,,319.39,percent of total billed charges,Drugs,319.39,30,,319.39,percent of total billed charges,Drugs,361.97,34,"If Charge > 500, then 34 percent",361.97,percent of total billed charges,Drugs,319.39,30,,319.39,percent of total billed charges,Drugs,319.39,30,,319.39,percent of total billed charges,Drugs,319.39,30,,319.39,percent of total billed charges,Drugs,319.39,30,,319.39,percent of total billed charges,Drugs,319.39,30,,319.39,percent of total billed charges,Drugs,319.39,30,,319.39,percent of total billed charges,Drugs,319.39,30,,319.39,percent of total billed charges,Drugs,319.39,30,,319.39,percent of total billed charges,Drugs,319.39,30,,319.39,percent of total billed charges,Drugs,319.39,30,,319.39,percent of total billed charges,Drugs,319.39,30,,319.39,percent of total billed charges,Drugs,319.39,30,,319.39,percent of total billed charges,Drugs,319.39,30,,319.39,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,361.97,34,,361.97,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,3572.6,,,3572.6,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,3671.85,
GLUCAGON RECOMBINANT 1 MG INJ   ,J1610,HCPCS,,40504391,CDM,636,RC,63323-0596-16,NDC,both,1,EA,371.63,1858.56,,,1858.56,Other,150% of Medicare + 9.63% HCRA Surcharge,1130.2,,,1130.2,Fee Schedule,Average Sale Price (ASP) x 6,111.49,30,,111.49,percent of total billed charges,Drugs,111.49,30,,111.49,percent of total billed charges,Drugs,111.49,30,,111.49,percent of total billed charges,Drugs,111.49,30,,111.49,percent of total billed charges,Drugs,111.49,30,,111.49,percent of total billed charges,Drugs,185.82,50,,185.82,percent of total billed charges,All Other,111.49,30,,111.49,percent of total billed charges,Drugs,111.49,30,,111.49,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,111.49,30,,111.49,percent of total billed charges,Drugs,111.49,30,,111.49,percent of total billed charges,Drugs,111.49,30,,111.49,percent of total billed charges,Drugs,111.49,30,,111.49,percent of total billed charges,Drugs,111.49,30,,111.49,percent of total billed charges,Drugs,111.49,30,,111.49,percent of total billed charges,Drugs,111.49,30,,111.49,percent of total billed charges,Drugs,111.49,30,,111.49,percent of total billed charges,Drugs,111.49,30,,111.49,percent of total billed charges,Drugs,111.49,30,,111.49,percent of total billed charges,Drugs,111.49,30,,111.49,percent of total billed charges,Drugs,111.49,30,,111.49,percent of total billed charges,Drugs,111.49,30,,111.49,percent of total billed charges,Drugs,162,,,162,Other,Drug Cost,162,,,162,Other,Drug Cost,162,,,162,Other,Drug Cost,162,,,162,Other,Drug Cost,162,,,162,Other,Drug Cost,126.35,34,,126.35,percent of total billed charges,Drugs,162,,,162,Other,Drug Cost,364.5,,,364.5,Other,225% Medicaid APG methodology,226.8,,,226.8,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1808.32,,,1808.32,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",162,,,162,Other,Drug Cost,162,,,162,Other,Drug Cost,202.5,,,202.5,Other,125% Medicaid APG methodology,0.01,1858.56,
HALOPERIDOL 5MG/ML INJ SLN 1ML  ,J1630,HCPCS,,40504417,CDM,636,RC,67457-0426-12,NDC,both,1,ML,2.21,13.97,,,13.97,Other,150% of Medicare + 9.63% HCRA Surcharge,8.5,,,8.5,Fee Schedule,Average Sale Price (ASP) x 6,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,1.11,50,,1.11,percent of total billed charges,All Other,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,0.75,34,,0.75,percent of total billed charges,Drugs,0.56,,,0.56,Other,Drug Cost,1.26,,,1.26,Other,225% Medicaid APG methodology,0.78,,,0.78,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,13.59,,,13.59,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,0.7,,,0.7,Other,125% Medicaid APG methodology,0.01,13.97,
HEPARIN FLUSH 100UNIT/ML IV1ML  ,J1642,HCPCS,,40504433,CDM,636,RC,63323-0545-01,NDC,both,1,ML,5.25,0.16,,,0.16,Other,150% of Medicare + 9.63% HCRA Surcharge,0.1,,,0.1,Fee Schedule,Average Sale Price (ASP) x 6,1.58,30,,1.58,percent of total billed charges,Drugs,1.58,30,,1.58,percent of total billed charges,Drugs,1.58,30,,1.58,percent of total billed charges,Drugs,1.58,30,,1.58,percent of total billed charges,Drugs,1.58,30,,1.58,percent of total billed charges,Drugs,2.63,50,,2.63,percent of total billed charges,All Other,1.58,30,,1.58,percent of total billed charges,Drugs,1.58,30,,1.58,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.58,30,,1.58,percent of total billed charges,Drugs,1.58,30,,1.58,percent of total billed charges,Drugs,1.58,30,,1.58,percent of total billed charges,Drugs,1.58,30,,1.58,percent of total billed charges,Drugs,1.58,30,,1.58,percent of total billed charges,Drugs,1.58,30,,1.58,percent of total billed charges,Drugs,1.58,30,,1.58,percent of total billed charges,Drugs,1.58,30,,1.58,percent of total billed charges,Drugs,1.58,30,,1.58,percent of total billed charges,Drugs,1.58,30,,1.58,percent of total billed charges,Drugs,1.58,30,,1.58,percent of total billed charges,Drugs,1.58,30,,1.58,percent of total billed charges,Drugs,1.58,30,,1.58,percent of total billed charges,Drugs,1.46,,,1.46,Other,Drug Cost,1.46,,,1.46,Other,Drug Cost,1.46,,,1.46,Other,Drug Cost,1.46,,,1.46,Other,Drug Cost,1.46,,,1.46,Other,Drug Cost,1.79,34,,1.79,percent of total billed charges,Drugs,1.46,,,1.46,Other,Drug Cost,3.29,,,3.29,Other,225% Medicaid APG methodology,2.04,,,2.04,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.15,,,0.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.46,,,1.46,Other,Drug Cost,1.46,,,1.46,Other,Drug Cost,1.83,,,1.83,Other,125% Medicaid APG methodology,0.01,3.29,
FONDAPARINUX 2.5MG/0.5ML SOLN   ,J1652,HCPCS,,40504458,CDM,636,RC,67457-0592-10,NDC,both,0.5,ML,132.97,10.78,,,10.78,Other,150% of Medicare + 9.63% HCRA Surcharge,6.56,,,6.56,Fee Schedule,Average Sale Price (ASP) x 6,39.89,30,,39.89,percent of total billed charges,Drugs,39.89,30,,39.89,percent of total billed charges,Drugs,39.89,30,,39.89,percent of total billed charges,Drugs,39.89,30,,39.89,percent of total billed charges,Drugs,39.89,30,,39.89,percent of total billed charges,Drugs,66.49,50,,66.49,percent of total billed charges,All Other,39.89,30,,39.89,percent of total billed charges,Drugs,39.89,30,,39.89,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,39.89,30,,39.89,percent of total billed charges,Drugs,39.89,30,,39.89,percent of total billed charges,Drugs,39.89,30,,39.89,percent of total billed charges,Drugs,39.89,30,,39.89,percent of total billed charges,Drugs,39.89,30,,39.89,percent of total billed charges,Drugs,39.89,30,,39.89,percent of total billed charges,Drugs,39.89,30,,39.89,percent of total billed charges,Drugs,39.89,30,,39.89,percent of total billed charges,Drugs,39.89,30,,39.89,percent of total billed charges,Drugs,39.89,30,,39.89,percent of total billed charges,Drugs,39.89,30,,39.89,percent of total billed charges,Drugs,39.89,30,,39.89,percent of total billed charges,Drugs,39.89,30,,39.89,percent of total billed charges,Drugs,4.97,,,4.97,Other,Drug Cost,4.97,,,4.97,Other,Drug Cost,4.97,,,4.97,Other,Drug Cost,4.97,,,4.97,Other,Drug Cost,4.97,,,4.97,Other,Drug Cost,45.21,34,,45.21,percent of total billed charges,Drugs,4.97,,,4.97,Other,Drug Cost,11.18,,,11.18,Other,225% Medicaid APG methodology,6.96,,,6.96,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,10.49,,,10.49,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.97,,,4.97,Other,Drug Cost,4.97,,,4.97,Other,Drug Cost,6.21,,,6.21,Other,125% Medicaid APG methodology,0.01,66.49,
MANNITOL 25% IV SOLN 50 ML      ,J2150,HCPCS,,40504482,CDM,636,RC,63323-0024-25,NDC,both,50,ML,15.82,25.6,,,25.6,Other,150% of Medicare + 9.63% HCRA Surcharge,15.57,,,15.57,Fee Schedule,Average Sale Price (ASP) x 6,4.75,30,,4.75,percent of total billed charges,Drugs,4.75,30,,4.75,percent of total billed charges,Drugs,4.75,30,,4.75,percent of total billed charges,Drugs,4.75,30,,4.75,percent of total billed charges,Drugs,4.75,30,,4.75,percent of total billed charges,Drugs,7.91,50,,7.91,percent of total billed charges,All Other,4.75,30,,4.75,percent of total billed charges,Drugs,4.75,30,,4.75,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.75,30,,4.75,percent of total billed charges,Drugs,4.75,30,,4.75,percent of total billed charges,Drugs,4.75,30,,4.75,percent of total billed charges,Drugs,4.75,30,,4.75,percent of total billed charges,Drugs,4.75,30,,4.75,percent of total billed charges,Drugs,4.75,30,,4.75,percent of total billed charges,Drugs,4.75,30,,4.75,percent of total billed charges,Drugs,4.75,30,,4.75,percent of total billed charges,Drugs,4.75,30,,4.75,percent of total billed charges,Drugs,4.75,30,,4.75,percent of total billed charges,Drugs,4.75,30,,4.75,percent of total billed charges,Drugs,4.75,30,,4.75,percent of total billed charges,Drugs,4.75,30,,4.75,percent of total billed charges,Drugs,2.2,,,2.2,Other,Drug Cost,2.2,,,2.2,Other,Drug Cost,2.2,,,2.2,Other,Drug Cost,2.2,,,2.2,Other,Drug Cost,2.2,,,2.2,Other,Drug Cost,5.38,34,,5.38,percent of total billed charges,Drugs,2.2,,,2.2,Other,Drug Cost,4.95,,,4.95,Other,225% Medicaid APG methodology,3.08,,,3.08,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,24.91,,,24.91,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.2,,,2.2,Other,Drug Cost,2.2,,,2.2,Other,Drug Cost,2.75,,,2.75,Other,125% Medicaid APG methodology,0.01,25.6,
OXYTOCIN 10 UNITS/ML INJ  1ML   ,J2590,HCPCS,,40504573,CDM,636,RC,63323-0012-07,NDC,both,1,ML,3.26,1.29,39.4668,,1.29,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,1.63,50,,1.63,percent of total billed charges,All Other,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.11,34,,1.11,percent of total billed charges,Drugs,1.5,,,1.5,Other,Drug Cost,3.38,,,3.38,Other,225% Medicaid APG methodology,2.1,,,2.1,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.5,,,1.5,Other,Drug Cost,1.5,,,1.5,Other,Drug Cost,1.88,,,1.88,Other,125% Medicaid APG methodology,0.01,3.38,
DESMOPRESSIN SUBQ 4 MCG/ML      ,J2597,HCPCS,,40504581,CDM,636,RC,65219-0293-01,NDC,both,1,ML,47.92,62.44,,,62.44,Other,150% of Medicare + 9.63% HCRA Surcharge,37.97,,,37.97,Fee Schedule,Average Sale Price (ASP) x 6,14.38,30,,14.38,percent of total billed charges,Drugs,14.38,30,,14.38,percent of total billed charges,Drugs,14.38,30,,14.38,percent of total billed charges,Drugs,14.38,30,,14.38,percent of total billed charges,Drugs,14.38,30,,14.38,percent of total billed charges,Drugs,23.96,50,,23.96,percent of total billed charges,All Other,14.38,30,,14.38,percent of total billed charges,Drugs,14.38,30,,14.38,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,14.38,30,,14.38,percent of total billed charges,Drugs,14.38,30,,14.38,percent of total billed charges,Drugs,14.38,30,,14.38,percent of total billed charges,Drugs,14.38,30,,14.38,percent of total billed charges,Drugs,14.38,30,,14.38,percent of total billed charges,Drugs,14.38,30,,14.38,percent of total billed charges,Drugs,14.38,30,,14.38,percent of total billed charges,Drugs,14.38,30,,14.38,percent of total billed charges,Drugs,14.38,30,,14.38,percent of total billed charges,Drugs,14.38,30,,14.38,percent of total billed charges,Drugs,14.38,30,,14.38,percent of total billed charges,Drugs,14.38,30,,14.38,percent of total billed charges,Drugs,14.38,30,,14.38,percent of total billed charges,Drugs,6.41,,,6.41,Other,Drug Cost,6.41,,,6.41,Other,Drug Cost,6.41,,,6.41,Other,Drug Cost,6.41,,,6.41,Other,Drug Cost,6.41,,,6.41,Other,Drug Cost,16.29,34,,16.29,percent of total billed charges,Drugs,6.41,,,6.41,Other,Drug Cost,14.42,,,14.42,Other,225% Medicaid APG methodology,8.97,,,8.97,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,60.75,,,60.75,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6.41,,,6.41,Other,Drug Cost,6.41,,,6.41,Other,Drug Cost,8.01,,,8.01,Other,125% Medicaid APG methodology,0.01,62.44,
FLUPHENAZINE DECAN 25MG/ML 5ML  ,J2680,HCPCS,,40504607,CDM,636,RC,00143-9529-01,NDC,both,5,ML,200.34,90.28,,,90.28,Other,150% of Medicare + 9.63% HCRA Surcharge,54.9,,,54.9,Fee Schedule,Average Sale Price (ASP) x 6,60.1,30,,60.1,percent of total billed charges,Drugs,60.1,30,,60.1,percent of total billed charges,Drugs,60.1,30,,60.1,percent of total billed charges,Drugs,60.1,30,,60.1,percent of total billed charges,Drugs,60.1,30,,60.1,percent of total billed charges,Drugs,100.17,50,,100.17,percent of total billed charges,All Other,60.1,30,,60.1,percent of total billed charges,Drugs,60.1,30,,60.1,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,60.1,30,,60.1,percent of total billed charges,Drugs,60.1,30,,60.1,percent of total billed charges,Drugs,60.1,30,,60.1,percent of total billed charges,Drugs,60.1,30,,60.1,percent of total billed charges,Drugs,60.1,30,,60.1,percent of total billed charges,Drugs,60.1,30,,60.1,percent of total billed charges,Drugs,60.1,30,,60.1,percent of total billed charges,Drugs,60.1,30,,60.1,percent of total billed charges,Drugs,60.1,30,,60.1,percent of total billed charges,Drugs,60.1,30,,60.1,percent of total billed charges,Drugs,60.1,30,,60.1,percent of total billed charges,Drugs,60.1,30,,60.1,percent of total billed charges,Drugs,60.1,30,,60.1,percent of total billed charges,Drugs,45.7,,,45.7,Other,Drug Cost,45.7,,,45.7,Other,Drug Cost,45.7,,,45.7,Other,Drug Cost,45.7,,,45.7,Other,Drug Cost,45.7,,,45.7,Other,Drug Cost,68.12,34,,68.12,percent of total billed charges,Drugs,45.7,,,45.7,Other,Drug Cost,102.83,,,102.83,Other,225% Medicaid APG methodology,63.98,,,63.98,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,87.84,,,87.84,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",45.7,,,45.7,Other,Drug Cost,45.7,,,45.7,Other,Drug Cost,57.13,,,57.13,Other,125% Medicaid APG methodology,0.01,102.83,
PROCAINAMIDE 1000MG/10ML INJ    ,J2690,HCPCS,,40504615,CDM,636,RC,00409-1902-01,NDC,both,10,ML,192.29,1443.67,,,1443.67,Other,150% of Medicare + 9.63% HCRA Surcharge,877.9,,,877.9,Fee Schedule,Average Sale Price (ASP) x 6,57.69,30,,57.69,percent of total billed charges,Drugs,57.69,30,,57.69,percent of total billed charges,Drugs,57.69,30,,57.69,percent of total billed charges,Drugs,57.69,30,,57.69,percent of total billed charges,Drugs,57.69,30,,57.69,percent of total billed charges,Drugs,96.15,50,,96.15,percent of total billed charges,All Other,57.69,30,,57.69,percent of total billed charges,Drugs,57.69,30,,57.69,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,57.69,30,,57.69,percent of total billed charges,Drugs,57.69,30,,57.69,percent of total billed charges,Drugs,57.69,30,,57.69,percent of total billed charges,Drugs,57.69,30,,57.69,percent of total billed charges,Drugs,57.69,30,,57.69,percent of total billed charges,Drugs,57.69,30,,57.69,percent of total billed charges,Drugs,57.69,30,,57.69,percent of total billed charges,Drugs,57.69,30,,57.69,percent of total billed charges,Drugs,57.69,30,,57.69,percent of total billed charges,Drugs,57.69,30,,57.69,percent of total billed charges,Drugs,57.69,30,,57.69,percent of total billed charges,Drugs,57.69,30,,57.69,percent of total billed charges,Drugs,57.69,30,,57.69,percent of total billed charges,Drugs,52.31,,,52.31,Other,Drug Cost,52.31,,,52.31,Other,Drug Cost,52.31,,,52.31,Other,Drug Cost,52.31,,,52.31,Other,Drug Cost,52.31,,,52.31,Other,Drug Cost,65.38,34,,65.38,percent of total billed charges,Drugs,52.31,,,52.31,Other,Drug Cost,117.7,,,117.7,Other,225% Medicaid APG methodology,73.23,,,73.23,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1404.64,,,1404.64,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",52.31,,,52.31,Other,Drug Cost,52.31,,,52.31,Other,Drug Cost,65.39,,,65.39,Other,125% Medicaid APG methodology,0.01,1443.67,
PHENTOLAMINE 5 MG INJ           ,J2760,HCPCS,,40504631,CDM,636,RC,00143-9564-01,NDC,both,1,EA,1378.02,4408.41,,,4408.41,Other,150% of Medicare + 9.63% HCRA Surcharge,2680.78,,,2680.78,Fee Schedule,Average Sale Price (ASP) x 6,413.41,30,,413.41,percent of total billed charges,Drugs,413.41,30,,413.41,percent of total billed charges,Drugs,413.41,30,,413.41,percent of total billed charges,Drugs,413.41,30,,413.41,percent of total billed charges,Drugs,413.41,30,,413.41,percent of total billed charges,Drugs,689.01,50,,689.01,percent of total billed charges,All Other,413.41,30,,413.41,percent of total billed charges,Drugs,413.41,30,,413.41,percent of total billed charges,Drugs,468.53,34,"If Charge > 500, then 34 percent",468.53,percent of total billed charges,Drugs,413.41,30,,413.41,percent of total billed charges,Drugs,413.41,30,,413.41,percent of total billed charges,Drugs,413.41,30,,413.41,percent of total billed charges,Drugs,413.41,30,,413.41,percent of total billed charges,Drugs,413.41,30,,413.41,percent of total billed charges,Drugs,413.41,30,,413.41,percent of total billed charges,Drugs,413.41,30,,413.41,percent of total billed charges,Drugs,413.41,30,,413.41,percent of total billed charges,Drugs,413.41,30,,413.41,percent of total billed charges,Drugs,413.41,30,,413.41,percent of total billed charges,Drugs,413.41,30,,413.41,percent of total billed charges,Drugs,413.41,30,,413.41,percent of total billed charges,Drugs,413.41,30,,413.41,percent of total billed charges,Drugs,289.79,,,289.79,Other,Drug Cost,289.79,,,289.79,Other,Drug Cost,289.79,,,289.79,Other,Drug Cost,289.79,,,289.79,Other,Drug Cost,289.79,,,289.79,Other,Drug Cost,468.53,34,,468.53,percent of total billed charges,Drugs,289.79,,,289.79,Other,Drug Cost,652.03,,,652.03,Other,225% Medicaid APG methodology,405.71,,,405.71,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,4289.25,,,4289.25,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",289.79,,,289.79,Other,Drug Cost,289.79,,,289.79,Other,Drug Cost,362.24,,,362.24,Other,125% Medicaid APG methodology,0.01,4408.41,
"STREPTOMYCIN INJ, 1GM, P1GM     ",J3000,HCPCS,,40504706,CDM,636,RC,39822-0706-02,NDC,both,1,EA,244.02,320.83,,,320.83,Other,150% of Medicare + 9.63% HCRA Surcharge,195.1,,,195.1,Fee Schedule,Average Sale Price (ASP) x 6,73.21,30,,73.21,percent of total billed charges,Drugs,73.21,30,,73.21,percent of total billed charges,Drugs,73.21,30,,73.21,percent of total billed charges,Drugs,73.21,30,,73.21,percent of total billed charges,Drugs,73.21,30,,73.21,percent of total billed charges,Drugs,122.01,50,,122.01,percent of total billed charges,All Other,73.21,30,,73.21,percent of total billed charges,Drugs,73.21,30,,73.21,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,73.21,30,,73.21,percent of total billed charges,Drugs,73.21,30,,73.21,percent of total billed charges,Drugs,73.21,30,,73.21,percent of total billed charges,Drugs,73.21,30,,73.21,percent of total billed charges,Drugs,73.21,30,,73.21,percent of total billed charges,Drugs,73.21,30,,73.21,percent of total billed charges,Drugs,73.21,30,,73.21,percent of total billed charges,Drugs,73.21,30,,73.21,percent of total billed charges,Drugs,73.21,30,,73.21,percent of total billed charges,Drugs,73.21,30,,73.21,percent of total billed charges,Drugs,73.21,30,,73.21,percent of total billed charges,Drugs,73.21,30,,73.21,percent of total billed charges,Drugs,73.21,30,,73.21,percent of total billed charges,Drugs,9.05,,,9.05,Other,Drug Cost,9.05,,,9.05,Other,Drug Cost,9.05,,,9.05,Other,Drug Cost,9.05,,,9.05,Other,Drug Cost,9.05,,,9.05,Other,Drug Cost,82.97,34,,82.97,percent of total billed charges,Drugs,9.05,,,9.05,Other,Drug Cost,20.36,,,20.36,Other,225% Medicaid APG methodology,12.67,,,12.67,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,312.15,,,312.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",9.05,,,9.05,Other,Drug Cost,9.05,,,9.05,Other,Drug Cost,11.31,,,11.31,Other,125% Medicaid APG methodology,0.01,320.83,
SUMATRPTAN 6MG/0.5ML SUBQ0.5ML  ,J3030,HCPCS,,40504722,CDM,636,RC,55150-0173-01,NDC,both,0.5,ML,16.1,6.35,39.4668,,6.35,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,4.83,30,,4.83,percent of total billed charges,Drugs,4.83,30,,4.83,percent of total billed charges,Drugs,4.83,30,,4.83,percent of total billed charges,Drugs,4.83,30,,4.83,percent of total billed charges,Drugs,4.83,30,,4.83,percent of total billed charges,Drugs,8.05,50,,8.05,percent of total billed charges,All Other,4.83,30,,4.83,percent of total billed charges,Drugs,4.83,30,,4.83,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.83,30,,4.83,percent of total billed charges,Drugs,4.83,30,,4.83,percent of total billed charges,Drugs,4.83,30,,4.83,percent of total billed charges,Drugs,4.83,30,,4.83,percent of total billed charges,Drugs,4.83,30,,4.83,percent of total billed charges,Drugs,4.83,30,,4.83,percent of total billed charges,Drugs,4.83,30,,4.83,percent of total billed charges,Drugs,4.83,30,,4.83,percent of total billed charges,Drugs,4.83,30,,4.83,percent of total billed charges,Drugs,4.83,30,,4.83,percent of total billed charges,Drugs,4.83,30,,4.83,percent of total billed charges,Drugs,4.83,30,,4.83,percent of total billed charges,Drugs,4.83,30,,4.83,percent of total billed charges,Drugs,3.01,,,3.01,Other,Drug Cost,3.01,,,3.01,Other,Drug Cost,3.01,,,3.01,Other,Drug Cost,3.01,,,3.01,Other,Drug Cost,3.01,,,3.01,Other,Drug Cost,5.47,34,,5.47,percent of total billed charges,Drugs,3.01,,,3.01,Other,Drug Cost,6.77,,,6.77,Other,225% Medicaid APG methodology,4.21,,,4.21,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.01,,,3.01,Other,Drug Cost,3.01,,,3.01,Other,Drug Cost,3.76,,,3.76,Other,125% Medicaid APG methodology,0.01,8.05,
TOBRAMYCIN 40MG/ML INJ SLN 2ML  ,J3260,HCPCS,,40504763,CDM,636,RC,67457-0473-22,NDC,both,2,ML,6.44,26.28,,,26.28,Other,150% of Medicare + 9.63% HCRA Surcharge,15.98,,,15.98,Fee Schedule,Average Sale Price (ASP) x 6,1.93,30,,1.93,percent of total billed charges,Drugs,1.93,30,,1.93,percent of total billed charges,Drugs,1.93,30,,1.93,percent of total billed charges,Drugs,1.93,30,,1.93,percent of total billed charges,Drugs,1.93,30,,1.93,percent of total billed charges,Drugs,3.22,50,,3.22,percent of total billed charges,All Other,1.93,30,,1.93,percent of total billed charges,Drugs,1.93,30,,1.93,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.93,30,,1.93,percent of total billed charges,Drugs,1.93,30,,1.93,percent of total billed charges,Drugs,1.93,30,,1.93,percent of total billed charges,Drugs,1.93,30,,1.93,percent of total billed charges,Drugs,1.93,30,,1.93,percent of total billed charges,Drugs,1.93,30,,1.93,percent of total billed charges,Drugs,1.93,30,,1.93,percent of total billed charges,Drugs,1.93,30,,1.93,percent of total billed charges,Drugs,1.93,30,,1.93,percent of total billed charges,Drugs,1.93,30,,1.93,percent of total billed charges,Drugs,1.93,30,,1.93,percent of total billed charges,Drugs,1.93,30,,1.93,percent of total billed charges,Drugs,1.93,30,,1.93,percent of total billed charges,Drugs,0.71,,,0.71,Other,Drug Cost,0.71,,,0.71,Other,Drug Cost,0.71,,,0.71,Other,Drug Cost,0.71,,,0.71,Other,Drug Cost,0.71,,,0.71,Other,Drug Cost,2.19,34,,2.19,percent of total billed charges,Drugs,0.71,,,0.71,Other,Drug Cost,1.6,,,1.6,Other,225% Medicaid APG methodology,0.99,,,0.99,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,25.57,,,25.57,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.71,,,0.71,Other,Drug Cost,0.71,,,0.71,Other,Drug Cost,0.89,,,0.89,Other,125% Medicaid APG methodology,0.01,26.28,
DIAZEPAM 5MG/ML INJ 2ML SYR     ,J3360,HCPCS,,40504789,CDM,636,RC,00409-1273-32,NDC,both,2,ML,77.42,53.92,,,53.92,Other,150% of Medicare + 9.63% HCRA Surcharge,32.79,,,32.79,Fee Schedule,Average Sale Price (ASP) x 6,23.23,30,,23.23,percent of total billed charges,Drugs,23.23,30,,23.23,percent of total billed charges,Drugs,23.23,30,,23.23,percent of total billed charges,Drugs,23.23,30,,23.23,percent of total billed charges,Drugs,23.23,30,,23.23,percent of total billed charges,Drugs,38.71,50,,38.71,percent of total billed charges,All Other,23.23,30,,23.23,percent of total billed charges,Drugs,23.23,30,,23.23,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,23.23,30,,23.23,percent of total billed charges,Drugs,23.23,30,,23.23,percent of total billed charges,Drugs,23.23,30,,23.23,percent of total billed charges,Drugs,23.23,30,,23.23,percent of total billed charges,Drugs,23.23,30,,23.23,percent of total billed charges,Drugs,23.23,30,,23.23,percent of total billed charges,Drugs,23.23,30,,23.23,percent of total billed charges,Drugs,23.23,30,,23.23,percent of total billed charges,Drugs,23.23,30,,23.23,percent of total billed charges,Drugs,23.23,30,,23.23,percent of total billed charges,Drugs,23.23,30,,23.23,percent of total billed charges,Drugs,23.23,30,,23.23,percent of total billed charges,Drugs,23.23,30,,23.23,percent of total billed charges,Drugs,7.56,,,7.56,Other,Drug Cost,7.56,,,7.56,Other,Drug Cost,7.56,,,7.56,Other,Drug Cost,7.56,,,7.56,Other,Drug Cost,7.56,,,7.56,Other,Drug Cost,26.32,34,,26.32,percent of total billed charges,Drugs,7.56,,,7.56,Other,Drug Cost,17.01,,,17.01,Other,225% Medicaid APG methodology,10.58,,,10.58,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,52.46,,,52.46,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",7.56,,,7.56,Other,Drug Cost,7.56,,,7.56,Other,Drug Cost,9.45,,,9.45,Other,125% Medicaid APG methodology,0.01,53.92,
THIAMINE 100MG/ML INJ SOLN 2ML  ,J3411,HCPCS,,40504813,CDM,636,RC,72485-0507-25,NDC,both,2,ML,12.25,24.25,,,24.25,Other,150% of Medicare + 9.63% HCRA Surcharge,14.75,,,14.75,Fee Schedule,Average Sale Price (ASP) x 6,3.68,30,,3.68,percent of total billed charges,Drugs,3.68,30,,3.68,percent of total billed charges,Drugs,3.68,30,,3.68,percent of total billed charges,Drugs,3.68,30,,3.68,percent of total billed charges,Drugs,3.68,30,,3.68,percent of total billed charges,Drugs,6.13,50,,6.13,percent of total billed charges,All Other,3.68,30,,3.68,percent of total billed charges,Drugs,3.68,30,,3.68,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.68,30,,3.68,percent of total billed charges,Drugs,3.68,30,,3.68,percent of total billed charges,Drugs,3.68,30,,3.68,percent of total billed charges,Drugs,3.68,30,,3.68,percent of total billed charges,Drugs,3.68,30,,3.68,percent of total billed charges,Drugs,3.68,30,,3.68,percent of total billed charges,Drugs,3.68,30,,3.68,percent of total billed charges,Drugs,3.68,30,,3.68,percent of total billed charges,Drugs,3.68,30,,3.68,percent of total billed charges,Drugs,3.68,30,,3.68,percent of total billed charges,Drugs,3.68,30,,3.68,percent of total billed charges,Drugs,3.68,30,,3.68,percent of total billed charges,Drugs,3.68,30,,3.68,percent of total billed charges,Drugs,2.97,,,2.97,Other,Drug Cost,2.97,,,2.97,Other,Drug Cost,2.97,,,2.97,Other,Drug Cost,2.97,,,2.97,Other,Drug Cost,2.97,,,2.97,Other,Drug Cost,4.17,34,,4.17,percent of total billed charges,Drugs,2.97,,,2.97,Other,Drug Cost,6.68,,,6.68,Other,225% Medicaid APG methodology,4.16,,,4.16,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,23.6,,,23.6,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.97,,,2.97,Other,Drug Cost,2.97,,,2.97,Other,Drug Cost,3.71,,,3.71,Other,125% Medicaid APG methodology,0.01,24.25,
PYRIDOXINE 100MG/ML INJ  1ML    ,J3415,HCPCS,,40504821,CDM,636,RC,63323-0180-01,NDC,both,1,ML,25.03,146.27,,,146.27,Other,150% of Medicare + 9.63% HCRA Surcharge,88.95,,,88.95,Fee Schedule,Average Sale Price (ASP) x 6,7.51,30,,7.51,percent of total billed charges,Drugs,7.51,30,,7.51,percent of total billed charges,Drugs,7.51,30,,7.51,percent of total billed charges,Drugs,7.51,30,,7.51,percent of total billed charges,Drugs,7.51,30,,7.51,percent of total billed charges,Drugs,12.52,50,,12.52,percent of total billed charges,All Other,7.51,30,,7.51,percent of total billed charges,Drugs,7.51,30,,7.51,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,7.51,30,,7.51,percent of total billed charges,Drugs,7.51,30,,7.51,percent of total billed charges,Drugs,7.51,30,,7.51,percent of total billed charges,Drugs,7.51,30,,7.51,percent of total billed charges,Drugs,7.51,30,,7.51,percent of total billed charges,Drugs,7.51,30,,7.51,percent of total billed charges,Drugs,7.51,30,,7.51,percent of total billed charges,Drugs,7.51,30,,7.51,percent of total billed charges,Drugs,7.51,30,,7.51,percent of total billed charges,Drugs,7.51,30,,7.51,percent of total billed charges,Drugs,7.51,30,,7.51,percent of total billed charges,Drugs,7.51,30,,7.51,percent of total billed charges,Drugs,7.51,30,,7.51,percent of total billed charges,Drugs,6.18,,,6.18,Other,Drug Cost,6.18,,,6.18,Other,Drug Cost,6.18,,,6.18,Other,Drug Cost,6.18,,,6.18,Other,Drug Cost,6.18,,,6.18,Other,Drug Cost,8.51,34,,8.51,percent of total billed charges,Drugs,6.18,,,6.18,Other,Drug Cost,13.91,,,13.91,Other,225% Medicaid APG methodology,8.65,,,8.65,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,142.32,,,142.32,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6.18,,,6.18,Other,Drug Cost,6.18,,,6.18,Other,Drug Cost,7.73,,,7.73,Other,125% Medicaid APG methodology,0.01,146.27,
CYANOCOBALAMIN 1000 MCG/ML INJ  ,J3420,HCPCS,,40504839,CDM,636,RC,71288-0303-02,NDC,both,1,ML,3.08,14.24,,,14.24,Other,150% of Medicare + 9.63% HCRA Surcharge,8.66,,,8.66,Fee Schedule,Average Sale Price (ASP) x 6,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,1.54,50,,1.54,percent of total billed charges,All Other,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,1.27,,,1.27,Other,Drug Cost,1.27,,,1.27,Other,Drug Cost,1.27,,,1.27,Other,Drug Cost,1.27,,,1.27,Other,Drug Cost,1.27,,,1.27,Other,Drug Cost,1.05,34,,1.05,percent of total billed charges,Drugs,1.27,,,1.27,Other,Drug Cost,2.86,,,2.86,Other,225% Medicaid APG methodology,1.78,,,1.78,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,13.85,,,13.85,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.27,,,1.27,Other,Drug Cost,1.27,,,1.27,Other,Drug Cost,1.59,,,1.59,Other,125% Medicaid APG methodology,0.01,14.24,
HYALURONIDASE 150 UNITS/ML INJ  ,J3473,HCPCS,,40504847,CDM,636,RC,18657-0117-04,NDC,both,1,ML,130.38,3.56,,,3.56,Other,150% of Medicare + 9.63% HCRA Surcharge,2.17,,,2.17,Fee Schedule,Average Sale Price (ASP) x 6,39.11,30,,39.11,percent of total billed charges,Drugs,39.11,30,,39.11,percent of total billed charges,Drugs,39.11,30,,39.11,percent of total billed charges,Drugs,39.11,30,,39.11,percent of total billed charges,Drugs,39.11,30,,39.11,percent of total billed charges,Drugs,65.19,50,,65.19,percent of total billed charges,All Other,39.11,30,,39.11,percent of total billed charges,Drugs,39.11,30,,39.11,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,39.11,30,,39.11,percent of total billed charges,Drugs,39.11,30,,39.11,percent of total billed charges,Drugs,39.11,30,,39.11,percent of total billed charges,Drugs,39.11,30,,39.11,percent of total billed charges,Drugs,39.11,30,,39.11,percent of total billed charges,Drugs,39.11,30,,39.11,percent of total billed charges,Drugs,39.11,30,,39.11,percent of total billed charges,Drugs,39.11,30,,39.11,percent of total billed charges,Drugs,39.11,30,,39.11,percent of total billed charges,Drugs,39.11,30,,39.11,percent of total billed charges,Drugs,39.11,30,,39.11,percent of total billed charges,Drugs,39.11,30,,39.11,percent of total billed charges,Drugs,39.11,30,,39.11,percent of total billed charges,Drugs,36.44,,,36.44,Other,Drug Cost,36.44,,,36.44,Other,Drug Cost,36.44,,,36.44,Other,Drug Cost,36.44,,,36.44,Other,Drug Cost,36.44,,,36.44,Other,Drug Cost,44.33,34,,44.33,percent of total billed charges,Drugs,36.44,,,36.44,Other,Drug Cost,81.99,,,81.99,Other,225% Medicaid APG methodology,51.02,,,51.02,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,3.47,,,3.47,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",36.44,,,36.44,Other,Drug Cost,36.44,,,36.44,Other,Drug Cost,45.55,,,45.55,Other,125% Medicaid APG methodology,0.01,81.99,
ZIDOVUDINE 10MG/ML IV SLN 20ML  ,J3485,HCPCS,,40504862,CDM,636,RC,49702-0213-26,NDC,both,20,ML,99.61,14.91,,,14.91,Other,150% of Medicare + 9.63% HCRA Surcharge,9.07,,,9.07,Fee Schedule,Average Sale Price (ASP) x 6,29.88,30,,29.88,percent of total billed charges,Drugs,29.88,30,,29.88,percent of total billed charges,Drugs,29.88,30,,29.88,percent of total billed charges,Drugs,29.88,30,,29.88,percent of total billed charges,Drugs,29.88,30,,29.88,percent of total billed charges,Drugs,49.81,50,,49.81,percent of total billed charges,All Other,29.88,30,,29.88,percent of total billed charges,Drugs,29.88,30,,29.88,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,29.88,30,,29.88,percent of total billed charges,Drugs,29.88,30,,29.88,percent of total billed charges,Drugs,29.88,30,,29.88,percent of total billed charges,Drugs,29.88,30,,29.88,percent of total billed charges,Drugs,29.88,30,,29.88,percent of total billed charges,Drugs,29.88,30,,29.88,percent of total billed charges,Drugs,29.88,30,,29.88,percent of total billed charges,Drugs,29.88,30,,29.88,percent of total billed charges,Drugs,29.88,30,,29.88,percent of total billed charges,Drugs,29.88,30,,29.88,percent of total billed charges,Drugs,29.88,30,,29.88,percent of total billed charges,Drugs,29.88,30,,29.88,percent of total billed charges,Drugs,29.88,30,,29.88,percent of total billed charges,Drugs,17.87,,,17.87,Other,Drug Cost,17.87,,,17.87,Other,Drug Cost,17.87,,,17.87,Other,Drug Cost,17.87,,,17.87,Other,Drug Cost,17.87,,,17.87,Other,Drug Cost,33.87,34,,33.87,percent of total billed charges,Drugs,17.87,,,17.87,Other,Drug Cost,40.21,,,40.21,Other,225% Medicaid APG methodology,25.02,,,25.02,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,14.51,,,14.51,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",17.87,,,17.87,Other,Drug Cost,17.87,,,17.87,Other,Drug Cost,22.34,,,22.34,Other,125% Medicaid APG methodology,0.01,49.81,
TACROLIMUS 5MG/ML IV SOLN 1ML   ,J7525,HCPCS,,40504896,CDM,636,RC,00469-3016-01,NDC,both,1,ML,278.71,2454.19,,,2454.19,Other,150% of Medicare + 9.63% HCRA Surcharge,1492.41,,,1492.41,Fee Schedule,Average Sale Price (ASP) x 6,83.61,30,,83.61,percent of total billed charges,Drugs,83.61,30,,83.61,percent of total billed charges,Drugs,83.61,30,,83.61,percent of total billed charges,Drugs,83.61,30,,83.61,percent of total billed charges,Drugs,83.61,30,,83.61,percent of total billed charges,Drugs,139.36,50,,139.36,percent of total billed charges,All Other,83.61,30,,83.61,percent of total billed charges,Drugs,83.61,30,,83.61,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,83.61,30,,83.61,percent of total billed charges,Drugs,83.61,30,,83.61,percent of total billed charges,Drugs,83.61,30,,83.61,percent of total billed charges,Drugs,83.61,30,,83.61,percent of total billed charges,Drugs,83.61,30,,83.61,percent of total billed charges,Drugs,83.61,30,,83.61,percent of total billed charges,Drugs,83.61,30,,83.61,percent of total billed charges,Drugs,83.61,30,,83.61,percent of total billed charges,Drugs,83.61,30,,83.61,percent of total billed charges,Drugs,83.61,30,,83.61,percent of total billed charges,Drugs,83.61,30,,83.61,percent of total billed charges,Drugs,83.61,30,,83.61,percent of total billed charges,Drugs,83.61,30,,83.61,percent of total billed charges,Drugs,194.79,,,194.79,Other,Drug Cost,194.79,,,194.79,Other,Drug Cost,194.79,,,194.79,Other,Drug Cost,194.79,,,194.79,Other,Drug Cost,194.79,,,194.79,Other,Drug Cost,94.76,34,,94.76,percent of total billed charges,Drugs,194.79,,,194.79,Other,Drug Cost,438.28,,,438.28,Other,225% Medicaid APG methodology,272.71,,,272.71,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2387.86,,,2387.86,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",194.79,,,194.79,Other,Drug Cost,194.79,,,194.79,Other,Drug Cost,243.49,,,243.49,Other,125% Medicaid APG methodology,0.01,2454.19,
FLUTICASONE-SALMETE 250-50 INH  ,J3535,HCPCS,,40505000,CDM,636,RC,00378-9321-32,NDC,both,1,EA,378.81,149.5,39.4668,,149.5,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,113.64,30,,113.64,percent of total billed charges,Drugs,113.64,30,,113.64,percent of total billed charges,Drugs,113.64,30,,113.64,percent of total billed charges,Drugs,113.64,30,,113.64,percent of total billed charges,Drugs,113.64,30,,113.64,percent of total billed charges,Drugs,189.41,50,,189.41,percent of total billed charges,All Other,113.64,30,,113.64,percent of total billed charges,Drugs,113.64,30,,113.64,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,113.64,30,,113.64,percent of total billed charges,Drugs,113.64,30,,113.64,percent of total billed charges,Drugs,113.64,30,,113.64,percent of total billed charges,Drugs,113.64,30,,113.64,percent of total billed charges,Drugs,113.64,30,,113.64,percent of total billed charges,Drugs,113.64,30,,113.64,percent of total billed charges,Drugs,113.64,30,,113.64,percent of total billed charges,Drugs,113.64,30,,113.64,percent of total billed charges,Drugs,113.64,30,,113.64,percent of total billed charges,Drugs,113.64,30,,113.64,percent of total billed charges,Drugs,113.64,30,,113.64,percent of total billed charges,Drugs,113.64,30,,113.64,percent of total billed charges,Drugs,113.64,30,,113.64,percent of total billed charges,Drugs,67.68,,,67.68,Other,Drug Cost,67.68,,,67.68,Other,Drug Cost,67.68,,,67.68,Other,Drug Cost,67.68,,,67.68,Other,Drug Cost,67.68,,,67.68,Other,Drug Cost,128.8,34,,128.8,percent of total billed charges,Drugs,67.68,,,67.68,Other,Drug Cost,152.28,,,152.28,Other,225% Medicaid APG methodology,94.75,,,94.75,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",67.68,,,67.68,Other,Drug Cost,67.68,,,67.68,Other,Drug Cost,84.6,,,84.6,Other,125% Medicaid APG methodology,0.01,189.41,
CEFAZOLIN 2000 MG INJ           ,J0690,HCPCS,,40505216,CDM,636,RC,60505-6231-05,NDC,both,1,EA,14.35,7.53,,,7.53,Other,150% of Medicare + 9.63% HCRA Surcharge,4.58,,,4.58,Fee Schedule,Average Sale Price (ASP) x 6,4.31,30,,4.31,percent of total billed charges,Drugs,4.31,30,,4.31,percent of total billed charges,Drugs,4.31,30,,4.31,percent of total billed charges,Drugs,4.31,30,,4.31,percent of total billed charges,Drugs,4.31,30,,4.31,percent of total billed charges,Drugs,7.18,50,,7.18,percent of total billed charges,All Other,4.31,30,,4.31,percent of total billed charges,Drugs,4.31,30,,4.31,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.31,30,,4.31,percent of total billed charges,Drugs,4.31,30,,4.31,percent of total billed charges,Drugs,4.31,30,,4.31,percent of total billed charges,Drugs,4.31,30,,4.31,percent of total billed charges,Drugs,4.31,30,,4.31,percent of total billed charges,Drugs,4.31,30,,4.31,percent of total billed charges,Drugs,4.31,30,,4.31,percent of total billed charges,Drugs,4.31,30,,4.31,percent of total billed charges,Drugs,4.31,30,,4.31,percent of total billed charges,Drugs,4.31,30,,4.31,percent of total billed charges,Drugs,4.31,30,,4.31,percent of total billed charges,Drugs,4.31,30,,4.31,percent of total billed charges,Drugs,4.31,30,,4.31,percent of total billed charges,Drugs,5.32,,,5.32,Other,Drug Cost,5.32,,,5.32,Other,Drug Cost,5.32,,,5.32,Other,Drug Cost,5.32,,,5.32,Other,Drug Cost,5.32,,,5.32,Other,Drug Cost,4.88,34,,4.88,percent of total billed charges,Drugs,5.32,,,5.32,Other,Drug Cost,11.97,,,11.97,Other,225% Medicaid APG methodology,7.45,,,7.45,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.32,,,7.32,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.32,,,5.32,Other,Drug Cost,5.32,,,5.32,Other,Drug Cost,6.65,,,6.65,Other,125% Medicaid APG methodology,0.01,11.97,
OMALIZUMAB 150 MG/ML 1 ML       ,J2357,HCPCS,,40505224,CDM,636,RC,50242-0215-01,NDC,both,1,ML,4555.64,389.33,,,389.33,Other,150% of Medicare + 9.63% HCRA Surcharge,236.75,,,236.75,Fee Schedule,Average Sale Price (ASP) x 6,1366.69,30,,1366.69,percent of total billed charges,Drugs,1366.69,30,,1366.69,percent of total billed charges,Drugs,1366.69,30,,1366.69,percent of total billed charges,Drugs,1366.69,30,,1366.69,percent of total billed charges,Drugs,1366.69,30,,1366.69,percent of total billed charges,Drugs,2277.82,50,,2277.82,percent of total billed charges,All Other,1366.69,30,,1366.69,percent of total billed charges,Drugs,1366.69,30,,1366.69,percent of total billed charges,Drugs,1548.92,34,"If Charge > 500, then 34 percent",1548.92,percent of total billed charges,Drugs,1366.69,30,,1366.69,percent of total billed charges,Drugs,1366.69,30,,1366.69,percent of total billed charges,Drugs,1366.69,30,,1366.69,percent of total billed charges,Drugs,1366.69,30,,1366.69,percent of total billed charges,Drugs,1366.69,30,,1366.69,percent of total billed charges,Drugs,1366.69,30,,1366.69,percent of total billed charges,Drugs,1366.69,30,,1366.69,percent of total billed charges,Drugs,1366.69,30,,1366.69,percent of total billed charges,Drugs,1366.69,30,,1366.69,percent of total billed charges,Drugs,1366.69,30,,1366.69,percent of total billed charges,Drugs,1366.69,30,,1366.69,percent of total billed charges,Drugs,1366.69,30,,1366.69,percent of total billed charges,Drugs,1366.69,30,,1366.69,percent of total billed charges,Drugs,853.97,,,853.97,Other,Drug Cost,853.97,,,853.97,Other,Drug Cost,853.97,,,853.97,Other,Drug Cost,853.97,,,853.97,Other,Drug Cost,853.97,,,853.97,Other,Drug Cost,1548.92,34,,1548.92,percent of total billed charges,Drugs,853.97,,,853.97,Other,Drug Cost,1921.43,,,1921.43,Other,225% Medicaid APG methodology,1195.56,,,1195.56,Other,140% Medicaid APG methodology,1548.92,34,"If Charge > 2,000, then 34 percent",1548.92,percent of total billed charges,Drugs,378.81,,,378.81,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",853.97,,,853.97,Other,Drug Cost,853.97,,,853.97,Other,Drug Cost,1067.46,,,1067.46,Other,125% Medicaid APG methodology,0.01,2277.82,
HYDROMORPHONE 10 MG/ML 1 ML     ,J1170,HCPCS,,40505364,CDM,636,RC,00409-2634-01,NDC,both,1,ML,6.72,45.3,,,45.3,Other,150% of Medicare + 9.63% HCRA Surcharge,27.55,,,27.55,Fee Schedule,Average Sale Price (ASP) x 6,2.02,30,,2.02,percent of total billed charges,Drugs,2.02,30,,2.02,percent of total billed charges,Drugs,2.02,30,,2.02,percent of total billed charges,Drugs,2.02,30,,2.02,percent of total billed charges,Drugs,2.02,30,,2.02,percent of total billed charges,Drugs,3.36,50,,3.36,percent of total billed charges,All Other,2.02,30,,2.02,percent of total billed charges,Drugs,2.02,30,,2.02,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.02,30,,2.02,percent of total billed charges,Drugs,2.02,30,,2.02,percent of total billed charges,Drugs,2.02,30,,2.02,percent of total billed charges,Drugs,2.02,30,,2.02,percent of total billed charges,Drugs,2.02,30,,2.02,percent of total billed charges,Drugs,2.02,30,,2.02,percent of total billed charges,Drugs,2.02,30,,2.02,percent of total billed charges,Drugs,2.02,30,,2.02,percent of total billed charges,Drugs,2.02,30,,2.02,percent of total billed charges,Drugs,2.02,30,,2.02,percent of total billed charges,Drugs,2.02,30,,2.02,percent of total billed charges,Drugs,2.02,30,,2.02,percent of total billed charges,Drugs,2.02,30,,2.02,percent of total billed charges,Drugs,1.53,,,1.53,Other,Drug Cost,1.53,,,1.53,Other,Drug Cost,1.53,,,1.53,Other,Drug Cost,1.53,,,1.53,Other,Drug Cost,1.53,,,1.53,Other,Drug Cost,2.28,34,,2.28,percent of total billed charges,Drugs,1.53,,,1.53,Other,Drug Cost,3.44,,,3.44,Other,225% Medicaid APG methodology,2.14,,,2.14,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,44.07,,,44.07,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.53,,,1.53,Other,Drug Cost,1.53,,,1.53,Other,Drug Cost,1.91,,,1.91,Other,125% Medicaid APG methodology,0.01,45.3,
IRON SUCROSE 20 MG/ML IV 10 ML  ,J1756,HCPCS,,40505372,CDM,636,RC,00517-2310-05,NDC,both,10,ML,208.29,2.18,,,2.18,Other,150% of Medicare + 9.63% HCRA Surcharge,1.33,,,1.33,Fee Schedule,Average Sale Price (ASP) x 6,62.49,30,,62.49,percent of total billed charges,Drugs,62.49,30,,62.49,percent of total billed charges,Drugs,62.49,30,,62.49,percent of total billed charges,Drugs,62.49,30,,62.49,percent of total billed charges,Drugs,62.49,30,,62.49,percent of total billed charges,Drugs,104.15,50,,104.15,percent of total billed charges,All Other,62.49,30,,62.49,percent of total billed charges,Drugs,62.49,30,,62.49,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,62.49,30,,62.49,percent of total billed charges,Drugs,62.49,30,,62.49,percent of total billed charges,Drugs,62.49,30,,62.49,percent of total billed charges,Drugs,62.49,30,,62.49,percent of total billed charges,Drugs,62.49,30,,62.49,percent of total billed charges,Drugs,62.49,30,,62.49,percent of total billed charges,Drugs,62.49,30,,62.49,percent of total billed charges,Drugs,62.49,30,,62.49,percent of total billed charges,Drugs,62.49,30,,62.49,percent of total billed charges,Drugs,62.49,30,,62.49,percent of total billed charges,Drugs,62.49,30,,62.49,percent of total billed charges,Drugs,62.49,30,,62.49,percent of total billed charges,Drugs,62.49,30,,62.49,percent of total billed charges,Drugs,45.48,,,45.48,Other,Drug Cost,45.48,,,45.48,Other,Drug Cost,45.48,,,45.48,Other,Drug Cost,45.48,,,45.48,Other,Drug Cost,45.48,,,45.48,Other,Drug Cost,70.82,34,,70.82,percent of total billed charges,Drugs,45.48,,,45.48,Other,Drug Cost,102.33,,,102.33,Other,225% Medicaid APG methodology,63.67,,,63.67,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.12,,,2.12,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",45.48,,,45.48,Other,Drug Cost,45.48,,,45.48,Other,Drug Cost,56.85,,,56.85,Other,125% Medicaid APG methodology,0.01,104.15,
IRON SUCROSE 20 MG/ML 2.5 ML    ,J1756,HCPCS,,40505380,CDM,636,RC,00517-2325-10,NDC,both,2.5,ML,58.56,2.18,,,2.18,Other,150% of Medicare + 9.63% HCRA Surcharge,1.33,,,1.33,Fee Schedule,Average Sale Price (ASP) x 6,17.57,30,,17.57,percent of total billed charges,Drugs,17.57,30,,17.57,percent of total billed charges,Drugs,17.57,30,,17.57,percent of total billed charges,Drugs,17.57,30,,17.57,percent of total billed charges,Drugs,17.57,30,,17.57,percent of total billed charges,Drugs,29.28,50,,29.28,percent of total billed charges,All Other,17.57,30,,17.57,percent of total billed charges,Drugs,17.57,30,,17.57,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,17.57,30,,17.57,percent of total billed charges,Drugs,17.57,30,,17.57,percent of total billed charges,Drugs,17.57,30,,17.57,percent of total billed charges,Drugs,17.57,30,,17.57,percent of total billed charges,Drugs,17.57,30,,17.57,percent of total billed charges,Drugs,17.57,30,,17.57,percent of total billed charges,Drugs,17.57,30,,17.57,percent of total billed charges,Drugs,17.57,30,,17.57,percent of total billed charges,Drugs,17.57,30,,17.57,percent of total billed charges,Drugs,17.57,30,,17.57,percent of total billed charges,Drugs,17.57,30,,17.57,percent of total billed charges,Drugs,17.57,30,,17.57,percent of total billed charges,Drugs,17.57,30,,17.57,percent of total billed charges,Drugs,11.37,,,11.37,Other,Drug Cost,11.37,,,11.37,Other,Drug Cost,11.37,,,11.37,Other,Drug Cost,11.37,,,11.37,Other,Drug Cost,11.37,,,11.37,Other,Drug Cost,19.91,34,,19.91,percent of total billed charges,Drugs,11.37,,,11.37,Other,Drug Cost,25.58,,,25.58,Other,225% Medicaid APG methodology,15.92,,,15.92,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.12,,,2.12,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",11.37,,,11.37,Other,Drug Cost,11.37,,,11.37,Other,Drug Cost,14.21,,,14.21,Other,125% Medicaid APG methodology,0.01,29.28,
LEUCOVORIN 500 MG INJ           ,J0640,HCPCS,,40505398,CDM,636,RC,25021-0828-50,NDC,both,1,EA,123.62,44.1,,,44.1,Other,150% of Medicare + 9.63% HCRA Surcharge,26.82,,,26.82,Fee Schedule,Average Sale Price (ASP) x 6,37.09,30,,37.09,percent of total billed charges,Drugs,37.09,30,,37.09,percent of total billed charges,Drugs,37.09,30,,37.09,percent of total billed charges,Drugs,37.09,30,,37.09,percent of total billed charges,Drugs,37.09,30,,37.09,percent of total billed charges,Drugs,61.81,50,,61.81,percent of total billed charges,All Other,37.09,30,,37.09,percent of total billed charges,Drugs,37.09,30,,37.09,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,37.09,30,,37.09,percent of total billed charges,Drugs,37.09,30,,37.09,percent of total billed charges,Drugs,37.09,30,,37.09,percent of total billed charges,Drugs,37.09,30,,37.09,percent of total billed charges,Drugs,37.09,30,,37.09,percent of total billed charges,Drugs,37.09,30,,37.09,percent of total billed charges,Drugs,37.09,30,,37.09,percent of total billed charges,Drugs,37.09,30,,37.09,percent of total billed charges,Drugs,37.09,30,,37.09,percent of total billed charges,Drugs,37.09,30,,37.09,percent of total billed charges,Drugs,37.09,30,,37.09,percent of total billed charges,Drugs,37.09,30,,37.09,percent of total billed charges,Drugs,37.09,30,,37.09,percent of total billed charges,Drugs,22.45,,,22.45,Other,Drug Cost,22.45,,,22.45,Other,Drug Cost,22.45,,,22.45,Other,Drug Cost,22.45,,,22.45,Other,Drug Cost,22.45,,,22.45,Other,Drug Cost,42.03,34,,42.03,percent of total billed charges,Drugs,22.45,,,22.45,Other,Drug Cost,50.51,,,50.51,Other,225% Medicaid APG methodology,31.43,,,31.43,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,42.91,,,42.91,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",22.45,,,22.45,Other,Drug Cost,22.45,,,22.45,Other,Drug Cost,28.06,,,28.06,Other,125% Medicaid APG methodology,0.01,61.81,
OMALIZUMAB 150 MG SUBCUT INJ    ,J2357,HCPCS,,40505414,CDM,636,RC,50242-0040-62,NDC,both,1,EA,4274.03,389.33,,,389.33,Other,150% of Medicare + 9.63% HCRA Surcharge,236.75,,,236.75,Fee Schedule,Average Sale Price (ASP) x 6,1282.21,30,,1282.21,percent of total billed charges,Drugs,1282.21,30,,1282.21,percent of total billed charges,Drugs,1282.21,30,,1282.21,percent of total billed charges,Drugs,1282.21,30,,1282.21,percent of total billed charges,Drugs,1282.21,30,,1282.21,percent of total billed charges,Drugs,2137.02,50,,2137.02,percent of total billed charges,All Other,1282.21,30,,1282.21,percent of total billed charges,Drugs,1282.21,30,,1282.21,percent of total billed charges,Drugs,1453.17,34,"If Charge > 500, then 34 percent",1453.17,percent of total billed charges,Drugs,1282.21,30,,1282.21,percent of total billed charges,Drugs,1282.21,30,,1282.21,percent of total billed charges,Drugs,1282.21,30,,1282.21,percent of total billed charges,Drugs,1282.21,30,,1282.21,percent of total billed charges,Drugs,1282.21,30,,1282.21,percent of total billed charges,Drugs,1282.21,30,,1282.21,percent of total billed charges,Drugs,1282.21,30,,1282.21,percent of total billed charges,Drugs,1282.21,30,,1282.21,percent of total billed charges,Drugs,1282.21,30,,1282.21,percent of total billed charges,Drugs,1282.21,30,,1282.21,percent of total billed charges,Drugs,1282.21,30,,1282.21,percent of total billed charges,Drugs,1282.21,30,,1282.21,percent of total billed charges,Drugs,1282.21,30,,1282.21,percent of total billed charges,Drugs,614.07,,,614.07,Other,Drug Cost,614.07,,,614.07,Other,Drug Cost,614.07,,,614.07,Other,Drug Cost,614.07,,,614.07,Other,Drug Cost,614.07,,,614.07,Other,Drug Cost,1453.17,34,,1453.17,percent of total billed charges,Drugs,614.07,,,614.07,Other,Drug Cost,1381.66,,,1381.66,Other,225% Medicaid APG methodology,859.7,,,859.7,Other,140% Medicaid APG methodology,1453.17,34,"If Charge > 2,000, then 34 percent",1453.17,percent of total billed charges,Drugs,378.81,,,378.81,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",614.07,,,614.07,Other,Drug Cost,614.07,,,614.07,Other,Drug Cost,767.59,,,767.59,Other,125% Medicaid APG methodology,0.01,2137.02,
TOPOTECAN 1 MG/ML IV SOLN 4 ML  ,J9351,HCPCS,,40505422,CDM,636,RC,00409-0302-01,NDC,both,4,ML,77.11,7.71,,,7.71,Other,150% of Medicare + 9.63% HCRA Surcharge,4.69,,,4.69,Fee Schedule,Average Sale Price (ASP) x 6,23.13,30,,23.13,percent of total billed charges,Drugs,23.13,30,,23.13,percent of total billed charges,Drugs,23.13,30,,23.13,percent of total billed charges,Drugs,23.13,30,,23.13,percent of total billed charges,Drugs,23.13,30,,23.13,percent of total billed charges,Drugs,38.56,50,,38.56,percent of total billed charges,All Other,23.13,30,,23.13,percent of total billed charges,Drugs,23.13,30,,23.13,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,23.13,30,,23.13,percent of total billed charges,Drugs,23.13,30,,23.13,percent of total billed charges,Drugs,23.13,30,,23.13,percent of total billed charges,Drugs,23.13,30,,23.13,percent of total billed charges,Drugs,23.13,30,,23.13,percent of total billed charges,Drugs,23.13,30,,23.13,percent of total billed charges,Drugs,23.13,30,,23.13,percent of total billed charges,Drugs,23.13,30,,23.13,percent of total billed charges,Drugs,23.13,30,,23.13,percent of total billed charges,Drugs,23.13,30,,23.13,percent of total billed charges,Drugs,23.13,30,,23.13,percent of total billed charges,Drugs,23.13,30,,23.13,percent of total billed charges,Drugs,23.13,30,,23.13,percent of total billed charges,Drugs,21.39,,,21.39,Other,Drug Cost,21.39,,,21.39,Other,Drug Cost,21.39,,,21.39,Other,Drug Cost,21.39,,,21.39,Other,Drug Cost,21.39,,,21.39,Other,Drug Cost,26.22,34,,26.22,percent of total billed charges,Drugs,21.39,,,21.39,Other,Drug Cost,48.13,,,48.13,Other,225% Medicaid APG methodology,29.95,,,29.95,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.5,,,7.5,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",21.39,,,21.39,Other,Drug Cost,21.39,,,21.39,Other,Drug Cost,26.74,,,26.74,Other,125% Medicaid APG methodology,0.01,48.13,
OXYTOCIN 10 UNITS/ML INJ 10 ML  ,J2590,HCPCS,,40505430,CDM,636,RC,42023-0116-02,NDC,both,10,ML,45.54,17.97,39.4668,,17.97,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,13.66,30,,13.66,percent of total billed charges,Drugs,13.66,30,,13.66,percent of total billed charges,Drugs,13.66,30,,13.66,percent of total billed charges,Drugs,13.66,30,,13.66,percent of total billed charges,Drugs,13.66,30,,13.66,percent of total billed charges,Drugs,22.77,50,,22.77,percent of total billed charges,All Other,13.66,30,,13.66,percent of total billed charges,Drugs,13.66,30,,13.66,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,13.66,30,,13.66,percent of total billed charges,Drugs,13.66,30,,13.66,percent of total billed charges,Drugs,13.66,30,,13.66,percent of total billed charges,Drugs,13.66,30,,13.66,percent of total billed charges,Drugs,13.66,30,,13.66,percent of total billed charges,Drugs,13.66,30,,13.66,percent of total billed charges,Drugs,13.66,30,,13.66,percent of total billed charges,Drugs,13.66,30,,13.66,percent of total billed charges,Drugs,13.66,30,,13.66,percent of total billed charges,Drugs,13.66,30,,13.66,percent of total billed charges,Drugs,13.66,30,,13.66,percent of total billed charges,Drugs,13.66,30,,13.66,percent of total billed charges,Drugs,13.66,30,,13.66,percent of total billed charges,Drugs,3.73,,,3.73,Other,Drug Cost,3.73,,,3.73,Other,Drug Cost,3.73,,,3.73,Other,Drug Cost,3.73,,,3.73,Other,Drug Cost,3.73,,,3.73,Other,Drug Cost,15.48,34,,15.48,percent of total billed charges,Drugs,3.73,,,3.73,Other,Drug Cost,8.39,,,8.39,Other,225% Medicaid APG methodology,5.22,,,5.22,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.73,,,3.73,Other,Drug Cost,3.73,,,3.73,Other,Drug Cost,4.66,,,4.66,Other,125% Medicaid APG methodology,0.01,22.77,
METHYLPRED SOD SUC 500 MG PF    ,J2930,HCPCS,,40505448,CDM,636,RC,00009-0003-02,NDC,both,1,EA,140.95,58.04,,,58.04,Other,150% of Medicare + 9.63% HCRA Surcharge,35.29,,,35.29,Fee Schedule,Average Sale Price (ASP) x 6,42.29,30,,42.29,percent of total billed charges,Drugs,42.29,30,,42.29,percent of total billed charges,Drugs,42.29,30,,42.29,percent of total billed charges,Drugs,42.29,30,,42.29,percent of total billed charges,Drugs,42.29,30,,42.29,percent of total billed charges,Drugs,70.48,50,,70.48,percent of total billed charges,All Other,42.29,30,,42.29,percent of total billed charges,Drugs,42.29,30,,42.29,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,42.29,30,,42.29,percent of total billed charges,Drugs,42.29,30,,42.29,percent of total billed charges,Drugs,42.29,30,,42.29,percent of total billed charges,Drugs,42.29,30,,42.29,percent of total billed charges,Drugs,42.29,30,,42.29,percent of total billed charges,Drugs,42.29,30,,42.29,percent of total billed charges,Drugs,42.29,30,,42.29,percent of total billed charges,Drugs,42.29,30,,42.29,percent of total billed charges,Drugs,42.29,30,,42.29,percent of total billed charges,Drugs,42.29,30,,42.29,percent of total billed charges,Drugs,42.29,30,,42.29,percent of total billed charges,Drugs,42.29,30,,42.29,percent of total billed charges,Drugs,42.29,30,,42.29,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,47.92,34,,47.92,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,56.47,,,56.47,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,70.48,
DEXTROSE 5% /0.45% NACL 500 ML  ,J7799,HCPCS,,40505455,CDM,636,RC,00338-0085-03,NDC,both,500,ML,16.45,6.49,39.4668,,6.49,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,4.94,30,,4.94,percent of total billed charges,Drugs,4.94,30,,4.94,percent of total billed charges,Drugs,4.94,30,,4.94,percent of total billed charges,Drugs,4.94,30,,4.94,percent of total billed charges,Drugs,4.94,30,,4.94,percent of total billed charges,Drugs,8.23,50,,8.23,percent of total billed charges,All Other,4.94,30,,4.94,percent of total billed charges,Drugs,4.94,30,,4.94,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.94,30,,4.94,percent of total billed charges,Drugs,4.94,30,,4.94,percent of total billed charges,Drugs,4.94,30,,4.94,percent of total billed charges,Drugs,4.94,30,,4.94,percent of total billed charges,Drugs,4.94,30,,4.94,percent of total billed charges,Drugs,4.94,30,,4.94,percent of total billed charges,Drugs,4.94,30,,4.94,percent of total billed charges,Drugs,4.94,30,,4.94,percent of total billed charges,Drugs,4.94,30,,4.94,percent of total billed charges,Drugs,4.94,30,,4.94,percent of total billed charges,Drugs,4.94,30,,4.94,percent of total billed charges,Drugs,4.94,30,,4.94,percent of total billed charges,Drugs,4.94,30,,4.94,percent of total billed charges,Drugs,4.7,,,4.7,Other,Drug Cost,4.7,,,4.7,Other,Drug Cost,4.7,,,4.7,Other,Drug Cost,4.7,,,4.7,Other,Drug Cost,4.7,,,4.7,Other,Drug Cost,5.59,34,,5.59,percent of total billed charges,Drugs,4.7,,,4.7,Other,Drug Cost,10.58,,,10.58,Other,225% Medicaid APG methodology,6.58,,,6.58,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.7,,,4.7,Other,Drug Cost,4.7,,,4.7,Other,Drug Cost,5.88,,,5.88,Other,125% Medicaid APG methodology,0.01,10.58,
DEXTROSE 5% /0.9% NACL 500 ML   ,J7042,HCPCS,,40505463,CDM,636,RC,00338-0089-03,NDC,both,500,ML,7.88,15.66,,,15.66,Other,150% of Medicare + 9.63% HCRA Surcharge,9.52,,,9.52,Fee Schedule,Average Sale Price (ASP) x 6,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,3.94,50,,3.94,percent of total billed charges,All Other,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,3.7,,,3.7,Other,Drug Cost,3.7,,,3.7,Other,Drug Cost,3.7,,,3.7,Other,Drug Cost,3.7,,,3.7,Other,Drug Cost,3.7,,,3.7,Other,Drug Cost,2.68,34,,2.68,percent of total billed charges,Drugs,3.7,,,3.7,Other,Drug Cost,8.33,,,8.33,Other,225% Medicaid APG methodology,5.18,,,5.18,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,15.24,,,15.24,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.7,,,3.7,Other,Drug Cost,3.7,,,3.7,Other,Drug Cost,4.63,,,4.63,Other,125% Medicaid APG methodology,0.01,15.66,
CLINDAMYCIN 300 MG/D5W 50 ML    ,J3490,HCPCS,,40505554,CDM,636,RC,00338-3410-24,NDC,both,50,ML,9.31,3.67,39.4668,,3.67,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,2.79,30,,2.79,percent of total billed charges,Drugs,2.79,30,,2.79,percent of total billed charges,Drugs,2.79,30,,2.79,percent of total billed charges,Drugs,2.79,30,,2.79,percent of total billed charges,Drugs,2.79,30,,2.79,percent of total billed charges,Drugs,4.66,50,,4.66,percent of total billed charges,All Other,2.79,30,,2.79,percent of total billed charges,Drugs,2.79,30,,2.79,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.79,30,,2.79,percent of total billed charges,Drugs,2.79,30,,2.79,percent of total billed charges,Drugs,2.79,30,,2.79,percent of total billed charges,Drugs,2.79,30,,2.79,percent of total billed charges,Drugs,2.79,30,,2.79,percent of total billed charges,Drugs,2.79,30,,2.79,percent of total billed charges,Drugs,2.79,30,,2.79,percent of total billed charges,Drugs,2.79,30,,2.79,percent of total billed charges,Drugs,2.79,30,,2.79,percent of total billed charges,Drugs,2.79,30,,2.79,percent of total billed charges,Drugs,2.79,30,,2.79,percent of total billed charges,Drugs,2.79,30,,2.79,percent of total billed charges,Drugs,2.79,30,,2.79,percent of total billed charges,Drugs,1.75,,,1.75,Other,Drug Cost,1.75,,,1.75,Other,Drug Cost,1.75,,,1.75,Other,Drug Cost,1.75,,,1.75,Other,Drug Cost,1.75,,,1.75,Other,Drug Cost,3.17,34,,3.17,percent of total billed charges,Drugs,1.75,,,1.75,Other,Drug Cost,3.94,,,3.94,Other,225% Medicaid APG methodology,2.45,,,2.45,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.75,,,1.75,Other,Drug Cost,1.75,,,1.75,Other,Drug Cost,2.19,,,2.19,Other,125% Medicaid APG methodology,0.01,4.66,
D5W W/ 0.45% NACL K 40 MEQ/L    ,J3480,HCPCS,,40505562,CDM,636,RC,00338-0675-04,NDC,both,1000,ML,17.15,1.18,,,1.18,Other,150% of Medicare + 9.63% HCRA Surcharge,0.72,,,0.72,Fee Schedule,Average Sale Price (ASP) x 6,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,8.58,50,,8.58,percent of total billed charges,All Other,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,5.15,30,,5.15,percent of total billed charges,Drugs,7.6,,,7.6,Other,Drug Cost,7.6,,,7.6,Other,Drug Cost,7.6,,,7.6,Other,Drug Cost,7.6,,,7.6,Other,Drug Cost,7.6,,,7.6,Other,Drug Cost,5.83,34,,5.83,percent of total billed charges,Drugs,7.6,,,7.6,Other,Drug Cost,17.1,,,17.1,Other,225% Medicaid APG methodology,10.64,,,10.64,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.15,,,1.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",7.6,,,7.6,Other,Drug Cost,7.6,,,7.6,Other,Drug Cost,9.5,,,9.5,Other,125% Medicaid APG methodology,0.01,17.1,
GENTAMICIN 100 MG/NS 100 ML     ,J1580,HCPCS,,40505612,CDM,636,RC,00338-0505-48,NDC,both,100,ML,10.22,26.49,,,26.49,Other,150% of Medicare + 9.63% HCRA Surcharge,16.11,,,16.11,Fee Schedule,Average Sale Price (ASP) x 6,3.07,30,,3.07,percent of total billed charges,Drugs,3.07,30,,3.07,percent of total billed charges,Drugs,3.07,30,,3.07,percent of total billed charges,Drugs,3.07,30,,3.07,percent of total billed charges,Drugs,3.07,30,,3.07,percent of total billed charges,Drugs,5.11,50,,5.11,percent of total billed charges,All Other,3.07,30,,3.07,percent of total billed charges,Drugs,3.07,30,,3.07,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.07,30,,3.07,percent of total billed charges,Drugs,3.07,30,,3.07,percent of total billed charges,Drugs,3.07,30,,3.07,percent of total billed charges,Drugs,3.07,30,,3.07,percent of total billed charges,Drugs,3.07,30,,3.07,percent of total billed charges,Drugs,3.07,30,,3.07,percent of total billed charges,Drugs,3.07,30,,3.07,percent of total billed charges,Drugs,3.07,30,,3.07,percent of total billed charges,Drugs,3.07,30,,3.07,percent of total billed charges,Drugs,3.07,30,,3.07,percent of total billed charges,Drugs,3.07,30,,3.07,percent of total billed charges,Drugs,3.07,30,,3.07,percent of total billed charges,Drugs,3.07,30,,3.07,percent of total billed charges,Drugs,1.85,,,1.85,Other,Drug Cost,1.85,,,1.85,Other,Drug Cost,1.85,,,1.85,Other,Drug Cost,1.85,,,1.85,Other,Drug Cost,1.85,,,1.85,Other,Drug Cost,3.47,34,,3.47,percent of total billed charges,Drugs,1.85,,,1.85,Other,Drug Cost,4.16,,,4.16,Other,225% Medicaid APG methodology,2.59,,,2.59,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,25.78,,,25.78,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.85,,,1.85,Other,Drug Cost,1.85,,,1.85,Other,Drug Cost,2.31,,,2.31,Other,125% Medicaid APG methodology,0.01,26.49,
GENTAMICIN 60 MG/NS 50 ML       ,J1580,HCPCS,,40505620,CDM,636,RC,00338-0507-41,NDC,both,50,ML,8.93,26.49,,,26.49,Other,150% of Medicare + 9.63% HCRA Surcharge,16.11,,,16.11,Fee Schedule,Average Sale Price (ASP) x 6,2.68,30,,2.68,percent of total billed charges,Drugs,2.68,30,,2.68,percent of total billed charges,Drugs,2.68,30,,2.68,percent of total billed charges,Drugs,2.68,30,,2.68,percent of total billed charges,Drugs,2.68,30,,2.68,percent of total billed charges,Drugs,4.47,50,,4.47,percent of total billed charges,All Other,2.68,30,,2.68,percent of total billed charges,Drugs,2.68,30,,2.68,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.68,30,,2.68,percent of total billed charges,Drugs,2.68,30,,2.68,percent of total billed charges,Drugs,2.68,30,,2.68,percent of total billed charges,Drugs,2.68,30,,2.68,percent of total billed charges,Drugs,2.68,30,,2.68,percent of total billed charges,Drugs,2.68,30,,2.68,percent of total billed charges,Drugs,2.68,30,,2.68,percent of total billed charges,Drugs,2.68,30,,2.68,percent of total billed charges,Drugs,2.68,30,,2.68,percent of total billed charges,Drugs,2.68,30,,2.68,percent of total billed charges,Drugs,2.68,30,,2.68,percent of total billed charges,Drugs,2.68,30,,2.68,percent of total billed charges,Drugs,2.68,30,,2.68,percent of total billed charges,Drugs,0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,3.04,34,,3.04,percent of total billed charges,Drugs,0.98,,,0.98,Other,Drug Cost,2.21,,,2.21,Other,225% Medicaid APG methodology,1.37,,,1.37,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,25.78,,,25.78,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,1.23,,,1.23,Other,125% Medicaid APG methodology,0.01,26.49,
AMPICILLIN 125 MG INJ           ,J0290,HCPCS,,40505786,CDM,636,RC,00781-3400-95,NDC,both,1,EA,10.89,9.98,,,9.98,Other,150% of Medicare + 9.63% HCRA Surcharge,6.07,,,6.07,Fee Schedule,Average Sale Price (ASP) x 6,3.27,30,,3.27,percent of total billed charges,Drugs,3.27,30,,3.27,percent of total billed charges,Drugs,3.27,30,,3.27,percent of total billed charges,Drugs,3.27,30,,3.27,percent of total billed charges,Drugs,3.27,30,,3.27,percent of total billed charges,Drugs,5.45,50,,5.45,percent of total billed charges,All Other,3.27,30,,3.27,percent of total billed charges,Drugs,3.27,30,,3.27,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.27,30,,3.27,percent of total billed charges,Drugs,3.27,30,,3.27,percent of total billed charges,Drugs,3.27,30,,3.27,percent of total billed charges,Drugs,3.27,30,,3.27,percent of total billed charges,Drugs,3.27,30,,3.27,percent of total billed charges,Drugs,3.27,30,,3.27,percent of total billed charges,Drugs,3.27,30,,3.27,percent of total billed charges,Drugs,3.27,30,,3.27,percent of total billed charges,Drugs,3.27,30,,3.27,percent of total billed charges,Drugs,3.27,30,,3.27,percent of total billed charges,Drugs,3.27,30,,3.27,percent of total billed charges,Drugs,3.27,30,,3.27,percent of total billed charges,Drugs,3.27,30,,3.27,percent of total billed charges,Drugs,1.73,,,1.73,Other,Drug Cost,1.73,,,1.73,Other,Drug Cost,1.73,,,1.73,Other,Drug Cost,1.73,,,1.73,Other,Drug Cost,1.73,,,1.73,Other,Drug Cost,3.7,34,,3.7,percent of total billed charges,Drugs,1.73,,,1.73,Other,Drug Cost,3.89,,,3.89,Other,225% Medicaid APG methodology,2.42,,,2.42,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,9.71,,,9.71,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.73,,,1.73,Other,Drug Cost,1.73,,,1.73,Other,Drug Cost,2.16,,,2.16,Other,125% Medicaid APG methodology,0.01,9.98,
DIA M-DIA S 66%-10% O & R 120   ,Q9963,HCPCS,,40505794,CDM,636,RC,00270-0445-40,NDC,both,120,ML,52.89,2.07,,,2.07,Other,150% of Medicare + 9.63% HCRA Surcharge,1.26,,,1.26,Fee Schedule,Average Sale Price (ASP) x 6,15.87,30,,15.87,percent of total billed charges,Drugs,15.87,30,,15.87,percent of total billed charges,Drugs,15.87,30,,15.87,percent of total billed charges,Drugs,15.87,30,,15.87,percent of total billed charges,Drugs,15.87,30,,15.87,percent of total billed charges,Drugs,26.45,50,,26.45,percent of total billed charges,All Other,15.87,30,,15.87,percent of total billed charges,Drugs,15.87,30,,15.87,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,15.87,30,,15.87,percent of total billed charges,Drugs,15.87,30,,15.87,percent of total billed charges,Drugs,15.87,30,,15.87,percent of total billed charges,Drugs,15.87,30,,15.87,percent of total billed charges,Drugs,15.87,30,,15.87,percent of total billed charges,Drugs,15.87,30,,15.87,percent of total billed charges,Drugs,15.87,30,,15.87,percent of total billed charges,Drugs,15.87,30,,15.87,percent of total billed charges,Drugs,15.87,30,,15.87,percent of total billed charges,Drugs,15.87,30,,15.87,percent of total billed charges,Drugs,15.87,30,,15.87,percent of total billed charges,Drugs,15.87,30,,15.87,percent of total billed charges,Drugs,15.87,30,,15.87,percent of total billed charges,Drugs,46.32,,,46.32,Other,Drug Cost,46.32,,,46.32,Other,Drug Cost,46.32,,,46.32,Other,Drug Cost,46.32,,,46.32,Other,Drug Cost,46.32,,,46.32,Other,Drug Cost,17.98,34,,17.98,percent of total billed charges,Drugs,46.32,,,46.32,Other,Drug Cost,104.22,,,104.22,Other,225% Medicaid APG methodology,64.85,,,64.85,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.02,,,2.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",46.32,,,46.32,Other,Drug Cost,46.32,,,46.32,Other,Drug Cost,57.9,,,57.9,Other,125% Medicaid APG methodology,0.01,104.22,
IOVERSOL 68% INJ SOLN 100 ML    ,Q9967,HCPCS,,40505810,CDM,636,RC,00019-1323-11,NDC,both,100,ML,113.05,1.16,,,1.16,Other,150% of Medicare + 9.63% HCRA Surcharge,0.71,,,0.71,Fee Schedule,Average Sale Price (ASP) x 6,33.92,30,,33.92,percent of total billed charges,Drugs,33.92,30,,33.92,percent of total billed charges,Drugs,33.92,30,,33.92,percent of total billed charges,Drugs,33.92,30,,33.92,percent of total billed charges,Drugs,33.92,30,,33.92,percent of total billed charges,Drugs,56.53,50,,56.53,percent of total billed charges,All Other,33.92,30,,33.92,percent of total billed charges,Drugs,33.92,30,,33.92,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,33.92,30,,33.92,percent of total billed charges,Drugs,33.92,30,,33.92,percent of total billed charges,Drugs,33.92,30,,33.92,percent of total billed charges,Drugs,33.92,30,,33.92,percent of total billed charges,Drugs,33.92,30,,33.92,percent of total billed charges,Drugs,33.92,30,,33.92,percent of total billed charges,Drugs,33.92,30,,33.92,percent of total billed charges,Drugs,33.92,30,,33.92,percent of total billed charges,Drugs,33.92,30,,33.92,percent of total billed charges,Drugs,33.92,30,,33.92,percent of total billed charges,Drugs,33.92,30,,33.92,percent of total billed charges,Drugs,33.92,30,,33.92,percent of total billed charges,Drugs,33.92,30,,33.92,percent of total billed charges,Drugs,31.65,,,31.65,Other,Drug Cost,31.65,,,31.65,Other,Drug Cost,31.65,,,31.65,Other,Drug Cost,31.65,,,31.65,Other,Drug Cost,31.65,,,31.65,Other,Drug Cost,38.44,34,,38.44,percent of total billed charges,Drugs,31.65,,,31.65,Other,Drug Cost,71.21,,,71.21,Other,225% Medicaid APG methodology,44.31,,,44.31,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.13,,,1.13,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",31.65,,,31.65,Other,Drug Cost,31.65,,,31.65,Other,Drug Cost,39.56,,,39.56,Other,125% Medicaid APG methodology,0.01,71.21,
IOVERSOL 68% INJ SOLN 50 ML     ,Q9967,HCPCS,,40505828,CDM,636,RC,00019-1323-06,NDC,both,50,ML,56.77,1.16,,,1.16,Other,150% of Medicare + 9.63% HCRA Surcharge,0.71,,,0.71,Fee Schedule,Average Sale Price (ASP) x 6,17.03,30,,17.03,percent of total billed charges,Drugs,17.03,30,,17.03,percent of total billed charges,Drugs,17.03,30,,17.03,percent of total billed charges,Drugs,17.03,30,,17.03,percent of total billed charges,Drugs,17.03,30,,17.03,percent of total billed charges,Drugs,28.39,50,,28.39,percent of total billed charges,All Other,17.03,30,,17.03,percent of total billed charges,Drugs,17.03,30,,17.03,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,17.03,30,,17.03,percent of total billed charges,Drugs,17.03,30,,17.03,percent of total billed charges,Drugs,17.03,30,,17.03,percent of total billed charges,Drugs,17.03,30,,17.03,percent of total billed charges,Drugs,17.03,30,,17.03,percent of total billed charges,Drugs,17.03,30,,17.03,percent of total billed charges,Drugs,17.03,30,,17.03,percent of total billed charges,Drugs,17.03,30,,17.03,percent of total billed charges,Drugs,17.03,30,,17.03,percent of total billed charges,Drugs,17.03,30,,17.03,percent of total billed charges,Drugs,17.03,30,,17.03,percent of total billed charges,Drugs,17.03,30,,17.03,percent of total billed charges,Drugs,17.03,30,,17.03,percent of total billed charges,Drugs,15.92,,,15.92,Other,Drug Cost,15.92,,,15.92,Other,Drug Cost,15.92,,,15.92,Other,Drug Cost,15.92,,,15.92,Other,Drug Cost,15.92,,,15.92,Other,Drug Cost,19.3,34,,19.3,percent of total billed charges,Drugs,15.92,,,15.92,Other,Drug Cost,35.82,,,35.82,Other,225% Medicaid APG methodology,22.29,,,22.29,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.13,,,1.13,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",15.92,,,15.92,Other,Drug Cost,15.92,,,15.92,Other,Drug Cost,19.9,,,19.9,Other,125% Medicaid APG methodology,0.01,35.82,
ROPIVACAINE 1% INJ SOLN 20 ML   ,J2795,HCPCS,,40505836,CDM,636,RC,63323-0288-20,NDC,both,20,ML,28.21,0.76,,,0.76,Other,150% of Medicare + 9.63% HCRA Surcharge,0.46,,,0.46,Fee Schedule,Average Sale Price (ASP) x 6,8.46,30,,8.46,percent of total billed charges,Drugs,8.46,30,,8.46,percent of total billed charges,Drugs,8.46,30,,8.46,percent of total billed charges,Drugs,8.46,30,,8.46,percent of total billed charges,Drugs,8.46,30,,8.46,percent of total billed charges,Drugs,14.11,50,,14.11,percent of total billed charges,All Other,8.46,30,,8.46,percent of total billed charges,Drugs,8.46,30,,8.46,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,8.46,30,,8.46,percent of total billed charges,Drugs,8.46,30,,8.46,percent of total billed charges,Drugs,8.46,30,,8.46,percent of total billed charges,Drugs,8.46,30,,8.46,percent of total billed charges,Drugs,8.46,30,,8.46,percent of total billed charges,Drugs,8.46,30,,8.46,percent of total billed charges,Drugs,8.46,30,,8.46,percent of total billed charges,Drugs,8.46,30,,8.46,percent of total billed charges,Drugs,8.46,30,,8.46,percent of total billed charges,Drugs,8.46,30,,8.46,percent of total billed charges,Drugs,8.46,30,,8.46,percent of total billed charges,Drugs,8.46,30,,8.46,percent of total billed charges,Drugs,8.46,30,,8.46,percent of total billed charges,Drugs,3.77,,,3.77,Other,Drug Cost,3.77,,,3.77,Other,Drug Cost,3.77,,,3.77,Other,Drug Cost,3.77,,,3.77,Other,Drug Cost,3.77,,,3.77,Other,Drug Cost,9.59,34,,9.59,percent of total billed charges,Drugs,3.77,,,3.77,Other,Drug Cost,8.48,,,8.48,Other,225% Medicaid APG methodology,5.28,,,5.28,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.74,,,0.74,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.77,,,3.77,Other,Drug Cost,3.77,,,3.77,Other,Drug Cost,4.71,,,4.71,Other,125% Medicaid APG methodology,0.01,14.11,
IOPAMIDOL 76% INJ SOLN 100 ML   ,Q9967,HCPCS,,40505844,CDM,636,RC,00270-1316-35,NDC,both,100,ML,40.71,1.16,,,1.16,Other,150% of Medicare + 9.63% HCRA Surcharge,0.71,,,0.71,Fee Schedule,Average Sale Price (ASP) x 6,12.21,30,,12.21,percent of total billed charges,Drugs,12.21,30,,12.21,percent of total billed charges,Drugs,12.21,30,,12.21,percent of total billed charges,Drugs,12.21,30,,12.21,percent of total billed charges,Drugs,12.21,30,,12.21,percent of total billed charges,Drugs,20.36,50,,20.36,percent of total billed charges,All Other,12.21,30,,12.21,percent of total billed charges,Drugs,12.21,30,,12.21,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,12.21,30,,12.21,percent of total billed charges,Drugs,12.21,30,,12.21,percent of total billed charges,Drugs,12.21,30,,12.21,percent of total billed charges,Drugs,12.21,30,,12.21,percent of total billed charges,Drugs,12.21,30,,12.21,percent of total billed charges,Drugs,12.21,30,,12.21,percent of total billed charges,Drugs,12.21,30,,12.21,percent of total billed charges,Drugs,12.21,30,,12.21,percent of total billed charges,Drugs,12.21,30,,12.21,percent of total billed charges,Drugs,12.21,30,,12.21,percent of total billed charges,Drugs,12.21,30,,12.21,percent of total billed charges,Drugs,12.21,30,,12.21,percent of total billed charges,Drugs,12.21,30,,12.21,percent of total billed charges,Drugs,11.63,,,11.63,Other,Drug Cost,11.63,,,11.63,Other,Drug Cost,11.63,,,11.63,Other,Drug Cost,11.63,,,11.63,Other,Drug Cost,11.63,,,11.63,Other,Drug Cost,13.84,34,,13.84,percent of total billed charges,Drugs,11.63,,,11.63,Other,Drug Cost,26.17,,,26.17,Other,225% Medicaid APG methodology,16.28,,,16.28,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.13,,,1.13,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",11.63,,,11.63,Other,Drug Cost,11.63,,,11.63,Other,Drug Cost,14.54,,,14.54,Other,125% Medicaid APG methodology,0.01,26.17,
GENTAMICIN 120 MG/NS 100 ML     ,J1580,HCPCS,,40505851,CDM,636,RC,00338-0507-48,NDC,both,100,ML,10.99,26.49,,,26.49,Other,150% of Medicare + 9.63% HCRA Surcharge,16.11,,,16.11,Fee Schedule,Average Sale Price (ASP) x 6,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,5.5,50,,5.5,percent of total billed charges,All Other,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,3.3,30,,3.3,percent of total billed charges,Drugs,1.95,,,1.95,Other,Drug Cost,1.95,,,1.95,Other,Drug Cost,1.95,,,1.95,Other,Drug Cost,1.95,,,1.95,Other,Drug Cost,1.95,,,1.95,Other,Drug Cost,3.74,34,,3.74,percent of total billed charges,Drugs,1.95,,,1.95,Other,Drug Cost,4.39,,,4.39,Other,225% Medicaid APG methodology,2.73,,,2.73,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,25.78,,,25.78,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.95,,,1.95,Other,Drug Cost,1.95,,,1.95,Other,Drug Cost,2.44,,,2.44,Other,125% Medicaid APG methodology,0.01,26.49,
IOPAMIDOL 61% INJ SOLN 100 ML   ,Q9967,HCPCS,,40505869,CDM,636,RC,00270-1315-35,NDC,both,100,ML,36.68,1.16,,,1.16,Other,150% of Medicare + 9.63% HCRA Surcharge,0.71,,,0.71,Fee Schedule,Average Sale Price (ASP) x 6,11,30,,11,percent of total billed charges,Drugs,11,30,,11,percent of total billed charges,Drugs,11,30,,11,percent of total billed charges,Drugs,11,30,,11,percent of total billed charges,Drugs,11,30,,11,percent of total billed charges,Drugs,18.34,50,,18.34,percent of total billed charges,All Other,11,30,,11,percent of total billed charges,Drugs,11,30,,11,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,11,30,,11,percent of total billed charges,Drugs,11,30,,11,percent of total billed charges,Drugs,11,30,,11,percent of total billed charges,Drugs,11,30,,11,percent of total billed charges,Drugs,11,30,,11,percent of total billed charges,Drugs,11,30,,11,percent of total billed charges,Drugs,11,30,,11,percent of total billed charges,Drugs,11,30,,11,percent of total billed charges,Drugs,11,30,,11,percent of total billed charges,Drugs,11,30,,11,percent of total billed charges,Drugs,11,30,,11,percent of total billed charges,Drugs,11,30,,11,percent of total billed charges,Drugs,11,30,,11,percent of total billed charges,Drugs,10.48,,,10.48,Other,Drug Cost,10.48,,,10.48,Other,Drug Cost,10.48,,,10.48,Other,Drug Cost,10.48,,,10.48,Other,Drug Cost,10.48,,,10.48,Other,Drug Cost,12.47,34,,12.47,percent of total billed charges,Drugs,10.48,,,10.48,Other,Drug Cost,23.58,,,23.58,Other,225% Medicaid APG methodology,14.67,,,14.67,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.13,,,1.13,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",10.48,,,10.48,Other,Drug Cost,10.48,,,10.48,Other,Drug Cost,13.1,,,13.1,Other,125% Medicaid APG methodology,0.01,23.58,
GADOTERIDOL 279.3 MG/ML 15 ML   ,A9579,HCPCS,,40505877,CDM,636,RC,00270-1111-02,NDC,both,15,ML,126.88,14.98,,,14.98,Other,150% of Medicare + 9.63% HCRA Surcharge,9.11,,,9.11,Fee Schedule,Average Sale Price (ASP) x 6,38.06,30,,38.06,percent of total billed charges,Drugs,38.06,30,,38.06,percent of total billed charges,Drugs,38.06,30,,38.06,percent of total billed charges,Drugs,38.06,30,,38.06,percent of total billed charges,Drugs,38.06,30,,38.06,percent of total billed charges,Drugs,63.44,50,,63.44,percent of total billed charges,All Other,38.06,30,,38.06,percent of total billed charges,Drugs,38.06,30,,38.06,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,38.06,30,,38.06,percent of total billed charges,Drugs,38.06,30,,38.06,percent of total billed charges,Drugs,38.06,30,,38.06,percent of total billed charges,Drugs,38.06,30,,38.06,percent of total billed charges,Drugs,38.06,30,,38.06,percent of total billed charges,Drugs,38.06,30,,38.06,percent of total billed charges,Drugs,38.06,30,,38.06,percent of total billed charges,Drugs,38.06,30,,38.06,percent of total billed charges,Drugs,38.06,30,,38.06,percent of total billed charges,Drugs,38.06,30,,38.06,percent of total billed charges,Drugs,38.06,30,,38.06,percent of total billed charges,Drugs,38.06,30,,38.06,percent of total billed charges,Drugs,38.06,30,,38.06,percent of total billed charges,Drugs,36.7,,,36.7,Other,Drug Cost,36.7,,,36.7,Other,Drug Cost,36.7,,,36.7,Other,Drug Cost,36.7,,,36.7,Other,Drug Cost,36.7,,,36.7,Other,Drug Cost,43.14,34,,43.14,percent of total billed charges,Drugs,36.7,,,36.7,Other,Drug Cost,82.58,,,82.58,Other,225% Medicaid APG methodology,51.38,,,51.38,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,14.57,,,14.57,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",36.7,,,36.7,Other,Drug Cost,36.7,,,36.7,Other,Drug Cost,45.88,,,45.88,Other,125% Medicaid APG methodology,0.01,82.58,
GADOTERIDOL 279.3 MG/ML 20 ML   ,A9579,HCPCS,,40505885,CDM,636,RC,00270-1111-03,NDC,both,20,ML,169.19,14.98,,,14.98,Other,150% of Medicare + 9.63% HCRA Surcharge,9.11,,,9.11,Fee Schedule,Average Sale Price (ASP) x 6,50.76,30,,50.76,percent of total billed charges,Drugs,50.76,30,,50.76,percent of total billed charges,Drugs,50.76,30,,50.76,percent of total billed charges,Drugs,50.76,30,,50.76,percent of total billed charges,Drugs,50.76,30,,50.76,percent of total billed charges,Drugs,84.6,50,,84.6,percent of total billed charges,All Other,50.76,30,,50.76,percent of total billed charges,Drugs,50.76,30,,50.76,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,50.76,30,,50.76,percent of total billed charges,Drugs,50.76,30,,50.76,percent of total billed charges,Drugs,50.76,30,,50.76,percent of total billed charges,Drugs,50.76,30,,50.76,percent of total billed charges,Drugs,50.76,30,,50.76,percent of total billed charges,Drugs,50.76,30,,50.76,percent of total billed charges,Drugs,50.76,30,,50.76,percent of total billed charges,Drugs,50.76,30,,50.76,percent of total billed charges,Drugs,50.76,30,,50.76,percent of total billed charges,Drugs,50.76,30,,50.76,percent of total billed charges,Drugs,50.76,30,,50.76,percent of total billed charges,Drugs,50.76,30,,50.76,percent of total billed charges,Drugs,50.76,30,,50.76,percent of total billed charges,Drugs,48.94,,,48.94,Other,Drug Cost,48.94,,,48.94,Other,Drug Cost,48.94,,,48.94,Other,Drug Cost,48.94,,,48.94,Other,Drug Cost,48.94,,,48.94,Other,Drug Cost,57.52,34,,57.52,percent of total billed charges,Drugs,48.94,,,48.94,Other,Drug Cost,110.12,,,110.12,Other,225% Medicaid APG methodology,68.52,,,68.52,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,14.57,,,14.57,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",48.94,,,48.94,Other,Drug Cost,48.94,,,48.94,Other,Drug Cost,61.18,,,61.18,Other,125% Medicaid APG methodology,0.01,110.12,
FORMOTEROL 20 MCG/2 ML IN 2 ML  ,J7606,HCPCS,,40505901,CDM,636,RC,49502-0605-30,NDC,both,2,ML,15.3,40.46,,,40.46,Other,150% of Medicare + 9.63% HCRA Surcharge,24.61,,,24.61,Fee Schedule,Average Sale Price (ASP) x 6,4.59,30,,4.59,percent of total billed charges,Drugs,4.59,30,,4.59,percent of total billed charges,Drugs,4.59,30,,4.59,percent of total billed charges,Drugs,4.59,30,,4.59,percent of total billed charges,Drugs,4.59,30,,4.59,percent of total billed charges,Drugs,7.65,50,,7.65,percent of total billed charges,All Other,4.59,30,,4.59,percent of total billed charges,Drugs,4.59,30,,4.59,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.59,30,,4.59,percent of total billed charges,Drugs,4.59,30,,4.59,percent of total billed charges,Drugs,4.59,30,,4.59,percent of total billed charges,Drugs,4.59,30,,4.59,percent of total billed charges,Drugs,4.59,30,,4.59,percent of total billed charges,Drugs,4.59,30,,4.59,percent of total billed charges,Drugs,4.59,30,,4.59,percent of total billed charges,Drugs,4.59,30,,4.59,percent of total billed charges,Drugs,4.59,30,,4.59,percent of total billed charges,Drugs,4.59,30,,4.59,percent of total billed charges,Drugs,4.59,30,,4.59,percent of total billed charges,Drugs,4.59,30,,4.59,percent of total billed charges,Drugs,4.59,30,,4.59,percent of total billed charges,Drugs,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,5.2,34,,5.2,percent of total billed charges,Drugs,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,39.37,,,39.37,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,40.46,
P LIDO 0.8%-D5W SOLN 250 ML     ,J2001,HCPCS,,40505919,CDM,636,RC,00264-9598-20,NDC,both,250,ML,26.64,0.27,,,0.27,Other,150% of Medicare + 9.63% HCRA Surcharge,0.16,,,0.16,Fee Schedule,Average Sale Price (ASP) x 6,7.99,30,,7.99,percent of total billed charges,Drugs,7.99,30,,7.99,percent of total billed charges,Drugs,7.99,30,,7.99,percent of total billed charges,Drugs,7.99,30,,7.99,percent of total billed charges,Drugs,7.99,30,,7.99,percent of total billed charges,Drugs,13.32,50,,13.32,percent of total billed charges,All Other,7.99,30,,7.99,percent of total billed charges,Drugs,7.99,30,,7.99,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,7.99,30,,7.99,percent of total billed charges,Drugs,7.99,30,,7.99,percent of total billed charges,Drugs,7.99,30,,7.99,percent of total billed charges,Drugs,7.99,30,,7.99,percent of total billed charges,Drugs,7.99,30,,7.99,percent of total billed charges,Drugs,7.99,30,,7.99,percent of total billed charges,Drugs,7.99,30,,7.99,percent of total billed charges,Drugs,7.99,30,,7.99,percent of total billed charges,Drugs,7.99,30,,7.99,percent of total billed charges,Drugs,7.99,30,,7.99,percent of total billed charges,Drugs,7.99,30,,7.99,percent of total billed charges,Drugs,7.99,30,,7.99,percent of total billed charges,Drugs,7.99,30,,7.99,percent of total billed charges,Drugs,7.61,,,7.61,Other,Drug Cost,7.61,,,7.61,Other,Drug Cost,7.61,,,7.61,Other,Drug Cost,7.61,,,7.61,Other,Drug Cost,7.61,,,7.61,Other,Drug Cost,9.06,34,,9.06,percent of total billed charges,Drugs,7.61,,,7.61,Other,Drug Cost,17.12,,,17.12,Other,225% Medicaid APG methodology,10.65,,,10.65,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.26,,,0.26,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",7.61,,,7.61,Other,Drug Cost,7.61,,,7.61,Other,Drug Cost,9.51,,,9.51,Other,125% Medicaid APG methodology,0.01,17.12,
IN AS-IN AS PRO 30-70 U/ML 10   ,J1815,HCPCS,,40506081,CDM,636,RC,00169-3685-12,NDC,both,10,ML,359.38,141.84,39.4668,,141.84,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,107.81,30,,107.81,percent of total billed charges,Drugs,107.81,30,,107.81,percent of total billed charges,Drugs,107.81,30,,107.81,percent of total billed charges,Drugs,107.81,30,,107.81,percent of total billed charges,Drugs,107.81,30,,107.81,percent of total billed charges,Drugs,179.69,50,,179.69,percent of total billed charges,All Other,107.81,30,,107.81,percent of total billed charges,Drugs,107.81,30,,107.81,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,107.81,30,,107.81,percent of total billed charges,Drugs,107.81,30,,107.81,percent of total billed charges,Drugs,107.81,30,,107.81,percent of total billed charges,Drugs,107.81,30,,107.81,percent of total billed charges,Drugs,107.81,30,,107.81,percent of total billed charges,Drugs,107.81,30,,107.81,percent of total billed charges,Drugs,107.81,30,,107.81,percent of total billed charges,Drugs,107.81,30,,107.81,percent of total billed charges,Drugs,107.81,30,,107.81,percent of total billed charges,Drugs,107.81,30,,107.81,percent of total billed charges,Drugs,107.81,30,,107.81,percent of total billed charges,Drugs,107.81,30,,107.81,percent of total billed charges,Drugs,107.81,30,,107.81,percent of total billed charges,Drugs,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,122.19,34,,122.19,percent of total billed charges,Drugs,0.09,,,0.09,Other,Drug Cost,0.2,,,0.2,Other,225% Medicaid APG methodology,0.13,,,0.13,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,179.69,
ATROPINE 0.05 MG/ML INJ 5 ML    ,J0461,HCPCS,,40506156,CDM,636,RC,00409-9630-05,NDC,both,5,ML,51.28,0.75,,,0.75,Other,150% of Medicare + 9.63% HCRA Surcharge,0.46,,,0.46,Fee Schedule,Average Sale Price (ASP) x 6,15.38,30,,15.38,percent of total billed charges,Drugs,15.38,30,,15.38,percent of total billed charges,Drugs,15.38,30,,15.38,percent of total billed charges,Drugs,15.38,30,,15.38,percent of total billed charges,Drugs,15.38,30,,15.38,percent of total billed charges,Drugs,25.64,50,,25.64,percent of total billed charges,All Other,15.38,30,,15.38,percent of total billed charges,Drugs,15.38,30,,15.38,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,15.38,30,,15.38,percent of total billed charges,Drugs,15.38,30,,15.38,percent of total billed charges,Drugs,15.38,30,,15.38,percent of total billed charges,Drugs,15.38,30,,15.38,percent of total billed charges,Drugs,15.38,30,,15.38,percent of total billed charges,Drugs,15.38,30,,15.38,percent of total billed charges,Drugs,15.38,30,,15.38,percent of total billed charges,Drugs,15.38,30,,15.38,percent of total billed charges,Drugs,15.38,30,,15.38,percent of total billed charges,Drugs,15.38,30,,15.38,percent of total billed charges,Drugs,15.38,30,,15.38,percent of total billed charges,Drugs,15.38,30,,15.38,percent of total billed charges,Drugs,15.38,30,,15.38,percent of total billed charges,Drugs,6.04,,,6.04,Other,Drug Cost,6.04,,,6.04,Other,Drug Cost,6.04,,,6.04,Other,Drug Cost,6.04,,,6.04,Other,Drug Cost,6.04,,,6.04,Other,Drug Cost,17.44,34,,17.44,percent of total billed charges,Drugs,6.04,,,6.04,Other,Drug Cost,13.59,,,13.59,Other,225% Medicaid APG methodology,8.46,,,8.46,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.73,,,0.73,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6.04,,,6.04,Other,Drug Cost,6.04,,,6.04,Other,Drug Cost,7.55,,,7.55,Other,125% Medicaid APG methodology,0.01,25.64,
DARBE ALFA 25 MCG/ML 1 ML ESRD  ,J0882,HCPCS,,40506172,CDM,636,RC,55513-0002-01,NDC,both,1,ML,660.31,28.91,,,28.91,Other,150% of Medicare + 9.63% HCRA Surcharge,17.58,,,17.58,Fee Schedule,Average Sale Price (ASP) x 6,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,330.16,50,,330.16,percent of total billed charges,All Other,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,224.51,34,"If Charge > 500, then 34 percent",224.51,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,50.29,,,50.29,Other,Drug Cost,50.29,,,50.29,Other,Drug Cost,50.29,,,50.29,Other,Drug Cost,50.29,,,50.29,Other,Drug Cost,50.29,,,50.29,Other,Drug Cost,224.51,34,,224.51,percent of total billed charges,Drugs,50.29,,,50.29,Other,Drug Cost,113.15,,,113.15,Other,225% Medicaid APG methodology,70.41,,,70.41,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,28.13,,,28.13,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",50.29,,,50.29,Other,Drug Cost,50.29,,,50.29,Other,Drug Cost,62.86,,,62.86,Other,125% Medicaid APG methodology,0.01,330.16,
DARBE ALFA 60 MCG/ML 1 ML ESRD  ,J0882,HCPCS,,40506180,CDM,636,RC,55513-0004-01,NDC,both,1,ML,1584.77,28.91,,,28.91,Other,150% of Medicare + 9.63% HCRA Surcharge,17.58,,,17.58,Fee Schedule,Average Sale Price (ASP) x 6,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,792.39,50,,792.39,percent of total billed charges,All Other,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,538.82,34,"If Charge > 500, then 34 percent",538.82,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,120.7,,,120.7,Other,Drug Cost,120.7,,,120.7,Other,Drug Cost,120.7,,,120.7,Other,Drug Cost,120.7,,,120.7,Other,Drug Cost,120.7,,,120.7,Other,Drug Cost,538.82,34,,538.82,percent of total billed charges,Drugs,120.7,,,120.7,Other,Drug Cost,271.58,,,271.58,Other,225% Medicaid APG methodology,168.98,,,168.98,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,28.13,,,28.13,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",120.7,,,120.7,Other,Drug Cost,120.7,,,120.7,Other,Drug Cost,150.88,,,150.88,Other,125% Medicaid APG methodology,0.01,792.39,
DARBE ALFA 40 MCG/0.4 ML ESRD   ,J0882,HCPCS,,40506198,CDM,636,RC,55513-0021-01,NDC,both,0.4,ML,1056.51,28.91,,,28.91,Other,150% of Medicare + 9.63% HCRA Surcharge,17.58,,,17.58,Fee Schedule,Average Sale Price (ASP) x 6,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,528.26,50,,528.26,percent of total billed charges,All Other,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,359.21,34,"If Charge > 500, then 34 percent",359.21,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,70.74,,,70.74,Other,Drug Cost,70.74,,,70.74,Other,Drug Cost,70.74,,,70.74,Other,Drug Cost,70.74,,,70.74,Other,Drug Cost,70.74,,,70.74,Other,Drug Cost,359.21,34,,359.21,percent of total billed charges,Drugs,70.74,,,70.74,Other,Drug Cost,159.17,,,159.17,Other,225% Medicaid APG methodology,99.04,,,99.04,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,28.13,,,28.13,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",70.74,,,70.74,Other,Drug Cost,70.74,,,70.74,Other,Drug Cost,88.43,,,88.43,Other,125% Medicaid APG methodology,0.01,528.26,
ALBUMIN HUMAN 5% IV SOLN 50 ML  ,P9041,HCPCS,,40506222,CDM,636,RC,68516-5214-05,NDC,both,50,ML,89.32,104.74,,,104.74,Other,150% of Medicare + 9.63% HCRA Surcharge,63.69,,,63.69,Fee Schedule,Average Sale Price (ASP) x 6,26.8,30,,26.8,percent of total billed charges,Drugs,26.8,30,,26.8,percent of total billed charges,Drugs,26.8,30,,26.8,percent of total billed charges,Drugs,26.8,30,,26.8,percent of total billed charges,Drugs,26.8,30,,26.8,percent of total billed charges,Drugs,44.66,50,,44.66,percent of total billed charges,All Other,26.8,30,,26.8,percent of total billed charges,Drugs,26.8,30,,26.8,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,26.8,30,,26.8,percent of total billed charges,Drugs,26.8,30,,26.8,percent of total billed charges,Drugs,26.8,30,,26.8,percent of total billed charges,Drugs,26.8,30,,26.8,percent of total billed charges,Drugs,26.8,30,,26.8,percent of total billed charges,Drugs,26.8,30,,26.8,percent of total billed charges,Drugs,26.8,30,,26.8,percent of total billed charges,Drugs,26.8,30,,26.8,percent of total billed charges,Drugs,26.8,30,,26.8,percent of total billed charges,Drugs,26.8,30,,26.8,percent of total billed charges,Drugs,26.8,30,,26.8,percent of total billed charges,Drugs,26.8,30,,26.8,percent of total billed charges,Drugs,26.8,30,,26.8,percent of total billed charges,Drugs,5.2,,,5.2,Other,Drug Cost,5.2,,,5.2,Other,Drug Cost,5.2,,,5.2,Other,Drug Cost,5.2,,,5.2,Other,Drug Cost,5.2,,,5.2,Other,Drug Cost,30.37,34,,30.37,percent of total billed charges,Drugs,5.2,,,5.2,Other,Drug Cost,11.7,,,11.7,Other,225% Medicaid APG methodology,7.28,,,7.28,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,101.9,,,101.9,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.2,,,5.2,Other,Drug Cost,5.2,,,5.2,Other,Drug Cost,6.5,,,6.5,Other,125% Medicaid APG methodology,0.01,104.74,
BUTORPHANOL 1 MG/ML INJ 1 ML    ,J0595,HCPCS,,40506248,CDM,636,RC,00409-1623-01,NDC,both,1,ML,15.37,27.61,,,27.61,Other,150% of Medicare + 9.63% HCRA Surcharge,16.79,,,16.79,Fee Schedule,Average Sale Price (ASP) x 6,4.61,30,,4.61,percent of total billed charges,Drugs,4.61,30,,4.61,percent of total billed charges,Drugs,4.61,30,,4.61,percent of total billed charges,Drugs,4.61,30,,4.61,percent of total billed charges,Drugs,4.61,30,,4.61,percent of total billed charges,Drugs,7.69,50,,7.69,percent of total billed charges,All Other,4.61,30,,4.61,percent of total billed charges,Drugs,4.61,30,,4.61,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.61,30,,4.61,percent of total billed charges,Drugs,4.61,30,,4.61,percent of total billed charges,Drugs,4.61,30,,4.61,percent of total billed charges,Drugs,4.61,30,,4.61,percent of total billed charges,Drugs,4.61,30,,4.61,percent of total billed charges,Drugs,4.61,30,,4.61,percent of total billed charges,Drugs,4.61,30,,4.61,percent of total billed charges,Drugs,4.61,30,,4.61,percent of total billed charges,Drugs,4.61,30,,4.61,percent of total billed charges,Drugs,4.61,30,,4.61,percent of total billed charges,Drugs,4.61,30,,4.61,percent of total billed charges,Drugs,4.61,30,,4.61,percent of total billed charges,Drugs,4.61,30,,4.61,percent of total billed charges,Drugs,2.3,,,2.3,Other,Drug Cost,2.3,,,2.3,Other,Drug Cost,2.3,,,2.3,Other,Drug Cost,2.3,,,2.3,Other,Drug Cost,2.3,,,2.3,Other,Drug Cost,5.23,34,,5.23,percent of total billed charges,Drugs,2.3,,,2.3,Other,Drug Cost,5.18,,,5.18,Other,225% Medicaid APG methodology,3.22,,,3.22,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,26.86,,,26.86,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.3,,,2.3,Other,Drug Cost,2.3,,,2.3,Other,Drug Cost,2.88,,,2.88,Other,125% Medicaid APG methodology,0.01,27.61,
DOXERCALCIFEROL 2 MCG/ML 2 ML   ,J1270,HCPCS,,40506289,CDM,636,RC,71288-0802-04,NDC,both,2,ML,9.77,3.73,,,3.73,Other,150% of Medicare + 9.63% HCRA Surcharge,2.27,,,2.27,Fee Schedule,Average Sale Price (ASP) x 6,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,4.89,50,,4.89,percent of total billed charges,All Other,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,1.06,,,1.06,Other,Drug Cost,1.06,,,1.06,Other,Drug Cost,1.06,,,1.06,Other,Drug Cost,1.06,,,1.06,Other,Drug Cost,1.06,,,1.06,Other,Drug Cost,3.32,34,,3.32,percent of total billed charges,Drugs,1.06,,,1.06,Other,Drug Cost,2.39,,,2.39,Other,225% Medicaid APG methodology,1.48,,,1.48,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,3.63,,,3.63,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.06,,,1.06,Other,Drug Cost,1.06,,,1.06,Other,Drug Cost,1.33,,,1.33,Other,125% Medicaid APG methodology,0.01,4.89,
HEP 1000 UNITS/ML INJ  30 ML    ,J1643,HCPCS,,40506297,CDM,636,RC,63323-0540-36,NDC,both,30,ML,17.22,45.19,,,45.19,Other,150% of Medicare + 9.63% HCRA Surcharge,27.48,,,27.48,Fee Schedule,Average Sale Price (ASP) x 6,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,8.61,50,,8.61,percent of total billed charges,All Other,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,3.98,,,3.98,Other,Drug Cost,3.98,,,3.98,Other,Drug Cost,3.98,,,3.98,Other,Drug Cost,3.98,,,3.98,Other,Drug Cost,3.98,,,3.98,Other,Drug Cost,5.85,34,,5.85,percent of total billed charges,Drugs,3.98,,,3.98,Other,Drug Cost,8.96,,,8.96,Other,225% Medicaid APG methodology,5.57,,,5.57,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,43.97,,,43.97,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.98,,,3.98,Other,Drug Cost,3.98,,,3.98,Other,Drug Cost,4.98,,,4.98,Other,125% Medicaid APG methodology,0.01,45.19,
HEP 1000 UNIT(S) IN NS 500 ML   ,J1644,HCPCS,,40506438,CDM,636,RC,00409-1005-20,NDC,both,500,ML,12.36,2.64,,,2.64,Other,150% of Medicare + 9.63% HCRA Surcharge,1.61,,,1.61,Fee Schedule,Average Sale Price (ASP) x 6,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,6.18,50,,6.18,percent of total billed charges,All Other,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,4.53,,,4.53,Other,Drug Cost,4.53,,,4.53,Other,Drug Cost,4.53,,,4.53,Other,Drug Cost,4.53,,,4.53,Other,Drug Cost,4.53,,,4.53,Other,Drug Cost,4.2,34,,4.2,percent of total billed charges,Drugs,4.53,,,4.53,Other,Drug Cost,10.19,,,10.19,Other,225% Medicaid APG methodology,6.34,,,6.34,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.57,,,2.57,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.53,,,4.53,Other,Drug Cost,4.53,,,4.53,Other,Drug Cost,5.66,,,5.66,Other,125% Medicaid APG methodology,0.01,10.19,
IOPAMIDOL 76% INJ SOLN 150 ML   ,Q9967,HCPCS,,40506453,CDM,636,RC,00270-1316-37,NDC,both,150,ML,246.12,1.16,,,1.16,Other,150% of Medicare + 9.63% HCRA Surcharge,0.71,,,0.71,Fee Schedule,Average Sale Price (ASP) x 6,73.84,30,,73.84,percent of total billed charges,Drugs,73.84,30,,73.84,percent of total billed charges,Drugs,73.84,30,,73.84,percent of total billed charges,Drugs,73.84,30,,73.84,percent of total billed charges,Drugs,73.84,30,,73.84,percent of total billed charges,Drugs,123.06,50,,123.06,percent of total billed charges,All Other,73.84,30,,73.84,percent of total billed charges,Drugs,73.84,30,,73.84,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,73.84,30,,73.84,percent of total billed charges,Drugs,73.84,30,,73.84,percent of total billed charges,Drugs,73.84,30,,73.84,percent of total billed charges,Drugs,73.84,30,,73.84,percent of total billed charges,Drugs,73.84,30,,73.84,percent of total billed charges,Drugs,73.84,30,,73.84,percent of total billed charges,Drugs,73.84,30,,73.84,percent of total billed charges,Drugs,73.84,30,,73.84,percent of total billed charges,Drugs,73.84,30,,73.84,percent of total billed charges,Drugs,73.84,30,,73.84,percent of total billed charges,Drugs,73.84,30,,73.84,percent of total billed charges,Drugs,73.84,30,,73.84,percent of total billed charges,Drugs,73.84,30,,73.84,percent of total billed charges,Drugs,70.32,,,70.32,Other,Drug Cost,70.32,,,70.32,Other,Drug Cost,70.32,,,70.32,Other,Drug Cost,70.32,,,70.32,Other,Drug Cost,70.32,,,70.32,Other,Drug Cost,83.68,34,,83.68,percent of total billed charges,Drugs,70.32,,,70.32,Other,Drug Cost,158.22,,,158.22,Other,225% Medicaid APG methodology,98.45,,,98.45,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.13,,,1.13,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",70.32,,,70.32,Other,Drug Cost,70.32,,,70.32,Other,Drug Cost,87.9,,,87.9,Other,125% Medicaid APG methodology,0.01,158.22,
IOPAMIDOL 61% INJ SOLN 30 ML    ,Q9967,HCPCS,,40506487,CDM,636,RC,00270-1315-25,NDC,both,30,ML,17.64,1.16,,,1.16,Other,150% of Medicare + 9.63% HCRA Surcharge,0.71,,,0.71,Fee Schedule,Average Sale Price (ASP) x 6,5.29,30,,5.29,percent of total billed charges,Drugs,5.29,30,,5.29,percent of total billed charges,Drugs,5.29,30,,5.29,percent of total billed charges,Drugs,5.29,30,,5.29,percent of total billed charges,Drugs,5.29,30,,5.29,percent of total billed charges,Drugs,8.82,50,,8.82,percent of total billed charges,All Other,5.29,30,,5.29,percent of total billed charges,Drugs,5.29,30,,5.29,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,5.29,30,,5.29,percent of total billed charges,Drugs,5.29,30,,5.29,percent of total billed charges,Drugs,5.29,30,,5.29,percent of total billed charges,Drugs,5.29,30,,5.29,percent of total billed charges,Drugs,5.29,30,,5.29,percent of total billed charges,Drugs,5.29,30,,5.29,percent of total billed charges,Drugs,5.29,30,,5.29,percent of total billed charges,Drugs,5.29,30,,5.29,percent of total billed charges,Drugs,5.29,30,,5.29,percent of total billed charges,Drugs,5.29,30,,5.29,percent of total billed charges,Drugs,5.29,30,,5.29,percent of total billed charges,Drugs,5.29,30,,5.29,percent of total billed charges,Drugs,5.29,30,,5.29,percent of total billed charges,Drugs,5.04,,,5.04,Other,Drug Cost,5.04,,,5.04,Other,Drug Cost,5.04,,,5.04,Other,Drug Cost,5.04,,,5.04,Other,Drug Cost,5.04,,,5.04,Other,Drug Cost,6,34,,6,percent of total billed charges,Drugs,5.04,,,5.04,Other,Drug Cost,11.34,,,11.34,Other,225% Medicaid APG methodology,7.06,,,7.06,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.13,,,1.13,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.04,,,5.04,Other,Drug Cost,5.04,,,5.04,Other,Drug Cost,6.3,,,6.3,Other,125% Medicaid APG methodology,0.01,11.34,
DIATRIZOA MEGLUMINE 30% 300 ML  ,Q9958,HCPCS,,40506495,CDM,636,RC,00270-0149-57,NDC,both,300,ML,87.89,0.83,,,0.83,Other,150% of Medicare + 9.63% HCRA Surcharge,0.5,,,0.5,Fee Schedule,Average Sale Price (ASP) x 6,26.37,30,,26.37,percent of total billed charges,Drugs,26.37,30,,26.37,percent of total billed charges,Drugs,26.37,30,,26.37,percent of total billed charges,Drugs,26.37,30,,26.37,percent of total billed charges,Drugs,26.37,30,,26.37,percent of total billed charges,Drugs,43.95,50,,43.95,percent of total billed charges,All Other,26.37,30,,26.37,percent of total billed charges,Drugs,26.37,30,,26.37,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,26.37,30,,26.37,percent of total billed charges,Drugs,26.37,30,,26.37,percent of total billed charges,Drugs,26.37,30,,26.37,percent of total billed charges,Drugs,26.37,30,,26.37,percent of total billed charges,Drugs,26.37,30,,26.37,percent of total billed charges,Drugs,26.37,30,,26.37,percent of total billed charges,Drugs,26.37,30,,26.37,percent of total billed charges,Drugs,26.37,30,,26.37,percent of total billed charges,Drugs,26.37,30,,26.37,percent of total billed charges,Drugs,26.37,30,,26.37,percent of total billed charges,Drugs,26.37,30,,26.37,percent of total billed charges,Drugs,26.37,30,,26.37,percent of total billed charges,Drugs,26.37,30,,26.37,percent of total billed charges,Drugs,38.47,,,38.47,Other,Drug Cost,38.47,,,38.47,Other,Drug Cost,38.47,,,38.47,Other,Drug Cost,38.47,,,38.47,Other,Drug Cost,38.47,,,38.47,Other,Drug Cost,29.88,34,,29.88,percent of total billed charges,Drugs,38.47,,,38.47,Other,Drug Cost,86.56,,,86.56,Other,225% Medicaid APG methodology,53.86,,,53.86,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.81,,,0.81,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",38.47,,,38.47,Other,Drug Cost,38.47,,,38.47,Other,Drug Cost,48.09,,,48.09,Other,125% Medicaid APG methodology,0.01,86.56,
GADOTERIDOL 279.3 MG/ML 10 ML   ,A9579,HCPCS,,40506503,CDM,636,RC,00270-1111-01,NDC,both,10,ML,86.21,14.98,,,14.98,Other,150% of Medicare + 9.63% HCRA Surcharge,9.11,,,9.11,Fee Schedule,Average Sale Price (ASP) x 6,25.86,30,,25.86,percent of total billed charges,Drugs,25.86,30,,25.86,percent of total billed charges,Drugs,25.86,30,,25.86,percent of total billed charges,Drugs,25.86,30,,25.86,percent of total billed charges,Drugs,25.86,30,,25.86,percent of total billed charges,Drugs,43.11,50,,43.11,percent of total billed charges,All Other,25.86,30,,25.86,percent of total billed charges,Drugs,25.86,30,,25.86,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,25.86,30,,25.86,percent of total billed charges,Drugs,25.86,30,,25.86,percent of total billed charges,Drugs,25.86,30,,25.86,percent of total billed charges,Drugs,25.86,30,,25.86,percent of total billed charges,Drugs,25.86,30,,25.86,percent of total billed charges,Drugs,25.86,30,,25.86,percent of total billed charges,Drugs,25.86,30,,25.86,percent of total billed charges,Drugs,25.86,30,,25.86,percent of total billed charges,Drugs,25.86,30,,25.86,percent of total billed charges,Drugs,25.86,30,,25.86,percent of total billed charges,Drugs,25.86,30,,25.86,percent of total billed charges,Drugs,25.86,30,,25.86,percent of total billed charges,Drugs,25.86,30,,25.86,percent of total billed charges,Drugs,24.47,,,24.47,Other,Drug Cost,24.47,,,24.47,Other,Drug Cost,24.47,,,24.47,Other,Drug Cost,24.47,,,24.47,Other,Drug Cost,24.47,,,24.47,Other,Drug Cost,29.31,34,,29.31,percent of total billed charges,Drugs,24.47,,,24.47,Other,Drug Cost,55.06,,,55.06,Other,225% Medicaid APG methodology,34.26,,,34.26,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,14.57,,,14.57,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",24.47,,,24.47,Other,Drug Cost,24.47,,,24.47,Other,Drug Cost,30.59,,,30.59,Other,125% Medicaid APG methodology,0.01,55.06,
NA TETRADECYL SULF 1% INJ 2 ML  ,J3490,HCPCS,,40506552,CDM,636,RC,67457-0162-02,NDC,both,2,ML,241.4,95.27,39.4668,,95.27,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,72.42,30,,72.42,percent of total billed charges,Drugs,72.42,30,,72.42,percent of total billed charges,Drugs,72.42,30,,72.42,percent of total billed charges,Drugs,72.42,30,,72.42,percent of total billed charges,Drugs,72.42,30,,72.42,percent of total billed charges,Drugs,120.7,50,,120.7,percent of total billed charges,All Other,72.42,30,,72.42,percent of total billed charges,Drugs,72.42,30,,72.42,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,72.42,30,,72.42,percent of total billed charges,Drugs,72.42,30,,72.42,percent of total billed charges,Drugs,72.42,30,,72.42,percent of total billed charges,Drugs,72.42,30,,72.42,percent of total billed charges,Drugs,72.42,30,,72.42,percent of total billed charges,Drugs,72.42,30,,72.42,percent of total billed charges,Drugs,72.42,30,,72.42,percent of total billed charges,Drugs,72.42,30,,72.42,percent of total billed charges,Drugs,72.42,30,,72.42,percent of total billed charges,Drugs,72.42,30,,72.42,percent of total billed charges,Drugs,72.42,30,,72.42,percent of total billed charges,Drugs,72.42,30,,72.42,percent of total billed charges,Drugs,72.42,30,,72.42,percent of total billed charges,Drugs,32.34,,,32.34,Other,Drug Cost,32.34,,,32.34,Other,Drug Cost,32.34,,,32.34,Other,Drug Cost,32.34,,,32.34,Other,Drug Cost,32.34,,,32.34,Other,Drug Cost,82.08,34,,82.08,percent of total billed charges,Drugs,32.34,,,32.34,Other,Drug Cost,72.77,,,72.77,Other,225% Medicaid APG methodology,45.28,,,45.28,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",32.34,,,32.34,Other,Drug Cost,32.34,,,32.34,Other,Drug Cost,40.43,,,40.43,Other,125% Medicaid APG methodology,0.01,120.7,
IOPAMIDOL 76% INJ SOLN 125 ML   ,Q9967,HCPCS,,40506560,CDM,636,RC,00270-1316-04,NDC,both,125,ML,210.28,1.16,,,1.16,Other,150% of Medicare + 9.63% HCRA Surcharge,0.71,,,0.71,Fee Schedule,Average Sale Price (ASP) x 6,63.08,30,,63.08,percent of total billed charges,Drugs,63.08,30,,63.08,percent of total billed charges,Drugs,63.08,30,,63.08,percent of total billed charges,Drugs,63.08,30,,63.08,percent of total billed charges,Drugs,63.08,30,,63.08,percent of total billed charges,Drugs,105.14,50,,105.14,percent of total billed charges,All Other,63.08,30,,63.08,percent of total billed charges,Drugs,63.08,30,,63.08,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,63.08,30,,63.08,percent of total billed charges,Drugs,63.08,30,,63.08,percent of total billed charges,Drugs,63.08,30,,63.08,percent of total billed charges,Drugs,63.08,30,,63.08,percent of total billed charges,Drugs,63.08,30,,63.08,percent of total billed charges,Drugs,63.08,30,,63.08,percent of total billed charges,Drugs,63.08,30,,63.08,percent of total billed charges,Drugs,63.08,30,,63.08,percent of total billed charges,Drugs,63.08,30,,63.08,percent of total billed charges,Drugs,63.08,30,,63.08,percent of total billed charges,Drugs,63.08,30,,63.08,percent of total billed charges,Drugs,63.08,30,,63.08,percent of total billed charges,Drugs,63.08,30,,63.08,percent of total billed charges,Drugs,60.08,,,60.08,Other,Drug Cost,60.08,,,60.08,Other,Drug Cost,60.08,,,60.08,Other,Drug Cost,60.08,,,60.08,Other,Drug Cost,60.08,,,60.08,Other,Drug Cost,71.5,34,,71.5,percent of total billed charges,Drugs,60.08,,,60.08,Other,Drug Cost,135.18,,,135.18,Other,225% Medicaid APG methodology,84.11,,,84.11,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.13,,,1.13,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",60.08,,,60.08,Other,Drug Cost,60.08,,,60.08,Other,Drug Cost,75.1,,,75.1,Other,125% Medicaid APG methodology,0.01,135.18,
IOPAMIDOL 76% INJ SOLN 200 ML   ,Q9967,HCPCS,,40506578,CDM,636,RC,00270-1316-45,NDC,both,200,ML,75.43,1.16,,,1.16,Other,150% of Medicare + 9.63% HCRA Surcharge,0.71,,,0.71,Fee Schedule,Average Sale Price (ASP) x 6,22.63,30,,22.63,percent of total billed charges,Drugs,22.63,30,,22.63,percent of total billed charges,Drugs,22.63,30,,22.63,percent of total billed charges,Drugs,22.63,30,,22.63,percent of total billed charges,Drugs,22.63,30,,22.63,percent of total billed charges,Drugs,37.72,50,,37.72,percent of total billed charges,All Other,22.63,30,,22.63,percent of total billed charges,Drugs,22.63,30,,22.63,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,22.63,30,,22.63,percent of total billed charges,Drugs,22.63,30,,22.63,percent of total billed charges,Drugs,22.63,30,,22.63,percent of total billed charges,Drugs,22.63,30,,22.63,percent of total billed charges,Drugs,22.63,30,,22.63,percent of total billed charges,Drugs,22.63,30,,22.63,percent of total billed charges,Drugs,22.63,30,,22.63,percent of total billed charges,Drugs,22.63,30,,22.63,percent of total billed charges,Drugs,22.63,30,,22.63,percent of total billed charges,Drugs,22.63,30,,22.63,percent of total billed charges,Drugs,22.63,30,,22.63,percent of total billed charges,Drugs,22.63,30,,22.63,percent of total billed charges,Drugs,22.63,30,,22.63,percent of total billed charges,Drugs,21.55,,,21.55,Other,Drug Cost,21.55,,,21.55,Other,Drug Cost,21.55,,,21.55,Other,Drug Cost,21.55,,,21.55,Other,Drug Cost,21.55,,,21.55,Other,Drug Cost,25.65,34,,25.65,percent of total billed charges,Drugs,21.55,,,21.55,Other,Drug Cost,48.49,,,48.49,Other,225% Medicaid APG methodology,30.17,,,30.17,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.13,,,1.13,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",21.55,,,21.55,Other,Drug Cost,21.55,,,21.55,Other,Drug Cost,26.94,,,26.94,Other,125% Medicaid APG methodology,0.01,48.49,
IOPAMIDOL 61% INJ SOLN 200 ML   ,Q9967,HCPCS,,40506586,CDM,636,RC,00270-1315-45,NDC,both,200,ML,70.7,1.16,,,1.16,Other,150% of Medicare + 9.63% HCRA Surcharge,0.71,,,0.71,Fee Schedule,Average Sale Price (ASP) x 6,21.21,30,,21.21,percent of total billed charges,Drugs,21.21,30,,21.21,percent of total billed charges,Drugs,21.21,30,,21.21,percent of total billed charges,Drugs,21.21,30,,21.21,percent of total billed charges,Drugs,21.21,30,,21.21,percent of total billed charges,Drugs,35.35,50,,35.35,percent of total billed charges,All Other,21.21,30,,21.21,percent of total billed charges,Drugs,21.21,30,,21.21,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,21.21,30,,21.21,percent of total billed charges,Drugs,21.21,30,,21.21,percent of total billed charges,Drugs,21.21,30,,21.21,percent of total billed charges,Drugs,21.21,30,,21.21,percent of total billed charges,Drugs,21.21,30,,21.21,percent of total billed charges,Drugs,21.21,30,,21.21,percent of total billed charges,Drugs,21.21,30,,21.21,percent of total billed charges,Drugs,21.21,30,,21.21,percent of total billed charges,Drugs,21.21,30,,21.21,percent of total billed charges,Drugs,21.21,30,,21.21,percent of total billed charges,Drugs,21.21,30,,21.21,percent of total billed charges,Drugs,21.21,30,,21.21,percent of total billed charges,Drugs,21.21,30,,21.21,percent of total billed charges,Drugs,20.2,,,20.2,Other,Drug Cost,20.2,,,20.2,Other,Drug Cost,20.2,,,20.2,Other,Drug Cost,20.2,,,20.2,Other,Drug Cost,20.2,,,20.2,Other,Drug Cost,24.04,34,,24.04,percent of total billed charges,Drugs,20.2,,,20.2,Other,Drug Cost,45.45,,,45.45,Other,225% Medicaid APG methodology,28.28,,,28.28,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.13,,,1.13,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",20.2,,,20.2,Other,Drug Cost,20.2,,,20.2,Other,Drug Cost,25.25,,,25.25,Other,125% Medicaid APG methodology,0.01,45.45,
ILOPROST 20 MCG/ML INH 1 ML     ,Q4074,HCPCS,,40506602,CDM,636,RC,66215-0303-30,NDC,both,1,ML,260.4,1447.11,,,1447.11,Other,150% of Medicare + 9.63% HCRA Surcharge,880,,,880,Fee Schedule,Average Sale Price (ASP) x 6,78.12,30,,78.12,percent of total billed charges,Drugs,78.12,30,,78.12,percent of total billed charges,Drugs,78.12,30,,78.12,percent of total billed charges,Drugs,78.12,30,,78.12,percent of total billed charges,Drugs,78.12,30,,78.12,percent of total billed charges,Drugs,130.2,50,,130.2,percent of total billed charges,All Other,78.12,30,,78.12,percent of total billed charges,Drugs,78.12,30,,78.12,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,78.12,30,,78.12,percent of total billed charges,Drugs,78.12,30,,78.12,percent of total billed charges,Drugs,78.12,30,,78.12,percent of total billed charges,Drugs,78.12,30,,78.12,percent of total billed charges,Drugs,78.12,30,,78.12,percent of total billed charges,Drugs,78.12,30,,78.12,percent of total billed charges,Drugs,78.12,30,,78.12,percent of total billed charges,Drugs,78.12,30,,78.12,percent of total billed charges,Drugs,78.12,30,,78.12,percent of total billed charges,Drugs,78.12,30,,78.12,percent of total billed charges,Drugs,78.12,30,,78.12,percent of total billed charges,Drugs,78.12,30,,78.12,percent of total billed charges,Drugs,78.12,30,,78.12,percent of total billed charges,Drugs,74.4,,,74.4,Other,Drug Cost,74.4,,,74.4,Other,Drug Cost,74.4,,,74.4,Other,Drug Cost,74.4,,,74.4,Other,Drug Cost,74.4,,,74.4,Other,Drug Cost,88.54,34,,88.54,percent of total billed charges,Drugs,74.4,,,74.4,Other,Drug Cost,167.4,,,167.4,Other,225% Medicaid APG methodology,104.16,,,104.16,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1407.99,,,1407.99,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",74.4,,,74.4,Other,Drug Cost,74.4,,,74.4,Other,Drug Cost,93,,,93,Other,125% Medicaid APG methodology,0.01,1447.11,
CLEVIDIPINE 0.5 MG/ML IV 50 ML  ,C9248,HCPCS,,40506610,CDM,636,RC,10122-0610-10,NDC,both,50,ML,209.93,82.85,39.4668,,82.85,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,62.98,30,,62.98,percent of total billed charges,Drugs,62.98,30,,62.98,percent of total billed charges,Drugs,62.98,30,,62.98,percent of total billed charges,Drugs,62.98,30,,62.98,percent of total billed charges,Drugs,62.98,30,,62.98,percent of total billed charges,Drugs,104.97,50,,104.97,percent of total billed charges,All Other,62.98,30,,62.98,percent of total billed charges,Drugs,62.98,30,,62.98,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,62.98,30,,62.98,percent of total billed charges,Drugs,62.98,30,,62.98,percent of total billed charges,Drugs,62.98,30,,62.98,percent of total billed charges,Drugs,62.98,30,,62.98,percent of total billed charges,Drugs,62.98,30,,62.98,percent of total billed charges,Drugs,62.98,30,,62.98,percent of total billed charges,Drugs,62.98,30,,62.98,percent of total billed charges,Drugs,62.98,30,,62.98,percent of total billed charges,Drugs,62.98,30,,62.98,percent of total billed charges,Drugs,62.98,30,,62.98,percent of total billed charges,Drugs,62.98,30,,62.98,percent of total billed charges,Drugs,62.98,30,,62.98,percent of total billed charges,Drugs,62.98,30,,62.98,percent of total billed charges,Drugs,47.2,,,47.2,Other,Drug Cost,47.2,,,47.2,Other,Drug Cost,47.2,,,47.2,Other,Drug Cost,47.2,,,47.2,Other,Drug Cost,47.2,,,47.2,Other,Drug Cost,71.38,34,,71.38,percent of total billed charges,Drugs,47.2,,,47.2,Other,Drug Cost,106.2,,,106.2,Other,225% Medicaid APG methodology,66.08,,,66.08,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",47.2,,,47.2,Other,Drug Cost,47.2,,,47.2,Other,Drug Cost,59,,,59,Other,125% Medicaid APG methodology,0.01,106.2,
ADENOSINE 3 MG/ML IV SOL 20 ML  ,J0153,HCPCS,,40506628,CDM,636,RC,00409-1932-01,NDC,both,20,ML,374.61,5.93,,,5.93,Other,150% of Medicare + 9.63% HCRA Surcharge,3.61,,,3.61,Fee Schedule,Average Sale Price (ASP) x 6,112.38,30,,112.38,percent of total billed charges,Drugs,112.38,30,,112.38,percent of total billed charges,Drugs,112.38,30,,112.38,percent of total billed charges,Drugs,112.38,30,,112.38,percent of total billed charges,Drugs,112.38,30,,112.38,percent of total billed charges,Drugs,187.31,50,,187.31,percent of total billed charges,All Other,112.38,30,,112.38,percent of total billed charges,Drugs,112.38,30,,112.38,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,112.38,30,,112.38,percent of total billed charges,Drugs,112.38,30,,112.38,percent of total billed charges,Drugs,112.38,30,,112.38,percent of total billed charges,Drugs,112.38,30,,112.38,percent of total billed charges,Drugs,112.38,30,,112.38,percent of total billed charges,Drugs,112.38,30,,112.38,percent of total billed charges,Drugs,112.38,30,,112.38,percent of total billed charges,Drugs,112.38,30,,112.38,percent of total billed charges,Drugs,112.38,30,,112.38,percent of total billed charges,Drugs,112.38,30,,112.38,percent of total billed charges,Drugs,112.38,30,,112.38,percent of total billed charges,Drugs,112.38,30,,112.38,percent of total billed charges,Drugs,112.38,30,,112.38,percent of total billed charges,Drugs,107.03,,,107.03,Other,Drug Cost,107.03,,,107.03,Other,Drug Cost,107.03,,,107.03,Other,Drug Cost,107.03,,,107.03,Other,Drug Cost,107.03,,,107.03,Other,Drug Cost,127.37,34,,127.37,percent of total billed charges,Drugs,107.03,,,107.03,Other,Drug Cost,240.82,,,240.82,Other,225% Medicaid APG methodology,149.84,,,149.84,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,5.77,,,5.77,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",107.03,,,107.03,Other,Drug Cost,107.03,,,107.03,Other,Drug Cost,133.79,,,133.79,Other,125% Medicaid APG methodology,0.01,240.82,
HYDROMORPHONE 15 MG/NS 30 ML    ,J1170,HCPCS,,40506735,CDM,636,RC,00409-2634-01a,NDC,both,30,ML,21.98,45.3,,,45.3,Other,150% of Medicare + 9.63% HCRA Surcharge,27.55,,,27.55,Fee Schedule,Average Sale Price (ASP) x 6,6.59,30,,6.59,percent of total billed charges,Drugs,6.59,30,,6.59,percent of total billed charges,Drugs,6.59,30,,6.59,percent of total billed charges,Drugs,6.59,30,,6.59,percent of total billed charges,Drugs,6.59,30,,6.59,percent of total billed charges,Drugs,10.99,50,,10.99,percent of total billed charges,All Other,6.59,30,,6.59,percent of total billed charges,Drugs,6.59,30,,6.59,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,6.59,30,,6.59,percent of total billed charges,Drugs,6.59,30,,6.59,percent of total billed charges,Drugs,6.59,30,,6.59,percent of total billed charges,Drugs,6.59,30,,6.59,percent of total billed charges,Drugs,6.59,30,,6.59,percent of total billed charges,Drugs,6.59,30,,6.59,percent of total billed charges,Drugs,6.59,30,,6.59,percent of total billed charges,Drugs,6.59,30,,6.59,percent of total billed charges,Drugs,6.59,30,,6.59,percent of total billed charges,Drugs,6.59,30,,6.59,percent of total billed charges,Drugs,6.59,30,,6.59,percent of total billed charges,Drugs,6.59,30,,6.59,percent of total billed charges,Drugs,6.59,30,,6.59,percent of total billed charges,Drugs,6.28,,,6.28,Other,Drug Cost,6.28,,,6.28,Other,Drug Cost,6.28,,,6.28,Other,Drug Cost,6.28,,,6.28,Other,Drug Cost,6.28,,,6.28,Other,Drug Cost,7.47,34,,7.47,percent of total billed charges,Drugs,6.28,,,6.28,Other,Drug Cost,14.13,,,14.13,Other,225% Medicaid APG methodology,8.79,,,8.79,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,44.07,,,44.07,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6.28,,,6.28,Other,Drug Cost,6.28,,,6.28,Other,Drug Cost,7.85,,,7.85,Other,125% Medicaid APG methodology,0.01,45.3,
BUPIV-MELOX 200-6 MG/7 ML ER    ,C9088,HCPCS,,40506743,CDM,636,RC,47426-0303-01,NDC,both,7,ML,457.28,180.47,39.4668,,180.47,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,137.18,30,,137.18,percent of total billed charges,Drugs,137.18,30,,137.18,percent of total billed charges,Drugs,137.18,30,,137.18,percent of total billed charges,Drugs,137.18,30,,137.18,percent of total billed charges,Drugs,137.18,30,,137.18,percent of total billed charges,Drugs,228.64,50,,228.64,percent of total billed charges,All Other,137.18,30,,137.18,percent of total billed charges,Drugs,137.18,30,,137.18,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,137.18,30,,137.18,percent of total billed charges,Drugs,137.18,30,,137.18,percent of total billed charges,Drugs,137.18,30,,137.18,percent of total billed charges,Drugs,137.18,30,,137.18,percent of total billed charges,Drugs,137.18,30,,137.18,percent of total billed charges,Drugs,137.18,30,,137.18,percent of total billed charges,Drugs,137.18,30,,137.18,percent of total billed charges,Drugs,137.18,30,,137.18,percent of total billed charges,Drugs,137.18,30,,137.18,percent of total billed charges,Drugs,137.18,30,,137.18,percent of total billed charges,Drugs,137.18,30,,137.18,percent of total billed charges,Drugs,137.18,30,,137.18,percent of total billed charges,Drugs,137.18,30,,137.18,percent of total billed charges,Drugs,94.64,,,94.64,Other,Drug Cost,94.64,,,94.64,Other,Drug Cost,94.64,,,94.64,Other,Drug Cost,94.64,,,94.64,Other,Drug Cost,94.64,,,94.64,Other,Drug Cost,155.48,34,,155.48,percent of total billed charges,Drugs,94.64,,,94.64,Other,Drug Cost,212.94,,,212.94,Other,225% Medicaid APG methodology,132.5,,,132.5,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",94.64,,,94.64,Other,Drug Cost,94.64,,,94.64,Other,Drug Cost,118.3,,,118.3,Other,125% Medicaid APG methodology,0.01,228.64,
AZITH 500 MG IN 0.9% NS 250 ML  ,J0456,HCPCS,,40506750,CDM,636,RC,63323-0398-10a,NDC,both,250,ML,24.15,25.65,,,25.65,Other,150% of Medicare + 9.63% HCRA Surcharge,15.6,,,15.6,Fee Schedule,Average Sale Price (ASP) x 6,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,12.08,50,,12.08,percent of total billed charges,All Other,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,7.25,30,,7.25,percent of total billed charges,Drugs,1.47,,,1.47,Other,Drug Cost,1.47,,,1.47,Other,Drug Cost,1.47,,,1.47,Other,Drug Cost,1.47,,,1.47,Other,Drug Cost,1.47,,,1.47,Other,Drug Cost,8.21,34,,8.21,percent of total billed charges,Drugs,1.47,,,1.47,Other,Drug Cost,3.31,,,3.31,Other,225% Medicaid APG methodology,2.06,,,2.06,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,24.96,,,24.96,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.47,,,1.47,Other,Drug Cost,1.47,,,1.47,Other,Drug Cost,1.84,,,1.84,Other,125% Medicaid APG methodology,0.01,25.65,
BEVA-BVZR 25 MG/ML SOLN 16 ML   ,Q5118,HCPCS,,40506768,CDM,636,RC,00069-0342-01,NDC,both,16,ML,6992.3,212.24,,,212.24,Other,150% of Medicare + 9.63% HCRA Surcharge,129.07,,,129.07,Fee Schedule,Average Sale Price (ASP) x 6,2097.69,30,,2097.69,percent of total billed charges,Drugs,2097.69,30,,2097.69,percent of total billed charges,Drugs,2097.69,30,,2097.69,percent of total billed charges,Drugs,2097.69,30,,2097.69,percent of total billed charges,Drugs,2097.69,30,,2097.69,percent of total billed charges,Drugs,3496.15,50,,3496.15,percent of total billed charges,All Other,2097.69,30,,2097.69,percent of total billed charges,Drugs,2097.69,30,,2097.69,percent of total billed charges,Drugs,2377.38,34,"If Charge > 500, then 34 percent",2377.38,percent of total billed charges,Drugs,2097.69,30,,2097.69,percent of total billed charges,Drugs,2097.69,30,,2097.69,percent of total billed charges,Drugs,2097.69,30,,2097.69,percent of total billed charges,Drugs,2097.69,30,,2097.69,percent of total billed charges,Drugs,2097.69,30,,2097.69,percent of total billed charges,Drugs,2097.69,30,,2097.69,percent of total billed charges,Drugs,2097.69,30,,2097.69,percent of total billed charges,Drugs,2097.69,30,,2097.69,percent of total billed charges,Drugs,2097.69,30,,2097.69,percent of total billed charges,Drugs,2097.69,30,,2097.69,percent of total billed charges,Drugs,2097.69,30,,2097.69,percent of total billed charges,Drugs,2097.69,30,,2097.69,percent of total billed charges,Drugs,2097.69,30,,2097.69,percent of total billed charges,Drugs,1110.47,,,1110.47,Other,Drug Cost,1110.47,,,1110.47,Other,Drug Cost,1110.47,,,1110.47,Other,Drug Cost,1110.47,,,1110.47,Other,Drug Cost,1110.47,,,1110.47,Other,Drug Cost,2377.38,34,,2377.38,percent of total billed charges,Drugs,1110.47,,,1110.47,Other,Drug Cost,2498.56,,,2498.56,Other,225% Medicaid APG methodology,1554.66,,,1554.66,Other,140% Medicaid APG methodology,2377.38,34,"If Charge > 2,000, then 34 percent",2377.38,percent of total billed charges,Drugs,206.51,,,206.51,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1110.47,,,1110.47,Other,Drug Cost,1110.47,,,1110.47,Other,Drug Cost,1388.09,,,1388.09,Other,125% Medicaid APG methodology,0.01,3496.15,
LEUPROLIDE 22.5 MG/3 MONTHS     ,J9217,HCPCS,,40506800,CDM,636,RC,62935-0227-10,NDC,both,1,EA,982.94,1788.85,,,1788.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1087.81,,,1087.81,Fee Schedule,Average Sale Price (ASP) x 6,294.88,30,,294.88,percent of total billed charges,Drugs,294.88,30,,294.88,percent of total billed charges,Drugs,294.88,30,,294.88,percent of total billed charges,Drugs,294.88,30,,294.88,percent of total billed charges,Drugs,294.88,30,,294.88,percent of total billed charges,Drugs,491.47,50,,491.47,percent of total billed charges,All Other,294.88,30,,294.88,percent of total billed charges,Drugs,294.88,30,,294.88,percent of total billed charges,Drugs,334.2,34,"If Charge > 500, then 34 percent",334.2,percent of total billed charges,Drugs,294.88,30,,294.88,percent of total billed charges,Drugs,294.88,30,,294.88,percent of total billed charges,Drugs,294.88,30,,294.88,percent of total billed charges,Drugs,294.88,30,,294.88,percent of total billed charges,Drugs,294.88,30,,294.88,percent of total billed charges,Drugs,294.88,30,,294.88,percent of total billed charges,Drugs,294.88,30,,294.88,percent of total billed charges,Drugs,294.88,30,,294.88,percent of total billed charges,Drugs,294.88,30,,294.88,percent of total billed charges,Drugs,294.88,30,,294.88,percent of total billed charges,Drugs,294.88,30,,294.88,percent of total billed charges,Drugs,294.88,30,,294.88,percent of total billed charges,Drugs,294.88,30,,294.88,percent of total billed charges,Drugs,250.3,,,250.3,Other,Drug Cost,250.3,,,250.3,Other,Drug Cost,250.3,,,250.3,Other,Drug Cost,250.3,,,250.3,Other,Drug Cost,250.3,,,250.3,Other,Drug Cost,334.2,34,,334.2,percent of total billed charges,Drugs,250.3,,,250.3,Other,Drug Cost,563.18,,,563.18,Other,225% Medicaid APG methodology,350.42,,,350.42,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1740.5,,,1740.5,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",250.3,,,250.3,Other,Drug Cost,250.3,,,250.3,Other,Drug Cost,312.88,,,312.88,Other,125% Medicaid APG methodology,0.01,1788.85,
"LEUPROLIDE 45 MG/6 MO IM, ER    ",J9217,HCPCS,,40506818,CDM,636,RC,00074-3473-03,NDC,both,1,EA,39853.07,1788.85,,,1788.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1087.81,,,1087.81,Fee Schedule,Average Sale Price (ASP) x 6,11955.92,30,,11955.92,percent of total billed charges,Drugs,11955.92,30,,11955.92,percent of total billed charges,Drugs,11955.92,30,,11955.92,percent of total billed charges,Drugs,11955.92,30,,11955.92,percent of total billed charges,Drugs,11955.92,30,,11955.92,percent of total billed charges,Drugs,19926.54,50,,19926.54,percent of total billed charges,All Other,11955.92,30,,11955.92,percent of total billed charges,Drugs,11955.92,30,,11955.92,percent of total billed charges,Drugs,13550.04,34,"If Charge > 500, then 34 percent",13550.04,percent of total billed charges,Drugs,11955.92,30,,11955.92,percent of total billed charges,Drugs,11955.92,30,,11955.92,percent of total billed charges,Drugs,11955.92,30,,11955.92,percent of total billed charges,Drugs,11955.92,30,,11955.92,percent of total billed charges,Drugs,11955.92,30,,11955.92,percent of total billed charges,Drugs,11955.92,30,,11955.92,percent of total billed charges,Drugs,11955.92,30,,11955.92,percent of total billed charges,Drugs,11955.92,30,,11955.92,percent of total billed charges,Drugs,11955.92,30,,11955.92,percent of total billed charges,Drugs,11955.92,30,,11955.92,percent of total billed charges,Drugs,11955.92,30,,11955.92,percent of total billed charges,Drugs,11955.92,30,,11955.92,percent of total billed charges,Drugs,11955.92,30,,11955.92,percent of total billed charges,Drugs,379.14,,,379.14,Other,Drug Cost,379.14,,,379.14,Other,Drug Cost,379.14,,,379.14,Other,Drug Cost,379.14,,,379.14,Other,Drug Cost,379.14,,,379.14,Other,Drug Cost,13550.04,34,,13550.04,percent of total billed charges,Drugs,379.14,,,379.14,Other,Drug Cost,853.07,,,853.07,Other,225% Medicaid APG methodology,530.8,,,530.8,Other,140% Medicaid APG methodology,13550.04,34,"If Charge > 2,000, then 34 percent",13550.04,percent of total billed charges,Drugs,1740.5,,,1740.5,Other,160% Medicare Fee Schedule,13550.04,34,,13550.04,Other,"Drug Charges > 20,000, then 34% of Charges",379.14,,,379.14,Other,Drug Cost,379.14,,,379.14,Other,Drug Cost,473.93,,,473.93,Other,125% Medicaid APG methodology,379.14,19926.54,
PEGFIL-CBQV 6 MG/0.6 ML SQ SOL  ,Q5111,HCPCS,,40506867,CDM,636,RC,70114-0101-01,NDC,both,0.6,ML,5726.88,1204.75,,,1204.75,Other,150% of Medicare + 9.63% HCRA Surcharge,732.62,,,732.62,Fee Schedule,Average Sale Price (ASP) x 6,1718.06,30,,1718.06,percent of total billed charges,Drugs,1718.06,30,,1718.06,percent of total billed charges,Drugs,1718.06,30,,1718.06,percent of total billed charges,Drugs,1718.06,30,,1718.06,percent of total billed charges,Drugs,1718.06,30,,1718.06,percent of total billed charges,Drugs,2863.44,50,,2863.44,percent of total billed charges,All Other,1718.06,30,,1718.06,percent of total billed charges,Drugs,1718.06,30,,1718.06,percent of total billed charges,Drugs,1947.14,34,"If Charge > 500, then 34 percent",1947.14,percent of total billed charges,Drugs,1718.06,30,,1718.06,percent of total billed charges,Drugs,1718.06,30,,1718.06,percent of total billed charges,Drugs,1718.06,30,,1718.06,percent of total billed charges,Drugs,1718.06,30,,1718.06,percent of total billed charges,Drugs,1718.06,30,,1718.06,percent of total billed charges,Drugs,1718.06,30,,1718.06,percent of total billed charges,Drugs,1718.06,30,,1718.06,percent of total billed charges,Drugs,1718.06,30,,1718.06,percent of total billed charges,Drugs,1718.06,30,,1718.06,percent of total billed charges,Drugs,1718.06,30,,1718.06,percent of total billed charges,Drugs,1718.06,30,,1718.06,percent of total billed charges,Drugs,1718.06,30,,1718.06,percent of total billed charges,Drugs,1718.06,30,,1718.06,percent of total billed charges,Drugs,1062.28,,,1062.28,Other,Drug Cost,1062.28,,,1062.28,Other,Drug Cost,1062.28,,,1062.28,Other,Drug Cost,1062.28,,,1062.28,Other,Drug Cost,1062.28,,,1062.28,Other,Drug Cost,1947.14,34,,1947.14,percent of total billed charges,Drugs,1062.28,,,1062.28,Other,Drug Cost,2390.13,,,2390.13,Other,225% Medicaid APG methodology,1487.19,,,1487.19,Other,140% Medicaid APG methodology,1947.14,34,"If Charge > 2,000, then 34 percent",1947.14,percent of total billed charges,Drugs,1172.19,,,1172.19,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1062.28,,,1062.28,Other,Drug Cost,1062.28,,,1062.28,Other,Drug Cost,1327.85,,,1327.85,Other,125% Medicaid APG methodology,0.01,2863.44,
TRASTUZUMAB-DKST 420 MG IV INJ  ,Q5114,HCPCS,,40506883,CDM,636,RC,67457-0847-44,NDC,both,1,EA,8241.21,438.36,,,438.36,Other,150% of Medicare + 9.63% HCRA Surcharge,266.57,,,266.57,Fee Schedule,Average Sale Price (ASP) x 6,2472.36,30,,2472.36,percent of total billed charges,Drugs,2472.36,30,,2472.36,percent of total billed charges,Drugs,2472.36,30,,2472.36,percent of total billed charges,Drugs,2472.36,30,,2472.36,percent of total billed charges,Drugs,2472.36,30,,2472.36,percent of total billed charges,Drugs,4120.61,50,,4120.61,percent of total billed charges,All Other,2472.36,30,,2472.36,percent of total billed charges,Drugs,2472.36,30,,2472.36,percent of total billed charges,Drugs,2802.01,34,"If Charge > 500, then 34 percent",2802.01,percent of total billed charges,Drugs,2472.36,30,,2472.36,percent of total billed charges,Drugs,2472.36,30,,2472.36,percent of total billed charges,Drugs,2472.36,30,,2472.36,percent of total billed charges,Drugs,2472.36,30,,2472.36,percent of total billed charges,Drugs,2472.36,30,,2472.36,percent of total billed charges,Drugs,2472.36,30,,2472.36,percent of total billed charges,Drugs,2472.36,30,,2472.36,percent of total billed charges,Drugs,2472.36,30,,2472.36,percent of total billed charges,Drugs,2472.36,30,,2472.36,percent of total billed charges,Drugs,2472.36,30,,2472.36,percent of total billed charges,Drugs,2472.36,30,,2472.36,percent of total billed charges,Drugs,2472.36,30,,2472.36,percent of total billed charges,Drugs,2472.36,30,,2472.36,percent of total billed charges,Drugs,994.33,,,994.33,Other,Drug Cost,994.33,,,994.33,Other,Drug Cost,994.33,,,994.33,Other,Drug Cost,994.33,,,994.33,Other,Drug Cost,994.33,,,994.33,Other,Drug Cost,2802.01,34,,2802.01,percent of total billed charges,Drugs,994.33,,,994.33,Other,Drug Cost,2237.24,,,2237.24,Other,225% Medicaid APG methodology,1392.06,,,1392.06,Other,140% Medicaid APG methodology,2802.01,34,"If Charge > 2,000, then 34 percent",2802.01,percent of total billed charges,Drugs,426.51,,,426.51,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",994.33,,,994.33,Other,Drug Cost,994.33,,,994.33,Other,Drug Cost,1242.91,,,1242.91,Other,125% Medicaid APG methodology,0.01,4120.61,
PEN G POT 2.5 MIL U/100 ML NS   ,J2540,HCPCS,,40506917,CDM,636,RC,00049-0520-83a,NDC,both,100,ML,7.21,7.61,,,7.61,Other,150% of Medicare + 9.63% HCRA Surcharge,4.63,,,4.63,Fee Schedule,Average Sale Price (ASP) x 6,2.16,30,,2.16,percent of total billed charges,Drugs,2.16,30,,2.16,percent of total billed charges,Drugs,2.16,30,,2.16,percent of total billed charges,Drugs,2.16,30,,2.16,percent of total billed charges,Drugs,2.16,30,,2.16,percent of total billed charges,Drugs,3.61,50,,3.61,percent of total billed charges,All Other,2.16,30,,2.16,percent of total billed charges,Drugs,2.16,30,,2.16,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.16,30,,2.16,percent of total billed charges,Drugs,2.16,30,,2.16,percent of total billed charges,Drugs,2.16,30,,2.16,percent of total billed charges,Drugs,2.16,30,,2.16,percent of total billed charges,Drugs,2.16,30,,2.16,percent of total billed charges,Drugs,2.16,30,,2.16,percent of total billed charges,Drugs,2.16,30,,2.16,percent of total billed charges,Drugs,2.16,30,,2.16,percent of total billed charges,Drugs,2.16,30,,2.16,percent of total billed charges,Drugs,2.16,30,,2.16,percent of total billed charges,Drugs,2.16,30,,2.16,percent of total billed charges,Drugs,2.16,30,,2.16,percent of total billed charges,Drugs,2.16,30,,2.16,percent of total billed charges,Drugs,1.57,,,1.57,Other,Drug Cost,1.57,,,1.57,Other,Drug Cost,1.57,,,1.57,Other,Drug Cost,1.57,,,1.57,Other,Drug Cost,1.57,,,1.57,Other,Drug Cost,2.45,34,,2.45,percent of total billed charges,Drugs,1.57,,,1.57,Other,Drug Cost,3.53,,,3.53,Other,225% Medicaid APG methodology,2.2,,,2.2,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.4,,,7.4,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.57,,,1.57,Other,Drug Cost,1.57,,,1.57,Other,Drug Cost,1.96,,,1.96,Other,125% Medicaid APG methodology,0.01,7.61,
BUPIV-MELOX 400-12 MG/14 ML ER  ,C9088,HCPCS,,40506958,CDM,636,RC,47426-0301-02,NDC,both,14,ML,902.76,356.29,39.4668,,356.29,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,270.83,30,,270.83,percent of total billed charges,Drugs,270.83,30,,270.83,percent of total billed charges,Drugs,270.83,30,,270.83,percent of total billed charges,Drugs,270.83,30,,270.83,percent of total billed charges,Drugs,270.83,30,,270.83,percent of total billed charges,Drugs,451.38,50,,451.38,percent of total billed charges,All Other,270.83,30,,270.83,percent of total billed charges,Drugs,270.83,30,,270.83,percent of total billed charges,Drugs,306.94,34,"If Charge > 500, then 34 percent",306.94,percent of total billed charges,Drugs,270.83,30,,270.83,percent of total billed charges,Drugs,270.83,30,,270.83,percent of total billed charges,Drugs,270.83,30,,270.83,percent of total billed charges,Drugs,270.83,30,,270.83,percent of total billed charges,Drugs,270.83,30,,270.83,percent of total billed charges,Drugs,270.83,30,,270.83,percent of total billed charges,Drugs,270.83,30,,270.83,percent of total billed charges,Drugs,270.83,30,,270.83,percent of total billed charges,Drugs,270.83,30,,270.83,percent of total billed charges,Drugs,270.83,30,,270.83,percent of total billed charges,Drugs,270.83,30,,270.83,percent of total billed charges,Drugs,270.83,30,,270.83,percent of total billed charges,Drugs,270.83,30,,270.83,percent of total billed charges,Drugs,186.62,,,186.62,Other,Drug Cost,186.62,,,186.62,Other,Drug Cost,186.62,,,186.62,Other,Drug Cost,186.62,,,186.62,Other,Drug Cost,186.62,,,186.62,Other,Drug Cost,306.94,34,,306.94,percent of total billed charges,Drugs,186.62,,,186.62,Other,Drug Cost,419.9,,,419.9,Other,225% Medicaid APG methodology,261.27,,,261.27,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",186.62,,,186.62,Other,Drug Cost,186.62,,,186.62,Other,Drug Cost,233.28,,,233.28,Other,125% Medicaid APG methodology,0.01,451.38,
CEFTRIAX 1000 MG ADD-VANTAGE    ,J0696,HCPCS,,40506974,CDM,636,RC,00409-7333-04,NDC,both,1,EA,8.75,4.84,,,4.84,Other,150% of Medicare + 9.63% HCRA Surcharge,2.95,,,2.95,Fee Schedule,Average Sale Price (ASP) x 6,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,4.38,50,,4.38,percent of total billed charges,All Other,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,1.83,,,1.83,Other,Drug Cost,1.83,,,1.83,Other,Drug Cost,1.83,,,1.83,Other,Drug Cost,1.83,,,1.83,Other,Drug Cost,1.83,,,1.83,Other,Drug Cost,2.98,34,,2.98,percent of total billed charges,Drugs,1.83,,,1.83,Other,Drug Cost,4.12,,,4.12,Other,225% Medicaid APG methodology,2.56,,,2.56,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,4.71,,,4.71,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.83,,,1.83,Other,Drug Cost,1.83,,,1.83,Other,Drug Cost,2.29,,,2.29,Other,125% Medicaid APG methodology,0.01,4.84,
DILTIAZEM 100 MG ADD-VANTAGE    ,J3490,HCPCS,,40506982,CDM,636,RC,00409-4350-03,NDC,both,1,EA,31.26,12.34,39.4668,,12.34,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,9.38,30,,9.38,percent of total billed charges,Drugs,9.38,30,,9.38,percent of total billed charges,Drugs,9.38,30,,9.38,percent of total billed charges,Drugs,9.38,30,,9.38,percent of total billed charges,Drugs,9.38,30,,9.38,percent of total billed charges,Drugs,15.63,50,,15.63,percent of total billed charges,All Other,9.38,30,,9.38,percent of total billed charges,Drugs,9.38,30,,9.38,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,9.38,30,,9.38,percent of total billed charges,Drugs,9.38,30,,9.38,percent of total billed charges,Drugs,9.38,30,,9.38,percent of total billed charges,Drugs,9.38,30,,9.38,percent of total billed charges,Drugs,9.38,30,,9.38,percent of total billed charges,Drugs,9.38,30,,9.38,percent of total billed charges,Drugs,9.38,30,,9.38,percent of total billed charges,Drugs,9.38,30,,9.38,percent of total billed charges,Drugs,9.38,30,,9.38,percent of total billed charges,Drugs,9.38,30,,9.38,percent of total billed charges,Drugs,9.38,30,,9.38,percent of total billed charges,Drugs,9.38,30,,9.38,percent of total billed charges,Drugs,9.38,30,,9.38,percent of total billed charges,Drugs,5.93,,,5.93,Other,Drug Cost,5.93,,,5.93,Other,Drug Cost,5.93,,,5.93,Other,Drug Cost,5.93,,,5.93,Other,Drug Cost,5.93,,,5.93,Other,Drug Cost,10.63,34,,10.63,percent of total billed charges,Drugs,5.93,,,5.93,Other,Drug Cost,13.34,,,13.34,Other,225% Medicaid APG methodology,8.3,,,8.3,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.93,,,5.93,Other,Drug Cost,5.93,,,5.93,Other,Drug Cost,7.41,,,7.41,Other,125% Medicaid APG methodology,0.01,15.63,
"VANCOMYCIN 1,000 MG ADD-VAN     ",J3370,HCPCS,,40506990,CDM,636,RC,00409-6535-01,NDC,both,1,EA,19.22,22.76,,,22.76,Other,150% of Medicare + 9.63% HCRA Surcharge,13.84,,,13.84,Fee Schedule,Average Sale Price (ASP) x 6,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,9.61,50,,9.61,percent of total billed charges,All Other,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,3.42,,,3.42,Other,Drug Cost,3.42,,,3.42,Other,Drug Cost,3.42,,,3.42,Other,Drug Cost,3.42,,,3.42,Other,Drug Cost,3.42,,,3.42,Other,Drug Cost,6.53,34,,6.53,percent of total billed charges,Drugs,3.42,,,3.42,Other,Drug Cost,7.7,,,7.7,Other,225% Medicaid APG methodology,4.79,,,4.79,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,22.15,,,22.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.42,,,3.42,Other,Drug Cost,3.42,,,3.42,Other,Drug Cost,4.28,,,4.28,Other,125% Medicaid APG methodology,0.01,22.76,
PIP-TAZO 3.375 G INJ ADD-VAN    ,J2543,HCPCS,,40507022,CDM,636,RC,00409-3378-13,NDC,both,1,EA,26.11,11.61,,,11.61,Other,150% of Medicare + 9.63% HCRA Surcharge,7.06,,,7.06,Fee Schedule,Average Sale Price (ASP) x 6,7.83,30,,7.83,percent of total billed charges,Drugs,7.83,30,,7.83,percent of total billed charges,Drugs,7.83,30,,7.83,percent of total billed charges,Drugs,7.83,30,,7.83,percent of total billed charges,Drugs,7.83,30,,7.83,percent of total billed charges,Drugs,13.06,50,,13.06,percent of total billed charges,All Other,7.83,30,,7.83,percent of total billed charges,Drugs,7.83,30,,7.83,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,7.83,30,,7.83,percent of total billed charges,Drugs,7.83,30,,7.83,percent of total billed charges,Drugs,7.83,30,,7.83,percent of total billed charges,Drugs,7.83,30,,7.83,percent of total billed charges,Drugs,7.83,30,,7.83,percent of total billed charges,Drugs,7.83,30,,7.83,percent of total billed charges,Drugs,7.83,30,,7.83,percent of total billed charges,Drugs,7.83,30,,7.83,percent of total billed charges,Drugs,7.83,30,,7.83,percent of total billed charges,Drugs,7.83,30,,7.83,percent of total billed charges,Drugs,7.83,30,,7.83,percent of total billed charges,Drugs,7.83,30,,7.83,percent of total billed charges,Drugs,7.83,30,,7.83,percent of total billed charges,Drugs,4.94,,,4.94,Other,Drug Cost,4.94,,,4.94,Other,Drug Cost,4.94,,,4.94,Other,Drug Cost,4.94,,,4.94,Other,Drug Cost,4.94,,,4.94,Other,Drug Cost,8.88,34,,8.88,percent of total billed charges,Drugs,4.94,,,4.94,Other,Drug Cost,11.12,,,11.12,Other,225% Medicaid APG methodology,6.92,,,6.92,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,11.3,,,11.3,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.94,,,4.94,Other,Drug Cost,4.94,,,4.94,Other,Drug Cost,6.18,,,6.18,Other,125% Medicaid APG methodology,0.01,13.06,
NS IV SOLN 250 ML ADD-VANTAGE   ,J7050,HCPCS,,40507030,CDM,636,RC,00409-7101-02,NDC,both,250,ML,7.7,6.64,,,6.64,Other,150% of Medicare + 9.63% HCRA Surcharge,4.04,,,4.04,Fee Schedule,Average Sale Price (ASP) x 6,2.31,30,,2.31,percent of total billed charges,Drugs,2.31,30,,2.31,percent of total billed charges,Drugs,2.31,30,,2.31,percent of total billed charges,Drugs,2.31,30,,2.31,percent of total billed charges,Drugs,2.31,30,,2.31,percent of total billed charges,Drugs,3.85,50,,3.85,percent of total billed charges,All Other,2.31,30,,2.31,percent of total billed charges,Drugs,2.31,30,,2.31,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.31,30,,2.31,percent of total billed charges,Drugs,2.31,30,,2.31,percent of total billed charges,Drugs,2.31,30,,2.31,percent of total billed charges,Drugs,2.31,30,,2.31,percent of total billed charges,Drugs,2.31,30,,2.31,percent of total billed charges,Drugs,2.31,30,,2.31,percent of total billed charges,Drugs,2.31,30,,2.31,percent of total billed charges,Drugs,2.31,30,,2.31,percent of total billed charges,Drugs,2.31,30,,2.31,percent of total billed charges,Drugs,2.31,30,,2.31,percent of total billed charges,Drugs,2.31,30,,2.31,percent of total billed charges,Drugs,2.31,30,,2.31,percent of total billed charges,Drugs,2.31,30,,2.31,percent of total billed charges,Drugs,2.24,,,2.24,Other,Drug Cost,2.24,,,2.24,Other,Drug Cost,2.24,,,2.24,Other,Drug Cost,2.24,,,2.24,Other,Drug Cost,2.24,,,2.24,Other,Drug Cost,2.62,34,,2.62,percent of total billed charges,Drugs,2.24,,,2.24,Other,Drug Cost,5.04,,,5.04,Other,225% Medicaid APG methodology,3.14,,,3.14,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.46,,,6.46,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.24,,,2.24,Other,Drug Cost,2.24,,,2.24,Other,Drug Cost,2.8,,,2.8,Other,125% Medicaid APG methodology,0.01,6.64,
VANCOMYCIN 500 MG  ADD-VAN      ,J3370,HCPCS,,40507048,CDM,636,RC,00409-6534-01,NDC,both,1,EA,12.57,22.76,,,22.76,Other,150% of Medicare + 9.63% HCRA Surcharge,13.84,,,13.84,Fee Schedule,Average Sale Price (ASP) x 6,3.77,30,,3.77,percent of total billed charges,Drugs,3.77,30,,3.77,percent of total billed charges,Drugs,3.77,30,,3.77,percent of total billed charges,Drugs,3.77,30,,3.77,percent of total billed charges,Drugs,3.77,30,,3.77,percent of total billed charges,Drugs,6.29,50,,6.29,percent of total billed charges,All Other,3.77,30,,3.77,percent of total billed charges,Drugs,3.77,30,,3.77,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.77,30,,3.77,percent of total billed charges,Drugs,3.77,30,,3.77,percent of total billed charges,Drugs,3.77,30,,3.77,percent of total billed charges,Drugs,3.77,30,,3.77,percent of total billed charges,Drugs,3.77,30,,3.77,percent of total billed charges,Drugs,3.77,30,,3.77,percent of total billed charges,Drugs,3.77,30,,3.77,percent of total billed charges,Drugs,3.77,30,,3.77,percent of total billed charges,Drugs,3.77,30,,3.77,percent of total billed charges,Drugs,3.77,30,,3.77,percent of total billed charges,Drugs,3.77,30,,3.77,percent of total billed charges,Drugs,3.77,30,,3.77,percent of total billed charges,Drugs,3.77,30,,3.77,percent of total billed charges,Drugs,2.21,,,2.21,Other,Drug Cost,2.21,,,2.21,Other,Drug Cost,2.21,,,2.21,Other,Drug Cost,2.21,,,2.21,Other,Drug Cost,2.21,,,2.21,Other,Drug Cost,4.27,34,,4.27,percent of total billed charges,Drugs,2.21,,,2.21,Other,Drug Cost,4.97,,,4.97,Other,225% Medicaid APG methodology,3.09,,,3.09,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,22.15,,,22.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.21,,,2.21,Other,Drug Cost,2.21,,,2.21,Other,Drug Cost,2.76,,,2.76,Other,125% Medicaid APG methodology,0.01,22.76,
AZITH 500 MG INJ ADD-VANTAGE    ,J0456,HCPCS,,40507055,CDM,636,RC,00409-0144-11,NDC,both,1,EA,30.1,25.65,,,25.65,Other,150% of Medicare + 9.63% HCRA Surcharge,15.6,,,15.6,Fee Schedule,Average Sale Price (ASP) x 6,9.03,30,,9.03,percent of total billed charges,Drugs,9.03,30,,9.03,percent of total billed charges,Drugs,9.03,30,,9.03,percent of total billed charges,Drugs,9.03,30,,9.03,percent of total billed charges,Drugs,9.03,30,,9.03,percent of total billed charges,Drugs,15.05,50,,15.05,percent of total billed charges,All Other,9.03,30,,9.03,percent of total billed charges,Drugs,9.03,30,,9.03,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,9.03,30,,9.03,percent of total billed charges,Drugs,9.03,30,,9.03,percent of total billed charges,Drugs,9.03,30,,9.03,percent of total billed charges,Drugs,9.03,30,,9.03,percent of total billed charges,Drugs,9.03,30,,9.03,percent of total billed charges,Drugs,9.03,30,,9.03,percent of total billed charges,Drugs,9.03,30,,9.03,percent of total billed charges,Drugs,9.03,30,,9.03,percent of total billed charges,Drugs,9.03,30,,9.03,percent of total billed charges,Drugs,9.03,30,,9.03,percent of total billed charges,Drugs,9.03,30,,9.03,percent of total billed charges,Drugs,9.03,30,,9.03,percent of total billed charges,Drugs,9.03,30,,9.03,percent of total billed charges,Drugs,4.47,,,4.47,Other,Drug Cost,4.47,,,4.47,Other,Drug Cost,4.47,,,4.47,Other,Drug Cost,4.47,,,4.47,Other,Drug Cost,4.47,,,4.47,Other,Drug Cost,10.23,34,,10.23,percent of total billed charges,Drugs,4.47,,,4.47,Other,Drug Cost,10.06,,,10.06,Other,225% Medicaid APG methodology,6.26,,,6.26,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,24.96,,,24.96,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.47,,,4.47,Other,Drug Cost,4.47,,,4.47,Other,Drug Cost,5.59,,,5.59,Other,125% Medicaid APG methodology,0.01,25.65,
VANCOMYCIN 750 MG ADD-VAN       ,J3370,HCPCS,,40507063,CDM,636,RC,00409-6531-01,NDC,both,1,EA,19.22,22.76,,,22.76,Other,150% of Medicare + 9.63% HCRA Surcharge,13.84,,,13.84,Fee Schedule,Average Sale Price (ASP) x 6,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,9.61,50,,9.61,percent of total billed charges,All Other,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,5.77,30,,5.77,percent of total billed charges,Drugs,2.42,,,2.42,Other,Drug Cost,2.42,,,2.42,Other,Drug Cost,2.42,,,2.42,Other,Drug Cost,2.42,,,2.42,Other,Drug Cost,2.42,,,2.42,Other,Drug Cost,6.53,34,,6.53,percent of total billed charges,Drugs,2.42,,,2.42,Other,Drug Cost,5.45,,,5.45,Other,225% Medicaid APG methodology,3.39,,,3.39,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,22.15,,,22.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.42,,,2.42,Other,Drug Cost,2.42,,,2.42,Other,Drug Cost,3.03,,,3.03,Other,125% Medicaid APG methodology,0.01,22.76,
NS INH SOLN 15 ML               ,J7699,HCPCS,,40507154,CDM,636,RC,00378-6987-89,NDC,both,15,ML,2.07,0.82,39.4668,,0.82,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,1.04,50,,1.04,percent of total billed charges,All Other,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.72,,,0.72,Other,Drug Cost,0.72,,,0.72,Other,Drug Cost,0.72,,,0.72,Other,Drug Cost,0.72,,,0.72,Other,Drug Cost,0.72,,,0.72,Other,Drug Cost,0.7,34,,0.7,percent of total billed charges,Drugs,0.72,,,0.72,Other,Drug Cost,1.62,,,1.62,Other,225% Medicaid APG methodology,1.01,,,1.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.72,,,0.72,Other,Drug Cost,0.72,,,0.72,Other,Drug Cost,0.9,,,0.9,Other,125% Medicaid APG methodology,0.01,1.62,
IM GLOB (IGG) 15%-18% IM 2 ML   ,J1460,HCPCS,,40507196,CDM,636,RC,13533-0635-04,NDC,both,2,ML,330.58,500.5,,,500.5,Other,150% of Medicare + 9.63% HCRA Surcharge,304.36,,,304.36,Fee Schedule,Average Sale Price (ASP) x 6,99.17,30,,99.17,percent of total billed charges,Drugs,99.17,30,,99.17,percent of total billed charges,Drugs,99.17,30,,99.17,percent of total billed charges,Drugs,99.17,30,,99.17,percent of total billed charges,Drugs,99.17,30,,99.17,percent of total billed charges,Drugs,165.29,50,,165.29,percent of total billed charges,All Other,99.17,30,,99.17,percent of total billed charges,Drugs,99.17,30,,99.17,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,99.17,30,,99.17,percent of total billed charges,Drugs,99.17,30,,99.17,percent of total billed charges,Drugs,99.17,30,,99.17,percent of total billed charges,Drugs,99.17,30,,99.17,percent of total billed charges,Drugs,99.17,30,,99.17,percent of total billed charges,Drugs,99.17,30,,99.17,percent of total billed charges,Drugs,99.17,30,,99.17,percent of total billed charges,Drugs,99.17,30,,99.17,percent of total billed charges,Drugs,99.17,30,,99.17,percent of total billed charges,Drugs,99.17,30,,99.17,percent of total billed charges,Drugs,99.17,30,,99.17,percent of total billed charges,Drugs,99.17,30,,99.17,percent of total billed charges,Drugs,99.17,30,,99.17,percent of total billed charges,Drugs,10.71,,,10.71,Other,Drug Cost,10.71,,,10.71,Other,Drug Cost,10.71,,,10.71,Other,Drug Cost,10.71,,,10.71,Other,Drug Cost,10.71,,,10.71,Other,Drug Cost,112.4,34,,112.4,percent of total billed charges,Drugs,10.71,,,10.71,Other,Drug Cost,24.1,,,24.1,Other,225% Medicaid APG methodology,14.99,,,14.99,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,486.97,,,486.97,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",10.71,,,10.71,Other,Drug Cost,10.71,,,10.71,Other,Drug Cost,13.39,,,13.39,Other,125% Medicaid APG methodology,0.01,500.5,
IMMUNE GLOBULIN IM SOLN 2 ML    ,J1460,HCPCS,,40507204,CDM,636,RC,13533-0335-04,NDC,both,2,ML,171.08,500.5,,,500.5,Other,150% of Medicare + 9.63% HCRA Surcharge,304.36,,,304.36,Fee Schedule,Average Sale Price (ASP) x 6,51.32,30,,51.32,percent of total billed charges,Drugs,51.32,30,,51.32,percent of total billed charges,Drugs,51.32,30,,51.32,percent of total billed charges,Drugs,51.32,30,,51.32,percent of total billed charges,Drugs,51.32,30,,51.32,percent of total billed charges,Drugs,85.54,50,,85.54,percent of total billed charges,All Other,51.32,30,,51.32,percent of total billed charges,Drugs,51.32,30,,51.32,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,51.32,30,,51.32,percent of total billed charges,Drugs,51.32,30,,51.32,percent of total billed charges,Drugs,51.32,30,,51.32,percent of total billed charges,Drugs,51.32,30,,51.32,percent of total billed charges,Drugs,51.32,30,,51.32,percent of total billed charges,Drugs,51.32,30,,51.32,percent of total billed charges,Drugs,51.32,30,,51.32,percent of total billed charges,Drugs,51.32,30,,51.32,percent of total billed charges,Drugs,51.32,30,,51.32,percent of total billed charges,Drugs,51.32,30,,51.32,percent of total billed charges,Drugs,51.32,30,,51.32,percent of total billed charges,Drugs,51.32,30,,51.32,percent of total billed charges,Drugs,51.32,30,,51.32,percent of total billed charges,Drugs,48.88,,,48.88,Other,Drug Cost,48.88,,,48.88,Other,Drug Cost,48.88,,,48.88,Other,Drug Cost,48.88,,,48.88,Other,Drug Cost,48.88,,,48.88,Other,Drug Cost,58.17,34,,58.17,percent of total billed charges,Drugs,48.88,,,48.88,Other,Drug Cost,109.98,,,109.98,Other,225% Medicaid APG methodology,68.43,,,68.43,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,486.97,,,486.97,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",48.88,,,48.88,Other,Drug Cost,48.88,,,48.88,Other,Drug Cost,61.1,,,61.1,Other,125% Medicaid APG methodology,0.01,500.5,
"LEUPROLIDE 30 MG/4 MO SQ, ER    ",J9217,HCPCS,,40507238,CDM,636,RC,62935-0303-30,NDC,both,1,EA,1316,1788.85,,,1788.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1087.81,,,1087.81,Fee Schedule,Average Sale Price (ASP) x 6,394.8,30,,394.8,percent of total billed charges,Drugs,394.8,30,,394.8,percent of total billed charges,Drugs,394.8,30,,394.8,percent of total billed charges,Drugs,394.8,30,,394.8,percent of total billed charges,Drugs,394.8,30,,394.8,percent of total billed charges,Drugs,658,50,,658,percent of total billed charges,All Other,394.8,30,,394.8,percent of total billed charges,Drugs,394.8,30,,394.8,percent of total billed charges,Drugs,447.44,34,"If Charge > 500, then 34 percent",447.44,percent of total billed charges,Drugs,394.8,30,,394.8,percent of total billed charges,Drugs,394.8,30,,394.8,percent of total billed charges,Drugs,394.8,30,,394.8,percent of total billed charges,Drugs,394.8,30,,394.8,percent of total billed charges,Drugs,394.8,30,,394.8,percent of total billed charges,Drugs,394.8,30,,394.8,percent of total billed charges,Drugs,394.8,30,,394.8,percent of total billed charges,Drugs,394.8,30,,394.8,percent of total billed charges,Drugs,394.8,30,,394.8,percent of total billed charges,Drugs,394.8,30,,394.8,percent of total billed charges,Drugs,394.8,30,,394.8,percent of total billed charges,Drugs,394.8,30,,394.8,percent of total billed charges,Drugs,394.8,30,,394.8,percent of total billed charges,Drugs,352.67,,,352.67,Other,Drug Cost,352.67,,,352.67,Other,Drug Cost,352.67,,,352.67,Other,Drug Cost,352.67,,,352.67,Other,Drug Cost,352.67,,,352.67,Other,Drug Cost,447.44,34,,447.44,percent of total billed charges,Drugs,352.67,,,352.67,Other,Drug Cost,793.51,,,793.51,Other,225% Medicaid APG methodology,493.74,,,493.74,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1740.5,,,1740.5,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",352.67,,,352.67,Other,Drug Cost,352.67,,,352.67,Other,Drug Cost,440.84,,,440.84,Other,125% Medicaid APG methodology,0.01,1788.85,
OXYTOCIN 10 UNIT/ML INJ 30 ML   ,J2590,HCPCS,,40507246,CDM,636,RC,63323-0012-30,NDC,both,30,ML,140.74,55.55,39.4668,,55.55,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,42.22,30,,42.22,percent of total billed charges,Drugs,42.22,30,,42.22,percent of total billed charges,Drugs,42.22,30,,42.22,percent of total billed charges,Drugs,42.22,30,,42.22,percent of total billed charges,Drugs,42.22,30,,42.22,percent of total billed charges,Drugs,70.37,50,,70.37,percent of total billed charges,All Other,42.22,30,,42.22,percent of total billed charges,Drugs,42.22,30,,42.22,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,42.22,30,,42.22,percent of total billed charges,Drugs,42.22,30,,42.22,percent of total billed charges,Drugs,42.22,30,,42.22,percent of total billed charges,Drugs,42.22,30,,42.22,percent of total billed charges,Drugs,42.22,30,,42.22,percent of total billed charges,Drugs,42.22,30,,42.22,percent of total billed charges,Drugs,42.22,30,,42.22,percent of total billed charges,Drugs,42.22,30,,42.22,percent of total billed charges,Drugs,42.22,30,,42.22,percent of total billed charges,Drugs,42.22,30,,42.22,percent of total billed charges,Drugs,42.22,30,,42.22,percent of total billed charges,Drugs,42.22,30,,42.22,percent of total billed charges,Drugs,42.22,30,,42.22,percent of total billed charges,Drugs,11.79,,,11.79,Other,Drug Cost,11.79,,,11.79,Other,Drug Cost,11.79,,,11.79,Other,Drug Cost,11.79,,,11.79,Other,Drug Cost,11.79,,,11.79,Other,Drug Cost,47.85,34,,47.85,percent of total billed charges,Drugs,11.79,,,11.79,Other,Drug Cost,26.53,,,26.53,Other,225% Medicaid APG methodology,16.51,,,16.51,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",11.79,,,11.79,Other,Drug Cost,11.79,,,11.79,Other,Drug Cost,14.74,,,14.74,Other,125% Medicaid APG methodology,0.01,70.37,
MORPH 8 MG/ML PF IV SOLN 1 ML   ,J2270,HCPCS,,40507477,CDM,636,RC,00409-1892-01,NDC,both,1,ML,2.49,46.03,,,46.03,Other,150% of Medicare + 9.63% HCRA Surcharge,27.99,,,27.99,Fee Schedule,Average Sale Price (ASP) x 6,0.75,30,,0.75,percent of total billed charges,Drugs,0.75,30,,0.75,percent of total billed charges,Drugs,0.75,30,,0.75,percent of total billed charges,Drugs,0.75,30,,0.75,percent of total billed charges,Drugs,0.75,30,,0.75,percent of total billed charges,Drugs,1.25,50,,1.25,percent of total billed charges,All Other,0.75,30,,0.75,percent of total billed charges,Drugs,0.75,30,,0.75,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.75,30,,0.75,percent of total billed charges,Drugs,0.75,30,,0.75,percent of total billed charges,Drugs,0.75,30,,0.75,percent of total billed charges,Drugs,0.75,30,,0.75,percent of total billed charges,Drugs,0.75,30,,0.75,percent of total billed charges,Drugs,0.75,30,,0.75,percent of total billed charges,Drugs,0.75,30,,0.75,percent of total billed charges,Drugs,0.75,30,,0.75,percent of total billed charges,Drugs,0.75,30,,0.75,percent of total billed charges,Drugs,0.75,30,,0.75,percent of total billed charges,Drugs,0.75,30,,0.75,percent of total billed charges,Drugs,0.75,30,,0.75,percent of total billed charges,Drugs,0.75,30,,0.75,percent of total billed charges,Drugs,0.55,,,0.55,Other,Drug Cost,0.55,,,0.55,Other,Drug Cost,0.55,,,0.55,Other,Drug Cost,0.55,,,0.55,Other,Drug Cost,0.55,,,0.55,Other,Drug Cost,0.85,34,,0.85,percent of total billed charges,Drugs,0.55,,,0.55,Other,Drug Cost,1.24,,,1.24,Other,225% Medicaid APG methodology,0.77,,,0.77,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,44.78,,,44.78,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.55,,,0.55,Other,Drug Cost,0.55,,,0.55,Other,Drug Cost,0.69,,,0.69,Other,125% Medicaid APG methodology,0.01,46.03,
ALEMTUZUMAB 10 MG/ML IV 1.2 ML  ,J0202,HCPCS,,40507493,CDM,636,RC,58468-0200-01,NDC,both,1.2,ML,94752.39,22933.6,,,22933.6,Other,150% of Medicare + 9.63% HCRA Surcharge,13946.06,,,13946.06,Fee Schedule,Average Sale Price (ASP) x 6,28425.72,30,,28425.72,percent of total billed charges,Drugs,28425.72,30,,28425.72,percent of total billed charges,Drugs,28425.72,30,,28425.72,percent of total billed charges,Drugs,28425.72,30,,28425.72,percent of total billed charges,Drugs,28425.72,30,,28425.72,percent of total billed charges,Drugs,47376.2,50,,47376.2,percent of total billed charges,All Other,28425.72,30,,28425.72,percent of total billed charges,Drugs,28425.72,30,,28425.72,percent of total billed charges,Drugs,32215.81,34,"If Charge > 500, then 34 percent",32215.81,percent of total billed charges,Drugs,28425.72,30,,28425.72,percent of total billed charges,Drugs,28425.72,30,,28425.72,percent of total billed charges,Drugs,28425.72,30,,28425.72,percent of total billed charges,Drugs,28425.72,30,,28425.72,percent of total billed charges,Drugs,28425.72,30,,28425.72,percent of total billed charges,Drugs,28425.72,30,,28425.72,percent of total billed charges,Drugs,28425.72,30,,28425.72,percent of total billed charges,Drugs,28425.72,30,,28425.72,percent of total billed charges,Drugs,28425.72,30,,28425.72,percent of total billed charges,Drugs,28425.72,30,,28425.72,percent of total billed charges,Drugs,28425.72,30,,28425.72,percent of total billed charges,Drugs,28425.72,30,,28425.72,percent of total billed charges,Drugs,28425.72,30,,28425.72,percent of total billed charges,Drugs,27072.11,,,27072.11,Other,Drug Cost,27072.11,,,27072.11,Other,Drug Cost,27072.11,,,27072.11,Other,Drug Cost,27072.11,,,27072.11,Other,Drug Cost,27072.11,,,27072.11,Other,Drug Cost,32215.81,34,,32215.81,percent of total billed charges,Drugs,27072.11,,,27072.11,Other,Drug Cost,60912.25,,,60912.25,Other,225% Medicaid APG methodology,37900.95,,,37900.95,Other,140% Medicaid APG methodology,32215.81,34,"If Charge > 2,000, then 34 percent",32215.81,percent of total billed charges,Drugs,22313.7,,,22313.7,Other,160% Medicare Fee Schedule,32215.81,34,,32215.81,Other,"Drug Charges > 20,000, then 34% of Charges",27072.11,,,27072.11,Other,Drug Cost,27072.11,,,27072.11,Other,Drug Cost,33840.14,,,33840.14,Other,125% Medicaid APG methodology,13946.06,60912.25,
DARBE AL 25 MCG/ML INJ 1 ML NE  ,J0881,HCPCS,,40507501,CDM,636,RC,55513-0002-01,NDC,both,1,ML,660.31,28.91,,,28.91,Other,150% of Medicare + 9.63% HCRA Surcharge,17.58,,,17.58,Fee Schedule,Average Sale Price (ASP) x 6,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,330.16,50,,330.16,percent of total billed charges,All Other,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,224.51,34,"If Charge > 500, then 34 percent",224.51,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,198.09,30,,198.09,percent of total billed charges,Drugs,50.29,,,50.29,Other,Drug Cost,50.29,,,50.29,Other,Drug Cost,50.29,,,50.29,Other,Drug Cost,50.29,,,50.29,Other,Drug Cost,50.29,,,50.29,Other,Drug Cost,224.51,34,,224.51,percent of total billed charges,Drugs,50.29,,,50.29,Other,Drug Cost,113.15,,,113.15,Other,225% Medicaid APG methodology,70.41,,,70.41,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,28.13,,,28.13,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",50.29,,,50.29,Other,Drug Cost,50.29,,,50.29,Other,Drug Cost,62.86,,,62.86,Other,125% Medicaid APG methodology,0.01,330.16,
DARBE AL 40 MCG/0.4 ML INJ NE   ,J0881,HCPCS,,40507519,CDM,636,RC,55513-0021-01,NDC,both,0.4,ML,1056.51,28.91,,,28.91,Other,150% of Medicare + 9.63% HCRA Surcharge,17.58,,,17.58,Fee Schedule,Average Sale Price (ASP) x 6,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,528.26,50,,528.26,percent of total billed charges,All Other,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,359.21,34,"If Charge > 500, then 34 percent",359.21,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,316.95,30,,316.95,percent of total billed charges,Drugs,70.74,,,70.74,Other,Drug Cost,70.74,,,70.74,Other,Drug Cost,70.74,,,70.74,Other,Drug Cost,70.74,,,70.74,Other,Drug Cost,70.74,,,70.74,Other,Drug Cost,359.21,34,,359.21,percent of total billed charges,Drugs,70.74,,,70.74,Other,Drug Cost,159.17,,,159.17,Other,225% Medicaid APG methodology,99.04,,,99.04,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,28.13,,,28.13,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",70.74,,,70.74,Other,Drug Cost,70.74,,,70.74,Other,Drug Cost,88.43,,,88.43,Other,125% Medicaid APG methodology,0.01,528.26,
DARBE AL 60 MCG/ML INJ 1 ML NE  ,J0881,HCPCS,,40507527,CDM,636,RC,55513-0004-01,NDC,both,1,ML,1584.77,28.91,,,28.91,Other,150% of Medicare + 9.63% HCRA Surcharge,17.58,,,17.58,Fee Schedule,Average Sale Price (ASP) x 6,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,792.39,50,,792.39,percent of total billed charges,All Other,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,538.82,34,"If Charge > 500, then 34 percent",538.82,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,475.43,30,,475.43,percent of total billed charges,Drugs,120.7,,,120.7,Other,Drug Cost,120.7,,,120.7,Other,Drug Cost,120.7,,,120.7,Other,Drug Cost,120.7,,,120.7,Other,Drug Cost,120.7,,,120.7,Other,Drug Cost,538.82,34,,538.82,percent of total billed charges,Drugs,120.7,,,120.7,Other,Drug Cost,271.58,,,271.58,Other,225% Medicaid APG methodology,168.98,,,168.98,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,28.13,,,28.13,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",120.7,,,120.7,Other,Drug Cost,120.7,,,120.7,Other,Drug Cost,150.88,,,150.88,Other,125% Medicaid APG methodology,0.01,792.39,
IOPAMIDOL 61% INJ SOLN 150 ML   ,Q9967,HCPCS,,40507568,CDM,636,RC,00270-1315-50,NDC,both,150,ML,233.66,1.16,,,1.16,Other,150% of Medicare + 9.63% HCRA Surcharge,0.71,,,0.71,Fee Schedule,Average Sale Price (ASP) x 6,70.1,30,,70.1,percent of total billed charges,Drugs,70.1,30,,70.1,percent of total billed charges,Drugs,70.1,30,,70.1,percent of total billed charges,Drugs,70.1,30,,70.1,percent of total billed charges,Drugs,70.1,30,,70.1,percent of total billed charges,Drugs,116.83,50,,116.83,percent of total billed charges,All Other,70.1,30,,70.1,percent of total billed charges,Drugs,70.1,30,,70.1,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,70.1,30,,70.1,percent of total billed charges,Drugs,70.1,30,,70.1,percent of total billed charges,Drugs,70.1,30,,70.1,percent of total billed charges,Drugs,70.1,30,,70.1,percent of total billed charges,Drugs,70.1,30,,70.1,percent of total billed charges,Drugs,70.1,30,,70.1,percent of total billed charges,Drugs,70.1,30,,70.1,percent of total billed charges,Drugs,70.1,30,,70.1,percent of total billed charges,Drugs,70.1,30,,70.1,percent of total billed charges,Drugs,70.1,30,,70.1,percent of total billed charges,Drugs,70.1,30,,70.1,percent of total billed charges,Drugs,70.1,30,,70.1,percent of total billed charges,Drugs,70.1,30,,70.1,percent of total billed charges,Drugs,66.76,,,66.76,Other,Drug Cost,66.76,,,66.76,Other,Drug Cost,66.76,,,66.76,Other,Drug Cost,66.76,,,66.76,Other,Drug Cost,66.76,,,66.76,Other,Drug Cost,79.44,34,,79.44,percent of total billed charges,Drugs,66.76,,,66.76,Other,Drug Cost,150.21,,,150.21,Other,225% Medicaid APG methodology,93.46,,,93.46,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.13,,,1.13,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",66.76,,,66.76,Other,Drug Cost,66.76,,,66.76,Other,Drug Cost,83.45,,,83.45,Other,125% Medicaid APG methodology,0.01,150.21,
IOVERSOL 68% INJ SOLN 200 ML    ,Q9967,HCPCS,,40507576,CDM,636,RC,00019-1323-21,NDC,both,200,ML,215.57,1.16,,,1.16,Other,150% of Medicare + 9.63% HCRA Surcharge,0.71,,,0.71,Fee Schedule,Average Sale Price (ASP) x 6,64.67,30,,64.67,percent of total billed charges,Drugs,64.67,30,,64.67,percent of total billed charges,Drugs,64.67,30,,64.67,percent of total billed charges,Drugs,64.67,30,,64.67,percent of total billed charges,Drugs,64.67,30,,64.67,percent of total billed charges,Drugs,107.79,50,,107.79,percent of total billed charges,All Other,64.67,30,,64.67,percent of total billed charges,Drugs,64.67,30,,64.67,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,64.67,30,,64.67,percent of total billed charges,Drugs,64.67,30,,64.67,percent of total billed charges,Drugs,64.67,30,,64.67,percent of total billed charges,Drugs,64.67,30,,64.67,percent of total billed charges,Drugs,64.67,30,,64.67,percent of total billed charges,Drugs,64.67,30,,64.67,percent of total billed charges,Drugs,64.67,30,,64.67,percent of total billed charges,Drugs,64.67,30,,64.67,percent of total billed charges,Drugs,64.67,30,,64.67,percent of total billed charges,Drugs,64.67,30,,64.67,percent of total billed charges,Drugs,64.67,30,,64.67,percent of total billed charges,Drugs,64.67,30,,64.67,percent of total billed charges,Drugs,64.67,30,,64.67,percent of total billed charges,Drugs,60.3,,,60.3,Other,Drug Cost,60.3,,,60.3,Other,Drug Cost,60.3,,,60.3,Other,Drug Cost,60.3,,,60.3,Other,Drug Cost,60.3,,,60.3,Other,Drug Cost,73.29,34,,73.29,percent of total billed charges,Drugs,60.3,,,60.3,Other,Drug Cost,135.68,,,135.68,Other,225% Medicaid APG methodology,84.42,,,84.42,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.13,,,1.13,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",60.3,,,60.3,Other,Drug Cost,60.3,,,60.3,Other,Drug Cost,75.38,,,75.38,Other,125% Medicaid APG methodology,0.01,135.68,
IOVERSOL 68% INJ SOLN 75 ML     ,Q9967,HCPCS,,40507584,CDM,636,RC,00019-1323-95,NDC,both,75,ML,101.36,1.16,,,1.16,Other,150% of Medicare + 9.63% HCRA Surcharge,0.71,,,0.71,Fee Schedule,Average Sale Price (ASP) x 6,30.41,30,,30.41,percent of total billed charges,Drugs,30.41,30,,30.41,percent of total billed charges,Drugs,30.41,30,,30.41,percent of total billed charges,Drugs,30.41,30,,30.41,percent of total billed charges,Drugs,30.41,30,,30.41,percent of total billed charges,Drugs,50.68,50,,50.68,percent of total billed charges,All Other,30.41,30,,30.41,percent of total billed charges,Drugs,30.41,30,,30.41,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,30.41,30,,30.41,percent of total billed charges,Drugs,30.41,30,,30.41,percent of total billed charges,Drugs,30.41,30,,30.41,percent of total billed charges,Drugs,30.41,30,,30.41,percent of total billed charges,Drugs,30.41,30,,30.41,percent of total billed charges,Drugs,30.41,30,,30.41,percent of total billed charges,Drugs,30.41,30,,30.41,percent of total billed charges,Drugs,30.41,30,,30.41,percent of total billed charges,Drugs,30.41,30,,30.41,percent of total billed charges,Drugs,30.41,30,,30.41,percent of total billed charges,Drugs,30.41,30,,30.41,percent of total billed charges,Drugs,30.41,30,,30.41,percent of total billed charges,Drugs,30.41,30,,30.41,percent of total billed charges,Drugs,28.38,,,28.38,Other,Drug Cost,28.38,,,28.38,Other,Drug Cost,28.38,,,28.38,Other,Drug Cost,28.38,,,28.38,Other,Drug Cost,28.38,,,28.38,Other,Drug Cost,34.46,34,,34.46,percent of total billed charges,Drugs,28.38,,,28.38,Other,Drug Cost,63.86,,,63.86,Other,225% Medicaid APG methodology,39.73,,,39.73,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.13,,,1.13,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",28.38,,,28.38,Other,Drug Cost,28.38,,,28.38,Other,Drug Cost,35.48,,,35.48,Other,125% Medicaid APG methodology,0.01,63.86,
IOVERSOL 74% INJ SOLN 50 ML     ,Q9967,HCPCS,,40507592,CDM,636,RC,00019-1333-06,NDC,both,50,ML,61.67,1.16,,,1.16,Other,150% of Medicare + 9.63% HCRA Surcharge,0.71,,,0.71,Fee Schedule,Average Sale Price (ASP) x 6,18.5,30,,18.5,percent of total billed charges,Drugs,18.5,30,,18.5,percent of total billed charges,Drugs,18.5,30,,18.5,percent of total billed charges,Drugs,18.5,30,,18.5,percent of total billed charges,Drugs,18.5,30,,18.5,percent of total billed charges,Drugs,30.84,50,,30.84,percent of total billed charges,All Other,18.5,30,,18.5,percent of total billed charges,Drugs,18.5,30,,18.5,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,18.5,30,,18.5,percent of total billed charges,Drugs,18.5,30,,18.5,percent of total billed charges,Drugs,18.5,30,,18.5,percent of total billed charges,Drugs,18.5,30,,18.5,percent of total billed charges,Drugs,18.5,30,,18.5,percent of total billed charges,Drugs,18.5,30,,18.5,percent of total billed charges,Drugs,18.5,30,,18.5,percent of total billed charges,Drugs,18.5,30,,18.5,percent of total billed charges,Drugs,18.5,30,,18.5,percent of total billed charges,Drugs,18.5,30,,18.5,percent of total billed charges,Drugs,18.5,30,,18.5,percent of total billed charges,Drugs,18.5,30,,18.5,percent of total billed charges,Drugs,18.5,30,,18.5,percent of total billed charges,Drugs,17.28,,,17.28,Other,Drug Cost,17.28,,,17.28,Other,Drug Cost,17.28,,,17.28,Other,Drug Cost,17.28,,,17.28,Other,Drug Cost,17.28,,,17.28,Other,Drug Cost,20.97,34,,20.97,percent of total billed charges,Drugs,17.28,,,17.28,Other,Drug Cost,38.88,,,38.88,Other,225% Medicaid APG methodology,24.19,,,24.19,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.13,,,1.13,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",17.28,,,17.28,Other,Drug Cost,17.28,,,17.28,Other,Drug Cost,21.6,,,21.6,Other,125% Medicaid APG methodology,0.01,38.88,
"LEUPROLIDE 45 MG/6 MON SQ, ER   ",J9217,HCPCS,,40507600,CDM,636,RC,62935-0461-50,NDC,both,1,EA,1974,1788.85,,,1788.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1087.81,,,1087.81,Fee Schedule,Average Sale Price (ASP) x 6,592.2,30,,592.2,percent of total billed charges,Drugs,592.2,30,,592.2,percent of total billed charges,Drugs,592.2,30,,592.2,percent of total billed charges,Drugs,592.2,30,,592.2,percent of total billed charges,Drugs,592.2,30,,592.2,percent of total billed charges,Drugs,987,50,,987,percent of total billed charges,All Other,592.2,30,,592.2,percent of total billed charges,Drugs,592.2,30,,592.2,percent of total billed charges,Drugs,671.16,34,"If Charge > 500, then 34 percent",671.16,percent of total billed charges,Drugs,592.2,30,,592.2,percent of total billed charges,Drugs,592.2,30,,592.2,percent of total billed charges,Drugs,592.2,30,,592.2,percent of total billed charges,Drugs,592.2,30,,592.2,percent of total billed charges,Drugs,592.2,30,,592.2,percent of total billed charges,Drugs,592.2,30,,592.2,percent of total billed charges,Drugs,592.2,30,,592.2,percent of total billed charges,Drugs,592.2,30,,592.2,percent of total billed charges,Drugs,592.2,30,,592.2,percent of total billed charges,Drugs,592.2,30,,592.2,percent of total billed charges,Drugs,592.2,30,,592.2,percent of total billed charges,Drugs,592.2,30,,592.2,percent of total billed charges,Drugs,592.2,30,,592.2,percent of total billed charges,Drugs,444,,,444,Other,Drug Cost,444,,,444,Other,Drug Cost,444,,,444,Other,Drug Cost,444,,,444,Other,Drug Cost,444,,,444,Other,Drug Cost,671.16,34,,671.16,percent of total billed charges,Drugs,444,,,444,Other,Drug Cost,999,,,999,Other,225% Medicaid APG methodology,621.6,,,621.6,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1740.5,,,1740.5,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",444,,,444,Other,Drug Cost,444,,,444,Other,Drug Cost,555,,,555,Other,125% Medicaid APG methodology,0.01,1788.85,
LUSPATERCEPT-AAMT 25 MG SQ INJ  ,J0896,HCPCS,,40507626,CDM,636,RC,59572-0711-01,NDC,both,1,EA,13780.24,394.38,,,394.38,Other,150% of Medicare + 9.63% HCRA Surcharge,239.83,,,239.83,Fee Schedule,Average Sale Price (ASP) x 6,4134.07,30,,4134.07,percent of total billed charges,Drugs,4134.07,30,,4134.07,percent of total billed charges,Drugs,4134.07,30,,4134.07,percent of total billed charges,Drugs,4134.07,30,,4134.07,percent of total billed charges,Drugs,4134.07,30,,4134.07,percent of total billed charges,Drugs,6890.12,50,,6890.12,percent of total billed charges,All Other,4134.07,30,,4134.07,percent of total billed charges,Drugs,4134.07,30,,4134.07,percent of total billed charges,Drugs,4685.28,34,"If Charge > 500, then 34 percent",4685.28,percent of total billed charges,Drugs,4134.07,30,,4134.07,percent of total billed charges,Drugs,4134.07,30,,4134.07,percent of total billed charges,Drugs,4134.07,30,,4134.07,percent of total billed charges,Drugs,4134.07,30,,4134.07,percent of total billed charges,Drugs,4134.07,30,,4134.07,percent of total billed charges,Drugs,4134.07,30,,4134.07,percent of total billed charges,Drugs,4134.07,30,,4134.07,percent of total billed charges,Drugs,4134.07,30,,4134.07,percent of total billed charges,Drugs,4134.07,30,,4134.07,percent of total billed charges,Drugs,4134.07,30,,4134.07,percent of total billed charges,Drugs,4134.07,30,,4134.07,percent of total billed charges,Drugs,4134.07,30,,4134.07,percent of total billed charges,Drugs,4134.07,30,,4134.07,percent of total billed charges,Drugs,2927.51,,,2927.51,Other,Drug Cost,2927.51,,,2927.51,Other,Drug Cost,2927.51,,,2927.51,Other,Drug Cost,2927.51,,,2927.51,Other,Drug Cost,2927.51,,,2927.51,Other,Drug Cost,4685.28,34,,4685.28,percent of total billed charges,Drugs,2927.51,,,2927.51,Other,Drug Cost,6586.9,,,6586.9,Other,225% Medicaid APG methodology,4098.51,,,4098.51,Other,140% Medicaid APG methodology,4685.28,34,"If Charge > 2,000, then 34 percent",4685.28,percent of total billed charges,Drugs,383.72,,,383.72,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2927.51,,,2927.51,Other,Drug Cost,2927.51,,,2927.51,Other,Drug Cost,3659.39,,,3659.39,Other,125% Medicaid APG methodology,0.01,6890.12,
LUSPATERCEPT-AAMT 75 MG SQ INJ  ,J0896,HCPCS,,40507634,CDM,636,RC,59572-0775-01,NDC,both,1,EA,41340.57,394.38,,,394.38,Other,150% of Medicare + 9.63% HCRA Surcharge,239.83,,,239.83,Fee Schedule,Average Sale Price (ASP) x 6,12402.17,30,,12402.17,percent of total billed charges,Drugs,12402.17,30,,12402.17,percent of total billed charges,Drugs,12402.17,30,,12402.17,percent of total billed charges,Drugs,12402.17,30,,12402.17,percent of total billed charges,Drugs,12402.17,30,,12402.17,percent of total billed charges,Drugs,20670.29,50,,20670.29,percent of total billed charges,All Other,12402.17,30,,12402.17,percent of total billed charges,Drugs,12402.17,30,,12402.17,percent of total billed charges,Drugs,14055.79,34,"If Charge > 500, then 34 percent",14055.79,percent of total billed charges,Drugs,12402.17,30,,12402.17,percent of total billed charges,Drugs,12402.17,30,,12402.17,percent of total billed charges,Drugs,12402.17,30,,12402.17,percent of total billed charges,Drugs,12402.17,30,,12402.17,percent of total billed charges,Drugs,12402.17,30,,12402.17,percent of total billed charges,Drugs,12402.17,30,,12402.17,percent of total billed charges,Drugs,12402.17,30,,12402.17,percent of total billed charges,Drugs,12402.17,30,,12402.17,percent of total billed charges,Drugs,12402.17,30,,12402.17,percent of total billed charges,Drugs,12402.17,30,,12402.17,percent of total billed charges,Drugs,12402.17,30,,12402.17,percent of total billed charges,Drugs,12402.17,30,,12402.17,percent of total billed charges,Drugs,12402.17,30,,12402.17,percent of total billed charges,Drugs,8778.55,,,8778.55,Other,Drug Cost,8778.55,,,8778.55,Other,Drug Cost,8778.55,,,8778.55,Other,Drug Cost,8778.55,,,8778.55,Other,Drug Cost,8778.55,,,8778.55,Other,Drug Cost,14055.79,34,,14055.79,percent of total billed charges,Drugs,8778.55,,,8778.55,Other,Drug Cost,19751.74,,,19751.74,Other,225% Medicaid APG methodology,12289.97,,,12289.97,Other,140% Medicaid APG methodology,14055.79,34,"If Charge > 2,000, then 34 percent",14055.79,percent of total billed charges,Drugs,383.72,,,383.72,Other,160% Medicare Fee Schedule,14055.79,34,,14055.79,Other,"Drug Charges > 20,000, then 34% of Charges",8778.55,,,8778.55,Other,Drug Cost,8778.55,,,8778.55,Other,Drug Cost,10973.19,,,10973.19,Other,125% Medicaid APG methodology,239.83,20670.29,
COP CU 64 DOT 37 MBQ/ML  4 ML   ,A9592,HCPCS,,40507659,CDM,636,RC,69945-0064-01,NDC,both,4,EA,0.56,0.22,39.4668,,0.22,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.28,50,,0.28,percent of total billed charges,All Other,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.19,34,,0.19,percent of total billed charges,Drugs,0.16,,,0.16,Other,Drug Cost,0.36,,,0.36,Other,225% Medicaid APG methodology,0.22,,,0.22,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.2,,,0.2,Other,125% Medicaid APG methodology,0.01,0.36,
DOTAT 40 MCG IV INJ FOR GA 68   ,A9587,HCPCS,,40507667,CDM,636,RC,69488-0001-40,NDC,both,1,EA,121.21,47.84,39.4668,,47.84,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,36.36,30,,36.36,percent of total billed charges,Drugs,36.36,30,,36.36,percent of total billed charges,Drugs,36.36,30,,36.36,percent of total billed charges,Drugs,36.36,30,,36.36,percent of total billed charges,Drugs,36.36,30,,36.36,percent of total billed charges,Drugs,60.61,50,,60.61,percent of total billed charges,All Other,36.36,30,,36.36,percent of total billed charges,Drugs,36.36,30,,36.36,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,36.36,30,,36.36,percent of total billed charges,Drugs,36.36,30,,36.36,percent of total billed charges,Drugs,36.36,30,,36.36,percent of total billed charges,Drugs,36.36,30,,36.36,percent of total billed charges,Drugs,36.36,30,,36.36,percent of total billed charges,Drugs,36.36,30,,36.36,percent of total billed charges,Drugs,36.36,30,,36.36,percent of total billed charges,Drugs,36.36,30,,36.36,percent of total billed charges,Drugs,36.36,30,,36.36,percent of total billed charges,Drugs,36.36,30,,36.36,percent of total billed charges,Drugs,36.36,30,,36.36,percent of total billed charges,Drugs,36.36,30,,36.36,percent of total billed charges,Drugs,36.36,30,,36.36,percent of total billed charges,Drugs,34.63,,,34.63,Other,Drug Cost,34.63,,,34.63,Other,Drug Cost,34.63,,,34.63,Other,Drug Cost,34.63,,,34.63,Other,Drug Cost,34.63,,,34.63,Other,Drug Cost,41.21,34,,41.21,percent of total billed charges,Drugs,34.63,,,34.63,Other,Drug Cost,77.92,,,77.92,Other,225% Medicaid APG methodology,48.48,,,48.48,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",34.63,,,34.63,Other,Drug Cost,34.63,,,34.63,Other,Drug Cost,43.29,,,43.29,Other,125% Medicaid APG methodology,0.01,77.92,
GALL CI GA-67 2 MCI/ML  3.3 ML  ,A9556,HCPCS,,40507683,CDM,636,RC,11994-0121-06,NDC,both,3.3,ML,79.56,31.4,39.4668,,31.4,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,23.87,30,,23.87,percent of total billed charges,Drugs,23.87,30,,23.87,percent of total billed charges,Drugs,23.87,30,,23.87,percent of total billed charges,Drugs,23.87,30,,23.87,percent of total billed charges,Drugs,23.87,30,,23.87,percent of total billed charges,Drugs,39.78,50,,39.78,percent of total billed charges,All Other,23.87,30,,23.87,percent of total billed charges,Drugs,23.87,30,,23.87,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,23.87,30,,23.87,percent of total billed charges,Drugs,23.87,30,,23.87,percent of total billed charges,Drugs,23.87,30,,23.87,percent of total billed charges,Drugs,23.87,30,,23.87,percent of total billed charges,Drugs,23.87,30,,23.87,percent of total billed charges,Drugs,23.87,30,,23.87,percent of total billed charges,Drugs,23.87,30,,23.87,percent of total billed charges,Drugs,23.87,30,,23.87,percent of total billed charges,Drugs,23.87,30,,23.87,percent of total billed charges,Drugs,23.87,30,,23.87,percent of total billed charges,Drugs,23.87,30,,23.87,percent of total billed charges,Drugs,23.87,30,,23.87,percent of total billed charges,Drugs,23.87,30,,23.87,percent of total billed charges,Drugs,22.73,,,22.73,Other,Drug Cost,22.73,,,22.73,Other,Drug Cost,22.73,,,22.73,Other,Drug Cost,22.73,,,22.73,Other,Drug Cost,22.73,,,22.73,Other,Drug Cost,27.05,34,,27.05,percent of total billed charges,Drugs,22.73,,,22.73,Other,Drug Cost,51.14,,,51.14,Other,225% Medicaid APG methodology,31.82,,,31.82,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",22.73,,,22.73,Other,Drug Cost,22.73,,,22.73,Other,Drug Cost,28.41,,,28.41,Other,125% Medicaid APG methodology,0.01,51.14,
GALL CI GA-67 2 MCI/ML  6.6 ML  ,A9556,HCPCS,,40507691,CDM,636,RC,11994-0121-13,NDC,both,6.6,ML,9955.19,3928.99,39.4668,,3928.99,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,2986.56,30,,2986.56,percent of total billed charges,Drugs,2986.56,30,,2986.56,percent of total billed charges,Drugs,2986.56,30,,2986.56,percent of total billed charges,Drugs,2986.56,30,,2986.56,percent of total billed charges,Drugs,2986.56,30,,2986.56,percent of total billed charges,Drugs,4977.6,50,,4977.6,percent of total billed charges,All Other,2986.56,30,,2986.56,percent of total billed charges,Drugs,2986.56,30,,2986.56,percent of total billed charges,Drugs,3384.76,34,"If Charge > 500, then 34 percent",3384.76,percent of total billed charges,Drugs,2986.56,30,,2986.56,percent of total billed charges,Drugs,2986.56,30,,2986.56,percent of total billed charges,Drugs,2986.56,30,,2986.56,percent of total billed charges,Drugs,2986.56,30,,2986.56,percent of total billed charges,Drugs,2986.56,30,,2986.56,percent of total billed charges,Drugs,2986.56,30,,2986.56,percent of total billed charges,Drugs,2986.56,30,,2986.56,percent of total billed charges,Drugs,2986.56,30,,2986.56,percent of total billed charges,Drugs,2986.56,30,,2986.56,percent of total billed charges,Drugs,2986.56,30,,2986.56,percent of total billed charges,Drugs,2986.56,30,,2986.56,percent of total billed charges,Drugs,2986.56,30,,2986.56,percent of total billed charges,Drugs,2986.56,30,,2986.56,percent of total billed charges,Drugs,2844.34,,,2844.34,Other,Drug Cost,2844.34,,,2844.34,Other,Drug Cost,2844.34,,,2844.34,Other,Drug Cost,2844.34,,,2844.34,Other,Drug Cost,2844.34,,,2844.34,Other,Drug Cost,3384.76,34,,3384.76,percent of total billed charges,Drugs,2844.34,,,2844.34,Other,Drug Cost,6399.77,,,6399.77,Other,225% Medicaid APG methodology,3982.08,,,3982.08,Other,140% Medicaid APG methodology,3384.76,34,"If Charge > 2,000, then 34 percent",3384.76,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2844.34,,,2844.34,Other,Drug Cost,2844.34,,,2844.34,Other,Drug Cost,3555.43,,,3555.43,Other,125% Medicaid APG methodology,0.01,6399.77,
GALL CI GA-67 2 MCI/ML  9.9 ML  ,A9556,HCPCS,,40507709,CDM,636,RC,11994-0121-19,NDC,both,9.9,ML,20662.5,8154.83,39.4668,,8154.83,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,6198.75,30,,6198.75,percent of total billed charges,Drugs,6198.75,30,,6198.75,percent of total billed charges,Drugs,6198.75,30,,6198.75,percent of total billed charges,Drugs,6198.75,30,,6198.75,percent of total billed charges,Drugs,6198.75,30,,6198.75,percent of total billed charges,Drugs,10331.25,50,,10331.25,percent of total billed charges,All Other,6198.75,30,,6198.75,percent of total billed charges,Drugs,6198.75,30,,6198.75,percent of total billed charges,Drugs,7025.25,34,"If Charge > 500, then 34 percent",7025.25,percent of total billed charges,Drugs,6198.75,30,,6198.75,percent of total billed charges,Drugs,6198.75,30,,6198.75,percent of total billed charges,Drugs,6198.75,30,,6198.75,percent of total billed charges,Drugs,6198.75,30,,6198.75,percent of total billed charges,Drugs,6198.75,30,,6198.75,percent of total billed charges,Drugs,6198.75,30,,6198.75,percent of total billed charges,Drugs,6198.75,30,,6198.75,percent of total billed charges,Drugs,6198.75,30,,6198.75,percent of total billed charges,Drugs,6198.75,30,,6198.75,percent of total billed charges,Drugs,6198.75,30,,6198.75,percent of total billed charges,Drugs,6198.75,30,,6198.75,percent of total billed charges,Drugs,6198.75,30,,6198.75,percent of total billed charges,Drugs,6198.75,30,,6198.75,percent of total billed charges,Drugs,5903.57,,,5903.57,Other,Drug Cost,5903.57,,,5903.57,Other,Drug Cost,5903.57,,,5903.57,Other,Drug Cost,5903.57,,,5903.57,Other,Drug Cost,5903.57,,,5903.57,Other,Drug Cost,7025.25,34,,7025.25,percent of total billed charges,Drugs,5903.57,,,5903.57,Other,Drug Cost,13283.03,,,13283.03,Other,225% Medicaid APG methodology,8265,,,8265,Other,140% Medicaid APG methodology,7025.25,34,"If Charge > 2,000, then 34 percent",7025.25,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,7025.25,34,,7025.25,Other,"Drug Charges > 20,000, then 34% of Charges",5903.57,,,5903.57,Other,Drug Cost,5903.57,,,5903.57,Other,Drug Cost,7379.46,,,7379.46,Other,125% Medicaid APG methodology,0.01,13283.03,
GALLIUM GA-68 PSMA-11 IV SOLN   ,A9594,HCPCS,,40507717,CDM,636,RC,76394-2642-03,NDC,both,1,EA,18505.2,7303.41,39.4668,,7303.41,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,5551.56,30,,5551.56,percent of total billed charges,Drugs,5551.56,30,,5551.56,percent of total billed charges,Drugs,5551.56,30,,5551.56,percent of total billed charges,Drugs,5551.56,30,,5551.56,percent of total billed charges,Drugs,5551.56,30,,5551.56,percent of total billed charges,Drugs,9252.6,50,,9252.6,percent of total billed charges,All Other,5551.56,30,,5551.56,percent of total billed charges,Drugs,5551.56,30,,5551.56,percent of total billed charges,Drugs,6291.77,34,"If Charge > 500, then 34 percent",6291.77,percent of total billed charges,Drugs,5551.56,30,,5551.56,percent of total billed charges,Drugs,5551.56,30,,5551.56,percent of total billed charges,Drugs,5551.56,30,,5551.56,percent of total billed charges,Drugs,5551.56,30,,5551.56,percent of total billed charges,Drugs,5551.56,30,,5551.56,percent of total billed charges,Drugs,5551.56,30,,5551.56,percent of total billed charges,Drugs,5551.56,30,,5551.56,percent of total billed charges,Drugs,5551.56,30,,5551.56,percent of total billed charges,Drugs,5551.56,30,,5551.56,percent of total billed charges,Drugs,5551.56,30,,5551.56,percent of total billed charges,Drugs,5551.56,30,,5551.56,percent of total billed charges,Drugs,5551.56,30,,5551.56,percent of total billed charges,Drugs,5551.56,30,,5551.56,percent of total billed charges,Drugs,5287.2,,,5287.2,Other,Drug Cost,5287.2,,,5287.2,Other,Drug Cost,5287.2,,,5287.2,Other,Drug Cost,5287.2,,,5287.2,Other,Drug Cost,5287.2,,,5287.2,Other,Drug Cost,6291.77,34,,6291.77,percent of total billed charges,Drugs,5287.2,,,5287.2,Other,Drug Cost,11896.2,,,11896.2,Other,225% Medicaid APG methodology,7402.08,,,7402.08,Other,140% Medicaid APG methodology,6291.77,34,"If Charge > 2,000, then 34 percent",6291.77,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5287.2,,,5287.2,Other,Drug Cost,5287.2,,,5287.2,Other,Drug Cost,6609,,,6609,Other,125% Medicaid APG methodology,0.01,11896.2,
IND OXYQ IN-111 AUTOLOG LEUKO   ,A9547,HCPCS,,40507733,CDM,636,RC,17156-0021-01,NDC,both,1,ML,2148.72,848.03,39.4668,,848.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,644.62,30,,644.62,percent of total billed charges,Drugs,644.62,30,,644.62,percent of total billed charges,Drugs,644.62,30,,644.62,percent of total billed charges,Drugs,644.62,30,,644.62,percent of total billed charges,Drugs,644.62,30,,644.62,percent of total billed charges,Drugs,1074.36,50,,1074.36,percent of total billed charges,All Other,644.62,30,,644.62,percent of total billed charges,Drugs,644.62,30,,644.62,percent of total billed charges,Drugs,730.56,34,"If Charge > 500, then 34 percent",730.56,percent of total billed charges,Drugs,644.62,30,,644.62,percent of total billed charges,Drugs,644.62,30,,644.62,percent of total billed charges,Drugs,644.62,30,,644.62,percent of total billed charges,Drugs,644.62,30,,644.62,percent of total billed charges,Drugs,644.62,30,,644.62,percent of total billed charges,Drugs,644.62,30,,644.62,percent of total billed charges,Drugs,644.62,30,,644.62,percent of total billed charges,Drugs,644.62,30,,644.62,percent of total billed charges,Drugs,644.62,30,,644.62,percent of total billed charges,Drugs,644.62,30,,644.62,percent of total billed charges,Drugs,644.62,30,,644.62,percent of total billed charges,Drugs,644.62,30,,644.62,percent of total billed charges,Drugs,644.62,30,,644.62,percent of total billed charges,Drugs,613.92,,,613.92,Other,Drug Cost,613.92,,,613.92,Other,Drug Cost,613.92,,,613.92,Other,Drug Cost,613.92,,,613.92,Other,Drug Cost,613.92,,,613.92,Other,Drug Cost,730.56,34,,730.56,percent of total billed charges,Drugs,613.92,,,613.92,Other,Drug Cost,1381.32,,,1381.32,Other,225% Medicaid APG methodology,859.49,,,859.49,Other,140% Medicaid APG methodology,730.56,34,"If Charge > 2,000, then 34 percent",730.56,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",613.92,,,613.92,Other,Drug Cost,613.92,,,613.92,Other,Drug Cost,767.4,,,767.4,Other,125% Medicaid APG methodology,0.01,1381.32,
IND PE IN-111 1 MCI/ML  1.5 ML  ,A9548,HCPCS,,40507741,CDM,636,RC,17156-0251-08,NDC,both,1.5,ML,3008.67,1187.43,39.4668,,1187.43,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,902.6,30,,902.6,percent of total billed charges,Drugs,902.6,30,,902.6,percent of total billed charges,Drugs,902.6,30,,902.6,percent of total billed charges,Drugs,902.6,30,,902.6,percent of total billed charges,Drugs,902.6,30,,902.6,percent of total billed charges,Drugs,1504.34,50,,1504.34,percent of total billed charges,All Other,902.6,30,,902.6,percent of total billed charges,Drugs,902.6,30,,902.6,percent of total billed charges,Drugs,1022.95,34,"If Charge > 500, then 34 percent",1022.95,percent of total billed charges,Drugs,902.6,30,,902.6,percent of total billed charges,Drugs,902.6,30,,902.6,percent of total billed charges,Drugs,902.6,30,,902.6,percent of total billed charges,Drugs,902.6,30,,902.6,percent of total billed charges,Drugs,902.6,30,,902.6,percent of total billed charges,Drugs,902.6,30,,902.6,percent of total billed charges,Drugs,902.6,30,,902.6,percent of total billed charges,Drugs,902.6,30,,902.6,percent of total billed charges,Drugs,902.6,30,,902.6,percent of total billed charges,Drugs,902.6,30,,902.6,percent of total billed charges,Drugs,902.6,30,,902.6,percent of total billed charges,Drugs,902.6,30,,902.6,percent of total billed charges,Drugs,902.6,30,,902.6,percent of total billed charges,Drugs,859.62,,,859.62,Other,Drug Cost,859.62,,,859.62,Other,Drug Cost,859.62,,,859.62,Other,Drug Cost,859.62,,,859.62,Other,Drug Cost,859.62,,,859.62,Other,Drug Cost,1022.95,34,,1022.95,percent of total billed charges,Drugs,859.62,,,859.62,Other,Drug Cost,1934.15,,,1934.15,Other,225% Medicaid APG methodology,1203.47,,,1203.47,Other,140% Medicaid APG methodology,1022.95,34,"If Charge > 2,000, then 34 percent",1022.95,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",859.62,,,859.62,Other,Drug Cost,859.62,,,859.62,Other,Drug Cost,1074.53,,,1074.53,Other,125% Medicaid APG methodology,0.01,1934.15,
IOBENGUANE I-123 370 MBQ/5 ML   ,A9582,HCPCS,,40507766,CDM,636,RC,17156-0235-01,NDC,both,5,EA,65.87,26,39.4668,,26,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,19.76,30,,19.76,percent of total billed charges,Drugs,19.76,30,,19.76,percent of total billed charges,Drugs,19.76,30,,19.76,percent of total billed charges,Drugs,19.76,30,,19.76,percent of total billed charges,Drugs,19.76,30,,19.76,percent of total billed charges,Drugs,32.94,50,,32.94,percent of total billed charges,All Other,19.76,30,,19.76,percent of total billed charges,Drugs,19.76,30,,19.76,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,19.76,30,,19.76,percent of total billed charges,Drugs,19.76,30,,19.76,percent of total billed charges,Drugs,19.76,30,,19.76,percent of total billed charges,Drugs,19.76,30,,19.76,percent of total billed charges,Drugs,19.76,30,,19.76,percent of total billed charges,Drugs,19.76,30,,19.76,percent of total billed charges,Drugs,19.76,30,,19.76,percent of total billed charges,Drugs,19.76,30,,19.76,percent of total billed charges,Drugs,19.76,30,,19.76,percent of total billed charges,Drugs,19.76,30,,19.76,percent of total billed charges,Drugs,19.76,30,,19.76,percent of total billed charges,Drugs,19.76,30,,19.76,percent of total billed charges,Drugs,19.76,30,,19.76,percent of total billed charges,Drugs,18.82,,,18.82,Other,Drug Cost,18.82,,,18.82,Other,Drug Cost,18.82,,,18.82,Other,Drug Cost,18.82,,,18.82,Other,Drug Cost,18.82,,,18.82,Other,Drug Cost,22.4,34,,22.4,percent of total billed charges,Drugs,18.82,,,18.82,Other,Drug Cost,42.35,,,42.35,Other,225% Medicaid APG methodology,26.35,,,26.35,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",18.82,,,18.82,Other,Drug Cost,18.82,,,18.82,Other,Drug Cost,23.53,,,23.53,Other,125% Medicaid APG methodology,0.01,42.35,
IOBENGUANE I-131 IV SOLN        ,A9590,HCPCS,,40507774,CDM,636,RC,71258-0015-02,NDC,both,1,EA,1268.4,500.6,39.4668,,500.6,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,380.52,30,,380.52,percent of total billed charges,Drugs,380.52,30,,380.52,percent of total billed charges,Drugs,380.52,30,,380.52,percent of total billed charges,Drugs,380.52,30,,380.52,percent of total billed charges,Drugs,380.52,30,,380.52,percent of total billed charges,Drugs,634.2,50,,634.2,percent of total billed charges,All Other,380.52,30,,380.52,percent of total billed charges,Drugs,380.52,30,,380.52,percent of total billed charges,Drugs,431.26,34,"If Charge > 500, then 34 percent",431.26,percent of total billed charges,Drugs,380.52,30,,380.52,percent of total billed charges,Drugs,380.52,30,,380.52,percent of total billed charges,Drugs,380.52,30,,380.52,percent of total billed charges,Drugs,380.52,30,,380.52,percent of total billed charges,Drugs,380.52,30,,380.52,percent of total billed charges,Drugs,380.52,30,,380.52,percent of total billed charges,Drugs,380.52,30,,380.52,percent of total billed charges,Drugs,380.52,30,,380.52,percent of total billed charges,Drugs,380.52,30,,380.52,percent of total billed charges,Drugs,380.52,30,,380.52,percent of total billed charges,Drugs,380.52,30,,380.52,percent of total billed charges,Drugs,380.52,30,,380.52,percent of total billed charges,Drugs,380.52,30,,380.52,percent of total billed charges,Drugs,362.4,,,362.4,Other,Drug Cost,362.4,,,362.4,Other,Drug Cost,362.4,,,362.4,Other,Drug Cost,362.4,,,362.4,Other,Drug Cost,362.4,,,362.4,Other,Drug Cost,431.26,34,,431.26,percent of total billed charges,Drugs,362.4,,,362.4,Other,Drug Cost,815.4,,,815.4,Other,225% Medicaid APG methodology,507.36,,,507.36,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",362.4,,,362.4,Other,Drug Cost,362.4,,,362.4,Other,Drug Cost,453,,,453,Other,125% Medicaid APG methodology,0.01,815.4,
LUTETIUM LU 177 DOT 370 MBQ/ML  ,A9513,HCPCS,,40507782,CDM,636,RC,69488-0003-01,NDC,both,1,EA,21.53,8.5,39.4668,,8.5,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,6.46,30,,6.46,percent of total billed charges,Drugs,6.46,30,,6.46,percent of total billed charges,Drugs,6.46,30,,6.46,percent of total billed charges,Drugs,6.46,30,,6.46,percent of total billed charges,Drugs,6.46,30,,6.46,percent of total billed charges,Drugs,10.77,50,,10.77,percent of total billed charges,All Other,6.46,30,,6.46,percent of total billed charges,Drugs,6.46,30,,6.46,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,6.46,30,,6.46,percent of total billed charges,Drugs,6.46,30,,6.46,percent of total billed charges,Drugs,6.46,30,,6.46,percent of total billed charges,Drugs,6.46,30,,6.46,percent of total billed charges,Drugs,6.46,30,,6.46,percent of total billed charges,Drugs,6.46,30,,6.46,percent of total billed charges,Drugs,6.46,30,,6.46,percent of total billed charges,Drugs,6.46,30,,6.46,percent of total billed charges,Drugs,6.46,30,,6.46,percent of total billed charges,Drugs,6.46,30,,6.46,percent of total billed charges,Drugs,6.46,30,,6.46,percent of total billed charges,Drugs,6.46,30,,6.46,percent of total billed charges,Drugs,6.46,30,,6.46,percent of total billed charges,Drugs,6.15,,,6.15,Other,Drug Cost,6.15,,,6.15,Other,Drug Cost,6.15,,,6.15,Other,Drug Cost,6.15,,,6.15,Other,Drug Cost,6.15,,,6.15,Other,Drug Cost,7.32,34,,7.32,percent of total billed charges,Drugs,6.15,,,6.15,Other,Drug Cost,13.84,,,13.84,Other,225% Medicaid APG methodology,8.61,,,8.61,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6.15,,,6.15,Other,Drug Cost,6.15,,,6.15,Other,Drug Cost,7.69,,,7.69,Other,125% Medicaid APG methodology,0.01,13.84,
RADIUM RA 223 DICHLORIDE IV SO  ,A9606,HCPCS,,40507790,CDM,636,RC,50419-0208-01,NDC,both,1,EA,98571.06,38902.84,39.4668,,38902.84,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,29571.32,30,,29571.32,percent of total billed charges,Drugs,29571.32,30,,29571.32,percent of total billed charges,Drugs,29571.32,30,,29571.32,percent of total billed charges,Drugs,29571.32,30,,29571.32,percent of total billed charges,Drugs,29571.32,30,,29571.32,percent of total billed charges,Drugs,49285.53,50,,49285.53,percent of total billed charges,All Other,29571.32,30,,29571.32,percent of total billed charges,Drugs,29571.32,30,,29571.32,percent of total billed charges,Drugs,33514.16,34,"If Charge > 500, then 34 percent",33514.16,percent of total billed charges,Drugs,29571.32,30,,29571.32,percent of total billed charges,Drugs,29571.32,30,,29571.32,percent of total billed charges,Drugs,29571.32,30,,29571.32,percent of total billed charges,Drugs,29571.32,30,,29571.32,percent of total billed charges,Drugs,29571.32,30,,29571.32,percent of total billed charges,Drugs,29571.32,30,,29571.32,percent of total billed charges,Drugs,29571.32,30,,29571.32,percent of total billed charges,Drugs,29571.32,30,,29571.32,percent of total billed charges,Drugs,29571.32,30,,29571.32,percent of total billed charges,Drugs,29571.32,30,,29571.32,percent of total billed charges,Drugs,29571.32,30,,29571.32,percent of total billed charges,Drugs,29571.32,30,,29571.32,percent of total billed charges,Drugs,29571.32,30,,29571.32,percent of total billed charges,Drugs,28163.16,,,28163.16,Other,Drug Cost,28163.16,,,28163.16,Other,Drug Cost,28163.16,,,28163.16,Other,Drug Cost,28163.16,,,28163.16,Other,Drug Cost,28163.16,,,28163.16,Other,Drug Cost,33514.16,34,,33514.16,percent of total billed charges,Drugs,28163.16,,,28163.16,Other,Drug Cost,63367.11,,,63367.11,Other,225% Medicaid APG methodology,39428.42,,,39428.42,Other,140% Medicaid APG methodology,33514.16,34,"If Charge > 2,000, then 34 percent",33514.16,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,33514.16,34,,33514.16,Other,"Drug Charges > 20,000, then 34% of Charges",28163.16,,,28163.16,Other,Drug Cost,28163.16,,,28163.16,Other,Drug Cost,35203.95,,,35203.95,Other,125% Medicaid APG methodology,0.01,63367.11,
STRONTIUM-89 CH 1 MCI/ML 4 ML   ,A9600,HCPCS,,40507840,CDM,636,RC,17156-0524-01,NDC,both,4,EA,13009.5,5134.43,39.4668,,5134.43,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,3902.85,30,,3902.85,percent of total billed charges,Drugs,3902.85,30,,3902.85,percent of total billed charges,Drugs,3902.85,30,,3902.85,percent of total billed charges,Drugs,3902.85,30,,3902.85,percent of total billed charges,Drugs,3902.85,30,,3902.85,percent of total billed charges,Drugs,6504.75,50,,6504.75,percent of total billed charges,All Other,3902.85,30,,3902.85,percent of total billed charges,Drugs,3902.85,30,,3902.85,percent of total billed charges,Drugs,4423.23,34,"If Charge > 500, then 34 percent",4423.23,percent of total billed charges,Drugs,3902.85,30,,3902.85,percent of total billed charges,Drugs,3902.85,30,,3902.85,percent of total billed charges,Drugs,3902.85,30,,3902.85,percent of total billed charges,Drugs,3902.85,30,,3902.85,percent of total billed charges,Drugs,3902.85,30,,3902.85,percent of total billed charges,Drugs,3902.85,30,,3902.85,percent of total billed charges,Drugs,3902.85,30,,3902.85,percent of total billed charges,Drugs,3902.85,30,,3902.85,percent of total billed charges,Drugs,3902.85,30,,3902.85,percent of total billed charges,Drugs,3902.85,30,,3902.85,percent of total billed charges,Drugs,3902.85,30,,3902.85,percent of total billed charges,Drugs,3902.85,30,,3902.85,percent of total billed charges,Drugs,3902.85,30,,3902.85,percent of total billed charges,Drugs,3717,,,3717,Other,Drug Cost,3717,,,3717,Other,Drug Cost,3717,,,3717,Other,Drug Cost,3717,,,3717,Other,Drug Cost,3717,,,3717,Other,Drug Cost,4423.23,34,,4423.23,percent of total billed charges,Drugs,3717,,,3717,Other,Drug Cost,8363.25,,,8363.25,Other,225% Medicaid APG methodology,5203.8,,,5203.8,Other,140% Medicaid APG methodology,4423.23,34,"If Charge > 2,000, then 34 percent",4423.23,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3717,,,3717,Other,Drug Cost,3717,,,3717,Other,Drug Cost,4646.25,,,4646.25,Other,125% Medicaid APG methodology,0.01,8363.25,
"TEC TC-99M ALB AGG, INJ ORA SO  ",A9540,HCPCS,,40507857,CDM,636,RC,65174-0270-30,NDC,both,1,EA,2.84,1.12,39.4668,,1.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.85,30,,0.85,percent of total billed charges,Drugs,0.85,30,,0.85,percent of total billed charges,Drugs,0.85,30,,0.85,percent of total billed charges,Drugs,0.85,30,,0.85,percent of total billed charges,Drugs,0.85,30,,0.85,percent of total billed charges,Drugs,1.42,50,,1.42,percent of total billed charges,All Other,0.85,30,,0.85,percent of total billed charges,Drugs,0.85,30,,0.85,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.85,30,,0.85,percent of total billed charges,Drugs,0.85,30,,0.85,percent of total billed charges,Drugs,0.85,30,,0.85,percent of total billed charges,Drugs,0.85,30,,0.85,percent of total billed charges,Drugs,0.85,30,,0.85,percent of total billed charges,Drugs,0.85,30,,0.85,percent of total billed charges,Drugs,0.85,30,,0.85,percent of total billed charges,Drugs,0.85,30,,0.85,percent of total billed charges,Drugs,0.85,30,,0.85,percent of total billed charges,Drugs,0.85,30,,0.85,percent of total billed charges,Drugs,0.85,30,,0.85,percent of total billed charges,Drugs,0.85,30,,0.85,percent of total billed charges,Drugs,0.85,30,,0.85,percent of total billed charges,Drugs,0.81,,,0.81,Other,Drug Cost,0.81,,,0.81,Other,Drug Cost,0.81,,,0.81,Other,Drug Cost,0.81,,,0.81,Other,Drug Cost,0.81,,,0.81,Other,Drug Cost,0.97,34,,0.97,percent of total billed charges,Drugs,0.81,,,0.81,Other,Drug Cost,1.82,,,1.82,Other,225% Medicaid APG methodology,1.13,,,1.13,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.81,,,0.81,Other,Drug Cost,0.81,,,0.81,Other,Drug Cost,1.01,,,1.01,Other,125% Medicaid APG methodology,0.01,1.82,
TEC TC-99M EXAMET 0.5 MG INJ    ,A9521,HCPCS,,40507865,CDM,636,RC,17156-0022-05,NDC,both,1,EA,3281.25,1295,39.4668,,1295,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,984.38,30,,984.38,percent of total billed charges,Drugs,984.38,30,,984.38,percent of total billed charges,Drugs,984.38,30,,984.38,percent of total billed charges,Drugs,984.38,30,,984.38,percent of total billed charges,Drugs,984.38,30,,984.38,percent of total billed charges,Drugs,1640.63,50,,1640.63,percent of total billed charges,All Other,984.38,30,,984.38,percent of total billed charges,Drugs,984.38,30,,984.38,percent of total billed charges,Drugs,1115.63,34,"If Charge > 500, then 34 percent",1115.63,percent of total billed charges,Drugs,984.38,30,,984.38,percent of total billed charges,Drugs,984.38,30,,984.38,percent of total billed charges,Drugs,984.38,30,,984.38,percent of total billed charges,Drugs,984.38,30,,984.38,percent of total billed charges,Drugs,984.38,30,,984.38,percent of total billed charges,Drugs,984.38,30,,984.38,percent of total billed charges,Drugs,984.38,30,,984.38,percent of total billed charges,Drugs,984.38,30,,984.38,percent of total billed charges,Drugs,984.38,30,,984.38,percent of total billed charges,Drugs,984.38,30,,984.38,percent of total billed charges,Drugs,984.38,30,,984.38,percent of total billed charges,Drugs,984.38,30,,984.38,percent of total billed charges,Drugs,984.38,30,,984.38,percent of total billed charges,Drugs,937.5,,,937.5,Other,Drug Cost,937.5,,,937.5,Other,Drug Cost,937.5,,,937.5,Other,Drug Cost,937.5,,,937.5,Other,Drug Cost,937.5,,,937.5,Other,Drug Cost,1115.63,34,,1115.63,percent of total billed charges,Drugs,937.5,,,937.5,Other,Drug Cost,2109.38,,,2109.38,Other,225% Medicaid APG methodology,1312.5,,,1312.5,Other,140% Medicaid APG methodology,1115.63,34,"If Charge > 2,000, then 34 percent",1115.63,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",937.5,,,937.5,Other,Drug Cost,937.5,,,937.5,Other,Drug Cost,1171.88,,,1171.88,Other,125% Medicaid APG methodology,0.01,2109.38,
TEC TC-99M MEBR (CHOLETEC) INJ  ,A9537,HCPCS,,40507899,CDM,636,RC,00270-0083-20,NDC,both,1,EA,189.49,74.79,39.4668,,74.79,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,56.85,30,,56.85,percent of total billed charges,Drugs,56.85,30,,56.85,percent of total billed charges,Drugs,56.85,30,,56.85,percent of total billed charges,Drugs,56.85,30,,56.85,percent of total billed charges,Drugs,56.85,30,,56.85,percent of total billed charges,Drugs,94.75,50,,94.75,percent of total billed charges,All Other,56.85,30,,56.85,percent of total billed charges,Drugs,56.85,30,,56.85,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,56.85,30,,56.85,percent of total billed charges,Drugs,56.85,30,,56.85,percent of total billed charges,Drugs,56.85,30,,56.85,percent of total billed charges,Drugs,56.85,30,,56.85,percent of total billed charges,Drugs,56.85,30,,56.85,percent of total billed charges,Drugs,56.85,30,,56.85,percent of total billed charges,Drugs,56.85,30,,56.85,percent of total billed charges,Drugs,56.85,30,,56.85,percent of total billed charges,Drugs,56.85,30,,56.85,percent of total billed charges,Drugs,56.85,30,,56.85,percent of total billed charges,Drugs,56.85,30,,56.85,percent of total billed charges,Drugs,56.85,30,,56.85,percent of total billed charges,Drugs,56.85,30,,56.85,percent of total billed charges,Drugs,54.14,,,54.14,Other,Drug Cost,54.14,,,54.14,Other,Drug Cost,54.14,,,54.14,Other,Drug Cost,54.14,,,54.14,Other,Drug Cost,54.14,,,54.14,Other,Drug Cost,64.43,34,,64.43,percent of total billed charges,Drugs,54.14,,,54.14,Other,Drug Cost,121.82,,,121.82,Other,225% Medicaid APG methodology,75.8,,,75.8,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",54.14,,,54.14,Other,Drug Cost,54.14,,,54.14,Other,Drug Cost,67.68,,,67.68,Other,125% Medicaid APG methodology,0.01,121.82,
TEC TC-99M MEDR ACID 20 MG INJ  ,A9503,HCPCS,,40507907,CDM,636,RC,45567-0040-02,NDC,both,1,EA,315,124.32,39.4668,,124.32,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,94.5,30,,94.5,percent of total billed charges,Drugs,94.5,30,,94.5,percent of total billed charges,Drugs,94.5,30,,94.5,percent of total billed charges,Drugs,94.5,30,,94.5,percent of total billed charges,Drugs,94.5,30,,94.5,percent of total billed charges,Drugs,157.5,50,,157.5,percent of total billed charges,All Other,94.5,30,,94.5,percent of total billed charges,Drugs,94.5,30,,94.5,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,94.5,30,,94.5,percent of total billed charges,Drugs,94.5,30,,94.5,percent of total billed charges,Drugs,94.5,30,,94.5,percent of total billed charges,Drugs,94.5,30,,94.5,percent of total billed charges,Drugs,94.5,30,,94.5,percent of total billed charges,Drugs,94.5,30,,94.5,percent of total billed charges,Drugs,94.5,30,,94.5,percent of total billed charges,Drugs,94.5,30,,94.5,percent of total billed charges,Drugs,94.5,30,,94.5,percent of total billed charges,Drugs,94.5,30,,94.5,percent of total billed charges,Drugs,94.5,30,,94.5,percent of total billed charges,Drugs,94.5,30,,94.5,percent of total billed charges,Drugs,94.5,30,,94.5,percent of total billed charges,Drugs,90,,,90,Other,Drug Cost,90,,,90,Other,Drug Cost,90,,,90,Other,Drug Cost,90,,,90,Other,Drug Cost,90,,,90,Other,Drug Cost,107.1,34,,107.1,percent of total billed charges,Drugs,90,,,90,Other,Drug Cost,202.5,,,202.5,Other,225% Medicaid APG methodology,126,,,126,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",90,,,90,Other,Drug Cost,90,,,90,Other,Drug Cost,112.5,,,112.5,Other,125% Medicaid APG methodology,0.01,202.5,
TEC TC-99M SESTAMI (CARDI) INJ  ,A9500,HCPCS,,40507964,CDM,636,RC,69945-0092-20,NDC,both,1,EA,36.4,14.37,39.4668,,14.37,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,18.2,50,,18.2,percent of total billed charges,All Other,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,10.4,,,10.4,Other,Drug Cost,10.4,,,10.4,Other,Drug Cost,10.4,,,10.4,Other,Drug Cost,10.4,,,10.4,Other,Drug Cost,10.4,,,10.4,Other,Drug Cost,12.38,34,,12.38,percent of total billed charges,Drugs,10.4,,,10.4,Other,Drug Cost,23.4,,,23.4,Other,225% Medicaid APG methodology,14.56,,,14.56,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",10.4,,,10.4,Other,Drug Cost,10.4,,,10.4,Other,Drug Cost,13,,,13,Other,125% Medicaid APG methodology,0.01,23.4,
TEC TC-99M SULFUR COLLOID POWD  ,A9541,HCPCS,,40507998,CDM,636,RC,45567-0030-01,NDC,both,1,EA,1953,770.79,39.4668,,770.79,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,585.9,30,,585.9,percent of total billed charges,Drugs,585.9,30,,585.9,percent of total billed charges,Drugs,585.9,30,,585.9,percent of total billed charges,Drugs,585.9,30,,585.9,percent of total billed charges,Drugs,585.9,30,,585.9,percent of total billed charges,Drugs,976.5,50,,976.5,percent of total billed charges,All Other,585.9,30,,585.9,percent of total billed charges,Drugs,585.9,30,,585.9,percent of total billed charges,Drugs,664.02,34,"If Charge > 500, then 34 percent",664.02,percent of total billed charges,Drugs,585.9,30,,585.9,percent of total billed charges,Drugs,585.9,30,,585.9,percent of total billed charges,Drugs,585.9,30,,585.9,percent of total billed charges,Drugs,585.9,30,,585.9,percent of total billed charges,Drugs,585.9,30,,585.9,percent of total billed charges,Drugs,585.9,30,,585.9,percent of total billed charges,Drugs,585.9,30,,585.9,percent of total billed charges,Drugs,585.9,30,,585.9,percent of total billed charges,Drugs,585.9,30,,585.9,percent of total billed charges,Drugs,585.9,30,,585.9,percent of total billed charges,Drugs,585.9,30,,585.9,percent of total billed charges,Drugs,585.9,30,,585.9,percent of total billed charges,Drugs,585.9,30,,585.9,percent of total billed charges,Drugs,558,,,558,Other,Drug Cost,558,,,558,Other,Drug Cost,558,,,558,Other,Drug Cost,558,,,558,Other,Drug Cost,558,,,558,Other,Drug Cost,664.02,34,,664.02,percent of total billed charges,Drugs,558,,,558,Other,Drug Cost,1255.5,,,1255.5,Other,225% Medicaid APG methodology,781.2,,,781.2,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",558,,,558,Other,Drug Cost,558,,,558,Other,Drug Cost,697.5,,,697.5,Other,125% Medicaid APG methodology,0.01,1255.5,
TEC TC-99M TETROF (MYOVIE) INJ  ,A9502,HCPCS,,40508004,CDM,636,RC,17156-0026-30,NDC,both,1,EA,1705.55,673.13,39.4668,,673.13,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,511.67,30,,511.67,percent of total billed charges,Drugs,511.67,30,,511.67,percent of total billed charges,Drugs,511.67,30,,511.67,percent of total billed charges,Drugs,511.67,30,,511.67,percent of total billed charges,Drugs,511.67,30,,511.67,percent of total billed charges,Drugs,852.78,50,,852.78,percent of total billed charges,All Other,511.67,30,,511.67,percent of total billed charges,Drugs,511.67,30,,511.67,percent of total billed charges,Drugs,579.89,34,"If Charge > 500, then 34 percent",579.89,percent of total billed charges,Drugs,511.67,30,,511.67,percent of total billed charges,Drugs,511.67,30,,511.67,percent of total billed charges,Drugs,511.67,30,,511.67,percent of total billed charges,Drugs,511.67,30,,511.67,percent of total billed charges,Drugs,511.67,30,,511.67,percent of total billed charges,Drugs,511.67,30,,511.67,percent of total billed charges,Drugs,511.67,30,,511.67,percent of total billed charges,Drugs,511.67,30,,511.67,percent of total billed charges,Drugs,511.67,30,,511.67,percent of total billed charges,Drugs,511.67,30,,511.67,percent of total billed charges,Drugs,511.67,30,,511.67,percent of total billed charges,Drugs,511.67,30,,511.67,percent of total billed charges,Drugs,511.67,30,,511.67,percent of total billed charges,Drugs,487.3,,,487.3,Other,Drug Cost,487.3,,,487.3,Other,Drug Cost,487.3,,,487.3,Other,Drug Cost,487.3,,,487.3,Other,Drug Cost,487.3,,,487.3,Other,Drug Cost,579.89,34,,579.89,percent of total billed charges,Drugs,487.3,,,487.3,Other,Drug Cost,1096.43,,,1096.43,Other,225% Medicaid APG methodology,682.22,,,682.22,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",487.3,,,487.3,Other,Drug Cost,487.3,,,487.3,Other,Drug Cost,609.13,,,609.13,Other,125% Medicaid APG methodology,0.01,1096.43,
TEC TC-99M TILMAN (LYMPHOS) IM  ,A9520,HCPCS,,40508012,CDM,636,RC,65857-0450-05,NDC,both,1,EA,9865.8,3893.72,39.4668,,3893.72,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,2959.74,30,,2959.74,percent of total billed charges,Drugs,2959.74,30,,2959.74,percent of total billed charges,Drugs,2959.74,30,,2959.74,percent of total billed charges,Drugs,2959.74,30,,2959.74,percent of total billed charges,Drugs,2959.74,30,,2959.74,percent of total billed charges,Drugs,4932.9,50,,4932.9,percent of total billed charges,All Other,2959.74,30,,2959.74,percent of total billed charges,Drugs,2959.74,30,,2959.74,percent of total billed charges,Drugs,3354.37,34,"If Charge > 500, then 34 percent",3354.37,percent of total billed charges,Drugs,2959.74,30,,2959.74,percent of total billed charges,Drugs,2959.74,30,,2959.74,percent of total billed charges,Drugs,2959.74,30,,2959.74,percent of total billed charges,Drugs,2959.74,30,,2959.74,percent of total billed charges,Drugs,2959.74,30,,2959.74,percent of total billed charges,Drugs,2959.74,30,,2959.74,percent of total billed charges,Drugs,2959.74,30,,2959.74,percent of total billed charges,Drugs,2959.74,30,,2959.74,percent of total billed charges,Drugs,2959.74,30,,2959.74,percent of total billed charges,Drugs,2959.74,30,,2959.74,percent of total billed charges,Drugs,2959.74,30,,2959.74,percent of total billed charges,Drugs,2959.74,30,,2959.74,percent of total billed charges,Drugs,2959.74,30,,2959.74,percent of total billed charges,Drugs,2818.8,,,2818.8,Other,Drug Cost,2818.8,,,2818.8,Other,Drug Cost,2818.8,,,2818.8,Other,Drug Cost,2818.8,,,2818.8,Other,Drug Cost,2818.8,,,2818.8,Other,Drug Cost,3354.37,34,,3354.37,percent of total billed charges,Drugs,2818.8,,,2818.8,Other,Drug Cost,6342.3,,,6342.3,Other,225% Medicaid APG methodology,3946.32,,,3946.32,Other,140% Medicaid APG methodology,3354.37,34,"If Charge > 2,000, then 34 percent",3354.37,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2818.8,,,2818.8,Other,Drug Cost,2818.8,,,2818.8,Other,Drug Cost,3523.5,,,3523.5,Other,125% Medicaid APG methodology,0.01,6342.3,
XENON XE-133 10 MCI INHAL GAS   ,A9558,HCPCS,,40508038,CDM,636,RC,11994-0127-11,NDC,both,1,EA,143.54,56.65,39.4668,,56.65,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,43.06,30,,43.06,percent of total billed charges,Drugs,43.06,30,,43.06,percent of total billed charges,Drugs,43.06,30,,43.06,percent of total billed charges,Drugs,43.06,30,,43.06,percent of total billed charges,Drugs,43.06,30,,43.06,percent of total billed charges,Drugs,71.77,50,,71.77,percent of total billed charges,All Other,43.06,30,,43.06,percent of total billed charges,Drugs,43.06,30,,43.06,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,43.06,30,,43.06,percent of total billed charges,Drugs,43.06,30,,43.06,percent of total billed charges,Drugs,43.06,30,,43.06,percent of total billed charges,Drugs,43.06,30,,43.06,percent of total billed charges,Drugs,43.06,30,,43.06,percent of total billed charges,Drugs,43.06,30,,43.06,percent of total billed charges,Drugs,43.06,30,,43.06,percent of total billed charges,Drugs,43.06,30,,43.06,percent of total billed charges,Drugs,43.06,30,,43.06,percent of total billed charges,Drugs,43.06,30,,43.06,percent of total billed charges,Drugs,43.06,30,,43.06,percent of total billed charges,Drugs,43.06,30,,43.06,percent of total billed charges,Drugs,43.06,30,,43.06,percent of total billed charges,Drugs,41.01,,,41.01,Other,Drug Cost,41.01,,,41.01,Other,Drug Cost,41.01,,,41.01,Other,Drug Cost,41.01,,,41.01,Other,Drug Cost,41.01,,,41.01,Other,Drug Cost,48.8,34,,48.8,percent of total billed charges,Drugs,41.01,,,41.01,Other,Drug Cost,92.27,,,92.27,Other,225% Medicaid APG methodology,57.41,,,57.41,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",41.01,,,41.01,Other,Drug Cost,41.01,,,41.01,Other,Drug Cost,51.26,,,51.26,Other,125% Medicaid APG methodology,0.01,92.27,
XENON XE-133 20 MCI INHAL GAS   ,A9558,HCPCS,,40508046,CDM,636,RC,11994-0128-21,NDC,both,1,EA,287.11,113.31,39.4668,,113.31,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,86.13,30,,86.13,percent of total billed charges,Drugs,86.13,30,,86.13,percent of total billed charges,Drugs,86.13,30,,86.13,percent of total billed charges,Drugs,86.13,30,,86.13,percent of total billed charges,Drugs,86.13,30,,86.13,percent of total billed charges,Drugs,143.56,50,,143.56,percent of total billed charges,All Other,86.13,30,,86.13,percent of total billed charges,Drugs,86.13,30,,86.13,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,86.13,30,,86.13,percent of total billed charges,Drugs,86.13,30,,86.13,percent of total billed charges,Drugs,86.13,30,,86.13,percent of total billed charges,Drugs,86.13,30,,86.13,percent of total billed charges,Drugs,86.13,30,,86.13,percent of total billed charges,Drugs,86.13,30,,86.13,percent of total billed charges,Drugs,86.13,30,,86.13,percent of total billed charges,Drugs,86.13,30,,86.13,percent of total billed charges,Drugs,86.13,30,,86.13,percent of total billed charges,Drugs,86.13,30,,86.13,percent of total billed charges,Drugs,86.13,30,,86.13,percent of total billed charges,Drugs,86.13,30,,86.13,percent of total billed charges,Drugs,86.13,30,,86.13,percent of total billed charges,Drugs,82.03,,,82.03,Other,Drug Cost,82.03,,,82.03,Other,Drug Cost,82.03,,,82.03,Other,Drug Cost,82.03,,,82.03,Other,Drug Cost,82.03,,,82.03,Other,Drug Cost,97.62,34,,97.62,percent of total billed charges,Drugs,82.03,,,82.03,Other,Drug Cost,184.57,,,184.57,Other,225% Medicaid APG methodology,114.84,,,114.84,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",82.03,,,82.03,Other,Drug Cost,82.03,,,82.03,Other,Drug Cost,102.54,,,102.54,Other,125% Medicaid APG methodology,0.01,184.57,
Y-90 ZEVALIN (IBRITU TIUX) KIT  ,A9543,HCPCS,,40508053,CDM,636,RC,68152-0103-03,NDC,both,1,EA,202036.38,79737.29,39.4668,,79737.29,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,60610.91,30,,60610.91,percent of total billed charges,Drugs,60610.91,30,,60610.91,percent of total billed charges,Drugs,60610.91,30,,60610.91,percent of total billed charges,Drugs,60610.91,30,,60610.91,percent of total billed charges,Drugs,60610.91,30,,60610.91,percent of total billed charges,Drugs,101018.19,50,,101018.19,percent of total billed charges,All Other,60610.91,30,,60610.91,percent of total billed charges,Drugs,60610.91,30,,60610.91,percent of total billed charges,Drugs,68692.37,34,"If Charge > 500, then 34 percent",68692.37,percent of total billed charges,Drugs,60610.91,30,,60610.91,percent of total billed charges,Drugs,60610.91,30,,60610.91,percent of total billed charges,Drugs,60610.91,30,,60610.91,percent of total billed charges,Drugs,60610.91,30,,60610.91,percent of total billed charges,Drugs,60610.91,30,,60610.91,percent of total billed charges,Drugs,60610.91,30,,60610.91,percent of total billed charges,Drugs,60610.91,30,,60610.91,percent of total billed charges,Drugs,60610.91,30,,60610.91,percent of total billed charges,Drugs,60610.91,30,,60610.91,percent of total billed charges,Drugs,60610.91,30,,60610.91,percent of total billed charges,Drugs,60610.91,30,,60610.91,percent of total billed charges,Drugs,60610.91,30,,60610.91,percent of total billed charges,Drugs,60610.91,30,,60610.91,percent of total billed charges,Drugs,57724.68,,,57724.68,Other,Drug Cost,57724.68,,,57724.68,Other,Drug Cost,57724.68,,,57724.68,Other,Drug Cost,57724.68,,,57724.68,Other,Drug Cost,57724.68,,,57724.68,Other,Drug Cost,68692.37,34,,68692.37,percent of total billed charges,Drugs,57724.68,,,57724.68,Other,Drug Cost,129880.53,,,129880.53,Other,225% Medicaid APG methodology,80814.55,,,80814.55,Other,140% Medicaid APG methodology,68692.37,34,"If Charge > 2,000, then 34 percent",68692.37,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,68692.37,34,,68692.37,Other,"Drug Charges > 20,000, then 34% of Charges",57724.68,,,57724.68,Other,Drug Cost,57724.68,,,57724.68,Other,Drug Cost,72155.85,,,72155.85,Other,125% Medicaid APG methodology,0.01,129880.53,
PATISIRAN 2 MG/ML IV SOLN 5 ML  ,J0222,HCPCS,,40508095,CDM,636,RC,71336-1000-01,NDC,both,5,ML,171237.5,986.46,,,986.46,Other,150% of Medicare + 9.63% HCRA Surcharge,599.87,,,599.87,Fee Schedule,Average Sale Price (ASP) x 6,51371.25,30,,51371.25,percent of total billed charges,Drugs,51371.25,30,,51371.25,percent of total billed charges,Drugs,51371.25,30,,51371.25,percent of total billed charges,Drugs,51371.25,30,,51371.25,percent of total billed charges,Drugs,51371.25,30,,51371.25,percent of total billed charges,Drugs,85618.75,50,,85618.75,percent of total billed charges,All Other,51371.25,30,,51371.25,percent of total billed charges,Drugs,51371.25,30,,51371.25,percent of total billed charges,Drugs,58220.75,34,"If Charge > 500, then 34 percent",58220.75,percent of total billed charges,Drugs,51371.25,30,,51371.25,percent of total billed charges,Drugs,51371.25,30,,51371.25,percent of total billed charges,Drugs,51371.25,30,,51371.25,percent of total billed charges,Drugs,51371.25,30,,51371.25,percent of total billed charges,Drugs,51371.25,30,,51371.25,percent of total billed charges,Drugs,51371.25,30,,51371.25,percent of total billed charges,Drugs,51371.25,30,,51371.25,percent of total billed charges,Drugs,51371.25,30,,51371.25,percent of total billed charges,Drugs,51371.25,30,,51371.25,percent of total billed charges,Drugs,51371.25,30,,51371.25,percent of total billed charges,Drugs,51371.25,30,,51371.25,percent of total billed charges,Drugs,51371.25,30,,51371.25,percent of total billed charges,Drugs,51371.25,30,,51371.25,percent of total billed charges,Drugs,37076.75,,,37076.75,Other,Drug Cost,37076.75,,,37076.75,Other,Drug Cost,37076.75,,,37076.75,Other,Drug Cost,37076.75,,,37076.75,Other,Drug Cost,37076.75,,,37076.75,Other,Drug Cost,58220.75,34,,58220.75,percent of total billed charges,Drugs,37076.75,,,37076.75,Other,Drug Cost,83422.69,,,83422.69,Other,225% Medicaid APG methodology,51907.45,,,51907.45,Other,140% Medicaid APG methodology,58220.75,34,"If Charge > 2,000, then 34 percent",58220.75,percent of total billed charges,Drugs,959.8,,,959.8,Other,160% Medicare Fee Schedule,58220.75,34,,58220.75,Other,"Drug Charges > 20,000, then 34% of Charges",37076.75,,,37076.75,Other,Drug Cost,37076.75,,,37076.75,Other,Drug Cost,46345.94,,,46345.94,Other,125% Medicaid APG methodology,599.87,85618.75,
CLEVIDIPINE 0.5 MG/ML IV 100ML  ,C9248,HCPCS,,40508293,CDM,636,RC,10122-0611-10,NDC,both,100,ML,215.81,85.17,39.4668,,85.17,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,64.74,30,,64.74,percent of total billed charges,Drugs,64.74,30,,64.74,percent of total billed charges,Drugs,64.74,30,,64.74,percent of total billed charges,Drugs,64.74,30,,64.74,percent of total billed charges,Drugs,64.74,30,,64.74,percent of total billed charges,Drugs,107.91,50,,107.91,percent of total billed charges,All Other,64.74,30,,64.74,percent of total billed charges,Drugs,64.74,30,,64.74,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,64.74,30,,64.74,percent of total billed charges,Drugs,64.74,30,,64.74,percent of total billed charges,Drugs,64.74,30,,64.74,percent of total billed charges,Drugs,64.74,30,,64.74,percent of total billed charges,Drugs,64.74,30,,64.74,percent of total billed charges,Drugs,64.74,30,,64.74,percent of total billed charges,Drugs,64.74,30,,64.74,percent of total billed charges,Drugs,64.74,30,,64.74,percent of total billed charges,Drugs,64.74,30,,64.74,percent of total billed charges,Drugs,64.74,30,,64.74,percent of total billed charges,Drugs,64.74,30,,64.74,percent of total billed charges,Drugs,64.74,30,,64.74,percent of total billed charges,Drugs,64.74,30,,64.74,percent of total billed charges,Drugs,61.66,,,61.66,Other,Drug Cost,61.66,,,61.66,Other,Drug Cost,61.66,,,61.66,Other,Drug Cost,61.66,,,61.66,Other,Drug Cost,61.66,,,61.66,Other,Drug Cost,73.38,34,,73.38,percent of total billed charges,Drugs,61.66,,,61.66,Other,Drug Cost,138.74,,,138.74,Other,225% Medicaid APG methodology,86.32,,,86.32,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",61.66,,,61.66,Other,Drug Cost,61.66,,,61.66,Other,Drug Cost,77.08,,,77.08,Other,125% Medicaid APG methodology,0.01,138.74,
HEP B IMMUNE GLOBULIN IM 0.5ML  ,90371,CPT,,40508418,CDM,636,RC,13533-0636-03,NDC,both,0.5,ML,230.62,1360.54,,,1360.54,Other,150% of Medicare + 9.63% HCRA Surcharge,827.35,,,827.35,Fee Schedule,Average Sale Price (ASP) x 6,69.19,30,,69.19,percent of total billed charges,Drugs,69.19,30,,69.19,percent of total billed charges,Drugs,69.19,30,,69.19,percent of total billed charges,Drugs,69.19,30,,69.19,percent of total billed charges,Drugs,69.19,30,,69.19,percent of total billed charges,Drugs,115.31,50,,115.31,percent of total billed charges,All Other,69.19,30,,69.19,percent of total billed charges,Drugs,69.19,30,,69.19,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,69.19,30,,69.19,percent of total billed charges,Drugs,69.19,30,,69.19,percent of total billed charges,Drugs,69.19,30,,69.19,percent of total billed charges,Drugs,69.19,30,,69.19,percent of total billed charges,Drugs,69.19,30,,69.19,percent of total billed charges,Drugs,69.19,30,,69.19,percent of total billed charges,Drugs,69.19,30,,69.19,percent of total billed charges,Drugs,69.19,30,,69.19,percent of total billed charges,Drugs,69.19,30,,69.19,percent of total billed charges,Drugs,69.19,30,,69.19,percent of total billed charges,Drugs,69.19,30,,69.19,percent of total billed charges,Drugs,69.19,30,,69.19,percent of total billed charges,Drugs,69.19,30,,69.19,percent of total billed charges,Drugs,65.89,,,65.89,Other,Drug Cost,65.89,,,65.89,Other,Drug Cost,65.89,,,65.89,Other,Drug Cost,65.89,,,65.89,Other,Drug Cost,65.89,,,65.89,Other,Drug Cost,78.41,34,,78.41,percent of total billed charges,Drugs,65.89,,,65.89,Other,Drug Cost,148.25,,,148.25,Other,225% Medicaid APG methodology,92.25,,,92.25,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1323.76,,,1323.76,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",65.89,,,65.89,Other,Drug Cost,65.89,,,65.89,Other,Drug Cost,82.36,,,82.36,Other,125% Medicaid APG methodology,0.01,1360.54,
LEUPROLIDE 7.5 MG/MONTH POW     ,J9217,HCPCS,,40508459,CDM,636,RC,62935-0753-75,NDC,both,1,EA,327.81,1788.85,,,1788.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1087.81,,,1087.81,Fee Schedule,Average Sale Price (ASP) x 6,98.34,30,,98.34,percent of total billed charges,Drugs,98.34,30,,98.34,percent of total billed charges,Drugs,98.34,30,,98.34,percent of total billed charges,Drugs,98.34,30,,98.34,percent of total billed charges,Drugs,98.34,30,,98.34,percent of total billed charges,Drugs,163.91,50,,163.91,percent of total billed charges,All Other,98.34,30,,98.34,percent of total billed charges,Drugs,98.34,30,,98.34,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,98.34,30,,98.34,percent of total billed charges,Drugs,98.34,30,,98.34,percent of total billed charges,Drugs,98.34,30,,98.34,percent of total billed charges,Drugs,98.34,30,,98.34,percent of total billed charges,Drugs,98.34,30,,98.34,percent of total billed charges,Drugs,98.34,30,,98.34,percent of total billed charges,Drugs,98.34,30,,98.34,percent of total billed charges,Drugs,98.34,30,,98.34,percent of total billed charges,Drugs,98.34,30,,98.34,percent of total billed charges,Drugs,98.34,30,,98.34,percent of total billed charges,Drugs,98.34,30,,98.34,percent of total billed charges,Drugs,98.34,30,,98.34,percent of total billed charges,Drugs,98.34,30,,98.34,percent of total billed charges,Drugs,92.52,,,92.52,Other,Drug Cost,92.52,,,92.52,Other,Drug Cost,92.52,,,92.52,Other,Drug Cost,92.52,,,92.52,Other,Drug Cost,92.52,,,92.52,Other,Drug Cost,111.46,34,,111.46,percent of total billed charges,Drugs,92.52,,,92.52,Other,Drug Cost,208.17,,,208.17,Other,225% Medicaid APG methodology,129.53,,,129.53,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1740.5,,,1740.5,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",92.52,,,92.52,Other,Drug Cost,92.52,,,92.52,Other,Drug Cost,115.65,,,115.65,Other,125% Medicaid APG methodology,0.01,1788.85,
MAG SULF 50% PF INJ SOLN 20 ML  ,J3475,HCPCS,,40508475,CDM,636,RC,63323-0642-20,NDC,both,20,ML,1.75,6.82,,,6.82,Other,150% of Medicare + 9.63% HCRA Surcharge,4.15,,,4.15,Fee Schedule,Average Sale Price (ASP) x 6,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.88,50,,0.88,percent of total billed charges,All Other,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.6,34,,0.6,percent of total billed charges,Drugs,0.5,,,0.5,Other,Drug Cost,1.13,,,1.13,Other,225% Medicaid APG methodology,0.7,,,0.7,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.63,,,6.63,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.63,,,0.63,Other,125% Medicaid APG methodology,0.01,6.82,
RISANKIZUMAB RZAA 60 MG/ML SOL  ,J2327,HCPCS,,40508558,CDM,636,RC,00074-5015-01,NDC,both,10,ML,35266.7,151.58,,,151.58,Other,150% of Medicare + 9.63% HCRA Surcharge,92.18,,,92.18,Fee Schedule,Average Sale Price (ASP) x 6,10580.01,30,,10580.01,percent of total billed charges,Drugs,10580.01,30,,10580.01,percent of total billed charges,Drugs,10580.01,30,,10580.01,percent of total billed charges,Drugs,10580.01,30,,10580.01,percent of total billed charges,Drugs,10580.01,30,,10580.01,percent of total billed charges,Drugs,17633.35,50,,17633.35,percent of total billed charges,All Other,10580.01,30,,10580.01,percent of total billed charges,Drugs,10580.01,30,,10580.01,percent of total billed charges,Drugs,11990.68,34,"If Charge > 500, then 34 percent",11990.68,percent of total billed charges,Drugs,10580.01,30,,10580.01,percent of total billed charges,Drugs,10580.01,30,,10580.01,percent of total billed charges,Drugs,10580.01,30,,10580.01,percent of total billed charges,Drugs,10580.01,30,,10580.01,percent of total billed charges,Drugs,10580.01,30,,10580.01,percent of total billed charges,Drugs,10580.01,30,,10580.01,percent of total billed charges,Drugs,10580.01,30,,10580.01,percent of total billed charges,Drugs,10580.01,30,,10580.01,percent of total billed charges,Drugs,10580.01,30,,10580.01,percent of total billed charges,Drugs,10580.01,30,,10580.01,percent of total billed charges,Drugs,10580.01,30,,10580.01,percent of total billed charges,Drugs,10580.01,30,,10580.01,percent of total billed charges,Drugs,10580.01,30,,10580.01,percent of total billed charges,Drugs,4881.51,,,4881.51,Other,Drug Cost,4881.51,,,4881.51,Other,Drug Cost,4881.51,,,4881.51,Other,Drug Cost,4881.51,,,4881.51,Other,Drug Cost,4881.51,,,4881.51,Other,Drug Cost,11990.68,34,,11990.68,percent of total billed charges,Drugs,4881.51,,,4881.51,Other,Drug Cost,10983.4,,,10983.4,Other,225% Medicaid APG methodology,6834.11,,,6834.11,Other,140% Medicaid APG methodology,11990.68,34,"If Charge > 2,000, then 34 percent",11990.68,percent of total billed charges,Drugs,147.48,,,147.48,Other,160% Medicare Fee Schedule,11990.68,34,,11990.68,Other,"Drug Charges > 20,000, then 34% of Charges",4881.51,,,4881.51,Other,Drug Cost,4881.51,,,4881.51,Other,Drug Cost,6101.89,,,6101.89,Other,125% Medicaid APG methodology,92.18,17633.35,
TACROLIMUS 1 MG ORAL GRANULE    ,J7507,HCPCS,,40508582,CDM,636,RC,00469-1330-50,NDC,both,1,EA,0.63,2.33,,,2.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1.42,,,1.42,Fee Schedule,Average Sale Price (ASP) x 6,0.19,30,,0.19,percent of total billed charges,Drugs,0.19,30,,0.19,percent of total billed charges,Drugs,0.19,30,,0.19,percent of total billed charges,Drugs,0.19,30,,0.19,percent of total billed charges,Drugs,0.19,30,,0.19,percent of total billed charges,Drugs,0.32,50,,0.32,percent of total billed charges,All Other,0.19,30,,0.19,percent of total billed charges,Drugs,0.19,30,,0.19,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.19,30,,0.19,percent of total billed charges,Drugs,0.19,30,,0.19,percent of total billed charges,Drugs,0.19,30,,0.19,percent of total billed charges,Drugs,0.19,30,,0.19,percent of total billed charges,Drugs,0.19,30,,0.19,percent of total billed charges,Drugs,0.19,30,,0.19,percent of total billed charges,Drugs,0.19,30,,0.19,percent of total billed charges,Drugs,0.19,30,,0.19,percent of total billed charges,Drugs,0.19,30,,0.19,percent of total billed charges,Drugs,0.19,30,,0.19,percent of total billed charges,Drugs,0.19,30,,0.19,percent of total billed charges,Drugs,0.19,30,,0.19,percent of total billed charges,Drugs,0.19,30,,0.19,percent of total billed charges,Drugs,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.21,34,,0.21,percent of total billed charges,Drugs,0.18,,,0.18,Other,Drug Cost,0.41,,,0.41,Other,225% Medicaid APG methodology,0.25,,,0.25,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.27,,,2.27,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.18,,,0.18,Other,Drug Cost,0.18,,,0.18,Other,Drug Cost,0.23,,,0.23,Other,125% Medicaid APG methodology,0.01,2.33,
TEZEPELUMAB EKKO 210 MG/1.91ML  ,J2356,HCPCS,,40508723,CDM,636,RC,55513-0112-01,NDC,both,1.91,ML,13413.23,183.39,,,183.39,Other,150% of Medicare + 9.63% HCRA Surcharge,111.52,,,111.52,Fee Schedule,Average Sale Price (ASP) x 6,4023.97,30,,4023.97,percent of total billed charges,Drugs,4023.97,30,,4023.97,percent of total billed charges,Drugs,4023.97,30,,4023.97,percent of total billed charges,Drugs,4023.97,30,,4023.97,percent of total billed charges,Drugs,4023.97,30,,4023.97,percent of total billed charges,Drugs,6706.62,50,,6706.62,percent of total billed charges,All Other,4023.97,30,,4023.97,percent of total billed charges,Drugs,4023.97,30,,4023.97,percent of total billed charges,Drugs,4560.5,34,"If Charge > 500, then 34 percent",4560.5,percent of total billed charges,Drugs,4023.97,30,,4023.97,percent of total billed charges,Drugs,4023.97,30,,4023.97,percent of total billed charges,Drugs,4023.97,30,,4023.97,percent of total billed charges,Drugs,4023.97,30,,4023.97,percent of total billed charges,Drugs,4023.97,30,,4023.97,percent of total billed charges,Drugs,4023.97,30,,4023.97,percent of total billed charges,Drugs,4023.97,30,,4023.97,percent of total billed charges,Drugs,4023.97,30,,4023.97,percent of total billed charges,Drugs,4023.97,30,,4023.97,percent of total billed charges,Drugs,4023.97,30,,4023.97,percent of total billed charges,Drugs,4023.97,30,,4023.97,percent of total billed charges,Drugs,4023.97,30,,4023.97,percent of total billed charges,Drugs,4023.97,30,,4023.97,percent of total billed charges,Drugs,2685.96,,,2685.96,Other,Drug Cost,2685.96,,,2685.96,Other,Drug Cost,2685.96,,,2685.96,Other,Drug Cost,2685.96,,,2685.96,Other,Drug Cost,2685.96,,,2685.96,Other,Drug Cost,4560.5,34,,4560.5,percent of total billed charges,Drugs,2685.96,,,2685.96,Other,Drug Cost,6043.41,,,6043.41,Other,225% Medicaid APG methodology,3760.34,,,3760.34,Other,140% Medicaid APG methodology,4560.5,34,"If Charge > 2,000, then 34 percent",4560.5,percent of total billed charges,Drugs,178.44,,,178.44,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2685.96,,,2685.96,Other,Drug Cost,2685.96,,,2685.96,Other,Drug Cost,3357.45,,,3357.45,Other,125% Medicaid APG methodology,0.01,6706.62,
GAL 68 GOZE 25MCG (0.292 M) IV  ,A9596,HCPCS,,40508731,CDM,636,RC,74725-0100-25,NDC,both,1,EA,16450,6492.29,39.4668,,6492.29,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,8225,50,,8225,percent of total billed charges,All Other,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,5593,34,"If Charge > 500, then 34 percent",5593,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,4700,,,4700,Other,Drug Cost,4700,,,4700,Other,Drug Cost,4700,,,4700,Other,Drug Cost,4700,,,4700,Other,Drug Cost,4700,,,4700,Other,Drug Cost,5593,34,,5593,percent of total billed charges,Drugs,4700,,,4700,Other,Drug Cost,10575,,,10575,Other,225% Medicaid APG methodology,6580,,,6580,Other,140% Medicaid APG methodology,5593,34,"If Charge > 2,000, then 34 percent",5593,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4700,,,4700,Other,Drug Cost,4700,,,4700,Other,Drug Cost,5875,,,5875,Other,125% Medicaid APG methodology,0.01,10575,
GAL 68 GOZE 25MCG (0.175 M) IV  ,A9596,HCPCS,,40508756,CDM,636,RC,74725-0100-64,NDC,both,1,EA,16450,6492.29,39.4668,,6492.29,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,8225,50,,8225,percent of total billed charges,All Other,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,5593,34,"If Charge > 500, then 34 percent",5593,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,4935,30,,4935,percent of total billed charges,Drugs,4700,,,4700,Other,Drug Cost,4700,,,4700,Other,Drug Cost,4700,,,4700,Other,Drug Cost,4700,,,4700,Other,Drug Cost,4700,,,4700,Other,Drug Cost,5593,34,,5593,percent of total billed charges,Drugs,4700,,,4700,Other,Drug Cost,10575,,,10575,Other,225% Medicaid APG methodology,6580,,,6580,Other,140% Medicaid APG methodology,5593,34,"If Charge > 2,000, then 34 percent",5593,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4700,,,4700,Other,Drug Cost,4700,,,4700,Other,Drug Cost,5875,,,5875,Other,125% Medicaid APG methodology,0.01,10575,
DOCETAXEL 10 MG/ML SOL 8 ML     ,J9171,HCPCS,,40508798,CDM,636,RC,67457-0532-08,NDC,both,8,ML,1155,9.82,,,9.82,Other,150% of Medicare + 9.63% HCRA Surcharge,5.97,,,5.97,Fee Schedule,Average Sale Price (ASP) x 6,346.5,30,,346.5,percent of total billed charges,Drugs,346.5,30,,346.5,percent of total billed charges,Drugs,346.5,30,,346.5,percent of total billed charges,Drugs,346.5,30,,346.5,percent of total billed charges,Drugs,346.5,30,,346.5,percent of total billed charges,Drugs,577.5,50,,577.5,percent of total billed charges,All Other,346.5,30,,346.5,percent of total billed charges,Drugs,346.5,30,,346.5,percent of total billed charges,Drugs,392.7,34,"If Charge > 500, then 34 percent",392.7,percent of total billed charges,Drugs,346.5,30,,346.5,percent of total billed charges,Drugs,346.5,30,,346.5,percent of total billed charges,Drugs,346.5,30,,346.5,percent of total billed charges,Drugs,346.5,30,,346.5,percent of total billed charges,Drugs,346.5,30,,346.5,percent of total billed charges,Drugs,346.5,30,,346.5,percent of total billed charges,Drugs,346.5,30,,346.5,percent of total billed charges,Drugs,346.5,30,,346.5,percent of total billed charges,Drugs,346.5,30,,346.5,percent of total billed charges,Drugs,346.5,30,,346.5,percent of total billed charges,Drugs,346.5,30,,346.5,percent of total billed charges,Drugs,346.5,30,,346.5,percent of total billed charges,Drugs,346.5,30,,346.5,percent of total billed charges,Drugs,330,,,330,Other,Drug Cost,330,,,330,Other,Drug Cost,330,,,330,Other,Drug Cost,330,,,330,Other,Drug Cost,330,,,330,Other,Drug Cost,392.7,34,,392.7,percent of total billed charges,Drugs,330,,,330,Other,Drug Cost,742.5,,,742.5,Other,225% Medicaid APG methodology,462,,,462,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,9.55,,,9.55,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",330,,,330,Other,Drug Cost,330,,,330,Other,Drug Cost,412.5,,,412.5,Other,125% Medicaid APG methodology,0.01,742.5,
IRINOTECAN 20 MG/ML IV 15 ML    ,J9206,HCPCS,,40508806,CDM,636,RC,00009-7529-05,NDC,both,15,ML,470.4,19.19,,,19.19,Other,150% of Medicare + 9.63% HCRA Surcharge,11.67,,,11.67,Fee Schedule,Average Sale Price (ASP) x 6,141.12,30,,141.12,percent of total billed charges,Drugs,141.12,30,,141.12,percent of total billed charges,Drugs,141.12,30,,141.12,percent of total billed charges,Drugs,141.12,30,,141.12,percent of total billed charges,Drugs,141.12,30,,141.12,percent of total billed charges,Drugs,235.2,50,,235.2,percent of total billed charges,All Other,141.12,30,,141.12,percent of total billed charges,Drugs,141.12,30,,141.12,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,141.12,30,,141.12,percent of total billed charges,Drugs,141.12,30,,141.12,percent of total billed charges,Drugs,141.12,30,,141.12,percent of total billed charges,Drugs,141.12,30,,141.12,percent of total billed charges,Drugs,141.12,30,,141.12,percent of total billed charges,Drugs,141.12,30,,141.12,percent of total billed charges,Drugs,141.12,30,,141.12,percent of total billed charges,Drugs,141.12,30,,141.12,percent of total billed charges,Drugs,141.12,30,,141.12,percent of total billed charges,Drugs,141.12,30,,141.12,percent of total billed charges,Drugs,141.12,30,,141.12,percent of total billed charges,Drugs,141.12,30,,141.12,percent of total billed charges,Drugs,141.12,30,,141.12,percent of total billed charges,Drugs,134.4,,,134.4,Other,Drug Cost,134.4,,,134.4,Other,Drug Cost,134.4,,,134.4,Other,Drug Cost,134.4,,,134.4,Other,Drug Cost,134.4,,,134.4,Other,Drug Cost,159.94,34,,159.94,percent of total billed charges,Drugs,134.4,,,134.4,Other,Drug Cost,302.4,,,302.4,Other,225% Medicaid APG methodology,188.16,,,188.16,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,18.67,,,18.67,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",134.4,,,134.4,Other,Drug Cost,134.4,,,134.4,Other,Drug Cost,168,,,168,Other,125% Medicaid APG methodology,0.01,302.4,
OMALIZUMAB 75 MG/0.5 ML SOLN    ,J2357,HCPCS,,40508814,CDM,636,RC,50242-0214-01,NDC,both,1,ML,5028.24,389.33,,,389.33,Other,150% of Medicare + 9.63% HCRA Surcharge,236.75,,,236.75,Fee Schedule,Average Sale Price (ASP) x 6,1508.47,30,,1508.47,percent of total billed charges,Drugs,1508.47,30,,1508.47,percent of total billed charges,Drugs,1508.47,30,,1508.47,percent of total billed charges,Drugs,1508.47,30,,1508.47,percent of total billed charges,Drugs,1508.47,30,,1508.47,percent of total billed charges,Drugs,2514.12,50,,2514.12,percent of total billed charges,All Other,1508.47,30,,1508.47,percent of total billed charges,Drugs,1508.47,30,,1508.47,percent of total billed charges,Drugs,1709.6,34,"If Charge > 500, then 34 percent",1709.6,percent of total billed charges,Drugs,1508.47,30,,1508.47,percent of total billed charges,Drugs,1508.47,30,,1508.47,percent of total billed charges,Drugs,1508.47,30,,1508.47,percent of total billed charges,Drugs,1508.47,30,,1508.47,percent of total billed charges,Drugs,1508.47,30,,1508.47,percent of total billed charges,Drugs,1508.47,30,,1508.47,percent of total billed charges,Drugs,1508.47,30,,1508.47,percent of total billed charges,Drugs,1508.47,30,,1508.47,percent of total billed charges,Drugs,1508.47,30,,1508.47,percent of total billed charges,Drugs,1508.47,30,,1508.47,percent of total billed charges,Drugs,1508.47,30,,1508.47,percent of total billed charges,Drugs,1508.47,30,,1508.47,percent of total billed charges,Drugs,1508.47,30,,1508.47,percent of total billed charges,Drugs,1436.64,,,1436.64,Other,Drug Cost,1436.64,,,1436.64,Other,Drug Cost,1436.64,,,1436.64,Other,Drug Cost,1436.64,,,1436.64,Other,Drug Cost,1436.64,,,1436.64,Other,Drug Cost,1709.6,34,,1709.6,percent of total billed charges,Drugs,1436.64,,,1436.64,Other,Drug Cost,3232.44,,,3232.44,Other,225% Medicaid APG methodology,2011.3,,,2011.3,Other,140% Medicaid APG methodology,1709.6,34,"If Charge > 2,000, then 34 percent",1709.6,percent of total billed charges,Drugs,378.81,,,378.81,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1436.64,,,1436.64,Other,Drug Cost,1436.64,,,1436.64,Other,Drug Cost,1795.8,,,1795.8,Other,125% Medicaid APG methodology,0.01,3232.44,
"EPO A EPBX 20,000 UNITS/ML E    ",Q5105,HCPCS,,40508855,CDM,636,RC,00069-1311-10,NDC,both,1,ML,633.15,7.72,,,7.72,Other,150% of Medicare + 9.63% HCRA Surcharge,4.69,,,4.69,Fee Schedule,Average Sale Price (ASP) x 6,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,316.58,50,,316.58,percent of total billed charges,All Other,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,215.27,34,"If Charge > 500, then 34 percent",215.27,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,60.6,,,60.6,Other,Drug Cost,60.6,,,60.6,Other,Drug Cost,60.6,,,60.6,Other,Drug Cost,60.6,,,60.6,Other,Drug Cost,60.6,,,60.6,Other,Drug Cost,215.27,34,,215.27,percent of total billed charges,Drugs,60.6,,,60.6,Other,Drug Cost,136.35,,,136.35,Other,225% Medicaid APG methodology,84.84,,,84.84,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.51,,,7.51,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",60.6,,,60.6,Other,Drug Cost,60.6,,,60.6,Other,Drug Cost,75.75,,,75.75,Other,125% Medicaid APG methodology,0.01,316.58,
"EPO A EPBX 20,000 UNITS/ML NE   ",Q5106,HCPCS,,40508863,CDM,636,RC,00069-1311-10,NDC,both,1,ML,633.15,77.2,,,77.2,Other,150% of Medicare + 9.63% HCRA Surcharge,46.94,,,46.94,Fee Schedule,Average Sale Price (ASP) x 6,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,316.58,50,,316.58,percent of total billed charges,All Other,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,215.27,34,"If Charge > 500, then 34 percent",215.27,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,60.6,,,60.6,Other,Drug Cost,60.6,,,60.6,Other,Drug Cost,60.6,,,60.6,Other,Drug Cost,60.6,,,60.6,Other,Drug Cost,60.6,,,60.6,Other,Drug Cost,215.27,34,,215.27,percent of total billed charges,Drugs,60.6,,,60.6,Other,Drug Cost,136.35,,,136.35,Other,225% Medicaid APG methodology,84.84,,,84.84,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,75.11,,,75.11,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",60.6,,,60.6,Other,Drug Cost,60.6,,,60.6,Other,Drug Cost,75.75,,,75.75,Other,125% Medicaid APG methodology,0.01,316.58,
INFLIXIMAB AXXQ 100 MG IV INJ   ,Q5121,HCPCS,,40508921,CDM,636,RC,55513-0670-01,NDC,both,1,EA,1650.71,252.14,,,252.14,Other,150% of Medicare + 9.63% HCRA Surcharge,153.33,,,153.33,Fee Schedule,Average Sale Price (ASP) x 6,495.21,30,,495.21,percent of total billed charges,Drugs,495.21,30,,495.21,percent of total billed charges,Drugs,495.21,30,,495.21,percent of total billed charges,Drugs,495.21,30,,495.21,percent of total billed charges,Drugs,495.21,30,,495.21,percent of total billed charges,Drugs,825.36,50,,825.36,percent of total billed charges,All Other,495.21,30,,495.21,percent of total billed charges,Drugs,495.21,30,,495.21,percent of total billed charges,Drugs,561.24,34,"If Charge > 500, then 34 percent",561.24,percent of total billed charges,Drugs,495.21,30,,495.21,percent of total billed charges,Drugs,495.21,30,,495.21,percent of total billed charges,Drugs,495.21,30,,495.21,percent of total billed charges,Drugs,495.21,30,,495.21,percent of total billed charges,Drugs,495.21,30,,495.21,percent of total billed charges,Drugs,495.21,30,,495.21,percent of total billed charges,Drugs,495.21,30,,495.21,percent of total billed charges,Drugs,495.21,30,,495.21,percent of total billed charges,Drugs,495.21,30,,495.21,percent of total billed charges,Drugs,495.21,30,,495.21,percent of total billed charges,Drugs,495.21,30,,495.21,percent of total billed charges,Drugs,495.21,30,,495.21,percent of total billed charges,Drugs,495.21,30,,495.21,percent of total billed charges,Drugs,172.35,,,172.35,Other,Drug Cost,172.35,,,172.35,Other,Drug Cost,172.35,,,172.35,Other,Drug Cost,172.35,,,172.35,Other,Drug Cost,172.35,,,172.35,Other,Drug Cost,561.24,34,,561.24,percent of total billed charges,Drugs,172.35,,,172.35,Other,Drug Cost,387.79,,,387.79,Other,225% Medicaid APG methodology,241.29,,,241.29,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,245.33,,,245.33,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",172.35,,,172.35,Other,Drug Cost,172.35,,,172.35,Other,Drug Cost,215.44,,,215.44,Other,125% Medicaid APG methodology,0.01,825.36,
METHOTREXATE 25MG/ML PF INJ2ML  ,J9250,HCPCS,,40509093,CDM,636,RC,61703-0350-38,NDC,both,2,ML,15.61,3.03,,,3.03,Other,150% of Medicare + 9.63% HCRA Surcharge,1.84,,,1.84,Fee Schedule,Average Sale Price (ASP) x 6,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,7.81,50,,7.81,percent of total billed charges,All Other,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,4.68,30,,4.68,percent of total billed charges,Drugs,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,5.31,34,,5.31,percent of total billed charges,Drugs,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.95,,,2.95,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,7.81,
AMINOPHYLLINE 25MG/ML IV  20ML  ,J0280,HCPCS,,40509275,CDM,636,RC,00409-5922-01,NDC,both,20,ML,24.5,50.64,,,50.64,Other,150% of Medicare + 9.63% HCRA Surcharge,30.79,,,30.79,Fee Schedule,Average Sale Price (ASP) x 6,7.35,30,,7.35,percent of total billed charges,Drugs,7.35,30,,7.35,percent of total billed charges,Drugs,7.35,30,,7.35,percent of total billed charges,Drugs,7.35,30,,7.35,percent of total billed charges,Drugs,7.35,30,,7.35,percent of total billed charges,Drugs,12.25,50,,12.25,percent of total billed charges,All Other,7.35,30,,7.35,percent of total billed charges,Drugs,7.35,30,,7.35,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,7.35,30,,7.35,percent of total billed charges,Drugs,7.35,30,,7.35,percent of total billed charges,Drugs,7.35,30,,7.35,percent of total billed charges,Drugs,7.35,30,,7.35,percent of total billed charges,Drugs,7.35,30,,7.35,percent of total billed charges,Drugs,7.35,30,,7.35,percent of total billed charges,Drugs,7.35,30,,7.35,percent of total billed charges,Drugs,7.35,30,,7.35,percent of total billed charges,Drugs,7.35,30,,7.35,percent of total billed charges,Drugs,7.35,30,,7.35,percent of total billed charges,Drugs,7.35,30,,7.35,percent of total billed charges,Drugs,7.35,30,,7.35,percent of total billed charges,Drugs,7.35,30,,7.35,percent of total billed charges,Drugs,4.32,,,4.32,Other,Drug Cost,4.32,,,4.32,Other,Drug Cost,4.32,,,4.32,Other,Drug Cost,4.32,,,4.32,Other,Drug Cost,4.32,,,4.32,Other,Drug Cost,8.33,34,,8.33,percent of total billed charges,Drugs,4.32,,,4.32,Other,Drug Cost,9.72,,,9.72,Other,225% Medicaid APG methodology,6.05,,,6.05,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,49.27,,,49.27,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.32,,,4.32,Other,Drug Cost,4.32,,,4.32,Other,Drug Cost,5.4,,,5.4,Other,125% Medicaid APG methodology,0.01,50.64,
DOBUTAMINE 250MG IV SOLN 20ML   ,J1250,HCPCS,,40509424,CDM,636,RC,00409-2344-02,NDC,both,20,ML,15.75,97.17,,,97.17,Other,150% of Medicare + 9.63% HCRA Surcharge,59.09,,,59.09,Fee Schedule,Average Sale Price (ASP) x 6,4.73,30,,4.73,percent of total billed charges,Drugs,4.73,30,,4.73,percent of total billed charges,Drugs,4.73,30,,4.73,percent of total billed charges,Drugs,4.73,30,,4.73,percent of total billed charges,Drugs,4.73,30,,4.73,percent of total billed charges,Drugs,7.88,50,,7.88,percent of total billed charges,All Other,4.73,30,,4.73,percent of total billed charges,Drugs,4.73,30,,4.73,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.73,30,,4.73,percent of total billed charges,Drugs,4.73,30,,4.73,percent of total billed charges,Drugs,4.73,30,,4.73,percent of total billed charges,Drugs,4.73,30,,4.73,percent of total billed charges,Drugs,4.73,30,,4.73,percent of total billed charges,Drugs,4.73,30,,4.73,percent of total billed charges,Drugs,4.73,30,,4.73,percent of total billed charges,Drugs,4.73,30,,4.73,percent of total billed charges,Drugs,4.73,30,,4.73,percent of total billed charges,Drugs,4.73,30,,4.73,percent of total billed charges,Drugs,4.73,30,,4.73,percent of total billed charges,Drugs,4.73,30,,4.73,percent of total billed charges,Drugs,4.73,30,,4.73,percent of total billed charges,Drugs,3.5,,,3.5,Other,Drug Cost,3.5,,,3.5,Other,Drug Cost,3.5,,,3.5,Other,Drug Cost,3.5,,,3.5,Other,Drug Cost,3.5,,,3.5,Other,Drug Cost,5.36,34,,5.36,percent of total billed charges,Drugs,3.5,,,3.5,Other,Drug Cost,7.88,,,7.88,Other,225% Medicaid APG methodology,4.9,,,4.9,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,94.54,,,94.54,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.5,,,3.5,Other,Drug Cost,3.5,,,3.5,Other,Drug Cost,4.38,,,4.38,Other,125% Medicaid APG methodology,0.01,97.17,
PROCAINAMIDE 1000MG/2ML INJSLN  ,J2690,HCPCS,,40509515,CDM,636,RC,00409-1903-01,NDC,both,2,ML,162.68,1443.67,,,1443.67,Other,150% of Medicare + 9.63% HCRA Surcharge,877.9,,,877.9,Fee Schedule,Average Sale Price (ASP) x 6,48.8,30,,48.8,percent of total billed charges,Drugs,48.8,30,,48.8,percent of total billed charges,Drugs,48.8,30,,48.8,percent of total billed charges,Drugs,48.8,30,,48.8,percent of total billed charges,Drugs,48.8,30,,48.8,percent of total billed charges,Drugs,81.34,50,,81.34,percent of total billed charges,All Other,48.8,30,,48.8,percent of total billed charges,Drugs,48.8,30,,48.8,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,48.8,30,,48.8,percent of total billed charges,Drugs,48.8,30,,48.8,percent of total billed charges,Drugs,48.8,30,,48.8,percent of total billed charges,Drugs,48.8,30,,48.8,percent of total billed charges,Drugs,48.8,30,,48.8,percent of total billed charges,Drugs,48.8,30,,48.8,percent of total billed charges,Drugs,48.8,30,,48.8,percent of total billed charges,Drugs,48.8,30,,48.8,percent of total billed charges,Drugs,48.8,30,,48.8,percent of total billed charges,Drugs,48.8,30,,48.8,percent of total billed charges,Drugs,48.8,30,,48.8,percent of total billed charges,Drugs,48.8,30,,48.8,percent of total billed charges,Drugs,48.8,30,,48.8,percent of total billed charges,Drugs,36.93,,,36.93,Other,Drug Cost,36.93,,,36.93,Other,Drug Cost,36.93,,,36.93,Other,Drug Cost,36.93,,,36.93,Other,Drug Cost,36.93,,,36.93,Other,Drug Cost,55.31,34,,55.31,percent of total billed charges,Drugs,36.93,,,36.93,Other,Drug Cost,83.09,,,83.09,Other,225% Medicaid APG methodology,51.7,,,51.7,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1404.64,,,1404.64,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",36.93,,,36.93,Other,Drug Cost,36.93,,,36.93,Other,Drug Cost,46.16,,,46.16,Other,125% Medicaid APG methodology,0.01,1443.67,
PAPAVERINE 30MG/ML INJ SLN 2ML  ,J2440,HCPCS,,40510166,CDM,636,RC,00517-4002-25,NDC,both,2,ML,89.29,35.24,39.4668,,35.24,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,26.79,30,,26.79,percent of total billed charges,Drugs,26.79,30,,26.79,percent of total billed charges,Drugs,26.79,30,,26.79,percent of total billed charges,Drugs,26.79,30,,26.79,percent of total billed charges,Drugs,26.79,30,,26.79,percent of total billed charges,Drugs,44.65,50,,44.65,percent of total billed charges,All Other,26.79,30,,26.79,percent of total billed charges,Drugs,26.79,30,,26.79,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,26.79,30,,26.79,percent of total billed charges,Drugs,26.79,30,,26.79,percent of total billed charges,Drugs,26.79,30,,26.79,percent of total billed charges,Drugs,26.79,30,,26.79,percent of total billed charges,Drugs,26.79,30,,26.79,percent of total billed charges,Drugs,26.79,30,,26.79,percent of total billed charges,Drugs,26.79,30,,26.79,percent of total billed charges,Drugs,26.79,30,,26.79,percent of total billed charges,Drugs,26.79,30,,26.79,percent of total billed charges,Drugs,26.79,30,,26.79,percent of total billed charges,Drugs,26.79,30,,26.79,percent of total billed charges,Drugs,26.79,30,,26.79,percent of total billed charges,Drugs,26.79,30,,26.79,percent of total billed charges,Drugs,6.24,,,6.24,Other,Drug Cost,6.24,,,6.24,Other,Drug Cost,6.24,,,6.24,Other,Drug Cost,6.24,,,6.24,Other,Drug Cost,6.24,,,6.24,Other,Drug Cost,30.36,34,,30.36,percent of total billed charges,Drugs,6.24,,,6.24,Other,Drug Cost,14.04,,,14.04,Other,225% Medicaid APG methodology,8.74,,,8.74,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6.24,,,6.24,Other,Drug Cost,6.24,,,6.24,Other,Drug Cost,7.8,,,7.8,Other,125% Medicaid APG methodology,0.01,44.65,
ALPROSTADIL 0.5MG/ML INJ  1ML   ,J0270,HCPCS,,40510182,CDM,636,RC,00009-3169-06,NDC,both,1,ML,401.56,158.48,39.4668,,158.48,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,200.78,50,,200.78,percent of total billed charges,All Other,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,86.18,,,86.18,Other,Drug Cost,86.18,,,86.18,Other,Drug Cost,86.18,,,86.18,Other,Drug Cost,86.18,,,86.18,Other,Drug Cost,86.18,,,86.18,Other,Drug Cost,136.53,34,,136.53,percent of total billed charges,Drugs,86.18,,,86.18,Other,Drug Cost,193.91,,,193.91,Other,225% Medicaid APG methodology,120.65,,,120.65,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",86.18,,,86.18,Other,Drug Cost,86.18,,,86.18,Other,Drug Cost,107.73,,,107.73,Other,125% Medicaid APG methodology,0.01,200.78,
ACETYLCYSTEINE 10% INHSOLN 4ML  ,J7608,HCPCS,,40510299,CDM,636,RC,00517-7504-25,NDC,both,4,ML,15.26,67.34,,,67.34,Other,150% of Medicare + 9.63% HCRA Surcharge,40.95,,,40.95,Fee Schedule,Average Sale Price (ASP) x 6,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,7.63,50,,7.63,percent of total billed charges,All Other,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,1.98,,,1.98,Other,Drug Cost,1.98,,,1.98,Other,Drug Cost,1.98,,,1.98,Other,Drug Cost,1.98,,,1.98,Other,Drug Cost,1.98,,,1.98,Other,Drug Cost,5.19,34,,5.19,percent of total billed charges,Drugs,1.98,,,1.98,Other,Drug Cost,4.46,,,4.46,Other,225% Medicaid APG methodology,2.77,,,2.77,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,65.52,,,65.52,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.98,,,1.98,Other,Drug Cost,1.98,,,1.98,Other,Drug Cost,2.48,,,2.48,Other,125% Medicaid APG methodology,0.01,67.34,
DILTIAZEM 5 MG/ML IV SOLN 5 ML  ,J3490,HCPCS,,40510364,CDM,636,RC,55150-0425-10,NDC,both,5,ML,12.36,4.88,39.4668,,4.88,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,6.18,50,,6.18,percent of total billed charges,All Other,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,3.71,30,,3.71,percent of total billed charges,Drugs,2.72,,,2.72,Other,Drug Cost,2.72,,,2.72,Other,Drug Cost,2.72,,,2.72,Other,Drug Cost,2.72,,,2.72,Other,Drug Cost,2.72,,,2.72,Other,Drug Cost,4.2,34,,4.2,percent of total billed charges,Drugs,2.72,,,2.72,Other,Drug Cost,6.12,,,6.12,Other,225% Medicaid APG methodology,3.81,,,3.81,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.72,,,2.72,Other,Drug Cost,2.72,,,2.72,Other,Drug Cost,3.4,,,3.4,Other,125% Medicaid APG methodology,0.01,6.18,
LACTATED RINGERS IV SLN 1000ML  ,J7120,HCPCS,,40510430,CDM,636,RC,00338-0117-04,NDC,both,1000,ML,8.05,25.56,,,25.56,Other,150% of Medicare + 9.63% HCRA Surcharge,15.55,,,15.55,Fee Schedule,Average Sale Price (ASP) x 6,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,4.03,50,,4.03,percent of total billed charges,All Other,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,0.77,,,0.77,Other,Drug Cost,0.77,,,0.77,Other,Drug Cost,0.77,,,0.77,Other,Drug Cost,0.77,,,0.77,Other,Drug Cost,0.77,,,0.77,Other,Drug Cost,2.74,34,,2.74,percent of total billed charges,Drugs,0.77,,,0.77,Other,Drug Cost,1.73,,,1.73,Other,225% Medicaid APG methodology,1.08,,,1.08,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,24.87,,,24.87,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.77,,,0.77,Other,Drug Cost,0.77,,,0.77,Other,Drug Cost,0.96,,,0.96,Other,125% Medicaid APG methodology,0.01,25.56,
POT CL 10 MEQ IN IV SLN  100ML  ,J3480,HCPCS,,40510711,CDM,636,RC,00338-0709-48,NDC,both,100,ML,10.01,1.18,,,1.18,Other,150% of Medicare + 9.63% HCRA Surcharge,0.72,,,0.72,Fee Schedule,Average Sale Price (ASP) x 6,3,30,,3,percent of total billed charges,Drugs,3,30,,3,percent of total billed charges,Drugs,3,30,,3,percent of total billed charges,Drugs,3,30,,3,percent of total billed charges,Drugs,3,30,,3,percent of total billed charges,Drugs,5.01,50,,5.01,percent of total billed charges,All Other,3,30,,3,percent of total billed charges,Drugs,3,30,,3,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3,30,,3,percent of total billed charges,Drugs,3,30,,3,percent of total billed charges,Drugs,3,30,,3,percent of total billed charges,Drugs,3,30,,3,percent of total billed charges,Drugs,3,30,,3,percent of total billed charges,Drugs,3,30,,3,percent of total billed charges,Drugs,3,30,,3,percent of total billed charges,Drugs,3,30,,3,percent of total billed charges,Drugs,3,30,,3,percent of total billed charges,Drugs,3,30,,3,percent of total billed charges,Drugs,3,30,,3,percent of total billed charges,Drugs,3,30,,3,percent of total billed charges,Drugs,3,30,,3,percent of total billed charges,Drugs,1.36,,,1.36,Other,Drug Cost,1.36,,,1.36,Other,Drug Cost,1.36,,,1.36,Other,Drug Cost,1.36,,,1.36,Other,Drug Cost,1.36,,,1.36,Other,Drug Cost,3.4,34,,3.4,percent of total billed charges,Drugs,1.36,,,1.36,Other,Drug Cost,3.06,,,3.06,Other,225% Medicaid APG methodology,1.9,,,1.9,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.15,,,1.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.36,,,1.36,Other,Drug Cost,1.36,,,1.36,Other,Drug Cost,1.7,,,1.7,Other,125% Medicaid APG methodology,0.01,5.01,
POT CL 2 MEQ/ML IV SLN 20ML     ,J3480,HCPCS,,40510752,CDM,636,RC,63323-0965-20,NDC,both,20,ML,4.41,1.18,,,1.18,Other,150% of Medicare + 9.63% HCRA Surcharge,0.72,,,0.72,Fee Schedule,Average Sale Price (ASP) x 6,1.32,30,,1.32,percent of total billed charges,Drugs,1.32,30,,1.32,percent of total billed charges,Drugs,1.32,30,,1.32,percent of total billed charges,Drugs,1.32,30,,1.32,percent of total billed charges,Drugs,1.32,30,,1.32,percent of total billed charges,Drugs,2.21,50,,2.21,percent of total billed charges,All Other,1.32,30,,1.32,percent of total billed charges,Drugs,1.32,30,,1.32,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.32,30,,1.32,percent of total billed charges,Drugs,1.32,30,,1.32,percent of total billed charges,Drugs,1.32,30,,1.32,percent of total billed charges,Drugs,1.32,30,,1.32,percent of total billed charges,Drugs,1.32,30,,1.32,percent of total billed charges,Drugs,1.32,30,,1.32,percent of total billed charges,Drugs,1.32,30,,1.32,percent of total billed charges,Drugs,1.32,30,,1.32,percent of total billed charges,Drugs,1.32,30,,1.32,percent of total billed charges,Drugs,1.32,30,,1.32,percent of total billed charges,Drugs,1.32,30,,1.32,percent of total billed charges,Drugs,1.32,30,,1.32,percent of total billed charges,Drugs,1.32,30,,1.32,percent of total billed charges,Drugs,0.79,,,0.79,Other,Drug Cost,0.79,,,0.79,Other,Drug Cost,0.79,,,0.79,Other,Drug Cost,0.79,,,0.79,Other,Drug Cost,0.79,,,0.79,Other,Drug Cost,1.5,34,,1.5,percent of total billed charges,Drugs,0.79,,,0.79,Other,Drug Cost,1.78,,,1.78,Other,225% Medicaid APG methodology,1.11,,,1.11,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.15,,,1.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.79,,,0.79,Other,Drug Cost,0.79,,,0.79,Other,Drug Cost,0.99,,,0.99,Other,125% Medicaid APG methodology,0.01,2.21,
POT CL 2 MEQ/ML IV SLN 10ML     ,J3480,HCPCS,,40510760,CDM,636,RC,00409-6651-06,NDC,both,10,ML,9.94,1.18,,,1.18,Other,150% of Medicare + 9.63% HCRA Surcharge,0.72,,,0.72,Fee Schedule,Average Sale Price (ASP) x 6,2.98,30,,2.98,percent of total billed charges,Drugs,2.98,30,,2.98,percent of total billed charges,Drugs,2.98,30,,2.98,percent of total billed charges,Drugs,2.98,30,,2.98,percent of total billed charges,Drugs,2.98,30,,2.98,percent of total billed charges,Drugs,4.97,50,,4.97,percent of total billed charges,All Other,2.98,30,,2.98,percent of total billed charges,Drugs,2.98,30,,2.98,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.98,30,,2.98,percent of total billed charges,Drugs,2.98,30,,2.98,percent of total billed charges,Drugs,2.98,30,,2.98,percent of total billed charges,Drugs,2.98,30,,2.98,percent of total billed charges,Drugs,2.98,30,,2.98,percent of total billed charges,Drugs,2.98,30,,2.98,percent of total billed charges,Drugs,2.98,30,,2.98,percent of total billed charges,Drugs,2.98,30,,2.98,percent of total billed charges,Drugs,2.98,30,,2.98,percent of total billed charges,Drugs,2.98,30,,2.98,percent of total billed charges,Drugs,2.98,30,,2.98,percent of total billed charges,Drugs,2.98,30,,2.98,percent of total billed charges,Drugs,2.98,30,,2.98,percent of total billed charges,Drugs,1.88,,,1.88,Other,Drug Cost,1.88,,,1.88,Other,Drug Cost,1.88,,,1.88,Other,Drug Cost,1.88,,,1.88,Other,Drug Cost,1.88,,,1.88,Other,Drug Cost,3.38,34,,3.38,percent of total billed charges,Drugs,1.88,,,1.88,Other,Drug Cost,4.23,,,4.23,Other,225% Medicaid APG methodology,2.63,,,2.63,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.15,,,1.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.88,,,1.88,Other,Drug Cost,1.88,,,1.88,Other,Drug Cost,2.35,,,2.35,Other,125% Medicaid APG methodology,0.01,4.97,
METOPROLOL 1MG/ML INJ SOLN 5ML  ,J3490,HCPCS,,40510836,CDM,636,RC,00409-1778-05,NDC,both,5,ML,1.89,0.75,39.4668,,0.75,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.95,50,,0.95,percent of total billed charges,All Other,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.64,34,,0.64,percent of total billed charges,Drugs,0.45,,,0.45,Other,Drug Cost,1.01,,,1.01,Other,225% Medicaid APG methodology,0.63,,,0.63,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.45,,,0.45,Other,Drug Cost,0.45,,,0.45,Other,Drug Cost,0.56,,,0.56,Other,125% Medicaid APG methodology,0.01,1.01,
CAL GLUC 100MG/ML SLN 10ML      ,J0612,HCPCS,,40510893,CDM,636,RC,00143-9180-25,NDC,both,10,ML,25.87,0.49,,,0.49,Other,150% of Medicare + 9.63% HCRA Surcharge,0.3,,,0.3,Fee Schedule,Average Sale Price (ASP) x 6,7.76,30,,7.76,percent of total billed charges,Drugs,7.76,30,,7.76,percent of total billed charges,Drugs,7.76,30,,7.76,percent of total billed charges,Drugs,7.76,30,,7.76,percent of total billed charges,Drugs,7.76,30,,7.76,percent of total billed charges,Drugs,12.94,50,,12.94,percent of total billed charges,All Other,7.76,30,,7.76,percent of total billed charges,Drugs,7.76,30,,7.76,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,7.76,30,,7.76,percent of total billed charges,Drugs,7.76,30,,7.76,percent of total billed charges,Drugs,7.76,30,,7.76,percent of total billed charges,Drugs,7.76,30,,7.76,percent of total billed charges,Drugs,7.76,30,,7.76,percent of total billed charges,Drugs,7.76,30,,7.76,percent of total billed charges,Drugs,7.76,30,,7.76,percent of total billed charges,Drugs,7.76,30,,7.76,percent of total billed charges,Drugs,7.76,30,,7.76,percent of total billed charges,Drugs,7.76,30,,7.76,percent of total billed charges,Drugs,7.76,30,,7.76,percent of total billed charges,Drugs,7.76,30,,7.76,percent of total billed charges,Drugs,7.76,30,,7.76,percent of total billed charges,Drugs,7.21,,,7.21,Other,Drug Cost,7.21,,,7.21,Other,Drug Cost,7.21,,,7.21,Other,Drug Cost,7.21,,,7.21,Other,Drug Cost,7.21,,,7.21,Other,Drug Cost,8.8,34,,8.8,percent of total billed charges,Drugs,7.21,,,7.21,Other,Drug Cost,16.22,,,16.22,Other,225% Medicaid APG methodology,10.09,,,10.09,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.48,,,0.48,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",7.21,,,7.21,Other,Drug Cost,7.21,,,7.21,Other,Drug Cost,9.01,,,9.01,Other,125% Medicaid APG methodology,0.01,16.22,
MAG SULF 50% PF INJ SLN 2ML     ,J3475,HCPCS,,40510950,CDM,636,RC,63323-0064-03,NDC,both,2,ML,3.71,6.82,,,6.82,Other,150% of Medicare + 9.63% HCRA Surcharge,4.15,,,4.15,Fee Schedule,Average Sale Price (ASP) x 6,1.11,30,,1.11,percent of total billed charges,Drugs,1.11,30,,1.11,percent of total billed charges,Drugs,1.11,30,,1.11,percent of total billed charges,Drugs,1.11,30,,1.11,percent of total billed charges,Drugs,1.11,30,,1.11,percent of total billed charges,Drugs,1.86,50,,1.86,percent of total billed charges,All Other,1.11,30,,1.11,percent of total billed charges,Drugs,1.11,30,,1.11,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.11,30,,1.11,percent of total billed charges,Drugs,1.11,30,,1.11,percent of total billed charges,Drugs,1.11,30,,1.11,percent of total billed charges,Drugs,1.11,30,,1.11,percent of total billed charges,Drugs,1.11,30,,1.11,percent of total billed charges,Drugs,1.11,30,,1.11,percent of total billed charges,Drugs,1.11,30,,1.11,percent of total billed charges,Drugs,1.11,30,,1.11,percent of total billed charges,Drugs,1.11,30,,1.11,percent of total billed charges,Drugs,1.11,30,,1.11,percent of total billed charges,Drugs,1.11,30,,1.11,percent of total billed charges,Drugs,1.11,30,,1.11,percent of total billed charges,Drugs,1.11,30,,1.11,percent of total billed charges,Drugs,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,1.26,34,,1.26,percent of total billed charges,Drugs,0.22,,,0.22,Other,Drug Cost,0.5,,,0.5,Other,225% Medicaid APG methodology,0.31,,,0.31,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.63,,,6.63,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.22,,,0.22,Other,Drug Cost,0.22,,,0.22,Other,Drug Cost,0.28,,,0.28,Other,125% Medicaid APG methodology,0.01,6.82,
DEXTROSE 50%ABBOJECT INJ 50ML   ,J7799,HCPCS,,40511420,CDM,636,RC,00409-4902-34,NDC,both,50,ML,26.25,10.36,39.4668,,10.36,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,7.88,30,,7.88,percent of total billed charges,Drugs,7.88,30,,7.88,percent of total billed charges,Drugs,7.88,30,,7.88,percent of total billed charges,Drugs,7.88,30,,7.88,percent of total billed charges,Drugs,7.88,30,,7.88,percent of total billed charges,Drugs,13.13,50,,13.13,percent of total billed charges,All Other,7.88,30,,7.88,percent of total billed charges,Drugs,7.88,30,,7.88,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,7.88,30,,7.88,percent of total billed charges,Drugs,7.88,30,,7.88,percent of total billed charges,Drugs,7.88,30,,7.88,percent of total billed charges,Drugs,7.88,30,,7.88,percent of total billed charges,Drugs,7.88,30,,7.88,percent of total billed charges,Drugs,7.88,30,,7.88,percent of total billed charges,Drugs,7.88,30,,7.88,percent of total billed charges,Drugs,7.88,30,,7.88,percent of total billed charges,Drugs,7.88,30,,7.88,percent of total billed charges,Drugs,7.88,30,,7.88,percent of total billed charges,Drugs,7.88,30,,7.88,percent of total billed charges,Drugs,7.88,30,,7.88,percent of total billed charges,Drugs,7.88,30,,7.88,percent of total billed charges,Drugs,3,,,3,Other,Drug Cost,3,,,3,Other,Drug Cost,3,,,3,Other,Drug Cost,3,,,3,Other,Drug Cost,3,,,3,Other,Drug Cost,8.93,34,,8.93,percent of total billed charges,Drugs,3,,,3,Other,Drug Cost,6.75,,,6.75,Other,225% Medicaid APG methodology,4.2,,,4.2,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3,,,3,Other,Drug Cost,3,,,3,Other,Drug Cost,3.75,,,3.75,Other,125% Medicaid APG methodology,0.01,13.13,
DEFEROXAMINE 500 MG INJ         ,J0895,HCPCS,,40511610,CDM,636,RC,63323-0597-10,NDC,both,1,EA,35.98,84.82,,,84.82,Other,150% of Medicare + 9.63% HCRA Surcharge,51.58,,,51.58,Fee Schedule,Average Sale Price (ASP) x 6,10.79,30,,10.79,percent of total billed charges,Drugs,10.79,30,,10.79,percent of total billed charges,Drugs,10.79,30,,10.79,percent of total billed charges,Drugs,10.79,30,,10.79,percent of total billed charges,Drugs,10.79,30,,10.79,percent of total billed charges,Drugs,17.99,50,,17.99,percent of total billed charges,All Other,10.79,30,,10.79,percent of total billed charges,Drugs,10.79,30,,10.79,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,10.79,30,,10.79,percent of total billed charges,Drugs,10.79,30,,10.79,percent of total billed charges,Drugs,10.79,30,,10.79,percent of total billed charges,Drugs,10.79,30,,10.79,percent of total billed charges,Drugs,10.79,30,,10.79,percent of total billed charges,Drugs,10.79,30,,10.79,percent of total billed charges,Drugs,10.79,30,,10.79,percent of total billed charges,Drugs,10.79,30,,10.79,percent of total billed charges,Drugs,10.79,30,,10.79,percent of total billed charges,Drugs,10.79,30,,10.79,percent of total billed charges,Drugs,10.79,30,,10.79,percent of total billed charges,Drugs,10.79,30,,10.79,percent of total billed charges,Drugs,10.79,30,,10.79,percent of total billed charges,Drugs,6.36,,,6.36,Other,Drug Cost,6.36,,,6.36,Other,Drug Cost,6.36,,,6.36,Other,Drug Cost,6.36,,,6.36,Other,Drug Cost,6.36,,,6.36,Other,Drug Cost,12.23,34,,12.23,percent of total billed charges,Drugs,6.36,,,6.36,Other,Drug Cost,14.31,,,14.31,Other,225% Medicaid APG methodology,8.9,,,8.9,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,82.53,,,82.53,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6.36,,,6.36,Other,Drug Cost,6.36,,,6.36,Other,Drug Cost,7.95,,,7.95,Other,125% Medicaid APG methodology,0.01,84.82,
FOMEPIZOLE 1000MG/ML IV  1.5ML  ,J1451,HCPCS,,40511727,CDM,636,RC,67457-0211-02,NDC,both,1.5,ML,3208.07,1266.12,39.4668,,1266.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,962.42,30,,962.42,percent of total billed charges,Drugs,962.42,30,,962.42,percent of total billed charges,Drugs,962.42,30,,962.42,percent of total billed charges,Drugs,962.42,30,,962.42,percent of total billed charges,Drugs,962.42,30,,962.42,percent of total billed charges,Drugs,1604.04,50,,1604.04,percent of total billed charges,All Other,962.42,30,,962.42,percent of total billed charges,Drugs,962.42,30,,962.42,percent of total billed charges,Drugs,1090.74,34,"If Charge > 500, then 34 percent",1090.74,percent of total billed charges,Drugs,962.42,30,,962.42,percent of total billed charges,Drugs,962.42,30,,962.42,percent of total billed charges,Drugs,962.42,30,,962.42,percent of total billed charges,Drugs,962.42,30,,962.42,percent of total billed charges,Drugs,962.42,30,,962.42,percent of total billed charges,Drugs,962.42,30,,962.42,percent of total billed charges,Drugs,962.42,30,,962.42,percent of total billed charges,Drugs,962.42,30,,962.42,percent of total billed charges,Drugs,962.42,30,,962.42,percent of total billed charges,Drugs,962.42,30,,962.42,percent of total billed charges,Drugs,962.42,30,,962.42,percent of total billed charges,Drugs,962.42,30,,962.42,percent of total billed charges,Drugs,962.42,30,,962.42,percent of total billed charges,Drugs,530.05,,,530.05,Other,Drug Cost,530.05,,,530.05,Other,Drug Cost,530.05,,,530.05,Other,Drug Cost,530.05,,,530.05,Other,Drug Cost,530.05,,,530.05,Other,Drug Cost,1090.74,34,,1090.74,percent of total billed charges,Drugs,530.05,,,530.05,Other,Drug Cost,1192.61,,,1192.61,Other,225% Medicaid APG methodology,742.07,,,742.07,Other,140% Medicaid APG methodology,1090.74,34,"If Charge > 2,000, then 34 percent",1090.74,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",530.05,,,530.05,Other,Drug Cost,530.05,,,530.05,Other,Drug Cost,662.56,,,662.56,Other,125% Medicaid APG methodology,0.01,1604.04,
CYCLOSPORINE 50MG/ML INJ  5ML   ,J7516,HCPCS,,40511818,CDM,636,RC,00078-0109-01,NDC,both,5,ML,195.83,77.29,39.4668,,77.29,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,58.75,30,,58.75,percent of total billed charges,Drugs,58.75,30,,58.75,percent of total billed charges,Drugs,58.75,30,,58.75,percent of total billed charges,Drugs,58.75,30,,58.75,percent of total billed charges,Drugs,58.75,30,,58.75,percent of total billed charges,Drugs,97.92,50,,97.92,percent of total billed charges,All Other,58.75,30,,58.75,percent of total billed charges,Drugs,58.75,30,,58.75,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,58.75,30,,58.75,percent of total billed charges,Drugs,58.75,30,,58.75,percent of total billed charges,Drugs,58.75,30,,58.75,percent of total billed charges,Drugs,58.75,30,,58.75,percent of total billed charges,Drugs,58.75,30,,58.75,percent of total billed charges,Drugs,58.75,30,,58.75,percent of total billed charges,Drugs,58.75,30,,58.75,percent of total billed charges,Drugs,58.75,30,,58.75,percent of total billed charges,Drugs,58.75,30,,58.75,percent of total billed charges,Drugs,58.75,30,,58.75,percent of total billed charges,Drugs,58.75,30,,58.75,percent of total billed charges,Drugs,58.75,30,,58.75,percent of total billed charges,Drugs,58.75,30,,58.75,percent of total billed charges,Drugs,15.82,,,15.82,Other,Drug Cost,15.82,,,15.82,Other,Drug Cost,15.82,,,15.82,Other,Drug Cost,15.82,,,15.82,Other,Drug Cost,15.82,,,15.82,Other,Drug Cost,66.58,34,,66.58,percent of total billed charges,Drugs,15.82,,,15.82,Other,Drug Cost,35.6,,,35.6,Other,225% Medicaid APG methodology,22.15,,,22.15,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",15.82,,,15.82,Other,Drug Cost,15.82,,,15.82,Other,Drug Cost,19.78,,,19.78,Other,125% Medicaid APG methodology,0.01,97.92,
SINCALIDE 5 MCG IV INJ          ,J2805,HCPCS,,40512212,CDM,636,RC,63323-0579-05,NDC,both,1,EA,224.7,1313.25,,,1313.25,Other,150% of Medicare + 9.63% HCRA Surcharge,798.59,,,798.59,Fee Schedule,Average Sale Price (ASP) x 6,67.41,30,,67.41,percent of total billed charges,Drugs,67.41,30,,67.41,percent of total billed charges,Drugs,67.41,30,,67.41,percent of total billed charges,Drugs,67.41,30,,67.41,percent of total billed charges,Drugs,67.41,30,,67.41,percent of total billed charges,Drugs,112.35,50,,112.35,percent of total billed charges,All Other,67.41,30,,67.41,percent of total billed charges,Drugs,67.41,30,,67.41,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,67.41,30,,67.41,percent of total billed charges,Drugs,67.41,30,,67.41,percent of total billed charges,Drugs,67.41,30,,67.41,percent of total billed charges,Drugs,67.41,30,,67.41,percent of total billed charges,Drugs,67.41,30,,67.41,percent of total billed charges,Drugs,67.41,30,,67.41,percent of total billed charges,Drugs,67.41,30,,67.41,percent of total billed charges,Drugs,67.41,30,,67.41,percent of total billed charges,Drugs,67.41,30,,67.41,percent of total billed charges,Drugs,67.41,30,,67.41,percent of total billed charges,Drugs,67.41,30,,67.41,percent of total billed charges,Drugs,67.41,30,,67.41,percent of total billed charges,Drugs,67.41,30,,67.41,percent of total billed charges,Drugs,53.13,,,53.13,Other,Drug Cost,53.13,,,53.13,Other,Drug Cost,53.13,,,53.13,Other,Drug Cost,53.13,,,53.13,Other,Drug Cost,53.13,,,53.13,Other,Drug Cost,76.4,34,,76.4,percent of total billed charges,Drugs,53.13,,,53.13,Other,Drug Cost,119.54,,,119.54,Other,225% Medicaid APG methodology,74.38,,,74.38,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1277.75,,,1277.75,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",53.13,,,53.13,Other,Drug Cost,53.13,,,53.13,Other,Drug Cost,66.41,,,66.41,Other,125% Medicaid APG methodology,0.01,1313.25,
PREDNISONE 2.5 MG TAB           ,J7512,HCPCS,,40512626,CDM,636,RC,00054-8740-25,NDC,both,1,EA,0.39,0.07,,,0.07,Other,150% of Medicare + 9.63% HCRA Surcharge,0.04,,,0.04,Fee Schedule,Average Sale Price (ASP) x 6,0.12,30,,0.12,percent of total billed charges,Drugs,0.12,30,,0.12,percent of total billed charges,Drugs,0.12,30,,0.12,percent of total billed charges,Drugs,0.12,30,,0.12,percent of total billed charges,Drugs,0.12,30,,0.12,percent of total billed charges,Drugs,0.2,50,,0.2,percent of total billed charges,All Other,0.12,30,,0.12,percent of total billed charges,Drugs,0.12,30,,0.12,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.12,30,,0.12,percent of total billed charges,Drugs,0.12,30,,0.12,percent of total billed charges,Drugs,0.12,30,,0.12,percent of total billed charges,Drugs,0.12,30,,0.12,percent of total billed charges,Drugs,0.12,30,,0.12,percent of total billed charges,Drugs,0.12,30,,0.12,percent of total billed charges,Drugs,0.12,30,,0.12,percent of total billed charges,Drugs,0.12,30,,0.12,percent of total billed charges,Drugs,0.12,30,,0.12,percent of total billed charges,Drugs,0.12,30,,0.12,percent of total billed charges,Drugs,0.12,30,,0.12,percent of total billed charges,Drugs,0.12,30,,0.12,percent of total billed charges,Drugs,0.12,30,,0.12,percent of total billed charges,Drugs,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.13,34,,0.13,percent of total billed charges,Drugs,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.07,,,0.07,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.2,
PREDNISONE 10 MG TAB            ,J7512,HCPCS,,40512881,CDM,636,RC,00603-5338-21,NDC,both,1,EA,0.56,0.07,,,0.07,Other,150% of Medicare + 9.63% HCRA Surcharge,0.04,,,0.04,Fee Schedule,Average Sale Price (ASP) x 6,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.28,50,,0.28,percent of total billed charges,All Other,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.19,34,,0.19,percent of total billed charges,Drugs,0.1,,,0.1,Other,Drug Cost,0.23,,,0.23,Other,225% Medicaid APG methodology,0.14,,,0.14,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.07,,,0.07,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.13,,,0.13,Other,125% Medicaid APG methodology,0.01,0.28,
TACROLIMUS 1 MG CAP             ,J7507,HCPCS,,40513145,CDM,636,RC,70377-0015-11,NDC,both,1,EA,1.02,2.33,,,2.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1.42,,,1.42,Fee Schedule,Average Sale Price (ASP) x 6,0.31,30,,0.31,percent of total billed charges,Drugs,0.31,30,,0.31,percent of total billed charges,Drugs,0.31,30,,0.31,percent of total billed charges,Drugs,0.31,30,,0.31,percent of total billed charges,Drugs,0.31,30,,0.31,percent of total billed charges,Drugs,0.51,50,,0.51,percent of total billed charges,All Other,0.31,30,,0.31,percent of total billed charges,Drugs,0.31,30,,0.31,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.31,30,,0.31,percent of total billed charges,Drugs,0.31,30,,0.31,percent of total billed charges,Drugs,0.31,30,,0.31,percent of total billed charges,Drugs,0.31,30,,0.31,percent of total billed charges,Drugs,0.31,30,,0.31,percent of total billed charges,Drugs,0.31,30,,0.31,percent of total billed charges,Drugs,0.31,30,,0.31,percent of total billed charges,Drugs,0.31,30,,0.31,percent of total billed charges,Drugs,0.31,30,,0.31,percent of total billed charges,Drugs,0.31,30,,0.31,percent of total billed charges,Drugs,0.31,30,,0.31,percent of total billed charges,Drugs,0.31,30,,0.31,percent of total billed charges,Drugs,0.31,30,,0.31,percent of total billed charges,Drugs,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.35,34,,0.35,percent of total billed charges,Drugs,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.27,,,2.27,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,2.33,
TACROLIMUS 5 MG CAP             ,J7507,HCPCS,,40513368,CDM,636,RC,16729-0043-01,NDC,both,1,EA,4.62,2.33,,,2.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1.42,,,1.42,Fee Schedule,Average Sale Price (ASP) x 6,1.39,30,,1.39,percent of total billed charges,Drugs,1.39,30,,1.39,percent of total billed charges,Drugs,1.39,30,,1.39,percent of total billed charges,Drugs,1.39,30,,1.39,percent of total billed charges,Drugs,1.39,30,,1.39,percent of total billed charges,Drugs,2.31,50,,2.31,percent of total billed charges,All Other,1.39,30,,1.39,percent of total billed charges,Drugs,1.39,30,,1.39,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.39,30,,1.39,percent of total billed charges,Drugs,1.39,30,,1.39,percent of total billed charges,Drugs,1.39,30,,1.39,percent of total billed charges,Drugs,1.39,30,,1.39,percent of total billed charges,Drugs,1.39,30,,1.39,percent of total billed charges,Drugs,1.39,30,,1.39,percent of total billed charges,Drugs,1.39,30,,1.39,percent of total billed charges,Drugs,1.39,30,,1.39,percent of total billed charges,Drugs,1.39,30,,1.39,percent of total billed charges,Drugs,1.39,30,,1.39,percent of total billed charges,Drugs,1.39,30,,1.39,percent of total billed charges,Drugs,1.39,30,,1.39,percent of total billed charges,Drugs,1.39,30,,1.39,percent of total billed charges,Drugs,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,1.57,34,,1.57,percent of total billed charges,Drugs,0.5,,,0.5,Other,Drug Cost,1.13,,,1.13,Other,225% Medicaid APG methodology,0.7,,,0.7,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.27,,,2.27,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.5,,,0.5,Other,Drug Cost,0.5,,,0.5,Other,Drug Cost,0.63,,,0.63,Other,125% Medicaid APG methodology,0.01,2.33,
MYCOPHENOLATE MOFETIL 250MGCAP  ,J7517,HCPCS,,40513459,CDM,636,RC,50268-0557-15,NDC,both,1,EA,1.47,1.85,,,1.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1.13,,,1.13,Fee Schedule,Average Sale Price (ASP) x 6,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.74,50,,0.74,percent of total billed charges,All Other,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.5,34,,0.5,percent of total billed charges,Drugs,0.36,,,0.36,Other,Drug Cost,0.81,,,0.81,Other,225% Medicaid APG methodology,0.5,,,0.5,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.8,,,1.8,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.45,,,0.45,Other,125% Medicaid APG methodology,0.01,1.85,
CYCLOSPORINE MOD 100 MG CAP     ,J7502,HCPCS,,40513566,CDM,636,RC,00074-3109-32,NDC,both,1,EA,11.59,22.34,,,22.34,Other,150% of Medicare + 9.63% HCRA Surcharge,13.58,,,13.58,Fee Schedule,Average Sale Price (ASP) x 6,3.48,30,,3.48,percent of total billed charges,Drugs,3.48,30,,3.48,percent of total billed charges,Drugs,3.48,30,,3.48,percent of total billed charges,Drugs,3.48,30,,3.48,percent of total billed charges,Drugs,3.48,30,,3.48,percent of total billed charges,Drugs,5.8,50,,5.8,percent of total billed charges,All Other,3.48,30,,3.48,percent of total billed charges,Drugs,3.48,30,,3.48,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.48,30,,3.48,percent of total billed charges,Drugs,3.48,30,,3.48,percent of total billed charges,Drugs,3.48,30,,3.48,percent of total billed charges,Drugs,3.48,30,,3.48,percent of total billed charges,Drugs,3.48,30,,3.48,percent of total billed charges,Drugs,3.48,30,,3.48,percent of total billed charges,Drugs,3.48,30,,3.48,percent of total billed charges,Drugs,3.48,30,,3.48,percent of total billed charges,Drugs,3.48,30,,3.48,percent of total billed charges,Drugs,3.48,30,,3.48,percent of total billed charges,Drugs,3.48,30,,3.48,percent of total billed charges,Drugs,3.48,30,,3.48,percent of total billed charges,Drugs,3.48,30,,3.48,percent of total billed charges,Drugs,2.51,,,2.51,Other,Drug Cost,2.51,,,2.51,Other,Drug Cost,2.51,,,2.51,Other,Drug Cost,2.51,,,2.51,Other,Drug Cost,2.51,,,2.51,Other,Drug Cost,3.94,34,,3.94,percent of total billed charges,Drugs,2.51,,,2.51,Other,Drug Cost,5.65,,,5.65,Other,225% Medicaid APG methodology,3.51,,,3.51,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,21.73,,,21.73,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.51,,,2.51,Other,Drug Cost,2.51,,,2.51,Other,Drug Cost,3.14,,,3.14,Other,125% Medicaid APG methodology,0.01,22.34,
CYCLOSPORINE MOD 25 MG CAP      ,J7515,HCPCS,,40513574,CDM,636,RC,23155-0837-30,NDC,both,1,EA,2.21,8.26,,,8.26,Other,150% of Medicare + 9.63% HCRA Surcharge,5.02,,,5.02,Fee Schedule,Average Sale Price (ASP) x 6,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,1.11,50,,1.11,percent of total billed charges,All Other,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.75,34,,0.75,percent of total billed charges,Drugs,0.46,,,0.46,Other,Drug Cost,1.04,,,1.04,Other,225% Medicaid APG methodology,0.64,,,0.64,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,8.04,,,8.04,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.58,,,0.58,Other,125% Medicaid APG methodology,0.01,8.26,
CYCLOSPORINE 100MG/ML ORL 50ML  ,J7502,HCPCS,,40513582,CDM,636,RC,00172-7313-20,NDC,both,50,ML,531.27,22.34,,,22.34,Other,150% of Medicare + 9.63% HCRA Surcharge,13.58,,,13.58,Fee Schedule,Average Sale Price (ASP) x 6,159.38,30,,159.38,percent of total billed charges,Drugs,159.38,30,,159.38,percent of total billed charges,Drugs,159.38,30,,159.38,percent of total billed charges,Drugs,159.38,30,,159.38,percent of total billed charges,Drugs,159.38,30,,159.38,percent of total billed charges,Drugs,265.64,50,,265.64,percent of total billed charges,All Other,159.38,30,,159.38,percent of total billed charges,Drugs,159.38,30,,159.38,percent of total billed charges,Drugs,180.63,34,"If Charge > 500, then 34 percent",180.63,percent of total billed charges,Drugs,159.38,30,,159.38,percent of total billed charges,Drugs,159.38,30,,159.38,percent of total billed charges,Drugs,159.38,30,,159.38,percent of total billed charges,Drugs,159.38,30,,159.38,percent of total billed charges,Drugs,159.38,30,,159.38,percent of total billed charges,Drugs,159.38,30,,159.38,percent of total billed charges,Drugs,159.38,30,,159.38,percent of total billed charges,Drugs,159.38,30,,159.38,percent of total billed charges,Drugs,159.38,30,,159.38,percent of total billed charges,Drugs,159.38,30,,159.38,percent of total billed charges,Drugs,159.38,30,,159.38,percent of total billed charges,Drugs,159.38,30,,159.38,percent of total billed charges,Drugs,159.38,30,,159.38,percent of total billed charges,Drugs,10.73,,,10.73,Other,Drug Cost,10.73,,,10.73,Other,Drug Cost,10.73,,,10.73,Other,Drug Cost,10.73,,,10.73,Other,Drug Cost,10.73,,,10.73,Other,Drug Cost,180.63,34,,180.63,percent of total billed charges,Drugs,10.73,,,10.73,Other,Drug Cost,24.14,,,24.14,Other,225% Medicaid APG methodology,15.02,,,15.02,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,21.73,,,21.73,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",10.73,,,10.73,Other,Drug Cost,10.73,,,10.73,Other,Drug Cost,13.41,,,13.41,Other,125% Medicaid APG methodology,0.01,265.64,
ATROPINE 0.4MG/ML INJ SOLN 1ML  ,J0461,HCPCS,,40514572,CDM,636,RC,00517-0401-25,NDC,both,1,ML,14.53,0.75,,,0.75,Other,150% of Medicare + 9.63% HCRA Surcharge,0.46,,,0.46,Fee Schedule,Average Sale Price (ASP) x 6,4.36,30,,4.36,percent of total billed charges,Drugs,4.36,30,,4.36,percent of total billed charges,Drugs,4.36,30,,4.36,percent of total billed charges,Drugs,4.36,30,,4.36,percent of total billed charges,Drugs,4.36,30,,4.36,percent of total billed charges,Drugs,7.27,50,,7.27,percent of total billed charges,All Other,4.36,30,,4.36,percent of total billed charges,Drugs,4.36,30,,4.36,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.36,30,,4.36,percent of total billed charges,Drugs,4.36,30,,4.36,percent of total billed charges,Drugs,4.36,30,,4.36,percent of total billed charges,Drugs,4.36,30,,4.36,percent of total billed charges,Drugs,4.36,30,,4.36,percent of total billed charges,Drugs,4.36,30,,4.36,percent of total billed charges,Drugs,4.36,30,,4.36,percent of total billed charges,Drugs,4.36,30,,4.36,percent of total billed charges,Drugs,4.36,30,,4.36,percent of total billed charges,Drugs,4.36,30,,4.36,percent of total billed charges,Drugs,4.36,30,,4.36,percent of total billed charges,Drugs,4.36,30,,4.36,percent of total billed charges,Drugs,4.36,30,,4.36,percent of total billed charges,Drugs,2.58,,,2.58,Other,Drug Cost,2.58,,,2.58,Other,Drug Cost,2.58,,,2.58,Other,Drug Cost,2.58,,,2.58,Other,Drug Cost,2.58,,,2.58,Other,Drug Cost,4.94,34,,4.94,percent of total billed charges,Drugs,2.58,,,2.58,Other,Drug Cost,5.81,,,5.81,Other,225% Medicaid APG methodology,3.61,,,3.61,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.73,,,0.73,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.58,,,2.58,Other,Drug Cost,2.58,,,2.58,Other,Drug Cost,3.23,,,3.23,Other,125% Medicaid APG methodology,0.01,7.27,
PIP-TAZO 3.375 G/50ML           ,J2543,HCPCS,,40514614,CDM,636,RC,00781-3113-95,NDC,both,1,EA,11.13,11.61,,,11.61,Other,150% of Medicare + 9.63% HCRA Surcharge,7.06,,,7.06,Fee Schedule,Average Sale Price (ASP) x 6,3.34,30,,3.34,percent of total billed charges,Drugs,3.34,30,,3.34,percent of total billed charges,Drugs,3.34,30,,3.34,percent of total billed charges,Drugs,3.34,30,,3.34,percent of total billed charges,Drugs,3.34,30,,3.34,percent of total billed charges,Drugs,5.57,50,,5.57,percent of total billed charges,All Other,3.34,30,,3.34,percent of total billed charges,Drugs,3.34,30,,3.34,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.34,30,,3.34,percent of total billed charges,Drugs,3.34,30,,3.34,percent of total billed charges,Drugs,3.34,30,,3.34,percent of total billed charges,Drugs,3.34,30,,3.34,percent of total billed charges,Drugs,3.34,30,,3.34,percent of total billed charges,Drugs,3.34,30,,3.34,percent of total billed charges,Drugs,3.34,30,,3.34,percent of total billed charges,Drugs,3.34,30,,3.34,percent of total billed charges,Drugs,3.34,30,,3.34,percent of total billed charges,Drugs,3.34,30,,3.34,percent of total billed charges,Drugs,3.34,30,,3.34,percent of total billed charges,Drugs,3.34,30,,3.34,percent of total billed charges,Drugs,3.34,30,,3.34,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,3.78,34,,3.78,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,11.3,,,11.3,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,11.61,
CEFTRIAXONE 2000 MG INJ         ,J0696,HCPCS,,40514622,CDM,636,RC,00409-7335-03,NDC,both,1,EA,7.88,4.84,,,4.84,Other,150% of Medicare + 9.63% HCRA Surcharge,2.95,,,2.95,Fee Schedule,Average Sale Price (ASP) x 6,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,3.94,50,,3.94,percent of total billed charges,All Other,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,2.36,30,,2.36,percent of total billed charges,Drugs,1.75,,,1.75,Other,Drug Cost,1.75,,,1.75,Other,Drug Cost,1.75,,,1.75,Other,Drug Cost,1.75,,,1.75,Other,Drug Cost,1.75,,,1.75,Other,Drug Cost,2.68,34,,2.68,percent of total billed charges,Drugs,1.75,,,1.75,Other,Drug Cost,3.94,,,3.94,Other,225% Medicaid APG methodology,2.45,,,2.45,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,4.71,,,4.71,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.75,,,1.75,Other,Drug Cost,1.75,,,1.75,Other,Drug Cost,2.19,,,2.19,Other,125% Medicaid APG methodology,0.01,4.84,
LEUCOVORIN 350 MG INJ           ,J0640,HCPCS,,40514671,CDM,636,RC,25021-0816-30,NDC,both,1,EA,41.48,44.1,,,44.1,Other,150% of Medicare + 9.63% HCRA Surcharge,26.82,,,26.82,Fee Schedule,Average Sale Price (ASP) x 6,12.44,30,,12.44,percent of total billed charges,Drugs,12.44,30,,12.44,percent of total billed charges,Drugs,12.44,30,,12.44,percent of total billed charges,Drugs,12.44,30,,12.44,percent of total billed charges,Drugs,12.44,30,,12.44,percent of total billed charges,Drugs,20.74,50,,20.74,percent of total billed charges,All Other,12.44,30,,12.44,percent of total billed charges,Drugs,12.44,30,,12.44,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,12.44,30,,12.44,percent of total billed charges,Drugs,12.44,30,,12.44,percent of total billed charges,Drugs,12.44,30,,12.44,percent of total billed charges,Drugs,12.44,30,,12.44,percent of total billed charges,Drugs,12.44,30,,12.44,percent of total billed charges,Drugs,12.44,30,,12.44,percent of total billed charges,Drugs,12.44,30,,12.44,percent of total billed charges,Drugs,12.44,30,,12.44,percent of total billed charges,Drugs,12.44,30,,12.44,percent of total billed charges,Drugs,12.44,30,,12.44,percent of total billed charges,Drugs,12.44,30,,12.44,percent of total billed charges,Drugs,12.44,30,,12.44,percent of total billed charges,Drugs,12.44,30,,12.44,percent of total billed charges,Drugs,21.99,,,21.99,Other,Drug Cost,21.99,,,21.99,Other,Drug Cost,21.99,,,21.99,Other,Drug Cost,21.99,,,21.99,Other,Drug Cost,21.99,,,21.99,Other,Drug Cost,14.1,34,,14.1,percent of total billed charges,Drugs,21.99,,,21.99,Other,Drug Cost,49.48,,,49.48,Other,225% Medicaid APG methodology,30.79,,,30.79,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,42.91,,,42.91,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",21.99,,,21.99,Other,Drug Cost,21.99,,,21.99,Other,Drug Cost,27.49,,,27.49,Other,125% Medicaid APG methodology,0.01,49.48,
FAMOTIDINE 20MG IN IV SLN 50ML  ,J3490,HCPCS,,40514754,CDM,636,RC,00338-5197-41,NDC,both,50,ML,14,5.53,39.4668,,5.53,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,7,50,,7,percent of total billed charges,All Other,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,4.76,34,,4.76,percent of total billed charges,Drugs,2,,,2,Other,Drug Cost,4.5,,,4.5,Other,225% Medicaid APG methodology,2.8,,,2.8,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,2.5,,,2.5,Other,125% Medicaid APG methodology,0.01,7,
CEFAZOLIN 500 MG INJ            ,J0690,HCPCS,,40514838,CDM,636,RC,00143-9923-90,NDC,both,1,EA,4.06,7.53,,,7.53,Other,150% of Medicare + 9.63% HCRA Surcharge,4.58,,,4.58,Fee Schedule,Average Sale Price (ASP) x 6,1.22,30,,1.22,percent of total billed charges,Drugs,1.22,30,,1.22,percent of total billed charges,Drugs,1.22,30,,1.22,percent of total billed charges,Drugs,1.22,30,,1.22,percent of total billed charges,Drugs,1.22,30,,1.22,percent of total billed charges,Drugs,2.03,50,,2.03,percent of total billed charges,All Other,1.22,30,,1.22,percent of total billed charges,Drugs,1.22,30,,1.22,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.22,30,,1.22,percent of total billed charges,Drugs,1.22,30,,1.22,percent of total billed charges,Drugs,1.22,30,,1.22,percent of total billed charges,Drugs,1.22,30,,1.22,percent of total billed charges,Drugs,1.22,30,,1.22,percent of total billed charges,Drugs,1.22,30,,1.22,percent of total billed charges,Drugs,1.22,30,,1.22,percent of total billed charges,Drugs,1.22,30,,1.22,percent of total billed charges,Drugs,1.22,30,,1.22,percent of total billed charges,Drugs,1.22,30,,1.22,percent of total billed charges,Drugs,1.22,30,,1.22,percent of total billed charges,Drugs,1.22,30,,1.22,percent of total billed charges,Drugs,1.22,30,,1.22,percent of total billed charges,Drugs,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,1.38,34,,1.38,percent of total billed charges,Drugs,0.84,,,0.84,Other,Drug Cost,1.89,,,1.89,Other,225% Medicaid APG methodology,1.18,,,1.18,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.32,,,7.32,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,1.05,,,1.05,Other,125% Medicaid APG methodology,0.01,7.53,
CEFAZOLIN 1000 MG INJ           ,J0690,HCPCS,,40514846,CDM,636,RC,00143-9924-90,NDC,both,1,EA,2.31,7.53,,,7.53,Other,150% of Medicare + 9.63% HCRA Surcharge,4.58,,,4.58,Fee Schedule,Average Sale Price (ASP) x 6,0.69,30,,0.69,percent of total billed charges,Drugs,0.69,30,,0.69,percent of total billed charges,Drugs,0.69,30,,0.69,percent of total billed charges,Drugs,0.69,30,,0.69,percent of total billed charges,Drugs,0.69,30,,0.69,percent of total billed charges,Drugs,1.16,50,,1.16,percent of total billed charges,All Other,0.69,30,,0.69,percent of total billed charges,Drugs,0.69,30,,0.69,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.69,30,,0.69,percent of total billed charges,Drugs,0.69,30,,0.69,percent of total billed charges,Drugs,0.69,30,,0.69,percent of total billed charges,Drugs,0.69,30,,0.69,percent of total billed charges,Drugs,0.69,30,,0.69,percent of total billed charges,Drugs,0.69,30,,0.69,percent of total billed charges,Drugs,0.69,30,,0.69,percent of total billed charges,Drugs,0.69,30,,0.69,percent of total billed charges,Drugs,0.69,30,,0.69,percent of total billed charges,Drugs,0.69,30,,0.69,percent of total billed charges,Drugs,0.69,30,,0.69,percent of total billed charges,Drugs,0.69,30,,0.69,percent of total billed charges,Drugs,0.69,30,,0.69,percent of total billed charges,Drugs,0.59,,,0.59,Other,Drug Cost,0.59,,,0.59,Other,Drug Cost,0.59,,,0.59,Other,Drug Cost,0.59,,,0.59,Other,Drug Cost,0.59,,,0.59,Other,Drug Cost,0.79,34,,0.79,percent of total billed charges,Drugs,0.59,,,0.59,Other,Drug Cost,1.33,,,1.33,Other,225% Medicaid APG methodology,0.83,,,0.83,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.32,,,7.32,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.59,,,0.59,Other,Drug Cost,0.59,,,0.59,Other,Drug Cost,0.74,,,0.74,Other,125% Medicaid APG methodology,0.01,7.53,
"HEP B VACC, 10MCG IM,           ",90746,CPT,,40514879,CDM,636,RC,00006-4094-02,NDC,both,1,ML,195.3,694.38,,,694.38,Other,150% of Medicare + 9.63% HCRA Surcharge,422.26,,,422.26,Fee Schedule,Average Sale Price (ASP) x 6,58.59,30,,58.59,percent of total billed charges,Drugs,58.59,30,,58.59,percent of total billed charges,Drugs,58.59,30,,58.59,percent of total billed charges,Drugs,58.59,30,,58.59,percent of total billed charges,Drugs,58.59,30,,58.59,percent of total billed charges,Drugs,97.65,50,,97.65,percent of total billed charges,All Other,58.59,30,,58.59,percent of total billed charges,Drugs,58.59,30,,58.59,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,58.59,30,,58.59,percent of total billed charges,Drugs,58.59,30,,58.59,percent of total billed charges,Drugs,58.59,30,,58.59,percent of total billed charges,Drugs,58.59,30,,58.59,percent of total billed charges,Drugs,58.59,30,,58.59,percent of total billed charges,Drugs,58.59,30,,58.59,percent of total billed charges,Drugs,58.59,30,,58.59,percent of total billed charges,Drugs,58.59,30,,58.59,percent of total billed charges,Drugs,58.59,30,,58.59,percent of total billed charges,Drugs,58.59,30,,58.59,percent of total billed charges,Drugs,58.59,30,,58.59,percent of total billed charges,Drugs,58.59,30,,58.59,percent of total billed charges,Drugs,58.59,30,,58.59,percent of total billed charges,Drugs,39.71,,,39.71,Other,Drug Cost,39.71,,,39.71,Other,Drug Cost,39.71,,,39.71,Other,Drug Cost,39.71,,,39.71,Other,Drug Cost,39.71,,,39.71,Other,Drug Cost,66.4,34,,66.4,percent of total billed charges,Drugs,39.71,,,39.71,Other,Drug Cost,89.35,,,89.35,Other,225% Medicaid APG methodology,55.59,,,55.59,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,675.61,,,675.61,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",39.71,,,39.71,Other,Drug Cost,39.71,,,39.71,Other,Drug Cost,49.64,,,49.64,Other,125% Medicaid APG methodology,0.01,694.38,
MILRINONE 20MG/D5W 100ML        ,J2260,HCPCS,,40514903,CDM,636,RC,25021-0313-82,NDC,both,100,ML,271.6,15.41,,,15.41,Other,150% of Medicare + 9.63% HCRA Surcharge,9.37,,,9.37,Fee Schedule,Average Sale Price (ASP) x 6,81.48,30,,81.48,percent of total billed charges,Drugs,81.48,30,,81.48,percent of total billed charges,Drugs,81.48,30,,81.48,percent of total billed charges,Drugs,81.48,30,,81.48,percent of total billed charges,Drugs,81.48,30,,81.48,percent of total billed charges,Drugs,135.8,50,,135.8,percent of total billed charges,All Other,81.48,30,,81.48,percent of total billed charges,Drugs,81.48,30,,81.48,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,81.48,30,,81.48,percent of total billed charges,Drugs,81.48,30,,81.48,percent of total billed charges,Drugs,81.48,30,,81.48,percent of total billed charges,Drugs,81.48,30,,81.48,percent of total billed charges,Drugs,81.48,30,,81.48,percent of total billed charges,Drugs,81.48,30,,81.48,percent of total billed charges,Drugs,81.48,30,,81.48,percent of total billed charges,Drugs,81.48,30,,81.48,percent of total billed charges,Drugs,81.48,30,,81.48,percent of total billed charges,Drugs,81.48,30,,81.48,percent of total billed charges,Drugs,81.48,30,,81.48,percent of total billed charges,Drugs,81.48,30,,81.48,percent of total billed charges,Drugs,81.48,30,,81.48,percent of total billed charges,Drugs,69.67,,,69.67,Other,Drug Cost,69.67,,,69.67,Other,Drug Cost,69.67,,,69.67,Other,Drug Cost,69.67,,,69.67,Other,Drug Cost,69.67,,,69.67,Other,Drug Cost,92.34,34,,92.34,percent of total billed charges,Drugs,69.67,,,69.67,Other,Drug Cost,156.76,,,156.76,Other,225% Medicaid APG methodology,97.54,,,97.54,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,15,,,15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",69.67,,,69.67,Other,Drug Cost,69.67,,,69.67,Other,Drug Cost,87.09,,,87.09,Other,125% Medicaid APG methodology,0.01,156.76,
IBUTILIDE 0.1MG/ML IV SLN 10ML  ,J1742,HCPCS,,40515074,CDM,636,RC,00009-3794-01,NDC,both,10,ML,265.3,104.71,39.4668,,104.71,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,79.59,30,,79.59,percent of total billed charges,Drugs,79.59,30,,79.59,percent of total billed charges,Drugs,79.59,30,,79.59,percent of total billed charges,Drugs,79.59,30,,79.59,percent of total billed charges,Drugs,79.59,30,,79.59,percent of total billed charges,Drugs,132.65,50,,132.65,percent of total billed charges,All Other,79.59,30,,79.59,percent of total billed charges,Drugs,79.59,30,,79.59,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,79.59,30,,79.59,percent of total billed charges,Drugs,79.59,30,,79.59,percent of total billed charges,Drugs,79.59,30,,79.59,percent of total billed charges,Drugs,79.59,30,,79.59,percent of total billed charges,Drugs,79.59,30,,79.59,percent of total billed charges,Drugs,79.59,30,,79.59,percent of total billed charges,Drugs,79.59,30,,79.59,percent of total billed charges,Drugs,79.59,30,,79.59,percent of total billed charges,Drugs,79.59,30,,79.59,percent of total billed charges,Drugs,79.59,30,,79.59,percent of total billed charges,Drugs,79.59,30,,79.59,percent of total billed charges,Drugs,79.59,30,,79.59,percent of total billed charges,Drugs,79.59,30,,79.59,percent of total billed charges,Drugs,45.03,,,45.03,Other,Drug Cost,45.03,,,45.03,Other,Drug Cost,45.03,,,45.03,Other,Drug Cost,45.03,,,45.03,Other,Drug Cost,45.03,,,45.03,Other,Drug Cost,90.2,34,,90.2,percent of total billed charges,Drugs,45.03,,,45.03,Other,Drug Cost,101.32,,,101.32,Other,225% Medicaid APG methodology,63.04,,,63.04,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",45.03,,,45.03,Other,Drug Cost,45.03,,,45.03,Other,Drug Cost,56.29,,,56.29,Other,125% Medicaid APG methodology,0.01,132.65,
LORAZEPAM 2MG/ML INJ SOLN 10ML  ,J2060,HCPCS,,40515132,CDM,636,RC,00641-6050-10,NDC,both,10,ML,31.82,11.07,,,11.07,Other,150% of Medicare + 9.63% HCRA Surcharge,6.73,,,6.73,Fee Schedule,Average Sale Price (ASP) x 6,9.55,30,,9.55,percent of total billed charges,Drugs,9.55,30,,9.55,percent of total billed charges,Drugs,9.55,30,,9.55,percent of total billed charges,Drugs,9.55,30,,9.55,percent of total billed charges,Drugs,9.55,30,,9.55,percent of total billed charges,Drugs,15.91,50,,15.91,percent of total billed charges,All Other,9.55,30,,9.55,percent of total billed charges,Drugs,9.55,30,,9.55,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,9.55,30,,9.55,percent of total billed charges,Drugs,9.55,30,,9.55,percent of total billed charges,Drugs,9.55,30,,9.55,percent of total billed charges,Drugs,9.55,30,,9.55,percent of total billed charges,Drugs,9.55,30,,9.55,percent of total billed charges,Drugs,9.55,30,,9.55,percent of total billed charges,Drugs,9.55,30,,9.55,percent of total billed charges,Drugs,9.55,30,,9.55,percent of total billed charges,Drugs,9.55,30,,9.55,percent of total billed charges,Drugs,9.55,30,,9.55,percent of total billed charges,Drugs,9.55,30,,9.55,percent of total billed charges,Drugs,9.55,30,,9.55,percent of total billed charges,Drugs,9.55,30,,9.55,percent of total billed charges,Drugs,9.09,,,9.09,Other,Drug Cost,9.09,,,9.09,Other,Drug Cost,9.09,,,9.09,Other,Drug Cost,9.09,,,9.09,Other,Drug Cost,9.09,,,9.09,Other,Drug Cost,10.82,34,,10.82,percent of total billed charges,Drugs,9.09,,,9.09,Other,Drug Cost,20.45,,,20.45,Other,225% Medicaid APG methodology,12.73,,,12.73,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,10.77,,,10.77,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",9.09,,,9.09,Other,Drug Cost,9.09,,,9.09,Other,Drug Cost,11.36,,,11.36,Other,125% Medicaid APG methodology,0.01,20.45,
CHLOROTHIAZIDE 500 MG IV INJ    ,J1205,HCPCS,,40515140,CDM,636,RC,63323-0658-20,NDC,both,1,EA,138.29,1197.28,,,1197.28,Other,150% of Medicare + 9.63% HCRA Surcharge,728.08,,,728.08,Fee Schedule,Average Sale Price (ASP) x 6,41.49,30,,41.49,percent of total billed charges,Drugs,41.49,30,,41.49,percent of total billed charges,Drugs,41.49,30,,41.49,percent of total billed charges,Drugs,41.49,30,,41.49,percent of total billed charges,Drugs,41.49,30,,41.49,percent of total billed charges,Drugs,69.15,50,,69.15,percent of total billed charges,All Other,41.49,30,,41.49,percent of total billed charges,Drugs,41.49,30,,41.49,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,41.49,30,,41.49,percent of total billed charges,Drugs,41.49,30,,41.49,percent of total billed charges,Drugs,41.49,30,,41.49,percent of total billed charges,Drugs,41.49,30,,41.49,percent of total billed charges,Drugs,41.49,30,,41.49,percent of total billed charges,Drugs,41.49,30,,41.49,percent of total billed charges,Drugs,41.49,30,,41.49,percent of total billed charges,Drugs,41.49,30,,41.49,percent of total billed charges,Drugs,41.49,30,,41.49,percent of total billed charges,Drugs,41.49,30,,41.49,percent of total billed charges,Drugs,41.49,30,,41.49,percent of total billed charges,Drugs,41.49,30,,41.49,percent of total billed charges,Drugs,41.49,30,,41.49,percent of total billed charges,Drugs,60.67,,,60.67,Other,Drug Cost,60.67,,,60.67,Other,Drug Cost,60.67,,,60.67,Other,Drug Cost,60.67,,,60.67,Other,Drug Cost,60.67,,,60.67,Other,Drug Cost,47.02,34,,47.02,percent of total billed charges,Drugs,60.67,,,60.67,Other,Drug Cost,136.51,,,136.51,Other,225% Medicaid APG methodology,84.94,,,84.94,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1164.92,,,1164.92,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",60.67,,,60.67,Other,Drug Cost,60.67,,,60.67,Other,Drug Cost,75.84,,,75.84,Other,125% Medicaid APG methodology,0.01,1197.28,
LEVOFLOXACIN 250MG IN IV  50ML  ,J1956,HCPCS,,40515181,CDM,636,RC,25021-0132-81,NDC,both,50,ML,7.81,8.96,,,8.96,Other,150% of Medicare + 9.63% HCRA Surcharge,5.45,,,5.45,Fee Schedule,Average Sale Price (ASP) x 6,2.34,30,,2.34,percent of total billed charges,Drugs,2.34,30,,2.34,percent of total billed charges,Drugs,2.34,30,,2.34,percent of total billed charges,Drugs,2.34,30,,2.34,percent of total billed charges,Drugs,2.34,30,,2.34,percent of total billed charges,Drugs,3.91,50,,3.91,percent of total billed charges,All Other,2.34,30,,2.34,percent of total billed charges,Drugs,2.34,30,,2.34,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.34,30,,2.34,percent of total billed charges,Drugs,2.34,30,,2.34,percent of total billed charges,Drugs,2.34,30,,2.34,percent of total billed charges,Drugs,2.34,30,,2.34,percent of total billed charges,Drugs,2.34,30,,2.34,percent of total billed charges,Drugs,2.34,30,,2.34,percent of total billed charges,Drugs,2.34,30,,2.34,percent of total billed charges,Drugs,2.34,30,,2.34,percent of total billed charges,Drugs,2.34,30,,2.34,percent of total billed charges,Drugs,2.34,30,,2.34,percent of total billed charges,Drugs,2.34,30,,2.34,percent of total billed charges,Drugs,2.34,30,,2.34,percent of total billed charges,Drugs,2.34,30,,2.34,percent of total billed charges,Drugs,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,2.66,34,,2.66,percent of total billed charges,Drugs,0.46,,,0.46,Other,Drug Cost,1.04,,,1.04,Other,225% Medicaid APG methodology,0.64,,,0.64,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,8.72,,,8.72,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.46,,,0.46,Other,Drug Cost,0.46,,,0.46,Other,Drug Cost,0.58,,,0.58,Other,125% Medicaid APG methodology,0.01,8.96,
LEVOFLOXACIN 500MG IN IV 100ML  ,J1956,HCPCS,,40515199,CDM,636,RC,00143-9721-24,NDC,both,100,ML,6.55,8.96,,,8.96,Other,150% of Medicare + 9.63% HCRA Surcharge,5.45,,,5.45,Fee Schedule,Average Sale Price (ASP) x 6,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,3.28,50,,3.28,percent of total billed charges,All Other,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.62,,,1.62,Other,Drug Cost,1.62,,,1.62,Other,Drug Cost,1.62,,,1.62,Other,Drug Cost,1.62,,,1.62,Other,Drug Cost,1.62,,,1.62,Other,Drug Cost,2.23,34,,2.23,percent of total billed charges,Drugs,1.62,,,1.62,Other,Drug Cost,3.65,,,3.65,Other,225% Medicaid APG methodology,2.27,,,2.27,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,8.72,,,8.72,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.62,,,1.62,Other,Drug Cost,1.62,,,1.62,Other,Drug Cost,2.03,,,2.03,Other,125% Medicaid APG methodology,0.01,8.96,
PIP-TAZO 4.5 G/100ML PM         ,J2543,HCPCS,,40515215,CDM,636,RC,64679-0012-01,NDC,both,1,EA,15.12,11.61,,,11.61,Other,150% of Medicare + 9.63% HCRA Surcharge,7.06,,,7.06,Fee Schedule,Average Sale Price (ASP) x 6,4.54,30,,4.54,percent of total billed charges,Drugs,4.54,30,,4.54,percent of total billed charges,Drugs,4.54,30,,4.54,percent of total billed charges,Drugs,4.54,30,,4.54,percent of total billed charges,Drugs,4.54,30,,4.54,percent of total billed charges,Drugs,7.56,50,,7.56,percent of total billed charges,All Other,4.54,30,,4.54,percent of total billed charges,Drugs,4.54,30,,4.54,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.54,30,,4.54,percent of total billed charges,Drugs,4.54,30,,4.54,percent of total billed charges,Drugs,4.54,30,,4.54,percent of total billed charges,Drugs,4.54,30,,4.54,percent of total billed charges,Drugs,4.54,30,,4.54,percent of total billed charges,Drugs,4.54,30,,4.54,percent of total billed charges,Drugs,4.54,30,,4.54,percent of total billed charges,Drugs,4.54,30,,4.54,percent of total billed charges,Drugs,4.54,30,,4.54,percent of total billed charges,Drugs,4.54,30,,4.54,percent of total billed charges,Drugs,4.54,30,,4.54,percent of total billed charges,Drugs,4.54,30,,4.54,percent of total billed charges,Drugs,4.54,30,,4.54,percent of total billed charges,Drugs,3.33,,,3.33,Other,Drug Cost,3.33,,,3.33,Other,Drug Cost,3.33,,,3.33,Other,Drug Cost,3.33,,,3.33,Other,Drug Cost,3.33,,,3.33,Other,Drug Cost,5.14,34,,5.14,percent of total billed charges,Drugs,3.33,,,3.33,Other,Drug Cost,7.49,,,7.49,Other,225% Medicaid APG methodology,4.66,,,4.66,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,11.3,,,11.3,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.33,,,3.33,Other,Drug Cost,3.33,,,3.33,Other,Drug Cost,4.16,,,4.16,Other,125% Medicaid APG methodology,0.01,11.61,
PROPOFOL 10MG/ML IV EMUL 50ML   ,J2704,HCPCS,,40515447,CDM,636,RC,63323-0269-50,NDC,both,50,ML,18.2,1.26,,,1.26,Other,150% of Medicare + 9.63% HCRA Surcharge,0.77,,,0.77,Fee Schedule,Average Sale Price (ASP) x 6,5.46,30,,5.46,percent of total billed charges,Drugs,5.46,30,,5.46,percent of total billed charges,Drugs,5.46,30,,5.46,percent of total billed charges,Drugs,5.46,30,,5.46,percent of total billed charges,Drugs,5.46,30,,5.46,percent of total billed charges,Drugs,9.1,50,,9.1,percent of total billed charges,All Other,5.46,30,,5.46,percent of total billed charges,Drugs,5.46,30,,5.46,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,5.46,30,,5.46,percent of total billed charges,Drugs,5.46,30,,5.46,percent of total billed charges,Drugs,5.46,30,,5.46,percent of total billed charges,Drugs,5.46,30,,5.46,percent of total billed charges,Drugs,5.46,30,,5.46,percent of total billed charges,Drugs,5.46,30,,5.46,percent of total billed charges,Drugs,5.46,30,,5.46,percent of total billed charges,Drugs,5.46,30,,5.46,percent of total billed charges,Drugs,5.46,30,,5.46,percent of total billed charges,Drugs,5.46,30,,5.46,percent of total billed charges,Drugs,5.46,30,,5.46,percent of total billed charges,Drugs,5.46,30,,5.46,percent of total billed charges,Drugs,5.46,30,,5.46,percent of total billed charges,Drugs,4.03,,,4.03,Other,Drug Cost,4.03,,,4.03,Other,Drug Cost,4.03,,,4.03,Other,Drug Cost,4.03,,,4.03,Other,Drug Cost,4.03,,,4.03,Other,Drug Cost,6.19,34,,6.19,percent of total billed charges,Drugs,4.03,,,4.03,Other,Drug Cost,9.07,,,9.07,Other,225% Medicaid APG methodology,5.64,,,5.64,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.23,,,1.23,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.03,,,4.03,Other,Drug Cost,4.03,,,4.03,Other,Drug Cost,5.04,,,5.04,Other,125% Medicaid APG methodology,0.01,9.1,
PROPOFOL 10MG/ML IV 100ML       ,J2704,HCPCS,,40515454,CDM,636,RC,63323-0269-65,NDC,both,100,ML,36.4,1.26,,,1.26,Other,150% of Medicare + 9.63% HCRA Surcharge,0.77,,,0.77,Fee Schedule,Average Sale Price (ASP) x 6,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,18.2,50,,18.2,percent of total billed charges,All Other,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,10.92,30,,10.92,percent of total billed charges,Drugs,8.05,,,8.05,Other,Drug Cost,8.05,,,8.05,Other,Drug Cost,8.05,,,8.05,Other,Drug Cost,8.05,,,8.05,Other,Drug Cost,8.05,,,8.05,Other,Drug Cost,12.38,34,,12.38,percent of total billed charges,Drugs,8.05,,,8.05,Other,Drug Cost,18.11,,,18.11,Other,225% Medicaid APG methodology,11.27,,,11.27,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.23,,,1.23,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",8.05,,,8.05,Other,Drug Cost,8.05,,,8.05,Other,Drug Cost,10.06,,,10.06,Other,125% Medicaid APG methodology,0.01,18.2,
LINEZOLID 600MG IN IV  300ML    ,J2020,HCPCS,,40515488,CDM,636,RC,63323-0713-13,NDC,both,300,ML,341.18,32.54,,,32.54,Other,150% of Medicare + 9.63% HCRA Surcharge,19.79,,,19.79,Fee Schedule,Average Sale Price (ASP) x 6,102.35,30,,102.35,percent of total billed charges,Drugs,102.35,30,,102.35,percent of total billed charges,Drugs,102.35,30,,102.35,percent of total billed charges,Drugs,102.35,30,,102.35,percent of total billed charges,Drugs,102.35,30,,102.35,percent of total billed charges,Drugs,170.59,50,,170.59,percent of total billed charges,All Other,102.35,30,,102.35,percent of total billed charges,Drugs,102.35,30,,102.35,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,102.35,30,,102.35,percent of total billed charges,Drugs,102.35,30,,102.35,percent of total billed charges,Drugs,102.35,30,,102.35,percent of total billed charges,Drugs,102.35,30,,102.35,percent of total billed charges,Drugs,102.35,30,,102.35,percent of total billed charges,Drugs,102.35,30,,102.35,percent of total billed charges,Drugs,102.35,30,,102.35,percent of total billed charges,Drugs,102.35,30,,102.35,percent of total billed charges,Drugs,102.35,30,,102.35,percent of total billed charges,Drugs,102.35,30,,102.35,percent of total billed charges,Drugs,102.35,30,,102.35,percent of total billed charges,Drugs,102.35,30,,102.35,percent of total billed charges,Drugs,102.35,30,,102.35,percent of total billed charges,Drugs,63.08,,,63.08,Other,Drug Cost,63.08,,,63.08,Other,Drug Cost,63.08,,,63.08,Other,Drug Cost,63.08,,,63.08,Other,Drug Cost,63.08,,,63.08,Other,Drug Cost,116,34,,116,percent of total billed charges,Drugs,63.08,,,63.08,Other,Drug Cost,141.93,,,141.93,Other,225% Medicaid APG methodology,88.31,,,88.31,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,31.66,,,31.66,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",63.08,,,63.08,Other,Drug Cost,63.08,,,63.08,Other,Drug Cost,78.85,,,78.85,Other,125% Medicaid APG methodology,0.01,170.59,
FLUCONAZOLE 200MG IN NS 100ML   ,J1450,HCPCS,,40515587,CDM,636,RC,00338-6046-48,NDC,both,100,ML,23.49,27.6,,,27.6,Other,150% of Medicare + 9.63% HCRA Surcharge,16.78,,,16.78,Fee Schedule,Average Sale Price (ASP) x 6,7.05,30,,7.05,percent of total billed charges,Drugs,7.05,30,,7.05,percent of total billed charges,Drugs,7.05,30,,7.05,percent of total billed charges,Drugs,7.05,30,,7.05,percent of total billed charges,Drugs,7.05,30,,7.05,percent of total billed charges,Drugs,11.75,50,,11.75,percent of total billed charges,All Other,7.05,30,,7.05,percent of total billed charges,Drugs,7.05,30,,7.05,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,7.05,30,,7.05,percent of total billed charges,Drugs,7.05,30,,7.05,percent of total billed charges,Drugs,7.05,30,,7.05,percent of total billed charges,Drugs,7.05,30,,7.05,percent of total billed charges,Drugs,7.05,30,,7.05,percent of total billed charges,Drugs,7.05,30,,7.05,percent of total billed charges,Drugs,7.05,30,,7.05,percent of total billed charges,Drugs,7.05,30,,7.05,percent of total billed charges,Drugs,7.05,30,,7.05,percent of total billed charges,Drugs,7.05,30,,7.05,percent of total billed charges,Drugs,7.05,30,,7.05,percent of total billed charges,Drugs,7.05,30,,7.05,percent of total billed charges,Drugs,7.05,30,,7.05,percent of total billed charges,Drugs,5.8,,,5.8,Other,Drug Cost,5.8,,,5.8,Other,Drug Cost,5.8,,,5.8,Other,Drug Cost,5.8,,,5.8,Other,Drug Cost,5.8,,,5.8,Other,Drug Cost,7.99,34,,7.99,percent of total billed charges,Drugs,5.8,,,5.8,Other,Drug Cost,13.05,,,13.05,Other,225% Medicaid APG methodology,8.12,,,8.12,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,26.85,,,26.85,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.8,,,5.8,Other,Drug Cost,5.8,,,5.8,Other,Drug Cost,7.25,,,7.25,Other,125% Medicaid APG methodology,0.01,27.6,
FLUCONAZOLE 400MG IN NS 200ML   ,J1450,HCPCS,,40515595,CDM,636,RC,00338-6045-37,NDC,both,200,ML,26.04,27.6,,,27.6,Other,150% of Medicare + 9.63% HCRA Surcharge,16.78,,,16.78,Fee Schedule,Average Sale Price (ASP) x 6,7.81,30,,7.81,percent of total billed charges,Drugs,7.81,30,,7.81,percent of total billed charges,Drugs,7.81,30,,7.81,percent of total billed charges,Drugs,7.81,30,,7.81,percent of total billed charges,Drugs,7.81,30,,7.81,percent of total billed charges,Drugs,13.02,50,,13.02,percent of total billed charges,All Other,7.81,30,,7.81,percent of total billed charges,Drugs,7.81,30,,7.81,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,7.81,30,,7.81,percent of total billed charges,Drugs,7.81,30,,7.81,percent of total billed charges,Drugs,7.81,30,,7.81,percent of total billed charges,Drugs,7.81,30,,7.81,percent of total billed charges,Drugs,7.81,30,,7.81,percent of total billed charges,Drugs,7.81,30,,7.81,percent of total billed charges,Drugs,7.81,30,,7.81,percent of total billed charges,Drugs,7.81,30,,7.81,percent of total billed charges,Drugs,7.81,30,,7.81,percent of total billed charges,Drugs,7.81,30,,7.81,percent of total billed charges,Drugs,7.81,30,,7.81,percent of total billed charges,Drugs,7.81,30,,7.81,percent of total billed charges,Drugs,7.81,30,,7.81,percent of total billed charges,Drugs,6.15,,,6.15,Other,Drug Cost,6.15,,,6.15,Other,Drug Cost,6.15,,,6.15,Other,Drug Cost,6.15,,,6.15,Other,Drug Cost,6.15,,,6.15,Other,Drug Cost,8.85,34,,8.85,percent of total billed charges,Drugs,6.15,,,6.15,Other,Drug Cost,13.84,,,13.84,Other,225% Medicaid APG methodology,8.61,,,8.61,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,26.85,,,26.85,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6.15,,,6.15,Other,Drug Cost,6.15,,,6.15,Other,Drug Cost,7.69,,,7.69,Other,125% Medicaid APG methodology,0.01,27.6,
BORTEZOMIB 3.5 MG INJ           ,J9041,HCPCS,,40515611,CDM,636,RC,10019-0991-01,NDC,both,1,EA,234.26,19.33,,,19.33,Other,150% of Medicare + 9.63% HCRA Surcharge,11.75,,,11.75,Fee Schedule,Average Sale Price (ASP) x 6,70.28,30,,70.28,percent of total billed charges,Drugs,70.28,30,,70.28,percent of total billed charges,Drugs,70.28,30,,70.28,percent of total billed charges,Drugs,70.28,30,,70.28,percent of total billed charges,Drugs,70.28,30,,70.28,percent of total billed charges,Drugs,117.13,50,,117.13,percent of total billed charges,All Other,70.28,30,,70.28,percent of total billed charges,Drugs,70.28,30,,70.28,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,70.28,30,,70.28,percent of total billed charges,Drugs,70.28,30,,70.28,percent of total billed charges,Drugs,70.28,30,,70.28,percent of total billed charges,Drugs,70.28,30,,70.28,percent of total billed charges,Drugs,70.28,30,,70.28,percent of total billed charges,Drugs,70.28,30,,70.28,percent of total billed charges,Drugs,70.28,30,,70.28,percent of total billed charges,Drugs,70.28,30,,70.28,percent of total billed charges,Drugs,70.28,30,,70.28,percent of total billed charges,Drugs,70.28,30,,70.28,percent of total billed charges,Drugs,70.28,30,,70.28,percent of total billed charges,Drugs,70.28,30,,70.28,percent of total billed charges,Drugs,70.28,30,,70.28,percent of total billed charges,Drugs,34.22,,,34.22,Other,Drug Cost,34.22,,,34.22,Other,Drug Cost,34.22,,,34.22,Other,Drug Cost,34.22,,,34.22,Other,Drug Cost,34.22,,,34.22,Other,Drug Cost,79.65,34,,79.65,percent of total billed charges,Drugs,34.22,,,34.22,Other,Drug Cost,77,,,77,Other,225% Medicaid APG methodology,47.91,,,47.91,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,18.81,,,18.81,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",34.22,,,34.22,Other,Drug Cost,34.22,,,34.22,Other,Drug Cost,42.78,,,42.78,Other,125% Medicaid APG methodology,0.01,117.13,
DORNASE ALFA 2.5MG/2.5ML INH    ,J7639,HCPCS,,40516213,CDM,636,RC,50242-0100-40,NDC,both,2.5,ML,373.91,513.83,,,513.83,Other,150% of Medicare + 9.63% HCRA Surcharge,312.46,,,312.46,Fee Schedule,Average Sale Price (ASP) x 6,112.17,30,,112.17,percent of total billed charges,Drugs,112.17,30,,112.17,percent of total billed charges,Drugs,112.17,30,,112.17,percent of total billed charges,Drugs,112.17,30,,112.17,percent of total billed charges,Drugs,112.17,30,,112.17,percent of total billed charges,Drugs,186.96,50,,186.96,percent of total billed charges,All Other,112.17,30,,112.17,percent of total billed charges,Drugs,112.17,30,,112.17,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,112.17,30,,112.17,percent of total billed charges,Drugs,112.17,30,,112.17,percent of total billed charges,Drugs,112.17,30,,112.17,percent of total billed charges,Drugs,112.17,30,,112.17,percent of total billed charges,Drugs,112.17,30,,112.17,percent of total billed charges,Drugs,112.17,30,,112.17,percent of total billed charges,Drugs,112.17,30,,112.17,percent of total billed charges,Drugs,112.17,30,,112.17,percent of total billed charges,Drugs,112.17,30,,112.17,percent of total billed charges,Drugs,112.17,30,,112.17,percent of total billed charges,Drugs,112.17,30,,112.17,percent of total billed charges,Drugs,112.17,30,,112.17,percent of total billed charges,Drugs,112.17,30,,112.17,percent of total billed charges,Drugs,19.6,,,19.6,Other,Drug Cost,19.6,,,19.6,Other,Drug Cost,19.6,,,19.6,Other,Drug Cost,19.6,,,19.6,Other,Drug Cost,19.6,,,19.6,Other,Drug Cost,127.13,34,,127.13,percent of total billed charges,Drugs,19.6,,,19.6,Other,Drug Cost,44.1,,,44.1,Other,225% Medicaid APG methodology,27.44,,,27.44,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,499.94,,,499.94,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",19.6,,,19.6,Other,Drug Cost,19.6,,,19.6,Other,Drug Cost,24.5,,,24.5,Other,125% Medicaid APG methodology,0.01,513.83,
ACETYLCYSTEINE 20% INH SLN 4ML  ,J7608,HCPCS,,40516239,CDM,636,RC,63323-0694-04,NDC,both,4,ML,41.62,67.34,,,67.34,Other,150% of Medicare + 9.63% HCRA Surcharge,40.95,,,40.95,Fee Schedule,Average Sale Price (ASP) x 6,12.49,30,,12.49,percent of total billed charges,Drugs,12.49,30,,12.49,percent of total billed charges,Drugs,12.49,30,,12.49,percent of total billed charges,Drugs,12.49,30,,12.49,percent of total billed charges,Drugs,12.49,30,,12.49,percent of total billed charges,Drugs,20.81,50,,20.81,percent of total billed charges,All Other,12.49,30,,12.49,percent of total billed charges,Drugs,12.49,30,,12.49,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,12.49,30,,12.49,percent of total billed charges,Drugs,12.49,30,,12.49,percent of total billed charges,Drugs,12.49,30,,12.49,percent of total billed charges,Drugs,12.49,30,,12.49,percent of total billed charges,Drugs,12.49,30,,12.49,percent of total billed charges,Drugs,12.49,30,,12.49,percent of total billed charges,Drugs,12.49,30,,12.49,percent of total billed charges,Drugs,12.49,30,,12.49,percent of total billed charges,Drugs,12.49,30,,12.49,percent of total billed charges,Drugs,12.49,30,,12.49,percent of total billed charges,Drugs,12.49,30,,12.49,percent of total billed charges,Drugs,12.49,30,,12.49,percent of total billed charges,Drugs,12.49,30,,12.49,percent of total billed charges,Drugs,2.85,,,2.85,Other,Drug Cost,2.85,,,2.85,Other,Drug Cost,2.85,,,2.85,Other,Drug Cost,2.85,,,2.85,Other,Drug Cost,2.85,,,2.85,Other,Drug Cost,14.15,34,,14.15,percent of total billed charges,Drugs,2.85,,,2.85,Other,Drug Cost,6.41,,,6.41,Other,225% Medicaid APG methodology,3.99,,,3.99,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,65.52,,,65.52,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.85,,,2.85,Other,Drug Cost,2.85,,,2.85,Other,Drug Cost,3.56,,,3.56,Other,125% Medicaid APG methodology,0.01,67.34,
METHYLERGONOVINE 0.2MG INJ 1ML  ,J2210,HCPCS,,40516478,CDM,636,RC,51991-0144-17,NDC,both,1,ML,64.3,193.42,,,193.42,Other,150% of Medicare + 9.63% HCRA Surcharge,117.62,,,117.62,Fee Schedule,Average Sale Price (ASP) x 6,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,32.15,50,,32.15,percent of total billed charges,All Other,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,13.25,,,13.25,Other,Drug Cost,13.25,,,13.25,Other,Drug Cost,13.25,,,13.25,Other,Drug Cost,13.25,,,13.25,Other,Drug Cost,13.25,,,13.25,Other,Drug Cost,21.86,34,,21.86,percent of total billed charges,Drugs,13.25,,,13.25,Other,Drug Cost,29.81,,,29.81,Other,225% Medicaid APG methodology,18.55,,,18.55,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,188.19,,,188.19,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",13.25,,,13.25,Other,Drug Cost,13.25,,,13.25,Other,Drug Cost,16.56,,,16.56,Other,125% Medicaid APG methodology,0.01,193.42,
INSULIN (NPH) 100UNITS/ML 3ML   ,J1815,HCPCS,,40516569,CDM,636,RC,00002-8315-17,NDC,both,0.01,ML,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.02,50,,0.02,percent of total billed charges,All Other,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,34,,0.01,percent of total billed charges,Drugs,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.09,
CHLOROPROCAINE 2% PF INJ  20ML  ,J2401,HCPCS,,40516627,CDM,636,RC,63323-0477-27,NDC,both,20,ML,65.17,0.37,,,0.37,Other,150% of Medicare + 9.63% HCRA Surcharge,0.22,,,0.22,Fee Schedule,Average Sale Price (ASP) x 6,19.55,30,,19.55,percent of total billed charges,Drugs,19.55,30,,19.55,percent of total billed charges,Drugs,19.55,30,,19.55,percent of total billed charges,Drugs,19.55,30,,19.55,percent of total billed charges,Drugs,19.55,30,,19.55,percent of total billed charges,Drugs,32.59,50,,32.59,percent of total billed charges,All Other,19.55,30,,19.55,percent of total billed charges,Drugs,19.55,30,,19.55,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,19.55,30,,19.55,percent of total billed charges,Drugs,19.55,30,,19.55,percent of total billed charges,Drugs,19.55,30,,19.55,percent of total billed charges,Drugs,19.55,30,,19.55,percent of total billed charges,Drugs,19.55,30,,19.55,percent of total billed charges,Drugs,19.55,30,,19.55,percent of total billed charges,Drugs,19.55,30,,19.55,percent of total billed charges,Drugs,19.55,30,,19.55,percent of total billed charges,Drugs,19.55,30,,19.55,percent of total billed charges,Drugs,19.55,30,,19.55,percent of total billed charges,Drugs,19.55,30,,19.55,percent of total billed charges,Drugs,19.55,30,,19.55,percent of total billed charges,Drugs,19.55,30,,19.55,percent of total billed charges,Drugs,10.13,,,10.13,Other,Drug Cost,10.13,,,10.13,Other,Drug Cost,10.13,,,10.13,Other,Drug Cost,10.13,,,10.13,Other,Drug Cost,10.13,,,10.13,Other,Drug Cost,22.16,34,,22.16,percent of total billed charges,Drugs,10.13,,,10.13,Other,Drug Cost,22.79,,,22.79,Other,225% Medicaid APG methodology,14.18,,,14.18,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.36,,,0.36,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",10.13,,,10.13,Other,Drug Cost,10.13,,,10.13,Other,Drug Cost,12.66,,,12.66,Other,125% Medicaid APG methodology,0.01,32.59,
CHLOROPROCAINE 3% PF INJ  20ML  ,J2401,HCPCS,,40516635,CDM,636,RC,00143-9210-10,NDC,both,20,ML,64.23,0.37,,,0.37,Other,150% of Medicare + 9.63% HCRA Surcharge,0.22,,,0.22,Fee Schedule,Average Sale Price (ASP) x 6,19.27,30,,19.27,percent of total billed charges,Drugs,19.27,30,,19.27,percent of total billed charges,Drugs,19.27,30,,19.27,percent of total billed charges,Drugs,19.27,30,,19.27,percent of total billed charges,Drugs,19.27,30,,19.27,percent of total billed charges,Drugs,32.12,50,,32.12,percent of total billed charges,All Other,19.27,30,,19.27,percent of total billed charges,Drugs,19.27,30,,19.27,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,19.27,30,,19.27,percent of total billed charges,Drugs,19.27,30,,19.27,percent of total billed charges,Drugs,19.27,30,,19.27,percent of total billed charges,Drugs,19.27,30,,19.27,percent of total billed charges,Drugs,19.27,30,,19.27,percent of total billed charges,Drugs,19.27,30,,19.27,percent of total billed charges,Drugs,19.27,30,,19.27,percent of total billed charges,Drugs,19.27,30,,19.27,percent of total billed charges,Drugs,19.27,30,,19.27,percent of total billed charges,Drugs,19.27,30,,19.27,percent of total billed charges,Drugs,19.27,30,,19.27,percent of total billed charges,Drugs,19.27,30,,19.27,percent of total billed charges,Drugs,19.27,30,,19.27,percent of total billed charges,Drugs,10.5,,,10.5,Other,Drug Cost,10.5,,,10.5,Other,Drug Cost,10.5,,,10.5,Other,Drug Cost,10.5,,,10.5,Other,Drug Cost,10.5,,,10.5,Other,Drug Cost,21.84,34,,21.84,percent of total billed charges,Drugs,10.5,,,10.5,Other,Drug Cost,23.63,,,23.63,Other,225% Medicaid APG methodology,14.7,,,14.7,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.36,,,0.36,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",10.5,,,10.5,Other,Drug Cost,10.5,,,10.5,Other,Drug Cost,13.13,,,13.13,Other,125% Medicaid APG methodology,0.01,32.12,
LIDOCAINE 2%PF ABBOJECT INJ5ML  ,J2001,HCPCS,,40516676,CDM,636,RC,76329-3390-01,NDC,both,5,ML,15.47,0.27,,,0.27,Other,150% of Medicare + 9.63% HCRA Surcharge,0.16,,,0.16,Fee Schedule,Average Sale Price (ASP) x 6,4.64,30,,4.64,percent of total billed charges,Drugs,4.64,30,,4.64,percent of total billed charges,Drugs,4.64,30,,4.64,percent of total billed charges,Drugs,4.64,30,,4.64,percent of total billed charges,Drugs,4.64,30,,4.64,percent of total billed charges,Drugs,7.74,50,,7.74,percent of total billed charges,All Other,4.64,30,,4.64,percent of total billed charges,Drugs,4.64,30,,4.64,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.64,30,,4.64,percent of total billed charges,Drugs,4.64,30,,4.64,percent of total billed charges,Drugs,4.64,30,,4.64,percent of total billed charges,Drugs,4.64,30,,4.64,percent of total billed charges,Drugs,4.64,30,,4.64,percent of total billed charges,Drugs,4.64,30,,4.64,percent of total billed charges,Drugs,4.64,30,,4.64,percent of total billed charges,Drugs,4.64,30,,4.64,percent of total billed charges,Drugs,4.64,30,,4.64,percent of total billed charges,Drugs,4.64,30,,4.64,percent of total billed charges,Drugs,4.64,30,,4.64,percent of total billed charges,Drugs,4.64,30,,4.64,percent of total billed charges,Drugs,4.64,30,,4.64,percent of total billed charges,Drugs,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,5.26,34,,5.26,percent of total billed charges,Drugs,1.94,,,1.94,Other,Drug Cost,4.37,,,4.37,Other,225% Medicaid APG methodology,2.72,,,2.72,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.26,,,0.26,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.94,,,1.94,Other,Drug Cost,1.94,,,1.94,Other,Drug Cost,2.43,,,2.43,Other,125% Medicaid APG methodology,0.01,7.74,
"MEPIVACAINE HCL 2% P10 ML,      ",J0670,HCPCS,,40516775,CDM,636,RC,63323-0294-27,NDC,both,20,ML,21.91,32.46,,,32.46,Other,150% of Medicare + 9.63% HCRA Surcharge,19.74,,,19.74,Fee Schedule,Average Sale Price (ASP) x 6,6.57,30,,6.57,percent of total billed charges,Drugs,6.57,30,,6.57,percent of total billed charges,Drugs,6.57,30,,6.57,percent of total billed charges,Drugs,6.57,30,,6.57,percent of total billed charges,Drugs,6.57,30,,6.57,percent of total billed charges,Drugs,10.96,50,,10.96,percent of total billed charges,All Other,6.57,30,,6.57,percent of total billed charges,Drugs,6.57,30,,6.57,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,6.57,30,,6.57,percent of total billed charges,Drugs,6.57,30,,6.57,percent of total billed charges,Drugs,6.57,30,,6.57,percent of total billed charges,Drugs,6.57,30,,6.57,percent of total billed charges,Drugs,6.57,30,,6.57,percent of total billed charges,Drugs,6.57,30,,6.57,percent of total billed charges,Drugs,6.57,30,,6.57,percent of total billed charges,Drugs,6.57,30,,6.57,percent of total billed charges,Drugs,6.57,30,,6.57,percent of total billed charges,Drugs,6.57,30,,6.57,percent of total billed charges,Drugs,6.57,30,,6.57,percent of total billed charges,Drugs,6.57,30,,6.57,percent of total billed charges,Drugs,6.57,30,,6.57,percent of total billed charges,Drugs,2.67,,,2.67,Other,Drug Cost,2.67,,,2.67,Other,Drug Cost,2.67,,,2.67,Other,Drug Cost,2.67,,,2.67,Other,Drug Cost,2.67,,,2.67,Other,Drug Cost,7.45,34,,7.45,percent of total billed charges,Drugs,2.67,,,2.67,Other,Drug Cost,6.01,,,6.01,Other,225% Medicaid APG methodology,3.74,,,3.74,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,31.58,,,31.58,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.67,,,2.67,Other,Drug Cost,2.67,,,2.67,Other,Drug Cost,3.34,,,3.34,Other,125% Medicaid APG methodology,0.01,32.46,
ETOMIDATE 2MG/ML IV SOLN 10ML   ,J3490,HCPCS,,40517039,CDM,636,RC,65219-0445-10,NDC,both,1,ML,0.88,0.35,39.4668,,0.35,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.26,30,,0.26,percent of total billed charges,Drugs,0.26,30,,0.26,percent of total billed charges,Drugs,0.26,30,,0.26,percent of total billed charges,Drugs,0.26,30,,0.26,percent of total billed charges,Drugs,0.26,30,,0.26,percent of total billed charges,Drugs,0.44,50,,0.44,percent of total billed charges,All Other,0.26,30,,0.26,percent of total billed charges,Drugs,0.26,30,,0.26,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.26,30,,0.26,percent of total billed charges,Drugs,0.26,30,,0.26,percent of total billed charges,Drugs,0.26,30,,0.26,percent of total billed charges,Drugs,0.26,30,,0.26,percent of total billed charges,Drugs,0.26,30,,0.26,percent of total billed charges,Drugs,0.26,30,,0.26,percent of total billed charges,Drugs,0.26,30,,0.26,percent of total billed charges,Drugs,0.26,30,,0.26,percent of total billed charges,Drugs,0.26,30,,0.26,percent of total billed charges,Drugs,0.26,30,,0.26,percent of total billed charges,Drugs,0.26,30,,0.26,percent of total billed charges,Drugs,0.26,30,,0.26,percent of total billed charges,Drugs,0.26,30,,0.26,percent of total billed charges,Drugs,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.3,34,,0.3,percent of total billed charges,Drugs,0.19,,,0.19,Other,Drug Cost,0.43,,,0.43,Other,225% Medicaid APG methodology,0.27,,,0.27,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.19,,,0.19,Other,Drug Cost,0.19,,,0.19,Other,Drug Cost,0.24,,,0.24,Other,125% Medicaid APG methodology,0.01,0.44,
INSULIN GLARGNE 1000UNITS/10ML  ,J1815,HCPCS,,40517138,CDM,636,RC,00088-2220-33,NDC,both,0.01,ML,0.28,0.11,39.4668,,0.11,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.14,50,,0.14,percent of total billed charges,All Other,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.1,34,,0.1,percent of total billed charges,Drugs,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% Medicaid APG methodology,0.11,,,0.11,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.18,
PERPHENAZINE 2 MG TAB           ,Q0175,HCPCS,,40517914,CDM,636,RC,52536-0162-01,NDC,both,1,EA,1.12,0.44,39.4668,,0.44,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.34,30,,0.34,percent of total billed charges,Drugs,0.34,30,,0.34,percent of total billed charges,Drugs,0.34,30,,0.34,percent of total billed charges,Drugs,0.34,30,,0.34,percent of total billed charges,Drugs,0.34,30,,0.34,percent of total billed charges,Drugs,0.56,50,,0.56,percent of total billed charges,All Other,0.34,30,,0.34,percent of total billed charges,Drugs,0.34,30,,0.34,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.34,30,,0.34,percent of total billed charges,Drugs,0.34,30,,0.34,percent of total billed charges,Drugs,0.34,30,,0.34,percent of total billed charges,Drugs,0.34,30,,0.34,percent of total billed charges,Drugs,0.34,30,,0.34,percent of total billed charges,Drugs,0.34,30,,0.34,percent of total billed charges,Drugs,0.34,30,,0.34,percent of total billed charges,Drugs,0.34,30,,0.34,percent of total billed charges,Drugs,0.34,30,,0.34,percent of total billed charges,Drugs,0.34,30,,0.34,percent of total billed charges,Drugs,0.34,30,,0.34,percent of total billed charges,Drugs,0.34,30,,0.34,percent of total billed charges,Drugs,0.34,30,,0.34,percent of total billed charges,Drugs,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.38,34,,0.38,percent of total billed charges,Drugs,0.12,,,0.12,Other,Drug Cost,0.27,,,0.27,Other,225% Medicaid APG methodology,0.17,,,0.17,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.15,,,0.15,Other,125% Medicaid APG methodology,0.01,0.56,
PERPHENAZINE 4 MG TAB           ,Q0175,HCPCS,,40517922,CDM,636,RC,00904-6600-61,NDC,both,1,EA,3.05,1.2,39.4668,,1.2,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,1.53,50,,1.53,percent of total billed charges,All Other,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,0.92,30,,0.92,percent of total billed charges,Drugs,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,1.04,34,,1.04,percent of total billed charges,Drugs,0.51,,,0.51,Other,Drug Cost,1.15,,,1.15,Other,225% Medicaid APG methodology,0.71,,,0.71,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.64,,,0.64,Other,125% Medicaid APG methodology,0.01,1.53,
PERPHENAZINE 8 MG TAB           ,Q0175,HCPCS,,40517930,CDM,636,RC,52536-0168-01,NDC,both,1,EA,1.82,0.72,39.4668,,0.72,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.55,30,,0.55,percent of total billed charges,Drugs,0.55,30,,0.55,percent of total billed charges,Drugs,0.55,30,,0.55,percent of total billed charges,Drugs,0.55,30,,0.55,percent of total billed charges,Drugs,0.55,30,,0.55,percent of total billed charges,Drugs,0.91,50,,0.91,percent of total billed charges,All Other,0.55,30,,0.55,percent of total billed charges,Drugs,0.55,30,,0.55,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.55,30,,0.55,percent of total billed charges,Drugs,0.55,30,,0.55,percent of total billed charges,Drugs,0.55,30,,0.55,percent of total billed charges,Drugs,0.55,30,,0.55,percent of total billed charges,Drugs,0.55,30,,0.55,percent of total billed charges,Drugs,0.55,30,,0.55,percent of total billed charges,Drugs,0.55,30,,0.55,percent of total billed charges,Drugs,0.55,30,,0.55,percent of total billed charges,Drugs,0.55,30,,0.55,percent of total billed charges,Drugs,0.55,30,,0.55,percent of total billed charges,Drugs,0.55,30,,0.55,percent of total billed charges,Drugs,0.55,30,,0.55,percent of total billed charges,Drugs,0.55,30,,0.55,percent of total billed charges,Drugs,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.62,34,,0.62,percent of total billed charges,Drugs,0.14,,,0.14,Other,Drug Cost,0.32,,,0.32,Other,225% Medicaid APG methodology,0.2,,,0.2,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.18,,,0.18,Other,125% Medicaid APG methodology,0.01,0.91,
PROCHLORPERAZINE 5 MG TAB       ,Q0164,HCPCS,,40518029,CDM,636,RC,00904-7381-06,NDC,both,1,EA,3.33,1.31,39.4668,,1.31,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,1.67,50,,1.67,percent of total billed charges,All Other,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,1.13,34,,1.13,percent of total billed charges,Drugs,0.91,,,0.91,Other,Drug Cost,2.05,,,2.05,Other,225% Medicaid APG methodology,1.27,,,1.27,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.91,,,0.91,Other,Drug Cost,0.91,,,0.91,Other,Drug Cost,1.14,,,1.14,Other,125% Medicaid APG methodology,0.01,2.05,
HALOPERIDOL DEC 50MG/ML IM 1ML  ,J1631,HCPCS,,40518037,CDM,636,RC,63323-0469-01,NDC,both,1,ML,52.61,86.6,,,86.6,Other,150% of Medicare + 9.63% HCRA Surcharge,52.66,,,52.66,Fee Schedule,Average Sale Price (ASP) x 6,15.78,30,,15.78,percent of total billed charges,Drugs,15.78,30,,15.78,percent of total billed charges,Drugs,15.78,30,,15.78,percent of total billed charges,Drugs,15.78,30,,15.78,percent of total billed charges,Drugs,15.78,30,,15.78,percent of total billed charges,Drugs,26.31,50,,26.31,percent of total billed charges,All Other,15.78,30,,15.78,percent of total billed charges,Drugs,15.78,30,,15.78,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,15.78,30,,15.78,percent of total billed charges,Drugs,15.78,30,,15.78,percent of total billed charges,Drugs,15.78,30,,15.78,percent of total billed charges,Drugs,15.78,30,,15.78,percent of total billed charges,Drugs,15.78,30,,15.78,percent of total billed charges,Drugs,15.78,30,,15.78,percent of total billed charges,Drugs,15.78,30,,15.78,percent of total billed charges,Drugs,15.78,30,,15.78,percent of total billed charges,Drugs,15.78,30,,15.78,percent of total billed charges,Drugs,15.78,30,,15.78,percent of total billed charges,Drugs,15.78,30,,15.78,percent of total billed charges,Drugs,15.78,30,,15.78,percent of total billed charges,Drugs,15.78,30,,15.78,percent of total billed charges,Drugs,8.84,,,8.84,Other,Drug Cost,8.84,,,8.84,Other,Drug Cost,8.84,,,8.84,Other,Drug Cost,8.84,,,8.84,Other,Drug Cost,8.84,,,8.84,Other,Drug Cost,17.89,34,,17.89,percent of total billed charges,Drugs,8.84,,,8.84,Other,Drug Cost,19.89,,,19.89,Other,225% Medicaid APG methodology,12.38,,,12.38,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,84.26,,,84.26,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",8.84,,,8.84,Other,Drug Cost,8.84,,,8.84,Other,Drug Cost,11.05,,,11.05,Other,125% Medicaid APG methodology,0.01,86.6,
MORPHINE 2MG/ML PF CARPUJECT    ,J2270,HCPCS,,40518912,CDM,636,RC,00409-1890-11,NDC,both,1,ML,7.77,46.03,,,46.03,Other,150% of Medicare + 9.63% HCRA Surcharge,27.99,,,27.99,Fee Schedule,Average Sale Price (ASP) x 6,2.33,30,,2.33,percent of total billed charges,Drugs,2.33,30,,2.33,percent of total billed charges,Drugs,2.33,30,,2.33,percent of total billed charges,Drugs,2.33,30,,2.33,percent of total billed charges,Drugs,2.33,30,,2.33,percent of total billed charges,Drugs,3.89,50,,3.89,percent of total billed charges,All Other,2.33,30,,2.33,percent of total billed charges,Drugs,2.33,30,,2.33,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.33,30,,2.33,percent of total billed charges,Drugs,2.33,30,,2.33,percent of total billed charges,Drugs,2.33,30,,2.33,percent of total billed charges,Drugs,2.33,30,,2.33,percent of total billed charges,Drugs,2.33,30,,2.33,percent of total billed charges,Drugs,2.33,30,,2.33,percent of total billed charges,Drugs,2.33,30,,2.33,percent of total billed charges,Drugs,2.33,30,,2.33,percent of total billed charges,Drugs,2.33,30,,2.33,percent of total billed charges,Drugs,2.33,30,,2.33,percent of total billed charges,Drugs,2.33,30,,2.33,percent of total billed charges,Drugs,2.33,30,,2.33,percent of total billed charges,Drugs,2.33,30,,2.33,percent of total billed charges,Drugs,2.22,,,2.22,Other,Drug Cost,2.22,,,2.22,Other,Drug Cost,2.22,,,2.22,Other,Drug Cost,2.22,,,2.22,Other,Drug Cost,2.22,,,2.22,Other,Drug Cost,2.64,34,,2.64,percent of total billed charges,Drugs,2.22,,,2.22,Other,Drug Cost,5,,,5,Other,225% Medicaid APG methodology,3.11,,,3.11,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,44.78,,,44.78,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.22,,,2.22,Other,Drug Cost,2.22,,,2.22,Other,Drug Cost,2.78,,,2.78,Other,125% Medicaid APG methodology,0.01,46.03,
HYDROMORPHONE 2MG/ML INJ 1ML    ,J1170,HCPCS,,40518987,CDM,636,RC,63323-0853-25,NDC,both,1,ML,8.19,45.3,,,45.3,Other,150% of Medicare + 9.63% HCRA Surcharge,27.55,,,27.55,Fee Schedule,Average Sale Price (ASP) x 6,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,4.1,50,,4.1,percent of total billed charges,All Other,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,0.7,,,0.7,Other,Drug Cost,0.7,,,0.7,Other,Drug Cost,0.7,,,0.7,Other,Drug Cost,0.7,,,0.7,Other,Drug Cost,0.7,,,0.7,Other,Drug Cost,2.78,34,,2.78,percent of total billed charges,Drugs,0.7,,,0.7,Other,Drug Cost,1.58,,,1.58,Other,225% Medicaid APG methodology,0.98,,,0.98,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,44.07,,,44.07,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.7,,,0.7,Other,Drug Cost,0.7,,,0.7,Other,Drug Cost,0.88,,,0.88,Other,125% Medicaid APG methodology,0.01,45.3,
MORPHINE PCA 1MG/ML INJ  30ML   ,J2270,HCPCS,,40519035,CDM,636,RC,70092-1519-48,NDC,both,30,ML,25.94,46.03,,,46.03,Other,150% of Medicare + 9.63% HCRA Surcharge,27.99,,,27.99,Fee Schedule,Average Sale Price (ASP) x 6,7.78,30,,7.78,percent of total billed charges,Drugs,7.78,30,,7.78,percent of total billed charges,Drugs,7.78,30,,7.78,percent of total billed charges,Drugs,7.78,30,,7.78,percent of total billed charges,Drugs,7.78,30,,7.78,percent of total billed charges,Drugs,12.97,50,,12.97,percent of total billed charges,All Other,7.78,30,,7.78,percent of total billed charges,Drugs,7.78,30,,7.78,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,7.78,30,,7.78,percent of total billed charges,Drugs,7.78,30,,7.78,percent of total billed charges,Drugs,7.78,30,,7.78,percent of total billed charges,Drugs,7.78,30,,7.78,percent of total billed charges,Drugs,7.78,30,,7.78,percent of total billed charges,Drugs,7.78,30,,7.78,percent of total billed charges,Drugs,7.78,30,,7.78,percent of total billed charges,Drugs,7.78,30,,7.78,percent of total billed charges,Drugs,7.78,30,,7.78,percent of total billed charges,Drugs,7.78,30,,7.78,percent of total billed charges,Drugs,7.78,30,,7.78,percent of total billed charges,Drugs,7.78,30,,7.78,percent of total billed charges,Drugs,7.78,30,,7.78,percent of total billed charges,Drugs,6.92,,,6.92,Other,Drug Cost,6.92,,,6.92,Other,Drug Cost,6.92,,,6.92,Other,Drug Cost,6.92,,,6.92,Other,Drug Cost,6.92,,,6.92,Other,Drug Cost,8.82,34,,8.82,percent of total billed charges,Drugs,6.92,,,6.92,Other,Drug Cost,15.57,,,15.57,Other,225% Medicaid APG methodology,9.69,,,9.69,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,44.78,,,44.78,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6.92,,,6.92,Other,Drug Cost,6.92,,,6.92,Other,Drug Cost,8.65,,,8.65,Other,125% Medicaid APG methodology,0.01,46.03,
FENTANYL 50 MCG/ML INJ SLN 2ML  ,J3010,HCPCS,,40519167,CDM,636,RC,00409-9093-32,NDC,both,2,ML,4.76,9.55,,,9.55,Other,150% of Medicare + 9.63% HCRA Surcharge,5.81,,,5.81,Fee Schedule,Average Sale Price (ASP) x 6,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,2.38,50,,2.38,percent of total billed charges,All Other,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,1.62,34,,1.62,percent of total billed charges,Drugs,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,9.29,,,9.29,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,9.55,
FENTANYL 50 MCG/ML INJ SLN 5ML  ,J3010,HCPCS,,40519175,CDM,636,RC,17478-0030-05,NDC,both,5,ML,5.99,9.55,,,9.55,Other,150% of Medicare + 9.63% HCRA Surcharge,5.81,,,5.81,Fee Schedule,Average Sale Price (ASP) x 6,1.8,30,,1.8,percent of total billed charges,Drugs,1.8,30,,1.8,percent of total billed charges,Drugs,1.8,30,,1.8,percent of total billed charges,Drugs,1.8,30,,1.8,percent of total billed charges,Drugs,1.8,30,,1.8,percent of total billed charges,Drugs,3,50,,3,percent of total billed charges,All Other,1.8,30,,1.8,percent of total billed charges,Drugs,1.8,30,,1.8,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.8,30,,1.8,percent of total billed charges,Drugs,1.8,30,,1.8,percent of total billed charges,Drugs,1.8,30,,1.8,percent of total billed charges,Drugs,1.8,30,,1.8,percent of total billed charges,Drugs,1.8,30,,1.8,percent of total billed charges,Drugs,1.8,30,,1.8,percent of total billed charges,Drugs,1.8,30,,1.8,percent of total billed charges,Drugs,1.8,30,,1.8,percent of total billed charges,Drugs,1.8,30,,1.8,percent of total billed charges,Drugs,1.8,30,,1.8,percent of total billed charges,Drugs,1.8,30,,1.8,percent of total billed charges,Drugs,1.8,30,,1.8,percent of total billed charges,Drugs,1.8,30,,1.8,percent of total billed charges,Drugs,0.96,,,0.96,Other,Drug Cost,0.96,,,0.96,Other,Drug Cost,0.96,,,0.96,Other,Drug Cost,0.96,,,0.96,Other,Drug Cost,0.96,,,0.96,Other,Drug Cost,2.04,34,,2.04,percent of total billed charges,Drugs,0.96,,,0.96,Other,Drug Cost,2.16,,,2.16,Other,225% Medicaid APG methodology,1.34,,,1.34,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,9.29,,,9.29,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.96,,,0.96,Other,Drug Cost,0.96,,,0.96,Other,Drug Cost,1.2,,,1.2,Other,125% Medicaid APG methodology,0.01,9.55,
NALOXONE 0.4MG/ML INJ SOLN 1ML  ,J2310,HCPCS,,40519431,CDM,636,RC,00409-1215-01,NDC,both,1,ML,51.52,71.91,,,71.91,Other,150% of Medicare + 9.63% HCRA Surcharge,43.73,,,43.73,Fee Schedule,Average Sale Price (ASP) x 6,15.46,30,,15.46,percent of total billed charges,Drugs,15.46,30,,15.46,percent of total billed charges,Drugs,15.46,30,,15.46,percent of total billed charges,Drugs,15.46,30,,15.46,percent of total billed charges,Drugs,15.46,30,,15.46,percent of total billed charges,Drugs,25.76,50,,25.76,percent of total billed charges,All Other,15.46,30,,15.46,percent of total billed charges,Drugs,15.46,30,,15.46,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,15.46,30,,15.46,percent of total billed charges,Drugs,15.46,30,,15.46,percent of total billed charges,Drugs,15.46,30,,15.46,percent of total billed charges,Drugs,15.46,30,,15.46,percent of total billed charges,Drugs,15.46,30,,15.46,percent of total billed charges,Drugs,15.46,30,,15.46,percent of total billed charges,Drugs,15.46,30,,15.46,percent of total billed charges,Drugs,15.46,30,,15.46,percent of total billed charges,Drugs,15.46,30,,15.46,percent of total billed charges,Drugs,15.46,30,,15.46,percent of total billed charges,Drugs,15.46,30,,15.46,percent of total billed charges,Drugs,15.46,30,,15.46,percent of total billed charges,Drugs,15.46,30,,15.46,percent of total billed charges,Drugs,4.82,,,4.82,Other,Drug Cost,4.82,,,4.82,Other,Drug Cost,4.82,,,4.82,Other,Drug Cost,4.82,,,4.82,Other,Drug Cost,4.82,,,4.82,Other,Drug Cost,17.52,34,,17.52,percent of total billed charges,Drugs,4.82,,,4.82,Other,Drug Cost,10.85,,,10.85,Other,225% Medicaid APG methodology,6.75,,,6.75,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,69.96,,,69.96,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.82,,,4.82,Other,Drug Cost,4.82,,,4.82,Other,Drug Cost,6.03,,,6.03,Other,125% Medicaid APG methodology,0.01,71.91,
BENZTROPINE 1MG/ML INJ SLN 2ML  ,J0515,HCPCS,,40519720,CDM,636,RC,00143-9233-05,NDC,both,2,ML,157.47,162.16,,,162.16,Other,150% of Medicare + 9.63% HCRA Surcharge,98.61,,,98.61,Fee Schedule,Average Sale Price (ASP) x 6,47.24,30,,47.24,percent of total billed charges,Drugs,47.24,30,,47.24,percent of total billed charges,Drugs,47.24,30,,47.24,percent of total billed charges,Drugs,47.24,30,,47.24,percent of total billed charges,Drugs,47.24,30,,47.24,percent of total billed charges,Drugs,78.74,50,,78.74,percent of total billed charges,All Other,47.24,30,,47.24,percent of total billed charges,Drugs,47.24,30,,47.24,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,47.24,30,,47.24,percent of total billed charges,Drugs,47.24,30,,47.24,percent of total billed charges,Drugs,47.24,30,,47.24,percent of total billed charges,Drugs,47.24,30,,47.24,percent of total billed charges,Drugs,47.24,30,,47.24,percent of total billed charges,Drugs,47.24,30,,47.24,percent of total billed charges,Drugs,47.24,30,,47.24,percent of total billed charges,Drugs,47.24,30,,47.24,percent of total billed charges,Drugs,47.24,30,,47.24,percent of total billed charges,Drugs,47.24,30,,47.24,percent of total billed charges,Drugs,47.24,30,,47.24,percent of total billed charges,Drugs,47.24,30,,47.24,percent of total billed charges,Drugs,47.24,30,,47.24,percent of total billed charges,Drugs,18.58,,,18.58,Other,Drug Cost,18.58,,,18.58,Other,Drug Cost,18.58,,,18.58,Other,Drug Cost,18.58,,,18.58,Other,Drug Cost,18.58,,,18.58,Other,Drug Cost,53.54,34,,53.54,percent of total billed charges,Drugs,18.58,,,18.58,Other,Drug Cost,41.81,,,41.81,Other,225% Medicaid APG methodology,26.01,,,26.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,157.78,,,157.78,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",18.58,,,18.58,Other,Drug Cost,18.58,,,18.58,Other,Drug Cost,23.23,,,23.23,Other,125% Medicaid APG methodology,0.01,162.16,
NEOSTIGMINE 1MG/ML IV SLN 10ML  ,J2710,HCPCS,,40520074,CDM,636,RC,00641-6149-10,NDC,both,10,ML,14.28,5.64,39.4668,,5.64,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,7.14,50,,7.14,percent of total billed charges,All Other,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,3.18,,,3.18,Other,Drug Cost,3.18,,,3.18,Other,Drug Cost,3.18,,,3.18,Other,Drug Cost,3.18,,,3.18,Other,Drug Cost,3.18,,,3.18,Other,Drug Cost,4.86,34,,4.86,percent of total billed charges,Drugs,3.18,,,3.18,Other,Drug Cost,7.16,,,7.16,Other,225% Medicaid APG methodology,4.45,,,4.45,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.18,,,3.18,Other,Drug Cost,3.18,,,3.18,Other,Drug Cost,3.98,,,3.98,Other,125% Medicaid APG methodology,0.01,7.16,
LABETALOL 5MG/ML IV SOLN 20ML   ,J3490,HCPCS,,40520132,CDM,636,RC,25021-0317-20,NDC,both,20,ML,7.14,2.82,39.4668,,2.82,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,2.14,30,,2.14,percent of total billed charges,Drugs,2.14,30,,2.14,percent of total billed charges,Drugs,2.14,30,,2.14,percent of total billed charges,Drugs,2.14,30,,2.14,percent of total billed charges,Drugs,2.14,30,,2.14,percent of total billed charges,Drugs,3.57,50,,3.57,percent of total billed charges,All Other,2.14,30,,2.14,percent of total billed charges,Drugs,2.14,30,,2.14,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.14,30,,2.14,percent of total billed charges,Drugs,2.14,30,,2.14,percent of total billed charges,Drugs,2.14,30,,2.14,percent of total billed charges,Drugs,2.14,30,,2.14,percent of total billed charges,Drugs,2.14,30,,2.14,percent of total billed charges,Drugs,2.14,30,,2.14,percent of total billed charges,Drugs,2.14,30,,2.14,percent of total billed charges,Drugs,2.14,30,,2.14,percent of total billed charges,Drugs,2.14,30,,2.14,percent of total billed charges,Drugs,2.14,30,,2.14,percent of total billed charges,Drugs,2.14,30,,2.14,percent of total billed charges,Drugs,2.14,30,,2.14,percent of total billed charges,Drugs,2.14,30,,2.14,percent of total billed charges,Drugs,1.9,,,1.9,Other,Drug Cost,1.9,,,1.9,Other,Drug Cost,1.9,,,1.9,Other,Drug Cost,1.9,,,1.9,Other,Drug Cost,1.9,,,1.9,Other,Drug Cost,2.43,34,,2.43,percent of total billed charges,Drugs,1.9,,,1.9,Other,Drug Cost,4.28,,,4.28,Other,225% Medicaid APG methodology,2.66,,,2.66,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.9,,,1.9,Other,Drug Cost,1.9,,,1.9,Other,Drug Cost,2.38,,,2.38,Other,125% Medicaid APG methodology,0.01,4.28,
DICYCLOMINE 10MG/ML IM SLN 2ML  ,J0500,HCPCS,,40520249,CDM,636,RC,00517-1980-05,NDC,both,2,ML,59.36,246.32,,,246.32,Other,150% of Medicare + 9.63% HCRA Surcharge,149.79,,,149.79,Fee Schedule,Average Sale Price (ASP) x 6,17.81,30,,17.81,percent of total billed charges,Drugs,17.81,30,,17.81,percent of total billed charges,Drugs,17.81,30,,17.81,percent of total billed charges,Drugs,17.81,30,,17.81,percent of total billed charges,Drugs,17.81,30,,17.81,percent of total billed charges,Drugs,29.68,50,,29.68,percent of total billed charges,All Other,17.81,30,,17.81,percent of total billed charges,Drugs,17.81,30,,17.81,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,17.81,30,,17.81,percent of total billed charges,Drugs,17.81,30,,17.81,percent of total billed charges,Drugs,17.81,30,,17.81,percent of total billed charges,Drugs,17.81,30,,17.81,percent of total billed charges,Drugs,17.81,30,,17.81,percent of total billed charges,Drugs,17.81,30,,17.81,percent of total billed charges,Drugs,17.81,30,,17.81,percent of total billed charges,Drugs,17.81,30,,17.81,percent of total billed charges,Drugs,17.81,30,,17.81,percent of total billed charges,Drugs,17.81,30,,17.81,percent of total billed charges,Drugs,17.81,30,,17.81,percent of total billed charges,Drugs,17.81,30,,17.81,percent of total billed charges,Drugs,17.81,30,,17.81,percent of total billed charges,Drugs,19.54,,,19.54,Other,Drug Cost,19.54,,,19.54,Other,Drug Cost,19.54,,,19.54,Other,Drug Cost,19.54,,,19.54,Other,Drug Cost,19.54,,,19.54,Other,Drug Cost,20.18,34,,20.18,percent of total billed charges,Drugs,19.54,,,19.54,Other,Drug Cost,43.97,,,43.97,Other,225% Medicaid APG methodology,27.36,,,27.36,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,239.66,,,239.66,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",19.54,,,19.54,Other,Drug Cost,19.54,,,19.54,Other,Drug Cost,24.43,,,24.43,Other,125% Medicaid APG methodology,0.01,246.32,
EPINEPH 0.1MG/ML INJ SLN 10ML   ,J0171,HCPCS,,40520306,CDM,636,RC,00409-4933-01,NDC,both,10,ML,17.54,7.38,,,7.38,Other,150% of Medicare + 9.63% HCRA Surcharge,4.49,,,4.49,Fee Schedule,Average Sale Price (ASP) x 6,5.26,30,,5.26,percent of total billed charges,Drugs,5.26,30,,5.26,percent of total billed charges,Drugs,5.26,30,,5.26,percent of total billed charges,Drugs,5.26,30,,5.26,percent of total billed charges,Drugs,5.26,30,,5.26,percent of total billed charges,Drugs,8.77,50,,8.77,percent of total billed charges,All Other,5.26,30,,5.26,percent of total billed charges,Drugs,5.26,30,,5.26,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,5.26,30,,5.26,percent of total billed charges,Drugs,5.26,30,,5.26,percent of total billed charges,Drugs,5.26,30,,5.26,percent of total billed charges,Drugs,5.26,30,,5.26,percent of total billed charges,Drugs,5.26,30,,5.26,percent of total billed charges,Drugs,5.26,30,,5.26,percent of total billed charges,Drugs,5.26,30,,5.26,percent of total billed charges,Drugs,5.26,30,,5.26,percent of total billed charges,Drugs,5.26,30,,5.26,percent of total billed charges,Drugs,5.26,30,,5.26,percent of total billed charges,Drugs,5.26,30,,5.26,percent of total billed charges,Drugs,5.26,30,,5.26,percent of total billed charges,Drugs,5.26,30,,5.26,percent of total billed charges,Drugs,3.56,,,3.56,Other,Drug Cost,3.56,,,3.56,Other,Drug Cost,3.56,,,3.56,Other,Drug Cost,3.56,,,3.56,Other,Drug Cost,3.56,,,3.56,Other,Drug Cost,5.96,34,,5.96,percent of total billed charges,Drugs,3.56,,,3.56,Other,Drug Cost,8.01,,,8.01,Other,225% Medicaid APG methodology,4.98,,,4.98,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.18,,,7.18,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.56,,,3.56,Other,Drug Cost,3.56,,,3.56,Other,Drug Cost,4.45,,,4.45,Other,125% Medicaid APG methodology,0.01,8.77,
DOPAMINE 40MG/ML IV SOLN 10ML   ,J1265,HCPCS,,40520421,CDM,636,RC,00409-9104-20,NDC,both,10,ML,6.62,7.62,,,7.62,Other,150% of Medicare + 9.63% HCRA Surcharge,4.63,,,4.63,Fee Schedule,Average Sale Price (ASP) x 6,1.99,30,,1.99,percent of total billed charges,Drugs,1.99,30,,1.99,percent of total billed charges,Drugs,1.99,30,,1.99,percent of total billed charges,Drugs,1.99,30,,1.99,percent of total billed charges,Drugs,1.99,30,,1.99,percent of total billed charges,Drugs,3.31,50,,3.31,percent of total billed charges,All Other,1.99,30,,1.99,percent of total billed charges,Drugs,1.99,30,,1.99,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.99,30,,1.99,percent of total billed charges,Drugs,1.99,30,,1.99,percent of total billed charges,Drugs,1.99,30,,1.99,percent of total billed charges,Drugs,1.99,30,,1.99,percent of total billed charges,Drugs,1.99,30,,1.99,percent of total billed charges,Drugs,1.99,30,,1.99,percent of total billed charges,Drugs,1.99,30,,1.99,percent of total billed charges,Drugs,1.99,30,,1.99,percent of total billed charges,Drugs,1.99,30,,1.99,percent of total billed charges,Drugs,1.99,30,,1.99,percent of total billed charges,Drugs,1.99,30,,1.99,percent of total billed charges,Drugs,1.99,30,,1.99,percent of total billed charges,Drugs,1.99,30,,1.99,percent of total billed charges,Drugs,1.42,,,1.42,Other,Drug Cost,1.42,,,1.42,Other,Drug Cost,1.42,,,1.42,Other,Drug Cost,1.42,,,1.42,Other,Drug Cost,1.42,,,1.42,Other,Drug Cost,2.25,34,,2.25,percent of total billed charges,Drugs,1.42,,,1.42,Other,Drug Cost,3.2,,,3.2,Other,225% Medicaid APG methodology,1.99,,,1.99,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.41,,,7.41,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.42,,,1.42,Other,Drug Cost,1.42,,,1.42,Other,Drug Cost,1.78,,,1.78,Other,125% Medicaid APG methodology,0.01,7.62,
ONDANSETRON 2MG/ML INJ  20ML    ,J2405,HCPCS,,40520454,CDM,636,RC,72266-0124-01,NDC,both,20,ML,8.75,0.99,,,0.99,Other,150% of Medicare + 9.63% HCRA Surcharge,0.6,,,0.6,Fee Schedule,Average Sale Price (ASP) x 6,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,4.38,50,,4.38,percent of total billed charges,All Other,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,2.63,30,,2.63,percent of total billed charges,Drugs,2.24,,,2.24,Other,Drug Cost,2.24,,,2.24,Other,Drug Cost,2.24,,,2.24,Other,Drug Cost,2.24,,,2.24,Other,Drug Cost,2.24,,,2.24,Other,Drug Cost,2.98,34,,2.98,percent of total billed charges,Drugs,2.24,,,2.24,Other,Drug Cost,5.04,,,5.04,Other,225% Medicaid APG methodology,3.14,,,3.14,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.96,,,0.96,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.24,,,2.24,Other,Drug Cost,2.24,,,2.24,Other,Drug Cost,2.8,,,2.8,Other,125% Medicaid APG methodology,0.01,5.04,
ONDANSETRON 2MG/ML INJ SLN 2ML  ,J2405,HCPCS,,40520462,CDM,636,RC,00641-6078-25,NDC,both,2,ML,1.26,0.99,,,0.99,Other,150% of Medicare + 9.63% HCRA Surcharge,0.6,,,0.6,Fee Schedule,Average Sale Price (ASP) x 6,0.38,30,,0.38,percent of total billed charges,Drugs,0.38,30,,0.38,percent of total billed charges,Drugs,0.38,30,,0.38,percent of total billed charges,Drugs,0.38,30,,0.38,percent of total billed charges,Drugs,0.38,30,,0.38,percent of total billed charges,Drugs,0.63,50,,0.63,percent of total billed charges,All Other,0.38,30,,0.38,percent of total billed charges,Drugs,0.38,30,,0.38,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.38,30,,0.38,percent of total billed charges,Drugs,0.38,30,,0.38,percent of total billed charges,Drugs,0.38,30,,0.38,percent of total billed charges,Drugs,0.38,30,,0.38,percent of total billed charges,Drugs,0.38,30,,0.38,percent of total billed charges,Drugs,0.38,30,,0.38,percent of total billed charges,Drugs,0.38,30,,0.38,percent of total billed charges,Drugs,0.38,30,,0.38,percent of total billed charges,Drugs,0.38,30,,0.38,percent of total billed charges,Drugs,0.38,30,,0.38,percent of total billed charges,Drugs,0.38,30,,0.38,percent of total billed charges,Drugs,0.38,30,,0.38,percent of total billed charges,Drugs,0.38,30,,0.38,percent of total billed charges,Drugs,0.35,,,0.35,Other,Drug Cost,0.35,,,0.35,Other,Drug Cost,0.35,,,0.35,Other,Drug Cost,0.35,,,0.35,Other,Drug Cost,0.35,,,0.35,Other,Drug Cost,0.43,34,,0.43,percent of total billed charges,Drugs,0.35,,,0.35,Other,Drug Cost,0.79,,,0.79,Other,225% Medicaid APG methodology,0.49,,,0.49,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.96,,,0.96,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.35,,,0.35,Other,Drug Cost,0.35,,,0.35,Other,Drug Cost,0.44,,,0.44,Other,125% Medicaid APG methodology,0.01,0.99,
PHENYLEPHRINE 10MG/ML INJ 1ML   ,J2371,HCPCS,,40520603,CDM,636,RC,00641-6142-25,NDC,both,1,ML,10.26,4.05,39.4668,,4.05,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,3.08,30,,3.08,percent of total billed charges,Drugs,3.08,30,,3.08,percent of total billed charges,Drugs,3.08,30,,3.08,percent of total billed charges,Drugs,3.08,30,,3.08,percent of total billed charges,Drugs,3.08,30,,3.08,percent of total billed charges,Drugs,5.13,50,,5.13,percent of total billed charges,All Other,3.08,30,,3.08,percent of total billed charges,Drugs,3.08,30,,3.08,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.08,30,,3.08,percent of total billed charges,Drugs,3.08,30,,3.08,percent of total billed charges,Drugs,3.08,30,,3.08,percent of total billed charges,Drugs,3.08,30,,3.08,percent of total billed charges,Drugs,3.08,30,,3.08,percent of total billed charges,Drugs,3.08,30,,3.08,percent of total billed charges,Drugs,3.08,30,,3.08,percent of total billed charges,Drugs,3.08,30,,3.08,percent of total billed charges,Drugs,3.08,30,,3.08,percent of total billed charges,Drugs,3.08,30,,3.08,percent of total billed charges,Drugs,3.08,30,,3.08,percent of total billed charges,Drugs,3.08,30,,3.08,percent of total billed charges,Drugs,3.08,30,,3.08,percent of total billed charges,Drugs,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,3.49,34,,3.49,percent of total billed charges,Drugs,1,,,1,Other,Drug Cost,2.25,,,2.25,Other,225% Medicaid APG methodology,1.4,,,1.4,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1.25,,,1.25,Other,125% Medicaid APG methodology,0.01,5.13,
METOCLOPRAMIDE 5MG/ML INJ 2ML   ,J2765,HCPCS,,40520660,CDM,636,RC,00409-3414-01,NDC,both,2,ML,3.4,10.79,,,10.79,Other,150% of Medicare + 9.63% HCRA Surcharge,6.56,,,6.56,Fee Schedule,Average Sale Price (ASP) x 6,1.02,30,,1.02,percent of total billed charges,Drugs,1.02,30,,1.02,percent of total billed charges,Drugs,1.02,30,,1.02,percent of total billed charges,Drugs,1.02,30,,1.02,percent of total billed charges,Drugs,1.02,30,,1.02,percent of total billed charges,Drugs,1.7,50,,1.7,percent of total billed charges,All Other,1.02,30,,1.02,percent of total billed charges,Drugs,1.02,30,,1.02,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.02,30,,1.02,percent of total billed charges,Drugs,1.02,30,,1.02,percent of total billed charges,Drugs,1.02,30,,1.02,percent of total billed charges,Drugs,1.02,30,,1.02,percent of total billed charges,Drugs,1.02,30,,1.02,percent of total billed charges,Drugs,1.02,30,,1.02,percent of total billed charges,Drugs,1.02,30,,1.02,percent of total billed charges,Drugs,1.02,30,,1.02,percent of total billed charges,Drugs,1.02,30,,1.02,percent of total billed charges,Drugs,1.02,30,,1.02,percent of total billed charges,Drugs,1.02,30,,1.02,percent of total billed charges,Drugs,1.02,30,,1.02,percent of total billed charges,Drugs,1.02,30,,1.02,percent of total billed charges,Drugs,0.81,,,0.81,Other,Drug Cost,0.81,,,0.81,Other,Drug Cost,0.81,,,0.81,Other,Drug Cost,0.81,,,0.81,Other,Drug Cost,0.81,,,0.81,Other,Drug Cost,1.16,34,,1.16,percent of total billed charges,Drugs,0.81,,,0.81,Other,Drug Cost,1.82,,,1.82,Other,225% Medicaid APG methodology,1.13,,,1.13,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,10.5,,,10.5,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.81,,,0.81,Other,Drug Cost,0.81,,,0.81,Other,Drug Cost,1.01,,,1.01,Other,125% Medicaid APG methodology,0.01,10.79,
PROPRANOLOL 1MG/1ML VIAL        ,J1800,HCPCS,,40520728,CDM,636,RC,00143-9872-10,NDC,both,1,ML,6.37,2.51,39.4668,,2.51,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,1.91,30,,1.91,percent of total billed charges,Drugs,1.91,30,,1.91,percent of total billed charges,Drugs,1.91,30,,1.91,percent of total billed charges,Drugs,1.91,30,,1.91,percent of total billed charges,Drugs,1.91,30,,1.91,percent of total billed charges,Drugs,3.19,50,,3.19,percent of total billed charges,All Other,1.91,30,,1.91,percent of total billed charges,Drugs,1.91,30,,1.91,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.91,30,,1.91,percent of total billed charges,Drugs,1.91,30,,1.91,percent of total billed charges,Drugs,1.91,30,,1.91,percent of total billed charges,Drugs,1.91,30,,1.91,percent of total billed charges,Drugs,1.91,30,,1.91,percent of total billed charges,Drugs,1.91,30,,1.91,percent of total billed charges,Drugs,1.91,30,,1.91,percent of total billed charges,Drugs,1.91,30,,1.91,percent of total billed charges,Drugs,1.91,30,,1.91,percent of total billed charges,Drugs,1.91,30,,1.91,percent of total billed charges,Drugs,1.91,30,,1.91,percent of total billed charges,Drugs,1.91,30,,1.91,percent of total billed charges,Drugs,1.91,30,,1.91,percent of total billed charges,Drugs,0.78,,,0.78,Other,Drug Cost,0.78,,,0.78,Other,Drug Cost,0.78,,,0.78,Other,Drug Cost,0.78,,,0.78,Other,Drug Cost,0.78,,,0.78,Other,Drug Cost,2.17,34,,2.17,percent of total billed charges,Drugs,0.78,,,0.78,Other,Drug Cost,1.76,,,1.76,Other,225% Medicaid APG methodology,1.09,,,1.09,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.78,,,0.78,Other,Drug Cost,0.78,,,0.78,Other,Drug Cost,0.98,,,0.98,Other,125% Medicaid APG methodology,0.01,3.19,
DIHYDRORGOTAMINE 1MG/ML INJ1ML  ,J1110,HCPCS,,40521064,CDM,636,RC,81284-0411-10,NDC,both,1,ML,142.03,417.77,,,417.77,Other,150% of Medicare + 9.63% HCRA Surcharge,254.05,,,254.05,Fee Schedule,Average Sale Price (ASP) x 6,42.61,30,,42.61,percent of total billed charges,Drugs,42.61,30,,42.61,percent of total billed charges,Drugs,42.61,30,,42.61,percent of total billed charges,Drugs,42.61,30,,42.61,percent of total billed charges,Drugs,42.61,30,,42.61,percent of total billed charges,Drugs,71.02,50,,71.02,percent of total billed charges,All Other,42.61,30,,42.61,percent of total billed charges,Drugs,42.61,30,,42.61,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,42.61,30,,42.61,percent of total billed charges,Drugs,42.61,30,,42.61,percent of total billed charges,Drugs,42.61,30,,42.61,percent of total billed charges,Drugs,42.61,30,,42.61,percent of total billed charges,Drugs,42.61,30,,42.61,percent of total billed charges,Drugs,42.61,30,,42.61,percent of total billed charges,Drugs,42.61,30,,42.61,percent of total billed charges,Drugs,42.61,30,,42.61,percent of total billed charges,Drugs,42.61,30,,42.61,percent of total billed charges,Drugs,42.61,30,,42.61,percent of total billed charges,Drugs,42.61,30,,42.61,percent of total billed charges,Drugs,42.61,30,,42.61,percent of total billed charges,Drugs,42.61,30,,42.61,percent of total billed charges,Drugs,28.2,,,28.2,Other,Drug Cost,28.2,,,28.2,Other,Drug Cost,28.2,,,28.2,Other,Drug Cost,28.2,,,28.2,Other,Drug Cost,28.2,,,28.2,Other,Drug Cost,48.29,34,,48.29,percent of total billed charges,Drugs,28.2,,,28.2,Other,Drug Cost,63.45,,,63.45,Other,225% Medicaid APG methodology,39.48,,,39.48,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,406.47,,,406.47,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",28.2,,,28.2,Other,Drug Cost,28.2,,,28.2,Other,Drug Cost,35.25,,,35.25,Other,125% Medicaid APG methodology,0.01,417.77,
MILRINONE 1MG/ML PF IV  10ML    ,J2260,HCPCS,,40521106,CDM,636,RC,63323-0617-10,NDC,both,10,ML,140,15.41,,,15.41,Other,150% of Medicare + 9.63% HCRA Surcharge,9.37,,,9.37,Fee Schedule,Average Sale Price (ASP) x 6,42,30,,42,percent of total billed charges,Drugs,42,30,,42,percent of total billed charges,Drugs,42,30,,42,percent of total billed charges,Drugs,42,30,,42,percent of total billed charges,Drugs,42,30,,42,percent of total billed charges,Drugs,70,50,,70,percent of total billed charges,All Other,42,30,,42,percent of total billed charges,Drugs,42,30,,42,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,42,30,,42,percent of total billed charges,Drugs,42,30,,42,percent of total billed charges,Drugs,42,30,,42,percent of total billed charges,Drugs,42,30,,42,percent of total billed charges,Drugs,42,30,,42,percent of total billed charges,Drugs,42,30,,42,percent of total billed charges,Drugs,42,30,,42,percent of total billed charges,Drugs,42,30,,42,percent of total billed charges,Drugs,42,30,,42,percent of total billed charges,Drugs,42,30,,42,percent of total billed charges,Drugs,42,30,,42,percent of total billed charges,Drugs,42,30,,42,percent of total billed charges,Drugs,42,30,,42,percent of total billed charges,Drugs,40,,,40,Other,Drug Cost,40,,,40,Other,Drug Cost,40,,,40,Other,Drug Cost,40,,,40,Other,Drug Cost,40,,,40,Other,Drug Cost,47.6,34,,47.6,percent of total billed charges,Drugs,40,,,40,Other,Drug Cost,90,,,90,Other,225% Medicaid APG methodology,56,,,56,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,15,,,15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",40,,,40,Other,Drug Cost,40,,,40,Other,Drug Cost,50,,,50,Other,125% Medicaid APG methodology,0.01,90,
EPOETIN 2000 UNITS/ML PF ESRD   ,J0885,HCPCS,,40521486,CDM,636,RC,59676-0302-01,NDC,both,1,ML,180.6,87.68,,,87.68,Other,150% of Medicare + 9.63% HCRA Surcharge,53.32,,,53.32,Fee Schedule,Average Sale Price (ASP) x 6,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,90.3,50,,90.3,percent of total billed charges,All Other,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,14.15,,,14.15,Other,Drug Cost,14.15,,,14.15,Other,Drug Cost,14.15,,,14.15,Other,Drug Cost,14.15,,,14.15,Other,Drug Cost,14.15,,,14.15,Other,Drug Cost,61.4,34,,61.4,percent of total billed charges,Drugs,14.15,,,14.15,Other,Drug Cost,31.84,,,31.84,Other,225% Medicaid APG methodology,19.81,,,19.81,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,85.31,,,85.31,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",14.15,,,14.15,Other,Drug Cost,14.15,,,14.15,Other,Drug Cost,17.69,,,17.69,Other,125% Medicaid APG methodology,0.01,90.3,
EPOETIN 4000 UNITS/ML PF ESRD   ,J0885,HCPCS,,40521494,CDM,636,RC,59676-0304-01,NDC,both,1,ML,361.17,87.68,,,87.68,Other,150% of Medicare + 9.63% HCRA Surcharge,53.32,,,53.32,Fee Schedule,Average Sale Price (ASP) x 6,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,180.59,50,,180.59,percent of total billed charges,All Other,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,30.52,,,30.52,Other,Drug Cost,30.52,,,30.52,Other,Drug Cost,30.52,,,30.52,Other,Drug Cost,30.52,,,30.52,Other,Drug Cost,30.52,,,30.52,Other,Drug Cost,122.8,34,,122.8,percent of total billed charges,Drugs,30.52,,,30.52,Other,Drug Cost,68.67,,,68.67,Other,225% Medicaid APG methodology,42.73,,,42.73,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,85.31,,,85.31,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",30.52,,,30.52,Other,Drug Cost,30.52,,,30.52,Other,Drug Cost,38.15,,,38.15,Other,125% Medicaid APG methodology,0.01,180.59,
EPOETIN 3000 UNITS/ML PF ESRD   ,J0885,HCPCS,,40521510,CDM,636,RC,59676-0303-01,NDC,both,1,ML,270.87,87.68,,,87.68,Other,150% of Medicare + 9.63% HCRA Surcharge,53.32,,,53.32,Fee Schedule,Average Sale Price (ASP) x 6,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,135.44,50,,135.44,percent of total billed charges,All Other,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,19.23,,,19.23,Other,Drug Cost,19.23,,,19.23,Other,Drug Cost,19.23,,,19.23,Other,Drug Cost,19.23,,,19.23,Other,Drug Cost,19.23,,,19.23,Other,Drug Cost,92.1,34,,92.1,percent of total billed charges,Drugs,19.23,,,19.23,Other,Drug Cost,43.27,,,43.27,Other,225% Medicaid APG methodology,26.92,,,26.92,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,85.31,,,85.31,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",19.23,,,19.23,Other,Drug Cost,19.23,,,19.23,Other,Drug Cost,24.04,,,24.04,Other,125% Medicaid APG methodology,0.01,135.44,
AMINOCAPROIC 250MG/ML IV 20ML   ,J3490,HCPCS,,40521627,CDM,636,RC,00409-4346-73,NDC,both,20,ML,21.7,8.56,39.4668,,8.56,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,10.85,50,,10.85,percent of total billed charges,All Other,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,1.6,,,1.6,Other,Drug Cost,1.6,,,1.6,Other,Drug Cost,1.6,,,1.6,Other,Drug Cost,1.6,,,1.6,Other,Drug Cost,1.6,,,1.6,Other,Drug Cost,7.38,34,,7.38,percent of total billed charges,Drugs,1.6,,,1.6,Other,Drug Cost,3.6,,,3.6,Other,225% Medicaid APG methodology,2.24,,,2.24,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.6,,,1.6,Other,Drug Cost,1.6,,,1.6,Other,Drug Cost,2,,,2,Other,125% Medicaid APG methodology,0.01,10.85,
HEPARIN 5000 UNITS/ML INJ  1ML  ,J1644,HCPCS,,40521650,CDM,636,RC,63323-0262-26,NDC,both,1,ML,3.01,2.64,,,2.64,Other,150% of Medicare + 9.63% HCRA Surcharge,1.61,,,1.61,Fee Schedule,Average Sale Price (ASP) x 6,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,1.51,50,,1.51,percent of total billed charges,All Other,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,1.02,34,,1.02,percent of total billed charges,Drugs,2,,,2,Other,Drug Cost,4.5,,,4.5,Other,225% Medicaid APG methodology,2.8,,,2.8,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.57,,,2.57,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2,,,2,Other,Drug Cost,2,,,2,Other,Drug Cost,2.5,,,2.5,Other,125% Medicaid APG methodology,0.01,4.5,
HEPARIN 5000 UNITS/ML INJ 10ML  ,J1644,HCPCS,,40521668,CDM,636,RC,63323-0047-10,NDC,both,10,ML,22.4,2.64,,,2.64,Other,150% of Medicare + 9.63% HCRA Surcharge,1.61,,,1.61,Fee Schedule,Average Sale Price (ASP) x 6,6.72,30,,6.72,percent of total billed charges,Drugs,6.72,30,,6.72,percent of total billed charges,Drugs,6.72,30,,6.72,percent of total billed charges,Drugs,6.72,30,,6.72,percent of total billed charges,Drugs,6.72,30,,6.72,percent of total billed charges,Drugs,11.2,50,,11.2,percent of total billed charges,All Other,6.72,30,,6.72,percent of total billed charges,Drugs,6.72,30,,6.72,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,6.72,30,,6.72,percent of total billed charges,Drugs,6.72,30,,6.72,percent of total billed charges,Drugs,6.72,30,,6.72,percent of total billed charges,Drugs,6.72,30,,6.72,percent of total billed charges,Drugs,6.72,30,,6.72,percent of total billed charges,Drugs,6.72,30,,6.72,percent of total billed charges,Drugs,6.72,30,,6.72,percent of total billed charges,Drugs,6.72,30,,6.72,percent of total billed charges,Drugs,6.72,30,,6.72,percent of total billed charges,Drugs,6.72,30,,6.72,percent of total billed charges,Drugs,6.72,30,,6.72,percent of total billed charges,Drugs,6.72,30,,6.72,percent of total billed charges,Drugs,6.72,30,,6.72,percent of total billed charges,Drugs,4.2,,,4.2,Other,Drug Cost,4.2,,,4.2,Other,Drug Cost,4.2,,,4.2,Other,Drug Cost,4.2,,,4.2,Other,Drug Cost,4.2,,,4.2,Other,Drug Cost,7.62,34,,7.62,percent of total billed charges,Drugs,4.2,,,4.2,Other,Drug Cost,9.45,,,9.45,Other,225% Medicaid APG methodology,5.88,,,5.88,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.57,,,2.57,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.2,,,4.2,Other,Drug Cost,4.2,,,4.2,Other,Drug Cost,5.25,,,5.25,Other,125% Medicaid APG methodology,0.01,11.2,
PROTAMINE 10MG/ML INJ SLN 25ML  ,J2720,HCPCS,,40521759,CDM,636,RC,63323-0229-30,NDC,both,25,ML,92.58,16.36,,,16.36,Other,150% of Medicare + 9.63% HCRA Surcharge,9.95,,,9.95,Fee Schedule,Average Sale Price (ASP) x 6,27.77,30,,27.77,percent of total billed charges,Drugs,27.77,30,,27.77,percent of total billed charges,Drugs,27.77,30,,27.77,percent of total billed charges,Drugs,27.77,30,,27.77,percent of total billed charges,Drugs,27.77,30,,27.77,percent of total billed charges,Drugs,46.29,50,,46.29,percent of total billed charges,All Other,27.77,30,,27.77,percent of total billed charges,Drugs,27.77,30,,27.77,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,27.77,30,,27.77,percent of total billed charges,Drugs,27.77,30,,27.77,percent of total billed charges,Drugs,27.77,30,,27.77,percent of total billed charges,Drugs,27.77,30,,27.77,percent of total billed charges,Drugs,27.77,30,,27.77,percent of total billed charges,Drugs,27.77,30,,27.77,percent of total billed charges,Drugs,27.77,30,,27.77,percent of total billed charges,Drugs,27.77,30,,27.77,percent of total billed charges,Drugs,27.77,30,,27.77,percent of total billed charges,Drugs,27.77,30,,27.77,percent of total billed charges,Drugs,27.77,30,,27.77,percent of total billed charges,Drugs,27.77,30,,27.77,percent of total billed charges,Drugs,27.77,30,,27.77,percent of total billed charges,Drugs,15.05,,,15.05,Other,Drug Cost,15.05,,,15.05,Other,Drug Cost,15.05,,,15.05,Other,Drug Cost,15.05,,,15.05,Other,Drug Cost,15.05,,,15.05,Other,Drug Cost,31.48,34,,31.48,percent of total billed charges,Drugs,15.05,,,15.05,Other,Drug Cost,33.86,,,33.86,Other,225% Medicaid APG methodology,21.07,,,21.07,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,15.92,,,15.92,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",15.05,,,15.05,Other,Drug Cost,15.05,,,15.05,Other,Drug Cost,18.81,,,18.81,Other,125% Medicaid APG methodology,0.01,46.29,
SECRETIN SYNTHTIC  16MCG INJ    ,J2850,HCPCS,,40521916,CDM,636,RC,67066-0005-01,NDC,both,1,EA,1837.5,725.2,39.4668,,725.2,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,551.25,30,,551.25,percent of total billed charges,Drugs,551.25,30,,551.25,percent of total billed charges,Drugs,551.25,30,,551.25,percent of total billed charges,Drugs,551.25,30,,551.25,percent of total billed charges,Drugs,551.25,30,,551.25,percent of total billed charges,Drugs,918.75,50,,918.75,percent of total billed charges,All Other,551.25,30,,551.25,percent of total billed charges,Drugs,551.25,30,,551.25,percent of total billed charges,Drugs,624.75,34,"If Charge > 500, then 34 percent",624.75,percent of total billed charges,Drugs,551.25,30,,551.25,percent of total billed charges,Drugs,551.25,30,,551.25,percent of total billed charges,Drugs,551.25,30,,551.25,percent of total billed charges,Drugs,551.25,30,,551.25,percent of total billed charges,Drugs,551.25,30,,551.25,percent of total billed charges,Drugs,551.25,30,,551.25,percent of total billed charges,Drugs,551.25,30,,551.25,percent of total billed charges,Drugs,551.25,30,,551.25,percent of total billed charges,Drugs,551.25,30,,551.25,percent of total billed charges,Drugs,551.25,30,,551.25,percent of total billed charges,Drugs,551.25,30,,551.25,percent of total billed charges,Drugs,551.25,30,,551.25,percent of total billed charges,Drugs,551.25,30,,551.25,percent of total billed charges,Drugs,525,,,525,Other,Drug Cost,525,,,525,Other,Drug Cost,525,,,525,Other,Drug Cost,525,,,525,Other,Drug Cost,525,,,525,Other,Drug Cost,624.75,34,,624.75,percent of total billed charges,Drugs,525,,,525,Other,Drug Cost,1181.25,,,1181.25,Other,225% Medicaid APG methodology,735,,,735,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",525,,,525,Other,Drug Cost,525,,,525,Other,Drug Cost,656.25,,,656.25,Other,125% Medicaid APG methodology,0.01,1181.25,
CALCITONIN 200UNITS/ML INJ 2ML  ,J0630,HCPCS,,40522179,CDM,636,RC,42023-0205-01,NDC,both,2,ML,3493.88,10552.43,,,10552.43,Other,150% of Medicare + 9.63% HCRA Surcharge,6416.99,,,6416.99,Fee Schedule,Average Sale Price (ASP) x 6,1048.16,30,,1048.16,percent of total billed charges,Drugs,1048.16,30,,1048.16,percent of total billed charges,Drugs,1048.16,30,,1048.16,percent of total billed charges,Drugs,1048.16,30,,1048.16,percent of total billed charges,Drugs,1048.16,30,,1048.16,percent of total billed charges,Drugs,1746.94,50,,1746.94,percent of total billed charges,All Other,1048.16,30,,1048.16,percent of total billed charges,Drugs,1048.16,30,,1048.16,percent of total billed charges,Drugs,1187.92,34,"If Charge > 500, then 34 percent",1187.92,percent of total billed charges,Drugs,1048.16,30,,1048.16,percent of total billed charges,Drugs,1048.16,30,,1048.16,percent of total billed charges,Drugs,1048.16,30,,1048.16,percent of total billed charges,Drugs,1048.16,30,,1048.16,percent of total billed charges,Drugs,1048.16,30,,1048.16,percent of total billed charges,Drugs,1048.16,30,,1048.16,percent of total billed charges,Drugs,1048.16,30,,1048.16,percent of total billed charges,Drugs,1048.16,30,,1048.16,percent of total billed charges,Drugs,1048.16,30,,1048.16,percent of total billed charges,Drugs,1048.16,30,,1048.16,percent of total billed charges,Drugs,1048.16,30,,1048.16,percent of total billed charges,Drugs,1048.16,30,,1048.16,percent of total billed charges,Drugs,1048.16,30,,1048.16,percent of total billed charges,Drugs,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,1187.92,34,,1187.92,percent of total billed charges,Drugs,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,1187.92,34,"If Charge > 2,000, then 34 percent",1187.92,percent of total billed charges,Drugs,10267.19,,,10267.19,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,10552.43,
PAMIDRONATE 3MG/ML IV SLN 10ML  ,J2430,HCPCS,,40522237,CDM,636,RC,61703-0324-18,NDC,both,10,ML,45.61,87.56,,,87.56,Other,150% of Medicare + 9.63% HCRA Surcharge,53.24,,,53.24,Fee Schedule,Average Sale Price (ASP) x 6,13.68,30,,13.68,percent of total billed charges,Drugs,13.68,30,,13.68,percent of total billed charges,Drugs,13.68,30,,13.68,percent of total billed charges,Drugs,13.68,30,,13.68,percent of total billed charges,Drugs,13.68,30,,13.68,percent of total billed charges,Drugs,22.81,50,,22.81,percent of total billed charges,All Other,13.68,30,,13.68,percent of total billed charges,Drugs,13.68,30,,13.68,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,13.68,30,,13.68,percent of total billed charges,Drugs,13.68,30,,13.68,percent of total billed charges,Drugs,13.68,30,,13.68,percent of total billed charges,Drugs,13.68,30,,13.68,percent of total billed charges,Drugs,13.68,30,,13.68,percent of total billed charges,Drugs,13.68,30,,13.68,percent of total billed charges,Drugs,13.68,30,,13.68,percent of total billed charges,Drugs,13.68,30,,13.68,percent of total billed charges,Drugs,13.68,30,,13.68,percent of total billed charges,Drugs,13.68,30,,13.68,percent of total billed charges,Drugs,13.68,30,,13.68,percent of total billed charges,Drugs,13.68,30,,13.68,percent of total billed charges,Drugs,13.68,30,,13.68,percent of total billed charges,Drugs,8.22,,,8.22,Other,Drug Cost,8.22,,,8.22,Other,Drug Cost,8.22,,,8.22,Other,Drug Cost,8.22,,,8.22,Other,Drug Cost,8.22,,,8.22,Other,Drug Cost,15.51,34,,15.51,percent of total billed charges,Drugs,8.22,,,8.22,Other,Drug Cost,18.5,,,18.5,Other,225% Medicaid APG methodology,11.51,,,11.51,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,85.19,,,85.19,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",8.22,,,8.22,Other,Drug Cost,8.22,,,8.22,Other,Drug Cost,10.28,,,10.28,Other,125% Medicaid APG methodology,0.01,87.56,
PAMIDRONATE 9MG/ML IV SLN 10ML  ,J2430,HCPCS,,40522252,CDM,636,RC,61703-0326-18,NDC,both,10,ML,118.41,87.56,,,87.56,Other,150% of Medicare + 9.63% HCRA Surcharge,53.24,,,53.24,Fee Schedule,Average Sale Price (ASP) x 6,35.52,30,,35.52,percent of total billed charges,Drugs,35.52,30,,35.52,percent of total billed charges,Drugs,35.52,30,,35.52,percent of total billed charges,Drugs,35.52,30,,35.52,percent of total billed charges,Drugs,35.52,30,,35.52,percent of total billed charges,Drugs,59.21,50,,59.21,percent of total billed charges,All Other,35.52,30,,35.52,percent of total billed charges,Drugs,35.52,30,,35.52,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,35.52,30,,35.52,percent of total billed charges,Drugs,35.52,30,,35.52,percent of total billed charges,Drugs,35.52,30,,35.52,percent of total billed charges,Drugs,35.52,30,,35.52,percent of total billed charges,Drugs,35.52,30,,35.52,percent of total billed charges,Drugs,35.52,30,,35.52,percent of total billed charges,Drugs,35.52,30,,35.52,percent of total billed charges,Drugs,35.52,30,,35.52,percent of total billed charges,Drugs,35.52,30,,35.52,percent of total billed charges,Drugs,35.52,30,,35.52,percent of total billed charges,Drugs,35.52,30,,35.52,percent of total billed charges,Drugs,35.52,30,,35.52,percent of total billed charges,Drugs,35.52,30,,35.52,percent of total billed charges,Drugs,22.6,,,22.6,Other,Drug Cost,22.6,,,22.6,Other,Drug Cost,22.6,,,22.6,Other,Drug Cost,22.6,,,22.6,Other,Drug Cost,22.6,,,22.6,Other,Drug Cost,40.26,34,,40.26,percent of total billed charges,Drugs,22.6,,,22.6,Other,Drug Cost,50.85,,,50.85,Other,225% Medicaid APG methodology,31.64,,,31.64,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,85.19,,,85.19,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",22.6,,,22.6,Other,Drug Cost,22.6,,,22.6,Other,Drug Cost,28.25,,,28.25,Other,125% Medicaid APG methodology,0.01,87.56,
METHYLPREDNISOLONE ACE 40MG/ML  ,J1030,HCPCS,,40522443,CDM,636,RC,00009-3073-03,NDC,both,1,ML,21.6,63.33,,,63.33,Other,150% of Medicare + 9.63% HCRA Surcharge,38.51,,,38.51,Fee Schedule,Average Sale Price (ASP) x 6,6.48,30,,6.48,percent of total billed charges,Drugs,6.48,30,,6.48,percent of total billed charges,Drugs,6.48,30,,6.48,percent of total billed charges,Drugs,6.48,30,,6.48,percent of total billed charges,Drugs,6.48,30,,6.48,percent of total billed charges,Drugs,10.8,50,,10.8,percent of total billed charges,All Other,6.48,30,,6.48,percent of total billed charges,Drugs,6.48,30,,6.48,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,6.48,30,,6.48,percent of total billed charges,Drugs,6.48,30,,6.48,percent of total billed charges,Drugs,6.48,30,,6.48,percent of total billed charges,Drugs,6.48,30,,6.48,percent of total billed charges,Drugs,6.48,30,,6.48,percent of total billed charges,Drugs,6.48,30,,6.48,percent of total billed charges,Drugs,6.48,30,,6.48,percent of total billed charges,Drugs,6.48,30,,6.48,percent of total billed charges,Drugs,6.48,30,,6.48,percent of total billed charges,Drugs,6.48,30,,6.48,percent of total billed charges,Drugs,6.48,30,,6.48,percent of total billed charges,Drugs,6.48,30,,6.48,percent of total billed charges,Drugs,6.48,30,,6.48,percent of total billed charges,Drugs,3.38,,,3.38,Other,Drug Cost,3.38,,,3.38,Other,Drug Cost,3.38,,,3.38,Other,Drug Cost,3.38,,,3.38,Other,Drug Cost,3.38,,,3.38,Other,Drug Cost,7.34,34,,7.34,percent of total billed charges,Drugs,3.38,,,3.38,Other,Drug Cost,7.61,,,7.61,Other,225% Medicaid APG methodology,4.73,,,4.73,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,61.62,,,61.62,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.38,,,3.38,Other,Drug Cost,3.38,,,3.38,Other,Drug Cost,4.23,,,4.23,Other,125% Medicaid APG methodology,0.01,63.33,
METHYLPRDNISOLNE SUC 125MG PF   ,J2930,HCPCS,,40522468,CDM,636,RC,00009-0047-26,NDC,both,1,EA,24.96,58.04,,,58.04,Other,150% of Medicare + 9.63% HCRA Surcharge,35.29,,,35.29,Fee Schedule,Average Sale Price (ASP) x 6,7.49,30,,7.49,percent of total billed charges,Drugs,7.49,30,,7.49,percent of total billed charges,Drugs,7.49,30,,7.49,percent of total billed charges,Drugs,7.49,30,,7.49,percent of total billed charges,Drugs,7.49,30,,7.49,percent of total billed charges,Drugs,12.48,50,,12.48,percent of total billed charges,All Other,7.49,30,,7.49,percent of total billed charges,Drugs,7.49,30,,7.49,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,7.49,30,,7.49,percent of total billed charges,Drugs,7.49,30,,7.49,percent of total billed charges,Drugs,7.49,30,,7.49,percent of total billed charges,Drugs,7.49,30,,7.49,percent of total billed charges,Drugs,7.49,30,,7.49,percent of total billed charges,Drugs,7.49,30,,7.49,percent of total billed charges,Drugs,7.49,30,,7.49,percent of total billed charges,Drugs,7.49,30,,7.49,percent of total billed charges,Drugs,7.49,30,,7.49,percent of total billed charges,Drugs,7.49,30,,7.49,percent of total billed charges,Drugs,7.49,30,,7.49,percent of total billed charges,Drugs,7.49,30,,7.49,percent of total billed charges,Drugs,7.49,30,,7.49,percent of total billed charges,Drugs,9.74,,,9.74,Other,Drug Cost,9.74,,,9.74,Other,Drug Cost,9.74,,,9.74,Other,Drug Cost,9.74,,,9.74,Other,Drug Cost,9.74,,,9.74,Other,Drug Cost,8.49,34,,8.49,percent of total billed charges,Drugs,9.74,,,9.74,Other,Drug Cost,21.92,,,21.92,Other,225% Medicaid APG methodology,13.64,,,13.64,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,56.47,,,56.47,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",9.74,,,9.74,Other,Drug Cost,9.74,,,9.74,Other,Drug Cost,12.18,,,12.18,Other,125% Medicaid APG methodology,0.01,58.04,
METHYLPREDNISOLON SUC 40MG INJ  ,J2920,HCPCS,,40522476,CDM,636,RC,00009-0039-28,NDC,both,1,EA,15.68,41.32,,,41.32,Other,150% of Medicare + 9.63% HCRA Surcharge,25.13,,,25.13,Fee Schedule,Average Sale Price (ASP) x 6,4.7,30,,4.7,percent of total billed charges,Drugs,4.7,30,,4.7,percent of total billed charges,Drugs,4.7,30,,4.7,percent of total billed charges,Drugs,4.7,30,,4.7,percent of total billed charges,Drugs,4.7,30,,4.7,percent of total billed charges,Drugs,7.84,50,,7.84,percent of total billed charges,All Other,4.7,30,,4.7,percent of total billed charges,Drugs,4.7,30,,4.7,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.7,30,,4.7,percent of total billed charges,Drugs,4.7,30,,4.7,percent of total billed charges,Drugs,4.7,30,,4.7,percent of total billed charges,Drugs,4.7,30,,4.7,percent of total billed charges,Drugs,4.7,30,,4.7,percent of total billed charges,Drugs,4.7,30,,4.7,percent of total billed charges,Drugs,4.7,30,,4.7,percent of total billed charges,Drugs,4.7,30,,4.7,percent of total billed charges,Drugs,4.7,30,,4.7,percent of total billed charges,Drugs,4.7,30,,4.7,percent of total billed charges,Drugs,4.7,30,,4.7,percent of total billed charges,Drugs,4.7,30,,4.7,percent of total billed charges,Drugs,4.7,30,,4.7,percent of total billed charges,Drugs,0.53,,,0.53,Other,Drug Cost,0.53,,,0.53,Other,Drug Cost,0.53,,,0.53,Other,Drug Cost,0.53,,,0.53,Other,Drug Cost,0.53,,,0.53,Other,Drug Cost,5.33,34,,5.33,percent of total billed charges,Drugs,0.53,,,0.53,Other,Drug Cost,1.19,,,1.19,Other,225% Medicaid APG methodology,0.74,,,0.74,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,40.2,,,40.2,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.53,,,0.53,Other,Drug Cost,0.53,,,0.53,Other,Drug Cost,0.66,,,0.66,Other,125% Medicaid APG methodology,0.01,41.32,
METHYLPREDNISOLONE 16 MG TAB    ,J7509,HCPCS,,40522500,CDM,636,RC,00009-0073-01,NDC,both,1,EA,9.35,2.24,,,2.24,Other,150% of Medicare + 9.63% HCRA Surcharge,1.36,,,1.36,Fee Schedule,Average Sale Price (ASP) x 6,2.81,30,,2.81,percent of total billed charges,Drugs,2.81,30,,2.81,percent of total billed charges,Drugs,2.81,30,,2.81,percent of total billed charges,Drugs,2.81,30,,2.81,percent of total billed charges,Drugs,2.81,30,,2.81,percent of total billed charges,Drugs,4.68,50,,4.68,percent of total billed charges,All Other,2.81,30,,2.81,percent of total billed charges,Drugs,2.81,30,,2.81,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.81,30,,2.81,percent of total billed charges,Drugs,2.81,30,,2.81,percent of total billed charges,Drugs,2.81,30,,2.81,percent of total billed charges,Drugs,2.81,30,,2.81,percent of total billed charges,Drugs,2.81,30,,2.81,percent of total billed charges,Drugs,2.81,30,,2.81,percent of total billed charges,Drugs,2.81,30,,2.81,percent of total billed charges,Drugs,2.81,30,,2.81,percent of total billed charges,Drugs,2.81,30,,2.81,percent of total billed charges,Drugs,2.81,30,,2.81,percent of total billed charges,Drugs,2.81,30,,2.81,percent of total billed charges,Drugs,2.81,30,,2.81,percent of total billed charges,Drugs,2.81,30,,2.81,percent of total billed charges,Drugs,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,3.18,34,,3.18,percent of total billed charges,Drugs,0.1,,,0.1,Other,Drug Cost,0.23,,,0.23,Other,225% Medicaid APG methodology,0.14,,,0.14,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.18,,,2.18,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.13,,,0.13,Other,125% Medicaid APG methodology,0.01,4.68,
METHYLPREDNISOLONE 4 MG TAB     ,J7509,HCPCS,,40522518,CDM,636,RC,00904-6914-61,NDC,both,1,EA,4.34,2.24,,,2.24,Other,150% of Medicare + 9.63% HCRA Surcharge,1.36,,,1.36,Fee Schedule,Average Sale Price (ASP) x 6,1.3,30,,1.3,percent of total billed charges,Drugs,1.3,30,,1.3,percent of total billed charges,Drugs,1.3,30,,1.3,percent of total billed charges,Drugs,1.3,30,,1.3,percent of total billed charges,Drugs,1.3,30,,1.3,percent of total billed charges,Drugs,2.17,50,,2.17,percent of total billed charges,All Other,1.3,30,,1.3,percent of total billed charges,Drugs,1.3,30,,1.3,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.3,30,,1.3,percent of total billed charges,Drugs,1.3,30,,1.3,percent of total billed charges,Drugs,1.3,30,,1.3,percent of total billed charges,Drugs,1.3,30,,1.3,percent of total billed charges,Drugs,1.3,30,,1.3,percent of total billed charges,Drugs,1.3,30,,1.3,percent of total billed charges,Drugs,1.3,30,,1.3,percent of total billed charges,Drugs,1.3,30,,1.3,percent of total billed charges,Drugs,1.3,30,,1.3,percent of total billed charges,Drugs,1.3,30,,1.3,percent of total billed charges,Drugs,1.3,30,,1.3,percent of total billed charges,Drugs,1.3,30,,1.3,percent of total billed charges,Drugs,1.3,30,,1.3,percent of total billed charges,Drugs,1.13,,,1.13,Other,Drug Cost,1.13,,,1.13,Other,Drug Cost,1.13,,,1.13,Other,Drug Cost,1.13,,,1.13,Other,Drug Cost,1.13,,,1.13,Other,Drug Cost,1.48,34,,1.48,percent of total billed charges,Drugs,1.13,,,1.13,Other,Drug Cost,2.54,,,2.54,Other,225% Medicaid APG methodology,1.58,,,1.58,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.18,,,2.18,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.13,,,1.13,Other,Drug Cost,1.13,,,1.13,Other,Drug Cost,1.41,,,1.41,Other,125% Medicaid APG methodology,0.01,2.54,
PREDNISONE 5MG/5ML ORL  5ML UD  ,J7512,HCPCS,,40522526,CDM,636,RC,00054-3722-50,NDC,both,5,ML,9.59,0.07,,,0.07,Other,150% of Medicare + 9.63% HCRA Surcharge,0.04,,,0.04,Fee Schedule,Average Sale Price (ASP) x 6,2.88,30,,2.88,percent of total billed charges,Drugs,2.88,30,,2.88,percent of total billed charges,Drugs,2.88,30,,2.88,percent of total billed charges,Drugs,2.88,30,,2.88,percent of total billed charges,Drugs,2.88,30,,2.88,percent of total billed charges,Drugs,4.8,50,,4.8,percent of total billed charges,All Other,2.88,30,,2.88,percent of total billed charges,Drugs,2.88,30,,2.88,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.88,30,,2.88,percent of total billed charges,Drugs,2.88,30,,2.88,percent of total billed charges,Drugs,2.88,30,,2.88,percent of total billed charges,Drugs,2.88,30,,2.88,percent of total billed charges,Drugs,2.88,30,,2.88,percent of total billed charges,Drugs,2.88,30,,2.88,percent of total billed charges,Drugs,2.88,30,,2.88,percent of total billed charges,Drugs,2.88,30,,2.88,percent of total billed charges,Drugs,2.88,30,,2.88,percent of total billed charges,Drugs,2.88,30,,2.88,percent of total billed charges,Drugs,2.88,30,,2.88,percent of total billed charges,Drugs,2.88,30,,2.88,percent of total billed charges,Drugs,2.88,30,,2.88,percent of total billed charges,Drugs,0.67,,,0.67,Other,Drug Cost,0.67,,,0.67,Other,Drug Cost,0.67,,,0.67,Other,Drug Cost,0.67,,,0.67,Other,Drug Cost,0.67,,,0.67,Other,Drug Cost,3.26,34,,3.26,percent of total billed charges,Drugs,0.67,,,0.67,Other,Drug Cost,1.51,,,1.51,Other,225% Medicaid APG methodology,0.94,,,0.94,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.07,,,0.07,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.67,,,0.67,Other,Drug Cost,0.67,,,0.67,Other,Drug Cost,0.84,,,0.84,Other,125% Medicaid APG methodology,0.01,4.8,
PREDNISONE 1 MG TAB             ,J7512,HCPCS,,40522534,CDM,636,RC,00603-5335-21,NDC,both,1,EA,0.67,0.07,,,0.07,Other,150% of Medicare + 9.63% HCRA Surcharge,0.04,,,0.04,Fee Schedule,Average Sale Price (ASP) x 6,0.2,30,,0.2,percent of total billed charges,Drugs,0.2,30,,0.2,percent of total billed charges,Drugs,0.2,30,,0.2,percent of total billed charges,Drugs,0.2,30,,0.2,percent of total billed charges,Drugs,0.2,30,,0.2,percent of total billed charges,Drugs,0.34,50,,0.34,percent of total billed charges,All Other,0.2,30,,0.2,percent of total billed charges,Drugs,0.2,30,,0.2,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.2,30,,0.2,percent of total billed charges,Drugs,0.2,30,,0.2,percent of total billed charges,Drugs,0.2,30,,0.2,percent of total billed charges,Drugs,0.2,30,,0.2,percent of total billed charges,Drugs,0.2,30,,0.2,percent of total billed charges,Drugs,0.2,30,,0.2,percent of total billed charges,Drugs,0.2,30,,0.2,percent of total billed charges,Drugs,0.2,30,,0.2,percent of total billed charges,Drugs,0.2,30,,0.2,percent of total billed charges,Drugs,0.2,30,,0.2,percent of total billed charges,Drugs,0.2,30,,0.2,percent of total billed charges,Drugs,0.2,30,,0.2,percent of total billed charges,Drugs,0.2,30,,0.2,percent of total billed charges,Drugs,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.23,34,,0.23,percent of total billed charges,Drugs,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.07,,,0.07,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.34,
PREDNISONE 20 MG TAB            ,J7512,HCPCS,,40522542,CDM,636,RC,00054-0018-20,NDC,both,1,EA,0.53,0.07,,,0.07,Other,150% of Medicare + 9.63% HCRA Surcharge,0.04,,,0.04,Fee Schedule,Average Sale Price (ASP) x 6,0.16,30,,0.16,percent of total billed charges,Drugs,0.16,30,,0.16,percent of total billed charges,Drugs,0.16,30,,0.16,percent of total billed charges,Drugs,0.16,30,,0.16,percent of total billed charges,Drugs,0.16,30,,0.16,percent of total billed charges,Drugs,0.27,50,,0.27,percent of total billed charges,All Other,0.16,30,,0.16,percent of total billed charges,Drugs,0.16,30,,0.16,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.16,30,,0.16,percent of total billed charges,Drugs,0.16,30,,0.16,percent of total billed charges,Drugs,0.16,30,,0.16,percent of total billed charges,Drugs,0.16,30,,0.16,percent of total billed charges,Drugs,0.16,30,,0.16,percent of total billed charges,Drugs,0.16,30,,0.16,percent of total billed charges,Drugs,0.16,30,,0.16,percent of total billed charges,Drugs,0.16,30,,0.16,percent of total billed charges,Drugs,0.16,30,,0.16,percent of total billed charges,Drugs,0.16,30,,0.16,percent of total billed charges,Drugs,0.16,30,,0.16,percent of total billed charges,Drugs,0.16,30,,0.16,percent of total billed charges,Drugs,0.16,30,,0.16,percent of total billed charges,Drugs,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.18,34,,0.18,percent of total billed charges,Drugs,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.07,,,0.07,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.27,
PREDNISONE 5 MG TAB             ,J7512,HCPCS,,40522559,CDM,636,RC,64380-0783-06,NDC,both,1,EA,0.28,0.07,,,0.07,Other,150% of Medicare + 9.63% HCRA Surcharge,0.04,,,0.04,Fee Schedule,Average Sale Price (ASP) x 6,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.14,50,,0.14,percent of total billed charges,All Other,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.1,34,,0.1,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.07,,,0.07,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.14,
DEXAMETHASONE 4MG/ML INJ  1ML   ,J1100,HCPCS,,40522583,CDM,636,RC,67457-0423-12,NDC,both,1,ML,1.58,1.17,,,1.17,Other,150% of Medicare + 9.63% HCRA Surcharge,0.71,,,0.71,Fee Schedule,Average Sale Price (ASP) x 6,0.47,30,,0.47,percent of total billed charges,Drugs,0.47,30,,0.47,percent of total billed charges,Drugs,0.47,30,,0.47,percent of total billed charges,Drugs,0.47,30,,0.47,percent of total billed charges,Drugs,0.47,30,,0.47,percent of total billed charges,Drugs,0.79,50,,0.79,percent of total billed charges,All Other,0.47,30,,0.47,percent of total billed charges,Drugs,0.47,30,,0.47,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.47,30,,0.47,percent of total billed charges,Drugs,0.47,30,,0.47,percent of total billed charges,Drugs,0.47,30,,0.47,percent of total billed charges,Drugs,0.47,30,,0.47,percent of total billed charges,Drugs,0.47,30,,0.47,percent of total billed charges,Drugs,0.47,30,,0.47,percent of total billed charges,Drugs,0.47,30,,0.47,percent of total billed charges,Drugs,0.47,30,,0.47,percent of total billed charges,Drugs,0.47,30,,0.47,percent of total billed charges,Drugs,0.47,30,,0.47,percent of total billed charges,Drugs,0.47,30,,0.47,percent of total billed charges,Drugs,0.47,30,,0.47,percent of total billed charges,Drugs,0.47,30,,0.47,percent of total billed charges,Drugs,0.43,,,0.43,Other,Drug Cost,0.43,,,0.43,Other,Drug Cost,0.43,,,0.43,Other,Drug Cost,0.43,,,0.43,Other,Drug Cost,0.43,,,0.43,Other,Drug Cost,0.54,34,,0.54,percent of total billed charges,Drugs,0.43,,,0.43,Other,Drug Cost,0.97,,,0.97,Other,225% Medicaid APG methodology,0.6,,,0.6,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.14,,,1.14,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.43,,,0.43,Other,Drug Cost,0.43,,,0.43,Other,Drug Cost,0.54,,,0.54,Other,125% Medicaid APG methodology,0.01,1.17,
DEXAMETHASONE 0.5 MG TAB        ,J8540,HCPCS,,40522625,CDM,636,RC,00054-8179-25,NDC,both,1,EA,0.56,0.82,,,0.82,Other,150% of Medicare + 9.63% HCRA Surcharge,0.5,,,0.5,Fee Schedule,Average Sale Price (ASP) x 6,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.28,50,,0.28,percent of total billed charges,All Other,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.17,30,,0.17,percent of total billed charges,Drugs,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.19,34,,0.19,percent of total billed charges,Drugs,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.8,,,0.8,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.82,
DEXAMETHASONE 4 MG TAB          ,J8540,HCPCS,,40522641,CDM,636,RC,66993-0730-80,NDC,both,1,EA,0.28,0.82,,,0.82,Other,150% of Medicare + 9.63% HCRA Surcharge,0.5,,,0.5,Fee Schedule,Average Sale Price (ASP) x 6,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.14,50,,0.14,percent of total billed charges,All Other,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.1,34,,0.1,percent of total billed charges,Drugs,0.16,,,0.16,Other,Drug Cost,0.36,,,0.36,Other,225% Medicaid APG methodology,0.22,,,0.22,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.8,,,0.8,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.16,,,0.16,Other,Drug Cost,0.16,,,0.16,Other,Drug Cost,0.2,,,0.2,Other,125% Medicaid APG methodology,0.01,0.82,
TRIAMCINO ACET 10MG/ML INJ 5ML  ,J3301,HCPCS,,40522658,CDM,636,RC,00003-0494-20,NDC,both,5,ML,39.34,9.33,,,9.33,Other,150% of Medicare + 9.63% HCRA Surcharge,5.68,,,5.68,Fee Schedule,Average Sale Price (ASP) x 6,11.8,30,,11.8,percent of total billed charges,Drugs,11.8,30,,11.8,percent of total billed charges,Drugs,11.8,30,,11.8,percent of total billed charges,Drugs,11.8,30,,11.8,percent of total billed charges,Drugs,11.8,30,,11.8,percent of total billed charges,Drugs,19.67,50,,19.67,percent of total billed charges,All Other,11.8,30,,11.8,percent of total billed charges,Drugs,11.8,30,,11.8,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,11.8,30,,11.8,percent of total billed charges,Drugs,11.8,30,,11.8,percent of total billed charges,Drugs,11.8,30,,11.8,percent of total billed charges,Drugs,11.8,30,,11.8,percent of total billed charges,Drugs,11.8,30,,11.8,percent of total billed charges,Drugs,11.8,30,,11.8,percent of total billed charges,Drugs,11.8,30,,11.8,percent of total billed charges,Drugs,11.8,30,,11.8,percent of total billed charges,Drugs,11.8,30,,11.8,percent of total billed charges,Drugs,11.8,30,,11.8,percent of total billed charges,Drugs,11.8,30,,11.8,percent of total billed charges,Drugs,11.8,30,,11.8,percent of total billed charges,Drugs,11.8,30,,11.8,percent of total billed charges,Drugs,4.36,,,4.36,Other,Drug Cost,4.36,,,4.36,Other,Drug Cost,4.36,,,4.36,Other,Drug Cost,4.36,,,4.36,Other,Drug Cost,4.36,,,4.36,Other,Drug Cost,13.38,34,,13.38,percent of total billed charges,Drugs,4.36,,,4.36,Other,Drug Cost,9.81,,,9.81,Other,225% Medicaid APG methodology,6.1,,,6.1,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,9.08,,,9.08,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.36,,,4.36,Other,Drug Cost,4.36,,,4.36,Other,Drug Cost,5.45,,,5.45,Other,125% Medicaid APG methodology,0.01,19.67,
TRIAMCINOLO ACET 40MG/ML INJ    ,J3301,HCPCS,,40522666,CDM,636,RC,70121-1049-05,NDC,both,1,ML,11.55,9.33,,,9.33,Other,150% of Medicare + 9.63% HCRA Surcharge,5.68,,,5.68,Fee Schedule,Average Sale Price (ASP) x 6,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,5.78,50,,5.78,percent of total billed charges,All Other,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,1.77,,,1.77,Other,Drug Cost,1.77,,,1.77,Other,Drug Cost,1.77,,,1.77,Other,Drug Cost,1.77,,,1.77,Other,Drug Cost,1.77,,,1.77,Other,Drug Cost,3.93,34,,3.93,percent of total billed charges,Drugs,1.77,,,1.77,Other,Drug Cost,3.98,,,3.98,Other,225% Medicaid APG methodology,2.48,,,2.48,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,9.08,,,9.08,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.77,,,1.77,Other,Drug Cost,1.77,,,1.77,Other,Drug Cost,2.21,,,2.21,Other,125% Medicaid APG methodology,0.01,9.33,
TACROLIMUS 0.5 MG CAP           ,J7507,HCPCS,,40522989,CDM,636,RC,00469-0607-73,NDC,both,1,EA,4.27,2.33,,,2.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1.42,,,1.42,Fee Schedule,Average Sale Price (ASP) x 6,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,2.14,50,,2.14,percent of total billed charges,All Other,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,1.13,,,1.13,Other,Drug Cost,1.13,,,1.13,Other,Drug Cost,1.13,,,1.13,Other,Drug Cost,1.13,,,1.13,Other,Drug Cost,1.13,,,1.13,Other,Drug Cost,1.45,34,,1.45,percent of total billed charges,Drugs,1.13,,,1.13,Other,Drug Cost,2.54,,,2.54,Other,225% Medicaid APG methodology,1.58,,,1.58,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.27,,,2.27,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.13,,,1.13,Other,Drug Cost,1.13,,,1.13,Other,Drug Cost,1.41,,,1.41,Other,125% Medicaid APG methodology,0.01,2.54,
MANNITOL 20% IV SOLN  250 ML    ,J7799,HCPCS,,40524514,CDM,636,RC,00409-7715-02,NDC,both,250,ML,70.81,27.95,39.4668,,27.95,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,21.24,30,,21.24,percent of total billed charges,Drugs,21.24,30,,21.24,percent of total billed charges,Drugs,21.24,30,,21.24,percent of total billed charges,Drugs,21.24,30,,21.24,percent of total billed charges,Drugs,21.24,30,,21.24,percent of total billed charges,Drugs,35.41,50,,35.41,percent of total billed charges,All Other,21.24,30,,21.24,percent of total billed charges,Drugs,21.24,30,,21.24,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,21.24,30,,21.24,percent of total billed charges,Drugs,21.24,30,,21.24,percent of total billed charges,Drugs,21.24,30,,21.24,percent of total billed charges,Drugs,21.24,30,,21.24,percent of total billed charges,Drugs,21.24,30,,21.24,percent of total billed charges,Drugs,21.24,30,,21.24,percent of total billed charges,Drugs,21.24,30,,21.24,percent of total billed charges,Drugs,21.24,30,,21.24,percent of total billed charges,Drugs,21.24,30,,21.24,percent of total billed charges,Drugs,21.24,30,,21.24,percent of total billed charges,Drugs,21.24,30,,21.24,percent of total billed charges,Drugs,21.24,30,,21.24,percent of total billed charges,Drugs,21.24,30,,21.24,percent of total billed charges,Drugs,2.43,,,2.43,Other,Drug Cost,2.43,,,2.43,Other,Drug Cost,2.43,,,2.43,Other,Drug Cost,2.43,,,2.43,Other,Drug Cost,2.43,,,2.43,Other,Drug Cost,24.08,34,,24.08,percent of total billed charges,Drugs,2.43,,,2.43,Other,Drug Cost,5.47,,,5.47,Other,225% Medicaid APG methodology,3.4,,,3.4,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.43,,,2.43,Other,Drug Cost,2.43,,,2.43,Other,Drug Cost,3.04,,,3.04,Other,125% Medicaid APG methodology,0.01,35.41,
ACETAZOLAMIDE 500 MG IV INJ     ,J1120,HCPCS,,40524548,CDM,636,RC,00143-9503-01,NDC,both,1,EA,79.73,277.44,,,277.44,Other,150% of Medicare + 9.63% HCRA Surcharge,168.71,,,168.71,Fee Schedule,Average Sale Price (ASP) x 6,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,39.87,50,,39.87,percent of total billed charges,All Other,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,23.92,30,,23.92,percent of total billed charges,Drugs,20.02,,,20.02,Other,Drug Cost,20.02,,,20.02,Other,Drug Cost,20.02,,,20.02,Other,Drug Cost,20.02,,,20.02,Other,Drug Cost,20.02,,,20.02,Other,Drug Cost,27.11,34,,27.11,percent of total billed charges,Drugs,20.02,,,20.02,Other,Drug Cost,45.05,,,45.05,Other,225% Medicaid APG methodology,28.03,,,28.03,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,269.94,,,269.94,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",20.02,,,20.02,Other,Drug Cost,20.02,,,20.02,Other,Drug Cost,25.03,,,25.03,Other,125% Medicaid APG methodology,0.01,277.44,
BUMETANIDE 0.25MG/ML INJ 10ML   ,J1939,HCPCS,,40524605,CDM,636,RC,00641-6007-10,NDC,both,10,ML,6.65,6.56,,,6.56,Other,150% of Medicare + 9.63% HCRA Surcharge,3.99,,,3.99,Fee Schedule,Average Sale Price (ASP) x 6,2,30,,2,percent of total billed charges,Drugs,2,30,,2,percent of total billed charges,Drugs,2,30,,2,percent of total billed charges,Drugs,2,30,,2,percent of total billed charges,Drugs,2,30,,2,percent of total billed charges,Drugs,3.33,50,,3.33,percent of total billed charges,All Other,2,30,,2,percent of total billed charges,Drugs,2,30,,2,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2,30,,2,percent of total billed charges,Drugs,2,30,,2,percent of total billed charges,Drugs,2,30,,2,percent of total billed charges,Drugs,2,30,,2,percent of total billed charges,Drugs,2,30,,2,percent of total billed charges,Drugs,2,30,,2,percent of total billed charges,Drugs,2,30,,2,percent of total billed charges,Drugs,2,30,,2,percent of total billed charges,Drugs,2,30,,2,percent of total billed charges,Drugs,2,30,,2,percent of total billed charges,Drugs,2,30,,2,percent of total billed charges,Drugs,2,30,,2,percent of total billed charges,Drugs,2,30,,2,percent of total billed charges,Drugs,1.9,,,1.9,Other,Drug Cost,1.9,,,1.9,Other,Drug Cost,1.9,,,1.9,Other,Drug Cost,1.9,,,1.9,Other,Drug Cost,1.9,,,1.9,Other,Drug Cost,2.26,34,,2.26,percent of total billed charges,Drugs,1.9,,,1.9,Other,Drug Cost,4.28,,,4.28,Other,225% Medicaid APG methodology,2.66,,,2.66,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.38,,,6.38,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.9,,,1.9,Other,Drug Cost,1.9,,,1.9,Other,Drug Cost,2.38,,,2.38,Other,125% Medicaid APG methodology,0.01,6.56,
FUROSEMIDE 10MG/ML INJ SLN 2ML  ,J1940,HCPCS,,40524670,CDM,636,RC,00409-6102-02,NDC,both,2,ML,2.21,5.65,,,5.65,Other,150% of Medicare + 9.63% HCRA Surcharge,3.44,,,3.44,Fee Schedule,Average Sale Price (ASP) x 6,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,1.11,50,,1.11,percent of total billed charges,All Other,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.66,30,,0.66,percent of total billed charges,Drugs,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.75,34,,0.75,percent of total billed charges,Drugs,0.28,,,0.28,Other,Drug Cost,0.63,,,0.63,Other,225% Medicaid APG methodology,0.39,,,0.39,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,5.5,,,5.5,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.28,,,0.28,Other,Drug Cost,0.28,,,0.28,Other,Drug Cost,0.35,,,0.35,Other,125% Medicaid APG methodology,0.01,5.65,
FUROSEMIDE 10MG/ML SLN 10ML     ,J1940,HCPCS,,40524688,CDM,636,RC,00409-6102-10,NDC,both,10,ML,3.33,5.65,,,5.65,Other,150% of Medicare + 9.63% HCRA Surcharge,3.44,,,3.44,Fee Schedule,Average Sale Price (ASP) x 6,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,1.67,50,,1.67,percent of total billed charges,All Other,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,1,30,,1,percent of total billed charges,Drugs,1.4,,,1.4,Other,Drug Cost,1.4,,,1.4,Other,Drug Cost,1.4,,,1.4,Other,Drug Cost,1.4,,,1.4,Other,Drug Cost,1.4,,,1.4,Other,Drug Cost,1.13,34,,1.13,percent of total billed charges,Drugs,1.4,,,1.4,Other,Drug Cost,3.15,,,3.15,Other,225% Medicaid APG methodology,1.96,,,1.96,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,5.5,,,5.5,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.4,,,1.4,Other,Drug Cost,1.4,,,1.4,Other,Drug Cost,1.75,,,1.75,Other,125% Medicaid APG methodology,0.01,5.65,
FUROSEMIDE 10MG/ML INJ SLN 4ML  ,J1940,HCPCS,,40524696,CDM,636,RC,00409-6102-04,NDC,both,4,ML,2.35,5.65,,,5.65,Other,150% of Medicare + 9.63% HCRA Surcharge,3.44,,,3.44,Fee Schedule,Average Sale Price (ASP) x 6,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,1.18,50,,1.18,percent of total billed charges,All Other,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,0.8,34,,0.8,percent of total billed charges,Drugs,0.56,,,0.56,Other,Drug Cost,1.26,,,1.26,Other,225% Medicaid APG methodology,0.78,,,0.78,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,5.5,,,5.5,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.56,,,0.56,Other,Drug Cost,0.56,,,0.56,Other,Drug Cost,0.7,,,0.7,Other,125% Medicaid APG methodology,0.01,5.65,
KETOROLAC 30MG/ML INJ SOLN 1ML  ,J1885,HCPCS,,40524837,CDM,636,RC,70512-0843-25,NDC,both,1,ML,5.15,4.81,,,4.81,Other,150% of Medicare + 9.63% HCRA Surcharge,2.93,,,2.93,Fee Schedule,Average Sale Price (ASP) x 6,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,2.58,50,,2.58,percent of total billed charges,All Other,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,1.75,34,,1.75,percent of total billed charges,Drugs,1.48,,,1.48,Other,Drug Cost,3.33,,,3.33,Other,225% Medicaid APG methodology,2.07,,,2.07,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,4.68,,,4.68,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.48,,,1.48,Other,Drug Cost,1.48,,,1.48,Other,Drug Cost,1.85,,,1.85,Other,125% Medicaid APG methodology,0.01,4.81,
METHOTRXATE 25MG/ML PF INJ10ML  ,J9250,HCPCS,,40525412,CDM,636,RC,00703-3675-01,NDC,both,10,ML,14.95,3.03,,,3.03,Other,150% of Medicare + 9.63% HCRA Surcharge,1.84,,,1.84,Fee Schedule,Average Sale Price (ASP) x 6,4.49,30,,4.49,percent of total billed charges,Drugs,4.49,30,,4.49,percent of total billed charges,Drugs,4.49,30,,4.49,percent of total billed charges,Drugs,4.49,30,,4.49,percent of total billed charges,Drugs,4.49,30,,4.49,percent of total billed charges,Drugs,7.48,50,,7.48,percent of total billed charges,All Other,4.49,30,,4.49,percent of total billed charges,Drugs,4.49,30,,4.49,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.49,30,,4.49,percent of total billed charges,Drugs,4.49,30,,4.49,percent of total billed charges,Drugs,4.49,30,,4.49,percent of total billed charges,Drugs,4.49,30,,4.49,percent of total billed charges,Drugs,4.49,30,,4.49,percent of total billed charges,Drugs,4.49,30,,4.49,percent of total billed charges,Drugs,4.49,30,,4.49,percent of total billed charges,Drugs,4.49,30,,4.49,percent of total billed charges,Drugs,4.49,30,,4.49,percent of total billed charges,Drugs,4.49,30,,4.49,percent of total billed charges,Drugs,4.49,30,,4.49,percent of total billed charges,Drugs,4.49,30,,4.49,percent of total billed charges,Drugs,4.49,30,,4.49,percent of total billed charges,Drugs,4.55,,,4.55,Other,Drug Cost,4.55,,,4.55,Other,Drug Cost,4.55,,,4.55,Other,Drug Cost,4.55,,,4.55,Other,Drug Cost,4.55,,,4.55,Other,Drug Cost,5.08,34,,5.08,percent of total billed charges,Drugs,4.55,,,4.55,Other,Drug Cost,10.24,,,10.24,Other,225% Medicaid APG methodology,6.37,,,6.37,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.95,,,2.95,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.55,,,4.55,Other,Drug Cost,4.55,,,4.55,Other,Drug Cost,5.69,,,5.69,Other,125% Medicaid APG methodology,0.01,10.24,
DOXORUBICIN 50 MG IV INJ        ,J9000,HCPCS,,40525560,CDM,636,RC,63323-0883-30,NDC,both,25,ML,108.4,32.35,,,32.35,Other,150% of Medicare + 9.63% HCRA Surcharge,19.67,,,19.67,Fee Schedule,Average Sale Price (ASP) x 6,32.52,30,,32.52,percent of total billed charges,Drugs,32.52,30,,32.52,percent of total billed charges,Drugs,32.52,30,,32.52,percent of total billed charges,Drugs,32.52,30,,32.52,percent of total billed charges,Drugs,32.52,30,,32.52,percent of total billed charges,Drugs,54.2,50,,54.2,percent of total billed charges,All Other,32.52,30,,32.52,percent of total billed charges,Drugs,32.52,30,,32.52,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,32.52,30,,32.52,percent of total billed charges,Drugs,32.52,30,,32.52,percent of total billed charges,Drugs,32.52,30,,32.52,percent of total billed charges,Drugs,32.52,30,,32.52,percent of total billed charges,Drugs,32.52,30,,32.52,percent of total billed charges,Drugs,32.52,30,,32.52,percent of total billed charges,Drugs,32.52,30,,32.52,percent of total billed charges,Drugs,32.52,30,,32.52,percent of total billed charges,Drugs,32.52,30,,32.52,percent of total billed charges,Drugs,32.52,30,,32.52,percent of total billed charges,Drugs,32.52,30,,32.52,percent of total billed charges,Drugs,32.52,30,,32.52,percent of total billed charges,Drugs,32.52,30,,32.52,percent of total billed charges,Drugs,7.54,,,7.54,Other,Drug Cost,7.54,,,7.54,Other,Drug Cost,7.54,,,7.54,Other,Drug Cost,7.54,,,7.54,Other,Drug Cost,7.54,,,7.54,Other,Drug Cost,36.86,34,,36.86,percent of total billed charges,Drugs,7.54,,,7.54,Other,Drug Cost,16.97,,,16.97,Other,225% Medicaid APG methodology,10.56,,,10.56,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,31.48,,,31.48,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",7.54,,,7.54,Other,Drug Cost,7.54,,,7.54,Other,Drug Cost,9.43,,,9.43,Other,125% Medicaid APG methodology,0.01,54.2,
MITOMYCIN 20 MG IV INJ          ,J9280,HCPCS,,40525578,CDM,636,RC,25021-0251-50,NDC,both,1,EA,159.53,625.04,,,625.04,Other,150% of Medicare + 9.63% HCRA Surcharge,380.09,,,380.09,Fee Schedule,Average Sale Price (ASP) x 6,47.86,30,,47.86,percent of total billed charges,Drugs,47.86,30,,47.86,percent of total billed charges,Drugs,47.86,30,,47.86,percent of total billed charges,Drugs,47.86,30,,47.86,percent of total billed charges,Drugs,47.86,30,,47.86,percent of total billed charges,Drugs,79.77,50,,79.77,percent of total billed charges,All Other,47.86,30,,47.86,percent of total billed charges,Drugs,47.86,30,,47.86,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,47.86,30,,47.86,percent of total billed charges,Drugs,47.86,30,,47.86,percent of total billed charges,Drugs,47.86,30,,47.86,percent of total billed charges,Drugs,47.86,30,,47.86,percent of total billed charges,Drugs,47.86,30,,47.86,percent of total billed charges,Drugs,47.86,30,,47.86,percent of total billed charges,Drugs,47.86,30,,47.86,percent of total billed charges,Drugs,47.86,30,,47.86,percent of total billed charges,Drugs,47.86,30,,47.86,percent of total billed charges,Drugs,47.86,30,,47.86,percent of total billed charges,Drugs,47.86,30,,47.86,percent of total billed charges,Drugs,47.86,30,,47.86,percent of total billed charges,Drugs,47.86,30,,47.86,percent of total billed charges,Drugs,53,,,53,Other,Drug Cost,53,,,53,Other,Drug Cost,53,,,53,Other,Drug Cost,53,,,53,Other,Drug Cost,53,,,53,Other,Drug Cost,54.24,34,,54.24,percent of total billed charges,Drugs,53,,,53,Other,Drug Cost,119.25,,,119.25,Other,225% Medicaid APG methodology,74.2,,,74.2,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,608.14,,,608.14,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",53,,,53,Other,Drug Cost,53,,,53,Other,Drug Cost,66.25,,,66.25,Other,125% Medicaid APG methodology,0.01,625.04,
TAMOXIFEN 10 MG TAB             ,J8999,HCPCS,,40525651,CDM,636,RC,00591-2472-60,NDC,both,1,EA,1.23,0.49,39.4668,,0.49,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.62,50,,0.62,percent of total billed charges,All Other,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.42,34,,0.42,percent of total billed charges,Drugs,0.11,,,0.11,Other,Drug Cost,0.25,,,0.25,Other,225% Medicaid APG methodology,0.15,,,0.15,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.14,,,0.14,Other,125% Medicaid APG methodology,0.01,0.62,
DACARBAZINE 200 MG IV INJ       ,J9130,HCPCS,,40525669,CDM,636,RC,00703-5075-01,NDC,both,1,EA,35.32,36.83,,,36.83,Other,150% of Medicare + 9.63% HCRA Surcharge,22.4,,,22.4,Fee Schedule,Average Sale Price (ASP) x 6,10.6,30,,10.6,percent of total billed charges,Drugs,10.6,30,,10.6,percent of total billed charges,Drugs,10.6,30,,10.6,percent of total billed charges,Drugs,10.6,30,,10.6,percent of total billed charges,Drugs,10.6,30,,10.6,percent of total billed charges,Drugs,17.66,50,,17.66,percent of total billed charges,All Other,10.6,30,,10.6,percent of total billed charges,Drugs,10.6,30,,10.6,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,10.6,30,,10.6,percent of total billed charges,Drugs,10.6,30,,10.6,percent of total billed charges,Drugs,10.6,30,,10.6,percent of total billed charges,Drugs,10.6,30,,10.6,percent of total billed charges,Drugs,10.6,30,,10.6,percent of total billed charges,Drugs,10.6,30,,10.6,percent of total billed charges,Drugs,10.6,30,,10.6,percent of total billed charges,Drugs,10.6,30,,10.6,percent of total billed charges,Drugs,10.6,30,,10.6,percent of total billed charges,Drugs,10.6,30,,10.6,percent of total billed charges,Drugs,10.6,30,,10.6,percent of total billed charges,Drugs,10.6,30,,10.6,percent of total billed charges,Drugs,10.6,30,,10.6,percent of total billed charges,Drugs,5.08,,,5.08,Other,Drug Cost,5.08,,,5.08,Other,Drug Cost,5.08,,,5.08,Other,Drug Cost,5.08,,,5.08,Other,Drug Cost,5.08,,,5.08,Other,Drug Cost,12.01,34,,12.01,percent of total billed charges,Drugs,5.08,,,5.08,Other,Drug Cost,11.43,,,11.43,Other,225% Medicaid APG methodology,7.11,,,7.11,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,35.84,,,35.84,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.08,,,5.08,Other,Drug Cost,5.08,,,5.08,Other,Drug Cost,6.35,,,6.35,Other,125% Medicaid APG methodology,0.01,36.83,
PENICILLIN G SOD 5000000 INJ    ,J3490,HCPCS,,40525701,CDM,636,RC,00781-6153-95,NDC,both,1,EA,129.78,51.22,39.4668,,51.22,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,38.93,30,,38.93,percent of total billed charges,Drugs,38.93,30,,38.93,percent of total billed charges,Drugs,38.93,30,,38.93,percent of total billed charges,Drugs,38.93,30,,38.93,percent of total billed charges,Drugs,38.93,30,,38.93,percent of total billed charges,Drugs,64.89,50,,64.89,percent of total billed charges,All Other,38.93,30,,38.93,percent of total billed charges,Drugs,38.93,30,,38.93,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,38.93,30,,38.93,percent of total billed charges,Drugs,38.93,30,,38.93,percent of total billed charges,Drugs,38.93,30,,38.93,percent of total billed charges,Drugs,38.93,30,,38.93,percent of total billed charges,Drugs,38.93,30,,38.93,percent of total billed charges,Drugs,38.93,30,,38.93,percent of total billed charges,Drugs,38.93,30,,38.93,percent of total billed charges,Drugs,38.93,30,,38.93,percent of total billed charges,Drugs,38.93,30,,38.93,percent of total billed charges,Drugs,38.93,30,,38.93,percent of total billed charges,Drugs,38.93,30,,38.93,percent of total billed charges,Drugs,38.93,30,,38.93,percent of total billed charges,Drugs,38.93,30,,38.93,percent of total billed charges,Drugs,26.52,,,26.52,Other,Drug Cost,26.52,,,26.52,Other,Drug Cost,26.52,,,26.52,Other,Drug Cost,26.52,,,26.52,Other,Drug Cost,26.52,,,26.52,Other,Drug Cost,44.13,34,,44.13,percent of total billed charges,Drugs,26.52,,,26.52,Other,Drug Cost,59.67,,,59.67,Other,225% Medicaid APG methodology,37.13,,,37.13,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",26.52,,,26.52,Other,Drug Cost,26.52,,,26.52,Other,Drug Cost,33.15,,,33.15,Other,125% Medicaid APG methodology,0.01,64.89,
PENICILLIN G POT 5000000 INJ    ,J2540,HCPCS,,40525727,CDM,636,RC,00049-0520-83,NDC,both,1,EA,14.42,7.61,,,7.61,Other,150% of Medicare + 9.63% HCRA Surcharge,4.63,,,4.63,Fee Schedule,Average Sale Price (ASP) x 6,4.33,30,,4.33,percent of total billed charges,Drugs,4.33,30,,4.33,percent of total billed charges,Drugs,4.33,30,,4.33,percent of total billed charges,Drugs,4.33,30,,4.33,percent of total billed charges,Drugs,4.33,30,,4.33,percent of total billed charges,Drugs,7.21,50,,7.21,percent of total billed charges,All Other,4.33,30,,4.33,percent of total billed charges,Drugs,4.33,30,,4.33,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.33,30,,4.33,percent of total billed charges,Drugs,4.33,30,,4.33,percent of total billed charges,Drugs,4.33,30,,4.33,percent of total billed charges,Drugs,4.33,30,,4.33,percent of total billed charges,Drugs,4.33,30,,4.33,percent of total billed charges,Drugs,4.33,30,,4.33,percent of total billed charges,Drugs,4.33,30,,4.33,percent of total billed charges,Drugs,4.33,30,,4.33,percent of total billed charges,Drugs,4.33,30,,4.33,percent of total billed charges,Drugs,4.33,30,,4.33,percent of total billed charges,Drugs,4.33,30,,4.33,percent of total billed charges,Drugs,4.33,30,,4.33,percent of total billed charges,Drugs,4.33,30,,4.33,percent of total billed charges,Drugs,3.96,,,3.96,Other,Drug Cost,3.96,,,3.96,Other,Drug Cost,3.96,,,3.96,Other,Drug Cost,3.96,,,3.96,Other,Drug Cost,3.96,,,3.96,Other,Drug Cost,4.9,34,,4.9,percent of total billed charges,Drugs,3.96,,,3.96,Other,Drug Cost,8.91,,,8.91,Other,225% Medicaid APG methodology,5.54,,,5.54,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.4,,,7.4,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.96,,,3.96,Other,Drug Cost,3.96,,,3.96,Other,Drug Cost,4.95,,,4.95,Other,125% Medicaid APG methodology,0.01,8.91,
CARBOPLATIN 10MG/ML IV SLN45ML  ,J9045,HCPCS,,40525792,CDM,636,RC,00703-4248-01,NDC,both,45,ML,80.01,35.51,,,35.51,Other,150% of Medicare + 9.63% HCRA Surcharge,21.59,,,21.59,Fee Schedule,Average Sale Price (ASP) x 6,24,30,,24,percent of total billed charges,Drugs,24,30,,24,percent of total billed charges,Drugs,24,30,,24,percent of total billed charges,Drugs,24,30,,24,percent of total billed charges,Drugs,24,30,,24,percent of total billed charges,Drugs,40.01,50,,40.01,percent of total billed charges,All Other,24,30,,24,percent of total billed charges,Drugs,24,30,,24,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,24,30,,24,percent of total billed charges,Drugs,24,30,,24,percent of total billed charges,Drugs,24,30,,24,percent of total billed charges,Drugs,24,30,,24,percent of total billed charges,Drugs,24,30,,24,percent of total billed charges,Drugs,24,30,,24,percent of total billed charges,Drugs,24,30,,24,percent of total billed charges,Drugs,24,30,,24,percent of total billed charges,Drugs,24,30,,24,percent of total billed charges,Drugs,24,30,,24,percent of total billed charges,Drugs,24,30,,24,percent of total billed charges,Drugs,24,30,,24,percent of total billed charges,Drugs,24,30,,24,percent of total billed charges,Drugs,18.15,,,18.15,Other,Drug Cost,18.15,,,18.15,Other,Drug Cost,18.15,,,18.15,Other,Drug Cost,18.15,,,18.15,Other,Drug Cost,18.15,,,18.15,Other,Drug Cost,27.2,34,,27.2,percent of total billed charges,Drugs,18.15,,,18.15,Other,Drug Cost,40.84,,,40.84,Other,225% Medicaid APG methodology,25.41,,,25.41,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,34.55,,,34.55,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",18.15,,,18.15,Other,Drug Cost,18.15,,,18.15,Other,Drug Cost,22.69,,,22.69,Other,125% Medicaid APG methodology,0.01,40.84,
MESNA 100 MG/ML INJ SOLN 10 ML  ,J9209,HCPCS,,40525842,CDM,636,RC,63323-0733-11,NDC,both,10,ML,215.67,13.54,,,13.54,Other,150% of Medicare + 9.63% HCRA Surcharge,8.23,,,8.23,Fee Schedule,Average Sale Price (ASP) x 6,64.7,30,,64.7,percent of total billed charges,Drugs,64.7,30,,64.7,percent of total billed charges,Drugs,64.7,30,,64.7,percent of total billed charges,Drugs,64.7,30,,64.7,percent of total billed charges,Drugs,64.7,30,,64.7,percent of total billed charges,Drugs,107.84,50,,107.84,percent of total billed charges,All Other,64.7,30,,64.7,percent of total billed charges,Drugs,64.7,30,,64.7,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,64.7,30,,64.7,percent of total billed charges,Drugs,64.7,30,,64.7,percent of total billed charges,Drugs,64.7,30,,64.7,percent of total billed charges,Drugs,64.7,30,,64.7,percent of total billed charges,Drugs,64.7,30,,64.7,percent of total billed charges,Drugs,64.7,30,,64.7,percent of total billed charges,Drugs,64.7,30,,64.7,percent of total billed charges,Drugs,64.7,30,,64.7,percent of total billed charges,Drugs,64.7,30,,64.7,percent of total billed charges,Drugs,64.7,30,,64.7,percent of total billed charges,Drugs,64.7,30,,64.7,percent of total billed charges,Drugs,64.7,30,,64.7,percent of total billed charges,Drugs,64.7,30,,64.7,percent of total billed charges,Drugs,12.45,,,12.45,Other,Drug Cost,12.45,,,12.45,Other,Drug Cost,12.45,,,12.45,Other,Drug Cost,12.45,,,12.45,Other,Drug Cost,12.45,,,12.45,Other,Drug Cost,73.33,34,,73.33,percent of total billed charges,Drugs,12.45,,,12.45,Other,Drug Cost,28.01,,,28.01,Other,225% Medicaid APG methodology,17.43,,,17.43,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,13.17,,,13.17,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",12.45,,,12.45,Other,Drug Cost,12.45,,,12.45,Other,Drug Cost,15.56,,,15.56,Other,125% Medicaid APG methodology,0.01,107.84,
AMPICILLIN 1000 MG INJ          ,J0290,HCPCS,,40525891,CDM,636,RC,00781-3404-95,NDC,both,1,EA,4.97,9.98,,,9.98,Other,150% of Medicare + 9.63% HCRA Surcharge,6.07,,,6.07,Fee Schedule,Average Sale Price (ASP) x 6,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,2.49,50,,2.49,percent of total billed charges,All Other,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,1.69,34,,1.69,percent of total billed charges,Drugs,0.41,,,0.41,Other,Drug Cost,0.92,,,0.92,Other,225% Medicaid APG methodology,0.57,,,0.57,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,9.71,,,9.71,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.41,,,0.41,Other,Drug Cost,0.41,,,0.41,Other,Drug Cost,0.51,,,0.51,Other,125% Medicaid APG methodology,0.01,9.98,
AMPICILLIN 2000 MG INJ          ,J0290,HCPCS,,40525909,CDM,636,RC,67850-0022-10,NDC,both,1,EA,16.24,9.98,,,9.98,Other,150% of Medicare + 9.63% HCRA Surcharge,6.07,,,6.07,Fee Schedule,Average Sale Price (ASP) x 6,4.87,30,,4.87,percent of total billed charges,Drugs,4.87,30,,4.87,percent of total billed charges,Drugs,4.87,30,,4.87,percent of total billed charges,Drugs,4.87,30,,4.87,percent of total billed charges,Drugs,4.87,30,,4.87,percent of total billed charges,Drugs,8.12,50,,8.12,percent of total billed charges,All Other,4.87,30,,4.87,percent of total billed charges,Drugs,4.87,30,,4.87,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.87,30,,4.87,percent of total billed charges,Drugs,4.87,30,,4.87,percent of total billed charges,Drugs,4.87,30,,4.87,percent of total billed charges,Drugs,4.87,30,,4.87,percent of total billed charges,Drugs,4.87,30,,4.87,percent of total billed charges,Drugs,4.87,30,,4.87,percent of total billed charges,Drugs,4.87,30,,4.87,percent of total billed charges,Drugs,4.87,30,,4.87,percent of total billed charges,Drugs,4.87,30,,4.87,percent of total billed charges,Drugs,4.87,30,,4.87,percent of total billed charges,Drugs,4.87,30,,4.87,percent of total billed charges,Drugs,4.87,30,,4.87,percent of total billed charges,Drugs,4.87,30,,4.87,percent of total billed charges,Drugs,3.4,,,3.4,Other,Drug Cost,3.4,,,3.4,Other,Drug Cost,3.4,,,3.4,Other,Drug Cost,3.4,,,3.4,Other,Drug Cost,3.4,,,3.4,Other,Drug Cost,5.52,34,,5.52,percent of total billed charges,Drugs,3.4,,,3.4,Other,Drug Cost,7.65,,,7.65,Other,225% Medicaid APG methodology,4.76,,,4.76,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,9.71,,,9.71,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.4,,,3.4,Other,Drug Cost,3.4,,,3.4,Other,Drug Cost,4.25,,,4.25,Other,125% Medicaid APG methodology,0.01,9.98,
AMPICILLIN 250 MG INJ           ,J0290,HCPCS,,40525941,CDM,636,RC,00781-3402-95,NDC,both,1,EA,2.07,9.98,,,9.98,Other,150% of Medicare + 9.63% HCRA Surcharge,6.07,,,6.07,Fee Schedule,Average Sale Price (ASP) x 6,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,1.04,50,,1.04,percent of total billed charges,All Other,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.62,30,,0.62,percent of total billed charges,Drugs,0.37,,,0.37,Other,Drug Cost,0.37,,,0.37,Other,Drug Cost,0.37,,,0.37,Other,Drug Cost,0.37,,,0.37,Other,Drug Cost,0.37,,,0.37,Other,Drug Cost,0.7,34,,0.7,percent of total billed charges,Drugs,0.37,,,0.37,Other,Drug Cost,0.83,,,0.83,Other,225% Medicaid APG methodology,0.52,,,0.52,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,9.71,,,9.71,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.37,,,0.37,Other,Drug Cost,0.37,,,0.37,Other,Drug Cost,0.46,,,0.46,Other,125% Medicaid APG methodology,0.01,9.98,
NAFCILLIN 1000MG VL P2GM        ,J3490,HCPCS,,40526014,CDM,636,RC,44567-0221-10,NDC,both,1,EA,35.7,14.09,39.4668,,14.09,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,10.71,30,,10.71,percent of total billed charges,Drugs,10.71,30,,10.71,percent of total billed charges,Drugs,10.71,30,,10.71,percent of total billed charges,Drugs,10.71,30,,10.71,percent of total billed charges,Drugs,10.71,30,,10.71,percent of total billed charges,Drugs,17.85,50,,17.85,percent of total billed charges,All Other,10.71,30,,10.71,percent of total billed charges,Drugs,10.71,30,,10.71,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,10.71,30,,10.71,percent of total billed charges,Drugs,10.71,30,,10.71,percent of total billed charges,Drugs,10.71,30,,10.71,percent of total billed charges,Drugs,10.71,30,,10.71,percent of total billed charges,Drugs,10.71,30,,10.71,percent of total billed charges,Drugs,10.71,30,,10.71,percent of total billed charges,Drugs,10.71,30,,10.71,percent of total billed charges,Drugs,10.71,30,,10.71,percent of total billed charges,Drugs,10.71,30,,10.71,percent of total billed charges,Drugs,10.71,30,,10.71,percent of total billed charges,Drugs,10.71,30,,10.71,percent of total billed charges,Drugs,10.71,30,,10.71,percent of total billed charges,Drugs,10.71,30,,10.71,percent of total billed charges,Drugs,4.4,,,4.4,Other,Drug Cost,4.4,,,4.4,Other,Drug Cost,4.4,,,4.4,Other,Drug Cost,4.4,,,4.4,Other,Drug Cost,4.4,,,4.4,Other,Drug Cost,12.14,34,,12.14,percent of total billed charges,Drugs,4.4,,,4.4,Other,Drug Cost,9.9,,,9.9,Other,225% Medicaid APG methodology,6.16,,,6.16,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.4,,,4.4,Other,Drug Cost,4.4,,,4.4,Other,Drug Cost,5.5,,,5.5,Other,125% Medicaid APG methodology,0.01,17.85,
CEFOXITIN 2000 MG INJ           ,J0694,HCPCS,,40526204,CDM,636,RC,25021-0110-20,NDC,both,1,EA,23.1,50.11,,,50.11,Other,150% of Medicare + 9.63% HCRA Surcharge,30.47,,,30.47,Fee Schedule,Average Sale Price (ASP) x 6,6.93,30,,6.93,percent of total billed charges,Drugs,6.93,30,,6.93,percent of total billed charges,Drugs,6.93,30,,6.93,percent of total billed charges,Drugs,6.93,30,,6.93,percent of total billed charges,Drugs,6.93,30,,6.93,percent of total billed charges,Drugs,11.55,50,,11.55,percent of total billed charges,All Other,6.93,30,,6.93,percent of total billed charges,Drugs,6.93,30,,6.93,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,6.93,30,,6.93,percent of total billed charges,Drugs,6.93,30,,6.93,percent of total billed charges,Drugs,6.93,30,,6.93,percent of total billed charges,Drugs,6.93,30,,6.93,percent of total billed charges,Drugs,6.93,30,,6.93,percent of total billed charges,Drugs,6.93,30,,6.93,percent of total billed charges,Drugs,6.93,30,,6.93,percent of total billed charges,Drugs,6.93,30,,6.93,percent of total billed charges,Drugs,6.93,30,,6.93,percent of total billed charges,Drugs,6.93,30,,6.93,percent of total billed charges,Drugs,6.93,30,,6.93,percent of total billed charges,Drugs,6.93,30,,6.93,percent of total billed charges,Drugs,6.93,30,,6.93,percent of total billed charges,Drugs,4.57,,,4.57,Other,Drug Cost,4.57,,,4.57,Other,Drug Cost,4.57,,,4.57,Other,Drug Cost,4.57,,,4.57,Other,Drug Cost,4.57,,,4.57,Other,Drug Cost,7.85,34,,7.85,percent of total billed charges,Drugs,4.57,,,4.57,Other,Drug Cost,10.28,,,10.28,Other,225% Medicaid APG methodology,6.4,,,6.4,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,48.76,,,48.76,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.57,,,4.57,Other,Drug Cost,4.57,,,4.57,Other,Drug Cost,5.71,,,5.71,Other,125% Medicaid APG methodology,0.01,50.11,
CEFTRIAXONE 250 MG INJ          ,J0696,HCPCS,,40526238,CDM,636,RC,00409-7337-01,NDC,both,1,EA,2,4.84,,,4.84,Other,150% of Medicare + 9.63% HCRA Surcharge,2.95,,,2.95,Fee Schedule,Average Sale Price (ASP) x 6,0.6,30,,0.6,percent of total billed charges,Drugs,0.6,30,,0.6,percent of total billed charges,Drugs,0.6,30,,0.6,percent of total billed charges,Drugs,0.6,30,,0.6,percent of total billed charges,Drugs,0.6,30,,0.6,percent of total billed charges,Drugs,1,50,,1,percent of total billed charges,All Other,0.6,30,,0.6,percent of total billed charges,Drugs,0.6,30,,0.6,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.6,30,,0.6,percent of total billed charges,Drugs,0.6,30,,0.6,percent of total billed charges,Drugs,0.6,30,,0.6,percent of total billed charges,Drugs,0.6,30,,0.6,percent of total billed charges,Drugs,0.6,30,,0.6,percent of total billed charges,Drugs,0.6,30,,0.6,percent of total billed charges,Drugs,0.6,30,,0.6,percent of total billed charges,Drugs,0.6,30,,0.6,percent of total billed charges,Drugs,0.6,30,,0.6,percent of total billed charges,Drugs,0.6,30,,0.6,percent of total billed charges,Drugs,0.6,30,,0.6,percent of total billed charges,Drugs,0.6,30,,0.6,percent of total billed charges,Drugs,0.6,30,,0.6,percent of total billed charges,Drugs,0.52,,,0.52,Other,Drug Cost,0.52,,,0.52,Other,Drug Cost,0.52,,,0.52,Other,Drug Cost,0.52,,,0.52,Other,Drug Cost,0.52,,,0.52,Other,Drug Cost,0.68,34,,0.68,percent of total billed charges,Drugs,0.52,,,0.52,Other,Drug Cost,1.17,,,1.17,Other,225% Medicaid APG methodology,0.73,,,0.73,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,4.71,,,4.71,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.52,,,0.52,Other,Drug Cost,0.52,,,0.52,Other,Drug Cost,0.65,,,0.65,Other,125% Medicaid APG methodology,0.01,4.84,
CEFTRIAXONE 1000 MG INJ         ,J0696,HCPCS,,40526246,CDM,636,RC,60505-6148-04,NDC,both,1,EA,4.94,4.84,,,4.84,Other,150% of Medicare + 9.63% HCRA Surcharge,2.95,,,2.95,Fee Schedule,Average Sale Price (ASP) x 6,1.48,30,,1.48,percent of total billed charges,Drugs,1.48,30,,1.48,percent of total billed charges,Drugs,1.48,30,,1.48,percent of total billed charges,Drugs,1.48,30,,1.48,percent of total billed charges,Drugs,1.48,30,,1.48,percent of total billed charges,Drugs,2.47,50,,2.47,percent of total billed charges,All Other,1.48,30,,1.48,percent of total billed charges,Drugs,1.48,30,,1.48,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.48,30,,1.48,percent of total billed charges,Drugs,1.48,30,,1.48,percent of total billed charges,Drugs,1.48,30,,1.48,percent of total billed charges,Drugs,1.48,30,,1.48,percent of total billed charges,Drugs,1.48,30,,1.48,percent of total billed charges,Drugs,1.48,30,,1.48,percent of total billed charges,Drugs,1.48,30,,1.48,percent of total billed charges,Drugs,1.48,30,,1.48,percent of total billed charges,Drugs,1.48,30,,1.48,percent of total billed charges,Drugs,1.48,30,,1.48,percent of total billed charges,Drugs,1.48,30,,1.48,percent of total billed charges,Drugs,1.48,30,,1.48,percent of total billed charges,Drugs,1.48,30,,1.48,percent of total billed charges,Drugs,0.77,,,0.77,Other,Drug Cost,0.77,,,0.77,Other,Drug Cost,0.77,,,0.77,Other,Drug Cost,0.77,,,0.77,Other,Drug Cost,0.77,,,0.77,Other,Drug Cost,1.68,34,,1.68,percent of total billed charges,Drugs,0.77,,,0.77,Other,Drug Cost,1.73,,,1.73,Other,225% Medicaid APG methodology,1.08,,,1.08,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,4.71,,,4.71,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.77,,,0.77,Other,Drug Cost,0.77,,,0.77,Other,Drug Cost,0.96,,,0.96,Other,125% Medicaid APG methodology,0.01,4.84,
DOXYCYCLINE 100 MG INJ          ,J3490,HCPCS,,40526410,CDM,636,RC,00143-9381-10,NDC,both,1,EA,41.27,16.29,39.4668,,16.29,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,12.38,30,,12.38,percent of total billed charges,Drugs,12.38,30,,12.38,percent of total billed charges,Drugs,12.38,30,,12.38,percent of total billed charges,Drugs,12.38,30,,12.38,percent of total billed charges,Drugs,12.38,30,,12.38,percent of total billed charges,Drugs,20.64,50,,20.64,percent of total billed charges,All Other,12.38,30,,12.38,percent of total billed charges,Drugs,12.38,30,,12.38,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,12.38,30,,12.38,percent of total billed charges,Drugs,12.38,30,,12.38,percent of total billed charges,Drugs,12.38,30,,12.38,percent of total billed charges,Drugs,12.38,30,,12.38,percent of total billed charges,Drugs,12.38,30,,12.38,percent of total billed charges,Drugs,12.38,30,,12.38,percent of total billed charges,Drugs,12.38,30,,12.38,percent of total billed charges,Drugs,12.38,30,,12.38,percent of total billed charges,Drugs,12.38,30,,12.38,percent of total billed charges,Drugs,12.38,30,,12.38,percent of total billed charges,Drugs,12.38,30,,12.38,percent of total billed charges,Drugs,12.38,30,,12.38,percent of total billed charges,Drugs,12.38,30,,12.38,percent of total billed charges,Drugs,10.5,,,10.5,Other,Drug Cost,10.5,,,10.5,Other,Drug Cost,10.5,,,10.5,Other,Drug Cost,10.5,,,10.5,Other,Drug Cost,10.5,,,10.5,Other,Drug Cost,14.03,34,,14.03,percent of total billed charges,Drugs,10.5,,,10.5,Other,Drug Cost,23.63,,,23.63,Other,225% Medicaid APG methodology,14.7,,,14.7,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",10.5,,,10.5,Other,Drug Cost,10.5,,,10.5,Other,Drug Cost,13.13,,,13.13,Other,125% Medicaid APG methodology,0.01,23.63,
CLINDAMYCIN 150MG/ML INJ  4ML   ,J3490,HCPCS,,40526568,CDM,636,RC,00009-0775-26,NDC,both,4,ML,7.84,3.09,39.4668,,3.09,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,2.35,30,,2.35,percent of total billed charges,Drugs,2.35,30,,2.35,percent of total billed charges,Drugs,2.35,30,,2.35,percent of total billed charges,Drugs,2.35,30,,2.35,percent of total billed charges,Drugs,2.35,30,,2.35,percent of total billed charges,Drugs,3.92,50,,3.92,percent of total billed charges,All Other,2.35,30,,2.35,percent of total billed charges,Drugs,2.35,30,,2.35,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.35,30,,2.35,percent of total billed charges,Drugs,2.35,30,,2.35,percent of total billed charges,Drugs,2.35,30,,2.35,percent of total billed charges,Drugs,2.35,30,,2.35,percent of total billed charges,Drugs,2.35,30,,2.35,percent of total billed charges,Drugs,2.35,30,,2.35,percent of total billed charges,Drugs,2.35,30,,2.35,percent of total billed charges,Drugs,2.35,30,,2.35,percent of total billed charges,Drugs,2.35,30,,2.35,percent of total billed charges,Drugs,2.35,30,,2.35,percent of total billed charges,Drugs,2.35,30,,2.35,percent of total billed charges,Drugs,2.35,30,,2.35,percent of total billed charges,Drugs,2.35,30,,2.35,percent of total billed charges,Drugs,1.8,,,1.8,Other,Drug Cost,1.8,,,1.8,Other,Drug Cost,1.8,,,1.8,Other,Drug Cost,1.8,,,1.8,Other,Drug Cost,1.8,,,1.8,Other,Drug Cost,2.67,34,,2.67,percent of total billed charges,Drugs,1.8,,,1.8,Other,Drug Cost,4.05,,,4.05,Other,225% Medicaid APG methodology,2.52,,,2.52,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.8,,,1.8,Other,Drug Cost,1.8,,,1.8,Other,Drug Cost,2.25,,,2.25,Other,125% Medicaid APG methodology,0.01,4.05,
MIDAZOLAM 1MG/ML INJ SOLN 2ML   ,J2250,HCPCS,,40526618,CDM,636,RC,23155-0600-41,NDC,both,2,ML,1.23,1.4,,,1.4,Other,150% of Medicare + 9.63% HCRA Surcharge,0.85,,,0.85,Fee Schedule,Average Sale Price (ASP) x 6,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.62,50,,0.62,percent of total billed charges,All Other,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.37,30,,0.37,percent of total billed charges,Drugs,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.42,34,,0.42,percent of total billed charges,Drugs,0.27,,,0.27,Other,Drug Cost,0.61,,,0.61,Other,225% Medicaid APG methodology,0.38,,,0.38,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.36,,,1.36,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.34,,,0.34,Other,125% Medicaid APG methodology,0.01,1.4,
MIDAZOLAM 5MG/ML INJ SOLN 10ML  ,J2250,HCPCS,,40526626,CDM,636,RC,00641-6060-10,NDC,both,10,ML,6.55,1.4,,,1.4,Other,150% of Medicare + 9.63% HCRA Surcharge,0.85,,,0.85,Fee Schedule,Average Sale Price (ASP) x 6,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,3.28,50,,3.28,percent of total billed charges,All Other,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,2.25,,,2.25,Other,Drug Cost,2.25,,,2.25,Other,Drug Cost,2.25,,,2.25,Other,Drug Cost,2.25,,,2.25,Other,Drug Cost,2.25,,,2.25,Other,Drug Cost,2.23,34,,2.23,percent of total billed charges,Drugs,2.25,,,2.25,Other,Drug Cost,5.06,,,5.06,Other,225% Medicaid APG methodology,3.15,,,3.15,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.36,,,1.36,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.25,,,2.25,Other,Drug Cost,2.25,,,2.25,Other,Drug Cost,2.81,,,2.81,Other,125% Medicaid APG methodology,0.01,5.06,
CHLORAMPHENICOL 1000 MG INJ     ,J0720,HCPCS,,40526659,CDM,636,RC,63323-0011-15,NDC,both,1,EA,126.63,49.98,39.4668,,49.98,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,37.99,30,,37.99,percent of total billed charges,Drugs,37.99,30,,37.99,percent of total billed charges,Drugs,37.99,30,,37.99,percent of total billed charges,Drugs,37.99,30,,37.99,percent of total billed charges,Drugs,37.99,30,,37.99,percent of total billed charges,Drugs,63.32,50,,63.32,percent of total billed charges,All Other,37.99,30,,37.99,percent of total billed charges,Drugs,37.99,30,,37.99,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,37.99,30,,37.99,percent of total billed charges,Drugs,37.99,30,,37.99,percent of total billed charges,Drugs,37.99,30,,37.99,percent of total billed charges,Drugs,37.99,30,,37.99,percent of total billed charges,Drugs,37.99,30,,37.99,percent of total billed charges,Drugs,37.99,30,,37.99,percent of total billed charges,Drugs,37.99,30,,37.99,percent of total billed charges,Drugs,37.99,30,,37.99,percent of total billed charges,Drugs,37.99,30,,37.99,percent of total billed charges,Drugs,37.99,30,,37.99,percent of total billed charges,Drugs,37.99,30,,37.99,percent of total billed charges,Drugs,37.99,30,,37.99,percent of total billed charges,Drugs,37.99,30,,37.99,percent of total billed charges,Drugs,24.78,,,24.78,Other,Drug Cost,24.78,,,24.78,Other,Drug Cost,24.78,,,24.78,Other,Drug Cost,24.78,,,24.78,Other,Drug Cost,24.78,,,24.78,Other,Drug Cost,43.05,34,,43.05,percent of total billed charges,Drugs,24.78,,,24.78,Other,Drug Cost,55.76,,,55.76,Other,225% Medicaid APG methodology,34.69,,,34.69,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",24.78,,,24.78,Other,Drug Cost,24.78,,,24.78,Other,Drug Cost,30.98,,,30.98,Other,125% Medicaid APG methodology,0.01,63.32,
GENTAMICIN 10MG/ML INJ SLN 2ML  ,J1580,HCPCS,,40526733,CDM,636,RC,63323-0173-02,NDC,both,2,ML,5.81,26.49,,,26.49,Other,150% of Medicare + 9.63% HCRA Surcharge,16.11,,,16.11,Fee Schedule,Average Sale Price (ASP) x 6,1.74,30,,1.74,percent of total billed charges,Drugs,1.74,30,,1.74,percent of total billed charges,Drugs,1.74,30,,1.74,percent of total billed charges,Drugs,1.74,30,,1.74,percent of total billed charges,Drugs,1.74,30,,1.74,percent of total billed charges,Drugs,2.91,50,,2.91,percent of total billed charges,All Other,1.74,30,,1.74,percent of total billed charges,Drugs,1.74,30,,1.74,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.74,30,,1.74,percent of total billed charges,Drugs,1.74,30,,1.74,percent of total billed charges,Drugs,1.74,30,,1.74,percent of total billed charges,Drugs,1.74,30,,1.74,percent of total billed charges,Drugs,1.74,30,,1.74,percent of total billed charges,Drugs,1.74,30,,1.74,percent of total billed charges,Drugs,1.74,30,,1.74,percent of total billed charges,Drugs,1.74,30,,1.74,percent of total billed charges,Drugs,1.74,30,,1.74,percent of total billed charges,Drugs,1.74,30,,1.74,percent of total billed charges,Drugs,1.74,30,,1.74,percent of total billed charges,Drugs,1.74,30,,1.74,percent of total billed charges,Drugs,1.74,30,,1.74,percent of total billed charges,Drugs,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,1.98,34,,1.98,percent of total billed charges,Drugs,1.49,,,1.49,Other,Drug Cost,3.35,,,3.35,Other,225% Medicaid APG methodology,2.09,,,2.09,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,25.78,,,25.78,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.49,,,1.49,Other,Drug Cost,1.49,,,1.49,Other,Drug Cost,1.86,,,1.86,Other,125% Medicaid APG methodology,0.01,26.49,
GENTAMICIN 40MG/ML INJ SLN 2ML  ,J1580,HCPCS,,40526758,CDM,636,RC,63323-0010-02,NDC,both,2,ML,10.47,26.49,,,26.49,Other,150% of Medicare + 9.63% HCRA Surcharge,16.11,,,16.11,Fee Schedule,Average Sale Price (ASP) x 6,3.14,30,,3.14,percent of total billed charges,Drugs,3.14,30,,3.14,percent of total billed charges,Drugs,3.14,30,,3.14,percent of total billed charges,Drugs,3.14,30,,3.14,percent of total billed charges,Drugs,3.14,30,,3.14,percent of total billed charges,Drugs,5.24,50,,5.24,percent of total billed charges,All Other,3.14,30,,3.14,percent of total billed charges,Drugs,3.14,30,,3.14,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.14,30,,3.14,percent of total billed charges,Drugs,3.14,30,,3.14,percent of total billed charges,Drugs,3.14,30,,3.14,percent of total billed charges,Drugs,3.14,30,,3.14,percent of total billed charges,Drugs,3.14,30,,3.14,percent of total billed charges,Drugs,3.14,30,,3.14,percent of total billed charges,Drugs,3.14,30,,3.14,percent of total billed charges,Drugs,3.14,30,,3.14,percent of total billed charges,Drugs,3.14,30,,3.14,percent of total billed charges,Drugs,3.14,30,,3.14,percent of total billed charges,Drugs,3.14,30,,3.14,percent of total billed charges,Drugs,3.14,30,,3.14,percent of total billed charges,Drugs,3.14,30,,3.14,percent of total billed charges,Drugs,1.04,,,1.04,Other,Drug Cost,1.04,,,1.04,Other,Drug Cost,1.04,,,1.04,Other,Drug Cost,1.04,,,1.04,Other,Drug Cost,1.04,,,1.04,Other,Drug Cost,3.56,34,,3.56,percent of total billed charges,Drugs,1.04,,,1.04,Other,Drug Cost,2.34,,,2.34,Other,225% Medicaid APG methodology,1.46,,,1.46,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,25.78,,,25.78,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.04,,,1.04,Other,Drug Cost,1.04,,,1.04,Other,Drug Cost,1.3,,,1.3,Other,125% Medicaid APG methodology,0.01,26.49,
TOBRAMYCIN 1.2 G INJ            ,J3260,HCPCS,,40526782,CDM,636,RC,63323-0303-51,NDC,both,1,EA,228.38,26.28,,,26.28,Other,150% of Medicare + 9.63% HCRA Surcharge,15.98,,,15.98,Fee Schedule,Average Sale Price (ASP) x 6,68.51,30,,68.51,percent of total billed charges,Drugs,68.51,30,,68.51,percent of total billed charges,Drugs,68.51,30,,68.51,percent of total billed charges,Drugs,68.51,30,,68.51,percent of total billed charges,Drugs,68.51,30,,68.51,percent of total billed charges,Drugs,114.19,50,,114.19,percent of total billed charges,All Other,68.51,30,,68.51,percent of total billed charges,Drugs,68.51,30,,68.51,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,68.51,30,,68.51,percent of total billed charges,Drugs,68.51,30,,68.51,percent of total billed charges,Drugs,68.51,30,,68.51,percent of total billed charges,Drugs,68.51,30,,68.51,percent of total billed charges,Drugs,68.51,30,,68.51,percent of total billed charges,Drugs,68.51,30,,68.51,percent of total billed charges,Drugs,68.51,30,,68.51,percent of total billed charges,Drugs,68.51,30,,68.51,percent of total billed charges,Drugs,68.51,30,,68.51,percent of total billed charges,Drugs,68.51,30,,68.51,percent of total billed charges,Drugs,68.51,30,,68.51,percent of total billed charges,Drugs,68.51,30,,68.51,percent of total billed charges,Drugs,68.51,30,,68.51,percent of total billed charges,Drugs,34.1,,,34.1,Other,Drug Cost,34.1,,,34.1,Other,Drug Cost,34.1,,,34.1,Other,Drug Cost,34.1,,,34.1,Other,Drug Cost,34.1,,,34.1,Other,Drug Cost,77.65,34,,77.65,percent of total billed charges,Drugs,34.1,,,34.1,Other,Drug Cost,76.73,,,76.73,Other,225% Medicaid APG methodology,47.74,,,47.74,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,25.57,,,25.57,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",34.1,,,34.1,Other,Drug Cost,34.1,,,34.1,Other,Drug Cost,42.63,,,42.63,Other,125% Medicaid APG methodology,0.01,114.19,
AMIKACIN 250MG/ML INJ SOLN 2ML  ,J0278,HCPCS,,40526824,CDM,636,RC,25021-0173-02,NDC,both,2,ML,23.84,8.18,,,8.18,Other,150% of Medicare + 9.63% HCRA Surcharge,4.97,,,4.97,Fee Schedule,Average Sale Price (ASP) x 6,7.15,30,,7.15,percent of total billed charges,Drugs,7.15,30,,7.15,percent of total billed charges,Drugs,7.15,30,,7.15,percent of total billed charges,Drugs,7.15,30,,7.15,percent of total billed charges,Drugs,7.15,30,,7.15,percent of total billed charges,Drugs,11.92,50,,11.92,percent of total billed charges,All Other,7.15,30,,7.15,percent of total billed charges,Drugs,7.15,30,,7.15,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,7.15,30,,7.15,percent of total billed charges,Drugs,7.15,30,,7.15,percent of total billed charges,Drugs,7.15,30,,7.15,percent of total billed charges,Drugs,7.15,30,,7.15,percent of total billed charges,Drugs,7.15,30,,7.15,percent of total billed charges,Drugs,7.15,30,,7.15,percent of total billed charges,Drugs,7.15,30,,7.15,percent of total billed charges,Drugs,7.15,30,,7.15,percent of total billed charges,Drugs,7.15,30,,7.15,percent of total billed charges,Drugs,7.15,30,,7.15,percent of total billed charges,Drugs,7.15,30,,7.15,percent of total billed charges,Drugs,7.15,30,,7.15,percent of total billed charges,Drugs,7.15,30,,7.15,percent of total billed charges,Drugs,4.63,,,4.63,Other,Drug Cost,4.63,,,4.63,Other,Drug Cost,4.63,,,4.63,Other,Drug Cost,4.63,,,4.63,Other,Drug Cost,4.63,,,4.63,Other,Drug Cost,8.11,34,,8.11,percent of total billed charges,Drugs,4.63,,,4.63,Other,Drug Cost,10.42,,,10.42,Other,225% Medicaid APG methodology,6.48,,,6.48,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.96,,,7.96,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.63,,,4.63,Other,Drug Cost,4.63,,,4.63,Other,Drug Cost,5.79,,,5.79,Other,125% Medicaid APG methodology,0.01,11.92,
AMIKACIN 250MG/ML INJ SOLN 4ML  ,J0278,HCPCS,,40526832,CDM,636,RC,25021-0173-04,NDC,both,4,ML,28.81,8.18,,,8.18,Other,150% of Medicare + 9.63% HCRA Surcharge,4.97,,,4.97,Fee Schedule,Average Sale Price (ASP) x 6,8.64,30,,8.64,percent of total billed charges,Drugs,8.64,30,,8.64,percent of total billed charges,Drugs,8.64,30,,8.64,percent of total billed charges,Drugs,8.64,30,,8.64,percent of total billed charges,Drugs,8.64,30,,8.64,percent of total billed charges,Drugs,14.41,50,,14.41,percent of total billed charges,All Other,8.64,30,,8.64,percent of total billed charges,Drugs,8.64,30,,8.64,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,8.64,30,,8.64,percent of total billed charges,Drugs,8.64,30,,8.64,percent of total billed charges,Drugs,8.64,30,,8.64,percent of total billed charges,Drugs,8.64,30,,8.64,percent of total billed charges,Drugs,8.64,30,,8.64,percent of total billed charges,Drugs,8.64,30,,8.64,percent of total billed charges,Drugs,8.64,30,,8.64,percent of total billed charges,Drugs,8.64,30,,8.64,percent of total billed charges,Drugs,8.64,30,,8.64,percent of total billed charges,Drugs,8.64,30,,8.64,percent of total billed charges,Drugs,8.64,30,,8.64,percent of total billed charges,Drugs,8.64,30,,8.64,percent of total billed charges,Drugs,8.64,30,,8.64,percent of total billed charges,Drugs,9.25,,,9.25,Other,Drug Cost,9.25,,,9.25,Other,Drug Cost,9.25,,,9.25,Other,Drug Cost,9.25,,,9.25,Other,Drug Cost,9.25,,,9.25,Other,Drug Cost,9.8,34,,9.8,percent of total billed charges,Drugs,9.25,,,9.25,Other,Drug Cost,20.81,,,20.81,Other,225% Medicaid APG methodology,12.95,,,12.95,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.96,,,7.96,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",9.25,,,9.25,Other,Drug Cost,9.25,,,9.25,Other,Drug Cost,11.56,,,11.56,Other,125% Medicaid APG methodology,0.01,20.81,
VANCOMYCIN 1000 MG IV INJ       ,J3370,HCPCS,,40526907,CDM,636,RC,00409-6533-01,NDC,both,1,EA,56.42,22.76,,,22.76,Other,150% of Medicare + 9.63% HCRA Surcharge,13.84,,,13.84,Fee Schedule,Average Sale Price (ASP) x 6,16.93,30,,16.93,percent of total billed charges,Drugs,16.93,30,,16.93,percent of total billed charges,Drugs,16.93,30,,16.93,percent of total billed charges,Drugs,16.93,30,,16.93,percent of total billed charges,Drugs,16.93,30,,16.93,percent of total billed charges,Drugs,28.21,50,,28.21,percent of total billed charges,All Other,16.93,30,,16.93,percent of total billed charges,Drugs,16.93,30,,16.93,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,16.93,30,,16.93,percent of total billed charges,Drugs,16.93,30,,16.93,percent of total billed charges,Drugs,16.93,30,,16.93,percent of total billed charges,Drugs,16.93,30,,16.93,percent of total billed charges,Drugs,16.93,30,,16.93,percent of total billed charges,Drugs,16.93,30,,16.93,percent of total billed charges,Drugs,16.93,30,,16.93,percent of total billed charges,Drugs,16.93,30,,16.93,percent of total billed charges,Drugs,16.93,30,,16.93,percent of total billed charges,Drugs,16.93,30,,16.93,percent of total billed charges,Drugs,16.93,30,,16.93,percent of total billed charges,Drugs,16.93,30,,16.93,percent of total billed charges,Drugs,16.93,30,,16.93,percent of total billed charges,Drugs,16.12,,,16.12,Other,Drug Cost,16.12,,,16.12,Other,Drug Cost,16.12,,,16.12,Other,Drug Cost,16.12,,,16.12,Other,Drug Cost,16.12,,,16.12,Other,Drug Cost,19.18,34,,19.18,percent of total billed charges,Drugs,16.12,,,16.12,Other,Drug Cost,36.27,,,36.27,Other,225% Medicaid APG methodology,22.57,,,22.57,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,22.15,,,22.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",16.12,,,16.12,Other,Drug Cost,16.12,,,16.12,Other,Drug Cost,20.15,,,20.15,Other,125% Medicaid APG methodology,0.01,36.27,
"VANCOMYCIN 10GM VIAL, 500 MG    ",J3370,HCPCS,,40526931,CDM,636,RC,63323-0314-68,NDC,both,1,EA,691.39,22.76,,,22.76,Other,150% of Medicare + 9.63% HCRA Surcharge,13.84,,,13.84,Fee Schedule,Average Sale Price (ASP) x 6,207.42,30,,207.42,percent of total billed charges,Drugs,207.42,30,,207.42,percent of total billed charges,Drugs,207.42,30,,207.42,percent of total billed charges,Drugs,207.42,30,,207.42,percent of total billed charges,Drugs,207.42,30,,207.42,percent of total billed charges,Drugs,345.7,50,,345.7,percent of total billed charges,All Other,207.42,30,,207.42,percent of total billed charges,Drugs,207.42,30,,207.42,percent of total billed charges,Drugs,235.07,34,"If Charge > 500, then 34 percent",235.07,percent of total billed charges,Drugs,207.42,30,,207.42,percent of total billed charges,Drugs,207.42,30,,207.42,percent of total billed charges,Drugs,207.42,30,,207.42,percent of total billed charges,Drugs,207.42,30,,207.42,percent of total billed charges,Drugs,207.42,30,,207.42,percent of total billed charges,Drugs,207.42,30,,207.42,percent of total billed charges,Drugs,207.42,30,,207.42,percent of total billed charges,Drugs,207.42,30,,207.42,percent of total billed charges,Drugs,207.42,30,,207.42,percent of total billed charges,Drugs,207.42,30,,207.42,percent of total billed charges,Drugs,207.42,30,,207.42,percent of total billed charges,Drugs,207.42,30,,207.42,percent of total billed charges,Drugs,207.42,30,,207.42,percent of total billed charges,Drugs,193.29,,,193.29,Other,Drug Cost,193.29,,,193.29,Other,Drug Cost,193.29,,,193.29,Other,Drug Cost,193.29,,,193.29,Other,Drug Cost,193.29,,,193.29,Other,Drug Cost,235.07,34,,235.07,percent of total billed charges,Drugs,193.29,,,193.29,Other,Drug Cost,434.9,,,434.9,Other,225% Medicaid APG methodology,270.61,,,270.61,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,22.15,,,22.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",193.29,,,193.29,Other,Drug Cost,193.29,,,193.29,Other,Drug Cost,241.61,,,241.61,Other,125% Medicaid APG methodology,0.01,434.9,
AZTREONAM 1000 MG INJ           ,J3490,HCPCS,,40527194,CDM,636,RC,63323-0401-20,NDC,both,1,EA,89.46,35.31,39.4668,,35.31,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,44.73,50,,44.73,percent of total billed charges,All Other,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,8.18,,,8.18,Other,Drug Cost,8.18,,,8.18,Other,Drug Cost,8.18,,,8.18,Other,Drug Cost,8.18,,,8.18,Other,Drug Cost,8.18,,,8.18,Other,Drug Cost,30.42,34,,30.42,percent of total billed charges,Drugs,8.18,,,8.18,Other,Drug Cost,18.41,,,18.41,Other,225% Medicaid APG methodology,11.45,,,11.45,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",8.18,,,8.18,Other,Drug Cost,8.18,,,8.18,Other,Drug Cost,10.23,,,10.23,Other,125% Medicaid APG methodology,0.01,44.73,
AZTREONAM 2000 MG INJ           ,J3490,HCPCS,,40527202,CDM,636,RC,63323-0402-20,NDC,both,1,EA,178.96,70.63,39.4668,,70.63,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,53.69,30,,53.69,percent of total billed charges,Drugs,53.69,30,,53.69,percent of total billed charges,Drugs,53.69,30,,53.69,percent of total billed charges,Drugs,53.69,30,,53.69,percent of total billed charges,Drugs,53.69,30,,53.69,percent of total billed charges,Drugs,89.48,50,,89.48,percent of total billed charges,All Other,53.69,30,,53.69,percent of total billed charges,Drugs,53.69,30,,53.69,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,53.69,30,,53.69,percent of total billed charges,Drugs,53.69,30,,53.69,percent of total billed charges,Drugs,53.69,30,,53.69,percent of total billed charges,Drugs,53.69,30,,53.69,percent of total billed charges,Drugs,53.69,30,,53.69,percent of total billed charges,Drugs,53.69,30,,53.69,percent of total billed charges,Drugs,53.69,30,,53.69,percent of total billed charges,Drugs,53.69,30,,53.69,percent of total billed charges,Drugs,53.69,30,,53.69,percent of total billed charges,Drugs,53.69,30,,53.69,percent of total billed charges,Drugs,53.69,30,,53.69,percent of total billed charges,Drugs,53.69,30,,53.69,percent of total billed charges,Drugs,53.69,30,,53.69,percent of total billed charges,Drugs,21.94,,,21.94,Other,Drug Cost,21.94,,,21.94,Other,Drug Cost,21.94,,,21.94,Other,Drug Cost,21.94,,,21.94,Other,Drug Cost,21.94,,,21.94,Other,Drug Cost,60.85,34,,60.85,percent of total billed charges,Drugs,21.94,,,21.94,Other,Drug Cost,49.37,,,49.37,Other,225% Medicaid APG methodology,30.72,,,30.72,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",21.94,,,21.94,Other,Drug Cost,21.94,,,21.94,Other,Drug Cost,27.43,,,27.43,Other,125% Medicaid APG methodology,0.01,89.48,
METRONIDAZOLE 500MG  IV 100ML   ,J3490,HCPCS,,40527558,CDM,636,RC,00338-1055-48,NDC,both,100,ML,7,2.76,39.4668,,2.76,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,3.5,50,,3.5,percent of total billed charges,All Other,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,2.1,30,,2.1,percent of total billed charges,Drugs,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,2.38,34,,2.38,percent of total billed charges,Drugs,1,,,1,Other,Drug Cost,2.25,,,2.25,Other,225% Medicaid APG methodology,1.4,,,1.4,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1,,,1,Other,Drug Cost,1,,,1,Other,Drug Cost,1.25,,,1.25,Other,125% Medicaid APG methodology,0.01,3.5,
ACYCLOVIR 50MG/ML IV SOLN 10ML  ,J0133,HCPCS,,40527673,CDM,636,RC,63323-0325-10,NDC,both,10,ML,9.49,0.55,,,0.55,Other,150% of Medicare + 9.63% HCRA Surcharge,0.34,,,0.34,Fee Schedule,Average Sale Price (ASP) x 6,2.85,30,,2.85,percent of total billed charges,Drugs,2.85,30,,2.85,percent of total billed charges,Drugs,2.85,30,,2.85,percent of total billed charges,Drugs,2.85,30,,2.85,percent of total billed charges,Drugs,2.85,30,,2.85,percent of total billed charges,Drugs,4.75,50,,4.75,percent of total billed charges,All Other,2.85,30,,2.85,percent of total billed charges,Drugs,2.85,30,,2.85,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.85,30,,2.85,percent of total billed charges,Drugs,2.85,30,,2.85,percent of total billed charges,Drugs,2.85,30,,2.85,percent of total billed charges,Drugs,2.85,30,,2.85,percent of total billed charges,Drugs,2.85,30,,2.85,percent of total billed charges,Drugs,2.85,30,,2.85,percent of total billed charges,Drugs,2.85,30,,2.85,percent of total billed charges,Drugs,2.85,30,,2.85,percent of total billed charges,Drugs,2.85,30,,2.85,percent of total billed charges,Drugs,2.85,30,,2.85,percent of total billed charges,Drugs,2.85,30,,2.85,percent of total billed charges,Drugs,2.85,30,,2.85,percent of total billed charges,Drugs,2.85,30,,2.85,percent of total billed charges,Drugs,1.77,,,1.77,Other,Drug Cost,1.77,,,1.77,Other,Drug Cost,1.77,,,1.77,Other,Drug Cost,1.77,,,1.77,Other,Drug Cost,1.77,,,1.77,Other,Drug Cost,3.23,34,,3.23,percent of total billed charges,Drugs,1.77,,,1.77,Other,Drug Cost,3.98,,,3.98,Other,225% Medicaid APG methodology,2.48,,,2.48,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.54,,,0.54,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.77,,,1.77,Other,Drug Cost,1.77,,,1.77,Other,Drug Cost,2.21,,,2.21,Other,125% Medicaid APG methodology,0.01,4.75,
"HEP B VACC, 5MCG, IM            ",90743,CPT,,40527715,CDM,636,RC,00006-4981-00,NDC,both,0.5,ML,38.33,741.43,,,741.43,Other,150% of Medicare + 9.63% HCRA Surcharge,450.87,,,450.87,Fee Schedule,Average Sale Price (ASP) x 6,11.5,30,,11.5,percent of total billed charges,Drugs,11.5,30,,11.5,percent of total billed charges,Drugs,11.5,30,,11.5,percent of total billed charges,Drugs,11.5,30,,11.5,percent of total billed charges,Drugs,11.5,30,,11.5,percent of total billed charges,Drugs,19.17,50,,19.17,percent of total billed charges,All Other,11.5,30,,11.5,percent of total billed charges,Drugs,11.5,30,,11.5,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,11.5,30,,11.5,percent of total billed charges,Drugs,11.5,30,,11.5,percent of total billed charges,Drugs,11.5,30,,11.5,percent of total billed charges,Drugs,11.5,30,,11.5,percent of total billed charges,Drugs,11.5,30,,11.5,percent of total billed charges,Drugs,11.5,30,,11.5,percent of total billed charges,Drugs,11.5,30,,11.5,percent of total billed charges,Drugs,11.5,30,,11.5,percent of total billed charges,Drugs,11.5,30,,11.5,percent of total billed charges,Drugs,11.5,30,,11.5,percent of total billed charges,Drugs,11.5,30,,11.5,percent of total billed charges,Drugs,11.5,30,,11.5,percent of total billed charges,Drugs,11.5,30,,11.5,percent of total billed charges,Drugs,6.05,,,6.05,Other,Drug Cost,6.05,,,6.05,Other,Drug Cost,6.05,,,6.05,Other,Drug Cost,6.05,,,6.05,Other,Drug Cost,6.05,,,6.05,Other,Drug Cost,13.03,34,,13.03,percent of total billed charges,Drugs,6.05,,,6.05,Other,Drug Cost,13.61,,,13.61,Other,225% Medicaid APG methodology,8.47,,,8.47,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,721.39,,,721.39,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6.05,,,6.05,Other,Drug Cost,6.05,,,6.05,Other,Drug Cost,7.56,,,7.56,Other,125% Medicaid APG methodology,0.01,741.43,
TETANUS IMM GLOB 250 UN IM SLN  ,J1670,HCPCS,,40527806,CDM,636,RC,13533-0634-02,NDC,both,1,EA,1651.83,5709,,,5709,Other,150% of Medicare + 9.63% HCRA Surcharge,3471.68,,,3471.68,Fee Schedule,Average Sale Price (ASP) x 6,495.55,30,,495.55,percent of total billed charges,Drugs,495.55,30,,495.55,percent of total billed charges,Drugs,495.55,30,,495.55,percent of total billed charges,Drugs,495.55,30,,495.55,percent of total billed charges,Drugs,495.55,30,,495.55,percent of total billed charges,Drugs,825.92,50,,825.92,percent of total billed charges,All Other,495.55,30,,495.55,percent of total billed charges,Drugs,495.55,30,,495.55,percent of total billed charges,Drugs,561.62,34,"If Charge > 500, then 34 percent",561.62,percent of total billed charges,Drugs,495.55,30,,495.55,percent of total billed charges,Drugs,495.55,30,,495.55,percent of total billed charges,Drugs,495.55,30,,495.55,percent of total billed charges,Drugs,495.55,30,,495.55,percent of total billed charges,Drugs,495.55,30,,495.55,percent of total billed charges,Drugs,495.55,30,,495.55,percent of total billed charges,Drugs,495.55,30,,495.55,percent of total billed charges,Drugs,495.55,30,,495.55,percent of total billed charges,Drugs,495.55,30,,495.55,percent of total billed charges,Drugs,495.55,30,,495.55,percent of total billed charges,Drugs,495.55,30,,495.55,percent of total billed charges,Drugs,495.55,30,,495.55,percent of total billed charges,Drugs,495.55,30,,495.55,percent of total billed charges,Drugs,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,561.62,34,,561.62,percent of total billed charges,Drugs,2.5,,,2.5,Other,Drug Cost,5.63,,,5.63,Other,225% Medicaid APG methodology,3.5,,,3.5,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,5554.68,,,5554.68,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.5,,,2.5,Other,Drug Cost,2.5,,,2.5,Other,Drug Cost,3.13,,,3.13,Other,125% Medicaid APG methodology,0.01,5709,
TET-DIP TOX(TD) 2UN-0.5ML SUSP  ,90714,CPT,,40528093,CDM,636,RC,13533-0131-01,NDC,both,1,EA,140.46,299.4,,,299.4,Other,150% of Medicare + 9.63% HCRA Surcharge,182.06,,,182.06,Fee Schedule,Average Sale Price (ASP) x 6,42.14,30,,42.14,percent of total billed charges,Drugs,42.14,30,,42.14,percent of total billed charges,Drugs,42.14,30,,42.14,percent of total billed charges,Drugs,42.14,30,,42.14,percent of total billed charges,Drugs,42.14,30,,42.14,percent of total billed charges,Drugs,70.23,50,,70.23,percent of total billed charges,All Other,42.14,30,,42.14,percent of total billed charges,Drugs,42.14,30,,42.14,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,42.14,30,,42.14,percent of total billed charges,Drugs,42.14,30,,42.14,percent of total billed charges,Drugs,42.14,30,,42.14,percent of total billed charges,Drugs,42.14,30,,42.14,percent of total billed charges,Drugs,42.14,30,,42.14,percent of total billed charges,Drugs,42.14,30,,42.14,percent of total billed charges,Drugs,42.14,30,,42.14,percent of total billed charges,Drugs,42.14,30,,42.14,percent of total billed charges,Drugs,42.14,30,,42.14,percent of total billed charges,Drugs,42.14,30,,42.14,percent of total billed charges,Drugs,42.14,30,,42.14,percent of total billed charges,Drugs,42.14,30,,42.14,percent of total billed charges,Drugs,42.14,30,,42.14,percent of total billed charges,Drugs,47.36,,,47.36,Other,Drug Cost,47.36,,,47.36,Other,Drug Cost,47.36,,,47.36,Other,Drug Cost,47.36,,,47.36,Other,Drug Cost,47.36,,,47.36,Other,Drug Cost,47.76,34,,47.76,percent of total billed charges,Drugs,47.36,,,47.36,Other,Drug Cost,106.56,,,106.56,Other,225% Medicaid APG methodology,66.3,,,66.3,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,291.3,,,291.3,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",47.36,,,47.36,Other,Drug Cost,47.36,,,47.36,Other,Drug Cost,59.2,,,59.2,Other,125% Medicaid APG methodology,0.01,299.4,
MEASLES/MUMPS/RUBELLA VACCINE   ,90707,CPT,,40528101,CDM,636,RC,00006-4681-00,NDC,both,1,EA,248.19,97.95,39.4668,,97.95,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,74.46,30,,74.46,percent of total billed charges,Drugs,74.46,30,,74.46,percent of total billed charges,Drugs,74.46,30,,74.46,percent of total billed charges,Drugs,74.46,30,,74.46,percent of total billed charges,Drugs,74.46,30,,74.46,percent of total billed charges,Drugs,124.1,50,,124.1,percent of total billed charges,All Other,74.46,30,,74.46,percent of total billed charges,Drugs,74.46,30,,74.46,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,74.46,30,,74.46,percent of total billed charges,Drugs,74.46,30,,74.46,percent of total billed charges,Drugs,74.46,30,,74.46,percent of total billed charges,Drugs,74.46,30,,74.46,percent of total billed charges,Drugs,74.46,30,,74.46,percent of total billed charges,Drugs,74.46,30,,74.46,percent of total billed charges,Drugs,74.46,30,,74.46,percent of total billed charges,Drugs,74.46,30,,74.46,percent of total billed charges,Drugs,74.46,30,,74.46,percent of total billed charges,Drugs,74.46,30,,74.46,percent of total billed charges,Drugs,74.46,30,,74.46,percent of total billed charges,Drugs,74.46,30,,74.46,percent of total billed charges,Drugs,74.46,30,,74.46,percent of total billed charges,Drugs,74.29,,,74.29,Other,Drug Cost,74.29,,,74.29,Other,Drug Cost,74.29,,,74.29,Other,Drug Cost,74.29,,,74.29,Other,Drug Cost,74.29,,,74.29,Other,Drug Cost,84.38,34,,84.38,percent of total billed charges,Drugs,74.29,,,74.29,Other,Drug Cost,167.15,,,167.15,Other,225% Medicaid APG methodology,104.01,,,104.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",74.29,,,74.29,Other,Drug Cost,74.29,,,74.29,Other,Drug Cost,92.86,,,92.86,Other,125% Medicaid APG methodology,0.01,167.15,
GANCICLOVIR 500 MG IV INJ       ,J1570,HCPCS,,40528143,CDM,636,RC,63323-0315-10,NDC,both,1,EA,157.01,443.23,,,443.23,Other,150% of Medicare + 9.63% HCRA Surcharge,269.53,,,269.53,Fee Schedule,Average Sale Price (ASP) x 6,47.1,30,,47.1,percent of total billed charges,Drugs,47.1,30,,47.1,percent of total billed charges,Drugs,47.1,30,,47.1,percent of total billed charges,Drugs,47.1,30,,47.1,percent of total billed charges,Drugs,47.1,30,,47.1,percent of total billed charges,Drugs,78.51,50,,78.51,percent of total billed charges,All Other,47.1,30,,47.1,percent of total billed charges,Drugs,47.1,30,,47.1,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,47.1,30,,47.1,percent of total billed charges,Drugs,47.1,30,,47.1,percent of total billed charges,Drugs,47.1,30,,47.1,percent of total billed charges,Drugs,47.1,30,,47.1,percent of total billed charges,Drugs,47.1,30,,47.1,percent of total billed charges,Drugs,47.1,30,,47.1,percent of total billed charges,Drugs,47.1,30,,47.1,percent of total billed charges,Drugs,47.1,30,,47.1,percent of total billed charges,Drugs,47.1,30,,47.1,percent of total billed charges,Drugs,47.1,30,,47.1,percent of total billed charges,Drugs,47.1,30,,47.1,percent of total billed charges,Drugs,47.1,30,,47.1,percent of total billed charges,Drugs,47.1,30,,47.1,percent of total billed charges,Drugs,33.8,,,33.8,Other,Drug Cost,33.8,,,33.8,Other,Drug Cost,33.8,,,33.8,Other,Drug Cost,33.8,,,33.8,Other,Drug Cost,33.8,,,33.8,Other,Drug Cost,53.38,34,,53.38,percent of total billed charges,Drugs,33.8,,,33.8,Other,Drug Cost,76.05,,,76.05,Other,225% Medicaid APG methodology,47.32,,,47.32,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,431.25,,,431.25,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",33.8,,,33.8,Other,Drug Cost,33.8,,,33.8,Other,Drug Cost,42.25,,,42.25,Other,125% Medicaid APG methodology,0.01,443.23,
RAMUCIRUMAB 10MG/ML IVSLN 50ML  ,J9308,HCPCS,,40528531,CDM,636,RC,00002-7678-01,NDC,both,50,ML,22644.44,693.08,,,693.08,Other,150% of Medicare + 9.63% HCRA Surcharge,421.46,,,421.46,Fee Schedule,Average Sale Price (ASP) x 6,6793.33,30,,6793.33,percent of total billed charges,Drugs,6793.33,30,,6793.33,percent of total billed charges,Drugs,6793.33,30,,6793.33,percent of total billed charges,Drugs,6793.33,30,,6793.33,percent of total billed charges,Drugs,6793.33,30,,6793.33,percent of total billed charges,Drugs,11322.22,50,,11322.22,percent of total billed charges,All Other,6793.33,30,,6793.33,percent of total billed charges,Drugs,6793.33,30,,6793.33,percent of total billed charges,Drugs,7699.11,34,"If Charge > 500, then 34 percent",7699.11,percent of total billed charges,Drugs,6793.33,30,,6793.33,percent of total billed charges,Drugs,6793.33,30,,6793.33,percent of total billed charges,Drugs,6793.33,30,,6793.33,percent of total billed charges,Drugs,6793.33,30,,6793.33,percent of total billed charges,Drugs,6793.33,30,,6793.33,percent of total billed charges,Drugs,6793.33,30,,6793.33,percent of total billed charges,Drugs,6793.33,30,,6793.33,percent of total billed charges,Drugs,6793.33,30,,6793.33,percent of total billed charges,Drugs,6793.33,30,,6793.33,percent of total billed charges,Drugs,6793.33,30,,6793.33,percent of total billed charges,Drugs,6793.33,30,,6793.33,percent of total billed charges,Drugs,6793.33,30,,6793.33,percent of total billed charges,Drugs,6793.33,30,,6793.33,percent of total billed charges,Drugs,4414.31,,,4414.31,Other,Drug Cost,4414.31,,,4414.31,Other,Drug Cost,4414.31,,,4414.31,Other,Drug Cost,4414.31,,,4414.31,Other,Drug Cost,4414.31,,,4414.31,Other,Drug Cost,7699.11,34,,7699.11,percent of total billed charges,Drugs,4414.31,,,4414.31,Other,Drug Cost,9932.2,,,9932.2,Other,225% Medicaid APG methodology,6180.03,,,6180.03,Other,140% Medicaid APG methodology,7699.11,34,"If Charge > 2,000, then 34 percent",7699.11,percent of total billed charges,Drugs,674.34,,,674.34,Other,160% Medicare Fee Schedule,7699.11,34,,7699.11,Other,"Drug Charges > 20,000, then 34% of Charges",4414.31,,,4414.31,Other,Drug Cost,4414.31,,,4414.31,Other,Drug Cost,5517.89,,,5517.89,Other,125% Medicaid APG methodology,421.46,11322.22,
FAMOTIDINE 10MG/ML IV SOLN 2ML  ,J3490,HCPCS,,40528572,CDM,636,RC,63323-0739-12,NDC,both,2,ML,2.94,1.16,39.4668,,1.16,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.88,30,,0.88,percent of total billed charges,Drugs,0.88,30,,0.88,percent of total billed charges,Drugs,0.88,30,,0.88,percent of total billed charges,Drugs,0.88,30,,0.88,percent of total billed charges,Drugs,0.88,30,,0.88,percent of total billed charges,Drugs,1.47,50,,1.47,percent of total billed charges,All Other,0.88,30,,0.88,percent of total billed charges,Drugs,0.88,30,,0.88,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.88,30,,0.88,percent of total billed charges,Drugs,0.88,30,,0.88,percent of total billed charges,Drugs,0.88,30,,0.88,percent of total billed charges,Drugs,0.88,30,,0.88,percent of total billed charges,Drugs,0.88,30,,0.88,percent of total billed charges,Drugs,0.88,30,,0.88,percent of total billed charges,Drugs,0.88,30,,0.88,percent of total billed charges,Drugs,0.88,30,,0.88,percent of total billed charges,Drugs,0.88,30,,0.88,percent of total billed charges,Drugs,0.88,30,,0.88,percent of total billed charges,Drugs,0.88,30,,0.88,percent of total billed charges,Drugs,0.88,30,,0.88,percent of total billed charges,Drugs,0.88,30,,0.88,percent of total billed charges,Drugs,0.4,,,0.4,Other,Drug Cost,0.4,,,0.4,Other,Drug Cost,0.4,,,0.4,Other,Drug Cost,0.4,,,0.4,Other,Drug Cost,0.4,,,0.4,Other,Drug Cost,1,34,,1,percent of total billed charges,Drugs,0.4,,,0.4,Other,Drug Cost,0.9,,,0.9,Other,225% Medicaid APG methodology,0.56,,,0.56,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.4,,,0.4,Other,Drug Cost,0.4,,,0.4,Other,Drug Cost,0.5,,,0.5,Other,125% Medicaid APG methodology,0.01,1.47,
AZATHIOPRINE 50 MG TAB          ,J7500,HCPCS,,40528705,CDM,636,RC,68084-0229-01,NDC,both,1,EA,1.75,44.98,,,44.98,Other,150% of Medicare + 9.63% HCRA Surcharge,27.35,,,27.35,Fee Schedule,Average Sale Price (ASP) x 6,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.88,50,,0.88,percent of total billed charges,All Other,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.53,30,,0.53,percent of total billed charges,Drugs,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.6,34,,0.6,percent of total billed charges,Drugs,0.25,,,0.25,Other,Drug Cost,0.56,,,0.56,Other,225% Medicaid APG methodology,0.35,,,0.35,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,43.77,,,43.77,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.25,,,0.25,Other,Drug Cost,0.25,,,0.25,Other,Drug Cost,0.31,,,0.31,Other,125% Medicaid APG methodology,0.01,44.98,
HEPARIN 1000 UNITS/ML INJ 10ML  ,J1644,HCPCS,,40528770,CDM,636,RC,63323-0540-15,NDC,both,10,ML,6.41,2.64,,,2.64,Other,150% of Medicare + 9.63% HCRA Surcharge,1.61,,,1.61,Fee Schedule,Average Sale Price (ASP) x 6,1.92,30,,1.92,percent of total billed charges,Drugs,1.92,30,,1.92,percent of total billed charges,Drugs,1.92,30,,1.92,percent of total billed charges,Drugs,1.92,30,,1.92,percent of total billed charges,Drugs,1.92,30,,1.92,percent of total billed charges,Drugs,3.21,50,,3.21,percent of total billed charges,All Other,1.92,30,,1.92,percent of total billed charges,Drugs,1.92,30,,1.92,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.92,30,,1.92,percent of total billed charges,Drugs,1.92,30,,1.92,percent of total billed charges,Drugs,1.92,30,,1.92,percent of total billed charges,Drugs,1.92,30,,1.92,percent of total billed charges,Drugs,1.92,30,,1.92,percent of total billed charges,Drugs,1.92,30,,1.92,percent of total billed charges,Drugs,1.92,30,,1.92,percent of total billed charges,Drugs,1.92,30,,1.92,percent of total billed charges,Drugs,1.92,30,,1.92,percent of total billed charges,Drugs,1.92,30,,1.92,percent of total billed charges,Drugs,1.92,30,,1.92,percent of total billed charges,Drugs,1.92,30,,1.92,percent of total billed charges,Drugs,1.92,30,,1.92,percent of total billed charges,Drugs,0.83,,,0.83,Other,Drug Cost,0.83,,,0.83,Other,Drug Cost,0.83,,,0.83,Other,Drug Cost,0.83,,,0.83,Other,Drug Cost,0.83,,,0.83,Other,Drug Cost,2.18,34,,2.18,percent of total billed charges,Drugs,0.83,,,0.83,Other,Drug Cost,1.87,,,1.87,Other,225% Medicaid APG methodology,1.16,,,1.16,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.57,,,2.57,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.83,,,0.83,Other,Drug Cost,0.83,,,0.83,Other,Drug Cost,1.04,,,1.04,Other,125% Medicaid APG methodology,0.01,3.21,
MYCOPHENOLATE MOFETIL 500MGTAB  ,J7517,HCPCS,,40528986,CDM,636,RC,64380-0725-06,NDC,both,1,EA,1.61,1.85,,,1.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1.13,,,1.13,Fee Schedule,Average Sale Price (ASP) x 6,0.48,30,,0.48,percent of total billed charges,Drugs,0.48,30,,0.48,percent of total billed charges,Drugs,0.48,30,,0.48,percent of total billed charges,Drugs,0.48,30,,0.48,percent of total billed charges,Drugs,0.48,30,,0.48,percent of total billed charges,Drugs,0.81,50,,0.81,percent of total billed charges,All Other,0.48,30,,0.48,percent of total billed charges,Drugs,0.48,30,,0.48,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.48,30,,0.48,percent of total billed charges,Drugs,0.48,30,,0.48,percent of total billed charges,Drugs,0.48,30,,0.48,percent of total billed charges,Drugs,0.48,30,,0.48,percent of total billed charges,Drugs,0.48,30,,0.48,percent of total billed charges,Drugs,0.48,30,,0.48,percent of total billed charges,Drugs,0.48,30,,0.48,percent of total billed charges,Drugs,0.48,30,,0.48,percent of total billed charges,Drugs,0.48,30,,0.48,percent of total billed charges,Drugs,0.48,30,,0.48,percent of total billed charges,Drugs,0.48,30,,0.48,percent of total billed charges,Drugs,0.48,30,,0.48,percent of total billed charges,Drugs,0.48,30,,0.48,percent of total billed charges,Drugs,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.55,34,,0.55,percent of total billed charges,Drugs,0.13,,,0.13,Other,Drug Cost,0.29,,,0.29,Other,225% Medicaid APG methodology,0.18,,,0.18,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.8,,,1.8,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.13,,,0.13,Other,Drug Cost,0.13,,,0.13,Other,Drug Cost,0.16,,,0.16,Other,125% Medicaid APG methodology,0.01,1.85,
EPTIFIBATIDE 0.75MG/ML IV100ML  ,J1327,HCPCS,,40529190,CDM,636,RC,67457-0631-10,NDC,both,100,ML,204.96,80.89,39.4668,,80.89,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,61.49,30,,61.49,percent of total billed charges,Drugs,61.49,30,,61.49,percent of total billed charges,Drugs,61.49,30,,61.49,percent of total billed charges,Drugs,61.49,30,,61.49,percent of total billed charges,Drugs,61.49,30,,61.49,percent of total billed charges,Drugs,102.48,50,,102.48,percent of total billed charges,All Other,61.49,30,,61.49,percent of total billed charges,Drugs,61.49,30,,61.49,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,61.49,30,,61.49,percent of total billed charges,Drugs,61.49,30,,61.49,percent of total billed charges,Drugs,61.49,30,,61.49,percent of total billed charges,Drugs,61.49,30,,61.49,percent of total billed charges,Drugs,61.49,30,,61.49,percent of total billed charges,Drugs,61.49,30,,61.49,percent of total billed charges,Drugs,61.49,30,,61.49,percent of total billed charges,Drugs,61.49,30,,61.49,percent of total billed charges,Drugs,61.49,30,,61.49,percent of total billed charges,Drugs,61.49,30,,61.49,percent of total billed charges,Drugs,61.49,30,,61.49,percent of total billed charges,Drugs,61.49,30,,61.49,percent of total billed charges,Drugs,61.49,30,,61.49,percent of total billed charges,Drugs,13.88,,,13.88,Other,Drug Cost,13.88,,,13.88,Other,Drug Cost,13.88,,,13.88,Other,Drug Cost,13.88,,,13.88,Other,Drug Cost,13.88,,,13.88,Other,Drug Cost,69.69,34,,69.69,percent of total billed charges,Drugs,13.88,,,13.88,Other,Drug Cost,31.23,,,31.23,Other,225% Medicaid APG methodology,19.43,,,19.43,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",13.88,,,13.88,Other,Drug Cost,13.88,,,13.88,Other,Drug Cost,17.35,,,17.35,Other,125% Medicaid APG methodology,0.01,102.48,
EPTIFIBATIDE 2MG/ML IV  10ML    ,J1327,HCPCS,,40529208,CDM,636,RC,67457-0629-10,NDC,both,10,ML,65.03,25.67,39.4668,,25.67,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,19.51,30,,19.51,percent of total billed charges,Drugs,19.51,30,,19.51,percent of total billed charges,Drugs,19.51,30,,19.51,percent of total billed charges,Drugs,19.51,30,,19.51,percent of total billed charges,Drugs,19.51,30,,19.51,percent of total billed charges,Drugs,32.52,50,,32.52,percent of total billed charges,All Other,19.51,30,,19.51,percent of total billed charges,Drugs,19.51,30,,19.51,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,19.51,30,,19.51,percent of total billed charges,Drugs,19.51,30,,19.51,percent of total billed charges,Drugs,19.51,30,,19.51,percent of total billed charges,Drugs,19.51,30,,19.51,percent of total billed charges,Drugs,19.51,30,,19.51,percent of total billed charges,Drugs,19.51,30,,19.51,percent of total billed charges,Drugs,19.51,30,,19.51,percent of total billed charges,Drugs,19.51,30,,19.51,percent of total billed charges,Drugs,19.51,30,,19.51,percent of total billed charges,Drugs,19.51,30,,19.51,percent of total billed charges,Drugs,19.51,30,,19.51,percent of total billed charges,Drugs,19.51,30,,19.51,percent of total billed charges,Drugs,19.51,30,,19.51,percent of total billed charges,Drugs,4.26,,,4.26,Other,Drug Cost,4.26,,,4.26,Other,Drug Cost,4.26,,,4.26,Other,Drug Cost,4.26,,,4.26,Other,Drug Cost,4.26,,,4.26,Other,Drug Cost,22.11,34,,22.11,percent of total billed charges,Drugs,4.26,,,4.26,Other,Drug Cost,9.59,,,9.59,Other,225% Medicaid APG methodology,5.96,,,5.96,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.26,,,4.26,Other,Drug Cost,4.26,,,4.26,Other,Drug Cost,5.33,,,5.33,Other,125% Medicaid APG methodology,0.01,32.52,
CAFFEINE CITRATE20MG/ML IV 3ML  ,J0706,HCPCS,,40529299,CDM,636,RC,51754-0500-01,NDC,both,3,ML,19.71,7.78,39.4668,,7.78,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,9.86,50,,9.86,percent of total billed charges,All Other,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,5.91,30,,5.91,percent of total billed charges,Drugs,4.32,,,4.32,Other,Drug Cost,4.32,,,4.32,Other,Drug Cost,4.32,,,4.32,Other,Drug Cost,4.32,,,4.32,Other,Drug Cost,4.32,,,4.32,Other,Drug Cost,6.7,34,,6.7,percent of total billed charges,Drugs,4.32,,,4.32,Other,Drug Cost,9.72,,,9.72,Other,225% Medicaid APG methodology,6.05,,,6.05,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.32,,,4.32,Other,Drug Cost,4.32,,,4.32,Other,Drug Cost,5.4,,,5.4,Other,125% Medicaid APG methodology,0.01,9.86,
CIPROFLOXACIN 200MGD5W IV100ML  ,J0744,HCPCS,,40529349,CDM,636,RC,36000-0008-24,NDC,both,100,ML,4.87,19.07,,,19.07,Other,150% of Medicare + 9.63% HCRA Surcharge,11.6,,,11.6,Fee Schedule,Average Sale Price (ASP) x 6,1.46,30,,1.46,percent of total billed charges,Drugs,1.46,30,,1.46,percent of total billed charges,Drugs,1.46,30,,1.46,percent of total billed charges,Drugs,1.46,30,,1.46,percent of total billed charges,Drugs,1.46,30,,1.46,percent of total billed charges,Drugs,2.44,50,,2.44,percent of total billed charges,All Other,1.46,30,,1.46,percent of total billed charges,Drugs,1.46,30,,1.46,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.46,30,,1.46,percent of total billed charges,Drugs,1.46,30,,1.46,percent of total billed charges,Drugs,1.46,30,,1.46,percent of total billed charges,Drugs,1.46,30,,1.46,percent of total billed charges,Drugs,1.46,30,,1.46,percent of total billed charges,Drugs,1.46,30,,1.46,percent of total billed charges,Drugs,1.46,30,,1.46,percent of total billed charges,Drugs,1.46,30,,1.46,percent of total billed charges,Drugs,1.46,30,,1.46,percent of total billed charges,Drugs,1.46,30,,1.46,percent of total billed charges,Drugs,1.46,30,,1.46,percent of total billed charges,Drugs,1.46,30,,1.46,percent of total billed charges,Drugs,1.46,30,,1.46,percent of total billed charges,Drugs,1.29,,,1.29,Other,Drug Cost,1.29,,,1.29,Other,Drug Cost,1.29,,,1.29,Other,Drug Cost,1.29,,,1.29,Other,Drug Cost,1.29,,,1.29,Other,Drug Cost,1.66,34,,1.66,percent of total billed charges,Drugs,1.29,,,1.29,Other,Drug Cost,2.9,,,2.9,Other,225% Medicaid APG methodology,1.81,,,1.81,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,18.56,,,18.56,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.29,,,1.29,Other,Drug Cost,1.29,,,1.29,Other,Drug Cost,1.61,,,1.61,Other,125% Medicaid APG methodology,0.01,19.07,
CIPROFLOXACIN 400MGD5W IV200ML  ,J0744,HCPCS,,40529356,CDM,636,RC,36000-0009-24,NDC,both,200,ML,7.04,19.07,,,19.07,Other,150% of Medicare + 9.63% HCRA Surcharge,11.6,,,11.6,Fee Schedule,Average Sale Price (ASP) x 6,2.11,30,,2.11,percent of total billed charges,Drugs,2.11,30,,2.11,percent of total billed charges,Drugs,2.11,30,,2.11,percent of total billed charges,Drugs,2.11,30,,2.11,percent of total billed charges,Drugs,2.11,30,,2.11,percent of total billed charges,Drugs,3.52,50,,3.52,percent of total billed charges,All Other,2.11,30,,2.11,percent of total billed charges,Drugs,2.11,30,,2.11,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.11,30,,2.11,percent of total billed charges,Drugs,2.11,30,,2.11,percent of total billed charges,Drugs,2.11,30,,2.11,percent of total billed charges,Drugs,2.11,30,,2.11,percent of total billed charges,Drugs,2.11,30,,2.11,percent of total billed charges,Drugs,2.11,30,,2.11,percent of total billed charges,Drugs,2.11,30,,2.11,percent of total billed charges,Drugs,2.11,30,,2.11,percent of total billed charges,Drugs,2.11,30,,2.11,percent of total billed charges,Drugs,2.11,30,,2.11,percent of total billed charges,Drugs,2.11,30,,2.11,percent of total billed charges,Drugs,2.11,30,,2.11,percent of total billed charges,Drugs,2.11,30,,2.11,percent of total billed charges,Drugs,1.82,,,1.82,Other,Drug Cost,1.82,,,1.82,Other,Drug Cost,1.82,,,1.82,Other,Drug Cost,1.82,,,1.82,Other,Drug Cost,1.82,,,1.82,Other,Drug Cost,2.39,34,,2.39,percent of total billed charges,Drugs,1.82,,,1.82,Other,Drug Cost,4.1,,,4.1,Other,225% Medicaid APG methodology,2.55,,,2.55,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,18.56,,,18.56,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.82,,,1.82,Other,Drug Cost,1.82,,,1.82,Other,Drug Cost,2.28,,,2.28,Other,125% Medicaid APG methodology,0.01,19.07,
IMIPENEM-CILASTATIN 500MG INJ   ,J0743,HCPCS,,40529844,CDM,636,RC,63323-0322-25,NDC,both,1,EA,34.72,79.95,,,79.95,Other,150% of Medicare + 9.63% HCRA Surcharge,48.62,,,48.62,Fee Schedule,Average Sale Price (ASP) x 6,10.42,30,,10.42,percent of total billed charges,Drugs,10.42,30,,10.42,percent of total billed charges,Drugs,10.42,30,,10.42,percent of total billed charges,Drugs,10.42,30,,10.42,percent of total billed charges,Drugs,10.42,30,,10.42,percent of total billed charges,Drugs,17.36,50,,17.36,percent of total billed charges,All Other,10.42,30,,10.42,percent of total billed charges,Drugs,10.42,30,,10.42,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,10.42,30,,10.42,percent of total billed charges,Drugs,10.42,30,,10.42,percent of total billed charges,Drugs,10.42,30,,10.42,percent of total billed charges,Drugs,10.42,30,,10.42,percent of total billed charges,Drugs,10.42,30,,10.42,percent of total billed charges,Drugs,10.42,30,,10.42,percent of total billed charges,Drugs,10.42,30,,10.42,percent of total billed charges,Drugs,10.42,30,,10.42,percent of total billed charges,Drugs,10.42,30,,10.42,percent of total billed charges,Drugs,10.42,30,,10.42,percent of total billed charges,Drugs,10.42,30,,10.42,percent of total billed charges,Drugs,10.42,30,,10.42,percent of total billed charges,Drugs,10.42,30,,10.42,percent of total billed charges,Drugs,5.68,,,5.68,Other,Drug Cost,5.68,,,5.68,Other,Drug Cost,5.68,,,5.68,Other,Drug Cost,5.68,,,5.68,Other,Drug Cost,5.68,,,5.68,Other,Drug Cost,11.8,34,,11.8,percent of total billed charges,Drugs,5.68,,,5.68,Other,Drug Cost,12.78,,,12.78,Other,225% Medicaid APG methodology,7.95,,,7.95,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,77.79,,,77.79,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.68,,,5.68,Other,Drug Cost,5.68,,,5.68,Other,Drug Cost,7.1,,,7.1,Other,125% Medicaid APG methodology,0.01,79.95,
POLIOVIRUS VACC INACT INJ  5ML  ,90713,CPT,,40529976,CDM,636,RC,49281-0860-10,NDC,both,0.5,ML,108.99,43.01,39.4668,,43.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,32.7,30,,32.7,percent of total billed charges,Drugs,32.7,30,,32.7,percent of total billed charges,Drugs,32.7,30,,32.7,percent of total billed charges,Drugs,32.7,30,,32.7,percent of total billed charges,Drugs,32.7,30,,32.7,percent of total billed charges,Drugs,54.5,50,,54.5,percent of total billed charges,All Other,32.7,30,,32.7,percent of total billed charges,Drugs,32.7,30,,32.7,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,32.7,30,,32.7,percent of total billed charges,Drugs,32.7,30,,32.7,percent of total billed charges,Drugs,32.7,30,,32.7,percent of total billed charges,Drugs,32.7,30,,32.7,percent of total billed charges,Drugs,32.7,30,,32.7,percent of total billed charges,Drugs,32.7,30,,32.7,percent of total billed charges,Drugs,32.7,30,,32.7,percent of total billed charges,Drugs,32.7,30,,32.7,percent of total billed charges,Drugs,32.7,30,,32.7,percent of total billed charges,Drugs,32.7,30,,32.7,percent of total billed charges,Drugs,32.7,30,,32.7,percent of total billed charges,Drugs,32.7,30,,32.7,percent of total billed charges,Drugs,32.7,30,,32.7,percent of total billed charges,Drugs,29.6,,,29.6,Other,Drug Cost,29.6,,,29.6,Other,Drug Cost,29.6,,,29.6,Other,Drug Cost,29.6,,,29.6,Other,Drug Cost,29.6,,,29.6,Other,Drug Cost,37.06,34,,37.06,percent of total billed charges,Drugs,29.6,,,29.6,Other,Drug Cost,66.6,,,66.6,Other,225% Medicaid APG methodology,41.44,,,41.44,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",29.6,,,29.6,Other,Drug Cost,29.6,,,29.6,Other,Drug Cost,37,,,37,Other,125% Medicaid APG methodology,0.01,66.6,
IFOSFAMIDE 50MG/ML IV SLN 60ML  ,J9208,HCPCS,,40530073,CDM,636,RC,10019-0926-02,NDC,both,1,EA,290.08,263.95,,,263.95,Other,150% of Medicare + 9.63% HCRA Surcharge,160.51,,,160.51,Fee Schedule,Average Sale Price (ASP) x 6,87.02,30,,87.02,percent of total billed charges,Drugs,87.02,30,,87.02,percent of total billed charges,Drugs,87.02,30,,87.02,percent of total billed charges,Drugs,87.02,30,,87.02,percent of total billed charges,Drugs,87.02,30,,87.02,percent of total billed charges,Drugs,145.04,50,,145.04,percent of total billed charges,All Other,87.02,30,,87.02,percent of total billed charges,Drugs,87.02,30,,87.02,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,87.02,30,,87.02,percent of total billed charges,Drugs,87.02,30,,87.02,percent of total billed charges,Drugs,87.02,30,,87.02,percent of total billed charges,Drugs,87.02,30,,87.02,percent of total billed charges,Drugs,87.02,30,,87.02,percent of total billed charges,Drugs,87.02,30,,87.02,percent of total billed charges,Drugs,87.02,30,,87.02,percent of total billed charges,Drugs,87.02,30,,87.02,percent of total billed charges,Drugs,87.02,30,,87.02,percent of total billed charges,Drugs,87.02,30,,87.02,percent of total billed charges,Drugs,87.02,30,,87.02,percent of total billed charges,Drugs,87.02,30,,87.02,percent of total billed charges,Drugs,87.02,30,,87.02,percent of total billed charges,Drugs,53.94,,,53.94,Other,Drug Cost,53.94,,,53.94,Other,Drug Cost,53.94,,,53.94,Other,Drug Cost,53.94,,,53.94,Other,Drug Cost,53.94,,,53.94,Other,Drug Cost,98.63,34,,98.63,percent of total billed charges,Drugs,53.94,,,53.94,Other,Drug Cost,121.37,,,121.37,Other,225% Medicaid APG methodology,75.52,,,75.52,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,256.82,,,256.82,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",53.94,,,53.94,Other,Drug Cost,53.94,,,53.94,Other,Drug Cost,67.43,,,67.43,Other,125% Medicaid APG methodology,0.01,263.95,
MYCOPHEN MOFE 200MG/ML 5ML      ,J7517,HCPCS,,40530446,CDM,636,RC,66689-0307-05,NDC,both,5,ML,45.96,1.85,,,1.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1.13,,,1.13,Fee Schedule,Average Sale Price (ASP) x 6,13.79,30,,13.79,percent of total billed charges,Drugs,13.79,30,,13.79,percent of total billed charges,Drugs,13.79,30,,13.79,percent of total billed charges,Drugs,13.79,30,,13.79,percent of total billed charges,Drugs,13.79,30,,13.79,percent of total billed charges,Drugs,22.98,50,,22.98,percent of total billed charges,All Other,13.79,30,,13.79,percent of total billed charges,Drugs,13.79,30,,13.79,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,13.79,30,,13.79,percent of total billed charges,Drugs,13.79,30,,13.79,percent of total billed charges,Drugs,13.79,30,,13.79,percent of total billed charges,Drugs,13.79,30,,13.79,percent of total billed charges,Drugs,13.79,30,,13.79,percent of total billed charges,Drugs,13.79,30,,13.79,percent of total billed charges,Drugs,13.79,30,,13.79,percent of total billed charges,Drugs,13.79,30,,13.79,percent of total billed charges,Drugs,13.79,30,,13.79,percent of total billed charges,Drugs,13.79,30,,13.79,percent of total billed charges,Drugs,13.79,30,,13.79,percent of total billed charges,Drugs,13.79,30,,13.79,percent of total billed charges,Drugs,13.79,30,,13.79,percent of total billed charges,Drugs,1.35,,,1.35,Other,Drug Cost,1.35,,,1.35,Other,Drug Cost,1.35,,,1.35,Other,Drug Cost,1.35,,,1.35,Other,Drug Cost,1.35,,,1.35,Other,Drug Cost,15.63,34,,15.63,percent of total billed charges,Drugs,1.35,,,1.35,Other,Drug Cost,3.04,,,3.04,Other,225% Medicaid APG methodology,1.89,,,1.89,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.8,,,1.8,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.35,,,1.35,Other,Drug Cost,1.35,,,1.35,Other,Drug Cost,1.69,,,1.69,Other,125% Medicaid APG methodology,0.01,22.98,
DEXTRAN 10%-NS SOL 500ML        ,J7100,HCPCS,,40530594,CDM,636,RC,00409-7419-03,NDC,both,500,ML,78.58,31.01,39.4668,,31.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,23.57,30,,23.57,percent of total billed charges,Drugs,23.57,30,,23.57,percent of total billed charges,Drugs,23.57,30,,23.57,percent of total billed charges,Drugs,23.57,30,,23.57,percent of total billed charges,Drugs,23.57,30,,23.57,percent of total billed charges,Drugs,39.29,50,,39.29,percent of total billed charges,All Other,23.57,30,,23.57,percent of total billed charges,Drugs,23.57,30,,23.57,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,23.57,30,,23.57,percent of total billed charges,Drugs,23.57,30,,23.57,percent of total billed charges,Drugs,23.57,30,,23.57,percent of total billed charges,Drugs,23.57,30,,23.57,percent of total billed charges,Drugs,23.57,30,,23.57,percent of total billed charges,Drugs,23.57,30,,23.57,percent of total billed charges,Drugs,23.57,30,,23.57,percent of total billed charges,Drugs,23.57,30,,23.57,percent of total billed charges,Drugs,23.57,30,,23.57,percent of total billed charges,Drugs,23.57,30,,23.57,percent of total billed charges,Drugs,23.57,30,,23.57,percent of total billed charges,Drugs,23.57,30,,23.57,percent of total billed charges,Drugs,23.57,30,,23.57,percent of total billed charges,Drugs,16.37,,,16.37,Other,Drug Cost,16.37,,,16.37,Other,Drug Cost,16.37,,,16.37,Other,Drug Cost,16.37,,,16.37,Other,Drug Cost,16.37,,,16.37,Other,Drug Cost,26.72,34,,26.72,percent of total billed charges,Drugs,16.37,,,16.37,Other,Drug Cost,36.83,,,36.83,Other,225% Medicaid APG methodology,22.92,,,22.92,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",16.37,,,16.37,Other,Drug Cost,16.37,,,16.37,Other,Drug Cost,20.46,,,20.46,Other,125% Medicaid APG methodology,0.01,39.29,
PACLITAXEL 6MG/ML IV  16.7ML    ,J9267,HCPCS,,40530727,CDM,636,RC,44567-0505-01,NDC,both,16.7,ML,115.5,1.07,,,1.07,Other,150% of Medicare + 9.63% HCRA Surcharge,0.65,,,0.65,Fee Schedule,Average Sale Price (ASP) x 6,34.65,30,,34.65,percent of total billed charges,Drugs,34.65,30,,34.65,percent of total billed charges,Drugs,34.65,30,,34.65,percent of total billed charges,Drugs,34.65,30,,34.65,percent of total billed charges,Drugs,34.65,30,,34.65,percent of total billed charges,Drugs,57.75,50,,57.75,percent of total billed charges,All Other,34.65,30,,34.65,percent of total billed charges,Drugs,34.65,30,,34.65,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,34.65,30,,34.65,percent of total billed charges,Drugs,34.65,30,,34.65,percent of total billed charges,Drugs,34.65,30,,34.65,percent of total billed charges,Drugs,34.65,30,,34.65,percent of total billed charges,Drugs,34.65,30,,34.65,percent of total billed charges,Drugs,34.65,30,,34.65,percent of total billed charges,Drugs,34.65,30,,34.65,percent of total billed charges,Drugs,34.65,30,,34.65,percent of total billed charges,Drugs,34.65,30,,34.65,percent of total billed charges,Drugs,34.65,30,,34.65,percent of total billed charges,Drugs,34.65,30,,34.65,percent of total billed charges,Drugs,34.65,30,,34.65,percent of total billed charges,Drugs,34.65,30,,34.65,percent of total billed charges,Drugs,33,,,33,Other,Drug Cost,33,,,33,Other,Drug Cost,33,,,33,Other,Drug Cost,33,,,33,Other,Drug Cost,33,,,33,Other,Drug Cost,39.27,34,,39.27,percent of total billed charges,Drugs,33,,,33,Other,Drug Cost,74.25,,,74.25,Other,225% Medicaid APG methodology,46.2,,,46.2,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.04,,,1.04,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",33,,,33,Other,Drug Cost,33,,,33,Other,Drug Cost,41.25,,,41.25,Other,125% Medicaid APG methodology,0.01,74.25,
VASOPRESSIN 20 UNITS/ML IV 1ML  ,J3490,HCPCS,,40530768,CDM,636,RC,42023-0164-25,NDC,both,1,ML,572.71,226.03,39.4668,,226.03,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,171.81,30,,171.81,percent of total billed charges,Drugs,171.81,30,,171.81,percent of total billed charges,Drugs,171.81,30,,171.81,percent of total billed charges,Drugs,171.81,30,,171.81,percent of total billed charges,Drugs,171.81,30,,171.81,percent of total billed charges,Drugs,286.36,50,,286.36,percent of total billed charges,All Other,171.81,30,,171.81,percent of total billed charges,Drugs,171.81,30,,171.81,percent of total billed charges,Drugs,194.72,34,"If Charge > 500, then 34 percent",194.72,percent of total billed charges,Drugs,171.81,30,,171.81,percent of total billed charges,Drugs,171.81,30,,171.81,percent of total billed charges,Drugs,171.81,30,,171.81,percent of total billed charges,Drugs,171.81,30,,171.81,percent of total billed charges,Drugs,171.81,30,,171.81,percent of total billed charges,Drugs,171.81,30,,171.81,percent of total billed charges,Drugs,171.81,30,,171.81,percent of total billed charges,Drugs,171.81,30,,171.81,percent of total billed charges,Drugs,171.81,30,,171.81,percent of total billed charges,Drugs,171.81,30,,171.81,percent of total billed charges,Drugs,171.81,30,,171.81,percent of total billed charges,Drugs,171.81,30,,171.81,percent of total billed charges,Drugs,171.81,30,,171.81,percent of total billed charges,Drugs,10.76,,,10.76,Other,Drug Cost,10.76,,,10.76,Other,Drug Cost,10.76,,,10.76,Other,Drug Cost,10.76,,,10.76,Other,Drug Cost,10.76,,,10.76,Other,Drug Cost,194.72,34,,194.72,percent of total billed charges,Drugs,10.76,,,10.76,Other,Drug Cost,24.21,,,24.21,Other,225% Medicaid APG methodology,15.06,,,15.06,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",10.76,,,10.76,Other,Drug Cost,10.76,,,10.76,Other,Drug Cost,13.45,,,13.45,Other,125% Medicaid APG methodology,0.01,286.36,
AMPICILLIN-SULBACTAM 3 G INJ    ,J0295,HCPCS,,40531261,CDM,636,RC,71288-0032-21,NDC,both,1,EA,14.28,17.45,,,17.45,Other,150% of Medicare + 9.63% HCRA Surcharge,10.61,,,10.61,Fee Schedule,Average Sale Price (ASP) x 6,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,7.14,50,,7.14,percent of total billed charges,All Other,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,4.28,30,,4.28,percent of total billed charges,Drugs,6.39,,,6.39,Other,Drug Cost,6.39,,,6.39,Other,Drug Cost,6.39,,,6.39,Other,Drug Cost,6.39,,,6.39,Other,Drug Cost,6.39,,,6.39,Other,Drug Cost,4.86,34,,4.86,percent of total billed charges,Drugs,6.39,,,6.39,Other,Drug Cost,14.38,,,14.38,Other,225% Medicaid APG methodology,8.95,,,8.95,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,16.98,,,16.98,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6.39,,,6.39,Other,Drug Cost,6.39,,,6.39,Other,Drug Cost,7.99,,,7.99,Other,125% Medicaid APG methodology,0.01,17.45,
SMX-TMP 80MG-16MG/ML IV  5ML    ,J3490,HCPCS,,40531329,CDM,636,RC,67457-0778-05,NDC,both,5,ML,14,5.53,39.4668,,5.53,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,7,50,,7,percent of total billed charges,All Other,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,4.2,30,,4.2,percent of total billed charges,Drugs,3.15,,,3.15,Other,Drug Cost,3.15,,,3.15,Other,Drug Cost,3.15,,,3.15,Other,Drug Cost,3.15,,,3.15,Other,Drug Cost,3.15,,,3.15,Other,Drug Cost,4.76,34,,4.76,percent of total billed charges,Drugs,3.15,,,3.15,Other,Drug Cost,7.09,,,7.09,Other,225% Medicaid APG methodology,4.41,,,4.41,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.15,,,3.15,Other,Drug Cost,3.15,,,3.15,Other,Drug Cost,3.94,,,3.94,Other,125% Medicaid APG methodology,0.01,7.09,
PHYTONADONE 1MG/0.5ML INJ0.5ML  ,J3430,HCPCS,,40531899,CDM,636,RC,76329-1240-01p,NDC,both,1,ML,137.76,28.6,,,28.6,Other,150% of Medicare + 9.63% HCRA Surcharge,17.39,,,17.39,Fee Schedule,Average Sale Price (ASP) x 6,41.33,30,,41.33,percent of total billed charges,Drugs,41.33,30,,41.33,percent of total billed charges,Drugs,41.33,30,,41.33,percent of total billed charges,Drugs,41.33,30,,41.33,percent of total billed charges,Drugs,41.33,30,,41.33,percent of total billed charges,Drugs,68.88,50,,68.88,percent of total billed charges,All Other,41.33,30,,41.33,percent of total billed charges,Drugs,41.33,30,,41.33,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,41.33,30,,41.33,percent of total billed charges,Drugs,41.33,30,,41.33,percent of total billed charges,Drugs,41.33,30,,41.33,percent of total billed charges,Drugs,41.33,30,,41.33,percent of total billed charges,Drugs,41.33,30,,41.33,percent of total billed charges,Drugs,41.33,30,,41.33,percent of total billed charges,Drugs,41.33,30,,41.33,percent of total billed charges,Drugs,41.33,30,,41.33,percent of total billed charges,Drugs,41.33,30,,41.33,percent of total billed charges,Drugs,41.33,30,,41.33,percent of total billed charges,Drugs,41.33,30,,41.33,percent of total billed charges,Drugs,41.33,30,,41.33,percent of total billed charges,Drugs,41.33,30,,41.33,percent of total billed charges,Drugs,1.98,,,1.98,Other,Drug Cost,1.98,,,1.98,Other,Drug Cost,1.98,,,1.98,Other,Drug Cost,1.98,,,1.98,Other,Drug Cost,1.98,,,1.98,Other,Drug Cost,46.84,34,,46.84,percent of total billed charges,Drugs,1.98,,,1.98,Other,Drug Cost,4.46,,,4.46,Other,225% Medicaid APG methodology,2.77,,,2.77,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,27.83,,,27.83,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.98,,,1.98,Other,Drug Cost,1.98,,,1.98,Other,Drug Cost,2.48,,,2.48,Other,125% Medicaid APG methodology,0.01,68.88,
LEUCOVORIN 100 MG INJ           ,J0640,HCPCS,,40531980,CDM,636,RC,25021-0814-30,NDC,both,1,EA,21.81,44.1,,,44.1,Other,150% of Medicare + 9.63% HCRA Surcharge,26.82,,,26.82,Fee Schedule,Average Sale Price (ASP) x 6,6.54,30,,6.54,percent of total billed charges,Drugs,6.54,30,,6.54,percent of total billed charges,Drugs,6.54,30,,6.54,percent of total billed charges,Drugs,6.54,30,,6.54,percent of total billed charges,Drugs,6.54,30,,6.54,percent of total billed charges,Drugs,10.91,50,,10.91,percent of total billed charges,All Other,6.54,30,,6.54,percent of total billed charges,Drugs,6.54,30,,6.54,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,6.54,30,,6.54,percent of total billed charges,Drugs,6.54,30,,6.54,percent of total billed charges,Drugs,6.54,30,,6.54,percent of total billed charges,Drugs,6.54,30,,6.54,percent of total billed charges,Drugs,6.54,30,,6.54,percent of total billed charges,Drugs,6.54,30,,6.54,percent of total billed charges,Drugs,6.54,30,,6.54,percent of total billed charges,Drugs,6.54,30,,6.54,percent of total billed charges,Drugs,6.54,30,,6.54,percent of total billed charges,Drugs,6.54,30,,6.54,percent of total billed charges,Drugs,6.54,30,,6.54,percent of total billed charges,Drugs,6.54,30,,6.54,percent of total billed charges,Drugs,6.54,30,,6.54,percent of total billed charges,Drugs,4.46,,,4.46,Other,Drug Cost,4.46,,,4.46,Other,Drug Cost,4.46,,,4.46,Other,Drug Cost,4.46,,,4.46,Other,Drug Cost,4.46,,,4.46,Other,Drug Cost,7.42,34,,7.42,percent of total billed charges,Drugs,4.46,,,4.46,Other,Drug Cost,10.04,,,10.04,Other,225% Medicaid APG methodology,6.24,,,6.24,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,42.91,,,42.91,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.46,,,4.46,Other,Drug Cost,4.46,,,4.46,Other,Drug Cost,5.58,,,5.58,Other,125% Medicaid APG methodology,0.01,44.1,
AMPHTERCIN B LIPID  5MG/ML IV   ,J0287,HCPCS,,40533143,CDM,636,RC,57665-0101-41,NDC,both,20,ML,304.89,120.33,39.4668,,120.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,91.47,30,,91.47,percent of total billed charges,Drugs,91.47,30,,91.47,percent of total billed charges,Drugs,91.47,30,,91.47,percent of total billed charges,Drugs,91.47,30,,91.47,percent of total billed charges,Drugs,91.47,30,,91.47,percent of total billed charges,Drugs,152.45,50,,152.45,percent of total billed charges,All Other,91.47,30,,91.47,percent of total billed charges,Drugs,91.47,30,,91.47,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,91.47,30,,91.47,percent of total billed charges,Drugs,91.47,30,,91.47,percent of total billed charges,Drugs,91.47,30,,91.47,percent of total billed charges,Drugs,91.47,30,,91.47,percent of total billed charges,Drugs,91.47,30,,91.47,percent of total billed charges,Drugs,91.47,30,,91.47,percent of total billed charges,Drugs,91.47,30,,91.47,percent of total billed charges,Drugs,91.47,30,,91.47,percent of total billed charges,Drugs,91.47,30,,91.47,percent of total billed charges,Drugs,91.47,30,,91.47,percent of total billed charges,Drugs,91.47,30,,91.47,percent of total billed charges,Drugs,91.47,30,,91.47,percent of total billed charges,Drugs,91.47,30,,91.47,percent of total billed charges,Drugs,62.93,,,62.93,Other,Drug Cost,62.93,,,62.93,Other,Drug Cost,62.93,,,62.93,Other,Drug Cost,62.93,,,62.93,Other,Drug Cost,62.93,,,62.93,Other,Drug Cost,103.66,34,,103.66,percent of total billed charges,Drugs,62.93,,,62.93,Other,Drug Cost,141.59,,,141.59,Other,225% Medicaid APG methodology,88.1,,,88.1,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",62.93,,,62.93,Other,Drug Cost,62.93,,,62.93,Other,Drug Cost,78.66,,,78.66,Other,125% Medicaid APG methodology,0.01,152.45,
DIMERCAPROL 10% INJ SOLN 3 ML   ,J0470,HCPCS,,40533150,CDM,636,RC,17478-0526-03,NDC,both,3,ML,521.4,205.78,39.4668,,205.78,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,156.42,30,,156.42,percent of total billed charges,Drugs,156.42,30,,156.42,percent of total billed charges,Drugs,156.42,30,,156.42,percent of total billed charges,Drugs,156.42,30,,156.42,percent of total billed charges,Drugs,156.42,30,,156.42,percent of total billed charges,Drugs,260.7,50,,260.7,percent of total billed charges,All Other,156.42,30,,156.42,percent of total billed charges,Drugs,156.42,30,,156.42,percent of total billed charges,Drugs,177.28,34,"If Charge > 500, then 34 percent",177.28,percent of total billed charges,Drugs,156.42,30,,156.42,percent of total billed charges,Drugs,156.42,30,,156.42,percent of total billed charges,Drugs,156.42,30,,156.42,percent of total billed charges,Drugs,156.42,30,,156.42,percent of total billed charges,Drugs,156.42,30,,156.42,percent of total billed charges,Drugs,156.42,30,,156.42,percent of total billed charges,Drugs,156.42,30,,156.42,percent of total billed charges,Drugs,156.42,30,,156.42,percent of total billed charges,Drugs,156.42,30,,156.42,percent of total billed charges,Drugs,156.42,30,,156.42,percent of total billed charges,Drugs,156.42,30,,156.42,percent of total billed charges,Drugs,156.42,30,,156.42,percent of total billed charges,Drugs,156.42,30,,156.42,percent of total billed charges,Drugs,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,177.28,34,,177.28,percent of total billed charges,Drugs,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,260.7,
PROCHLORPERAZINE 5MG/ML INJ2ML  ,J0780,HCPCS,,40533192,CDM,636,RC,00713-0351-09,NDC,both,2,ML,15.05,33.83,,,33.83,Other,150% of Medicare + 9.63% HCRA Surcharge,20.57,,,20.57,Fee Schedule,Average Sale Price (ASP) x 6,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,7.53,50,,7.53,percent of total billed charges,All Other,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,2.58,,,2.58,Other,Drug Cost,2.58,,,2.58,Other,Drug Cost,2.58,,,2.58,Other,Drug Cost,2.58,,,2.58,Other,Drug Cost,2.58,,,2.58,Other,Drug Cost,5.12,34,,5.12,percent of total billed charges,Drugs,2.58,,,2.58,Other,Drug Cost,5.81,,,5.81,Other,225% Medicaid APG methodology,3.61,,,3.61,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,32.92,,,32.92,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.58,,,2.58,Other,Drug Cost,2.58,,,2.58,Other,Drug Cost,3.23,,,3.23,Other,125% Medicaid APG methodology,0.01,33.83,
COSYNTROPIN 0.25 MG INJ         ,J0834,HCPCS,,40533200,CDM,636,RC,00781-3440-95,NDC,both,1,EA,57.4,267.53,,,267.53,Other,150% of Medicare + 9.63% HCRA Surcharge,162.68,,,162.68,Fee Schedule,Average Sale Price (ASP) x 6,17.22,30,,17.22,percent of total billed charges,Drugs,17.22,30,,17.22,percent of total billed charges,Drugs,17.22,30,,17.22,percent of total billed charges,Drugs,17.22,30,,17.22,percent of total billed charges,Drugs,17.22,30,,17.22,percent of total billed charges,Drugs,28.7,50,,28.7,percent of total billed charges,All Other,17.22,30,,17.22,percent of total billed charges,Drugs,17.22,30,,17.22,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,17.22,30,,17.22,percent of total billed charges,Drugs,17.22,30,,17.22,percent of total billed charges,Drugs,17.22,30,,17.22,percent of total billed charges,Drugs,17.22,30,,17.22,percent of total billed charges,Drugs,17.22,30,,17.22,percent of total billed charges,Drugs,17.22,30,,17.22,percent of total billed charges,Drugs,17.22,30,,17.22,percent of total billed charges,Drugs,17.22,30,,17.22,percent of total billed charges,Drugs,17.22,30,,17.22,percent of total billed charges,Drugs,17.22,30,,17.22,percent of total billed charges,Drugs,17.22,30,,17.22,percent of total billed charges,Drugs,17.22,30,,17.22,percent of total billed charges,Drugs,17.22,30,,17.22,percent of total billed charges,Drugs,27.15,,,27.15,Other,Drug Cost,27.15,,,27.15,Other,Drug Cost,27.15,,,27.15,Other,Drug Cost,27.15,,,27.15,Other,Drug Cost,27.15,,,27.15,Other,Drug Cost,19.52,34,,19.52,percent of total billed charges,Drugs,27.15,,,27.15,Other,Drug Cost,61.09,,,61.09,Other,225% Medicaid APG methodology,38.01,,,38.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,260.29,,,260.29,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",27.15,,,27.15,Other,Drug Cost,27.15,,,27.15,Other,Drug Cost,33.94,,,33.94,Other,125% Medicaid APG methodology,0.01,267.53,
DIGOXIN IMMUNE FAB 40 MG INJ    ,J1162,HCPCS,,40533267,CDM,636,RC,50633-0120-11,NDC,both,1,EA,13447.14,47137.58,,,47137.58,Other,150% of Medicare + 9.63% HCRA Surcharge,28664.65,,,28664.65,Fee Schedule,Average Sale Price (ASP) x 6,4034.14,30,,4034.14,percent of total billed charges,Drugs,4034.14,30,,4034.14,percent of total billed charges,Drugs,4034.14,30,,4034.14,percent of total billed charges,Drugs,4034.14,30,,4034.14,percent of total billed charges,Drugs,4034.14,30,,4034.14,percent of total billed charges,Drugs,6723.57,50,,6723.57,percent of total billed charges,All Other,4034.14,30,,4034.14,percent of total billed charges,Drugs,4034.14,30,,4034.14,percent of total billed charges,Drugs,4572.03,34,"If Charge > 500, then 34 percent",4572.03,percent of total billed charges,Drugs,4034.14,30,,4034.14,percent of total billed charges,Drugs,4034.14,30,,4034.14,percent of total billed charges,Drugs,4034.14,30,,4034.14,percent of total billed charges,Drugs,4034.14,30,,4034.14,percent of total billed charges,Drugs,4034.14,30,,4034.14,percent of total billed charges,Drugs,4034.14,30,,4034.14,percent of total billed charges,Drugs,4034.14,30,,4034.14,percent of total billed charges,Drugs,4034.14,30,,4034.14,percent of total billed charges,Drugs,4034.14,30,,4034.14,percent of total billed charges,Drugs,4034.14,30,,4034.14,percent of total billed charges,Drugs,4034.14,30,,4034.14,percent of total billed charges,Drugs,4034.14,30,,4034.14,percent of total billed charges,Drugs,4034.14,30,,4034.14,percent of total billed charges,Drugs,3759.38,,,3759.38,Other,Drug Cost,3759.38,,,3759.38,Other,Drug Cost,3759.38,,,3759.38,Other,Drug Cost,3759.38,,,3759.38,Other,Drug Cost,3759.38,,,3759.38,Other,Drug Cost,4572.03,34,,4572.03,percent of total billed charges,Drugs,3759.38,,,3759.38,Other,Drug Cost,8458.61,,,8458.61,Other,225% Medicaid APG methodology,5263.13,,,5263.13,Other,140% Medicaid APG methodology,4572.03,34,"If Charge > 2,000, then 34 percent",4572.03,percent of total billed charges,Drugs,45863.43,,,45863.43,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3759.38,,,3759.38,Other,Drug Cost,3759.38,,,3759.38,Other,Drug Cost,4699.23,,,4699.23,Other,125% Medicaid APG methodology,0.01,47137.58,
PHENYTOIN 50MG/ML INJ SOLN 2ML  ,J1165,HCPCS,,40533275,CDM,636,RC,00641-0493-25,NDC,both,2,ML,3.61,6.22,,,6.22,Other,150% of Medicare + 9.63% HCRA Surcharge,3.78,,,3.78,Fee Schedule,Average Sale Price (ASP) x 6,1.08,30,,1.08,percent of total billed charges,Drugs,1.08,30,,1.08,percent of total billed charges,Drugs,1.08,30,,1.08,percent of total billed charges,Drugs,1.08,30,,1.08,percent of total billed charges,Drugs,1.08,30,,1.08,percent of total billed charges,Drugs,1.81,50,,1.81,percent of total billed charges,All Other,1.08,30,,1.08,percent of total billed charges,Drugs,1.08,30,,1.08,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.08,30,,1.08,percent of total billed charges,Drugs,1.08,30,,1.08,percent of total billed charges,Drugs,1.08,30,,1.08,percent of total billed charges,Drugs,1.08,30,,1.08,percent of total billed charges,Drugs,1.08,30,,1.08,percent of total billed charges,Drugs,1.08,30,,1.08,percent of total billed charges,Drugs,1.08,30,,1.08,percent of total billed charges,Drugs,1.08,30,,1.08,percent of total billed charges,Drugs,1.08,30,,1.08,percent of total billed charges,Drugs,1.08,30,,1.08,percent of total billed charges,Drugs,1.08,30,,1.08,percent of total billed charges,Drugs,1.08,30,,1.08,percent of total billed charges,Drugs,1.08,30,,1.08,percent of total billed charges,Drugs,0.66,,,0.66,Other,Drug Cost,0.66,,,0.66,Other,Drug Cost,0.66,,,0.66,Other,Drug Cost,0.66,,,0.66,Other,Drug Cost,0.66,,,0.66,Other,Drug Cost,1.23,34,,1.23,percent of total billed charges,Drugs,0.66,,,0.66,Other,Drug Cost,1.49,,,1.49,Other,225% Medicaid APG methodology,0.92,,,0.92,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.05,,,6.05,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.66,,,0.66,Other,Drug Cost,0.66,,,0.66,Other,Drug Cost,0.83,,,0.83,Other,125% Medicaid APG methodology,0.01,6.22,
TRIMETHOBENZAMIDE 100MG/ML 2ML  ,J3250,HCPCS,,40533382,CDM,636,RC,42023-0119-25,NDC,both,2,ML,133,472.01,,,472.01,Other,150% of Medicare + 9.63% HCRA Surcharge,287.03,,,287.03,Fee Schedule,Average Sale Price (ASP) x 6,39.9,30,,39.9,percent of total billed charges,Drugs,39.9,30,,39.9,percent of total billed charges,Drugs,39.9,30,,39.9,percent of total billed charges,Drugs,39.9,30,,39.9,percent of total billed charges,Drugs,39.9,30,,39.9,percent of total billed charges,Drugs,66.5,50,,66.5,percent of total billed charges,All Other,39.9,30,,39.9,percent of total billed charges,Drugs,39.9,30,,39.9,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,39.9,30,,39.9,percent of total billed charges,Drugs,39.9,30,,39.9,percent of total billed charges,Drugs,39.9,30,,39.9,percent of total billed charges,Drugs,39.9,30,,39.9,percent of total billed charges,Drugs,39.9,30,,39.9,percent of total billed charges,Drugs,39.9,30,,39.9,percent of total billed charges,Drugs,39.9,30,,39.9,percent of total billed charges,Drugs,39.9,30,,39.9,percent of total billed charges,Drugs,39.9,30,,39.9,percent of total billed charges,Drugs,39.9,30,,39.9,percent of total billed charges,Drugs,39.9,30,,39.9,percent of total billed charges,Drugs,39.9,30,,39.9,percent of total billed charges,Drugs,39.9,30,,39.9,percent of total billed charges,Drugs,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,45.22,34,,45.22,percent of total billed charges,Drugs,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,459.25,,,459.25,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,472.01,
BETAMETHASONE 6MG/ML INJ  5ML   ,J0702,HCPCS,,40533465,CDM,636,RC,78206-0118-01,NDC,both,5,ML,121.52,67.25,,,67.25,Other,150% of Medicare + 9.63% HCRA Surcharge,40.9,,,40.9,Fee Schedule,Average Sale Price (ASP) x 6,36.46,30,,36.46,percent of total billed charges,Drugs,36.46,30,,36.46,percent of total billed charges,Drugs,36.46,30,,36.46,percent of total billed charges,Drugs,36.46,30,,36.46,percent of total billed charges,Drugs,36.46,30,,36.46,percent of total billed charges,Drugs,60.76,50,,60.76,percent of total billed charges,All Other,36.46,30,,36.46,percent of total billed charges,Drugs,36.46,30,,36.46,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,36.46,30,,36.46,percent of total billed charges,Drugs,36.46,30,,36.46,percent of total billed charges,Drugs,36.46,30,,36.46,percent of total billed charges,Drugs,36.46,30,,36.46,percent of total billed charges,Drugs,36.46,30,,36.46,percent of total billed charges,Drugs,36.46,30,,36.46,percent of total billed charges,Drugs,36.46,30,,36.46,percent of total billed charges,Drugs,36.46,30,,36.46,percent of total billed charges,Drugs,36.46,30,,36.46,percent of total billed charges,Drugs,36.46,30,,36.46,percent of total billed charges,Drugs,36.46,30,,36.46,percent of total billed charges,Drugs,36.46,30,,36.46,percent of total billed charges,Drugs,36.46,30,,36.46,percent of total billed charges,Drugs,8.24,,,8.24,Other,Drug Cost,8.24,,,8.24,Other,Drug Cost,8.24,,,8.24,Other,Drug Cost,8.24,,,8.24,Other,Drug Cost,8.24,,,8.24,Other,Drug Cost,41.32,34,,41.32,percent of total billed charges,Drugs,8.24,,,8.24,Other,Drug Cost,18.54,,,18.54,Other,225% Medicaid APG methodology,11.54,,,11.54,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,65.43,,,65.43,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",8.24,,,8.24,Other,Drug Cost,8.24,,,8.24,Other,Drug Cost,10.3,,,10.3,Other,125% Medicaid APG methodology,0.01,67.25,
MICAFUNGIN 50 MG IV INJ         ,J2248,HCPCS,,40533473,CDM,636,RC,00469-3250-50,NDC,both,1,EA,327.25,7.47,,,7.47,Other,150% of Medicare + 9.63% HCRA Surcharge,4.54,,,4.54,Fee Schedule,Average Sale Price (ASP) x 6,98.18,30,,98.18,percent of total billed charges,Drugs,98.18,30,,98.18,percent of total billed charges,Drugs,98.18,30,,98.18,percent of total billed charges,Drugs,98.18,30,,98.18,percent of total billed charges,Drugs,98.18,30,,98.18,percent of total billed charges,Drugs,163.63,50,,163.63,percent of total billed charges,All Other,98.18,30,,98.18,percent of total billed charges,Drugs,98.18,30,,98.18,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,98.18,30,,98.18,percent of total billed charges,Drugs,98.18,30,,98.18,percent of total billed charges,Drugs,98.18,30,,98.18,percent of total billed charges,Drugs,98.18,30,,98.18,percent of total billed charges,Drugs,98.18,30,,98.18,percent of total billed charges,Drugs,98.18,30,,98.18,percent of total billed charges,Drugs,98.18,30,,98.18,percent of total billed charges,Drugs,98.18,30,,98.18,percent of total billed charges,Drugs,98.18,30,,98.18,percent of total billed charges,Drugs,98.18,30,,98.18,percent of total billed charges,Drugs,98.18,30,,98.18,percent of total billed charges,Drugs,98.18,30,,98.18,percent of total billed charges,Drugs,98.18,30,,98.18,percent of total billed charges,Drugs,93.5,,,93.5,Other,Drug Cost,93.5,,,93.5,Other,Drug Cost,93.5,,,93.5,Other,Drug Cost,93.5,,,93.5,Other,Drug Cost,93.5,,,93.5,Other,Drug Cost,111.27,34,,111.27,percent of total billed charges,Drugs,93.5,,,93.5,Other,Drug Cost,210.38,,,210.38,Other,225% Medicaid APG methodology,130.9,,,130.9,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.27,,,7.27,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",93.5,,,93.5,Other,Drug Cost,93.5,,,93.5,Other,Drug Cost,116.88,,,116.88,Other,125% Medicaid APG methodology,0.01,210.38,
LEVETIRACETAM 100MG/ML IV  5ML  ,J1953,HCPCS,,40533515,CDM,636,RC,25021-0780-05,NDC,both,5,ML,7.63,0.62,,,0.62,Other,150% of Medicare + 9.63% HCRA Surcharge,0.38,,,0.38,Fee Schedule,Average Sale Price (ASP) x 6,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,3.82,50,,3.82,percent of total billed charges,All Other,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.16,,,2.16,Other,Drug Cost,2.16,,,2.16,Other,Drug Cost,2.16,,,2.16,Other,Drug Cost,2.16,,,2.16,Other,Drug Cost,2.16,,,2.16,Other,Drug Cost,2.59,34,,2.59,percent of total billed charges,Drugs,2.16,,,2.16,Other,Drug Cost,4.86,,,4.86,Other,225% Medicaid APG methodology,3.02,,,3.02,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.6,,,0.6,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.16,,,2.16,Other,Drug Cost,2.16,,,2.16,Other,Drug Cost,2.7,,,2.7,Other,125% Medicaid APG methodology,0.01,4.86,
RISPERIDONE 25MG IM INJ ER      ,J2794,HCPCS,,40533648,CDM,636,RC,50458-0306-11,NDC,both,1,EA,1957.03,119.89,,,119.89,Other,150% of Medicare + 9.63% HCRA Surcharge,72.91,,,72.91,Fee Schedule,Average Sale Price (ASP) x 6,587.11,30,,587.11,percent of total billed charges,Drugs,587.11,30,,587.11,percent of total billed charges,Drugs,587.11,30,,587.11,percent of total billed charges,Drugs,587.11,30,,587.11,percent of total billed charges,Drugs,587.11,30,,587.11,percent of total billed charges,Drugs,978.52,50,,978.52,percent of total billed charges,All Other,587.11,30,,587.11,percent of total billed charges,Drugs,587.11,30,,587.11,percent of total billed charges,Drugs,665.39,34,"If Charge > 500, then 34 percent",665.39,percent of total billed charges,Drugs,587.11,30,,587.11,percent of total billed charges,Drugs,587.11,30,,587.11,percent of total billed charges,Drugs,587.11,30,,587.11,percent of total billed charges,Drugs,587.11,30,,587.11,percent of total billed charges,Drugs,587.11,30,,587.11,percent of total billed charges,Drugs,587.11,30,,587.11,percent of total billed charges,Drugs,587.11,30,,587.11,percent of total billed charges,Drugs,587.11,30,,587.11,percent of total billed charges,Drugs,587.11,30,,587.11,percent of total billed charges,Drugs,587.11,30,,587.11,percent of total billed charges,Drugs,587.11,30,,587.11,percent of total billed charges,Drugs,587.11,30,,587.11,percent of total billed charges,Drugs,587.11,30,,587.11,percent of total billed charges,Drugs,207.38,,,207.38,Other,Drug Cost,207.38,,,207.38,Other,Drug Cost,207.38,,,207.38,Other,Drug Cost,207.38,,,207.38,Other,Drug Cost,207.38,,,207.38,Other,Drug Cost,665.39,34,,665.39,percent of total billed charges,Drugs,207.38,,,207.38,Other,Drug Cost,466.61,,,466.61,Other,225% Medicaid APG methodology,290.33,,,290.33,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,116.65,,,116.65,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",207.38,,,207.38,Other,Drug Cost,207.38,,,207.38,Other,Drug Cost,259.23,,,259.23,Other,125% Medicaid APG methodology,0.01,978.52,
RISPERIDONE 37.5MG IM INJ ER    ,J2794,HCPCS,,40533655,CDM,636,RC,50458-0307-11,NDC,both,1,EA,2548.91,119.89,,,119.89,Other,150% of Medicare + 9.63% HCRA Surcharge,72.91,,,72.91,Fee Schedule,Average Sale Price (ASP) x 6,764.67,30,,764.67,percent of total billed charges,Drugs,764.67,30,,764.67,percent of total billed charges,Drugs,764.67,30,,764.67,percent of total billed charges,Drugs,764.67,30,,764.67,percent of total billed charges,Drugs,764.67,30,,764.67,percent of total billed charges,Drugs,1274.46,50,,1274.46,percent of total billed charges,All Other,764.67,30,,764.67,percent of total billed charges,Drugs,764.67,30,,764.67,percent of total billed charges,Drugs,866.63,34,"If Charge > 500, then 34 percent",866.63,percent of total billed charges,Drugs,764.67,30,,764.67,percent of total billed charges,Drugs,764.67,30,,764.67,percent of total billed charges,Drugs,764.67,30,,764.67,percent of total billed charges,Drugs,764.67,30,,764.67,percent of total billed charges,Drugs,764.67,30,,764.67,percent of total billed charges,Drugs,764.67,30,,764.67,percent of total billed charges,Drugs,764.67,30,,764.67,percent of total billed charges,Drugs,764.67,30,,764.67,percent of total billed charges,Drugs,764.67,30,,764.67,percent of total billed charges,Drugs,764.67,30,,764.67,percent of total billed charges,Drugs,764.67,30,,764.67,percent of total billed charges,Drugs,764.67,30,,764.67,percent of total billed charges,Drugs,764.67,30,,764.67,percent of total billed charges,Drugs,271.13,,,271.13,Other,Drug Cost,271.13,,,271.13,Other,Drug Cost,271.13,,,271.13,Other,Drug Cost,271.13,,,271.13,Other,Drug Cost,271.13,,,271.13,Other,Drug Cost,866.63,34,,866.63,percent of total billed charges,Drugs,271.13,,,271.13,Other,Drug Cost,610.04,,,610.04,Other,225% Medicaid APG methodology,379.58,,,379.58,Other,140% Medicaid APG methodology,866.63,34,"If Charge > 2,000, then 34 percent",866.63,percent of total billed charges,Drugs,116.65,,,116.65,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",271.13,,,271.13,Other,Drug Cost,271.13,,,271.13,Other,Drug Cost,338.91,,,338.91,Other,125% Medicaid APG methodology,0.01,1274.46,
ALTEPLASE 2 MG INJ              ,J2997,HCPCS,,40533671,CDM,636,RC,50242-0041-64,NDC,both,1,EA,573.02,877.88,,,877.88,Other,150% of Medicare + 9.63% HCRA Surcharge,533.84,,,533.84,Fee Schedule,Average Sale Price (ASP) x 6,171.91,30,,171.91,percent of total billed charges,Drugs,171.91,30,,171.91,percent of total billed charges,Drugs,171.91,30,,171.91,percent of total billed charges,Drugs,171.91,30,,171.91,percent of total billed charges,Drugs,171.91,30,,171.91,percent of total billed charges,Drugs,286.51,50,,286.51,percent of total billed charges,All Other,171.91,30,,171.91,percent of total billed charges,Drugs,171.91,30,,171.91,percent of total billed charges,Drugs,194.83,34,"If Charge > 500, then 34 percent",194.83,percent of total billed charges,Drugs,171.91,30,,171.91,percent of total billed charges,Drugs,171.91,30,,171.91,percent of total billed charges,Drugs,171.91,30,,171.91,percent of total billed charges,Drugs,171.91,30,,171.91,percent of total billed charges,Drugs,171.91,30,,171.91,percent of total billed charges,Drugs,171.91,30,,171.91,percent of total billed charges,Drugs,171.91,30,,171.91,percent of total billed charges,Drugs,171.91,30,,171.91,percent of total billed charges,Drugs,171.91,30,,171.91,percent of total billed charges,Drugs,171.91,30,,171.91,percent of total billed charges,Drugs,171.91,30,,171.91,percent of total billed charges,Drugs,171.91,30,,171.91,percent of total billed charges,Drugs,171.91,30,,171.91,percent of total billed charges,Drugs,43.56,,,43.56,Other,Drug Cost,43.56,,,43.56,Other,Drug Cost,43.56,,,43.56,Other,Drug Cost,43.56,,,43.56,Other,Drug Cost,43.56,,,43.56,Other,Drug Cost,194.83,34,,194.83,percent of total billed charges,Drugs,43.56,,,43.56,Other,Drug Cost,98.01,,,98.01,Other,225% Medicaid APG methodology,60.98,,,60.98,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,854.15,,,854.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",43.56,,,43.56,Other,Drug Cost,43.56,,,43.56,Other,Drug Cost,54.45,,,54.45,Other,125% Medicaid APG methodology,0.01,877.88,
ADENOSINE 3 MG/ML IV SOLN 2 ML  ,J0153,HCPCS,,40533697,CDM,636,RC,25021-0318-02,NDC,both,2,ML,8.79,5.93,,,5.93,Other,150% of Medicare + 9.63% HCRA Surcharge,3.61,,,3.61,Fee Schedule,Average Sale Price (ASP) x 6,2.64,30,,2.64,percent of total billed charges,Drugs,2.64,30,,2.64,percent of total billed charges,Drugs,2.64,30,,2.64,percent of total billed charges,Drugs,2.64,30,,2.64,percent of total billed charges,Drugs,2.64,30,,2.64,percent of total billed charges,Drugs,4.4,50,,4.4,percent of total billed charges,All Other,2.64,30,,2.64,percent of total billed charges,Drugs,2.64,30,,2.64,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.64,30,,2.64,percent of total billed charges,Drugs,2.64,30,,2.64,percent of total billed charges,Drugs,2.64,30,,2.64,percent of total billed charges,Drugs,2.64,30,,2.64,percent of total billed charges,Drugs,2.64,30,,2.64,percent of total billed charges,Drugs,2.64,30,,2.64,percent of total billed charges,Drugs,2.64,30,,2.64,percent of total billed charges,Drugs,2.64,30,,2.64,percent of total billed charges,Drugs,2.64,30,,2.64,percent of total billed charges,Drugs,2.64,30,,2.64,percent of total billed charges,Drugs,2.64,30,,2.64,percent of total billed charges,Drugs,2.64,30,,2.64,percent of total billed charges,Drugs,2.64,30,,2.64,percent of total billed charges,Drugs,3.76,,,3.76,Other,Drug Cost,3.76,,,3.76,Other,Drug Cost,3.76,,,3.76,Other,Drug Cost,3.76,,,3.76,Other,Drug Cost,3.76,,,3.76,Other,Drug Cost,2.99,34,,2.99,percent of total billed charges,Drugs,3.76,,,3.76,Other,Drug Cost,8.46,,,8.46,Other,225% Medicaid APG methodology,5.26,,,5.26,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,5.77,,,5.77,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.76,,,3.76,Other,Drug Cost,3.76,,,3.76,Other,Drug Cost,4.7,,,4.7,Other,125% Medicaid APG methodology,0.01,8.46,
ACETYLCYSTEINE 20% IV SLN 30ML  ,J0132,HCPCS,,40533713,CDM,636,RC,00574-0805-30,NDC,both,30,ML,611.7,6.95,,,6.95,Other,150% of Medicare + 9.63% HCRA Surcharge,4.22,,,4.22,Fee Schedule,Average Sale Price (ASP) x 6,183.51,30,,183.51,percent of total billed charges,Drugs,183.51,30,,183.51,percent of total billed charges,Drugs,183.51,30,,183.51,percent of total billed charges,Drugs,183.51,30,,183.51,percent of total billed charges,Drugs,183.51,30,,183.51,percent of total billed charges,Drugs,305.85,50,,305.85,percent of total billed charges,All Other,183.51,30,,183.51,percent of total billed charges,Drugs,183.51,30,,183.51,percent of total billed charges,Drugs,207.98,34,"If Charge > 500, then 34 percent",207.98,percent of total billed charges,Drugs,183.51,30,,183.51,percent of total billed charges,Drugs,183.51,30,,183.51,percent of total billed charges,Drugs,183.51,30,,183.51,percent of total billed charges,Drugs,183.51,30,,183.51,percent of total billed charges,Drugs,183.51,30,,183.51,percent of total billed charges,Drugs,183.51,30,,183.51,percent of total billed charges,Drugs,183.51,30,,183.51,percent of total billed charges,Drugs,183.51,30,,183.51,percent of total billed charges,Drugs,183.51,30,,183.51,percent of total billed charges,Drugs,183.51,30,,183.51,percent of total billed charges,Drugs,183.51,30,,183.51,percent of total billed charges,Drugs,183.51,30,,183.51,percent of total billed charges,Drugs,183.51,30,,183.51,percent of total billed charges,Drugs,25.6,,,25.6,Other,Drug Cost,25.6,,,25.6,Other,Drug Cost,25.6,,,25.6,Other,Drug Cost,25.6,,,25.6,Other,Drug Cost,25.6,,,25.6,Other,Drug Cost,207.98,34,,207.98,percent of total billed charges,Drugs,25.6,,,25.6,Other,Drug Cost,57.6,,,57.6,Other,225% Medicaid APG methodology,35.84,,,35.84,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.76,,,6.76,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",25.6,,,25.6,Other,Drug Cost,25.6,,,25.6,Other,Drug Cost,32,,,32,Other,125% Medicaid APG methodology,0.01,305.85,
DIPHTH-TET TOX (DT) PED 0.5ML   ,90714,CPT,,40534315,CDM,636,RC,49281-0225-10,NDC,both,0.5,ML,180.99,299.4,,,299.4,Other,150% of Medicare + 9.63% HCRA Surcharge,182.06,,,182.06,Fee Schedule,Average Sale Price (ASP) x 6,54.3,30,,54.3,percent of total billed charges,Drugs,54.3,30,,54.3,percent of total billed charges,Drugs,54.3,30,,54.3,percent of total billed charges,Drugs,54.3,30,,54.3,percent of total billed charges,Drugs,54.3,30,,54.3,percent of total billed charges,Drugs,90.5,50,,90.5,percent of total billed charges,All Other,54.3,30,,54.3,percent of total billed charges,Drugs,54.3,30,,54.3,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,54.3,30,,54.3,percent of total billed charges,Drugs,54.3,30,,54.3,percent of total billed charges,Drugs,54.3,30,,54.3,percent of total billed charges,Drugs,54.3,30,,54.3,percent of total billed charges,Drugs,54.3,30,,54.3,percent of total billed charges,Drugs,54.3,30,,54.3,percent of total billed charges,Drugs,54.3,30,,54.3,percent of total billed charges,Drugs,54.3,30,,54.3,percent of total billed charges,Drugs,54.3,30,,54.3,percent of total billed charges,Drugs,54.3,30,,54.3,percent of total billed charges,Drugs,54.3,30,,54.3,percent of total billed charges,Drugs,54.3,30,,54.3,percent of total billed charges,Drugs,54.3,30,,54.3,percent of total billed charges,Drugs,50.05,,,50.05,Other,Drug Cost,50.05,,,50.05,Other,Drug Cost,50.05,,,50.05,Other,Drug Cost,50.05,,,50.05,Other,Drug Cost,50.05,,,50.05,Other,Drug Cost,61.54,34,,61.54,percent of total billed charges,Drugs,50.05,,,50.05,Other,Drug Cost,112.61,,,112.61,Other,225% Medicaid APG methodology,70.07,,,70.07,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,291.3,,,291.3,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",50.05,,,50.05,Other,Drug Cost,50.05,,,50.05,Other,Drug Cost,62.56,,,62.56,Other,125% Medicaid APG methodology,0.01,299.4,
DIPH/TET/PERT(DTAP) PED 0.5ML   ,90700,CPT,,40534356,CDM,636,RC,58160-0810-52,NDC,both,0.5,ML,66.89,26.4,39.4668,,26.4,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,20.07,30,,20.07,percent of total billed charges,Drugs,20.07,30,,20.07,percent of total billed charges,Drugs,20.07,30,,20.07,percent of total billed charges,Drugs,20.07,30,,20.07,percent of total billed charges,Drugs,20.07,30,,20.07,percent of total billed charges,Drugs,33.45,50,,33.45,percent of total billed charges,All Other,20.07,30,,20.07,percent of total billed charges,Drugs,20.07,30,,20.07,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,20.07,30,,20.07,percent of total billed charges,Drugs,20.07,30,,20.07,percent of total billed charges,Drugs,20.07,30,,20.07,percent of total billed charges,Drugs,20.07,30,,20.07,percent of total billed charges,Drugs,20.07,30,,20.07,percent of total billed charges,Drugs,20.07,30,,20.07,percent of total billed charges,Drugs,20.07,30,,20.07,percent of total billed charges,Drugs,20.07,30,,20.07,percent of total billed charges,Drugs,20.07,30,,20.07,percent of total billed charges,Drugs,20.07,30,,20.07,percent of total billed charges,Drugs,20.07,30,,20.07,percent of total billed charges,Drugs,20.07,30,,20.07,percent of total billed charges,Drugs,20.07,30,,20.07,percent of total billed charges,Drugs,22.68,,,22.68,Other,Drug Cost,22.68,,,22.68,Other,Drug Cost,22.68,,,22.68,Other,Drug Cost,22.68,,,22.68,Other,Drug Cost,22.68,,,22.68,Other,Drug Cost,22.74,34,,22.74,percent of total billed charges,Drugs,22.68,,,22.68,Other,Drug Cost,51.03,,,51.03,Other,225% Medicaid APG methodology,31.75,,,31.75,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",22.68,,,22.68,Other,Drug Cost,22.68,,,22.68,Other,Drug Cost,28.35,,,28.35,Other,125% Medicaid APG methodology,0.01,51.03,
ATROPINE 0.1MG/ML SLN 10ML      ,J0461,HCPCS,,40534703,CDM,636,RC,64253-0400-91,NDC,both,10,ML,28.46,0.75,,,0.75,Other,150% of Medicare + 9.63% HCRA Surcharge,0.46,,,0.46,Fee Schedule,Average Sale Price (ASP) x 6,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,14.23,50,,14.23,percent of total billed charges,All Other,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,8.54,30,,8.54,percent of total billed charges,Drugs,7.93,,,7.93,Other,Drug Cost,7.93,,,7.93,Other,Drug Cost,7.93,,,7.93,Other,Drug Cost,7.93,,,7.93,Other,Drug Cost,7.93,,,7.93,Other,Drug Cost,9.68,34,,9.68,percent of total billed charges,Drugs,7.93,,,7.93,Other,Drug Cost,17.84,,,17.84,Other,225% Medicaid APG methodology,11.1,,,11.1,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.73,,,0.73,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",7.93,,,7.93,Other,Drug Cost,7.93,,,7.93,Other,Drug Cost,9.91,,,9.91,Other,125% Medicaid APG methodology,0.01,17.84,
MORPHINE 50MG/ML INJ SOLN 20ML  ,J2270,HCPCS,,40534745,CDM,636,RC,00409-1134-03,NDC,both,20,ML,37.66,46.03,,,46.03,Other,150% of Medicare + 9.63% HCRA Surcharge,27.99,,,27.99,Fee Schedule,Average Sale Price (ASP) x 6,11.3,30,,11.3,percent of total billed charges,Drugs,11.3,30,,11.3,percent of total billed charges,Drugs,11.3,30,,11.3,percent of total billed charges,Drugs,11.3,30,,11.3,percent of total billed charges,Drugs,11.3,30,,11.3,percent of total billed charges,Drugs,18.83,50,,18.83,percent of total billed charges,All Other,11.3,30,,11.3,percent of total billed charges,Drugs,11.3,30,,11.3,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,11.3,30,,11.3,percent of total billed charges,Drugs,11.3,30,,11.3,percent of total billed charges,Drugs,11.3,30,,11.3,percent of total billed charges,Drugs,11.3,30,,11.3,percent of total billed charges,Drugs,11.3,30,,11.3,percent of total billed charges,Drugs,11.3,30,,11.3,percent of total billed charges,Drugs,11.3,30,,11.3,percent of total billed charges,Drugs,11.3,30,,11.3,percent of total billed charges,Drugs,11.3,30,,11.3,percent of total billed charges,Drugs,11.3,30,,11.3,percent of total billed charges,Drugs,11.3,30,,11.3,percent of total billed charges,Drugs,11.3,30,,11.3,percent of total billed charges,Drugs,11.3,30,,11.3,percent of total billed charges,Drugs,8.19,,,8.19,Other,Drug Cost,8.19,,,8.19,Other,Drug Cost,8.19,,,8.19,Other,Drug Cost,8.19,,,8.19,Other,Drug Cost,8.19,,,8.19,Other,Drug Cost,12.8,34,,12.8,percent of total billed charges,Drugs,8.19,,,8.19,Other,Drug Cost,18.43,,,18.43,Other,225% Medicaid APG methodology,11.47,,,11.47,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,44.78,,,44.78,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",8.19,,,8.19,Other,Drug Cost,8.19,,,8.19,Other,Drug Cost,10.24,,,10.24,Other,125% Medicaid APG methodology,0.01,46.03,
OXACILLIN 2000 MG INJ           ,J2700,HCPCS,,40535130,CDM,636,RC,63323-0812-20,NDC,both,1,EA,24.85,10.34,,,10.34,Other,150% of Medicare + 9.63% HCRA Surcharge,6.29,,,6.29,Fee Schedule,Average Sale Price (ASP) x 6,7.46,30,,7.46,percent of total billed charges,Drugs,7.46,30,,7.46,percent of total billed charges,Drugs,7.46,30,,7.46,percent of total billed charges,Drugs,7.46,30,,7.46,percent of total billed charges,Drugs,7.46,30,,7.46,percent of total billed charges,Drugs,12.43,50,,12.43,percent of total billed charges,All Other,7.46,30,,7.46,percent of total billed charges,Drugs,7.46,30,,7.46,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,7.46,30,,7.46,percent of total billed charges,Drugs,7.46,30,,7.46,percent of total billed charges,Drugs,7.46,30,,7.46,percent of total billed charges,Drugs,7.46,30,,7.46,percent of total billed charges,Drugs,7.46,30,,7.46,percent of total billed charges,Drugs,7.46,30,,7.46,percent of total billed charges,Drugs,7.46,30,,7.46,percent of total billed charges,Drugs,7.46,30,,7.46,percent of total billed charges,Drugs,7.46,30,,7.46,percent of total billed charges,Drugs,7.46,30,,7.46,percent of total billed charges,Drugs,7.46,30,,7.46,percent of total billed charges,Drugs,7.46,30,,7.46,percent of total billed charges,Drugs,7.46,30,,7.46,percent of total billed charges,Drugs,7.51,,,7.51,Other,Drug Cost,7.51,,,7.51,Other,Drug Cost,7.51,,,7.51,Other,Drug Cost,7.51,,,7.51,Other,Drug Cost,7.51,,,7.51,Other,Drug Cost,8.45,34,,8.45,percent of total billed charges,Drugs,7.51,,,7.51,Other,Drug Cost,16.9,,,16.9,Other,225% Medicaid APG methodology,10.51,,,10.51,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,10.06,,,10.06,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",7.51,,,7.51,Other,Drug Cost,7.51,,,7.51,Other,Drug Cost,9.39,,,9.39,Other,125% Medicaid APG methodology,0.01,16.9,
TIGECYCLINE 1MG/ML 0.9% NACL    ,J3243,HCPCS,,40535148,CDM,636,RC,63323-0960-10p,NDC,both,1,ML,1.86,7.26,,,7.26,Other,150% of Medicare + 9.63% HCRA Surcharge,4.42,,,4.42,Fee Schedule,Average Sale Price (ASP) x 6,0.56,30,,0.56,percent of total billed charges,Drugs,0.56,30,,0.56,percent of total billed charges,Drugs,0.56,30,,0.56,percent of total billed charges,Drugs,0.56,30,,0.56,percent of total billed charges,Drugs,0.56,30,,0.56,percent of total billed charges,Drugs,0.93,50,,0.93,percent of total billed charges,All Other,0.56,30,,0.56,percent of total billed charges,Drugs,0.56,30,,0.56,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.56,30,,0.56,percent of total billed charges,Drugs,0.56,30,,0.56,percent of total billed charges,Drugs,0.56,30,,0.56,percent of total billed charges,Drugs,0.56,30,,0.56,percent of total billed charges,Drugs,0.56,30,,0.56,percent of total billed charges,Drugs,0.56,30,,0.56,percent of total billed charges,Drugs,0.56,30,,0.56,percent of total billed charges,Drugs,0.56,30,,0.56,percent of total billed charges,Drugs,0.56,30,,0.56,percent of total billed charges,Drugs,0.56,30,,0.56,percent of total billed charges,Drugs,0.56,30,,0.56,percent of total billed charges,Drugs,0.56,30,,0.56,percent of total billed charges,Drugs,0.56,30,,0.56,percent of total billed charges,Drugs,0.64,,,0.64,Other,Drug Cost,0.64,,,0.64,Other,Drug Cost,0.64,,,0.64,Other,Drug Cost,0.64,,,0.64,Other,Drug Cost,0.64,,,0.64,Other,Drug Cost,0.63,34,,0.63,percent of total billed charges,Drugs,0.64,,,0.64,Other,Drug Cost,1.44,,,1.44,Other,225% Medicaid APG methodology,0.9,,,0.9,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.07,,,7.07,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.64,,,0.64,Other,Drug Cost,0.64,,,0.64,Other,Drug Cost,0.8,,,0.8,Other,125% Medicaid APG methodology,0.01,7.26,
"EPO AL-EPBX 10,000 U/ML 2ML NE  ",Q5106,HCPCS,,40536005,CDM,636,RC,00069-1318-10,NDC,both,2,ML,633.15,77.2,,,77.2,Other,150% of Medicare + 9.63% HCRA Surcharge,46.94,,,46.94,Fee Schedule,Average Sale Price (ASP) x 6,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,316.58,50,,316.58,percent of total billed charges,All Other,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,215.27,34,"If Charge > 500, then 34 percent",215.27,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,22.28,,,22.28,Other,Drug Cost,22.28,,,22.28,Other,Drug Cost,22.28,,,22.28,Other,Drug Cost,22.28,,,22.28,Other,Drug Cost,22.28,,,22.28,Other,Drug Cost,215.27,34,,215.27,percent of total billed charges,Drugs,22.28,,,22.28,Other,Drug Cost,50.13,,,50.13,Other,225% Medicaid APG methodology,31.19,,,31.19,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,75.11,,,75.11,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",22.28,,,22.28,Other,Drug Cost,22.28,,,22.28,Other,Drug Cost,27.85,,,27.85,Other,125% Medicaid APG methodology,0.01,316.58,
MAG SULF 20 G IN IV SLN 500ML   ,J3475,HCPCS,,40536021,CDM,636,RC,00409-6729-03,NDC,both,500,ML,11.55,6.82,,,6.82,Other,150% of Medicare + 9.63% HCRA Surcharge,4.15,,,4.15,Fee Schedule,Average Sale Price (ASP) x 6,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,5.78,50,,5.78,percent of total billed charges,All Other,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,3.47,30,,3.47,percent of total billed charges,Drugs,4.79,,,4.79,Other,Drug Cost,4.79,,,4.79,Other,Drug Cost,4.79,,,4.79,Other,Drug Cost,4.79,,,4.79,Other,Drug Cost,4.79,,,4.79,Other,Drug Cost,3.93,34,,3.93,percent of total billed charges,Drugs,4.79,,,4.79,Other,Drug Cost,10.78,,,10.78,Other,225% Medicaid APG methodology,6.71,,,6.71,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.63,,,6.63,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.79,,,4.79,Other,Drug Cost,4.79,,,4.79,Other,Drug Cost,5.99,,,5.99,Other,125% Medicaid APG methodology,0.01,10.78,
LEVOFLOXACIN 750MG IN IV 150ML  ,J1956,HCPCS,,40536062,CDM,636,RC,25021-0132-83,NDC,both,150,ML,13.02,8.96,,,8.96,Other,150% of Medicare + 9.63% HCRA Surcharge,5.45,,,5.45,Fee Schedule,Average Sale Price (ASP) x 6,3.91,30,,3.91,percent of total billed charges,Drugs,3.91,30,,3.91,percent of total billed charges,Drugs,3.91,30,,3.91,percent of total billed charges,Drugs,3.91,30,,3.91,percent of total billed charges,Drugs,3.91,30,,3.91,percent of total billed charges,Drugs,6.51,50,,6.51,percent of total billed charges,All Other,3.91,30,,3.91,percent of total billed charges,Drugs,3.91,30,,3.91,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.91,30,,3.91,percent of total billed charges,Drugs,3.91,30,,3.91,percent of total billed charges,Drugs,3.91,30,,3.91,percent of total billed charges,Drugs,3.91,30,,3.91,percent of total billed charges,Drugs,3.91,30,,3.91,percent of total billed charges,Drugs,3.91,30,,3.91,percent of total billed charges,Drugs,3.91,30,,3.91,percent of total billed charges,Drugs,3.91,30,,3.91,percent of total billed charges,Drugs,3.91,30,,3.91,percent of total billed charges,Drugs,3.91,30,,3.91,percent of total billed charges,Drugs,3.91,30,,3.91,percent of total billed charges,Drugs,3.91,30,,3.91,percent of total billed charges,Drugs,3.91,30,,3.91,percent of total billed charges,Drugs,1.36,,,1.36,Other,Drug Cost,1.36,,,1.36,Other,Drug Cost,1.36,,,1.36,Other,Drug Cost,1.36,,,1.36,Other,Drug Cost,1.36,,,1.36,Other,Drug Cost,4.43,34,,4.43,percent of total billed charges,Drugs,1.36,,,1.36,Other,Drug Cost,3.06,,,3.06,Other,225% Medicaid APG methodology,1.9,,,1.9,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,8.72,,,8.72,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.36,,,1.36,Other,Drug Cost,1.36,,,1.36,Other,Drug Cost,1.7,,,1.7,Other,125% Medicaid APG methodology,0.01,8.96,
HEPARIN 100UNITS/ML D5W 250ML   ,J1644,HCPCS,,40536096,CDM,636,RC,63323-0523-74,NDC,both,250,ML,25.69,2.64,,,2.64,Other,150% of Medicare + 9.63% HCRA Surcharge,1.61,,,1.61,Fee Schedule,Average Sale Price (ASP) x 6,7.71,30,,7.71,percent of total billed charges,Drugs,7.71,30,,7.71,percent of total billed charges,Drugs,7.71,30,,7.71,percent of total billed charges,Drugs,7.71,30,,7.71,percent of total billed charges,Drugs,7.71,30,,7.71,percent of total billed charges,Drugs,12.85,50,,12.85,percent of total billed charges,All Other,7.71,30,,7.71,percent of total billed charges,Drugs,7.71,30,,7.71,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,7.71,30,,7.71,percent of total billed charges,Drugs,7.71,30,,7.71,percent of total billed charges,Drugs,7.71,30,,7.71,percent of total billed charges,Drugs,7.71,30,,7.71,percent of total billed charges,Drugs,7.71,30,,7.71,percent of total billed charges,Drugs,7.71,30,,7.71,percent of total billed charges,Drugs,7.71,30,,7.71,percent of total billed charges,Drugs,7.71,30,,7.71,percent of total billed charges,Drugs,7.71,30,,7.71,percent of total billed charges,Drugs,7.71,30,,7.71,percent of total billed charges,Drugs,7.71,30,,7.71,percent of total billed charges,Drugs,7.71,30,,7.71,percent of total billed charges,Drugs,7.71,30,,7.71,percent of total billed charges,Drugs,3.82,,,3.82,Other,Drug Cost,3.82,,,3.82,Other,Drug Cost,3.82,,,3.82,Other,Drug Cost,3.82,,,3.82,Other,Drug Cost,3.82,,,3.82,Other,Drug Cost,8.73,34,,8.73,percent of total billed charges,Drugs,3.82,,,3.82,Other,Drug Cost,8.6,,,8.6,Other,225% Medicaid APG methodology,5.35,,,5.35,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.57,,,2.57,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.82,,,3.82,Other,Drug Cost,3.82,,,3.82,Other,Drug Cost,4.78,,,4.78,Other,125% Medicaid APG methodology,0.01,12.85,
DOPAMINE 40 MG/ML IV SOLN 5 ML  ,J1265,HCPCS,,40536104,CDM,636,RC,00409-5820-01,NDC,both,5,ML,8.89,7.62,,,7.62,Other,150% of Medicare + 9.63% HCRA Surcharge,4.63,,,4.63,Fee Schedule,Average Sale Price (ASP) x 6,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,4.45,50,,4.45,percent of total billed charges,All Other,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,1.47,,,1.47,Other,Drug Cost,1.47,,,1.47,Other,Drug Cost,1.47,,,1.47,Other,Drug Cost,1.47,,,1.47,Other,Drug Cost,1.47,,,1.47,Other,Drug Cost,3.02,34,,3.02,percent of total billed charges,Drugs,1.47,,,1.47,Other,Drug Cost,3.31,,,3.31,Other,225% Medicaid APG methodology,2.06,,,2.06,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.41,,,7.41,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.47,,,1.47,Other,Drug Cost,1.47,,,1.47,Other,Drug Cost,1.84,,,1.84,Other,125% Medicaid APG methodology,0.01,7.62,
EPOETIN 10000 UNITS/ML PF ESRD  ,J0885,HCPCS,,40536120,CDM,636,RC,59676-0310-01,NDC,both,1,ML,492.49,87.68,,,87.68,Other,150% of Medicare + 9.63% HCRA Surcharge,53.32,,,53.32,Fee Schedule,Average Sale Price (ASP) x 6,147.75,30,,147.75,percent of total billed charges,Drugs,147.75,30,,147.75,percent of total billed charges,Drugs,147.75,30,,147.75,percent of total billed charges,Drugs,147.75,30,,147.75,percent of total billed charges,Drugs,147.75,30,,147.75,percent of total billed charges,Drugs,246.25,50,,246.25,percent of total billed charges,All Other,147.75,30,,147.75,percent of total billed charges,Drugs,147.75,30,,147.75,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,147.75,30,,147.75,percent of total billed charges,Drugs,147.75,30,,147.75,percent of total billed charges,Drugs,147.75,30,,147.75,percent of total billed charges,Drugs,147.75,30,,147.75,percent of total billed charges,Drugs,147.75,30,,147.75,percent of total billed charges,Drugs,147.75,30,,147.75,percent of total billed charges,Drugs,147.75,30,,147.75,percent of total billed charges,Drugs,147.75,30,,147.75,percent of total billed charges,Drugs,147.75,30,,147.75,percent of total billed charges,Drugs,147.75,30,,147.75,percent of total billed charges,Drugs,147.75,30,,147.75,percent of total billed charges,Drugs,147.75,30,,147.75,percent of total billed charges,Drugs,147.75,30,,147.75,percent of total billed charges,Drugs,68.4,,,68.4,Other,Drug Cost,68.4,,,68.4,Other,Drug Cost,68.4,,,68.4,Other,Drug Cost,68.4,,,68.4,Other,Drug Cost,68.4,,,68.4,Other,Drug Cost,167.45,34,,167.45,percent of total billed charges,Drugs,68.4,,,68.4,Other,Drug Cost,153.9,,,153.9,Other,225% Medicaid APG methodology,95.76,,,95.76,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,85.31,,,85.31,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",68.4,,,68.4,Other,Drug Cost,68.4,,,68.4,Other,Drug Cost,85.5,,,85.5,Other,125% Medicaid APG methodology,0.01,246.25,
ALTEPLASE 100MG IN SW 100ML     ,J2997,HCPCS,,40536153,CDM,636,RC,50242-0085-27,NDC,both,1,EA,28632.84,877.88,,,877.88,Other,150% of Medicare + 9.63% HCRA Surcharge,533.84,,,533.84,Fee Schedule,Average Sale Price (ASP) x 6,8589.85,30,,8589.85,percent of total billed charges,Drugs,8589.85,30,,8589.85,percent of total billed charges,Drugs,8589.85,30,,8589.85,percent of total billed charges,Drugs,8589.85,30,,8589.85,percent of total billed charges,Drugs,8589.85,30,,8589.85,percent of total billed charges,Drugs,14316.42,50,,14316.42,percent of total billed charges,All Other,8589.85,30,,8589.85,percent of total billed charges,Drugs,8589.85,30,,8589.85,percent of total billed charges,Drugs,9735.17,34,"If Charge > 500, then 34 percent",9735.17,percent of total billed charges,Drugs,8589.85,30,,8589.85,percent of total billed charges,Drugs,8589.85,30,,8589.85,percent of total billed charges,Drugs,8589.85,30,,8589.85,percent of total billed charges,Drugs,8589.85,30,,8589.85,percent of total billed charges,Drugs,8589.85,30,,8589.85,percent of total billed charges,Drugs,8589.85,30,,8589.85,percent of total billed charges,Drugs,8589.85,30,,8589.85,percent of total billed charges,Drugs,8589.85,30,,8589.85,percent of total billed charges,Drugs,8589.85,30,,8589.85,percent of total billed charges,Drugs,8589.85,30,,8589.85,percent of total billed charges,Drugs,8589.85,30,,8589.85,percent of total billed charges,Drugs,8589.85,30,,8589.85,percent of total billed charges,Drugs,8589.85,30,,8589.85,percent of total billed charges,Drugs,2020.72,,,2020.72,Other,Drug Cost,2020.72,,,2020.72,Other,Drug Cost,2020.72,,,2020.72,Other,Drug Cost,2020.72,,,2020.72,Other,Drug Cost,2020.72,,,2020.72,Other,Drug Cost,9735.17,34,,9735.17,percent of total billed charges,Drugs,2020.72,,,2020.72,Other,Drug Cost,4546.62,,,4546.62,Other,225% Medicaid APG methodology,2829.01,,,2829.01,Other,140% Medicaid APG methodology,9735.17,34,"If Charge > 2,000, then 34 percent",9735.17,percent of total billed charges,Drugs,854.15,,,854.15,Other,160% Medicare Fee Schedule,9735.17,34,,9735.17,Other,"Drug Charges > 20,000, then 34% of Charges",2020.72,,,2020.72,Other,Drug Cost,2020.72,,,2020.72,Other,Drug Cost,2525.9,,,2525.9,Other,125% Medicaid APG methodology,533.84,14316.42,
VUTRISIRAN 25 MG/0.5 ML SOLN    ,J0225,HCPCS,,40536161,CDM,636,RC,71336-1003-01,NDC,both,0.5,ML,439901,48814.34,,,48814.34,Other,150% of Medicare + 9.63% HCRA Surcharge,29684.3,,,29684.3,Fee Schedule,Average Sale Price (ASP) x 6,131970.3,30,,131970.3,percent of total billed charges,Drugs,131970.3,30,,131970.3,percent of total billed charges,Drugs,131970.3,30,,131970.3,percent of total billed charges,Drugs,131970.3,30,,131970.3,percent of total billed charges,Drugs,131970.3,30,,131970.3,percent of total billed charges,Drugs,219950.5,50,,219950.5,percent of total billed charges,All Other,131970.3,30,,131970.3,percent of total billed charges,Drugs,131970.3,30,,131970.3,percent of total billed charges,Drugs,149566.34,34,"If Charge > 500, then 34 percent",149566.34,percent of total billed charges,Drugs,131970.3,30,,131970.3,percent of total billed charges,Drugs,131970.3,30,,131970.3,percent of total billed charges,Drugs,131970.3,30,,131970.3,percent of total billed charges,Drugs,131970.3,30,,131970.3,percent of total billed charges,Drugs,131970.3,30,,131970.3,percent of total billed charges,Drugs,131970.3,30,,131970.3,percent of total billed charges,Drugs,131970.3,30,,131970.3,percent of total billed charges,Drugs,131970.3,30,,131970.3,percent of total billed charges,Drugs,131970.3,30,,131970.3,percent of total billed charges,Drugs,131970.3,30,,131970.3,percent of total billed charges,Drugs,131970.3,30,,131970.3,percent of total billed charges,Drugs,131970.3,30,,131970.3,percent of total billed charges,Drugs,131970.3,30,,131970.3,percent of total billed charges,Drugs,88566.24,,,88566.24,Other,Drug Cost,88566.24,,,88566.24,Other,Drug Cost,88566.24,,,88566.24,Other,Drug Cost,88566.24,,,88566.24,Other,Drug Cost,88566.24,,,88566.24,Other,Drug Cost,149566.34,34,,149566.34,percent of total billed charges,Drugs,88566.24,,,88566.24,Other,Drug Cost,199274.04,,,199274.04,Other,225% Medicaid APG methodology,123992.74,,,123992.74,Other,140% Medicaid APG methodology,149566.34,34,"If Charge > 2,000, then 34 percent",149566.34,percent of total billed charges,Drugs,47494.88,,,47494.88,Other,160% Medicare Fee Schedule,149566.34,34,,149566.34,Other,"Drug Charges > 20,000, then 34% of Charges",88566.24,,,88566.24,Other,Drug Cost,88566.24,,,88566.24,Other,Drug Cost,110707.8,,,110707.8,Other,125% Medicaid APG methodology,29684.3,219950.5,
DECITABINE 50 MG IV INJ         ,J0894,HCPCS,,40536179,CDM,636,RC,55111-0556-10,NDC,both,1,EA,264.43,16.71,,,16.71,Other,150% of Medicare + 9.63% HCRA Surcharge,10.16,,,10.16,Fee Schedule,Average Sale Price (ASP) x 6,79.33,30,,79.33,percent of total billed charges,Drugs,79.33,30,,79.33,percent of total billed charges,Drugs,79.33,30,,79.33,percent of total billed charges,Drugs,79.33,30,,79.33,percent of total billed charges,Drugs,79.33,30,,79.33,percent of total billed charges,Drugs,132.22,50,,132.22,percent of total billed charges,All Other,79.33,30,,79.33,percent of total billed charges,Drugs,79.33,30,,79.33,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,79.33,30,,79.33,percent of total billed charges,Drugs,79.33,30,,79.33,percent of total billed charges,Drugs,79.33,30,,79.33,percent of total billed charges,Drugs,79.33,30,,79.33,percent of total billed charges,Drugs,79.33,30,,79.33,percent of total billed charges,Drugs,79.33,30,,79.33,percent of total billed charges,Drugs,79.33,30,,79.33,percent of total billed charges,Drugs,79.33,30,,79.33,percent of total billed charges,Drugs,79.33,30,,79.33,percent of total billed charges,Drugs,79.33,30,,79.33,percent of total billed charges,Drugs,79.33,30,,79.33,percent of total billed charges,Drugs,79.33,30,,79.33,percent of total billed charges,Drugs,79.33,30,,79.33,percent of total billed charges,Drugs,40.93,,,40.93,Other,Drug Cost,40.93,,,40.93,Other,Drug Cost,40.93,,,40.93,Other,Drug Cost,40.93,,,40.93,Other,Drug Cost,40.93,,,40.93,Other,Drug Cost,89.91,34,,89.91,percent of total billed charges,Drugs,40.93,,,40.93,Other,Drug Cost,92.09,,,92.09,Other,225% Medicaid APG methodology,57.3,,,57.3,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,16.26,,,16.26,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",40.93,,,40.93,Other,Drug Cost,40.93,,,40.93,Other,Drug Cost,51.16,,,51.16,Other,125% Medicaid APG methodology,0.01,132.22,
PEDS ACYCLOVIR 5 MG/ML IN D5W   ,J0133,HCPCS,,40536245,CDM,636,RC,63323-0325-10n,NDC,both,1,ML,0.11,0.55,,,0.55,Other,150% of Medicare + 9.63% HCRA Surcharge,0.34,,,0.34,Fee Schedule,Average Sale Price (ASP) x 6,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.06,50,,0.06,percent of total billed charges,All Other,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,34,,0.04,percent of total billed charges,Drugs,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.54,,,0.54,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,0.55,
AMIKACIN 5MG/ML IN 0.9% NACL    ,J0278,HCPCS,,40536260,CDM,636,RC,23155-0290-41n,NDC,both,1,ML,0.07,8.18,,,8.18,Other,150% of Medicare + 9.63% HCRA Surcharge,4.97,,,4.97,Fee Schedule,Average Sale Price (ASP) x 6,0.02,30,,0.02,percent of total billed charges,Drugs,0.02,30,,0.02,percent of total billed charges,Drugs,0.02,30,,0.02,percent of total billed charges,Drugs,0.02,30,,0.02,percent of total billed charges,Drugs,0.02,30,,0.02,percent of total billed charges,Drugs,0.04,50,,0.04,percent of total billed charges,All Other,0.02,30,,0.02,percent of total billed charges,Drugs,0.02,30,,0.02,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,30,,0.02,percent of total billed charges,Drugs,0.02,30,,0.02,percent of total billed charges,Drugs,0.02,30,,0.02,percent of total billed charges,Drugs,0.02,30,,0.02,percent of total billed charges,Drugs,0.02,30,,0.02,percent of total billed charges,Drugs,0.02,30,,0.02,percent of total billed charges,Drugs,0.02,30,,0.02,percent of total billed charges,Drugs,0.02,30,,0.02,percent of total billed charges,Drugs,0.02,30,,0.02,percent of total billed charges,Drugs,0.02,30,,0.02,percent of total billed charges,Drugs,0.02,30,,0.02,percent of total billed charges,Drugs,0.02,30,,0.02,percent of total billed charges,Drugs,0.02,30,,0.02,percent of total billed charges,Drugs,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.02,34,,0.02,percent of total billed charges,Drugs,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.96,,,7.96,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,8.18,
AMINOPHYLLINE 5MG/ML IN D5W     ,J0280,HCPCS,,40536286,CDM,636,RC,00409-5922-01n,NDC,both,1,ML,0.25,50.64,,,50.64,Other,150% of Medicare + 9.63% HCRA Surcharge,30.79,,,30.79,Fee Schedule,Average Sale Price (ASP) x 6,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.13,50,,0.13,percent of total billed charges,All Other,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.08,30,,0.08,percent of total billed charges,Drugs,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.09,34,,0.09,percent of total billed charges,Drugs,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,49.27,,,49.27,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,50.64,
AMPHOTERICIN B 0.1MG/ML IN D5W  ,J0285,HCPCS,,40536328,CDM,636,RC,57665-0101-41n,NDC,both,1,ML,15.26,94.09,,,94.09,Other,150% of Medicare + 9.63% HCRA Surcharge,57.22,,,57.22,Fee Schedule,Average Sale Price (ASP) x 6,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,7.63,50,,7.63,percent of total billed charges,All Other,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,4.58,30,,4.58,percent of total billed charges,Drugs,3.18,,,3.18,Other,Drug Cost,3.18,,,3.18,Other,Drug Cost,3.18,,,3.18,Other,Drug Cost,3.18,,,3.18,Other,Drug Cost,3.18,,,3.18,Other,Drug Cost,5.19,34,,5.19,percent of total billed charges,Drugs,3.18,,,3.18,Other,Drug Cost,7.16,,,7.16,Other,225% Medicaid APG methodology,4.45,,,4.45,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,91.55,,,91.55,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.18,,,3.18,Other,Drug Cost,3.18,,,3.18,Other,Drug Cost,3.98,,,3.98,Other,125% Medicaid APG methodology,0.01,94.09,
AMPICILLIN 20MG/ML IN NS        ,J0290,HCPCS,,40536369,CDM,636,RC,00781-3402-95n,NDC,both,1,ML,2.1,9.98,,,9.98,Other,150% of Medicare + 9.63% HCRA Surcharge,6.07,,,6.07,Fee Schedule,Average Sale Price (ASP) x 6,0.63,30,,0.63,percent of total billed charges,Drugs,0.63,30,,0.63,percent of total billed charges,Drugs,0.63,30,,0.63,percent of total billed charges,Drugs,0.63,30,,0.63,percent of total billed charges,Drugs,0.63,30,,0.63,percent of total billed charges,Drugs,1.05,50,,1.05,percent of total billed charges,All Other,0.63,30,,0.63,percent of total billed charges,Drugs,0.63,30,,0.63,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.63,30,,0.63,percent of total billed charges,Drugs,0.63,30,,0.63,percent of total billed charges,Drugs,0.63,30,,0.63,percent of total billed charges,Drugs,0.63,30,,0.63,percent of total billed charges,Drugs,0.63,30,,0.63,percent of total billed charges,Drugs,0.63,30,,0.63,percent of total billed charges,Drugs,0.63,30,,0.63,percent of total billed charges,Drugs,0.63,30,,0.63,percent of total billed charges,Drugs,0.63,30,,0.63,percent of total billed charges,Drugs,0.63,30,,0.63,percent of total billed charges,Drugs,0.63,30,,0.63,percent of total billed charges,Drugs,0.63,30,,0.63,percent of total billed charges,Drugs,0.63,30,,0.63,percent of total billed charges,Drugs,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.71,34,,0.71,percent of total billed charges,Drugs,0.34,,,0.34,Other,Drug Cost,0.77,,,0.77,Other,225% Medicaid APG methodology,0.48,,,0.48,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,9.71,,,9.71,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.34,,,0.34,Other,Drug Cost,0.34,,,0.34,Other,Drug Cost,0.43,,,0.43,Other,125% Medicaid APG methodology,0.01,9.98,
PEDS AZTREONAM 20 MG/ML IN D5W  ,J0457,HCPCS,,40536427,CDM,636,RC,63323-0401-20n,NDC,both,1,ML,89.46,25.05,,,25.05,Other,150% of Medicare + 9.63% HCRA Surcharge,15.23,,,15.23,Fee Schedule,Average Sale Price (ASP) x 6,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,44.73,50,,44.73,percent of total billed charges,All Other,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,26.84,30,,26.84,percent of total billed charges,Drugs,8.18,,,8.18,Other,Drug Cost,8.18,,,8.18,Other,Drug Cost,8.18,,,8.18,Other,Drug Cost,8.18,,,8.18,Other,Drug Cost,8.18,,,8.18,Other,Drug Cost,30.42,34,,30.42,percent of total billed charges,Drugs,8.18,,,8.18,Other,Drug Cost,18.41,,,18.41,Other,225% Medicaid APG methodology,11.45,,,11.45,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,24.37,,,24.37,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",8.18,,,8.18,Other,Drug Cost,8.18,,,8.18,Other,Drug Cost,10.23,,,10.23,Other,125% Medicaid APG methodology,0.01,44.73,
PEDS CEFAZOLIN 20 MG/ML IN D5W  ,J0690,HCPCS,,40536500,CDM,636,RC,00143-9924-90n,NDC,both,1,ML,0.04,7.53,,,7.53,Other,150% of Medicare + 9.63% HCRA Surcharge,4.58,,,4.58,Fee Schedule,Average Sale Price (ASP) x 6,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.02,50,,0.02,percent of total billed charges,All Other,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.32,,,7.32,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,7.53,
CEFTAZIDIME 20MG/ML IN D5W      ,J0713,HCPCS,,40536583,CDM,636,RC,44567-0235-25a,NDC,both,1,ML,0.21,16.71,,,16.71,Other,150% of Medicare + 9.63% HCRA Surcharge,10.16,,,10.16,Fee Schedule,Average Sale Price (ASP) x 6,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.11,50,,0.11,percent of total billed charges,All Other,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.07,34,,0.07,percent of total billed charges,Drugs,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,16.26,,,16.26,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,16.71,
PEDS CLINDAMYCIN 12 MG/ML D5W   ,J0736,HCPCS,,40536666,CDM,636,RC,00781-3289-09p,NDC,both,1,ML,0.77,18.79,,,18.79,Other,150% of Medicare + 9.63% HCRA Surcharge,11.42,,,11.42,Fee Schedule,Average Sale Price (ASP) x 6,0.23,30,,0.23,percent of total billed charges,Drugs,0.23,30,,0.23,percent of total billed charges,Drugs,0.23,30,,0.23,percent of total billed charges,Drugs,0.23,30,,0.23,percent of total billed charges,Drugs,0.23,30,,0.23,percent of total billed charges,Drugs,0.39,50,,0.39,percent of total billed charges,All Other,0.23,30,,0.23,percent of total billed charges,Drugs,0.23,30,,0.23,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.23,30,,0.23,percent of total billed charges,Drugs,0.23,30,,0.23,percent of total billed charges,Drugs,0.23,30,,0.23,percent of total billed charges,Drugs,0.23,30,,0.23,percent of total billed charges,Drugs,0.23,30,,0.23,percent of total billed charges,Drugs,0.23,30,,0.23,percent of total billed charges,Drugs,0.23,30,,0.23,percent of total billed charges,Drugs,0.23,30,,0.23,percent of total billed charges,Drugs,0.23,30,,0.23,percent of total billed charges,Drugs,0.23,30,,0.23,percent of total billed charges,Drugs,0.23,30,,0.23,percent of total billed charges,Drugs,0.23,30,,0.23,percent of total billed charges,Drugs,0.23,30,,0.23,percent of total billed charges,Drugs,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.26,34,,0.26,percent of total billed charges,Drugs,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% Medicaid APG methodology,0.11,,,0.11,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,18.28,,,18.28,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,18.79,
ENOXAPARIN SUBQ 100MG/ML        ,J1650,HCPCS,,40536781,CDM,636,RC,63323-0605-84p,NDC,both,1,ML,29.96,6.71,,,6.71,Other,150% of Medicare + 9.63% HCRA Surcharge,4.08,,,4.08,Fee Schedule,Average Sale Price (ASP) x 6,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,14.98,50,,14.98,percent of total billed charges,All Other,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,5.93,,,5.93,Other,Drug Cost,5.93,,,5.93,Other,Drug Cost,5.93,,,5.93,Other,Drug Cost,5.93,,,5.93,Other,Drug Cost,5.93,,,5.93,Other,Drug Cost,10.19,34,,10.19,percent of total billed charges,Drugs,5.93,,,5.93,Other,Drug Cost,13.34,,,13.34,Other,225% Medicaid APG methodology,8.3,,,8.3,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.53,,,6.53,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.93,,,5.93,Other,Drug Cost,5.93,,,5.93,Other,Drug Cost,7.41,,,7.41,Other,125% Medicaid APG methodology,0.01,14.98,
FLUCONAZOLE 2MG/ML 0.9% NACL    ,J1450,HCPCS,,40536872,CDM,636,RC,25021-0184-82n,NDC,both,1,ML,0.14,27.6,,,27.6,Other,150% of Medicare + 9.63% HCRA Surcharge,16.78,,,16.78,Fee Schedule,Average Sale Price (ASP) x 6,0.04,30,,0.04,percent of total billed charges,Drugs,0.04,30,,0.04,percent of total billed charges,Drugs,0.04,30,,0.04,percent of total billed charges,Drugs,0.04,30,,0.04,percent of total billed charges,Drugs,0.04,30,,0.04,percent of total billed charges,Drugs,0.07,50,,0.07,percent of total billed charges,All Other,0.04,30,,0.04,percent of total billed charges,Drugs,0.04,30,,0.04,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.04,30,,0.04,percent of total billed charges,Drugs,0.04,30,,0.04,percent of total billed charges,Drugs,0.04,30,,0.04,percent of total billed charges,Drugs,0.04,30,,0.04,percent of total billed charges,Drugs,0.04,30,,0.04,percent of total billed charges,Drugs,0.04,30,,0.04,percent of total billed charges,Drugs,0.04,30,,0.04,percent of total billed charges,Drugs,0.04,30,,0.04,percent of total billed charges,Drugs,0.04,30,,0.04,percent of total billed charges,Drugs,0.04,30,,0.04,percent of total billed charges,Drugs,0.04,30,,0.04,percent of total billed charges,Drugs,0.04,30,,0.04,percent of total billed charges,Drugs,0.04,30,,0.04,percent of total billed charges,Drugs,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.05,34,,0.05,percent of total billed charges,Drugs,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,26.85,,,26.85,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,27.6,
GENTAMICIN 2MG/ML IN 0.9% NACL  ,J1580,HCPCS,,40536948,CDM,636,RC,63323-0173-02n,NDC,both,1,ML,2.98,26.49,,,26.49,Other,150% of Medicare + 9.63% HCRA Surcharge,16.11,,,16.11,Fee Schedule,Average Sale Price (ASP) x 6,0.89,30,,0.89,percent of total billed charges,Drugs,0.89,30,,0.89,percent of total billed charges,Drugs,0.89,30,,0.89,percent of total billed charges,Drugs,0.89,30,,0.89,percent of total billed charges,Drugs,0.89,30,,0.89,percent of total billed charges,Drugs,1.49,50,,1.49,percent of total billed charges,All Other,0.89,30,,0.89,percent of total billed charges,Drugs,0.89,30,,0.89,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.89,30,,0.89,percent of total billed charges,Drugs,0.89,30,,0.89,percent of total billed charges,Drugs,0.89,30,,0.89,percent of total billed charges,Drugs,0.89,30,,0.89,percent of total billed charges,Drugs,0.89,30,,0.89,percent of total billed charges,Drugs,0.89,30,,0.89,percent of total billed charges,Drugs,0.89,30,,0.89,percent of total billed charges,Drugs,0.89,30,,0.89,percent of total billed charges,Drugs,0.89,30,,0.89,percent of total billed charges,Drugs,0.89,30,,0.89,percent of total billed charges,Drugs,0.89,30,,0.89,percent of total billed charges,Drugs,0.89,30,,0.89,percent of total billed charges,Drugs,0.89,30,,0.89,percent of total billed charges,Drugs,0.79,,,0.79,Other,Drug Cost,0.79,,,0.79,Other,Drug Cost,0.79,,,0.79,Other,Drug Cost,0.79,,,0.79,Other,Drug Cost,0.79,,,0.79,Other,Drug Cost,1.01,34,,1.01,percent of total billed charges,Drugs,0.79,,,0.79,Other,Drug Cost,1.78,,,1.78,Other,225% Medicaid APG methodology,1.11,,,1.11,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,25.78,,,25.78,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.79,,,0.79,Other,Drug Cost,0.79,,,0.79,Other,Drug Cost,0.99,,,0.99,Other,125% Medicaid APG methodology,0.01,26.49,
KETOROLAC 15MG/ML INJ SOLN 1ML  ,J1885,HCPCS,,40537037,CDM,636,RC,63323-0161-01,NDC,both,1,ML,2.14,4.81,,,4.81,Other,150% of Medicare + 9.63% HCRA Surcharge,2.93,,,2.93,Fee Schedule,Average Sale Price (ASP) x 6,0.64,30,,0.64,percent of total billed charges,Drugs,0.64,30,,0.64,percent of total billed charges,Drugs,0.64,30,,0.64,percent of total billed charges,Drugs,0.64,30,,0.64,percent of total billed charges,Drugs,0.64,30,,0.64,percent of total billed charges,Drugs,1.07,50,,1.07,percent of total billed charges,All Other,0.64,30,,0.64,percent of total billed charges,Drugs,0.64,30,,0.64,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.64,30,,0.64,percent of total billed charges,Drugs,0.64,30,,0.64,percent of total billed charges,Drugs,0.64,30,,0.64,percent of total billed charges,Drugs,0.64,30,,0.64,percent of total billed charges,Drugs,0.64,30,,0.64,percent of total billed charges,Drugs,0.64,30,,0.64,percent of total billed charges,Drugs,0.64,30,,0.64,percent of total billed charges,Drugs,0.64,30,,0.64,percent of total billed charges,Drugs,0.64,30,,0.64,percent of total billed charges,Drugs,0.64,30,,0.64,percent of total billed charges,Drugs,0.64,30,,0.64,percent of total billed charges,Drugs,0.64,30,,0.64,percent of total billed charges,Drugs,0.64,30,,0.64,percent of total billed charges,Drugs,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.73,34,,0.73,percent of total billed charges,Drugs,0.33,,,0.33,Other,Drug Cost,0.74,,,0.74,Other,225% Medicaid APG methodology,0.46,,,0.46,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,4.68,,,4.68,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.33,,,0.33,Other,Drug Cost,0.33,,,0.33,Other,Drug Cost,0.41,,,0.41,Other,125% Medicaid APG methodology,0.01,4.81,
MEROPENEM 500 MG IV INJ         ,J2185,HCPCS,,40537094,CDM,636,RC,00409-1390-51,NDC,both,1,EA,47.43,4.46,,,4.46,Other,150% of Medicare + 9.63% HCRA Surcharge,2.71,,,2.71,Fee Schedule,Average Sale Price (ASP) x 6,14.23,30,,14.23,percent of total billed charges,Drugs,14.23,30,,14.23,percent of total billed charges,Drugs,14.23,30,,14.23,percent of total billed charges,Drugs,14.23,30,,14.23,percent of total billed charges,Drugs,14.23,30,,14.23,percent of total billed charges,Drugs,23.72,50,,23.72,percent of total billed charges,All Other,14.23,30,,14.23,percent of total billed charges,Drugs,14.23,30,,14.23,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,14.23,30,,14.23,percent of total billed charges,Drugs,14.23,30,,14.23,percent of total billed charges,Drugs,14.23,30,,14.23,percent of total billed charges,Drugs,14.23,30,,14.23,percent of total billed charges,Drugs,14.23,30,,14.23,percent of total billed charges,Drugs,14.23,30,,14.23,percent of total billed charges,Drugs,14.23,30,,14.23,percent of total billed charges,Drugs,14.23,30,,14.23,percent of total billed charges,Drugs,14.23,30,,14.23,percent of total billed charges,Drugs,14.23,30,,14.23,percent of total billed charges,Drugs,14.23,30,,14.23,percent of total billed charges,Drugs,14.23,30,,14.23,percent of total billed charges,Drugs,14.23,30,,14.23,percent of total billed charges,Drugs,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,16.13,34,,16.13,percent of total billed charges,Drugs,0.6,,,0.6,Other,Drug Cost,1.35,,,1.35,Other,225% Medicaid APG methodology,0.84,,,0.84,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,4.34,,,4.34,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.75,,,0.75,Other,125% Medicaid APG methodology,0.01,23.72,
MEROPENEM 20MG/ML IN 0.9% NACL  ,J2185,HCPCS,,40537102,CDM,636,RC,63323-0507-20n,NDC,both,1,ML,17.71,4.46,,,4.46,Other,150% of Medicare + 9.63% HCRA Surcharge,2.71,,,2.71,Fee Schedule,Average Sale Price (ASP) x 6,5.31,30,,5.31,percent of total billed charges,Drugs,5.31,30,,5.31,percent of total billed charges,Drugs,5.31,30,,5.31,percent of total billed charges,Drugs,5.31,30,,5.31,percent of total billed charges,Drugs,5.31,30,,5.31,percent of total billed charges,Drugs,8.86,50,,8.86,percent of total billed charges,All Other,5.31,30,,5.31,percent of total billed charges,Drugs,5.31,30,,5.31,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,5.31,30,,5.31,percent of total billed charges,Drugs,5.31,30,,5.31,percent of total billed charges,Drugs,5.31,30,,5.31,percent of total billed charges,Drugs,5.31,30,,5.31,percent of total billed charges,Drugs,5.31,30,,5.31,percent of total billed charges,Drugs,5.31,30,,5.31,percent of total billed charges,Drugs,5.31,30,,5.31,percent of total billed charges,Drugs,5.31,30,,5.31,percent of total billed charges,Drugs,5.31,30,,5.31,percent of total billed charges,Drugs,5.31,30,,5.31,percent of total billed charges,Drugs,5.31,30,,5.31,percent of total billed charges,Drugs,5.31,30,,5.31,percent of total billed charges,Drugs,5.31,30,,5.31,percent of total billed charges,Drugs,3.41,,,3.41,Other,Drug Cost,3.41,,,3.41,Other,Drug Cost,3.41,,,3.41,Other,Drug Cost,3.41,,,3.41,Other,Drug Cost,3.41,,,3.41,Other,Drug Cost,6.02,34,,6.02,percent of total billed charges,Drugs,3.41,,,3.41,Other,Drug Cost,7.67,,,7.67,Other,225% Medicaid APG methodology,4.77,,,4.77,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,4.34,,,4.34,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.41,,,3.41,Other,Drug Cost,3.41,,,3.41,Other,Drug Cost,4.26,,,4.26,Other,125% Medicaid APG methodology,0.01,8.86,
METRONIDAZOLE 5MG/ML IN NS      ,J1836,HCPCS,,40537185,CDM,636,RC,00409-7811-24n,NDC,both,1,ML,0.04,0.24,,,0.24,Other,150% of Medicare + 9.63% HCRA Surcharge,0.14,,,0.14,Fee Schedule,Average Sale Price (ASP) x 6,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.02,50,,0.02,percent of total billed charges,All Other,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.23,,,0.23,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,0.24,
PIP-TAZO 36 G-4.5 G IV INJ      ,J2543,HCPCS,,40537300,CDM,636,RC,44567-0804-01,NDC,both,1,EA,325.36,11.61,,,11.61,Other,150% of Medicare + 9.63% HCRA Surcharge,7.06,,,7.06,Fee Schedule,Average Sale Price (ASP) x 6,97.61,30,,97.61,percent of total billed charges,Drugs,97.61,30,,97.61,percent of total billed charges,Drugs,97.61,30,,97.61,percent of total billed charges,Drugs,97.61,30,,97.61,percent of total billed charges,Drugs,97.61,30,,97.61,percent of total billed charges,Drugs,162.68,50,,162.68,percent of total billed charges,All Other,97.61,30,,97.61,percent of total billed charges,Drugs,97.61,30,,97.61,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,97.61,30,,97.61,percent of total billed charges,Drugs,97.61,30,,97.61,percent of total billed charges,Drugs,97.61,30,,97.61,percent of total billed charges,Drugs,97.61,30,,97.61,percent of total billed charges,Drugs,97.61,30,,97.61,percent of total billed charges,Drugs,97.61,30,,97.61,percent of total billed charges,Drugs,97.61,30,,97.61,percent of total billed charges,Drugs,97.61,30,,97.61,percent of total billed charges,Drugs,97.61,30,,97.61,percent of total billed charges,Drugs,97.61,30,,97.61,percent of total billed charges,Drugs,97.61,30,,97.61,percent of total billed charges,Drugs,97.61,30,,97.61,percent of total billed charges,Drugs,97.61,30,,97.61,percent of total billed charges,Drugs,54.89,,,54.89,Other,Drug Cost,54.89,,,54.89,Other,Drug Cost,54.89,,,54.89,Other,Drug Cost,54.89,,,54.89,Other,Drug Cost,54.89,,,54.89,Other,Drug Cost,110.62,34,,110.62,percent of total billed charges,Drugs,54.89,,,54.89,Other,Drug Cost,123.5,,,123.5,Other,225% Medicaid APG methodology,76.85,,,76.85,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,11.3,,,11.3,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",54.89,,,54.89,Other,Drug Cost,54.89,,,54.89,Other,Drug Cost,68.61,,,68.61,Other,125% Medicaid APG methodology,0.01,162.68,
TOBRAMYCIN 2MG/ML IN 0.9% NACL  ,J3260,HCPCS,,40537425,CDM,636,RC,63323-0306-02n,NDC,both,1,ML,0.11,26.28,,,26.28,Other,150% of Medicare + 9.63% HCRA Surcharge,15.98,,,15.98,Fee Schedule,Average Sale Price (ASP) x 6,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.06,50,,0.06,percent of total billed charges,All Other,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.04,34,,0.04,percent of total billed charges,Drugs,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,25.57,,,25.57,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,26.28,
NICU VANCOMYCIN 5 MG/ML IN D5W  ,J3370,HCPCS,,40537458,CDM,636,RC,00409-4332-01n,NDC,both,1,ML,8.05,22.76,,,22.76,Other,150% of Medicare + 9.63% HCRA Surcharge,13.84,,,13.84,Fee Schedule,Average Sale Price (ASP) x 6,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,4.03,50,,4.03,percent of total billed charges,All Other,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,1.45,,,1.45,Other,Drug Cost,1.45,,,1.45,Other,Drug Cost,1.45,,,1.45,Other,Drug Cost,1.45,,,1.45,Other,Drug Cost,1.45,,,1.45,Other,Drug Cost,2.74,34,,2.74,percent of total billed charges,Drugs,1.45,,,1.45,Other,Drug Cost,3.26,,,3.26,Other,225% Medicaid APG methodology,2.03,,,2.03,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,22.15,,,22.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.45,,,1.45,Other,Drug Cost,1.45,,,1.45,Other,Drug Cost,1.81,,,1.81,Other,125% Medicaid APG methodology,0.01,22.76,
PEDS ZIDOVUDINE 4 MG/ML D5W     ,J3485,HCPCS,,40537482,CDM,636,RC,49702-0213-26n,NDC,both,1,ML,4.97,14.91,,,14.91,Other,150% of Medicare + 9.63% HCRA Surcharge,9.07,,,9.07,Fee Schedule,Average Sale Price (ASP) x 6,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,2.49,50,,2.49,percent of total billed charges,All Other,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,1.49,30,,1.49,percent of total billed charges,Drugs,0.89,,,0.89,Other,Drug Cost,0.89,,,0.89,Other,Drug Cost,0.89,,,0.89,Other,Drug Cost,0.89,,,0.89,Other,Drug Cost,0.89,,,0.89,Other,Drug Cost,1.69,34,,1.69,percent of total billed charges,Drugs,0.89,,,0.89,Other,Drug Cost,2,,,2,Other,225% Medicaid APG methodology,1.25,,,1.25,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,14.51,,,14.51,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.89,,,0.89,Other,Drug Cost,0.89,,,0.89,Other,Drug Cost,1.11,,,1.11,Other,125% Medicaid APG methodology,0.01,14.91,
CEFAZOLIN 1000MG/50ML IV DUPLX  ,J0690,HCPCS,,40537607,CDM,636,RC,00264-3103-11,NDC,both,1,EA,39.73,7.53,,,7.53,Other,150% of Medicare + 9.63% HCRA Surcharge,4.58,,,4.58,Fee Schedule,Average Sale Price (ASP) x 6,11.92,30,,11.92,percent of total billed charges,Drugs,11.92,30,,11.92,percent of total billed charges,Drugs,11.92,30,,11.92,percent of total billed charges,Drugs,11.92,30,,11.92,percent of total billed charges,Drugs,11.92,30,,11.92,percent of total billed charges,Drugs,19.87,50,,19.87,percent of total billed charges,All Other,11.92,30,,11.92,percent of total billed charges,Drugs,11.92,30,,11.92,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,11.92,30,,11.92,percent of total billed charges,Drugs,11.92,30,,11.92,percent of total billed charges,Drugs,11.92,30,,11.92,percent of total billed charges,Drugs,11.92,30,,11.92,percent of total billed charges,Drugs,11.92,30,,11.92,percent of total billed charges,Drugs,11.92,30,,11.92,percent of total billed charges,Drugs,11.92,30,,11.92,percent of total billed charges,Drugs,11.92,30,,11.92,percent of total billed charges,Drugs,11.92,30,,11.92,percent of total billed charges,Drugs,11.92,30,,11.92,percent of total billed charges,Drugs,11.92,30,,11.92,percent of total billed charges,Drugs,11.92,30,,11.92,percent of total billed charges,Drugs,11.92,30,,11.92,percent of total billed charges,Drugs,11.35,,,11.35,Other,Drug Cost,11.35,,,11.35,Other,Drug Cost,11.35,,,11.35,Other,Drug Cost,11.35,,,11.35,Other,Drug Cost,11.35,,,11.35,Other,Drug Cost,13.51,34,,13.51,percent of total billed charges,Drugs,11.35,,,11.35,Other,Drug Cost,25.54,,,25.54,Other,225% Medicaid APG methodology,15.89,,,15.89,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.32,,,7.32,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",11.35,,,11.35,Other,Drug Cost,11.35,,,11.35,Other,Drug Cost,14.19,,,14.19,Other,125% Medicaid APG methodology,0.01,25.54,
DOBUTAMINE 500MG/D5W 250ML      ,J1250,HCPCS,,40537698,CDM,636,RC,00409-2347-32,NDC,both,250,ML,34.13,97.17,,,97.17,Other,150% of Medicare + 9.63% HCRA Surcharge,59.09,,,59.09,Fee Schedule,Average Sale Price (ASP) x 6,10.24,30,,10.24,percent of total billed charges,Drugs,10.24,30,,10.24,percent of total billed charges,Drugs,10.24,30,,10.24,percent of total billed charges,Drugs,10.24,30,,10.24,percent of total billed charges,Drugs,10.24,30,,10.24,percent of total billed charges,Drugs,17.07,50,,17.07,percent of total billed charges,All Other,10.24,30,,10.24,percent of total billed charges,Drugs,10.24,30,,10.24,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,10.24,30,,10.24,percent of total billed charges,Drugs,10.24,30,,10.24,percent of total billed charges,Drugs,10.24,30,,10.24,percent of total billed charges,Drugs,10.24,30,,10.24,percent of total billed charges,Drugs,10.24,30,,10.24,percent of total billed charges,Drugs,10.24,30,,10.24,percent of total billed charges,Drugs,10.24,30,,10.24,percent of total billed charges,Drugs,10.24,30,,10.24,percent of total billed charges,Drugs,10.24,30,,10.24,percent of total billed charges,Drugs,10.24,30,,10.24,percent of total billed charges,Drugs,10.24,30,,10.24,percent of total billed charges,Drugs,10.24,30,,10.24,percent of total billed charges,Drugs,10.24,30,,10.24,percent of total billed charges,Drugs,8.57,,,8.57,Other,Drug Cost,8.57,,,8.57,Other,Drug Cost,8.57,,,8.57,Other,Drug Cost,8.57,,,8.57,Other,Drug Cost,8.57,,,8.57,Other,Drug Cost,11.6,34,,11.6,percent of total billed charges,Drugs,8.57,,,8.57,Other,Drug Cost,19.28,,,19.28,Other,225% Medicaid APG methodology,12,,,12,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,94.54,,,94.54,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",8.57,,,8.57,Other,Drug Cost,8.57,,,8.57,Other,Drug Cost,10.71,,,10.71,Other,125% Medicaid APG methodology,0.01,97.17,
DOPAMINE 400MG/D5W 250ML        ,J1265,HCPCS,,40537706,CDM,636,RC,00409-7809-22,NDC,both,250,ML,23.14,7.62,,,7.62,Other,150% of Medicare + 9.63% HCRA Surcharge,4.63,,,4.63,Fee Schedule,Average Sale Price (ASP) x 6,6.94,30,,6.94,percent of total billed charges,Drugs,6.94,30,,6.94,percent of total billed charges,Drugs,6.94,30,,6.94,percent of total billed charges,Drugs,6.94,30,,6.94,percent of total billed charges,Drugs,6.94,30,,6.94,percent of total billed charges,Drugs,11.57,50,,11.57,percent of total billed charges,All Other,6.94,30,,6.94,percent of total billed charges,Drugs,6.94,30,,6.94,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,6.94,30,,6.94,percent of total billed charges,Drugs,6.94,30,,6.94,percent of total billed charges,Drugs,6.94,30,,6.94,percent of total billed charges,Drugs,6.94,30,,6.94,percent of total billed charges,Drugs,6.94,30,,6.94,percent of total billed charges,Drugs,6.94,30,,6.94,percent of total billed charges,Drugs,6.94,30,,6.94,percent of total billed charges,Drugs,6.94,30,,6.94,percent of total billed charges,Drugs,6.94,30,,6.94,percent of total billed charges,Drugs,6.94,30,,6.94,percent of total billed charges,Drugs,6.94,30,,6.94,percent of total billed charges,Drugs,6.94,30,,6.94,percent of total billed charges,Drugs,6.94,30,,6.94,percent of total billed charges,Drugs,4.05,,,4.05,Other,Drug Cost,4.05,,,4.05,Other,Drug Cost,4.05,,,4.05,Other,Drug Cost,4.05,,,4.05,Other,Drug Cost,4.05,,,4.05,Other,Drug Cost,7.87,34,,7.87,percent of total billed charges,Drugs,4.05,,,4.05,Other,Drug Cost,9.11,,,9.11,Other,225% Medicaid APG methodology,5.67,,,5.67,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.41,,,7.41,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.05,,,4.05,Other,Drug Cost,4.05,,,4.05,Other,Drug Cost,5.06,,,5.06,Other,125% Medicaid APG methodology,0.01,11.57,
ESMOLOL 10MG/ML IV SLN 250ML    ,J3490,HCPCS,,40537714,CDM,636,RC,67457-0657-25,NDC,both,250,ML,1765.89,696.94,39.4668,,696.94,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,529.77,30,,529.77,percent of total billed charges,Drugs,529.77,30,,529.77,percent of total billed charges,Drugs,529.77,30,,529.77,percent of total billed charges,Drugs,529.77,30,,529.77,percent of total billed charges,Drugs,529.77,30,,529.77,percent of total billed charges,Drugs,882.95,50,,882.95,percent of total billed charges,All Other,529.77,30,,529.77,percent of total billed charges,Drugs,529.77,30,,529.77,percent of total billed charges,Drugs,600.4,34,"If Charge > 500, then 34 percent",600.4,percent of total billed charges,Drugs,529.77,30,,529.77,percent of total billed charges,Drugs,529.77,30,,529.77,percent of total billed charges,Drugs,529.77,30,,529.77,percent of total billed charges,Drugs,529.77,30,,529.77,percent of total billed charges,Drugs,529.77,30,,529.77,percent of total billed charges,Drugs,529.77,30,,529.77,percent of total billed charges,Drugs,529.77,30,,529.77,percent of total billed charges,Drugs,529.77,30,,529.77,percent of total billed charges,Drugs,529.77,30,,529.77,percent of total billed charges,Drugs,529.77,30,,529.77,percent of total billed charges,Drugs,529.77,30,,529.77,percent of total billed charges,Drugs,529.77,30,,529.77,percent of total billed charges,Drugs,529.77,30,,529.77,percent of total billed charges,Drugs,504.54,,,504.54,Other,Drug Cost,504.54,,,504.54,Other,Drug Cost,504.54,,,504.54,Other,Drug Cost,504.54,,,504.54,Other,Drug Cost,504.54,,,504.54,Other,Drug Cost,600.4,34,,600.4,percent of total billed charges,Drugs,504.54,,,504.54,Other,Drug Cost,1135.22,,,1135.22,Other,225% Medicaid APG methodology,706.36,,,706.36,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",504.54,,,504.54,Other,Drug Cost,504.54,,,504.54,Other,Drug Cost,630.68,,,630.68,Other,125% Medicaid APG methodology,0.01,1135.22,
MAG SULF 1000MG IN D5W100ML     ,J3475,HCPCS,,40537763,CDM,636,RC,44567-0410-24,NDC,both,100,ML,6.9,6.82,,,6.82,Other,150% of Medicare + 9.63% HCRA Surcharge,4.15,,,4.15,Fee Schedule,Average Sale Price (ASP) x 6,2.07,30,,2.07,percent of total billed charges,Drugs,2.07,30,,2.07,percent of total billed charges,Drugs,2.07,30,,2.07,percent of total billed charges,Drugs,2.07,30,,2.07,percent of total billed charges,Drugs,2.07,30,,2.07,percent of total billed charges,Drugs,3.45,50,,3.45,percent of total billed charges,All Other,2.07,30,,2.07,percent of total billed charges,Drugs,2.07,30,,2.07,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.07,30,,2.07,percent of total billed charges,Drugs,2.07,30,,2.07,percent of total billed charges,Drugs,2.07,30,,2.07,percent of total billed charges,Drugs,2.07,30,,2.07,percent of total billed charges,Drugs,2.07,30,,2.07,percent of total billed charges,Drugs,2.07,30,,2.07,percent of total billed charges,Drugs,2.07,30,,2.07,percent of total billed charges,Drugs,2.07,30,,2.07,percent of total billed charges,Drugs,2.07,30,,2.07,percent of total billed charges,Drugs,2.07,30,,2.07,percent of total billed charges,Drugs,2.07,30,,2.07,percent of total billed charges,Drugs,2.07,30,,2.07,percent of total billed charges,Drugs,2.07,30,,2.07,percent of total billed charges,Drugs,2.86,,,2.86,Other,Drug Cost,2.86,,,2.86,Other,Drug Cost,2.86,,,2.86,Other,Drug Cost,2.86,,,2.86,Other,Drug Cost,2.86,,,2.86,Other,Drug Cost,2.35,34,,2.35,percent of total billed charges,Drugs,2.86,,,2.86,Other,Drug Cost,6.44,,,6.44,Other,225% Medicaid APG methodology,4,,,4,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.63,,,6.63,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.86,,,2.86,Other,Drug Cost,2.86,,,2.86,Other,Drug Cost,3.58,,,3.58,Other,125% Medicaid APG methodology,0.01,6.82,
POT CL 20 MEQ IN IV SLN 100ML   ,J3480,HCPCS,,40537789,CDM,636,RC,00338-0705-48,NDC,both,100,ML,9.91,1.18,,,1.18,Other,150% of Medicare + 9.63% HCRA Surcharge,0.72,,,0.72,Fee Schedule,Average Sale Price (ASP) x 6,2.97,30,,2.97,percent of total billed charges,Drugs,2.97,30,,2.97,percent of total billed charges,Drugs,2.97,30,,2.97,percent of total billed charges,Drugs,2.97,30,,2.97,percent of total billed charges,Drugs,2.97,30,,2.97,percent of total billed charges,Drugs,4.96,50,,4.96,percent of total billed charges,All Other,2.97,30,,2.97,percent of total billed charges,Drugs,2.97,30,,2.97,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.97,30,,2.97,percent of total billed charges,Drugs,2.97,30,,2.97,percent of total billed charges,Drugs,2.97,30,,2.97,percent of total billed charges,Drugs,2.97,30,,2.97,percent of total billed charges,Drugs,2.97,30,,2.97,percent of total billed charges,Drugs,2.97,30,,2.97,percent of total billed charges,Drugs,2.97,30,,2.97,percent of total billed charges,Drugs,2.97,30,,2.97,percent of total billed charges,Drugs,2.97,30,,2.97,percent of total billed charges,Drugs,2.97,30,,2.97,percent of total billed charges,Drugs,2.97,30,,2.97,percent of total billed charges,Drugs,2.97,30,,2.97,percent of total billed charges,Drugs,2.97,30,,2.97,percent of total billed charges,Drugs,1.56,,,1.56,Other,Drug Cost,1.56,,,1.56,Other,Drug Cost,1.56,,,1.56,Other,Drug Cost,1.56,,,1.56,Other,Drug Cost,1.56,,,1.56,Other,Drug Cost,3.37,34,,3.37,percent of total billed charges,Drugs,1.56,,,1.56,Other,Drug Cost,3.51,,,3.51,Other,225% Medicaid APG methodology,2.18,,,2.18,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.15,,,1.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.56,,,1.56,Other,Drug Cost,1.56,,,1.56,Other,Drug Cost,1.95,,,1.95,Other,125% Medicaid APG methodology,0.01,4.96,
AZACITIDINE 100 MG INJ          ,J9025,HCPCS,,40537821,CDM,636,RC,43598-0305-62,NDC,both,1,EA,113.61,3.48,,,3.48,Other,150% of Medicare + 9.63% HCRA Surcharge,2.12,,,2.12,Fee Schedule,Average Sale Price (ASP) x 6,34.08,30,,34.08,percent of total billed charges,Drugs,34.08,30,,34.08,percent of total billed charges,Drugs,34.08,30,,34.08,percent of total billed charges,Drugs,34.08,30,,34.08,percent of total billed charges,Drugs,34.08,30,,34.08,percent of total billed charges,Drugs,56.81,50,,56.81,percent of total billed charges,All Other,34.08,30,,34.08,percent of total billed charges,Drugs,34.08,30,,34.08,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,34.08,30,,34.08,percent of total billed charges,Drugs,34.08,30,,34.08,percent of total billed charges,Drugs,34.08,30,,34.08,percent of total billed charges,Drugs,34.08,30,,34.08,percent of total billed charges,Drugs,34.08,30,,34.08,percent of total billed charges,Drugs,34.08,30,,34.08,percent of total billed charges,Drugs,34.08,30,,34.08,percent of total billed charges,Drugs,34.08,30,,34.08,percent of total billed charges,Drugs,34.08,30,,34.08,percent of total billed charges,Drugs,34.08,30,,34.08,percent of total billed charges,Drugs,34.08,30,,34.08,percent of total billed charges,Drugs,34.08,30,,34.08,percent of total billed charges,Drugs,34.08,30,,34.08,percent of total billed charges,Drugs,30.78,,,30.78,Other,Drug Cost,30.78,,,30.78,Other,Drug Cost,30.78,,,30.78,Other,Drug Cost,30.78,,,30.78,Other,Drug Cost,30.78,,,30.78,Other,Drug Cost,38.63,34,,38.63,percent of total billed charges,Drugs,30.78,,,30.78,Other,Drug Cost,69.26,,,69.26,Other,225% Medicaid APG methodology,43.09,,,43.09,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,3.39,,,3.39,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",30.78,,,30.78,Other,Drug Cost,30.78,,,30.78,Other,Drug Cost,38.48,,,38.48,Other,125% Medicaid APG methodology,0.01,69.26,
PEMETREXED 500 MG IV INJ        ,J9305,HCPCS,,40538134,CDM,636,RC,16729-0230-11,NDC,both,1,EA,427.11,43.13,,,43.13,Other,150% of Medicare + 9.63% HCRA Surcharge,26.23,,,26.23,Fee Schedule,Average Sale Price (ASP) x 6,128.13,30,,128.13,percent of total billed charges,Drugs,128.13,30,,128.13,percent of total billed charges,Drugs,128.13,30,,128.13,percent of total billed charges,Drugs,128.13,30,,128.13,percent of total billed charges,Drugs,128.13,30,,128.13,percent of total billed charges,Drugs,213.56,50,,213.56,percent of total billed charges,All Other,128.13,30,,128.13,percent of total billed charges,Drugs,128.13,30,,128.13,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,128.13,30,,128.13,percent of total billed charges,Drugs,128.13,30,,128.13,percent of total billed charges,Drugs,128.13,30,,128.13,percent of total billed charges,Drugs,128.13,30,,128.13,percent of total billed charges,Drugs,128.13,30,,128.13,percent of total billed charges,Drugs,128.13,30,,128.13,percent of total billed charges,Drugs,128.13,30,,128.13,percent of total billed charges,Drugs,128.13,30,,128.13,percent of total billed charges,Drugs,128.13,30,,128.13,percent of total billed charges,Drugs,128.13,30,,128.13,percent of total billed charges,Drugs,128.13,30,,128.13,percent of total billed charges,Drugs,128.13,30,,128.13,percent of total billed charges,Drugs,128.13,30,,128.13,percent of total billed charges,Drugs,83.16,,,83.16,Other,Drug Cost,83.16,,,83.16,Other,Drug Cost,83.16,,,83.16,Other,Drug Cost,83.16,,,83.16,Other,Drug Cost,83.16,,,83.16,Other,Drug Cost,145.22,34,,145.22,percent of total billed charges,Drugs,83.16,,,83.16,Other,Drug Cost,187.11,,,187.11,Other,225% Medicaid APG methodology,116.42,,,116.42,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,41.96,,,41.96,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",83.16,,,83.16,Other,Drug Cost,83.16,,,83.16,Other,Drug Cost,103.95,,,103.95,Other,125% Medicaid APG methodology,0.01,213.56,
MIDAZOLAM 1MG/ML INJ SOLN 5ML   ,J2250,HCPCS,,40538142,CDM,636,RC,63323-0411-25,NDC,both,5,ML,4.52,1.4,,,1.4,Other,150% of Medicare + 9.63% HCRA Surcharge,0.85,,,0.85,Fee Schedule,Average Sale Price (ASP) x 6,1.36,30,,1.36,percent of total billed charges,Drugs,1.36,30,,1.36,percent of total billed charges,Drugs,1.36,30,,1.36,percent of total billed charges,Drugs,1.36,30,,1.36,percent of total billed charges,Drugs,1.36,30,,1.36,percent of total billed charges,Drugs,2.26,50,,2.26,percent of total billed charges,All Other,1.36,30,,1.36,percent of total billed charges,Drugs,1.36,30,,1.36,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.36,30,,1.36,percent of total billed charges,Drugs,1.36,30,,1.36,percent of total billed charges,Drugs,1.36,30,,1.36,percent of total billed charges,Drugs,1.36,30,,1.36,percent of total billed charges,Drugs,1.36,30,,1.36,percent of total billed charges,Drugs,1.36,30,,1.36,percent of total billed charges,Drugs,1.36,30,,1.36,percent of total billed charges,Drugs,1.36,30,,1.36,percent of total billed charges,Drugs,1.36,30,,1.36,percent of total billed charges,Drugs,1.36,30,,1.36,percent of total billed charges,Drugs,1.36,30,,1.36,percent of total billed charges,Drugs,1.36,30,,1.36,percent of total billed charges,Drugs,1.36,30,,1.36,percent of total billed charges,Drugs,1.02,,,1.02,Other,Drug Cost,1.02,,,1.02,Other,Drug Cost,1.02,,,1.02,Other,Drug Cost,1.02,,,1.02,Other,Drug Cost,1.02,,,1.02,Other,Drug Cost,1.54,34,,1.54,percent of total billed charges,Drugs,1.02,,,1.02,Other,Drug Cost,2.3,,,2.3,Other,225% Medicaid APG methodology,1.43,,,1.43,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.36,,,1.36,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.02,,,1.02,Other,Drug Cost,1.02,,,1.02,Other,Drug Cost,1.28,,,1.28,Other,125% Medicaid APG methodology,0.01,2.3,
EPINEPH 0.3MG INJ KIT (EPIPEN)  ,J0171,HCPCS,,40538209,CDM,636,RC,49502-0500-02,NDC,both,1,EA,980.18,7.38,,,7.38,Other,150% of Medicare + 9.63% HCRA Surcharge,4.49,,,4.49,Fee Schedule,Average Sale Price (ASP) x 6,294.05,30,,294.05,percent of total billed charges,Drugs,294.05,30,,294.05,percent of total billed charges,Drugs,294.05,30,,294.05,percent of total billed charges,Drugs,294.05,30,,294.05,percent of total billed charges,Drugs,294.05,30,,294.05,percent of total billed charges,Drugs,490.09,50,,490.09,percent of total billed charges,All Other,294.05,30,,294.05,percent of total billed charges,Drugs,294.05,30,,294.05,percent of total billed charges,Drugs,333.26,34,"If Charge > 500, then 34 percent",333.26,percent of total billed charges,Drugs,294.05,30,,294.05,percent of total billed charges,Drugs,294.05,30,,294.05,percent of total billed charges,Drugs,294.05,30,,294.05,percent of total billed charges,Drugs,294.05,30,,294.05,percent of total billed charges,Drugs,294.05,30,,294.05,percent of total billed charges,Drugs,294.05,30,,294.05,percent of total billed charges,Drugs,294.05,30,,294.05,percent of total billed charges,Drugs,294.05,30,,294.05,percent of total billed charges,Drugs,294.05,30,,294.05,percent of total billed charges,Drugs,294.05,30,,294.05,percent of total billed charges,Drugs,294.05,30,,294.05,percent of total billed charges,Drugs,294.05,30,,294.05,percent of total billed charges,Drugs,294.05,30,,294.05,percent of total billed charges,Drugs,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,333.26,34,,333.26,percent of total billed charges,Drugs,0.02,,,0.02,Other,Drug Cost,0.05,,,0.05,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.18,,,7.18,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.02,,,0.02,Other,Drug Cost,0.02,,,0.02,Other,Drug Cost,0.03,,,0.03,Other,125% Medicaid APG methodology,0.01,490.09,
LABETALOL 5MG/ML IV SOLN 40ML   ,J3490,HCPCS,,40538332,CDM,636,RC,47781-0586-56,NDC,both,40,ML,16.8,6.63,39.4668,,6.63,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,5.04,30,,5.04,percent of total billed charges,Drugs,5.04,30,,5.04,percent of total billed charges,Drugs,5.04,30,,5.04,percent of total billed charges,Drugs,5.04,30,,5.04,percent of total billed charges,Drugs,5.04,30,,5.04,percent of total billed charges,Drugs,8.4,50,,8.4,percent of total billed charges,All Other,5.04,30,,5.04,percent of total billed charges,Drugs,5.04,30,,5.04,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,5.04,30,,5.04,percent of total billed charges,Drugs,5.04,30,,5.04,percent of total billed charges,Drugs,5.04,30,,5.04,percent of total billed charges,Drugs,5.04,30,,5.04,percent of total billed charges,Drugs,5.04,30,,5.04,percent of total billed charges,Drugs,5.04,30,,5.04,percent of total billed charges,Drugs,5.04,30,,5.04,percent of total billed charges,Drugs,5.04,30,,5.04,percent of total billed charges,Drugs,5.04,30,,5.04,percent of total billed charges,Drugs,5.04,30,,5.04,percent of total billed charges,Drugs,5.04,30,,5.04,percent of total billed charges,Drugs,5.04,30,,5.04,percent of total billed charges,Drugs,5.04,30,,5.04,percent of total billed charges,Drugs,5.6,,,5.6,Other,Drug Cost,5.6,,,5.6,Other,Drug Cost,5.6,,,5.6,Other,Drug Cost,5.6,,,5.6,Other,Drug Cost,5.6,,,5.6,Other,Drug Cost,5.71,34,,5.71,percent of total billed charges,Drugs,5.6,,,5.6,Other,Drug Cost,12.6,,,12.6,Other,225% Medicaid APG methodology,7.84,,,7.84,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.6,,,5.6,Other,Drug Cost,5.6,,,5.6,Other,Drug Cost,7,,,7,Other,125% Medicaid APG methodology,0.01,12.6,
AMIODARONE 150MG D5W IV  100ML  ,J0282,HCPCS,,40538498,CDM,636,RC,43066-0150-10,NDC,both,100,ML,112.88,44.55,39.4668,,44.55,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,33.86,30,,33.86,percent of total billed charges,Drugs,33.86,30,,33.86,percent of total billed charges,Drugs,33.86,30,,33.86,percent of total billed charges,Drugs,33.86,30,,33.86,percent of total billed charges,Drugs,33.86,30,,33.86,percent of total billed charges,Drugs,56.44,50,,56.44,percent of total billed charges,All Other,33.86,30,,33.86,percent of total billed charges,Drugs,33.86,30,,33.86,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,33.86,30,,33.86,percent of total billed charges,Drugs,33.86,30,,33.86,percent of total billed charges,Drugs,33.86,30,,33.86,percent of total billed charges,Drugs,33.86,30,,33.86,percent of total billed charges,Drugs,33.86,30,,33.86,percent of total billed charges,Drugs,33.86,30,,33.86,percent of total billed charges,Drugs,33.86,30,,33.86,percent of total billed charges,Drugs,33.86,30,,33.86,percent of total billed charges,Drugs,33.86,30,,33.86,percent of total billed charges,Drugs,33.86,30,,33.86,percent of total billed charges,Drugs,33.86,30,,33.86,percent of total billed charges,Drugs,33.86,30,,33.86,percent of total billed charges,Drugs,33.86,30,,33.86,percent of total billed charges,Drugs,17.79,,,17.79,Other,Drug Cost,17.79,,,17.79,Other,Drug Cost,17.79,,,17.79,Other,Drug Cost,17.79,,,17.79,Other,Drug Cost,17.79,,,17.79,Other,Drug Cost,38.38,34,,38.38,percent of total billed charges,Drugs,17.79,,,17.79,Other,Drug Cost,40.03,,,40.03,Other,225% Medicaid APG methodology,24.91,,,24.91,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",17.79,,,17.79,Other,Drug Cost,17.79,,,17.79,Other,Drug Cost,22.24,,,22.24,Other,125% Medicaid APG methodology,0.01,56.44,
ENFORTUMAB VEDO EJFV 30 MG POW  ,J9177,HCPCS,,40538613,CDM,636,RC,51144-0030-01,NDC,both,1,EA,13917.75,345.61,,,345.61,Other,150% of Medicare + 9.63% HCRA Surcharge,210.17,,,210.17,Fee Schedule,Average Sale Price (ASP) x 6,4175.33,30,,4175.33,percent of total billed charges,Drugs,4175.33,30,,4175.33,percent of total billed charges,Drugs,4175.33,30,,4175.33,percent of total billed charges,Drugs,4175.33,30,,4175.33,percent of total billed charges,Drugs,4175.33,30,,4175.33,percent of total billed charges,Drugs,6958.88,50,,6958.88,percent of total billed charges,All Other,4175.33,30,,4175.33,percent of total billed charges,Drugs,4175.33,30,,4175.33,percent of total billed charges,Drugs,4732.04,34,"If Charge > 500, then 34 percent",4732.04,percent of total billed charges,Drugs,4175.33,30,,4175.33,percent of total billed charges,Drugs,4175.33,30,,4175.33,percent of total billed charges,Drugs,4175.33,30,,4175.33,percent of total billed charges,Drugs,4175.33,30,,4175.33,percent of total billed charges,Drugs,4175.33,30,,4175.33,percent of total billed charges,Drugs,4175.33,30,,4175.33,percent of total billed charges,Drugs,4175.33,30,,4175.33,percent of total billed charges,Drugs,4175.33,30,,4175.33,percent of total billed charges,Drugs,4175.33,30,,4175.33,percent of total billed charges,Drugs,4175.33,30,,4175.33,percent of total billed charges,Drugs,4175.33,30,,4175.33,percent of total billed charges,Drugs,4175.33,30,,4175.33,percent of total billed charges,Drugs,4175.33,30,,4175.33,percent of total billed charges,Drugs,2770.9,,,2770.9,Other,Drug Cost,2770.9,,,2770.9,Other,Drug Cost,2770.9,,,2770.9,Other,Drug Cost,2770.9,,,2770.9,Other,Drug Cost,2770.9,,,2770.9,Other,Drug Cost,4732.04,34,,4732.04,percent of total billed charges,Drugs,2770.9,,,2770.9,Other,Drug Cost,6234.53,,,6234.53,Other,225% Medicaid APG methodology,3879.26,,,3879.26,Other,140% Medicaid APG methodology,4732.04,34,"If Charge > 2,000, then 34 percent",4732.04,percent of total billed charges,Drugs,336.27,,,336.27,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2770.9,,,2770.9,Other,Drug Cost,2770.9,,,2770.9,Other,Drug Cost,3463.63,,,3463.63,Other,125% Medicaid APG methodology,0.01,6958.88,
SARS-COV-2 VAC 0.3ML COMIRNATY  ,91320,CPT,,40538639,CDM,636,RC,00069-2392-10,NDC,both,0.3,ML,418.39,1293.52,,,1293.52,Other,150% of Medicare + 9.63% HCRA Surcharge,786.6,,,786.6,Fee Schedule,Average Sale Price (ASP) x 6,125.52,30,,125.52,percent of total billed charges,Drugs,125.52,30,,125.52,percent of total billed charges,Drugs,125.52,30,,125.52,percent of total billed charges,Drugs,125.52,30,,125.52,percent of total billed charges,Drugs,125.52,30,,125.52,percent of total billed charges,Drugs,209.2,50,,209.2,percent of total billed charges,All Other,125.52,30,,125.52,percent of total billed charges,Drugs,125.52,30,,125.52,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,125.52,30,,125.52,percent of total billed charges,Drugs,125.52,30,,125.52,percent of total billed charges,Drugs,125.52,30,,125.52,percent of total billed charges,Drugs,125.52,30,,125.52,percent of total billed charges,Drugs,125.52,30,,125.52,percent of total billed charges,Drugs,125.52,30,,125.52,percent of total billed charges,Drugs,125.52,30,,125.52,percent of total billed charges,Drugs,125.52,30,,125.52,percent of total billed charges,Drugs,125.52,30,,125.52,percent of total billed charges,Drugs,125.52,30,,125.52,percent of total billed charges,Drugs,125.52,30,,125.52,percent of total billed charges,Drugs,125.52,30,,125.52,percent of total billed charges,Drugs,125.52,30,,125.52,percent of total billed charges,Drugs,119.54,,,119.54,Other,Drug Cost,119.54,,,119.54,Other,Drug Cost,119.54,,,119.54,Other,Drug Cost,119.54,,,119.54,Other,Drug Cost,119.54,,,119.54,Other,Drug Cost,142.25,34,,142.25,percent of total billed charges,Drugs,119.54,,,119.54,Other,Drug Cost,268.97,,,268.97,Other,225% Medicaid APG methodology,167.36,,,167.36,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1258.56,,,1258.56,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",119.54,,,119.54,Other,Drug Cost,119.54,,,119.54,Other,Drug Cost,149.43,,,149.43,Other,125% Medicaid APG methodology,0.01,1293.52,
SARS-COV-2 VAC 0.25ML SPIKEVAX  ,91321,CPT,,40538647,CDM,636,RC,80777-0287-92,NDC,both,0.25,ML,398.55,1439.75,,,1439.75,Other,150% of Medicare + 9.63% HCRA Surcharge,875.52,,,875.52,Fee Schedule,Average Sale Price (ASP) x 6,119.57,30,,119.57,percent of total billed charges,Drugs,119.57,30,,119.57,percent of total billed charges,Drugs,119.57,30,,119.57,percent of total billed charges,Drugs,119.57,30,,119.57,percent of total billed charges,Drugs,119.57,30,,119.57,percent of total billed charges,Drugs,199.28,50,,199.28,percent of total billed charges,All Other,119.57,30,,119.57,percent of total billed charges,Drugs,119.57,30,,119.57,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,119.57,30,,119.57,percent of total billed charges,Drugs,119.57,30,,119.57,percent of total billed charges,Drugs,119.57,30,,119.57,percent of total billed charges,Drugs,119.57,30,,119.57,percent of total billed charges,Drugs,119.57,30,,119.57,percent of total billed charges,Drugs,119.57,30,,119.57,percent of total billed charges,Drugs,119.57,30,,119.57,percent of total billed charges,Drugs,119.57,30,,119.57,percent of total billed charges,Drugs,119.57,30,,119.57,percent of total billed charges,Drugs,119.57,30,,119.57,percent of total billed charges,Drugs,119.57,30,,119.57,percent of total billed charges,Drugs,119.57,30,,119.57,percent of total billed charges,Drugs,119.57,30,,119.57,percent of total billed charges,Drugs,113.87,,,113.87,Other,Drug Cost,113.87,,,113.87,Other,Drug Cost,113.87,,,113.87,Other,Drug Cost,113.87,,,113.87,Other,Drug Cost,113.87,,,113.87,Other,Drug Cost,135.51,34,,135.51,percent of total billed charges,Drugs,113.87,,,113.87,Other,Drug Cost,256.21,,,256.21,Other,225% Medicaid APG methodology,159.42,,,159.42,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1400.83,,,1400.83,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",113.87,,,113.87,Other,Drug Cost,113.87,,,113.87,Other,Drug Cost,142.34,,,142.34,Other,125% Medicaid APG methodology,0.01,1439.75,
SARS-COV-2 VAC 0.5ML SPIKEVAX   ,91322,CPT,,40538654,CDM,636,RC,80777-0102-93,NDC,both,0.5,ML,403.24,1439.75,,,1439.75,Other,150% of Medicare + 9.63% HCRA Surcharge,875.52,,,875.52,Fee Schedule,Average Sale Price (ASP) x 6,120.97,30,,120.97,percent of total billed charges,Drugs,120.97,30,,120.97,percent of total billed charges,Drugs,120.97,30,,120.97,percent of total billed charges,Drugs,120.97,30,,120.97,percent of total billed charges,Drugs,120.97,30,,120.97,percent of total billed charges,Drugs,201.62,50,,201.62,percent of total billed charges,All Other,120.97,30,,120.97,percent of total billed charges,Drugs,120.97,30,,120.97,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,120.97,30,,120.97,percent of total billed charges,Drugs,120.97,30,,120.97,percent of total billed charges,Drugs,120.97,30,,120.97,percent of total billed charges,Drugs,120.97,30,,120.97,percent of total billed charges,Drugs,120.97,30,,120.97,percent of total billed charges,Drugs,120.97,30,,120.97,percent of total billed charges,Drugs,120.97,30,,120.97,percent of total billed charges,Drugs,120.97,30,,120.97,percent of total billed charges,Drugs,120.97,30,,120.97,percent of total billed charges,Drugs,120.97,30,,120.97,percent of total billed charges,Drugs,120.97,30,,120.97,percent of total billed charges,Drugs,120.97,30,,120.97,percent of total billed charges,Drugs,120.97,30,,120.97,percent of total billed charges,Drugs,115.21,,,115.21,Other,Drug Cost,115.21,,,115.21,Other,Drug Cost,115.21,,,115.21,Other,Drug Cost,115.21,,,115.21,Other,Drug Cost,115.21,,,115.21,Other,Drug Cost,137.1,34,,137.1,percent of total billed charges,Drugs,115.21,,,115.21,Other,Drug Cost,259.22,,,259.22,Other,225% Medicaid APG methodology,161.29,,,161.29,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1400.83,,,1400.83,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",115.21,,,115.21,Other,Drug Cost,115.21,,,115.21,Other,Drug Cost,144.01,,,144.01,Other,125% Medicaid APG methodology,0.01,1439.75,
MEAS/MUM/RUB/VAR VIRUS VACC SQ  ,90710,CPT,,40538738,CDM,636,RC,00006-4171-00,NDC,both,1,EA,854.74,337.34,39.4668,,337.34,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,256.42,30,,256.42,percent of total billed charges,Drugs,256.42,30,,256.42,percent of total billed charges,Drugs,256.42,30,,256.42,percent of total billed charges,Drugs,256.42,30,,256.42,percent of total billed charges,Drugs,256.42,30,,256.42,percent of total billed charges,Drugs,427.37,50,,427.37,percent of total billed charges,All Other,256.42,30,,256.42,percent of total billed charges,Drugs,256.42,30,,256.42,percent of total billed charges,Drugs,290.61,34,"If Charge > 500, then 34 percent",290.61,percent of total billed charges,Drugs,256.42,30,,256.42,percent of total billed charges,Drugs,256.42,30,,256.42,percent of total billed charges,Drugs,256.42,30,,256.42,percent of total billed charges,Drugs,256.42,30,,256.42,percent of total billed charges,Drugs,256.42,30,,256.42,percent of total billed charges,Drugs,256.42,30,,256.42,percent of total billed charges,Drugs,256.42,30,,256.42,percent of total billed charges,Drugs,256.42,30,,256.42,percent of total billed charges,Drugs,256.42,30,,256.42,percent of total billed charges,Drugs,256.42,30,,256.42,percent of total billed charges,Drugs,256.42,30,,256.42,percent of total billed charges,Drugs,256.42,30,,256.42,percent of total billed charges,Drugs,256.42,30,,256.42,percent of total billed charges,Drugs,262.37,,,262.37,Other,Drug Cost,262.37,,,262.37,Other,Drug Cost,262.37,,,262.37,Other,Drug Cost,262.37,,,262.37,Other,Drug Cost,262.37,,,262.37,Other,Drug Cost,290.61,34,,290.61,percent of total billed charges,Drugs,262.37,,,262.37,Other,Drug Cost,590.33,,,590.33,Other,225% Medicaid APG methodology,367.32,,,367.32,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",262.37,,,262.37,Other,Drug Cost,262.37,,,262.37,Other,Drug Cost,327.96,,,327.96,Other,125% Medicaid APG methodology,0.01,590.33,
EPO(PR/EP) 20K UNIT/ML 1 ML NE  ,J0885,HCPCS,,40538795,CDM,636,RC,59676-0320-04,NDC,both,1,ML,984.97,87.68,,,87.68,Other,150% of Medicare + 9.63% HCRA Surcharge,53.32,,,53.32,Fee Schedule,Average Sale Price (ASP) x 6,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,492.49,50,,492.49,percent of total billed charges,All Other,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,334.89,34,"If Charge > 500, then 34 percent",334.89,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,136.8,,,136.8,Other,Drug Cost,136.8,,,136.8,Other,Drug Cost,136.8,,,136.8,Other,Drug Cost,136.8,,,136.8,Other,Drug Cost,136.8,,,136.8,Other,Drug Cost,334.89,34,,334.89,percent of total billed charges,Drugs,136.8,,,136.8,Other,Drug Cost,307.8,,,307.8,Other,225% Medicaid APG methodology,191.52,,,191.52,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,85.31,,,85.31,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",136.8,,,136.8,Other,Drug Cost,136.8,,,136.8,Other,Drug Cost,171,,,171,Other,125% Medicaid APG methodology,0.01,492.49,
INCLISIRAN 284 MG/1.5 ML SOL    ,J1306,HCPCS,,40538803,CDM,636,RC,00078-1000-60,NDC,both,1.5,ML,11905.53,119.72,,,119.72,Other,150% of Medicare + 9.63% HCRA Surcharge,72.8,,,72.8,Fee Schedule,Average Sale Price (ASP) x 6,3571.66,30,,3571.66,percent of total billed charges,Drugs,3571.66,30,,3571.66,percent of total billed charges,Drugs,3571.66,30,,3571.66,percent of total billed charges,Drugs,3571.66,30,,3571.66,percent of total billed charges,Drugs,3571.66,30,,3571.66,percent of total billed charges,Drugs,5952.77,50,,5952.77,percent of total billed charges,All Other,3571.66,30,,3571.66,percent of total billed charges,Drugs,3571.66,30,,3571.66,percent of total billed charges,Drugs,4047.88,34,"If Charge > 500, then 34 percent",4047.88,percent of total billed charges,Drugs,3571.66,30,,3571.66,percent of total billed charges,Drugs,3571.66,30,,3571.66,percent of total billed charges,Drugs,3571.66,30,,3571.66,percent of total billed charges,Drugs,3571.66,30,,3571.66,percent of total billed charges,Drugs,3571.66,30,,3571.66,percent of total billed charges,Drugs,3571.66,30,,3571.66,percent of total billed charges,Drugs,3571.66,30,,3571.66,percent of total billed charges,Drugs,3571.66,30,,3571.66,percent of total billed charges,Drugs,3571.66,30,,3571.66,percent of total billed charges,Drugs,3571.66,30,,3571.66,percent of total billed charges,Drugs,3571.66,30,,3571.66,percent of total billed charges,Drugs,3571.66,30,,3571.66,percent of total billed charges,Drugs,3571.66,30,,3571.66,percent of total billed charges,Drugs,2320.29,,,2320.29,Other,Drug Cost,2320.29,,,2320.29,Other,Drug Cost,2320.29,,,2320.29,Other,Drug Cost,2320.29,,,2320.29,Other,Drug Cost,2320.29,,,2320.29,Other,Drug Cost,4047.88,34,,4047.88,percent of total billed charges,Drugs,2320.29,,,2320.29,Other,Drug Cost,5220.65,,,5220.65,Other,225% Medicaid APG methodology,3248.41,,,3248.41,Other,140% Medicaid APG methodology,4047.88,34,"If Charge > 2,000, then 34 percent",4047.88,percent of total billed charges,Drugs,116.49,,,116.49,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2320.29,,,2320.29,Other,Drug Cost,2320.29,,,2320.29,Other,Drug Cost,2900.36,,,2900.36,Other,125% Medicaid APG methodology,0.01,5952.77,
IVIG 10% (40G) 400 ML (GAM-C)   ,J1561,HCPCS,,40538811,CDM,636,RC,13533-0800-40,NDC,both,400,ML,14742,491.22,,,491.22,Other,150% of Medicare + 9.63% HCRA Surcharge,298.72,,,298.72,Fee Schedule,Average Sale Price (ASP) x 6,4422.6,30,,4422.6,percent of total billed charges,Drugs,4422.6,30,,4422.6,percent of total billed charges,Drugs,4422.6,30,,4422.6,percent of total billed charges,Drugs,4422.6,30,,4422.6,percent of total billed charges,Drugs,4422.6,30,,4422.6,percent of total billed charges,Drugs,7371,50,,7371,percent of total billed charges,All Other,4422.6,30,,4422.6,percent of total billed charges,Drugs,4422.6,30,,4422.6,percent of total billed charges,Drugs,5012.28,34,"If Charge > 500, then 34 percent",5012.28,percent of total billed charges,Drugs,4422.6,30,,4422.6,percent of total billed charges,Drugs,4422.6,30,,4422.6,percent of total billed charges,Drugs,4422.6,30,,4422.6,percent of total billed charges,Drugs,4422.6,30,,4422.6,percent of total billed charges,Drugs,4422.6,30,,4422.6,percent of total billed charges,Drugs,4422.6,30,,4422.6,percent of total billed charges,Drugs,4422.6,30,,4422.6,percent of total billed charges,Drugs,4422.6,30,,4422.6,percent of total billed charges,Drugs,4422.6,30,,4422.6,percent of total billed charges,Drugs,4422.6,30,,4422.6,percent of total billed charges,Drugs,4422.6,30,,4422.6,percent of total billed charges,Drugs,4422.6,30,,4422.6,percent of total billed charges,Drugs,4422.6,30,,4422.6,percent of total billed charges,Drugs,2888,,,2888,Other,Drug Cost,2888,,,2888,Other,Drug Cost,2888,,,2888,Other,Drug Cost,2888,,,2888,Other,Drug Cost,2888,,,2888,Other,Drug Cost,5012.28,34,,5012.28,percent of total billed charges,Drugs,2888,,,2888,Other,Drug Cost,6498,,,6498,Other,225% Medicaid APG methodology,4043.2,,,4043.2,Other,140% Medicaid APG methodology,5012.28,34,"If Charge > 2,000, then 34 percent",5012.28,percent of total billed charges,Drugs,477.95,,,477.95,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2888,,,2888,Other,Drug Cost,2888,,,2888,Other,Drug Cost,3610,,,3610,Other,125% Medicaid APG methodology,0.01,7371,
BIMATOPROST 10 MCG IMP          ,J7351,HCPCS,,40538928,CDM,636,RC,00023-9652-01,NDC,both,1,EA,6825,2034.56,,,2034.56,Other,150% of Medicare + 9.63% HCRA Surcharge,1237.23,,,1237.23,Fee Schedule,Average Sale Price (ASP) x 6,2047.5,30,,2047.5,percent of total billed charges,Drugs,2047.5,30,,2047.5,percent of total billed charges,Drugs,2047.5,30,,2047.5,percent of total billed charges,Drugs,2047.5,30,,2047.5,percent of total billed charges,Drugs,2047.5,30,,2047.5,percent of total billed charges,Drugs,3412.5,50,,3412.5,percent of total billed charges,All Other,2047.5,30,,2047.5,percent of total billed charges,Drugs,2047.5,30,,2047.5,percent of total billed charges,Drugs,2320.5,34,"If Charge > 500, then 34 percent",2320.5,percent of total billed charges,Drugs,2047.5,30,,2047.5,percent of total billed charges,Drugs,2047.5,30,,2047.5,percent of total billed charges,Drugs,2047.5,30,,2047.5,percent of total billed charges,Drugs,2047.5,30,,2047.5,percent of total billed charges,Drugs,2047.5,30,,2047.5,percent of total billed charges,Drugs,2047.5,30,,2047.5,percent of total billed charges,Drugs,2047.5,30,,2047.5,percent of total billed charges,Drugs,2047.5,30,,2047.5,percent of total billed charges,Drugs,2047.5,30,,2047.5,percent of total billed charges,Drugs,2047.5,30,,2047.5,percent of total billed charges,Drugs,2047.5,30,,2047.5,percent of total billed charges,Drugs,2047.5,30,,2047.5,percent of total billed charges,Drugs,2047.5,30,,2047.5,percent of total billed charges,Drugs,1499.14,,,1499.14,Other,Drug Cost,1499.14,,,1499.14,Other,Drug Cost,1499.14,,,1499.14,Other,Drug Cost,1499.14,,,1499.14,Other,Drug Cost,1499.14,,,1499.14,Other,Drug Cost,2320.5,34,,2320.5,percent of total billed charges,Drugs,1499.14,,,1499.14,Other,Drug Cost,3373.07,,,3373.07,Other,225% Medicaid APG methodology,2098.8,,,2098.8,Other,140% Medicaid APG methodology,2320.5,34,"If Charge > 2,000, then 34 percent",2320.5,percent of total billed charges,Drugs,1979.57,,,1979.57,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1499.14,,,1499.14,Other,Drug Cost,1499.14,,,1499.14,Other,Drug Cost,1873.93,,,1873.93,Other,125% Medicaid APG methodology,0.01,3412.5,
OXALIPLATIN 5MG/ML SOLN 20 ML   ,J9263,HCPCS,,40538977,CDM,636,RC,72266-0162-01,NDC,both,20,ML,105,0.7,,,0.7,Other,150% of Medicare + 9.63% HCRA Surcharge,0.43,,,0.43,Fee Schedule,Average Sale Price (ASP) x 6,31.5,30,,31.5,percent of total billed charges,Drugs,31.5,30,,31.5,percent of total billed charges,Drugs,31.5,30,,31.5,percent of total billed charges,Drugs,31.5,30,,31.5,percent of total billed charges,Drugs,31.5,30,,31.5,percent of total billed charges,Drugs,52.5,50,,52.5,percent of total billed charges,All Other,31.5,30,,31.5,percent of total billed charges,Drugs,31.5,30,,31.5,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,31.5,30,,31.5,percent of total billed charges,Drugs,31.5,30,,31.5,percent of total billed charges,Drugs,31.5,30,,31.5,percent of total billed charges,Drugs,31.5,30,,31.5,percent of total billed charges,Drugs,31.5,30,,31.5,percent of total billed charges,Drugs,31.5,30,,31.5,percent of total billed charges,Drugs,31.5,30,,31.5,percent of total billed charges,Drugs,31.5,30,,31.5,percent of total billed charges,Drugs,31.5,30,,31.5,percent of total billed charges,Drugs,31.5,30,,31.5,percent of total billed charges,Drugs,31.5,30,,31.5,percent of total billed charges,Drugs,31.5,30,,31.5,percent of total billed charges,Drugs,31.5,30,,31.5,percent of total billed charges,Drugs,30,,,30,Other,Drug Cost,30,,,30,Other,Drug Cost,30,,,30,Other,Drug Cost,30,,,30,Other,Drug Cost,30,,,30,Other,Drug Cost,35.7,34,,35.7,percent of total billed charges,Drugs,30,,,30,Other,Drug Cost,67.5,,,67.5,Other,225% Medicaid APG methodology,42,,,42,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.68,,,0.68,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",30,,,30,Other,Drug Cost,30,,,30,Other,Drug Cost,37.5,,,37.5,Other,125% Medicaid APG methodology,0.01,67.5,
MENQUADFI IM SOLN 0.5 ML        ,90619,CPT,,40539389,CDM,636,RC,49281-0590-05,NDC,both,0.5,ML,458.92,181.12,39.4668,,181.12,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,137.68,30,,137.68,percent of total billed charges,Drugs,137.68,30,,137.68,percent of total billed charges,Drugs,137.68,30,,137.68,percent of total billed charges,Drugs,137.68,30,,137.68,percent of total billed charges,Drugs,137.68,30,,137.68,percent of total billed charges,Drugs,229.46,50,,229.46,percent of total billed charges,All Other,137.68,30,,137.68,percent of total billed charges,Drugs,137.68,30,,137.68,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,137.68,30,,137.68,percent of total billed charges,Drugs,137.68,30,,137.68,percent of total billed charges,Drugs,137.68,30,,137.68,percent of total billed charges,Drugs,137.68,30,,137.68,percent of total billed charges,Drugs,137.68,30,,137.68,percent of total billed charges,Drugs,137.68,30,,137.68,percent of total billed charges,Drugs,137.68,30,,137.68,percent of total billed charges,Drugs,137.68,30,,137.68,percent of total billed charges,Drugs,137.68,30,,137.68,percent of total billed charges,Drugs,137.68,30,,137.68,percent of total billed charges,Drugs,137.68,30,,137.68,percent of total billed charges,Drugs,137.68,30,,137.68,percent of total billed charges,Drugs,137.68,30,,137.68,percent of total billed charges,Drugs,122.75,,,122.75,Other,Drug Cost,122.75,,,122.75,Other,Drug Cost,122.75,,,122.75,Other,Drug Cost,122.75,,,122.75,Other,Drug Cost,122.75,,,122.75,Other,Drug Cost,156.03,34,,156.03,percent of total billed charges,Drugs,122.75,,,122.75,Other,Drug Cost,276.19,,,276.19,Other,225% Medicaid APG methodology,171.85,,,171.85,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",122.75,,,122.75,Other,Drug Cost,122.75,,,122.75,Other,Drug Cost,153.44,,,153.44,Other,125% Medicaid APG methodology,0.01,276.19,
BEBTELOVIMAB 175 MG (LILLY)     ,Q0222,HCPCS,,40539397,CDM,636,RC,00002-7589-01,NDC,both,2,ML,7350,2900.81,39.4668,,2900.81,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,2205,30,,2205,percent of total billed charges,Drugs,2205,30,,2205,percent of total billed charges,Drugs,2205,30,,2205,percent of total billed charges,Drugs,2205,30,,2205,percent of total billed charges,Drugs,2205,30,,2205,percent of total billed charges,Drugs,3675,50,,3675,percent of total billed charges,All Other,2205,30,,2205,percent of total billed charges,Drugs,2205,30,,2205,percent of total billed charges,Drugs,2499,34,"If Charge > 500, then 34 percent",2499,percent of total billed charges,Drugs,2205,30,,2205,percent of total billed charges,Drugs,2205,30,,2205,percent of total billed charges,Drugs,2205,30,,2205,percent of total billed charges,Drugs,2205,30,,2205,percent of total billed charges,Drugs,2205,30,,2205,percent of total billed charges,Drugs,2205,30,,2205,percent of total billed charges,Drugs,2205,30,,2205,percent of total billed charges,Drugs,2205,30,,2205,percent of total billed charges,Drugs,2205,30,,2205,percent of total billed charges,Drugs,2205,30,,2205,percent of total billed charges,Drugs,2205,30,,2205,percent of total billed charges,Drugs,2205,30,,2205,percent of total billed charges,Drugs,2205,30,,2205,percent of total billed charges,Drugs,2100,,,2100,Other,Drug Cost,2100,,,2100,Other,Drug Cost,2100,,,2100,Other,Drug Cost,2100,,,2100,Other,Drug Cost,2100,,,2100,Other,Drug Cost,2499,34,,2499,percent of total billed charges,Drugs,2100,,,2100,Other,Drug Cost,4725,,,4725,Other,225% Medicaid APG methodology,2940,,,2940,Other,140% Medicaid APG methodology,2499,34,"If Charge > 2,000, then 34 percent",2499,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2100,,,2100,Other,Drug Cost,2100,,,2100,Other,Drug Cost,2625,,,2625,Other,125% Medicaid APG methodology,0.01,4725,
PEDS CEFTRIAXONE 40 MG/ML D5W   ,J0696,HCPCS,,40539736,CDM,636,RC,00409-7332-01n,NDC,both,1,ML,4.27,4.84,,,4.84,Other,150% of Medicare + 9.63% HCRA Surcharge,2.95,,,2.95,Fee Schedule,Average Sale Price (ASP) x 6,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,2.14,50,,2.14,percent of total billed charges,All Other,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,1.28,30,,1.28,percent of total billed charges,Drugs,1.03,,,1.03,Other,Drug Cost,1.03,,,1.03,Other,Drug Cost,1.03,,,1.03,Other,Drug Cost,1.03,,,1.03,Other,Drug Cost,1.03,,,1.03,Other,Drug Cost,1.45,34,,1.45,percent of total billed charges,Drugs,1.03,,,1.03,Other,Drug Cost,2.32,,,2.32,Other,225% Medicaid APG methodology,1.44,,,1.44,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,4.71,,,4.71,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.03,,,1.03,Other,Drug Cost,1.03,,,1.03,Other,Drug Cost,1.29,,,1.29,Other,125% Medicaid APG methodology,0.01,4.84,
LEVETIRACETAM 10MG/ML NS        ,J1953,HCPCS,,40539751,CDM,636,RC,63323-0400-05n,NDC,both,1,ML,2.38,0.62,,,0.62,Other,150% of Medicare + 9.63% HCRA Surcharge,0.38,,,0.38,Fee Schedule,Average Sale Price (ASP) x 6,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,1.19,50,,1.19,percent of total billed charges,All Other,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.71,30,,0.71,percent of total billed charges,Drugs,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.81,34,,0.81,percent of total billed charges,Drugs,0.38,,,0.38,Other,Drug Cost,0.86,,,0.86,Other,225% Medicaid APG methodology,0.53,,,0.53,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.6,,,0.6,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.48,,,0.48,Other,125% Medicaid APG methodology,0.01,1.19,
DIPHENHYDRAMINE 50MG/ML PREMIX  ,J1200,HCPCS,,40540064,CDM,636,RC,00641-0376-25n,NDC,both,1,ML,1.93,7.93,,,7.93,Other,150% of Medicare + 9.63% HCRA Surcharge,4.82,,,4.82,Fee Schedule,Average Sale Price (ASP) x 6,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.97,50,,0.97,percent of total billed charges,All Other,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.58,30,,0.58,percent of total billed charges,Drugs,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.66,34,,0.66,percent of total billed charges,Drugs,0.6,,,0.6,Other,Drug Cost,1.35,,,1.35,Other,225% Medicaid APG methodology,0.84,,,0.84,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.72,,,7.72,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.6,,,0.6,Other,Drug Cost,0.6,,,0.6,Other,Drug Cost,0.75,,,0.75,Other,125% Medicaid APG methodology,0.01,7.93,
TESTOSTERONE CYP200MG/ML IM1ML  ,J0180,HCPCS,,40540171,CDM,636,RC,69097-0537-31,NDC,both,1,ML,43.86,2154.31,,,2154.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1310.05,,,1310.05,Fee Schedule,Average Sale Price (ASP) x 6,13.16,30,,13.16,percent of total billed charges,Drugs,13.16,30,,13.16,percent of total billed charges,Drugs,13.16,30,,13.16,percent of total billed charges,Drugs,13.16,30,,13.16,percent of total billed charges,Drugs,13.16,30,,13.16,percent of total billed charges,Drugs,21.93,50,,21.93,percent of total billed charges,All Other,13.16,30,,13.16,percent of total billed charges,Drugs,13.16,30,,13.16,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,13.16,30,,13.16,percent of total billed charges,Drugs,13.16,30,,13.16,percent of total billed charges,Drugs,13.16,30,,13.16,percent of total billed charges,Drugs,13.16,30,,13.16,percent of total billed charges,Drugs,13.16,30,,13.16,percent of total billed charges,Drugs,13.16,30,,13.16,percent of total billed charges,Drugs,13.16,30,,13.16,percent of total billed charges,Drugs,13.16,30,,13.16,percent of total billed charges,Drugs,13.16,30,,13.16,percent of total billed charges,Drugs,13.16,30,,13.16,percent of total billed charges,Drugs,13.16,30,,13.16,percent of total billed charges,Drugs,13.16,30,,13.16,percent of total billed charges,Drugs,13.16,30,,13.16,percent of total billed charges,Drugs,11.78,,,11.78,Other,Drug Cost,11.78,,,11.78,Other,Drug Cost,11.78,,,11.78,Other,Drug Cost,11.78,,,11.78,Other,Drug Cost,11.78,,,11.78,Other,Drug Cost,14.91,34,,14.91,percent of total billed charges,Drugs,11.78,,,11.78,Other,Drug Cost,26.51,,,26.51,Other,225% Medicaid APG methodology,16.49,,,16.49,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2096.07,,,2096.07,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",11.78,,,11.78,Other,Drug Cost,11.78,,,11.78,Other,Drug Cost,14.73,,,14.73,Other,125% Medicaid APG methodology,0.01,2154.31,
DOCETAXEL 20MG/ML IV SOLN 8ML   ,J9171,HCPCS,,40540221,CDM,636,RC,00955-1022-08,NDC,both,8,ML,1415.33,9.82,,,9.82,Other,150% of Medicare + 9.63% HCRA Surcharge,5.97,,,5.97,Fee Schedule,Average Sale Price (ASP) x 6,424.6,30,,424.6,percent of total billed charges,Drugs,424.6,30,,424.6,percent of total billed charges,Drugs,424.6,30,,424.6,percent of total billed charges,Drugs,424.6,30,,424.6,percent of total billed charges,Drugs,424.6,30,,424.6,percent of total billed charges,Drugs,707.67,50,,707.67,percent of total billed charges,All Other,424.6,30,,424.6,percent of total billed charges,Drugs,424.6,30,,424.6,percent of total billed charges,Drugs,481.21,34,"If Charge > 500, then 34 percent",481.21,percent of total billed charges,Drugs,424.6,30,,424.6,percent of total billed charges,Drugs,424.6,30,,424.6,percent of total billed charges,Drugs,424.6,30,,424.6,percent of total billed charges,Drugs,424.6,30,,424.6,percent of total billed charges,Drugs,424.6,30,,424.6,percent of total billed charges,Drugs,424.6,30,,424.6,percent of total billed charges,Drugs,424.6,30,,424.6,percent of total billed charges,Drugs,424.6,30,,424.6,percent of total billed charges,Drugs,424.6,30,,424.6,percent of total billed charges,Drugs,424.6,30,,424.6,percent of total billed charges,Drugs,424.6,30,,424.6,percent of total billed charges,Drugs,424.6,30,,424.6,percent of total billed charges,Drugs,424.6,30,,424.6,percent of total billed charges,Drugs,52.55,,,52.55,Other,Drug Cost,52.55,,,52.55,Other,Drug Cost,52.55,,,52.55,Other,Drug Cost,52.55,,,52.55,Other,Drug Cost,52.55,,,52.55,Other,Drug Cost,481.21,34,,481.21,percent of total billed charges,Drugs,52.55,,,52.55,Other,Drug Cost,118.24,,,118.24,Other,225% Medicaid APG methodology,73.57,,,73.57,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,9.55,,,9.55,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",52.55,,,52.55,Other,Drug Cost,52.55,,,52.55,Other,Drug Cost,65.69,,,65.69,Other,125% Medicaid APG methodology,0.01,707.67,
RITUXIMAB 10MG/ML IV SOLN 10ML  ,J9312,HCPCS,,40540239,CDM,636,RC,50242-0051-21,NDC,both,10,ML,2620.66,781.42,,,781.42,Other,150% of Medicare + 9.63% HCRA Surcharge,475.19,,,475.19,Fee Schedule,Average Sale Price (ASP) x 6,786.2,30,,786.2,percent of total billed charges,Drugs,786.2,30,,786.2,percent of total billed charges,Drugs,786.2,30,,786.2,percent of total billed charges,Drugs,786.2,30,,786.2,percent of total billed charges,Drugs,786.2,30,,786.2,percent of total billed charges,Drugs,1310.33,50,,1310.33,percent of total billed charges,All Other,786.2,30,,786.2,percent of total billed charges,Drugs,786.2,30,,786.2,percent of total billed charges,Drugs,891.02,34,"If Charge > 500, then 34 percent",891.02,percent of total billed charges,Drugs,786.2,30,,786.2,percent of total billed charges,Drugs,786.2,30,,786.2,percent of total billed charges,Drugs,786.2,30,,786.2,percent of total billed charges,Drugs,786.2,30,,786.2,percent of total billed charges,Drugs,786.2,30,,786.2,percent of total billed charges,Drugs,786.2,30,,786.2,percent of total billed charges,Drugs,786.2,30,,786.2,percent of total billed charges,Drugs,786.2,30,,786.2,percent of total billed charges,Drugs,786.2,30,,786.2,percent of total billed charges,Drugs,786.2,30,,786.2,percent of total billed charges,Drugs,786.2,30,,786.2,percent of total billed charges,Drugs,786.2,30,,786.2,percent of total billed charges,Drugs,786.2,30,,786.2,percent of total billed charges,Drugs,404.99,,,404.99,Other,Drug Cost,404.99,,,404.99,Other,Drug Cost,404.99,,,404.99,Other,Drug Cost,404.99,,,404.99,Other,Drug Cost,404.99,,,404.99,Other,Drug Cost,891.02,34,,891.02,percent of total billed charges,Drugs,404.99,,,404.99,Other,Drug Cost,911.23,,,911.23,Other,225% Medicaid APG methodology,566.99,,,566.99,Other,140% Medicaid APG methodology,891.02,34,"If Charge > 2,000, then 34 percent",891.02,percent of total billed charges,Drugs,760.3,,,760.3,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",404.99,,,404.99,Other,Drug Cost,404.99,,,404.99,Other,Drug Cost,506.24,,,506.24,Other,125% Medicaid APG methodology,0.01,1310.33,
FLUCONAZOLE 100MG NS IV 50ML    ,J1450,HCPCS,,40540254,CDM,636,RC,25021-0184-82a,NDC,both,50,ML,6.51,27.6,,,27.6,Other,150% of Medicare + 9.63% HCRA Surcharge,16.78,,,16.78,Fee Schedule,Average Sale Price (ASP) x 6,1.95,30,,1.95,percent of total billed charges,Drugs,1.95,30,,1.95,percent of total billed charges,Drugs,1.95,30,,1.95,percent of total billed charges,Drugs,1.95,30,,1.95,percent of total billed charges,Drugs,1.95,30,,1.95,percent of total billed charges,Drugs,3.26,50,,3.26,percent of total billed charges,All Other,1.95,30,,1.95,percent of total billed charges,Drugs,1.95,30,,1.95,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.95,30,,1.95,percent of total billed charges,Drugs,1.95,30,,1.95,percent of total billed charges,Drugs,1.95,30,,1.95,percent of total billed charges,Drugs,1.95,30,,1.95,percent of total billed charges,Drugs,1.95,30,,1.95,percent of total billed charges,Drugs,1.95,30,,1.95,percent of total billed charges,Drugs,1.95,30,,1.95,percent of total billed charges,Drugs,1.95,30,,1.95,percent of total billed charges,Drugs,1.95,30,,1.95,percent of total billed charges,Drugs,1.95,30,,1.95,percent of total billed charges,Drugs,1.95,30,,1.95,percent of total billed charges,Drugs,1.95,30,,1.95,percent of total billed charges,Drugs,1.95,30,,1.95,percent of total billed charges,Drugs,1.45,,,1.45,Other,Drug Cost,1.45,,,1.45,Other,Drug Cost,1.45,,,1.45,Other,Drug Cost,1.45,,,1.45,Other,Drug Cost,1.45,,,1.45,Other,Drug Cost,2.21,34,,2.21,percent of total billed charges,Drugs,1.45,,,1.45,Other,Drug Cost,3.26,,,3.26,Other,225% Medicaid APG methodology,2.03,,,2.03,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,26.85,,,26.85,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.45,,,1.45,Other,Drug Cost,1.45,,,1.45,Other,Drug Cost,1.81,,,1.81,Other,125% Medicaid APG methodology,0.01,27.6,
ANIDULAFUNGIN 100 MG IV INJ     ,J0348,HCPCS,,40540551,CDM,636,RC,00049-0116-28,NDC,both,1,EA,282.52,4.54,,,4.54,Other,150% of Medicare + 9.63% HCRA Surcharge,2.76,,,2.76,Fee Schedule,Average Sale Price (ASP) x 6,84.76,30,,84.76,percent of total billed charges,Drugs,84.76,30,,84.76,percent of total billed charges,Drugs,84.76,30,,84.76,percent of total billed charges,Drugs,84.76,30,,84.76,percent of total billed charges,Drugs,84.76,30,,84.76,percent of total billed charges,Drugs,141.26,50,,141.26,percent of total billed charges,All Other,84.76,30,,84.76,percent of total billed charges,Drugs,84.76,30,,84.76,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,84.76,30,,84.76,percent of total billed charges,Drugs,84.76,30,,84.76,percent of total billed charges,Drugs,84.76,30,,84.76,percent of total billed charges,Drugs,84.76,30,,84.76,percent of total billed charges,Drugs,84.76,30,,84.76,percent of total billed charges,Drugs,84.76,30,,84.76,percent of total billed charges,Drugs,84.76,30,,84.76,percent of total billed charges,Drugs,84.76,30,,84.76,percent of total billed charges,Drugs,84.76,30,,84.76,percent of total billed charges,Drugs,84.76,30,,84.76,percent of total billed charges,Drugs,84.76,30,,84.76,percent of total billed charges,Drugs,84.76,30,,84.76,percent of total billed charges,Drugs,84.76,30,,84.76,percent of total billed charges,Drugs,37.53,,,37.53,Other,Drug Cost,37.53,,,37.53,Other,Drug Cost,37.53,,,37.53,Other,Drug Cost,37.53,,,37.53,Other,Drug Cost,37.53,,,37.53,Other,Drug Cost,96.06,34,,96.06,percent of total billed charges,Drugs,37.53,,,37.53,Other,Drug Cost,84.44,,,84.44,Other,225% Medicaid APG methodology,52.54,,,52.54,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,4.42,,,4.42,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",37.53,,,37.53,Other,Drug Cost,37.53,,,37.53,Other,Drug Cost,46.91,,,46.91,Other,125% Medicaid APG methodology,0.01,141.26,
PNEUMOCOCCAL 15 (VAXNEUVANCE)   ,90671,CPT,,40540577,CDM,636,RC,00006-4329-03,NDC,both,0.5,ML,668.22,2501.8,,,2501.8,Other,150% of Medicare + 9.63% HCRA Surcharge,1521.36,,,1521.36,Fee Schedule,Average Sale Price (ASP) x 6,200.47,30,,200.47,percent of total billed charges,Drugs,200.47,30,,200.47,percent of total billed charges,Drugs,200.47,30,,200.47,percent of total billed charges,Drugs,200.47,30,,200.47,percent of total billed charges,Drugs,200.47,30,,200.47,percent of total billed charges,Drugs,334.11,50,,334.11,percent of total billed charges,All Other,200.47,30,,200.47,percent of total billed charges,Drugs,200.47,30,,200.47,percent of total billed charges,Drugs,227.19,34,"If Charge > 500, then 34 percent",227.19,percent of total billed charges,Drugs,200.47,30,,200.47,percent of total billed charges,Drugs,200.47,30,,200.47,percent of total billed charges,Drugs,200.47,30,,200.47,percent of total billed charges,Drugs,200.47,30,,200.47,percent of total billed charges,Drugs,200.47,30,,200.47,percent of total billed charges,Drugs,200.47,30,,200.47,percent of total billed charges,Drugs,200.47,30,,200.47,percent of total billed charges,Drugs,200.47,30,,200.47,percent of total billed charges,Drugs,200.47,30,,200.47,percent of total billed charges,Drugs,200.47,30,,200.47,percent of total billed charges,Drugs,200.47,30,,200.47,percent of total billed charges,Drugs,200.47,30,,200.47,percent of total billed charges,Drugs,200.47,30,,200.47,percent of total billed charges,Drugs,196.62,,,196.62,Other,Drug Cost,196.62,,,196.62,Other,Drug Cost,196.62,,,196.62,Other,Drug Cost,196.62,,,196.62,Other,Drug Cost,196.62,,,196.62,Other,Drug Cost,227.19,34,,227.19,percent of total billed charges,Drugs,196.62,,,196.62,Other,Drug Cost,442.4,,,442.4,Other,225% Medicaid APG methodology,275.27,,,275.27,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2434.18,,,2434.18,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",196.62,,,196.62,Other,Drug Cost,196.62,,,196.62,Other,Drug Cost,245.78,,,245.78,Other,125% Medicaid APG methodology,0.01,2501.8,
FERUMOXYTOL 30 MG/ML  NON-ESRD  ,Q0138,HCPCS,,40540981,CDM,636,RC,59338-0775-01,NDC,both,17,ML,1350.23,3.52,,,3.52,Other,150% of Medicare + 9.63% HCRA Surcharge,2.14,,,2.14,Fee Schedule,Average Sale Price (ASP) x 6,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,675.12,50,,675.12,percent of total billed charges,All Other,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,459.08,34,"If Charge > 500, then 34 percent",459.08,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,177.4,,,177.4,Other,Drug Cost,177.4,,,177.4,Other,Drug Cost,177.4,,,177.4,Other,Drug Cost,177.4,,,177.4,Other,Drug Cost,177.4,,,177.4,Other,Drug Cost,459.08,34,,459.08,percent of total billed charges,Drugs,177.4,,,177.4,Other,Drug Cost,399.15,,,399.15,Other,225% Medicaid APG methodology,248.36,,,248.36,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,3.43,,,3.43,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",177.4,,,177.4,Other,Drug Cost,177.4,,,177.4,Other,Drug Cost,221.75,,,221.75,Other,125% Medicaid APG methodology,0.01,675.12,
ENFORTUMAB VEDOTIN EJFV 20 MG   ,J9177,HCPCS,,40541013,CDM,636,RC,51144-0020-01,NDC,both,1,EA,9639,345.61,,,345.61,Other,150% of Medicare + 9.63% HCRA Surcharge,210.17,,,210.17,Fee Schedule,Average Sale Price (ASP) x 6,2891.7,30,,2891.7,percent of total billed charges,Drugs,2891.7,30,,2891.7,percent of total billed charges,Drugs,2891.7,30,,2891.7,percent of total billed charges,Drugs,2891.7,30,,2891.7,percent of total billed charges,Drugs,2891.7,30,,2891.7,percent of total billed charges,Drugs,4819.5,50,,4819.5,percent of total billed charges,All Other,2891.7,30,,2891.7,percent of total billed charges,Drugs,2891.7,30,,2891.7,percent of total billed charges,Drugs,3277.26,34,"If Charge > 500, then 34 percent",3277.26,percent of total billed charges,Drugs,2891.7,30,,2891.7,percent of total billed charges,Drugs,2891.7,30,,2891.7,percent of total billed charges,Drugs,2891.7,30,,2891.7,percent of total billed charges,Drugs,2891.7,30,,2891.7,percent of total billed charges,Drugs,2891.7,30,,2891.7,percent of total billed charges,Drugs,2891.7,30,,2891.7,percent of total billed charges,Drugs,2891.7,30,,2891.7,percent of total billed charges,Drugs,2891.7,30,,2891.7,percent of total billed charges,Drugs,2891.7,30,,2891.7,percent of total billed charges,Drugs,2891.7,30,,2891.7,percent of total billed charges,Drugs,2891.7,30,,2891.7,percent of total billed charges,Drugs,2891.7,30,,2891.7,percent of total billed charges,Drugs,2891.7,30,,2891.7,percent of total billed charges,Drugs,1866.8,,,1866.8,Other,Drug Cost,1866.8,,,1866.8,Other,Drug Cost,1866.8,,,1866.8,Other,Drug Cost,1866.8,,,1866.8,Other,Drug Cost,1866.8,,,1866.8,Other,Drug Cost,3277.26,34,,3277.26,percent of total billed charges,Drugs,1866.8,,,1866.8,Other,Drug Cost,4200.3,,,4200.3,Other,225% Medicaid APG methodology,2613.52,,,2613.52,Other,140% Medicaid APG methodology,3277.26,34,"If Charge > 2,000, then 34 percent",3277.26,percent of total billed charges,Drugs,336.27,,,336.27,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1866.8,,,1866.8,Other,Drug Cost,1866.8,,,1866.8,Other,Drug Cost,2333.5,,,2333.5,Other,125% Medicaid APG methodology,0.01,4819.5,
AMINOCAP ACID 5 G IN NS 250 ML  ,J3490,HCPCS,,40541260,CDM,636,RC,00517-9120-25a,NDC,both,250,ML,24.01,9.48,39.4668,,9.48,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,7.2,30,,7.2,percent of total billed charges,Drugs,7.2,30,,7.2,percent of total billed charges,Drugs,7.2,30,,7.2,percent of total billed charges,Drugs,7.2,30,,7.2,percent of total billed charges,Drugs,7.2,30,,7.2,percent of total billed charges,Drugs,12.01,50,,12.01,percent of total billed charges,All Other,7.2,30,,7.2,percent of total billed charges,Drugs,7.2,30,,7.2,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,7.2,30,,7.2,percent of total billed charges,Drugs,7.2,30,,7.2,percent of total billed charges,Drugs,7.2,30,,7.2,percent of total billed charges,Drugs,7.2,30,,7.2,percent of total billed charges,Drugs,7.2,30,,7.2,percent of total billed charges,Drugs,7.2,30,,7.2,percent of total billed charges,Drugs,7.2,30,,7.2,percent of total billed charges,Drugs,7.2,30,,7.2,percent of total billed charges,Drugs,7.2,30,,7.2,percent of total billed charges,Drugs,7.2,30,,7.2,percent of total billed charges,Drugs,7.2,30,,7.2,percent of total billed charges,Drugs,7.2,30,,7.2,percent of total billed charges,Drugs,7.2,30,,7.2,percent of total billed charges,Drugs,5.98,,,5.98,Other,Drug Cost,5.98,,,5.98,Other,Drug Cost,5.98,,,5.98,Other,Drug Cost,5.98,,,5.98,Other,Drug Cost,5.98,,,5.98,Other,Drug Cost,8.16,34,,8.16,percent of total billed charges,Drugs,5.98,,,5.98,Other,Drug Cost,13.46,,,13.46,Other,225% Medicaid APG methodology,8.37,,,8.37,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.98,,,5.98,Other,Drug Cost,5.98,,,5.98,Other,Drug Cost,7.48,,,7.48,Other,125% Medicaid APG methodology,0.01,13.46,
INSUL REG 100 UNITS NS 100 ML   ,J1815,HCPCS,,40541278,CDM,636,RC,00002-8215-01a,NDC,both,100,ML,11.87,4.68,39.4668,,4.68,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,3.56,30,,3.56,percent of total billed charges,Drugs,3.56,30,,3.56,percent of total billed charges,Drugs,3.56,30,,3.56,percent of total billed charges,Drugs,3.56,30,,3.56,percent of total billed charges,Drugs,3.56,30,,3.56,percent of total billed charges,Drugs,5.94,50,,5.94,percent of total billed charges,All Other,3.56,30,,3.56,percent of total billed charges,Drugs,3.56,30,,3.56,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.56,30,,3.56,percent of total billed charges,Drugs,3.56,30,,3.56,percent of total billed charges,Drugs,3.56,30,,3.56,percent of total billed charges,Drugs,3.56,30,,3.56,percent of total billed charges,Drugs,3.56,30,,3.56,percent of total billed charges,Drugs,3.56,30,,3.56,percent of total billed charges,Drugs,3.56,30,,3.56,percent of total billed charges,Drugs,3.56,30,,3.56,percent of total billed charges,Drugs,3.56,30,,3.56,percent of total billed charges,Drugs,3.56,30,,3.56,percent of total billed charges,Drugs,3.56,30,,3.56,percent of total billed charges,Drugs,3.56,30,,3.56,percent of total billed charges,Drugs,3.56,30,,3.56,percent of total billed charges,Drugs,5.62,,,5.62,Other,Drug Cost,5.62,,,5.62,Other,Drug Cost,5.62,,,5.62,Other,Drug Cost,5.62,,,5.62,Other,Drug Cost,5.62,,,5.62,Other,Drug Cost,4.04,34,,4.04,percent of total billed charges,Drugs,5.62,,,5.62,Other,Drug Cost,12.65,,,12.65,Other,225% Medicaid APG methodology,7.87,,,7.87,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.62,,,5.62,Other,Drug Cost,5.62,,,5.62,Other,Drug Cost,7.03,,,7.03,Other,125% Medicaid APG methodology,0.01,12.65,
ANES VANCO 2 G IN NS 500 ML     ,J3370,HCPCS,,40541286,CDM,636,RC,00409-6533-21a,NDC,both,500,ML,23.56,22.76,,,22.76,Other,150% of Medicare + 9.63% HCRA Surcharge,13.84,,,13.84,Fee Schedule,Average Sale Price (ASP) x 6,7.07,30,,7.07,percent of total billed charges,Drugs,7.07,30,,7.07,percent of total billed charges,Drugs,7.07,30,,7.07,percent of total billed charges,Drugs,7.07,30,,7.07,percent of total billed charges,Drugs,7.07,30,,7.07,percent of total billed charges,Drugs,11.78,50,,11.78,percent of total billed charges,All Other,7.07,30,,7.07,percent of total billed charges,Drugs,7.07,30,,7.07,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,7.07,30,,7.07,percent of total billed charges,Drugs,7.07,30,,7.07,percent of total billed charges,Drugs,7.07,30,,7.07,percent of total billed charges,Drugs,7.07,30,,7.07,percent of total billed charges,Drugs,7.07,30,,7.07,percent of total billed charges,Drugs,7.07,30,,7.07,percent of total billed charges,Drugs,7.07,30,,7.07,percent of total billed charges,Drugs,7.07,30,,7.07,percent of total billed charges,Drugs,7.07,30,,7.07,percent of total billed charges,Drugs,7.07,30,,7.07,percent of total billed charges,Drugs,7.07,30,,7.07,percent of total billed charges,Drugs,7.07,30,,7.07,percent of total billed charges,Drugs,7.07,30,,7.07,percent of total billed charges,Drugs,5.39,,,5.39,Other,Drug Cost,5.39,,,5.39,Other,Drug Cost,5.39,,,5.39,Other,Drug Cost,5.39,,,5.39,Other,Drug Cost,5.39,,,5.39,Other,Drug Cost,8.01,34,,8.01,percent of total billed charges,Drugs,5.39,,,5.39,Other,Drug Cost,12.13,,,12.13,Other,225% Medicaid APG methodology,7.55,,,7.55,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,22.15,,,22.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.39,,,5.39,Other,Drug Cost,5.39,,,5.39,Other,Drug Cost,6.74,,,6.74,Other,125% Medicaid APG methodology,0.01,22.76,
DARBEPOETIN 300 MCG NON-ESRD    ,J0881,HCPCS,,40541609,CDM,636,RC,55513-0111-01,NDC,both,0.6,ML,7606.87,28.91,,,28.91,Other,150% of Medicare + 9.63% HCRA Surcharge,17.58,,,17.58,Fee Schedule,Average Sale Price (ASP) x 6,2282.06,30,,2282.06,percent of total billed charges,Drugs,2282.06,30,,2282.06,percent of total billed charges,Drugs,2282.06,30,,2282.06,percent of total billed charges,Drugs,2282.06,30,,2282.06,percent of total billed charges,Drugs,2282.06,30,,2282.06,percent of total billed charges,Drugs,3803.44,50,,3803.44,percent of total billed charges,All Other,2282.06,30,,2282.06,percent of total billed charges,Drugs,2282.06,30,,2282.06,percent of total billed charges,Drugs,2586.34,34,"If Charge > 500, then 34 percent",2586.34,percent of total billed charges,Drugs,2282.06,30,,2282.06,percent of total billed charges,Drugs,2282.06,30,,2282.06,percent of total billed charges,Drugs,2282.06,30,,2282.06,percent of total billed charges,Drugs,2282.06,30,,2282.06,percent of total billed charges,Drugs,2282.06,30,,2282.06,percent of total billed charges,Drugs,2282.06,30,,2282.06,percent of total billed charges,Drugs,2282.06,30,,2282.06,percent of total billed charges,Drugs,2282.06,30,,2282.06,percent of total billed charges,Drugs,2282.06,30,,2282.06,percent of total billed charges,Drugs,2282.06,30,,2282.06,percent of total billed charges,Drugs,2282.06,30,,2282.06,percent of total billed charges,Drugs,2282.06,30,,2282.06,percent of total billed charges,Drugs,2282.06,30,,2282.06,percent of total billed charges,Drugs,550.46,,,550.46,Other,Drug Cost,550.46,,,550.46,Other,Drug Cost,550.46,,,550.46,Other,Drug Cost,550.46,,,550.46,Other,Drug Cost,550.46,,,550.46,Other,Drug Cost,2586.34,34,,2586.34,percent of total billed charges,Drugs,550.46,,,550.46,Other,Drug Cost,1238.54,,,1238.54,Other,225% Medicaid APG methodology,770.64,,,770.64,Other,140% Medicaid APG methodology,2586.34,34,"If Charge > 2,000, then 34 percent",2586.34,percent of total billed charges,Drugs,28.13,,,28.13,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",550.46,,,550.46,Other,Drug Cost,550.46,,,550.46,Other,Drug Cost,688.08,,,688.08,Other,125% Medicaid APG methodology,0.01,3803.44,
EPOETIN ALFA-EPBX 20K UN ESRD   ,Q5105,HCPCS,,40541815,CDM,636,RC,00069-1318-10,NDC,both,2,ML,633.15,7.72,,,7.72,Other,150% of Medicare + 9.63% HCRA Surcharge,4.69,,,4.69,Fee Schedule,Average Sale Price (ASP) x 6,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,316.58,50,,316.58,percent of total billed charges,All Other,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,215.27,34,"If Charge > 500, then 34 percent",215.27,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,189.95,30,,189.95,percent of total billed charges,Drugs,22.28,,,22.28,Other,Drug Cost,22.28,,,22.28,Other,Drug Cost,22.28,,,22.28,Other,Drug Cost,22.28,,,22.28,Other,Drug Cost,22.28,,,22.28,Other,Drug Cost,215.27,34,,215.27,percent of total billed charges,Drugs,22.28,,,22.28,Other,Drug Cost,50.13,,,50.13,Other,225% Medicaid APG methodology,31.19,,,31.19,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.51,,,7.51,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",22.28,,,22.28,Other,Drug Cost,22.28,,,22.28,Other,Drug Cost,27.85,,,27.85,Other,125% Medicaid APG methodology,0.01,316.58,
"EPOETIN 20,000 UNITS/1ML ESRD   ",Q4081,HCPCS,,40541823,CDM,636,RC,59676-0320-04,NDC,both,1,ML,984.97,8.77,,,8.77,Other,150% of Medicare + 9.63% HCRA Surcharge,5.33,,,5.33,Fee Schedule,Average Sale Price (ASP) x 6,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,492.49,50,,492.49,percent of total billed charges,All Other,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,334.89,34,"If Charge > 500, then 34 percent",334.89,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,295.49,30,,295.49,percent of total billed charges,Drugs,136.8,,,136.8,Other,Drug Cost,136.8,,,136.8,Other,Drug Cost,136.8,,,136.8,Other,Drug Cost,136.8,,,136.8,Other,Drug Cost,136.8,,,136.8,Other,Drug Cost,334.89,34,,334.89,percent of total billed charges,Drugs,136.8,,,136.8,Other,Drug Cost,307.8,,,307.8,Other,225% Medicaid APG methodology,191.52,,,191.52,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,8.53,,,8.53,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",136.8,,,136.8,Other,Drug Cost,136.8,,,136.8,Other,Drug Cost,171,,,171,Other,125% Medicaid APG methodology,0.01,492.49,
MORPHINE 1500 MCG IN D5W15ML    ,J2270,HCPCS,,40542466,CDM,636,RC,76045-0004-10y,NDC,both,15,ML,1.89,46.03,,,46.03,Other,150% of Medicare + 9.63% HCRA Surcharge,27.99,,,27.99,Fee Schedule,Average Sale Price (ASP) x 6,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.95,50,,0.95,percent of total billed charges,All Other,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.57,30,,0.57,percent of total billed charges,Drugs,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.64,34,,0.64,percent of total billed charges,Drugs,0.54,,,0.54,Other,Drug Cost,1.22,,,1.22,Other,225% Medicaid APG methodology,0.76,,,0.76,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,44.78,,,44.78,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.68,,,0.68,Other,125% Medicaid APG methodology,0.01,46.03,
PEDS CEFEPIME 40 MG/ML IN D5W   ,J0692,HCPCS,,40542953,CDM,636,RC,60505-6146-04n,NDC,both,1,ML,8.19,12.45,,,12.45,Other,150% of Medicare + 9.63% HCRA Surcharge,7.57,,,7.57,Fee Schedule,Average Sale Price (ASP) x 6,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,4.1,50,,4.1,percent of total billed charges,All Other,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,2.46,30,,2.46,percent of total billed charges,Drugs,3.05,,,3.05,Other,Drug Cost,3.05,,,3.05,Other,Drug Cost,3.05,,,3.05,Other,Drug Cost,3.05,,,3.05,Other,Drug Cost,3.05,,,3.05,Other,Drug Cost,2.78,34,,2.78,percent of total billed charges,Drugs,3.05,,,3.05,Other,Drug Cost,6.86,,,6.86,Other,225% Medicaid APG methodology,4.27,,,4.27,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,12.12,,,12.12,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.05,,,3.05,Other,Drug Cost,3.05,,,3.05,Other,Drug Cost,3.81,,,3.81,Other,125% Medicaid APG methodology,0.01,12.45,
DEXAMETHASONE 4MG/ML INJ  5ML   ,J1100,HCPCS,,40542979,CDM,636,RC,63323-0165-05,NDC,both,5,ML,18.73,1.17,,,1.17,Other,150% of Medicare + 9.63% HCRA Surcharge,0.71,,,0.71,Fee Schedule,Average Sale Price (ASP) x 6,5.62,30,,5.62,percent of total billed charges,Drugs,5.62,30,,5.62,percent of total billed charges,Drugs,5.62,30,,5.62,percent of total billed charges,Drugs,5.62,30,,5.62,percent of total billed charges,Drugs,5.62,30,,5.62,percent of total billed charges,Drugs,9.37,50,,9.37,percent of total billed charges,All Other,5.62,30,,5.62,percent of total billed charges,Drugs,5.62,30,,5.62,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,5.62,30,,5.62,percent of total billed charges,Drugs,5.62,30,,5.62,percent of total billed charges,Drugs,5.62,30,,5.62,percent of total billed charges,Drugs,5.62,30,,5.62,percent of total billed charges,Drugs,5.62,30,,5.62,percent of total billed charges,Drugs,5.62,30,,5.62,percent of total billed charges,Drugs,5.62,30,,5.62,percent of total billed charges,Drugs,5.62,30,,5.62,percent of total billed charges,Drugs,5.62,30,,5.62,percent of total billed charges,Drugs,5.62,30,,5.62,percent of total billed charges,Drugs,5.62,30,,5.62,percent of total billed charges,Drugs,5.62,30,,5.62,percent of total billed charges,Drugs,5.62,30,,5.62,percent of total billed charges,Drugs,3.01,,,3.01,Other,Drug Cost,3.01,,,3.01,Other,Drug Cost,3.01,,,3.01,Other,Drug Cost,3.01,,,3.01,Other,Drug Cost,3.01,,,3.01,Other,Drug Cost,6.37,34,,6.37,percent of total billed charges,Drugs,3.01,,,3.01,Other,Drug Cost,6.77,,,6.77,Other,225% Medicaid APG methodology,4.21,,,4.21,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.14,,,1.14,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.01,,,3.01,Other,Drug Cost,3.01,,,3.01,Other,Drug Cost,3.76,,,3.76,Other,125% Medicaid APG methodology,0.01,9.37,
HEPARIN 1000 UNITS/ML INJ  2ML  ,J1644,HCPCS,,40543001,CDM,636,RC,63323-0276-02,NDC,both,2,ML,17.22,2.64,,,2.64,Other,150% of Medicare + 9.63% HCRA Surcharge,1.61,,,1.61,Fee Schedule,Average Sale Price (ASP) x 6,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,8.61,50,,8.61,percent of total billed charges,All Other,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,5.17,30,,5.17,percent of total billed charges,Drugs,4.23,,,4.23,Other,Drug Cost,4.23,,,4.23,Other,Drug Cost,4.23,,,4.23,Other,Drug Cost,4.23,,,4.23,Other,Drug Cost,4.23,,,4.23,Other,Drug Cost,5.85,34,,5.85,percent of total billed charges,Drugs,4.23,,,4.23,Other,Drug Cost,9.52,,,9.52,Other,225% Medicaid APG methodology,5.92,,,5.92,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.57,,,2.57,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.23,,,4.23,Other,Drug Cost,4.23,,,4.23,Other,Drug Cost,5.29,,,5.29,Other,125% Medicaid APG methodology,0.01,9.52,
HEPARIN FLUSH 100UNIT/ML IV5ML  ,J1642,HCPCS,,40543035,CDM,636,RC,64253-0333-35,NDC,both,5,ML,1.47,0.16,,,0.16,Other,150% of Medicare + 9.63% HCRA Surcharge,0.1,,,0.1,Fee Schedule,Average Sale Price (ASP) x 6,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.74,50,,0.74,percent of total billed charges,All Other,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.5,34,,0.5,percent of total billed charges,Drugs,0.38,,,0.38,Other,Drug Cost,0.86,,,0.86,Other,225% Medicaid APG methodology,0.53,,,0.53,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.15,,,0.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.48,,,0.48,Other,125% Medicaid APG methodology,0.01,0.86,
CLINDAMYCIN 600MG D5W IV 50ML   ,J3490,HCPCS,,40543506,CDM,636,RC,00781-3289-09,NDC,both,50,ML,19.25,7.6,39.4668,,7.6,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,5.78,30,,5.78,percent of total billed charges,Drugs,5.78,30,,5.78,percent of total billed charges,Drugs,5.78,30,,5.78,percent of total billed charges,Drugs,5.78,30,,5.78,percent of total billed charges,Drugs,5.78,30,,5.78,percent of total billed charges,Drugs,9.63,50,,9.63,percent of total billed charges,All Other,5.78,30,,5.78,percent of total billed charges,Drugs,5.78,30,,5.78,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,5.78,30,,5.78,percent of total billed charges,Drugs,5.78,30,,5.78,percent of total billed charges,Drugs,5.78,30,,5.78,percent of total billed charges,Drugs,5.78,30,,5.78,percent of total billed charges,Drugs,5.78,30,,5.78,percent of total billed charges,Drugs,5.78,30,,5.78,percent of total billed charges,Drugs,5.78,30,,5.78,percent of total billed charges,Drugs,5.78,30,,5.78,percent of total billed charges,Drugs,5.78,30,,5.78,percent of total billed charges,Drugs,5.78,30,,5.78,percent of total billed charges,Drugs,5.78,30,,5.78,percent of total billed charges,Drugs,5.78,30,,5.78,percent of total billed charges,Drugs,5.78,30,,5.78,percent of total billed charges,Drugs,4,,,4,Other,Drug Cost,4,,,4,Other,Drug Cost,4,,,4,Other,Drug Cost,4,,,4,Other,Drug Cost,4,,,4,Other,Drug Cost,6.55,34,,6.55,percent of total billed charges,Drugs,4,,,4,Other,Drug Cost,9,,,9,Other,225% Medicaid APG methodology,5.6,,,5.6,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4,,,4,Other,Drug Cost,4,,,4,Other,Drug Cost,5,,,5,Other,125% Medicaid APG methodology,0.01,9.63,
CLINDAMYCIN 900MG D5W IV 50ML   ,J3490,HCPCS,,40543514,CDM,636,RC,00781-3290-09,NDC,both,50,ML,22.75,8.98,39.4668,,8.98,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,6.83,30,,6.83,percent of total billed charges,Drugs,6.83,30,,6.83,percent of total billed charges,Drugs,6.83,30,,6.83,percent of total billed charges,Drugs,6.83,30,,6.83,percent of total billed charges,Drugs,6.83,30,,6.83,percent of total billed charges,Drugs,11.38,50,,11.38,percent of total billed charges,All Other,6.83,30,,6.83,percent of total billed charges,Drugs,6.83,30,,6.83,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,6.83,30,,6.83,percent of total billed charges,Drugs,6.83,30,,6.83,percent of total billed charges,Drugs,6.83,30,,6.83,percent of total billed charges,Drugs,6.83,30,,6.83,percent of total billed charges,Drugs,6.83,30,,6.83,percent of total billed charges,Drugs,6.83,30,,6.83,percent of total billed charges,Drugs,6.83,30,,6.83,percent of total billed charges,Drugs,6.83,30,,6.83,percent of total billed charges,Drugs,6.83,30,,6.83,percent of total billed charges,Drugs,6.83,30,,6.83,percent of total billed charges,Drugs,6.83,30,,6.83,percent of total billed charges,Drugs,6.83,30,,6.83,percent of total billed charges,Drugs,6.83,30,,6.83,percent of total billed charges,Drugs,5,,,5,Other,Drug Cost,5,,,5,Other,Drug Cost,5,,,5,Other,Drug Cost,5,,,5,Other,Drug Cost,5,,,5,Other,Drug Cost,7.74,34,,7.74,percent of total billed charges,Drugs,5,,,5,Other,Drug Cost,11.25,,,11.25,Other,225% Medicaid APG methodology,7,,,7,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5,,,5,Other,Drug Cost,5,,,5,Other,Drug Cost,6.25,,,6.25,Other,125% Medicaid APG methodology,0.01,11.38,
ZIPRASIDONE 20 MG IM INJ        ,J3486,HCPCS,,40543662,CDM,636,RC,72266-0160-10,NDC,both,1,EA,39.52,96.25,,,96.25,Other,150% of Medicare + 9.63% HCRA Surcharge,58.53,,,58.53,Fee Schedule,Average Sale Price (ASP) x 6,11.86,30,,11.86,percent of total billed charges,Drugs,11.86,30,,11.86,percent of total billed charges,Drugs,11.86,30,,11.86,percent of total billed charges,Drugs,11.86,30,,11.86,percent of total billed charges,Drugs,11.86,30,,11.86,percent of total billed charges,Drugs,19.76,50,,19.76,percent of total billed charges,All Other,11.86,30,,11.86,percent of total billed charges,Drugs,11.86,30,,11.86,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,11.86,30,,11.86,percent of total billed charges,Drugs,11.86,30,,11.86,percent of total billed charges,Drugs,11.86,30,,11.86,percent of total billed charges,Drugs,11.86,30,,11.86,percent of total billed charges,Drugs,11.86,30,,11.86,percent of total billed charges,Drugs,11.86,30,,11.86,percent of total billed charges,Drugs,11.86,30,,11.86,percent of total billed charges,Drugs,11.86,30,,11.86,percent of total billed charges,Drugs,11.86,30,,11.86,percent of total billed charges,Drugs,11.86,30,,11.86,percent of total billed charges,Drugs,11.86,30,,11.86,percent of total billed charges,Drugs,11.86,30,,11.86,percent of total billed charges,Drugs,11.86,30,,11.86,percent of total billed charges,Drugs,12.39,,,12.39,Other,Drug Cost,12.39,,,12.39,Other,Drug Cost,12.39,,,12.39,Other,Drug Cost,12.39,,,12.39,Other,Drug Cost,12.39,,,12.39,Other,Drug Cost,13.44,34,,13.44,percent of total billed charges,Drugs,12.39,,,12.39,Other,Drug Cost,27.88,,,27.88,Other,225% Medicaid APG methodology,17.35,,,17.35,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,93.65,,,93.65,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",12.39,,,12.39,Other,Drug Cost,12.39,,,12.39,Other,Drug Cost,15.49,,,15.49,Other,125% Medicaid APG methodology,0.01,96.25,
EPINEPH 1MG/ML INJ SLN 30ML     ,J0171,HCPCS,,40544132,CDM,636,RC,42023-0168-01,NDC,both,30,ML,553.11,7.38,,,7.38,Other,150% of Medicare + 9.63% HCRA Surcharge,4.49,,,4.49,Fee Schedule,Average Sale Price (ASP) x 6,165.93,30,,165.93,percent of total billed charges,Drugs,165.93,30,,165.93,percent of total billed charges,Drugs,165.93,30,,165.93,percent of total billed charges,Drugs,165.93,30,,165.93,percent of total billed charges,Drugs,165.93,30,,165.93,percent of total billed charges,Drugs,276.56,50,,276.56,percent of total billed charges,All Other,165.93,30,,165.93,percent of total billed charges,Drugs,165.93,30,,165.93,percent of total billed charges,Drugs,188.06,34,"If Charge > 500, then 34 percent",188.06,percent of total billed charges,Drugs,165.93,30,,165.93,percent of total billed charges,Drugs,165.93,30,,165.93,percent of total billed charges,Drugs,165.93,30,,165.93,percent of total billed charges,Drugs,165.93,30,,165.93,percent of total billed charges,Drugs,165.93,30,,165.93,percent of total billed charges,Drugs,165.93,30,,165.93,percent of total billed charges,Drugs,165.93,30,,165.93,percent of total billed charges,Drugs,165.93,30,,165.93,percent of total billed charges,Drugs,165.93,30,,165.93,percent of total billed charges,Drugs,165.93,30,,165.93,percent of total billed charges,Drugs,165.93,30,,165.93,percent of total billed charges,Drugs,165.93,30,,165.93,percent of total billed charges,Drugs,165.93,30,,165.93,percent of total billed charges,Drugs,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,188.06,34,,188.06,percent of total billed charges,Drugs,0.27,,,0.27,Other,Drug Cost,0.61,,,0.61,Other,225% Medicaid APG methodology,0.38,,,0.38,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.18,,,7.18,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.27,,,0.27,Other,Drug Cost,0.27,,,0.27,Other,Drug Cost,0.34,,,0.34,Other,125% Medicaid APG methodology,0.01,276.56,
ERYTHROMYCIN LACTOB 500MG INJ   ,J1364,HCPCS,,40544611,CDM,636,RC,00409-6482-01,NDC,both,1,EA,249.8,796.98,,,796.98,Other,150% of Medicare + 9.63% HCRA Surcharge,484.65,,,484.65,Fee Schedule,Average Sale Price (ASP) x 6,74.94,30,,74.94,percent of total billed charges,Drugs,74.94,30,,74.94,percent of total billed charges,Drugs,74.94,30,,74.94,percent of total billed charges,Drugs,74.94,30,,74.94,percent of total billed charges,Drugs,74.94,30,,74.94,percent of total billed charges,Drugs,124.9,50,,124.9,percent of total billed charges,All Other,74.94,30,,74.94,percent of total billed charges,Drugs,74.94,30,,74.94,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,74.94,30,,74.94,percent of total billed charges,Drugs,74.94,30,,74.94,percent of total billed charges,Drugs,74.94,30,,74.94,percent of total billed charges,Drugs,74.94,30,,74.94,percent of total billed charges,Drugs,74.94,30,,74.94,percent of total billed charges,Drugs,74.94,30,,74.94,percent of total billed charges,Drugs,74.94,30,,74.94,percent of total billed charges,Drugs,74.94,30,,74.94,percent of total billed charges,Drugs,74.94,30,,74.94,percent of total billed charges,Drugs,74.94,30,,74.94,percent of total billed charges,Drugs,74.94,30,,74.94,percent of total billed charges,Drugs,74.94,30,,74.94,percent of total billed charges,Drugs,74.94,30,,74.94,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,84.93,34,,84.93,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,775.44,,,775.44,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,796.98,
PHENYLEPHRINE 1000MCG NS 10ML   ,J2371,HCPCS,,40544850,CDM,636,RC,70069-0801-25a,NDC,both,10,ML,16.21,6.4,39.4668,,6.4,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,8.11,50,,8.11,percent of total billed charges,All Other,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,4.63,,,4.63,Other,Drug Cost,4.63,,,4.63,Other,Drug Cost,4.63,,,4.63,Other,Drug Cost,4.63,,,4.63,Other,Drug Cost,4.63,,,4.63,Other,Drug Cost,5.51,34,,5.51,percent of total billed charges,Drugs,4.63,,,4.63,Other,Drug Cost,10.42,,,10.42,Other,225% Medicaid APG methodology,6.48,,,6.48,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.63,,,4.63,Other,Drug Cost,4.63,,,4.63,Other,Drug Cost,5.79,,,5.79,Other,125% Medicaid APG methodology,0.01,10.42,
ROMIPLOSTIM 250 MCG SUBCUT INJ  ,J2796,HCPCS,,40544900,CDM,636,RC,55513-0221-01,NDC,both,1,EA,8315.69,947.47,,,947.47,Other,150% of Medicare + 9.63% HCRA Surcharge,576.16,,,576.16,Fee Schedule,Average Sale Price (ASP) x 6,2494.71,30,,2494.71,percent of total billed charges,Drugs,2494.71,30,,2494.71,percent of total billed charges,Drugs,2494.71,30,,2494.71,percent of total billed charges,Drugs,2494.71,30,,2494.71,percent of total billed charges,Drugs,2494.71,30,,2494.71,percent of total billed charges,Drugs,4157.85,50,,4157.85,percent of total billed charges,All Other,2494.71,30,,2494.71,percent of total billed charges,Drugs,2494.71,30,,2494.71,percent of total billed charges,Drugs,2827.33,34,"If Charge > 500, then 34 percent",2827.33,percent of total billed charges,Drugs,2494.71,30,,2494.71,percent of total billed charges,Drugs,2494.71,30,,2494.71,percent of total billed charges,Drugs,2494.71,30,,2494.71,percent of total billed charges,Drugs,2494.71,30,,2494.71,percent of total billed charges,Drugs,2494.71,30,,2494.71,percent of total billed charges,Drugs,2494.71,30,,2494.71,percent of total billed charges,Drugs,2494.71,30,,2494.71,percent of total billed charges,Drugs,2494.71,30,,2494.71,percent of total billed charges,Drugs,2494.71,30,,2494.71,percent of total billed charges,Drugs,2494.71,30,,2494.71,percent of total billed charges,Drugs,2494.71,30,,2494.71,percent of total billed charges,Drugs,2494.71,30,,2494.71,percent of total billed charges,Drugs,2494.71,30,,2494.71,percent of total billed charges,Drugs,912.32,,,912.32,Other,Drug Cost,912.32,,,912.32,Other,Drug Cost,912.32,,,912.32,Other,Drug Cost,912.32,,,912.32,Other,Drug Cost,912.32,,,912.32,Other,Drug Cost,2827.33,34,,2827.33,percent of total billed charges,Drugs,912.32,,,912.32,Other,Drug Cost,2052.72,,,2052.72,Other,225% Medicaid APG methodology,1277.25,,,1277.25,Other,140% Medicaid APG methodology,2827.33,34,"If Charge > 2,000, then 34 percent",2827.33,percent of total billed charges,Drugs,921.86,,,921.86,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",912.32,,,912.32,Other,Drug Cost,912.32,,,912.32,Other,Drug Cost,1140.4,,,1140.4,Other,125% Medicaid APG methodology,0.01,4157.85,
DEXAMETHASONE 1 MG TAB          ,J8540,HCPCS,,40545121,CDM,636,RC,00054-4181-25,NDC,both,1,EA,0.74,0.82,,,0.82,Other,150% of Medicare + 9.63% HCRA Surcharge,0.5,,,0.5,Fee Schedule,Average Sale Price (ASP) x 6,0.22,30,,0.22,percent of total billed charges,Drugs,0.22,30,,0.22,percent of total billed charges,Drugs,0.22,30,,0.22,percent of total billed charges,Drugs,0.22,30,,0.22,percent of total billed charges,Drugs,0.22,30,,0.22,percent of total billed charges,Drugs,0.37,50,,0.37,percent of total billed charges,All Other,0.22,30,,0.22,percent of total billed charges,Drugs,0.22,30,,0.22,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.22,30,,0.22,percent of total billed charges,Drugs,0.22,30,,0.22,percent of total billed charges,Drugs,0.22,30,,0.22,percent of total billed charges,Drugs,0.22,30,,0.22,percent of total billed charges,Drugs,0.22,30,,0.22,percent of total billed charges,Drugs,0.22,30,,0.22,percent of total billed charges,Drugs,0.22,30,,0.22,percent of total billed charges,Drugs,0.22,30,,0.22,percent of total billed charges,Drugs,0.22,30,,0.22,percent of total billed charges,Drugs,0.22,30,,0.22,percent of total billed charges,Drugs,0.22,30,,0.22,percent of total billed charges,Drugs,0.22,30,,0.22,percent of total billed charges,Drugs,0.22,30,,0.22,percent of total billed charges,Drugs,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.25,34,,0.25,percent of total billed charges,Drugs,0.12,,,0.12,Other,Drug Cost,0.27,,,0.27,Other,225% Medicaid APG methodology,0.17,,,0.17,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.8,,,0.8,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.12,,,0.12,Other,Drug Cost,0.12,,,0.12,Other,Drug Cost,0.15,,,0.15,Other,125% Medicaid APG methodology,0.01,0.82,
DEXAMETHASONE 2 MG TAB          ,J8540,HCPCS,,40545139,CDM,636,RC,00054-4183-25,NDC,both,1,EA,1.47,0.82,,,0.82,Other,150% of Medicare + 9.63% HCRA Surcharge,0.5,,,0.5,Fee Schedule,Average Sale Price (ASP) x 6,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.74,50,,0.74,percent of total billed charges,All Other,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.44,30,,0.44,percent of total billed charges,Drugs,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.5,34,,0.5,percent of total billed charges,Drugs,0.26,,,0.26,Other,Drug Cost,0.59,,,0.59,Other,225% Medicaid APG methodology,0.36,,,0.36,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.8,,,0.8,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.26,,,0.26,Other,Drug Cost,0.26,,,0.26,Other,Drug Cost,0.33,,,0.33,Other,125% Medicaid APG methodology,0.01,0.82,
DEXAMETHASONE 10MG/MLPF INJ1ML  ,J1100,HCPCS,,40545154,CDM,636,RC,70069-0021-25,NDC,both,1,ML,8.72,1.17,,,1.17,Other,150% of Medicare + 9.63% HCRA Surcharge,0.71,,,0.71,Fee Schedule,Average Sale Price (ASP) x 6,2.62,30,,2.62,percent of total billed charges,Drugs,2.62,30,,2.62,percent of total billed charges,Drugs,2.62,30,,2.62,percent of total billed charges,Drugs,2.62,30,,2.62,percent of total billed charges,Drugs,2.62,30,,2.62,percent of total billed charges,Drugs,4.36,50,,4.36,percent of total billed charges,All Other,2.62,30,,2.62,percent of total billed charges,Drugs,2.62,30,,2.62,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.62,30,,2.62,percent of total billed charges,Drugs,2.62,30,,2.62,percent of total billed charges,Drugs,2.62,30,,2.62,percent of total billed charges,Drugs,2.62,30,,2.62,percent of total billed charges,Drugs,2.62,30,,2.62,percent of total billed charges,Drugs,2.62,30,,2.62,percent of total billed charges,Drugs,2.62,30,,2.62,percent of total billed charges,Drugs,2.62,30,,2.62,percent of total billed charges,Drugs,2.62,30,,2.62,percent of total billed charges,Drugs,2.62,30,,2.62,percent of total billed charges,Drugs,2.62,30,,2.62,percent of total billed charges,Drugs,2.62,30,,2.62,percent of total billed charges,Drugs,2.62,30,,2.62,percent of total billed charges,Drugs,2.27,,,2.27,Other,Drug Cost,2.27,,,2.27,Other,Drug Cost,2.27,,,2.27,Other,Drug Cost,2.27,,,2.27,Other,Drug Cost,2.27,,,2.27,Other,Drug Cost,2.96,34,,2.96,percent of total billed charges,Drugs,2.27,,,2.27,Other,Drug Cost,5.11,,,5.11,Other,225% Medicaid APG methodology,3.18,,,3.18,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.14,,,1.14,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.27,,,2.27,Other,Drug Cost,2.27,,,2.27,Other,Drug Cost,2.84,,,2.84,Other,125% Medicaid APG methodology,0.01,5.11,
CALCIUM GLUCONATE 50MG/ML D5W   ,J0612,HCPCS,,40545402,CDM,636,RC,63323-0360-19n,NDC,both,1,ML,3.01,0.49,,,0.49,Other,150% of Medicare + 9.63% HCRA Surcharge,0.3,,,0.3,Fee Schedule,Average Sale Price (ASP) x 6,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,1.51,50,,1.51,percent of total billed charges,All Other,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.9,30,,0.9,percent of total billed charges,Drugs,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,1.02,34,,1.02,percent of total billed charges,Drugs,0.1,,,0.1,Other,Drug Cost,0.23,,,0.23,Other,225% Medicaid APG methodology,0.14,,,0.14,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.48,,,0.48,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.1,,,0.1,Other,Drug Cost,0.1,,,0.1,Other,Drug Cost,0.13,,,0.13,Other,125% Medicaid APG methodology,0.01,1.51,
MAG SULF 10MG/ML IN D5W         ,J3475,HCPCS,,40545436,CDM,636,RC,63323-0064-03n,NDC,both,1,ML,0.04,6.82,,,6.82,Other,150% of Medicare + 9.63% HCRA Surcharge,4.15,,,4.15,Fee Schedule,Average Sale Price (ASP) x 6,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.02,50,,0.02,percent of total billed charges,All Other,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.63,,,6.63,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,6.82,
PACLITAXEL PROTEIN 100MG INJ    ,J9264,HCPCS,,40545592,CDM,636,RC,68817-0134-50,NDC,both,1,EA,5391.96,141.03,,,141.03,Other,150% of Medicare + 9.63% HCRA Surcharge,85.76,,,85.76,Fee Schedule,Average Sale Price (ASP) x 6,1617.59,30,,1617.59,percent of total billed charges,Drugs,1617.59,30,,1617.59,percent of total billed charges,Drugs,1617.59,30,,1617.59,percent of total billed charges,Drugs,1617.59,30,,1617.59,percent of total billed charges,Drugs,1617.59,30,,1617.59,percent of total billed charges,Drugs,2695.98,50,,2695.98,percent of total billed charges,All Other,1617.59,30,,1617.59,percent of total billed charges,Drugs,1617.59,30,,1617.59,percent of total billed charges,Drugs,1833.27,34,"If Charge > 500, then 34 percent",1833.27,percent of total billed charges,Drugs,1617.59,30,,1617.59,percent of total billed charges,Drugs,1617.59,30,,1617.59,percent of total billed charges,Drugs,1617.59,30,,1617.59,percent of total billed charges,Drugs,1617.59,30,,1617.59,percent of total billed charges,Drugs,1617.59,30,,1617.59,percent of total billed charges,Drugs,1617.59,30,,1617.59,percent of total billed charges,Drugs,1617.59,30,,1617.59,percent of total billed charges,Drugs,1617.59,30,,1617.59,percent of total billed charges,Drugs,1617.59,30,,1617.59,percent of total billed charges,Drugs,1617.59,30,,1617.59,percent of total billed charges,Drugs,1617.59,30,,1617.59,percent of total billed charges,Drugs,1617.59,30,,1617.59,percent of total billed charges,Drugs,1617.59,30,,1617.59,percent of total billed charges,Drugs,839.97,,,839.97,Other,Drug Cost,839.97,,,839.97,Other,Drug Cost,839.97,,,839.97,Other,Drug Cost,839.97,,,839.97,Other,Drug Cost,839.97,,,839.97,Other,Drug Cost,1833.27,34,,1833.27,percent of total billed charges,Drugs,839.97,,,839.97,Other,Drug Cost,1889.93,,,1889.93,Other,225% Medicaid APG methodology,1175.96,,,1175.96,Other,140% Medicaid APG methodology,1833.27,34,"If Charge > 2,000, then 34 percent",1833.27,percent of total billed charges,Drugs,137.22,,,137.22,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",839.97,,,839.97,Other,Drug Cost,839.97,,,839.97,Other,Drug Cost,1049.96,,,1049.96,Other,125% Medicaid APG methodology,0.01,2695.98,
FENTANYL 50 MCG/ML INJ  50ML    ,J3010,HCPCS,,40545642,CDM,636,RC,00409-9094-61,NDC,both,50,ML,13.06,9.55,,,9.55,Other,150% of Medicare + 9.63% HCRA Surcharge,5.81,,,5.81,Fee Schedule,Average Sale Price (ASP) x 6,3.92,30,,3.92,percent of total billed charges,Drugs,3.92,30,,3.92,percent of total billed charges,Drugs,3.92,30,,3.92,percent of total billed charges,Drugs,3.92,30,,3.92,percent of total billed charges,Drugs,3.92,30,,3.92,percent of total billed charges,Drugs,6.53,50,,6.53,percent of total billed charges,All Other,3.92,30,,3.92,percent of total billed charges,Drugs,3.92,30,,3.92,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.92,30,,3.92,percent of total billed charges,Drugs,3.92,30,,3.92,percent of total billed charges,Drugs,3.92,30,,3.92,percent of total billed charges,Drugs,3.92,30,,3.92,percent of total billed charges,Drugs,3.92,30,,3.92,percent of total billed charges,Drugs,3.92,30,,3.92,percent of total billed charges,Drugs,3.92,30,,3.92,percent of total billed charges,Drugs,3.92,30,,3.92,percent of total billed charges,Drugs,3.92,30,,3.92,percent of total billed charges,Drugs,3.92,30,,3.92,percent of total billed charges,Drugs,3.92,30,,3.92,percent of total billed charges,Drugs,3.92,30,,3.92,percent of total billed charges,Drugs,3.92,30,,3.92,percent of total billed charges,Drugs,10.23,,,10.23,Other,Drug Cost,10.23,,,10.23,Other,Drug Cost,10.23,,,10.23,Other,Drug Cost,10.23,,,10.23,Other,Drug Cost,10.23,,,10.23,Other,Drug Cost,4.44,34,,4.44,percent of total billed charges,Drugs,10.23,,,10.23,Other,Drug Cost,23.02,,,23.02,Other,225% Medicaid APG methodology,14.32,,,14.32,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,9.29,,,9.29,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",10.23,,,10.23,Other,Drug Cost,10.23,,,10.23,Other,Drug Cost,12.79,,,12.79,Other,125% Medicaid APG methodology,0.01,23.02,
ROPIVACAINE 0.5% INJ SOLN 20ML  ,J2795,HCPCS,,40545840,CDM,636,RC,55150-0197-20,NDC,both,20,ML,9.28,0.76,,,0.76,Other,150% of Medicare + 9.63% HCRA Surcharge,0.46,,,0.46,Fee Schedule,Average Sale Price (ASP) x 6,2.78,30,,2.78,percent of total billed charges,Drugs,2.78,30,,2.78,percent of total billed charges,Drugs,2.78,30,,2.78,percent of total billed charges,Drugs,2.78,30,,2.78,percent of total billed charges,Drugs,2.78,30,,2.78,percent of total billed charges,Drugs,4.64,50,,4.64,percent of total billed charges,All Other,2.78,30,,2.78,percent of total billed charges,Drugs,2.78,30,,2.78,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.78,30,,2.78,percent of total billed charges,Drugs,2.78,30,,2.78,percent of total billed charges,Drugs,2.78,30,,2.78,percent of total billed charges,Drugs,2.78,30,,2.78,percent of total billed charges,Drugs,2.78,30,,2.78,percent of total billed charges,Drugs,2.78,30,,2.78,percent of total billed charges,Drugs,2.78,30,,2.78,percent of total billed charges,Drugs,2.78,30,,2.78,percent of total billed charges,Drugs,2.78,30,,2.78,percent of total billed charges,Drugs,2.78,30,,2.78,percent of total billed charges,Drugs,2.78,30,,2.78,percent of total billed charges,Drugs,2.78,30,,2.78,percent of total billed charges,Drugs,2.78,30,,2.78,percent of total billed charges,Drugs,1.82,,,1.82,Other,Drug Cost,1.82,,,1.82,Other,Drug Cost,1.82,,,1.82,Other,Drug Cost,1.82,,,1.82,Other,Drug Cost,1.82,,,1.82,Other,Drug Cost,3.16,34,,3.16,percent of total billed charges,Drugs,1.82,,,1.82,Other,Drug Cost,4.1,,,4.1,Other,225% Medicaid APG methodology,2.55,,,2.55,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.74,,,0.74,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.82,,,1.82,Other,Drug Cost,1.82,,,1.82,Other,Drug Cost,2.28,,,2.28,Other,125% Medicaid APG methodology,0.01,4.64,
FLUCONAZOLE 50MG NACL IV 25ML   ,J1450,HCPCS,,40545899,CDM,636,RC,25021-0184-82b,NDC,both,25,ML,3.26,27.6,,,27.6,Other,150% of Medicare + 9.63% HCRA Surcharge,16.78,,,16.78,Fee Schedule,Average Sale Price (ASP) x 6,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,1.63,50,,1.63,percent of total billed charges,All Other,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.73,,,0.73,Other,Drug Cost,0.73,,,0.73,Other,Drug Cost,0.73,,,0.73,Other,Drug Cost,0.73,,,0.73,Other,Drug Cost,0.73,,,0.73,Other,Drug Cost,1.11,34,,1.11,percent of total billed charges,Drugs,0.73,,,0.73,Other,Drug Cost,1.64,,,1.64,Other,225% Medicaid APG methodology,1.02,,,1.02,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,26.85,,,26.85,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.73,,,0.73,Other,Drug Cost,0.73,,,0.73,Other,Drug Cost,0.91,,,0.91,Other,125% Medicaid APG methodology,0.01,27.6,
GLYCOPYRROLATE 0.2MG/ML INJ1ML  ,J3490,HCPCS,,40545964,CDM,636,RC,70860-0781-01,NDC,both,1,ML,2.03,0.8,39.4668,,0.8,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.61,30,,0.61,percent of total billed charges,Drugs,0.61,30,,0.61,percent of total billed charges,Drugs,0.61,30,,0.61,percent of total billed charges,Drugs,0.61,30,,0.61,percent of total billed charges,Drugs,0.61,30,,0.61,percent of total billed charges,Drugs,1.02,50,,1.02,percent of total billed charges,All Other,0.61,30,,0.61,percent of total billed charges,Drugs,0.61,30,,0.61,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.61,30,,0.61,percent of total billed charges,Drugs,0.61,30,,0.61,percent of total billed charges,Drugs,0.61,30,,0.61,percent of total billed charges,Drugs,0.61,30,,0.61,percent of total billed charges,Drugs,0.61,30,,0.61,percent of total billed charges,Drugs,0.61,30,,0.61,percent of total billed charges,Drugs,0.61,30,,0.61,percent of total billed charges,Drugs,0.61,30,,0.61,percent of total billed charges,Drugs,0.61,30,,0.61,percent of total billed charges,Drugs,0.61,30,,0.61,percent of total billed charges,Drugs,0.61,30,,0.61,percent of total billed charges,Drugs,0.61,30,,0.61,percent of total billed charges,Drugs,0.61,30,,0.61,percent of total billed charges,Drugs,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.69,34,,0.69,percent of total billed charges,Drugs,0.51,,,0.51,Other,Drug Cost,1.15,,,1.15,Other,225% Medicaid APG methodology,0.71,,,0.71,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.51,,,0.51,Other,Drug Cost,0.51,,,0.51,Other,Drug Cost,0.64,,,0.64,Other,125% Medicaid APG methodology,0.01,1.15,
ZOLEDRONIC ACID 4MG/5ML IV 5ML  ,J3489,HCPCS,,40545980,CDM,636,RC,55111-0685-07,NDC,both,5,ML,42.32,71.17,,,71.17,Other,150% of Medicare + 9.63% HCRA Surcharge,43.28,,,43.28,Fee Schedule,Average Sale Price (ASP) x 6,12.7,30,,12.7,percent of total billed charges,Drugs,12.7,30,,12.7,percent of total billed charges,Drugs,12.7,30,,12.7,percent of total billed charges,Drugs,12.7,30,,12.7,percent of total billed charges,Drugs,12.7,30,,12.7,percent of total billed charges,Drugs,21.16,50,,21.16,percent of total billed charges,All Other,12.7,30,,12.7,percent of total billed charges,Drugs,12.7,30,,12.7,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,12.7,30,,12.7,percent of total billed charges,Drugs,12.7,30,,12.7,percent of total billed charges,Drugs,12.7,30,,12.7,percent of total billed charges,Drugs,12.7,30,,12.7,percent of total billed charges,Drugs,12.7,30,,12.7,percent of total billed charges,Drugs,12.7,30,,12.7,percent of total billed charges,Drugs,12.7,30,,12.7,percent of total billed charges,Drugs,12.7,30,,12.7,percent of total billed charges,Drugs,12.7,30,,12.7,percent of total billed charges,Drugs,12.7,30,,12.7,percent of total billed charges,Drugs,12.7,30,,12.7,percent of total billed charges,Drugs,12.7,30,,12.7,percent of total billed charges,Drugs,12.7,30,,12.7,percent of total billed charges,Drugs,3.72,,,3.72,Other,Drug Cost,3.72,,,3.72,Other,Drug Cost,3.72,,,3.72,Other,Drug Cost,3.72,,,3.72,Other,Drug Cost,3.72,,,3.72,Other,Drug Cost,14.39,34,,14.39,percent of total billed charges,Drugs,3.72,,,3.72,Other,Drug Cost,8.37,,,8.37,Other,225% Medicaid APG methodology,5.21,,,5.21,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,69.24,,,69.24,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.72,,,3.72,Other,Drug Cost,3.72,,,3.72,Other,Drug Cost,4.65,,,4.65,Other,125% Medicaid APG methodology,0.01,71.17,
"IODIXANOL 320 150ML, P 1ML      ",Q9967,HCPCS,,40546376,CDM,636,RC,00407-2223-19,NDC,both,150,ML,176.19,1.16,,,1.16,Other,150% of Medicare + 9.63% HCRA Surcharge,0.71,,,0.71,Fee Schedule,Average Sale Price (ASP) x 6,52.86,30,,52.86,percent of total billed charges,Drugs,52.86,30,,52.86,percent of total billed charges,Drugs,52.86,30,,52.86,percent of total billed charges,Drugs,52.86,30,,52.86,percent of total billed charges,Drugs,52.86,30,,52.86,percent of total billed charges,Drugs,88.1,50,,88.1,percent of total billed charges,All Other,52.86,30,,52.86,percent of total billed charges,Drugs,52.86,30,,52.86,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,52.86,30,,52.86,percent of total billed charges,Drugs,52.86,30,,52.86,percent of total billed charges,Drugs,52.86,30,,52.86,percent of total billed charges,Drugs,52.86,30,,52.86,percent of total billed charges,Drugs,52.86,30,,52.86,percent of total billed charges,Drugs,52.86,30,,52.86,percent of total billed charges,Drugs,52.86,30,,52.86,percent of total billed charges,Drugs,52.86,30,,52.86,percent of total billed charges,Drugs,52.86,30,,52.86,percent of total billed charges,Drugs,52.86,30,,52.86,percent of total billed charges,Drugs,52.86,30,,52.86,percent of total billed charges,Drugs,52.86,30,,52.86,percent of total billed charges,Drugs,52.86,30,,52.86,percent of total billed charges,Drugs,41.33,,,41.33,Other,Drug Cost,41.33,,,41.33,Other,Drug Cost,41.33,,,41.33,Other,Drug Cost,41.33,,,41.33,Other,Drug Cost,41.33,,,41.33,Other,Drug Cost,59.9,34,,59.9,percent of total billed charges,Drugs,41.33,,,41.33,Other,Drug Cost,92.99,,,92.99,Other,225% Medicaid APG methodology,57.86,,,57.86,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.13,,,1.13,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",41.33,,,41.33,Other,Drug Cost,41.33,,,41.33,Other,Drug Cost,51.66,,,51.66,Other,125% Medicaid APG methodology,0.01,92.99,
DIATRIZ MEG-SOD 66%-10% 30ML    ,Q9963,HCPCS,,40546384,CDM,636,RC,00270-0445-35,NDC,both,30,ML,23.8,2.07,,,2.07,Other,150% of Medicare + 9.63% HCRA Surcharge,1.26,,,1.26,Fee Schedule,Average Sale Price (ASP) x 6,7.14,30,,7.14,percent of total billed charges,Drugs,7.14,30,,7.14,percent of total billed charges,Drugs,7.14,30,,7.14,percent of total billed charges,Drugs,7.14,30,,7.14,percent of total billed charges,Drugs,7.14,30,,7.14,percent of total billed charges,Drugs,11.9,50,,11.9,percent of total billed charges,All Other,7.14,30,,7.14,percent of total billed charges,Drugs,7.14,30,,7.14,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,7.14,30,,7.14,percent of total billed charges,Drugs,7.14,30,,7.14,percent of total billed charges,Drugs,7.14,30,,7.14,percent of total billed charges,Drugs,7.14,30,,7.14,percent of total billed charges,Drugs,7.14,30,,7.14,percent of total billed charges,Drugs,7.14,30,,7.14,percent of total billed charges,Drugs,7.14,30,,7.14,percent of total billed charges,Drugs,7.14,30,,7.14,percent of total billed charges,Drugs,7.14,30,,7.14,percent of total billed charges,Drugs,7.14,30,,7.14,percent of total billed charges,Drugs,7.14,30,,7.14,percent of total billed charges,Drugs,7.14,30,,7.14,percent of total billed charges,Drugs,7.14,30,,7.14,percent of total billed charges,Drugs,16.06,,,16.06,Other,Drug Cost,16.06,,,16.06,Other,Drug Cost,16.06,,,16.06,Other,Drug Cost,16.06,,,16.06,Other,Drug Cost,16.06,,,16.06,Other,Drug Cost,8.09,34,,8.09,percent of total billed charges,Drugs,16.06,,,16.06,Other,Drug Cost,36.14,,,36.14,Other,225% Medicaid APG methodology,22.48,,,22.48,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.02,,,2.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",16.06,,,16.06,Other,Drug Cost,16.06,,,16.06,Other,Drug Cost,20.08,,,20.08,Other,125% Medicaid APG methodology,0.01,36.14,
MORPHINE 375 MCG IN D5W15ML     ,J2270,HCPCS,,40546533,CDM,636,RC,76045-0004-10z,NDC,both,15,ML,0.18,46.03,,,46.03,Other,150% of Medicare + 9.63% HCRA Surcharge,27.99,,,27.99,Fee Schedule,Average Sale Price (ASP) x 6,0.05,30,,0.05,percent of total billed charges,Drugs,0.05,30,,0.05,percent of total billed charges,Drugs,0.05,30,,0.05,percent of total billed charges,Drugs,0.05,30,,0.05,percent of total billed charges,Drugs,0.05,30,,0.05,percent of total billed charges,Drugs,0.09,50,,0.09,percent of total billed charges,All Other,0.05,30,,0.05,percent of total billed charges,Drugs,0.05,30,,0.05,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.05,30,,0.05,percent of total billed charges,Drugs,0.05,30,,0.05,percent of total billed charges,Drugs,0.05,30,,0.05,percent of total billed charges,Drugs,0.05,30,,0.05,percent of total billed charges,Drugs,0.05,30,,0.05,percent of total billed charges,Drugs,0.05,30,,0.05,percent of total billed charges,Drugs,0.05,30,,0.05,percent of total billed charges,Drugs,0.05,30,,0.05,percent of total billed charges,Drugs,0.05,30,,0.05,percent of total billed charges,Drugs,0.05,30,,0.05,percent of total billed charges,Drugs,0.05,30,,0.05,percent of total billed charges,Drugs,0.05,30,,0.05,percent of total billed charges,Drugs,0.05,30,,0.05,percent of total billed charges,Drugs,3.75,,,3.75,Other,Drug Cost,3.75,,,3.75,Other,Drug Cost,3.75,,,3.75,Other,Drug Cost,3.75,,,3.75,Other,Drug Cost,3.75,,,3.75,Other,Drug Cost,0.06,34,,0.06,percent of total billed charges,Drugs,3.75,,,3.75,Other,Drug Cost,8.44,,,8.44,Other,225% Medicaid APG methodology,5.25,,,5.25,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,44.78,,,44.78,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.75,,,3.75,Other,Drug Cost,3.75,,,3.75,Other,Drug Cost,4.69,,,4.69,Other,125% Medicaid APG methodology,0.01,46.03,
MORPHINE 750 MCG IN D5W15ML     ,J2270,HCPCS,,40546541,CDM,636,RC,76045-0004-10w,NDC,both,15,ML,0.04,46.03,,,46.03,Other,150% of Medicare + 9.63% HCRA Surcharge,27.99,,,27.99,Fee Schedule,Average Sale Price (ASP) x 6,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.02,50,,0.02,percent of total billed charges,All Other,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,34,,0.01,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,44.78,,,44.78,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,46.03,
TEMSIROLIMUS 25MG/ML IV  1ML    ,J9330,HCPCS,,40546657,CDM,636,RC,00008-1179-01,NDC,both,1,ML,6068.93,305.8,,,305.8,Other,150% of Medicare + 9.63% HCRA Surcharge,185.96,,,185.96,Fee Schedule,Average Sale Price (ASP) x 6,1820.68,30,,1820.68,percent of total billed charges,Drugs,1820.68,30,,1820.68,percent of total billed charges,Drugs,1820.68,30,,1820.68,percent of total billed charges,Drugs,1820.68,30,,1820.68,percent of total billed charges,Drugs,1820.68,30,,1820.68,percent of total billed charges,Drugs,3034.47,50,,3034.47,percent of total billed charges,All Other,1820.68,30,,1820.68,percent of total billed charges,Drugs,1820.68,30,,1820.68,percent of total billed charges,Drugs,2063.44,34,"If Charge > 500, then 34 percent",2063.44,percent of total billed charges,Drugs,1820.68,30,,1820.68,percent of total billed charges,Drugs,1820.68,30,,1820.68,percent of total billed charges,Drugs,1820.68,30,,1820.68,percent of total billed charges,Drugs,1820.68,30,,1820.68,percent of total billed charges,Drugs,1820.68,30,,1820.68,percent of total billed charges,Drugs,1820.68,30,,1820.68,percent of total billed charges,Drugs,1820.68,30,,1820.68,percent of total billed charges,Drugs,1820.68,30,,1820.68,percent of total billed charges,Drugs,1820.68,30,,1820.68,percent of total billed charges,Drugs,1820.68,30,,1820.68,percent of total billed charges,Drugs,1820.68,30,,1820.68,percent of total billed charges,Drugs,1820.68,30,,1820.68,percent of total billed charges,Drugs,1820.68,30,,1820.68,percent of total billed charges,Drugs,1006.86,,,1006.86,Other,Drug Cost,1006.86,,,1006.86,Other,Drug Cost,1006.86,,,1006.86,Other,Drug Cost,1006.86,,,1006.86,Other,Drug Cost,1006.86,,,1006.86,Other,Drug Cost,2063.44,34,,2063.44,percent of total billed charges,Drugs,1006.86,,,1006.86,Other,Drug Cost,2265.44,,,2265.44,Other,225% Medicaid APG methodology,1409.6,,,1409.6,Other,140% Medicaid APG methodology,2063.44,34,"If Charge > 2,000, then 34 percent",2063.44,percent of total billed charges,Drugs,297.53,,,297.53,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1006.86,,,1006.86,Other,Drug Cost,1006.86,,,1006.86,Other,Drug Cost,1258.58,,,1258.58,Other,125% Medicaid APG methodology,0.01,3034.47,
PHENOBARBITAL 130MG/ML INJ 1ML  ,J2560,HCPCS,,40546715,CDM,636,RC,00641-0477-25,NDC,both,1,ML,166.88,310.13,,,310.13,Other,150% of Medicare + 9.63% HCRA Surcharge,188.59,,,188.59,Fee Schedule,Average Sale Price (ASP) x 6,50.06,30,,50.06,percent of total billed charges,Drugs,50.06,30,,50.06,percent of total billed charges,Drugs,50.06,30,,50.06,percent of total billed charges,Drugs,50.06,30,,50.06,percent of total billed charges,Drugs,50.06,30,,50.06,percent of total billed charges,Drugs,83.44,50,,83.44,percent of total billed charges,All Other,50.06,30,,50.06,percent of total billed charges,Drugs,50.06,30,,50.06,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,50.06,30,,50.06,percent of total billed charges,Drugs,50.06,30,,50.06,percent of total billed charges,Drugs,50.06,30,,50.06,percent of total billed charges,Drugs,50.06,30,,50.06,percent of total billed charges,Drugs,50.06,30,,50.06,percent of total billed charges,Drugs,50.06,30,,50.06,percent of total billed charges,Drugs,50.06,30,,50.06,percent of total billed charges,Drugs,50.06,30,,50.06,percent of total billed charges,Drugs,50.06,30,,50.06,percent of total billed charges,Drugs,50.06,30,,50.06,percent of total billed charges,Drugs,50.06,30,,50.06,percent of total billed charges,Drugs,50.06,30,,50.06,percent of total billed charges,Drugs,50.06,30,,50.06,percent of total billed charges,Drugs,23.32,,,23.32,Other,Drug Cost,23.32,,,23.32,Other,Drug Cost,23.32,,,23.32,Other,Drug Cost,23.32,,,23.32,Other,Drug Cost,23.32,,,23.32,Other,Drug Cost,56.74,34,,56.74,percent of total billed charges,Drugs,23.32,,,23.32,Other,Drug Cost,52.47,,,52.47,Other,225% Medicaid APG methodology,32.65,,,32.65,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,301.75,,,301.75,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",23.32,,,23.32,Other,Drug Cost,23.32,,,23.32,Other,Drug Cost,29.15,,,29.15,Other,125% Medicaid APG methodology,0.01,310.13,
LEUPROLIDE 22.5MG/3  IM KIT     ,J9217,HCPCS,,40546731,CDM,636,RC,00074-3346-03,NDC,both,1,EA,18981.45,1788.85,,,1788.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1087.81,,,1087.81,Fee Schedule,Average Sale Price (ASP) x 6,5694.44,30,,5694.44,percent of total billed charges,Drugs,5694.44,30,,5694.44,percent of total billed charges,Drugs,5694.44,30,,5694.44,percent of total billed charges,Drugs,5694.44,30,,5694.44,percent of total billed charges,Drugs,5694.44,30,,5694.44,percent of total billed charges,Drugs,9490.73,50,,9490.73,percent of total billed charges,All Other,5694.44,30,,5694.44,percent of total billed charges,Drugs,5694.44,30,,5694.44,percent of total billed charges,Drugs,6453.69,34,"If Charge > 500, then 34 percent",6453.69,percent of total billed charges,Drugs,5694.44,30,,5694.44,percent of total billed charges,Drugs,5694.44,30,,5694.44,percent of total billed charges,Drugs,5694.44,30,,5694.44,percent of total billed charges,Drugs,5694.44,30,,5694.44,percent of total billed charges,Drugs,5694.44,30,,5694.44,percent of total billed charges,Drugs,5694.44,30,,5694.44,percent of total billed charges,Drugs,5694.44,30,,5694.44,percent of total billed charges,Drugs,5694.44,30,,5694.44,percent of total billed charges,Drugs,5694.44,30,,5694.44,percent of total billed charges,Drugs,5694.44,30,,5694.44,percent of total billed charges,Drugs,5694.44,30,,5694.44,percent of total billed charges,Drugs,5694.44,30,,5694.44,percent of total billed charges,Drugs,5694.44,30,,5694.44,percent of total billed charges,Drugs,299.01,,,299.01,Other,Drug Cost,299.01,,,299.01,Other,Drug Cost,299.01,,,299.01,Other,Drug Cost,299.01,,,299.01,Other,Drug Cost,299.01,,,299.01,Other,Drug Cost,6453.69,34,,6453.69,percent of total billed charges,Drugs,299.01,,,299.01,Other,Drug Cost,672.77,,,672.77,Other,225% Medicaid APG methodology,418.61,,,418.61,Other,140% Medicaid APG methodology,6453.69,34,"If Charge > 2,000, then 34 percent",6453.69,percent of total billed charges,Drugs,1740.5,,,1740.5,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",299.01,,,299.01,Other,Drug Cost,299.01,,,299.01,Other,Drug Cost,373.76,,,373.76,Other,125% Medicaid APG methodology,0.01,9490.73,
EPIRUBICIN 2MG/ML IV SOLN 25ML  ,J9178,HCPCS,,40546814,CDM,636,RC,00009-5091-01,NDC,both,25,ML,100.84,13.62,,,13.62,Other,150% of Medicare + 9.63% HCRA Surcharge,8.28,,,8.28,Fee Schedule,Average Sale Price (ASP) x 6,30.25,30,,30.25,percent of total billed charges,Drugs,30.25,30,,30.25,percent of total billed charges,Drugs,30.25,30,,30.25,percent of total billed charges,Drugs,30.25,30,,30.25,percent of total billed charges,Drugs,30.25,30,,30.25,percent of total billed charges,Drugs,50.42,50,,50.42,percent of total billed charges,All Other,30.25,30,,30.25,percent of total billed charges,Drugs,30.25,30,,30.25,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,30.25,30,,30.25,percent of total billed charges,Drugs,30.25,30,,30.25,percent of total billed charges,Drugs,30.25,30,,30.25,percent of total billed charges,Drugs,30.25,30,,30.25,percent of total billed charges,Drugs,30.25,30,,30.25,percent of total billed charges,Drugs,30.25,30,,30.25,percent of total billed charges,Drugs,30.25,30,,30.25,percent of total billed charges,Drugs,30.25,30,,30.25,percent of total billed charges,Drugs,30.25,30,,30.25,percent of total billed charges,Drugs,30.25,30,,30.25,percent of total billed charges,Drugs,30.25,30,,30.25,percent of total billed charges,Drugs,30.25,30,,30.25,percent of total billed charges,Drugs,30.25,30,,30.25,percent of total billed charges,Drugs,16.07,,,16.07,Other,Drug Cost,16.07,,,16.07,Other,Drug Cost,16.07,,,16.07,Other,Drug Cost,16.07,,,16.07,Other,Drug Cost,16.07,,,16.07,Other,Drug Cost,34.29,34,,34.29,percent of total billed charges,Drugs,16.07,,,16.07,Other,Drug Cost,36.16,,,36.16,Other,225% Medicaid APG methodology,22.5,,,22.5,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,13.25,,,13.25,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",16.07,,,16.07,Other,Drug Cost,16.07,,,16.07,Other,Drug Cost,20.09,,,20.09,Other,125% Medicaid APG methodology,0.01,50.42,
BENDAMUSTINE 25MG/ML IV SLN4ML  ,J9034,HCPCS,,40546863,CDM,636,RC,63459-0348-04,NDC,both,4,ML,5740.46,145.59,,,145.59,Other,150% of Medicare + 9.63% HCRA Surcharge,88.54,,,88.54,Fee Schedule,Average Sale Price (ASP) x 6,1722.14,30,,1722.14,percent of total billed charges,Drugs,1722.14,30,,1722.14,percent of total billed charges,Drugs,1722.14,30,,1722.14,percent of total billed charges,Drugs,1722.14,30,,1722.14,percent of total billed charges,Drugs,1722.14,30,,1722.14,percent of total billed charges,Drugs,2870.23,50,,2870.23,percent of total billed charges,All Other,1722.14,30,,1722.14,percent of total billed charges,Drugs,1722.14,30,,1722.14,percent of total billed charges,Drugs,1951.76,34,"If Charge > 500, then 34 percent",1951.76,percent of total billed charges,Drugs,1722.14,30,,1722.14,percent of total billed charges,Drugs,1722.14,30,,1722.14,percent of total billed charges,Drugs,1722.14,30,,1722.14,percent of total billed charges,Drugs,1722.14,30,,1722.14,percent of total billed charges,Drugs,1722.14,30,,1722.14,percent of total billed charges,Drugs,1722.14,30,,1722.14,percent of total billed charges,Drugs,1722.14,30,,1722.14,percent of total billed charges,Drugs,1722.14,30,,1722.14,percent of total billed charges,Drugs,1722.14,30,,1722.14,percent of total billed charges,Drugs,1722.14,30,,1722.14,percent of total billed charges,Drugs,1722.14,30,,1722.14,percent of total billed charges,Drugs,1722.14,30,,1722.14,percent of total billed charges,Drugs,1722.14,30,,1722.14,percent of total billed charges,Drugs,1180.38,,,1180.38,Other,Drug Cost,1180.38,,,1180.38,Other,Drug Cost,1180.38,,,1180.38,Other,Drug Cost,1180.38,,,1180.38,Other,Drug Cost,1180.38,,,1180.38,Other,Drug Cost,1951.76,34,,1951.76,percent of total billed charges,Drugs,1180.38,,,1180.38,Other,Drug Cost,2655.86,,,2655.86,Other,225% Medicaid APG methodology,1652.53,,,1652.53,Other,140% Medicaid APG methodology,1951.76,34,"If Charge > 2,000, then 34 percent",1951.76,percent of total billed charges,Drugs,141.66,,,141.66,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1180.38,,,1180.38,Other,Drug Cost,1180.38,,,1180.38,Other,Drug Cost,1475.48,,,1475.48,Other,125% Medicaid APG methodology,0.01,2870.23,
ADACEL TDAP IM SUSP 0.5ML       ,90715,CPT,,40546897,CDM,636,RC,49281-0400-20,NDC,both,0.5,ML,34.2,377.94,,,377.94,Other,150% of Medicare + 9.63% HCRA Surcharge,229.83,,,229.83,Fee Schedule,Average Sale Price (ASP) x 6,10.26,30,,10.26,percent of total billed charges,Drugs,10.26,30,,10.26,percent of total billed charges,Drugs,10.26,30,,10.26,percent of total billed charges,Drugs,10.26,30,,10.26,percent of total billed charges,Drugs,10.26,30,,10.26,percent of total billed charges,Drugs,17.1,50,,17.1,percent of total billed charges,All Other,10.26,30,,10.26,percent of total billed charges,Drugs,10.26,30,,10.26,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,10.26,30,,10.26,percent of total billed charges,Drugs,10.26,30,,10.26,percent of total billed charges,Drugs,10.26,30,,10.26,percent of total billed charges,Drugs,10.26,30,,10.26,percent of total billed charges,Drugs,10.26,30,,10.26,percent of total billed charges,Drugs,10.26,30,,10.26,percent of total billed charges,Drugs,10.26,30,,10.26,percent of total billed charges,Drugs,10.26,30,,10.26,percent of total billed charges,Drugs,10.26,30,,10.26,percent of total billed charges,Drugs,10.26,30,,10.26,percent of total billed charges,Drugs,10.26,30,,10.26,percent of total billed charges,Drugs,10.26,30,,10.26,percent of total billed charges,Drugs,10.26,30,,10.26,percent of total billed charges,Drugs,8.78,,,8.78,Other,Drug Cost,8.78,,,8.78,Other,Drug Cost,8.78,,,8.78,Other,Drug Cost,8.78,,,8.78,Other,Drug Cost,8.78,,,8.78,Other,Drug Cost,11.63,34,,11.63,percent of total billed charges,Drugs,8.78,,,8.78,Other,Drug Cost,19.76,,,19.76,Other,225% Medicaid APG methodology,12.29,,,12.29,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,367.73,,,367.73,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",8.78,,,8.78,Other,Drug Cost,8.78,,,8.78,Other,Drug Cost,10.98,,,10.98,Other,125% Medicaid APG methodology,0.01,377.94,
ABRYSVO RSV VACCINE PF 0.5 ML   ,90678,CPT,,40547127,CDM,636,RC,00069-0344-05,NDC,both,1,EA,948.99,374.54,39.4668,,374.54,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,284.7,30,,284.7,percent of total billed charges,Drugs,284.7,30,,284.7,percent of total billed charges,Drugs,284.7,30,,284.7,percent of total billed charges,Drugs,284.7,30,,284.7,percent of total billed charges,Drugs,284.7,30,,284.7,percent of total billed charges,Drugs,474.5,50,,474.5,percent of total billed charges,All Other,284.7,30,,284.7,percent of total billed charges,Drugs,284.7,30,,284.7,percent of total billed charges,Drugs,322.66,34,"If Charge > 500, then 34 percent",322.66,percent of total billed charges,Drugs,284.7,30,,284.7,percent of total billed charges,Drugs,284.7,30,,284.7,percent of total billed charges,Drugs,284.7,30,,284.7,percent of total billed charges,Drugs,284.7,30,,284.7,percent of total billed charges,Drugs,284.7,30,,284.7,percent of total billed charges,Drugs,284.7,30,,284.7,percent of total billed charges,Drugs,284.7,30,,284.7,percent of total billed charges,Drugs,284.7,30,,284.7,percent of total billed charges,Drugs,284.7,30,,284.7,percent of total billed charges,Drugs,284.7,30,,284.7,percent of total billed charges,Drugs,284.7,30,,284.7,percent of total billed charges,Drugs,284.7,30,,284.7,percent of total billed charges,Drugs,284.7,30,,284.7,percent of total billed charges,Drugs,286.3,,,286.3,Other,Drug Cost,286.3,,,286.3,Other,Drug Cost,286.3,,,286.3,Other,Drug Cost,286.3,,,286.3,Other,Drug Cost,286.3,,,286.3,Other,Drug Cost,322.66,34,,322.66,percent of total billed charges,Drugs,286.3,,,286.3,Other,Drug Cost,644.18,,,644.18,Other,225% Medicaid APG methodology,400.82,,,400.82,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",286.3,,,286.3,Other,Drug Cost,286.3,,,286.3,Other,Drug Cost,357.88,,,357.88,Other,125% Medicaid APG methodology,0.01,644.18,
AREXVY RSV VACCINE 0.5 ML       ,90679,CPT,,40547150,CDM,636,RC,58160-0848-11,NDC,both,0.5,ML,445.83,175.95,39.4668,,175.95,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,133.75,30,,133.75,percent of total billed charges,Drugs,133.75,30,,133.75,percent of total billed charges,Drugs,133.75,30,,133.75,percent of total billed charges,Drugs,133.75,30,,133.75,percent of total billed charges,Drugs,133.75,30,,133.75,percent of total billed charges,Drugs,222.92,50,,222.92,percent of total billed charges,All Other,133.75,30,,133.75,percent of total billed charges,Drugs,133.75,30,,133.75,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,133.75,30,,133.75,percent of total billed charges,Drugs,133.75,30,,133.75,percent of total billed charges,Drugs,133.75,30,,133.75,percent of total billed charges,Drugs,133.75,30,,133.75,percent of total billed charges,Drugs,133.75,30,,133.75,percent of total billed charges,Drugs,133.75,30,,133.75,percent of total billed charges,Drugs,133.75,30,,133.75,percent of total billed charges,Drugs,133.75,30,,133.75,percent of total billed charges,Drugs,133.75,30,,133.75,percent of total billed charges,Drugs,133.75,30,,133.75,percent of total billed charges,Drugs,133.75,30,,133.75,percent of total billed charges,Drugs,133.75,30,,133.75,percent of total billed charges,Drugs,133.75,30,,133.75,percent of total billed charges,Drugs,127.38,,,127.38,Other,Drug Cost,127.38,,,127.38,Other,Drug Cost,127.38,,,127.38,Other,Drug Cost,127.38,,,127.38,Other,Drug Cost,127.38,,,127.38,Other,Drug Cost,151.58,34,,151.58,percent of total billed charges,Drugs,127.38,,,127.38,Other,Drug Cost,286.61,,,286.61,Other,225% Medicaid APG methodology,178.33,,,178.33,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",127.38,,,127.38,Other,Drug Cost,127.38,,,127.38,Other,Drug Cost,159.23,,,159.23,Other,125% Medicaid APG methodology,0.01,286.61,
MEPOLIZUMAB 100 MG/ML SYR 1 ML  ,J2182,HCPCS,,40547689,CDM,636,RC,00173-0892-01,NDC,both,1,ML,12857.99,300.98,,,300.98,Other,150% of Medicare + 9.63% HCRA Surcharge,183.03,,,183.03,Fee Schedule,Average Sale Price (ASP) x 6,3857.4,30,,3857.4,percent of total billed charges,Drugs,3857.4,30,,3857.4,percent of total billed charges,Drugs,3857.4,30,,3857.4,percent of total billed charges,Drugs,3857.4,30,,3857.4,percent of total billed charges,Drugs,3857.4,30,,3857.4,percent of total billed charges,Drugs,6429,50,,6429,percent of total billed charges,All Other,3857.4,30,,3857.4,percent of total billed charges,Drugs,3857.4,30,,3857.4,percent of total billed charges,Drugs,4371.72,34,"If Charge > 500, then 34 percent",4371.72,percent of total billed charges,Drugs,3857.4,30,,3857.4,percent of total billed charges,Drugs,3857.4,30,,3857.4,percent of total billed charges,Drugs,3857.4,30,,3857.4,percent of total billed charges,Drugs,3857.4,30,,3857.4,percent of total billed charges,Drugs,3857.4,30,,3857.4,percent of total billed charges,Drugs,3857.4,30,,3857.4,percent of total billed charges,Drugs,3857.4,30,,3857.4,percent of total billed charges,Drugs,3857.4,30,,3857.4,percent of total billed charges,Drugs,3857.4,30,,3857.4,percent of total billed charges,Drugs,3857.4,30,,3857.4,percent of total billed charges,Drugs,3857.4,30,,3857.4,percent of total billed charges,Drugs,3857.4,30,,3857.4,percent of total billed charges,Drugs,3857.4,30,,3857.4,percent of total billed charges,Drugs,2439.31,,,2439.31,Other,Drug Cost,2439.31,,,2439.31,Other,Drug Cost,2439.31,,,2439.31,Other,Drug Cost,2439.31,,,2439.31,Other,Drug Cost,2439.31,,,2439.31,Other,Drug Cost,4371.72,34,,4371.72,percent of total billed charges,Drugs,2439.31,,,2439.31,Other,Drug Cost,5488.45,,,5488.45,Other,225% Medicaid APG methodology,3415.03,,,3415.03,Other,140% Medicaid APG methodology,4371.72,34,"If Charge > 2,000, then 34 percent",4371.72,percent of total billed charges,Drugs,292.85,,,292.85,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2439.31,,,2439.31,Other,Drug Cost,2439.31,,,2439.31,Other,Drug Cost,3049.14,,,3049.14,Other,125% Medicaid APG methodology,0.01,6429,
HYDROMORPHONE 0.5MG/0.5ML INJ   ,J1170,HCPCS,,40570350,CDM,636,RC,00409-4264-01,NDC,both,0.5,ML,10.15,45.3,,,45.3,Other,150% of Medicare + 9.63% HCRA Surcharge,27.55,,,27.55,Fee Schedule,Average Sale Price (ASP) x 6,3.05,30,,3.05,percent of total billed charges,Drugs,3.05,30,,3.05,percent of total billed charges,Drugs,3.05,30,,3.05,percent of total billed charges,Drugs,3.05,30,,3.05,percent of total billed charges,Drugs,3.05,30,,3.05,percent of total billed charges,Drugs,5.08,50,,5.08,percent of total billed charges,All Other,3.05,30,,3.05,percent of total billed charges,Drugs,3.05,30,,3.05,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.05,30,,3.05,percent of total billed charges,Drugs,3.05,30,,3.05,percent of total billed charges,Drugs,3.05,30,,3.05,percent of total billed charges,Drugs,3.05,30,,3.05,percent of total billed charges,Drugs,3.05,30,,3.05,percent of total billed charges,Drugs,3.05,30,,3.05,percent of total billed charges,Drugs,3.05,30,,3.05,percent of total billed charges,Drugs,3.05,30,,3.05,percent of total billed charges,Drugs,3.05,30,,3.05,percent of total billed charges,Drugs,3.05,30,,3.05,percent of total billed charges,Drugs,3.05,30,,3.05,percent of total billed charges,Drugs,3.05,30,,3.05,percent of total billed charges,Drugs,3.05,30,,3.05,percent of total billed charges,Drugs,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,3.45,34,,3.45,percent of total billed charges,Drugs,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,44.07,,,44.07,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,45.3,
ENOXAPARIN 120MG/0.8ML INJ SLN  ,J1650,HCPCS,,40570533,CDM,636,RC,70710-1762-06,NDC,both,0.8,ML,35.63,6.71,,,6.71,Other,150% of Medicare + 9.63% HCRA Surcharge,4.08,,,4.08,Fee Schedule,Average Sale Price (ASP) x 6,10.69,30,,10.69,percent of total billed charges,Drugs,10.69,30,,10.69,percent of total billed charges,Drugs,10.69,30,,10.69,percent of total billed charges,Drugs,10.69,30,,10.69,percent of total billed charges,Drugs,10.69,30,,10.69,percent of total billed charges,Drugs,17.82,50,,17.82,percent of total billed charges,All Other,10.69,30,,10.69,percent of total billed charges,Drugs,10.69,30,,10.69,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,10.69,30,,10.69,percent of total billed charges,Drugs,10.69,30,,10.69,percent of total billed charges,Drugs,10.69,30,,10.69,percent of total billed charges,Drugs,10.69,30,,10.69,percent of total billed charges,Drugs,10.69,30,,10.69,percent of total billed charges,Drugs,10.69,30,,10.69,percent of total billed charges,Drugs,10.69,30,,10.69,percent of total billed charges,Drugs,10.69,30,,10.69,percent of total billed charges,Drugs,10.69,30,,10.69,percent of total billed charges,Drugs,10.69,30,,10.69,percent of total billed charges,Drugs,10.69,30,,10.69,percent of total billed charges,Drugs,10.69,30,,10.69,percent of total billed charges,Drugs,10.69,30,,10.69,percent of total billed charges,Drugs,6.26,,,6.26,Other,Drug Cost,6.26,,,6.26,Other,Drug Cost,6.26,,,6.26,Other,Drug Cost,6.26,,,6.26,Other,Drug Cost,6.26,,,6.26,Other,Drug Cost,12.11,34,,12.11,percent of total billed charges,Drugs,6.26,,,6.26,Other,Drug Cost,14.09,,,14.09,Other,225% Medicaid APG methodology,8.76,,,8.76,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.53,,,6.53,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6.26,,,6.26,Other,Drug Cost,6.26,,,6.26,Other,Drug Cost,7.83,,,7.83,Other,125% Medicaid APG methodology,0.01,17.82,
ENOXAPARIN 150MG/ML INJ 1ML     ,J1650,HCPCS,,40570541,CDM,636,RC,63323-0589-94,NDC,both,1,ML,45.08,6.71,,,6.71,Other,150% of Medicare + 9.63% HCRA Surcharge,4.08,,,4.08,Fee Schedule,Average Sale Price (ASP) x 6,13.52,30,,13.52,percent of total billed charges,Drugs,13.52,30,,13.52,percent of total billed charges,Drugs,13.52,30,,13.52,percent of total billed charges,Drugs,13.52,30,,13.52,percent of total billed charges,Drugs,13.52,30,,13.52,percent of total billed charges,Drugs,22.54,50,,22.54,percent of total billed charges,All Other,13.52,30,,13.52,percent of total billed charges,Drugs,13.52,30,,13.52,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,13.52,30,,13.52,percent of total billed charges,Drugs,13.52,30,,13.52,percent of total billed charges,Drugs,13.52,30,,13.52,percent of total billed charges,Drugs,13.52,30,,13.52,percent of total billed charges,Drugs,13.52,30,,13.52,percent of total billed charges,Drugs,13.52,30,,13.52,percent of total billed charges,Drugs,13.52,30,,13.52,percent of total billed charges,Drugs,13.52,30,,13.52,percent of total billed charges,Drugs,13.52,30,,13.52,percent of total billed charges,Drugs,13.52,30,,13.52,percent of total billed charges,Drugs,13.52,30,,13.52,percent of total billed charges,Drugs,13.52,30,,13.52,percent of total billed charges,Drugs,13.52,30,,13.52,percent of total billed charges,Drugs,12.73,,,12.73,Other,Drug Cost,12.73,,,12.73,Other,Drug Cost,12.73,,,12.73,Other,Drug Cost,12.73,,,12.73,Other,Drug Cost,12.73,,,12.73,Other,Drug Cost,15.33,34,,15.33,percent of total billed charges,Drugs,12.73,,,12.73,Other,Drug Cost,28.64,,,28.64,Other,225% Medicaid APG methodology,17.82,,,17.82,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.53,,,6.53,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",12.73,,,12.73,Other,Drug Cost,12.73,,,12.73,Other,Drug Cost,15.91,,,15.91,Other,125% Medicaid APG methodology,0.01,28.64,
FONDAPARINUX 7.5MG/0.6ML SOLN   ,J1652,HCPCS,,40570566,CDM,636,RC,70710-1516-09,NDC,both,0.6,ML,62.09,10.78,,,10.78,Other,150% of Medicare + 9.63% HCRA Surcharge,6.56,,,6.56,Fee Schedule,Average Sale Price (ASP) x 6,18.63,30,,18.63,percent of total billed charges,Drugs,18.63,30,,18.63,percent of total billed charges,Drugs,18.63,30,,18.63,percent of total billed charges,Drugs,18.63,30,,18.63,percent of total billed charges,Drugs,18.63,30,,18.63,percent of total billed charges,Drugs,31.05,50,,31.05,percent of total billed charges,All Other,18.63,30,,18.63,percent of total billed charges,Drugs,18.63,30,,18.63,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,18.63,30,,18.63,percent of total billed charges,Drugs,18.63,30,,18.63,percent of total billed charges,Drugs,18.63,30,,18.63,percent of total billed charges,Drugs,18.63,30,,18.63,percent of total billed charges,Drugs,18.63,30,,18.63,percent of total billed charges,Drugs,18.63,30,,18.63,percent of total billed charges,Drugs,18.63,30,,18.63,percent of total billed charges,Drugs,18.63,30,,18.63,percent of total billed charges,Drugs,18.63,30,,18.63,percent of total billed charges,Drugs,18.63,30,,18.63,percent of total billed charges,Drugs,18.63,30,,18.63,percent of total billed charges,Drugs,18.63,30,,18.63,percent of total billed charges,Drugs,18.63,30,,18.63,percent of total billed charges,Drugs,16.92,,,16.92,Other,Drug Cost,16.92,,,16.92,Other,Drug Cost,16.92,,,16.92,Other,Drug Cost,16.92,,,16.92,Other,Drug Cost,16.92,,,16.92,Other,Drug Cost,21.11,34,,21.11,percent of total billed charges,Drugs,16.92,,,16.92,Other,Drug Cost,38.07,,,38.07,Other,225% Medicaid APG methodology,23.69,,,23.69,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,10.49,,,10.49,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",16.92,,,16.92,Other,Drug Cost,16.92,,,16.92,Other,Drug Cost,21.15,,,21.15,Other,125% Medicaid APG methodology,0.01,38.07,
CALCITRIOL 1 MCG/ML SLN 1ML     ,J0636,HCPCS,,40570665,CDM,636,RC,72266-0251-10,NDC,both,1,ML,29.72,11.73,39.4668,,11.73,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,8.92,30,,8.92,percent of total billed charges,Drugs,8.92,30,,8.92,percent of total billed charges,Drugs,8.92,30,,8.92,percent of total billed charges,Drugs,8.92,30,,8.92,percent of total billed charges,Drugs,8.92,30,,8.92,percent of total billed charges,Drugs,14.86,50,,14.86,percent of total billed charges,All Other,8.92,30,,8.92,percent of total billed charges,Drugs,8.92,30,,8.92,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,8.92,30,,8.92,percent of total billed charges,Drugs,8.92,30,,8.92,percent of total billed charges,Drugs,8.92,30,,8.92,percent of total billed charges,Drugs,8.92,30,,8.92,percent of total billed charges,Drugs,8.92,30,,8.92,percent of total billed charges,Drugs,8.92,30,,8.92,percent of total billed charges,Drugs,8.92,30,,8.92,percent of total billed charges,Drugs,8.92,30,,8.92,percent of total billed charges,Drugs,8.92,30,,8.92,percent of total billed charges,Drugs,8.92,30,,8.92,percent of total billed charges,Drugs,8.92,30,,8.92,percent of total billed charges,Drugs,8.92,30,,8.92,percent of total billed charges,Drugs,8.92,30,,8.92,percent of total billed charges,Drugs,8.49,,,8.49,Other,Drug Cost,8.49,,,8.49,Other,Drug Cost,8.49,,,8.49,Other,Drug Cost,8.49,,,8.49,Other,Drug Cost,8.49,,,8.49,Other,Drug Cost,10.1,34,,10.1,percent of total billed charges,Drugs,8.49,,,8.49,Other,Drug Cost,19.1,,,19.1,Other,225% Medicaid APG methodology,11.89,,,11.89,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",8.49,,,8.49,Other,Drug Cost,8.49,,,8.49,Other,Drug Cost,10.61,,,10.61,Other,125% Medicaid APG methodology,0.01,19.1,
METHYLNALTREXONE 12MG/0.6ML     ,J2212,HCPCS,,40571051,CDM,636,RC,65649-0551-02,NDC,both,0.6,ML,437.64,172.72,39.4668,,172.72,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,131.29,30,,131.29,percent of total billed charges,Drugs,131.29,30,,131.29,percent of total billed charges,Drugs,131.29,30,,131.29,percent of total billed charges,Drugs,131.29,30,,131.29,percent of total billed charges,Drugs,131.29,30,,131.29,percent of total billed charges,Drugs,218.82,50,,218.82,percent of total billed charges,All Other,131.29,30,,131.29,percent of total billed charges,Drugs,131.29,30,,131.29,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,131.29,30,,131.29,percent of total billed charges,Drugs,131.29,30,,131.29,percent of total billed charges,Drugs,131.29,30,,131.29,percent of total billed charges,Drugs,131.29,30,,131.29,percent of total billed charges,Drugs,131.29,30,,131.29,percent of total billed charges,Drugs,131.29,30,,131.29,percent of total billed charges,Drugs,131.29,30,,131.29,percent of total billed charges,Drugs,131.29,30,,131.29,percent of total billed charges,Drugs,131.29,30,,131.29,percent of total billed charges,Drugs,131.29,30,,131.29,percent of total billed charges,Drugs,131.29,30,,131.29,percent of total billed charges,Drugs,131.29,30,,131.29,percent of total billed charges,Drugs,131.29,30,,131.29,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,148.8,34,,148.8,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,218.82,
MORPHINE 10MG/ML PF INJ  20ML   ,J2274,HCPCS,,40571101,CDM,636,RC,00641-6039-01,NDC,both,20,ML,669.94,110.94,,,110.94,Other,150% of Medicare + 9.63% HCRA Surcharge,67.46,,,67.46,Fee Schedule,Average Sale Price (ASP) x 6,200.98,30,,200.98,percent of total billed charges,Drugs,200.98,30,,200.98,percent of total billed charges,Drugs,200.98,30,,200.98,percent of total billed charges,Drugs,200.98,30,,200.98,percent of total billed charges,Drugs,200.98,30,,200.98,percent of total billed charges,Drugs,334.97,50,,334.97,percent of total billed charges,All Other,200.98,30,,200.98,percent of total billed charges,Drugs,200.98,30,,200.98,percent of total billed charges,Drugs,227.78,34,"If Charge > 500, then 34 percent",227.78,percent of total billed charges,Drugs,200.98,30,,200.98,percent of total billed charges,Drugs,200.98,30,,200.98,percent of total billed charges,Drugs,200.98,30,,200.98,percent of total billed charges,Drugs,200.98,30,,200.98,percent of total billed charges,Drugs,200.98,30,,200.98,percent of total billed charges,Drugs,200.98,30,,200.98,percent of total billed charges,Drugs,200.98,30,,200.98,percent of total billed charges,Drugs,200.98,30,,200.98,percent of total billed charges,Drugs,200.98,30,,200.98,percent of total billed charges,Drugs,200.98,30,,200.98,percent of total billed charges,Drugs,200.98,30,,200.98,percent of total billed charges,Drugs,200.98,30,,200.98,percent of total billed charges,Drugs,200.98,30,,200.98,percent of total billed charges,Drugs,85.94,,,85.94,Other,Drug Cost,85.94,,,85.94,Other,Drug Cost,85.94,,,85.94,Other,Drug Cost,85.94,,,85.94,Other,Drug Cost,85.94,,,85.94,Other,Drug Cost,227.78,34,,227.78,percent of total billed charges,Drugs,85.94,,,85.94,Other,Drug Cost,193.37,,,193.37,Other,225% Medicaid APG methodology,120.32,,,120.32,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,107.94,,,107.94,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",85.94,,,85.94,Other,Drug Cost,85.94,,,85.94,Other,Drug Cost,107.43,,,107.43,Other,125% Medicaid APG methodology,0.01,334.97,
AMPICILLIN-SULBACTAM 20MG/MLNS  ,J0295,HCPCS,,40571291,CDM,636,RC,00049-0013-83n,NDC,both,1,ML,0.49,17.45,,,17.45,Other,150% of Medicare + 9.63% HCRA Surcharge,10.61,,,10.61,Fee Schedule,Average Sale Price (ASP) x 6,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.25,50,,0.25,percent of total billed charges,All Other,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.17,34,,0.17,percent of total billed charges,Drugs,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,16.98,,,16.98,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,17.45,
PIP-TAZO60MG/ML D5W             ,J2543,HCPCS,,40571333,CDM,636,RC,00781-3113-95n,NDC,both,1,ML,0.21,11.61,,,11.61,Other,150% of Medicare + 9.63% HCRA Surcharge,7.06,,,7.06,Fee Schedule,Average Sale Price (ASP) x 6,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.11,50,,0.11,percent of total billed charges,All Other,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,30,,0.06,percent of total billed charges,Drugs,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.07,34,,0.07,percent of total billed charges,Drugs,0.06,,,0.06,Other,Drug Cost,0.14,,,0.14,Other,225% Medicaid APG methodology,0.08,,,0.08,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,11.3,,,11.3,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.06,,,0.06,Other,Drug Cost,0.06,,,0.06,Other,Drug Cost,0.08,,,0.08,Other,125% Medicaid APG methodology,0.01,11.61,
TOBRAMYCIN 60MG/ML INH SLN 5ML  ,J7682,HCPCS,,40571838,CDM,636,RC,65162-0914-46,NDC,both,5,ML,55.2,215.03,,,215.03,Other,150% of Medicare + 9.63% HCRA Surcharge,130.76,,,130.76,Fee Schedule,Average Sale Price (ASP) x 6,16.56,30,,16.56,percent of total billed charges,Drugs,16.56,30,,16.56,percent of total billed charges,Drugs,16.56,30,,16.56,percent of total billed charges,Drugs,16.56,30,,16.56,percent of total billed charges,Drugs,16.56,30,,16.56,percent of total billed charges,Drugs,27.6,50,,27.6,percent of total billed charges,All Other,16.56,30,,16.56,percent of total billed charges,Drugs,16.56,30,,16.56,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,16.56,30,,16.56,percent of total billed charges,Drugs,16.56,30,,16.56,percent of total billed charges,Drugs,16.56,30,,16.56,percent of total billed charges,Drugs,16.56,30,,16.56,percent of total billed charges,Drugs,16.56,30,,16.56,percent of total billed charges,Drugs,16.56,30,,16.56,percent of total billed charges,Drugs,16.56,30,,16.56,percent of total billed charges,Drugs,16.56,30,,16.56,percent of total billed charges,Drugs,16.56,30,,16.56,percent of total billed charges,Drugs,16.56,30,,16.56,percent of total billed charges,Drugs,16.56,30,,16.56,percent of total billed charges,Drugs,16.56,30,,16.56,percent of total billed charges,Drugs,16.56,30,,16.56,percent of total billed charges,Drugs,4.21,,,4.21,Other,Drug Cost,4.21,,,4.21,Other,Drug Cost,4.21,,,4.21,Other,Drug Cost,4.21,,,4.21,Other,Drug Cost,4.21,,,4.21,Other,Drug Cost,18.77,34,,18.77,percent of total billed charges,Drugs,4.21,,,4.21,Other,Drug Cost,9.47,,,9.47,Other,225% Medicaid APG methodology,5.89,,,5.89,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,209.22,,,209.22,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.21,,,4.21,Other,Drug Cost,4.21,,,4.21,Other,Drug Cost,5.26,,,5.26,Other,125% Medicaid APG methodology,0.01,215.03,
CEFTAZIDIME 1000 MG INJ         ,J0713,HCPCS,,40572075,CDM,636,RC,00409-5082-16,NDC,both,1,EA,13.72,16.71,,,16.71,Other,150% of Medicare + 9.63% HCRA Surcharge,10.16,,,10.16,Fee Schedule,Average Sale Price (ASP) x 6,4.12,30,,4.12,percent of total billed charges,Drugs,4.12,30,,4.12,percent of total billed charges,Drugs,4.12,30,,4.12,percent of total billed charges,Drugs,4.12,30,,4.12,percent of total billed charges,Drugs,4.12,30,,4.12,percent of total billed charges,Drugs,6.86,50,,6.86,percent of total billed charges,All Other,4.12,30,,4.12,percent of total billed charges,Drugs,4.12,30,,4.12,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.12,30,,4.12,percent of total billed charges,Drugs,4.12,30,,4.12,percent of total billed charges,Drugs,4.12,30,,4.12,percent of total billed charges,Drugs,4.12,30,,4.12,percent of total billed charges,Drugs,4.12,30,,4.12,percent of total billed charges,Drugs,4.12,30,,4.12,percent of total billed charges,Drugs,4.12,30,,4.12,percent of total billed charges,Drugs,4.12,30,,4.12,percent of total billed charges,Drugs,4.12,30,,4.12,percent of total billed charges,Drugs,4.12,30,,4.12,percent of total billed charges,Drugs,4.12,30,,4.12,percent of total billed charges,Drugs,4.12,30,,4.12,percent of total billed charges,Drugs,4.12,30,,4.12,percent of total billed charges,Drugs,2.45,,,2.45,Other,Drug Cost,2.45,,,2.45,Other,Drug Cost,2.45,,,2.45,Other,Drug Cost,2.45,,,2.45,Other,Drug Cost,2.45,,,2.45,Other,Drug Cost,4.66,34,,4.66,percent of total billed charges,Drugs,2.45,,,2.45,Other,Drug Cost,5.51,,,5.51,Other,225% Medicaid APG methodology,3.43,,,3.43,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,16.26,,,16.26,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.45,,,2.45,Other,Drug Cost,2.45,,,2.45,Other,Drug Cost,3.06,,,3.06,Other,125% Medicaid APG methodology,0.01,16.71,
CEFTAZIDIME 2000 MG INJ         ,J0713,HCPCS,,40572083,CDM,636,RC,00409-5093-11,NDC,both,1,EA,36.33,16.71,,,16.71,Other,150% of Medicare + 9.63% HCRA Surcharge,10.16,,,10.16,Fee Schedule,Average Sale Price (ASP) x 6,10.9,30,,10.9,percent of total billed charges,Drugs,10.9,30,,10.9,percent of total billed charges,Drugs,10.9,30,,10.9,percent of total billed charges,Drugs,10.9,30,,10.9,percent of total billed charges,Drugs,10.9,30,,10.9,percent of total billed charges,Drugs,18.17,50,,18.17,percent of total billed charges,All Other,10.9,30,,10.9,percent of total billed charges,Drugs,10.9,30,,10.9,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,10.9,30,,10.9,percent of total billed charges,Drugs,10.9,30,,10.9,percent of total billed charges,Drugs,10.9,30,,10.9,percent of total billed charges,Drugs,10.9,30,,10.9,percent of total billed charges,Drugs,10.9,30,,10.9,percent of total billed charges,Drugs,10.9,30,,10.9,percent of total billed charges,Drugs,10.9,30,,10.9,percent of total billed charges,Drugs,10.9,30,,10.9,percent of total billed charges,Drugs,10.9,30,,10.9,percent of total billed charges,Drugs,10.9,30,,10.9,percent of total billed charges,Drugs,10.9,30,,10.9,percent of total billed charges,Drugs,10.9,30,,10.9,percent of total billed charges,Drugs,10.9,30,,10.9,percent of total billed charges,Drugs,3.8,,,3.8,Other,Drug Cost,3.8,,,3.8,Other,Drug Cost,3.8,,,3.8,Other,Drug Cost,3.8,,,3.8,Other,Drug Cost,3.8,,,3.8,Other,Drug Cost,12.35,34,,12.35,percent of total billed charges,Drugs,3.8,,,3.8,Other,Drug Cost,8.55,,,8.55,Other,225% Medicaid APG methodology,5.32,,,5.32,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,16.26,,,16.26,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.8,,,3.8,Other,Drug Cost,3.8,,,3.8,Other,Drug Cost,4.75,,,4.75,Other,125% Medicaid APG methodology,0.01,18.17,
IMM GLOB10%(10G)100ML(PRIVIGEN  ,J1459,HCPCS,,40572158,CDM,636,RC,44206-0437-10,NDC,both,100,ML,3149.76,476.46,,,476.46,Other,150% of Medicare + 9.63% HCRA Surcharge,289.74,,,289.74,Fee Schedule,Average Sale Price (ASP) x 6,944.93,30,,944.93,percent of total billed charges,Drugs,944.93,30,,944.93,percent of total billed charges,Drugs,944.93,30,,944.93,percent of total billed charges,Drugs,944.93,30,,944.93,percent of total billed charges,Drugs,944.93,30,,944.93,percent of total billed charges,Drugs,1574.88,50,,1574.88,percent of total billed charges,All Other,944.93,30,,944.93,percent of total billed charges,Drugs,944.93,30,,944.93,percent of total billed charges,Drugs,1070.92,34,"If Charge > 500, then 34 percent",1070.92,percent of total billed charges,Drugs,944.93,30,,944.93,percent of total billed charges,Drugs,944.93,30,,944.93,percent of total billed charges,Drugs,944.93,30,,944.93,percent of total billed charges,Drugs,944.93,30,,944.93,percent of total billed charges,Drugs,944.93,30,,944.93,percent of total billed charges,Drugs,944.93,30,,944.93,percent of total billed charges,Drugs,944.93,30,,944.93,percent of total billed charges,Drugs,944.93,30,,944.93,percent of total billed charges,Drugs,944.93,30,,944.93,percent of total billed charges,Drugs,944.93,30,,944.93,percent of total billed charges,Drugs,944.93,30,,944.93,percent of total billed charges,Drugs,944.93,30,,944.93,percent of total billed charges,Drugs,944.93,30,,944.93,percent of total billed charges,Drugs,617.6,,,617.6,Other,Drug Cost,617.6,,,617.6,Other,Drug Cost,617.6,,,617.6,Other,Drug Cost,617.6,,,617.6,Other,Drug Cost,617.6,,,617.6,Other,Drug Cost,1070.92,34,,1070.92,percent of total billed charges,Drugs,617.6,,,617.6,Other,Drug Cost,1389.6,,,1389.6,Other,225% Medicaid APG methodology,864.64,,,864.64,Other,140% Medicaid APG methodology,1070.92,34,"If Charge > 2,000, then 34 percent",1070.92,percent of total billed charges,Drugs,463.58,,,463.58,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",617.6,,,617.6,Other,Drug Cost,617.6,,,617.6,Other,Drug Cost,772,,,772,Other,125% Medicaid APG methodology,0.01,1574.88,
HAVRIX 1440 UNIT/0.5ML SYRINGE  ,90632,CPT,,40572190,CDM,636,RC,58160-0826-52,NDC,both,1,ML,212.8,693.24,,,693.24,Other,150% of Medicare + 9.63% HCRA Surcharge,421.57,,,421.57,Fee Schedule,Average Sale Price (ASP) x 6,63.84,30,,63.84,percent of total billed charges,Drugs,63.84,30,,63.84,percent of total billed charges,Drugs,63.84,30,,63.84,percent of total billed charges,Drugs,63.84,30,,63.84,percent of total billed charges,Drugs,63.84,30,,63.84,percent of total billed charges,Drugs,106.4,50,,106.4,percent of total billed charges,All Other,63.84,30,,63.84,percent of total billed charges,Drugs,63.84,30,,63.84,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,63.84,30,,63.84,percent of total billed charges,Drugs,63.84,30,,63.84,percent of total billed charges,Drugs,63.84,30,,63.84,percent of total billed charges,Drugs,63.84,30,,63.84,percent of total billed charges,Drugs,63.84,30,,63.84,percent of total billed charges,Drugs,63.84,30,,63.84,percent of total billed charges,Drugs,63.84,30,,63.84,percent of total billed charges,Drugs,63.84,30,,63.84,percent of total billed charges,Drugs,63.84,30,,63.84,percent of total billed charges,Drugs,63.84,30,,63.84,percent of total billed charges,Drugs,63.84,30,,63.84,percent of total billed charges,Drugs,63.84,30,,63.84,percent of total billed charges,Drugs,63.84,30,,63.84,percent of total billed charges,Drugs,58.63,,,58.63,Other,Drug Cost,58.63,,,58.63,Other,Drug Cost,58.63,,,58.63,Other,Drug Cost,58.63,,,58.63,Other,Drug Cost,58.63,,,58.63,Other,Drug Cost,72.35,34,,72.35,percent of total billed charges,Drugs,58.63,,,58.63,Other,Drug Cost,131.92,,,131.92,Other,225% Medicaid APG methodology,82.08,,,82.08,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,674.51,,,674.51,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",58.63,,,58.63,Other,Drug Cost,58.63,,,58.63,Other,Drug Cost,73.29,,,73.29,Other,125% Medicaid APG methodology,0.01,693.24,
BEVACIZUMAB 25MG/ML IVSLN 16ML  ,J9035,HCPCS,,40572331,CDM,636,RC,50242-0061-01,NDC,both,16,ML,8891.82,730.86,,,730.86,Other,150% of Medicare + 9.63% HCRA Surcharge,444.44,,,444.44,Fee Schedule,Average Sale Price (ASP) x 6,2667.55,30,,2667.55,percent of total billed charges,Drugs,2667.55,30,,2667.55,percent of total billed charges,Drugs,2667.55,30,,2667.55,percent of total billed charges,Drugs,2667.55,30,,2667.55,percent of total billed charges,Drugs,2667.55,30,,2667.55,percent of total billed charges,Drugs,4445.91,50,,4445.91,percent of total billed charges,All Other,2667.55,30,,2667.55,percent of total billed charges,Drugs,2667.55,30,,2667.55,percent of total billed charges,Drugs,3023.22,34,"If Charge > 500, then 34 percent",3023.22,percent of total billed charges,Drugs,2667.55,30,,2667.55,percent of total billed charges,Drugs,2667.55,30,,2667.55,percent of total billed charges,Drugs,2667.55,30,,2667.55,percent of total billed charges,Drugs,2667.55,30,,2667.55,percent of total billed charges,Drugs,2667.55,30,,2667.55,percent of total billed charges,Drugs,2667.55,30,,2667.55,percent of total billed charges,Drugs,2667.55,30,,2667.55,percent of total billed charges,Drugs,2667.55,30,,2667.55,percent of total billed charges,Drugs,2667.55,30,,2667.55,percent of total billed charges,Drugs,2667.55,30,,2667.55,percent of total billed charges,Drugs,2667.55,30,,2667.55,percent of total billed charges,Drugs,2667.55,30,,2667.55,percent of total billed charges,Drugs,2667.55,30,,2667.55,percent of total billed charges,Drugs,1956.31,,,1956.31,Other,Drug Cost,1956.31,,,1956.31,Other,Drug Cost,1956.31,,,1956.31,Other,Drug Cost,1956.31,,,1956.31,Other,Drug Cost,1956.31,,,1956.31,Other,Drug Cost,3023.22,34,,3023.22,percent of total billed charges,Drugs,1956.31,,,1956.31,Other,Drug Cost,4401.7,,,4401.7,Other,225% Medicaid APG methodology,2738.83,,,2738.83,Other,140% Medicaid APG methodology,3023.22,34,"If Charge > 2,000, then 34 percent",3023.22,percent of total billed charges,Drugs,711.1,,,711.1,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1956.31,,,1956.31,Other,Drug Cost,1956.31,,,1956.31,Other,Drug Cost,2445.39,,,2445.39,Other,125% Medicaid APG methodology,0.01,4445.91,
VANCOMYCIN RECTAL 500MG         ,J3370,HCPCS,,40572380,CDM,636,RC,00409-4332-01e,NDC,both,100,ML,79.07,22.76,,,22.76,Other,150% of Medicare + 9.63% HCRA Surcharge,13.84,,,13.84,Fee Schedule,Average Sale Price (ASP) x 6,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,39.54,50,,39.54,percent of total billed charges,All Other,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,15.59,,,15.59,Other,Drug Cost,15.59,,,15.59,Other,Drug Cost,15.59,,,15.59,Other,Drug Cost,15.59,,,15.59,Other,Drug Cost,15.59,,,15.59,Other,Drug Cost,26.88,34,,26.88,percent of total billed charges,Drugs,15.59,,,15.59,Other,Drug Cost,35.08,,,35.08,Other,225% Medicaid APG methodology,21.83,,,21.83,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,22.15,,,22.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",15.59,,,15.59,Other,Drug Cost,15.59,,,15.59,Other,Drug Cost,19.49,,,19.49,Other,125% Medicaid APG methodology,0.01,39.54,
CEFEPIME 1000 MG INJ            ,J0692,HCPCS,,40572810,CDM,636,RC,60505-6146-04,NDC,both,1,EA,8.05,12.45,,,12.45,Other,150% of Medicare + 9.63% HCRA Surcharge,7.57,,,7.57,Fee Schedule,Average Sale Price (ASP) x 6,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,4.03,50,,4.03,percent of total billed charges,All Other,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.42,30,,2.42,percent of total billed charges,Drugs,2.73,,,2.73,Other,Drug Cost,2.73,,,2.73,Other,Drug Cost,2.73,,,2.73,Other,Drug Cost,2.73,,,2.73,Other,Drug Cost,2.73,,,2.73,Other,Drug Cost,2.74,34,,2.74,percent of total billed charges,Drugs,2.73,,,2.73,Other,Drug Cost,6.14,,,6.14,Other,225% Medicaid APG methodology,3.82,,,3.82,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,12.12,,,12.12,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.73,,,2.73,Other,Drug Cost,2.73,,,2.73,Other,Drug Cost,3.41,,,3.41,Other,125% Medicaid APG methodology,0.01,12.45,
GOSERELIN 3.6MG SUBCUT IMPLANT  ,J9202,HCPCS,,40572869,CDM,636,RC,70720-0950-36,NDC,both,1,EA,2614.54,6008.91,,,6008.91,Other,150% of Medicare + 9.63% HCRA Surcharge,3654.05,,,3654.05,Fee Schedule,Average Sale Price (ASP) x 6,784.36,30,,784.36,percent of total billed charges,Drugs,784.36,30,,784.36,percent of total billed charges,Drugs,784.36,30,,784.36,percent of total billed charges,Drugs,784.36,30,,784.36,percent of total billed charges,Drugs,784.36,30,,784.36,percent of total billed charges,Drugs,1307.27,50,,1307.27,percent of total billed charges,All Other,784.36,30,,784.36,percent of total billed charges,Drugs,784.36,30,,784.36,percent of total billed charges,Drugs,888.94,34,"If Charge > 500, then 34 percent",888.94,percent of total billed charges,Drugs,784.36,30,,784.36,percent of total billed charges,Drugs,784.36,30,,784.36,percent of total billed charges,Drugs,784.36,30,,784.36,percent of total billed charges,Drugs,784.36,30,,784.36,percent of total billed charges,Drugs,784.36,30,,784.36,percent of total billed charges,Drugs,784.36,30,,784.36,percent of total billed charges,Drugs,784.36,30,,784.36,percent of total billed charges,Drugs,784.36,30,,784.36,percent of total billed charges,Drugs,784.36,30,,784.36,percent of total billed charges,Drugs,784.36,30,,784.36,percent of total billed charges,Drugs,784.36,30,,784.36,percent of total billed charges,Drugs,784.36,30,,784.36,percent of total billed charges,Drugs,784.36,30,,784.36,percent of total billed charges,Drugs,485.56,,,485.56,Other,Drug Cost,485.56,,,485.56,Other,Drug Cost,485.56,,,485.56,Other,Drug Cost,485.56,,,485.56,Other,Drug Cost,485.56,,,485.56,Other,Drug Cost,888.94,34,,888.94,percent of total billed charges,Drugs,485.56,,,485.56,Other,Drug Cost,1092.51,,,1092.51,Other,225% Medicaid APG methodology,679.78,,,679.78,Other,140% Medicaid APG methodology,888.94,34,"If Charge > 2,000, then 34 percent",888.94,percent of total billed charges,Drugs,5846.49,,,5846.49,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",485.56,,,485.56,Other,Drug Cost,485.56,,,485.56,Other,Drug Cost,606.95,,,606.95,Other,125% Medicaid APG methodology,0.01,6008.91,
"HYALURONIDASE,OVINE 200         ",J3471,HCPCS,,40572919,CDM,636,RC,24208-0002-02,NDC,both,1.2,ML,392.25,4.92,,,4.92,Other,150% of Medicare + 9.63% HCRA Surcharge,2.99,,,2.99,Fee Schedule,Average Sale Price (ASP) x 6,117.68,30,,117.68,percent of total billed charges,Drugs,117.68,30,,117.68,percent of total billed charges,Drugs,117.68,30,,117.68,percent of total billed charges,Drugs,117.68,30,,117.68,percent of total billed charges,Drugs,117.68,30,,117.68,percent of total billed charges,Drugs,196.13,50,,196.13,percent of total billed charges,All Other,117.68,30,,117.68,percent of total billed charges,Drugs,117.68,30,,117.68,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,117.68,30,,117.68,percent of total billed charges,Drugs,117.68,30,,117.68,percent of total billed charges,Drugs,117.68,30,,117.68,percent of total billed charges,Drugs,117.68,30,,117.68,percent of total billed charges,Drugs,117.68,30,,117.68,percent of total billed charges,Drugs,117.68,30,,117.68,percent of total billed charges,Drugs,117.68,30,,117.68,percent of total billed charges,Drugs,117.68,30,,117.68,percent of total billed charges,Drugs,117.68,30,,117.68,percent of total billed charges,Drugs,117.68,30,,117.68,percent of total billed charges,Drugs,117.68,30,,117.68,percent of total billed charges,Drugs,117.68,30,,117.68,percent of total billed charges,Drugs,117.68,30,,117.68,percent of total billed charges,Drugs,3.04,,,3.04,Other,Drug Cost,3.04,,,3.04,Other,Drug Cost,3.04,,,3.04,Other,Drug Cost,3.04,,,3.04,Other,Drug Cost,3.04,,,3.04,Other,Drug Cost,133.37,34,,133.37,percent of total billed charges,Drugs,3.04,,,3.04,Other,Drug Cost,6.84,,,6.84,Other,225% Medicaid APG methodology,4.26,,,4.26,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,4.79,,,4.79,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.04,,,3.04,Other,Drug Cost,3.04,,,3.04,Other,Drug Cost,3.8,,,3.8,Other,125% Medicaid APG methodology,0.01,196.13,
SOD FERRIC GLUCON COMP 5ML      ,J2916,HCPCS,,40572927,CDM,636,RC,00143-9570-10,NDC,both,5,ML,25.55,23.42,,,23.42,Other,150% of Medicare + 9.63% HCRA Surcharge,14.24,,,14.24,Fee Schedule,Average Sale Price (ASP) x 6,7.67,30,,7.67,percent of total billed charges,Drugs,7.67,30,,7.67,percent of total billed charges,Drugs,7.67,30,,7.67,percent of total billed charges,Drugs,7.67,30,,7.67,percent of total billed charges,Drugs,7.67,30,,7.67,percent of total billed charges,Drugs,12.78,50,,12.78,percent of total billed charges,All Other,7.67,30,,7.67,percent of total billed charges,Drugs,7.67,30,,7.67,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,7.67,30,,7.67,percent of total billed charges,Drugs,7.67,30,,7.67,percent of total billed charges,Drugs,7.67,30,,7.67,percent of total billed charges,Drugs,7.67,30,,7.67,percent of total billed charges,Drugs,7.67,30,,7.67,percent of total billed charges,Drugs,7.67,30,,7.67,percent of total billed charges,Drugs,7.67,30,,7.67,percent of total billed charges,Drugs,7.67,30,,7.67,percent of total billed charges,Drugs,7.67,30,,7.67,percent of total billed charges,Drugs,7.67,30,,7.67,percent of total billed charges,Drugs,7.67,30,,7.67,percent of total billed charges,Drugs,7.67,30,,7.67,percent of total billed charges,Drugs,7.67,30,,7.67,percent of total billed charges,Drugs,7.15,,,7.15,Other,Drug Cost,7.15,,,7.15,Other,Drug Cost,7.15,,,7.15,Other,Drug Cost,7.15,,,7.15,Other,Drug Cost,7.15,,,7.15,Other,Drug Cost,8.69,34,,8.69,percent of total billed charges,Drugs,7.15,,,7.15,Other,Drug Cost,16.09,,,16.09,Other,225% Medicaid APG methodology,10.01,,,10.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,22.79,,,22.79,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",7.15,,,7.15,Other,Drug Cost,7.15,,,7.15,Other,Drug Cost,8.94,,,8.94,Other,125% Medicaid APG methodology,0.01,23.42,
VARICELLA VIRUS VACC INJ 0.5ML  ,90716,CPT,,40573040,CDM,636,RC,00006-4827-00,NDC,both,1,EA,451.43,178.16,39.4668,,178.16,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,135.43,30,,135.43,percent of total billed charges,Drugs,135.43,30,,135.43,percent of total billed charges,Drugs,135.43,30,,135.43,percent of total billed charges,Drugs,135.43,30,,135.43,percent of total billed charges,Drugs,135.43,30,,135.43,percent of total billed charges,Drugs,225.72,50,,225.72,percent of total billed charges,All Other,135.43,30,,135.43,percent of total billed charges,Drugs,135.43,30,,135.43,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,135.43,30,,135.43,percent of total billed charges,Drugs,135.43,30,,135.43,percent of total billed charges,Drugs,135.43,30,,135.43,percent of total billed charges,Drugs,135.43,30,,135.43,percent of total billed charges,Drugs,135.43,30,,135.43,percent of total billed charges,Drugs,135.43,30,,135.43,percent of total billed charges,Drugs,135.43,30,,135.43,percent of total billed charges,Drugs,135.43,30,,135.43,percent of total billed charges,Drugs,135.43,30,,135.43,percent of total billed charges,Drugs,135.43,30,,135.43,percent of total billed charges,Drugs,135.43,30,,135.43,percent of total billed charges,Drugs,135.43,30,,135.43,percent of total billed charges,Drugs,135.43,30,,135.43,percent of total billed charges,Drugs,135.72,,,135.72,Other,Drug Cost,135.72,,,135.72,Other,Drug Cost,135.72,,,135.72,Other,Drug Cost,135.72,,,135.72,Other,Drug Cost,135.72,,,135.72,Other,Drug Cost,153.49,34,,153.49,percent of total billed charges,Drugs,135.72,,,135.72,Other,Drug Cost,305.37,,,305.37,Other,225% Medicaid APG methodology,190.01,,,190.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",135.72,,,135.72,Other,Drug Cost,135.72,,,135.72,Other,Drug Cost,169.65,,,169.65,Other,125% Medicaid APG methodology,0.01,305.37,
LABETALOL 5MG/ML  IV 4ML SYR    ,J3490,HCPCS,,40573297,CDM,636,RC,36000-0320-10,NDC,both,4,ML,11.38,4.49,39.4668,,4.49,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,3.41,30,,3.41,percent of total billed charges,Drugs,3.41,30,,3.41,percent of total billed charges,Drugs,3.41,30,,3.41,percent of total billed charges,Drugs,3.41,30,,3.41,percent of total billed charges,Drugs,3.41,30,,3.41,percent of total billed charges,Drugs,5.69,50,,5.69,percent of total billed charges,All Other,3.41,30,,3.41,percent of total billed charges,Drugs,3.41,30,,3.41,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.41,30,,3.41,percent of total billed charges,Drugs,3.41,30,,3.41,percent of total billed charges,Drugs,3.41,30,,3.41,percent of total billed charges,Drugs,3.41,30,,3.41,percent of total billed charges,Drugs,3.41,30,,3.41,percent of total billed charges,Drugs,3.41,30,,3.41,percent of total billed charges,Drugs,3.41,30,,3.41,percent of total billed charges,Drugs,3.41,30,,3.41,percent of total billed charges,Drugs,3.41,30,,3.41,percent of total billed charges,Drugs,3.41,30,,3.41,percent of total billed charges,Drugs,3.41,30,,3.41,percent of total billed charges,Drugs,3.41,30,,3.41,percent of total billed charges,Drugs,3.41,30,,3.41,percent of total billed charges,Drugs,2.71,,,2.71,Other,Drug Cost,2.71,,,2.71,Other,Drug Cost,2.71,,,2.71,Other,Drug Cost,2.71,,,2.71,Other,Drug Cost,2.71,,,2.71,Other,Drug Cost,3.87,34,,3.87,percent of total billed charges,Drugs,2.71,,,2.71,Other,Drug Cost,6.1,,,6.1,Other,225% Medicaid APG methodology,3.79,,,3.79,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.71,,,2.71,Other,Drug Cost,2.71,,,2.71,Other,Drug Cost,3.39,,,3.39,Other,125% Medicaid APG methodology,0.01,6.1,
HEPARIN 2 UNITS/ML- NS 1000ML   ,J1644,HCPCS,,40573446,CDM,636,RC,00409-7620-59,NDC,both,1000,ML,13.65,2.64,,,2.64,Other,150% of Medicare + 9.63% HCRA Surcharge,1.61,,,1.61,Fee Schedule,Average Sale Price (ASP) x 6,4.1,30,,4.1,percent of total billed charges,Drugs,4.1,30,,4.1,percent of total billed charges,Drugs,4.1,30,,4.1,percent of total billed charges,Drugs,4.1,30,,4.1,percent of total billed charges,Drugs,4.1,30,,4.1,percent of total billed charges,Drugs,6.83,50,,6.83,percent of total billed charges,All Other,4.1,30,,4.1,percent of total billed charges,Drugs,4.1,30,,4.1,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.1,30,,4.1,percent of total billed charges,Drugs,4.1,30,,4.1,percent of total billed charges,Drugs,4.1,30,,4.1,percent of total billed charges,Drugs,4.1,30,,4.1,percent of total billed charges,Drugs,4.1,30,,4.1,percent of total billed charges,Drugs,4.1,30,,4.1,percent of total billed charges,Drugs,4.1,30,,4.1,percent of total billed charges,Drugs,4.1,30,,4.1,percent of total billed charges,Drugs,4.1,30,,4.1,percent of total billed charges,Drugs,4.1,30,,4.1,percent of total billed charges,Drugs,4.1,30,,4.1,percent of total billed charges,Drugs,4.1,30,,4.1,percent of total billed charges,Drugs,4.1,30,,4.1,percent of total billed charges,Drugs,5.94,,,5.94,Other,Drug Cost,5.94,,,5.94,Other,Drug Cost,5.94,,,5.94,Other,Drug Cost,5.94,,,5.94,Other,Drug Cost,5.94,,,5.94,Other,Drug Cost,4.64,34,,4.64,percent of total billed charges,Drugs,5.94,,,5.94,Other,Drug Cost,13.37,,,13.37,Other,225% Medicaid APG methodology,8.32,,,8.32,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.57,,,2.57,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.94,,,5.94,Other,Drug Cost,5.94,,,5.94,Other,Drug Cost,7.43,,,7.43,Other,125% Medicaid APG methodology,0.01,13.37,
PNEUMOCOC 13-VAL CONJ 0.5ML     ,90670,CPT,,40574089,CDM,636,RC,00005-1971-05,NDC,both,0.5,ML,645.26,2545.5,,,2545.5,Other,150% of Medicare + 9.63% HCRA Surcharge,1547.93,,,1547.93,Fee Schedule,Average Sale Price (ASP) x 6,193.58,30,,193.58,percent of total billed charges,Drugs,193.58,30,,193.58,percent of total billed charges,Drugs,193.58,30,,193.58,percent of total billed charges,Drugs,193.58,30,,193.58,percent of total billed charges,Drugs,193.58,30,,193.58,percent of total billed charges,Drugs,322.63,50,,322.63,percent of total billed charges,All Other,193.58,30,,193.58,percent of total billed charges,Drugs,193.58,30,,193.58,percent of total billed charges,Drugs,219.39,34,"If Charge > 500, then 34 percent",219.39,percent of total billed charges,Drugs,193.58,30,,193.58,percent of total billed charges,Drugs,193.58,30,,193.58,percent of total billed charges,Drugs,193.58,30,,193.58,percent of total billed charges,Drugs,193.58,30,,193.58,percent of total billed charges,Drugs,193.58,30,,193.58,percent of total billed charges,Drugs,193.58,30,,193.58,percent of total billed charges,Drugs,193.58,30,,193.58,percent of total billed charges,Drugs,193.58,30,,193.58,percent of total billed charges,Drugs,193.58,30,,193.58,percent of total billed charges,Drugs,193.58,30,,193.58,percent of total billed charges,Drugs,193.58,30,,193.58,percent of total billed charges,Drugs,193.58,30,,193.58,percent of total billed charges,Drugs,193.58,30,,193.58,percent of total billed charges,Drugs,183.77,,,183.77,Other,Drug Cost,183.77,,,183.77,Other,Drug Cost,183.77,,,183.77,Other,Drug Cost,183.77,,,183.77,Other,Drug Cost,183.77,,,183.77,Other,Drug Cost,219.39,34,,219.39,percent of total billed charges,Drugs,183.77,,,183.77,Other,Drug Cost,413.48,,,413.48,Other,225% Medicaid APG methodology,257.28,,,257.28,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2476.69,,,2476.69,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",183.77,,,183.77,Other,Drug Cost,183.77,,,183.77,Other,Drug Cost,229.71,,,229.71,Other,125% Medicaid APG methodology,0.01,2545.5,
PHENOBARBITAL 65MG/ML INJ  1ML  ,J2560,HCPCS,,40574139,CDM,636,RC,00641-0476-25,NDC,both,1,ML,64.3,310.13,,,310.13,Other,150% of Medicare + 9.63% HCRA Surcharge,188.59,,,188.59,Fee Schedule,Average Sale Price (ASP) x 6,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,32.15,50,,32.15,percent of total billed charges,All Other,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,19.29,30,,19.29,percent of total billed charges,Drugs,13.79,,,13.79,Other,Drug Cost,13.79,,,13.79,Other,Drug Cost,13.79,,,13.79,Other,Drug Cost,13.79,,,13.79,Other,Drug Cost,13.79,,,13.79,Other,Drug Cost,21.86,34,,21.86,percent of total billed charges,Drugs,13.79,,,13.79,Other,Drug Cost,31.03,,,31.03,Other,225% Medicaid APG methodology,19.31,,,19.31,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,301.75,,,301.75,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",13.79,,,13.79,Other,Drug Cost,13.79,,,13.79,Other,Drug Cost,17.24,,,17.24,Other,125% Medicaid APG methodology,0.01,310.13,
BUMETANIDE 0.25MG/ML INJ  4ML   ,J3490,HCPCS,,40574196,CDM,636,RC,70860-0405-04,NDC,both,4,ML,8.89,3.51,39.4668,,3.51,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,4.45,50,,4.45,percent of total billed charges,All Other,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,2.67,30,,2.67,percent of total billed charges,Drugs,2.31,,,2.31,Other,Drug Cost,2.31,,,2.31,Other,Drug Cost,2.31,,,2.31,Other,Drug Cost,2.31,,,2.31,Other,Drug Cost,2.31,,,2.31,Other,Drug Cost,3.02,34,,3.02,percent of total billed charges,Drugs,2.31,,,2.31,Other,Drug Cost,5.2,,,5.2,Other,225% Medicaid APG methodology,3.23,,,3.23,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.31,,,2.31,Other,Drug Cost,2.31,,,2.31,Other,Drug Cost,2.89,,,2.89,Other,125% Medicaid APG methodology,0.01,5.2,
ADENOSINE 3MG/ML IV SOLN 30ML   ,J0153,HCPCS,,40574204,CDM,636,RC,67457-0857-30,NDC,both,30,ML,125.62,5.93,,,5.93,Other,150% of Medicare + 9.63% HCRA Surcharge,3.61,,,3.61,Fee Schedule,Average Sale Price (ASP) x 6,37.69,30,,37.69,percent of total billed charges,Drugs,37.69,30,,37.69,percent of total billed charges,Drugs,37.69,30,,37.69,percent of total billed charges,Drugs,37.69,30,,37.69,percent of total billed charges,Drugs,37.69,30,,37.69,percent of total billed charges,Drugs,62.81,50,,62.81,percent of total billed charges,All Other,37.69,30,,37.69,percent of total billed charges,Drugs,37.69,30,,37.69,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,37.69,30,,37.69,percent of total billed charges,Drugs,37.69,30,,37.69,percent of total billed charges,Drugs,37.69,30,,37.69,percent of total billed charges,Drugs,37.69,30,,37.69,percent of total billed charges,Drugs,37.69,30,,37.69,percent of total billed charges,Drugs,37.69,30,,37.69,percent of total billed charges,Drugs,37.69,30,,37.69,percent of total billed charges,Drugs,37.69,30,,37.69,percent of total billed charges,Drugs,37.69,30,,37.69,percent of total billed charges,Drugs,37.69,30,,37.69,percent of total billed charges,Drugs,37.69,30,,37.69,percent of total billed charges,Drugs,37.69,30,,37.69,percent of total billed charges,Drugs,37.69,30,,37.69,percent of total billed charges,Drugs,42.54,,,42.54,Other,Drug Cost,42.54,,,42.54,Other,Drug Cost,42.54,,,42.54,Other,Drug Cost,42.54,,,42.54,Other,Drug Cost,42.54,,,42.54,Other,Drug Cost,42.71,34,,42.71,percent of total billed charges,Drugs,42.54,,,42.54,Other,Drug Cost,95.72,,,95.72,Other,225% Medicaid APG methodology,59.56,,,59.56,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,5.77,,,5.77,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",42.54,,,42.54,Other,Drug Cost,42.54,,,42.54,Other,Drug Cost,53.18,,,53.18,Other,125% Medicaid APG methodology,0.01,95.72,
OXACILLIN 1000 MG INJ           ,J2700,HCPCS,,40574246,CDM,636,RC,63323-0813-20,NDC,both,1,EA,12.81,10.34,,,10.34,Other,150% of Medicare + 9.63% HCRA Surcharge,6.29,,,6.29,Fee Schedule,Average Sale Price (ASP) x 6,3.84,30,,3.84,percent of total billed charges,Drugs,3.84,30,,3.84,percent of total billed charges,Drugs,3.84,30,,3.84,percent of total billed charges,Drugs,3.84,30,,3.84,percent of total billed charges,Drugs,3.84,30,,3.84,percent of total billed charges,Drugs,6.41,50,,6.41,percent of total billed charges,All Other,3.84,30,,3.84,percent of total billed charges,Drugs,3.84,30,,3.84,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.84,30,,3.84,percent of total billed charges,Drugs,3.84,30,,3.84,percent of total billed charges,Drugs,3.84,30,,3.84,percent of total billed charges,Drugs,3.84,30,,3.84,percent of total billed charges,Drugs,3.84,30,,3.84,percent of total billed charges,Drugs,3.84,30,,3.84,percent of total billed charges,Drugs,3.84,30,,3.84,percent of total billed charges,Drugs,3.84,30,,3.84,percent of total billed charges,Drugs,3.84,30,,3.84,percent of total billed charges,Drugs,3.84,30,,3.84,percent of total billed charges,Drugs,3.84,30,,3.84,percent of total billed charges,Drugs,3.84,30,,3.84,percent of total billed charges,Drugs,3.84,30,,3.84,percent of total billed charges,Drugs,4.18,,,4.18,Other,Drug Cost,4.18,,,4.18,Other,Drug Cost,4.18,,,4.18,Other,Drug Cost,4.18,,,4.18,Other,Drug Cost,4.18,,,4.18,Other,Drug Cost,4.36,34,,4.36,percent of total billed charges,Drugs,4.18,,,4.18,Other,Drug Cost,9.41,,,9.41,Other,225% Medicaid APG methodology,5.85,,,5.85,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,10.06,,,10.06,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.18,,,4.18,Other,Drug Cost,4.18,,,4.18,Other,Drug Cost,5.23,,,5.23,Other,125% Medicaid APG methodology,0.01,10.34,
MEPERIDINE 25MG/ML INJ SLN 1ML  ,J2175,HCPCS,,40574378,CDM,636,RC,00641-6052-25,NDC,both,1,ML,6.58,72.02,,,72.02,Other,150% of Medicare + 9.63% HCRA Surcharge,43.79,,,43.79,Fee Schedule,Average Sale Price (ASP) x 6,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,3.29,50,,3.29,percent of total billed charges,All Other,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,1.97,30,,1.97,percent of total billed charges,Drugs,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,2.24,34,,2.24,percent of total billed charges,Drugs,0.65,,,0.65,Other,Drug Cost,1.46,,,1.46,Other,225% Medicaid APG methodology,0.91,,,0.91,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,70.07,,,70.07,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.65,,,0.65,Other,Drug Cost,0.65,,,0.65,Other,Drug Cost,0.81,,,0.81,Other,125% Medicaid APG methodology,0.01,72.02,
REGADENOSON 0.4MG/5ML IV  5ML   ,J2785,HCPCS,,40574444,CDM,636,RC,60505-6116-00,NDC,both,5,ML,26.36,140.9,,,140.9,Other,150% of Medicare + 9.63% HCRA Surcharge,85.68,,,85.68,Fee Schedule,Average Sale Price (ASP) x 6,7.91,30,,7.91,percent of total billed charges,Drugs,7.91,30,,7.91,percent of total billed charges,Drugs,7.91,30,,7.91,percent of total billed charges,Drugs,7.91,30,,7.91,percent of total billed charges,Drugs,7.91,30,,7.91,percent of total billed charges,Drugs,13.18,50,,13.18,percent of total billed charges,All Other,7.91,30,,7.91,percent of total billed charges,Drugs,7.91,30,,7.91,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,7.91,30,,7.91,percent of total billed charges,Drugs,7.91,30,,7.91,percent of total billed charges,Drugs,7.91,30,,7.91,percent of total billed charges,Drugs,7.91,30,,7.91,percent of total billed charges,Drugs,7.91,30,,7.91,percent of total billed charges,Drugs,7.91,30,,7.91,percent of total billed charges,Drugs,7.91,30,,7.91,percent of total billed charges,Drugs,7.91,30,,7.91,percent of total billed charges,Drugs,7.91,30,,7.91,percent of total billed charges,Drugs,7.91,30,,7.91,percent of total billed charges,Drugs,7.91,30,,7.91,percent of total billed charges,Drugs,7.91,30,,7.91,percent of total billed charges,Drugs,7.91,30,,7.91,percent of total billed charges,Drugs,11.46,,,11.46,Other,Drug Cost,11.46,,,11.46,Other,Drug Cost,11.46,,,11.46,Other,Drug Cost,11.46,,,11.46,Other,Drug Cost,11.46,,,11.46,Other,Drug Cost,8.96,34,,8.96,percent of total billed charges,Drugs,11.46,,,11.46,Other,Drug Cost,25.79,,,25.79,Other,225% Medicaid APG methodology,16.04,,,16.04,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,137.09,,,137.09,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",11.46,,,11.46,Other,Drug Cost,11.46,,,11.46,Other,Drug Cost,14.33,,,14.33,Other,125% Medicaid APG methodology,0.01,140.9,
AMPHTERCIN B LIPOSMAL 50MG INJ  ,J0289,HCPCS,,40574824,CDM,636,RC,00469-3051-30,NDC,both,1,EA,290.82,263.03,,,263.03,Other,150% of Medicare + 9.63% HCRA Surcharge,159.95,,,159.95,Fee Schedule,Average Sale Price (ASP) x 6,87.25,30,,87.25,percent of total billed charges,Drugs,87.25,30,,87.25,percent of total billed charges,Drugs,87.25,30,,87.25,percent of total billed charges,Drugs,87.25,30,,87.25,percent of total billed charges,Drugs,87.25,30,,87.25,percent of total billed charges,Drugs,145.41,50,,145.41,percent of total billed charges,All Other,87.25,30,,87.25,percent of total billed charges,Drugs,87.25,30,,87.25,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,87.25,30,,87.25,percent of total billed charges,Drugs,87.25,30,,87.25,percent of total billed charges,Drugs,87.25,30,,87.25,percent of total billed charges,Drugs,87.25,30,,87.25,percent of total billed charges,Drugs,87.25,30,,87.25,percent of total billed charges,Drugs,87.25,30,,87.25,percent of total billed charges,Drugs,87.25,30,,87.25,percent of total billed charges,Drugs,87.25,30,,87.25,percent of total billed charges,Drugs,87.25,30,,87.25,percent of total billed charges,Drugs,87.25,30,,87.25,percent of total billed charges,Drugs,87.25,30,,87.25,percent of total billed charges,Drugs,87.25,30,,87.25,percent of total billed charges,Drugs,87.25,30,,87.25,percent of total billed charges,Drugs,57.7,,,57.7,Other,Drug Cost,57.7,,,57.7,Other,Drug Cost,57.7,,,57.7,Other,Drug Cost,57.7,,,57.7,Other,Drug Cost,57.7,,,57.7,Other,Drug Cost,98.88,34,,98.88,percent of total billed charges,Drugs,57.7,,,57.7,Other,Drug Cost,129.83,,,129.83,Other,225% Medicaid APG methodology,80.78,,,80.78,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,255.92,,,255.92,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",57.7,,,57.7,Other,Drug Cost,57.7,,,57.7,Other,Drug Cost,72.13,,,72.13,Other,125% Medicaid APG methodology,0.01,263.03,
GEMCITABINE 38MG/ML IV  26.3ML  ,J9201,HCPCS,,40574923,CDM,636,RC,25021-0235-50,NDC,both,1,EA,53.59,36.02,,,36.02,Other,150% of Medicare + 9.63% HCRA Surcharge,21.91,,,21.91,Fee Schedule,Average Sale Price (ASP) x 6,16.08,30,,16.08,percent of total billed charges,Drugs,16.08,30,,16.08,percent of total billed charges,Drugs,16.08,30,,16.08,percent of total billed charges,Drugs,16.08,30,,16.08,percent of total billed charges,Drugs,16.08,30,,16.08,percent of total billed charges,Drugs,26.8,50,,26.8,percent of total billed charges,All Other,16.08,30,,16.08,percent of total billed charges,Drugs,16.08,30,,16.08,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,16.08,30,,16.08,percent of total billed charges,Drugs,16.08,30,,16.08,percent of total billed charges,Drugs,16.08,30,,16.08,percent of total billed charges,Drugs,16.08,30,,16.08,percent of total billed charges,Drugs,16.08,30,,16.08,percent of total billed charges,Drugs,16.08,30,,16.08,percent of total billed charges,Drugs,16.08,30,,16.08,percent of total billed charges,Drugs,16.08,30,,16.08,percent of total billed charges,Drugs,16.08,30,,16.08,percent of total billed charges,Drugs,16.08,30,,16.08,percent of total billed charges,Drugs,16.08,30,,16.08,percent of total billed charges,Drugs,16.08,30,,16.08,percent of total billed charges,Drugs,16.08,30,,16.08,percent of total billed charges,Drugs,9.28,,,9.28,Other,Drug Cost,9.28,,,9.28,Other,Drug Cost,9.28,,,9.28,Other,Drug Cost,9.28,,,9.28,Other,Drug Cost,9.28,,,9.28,Other,Drug Cost,18.22,34,,18.22,percent of total billed charges,Drugs,9.28,,,9.28,Other,Drug Cost,20.88,,,20.88,Other,225% Medicaid APG methodology,12.99,,,12.99,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,35.05,,,35.05,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",9.28,,,9.28,Other,Drug Cost,9.28,,,9.28,Other,Drug Cost,11.6,,,11.6,Other,125% Medicaid APG methodology,0.01,36.02,
ABATACEPT 250 MG IV INJ         ,J0129,HCPCS,,40574972,CDM,636,RC,00003-2187-13,NDC,both,1,EA,4708.9,425.88,,,425.88,Other,150% of Medicare + 9.63% HCRA Surcharge,258.98,,,258.98,Fee Schedule,Average Sale Price (ASP) x 6,1412.67,30,,1412.67,percent of total billed charges,Drugs,1412.67,30,,1412.67,percent of total billed charges,Drugs,1412.67,30,,1412.67,percent of total billed charges,Drugs,1412.67,30,,1412.67,percent of total billed charges,Drugs,1412.67,30,,1412.67,percent of total billed charges,Drugs,2354.45,50,,2354.45,percent of total billed charges,All Other,1412.67,30,,1412.67,percent of total billed charges,Drugs,1412.67,30,,1412.67,percent of total billed charges,Drugs,1601.03,34,"If Charge > 500, then 34 percent",1601.03,percent of total billed charges,Drugs,1412.67,30,,1412.67,percent of total billed charges,Drugs,1412.67,30,,1412.67,percent of total billed charges,Drugs,1412.67,30,,1412.67,percent of total billed charges,Drugs,1412.67,30,,1412.67,percent of total billed charges,Drugs,1412.67,30,,1412.67,percent of total billed charges,Drugs,1412.67,30,,1412.67,percent of total billed charges,Drugs,1412.67,30,,1412.67,percent of total billed charges,Drugs,1412.67,30,,1412.67,percent of total billed charges,Drugs,1412.67,30,,1412.67,percent of total billed charges,Drugs,1412.67,30,,1412.67,percent of total billed charges,Drugs,1412.67,30,,1412.67,percent of total billed charges,Drugs,1412.67,30,,1412.67,percent of total billed charges,Drugs,1412.67,30,,1412.67,percent of total billed charges,Drugs,419.79,,,419.79,Other,Drug Cost,419.79,,,419.79,Other,Drug Cost,419.79,,,419.79,Other,Drug Cost,419.79,,,419.79,Other,Drug Cost,419.79,,,419.79,Other,Drug Cost,1601.03,34,,1601.03,percent of total billed charges,Drugs,419.79,,,419.79,Other,Drug Cost,944.53,,,944.53,Other,225% Medicaid APG methodology,587.71,,,587.71,Other,140% Medicaid APG methodology,1601.03,34,"If Charge > 2,000, then 34 percent",1601.03,percent of total billed charges,Drugs,414.36,,,414.36,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",419.79,,,419.79,Other,Drug Cost,419.79,,,419.79,Other,Drug Cost,524.74,,,524.74,Other,125% Medicaid APG methodology,0.01,2354.45,
PEDS OXACILLIN 20 MG/ML IN D5W  ,J2700,HCPCS,,40575094,CDM,636,RC,55150-0127-15n,NDC,both,1,ML,0.35,10.34,,,10.34,Other,150% of Medicare + 9.63% HCRA Surcharge,6.29,,,6.29,Fee Schedule,Average Sale Price (ASP) x 6,0.11,30,,0.11,percent of total billed charges,Drugs,0.11,30,,0.11,percent of total billed charges,Drugs,0.11,30,,0.11,percent of total billed charges,Drugs,0.11,30,,0.11,percent of total billed charges,Drugs,0.11,30,,0.11,percent of total billed charges,Drugs,0.18,50,,0.18,percent of total billed charges,All Other,0.11,30,,0.11,percent of total billed charges,Drugs,0.11,30,,0.11,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.11,30,,0.11,percent of total billed charges,Drugs,0.11,30,,0.11,percent of total billed charges,Drugs,0.11,30,,0.11,percent of total billed charges,Drugs,0.11,30,,0.11,percent of total billed charges,Drugs,0.11,30,,0.11,percent of total billed charges,Drugs,0.11,30,,0.11,percent of total billed charges,Drugs,0.11,30,,0.11,percent of total billed charges,Drugs,0.11,30,,0.11,percent of total billed charges,Drugs,0.11,30,,0.11,percent of total billed charges,Drugs,0.11,30,,0.11,percent of total billed charges,Drugs,0.11,30,,0.11,percent of total billed charges,Drugs,0.11,30,,0.11,percent of total billed charges,Drugs,0.11,30,,0.11,percent of total billed charges,Drugs,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.12,34,,0.12,percent of total billed charges,Drugs,0.09,,,0.09,Other,Drug Cost,0.2,,,0.2,Other,225% Medicaid APG methodology,0.13,,,0.13,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,10.06,,,10.06,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,10.34,
APREPITANT 40 MG CAP            ,J8501,HCPCS,,40575144,CDM,636,RC,00781-2321-06,NDC,both,1,EA,150.43,41.69,,,41.69,Other,150% of Medicare + 9.63% HCRA Surcharge,25.35,,,25.35,Fee Schedule,Average Sale Price (ASP) x 6,45.13,30,,45.13,percent of total billed charges,Drugs,45.13,30,,45.13,percent of total billed charges,Drugs,45.13,30,,45.13,percent of total billed charges,Drugs,45.13,30,,45.13,percent of total billed charges,Drugs,45.13,30,,45.13,percent of total billed charges,Drugs,75.22,50,,75.22,percent of total billed charges,All Other,45.13,30,,45.13,percent of total billed charges,Drugs,45.13,30,,45.13,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,45.13,30,,45.13,percent of total billed charges,Drugs,45.13,30,,45.13,percent of total billed charges,Drugs,45.13,30,,45.13,percent of total billed charges,Drugs,45.13,30,,45.13,percent of total billed charges,Drugs,45.13,30,,45.13,percent of total billed charges,Drugs,45.13,30,,45.13,percent of total billed charges,Drugs,45.13,30,,45.13,percent of total billed charges,Drugs,45.13,30,,45.13,percent of total billed charges,Drugs,45.13,30,,45.13,percent of total billed charges,Drugs,45.13,30,,45.13,percent of total billed charges,Drugs,45.13,30,,45.13,percent of total billed charges,Drugs,45.13,30,,45.13,percent of total billed charges,Drugs,45.13,30,,45.13,percent of total billed charges,Drugs,12.91,,,12.91,Other,Drug Cost,12.91,,,12.91,Other,Drug Cost,12.91,,,12.91,Other,Drug Cost,12.91,,,12.91,Other,Drug Cost,12.91,,,12.91,Other,Drug Cost,51.15,34,,51.15,percent of total billed charges,Drugs,12.91,,,12.91,Other,Drug Cost,29.05,,,29.05,Other,225% Medicaid APG methodology,18.07,,,18.07,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,40.56,,,40.56,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",12.91,,,12.91,Other,Drug Cost,12.91,,,12.91,Other,Drug Cost,16.14,,,16.14,Other,125% Medicaid APG methodology,0.01,75.22,
PEGFILGRASTIM 6MG/0.6ML SYR     ,J2506,HCPCS,,40575490,CDM,636,RC,55513-0190-01,NDC,both,0.6,ML,15356.25,500.02,,,500.02,Other,150% of Medicare + 9.63% HCRA Surcharge,304.07,,,304.07,Fee Schedule,Average Sale Price (ASP) x 6,4606.88,30,,4606.88,percent of total billed charges,Drugs,4606.88,30,,4606.88,percent of total billed charges,Drugs,4606.88,30,,4606.88,percent of total billed charges,Drugs,4606.88,30,,4606.88,percent of total billed charges,Drugs,4606.88,30,,4606.88,percent of total billed charges,Drugs,7678.13,50,,7678.13,percent of total billed charges,All Other,4606.88,30,,4606.88,percent of total billed charges,Drugs,4606.88,30,,4606.88,percent of total billed charges,Drugs,5221.13,34,"If Charge > 500, then 34 percent",5221.13,percent of total billed charges,Drugs,4606.88,30,,4606.88,percent of total billed charges,Drugs,4606.88,30,,4606.88,percent of total billed charges,Drugs,4606.88,30,,4606.88,percent of total billed charges,Drugs,4606.88,30,,4606.88,percent of total billed charges,Drugs,4606.88,30,,4606.88,percent of total billed charges,Drugs,4606.88,30,,4606.88,percent of total billed charges,Drugs,4606.88,30,,4606.88,percent of total billed charges,Drugs,4606.88,30,,4606.88,percent of total billed charges,Drugs,4606.88,30,,4606.88,percent of total billed charges,Drugs,4606.88,30,,4606.88,percent of total billed charges,Drugs,4606.88,30,,4606.88,percent of total billed charges,Drugs,4606.88,30,,4606.88,percent of total billed charges,Drugs,4606.88,30,,4606.88,percent of total billed charges,Drugs,1735.7,,,1735.7,Other,Drug Cost,1735.7,,,1735.7,Other,Drug Cost,1735.7,,,1735.7,Other,Drug Cost,1735.7,,,1735.7,Other,Drug Cost,1735.7,,,1735.7,Other,Drug Cost,5221.13,34,,5221.13,percent of total billed charges,Drugs,1735.7,,,1735.7,Other,Drug Cost,3905.33,,,3905.33,Other,225% Medicaid APG methodology,2429.98,,,2429.98,Other,140% Medicaid APG methodology,5221.13,34,"If Charge > 2,000, then 34 percent",5221.13,percent of total billed charges,Drugs,486.51,,,486.51,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1735.7,,,1735.7,Other,Drug Cost,1735.7,,,1735.7,Other,Drug Cost,2169.63,,,2169.63,Other,125% Medicaid APG methodology,0.01,7678.13,
APAP 10 MG/ML (ADULTS > 50 KG)  ,J0134,HCPCS,,40575516,CDM,636,RC,63323-0434-00,NDC,both,100,ML,26.01,0.47,,,0.47,Other,150% of Medicare + 9.63% HCRA Surcharge,0.28,,,0.28,Fee Schedule,Average Sale Price (ASP) x 6,7.8,30,,7.8,percent of total billed charges,Drugs,7.8,30,,7.8,percent of total billed charges,Drugs,7.8,30,,7.8,percent of total billed charges,Drugs,7.8,30,,7.8,percent of total billed charges,Drugs,7.8,30,,7.8,percent of total billed charges,Drugs,13.01,50,,13.01,percent of total billed charges,All Other,7.8,30,,7.8,percent of total billed charges,Drugs,7.8,30,,7.8,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,7.8,30,,7.8,percent of total billed charges,Drugs,7.8,30,,7.8,percent of total billed charges,Drugs,7.8,30,,7.8,percent of total billed charges,Drugs,7.8,30,,7.8,percent of total billed charges,Drugs,7.8,30,,7.8,percent of total billed charges,Drugs,7.8,30,,7.8,percent of total billed charges,Drugs,7.8,30,,7.8,percent of total billed charges,Drugs,7.8,30,,7.8,percent of total billed charges,Drugs,7.8,30,,7.8,percent of total billed charges,Drugs,7.8,30,,7.8,percent of total billed charges,Drugs,7.8,30,,7.8,percent of total billed charges,Drugs,7.8,30,,7.8,percent of total billed charges,Drugs,7.8,30,,7.8,percent of total billed charges,Drugs,5.91,,,5.91,Other,Drug Cost,5.91,,,5.91,Other,Drug Cost,5.91,,,5.91,Other,Drug Cost,5.91,,,5.91,Other,Drug Cost,5.91,,,5.91,Other,Drug Cost,8.84,34,,8.84,percent of total billed charges,Drugs,5.91,,,5.91,Other,Drug Cost,13.3,,,13.3,Other,225% Medicaid APG methodology,8.27,,,8.27,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.45,,,0.45,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.91,,,5.91,Other,Drug Cost,5.91,,,5.91,Other,Drug Cost,7.39,,,7.39,Other,125% Medicaid APG methodology,0.01,13.3,
MENINGOCOCC VACC ACYW 0.5ML     ,90734,CPT,,40575532,CDM,636,RC,49281-0589-05,NDC,both,0.5,ML,762.65,300.99,39.4668,,300.99,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,228.8,30,,228.8,percent of total billed charges,Drugs,228.8,30,,228.8,percent of total billed charges,Drugs,228.8,30,,228.8,percent of total billed charges,Drugs,228.8,30,,228.8,percent of total billed charges,Drugs,228.8,30,,228.8,percent of total billed charges,Drugs,381.33,50,,381.33,percent of total billed charges,All Other,228.8,30,,228.8,percent of total billed charges,Drugs,228.8,30,,228.8,percent of total billed charges,Drugs,259.3,34,"If Charge > 500, then 34 percent",259.3,percent of total billed charges,Drugs,228.8,30,,228.8,percent of total billed charges,Drugs,228.8,30,,228.8,percent of total billed charges,Drugs,228.8,30,,228.8,percent of total billed charges,Drugs,228.8,30,,228.8,percent of total billed charges,Drugs,228.8,30,,228.8,percent of total billed charges,Drugs,228.8,30,,228.8,percent of total billed charges,Drugs,228.8,30,,228.8,percent of total billed charges,Drugs,228.8,30,,228.8,percent of total billed charges,Drugs,228.8,30,,228.8,percent of total billed charges,Drugs,228.8,30,,228.8,percent of total billed charges,Drugs,228.8,30,,228.8,percent of total billed charges,Drugs,228.8,30,,228.8,percent of total billed charges,Drugs,228.8,30,,228.8,percent of total billed charges,Drugs,207.79,,,207.79,Other,Drug Cost,207.79,,,207.79,Other,Drug Cost,207.79,,,207.79,Other,Drug Cost,207.79,,,207.79,Other,Drug Cost,207.79,,,207.79,Other,Drug Cost,259.3,34,,259.3,percent of total billed charges,Drugs,207.79,,,207.79,Other,Drug Cost,467.53,,,467.53,Other,225% Medicaid APG methodology,290.91,,,290.91,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",207.79,,,207.79,Other,Drug Cost,207.79,,,207.79,Other,Drug Cost,259.74,,,259.74,Other,125% Medicaid APG methodology,0.01,467.53,
IMM GLOB10%(20G)200ML(PRIVIGEN  ,J1459,HCPCS,,40575623,CDM,636,RC,44206-0438-20,NDC,both,200,ML,6299.48,476.46,,,476.46,Other,150% of Medicare + 9.63% HCRA Surcharge,289.74,,,289.74,Fee Schedule,Average Sale Price (ASP) x 6,1889.84,30,,1889.84,percent of total billed charges,Drugs,1889.84,30,,1889.84,percent of total billed charges,Drugs,1889.84,30,,1889.84,percent of total billed charges,Drugs,1889.84,30,,1889.84,percent of total billed charges,Drugs,1889.84,30,,1889.84,percent of total billed charges,Drugs,3149.74,50,,3149.74,percent of total billed charges,All Other,1889.84,30,,1889.84,percent of total billed charges,Drugs,1889.84,30,,1889.84,percent of total billed charges,Drugs,2141.82,34,"If Charge > 500, then 34 percent",2141.82,percent of total billed charges,Drugs,1889.84,30,,1889.84,percent of total billed charges,Drugs,1889.84,30,,1889.84,percent of total billed charges,Drugs,1889.84,30,,1889.84,percent of total billed charges,Drugs,1889.84,30,,1889.84,percent of total billed charges,Drugs,1889.84,30,,1889.84,percent of total billed charges,Drugs,1889.84,30,,1889.84,percent of total billed charges,Drugs,1889.84,30,,1889.84,percent of total billed charges,Drugs,1889.84,30,,1889.84,percent of total billed charges,Drugs,1889.84,30,,1889.84,percent of total billed charges,Drugs,1889.84,30,,1889.84,percent of total billed charges,Drugs,1889.84,30,,1889.84,percent of total billed charges,Drugs,1889.84,30,,1889.84,percent of total billed charges,Drugs,1889.84,30,,1889.84,percent of total billed charges,Drugs,1220.81,,,1220.81,Other,Drug Cost,1220.81,,,1220.81,Other,Drug Cost,1220.81,,,1220.81,Other,Drug Cost,1220.81,,,1220.81,Other,Drug Cost,1220.81,,,1220.81,Other,Drug Cost,2141.82,34,,2141.82,percent of total billed charges,Drugs,1220.81,,,1220.81,Other,Drug Cost,2746.82,,,2746.82,Other,225% Medicaid APG methodology,1709.13,,,1709.13,Other,140% Medicaid APG methodology,2141.82,34,"If Charge > 2,000, then 34 percent",2141.82,percent of total billed charges,Drugs,463.58,,,463.58,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1220.81,,,1220.81,Other,Drug Cost,1220.81,,,1220.81,Other,Drug Cost,1526.01,,,1526.01,Other,125% Medicaid APG methodology,0.01,3149.74,
IMM GLOB 10% 5G(PRIVIGEN) 50ML  ,J1459,HCPCS,,40575631,CDM,636,RC,44206-0436-05,NDC,both,50,ML,1574.86,476.46,,,476.46,Other,150% of Medicare + 9.63% HCRA Surcharge,289.74,,,289.74,Fee Schedule,Average Sale Price (ASP) x 6,472.46,30,,472.46,percent of total billed charges,Drugs,472.46,30,,472.46,percent of total billed charges,Drugs,472.46,30,,472.46,percent of total billed charges,Drugs,472.46,30,,472.46,percent of total billed charges,Drugs,472.46,30,,472.46,percent of total billed charges,Drugs,787.43,50,,787.43,percent of total billed charges,All Other,472.46,30,,472.46,percent of total billed charges,Drugs,472.46,30,,472.46,percent of total billed charges,Drugs,535.45,34,"If Charge > 500, then 34 percent",535.45,percent of total billed charges,Drugs,472.46,30,,472.46,percent of total billed charges,Drugs,472.46,30,,472.46,percent of total billed charges,Drugs,472.46,30,,472.46,percent of total billed charges,Drugs,472.46,30,,472.46,percent of total billed charges,Drugs,472.46,30,,472.46,percent of total billed charges,Drugs,472.46,30,,472.46,percent of total billed charges,Drugs,472.46,30,,472.46,percent of total billed charges,Drugs,472.46,30,,472.46,percent of total billed charges,Drugs,472.46,30,,472.46,percent of total billed charges,Drugs,472.46,30,,472.46,percent of total billed charges,Drugs,472.46,30,,472.46,percent of total billed charges,Drugs,472.46,30,,472.46,percent of total billed charges,Drugs,472.46,30,,472.46,percent of total billed charges,Drugs,309.18,,,309.18,Other,Drug Cost,309.18,,,309.18,Other,Drug Cost,309.18,,,309.18,Other,Drug Cost,309.18,,,309.18,Other,Drug Cost,309.18,,,309.18,Other,Drug Cost,535.45,34,,535.45,percent of total billed charges,Drugs,309.18,,,309.18,Other,Drug Cost,695.66,,,695.66,Other,225% Medicaid APG methodology,432.85,,,432.85,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,463.58,,,463.58,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",309.18,,,309.18,Other,Drug Cost,309.18,,,309.18,Other,Drug Cost,386.48,,,386.48,Other,125% Medicaid APG methodology,0.01,787.43,
FULVESTRANT 50MG/ML IM SLN 5ML  ,J9395,HCPCS,,40575664,CDM,636,RC,00143-9022-02,NDC,both,5,ML,183.02,83.32,,,83.32,Other,150% of Medicare + 9.63% HCRA Surcharge,50.67,,,50.67,Fee Schedule,Average Sale Price (ASP) x 6,54.91,30,,54.91,percent of total billed charges,Drugs,54.91,30,,54.91,percent of total billed charges,Drugs,54.91,30,,54.91,percent of total billed charges,Drugs,54.91,30,,54.91,percent of total billed charges,Drugs,54.91,30,,54.91,percent of total billed charges,Drugs,91.51,50,,91.51,percent of total billed charges,All Other,54.91,30,,54.91,percent of total billed charges,Drugs,54.91,30,,54.91,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,54.91,30,,54.91,percent of total billed charges,Drugs,54.91,30,,54.91,percent of total billed charges,Drugs,54.91,30,,54.91,percent of total billed charges,Drugs,54.91,30,,54.91,percent of total billed charges,Drugs,54.91,30,,54.91,percent of total billed charges,Drugs,54.91,30,,54.91,percent of total billed charges,Drugs,54.91,30,,54.91,percent of total billed charges,Drugs,54.91,30,,54.91,percent of total billed charges,Drugs,54.91,30,,54.91,percent of total billed charges,Drugs,54.91,30,,54.91,percent of total billed charges,Drugs,54.91,30,,54.91,percent of total billed charges,Drugs,54.91,30,,54.91,percent of total billed charges,Drugs,54.91,30,,54.91,percent of total billed charges,Drugs,23.02,,,23.02,Other,Drug Cost,23.02,,,23.02,Other,Drug Cost,23.02,,,23.02,Other,Drug Cost,23.02,,,23.02,Other,Drug Cost,23.02,,,23.02,Other,Drug Cost,62.23,34,,62.23,percent of total billed charges,Drugs,23.02,,,23.02,Other,Drug Cost,51.8,,,51.8,Other,225% Medicaid APG methodology,32.23,,,32.23,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,81.07,,,81.07,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",23.02,,,23.02,Other,Drug Cost,23.02,,,23.02,Other,Drug Cost,28.78,,,28.78,Other,125% Medicaid APG methodology,0.01,91.51,
PEMBROLIZUMAB 25MG/ML IV  4ML   ,J9271,HCPCS,,40575672,CDM,636,RC,00006-3026-02,NDC,both,4,ML,19755.05,549.87,,,549.87,Other,150% of Medicare + 9.63% HCRA Surcharge,334.38,,,334.38,Fee Schedule,Average Sale Price (ASP) x 6,5926.52,30,,5926.52,percent of total billed charges,Drugs,5926.52,30,,5926.52,percent of total billed charges,Drugs,5926.52,30,,5926.52,percent of total billed charges,Drugs,5926.52,30,,5926.52,percent of total billed charges,Drugs,5926.52,30,,5926.52,percent of total billed charges,Drugs,9877.53,50,,9877.53,percent of total billed charges,All Other,5926.52,30,,5926.52,percent of total billed charges,Drugs,5926.52,30,,5926.52,percent of total billed charges,Drugs,6716.72,34,"If Charge > 500, then 34 percent",6716.72,percent of total billed charges,Drugs,5926.52,30,,5926.52,percent of total billed charges,Drugs,5926.52,30,,5926.52,percent of total billed charges,Drugs,5926.52,30,,5926.52,percent of total billed charges,Drugs,5926.52,30,,5926.52,percent of total billed charges,Drugs,5926.52,30,,5926.52,percent of total billed charges,Drugs,5926.52,30,,5926.52,percent of total billed charges,Drugs,5926.52,30,,5926.52,percent of total billed charges,Drugs,5926.52,30,,5926.52,percent of total billed charges,Drugs,5926.52,30,,5926.52,percent of total billed charges,Drugs,5926.52,30,,5926.52,percent of total billed charges,Drugs,5926.52,30,,5926.52,percent of total billed charges,Drugs,5926.52,30,,5926.52,percent of total billed charges,Drugs,5926.52,30,,5926.52,percent of total billed charges,Drugs,4093.09,,,4093.09,Other,Drug Cost,4093.09,,,4093.09,Other,Drug Cost,4093.09,,,4093.09,Other,Drug Cost,4093.09,,,4093.09,Other,Drug Cost,4093.09,,,4093.09,Other,Drug Cost,6716.72,34,,6716.72,percent of total billed charges,Drugs,4093.09,,,4093.09,Other,Drug Cost,9209.45,,,9209.45,Other,225% Medicaid APG methodology,5730.33,,,5730.33,Other,140% Medicaid APG methodology,6716.72,34,"If Charge > 2,000, then 34 percent",6716.72,percent of total billed charges,Drugs,535.01,,,535.01,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4093.09,,,4093.09,Other,Drug Cost,4093.09,,,4093.09,Other,Drug Cost,5116.36,,,5116.36,Other,125% Medicaid APG methodology,0.01,9877.53,
HEPATITIS B IMM GLOB (NABI-HB)  ,90371,CPT,,40575995,CDM,636,RC,69800-4202-01,NDC,both,1,ML,527.14,1360.54,,,1360.54,Other,150% of Medicare + 9.63% HCRA Surcharge,827.35,,,827.35,Fee Schedule,Average Sale Price (ASP) x 6,158.14,30,,158.14,percent of total billed charges,Drugs,158.14,30,,158.14,percent of total billed charges,Drugs,158.14,30,,158.14,percent of total billed charges,Drugs,158.14,30,,158.14,percent of total billed charges,Drugs,158.14,30,,158.14,percent of total billed charges,Drugs,263.57,50,,263.57,percent of total billed charges,All Other,158.14,30,,158.14,percent of total billed charges,Drugs,158.14,30,,158.14,percent of total billed charges,Drugs,179.23,34,"If Charge > 500, then 34 percent",179.23,percent of total billed charges,Drugs,158.14,30,,158.14,percent of total billed charges,Drugs,158.14,30,,158.14,percent of total billed charges,Drugs,158.14,30,,158.14,percent of total billed charges,Drugs,158.14,30,,158.14,percent of total billed charges,Drugs,158.14,30,,158.14,percent of total billed charges,Drugs,158.14,30,,158.14,percent of total billed charges,Drugs,158.14,30,,158.14,percent of total billed charges,Drugs,158.14,30,,158.14,percent of total billed charges,Drugs,158.14,30,,158.14,percent of total billed charges,Drugs,158.14,30,,158.14,percent of total billed charges,Drugs,158.14,30,,158.14,percent of total billed charges,Drugs,158.14,30,,158.14,percent of total billed charges,Drugs,158.14,30,,158.14,percent of total billed charges,Drugs,107.17,,,107.17,Other,Drug Cost,107.17,,,107.17,Other,Drug Cost,107.17,,,107.17,Other,Drug Cost,107.17,,,107.17,Other,Drug Cost,107.17,,,107.17,Other,Drug Cost,179.23,34,,179.23,percent of total billed charges,Drugs,107.17,,,107.17,Other,Drug Cost,241.13,,,241.13,Other,225% Medicaid APG methodology,150.04,,,150.04,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1323.76,,,1323.76,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",107.17,,,107.17,Other,Drug Cost,107.17,,,107.17,Other,Drug Cost,133.96,,,133.96,Other,125% Medicaid APG methodology,0.01,1360.54,
PHYTONADIONE 10MG/ML NS         ,J3430,HCPCS,,40576050,CDM,636,RC,00409-9158-25,NDC,both,1,ML,83.34,28.6,,,28.6,Other,150% of Medicare + 9.63% HCRA Surcharge,17.39,,,17.39,Fee Schedule,Average Sale Price (ASP) x 6,25,30,,25,percent of total billed charges,Drugs,25,30,,25,percent of total billed charges,Drugs,25,30,,25,percent of total billed charges,Drugs,25,30,,25,percent of total billed charges,Drugs,25,30,,25,percent of total billed charges,Drugs,41.67,50,,41.67,percent of total billed charges,All Other,25,30,,25,percent of total billed charges,Drugs,25,30,,25,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,25,30,,25,percent of total billed charges,Drugs,25,30,,25,percent of total billed charges,Drugs,25,30,,25,percent of total billed charges,Drugs,25,30,,25,percent of total billed charges,Drugs,25,30,,25,percent of total billed charges,Drugs,25,30,,25,percent of total billed charges,Drugs,25,30,,25,percent of total billed charges,Drugs,25,30,,25,percent of total billed charges,Drugs,25,30,,25,percent of total billed charges,Drugs,25,30,,25,percent of total billed charges,Drugs,25,30,,25,percent of total billed charges,Drugs,25,30,,25,percent of total billed charges,Drugs,25,30,,25,percent of total billed charges,Drugs,47.99,,,47.99,Other,Drug Cost,47.99,,,47.99,Other,Drug Cost,47.99,,,47.99,Other,Drug Cost,47.99,,,47.99,Other,Drug Cost,47.99,,,47.99,Other,Drug Cost,28.34,34,,28.34,percent of total billed charges,Drugs,47.99,,,47.99,Other,Drug Cost,107.98,,,107.98,Other,225% Medicaid APG methodology,67.19,,,67.19,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,27.83,,,27.83,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",47.99,,,47.99,Other,Drug Cost,47.99,,,47.99,Other,Drug Cost,59.99,,,59.99,Other,125% Medicaid APG methodology,0.01,107.98,
OCTREOTIDE ACETATE 20MGINJ KIT  ,J2353,HCPCS,,40576084,CDM,636,RC,00078-0818-81,NDC,both,1,EA,14420.84,2080.19,,,2080.19,Other,150% of Medicare + 9.63% HCRA Surcharge,1264.97,,,1264.97,Fee Schedule,Average Sale Price (ASP) x 6,4326.25,30,,4326.25,percent of total billed charges,Drugs,4326.25,30,,4326.25,percent of total billed charges,Drugs,4326.25,30,,4326.25,percent of total billed charges,Drugs,4326.25,30,,4326.25,percent of total billed charges,Drugs,4326.25,30,,4326.25,percent of total billed charges,Drugs,7210.42,50,,7210.42,percent of total billed charges,All Other,4326.25,30,,4326.25,percent of total billed charges,Drugs,4326.25,30,,4326.25,percent of total billed charges,Drugs,4903.09,34,"If Charge > 500, then 34 percent",4903.09,percent of total billed charges,Drugs,4326.25,30,,4326.25,percent of total billed charges,Drugs,4326.25,30,,4326.25,percent of total billed charges,Drugs,4326.25,30,,4326.25,percent of total billed charges,Drugs,4326.25,30,,4326.25,percent of total billed charges,Drugs,4326.25,30,,4326.25,percent of total billed charges,Drugs,4326.25,30,,4326.25,percent of total billed charges,Drugs,4326.25,30,,4326.25,percent of total billed charges,Drugs,4326.25,30,,4326.25,percent of total billed charges,Drugs,4326.25,30,,4326.25,percent of total billed charges,Drugs,4326.25,30,,4326.25,percent of total billed charges,Drugs,4326.25,30,,4326.25,percent of total billed charges,Drugs,4326.25,30,,4326.25,percent of total billed charges,Drugs,4326.25,30,,4326.25,percent of total billed charges,Drugs,973.07,,,973.07,Other,Drug Cost,973.07,,,973.07,Other,Drug Cost,973.07,,,973.07,Other,Drug Cost,973.07,,,973.07,Other,Drug Cost,973.07,,,973.07,Other,Drug Cost,4903.09,34,,4903.09,percent of total billed charges,Drugs,973.07,,,973.07,Other,Drug Cost,2189.41,,,2189.41,Other,225% Medicaid APG methodology,1362.3,,,1362.3,Other,140% Medicaid APG methodology,4903.09,34,"If Charge > 2,000, then 34 percent",4903.09,percent of total billed charges,Drugs,2023.96,,,2023.96,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",973.07,,,973.07,Other,Drug Cost,973.07,,,973.07,Other,Drug Cost,1216.34,,,1216.34,Other,125% Medicaid APG methodology,0.01,7210.42,
DEXRAZOXANE 500 MG IV INJ       ,J1190,HCPCS,,40576159,CDM,636,RC,51991-0942-98,NDC,both,1,EA,1927.42,1065.66,,,1065.66,Other,150% of Medicare + 9.63% HCRA Surcharge,648.04,,,648.04,Fee Schedule,Average Sale Price (ASP) x 6,578.23,30,,578.23,percent of total billed charges,Drugs,578.23,30,,578.23,percent of total billed charges,Drugs,578.23,30,,578.23,percent of total billed charges,Drugs,578.23,30,,578.23,percent of total billed charges,Drugs,578.23,30,,578.23,percent of total billed charges,Drugs,963.71,50,,963.71,percent of total billed charges,All Other,578.23,30,,578.23,percent of total billed charges,Drugs,578.23,30,,578.23,percent of total billed charges,Drugs,655.32,34,"If Charge > 500, then 34 percent",655.32,percent of total billed charges,Drugs,578.23,30,,578.23,percent of total billed charges,Drugs,578.23,30,,578.23,percent of total billed charges,Drugs,578.23,30,,578.23,percent of total billed charges,Drugs,578.23,30,,578.23,percent of total billed charges,Drugs,578.23,30,,578.23,percent of total billed charges,Drugs,578.23,30,,578.23,percent of total billed charges,Drugs,578.23,30,,578.23,percent of total billed charges,Drugs,578.23,30,,578.23,percent of total billed charges,Drugs,578.23,30,,578.23,percent of total billed charges,Drugs,578.23,30,,578.23,percent of total billed charges,Drugs,578.23,30,,578.23,percent of total billed charges,Drugs,578.23,30,,578.23,percent of total billed charges,Drugs,578.23,30,,578.23,percent of total billed charges,Drugs,170.65,,,170.65,Other,Drug Cost,170.65,,,170.65,Other,Drug Cost,170.65,,,170.65,Other,Drug Cost,170.65,,,170.65,Other,Drug Cost,170.65,,,170.65,Other,Drug Cost,655.32,34,,655.32,percent of total billed charges,Drugs,170.65,,,170.65,Other,Drug Cost,383.96,,,383.96,Other,225% Medicaid APG methodology,238.91,,,238.91,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1036.86,,,1036.86,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",170.65,,,170.65,Other,Drug Cost,170.65,,,170.65,Other,Drug Cost,213.31,,,213.31,Other,125% Medicaid APG methodology,0.01,1065.66,
DOCETAXEL 20MG/ML IV SOLN 1ML   ,J9171,HCPCS,,40576191,CDM,636,RC,00955-1020-01,NDC,both,1,ML,354.66,9.82,,,9.82,Other,150% of Medicare + 9.63% HCRA Surcharge,5.97,,,5.97,Fee Schedule,Average Sale Price (ASP) x 6,106.4,30,,106.4,percent of total billed charges,Drugs,106.4,30,,106.4,percent of total billed charges,Drugs,106.4,30,,106.4,percent of total billed charges,Drugs,106.4,30,,106.4,percent of total billed charges,Drugs,106.4,30,,106.4,percent of total billed charges,Drugs,177.33,50,,177.33,percent of total billed charges,All Other,106.4,30,,106.4,percent of total billed charges,Drugs,106.4,30,,106.4,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,106.4,30,,106.4,percent of total billed charges,Drugs,106.4,30,,106.4,percent of total billed charges,Drugs,106.4,30,,106.4,percent of total billed charges,Drugs,106.4,30,,106.4,percent of total billed charges,Drugs,106.4,30,,106.4,percent of total billed charges,Drugs,106.4,30,,106.4,percent of total billed charges,Drugs,106.4,30,,106.4,percent of total billed charges,Drugs,106.4,30,,106.4,percent of total billed charges,Drugs,106.4,30,,106.4,percent of total billed charges,Drugs,106.4,30,,106.4,percent of total billed charges,Drugs,106.4,30,,106.4,percent of total billed charges,Drugs,106.4,30,,106.4,percent of total billed charges,Drugs,106.4,30,,106.4,percent of total billed charges,Drugs,7.4,,,7.4,Other,Drug Cost,7.4,,,7.4,Other,Drug Cost,7.4,,,7.4,Other,Drug Cost,7.4,,,7.4,Other,Drug Cost,7.4,,,7.4,Other,Drug Cost,120.58,34,,120.58,percent of total billed charges,Drugs,7.4,,,7.4,Other,Drug Cost,16.65,,,16.65,Other,225% Medicaid APG methodology,10.36,,,10.36,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,9.55,,,9.55,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",7.4,,,7.4,Other,Drug Cost,7.4,,,7.4,Other,Drug Cost,9.25,,,9.25,Other,125% Medicaid APG methodology,0.01,177.33,
DOCETAXEL 20MG/ML IV SOLN 4ML   ,J9171,HCPCS,,40576209,CDM,636,RC,16729-0267-64,NDC,both,4,ML,134.89,9.82,,,9.82,Other,150% of Medicare + 9.63% HCRA Surcharge,5.97,,,5.97,Fee Schedule,Average Sale Price (ASP) x 6,40.47,30,,40.47,percent of total billed charges,Drugs,40.47,30,,40.47,percent of total billed charges,Drugs,40.47,30,,40.47,percent of total billed charges,Drugs,40.47,30,,40.47,percent of total billed charges,Drugs,40.47,30,,40.47,percent of total billed charges,Drugs,67.45,50,,67.45,percent of total billed charges,All Other,40.47,30,,40.47,percent of total billed charges,Drugs,40.47,30,,40.47,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,40.47,30,,40.47,percent of total billed charges,Drugs,40.47,30,,40.47,percent of total billed charges,Drugs,40.47,30,,40.47,percent of total billed charges,Drugs,40.47,30,,40.47,percent of total billed charges,Drugs,40.47,30,,40.47,percent of total billed charges,Drugs,40.47,30,,40.47,percent of total billed charges,Drugs,40.47,30,,40.47,percent of total billed charges,Drugs,40.47,30,,40.47,percent of total billed charges,Drugs,40.47,30,,40.47,percent of total billed charges,Drugs,40.47,30,,40.47,percent of total billed charges,Drugs,40.47,30,,40.47,percent of total billed charges,Drugs,40.47,30,,40.47,percent of total billed charges,Drugs,40.47,30,,40.47,percent of total billed charges,Drugs,7.91,,,7.91,Other,Drug Cost,7.91,,,7.91,Other,Drug Cost,7.91,,,7.91,Other,Drug Cost,7.91,,,7.91,Other,Drug Cost,7.91,,,7.91,Other,Drug Cost,45.86,34,,45.86,percent of total billed charges,Drugs,7.91,,,7.91,Other,Drug Cost,17.8,,,17.8,Other,225% Medicaid APG methodology,11.07,,,11.07,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,9.55,,,9.55,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",7.91,,,7.91,Other,Drug Cost,7.91,,,7.91,Other,Drug Cost,9.89,,,9.89,Other,125% Medicaid APG methodology,0.01,67.45,
INSULIN REG HUM 500UNIT/ML      ,J1815,HCPCS,,40576217,CDM,636,RC,00002-8501-01,NDC,both,1,ML,0.49,0.19,39.4668,,0.19,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.25,50,,0.25,percent of total billed charges,All Other,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.15,30,,0.15,percent of total billed charges,Drugs,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.17,34,,0.17,percent of total billed charges,Drugs,0.14,,,0.14,Other,Drug Cost,0.32,,,0.32,Other,225% Medicaid APG methodology,0.2,,,0.2,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.14,,,0.14,Other,Drug Cost,0.14,,,0.14,Other,Drug Cost,0.18,,,0.18,Other,125% Medicaid APG methodology,0.01,0.32,
OXALIPLATIN 5MG/ML IV SLN 10ML  ,J9263,HCPCS,,40576225,CDM,636,RC,25021-0233-10,NDC,both,10,ML,65.07,0.7,,,0.7,Other,150% of Medicare + 9.63% HCRA Surcharge,0.43,,,0.43,Fee Schedule,Average Sale Price (ASP) x 6,19.52,30,,19.52,percent of total billed charges,Drugs,19.52,30,,19.52,percent of total billed charges,Drugs,19.52,30,,19.52,percent of total billed charges,Drugs,19.52,30,,19.52,percent of total billed charges,Drugs,19.52,30,,19.52,percent of total billed charges,Drugs,32.54,50,,32.54,percent of total billed charges,All Other,19.52,30,,19.52,percent of total billed charges,Drugs,19.52,30,,19.52,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,19.52,30,,19.52,percent of total billed charges,Drugs,19.52,30,,19.52,percent of total billed charges,Drugs,19.52,30,,19.52,percent of total billed charges,Drugs,19.52,30,,19.52,percent of total billed charges,Drugs,19.52,30,,19.52,percent of total billed charges,Drugs,19.52,30,,19.52,percent of total billed charges,Drugs,19.52,30,,19.52,percent of total billed charges,Drugs,19.52,30,,19.52,percent of total billed charges,Drugs,19.52,30,,19.52,percent of total billed charges,Drugs,19.52,30,,19.52,percent of total billed charges,Drugs,19.52,30,,19.52,percent of total billed charges,Drugs,19.52,30,,19.52,percent of total billed charges,Drugs,19.52,30,,19.52,percent of total billed charges,Drugs,1.93,,,1.93,Other,Drug Cost,1.93,,,1.93,Other,Drug Cost,1.93,,,1.93,Other,Drug Cost,1.93,,,1.93,Other,Drug Cost,1.93,,,1.93,Other,Drug Cost,22.12,34,,22.12,percent of total billed charges,Drugs,1.93,,,1.93,Other,Drug Cost,4.34,,,4.34,Other,225% Medicaid APG methodology,2.7,,,2.7,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.68,,,0.68,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.93,,,1.93,Other,Drug Cost,1.93,,,1.93,Other,Drug Cost,2.41,,,2.41,Other,125% Medicaid APG methodology,0.01,32.54,
SIROLIMUS 0.5 MG TAB            ,J7520,HCPCS,,40576332,CDM,636,RC,67877-0746-01,NDC,both,1,EA,8.16,26.36,,,26.36,Other,150% of Medicare + 9.63% HCRA Surcharge,16.03,,,16.03,Fee Schedule,Average Sale Price (ASP) x 6,2.45,30,,2.45,percent of total billed charges,Drugs,2.45,30,,2.45,percent of total billed charges,Drugs,2.45,30,,2.45,percent of total billed charges,Drugs,2.45,30,,2.45,percent of total billed charges,Drugs,2.45,30,,2.45,percent of total billed charges,Drugs,4.08,50,,4.08,percent of total billed charges,All Other,2.45,30,,2.45,percent of total billed charges,Drugs,2.45,30,,2.45,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.45,30,,2.45,percent of total billed charges,Drugs,2.45,30,,2.45,percent of total billed charges,Drugs,2.45,30,,2.45,percent of total billed charges,Drugs,2.45,30,,2.45,percent of total billed charges,Drugs,2.45,30,,2.45,percent of total billed charges,Drugs,2.45,30,,2.45,percent of total billed charges,Drugs,2.45,30,,2.45,percent of total billed charges,Drugs,2.45,30,,2.45,percent of total billed charges,Drugs,2.45,30,,2.45,percent of total billed charges,Drugs,2.45,30,,2.45,percent of total billed charges,Drugs,2.45,30,,2.45,percent of total billed charges,Drugs,2.45,30,,2.45,percent of total billed charges,Drugs,2.45,30,,2.45,percent of total billed charges,Drugs,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,2.77,34,,2.77,percent of total billed charges,Drugs,0.54,,,0.54,Other,Drug Cost,1.22,,,1.22,Other,225% Medicaid APG methodology,0.76,,,0.76,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,25.65,,,25.65,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.54,,,0.54,Other,Drug Cost,0.54,,,0.54,Other,Drug Cost,0.68,,,0.68,Other,125% Medicaid APG methodology,0.01,26.36,
ZOLEDRONIC ACID 5MG/100ML IV    ,J3489,HCPCS,,40576340,CDM,636,RC,71288-0806-51,NDC,both,100,ML,112.25,71.17,,,71.17,Other,150% of Medicare + 9.63% HCRA Surcharge,43.28,,,43.28,Fee Schedule,Average Sale Price (ASP) x 6,33.68,30,,33.68,percent of total billed charges,Drugs,33.68,30,,33.68,percent of total billed charges,Drugs,33.68,30,,33.68,percent of total billed charges,Drugs,33.68,30,,33.68,percent of total billed charges,Drugs,33.68,30,,33.68,percent of total billed charges,Drugs,56.13,50,,56.13,percent of total billed charges,All Other,33.68,30,,33.68,percent of total billed charges,Drugs,33.68,30,,33.68,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,33.68,30,,33.68,percent of total billed charges,Drugs,33.68,30,,33.68,percent of total billed charges,Drugs,33.68,30,,33.68,percent of total billed charges,Drugs,33.68,30,,33.68,percent of total billed charges,Drugs,33.68,30,,33.68,percent of total billed charges,Drugs,33.68,30,,33.68,percent of total billed charges,Drugs,33.68,30,,33.68,percent of total billed charges,Drugs,33.68,30,,33.68,percent of total billed charges,Drugs,33.68,30,,33.68,percent of total billed charges,Drugs,33.68,30,,33.68,percent of total billed charges,Drugs,33.68,30,,33.68,percent of total billed charges,Drugs,33.68,30,,33.68,percent of total billed charges,Drugs,33.68,30,,33.68,percent of total billed charges,Drugs,26.49,,,26.49,Other,Drug Cost,26.49,,,26.49,Other,Drug Cost,26.49,,,26.49,Other,Drug Cost,26.49,,,26.49,Other,Drug Cost,26.49,,,26.49,Other,Drug Cost,38.17,34,,38.17,percent of total billed charges,Drugs,26.49,,,26.49,Other,Drug Cost,59.6,,,59.6,Other,225% Medicaid APG methodology,37.09,,,37.09,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,69.24,,,69.24,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",26.49,,,26.49,Other,Drug Cost,26.49,,,26.49,Other,Drug Cost,33.11,,,33.11,Other,125% Medicaid APG methodology,0.01,71.17,
PROTAMINE 10MG/ML INJ SOLN 5ML  ,J2720,HCPCS,,40576498,CDM,636,RC,63323-0229-15,NDC,both,5,ML,30.8,16.36,,,16.36,Other,150% of Medicare + 9.63% HCRA Surcharge,9.95,,,9.95,Fee Schedule,Average Sale Price (ASP) x 6,9.24,30,,9.24,percent of total billed charges,Drugs,9.24,30,,9.24,percent of total billed charges,Drugs,9.24,30,,9.24,percent of total billed charges,Drugs,9.24,30,,9.24,percent of total billed charges,Drugs,9.24,30,,9.24,percent of total billed charges,Drugs,15.4,50,,15.4,percent of total billed charges,All Other,9.24,30,,9.24,percent of total billed charges,Drugs,9.24,30,,9.24,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,9.24,30,,9.24,percent of total billed charges,Drugs,9.24,30,,9.24,percent of total billed charges,Drugs,9.24,30,,9.24,percent of total billed charges,Drugs,9.24,30,,9.24,percent of total billed charges,Drugs,9.24,30,,9.24,percent of total billed charges,Drugs,9.24,30,,9.24,percent of total billed charges,Drugs,9.24,30,,9.24,percent of total billed charges,Drugs,9.24,30,,9.24,percent of total billed charges,Drugs,9.24,30,,9.24,percent of total billed charges,Drugs,9.24,30,,9.24,percent of total billed charges,Drugs,9.24,30,,9.24,percent of total billed charges,Drugs,9.24,30,,9.24,percent of total billed charges,Drugs,9.24,30,,9.24,percent of total billed charges,Drugs,9.79,,,9.79,Other,Drug Cost,9.79,,,9.79,Other,Drug Cost,9.79,,,9.79,Other,Drug Cost,9.79,,,9.79,Other,Drug Cost,9.79,,,9.79,Other,Drug Cost,10.47,34,,10.47,percent of total billed charges,Drugs,9.79,,,9.79,Other,Drug Cost,22.03,,,22.03,Other,225% Medicaid APG methodology,13.71,,,13.71,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,15.92,,,15.92,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",9.79,,,9.79,Other,Drug Cost,9.79,,,9.79,Other,Drug Cost,12.24,,,12.24,Other,125% Medicaid APG methodology,0.01,22.03,
CABAZITAXEL60MG/1.5ML IV 1.5ML  ,J9043,HCPCS,,40576530,CDM,636,RC,00024-5824-11,NDC,both,1.5,ML,41378.33,2076.48,,,2076.48,Other,150% of Medicare + 9.63% HCRA Surcharge,1262.72,,,1262.72,Fee Schedule,Average Sale Price (ASP) x 6,12413.5,30,,12413.5,percent of total billed charges,Drugs,12413.5,30,,12413.5,percent of total billed charges,Drugs,12413.5,30,,12413.5,percent of total billed charges,Drugs,12413.5,30,,12413.5,percent of total billed charges,Drugs,12413.5,30,,12413.5,percent of total billed charges,Drugs,20689.17,50,,20689.17,percent of total billed charges,All Other,12413.5,30,,12413.5,percent of total billed charges,Drugs,12413.5,30,,12413.5,percent of total billed charges,Drugs,14068.63,34,"If Charge > 500, then 34 percent",14068.63,percent of total billed charges,Drugs,12413.5,30,,12413.5,percent of total billed charges,Drugs,12413.5,30,,12413.5,percent of total billed charges,Drugs,12413.5,30,,12413.5,percent of total billed charges,Drugs,12413.5,30,,12413.5,percent of total billed charges,Drugs,12413.5,30,,12413.5,percent of total billed charges,Drugs,12413.5,30,,12413.5,percent of total billed charges,Drugs,12413.5,30,,12413.5,percent of total billed charges,Drugs,12413.5,30,,12413.5,percent of total billed charges,Drugs,12413.5,30,,12413.5,percent of total billed charges,Drugs,12413.5,30,,12413.5,percent of total billed charges,Drugs,12413.5,30,,12413.5,percent of total billed charges,Drugs,12413.5,30,,12413.5,percent of total billed charges,Drugs,12413.5,30,,12413.5,percent of total billed charges,Drugs,6803.53,,,6803.53,Other,Drug Cost,6803.53,,,6803.53,Other,Drug Cost,6803.53,,,6803.53,Other,Drug Cost,6803.53,,,6803.53,Other,Drug Cost,6803.53,,,6803.53,Other,Drug Cost,14068.63,34,,14068.63,percent of total billed charges,Drugs,6803.53,,,6803.53,Other,Drug Cost,15307.94,,,15307.94,Other,225% Medicaid APG methodology,9524.94,,,9524.94,Other,140% Medicaid APG methodology,14068.63,34,"If Charge > 2,000, then 34 percent",14068.63,percent of total billed charges,Drugs,2020.35,,,2020.35,Other,160% Medicare Fee Schedule,14068.63,34,,14068.63,Other,"Drug Charges > 20,000, then 34% of Charges",6803.53,,,6803.53,Other,Drug Cost,6803.53,,,6803.53,Other,Drug Cost,8504.41,,,8504.41,Other,125% Medicaid APG methodology,1262.72,20689.17,
AMPHTERCIN B LIPOSMAL2MG/MLD5W  ,J0289,HCPCS,,40576548,CDM,636,RC,00469-3051-30n,NDC,both,1,ML,11.31,263.03,,,263.03,Other,150% of Medicare + 9.63% HCRA Surcharge,159.95,,,159.95,Fee Schedule,Average Sale Price (ASP) x 6,3.39,30,,3.39,percent of total billed charges,Drugs,3.39,30,,3.39,percent of total billed charges,Drugs,3.39,30,,3.39,percent of total billed charges,Drugs,3.39,30,,3.39,percent of total billed charges,Drugs,3.39,30,,3.39,percent of total billed charges,Drugs,5.66,50,,5.66,percent of total billed charges,All Other,3.39,30,,3.39,percent of total billed charges,Drugs,3.39,30,,3.39,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.39,30,,3.39,percent of total billed charges,Drugs,3.39,30,,3.39,percent of total billed charges,Drugs,3.39,30,,3.39,percent of total billed charges,Drugs,3.39,30,,3.39,percent of total billed charges,Drugs,3.39,30,,3.39,percent of total billed charges,Drugs,3.39,30,,3.39,percent of total billed charges,Drugs,3.39,30,,3.39,percent of total billed charges,Drugs,3.39,30,,3.39,percent of total billed charges,Drugs,3.39,30,,3.39,percent of total billed charges,Drugs,3.39,30,,3.39,percent of total billed charges,Drugs,3.39,30,,3.39,percent of total billed charges,Drugs,3.39,30,,3.39,percent of total billed charges,Drugs,3.39,30,,3.39,percent of total billed charges,Drugs,2.14,,,2.14,Other,Drug Cost,2.14,,,2.14,Other,Drug Cost,2.14,,,2.14,Other,Drug Cost,2.14,,,2.14,Other,Drug Cost,2.14,,,2.14,Other,Drug Cost,3.85,34,,3.85,percent of total billed charges,Drugs,2.14,,,2.14,Other,Drug Cost,4.82,,,4.82,Other,225% Medicaid APG methodology,3,,,3,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,255.92,,,255.92,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.14,,,2.14,Other,Drug Cost,2.14,,,2.14,Other,Drug Cost,2.68,,,2.68,Other,125% Medicaid APG methodology,0.01,263.03,
ENOXAPARIN 40MG/0.4ML INJ SLN   ,J1650,HCPCS,,40576779,CDM,636,RC,00703-8540-23,NDC,both,0.4,ML,11.73,6.71,,,6.71,Other,150% of Medicare + 9.63% HCRA Surcharge,4.08,,,4.08,Fee Schedule,Average Sale Price (ASP) x 6,3.52,30,,3.52,percent of total billed charges,Drugs,3.52,30,,3.52,percent of total billed charges,Drugs,3.52,30,,3.52,percent of total billed charges,Drugs,3.52,30,,3.52,percent of total billed charges,Drugs,3.52,30,,3.52,percent of total billed charges,Drugs,5.87,50,,5.87,percent of total billed charges,All Other,3.52,30,,3.52,percent of total billed charges,Drugs,3.52,30,,3.52,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.52,30,,3.52,percent of total billed charges,Drugs,3.52,30,,3.52,percent of total billed charges,Drugs,3.52,30,,3.52,percent of total billed charges,Drugs,3.52,30,,3.52,percent of total billed charges,Drugs,3.52,30,,3.52,percent of total billed charges,Drugs,3.52,30,,3.52,percent of total billed charges,Drugs,3.52,30,,3.52,percent of total billed charges,Drugs,3.52,30,,3.52,percent of total billed charges,Drugs,3.52,30,,3.52,percent of total billed charges,Drugs,3.52,30,,3.52,percent of total billed charges,Drugs,3.52,30,,3.52,percent of total billed charges,Drugs,3.52,30,,3.52,percent of total billed charges,Drugs,3.52,30,,3.52,percent of total billed charges,Drugs,1.1,,,1.1,Other,Drug Cost,1.1,,,1.1,Other,Drug Cost,1.1,,,1.1,Other,Drug Cost,1.1,,,1.1,Other,Drug Cost,1.1,,,1.1,Other,Drug Cost,3.99,34,,3.99,percent of total billed charges,Drugs,1.1,,,1.1,Other,Drug Cost,2.48,,,2.48,Other,225% Medicaid APG methodology,1.54,,,1.54,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.53,,,6.53,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.1,,,1.1,Other,Drug Cost,1.1,,,1.1,Other,Drug Cost,1.38,,,1.38,Other,125% Medicaid APG methodology,0.01,6.71,
ENOXAPARIN 30MG/0.3ML INJ SLN   ,J1650,HCPCS,,40576787,CDM,636,RC,63323-0559-93,NDC,both,0.3,ML,19.43,6.71,,,6.71,Other,150% of Medicare + 9.63% HCRA Surcharge,4.08,,,4.08,Fee Schedule,Average Sale Price (ASP) x 6,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,9.72,50,,9.72,percent of total billed charges,All Other,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,5.83,30,,5.83,percent of total billed charges,Drugs,2.17,,,2.17,Other,Drug Cost,2.17,,,2.17,Other,Drug Cost,2.17,,,2.17,Other,Drug Cost,2.17,,,2.17,Other,Drug Cost,2.17,,,2.17,Other,Drug Cost,6.61,34,,6.61,percent of total billed charges,Drugs,2.17,,,2.17,Other,Drug Cost,4.88,,,4.88,Other,225% Medicaid APG methodology,3.04,,,3.04,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.53,,,6.53,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.17,,,2.17,Other,Drug Cost,2.17,,,2.17,Other,Drug Cost,2.71,,,2.71,Other,125% Medicaid APG methodology,0.01,9.72,
ENOXAPARIN 60MG/0.6ML INJ SLN   ,J1650,HCPCS,,40576795,CDM,636,RC,71288-0434-85,NDC,both,0.6,ML,17.47,6.71,,,6.71,Other,150% of Medicare + 9.63% HCRA Surcharge,4.08,,,4.08,Fee Schedule,Average Sale Price (ASP) x 6,5.24,30,,5.24,percent of total billed charges,Drugs,5.24,30,,5.24,percent of total billed charges,Drugs,5.24,30,,5.24,percent of total billed charges,Drugs,5.24,30,,5.24,percent of total billed charges,Drugs,5.24,30,,5.24,percent of total billed charges,Drugs,8.74,50,,8.74,percent of total billed charges,All Other,5.24,30,,5.24,percent of total billed charges,Drugs,5.24,30,,5.24,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,5.24,30,,5.24,percent of total billed charges,Drugs,5.24,30,,5.24,percent of total billed charges,Drugs,5.24,30,,5.24,percent of total billed charges,Drugs,5.24,30,,5.24,percent of total billed charges,Drugs,5.24,30,,5.24,percent of total billed charges,Drugs,5.24,30,,5.24,percent of total billed charges,Drugs,5.24,30,,5.24,percent of total billed charges,Drugs,5.24,30,,5.24,percent of total billed charges,Drugs,5.24,30,,5.24,percent of total billed charges,Drugs,5.24,30,,5.24,percent of total billed charges,Drugs,5.24,30,,5.24,percent of total billed charges,Drugs,5.24,30,,5.24,percent of total billed charges,Drugs,5.24,30,,5.24,percent of total billed charges,Drugs,2.19,,,2.19,Other,Drug Cost,2.19,,,2.19,Other,Drug Cost,2.19,,,2.19,Other,Drug Cost,2.19,,,2.19,Other,Drug Cost,2.19,,,2.19,Other,Drug Cost,5.94,34,,5.94,percent of total billed charges,Drugs,2.19,,,2.19,Other,Drug Cost,4.93,,,4.93,Other,225% Medicaid APG methodology,3.07,,,3.07,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.53,,,6.53,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.19,,,2.19,Other,Drug Cost,2.19,,,2.19,Other,Drug Cost,2.74,,,2.74,Other,125% Medicaid APG methodology,0.01,8.74,
ENOXAPARIN 80MG/0.8ML INJ SLN   ,J1650,HCPCS,,40576803,CDM,636,RC,63323-0531-90,NDC,both,0.8,ML,23.24,6.71,,,6.71,Other,150% of Medicare + 9.63% HCRA Surcharge,4.08,,,4.08,Fee Schedule,Average Sale Price (ASP) x 6,6.97,30,,6.97,percent of total billed charges,Drugs,6.97,30,,6.97,percent of total billed charges,Drugs,6.97,30,,6.97,percent of total billed charges,Drugs,6.97,30,,6.97,percent of total billed charges,Drugs,6.97,30,,6.97,percent of total billed charges,Drugs,11.62,50,,11.62,percent of total billed charges,All Other,6.97,30,,6.97,percent of total billed charges,Drugs,6.97,30,,6.97,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,6.97,30,,6.97,percent of total billed charges,Drugs,6.97,30,,6.97,percent of total billed charges,Drugs,6.97,30,,6.97,percent of total billed charges,Drugs,6.97,30,,6.97,percent of total billed charges,Drugs,6.97,30,,6.97,percent of total billed charges,Drugs,6.97,30,,6.97,percent of total billed charges,Drugs,6.97,30,,6.97,percent of total billed charges,Drugs,6.97,30,,6.97,percent of total billed charges,Drugs,6.97,30,,6.97,percent of total billed charges,Drugs,6.97,30,,6.97,percent of total billed charges,Drugs,6.97,30,,6.97,percent of total billed charges,Drugs,6.97,30,,6.97,percent of total billed charges,Drugs,6.97,30,,6.97,percent of total billed charges,Drugs,4.76,,,4.76,Other,Drug Cost,4.76,,,4.76,Other,Drug Cost,4.76,,,4.76,Other,Drug Cost,4.76,,,4.76,Other,Drug Cost,4.76,,,4.76,Other,Drug Cost,7.9,34,,7.9,percent of total billed charges,Drugs,4.76,,,4.76,Other,Drug Cost,10.71,,,10.71,Other,225% Medicaid APG methodology,6.66,,,6.66,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.53,,,6.53,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.76,,,4.76,Other,Drug Cost,4.76,,,4.76,Other,Drug Cost,5.95,,,5.95,Other,125% Medicaid APG methodology,0.01,11.62,
FENTANYL 50 MCG/ML INJ  20ML    ,J3010,HCPCS,,40576829,CDM,636,RC,00409-9094-31,NDC,both,20,ML,11.62,9.55,,,9.55,Other,150% of Medicare + 9.63% HCRA Surcharge,5.81,,,5.81,Fee Schedule,Average Sale Price (ASP) x 6,3.49,30,,3.49,percent of total billed charges,Drugs,3.49,30,,3.49,percent of total billed charges,Drugs,3.49,30,,3.49,percent of total billed charges,Drugs,3.49,30,,3.49,percent of total billed charges,Drugs,3.49,30,,3.49,percent of total billed charges,Drugs,5.81,50,,5.81,percent of total billed charges,All Other,3.49,30,,3.49,percent of total billed charges,Drugs,3.49,30,,3.49,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.49,30,,3.49,percent of total billed charges,Drugs,3.49,30,,3.49,percent of total billed charges,Drugs,3.49,30,,3.49,percent of total billed charges,Drugs,3.49,30,,3.49,percent of total billed charges,Drugs,3.49,30,,3.49,percent of total billed charges,Drugs,3.49,30,,3.49,percent of total billed charges,Drugs,3.49,30,,3.49,percent of total billed charges,Drugs,3.49,30,,3.49,percent of total billed charges,Drugs,3.49,30,,3.49,percent of total billed charges,Drugs,3.49,30,,3.49,percent of total billed charges,Drugs,3.49,30,,3.49,percent of total billed charges,Drugs,3.49,30,,3.49,percent of total billed charges,Drugs,3.49,30,,3.49,percent of total billed charges,Drugs,3.59,,,3.59,Other,Drug Cost,3.59,,,3.59,Other,Drug Cost,3.59,,,3.59,Other,Drug Cost,3.59,,,3.59,Other,Drug Cost,3.59,,,3.59,Other,Drug Cost,3.95,34,,3.95,percent of total billed charges,Drugs,3.59,,,3.59,Other,Drug Cost,8.08,,,8.08,Other,225% Medicaid APG methodology,5.03,,,5.03,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,9.29,,,9.29,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.59,,,3.59,Other,Drug Cost,3.59,,,3.59,Other,Drug Cost,4.49,,,4.49,Other,125% Medicaid APG methodology,0.01,9.55,
ROPIVACAINE 0.5% INJ SOLN 30ML  ,J2795,HCPCS,,40576852,CDM,636,RC,63323-0286-35,NDC,both,30,ML,16.21,0.76,,,0.76,Other,150% of Medicare + 9.63% HCRA Surcharge,0.46,,,0.46,Fee Schedule,Average Sale Price (ASP) x 6,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,8.11,50,,8.11,percent of total billed charges,All Other,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,4.86,30,,4.86,percent of total billed charges,Drugs,3.98,,,3.98,Other,Drug Cost,3.98,,,3.98,Other,Drug Cost,3.98,,,3.98,Other,Drug Cost,3.98,,,3.98,Other,Drug Cost,3.98,,,3.98,Other,Drug Cost,5.51,34,,5.51,percent of total billed charges,Drugs,3.98,,,3.98,Other,Drug Cost,8.96,,,8.96,Other,225% Medicaid APG methodology,5.57,,,5.57,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.74,,,0.74,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.98,,,3.98,Other,Drug Cost,3.98,,,3.98,Other,Drug Cost,4.98,,,4.98,Other,125% Medicaid APG methodology,0.01,8.96,
CETUXIMAB 2MG/ML IV SOLN 100ML  ,J9055,HCPCS,,40576894,CDM,636,RC,66733-0958-23,NDC,both,100,ML,4732.49,727.37,,,727.37,Other,150% of Medicare + 9.63% HCRA Surcharge,442.32,,,442.32,Fee Schedule,Average Sale Price (ASP) x 6,1419.75,30,,1419.75,percent of total billed charges,Drugs,1419.75,30,,1419.75,percent of total billed charges,Drugs,1419.75,30,,1419.75,percent of total billed charges,Drugs,1419.75,30,,1419.75,percent of total billed charges,Drugs,1419.75,30,,1419.75,percent of total billed charges,Drugs,2366.25,50,,2366.25,percent of total billed charges,All Other,1419.75,30,,1419.75,percent of total billed charges,Drugs,1419.75,30,,1419.75,percent of total billed charges,Drugs,1609.05,34,"If Charge > 500, then 34 percent",1609.05,percent of total billed charges,Drugs,1419.75,30,,1419.75,percent of total billed charges,Drugs,1419.75,30,,1419.75,percent of total billed charges,Drugs,1419.75,30,,1419.75,percent of total billed charges,Drugs,1419.75,30,,1419.75,percent of total billed charges,Drugs,1419.75,30,,1419.75,percent of total billed charges,Drugs,1419.75,30,,1419.75,percent of total billed charges,Drugs,1419.75,30,,1419.75,percent of total billed charges,Drugs,1419.75,30,,1419.75,percent of total billed charges,Drugs,1419.75,30,,1419.75,percent of total billed charges,Drugs,1419.75,30,,1419.75,percent of total billed charges,Drugs,1419.75,30,,1419.75,percent of total billed charges,Drugs,1419.75,30,,1419.75,percent of total billed charges,Drugs,1419.75,30,,1419.75,percent of total billed charges,Drugs,880.7,,,880.7,Other,Drug Cost,880.7,,,880.7,Other,Drug Cost,880.7,,,880.7,Other,Drug Cost,880.7,,,880.7,Other,Drug Cost,880.7,,,880.7,Other,Drug Cost,1609.05,34,,1609.05,percent of total billed charges,Drugs,880.7,,,880.7,Other,Drug Cost,1981.58,,,1981.58,Other,225% Medicaid APG methodology,1232.98,,,1232.98,Other,140% Medicaid APG methodology,1609.05,34,"If Charge > 2,000, then 34 percent",1609.05,percent of total billed charges,Drugs,707.71,,,707.71,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",880.7,,,880.7,Other,Drug Cost,880.7,,,880.7,Other,Drug Cost,1100.88,,,1100.88,Other,125% Medicaid APG methodology,0.01,2366.25,
ERIBULIN 1MG/2ML IV SOLN 2ML    ,J9179,HCPCS,,40577033,CDM,636,RC,62856-0389-01,NDC,both,2,ML,4368,1322.31,,,1322.31,Other,150% of Medicare + 9.63% HCRA Surcharge,804.1,,,804.1,Fee Schedule,Average Sale Price (ASP) x 6,1310.4,30,,1310.4,percent of total billed charges,Drugs,1310.4,30,,1310.4,percent of total billed charges,Drugs,1310.4,30,,1310.4,percent of total billed charges,Drugs,1310.4,30,,1310.4,percent of total billed charges,Drugs,1310.4,30,,1310.4,percent of total billed charges,Drugs,2184,50,,2184,percent of total billed charges,All Other,1310.4,30,,1310.4,percent of total billed charges,Drugs,1310.4,30,,1310.4,percent of total billed charges,Drugs,1485.12,34,"If Charge > 500, then 34 percent",1485.12,percent of total billed charges,Drugs,1310.4,30,,1310.4,percent of total billed charges,Drugs,1310.4,30,,1310.4,percent of total billed charges,Drugs,1310.4,30,,1310.4,percent of total billed charges,Drugs,1310.4,30,,1310.4,percent of total billed charges,Drugs,1310.4,30,,1310.4,percent of total billed charges,Drugs,1310.4,30,,1310.4,percent of total billed charges,Drugs,1310.4,30,,1310.4,percent of total billed charges,Drugs,1310.4,30,,1310.4,percent of total billed charges,Drugs,1310.4,30,,1310.4,percent of total billed charges,Drugs,1310.4,30,,1310.4,percent of total billed charges,Drugs,1310.4,30,,1310.4,percent of total billed charges,Drugs,1310.4,30,,1310.4,percent of total billed charges,Drugs,1310.4,30,,1310.4,percent of total billed charges,Drugs,758.27,,,758.27,Other,Drug Cost,758.27,,,758.27,Other,Drug Cost,758.27,,,758.27,Other,Drug Cost,758.27,,,758.27,Other,Drug Cost,758.27,,,758.27,Other,Drug Cost,1485.12,34,,1485.12,percent of total billed charges,Drugs,758.27,,,758.27,Other,Drug Cost,1706.11,,,1706.11,Other,225% Medicaid APG methodology,1061.58,,,1061.58,Other,140% Medicaid APG methodology,1485.12,34,"If Charge > 2,000, then 34 percent",1485.12,percent of total billed charges,Drugs,1286.56,,,1286.56,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",758.27,,,758.27,Other,Drug Cost,758.27,,,758.27,Other,Drug Cost,947.84,,,947.84,Other,125% Medicaid APG methodology,0.01,2184,
MIDAZOLAM 2MG CARPUJECT P1MG    ,J2250,HCPCS,,40577058,CDM,636,RC,00409-2305-17,NDC,both,2,ML,2.28,1.4,,,1.4,Other,150% of Medicare + 9.63% HCRA Surcharge,0.85,,,0.85,Fee Schedule,Average Sale Price (ASP) x 6,0.68,30,,0.68,percent of total billed charges,Drugs,0.68,30,,0.68,percent of total billed charges,Drugs,0.68,30,,0.68,percent of total billed charges,Drugs,0.68,30,,0.68,percent of total billed charges,Drugs,0.68,30,,0.68,percent of total billed charges,Drugs,1.14,50,,1.14,percent of total billed charges,All Other,0.68,30,,0.68,percent of total billed charges,Drugs,0.68,30,,0.68,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.68,30,,0.68,percent of total billed charges,Drugs,0.68,30,,0.68,percent of total billed charges,Drugs,0.68,30,,0.68,percent of total billed charges,Drugs,0.68,30,,0.68,percent of total billed charges,Drugs,0.68,30,,0.68,percent of total billed charges,Drugs,0.68,30,,0.68,percent of total billed charges,Drugs,0.68,30,,0.68,percent of total billed charges,Drugs,0.68,30,,0.68,percent of total billed charges,Drugs,0.68,30,,0.68,percent of total billed charges,Drugs,0.68,30,,0.68,percent of total billed charges,Drugs,0.68,30,,0.68,percent of total billed charges,Drugs,0.68,30,,0.68,percent of total billed charges,Drugs,0.68,30,,0.68,percent of total billed charges,Drugs,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.78,34,,0.78,percent of total billed charges,Drugs,0.36,,,0.36,Other,Drug Cost,0.81,,,0.81,Other,225% Medicaid APG methodology,0.5,,,0.5,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.36,,,1.36,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.36,,,0.36,Other,Drug Cost,0.36,,,0.36,Other,Drug Cost,0.45,,,0.45,Other,125% Medicaid APG methodology,0.01,1.4,
ENOXAPARIN 100MG/ML INJ 1ML     ,J1650,HCPCS,,40577272,CDM,636,RC,63323-0605-84,NDC,both,1,ML,29.96,6.71,,,6.71,Other,150% of Medicare + 9.63% HCRA Surcharge,4.08,,,4.08,Fee Schedule,Average Sale Price (ASP) x 6,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,14.98,50,,14.98,percent of total billed charges,All Other,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,8.99,30,,8.99,percent of total billed charges,Drugs,5.94,,,5.94,Other,Drug Cost,5.94,,,5.94,Other,Drug Cost,5.94,,,5.94,Other,Drug Cost,5.94,,,5.94,Other,Drug Cost,5.94,,,5.94,Other,Drug Cost,10.19,34,,10.19,percent of total billed charges,Drugs,5.94,,,5.94,Other,Drug Cost,13.37,,,13.37,Other,225% Medicaid APG methodology,8.32,,,8.32,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.53,,,6.53,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.94,,,5.94,Other,Drug Cost,5.94,,,5.94,Other,Drug Cost,7.43,,,7.43,Other,125% Medicaid APG methodology,0.01,14.98,
CARBOPLATIN 10MG/ML IV SLN60ML  ,J9045,HCPCS,,40577322,CDM,636,RC,61703-0339-56,NDC,both,60,ML,85.4,35.51,,,35.51,Other,150% of Medicare + 9.63% HCRA Surcharge,21.59,,,21.59,Fee Schedule,Average Sale Price (ASP) x 6,25.62,30,,25.62,percent of total billed charges,Drugs,25.62,30,,25.62,percent of total billed charges,Drugs,25.62,30,,25.62,percent of total billed charges,Drugs,25.62,30,,25.62,percent of total billed charges,Drugs,25.62,30,,25.62,percent of total billed charges,Drugs,42.7,50,,42.7,percent of total billed charges,All Other,25.62,30,,25.62,percent of total billed charges,Drugs,25.62,30,,25.62,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,25.62,30,,25.62,percent of total billed charges,Drugs,25.62,30,,25.62,percent of total billed charges,Drugs,25.62,30,,25.62,percent of total billed charges,Drugs,25.62,30,,25.62,percent of total billed charges,Drugs,25.62,30,,25.62,percent of total billed charges,Drugs,25.62,30,,25.62,percent of total billed charges,Drugs,25.62,30,,25.62,percent of total billed charges,Drugs,25.62,30,,25.62,percent of total billed charges,Drugs,25.62,30,,25.62,percent of total billed charges,Drugs,25.62,30,,25.62,percent of total billed charges,Drugs,25.62,30,,25.62,percent of total billed charges,Drugs,25.62,30,,25.62,percent of total billed charges,Drugs,25.62,30,,25.62,percent of total billed charges,Drugs,23.39,,,23.39,Other,Drug Cost,23.39,,,23.39,Other,Drug Cost,23.39,,,23.39,Other,Drug Cost,23.39,,,23.39,Other,Drug Cost,23.39,,,23.39,Other,Drug Cost,29.04,34,,29.04,percent of total billed charges,Drugs,23.39,,,23.39,Other,Drug Cost,52.63,,,52.63,Other,225% Medicaid APG methodology,32.75,,,32.75,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,34.55,,,34.55,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",23.39,,,23.39,Other,Drug Cost,23.39,,,23.39,Other,Drug Cost,29.24,,,29.24,Other,125% Medicaid APG methodology,0.01,52.63,
CISPLATIN 1MG/ML IV SOLN 50ML   ,J9060,HCPCS,,40577413,CDM,636,RC,00703-5747-11,NDC,both,50,ML,42.28,39.85,,,39.85,Other,150% of Medicare + 9.63% HCRA Surcharge,24.23,,,24.23,Fee Schedule,Average Sale Price (ASP) x 6,12.68,30,,12.68,percent of total billed charges,Drugs,12.68,30,,12.68,percent of total billed charges,Drugs,12.68,30,,12.68,percent of total billed charges,Drugs,12.68,30,,12.68,percent of total billed charges,Drugs,12.68,30,,12.68,percent of total billed charges,Drugs,21.14,50,,21.14,percent of total billed charges,All Other,12.68,30,,12.68,percent of total billed charges,Drugs,12.68,30,,12.68,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,12.68,30,,12.68,percent of total billed charges,Drugs,12.68,30,,12.68,percent of total billed charges,Drugs,12.68,30,,12.68,percent of total billed charges,Drugs,12.68,30,,12.68,percent of total billed charges,Drugs,12.68,30,,12.68,percent of total billed charges,Drugs,12.68,30,,12.68,percent of total billed charges,Drugs,12.68,30,,12.68,percent of total billed charges,Drugs,12.68,30,,12.68,percent of total billed charges,Drugs,12.68,30,,12.68,percent of total billed charges,Drugs,12.68,30,,12.68,percent of total billed charges,Drugs,12.68,30,,12.68,percent of total billed charges,Drugs,12.68,30,,12.68,percent of total billed charges,Drugs,12.68,30,,12.68,percent of total billed charges,Drugs,9.61,,,9.61,Other,Drug Cost,9.61,,,9.61,Other,Drug Cost,9.61,,,9.61,Other,Drug Cost,9.61,,,9.61,Other,Drug Cost,9.61,,,9.61,Other,Drug Cost,14.38,34,,14.38,percent of total billed charges,Drugs,9.61,,,9.61,Other,Drug Cost,21.62,,,21.62,Other,225% Medicaid APG methodology,13.45,,,13.45,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,38.77,,,38.77,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",9.61,,,9.61,Other,Drug Cost,9.61,,,9.61,Other,Drug Cost,12.01,,,12.01,Other,125% Medicaid APG methodology,0.01,39.85,
HYDROCORTISONE 250MGSUCC PFINJ  ,J1720,HCPCS,,40577462,CDM,636,RC,00009-0013-05,NDC,both,1,EA,92.02,176.07,,,176.07,Other,150% of Medicare + 9.63% HCRA Surcharge,107.07,,,107.07,Fee Schedule,Average Sale Price (ASP) x 6,27.61,30,,27.61,percent of total billed charges,Drugs,27.61,30,,27.61,percent of total billed charges,Drugs,27.61,30,,27.61,percent of total billed charges,Drugs,27.61,30,,27.61,percent of total billed charges,Drugs,27.61,30,,27.61,percent of total billed charges,Drugs,46.01,50,,46.01,percent of total billed charges,All Other,27.61,30,,27.61,percent of total billed charges,Drugs,27.61,30,,27.61,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,27.61,30,,27.61,percent of total billed charges,Drugs,27.61,30,,27.61,percent of total billed charges,Drugs,27.61,30,,27.61,percent of total billed charges,Drugs,27.61,30,,27.61,percent of total billed charges,Drugs,27.61,30,,27.61,percent of total billed charges,Drugs,27.61,30,,27.61,percent of total billed charges,Drugs,27.61,30,,27.61,percent of total billed charges,Drugs,27.61,30,,27.61,percent of total billed charges,Drugs,27.61,30,,27.61,percent of total billed charges,Drugs,27.61,30,,27.61,percent of total billed charges,Drugs,27.61,30,,27.61,percent of total billed charges,Drugs,27.61,30,,27.61,percent of total billed charges,Drugs,27.61,30,,27.61,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,31.29,34,,31.29,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,171.31,,,171.31,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,176.07,
MYCOPHENOLIC ACID 180MG DR TAB  ,J7518,HCPCS,,40577694,CDM,636,RC,68084-0907-21,NDC,both,1,EA,11.48,6.2,,,6.2,Other,150% of Medicare + 9.63% HCRA Surcharge,3.77,,,3.77,Fee Schedule,Average Sale Price (ASP) x 6,3.44,30,,3.44,percent of total billed charges,Drugs,3.44,30,,3.44,percent of total billed charges,Drugs,3.44,30,,3.44,percent of total billed charges,Drugs,3.44,30,,3.44,percent of total billed charges,Drugs,3.44,30,,3.44,percent of total billed charges,Drugs,5.74,50,,5.74,percent of total billed charges,All Other,3.44,30,,3.44,percent of total billed charges,Drugs,3.44,30,,3.44,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.44,30,,3.44,percent of total billed charges,Drugs,3.44,30,,3.44,percent of total billed charges,Drugs,3.44,30,,3.44,percent of total billed charges,Drugs,3.44,30,,3.44,percent of total billed charges,Drugs,3.44,30,,3.44,percent of total billed charges,Drugs,3.44,30,,3.44,percent of total billed charges,Drugs,3.44,30,,3.44,percent of total billed charges,Drugs,3.44,30,,3.44,percent of total billed charges,Drugs,3.44,30,,3.44,percent of total billed charges,Drugs,3.44,30,,3.44,percent of total billed charges,Drugs,3.44,30,,3.44,percent of total billed charges,Drugs,3.44,30,,3.44,percent of total billed charges,Drugs,3.44,30,,3.44,percent of total billed charges,Drugs,2.49,,,2.49,Other,Drug Cost,2.49,,,2.49,Other,Drug Cost,2.49,,,2.49,Other,Drug Cost,2.49,,,2.49,Other,Drug Cost,2.49,,,2.49,Other,Drug Cost,3.9,34,,3.9,percent of total billed charges,Drugs,2.49,,,2.49,Other,Drug Cost,5.6,,,5.6,Other,225% Medicaid APG methodology,3.49,,,3.49,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.03,,,6.03,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.49,,,2.49,Other,Drug Cost,2.49,,,2.49,Other,Drug Cost,3.11,,,3.11,Other,125% Medicaid APG methodology,0.01,6.2,
MYCOPHENOLIC ACID 360MG DR TAB  ,J7518,HCPCS,,40577702,CDM,636,RC,00078-0386-66,NDC,both,1,EA,42.77,6.2,,,6.2,Other,150% of Medicare + 9.63% HCRA Surcharge,3.77,,,3.77,Fee Schedule,Average Sale Price (ASP) x 6,12.83,30,,12.83,percent of total billed charges,Drugs,12.83,30,,12.83,percent of total billed charges,Drugs,12.83,30,,12.83,percent of total billed charges,Drugs,12.83,30,,12.83,percent of total billed charges,Drugs,12.83,30,,12.83,percent of total billed charges,Drugs,21.39,50,,21.39,percent of total billed charges,All Other,12.83,30,,12.83,percent of total billed charges,Drugs,12.83,30,,12.83,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,12.83,30,,12.83,percent of total billed charges,Drugs,12.83,30,,12.83,percent of total billed charges,Drugs,12.83,30,,12.83,percent of total billed charges,Drugs,12.83,30,,12.83,percent of total billed charges,Drugs,12.83,30,,12.83,percent of total billed charges,Drugs,12.83,30,,12.83,percent of total billed charges,Drugs,12.83,30,,12.83,percent of total billed charges,Drugs,12.83,30,,12.83,percent of total billed charges,Drugs,12.83,30,,12.83,percent of total billed charges,Drugs,12.83,30,,12.83,percent of total billed charges,Drugs,12.83,30,,12.83,percent of total billed charges,Drugs,12.83,30,,12.83,percent of total billed charges,Drugs,12.83,30,,12.83,percent of total billed charges,Drugs,3.72,,,3.72,Other,Drug Cost,3.72,,,3.72,Other,Drug Cost,3.72,,,3.72,Other,Drug Cost,3.72,,,3.72,Other,Drug Cost,3.72,,,3.72,Other,Drug Cost,14.54,34,,14.54,percent of total billed charges,Drugs,3.72,,,3.72,Other,Drug Cost,8.37,,,8.37,Other,225% Medicaid APG methodology,5.21,,,5.21,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.03,,,6.03,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.72,,,3.72,Other,Drug Cost,3.72,,,3.72,Other,Drug Cost,4.65,,,4.65,Other,125% Medicaid APG methodology,0.01,21.39,
PALONOSETRON 0.25MG IV SLN 5ML  ,J2469,HCPCS,,40577744,CDM,636,RC,55111-0694-07,NDC,both,5,ML,23.52,8.34,,,8.34,Other,150% of Medicare + 9.63% HCRA Surcharge,5.07,,,5.07,Fee Schedule,Average Sale Price (ASP) x 6,7.06,30,,7.06,percent of total billed charges,Drugs,7.06,30,,7.06,percent of total billed charges,Drugs,7.06,30,,7.06,percent of total billed charges,Drugs,7.06,30,,7.06,percent of total billed charges,Drugs,7.06,30,,7.06,percent of total billed charges,Drugs,11.76,50,,11.76,percent of total billed charges,All Other,7.06,30,,7.06,percent of total billed charges,Drugs,7.06,30,,7.06,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,7.06,30,,7.06,percent of total billed charges,Drugs,7.06,30,,7.06,percent of total billed charges,Drugs,7.06,30,,7.06,percent of total billed charges,Drugs,7.06,30,,7.06,percent of total billed charges,Drugs,7.06,30,,7.06,percent of total billed charges,Drugs,7.06,30,,7.06,percent of total billed charges,Drugs,7.06,30,,7.06,percent of total billed charges,Drugs,7.06,30,,7.06,percent of total billed charges,Drugs,7.06,30,,7.06,percent of total billed charges,Drugs,7.06,30,,7.06,percent of total billed charges,Drugs,7.06,30,,7.06,percent of total billed charges,Drugs,7.06,30,,7.06,percent of total billed charges,Drugs,7.06,30,,7.06,percent of total billed charges,Drugs,4.08,,,4.08,Other,Drug Cost,4.08,,,4.08,Other,Drug Cost,4.08,,,4.08,Other,Drug Cost,4.08,,,4.08,Other,Drug Cost,4.08,,,4.08,Other,Drug Cost,8,34,,8,percent of total billed charges,Drugs,4.08,,,4.08,Other,Drug Cost,9.18,,,9.18,Other,225% Medicaid APG methodology,5.71,,,5.71,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,8.11,,,8.11,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.08,,,4.08,Other,Drug Cost,4.08,,,4.08,Other,Drug Cost,5.1,,,5.1,Other,125% Medicaid APG methodology,0.01,11.76,
PERFLUTREN 1.3ML NS 8.7ML       ,Q9957,HCPCS,,40577801,CDM,636,RC,11994-0011-16,NDC,both,10,ML,1890,415.97,,,415.97,Other,150% of Medicare + 9.63% HCRA Surcharge,252.95,,,252.95,Fee Schedule,Average Sale Price (ASP) x 6,567,30,,567,percent of total billed charges,Drugs,567,30,,567,percent of total billed charges,Drugs,567,30,,567,percent of total billed charges,Drugs,567,30,,567,percent of total billed charges,Drugs,567,30,,567,percent of total billed charges,Drugs,945,50,,945,percent of total billed charges,All Other,567,30,,567,percent of total billed charges,Drugs,567,30,,567,percent of total billed charges,Drugs,642.6,34,"If Charge > 500, then 34 percent",642.6,percent of total billed charges,Drugs,567,30,,567,percent of total billed charges,Drugs,567,30,,567,percent of total billed charges,Drugs,567,30,,567,percent of total billed charges,Drugs,567,30,,567,percent of total billed charges,Drugs,567,30,,567,percent of total billed charges,Drugs,567,30,,567,percent of total billed charges,Drugs,567,30,,567,percent of total billed charges,Drugs,567,30,,567,percent of total billed charges,Drugs,567,30,,567,percent of total billed charges,Drugs,567,30,,567,percent of total billed charges,Drugs,567,30,,567,percent of total billed charges,Drugs,567,30,,567,percent of total billed charges,Drugs,567,30,,567,percent of total billed charges,Drugs,540,,,540,Other,Drug Cost,540,,,540,Other,Drug Cost,540,,,540,Other,Drug Cost,540,,,540,Other,Drug Cost,540,,,540,Other,Drug Cost,642.6,34,,642.6,percent of total billed charges,Drugs,540,,,540,Other,Drug Cost,1215,,,1215,Other,225% Medicaid APG methodology,756,,,756,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,404.73,,,404.73,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",540,,,540,Other,Drug Cost,540,,,540,Other,Drug Cost,675,,,675,Other,125% Medicaid APG methodology,0.01,1215,
IPILIMUMAB 5MG/ML IV SOLN 10ML  ,J9228,HCPCS,,40578148,CDM,636,RC,00003-2327-11,NDC,both,10,ML,29166.9,1701.21,,,1701.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1034.51,,,1034.51,Fee Schedule,Average Sale Price (ASP) x 6,8750.07,30,,8750.07,percent of total billed charges,Drugs,8750.07,30,,8750.07,percent of total billed charges,Drugs,8750.07,30,,8750.07,percent of total billed charges,Drugs,8750.07,30,,8750.07,percent of total billed charges,Drugs,8750.07,30,,8750.07,percent of total billed charges,Drugs,14583.45,50,,14583.45,percent of total billed charges,All Other,8750.07,30,,8750.07,percent of total billed charges,Drugs,8750.07,30,,8750.07,percent of total billed charges,Drugs,9916.75,34,"If Charge > 500, then 34 percent",9916.75,percent of total billed charges,Drugs,8750.07,30,,8750.07,percent of total billed charges,Drugs,8750.07,30,,8750.07,percent of total billed charges,Drugs,8750.07,30,,8750.07,percent of total billed charges,Drugs,8750.07,30,,8750.07,percent of total billed charges,Drugs,8750.07,30,,8750.07,percent of total billed charges,Drugs,8750.07,30,,8750.07,percent of total billed charges,Drugs,8750.07,30,,8750.07,percent of total billed charges,Drugs,8750.07,30,,8750.07,percent of total billed charges,Drugs,8750.07,30,,8750.07,percent of total billed charges,Drugs,8750.07,30,,8750.07,percent of total billed charges,Drugs,8750.07,30,,8750.07,percent of total billed charges,Drugs,8750.07,30,,8750.07,percent of total billed charges,Drugs,8750.07,30,,8750.07,percent of total billed charges,Drugs,5952.99,,,5952.99,Other,Drug Cost,5952.99,,,5952.99,Other,Drug Cost,5952.99,,,5952.99,Other,Drug Cost,5952.99,,,5952.99,Other,Drug Cost,5952.99,,,5952.99,Other,Drug Cost,9916.75,34,,9916.75,percent of total billed charges,Drugs,5952.99,,,5952.99,Other,Drug Cost,13394.23,,,13394.23,Other,225% Medicaid APG methodology,8334.19,,,8334.19,Other,140% Medicaid APG methodology,9916.75,34,"If Charge > 2,000, then 34 percent",9916.75,percent of total billed charges,Drugs,1655.22,,,1655.22,Other,160% Medicare Fee Schedule,9916.75,34,,9916.75,Other,"Drug Charges > 20,000, then 34% of Charges",5952.99,,,5952.99,Other,Drug Cost,5952.99,,,5952.99,Other,Drug Cost,7441.24,,,7441.24,Other,125% Medicaid APG methodology,1034.51,14583.45,
DEGARELIX 120 MG INJ KIT        ,J9155,HCPCS,,40578296,CDM,636,RC,55566-8403-01,NDC,both,1,EA,2479.54,41.31,,,41.31,Other,150% of Medicare + 9.63% HCRA Surcharge,25.12,,,25.12,Fee Schedule,Average Sale Price (ASP) x 6,743.86,30,,743.86,percent of total billed charges,Drugs,743.86,30,,743.86,percent of total billed charges,Drugs,743.86,30,,743.86,percent of total billed charges,Drugs,743.86,30,,743.86,percent of total billed charges,Drugs,743.86,30,,743.86,percent of total billed charges,Drugs,1239.77,50,,1239.77,percent of total billed charges,All Other,743.86,30,,743.86,percent of total billed charges,Drugs,743.86,30,,743.86,percent of total billed charges,Drugs,843.04,34,"If Charge > 500, then 34 percent",843.04,percent of total billed charges,Drugs,743.86,30,,743.86,percent of total billed charges,Drugs,743.86,30,,743.86,percent of total billed charges,Drugs,743.86,30,,743.86,percent of total billed charges,Drugs,743.86,30,,743.86,percent of total billed charges,Drugs,743.86,30,,743.86,percent of total billed charges,Drugs,743.86,30,,743.86,percent of total billed charges,Drugs,743.86,30,,743.86,percent of total billed charges,Drugs,743.86,30,,743.86,percent of total billed charges,Drugs,743.86,30,,743.86,percent of total billed charges,Drugs,743.86,30,,743.86,percent of total billed charges,Drugs,743.86,30,,743.86,percent of total billed charges,Drugs,743.86,30,,743.86,percent of total billed charges,Drugs,743.86,30,,743.86,percent of total billed charges,Drugs,262.57,,,262.57,Other,Drug Cost,262.57,,,262.57,Other,Drug Cost,262.57,,,262.57,Other,Drug Cost,262.57,,,262.57,Other,Drug Cost,262.57,,,262.57,Other,Drug Cost,843.04,34,,843.04,percent of total billed charges,Drugs,262.57,,,262.57,Other,Drug Cost,590.78,,,590.78,Other,225% Medicaid APG methodology,367.6,,,367.6,Other,140% Medicaid APG methodology,843.04,34,"If Charge > 2,000, then 34 percent",843.04,percent of total billed charges,Drugs,40.2,,,40.2,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",262.57,,,262.57,Other,Drug Cost,262.57,,,262.57,Other,Drug Cost,328.21,,,328.21,Other,125% Medicaid APG methodology,0.01,1239.77,
PALIPERIDONE 156MG IM SUS ER    ,J2426,HCPCS,,40578718,CDM,636,RC,50458-0563-01,NDC,both,1,ML,7109.59,141.27,,,141.27,Other,150% of Medicare + 9.63% HCRA Surcharge,85.91,,,85.91,Fee Schedule,Average Sale Price (ASP) x 6,2132.88,30,,2132.88,percent of total billed charges,Drugs,2132.88,30,,2132.88,percent of total billed charges,Drugs,2132.88,30,,2132.88,percent of total billed charges,Drugs,2132.88,30,,2132.88,percent of total billed charges,Drugs,2132.88,30,,2132.88,percent of total billed charges,Drugs,3554.8,50,,3554.8,percent of total billed charges,All Other,2132.88,30,,2132.88,percent of total billed charges,Drugs,2132.88,30,,2132.88,percent of total billed charges,Drugs,2417.26,34,"If Charge > 500, then 34 percent",2417.26,percent of total billed charges,Drugs,2132.88,30,,2132.88,percent of total billed charges,Drugs,2132.88,30,,2132.88,percent of total billed charges,Drugs,2132.88,30,,2132.88,percent of total billed charges,Drugs,2132.88,30,,2132.88,percent of total billed charges,Drugs,2132.88,30,,2132.88,percent of total billed charges,Drugs,2132.88,30,,2132.88,percent of total billed charges,Drugs,2132.88,30,,2132.88,percent of total billed charges,Drugs,2132.88,30,,2132.88,percent of total billed charges,Drugs,2132.88,30,,2132.88,percent of total billed charges,Drugs,2132.88,30,,2132.88,percent of total billed charges,Drugs,2132.88,30,,2132.88,percent of total billed charges,Drugs,2132.88,30,,2132.88,percent of total billed charges,Drugs,2132.88,30,,2132.88,percent of total billed charges,Drugs,805.56,,,805.56,Other,Drug Cost,805.56,,,805.56,Other,Drug Cost,805.56,,,805.56,Other,Drug Cost,805.56,,,805.56,Other,Drug Cost,805.56,,,805.56,Other,Drug Cost,2417.26,34,,2417.26,percent of total billed charges,Drugs,805.56,,,805.56,Other,Drug Cost,1812.51,,,1812.51,Other,225% Medicaid APG methodology,1127.78,,,1127.78,Other,140% Medicaid APG methodology,2417.26,34,"If Charge > 2,000, then 34 percent",2417.26,percent of total billed charges,Drugs,137.45,,,137.45,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",805.56,,,805.56,Other,Drug Cost,805.56,,,805.56,Other,Drug Cost,1006.95,,,1006.95,Other,125% Medicaid APG methodology,0.01,3554.8,
CARFILZOMIB 60 MG IV INJ        ,J9047,HCPCS,,40578908,CDM,636,RC,76075-0101-01,NDC,both,1,EA,9025.98,464.57,,,464.57,Other,150% of Medicare + 9.63% HCRA Surcharge,282.51,,,282.51,Fee Schedule,Average Sale Price (ASP) x 6,2707.79,30,,2707.79,percent of total billed charges,Drugs,2707.79,30,,2707.79,percent of total billed charges,Drugs,2707.79,30,,2707.79,percent of total billed charges,Drugs,2707.79,30,,2707.79,percent of total billed charges,Drugs,2707.79,30,,2707.79,percent of total billed charges,Drugs,4512.99,50,,4512.99,percent of total billed charges,All Other,2707.79,30,,2707.79,percent of total billed charges,Drugs,2707.79,30,,2707.79,percent of total billed charges,Drugs,3068.83,34,"If Charge > 500, then 34 percent",3068.83,percent of total billed charges,Drugs,2707.79,30,,2707.79,percent of total billed charges,Drugs,2707.79,30,,2707.79,percent of total billed charges,Drugs,2707.79,30,,2707.79,percent of total billed charges,Drugs,2707.79,30,,2707.79,percent of total billed charges,Drugs,2707.79,30,,2707.79,percent of total billed charges,Drugs,2707.79,30,,2707.79,percent of total billed charges,Drugs,2707.79,30,,2707.79,percent of total billed charges,Drugs,2707.79,30,,2707.79,percent of total billed charges,Drugs,2707.79,30,,2707.79,percent of total billed charges,Drugs,2707.79,30,,2707.79,percent of total billed charges,Drugs,2707.79,30,,2707.79,percent of total billed charges,Drugs,2707.79,30,,2707.79,percent of total billed charges,Drugs,2707.79,30,,2707.79,percent of total billed charges,Drugs,1358.85,,,1358.85,Other,Drug Cost,1358.85,,,1358.85,Other,Drug Cost,1358.85,,,1358.85,Other,Drug Cost,1358.85,,,1358.85,Other,Drug Cost,1358.85,,,1358.85,Other,Drug Cost,3068.83,34,,3068.83,percent of total billed charges,Drugs,1358.85,,,1358.85,Other,Drug Cost,3057.41,,,3057.41,Other,225% Medicaid APG methodology,1902.39,,,1902.39,Other,140% Medicaid APG methodology,3068.83,34,"If Charge > 2,000, then 34 percent",3068.83,percent of total billed charges,Drugs,452.02,,,452.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1358.85,,,1358.85,Other,Drug Cost,1358.85,,,1358.85,Other,Drug Cost,1698.56,,,1698.56,Other,125% Medicaid APG methodology,0.01,4512.99,
FOSAPREPITANT 150 MG IV INJ     ,J1453,HCPCS,,40578973,CDM,636,RC,00143-9384-01,NDC,both,1,EA,74.83,1.36,,,1.36,Other,150% of Medicare + 9.63% HCRA Surcharge,0.83,,,0.83,Fee Schedule,Average Sale Price (ASP) x 6,22.45,30,,22.45,percent of total billed charges,Drugs,22.45,30,,22.45,percent of total billed charges,Drugs,22.45,30,,22.45,percent of total billed charges,Drugs,22.45,30,,22.45,percent of total billed charges,Drugs,22.45,30,,22.45,percent of total billed charges,Drugs,37.42,50,,37.42,percent of total billed charges,All Other,22.45,30,,22.45,percent of total billed charges,Drugs,22.45,30,,22.45,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,22.45,30,,22.45,percent of total billed charges,Drugs,22.45,30,,22.45,percent of total billed charges,Drugs,22.45,30,,22.45,percent of total billed charges,Drugs,22.45,30,,22.45,percent of total billed charges,Drugs,22.45,30,,22.45,percent of total billed charges,Drugs,22.45,30,,22.45,percent of total billed charges,Drugs,22.45,30,,22.45,percent of total billed charges,Drugs,22.45,30,,22.45,percent of total billed charges,Drugs,22.45,30,,22.45,percent of total billed charges,Drugs,22.45,30,,22.45,percent of total billed charges,Drugs,22.45,30,,22.45,percent of total billed charges,Drugs,22.45,30,,22.45,percent of total billed charges,Drugs,22.45,30,,22.45,percent of total billed charges,Drugs,16.56,,,16.56,Other,Drug Cost,16.56,,,16.56,Other,Drug Cost,16.56,,,16.56,Other,Drug Cost,16.56,,,16.56,Other,Drug Cost,16.56,,,16.56,Other,Drug Cost,25.44,34,,25.44,percent of total billed charges,Drugs,16.56,,,16.56,Other,Drug Cost,37.26,,,37.26,Other,225% Medicaid APG methodology,23.18,,,23.18,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.33,,,1.33,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",16.56,,,16.56,Other,Drug Cost,16.56,,,16.56,Other,Drug Cost,20.7,,,20.7,Other,125% Medicaid APG methodology,0.01,37.42,
MORPHINE 0.5MG/ML PF INJ 10ML   ,J2274,HCPCS,,40578981,CDM,636,RC,00641-6020-10,NDC,both,10,ML,89.5,110.94,,,110.94,Other,150% of Medicare + 9.63% HCRA Surcharge,67.46,,,67.46,Fee Schedule,Average Sale Price (ASP) x 6,26.85,30,,26.85,percent of total billed charges,Drugs,26.85,30,,26.85,percent of total billed charges,Drugs,26.85,30,,26.85,percent of total billed charges,Drugs,26.85,30,,26.85,percent of total billed charges,Drugs,26.85,30,,26.85,percent of total billed charges,Drugs,44.75,50,,44.75,percent of total billed charges,All Other,26.85,30,,26.85,percent of total billed charges,Drugs,26.85,30,,26.85,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,26.85,30,,26.85,percent of total billed charges,Drugs,26.85,30,,26.85,percent of total billed charges,Drugs,26.85,30,,26.85,percent of total billed charges,Drugs,26.85,30,,26.85,percent of total billed charges,Drugs,26.85,30,,26.85,percent of total billed charges,Drugs,26.85,30,,26.85,percent of total billed charges,Drugs,26.85,30,,26.85,percent of total billed charges,Drugs,26.85,30,,26.85,percent of total billed charges,Drugs,26.85,30,,26.85,percent of total billed charges,Drugs,26.85,30,,26.85,percent of total billed charges,Drugs,26.85,30,,26.85,percent of total billed charges,Drugs,26.85,30,,26.85,percent of total billed charges,Drugs,26.85,30,,26.85,percent of total billed charges,Drugs,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,30.43,34,,30.43,percent of total billed charges,Drugs,0.09,,,0.09,Other,Drug Cost,0.2,,,0.2,Other,225% Medicaid APG methodology,0.13,,,0.13,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,107.94,,,107.94,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,110.94,
NEOSTIGMINE 0.5MG/ML IV  10ML   ,J2710,HCPCS,,40579047,CDM,636,RC,63323-0413-10,NDC,both,10,ML,21.7,8.56,39.4668,,8.56,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,10.85,50,,10.85,percent of total billed charges,All Other,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,6.51,30,,6.51,percent of total billed charges,Drugs,9.8,,,9.8,Other,Drug Cost,9.8,,,9.8,Other,Drug Cost,9.8,,,9.8,Other,Drug Cost,9.8,,,9.8,Other,Drug Cost,9.8,,,9.8,Other,Drug Cost,7.38,34,,7.38,percent of total billed charges,Drugs,9.8,,,9.8,Other,Drug Cost,22.05,,,22.05,Other,225% Medicaid APG methodology,13.72,,,13.72,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",9.8,,,9.8,Other,Drug Cost,9.8,,,9.8,Other,Drug Cost,12.25,,,12.25,Other,125% Medicaid APG methodology,0.01,22.05,
PENICILLIN GK100000UNIT/ML NS   ,J2540,HCPCS,,40579054,CDM,636,RC,00049-0520-83n,NDC,both,1,ML,20.72,7.61,,,7.61,Other,150% of Medicare + 9.63% HCRA Surcharge,4.63,,,4.63,Fee Schedule,Average Sale Price (ASP) x 6,6.22,30,,6.22,percent of total billed charges,Drugs,6.22,30,,6.22,percent of total billed charges,Drugs,6.22,30,,6.22,percent of total billed charges,Drugs,6.22,30,,6.22,percent of total billed charges,Drugs,6.22,30,,6.22,percent of total billed charges,Drugs,10.36,50,,10.36,percent of total billed charges,All Other,6.22,30,,6.22,percent of total billed charges,Drugs,6.22,30,,6.22,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,6.22,30,,6.22,percent of total billed charges,Drugs,6.22,30,,6.22,percent of total billed charges,Drugs,6.22,30,,6.22,percent of total billed charges,Drugs,6.22,30,,6.22,percent of total billed charges,Drugs,6.22,30,,6.22,percent of total billed charges,Drugs,6.22,30,,6.22,percent of total billed charges,Drugs,6.22,30,,6.22,percent of total billed charges,Drugs,6.22,30,,6.22,percent of total billed charges,Drugs,6.22,30,,6.22,percent of total billed charges,Drugs,6.22,30,,6.22,percent of total billed charges,Drugs,6.22,30,,6.22,percent of total billed charges,Drugs,6.22,30,,6.22,percent of total billed charges,Drugs,6.22,30,,6.22,percent of total billed charges,Drugs,3.78,,,3.78,Other,Drug Cost,3.78,,,3.78,Other,Drug Cost,3.78,,,3.78,Other,Drug Cost,3.78,,,3.78,Other,Drug Cost,3.78,,,3.78,Other,Drug Cost,7.04,34,,7.04,percent of total billed charges,Drugs,3.78,,,3.78,Other,Drug Cost,8.51,,,8.51,Other,225% Medicaid APG methodology,5.29,,,5.29,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.4,,,7.4,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.78,,,3.78,Other,Drug Cost,3.78,,,3.78,Other,Drug Cost,4.73,,,4.73,Other,125% Medicaid APG methodology,0.01,10.36,
PEGFILGRASTIM 6MG/0.6ML KIT     ,J2506,HCPCS,,40579203,CDM,636,RC,55513-0192-01,NDC,both,0.6,ML,12284.48,500.02,,,500.02,Other,150% of Medicare + 9.63% HCRA Surcharge,304.07,,,304.07,Fee Schedule,Average Sale Price (ASP) x 6,3685.34,30,,3685.34,percent of total billed charges,Drugs,3685.34,30,,3685.34,percent of total billed charges,Drugs,3685.34,30,,3685.34,percent of total billed charges,Drugs,3685.34,30,,3685.34,percent of total billed charges,Drugs,3685.34,30,,3685.34,percent of total billed charges,Drugs,6142.24,50,,6142.24,percent of total billed charges,All Other,3685.34,30,,3685.34,percent of total billed charges,Drugs,3685.34,30,,3685.34,percent of total billed charges,Drugs,4176.72,34,"If Charge > 500, then 34 percent",4176.72,percent of total billed charges,Drugs,3685.34,30,,3685.34,percent of total billed charges,Drugs,3685.34,30,,3685.34,percent of total billed charges,Drugs,3685.34,30,,3685.34,percent of total billed charges,Drugs,3685.34,30,,3685.34,percent of total billed charges,Drugs,3685.34,30,,3685.34,percent of total billed charges,Drugs,3685.34,30,,3685.34,percent of total billed charges,Drugs,3685.34,30,,3685.34,percent of total billed charges,Drugs,3685.34,30,,3685.34,percent of total billed charges,Drugs,3685.34,30,,3685.34,percent of total billed charges,Drugs,3685.34,30,,3685.34,percent of total billed charges,Drugs,3685.34,30,,3685.34,percent of total billed charges,Drugs,3685.34,30,,3685.34,percent of total billed charges,Drugs,3685.34,30,,3685.34,percent of total billed charges,Drugs,764.22,,,764.22,Other,Drug Cost,764.22,,,764.22,Other,Drug Cost,764.22,,,764.22,Other,Drug Cost,764.22,,,764.22,Other,Drug Cost,764.22,,,764.22,Other,Drug Cost,4176.72,34,,4176.72,percent of total billed charges,Drugs,764.22,,,764.22,Other,Drug Cost,1719.5,,,1719.5,Other,225% Medicaid APG methodology,1069.91,,,1069.91,Other,140% Medicaid APG methodology,4176.72,34,"If Charge > 2,000, then 34 percent",4176.72,percent of total billed charges,Drugs,486.51,,,486.51,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",764.22,,,764.22,Other,Drug Cost,764.22,,,764.22,Other,Drug Cost,955.28,,,955.28,Other,125% Medicaid APG methodology,0.01,6142.24,
PERTUZUMAB 420MG/14ML IV  14ML  ,J9306,HCPCS,,40579229,CDM,636,RC,50242-0145-01,NDC,both,14,ML,22094.1,152.21,,,152.21,Other,150% of Medicare + 9.63% HCRA Surcharge,92.56,,,92.56,Fee Schedule,Average Sale Price (ASP) x 6,6628.23,30,,6628.23,percent of total billed charges,Drugs,6628.23,30,,6628.23,percent of total billed charges,Drugs,6628.23,30,,6628.23,percent of total billed charges,Drugs,6628.23,30,,6628.23,percent of total billed charges,Drugs,6628.23,30,,6628.23,percent of total billed charges,Drugs,11047.05,50,,11047.05,percent of total billed charges,All Other,6628.23,30,,6628.23,percent of total billed charges,Drugs,6628.23,30,,6628.23,percent of total billed charges,Drugs,7511.99,34,"If Charge > 500, then 34 percent",7511.99,percent of total billed charges,Drugs,6628.23,30,,6628.23,percent of total billed charges,Drugs,6628.23,30,,6628.23,percent of total billed charges,Drugs,6628.23,30,,6628.23,percent of total billed charges,Drugs,6628.23,30,,6628.23,percent of total billed charges,Drugs,6628.23,30,,6628.23,percent of total billed charges,Drugs,6628.23,30,,6628.23,percent of total billed charges,Drugs,6628.23,30,,6628.23,percent of total billed charges,Drugs,6628.23,30,,6628.23,percent of total billed charges,Drugs,6628.23,30,,6628.23,percent of total billed charges,Drugs,6628.23,30,,6628.23,percent of total billed charges,Drugs,6628.23,30,,6628.23,percent of total billed charges,Drugs,6628.23,30,,6628.23,percent of total billed charges,Drugs,6628.23,30,,6628.23,percent of total billed charges,Drugs,3828.16,,,3828.16,Other,Drug Cost,3828.16,,,3828.16,Other,Drug Cost,3828.16,,,3828.16,Other,Drug Cost,3828.16,,,3828.16,Other,Drug Cost,3828.16,,,3828.16,Other,Drug Cost,7511.99,34,,7511.99,percent of total billed charges,Drugs,3828.16,,,3828.16,Other,Drug Cost,8613.36,,,8613.36,Other,225% Medicaid APG methodology,5359.42,,,5359.42,Other,140% Medicaid APG methodology,7511.99,34,"If Charge > 2,000, then 34 percent",7511.99,percent of total billed charges,Drugs,148.1,,,148.1,Other,160% Medicare Fee Schedule,7511.99,34,,7511.99,Other,"Drug Charges > 20,000, then 34% of Charges",3828.16,,,3828.16,Other,Drug Cost,3828.16,,,3828.16,Other,Drug Cost,4785.2,,,4785.2,Other,125% Medicaid APG methodology,92.56,11047.05,
DENOSUMAB 120MG/1.7ML INJ1.7ML  ,J0897,HCPCS,,40579260,CDM,636,RC,55513-0730-01,NDC,both,1.7,ML,9711.1,248.62,,,248.62,Other,150% of Medicare + 9.63% HCRA Surcharge,151.19,,,151.19,Fee Schedule,Average Sale Price (ASP) x 6,2913.33,30,,2913.33,percent of total billed charges,Drugs,2913.33,30,,2913.33,percent of total billed charges,Drugs,2913.33,30,,2913.33,percent of total billed charges,Drugs,2913.33,30,,2913.33,percent of total billed charges,Drugs,2913.33,30,,2913.33,percent of total billed charges,Drugs,4855.55,50,,4855.55,percent of total billed charges,All Other,2913.33,30,,2913.33,percent of total billed charges,Drugs,2913.33,30,,2913.33,percent of total billed charges,Drugs,3301.77,34,"If Charge > 500, then 34 percent",3301.77,percent of total billed charges,Drugs,2913.33,30,,2913.33,percent of total billed charges,Drugs,2913.33,30,,2913.33,percent of total billed charges,Drugs,2913.33,30,,2913.33,percent of total billed charges,Drugs,2913.33,30,,2913.33,percent of total billed charges,Drugs,2913.33,30,,2913.33,percent of total billed charges,Drugs,2913.33,30,,2913.33,percent of total billed charges,Drugs,2913.33,30,,2913.33,percent of total billed charges,Drugs,2913.33,30,,2913.33,percent of total billed charges,Drugs,2913.33,30,,2913.33,percent of total billed charges,Drugs,2913.33,30,,2913.33,percent of total billed charges,Drugs,2913.33,30,,2913.33,percent of total billed charges,Drugs,2913.33,30,,2913.33,percent of total billed charges,Drugs,2913.33,30,,2913.33,percent of total billed charges,Drugs,1575.41,,,1575.41,Other,Drug Cost,1575.41,,,1575.41,Other,Drug Cost,1575.41,,,1575.41,Other,Drug Cost,1575.41,,,1575.41,Other,Drug Cost,1575.41,,,1575.41,Other,Drug Cost,3301.77,34,,3301.77,percent of total billed charges,Drugs,1575.41,,,1575.41,Other,Drug Cost,3544.67,,,3544.67,Other,225% Medicaid APG methodology,2205.57,,,2205.57,Other,140% Medicaid APG methodology,3301.77,34,"If Charge > 2,000, then 34 percent",3301.77,percent of total billed charges,Drugs,241.9,,,241.9,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1575.41,,,1575.41,Other,Drug Cost,1575.41,,,1575.41,Other,Drug Cost,1969.26,,,1969.26,Other,125% Medicaid APG methodology,0.01,4855.55,
VANCOMYCIN 5 G IV INJ BULK      ,J3370,HCPCS,,40579385,CDM,636,RC,67457-0341-05,NDC,both,1,EA,286.09,22.76,,,22.76,Other,150% of Medicare + 9.63% HCRA Surcharge,13.84,,,13.84,Fee Schedule,Average Sale Price (ASP) x 6,85.83,30,,85.83,percent of total billed charges,Drugs,85.83,30,,85.83,percent of total billed charges,Drugs,85.83,30,,85.83,percent of total billed charges,Drugs,85.83,30,,85.83,percent of total billed charges,Drugs,85.83,30,,85.83,percent of total billed charges,Drugs,143.05,50,,143.05,percent of total billed charges,All Other,85.83,30,,85.83,percent of total billed charges,Drugs,85.83,30,,85.83,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,85.83,30,,85.83,percent of total billed charges,Drugs,85.83,30,,85.83,percent of total billed charges,Drugs,85.83,30,,85.83,percent of total billed charges,Drugs,85.83,30,,85.83,percent of total billed charges,Drugs,85.83,30,,85.83,percent of total billed charges,Drugs,85.83,30,,85.83,percent of total billed charges,Drugs,85.83,30,,85.83,percent of total billed charges,Drugs,85.83,30,,85.83,percent of total billed charges,Drugs,85.83,30,,85.83,percent of total billed charges,Drugs,85.83,30,,85.83,percent of total billed charges,Drugs,85.83,30,,85.83,percent of total billed charges,Drugs,85.83,30,,85.83,percent of total billed charges,Drugs,85.83,30,,85.83,percent of total billed charges,Drugs,17.6,,,17.6,Other,Drug Cost,17.6,,,17.6,Other,Drug Cost,17.6,,,17.6,Other,Drug Cost,17.6,,,17.6,Other,Drug Cost,17.6,,,17.6,Other,Drug Cost,97.27,34,,97.27,percent of total billed charges,Drugs,17.6,,,17.6,Other,Drug Cost,39.6,,,39.6,Other,225% Medicaid APG methodology,24.64,,,24.64,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,22.15,,,22.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",17.6,,,17.6,Other,Drug Cost,17.6,,,17.6,Other,Drug Cost,22,,,22,Other,125% Medicaid APG methodology,0.01,143.05,
HAVRIX 720 UNIT/0.5 ML SYRINGE  ,90633,CPT,,40579443,CDM,636,RC,58160-0825-52,NDC,both,0.5,ML,94.33,37.23,39.4668,,37.23,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,28.3,30,,28.3,percent of total billed charges,Drugs,28.3,30,,28.3,percent of total billed charges,Drugs,28.3,30,,28.3,percent of total billed charges,Drugs,28.3,30,,28.3,percent of total billed charges,Drugs,28.3,30,,28.3,percent of total billed charges,Drugs,47.17,50,,47.17,percent of total billed charges,All Other,28.3,30,,28.3,percent of total billed charges,Drugs,28.3,30,,28.3,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,28.3,30,,28.3,percent of total billed charges,Drugs,28.3,30,,28.3,percent of total billed charges,Drugs,28.3,30,,28.3,percent of total billed charges,Drugs,28.3,30,,28.3,percent of total billed charges,Drugs,28.3,30,,28.3,percent of total billed charges,Drugs,28.3,30,,28.3,percent of total billed charges,Drugs,28.3,30,,28.3,percent of total billed charges,Drugs,28.3,30,,28.3,percent of total billed charges,Drugs,28.3,30,,28.3,percent of total billed charges,Drugs,28.3,30,,28.3,percent of total billed charges,Drugs,28.3,30,,28.3,percent of total billed charges,Drugs,28.3,30,,28.3,percent of total billed charges,Drugs,28.3,30,,28.3,percent of total billed charges,Drugs,25.35,,,25.35,Other,Drug Cost,25.35,,,25.35,Other,Drug Cost,25.35,,,25.35,Other,Drug Cost,25.35,,,25.35,Other,Drug Cost,25.35,,,25.35,Other,Drug Cost,32.07,34,,32.07,percent of total billed charges,Drugs,25.35,,,25.35,Other,Drug Cost,57.04,,,57.04,Other,225% Medicaid APG methodology,35.49,,,35.49,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",25.35,,,25.35,Other,Drug Cost,25.35,,,25.35,Other,Drug Cost,31.69,,,31.69,Other,125% Medicaid APG methodology,0.01,57.04,
FOSPHENYTOIN 50MG/1ML  10ML     ,Q2009,HCPCS,,40579450,CDM,636,RC,68462-0622-64,NDC,both,10,ML,342.16,135.04,39.4668,,135.04,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,102.65,30,,102.65,percent of total billed charges,Drugs,102.65,30,,102.65,percent of total billed charges,Drugs,102.65,30,,102.65,percent of total billed charges,Drugs,102.65,30,,102.65,percent of total billed charges,Drugs,102.65,30,,102.65,percent of total billed charges,Drugs,171.08,50,,171.08,percent of total billed charges,All Other,102.65,30,,102.65,percent of total billed charges,Drugs,102.65,30,,102.65,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,102.65,30,,102.65,percent of total billed charges,Drugs,102.65,30,,102.65,percent of total billed charges,Drugs,102.65,30,,102.65,percent of total billed charges,Drugs,102.65,30,,102.65,percent of total billed charges,Drugs,102.65,30,,102.65,percent of total billed charges,Drugs,102.65,30,,102.65,percent of total billed charges,Drugs,102.65,30,,102.65,percent of total billed charges,Drugs,102.65,30,,102.65,percent of total billed charges,Drugs,102.65,30,,102.65,percent of total billed charges,Drugs,102.65,30,,102.65,percent of total billed charges,Drugs,102.65,30,,102.65,percent of total billed charges,Drugs,102.65,30,,102.65,percent of total billed charges,Drugs,102.65,30,,102.65,percent of total billed charges,Drugs,93.91,,,93.91,Other,Drug Cost,93.91,,,93.91,Other,Drug Cost,93.91,,,93.91,Other,Drug Cost,93.91,,,93.91,Other,Drug Cost,93.91,,,93.91,Other,Drug Cost,116.33,34,,116.33,percent of total billed charges,Drugs,93.91,,,93.91,Other,Drug Cost,211.3,,,211.3,Other,225% Medicaid APG methodology,131.47,,,131.47,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",93.91,,,93.91,Other,Drug Cost,93.91,,,93.91,Other,Drug Cost,117.39,,,117.39,Other,125% Medicaid APG methodology,0.01,211.3,
ANTIVENIN POLYVALENT IV INJ     ,J0840,HCPCS,,40579476,CDM,636,RC,50633-0110-12,NDC,both,1,EA,10403.4,19239.25,,,19239.25,Other,150% of Medicare + 9.63% HCRA Surcharge,11699.5,,,11699.5,Fee Schedule,Average Sale Price (ASP) x 6,3121.02,30,,3121.02,percent of total billed charges,Drugs,3121.02,30,,3121.02,percent of total billed charges,Drugs,3121.02,30,,3121.02,percent of total billed charges,Drugs,3121.02,30,,3121.02,percent of total billed charges,Drugs,3121.02,30,,3121.02,percent of total billed charges,Drugs,5201.7,50,,5201.7,percent of total billed charges,All Other,3121.02,30,,3121.02,percent of total billed charges,Drugs,3121.02,30,,3121.02,percent of total billed charges,Drugs,3537.16,34,"If Charge > 500, then 34 percent",3537.16,percent of total billed charges,Drugs,3121.02,30,,3121.02,percent of total billed charges,Drugs,3121.02,30,,3121.02,percent of total billed charges,Drugs,3121.02,30,,3121.02,percent of total billed charges,Drugs,3121.02,30,,3121.02,percent of total billed charges,Drugs,3121.02,30,,3121.02,percent of total billed charges,Drugs,3121.02,30,,3121.02,percent of total billed charges,Drugs,3121.02,30,,3121.02,percent of total billed charges,Drugs,3121.02,30,,3121.02,percent of total billed charges,Drugs,3121.02,30,,3121.02,percent of total billed charges,Drugs,3121.02,30,,3121.02,percent of total billed charges,Drugs,3121.02,30,,3121.02,percent of total billed charges,Drugs,3121.02,30,,3121.02,percent of total billed charges,Drugs,3121.02,30,,3121.02,percent of total billed charges,Drugs,1454.45,,,1454.45,Other,Drug Cost,1454.45,,,1454.45,Other,Drug Cost,1454.45,,,1454.45,Other,Drug Cost,1454.45,,,1454.45,Other,Drug Cost,1454.45,,,1454.45,Other,Drug Cost,3537.16,34,,3537.16,percent of total billed charges,Drugs,1454.45,,,1454.45,Other,Drug Cost,3272.51,,,3272.51,Other,225% Medicaid APG methodology,2036.23,,,2036.23,Other,140% Medicaid APG methodology,3537.16,34,"If Charge > 2,000, then 34 percent",3537.16,percent of total billed charges,Drugs,18719.2,,,18719.2,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1454.45,,,1454.45,Other,Drug Cost,1454.45,,,1454.45,Other,Drug Cost,1818.06,,,1818.06,Other,125% Medicaid APG methodology,0.01,19239.25,
ISOSULFAN BLUE 10MG/ML INJ 5ML  ,Q9968,HCPCS,,40579542,CDM,636,RC,67457-0220-05,NDC,both,5,ML,3412.68,1346.88,39.4668,,1346.88,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,1023.8,30,,1023.8,percent of total billed charges,Drugs,1023.8,30,,1023.8,percent of total billed charges,Drugs,1023.8,30,,1023.8,percent of total billed charges,Drugs,1023.8,30,,1023.8,percent of total billed charges,Drugs,1023.8,30,,1023.8,percent of total billed charges,Drugs,1706.34,50,,1706.34,percent of total billed charges,All Other,1023.8,30,,1023.8,percent of total billed charges,Drugs,1023.8,30,,1023.8,percent of total billed charges,Drugs,1160.31,34,"If Charge > 500, then 34 percent",1160.31,percent of total billed charges,Drugs,1023.8,30,,1023.8,percent of total billed charges,Drugs,1023.8,30,,1023.8,percent of total billed charges,Drugs,1023.8,30,,1023.8,percent of total billed charges,Drugs,1023.8,30,,1023.8,percent of total billed charges,Drugs,1023.8,30,,1023.8,percent of total billed charges,Drugs,1023.8,30,,1023.8,percent of total billed charges,Drugs,1023.8,30,,1023.8,percent of total billed charges,Drugs,1023.8,30,,1023.8,percent of total billed charges,Drugs,1023.8,30,,1023.8,percent of total billed charges,Drugs,1023.8,30,,1023.8,percent of total billed charges,Drugs,1023.8,30,,1023.8,percent of total billed charges,Drugs,1023.8,30,,1023.8,percent of total billed charges,Drugs,1023.8,30,,1023.8,percent of total billed charges,Drugs,488.25,,,488.25,Other,Drug Cost,488.25,,,488.25,Other,Drug Cost,488.25,,,488.25,Other,Drug Cost,488.25,,,488.25,Other,Drug Cost,488.25,,,488.25,Other,Drug Cost,1160.31,34,,1160.31,percent of total billed charges,Drugs,488.25,,,488.25,Other,Drug Cost,1098.56,,,1098.56,Other,225% Medicaid APG methodology,683.55,,,683.55,Other,140% Medicaid APG methodology,1160.31,34,"If Charge > 2,000, then 34 percent",1160.31,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",488.25,,,488.25,Other,Drug Cost,488.25,,,488.25,Other,Drug Cost,610.31,,,610.31,Other,125% Medicaid APG methodology,0.01,1706.34,
LACOSAMIDE 200MG/20ML IV  20ML  ,C9254,HCPCS,,40579765,CDM,636,RC,70710-1359-06,NDC,both,20,ML,72.84,28.75,39.4668,,28.75,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,21.85,30,,21.85,percent of total billed charges,Drugs,21.85,30,,21.85,percent of total billed charges,Drugs,21.85,30,,21.85,percent of total billed charges,Drugs,21.85,30,,21.85,percent of total billed charges,Drugs,21.85,30,,21.85,percent of total billed charges,Drugs,36.42,50,,36.42,percent of total billed charges,All Other,21.85,30,,21.85,percent of total billed charges,Drugs,21.85,30,,21.85,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,21.85,30,,21.85,percent of total billed charges,Drugs,21.85,30,,21.85,percent of total billed charges,Drugs,21.85,30,,21.85,percent of total billed charges,Drugs,21.85,30,,21.85,percent of total billed charges,Drugs,21.85,30,,21.85,percent of total billed charges,Drugs,21.85,30,,21.85,percent of total billed charges,Drugs,21.85,30,,21.85,percent of total billed charges,Drugs,21.85,30,,21.85,percent of total billed charges,Drugs,21.85,30,,21.85,percent of total billed charges,Drugs,21.85,30,,21.85,percent of total billed charges,Drugs,21.85,30,,21.85,percent of total billed charges,Drugs,21.85,30,,21.85,percent of total billed charges,Drugs,21.85,30,,21.85,percent of total billed charges,Drugs,26.46,,,26.46,Other,Drug Cost,26.46,,,26.46,Other,Drug Cost,26.46,,,26.46,Other,Drug Cost,26.46,,,26.46,Other,Drug Cost,26.46,,,26.46,Other,Drug Cost,24.77,34,,24.77,percent of total billed charges,Drugs,26.46,,,26.46,Other,Drug Cost,59.54,,,59.54,Other,225% Medicaid APG methodology,37.04,,,37.04,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",26.46,,,26.46,Other,Drug Cost,26.46,,,26.46,Other,Drug Cost,33.08,,,33.08,Other,125% Medicaid APG methodology,0.01,59.54,
IPILIMUMAB 5MG/ML IV SOLN 40ML  ,J9228,HCPCS,,40579864,CDM,636,RC,00003-2328-22,NDC,both,40,ML,108193.68,1701.21,,,1701.21,Other,150% of Medicare + 9.63% HCRA Surcharge,1034.51,,,1034.51,Fee Schedule,Average Sale Price (ASP) x 6,32458.1,30,,32458.1,percent of total billed charges,Drugs,32458.1,30,,32458.1,percent of total billed charges,Drugs,32458.1,30,,32458.1,percent of total billed charges,Drugs,32458.1,30,,32458.1,percent of total billed charges,Drugs,32458.1,30,,32458.1,percent of total billed charges,Drugs,54096.84,50,,54096.84,percent of total billed charges,All Other,32458.1,30,,32458.1,percent of total billed charges,Drugs,32458.1,30,,32458.1,percent of total billed charges,Drugs,36785.85,34,"If Charge > 500, then 34 percent",36785.85,percent of total billed charges,Drugs,32458.1,30,,32458.1,percent of total billed charges,Drugs,32458.1,30,,32458.1,percent of total billed charges,Drugs,32458.1,30,,32458.1,percent of total billed charges,Drugs,32458.1,30,,32458.1,percent of total billed charges,Drugs,32458.1,30,,32458.1,percent of total billed charges,Drugs,32458.1,30,,32458.1,percent of total billed charges,Drugs,32458.1,30,,32458.1,percent of total billed charges,Drugs,32458.1,30,,32458.1,percent of total billed charges,Drugs,32458.1,30,,32458.1,percent of total billed charges,Drugs,32458.1,30,,32458.1,percent of total billed charges,Drugs,32458.1,30,,32458.1,percent of total billed charges,Drugs,32458.1,30,,32458.1,percent of total billed charges,Drugs,32458.1,30,,32458.1,percent of total billed charges,Drugs,21050.28,,,21050.28,Other,Drug Cost,21050.28,,,21050.28,Other,Drug Cost,21050.28,,,21050.28,Other,Drug Cost,21050.28,,,21050.28,Other,Drug Cost,21050.28,,,21050.28,Other,Drug Cost,36785.85,34,,36785.85,percent of total billed charges,Drugs,21050.28,,,21050.28,Other,Drug Cost,47363.13,,,47363.13,Other,225% Medicaid APG methodology,29470.39,,,29470.39,Other,140% Medicaid APG methodology,36785.85,34,"If Charge > 2,000, then 34 percent",36785.85,percent of total billed charges,Drugs,1655.22,,,1655.22,Other,160% Medicare Fee Schedule,36785.85,34,,36785.85,Other,"Drug Charges > 20,000, then 34% of Charges",21050.28,,,21050.28,Other,Drug Cost,21050.28,,,21050.28,Other,Drug Cost,26312.85,,,26312.85,Other,125% Medicaid APG methodology,1034.51,54096.84,
AMIODARONE 50MG/ML IV SLN 18ML  ,J0282,HCPCS,,40580128,CDM,636,RC,67457-0153-18,NDC,both,18,ML,44.24,17.46,39.4668,,17.46,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,13.27,30,,13.27,percent of total billed charges,Drugs,13.27,30,,13.27,percent of total billed charges,Drugs,13.27,30,,13.27,percent of total billed charges,Drugs,13.27,30,,13.27,percent of total billed charges,Drugs,13.27,30,,13.27,percent of total billed charges,Drugs,22.12,50,,22.12,percent of total billed charges,All Other,13.27,30,,13.27,percent of total billed charges,Drugs,13.27,30,,13.27,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,13.27,30,,13.27,percent of total billed charges,Drugs,13.27,30,,13.27,percent of total billed charges,Drugs,13.27,30,,13.27,percent of total billed charges,Drugs,13.27,30,,13.27,percent of total billed charges,Drugs,13.27,30,,13.27,percent of total billed charges,Drugs,13.27,30,,13.27,percent of total billed charges,Drugs,13.27,30,,13.27,percent of total billed charges,Drugs,13.27,30,,13.27,percent of total billed charges,Drugs,13.27,30,,13.27,percent of total billed charges,Drugs,13.27,30,,13.27,percent of total billed charges,Drugs,13.27,30,,13.27,percent of total billed charges,Drugs,13.27,30,,13.27,percent of total billed charges,Drugs,13.27,30,,13.27,percent of total billed charges,Drugs,6.58,,,6.58,Other,Drug Cost,6.58,,,6.58,Other,Drug Cost,6.58,,,6.58,Other,Drug Cost,6.58,,,6.58,Other,Drug Cost,6.58,,,6.58,Other,Drug Cost,15.04,34,,15.04,percent of total billed charges,Drugs,6.58,,,6.58,Other,Drug Cost,14.81,,,14.81,Other,225% Medicaid APG methodology,9.21,,,9.21,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6.58,,,6.58,Other,Drug Cost,6.58,,,6.58,Other,Drug Cost,8.23,,,8.23,Other,125% Medicaid APG methodology,0.01,22.12,
TOCILIZUMAB 20MG/ML IV  20ML    ,J3262,HCPCS,,40580136,CDM,636,RC,50242-0137-01,NDC,both,20,ML,7868.56,60.38,,,60.38,Other,150% of Medicare + 9.63% HCRA Surcharge,36.72,,,36.72,Fee Schedule,Average Sale Price (ASP) x 6,2360.57,30,,2360.57,percent of total billed charges,Drugs,2360.57,30,,2360.57,percent of total billed charges,Drugs,2360.57,30,,2360.57,percent of total billed charges,Drugs,2360.57,30,,2360.57,percent of total billed charges,Drugs,2360.57,30,,2360.57,percent of total billed charges,Drugs,3934.28,50,,3934.28,percent of total billed charges,All Other,2360.57,30,,2360.57,percent of total billed charges,Drugs,2360.57,30,,2360.57,percent of total billed charges,Drugs,2675.31,34,"If Charge > 500, then 34 percent",2675.31,percent of total billed charges,Drugs,2360.57,30,,2360.57,percent of total billed charges,Drugs,2360.57,30,,2360.57,percent of total billed charges,Drugs,2360.57,30,,2360.57,percent of total billed charges,Drugs,2360.57,30,,2360.57,percent of total billed charges,Drugs,2360.57,30,,2360.57,percent of total billed charges,Drugs,2360.57,30,,2360.57,percent of total billed charges,Drugs,2360.57,30,,2360.57,percent of total billed charges,Drugs,2360.57,30,,2360.57,percent of total billed charges,Drugs,2360.57,30,,2360.57,percent of total billed charges,Drugs,2360.57,30,,2360.57,percent of total billed charges,Drugs,2360.57,30,,2360.57,percent of total billed charges,Drugs,2360.57,30,,2360.57,percent of total billed charges,Drugs,2360.57,30,,2360.57,percent of total billed charges,Drugs,1074.08,,,1074.08,Other,Drug Cost,1074.08,,,1074.08,Other,Drug Cost,1074.08,,,1074.08,Other,Drug Cost,1074.08,,,1074.08,Other,Drug Cost,1074.08,,,1074.08,Other,Drug Cost,2675.31,34,,2675.31,percent of total billed charges,Drugs,1074.08,,,1074.08,Other,Drug Cost,2416.68,,,2416.68,Other,225% Medicaid APG methodology,1503.71,,,1503.71,Other,140% Medicaid APG methodology,2675.31,34,"If Charge > 2,000, then 34 percent",2675.31,percent of total billed charges,Drugs,58.75,,,58.75,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1074.08,,,1074.08,Other,Drug Cost,1074.08,,,1074.08,Other,Drug Cost,1342.6,,,1342.6,Other,125% Medicaid APG methodology,0.01,3934.28,
EPOETIN 40000 UNITS/ML PF ESRD  ,J0885,HCPCS,,40580425,CDM,636,RC,59676-0340-01,NDC,both,1,ML,1969.91,87.68,,,87.68,Other,150% of Medicare + 9.63% HCRA Surcharge,53.32,,,53.32,Fee Schedule,Average Sale Price (ASP) x 6,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,984.96,50,,984.96,percent of total billed charges,All Other,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,669.77,34,"If Charge > 500, then 34 percent",669.77,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,273.6,,,273.6,Other,Drug Cost,273.6,,,273.6,Other,Drug Cost,273.6,,,273.6,Other,Drug Cost,273.6,,,273.6,Other,Drug Cost,273.6,,,273.6,Other,Drug Cost,669.77,34,,669.77,percent of total billed charges,Drugs,273.6,,,273.6,Other,Drug Cost,615.6,,,615.6,Other,225% Medicaid APG methodology,383.04,,,383.04,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,85.31,,,85.31,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",273.6,,,273.6,Other,Drug Cost,273.6,,,273.6,Other,Drug Cost,342,,,342,Other,125% Medicaid APG methodology,0.01,984.96,
PALIPERIDONE 117MG/0.75ML  ER   ,J2426,HCPCS,,40580557,CDM,636,RC,50458-0562-01,NDC,both,0.75,ML,5331.97,141.27,,,141.27,Other,150% of Medicare + 9.63% HCRA Surcharge,85.91,,,85.91,Fee Schedule,Average Sale Price (ASP) x 6,1599.59,30,,1599.59,percent of total billed charges,Drugs,1599.59,30,,1599.59,percent of total billed charges,Drugs,1599.59,30,,1599.59,percent of total billed charges,Drugs,1599.59,30,,1599.59,percent of total billed charges,Drugs,1599.59,30,,1599.59,percent of total billed charges,Drugs,2665.99,50,,2665.99,percent of total billed charges,All Other,1599.59,30,,1599.59,percent of total billed charges,Drugs,1599.59,30,,1599.59,percent of total billed charges,Drugs,1812.87,34,"If Charge > 500, then 34 percent",1812.87,percent of total billed charges,Drugs,1599.59,30,,1599.59,percent of total billed charges,Drugs,1599.59,30,,1599.59,percent of total billed charges,Drugs,1599.59,30,,1599.59,percent of total billed charges,Drugs,1599.59,30,,1599.59,percent of total billed charges,Drugs,1599.59,30,,1599.59,percent of total billed charges,Drugs,1599.59,30,,1599.59,percent of total billed charges,Drugs,1599.59,30,,1599.59,percent of total billed charges,Drugs,1599.59,30,,1599.59,percent of total billed charges,Drugs,1599.59,30,,1599.59,percent of total billed charges,Drugs,1599.59,30,,1599.59,percent of total billed charges,Drugs,1599.59,30,,1599.59,percent of total billed charges,Drugs,1599.59,30,,1599.59,percent of total billed charges,Drugs,1599.59,30,,1599.59,percent of total billed charges,Drugs,629.55,,,629.55,Other,Drug Cost,629.55,,,629.55,Other,Drug Cost,629.55,,,629.55,Other,Drug Cost,629.55,,,629.55,Other,Drug Cost,629.55,,,629.55,Other,Drug Cost,1812.87,34,,1812.87,percent of total billed charges,Drugs,629.55,,,629.55,Other,Drug Cost,1416.49,,,1416.49,Other,225% Medicaid APG methodology,881.37,,,881.37,Other,140% Medicaid APG methodology,1812.87,34,"If Charge > 2,000, then 34 percent",1812.87,percent of total billed charges,Drugs,137.45,,,137.45,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",629.55,,,629.55,Other,Drug Cost,629.55,,,629.55,Other,Drug Cost,786.94,,,786.94,Other,125% Medicaid APG methodology,0.01,2665.99,
PHENYLEPHRINE 100MG NS 250ML    ,J2371,HCPCS,,40580714,CDM,636,RC,70004-0805-40,NDC,both,250,ML,401.17,158.33,39.4668,,158.33,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,120.35,30,,120.35,percent of total billed charges,Drugs,120.35,30,,120.35,percent of total billed charges,Drugs,120.35,30,,120.35,percent of total billed charges,Drugs,120.35,30,,120.35,percent of total billed charges,Drugs,120.35,30,,120.35,percent of total billed charges,Drugs,200.59,50,,200.59,percent of total billed charges,All Other,120.35,30,,120.35,percent of total billed charges,Drugs,120.35,30,,120.35,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,120.35,30,,120.35,percent of total billed charges,Drugs,120.35,30,,120.35,percent of total billed charges,Drugs,120.35,30,,120.35,percent of total billed charges,Drugs,120.35,30,,120.35,percent of total billed charges,Drugs,120.35,30,,120.35,percent of total billed charges,Drugs,120.35,30,,120.35,percent of total billed charges,Drugs,120.35,30,,120.35,percent of total billed charges,Drugs,120.35,30,,120.35,percent of total billed charges,Drugs,120.35,30,,120.35,percent of total billed charges,Drugs,120.35,30,,120.35,percent of total billed charges,Drugs,120.35,30,,120.35,percent of total billed charges,Drugs,120.35,30,,120.35,percent of total billed charges,Drugs,120.35,30,,120.35,percent of total billed charges,Drugs,114.62,,,114.62,Other,Drug Cost,114.62,,,114.62,Other,Drug Cost,114.62,,,114.62,Other,Drug Cost,114.62,,,114.62,Other,Drug Cost,114.62,,,114.62,Other,Drug Cost,136.4,34,,136.4,percent of total billed charges,Drugs,114.62,,,114.62,Other,Drug Cost,257.9,,,257.9,Other,225% Medicaid APG methodology,160.47,,,160.47,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",114.62,,,114.62,Other,Drug Cost,114.62,,,114.62,Other,Drug Cost,143.28,,,143.28,Other,125% Medicaid APG methodology,0.01,257.9,
HYDROMORPHONE 1MG/ML INJ  1ML   ,J1170,HCPCS,,40580730,CDM,636,RC,63323-0852-25,NDC,both,1,ML,11.69,45.3,,,45.3,Other,150% of Medicare + 9.63% HCRA Surcharge,27.55,,,27.55,Fee Schedule,Average Sale Price (ASP) x 6,3.51,30,,3.51,percent of total billed charges,Drugs,3.51,30,,3.51,percent of total billed charges,Drugs,3.51,30,,3.51,percent of total billed charges,Drugs,3.51,30,,3.51,percent of total billed charges,Drugs,3.51,30,,3.51,percent of total billed charges,Drugs,5.85,50,,5.85,percent of total billed charges,All Other,3.51,30,,3.51,percent of total billed charges,Drugs,3.51,30,,3.51,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.51,30,,3.51,percent of total billed charges,Drugs,3.51,30,,3.51,percent of total billed charges,Drugs,3.51,30,,3.51,percent of total billed charges,Drugs,3.51,30,,3.51,percent of total billed charges,Drugs,3.51,30,,3.51,percent of total billed charges,Drugs,3.51,30,,3.51,percent of total billed charges,Drugs,3.51,30,,3.51,percent of total billed charges,Drugs,3.51,30,,3.51,percent of total billed charges,Drugs,3.51,30,,3.51,percent of total billed charges,Drugs,3.51,30,,3.51,percent of total billed charges,Drugs,3.51,30,,3.51,percent of total billed charges,Drugs,3.51,30,,3.51,percent of total billed charges,Drugs,3.51,30,,3.51,percent of total billed charges,Drugs,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,3.97,34,,3.97,percent of total billed charges,Drugs,0.38,,,0.38,Other,Drug Cost,0.86,,,0.86,Other,225% Medicaid APG methodology,0.53,,,0.53,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,44.07,,,44.07,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.48,,,0.48,Other,125% Medicaid APG methodology,0.01,45.3,
IRINOTECAN 20MG/ML IV SOLN 2ML  ,J9206,HCPCS,,40580888,CDM,636,RC,25021-0230-02,NDC,both,2,ML,19.88,19.19,,,19.19,Other,150% of Medicare + 9.63% HCRA Surcharge,11.67,,,11.67,Fee Schedule,Average Sale Price (ASP) x 6,5.96,30,,5.96,percent of total billed charges,Drugs,5.96,30,,5.96,percent of total billed charges,Drugs,5.96,30,,5.96,percent of total billed charges,Drugs,5.96,30,,5.96,percent of total billed charges,Drugs,5.96,30,,5.96,percent of total billed charges,Drugs,9.94,50,,9.94,percent of total billed charges,All Other,5.96,30,,5.96,percent of total billed charges,Drugs,5.96,30,,5.96,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,5.96,30,,5.96,percent of total billed charges,Drugs,5.96,30,,5.96,percent of total billed charges,Drugs,5.96,30,,5.96,percent of total billed charges,Drugs,5.96,30,,5.96,percent of total billed charges,Drugs,5.96,30,,5.96,percent of total billed charges,Drugs,5.96,30,,5.96,percent of total billed charges,Drugs,5.96,30,,5.96,percent of total billed charges,Drugs,5.96,30,,5.96,percent of total billed charges,Drugs,5.96,30,,5.96,percent of total billed charges,Drugs,5.96,30,,5.96,percent of total billed charges,Drugs,5.96,30,,5.96,percent of total billed charges,Drugs,5.96,30,,5.96,percent of total billed charges,Drugs,5.96,30,,5.96,percent of total billed charges,Drugs,5.3,,,5.3,Other,Drug Cost,5.3,,,5.3,Other,Drug Cost,5.3,,,5.3,Other,Drug Cost,5.3,,,5.3,Other,Drug Cost,5.3,,,5.3,Other,Drug Cost,6.76,34,,6.76,percent of total billed charges,Drugs,5.3,,,5.3,Other,Drug Cost,11.93,,,11.93,Other,225% Medicaid APG methodology,7.42,,,7.42,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,18.67,,,18.67,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.3,,,5.3,Other,Drug Cost,5.3,,,5.3,Other,Drug Cost,6.63,,,6.63,Other,125% Medicaid APG methodology,0.01,19.19,
INFLUENZA QUAD PF (48M+) 0.5ML  ,90674,CPT,,40580896,CDM,636,RC,70461-0323-03,NDC,both,0.5,ML,81.48,337.16,,,337.16,Other,150% of Medicare + 9.63% HCRA Surcharge,205.03,,,205.03,Fee Schedule,Average Sale Price (ASP) x 6,24.44,30,,24.44,percent of total billed charges,Drugs,24.44,30,,24.44,percent of total billed charges,Drugs,24.44,30,,24.44,percent of total billed charges,Drugs,24.44,30,,24.44,percent of total billed charges,Drugs,24.44,30,,24.44,percent of total billed charges,Drugs,40.74,50,,40.74,percent of total billed charges,All Other,24.44,30,,24.44,percent of total billed charges,Drugs,24.44,30,,24.44,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,24.44,30,,24.44,percent of total billed charges,Drugs,24.44,30,,24.44,percent of total billed charges,Drugs,24.44,30,,24.44,percent of total billed charges,Drugs,24.44,30,,24.44,percent of total billed charges,Drugs,24.44,30,,24.44,percent of total billed charges,Drugs,24.44,30,,24.44,percent of total billed charges,Drugs,24.44,30,,24.44,percent of total billed charges,Drugs,24.44,30,,24.44,percent of total billed charges,Drugs,24.44,30,,24.44,percent of total billed charges,Drugs,24.44,30,,24.44,percent of total billed charges,Drugs,24.44,30,,24.44,percent of total billed charges,Drugs,24.44,30,,24.44,percent of total billed charges,Drugs,24.44,30,,24.44,percent of total billed charges,Drugs,23.28,,,23.28,Other,Drug Cost,23.28,,,23.28,Other,Drug Cost,23.28,,,23.28,Other,Drug Cost,23.28,,,23.28,Other,Drug Cost,23.28,,,23.28,Other,Drug Cost,27.7,34,,27.7,percent of total billed charges,Drugs,23.28,,,23.28,Other,Drug Cost,52.38,,,52.38,Other,225% Medicaid APG methodology,32.59,,,32.59,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,328.05,,,328.05,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",23.28,,,23.28,Other,Drug Cost,23.28,,,23.28,Other,Drug Cost,29.1,,,29.1,Other,125% Medicaid APG methodology,0.01,337.16,
EVEROLIMUS 5 MG TAB             ,J7527,HCPCS,,40580904,CDM,636,RC,00078-0566-51,NDC,both,1,EA,2265.59,27.14,,,27.14,Other,150% of Medicare + 9.63% HCRA Surcharge,16.51,,,16.51,Fee Schedule,Average Sale Price (ASP) x 6,679.68,30,,679.68,percent of total billed charges,Drugs,679.68,30,,679.68,percent of total billed charges,Drugs,679.68,30,,679.68,percent of total billed charges,Drugs,679.68,30,,679.68,percent of total billed charges,Drugs,679.68,30,,679.68,percent of total billed charges,Drugs,1132.8,50,,1132.8,percent of total billed charges,All Other,679.68,30,,679.68,percent of total billed charges,Drugs,679.68,30,,679.68,percent of total billed charges,Drugs,770.3,34,"If Charge > 500, then 34 percent",770.3,percent of total billed charges,Drugs,679.68,30,,679.68,percent of total billed charges,Drugs,679.68,30,,679.68,percent of total billed charges,Drugs,679.68,30,,679.68,percent of total billed charges,Drugs,679.68,30,,679.68,percent of total billed charges,Drugs,679.68,30,,679.68,percent of total billed charges,Drugs,679.68,30,,679.68,percent of total billed charges,Drugs,679.68,30,,679.68,percent of total billed charges,Drugs,679.68,30,,679.68,percent of total billed charges,Drugs,679.68,30,,679.68,percent of total billed charges,Drugs,679.68,30,,679.68,percent of total billed charges,Drugs,679.68,30,,679.68,percent of total billed charges,Drugs,679.68,30,,679.68,percent of total billed charges,Drugs,679.68,30,,679.68,percent of total billed charges,Drugs,97.33,,,97.33,Other,Drug Cost,97.33,,,97.33,Other,Drug Cost,97.33,,,97.33,Other,Drug Cost,97.33,,,97.33,Other,Drug Cost,97.33,,,97.33,Other,Drug Cost,770.3,34,,770.3,percent of total billed charges,Drugs,97.33,,,97.33,Other,Drug Cost,218.99,,,218.99,Other,225% Medicaid APG methodology,136.26,,,136.26,Other,140% Medicaid APG methodology,770.3,34,"If Charge > 2,000, then 34 percent",770.3,percent of total billed charges,Drugs,26.41,,,26.41,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",97.33,,,97.33,Other,Drug Cost,97.33,,,97.33,Other,Drug Cost,121.66,,,121.66,Other,125% Medicaid APG methodology,0.01,1132.8,
NIVOLUMAB 10MG/ML IV SOLN 10ML  ,J9299,HCPCS,,40581035,CDM,636,RC,00003-3774-12,NDC,both,10,ML,10084.27,306.75,,,306.75,Other,150% of Medicare + 9.63% HCRA Surcharge,186.53,,,186.53,Fee Schedule,Average Sale Price (ASP) x 6,3025.28,30,,3025.28,percent of total billed charges,Drugs,3025.28,30,,3025.28,percent of total billed charges,Drugs,3025.28,30,,3025.28,percent of total billed charges,Drugs,3025.28,30,,3025.28,percent of total billed charges,Drugs,3025.28,30,,3025.28,percent of total billed charges,Drugs,5042.14,50,,5042.14,percent of total billed charges,All Other,3025.28,30,,3025.28,percent of total billed charges,Drugs,3025.28,30,,3025.28,percent of total billed charges,Drugs,3428.65,34,"If Charge > 500, then 34 percent",3428.65,percent of total billed charges,Drugs,3025.28,30,,3025.28,percent of total billed charges,Drugs,3025.28,30,,3025.28,percent of total billed charges,Drugs,3025.28,30,,3025.28,percent of total billed charges,Drugs,3025.28,30,,3025.28,percent of total billed charges,Drugs,3025.28,30,,3025.28,percent of total billed charges,Drugs,3025.28,30,,3025.28,percent of total billed charges,Drugs,3025.28,30,,3025.28,percent of total billed charges,Drugs,3025.28,30,,3025.28,percent of total billed charges,Drugs,3025.28,30,,3025.28,percent of total billed charges,Drugs,3025.28,30,,3025.28,percent of total billed charges,Drugs,3025.28,30,,3025.28,percent of total billed charges,Drugs,3025.28,30,,3025.28,percent of total billed charges,Drugs,3025.28,30,,3025.28,percent of total billed charges,Drugs,2109.71,,,2109.71,Other,Drug Cost,2109.71,,,2109.71,Other,Drug Cost,2109.71,,,2109.71,Other,Drug Cost,2109.71,,,2109.71,Other,Drug Cost,2109.71,,,2109.71,Other,Drug Cost,3428.65,34,,3428.65,percent of total billed charges,Drugs,2109.71,,,2109.71,Other,Drug Cost,4746.85,,,4746.85,Other,225% Medicaid APG methodology,2953.59,,,2953.59,Other,140% Medicaid APG methodology,3428.65,34,"If Charge > 2,000, then 34 percent",3428.65,percent of total billed charges,Drugs,298.45,,,298.45,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2109.71,,,2109.71,Other,Drug Cost,2109.71,,,2109.71,Other,Drug Cost,2637.14,,,2637.14,Other,125% Medicaid APG methodology,0.01,5042.14,
PROTHROMBIN COMPLEX IV INJ      ,J7168,HCPCS,,40581092,CDM,636,RC,63833-0386-02,NDC,both,1,EA,7.63,3.01,39.4668,,3.01,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,3.82,50,,3.82,percent of total billed charges,All Other,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,1.26,,,1.26,Other,Drug Cost,1.26,,,1.26,Other,Drug Cost,1.26,,,1.26,Other,Drug Cost,1.26,,,1.26,Other,Drug Cost,1.26,,,1.26,Other,Drug Cost,2.59,34,,2.59,percent of total billed charges,Drugs,1.26,,,1.26,Other,Drug Cost,2.84,,,2.84,Other,225% Medicaid APG methodology,1.76,,,1.76,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.26,,,1.26,Other,Drug Cost,1.26,,,1.26,Other,Drug Cost,1.58,,,1.58,Other,125% Medicaid APG methodology,0.01,3.82,
CEFTAZDIME-AVIBCTAM 2-0.5G INJ  ,J0714,HCPCS,,40581134,CDM,636,RC,00456-2700-10,NDC,both,1,EA,1255.21,941.77,,,941.77,Other,150% of Medicare + 9.63% HCRA Surcharge,572.69,,,572.69,Fee Schedule,Average Sale Price (ASP) x 6,376.56,30,,376.56,percent of total billed charges,Drugs,376.56,30,,376.56,percent of total billed charges,Drugs,376.56,30,,376.56,percent of total billed charges,Drugs,376.56,30,,376.56,percent of total billed charges,Drugs,376.56,30,,376.56,percent of total billed charges,Drugs,627.61,50,,627.61,percent of total billed charges,All Other,376.56,30,,376.56,percent of total billed charges,Drugs,376.56,30,,376.56,percent of total billed charges,Drugs,426.77,34,"If Charge > 500, then 34 percent",426.77,percent of total billed charges,Drugs,376.56,30,,376.56,percent of total billed charges,Drugs,376.56,30,,376.56,percent of total billed charges,Drugs,376.56,30,,376.56,percent of total billed charges,Drugs,376.56,30,,376.56,percent of total billed charges,Drugs,376.56,30,,376.56,percent of total billed charges,Drugs,376.56,30,,376.56,percent of total billed charges,Drugs,376.56,30,,376.56,percent of total billed charges,Drugs,376.56,30,,376.56,percent of total billed charges,Drugs,376.56,30,,376.56,percent of total billed charges,Drugs,376.56,30,,376.56,percent of total billed charges,Drugs,376.56,30,,376.56,percent of total billed charges,Drugs,376.56,30,,376.56,percent of total billed charges,Drugs,376.56,30,,376.56,percent of total billed charges,Drugs,233.32,,,233.32,Other,Drug Cost,233.32,,,233.32,Other,Drug Cost,233.32,,,233.32,Other,Drug Cost,233.32,,,233.32,Other,Drug Cost,233.32,,,233.32,Other,Drug Cost,426.77,34,,426.77,percent of total billed charges,Drugs,233.32,,,233.32,Other,Drug Cost,524.97,,,524.97,Other,225% Medicaid APG methodology,326.65,,,326.65,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,916.31,,,916.31,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",233.32,,,233.32,Other,Drug Cost,233.32,,,233.32,Other,Drug Cost,291.65,,,291.65,Other,125% Medicaid APG methodology,0.01,941.77,
VWF-ANTIHEMO FACTOR (HUMATE P)  ,J7187,HCPCS,,40581159,CDM,636,RC,63833-0616-02,NDC,both,1,EA,3.5,13.3,,,13.3,Other,150% of Medicare + 9.63% HCRA Surcharge,8.09,,,8.09,Fee Schedule,Average Sale Price (ASP) x 6,1.05,30,,1.05,percent of total billed charges,Drugs,1.05,30,,1.05,percent of total billed charges,Drugs,1.05,30,,1.05,percent of total billed charges,Drugs,1.05,30,,1.05,percent of total billed charges,Drugs,1.05,30,,1.05,percent of total billed charges,Drugs,1.75,50,,1.75,percent of total billed charges,All Other,1.05,30,,1.05,percent of total billed charges,Drugs,1.05,30,,1.05,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.05,30,,1.05,percent of total billed charges,Drugs,1.05,30,,1.05,percent of total billed charges,Drugs,1.05,30,,1.05,percent of total billed charges,Drugs,1.05,30,,1.05,percent of total billed charges,Drugs,1.05,30,,1.05,percent of total billed charges,Drugs,1.05,30,,1.05,percent of total billed charges,Drugs,1.05,30,,1.05,percent of total billed charges,Drugs,1.05,30,,1.05,percent of total billed charges,Drugs,1.05,30,,1.05,percent of total billed charges,Drugs,1.05,30,,1.05,percent of total billed charges,Drugs,1.05,30,,1.05,percent of total billed charges,Drugs,1.05,30,,1.05,percent of total billed charges,Drugs,1.05,30,,1.05,percent of total billed charges,Drugs,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,1.19,34,,1.19,percent of total billed charges,Drugs,0.84,,,0.84,Other,Drug Cost,1.89,,,1.89,Other,225% Medicaid APG methodology,1.18,,,1.18,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,12.94,,,12.94,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.84,,,0.84,Other,Drug Cost,0.84,,,0.84,Other,Drug Cost,1.05,,,1.05,Other,125% Medicaid APG methodology,0.01,13.3,
"COAGULATION FACTOR VIIA,RECO 2  ",J7189,HCPCS,,40581175,CDM,636,RC,00169-7202-01,NDC,both,1,EA,13840.05,23.96,,,23.96,Other,150% of Medicare + 9.63% HCRA Surcharge,14.57,,,14.57,Fee Schedule,Average Sale Price (ASP) x 6,4152.02,30,,4152.02,percent of total billed charges,Drugs,4152.02,30,,4152.02,percent of total billed charges,Drugs,4152.02,30,,4152.02,percent of total billed charges,Drugs,4152.02,30,,4152.02,percent of total billed charges,Drugs,4152.02,30,,4152.02,percent of total billed charges,Drugs,6920.03,50,,6920.03,percent of total billed charges,All Other,4152.02,30,,4152.02,percent of total billed charges,Drugs,4152.02,30,,4152.02,percent of total billed charges,Drugs,4705.62,34,"If Charge > 500, then 34 percent",4705.62,percent of total billed charges,Drugs,4152.02,30,,4152.02,percent of total billed charges,Drugs,4152.02,30,,4152.02,percent of total billed charges,Drugs,4152.02,30,,4152.02,percent of total billed charges,Drugs,4152.02,30,,4152.02,percent of total billed charges,Drugs,4152.02,30,,4152.02,percent of total billed charges,Drugs,4152.02,30,,4152.02,percent of total billed charges,Drugs,4152.02,30,,4152.02,percent of total billed charges,Drugs,4152.02,30,,4152.02,percent of total billed charges,Drugs,4152.02,30,,4152.02,percent of total billed charges,Drugs,4152.02,30,,4152.02,percent of total billed charges,Drugs,4152.02,30,,4152.02,percent of total billed charges,Drugs,4152.02,30,,4152.02,percent of total billed charges,Drugs,4152.02,30,,4152.02,percent of total billed charges,Drugs,1822.94,,,1822.94,Other,Drug Cost,1822.94,,,1822.94,Other,Drug Cost,1822.94,,,1822.94,Other,Drug Cost,1822.94,,,1822.94,Other,Drug Cost,1822.94,,,1822.94,Other,Drug Cost,4705.62,34,,4705.62,percent of total billed charges,Drugs,1822.94,,,1822.94,Other,Drug Cost,4101.62,,,4101.62,Other,225% Medicaid APG methodology,2552.12,,,2552.12,Other,140% Medicaid APG methodology,4705.62,34,"If Charge > 2,000, then 34 percent",4705.62,percent of total billed charges,Drugs,23.31,,,23.31,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1822.94,,,1822.94,Other,Drug Cost,1822.94,,,1822.94,Other,Drug Cost,2278.68,,,2278.68,Other,125% Medicaid APG methodology,0.01,6920.03,
DARATUMUMAB 20MG/ML IV SLN 5ML  ,J9145,HCPCS,,40581266,CDM,636,RC,57894-0502-05,NDC,both,5,ML,2028.04,608.82,,,608.82,Other,150% of Medicare + 9.63% HCRA Surcharge,370.23,,,370.23,Fee Schedule,Average Sale Price (ASP) x 6,608.41,30,,608.41,percent of total billed charges,Drugs,608.41,30,,608.41,percent of total billed charges,Drugs,608.41,30,,608.41,percent of total billed charges,Drugs,608.41,30,,608.41,percent of total billed charges,Drugs,608.41,30,,608.41,percent of total billed charges,Drugs,1014.02,50,,1014.02,percent of total billed charges,All Other,608.41,30,,608.41,percent of total billed charges,Drugs,608.41,30,,608.41,percent of total billed charges,Drugs,689.53,34,"If Charge > 500, then 34 percent",689.53,percent of total billed charges,Drugs,608.41,30,,608.41,percent of total billed charges,Drugs,608.41,30,,608.41,percent of total billed charges,Drugs,608.41,30,,608.41,percent of total billed charges,Drugs,608.41,30,,608.41,percent of total billed charges,Drugs,608.41,30,,608.41,percent of total billed charges,Drugs,608.41,30,,608.41,percent of total billed charges,Drugs,608.41,30,,608.41,percent of total billed charges,Drugs,608.41,30,,608.41,percent of total billed charges,Drugs,608.41,30,,608.41,percent of total billed charges,Drugs,608.41,30,,608.41,percent of total billed charges,Drugs,608.41,30,,608.41,percent of total billed charges,Drugs,608.41,30,,608.41,percent of total billed charges,Drugs,608.41,30,,608.41,percent of total billed charges,Drugs,369.43,,,369.43,Other,Drug Cost,369.43,,,369.43,Other,Drug Cost,369.43,,,369.43,Other,Drug Cost,369.43,,,369.43,Other,Drug Cost,369.43,,,369.43,Other,Drug Cost,689.53,34,,689.53,percent of total billed charges,Drugs,369.43,,,369.43,Other,Drug Cost,831.22,,,831.22,Other,225% Medicaid APG methodology,517.2,,,517.2,Other,140% Medicaid APG methodology,689.53,34,"If Charge > 2,000, then 34 percent",689.53,percent of total billed charges,Drugs,592.37,,,592.37,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",369.43,,,369.43,Other,Drug Cost,369.43,,,369.43,Other,Drug Cost,461.79,,,461.79,Other,125% Medicaid APG methodology,0.01,1014.02,
DARATUMUMAB 20MG/ML IV 20ML     ,J9145,HCPCS,,40581274,CDM,636,RC,57894-0502-20,NDC,both,20,ML,9283.72,608.82,,,608.82,Other,150% of Medicare + 9.63% HCRA Surcharge,370.23,,,370.23,Fee Schedule,Average Sale Price (ASP) x 6,2785.12,30,,2785.12,percent of total billed charges,Drugs,2785.12,30,,2785.12,percent of total billed charges,Drugs,2785.12,30,,2785.12,percent of total billed charges,Drugs,2785.12,30,,2785.12,percent of total billed charges,Drugs,2785.12,30,,2785.12,percent of total billed charges,Drugs,4641.86,50,,4641.86,percent of total billed charges,All Other,2785.12,30,,2785.12,percent of total billed charges,Drugs,2785.12,30,,2785.12,percent of total billed charges,Drugs,3156.46,34,"If Charge > 500, then 34 percent",3156.46,percent of total billed charges,Drugs,2785.12,30,,2785.12,percent of total billed charges,Drugs,2785.12,30,,2785.12,percent of total billed charges,Drugs,2785.12,30,,2785.12,percent of total billed charges,Drugs,2785.12,30,,2785.12,percent of total billed charges,Drugs,2785.12,30,,2785.12,percent of total billed charges,Drugs,2785.12,30,,2785.12,percent of total billed charges,Drugs,2785.12,30,,2785.12,percent of total billed charges,Drugs,2785.12,30,,2785.12,percent of total billed charges,Drugs,2785.12,30,,2785.12,percent of total billed charges,Drugs,2785.12,30,,2785.12,percent of total billed charges,Drugs,2785.12,30,,2785.12,percent of total billed charges,Drugs,2785.12,30,,2785.12,percent of total billed charges,Drugs,2785.12,30,,2785.12,percent of total billed charges,Drugs,1664.77,,,1664.77,Other,Drug Cost,1664.77,,,1664.77,Other,Drug Cost,1664.77,,,1664.77,Other,Drug Cost,1664.77,,,1664.77,Other,Drug Cost,1664.77,,,1664.77,Other,Drug Cost,3156.46,34,,3156.46,percent of total billed charges,Drugs,1664.77,,,1664.77,Other,Drug Cost,3745.73,,,3745.73,Other,225% Medicaid APG methodology,2330.68,,,2330.68,Other,140% Medicaid APG methodology,3156.46,34,"If Charge > 2,000, then 34 percent",3156.46,percent of total billed charges,Drugs,592.37,,,592.37,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1664.77,,,1664.77,Other,Drug Cost,1664.77,,,1664.77,Other,Drug Cost,2080.96,,,2080.96,Other,125% Medicaid APG methodology,0.01,4641.86,
RAMUCIRUMAB 10MG/ML IVSLN 10ML  ,J9308,HCPCS,,40581399,CDM,636,RC,00002-7669-01,NDC,both,10,ML,4528.9,693.08,,,693.08,Other,150% of Medicare + 9.63% HCRA Surcharge,421.46,,,421.46,Fee Schedule,Average Sale Price (ASP) x 6,1358.67,30,,1358.67,percent of total billed charges,Drugs,1358.67,30,,1358.67,percent of total billed charges,Drugs,1358.67,30,,1358.67,percent of total billed charges,Drugs,1358.67,30,,1358.67,percent of total billed charges,Drugs,1358.67,30,,1358.67,percent of total billed charges,Drugs,2264.45,50,,2264.45,percent of total billed charges,All Other,1358.67,30,,1358.67,percent of total billed charges,Drugs,1358.67,30,,1358.67,percent of total billed charges,Drugs,1539.83,34,"If Charge > 500, then 34 percent",1539.83,percent of total billed charges,Drugs,1358.67,30,,1358.67,percent of total billed charges,Drugs,1358.67,30,,1358.67,percent of total billed charges,Drugs,1358.67,30,,1358.67,percent of total billed charges,Drugs,1358.67,30,,1358.67,percent of total billed charges,Drugs,1358.67,30,,1358.67,percent of total billed charges,Drugs,1358.67,30,,1358.67,percent of total billed charges,Drugs,1358.67,30,,1358.67,percent of total billed charges,Drugs,1358.67,30,,1358.67,percent of total billed charges,Drugs,1358.67,30,,1358.67,percent of total billed charges,Drugs,1358.67,30,,1358.67,percent of total billed charges,Drugs,1358.67,30,,1358.67,percent of total billed charges,Drugs,1358.67,30,,1358.67,percent of total billed charges,Drugs,1358.67,30,,1358.67,percent of total billed charges,Drugs,883.92,,,883.92,Other,Drug Cost,883.92,,,883.92,Other,Drug Cost,883.92,,,883.92,Other,Drug Cost,883.92,,,883.92,Other,Drug Cost,883.92,,,883.92,Other,Drug Cost,1539.83,34,,1539.83,percent of total billed charges,Drugs,883.92,,,883.92,Other,Drug Cost,1988.82,,,1988.82,Other,225% Medicaid APG methodology,1237.49,,,1237.49,Other,140% Medicaid APG methodology,1539.83,34,"If Charge > 2,000, then 34 percent",1539.83,percent of total billed charges,Drugs,674.34,,,674.34,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",883.92,,,883.92,Other,Drug Cost,883.92,,,883.92,Other,Drug Cost,1104.9,,,1104.9,Other,125% Medicaid APG methodology,0.01,2264.45,
NIVOLUMAB 10MG/ML IV SOLN 4ML   ,J9299,HCPCS,,40581407,CDM,636,RC,00003-3772-11,NDC,both,4,ML,4264.33,306.75,,,306.75,Other,150% of Medicare + 9.63% HCRA Surcharge,186.53,,,186.53,Fee Schedule,Average Sale Price (ASP) x 6,1279.3,30,,1279.3,percent of total billed charges,Drugs,1279.3,30,,1279.3,percent of total billed charges,Drugs,1279.3,30,,1279.3,percent of total billed charges,Drugs,1279.3,30,,1279.3,percent of total billed charges,Drugs,1279.3,30,,1279.3,percent of total billed charges,Drugs,2132.17,50,,2132.17,percent of total billed charges,All Other,1279.3,30,,1279.3,percent of total billed charges,Drugs,1279.3,30,,1279.3,percent of total billed charges,Drugs,1449.87,34,"If Charge > 500, then 34 percent",1449.87,percent of total billed charges,Drugs,1279.3,30,,1279.3,percent of total billed charges,Drugs,1279.3,30,,1279.3,percent of total billed charges,Drugs,1279.3,30,,1279.3,percent of total billed charges,Drugs,1279.3,30,,1279.3,percent of total billed charges,Drugs,1279.3,30,,1279.3,percent of total billed charges,Drugs,1279.3,30,,1279.3,percent of total billed charges,Drugs,1279.3,30,,1279.3,percent of total billed charges,Drugs,1279.3,30,,1279.3,percent of total billed charges,Drugs,1279.3,30,,1279.3,percent of total billed charges,Drugs,1279.3,30,,1279.3,percent of total billed charges,Drugs,1279.3,30,,1279.3,percent of total billed charges,Drugs,1279.3,30,,1279.3,percent of total billed charges,Drugs,1279.3,30,,1279.3,percent of total billed charges,Drugs,871.28,,,871.28,Other,Drug Cost,871.28,,,871.28,Other,Drug Cost,871.28,,,871.28,Other,Drug Cost,871.28,,,871.28,Other,Drug Cost,871.28,,,871.28,Other,Drug Cost,1449.87,34,,1449.87,percent of total billed charges,Drugs,871.28,,,871.28,Other,Drug Cost,1960.38,,,1960.38,Other,225% Medicaid APG methodology,1219.79,,,1219.79,Other,140% Medicaid APG methodology,1449.87,34,"If Charge > 2,000, then 34 percent",1449.87,percent of total billed charges,Drugs,298.45,,,298.45,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",871.28,,,871.28,Other,Drug Cost,871.28,,,871.28,Other,Drug Cost,1089.1,,,1089.1,Other,125% Medicaid APG methodology,0.01,2132.17,
MAG SULF 2 G IN IV SLN  50ML    ,J3475,HCPCS,,40581431,CDM,636,RC,25021-0612-81,NDC,both,50,ML,15.23,6.82,,,6.82,Other,150% of Medicare + 9.63% HCRA Surcharge,4.15,,,4.15,Fee Schedule,Average Sale Price (ASP) x 6,4.57,30,,4.57,percent of total billed charges,Drugs,4.57,30,,4.57,percent of total billed charges,Drugs,4.57,30,,4.57,percent of total billed charges,Drugs,4.57,30,,4.57,percent of total billed charges,Drugs,4.57,30,,4.57,percent of total billed charges,Drugs,7.62,50,,7.62,percent of total billed charges,All Other,4.57,30,,4.57,percent of total billed charges,Drugs,4.57,30,,4.57,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.57,30,,4.57,percent of total billed charges,Drugs,4.57,30,,4.57,percent of total billed charges,Drugs,4.57,30,,4.57,percent of total billed charges,Drugs,4.57,30,,4.57,percent of total billed charges,Drugs,4.57,30,,4.57,percent of total billed charges,Drugs,4.57,30,,4.57,percent of total billed charges,Drugs,4.57,30,,4.57,percent of total billed charges,Drugs,4.57,30,,4.57,percent of total billed charges,Drugs,4.57,30,,4.57,percent of total billed charges,Drugs,4.57,30,,4.57,percent of total billed charges,Drugs,4.57,30,,4.57,percent of total billed charges,Drugs,4.57,30,,4.57,percent of total billed charges,Drugs,4.57,30,,4.57,percent of total billed charges,Drugs,2.48,,,2.48,Other,Drug Cost,2.48,,,2.48,Other,Drug Cost,2.48,,,2.48,Other,Drug Cost,2.48,,,2.48,Other,Drug Cost,2.48,,,2.48,Other,Drug Cost,5.18,34,,5.18,percent of total billed charges,Drugs,2.48,,,2.48,Other,Drug Cost,5.58,,,5.58,Other,225% Medicaid APG methodology,3.47,,,3.47,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.63,,,6.63,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.48,,,2.48,Other,Drug Cost,2.48,,,2.48,Other,Drug Cost,3.1,,,3.1,Other,125% Medicaid APG methodology,0.01,7.62,
MENINGOCB VACC OMV ADJUV 0.5ML  ,90620,CPT,,40581548,CDM,636,RC,58160-0976-20,NDC,both,0.5,ML,984.9,388.71,39.4668,,388.71,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,295.47,30,,295.47,percent of total billed charges,Drugs,295.47,30,,295.47,percent of total billed charges,Drugs,295.47,30,,295.47,percent of total billed charges,Drugs,295.47,30,,295.47,percent of total billed charges,Drugs,295.47,30,,295.47,percent of total billed charges,Drugs,492.45,50,,492.45,percent of total billed charges,All Other,295.47,30,,295.47,percent of total billed charges,Drugs,295.47,30,,295.47,percent of total billed charges,Drugs,334.87,34,"If Charge > 500, then 34 percent",334.87,percent of total billed charges,Drugs,295.47,30,,295.47,percent of total billed charges,Drugs,295.47,30,,295.47,percent of total billed charges,Drugs,295.47,30,,295.47,percent of total billed charges,Drugs,295.47,30,,295.47,percent of total billed charges,Drugs,295.47,30,,295.47,percent of total billed charges,Drugs,295.47,30,,295.47,percent of total billed charges,Drugs,295.47,30,,295.47,percent of total billed charges,Drugs,295.47,30,,295.47,percent of total billed charges,Drugs,295.47,30,,295.47,percent of total billed charges,Drugs,295.47,30,,295.47,percent of total billed charges,Drugs,295.47,30,,295.47,percent of total billed charges,Drugs,295.47,30,,295.47,percent of total billed charges,Drugs,295.47,30,,295.47,percent of total billed charges,Drugs,285.03,,,285.03,Other,Drug Cost,285.03,,,285.03,Other,Drug Cost,285.03,,,285.03,Other,Drug Cost,285.03,,,285.03,Other,Drug Cost,285.03,,,285.03,Other,Drug Cost,334.87,34,,334.87,percent of total billed charges,Drugs,285.03,,,285.03,Other,Drug Cost,641.32,,,641.32,Other,225% Medicaid APG methodology,399.04,,,399.04,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",285.03,,,285.03,Other,Drug Cost,285.03,,,285.03,Other,Drug Cost,356.29,,,356.29,Other,125% Medicaid APG methodology,0.01,641.32,
RECOMBIVAX HB 40MCG/ML VIAL     ,90740,CPT,,40581555,CDM,636,RC,00006-4992-00,NDC,both,1,ML,528.85,1500.96,,,1500.96,Other,150% of Medicare + 9.63% HCRA Surcharge,912.74,,,912.74,Fee Schedule,Average Sale Price (ASP) x 6,158.66,30,,158.66,percent of total billed charges,Drugs,158.66,30,,158.66,percent of total billed charges,Drugs,158.66,30,,158.66,percent of total billed charges,Drugs,158.66,30,,158.66,percent of total billed charges,Drugs,158.66,30,,158.66,percent of total billed charges,Drugs,264.43,50,,264.43,percent of total billed charges,All Other,158.66,30,,158.66,percent of total billed charges,Drugs,158.66,30,,158.66,percent of total billed charges,Drugs,179.81,34,"If Charge > 500, then 34 percent",179.81,percent of total billed charges,Drugs,158.66,30,,158.66,percent of total billed charges,Drugs,158.66,30,,158.66,percent of total billed charges,Drugs,158.66,30,,158.66,percent of total billed charges,Drugs,158.66,30,,158.66,percent of total billed charges,Drugs,158.66,30,,158.66,percent of total billed charges,Drugs,158.66,30,,158.66,percent of total billed charges,Drugs,158.66,30,,158.66,percent of total billed charges,Drugs,158.66,30,,158.66,percent of total billed charges,Drugs,158.66,30,,158.66,percent of total billed charges,Drugs,158.66,30,,158.66,percent of total billed charges,Drugs,158.66,30,,158.66,percent of total billed charges,Drugs,158.66,30,,158.66,percent of total billed charges,Drugs,158.66,30,,158.66,percent of total billed charges,Drugs,93.71,,,93.71,Other,Drug Cost,93.71,,,93.71,Other,Drug Cost,93.71,,,93.71,Other,Drug Cost,93.71,,,93.71,Other,Drug Cost,93.71,,,93.71,Other,Drug Cost,179.81,34,,179.81,percent of total billed charges,Drugs,93.71,,,93.71,Other,Drug Cost,210.85,,,210.85,Other,225% Medicaid APG methodology,131.19,,,131.19,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1460.39,,,1460.39,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",93.71,,,93.71,Other,Drug Cost,93.71,,,93.71,Other,Drug Cost,117.14,,,117.14,Other,125% Medicaid APG methodology,0.01,1500.96,
BUPIV LIPO 1.3%(13.3MG/ML)20ML  ,C9290,HCPCS,,40581605,CDM,636,RC,65250-0266-09,NDC,both,20,ML,1204.7,475.46,39.4668,,475.46,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,361.41,30,,361.41,percent of total billed charges,Drugs,361.41,30,,361.41,percent of total billed charges,Drugs,361.41,30,,361.41,percent of total billed charges,Drugs,361.41,30,,361.41,percent of total billed charges,Drugs,361.41,30,,361.41,percent of total billed charges,Drugs,602.35,50,,602.35,percent of total billed charges,All Other,361.41,30,,361.41,percent of total billed charges,Drugs,361.41,30,,361.41,percent of total billed charges,Drugs,409.6,34,"If Charge > 500, then 34 percent",409.6,percent of total billed charges,Drugs,361.41,30,,361.41,percent of total billed charges,Drugs,361.41,30,,361.41,percent of total billed charges,Drugs,361.41,30,,361.41,percent of total billed charges,Drugs,361.41,30,,361.41,percent of total billed charges,Drugs,361.41,30,,361.41,percent of total billed charges,Drugs,361.41,30,,361.41,percent of total billed charges,Drugs,361.41,30,,361.41,percent of total billed charges,Drugs,361.41,30,,361.41,percent of total billed charges,Drugs,361.41,30,,361.41,percent of total billed charges,Drugs,361.41,30,,361.41,percent of total billed charges,Drugs,361.41,30,,361.41,percent of total billed charges,Drugs,361.41,30,,361.41,percent of total billed charges,Drugs,361.41,30,,361.41,percent of total billed charges,Drugs,344.2,,,344.2,Other,Drug Cost,344.2,,,344.2,Other,Drug Cost,344.2,,,344.2,Other,Drug Cost,344.2,,,344.2,Other,Drug Cost,344.2,,,344.2,Other,Drug Cost,409.6,34,,409.6,percent of total billed charges,Drugs,344.2,,,344.2,Other,Drug Cost,774.45,,,774.45,Other,225% Medicaid APG methodology,481.88,,,481.88,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",344.2,,,344.2,Other,Drug Cost,344.2,,,344.2,Other,Drug Cost,430.25,,,430.25,Other,125% Medicaid APG methodology,0.01,774.45,
NATALIZUMAB 300MG/15ML IV 15ML  ,J2323,HCPCS,,40581720,CDM,636,RC,64406-0008-01,NDC,both,15,ML,28732.73,241.26,,,241.26,Other,150% of Medicare + 9.63% HCRA Surcharge,146.71,,,146.71,Fee Schedule,Average Sale Price (ASP) x 6,8619.82,30,,8619.82,percent of total billed charges,Drugs,8619.82,30,,8619.82,percent of total billed charges,Drugs,8619.82,30,,8619.82,percent of total billed charges,Drugs,8619.82,30,,8619.82,percent of total billed charges,Drugs,8619.82,30,,8619.82,percent of total billed charges,Drugs,14366.37,50,,14366.37,percent of total billed charges,All Other,8619.82,30,,8619.82,percent of total billed charges,Drugs,8619.82,30,,8619.82,percent of total billed charges,Drugs,9769.13,34,"If Charge > 500, then 34 percent",9769.13,percent of total billed charges,Drugs,8619.82,30,,8619.82,percent of total billed charges,Drugs,8619.82,30,,8619.82,percent of total billed charges,Drugs,8619.82,30,,8619.82,percent of total billed charges,Drugs,8619.82,30,,8619.82,percent of total billed charges,Drugs,8619.82,30,,8619.82,percent of total billed charges,Drugs,8619.82,30,,8619.82,percent of total billed charges,Drugs,8619.82,30,,8619.82,percent of total billed charges,Drugs,8619.82,30,,8619.82,percent of total billed charges,Drugs,8619.82,30,,8619.82,percent of total billed charges,Drugs,8619.82,30,,8619.82,percent of total billed charges,Drugs,8619.82,30,,8619.82,percent of total billed charges,Drugs,8619.82,30,,8619.82,percent of total billed charges,Drugs,8619.82,30,,8619.82,percent of total billed charges,Drugs,1250.1,,,1250.1,Other,Drug Cost,1250.1,,,1250.1,Other,Drug Cost,1250.1,,,1250.1,Other,Drug Cost,1250.1,,,1250.1,Other,Drug Cost,1250.1,,,1250.1,Other,Drug Cost,9769.13,34,,9769.13,percent of total billed charges,Drugs,1250.1,,,1250.1,Other,Drug Cost,2812.73,,,2812.73,Other,225% Medicaid APG methodology,1750.14,,,1750.14,Other,140% Medicaid APG methodology,9769.13,34,"If Charge > 2,000, then 34 percent",9769.13,percent of total billed charges,Drugs,234.74,,,234.74,Other,160% Medicare Fee Schedule,9769.13,34,,9769.13,Other,"Drug Charges > 20,000, then 34% of Charges",1250.1,,,1250.1,Other,Drug Cost,1250.1,,,1250.1,Other,Drug Cost,1562.63,,,1562.63,Other,125% Medicaid APG methodology,146.71,14366.37,
SUCCINYLCHOL 20MG/ML 10ML       ,J0330,HCPCS,,40581803,CDM,636,RC,00409-6629-02,NDC,both,10,ML,63.04,24.88,39.4668,,24.88,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,18.91,30,,18.91,percent of total billed charges,Drugs,18.91,30,,18.91,percent of total billed charges,Drugs,18.91,30,,18.91,percent of total billed charges,Drugs,18.91,30,,18.91,percent of total billed charges,Drugs,18.91,30,,18.91,percent of total billed charges,Drugs,31.52,50,,31.52,percent of total billed charges,All Other,18.91,30,,18.91,percent of total billed charges,Drugs,18.91,30,,18.91,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,18.91,30,,18.91,percent of total billed charges,Drugs,18.91,30,,18.91,percent of total billed charges,Drugs,18.91,30,,18.91,percent of total billed charges,Drugs,18.91,30,,18.91,percent of total billed charges,Drugs,18.91,30,,18.91,percent of total billed charges,Drugs,18.91,30,,18.91,percent of total billed charges,Drugs,18.91,30,,18.91,percent of total billed charges,Drugs,18.91,30,,18.91,percent of total billed charges,Drugs,18.91,30,,18.91,percent of total billed charges,Drugs,18.91,30,,18.91,percent of total billed charges,Drugs,18.91,30,,18.91,percent of total billed charges,Drugs,18.91,30,,18.91,percent of total billed charges,Drugs,18.91,30,,18.91,percent of total billed charges,Drugs,2.42,,,2.42,Other,Drug Cost,2.42,,,2.42,Other,Drug Cost,2.42,,,2.42,Other,Drug Cost,2.42,,,2.42,Other,Drug Cost,2.42,,,2.42,Other,Drug Cost,21.43,34,,21.43,percent of total billed charges,Drugs,2.42,,,2.42,Other,Drug Cost,5.45,,,5.45,Other,225% Medicaid APG methodology,3.39,,,3.39,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.42,,,2.42,Other,Drug Cost,2.42,,,2.42,Other,Drug Cost,3.03,,,3.03,Other,125% Medicaid APG methodology,0.01,31.52,
CAL GLUC 100MG/ML SLN 100ML     ,J0612,HCPCS,,40581837,CDM,636,RC,63323-0360-61,NDC,both,100,ML,131.74,0.49,,,0.49,Other,150% of Medicare + 9.63% HCRA Surcharge,0.3,,,0.3,Fee Schedule,Average Sale Price (ASP) x 6,39.52,30,,39.52,percent of total billed charges,Drugs,39.52,30,,39.52,percent of total billed charges,Drugs,39.52,30,,39.52,percent of total billed charges,Drugs,39.52,30,,39.52,percent of total billed charges,Drugs,39.52,30,,39.52,percent of total billed charges,Drugs,65.87,50,,65.87,percent of total billed charges,All Other,39.52,30,,39.52,percent of total billed charges,Drugs,39.52,30,,39.52,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,39.52,30,,39.52,percent of total billed charges,Drugs,39.52,30,,39.52,percent of total billed charges,Drugs,39.52,30,,39.52,percent of total billed charges,Drugs,39.52,30,,39.52,percent of total billed charges,Drugs,39.52,30,,39.52,percent of total billed charges,Drugs,39.52,30,,39.52,percent of total billed charges,Drugs,39.52,30,,39.52,percent of total billed charges,Drugs,39.52,30,,39.52,percent of total billed charges,Drugs,39.52,30,,39.52,percent of total billed charges,Drugs,39.52,30,,39.52,percent of total billed charges,Drugs,39.52,30,,39.52,percent of total billed charges,Drugs,39.52,30,,39.52,percent of total billed charges,Drugs,39.52,30,,39.52,percent of total billed charges,Drugs,23.76,,,23.76,Other,Drug Cost,23.76,,,23.76,Other,Drug Cost,23.76,,,23.76,Other,Drug Cost,23.76,,,23.76,Other,Drug Cost,23.76,,,23.76,Other,Drug Cost,44.79,34,,44.79,percent of total billed charges,Drugs,23.76,,,23.76,Other,Drug Cost,53.46,,,53.46,Other,225% Medicaid APG methodology,33.26,,,33.26,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.48,,,0.48,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",23.76,,,23.76,Other,Drug Cost,23.76,,,23.76,Other,Drug Cost,29.7,,,29.7,Other,125% Medicaid APG methodology,0.01,65.87,
FLUOROURACIL 50MG/ML SLN 100ML  ,J9190,HCPCS,,40581902,CDM,636,RC,63323-0117-61,NDC,both,100,ML,56.98,31.72,,,31.72,Other,150% of Medicare + 9.63% HCRA Surcharge,19.29,,,19.29,Fee Schedule,Average Sale Price (ASP) x 6,17.09,30,,17.09,percent of total billed charges,Drugs,17.09,30,,17.09,percent of total billed charges,Drugs,17.09,30,,17.09,percent of total billed charges,Drugs,17.09,30,,17.09,percent of total billed charges,Drugs,17.09,30,,17.09,percent of total billed charges,Drugs,28.49,50,,28.49,percent of total billed charges,All Other,17.09,30,,17.09,percent of total billed charges,Drugs,17.09,30,,17.09,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,17.09,30,,17.09,percent of total billed charges,Drugs,17.09,30,,17.09,percent of total billed charges,Drugs,17.09,30,,17.09,percent of total billed charges,Drugs,17.09,30,,17.09,percent of total billed charges,Drugs,17.09,30,,17.09,percent of total billed charges,Drugs,17.09,30,,17.09,percent of total billed charges,Drugs,17.09,30,,17.09,percent of total billed charges,Drugs,17.09,30,,17.09,percent of total billed charges,Drugs,17.09,30,,17.09,percent of total billed charges,Drugs,17.09,30,,17.09,percent of total billed charges,Drugs,17.09,30,,17.09,percent of total billed charges,Drugs,17.09,30,,17.09,percent of total billed charges,Drugs,17.09,30,,17.09,percent of total billed charges,Drugs,12.29,,,12.29,Other,Drug Cost,12.29,,,12.29,Other,Drug Cost,12.29,,,12.29,Other,Drug Cost,12.29,,,12.29,Other,Drug Cost,12.29,,,12.29,Other,Drug Cost,19.37,34,,19.37,percent of total billed charges,Drugs,12.29,,,12.29,Other,Drug Cost,27.65,,,27.65,Other,225% Medicaid APG methodology,17.21,,,17.21,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,30.86,,,30.86,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",12.29,,,12.29,Other,Drug Cost,12.29,,,12.29,Other,Drug Cost,15.36,,,15.36,Other,125% Medicaid APG methodology,0.01,31.72,
"COAGULATION FACTOR VIIA,RECO 5  ",J7189,HCPCS,,40582157,CDM,636,RC,00169-7205-01,NDC,both,1,EA,34600.13,23.96,,,23.96,Other,150% of Medicare + 9.63% HCRA Surcharge,14.57,,,14.57,Fee Schedule,Average Sale Price (ASP) x 6,10380.04,30,,10380.04,percent of total billed charges,Drugs,10380.04,30,,10380.04,percent of total billed charges,Drugs,10380.04,30,,10380.04,percent of total billed charges,Drugs,10380.04,30,,10380.04,percent of total billed charges,Drugs,10380.04,30,,10380.04,percent of total billed charges,Drugs,17300.07,50,,17300.07,percent of total billed charges,All Other,10380.04,30,,10380.04,percent of total billed charges,Drugs,10380.04,30,,10380.04,percent of total billed charges,Drugs,11764.04,34,"If Charge > 500, then 34 percent",11764.04,percent of total billed charges,Drugs,10380.04,30,,10380.04,percent of total billed charges,Drugs,10380.04,30,,10380.04,percent of total billed charges,Drugs,10380.04,30,,10380.04,percent of total billed charges,Drugs,10380.04,30,,10380.04,percent of total billed charges,Drugs,10380.04,30,,10380.04,percent of total billed charges,Drugs,10380.04,30,,10380.04,percent of total billed charges,Drugs,10380.04,30,,10380.04,percent of total billed charges,Drugs,10380.04,30,,10380.04,percent of total billed charges,Drugs,10380.04,30,,10380.04,percent of total billed charges,Drugs,10380.04,30,,10380.04,percent of total billed charges,Drugs,10380.04,30,,10380.04,percent of total billed charges,Drugs,10380.04,30,,10380.04,percent of total billed charges,Drugs,10380.04,30,,10380.04,percent of total billed charges,Drugs,4541.87,,,4541.87,Other,Drug Cost,4541.87,,,4541.87,Other,Drug Cost,4541.87,,,4541.87,Other,Drug Cost,4541.87,,,4541.87,Other,Drug Cost,4541.87,,,4541.87,Other,Drug Cost,11764.04,34,,11764.04,percent of total billed charges,Drugs,4541.87,,,4541.87,Other,Drug Cost,10219.21,,,10219.21,Other,225% Medicaid APG methodology,6358.62,,,6358.62,Other,140% Medicaid APG methodology,11764.04,34,"If Charge > 2,000, then 34 percent",11764.04,percent of total billed charges,Drugs,23.31,,,23.31,Other,160% Medicare Fee Schedule,11764.04,34,,11764.04,Other,"Drug Charges > 20,000, then 34% of Charges",4541.87,,,4541.87,Other,Drug Cost,4541.87,,,4541.87,Other,Drug Cost,5677.34,,,5677.34,Other,125% Medicaid APG methodology,14.57,17300.07,
ATEZOLIZUMAB 60MG/ML IV  20ML   ,J9022,HCPCS,,40582314,CDM,636,RC,50242-0917-01,NDC,both,20,ML,38077.55,838.78,,,838.78,Other,150% of Medicare + 9.63% HCRA Surcharge,510.07,,,510.07,Fee Schedule,Average Sale Price (ASP) x 6,11423.27,30,,11423.27,percent of total billed charges,Drugs,11423.27,30,,11423.27,percent of total billed charges,Drugs,11423.27,30,,11423.27,percent of total billed charges,Drugs,11423.27,30,,11423.27,percent of total billed charges,Drugs,11423.27,30,,11423.27,percent of total billed charges,Drugs,19038.78,50,,19038.78,percent of total billed charges,All Other,11423.27,30,,11423.27,percent of total billed charges,Drugs,11423.27,30,,11423.27,percent of total billed charges,Drugs,12946.37,34,"If Charge > 500, then 34 percent",12946.37,percent of total billed charges,Drugs,11423.27,30,,11423.27,percent of total billed charges,Drugs,11423.27,30,,11423.27,percent of total billed charges,Drugs,11423.27,30,,11423.27,percent of total billed charges,Drugs,11423.27,30,,11423.27,percent of total billed charges,Drugs,11423.27,30,,11423.27,percent of total billed charges,Drugs,11423.27,30,,11423.27,percent of total billed charges,Drugs,11423.27,30,,11423.27,percent of total billed charges,Drugs,11423.27,30,,11423.27,percent of total billed charges,Drugs,11423.27,30,,11423.27,percent of total billed charges,Drugs,11423.27,30,,11423.27,percent of total billed charges,Drugs,11423.27,30,,11423.27,percent of total billed charges,Drugs,11423.27,30,,11423.27,percent of total billed charges,Drugs,11423.27,30,,11423.27,percent of total billed charges,Drugs,7396.34,,,7396.34,Other,Drug Cost,7396.34,,,7396.34,Other,Drug Cost,7396.34,,,7396.34,Other,Drug Cost,7396.34,,,7396.34,Other,Drug Cost,7396.34,,,7396.34,Other,Drug Cost,12946.37,34,,12946.37,percent of total billed charges,Drugs,7396.34,,,7396.34,Other,Drug Cost,16641.77,,,16641.77,Other,225% Medicaid APG methodology,10354.88,,,10354.88,Other,140% Medicaid APG methodology,12946.37,34,"If Charge > 2,000, then 34 percent",12946.37,percent of total billed charges,Drugs,816.11,,,816.11,Other,160% Medicare Fee Schedule,12946.37,34,,12946.37,Other,"Drug Charges > 20,000, then 34% of Charges",7396.34,,,7396.34,Other,Drug Cost,7396.34,,,7396.34,Other,Drug Cost,9245.43,,,9245.43,Other,125% Medicaid APG methodology,510.07,19038.78,
ADO-TRASTUZUMAB EMTANSINE100MG  ,J9354,HCPCS,,40582322,CDM,636,RC,50242-0088-01,NDC,both,1,EA,13565.27,378.57,,,378.57,Other,150% of Medicare + 9.63% HCRA Surcharge,230.21,,,230.21,Fee Schedule,Average Sale Price (ASP) x 6,4069.58,30,,4069.58,percent of total billed charges,Drugs,4069.58,30,,4069.58,percent of total billed charges,Drugs,4069.58,30,,4069.58,percent of total billed charges,Drugs,4069.58,30,,4069.58,percent of total billed charges,Drugs,4069.58,30,,4069.58,percent of total billed charges,Drugs,6782.64,50,,6782.64,percent of total billed charges,All Other,4069.58,30,,4069.58,percent of total billed charges,Drugs,4069.58,30,,4069.58,percent of total billed charges,Drugs,4612.19,34,"If Charge > 500, then 34 percent",4612.19,percent of total billed charges,Drugs,4069.58,30,,4069.58,percent of total billed charges,Drugs,4069.58,30,,4069.58,percent of total billed charges,Drugs,4069.58,30,,4069.58,percent of total billed charges,Drugs,4069.58,30,,4069.58,percent of total billed charges,Drugs,4069.58,30,,4069.58,percent of total billed charges,Drugs,4069.58,30,,4069.58,percent of total billed charges,Drugs,4069.58,30,,4069.58,percent of total billed charges,Drugs,4069.58,30,,4069.58,percent of total billed charges,Drugs,4069.58,30,,4069.58,percent of total billed charges,Drugs,4069.58,30,,4069.58,percent of total billed charges,Drugs,4069.58,30,,4069.58,percent of total billed charges,Drugs,4069.58,30,,4069.58,percent of total billed charges,Drugs,4069.58,30,,4069.58,percent of total billed charges,Drugs,2760.96,,,2760.96,Other,Drug Cost,2760.96,,,2760.96,Other,Drug Cost,2760.96,,,2760.96,Other,Drug Cost,2760.96,,,2760.96,Other,Drug Cost,2760.96,,,2760.96,Other,Drug Cost,4612.19,34,,4612.19,percent of total billed charges,Drugs,2760.96,,,2760.96,Other,Drug Cost,6212.16,,,6212.16,Other,225% Medicaid APG methodology,3865.34,,,3865.34,Other,140% Medicaid APG methodology,4612.19,34,"If Charge > 2,000, then 34 percent",4612.19,percent of total billed charges,Drugs,368.33,,,368.33,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2760.96,,,2760.96,Other,Drug Cost,2760.96,,,2760.96,Other,Drug Cost,3451.2,,,3451.2,Other,125% Medicaid APG methodology,0.01,6782.64,
ADO-TRASTUZUMAB EMTANSINE160MG  ,J9354,HCPCS,,40582330,CDM,636,RC,50242-0087-01,NDC,both,1,EA,21704.41,378.57,,,378.57,Other,150% of Medicare + 9.63% HCRA Surcharge,230.21,,,230.21,Fee Schedule,Average Sale Price (ASP) x 6,6511.32,30,,6511.32,percent of total billed charges,Drugs,6511.32,30,,6511.32,percent of total billed charges,Drugs,6511.32,30,,6511.32,percent of total billed charges,Drugs,6511.32,30,,6511.32,percent of total billed charges,Drugs,6511.32,30,,6511.32,percent of total billed charges,Drugs,10852.21,50,,10852.21,percent of total billed charges,All Other,6511.32,30,,6511.32,percent of total billed charges,Drugs,6511.32,30,,6511.32,percent of total billed charges,Drugs,7379.5,34,"If Charge > 500, then 34 percent",7379.5,percent of total billed charges,Drugs,6511.32,30,,6511.32,percent of total billed charges,Drugs,6511.32,30,,6511.32,percent of total billed charges,Drugs,6511.32,30,,6511.32,percent of total billed charges,Drugs,6511.32,30,,6511.32,percent of total billed charges,Drugs,6511.32,30,,6511.32,percent of total billed charges,Drugs,6511.32,30,,6511.32,percent of total billed charges,Drugs,6511.32,30,,6511.32,percent of total billed charges,Drugs,6511.32,30,,6511.32,percent of total billed charges,Drugs,6511.32,30,,6511.32,percent of total billed charges,Drugs,6511.32,30,,6511.32,percent of total billed charges,Drugs,6511.32,30,,6511.32,percent of total billed charges,Drugs,6511.32,30,,6511.32,percent of total billed charges,Drugs,6511.32,30,,6511.32,percent of total billed charges,Drugs,4420.52,,,4420.52,Other,Drug Cost,4420.52,,,4420.52,Other,Drug Cost,4420.52,,,4420.52,Other,Drug Cost,4420.52,,,4420.52,Other,Drug Cost,4420.52,,,4420.52,Other,Drug Cost,7379.5,34,,7379.5,percent of total billed charges,Drugs,4420.52,,,4420.52,Other,Drug Cost,9946.17,,,9946.17,Other,225% Medicaid APG methodology,6188.73,,,6188.73,Other,140% Medicaid APG methodology,7379.5,34,"If Charge > 2,000, then 34 percent",7379.5,percent of total billed charges,Drugs,368.33,,,368.33,Other,160% Medicare Fee Schedule,7379.5,34,,7379.5,Other,"Drug Charges > 20,000, then 34% of Charges",4420.52,,,4420.52,Other,Drug Cost,4420.52,,,4420.52,Other,Drug Cost,5525.65,,,5525.65,Other,125% Medicaid APG methodology,230.21,10852.21,
FERUMXYTOL 30MG/ML IV17ML ESRD  ,Q0139,HCPCS,,40582355,CDM,636,RC,59338-0775-01,NDC,both,17,ML,1350.23,3.52,,,3.52,Other,150% of Medicare + 9.63% HCRA Surcharge,2.14,,,2.14,Fee Schedule,Average Sale Price (ASP) x 6,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,675.12,50,,675.12,percent of total billed charges,All Other,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,459.08,34,"If Charge > 500, then 34 percent",459.08,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,405.07,30,,405.07,percent of total billed charges,Drugs,177.4,,,177.4,Other,Drug Cost,177.4,,,177.4,Other,Drug Cost,177.4,,,177.4,Other,Drug Cost,177.4,,,177.4,Other,Drug Cost,177.4,,,177.4,Other,Drug Cost,459.08,34,,459.08,percent of total billed charges,Drugs,177.4,,,177.4,Other,Drug Cost,399.15,,,399.15,Other,225% Medicaid APG methodology,248.36,,,248.36,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,3.43,,,3.43,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",177.4,,,177.4,Other,Drug Cost,177.4,,,177.4,Other,Drug Cost,221.75,,,221.75,Other,125% Medicaid APG methodology,0.01,675.12,
DARBPOET ALF 100MCG/0.5ML ESRD  ,J0881,HCPCS,,40582421,CDM,636,RC,55513-0025-04,NDC,both,0.5,ML,2535.65,28.91,,,28.91,Other,150% of Medicare + 9.63% HCRA Surcharge,17.58,,,17.58,Fee Schedule,Average Sale Price (ASP) x 6,760.7,30,,760.7,percent of total billed charges,Drugs,760.7,30,,760.7,percent of total billed charges,Drugs,760.7,30,,760.7,percent of total billed charges,Drugs,760.7,30,,760.7,percent of total billed charges,Drugs,760.7,30,,760.7,percent of total billed charges,Drugs,1267.83,50,,1267.83,percent of total billed charges,All Other,760.7,30,,760.7,percent of total billed charges,Drugs,760.7,30,,760.7,percent of total billed charges,Drugs,862.12,34,"If Charge > 500, then 34 percent",862.12,percent of total billed charges,Drugs,760.7,30,,760.7,percent of total billed charges,Drugs,760.7,30,,760.7,percent of total billed charges,Drugs,760.7,30,,760.7,percent of total billed charges,Drugs,760.7,30,,760.7,percent of total billed charges,Drugs,760.7,30,,760.7,percent of total billed charges,Drugs,760.7,30,,760.7,percent of total billed charges,Drugs,760.7,30,,760.7,percent of total billed charges,Drugs,760.7,30,,760.7,percent of total billed charges,Drugs,760.7,30,,760.7,percent of total billed charges,Drugs,760.7,30,,760.7,percent of total billed charges,Drugs,760.7,30,,760.7,percent of total billed charges,Drugs,760.7,30,,760.7,percent of total billed charges,Drugs,760.7,30,,760.7,percent of total billed charges,Drugs,209.95,,,209.95,Other,Drug Cost,209.95,,,209.95,Other,Drug Cost,209.95,,,209.95,Other,Drug Cost,209.95,,,209.95,Other,Drug Cost,209.95,,,209.95,Other,Drug Cost,862.12,34,,862.12,percent of total billed charges,Drugs,209.95,,,209.95,Other,Drug Cost,472.39,,,472.39,Other,225% Medicaid APG methodology,293.93,,,293.93,Other,140% Medicaid APG methodology,862.12,34,"If Charge > 2,000, then 34 percent",862.12,percent of total billed charges,Drugs,28.13,,,28.13,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",209.95,,,209.95,Other,Drug Cost,209.95,,,209.95,Other,Drug Cost,262.44,,,262.44,Other,125% Medicaid APG methodology,0.01,1267.83,
CEFAZOLIN 10 G INJ              ,J0690,HCPCS,,40582454,CDM,636,RC,00143-9983-03,NDC,both,1,EA,16.49,7.53,,,7.53,Other,150% of Medicare + 9.63% HCRA Surcharge,4.58,,,4.58,Fee Schedule,Average Sale Price (ASP) x 6,4.95,30,,4.95,percent of total billed charges,Drugs,4.95,30,,4.95,percent of total billed charges,Drugs,4.95,30,,4.95,percent of total billed charges,Drugs,4.95,30,,4.95,percent of total billed charges,Drugs,4.95,30,,4.95,percent of total billed charges,Drugs,8.25,50,,8.25,percent of total billed charges,All Other,4.95,30,,4.95,percent of total billed charges,Drugs,4.95,30,,4.95,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.95,30,,4.95,percent of total billed charges,Drugs,4.95,30,,4.95,percent of total billed charges,Drugs,4.95,30,,4.95,percent of total billed charges,Drugs,4.95,30,,4.95,percent of total billed charges,Drugs,4.95,30,,4.95,percent of total billed charges,Drugs,4.95,30,,4.95,percent of total billed charges,Drugs,4.95,30,,4.95,percent of total billed charges,Drugs,4.95,30,,4.95,percent of total billed charges,Drugs,4.95,30,,4.95,percent of total billed charges,Drugs,4.95,30,,4.95,percent of total billed charges,Drugs,4.95,30,,4.95,percent of total billed charges,Drugs,4.95,30,,4.95,percent of total billed charges,Drugs,4.95,30,,4.95,percent of total billed charges,Drugs,3.77,,,3.77,Other,Drug Cost,3.77,,,3.77,Other,Drug Cost,3.77,,,3.77,Other,Drug Cost,3.77,,,3.77,Other,Drug Cost,3.77,,,3.77,Other,Drug Cost,5.61,34,,5.61,percent of total billed charges,Drugs,3.77,,,3.77,Other,Drug Cost,8.48,,,8.48,Other,225% Medicaid APG methodology,5.28,,,5.28,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.32,,,7.32,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.77,,,3.77,Other,Drug Cost,3.77,,,3.77,Other,Drug Cost,4.71,,,4.71,Other,125% Medicaid APG methodology,0.01,8.48,
MEPOLIZUMAB 100 MG INJ          ,J2182,HCPCS,,40582470,CDM,636,RC,00173-0881-01,NDC,both,1,EA,10201.07,300.98,,,300.98,Other,150% of Medicare + 9.63% HCRA Surcharge,183.03,,,183.03,Fee Schedule,Average Sale Price (ASP) x 6,3060.32,30,,3060.32,percent of total billed charges,Drugs,3060.32,30,,3060.32,percent of total billed charges,Drugs,3060.32,30,,3060.32,percent of total billed charges,Drugs,3060.32,30,,3060.32,percent of total billed charges,Drugs,3060.32,30,,3060.32,percent of total billed charges,Drugs,5100.54,50,,5100.54,percent of total billed charges,All Other,3060.32,30,,3060.32,percent of total billed charges,Drugs,3060.32,30,,3060.32,percent of total billed charges,Drugs,3468.36,34,"If Charge > 500, then 34 percent",3468.36,percent of total billed charges,Drugs,3060.32,30,,3060.32,percent of total billed charges,Drugs,3060.32,30,,3060.32,percent of total billed charges,Drugs,3060.32,30,,3060.32,percent of total billed charges,Drugs,3060.32,30,,3060.32,percent of total billed charges,Drugs,3060.32,30,,3060.32,percent of total billed charges,Drugs,3060.32,30,,3060.32,percent of total billed charges,Drugs,3060.32,30,,3060.32,percent of total billed charges,Drugs,3060.32,30,,3060.32,percent of total billed charges,Drugs,3060.32,30,,3060.32,percent of total billed charges,Drugs,3060.32,30,,3060.32,percent of total billed charges,Drugs,3060.32,30,,3060.32,percent of total billed charges,Drugs,3060.32,30,,3060.32,percent of total billed charges,Drugs,3060.32,30,,3060.32,percent of total billed charges,Drugs,1913.8,,,1913.8,Other,Drug Cost,1913.8,,,1913.8,Other,Drug Cost,1913.8,,,1913.8,Other,Drug Cost,1913.8,,,1913.8,Other,Drug Cost,1913.8,,,1913.8,Other,Drug Cost,3468.36,34,,3468.36,percent of total billed charges,Drugs,1913.8,,,1913.8,Other,Drug Cost,4306.05,,,4306.05,Other,225% Medicaid APG methodology,2679.32,,,2679.32,Other,140% Medicaid APG methodology,3468.36,34,"If Charge > 2,000, then 34 percent",3468.36,percent of total billed charges,Drugs,292.85,,,292.85,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1913.8,,,1913.8,Other,Drug Cost,1913.8,,,1913.8,Other,Drug Cost,2392.25,,,2392.25,Other,125% Medicaid APG methodology,0.01,5100.54,
CALCIUM GLUCONATE 10% 50ML      ,J0612,HCPCS,,40582579,CDM,636,RC,63323-0360-59,NDC,both,50,ML,6.97,0.49,,,0.49,Other,150% of Medicare + 9.63% HCRA Surcharge,0.3,,,0.3,Fee Schedule,Average Sale Price (ASP) x 6,2.09,30,,2.09,percent of total billed charges,Drugs,2.09,30,,2.09,percent of total billed charges,Drugs,2.09,30,,2.09,percent of total billed charges,Drugs,2.09,30,,2.09,percent of total billed charges,Drugs,2.09,30,,2.09,percent of total billed charges,Drugs,3.49,50,,3.49,percent of total billed charges,All Other,2.09,30,,2.09,percent of total billed charges,Drugs,2.09,30,,2.09,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.09,30,,2.09,percent of total billed charges,Drugs,2.09,30,,2.09,percent of total billed charges,Drugs,2.09,30,,2.09,percent of total billed charges,Drugs,2.09,30,,2.09,percent of total billed charges,Drugs,2.09,30,,2.09,percent of total billed charges,Drugs,2.09,30,,2.09,percent of total billed charges,Drugs,2.09,30,,2.09,percent of total billed charges,Drugs,2.09,30,,2.09,percent of total billed charges,Drugs,2.09,30,,2.09,percent of total billed charges,Drugs,2.09,30,,2.09,percent of total billed charges,Drugs,2.09,30,,2.09,percent of total billed charges,Drugs,2.09,30,,2.09,percent of total billed charges,Drugs,2.09,30,,2.09,percent of total billed charges,Drugs,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,2.37,34,,2.37,percent of total billed charges,Drugs,0.48,,,0.48,Other,Drug Cost,1.08,,,1.08,Other,225% Medicaid APG methodology,0.67,,,0.67,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.48,,,0.48,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.48,,,0.48,Other,Drug Cost,0.48,,,0.48,Other,Drug Cost,0.6,,,0.6,Other,125% Medicaid APG methodology,0.01,3.49,
LEUCOVORIN 200 MG INJ           ,J0640,HCPCS,,40582587,CDM,636,RC,25021-0815-30,NDC,both,1,EA,87.85,44.1,,,44.1,Other,150% of Medicare + 9.63% HCRA Surcharge,26.82,,,26.82,Fee Schedule,Average Sale Price (ASP) x 6,26.36,30,,26.36,percent of total billed charges,Drugs,26.36,30,,26.36,percent of total billed charges,Drugs,26.36,30,,26.36,percent of total billed charges,Drugs,26.36,30,,26.36,percent of total billed charges,Drugs,26.36,30,,26.36,percent of total billed charges,Drugs,43.93,50,,43.93,percent of total billed charges,All Other,26.36,30,,26.36,percent of total billed charges,Drugs,26.36,30,,26.36,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,26.36,30,,26.36,percent of total billed charges,Drugs,26.36,30,,26.36,percent of total billed charges,Drugs,26.36,30,,26.36,percent of total billed charges,Drugs,26.36,30,,26.36,percent of total billed charges,Drugs,26.36,30,,26.36,percent of total billed charges,Drugs,26.36,30,,26.36,percent of total billed charges,Drugs,26.36,30,,26.36,percent of total billed charges,Drugs,26.36,30,,26.36,percent of total billed charges,Drugs,26.36,30,,26.36,percent of total billed charges,Drugs,26.36,30,,26.36,percent of total billed charges,Drugs,26.36,30,,26.36,percent of total billed charges,Drugs,26.36,30,,26.36,percent of total billed charges,Drugs,26.36,30,,26.36,percent of total billed charges,Drugs,8.87,,,8.87,Other,Drug Cost,8.87,,,8.87,Other,Drug Cost,8.87,,,8.87,Other,Drug Cost,8.87,,,8.87,Other,Drug Cost,8.87,,,8.87,Other,Drug Cost,29.87,34,,29.87,percent of total billed charges,Drugs,8.87,,,8.87,Other,Drug Cost,19.96,,,19.96,Other,225% Medicaid APG methodology,12.42,,,12.42,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,42.91,,,42.91,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",8.87,,,8.87,Other,Drug Cost,8.87,,,8.87,Other,Drug Cost,11.09,,,11.09,Other,125% Medicaid APG methodology,0.01,44.1,
EPI-LIDO1:200000-2%PF INJ10ML   ,J3490,HCPCS,,40582603,CDM,636,RC,63323-0489-17,NDC,both,10,ML,27.65,10.91,39.4668,,10.91,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,8.3,30,,8.3,percent of total billed charges,Drugs,8.3,30,,8.3,percent of total billed charges,Drugs,8.3,30,,8.3,percent of total billed charges,Drugs,8.3,30,,8.3,percent of total billed charges,Drugs,8.3,30,,8.3,percent of total billed charges,Drugs,13.83,50,,13.83,percent of total billed charges,All Other,8.3,30,,8.3,percent of total billed charges,Drugs,8.3,30,,8.3,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,8.3,30,,8.3,percent of total billed charges,Drugs,8.3,30,,8.3,percent of total billed charges,Drugs,8.3,30,,8.3,percent of total billed charges,Drugs,8.3,30,,8.3,percent of total billed charges,Drugs,8.3,30,,8.3,percent of total billed charges,Drugs,8.3,30,,8.3,percent of total billed charges,Drugs,8.3,30,,8.3,percent of total billed charges,Drugs,8.3,30,,8.3,percent of total billed charges,Drugs,8.3,30,,8.3,percent of total billed charges,Drugs,8.3,30,,8.3,percent of total billed charges,Drugs,8.3,30,,8.3,percent of total billed charges,Drugs,8.3,30,,8.3,percent of total billed charges,Drugs,8.3,30,,8.3,percent of total billed charges,Drugs,7.9,,,7.9,Other,Drug Cost,7.9,,,7.9,Other,Drug Cost,7.9,,,7.9,Other,Drug Cost,7.9,,,7.9,Other,Drug Cost,7.9,,,7.9,Other,Drug Cost,9.4,34,,9.4,percent of total billed charges,Drugs,7.9,,,7.9,Other,Drug Cost,17.78,,,17.78,Other,225% Medicaid APG methodology,11.06,,,11.06,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",7.9,,,7.9,Other,Drug Cost,7.9,,,7.9,Other,Drug Cost,9.88,,,9.88,Other,125% Medicaid APG methodology,0.01,17.78,
SOD ACE 2 MEQ/ML IV SLN 50ML    ,J3490,HCPCS,,40582611,CDM,636,RC,69784-0230-10,NDC,both,50,ML,41.65,16.44,39.4668,,16.44,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,12.5,30,,12.5,percent of total billed charges,Drugs,12.5,30,,12.5,percent of total billed charges,Drugs,12.5,30,,12.5,percent of total billed charges,Drugs,12.5,30,,12.5,percent of total billed charges,Drugs,12.5,30,,12.5,percent of total billed charges,Drugs,20.83,50,,20.83,percent of total billed charges,All Other,12.5,30,,12.5,percent of total billed charges,Drugs,12.5,30,,12.5,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,12.5,30,,12.5,percent of total billed charges,Drugs,12.5,30,,12.5,percent of total billed charges,Drugs,12.5,30,,12.5,percent of total billed charges,Drugs,12.5,30,,12.5,percent of total billed charges,Drugs,12.5,30,,12.5,percent of total billed charges,Drugs,12.5,30,,12.5,percent of total billed charges,Drugs,12.5,30,,12.5,percent of total billed charges,Drugs,12.5,30,,12.5,percent of total billed charges,Drugs,12.5,30,,12.5,percent of total billed charges,Drugs,12.5,30,,12.5,percent of total billed charges,Drugs,12.5,30,,12.5,percent of total billed charges,Drugs,12.5,30,,12.5,percent of total billed charges,Drugs,12.5,30,,12.5,percent of total billed charges,Drugs,8.1,,,8.1,Other,Drug Cost,8.1,,,8.1,Other,Drug Cost,8.1,,,8.1,Other,Drug Cost,8.1,,,8.1,Other,Drug Cost,8.1,,,8.1,Other,Drug Cost,14.16,34,,14.16,percent of total billed charges,Drugs,8.1,,,8.1,Other,Drug Cost,18.23,,,18.23,Other,225% Medicaid APG methodology,11.34,,,11.34,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",8.1,,,8.1,Other,Drug Cost,8.1,,,8.1,Other,Drug Cost,10.13,,,10.13,Other,125% Medicaid APG methodology,0.01,20.83,
MORPHINE 2MG/ML PF INJ 1ML SYR  ,J2270,HCPCS,,40582629,CDM,636,RC,76045-0004-11,NDC,both,1,ML,5.36,46.03,,,46.03,Other,150% of Medicare + 9.63% HCRA Surcharge,27.99,,,27.99,Fee Schedule,Average Sale Price (ASP) x 6,1.61,30,,1.61,percent of total billed charges,Drugs,1.61,30,,1.61,percent of total billed charges,Drugs,1.61,30,,1.61,percent of total billed charges,Drugs,1.61,30,,1.61,percent of total billed charges,Drugs,1.61,30,,1.61,percent of total billed charges,Drugs,2.68,50,,2.68,percent of total billed charges,All Other,1.61,30,,1.61,percent of total billed charges,Drugs,1.61,30,,1.61,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.61,30,,1.61,percent of total billed charges,Drugs,1.61,30,,1.61,percent of total billed charges,Drugs,1.61,30,,1.61,percent of total billed charges,Drugs,1.61,30,,1.61,percent of total billed charges,Drugs,1.61,30,,1.61,percent of total billed charges,Drugs,1.61,30,,1.61,percent of total billed charges,Drugs,1.61,30,,1.61,percent of total billed charges,Drugs,1.61,30,,1.61,percent of total billed charges,Drugs,1.61,30,,1.61,percent of total billed charges,Drugs,1.61,30,,1.61,percent of total billed charges,Drugs,1.61,30,,1.61,percent of total billed charges,Drugs,1.61,30,,1.61,percent of total billed charges,Drugs,1.61,30,,1.61,percent of total billed charges,Drugs,1.03,,,1.03,Other,Drug Cost,1.03,,,1.03,Other,Drug Cost,1.03,,,1.03,Other,Drug Cost,1.03,,,1.03,Other,Drug Cost,1.03,,,1.03,Other,Drug Cost,1.82,34,,1.82,percent of total billed charges,Drugs,1.03,,,1.03,Other,Drug Cost,2.32,,,2.32,Other,225% Medicaid APG methodology,1.44,,,1.44,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,44.78,,,44.78,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.03,,,1.03,Other,Drug Cost,1.03,,,1.03,Other,Drug Cost,1.29,,,1.29,Other,125% Medicaid APG methodology,0.01,46.03,
ENGERIX B 20MCG/ML IM 1ML VIAL  ,90746,CPT,,40582728,CDM,636,RC,58160-0821-11,NDC,both,1,ML,169.09,694.38,,,694.38,Other,150% of Medicare + 9.63% HCRA Surcharge,422.26,,,422.26,Fee Schedule,Average Sale Price (ASP) x 6,50.73,30,,50.73,percent of total billed charges,Drugs,50.73,30,,50.73,percent of total billed charges,Drugs,50.73,30,,50.73,percent of total billed charges,Drugs,50.73,30,,50.73,percent of total billed charges,Drugs,50.73,30,,50.73,percent of total billed charges,Drugs,84.55,50,,84.55,percent of total billed charges,All Other,50.73,30,,50.73,percent of total billed charges,Drugs,50.73,30,,50.73,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,50.73,30,,50.73,percent of total billed charges,Drugs,50.73,30,,50.73,percent of total billed charges,Drugs,50.73,30,,50.73,percent of total billed charges,Drugs,50.73,30,,50.73,percent of total billed charges,Drugs,50.73,30,,50.73,percent of total billed charges,Drugs,50.73,30,,50.73,percent of total billed charges,Drugs,50.73,30,,50.73,percent of total billed charges,Drugs,50.73,30,,50.73,percent of total billed charges,Drugs,50.73,30,,50.73,percent of total billed charges,Drugs,50.73,30,,50.73,percent of total billed charges,Drugs,50.73,30,,50.73,percent of total billed charges,Drugs,50.73,30,,50.73,percent of total billed charges,Drugs,50.73,30,,50.73,percent of total billed charges,Drugs,43.07,,,43.07,Other,Drug Cost,43.07,,,43.07,Other,Drug Cost,43.07,,,43.07,Other,Drug Cost,43.07,,,43.07,Other,Drug Cost,43.07,,,43.07,Other,Drug Cost,57.49,34,,57.49,percent of total billed charges,Drugs,43.07,,,43.07,Other,Drug Cost,96.91,,,96.91,Other,225% Medicaid APG methodology,60.3,,,60.3,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,675.61,,,675.61,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",43.07,,,43.07,Other,Drug Cost,43.07,,,43.07,Other,Drug Cost,53.84,,,53.84,Other,125% Medicaid APG methodology,0.01,694.38,
TRASTUZUMAB 150 MG IV INJ       ,J9355,HCPCS,,40582801,CDM,636,RC,50242-0132-01,NDC,both,1,EA,5454.47,793.92,,,793.92,Other,150% of Medicare + 9.63% HCRA Surcharge,482.79,,,482.79,Fee Schedule,Average Sale Price (ASP) x 6,1636.34,30,,1636.34,percent of total billed charges,Drugs,1636.34,30,,1636.34,percent of total billed charges,Drugs,1636.34,30,,1636.34,percent of total billed charges,Drugs,1636.34,30,,1636.34,percent of total billed charges,Drugs,1636.34,30,,1636.34,percent of total billed charges,Drugs,2727.24,50,,2727.24,percent of total billed charges,All Other,1636.34,30,,1636.34,percent of total billed charges,Drugs,1636.34,30,,1636.34,percent of total billed charges,Drugs,1854.52,34,"If Charge > 500, then 34 percent",1854.52,percent of total billed charges,Drugs,1636.34,30,,1636.34,percent of total billed charges,Drugs,1636.34,30,,1636.34,percent of total billed charges,Drugs,1636.34,30,,1636.34,percent of total billed charges,Drugs,1636.34,30,,1636.34,percent of total billed charges,Drugs,1636.34,30,,1636.34,percent of total billed charges,Drugs,1636.34,30,,1636.34,percent of total billed charges,Drugs,1636.34,30,,1636.34,percent of total billed charges,Drugs,1636.34,30,,1636.34,percent of total billed charges,Drugs,1636.34,30,,1636.34,percent of total billed charges,Drugs,1636.34,30,,1636.34,percent of total billed charges,Drugs,1636.34,30,,1636.34,percent of total billed charges,Drugs,1636.34,30,,1636.34,percent of total billed charges,Drugs,1636.34,30,,1636.34,percent of total billed charges,Drugs,779.21,,,779.21,Other,Drug Cost,779.21,,,779.21,Other,Drug Cost,779.21,,,779.21,Other,Drug Cost,779.21,,,779.21,Other,Drug Cost,779.21,,,779.21,Other,Drug Cost,1854.52,34,,1854.52,percent of total billed charges,Drugs,779.21,,,779.21,Other,Drug Cost,1753.22,,,1753.22,Other,225% Medicaid APG methodology,1090.89,,,1090.89,Other,140% Medicaid APG methodology,1854.52,34,"If Charge > 2,000, then 34 percent",1854.52,percent of total billed charges,Drugs,772.46,,,772.46,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",779.21,,,779.21,Other,Drug Cost,779.21,,,779.21,Other,Drug Cost,974.01,,,974.01,Other,125% Medicaid APG methodology,0.01,2727.24,
ACYCLOVIR 50MG/ML IV SOLN 20ML  ,J0133,HCPCS,,40582827,CDM,636,RC,55150-0155-21,NDC,both,20,ML,73.5,0.55,,,0.55,Other,150% of Medicare + 9.63% HCRA Surcharge,0.34,,,0.34,Fee Schedule,Average Sale Price (ASP) x 6,22.05,30,,22.05,percent of total billed charges,Drugs,22.05,30,,22.05,percent of total billed charges,Drugs,22.05,30,,22.05,percent of total billed charges,Drugs,22.05,30,,22.05,percent of total billed charges,Drugs,22.05,30,,22.05,percent of total billed charges,Drugs,36.75,50,,36.75,percent of total billed charges,All Other,22.05,30,,22.05,percent of total billed charges,Drugs,22.05,30,,22.05,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,22.05,30,,22.05,percent of total billed charges,Drugs,22.05,30,,22.05,percent of total billed charges,Drugs,22.05,30,,22.05,percent of total billed charges,Drugs,22.05,30,,22.05,percent of total billed charges,Drugs,22.05,30,,22.05,percent of total billed charges,Drugs,22.05,30,,22.05,percent of total billed charges,Drugs,22.05,30,,22.05,percent of total billed charges,Drugs,22.05,30,,22.05,percent of total billed charges,Drugs,22.05,30,,22.05,percent of total billed charges,Drugs,22.05,30,,22.05,percent of total billed charges,Drugs,22.05,30,,22.05,percent of total billed charges,Drugs,22.05,30,,22.05,percent of total billed charges,Drugs,22.05,30,,22.05,percent of total billed charges,Drugs,21,,,21,Other,Drug Cost,21,,,21,Other,Drug Cost,21,,,21,Other,Drug Cost,21,,,21,Other,Drug Cost,21,,,21,Other,Drug Cost,24.99,34,,24.99,percent of total billed charges,Drugs,21,,,21,Other,Drug Cost,47.25,,,47.25,Other,225% Medicaid APG methodology,29.4,,,29.4,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.54,,,0.54,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",21,,,21,Other,Drug Cost,21,,,21,Other,Drug Cost,26.25,,,26.25,Other,125% Medicaid APG methodology,0.01,47.25,
BLEOMYCIN 30 UNITS INJ          ,J9040,HCPCS,,40582892,CDM,636,RC,63323-0137-20,NDC,both,1,EA,202.83,207.44,,,207.44,Other,150% of Medicare + 9.63% HCRA Surcharge,126.14,,,126.14,Fee Schedule,Average Sale Price (ASP) x 6,60.85,30,,60.85,percent of total billed charges,Drugs,60.85,30,,60.85,percent of total billed charges,Drugs,60.85,30,,60.85,percent of total billed charges,Drugs,60.85,30,,60.85,percent of total billed charges,Drugs,60.85,30,,60.85,percent of total billed charges,Drugs,101.42,50,,101.42,percent of total billed charges,All Other,60.85,30,,60.85,percent of total billed charges,Drugs,60.85,30,,60.85,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,60.85,30,,60.85,percent of total billed charges,Drugs,60.85,30,,60.85,percent of total billed charges,Drugs,60.85,30,,60.85,percent of total billed charges,Drugs,60.85,30,,60.85,percent of total billed charges,Drugs,60.85,30,,60.85,percent of total billed charges,Drugs,60.85,30,,60.85,percent of total billed charges,Drugs,60.85,30,,60.85,percent of total billed charges,Drugs,60.85,30,,60.85,percent of total billed charges,Drugs,60.85,30,,60.85,percent of total billed charges,Drugs,60.85,30,,60.85,percent of total billed charges,Drugs,60.85,30,,60.85,percent of total billed charges,Drugs,60.85,30,,60.85,percent of total billed charges,Drugs,60.85,30,,60.85,percent of total billed charges,Drugs,29.11,,,29.11,Other,Drug Cost,29.11,,,29.11,Other,Drug Cost,29.11,,,29.11,Other,Drug Cost,29.11,,,29.11,Other,Drug Cost,29.11,,,29.11,Other,Drug Cost,68.96,34,,68.96,percent of total billed charges,Drugs,29.11,,,29.11,Other,Drug Cost,65.5,,,65.5,Other,225% Medicaid APG methodology,40.75,,,40.75,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,201.83,,,201.83,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",29.11,,,29.11,Other,Drug Cost,29.11,,,29.11,Other,Drug Cost,36.39,,,36.39,Other,125% Medicaid APG methodology,0.01,207.44,
TOCILIZUMAB 20MG/ML IV SLN 4ML  ,J3262,HCPCS,,40583023,CDM,636,RC,50242-0135-01,NDC,both,4,ML,1573.71,60.38,,,60.38,Other,150% of Medicare + 9.63% HCRA Surcharge,36.72,,,36.72,Fee Schedule,Average Sale Price (ASP) x 6,472.11,30,,472.11,percent of total billed charges,Drugs,472.11,30,,472.11,percent of total billed charges,Drugs,472.11,30,,472.11,percent of total billed charges,Drugs,472.11,30,,472.11,percent of total billed charges,Drugs,472.11,30,,472.11,percent of total billed charges,Drugs,786.86,50,,786.86,percent of total billed charges,All Other,472.11,30,,472.11,percent of total billed charges,Drugs,472.11,30,,472.11,percent of total billed charges,Drugs,535.06,34,"If Charge > 500, then 34 percent",535.06,percent of total billed charges,Drugs,472.11,30,,472.11,percent of total billed charges,Drugs,472.11,30,,472.11,percent of total billed charges,Drugs,472.11,30,,472.11,percent of total billed charges,Drugs,472.11,30,,472.11,percent of total billed charges,Drugs,472.11,30,,472.11,percent of total billed charges,Drugs,472.11,30,,472.11,percent of total billed charges,Drugs,472.11,30,,472.11,percent of total billed charges,Drugs,472.11,30,,472.11,percent of total billed charges,Drugs,472.11,30,,472.11,percent of total billed charges,Drugs,472.11,30,,472.11,percent of total billed charges,Drugs,472.11,30,,472.11,percent of total billed charges,Drugs,472.11,30,,472.11,percent of total billed charges,Drugs,472.11,30,,472.11,percent of total billed charges,Drugs,222.3,,,222.3,Other,Drug Cost,222.3,,,222.3,Other,Drug Cost,222.3,,,222.3,Other,Drug Cost,222.3,,,222.3,Other,Drug Cost,222.3,,,222.3,Other,Drug Cost,535.06,34,,535.06,percent of total billed charges,Drugs,222.3,,,222.3,Other,Drug Cost,500.18,,,500.18,Other,225% Medicaid APG methodology,311.22,,,311.22,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,58.75,,,58.75,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",222.3,,,222.3,Other,Drug Cost,222.3,,,222.3,Other,Drug Cost,277.88,,,277.88,Other,125% Medicaid APG methodology,0.01,786.86,
TOCILIZUMAB 20MG/ML IV 10ML     ,J3262,HCPCS,,40583031,CDM,636,RC,50242-0136-01,NDC,both,10,ML,3934.28,60.38,,,60.38,Other,150% of Medicare + 9.63% HCRA Surcharge,36.72,,,36.72,Fee Schedule,Average Sale Price (ASP) x 6,1180.28,30,,1180.28,percent of total billed charges,Drugs,1180.28,30,,1180.28,percent of total billed charges,Drugs,1180.28,30,,1180.28,percent of total billed charges,Drugs,1180.28,30,,1180.28,percent of total billed charges,Drugs,1180.28,30,,1180.28,percent of total billed charges,Drugs,1967.14,50,,1967.14,percent of total billed charges,All Other,1180.28,30,,1180.28,percent of total billed charges,Drugs,1180.28,30,,1180.28,percent of total billed charges,Drugs,1337.66,34,"If Charge > 500, then 34 percent",1337.66,percent of total billed charges,Drugs,1180.28,30,,1180.28,percent of total billed charges,Drugs,1180.28,30,,1180.28,percent of total billed charges,Drugs,1180.28,30,,1180.28,percent of total billed charges,Drugs,1180.28,30,,1180.28,percent of total billed charges,Drugs,1180.28,30,,1180.28,percent of total billed charges,Drugs,1180.28,30,,1180.28,percent of total billed charges,Drugs,1180.28,30,,1180.28,percent of total billed charges,Drugs,1180.28,30,,1180.28,percent of total billed charges,Drugs,1180.28,30,,1180.28,percent of total billed charges,Drugs,1180.28,30,,1180.28,percent of total billed charges,Drugs,1180.28,30,,1180.28,percent of total billed charges,Drugs,1180.28,30,,1180.28,percent of total billed charges,Drugs,1180.28,30,,1180.28,percent of total billed charges,Drugs,527.05,,,527.05,Other,Drug Cost,527.05,,,527.05,Other,Drug Cost,527.05,,,527.05,Other,Drug Cost,527.05,,,527.05,Other,Drug Cost,527.05,,,527.05,Other,Drug Cost,1337.66,34,,1337.66,percent of total billed charges,Drugs,527.05,,,527.05,Other,Drug Cost,1185.86,,,1185.86,Other,225% Medicaid APG methodology,737.87,,,737.87,Other,140% Medicaid APG methodology,1337.66,34,"If Charge > 2,000, then 34 percent",1337.66,percent of total billed charges,Drugs,58.75,,,58.75,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",527.05,,,527.05,Other,Drug Cost,527.05,,,527.05,Other,Drug Cost,658.81,,,658.81,Other,125% Medicaid APG methodology,0.01,1967.14,
LEVETIRACETAM 1000MGNS IV100ML  ,J1953,HCPCS,,40583254,CDM,636,RC,00264-1009-90,NDC,both,100,ML,30,0.62,,,0.62,Other,150% of Medicare + 9.63% HCRA Surcharge,0.38,,,0.38,Fee Schedule,Average Sale Price (ASP) x 6,9,30,,9,percent of total billed charges,Drugs,9,30,,9,percent of total billed charges,Drugs,9,30,,9,percent of total billed charges,Drugs,9,30,,9,percent of total billed charges,Drugs,9,30,,9,percent of total billed charges,Drugs,15,50,,15,percent of total billed charges,All Other,9,30,,9,percent of total billed charges,Drugs,9,30,,9,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,9,30,,9,percent of total billed charges,Drugs,9,30,,9,percent of total billed charges,Drugs,9,30,,9,percent of total billed charges,Drugs,9,30,,9,percent of total billed charges,Drugs,9,30,,9,percent of total billed charges,Drugs,9,30,,9,percent of total billed charges,Drugs,9,30,,9,percent of total billed charges,Drugs,9,30,,9,percent of total billed charges,Drugs,9,30,,9,percent of total billed charges,Drugs,9,30,,9,percent of total billed charges,Drugs,9,30,,9,percent of total billed charges,Drugs,9,30,,9,percent of total billed charges,Drugs,9,30,,9,percent of total billed charges,Drugs,5.95,,,5.95,Other,Drug Cost,5.95,,,5.95,Other,Drug Cost,5.95,,,5.95,Other,Drug Cost,5.95,,,5.95,Other,Drug Cost,5.95,,,5.95,Other,Drug Cost,10.2,34,,10.2,percent of total billed charges,Drugs,5.95,,,5.95,Other,Drug Cost,13.39,,,13.39,Other,225% Medicaid APG methodology,8.33,,,8.33,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.6,,,0.6,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.95,,,5.95,Other,Drug Cost,5.95,,,5.95,Other,Drug Cost,7.44,,,7.44,Other,125% Medicaid APG methodology,0.01,15,
LEVETIRACETAM 1500MGNS IV100ML  ,J1953,HCPCS,,40583262,CDM,636,RC,70860-0604-82,NDC,both,100,ML,257.04,0.62,,,0.62,Other,150% of Medicare + 9.63% HCRA Surcharge,0.38,,,0.38,Fee Schedule,Average Sale Price (ASP) x 6,77.11,30,,77.11,percent of total billed charges,Drugs,77.11,30,,77.11,percent of total billed charges,Drugs,77.11,30,,77.11,percent of total billed charges,Drugs,77.11,30,,77.11,percent of total billed charges,Drugs,77.11,30,,77.11,percent of total billed charges,Drugs,128.52,50,,128.52,percent of total billed charges,All Other,77.11,30,,77.11,percent of total billed charges,Drugs,77.11,30,,77.11,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,77.11,30,,77.11,percent of total billed charges,Drugs,77.11,30,,77.11,percent of total billed charges,Drugs,77.11,30,,77.11,percent of total billed charges,Drugs,77.11,30,,77.11,percent of total billed charges,Drugs,77.11,30,,77.11,percent of total billed charges,Drugs,77.11,30,,77.11,percent of total billed charges,Drugs,77.11,30,,77.11,percent of total billed charges,Drugs,77.11,30,,77.11,percent of total billed charges,Drugs,77.11,30,,77.11,percent of total billed charges,Drugs,77.11,30,,77.11,percent of total billed charges,Drugs,77.11,30,,77.11,percent of total billed charges,Drugs,77.11,30,,77.11,percent of total billed charges,Drugs,77.11,30,,77.11,percent of total billed charges,Drugs,15.76,,,15.76,Other,Drug Cost,15.76,,,15.76,Other,Drug Cost,15.76,,,15.76,Other,Drug Cost,15.76,,,15.76,Other,Drug Cost,15.76,,,15.76,Other,Drug Cost,87.39,34,,87.39,percent of total billed charges,Drugs,15.76,,,15.76,Other,Drug Cost,35.46,,,35.46,Other,225% Medicaid APG methodology,22.06,,,22.06,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.6,,,0.6,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",15.76,,,15.76,Other,Drug Cost,15.76,,,15.76,Other,Drug Cost,19.7,,,19.7,Other,125% Medicaid APG methodology,0.01,128.52,
LEVETIRACETAM 500MG NACL 100ML  ,J1953,HCPCS,,40583270,CDM,636,RC,44567-0501-10,NDC,both,100,ML,27.76,0.62,,,0.62,Other,150% of Medicare + 9.63% HCRA Surcharge,0.38,,,0.38,Fee Schedule,Average Sale Price (ASP) x 6,8.33,30,,8.33,percent of total billed charges,Drugs,8.33,30,,8.33,percent of total billed charges,Drugs,8.33,30,,8.33,percent of total billed charges,Drugs,8.33,30,,8.33,percent of total billed charges,Drugs,8.33,30,,8.33,percent of total billed charges,Drugs,13.88,50,,13.88,percent of total billed charges,All Other,8.33,30,,8.33,percent of total billed charges,Drugs,8.33,30,,8.33,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,8.33,30,,8.33,percent of total billed charges,Drugs,8.33,30,,8.33,percent of total billed charges,Drugs,8.33,30,,8.33,percent of total billed charges,Drugs,8.33,30,,8.33,percent of total billed charges,Drugs,8.33,30,,8.33,percent of total billed charges,Drugs,8.33,30,,8.33,percent of total billed charges,Drugs,8.33,30,,8.33,percent of total billed charges,Drugs,8.33,30,,8.33,percent of total billed charges,Drugs,8.33,30,,8.33,percent of total billed charges,Drugs,8.33,30,,8.33,percent of total billed charges,Drugs,8.33,30,,8.33,percent of total billed charges,Drugs,8.33,30,,8.33,percent of total billed charges,Drugs,8.33,30,,8.33,percent of total billed charges,Drugs,6,,,6,Other,Drug Cost,6,,,6,Other,Drug Cost,6,,,6,Other,Drug Cost,6,,,6,Other,Drug Cost,6,,,6,Other,Drug Cost,9.44,34,,9.44,percent of total billed charges,Drugs,6,,,6,Other,Drug Cost,13.5,,,13.5,Other,225% Medicaid APG methodology,8.4,,,8.4,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.6,,,0.6,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6,,,6,Other,Drug Cost,6,,,6,Other,Drug Cost,7.5,,,7.5,Other,125% Medicaid APG methodology,0.01,13.88,
AMIODARONE 360MG/D5W  200ML     ,J0282,HCPCS,,40583395,CDM,636,RC,43066-0360-20,NDC,both,200,ML,150.12,59.25,39.4668,,59.25,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,45.04,30,,45.04,percent of total billed charges,Drugs,45.04,30,,45.04,percent of total billed charges,Drugs,45.04,30,,45.04,percent of total billed charges,Drugs,45.04,30,,45.04,percent of total billed charges,Drugs,45.04,30,,45.04,percent of total billed charges,Drugs,75.06,50,,75.06,percent of total billed charges,All Other,45.04,30,,45.04,percent of total billed charges,Drugs,45.04,30,,45.04,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,45.04,30,,45.04,percent of total billed charges,Drugs,45.04,30,,45.04,percent of total billed charges,Drugs,45.04,30,,45.04,percent of total billed charges,Drugs,45.04,30,,45.04,percent of total billed charges,Drugs,45.04,30,,45.04,percent of total billed charges,Drugs,45.04,30,,45.04,percent of total billed charges,Drugs,45.04,30,,45.04,percent of total billed charges,Drugs,45.04,30,,45.04,percent of total billed charges,Drugs,45.04,30,,45.04,percent of total billed charges,Drugs,45.04,30,,45.04,percent of total billed charges,Drugs,45.04,30,,45.04,percent of total billed charges,Drugs,45.04,30,,45.04,percent of total billed charges,Drugs,45.04,30,,45.04,percent of total billed charges,Drugs,23.02,,,23.02,Other,Drug Cost,23.02,,,23.02,Other,Drug Cost,23.02,,,23.02,Other,Drug Cost,23.02,,,23.02,Other,Drug Cost,23.02,,,23.02,Other,Drug Cost,51.04,34,,51.04,percent of total billed charges,Drugs,23.02,,,23.02,Other,Drug Cost,51.8,,,51.8,Other,225% Medicaid APG methodology,32.23,,,32.23,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",23.02,,,23.02,Other,Drug Cost,23.02,,,23.02,Other,Drug Cost,28.78,,,28.78,Other,125% Medicaid APG methodology,0.01,75.06,
MICAFUNGIN 100 MG IV INJ        ,J2248,HCPCS,,40583411,CDM,636,RC,00469-3211-99,NDC,both,1,EA,654.5,7.47,,,7.47,Other,150% of Medicare + 9.63% HCRA Surcharge,4.54,,,4.54,Fee Schedule,Average Sale Price (ASP) x 6,196.35,30,,196.35,percent of total billed charges,Drugs,196.35,30,,196.35,percent of total billed charges,Drugs,196.35,30,,196.35,percent of total billed charges,Drugs,196.35,30,,196.35,percent of total billed charges,Drugs,196.35,30,,196.35,percent of total billed charges,Drugs,327.25,50,,327.25,percent of total billed charges,All Other,196.35,30,,196.35,percent of total billed charges,Drugs,196.35,30,,196.35,percent of total billed charges,Drugs,222.53,34,"If Charge > 500, then 34 percent",222.53,percent of total billed charges,Drugs,196.35,30,,196.35,percent of total billed charges,Drugs,196.35,30,,196.35,percent of total billed charges,Drugs,196.35,30,,196.35,percent of total billed charges,Drugs,196.35,30,,196.35,percent of total billed charges,Drugs,196.35,30,,196.35,percent of total billed charges,Drugs,196.35,30,,196.35,percent of total billed charges,Drugs,196.35,30,,196.35,percent of total billed charges,Drugs,196.35,30,,196.35,percent of total billed charges,Drugs,196.35,30,,196.35,percent of total billed charges,Drugs,196.35,30,,196.35,percent of total billed charges,Drugs,196.35,30,,196.35,percent of total billed charges,Drugs,196.35,30,,196.35,percent of total billed charges,Drugs,196.35,30,,196.35,percent of total billed charges,Drugs,187,,,187,Other,Drug Cost,187,,,187,Other,Drug Cost,187,,,187,Other,Drug Cost,187,,,187,Other,Drug Cost,187,,,187,Other,Drug Cost,222.53,34,,222.53,percent of total billed charges,Drugs,187,,,187,Other,Drug Cost,420.75,,,420.75,Other,225% Medicaid APG methodology,261.8,,,261.8,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.27,,,7.27,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",187,,,187,Other,Drug Cost,187,,,187,Other,Drug Cost,233.75,,,233.75,Other,125% Medicaid APG methodology,0.01,420.75,
MEROPENEM 1000 MG IV INJ        ,J2185,HCPCS,,40583429,CDM,636,RC,63323-0508-30,NDC,both,1,EA,18.83,4.46,,,4.46,Other,150% of Medicare + 9.63% HCRA Surcharge,2.71,,,2.71,Fee Schedule,Average Sale Price (ASP) x 6,5.65,30,,5.65,percent of total billed charges,Drugs,5.65,30,,5.65,percent of total billed charges,Drugs,5.65,30,,5.65,percent of total billed charges,Drugs,5.65,30,,5.65,percent of total billed charges,Drugs,5.65,30,,5.65,percent of total billed charges,Drugs,9.42,50,,9.42,percent of total billed charges,All Other,5.65,30,,5.65,percent of total billed charges,Drugs,5.65,30,,5.65,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,5.65,30,,5.65,percent of total billed charges,Drugs,5.65,30,,5.65,percent of total billed charges,Drugs,5.65,30,,5.65,percent of total billed charges,Drugs,5.65,30,,5.65,percent of total billed charges,Drugs,5.65,30,,5.65,percent of total billed charges,Drugs,5.65,30,,5.65,percent of total billed charges,Drugs,5.65,30,,5.65,percent of total billed charges,Drugs,5.65,30,,5.65,percent of total billed charges,Drugs,5.65,30,,5.65,percent of total billed charges,Drugs,5.65,30,,5.65,percent of total billed charges,Drugs,5.65,30,,5.65,percent of total billed charges,Drugs,5.65,30,,5.65,percent of total billed charges,Drugs,5.65,30,,5.65,percent of total billed charges,Drugs,4.86,,,4.86,Other,Drug Cost,4.86,,,4.86,Other,Drug Cost,4.86,,,4.86,Other,Drug Cost,4.86,,,4.86,Other,Drug Cost,4.86,,,4.86,Other,Drug Cost,6.4,34,,6.4,percent of total billed charges,Drugs,4.86,,,4.86,Other,Drug Cost,10.94,,,10.94,Other,225% Medicaid APG methodology,6.8,,,6.8,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,4.34,,,4.34,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.86,,,4.86,Other,Drug Cost,4.86,,,4.86,Other,Drug Cost,6.08,,,6.08,Other,125% Medicaid APG methodology,0.01,10.94,
CEFEPIME 2000 MG INJ            ,J0692,HCPCS,,40583437,CDM,636,RC,60505-6147-04,NDC,both,1,EA,15.05,12.45,,,12.45,Other,150% of Medicare + 9.63% HCRA Surcharge,7.57,,,7.57,Fee Schedule,Average Sale Price (ASP) x 6,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,7.53,50,,7.53,percent of total billed charges,All Other,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,4.52,30,,4.52,percent of total billed charges,Drugs,5.53,,,5.53,Other,Drug Cost,5.53,,,5.53,Other,Drug Cost,5.53,,,5.53,Other,Drug Cost,5.53,,,5.53,Other,Drug Cost,5.53,,,5.53,Other,Drug Cost,5.12,34,,5.12,percent of total billed charges,Drugs,5.53,,,5.53,Other,Drug Cost,12.44,,,12.44,Other,225% Medicaid APG methodology,7.74,,,7.74,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,12.12,,,12.12,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.53,,,5.53,Other,Drug Cost,5.53,,,5.53,Other,Drug Cost,6.91,,,6.91,Other,125% Medicaid APG methodology,0.01,12.45,
ROPIVACAINE 0.2% INJ SOLN 20ML  ,J2795,HCPCS,,40583510,CDM,636,RC,70069-0062-25,NDC,both,20,ML,27.41,0.76,,,0.76,Other,150% of Medicare + 9.63% HCRA Surcharge,0.46,,,0.46,Fee Schedule,Average Sale Price (ASP) x 6,8.22,30,,8.22,percent of total billed charges,Drugs,8.22,30,,8.22,percent of total billed charges,Drugs,8.22,30,,8.22,percent of total billed charges,Drugs,8.22,30,,8.22,percent of total billed charges,Drugs,8.22,30,,8.22,percent of total billed charges,Drugs,13.71,50,,13.71,percent of total billed charges,All Other,8.22,30,,8.22,percent of total billed charges,Drugs,8.22,30,,8.22,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,8.22,30,,8.22,percent of total billed charges,Drugs,8.22,30,,8.22,percent of total billed charges,Drugs,8.22,30,,8.22,percent of total billed charges,Drugs,8.22,30,,8.22,percent of total billed charges,Drugs,8.22,30,,8.22,percent of total billed charges,Drugs,8.22,30,,8.22,percent of total billed charges,Drugs,8.22,30,,8.22,percent of total billed charges,Drugs,8.22,30,,8.22,percent of total billed charges,Drugs,8.22,30,,8.22,percent of total billed charges,Drugs,8.22,30,,8.22,percent of total billed charges,Drugs,8.22,30,,8.22,percent of total billed charges,Drugs,8.22,30,,8.22,percent of total billed charges,Drugs,8.22,30,,8.22,percent of total billed charges,Drugs,6.69,,,6.69,Other,Drug Cost,6.69,,,6.69,Other,Drug Cost,6.69,,,6.69,Other,Drug Cost,6.69,,,6.69,Other,Drug Cost,6.69,,,6.69,Other,Drug Cost,9.32,34,,9.32,percent of total billed charges,Drugs,6.69,,,6.69,Other,Drug Cost,15.05,,,15.05,Other,225% Medicaid APG methodology,9.37,,,9.37,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.74,,,0.74,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6.69,,,6.69,Other,Drug Cost,6.69,,,6.69,Other,Drug Cost,8.36,,,8.36,Other,125% Medicaid APG methodology,0.01,15.05,
IODIXANOL 320MG/ML 50 ML        ,Q9967,HCPCS,,40583528,CDM,636,RC,00407-2223-16,NDC,both,50,ML,61.25,1.16,,,1.16,Other,150% of Medicare + 9.63% HCRA Surcharge,0.71,,,0.71,Fee Schedule,Average Sale Price (ASP) x 6,18.38,30,,18.38,percent of total billed charges,Drugs,18.38,30,,18.38,percent of total billed charges,Drugs,18.38,30,,18.38,percent of total billed charges,Drugs,18.38,30,,18.38,percent of total billed charges,Drugs,18.38,30,,18.38,percent of total billed charges,Drugs,30.63,50,,30.63,percent of total billed charges,All Other,18.38,30,,18.38,percent of total billed charges,Drugs,18.38,30,,18.38,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,18.38,30,,18.38,percent of total billed charges,Drugs,18.38,30,,18.38,percent of total billed charges,Drugs,18.38,30,,18.38,percent of total billed charges,Drugs,18.38,30,,18.38,percent of total billed charges,Drugs,18.38,30,,18.38,percent of total billed charges,Drugs,18.38,30,,18.38,percent of total billed charges,Drugs,18.38,30,,18.38,percent of total billed charges,Drugs,18.38,30,,18.38,percent of total billed charges,Drugs,18.38,30,,18.38,percent of total billed charges,Drugs,18.38,30,,18.38,percent of total billed charges,Drugs,18.38,30,,18.38,percent of total billed charges,Drugs,18.38,30,,18.38,percent of total billed charges,Drugs,18.38,30,,18.38,percent of total billed charges,Drugs,14.5,,,14.5,Other,Drug Cost,14.5,,,14.5,Other,Drug Cost,14.5,,,14.5,Other,Drug Cost,14.5,,,14.5,Other,Drug Cost,14.5,,,14.5,Other,Drug Cost,20.83,34,,20.83,percent of total billed charges,Drugs,14.5,,,14.5,Other,Drug Cost,32.63,,,32.63,Other,225% Medicaid APG methodology,20.3,,,20.3,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.13,,,1.13,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",14.5,,,14.5,Other,Drug Cost,14.5,,,14.5,Other,Drug Cost,18.13,,,18.13,Other,125% Medicaid APG methodology,0.01,32.63,
MORPHINE 4MG/ML PF IV 1ML SYR   ,J2270,HCPCS,,40583585,CDM,636,RC,76045-0005-11,NDC,both,1,ML,5.43,46.03,,,46.03,Other,150% of Medicare + 9.63% HCRA Surcharge,27.99,,,27.99,Fee Schedule,Average Sale Price (ASP) x 6,1.63,30,,1.63,percent of total billed charges,Drugs,1.63,30,,1.63,percent of total billed charges,Drugs,1.63,30,,1.63,percent of total billed charges,Drugs,1.63,30,,1.63,percent of total billed charges,Drugs,1.63,30,,1.63,percent of total billed charges,Drugs,2.72,50,,2.72,percent of total billed charges,All Other,1.63,30,,1.63,percent of total billed charges,Drugs,1.63,30,,1.63,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.63,30,,1.63,percent of total billed charges,Drugs,1.63,30,,1.63,percent of total billed charges,Drugs,1.63,30,,1.63,percent of total billed charges,Drugs,1.63,30,,1.63,percent of total billed charges,Drugs,1.63,30,,1.63,percent of total billed charges,Drugs,1.63,30,,1.63,percent of total billed charges,Drugs,1.63,30,,1.63,percent of total billed charges,Drugs,1.63,30,,1.63,percent of total billed charges,Drugs,1.63,30,,1.63,percent of total billed charges,Drugs,1.63,30,,1.63,percent of total billed charges,Drugs,1.63,30,,1.63,percent of total billed charges,Drugs,1.63,30,,1.63,percent of total billed charges,Drugs,1.63,30,,1.63,percent of total billed charges,Drugs,1.08,,,1.08,Other,Drug Cost,1.08,,,1.08,Other,Drug Cost,1.08,,,1.08,Other,Drug Cost,1.08,,,1.08,Other,Drug Cost,1.08,,,1.08,Other,Drug Cost,1.85,34,,1.85,percent of total billed charges,Drugs,1.08,,,1.08,Other,Drug Cost,2.43,,,2.43,Other,225% Medicaid APG methodology,1.51,,,1.51,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,44.78,,,44.78,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.08,,,1.08,Other,Drug Cost,1.08,,,1.08,Other,Drug Cost,1.35,,,1.35,Other,125% Medicaid APG methodology,0.01,46.03,
CEFTAROLINE 600 MG IV INJ       ,J0712,HCPCS,,40583601,CDM,636,RC,00456-0600-10,NDC,both,1,EA,551.32,37.84,,,37.84,Other,150% of Medicare + 9.63% HCRA Surcharge,23.01,,,23.01,Fee Schedule,Average Sale Price (ASP) x 6,165.4,30,,165.4,percent of total billed charges,Drugs,165.4,30,,165.4,percent of total billed charges,Drugs,165.4,30,,165.4,percent of total billed charges,Drugs,165.4,30,,165.4,percent of total billed charges,Drugs,165.4,30,,165.4,percent of total billed charges,Drugs,275.66,50,,275.66,percent of total billed charges,All Other,165.4,30,,165.4,percent of total billed charges,Drugs,165.4,30,,165.4,percent of total billed charges,Drugs,187.45,34,"If Charge > 500, then 34 percent",187.45,percent of total billed charges,Drugs,165.4,30,,165.4,percent of total billed charges,Drugs,165.4,30,,165.4,percent of total billed charges,Drugs,165.4,30,,165.4,percent of total billed charges,Drugs,165.4,30,,165.4,percent of total billed charges,Drugs,165.4,30,,165.4,percent of total billed charges,Drugs,165.4,30,,165.4,percent of total billed charges,Drugs,165.4,30,,165.4,percent of total billed charges,Drugs,165.4,30,,165.4,percent of total billed charges,Drugs,165.4,30,,165.4,percent of total billed charges,Drugs,165.4,30,,165.4,percent of total billed charges,Drugs,165.4,30,,165.4,percent of total billed charges,Drugs,165.4,30,,165.4,percent of total billed charges,Drugs,165.4,30,,165.4,percent of total billed charges,Drugs,2.89,,,2.89,Other,Drug Cost,2.89,,,2.89,Other,Drug Cost,2.89,,,2.89,Other,Drug Cost,2.89,,,2.89,Other,Drug Cost,2.89,,,2.89,Other,Drug Cost,187.45,34,,187.45,percent of total billed charges,Drugs,2.89,,,2.89,Other,Drug Cost,6.5,,,6.5,Other,225% Medicaid APG methodology,4.05,,,4.05,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,36.82,,,36.82,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.89,,,2.89,Other,Drug Cost,2.89,,,2.89,Other,Drug Cost,3.61,,,3.61,Other,125% Medicaid APG methodology,0.01,275.66,
DENOSUMAB 60MG/ML INJ SOLN 1ML  ,J0897,HCPCS,,40583619,CDM,636,RC,55513-0710-01,NDC,both,1,ML,4406.15,248.62,,,248.62,Other,150% of Medicare + 9.63% HCRA Surcharge,151.19,,,151.19,Fee Schedule,Average Sale Price (ASP) x 6,1321.85,30,,1321.85,percent of total billed charges,Drugs,1321.85,30,,1321.85,percent of total billed charges,Drugs,1321.85,30,,1321.85,percent of total billed charges,Drugs,1321.85,30,,1321.85,percent of total billed charges,Drugs,1321.85,30,,1321.85,percent of total billed charges,Drugs,2203.08,50,,2203.08,percent of total billed charges,All Other,1321.85,30,,1321.85,percent of total billed charges,Drugs,1321.85,30,,1321.85,percent of total billed charges,Drugs,1498.09,34,"If Charge > 500, then 34 percent",1498.09,percent of total billed charges,Drugs,1321.85,30,,1321.85,percent of total billed charges,Drugs,1321.85,30,,1321.85,percent of total billed charges,Drugs,1321.85,30,,1321.85,percent of total billed charges,Drugs,1321.85,30,,1321.85,percent of total billed charges,Drugs,1321.85,30,,1321.85,percent of total billed charges,Drugs,1321.85,30,,1321.85,percent of total billed charges,Drugs,1321.85,30,,1321.85,percent of total billed charges,Drugs,1321.85,30,,1321.85,percent of total billed charges,Drugs,1321.85,30,,1321.85,percent of total billed charges,Drugs,1321.85,30,,1321.85,percent of total billed charges,Drugs,1321.85,30,,1321.85,percent of total billed charges,Drugs,1321.85,30,,1321.85,percent of total billed charges,Drugs,1321.85,30,,1321.85,percent of total billed charges,Drugs,649.47,,,649.47,Other,Drug Cost,649.47,,,649.47,Other,Drug Cost,649.47,,,649.47,Other,Drug Cost,649.47,,,649.47,Other,Drug Cost,649.47,,,649.47,Other,Drug Cost,1498.09,34,,1498.09,percent of total billed charges,Drugs,649.47,,,649.47,Other,Drug Cost,1461.31,,,1461.31,Other,225% Medicaid APG methodology,909.26,,,909.26,Other,140% Medicaid APG methodology,1498.09,34,"If Charge > 2,000, then 34 percent",1498.09,percent of total billed charges,Drugs,241.9,,,241.9,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",649.47,,,649.47,Other,Drug Cost,649.47,,,649.47,Other,Drug Cost,811.84,,,811.84,Other,125% Medicaid APG methodology,0.01,2203.08,
AMIODARONE 50MG/ML IV SOLN 9ML  ,J0282,HCPCS,,40583726,CDM,636,RC,67457-0153-09,NDC,both,9,ML,23.31,9.2,39.4668,,9.2,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,6.99,30,,6.99,percent of total billed charges,Drugs,6.99,30,,6.99,percent of total billed charges,Drugs,6.99,30,,6.99,percent of total billed charges,Drugs,6.99,30,,6.99,percent of total billed charges,Drugs,6.99,30,,6.99,percent of total billed charges,Drugs,11.66,50,,11.66,percent of total billed charges,All Other,6.99,30,,6.99,percent of total billed charges,Drugs,6.99,30,,6.99,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,6.99,30,,6.99,percent of total billed charges,Drugs,6.99,30,,6.99,percent of total billed charges,Drugs,6.99,30,,6.99,percent of total billed charges,Drugs,6.99,30,,6.99,percent of total billed charges,Drugs,6.99,30,,6.99,percent of total billed charges,Drugs,6.99,30,,6.99,percent of total billed charges,Drugs,6.99,30,,6.99,percent of total billed charges,Drugs,6.99,30,,6.99,percent of total billed charges,Drugs,6.99,30,,6.99,percent of total billed charges,Drugs,6.99,30,,6.99,percent of total billed charges,Drugs,6.99,30,,6.99,percent of total billed charges,Drugs,6.99,30,,6.99,percent of total billed charges,Drugs,6.99,30,,6.99,percent of total billed charges,Drugs,3.51,,,3.51,Other,Drug Cost,3.51,,,3.51,Other,Drug Cost,3.51,,,3.51,Other,Drug Cost,3.51,,,3.51,Other,Drug Cost,3.51,,,3.51,Other,Drug Cost,7.93,34,,7.93,percent of total billed charges,Drugs,3.51,,,3.51,Other,Drug Cost,7.9,,,7.9,Other,225% Medicaid APG methodology,4.91,,,4.91,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.51,,,3.51,Other,Drug Cost,3.51,,,3.51,Other,Drug Cost,4.39,,,4.39,Other,125% Medicaid APG methodology,0.01,11.66,
PHENYTOIN 50MG/ML INJ SOLN 5ML  ,J1165,HCPCS,,40583734,CDM,636,RC,00641-2555-45,NDC,both,5,ML,5.22,6.22,,,6.22,Other,150% of Medicare + 9.63% HCRA Surcharge,3.78,,,3.78,Fee Schedule,Average Sale Price (ASP) x 6,1.57,30,,1.57,percent of total billed charges,Drugs,1.57,30,,1.57,percent of total billed charges,Drugs,1.57,30,,1.57,percent of total billed charges,Drugs,1.57,30,,1.57,percent of total billed charges,Drugs,1.57,30,,1.57,percent of total billed charges,Drugs,2.61,50,,2.61,percent of total billed charges,All Other,1.57,30,,1.57,percent of total billed charges,Drugs,1.57,30,,1.57,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.57,30,,1.57,percent of total billed charges,Drugs,1.57,30,,1.57,percent of total billed charges,Drugs,1.57,30,,1.57,percent of total billed charges,Drugs,1.57,30,,1.57,percent of total billed charges,Drugs,1.57,30,,1.57,percent of total billed charges,Drugs,1.57,30,,1.57,percent of total billed charges,Drugs,1.57,30,,1.57,percent of total billed charges,Drugs,1.57,30,,1.57,percent of total billed charges,Drugs,1.57,30,,1.57,percent of total billed charges,Drugs,1.57,30,,1.57,percent of total billed charges,Drugs,1.57,30,,1.57,percent of total billed charges,Drugs,1.57,30,,1.57,percent of total billed charges,Drugs,1.57,30,,1.57,percent of total billed charges,Drugs,0.9,,,0.9,Other,Drug Cost,0.9,,,0.9,Other,Drug Cost,0.9,,,0.9,Other,Drug Cost,0.9,,,0.9,Other,Drug Cost,0.9,,,0.9,Other,Drug Cost,1.77,34,,1.77,percent of total billed charges,Drugs,0.9,,,0.9,Other,Drug Cost,2.03,,,2.03,Other,225% Medicaid APG methodology,1.26,,,1.26,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.05,,,6.05,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.9,,,0.9,Other,Drug Cost,0.9,,,0.9,Other,Drug Cost,1.13,,,1.13,Other,125% Medicaid APG methodology,0.01,6.22,
ENGERIX-B PEDI 10 MCG/0.5ML     ,90744,CPT,,40583833,CDM,636,RC,58160-0820-52,NDC,both,0.5,ML,65.38,303.6,,,303.6,Other,150% of Medicare + 9.63% HCRA Surcharge,184.62,,,184.62,Fee Schedule,Average Sale Price (ASP) x 6,19.61,30,,19.61,percent of total billed charges,Drugs,19.61,30,,19.61,percent of total billed charges,Drugs,19.61,30,,19.61,percent of total billed charges,Drugs,19.61,30,,19.61,percent of total billed charges,Drugs,19.61,30,,19.61,percent of total billed charges,Drugs,32.69,50,,32.69,percent of total billed charges,All Other,19.61,30,,19.61,percent of total billed charges,Drugs,19.61,30,,19.61,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,19.61,30,,19.61,percent of total billed charges,Drugs,19.61,30,,19.61,percent of total billed charges,Drugs,19.61,30,,19.61,percent of total billed charges,Drugs,19.61,30,,19.61,percent of total billed charges,Drugs,19.61,30,,19.61,percent of total billed charges,Drugs,19.61,30,,19.61,percent of total billed charges,Drugs,19.61,30,,19.61,percent of total billed charges,Drugs,19.61,30,,19.61,percent of total billed charges,Drugs,19.61,30,,19.61,percent of total billed charges,Drugs,19.61,30,,19.61,percent of total billed charges,Drugs,19.61,30,,19.61,percent of total billed charges,Drugs,19.61,30,,19.61,percent of total billed charges,Drugs,19.61,30,,19.61,percent of total billed charges,Drugs,17.5,,,17.5,Other,Drug Cost,17.5,,,17.5,Other,Drug Cost,17.5,,,17.5,Other,Drug Cost,17.5,,,17.5,Other,Drug Cost,17.5,,,17.5,Other,Drug Cost,22.23,34,,22.23,percent of total billed charges,Drugs,17.5,,,17.5,Other,Drug Cost,39.38,,,39.38,Other,225% Medicaid APG methodology,24.5,,,24.5,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,295.39,,,295.39,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",17.5,,,17.5,Other,Drug Cost,17.5,,,17.5,Other,Drug Cost,21.88,,,21.88,Other,125% Medicaid APG methodology,0.01,303.6,
ROPIVACAINE 0.2% INJ SOLN 10ML  ,J2795,HCPCS,,40583908,CDM,636,RC,00409-9300-10,NDC,both,10,ML,5.71,0.76,,,0.76,Other,150% of Medicare + 9.63% HCRA Surcharge,0.46,,,0.46,Fee Schedule,Average Sale Price (ASP) x 6,1.71,30,,1.71,percent of total billed charges,Drugs,1.71,30,,1.71,percent of total billed charges,Drugs,1.71,30,,1.71,percent of total billed charges,Drugs,1.71,30,,1.71,percent of total billed charges,Drugs,1.71,30,,1.71,percent of total billed charges,Drugs,2.86,50,,2.86,percent of total billed charges,All Other,1.71,30,,1.71,percent of total billed charges,Drugs,1.71,30,,1.71,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.71,30,,1.71,percent of total billed charges,Drugs,1.71,30,,1.71,percent of total billed charges,Drugs,1.71,30,,1.71,percent of total billed charges,Drugs,1.71,30,,1.71,percent of total billed charges,Drugs,1.71,30,,1.71,percent of total billed charges,Drugs,1.71,30,,1.71,percent of total billed charges,Drugs,1.71,30,,1.71,percent of total billed charges,Drugs,1.71,30,,1.71,percent of total billed charges,Drugs,1.71,30,,1.71,percent of total billed charges,Drugs,1.71,30,,1.71,percent of total billed charges,Drugs,1.71,30,,1.71,percent of total billed charges,Drugs,1.71,30,,1.71,percent of total billed charges,Drugs,1.71,30,,1.71,percent of total billed charges,Drugs,1.3,,,1.3,Other,Drug Cost,1.3,,,1.3,Other,Drug Cost,1.3,,,1.3,Other,Drug Cost,1.3,,,1.3,Other,Drug Cost,1.3,,,1.3,Other,Drug Cost,1.94,34,,1.94,percent of total billed charges,Drugs,1.3,,,1.3,Other,Drug Cost,2.93,,,2.93,Other,225% Medicaid APG methodology,1.82,,,1.82,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.74,,,0.74,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.3,,,1.3,Other,Drug Cost,1.3,,,1.3,Other,Drug Cost,1.63,,,1.63,Other,125% Medicaid APG methodology,0.01,2.93,
IC - BELATACEPT 250 MG IV INJ   ,J0485,HCPCS,,40584013,CDM,636,RC,00003-0371-13,NDC,both,1,EA,3311.77,38.22,,,38.22,Other,150% of Medicare + 9.63% HCRA Surcharge,23.24,,,23.24,Fee Schedule,Average Sale Price (ASP) x 6,993.53,30,,993.53,percent of total billed charges,Drugs,993.53,30,,993.53,percent of total billed charges,Drugs,993.53,30,,993.53,percent of total billed charges,Drugs,993.53,30,,993.53,percent of total billed charges,Drugs,993.53,30,,993.53,percent of total billed charges,Drugs,1655.89,50,,1655.89,percent of total billed charges,All Other,993.53,30,,993.53,percent of total billed charges,Drugs,993.53,30,,993.53,percent of total billed charges,Drugs,1126,34,"If Charge > 500, then 34 percent",1126,percent of total billed charges,Drugs,993.53,30,,993.53,percent of total billed charges,Drugs,993.53,30,,993.53,percent of total billed charges,Drugs,993.53,30,,993.53,percent of total billed charges,Drugs,993.53,30,,993.53,percent of total billed charges,Drugs,993.53,30,,993.53,percent of total billed charges,Drugs,993.53,30,,993.53,percent of total billed charges,Drugs,993.53,30,,993.53,percent of total billed charges,Drugs,993.53,30,,993.53,percent of total billed charges,Drugs,993.53,30,,993.53,percent of total billed charges,Drugs,993.53,30,,993.53,percent of total billed charges,Drugs,993.53,30,,993.53,percent of total billed charges,Drugs,993.53,30,,993.53,percent of total billed charges,Drugs,993.53,30,,993.53,percent of total billed charges,Drugs,946.22,,,946.22,Other,Drug Cost,946.22,,,946.22,Other,Drug Cost,946.22,,,946.22,Other,Drug Cost,946.22,,,946.22,Other,Drug Cost,946.22,,,946.22,Other,Drug Cost,1126,34,,1126,percent of total billed charges,Drugs,946.22,,,946.22,Other,Drug Cost,2129,,,2129,Other,225% Medicaid APG methodology,1324.71,,,1324.71,Other,140% Medicaid APG methodology,1126,34,"If Charge > 2,000, then 34 percent",1126,percent of total billed charges,Drugs,37.19,,,37.19,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",946.22,,,946.22,Other,Drug Cost,946.22,,,946.22,Other,Drug Cost,1182.78,,,1182.78,Other,125% Medicaid APG methodology,0.01,2129,
CANGRELOR 50 MG IV INJ          ,C9460,HCPCS,,40584054,CDM,636,RC,10122-0620-10,NDC,both,1,EA,3094.84,1221.43,39.4668,,1221.43,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,928.45,30,,928.45,percent of total billed charges,Drugs,928.45,30,,928.45,percent of total billed charges,Drugs,928.45,30,,928.45,percent of total billed charges,Drugs,928.45,30,,928.45,percent of total billed charges,Drugs,928.45,30,,928.45,percent of total billed charges,Drugs,1547.42,50,,1547.42,percent of total billed charges,All Other,928.45,30,,928.45,percent of total billed charges,Drugs,928.45,30,,928.45,percent of total billed charges,Drugs,1052.25,34,"If Charge > 500, then 34 percent",1052.25,percent of total billed charges,Drugs,928.45,30,,928.45,percent of total billed charges,Drugs,928.45,30,,928.45,percent of total billed charges,Drugs,928.45,30,,928.45,percent of total billed charges,Drugs,928.45,30,,928.45,percent of total billed charges,Drugs,928.45,30,,928.45,percent of total billed charges,Drugs,928.45,30,,928.45,percent of total billed charges,Drugs,928.45,30,,928.45,percent of total billed charges,Drugs,928.45,30,,928.45,percent of total billed charges,Drugs,928.45,30,,928.45,percent of total billed charges,Drugs,928.45,30,,928.45,percent of total billed charges,Drugs,928.45,30,,928.45,percent of total billed charges,Drugs,928.45,30,,928.45,percent of total billed charges,Drugs,928.45,30,,928.45,percent of total billed charges,Drugs,591.62,,,591.62,Other,Drug Cost,591.62,,,591.62,Other,Drug Cost,591.62,,,591.62,Other,Drug Cost,591.62,,,591.62,Other,Drug Cost,591.62,,,591.62,Other,Drug Cost,1052.25,34,,1052.25,percent of total billed charges,Drugs,591.62,,,591.62,Other,Drug Cost,1331.15,,,1331.15,Other,225% Medicaid APG methodology,828.27,,,828.27,Other,140% Medicaid APG methodology,1052.25,34,"If Charge > 2,000, then 34 percent",1052.25,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",591.62,,,591.62,Other,Drug Cost,591.62,,,591.62,Other,Drug Cost,739.53,,,739.53,Other,125% Medicaid APG methodology,0.01,1547.42,
HPV VACCINE 9-VALENT PF         ,90651,CPT,,40584104,CDM,636,RC,00006-4121-02,NDC,both,0.5,ML,731.96,288.88,39.4668,,288.88,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,219.59,30,,219.59,percent of total billed charges,Drugs,219.59,30,,219.59,percent of total billed charges,Drugs,219.59,30,,219.59,percent of total billed charges,Drugs,219.59,30,,219.59,percent of total billed charges,Drugs,219.59,30,,219.59,percent of total billed charges,Drugs,365.98,50,,365.98,percent of total billed charges,All Other,219.59,30,,219.59,percent of total billed charges,Drugs,219.59,30,,219.59,percent of total billed charges,Drugs,248.87,34,"If Charge > 500, then 34 percent",248.87,percent of total billed charges,Drugs,219.59,30,,219.59,percent of total billed charges,Drugs,219.59,30,,219.59,percent of total billed charges,Drugs,219.59,30,,219.59,percent of total billed charges,Drugs,219.59,30,,219.59,percent of total billed charges,Drugs,219.59,30,,219.59,percent of total billed charges,Drugs,219.59,30,,219.59,percent of total billed charges,Drugs,219.59,30,,219.59,percent of total billed charges,Drugs,219.59,30,,219.59,percent of total billed charges,Drugs,219.59,30,,219.59,percent of total billed charges,Drugs,219.59,30,,219.59,percent of total billed charges,Drugs,219.59,30,,219.59,percent of total billed charges,Drugs,219.59,30,,219.59,percent of total billed charges,Drugs,219.59,30,,219.59,percent of total billed charges,Drugs,214.89,,,214.89,Other,Drug Cost,214.89,,,214.89,Other,Drug Cost,214.89,,,214.89,Other,Drug Cost,214.89,,,214.89,Other,Drug Cost,214.89,,,214.89,Other,Drug Cost,248.87,34,,248.87,percent of total billed charges,Drugs,214.89,,,214.89,Other,Drug Cost,483.5,,,483.5,Other,225% Medicaid APG methodology,300.85,,,300.85,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",214.89,,,214.89,Other,Drug Cost,214.89,,,214.89,Other,Drug Cost,268.61,,,268.61,Other,125% Medicaid APG methodology,0.01,483.5,
DURVALUMAB 50MG/ML IV SLN 10ML  ,J9173,HCPCS,,40584120,CDM,636,RC,00310-4611-50,NDC,both,10,ML,14385.53,796.3,,,796.3,Other,150% of Medicare + 9.63% HCRA Surcharge,484.24,,,484.24,Fee Schedule,Average Sale Price (ASP) x 6,4315.66,30,,4315.66,percent of total billed charges,Drugs,4315.66,30,,4315.66,percent of total billed charges,Drugs,4315.66,30,,4315.66,percent of total billed charges,Drugs,4315.66,30,,4315.66,percent of total billed charges,Drugs,4315.66,30,,4315.66,percent of total billed charges,Drugs,7192.77,50,,7192.77,percent of total billed charges,All Other,4315.66,30,,4315.66,percent of total billed charges,Drugs,4315.66,30,,4315.66,percent of total billed charges,Drugs,4891.08,34,"If Charge > 500, then 34 percent",4891.08,percent of total billed charges,Drugs,4315.66,30,,4315.66,percent of total billed charges,Drugs,4315.66,30,,4315.66,percent of total billed charges,Drugs,4315.66,30,,4315.66,percent of total billed charges,Drugs,4315.66,30,,4315.66,percent of total billed charges,Drugs,4315.66,30,,4315.66,percent of total billed charges,Drugs,4315.66,30,,4315.66,percent of total billed charges,Drugs,4315.66,30,,4315.66,percent of total billed charges,Drugs,4315.66,30,,4315.66,percent of total billed charges,Drugs,4315.66,30,,4315.66,percent of total billed charges,Drugs,4315.66,30,,4315.66,percent of total billed charges,Drugs,4315.66,30,,4315.66,percent of total billed charges,Drugs,4315.66,30,,4315.66,percent of total billed charges,Drugs,4315.66,30,,4315.66,percent of total billed charges,Drugs,2950.26,,,2950.26,Other,Drug Cost,2950.26,,,2950.26,Other,Drug Cost,2950.26,,,2950.26,Other,Drug Cost,2950.26,,,2950.26,Other,Drug Cost,2950.26,,,2950.26,Other,Drug Cost,4891.08,34,,4891.08,percent of total billed charges,Drugs,2950.26,,,2950.26,Other,Drug Cost,6638.09,,,6638.09,Other,225% Medicaid APG methodology,4130.36,,,4130.36,Other,140% Medicaid APG methodology,4891.08,34,"If Charge > 2,000, then 34 percent",4891.08,percent of total billed charges,Drugs,774.78,,,774.78,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2950.26,,,2950.26,Other,Drug Cost,2950.26,,,2950.26,Other,Drug Cost,3687.83,,,3687.83,Other,125% Medicaid APG methodology,0.01,7192.77,
USTEKINUMAB 5MG/ML IV SLN 26ML  ,J3358,HCPCS,,40584179,CDM,636,RC,57894-0054-27,NDC,both,26,ML,7053.2,124.51,,,124.51,Other,150% of Medicare + 9.63% HCRA Surcharge,75.71,,,75.71,Fee Schedule,Average Sale Price (ASP) x 6,2115.96,30,,2115.96,percent of total billed charges,Drugs,2115.96,30,,2115.96,percent of total billed charges,Drugs,2115.96,30,,2115.96,percent of total billed charges,Drugs,2115.96,30,,2115.96,percent of total billed charges,Drugs,2115.96,30,,2115.96,percent of total billed charges,Drugs,3526.6,50,,3526.6,percent of total billed charges,All Other,2115.96,30,,2115.96,percent of total billed charges,Drugs,2115.96,30,,2115.96,percent of total billed charges,Drugs,2398.09,34,"If Charge > 500, then 34 percent",2398.09,percent of total billed charges,Drugs,2115.96,30,,2115.96,percent of total billed charges,Drugs,2115.96,30,,2115.96,percent of total billed charges,Drugs,2115.96,30,,2115.96,percent of total billed charges,Drugs,2115.96,30,,2115.96,percent of total billed charges,Drugs,2115.96,30,,2115.96,percent of total billed charges,Drugs,2115.96,30,,2115.96,percent of total billed charges,Drugs,2115.96,30,,2115.96,percent of total billed charges,Drugs,2115.96,30,,2115.96,percent of total billed charges,Drugs,2115.96,30,,2115.96,percent of total billed charges,Drugs,2115.96,30,,2115.96,percent of total billed charges,Drugs,2115.96,30,,2115.96,percent of total billed charges,Drugs,2115.96,30,,2115.96,percent of total billed charges,Drugs,2115.96,30,,2115.96,percent of total billed charges,Drugs,1180.8,,,1180.8,Other,Drug Cost,1180.8,,,1180.8,Other,Drug Cost,1180.8,,,1180.8,Other,Drug Cost,1180.8,,,1180.8,Other,Drug Cost,1180.8,,,1180.8,Other,Drug Cost,2398.09,34,,2398.09,percent of total billed charges,Drugs,1180.8,,,1180.8,Other,Drug Cost,2656.8,,,2656.8,Other,225% Medicaid APG methodology,1653.12,,,1653.12,Other,140% Medicaid APG methodology,2398.09,34,"If Charge > 2,000, then 34 percent",2398.09,percent of total billed charges,Drugs,121.14,,,121.14,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1180.8,,,1180.8,Other,Drug Cost,1180.8,,,1180.8,Other,Drug Cost,1476,,,1476,Other,125% Medicaid APG methodology,0.01,3526.6,
NIVOLUMAB 10MG/ML IV SOLN 24ML  ,J9299,HCPCS,,40584203,CDM,636,RC,00003-3734-13,NDC,both,24,ML,26606.34,306.75,,,306.75,Other,150% of Medicare + 9.63% HCRA Surcharge,186.53,,,186.53,Fee Schedule,Average Sale Price (ASP) x 6,7981.9,30,,7981.9,percent of total billed charges,Drugs,7981.9,30,,7981.9,percent of total billed charges,Drugs,7981.9,30,,7981.9,percent of total billed charges,Drugs,7981.9,30,,7981.9,percent of total billed charges,Drugs,7981.9,30,,7981.9,percent of total billed charges,Drugs,13303.17,50,,13303.17,percent of total billed charges,All Other,7981.9,30,,7981.9,percent of total billed charges,Drugs,7981.9,30,,7981.9,percent of total billed charges,Drugs,9046.16,34,"If Charge > 500, then 34 percent",9046.16,percent of total billed charges,Drugs,7981.9,30,,7981.9,percent of total billed charges,Drugs,7981.9,30,,7981.9,percent of total billed charges,Drugs,7981.9,30,,7981.9,percent of total billed charges,Drugs,7981.9,30,,7981.9,percent of total billed charges,Drugs,7981.9,30,,7981.9,percent of total billed charges,Drugs,7981.9,30,,7981.9,percent of total billed charges,Drugs,7981.9,30,,7981.9,percent of total billed charges,Drugs,7981.9,30,,7981.9,percent of total billed charges,Drugs,7981.9,30,,7981.9,percent of total billed charges,Drugs,7981.9,30,,7981.9,percent of total billed charges,Drugs,7981.9,30,,7981.9,percent of total billed charges,Drugs,7981.9,30,,7981.9,percent of total billed charges,Drugs,7981.9,30,,7981.9,percent of total billed charges,Drugs,5465.54,,,5465.54,Other,Drug Cost,5465.54,,,5465.54,Other,Drug Cost,5465.54,,,5465.54,Other,Drug Cost,5465.54,,,5465.54,Other,Drug Cost,5465.54,,,5465.54,Other,Drug Cost,9046.16,34,,9046.16,percent of total billed charges,Drugs,5465.54,,,5465.54,Other,Drug Cost,12297.47,,,12297.47,Other,225% Medicaid APG methodology,7651.76,,,7651.76,Other,140% Medicaid APG methodology,9046.16,34,"If Charge > 2,000, then 34 percent",9046.16,percent of total billed charges,Drugs,298.45,,,298.45,Other,160% Medicare Fee Schedule,9046.16,34,,9046.16,Other,"Drug Charges > 20,000, then 34% of Charges",5465.54,,,5465.54,Other,Drug Cost,5465.54,,,5465.54,Other,Drug Cost,6831.93,,,6831.93,Other,125% Medicaid APG methodology,186.53,13303.17,
FILGRASTIM-SNDZ 300 MCG/0.5ML   ,Q5101,HCPCS,,40584526,CDM,636,RC,61314-0318-01,NDC,both,0.5,ML,486.85,3.15,,,3.15,Other,150% of Medicare + 9.63% HCRA Surcharge,1.91,,,1.91,Fee Schedule,Average Sale Price (ASP) x 6,146.06,30,,146.06,percent of total billed charges,Drugs,146.06,30,,146.06,percent of total billed charges,Drugs,146.06,30,,146.06,percent of total billed charges,Drugs,146.06,30,,146.06,percent of total billed charges,Drugs,146.06,30,,146.06,percent of total billed charges,Drugs,243.43,50,,243.43,percent of total billed charges,All Other,146.06,30,,146.06,percent of total billed charges,Drugs,146.06,30,,146.06,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,146.06,30,,146.06,percent of total billed charges,Drugs,146.06,30,,146.06,percent of total billed charges,Drugs,146.06,30,,146.06,percent of total billed charges,Drugs,146.06,30,,146.06,percent of total billed charges,Drugs,146.06,30,,146.06,percent of total billed charges,Drugs,146.06,30,,146.06,percent of total billed charges,Drugs,146.06,30,,146.06,percent of total billed charges,Drugs,146.06,30,,146.06,percent of total billed charges,Drugs,146.06,30,,146.06,percent of total billed charges,Drugs,146.06,30,,146.06,percent of total billed charges,Drugs,146.06,30,,146.06,percent of total billed charges,Drugs,146.06,30,,146.06,percent of total billed charges,Drugs,146.06,30,,146.06,percent of total billed charges,Drugs,55.03,,,55.03,Other,Drug Cost,55.03,,,55.03,Other,Drug Cost,55.03,,,55.03,Other,Drug Cost,55.03,,,55.03,Other,Drug Cost,55.03,,,55.03,Other,Drug Cost,165.53,34,,165.53,percent of total billed charges,Drugs,55.03,,,55.03,Other,Drug Cost,123.82,,,123.82,Other,225% Medicaid APG methodology,77.04,,,77.04,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,3.06,,,3.06,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",55.03,,,55.03,Other,Drug Cost,55.03,,,55.03,Other,Drug Cost,68.79,,,68.79,Other,125% Medicaid APG methodology,0.01,243.43,
OCTREOTIDE 100 MCG/ML INJ 1ML   ,J2354,HCPCS,,40584534,CDM,636,RC,25021-0452-01,NDC,both,1,ML,15.79,11.72,,,11.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7.13,,,7.13,Fee Schedule,Average Sale Price (ASP) x 6,4.74,30,,4.74,percent of total billed charges,Drugs,4.74,30,,4.74,percent of total billed charges,Drugs,4.74,30,,4.74,percent of total billed charges,Drugs,4.74,30,,4.74,percent of total billed charges,Drugs,4.74,30,,4.74,percent of total billed charges,Drugs,7.9,50,,7.9,percent of total billed charges,All Other,4.74,30,,4.74,percent of total billed charges,Drugs,4.74,30,,4.74,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.74,30,,4.74,percent of total billed charges,Drugs,4.74,30,,4.74,percent of total billed charges,Drugs,4.74,30,,4.74,percent of total billed charges,Drugs,4.74,30,,4.74,percent of total billed charges,Drugs,4.74,30,,4.74,percent of total billed charges,Drugs,4.74,30,,4.74,percent of total billed charges,Drugs,4.74,30,,4.74,percent of total billed charges,Drugs,4.74,30,,4.74,percent of total billed charges,Drugs,4.74,30,,4.74,percent of total billed charges,Drugs,4.74,30,,4.74,percent of total billed charges,Drugs,4.74,30,,4.74,percent of total billed charges,Drugs,4.74,30,,4.74,percent of total billed charges,Drugs,4.74,30,,4.74,percent of total billed charges,Drugs,4.23,,,4.23,Other,Drug Cost,4.23,,,4.23,Other,Drug Cost,4.23,,,4.23,Other,Drug Cost,4.23,,,4.23,Other,Drug Cost,4.23,,,4.23,Other,Drug Cost,5.37,34,,5.37,percent of total billed charges,Drugs,4.23,,,4.23,Other,Drug Cost,9.52,,,9.52,Other,225% Medicaid APG methodology,5.92,,,5.92,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,11.4,,,11.4,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.23,,,4.23,Other,Drug Cost,4.23,,,4.23,Other,Drug Cost,5.29,,,5.29,Other,125% Medicaid APG methodology,0.01,11.72,
FILGRASTIM-SNDZ 480 MCG/0.8ML   ,Q5101,HCPCS,,40584542,CDM,636,RC,61314-0326-01,NDC,both,0.8,ML,778.96,3.15,,,3.15,Other,150% of Medicare + 9.63% HCRA Surcharge,1.91,,,1.91,Fee Schedule,Average Sale Price (ASP) x 6,233.69,30,,233.69,percent of total billed charges,Drugs,233.69,30,,233.69,percent of total billed charges,Drugs,233.69,30,,233.69,percent of total billed charges,Drugs,233.69,30,,233.69,percent of total billed charges,Drugs,233.69,30,,233.69,percent of total billed charges,Drugs,389.48,50,,389.48,percent of total billed charges,All Other,233.69,30,,233.69,percent of total billed charges,Drugs,233.69,30,,233.69,percent of total billed charges,Drugs,264.85,34,"If Charge > 500, then 34 percent",264.85,percent of total billed charges,Drugs,233.69,30,,233.69,percent of total billed charges,Drugs,233.69,30,,233.69,percent of total billed charges,Drugs,233.69,30,,233.69,percent of total billed charges,Drugs,233.69,30,,233.69,percent of total billed charges,Drugs,233.69,30,,233.69,percent of total billed charges,Drugs,233.69,30,,233.69,percent of total billed charges,Drugs,233.69,30,,233.69,percent of total billed charges,Drugs,233.69,30,,233.69,percent of total billed charges,Drugs,233.69,30,,233.69,percent of total billed charges,Drugs,233.69,30,,233.69,percent of total billed charges,Drugs,233.69,30,,233.69,percent of total billed charges,Drugs,233.69,30,,233.69,percent of total billed charges,Drugs,233.69,30,,233.69,percent of total billed charges,Drugs,88.04,,,88.04,Other,Drug Cost,88.04,,,88.04,Other,Drug Cost,88.04,,,88.04,Other,Drug Cost,88.04,,,88.04,Other,Drug Cost,88.04,,,88.04,Other,Drug Cost,264.85,34,,264.85,percent of total billed charges,Drugs,88.04,,,88.04,Other,Drug Cost,198.09,,,198.09,Other,225% Medicaid APG methodology,123.26,,,123.26,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,3.06,,,3.06,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",88.04,,,88.04,Other,Drug Cost,88.04,,,88.04,Other,Drug Cost,110.05,,,110.05,Other,125% Medicaid APG methodology,0.01,389.48,
MORPHINE 4MG/ML PF INJ SLN 1ML  ,J2270,HCPCS,,40584625,CDM,636,RC,63323-0454-01,NDC,both,1,ML,5.29,46.03,,,46.03,Other,150% of Medicare + 9.63% HCRA Surcharge,27.99,,,27.99,Fee Schedule,Average Sale Price (ASP) x 6,1.59,30,,1.59,percent of total billed charges,Drugs,1.59,30,,1.59,percent of total billed charges,Drugs,1.59,30,,1.59,percent of total billed charges,Drugs,1.59,30,,1.59,percent of total billed charges,Drugs,1.59,30,,1.59,percent of total billed charges,Drugs,2.65,50,,2.65,percent of total billed charges,All Other,1.59,30,,1.59,percent of total billed charges,Drugs,1.59,30,,1.59,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.59,30,,1.59,percent of total billed charges,Drugs,1.59,30,,1.59,percent of total billed charges,Drugs,1.59,30,,1.59,percent of total billed charges,Drugs,1.59,30,,1.59,percent of total billed charges,Drugs,1.59,30,,1.59,percent of total billed charges,Drugs,1.59,30,,1.59,percent of total billed charges,Drugs,1.59,30,,1.59,percent of total billed charges,Drugs,1.59,30,,1.59,percent of total billed charges,Drugs,1.59,30,,1.59,percent of total billed charges,Drugs,1.59,30,,1.59,percent of total billed charges,Drugs,1.59,30,,1.59,percent of total billed charges,Drugs,1.59,30,,1.59,percent of total billed charges,Drugs,1.59,30,,1.59,percent of total billed charges,Drugs,1.08,,,1.08,Other,Drug Cost,1.08,,,1.08,Other,Drug Cost,1.08,,,1.08,Other,Drug Cost,1.08,,,1.08,Other,Drug Cost,1.08,,,1.08,Other,Drug Cost,1.8,34,,1.8,percent of total billed charges,Drugs,1.08,,,1.08,Other,Drug Cost,2.43,,,2.43,Other,225% Medicaid APG methodology,1.51,,,1.51,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,44.78,,,44.78,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.08,,,1.08,Other,Drug Cost,1.08,,,1.08,Other,Drug Cost,1.35,,,1.35,Other,125% Medicaid APG methodology,0.01,46.03,
ZOSTER VACC INACT ADJUV IM INJ  ,90750,CPT,,40584732,CDM,636,RC,58160-0823-11,NDC,both,1,EA,492.14,194.23,39.4668,,194.23,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,147.64,30,,147.64,percent of total billed charges,Drugs,147.64,30,,147.64,percent of total billed charges,Drugs,147.64,30,,147.64,percent of total billed charges,Drugs,147.64,30,,147.64,percent of total billed charges,Drugs,147.64,30,,147.64,percent of total billed charges,Drugs,246.07,50,,246.07,percent of total billed charges,All Other,147.64,30,,147.64,percent of total billed charges,Drugs,147.64,30,,147.64,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,147.64,30,,147.64,percent of total billed charges,Drugs,147.64,30,,147.64,percent of total billed charges,Drugs,147.64,30,,147.64,percent of total billed charges,Drugs,147.64,30,,147.64,percent of total billed charges,Drugs,147.64,30,,147.64,percent of total billed charges,Drugs,147.64,30,,147.64,percent of total billed charges,Drugs,147.64,30,,147.64,percent of total billed charges,Drugs,147.64,30,,147.64,percent of total billed charges,Drugs,147.64,30,,147.64,percent of total billed charges,Drugs,147.64,30,,147.64,percent of total billed charges,Drugs,147.64,30,,147.64,percent of total billed charges,Drugs,147.64,30,,147.64,percent of total billed charges,Drugs,147.64,30,,147.64,percent of total billed charges,Drugs,137.59,,,137.59,Other,Drug Cost,137.59,,,137.59,Other,Drug Cost,137.59,,,137.59,Other,Drug Cost,137.59,,,137.59,Other,Drug Cost,137.59,,,137.59,Other,Drug Cost,167.33,34,,167.33,percent of total billed charges,Drugs,137.59,,,137.59,Other,Drug Cost,309.58,,,309.58,Other,225% Medicaid APG methodology,192.63,,,192.63,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",137.59,,,137.59,Other,Drug Cost,137.59,,,137.59,Other,Drug Cost,171.99,,,171.99,Other,125% Medicaid APG methodology,0.01,309.58,
RABIES IMGLOB 300 INTUN/ML 1ML  ,90375,CPT,,40584781,CDM,636,RC,13533-0318-01,NDC,both,1,ML,1636.01,2861.14,,,2861.14,Other,150% of Medicare + 9.63% HCRA Surcharge,1739.87,,,1739.87,Fee Schedule,Average Sale Price (ASP) x 6,490.8,30,,490.8,percent of total billed charges,Drugs,490.8,30,,490.8,percent of total billed charges,Drugs,490.8,30,,490.8,percent of total billed charges,Drugs,490.8,30,,490.8,percent of total billed charges,Drugs,490.8,30,,490.8,percent of total billed charges,Drugs,818.01,50,,818.01,percent of total billed charges,All Other,490.8,30,,490.8,percent of total billed charges,Drugs,490.8,30,,490.8,percent of total billed charges,Drugs,556.24,34,"If Charge > 500, then 34 percent",556.24,percent of total billed charges,Drugs,490.8,30,,490.8,percent of total billed charges,Drugs,490.8,30,,490.8,percent of total billed charges,Drugs,490.8,30,,490.8,percent of total billed charges,Drugs,490.8,30,,490.8,percent of total billed charges,Drugs,490.8,30,,490.8,percent of total billed charges,Drugs,490.8,30,,490.8,percent of total billed charges,Drugs,490.8,30,,490.8,percent of total billed charges,Drugs,490.8,30,,490.8,percent of total billed charges,Drugs,490.8,30,,490.8,percent of total billed charges,Drugs,490.8,30,,490.8,percent of total billed charges,Drugs,490.8,30,,490.8,percent of total billed charges,Drugs,490.8,30,,490.8,percent of total billed charges,Drugs,490.8,30,,490.8,percent of total billed charges,Drugs,439.47,,,439.47,Other,Drug Cost,439.47,,,439.47,Other,Drug Cost,439.47,,,439.47,Other,Drug Cost,439.47,,,439.47,Other,Drug Cost,439.47,,,439.47,Other,Drug Cost,556.24,34,,556.24,percent of total billed charges,Drugs,439.47,,,439.47,Other,Drug Cost,988.81,,,988.81,Other,225% Medicaid APG methodology,615.26,,,615.26,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2783.8,,,2783.8,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",439.47,,,439.47,Other,Drug Cost,439.47,,,439.47,Other,Drug Cost,549.34,,,549.34,Other,125% Medicaid APG methodology,0.01,2861.14,
IMM GLOB10% 10G100ML GAMUNEX-C  ,J1561,HCPCS,,40584849,CDM,636,RC,13533-0800-71,NDC,both,100,ML,3688.93,491.22,,,491.22,Other,150% of Medicare + 9.63% HCRA Surcharge,298.72,,,298.72,Fee Schedule,Average Sale Price (ASP) x 6,1106.68,30,,1106.68,percent of total billed charges,Drugs,1106.68,30,,1106.68,percent of total billed charges,Drugs,1106.68,30,,1106.68,percent of total billed charges,Drugs,1106.68,30,,1106.68,percent of total billed charges,Drugs,1106.68,30,,1106.68,percent of total billed charges,Drugs,1844.47,50,,1844.47,percent of total billed charges,All Other,1106.68,30,,1106.68,percent of total billed charges,Drugs,1106.68,30,,1106.68,percent of total billed charges,Drugs,1254.24,34,"If Charge > 500, then 34 percent",1254.24,percent of total billed charges,Drugs,1106.68,30,,1106.68,percent of total billed charges,Drugs,1106.68,30,,1106.68,percent of total billed charges,Drugs,1106.68,30,,1106.68,percent of total billed charges,Drugs,1106.68,30,,1106.68,percent of total billed charges,Drugs,1106.68,30,,1106.68,percent of total billed charges,Drugs,1106.68,30,,1106.68,percent of total billed charges,Drugs,1106.68,30,,1106.68,percent of total billed charges,Drugs,1106.68,30,,1106.68,percent of total billed charges,Drugs,1106.68,30,,1106.68,percent of total billed charges,Drugs,1106.68,30,,1106.68,percent of total billed charges,Drugs,1106.68,30,,1106.68,percent of total billed charges,Drugs,1106.68,30,,1106.68,percent of total billed charges,Drugs,1106.68,30,,1106.68,percent of total billed charges,Drugs,744.85,,,744.85,Other,Drug Cost,744.85,,,744.85,Other,Drug Cost,744.85,,,744.85,Other,Drug Cost,744.85,,,744.85,Other,Drug Cost,744.85,,,744.85,Other,Drug Cost,1254.24,34,,1254.24,percent of total billed charges,Drugs,744.85,,,744.85,Other,Drug Cost,1675.91,,,1675.91,Other,225% Medicaid APG methodology,1042.79,,,1042.79,Other,140% Medicaid APG methodology,1254.24,34,"If Charge > 2,000, then 34 percent",1254.24,percent of total billed charges,Drugs,477.95,,,477.95,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",744.85,,,744.85,Other,Drug Cost,744.85,,,744.85,Other,Drug Cost,931.06,,,931.06,Other,125% Medicaid APG methodology,0.01,1844.47,
PEGLOTICASE 8MG/ML IV SOLN 1ML  ,J2507,HCPCS,,40584872,CDM,636,RC,75987-0080-10,NDC,both,1,ML,86966.46,33261.4,,,33261.4,Other,150% of Medicare + 9.63% HCRA Surcharge,20226.46,,,20226.46,Fee Schedule,Average Sale Price (ASP) x 6,26089.94,30,,26089.94,percent of total billed charges,Drugs,26089.94,30,,26089.94,percent of total billed charges,Drugs,26089.94,30,,26089.94,percent of total billed charges,Drugs,26089.94,30,,26089.94,percent of total billed charges,Drugs,26089.94,30,,26089.94,percent of total billed charges,Drugs,43483.23,50,,43483.23,percent of total billed charges,All Other,26089.94,30,,26089.94,percent of total billed charges,Drugs,26089.94,30,,26089.94,percent of total billed charges,Drugs,29568.6,34,"If Charge > 500, then 34 percent",29568.6,percent of total billed charges,Drugs,26089.94,30,,26089.94,percent of total billed charges,Drugs,26089.94,30,,26089.94,percent of total billed charges,Drugs,26089.94,30,,26089.94,percent of total billed charges,Drugs,26089.94,30,,26089.94,percent of total billed charges,Drugs,26089.94,30,,26089.94,percent of total billed charges,Drugs,26089.94,30,,26089.94,percent of total billed charges,Drugs,26089.94,30,,26089.94,percent of total billed charges,Drugs,26089.94,30,,26089.94,percent of total billed charges,Drugs,26089.94,30,,26089.94,percent of total billed charges,Drugs,26089.94,30,,26089.94,percent of total billed charges,Drugs,26089.94,30,,26089.94,percent of total billed charges,Drugs,26089.94,30,,26089.94,percent of total billed charges,Drugs,26089.94,30,,26089.94,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,29568.6,34,,29568.6,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,29568.6,34,"If Charge > 2,000, then 34 percent",29568.6,percent of total billed charges,Drugs,32362.33,,,32362.33,Other,160% Medicare Fee Schedule,29568.6,34,,29568.6,Other,"Drug Charges > 20,000, then 34% of Charges",0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,43483.23,
IMM GLOB10%(5G)50ML(GAMUNEX-C)  ,J1561,HCPCS,,40585036,CDM,636,RC,13533-0800-20,NDC,both,50,ML,1844.47,491.22,,,491.22,Other,150% of Medicare + 9.63% HCRA Surcharge,298.72,,,298.72,Fee Schedule,Average Sale Price (ASP) x 6,553.34,30,,553.34,percent of total billed charges,Drugs,553.34,30,,553.34,percent of total billed charges,Drugs,553.34,30,,553.34,percent of total billed charges,Drugs,553.34,30,,553.34,percent of total billed charges,Drugs,553.34,30,,553.34,percent of total billed charges,Drugs,922.24,50,,922.24,percent of total billed charges,All Other,553.34,30,,553.34,percent of total billed charges,Drugs,553.34,30,,553.34,percent of total billed charges,Drugs,627.12,34,"If Charge > 500, then 34 percent",627.12,percent of total billed charges,Drugs,553.34,30,,553.34,percent of total billed charges,Drugs,553.34,30,,553.34,percent of total billed charges,Drugs,553.34,30,,553.34,percent of total billed charges,Drugs,553.34,30,,553.34,percent of total billed charges,Drugs,553.34,30,,553.34,percent of total billed charges,Drugs,553.34,30,,553.34,percent of total billed charges,Drugs,553.34,30,,553.34,percent of total billed charges,Drugs,553.34,30,,553.34,percent of total billed charges,Drugs,553.34,30,,553.34,percent of total billed charges,Drugs,553.34,30,,553.34,percent of total billed charges,Drugs,553.34,30,,553.34,percent of total billed charges,Drugs,553.34,30,,553.34,percent of total billed charges,Drugs,553.34,30,,553.34,percent of total billed charges,Drugs,372.42,,,372.42,Other,Drug Cost,372.42,,,372.42,Other,Drug Cost,372.42,,,372.42,Other,Drug Cost,372.42,,,372.42,Other,Drug Cost,372.42,,,372.42,Other,Drug Cost,627.12,34,,627.12,percent of total billed charges,Drugs,372.42,,,372.42,Other,Drug Cost,837.95,,,837.95,Other,225% Medicaid APG methodology,521.39,,,521.39,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,477.95,,,477.95,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",372.42,,,372.42,Other,Drug Cost,372.42,,,372.42,Other,Drug Cost,465.53,,,465.53,Other,125% Medicaid APG methodology,0.01,922.24,
DOPAMINE 800MG/D5W 250ML        ,J1265,HCPCS,,40585044,CDM,636,RC,00409-7810-22,NDC,both,250,ML,32.62,7.62,,,7.62,Other,150% of Medicare + 9.63% HCRA Surcharge,4.63,,,4.63,Fee Schedule,Average Sale Price (ASP) x 6,9.79,30,,9.79,percent of total billed charges,Drugs,9.79,30,,9.79,percent of total billed charges,Drugs,9.79,30,,9.79,percent of total billed charges,Drugs,9.79,30,,9.79,percent of total billed charges,Drugs,9.79,30,,9.79,percent of total billed charges,Drugs,16.31,50,,16.31,percent of total billed charges,All Other,9.79,30,,9.79,percent of total billed charges,Drugs,9.79,30,,9.79,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,9.79,30,,9.79,percent of total billed charges,Drugs,9.79,30,,9.79,percent of total billed charges,Drugs,9.79,30,,9.79,percent of total billed charges,Drugs,9.79,30,,9.79,percent of total billed charges,Drugs,9.79,30,,9.79,percent of total billed charges,Drugs,9.79,30,,9.79,percent of total billed charges,Drugs,9.79,30,,9.79,percent of total billed charges,Drugs,9.79,30,,9.79,percent of total billed charges,Drugs,9.79,30,,9.79,percent of total billed charges,Drugs,9.79,30,,9.79,percent of total billed charges,Drugs,9.79,30,,9.79,percent of total billed charges,Drugs,9.79,30,,9.79,percent of total billed charges,Drugs,9.79,30,,9.79,percent of total billed charges,Drugs,7.68,,,7.68,Other,Drug Cost,7.68,,,7.68,Other,Drug Cost,7.68,,,7.68,Other,Drug Cost,7.68,,,7.68,Other,Drug Cost,7.68,,,7.68,Other,Drug Cost,11.09,34,,11.09,percent of total billed charges,Drugs,7.68,,,7.68,Other,Drug Cost,17.28,,,17.28,Other,225% Medicaid APG methodology,10.75,,,10.75,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.41,,,7.41,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",7.68,,,7.68,Other,Drug Cost,7.68,,,7.68,Other,Drug Cost,9.6,,,9.6,Other,125% Medicaid APG methodology,0.01,17.28,
CHLORPROMAZINE 25MG/ML INJ 1ML  ,J3230,HCPCS,,40585127,CDM,636,RC,70710-1849-07,NDC,both,1,ML,47.36,293.89,,,293.89,Other,150% of Medicare + 9.63% HCRA Surcharge,178.72,,,178.72,Fee Schedule,Average Sale Price (ASP) x 6,14.21,30,,14.21,percent of total billed charges,Drugs,14.21,30,,14.21,percent of total billed charges,Drugs,14.21,30,,14.21,percent of total billed charges,Drugs,14.21,30,,14.21,percent of total billed charges,Drugs,14.21,30,,14.21,percent of total billed charges,Drugs,23.68,50,,23.68,percent of total billed charges,All Other,14.21,30,,14.21,percent of total billed charges,Drugs,14.21,30,,14.21,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,14.21,30,,14.21,percent of total billed charges,Drugs,14.21,30,,14.21,percent of total billed charges,Drugs,14.21,30,,14.21,percent of total billed charges,Drugs,14.21,30,,14.21,percent of total billed charges,Drugs,14.21,30,,14.21,percent of total billed charges,Drugs,14.21,30,,14.21,percent of total billed charges,Drugs,14.21,30,,14.21,percent of total billed charges,Drugs,14.21,30,,14.21,percent of total billed charges,Drugs,14.21,30,,14.21,percent of total billed charges,Drugs,14.21,30,,14.21,percent of total billed charges,Drugs,14.21,30,,14.21,percent of total billed charges,Drugs,14.21,30,,14.21,percent of total billed charges,Drugs,14.21,30,,14.21,percent of total billed charges,Drugs,13.38,,,13.38,Other,Drug Cost,13.38,,,13.38,Other,Drug Cost,13.38,,,13.38,Other,Drug Cost,13.38,,,13.38,Other,Drug Cost,13.38,,,13.38,Other,Drug Cost,16.1,34,,16.1,percent of total billed charges,Drugs,13.38,,,13.38,Other,Drug Cost,30.11,,,30.11,Other,225% Medicaid APG methodology,18.73,,,18.73,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,285.95,,,285.95,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",13.38,,,13.38,Other,Drug Cost,13.38,,,13.38,Other,Drug Cost,16.73,,,16.73,Other,125% Medicaid APG methodology,0.01,293.89,
GOSERELIN 10.8MG SUBCUT IMPLNT  ,J9202,HCPCS,,40585317,CDM,636,RC,70720-0951-30,NDC,both,1,EA,7330.47,6008.91,,,6008.91,Other,150% of Medicare + 9.63% HCRA Surcharge,3654.05,,,3654.05,Fee Schedule,Average Sale Price (ASP) x 6,2199.14,30,,2199.14,percent of total billed charges,Drugs,2199.14,30,,2199.14,percent of total billed charges,Drugs,2199.14,30,,2199.14,percent of total billed charges,Drugs,2199.14,30,,2199.14,percent of total billed charges,Drugs,2199.14,30,,2199.14,percent of total billed charges,Drugs,3665.24,50,,3665.24,percent of total billed charges,All Other,2199.14,30,,2199.14,percent of total billed charges,Drugs,2199.14,30,,2199.14,percent of total billed charges,Drugs,2492.36,34,"If Charge > 500, then 34 percent",2492.36,percent of total billed charges,Drugs,2199.14,30,,2199.14,percent of total billed charges,Drugs,2199.14,30,,2199.14,percent of total billed charges,Drugs,2199.14,30,,2199.14,percent of total billed charges,Drugs,2199.14,30,,2199.14,percent of total billed charges,Drugs,2199.14,30,,2199.14,percent of total billed charges,Drugs,2199.14,30,,2199.14,percent of total billed charges,Drugs,2199.14,30,,2199.14,percent of total billed charges,Drugs,2199.14,30,,2199.14,percent of total billed charges,Drugs,2199.14,30,,2199.14,percent of total billed charges,Drugs,2199.14,30,,2199.14,percent of total billed charges,Drugs,2199.14,30,,2199.14,percent of total billed charges,Drugs,2199.14,30,,2199.14,percent of total billed charges,Drugs,2199.14,30,,2199.14,percent of total billed charges,Drugs,1361.37,,,1361.37,Other,Drug Cost,1361.37,,,1361.37,Other,Drug Cost,1361.37,,,1361.37,Other,Drug Cost,1361.37,,,1361.37,Other,Drug Cost,1361.37,,,1361.37,Other,Drug Cost,2492.36,34,,2492.36,percent of total billed charges,Drugs,1361.37,,,1361.37,Other,Drug Cost,3063.08,,,3063.08,Other,225% Medicaid APG methodology,1905.92,,,1905.92,Other,140% Medicaid APG methodology,2492.36,34,"If Charge > 2,000, then 34 percent",2492.36,percent of total billed charges,Drugs,5846.49,,,5846.49,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1361.37,,,1361.37,Other,Drug Cost,1361.37,,,1361.37,Other,Drug Cost,1701.71,,,1701.71,Other,125% Medicaid APG methodology,0.01,6008.91,
INFLIXIMAB-DYYB 100 MG IV INJ   ,Q5103,HCPCS,,40585440,CDM,636,RC,00069-0809-01,NDC,both,1,EA,1620.96,141.03,,,141.03,Other,150% of Medicare + 9.63% HCRA Surcharge,85.76,,,85.76,Fee Schedule,Average Sale Price (ASP) x 6,486.29,30,,486.29,percent of total billed charges,Drugs,486.29,30,,486.29,percent of total billed charges,Drugs,486.29,30,,486.29,percent of total billed charges,Drugs,486.29,30,,486.29,percent of total billed charges,Drugs,486.29,30,,486.29,percent of total billed charges,Drugs,810.48,50,,810.48,percent of total billed charges,All Other,486.29,30,,486.29,percent of total billed charges,Drugs,486.29,30,,486.29,percent of total billed charges,Drugs,551.13,34,"If Charge > 500, then 34 percent",551.13,percent of total billed charges,Drugs,486.29,30,,486.29,percent of total billed charges,Drugs,486.29,30,,486.29,percent of total billed charges,Drugs,486.29,30,,486.29,percent of total billed charges,Drugs,486.29,30,,486.29,percent of total billed charges,Drugs,486.29,30,,486.29,percent of total billed charges,Drugs,486.29,30,,486.29,percent of total billed charges,Drugs,486.29,30,,486.29,percent of total billed charges,Drugs,486.29,30,,486.29,percent of total billed charges,Drugs,486.29,30,,486.29,percent of total billed charges,Drugs,486.29,30,,486.29,percent of total billed charges,Drugs,486.29,30,,486.29,percent of total billed charges,Drugs,486.29,30,,486.29,percent of total billed charges,Drugs,486.29,30,,486.29,percent of total billed charges,Drugs,292.77,,,292.77,Other,Drug Cost,292.77,,,292.77,Other,Drug Cost,292.77,,,292.77,Other,Drug Cost,292.77,,,292.77,Other,Drug Cost,292.77,,,292.77,Other,Drug Cost,551.13,34,,551.13,percent of total billed charges,Drugs,292.77,,,292.77,Other,Drug Cost,658.73,,,658.73,Other,225% Medicaid APG methodology,409.88,,,409.88,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,137.22,,,137.22,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",292.77,,,292.77,Other,Drug Cost,292.77,,,292.77,Other,Drug Cost,365.96,,,365.96,Other,125% Medicaid APG methodology,0.01,810.48,
GEMCITABINE 38MG/ML IV  5.26ML  ,J9201,HCPCS,,40585457,CDM,636,RC,71288-0113-10,NDC,both,1,EA,13.97,36.02,,,36.02,Other,150% of Medicare + 9.63% HCRA Surcharge,21.91,,,21.91,Fee Schedule,Average Sale Price (ASP) x 6,4.19,30,,4.19,percent of total billed charges,Drugs,4.19,30,,4.19,percent of total billed charges,Drugs,4.19,30,,4.19,percent of total billed charges,Drugs,4.19,30,,4.19,percent of total billed charges,Drugs,4.19,30,,4.19,percent of total billed charges,Drugs,6.99,50,,6.99,percent of total billed charges,All Other,4.19,30,,4.19,percent of total billed charges,Drugs,4.19,30,,4.19,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.19,30,,4.19,percent of total billed charges,Drugs,4.19,30,,4.19,percent of total billed charges,Drugs,4.19,30,,4.19,percent of total billed charges,Drugs,4.19,30,,4.19,percent of total billed charges,Drugs,4.19,30,,4.19,percent of total billed charges,Drugs,4.19,30,,4.19,percent of total billed charges,Drugs,4.19,30,,4.19,percent of total billed charges,Drugs,4.19,30,,4.19,percent of total billed charges,Drugs,4.19,30,,4.19,percent of total billed charges,Drugs,4.19,30,,4.19,percent of total billed charges,Drugs,4.19,30,,4.19,percent of total billed charges,Drugs,4.19,30,,4.19,percent of total billed charges,Drugs,4.19,30,,4.19,percent of total billed charges,Drugs,3.99,,,3.99,Other,Drug Cost,3.99,,,3.99,Other,Drug Cost,3.99,,,3.99,Other,Drug Cost,3.99,,,3.99,Other,Drug Cost,3.99,,,3.99,Other,Drug Cost,4.75,34,,4.75,percent of total billed charges,Drugs,3.99,,,3.99,Other,Drug Cost,8.98,,,8.98,Other,225% Medicaid APG methodology,5.59,,,5.59,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,35.05,,,35.05,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.99,,,3.99,Other,Drug Cost,3.99,,,3.99,Other,Drug Cost,4.99,,,4.99,Other,125% Medicaid APG methodology,0.01,36.02,
OCRELIZUMAB 300MG/10ML IV 10ML  ,J2350,HCPCS,,40585507,CDM,636,RC,50242-0150-01,NDC,both,10,ML,65464.88,589.55,,,589.55,Other,150% of Medicare + 9.63% HCRA Surcharge,358.51,,,358.51,Fee Schedule,Average Sale Price (ASP) x 6,19639.46,30,,19639.46,percent of total billed charges,Drugs,19639.46,30,,19639.46,percent of total billed charges,Drugs,19639.46,30,,19639.46,percent of total billed charges,Drugs,19639.46,30,,19639.46,percent of total billed charges,Drugs,19639.46,30,,19639.46,percent of total billed charges,Drugs,32732.44,50,,32732.44,percent of total billed charges,All Other,19639.46,30,,19639.46,percent of total billed charges,Drugs,19639.46,30,,19639.46,percent of total billed charges,Drugs,22258.06,34,"If Charge > 500, then 34 percent",22258.06,percent of total billed charges,Drugs,19639.46,30,,19639.46,percent of total billed charges,Drugs,19639.46,30,,19639.46,percent of total billed charges,Drugs,19639.46,30,,19639.46,percent of total billed charges,Drugs,19639.46,30,,19639.46,percent of total billed charges,Drugs,19639.46,30,,19639.46,percent of total billed charges,Drugs,19639.46,30,,19639.46,percent of total billed charges,Drugs,19639.46,30,,19639.46,percent of total billed charges,Drugs,19639.46,30,,19639.46,percent of total billed charges,Drugs,19639.46,30,,19639.46,percent of total billed charges,Drugs,19639.46,30,,19639.46,percent of total billed charges,Drugs,19639.46,30,,19639.46,percent of total billed charges,Drugs,19639.46,30,,19639.46,percent of total billed charges,Drugs,19639.46,30,,19639.46,percent of total billed charges,Drugs,13291.02,,,13291.02,Other,Drug Cost,13291.02,,,13291.02,Other,Drug Cost,13291.02,,,13291.02,Other,Drug Cost,13291.02,,,13291.02,Other,Drug Cost,13291.02,,,13291.02,Other,Drug Cost,22258.06,34,,22258.06,percent of total billed charges,Drugs,13291.02,,,13291.02,Other,Drug Cost,29904.8,,,29904.8,Other,225% Medicaid APG methodology,18607.43,,,18607.43,Other,140% Medicaid APG methodology,22258.06,34,"If Charge > 2,000, then 34 percent",22258.06,percent of total billed charges,Drugs,573.61,,,573.61,Other,160% Medicare Fee Schedule,22258.06,34,,22258.06,Other,"Drug Charges > 20,000, then 34% of Charges",13291.02,,,13291.02,Other,Drug Cost,13291.02,,,13291.02,Other,Drug Cost,16613.78,,,16613.78,Other,125% Medicaid APG methodology,358.51,32732.44,
VINORELBINE 10 MG/ML IV SOLN    ,J9390,HCPCS,,40585549,CDM,636,RC,25021-0204-05,NDC,both,1,ML,22.12,73.17,,,73.17,Other,150% of Medicare + 9.63% HCRA Surcharge,44.5,,,44.5,Fee Schedule,Average Sale Price (ASP) x 6,6.64,30,,6.64,percent of total billed charges,Drugs,6.64,30,,6.64,percent of total billed charges,Drugs,6.64,30,,6.64,percent of total billed charges,Drugs,6.64,30,,6.64,percent of total billed charges,Drugs,6.64,30,,6.64,percent of total billed charges,Drugs,11.06,50,,11.06,percent of total billed charges,All Other,6.64,30,,6.64,percent of total billed charges,Drugs,6.64,30,,6.64,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,6.64,30,,6.64,percent of total billed charges,Drugs,6.64,30,,6.64,percent of total billed charges,Drugs,6.64,30,,6.64,percent of total billed charges,Drugs,6.64,30,,6.64,percent of total billed charges,Drugs,6.64,30,,6.64,percent of total billed charges,Drugs,6.64,30,,6.64,percent of total billed charges,Drugs,6.64,30,,6.64,percent of total billed charges,Drugs,6.64,30,,6.64,percent of total billed charges,Drugs,6.64,30,,6.64,percent of total billed charges,Drugs,6.64,30,,6.64,percent of total billed charges,Drugs,6.64,30,,6.64,percent of total billed charges,Drugs,6.64,30,,6.64,percent of total billed charges,Drugs,6.64,30,,6.64,percent of total billed charges,Drugs,7.69,,,7.69,Other,Drug Cost,7.69,,,7.69,Other,Drug Cost,7.69,,,7.69,Other,Drug Cost,7.69,,,7.69,Other,Drug Cost,7.69,,,7.69,Other,Drug Cost,7.52,34,,7.52,percent of total billed charges,Drugs,7.69,,,7.69,Other,Drug Cost,17.3,,,17.3,Other,225% Medicaid APG methodology,10.77,,,10.77,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,71.19,,,71.19,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",7.69,,,7.69,Other,Drug Cost,7.69,,,7.69,Other,Drug Cost,9.61,,,9.61,Other,125% Medicaid APG methodology,0.01,73.17,
IRINOTECAN LIPOS 4.3MG/ML 10ML  ,J9205,HCPCS,,40585598,CDM,636,RC,15054-0043-01,NDC,both,1,ML,865.2,611.93,,,611.93,Other,150% of Medicare + 9.63% HCRA Surcharge,372.12,,,372.12,Fee Schedule,Average Sale Price (ASP) x 6,259.56,30,,259.56,percent of total billed charges,Drugs,259.56,30,,259.56,percent of total billed charges,Drugs,259.56,30,,259.56,percent of total billed charges,Drugs,259.56,30,,259.56,percent of total billed charges,Drugs,259.56,30,,259.56,percent of total billed charges,Drugs,432.6,50,,432.6,percent of total billed charges,All Other,259.56,30,,259.56,percent of total billed charges,Drugs,259.56,30,,259.56,percent of total billed charges,Drugs,294.17,34,"If Charge > 500, then 34 percent",294.17,percent of total billed charges,Drugs,259.56,30,,259.56,percent of total billed charges,Drugs,259.56,30,,259.56,percent of total billed charges,Drugs,259.56,30,,259.56,percent of total billed charges,Drugs,259.56,30,,259.56,percent of total billed charges,Drugs,259.56,30,,259.56,percent of total billed charges,Drugs,259.56,30,,259.56,percent of total billed charges,Drugs,259.56,30,,259.56,percent of total billed charges,Drugs,259.56,30,,259.56,percent of total billed charges,Drugs,259.56,30,,259.56,percent of total billed charges,Drugs,259.56,30,,259.56,percent of total billed charges,Drugs,259.56,30,,259.56,percent of total billed charges,Drugs,259.56,30,,259.56,percent of total billed charges,Drugs,259.56,30,,259.56,percent of total billed charges,Drugs,126.45,,,126.45,Other,Drug Cost,126.45,,,126.45,Other,Drug Cost,126.45,,,126.45,Other,Drug Cost,126.45,,,126.45,Other,Drug Cost,126.45,,,126.45,Other,Drug Cost,294.17,34,,294.17,percent of total billed charges,Drugs,126.45,,,126.45,Other,Drug Cost,284.51,,,284.51,Other,225% Medicaid APG methodology,177.03,,,177.03,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,595.39,,,595.39,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",126.45,,,126.45,Other,Drug Cost,126.45,,,126.45,Other,Drug Cost,158.06,,,158.06,Other,125% Medicaid APG methodology,0.01,611.93,
ANDEXANET ALFA (ANDEXXA) VIAL   ,J7169,HCPCS,,40585663,CDM,636,RC,00310-3200-04,NDC,both,1,EA,8662.71,3418.89,39.4668,,3418.89,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,2598.81,30,,2598.81,percent of total billed charges,Drugs,2598.81,30,,2598.81,percent of total billed charges,Drugs,2598.81,30,,2598.81,percent of total billed charges,Drugs,2598.81,30,,2598.81,percent of total billed charges,Drugs,2598.81,30,,2598.81,percent of total billed charges,Drugs,4331.36,50,,4331.36,percent of total billed charges,All Other,2598.81,30,,2598.81,percent of total billed charges,Drugs,2598.81,30,,2598.81,percent of total billed charges,Drugs,2945.32,34,"If Charge > 500, then 34 percent",2945.32,percent of total billed charges,Drugs,2598.81,30,,2598.81,percent of total billed charges,Drugs,2598.81,30,,2598.81,percent of total billed charges,Drugs,2598.81,30,,2598.81,percent of total billed charges,Drugs,2598.81,30,,2598.81,percent of total billed charges,Drugs,2598.81,30,,2598.81,percent of total billed charges,Drugs,2598.81,30,,2598.81,percent of total billed charges,Drugs,2598.81,30,,2598.81,percent of total billed charges,Drugs,2598.81,30,,2598.81,percent of total billed charges,Drugs,2598.81,30,,2598.81,percent of total billed charges,Drugs,2598.81,30,,2598.81,percent of total billed charges,Drugs,2598.81,30,,2598.81,percent of total billed charges,Drugs,2598.81,30,,2598.81,percent of total billed charges,Drugs,2598.81,30,,2598.81,percent of total billed charges,Drugs,1910.88,,,1910.88,Other,Drug Cost,1910.88,,,1910.88,Other,Drug Cost,1910.88,,,1910.88,Other,Drug Cost,1910.88,,,1910.88,Other,Drug Cost,1910.88,,,1910.88,Other,Drug Cost,2945.32,34,,2945.32,percent of total billed charges,Drugs,1910.88,,,1910.88,Other,Drug Cost,4299.48,,,4299.48,Other,225% Medicaid APG methodology,2675.23,,,2675.23,Other,140% Medicaid APG methodology,2945.32,34,"If Charge > 2,000, then 34 percent",2945.32,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1910.88,,,1910.88,Other,Drug Cost,1910.88,,,1910.88,Other,Drug Cost,2388.6,,,2388.6,Other,125% Medicaid APG methodology,0.01,4331.36,
IMM GLOB10%(40G)400ML(PRIVIGEN  ,J1459,HCPCS,,40585838,CDM,636,RC,44206-0439-40,NDC,both,400,ML,11774,476.46,,,476.46,Other,150% of Medicare + 9.63% HCRA Surcharge,289.74,,,289.74,Fee Schedule,Average Sale Price (ASP) x 6,3532.2,30,,3532.2,percent of total billed charges,Drugs,3532.2,30,,3532.2,percent of total billed charges,Drugs,3532.2,30,,3532.2,percent of total billed charges,Drugs,3532.2,30,,3532.2,percent of total billed charges,Drugs,3532.2,30,,3532.2,percent of total billed charges,Drugs,5887,50,,5887,percent of total billed charges,All Other,3532.2,30,,3532.2,percent of total billed charges,Drugs,3532.2,30,,3532.2,percent of total billed charges,Drugs,4003.16,34,"If Charge > 500, then 34 percent",4003.16,percent of total billed charges,Drugs,3532.2,30,,3532.2,percent of total billed charges,Drugs,3532.2,30,,3532.2,percent of total billed charges,Drugs,3532.2,30,,3532.2,percent of total billed charges,Drugs,3532.2,30,,3532.2,percent of total billed charges,Drugs,3532.2,30,,3532.2,percent of total billed charges,Drugs,3532.2,30,,3532.2,percent of total billed charges,Drugs,3532.2,30,,3532.2,percent of total billed charges,Drugs,3532.2,30,,3532.2,percent of total billed charges,Drugs,3532.2,30,,3532.2,percent of total billed charges,Drugs,3532.2,30,,3532.2,percent of total billed charges,Drugs,3532.2,30,,3532.2,percent of total billed charges,Drugs,3532.2,30,,3532.2,percent of total billed charges,Drugs,3532.2,30,,3532.2,percent of total billed charges,Drugs,2360,,,2360,Other,Drug Cost,2360,,,2360,Other,Drug Cost,2360,,,2360,Other,Drug Cost,2360,,,2360,Other,Drug Cost,2360,,,2360,Other,Drug Cost,4003.16,34,,4003.16,percent of total billed charges,Drugs,2360,,,2360,Other,Drug Cost,5310,,,5310,Other,225% Medicaid APG methodology,3304,,,3304,Other,140% Medicaid APG methodology,4003.16,34,"If Charge > 2,000, then 34 percent",4003.16,percent of total billed charges,Drugs,463.58,,,463.58,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2360,,,2360,Other,Drug Cost,2360,,,2360,Other,Drug Cost,2950,,,2950,Other,125% Medicaid APG methodology,0.01,5887,
ICATIBANT 30 MG/3 ML SYRINGE    ,J1744,HCPCS,,40585960,CDM,636,RC,00093-3066-93,NDC,both,3,ML,8397.55,3314.24,39.4668,,3314.24,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,2519.27,30,,2519.27,percent of total billed charges,Drugs,2519.27,30,,2519.27,percent of total billed charges,Drugs,2519.27,30,,2519.27,percent of total billed charges,Drugs,2519.27,30,,2519.27,percent of total billed charges,Drugs,2519.27,30,,2519.27,percent of total billed charges,Drugs,4198.78,50,,4198.78,percent of total billed charges,All Other,2519.27,30,,2519.27,percent of total billed charges,Drugs,2519.27,30,,2519.27,percent of total billed charges,Drugs,2855.17,34,"If Charge > 500, then 34 percent",2855.17,percent of total billed charges,Drugs,2519.27,30,,2519.27,percent of total billed charges,Drugs,2519.27,30,,2519.27,percent of total billed charges,Drugs,2519.27,30,,2519.27,percent of total billed charges,Drugs,2519.27,30,,2519.27,percent of total billed charges,Drugs,2519.27,30,,2519.27,percent of total billed charges,Drugs,2519.27,30,,2519.27,percent of total billed charges,Drugs,2519.27,30,,2519.27,percent of total billed charges,Drugs,2519.27,30,,2519.27,percent of total billed charges,Drugs,2519.27,30,,2519.27,percent of total billed charges,Drugs,2519.27,30,,2519.27,percent of total billed charges,Drugs,2519.27,30,,2519.27,percent of total billed charges,Drugs,2519.27,30,,2519.27,percent of total billed charges,Drugs,2519.27,30,,2519.27,percent of total billed charges,Drugs,743.57,,,743.57,Other,Drug Cost,743.57,,,743.57,Other,Drug Cost,743.57,,,743.57,Other,Drug Cost,743.57,,,743.57,Other,Drug Cost,743.57,,,743.57,Other,Drug Cost,2855.17,34,,2855.17,percent of total billed charges,Drugs,743.57,,,743.57,Other,Drug Cost,1673.03,,,1673.03,Other,225% Medicaid APG methodology,1041,,,1041,Other,140% Medicaid APG methodology,2855.17,34,"If Charge > 2,000, then 34 percent",2855.17,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",743.57,,,743.57,Other,Drug Cost,743.57,,,743.57,Other,Drug Cost,929.46,,,929.46,Other,125% Medicaid APG methodology,0.01,4198.78,
EPOETIN ALFA-EPBX2000U/ML ESRD  ,Q5106,HCPCS,,40585994,CDM,636,RC,00069-1305-10,NDC,both,1,ML,60.31,77.2,,,77.2,Other,150% of Medicare + 9.63% HCRA Surcharge,46.94,,,46.94,Fee Schedule,Average Sale Price (ASP) x 6,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,30.16,50,,30.16,percent of total billed charges,All Other,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,6.6,,,6.6,Other,Drug Cost,6.6,,,6.6,Other,Drug Cost,6.6,,,6.6,Other,Drug Cost,6.6,,,6.6,Other,Drug Cost,6.6,,,6.6,Other,Drug Cost,20.51,34,,20.51,percent of total billed charges,Drugs,6.6,,,6.6,Other,Drug Cost,14.85,,,14.85,Other,225% Medicaid APG methodology,9.24,,,9.24,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,75.11,,,75.11,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6.6,,,6.6,Other,Drug Cost,6.6,,,6.6,Other,Drug Cost,8.25,,,8.25,Other,125% Medicaid APG methodology,0.01,77.2,
EPOETIN-EPBX 4000UN/ML PF ESRD  ,Q5106,HCPCS,,40586000,CDM,636,RC,00069-1307-10,NDC,both,1,ML,120.61,77.2,,,77.2,Other,150% of Medicare + 9.63% HCRA Surcharge,46.94,,,46.94,Fee Schedule,Average Sale Price (ASP) x 6,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,60.31,50,,60.31,percent of total billed charges,All Other,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,13.2,,,13.2,Other,Drug Cost,13.2,,,13.2,Other,Drug Cost,13.2,,,13.2,Other,Drug Cost,13.2,,,13.2,Other,Drug Cost,13.2,,,13.2,Other,Drug Cost,41.01,34,,41.01,percent of total billed charges,Drugs,13.2,,,13.2,Other,Drug Cost,29.7,,,29.7,Other,225% Medicaid APG methodology,18.48,,,18.48,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,75.11,,,75.11,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",13.2,,,13.2,Other,Drug Cost,13.2,,,13.2,Other,Drug Cost,16.5,,,16.5,Other,125% Medicaid APG methodology,0.01,77.2,
EPOETIN-EPBX 3000UN/ML PF ESRD  ,Q5106,HCPCS,,40586018,CDM,636,RC,00069-1306-10,NDC,both,1,ML,90.48,77.2,,,77.2,Other,150% of Medicare + 9.63% HCRA Surcharge,46.94,,,46.94,Fee Schedule,Average Sale Price (ASP) x 6,27.14,30,,27.14,percent of total billed charges,Drugs,27.14,30,,27.14,percent of total billed charges,Drugs,27.14,30,,27.14,percent of total billed charges,Drugs,27.14,30,,27.14,percent of total billed charges,Drugs,27.14,30,,27.14,percent of total billed charges,Drugs,45.24,50,,45.24,percent of total billed charges,All Other,27.14,30,,27.14,percent of total billed charges,Drugs,27.14,30,,27.14,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,27.14,30,,27.14,percent of total billed charges,Drugs,27.14,30,,27.14,percent of total billed charges,Drugs,27.14,30,,27.14,percent of total billed charges,Drugs,27.14,30,,27.14,percent of total billed charges,Drugs,27.14,30,,27.14,percent of total billed charges,Drugs,27.14,30,,27.14,percent of total billed charges,Drugs,27.14,30,,27.14,percent of total billed charges,Drugs,27.14,30,,27.14,percent of total billed charges,Drugs,27.14,30,,27.14,percent of total billed charges,Drugs,27.14,30,,27.14,percent of total billed charges,Drugs,27.14,30,,27.14,percent of total billed charges,Drugs,27.14,30,,27.14,percent of total billed charges,Drugs,27.14,30,,27.14,percent of total billed charges,Drugs,9.9,,,9.9,Other,Drug Cost,9.9,,,9.9,Other,Drug Cost,9.9,,,9.9,Other,Drug Cost,9.9,,,9.9,Other,Drug Cost,9.9,,,9.9,Other,Drug Cost,30.76,34,,30.76,percent of total billed charges,Drugs,9.9,,,9.9,Other,Drug Cost,22.28,,,22.28,Other,225% Medicaid APG methodology,13.86,,,13.86,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,75.11,,,75.11,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",9.9,,,9.9,Other,Drug Cost,9.9,,,9.9,Other,Drug Cost,12.38,,,12.38,Other,125% Medicaid APG methodology,0.01,77.2,
EPOTIN ALFA-EPBX10000U/ML ESRD  ,Q5106,HCPCS,,40586026,CDM,636,RC,00069-1308-10,NDC,both,1,ML,301.53,77.2,,,77.2,Other,150% of Medicare + 9.63% HCRA Surcharge,46.94,,,46.94,Fee Schedule,Average Sale Price (ASP) x 6,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,150.77,50,,150.77,percent of total billed charges,All Other,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,33,,,33,Other,Drug Cost,33,,,33,Other,Drug Cost,33,,,33,Other,Drug Cost,33,,,33,Other,Drug Cost,33,,,33,Other,Drug Cost,102.52,34,,102.52,percent of total billed charges,Drugs,33,,,33,Other,Drug Cost,74.25,,,74.25,Other,225% Medicaid APG methodology,46.2,,,46.2,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,75.11,,,75.11,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",33,,,33,Other,Drug Cost,33,,,33,Other,Drug Cost,41.25,,,41.25,Other,125% Medicaid APG methodology,0.01,150.77,
INJ RETACRIT ESRD ON DIALYSIS   ,Q5105,HCPCS,,40586034,CDM,636,RC,00069-1309-04,NDC,both,1,ML,1206.14,7.72,,,7.72,Other,150% of Medicare + 9.63% HCRA Surcharge,4.69,,,4.69,Fee Schedule,Average Sale Price (ASP) x 6,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,603.07,50,,603.07,percent of total billed charges,All Other,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,410.09,34,"If Charge > 500, then 34 percent",410.09,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,132,,,132,Other,Drug Cost,132,,,132,Other,Drug Cost,132,,,132,Other,Drug Cost,132,,,132,Other,Drug Cost,132,,,132,Other,Drug Cost,410.09,34,,410.09,percent of total billed charges,Drugs,132,,,132,Other,Drug Cost,297,,,297,Other,225% Medicaid APG methodology,184.8,,,184.8,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.51,,,7.51,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",132,,,132,Other,Drug Cost,132,,,132,Other,Drug Cost,165,,,165,Other,125% Medicaid APG methodology,0.01,603.07,
EPOETIN-EPBX 2000UN/ML ESRD     ,Q5106,HCPCS,,40586125,CDM,636,RC,00069-1305-10e,NDC,both,1,ML,60.31,77.2,,,77.2,Other,150% of Medicare + 9.63% HCRA Surcharge,46.94,,,46.94,Fee Schedule,Average Sale Price (ASP) x 6,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,30.16,50,,30.16,percent of total billed charges,All Other,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,6.6,,,6.6,Other,Drug Cost,6.6,,,6.6,Other,Drug Cost,6.6,,,6.6,Other,Drug Cost,6.6,,,6.6,Other,Drug Cost,6.6,,,6.6,Other,Drug Cost,20.51,34,,20.51,percent of total billed charges,Drugs,6.6,,,6.6,Other,Drug Cost,14.85,,,14.85,Other,225% Medicaid APG methodology,9.24,,,9.24,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,75.11,,,75.11,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6.6,,,6.6,Other,Drug Cost,6.6,,,6.6,Other,Drug Cost,8.25,,,8.25,Other,125% Medicaid APG methodology,0.01,77.2,
IMMUNE GLOBULIN IM SOLN 10 ML   ,J1460,HCPCS,,40586182,CDM,636,RC,13533-0335-12,NDC,both,10,ML,1463.04,500.5,,,500.5,Other,150% of Medicare + 9.63% HCRA Surcharge,304.36,,,304.36,Fee Schedule,Average Sale Price (ASP) x 6,438.91,30,,438.91,percent of total billed charges,Drugs,438.91,30,,438.91,percent of total billed charges,Drugs,438.91,30,,438.91,percent of total billed charges,Drugs,438.91,30,,438.91,percent of total billed charges,Drugs,438.91,30,,438.91,percent of total billed charges,Drugs,731.52,50,,731.52,percent of total billed charges,All Other,438.91,30,,438.91,percent of total billed charges,Drugs,438.91,30,,438.91,percent of total billed charges,Drugs,497.43,34,"If Charge > 500, then 34 percent",497.43,percent of total billed charges,Drugs,438.91,30,,438.91,percent of total billed charges,Drugs,438.91,30,,438.91,percent of total billed charges,Drugs,438.91,30,,438.91,percent of total billed charges,Drugs,438.91,30,,438.91,percent of total billed charges,Drugs,438.91,30,,438.91,percent of total billed charges,Drugs,438.91,30,,438.91,percent of total billed charges,Drugs,438.91,30,,438.91,percent of total billed charges,Drugs,438.91,30,,438.91,percent of total billed charges,Drugs,438.91,30,,438.91,percent of total billed charges,Drugs,438.91,30,,438.91,percent of total billed charges,Drugs,438.91,30,,438.91,percent of total billed charges,Drugs,438.91,30,,438.91,percent of total billed charges,Drugs,438.91,30,,438.91,percent of total billed charges,Drugs,48.7,,,48.7,Other,Drug Cost,48.7,,,48.7,Other,Drug Cost,48.7,,,48.7,Other,Drug Cost,48.7,,,48.7,Other,Drug Cost,48.7,,,48.7,Other,Drug Cost,497.43,34,,497.43,percent of total billed charges,Drugs,48.7,,,48.7,Other,Drug Cost,109.58,,,109.58,Other,225% Medicaid APG methodology,68.18,,,68.18,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,486.97,,,486.97,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",48.7,,,48.7,Other,Drug Cost,48.7,,,48.7,Other,Drug Cost,60.88,,,60.88,Other,125% Medicaid APG methodology,0.01,731.52,
ELOTUZUMAB 300 MG IV INJ        ,J9176,HCPCS,,40586208,CDM,636,RC,00003-2291-11,NDC,both,1,EA,7002.31,72.82,,,72.82,Other,150% of Medicare + 9.63% HCRA Surcharge,44.28,,,44.28,Fee Schedule,Average Sale Price (ASP) x 6,2100.69,30,,2100.69,percent of total billed charges,Drugs,2100.69,30,,2100.69,percent of total billed charges,Drugs,2100.69,30,,2100.69,percent of total billed charges,Drugs,2100.69,30,,2100.69,percent of total billed charges,Drugs,2100.69,30,,2100.69,percent of total billed charges,Drugs,3501.16,50,,3501.16,percent of total billed charges,All Other,2100.69,30,,2100.69,percent of total billed charges,Drugs,2100.69,30,,2100.69,percent of total billed charges,Drugs,2380.79,34,"If Charge > 500, then 34 percent",2380.79,percent of total billed charges,Drugs,2100.69,30,,2100.69,percent of total billed charges,Drugs,2100.69,30,,2100.69,percent of total billed charges,Drugs,2100.69,30,,2100.69,percent of total billed charges,Drugs,2100.69,30,,2100.69,percent of total billed charges,Drugs,2100.69,30,,2100.69,percent of total billed charges,Drugs,2100.69,30,,2100.69,percent of total billed charges,Drugs,2100.69,30,,2100.69,percent of total billed charges,Drugs,2100.69,30,,2100.69,percent of total billed charges,Drugs,2100.69,30,,2100.69,percent of total billed charges,Drugs,2100.69,30,,2100.69,percent of total billed charges,Drugs,2100.69,30,,2100.69,percent of total billed charges,Drugs,2100.69,30,,2100.69,percent of total billed charges,Drugs,2100.69,30,,2100.69,percent of total billed charges,Drugs,1471.53,,,1471.53,Other,Drug Cost,1471.53,,,1471.53,Other,Drug Cost,1471.53,,,1471.53,Other,Drug Cost,1471.53,,,1471.53,Other,Drug Cost,1471.53,,,1471.53,Other,Drug Cost,2380.79,34,,2380.79,percent of total billed charges,Drugs,1471.53,,,1471.53,Other,Drug Cost,3310.94,,,3310.94,Other,225% Medicaid APG methodology,2060.14,,,2060.14,Other,140% Medicaid APG methodology,2380.79,34,"If Charge > 2,000, then 34 percent",2380.79,percent of total billed charges,Drugs,70.85,,,70.85,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1471.53,,,1471.53,Other,Drug Cost,1471.53,,,1471.53,Other,Drug Cost,1839.41,,,1839.41,Other,125% Medicaid APG methodology,0.01,3501.16,
EMPLICITI 400 MG VIAL           ,J9176,HCPCS,,40586216,CDM,636,RC,00003-4522-11,NDC,both,1,EA,9336.36,72.82,,,72.82,Other,150% of Medicare + 9.63% HCRA Surcharge,44.28,,,44.28,Fee Schedule,Average Sale Price (ASP) x 6,2800.91,30,,2800.91,percent of total billed charges,Drugs,2800.91,30,,2800.91,percent of total billed charges,Drugs,2800.91,30,,2800.91,percent of total billed charges,Drugs,2800.91,30,,2800.91,percent of total billed charges,Drugs,2800.91,30,,2800.91,percent of total billed charges,Drugs,4668.18,50,,4668.18,percent of total billed charges,All Other,2800.91,30,,2800.91,percent of total billed charges,Drugs,2800.91,30,,2800.91,percent of total billed charges,Drugs,3174.36,34,"If Charge > 500, then 34 percent",3174.36,percent of total billed charges,Drugs,2800.91,30,,2800.91,percent of total billed charges,Drugs,2800.91,30,,2800.91,percent of total billed charges,Drugs,2800.91,30,,2800.91,percent of total billed charges,Drugs,2800.91,30,,2800.91,percent of total billed charges,Drugs,2800.91,30,,2800.91,percent of total billed charges,Drugs,2800.91,30,,2800.91,percent of total billed charges,Drugs,2800.91,30,,2800.91,percent of total billed charges,Drugs,2800.91,30,,2800.91,percent of total billed charges,Drugs,2800.91,30,,2800.91,percent of total billed charges,Drugs,2800.91,30,,2800.91,percent of total billed charges,Drugs,2800.91,30,,2800.91,percent of total billed charges,Drugs,2800.91,30,,2800.91,percent of total billed charges,Drugs,2800.91,30,,2800.91,percent of total billed charges,Drugs,1966.1,,,1966.1,Other,Drug Cost,1966.1,,,1966.1,Other,Drug Cost,1966.1,,,1966.1,Other,Drug Cost,1966.1,,,1966.1,Other,Drug Cost,1966.1,,,1966.1,Other,Drug Cost,3174.36,34,,3174.36,percent of total billed charges,Drugs,1966.1,,,1966.1,Other,Drug Cost,4423.73,,,4423.73,Other,225% Medicaid APG methodology,2752.54,,,2752.54,Other,140% Medicaid APG methodology,3174.36,34,"If Charge > 2,000, then 34 percent",3174.36,percent of total billed charges,Drugs,70.85,,,70.85,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1966.1,,,1966.1,Other,Drug Cost,1966.1,,,1966.1,Other,Drug Cost,2457.63,,,2457.63,Other,125% Medicaid APG methodology,0.01,4668.18,
OLANZAPINE 10 MG INJ            ,J2359,HCPCS,,40586703,CDM,636,RC,00781-3159-72,NDC,both,1,EA,68.18,9.34,,,9.34,Other,150% of Medicare + 9.63% HCRA Surcharge,5.68,,,5.68,Fee Schedule,Average Sale Price (ASP) x 6,20.45,30,,20.45,percent of total billed charges,Drugs,20.45,30,,20.45,percent of total billed charges,Drugs,20.45,30,,20.45,percent of total billed charges,Drugs,20.45,30,,20.45,percent of total billed charges,Drugs,20.45,30,,20.45,percent of total billed charges,Drugs,34.09,50,,34.09,percent of total billed charges,All Other,20.45,30,,20.45,percent of total billed charges,Drugs,20.45,30,,20.45,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,20.45,30,,20.45,percent of total billed charges,Drugs,20.45,30,,20.45,percent of total billed charges,Drugs,20.45,30,,20.45,percent of total billed charges,Drugs,20.45,30,,20.45,percent of total billed charges,Drugs,20.45,30,,20.45,percent of total billed charges,Drugs,20.45,30,,20.45,percent of total billed charges,Drugs,20.45,30,,20.45,percent of total billed charges,Drugs,20.45,30,,20.45,percent of total billed charges,Drugs,20.45,30,,20.45,percent of total billed charges,Drugs,20.45,30,,20.45,percent of total billed charges,Drugs,20.45,30,,20.45,percent of total billed charges,Drugs,20.45,30,,20.45,percent of total billed charges,Drugs,20.45,30,,20.45,percent of total billed charges,Drugs,14.9,,,14.9,Other,Drug Cost,14.9,,,14.9,Other,Drug Cost,14.9,,,14.9,Other,Drug Cost,14.9,,,14.9,Other,Drug Cost,14.9,,,14.9,Other,Drug Cost,23.18,34,,23.18,percent of total billed charges,Drugs,14.9,,,14.9,Other,Drug Cost,33.53,,,33.53,Other,225% Medicaid APG methodology,20.86,,,20.86,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,9.09,,,9.09,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",14.9,,,14.9,Other,Drug Cost,14.9,,,14.9,Other,Drug Cost,18.63,,,18.63,Other,125% Medicaid APG methodology,0.01,34.09,
INFLUENZA VACC HD (65Y+) 0.5ML  ,90662,CPT,,40587628,CDM,636,RC,49281-0123-65,NDC,both,0.7,ML,222.99,724.25,,,724.25,Other,150% of Medicare + 9.63% HCRA Surcharge,440.42,,,440.42,Fee Schedule,Average Sale Price (ASP) x 6,66.9,30,,66.9,percent of total billed charges,Drugs,66.9,30,,66.9,percent of total billed charges,Drugs,66.9,30,,66.9,percent of total billed charges,Drugs,66.9,30,,66.9,percent of total billed charges,Drugs,66.9,30,,66.9,percent of total billed charges,Drugs,111.5,50,,111.5,percent of total billed charges,All Other,66.9,30,,66.9,percent of total billed charges,Drugs,66.9,30,,66.9,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,66.9,30,,66.9,percent of total billed charges,Drugs,66.9,30,,66.9,percent of total billed charges,Drugs,66.9,30,,66.9,percent of total billed charges,Drugs,66.9,30,,66.9,percent of total billed charges,Drugs,66.9,30,,66.9,percent of total billed charges,Drugs,66.9,30,,66.9,percent of total billed charges,Drugs,66.9,30,,66.9,percent of total billed charges,Drugs,66.9,30,,66.9,percent of total billed charges,Drugs,66.9,30,,66.9,percent of total billed charges,Drugs,66.9,30,,66.9,percent of total billed charges,Drugs,66.9,30,,66.9,percent of total billed charges,Drugs,66.9,30,,66.9,percent of total billed charges,Drugs,66.9,30,,66.9,percent of total billed charges,Drugs,63.71,,,63.71,Other,Drug Cost,63.71,,,63.71,Other,Drug Cost,63.71,,,63.71,Other,Drug Cost,63.71,,,63.71,Other,Drug Cost,63.71,,,63.71,Other,Drug Cost,75.82,34,,75.82,percent of total billed charges,Drugs,63.71,,,63.71,Other,Drug Cost,143.35,,,143.35,Other,225% Medicaid APG methodology,89.19,,,89.19,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,704.67,,,704.67,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",63.71,,,63.71,Other,Drug Cost,63.71,,,63.71,Other,Drug Cost,79.64,,,79.64,Other,125% Medicaid APG methodology,0.01,724.25,
INFLUENZA QUAD PF (6M+) 0.5ML   ,90688,CPT,,40587636,CDM,636,RC,49281-0423-50,NDC,both,0.5,ML,66.5,206,,,206,Other,150% of Medicare + 9.63% HCRA Surcharge,125.27,,,125.27,Fee Schedule,Average Sale Price (ASP) x 6,19.95,30,,19.95,percent of total billed charges,Drugs,19.95,30,,19.95,percent of total billed charges,Drugs,19.95,30,,19.95,percent of total billed charges,Drugs,19.95,30,,19.95,percent of total billed charges,Drugs,19.95,30,,19.95,percent of total billed charges,Drugs,33.25,50,,33.25,percent of total billed charges,All Other,19.95,30,,19.95,percent of total billed charges,Drugs,19.95,30,,19.95,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,19.95,30,,19.95,percent of total billed charges,Drugs,19.95,30,,19.95,percent of total billed charges,Drugs,19.95,30,,19.95,percent of total billed charges,Drugs,19.95,30,,19.95,percent of total billed charges,Drugs,19.95,30,,19.95,percent of total billed charges,Drugs,19.95,30,,19.95,percent of total billed charges,Drugs,19.95,30,,19.95,percent of total billed charges,Drugs,19.95,30,,19.95,percent of total billed charges,Drugs,19.95,30,,19.95,percent of total billed charges,Drugs,19.95,30,,19.95,percent of total billed charges,Drugs,19.95,30,,19.95,percent of total billed charges,Drugs,19.95,30,,19.95,percent of total billed charges,Drugs,19.95,30,,19.95,percent of total billed charges,Drugs,19,,,19,Other,Drug Cost,19,,,19,Other,Drug Cost,19,,,19,Other,Drug Cost,19,,,19,Other,Drug Cost,19,,,19,Other,Drug Cost,22.61,34,,22.61,percent of total billed charges,Drugs,19,,,19,Other,Drug Cost,42.75,,,42.75,Other,225% Medicaid APG methodology,26.6,,,26.6,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,200.43,,,200.43,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",19,,,19,Other,Drug Cost,19,,,19,Other,Drug Cost,23.75,,,23.75,Other,125% Medicaid APG methodology,0.01,206,
INFLUENZA VACC MDCK QUAD SUS    ,90682,CPT,,40587644,CDM,636,RC,49281-0723-10,NDC,both,0.5,ML,204.23,724.25,,,724.25,Other,150% of Medicare + 9.63% HCRA Surcharge,440.42,,,440.42,Fee Schedule,Average Sale Price (ASP) x 6,61.27,30,,61.27,percent of total billed charges,Drugs,61.27,30,,61.27,percent of total billed charges,Drugs,61.27,30,,61.27,percent of total billed charges,Drugs,61.27,30,,61.27,percent of total billed charges,Drugs,61.27,30,,61.27,percent of total billed charges,Drugs,102.12,50,,102.12,percent of total billed charges,All Other,61.27,30,,61.27,percent of total billed charges,Drugs,61.27,30,,61.27,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,61.27,30,,61.27,percent of total billed charges,Drugs,61.27,30,,61.27,percent of total billed charges,Drugs,61.27,30,,61.27,percent of total billed charges,Drugs,61.27,30,,61.27,percent of total billed charges,Drugs,61.27,30,,61.27,percent of total billed charges,Drugs,61.27,30,,61.27,percent of total billed charges,Drugs,61.27,30,,61.27,percent of total billed charges,Drugs,61.27,30,,61.27,percent of total billed charges,Drugs,61.27,30,,61.27,percent of total billed charges,Drugs,61.27,30,,61.27,percent of total billed charges,Drugs,61.27,30,,61.27,percent of total billed charges,Drugs,61.27,30,,61.27,percent of total billed charges,Drugs,61.27,30,,61.27,percent of total billed charges,Drugs,58.35,,,58.35,Other,Drug Cost,58.35,,,58.35,Other,Drug Cost,58.35,,,58.35,Other,Drug Cost,58.35,,,58.35,Other,Drug Cost,58.35,,,58.35,Other,Drug Cost,69.44,34,,69.44,percent of total billed charges,Drugs,58.35,,,58.35,Other,Drug Cost,131.29,,,131.29,Other,225% Medicaid APG methodology,81.69,,,81.69,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,704.67,,,704.67,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",58.35,,,58.35,Other,Drug Cost,58.35,,,58.35,Other,Drug Cost,72.94,,,72.94,Other,125% Medicaid APG methodology,0.01,724.25,
ALBUMIN HUMAN 25% IV SLN 100ML  ,P9047,HCPCS,,40587768,CDM,636,RC,68516-5216-02,NDC,both,100,ML,273,523.69,,,523.69,Other,150% of Medicare + 9.63% HCRA Surcharge,318.46,,,318.46,Fee Schedule,Average Sale Price (ASP) x 6,81.9,30,,81.9,percent of total billed charges,Drugs,81.9,30,,81.9,percent of total billed charges,Drugs,81.9,30,,81.9,percent of total billed charges,Drugs,81.9,30,,81.9,percent of total billed charges,Drugs,81.9,30,,81.9,percent of total billed charges,Drugs,136.5,50,,136.5,percent of total billed charges,All Other,81.9,30,,81.9,percent of total billed charges,Drugs,81.9,30,,81.9,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,81.9,30,,81.9,percent of total billed charges,Drugs,81.9,30,,81.9,percent of total billed charges,Drugs,81.9,30,,81.9,percent of total billed charges,Drugs,81.9,30,,81.9,percent of total billed charges,Drugs,81.9,30,,81.9,percent of total billed charges,Drugs,81.9,30,,81.9,percent of total billed charges,Drugs,81.9,30,,81.9,percent of total billed charges,Drugs,81.9,30,,81.9,percent of total billed charges,Drugs,81.9,30,,81.9,percent of total billed charges,Drugs,81.9,30,,81.9,percent of total billed charges,Drugs,81.9,30,,81.9,percent of total billed charges,Drugs,81.9,30,,81.9,percent of total billed charges,Drugs,81.9,30,,81.9,percent of total billed charges,Drugs,49.08,,,49.08,Other,Drug Cost,49.08,,,49.08,Other,Drug Cost,49.08,,,49.08,Other,Drug Cost,49.08,,,49.08,Other,Drug Cost,49.08,,,49.08,Other,Drug Cost,92.82,34,,92.82,percent of total billed charges,Drugs,49.08,,,49.08,Other,Drug Cost,110.43,,,110.43,Other,225% Medicaid APG methodology,68.71,,,68.71,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,509.54,,,509.54,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",49.08,,,49.08,Other,Drug Cost,49.08,,,49.08,Other,Drug Cost,61.35,,,61.35,Other,125% Medicaid APG methodology,0.01,523.69,
CEFAZOLIN 20 G INJ              ,J0690,HCPCS,,40588048,CDM,636,RC,63323-0449-61,NDC,both,1,EA,110.36,7.53,,,7.53,Other,150% of Medicare + 9.63% HCRA Surcharge,4.58,,,4.58,Fee Schedule,Average Sale Price (ASP) x 6,33.11,30,,33.11,percent of total billed charges,Drugs,33.11,30,,33.11,percent of total billed charges,Drugs,33.11,30,,33.11,percent of total billed charges,Drugs,33.11,30,,33.11,percent of total billed charges,Drugs,33.11,30,,33.11,percent of total billed charges,Drugs,55.18,50,,55.18,percent of total billed charges,All Other,33.11,30,,33.11,percent of total billed charges,Drugs,33.11,30,,33.11,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,33.11,30,,33.11,percent of total billed charges,Drugs,33.11,30,,33.11,percent of total billed charges,Drugs,33.11,30,,33.11,percent of total billed charges,Drugs,33.11,30,,33.11,percent of total billed charges,Drugs,33.11,30,,33.11,percent of total billed charges,Drugs,33.11,30,,33.11,percent of total billed charges,Drugs,33.11,30,,33.11,percent of total billed charges,Drugs,33.11,30,,33.11,percent of total billed charges,Drugs,33.11,30,,33.11,percent of total billed charges,Drugs,33.11,30,,33.11,percent of total billed charges,Drugs,33.11,30,,33.11,percent of total billed charges,Drugs,33.11,30,,33.11,percent of total billed charges,Drugs,33.11,30,,33.11,percent of total billed charges,Drugs,31.53,,,31.53,Other,Drug Cost,31.53,,,31.53,Other,Drug Cost,31.53,,,31.53,Other,Drug Cost,31.53,,,31.53,Other,Drug Cost,31.53,,,31.53,Other,Drug Cost,37.52,34,,37.52,percent of total billed charges,Drugs,31.53,,,31.53,Other,Drug Cost,70.94,,,70.94,Other,225% Medicaid APG methodology,44.14,,,44.14,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.32,,,7.32,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",31.53,,,31.53,Other,Drug Cost,31.53,,,31.53,Other,Drug Cost,39.41,,,39.41,Other,125% Medicaid APG methodology,0.01,70.94,
CEFTRIAXONE 500 MG INJ          ,J0696,HCPCS,,40588055,CDM,636,RC,00409-7338-01,NDC,both,1,EA,2.24,4.84,,,4.84,Other,150% of Medicare + 9.63% HCRA Surcharge,2.95,,,2.95,Fee Schedule,Average Sale Price (ASP) x 6,0.67,30,,0.67,percent of total billed charges,Drugs,0.67,30,,0.67,percent of total billed charges,Drugs,0.67,30,,0.67,percent of total billed charges,Drugs,0.67,30,,0.67,percent of total billed charges,Drugs,0.67,30,,0.67,percent of total billed charges,Drugs,1.12,50,,1.12,percent of total billed charges,All Other,0.67,30,,0.67,percent of total billed charges,Drugs,0.67,30,,0.67,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.67,30,,0.67,percent of total billed charges,Drugs,0.67,30,,0.67,percent of total billed charges,Drugs,0.67,30,,0.67,percent of total billed charges,Drugs,0.67,30,,0.67,percent of total billed charges,Drugs,0.67,30,,0.67,percent of total billed charges,Drugs,0.67,30,,0.67,percent of total billed charges,Drugs,0.67,30,,0.67,percent of total billed charges,Drugs,0.67,30,,0.67,percent of total billed charges,Drugs,0.67,30,,0.67,percent of total billed charges,Drugs,0.67,30,,0.67,percent of total billed charges,Drugs,0.67,30,,0.67,percent of total billed charges,Drugs,0.67,30,,0.67,percent of total billed charges,Drugs,0.67,30,,0.67,percent of total billed charges,Drugs,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.76,34,,0.76,percent of total billed charges,Drugs,0.62,,,0.62,Other,Drug Cost,1.4,,,1.4,Other,225% Medicaid APG methodology,0.87,,,0.87,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,4.71,,,4.71,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.62,,,0.62,Other,Drug Cost,0.62,,,0.62,Other,Drug Cost,0.78,,,0.78,Other,125% Medicaid APG methodology,0.01,4.84,
DEXAMETHASONE 1.5 MG TAB        ,J8540,HCPCS,,40588352,CDM,636,RC,00054-8181-25,NDC,both,1,EA,1.44,0.82,,,0.82,Other,150% of Medicare + 9.63% HCRA Surcharge,0.5,,,0.5,Fee Schedule,Average Sale Price (ASP) x 6,0.43,30,,0.43,percent of total billed charges,Drugs,0.43,30,,0.43,percent of total billed charges,Drugs,0.43,30,,0.43,percent of total billed charges,Drugs,0.43,30,,0.43,percent of total billed charges,Drugs,0.43,30,,0.43,percent of total billed charges,Drugs,0.72,50,,0.72,percent of total billed charges,All Other,0.43,30,,0.43,percent of total billed charges,Drugs,0.43,30,,0.43,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.43,30,,0.43,percent of total billed charges,Drugs,0.43,30,,0.43,percent of total billed charges,Drugs,0.43,30,,0.43,percent of total billed charges,Drugs,0.43,30,,0.43,percent of total billed charges,Drugs,0.43,30,,0.43,percent of total billed charges,Drugs,0.43,30,,0.43,percent of total billed charges,Drugs,0.43,30,,0.43,percent of total billed charges,Drugs,0.43,30,,0.43,percent of total billed charges,Drugs,0.43,30,,0.43,percent of total billed charges,Drugs,0.43,30,,0.43,percent of total billed charges,Drugs,0.43,30,,0.43,percent of total billed charges,Drugs,0.43,30,,0.43,percent of total billed charges,Drugs,0.43,30,,0.43,percent of total billed charges,Drugs,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.49,34,,0.49,percent of total billed charges,Drugs,0.08,,,0.08,Other,Drug Cost,0.18,,,0.18,Other,225% Medicaid APG methodology,0.11,,,0.11,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.8,,,0.8,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.08,,,0.08,Other,Drug Cost,0.08,,,0.08,Other,Drug Cost,0.1,,,0.1,Other,125% Medicaid APG methodology,0.01,0.82,
D5W LACTATED RINGERS IV 500ML   ,J7121,HCPCS,,40588436,CDM,636,RC,00338-0125-03,NDC,both,500,ML,17.5,6.91,39.4668,,6.91,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,5.25,30,,5.25,percent of total billed charges,Drugs,5.25,30,,5.25,percent of total billed charges,Drugs,5.25,30,,5.25,percent of total billed charges,Drugs,5.25,30,,5.25,percent of total billed charges,Drugs,5.25,30,,5.25,percent of total billed charges,Drugs,8.75,50,,8.75,percent of total billed charges,All Other,5.25,30,,5.25,percent of total billed charges,Drugs,5.25,30,,5.25,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,5.25,30,,5.25,percent of total billed charges,Drugs,5.25,30,,5.25,percent of total billed charges,Drugs,5.25,30,,5.25,percent of total billed charges,Drugs,5.25,30,,5.25,percent of total billed charges,Drugs,5.25,30,,5.25,percent of total billed charges,Drugs,5.25,30,,5.25,percent of total billed charges,Drugs,5.25,30,,5.25,percent of total billed charges,Drugs,5.25,30,,5.25,percent of total billed charges,Drugs,5.25,30,,5.25,percent of total billed charges,Drugs,5.25,30,,5.25,percent of total billed charges,Drugs,5.25,30,,5.25,percent of total billed charges,Drugs,5.25,30,,5.25,percent of total billed charges,Drugs,5.25,30,,5.25,percent of total billed charges,Drugs,5,,,5,Other,Drug Cost,5,,,5,Other,Drug Cost,5,,,5,Other,Drug Cost,5,,,5,Other,Drug Cost,5,,,5,Other,Drug Cost,5.95,34,,5.95,percent of total billed charges,Drugs,5,,,5,Other,Drug Cost,11.25,,,11.25,Other,225% Medicaid APG methodology,7,,,7,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5,,,5,Other,Drug Cost,5,,,5,Other,Drug Cost,6.25,,,6.25,Other,125% Medicaid APG methodology,0.01,11.25,
DOCETAXEL 10MG/ML IV SOLN 16ML  ,J9171,HCPCS,,40588535,CDM,636,RC,67457-0533-16,NDC,both,16,ML,70.07,9.82,,,9.82,Other,150% of Medicare + 9.63% HCRA Surcharge,5.97,,,5.97,Fee Schedule,Average Sale Price (ASP) x 6,21.02,30,,21.02,percent of total billed charges,Drugs,21.02,30,,21.02,percent of total billed charges,Drugs,21.02,30,,21.02,percent of total billed charges,Drugs,21.02,30,,21.02,percent of total billed charges,Drugs,21.02,30,,21.02,percent of total billed charges,Drugs,35.04,50,,35.04,percent of total billed charges,All Other,21.02,30,,21.02,percent of total billed charges,Drugs,21.02,30,,21.02,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,21.02,30,,21.02,percent of total billed charges,Drugs,21.02,30,,21.02,percent of total billed charges,Drugs,21.02,30,,21.02,percent of total billed charges,Drugs,21.02,30,,21.02,percent of total billed charges,Drugs,21.02,30,,21.02,percent of total billed charges,Drugs,21.02,30,,21.02,percent of total billed charges,Drugs,21.02,30,,21.02,percent of total billed charges,Drugs,21.02,30,,21.02,percent of total billed charges,Drugs,21.02,30,,21.02,percent of total billed charges,Drugs,21.02,30,,21.02,percent of total billed charges,Drugs,21.02,30,,21.02,percent of total billed charges,Drugs,21.02,30,,21.02,percent of total billed charges,Drugs,21.02,30,,21.02,percent of total billed charges,Drugs,20.02,,,20.02,Other,Drug Cost,20.02,,,20.02,Other,Drug Cost,20.02,,,20.02,Other,Drug Cost,20.02,,,20.02,Other,Drug Cost,20.02,,,20.02,Other,Drug Cost,23.82,34,,23.82,percent of total billed charges,Drugs,20.02,,,20.02,Other,Drug Cost,45.05,,,45.05,Other,225% Medicaid APG methodology,28.03,,,28.03,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,9.55,,,9.55,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",20.02,,,20.02,Other,Drug Cost,20.02,,,20.02,Other,Drug Cost,25.03,,,25.03,Other,125% Medicaid APG methodology,0.01,45.05,
FLUOROURACIL 50MG/ML SLN 20ML   ,J9190,HCPCS,,40588709,CDM,636,RC,63323-0117-20,NDC,both,20,ML,15.51,31.72,,,31.72,Other,150% of Medicare + 9.63% HCRA Surcharge,19.29,,,19.29,Fee Schedule,Average Sale Price (ASP) x 6,4.65,30,,4.65,percent of total billed charges,Drugs,4.65,30,,4.65,percent of total billed charges,Drugs,4.65,30,,4.65,percent of total billed charges,Drugs,4.65,30,,4.65,percent of total billed charges,Drugs,4.65,30,,4.65,percent of total billed charges,Drugs,7.76,50,,7.76,percent of total billed charges,All Other,4.65,30,,4.65,percent of total billed charges,Drugs,4.65,30,,4.65,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.65,30,,4.65,percent of total billed charges,Drugs,4.65,30,,4.65,percent of total billed charges,Drugs,4.65,30,,4.65,percent of total billed charges,Drugs,4.65,30,,4.65,percent of total billed charges,Drugs,4.65,30,,4.65,percent of total billed charges,Drugs,4.65,30,,4.65,percent of total billed charges,Drugs,4.65,30,,4.65,percent of total billed charges,Drugs,4.65,30,,4.65,percent of total billed charges,Drugs,4.65,30,,4.65,percent of total billed charges,Drugs,4.65,30,,4.65,percent of total billed charges,Drugs,4.65,30,,4.65,percent of total billed charges,Drugs,4.65,30,,4.65,percent of total billed charges,Drugs,4.65,30,,4.65,percent of total billed charges,Drugs,2.46,,,2.46,Other,Drug Cost,2.46,,,2.46,Other,Drug Cost,2.46,,,2.46,Other,Drug Cost,2.46,,,2.46,Other,Drug Cost,2.46,,,2.46,Other,Drug Cost,5.27,34,,5.27,percent of total billed charges,Drugs,2.46,,,2.46,Other,Drug Cost,5.54,,,5.54,Other,225% Medicaid APG methodology,3.44,,,3.44,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,30.86,,,30.86,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.46,,,2.46,Other,Drug Cost,2.46,,,2.46,Other,Drug Cost,3.08,,,3.08,Other,125% Medicaid APG methodology,0.01,31.72,
FLUOROURACIL 50MG/ML SLN 50ML   ,J9190,HCPCS,,40588717,CDM,636,RC,25021-0215-98,NDC,both,50,ML,27.34,31.72,,,31.72,Other,150% of Medicare + 9.63% HCRA Surcharge,19.29,,,19.29,Fee Schedule,Average Sale Price (ASP) x 6,8.2,30,,8.2,percent of total billed charges,Drugs,8.2,30,,8.2,percent of total billed charges,Drugs,8.2,30,,8.2,percent of total billed charges,Drugs,8.2,30,,8.2,percent of total billed charges,Drugs,8.2,30,,8.2,percent of total billed charges,Drugs,13.67,50,,13.67,percent of total billed charges,All Other,8.2,30,,8.2,percent of total billed charges,Drugs,8.2,30,,8.2,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,8.2,30,,8.2,percent of total billed charges,Drugs,8.2,30,,8.2,percent of total billed charges,Drugs,8.2,30,,8.2,percent of total billed charges,Drugs,8.2,30,,8.2,percent of total billed charges,Drugs,8.2,30,,8.2,percent of total billed charges,Drugs,8.2,30,,8.2,percent of total billed charges,Drugs,8.2,30,,8.2,percent of total billed charges,Drugs,8.2,30,,8.2,percent of total billed charges,Drugs,8.2,30,,8.2,percent of total billed charges,Drugs,8.2,30,,8.2,percent of total billed charges,Drugs,8.2,30,,8.2,percent of total billed charges,Drugs,8.2,30,,8.2,percent of total billed charges,Drugs,8.2,30,,8.2,percent of total billed charges,Drugs,5.96,,,5.96,Other,Drug Cost,5.96,,,5.96,Other,Drug Cost,5.96,,,5.96,Other,Drug Cost,5.96,,,5.96,Other,Drug Cost,5.96,,,5.96,Other,Drug Cost,9.3,34,,9.3,percent of total billed charges,Drugs,5.96,,,5.96,Other,Drug Cost,13.41,,,13.41,Other,225% Medicaid APG methodology,8.34,,,8.34,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,30.86,,,30.86,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.96,,,5.96,Other,Drug Cost,5.96,,,5.96,Other,Drug Cost,7.45,,,7.45,Other,125% Medicaid APG methodology,0.01,31.72,
HEPARIN 1000 UNITS/ML INJ  1ML  ,J1644,HCPCS,,40588774,CDM,636,RC,63323-0540-01,NDC,both,1,ML,5.18,2.64,,,2.64,Other,150% of Medicare + 9.63% HCRA Surcharge,1.61,,,1.61,Fee Schedule,Average Sale Price (ASP) x 6,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,2.59,50,,2.59,percent of total billed charges,All Other,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,1.55,30,,1.55,percent of total billed charges,Drugs,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,1.76,34,,1.76,percent of total billed charges,Drugs,0.07,,,0.07,Other,Drug Cost,0.16,,,0.16,Other,225% Medicaid APG methodology,0.1,,,0.1,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2.57,,,2.57,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.07,,,0.07,Other,Drug Cost,0.07,,,0.07,Other,Drug Cost,0.09,,,0.09,Other,125% Medicaid APG methodology,0.01,2.64,
INFLIXIMAB-ABDA 100MG IV INJ    ,Q5104,HCPCS,,40589004,CDM,636,RC,78206-0162-01,NDC,both,1,EA,1969.24,310.79,,,310.79,Other,150% of Medicare + 9.63% HCRA Surcharge,188.99,,,188.99,Fee Schedule,Average Sale Price (ASP) x 6,590.77,30,,590.77,percent of total billed charges,Drugs,590.77,30,,590.77,percent of total billed charges,Drugs,590.77,30,,590.77,percent of total billed charges,Drugs,590.77,30,,590.77,percent of total billed charges,Drugs,590.77,30,,590.77,percent of total billed charges,Drugs,984.62,50,,984.62,percent of total billed charges,All Other,590.77,30,,590.77,percent of total billed charges,Drugs,590.77,30,,590.77,percent of total billed charges,Drugs,669.54,34,"If Charge > 500, then 34 percent",669.54,percent of total billed charges,Drugs,590.77,30,,590.77,percent of total billed charges,Drugs,590.77,30,,590.77,percent of total billed charges,Drugs,590.77,30,,590.77,percent of total billed charges,Drugs,590.77,30,,590.77,percent of total billed charges,Drugs,590.77,30,,590.77,percent of total billed charges,Drugs,590.77,30,,590.77,percent of total billed charges,Drugs,590.77,30,,590.77,percent of total billed charges,Drugs,590.77,30,,590.77,percent of total billed charges,Drugs,590.77,30,,590.77,percent of total billed charges,Drugs,590.77,30,,590.77,percent of total billed charges,Drugs,590.77,30,,590.77,percent of total billed charges,Drugs,590.77,30,,590.77,percent of total billed charges,Drugs,590.77,30,,590.77,percent of total billed charges,Drugs,211.02,,,211.02,Other,Drug Cost,211.02,,,211.02,Other,Drug Cost,211.02,,,211.02,Other,Drug Cost,211.02,,,211.02,Other,Drug Cost,211.02,,,211.02,Other,Drug Cost,669.54,34,,669.54,percent of total billed charges,Drugs,211.02,,,211.02,Other,Drug Cost,474.8,,,474.8,Other,225% Medicaid APG methodology,295.43,,,295.43,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,302.39,,,302.39,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",211.02,,,211.02,Other,Drug Cost,211.02,,,211.02,Other,Drug Cost,263.78,,,263.78,Other,125% Medicaid APG methodology,0.01,984.62,
INSULIN NPH 100UNITS/ML 10ML    ,J1815,HCPCS,,40589012,CDM,636,RC,00002-8315-01,NDC,both,0.01,ML,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.02,50,,0.02,percent of total billed charges,All Other,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,34,,0.01,percent of total billed charges,Drugs,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.09,
INSULIN N-INSULIN R 70-30 10ML  ,J1815,HCPCS,,40589020,CDM,636,RC,00002-8715-01,NDC,both,0.01,ML,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.02,50,,0.02,percent of total billed charges,All Other,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.01,34,,0.01,percent of total billed charges,Drugs,0.11,,,0.11,Other,Drug Cost,0.25,,,0.25,Other,225% Medicaid APG methodology,0.15,,,0.15,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.11,,,0.11,Other,Drug Cost,0.11,,,0.11,Other,Drug Cost,0.14,,,0.14,Other,125% Medicaid APG methodology,0.01,0.25,
INSULIN REG 100 UN/ML INJ 10ML  ,J1815,HCPCS,,40589038,CDM,636,RC,00002-8215-01b,NDC,both,0.01,ML,0.04,0.02,39.4668,,0.02,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.02,50,,0.02,percent of total billed charges,All Other,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.01,30,,0.01,percent of total billed charges,Drugs,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.01,34,,0.01,percent of total billed charges,Drugs,0.04,,,0.04,Other,Drug Cost,0.09,,,0.09,Other,225% Medicaid APG methodology,0.06,,,0.06,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.04,,,0.04,Other,Drug Cost,0.04,,,0.04,Other,Drug Cost,0.05,,,0.05,Other,125% Medicaid APG methodology,0.01,0.09,
KETORA-PHENYLEPH0.3%-1% OPT4ML  ,J1097,HCPCS,,40589129,CDM,636,RC,82604-0600-04,NDC,both,4,ML,1646.12,649.67,39.4668,,649.67,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,493.84,30,,493.84,percent of total billed charges,Drugs,493.84,30,,493.84,percent of total billed charges,Drugs,493.84,30,,493.84,percent of total billed charges,Drugs,493.84,30,,493.84,percent of total billed charges,Drugs,493.84,30,,493.84,percent of total billed charges,Drugs,823.06,50,,823.06,percent of total billed charges,All Other,493.84,30,,493.84,percent of total billed charges,Drugs,493.84,30,,493.84,percent of total billed charges,Drugs,559.68,34,"If Charge > 500, then 34 percent",559.68,percent of total billed charges,Drugs,493.84,30,,493.84,percent of total billed charges,Drugs,493.84,30,,493.84,percent of total billed charges,Drugs,493.84,30,,493.84,percent of total billed charges,Drugs,493.84,30,,493.84,percent of total billed charges,Drugs,493.84,30,,493.84,percent of total billed charges,Drugs,493.84,30,,493.84,percent of total billed charges,Drugs,493.84,30,,493.84,percent of total billed charges,Drugs,493.84,30,,493.84,percent of total billed charges,Drugs,493.84,30,,493.84,percent of total billed charges,Drugs,493.84,30,,493.84,percent of total billed charges,Drugs,493.84,30,,493.84,percent of total billed charges,Drugs,493.84,30,,493.84,percent of total billed charges,Drugs,493.84,30,,493.84,percent of total billed charges,Drugs,282.08,,,282.08,Other,Drug Cost,282.08,,,282.08,Other,Drug Cost,282.08,,,282.08,Other,Drug Cost,282.08,,,282.08,Other,Drug Cost,282.08,,,282.08,Other,Drug Cost,559.68,34,,559.68,percent of total billed charges,Drugs,282.08,,,282.08,Other,Drug Cost,634.68,,,634.68,Other,225% Medicaid APG methodology,394.91,,,394.91,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",282.08,,,282.08,Other,Drug Cost,282.08,,,282.08,Other,Drug Cost,352.6,,,352.6,Other,125% Medicaid APG methodology,0.01,823.06,
LACTATED RINGERS IV SOLN 500ML  ,J7120,HCPCS,,40589160,CDM,636,RC,00338-0117-03,NDC,both,500,ML,7.49,25.56,,,25.56,Other,150% of Medicare + 9.63% HCRA Surcharge,15.55,,,15.55,Fee Schedule,Average Sale Price (ASP) x 6,2.25,30,,2.25,percent of total billed charges,Drugs,2.25,30,,2.25,percent of total billed charges,Drugs,2.25,30,,2.25,percent of total billed charges,Drugs,2.25,30,,2.25,percent of total billed charges,Drugs,2.25,30,,2.25,percent of total billed charges,Drugs,3.75,50,,3.75,percent of total billed charges,All Other,2.25,30,,2.25,percent of total billed charges,Drugs,2.25,30,,2.25,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.25,30,,2.25,percent of total billed charges,Drugs,2.25,30,,2.25,percent of total billed charges,Drugs,2.25,30,,2.25,percent of total billed charges,Drugs,2.25,30,,2.25,percent of total billed charges,Drugs,2.25,30,,2.25,percent of total billed charges,Drugs,2.25,30,,2.25,percent of total billed charges,Drugs,2.25,30,,2.25,percent of total billed charges,Drugs,2.25,30,,2.25,percent of total billed charges,Drugs,2.25,30,,2.25,percent of total billed charges,Drugs,2.25,30,,2.25,percent of total billed charges,Drugs,2.25,30,,2.25,percent of total billed charges,Drugs,2.25,30,,2.25,percent of total billed charges,Drugs,2.25,30,,2.25,percent of total billed charges,Drugs,3.6,,,3.6,Other,Drug Cost,3.6,,,3.6,Other,Drug Cost,3.6,,,3.6,Other,Drug Cost,3.6,,,3.6,Other,Drug Cost,3.6,,,3.6,Other,Drug Cost,2.55,34,,2.55,percent of total billed charges,Drugs,3.6,,,3.6,Other,Drug Cost,8.1,,,8.1,Other,225% Medicaid APG methodology,5.04,,,5.04,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,24.87,,,24.87,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.6,,,3.6,Other,Drug Cost,3.6,,,3.6,Other,Drug Cost,4.5,,,4.5,Other,125% Medicaid APG methodology,0.01,25.56,
LIDOCAINE 1% PFABBOJECT INJ5ML  ,J2001,HCPCS,,40589228,CDM,636,RC,00409-9137-05,NDC,both,5,ML,20.2,0.27,,,0.27,Other,150% of Medicare + 9.63% HCRA Surcharge,0.16,,,0.16,Fee Schedule,Average Sale Price (ASP) x 6,6.06,30,,6.06,percent of total billed charges,Drugs,6.06,30,,6.06,percent of total billed charges,Drugs,6.06,30,,6.06,percent of total billed charges,Drugs,6.06,30,,6.06,percent of total billed charges,Drugs,6.06,30,,6.06,percent of total billed charges,Drugs,10.1,50,,10.1,percent of total billed charges,All Other,6.06,30,,6.06,percent of total billed charges,Drugs,6.06,30,,6.06,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,6.06,30,,6.06,percent of total billed charges,Drugs,6.06,30,,6.06,percent of total billed charges,Drugs,6.06,30,,6.06,percent of total billed charges,Drugs,6.06,30,,6.06,percent of total billed charges,Drugs,6.06,30,,6.06,percent of total billed charges,Drugs,6.06,30,,6.06,percent of total billed charges,Drugs,6.06,30,,6.06,percent of total billed charges,Drugs,6.06,30,,6.06,percent of total billed charges,Drugs,6.06,30,,6.06,percent of total billed charges,Drugs,6.06,30,,6.06,percent of total billed charges,Drugs,6.06,30,,6.06,percent of total billed charges,Drugs,6.06,30,,6.06,percent of total billed charges,Drugs,6.06,30,,6.06,percent of total billed charges,Drugs,3.95,,,3.95,Other,Drug Cost,3.95,,,3.95,Other,Drug Cost,3.95,,,3.95,Other,Drug Cost,3.95,,,3.95,Other,Drug Cost,3.95,,,3.95,Other,Drug Cost,6.87,34,,6.87,percent of total billed charges,Drugs,3.95,,,3.95,Other,Drug Cost,8.89,,,8.89,Other,225% Medicaid APG methodology,5.53,,,5.53,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.26,,,0.26,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.95,,,3.95,Other,Drug Cost,3.95,,,3.95,Other,Drug Cost,4.94,,,4.94,Other,125% Medicaid APG methodology,0.01,10.1,
LIDOCAINE 2% PF INJ SOLN 10 ML  ,J2001,HCPCS,,40589251,CDM,636,RC,00409-4282-02,NDC,both,10,ML,6.76,0.27,,,0.27,Other,150% of Medicare + 9.63% HCRA Surcharge,0.16,,,0.16,Fee Schedule,Average Sale Price (ASP) x 6,2.03,30,,2.03,percent of total billed charges,Drugs,2.03,30,,2.03,percent of total billed charges,Drugs,2.03,30,,2.03,percent of total billed charges,Drugs,2.03,30,,2.03,percent of total billed charges,Drugs,2.03,30,,2.03,percent of total billed charges,Drugs,3.38,50,,3.38,percent of total billed charges,All Other,2.03,30,,2.03,percent of total billed charges,Drugs,2.03,30,,2.03,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.03,30,,2.03,percent of total billed charges,Drugs,2.03,30,,2.03,percent of total billed charges,Drugs,2.03,30,,2.03,percent of total billed charges,Drugs,2.03,30,,2.03,percent of total billed charges,Drugs,2.03,30,,2.03,percent of total billed charges,Drugs,2.03,30,,2.03,percent of total billed charges,Drugs,2.03,30,,2.03,percent of total billed charges,Drugs,2.03,30,,2.03,percent of total billed charges,Drugs,2.03,30,,2.03,percent of total billed charges,Drugs,2.03,30,,2.03,percent of total billed charges,Drugs,2.03,30,,2.03,percent of total billed charges,Drugs,2.03,30,,2.03,percent of total billed charges,Drugs,2.03,30,,2.03,percent of total billed charges,Drugs,2.1,,,2.1,Other,Drug Cost,2.1,,,2.1,Other,Drug Cost,2.1,,,2.1,Other,Drug Cost,2.1,,,2.1,Other,Drug Cost,2.1,,,2.1,Other,Drug Cost,2.3,34,,2.3,percent of total billed charges,Drugs,2.1,,,2.1,Other,Drug Cost,4.73,,,4.73,Other,225% Medicaid APG methodology,2.94,,,2.94,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.26,,,0.26,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.1,,,2.1,Other,Drug Cost,2.1,,,2.1,Other,Drug Cost,2.63,,,2.63,Other,125% Medicaid APG methodology,0.01,4.73,
MAG SULF 4 G IN IV SLN 100ML    ,J3475,HCPCS,,40589376,CDM,636,RC,63323-0106-01,NDC,both,100,ML,7.63,6.82,,,6.82,Other,150% of Medicare + 9.63% HCRA Surcharge,4.15,,,4.15,Fee Schedule,Average Sale Price (ASP) x 6,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,3.82,50,,3.82,percent of total billed charges,All Other,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.29,30,,2.29,percent of total billed charges,Drugs,2.62,,,2.62,Other,Drug Cost,2.62,,,2.62,Other,Drug Cost,2.62,,,2.62,Other,Drug Cost,2.62,,,2.62,Other,Drug Cost,2.62,,,2.62,Other,Drug Cost,2.59,34,,2.59,percent of total billed charges,Drugs,2.62,,,2.62,Other,Drug Cost,5.9,,,5.9,Other,225% Medicaid APG methodology,3.67,,,3.67,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.63,,,6.63,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.62,,,2.62,Other,Drug Cost,2.62,,,2.62,Other,Drug Cost,3.28,,,3.28,Other,125% Medicaid APG methodology,0.01,6.82,
MAG SULF 50% PF INJ SLN 10ML    ,J3475,HCPCS,,40589392,CDM,636,RC,63323-0064-11,NDC,both,10,ML,4.76,6.82,,,6.82,Other,150% of Medicare + 9.63% HCRA Surcharge,4.15,,,4.15,Fee Schedule,Average Sale Price (ASP) x 6,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,2.38,50,,2.38,percent of total billed charges,All Other,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,1.43,30,,1.43,percent of total billed charges,Drugs,1.09,,,1.09,Other,Drug Cost,1.09,,,1.09,Other,Drug Cost,1.09,,,1.09,Other,Drug Cost,1.09,,,1.09,Other,Drug Cost,1.09,,,1.09,Other,Drug Cost,1.62,34,,1.62,percent of total billed charges,Drugs,1.09,,,1.09,Other,Drug Cost,2.45,,,2.45,Other,225% Medicaid APG methodology,1.53,,,1.53,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,6.63,,,6.63,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.09,,,1.09,Other,Drug Cost,1.09,,,1.09,Other,Drug Cost,1.36,,,1.36,Other,125% Medicaid APG methodology,0.01,6.82,
MEPIVACAINE 1.5% PF INJ  30ML   ,J0670,HCPCS,,40589483,CDM,636,RC,63323-0293-37,NDC,both,30,ML,26.74,32.46,,,32.46,Other,150% of Medicare + 9.63% HCRA Surcharge,19.74,,,19.74,Fee Schedule,Average Sale Price (ASP) x 6,8.02,30,,8.02,percent of total billed charges,Drugs,8.02,30,,8.02,percent of total billed charges,Drugs,8.02,30,,8.02,percent of total billed charges,Drugs,8.02,30,,8.02,percent of total billed charges,Drugs,8.02,30,,8.02,percent of total billed charges,Drugs,13.37,50,,13.37,percent of total billed charges,All Other,8.02,30,,8.02,percent of total billed charges,Drugs,8.02,30,,8.02,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,8.02,30,,8.02,percent of total billed charges,Drugs,8.02,30,,8.02,percent of total billed charges,Drugs,8.02,30,,8.02,percent of total billed charges,Drugs,8.02,30,,8.02,percent of total billed charges,Drugs,8.02,30,,8.02,percent of total billed charges,Drugs,8.02,30,,8.02,percent of total billed charges,Drugs,8.02,30,,8.02,percent of total billed charges,Drugs,8.02,30,,8.02,percent of total billed charges,Drugs,8.02,30,,8.02,percent of total billed charges,Drugs,8.02,30,,8.02,percent of total billed charges,Drugs,8.02,30,,8.02,percent of total billed charges,Drugs,8.02,30,,8.02,percent of total billed charges,Drugs,8.02,30,,8.02,percent of total billed charges,Drugs,5.48,,,5.48,Other,Drug Cost,5.48,,,5.48,Other,Drug Cost,5.48,,,5.48,Other,Drug Cost,5.48,,,5.48,Other,Drug Cost,5.48,,,5.48,Other,Drug Cost,9.09,34,,9.09,percent of total billed charges,Drugs,5.48,,,5.48,Other,Drug Cost,12.33,,,12.33,Other,225% Medicaid APG methodology,7.67,,,7.67,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,31.58,,,31.58,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",5.48,,,5.48,Other,Drug Cost,5.48,,,5.48,Other,Drug Cost,6.85,,,6.85,Other,125% Medicaid APG methodology,0.01,32.46,
MILRINONE 1MG/ML IV SOLN 20ML   ,J2260,HCPCS,,40589616,CDM,636,RC,63323-0617-20,NDC,both,20,ML,19.53,15.41,,,15.41,Other,150% of Medicare + 9.63% HCRA Surcharge,9.37,,,9.37,Fee Schedule,Average Sale Price (ASP) x 6,5.86,30,,5.86,percent of total billed charges,Drugs,5.86,30,,5.86,percent of total billed charges,Drugs,5.86,30,,5.86,percent of total billed charges,Drugs,5.86,30,,5.86,percent of total billed charges,Drugs,5.86,30,,5.86,percent of total billed charges,Drugs,9.77,50,,9.77,percent of total billed charges,All Other,5.86,30,,5.86,percent of total billed charges,Drugs,5.86,30,,5.86,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,5.86,30,,5.86,percent of total billed charges,Drugs,5.86,30,,5.86,percent of total billed charges,Drugs,5.86,30,,5.86,percent of total billed charges,Drugs,5.86,30,,5.86,percent of total billed charges,Drugs,5.86,30,,5.86,percent of total billed charges,Drugs,5.86,30,,5.86,percent of total billed charges,Drugs,5.86,30,,5.86,percent of total billed charges,Drugs,5.86,30,,5.86,percent of total billed charges,Drugs,5.86,30,,5.86,percent of total billed charges,Drugs,5.86,30,,5.86,percent of total billed charges,Drugs,5.86,30,,5.86,percent of total billed charges,Drugs,5.86,30,,5.86,percent of total billed charges,Drugs,5.86,30,,5.86,percent of total billed charges,Drugs,10.24,,,10.24,Other,Drug Cost,10.24,,,10.24,Other,Drug Cost,10.24,,,10.24,Other,Drug Cost,10.24,,,10.24,Other,Drug Cost,10.24,,,10.24,Other,Drug Cost,6.64,34,,6.64,percent of total billed charges,Drugs,10.24,,,10.24,Other,Drug Cost,23.04,,,23.04,Other,225% Medicaid APG methodology,14.34,,,14.34,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,15,,,15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",10.24,,,10.24,Other,Drug Cost,10.24,,,10.24,Other,Drug Cost,12.8,,,12.8,Other,125% Medicaid APG methodology,0.01,23.04,
MITOMYCIN 40 MG IV INJ          ,J9280,HCPCS,,40589624,CDM,636,RC,16729-0116-38,NDC,both,1,EA,4112.43,625.04,,,625.04,Other,150% of Medicare + 9.63% HCRA Surcharge,380.09,,,380.09,Fee Schedule,Average Sale Price (ASP) x 6,1233.73,30,,1233.73,percent of total billed charges,Drugs,1233.73,30,,1233.73,percent of total billed charges,Drugs,1233.73,30,,1233.73,percent of total billed charges,Drugs,1233.73,30,,1233.73,percent of total billed charges,Drugs,1233.73,30,,1233.73,percent of total billed charges,Drugs,2056.22,50,,2056.22,percent of total billed charges,All Other,1233.73,30,,1233.73,percent of total billed charges,Drugs,1233.73,30,,1233.73,percent of total billed charges,Drugs,1398.23,34,"If Charge > 500, then 34 percent",1398.23,percent of total billed charges,Drugs,1233.73,30,,1233.73,percent of total billed charges,Drugs,1233.73,30,,1233.73,percent of total billed charges,Drugs,1233.73,30,,1233.73,percent of total billed charges,Drugs,1233.73,30,,1233.73,percent of total billed charges,Drugs,1233.73,30,,1233.73,percent of total billed charges,Drugs,1233.73,30,,1233.73,percent of total billed charges,Drugs,1233.73,30,,1233.73,percent of total billed charges,Drugs,1233.73,30,,1233.73,percent of total billed charges,Drugs,1233.73,30,,1233.73,percent of total billed charges,Drugs,1233.73,30,,1233.73,percent of total billed charges,Drugs,1233.73,30,,1233.73,percent of total billed charges,Drugs,1233.73,30,,1233.73,percent of total billed charges,Drugs,1233.73,30,,1233.73,percent of total billed charges,Drugs,190.15,,,190.15,Other,Drug Cost,190.15,,,190.15,Other,Drug Cost,190.15,,,190.15,Other,Drug Cost,190.15,,,190.15,Other,Drug Cost,190.15,,,190.15,Other,Drug Cost,1398.23,34,,1398.23,percent of total billed charges,Drugs,190.15,,,190.15,Other,Drug Cost,427.84,,,427.84,Other,225% Medicaid APG methodology,266.21,,,266.21,Other,140% Medicaid APG methodology,1398.23,34,"If Charge > 2,000, then 34 percent",1398.23,percent of total billed charges,Drugs,608.14,,,608.14,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",190.15,,,190.15,Other,Drug Cost,190.15,,,190.15,Other,Drug Cost,237.69,,,237.69,Other,125% Medicaid APG methodology,0.01,2056.22,
IMM GLOB10% 20G200ML GAMUNEX-C  ,J1561,HCPCS,,40589772,CDM,636,RC,13533-0800-24,NDC,both,200,ML,7377.83,491.22,,,491.22,Other,150% of Medicare + 9.63% HCRA Surcharge,298.72,,,298.72,Fee Schedule,Average Sale Price (ASP) x 6,2213.35,30,,2213.35,percent of total billed charges,Drugs,2213.35,30,,2213.35,percent of total billed charges,Drugs,2213.35,30,,2213.35,percent of total billed charges,Drugs,2213.35,30,,2213.35,percent of total billed charges,Drugs,2213.35,30,,2213.35,percent of total billed charges,Drugs,3688.92,50,,3688.92,percent of total billed charges,All Other,2213.35,30,,2213.35,percent of total billed charges,Drugs,2213.35,30,,2213.35,percent of total billed charges,Drugs,2508.46,34,"If Charge > 500, then 34 percent",2508.46,percent of total billed charges,Drugs,2213.35,30,,2213.35,percent of total billed charges,Drugs,2213.35,30,,2213.35,percent of total billed charges,Drugs,2213.35,30,,2213.35,percent of total billed charges,Drugs,2213.35,30,,2213.35,percent of total billed charges,Drugs,2213.35,30,,2213.35,percent of total billed charges,Drugs,2213.35,30,,2213.35,percent of total billed charges,Drugs,2213.35,30,,2213.35,percent of total billed charges,Drugs,2213.35,30,,2213.35,percent of total billed charges,Drugs,2213.35,30,,2213.35,percent of total billed charges,Drugs,2213.35,30,,2213.35,percent of total billed charges,Drugs,2213.35,30,,2213.35,percent of total billed charges,Drugs,2213.35,30,,2213.35,percent of total billed charges,Drugs,2213.35,30,,2213.35,percent of total billed charges,Drugs,1470.01,,,1470.01,Other,Drug Cost,1470.01,,,1470.01,Other,Drug Cost,1470.01,,,1470.01,Other,Drug Cost,1470.01,,,1470.01,Other,Drug Cost,1470.01,,,1470.01,Other,Drug Cost,2508.46,34,,2508.46,percent of total billed charges,Drugs,1470.01,,,1470.01,Other,Drug Cost,3307.52,,,3307.52,Other,225% Medicaid APG methodology,2058.01,,,2058.01,Other,140% Medicaid APG methodology,2508.46,34,"If Charge > 2,000, then 34 percent",2508.46,percent of total billed charges,Drugs,477.95,,,477.95,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1470.01,,,1470.01,Other,Drug Cost,1470.01,,,1470.01,Other,Drug Cost,1837.51,,,1837.51,Other,125% Medicaid APG methodology,0.01,3688.92,
OCTREOTIDE 500 MCG/ML INJ 1 ML  ,J2354,HCPCS,,40589830,CDM,636,RC,63323-0377-01,NDC,both,1,ML,38.19,11.72,,,11.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7.13,,,7.13,Fee Schedule,Average Sale Price (ASP) x 6,11.46,30,,11.46,percent of total billed charges,Drugs,11.46,30,,11.46,percent of total billed charges,Drugs,11.46,30,,11.46,percent of total billed charges,Drugs,11.46,30,,11.46,percent of total billed charges,Drugs,11.46,30,,11.46,percent of total billed charges,Drugs,19.1,50,,19.1,percent of total billed charges,All Other,11.46,30,,11.46,percent of total billed charges,Drugs,11.46,30,,11.46,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,11.46,30,,11.46,percent of total billed charges,Drugs,11.46,30,,11.46,percent of total billed charges,Drugs,11.46,30,,11.46,percent of total billed charges,Drugs,11.46,30,,11.46,percent of total billed charges,Drugs,11.46,30,,11.46,percent of total billed charges,Drugs,11.46,30,,11.46,percent of total billed charges,Drugs,11.46,30,,11.46,percent of total billed charges,Drugs,11.46,30,,11.46,percent of total billed charges,Drugs,11.46,30,,11.46,percent of total billed charges,Drugs,11.46,30,,11.46,percent of total billed charges,Drugs,11.46,30,,11.46,percent of total billed charges,Drugs,11.46,30,,11.46,percent of total billed charges,Drugs,11.46,30,,11.46,percent of total billed charges,Drugs,17.25,,,17.25,Other,Drug Cost,17.25,,,17.25,Other,Drug Cost,17.25,,,17.25,Other,Drug Cost,17.25,,,17.25,Other,Drug Cost,17.25,,,17.25,Other,Drug Cost,12.98,34,,12.98,percent of total billed charges,Drugs,17.25,,,17.25,Other,Drug Cost,38.81,,,38.81,Other,225% Medicaid APG methodology,24.15,,,24.15,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,11.4,,,11.4,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",17.25,,,17.25,Other,Drug Cost,17.25,,,17.25,Other,Drug Cost,21.56,,,21.56,Other,125% Medicaid APG methodology,0.01,38.81,
PENICILLIN G POT 20000000INJ    ,J2540,HCPCS,,40589996,CDM,636,RC,00781-6136-94,NDC,both,1,EA,386.44,7.61,,,7.61,Other,150% of Medicare + 9.63% HCRA Surcharge,4.63,,,4.63,Fee Schedule,Average Sale Price (ASP) x 6,115.93,30,,115.93,percent of total billed charges,Drugs,115.93,30,,115.93,percent of total billed charges,Drugs,115.93,30,,115.93,percent of total billed charges,Drugs,115.93,30,,115.93,percent of total billed charges,Drugs,115.93,30,,115.93,percent of total billed charges,Drugs,193.22,50,,193.22,percent of total billed charges,All Other,115.93,30,,115.93,percent of total billed charges,Drugs,115.93,30,,115.93,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,115.93,30,,115.93,percent of total billed charges,Drugs,115.93,30,,115.93,percent of total billed charges,Drugs,115.93,30,,115.93,percent of total billed charges,Drugs,115.93,30,,115.93,percent of total billed charges,Drugs,115.93,30,,115.93,percent of total billed charges,Drugs,115.93,30,,115.93,percent of total billed charges,Drugs,115.93,30,,115.93,percent of total billed charges,Drugs,115.93,30,,115.93,percent of total billed charges,Drugs,115.93,30,,115.93,percent of total billed charges,Drugs,115.93,30,,115.93,percent of total billed charges,Drugs,115.93,30,,115.93,percent of total billed charges,Drugs,115.93,30,,115.93,percent of total billed charges,Drugs,115.93,30,,115.93,percent of total billed charges,Drugs,19.17,,,19.17,Other,Drug Cost,19.17,,,19.17,Other,Drug Cost,19.17,,,19.17,Other,Drug Cost,19.17,,,19.17,Other,Drug Cost,19.17,,,19.17,Other,Drug Cost,131.39,34,,131.39,percent of total billed charges,Drugs,19.17,,,19.17,Other,Drug Cost,43.13,,,43.13,Other,225% Medicaid APG methodology,26.84,,,26.84,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.4,,,7.4,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",19.17,,,19.17,Other,Drug Cost,19.17,,,19.17,Other,Drug Cost,23.96,,,23.96,Other,125% Medicaid APG methodology,0.01,193.22,
POT CL 2 MEQ/ML IV SLN 30ML     ,J3480,HCPCS,,40590010,CDM,636,RC,63323-0967-30,NDC,both,30,ML,9.77,1.18,,,1.18,Other,150% of Medicare + 9.63% HCRA Surcharge,0.72,,,0.72,Fee Schedule,Average Sale Price (ASP) x 6,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,4.89,50,,4.89,percent of total billed charges,All Other,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,2.93,30,,2.93,percent of total billed charges,Drugs,1.58,,,1.58,Other,Drug Cost,1.58,,,1.58,Other,Drug Cost,1.58,,,1.58,Other,Drug Cost,1.58,,,1.58,Other,Drug Cost,1.58,,,1.58,Other,Drug Cost,3.32,34,,3.32,percent of total billed charges,Drugs,1.58,,,1.58,Other,Drug Cost,3.56,,,3.56,Other,225% Medicaid APG methodology,2.21,,,2.21,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.15,,,1.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.58,,,1.58,Other,Drug Cost,1.58,,,1.58,Other,Drug Cost,1.98,,,1.98,Other,125% Medicaid APG methodology,0.01,4.89,
ROPIVACAINE 0.2% INJ SLN 100ML  ,J2795,HCPCS,,40590127,CDM,636,RC,25021-0671-82,NDC,both,100,ML,79.07,0.76,,,0.76,Other,150% of Medicare + 9.63% HCRA Surcharge,0.46,,,0.46,Fee Schedule,Average Sale Price (ASP) x 6,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,39.54,50,,39.54,percent of total billed charges,All Other,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,23.72,30,,23.72,percent of total billed charges,Drugs,22.36,,,22.36,Other,Drug Cost,22.36,,,22.36,Other,Drug Cost,22.36,,,22.36,Other,Drug Cost,22.36,,,22.36,Other,Drug Cost,22.36,,,22.36,Other,Drug Cost,26.88,34,,26.88,percent of total billed charges,Drugs,22.36,,,22.36,Other,Drug Cost,50.31,,,50.31,Other,225% Medicaid APG methodology,31.3,,,31.3,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.74,,,0.74,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",22.36,,,22.36,Other,Drug Cost,22.36,,,22.36,Other,Drug Cost,27.95,,,27.95,Other,125% Medicaid APG methodology,0.01,50.31,
ROPIVACAINE 1% INJ SOLN 10 ML   ,J2795,HCPCS,,40590143,CDM,636,RC,63323-0288-11,NDC,both,10,ML,12.95,0.76,,,0.76,Other,150% of Medicare + 9.63% HCRA Surcharge,0.46,,,0.46,Fee Schedule,Average Sale Price (ASP) x 6,3.89,30,,3.89,percent of total billed charges,Drugs,3.89,30,,3.89,percent of total billed charges,Drugs,3.89,30,,3.89,percent of total billed charges,Drugs,3.89,30,,3.89,percent of total billed charges,Drugs,3.89,30,,3.89,percent of total billed charges,Drugs,6.48,50,,6.48,percent of total billed charges,All Other,3.89,30,,3.89,percent of total billed charges,Drugs,3.89,30,,3.89,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.89,30,,3.89,percent of total billed charges,Drugs,3.89,30,,3.89,percent of total billed charges,Drugs,3.89,30,,3.89,percent of total billed charges,Drugs,3.89,30,,3.89,percent of total billed charges,Drugs,3.89,30,,3.89,percent of total billed charges,Drugs,3.89,30,,3.89,percent of total billed charges,Drugs,3.89,30,,3.89,percent of total billed charges,Drugs,3.89,30,,3.89,percent of total billed charges,Drugs,3.89,30,,3.89,percent of total billed charges,Drugs,3.89,30,,3.89,percent of total billed charges,Drugs,3.89,30,,3.89,percent of total billed charges,Drugs,3.89,30,,3.89,percent of total billed charges,Drugs,3.89,30,,3.89,percent of total billed charges,Drugs,2.3,,,2.3,Other,Drug Cost,2.3,,,2.3,Other,Drug Cost,2.3,,,2.3,Other,Drug Cost,2.3,,,2.3,Other,Drug Cost,2.3,,,2.3,Other,Drug Cost,4.4,34,,4.4,percent of total billed charges,Drugs,2.3,,,2.3,Other,Drug Cost,5.18,,,5.18,Other,225% Medicaid APG methodology,3.22,,,3.22,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.74,,,0.74,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.3,,,2.3,Other,Drug Cost,2.3,,,2.3,Other,Drug Cost,2.88,,,2.88,Other,125% Medicaid APG methodology,0.01,6.48,
VANCOMYCIN 750 MG IV INJ        ,J3370,HCPCS,,40590473,CDM,636,RC,00409-6531-02,NDC,both,1,EA,24.29,22.76,,,22.76,Other,150% of Medicare + 9.63% HCRA Surcharge,13.84,,,13.84,Fee Schedule,Average Sale Price (ASP) x 6,7.29,30,,7.29,percent of total billed charges,Drugs,7.29,30,,7.29,percent of total billed charges,Drugs,7.29,30,,7.29,percent of total billed charges,Drugs,7.29,30,,7.29,percent of total billed charges,Drugs,7.29,30,,7.29,percent of total billed charges,Drugs,12.15,50,,12.15,percent of total billed charges,All Other,7.29,30,,7.29,percent of total billed charges,Drugs,7.29,30,,7.29,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,7.29,30,,7.29,percent of total billed charges,Drugs,7.29,30,,7.29,percent of total billed charges,Drugs,7.29,30,,7.29,percent of total billed charges,Drugs,7.29,30,,7.29,percent of total billed charges,Drugs,7.29,30,,7.29,percent of total billed charges,Drugs,7.29,30,,7.29,percent of total billed charges,Drugs,7.29,30,,7.29,percent of total billed charges,Drugs,7.29,30,,7.29,percent of total billed charges,Drugs,7.29,30,,7.29,percent of total billed charges,Drugs,7.29,30,,7.29,percent of total billed charges,Drugs,7.29,30,,7.29,percent of total billed charges,Drugs,7.29,30,,7.29,percent of total billed charges,Drugs,7.29,30,,7.29,percent of total billed charges,Drugs,2.3,,,2.3,Other,Drug Cost,2.3,,,2.3,Other,Drug Cost,2.3,,,2.3,Other,Drug Cost,2.3,,,2.3,Other,Drug Cost,2.3,,,2.3,Other,Drug Cost,8.26,34,,8.26,percent of total billed charges,Drugs,2.3,,,2.3,Other,Drug Cost,5.18,,,5.18,Other,225% Medicaid APG methodology,3.22,,,3.22,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,22.15,,,22.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",2.3,,,2.3,Other,Drug Cost,2.3,,,2.3,Other,Drug Cost,2.88,,,2.88,Other,125% Medicaid APG methodology,0.01,22.76,
LEUPROLIDE 30MG/4 MON IM KIT    ,J9217,HCPCS,,40590671,CDM,636,RC,00074-3683-03,NDC,both,1,EA,25308.64,1788.85,,,1788.85,Other,150% of Medicare + 9.63% HCRA Surcharge,1087.81,,,1087.81,Fee Schedule,Average Sale Price (ASP) x 6,7592.59,30,,7592.59,percent of total billed charges,Drugs,7592.59,30,,7592.59,percent of total billed charges,Drugs,7592.59,30,,7592.59,percent of total billed charges,Drugs,7592.59,30,,7592.59,percent of total billed charges,Drugs,7592.59,30,,7592.59,percent of total billed charges,Drugs,12654.32,50,,12654.32,percent of total billed charges,All Other,7592.59,30,,7592.59,percent of total billed charges,Drugs,7592.59,30,,7592.59,percent of total billed charges,Drugs,8604.94,34,"If Charge > 500, then 34 percent",8604.94,percent of total billed charges,Drugs,7592.59,30,,7592.59,percent of total billed charges,Drugs,7592.59,30,,7592.59,percent of total billed charges,Drugs,7592.59,30,,7592.59,percent of total billed charges,Drugs,7592.59,30,,7592.59,percent of total billed charges,Drugs,7592.59,30,,7592.59,percent of total billed charges,Drugs,7592.59,30,,7592.59,percent of total billed charges,Drugs,7592.59,30,,7592.59,percent of total billed charges,Drugs,7592.59,30,,7592.59,percent of total billed charges,Drugs,7592.59,30,,7592.59,percent of total billed charges,Drugs,7592.59,30,,7592.59,percent of total billed charges,Drugs,7592.59,30,,7592.59,percent of total billed charges,Drugs,7592.59,30,,7592.59,percent of total billed charges,Drugs,7592.59,30,,7592.59,percent of total billed charges,Drugs,306.47,,,306.47,Other,Drug Cost,306.47,,,306.47,Other,Drug Cost,306.47,,,306.47,Other,Drug Cost,306.47,,,306.47,Other,Drug Cost,306.47,,,306.47,Other,Drug Cost,8604.94,34,,8604.94,percent of total billed charges,Drugs,306.47,,,306.47,Other,Drug Cost,689.56,,,689.56,Other,225% Medicaid APG methodology,429.06,,,429.06,Other,140% Medicaid APG methodology,8604.94,34,"If Charge > 2,000, then 34 percent",8604.94,percent of total billed charges,Drugs,1740.5,,,1740.5,Other,160% Medicare Fee Schedule,8604.94,34,,8604.94,Other,"Drug Charges > 20,000, then 34% of Charges",306.47,,,306.47,Other,Drug Cost,306.47,,,306.47,Other,Drug Cost,383.09,,,383.09,Other,125% Medicaid APG methodology,306.47,12654.32,
CARFILZOMIB 30 MG IV INJ        ,J9047,HCPCS,,40592073,CDM,636,RC,76075-0102-01,NDC,both,1,EA,4513.01,464.57,,,464.57,Other,150% of Medicare + 9.63% HCRA Surcharge,282.51,,,282.51,Fee Schedule,Average Sale Price (ASP) x 6,1353.9,30,,1353.9,percent of total billed charges,Drugs,1353.9,30,,1353.9,percent of total billed charges,Drugs,1353.9,30,,1353.9,percent of total billed charges,Drugs,1353.9,30,,1353.9,percent of total billed charges,Drugs,1353.9,30,,1353.9,percent of total billed charges,Drugs,2256.51,50,,2256.51,percent of total billed charges,All Other,1353.9,30,,1353.9,percent of total billed charges,Drugs,1353.9,30,,1353.9,percent of total billed charges,Drugs,1534.42,34,"If Charge > 500, then 34 percent",1534.42,percent of total billed charges,Drugs,1353.9,30,,1353.9,percent of total billed charges,Drugs,1353.9,30,,1353.9,percent of total billed charges,Drugs,1353.9,30,,1353.9,percent of total billed charges,Drugs,1353.9,30,,1353.9,percent of total billed charges,Drugs,1353.9,30,,1353.9,percent of total billed charges,Drugs,1353.9,30,,1353.9,percent of total billed charges,Drugs,1353.9,30,,1353.9,percent of total billed charges,Drugs,1353.9,30,,1353.9,percent of total billed charges,Drugs,1353.9,30,,1353.9,percent of total billed charges,Drugs,1353.9,30,,1353.9,percent of total billed charges,Drugs,1353.9,30,,1353.9,percent of total billed charges,Drugs,1353.9,30,,1353.9,percent of total billed charges,Drugs,1353.9,30,,1353.9,percent of total billed charges,Drugs,764.24,,,764.24,Other,Drug Cost,764.24,,,764.24,Other,Drug Cost,764.24,,,764.24,Other,Drug Cost,764.24,,,764.24,Other,Drug Cost,764.24,,,764.24,Other,Drug Cost,1534.42,34,,1534.42,percent of total billed charges,Drugs,764.24,,,764.24,Other,Drug Cost,1719.54,,,1719.54,Other,225% Medicaid APG methodology,1069.94,,,1069.94,Other,140% Medicaid APG methodology,1534.42,34,"If Charge > 2,000, then 34 percent",1534.42,percent of total billed charges,Drugs,452.02,,,452.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",764.24,,,764.24,Other,Drug Cost,764.24,,,764.24,Other,Drug Cost,955.3,,,955.3,Other,125% Medicaid APG methodology,0.01,2256.51,
LIDOCAINE 2% INJ SOLN 2 ML      ,J2001,HCPCS,,40592263,CDM,636,RC,63323-0202-02,NDC,both,2,ML,7.95,0.27,,,0.27,Other,150% of Medicare + 9.63% HCRA Surcharge,0.16,,,0.16,Fee Schedule,Average Sale Price (ASP) x 6,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,3.98,50,,3.98,percent of total billed charges,All Other,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,2.39,30,,2.39,percent of total billed charges,Drugs,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,2.7,34,,2.7,percent of total billed charges,Drugs,0.97,,,0.97,Other,Drug Cost,2.18,,,2.18,Other,225% Medicaid APG methodology,1.36,,,1.36,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.26,,,0.26,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.97,,,0.97,Other,Drug Cost,0.97,,,0.97,Other,Drug Cost,1.21,,,1.21,Other,125% Medicaid APG methodology,0.01,3.98,
TRIAMCINO ACET 40MG/ML INJ 5ML  ,J3301,HCPCS,,40592388,CDM,636,RC,70121-1168-01,NDC,both,5,ML,61.81,9.33,,,9.33,Other,150% of Medicare + 9.63% HCRA Surcharge,5.68,,,5.68,Fee Schedule,Average Sale Price (ASP) x 6,18.54,30,,18.54,percent of total billed charges,Drugs,18.54,30,,18.54,percent of total billed charges,Drugs,18.54,30,,18.54,percent of total billed charges,Drugs,18.54,30,,18.54,percent of total billed charges,Drugs,18.54,30,,18.54,percent of total billed charges,Drugs,30.91,50,,30.91,percent of total billed charges,All Other,18.54,30,,18.54,percent of total billed charges,Drugs,18.54,30,,18.54,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,18.54,30,,18.54,percent of total billed charges,Drugs,18.54,30,,18.54,percent of total billed charges,Drugs,18.54,30,,18.54,percent of total billed charges,Drugs,18.54,30,,18.54,percent of total billed charges,Drugs,18.54,30,,18.54,percent of total billed charges,Drugs,18.54,30,,18.54,percent of total billed charges,Drugs,18.54,30,,18.54,percent of total billed charges,Drugs,18.54,30,,18.54,percent of total billed charges,Drugs,18.54,30,,18.54,percent of total billed charges,Drugs,18.54,30,,18.54,percent of total billed charges,Drugs,18.54,30,,18.54,percent of total billed charges,Drugs,18.54,30,,18.54,percent of total billed charges,Drugs,18.54,30,,18.54,percent of total billed charges,Drugs,14.73,,,14.73,Other,Drug Cost,14.73,,,14.73,Other,Drug Cost,14.73,,,14.73,Other,Drug Cost,14.73,,,14.73,Other,Drug Cost,14.73,,,14.73,Other,Drug Cost,21.02,34,,21.02,percent of total billed charges,Drugs,14.73,,,14.73,Other,Drug Cost,33.14,,,33.14,Other,225% Medicaid APG methodology,20.62,,,20.62,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,9.08,,,9.08,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",14.73,,,14.73,Other,Drug Cost,14.73,,,14.73,Other,Drug Cost,18.41,,,18.41,Other,125% Medicaid APG methodology,0.01,33.14,
HYDROMORPHONE 50MG/5ML INJ      ,J1170,HCPCS,,40592487,CDM,636,RC,17478-0540-05,NDC,both,5,ML,20.23,45.3,,,45.3,Other,150% of Medicare + 9.63% HCRA Surcharge,27.55,,,27.55,Fee Schedule,Average Sale Price (ASP) x 6,6.07,30,,6.07,percent of total billed charges,Drugs,6.07,30,,6.07,percent of total billed charges,Drugs,6.07,30,,6.07,percent of total billed charges,Drugs,6.07,30,,6.07,percent of total billed charges,Drugs,6.07,30,,6.07,percent of total billed charges,Drugs,10.12,50,,10.12,percent of total billed charges,All Other,6.07,30,,6.07,percent of total billed charges,Drugs,6.07,30,,6.07,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,6.07,30,,6.07,percent of total billed charges,Drugs,6.07,30,,6.07,percent of total billed charges,Drugs,6.07,30,,6.07,percent of total billed charges,Drugs,6.07,30,,6.07,percent of total billed charges,Drugs,6.07,30,,6.07,percent of total billed charges,Drugs,6.07,30,,6.07,percent of total billed charges,Drugs,6.07,30,,6.07,percent of total billed charges,Drugs,6.07,30,,6.07,percent of total billed charges,Drugs,6.07,30,,6.07,percent of total billed charges,Drugs,6.07,30,,6.07,percent of total billed charges,Drugs,6.07,30,,6.07,percent of total billed charges,Drugs,6.07,30,,6.07,percent of total billed charges,Drugs,6.07,30,,6.07,percent of total billed charges,Drugs,4.49,,,4.49,Other,Drug Cost,4.49,,,4.49,Other,Drug Cost,4.49,,,4.49,Other,Drug Cost,4.49,,,4.49,Other,Drug Cost,4.49,,,4.49,Other,Drug Cost,6.88,34,,6.88,percent of total billed charges,Drugs,4.49,,,4.49,Other,Drug Cost,10.1,,,10.1,Other,225% Medicaid APG methodology,6.29,,,6.29,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,44.07,,,44.07,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",4.49,,,4.49,Other,Drug Cost,4.49,,,4.49,Other,Drug Cost,5.61,,,5.61,Other,125% Medicaid APG methodology,0.01,45.3,
MIDAZOLAM 5MG/ML PF INJ  2ML    ,J2250,HCPCS,,40592495,CDM,636,RC,00409-2308-02,NDC,both,2,ML,3.26,1.4,,,1.4,Other,150% of Medicare + 9.63% HCRA Surcharge,0.85,,,0.85,Fee Schedule,Average Sale Price (ASP) x 6,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,1.63,50,,1.63,percent of total billed charges,All Other,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,30,,0.98,percent of total billed charges,Drugs,0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,1.11,34,,1.11,percent of total billed charges,Drugs,0.98,,,0.98,Other,Drug Cost,2.21,,,2.21,Other,225% Medicaid APG methodology,1.37,,,1.37,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,1.36,,,1.36,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.98,,,0.98,Other,Drug Cost,0.98,,,0.98,Other,Drug Cost,1.23,,,1.23,Other,125% Medicaid APG methodology,0.01,2.21,
PHENYLEPHRINE 20MG NS 250ML     ,J2371,HCPCS,,40592677,CDM,636,RC,00641-6142-25z,NDC,both,250,ML,75.08,29.63,39.4668,,29.63,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,22.52,30,,22.52,percent of total billed charges,Drugs,22.52,30,,22.52,percent of total billed charges,Drugs,22.52,30,,22.52,percent of total billed charges,Drugs,22.52,30,,22.52,percent of total billed charges,Drugs,22.52,30,,22.52,percent of total billed charges,Drugs,37.54,50,,37.54,percent of total billed charges,All Other,22.52,30,,22.52,percent of total billed charges,Drugs,22.52,30,,22.52,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,22.52,30,,22.52,percent of total billed charges,Drugs,22.52,30,,22.52,percent of total billed charges,Drugs,22.52,30,,22.52,percent of total billed charges,Drugs,22.52,30,,22.52,percent of total billed charges,Drugs,22.52,30,,22.52,percent of total billed charges,Drugs,22.52,30,,22.52,percent of total billed charges,Drugs,22.52,30,,22.52,percent of total billed charges,Drugs,22.52,30,,22.52,percent of total billed charges,Drugs,22.52,30,,22.52,percent of total billed charges,Drugs,22.52,30,,22.52,percent of total billed charges,Drugs,22.52,30,,22.52,percent of total billed charges,Drugs,22.52,30,,22.52,percent of total billed charges,Drugs,22.52,30,,22.52,percent of total billed charges,Drugs,21.45,,,21.45,Other,Drug Cost,21.45,,,21.45,Other,Drug Cost,21.45,,,21.45,Other,Drug Cost,21.45,,,21.45,Other,Drug Cost,21.45,,,21.45,Other,Drug Cost,25.53,34,,25.53,percent of total billed charges,Drugs,21.45,,,21.45,Other,Drug Cost,48.26,,,48.26,Other,225% Medicaid APG methodology,30.03,,,30.03,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",21.45,,,21.45,Other,Drug Cost,21.45,,,21.45,Other,Drug Cost,26.81,,,26.81,Other,125% Medicaid APG methodology,0.01,48.26,
GLATIRAMER 40MG/ML SUBQ  1ML    ,J1595,HCPCS,,40592974,CDM,636,RC,68546-0325-12,NDC,both,1,ML,1658.48,654.55,39.4668,,654.55,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,497.54,30,,497.54,percent of total billed charges,Drugs,497.54,30,,497.54,percent of total billed charges,Drugs,497.54,30,,497.54,percent of total billed charges,Drugs,497.54,30,,497.54,percent of total billed charges,Drugs,497.54,30,,497.54,percent of total billed charges,Drugs,829.24,50,,829.24,percent of total billed charges,All Other,497.54,30,,497.54,percent of total billed charges,Drugs,497.54,30,,497.54,percent of total billed charges,Drugs,563.88,34,"If Charge > 500, then 34 percent",563.88,percent of total billed charges,Drugs,497.54,30,,497.54,percent of total billed charges,Drugs,497.54,30,,497.54,percent of total billed charges,Drugs,497.54,30,,497.54,percent of total billed charges,Drugs,497.54,30,,497.54,percent of total billed charges,Drugs,497.54,30,,497.54,percent of total billed charges,Drugs,497.54,30,,497.54,percent of total billed charges,Drugs,497.54,30,,497.54,percent of total billed charges,Drugs,497.54,30,,497.54,percent of total billed charges,Drugs,497.54,30,,497.54,percent of total billed charges,Drugs,497.54,30,,497.54,percent of total billed charges,Drugs,497.54,30,,497.54,percent of total billed charges,Drugs,497.54,30,,497.54,percent of total billed charges,Drugs,497.54,30,,497.54,percent of total billed charges,Drugs,66.21,,,66.21,Other,Drug Cost,66.21,,,66.21,Other,Drug Cost,66.21,,,66.21,Other,Drug Cost,66.21,,,66.21,Other,Drug Cost,66.21,,,66.21,Other,Drug Cost,563.88,34,,563.88,percent of total billed charges,Drugs,66.21,,,66.21,Other,Drug Cost,148.97,,,148.97,Other,225% Medicaid APG methodology,92.69,,,92.69,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",66.21,,,66.21,Other,Drug Cost,66.21,,,66.21,Other,Drug Cost,82.76,,,82.76,Other,125% Medicaid APG methodology,0.01,829.24,
USTEKINUMAB 90MG/ML SUBQ  1ML   ,J3357,HCPCS,,40593386,CDM,636,RC,57894-0061-03,NDC,both,1,ML,78707.27,1519.03,,,1519.03,Other,150% of Medicare + 9.63% HCRA Surcharge,923.73,,,923.73,Fee Schedule,Average Sale Price (ASP) x 6,23612.18,30,,23612.18,percent of total billed charges,Drugs,23612.18,30,,23612.18,percent of total billed charges,Drugs,23612.18,30,,23612.18,percent of total billed charges,Drugs,23612.18,30,,23612.18,percent of total billed charges,Drugs,23612.18,30,,23612.18,percent of total billed charges,Drugs,39353.64,50,,39353.64,percent of total billed charges,All Other,23612.18,30,,23612.18,percent of total billed charges,Drugs,23612.18,30,,23612.18,percent of total billed charges,Drugs,26760.47,34,"If Charge > 500, then 34 percent",26760.47,percent of total billed charges,Drugs,23612.18,30,,23612.18,percent of total billed charges,Drugs,23612.18,30,,23612.18,percent of total billed charges,Drugs,23612.18,30,,23612.18,percent of total billed charges,Drugs,23612.18,30,,23612.18,percent of total billed charges,Drugs,23612.18,30,,23612.18,percent of total billed charges,Drugs,23612.18,30,,23612.18,percent of total billed charges,Drugs,23612.18,30,,23612.18,percent of total billed charges,Drugs,23612.18,30,,23612.18,percent of total billed charges,Drugs,23612.18,30,,23612.18,percent of total billed charges,Drugs,23612.18,30,,23612.18,percent of total billed charges,Drugs,23612.18,30,,23612.18,percent of total billed charges,Drugs,23612.18,30,,23612.18,percent of total billed charges,Drugs,23612.18,30,,23612.18,percent of total billed charges,Drugs,4621.13,,,4621.13,Other,Drug Cost,4621.13,,,4621.13,Other,Drug Cost,4621.13,,,4621.13,Other,Drug Cost,4621.13,,,4621.13,Other,Drug Cost,4621.13,,,4621.13,Other,Drug Cost,26760.47,34,,26760.47,percent of total billed charges,Drugs,4621.13,,,4621.13,Other,Drug Cost,10397.54,,,10397.54,Other,225% Medicaid APG methodology,6469.58,,,6469.58,Other,140% Medicaid APG methodology,26760.47,34,"If Charge > 2,000, then 34 percent",26760.47,percent of total billed charges,Drugs,1477.97,,,1477.97,Other,160% Medicare Fee Schedule,26760.47,34,,26760.47,Other,"Drug Charges > 20,000, then 34% of Charges",4621.13,,,4621.13,Other,Drug Cost,4621.13,,,4621.13,Other,Drug Cost,5776.41,,,5776.41,Other,125% Medicaid APG methodology,923.73,39353.64,
PREDNISONE 5MG/5ML ORL  500ML   ,J7512,HCPCS,,40593535,CDM,636,RC,00054-3722-63,NDC,both,500,ML,1008.56,0.07,,,0.07,Other,150% of Medicare + 9.63% HCRA Surcharge,0.04,,,0.04,Fee Schedule,Average Sale Price (ASP) x 6,302.57,30,,302.57,percent of total billed charges,Drugs,302.57,30,,302.57,percent of total billed charges,Drugs,302.57,30,,302.57,percent of total billed charges,Drugs,302.57,30,,302.57,percent of total billed charges,Drugs,302.57,30,,302.57,percent of total billed charges,Drugs,504.28,50,,504.28,percent of total billed charges,All Other,302.57,30,,302.57,percent of total billed charges,Drugs,302.57,30,,302.57,percent of total billed charges,Drugs,342.91,34,"If Charge > 500, then 34 percent",342.91,percent of total billed charges,Drugs,302.57,30,,302.57,percent of total billed charges,Drugs,302.57,30,,302.57,percent of total billed charges,Drugs,302.57,30,,302.57,percent of total billed charges,Drugs,302.57,30,,302.57,percent of total billed charges,Drugs,302.57,30,,302.57,percent of total billed charges,Drugs,302.57,30,,302.57,percent of total billed charges,Drugs,302.57,30,,302.57,percent of total billed charges,Drugs,302.57,30,,302.57,percent of total billed charges,Drugs,302.57,30,,302.57,percent of total billed charges,Drugs,302.57,30,,302.57,percent of total billed charges,Drugs,302.57,30,,302.57,percent of total billed charges,Drugs,302.57,30,,302.57,percent of total billed charges,Drugs,302.57,30,,302.57,percent of total billed charges,Drugs,60.42,,,60.42,Other,Drug Cost,60.42,,,60.42,Other,Drug Cost,60.42,,,60.42,Other,Drug Cost,60.42,,,60.42,Other,Drug Cost,60.42,,,60.42,Other,Drug Cost,342.91,34,,342.91,percent of total billed charges,Drugs,60.42,,,60.42,Other,Drug Cost,135.95,,,135.95,Other,225% Medicaid APG methodology,84.59,,,84.59,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.07,,,0.07,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",60.42,,,60.42,Other,Drug Cost,60.42,,,60.42,Other,Drug Cost,75.53,,,75.53,Other,125% Medicaid APG methodology,0.01,504.28,
GENTAMICIN 80MG NS IV  100ML    ,J1580,HCPCS,,40593592,CDM,636,RC,00338-0503-48,NDC,both,100,ML,9.21,26.49,,,26.49,Other,150% of Medicare + 9.63% HCRA Surcharge,16.11,,,16.11,Fee Schedule,Average Sale Price (ASP) x 6,2.76,30,,2.76,percent of total billed charges,Drugs,2.76,30,,2.76,percent of total billed charges,Drugs,2.76,30,,2.76,percent of total billed charges,Drugs,2.76,30,,2.76,percent of total billed charges,Drugs,2.76,30,,2.76,percent of total billed charges,Drugs,4.61,50,,4.61,percent of total billed charges,All Other,2.76,30,,2.76,percent of total billed charges,Drugs,2.76,30,,2.76,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.76,30,,2.76,percent of total billed charges,Drugs,2.76,30,,2.76,percent of total billed charges,Drugs,2.76,30,,2.76,percent of total billed charges,Drugs,2.76,30,,2.76,percent of total billed charges,Drugs,2.76,30,,2.76,percent of total billed charges,Drugs,2.76,30,,2.76,percent of total billed charges,Drugs,2.76,30,,2.76,percent of total billed charges,Drugs,2.76,30,,2.76,percent of total billed charges,Drugs,2.76,30,,2.76,percent of total billed charges,Drugs,2.76,30,,2.76,percent of total billed charges,Drugs,2.76,30,,2.76,percent of total billed charges,Drugs,2.76,30,,2.76,percent of total billed charges,Drugs,2.76,30,,2.76,percent of total billed charges,Drugs,1.67,,,1.67,Other,Drug Cost,1.67,,,1.67,Other,Drug Cost,1.67,,,1.67,Other,Drug Cost,1.67,,,1.67,Other,Drug Cost,1.67,,,1.67,Other,Drug Cost,3.13,34,,3.13,percent of total billed charges,Drugs,1.67,,,1.67,Other,Drug Cost,3.76,,,3.76,Other,225% Medicaid APG methodology,2.34,,,2.34,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,25.78,,,25.78,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1.67,,,1.67,Other,Drug Cost,1.67,,,1.67,Other,Drug Cost,2.09,,,2.09,Other,125% Medicaid APG methodology,0.01,26.49,
TOCILIZUMAB 162MG/0.9ML SQ      ,J3262,HCPCS,,40593659,CDM,636,RC,50242-0138-01,NDC,both,0.9,ML,3671.96,60.38,,,60.38,Other,150% of Medicare + 9.63% HCRA Surcharge,36.72,,,36.72,Fee Schedule,Average Sale Price (ASP) x 6,1101.59,30,,1101.59,percent of total billed charges,Drugs,1101.59,30,,1101.59,percent of total billed charges,Drugs,1101.59,30,,1101.59,percent of total billed charges,Drugs,1101.59,30,,1101.59,percent of total billed charges,Drugs,1101.59,30,,1101.59,percent of total billed charges,Drugs,1835.98,50,,1835.98,percent of total billed charges,All Other,1101.59,30,,1101.59,percent of total billed charges,Drugs,1101.59,30,,1101.59,percent of total billed charges,Drugs,1248.47,34,"If Charge > 500, then 34 percent",1248.47,percent of total billed charges,Drugs,1101.59,30,,1101.59,percent of total billed charges,Drugs,1101.59,30,,1101.59,percent of total billed charges,Drugs,1101.59,30,,1101.59,percent of total billed charges,Drugs,1101.59,30,,1101.59,percent of total billed charges,Drugs,1101.59,30,,1101.59,percent of total billed charges,Drugs,1101.59,30,,1101.59,percent of total billed charges,Drugs,1101.59,30,,1101.59,percent of total billed charges,Drugs,1101.59,30,,1101.59,percent of total billed charges,Drugs,1101.59,30,,1101.59,percent of total billed charges,Drugs,1101.59,30,,1101.59,percent of total billed charges,Drugs,1101.59,30,,1101.59,percent of total billed charges,Drugs,1101.59,30,,1101.59,percent of total billed charges,Drugs,1101.59,30,,1101.59,percent of total billed charges,Drugs,422.43,,,422.43,Other,Drug Cost,422.43,,,422.43,Other,Drug Cost,422.43,,,422.43,Other,Drug Cost,422.43,,,422.43,Other,Drug Cost,422.43,,,422.43,Other,Drug Cost,1248.47,34,,1248.47,percent of total billed charges,Drugs,422.43,,,422.43,Other,Drug Cost,950.47,,,950.47,Other,225% Medicaid APG methodology,591.4,,,591.4,Other,140% Medicaid APG methodology,1248.47,34,"If Charge > 2,000, then 34 percent",1248.47,percent of total billed charges,Drugs,58.75,,,58.75,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",422.43,,,422.43,Other,Drug Cost,422.43,,,422.43,Other,Drug Cost,528.04,,,528.04,Other,125% Medicaid APG methodology,0.01,1835.98,
TENECTEPLASE 50 MG IV INJ       ,J3101,HCPCS,,40593709,CDM,636,RC,50242-0120-47,NDC,both,1,EA,25434.99,1510.73,,,1510.73,Other,150% of Medicare + 9.63% HCRA Surcharge,918.68,,,918.68,Fee Schedule,Average Sale Price (ASP) x 6,7630.5,30,,7630.5,percent of total billed charges,Drugs,7630.5,30,,7630.5,percent of total billed charges,Drugs,7630.5,30,,7630.5,percent of total billed charges,Drugs,7630.5,30,,7630.5,percent of total billed charges,Drugs,7630.5,30,,7630.5,percent of total billed charges,Drugs,12717.5,50,,12717.5,percent of total billed charges,All Other,7630.5,30,,7630.5,percent of total billed charges,Drugs,7630.5,30,,7630.5,percent of total billed charges,Drugs,8647.9,34,"If Charge > 500, then 34 percent",8647.9,percent of total billed charges,Drugs,7630.5,30,,7630.5,percent of total billed charges,Drugs,7630.5,30,,7630.5,percent of total billed charges,Drugs,7630.5,30,,7630.5,percent of total billed charges,Drugs,7630.5,30,,7630.5,percent of total billed charges,Drugs,7630.5,30,,7630.5,percent of total billed charges,Drugs,7630.5,30,,7630.5,percent of total billed charges,Drugs,7630.5,30,,7630.5,percent of total billed charges,Drugs,7630.5,30,,7630.5,percent of total billed charges,Drugs,7630.5,30,,7630.5,percent of total billed charges,Drugs,7630.5,30,,7630.5,percent of total billed charges,Drugs,7630.5,30,,7630.5,percent of total billed charges,Drugs,7630.5,30,,7630.5,percent of total billed charges,Drugs,7630.5,30,,7630.5,percent of total billed charges,Drugs,1860.19,,,1860.19,Other,Drug Cost,1860.19,,,1860.19,Other,Drug Cost,1860.19,,,1860.19,Other,Drug Cost,1860.19,,,1860.19,Other,Drug Cost,1860.19,,,1860.19,Other,Drug Cost,8647.9,34,,8647.9,percent of total billed charges,Drugs,1860.19,,,1860.19,Other,Drug Cost,4185.43,,,4185.43,Other,225% Medicaid APG methodology,2604.27,,,2604.27,Other,140% Medicaid APG methodology,8647.9,34,"If Charge > 2,000, then 34 percent",8647.9,percent of total billed charges,Drugs,1469.89,,,1469.89,Other,160% Medicare Fee Schedule,8647.9,34,,8647.9,Other,"Drug Charges > 20,000, then 34% of Charges",1860.19,,,1860.19,Other,Drug Cost,1860.19,,,1860.19,Other,Drug Cost,2325.24,,,2325.24,Other,125% Medicaid APG methodology,918.68,12717.5,
CYCLOSPORINE 100MG CAP(NON-MOD  ,J7502,HCPCS,,40594004,CDM,636,RC,00078-0241-15,NDC,both,1,EA,52.75,22.34,,,22.34,Other,150% of Medicare + 9.63% HCRA Surcharge,13.58,,,13.58,Fee Schedule,Average Sale Price (ASP) x 6,15.83,30,,15.83,percent of total billed charges,Drugs,15.83,30,,15.83,percent of total billed charges,Drugs,15.83,30,,15.83,percent of total billed charges,Drugs,15.83,30,,15.83,percent of total billed charges,Drugs,15.83,30,,15.83,percent of total billed charges,Drugs,26.38,50,,26.38,percent of total billed charges,All Other,15.83,30,,15.83,percent of total billed charges,Drugs,15.83,30,,15.83,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,15.83,30,,15.83,percent of total billed charges,Drugs,15.83,30,,15.83,percent of total billed charges,Drugs,15.83,30,,15.83,percent of total billed charges,Drugs,15.83,30,,15.83,percent of total billed charges,Drugs,15.83,30,,15.83,percent of total billed charges,Drugs,15.83,30,,15.83,percent of total billed charges,Drugs,15.83,30,,15.83,percent of total billed charges,Drugs,15.83,30,,15.83,percent of total billed charges,Drugs,15.83,30,,15.83,percent of total billed charges,Drugs,15.83,30,,15.83,percent of total billed charges,Drugs,15.83,30,,15.83,percent of total billed charges,Drugs,15.83,30,,15.83,percent of total billed charges,Drugs,15.83,30,,15.83,percent of total billed charges,Drugs,3.23,,,3.23,Other,Drug Cost,3.23,,,3.23,Other,Drug Cost,3.23,,,3.23,Other,Drug Cost,3.23,,,3.23,Other,Drug Cost,3.23,,,3.23,Other,Drug Cost,17.94,34,,17.94,percent of total billed charges,Drugs,3.23,,,3.23,Other,Drug Cost,7.27,,,7.27,Other,225% Medicaid APG methodology,4.52,,,4.52,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,21.73,,,21.73,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3.23,,,3.23,Other,Drug Cost,3.23,,,3.23,Other,Drug Cost,4.04,,,4.04,Other,125% Medicaid APG methodology,0.01,26.38,
CYCLOSPORINE 25 MG CAP          ,J7515,HCPCS,,40594012,CDM,636,RC,00078-0240-15,NDC,both,1,EA,13.23,8.26,,,8.26,Other,150% of Medicare + 9.63% HCRA Surcharge,5.02,,,5.02,Fee Schedule,Average Sale Price (ASP) x 6,3.97,30,,3.97,percent of total billed charges,Drugs,3.97,30,,3.97,percent of total billed charges,Drugs,3.97,30,,3.97,percent of total billed charges,Drugs,3.97,30,,3.97,percent of total billed charges,Drugs,3.97,30,,3.97,percent of total billed charges,Drugs,6.62,50,,6.62,percent of total billed charges,All Other,3.97,30,,3.97,percent of total billed charges,Drugs,3.97,30,,3.97,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,3.97,30,,3.97,percent of total billed charges,Drugs,3.97,30,,3.97,percent of total billed charges,Drugs,3.97,30,,3.97,percent of total billed charges,Drugs,3.97,30,,3.97,percent of total billed charges,Drugs,3.97,30,,3.97,percent of total billed charges,Drugs,3.97,30,,3.97,percent of total billed charges,Drugs,3.97,30,,3.97,percent of total billed charges,Drugs,3.97,30,,3.97,percent of total billed charges,Drugs,3.97,30,,3.97,percent of total billed charges,Drugs,3.97,30,,3.97,percent of total billed charges,Drugs,3.97,30,,3.97,percent of total billed charges,Drugs,3.97,30,,3.97,percent of total billed charges,Drugs,3.97,30,,3.97,percent of total billed charges,Drugs,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,4.5,34,,4.5,percent of total billed charges,Drugs,0.82,,,0.82,Other,Drug Cost,1.85,,,1.85,Other,225% Medicaid APG methodology,1.15,,,1.15,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,8.04,,,8.04,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.82,,,0.82,Other,Drug Cost,0.82,,,0.82,Other,Drug Cost,1.03,,,1.03,Other,125% Medicaid APG methodology,0.01,8.26,
PEMETREXED 100 MG IV INJ        ,J9305,HCPCS,,40594061,CDM,636,RC,71288-0166-10,NDC,both,1,EA,37.03,43.13,,,43.13,Other,150% of Medicare + 9.63% HCRA Surcharge,26.23,,,26.23,Fee Schedule,Average Sale Price (ASP) x 6,11.11,30,,11.11,percent of total billed charges,Drugs,11.11,30,,11.11,percent of total billed charges,Drugs,11.11,30,,11.11,percent of total billed charges,Drugs,11.11,30,,11.11,percent of total billed charges,Drugs,11.11,30,,11.11,percent of total billed charges,Drugs,18.52,50,,18.52,percent of total billed charges,All Other,11.11,30,,11.11,percent of total billed charges,Drugs,11.11,30,,11.11,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,11.11,30,,11.11,percent of total billed charges,Drugs,11.11,30,,11.11,percent of total billed charges,Drugs,11.11,30,,11.11,percent of total billed charges,Drugs,11.11,30,,11.11,percent of total billed charges,Drugs,11.11,30,,11.11,percent of total billed charges,Drugs,11.11,30,,11.11,percent of total billed charges,Drugs,11.11,30,,11.11,percent of total billed charges,Drugs,11.11,30,,11.11,percent of total billed charges,Drugs,11.11,30,,11.11,percent of total billed charges,Drugs,11.11,30,,11.11,percent of total billed charges,Drugs,11.11,30,,11.11,percent of total billed charges,Drugs,11.11,30,,11.11,percent of total billed charges,Drugs,11.11,30,,11.11,percent of total billed charges,Drugs,12.55,,,12.55,Other,Drug Cost,12.55,,,12.55,Other,Drug Cost,12.55,,,12.55,Other,Drug Cost,12.55,,,12.55,Other,Drug Cost,12.55,,,12.55,Other,Drug Cost,12.59,34,,12.59,percent of total billed charges,Drugs,12.55,,,12.55,Other,Drug Cost,28.24,,,28.24,Other,225% Medicaid APG methodology,17.57,,,17.57,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,41.96,,,41.96,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",12.55,,,12.55,Other,Drug Cost,12.55,,,12.55,Other,Drug Cost,15.69,,,15.69,Other,125% Medicaid APG methodology,0.01,43.13,
PROMETHAZINE 6.25 MG/5 ML UD    ,Q0169,HCPCS,,40594327,CDM,636,RC,70408-0146-34,NDC,both,5,ML,1.37,0.54,39.4668,,0.54,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,0.41,30,,0.41,percent of total billed charges,Drugs,0.41,30,,0.41,percent of total billed charges,Drugs,0.41,30,,0.41,percent of total billed charges,Drugs,0.41,30,,0.41,percent of total billed charges,Drugs,0.41,30,,0.41,percent of total billed charges,Drugs,0.69,50,,0.69,percent of total billed charges,All Other,0.41,30,,0.41,percent of total billed charges,Drugs,0.41,30,,0.41,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.41,30,,0.41,percent of total billed charges,Drugs,0.41,30,,0.41,percent of total billed charges,Drugs,0.41,30,,0.41,percent of total billed charges,Drugs,0.41,30,,0.41,percent of total billed charges,Drugs,0.41,30,,0.41,percent of total billed charges,Drugs,0.41,30,,0.41,percent of total billed charges,Drugs,0.41,30,,0.41,percent of total billed charges,Drugs,0.41,30,,0.41,percent of total billed charges,Drugs,0.41,30,,0.41,percent of total billed charges,Drugs,0.41,30,,0.41,percent of total billed charges,Drugs,0.41,30,,0.41,percent of total billed charges,Drugs,0.41,30,,0.41,percent of total billed charges,Drugs,0.41,30,,0.41,percent of total billed charges,Drugs,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.47,34,,0.47,percent of total billed charges,Drugs,0.38,,,0.38,Other,Drug Cost,0.86,,,0.86,Other,225% Medicaid APG methodology,0.53,,,0.53,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.38,,,0.38,Other,Drug Cost,0.38,,,0.38,Other,Drug Cost,0.48,,,0.48,Other,125% Medicaid APG methodology,0.01,0.86,
TIGECYCLINE 50 MG IV INJ        ,J3243,HCPCS,,40594343,CDM,636,RC,63323-0960-10,NDC,both,1,EA,92.68,7.26,,,7.26,Other,150% of Medicare + 9.63% HCRA Surcharge,4.42,,,4.42,Fee Schedule,Average Sale Price (ASP) x 6,27.8,30,,27.8,percent of total billed charges,Drugs,27.8,30,,27.8,percent of total billed charges,Drugs,27.8,30,,27.8,percent of total billed charges,Drugs,27.8,30,,27.8,percent of total billed charges,Drugs,27.8,30,,27.8,percent of total billed charges,Drugs,46.34,50,,46.34,percent of total billed charges,All Other,27.8,30,,27.8,percent of total billed charges,Drugs,27.8,30,,27.8,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,27.8,30,,27.8,percent of total billed charges,Drugs,27.8,30,,27.8,percent of total billed charges,Drugs,27.8,30,,27.8,percent of total billed charges,Drugs,27.8,30,,27.8,percent of total billed charges,Drugs,27.8,30,,27.8,percent of total billed charges,Drugs,27.8,30,,27.8,percent of total billed charges,Drugs,27.8,30,,27.8,percent of total billed charges,Drugs,27.8,30,,27.8,percent of total billed charges,Drugs,27.8,30,,27.8,percent of total billed charges,Drugs,27.8,30,,27.8,percent of total billed charges,Drugs,27.8,30,,27.8,percent of total billed charges,Drugs,27.8,30,,27.8,percent of total billed charges,Drugs,27.8,30,,27.8,percent of total billed charges,Drugs,31.83,,,31.83,Other,Drug Cost,31.83,,,31.83,Other,Drug Cost,31.83,,,31.83,Other,Drug Cost,31.83,,,31.83,Other,Drug Cost,31.83,,,31.83,Other,Drug Cost,31.51,34,,31.51,percent of total billed charges,Drugs,31.83,,,31.83,Other,Drug Cost,71.62,,,71.62,Other,225% Medicaid APG methodology,44.56,,,44.56,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,7.07,,,7.07,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",31.83,,,31.83,Other,Drug Cost,31.83,,,31.83,Other,Drug Cost,39.79,,,39.79,Other,125% Medicaid APG methodology,0.01,71.62,
METHYLPREDNISOLON SUC 1G INJ    ,J2930,HCPCS,,40594376,CDM,636,RC,63323-0265-30,NDC,both,1,EA,38.75,58.04,,,58.04,Other,150% of Medicare + 9.63% HCRA Surcharge,35.29,,,35.29,Fee Schedule,Average Sale Price (ASP) x 6,11.63,30,,11.63,percent of total billed charges,Drugs,11.63,30,,11.63,percent of total billed charges,Drugs,11.63,30,,11.63,percent of total billed charges,Drugs,11.63,30,,11.63,percent of total billed charges,Drugs,11.63,30,,11.63,percent of total billed charges,Drugs,19.38,50,,19.38,percent of total billed charges,All Other,11.63,30,,11.63,percent of total billed charges,Drugs,11.63,30,,11.63,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,11.63,30,,11.63,percent of total billed charges,Drugs,11.63,30,,11.63,percent of total billed charges,Drugs,11.63,30,,11.63,percent of total billed charges,Drugs,11.63,30,,11.63,percent of total billed charges,Drugs,11.63,30,,11.63,percent of total billed charges,Drugs,11.63,30,,11.63,percent of total billed charges,Drugs,11.63,30,,11.63,percent of total billed charges,Drugs,11.63,30,,11.63,percent of total billed charges,Drugs,11.63,30,,11.63,percent of total billed charges,Drugs,11.63,30,,11.63,percent of total billed charges,Drugs,11.63,30,,11.63,percent of total billed charges,Drugs,11.63,30,,11.63,percent of total billed charges,Drugs,11.63,30,,11.63,percent of total billed charges,Drugs,14.56,,,14.56,Other,Drug Cost,14.56,,,14.56,Other,Drug Cost,14.56,,,14.56,Other,Drug Cost,14.56,,,14.56,Other,Drug Cost,14.56,,,14.56,Other,Drug Cost,13.18,34,,13.18,percent of total billed charges,Drugs,14.56,,,14.56,Other,Drug Cost,32.76,,,32.76,Other,225% Medicaid APG methodology,20.38,,,20.38,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,56.47,,,56.47,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",14.56,,,14.56,Other,Drug Cost,14.56,,,14.56,Other,Drug Cost,18.2,,,18.2,Other,125% Medicaid APG methodology,0.01,58.04,
ACETYLCYSTEINE 20% INHSOLN30ML  ,J7608,HCPCS,,40594400,CDM,636,RC,00409-3308-03,NDC,both,30,ML,31.15,67.34,,,67.34,Other,150% of Medicare + 9.63% HCRA Surcharge,40.95,,,40.95,Fee Schedule,Average Sale Price (ASP) x 6,9.35,30,,9.35,percent of total billed charges,Drugs,9.35,30,,9.35,percent of total billed charges,Drugs,9.35,30,,9.35,percent of total billed charges,Drugs,9.35,30,,9.35,percent of total billed charges,Drugs,9.35,30,,9.35,percent of total billed charges,Drugs,15.58,50,,15.58,percent of total billed charges,All Other,9.35,30,,9.35,percent of total billed charges,Drugs,9.35,30,,9.35,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,9.35,30,,9.35,percent of total billed charges,Drugs,9.35,30,,9.35,percent of total billed charges,Drugs,9.35,30,,9.35,percent of total billed charges,Drugs,9.35,30,,9.35,percent of total billed charges,Drugs,9.35,30,,9.35,percent of total billed charges,Drugs,9.35,30,,9.35,percent of total billed charges,Drugs,9.35,30,,9.35,percent of total billed charges,Drugs,9.35,30,,9.35,percent of total billed charges,Drugs,9.35,30,,9.35,percent of total billed charges,Drugs,9.35,30,,9.35,percent of total billed charges,Drugs,9.35,30,,9.35,percent of total billed charges,Drugs,9.35,30,,9.35,percent of total billed charges,Drugs,9.35,30,,9.35,percent of total billed charges,Drugs,6.49,,,6.49,Other,Drug Cost,6.49,,,6.49,Other,Drug Cost,6.49,,,6.49,Other,Drug Cost,6.49,,,6.49,Other,Drug Cost,6.49,,,6.49,Other,Drug Cost,10.59,34,,10.59,percent of total billed charges,Drugs,6.49,,,6.49,Other,Drug Cost,14.6,,,14.6,Other,225% Medicaid APG methodology,9.09,,,9.09,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,65.52,,,65.52,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6.49,,,6.49,Other,Drug Cost,6.49,,,6.49,Other,Drug Cost,8.11,,,8.11,Other,125% Medicaid APG methodology,0.01,67.34,
HYDROCORTISONE 500MGSUCC PFINJ  ,J1720,HCPCS,,40594426,CDM,636,RC,00009-0016-12,NDC,both,1,EA,163.63,176.07,,,176.07,Other,150% of Medicare + 9.63% HCRA Surcharge,107.07,,,107.07,Fee Schedule,Average Sale Price (ASP) x 6,49.09,30,,49.09,percent of total billed charges,Drugs,49.09,30,,49.09,percent of total billed charges,Drugs,49.09,30,,49.09,percent of total billed charges,Drugs,49.09,30,,49.09,percent of total billed charges,Drugs,49.09,30,,49.09,percent of total billed charges,Drugs,81.82,50,,81.82,percent of total billed charges,All Other,49.09,30,,49.09,percent of total billed charges,Drugs,49.09,30,,49.09,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,49.09,30,,49.09,percent of total billed charges,Drugs,49.09,30,,49.09,percent of total billed charges,Drugs,49.09,30,,49.09,percent of total billed charges,Drugs,49.09,30,,49.09,percent of total billed charges,Drugs,49.09,30,,49.09,percent of total billed charges,Drugs,49.09,30,,49.09,percent of total billed charges,Drugs,49.09,30,,49.09,percent of total billed charges,Drugs,49.09,30,,49.09,percent of total billed charges,Drugs,49.09,30,,49.09,percent of total billed charges,Drugs,49.09,30,,49.09,percent of total billed charges,Drugs,49.09,30,,49.09,percent of total billed charges,Drugs,49.09,30,,49.09,percent of total billed charges,Drugs,49.09,30,,49.09,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,55.63,34,,55.63,percent of total billed charges,Drugs,0.01,,,0.01,Other,Drug Cost,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,171.31,,,171.31,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,Drug Cost,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,176.07,
ALTEPLASE 10MG IN 50ML NS  SYR  ,J2997,HCPCS,,40594574,CDM,636,RC,50242-0041-64d,NDC,both,1,EA,2489.9,877.88,,,877.88,Other,150% of Medicare + 9.63% HCRA Surcharge,533.84,,,533.84,Fee Schedule,Average Sale Price (ASP) x 6,746.97,30,,746.97,percent of total billed charges,Drugs,746.97,30,,746.97,percent of total billed charges,Drugs,746.97,30,,746.97,percent of total billed charges,Drugs,746.97,30,,746.97,percent of total billed charges,Drugs,746.97,30,,746.97,percent of total billed charges,Drugs,1244.95,50,,1244.95,percent of total billed charges,All Other,746.97,30,,746.97,percent of total billed charges,Drugs,746.97,30,,746.97,percent of total billed charges,Drugs,846.57,34,"If Charge > 500, then 34 percent",846.57,percent of total billed charges,Drugs,746.97,30,,746.97,percent of total billed charges,Drugs,746.97,30,,746.97,percent of total billed charges,Drugs,746.97,30,,746.97,percent of total billed charges,Drugs,746.97,30,,746.97,percent of total billed charges,Drugs,746.97,30,,746.97,percent of total billed charges,Drugs,746.97,30,,746.97,percent of total billed charges,Drugs,746.97,30,,746.97,percent of total billed charges,Drugs,746.97,30,,746.97,percent of total billed charges,Drugs,746.97,30,,746.97,percent of total billed charges,Drugs,746.97,30,,746.97,percent of total billed charges,Drugs,746.97,30,,746.97,percent of total billed charges,Drugs,746.97,30,,746.97,percent of total billed charges,Drugs,746.97,30,,746.97,percent of total billed charges,Drugs,196.55,,,196.55,Other,Drug Cost,196.55,,,196.55,Other,Drug Cost,196.55,,,196.55,Other,Drug Cost,196.55,,,196.55,Other,Drug Cost,196.55,,,196.55,Other,Drug Cost,846.57,34,,846.57,percent of total billed charges,Drugs,196.55,,,196.55,Other,Drug Cost,442.24,,,442.24,Other,225% Medicaid APG methodology,275.17,,,275.17,Other,140% Medicaid APG methodology,846.57,34,"If Charge > 2,000, then 34 percent",846.57,percent of total billed charges,Drugs,854.15,,,854.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",196.55,,,196.55,Other,Drug Cost,196.55,,,196.55,Other,Drug Cost,245.69,,,245.69,Other,125% Medicaid APG methodology,0.01,1244.95,
EPOETIN-EPBX 2000U/ML NON-ESRD  ,Q5106,HCPCS,,40594996,CDM,636,RC,00069-1305-10,NDC,both,1,ML,60.31,77.2,,,77.2,Other,150% of Medicare + 9.63% HCRA Surcharge,46.94,,,46.94,Fee Schedule,Average Sale Price (ASP) x 6,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,30.16,50,,30.16,percent of total billed charges,All Other,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,18.09,30,,18.09,percent of total billed charges,Drugs,6.6,,,6.6,Other,Drug Cost,6.6,,,6.6,Other,Drug Cost,6.6,,,6.6,Other,Drug Cost,6.6,,,6.6,Other,Drug Cost,6.6,,,6.6,Other,Drug Cost,20.51,34,,20.51,percent of total billed charges,Drugs,6.6,,,6.6,Other,Drug Cost,14.85,,,14.85,Other,225% Medicaid APG methodology,9.24,,,9.24,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,75.11,,,75.11,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",6.6,,,6.6,Other,Drug Cost,6.6,,,6.6,Other,Drug Cost,8.25,,,8.25,Other,125% Medicaid APG methodology,0.01,77.2,
EPOETIN-EPBX 4000U/ML NON-ESRD  ,Q5106,HCPCS,,40595001,CDM,636,RC,00069-1307-10,NDC,both,1,ML,120.61,77.2,,,77.2,Other,150% of Medicare + 9.63% HCRA Surcharge,46.94,,,46.94,Fee Schedule,Average Sale Price (ASP) x 6,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,60.31,50,,60.31,percent of total billed charges,All Other,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,36.18,30,,36.18,percent of total billed charges,Drugs,13.2,,,13.2,Other,Drug Cost,13.2,,,13.2,Other,Drug Cost,13.2,,,13.2,Other,Drug Cost,13.2,,,13.2,Other,Drug Cost,13.2,,,13.2,Other,Drug Cost,41.01,34,,41.01,percent of total billed charges,Drugs,13.2,,,13.2,Other,Drug Cost,29.7,,,29.7,Other,225% Medicaid APG methodology,18.48,,,18.48,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,75.11,,,75.11,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",13.2,,,13.2,Other,Drug Cost,13.2,,,13.2,Other,Drug Cost,16.5,,,16.5,Other,125% Medicaid APG methodology,0.01,77.2,
EPOETN-EPBX 40000U/ML NON-ESRD  ,Q5106,HCPCS,,40595027,CDM,636,RC,00069-1309-04,NDC,both,1,ML,1206.14,77.2,,,77.2,Other,150% of Medicare + 9.63% HCRA Surcharge,46.94,,,46.94,Fee Schedule,Average Sale Price (ASP) x 6,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,603.07,50,,603.07,percent of total billed charges,All Other,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,410.09,34,"If Charge > 500, then 34 percent",410.09,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,361.84,30,,361.84,percent of total billed charges,Drugs,132,,,132,Other,Drug Cost,132,,,132,Other,Drug Cost,132,,,132,Other,Drug Cost,132,,,132,Other,Drug Cost,132,,,132,Other,Drug Cost,410.09,34,,410.09,percent of total billed charges,Drugs,132,,,132,Other,Drug Cost,297,,,297,Other,225% Medicaid APG methodology,184.8,,,184.8,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,75.11,,,75.11,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",132,,,132,Other,Drug Cost,132,,,132,Other,Drug Cost,165,,,165,Other,125% Medicaid APG methodology,0.01,603.07,
EPOETN-EPBX 10000U/ML NON-ESRD  ,Q5106,HCPCS,,40595035,CDM,636,RC,00069-1308-10,NDC,both,1,ML,301.53,77.2,,,77.2,Other,150% of Medicare + 9.63% HCRA Surcharge,46.94,,,46.94,Fee Schedule,Average Sale Price (ASP) x 6,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,150.77,50,,150.77,percent of total billed charges,All Other,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,90.46,30,,90.46,percent of total billed charges,Drugs,33,,,33,Other,Drug Cost,33,,,33,Other,Drug Cost,33,,,33,Other,Drug Cost,33,,,33,Other,Drug Cost,33,,,33,Other,Drug Cost,102.52,34,,102.52,percent of total billed charges,Drugs,33,,,33,Other,Drug Cost,74.25,,,74.25,Other,225% Medicaid APG methodology,46.2,,,46.2,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,75.11,,,75.11,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",33,,,33,Other,Drug Cost,33,,,33,Other,Drug Cost,41.25,,,41.25,Other,125% Medicaid APG methodology,0.01,150.77,
EPOETIN 10000UNITS/ML NON-ESRD  ,J0888,HCPCS,,40595068,CDM,636,RC,55513-0144-10,NDC,both,1,ML,560.14,15.96,,,15.96,Other,150% of Medicare + 9.63% HCRA Surcharge,9.71,,,9.71,Fee Schedule,Average Sale Price (ASP) x 6,168.04,30,,168.04,percent of total billed charges,Drugs,168.04,30,,168.04,percent of total billed charges,Drugs,168.04,30,,168.04,percent of total billed charges,Drugs,168.04,30,,168.04,percent of total billed charges,Drugs,168.04,30,,168.04,percent of total billed charges,Drugs,280.07,50,,280.07,percent of total billed charges,All Other,168.04,30,,168.04,percent of total billed charges,Drugs,168.04,30,,168.04,percent of total billed charges,Drugs,190.45,34,"If Charge > 500, then 34 percent",190.45,percent of total billed charges,Drugs,168.04,30,,168.04,percent of total billed charges,Drugs,168.04,30,,168.04,percent of total billed charges,Drugs,168.04,30,,168.04,percent of total billed charges,Drugs,168.04,30,,168.04,percent of total billed charges,Drugs,168.04,30,,168.04,percent of total billed charges,Drugs,168.04,30,,168.04,percent of total billed charges,Drugs,168.04,30,,168.04,percent of total billed charges,Drugs,168.04,30,,168.04,percent of total billed charges,Drugs,168.04,30,,168.04,percent of total billed charges,Drugs,168.04,30,,168.04,percent of total billed charges,Drugs,168.04,30,,168.04,percent of total billed charges,Drugs,168.04,30,,168.04,percent of total billed charges,Drugs,168.04,30,,168.04,percent of total billed charges,Drugs,46.76,,,46.76,Other,Drug Cost,46.76,,,46.76,Other,Drug Cost,46.76,,,46.76,Other,Drug Cost,46.76,,,46.76,Other,Drug Cost,46.76,,,46.76,Other,Drug Cost,190.45,34,,190.45,percent of total billed charges,Drugs,46.76,,,46.76,Other,Drug Cost,105.21,,,105.21,Other,225% Medicaid APG methodology,65.46,,,65.46,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,15.53,,,15.53,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",46.76,,,46.76,Other,Drug Cost,46.76,,,46.76,Other,Drug Cost,58.45,,,58.45,Other,125% Medicaid APG methodology,0.01,280.07,
EPOETIN 2000UNITS/ML NON-ESRD   ,J0888,HCPCS,,40595076,CDM,636,RC,59676-0302-01,NDC,both,1,ML,180.6,15.96,,,15.96,Other,150% of Medicare + 9.63% HCRA Surcharge,9.71,,,9.71,Fee Schedule,Average Sale Price (ASP) x 6,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,90.3,50,,90.3,percent of total billed charges,All Other,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,54.18,30,,54.18,percent of total billed charges,Drugs,14.15,,,14.15,Other,Drug Cost,14.15,,,14.15,Other,Drug Cost,14.15,,,14.15,Other,Drug Cost,14.15,,,14.15,Other,Drug Cost,14.15,,,14.15,Other,Drug Cost,61.4,34,,61.4,percent of total billed charges,Drugs,14.15,,,14.15,Other,Drug Cost,31.84,,,31.84,Other,225% Medicaid APG methodology,19.81,,,19.81,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,15.53,,,15.53,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",14.15,,,14.15,Other,Drug Cost,14.15,,,14.15,Other,Drug Cost,17.69,,,17.69,Other,125% Medicaid APG methodology,0.01,90.3,
EPOETIN 3000 UNITS/ML NON-ESRD  ,J0888,HCPCS,,40595084,CDM,636,RC,59676-0303-01,NDC,both,1,ML,270.87,15.96,,,15.96,Other,150% of Medicare + 9.63% HCRA Surcharge,9.71,,,9.71,Fee Schedule,Average Sale Price (ASP) x 6,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,135.44,50,,135.44,percent of total billed charges,All Other,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,81.26,30,,81.26,percent of total billed charges,Drugs,19.23,,,19.23,Other,Drug Cost,19.23,,,19.23,Other,Drug Cost,19.23,,,19.23,Other,Drug Cost,19.23,,,19.23,Other,Drug Cost,19.23,,,19.23,Other,Drug Cost,92.1,34,,92.1,percent of total billed charges,Drugs,19.23,,,19.23,Other,Drug Cost,43.27,,,43.27,Other,225% Medicaid APG methodology,26.92,,,26.92,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,15.53,,,15.53,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",19.23,,,19.23,Other,Drug Cost,19.23,,,19.23,Other,Drug Cost,24.04,,,24.04,Other,125% Medicaid APG methodology,0.01,135.44,
EPOETIN 40000UNITS/ML NON-ESRD  ,J0888,HCPCS,,40595092,CDM,636,RC,59676-0340-01,NDC,both,1,ML,1969.91,15.96,,,15.96,Other,150% of Medicare + 9.63% HCRA Surcharge,9.71,,,9.71,Fee Schedule,Average Sale Price (ASP) x 6,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,984.96,50,,984.96,percent of total billed charges,All Other,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,669.77,34,"If Charge > 500, then 34 percent",669.77,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,590.97,30,,590.97,percent of total billed charges,Drugs,273.6,,,273.6,Other,Drug Cost,273.6,,,273.6,Other,Drug Cost,273.6,,,273.6,Other,Drug Cost,273.6,,,273.6,Other,Drug Cost,273.6,,,273.6,Other,Drug Cost,669.77,34,,669.77,percent of total billed charges,Drugs,273.6,,,273.6,Other,Drug Cost,615.6,,,615.6,Other,225% Medicaid APG methodology,383.04,,,383.04,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,15.53,,,15.53,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",273.6,,,273.6,Other,Drug Cost,273.6,,,273.6,Other,Drug Cost,342,,,342,Other,125% Medicaid APG methodology,0.01,984.96,
EPOETIN 4000 UNITS/ML NON-ESRD  ,J0888,HCPCS,,40595100,CDM,636,RC,59676-0304-01,NDC,both,1,ML,361.17,15.96,,,15.96,Other,150% of Medicare + 9.63% HCRA Surcharge,9.71,,,9.71,Fee Schedule,Average Sale Price (ASP) x 6,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,180.59,50,,180.59,percent of total billed charges,All Other,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,108.35,30,,108.35,percent of total billed charges,Drugs,30.52,,,30.52,Other,Drug Cost,30.52,,,30.52,Other,Drug Cost,30.52,,,30.52,Other,Drug Cost,30.52,,,30.52,Other,Drug Cost,30.52,,,30.52,Other,Drug Cost,122.8,34,,122.8,percent of total billed charges,Drugs,30.52,,,30.52,Other,Drug Cost,68.67,,,68.67,Other,225% Medicaid APG methodology,42.73,,,42.73,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,15.53,,,15.53,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",30.52,,,30.52,Other,Drug Cost,30.52,,,30.52,Other,Drug Cost,38.15,,,38.15,Other,125% Medicaid APG methodology,0.01,180.59,
EPOETIN-EPBX 3000U/ML NON-ESRD  ,Q5106,HCPCS,,40595233,CDM,636,RC,00069-1306-10,NDC,both,1,ML,904.58,77.2,,,77.2,Other,150% of Medicare + 9.63% HCRA Surcharge,46.94,,,46.94,Fee Schedule,Average Sale Price (ASP) x 6,271.37,30,,271.37,percent of total billed charges,Drugs,271.37,30,,271.37,percent of total billed charges,Drugs,271.37,30,,271.37,percent of total billed charges,Drugs,271.37,30,,271.37,percent of total billed charges,Drugs,271.37,30,,271.37,percent of total billed charges,Drugs,452.29,50,,452.29,percent of total billed charges,All Other,271.37,30,,271.37,percent of total billed charges,Drugs,271.37,30,,271.37,percent of total billed charges,Drugs,307.56,34,"If Charge > 500, then 34 percent",307.56,percent of total billed charges,Drugs,271.37,30,,271.37,percent of total billed charges,Drugs,271.37,30,,271.37,percent of total billed charges,Drugs,271.37,30,,271.37,percent of total billed charges,Drugs,271.37,30,,271.37,percent of total billed charges,Drugs,271.37,30,,271.37,percent of total billed charges,Drugs,271.37,30,,271.37,percent of total billed charges,Drugs,271.37,30,,271.37,percent of total billed charges,Drugs,271.37,30,,271.37,percent of total billed charges,Drugs,271.37,30,,271.37,percent of total billed charges,Drugs,271.37,30,,271.37,percent of total billed charges,Drugs,271.37,30,,271.37,percent of total billed charges,Drugs,271.37,30,,271.37,percent of total billed charges,Drugs,271.37,30,,271.37,percent of total billed charges,Drugs,9.9,,,9.9,Other,Drug Cost,9.9,,,9.9,Other,Drug Cost,9.9,,,9.9,Other,Drug Cost,9.9,,,9.9,Other,Drug Cost,9.9,,,9.9,Other,Drug Cost,307.56,34,,307.56,percent of total billed charges,Drugs,9.9,,,9.9,Other,Drug Cost,22.28,,,22.28,Other,225% Medicaid APG methodology,13.86,,,13.86,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,75.11,,,75.11,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",9.9,,,9.9,Other,Drug Cost,9.9,,,9.9,Other,Drug Cost,12.38,,,12.38,Other,125% Medicaid APG methodology,0.01,452.29,
LEVOTHYROXINE 20 MCG/ML INJ     ,J3490,HCPCS,,40595274,CDM,636,RC,63323-0885-10,NDC,both,5,ML,232.16,91.63,39.4668,,91.63,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,69.65,30,,69.65,percent of total billed charges,Drugs,69.65,30,,69.65,percent of total billed charges,Drugs,69.65,30,,69.65,percent of total billed charges,Drugs,69.65,30,,69.65,percent of total billed charges,Drugs,69.65,30,,69.65,percent of total billed charges,Drugs,116.08,50,,116.08,percent of total billed charges,All Other,69.65,30,,69.65,percent of total billed charges,Drugs,69.65,30,,69.65,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,69.65,30,,69.65,percent of total billed charges,Drugs,69.65,30,,69.65,percent of total billed charges,Drugs,69.65,30,,69.65,percent of total billed charges,Drugs,69.65,30,,69.65,percent of total billed charges,Drugs,69.65,30,,69.65,percent of total billed charges,Drugs,69.65,30,,69.65,percent of total billed charges,Drugs,69.65,30,,69.65,percent of total billed charges,Drugs,69.65,30,,69.65,percent of total billed charges,Drugs,69.65,30,,69.65,percent of total billed charges,Drugs,69.65,30,,69.65,percent of total billed charges,Drugs,69.65,30,,69.65,percent of total billed charges,Drugs,69.65,30,,69.65,percent of total billed charges,Drugs,69.65,30,,69.65,percent of total billed charges,Drugs,31.69,,,31.69,Other,Drug Cost,31.69,,,31.69,Other,Drug Cost,31.69,,,31.69,Other,Drug Cost,31.69,,,31.69,Other,Drug Cost,31.69,,,31.69,Other,Drug Cost,78.93,34,,78.93,percent of total billed charges,Drugs,31.69,,,31.69,Other,Drug Cost,71.3,,,71.3,Other,225% Medicaid APG methodology,44.37,,,44.37,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",31.69,,,31.69,Other,Drug Cost,31.69,,,31.69,Other,Drug Cost,39.61,,,39.61,Other,125% Medicaid APG methodology,0.01,116.08,
DARZALEX FASPRO 400MG/20ML VL   ,J9144,HCPCS,,40595506,CDM,636,RC,57894-0503-01,NDC,both,15,ML,33610.96,483.97,,,483.97,Other,150% of Medicare + 9.63% HCRA Surcharge,294.31,,,294.31,Fee Schedule,Average Sale Price (ASP) x 6,10083.29,30,,10083.29,percent of total billed charges,Drugs,10083.29,30,,10083.29,percent of total billed charges,Drugs,10083.29,30,,10083.29,percent of total billed charges,Drugs,10083.29,30,,10083.29,percent of total billed charges,Drugs,10083.29,30,,10083.29,percent of total billed charges,Drugs,16805.48,50,,16805.48,percent of total billed charges,All Other,10083.29,30,,10083.29,percent of total billed charges,Drugs,10083.29,30,,10083.29,percent of total billed charges,Drugs,11427.73,34,"If Charge > 500, then 34 percent",11427.73,percent of total billed charges,Drugs,10083.29,30,,10083.29,percent of total billed charges,Drugs,10083.29,30,,10083.29,percent of total billed charges,Drugs,10083.29,30,,10083.29,percent of total billed charges,Drugs,10083.29,30,,10083.29,percent of total billed charges,Drugs,10083.29,30,,10083.29,percent of total billed charges,Drugs,10083.29,30,,10083.29,percent of total billed charges,Drugs,10083.29,30,,10083.29,percent of total billed charges,Drugs,10083.29,30,,10083.29,percent of total billed charges,Drugs,10083.29,30,,10083.29,percent of total billed charges,Drugs,10083.29,30,,10083.29,percent of total billed charges,Drugs,10083.29,30,,10083.29,percent of total billed charges,Drugs,10083.29,30,,10083.29,percent of total billed charges,Drugs,10083.29,30,,10083.29,percent of total billed charges,Drugs,6621.15,,,6621.15,Other,Drug Cost,6621.15,,,6621.15,Other,Drug Cost,6621.15,,,6621.15,Other,Drug Cost,6621.15,,,6621.15,Other,Drug Cost,6621.15,,,6621.15,Other,Drug Cost,11427.73,34,,11427.73,percent of total billed charges,Drugs,6621.15,,,6621.15,Other,Drug Cost,14897.59,,,14897.59,Other,225% Medicaid APG methodology,9269.61,,,9269.61,Other,140% Medicaid APG methodology,11427.73,34,"If Charge > 2,000, then 34 percent",11427.73,percent of total billed charges,Drugs,470.89,,,470.89,Other,160% Medicare Fee Schedule,11427.73,34,,11427.73,Other,"Drug Charges > 20,000, then 34% of Charges",6621.15,,,6621.15,Other,Drug Cost,6621.15,,,6621.15,Other,Drug Cost,8276.44,,,8276.44,Other,125% Medicaid APG methodology,294.31,16805.48,
TRASTUZUMAB-ANNS 150MG VIAL     ,Q5117,HCPCS,,40595522,CDM,636,RC,55513-0141-01,NDC,both,1,EA,4490.12,132.71,,,132.71,Other,150% of Medicare + 9.63% HCRA Surcharge,80.7,,,80.7,Fee Schedule,Average Sale Price (ASP) x 6,1347.04,30,,1347.04,percent of total billed charges,Drugs,1347.04,30,,1347.04,percent of total billed charges,Drugs,1347.04,30,,1347.04,percent of total billed charges,Drugs,1347.04,30,,1347.04,percent of total billed charges,Drugs,1347.04,30,,1347.04,percent of total billed charges,Drugs,2245.06,50,,2245.06,percent of total billed charges,All Other,1347.04,30,,1347.04,percent of total billed charges,Drugs,1347.04,30,,1347.04,percent of total billed charges,Drugs,1526.64,34,"If Charge > 500, then 34 percent",1526.64,percent of total billed charges,Drugs,1347.04,30,,1347.04,percent of total billed charges,Drugs,1347.04,30,,1347.04,percent of total billed charges,Drugs,1347.04,30,,1347.04,percent of total billed charges,Drugs,1347.04,30,,1347.04,percent of total billed charges,Drugs,1347.04,30,,1347.04,percent of total billed charges,Drugs,1347.04,30,,1347.04,percent of total billed charges,Drugs,1347.04,30,,1347.04,percent of total billed charges,Drugs,1347.04,30,,1347.04,percent of total billed charges,Drugs,1347.04,30,,1347.04,percent of total billed charges,Drugs,1347.04,30,,1347.04,percent of total billed charges,Drugs,1347.04,30,,1347.04,percent of total billed charges,Drugs,1347.04,30,,1347.04,percent of total billed charges,Drugs,1347.04,30,,1347.04,percent of total billed charges,Drugs,107.85,,,107.85,Other,Drug Cost,107.85,,,107.85,Other,Drug Cost,107.85,,,107.85,Other,Drug Cost,107.85,,,107.85,Other,Drug Cost,107.85,,,107.85,Other,Drug Cost,1526.64,34,,1526.64,percent of total billed charges,Drugs,107.85,,,107.85,Other,Drug Cost,242.66,,,242.66,Other,225% Medicaid APG methodology,150.99,,,150.99,Other,140% Medicaid APG methodology,1526.64,34,"If Charge > 2,000, then 34 percent",1526.64,percent of total billed charges,Drugs,129.12,,,129.12,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",107.85,,,107.85,Other,Drug Cost,107.85,,,107.85,Other,Drug Cost,134.81,,,134.81,Other,125% Medicaid APG methodology,0.01,2245.06,
TRASTUZUMAB-ANNS 420MG VIAL     ,Q5117,HCPCS,,40595530,CDM,636,RC,55513-0132-01,NDC,both,1,EA,12572.25,132.71,,,132.71,Other,150% of Medicare + 9.63% HCRA Surcharge,80.7,,,80.7,Fee Schedule,Average Sale Price (ASP) x 6,3771.68,30,,3771.68,percent of total billed charges,Drugs,3771.68,30,,3771.68,percent of total billed charges,Drugs,3771.68,30,,3771.68,percent of total billed charges,Drugs,3771.68,30,,3771.68,percent of total billed charges,Drugs,3771.68,30,,3771.68,percent of total billed charges,Drugs,6286.13,50,,6286.13,percent of total billed charges,All Other,3771.68,30,,3771.68,percent of total billed charges,Drugs,3771.68,30,,3771.68,percent of total billed charges,Drugs,4274.57,34,"If Charge > 500, then 34 percent",4274.57,percent of total billed charges,Drugs,3771.68,30,,3771.68,percent of total billed charges,Drugs,3771.68,30,,3771.68,percent of total billed charges,Drugs,3771.68,30,,3771.68,percent of total billed charges,Drugs,3771.68,30,,3771.68,percent of total billed charges,Drugs,3771.68,30,,3771.68,percent of total billed charges,Drugs,3771.68,30,,3771.68,percent of total billed charges,Drugs,3771.68,30,,3771.68,percent of total billed charges,Drugs,3771.68,30,,3771.68,percent of total billed charges,Drugs,3771.68,30,,3771.68,percent of total billed charges,Drugs,3771.68,30,,3771.68,percent of total billed charges,Drugs,3771.68,30,,3771.68,percent of total billed charges,Drugs,3771.68,30,,3771.68,percent of total billed charges,Drugs,3771.68,30,,3771.68,percent of total billed charges,Drugs,351.26,,,351.26,Other,Drug Cost,351.26,,,351.26,Other,Drug Cost,351.26,,,351.26,Other,Drug Cost,351.26,,,351.26,Other,Drug Cost,351.26,,,351.26,Other,Drug Cost,4274.57,34,,4274.57,percent of total billed charges,Drugs,351.26,,,351.26,Other,Drug Cost,790.34,,,790.34,Other,225% Medicaid APG methodology,491.76,,,491.76,Other,140% Medicaid APG methodology,4274.57,34,"If Charge > 2,000, then 34 percent",4274.57,percent of total billed charges,Drugs,129.12,,,129.12,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",351.26,,,351.26,Other,Drug Cost,351.26,,,351.26,Other,Drug Cost,439.08,,,439.08,Other,125% Medicaid APG methodology,0.01,6286.13,
INSULIN REG 100 UN/ML INJ 3ML   ,J1815,HCPCS,,40595944,CDM,636,RC,00002-8215-17,NDC,both,3,ML,15.72,6.2,39.4668,,6.2,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,4.72,30,,4.72,percent of total billed charges,Drugs,4.72,30,,4.72,percent of total billed charges,Drugs,4.72,30,,4.72,percent of total billed charges,Drugs,4.72,30,,4.72,percent of total billed charges,Drugs,4.72,30,,4.72,percent of total billed charges,Drugs,7.86,50,,7.86,percent of total billed charges,All Other,4.72,30,,4.72,percent of total billed charges,Drugs,4.72,30,,4.72,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,4.72,30,,4.72,percent of total billed charges,Drugs,4.72,30,,4.72,percent of total billed charges,Drugs,4.72,30,,4.72,percent of total billed charges,Drugs,4.72,30,,4.72,percent of total billed charges,Drugs,4.72,30,,4.72,percent of total billed charges,Drugs,4.72,30,,4.72,percent of total billed charges,Drugs,4.72,30,,4.72,percent of total billed charges,Drugs,4.72,30,,4.72,percent of total billed charges,Drugs,4.72,30,,4.72,percent of total billed charges,Drugs,4.72,30,,4.72,percent of total billed charges,Drugs,4.72,30,,4.72,percent of total billed charges,Drugs,4.72,30,,4.72,percent of total billed charges,Drugs,4.72,30,,4.72,percent of total billed charges,Drugs,10.85,,,10.85,Other,Drug Cost,10.85,,,10.85,Other,Drug Cost,10.85,,,10.85,Other,Drug Cost,10.85,,,10.85,Other,Drug Cost,10.85,,,10.85,Other,Drug Cost,5.34,34,,5.34,percent of total billed charges,Drugs,10.85,,,10.85,Other,Drug Cost,24.41,,,24.41,Other,225% Medicaid APG methodology,15.19,,,15.19,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",10.85,,,10.85,Other,Drug Cost,10.85,,,10.85,Other,Drug Cost,13.56,,,13.56,Other,125% Medicaid APG methodology,0.01,24.41,
AVELUMAB 20 MG/ML SOL           ,J9023,HCPCS,,40596116,CDM,636,RC,44087-3535-01,NDC,both,10,ML,6747.02,911.38,,,911.38,Other,150% of Medicare + 9.63% HCRA Surcharge,554.21,,,554.21,Fee Schedule,Average Sale Price (ASP) x 6,2024.11,30,,2024.11,percent of total billed charges,Drugs,2024.11,30,,2024.11,percent of total billed charges,Drugs,2024.11,30,,2024.11,percent of total billed charges,Drugs,2024.11,30,,2024.11,percent of total billed charges,Drugs,2024.11,30,,2024.11,percent of total billed charges,Drugs,3373.51,50,,3373.51,percent of total billed charges,All Other,2024.11,30,,2024.11,percent of total billed charges,Drugs,2024.11,30,,2024.11,percent of total billed charges,Drugs,2293.99,34,"If Charge > 500, then 34 percent",2293.99,percent of total billed charges,Drugs,2024.11,30,,2024.11,percent of total billed charges,Drugs,2024.11,30,,2024.11,percent of total billed charges,Drugs,2024.11,30,,2024.11,percent of total billed charges,Drugs,2024.11,30,,2024.11,percent of total billed charges,Drugs,2024.11,30,,2024.11,percent of total billed charges,Drugs,2024.11,30,,2024.11,percent of total billed charges,Drugs,2024.11,30,,2024.11,percent of total billed charges,Drugs,2024.11,30,,2024.11,percent of total billed charges,Drugs,2024.11,30,,2024.11,percent of total billed charges,Drugs,2024.11,30,,2024.11,percent of total billed charges,Drugs,2024.11,30,,2024.11,percent of total billed charges,Drugs,2024.11,30,,2024.11,percent of total billed charges,Drugs,2024.11,30,,2024.11,percent of total billed charges,Drugs,1362.17,,,1362.17,Other,Drug Cost,1362.17,,,1362.17,Other,Drug Cost,1362.17,,,1362.17,Other,Drug Cost,1362.17,,,1362.17,Other,Drug Cost,1362.17,,,1362.17,Other,Drug Cost,2293.99,34,,2293.99,percent of total billed charges,Drugs,1362.17,,,1362.17,Other,Drug Cost,3064.88,,,3064.88,Other,225% Medicaid APG methodology,1907.04,,,1907.04,Other,140% Medicaid APG methodology,2293.99,34,"If Charge > 2,000, then 34 percent",2293.99,percent of total billed charges,Drugs,886.74,,,886.74,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1362.17,,,1362.17,Other,Drug Cost,1362.17,,,1362.17,Other,Drug Cost,1702.71,,,1702.71,Other,125% Medicaid APG methodology,0.01,3373.51,
PHENYLEPHRINE 10 MG/ML INJ 5ML  ,J2371,HCPCS,,40596132,CDM,636,RC,00781-3458-95,NDC,both,1,ML,7.25,2.86,39.4668,,2.86,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,3.63,50,,3.63,percent of total billed charges,All Other,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,2.18,30,,2.18,percent of total billed charges,Drugs,0.89,,,0.89,Other,Drug Cost,0.89,,,0.89,Other,Drug Cost,0.89,,,0.89,Other,Drug Cost,0.89,,,0.89,Other,Drug Cost,0.89,,,0.89,Other,Drug Cost,2.47,34,,2.47,percent of total billed charges,Drugs,0.89,,,0.89,Other,Drug Cost,2,,,2,Other,225% Medicaid APG methodology,1.25,,,1.25,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.89,,,0.89,Other,Drug Cost,0.89,,,0.89,Other,Drug Cost,1.11,,,1.11,Other,125% Medicaid APG methodology,0.01,3.63,
NF REMDESIVIR 100MG POWDER INJ  ,J0248,HCPCS,,40597023,CDM,636,RC,61958-2901-02,NDC,both,1,EA,2000.18,59.77,,,59.77,Other,150% of Medicare + 9.63% HCRA Surcharge,36.35,,,36.35,Fee Schedule,Average Sale Price (ASP) x 6,600.05,30,,600.05,percent of total billed charges,Drugs,600.05,30,,600.05,percent of total billed charges,Drugs,600.05,30,,600.05,percent of total billed charges,Drugs,600.05,30,,600.05,percent of total billed charges,Drugs,600.05,30,,600.05,percent of total billed charges,Drugs,1000.09,50,,1000.09,percent of total billed charges,All Other,600.05,30,,600.05,percent of total billed charges,Drugs,600.05,30,,600.05,percent of total billed charges,Drugs,680.06,34,"If Charge > 500, then 34 percent",680.06,percent of total billed charges,Drugs,600.05,30,,600.05,percent of total billed charges,Drugs,600.05,30,,600.05,percent of total billed charges,Drugs,600.05,30,,600.05,percent of total billed charges,Drugs,600.05,30,,600.05,percent of total billed charges,Drugs,600.05,30,,600.05,percent of total billed charges,Drugs,600.05,30,,600.05,percent of total billed charges,Drugs,600.05,30,,600.05,percent of total billed charges,Drugs,600.05,30,,600.05,percent of total billed charges,Drugs,600.05,30,,600.05,percent of total billed charges,Drugs,600.05,30,,600.05,percent of total billed charges,Drugs,600.05,30,,600.05,percent of total billed charges,Drugs,600.05,30,,600.05,percent of total billed charges,Drugs,600.05,30,,600.05,percent of total billed charges,Drugs,435.6,,,435.6,Other,Drug Cost,435.6,,,435.6,Other,Drug Cost,435.6,,,435.6,Other,Drug Cost,435.6,,,435.6,Other,Drug Cost,435.6,,,435.6,Other,Drug Cost,680.06,34,,680.06,percent of total billed charges,Drugs,435.6,,,435.6,Other,Drug Cost,980.1,,,980.1,Other,225% Medicaid APG methodology,609.84,,,609.84,Other,140% Medicaid APG methodology,680.06,34,"If Charge > 2,000, then 34 percent",680.06,percent of total billed charges,Drugs,58.16,,,58.16,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",435.6,,,435.6,Other,Drug Cost,435.6,,,435.6,Other,Drug Cost,544.5,,,544.5,Other,125% Medicaid APG methodology,0.01,1000.09,
IC - LANREOTIDE 120 MG/0.5 ML   ,J1930,HCPCS,,40597049,CDM,636,RC,15054-1120-04,NDC,both,0.5,ML,33339.81,477.97,,,477.97,Other,150% of Medicare + 9.63% HCRA Surcharge,290.66,,,290.66,Fee Schedule,Average Sale Price (ASP) x 6,10001.94,30,,10001.94,percent of total billed charges,Drugs,10001.94,30,,10001.94,percent of total billed charges,Drugs,10001.94,30,,10001.94,percent of total billed charges,Drugs,10001.94,30,,10001.94,percent of total billed charges,Drugs,10001.94,30,,10001.94,percent of total billed charges,Drugs,16669.91,50,,16669.91,percent of total billed charges,All Other,10001.94,30,,10001.94,percent of total billed charges,Drugs,10001.94,30,,10001.94,percent of total billed charges,Drugs,11335.54,34,"If Charge > 500, then 34 percent",11335.54,percent of total billed charges,Drugs,10001.94,30,,10001.94,percent of total billed charges,Drugs,10001.94,30,,10001.94,percent of total billed charges,Drugs,10001.94,30,,10001.94,percent of total billed charges,Drugs,10001.94,30,,10001.94,percent of total billed charges,Drugs,10001.94,30,,10001.94,percent of total billed charges,Drugs,10001.94,30,,10001.94,percent of total billed charges,Drugs,10001.94,30,,10001.94,percent of total billed charges,Drugs,10001.94,30,,10001.94,percent of total billed charges,Drugs,10001.94,30,,10001.94,percent of total billed charges,Drugs,10001.94,30,,10001.94,percent of total billed charges,Drugs,10001.94,30,,10001.94,percent of total billed charges,Drugs,10001.94,30,,10001.94,percent of total billed charges,Drugs,10001.94,30,,10001.94,percent of total billed charges,Drugs,2934.28,,,2934.28,Other,Drug Cost,2934.28,,,2934.28,Other,Drug Cost,2934.28,,,2934.28,Other,Drug Cost,2934.28,,,2934.28,Other,Drug Cost,2934.28,,,2934.28,Other,Drug Cost,11335.54,34,,11335.54,percent of total billed charges,Drugs,2934.28,,,2934.28,Other,Drug Cost,6602.13,,,6602.13,Other,225% Medicaid APG methodology,4107.99,,,4107.99,Other,140% Medicaid APG methodology,11335.54,34,"If Charge > 2,000, then 34 percent",11335.54,percent of total billed charges,Drugs,465.05,,,465.05,Other,160% Medicare Fee Schedule,11335.54,34,,11335.54,Other,"Drug Charges > 20,000, then 34% of Charges",2934.28,,,2934.28,Other,Drug Cost,2934.28,,,2934.28,Other,Drug Cost,3667.85,,,3667.85,Other,125% Medicaid APG methodology,290.66,16669.91,
NF -CEFIDEROCOL 1 G POWDER INJ  ,J0699,HCPCS,,40597205,CDM,636,RC,59630-0266-10,NDC,both,1,EA,617.37,21.44,,,21.44,Other,150% of Medicare + 9.63% HCRA Surcharge,13.04,,,13.04,Fee Schedule,Average Sale Price (ASP) x 6,185.21,30,,185.21,percent of total billed charges,Drugs,185.21,30,,185.21,percent of total billed charges,Drugs,185.21,30,,185.21,percent of total billed charges,Drugs,185.21,30,,185.21,percent of total billed charges,Drugs,185.21,30,,185.21,percent of total billed charges,Drugs,308.69,50,,308.69,percent of total billed charges,All Other,185.21,30,,185.21,percent of total billed charges,Drugs,185.21,30,,185.21,percent of total billed charges,Drugs,209.91,34,"If Charge > 500, then 34 percent",209.91,percent of total billed charges,Drugs,185.21,30,,185.21,percent of total billed charges,Drugs,185.21,30,,185.21,percent of total billed charges,Drugs,185.21,30,,185.21,percent of total billed charges,Drugs,185.21,30,,185.21,percent of total billed charges,Drugs,185.21,30,,185.21,percent of total billed charges,Drugs,185.21,30,,185.21,percent of total billed charges,Drugs,185.21,30,,185.21,percent of total billed charges,Drugs,185.21,30,,185.21,percent of total billed charges,Drugs,185.21,30,,185.21,percent of total billed charges,Drugs,185.21,30,,185.21,percent of total billed charges,Drugs,185.21,30,,185.21,percent of total billed charges,Drugs,185.21,30,,185.21,percent of total billed charges,Drugs,185.21,30,,185.21,percent of total billed charges,Drugs,131.34,,,131.34,Other,Drug Cost,131.34,,,131.34,Other,Drug Cost,131.34,,,131.34,Other,Drug Cost,131.34,,,131.34,Other,Drug Cost,131.34,,,131.34,Other,Drug Cost,209.91,34,,209.91,percent of total billed charges,Drugs,131.34,,,131.34,Other,Drug Cost,295.52,,,295.52,Other,225% Medicaid APG methodology,183.88,,,183.88,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,20.86,,,20.86,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",131.34,,,131.34,Other,Drug Cost,131.34,,,131.34,Other,Drug Cost,164.18,,,164.18,Other,125% Medicaid APG methodology,0.01,308.69,
NF-INSUL LISPRO (ADMELOG)  PEN  ,J1815,HCPCS,,40597213,CDM,636,RC,00024-5925-05,NDC,both,3,ML,164.29,64.84,39.4668,,64.84,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,49.29,30,,49.29,percent of total billed charges,Drugs,49.29,30,,49.29,percent of total billed charges,Drugs,49.29,30,,49.29,percent of total billed charges,Drugs,49.29,30,,49.29,percent of total billed charges,Drugs,49.29,30,,49.29,percent of total billed charges,Drugs,82.15,50,,82.15,percent of total billed charges,All Other,49.29,30,,49.29,percent of total billed charges,Drugs,49.29,30,,49.29,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,49.29,30,,49.29,percent of total billed charges,Drugs,49.29,30,,49.29,percent of total billed charges,Drugs,49.29,30,,49.29,percent of total billed charges,Drugs,49.29,30,,49.29,percent of total billed charges,Drugs,49.29,30,,49.29,percent of total billed charges,Drugs,49.29,30,,49.29,percent of total billed charges,Drugs,49.29,30,,49.29,percent of total billed charges,Drugs,49.29,30,,49.29,percent of total billed charges,Drugs,49.29,30,,49.29,percent of total billed charges,Drugs,49.29,30,,49.29,percent of total billed charges,Drugs,49.29,30,,49.29,percent of total billed charges,Drugs,49.29,30,,49.29,percent of total billed charges,Drugs,49.29,30,,49.29,percent of total billed charges,Drugs,35.32,,,35.32,Other,Drug Cost,35.32,,,35.32,Other,Drug Cost,35.32,,,35.32,Other,Drug Cost,35.32,,,35.32,Other,Drug Cost,35.32,,,35.32,Other,Drug Cost,55.86,34,,55.86,percent of total billed charges,Drugs,35.32,,,35.32,Other,Drug Cost,79.47,,,79.47,Other,225% Medicaid APG methodology,49.45,,,49.45,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",35.32,,,35.32,Other,Drug Cost,35.32,,,35.32,Other,Drug Cost,44.15,,,44.15,Other,125% Medicaid APG methodology,0.01,82.15,
NF-ETONOGESTREL 68MG IMPLANT    ,J7307,HCPCS,,40597296,CDM,636,RC,78206-0145-01,NDC,both,1,EA,3607.24,1423.66,39.4668,,1423.66,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,1082.17,30,,1082.17,percent of total billed charges,Drugs,1082.17,30,,1082.17,percent of total billed charges,Drugs,1082.17,30,,1082.17,percent of total billed charges,Drugs,1082.17,30,,1082.17,percent of total billed charges,Drugs,1082.17,30,,1082.17,percent of total billed charges,Drugs,1803.62,50,,1803.62,percent of total billed charges,All Other,1082.17,30,,1082.17,percent of total billed charges,Drugs,1082.17,30,,1082.17,percent of total billed charges,Drugs,1226.46,34,"If Charge > 500, then 34 percent",1226.46,percent of total billed charges,Drugs,1082.17,30,,1082.17,percent of total billed charges,Drugs,1082.17,30,,1082.17,percent of total billed charges,Drugs,1082.17,30,,1082.17,percent of total billed charges,Drugs,1082.17,30,,1082.17,percent of total billed charges,Drugs,1082.17,30,,1082.17,percent of total billed charges,Drugs,1082.17,30,,1082.17,percent of total billed charges,Drugs,1082.17,30,,1082.17,percent of total billed charges,Drugs,1082.17,30,,1082.17,percent of total billed charges,Drugs,1082.17,30,,1082.17,percent of total billed charges,Drugs,1082.17,30,,1082.17,percent of total billed charges,Drugs,1082.17,30,,1082.17,percent of total billed charges,Drugs,1082.17,30,,1082.17,percent of total billed charges,Drugs,1082.17,30,,1082.17,percent of total billed charges,Drugs,1030.64,,,1030.64,Other,Drug Cost,1030.64,,,1030.64,Other,Drug Cost,1030.64,,,1030.64,Other,Drug Cost,1030.64,,,1030.64,Other,Drug Cost,1030.64,,,1030.64,Other,Drug Cost,1226.46,34,,1226.46,percent of total billed charges,Drugs,1030.64,,,1030.64,Other,Drug Cost,2318.94,,,2318.94,Other,225% Medicaid APG methodology,1442.9,,,1442.9,Other,140% Medicaid APG methodology,1226.46,34,"If Charge > 2,000, then 34 percent",1226.46,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1030.64,,,1030.64,Other,Drug Cost,1030.64,,,1030.64,Other,Drug Cost,1288.3,,,1288.3,Other,125% Medicaid APG methodology,0.01,2318.94,
IC - EPTINEZUMAB 100 MG/ML SOL  ,J3032,HCPCS,,40597452,CDM,636,RC,67386-0130-51,NDC,both,1,ML,5955.15,178.18,,,178.18,Other,150% of Medicare + 9.63% HCRA Surcharge,108.35,,,108.35,Fee Schedule,Average Sale Price (ASP) x 6,1786.55,30,,1786.55,percent of total billed charges,Drugs,1786.55,30,,1786.55,percent of total billed charges,Drugs,1786.55,30,,1786.55,percent of total billed charges,Drugs,1786.55,30,,1786.55,percent of total billed charges,Drugs,1786.55,30,,1786.55,percent of total billed charges,Drugs,2977.58,50,,2977.58,percent of total billed charges,All Other,1786.55,30,,1786.55,percent of total billed charges,Drugs,1786.55,30,,1786.55,percent of total billed charges,Drugs,2024.75,34,"If Charge > 500, then 34 percent",2024.75,percent of total billed charges,Drugs,1786.55,30,,1786.55,percent of total billed charges,Drugs,1786.55,30,,1786.55,percent of total billed charges,Drugs,1786.55,30,,1786.55,percent of total billed charges,Drugs,1786.55,30,,1786.55,percent of total billed charges,Drugs,1786.55,30,,1786.55,percent of total billed charges,Drugs,1786.55,30,,1786.55,percent of total billed charges,Drugs,1786.55,30,,1786.55,percent of total billed charges,Drugs,1786.55,30,,1786.55,percent of total billed charges,Drugs,1786.55,30,,1786.55,percent of total billed charges,Drugs,1786.55,30,,1786.55,percent of total billed charges,Drugs,1786.55,30,,1786.55,percent of total billed charges,Drugs,1786.55,30,,1786.55,percent of total billed charges,Drugs,1786.55,30,,1786.55,percent of total billed charges,Drugs,1253.76,,,1253.76,Other,Drug Cost,1253.76,,,1253.76,Other,Drug Cost,1253.76,,,1253.76,Other,Drug Cost,1253.76,,,1253.76,Other,Drug Cost,1253.76,,,1253.76,Other,Drug Cost,2024.75,34,,2024.75,percent of total billed charges,Drugs,1253.76,,,1253.76,Other,Drug Cost,2820.96,,,2820.96,Other,225% Medicaid APG methodology,1755.26,,,1755.26,Other,140% Medicaid APG methodology,2024.75,34,"If Charge > 2,000, then 34 percent",2024.75,percent of total billed charges,Drugs,173.37,,,173.37,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1253.76,,,1253.76,Other,Drug Cost,1253.76,,,1253.76,Other,Drug Cost,1567.2,,,1567.2,Other,125% Medicaid APG methodology,0.01,2977.58,
IC - RITUXIMAB ABBS  10 ML      ,Q5115,HCPCS,,40597460,CDM,636,RC,63459-0103-10,NDC,both,10,ML,1947.68,354.14,,,354.14,Other,150% of Medicare + 9.63% HCRA Surcharge,215.35,,,215.35,Fee Schedule,Average Sale Price (ASP) x 6,584.3,30,,584.3,percent of total billed charges,Drugs,584.3,30,,584.3,percent of total billed charges,Drugs,584.3,30,,584.3,percent of total billed charges,Drugs,584.3,30,,584.3,percent of total billed charges,Drugs,584.3,30,,584.3,percent of total billed charges,Drugs,973.84,50,,973.84,percent of total billed charges,All Other,584.3,30,,584.3,percent of total billed charges,Drugs,584.3,30,,584.3,percent of total billed charges,Drugs,662.21,34,"If Charge > 500, then 34 percent",662.21,percent of total billed charges,Drugs,584.3,30,,584.3,percent of total billed charges,Drugs,584.3,30,,584.3,percent of total billed charges,Drugs,584.3,30,,584.3,percent of total billed charges,Drugs,584.3,30,,584.3,percent of total billed charges,Drugs,584.3,30,,584.3,percent of total billed charges,Drugs,584.3,30,,584.3,percent of total billed charges,Drugs,584.3,30,,584.3,percent of total billed charges,Drugs,584.3,30,,584.3,percent of total billed charges,Drugs,584.3,30,,584.3,percent of total billed charges,Drugs,584.3,30,,584.3,percent of total billed charges,Drugs,584.3,30,,584.3,percent of total billed charges,Drugs,584.3,30,,584.3,percent of total billed charges,Drugs,584.3,30,,584.3,percent of total billed charges,Drugs,239.71,,,239.71,Other,Drug Cost,239.71,,,239.71,Other,Drug Cost,239.71,,,239.71,Other,Drug Cost,239.71,,,239.71,Other,Drug Cost,239.71,,,239.71,Other,Drug Cost,662.21,34,,662.21,percent of total billed charges,Drugs,239.71,,,239.71,Other,Drug Cost,539.35,,,539.35,Other,225% Medicaid APG methodology,335.59,,,335.59,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,344.56,,,344.56,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",239.71,,,239.71,Other,Drug Cost,239.71,,,239.71,Other,Drug Cost,299.64,,,299.64,Other,125% Medicaid APG methodology,0.01,973.84,
IC - RITUXIMAB ABBS 50 ML       ,Q5115,HCPCS,,40597478,CDM,636,RC,63459-0104-50,NDC,both,50,ML,10254.41,354.14,,,354.14,Other,150% of Medicare + 9.63% HCRA Surcharge,215.35,,,215.35,Fee Schedule,Average Sale Price (ASP) x 6,3076.32,30,,3076.32,percent of total billed charges,Drugs,3076.32,30,,3076.32,percent of total billed charges,Drugs,3076.32,30,,3076.32,percent of total billed charges,Drugs,3076.32,30,,3076.32,percent of total billed charges,Drugs,3076.32,30,,3076.32,percent of total billed charges,Drugs,5127.21,50,,5127.21,percent of total billed charges,All Other,3076.32,30,,3076.32,percent of total billed charges,Drugs,3076.32,30,,3076.32,percent of total billed charges,Drugs,3486.5,34,"If Charge > 500, then 34 percent",3486.5,percent of total billed charges,Drugs,3076.32,30,,3076.32,percent of total billed charges,Drugs,3076.32,30,,3076.32,percent of total billed charges,Drugs,3076.32,30,,3076.32,percent of total billed charges,Drugs,3076.32,30,,3076.32,percent of total billed charges,Drugs,3076.32,30,,3076.32,percent of total billed charges,Drugs,3076.32,30,,3076.32,percent of total billed charges,Drugs,3076.32,30,,3076.32,percent of total billed charges,Drugs,3076.32,30,,3076.32,percent of total billed charges,Drugs,3076.32,30,,3076.32,percent of total billed charges,Drugs,3076.32,30,,3076.32,percent of total billed charges,Drugs,3076.32,30,,3076.32,percent of total billed charges,Drugs,3076.32,30,,3076.32,percent of total billed charges,Drugs,3076.32,30,,3076.32,percent of total billed charges,Drugs,902.1,,,902.1,Other,Drug Cost,902.1,,,902.1,Other,Drug Cost,902.1,,,902.1,Other,Drug Cost,902.1,,,902.1,Other,Drug Cost,902.1,,,902.1,Other,Drug Cost,3486.5,34,,3486.5,percent of total billed charges,Drugs,902.1,,,902.1,Other,Drug Cost,2029.73,,,2029.73,Other,225% Medicaid APG methodology,1262.94,,,1262.94,Other,140% Medicaid APG methodology,3486.5,34,"If Charge > 2,000, then 34 percent",3486.5,percent of total billed charges,Drugs,344.56,,,344.56,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",902.1,,,902.1,Other,Drug Cost,902.1,,,902.1,Other,Drug Cost,1127.63,,,1127.63,Other,125% Medicaid APG methodology,0.01,5127.21,
ETESEVIMAB 35 MG/ML INJ 20 ML   ,Q0245,HCPCS,,40597510,CDM,636,RC,00002-7950-01,NDC,both,1,ML,30.59,12.07,39.4668,,12.07,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,9.18,30,,9.18,percent of total billed charges,Drugs,9.18,30,,9.18,percent of total billed charges,Drugs,9.18,30,,9.18,percent of total billed charges,Drugs,9.18,30,,9.18,percent of total billed charges,Drugs,9.18,30,,9.18,percent of total billed charges,Drugs,15.3,50,,15.3,percent of total billed charges,All Other,9.18,30,,9.18,percent of total billed charges,Drugs,9.18,30,,9.18,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,9.18,30,,9.18,percent of total billed charges,Drugs,9.18,30,,9.18,percent of total billed charges,Drugs,9.18,30,,9.18,percent of total billed charges,Drugs,9.18,30,,9.18,percent of total billed charges,Drugs,9.18,30,,9.18,percent of total billed charges,Drugs,9.18,30,,9.18,percent of total billed charges,Drugs,9.18,30,,9.18,percent of total billed charges,Drugs,9.18,30,,9.18,percent of total billed charges,Drugs,9.18,30,,9.18,percent of total billed charges,Drugs,9.18,30,,9.18,percent of total billed charges,Drugs,9.18,30,,9.18,percent of total billed charges,Drugs,9.18,30,,9.18,percent of total billed charges,Drugs,9.18,30,,9.18,percent of total billed charges,Drugs,8.74,,,8.74,Other,Drug Cost,8.74,,,8.74,Other,Drug Cost,8.74,,,8.74,Other,Drug Cost,8.74,,,8.74,Other,Drug Cost,8.74,,,8.74,Other,Drug Cost,10.4,34,,10.4,percent of total billed charges,Drugs,8.74,,,8.74,Other,Drug Cost,19.67,,,19.67,Other,225% Medicaid APG methodology,12.24,,,12.24,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",8.74,,,8.74,Other,Drug Cost,8.74,,,8.74,Other,Drug Cost,10.93,,,10.93,Other,125% Medicaid APG methodology,0.01,19.67,
IMM GLOB 10%  50 ML (GAMMAGARD  ,J1569,HCPCS,,40597627,CDM,636,RC,00944-2700-04,NDC,both,50,ML,1211.46,435.63,,,435.63,Other,150% of Medicare + 9.63% HCRA Surcharge,264.91,,,264.91,Fee Schedule,Average Sale Price (ASP) x 6,363.44,30,,363.44,percent of total billed charges,Drugs,363.44,30,,363.44,percent of total billed charges,Drugs,363.44,30,,363.44,percent of total billed charges,Drugs,363.44,30,,363.44,percent of total billed charges,Drugs,363.44,30,,363.44,percent of total billed charges,Drugs,605.73,50,,605.73,percent of total billed charges,All Other,363.44,30,,363.44,percent of total billed charges,Drugs,363.44,30,,363.44,percent of total billed charges,Drugs,411.9,34,"If Charge > 500, then 34 percent",411.9,percent of total billed charges,Drugs,363.44,30,,363.44,percent of total billed charges,Drugs,363.44,30,,363.44,percent of total billed charges,Drugs,363.44,30,,363.44,percent of total billed charges,Drugs,363.44,30,,363.44,percent of total billed charges,Drugs,363.44,30,,363.44,percent of total billed charges,Drugs,363.44,30,,363.44,percent of total billed charges,Drugs,363.44,30,,363.44,percent of total billed charges,Drugs,363.44,30,,363.44,percent of total billed charges,Drugs,363.44,30,,363.44,percent of total billed charges,Drugs,363.44,30,,363.44,percent of total billed charges,Drugs,363.44,30,,363.44,percent of total billed charges,Drugs,363.44,30,,363.44,percent of total billed charges,Drugs,363.44,30,,363.44,percent of total billed charges,Drugs,259.22,,,259.22,Other,Drug Cost,259.22,,,259.22,Other,Drug Cost,259.22,,,259.22,Other,Drug Cost,259.22,,,259.22,Other,Drug Cost,259.22,,,259.22,Other,Drug Cost,411.9,34,,411.9,percent of total billed charges,Drugs,259.22,,,259.22,Other,Drug Cost,583.25,,,583.25,Other,225% Medicaid APG methodology,362.91,,,362.91,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,423.86,,,423.86,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",259.22,,,259.22,Other,Drug Cost,259.22,,,259.22,Other,Drug Cost,324.03,,,324.03,Other,125% Medicaid APG methodology,0.01,605.73,
GAMMAGARD 10G INJ SOLN 100 ML   ,J1569,HCPCS,,40597643,CDM,636,RC,00944-2700-05,NDC,both,100,ML,2422.88,435.63,,,435.63,Other,150% of Medicare + 9.63% HCRA Surcharge,264.91,,,264.91,Fee Schedule,Average Sale Price (ASP) x 6,726.86,30,,726.86,percent of total billed charges,Drugs,726.86,30,,726.86,percent of total billed charges,Drugs,726.86,30,,726.86,percent of total billed charges,Drugs,726.86,30,,726.86,percent of total billed charges,Drugs,726.86,30,,726.86,percent of total billed charges,Drugs,1211.44,50,,1211.44,percent of total billed charges,All Other,726.86,30,,726.86,percent of total billed charges,Drugs,726.86,30,,726.86,percent of total billed charges,Drugs,823.78,34,"If Charge > 500, then 34 percent",823.78,percent of total billed charges,Drugs,726.86,30,,726.86,percent of total billed charges,Drugs,726.86,30,,726.86,percent of total billed charges,Drugs,726.86,30,,726.86,percent of total billed charges,Drugs,726.86,30,,726.86,percent of total billed charges,Drugs,726.86,30,,726.86,percent of total billed charges,Drugs,726.86,30,,726.86,percent of total billed charges,Drugs,726.86,30,,726.86,percent of total billed charges,Drugs,726.86,30,,726.86,percent of total billed charges,Drugs,726.86,30,,726.86,percent of total billed charges,Drugs,726.86,30,,726.86,percent of total billed charges,Drugs,726.86,30,,726.86,percent of total billed charges,Drugs,726.86,30,,726.86,percent of total billed charges,Drugs,726.86,30,,726.86,percent of total billed charges,Drugs,518.43,,,518.43,Other,Drug Cost,518.43,,,518.43,Other,Drug Cost,518.43,,,518.43,Other,Drug Cost,518.43,,,518.43,Other,Drug Cost,518.43,,,518.43,Other,Drug Cost,823.78,34,,823.78,percent of total billed charges,Drugs,518.43,,,518.43,Other,Drug Cost,1166.47,,,1166.47,Other,225% Medicaid APG methodology,725.8,,,725.8,Other,140% Medicaid APG methodology,823.78,34,"If Charge > 2,000, then 34 percent",823.78,percent of total billed charges,Drugs,423.86,,,423.86,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",518.43,,,518.43,Other,Drug Cost,518.43,,,518.43,Other,Drug Cost,648.04,,,648.04,Other,125% Medicaid APG methodology,0.01,1211.44,
ALPROSTADIL 450 MCG NS 45 ML    ,J0270,HCPCS,,40597726,CDM,636,RC,00009-3169-06z,NDC,both,45,ML,401.56,158.48,39.4668,,158.48,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,200.78,50,,200.78,percent of total billed charges,All Other,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,120.47,30,,120.47,percent of total billed charges,Drugs,86.18,,,86.18,Other,Drug Cost,86.18,,,86.18,Other,Drug Cost,86.18,,,86.18,Other,Drug Cost,86.18,,,86.18,Other,Drug Cost,86.18,,,86.18,Other,Drug Cost,136.53,34,,136.53,percent of total billed charges,Drugs,86.18,,,86.18,Other,Drug Cost,193.91,,,193.91,Other,225% Medicaid APG methodology,120.65,,,120.65,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",86.18,,,86.18,Other,Drug Cost,86.18,,,86.18,Other,Drug Cost,107.73,,,107.73,Other,125% Medicaid APG methodology,0.01,200.78,
BEVACIZUMAB AWWB 25 MG/ML 4ML   ,Q5107,HCPCS,,40597759,CDM,636,RC,55513-0206-01,NDC,both,4,ML,2213.44,252.78,,,252.78,Other,150% of Medicare + 9.63% HCRA Surcharge,153.72,,,153.72,Fee Schedule,Average Sale Price (ASP) x 6,664.03,30,,664.03,percent of total billed charges,Drugs,664.03,30,,664.03,percent of total billed charges,Drugs,664.03,30,,664.03,percent of total billed charges,Drugs,664.03,30,,664.03,percent of total billed charges,Drugs,664.03,30,,664.03,percent of total billed charges,Drugs,1106.72,50,,1106.72,percent of total billed charges,All Other,664.03,30,,664.03,percent of total billed charges,Drugs,664.03,30,,664.03,percent of total billed charges,Drugs,752.57,34,"If Charge > 500, then 34 percent",752.57,percent of total billed charges,Drugs,664.03,30,,664.03,percent of total billed charges,Drugs,664.03,30,,664.03,percent of total billed charges,Drugs,664.03,30,,664.03,percent of total billed charges,Drugs,664.03,30,,664.03,percent of total billed charges,Drugs,664.03,30,,664.03,percent of total billed charges,Drugs,664.03,30,,664.03,percent of total billed charges,Drugs,664.03,30,,664.03,percent of total billed charges,Drugs,664.03,30,,664.03,percent of total billed charges,Drugs,664.03,30,,664.03,percent of total billed charges,Drugs,664.03,30,,664.03,percent of total billed charges,Drugs,664.03,30,,664.03,percent of total billed charges,Drugs,664.03,30,,664.03,percent of total billed charges,Drugs,664.03,30,,664.03,percent of total billed charges,Drugs,131.05,,,131.05,Other,Drug Cost,131.05,,,131.05,Other,Drug Cost,131.05,,,131.05,Other,Drug Cost,131.05,,,131.05,Other,Drug Cost,131.05,,,131.05,Other,Drug Cost,752.57,34,,752.57,percent of total billed charges,Drugs,131.05,,,131.05,Other,Drug Cost,294.86,,,294.86,Other,225% Medicaid APG methodology,183.47,,,183.47,Other,140% Medicaid APG methodology,752.57,34,"If Charge > 2,000, then 34 percent",752.57,percent of total billed charges,Drugs,245.95,,,245.95,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",131.05,,,131.05,Other,Drug Cost,131.05,,,131.05,Other,Drug Cost,163.81,,,163.81,Other,125% Medicaid APG methodology,0.01,1106.72,
BEVACIZUMAB AWWB 25 MG/ML 16ML  ,Q5107,HCPCS,,40597767,CDM,636,RC,55513-0207-01,NDC,both,16,ML,8969.1,252.78,,,252.78,Other,150% of Medicare + 9.63% HCRA Surcharge,153.72,,,153.72,Fee Schedule,Average Sale Price (ASP) x 6,2690.73,30,,2690.73,percent of total billed charges,Drugs,2690.73,30,,2690.73,percent of total billed charges,Drugs,2690.73,30,,2690.73,percent of total billed charges,Drugs,2690.73,30,,2690.73,percent of total billed charges,Drugs,2690.73,30,,2690.73,percent of total billed charges,Drugs,4484.55,50,,4484.55,percent of total billed charges,All Other,2690.73,30,,2690.73,percent of total billed charges,Drugs,2690.73,30,,2690.73,percent of total billed charges,Drugs,3049.49,34,"If Charge > 500, then 34 percent",3049.49,percent of total billed charges,Drugs,2690.73,30,,2690.73,percent of total billed charges,Drugs,2690.73,30,,2690.73,percent of total billed charges,Drugs,2690.73,30,,2690.73,percent of total billed charges,Drugs,2690.73,30,,2690.73,percent of total billed charges,Drugs,2690.73,30,,2690.73,percent of total billed charges,Drugs,2690.73,30,,2690.73,percent of total billed charges,Drugs,2690.73,30,,2690.73,percent of total billed charges,Drugs,2690.73,30,,2690.73,percent of total billed charges,Drugs,2690.73,30,,2690.73,percent of total billed charges,Drugs,2690.73,30,,2690.73,percent of total billed charges,Drugs,2690.73,30,,2690.73,percent of total billed charges,Drugs,2690.73,30,,2690.73,percent of total billed charges,Drugs,2690.73,30,,2690.73,percent of total billed charges,Drugs,1279.28,,,1279.28,Other,Drug Cost,1279.28,,,1279.28,Other,Drug Cost,1279.28,,,1279.28,Other,Drug Cost,1279.28,,,1279.28,Other,Drug Cost,1279.28,,,1279.28,Other,Drug Cost,3049.49,34,,3049.49,percent of total billed charges,Drugs,1279.28,,,1279.28,Other,Drug Cost,2878.38,,,2878.38,Other,225% Medicaid APG methodology,1790.99,,,1790.99,Other,140% Medicaid APG methodology,3049.49,34,"If Charge > 2,000, then 34 percent",3049.49,percent of total billed charges,Drugs,245.95,,,245.95,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1279.28,,,1279.28,Other,Drug Cost,1279.28,,,1279.28,Other,Drug Cost,1599.1,,,1599.1,Other,125% Medicaid APG methodology,0.01,4484.55,
VELAGLUCERASE ALFA 400 UNITS    ,J3385,HCPCS,,40598021,CDM,636,RC,54092-0701-04,NDC,both,1,EA,5113.01,3625.08,,,3625.08,Other,150% of Medicare + 9.63% HCRA Surcharge,2204.44,,,2204.44,Fee Schedule,Average Sale Price (ASP) x 6,1533.9,30,,1533.9,percent of total billed charges,Drugs,1533.9,30,,1533.9,percent of total billed charges,Drugs,1533.9,30,,1533.9,percent of total billed charges,Drugs,1533.9,30,,1533.9,percent of total billed charges,Drugs,1533.9,30,,1533.9,percent of total billed charges,Drugs,2556.51,50,,2556.51,percent of total billed charges,All Other,1533.9,30,,1533.9,percent of total billed charges,Drugs,1533.9,30,,1533.9,percent of total billed charges,Drugs,1738.42,34,"If Charge > 500, then 34 percent",1738.42,percent of total billed charges,Drugs,1533.9,30,,1533.9,percent of total billed charges,Drugs,1533.9,30,,1533.9,percent of total billed charges,Drugs,1533.9,30,,1533.9,percent of total billed charges,Drugs,1533.9,30,,1533.9,percent of total billed charges,Drugs,1533.9,30,,1533.9,percent of total billed charges,Drugs,1533.9,30,,1533.9,percent of total billed charges,Drugs,1533.9,30,,1533.9,percent of total billed charges,Drugs,1533.9,30,,1533.9,percent of total billed charges,Drugs,1533.9,30,,1533.9,percent of total billed charges,Drugs,1533.9,30,,1533.9,percent of total billed charges,Drugs,1533.9,30,,1533.9,percent of total billed charges,Drugs,1533.9,30,,1533.9,percent of total billed charges,Drugs,1533.9,30,,1533.9,percent of total billed charges,Drugs,1064.41,,,1064.41,Other,Drug Cost,1064.41,,,1064.41,Other,Drug Cost,1064.41,,,1064.41,Other,Drug Cost,1064.41,,,1064.41,Other,Drug Cost,1064.41,,,1064.41,Other,Drug Cost,1738.42,34,,1738.42,percent of total billed charges,Drugs,1064.41,,,1064.41,Other,Drug Cost,2394.92,,,2394.92,Other,225% Medicaid APG methodology,1490.17,,,1490.17,Other,140% Medicaid APG methodology,1738.42,34,"If Charge > 2,000, then 34 percent",1738.42,percent of total billed charges,Drugs,3527.1,,,3527.1,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1064.41,,,1064.41,Other,Drug Cost,1064.41,,,1064.41,Other,Drug Cost,1330.51,,,1330.51,Other,125% Medicaid APG methodology,0.01,3625.08,
NF-TRIAMCINOLONE 40MG INTRAVIT  ,J3301,HCPCS,,40598088,CDM,636,RC,00065-0543-01,NDC,both,1,ML,489.37,9.33,,,9.33,Other,150% of Medicare + 9.63% HCRA Surcharge,5.68,,,5.68,Fee Schedule,Average Sale Price (ASP) x 6,146.81,30,,146.81,percent of total billed charges,Drugs,146.81,30,,146.81,percent of total billed charges,Drugs,146.81,30,,146.81,percent of total billed charges,Drugs,146.81,30,,146.81,percent of total billed charges,Drugs,146.81,30,,146.81,percent of total billed charges,Drugs,244.69,50,,244.69,percent of total billed charges,All Other,146.81,30,,146.81,percent of total billed charges,Drugs,146.81,30,,146.81,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,146.81,30,,146.81,percent of total billed charges,Drugs,146.81,30,,146.81,percent of total billed charges,Drugs,146.81,30,,146.81,percent of total billed charges,Drugs,146.81,30,,146.81,percent of total billed charges,Drugs,146.81,30,,146.81,percent of total billed charges,Drugs,146.81,30,,146.81,percent of total billed charges,Drugs,146.81,30,,146.81,percent of total billed charges,Drugs,146.81,30,,146.81,percent of total billed charges,Drugs,146.81,30,,146.81,percent of total billed charges,Drugs,146.81,30,,146.81,percent of total billed charges,Drugs,146.81,30,,146.81,percent of total billed charges,Drugs,146.81,30,,146.81,percent of total billed charges,Drugs,146.81,30,,146.81,percent of total billed charges,Drugs,104.29,,,104.29,Other,Drug Cost,104.29,,,104.29,Other,Drug Cost,104.29,,,104.29,Other,Drug Cost,104.29,,,104.29,Other,Drug Cost,104.29,,,104.29,Other,Drug Cost,166.39,34,,166.39,percent of total billed charges,Drugs,104.29,,,104.29,Other,Drug Cost,234.65,,,234.65,Other,225% Medicaid APG methodology,146.01,,,146.01,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,9.08,,,9.08,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",104.29,,,104.29,Other,Drug Cost,104.29,,,104.29,Other,Drug Cost,130.36,,,130.36,Other,125% Medicaid APG methodology,0.01,244.69,
INSUL DETEMIR 100UN/ML SQ 10ML  ,J1815,HCPCS,,40598146,CDM,636,RC,00169-3687-12,NDC,both,10,ML,783.93,309.39,39.4668,,309.39,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,235.18,30,,235.18,percent of total billed charges,Drugs,235.18,30,,235.18,percent of total billed charges,Drugs,235.18,30,,235.18,percent of total billed charges,Drugs,235.18,30,,235.18,percent of total billed charges,Drugs,235.18,30,,235.18,percent of total billed charges,Drugs,391.97,50,,391.97,percent of total billed charges,All Other,235.18,30,,235.18,percent of total billed charges,Drugs,235.18,30,,235.18,percent of total billed charges,Drugs,266.54,34,"If Charge > 500, then 34 percent",266.54,percent of total billed charges,Drugs,235.18,30,,235.18,percent of total billed charges,Drugs,235.18,30,,235.18,percent of total billed charges,Drugs,235.18,30,,235.18,percent of total billed charges,Drugs,235.18,30,,235.18,percent of total billed charges,Drugs,235.18,30,,235.18,percent of total billed charges,Drugs,235.18,30,,235.18,percent of total billed charges,Drugs,235.18,30,,235.18,percent of total billed charges,Drugs,235.18,30,,235.18,percent of total billed charges,Drugs,235.18,30,,235.18,percent of total billed charges,Drugs,235.18,30,,235.18,percent of total billed charges,Drugs,235.18,30,,235.18,percent of total billed charges,Drugs,235.18,30,,235.18,percent of total billed charges,Drugs,235.18,30,,235.18,percent of total billed charges,Drugs,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,266.54,34,,266.54,percent of total billed charges,Drugs,0.09,,,0.09,Other,Drug Cost,0.2,,,0.2,Other,225% Medicaid APG methodology,0.13,,,0.13,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.09,,,0.09,Other,Drug Cost,0.09,,,0.09,Other,Drug Cost,0.11,,,0.11,Other,125% Medicaid APG methodology,0.01,391.97,
ALTEPLASE 4 MG IN 30 ML NS SYR  ,J2997,HCPCS,,40598401,CDM,636,RC,50242-0041-64f,NDC,both,1,EA,995.96,877.88,,,877.88,Other,150% of Medicare + 9.63% HCRA Surcharge,533.84,,,533.84,Fee Schedule,Average Sale Price (ASP) x 6,298.79,30,,298.79,percent of total billed charges,Drugs,298.79,30,,298.79,percent of total billed charges,Drugs,298.79,30,,298.79,percent of total billed charges,Drugs,298.79,30,,298.79,percent of total billed charges,Drugs,298.79,30,,298.79,percent of total billed charges,Drugs,497.98,50,,497.98,percent of total billed charges,All Other,298.79,30,,298.79,percent of total billed charges,Drugs,298.79,30,,298.79,percent of total billed charges,Drugs,338.63,34,"If Charge > 500, then 34 percent",338.63,percent of total billed charges,Drugs,298.79,30,,298.79,percent of total billed charges,Drugs,298.79,30,,298.79,percent of total billed charges,Drugs,298.79,30,,298.79,percent of total billed charges,Drugs,298.79,30,,298.79,percent of total billed charges,Drugs,298.79,30,,298.79,percent of total billed charges,Drugs,298.79,30,,298.79,percent of total billed charges,Drugs,298.79,30,,298.79,percent of total billed charges,Drugs,298.79,30,,298.79,percent of total billed charges,Drugs,298.79,30,,298.79,percent of total billed charges,Drugs,298.79,30,,298.79,percent of total billed charges,Drugs,298.79,30,,298.79,percent of total billed charges,Drugs,298.79,30,,298.79,percent of total billed charges,Drugs,298.79,30,,298.79,percent of total billed charges,Drugs,78.62,,,78.62,Other,Drug Cost,78.62,,,78.62,Other,Drug Cost,78.62,,,78.62,Other,Drug Cost,78.62,,,78.62,Other,Drug Cost,78.62,,,78.62,Other,Drug Cost,338.63,34,,338.63,percent of total billed charges,Drugs,78.62,,,78.62,Other,Drug Cost,176.9,,,176.9,Other,225% Medicaid APG methodology,110.07,,,110.07,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,854.15,,,854.15,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",78.62,,,78.62,Other,Drug Cost,78.62,,,78.62,Other,Drug Cost,98.28,,,98.28,Other,125% Medicaid APG methodology,0.01,877.88,
BENRALIZUMAB 30 MG/ML SOL       ,J0517,HCPCS,,40598492,CDM,636,RC,00310-1730-30,NDC,both,1,ML,17546.2,1672.42,,,1672.42,Other,150% of Medicare + 9.63% HCRA Surcharge,1017.01,,,1017.01,Fee Schedule,Average Sale Price (ASP) x 6,5263.86,30,,5263.86,percent of total billed charges,Drugs,5263.86,30,,5263.86,percent of total billed charges,Drugs,5263.86,30,,5263.86,percent of total billed charges,Drugs,5263.86,30,,5263.86,percent of total billed charges,Drugs,5263.86,30,,5263.86,percent of total billed charges,Drugs,8773.1,50,,8773.1,percent of total billed charges,All Other,5263.86,30,,5263.86,percent of total billed charges,Drugs,5263.86,30,,5263.86,percent of total billed charges,Drugs,5965.71,34,"If Charge > 500, then 34 percent",5965.71,percent of total billed charges,Drugs,5263.86,30,,5263.86,percent of total billed charges,Drugs,5263.86,30,,5263.86,percent of total billed charges,Drugs,5263.86,30,,5263.86,percent of total billed charges,Drugs,5263.86,30,,5263.86,percent of total billed charges,Drugs,5263.86,30,,5263.86,percent of total billed charges,Drugs,5263.86,30,,5263.86,percent of total billed charges,Drugs,5263.86,30,,5263.86,percent of total billed charges,Drugs,5263.86,30,,5263.86,percent of total billed charges,Drugs,5263.86,30,,5263.86,percent of total billed charges,Drugs,5263.86,30,,5263.86,percent of total billed charges,Drugs,5263.86,30,,5263.86,percent of total billed charges,Drugs,5263.86,30,,5263.86,percent of total billed charges,Drugs,5263.86,30,,5263.86,percent of total billed charges,Drugs,3636.52,,,3636.52,Other,Drug Cost,3636.52,,,3636.52,Other,Drug Cost,3636.52,,,3636.52,Other,Drug Cost,3636.52,,,3636.52,Other,Drug Cost,3636.52,,,3636.52,Other,Drug Cost,5965.71,34,,5965.71,percent of total billed charges,Drugs,3636.52,,,3636.52,Other,Drug Cost,8182.17,,,8182.17,Other,225% Medicaid APG methodology,5091.13,,,5091.13,Other,140% Medicaid APG methodology,5965.71,34,"If Charge > 2,000, then 34 percent",5965.71,percent of total billed charges,Drugs,1627.21,,,1627.21,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",3636.52,,,3636.52,Other,Drug Cost,3636.52,,,3636.52,Other,Drug Cost,4545.65,,,4545.65,Other,125% Medicaid APG methodology,0.01,8773.1,
IC -DURVALUMAB 50 MG/ML 2.4 ML  ,J9173,HCPCS,,40598567,CDM,636,RC,00310-4500-12,NDC,both,2.4,ML,3171.67,796.3,,,796.3,Other,150% of Medicare + 9.63% HCRA Surcharge,484.24,,,484.24,Fee Schedule,Average Sale Price (ASP) x 6,951.5,30,,951.5,percent of total billed charges,Drugs,951.5,30,,951.5,percent of total billed charges,Drugs,951.5,30,,951.5,percent of total billed charges,Drugs,951.5,30,,951.5,percent of total billed charges,Drugs,951.5,30,,951.5,percent of total billed charges,Drugs,1585.84,50,,1585.84,percent of total billed charges,All Other,951.5,30,,951.5,percent of total billed charges,Drugs,951.5,30,,951.5,percent of total billed charges,Drugs,1078.37,34,"If Charge > 500, then 34 percent",1078.37,percent of total billed charges,Drugs,951.5,30,,951.5,percent of total billed charges,Drugs,951.5,30,,951.5,percent of total billed charges,Drugs,951.5,30,,951.5,percent of total billed charges,Drugs,951.5,30,,951.5,percent of total billed charges,Drugs,951.5,30,,951.5,percent of total billed charges,Drugs,951.5,30,,951.5,percent of total billed charges,Drugs,951.5,30,,951.5,percent of total billed charges,Drugs,951.5,30,,951.5,percent of total billed charges,Drugs,951.5,30,,951.5,percent of total billed charges,Drugs,951.5,30,,951.5,percent of total billed charges,Drugs,951.5,30,,951.5,percent of total billed charges,Drugs,951.5,30,,951.5,percent of total billed charges,Drugs,951.5,30,,951.5,percent of total billed charges,Drugs,660.86,,,660.86,Other,Drug Cost,660.86,,,660.86,Other,Drug Cost,660.86,,,660.86,Other,Drug Cost,660.86,,,660.86,Other,Drug Cost,660.86,,,660.86,Other,Drug Cost,1078.37,34,,1078.37,percent of total billed charges,Drugs,660.86,,,660.86,Other,Drug Cost,1486.94,,,1486.94,Other,225% Medicaid APG methodology,925.2,,,925.2,Other,140% Medicaid APG methodology,1078.37,34,"If Charge > 2,000, then 34 percent",1078.37,percent of total billed charges,Drugs,774.78,,,774.78,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",660.86,,,660.86,Other,Drug Cost,660.86,,,660.86,Other,Drug Cost,826.08,,,826.08,Other,125% Medicaid APG methodology,0.01,1585.84,
FLUARIX QUADRIVALENT SUS        ,90686,CPT,,40598732,CDM,636,RC,58160-0909-52,NDC,both,0.5,ML,56.14,220.52,,,220.52,Other,150% of Medicare + 9.63% HCRA Surcharge,134.1,,,134.1,Fee Schedule,Average Sale Price (ASP) x 6,16.84,30,,16.84,percent of total billed charges,Drugs,16.84,30,,16.84,percent of total billed charges,Drugs,16.84,30,,16.84,percent of total billed charges,Drugs,16.84,30,,16.84,percent of total billed charges,Drugs,16.84,30,,16.84,percent of total billed charges,Drugs,28.07,50,,28.07,percent of total billed charges,All Other,16.84,30,,16.84,percent of total billed charges,Drugs,16.84,30,,16.84,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,16.84,30,,16.84,percent of total billed charges,Drugs,16.84,30,,16.84,percent of total billed charges,Drugs,16.84,30,,16.84,percent of total billed charges,Drugs,16.84,30,,16.84,percent of total billed charges,Drugs,16.84,30,,16.84,percent of total billed charges,Drugs,16.84,30,,16.84,percent of total billed charges,Drugs,16.84,30,,16.84,percent of total billed charges,Drugs,16.84,30,,16.84,percent of total billed charges,Drugs,16.84,30,,16.84,percent of total billed charges,Drugs,16.84,30,,16.84,percent of total billed charges,Drugs,16.84,30,,16.84,percent of total billed charges,Drugs,16.84,30,,16.84,percent of total billed charges,Drugs,16.84,30,,16.84,percent of total billed charges,Drugs,16.04,,,16.04,Other,Drug Cost,16.04,,,16.04,Other,Drug Cost,16.04,,,16.04,Other,Drug Cost,16.04,,,16.04,Other,Drug Cost,16.04,,,16.04,Other,Drug Cost,19.09,34,,19.09,percent of total billed charges,Drugs,16.04,,,16.04,Other,Drug Cost,36.09,,,36.09,Other,225% Medicaid APG methodology,22.46,,,22.46,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,214.56,,,214.56,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",16.04,,,16.04,Other,Drug Cost,16.04,,,16.04,Other,Drug Cost,20.05,,,20.05,Other,125% Medicaid APG methodology,0.01,220.52,
DEGARELIX 80 MG SUBCUT INJ      ,J9155,HCPCS,,40598781,CDM,636,RC,55566-8303-01,NDC,both,1,EA,1589.21,41.31,,,41.31,Other,150% of Medicare + 9.63% HCRA Surcharge,25.12,,,25.12,Fee Schedule,Average Sale Price (ASP) x 6,476.76,30,,476.76,percent of total billed charges,Drugs,476.76,30,,476.76,percent of total billed charges,Drugs,476.76,30,,476.76,percent of total billed charges,Drugs,476.76,30,,476.76,percent of total billed charges,Drugs,476.76,30,,476.76,percent of total billed charges,Drugs,794.61,50,,794.61,percent of total billed charges,All Other,476.76,30,,476.76,percent of total billed charges,Drugs,476.76,30,,476.76,percent of total billed charges,Drugs,540.33,34,"If Charge > 500, then 34 percent",540.33,percent of total billed charges,Drugs,476.76,30,,476.76,percent of total billed charges,Drugs,476.76,30,,476.76,percent of total billed charges,Drugs,476.76,30,,476.76,percent of total billed charges,Drugs,476.76,30,,476.76,percent of total billed charges,Drugs,476.76,30,,476.76,percent of total billed charges,Drugs,476.76,30,,476.76,percent of total billed charges,Drugs,476.76,30,,476.76,percent of total billed charges,Drugs,476.76,30,,476.76,percent of total billed charges,Drugs,476.76,30,,476.76,percent of total billed charges,Drugs,476.76,30,,476.76,percent of total billed charges,Drugs,476.76,30,,476.76,percent of total billed charges,Drugs,476.76,30,,476.76,percent of total billed charges,Drugs,476.76,30,,476.76,percent of total billed charges,Drugs,180.41,,,180.41,Other,Drug Cost,180.41,,,180.41,Other,Drug Cost,180.41,,,180.41,Other,Drug Cost,180.41,,,180.41,Other,Drug Cost,180.41,,,180.41,Other,Drug Cost,540.33,34,,540.33,percent of total billed charges,Drugs,180.41,,,180.41,Other,Drug Cost,405.92,,,405.92,Other,225% Medicaid APG methodology,252.57,,,252.57,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,40.2,,,40.2,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",180.41,,,180.41,Other,Drug Cost,180.41,,,180.41,Other,Drug Cost,225.51,,,225.51,Other,125% Medicaid APG methodology,0.01,794.61,
BUPIV LIPOSOME 1.3% 10 ML       ,C9290,HCPCS,,40599110,CDM,636,RC,65250-0133-09,NDC,both,10,ML,751.45,296.57,39.4668,,296.57,percent of total billed charges,Non-covered Medicare Charges 36% + 9.63% HCRA Surcharge,0.01,,,0.01,Fee Schedule,Average Sale Price (ASP) x 6,225.44,30,,225.44,percent of total billed charges,Drugs,225.44,30,,225.44,percent of total billed charges,Drugs,225.44,30,,225.44,percent of total billed charges,Drugs,225.44,30,,225.44,percent of total billed charges,Drugs,225.44,30,,225.44,percent of total billed charges,Drugs,375.73,50,,375.73,percent of total billed charges,All Other,225.44,30,,225.44,percent of total billed charges,Drugs,225.44,30,,225.44,percent of total billed charges,Drugs,255.49,34,"If Charge > 500, then 34 percent",255.49,percent of total billed charges,Drugs,225.44,30,,225.44,percent of total billed charges,Drugs,225.44,30,,225.44,percent of total billed charges,Drugs,225.44,30,,225.44,percent of total billed charges,Drugs,225.44,30,,225.44,percent of total billed charges,Drugs,225.44,30,,225.44,percent of total billed charges,Drugs,225.44,30,,225.44,percent of total billed charges,Drugs,225.44,30,,225.44,percent of total billed charges,Drugs,225.44,30,,225.44,percent of total billed charges,Drugs,225.44,30,,225.44,percent of total billed charges,Drugs,225.44,30,,225.44,percent of total billed charges,Drugs,225.44,30,,225.44,percent of total billed charges,Drugs,225.44,30,,225.44,percent of total billed charges,Drugs,225.44,30,,225.44,percent of total billed charges,Drugs,160.39,,,160.39,Other,Drug Cost,160.39,,,160.39,Other,Drug Cost,160.39,,,160.39,Other,Drug Cost,160.39,,,160.39,Other,Drug Cost,160.39,,,160.39,Other,Drug Cost,255.49,34,,255.49,percent of total billed charges,Drugs,160.39,,,160.39,Other,Drug Cost,360.88,,,360.88,Other,225% Medicaid APG methodology,224.55,,,224.55,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.02,,,0.02,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",160.39,,,160.39,Other,Drug Cost,160.39,,,160.39,Other,Drug Cost,200.49,,,200.49,Other,125% Medicaid APG methodology,0.01,375.73,
NICU DEXAMETH 0.1MG/ML  SYR     ,J8540,HCPCS,,40599193,CDM,636,RC,00054-3177-63a,NDC,both,1,ML,0.11,0.82,,,0.82,Other,150% of Medicare + 9.63% HCRA Surcharge,0.5,,,0.5,Fee Schedule,Average Sale Price (ASP) x 6,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.06,50,,0.06,percent of total billed charges,All Other,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,30,,0.03,percent of total billed charges,Drugs,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,34,,0.04,percent of total billed charges,Drugs,0.03,,,0.03,Other,Drug Cost,0.07,,,0.07,Other,225% Medicaid APG methodology,0.04,,,0.04,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,0.8,,,0.8,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",0.03,,,0.03,Other,Drug Cost,0.03,,,0.03,Other,Drug Cost,0.04,,,0.04,Other,125% Medicaid APG methodology,0.01,0.82,
ROMOSOZUMAB 105 MG/1.17 ML SOL  ,J3111,HCPCS,,40599227,CDM,636,RC,55513-0998-02,NDC,both,1.17,ML,4363.59,105.84,,,105.84,Other,150% of Medicare + 9.63% HCRA Surcharge,64.36,,,64.36,Fee Schedule,Average Sale Price (ASP) x 6,1309.08,30,,1309.08,percent of total billed charges,Drugs,1309.08,30,,1309.08,percent of total billed charges,Drugs,1309.08,30,,1309.08,percent of total billed charges,Drugs,1309.08,30,,1309.08,percent of total billed charges,Drugs,1309.08,30,,1309.08,percent of total billed charges,Drugs,2181.8,50,,2181.8,percent of total billed charges,All Other,1309.08,30,,1309.08,percent of total billed charges,Drugs,1309.08,30,,1309.08,percent of total billed charges,Drugs,1483.62,34,"If Charge > 500, then 34 percent",1483.62,percent of total billed charges,Drugs,1309.08,30,,1309.08,percent of total billed charges,Drugs,1309.08,30,,1309.08,percent of total billed charges,Drugs,1309.08,30,,1309.08,percent of total billed charges,Drugs,1309.08,30,,1309.08,percent of total billed charges,Drugs,1309.08,30,,1309.08,percent of total billed charges,Drugs,1309.08,30,,1309.08,percent of total billed charges,Drugs,1309.08,30,,1309.08,percent of total billed charges,Drugs,1309.08,30,,1309.08,percent of total billed charges,Drugs,1309.08,30,,1309.08,percent of total billed charges,Drugs,1309.08,30,,1309.08,percent of total billed charges,Drugs,1309.08,30,,1309.08,percent of total billed charges,Drugs,1309.08,30,,1309.08,percent of total billed charges,Drugs,1309.08,30,,1309.08,percent of total billed charges,Drugs,816.3,,,816.3,Other,Drug Cost,816.3,,,816.3,Other,Drug Cost,816.3,,,816.3,Other,Drug Cost,816.3,,,816.3,Other,Drug Cost,816.3,,,816.3,Other,Drug Cost,1483.62,34,,1483.62,percent of total billed charges,Drugs,816.3,,,816.3,Other,Drug Cost,1836.68,,,1836.68,Other,225% Medicaid APG methodology,1142.82,,,1142.82,Other,140% Medicaid APG methodology,1483.62,34,"If Charge > 2,000, then 34 percent",1483.62,percent of total billed charges,Drugs,102.98,,,102.98,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",816.3,,,816.3,Other,Drug Cost,816.3,,,816.3,Other,Drug Cost,1020.38,,,1020.38,Other,125% Medicaid APG methodology,0.01,2181.8,
MITOMYCIN 0.4MG OPHTH TOP 1 ML  ,J9280,HCPCS,,40599458,CDM,636,RC,16729-0115-05a,NDC,both,1,EA,120.79,625.04,,,625.04,Other,150% of Medicare + 9.63% HCRA Surcharge,380.09,,,380.09,Fee Schedule,Average Sale Price (ASP) x 6,36.24,30,,36.24,percent of total billed charges,Drugs,36.24,30,,36.24,percent of total billed charges,Drugs,36.24,30,,36.24,percent of total billed charges,Drugs,36.24,30,,36.24,percent of total billed charges,Drugs,36.24,30,,36.24,percent of total billed charges,Drugs,60.4,50,,60.4,percent of total billed charges,All Other,36.24,30,,36.24,percent of total billed charges,Drugs,36.24,30,,36.24,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,36.24,30,,36.24,percent of total billed charges,Drugs,36.24,30,,36.24,percent of total billed charges,Drugs,36.24,30,,36.24,percent of total billed charges,Drugs,36.24,30,,36.24,percent of total billed charges,Drugs,36.24,30,,36.24,percent of total billed charges,Drugs,36.24,30,,36.24,percent of total billed charges,Drugs,36.24,30,,36.24,percent of total billed charges,Drugs,36.24,30,,36.24,percent of total billed charges,Drugs,36.24,30,,36.24,percent of total billed charges,Drugs,36.24,30,,36.24,percent of total billed charges,Drugs,36.24,30,,36.24,percent of total billed charges,Drugs,36.24,30,,36.24,percent of total billed charges,Drugs,36.24,30,,36.24,percent of total billed charges,Drugs,17.93,,,17.93,Other,Drug Cost,17.93,,,17.93,Other,Drug Cost,17.93,,,17.93,Other,Drug Cost,17.93,,,17.93,Other,Drug Cost,17.93,,,17.93,Other,Drug Cost,41.07,34,,41.07,percent of total billed charges,Drugs,17.93,,,17.93,Other,Drug Cost,40.34,,,40.34,Other,225% Medicaid APG methodology,25.1,,,25.1,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,608.14,,,608.14,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",17.93,,,17.93,Other,Drug Cost,17.93,,,17.93,Other,Drug Cost,22.41,,,22.41,Other,125% Medicaid APG methodology,0.01,625.04,
MITOMYCIN 0.3MG OPHTH TOP 1 ML  ,J9280,HCPCS,,40599466,CDM,636,RC,16729-0246-05b,NDC,both,1,EA,42.46,625.04,,,625.04,Other,150% of Medicare + 9.63% HCRA Surcharge,380.09,,,380.09,Fee Schedule,Average Sale Price (ASP) x 6,12.74,30,,12.74,percent of total billed charges,Drugs,12.74,30,,12.74,percent of total billed charges,Drugs,12.74,30,,12.74,percent of total billed charges,Drugs,12.74,30,,12.74,percent of total billed charges,Drugs,12.74,30,,12.74,percent of total billed charges,Drugs,21.23,50,,21.23,percent of total billed charges,All Other,12.74,30,,12.74,percent of total billed charges,Drugs,12.74,30,,12.74,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,12.74,30,,12.74,percent of total billed charges,Drugs,12.74,30,,12.74,percent of total billed charges,Drugs,12.74,30,,12.74,percent of total billed charges,Drugs,12.74,30,,12.74,percent of total billed charges,Drugs,12.74,30,,12.74,percent of total billed charges,Drugs,12.74,30,,12.74,percent of total billed charges,Drugs,12.74,30,,12.74,percent of total billed charges,Drugs,12.74,30,,12.74,percent of total billed charges,Drugs,12.74,30,,12.74,percent of total billed charges,Drugs,12.74,30,,12.74,percent of total billed charges,Drugs,12.74,30,,12.74,percent of total billed charges,Drugs,12.74,30,,12.74,percent of total billed charges,Drugs,12.74,30,,12.74,percent of total billed charges,Drugs,12.13,,,12.13,Other,Drug Cost,12.13,,,12.13,Other,Drug Cost,12.13,,,12.13,Other,Drug Cost,12.13,,,12.13,Other,Drug Cost,12.13,,,12.13,Other,Drug Cost,14.44,34,,14.44,percent of total billed charges,Drugs,12.13,,,12.13,Other,Drug Cost,27.29,,,27.29,Other,225% Medicaid APG methodology,16.98,,,16.98,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,608.14,,,608.14,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",12.13,,,12.13,Other,Drug Cost,12.13,,,12.13,Other,Drug Cost,15.16,,,15.16,Other,125% Medicaid APG methodology,0.01,625.04,
MITOMYCIN 0.2MG OPHTH TOP 1 ML  ,J9280,HCPCS,,40599474,CDM,636,RC,16729-0246-05a,NDC,both,1,EA,42.04,625.04,,,625.04,Other,150% of Medicare + 9.63% HCRA Surcharge,380.09,,,380.09,Fee Schedule,Average Sale Price (ASP) x 6,12.61,30,,12.61,percent of total billed charges,Drugs,12.61,30,,12.61,percent of total billed charges,Drugs,12.61,30,,12.61,percent of total billed charges,Drugs,12.61,30,,12.61,percent of total billed charges,Drugs,12.61,30,,12.61,percent of total billed charges,Drugs,21.02,50,,21.02,percent of total billed charges,All Other,12.61,30,,12.61,percent of total billed charges,Drugs,12.61,30,,12.61,percent of total billed charges,Drugs,0.01,34,"If Charge > 500, then 34 percent",0.01,percent of total billed charges,Drugs,12.61,30,,12.61,percent of total billed charges,Drugs,12.61,30,,12.61,percent of total billed charges,Drugs,12.61,30,,12.61,percent of total billed charges,Drugs,12.61,30,,12.61,percent of total billed charges,Drugs,12.61,30,,12.61,percent of total billed charges,Drugs,12.61,30,,12.61,percent of total billed charges,Drugs,12.61,30,,12.61,percent of total billed charges,Drugs,12.61,30,,12.61,percent of total billed charges,Drugs,12.61,30,,12.61,percent of total billed charges,Drugs,12.61,30,,12.61,percent of total billed charges,Drugs,12.61,30,,12.61,percent of total billed charges,Drugs,12.61,30,,12.61,percent of total billed charges,Drugs,12.61,30,,12.61,percent of total billed charges,Drugs,12.01,,,12.01,Other,Drug Cost,12.01,,,12.01,Other,Drug Cost,12.01,,,12.01,Other,Drug Cost,12.01,,,12.01,Other,Drug Cost,12.01,,,12.01,Other,Drug Cost,14.29,34,,14.29,percent of total billed charges,Drugs,12.01,,,12.01,Other,Drug Cost,27.02,,,27.02,Other,225% Medicaid APG methodology,16.81,,,16.81,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,608.14,,,608.14,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",12.01,,,12.01,Other,Drug Cost,12.01,,,12.01,Other,Drug Cost,15.01,,,15.01,Other,125% Medicaid APG methodology,0.01,625.04,
RITUXIMAB PVVR IV SOLN 50 ML    ,Q5119,HCPCS,,40599722,CDM,636,RC,00069-0249-01,NDC,both,50,ML,9782.5,201.74,,,201.74,Other,150% of Medicare + 9.63% HCRA Surcharge,122.68,,,122.68,Fee Schedule,Average Sale Price (ASP) x 6,2934.75,30,,2934.75,percent of total billed charges,Drugs,2934.75,30,,2934.75,percent of total billed charges,Drugs,2934.75,30,,2934.75,percent of total billed charges,Drugs,2934.75,30,,2934.75,percent of total billed charges,Drugs,2934.75,30,,2934.75,percent of total billed charges,Drugs,4891.25,50,,4891.25,percent of total billed charges,All Other,2934.75,30,,2934.75,percent of total billed charges,Drugs,2934.75,30,,2934.75,percent of total billed charges,Drugs,3326.05,34,"If Charge > 500, then 34 percent",3326.05,percent of total billed charges,Drugs,2934.75,30,,2934.75,percent of total billed charges,Drugs,2934.75,30,,2934.75,percent of total billed charges,Drugs,2934.75,30,,2934.75,percent of total billed charges,Drugs,2934.75,30,,2934.75,percent of total billed charges,Drugs,2934.75,30,,2934.75,percent of total billed charges,Drugs,2934.75,30,,2934.75,percent of total billed charges,Drugs,2934.75,30,,2934.75,percent of total billed charges,Drugs,2934.75,30,,2934.75,percent of total billed charges,Drugs,2934.75,30,,2934.75,percent of total billed charges,Drugs,2934.75,30,,2934.75,percent of total billed charges,Drugs,2934.75,30,,2934.75,percent of total billed charges,Drugs,2934.75,30,,2934.75,percent of total billed charges,Drugs,2934.75,30,,2934.75,percent of total billed charges,Drugs,1203.3,,,1203.3,Other,Drug Cost,1203.3,,,1203.3,Other,Drug Cost,1203.3,,,1203.3,Other,Drug Cost,1203.3,,,1203.3,Other,Drug Cost,1203.3,,,1203.3,Other,Drug Cost,3326.05,34,,3326.05,percent of total billed charges,Drugs,1203.3,,,1203.3,Other,Drug Cost,2707.43,,,2707.43,Other,225% Medicaid APG methodology,1684.62,,,1684.62,Other,140% Medicaid APG methodology,3326.05,34,"If Charge > 2,000, then 34 percent",3326.05,percent of total billed charges,Drugs,196.29,,,196.29,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",1203.3,,,1203.3,Other,Drug Cost,1203.3,,,1203.3,Other,Drug Cost,1504.13,,,1504.13,Other,125% Medicaid APG methodology,0.01,4891.25,
RITUXIMAB PVVR IV SOLN 10 ML    ,Q5119,HCPCS,,40599730,CDM,636,RC,00069-0238-01,NDC,both,10,ML,1956.5,201.74,,,201.74,Other,150% of Medicare + 9.63% HCRA Surcharge,122.68,,,122.68,Fee Schedule,Average Sale Price (ASP) x 6,586.95,30,,586.95,percent of total billed charges,Drugs,586.95,30,,586.95,percent of total billed charges,Drugs,586.95,30,,586.95,percent of total billed charges,Drugs,586.95,30,,586.95,percent of total billed charges,Drugs,586.95,30,,586.95,percent of total billed charges,Drugs,978.25,50,,978.25,percent of total billed charges,All Other,586.95,30,,586.95,percent of total billed charges,Drugs,586.95,30,,586.95,percent of total billed charges,Drugs,665.21,34,"If Charge > 500, then 34 percent",665.21,percent of total billed charges,Drugs,586.95,30,,586.95,percent of total billed charges,Drugs,586.95,30,,586.95,percent of total billed charges,Drugs,586.95,30,,586.95,percent of total billed charges,Drugs,586.95,30,,586.95,percent of total billed charges,Drugs,586.95,30,,586.95,percent of total billed charges,Drugs,586.95,30,,586.95,percent of total billed charges,Drugs,586.95,30,,586.95,percent of total billed charges,Drugs,586.95,30,,586.95,percent of total billed charges,Drugs,586.95,30,,586.95,percent of total billed charges,Drugs,586.95,30,,586.95,percent of total billed charges,Drugs,586.95,30,,586.95,percent of total billed charges,Drugs,586.95,30,,586.95,percent of total billed charges,Drugs,586.95,30,,586.95,percent of total billed charges,Drugs,240.66,,,240.66,Other,Drug Cost,240.66,,,240.66,Other,Drug Cost,240.66,,,240.66,Other,Drug Cost,240.66,,,240.66,Other,Drug Cost,240.66,,,240.66,Other,Drug Cost,665.21,34,,665.21,percent of total billed charges,Drugs,240.66,,,240.66,Other,Drug Cost,541.49,,,541.49,Other,225% Medicaid APG methodology,336.92,,,336.92,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,196.29,,,196.29,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",240.66,,,240.66,Other,Drug Cost,240.66,,,240.66,Other,Drug Cost,300.83,,,300.83,Other,125% Medicaid APG methodology,0.01,978.25,
BEVACIZUMAB BVZR 25 MG/ML       ,Q5118,HCPCS,,40599763,CDM,636,RC,00069-0315-01,NDC,both,4,ML,1748.08,212.24,,,212.24,Other,150% of Medicare + 9.63% HCRA Surcharge,129.07,,,129.07,Fee Schedule,Average Sale Price (ASP) x 6,524.42,30,,524.42,percent of total billed charges,Drugs,524.42,30,,524.42,percent of total billed charges,Drugs,524.42,30,,524.42,percent of total billed charges,Drugs,524.42,30,,524.42,percent of total billed charges,Drugs,524.42,30,,524.42,percent of total billed charges,Drugs,874.04,50,,874.04,percent of total billed charges,All Other,524.42,30,,524.42,percent of total billed charges,Drugs,524.42,30,,524.42,percent of total billed charges,Drugs,594.35,34,"If Charge > 500, then 34 percent",594.35,percent of total billed charges,Drugs,524.42,30,,524.42,percent of total billed charges,Drugs,524.42,30,,524.42,percent of total billed charges,Drugs,524.42,30,,524.42,percent of total billed charges,Drugs,524.42,30,,524.42,percent of total billed charges,Drugs,524.42,30,,524.42,percent of total billed charges,Drugs,524.42,30,,524.42,percent of total billed charges,Drugs,524.42,30,,524.42,percent of total billed charges,Drugs,524.42,30,,524.42,percent of total billed charges,Drugs,524.42,30,,524.42,percent of total billed charges,Drugs,524.42,30,,524.42,percent of total billed charges,Drugs,524.42,30,,524.42,percent of total billed charges,Drugs,524.42,30,,524.42,percent of total billed charges,Drugs,524.42,30,,524.42,percent of total billed charges,Drugs,277.62,,,277.62,Other,Drug Cost,277.62,,,277.62,Other,Drug Cost,277.62,,,277.62,Other,Drug Cost,277.62,,,277.62,Other,Drug Cost,277.62,,,277.62,Other,Drug Cost,594.35,34,,594.35,percent of total billed charges,Drugs,277.62,,,277.62,Other,Drug Cost,624.65,,,624.65,Other,225% Medicaid APG methodology,388.67,,,388.67,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,206.51,,,206.51,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",277.62,,,277.62,Other,Drug Cost,277.62,,,277.62,Other,Drug Cost,347.03,,,347.03,Other,125% Medicaid APG methodology,0.01,874.04,
PREVNAR 20                      ,90677,CPT,,40599953,CDM,636,RC,00005-2000-10,NDC,both,0.5,ML,802.1,2848.16,,,2848.16,Other,150% of Medicare + 9.63% HCRA Surcharge,1731.98,,,1731.98,Fee Schedule,Average Sale Price (ASP) x 6,240.63,30,,240.63,percent of total billed charges,Drugs,240.63,30,,240.63,percent of total billed charges,Drugs,240.63,30,,240.63,percent of total billed charges,Drugs,240.63,30,,240.63,percent of total billed charges,Drugs,240.63,30,,240.63,percent of total billed charges,Drugs,401.05,50,,401.05,percent of total billed charges,All Other,240.63,30,,240.63,percent of total billed charges,Drugs,240.63,30,,240.63,percent of total billed charges,Drugs,272.71,34,"If Charge > 500, then 34 percent",272.71,percent of total billed charges,Drugs,240.63,30,,240.63,percent of total billed charges,Drugs,240.63,30,,240.63,percent of total billed charges,Drugs,240.63,30,,240.63,percent of total billed charges,Drugs,240.63,30,,240.63,percent of total billed charges,Drugs,240.63,30,,240.63,percent of total billed charges,Drugs,240.63,30,,240.63,percent of total billed charges,Drugs,240.63,30,,240.63,percent of total billed charges,Drugs,240.63,30,,240.63,percent of total billed charges,Drugs,240.63,30,,240.63,percent of total billed charges,Drugs,240.63,30,,240.63,percent of total billed charges,Drugs,240.63,30,,240.63,percent of total billed charges,Drugs,240.63,30,,240.63,percent of total billed charges,Drugs,240.63,30,,240.63,percent of total billed charges,Drugs,228.77,,,228.77,Other,Drug Cost,228.77,,,228.77,Other,Drug Cost,228.77,,,228.77,Other,Drug Cost,228.77,,,228.77,Other,Drug Cost,228.77,,,228.77,Other,Drug Cost,272.71,34,,272.71,percent of total billed charges,Drugs,228.77,,,228.77,Other,Drug Cost,514.73,,,514.73,Other,225% Medicaid APG methodology,320.28,,,320.28,Other,140% Medicaid APG methodology,0.01,34,"If Charge > 2,000, then 34 percent",0.01,percent of total billed charges,Drugs,2771.17,,,2771.17,Other,160% Medicare Fee Schedule,0.01,34,,0.01,Other,"Drug Charges > 20,000, then 34% of Charges",228.77,,,228.77,Other,Drug Cost,228.77,,,228.77,Other,Drug Cost,285.96,,,285.96,Other,125% Medicaid APG methodology,0.01,2848.16,
TRAUMA RESPONS W/HOSP CRIT LV3  ,G0390,HCPCS,,50058163,CDM,683,RC,,,both,,,6851,2603.55,,,2603.55,Other,150% of Medicare + 9.63% HCRA Surcharge,1583.24,,,1583.24,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,3425.5,50,,3425.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,4658.68,68,,4658.68,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,5480.8,80,,5480.8,percent of total billed charges,All Other Outpatient,5686.33,83,,5686.33,percent of total billed charges,All Other Outpatient,5686.33,83,,5686.33,percent of total billed charges,All Other Outpatient,5480.8,80,,5480.8,percent of total billed charges,All Other Outpatient,5686.33,83,,5686.33,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,4795.7,70,,4795.7,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,5686.33,
VAGINAL DELIVERY ONLY           ,59409,CPT,,48300586,CDM,722,RC,,,both,,,16449,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,8224.5,50,,8224.5,percent of total billed charges,All Other Outpatient,7402.05,45,,7402.05,percent of total billed charges,All Other Outpatient,8224.5,50,,8224.5,percent of total billed charges,All Other Outpatient,7402.05,45,,7402.05,percent of total billed charges,All Other Outpatient,7073.07,43,,7073.07,percent of total billed charges,All Other Outpatient,8224.5,50,,8224.5,percent of total billed charges,All Other,11514.3,70,,11514.3,percent of total billed charges,All Other,11185.32,68,,11185.32,percent of total billed charges,All Other Outpatient,4484.21,,,4484.21,Other,186% Medicaid methodology,13159.2,80,,13159.2,percent of total billed charges,All Other Outpatient,13652.67,83,,13652.67,percent of total billed charges,All Other Outpatient,13652.67,83,,13652.67,percent of total billed charges,All Other Outpatient,13159.2,80,,13159.2,percent of total billed charges,All Other Outpatient,13652.67,83,,13652.67,percent of total billed charges,All Other Outpatient,14804.1,90,,14804.1,percent of total billed charges,All Other,11514.3,70,,11514.3,percent of total billed charges,All Other,3915.45,,,3915.45,Fee Schedule,,3322.2,,,3322.2,Fee Schedule,,1234,,,1234,Case Rate,Labor Room per Visit,1562,,,1562,Case Rate,Labor Room per Visit,1734,,,1734,Case Rate,Labor Room per Visit,1474,,,1474,Case Rate,Labor Room per Visit,2410.87,,,2410.87,Other,New York Medicaid APG methodology,2410.87,,,2410.87,Other,100% Medicaid APG methodology,2410.87,,,2410.87,Other,100% Medicaid APG methodology,2410.87,,,2410.87,Other,100% Medicaid APG methodology,5424.45,,,5424.45,Other,225% Medicaid APG methodology,5424.45,,,5424.45,Other,225% Medicaid APG methodology,3688.62,,,3688.62,Other,153% Medicaid APG methodology,5424.45,,,5424.45,Other,225% Medicaid APG methodology,3375.21,,,3375.21,Other,140% Medicaid APG methodology,5424.45,,,5424.45,Other,225% Medicaid APG methodology,6268.25,,,6268.25,Other,260% Medicaid APG methodology,7811.2,,,7811.2,Other,324% Medicaid APG methodology,5183.36,,,5183.36,Other,215% Medicaid APG methodology,5183.36,,,5183.36,Other,215% Medicaid APG methodology,3013.58,,,3013.58,Other,125% Medicaid APG methodology,1234,14804.1,
CIRCUMCISION W/REGIONL BLOCK    ,54150,CPT,,48301071,CDM,723,RC,,,both,,,5259,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,2629.5,50,,2629.5,percent of total billed charges,All Other Outpatient,2366.55,45,,2366.55,percent of total billed charges,All Other Outpatient,2629.5,50,,2629.5,percent of total billed charges,All Other Outpatient,2366.55,45,,2366.55,percent of total billed charges,All Other Outpatient,2261.37,43,,2261.37,percent of total billed charges,All Other Outpatient,2629.5,50,,2629.5,percent of total billed charges,All Other,3681.3,70,,3681.3,percent of total billed charges,All Other,3576.12,68,,3576.12,percent of total billed charges,All Other Outpatient,1936.07,,,1936.07,Other,186% Medicaid methodology,4207.2,80,,4207.2,percent of total billed charges,All Other Outpatient,4364.97,83,,4364.97,percent of total billed charges,All Other Outpatient,4364.97,83,,4364.97,percent of total billed charges,All Other Outpatient,4207.2,80,,4207.2,percent of total billed charges,All Other Outpatient,4364.97,83,,4364.97,percent of total billed charges,All Other Outpatient,4733.1,90,,4733.1,percent of total billed charges,All Other,3681.3,70,,3681.3,percent of total billed charges,All Other,468.6,,,468.6,Fee Schedule,,397.6,,,397.6,Fee Schedule,,3681.3,70,,3681.3,percent of total billed charges,All Other,3681.3,70,,3681.3,percent of total billed charges,All Other,3681.3,70,,3681.3,percent of total billed charges,All Other,3681.3,70,,3681.3,percent of total billed charges,All Other,1040.9,,,1040.9,Other,New York Medicaid APG methodology,1040.9,,,1040.9,Other,100% Medicaid APG methodology,1040.9,,,1040.9,Other,100% Medicaid APG methodology,1040.9,,,1040.9,Other,100% Medicaid APG methodology,2342.02,,,2342.02,Other,225% Medicaid APG methodology,2342.02,,,2342.02,Other,225% Medicaid APG methodology,1592.58,,,1592.58,Other,153% Medicaid APG methodology,2342.02,,,2342.02,Other,225% Medicaid APG methodology,1457.26,,,1457.26,Other,140% Medicaid APG methodology,2342.02,,,2342.02,Other,225% Medicaid APG methodology,2706.34,,,2706.34,Other,260% Medicaid APG methodology,3372.51,,,3372.51,Other,324% Medicaid APG methodology,2237.93,,,2237.93,Other,215% Medicaid APG methodology,2237.93,,,2237.93,Other,215% Medicaid APG methodology,1301.12,,,1301.12,Other,125% Medicaid APG methodology,397.6,4733.1,
CIRCUMCISION NEONATE <=28 DAYS  ,54160,CPT,,48301089,CDM,723,RC,,,both,,,6600,1299.03,,,1299.03,Other,150% of Medicare + 9.63% HCRA Surcharge,789.95,,,789.95,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,3300,50,,3300,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Non-covered service,2235.12,,,2235.12,Other,186% Medicaid methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,4620,70,,4620,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% Medicaid APG methodology,1201.68,,,1201.68,Other,100% Medicaid APG methodology,1201.68,,,1201.68,Other,100% Medicaid APG methodology,2703.77,,,2703.77,Other,225% Medicaid APG methodology,2703.77,,,2703.77,Other,225% Medicaid APG methodology,1838.57,,,1838.57,Other,153% Medicaid APG methodology,2703.77,,,2703.77,Other,225% Medicaid APG methodology,1682.35,,,1682.35,Other,140% Medicaid APG methodology,2703.77,,,2703.77,Other,225% Medicaid APG methodology,3124.36,,,3124.36,Other,260% Medicaid APG methodology,3893.43,,,3893.43,Other,324% Medicaid APG methodology,2583.61,,,2583.61,Other,215% Medicaid APG methodology,2583.61,,,2583.61,Other,215% Medicaid APG methodology,1502.1,,,1502.1,Other,125% Medicaid APG methodology,0.01,4620,
ELECTROCARDIOGRAM TRACING       ,93005,CPT,,44401297,CDM,730,RC,,,both,,,730,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,32.42,,,32.42,Fee Schedule,,29.18,,,29.18,Fee Schedule,,99.87,,,99.87,Fee Schedule,,89.86,,,89.86,Fee Schedule,,84.85,,,84.85,Fee Schedule,,365,50,,365,percent of total billed charges,All Other,511,70,,511,percent of total billed charges,All Other,29.18,,,29.18,Fee Schedule,,124.73,,,124.73,Other,186% Medicaid methodology,34.34,,,34.34,Fee Schedule,,452.6,,,452.6,Fee Schedule,,16.17,,,16.17,Fee Schedule,,34.34,,,34.34,Fee Schedule,,452.6,,,452.6,Fee Schedule,,657,90,,657,percent of total billed charges,All Other,511,70,,511,percent of total billed charges,All Other,29.7,,,29.7,Fee Schedule,,25.2,,,25.2,Fee Schedule,,477,,,477,Case Rate,EKG and ECG Per Visit,743,,,743,Case Rate,EKG and ECG Per Visit,824,,,824,Case Rate,EKG and ECG Per Visit,700,,,700,Case Rate,EKG and ECG Per Visit,67.06,,,67.06,Other,New York Medicaid APG methodology,67.06,,,67.06,Other,100% Medicaid APG methodology,67.06,,,67.06,Other,100% Medicaid APG methodology,67.06,,,67.06,Other,100% Medicaid APG methodology,150.89,,,150.89,Other,225% Medicaid APG methodology,150.89,,,150.89,Other,225% Medicaid APG methodology,102.6,,,102.6,Other,153% Medicaid APG methodology,150.89,,,150.89,Other,225% Medicaid APG methodology,93.89,,,93.89,Other,140% Medicaid APG methodology,150.89,,,150.89,Other,225% Medicaid APG methodology,174.36,,,174.36,Other,260% Medicaid APG methodology,217.28,,,217.28,Other,324% Medicaid APG methodology,144.18,,,144.18,Other,215% Medicaid APG methodology,144.18,,,144.18,Other,215% Medicaid APG methodology,83.83,,,83.83,Other,125% Medicaid APG methodology,16.17,824,
ELECTROCARDIOGRAM TRACING       ,93005,CPT,,44401388,CDM,730,RC,,,both,,,730,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,32.42,,,32.42,Fee Schedule,,29.18,,,29.18,Fee Schedule,,99.87,,,99.87,Fee Schedule,,89.86,,,89.86,Fee Schedule,,84.85,,,84.85,Fee Schedule,,365,50,,365,percent of total billed charges,All Other,511,70,,511,percent of total billed charges,All Other,29.18,,,29.18,Fee Schedule,,124.73,,,124.73,Other,186% Medicaid methodology,34.34,,,34.34,Fee Schedule,,452.6,,,452.6,Fee Schedule,,16.17,,,16.17,Fee Schedule,,34.34,,,34.34,Fee Schedule,,452.6,,,452.6,Fee Schedule,,657,90,,657,percent of total billed charges,All Other,511,70,,511,percent of total billed charges,All Other,29.7,,,29.7,Fee Schedule,,25.2,,,25.2,Fee Schedule,,477,,,477,Case Rate,EKG and ECG Per Visit,743,,,743,Case Rate,EKG and ECG Per Visit,824,,,824,Case Rate,EKG and ECG Per Visit,700,,,700,Case Rate,EKG and ECG Per Visit,67.06,,,67.06,Other,New York Medicaid APG methodology,67.06,,,67.06,Other,100% Medicaid APG methodology,67.06,,,67.06,Other,100% Medicaid APG methodology,67.06,,,67.06,Other,100% Medicaid APG methodology,150.89,,,150.89,Other,225% Medicaid APG methodology,150.89,,,150.89,Other,225% Medicaid APG methodology,102.6,,,102.6,Other,153% Medicaid APG methodology,150.89,,,150.89,Other,225% Medicaid APG methodology,93.89,,,93.89,Other,140% Medicaid APG methodology,150.89,,,150.89,Other,225% Medicaid APG methodology,174.36,,,174.36,Other,260% Medicaid APG methodology,217.28,,,217.28,Other,324% Medicaid APG methodology,144.18,,,144.18,Other,215% Medicaid APG methodology,144.18,,,144.18,Other,215% Medicaid APG methodology,83.83,,,83.83,Other,125% Medicaid APG methodology,16.17,824,
ECG UP TO 48 HRS RECORDING      ,93225,CPT,,44401214,CDM,731,RC,,,both,,,1217,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,91.95,,,91.95,Fee Schedule,,82.77,,,82.77,Fee Schedule,,286.98,,,286.98,Fee Schedule,,258.21,,,258.21,Fee Schedule,,243.82,,,243.82,Fee Schedule,,608.5,50,,608.5,percent of total billed charges,All Other,851.9,70,,851.9,percent of total billed charges,All Other,82.77,,,82.77,Fee Schedule,,412.61,,,412.61,Other,186% Medicaid methodology,97.41,,,97.41,Fee Schedule,,754.54,,,754.54,Fee Schedule,,45.86,,,45.86,Fee Schedule,,97.41,,,97.41,Fee Schedule,,754.54,,,754.54,Fee Schedule,,1095.3,90,,1095.3,percent of total billed charges,All Other,851.9,70,,851.9,percent of total billed charges,All Other,94.05,,,94.05,Fee Schedule,,79.8,,,79.8,Fee Schedule,,1306,,,1306,Case Rate,Holter Monitor Per Visit,2029,,,2029,Case Rate,Holter Monitor Per Visit,2253,,,2253,Case Rate,Holter Monitor Per Visit,1915,,,1915,Case Rate,Holter Monitor Per Visit,221.83,,,221.83,Other,New York Medicaid APG methodology,221.83,,,221.83,Other,100% Medicaid APG methodology,221.83,,,221.83,Other,100% Medicaid APG methodology,221.83,,,221.83,Other,100% Medicaid APG methodology,499.12,,,499.12,Other,225% Medicaid APG methodology,499.12,,,499.12,Other,225% Medicaid APG methodology,339.4,,,339.4,Other,153% Medicaid APG methodology,499.12,,,499.12,Other,225% Medicaid APG methodology,310.57,,,310.57,Other,140% Medicaid APG methodology,499.12,,,499.12,Other,225% Medicaid APG methodology,576.77,,,576.77,Other,260% Medicaid APG methodology,718.74,,,718.74,Other,324% Medicaid APG methodology,476.94,,,476.94,Other,215% Medicaid APG methodology,476.94,,,476.94,Other,215% Medicaid APG methodology,277.29,,,277.29,Other,125% Medicaid APG methodology,45.86,2253,
EEG AWAKE AND ASLEEP            ,95819,CPT,,46100129,CDM,740,RC,,,both,,,5046,596.88,,,596.88,Other,150% of Medicare + 9.63% HCRA Surcharge,362.97,,,362.97,Other,Medicare OPPS methodology,1473.05,,,1473.05,Fee Schedule,,1326.69,,,1326.69,Fee Schedule,,2488.3,,,2488.3,Fee Schedule,,2238.78,,,2238.78,Fee Schedule,,2114.02,,,2114.02,Fee Schedule,,2523,50,,2523,percent of total billed charges,All Other,3532.2,70,,3532.2,percent of total billed charges,All Other,1789.37,,,1789.37,Fee Schedule,,397.38,,,397.38,Other,186% Medicaid methodology,2105.7,,,2105.7,Fee Schedule,,3128.52,,,3128.52,Fee Schedule,,991.47,,,991.47,Fee Schedule,,2105.7,,,2105.7,Fee Schedule,,3128.52,,,3128.52,Fee Schedule,,4541.4,90,,4541.4,percent of total billed charges,All Other,3532.2,70,,3532.2,percent of total billed charges,All Other,1920.6,,,1920.6,Fee Schedule,,1629.6,,,1629.6,Fee Schedule,,8236,,,8236,Case Rate,EEG Per Visit,7476,,,7476,Case Rate,EEG Per Visit,8306,,,8306,Case Rate,EEG Per Visit,7061,,,7061,Case Rate,EEG Per Visit,213.65,,,213.65,Other,New York Medicaid APG methodology,213.65,,,213.65,Other,100% Medicaid APG methodology,213.65,,,213.65,Other,100% Medicaid APG methodology,213.65,,,213.65,Other,100% Medicaid APG methodology,480.7,,,480.7,Other,225% Medicaid APG methodology,480.7,,,480.7,Other,225% Medicaid APG methodology,326.88,,,326.88,Other,153% Medicaid APG methodology,480.7,,,480.7,Other,225% Medicaid APG methodology,299.11,,,299.11,Other,140% Medicaid APG methodology,480.7,,,480.7,Other,225% Medicaid APG methodology,555.48,,,555.48,Other,260% Medicaid APG methodology,692.22,,,692.22,Other,324% Medicaid APG methodology,459.34,,,459.34,Other,215% Medicaid APG methodology,459.34,,,459.34,Other,215% Medicaid APG methodology,267.06,,,267.06,Other,125% Medicaid APG methodology,213.65,8306,
EEG AWAKE AND DROWSY            ,95816,CPT,,46100160,CDM,740,RC,,,both,,,5046,596.88,,,596.88,Other,150% of Medicare + 9.63% HCRA Surcharge,362.97,,,362.97,Other,Medicare OPPS methodology,1251.65,,,1251.65,Fee Schedule,,1127.29,,,1127.29,Fee Schedule,,2176.55,,,2176.55,Fee Schedule,,1958.28,,,1958.28,Fee Schedule,,1849.15,,,1849.15,Fee Schedule,,2523,50,,2523,percent of total billed charges,All Other,3532.2,70,,3532.2,percent of total billed charges,All Other,1520.43,,,1520.43,Fee Schedule,,397.38,,,397.38,Other,186% Medicaid methodology,1789.22,,,1789.22,Fee Schedule,,3128.52,,,3128.52,Fee Schedule,,842.46,,,842.46,Fee Schedule,,1789.22,,,1789.22,Fee Schedule,,3128.52,,,3128.52,Fee Schedule,,4541.4,90,,4541.4,percent of total billed charges,All Other,3532.2,70,,3532.2,percent of total billed charges,All Other,1597.2,,,1597.2,Fee Schedule,,1355.2,,,1355.2,Fee Schedule,,8236,,,8236,Case Rate,EEG Per Visit,7476,,,7476,Case Rate,EEG Per Visit,8306,,,8306,Case Rate,EEG Per Visit,7061,,,7061,Case Rate,EEG Per Visit,213.65,,,213.65,Other,New York Medicaid APG methodology,213.65,,,213.65,Other,100% Medicaid APG methodology,213.65,,,213.65,Other,100% Medicaid APG methodology,213.65,,,213.65,Other,100% Medicaid APG methodology,480.7,,,480.7,Other,225% Medicaid APG methodology,480.7,,,480.7,Other,225% Medicaid APG methodology,326.88,,,326.88,Other,153% Medicaid APG methodology,480.7,,,480.7,Other,225% Medicaid APG methodology,299.11,,,299.11,Other,140% Medicaid APG methodology,480.7,,,480.7,Other,225% Medicaid APG methodology,555.48,,,555.48,Other,260% Medicaid APG methodology,692.22,,,692.22,Other,324% Medicaid APG methodology,459.34,,,459.34,Other,215% Medicaid APG methodology,459.34,,,459.34,Other,215% Medicaid APG methodology,267.06,,,267.06,Other,125% Medicaid APG methodology,213.65,8306,
EEG EXTND MNTR 61-119 MIN       ,95813,CPT,,46100228,CDM,740,RC,,,both,,,5046,596.88,,,596.88,Other,150% of Medicare + 9.63% HCRA Surcharge,362.97,,,362.97,Other,Medicare OPPS methodology,1325.19,,,1325.19,Fee Schedule,,1193.52,,,1193.52,Fee Schedule,,2466.62,,,2466.62,Fee Schedule,,2219.27,,,2219.27,Fee Schedule,,2095.59,,,2095.59,Fee Schedule,,2523,50,,2523,percent of total billed charges,All Other,3532.2,70,,3532.2,percent of total billed charges,All Other,1609.76,,,1609.76,Fee Schedule,,686.54,,,686.54,Other,186% Medicaid methodology,1894.34,,,1894.34,Fee Schedule,,3128.52,,,3128.52,Fee Schedule,,891.95,,,891.95,Fee Schedule,,1894.34,,,1894.34,Fee Schedule,,3128.52,,,3128.52,Fee Schedule,,4541.4,90,,4541.4,percent of total billed charges,All Other,3532.2,70,,3532.2,percent of total billed charges,All Other,1681.35,,,1681.35,Fee Schedule,,1426.6,,,1426.6,Fee Schedule,,8236,,,8236,Case Rate,EEG Per Visit,7476,,,7476,Case Rate,EEG Per Visit,8306,,,8306,Case Rate,EEG Per Visit,7061,,,7061,Case Rate,EEG Per Visit,369.11,,,369.11,Other,New York Medicaid APG methodology,369.11,,,369.11,Other,100% Medicaid APG methodology,369.11,,,369.11,Other,100% Medicaid APG methodology,369.11,,,369.11,Other,100% Medicaid APG methodology,830.49,,,830.49,Other,225% Medicaid APG methodology,830.49,,,830.49,Other,225% Medicaid APG methodology,564.73,,,564.73,Other,153% Medicaid APG methodology,830.49,,,830.49,Other,225% Medicaid APG methodology,516.75,,,516.75,Other,140% Medicaid APG methodology,830.49,,,830.49,Other,225% Medicaid APG methodology,959.68,,,959.68,Other,260% Medicaid APG methodology,1195.91,,,1195.91,Other,324% Medicaid APG methodology,793.58,,,793.58,Other,215% Medicaid APG methodology,793.58,,,793.58,Other,215% Medicaid APG methodology,461.38,,,461.38,Other,125% Medicaid APG methodology,362.97,8306,
EEG COMA OR SLEEP ONLY          ,95822,CPT,,46100236,CDM,740,RC,,,both,,,2921,596.88,,,596.88,Other,150% of Medicare + 9.63% HCRA Surcharge,362.97,,,362.97,Other,Medicare OPPS methodology,1319.07,,,1319.07,Fee Schedule,,1188.01,,,1188.01,Fee Schedule,,2295.02,,,2295.02,Fee Schedule,,2064.87,,,2064.87,Fee Schedule,,1949.8,,,1949.8,Fee Schedule,,1460.5,50,,1460.5,percent of total billed charges,All Other,2044.7,70,,2044.7,percent of total billed charges,All Other,1602.34,,,1602.34,Fee Schedule,,397.38,,,397.38,Other,186% Medicaid methodology,1885.6,,,1885.6,Fee Schedule,,1811.02,,,1811.02,Fee Schedule,,887.84,,,887.84,Fee Schedule,,1885.6,,,1885.6,Fee Schedule,,1811.02,,,1811.02,Fee Schedule,,2628.9,90,,2628.9,percent of total billed charges,All Other,2044.7,70,,2044.7,percent of total billed charges,All Other,1763.85,,,1763.85,Fee Schedule,,1496.6,,,1496.6,Fee Schedule,,8236,,,8236,Case Rate,EEG Per Visit,7476,,,7476,Case Rate,EEG Per Visit,8306,,,8306,Case Rate,EEG Per Visit,7061,,,7061,Case Rate,EEG Per Visit,213.65,,,213.65,Other,New York Medicaid APG methodology,213.65,,,213.65,Other,100% Medicaid APG methodology,213.65,,,213.65,Other,100% Medicaid APG methodology,213.65,,,213.65,Other,100% Medicaid APG methodology,480.7,,,480.7,Other,225% Medicaid APG methodology,480.7,,,480.7,Other,225% Medicaid APG methodology,326.88,,,326.88,Other,153% Medicaid APG methodology,480.7,,,480.7,Other,225% Medicaid APG methodology,299.11,,,299.11,Other,140% Medicaid APG methodology,480.7,,,480.7,Other,225% Medicaid APG methodology,555.48,,,555.48,Other,260% Medicaid APG methodology,692.22,,,692.22,Other,324% Medicaid APG methodology,459.34,,,459.34,Other,215% Medicaid APG methodology,459.34,,,459.34,Other,215% Medicaid APG methodology,267.06,,,267.06,Other,125% Medicaid APG methodology,213.65,8306,
EEG 41-60 MINUTES               ,95812,CPT,,46100418,CDM,740,RC,,,both,,,5046,596.88,,,596.88,Other,150% of Medicare + 9.63% HCRA Surcharge,362.97,,,362.97,Other,Medicare OPPS methodology,1087.85,,,1087.85,Fee Schedule,,979.76,,,979.76,Fee Schedule,,2394.82,,,2394.82,Fee Schedule,,2154.67,,,2154.67,Fee Schedule,,2034.59,,,2034.59,Fee Schedule,,2523,50,,2523,percent of total billed charges,All Other,3532.2,70,,3532.2,percent of total billed charges,All Other,1321.46,,,1321.46,Fee Schedule,,686.54,,,686.54,Other,186% Medicaid methodology,1555.07,,,1555.07,Fee Schedule,,3128.52,,,3128.52,Fee Schedule,,732.21,,,732.21,Fee Schedule,,1555.07,,,1555.07,Fee Schedule,,3128.52,,,3128.52,Fee Schedule,,4541.4,90,,4541.4,percent of total billed charges,All Other,3532.2,70,,3532.2,percent of total billed charges,All Other,1422.3,,,1422.3,Fee Schedule,,1206.8,,,1206.8,Fee Schedule,,8236,,,8236,Case Rate,EEG Per Visit,7476,,,7476,Case Rate,EEG Per Visit,8306,,,8306,Case Rate,EEG Per Visit,7061,,,7061,Case Rate,EEG Per Visit,369.11,,,369.11,Other,New York Medicaid APG methodology,369.11,,,369.11,Other,100% Medicaid APG methodology,369.11,,,369.11,Other,100% Medicaid APG methodology,369.11,,,369.11,Other,100% Medicaid APG methodology,830.49,,,830.49,Other,225% Medicaid APG methodology,830.49,,,830.49,Other,225% Medicaid APG methodology,564.73,,,564.73,Other,153% Medicaid APG methodology,830.49,,,830.49,Other,225% Medicaid APG methodology,516.75,,,516.75,Other,140% Medicaid APG methodology,830.49,,,830.49,Other,225% Medicaid APG methodology,959.68,,,959.68,Other,260% Medicaid APG methodology,1195.91,,,1195.91,Other,324% Medicaid APG methodology,793.58,,,793.58,Other,215% Medicaid APG methodology,793.58,,,793.58,Other,215% Medicaid APG methodology,461.38,,,461.38,Other,125% Medicaid APG methodology,362.97,8306,
EEG CEREBRAL DEATH ONLY         ,95824,CPT,,46100426,CDM,740,RC,,,both,,,3845,1019.25,,,1019.25,Other,150% of Medicare + 9.63% HCRA Surcharge,619.81,,,619.81,Other,Medicare OPPS methodology,1922.5,50,,1922.5,percent of total billed charges,All Other Outpatient,1730.25,45,,1730.25,percent of total billed charges,All Other Outpatient,60.2,,,60.2,Fee Schedule,,60.2,,,60.2,Fee Schedule,,60.2,,,60.2,Fee Schedule,,1922.5,50,,1922.5,percent of total billed charges,All Other,2691.5,70,,2691.5,percent of total billed charges,All Other,2614.6,68,,2614.6,percent of total billed charges,All Other Outpatient,397.38,,,397.38,Other,186% Medicaid methodology,3076,80,,3076,percent of total billed charges,All Other Outpatient,3191.35,83,,3191.35,percent of total billed charges,All Other Outpatient,3191.35,83,,3191.35,percent of total billed charges,All Other Outpatient,3076,80,,3076,percent of total billed charges,All Other Outpatient,3191.35,83,,3191.35,percent of total billed charges,All Other Outpatient,3460.5,90,,3460.5,percent of total billed charges,All Other,2691.5,70,,2691.5,percent of total billed charges,All Other,1922.5,50,,1922.5,percent of total billed charges,All Other,1922.5,50,,1922.5,percent of total billed charges,All Other,8236,,,8236,Case Rate,EEG Per Visit,7476,,,7476,Case Rate,EEG Per Visit,8306,,,8306,Case Rate,EEG Per Visit,7061,,,7061,Case Rate,EEG Per Visit,213.65,,,213.65,Other,New York Medicaid APG methodology,213.65,,,213.65,Other,100% Medicaid APG methodology,213.65,,,213.65,Other,100% Medicaid APG methodology,213.65,,,213.65,Other,100% Medicaid APG methodology,480.7,,,480.7,Other,225% Medicaid APG methodology,480.7,,,480.7,Other,225% Medicaid APG methodology,326.88,,,326.88,Other,153% Medicaid APG methodology,480.7,,,480.7,Other,225% Medicaid APG methodology,299.11,,,299.11,Other,140% Medicaid APG methodology,480.7,,,480.7,Other,225% Medicaid APG methodology,555.48,,,555.48,Other,260% Medicaid APG methodology,692.22,,,692.22,Other,324% Medicaid APG methodology,459.34,,,459.34,Other,215% Medicaid APG methodology,459.34,,,459.34,Other,215% Medicaid APG methodology,267.06,,,267.06,Other,125% Medicaid APG methodology,60.2,8306,
EEG CONT REC W/VID EEG TECH     ,95700,CPT,,46100749,CDM,740,RC,,,both,,,862,297.05,,,297.05,Other,150% of Medicare + 9.63% HCRA Surcharge,180.63,,,180.63,Other,Medicare OPPS methodology,431,50,,431,percent of total billed charges,All Other Outpatient,387.9,45,,387.9,percent of total billed charges,All Other Outpatient,307.45,,,307.45,Fee Schedule,,307.45,,,307.45,Fee Schedule,,307.45,,,307.45,Fee Schedule,,431,50,,431,percent of total billed charges,All Other,603.4,70,,603.4,percent of total billed charges,All Other,586.16,68,,586.16,percent of total billed charges,All Other Outpatient,397.38,,,397.38,Other,186% Medicaid methodology,689.6,80,,689.6,percent of total billed charges,All Other Outpatient,715.46,83,,715.46,percent of total billed charges,All Other Outpatient,715.46,83,,715.46,percent of total billed charges,All Other Outpatient,689.6,80,,689.6,percent of total billed charges,All Other Outpatient,715.46,83,,715.46,percent of total billed charges,All Other Outpatient,775.8,90,,775.8,percent of total billed charges,All Other,603.4,70,,603.4,percent of total billed charges,All Other,431,50,,431,percent of total billed charges,All Other,431,50,,431,percent of total billed charges,All Other,8236,,,8236,Case Rate,EEG Per Visit,7476,,,7476,Case Rate,EEG Per Visit,8306,,,8306,Case Rate,EEG Per Visit,7061,,,7061,Case Rate,EEG Per Visit,213.65,,,213.65,Other,New York Medicaid APG methodology,213.65,,,213.65,Other,100% Medicaid APG methodology,213.65,,,213.65,Other,100% Medicaid APG methodology,213.65,,,213.65,Other,100% Medicaid APG methodology,480.7,,,480.7,Other,225% Medicaid APG methodology,480.7,,,480.7,Other,225% Medicaid APG methodology,326.88,,,326.88,Other,153% Medicaid APG methodology,480.7,,,480.7,Other,225% Medicaid APG methodology,299.11,,,299.11,Other,140% Medicaid APG methodology,480.7,,,480.7,Other,225% Medicaid APG methodology,555.48,,,555.48,Other,260% Medicaid APG methodology,692.22,,,692.22,Other,324% Medicaid APG methodology,459.34,,,459.34,Other,215% Medicaid APG methodology,459.34,,,459.34,Other,215% Medicaid APG methodology,267.06,,,267.06,Other,125% Medicaid APG methodology,180.63,8306,
VEEG EA 12-26HR INTMT MNTR      ,95715,CPT,,46100756,CDM,740,RC,,,both,,,1769,1019.25,,,1019.25,Other,150% of Medicare + 9.63% HCRA Surcharge,619.81,,,619.81,Other,Medicare OPPS methodology,884.5,50,,884.5,percent of total billed charges,All Other Outpatient,796.05,45,,796.05,percent of total billed charges,All Other Outpatient,1361.61,,,1361.61,Fee Schedule,,1361.61,,,1361.61,Fee Schedule,,1361.61,,,1361.61,Fee Schedule,,884.5,50,,884.5,percent of total billed charges,All Other,1238.3,70,,1238.3,percent of total billed charges,All Other,1202.92,68,,1202.92,percent of total billed charges,All Other Outpatient,686.54,,,686.54,Other,186% Medicaid methodology,1415.2,80,,1415.2,percent of total billed charges,All Other Outpatient,1468.27,83,,1468.27,percent of total billed charges,All Other Outpatient,1468.27,83,,1468.27,percent of total billed charges,All Other Outpatient,1415.2,80,,1415.2,percent of total billed charges,All Other Outpatient,1468.27,83,,1468.27,percent of total billed charges,All Other Outpatient,1592.1,90,,1592.1,percent of total billed charges,All Other,1238.3,70,,1238.3,percent of total billed charges,All Other,884.5,50,,884.5,percent of total billed charges,All Other,884.5,50,,884.5,percent of total billed charges,All Other,8236,,,8236,Case Rate,EEG Per Visit,7476,,,7476,Case Rate,EEG Per Visit,8306,,,8306,Case Rate,EEG Per Visit,7061,,,7061,Case Rate,EEG Per Visit,369.11,,,369.11,Other,New York Medicaid APG methodology,369.11,,,369.11,Other,100% Medicaid APG methodology,369.11,,,369.11,Other,100% Medicaid APG methodology,369.11,,,369.11,Other,100% Medicaid APG methodology,830.49,,,830.49,Other,225% Medicaid APG methodology,830.49,,,830.49,Other,225% Medicaid APG methodology,564.73,,,564.73,Other,153% Medicaid APG methodology,830.49,,,830.49,Other,225% Medicaid APG methodology,516.75,,,516.75,Other,140% Medicaid APG methodology,830.49,,,830.49,Other,225% Medicaid APG methodology,959.68,,,959.68,Other,260% Medicaid APG methodology,1195.91,,,1195.91,Other,324% Medicaid APG methodology,793.58,,,793.58,Other,215% Medicaid APG methodology,793.58,,,793.58,Other,215% Medicaid APG methodology,461.38,,,461.38,Other,125% Medicaid APG methodology,369.11,8306,
VEEG 2-12 HR INTMT MNTR         ,95712,CPT,,46100764,CDM,740,RC,,,both,,,923,596.88,,,596.88,Other,150% of Medicare + 9.63% HCRA Surcharge,362.97,,,362.97,Other,Medicare OPPS methodology,461.5,50,,461.5,percent of total billed charges,All Other Outpatient,415.35,45,,415.35,percent of total billed charges,All Other Outpatient,550.28,,,550.28,Fee Schedule,,550.28,,,550.28,Fee Schedule,,550.28,,,550.28,Fee Schedule,,461.5,50,,461.5,percent of total billed charges,All Other,646.1,70,,646.1,percent of total billed charges,All Other,627.64,68,,627.64,percent of total billed charges,All Other Outpatient,397.38,,,397.38,Other,186% Medicaid methodology,738.4,80,,738.4,percent of total billed charges,All Other Outpatient,766.09,83,,766.09,percent of total billed charges,All Other Outpatient,766.09,83,,766.09,percent of total billed charges,All Other Outpatient,738.4,80,,738.4,percent of total billed charges,All Other Outpatient,766.09,83,,766.09,percent of total billed charges,All Other Outpatient,830.7,90,,830.7,percent of total billed charges,All Other,646.1,70,,646.1,percent of total billed charges,All Other,461.5,50,,461.5,percent of total billed charges,All Other,461.5,50,,461.5,percent of total billed charges,All Other,8236,,,8236,Case Rate,EEG Per Visit,7476,,,7476,Case Rate,EEG Per Visit,8306,,,8306,Case Rate,EEG Per Visit,7061,,,7061,Case Rate,EEG Per Visit,213.65,,,213.65,Other,New York Medicaid APG methodology,213.65,,,213.65,Other,100% Medicaid APG methodology,213.65,,,213.65,Other,100% Medicaid APG methodology,213.65,,,213.65,Other,100% Medicaid APG methodology,480.7,,,480.7,Other,225% Medicaid APG methodology,480.7,,,480.7,Other,225% Medicaid APG methodology,326.88,,,326.88,Other,153% Medicaid APG methodology,480.7,,,480.7,Other,225% Medicaid APG methodology,299.11,,,299.11,Other,140% Medicaid APG methodology,480.7,,,480.7,Other,225% Medicaid APG methodology,555.48,,,555.48,Other,260% Medicaid APG methodology,692.22,,,692.22,Other,324% Medicaid APG methodology,459.34,,,459.34,Other,215% Medicaid APG methodology,459.34,,,459.34,Other,215% Medicaid APG methodology,267.06,,,267.06,Other,125% Medicaid APG methodology,213.65,8306,
EEG WO VID EA 12-26HR UNMNTR    ,95708,CPT,,46100772,CDM,740,RC,,,both,,,9683,1019.25,,,1019.25,Other,150% of Medicare + 9.63% HCRA Surcharge,619.81,,,619.81,Other,Medicare OPPS methodology,4841.5,50,,4841.5,percent of total billed charges,All Other Outpatient,4357.35,45,,4357.35,percent of total billed charges,All Other Outpatient,550.28,,,550.28,Fee Schedule,,550.28,,,550.28,Fee Schedule,,550.28,,,550.28,Fee Schedule,,4841.5,50,,4841.5,percent of total billed charges,All Other,6778.1,70,,6778.1,percent of total billed charges,All Other,6584.44,68,,6584.44,percent of total billed charges,All Other Outpatient,686.54,,,686.54,Other,186% Medicaid methodology,7746.4,80,,7746.4,percent of total billed charges,All Other Outpatient,8036.89,83,,8036.89,percent of total billed charges,All Other Outpatient,8036.89,83,,8036.89,percent of total billed charges,All Other Outpatient,7746.4,80,,7746.4,percent of total billed charges,All Other Outpatient,8036.89,83,,8036.89,percent of total billed charges,All Other Outpatient,8714.7,90,,8714.7,percent of total billed charges,All Other,6778.1,70,,6778.1,percent of total billed charges,All Other,4841.5,50,,4841.5,percent of total billed charges,All Other,4841.5,50,,4841.5,percent of total billed charges,All Other,8236,,,8236,Case Rate,EEG Per Visit,7476,,,7476,Case Rate,EEG Per Visit,8306,,,8306,Case Rate,EEG Per Visit,7061,,,7061,Case Rate,EEG Per Visit,369.11,,,369.11,Other,New York Medicaid APG methodology,369.11,,,369.11,Other,100% Medicaid APG methodology,369.11,,,369.11,Other,100% Medicaid APG methodology,369.11,,,369.11,Other,100% Medicaid APG methodology,830.49,,,830.49,Other,225% Medicaid APG methodology,830.49,,,830.49,Other,225% Medicaid APG methodology,564.73,,,564.73,Other,153% Medicaid APG methodology,830.49,,,830.49,Other,225% Medicaid APG methodology,516.75,,,516.75,Other,140% Medicaid APG methodology,830.49,,,830.49,Other,225% Medicaid APG methodology,959.68,,,959.68,Other,260% Medicaid APG methodology,1195.91,,,1195.91,Other,324% Medicaid APG methodology,793.58,,,793.58,Other,215% Medicaid APG methodology,793.58,,,793.58,Other,215% Medicaid APG methodology,461.38,,,461.38,Other,125% Medicaid APG methodology,369.11,8714.7,
EEG W/O VID 2-12 HR UNMNTR      ,95705,CPT,,46100780,CDM,740,RC,,,both,,,923,596.88,,,596.88,Other,150% of Medicare + 9.63% HCRA Surcharge,362.97,,,362.97,Other,Medicare OPPS methodology,461.5,50,,461.5,percent of total billed charges,All Other Outpatient,415.35,45,,415.35,percent of total billed charges,All Other Outpatient,550.28,,,550.28,Fee Schedule,,550.28,,,550.28,Fee Schedule,,550.28,,,550.28,Fee Schedule,,461.5,50,,461.5,percent of total billed charges,All Other,646.1,70,,646.1,percent of total billed charges,All Other,627.64,68,,627.64,percent of total billed charges,All Other Outpatient,397.38,,,397.38,Other,186% Medicaid methodology,738.4,80,,738.4,percent of total billed charges,All Other Outpatient,766.09,83,,766.09,percent of total billed charges,All Other Outpatient,766.09,83,,766.09,percent of total billed charges,All Other Outpatient,738.4,80,,738.4,percent of total billed charges,All Other Outpatient,766.09,83,,766.09,percent of total billed charges,All Other Outpatient,830.7,90,,830.7,percent of total billed charges,All Other,646.1,70,,646.1,percent of total billed charges,All Other,461.5,50,,461.5,percent of total billed charges,All Other,461.5,50,,461.5,percent of total billed charges,All Other,8236,,,8236,Case Rate,EEG Per Visit,7476,,,7476,Case Rate,EEG Per Visit,8306,,,8306,Case Rate,EEG Per Visit,7061,,,7061,Case Rate,EEG Per Visit,213.65,,,213.65,Other,New York Medicaid APG methodology,213.65,,,213.65,Other,100% Medicaid APG methodology,213.65,,,213.65,Other,100% Medicaid APG methodology,213.65,,,213.65,Other,100% Medicaid APG methodology,480.7,,,480.7,Other,225% Medicaid APG methodology,480.7,,,480.7,Other,225% Medicaid APG methodology,326.88,,,326.88,Other,153% Medicaid APG methodology,480.7,,,480.7,Other,225% Medicaid APG methodology,299.11,,,299.11,Other,140% Medicaid APG methodology,480.7,,,480.7,Other,225% Medicaid APG methodology,555.48,,,555.48,Other,260% Medicaid APG methodology,692.22,,,692.22,Other,324% Medicaid APG methodology,459.34,,,459.34,Other,215% Medicaid APG methodology,459.34,,,459.34,Other,215% Medicaid APG methodology,267.06,,,267.06,Other,125% Medicaid APG methodology,213.65,8306,
VEEG 2-12 HR CONT MNTR          ,95713,CPT,,46100806,CDM,740,RC,,,both,,,1769,1019.25,,,1019.25,Other,150% of Medicare + 9.63% HCRA Surcharge,619.81,,,619.81,Other,Medicare OPPS methodology,884.5,50,,884.5,percent of total billed charges,All Other Outpatient,796.05,45,,796.05,percent of total billed charges,All Other Outpatient,550.28,,,550.28,Fee Schedule,,550.28,,,550.28,Fee Schedule,,550.28,,,550.28,Fee Schedule,,884.5,50,,884.5,percent of total billed charges,All Other,1238.3,70,,1238.3,percent of total billed charges,All Other,1202.92,68,,1202.92,percent of total billed charges,All Other Outpatient,397.38,,,397.38,Other,186% Medicaid methodology,1415.2,80,,1415.2,percent of total billed charges,All Other Outpatient,1468.27,83,,1468.27,percent of total billed charges,All Other Outpatient,1468.27,83,,1468.27,percent of total billed charges,All Other Outpatient,1415.2,80,,1415.2,percent of total billed charges,All Other Outpatient,1468.27,83,,1468.27,percent of total billed charges,All Other Outpatient,1592.1,90,,1592.1,percent of total billed charges,All Other,1238.3,70,,1238.3,percent of total billed charges,All Other,884.5,50,,884.5,percent of total billed charges,All Other,884.5,50,,884.5,percent of total billed charges,All Other,8236,,,8236,Case Rate,EEG Per Visit,7476,,,7476,Case Rate,EEG Per Visit,8306,,,8306,Case Rate,EEG Per Visit,7061,,,7061,Case Rate,EEG Per Visit,213.65,,,213.65,Other,New York Medicaid APG methodology,213.65,,,213.65,Other,100% Medicaid APG methodology,213.65,,,213.65,Other,100% Medicaid APG methodology,213.65,,,213.65,Other,100% Medicaid APG methodology,480.7,,,480.7,Other,225% Medicaid APG methodology,480.7,,,480.7,Other,225% Medicaid APG methodology,326.88,,,326.88,Other,153% Medicaid APG methodology,480.7,,,480.7,Other,225% Medicaid APG methodology,299.11,,,299.11,Other,140% Medicaid APG methodology,480.7,,,480.7,Other,225% Medicaid APG methodology,555.48,,,555.48,Other,260% Medicaid APG methodology,692.22,,,692.22,Other,324% Medicaid APG methodology,459.34,,,459.34,Other,215% Medicaid APG methodology,459.34,,,459.34,Other,215% Medicaid APG methodology,267.06,,,267.06,Other,125% Medicaid APG methodology,213.65,8306,
VEEG EA 12-26HR CONT MNTR       ,95716,CPT,,46100814,CDM,740,RC,,,both,,,3363,1988.24,,,1988.24,Other,150% of Medicare + 9.63% HCRA Surcharge,1209.06,,,1209.06,Other,Medicare OPPS methodology,1681.5,50,,1681.5,percent of total billed charges,All Other Outpatient,1513.35,45,,1513.35,percent of total billed charges,All Other Outpatient,1361.61,,,1361.61,Fee Schedule,,1361.61,,,1361.61,Fee Schedule,,1361.61,,,1361.61,Fee Schedule,,1681.5,50,,1681.5,percent of total billed charges,All Other,2354.1,70,,2354.1,percent of total billed charges,All Other,2286.84,68,,2286.84,percent of total billed charges,All Other Outpatient,686.54,,,686.54,Other,186% Medicaid methodology,2690.4,80,,2690.4,percent of total billed charges,All Other Outpatient,2791.29,83,,2791.29,percent of total billed charges,All Other Outpatient,2791.29,83,,2791.29,percent of total billed charges,All Other Outpatient,2690.4,80,,2690.4,percent of total billed charges,All Other Outpatient,2791.29,83,,2791.29,percent of total billed charges,All Other Outpatient,3026.7,90,,3026.7,percent of total billed charges,All Other,2354.1,70,,2354.1,percent of total billed charges,All Other,1681.5,50,,1681.5,percent of total billed charges,All Other,1681.5,50,,1681.5,percent of total billed charges,All Other,8236,,,8236,Case Rate,EEG Per Visit,7476,,,7476,Case Rate,EEG Per Visit,8306,,,8306,Case Rate,EEG Per Visit,7061,,,7061,Case Rate,EEG Per Visit,369.11,,,369.11,Other,New York Medicaid APG methodology,369.11,,,369.11,Other,100% Medicaid APG methodology,369.11,,,369.11,Other,100% Medicaid APG methodology,369.11,,,369.11,Other,100% Medicaid APG methodology,830.49,,,830.49,Other,225% Medicaid APG methodology,830.49,,,830.49,Other,225% Medicaid APG methodology,564.73,,,564.73,Other,153% Medicaid APG methodology,830.49,,,830.49,Other,225% Medicaid APG methodology,516.75,,,516.75,Other,140% Medicaid APG methodology,830.49,,,830.49,Other,225% Medicaid APG methodology,959.68,,,959.68,Other,260% Medicaid APG methodology,1195.91,,,1195.91,Other,324% Medicaid APG methodology,793.58,,,793.58,Other,215% Medicaid APG methodology,793.58,,,793.58,Other,215% Medicaid APG methodology,461.38,,,461.38,Other,125% Medicaid APG methodology,369.11,8306,
POLYSOM 6/>YRS CPAP 4/> PARM    ,95811,CPT,,46700043,CDM,740,RC,,,both,,,18122,1988.24,,,1988.24,Other,150% of Medicare + 9.63% HCRA Surcharge,1209.06,,,1209.06,Other,Medicare OPPS methodology,3746,,,3746,Case Rate,,3371,,,3371,Case Rate,,5672.77,,,5672.77,Fee Schedule,,5103.92,,,5103.92,Fee Schedule,,4819.49,,,4819.49,Fee Schedule,,9061,50,,9061,percent of total billed charges,All Other,12685.4,70,,12685.4,percent of total billed charges,All Other,12322.96,68,,12322.96,percent of total billed charges,All Other Outpatient,1758.79,,,1758.79,Other,186% Medicaid methodology,14497.6,80,,14497.6,percent of total billed charges,All Other Outpatient,15041.26,83,,15041.26,percent of total billed charges,All Other Outpatient,15041.26,83,,15041.26,percent of total billed charges,All Other Outpatient,14497.6,80,,14497.6,percent of total billed charges,All Other Outpatient,15041.26,83,,15041.26,percent of total billed charges,All Other Outpatient,16309.8,90,,16309.8,percent of total billed charges,All Other,12685.4,70,,12685.4,percent of total billed charges,All Other,2499.75,,,2499.75,Fee Schedule,,2121,,,2121,Fee Schedule,,2059,,,2059,Case Rate,Sleep Study Case Rate,1886,,,1886,Case Rate,Sleep Study Case Rate,2095,,,2095,Case Rate,Sleep Study Case Rate,1780,,,1780,Case Rate,Sleep Study Case Rate,945.58,,,945.58,Other,New York Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,1446.74,,,1446.74,Other,153% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,1323.82,,,1323.82,Other,140% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,2458.52,,,2458.52,Other,260% Medicaid APG methodology,3063.69,,,3063.69,Other,324% Medicaid APG methodology,2033.01,,,2033.01,Other,215% Medicaid APG methodology,2033.01,,,2033.01,Other,215% Medicaid APG methodology,1181.98,,,1181.98,Other,125% Medicaid APG methodology,945.58,16309.8,
SLEEP STUDY UNATT&RESP EFFT     ,95806,CPT,,46700118,CDM,740,RC,,,both,,,2759,297.05,,,297.05,Other,150% of Medicare + 9.63% HCRA Surcharge,180.63,,,180.63,Other,Medicare OPPS methodology,3746,,,3746,Case Rate,,3371,,,3371,Case Rate,,1094.73,,,1094.73,Fee Schedule,,984.96,,,984.96,Fee Schedule,,930.07,,,930.07,Fee Schedule,,1379.5,50,,1379.5,percent of total billed charges,All Other,1931.3,70,,1931.3,percent of total billed charges,All Other,1876.12,68,,1876.12,percent of total billed charges,All Other Outpatient,1008.88,,,1008.88,Other,186% Medicaid methodology,2207.2,80,,2207.2,percent of total billed charges,All Other Outpatient,2289.97,83,,2289.97,percent of total billed charges,All Other Outpatient,2289.97,83,,2289.97,percent of total billed charges,All Other Outpatient,2207.2,80,,2207.2,percent of total billed charges,All Other Outpatient,2289.97,83,,2289.97,percent of total billed charges,All Other Outpatient,2483.1,90,,2483.1,percent of total billed charges,All Other,1931.3,70,,1931.3,percent of total billed charges,All Other,231,,,231,Fee Schedule,,196,,,196,Fee Schedule,,346,,,346,Case Rate,Sleep Study Case Rate,274,,,274,Case Rate,Sleep Study Case Rate,304,,,304,Case Rate,Sleep Study Case Rate,258,,,258,Case Rate,Sleep Study Case Rate,542.41,,,542.41,Other,New York Medicaid APG methodology,542.41,,,542.41,Other,100% Medicaid APG methodology,542.41,,,542.41,Other,100% Medicaid APG methodology,542.41,,,542.41,Other,100% Medicaid APG methodology,1220.42,,,1220.42,Other,225% Medicaid APG methodology,1220.42,,,1220.42,Other,225% Medicaid APG methodology,829.88,,,829.88,Other,153% Medicaid APG methodology,1220.42,,,1220.42,Other,225% Medicaid APG methodology,759.37,,,759.37,Other,140% Medicaid APG methodology,1220.42,,,1220.42,Other,225% Medicaid APG methodology,1410.26,,,1410.26,Other,260% Medicaid APG methodology,1757.4,,,1757.4,Other,324% Medicaid APG methodology,1166.18,,,1166.18,Other,215% Medicaid APG methodology,1166.18,,,1166.18,Other,215% Medicaid APG methodology,678.01,,,678.01,Other,125% Medicaid APG methodology,180.63,3746,
POLYSOM <6 YRS 4/> PARAMTRS     ,95782,CPT,,46700126,CDM,740,RC,,,both,,,18122,1988.24,,,1988.24,Other,150% of Medicare + 9.63% HCRA Surcharge,1209.06,,,1209.06,Other,Medicare OPPS methodology,3746,,,3746,Case Rate,,3371,,,3371,Case Rate,,761.82,,,761.82,Fee Schedule,,761.82,,,761.82,Fee Schedule,,761.82,,,761.82,Fee Schedule,,9061,50,,9061,percent of total billed charges,All Other,12685.4,70,,12685.4,percent of total billed charges,All Other,12322.96,68,,12322.96,percent of total billed charges,All Other Outpatient,1758.79,,,1758.79,Other,186% Medicaid methodology,14497.6,80,,14497.6,percent of total billed charges,All Other Outpatient,15041.26,83,,15041.26,percent of total billed charges,All Other Outpatient,15041.26,83,,15041.26,percent of total billed charges,All Other Outpatient,14497.6,80,,14497.6,percent of total billed charges,All Other Outpatient,15041.26,83,,15041.26,percent of total billed charges,All Other Outpatient,16309.8,90,,16309.8,percent of total billed charges,All Other,12685.4,70,,12685.4,percent of total billed charges,All Other,4011.15,,,4011.15,Fee Schedule,,3403.4,,,3403.4,Fee Schedule,,2059,,,2059,Case Rate,Sleep Study Case Rate,1886,,,1886,Case Rate,Sleep Study Case Rate,2095,,,2095,Case Rate,Sleep Study Case Rate,1780,,,1780,Case Rate,Sleep Study Case Rate,945.58,,,945.58,Other,New York Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,1446.74,,,1446.74,Other,153% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,1323.82,,,1323.82,Other,140% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,2458.52,,,2458.52,Other,260% Medicaid APG methodology,3063.69,,,3063.69,Other,324% Medicaid APG methodology,2033.01,,,2033.01,Other,215% Medicaid APG methodology,2033.01,,,2033.01,Other,215% Medicaid APG methodology,1181.98,,,1181.98,Other,125% Medicaid APG methodology,761.82,16309.8,
POLYSOM <6 YRS CPAP/BILVL       ,95783,CPT,,46700134,CDM,740,RC,,,both,,,7306,1988.24,,,1988.24,Other,150% of Medicare + 9.63% HCRA Surcharge,1209.06,,,1209.06,Other,Medicare OPPS methodology,3746,,,3746,Case Rate,,3371,,,3371,Case Rate,,809.78,,,809.78,Fee Schedule,,809.78,,,809.78,Fee Schedule,,809.78,,,809.78,Fee Schedule,,3653,50,,3653,percent of total billed charges,All Other,5114.2,70,,5114.2,percent of total billed charges,All Other,4968.08,68,,4968.08,percent of total billed charges,All Other Outpatient,1758.79,,,1758.79,Other,186% Medicaid methodology,5844.8,80,,5844.8,percent of total billed charges,All Other Outpatient,6063.98,83,,6063.98,percent of total billed charges,All Other Outpatient,6063.98,83,,6063.98,percent of total billed charges,All Other Outpatient,5844.8,80,,5844.8,percent of total billed charges,All Other Outpatient,6063.98,83,,6063.98,percent of total billed charges,All Other Outpatient,6575.4,90,,6575.4,percent of total billed charges,All Other,5114.2,70,,5114.2,percent of total billed charges,All Other,4230.6,,,4230.6,Fee Schedule,,3589.6,,,3589.6,Fee Schedule,,2059,,,2059,Case Rate,Sleep Study Case Rate,1886,,,1886,Case Rate,Sleep Study Case Rate,2095,,,2095,Case Rate,Sleep Study Case Rate,1780,,,1780,Case Rate,Sleep Study Case Rate,945.58,,,945.58,Other,New York Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,1446.74,,,1446.74,Other,153% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,1323.82,,,1323.82,Other,140% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,2458.52,,,2458.52,Other,260% Medicaid APG methodology,3063.69,,,3063.69,Other,324% Medicaid APG methodology,2033.01,,,2033.01,Other,215% Medicaid APG methodology,2033.01,,,2033.01,Other,215% Medicaid APG methodology,1181.98,,,1181.98,Other,125% Medicaid APG methodology,809.78,6575.4,
POLYSOM <6 YRS 4/> PARMTRS RED  ,95782,CPT,52,46700142,CDM,740,RC,,,both,,,18122,1988.24,,,1988.24,Other,150% of Medicare + 9.63% HCRA Surcharge,1209.06,,,1209.06,Other,Medicare OPPS methodology,3746,,,3746,Case Rate,,3371,,,3371,Case Rate,,761.82,,,761.82,Fee Schedule,,761.82,,,761.82,Fee Schedule,,761.82,,,761.82,Fee Schedule,,9061,50,,9061,percent of total billed charges,All Other,12685.4,70,,12685.4,percent of total billed charges,All Other,12322.96,68,,12322.96,percent of total billed charges,All Other Outpatient,1758.79,,,1758.79,Other,186% Medicaid methodology,14497.6,80,,14497.6,percent of total billed charges,All Other Outpatient,15041.26,83,,15041.26,percent of total billed charges,All Other Outpatient,15041.26,83,,15041.26,percent of total billed charges,All Other Outpatient,14497.6,80,,14497.6,percent of total billed charges,All Other Outpatient,15041.26,83,,15041.26,percent of total billed charges,All Other Outpatient,16309.8,90,,16309.8,percent of total billed charges,All Other,12685.4,70,,12685.4,percent of total billed charges,All Other,4011.15,,,4011.15,Fee Schedule,,3403.4,,,3403.4,Fee Schedule,,2059,,,2059,Case Rate,Sleep Study Case Rate,1886,,,1886,Case Rate,Sleep Study Case Rate,2095,,,2095,Case Rate,Sleep Study Case Rate,1780,,,1780,Case Rate,Sleep Study Case Rate,945.58,,,945.58,Other,New York Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,1446.74,,,1446.74,Other,153% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,1323.82,,,1323.82,Other,140% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,2458.52,,,2458.52,Other,260% Medicaid APG methodology,3063.69,,,3063.69,Other,324% Medicaid APG methodology,2033.01,,,2033.01,Other,215% Medicaid APG methodology,2033.01,,,2033.01,Other,215% Medicaid APG methodology,1181.98,,,1181.98,Other,125% Medicaid APG methodology,761.82,16309.8,
SLEEP STUDY ATTENDED            ,95807,CPT,,46700159,CDM,740,RC,,,both,,,7263,1019.25,,,1019.25,Other,150% of Medicare + 9.63% HCRA Surcharge,619.81,,,619.81,Other,Medicare OPPS methodology,3746,,,3746,Case Rate,,3371,,,3371,Case Rate,,3733.24,,,3733.24,Fee Schedule,,3358.88,,,3358.88,Fee Schedule,,3171.7,,,3171.7,Fee Schedule,,3631.5,50,,3631.5,percent of total billed charges,All Other,5084.1,70,,5084.1,percent of total billed charges,All Other,4938.84,68,,4938.84,percent of total billed charges,All Other Outpatient,1758.79,,,1758.79,Other,186% Medicaid methodology,5810.4,80,,5810.4,percent of total billed charges,All Other Outpatient,6028.29,83,,6028.29,percent of total billed charges,All Other Outpatient,6028.29,83,,6028.29,percent of total billed charges,All Other Outpatient,5810.4,80,,5810.4,percent of total billed charges,All Other Outpatient,6028.29,83,,6028.29,percent of total billed charges,All Other Outpatient,6536.7,90,,6536.7,percent of total billed charges,All Other,5084.1,70,,5084.1,percent of total billed charges,All Other,1560.9,,,1560.9,Fee Schedule,,1324.4,,,1324.4,Fee Schedule,,2059,,,2059,Case Rate,Sleep Study Case Rate,1886,,,1886,Case Rate,Sleep Study Case Rate,2095,,,2095,Case Rate,Sleep Study Case Rate,1780,,,1780,Case Rate,Sleep Study Case Rate,945.58,,,945.58,Other,New York Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,1446.74,,,1446.74,Other,153% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,1323.82,,,1323.82,Other,140% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,2458.52,,,2458.52,Other,260% Medicaid APG methodology,3063.69,,,3063.69,Other,324% Medicaid APG methodology,2033.01,,,2033.01,Other,215% Medicaid APG methodology,2033.01,,,2033.01,Other,215% Medicaid APG methodology,1181.98,,,1181.98,Other,125% Medicaid APG methodology,619.81,6536.7,
POLYSOM ANY AGE 1-3> PARAM      ,95808,CPT,,46700167,CDM,740,RC,,,both,,,3325,1988.24,,,1988.24,Other,150% of Medicare + 9.63% HCRA Surcharge,1209.06,,,1209.06,Other,Medicare OPPS methodology,3746,,,3746,Case Rate,,3371,,,3371,Case Rate,,5136.21,,,5136.21,Fee Schedule,,4621.16,,,4621.16,Fee Schedule,,4363.64,,,4363.64,Fee Schedule,,1662.5,50,,1662.5,percent of total billed charges,All Other,2327.5,70,,2327.5,percent of total billed charges,All Other,2261,68,,2261,percent of total billed charges,All Other Outpatient,1758.79,,,1758.79,Other,186% Medicaid methodology,2660,80,,2660,percent of total billed charges,All Other Outpatient,2759.75,83,,2759.75,percent of total billed charges,All Other Outpatient,2759.75,83,,2759.75,percent of total billed charges,All Other Outpatient,2660,80,,2660,percent of total billed charges,All Other Outpatient,2759.75,83,,2759.75,percent of total billed charges,All Other Outpatient,2992.5,90,,2992.5,percent of total billed charges,All Other,2327.5,70,,2327.5,percent of total billed charges,All Other,2846.25,,,2846.25,Fee Schedule,,2415,,,2415,Fee Schedule,,2059,,,2059,Case Rate,Sleep Study Case Rate,1886,,,1886,Case Rate,Sleep Study Case Rate,2095,,,2095,Case Rate,Sleep Study Case Rate,1780,,,1780,Case Rate,Sleep Study Case Rate,945.58,,,945.58,Other,New York Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,1446.74,,,1446.74,Other,153% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,1323.82,,,1323.82,Other,140% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,2458.52,,,2458.52,Other,260% Medicaid APG methodology,3063.69,,,3063.69,Other,324% Medicaid APG methodology,2033.01,,,2033.01,Other,215% Medicaid APG methodology,2033.01,,,2033.01,Other,215% Medicaid APG methodology,1181.98,,,1181.98,Other,125% Medicaid APG methodology,945.58,5136.21,
MULTIPLE SLEEP LATENCY TST RED  ,95805,CPT,52,46700175,CDM,740,RC,,,both,,,9683,1019.25,,,1019.25,Other,150% of Medicare + 9.63% HCRA Surcharge,619.81,,,619.81,Other,Medicare OPPS methodology,3746,,,3746,Case Rate,,3371,,,3371,Case Rate,,3199.34,,,3199.34,Fee Schedule,,2878.51,,,2878.51,Fee Schedule,,2718.1,,,2718.1,Fee Schedule,,4841.5,50,,4841.5,percent of total billed charges,All Other,6778.1,70,,6778.1,percent of total billed charges,All Other,6584.44,68,,6584.44,percent of total billed charges,All Other Outpatient,1758.79,,,1758.79,Other,186% Medicaid methodology,7746.4,80,,7746.4,percent of total billed charges,All Other Outpatient,8036.89,83,,8036.89,percent of total billed charges,All Other Outpatient,8036.89,83,,8036.89,percent of total billed charges,All Other Outpatient,7746.4,80,,7746.4,percent of total billed charges,All Other Outpatient,8036.89,83,,8036.89,percent of total billed charges,All Other Outpatient,8714.7,90,,8714.7,percent of total billed charges,All Other,6778.1,70,,6778.1,percent of total billed charges,All Other,1758.9,,,1758.9,Fee Schedule,,1492.4,,,1492.4,Fee Schedule,,2059,,,2059,Case Rate,Sleep Study Case Rate,1886,,,1886,Case Rate,Sleep Study Case Rate,2095,,,2095,Case Rate,Sleep Study Case Rate,1780,,,1780,Case Rate,Sleep Study Case Rate,945.58,,,945.58,Other,New York Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,1446.74,,,1446.74,Other,153% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,1323.82,,,1323.82,Other,140% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,2458.52,,,2458.52,Other,260% Medicaid APG methodology,3063.69,,,3063.69,Other,324% Medicaid APG methodology,2033.01,,,2033.01,Other,215% Medicaid APG methodology,2033.01,,,2033.01,Other,215% Medicaid APG methodology,1181.98,,,1181.98,Other,125% Medicaid APG methodology,619.81,8714.7,
SLEEP STUDY UNAT&RESP EFFT RED  ,95806,CPT,52,46700183,CDM,740,RC,,,both,,,2759,297.05,,,297.05,Other,150% of Medicare + 9.63% HCRA Surcharge,180.63,,,180.63,Other,Medicare OPPS methodology,3746,,,3746,Case Rate,,3371,,,3371,Case Rate,,1094.73,,,1094.73,Fee Schedule,,984.96,,,984.96,Fee Schedule,,930.07,,,930.07,Fee Schedule,,1379.5,50,,1379.5,percent of total billed charges,All Other,1931.3,70,,1931.3,percent of total billed charges,All Other,1876.12,68,,1876.12,percent of total billed charges,All Other Outpatient,1008.88,,,1008.88,Other,186% Medicaid methodology,2207.2,80,,2207.2,percent of total billed charges,All Other Outpatient,2289.97,83,,2289.97,percent of total billed charges,All Other Outpatient,2289.97,83,,2289.97,percent of total billed charges,All Other Outpatient,2207.2,80,,2207.2,percent of total billed charges,All Other Outpatient,2289.97,83,,2289.97,percent of total billed charges,All Other Outpatient,2483.1,90,,2483.1,percent of total billed charges,All Other,1931.3,70,,1931.3,percent of total billed charges,All Other,231,,,231,Fee Schedule,,196,,,196,Fee Schedule,,346,,,346,Case Rate,Sleep Study Case Rate,274,,,274,Case Rate,Sleep Study Case Rate,304,,,304,Case Rate,Sleep Study Case Rate,258,,,258,Case Rate,Sleep Study Case Rate,542.41,,,542.41,Other,New York Medicaid APG methodology,542.41,,,542.41,Other,100% Medicaid APG methodology,542.41,,,542.41,Other,100% Medicaid APG methodology,542.41,,,542.41,Other,100% Medicaid APG methodology,1220.42,,,1220.42,Other,225% Medicaid APG methodology,1220.42,,,1220.42,Other,225% Medicaid APG methodology,829.88,,,829.88,Other,153% Medicaid APG methodology,1220.42,,,1220.42,Other,225% Medicaid APG methodology,759.37,,,759.37,Other,140% Medicaid APG methodology,1220.42,,,1220.42,Other,225% Medicaid APG methodology,1410.26,,,1410.26,Other,260% Medicaid APG methodology,1757.4,,,1757.4,Other,324% Medicaid APG methodology,1166.18,,,1166.18,Other,215% Medicaid APG methodology,1166.18,,,1166.18,Other,215% Medicaid APG methodology,678.01,,,678.01,Other,125% Medicaid APG methodology,180.63,3746,
SLEEP STUDY ATTENDED RED        ,95807,CPT,52,46700191,CDM,740,RC,,,both,,,7263,1019.25,,,1019.25,Other,150% of Medicare + 9.63% HCRA Surcharge,619.81,,,619.81,Other,Medicare OPPS methodology,3746,,,3746,Case Rate,,3371,,,3371,Case Rate,,3733.24,,,3733.24,Fee Schedule,,3358.88,,,3358.88,Fee Schedule,,3171.7,,,3171.7,Fee Schedule,,3631.5,50,,3631.5,percent of total billed charges,All Other,5084.1,70,,5084.1,percent of total billed charges,All Other,4938.84,68,,4938.84,percent of total billed charges,All Other Outpatient,1758.79,,,1758.79,Other,186% Medicaid methodology,5810.4,80,,5810.4,percent of total billed charges,All Other Outpatient,6028.29,83,,6028.29,percent of total billed charges,All Other Outpatient,6028.29,83,,6028.29,percent of total billed charges,All Other Outpatient,5810.4,80,,5810.4,percent of total billed charges,All Other Outpatient,6028.29,83,,6028.29,percent of total billed charges,All Other Outpatient,6536.7,90,,6536.7,percent of total billed charges,All Other,5084.1,70,,5084.1,percent of total billed charges,All Other,1560.9,,,1560.9,Fee Schedule,,1324.4,,,1324.4,Fee Schedule,,2059,,,2059,Case Rate,Sleep Study Case Rate,1886,,,1886,Case Rate,Sleep Study Case Rate,2095,,,2095,Case Rate,Sleep Study Case Rate,1780,,,1780,Case Rate,Sleep Study Case Rate,945.58,,,945.58,Other,New York Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,1446.74,,,1446.74,Other,153% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,1323.82,,,1323.82,Other,140% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,2458.52,,,2458.52,Other,260% Medicaid APG methodology,3063.69,,,3063.69,Other,324% Medicaid APG methodology,2033.01,,,2033.01,Other,215% Medicaid APG methodology,2033.01,,,2033.01,Other,215% Medicaid APG methodology,1181.98,,,1181.98,Other,125% Medicaid APG methodology,619.81,6536.7,
POLYSOM ANY AGE 1-3> PARAM RED  ,95808,CPT,52,46700209,CDM,740,RC,,,both,,,3325,1988.24,,,1988.24,Other,150% of Medicare + 9.63% HCRA Surcharge,1209.06,,,1209.06,Other,Medicare OPPS methodology,3746,,,3746,Case Rate,,3371,,,3371,Case Rate,,5136.21,,,5136.21,Fee Schedule,,4621.16,,,4621.16,Fee Schedule,,4363.64,,,4363.64,Fee Schedule,,1662.5,50,,1662.5,percent of total billed charges,All Other,2327.5,70,,2327.5,percent of total billed charges,All Other,2261,68,,2261,percent of total billed charges,All Other Outpatient,1758.79,,,1758.79,Other,186% Medicaid methodology,2660,80,,2660,percent of total billed charges,All Other Outpatient,2759.75,83,,2759.75,percent of total billed charges,All Other Outpatient,2759.75,83,,2759.75,percent of total billed charges,All Other Outpatient,2660,80,,2660,percent of total billed charges,All Other Outpatient,2759.75,83,,2759.75,percent of total billed charges,All Other Outpatient,2992.5,90,,2992.5,percent of total billed charges,All Other,2327.5,70,,2327.5,percent of total billed charges,All Other,2846.25,,,2846.25,Fee Schedule,,2415,,,2415,Fee Schedule,,2059,,,2059,Case Rate,Sleep Study Case Rate,1886,,,1886,Case Rate,Sleep Study Case Rate,2095,,,2095,Case Rate,Sleep Study Case Rate,1780,,,1780,Case Rate,Sleep Study Case Rate,945.58,,,945.58,Other,New York Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,1446.74,,,1446.74,Other,153% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,1323.82,,,1323.82,Other,140% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,2458.52,,,2458.52,Other,260% Medicaid APG methodology,3063.69,,,3063.69,Other,324% Medicaid APG methodology,2033.01,,,2033.01,Other,215% Medicaid APG methodology,2033.01,,,2033.01,Other,215% Medicaid APG methodology,1181.98,,,1181.98,Other,125% Medicaid APG methodology,945.58,5136.21,
POLYSOM <6 YRS CPAP/BILVL RED   ,95783,CPT,52,46700217,CDM,740,RC,,,both,,,7306,1988.24,,,1988.24,Other,150% of Medicare + 9.63% HCRA Surcharge,1209.06,,,1209.06,Other,Medicare OPPS methodology,3746,,,3746,Case Rate,,3371,,,3371,Case Rate,,809.78,,,809.78,Fee Schedule,,809.78,,,809.78,Fee Schedule,,809.78,,,809.78,Fee Schedule,,3653,50,,3653,percent of total billed charges,All Other,5114.2,70,,5114.2,percent of total billed charges,All Other,4968.08,68,,4968.08,percent of total billed charges,All Other Outpatient,1758.79,,,1758.79,Other,186% Medicaid methodology,5844.8,80,,5844.8,percent of total billed charges,All Other Outpatient,6063.98,83,,6063.98,percent of total billed charges,All Other Outpatient,6063.98,83,,6063.98,percent of total billed charges,All Other Outpatient,5844.8,80,,5844.8,percent of total billed charges,All Other Outpatient,6063.98,83,,6063.98,percent of total billed charges,All Other Outpatient,6575.4,90,,6575.4,percent of total billed charges,All Other,5114.2,70,,5114.2,percent of total billed charges,All Other,4230.6,,,4230.6,Fee Schedule,,3589.6,,,3589.6,Fee Schedule,,2059,,,2059,Case Rate,Sleep Study Case Rate,1886,,,1886,Case Rate,Sleep Study Case Rate,2095,,,2095,Case Rate,Sleep Study Case Rate,1780,,,1780,Case Rate,Sleep Study Case Rate,945.58,,,945.58,Other,New York Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,1446.74,,,1446.74,Other,153% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,1323.82,,,1323.82,Other,140% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,2458.52,,,2458.52,Other,260% Medicaid APG methodology,3063.69,,,3063.69,Other,324% Medicaid APG methodology,2033.01,,,2033.01,Other,215% Medicaid APG methodology,2033.01,,,2033.01,Other,215% Medicaid APG methodology,1181.98,,,1181.98,Other,125% Medicaid APG methodology,809.78,6575.4,
DRAW BLOOD OFF VENOUS DEVICE    ,36591,CPT,,40800146,CDM,761,RC,,,both,,,2033,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,1016.5,50,,1016.5,percent of total billed charges,All Other Outpatient,914.85,45,,914.85,percent of total billed charges,All Other Outpatient,212.17,,,212.17,Fee Schedule,,190.89,,,190.89,Fee Schedule,,180.26,,,180.26,Fee Schedule,,1016.5,50,,1016.5,percent of total billed charges,All Other,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper,1382.44,68,,1382.44,percent of total billed charges,All Other Outpatient,104.72,,,104.72,Other,186% Medicaid methodology,1626.4,80,,1626.4,percent of total billed charges,All Other Outpatient,1687.39,83,,1687.39,percent of total billed charges,All Other Outpatient,1687.39,83,,1687.39,percent of total billed charges,All Other Outpatient,1626.4,80,,1626.4,percent of total billed charges,All Other Outpatient,1687.39,83,,1687.39,percent of total billed charges,All Other Outpatient,1829.7,90,,1829.7,percent of total billed charges,All Other,1423.1,70,,1423.1,percent of total billed charges,All Other,130.35,,,130.35,Fee Schedule,,110.6,,,110.6,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,56.3,,,56.3,Other,New York Medicaid APG methodology,56.3,,,56.3,Other,100% Medicaid APG methodology,56.3,,,56.3,Other,100% Medicaid APG methodology,56.3,,,56.3,Other,100% Medicaid APG methodology,126.68,,,126.68,Other,225% Medicaid APG methodology,126.68,,,126.68,Other,225% Medicaid APG methodology,86.14,,,86.14,Other,153% Medicaid APG methodology,126.68,,,126.68,Other,225% Medicaid APG methodology,78.82,,,78.82,Other,140% Medicaid APG methodology,126.68,,,126.68,Other,225% Medicaid APG methodology,146.38,,,146.38,Other,260% Medicaid APG methodology,182.41,,,182.41,Other,324% Medicaid APG methodology,121.05,,,121.05,Other,215% Medicaid APG methodology,121.05,,,121.05,Other,215% Medicaid APG methodology,70.38,,,70.38,Other,125% Medicaid APG methodology,0.01,3567,
THER/PROPH/DIAG INJ IA          ,96373,CPT,,40800211,CDM,761,RC,,,both,,,1005,407.6,,,407.6,Other,150% of Medicare + 9.63% HCRA Surcharge,247.86,,,247.86,Other,Medicare OPPS methodology,502.5,50,,502.5,percent of total billed charges,All Other Outpatient,452.25,45,,452.25,percent of total billed charges,All Other Outpatient,502.5,50,,502.5,percent of total billed charges,All Other Outpatient,452.25,45,,452.25,percent of total billed charges,All Other Outpatient,432.15,43,,432.15,percent of total billed charges,All Other Outpatient,502.5,50,,502.5,percent of total billed charges,All Other,703.5,70,,703.5,percent of total billed charges,All Other,683.4,68,,683.4,percent of total billed charges,All Other Outpatient,116.47,,,116.47,Other,186% Medicaid methodology,804,80,,804,percent of total billed charges,All Other Outpatient,834.15,83,,834.15,percent of total billed charges,All Other Outpatient,834.15,83,,834.15,percent of total billed charges,All Other Outpatient,804,80,,804,percent of total billed charges,All Other Outpatient,834.15,83,,834.15,percent of total billed charges,All Other Outpatient,904.5,90,,904.5,percent of total billed charges,All Other,703.5,70,,703.5,percent of total billed charges,All Other,87.45,,,87.45,Fee Schedule,,74.2,,,74.2,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,62.62,,,62.62,Other,New York Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,95.8,,,95.8,Other,153% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,87.66,,,87.66,Other,140% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,162.81,,,162.81,Other,260% Medicaid APG methodology,202.88,,,202.88,Other,324% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,78.27,,,78.27,Other,125% Medicaid APG methodology,62.62,3567,
TX/PRO/DX INJ NEW DRUG ADDON    ,96375,CPT,,40800229,CDM,761,RC,,,both,,,742,90.33,,,90.33,Other,150% of Medicare + 9.63% HCRA Surcharge,54.93,,,54.93,Other,Medicare OPPS methodology,371,50,,371,percent of total billed charges,All Other Outpatient,333.9,45,,333.9,percent of total billed charges,All Other Outpatient,371,50,,371,percent of total billed charges,All Other Outpatient,333.9,45,,333.9,percent of total billed charges,All Other Outpatient,319.06,43,,319.06,percent of total billed charges,All Other Outpatient,371,50,,371,percent of total billed charges,All Other,519.4,70,,519.4,percent of total billed charges,All Other,504.56,68,,504.56,percent of total billed charges,All Other Outpatient,116.47,,,116.47,Other,186% Medicaid methodology,593.6,80,,593.6,percent of total billed charges,All Other Outpatient,615.86,83,,615.86,percent of total billed charges,All Other Outpatient,615.86,83,,615.86,percent of total billed charges,All Other Outpatient,593.6,80,,593.6,percent of total billed charges,All Other Outpatient,615.86,83,,615.86,percent of total billed charges,All Other Outpatient,667.8,90,,667.8,percent of total billed charges,All Other,519.4,70,,519.4,percent of total billed charges,All Other,77.55,,,77.55,Fee Schedule,,65.8,,,65.8,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,62.62,,,62.62,Other,New York Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,95.8,,,95.8,Other,153% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,87.66,,,87.66,Other,140% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,162.81,,,162.81,Other,260% Medicaid APG methodology,202.88,,,202.88,Other,324% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,78.27,,,78.27,Other,125% Medicaid APG methodology,54.93,3567,
BLOOD TRANSFUSION SERVICE       ,36430,CPT,,40800252,CDM,761,RC,,,both,,,3124,825.51,,,825.51,Other,150% of Medicare + 9.63% HCRA Surcharge,502,,,502,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1562,50,,1562,percent of total billed charges,All Other,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,2124.32,68,,2124.32,percent of total billed charges,All Other Outpatient,1373.44,,,1373.44,Other,186% Medicaid methodology,2499.2,80,,2499.2,percent of total billed charges,All Other Outpatient,2592.92,83,,2592.92,percent of total billed charges,All Other Outpatient,2592.92,83,,2592.92,percent of total billed charges,All Other Outpatient,2499.2,80,,2499.2,percent of total billed charges,All Other Outpatient,2592.92,83,,2592.92,percent of total billed charges,All Other Outpatient,2811.6,90,,2811.6,percent of total billed charges,All Other,2186.8,70,,2186.8,percent of total billed charges,All Other,186.45,,,186.45,Fee Schedule,,158.2,,,158.2,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,738.41,,,738.41,Other,New York Medicaid APG methodology,738.41,,,738.41,Other,100% Medicaid APG methodology,738.41,,,738.41,Other,100% Medicaid APG methodology,738.41,,,738.41,Other,100% Medicaid APG methodology,1661.41,,,1661.41,Other,225% Medicaid APG methodology,1661.41,,,1661.41,Other,225% Medicaid APG methodology,1129.76,,,1129.76,Other,153% Medicaid APG methodology,1661.41,,,1661.41,Other,225% Medicaid APG methodology,1033.77,,,1033.77,Other,140% Medicaid APG methodology,1661.41,,,1661.41,Other,225% Medicaid APG methodology,1919.86,,,1919.86,Other,260% Medicaid APG methodology,2392.44,,,2392.44,Other,324% Medicaid APG methodology,1587.57,,,1587.57,Other,215% Medicaid APG methodology,1587.57,,,1587.57,Other,215% Medicaid APG methodology,923.01,,,923.01,Other,125% Medicaid APG methodology,158.2,4343,
COLLECT BLOOD FROM PICC         ,36592,CPT,,40800344,CDM,761,RC,,,both,,,2033,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,1016.5,50,,1016.5,percent of total billed charges,All Other Outpatient,914.85,45,,914.85,percent of total billed charges,All Other Outpatient,237.08,,,237.08,Fee Schedule,,213.31,,,213.31,Fee Schedule,,201.42,,,201.42,Fee Schedule,,1016.5,50,,1016.5,percent of total billed charges,All Other,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper,1382.44,68,,1382.44,percent of total billed charges,All Other Outpatient,104.72,,,104.72,Other,186% Medicaid methodology,1626.4,80,,1626.4,percent of total billed charges,All Other Outpatient,1687.39,83,,1687.39,percent of total billed charges,All Other Outpatient,1687.39,83,,1687.39,percent of total billed charges,All Other Outpatient,1626.4,80,,1626.4,percent of total billed charges,All Other Outpatient,1687.39,83,,1687.39,percent of total billed charges,All Other Outpatient,1829.7,90,,1829.7,percent of total billed charges,All Other,1423.1,70,,1423.1,percent of total billed charges,All Other,145.2,,,145.2,Fee Schedule,,123.2,,,123.2,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,56.3,,,56.3,Other,New York Medicaid APG methodology,56.3,,,56.3,Other,100% Medicaid APG methodology,56.3,,,56.3,Other,100% Medicaid APG methodology,56.3,,,56.3,Other,100% Medicaid APG methodology,126.68,,,126.68,Other,225% Medicaid APG methodology,126.68,,,126.68,Other,225% Medicaid APG methodology,86.14,,,86.14,Other,153% Medicaid APG methodology,126.68,,,126.68,Other,225% Medicaid APG methodology,78.82,,,78.82,Other,140% Medicaid APG methodology,126.68,,,126.68,Other,225% Medicaid APG methodology,146.38,,,146.38,Other,260% Medicaid APG methodology,182.41,,,182.41,Other,324% Medicaid APG methodology,121.05,,,121.05,Other,215% Medicaid APG methodology,121.05,,,121.05,Other,215% Medicaid APG methodology,70.38,,,70.38,Other,125% Medicaid APG methodology,0.01,3567,
IRRIG DRUG DELIVERY DEVICE      ,96523,CPT,,40800575,CDM,761,RC,,,both,,,236,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,118,50,,118,percent of total billed charges,All Other Outpatient,106.2,45,,106.2,percent of total billed charges,All Other Outpatient,231.77,,,231.77,Fee Schedule,,208.53,,,208.53,Fee Schedule,,196.91,,,196.91,Fee Schedule,,118,50,,118,percent of total billed charges,All Other,165.2,70,,165.2,percent of total billed charges,All Other,160.48,68,,160.48,percent of total billed charges,All Other Outpatient,116.47,,,116.47,Other,186% Medicaid methodology,188.8,80,,188.8,percent of total billed charges,All Other Outpatient,195.88,83,,195.88,percent of total billed charges,All Other Outpatient,195.88,83,,195.88,percent of total billed charges,All Other Outpatient,188.8,80,,188.8,percent of total billed charges,All Other Outpatient,195.88,83,,195.88,percent of total billed charges,All Other Outpatient,212.4,90,,212.4,percent of total billed charges,All Other,165.2,70,,165.2,percent of total billed charges,All Other,130.35,,,130.35,Fee Schedule,,110.6,,,110.6,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,62.62,,,62.62,Other,New York Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,95.8,,,95.8,Other,153% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,87.66,,,87.66,Other,140% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,162.81,,,162.81,Other,260% Medicaid APG methodology,202.88,,,202.88,Other,324% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,78.27,,,78.27,Other,125% Medicaid APG methodology,62.62,3567,
BLOOD TRANSFUSION SERVICE       ,36430,CPT,,40800963,CDM,761,RC,,,both,,,2840,825.51,,,825.51,Other,150% of Medicare + 9.63% HCRA Surcharge,502,,,502,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1420,50,,1420,percent of total billed charges,All Other,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,1931.2,68,,1931.2,percent of total billed charges,All Other Outpatient,1373.44,,,1373.44,Other,186% Medicaid methodology,2272,80,,2272,percent of total billed charges,All Other Outpatient,2357.2,83,,2357.2,percent of total billed charges,All Other Outpatient,2357.2,83,,2357.2,percent of total billed charges,All Other Outpatient,2272,80,,2272,percent of total billed charges,All Other Outpatient,2357.2,83,,2357.2,percent of total billed charges,All Other Outpatient,2556,90,,2556,percent of total billed charges,All Other,1988,70,,1988,percent of total billed charges,All Other,186.45,,,186.45,Fee Schedule,,158.2,,,158.2,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,738.41,,,738.41,Other,New York Medicaid APG methodology,738.41,,,738.41,Other,100% Medicaid APG methodology,738.41,,,738.41,Other,100% Medicaid APG methodology,738.41,,,738.41,Other,100% Medicaid APG methodology,1661.41,,,1661.41,Other,225% Medicaid APG methodology,1661.41,,,1661.41,Other,225% Medicaid APG methodology,1129.76,,,1129.76,Other,153% Medicaid APG methodology,1661.41,,,1661.41,Other,225% Medicaid APG methodology,1033.77,,,1033.77,Other,140% Medicaid APG methodology,1661.41,,,1661.41,Other,225% Medicaid APG methodology,1919.86,,,1919.86,Other,260% Medicaid APG methodology,2392.44,,,2392.44,Other,324% Medicaid APG methodology,1587.57,,,1587.57,Other,215% Medicaid APG methodology,1587.57,,,1587.57,Other,215% Medicaid APG methodology,923.01,,,923.01,Other,125% Medicaid APG methodology,158.2,4343,
BL PUSH TRANSFUSE 2 YR/<        ,36440,CPT,,40800971,CDM,761,RC,,,both,,,1840,825.51,,,825.51,Other,150% of Medicare + 9.63% HCRA Surcharge,502,,,502,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,920,50,,920,percent of total billed charges,All Other,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,1251.2,68,,1251.2,percent of total billed charges,All Other Outpatient,1127.51,,,1127.51,Other,186% Medicaid methodology,1472,80,,1472,percent of total billed charges,All Other Outpatient,1527.2,83,,1527.2,percent of total billed charges,All Other Outpatient,1527.2,83,,1527.2,percent of total billed charges,All Other Outpatient,1472,80,,1472,percent of total billed charges,All Other Outpatient,1527.2,83,,1527.2,percent of total billed charges,All Other Outpatient,1656,90,,1656,percent of total billed charges,All Other,1288,70,,1288,percent of total billed charges,All Other,245.85,,,245.85,Fee Schedule,,208.6,,,208.6,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,606.19,,,606.19,Other,New York Medicaid APG methodology,606.19,,,606.19,Other,100% Medicaid APG methodology,606.19,,,606.19,Other,100% Medicaid APG methodology,606.19,,,606.19,Other,100% Medicaid APG methodology,1363.92,,,1363.92,Other,225% Medicaid APG methodology,1363.92,,,1363.92,Other,225% Medicaid APG methodology,927.47,,,927.47,Other,153% Medicaid APG methodology,1363.92,,,1363.92,Other,225% Medicaid APG methodology,848.66,,,848.66,Other,140% Medicaid APG methodology,1363.92,,,1363.92,Other,225% Medicaid APG methodology,1576.09,,,1576.09,Other,260% Medicaid APG methodology,1964.05,,,1964.05,Other,324% Medicaid APG methodology,1303.3,,,1303.3,Other,215% Medicaid APG methodology,1303.3,,,1303.3,Other,215% Medicaid APG methodology,757.74,,,757.74,Other,125% Medicaid APG methodology,208.6,4343,
INJECTION FOR BLADDER X-RAY     ,51600,CPT,,45005287,CDM,761,RC,,,both,,,8848,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4424,50,,4424,percent of total billed charges,All Other,6193.6,70,,6193.6,percent of total billed charges,All Other,6016.64,68,,6016.64,percent of total billed charges,All Other Outpatient,969.7,,,969.7,Other,186% Medicaid methodology,7078.4,80,,7078.4,percent of total billed charges,All Other Outpatient,7343.84,83,,7343.84,percent of total billed charges,All Other Outpatient,7343.84,83,,7343.84,percent of total billed charges,All Other Outpatient,7078.4,80,,7078.4,percent of total billed charges,All Other Outpatient,7343.84,83,,7343.84,percent of total billed charges,All Other Outpatient,7963.2,90,,7963.2,percent of total billed charges,All Other,6193.6,70,,6193.6,percent of total billed charges,All Other,211.2,,,211.2,Fee Schedule,,179.2,,,179.2,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,521.34,,,521.34,Other,New York Medicaid APG methodology,521.34,,,521.34,Other,100% Medicaid APG methodology,521.34,,,521.34,Other,100% Medicaid APG methodology,521.34,,,521.34,Other,100% Medicaid APG methodology,1173.02,,,1173.02,Other,225% Medicaid APG methodology,1173.02,,,1173.02,Other,225% Medicaid APG methodology,797.65,,,797.65,Other,153% Medicaid APG methodology,1173.02,,,1173.02,Other,225% Medicaid APG methodology,729.88,,,729.88,Other,140% Medicaid APG methodology,1173.02,,,1173.02,Other,225% Medicaid APG methodology,1355.49,,,1355.49,Other,260% Medicaid APG methodology,1689.15,,,1689.15,Other,324% Medicaid APG methodology,1120.89,,,1120.89,Other,215% Medicaid APG methodology,1120.89,,,1120.89,Other,215% Medicaid APG methodology,651.68,,,651.68,Other,125% Medicaid APG methodology,0.01,9074,
XR Arthrogram Injection Elbow Left,24220,CPT,TCLT,45005827,CDM,761,RC,,,both,,,2635,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1317.5,50,,1317.5,percent of total billed charges,All Other,1844.5,70,,1844.5,percent of total billed charges,All Other,1791.8,68,,1791.8,percent of total billed charges,All Other Outpatient,1205.26,,,1205.26,Other,186% Medicaid methodology,2108,80,,2108,percent of total billed charges,All Other Outpatient,2187.05,83,,2187.05,percent of total billed charges,All Other Outpatient,2187.05,83,,2187.05,percent of total billed charges,All Other Outpatient,2108,80,,2108,percent of total billed charges,All Other Outpatient,2187.05,83,,2187.05,percent of total billed charges,All Other Outpatient,2371.5,90,,2371.5,percent of total billed charges,All Other,1844.5,70,,1844.5,percent of total billed charges,All Other,320.1,,,320.1,Fee Schedule,,271.6,,,271.6,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,647.99,,,647.99,Other,New York Medicaid APG methodology,647.99,,,647.99,Other,100% Medicaid APG methodology,647.99,,,647.99,Other,100% Medicaid APG methodology,647.99,,,647.99,Other,100% Medicaid APG methodology,1457.97,,,1457.97,Other,225% Medicaid APG methodology,1457.97,,,1457.97,Other,225% Medicaid APG methodology,991.42,,,991.42,Other,153% Medicaid APG methodology,1457.97,,,1457.97,Other,225% Medicaid APG methodology,907.18,,,907.18,Other,140% Medicaid APG methodology,1457.97,,,1457.97,Other,225% Medicaid APG methodology,1684.77,,,1684.77,Other,260% Medicaid APG methodology,2099.48,,,2099.48,Other,324% Medicaid APG methodology,1393.17,,,1393.17,Other,215% Medicaid APG methodology,1393.17,,,1393.17,Other,215% Medicaid APG methodology,809.98,,,809.98,Other,125% Medicaid APG methodology,0.01,4343,
INJECTION FOR ANKLE X-RAY       ,27648,CPT,,45005840,CDM,761,RC,,,both,,,1055,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,527.5,50,,527.5,percent of total billed charges,All Other,738.5,70,,738.5,percent of total billed charges,All Other,717.4,68,,717.4,percent of total billed charges,All Other Outpatient,969.7,,,969.7,Other,186% Medicaid methodology,844,80,,844,percent of total billed charges,All Other Outpatient,875.65,83,,875.65,percent of total billed charges,All Other Outpatient,875.65,83,,875.65,percent of total billed charges,All Other Outpatient,844,80,,844,percent of total billed charges,All Other Outpatient,875.65,83,,875.65,percent of total billed charges,All Other Outpatient,949.5,90,,949.5,percent of total billed charges,All Other,738.5,70,,738.5,percent of total billed charges,All Other,247.5,,,247.5,Fee Schedule,,210,,,210,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,521.34,,,521.34,Other,New York Medicaid APG methodology,521.34,,,521.34,Other,100% Medicaid APG methodology,521.34,,,521.34,Other,100% Medicaid APG methodology,521.34,,,521.34,Other,100% Medicaid APG methodology,1173.02,,,1173.02,Other,225% Medicaid APG methodology,1173.02,,,1173.02,Other,225% Medicaid APG methodology,797.65,,,797.65,Other,153% Medicaid APG methodology,1173.02,,,1173.02,Other,225% Medicaid APG methodology,729.88,,,729.88,Other,140% Medicaid APG methodology,1173.02,,,1173.02,Other,225% Medicaid APG methodology,1355.49,,,1355.49,Other,260% Medicaid APG methodology,1689.15,,,1689.15,Other,324% Medicaid APG methodology,1120.89,,,1120.89,Other,215% Medicaid APG methodology,1120.89,,,1120.89,Other,215% Medicaid APG methodology,651.68,,,651.68,Other,125% Medicaid APG methodology,0.01,4343,
INJECTION FOR HIP X-RAY         ,27093,CPT,,45005865,CDM,761,RC,,,both,,,4116,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2058,50,,2058,percent of total billed charges,All Other,2881.2,70,,2881.2,percent of total billed charges,All Other,2798.88,68,,2798.88,percent of total billed charges,All Other Outpatient,969.7,,,969.7,Other,186% Medicaid methodology,3292.8,80,,3292.8,percent of total billed charges,All Other Outpatient,3416.28,83,,3416.28,percent of total billed charges,All Other Outpatient,3416.28,83,,3416.28,percent of total billed charges,All Other Outpatient,3292.8,80,,3292.8,percent of total billed charges,All Other Outpatient,3416.28,83,,3416.28,percent of total billed charges,All Other Outpatient,3704.4,90,,3704.4,percent of total billed charges,All Other,2881.2,70,,2881.2,percent of total billed charges,All Other,326.7,,,326.7,Fee Schedule,,277.2,,,277.2,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,521.34,,,521.34,Other,New York Medicaid APG methodology,521.34,,,521.34,Other,100% Medicaid APG methodology,521.34,,,521.34,Other,100% Medicaid APG methodology,521.34,,,521.34,Other,100% Medicaid APG methodology,1173.02,,,1173.02,Other,225% Medicaid APG methodology,1173.02,,,1173.02,Other,225% Medicaid APG methodology,797.65,,,797.65,Other,153% Medicaid APG methodology,1173.02,,,1173.02,Other,225% Medicaid APG methodology,729.88,,,729.88,Other,140% Medicaid APG methodology,1173.02,,,1173.02,Other,225% Medicaid APG methodology,1355.49,,,1355.49,Other,260% Medicaid APG methodology,1689.15,,,1689.15,Other,324% Medicaid APG methodology,1120.89,,,1120.89,Other,215% Medicaid APG methodology,1120.89,,,1120.89,Other,215% Medicaid APG methodology,651.68,,,651.68,Other,125% Medicaid APG methodology,0.01,4343,
INJECTION FOR SHOULDER X-RAY    ,23350,CPT,,45005881,CDM,761,RC,,,both,,,3506,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1753,50,,1753,percent of total billed charges,All Other,2454.2,70,,2454.2,percent of total billed charges,All Other,2384.08,68,,2384.08,percent of total billed charges,All Other Outpatient,969.7,,,969.7,Other,186% Medicaid methodology,2804.8,80,,2804.8,percent of total billed charges,All Other Outpatient,2909.98,83,,2909.98,percent of total billed charges,All Other Outpatient,2909.98,83,,2909.98,percent of total billed charges,All Other Outpatient,2804.8,80,,2804.8,percent of total billed charges,All Other Outpatient,2909.98,83,,2909.98,percent of total billed charges,All Other Outpatient,3155.4,90,,3155.4,percent of total billed charges,All Other,2454.2,70,,2454.2,percent of total billed charges,All Other,240.9,,,240.9,Fee Schedule,,204.4,,,204.4,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,521.34,,,521.34,Other,New York Medicaid APG methodology,521.34,,,521.34,Other,100% Medicaid APG methodology,521.34,,,521.34,Other,100% Medicaid APG methodology,521.34,,,521.34,Other,100% Medicaid APG methodology,1173.02,,,1173.02,Other,225% Medicaid APG methodology,1173.02,,,1173.02,Other,225% Medicaid APG methodology,797.65,,,797.65,Other,153% Medicaid APG methodology,1173.02,,,1173.02,Other,225% Medicaid APG methodology,729.88,,,729.88,Other,140% Medicaid APG methodology,1173.02,,,1173.02,Other,225% Medicaid APG methodology,1355.49,,,1355.49,Other,260% Medicaid APG methodology,1689.15,,,1689.15,Other,324% Medicaid APG methodology,1120.89,,,1120.89,Other,215% Medicaid APG methodology,1120.89,,,1120.89,Other,215% Medicaid APG methodology,651.68,,,651.68,Other,125% Medicaid APG methodology,0.01,4343,
INJECTION FOR WRIST X-RAY       ,25246,CPT,,45005899,CDM,761,RC,,,both,,,2630,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1315,50,,1315,percent of total billed charges,All Other,1841,70,,1841,percent of total billed charges,All Other,1788.4,68,,1788.4,percent of total billed charges,All Other Outpatient,969.7,,,969.7,Other,186% Medicaid methodology,2104,80,,2104,percent of total billed charges,All Other Outpatient,2182.9,83,,2182.9,percent of total billed charges,All Other Outpatient,2182.9,83,,2182.9,percent of total billed charges,All Other Outpatient,2104,80,,2104,percent of total billed charges,All Other Outpatient,2182.9,83,,2182.9,percent of total billed charges,All Other Outpatient,2367,90,,2367,percent of total billed charges,All Other,1841,70,,1841,percent of total billed charges,All Other,351.45,,,351.45,Fee Schedule,,298.2,,,298.2,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,521.34,,,521.34,Other,New York Medicaid APG methodology,521.34,,,521.34,Other,100% Medicaid APG methodology,521.34,,,521.34,Other,100% Medicaid APG methodology,521.34,,,521.34,Other,100% Medicaid APG methodology,1173.02,,,1173.02,Other,225% Medicaid APG methodology,1173.02,,,1173.02,Other,225% Medicaid APG methodology,797.65,,,797.65,Other,153% Medicaid APG methodology,1173.02,,,1173.02,Other,225% Medicaid APG methodology,729.88,,,729.88,Other,140% Medicaid APG methodology,1173.02,,,1173.02,Other,225% Medicaid APG methodology,1355.49,,,1355.49,Other,260% Medicaid APG methodology,1689.15,,,1689.15,Other,324% Medicaid APG methodology,1120.89,,,1120.89,Other,215% Medicaid APG methodology,1120.89,,,1120.89,Other,215% Medicaid APG methodology,651.68,,,651.68,Other,125% Medicaid APG methodology,0.01,4343,
PERQ DEVICE BREAST 1ST IMAG     ,19281,CPT,,45006046,CDM,761,RC,,,both,,,10533,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5266.5,50,,5266.5,percent of total billed charges,All Other,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,7162.44,68,,7162.44,percent of total billed charges,All Other Outpatient,3569.69,,,3569.69,Other,186% Medicaid methodology,8426.4,80,,8426.4,percent of total billed charges,All Other Outpatient,8742.39,83,,8742.39,percent of total billed charges,All Other Outpatient,8742.39,83,,8742.39,percent of total billed charges,All Other Outpatient,8426.4,80,,8426.4,percent of total billed charges,All Other Outpatient,8742.39,83,,8742.39,percent of total billed charges,All Other Outpatient,9479.7,90,,9479.7,percent of total billed charges,All Other,7373.1,70,,7373.1,percent of total billed charges,All Other,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1919.19,,,1919.19,Other,New York Medicaid APG methodology,1919.19,,,1919.19,Other,100% Medicaid APG methodology,1919.19,,,1919.19,Other,100% Medicaid APG methodology,1919.19,,,1919.19,Other,100% Medicaid APG methodology,4318.17,,,4318.17,Other,225% Medicaid APG methodology,4318.17,,,4318.17,Other,225% Medicaid APG methodology,2936.36,,,2936.36,Other,153% Medicaid APG methodology,4318.17,,,4318.17,Other,225% Medicaid APG methodology,2686.86,,,2686.86,Other,140% Medicaid APG methodology,4318.17,,,4318.17,Other,225% Medicaid APG methodology,4989.89,,,4989.89,Other,260% Medicaid APG methodology,6218.17,,,6218.17,Other,324% Medicaid APG methodology,4126.25,,,4126.25,Other,215% Medicaid APG methodology,4126.25,,,4126.25,Other,215% Medicaid APG methodology,2398.98,,,2398.98,Other,125% Medicaid APG methodology,1874.86,13157,
XR Arthrogram Injection Knee Left,20610,CPT,TCLT,45006251,CDM,761,RC,,,both,,,935,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,467.5,50,,467.5,percent of total billed charges,All Other,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,635.8,68,,635.8,percent of total billed charges,All Other Outpatient,841.15,,,841.15,Other,186% Medicaid methodology,748,80,,748,percent of total billed charges,All Other Outpatient,776.05,83,,776.05,percent of total billed charges,All Other Outpatient,776.05,83,,776.05,percent of total billed charges,All Other Outpatient,748,80,,748,percent of total billed charges,All Other Outpatient,776.05,83,,776.05,percent of total billed charges,All Other Outpatient,841.5,90,,841.5,percent of total billed charges,All Other,654.5,70,,654.5,percent of total billed charges,All Other,219.45,,,219.45,Fee Schedule,,186.2,,,186.2,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,452.23,,,452.23,Other,New York Medicaid APG methodology,452.23,,,452.23,Other,100% Medicaid APG methodology,452.23,,,452.23,Other,100% Medicaid APG methodology,452.23,,,452.23,Other,100% Medicaid APG methodology,1017.52,,,1017.52,Other,225% Medicaid APG methodology,1017.52,,,1017.52,Other,225% Medicaid APG methodology,691.91,,,691.91,Other,153% Medicaid APG methodology,1017.52,,,1017.52,Other,225% Medicaid APG methodology,633.12,,,633.12,Other,140% Medicaid APG methodology,1017.52,,,1017.52,Other,225% Medicaid APG methodology,1175.8,,,1175.8,Other,260% Medicaid APG methodology,1465.23,,,1465.23,Other,324% Medicaid APG methodology,972.3,,,972.3,Other,215% Medicaid APG methodology,972.3,,,972.3,Other,215% Medicaid APG methodology,565.29,,,565.29,Other,125% Medicaid APG methodology,186.2,4343,
XR Arthrogram Injection Knee Right,20610,CPT,TCRT,45006269,CDM,761,RC,,,both,,,935,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,467.5,50,,467.5,percent of total billed charges,All Other,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,635.8,68,,635.8,percent of total billed charges,All Other Outpatient,841.15,,,841.15,Other,186% Medicaid methodology,748,80,,748,percent of total billed charges,All Other Outpatient,776.05,83,,776.05,percent of total billed charges,All Other Outpatient,776.05,83,,776.05,percent of total billed charges,All Other Outpatient,748,80,,748,percent of total billed charges,All Other Outpatient,776.05,83,,776.05,percent of total billed charges,All Other Outpatient,841.5,90,,841.5,percent of total billed charges,All Other,654.5,70,,654.5,percent of total billed charges,All Other,219.45,,,219.45,Fee Schedule,,186.2,,,186.2,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,452.23,,,452.23,Other,New York Medicaid APG methodology,452.23,,,452.23,Other,100% Medicaid APG methodology,452.23,,,452.23,Other,100% Medicaid APG methodology,452.23,,,452.23,Other,100% Medicaid APG methodology,1017.52,,,1017.52,Other,225% Medicaid APG methodology,1017.52,,,1017.52,Other,225% Medicaid APG methodology,691.91,,,691.91,Other,153% Medicaid APG methodology,1017.52,,,1017.52,Other,225% Medicaid APG methodology,633.12,,,633.12,Other,140% Medicaid APG methodology,1017.52,,,1017.52,Other,225% Medicaid APG methodology,1175.8,,,1175.8,Other,260% Medicaid APG methodology,1465.23,,,1465.23,Other,324% Medicaid APG methodology,972.3,,,972.3,Other,215% Medicaid APG methodology,972.3,,,972.3,Other,215% Medicaid APG methodology,565.29,,,565.29,Other,125% Medicaid APG methodology,186.2,4343,
INSJ PICC 5 YR+ W/O IMAGING     ,36569,CPT,,45200011,CDM,761,RC,,,both,,,6724,3045.56,,,3045.56,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.02,,,1852.02,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,3362,50,,3362,percent of total billed charges,All Other,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,4572.32,68,,4572.32,percent of total billed charges,All Other Outpatient,507.79,,,507.79,Other,186% Medicaid methodology,5379.2,80,,5379.2,percent of total billed charges,All Other Outpatient,5580.92,83,,5580.92,percent of total billed charges,All Other Outpatient,5580.92,83,,5580.92,percent of total billed charges,All Other Outpatient,5379.2,80,,5379.2,percent of total billed charges,All Other Outpatient,5580.92,83,,5580.92,percent of total billed charges,All Other Outpatient,6051.6,90,,6051.6,percent of total billed charges,All Other,4706.8,70,,4706.8,percent of total billed charges,All Other,452.1,,,452.1,Fee Schedule,,383.6,,,383.6,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,273.01,,,273.01,Other,New York Medicaid APG methodology,273.01,,,273.01,Other,100% Medicaid APG methodology,273.01,,,273.01,Other,100% Medicaid APG methodology,273.01,,,273.01,Other,100% Medicaid APG methodology,614.27,,,614.27,Other,225% Medicaid APG methodology,614.27,,,614.27,Other,225% Medicaid APG methodology,417.7,,,417.7,Other,153% Medicaid APG methodology,614.27,,,614.27,Other,225% Medicaid APG methodology,382.21,,,382.21,Other,140% Medicaid APG methodology,614.27,,,614.27,Other,225% Medicaid APG methodology,709.82,,,709.82,Other,260% Medicaid APG methodology,884.55,,,884.55,Other,324% Medicaid APG methodology,586.97,,,586.97,Other,215% Medicaid APG methodology,586.97,,,586.97,Other,215% Medicaid APG methodology,341.26,,,341.26,Other,125% Medicaid APG methodology,273.01,6051.6,
INSJ PICC RS&I 5 YR+            ,36573,CPT,,45200292,CDM,761,RC,,,both,,,9705,3045.56,,,3045.56,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.02,,,1852.02,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,4852.5,50,,4852.5,percent of total billed charges,All Other,7394,,"100% primary, 50% supplemental procedure",7394,Other,Cigna ASC Grouper,6599.4,68,,6599.4,percent of total billed charges,All Other Outpatient,713.01,,,713.01,Other,186% Medicaid methodology,7764,80,,7764,percent of total billed charges,All Other Outpatient,8055.15,83,,8055.15,percent of total billed charges,All Other Outpatient,8055.15,83,,8055.15,percent of total billed charges,All Other Outpatient,7764,80,,7764,percent of total billed charges,All Other Outpatient,8055.15,83,,8055.15,percent of total billed charges,All Other Outpatient,8734.5,90,,8734.5,percent of total billed charges,All Other,6793.5,70,,6793.5,percent of total billed charges,All Other,405.9,,,405.9,Fee Schedule,,344.4,,,344.4,Fee Schedule,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,383.34,,,383.34,Other,New York Medicaid APG methodology,383.34,,,383.34,Other,100% Medicaid APG methodology,383.34,,,383.34,Other,100% Medicaid APG methodology,383.34,,,383.34,Other,100% Medicaid APG methodology,862.51,,,862.51,Other,225% Medicaid APG methodology,862.51,,,862.51,Other,225% Medicaid APG methodology,586.51,,,586.51,Other,153% Medicaid APG methodology,862.51,,,862.51,Other,225% Medicaid APG methodology,536.67,,,536.67,Other,140% Medicaid APG methodology,862.51,,,862.51,Other,225% Medicaid APG methodology,996.68,,,996.68,Other,260% Medicaid APG methodology,1242.01,,,1242.01,Other,324% Medicaid APG methodology,824.17,,,824.17,Other,215% Medicaid APG methodology,824.17,,,824.17,Other,215% Medicaid APG methodology,479.17,,,479.17,Other,125% Medicaid APG methodology,344.4,8734.5,
N/T SUCTIONING                  ,31720,CPT,,46600011,CDM,761,RC,,,both,,,690,405.6,,,405.6,Other,150% of Medicare + 9.63% HCRA Surcharge,246.65,,,246.65,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,345,50,,345,percent of total billed charges,All Other,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,469.2,68,,469.2,percent of total billed charges,All Other Outpatient,373.11,,,373.11,Other,186% Medicaid methodology,552,80,,552,percent of total billed charges,All Other Outpatient,572.7,83,,572.7,percent of total billed charges,All Other Outpatient,572.7,83,,572.7,percent of total billed charges,All Other Outpatient,552,80,,552,percent of total billed charges,All Other Outpatient,572.7,83,,572.7,percent of total billed charges,All Other Outpatient,621,90,,621,percent of total billed charges,All Other,483,70,,483,percent of total billed charges,All Other,287.1,,,287.1,Fee Schedule,,243.6,,,243.6,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,200.6,,,200.6,Other,New York Medicaid APG methodology,200.6,,,200.6,Other,100% Medicaid APG methodology,200.6,,,200.6,Other,100% Medicaid APG methodology,200.6,,,200.6,Other,100% Medicaid APG methodology,451.34,,,451.34,Other,225% Medicaid APG methodology,451.34,,,451.34,Other,225% Medicaid APG methodology,306.91,,,306.91,Other,153% Medicaid APG methodology,451.34,,,451.34,Other,225% Medicaid APG methodology,280.83,,,280.83,Other,140% Medicaid APG methodology,451.34,,,451.34,Other,225% Medicaid APG methodology,521.55,,,521.55,Other,260% Medicaid APG methodology,649.93,,,649.93,Other,324% Medicaid APG methodology,431.28,,,431.28,Other,215% Medicaid APG methodology,431.28,,,431.28,Other,215% Medicaid APG methodology,250.74,,,250.74,Other,125% Medicaid APG methodology,200.6,4343,
PERQ DEV BREAST 1ST US IMAG     ,19285,CPT,,47101464,CDM,761,RC,,,both,,,9851,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4925.5,50,,4925.5,percent of total billed charges,All Other,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6698.68,68,,6698.68,percent of total billed charges,All Other Outpatient,3569.69,,,3569.69,Other,186% Medicaid methodology,7880.8,80,,7880.8,percent of total billed charges,All Other Outpatient,8176.33,83,,8176.33,percent of total billed charges,All Other Outpatient,8176.33,83,,8176.33,percent of total billed charges,All Other Outpatient,7880.8,80,,7880.8,percent of total billed charges,All Other Outpatient,8176.33,83,,8176.33,percent of total billed charges,All Other Outpatient,8865.9,90,,8865.9,percent of total billed charges,All Other,6895.7,70,,6895.7,percent of total billed charges,All Other,409.2,,,409.2,Fee Schedule,,347.2,,,347.2,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1919.19,,,1919.19,Other,New York Medicaid APG methodology,1919.19,,,1919.19,Other,100% Medicaid APG methodology,1919.19,,,1919.19,Other,100% Medicaid APG methodology,1919.19,,,1919.19,Other,100% Medicaid APG methodology,4318.17,,,4318.17,Other,225% Medicaid APG methodology,4318.17,,,4318.17,Other,225% Medicaid APG methodology,2936.36,,,2936.36,Other,153% Medicaid APG methodology,4318.17,,,4318.17,Other,225% Medicaid APG methodology,2686.86,,,2686.86,Other,140% Medicaid APG methodology,4318.17,,,4318.17,Other,225% Medicaid APG methodology,4989.89,,,4989.89,Other,260% Medicaid APG methodology,6218.17,,,6218.17,Other,324% Medicaid APG methodology,4126.25,,,4126.25,Other,215% Medicaid APG methodology,4126.25,,,4126.25,Other,215% Medicaid APG methodology,2398.98,,,2398.98,Other,125% Medicaid APG methodology,347.2,8865.9,
OFFICE O/P NEW SF 15-29 MIN     ,99202,CPT,25,47900030,CDM,761,RC,,,both,,,477,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,238.5,50,,238.5,percent of total billed charges,All Other Outpatient,214.65,45,,214.65,percent of total billed charges,All Other Outpatient,238.5,50,,238.5,percent of total billed charges,All Other Outpatient,214.65,45,,214.65,percent of total billed charges,All Other Outpatient,205.11,43,,205.11,percent of total billed charges,All Other Outpatient,238.5,50,,238.5,percent of total billed charges,All Other,333.9,70,,333.9,percent of total billed charges,All Other,324.36,68,,324.36,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,381.6,80,,381.6,percent of total billed charges,All Other Outpatient,395.91,83,,395.91,percent of total billed charges,All Other Outpatient,395.91,83,,395.91,percent of total billed charges,All Other Outpatient,381.6,80,,381.6,percent of total billed charges,All Other Outpatient,395.91,83,,395.91,percent of total billed charges,All Other Outpatient,429.3,90,,429.3,percent of total billed charges,All Other,333.9,70,,333.9,percent of total billed charges,All Other,235.95,,,235.95,Fee Schedule,,200.2,,,200.2,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,3567,
OFFICE O/P NEW LOW 30-44 MIN    ,99203,CPT,,47900048,CDM,761,RC,,,both,,,634,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,317,50,,317,percent of total billed charges,All Other Outpatient,285.3,45,,285.3,percent of total billed charges,All Other Outpatient,317,50,,317,percent of total billed charges,All Other Outpatient,285.3,45,,285.3,percent of total billed charges,All Other Outpatient,272.62,43,,272.62,percent of total billed charges,All Other Outpatient,317,50,,317,percent of total billed charges,All Other,443.8,70,,443.8,percent of total billed charges,All Other,431.12,68,,431.12,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,507.2,80,,507.2,percent of total billed charges,All Other Outpatient,526.22,83,,526.22,percent of total billed charges,All Other Outpatient,526.22,83,,526.22,percent of total billed charges,All Other Outpatient,507.2,80,,507.2,percent of total billed charges,All Other Outpatient,526.22,83,,526.22,percent of total billed charges,All Other Outpatient,570.6,90,,570.6,percent of total billed charges,All Other,443.8,70,,443.8,percent of total billed charges,All Other,402.6,,,402.6,Fee Schedule,,341.6,,,341.6,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,3567,
OFFICE O/P EST MINIMAL PROB     ,99211,CPT,25,47900105,CDM,761,RC,,,both,,,218,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,109,50,,109,percent of total billed charges,All Other Outpatient,98.1,45,,98.1,percent of total billed charges,All Other Outpatient,109,50,,109,percent of total billed charges,All Other Outpatient,98.1,45,,98.1,percent of total billed charges,All Other Outpatient,93.74,43,,93.74,percent of total billed charges,All Other Outpatient,109,50,,109,percent of total billed charges,All Other,152.6,70,,152.6,percent of total billed charges,All Other,148.24,68,,148.24,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,174.4,80,,174.4,percent of total billed charges,All Other Outpatient,180.94,83,,180.94,percent of total billed charges,All Other Outpatient,180.94,83,,180.94,percent of total billed charges,All Other Outpatient,174.4,80,,174.4,percent of total billed charges,All Other Outpatient,180.94,83,,180.94,percent of total billed charges,All Other Outpatient,196.2,90,,196.2,percent of total billed charges,All Other,152.6,70,,152.6,percent of total billed charges,All Other,42.9,,,42.9,Fee Schedule,,36.4,,,36.4,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,3567,
OFFICE O/P EST SF 10-19 MIN     ,99212,CPT,25,47900139,CDM,761,RC,,,both,,,329,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,164.5,50,,164.5,percent of total billed charges,All Other Outpatient,148.05,45,,148.05,percent of total billed charges,All Other Outpatient,164.5,50,,164.5,percent of total billed charges,All Other Outpatient,148.05,45,,148.05,percent of total billed charges,All Other Outpatient,141.47,43,,141.47,percent of total billed charges,All Other Outpatient,164.5,50,,164.5,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,223.72,68,,223.72,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,263.2,80,,263.2,percent of total billed charges,All Other Outpatient,273.07,83,,273.07,percent of total billed charges,All Other Outpatient,273.07,83,,273.07,percent of total billed charges,All Other Outpatient,263.2,80,,263.2,percent of total billed charges,All Other Outpatient,273.07,83,,273.07,percent of total billed charges,All Other Outpatient,296.1,90,,296.1,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,174.9,,,174.9,Fee Schedule,,148.4,,,148.4,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,3567,
OFFICE O/P EST LOW 20-29 MIN    ,99213,CPT,25,47900147,CDM,761,RC,,,both,,,371,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,185.5,50,,185.5,percent of total billed charges,All Other Outpatient,166.95,45,,166.95,percent of total billed charges,All Other Outpatient,185.5,50,,185.5,percent of total billed charges,All Other Outpatient,166.95,45,,166.95,percent of total billed charges,All Other Outpatient,159.53,43,,159.53,percent of total billed charges,All Other Outpatient,185.5,50,,185.5,percent of total billed charges,All Other,259.7,70,,259.7,percent of total billed charges,All Other,252.28,68,,252.28,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,296.8,80,,296.8,percent of total billed charges,All Other Outpatient,307.93,83,,307.93,percent of total billed charges,All Other Outpatient,307.93,83,,307.93,percent of total billed charges,All Other Outpatient,296.8,80,,296.8,percent of total billed charges,All Other Outpatient,307.93,83,,307.93,percent of total billed charges,All Other Outpatient,333.9,90,,333.9,percent of total billed charges,All Other,259.7,70,,259.7,percent of total billed charges,All Other,321.75,,,321.75,Fee Schedule,,273,,,273,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,3567,
DRAINAGE OF SKIN ABSCESS SNGL   ,10060,CPT,,47900808,CDM,761,RC,,,both,,,1931,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,965.5,50,,965.5,percent of total billed charges,All Other,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper,1313.08,68,,1313.08,percent of total billed charges,All Other Outpatient,902.56,,,902.56,Other,186% Medicaid methodology,1544.8,80,,1544.8,percent of total billed charges,All Other Outpatient,1602.73,83,,1602.73,percent of total billed charges,All Other Outpatient,1602.73,83,,1602.73,percent of total billed charges,All Other Outpatient,1544.8,80,,1544.8,percent of total billed charges,All Other Outpatient,1602.73,83,,1602.73,percent of total billed charges,All Other Outpatient,1737.9,90,,1737.9,percent of total billed charges,All Other,1351.7,70,,1351.7,percent of total billed charges,All Other,508.2,,,508.2,Fee Schedule,,431.2,,,431.2,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,742.43,,,742.43,Other,153% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,679.35,,,679.35,Other,140% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,1261.65,,,1261.65,Other,260% Medicaid APG methodology,1572.2,,,1572.2,Other,324% Medicaid APG methodology,1043.28,,,1043.28,Other,215% Medicaid APG methodology,1043.28,,,1043.28,Other,215% Medicaid APG methodology,606.56,,,606.56,Other,125% Medicaid APG methodology,0.01,4343,
OFFICE O/P EST MINIMAL PROB     ,99211,CPT,,47900824,CDM,761,RC,,,both,,,218,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,109,50,,109,percent of total billed charges,All Other Outpatient,98.1,45,,98.1,percent of total billed charges,All Other Outpatient,109,50,,109,percent of total billed charges,All Other Outpatient,98.1,45,,98.1,percent of total billed charges,All Other Outpatient,93.74,43,,93.74,percent of total billed charges,All Other Outpatient,109,50,,109,percent of total billed charges,All Other,152.6,70,,152.6,percent of total billed charges,All Other,148.24,68,,148.24,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,174.4,80,,174.4,percent of total billed charges,All Other Outpatient,180.94,83,,180.94,percent of total billed charges,All Other Outpatient,180.94,83,,180.94,percent of total billed charges,All Other Outpatient,174.4,80,,174.4,percent of total billed charges,All Other Outpatient,180.94,83,,180.94,percent of total billed charges,All Other Outpatient,196.2,90,,196.2,percent of total billed charges,All Other,152.6,70,,152.6,percent of total billed charges,All Other,42.9,,,42.9,Fee Schedule,,36.4,,,36.4,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,3567,
OFFICE O/P NEW SF 15-29 MIN     ,99202,CPT,,47900832,CDM,761,RC,,,both,,,477,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,238.5,50,,238.5,percent of total billed charges,All Other Outpatient,214.65,45,,214.65,percent of total billed charges,All Other Outpatient,238.5,50,,238.5,percent of total billed charges,All Other Outpatient,214.65,45,,214.65,percent of total billed charges,All Other Outpatient,205.11,43,,205.11,percent of total billed charges,All Other Outpatient,238.5,50,,238.5,percent of total billed charges,All Other,333.9,70,,333.9,percent of total billed charges,All Other,324.36,68,,324.36,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,381.6,80,,381.6,percent of total billed charges,All Other Outpatient,395.91,83,,395.91,percent of total billed charges,All Other Outpatient,395.91,83,,395.91,percent of total billed charges,All Other Outpatient,381.6,80,,381.6,percent of total billed charges,All Other Outpatient,395.91,83,,395.91,percent of total billed charges,All Other Outpatient,429.3,90,,429.3,percent of total billed charges,All Other,333.9,70,,333.9,percent of total billed charges,All Other,235.95,,,235.95,Fee Schedule,,200.2,,,200.2,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,3567,
OFFICE O/P EST SF 10-19 MIN     ,99212,CPT,,47900840,CDM,761,RC,,,both,,,329,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,164.5,50,,164.5,percent of total billed charges,All Other Outpatient,148.05,45,,148.05,percent of total billed charges,All Other Outpatient,164.5,50,,164.5,percent of total billed charges,All Other Outpatient,148.05,45,,148.05,percent of total billed charges,All Other Outpatient,141.47,43,,141.47,percent of total billed charges,All Other Outpatient,164.5,50,,164.5,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,223.72,68,,223.72,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,263.2,80,,263.2,percent of total billed charges,All Other Outpatient,273.07,83,,273.07,percent of total billed charges,All Other Outpatient,273.07,83,,273.07,percent of total billed charges,All Other Outpatient,263.2,80,,263.2,percent of total billed charges,All Other Outpatient,273.07,83,,273.07,percent of total billed charges,All Other Outpatient,296.1,90,,296.1,percent of total billed charges,All Other,230.3,70,,230.3,percent of total billed charges,All Other,174.9,,,174.9,Fee Schedule,,148.4,,,148.4,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,3567,
OFFICE O/P NEW LOW 30-44 MIN    ,99203,CPT,,47900857,CDM,761,RC,,,both,,,634,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,317,50,,317,percent of total billed charges,All Other Outpatient,285.3,45,,285.3,percent of total billed charges,All Other Outpatient,317,50,,317,percent of total billed charges,All Other Outpatient,285.3,45,,285.3,percent of total billed charges,All Other Outpatient,272.62,43,,272.62,percent of total billed charges,All Other Outpatient,317,50,,317,percent of total billed charges,All Other,443.8,70,,443.8,percent of total billed charges,All Other,431.12,68,,431.12,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,507.2,80,,507.2,percent of total billed charges,All Other Outpatient,526.22,83,,526.22,percent of total billed charges,All Other Outpatient,526.22,83,,526.22,percent of total billed charges,All Other Outpatient,507.2,80,,507.2,percent of total billed charges,All Other Outpatient,526.22,83,,526.22,percent of total billed charges,All Other Outpatient,570.6,90,,570.6,percent of total billed charges,All Other,443.8,70,,443.8,percent of total billed charges,All Other,402.6,,,402.6,Fee Schedule,,341.6,,,341.6,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,3567,
OFFICE O/P EST LOW 20-29 MIN    ,99213,CPT,,47900865,CDM,761,RC,,,both,,,371,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,185.5,50,,185.5,percent of total billed charges,All Other Outpatient,166.95,45,,166.95,percent of total billed charges,All Other Outpatient,185.5,50,,185.5,percent of total billed charges,All Other Outpatient,166.95,45,,166.95,percent of total billed charges,All Other Outpatient,159.53,43,,159.53,percent of total billed charges,All Other Outpatient,185.5,50,,185.5,percent of total billed charges,All Other,259.7,70,,259.7,percent of total billed charges,All Other,252.28,68,,252.28,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,296.8,80,,296.8,percent of total billed charges,All Other Outpatient,307.93,83,,307.93,percent of total billed charges,All Other Outpatient,307.93,83,,307.93,percent of total billed charges,All Other Outpatient,296.8,80,,296.8,percent of total billed charges,All Other Outpatient,307.93,83,,307.93,percent of total billed charges,All Other Outpatient,333.9,90,,333.9,percent of total billed charges,All Other,259.7,70,,259.7,percent of total billed charges,All Other,321.75,,,321.75,Fee Schedule,,273,,,273,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,3567,
OFFICE O/P NEW MOD 45-59 MIN    ,99204,CPT,,47900873,CDM,761,RC,,,both,,,870,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,435,50,,435,percent of total billed charges,All Other Outpatient,391.5,45,,391.5,percent of total billed charges,All Other Outpatient,435,50,,435,percent of total billed charges,All Other Outpatient,391.5,45,,391.5,percent of total billed charges,All Other Outpatient,374.1,43,,374.1,percent of total billed charges,All Other Outpatient,435,50,,435,percent of total billed charges,All Other,609,70,,609,percent of total billed charges,All Other,591.6,68,,591.6,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,696,80,,696,percent of total billed charges,All Other Outpatient,722.1,83,,722.1,percent of total billed charges,All Other Outpatient,722.1,83,,722.1,percent of total billed charges,All Other Outpatient,696,80,,696,percent of total billed charges,All Other Outpatient,722.1,83,,722.1,percent of total billed charges,All Other Outpatient,783,90,,783,percent of total billed charges,All Other,609,70,,609,percent of total billed charges,All Other,651.75,,,651.75,Fee Schedule,,553,,,553,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,3567,
OFFICE O/P EST MOD 30-39 MIN    ,99214,CPT,,47900881,CDM,761,RC,,,both,,,581,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,290.5,50,,290.5,percent of total billed charges,All Other Outpatient,261.45,45,,261.45,percent of total billed charges,All Other Outpatient,290.5,50,,290.5,percent of total billed charges,All Other Outpatient,261.45,45,,261.45,percent of total billed charges,All Other Outpatient,249.83,43,,249.83,percent of total billed charges,All Other Outpatient,290.5,50,,290.5,percent of total billed charges,All Other,406.7,70,,406.7,percent of total billed charges,All Other,395.08,68,,395.08,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,464.8,80,,464.8,percent of total billed charges,All Other Outpatient,482.23,83,,482.23,percent of total billed charges,All Other Outpatient,482.23,83,,482.23,percent of total billed charges,All Other Outpatient,464.8,80,,464.8,percent of total billed charges,All Other Outpatient,482.23,83,,482.23,percent of total billed charges,All Other Outpatient,522.9,90,,522.9,percent of total billed charges,All Other,406.7,70,,406.7,percent of total billed charges,All Other,471.9,,,471.9,Fee Schedule,,400.4,,,400.4,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,3567,
OFFICE O/P EST HI 40-54 MIN     ,99215,CPT,,47900899,CDM,761,RC,,,both,,,787,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,393.5,50,,393.5,percent of total billed charges,All Other Outpatient,354.15,45,,354.15,percent of total billed charges,All Other Outpatient,393.5,50,,393.5,percent of total billed charges,All Other Outpatient,354.15,45,,354.15,percent of total billed charges,All Other Outpatient,338.41,43,,338.41,percent of total billed charges,All Other Outpatient,393.5,50,,393.5,percent of total billed charges,All Other,550.9,70,,550.9,percent of total billed charges,All Other,535.16,68,,535.16,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,629.6,80,,629.6,percent of total billed charges,All Other Outpatient,653.21,83,,653.21,percent of total billed charges,All Other Outpatient,653.21,83,,653.21,percent of total billed charges,All Other Outpatient,629.6,80,,629.6,percent of total billed charges,All Other Outpatient,653.21,83,,653.21,percent of total billed charges,All Other Outpatient,708.3,90,,708.3,percent of total billed charges,All Other,550.9,70,,550.9,percent of total billed charges,All Other,701.25,,,701.25,Fee Schedule,,595,,,595,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,3567,
APPLICATION OF PASTE BOOT       ,29580,CPT,,47900907,CDM,761,RC,,,both,,,1938,299.64,,,299.64,Other,150% of Medicare + 9.63% HCRA Surcharge,182.21,,,182.21,Other,Medicare OPPS methodology,969,50,,969,percent of total billed charges,All Other Outpatient,872.1,45,,872.1,percent of total billed charges,All Other Outpatient,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,969,50,,969,percent of total billed charges,All Other,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper,1317.84,68,,1317.84,percent of total billed charges,All Other Outpatient,621.41,,,621.41,Other,186% Medicaid methodology,1550.4,80,,1550.4,percent of total billed charges,All Other Outpatient,1608.54,83,,1608.54,percent of total billed charges,All Other Outpatient,1608.54,83,,1608.54,percent of total billed charges,All Other Outpatient,1550.4,80,,1550.4,percent of total billed charges,All Other Outpatient,1608.54,83,,1608.54,percent of total billed charges,All Other Outpatient,1744.2,90,,1744.2,percent of total billed charges,All Other,1356.6,70,,1356.6,percent of total billed charges,All Other,130.35,,,130.35,Fee Schedule,,110.6,,,110.6,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,334.09,,,334.09,Other,New York Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,511.16,,,511.16,Other,153% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,467.73,,,467.73,Other,140% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,868.64,,,868.64,Other,260% Medicaid APG methodology,1082.45,,,1082.45,Other,324% Medicaid APG methodology,718.29,,,718.29,Other,215% Medicaid APG methodology,718.29,,,718.29,Other,215% Medicaid APG methodology,417.61,,,417.61,Other,125% Medicaid APG methodology,0.01,4343,
APPLICATION OF PASTE BOOT       ,29580,CPT,LT       ,47900915,CDM,761,RC,,,both,,,1938,299.64,,,299.64,Other,150% of Medicare + 9.63% HCRA Surcharge,182.21,,,182.21,Other,Medicare OPPS methodology,969,50,,969,percent of total billed charges,All Other Outpatient,872.1,45,,872.1,percent of total billed charges,All Other Outpatient,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,969,50,,969,percent of total billed charges,All Other,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper,1317.84,68,,1317.84,percent of total billed charges,All Other Outpatient,621.41,,,621.41,Other,186% Medicaid methodology,1550.4,80,,1550.4,percent of total billed charges,All Other Outpatient,1608.54,83,,1608.54,percent of total billed charges,All Other Outpatient,1608.54,83,,1608.54,percent of total billed charges,All Other Outpatient,1550.4,80,,1550.4,percent of total billed charges,All Other Outpatient,1608.54,83,,1608.54,percent of total billed charges,All Other Outpatient,1744.2,90,,1744.2,percent of total billed charges,All Other,1356.6,70,,1356.6,percent of total billed charges,All Other,130.35,,,130.35,Fee Schedule,,110.6,,,110.6,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,334.09,,,334.09,Other,New York Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,511.16,,,511.16,Other,153% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,467.73,,,467.73,Other,140% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,868.64,,,868.64,Other,260% Medicaid APG methodology,1082.45,,,1082.45,Other,324% Medicaid APG methodology,718.29,,,718.29,Other,215% Medicaid APG methodology,718.29,,,718.29,Other,215% Medicaid APG methodology,417.61,,,417.61,Other,125% Medicaid APG methodology,0.01,4343,
APPLICATION OF PASTE BOOT       ,29580,CPT,RT       ,47900923,CDM,761,RC,,,both,,,1938,299.64,,,299.64,Other,150% of Medicare + 9.63% HCRA Surcharge,182.21,,,182.21,Other,Medicare OPPS methodology,969,50,,969,percent of total billed charges,All Other Outpatient,872.1,45,,872.1,percent of total billed charges,All Other Outpatient,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,969,50,,969,percent of total billed charges,All Other,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper,1317.84,68,,1317.84,percent of total billed charges,All Other Outpatient,621.41,,,621.41,Other,186% Medicaid methodology,1550.4,80,,1550.4,percent of total billed charges,All Other Outpatient,1608.54,83,,1608.54,percent of total billed charges,All Other Outpatient,1608.54,83,,1608.54,percent of total billed charges,All Other Outpatient,1550.4,80,,1550.4,percent of total billed charges,All Other Outpatient,1608.54,83,,1608.54,percent of total billed charges,All Other Outpatient,1744.2,90,,1744.2,percent of total billed charges,All Other,1356.6,70,,1356.6,percent of total billed charges,All Other,130.35,,,130.35,Fee Schedule,,110.6,,,110.6,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,334.09,,,334.09,Other,New York Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,511.16,,,511.16,Other,153% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,467.73,,,467.73,Other,140% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,868.64,,,868.64,Other,260% Medicaid APG methodology,1082.45,,,1082.45,Other,324% Medicaid APG methodology,718.29,,,718.29,Other,215% Medicaid APG methodology,718.29,,,718.29,Other,215% Medicaid APG methodology,417.61,,,417.61,Other,125% Medicaid APG methodology,0.01,4343,
NEG PRESS WOUND TX <=50 CM      ,97605,CPT,,47900931,CDM,761,RC,,,both,,,623,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,311.5,50,,311.5,percent of total billed charges,All Other Outpatient,280.35,45,,280.35,percent of total billed charges,All Other Outpatient,311.5,50,,311.5,percent of total billed charges,All Other Outpatient,280.35,45,,280.35,percent of total billed charges,All Other Outpatient,267.89,43,,267.89,percent of total billed charges,All Other Outpatient,311.5,50,,311.5,percent of total billed charges,All Other,436.1,70,,436.1,percent of total billed charges,All Other,423.64,68,,423.64,percent of total billed charges,All Other Outpatient,958.5,,,958.5,Other,186% Medicaid methodology,498.4,80,,498.4,percent of total billed charges,All Other Outpatient,517.09,83,,517.09,percent of total billed charges,All Other Outpatient,517.09,83,,517.09,percent of total billed charges,All Other Outpatient,498.4,80,,498.4,percent of total billed charges,All Other Outpatient,517.09,83,,517.09,percent of total billed charges,All Other Outpatient,560.7,90,,560.7,percent of total billed charges,All Other,436.1,70,,436.1,percent of total billed charges,All Other,120.45,,,120.45,Fee Schedule,,102.2,,,102.2,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,515.32,,,515.32,Other,New York Medicaid APG methodology,515.32,,,515.32,Other,100% Medicaid APG methodology,515.32,,,515.32,Other,100% Medicaid APG methodology,515.32,,,515.32,Other,100% Medicaid APG methodology,1159.47,,,1159.47,Other,225% Medicaid APG methodology,1159.47,,,1159.47,Other,225% Medicaid APG methodology,788.44,,,788.44,Other,153% Medicaid APG methodology,1159.47,,,1159.47,Other,225% Medicaid APG methodology,721.45,,,721.45,Other,140% Medicaid APG methodology,1159.47,,,1159.47,Other,225% Medicaid APG methodology,1339.84,,,1339.84,Other,260% Medicaid APG methodology,1669.64,,,1669.64,Other,324% Medicaid APG methodology,1107.94,,,1107.94,Other,215% Medicaid APG methodology,1107.94,,,1107.94,Other,215% Medicaid APG methodology,644.15,,,644.15,Other,125% Medicaid APG methodology,102.2,3567,
NEG PRESS WOUND TX >50 CM       ,97606,CPT,,47900949,CDM,761,RC,,,both,,,1343,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,671.5,50,,671.5,percent of total billed charges,All Other Outpatient,604.35,45,,604.35,percent of total billed charges,All Other Outpatient,671.5,50,,671.5,percent of total billed charges,All Other Outpatient,604.35,45,,604.35,percent of total billed charges,All Other Outpatient,577.49,43,,577.49,percent of total billed charges,All Other Outpatient,671.5,50,,671.5,percent of total billed charges,All Other,940.1,70,,940.1,percent of total billed charges,All Other,913.24,68,,913.24,percent of total billed charges,All Other Outpatient,1438.1,,,1438.1,Other,186% Medicaid methodology,1074.4,80,,1074.4,percent of total billed charges,All Other Outpatient,1114.69,83,,1114.69,percent of total billed charges,All Other Outpatient,1114.69,83,,1114.69,percent of total billed charges,All Other Outpatient,1074.4,80,,1074.4,percent of total billed charges,All Other Outpatient,1114.69,83,,1114.69,percent of total billed charges,All Other Outpatient,1208.7,90,,1208.7,percent of total billed charges,All Other,940.1,70,,940.1,percent of total billed charges,All Other,132,,,132,Fee Schedule,,112,,,112,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,773.17,,,773.17,Other,New York Medicaid APG methodology,773.17,,,773.17,Other,100% Medicaid APG methodology,773.17,,,773.17,Other,100% Medicaid APG methodology,773.17,,,773.17,Other,100% Medicaid APG methodology,1739.64,,,1739.64,Other,225% Medicaid APG methodology,1739.64,,,1739.64,Other,225% Medicaid APG methodology,1182.95,,,1182.95,Other,153% Medicaid APG methodology,1739.64,,,1739.64,Other,225% Medicaid APG methodology,1082.44,,,1082.44,Other,140% Medicaid APG methodology,1739.64,,,1739.64,Other,225% Medicaid APG methodology,2010.25,,,2010.25,Other,260% Medicaid APG methodology,2505.08,,,2505.08,Other,324% Medicaid APG methodology,1662.32,,,1662.32,Other,215% Medicaid APG methodology,1662.32,,,1662.32,Other,215% Medicaid APG methodology,966.46,,,966.46,Other,125% Medicaid APG methodology,112,3567,
CHEM CAUT OF GRANLTJ TISSUE     ,17250,CPT,,47900956,CDM,761,RC,,,both,,,924,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,462,50,,462,percent of total billed charges,All Other,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper,628.32,68,,628.32,percent of total billed charges,All Other Outpatient,902.56,,,902.56,Other,186% Medicaid methodology,739.2,80,,739.2,percent of total billed charges,All Other Outpatient,766.92,83,,766.92,percent of total billed charges,All Other Outpatient,766.92,83,,766.92,percent of total billed charges,All Other Outpatient,739.2,80,,739.2,percent of total billed charges,All Other Outpatient,766.92,83,,766.92,percent of total billed charges,All Other Outpatient,831.6,90,,831.6,percent of total billed charges,All Other,646.8,70,,646.8,percent of total billed charges,All Other,181.5,,,181.5,Fee Schedule,,154,,,154,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,742.43,,,742.43,Other,153% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,679.35,,,679.35,Other,140% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,1261.65,,,1261.65,Other,260% Medicaid APG methodology,1572.2,,,1572.2,Other,324% Medicaid APG methodology,1043.28,,,1043.28,Other,215% Medicaid APG methodology,1043.28,,,1043.28,Other,215% Medicaid APG methodology,606.56,,,606.56,Other,125% Medicaid APG methodology,0.01,4343,
APPLY MULTLAY COMPRS LWR LEG    ,29581,CPT,RT       ,47900972,CDM,761,RC,,,both,,,889,299.64,,,299.64,Other,150% of Medicare + 9.63% HCRA Surcharge,182.21,,,182.21,Other,Medicare OPPS methodology,444.5,50,,444.5,percent of total billed charges,All Other Outpatient,400.05,45,,400.05,percent of total billed charges,All Other Outpatient,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,444.5,50,,444.5,percent of total billed charges,All Other,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper,604.52,68,,604.52,percent of total billed charges,All Other Outpatient,621.41,,,621.41,Other,186% Medicaid methodology,711.2,80,,711.2,percent of total billed charges,All Other Outpatient,737.87,83,,737.87,percent of total billed charges,All Other Outpatient,737.87,83,,737.87,percent of total billed charges,All Other Outpatient,711.2,80,,711.2,percent of total billed charges,All Other Outpatient,737.87,83,,737.87,percent of total billed charges,All Other Outpatient,800.1,90,,800.1,percent of total billed charges,All Other,622.3,70,,622.3,percent of total billed charges,All Other,132,,,132,Fee Schedule,,112,,,112,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,334.09,,,334.09,Other,New York Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,511.16,,,511.16,Other,153% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,467.73,,,467.73,Other,140% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,868.64,,,868.64,Other,260% Medicaid APG methodology,1082.45,,,1082.45,Other,324% Medicaid APG methodology,718.29,,,718.29,Other,215% Medicaid APG methodology,718.29,,,718.29,Other,215% Medicaid APG methodology,417.61,,,417.61,Other,125% Medicaid APG methodology,0.01,4343,
APPLY MULTLAY COMPRS LWR LEG    ,29581,CPT,LT       ,47900980,CDM,761,RC,,,both,,,889,299.64,,,299.64,Other,150% of Medicare + 9.63% HCRA Surcharge,182.21,,,182.21,Other,Medicare OPPS methodology,444.5,50,,444.5,percent of total billed charges,All Other Outpatient,400.05,45,,400.05,percent of total billed charges,All Other Outpatient,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,444.5,50,,444.5,percent of total billed charges,All Other,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper,604.52,68,,604.52,percent of total billed charges,All Other Outpatient,621.41,,,621.41,Other,186% Medicaid methodology,711.2,80,,711.2,percent of total billed charges,All Other Outpatient,737.87,83,,737.87,percent of total billed charges,All Other Outpatient,737.87,83,,737.87,percent of total billed charges,All Other Outpatient,711.2,80,,711.2,percent of total billed charges,All Other Outpatient,737.87,83,,737.87,percent of total billed charges,All Other Outpatient,800.1,90,,800.1,percent of total billed charges,All Other,622.3,70,,622.3,percent of total billed charges,All Other,132,,,132,Fee Schedule,,112,,,112,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,334.09,,,334.09,Other,New York Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,511.16,,,511.16,Other,153% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,467.73,,,467.73,Other,140% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,868.64,,,868.64,Other,260% Medicaid APG methodology,1082.45,,,1082.45,Other,324% Medicaid APG methodology,718.29,,,718.29,Other,215% Medicaid APG methodology,718.29,,,718.29,Other,215% Medicaid APG methodology,417.61,,,417.61,Other,125% Medicaid APG methodology,0.01,4343,
APPLY MULTLAY COMP LWR LEG BI   ,29581,CPT,50,47900998,CDM,761,RC,,,both,,,1333,299.64,,,299.64,Other,150% of Medicare + 9.63% HCRA Surcharge,182.21,,,182.21,Other,Medicare OPPS methodology,666.5,50,,666.5,percent of total billed charges,All Other Outpatient,599.85,45,,599.85,percent of total billed charges,All Other Outpatient,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,666.5,50,,666.5,percent of total billed charges,All Other,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper,906.44,68,,906.44,percent of total billed charges,All Other Outpatient,621.41,,,621.41,Other,186% Medicaid methodology,1066.4,80,,1066.4,percent of total billed charges,All Other Outpatient,1106.39,83,,1106.39,percent of total billed charges,All Other Outpatient,1106.39,83,,1106.39,percent of total billed charges,All Other Outpatient,1066.4,80,,1066.4,percent of total billed charges,All Other Outpatient,1106.39,83,,1106.39,percent of total billed charges,All Other Outpatient,1199.7,90,,1199.7,percent of total billed charges,All Other,933.1,70,,933.1,percent of total billed charges,All Other,132,,,132,Fee Schedule,,112,,,112,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,334.09,,,334.09,Other,New York Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,511.16,,,511.16,Other,153% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,467.73,,,467.73,Other,140% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,868.64,,,868.64,Other,260% Medicaid APG methodology,1082.45,,,1082.45,Other,324% Medicaid APG methodology,718.29,,,718.29,Other,215% Medicaid APG methodology,718.29,,,718.29,Other,215% Medicaid APG methodology,417.61,,,417.61,Other,125% Medicaid APG methodology,0.01,4343,
DEB SUBQ TISSUE ADD-ON          ,11045,CPT,,47901004,CDM,761,RC,,,both,,,1672,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,836,50,,836,percent of total billed charges,All Other,1170.4,70,,1170.4,percent of total billed charges,All Other,1136.96,68,,1136.96,percent of total billed charges,All Other Outpatient,3180.63,,,3180.63,Other,186% Medicaid methodology,1337.6,80,,1337.6,percent of total billed charges,All Other Outpatient,1387.76,83,,1387.76,percent of total billed charges,All Other Outpatient,1387.76,83,,1387.76,percent of total billed charges,All Other Outpatient,1337.6,80,,1337.6,percent of total billed charges,All Other Outpatient,1387.76,83,,1387.76,percent of total billed charges,All Other Outpatient,1504.8,90,,1504.8,percent of total billed charges,All Other,1170.4,70,,1170.4,percent of total billed charges,All Other,127.05,,,127.05,Fee Schedule,,107.8,,,107.8,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% Medicaid APG methodology,1710.01,,,1710.01,Other,100% Medicaid APG methodology,1710.01,,,1710.01,Other,100% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,2616.32,,,2616.32,Other,153% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,2394.02,,,2394.02,Other,140% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,4446.04,,,4446.04,Other,260% Medicaid APG methodology,5540.45,,,5540.45,Other,324% Medicaid APG methodology,3676.53,,,3676.53,Other,215% Medicaid APG methodology,3676.53,,,3676.53,Other,215% Medicaid APG methodology,2137.52,,,2137.52,Other,125% Medicaid APG methodology,0.01,5540.45,
DEB SUBQ TISSUE 20 SQ CM/<      ,11042,CPT,,47901012,CDM,761,RC,,,both,,,1938,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,969,50,,969,percent of total billed charges,All Other,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,1317.84,68,,1317.84,percent of total billed charges,All Other Outpatient,1704.43,,,1704.43,Other,186% Medicaid methodology,1550.4,80,,1550.4,percent of total billed charges,All Other Outpatient,1608.54,83,,1608.54,percent of total billed charges,All Other Outpatient,1608.54,83,,1608.54,percent of total billed charges,All Other Outpatient,1550.4,80,,1550.4,percent of total billed charges,All Other Outpatient,1608.54,83,,1608.54,percent of total billed charges,All Other Outpatient,1744.2,90,,1744.2,percent of total billed charges,All Other,1356.6,70,,1356.6,percent of total billed charges,All Other,290.4,,,290.4,Fee Schedule,,246.4,,,246.4,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1402.03,,,1402.03,Other,153% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1282.9,,,1282.9,Other,140% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2382.54,,,2382.54,Other,260% Medicaid APG methodology,2969.01,,,2969.01,Other,324% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1145.45,,,1145.45,Other,125% Medicaid APG methodology,246.4,5845,
DEB SUBQ TISSUE 20 SQ CM/<      ,11046,CPT,,47901020,CDM,761,RC,,,both,,,1672,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,836,50,,836,percent of total billed charges,All Other,1170.4,70,,1170.4,percent of total billed charges,All Other,1136.96,68,,1136.96,percent of total billed charges,All Other Outpatient,3180.63,,,3180.63,Other,186% Medicaid methodology,1337.6,80,,1337.6,percent of total billed charges,All Other Outpatient,1387.76,83,,1387.76,percent of total billed charges,All Other Outpatient,1387.76,83,,1387.76,percent of total billed charges,All Other Outpatient,1337.6,80,,1337.6,percent of total billed charges,All Other Outpatient,1387.76,83,,1387.76,percent of total billed charges,All Other Outpatient,1504.8,90,,1504.8,percent of total billed charges,All Other,1170.4,70,,1170.4,percent of total billed charges,All Other,268.95,,,268.95,Fee Schedule,,228.2,,,228.2,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% Medicaid APG methodology,1710.01,,,1710.01,Other,100% Medicaid APG methodology,1710.01,,,1710.01,Other,100% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,2616.32,,,2616.32,Other,153% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,2394.02,,,2394.02,Other,140% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,4446.04,,,4446.04,Other,260% Medicaid APG methodology,5540.45,,,5540.45,Other,324% Medicaid APG methodology,3676.53,,,3676.53,Other,215% Medicaid APG methodology,3676.53,,,3676.53,Other,215% Medicaid APG methodology,2137.52,,,2137.52,Other,125% Medicaid APG methodology,0.01,5540.45,
DEB BONE 20 SQ CM/<             ,11044,CPT,,47901038,CDM,761,RC,,,both,,,4888,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,2444,50,,2444,percent of total billed charges,All Other,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,3323.84,68,,3323.84,percent of total billed charges,All Other Outpatient,3180.63,,,3180.63,Other,186% Medicaid methodology,3910.4,80,,3910.4,percent of total billed charges,All Other Outpatient,4057.04,83,,4057.04,percent of total billed charges,All Other Outpatient,4057.04,83,,4057.04,percent of total billed charges,All Other Outpatient,3910.4,80,,3910.4,percent of total billed charges,All Other Outpatient,4057.04,83,,4057.04,percent of total billed charges,All Other Outpatient,4399.2,90,,4399.2,percent of total billed charges,All Other,3421.6,70,,3421.6,percent of total billed charges,All Other,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% Medicaid APG methodology,1710.01,,,1710.01,Other,100% Medicaid APG methodology,1710.01,,,1710.01,Other,100% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,2616.32,,,2616.32,Other,153% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,2394.02,,,2394.02,Other,140% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,4446.04,,,4446.04,Other,260% Medicaid APG methodology,5540.45,,,5540.45,Other,324% Medicaid APG methodology,3676.53,,,3676.53,Other,215% Medicaid APG methodology,3676.53,,,3676.53,Other,215% Medicaid APG methodology,2137.52,,,2137.52,Other,125% Medicaid APG methodology,1710.01,13157,
DEB BONE ADD-ON                 ,11047,CPT,,47901046,CDM,761,RC,,,both,,,4856,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,2428,50,,2428,percent of total billed charges,All Other,3399.2,70,,3399.2,percent of total billed charges,All Other,3302.08,68,,3302.08,percent of total billed charges,All Other Outpatient,3180.63,,,3180.63,Other,186% Medicaid methodology,3884.8,80,,3884.8,percent of total billed charges,All Other Outpatient,4030.48,83,,4030.48,percent of total billed charges,All Other Outpatient,4030.48,83,,4030.48,percent of total billed charges,All Other Outpatient,3884.8,80,,3884.8,percent of total billed charges,All Other Outpatient,4030.48,83,,4030.48,percent of total billed charges,All Other Outpatient,4370.4,90,,4370.4,percent of total billed charges,All Other,3399.2,70,,3399.2,percent of total billed charges,All Other,470.25,,,470.25,Fee Schedule,,399,,,399,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% Medicaid APG methodology,1710.01,,,1710.01,Other,100% Medicaid APG methodology,1710.01,,,1710.01,Other,100% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,2616.32,,,2616.32,Other,153% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,2394.02,,,2394.02,Other,140% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,4446.04,,,4446.04,Other,260% Medicaid APG methodology,5540.45,,,5540.45,Other,324% Medicaid APG methodology,3676.53,,,3676.53,Other,215% Medicaid APG methodology,3676.53,,,3676.53,Other,215% Medicaid APG methodology,2137.52,,,2137.52,Other,125% Medicaid APG methodology,0.01,11390,
RMVL DEVITAL TIS 20 CM/<        ,97597,CPT,,47901053,CDM,761,RC,,,both,,,915,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,457.5,50,,457.5,percent of total billed charges,All Other,640.5,70,,640.5,percent of total billed charges,All Other,622.2,68,,622.2,percent of total billed charges,All Other Outpatient,958.5,,,958.5,Other,186% Medicaid methodology,732,80,,732,percent of total billed charges,All Other Outpatient,759.45,83,,759.45,percent of total billed charges,All Other Outpatient,759.45,83,,759.45,percent of total billed charges,All Other Outpatient,732,80,,732,percent of total billed charges,All Other Outpatient,759.45,83,,759.45,percent of total billed charges,All Other Outpatient,823.5,90,,823.5,percent of total billed charges,All Other,640.5,70,,640.5,percent of total billed charges,All Other,174.9,,,174.9,Fee Schedule,,148.4,,,148.4,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,515.32,,,515.32,Other,New York Medicaid APG methodology,515.32,,,515.32,Other,100% Medicaid APG methodology,515.32,,,515.32,Other,100% Medicaid APG methodology,515.32,,,515.32,Other,100% Medicaid APG methodology,1159.47,,,1159.47,Other,225% Medicaid APG methodology,1159.47,,,1159.47,Other,225% Medicaid APG methodology,788.44,,,788.44,Other,153% Medicaid APG methodology,1159.47,,,1159.47,Other,225% Medicaid APG methodology,721.45,,,721.45,Other,140% Medicaid APG methodology,1159.47,,,1159.47,Other,225% Medicaid APG methodology,1339.84,,,1339.84,Other,260% Medicaid APG methodology,1669.64,,,1669.64,Other,324% Medicaid APG methodology,1107.94,,,1107.94,Other,215% Medicaid APG methodology,1107.94,,,1107.94,Other,215% Medicaid APG methodology,644.15,,,644.15,Other,125% Medicaid APG methodology,148.4,4343,
RMVL DEVITAL TIS ADDL 20CM/<    ,97598,CPT,,47901061,CDM,761,RC,,,both,,,771,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,385.5,50,,385.5,percent of total billed charges,All Other,539.7,70,,539.7,percent of total billed charges,All Other,524.28,68,,524.28,percent of total billed charges,All Other Outpatient,2823.29,,,2823.29,Other,186% Medicaid methodology,616.8,80,,616.8,percent of total billed charges,All Other Outpatient,639.93,83,,639.93,percent of total billed charges,All Other Outpatient,639.93,83,,639.93,percent of total billed charges,All Other Outpatient,616.8,80,,616.8,percent of total billed charges,All Other Outpatient,639.93,83,,639.93,percent of total billed charges,All Other Outpatient,693.9,90,,693.9,percent of total billed charges,All Other,539.7,70,,539.7,percent of total billed charges,All Other,122.1,,,122.1,Fee Schedule,,103.6,,,103.6,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1517.9,,,1517.9,Other,New York Medicaid APG methodology,1517.9,,,1517.9,Other,100% Medicaid APG methodology,1517.9,,,1517.9,Other,100% Medicaid APG methodology,1517.9,,,1517.9,Other,100% Medicaid APG methodology,3415.27,,,3415.27,Other,225% Medicaid APG methodology,3415.27,,,3415.27,Other,225% Medicaid APG methodology,2322.39,,,2322.39,Other,153% Medicaid APG methodology,3415.27,,,3415.27,Other,225% Medicaid APG methodology,2125.06,,,2125.06,Other,140% Medicaid APG methodology,3415.27,,,3415.27,Other,225% Medicaid APG methodology,3946.54,,,3946.54,Other,260% Medicaid APG methodology,4917.99,,,4917.99,Other,324% Medicaid APG methodology,3263.48,,,3263.48,Other,215% Medicaid APG methodology,3263.48,,,3263.48,Other,215% Medicaid APG methodology,1897.37,,,1897.37,Other,125% Medicaid APG methodology,0.01,4917.99,
APPLY RIGID LEG CAST            ,29445,CPT,LT       ,47901079,CDM,761,RC,,,both,,,1407,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,703.5,50,,703.5,percent of total billed charges,All Other Outpatient,633.15,45,,633.15,percent of total billed charges,All Other Outpatient,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,703.5,50,,703.5,percent of total billed charges,All Other,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper,956.76,68,,956.76,percent of total billed charges,All Other Outpatient,621.41,,,621.41,Other,186% Medicaid methodology,1125.6,80,,1125.6,percent of total billed charges,All Other Outpatient,1167.81,83,,1167.81,percent of total billed charges,All Other Outpatient,1167.81,83,,1167.81,percent of total billed charges,All Other Outpatient,1125.6,80,,1125.6,percent of total billed charges,All Other Outpatient,1167.81,83,,1167.81,percent of total billed charges,All Other Outpatient,1266.3,90,,1266.3,percent of total billed charges,All Other,984.9,70,,984.9,percent of total billed charges,All Other,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,334.09,,,334.09,Other,New York Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,511.16,,,511.16,Other,153% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,467.73,,,467.73,Other,140% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,868.64,,,868.64,Other,260% Medicaid APG methodology,1082.45,,,1082.45,Other,324% Medicaid APG methodology,718.29,,,718.29,Other,215% Medicaid APG methodology,718.29,,,718.29,Other,215% Medicaid APG methodology,417.61,,,417.61,Other,125% Medicaid APG methodology,0.01,13157,
APPLY RIGID LEG CAST            ,29445,CPT,RT       ,47901087,CDM,761,RC,,,both,,,1407,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,703.5,50,,703.5,percent of total billed charges,All Other Outpatient,633.15,45,,633.15,percent of total billed charges,All Other Outpatient,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,703.5,50,,703.5,percent of total billed charges,All Other,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper,956.76,68,,956.76,percent of total billed charges,All Other Outpatient,621.41,,,621.41,Other,186% Medicaid methodology,1125.6,80,,1125.6,percent of total billed charges,All Other Outpatient,1167.81,83,,1167.81,percent of total billed charges,All Other Outpatient,1167.81,83,,1167.81,percent of total billed charges,All Other Outpatient,1125.6,80,,1125.6,percent of total billed charges,All Other Outpatient,1167.81,83,,1167.81,percent of total billed charges,All Other Outpatient,1266.3,90,,1266.3,percent of total billed charges,All Other,984.9,70,,984.9,percent of total billed charges,All Other,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,334.09,,,334.09,Other,New York Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,334.09,,,334.09,Other,100% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,511.16,,,511.16,Other,153% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,467.73,,,467.73,Other,140% Medicaid APG methodology,751.7,,,751.7,Other,225% Medicaid APG methodology,868.64,,,868.64,Other,260% Medicaid APG methodology,1082.45,,,1082.45,Other,324% Medicaid APG methodology,718.29,,,718.29,Other,215% Medicaid APG methodology,718.29,,,718.29,Other,215% Medicaid APG methodology,417.61,,,417.61,Other,125% Medicaid APG methodology,0.01,13157,
TANGNTL BX SKIN SINGLE LES      ,11102,CPT,,47901095,CDM,761,RC,,,both,,,1660,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,830,50,,830,percent of total billed charges,All Other,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper,1128.8,68,,1128.8,percent of total billed charges,All Other Outpatient,1559.83,,,1559.83,Other,186% Medicaid methodology,1328,80,,1328,percent of total billed charges,All Other Outpatient,1377.8,83,,1377.8,percent of total billed charges,All Other Outpatient,1377.8,83,,1377.8,percent of total billed charges,All Other Outpatient,1328,80,,1328,percent of total billed charges,All Other Outpatient,1377.8,83,,1377.8,percent of total billed charges,All Other Outpatient,1494,90,,1494,percent of total billed charges,All Other,1162,70,,1162,percent of total billed charges,All Other,181.5,,,181.5,Fee Schedule,,154,,,154,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1283.09,,,1283.09,Other,153% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1174.07,,,1174.07,Other,140% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,2180.41,,,2180.41,Other,260% Medicaid APG methodology,2717.12,,,2717.12,Other,324% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1048.27,,,1048.27,Other,125% Medicaid APG methodology,0.01,4343,
OFFICE O/P NEW HI 60-74 MIN     ,99205,CPT,25,47901103,CDM,761,RC,,,both,,,1042,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,521,50,,521,percent of total billed charges,All Other Outpatient,468.9,45,,468.9,percent of total billed charges,All Other Outpatient,521,50,,521,percent of total billed charges,All Other Outpatient,468.9,45,,468.9,percent of total billed charges,All Other Outpatient,448.06,43,,448.06,percent of total billed charges,All Other Outpatient,521,50,,521,percent of total billed charges,All Other,729.4,70,,729.4,percent of total billed charges,All Other,708.56,68,,708.56,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,833.6,80,,833.6,percent of total billed charges,All Other Outpatient,864.86,83,,864.86,percent of total billed charges,All Other Outpatient,864.86,83,,864.86,percent of total billed charges,All Other Outpatient,833.6,80,,833.6,percent of total billed charges,All Other Outpatient,864.86,83,,864.86,percent of total billed charges,All Other Outpatient,937.8,90,,937.8,percent of total billed charges,All Other,729.4,70,,729.4,percent of total billed charges,All Other,884.4,,,884.4,Fee Schedule,,750.4,,,750.4,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,3567,
SKN SUB GRFT F/N/HF/G CHILD     ,15277,CPT,,47901111,CDM,761,RC,,,both,,,4393,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,2196.5,50,,2196.5,percent of total billed charges,All Other,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,2987.24,68,,2987.24,percent of total billed charges,All Other Outpatient,3310.98,,,3310.98,Other,186% Medicaid methodology,3514.4,80,,3514.4,percent of total billed charges,All Other Outpatient,3646.19,83,,3646.19,percent of total billed charges,All Other Outpatient,3646.19,83,,3646.19,percent of total billed charges,All Other Outpatient,3514.4,80,,3514.4,percent of total billed charges,All Other Outpatient,3646.19,83,,3646.19,percent of total billed charges,All Other Outpatient,3953.7,90,,3953.7,percent of total billed charges,All Other,3075.1,70,,3075.1,percent of total billed charges,All Other,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,2723.55,,,2723.55,Other,153% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,2492.13,,,2492.13,Other,140% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,4628.25,,,4628.25,Other,260% Medicaid APG methodology,5767.51,,,5767.51,Other,324% Medicaid APG methodology,3827.2,,,3827.2,Other,215% Medicaid APG methodology,3827.2,,,3827.2,Other,215% Medicaid APG methodology,2225.12,,,2225.12,Other,125% Medicaid APG methodology,1780.1,13157,
SKIN SUB GRAFT FACE/NK/HF/G     ,15275,CPT,,47901137,CDM,761,RC,,,both,,,6212,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,3106,50,,3106,percent of total billed charges,All Other,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,4224.16,68,,4224.16,percent of total billed charges,All Other Outpatient,3310.98,,,3310.98,Other,186% Medicaid methodology,4969.6,80,,4969.6,percent of total billed charges,All Other Outpatient,5155.96,83,,5155.96,percent of total billed charges,All Other Outpatient,5155.96,83,,5155.96,percent of total billed charges,All Other Outpatient,4969.6,80,,4969.6,percent of total billed charges,All Other Outpatient,5155.96,83,,5155.96,percent of total billed charges,All Other Outpatient,5590.8,90,,5590.8,percent of total billed charges,All Other,4348.4,70,,4348.4,percent of total billed charges,All Other,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,2723.55,,,2723.55,Other,153% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,2492.13,,,2492.13,Other,140% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,4628.25,,,4628.25,Other,260% Medicaid APG methodology,5767.51,,,5767.51,Other,324% Medicaid APG methodology,3827.2,,,3827.2,Other,215% Medicaid APG methodology,3827.2,,,3827.2,Other,215% Medicaid APG methodology,2225.12,,,2225.12,Other,125% Medicaid APG methodology,1780.1,13157,
SKIN SUB GRAFT F/N/HF/G ADDL    ,15276,CPT,,47901145,CDM,761,RC,,,both,,,965,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,482.5,50,,482.5,percent of total billed charges,All Other,675.5,70,,675.5,percent of total billed charges,All Other,656.2,68,,656.2,percent of total billed charges,All Other Outpatient,3310.98,,,3310.98,Other,186% Medicaid methodology,772,80,,772,percent of total billed charges,All Other Outpatient,800.95,83,,800.95,percent of total billed charges,All Other Outpatient,800.95,83,,800.95,percent of total billed charges,All Other Outpatient,772,80,,772,percent of total billed charges,All Other Outpatient,800.95,83,,800.95,percent of total billed charges,All Other Outpatient,868.5,90,,868.5,percent of total billed charges,All Other,675.5,70,,675.5,percent of total billed charges,All Other,123.75,,,123.75,Fee Schedule,,105,,,105,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,2723.55,,,2723.55,Other,153% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,2492.13,,,2492.13,Other,140% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,4628.25,,,4628.25,Other,260% Medicaid APG methodology,5767.51,,,5767.51,Other,324% Medicaid APG methodology,3827.2,,,3827.2,Other,215% Medicaid APG methodology,3827.2,,,3827.2,Other,215% Medicaid APG methodology,2225.12,,,2225.12,Other,125% Medicaid APG methodology,0.01,5767.51,
SKIN SUB GRFT T/ARM/LG CHILD    ,15273,CPT,,47901152,CDM,761,RC,,,both,,,9384,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,4692,50,,4692,percent of total billed charges,All Other,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6381.12,68,,6381.12,percent of total billed charges,All Other Outpatient,3310.98,,,3310.98,Other,186% Medicaid methodology,7507.2,80,,7507.2,percent of total billed charges,All Other Outpatient,7788.72,83,,7788.72,percent of total billed charges,All Other Outpatient,7788.72,83,,7788.72,percent of total billed charges,All Other Outpatient,7507.2,80,,7507.2,percent of total billed charges,All Other Outpatient,7788.72,83,,7788.72,percent of total billed charges,All Other Outpatient,8445.6,90,,8445.6,percent of total billed charges,All Other,6568.8,70,,6568.8,percent of total billed charges,All Other,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,2723.55,,,2723.55,Other,153% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,2492.13,,,2492.13,Other,140% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,4628.25,,,4628.25,Other,260% Medicaid APG methodology,5767.51,,,5767.51,Other,324% Medicaid APG methodology,3827.2,,,3827.2,Other,215% Medicaid APG methodology,3827.2,,,3827.2,Other,215% Medicaid APG methodology,2225.12,,,2225.12,Other,125% Medicaid APG methodology,1780.1,13157,
SKN SUB GRFT T/A/L CHILD ADD    ,15274,CPT,,47901160,CDM,761,RC,,,both,,,2207,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1103.5,50,,1103.5,percent of total billed charges,All Other,1544.9,70,,1544.9,percent of total billed charges,All Other,1500.76,68,,1500.76,percent of total billed charges,All Other Outpatient,3310.98,,,3310.98,Other,186% Medicaid methodology,1765.6,80,,1765.6,percent of total billed charges,All Other Outpatient,1831.81,83,,1831.81,percent of total billed charges,All Other Outpatient,1831.81,83,,1831.81,percent of total billed charges,All Other Outpatient,1765.6,80,,1765.6,percent of total billed charges,All Other Outpatient,1831.81,83,,1831.81,percent of total billed charges,All Other Outpatient,1986.3,90,,1986.3,percent of total billed charges,All Other,1544.9,70,,1544.9,percent of total billed charges,All Other,221.1,,,221.1,Fee Schedule,,187.6,,,187.6,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,2723.55,,,2723.55,Other,153% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,2492.13,,,2492.13,Other,140% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,4628.25,,,4628.25,Other,260% Medicaid APG methodology,5767.51,,,5767.51,Other,324% Medicaid APG methodology,3827.2,,,3827.2,Other,215% Medicaid APG methodology,3827.2,,,3827.2,Other,215% Medicaid APG methodology,2225.12,,,2225.12,Other,125% Medicaid APG methodology,0.01,5767.51,
SKIN SUB GRAFT T/A/L ADD-ON     ,15272,CPT,,47901178,CDM,761,RC,,,both,,,3368,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1684,50,,1684,percent of total billed charges,All Other,2357.6,70,,2357.6,percent of total billed charges,All Other,2290.24,68,,2290.24,percent of total billed charges,All Other Outpatient,3310.98,,,3310.98,Other,186% Medicaid methodology,2694.4,80,,2694.4,percent of total billed charges,All Other Outpatient,2795.44,83,,2795.44,percent of total billed charges,All Other Outpatient,2795.44,83,,2795.44,percent of total billed charges,All Other Outpatient,2694.4,80,,2694.4,percent of total billed charges,All Other Outpatient,2795.44,83,,2795.44,percent of total billed charges,All Other Outpatient,3031.2,90,,3031.2,percent of total billed charges,All Other,2357.6,70,,2357.6,percent of total billed charges,All Other,85.8,,,85.8,Fee Schedule,,72.8,,,72.8,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,2723.55,,,2723.55,Other,153% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,2492.13,,,2492.13,Other,140% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,4628.25,,,4628.25,Other,260% Medicaid APG methodology,5767.51,,,5767.51,Other,324% Medicaid APG methodology,3827.2,,,3827.2,Other,215% Medicaid APG methodology,3827.2,,,3827.2,Other,215% Medicaid APG methodology,2225.12,,,2225.12,Other,125% Medicaid APG methodology,0.01,5767.51,
SKIN SUB GRAFT TRNK/ARM/LEG     ,15271,CPT,,47901186,CDM,761,RC,,,both,,,6212,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,3106,50,,3106,percent of total billed charges,All Other,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,4224.16,68,,4224.16,percent of total billed charges,All Other Outpatient,3310.98,,,3310.98,Other,186% Medicaid methodology,4969.6,80,,4969.6,percent of total billed charges,All Other Outpatient,5155.96,83,,5155.96,percent of total billed charges,All Other Outpatient,5155.96,83,,5155.96,percent of total billed charges,All Other Outpatient,4969.6,80,,4969.6,percent of total billed charges,All Other Outpatient,5155.96,83,,5155.96,percent of total billed charges,All Other Outpatient,5590.8,90,,5590.8,percent of total billed charges,All Other,4348.4,70,,4348.4,percent of total billed charges,All Other,405.9,,,405.9,Fee Schedule,,344.4,,,344.4,Fee Schedule,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,1780.1,,,1780.1,Other,100% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,2723.55,,,2723.55,Other,153% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,2492.13,,,2492.13,Other,140% Medicaid APG methodology,4005.21,,,4005.21,Other,225% Medicaid APG methodology,4628.25,,,4628.25,Other,260% Medicaid APG methodology,5767.51,,,5767.51,Other,324% Medicaid APG methodology,3827.2,,,3827.2,Other,215% Medicaid APG methodology,3827.2,,,3827.2,Other,215% Medicaid APG methodology,2225.12,,,2225.12,Other,125% Medicaid APG methodology,344.4,6315,
RMVL DEVITAL TIS 20 CM/<        ,97597,CPT,59,47901194,CDM,761,RC,,,both,,,915,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,457.5,50,,457.5,percent of total billed charges,All Other,640.5,70,,640.5,percent of total billed charges,All Other,622.2,68,,622.2,percent of total billed charges,All Other Outpatient,958.5,,,958.5,Other,186% Medicaid methodology,732,80,,732,percent of total billed charges,All Other Outpatient,759.45,83,,759.45,percent of total billed charges,All Other Outpatient,759.45,83,,759.45,percent of total billed charges,All Other Outpatient,732,80,,732,percent of total billed charges,All Other Outpatient,759.45,83,,759.45,percent of total billed charges,All Other Outpatient,823.5,90,,823.5,percent of total billed charges,All Other,640.5,70,,640.5,percent of total billed charges,All Other,174.9,,,174.9,Fee Schedule,,148.4,,,148.4,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,515.32,,,515.32,Other,New York Medicaid APG methodology,515.32,,,515.32,Other,100% Medicaid APG methodology,515.32,,,515.32,Other,100% Medicaid APG methodology,515.32,,,515.32,Other,100% Medicaid APG methodology,1159.47,,,1159.47,Other,225% Medicaid APG methodology,1159.47,,,1159.47,Other,225% Medicaid APG methodology,788.44,,,788.44,Other,153% Medicaid APG methodology,1159.47,,,1159.47,Other,225% Medicaid APG methodology,721.45,,,721.45,Other,140% Medicaid APG methodology,1159.47,,,1159.47,Other,225% Medicaid APG methodology,1339.84,,,1339.84,Other,260% Medicaid APG methodology,1669.64,,,1669.64,Other,324% Medicaid APG methodology,1107.94,,,1107.94,Other,215% Medicaid APG methodology,1107.94,,,1107.94,Other,215% Medicaid APG methodology,644.15,,,644.15,Other,125% Medicaid APG methodology,148.4,4343,
DEB BONE 20 SQ CM/<             ,11044,CPT,59,47901202,CDM,761,RC,,,both,,,4888,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,2444,50,,2444,percent of total billed charges,All Other,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,3323.84,68,,3323.84,percent of total billed charges,All Other Outpatient,3180.63,,,3180.63,Other,186% Medicaid methodology,3910.4,80,,3910.4,percent of total billed charges,All Other Outpatient,4057.04,83,,4057.04,percent of total billed charges,All Other Outpatient,4057.04,83,,4057.04,percent of total billed charges,All Other Outpatient,3910.4,80,,3910.4,percent of total billed charges,All Other Outpatient,4057.04,83,,4057.04,percent of total billed charges,All Other Outpatient,4399.2,90,,4399.2,percent of total billed charges,All Other,3421.6,70,,3421.6,percent of total billed charges,All Other,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% Medicaid APG methodology,1710.01,,,1710.01,Other,100% Medicaid APG methodology,1710.01,,,1710.01,Other,100% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,2616.32,,,2616.32,Other,153% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,2394.02,,,2394.02,Other,140% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,4446.04,,,4446.04,Other,260% Medicaid APG methodology,5540.45,,,5540.45,Other,324% Medicaid APG methodology,3676.53,,,3676.53,Other,215% Medicaid APG methodology,3676.53,,,3676.53,Other,215% Medicaid APG methodology,2137.52,,,2137.52,Other,125% Medicaid APG methodology,1710.01,13157,
DEB MUSC/FASCIA 20 SQ CM/<      ,11043,CPT,59,47901210,CDM,761,RC,,,both,,,1938,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,969,50,,969,percent of total billed charges,All Other,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,1317.84,68,,1317.84,percent of total billed charges,All Other Outpatient,1704.43,,,1704.43,Other,186% Medicaid methodology,1550.4,80,,1550.4,percent of total billed charges,All Other Outpatient,1608.54,83,,1608.54,percent of total billed charges,All Other Outpatient,1608.54,83,,1608.54,percent of total billed charges,All Other Outpatient,1550.4,80,,1550.4,percent of total billed charges,All Other Outpatient,1608.54,83,,1608.54,percent of total billed charges,All Other Outpatient,1744.2,90,,1744.2,percent of total billed charges,All Other,1356.6,70,,1356.6,percent of total billed charges,All Other,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1402.03,,,1402.03,Other,153% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1282.9,,,1282.9,Other,140% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2382.54,,,2382.54,Other,260% Medicaid APG methodology,2969.01,,,2969.01,Other,324% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1145.45,,,1145.45,Other,125% Medicaid APG methodology,726.28,13157,
LOW COST SKIN SUBST APP <100    ,C5271,HCPCS,,47901236,CDM,761,RC,,,both,,,5203,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2601.5,50,,2601.5,percent of total billed charges,All Other,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,3538.04,68,,3538.04,percent of total billed charges,All Other Outpatient,2945.61,,,2945.61,Other,186% Medicaid methodology,4162.4,80,,4162.4,percent of total billed charges,All Other Outpatient,4318.49,83,,4318.49,percent of total billed charges,All Other Outpatient,4318.49,83,,4318.49,percent of total billed charges,All Other Outpatient,4162.4,80,,4162.4,percent of total billed charges,All Other Outpatient,4318.49,83,,4318.49,percent of total billed charges,All Other Outpatient,4682.7,90,,4682.7,percent of total billed charges,All Other,3642.1,70,,3642.1,percent of total billed charges,All Other,2601.5,50,,2601.5,percent of total billed charges,All Other,2601.5,50,,2601.5,percent of total billed charges,All Other,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1583.66,,,1583.66,Other,New York Medicaid APG methodology,1583.66,,,1583.66,Other,100% Medicaid APG methodology,1583.66,,,1583.66,Other,100% Medicaid APG methodology,1583.66,,,1583.66,Other,100% Medicaid APG methodology,3563.23,,,3563.23,Other,225% Medicaid APG methodology,3563.23,,,3563.23,Other,225% Medicaid APG methodology,2423,,,2423,Other,153% Medicaid APG methodology,3563.23,,,3563.23,Other,225% Medicaid APG methodology,2217.12,,,2217.12,Other,140% Medicaid APG methodology,3563.23,,,3563.23,Other,225% Medicaid APG methodology,4117.52,,,4117.52,Other,260% Medicaid APG methodology,5131.06,,,5131.06,Other,324% Medicaid APG methodology,3404.87,,,3404.87,Other,215% Medicaid APG methodology,3404.87,,,3404.87,Other,215% Medicaid APG methodology,1979.57,,,1979.57,Other,125% Medicaid APG methodology,726.28,5845,
LOW COST SKIN SUBST APP >100    ,C5273,HCPCS,,47901244,CDM,761,RC,,,both,,,9384,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,4692,50,,4692,percent of total billed charges,All Other,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6381.12,68,,6381.12,percent of total billed charges,All Other Outpatient,2945.61,,,2945.61,Other,186% Medicaid methodology,7507.2,80,,7507.2,percent of total billed charges,All Other Outpatient,7788.72,83,,7788.72,percent of total billed charges,All Other Outpatient,7788.72,83,,7788.72,percent of total billed charges,All Other Outpatient,7507.2,80,,7507.2,percent of total billed charges,All Other Outpatient,7788.72,83,,7788.72,percent of total billed charges,All Other Outpatient,8445.6,90,,8445.6,percent of total billed charges,All Other,6568.8,70,,6568.8,percent of total billed charges,All Other,4692,50,,4692,percent of total billed charges,All Other,4692,50,,4692,percent of total billed charges,All Other,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1583.66,,,1583.66,Other,New York Medicaid APG methodology,1583.66,,,1583.66,Other,100% Medicaid APG methodology,1583.66,,,1583.66,Other,100% Medicaid APG methodology,1583.66,,,1583.66,Other,100% Medicaid APG methodology,3563.23,,,3563.23,Other,225% Medicaid APG methodology,3563.23,,,3563.23,Other,225% Medicaid APG methodology,2423,,,2423,Other,153% Medicaid APG methodology,3563.23,,,3563.23,Other,225% Medicaid APG methodology,2217.12,,,2217.12,Other,140% Medicaid APG methodology,3563.23,,,3563.23,Other,225% Medicaid APG methodology,4117.52,,,4117.52,Other,260% Medicaid APG methodology,5131.06,,,5131.06,Other,324% Medicaid APG methodology,3404.87,,,3404.87,Other,215% Medicaid APG methodology,3404.87,,,3404.87,Other,215% Medicaid APG methodology,1979.57,,,1979.57,Other,125% Medicaid APG methodology,1583.66,8445.6,
LOW COST SKIN SUBST APP >100 +  ,C5274,HCPCS,,47901251,CDM,761,RC,,,both,,,2207,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1103.5,50,,1103.5,percent of total billed charges,All Other,1544.9,70,,1544.9,percent of total billed charges,All Other,1500.76,68,,1500.76,percent of total billed charges,All Other Outpatient,2945.61,,,2945.61,Other,186% Medicaid methodology,1765.6,80,,1765.6,percent of total billed charges,All Other Outpatient,1831.81,83,,1831.81,percent of total billed charges,All Other Outpatient,1831.81,83,,1831.81,percent of total billed charges,All Other Outpatient,1765.6,80,,1765.6,percent of total billed charges,All Other Outpatient,1831.81,83,,1831.81,percent of total billed charges,All Other Outpatient,1986.3,90,,1986.3,percent of total billed charges,All Other,1544.9,70,,1544.9,percent of total billed charges,All Other,1103.5,50,,1103.5,percent of total billed charges,All Other,1103.5,50,,1103.5,percent of total billed charges,All Other,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1583.66,,,1583.66,Other,New York Medicaid APG methodology,1583.66,,,1583.66,Other,100% Medicaid APG methodology,1583.66,,,1583.66,Other,100% Medicaid APG methodology,1583.66,,,1583.66,Other,100% Medicaid APG methodology,3563.23,,,3563.23,Other,225% Medicaid APG methodology,3563.23,,,3563.23,Other,225% Medicaid APG methodology,2423,,,2423,Other,153% Medicaid APG methodology,3563.23,,,3563.23,Other,225% Medicaid APG methodology,2217.12,,,2217.12,Other,140% Medicaid APG methodology,3563.23,,,3563.23,Other,225% Medicaid APG methodology,4117.52,,,4117.52,Other,260% Medicaid APG methodology,5131.06,,,5131.06,Other,324% Medicaid APG methodology,3404.87,,,3404.87,Other,215% Medicaid APG methodology,3404.87,,,3404.87,Other,215% Medicaid APG methodology,1979.57,,,1979.57,Other,125% Medicaid APG methodology,0.01,5131.06,
LOW COST SKIN SUBST APP <100    ,C5275,HCPCS,,47901269,CDM,761,RC,,,both,,,5671,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2835.5,50,,2835.5,percent of total billed charges,All Other,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,3856.28,68,,3856.28,percent of total billed charges,All Other Outpatient,2945.61,,,2945.61,Other,186% Medicaid methodology,4536.8,80,,4536.8,percent of total billed charges,All Other Outpatient,4706.93,83,,4706.93,percent of total billed charges,All Other Outpatient,4706.93,83,,4706.93,percent of total billed charges,All Other Outpatient,4536.8,80,,4536.8,percent of total billed charges,All Other Outpatient,4706.93,83,,4706.93,percent of total billed charges,All Other Outpatient,5103.9,90,,5103.9,percent of total billed charges,All Other,3969.7,70,,3969.7,percent of total billed charges,All Other,2835.5,50,,2835.5,percent of total billed charges,All Other,2835.5,50,,2835.5,percent of total billed charges,All Other,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1583.66,,,1583.66,Other,New York Medicaid APG methodology,1583.66,,,1583.66,Other,100% Medicaid APG methodology,1583.66,,,1583.66,Other,100% Medicaid APG methodology,1583.66,,,1583.66,Other,100% Medicaid APG methodology,3563.23,,,3563.23,Other,225% Medicaid APG methodology,3563.23,,,3563.23,Other,225% Medicaid APG methodology,2423,,,2423,Other,153% Medicaid APG methodology,3563.23,,,3563.23,Other,225% Medicaid APG methodology,2217.12,,,2217.12,Other,140% Medicaid APG methodology,3563.23,,,3563.23,Other,225% Medicaid APG methodology,4117.52,,,4117.52,Other,260% Medicaid APG methodology,5131.06,,,5131.06,Other,324% Medicaid APG methodology,3404.87,,,3404.87,Other,215% Medicaid APG methodology,3404.87,,,3404.87,Other,215% Medicaid APG methodology,1979.57,,,1979.57,Other,125% Medicaid APG methodology,726.28,5845,
LOW COST SKIN SUBST APP >100 +  ,C5276,HCPCS,,47901277,CDM,761,RC,,,both,,,965,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,482.5,50,,482.5,percent of total billed charges,All Other,675.5,70,,675.5,percent of total billed charges,All Other,656.2,68,,656.2,percent of total billed charges,All Other Outpatient,2945.61,,,2945.61,Other,186% Medicaid methodology,772,80,,772,percent of total billed charges,All Other Outpatient,800.95,83,,800.95,percent of total billed charges,All Other Outpatient,800.95,83,,800.95,percent of total billed charges,All Other Outpatient,772,80,,772,percent of total billed charges,All Other Outpatient,800.95,83,,800.95,percent of total billed charges,All Other Outpatient,868.5,90,,868.5,percent of total billed charges,All Other,675.5,70,,675.5,percent of total billed charges,All Other,482.5,50,,482.5,percent of total billed charges,All Other,482.5,50,,482.5,percent of total billed charges,All Other,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1583.66,,,1583.66,Other,New York Medicaid APG methodology,1583.66,,,1583.66,Other,100% Medicaid APG methodology,1583.66,,,1583.66,Other,100% Medicaid APG methodology,1583.66,,,1583.66,Other,100% Medicaid APG methodology,3563.23,,,3563.23,Other,225% Medicaid APG methodology,3563.23,,,3563.23,Other,225% Medicaid APG methodology,2423,,,2423,Other,153% Medicaid APG methodology,3563.23,,,3563.23,Other,225% Medicaid APG methodology,2217.12,,,2217.12,Other,140% Medicaid APG methodology,3563.23,,,3563.23,Other,225% Medicaid APG methodology,4117.52,,,4117.52,Other,260% Medicaid APG methodology,5131.06,,,5131.06,Other,324% Medicaid APG methodology,3404.87,,,3404.87,Other,215% Medicaid APG methodology,3404.87,,,3404.87,Other,215% Medicaid APG methodology,1979.57,,,1979.57,Other,125% Medicaid APG methodology,0.01,5131.06,
DRAINAGE OF SKIN ABSCESS MULT   ,10061,CPT,,47901285,CDM,761,RC,,,both,,,1811,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,905.5,50,,905.5,percent of total billed charges,All Other,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,1231.48,68,,1231.48,percent of total billed charges,All Other Outpatient,902.56,,,902.56,Other,186% Medicaid methodology,1448.8,80,,1448.8,percent of total billed charges,All Other Outpatient,1503.13,83,,1503.13,percent of total billed charges,All Other Outpatient,1503.13,83,,1503.13,percent of total billed charges,All Other Outpatient,1448.8,80,,1448.8,percent of total billed charges,All Other Outpatient,1503.13,83,,1503.13,percent of total billed charges,All Other Outpatient,1629.9,90,,1629.9,percent of total billed charges,All Other,1267.7,70,,1267.7,percent of total billed charges,All Other,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,485.25,,,485.25,Other,100% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,742.43,,,742.43,Other,153% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,679.35,,,679.35,Other,140% Medicaid APG methodology,1091.81,,,1091.81,Other,225% Medicaid APG methodology,1261.65,,,1261.65,Other,260% Medicaid APG methodology,1572.2,,,1572.2,Other,324% Medicaid APG methodology,1043.28,,,1043.28,Other,215% Medicaid APG methodology,1043.28,,,1043.28,Other,215% Medicaid APG methodology,606.56,,,606.56,Other,125% Medicaid APG methodology,461.11,13157,
INCAL BX SKN EA SEP/ADDL        ,11107,CPT,,47901293,CDM,761,RC,,,both,,,393,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,196.5,50,,196.5,percent of total billed charges,All Other,275.1,70,,275.1,percent of total billed charges,All Other,267.24,68,,267.24,percent of total billed charges,All Other Outpatient,1559.83,,,1559.83,Other,186% Medicaid methodology,314.4,80,,314.4,percent of total billed charges,All Other Outpatient,326.19,83,,326.19,percent of total billed charges,All Other Outpatient,326.19,83,,326.19,percent of total billed charges,All Other Outpatient,314.4,80,,314.4,percent of total billed charges,All Other Outpatient,326.19,83,,326.19,percent of total billed charges,All Other Outpatient,353.7,90,,353.7,percent of total billed charges,All Other,275.1,70,,275.1,percent of total billed charges,All Other,150.15,,,150.15,Fee Schedule,,127.4,,,127.4,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1283.09,,,1283.09,Other,153% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1174.07,,,1174.07,Other,140% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,2180.41,,,2180.41,Other,260% Medicaid APG methodology,2717.12,,,2717.12,Other,324% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1048.27,,,1048.27,Other,125% Medicaid APG methodology,0.01,4343,
REMOVAL TUNNELED CV CATH        ,36589,CPT,,47901343,CDM,761,RC,,,both,,,3047,1194.63,,,1194.63,Other,150% of Medicare + 9.63% HCRA Surcharge,726.46,,,726.46,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1523.5,50,,1523.5,percent of total billed charges,All Other,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,2071.96,68,,2071.96,percent of total billed charges,All Other Outpatient,1686.14,,,1686.14,Other,186% Medicaid methodology,2437.6,80,,2437.6,percent of total billed charges,All Other Outpatient,2529.01,83,,2529.01,percent of total billed charges,All Other Outpatient,2529.01,83,,2529.01,percent of total billed charges,All Other Outpatient,2437.6,80,,2437.6,percent of total billed charges,All Other Outpatient,2529.01,83,,2529.01,percent of total billed charges,All Other Outpatient,2742.3,90,,2742.3,percent of total billed charges,All Other,2132.9,70,,2132.9,percent of total billed charges,All Other,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,906.53,,,906.53,Other,New York Medicaid APG methodology,906.53,,,906.53,Other,100% Medicaid APG methodology,906.53,,,906.53,Other,100% Medicaid APG methodology,906.53,,,906.53,Other,100% Medicaid APG methodology,2039.69,,,2039.69,Other,225% Medicaid APG methodology,2039.69,,,2039.69,Other,225% Medicaid APG methodology,1386.99,,,1386.99,Other,153% Medicaid APG methodology,2039.69,,,2039.69,Other,225% Medicaid APG methodology,1269.14,,,1269.14,Other,140% Medicaid APG methodology,2039.69,,,2039.69,Other,225% Medicaid APG methodology,2356.97,,,2356.97,Other,260% Medicaid APG methodology,2937.15,,,2937.15,Other,324% Medicaid APG methodology,1949.04,,,1949.04,Other,215% Medicaid APG methodology,1949.04,,,1949.04,Other,215% Medicaid APG methodology,1133.16,,,1133.16,Other,125% Medicaid APG methodology,726.46,13157,
PUNCH BX SKIN SINGLE LESION     ,11104,CPT,,47901368,CDM,761,RC,,,both,,,701,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,350.5,50,,350.5,percent of total billed charges,All Other,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper,476.68,68,,476.68,percent of total billed charges,All Other Outpatient,1559.83,,,1559.83,Other,186% Medicaid methodology,560.8,80,,560.8,percent of total billed charges,All Other Outpatient,581.83,83,,581.83,percent of total billed charges,All Other Outpatient,581.83,83,,581.83,percent of total billed charges,All Other Outpatient,560.8,80,,560.8,percent of total billed charges,All Other Outpatient,581.83,83,,581.83,percent of total billed charges,All Other Outpatient,630.9,90,,630.9,percent of total billed charges,All Other,490.7,70,,490.7,percent of total billed charges,All Other,226.05,,,226.05,Fee Schedule,,191.8,,,191.8,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1283.09,,,1283.09,Other,153% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1174.07,,,1174.07,Other,140% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,2180.41,,,2180.41,Other,260% Medicaid APG methodology,2717.12,,,2717.12,Other,324% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1048.27,,,1048.27,Other,125% Medicaid APG methodology,0.01,4343,
INCAL BX SKN SINGLE LES         ,11106,CPT,,47901376,CDM,761,RC,,,both,,,2259,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1129.5,50,,1129.5,percent of total billed charges,All Other,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,1536.12,68,,1536.12,percent of total billed charges,All Other Outpatient,1559.83,,,1559.83,Other,186% Medicaid methodology,1807.2,80,,1807.2,percent of total billed charges,All Other Outpatient,1874.97,83,,1874.97,percent of total billed charges,All Other Outpatient,1874.97,83,,1874.97,percent of total billed charges,All Other Outpatient,1807.2,80,,1807.2,percent of total billed charges,All Other Outpatient,1874.97,83,,1874.97,percent of total billed charges,All Other Outpatient,2033.1,90,,2033.1,percent of total billed charges,All Other,1581.3,70,,1581.3,percent of total billed charges,All Other,273.9,,,273.9,Fee Schedule,,232.4,,,232.4,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1283.09,,,1283.09,Other,153% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1174.07,,,1174.07,Other,140% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,2180.41,,,2180.41,Other,260% Medicaid APG methodology,2717.12,,,2717.12,Other,324% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1048.27,,,1048.27,Other,125% Medicaid APG methodology,232.4,4343,
TANGNTL BX SKIN EA SEP/ADDL     ,11103,CPT,,47901384,CDM,761,RC,,,both,,,393,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,196.5,50,,196.5,percent of total billed charges,All Other,275.1,70,,275.1,percent of total billed charges,All Other,267.24,68,,267.24,percent of total billed charges,All Other Outpatient,1559.83,,,1559.83,Other,186% Medicaid methodology,314.4,80,,314.4,percent of total billed charges,All Other Outpatient,326.19,83,,326.19,percent of total billed charges,All Other Outpatient,326.19,83,,326.19,percent of total billed charges,All Other Outpatient,314.4,80,,314.4,percent of total billed charges,All Other Outpatient,326.19,83,,326.19,percent of total billed charges,All Other Outpatient,353.7,90,,353.7,percent of total billed charges,All Other,275.1,70,,275.1,percent of total billed charges,All Other,105.6,,,105.6,Fee Schedule,,89.6,,,89.6,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1283.09,,,1283.09,Other,153% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1174.07,,,1174.07,Other,140% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,2180.41,,,2180.41,Other,260% Medicaid APG methodology,2717.12,,,2717.12,Other,324% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1048.27,,,1048.27,Other,125% Medicaid APG methodology,0.01,4343,
PUNCH BX SKIN EA SEP/ADDL       ,11105,CPT,,47901392,CDM,761,RC,,,both,,,393,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,196.5,50,,196.5,percent of total billed charges,All Other,275.1,70,,275.1,percent of total billed charges,All Other,267.24,68,,267.24,percent of total billed charges,All Other Outpatient,1559.83,,,1559.83,Other,186% Medicaid methodology,314.4,80,,314.4,percent of total billed charges,All Other Outpatient,326.19,83,,326.19,percent of total billed charges,All Other Outpatient,326.19,83,,326.19,percent of total billed charges,All Other Outpatient,314.4,80,,314.4,percent of total billed charges,All Other Outpatient,326.19,83,,326.19,percent of total billed charges,All Other Outpatient,353.7,90,,353.7,percent of total billed charges,All Other,275.1,70,,275.1,percent of total billed charges,All Other,123.75,,,123.75,Fee Schedule,,105,,,105,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1283.09,,,1283.09,Other,153% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1174.07,,,1174.07,Other,140% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,2180.41,,,2180.41,Other,260% Medicaid APG methodology,2717.12,,,2717.12,Other,324% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1048.27,,,1048.27,Other,125% Medicaid APG methodology,0.01,4343,
HOSPITAL OUTPT CLINIC VISIT     ,G0463,HCPCS,,47901814,CDM,761,RC,,,both,,,477,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,238.5,50,,238.5,percent of total billed charges,All Other Outpatient,214.65,45,,214.65,percent of total billed charges,All Other Outpatient,238.5,50,,238.5,percent of total billed charges,All Other Outpatient,214.65,45,,214.65,percent of total billed charges,All Other Outpatient,205.11,43,,205.11,percent of total billed charges,All Other Outpatient,238.5,50,,238.5,percent of total billed charges,All Other,333.9,70,,333.9,percent of total billed charges,All Other,324.36,68,,324.36,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,381.6,80,,381.6,percent of total billed charges,All Other Outpatient,395.91,83,,395.91,percent of total billed charges,All Other Outpatient,395.91,83,,395.91,percent of total billed charges,All Other Outpatient,381.6,80,,381.6,percent of total billed charges,All Other Outpatient,395.91,83,,395.91,percent of total billed charges,All Other Outpatient,429.3,90,,429.3,percent of total billed charges,All Other,333.9,70,,333.9,percent of total billed charges,All Other,238.5,50,,238.5,percent of total billed charges,All Other,238.5,50,,238.5,percent of total billed charges,All Other,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,3567,
DEBRIDE NAIL 1-5                ,11720,CPT,,47901830,CDM,761,RC,,,both,,,602,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,301,50,,301,percent of total billed charges,All Other,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper,409.36,68,,409.36,percent of total billed charges,All Other Outpatient,411.2,,,411.2,Other,186% Medicaid methodology,481.6,80,,481.6,percent of total billed charges,All Other Outpatient,499.66,83,,499.66,percent of total billed charges,All Other Outpatient,499.66,83,,499.66,percent of total billed charges,All Other Outpatient,481.6,80,,481.6,percent of total billed charges,All Other Outpatient,499.66,83,,499.66,percent of total billed charges,All Other Outpatient,541.8,90,,541.8,percent of total billed charges,All Other,421.4,70,,421.4,percent of total billed charges,All Other,70.95,,,70.95,Fee Schedule,,60.2,,,60.2,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,221.08,,,221.08,Other,New York Medicaid APG methodology,221.08,,,221.08,Other,100% Medicaid APG methodology,221.08,,,221.08,Other,100% Medicaid APG methodology,221.08,,,221.08,Other,100% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,338.25,,,338.25,Other,153% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,309.51,,,309.51,Other,140% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,574.8,,,574.8,Other,260% Medicaid APG methodology,716.29,,,716.29,Other,324% Medicaid APG methodology,475.32,,,475.32,Other,215% Medicaid APG methodology,475.32,,,475.32,Other,215% Medicaid APG methodology,276.35,,,276.35,Other,125% Medicaid APG methodology,0.01,4343,
DEBRIDE NAIL 6 OR MORE          ,11721,CPT,,47901848,CDM,761,RC,,,both,,,600,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,300,50,,300,percent of total billed charges,All Other,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper,408,68,,408,percent of total billed charges,All Other Outpatient,411.2,,,411.2,Other,186% Medicaid methodology,480,80,,480,percent of total billed charges,All Other Outpatient,498,83,,498,percent of total billed charges,All Other Outpatient,498,83,,498,percent of total billed charges,All Other Outpatient,480,80,,480,percent of total billed charges,All Other Outpatient,498,83,,498,percent of total billed charges,All Other Outpatient,540,90,,540,percent of total billed charges,All Other,420,70,,420,percent of total billed charges,All Other,115.5,,,115.5,Fee Schedule,,98,,,98,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,221.08,,,221.08,Other,New York Medicaid APG methodology,221.08,,,221.08,Other,100% Medicaid APG methodology,221.08,,,221.08,Other,100% Medicaid APG methodology,221.08,,,221.08,Other,100% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,338.25,,,338.25,Other,153% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,309.51,,,309.51,Other,140% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,574.8,,,574.8,Other,260% Medicaid APG methodology,716.29,,,716.29,Other,324% Medicaid APG methodology,475.32,,,475.32,Other,215% Medicaid APG methodology,475.32,,,475.32,Other,215% Medicaid APG methodology,276.35,,,276.35,Other,125% Medicaid APG methodology,0.01,4343,
REMOVE IMPACTED EAR WAX UNI     ,69210,CPT,,47901855,CDM,761,RC,,,both,,,616,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,308,50,,308,percent of total billed charges,All Other,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper,418.88,68,,418.88,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,492.8,80,,492.8,percent of total billed charges,All Other Outpatient,511.28,83,,511.28,percent of total billed charges,All Other Outpatient,511.28,83,,511.28,percent of total billed charges,All Other Outpatient,492.8,80,,492.8,percent of total billed charges,All Other Outpatient,511.28,83,,511.28,percent of total billed charges,All Other Outpatient,554.4,90,,554.4,percent of total billed charges,All Other,431.2,70,,431.2,percent of total billed charges,All Other,160.05,,,160.05,Fee Schedule,,135.8,,,135.8,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,4343,
REMOVE IMPACTED EAR WAX UNI     ,69209,CPT,,47901863,CDM,761,RC,,,both,,,214,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,107,50,,107,percent of total billed charges,All Other,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper,145.52,68,,145.52,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,171.2,80,,171.2,percent of total billed charges,All Other Outpatient,177.62,83,,177.62,percent of total billed charges,All Other Outpatient,177.62,83,,177.62,percent of total billed charges,All Other Outpatient,171.2,80,,171.2,percent of total billed charges,All Other Outpatient,177.62,83,,177.62,percent of total billed charges,All Other Outpatient,192.6,90,,192.6,percent of total billed charges,All Other,149.8,70,,149.8,percent of total billed charges,All Other,74.25,,,74.25,Fee Schedule,,63,,,63,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,4343,
WOUND(S) CARE NON-SELECTIVE     ,97602,CPT,,47901871,CDM,761,RC,,,both,,,651,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,325.5,50,,325.5,percent of total billed charges,All Other Outpatient,292.95,45,,292.95,percent of total billed charges,All Other Outpatient,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,325.5,50,,325.5,percent of total billed charges,All Other,455.7,70,,455.7,percent of total billed charges,All Other,442.68,68,,442.68,percent of total billed charges,All Other Outpatient,1438.1,,,1438.1,Other,186% Medicaid methodology,520.8,80,,520.8,percent of total billed charges,All Other Outpatient,540.33,83,,540.33,percent of total billed charges,All Other Outpatient,540.33,83,,540.33,percent of total billed charges,All Other Outpatient,520.8,80,,520.8,percent of total billed charges,All Other Outpatient,540.33,83,,540.33,percent of total billed charges,All Other Outpatient,585.9,90,,585.9,percent of total billed charges,All Other,455.7,70,,455.7,percent of total billed charges,All Other,325.5,50,,325.5,percent of total billed charges,All Other,325.5,50,,325.5,percent of total billed charges,All Other,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,773.17,,,773.17,Other,New York Medicaid APG methodology,773.17,,,773.17,Other,100% Medicaid APG methodology,773.17,,,773.17,Other,100% Medicaid APG methodology,773.17,,,773.17,Other,100% Medicaid APG methodology,1739.64,,,1739.64,Other,225% Medicaid APG methodology,1739.64,,,1739.64,Other,225% Medicaid APG methodology,1182.95,,,1182.95,Other,153% Medicaid APG methodology,1739.64,,,1739.64,Other,225% Medicaid APG methodology,1082.44,,,1082.44,Other,140% Medicaid APG methodology,1739.64,,,1739.64,Other,225% Medicaid APG methodology,2010.25,,,2010.25,Other,260% Medicaid APG methodology,2505.08,,,2505.08,Other,324% Medicaid APG methodology,1662.32,,,1662.32,Other,215% Medicaid APG methodology,1662.32,,,1662.32,Other,215% Medicaid APG methodology,966.46,,,966.46,Other,125% Medicaid APG methodology,231.51,4343,
NEG PRESS WND TX <=50 SQ CM     ,97607,CPT,,47901889,CDM,761,RC,,,both,,,1207,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,603.5,50,,603.5,percent of total billed charges,All Other Outpatient,543.15,45,,543.15,percent of total billed charges,All Other Outpatient,603.5,50,,603.5,percent of total billed charges,All Other Outpatient,543.15,45,,543.15,percent of total billed charges,All Other Outpatient,519.01,43,,519.01,percent of total billed charges,All Other Outpatient,603.5,50,,603.5,percent of total billed charges,All Other,844.9,70,,844.9,percent of total billed charges,All Other,820.76,68,,820.76,percent of total billed charges,All Other Outpatient,1438.1,,,1438.1,Other,186% Medicaid methodology,965.6,80,,965.6,percent of total billed charges,All Other Outpatient,1001.81,83,,1001.81,percent of total billed charges,All Other Outpatient,1001.81,83,,1001.81,percent of total billed charges,All Other Outpatient,965.6,80,,965.6,percent of total billed charges,All Other Outpatient,1001.81,83,,1001.81,percent of total billed charges,All Other Outpatient,1086.3,90,,1086.3,percent of total billed charges,All Other,844.9,70,,844.9,percent of total billed charges,All Other,108.9,,,108.9,Fee Schedule,,92.4,,,92.4,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,773.17,,,773.17,Other,New York Medicaid APG methodology,773.17,,,773.17,Other,100% Medicaid APG methodology,773.17,,,773.17,Other,100% Medicaid APG methodology,773.17,,,773.17,Other,100% Medicaid APG methodology,1739.64,,,1739.64,Other,225% Medicaid APG methodology,1739.64,,,1739.64,Other,225% Medicaid APG methodology,1182.95,,,1182.95,Other,153% Medicaid APG methodology,1739.64,,,1739.64,Other,225% Medicaid APG methodology,1082.44,,,1082.44,Other,140% Medicaid APG methodology,1739.64,,,1739.64,Other,225% Medicaid APG methodology,2010.25,,,2010.25,Other,260% Medicaid APG methodology,2505.08,,,2505.08,Other,324% Medicaid APG methodology,1662.32,,,1662.32,Other,215% Medicaid APG methodology,1662.32,,,1662.32,Other,215% Medicaid APG methodology,966.46,,,966.46,Other,125% Medicaid APG methodology,92.4,3567,
NEG PRESS WOUND TX >50 CM       ,97608,CPT,,47901897,CDM,761,RC,,,both,,,1588,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,794,50,,794,percent of total billed charges,All Other Outpatient,714.6,45,,714.6,percent of total billed charges,All Other Outpatient,794,50,,794,percent of total billed charges,All Other Outpatient,714.6,45,,714.6,percent of total billed charges,All Other Outpatient,682.84,43,,682.84,percent of total billed charges,All Other Outpatient,794,50,,794,percent of total billed charges,All Other,1111.6,70,,1111.6,percent of total billed charges,All Other,1079.84,68,,1079.84,percent of total billed charges,All Other Outpatient,1438.1,,,1438.1,Other,186% Medicaid methodology,1270.4,80,,1270.4,percent of total billed charges,All Other Outpatient,1318.04,83,,1318.04,percent of total billed charges,All Other Outpatient,1318.04,83,,1318.04,percent of total billed charges,All Other Outpatient,1270.4,80,,1270.4,percent of total billed charges,All Other Outpatient,1318.04,83,,1318.04,percent of total billed charges,All Other Outpatient,1429.2,90,,1429.2,percent of total billed charges,All Other,1111.6,70,,1111.6,percent of total billed charges,All Other,122.1,,,122.1,Fee Schedule,,103.6,,,103.6,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,773.17,,,773.17,Other,New York Medicaid APG methodology,773.17,,,773.17,Other,100% Medicaid APG methodology,773.17,,,773.17,Other,100% Medicaid APG methodology,773.17,,,773.17,Other,100% Medicaid APG methodology,1739.64,,,1739.64,Other,225% Medicaid APG methodology,1739.64,,,1739.64,Other,225% Medicaid APG methodology,1182.95,,,1182.95,Other,153% Medicaid APG methodology,1739.64,,,1739.64,Other,225% Medicaid APG methodology,1082.44,,,1082.44,Other,140% Medicaid APG methodology,1739.64,,,1739.64,Other,225% Medicaid APG methodology,2010.25,,,2010.25,Other,260% Medicaid APG methodology,2505.08,,,2505.08,Other,324% Medicaid APG methodology,1662.32,,,1662.32,Other,215% Medicaid APG methodology,1662.32,,,1662.32,Other,215% Medicaid APG methodology,966.46,,,966.46,Other,125% Medicaid APG methodology,103.6,3567,
DRESS/DEBRID P-THICK BURN S     ,16020,CPT,,47901905,CDM,761,RC,,,both,,,517,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,258.5,50,,258.5,percent of total billed charges,All Other,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,351.56,68,,351.56,percent of total billed charges,All Other Outpatient,1193.32,,,1193.32,Other,186% Medicaid methodology,413.6,80,,413.6,percent of total billed charges,All Other Outpatient,429.11,83,,429.11,percent of total billed charges,All Other Outpatient,429.11,83,,429.11,percent of total billed charges,All Other Outpatient,413.6,80,,413.6,percent of total billed charges,All Other Outpatient,429.11,83,,429.11,percent of total billed charges,All Other Outpatient,465.3,90,,465.3,percent of total billed charges,All Other,361.9,70,,361.9,percent of total billed charges,All Other,264,,,264,Fee Schedule,,224,,,224,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,981.6,,,981.6,Other,153% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,898.2,,,898.2,Other,140% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1668.08,,,1668.08,Other,260% Medicaid APG methodology,2078.69,,,2078.69,Other,324% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,801.96,,,801.96,Other,125% Medicaid APG methodology,224,4343,
DRESS/DEBRID P-THICK BURN M     ,16025,CPT,,47901913,CDM,761,RC,,,both,,,747,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,373.5,50,,373.5,percent of total billed charges,All Other,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,507.96,68,,507.96,percent of total billed charges,All Other Outpatient,1193.32,,,1193.32,Other,186% Medicaid methodology,597.6,80,,597.6,percent of total billed charges,All Other Outpatient,620.01,83,,620.01,percent of total billed charges,All Other Outpatient,620.01,83,,620.01,percent of total billed charges,All Other Outpatient,597.6,80,,597.6,percent of total billed charges,All Other Outpatient,620.01,83,,620.01,percent of total billed charges,All Other Outpatient,672.3,90,,672.3,percent of total billed charges,All Other,522.9,70,,522.9,percent of total billed charges,All Other,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,641.57,,,641.57,Other,100% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,981.6,,,981.6,Other,153% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,898.2,,,898.2,Other,140% Medicaid APG methodology,1443.53,,,1443.53,Other,225% Medicaid APG methodology,1668.08,,,1668.08,Other,260% Medicaid APG methodology,2078.69,,,2078.69,Other,324% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,1379.38,,,1379.38,Other,215% Medicaid APG methodology,801.96,,,801.96,Other,125% Medicaid APG methodology,231.51,13157,
DRESS/DEBRID P-THICK BURN L     ,16030,CPT,,47901921,CDM,761,RC,,,both,,,1339,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,669.5,50,,669.5,percent of total billed charges,All Other,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,910.52,68,,910.52,percent of total billed charges,All Other Outpatient,1704.43,,,1704.43,Other,186% Medicaid methodology,1071.2,80,,1071.2,percent of total billed charges,All Other Outpatient,1111.37,83,,1111.37,percent of total billed charges,All Other Outpatient,1111.37,83,,1111.37,percent of total billed charges,All Other Outpatient,1071.2,80,,1071.2,percent of total billed charges,All Other Outpatient,1111.37,83,,1111.37,percent of total billed charges,All Other Outpatient,1205.1,90,,1205.1,percent of total billed charges,All Other,937.3,70,,937.3,percent of total billed charges,All Other,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1402.03,,,1402.03,Other,153% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1282.9,,,1282.9,Other,140% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2382.54,,,2382.54,Other,260% Medicaid APG methodology,2969.01,,,2969.01,Other,324% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1145.45,,,1145.45,Other,125% Medicaid APG methodology,461.11,13157,
DRAINAGE OF HEMATOMA/FLUID      ,10140,CPT,,47901939,CDM,761,RC,,,both,,,6422,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,3211,50,,3211,percent of total billed charges,All Other,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper,4366.96,68,,4366.96,percent of total billed charges,All Other Outpatient,1516.17,,,1516.17,Other,186% Medicaid methodology,5137.6,80,,5137.6,percent of total billed charges,All Other Outpatient,5330.26,83,,5330.26,percent of total billed charges,All Other Outpatient,5330.26,83,,5330.26,percent of total billed charges,All Other Outpatient,5137.6,80,,5137.6,percent of total billed charges,All Other Outpatient,5330.26,83,,5330.26,percent of total billed charges,All Other Outpatient,5779.8,90,,5779.8,percent of total billed charges,All Other,4495.4,70,,4495.4,percent of total billed charges,All Other,572.55,,,572.55,Fee Schedule,,485.8,,,485.8,Fee Schedule,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,815.14,,,815.14,Other,New York Medicaid APG methodology,815.14,,,815.14,Other,100% Medicaid APG methodology,815.14,,,815.14,Other,100% Medicaid APG methodology,815.14,,,815.14,Other,100% Medicaid APG methodology,1834.07,,,1834.07,Other,225% Medicaid APG methodology,1834.07,,,1834.07,Other,225% Medicaid APG methodology,1247.17,,,1247.17,Other,153% Medicaid APG methodology,1834.07,,,1834.07,Other,225% Medicaid APG methodology,1141.2,,,1141.2,Other,140% Medicaid APG methodology,1834.07,,,1834.07,Other,225% Medicaid APG methodology,2119.37,,,2119.37,Other,260% Medicaid APG methodology,2641.06,,,2641.06,Other,324% Medicaid APG methodology,1752.56,,,1752.56,Other,215% Medicaid APG methodology,1752.56,,,1752.56,Other,215% Medicaid APG methodology,1018.93,,,1018.93,Other,125% Medicaid APG methodology,0.01,6315,
REMOVAL OF NAIL PLATE           ,11730,CPT,,47901970,CDM,761,RC,,,both,,,1427,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,713.5,50,,713.5,percent of total billed charges,All Other,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper,970.36,68,,970.36,percent of total billed charges,All Other Outpatient,411.2,,,411.2,Other,186% Medicaid methodology,1141.6,80,,1141.6,percent of total billed charges,All Other Outpatient,1184.41,83,,1184.41,percent of total billed charges,All Other Outpatient,1184.41,83,,1184.41,percent of total billed charges,All Other Outpatient,1141.6,80,,1141.6,percent of total billed charges,All Other Outpatient,1184.41,83,,1184.41,percent of total billed charges,All Other Outpatient,1284.3,90,,1284.3,percent of total billed charges,All Other,998.9,70,,998.9,percent of total billed charges,All Other,259.05,,,259.05,Fee Schedule,,219.8,,,219.8,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,221.08,,,221.08,Other,New York Medicaid APG methodology,221.08,,,221.08,Other,100% Medicaid APG methodology,221.08,,,221.08,Other,100% Medicaid APG methodology,221.08,,,221.08,Other,100% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,338.25,,,338.25,Other,153% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,309.51,,,309.51,Other,140% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,574.8,,,574.8,Other,260% Medicaid APG methodology,716.29,,,716.29,Other,324% Medicaid APG methodology,475.32,,,475.32,Other,215% Medicaid APG methodology,475.32,,,475.32,Other,215% Medicaid APG methodology,276.35,,,276.35,Other,125% Medicaid APG methodology,0.01,4343,
TRIM NAIL(S) ANY NUMBER         ,11719,CPT,,47901996,CDM,761,RC,,,both,,,269,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,134.5,50,,134.5,percent of total billed charges,All Other,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper,182.92,68,,182.92,percent of total billed charges,All Other Outpatient,411.2,,,411.2,Other,186% Medicaid methodology,215.2,80,,215.2,percent of total billed charges,All Other Outpatient,223.27,83,,223.27,percent of total billed charges,All Other Outpatient,223.27,83,,223.27,percent of total billed charges,All Other Outpatient,215.2,80,,215.2,percent of total billed charges,All Other Outpatient,223.27,83,,223.27,percent of total billed charges,All Other Outpatient,242.1,90,,242.1,percent of total billed charges,All Other,188.3,70,,188.3,percent of total billed charges,All Other,36.3,,,36.3,Fee Schedule,,30.8,,,30.8,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,221.08,,,221.08,Other,New York Medicaid APG methodology,221.08,,,221.08,Other,100% Medicaid APG methodology,221.08,,,221.08,Other,100% Medicaid APG methodology,221.08,,,221.08,Other,100% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,338.25,,,338.25,Other,153% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,309.51,,,309.51,Other,140% Medicaid APG methodology,497.42,,,497.42,Other,225% Medicaid APG methodology,574.8,,,574.8,Other,260% Medicaid APG methodology,716.29,,,716.29,Other,324% Medicaid APG methodology,475.32,,,475.32,Other,215% Medicaid APG methodology,475.32,,,475.32,Other,215% Medicaid APG methodology,276.35,,,276.35,Other,125% Medicaid APG methodology,0.01,9074,
REMOVAL OF NAIL BED             ,11750,CPT,,47902002,CDM,761,RC,,,both,,,889,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,444.5,50,,444.5,percent of total billed charges,All Other,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,604.52,68,,604.52,percent of total billed charges,All Other Outpatient,1559.83,,,1559.83,Other,186% Medicaid methodology,711.2,80,,711.2,percent of total billed charges,All Other Outpatient,737.87,83,,737.87,percent of total billed charges,All Other Outpatient,737.87,83,,737.87,percent of total billed charges,All Other Outpatient,711.2,80,,711.2,percent of total billed charges,All Other Outpatient,737.87,83,,737.87,percent of total billed charges,All Other Outpatient,800.1,90,,800.1,percent of total billed charges,All Other,622.3,70,,622.3,percent of total billed charges,All Other,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,838.62,,,838.62,Other,100% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1283.09,,,1283.09,Other,153% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,1174.07,,,1174.07,Other,140% Medicaid APG methodology,1886.89,,,1886.89,Other,225% Medicaid APG methodology,2180.41,,,2180.41,Other,260% Medicaid APG methodology,2717.12,,,2717.12,Other,324% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1803.03,,,1803.03,Other,215% Medicaid APG methodology,1048.27,,,1048.27,Other,125% Medicaid APG methodology,444.5,13157,
DEB BONE 20 SQ CM/<             ,11044,CPT,,47902028,CDM,761,RC,,,both,,,5398,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,2699,50,,2699,percent of total billed charges,All Other,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,3670.64,68,,3670.64,percent of total billed charges,All Other Outpatient,3180.63,,,3180.63,Other,186% Medicaid methodology,4318.4,80,,4318.4,percent of total billed charges,All Other Outpatient,4480.34,83,,4480.34,percent of total billed charges,All Other Outpatient,4480.34,83,,4480.34,percent of total billed charges,All Other Outpatient,4318.4,80,,4318.4,percent of total billed charges,All Other Outpatient,4480.34,83,,4480.34,percent of total billed charges,All Other Outpatient,4858.2,90,,4858.2,percent of total billed charges,All Other,3778.6,70,,3778.6,percent of total billed charges,All Other,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% Medicaid APG methodology,1710.01,,,1710.01,Other,100% Medicaid APG methodology,1710.01,,,1710.01,Other,100% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,2616.32,,,2616.32,Other,153% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,2394.02,,,2394.02,Other,140% Medicaid APG methodology,3847.53,,,3847.53,Other,225% Medicaid APG methodology,4446.04,,,4446.04,Other,260% Medicaid APG methodology,5540.45,,,5540.45,Other,324% Medicaid APG methodology,3676.53,,,3676.53,Other,215% Medicaid APG methodology,3676.53,,,3676.53,Other,215% Medicaid APG methodology,2137.52,,,2137.52,Other,125% Medicaid APG methodology,1710.01,13157,
DEB MUSC/FASCIA 20 SQ CM/<      ,11043,CPT,,47902036,CDM,761,RC,,,both,,,2091,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1045.5,50,,1045.5,percent of total billed charges,All Other,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,1421.88,68,,1421.88,percent of total billed charges,All Other Outpatient,1704.43,,,1704.43,Other,186% Medicaid methodology,1672.8,80,,1672.8,percent of total billed charges,All Other Outpatient,1735.53,83,,1735.53,percent of total billed charges,All Other Outpatient,1735.53,83,,1735.53,percent of total billed charges,All Other Outpatient,1672.8,80,,1672.8,percent of total billed charges,All Other Outpatient,1735.53,83,,1735.53,percent of total billed charges,All Other Outpatient,1881.9,90,,1881.9,percent of total billed charges,All Other,1463.7,70,,1463.7,percent of total billed charges,All Other,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1402.03,,,1402.03,Other,153% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1282.9,,,1282.9,Other,140% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2382.54,,,2382.54,Other,260% Medicaid APG methodology,2969.01,,,2969.01,Other,324% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1145.45,,,1145.45,Other,125% Medicaid APG methodology,726.28,13157,
DEB SUBQ TISSUE 20 SQ CM/<      ,11042,CPT,,47902044,CDM,761,RC,,,both,,,2132,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1066,50,,1066,percent of total billed charges,All Other,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,1449.76,68,,1449.76,percent of total billed charges,All Other Outpatient,1704.43,,,1704.43,Other,186% Medicaid methodology,1705.6,80,,1705.6,percent of total billed charges,All Other Outpatient,1769.56,83,,1769.56,percent of total billed charges,All Other Outpatient,1769.56,83,,1769.56,percent of total billed charges,All Other Outpatient,1705.6,80,,1705.6,percent of total billed charges,All Other Outpatient,1769.56,83,,1769.56,percent of total billed charges,All Other Outpatient,1918.8,90,,1918.8,percent of total billed charges,All Other,1492.4,70,,1492.4,percent of total billed charges,All Other,290.4,,,290.4,Fee Schedule,,246.4,,,246.4,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,916.36,,,916.36,Other,100% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1402.03,,,1402.03,Other,153% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,1282.9,,,1282.9,Other,140% Medicaid APG methodology,2061.81,,,2061.81,Other,225% Medicaid APG methodology,2382.54,,,2382.54,Other,260% Medicaid APG methodology,2969.01,,,2969.01,Other,324% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1970.17,,,1970.17,Other,215% Medicaid APG methodology,1145.45,,,1145.45,Other,125% Medicaid APG methodology,246.4,5845,
LOW COST SKIN SUBSTITUTE APP    ,C5277,HCPCS,,47902069,CDM,761,RC,,,both,,,4393,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2196.5,50,,2196.5,percent of total billed charges,All Other,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,2987.24,68,,2987.24,percent of total billed charges,All Other Outpatient,2945.61,,,2945.61,Other,186% Medicaid methodology,3514.4,80,,3514.4,percent of total billed charges,All Other Outpatient,3646.19,83,,3646.19,percent of total billed charges,All Other Outpatient,3646.19,83,,3646.19,percent of total billed charges,All Other Outpatient,3514.4,80,,3514.4,percent of total billed charges,All Other Outpatient,3646.19,83,,3646.19,percent of total billed charges,All Other Outpatient,3953.7,90,,3953.7,percent of total billed charges,All Other,3075.1,70,,3075.1,percent of total billed charges,All Other,2196.5,50,,2196.5,percent of total billed charges,All Other,2196.5,50,,2196.5,percent of total billed charges,All Other,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1583.66,,,1583.66,Other,New York Medicaid APG methodology,1583.66,,,1583.66,Other,100% Medicaid APG methodology,1583.66,,,1583.66,Other,100% Medicaid APG methodology,1583.66,,,1583.66,Other,100% Medicaid APG methodology,3563.23,,,3563.23,Other,225% Medicaid APG methodology,3563.23,,,3563.23,Other,225% Medicaid APG methodology,2423,,,2423,Other,153% Medicaid APG methodology,3563.23,,,3563.23,Other,225% Medicaid APG methodology,2217.12,,,2217.12,Other,140% Medicaid APG methodology,3563.23,,,3563.23,Other,225% Medicaid APG methodology,4117.52,,,4117.52,Other,260% Medicaid APG methodology,5131.06,,,5131.06,Other,324% Medicaid APG methodology,3404.87,,,3404.87,Other,215% Medicaid APG methodology,3404.87,,,3404.87,Other,215% Medicaid APG methodology,1979.57,,,1979.57,Other,125% Medicaid APG methodology,726.28,5845,
ANTEPARTUM MANIPULATION         ,59412,CPT,,48300289,CDM,761,RC,,,both,,,6871,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,3435.5,50,,3435.5,percent of total billed charges,All Other Outpatient,3091.95,45,,3091.95,percent of total billed charges,All Other Outpatient,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,3435.5,50,,3435.5,percent of total billed charges,All Other,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,4672.28,68,,4672.28,percent of total billed charges,All Other Outpatient,1560.74,,,1560.74,Other,186% Medicaid methodology,5496.8,80,,5496.8,percent of total billed charges,All Other Outpatient,5702.93,83,,5702.93,percent of total billed charges,All Other Outpatient,5702.93,83,,5702.93,percent of total billed charges,All Other Outpatient,5496.8,80,,5496.8,percent of total billed charges,All Other Outpatient,5702.93,83,,5702.93,percent of total billed charges,All Other Outpatient,6183.9,90,,6183.9,percent of total billed charges,All Other,4809.7,70,,4809.7,percent of total billed charges,All Other,499.95,,,499.95,Fee Schedule,,424.2,,,424.2,Fee Schedule,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,839.11,,,839.11,Other,New York Medicaid APG methodology,839.11,,,839.11,Other,100% Medicaid APG methodology,839.11,,,839.11,Other,100% Medicaid APG methodology,839.11,,,839.11,Other,100% Medicaid APG methodology,1888,,,1888,Other,225% Medicaid APG methodology,1888,,,1888,Other,225% Medicaid APG methodology,1283.84,,,1283.84,Other,153% Medicaid APG methodology,1888,,,1888,Other,225% Medicaid APG methodology,1174.75,,,1174.75,Other,140% Medicaid APG methodology,1888,,,1888,Other,225% Medicaid APG methodology,2181.69,,,2181.69,Other,260% Medicaid APG methodology,2718.72,,,2718.72,Other,324% Medicaid APG methodology,1804.09,,,1804.09,Other,215% Medicaid APG methodology,1804.09,,,1804.09,Other,215% Medicaid APG methodology,1048.89,,,1048.89,Other,125% Medicaid APG methodology,424.2,7616,
THER/PROPH/DIAG IV INF ADDON    ,96366,CPT,,48300842,CDM,761,RC,,,both,,,418,90.33,,,90.33,Other,150% of Medicare + 9.63% HCRA Surcharge,54.93,,,54.93,Other,Medicare OPPS methodology,209,50,,209,percent of total billed charges,All Other Outpatient,188.1,45,,188.1,percent of total billed charges,All Other Outpatient,1342,,,1342,Case Rate,IV Therapy Per Visit,1208,,,1208,Case Rate,IV Therapy Per Visit,1141,,,1141,Case Rate,IV Therapy Per Visit,209,50,,209,percent of total billed charges,All Other,292.6,70,,292.6,percent of total billed charges,All Other,284.24,68,,284.24,percent of total billed charges,All Other Outpatient,1474.51,,,1474.51,Other,186% Medicaid methodology,334.4,80,,334.4,percent of total billed charges,All Other Outpatient,346.94,83,,346.94,percent of total billed charges,All Other Outpatient,346.94,83,,346.94,percent of total billed charges,All Other Outpatient,334.4,80,,334.4,percent of total billed charges,All Other Outpatient,346.94,83,,346.94,percent of total billed charges,All Other Outpatient,376.2,90,,376.2,percent of total billed charges,All Other,292.6,70,,292.6,percent of total billed charges,All Other,102.3,,,102.3,Fee Schedule,,86.8,,,86.8,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,792.75,,,792.75,Other,New York Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1212.91,,,1212.91,Other,153% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1109.85,,,1109.85,Other,140% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,2061.15,,,2061.15,Other,260% Medicaid APG methodology,2568.51,,,2568.51,Other,324% Medicaid APG methodology,1704.41,,,1704.41,Other,215% Medicaid APG methodology,1704.41,,,1704.41,Other,215% Medicaid APG methodology,990.94,,,990.94,Other,125% Medicaid APG methodology,54.93,3567,
TX/PROPH/DG ADDL SEQ IV INF     ,96367,CPT,,48300859,CDM,761,RC,,,both,,,656,133.96,,,133.96,Other,150% of Medicare + 9.63% HCRA Surcharge,81.46,,,81.46,Other,Medicare OPPS methodology,328,50,,328,percent of total billed charges,All Other Outpatient,295.2,45,,295.2,percent of total billed charges,All Other Outpatient,1342,,,1342,Case Rate,IV Therapy Per Visit,1208,,,1208,Case Rate,IV Therapy Per Visit,1141,,,1141,Case Rate,IV Therapy Per Visit,328,50,,328,percent of total billed charges,All Other,459.2,70,,459.2,percent of total billed charges,All Other,446.08,68,,446.08,percent of total billed charges,All Other Outpatient,577.69,,,577.69,Other,186% Medicaid methodology,524.8,80,,524.8,percent of total billed charges,All Other Outpatient,544.48,83,,544.48,percent of total billed charges,All Other Outpatient,544.48,83,,544.48,percent of total billed charges,All Other Outpatient,524.8,80,,524.8,percent of total billed charges,All Other Outpatient,544.48,83,,544.48,percent of total billed charges,All Other Outpatient,590.4,90,,590.4,percent of total billed charges,All Other,459.2,70,,459.2,percent of total billed charges,All Other,146.85,,,146.85,Fee Schedule,,124.6,,,124.6,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,310.58,,,310.58,Other,New York Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,475.19,,,475.19,Other,153% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,434.82,,,434.82,Other,140% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,807.52,,,807.52,Other,260% Medicaid APG methodology,1006.29,,,1006.29,Other,324% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,388.23,,,388.23,Other,125% Medicaid APG methodology,81.46,3567,
THER/DIAG CONCURRENT INF        ,96368,CPT,,48300867,CDM,761,RC,,,both,,,297,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,148.5,50,,148.5,percent of total billed charges,All Other Outpatient,133.65,45,,133.65,percent of total billed charges,All Other Outpatient,1342,,,1342,Case Rate,IV Therapy Per Visit,1208,,,1208,Case Rate,IV Therapy Per Visit,1141,,,1141,Case Rate,IV Therapy Per Visit,148.5,50,,148.5,percent of total billed charges,All Other,207.9,70,,207.9,percent of total billed charges,All Other,201.96,68,,201.96,percent of total billed charges,All Other Outpatient,577.69,,,577.69,Other,186% Medicaid methodology,237.6,80,,237.6,percent of total billed charges,All Other Outpatient,246.51,83,,246.51,percent of total billed charges,All Other Outpatient,246.51,83,,246.51,percent of total billed charges,All Other Outpatient,237.6,80,,237.6,percent of total billed charges,All Other Outpatient,246.51,83,,246.51,percent of total billed charges,All Other Outpatient,267.3,90,,267.3,percent of total billed charges,All Other,207.9,70,,207.9,percent of total billed charges,All Other,99,,,99,Fee Schedule,,84,,,84,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,310.58,,,310.58,Other,New York Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,475.19,,,475.19,Other,153% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,434.82,,,434.82,Other,140% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,807.52,,,807.52,Other,260% Medicaid APG methodology,1006.29,,,1006.29,Other,324% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,388.23,,,388.23,Other,125% Medicaid APG methodology,0.01,3567,
THER/PROPH/DIAG INJ SC/IM       ,96372,CPT,,48300875,CDM,761,RC,,,both,,,659,133.96,,,133.96,Other,150% of Medicare + 9.63% HCRA Surcharge,81.46,,,81.46,Other,Medicare OPPS methodology,329.5,50,,329.5,percent of total billed charges,All Other Outpatient,296.55,45,,296.55,percent of total billed charges,All Other Outpatient,329.5,50,,329.5,percent of total billed charges,All Other Outpatient,296.55,45,,296.55,percent of total billed charges,All Other Outpatient,283.37,43,,283.37,percent of total billed charges,All Other Outpatient,329.5,50,,329.5,percent of total billed charges,All Other,461.3,70,,461.3,percent of total billed charges,All Other,448.12,68,,448.12,percent of total billed charges,All Other Outpatient,116.47,,,116.47,Other,186% Medicaid methodology,527.2,80,,527.2,percent of total billed charges,All Other Outpatient,546.97,83,,546.97,percent of total billed charges,All Other Outpatient,546.97,83,,546.97,percent of total billed charges,All Other Outpatient,527.2,80,,527.2,percent of total billed charges,All Other Outpatient,546.97,83,,546.97,percent of total billed charges,All Other Outpatient,593.1,90,,593.1,percent of total billed charges,All Other,461.3,70,,461.3,percent of total billed charges,All Other,69.3,,,69.3,Fee Schedule,,58.8,,,58.8,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,62.62,,,62.62,Other,New York Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,95.8,,,95.8,Other,153% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,87.66,,,87.66,Other,140% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,162.81,,,162.81,Other,260% Medicaid APG methodology,202.88,,,202.88,Other,324% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,78.27,,,78.27,Other,125% Medicaid APG methodology,58.8,3567,
THER/PROPH/DIAG INJ IV PUSH     ,96374,CPT,,48300891,CDM,761,RC,,,both,,,1005,407.6,,,407.6,Other,150% of Medicare + 9.63% HCRA Surcharge,247.86,,,247.86,Other,Medicare OPPS methodology,502.5,50,,502.5,percent of total billed charges,All Other Outpatient,452.25,45,,452.25,percent of total billed charges,All Other Outpatient,502.5,50,,502.5,percent of total billed charges,All Other Outpatient,452.25,45,,452.25,percent of total billed charges,All Other Outpatient,432.15,43,,432.15,percent of total billed charges,All Other Outpatient,502.5,50,,502.5,percent of total billed charges,All Other,703.5,70,,703.5,percent of total billed charges,All Other,683.4,68,,683.4,percent of total billed charges,All Other Outpatient,116.47,,,116.47,Other,186% Medicaid methodology,804,80,,804,percent of total billed charges,All Other Outpatient,834.15,83,,834.15,percent of total billed charges,All Other Outpatient,834.15,83,,834.15,percent of total billed charges,All Other Outpatient,804,80,,804,percent of total billed charges,All Other Outpatient,834.15,83,,834.15,percent of total billed charges,All Other Outpatient,904.5,90,,904.5,percent of total billed charges,All Other,703.5,70,,703.5,percent of total billed charges,All Other,191.4,,,191.4,Fee Schedule,,162.4,,,162.4,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,62.62,,,62.62,Other,New York Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,95.8,,,95.8,Other,153% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,87.66,,,87.66,Other,140% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,162.81,,,162.81,Other,260% Medicaid APG methodology,202.88,,,202.88,Other,324% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,78.27,,,78.27,Other,125% Medicaid APG methodology,62.62,3567,
TX/PRO/DX INJ NEW DRUG ADDON    ,96375,CPT,,48300909,CDM,761,RC,,,both,,,674,90.33,,,90.33,Other,150% of Medicare + 9.63% HCRA Surcharge,54.93,,,54.93,Other,Medicare OPPS methodology,337,50,,337,percent of total billed charges,All Other Outpatient,303.3,45,,303.3,percent of total billed charges,All Other Outpatient,337,50,,337,percent of total billed charges,All Other Outpatient,303.3,45,,303.3,percent of total billed charges,All Other Outpatient,289.82,43,,289.82,percent of total billed charges,All Other Outpatient,337,50,,337,percent of total billed charges,All Other,471.8,70,,471.8,percent of total billed charges,All Other,458.32,68,,458.32,percent of total billed charges,All Other Outpatient,116.47,,,116.47,Other,186% Medicaid methodology,539.2,80,,539.2,percent of total billed charges,All Other Outpatient,559.42,83,,559.42,percent of total billed charges,All Other Outpatient,559.42,83,,559.42,percent of total billed charges,All Other Outpatient,539.2,80,,539.2,percent of total billed charges,All Other Outpatient,559.42,83,,559.42,percent of total billed charges,All Other Outpatient,606.6,90,,606.6,percent of total billed charges,All Other,471.8,70,,471.8,percent of total billed charges,All Other,77.55,,,77.55,Fee Schedule,,65.8,,,65.8,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,62.62,,,62.62,Other,New York Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,95.8,,,95.8,Other,153% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,87.66,,,87.66,Other,140% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,162.81,,,162.81,Other,260% Medicaid APG methodology,202.88,,,202.88,Other,324% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,78.27,,,78.27,Other,125% Medicaid APG methodology,54.93,3567,
FETAL CORD PUNCTURE PRENATAL    ,59012,CPT,,48301196,CDM,761,RC,,,both,,,2622,610.06,,,610.06,Other,150% of Medicare + 9.63% HCRA Surcharge,370.98,,,370.98,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1311,50,,1311,percent of total billed charges,All Other,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper,1782.96,68,,1782.96,percent of total billed charges,All Other Outpatient,1560.74,,,1560.74,Other,186% Medicaid methodology,2097.6,80,,2097.6,percent of total billed charges,All Other Outpatient,2176.26,83,,2176.26,percent of total billed charges,All Other Outpatient,2176.26,83,,2176.26,percent of total billed charges,All Other Outpatient,2097.6,80,,2097.6,percent of total billed charges,All Other Outpatient,2176.26,83,,2176.26,percent of total billed charges,All Other Outpatient,2359.8,90,,2359.8,percent of total billed charges,All Other,1835.4,70,,1835.4,percent of total billed charges,All Other,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,839.11,,,839.11,Other,New York Medicaid APG methodology,839.11,,,839.11,Other,100% Medicaid APG methodology,839.11,,,839.11,Other,100% Medicaid APG methodology,839.11,,,839.11,Other,100% Medicaid APG methodology,1888,,,1888,Other,225% Medicaid APG methodology,1888,,,1888,Other,225% Medicaid APG methodology,1283.84,,,1283.84,Other,153% Medicaid APG methodology,1888,,,1888,Other,225% Medicaid APG methodology,1174.75,,,1174.75,Other,140% Medicaid APG methodology,1888,,,1888,Other,225% Medicaid APG methodology,2181.69,,,2181.69,Other,260% Medicaid APG methodology,2718.72,,,2718.72,Other,324% Medicaid APG methodology,1804.09,,,1804.09,Other,215% Medicaid APG methodology,1804.09,,,1804.09,Other,215% Medicaid APG methodology,1048.89,,,1048.89,Other,125% Medicaid APG methodology,0.01,13157,
INSERT CERVICAL DILATOR         ,59200,CPT,,48301832,CDM,761,RC,,,both,,,2831,610.06,,,610.06,Other,150% of Medicare + 9.63% HCRA Surcharge,370.98,,,370.98,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1415.5,50,,1415.5,percent of total billed charges,All Other,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,1925.08,68,,1925.08,percent of total billed charges,All Other Outpatient,1560.74,,,1560.74,Other,186% Medicaid methodology,2264.8,80,,2264.8,percent of total billed charges,All Other Outpatient,2349.73,83,,2349.73,percent of total billed charges,All Other Outpatient,2349.73,83,,2349.73,percent of total billed charges,All Other Outpatient,2264.8,80,,2264.8,percent of total billed charges,All Other Outpatient,2349.73,83,,2349.73,percent of total billed charges,All Other Outpatient,2547.9,90,,2547.9,percent of total billed charges,All Other,1981.7,70,,1981.7,percent of total billed charges,All Other,216.15,,,216.15,Fee Schedule,,183.4,,,183.4,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,839.11,,,839.11,Other,New York Medicaid APG methodology,839.11,,,839.11,Other,100% Medicaid APG methodology,839.11,,,839.11,Other,100% Medicaid APG methodology,839.11,,,839.11,Other,100% Medicaid APG methodology,1888,,,1888,Other,225% Medicaid APG methodology,1888,,,1888,Other,225% Medicaid APG methodology,1283.84,,,1283.84,Other,153% Medicaid APG methodology,1888,,,1888,Other,225% Medicaid APG methodology,1174.75,,,1174.75,Other,140% Medicaid APG methodology,1888,,,1888,Other,225% Medicaid APG methodology,2181.69,,,2181.69,Other,260% Medicaid APG methodology,2718.72,,,2718.72,Other,324% Medicaid APG methodology,1804.09,,,1804.09,Other,215% Medicaid APG methodology,1804.09,,,1804.09,Other,215% Medicaid APG methodology,1048.89,,,1048.89,Other,125% Medicaid APG methodology,183.4,4343,
DECLOT VASCULAR DEVICE          ,36593,CPT,,48400279,CDM,761,RC,,,both,,,1025,644.03,,,644.03,Other,150% of Medicare + 9.63% HCRA Surcharge,391.64,,,391.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,512.5,50,,512.5,percent of total billed charges,All Other,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper,697,68,,697,percent of total billed charges,All Other Outpatient,577.69,,,577.69,Other,186% Medicaid methodology,820,80,,820,percent of total billed charges,All Other Outpatient,850.75,83,,850.75,percent of total billed charges,All Other Outpatient,850.75,83,,850.75,percent of total billed charges,All Other Outpatient,820,80,,820,percent of total billed charges,All Other Outpatient,850.75,83,,850.75,percent of total billed charges,All Other Outpatient,922.5,90,,922.5,percent of total billed charges,All Other,717.5,70,,717.5,percent of total billed charges,All Other,160.05,,,160.05,Fee Schedule,,135.8,,,135.8,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,310.58,,,310.58,Other,New York Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,475.19,,,475.19,Other,153% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,434.82,,,434.82,Other,140% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,807.52,,,807.52,Other,260% Medicaid APG methodology,1006.29,,,1006.29,Other,324% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,388.23,,,388.23,Other,125% Medicaid APG methodology,0.01,4343,
APHERESIS WBC                   ,36511,CPT,,48401251,CDM,761,RC,,,both,,,4838,2917.74,,,2917.74,Other,150% of Medicare + 9.63% HCRA Surcharge,1774.3,,,1774.3,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,2419,50,,2419,percent of total billed charges,All Other,3386.6,70,,3386.6,percent of total billed charges,All Other,3289.84,68,,3289.84,percent of total billed charges,All Other Outpatient,4580.06,,,4580.06,Other,186% Medicaid methodology,3870.4,80,,3870.4,percent of total billed charges,All Other Outpatient,4015.54,83,,4015.54,percent of total billed charges,All Other Outpatient,4015.54,83,,4015.54,percent of total billed charges,All Other Outpatient,3870.4,80,,3870.4,percent of total billed charges,All Other Outpatient,4015.54,83,,4015.54,percent of total billed charges,All Other Outpatient,4354.2,90,,4354.2,percent of total billed charges,All Other,3386.6,70,,3386.6,percent of total billed charges,All Other,526.35,,,526.35,Fee Schedule,,446.6,,,446.6,Fee Schedule,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2462.4,,,2462.4,Other,New York Medicaid APG methodology,2462.4,,,2462.4,Other,100% Medicaid APG methodology,2462.4,,,2462.4,Other,100% Medicaid APG methodology,2462.4,,,2462.4,Other,100% Medicaid APG methodology,5540.39,,,5540.39,Other,225% Medicaid APG methodology,5540.39,,,5540.39,Other,225% Medicaid APG methodology,3767.47,,,3767.47,Other,153% Medicaid APG methodology,5540.39,,,5540.39,Other,225% Medicaid APG methodology,3447.35,,,3447.35,Other,140% Medicaid APG methodology,5540.39,,,5540.39,Other,225% Medicaid APG methodology,6402.23,,,6402.23,Other,260% Medicaid APG methodology,7978.16,,,7978.16,Other,324% Medicaid APG methodology,5294.15,,,5294.15,Other,215% Medicaid APG methodology,5294.15,,,5294.15,Other,215% Medicaid APG methodology,3077.99,,,3077.99,Other,125% Medicaid APG methodology,446.6,7978.16,
APHERESIS RBC                   ,36512,CPT,,48401269,CDM,761,RC,,,both,,,4838,2917.74,,,2917.74,Other,150% of Medicare + 9.63% HCRA Surcharge,1774.3,,,1774.3,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,2419,50,,2419,percent of total billed charges,All Other,3386.6,70,,3386.6,percent of total billed charges,All Other,3289.84,68,,3289.84,percent of total billed charges,All Other Outpatient,4580.06,,,4580.06,Other,186% Medicaid methodology,3870.4,80,,3870.4,percent of total billed charges,All Other Outpatient,4015.54,83,,4015.54,percent of total billed charges,All Other Outpatient,4015.54,83,,4015.54,percent of total billed charges,All Other Outpatient,3870.4,80,,3870.4,percent of total billed charges,All Other Outpatient,4015.54,83,,4015.54,percent of total billed charges,All Other Outpatient,4354.2,90,,4354.2,percent of total billed charges,All Other,3386.6,70,,3386.6,percent of total billed charges,All Other,514.8,,,514.8,Fee Schedule,,436.8,,,436.8,Fee Schedule,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2462.4,,,2462.4,Other,New York Medicaid APG methodology,2462.4,,,2462.4,Other,100% Medicaid APG methodology,2462.4,,,2462.4,Other,100% Medicaid APG methodology,2462.4,,,2462.4,Other,100% Medicaid APG methodology,5540.39,,,5540.39,Other,225% Medicaid APG methodology,5540.39,,,5540.39,Other,225% Medicaid APG methodology,3767.47,,,3767.47,Other,153% Medicaid APG methodology,5540.39,,,5540.39,Other,225% Medicaid APG methodology,3447.35,,,3447.35,Other,140% Medicaid APG methodology,5540.39,,,5540.39,Other,225% Medicaid APG methodology,6402.23,,,6402.23,Other,260% Medicaid APG methodology,7978.16,,,7978.16,Other,324% Medicaid APG methodology,5294.15,,,5294.15,Other,215% Medicaid APG methodology,5294.15,,,5294.15,Other,215% Medicaid APG methodology,3077.99,,,3077.99,Other,125% Medicaid APG methodology,436.8,7978.16,
APHERESIS PLATELETS             ,36513,CPT,,48401277,CDM,761,RC,,,both,,,1840,825.51,,,825.51,Other,150% of Medicare + 9.63% HCRA Surcharge,502,,,502,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,920,50,,920,percent of total billed charges,All Other,1288,70,,1288,percent of total billed charges,All Other,1251.2,68,,1251.2,percent of total billed charges,All Other Outpatient,4580.06,,,4580.06,Other,186% Medicaid methodology,1472,80,,1472,percent of total billed charges,All Other Outpatient,1527.2,83,,1527.2,percent of total billed charges,All Other Outpatient,1527.2,83,,1527.2,percent of total billed charges,All Other Outpatient,1472,80,,1472,percent of total billed charges,All Other Outpatient,1527.2,83,,1527.2,percent of total billed charges,All Other Outpatient,1656,90,,1656,percent of total billed charges,All Other,1288,70,,1288,percent of total billed charges,All Other,513.15,,,513.15,Fee Schedule,,435.4,,,435.4,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,2462.4,,,2462.4,Other,New York Medicaid APG methodology,2462.4,,,2462.4,Other,100% Medicaid APG methodology,2462.4,,,2462.4,Other,100% Medicaid APG methodology,2462.4,,,2462.4,Other,100% Medicaid APG methodology,5540.39,,,5540.39,Other,225% Medicaid APG methodology,5540.39,,,5540.39,Other,225% Medicaid APG methodology,3767.47,,,3767.47,Other,153% Medicaid APG methodology,5540.39,,,5540.39,Other,225% Medicaid APG methodology,3447.35,,,3447.35,Other,140% Medicaid APG methodology,5540.39,,,5540.39,Other,225% Medicaid APG methodology,6402.23,,,6402.23,Other,260% Medicaid APG methodology,7978.16,,,7978.16,Other,324% Medicaid APG methodology,5294.15,,,5294.15,Other,215% Medicaid APG methodology,5294.15,,,5294.15,Other,215% Medicaid APG methodology,3077.99,,,3077.99,Other,125% Medicaid APG methodology,435.4,7978.16,
APHERESIS PLASMA                ,36514,CPT,,48401285,CDM,761,RC,,,both,,,4838,2917.74,,,2917.74,Other,150% of Medicare + 9.63% HCRA Surcharge,1774.3,,,1774.3,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,2419,50,,2419,percent of total billed charges,All Other,3386.6,70,,3386.6,percent of total billed charges,All Other,3289.84,68,,3289.84,percent of total billed charges,All Other Outpatient,4580.06,,,4580.06,Other,186% Medicaid methodology,3870.4,80,,3870.4,percent of total billed charges,All Other Outpatient,4015.54,83,,4015.54,percent of total billed charges,All Other Outpatient,4015.54,83,,4015.54,percent of total billed charges,All Other Outpatient,3870.4,80,,3870.4,percent of total billed charges,All Other Outpatient,4015.54,83,,4015.54,percent of total billed charges,All Other Outpatient,4354.2,90,,4354.2,percent of total billed charges,All Other,3386.6,70,,3386.6,percent of total billed charges,All Other,452.1,,,452.1,Fee Schedule,,383.6,,,383.6,Fee Schedule,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2462.4,,,2462.4,Other,New York Medicaid APG methodology,2462.4,,,2462.4,Other,100% Medicaid APG methodology,2462.4,,,2462.4,Other,100% Medicaid APG methodology,2462.4,,,2462.4,Other,100% Medicaid APG methodology,5540.39,,,5540.39,Other,225% Medicaid APG methodology,5540.39,,,5540.39,Other,225% Medicaid APG methodology,3767.47,,,3767.47,Other,153% Medicaid APG methodology,5540.39,,,5540.39,Other,225% Medicaid APG methodology,3447.35,,,3447.35,Other,140% Medicaid APG methodology,5540.39,,,5540.39,Other,225% Medicaid APG methodology,6402.23,,,6402.23,Other,260% Medicaid APG methodology,7978.16,,,7978.16,Other,324% Medicaid APG methodology,5294.15,,,5294.15,Other,215% Medicaid APG methodology,5294.15,,,5294.15,Other,215% Medicaid APG methodology,3077.99,,,3077.99,Other,125% Medicaid APG methodology,383.6,7978.16,
HARVEST AUTO STEM CELLS         ,38206,CPT,,48401319,CDM,761,RC,,,both,,,4838,2917.74,,,2917.74,Other,150% of Medicare + 9.63% HCRA Surcharge,1774.3,,,1774.3,Other,Medicare OPPS methodology,2419,50,,2419,percent of total billed charges,All Other Outpatient,2177.1,45,,2177.1,percent of total billed charges,All Other Outpatient,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,2419,50,,2419,percent of total billed charges,All Other,3386.6,70,,3386.6,percent of total billed charges,All Other,3289.84,68,,3289.84,percent of total billed charges,All Other Outpatient,4136.45,,,4136.45,Other,186% Medicaid methodology,3870.4,80,,3870.4,percent of total billed charges,All Other Outpatient,4015.54,83,,4015.54,percent of total billed charges,All Other Outpatient,4015.54,83,,4015.54,percent of total billed charges,All Other Outpatient,3870.4,80,,3870.4,percent of total billed charges,All Other Outpatient,4015.54,83,,4015.54,percent of total billed charges,All Other Outpatient,4354.2,90,,4354.2,percent of total billed charges,All Other,3386.6,70,,3386.6,percent of total billed charges,All Other,409.2,,,409.2,Fee Schedule,,347.2,,,347.2,Fee Schedule,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2223.9,,,2223.9,Other,New York Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,3402.56,,,3402.56,Other,153% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,3113.46,,,3113.46,Other,140% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,5782.13,,,5782.13,Other,260% Medicaid APG methodology,7205.43,,,7205.43,Other,324% Medicaid APG methodology,4781.38,,,4781.38,Other,215% Medicaid APG methodology,4781.38,,,4781.38,Other,215% Medicaid APG methodology,2779.87,,,2779.87,Other,125% Medicaid APG methodology,347.2,7205.43,
TRANSPLT ALLO LYMPHOCYTES       ,38242,CPT,,48401434,CDM,761,RC,,,both,,,4838,2917.74,,,2917.74,Other,150% of Medicare + 9.63% HCRA Surcharge,1774.3,,,1774.3,Other,Medicare OPPS methodology,2419,50,,2419,percent of total billed charges,All Other Outpatient,2177.1,45,,2177.1,percent of total billed charges,All Other Outpatient,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,2419,50,,2419,percent of total billed charges,All Other,3386.6,70,,3386.6,percent of total billed charges,All Other,3289.84,68,,3289.84,percent of total billed charges,All Other Outpatient,4580.06,,,4580.06,Other,186% Medicaid methodology,3870.4,80,,3870.4,percent of total billed charges,All Other Outpatient,4015.54,83,,4015.54,percent of total billed charges,All Other Outpatient,4015.54,83,,4015.54,percent of total billed charges,All Other Outpatient,3870.4,80,,3870.4,percent of total billed charges,All Other Outpatient,4015.54,83,,4015.54,percent of total billed charges,All Other Outpatient,4354.2,90,,4354.2,percent of total billed charges,All Other,3386.6,70,,3386.6,percent of total billed charges,All Other,610.5,,,610.5,Fee Schedule,,518,,,518,Fee Schedule,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2462.4,,,2462.4,Other,New York Medicaid APG methodology,2462.4,,,2462.4,Other,100% Medicaid APG methodology,2462.4,,,2462.4,Other,100% Medicaid APG methodology,2462.4,,,2462.4,Other,100% Medicaid APG methodology,5540.39,,,5540.39,Other,225% Medicaid APG methodology,5540.39,,,5540.39,Other,225% Medicaid APG methodology,3767.47,,,3767.47,Other,153% Medicaid APG methodology,5540.39,,,5540.39,Other,225% Medicaid APG methodology,3447.35,,,3447.35,Other,140% Medicaid APG methodology,5540.39,,,5540.39,Other,225% Medicaid APG methodology,6402.23,,,6402.23,Other,260% Medicaid APG methodology,7978.16,,,7978.16,Other,324% Medicaid APG methodology,5294.15,,,5294.15,Other,215% Medicaid APG methodology,5294.15,,,5294.15,Other,215% Medicaid APG methodology,3077.99,,,3077.99,Other,125% Medicaid APG methodology,518,7978.16,
BLOOD TRANSFUSION SERVICE       ,36430,CPT,,48401731,CDM,761,RC,,,both,,,3124,825.51,,,825.51,Other,150% of Medicare + 9.63% HCRA Surcharge,502,,,502,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1562,50,,1562,percent of total billed charges,All Other,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,2124.32,68,,2124.32,percent of total billed charges,All Other Outpatient,1373.44,,,1373.44,Other,186% Medicaid methodology,2499.2,80,,2499.2,percent of total billed charges,All Other Outpatient,2592.92,83,,2592.92,percent of total billed charges,All Other Outpatient,2592.92,83,,2592.92,percent of total billed charges,All Other Outpatient,2499.2,80,,2499.2,percent of total billed charges,All Other Outpatient,2592.92,83,,2592.92,percent of total billed charges,All Other Outpatient,2811.6,90,,2811.6,percent of total billed charges,All Other,2186.8,70,,2186.8,percent of total billed charges,All Other,186.45,,,186.45,Fee Schedule,,158.2,,,158.2,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,738.41,,,738.41,Other,New York Medicaid APG methodology,738.41,,,738.41,Other,100% Medicaid APG methodology,738.41,,,738.41,Other,100% Medicaid APG methodology,738.41,,,738.41,Other,100% Medicaid APG methodology,1661.41,,,1661.41,Other,225% Medicaid APG methodology,1661.41,,,1661.41,Other,225% Medicaid APG methodology,1129.76,,,1129.76,Other,153% Medicaid APG methodology,1661.41,,,1661.41,Other,225% Medicaid APG methodology,1033.77,,,1033.77,Other,140% Medicaid APG methodology,1661.41,,,1661.41,Other,225% Medicaid APG methodology,1919.86,,,1919.86,Other,260% Medicaid APG methodology,2392.44,,,2392.44,Other,324% Medicaid APG methodology,1587.57,,,1587.57,Other,215% Medicaid APG methodology,1587.57,,,1587.57,Other,215% Medicaid APG methodology,923.01,,,923.01,Other,125% Medicaid APG methodology,158.2,4343,
PHOTOPHERESIS                   ,36522,CPT,,48402788,CDM,761,RC,,,both,,,14801,8800.46,,,8800.46,Other,150% of Medicare + 9.63% HCRA Surcharge,5351.62,,,5351.62,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,7400.5,50,,7400.5,percent of total billed charges,All Other,10360.7,70,,10360.7,percent of total billed charges,All Other,10064.68,68,,10064.68,percent of total billed charges,All Other Outpatient,4580.05,,,4580.05,Other,186% Medicaid methodology,11840.8,80,,11840.8,percent of total billed charges,All Other Outpatient,12284.83,83,,12284.83,percent of total billed charges,All Other Outpatient,12284.83,83,,12284.83,percent of total billed charges,All Other Outpatient,11840.8,80,,11840.8,percent of total billed charges,All Other Outpatient,12284.83,83,,12284.83,percent of total billed charges,All Other Outpatient,13320.9,90,,13320.9,percent of total billed charges,All Other,10360.7,70,,10360.7,percent of total billed charges,All Other,466.95,,,466.95,Fee Schedule,,396.2,,,396.2,Fee Schedule,,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2462.39,,,2462.39,Other,New York Medicaid APG methodology,2462.39,,,2462.39,Other,100% Medicaid APG methodology,2462.39,,,2462.39,Other,100% Medicaid APG methodology,2462.39,,,2462.39,Other,100% Medicaid APG methodology,5540.38,,,5540.38,Other,225% Medicaid APG methodology,5540.38,,,5540.38,Other,225% Medicaid APG methodology,3767.46,,,3767.46,Other,153% Medicaid APG methodology,5540.38,,,5540.38,Other,225% Medicaid APG methodology,3447.35,,,3447.35,Other,140% Medicaid APG methodology,5540.38,,,5540.38,Other,225% Medicaid APG methodology,6402.21,,,6402.21,Other,260% Medicaid APG methodology,7978.14,,,7978.14,Other,324% Medicaid APG methodology,5294.14,,,5294.14,Other,215% Medicaid APG methodology,5294.14,,,5294.14,Other,215% Medicaid APG methodology,3077.99,,,3077.99,Other,125% Medicaid APG methodology,396.2,13320.9,
DRAIN BL W/CATH INSERTION       ,51102,CPT,,50055219,CDM,761,RC,,,both,,,6151,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,3075.5,50,,3075.5,percent of total billed charges,All Other,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,4182.68,68,,4182.68,percent of total billed charges,All Other Outpatient,3289.6,,,3289.6,Other,186% Medicaid methodology,4920.8,80,,4920.8,percent of total billed charges,All Other Outpatient,5105.33,83,,5105.33,percent of total billed charges,All Other Outpatient,5105.33,83,,5105.33,percent of total billed charges,All Other Outpatient,4920.8,80,,4920.8,percent of total billed charges,All Other Outpatient,5105.33,83,,5105.33,percent of total billed charges,All Other Outpatient,5535.9,90,,5535.9,percent of total billed charges,All Other,4305.7,70,,4305.7,percent of total billed charges,All Other,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1768.6,,,1768.6,Other,New York Medicaid APG methodology,1768.6,,,1768.6,Other,100% Medicaid APG methodology,1768.6,,,1768.6,Other,100% Medicaid APG methodology,1768.6,,,1768.6,Other,100% Medicaid APG methodology,3979.36,,,3979.36,Other,225% Medicaid APG methodology,3979.36,,,3979.36,Other,225% Medicaid APG methodology,2705.96,,,2705.96,Other,153% Medicaid APG methodology,3979.36,,,3979.36,Other,225% Medicaid APG methodology,2476.04,,,2476.04,Other,140% Medicaid APG methodology,3979.36,,,3979.36,Other,225% Medicaid APG methodology,4598.37,,,4598.37,Other,260% Medicaid APG methodology,5730.27,,,5730.27,Other,324% Medicaid APG methodology,3802.5,,,3802.5,Other,215% Medicaid APG methodology,3802.5,,,3802.5,Other,215% Medicaid APG methodology,2210.75,,,2210.75,Other,125% Medicaid APG methodology,1768.6,13157,
HOSPITAL OBSERVATION PER HR     , G0378 ,HCPCS,,"50,057,819.00",CDM,762,RC,,,both,,,787,0.01,,,0.01,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,7173,,,7173,Case Rate,Observation Visit,6456,,,6456,Case Rate,Observation Visit,8858,,,8858,Case Rate,Observation Visit,7972,,,7972,Case Rate,Observation Visit,7529,,,7529,Case Rate,Observation Visit,393.5,50,,393.5,percent of total billed charges,All Other,6731,,,6731,Case Rate,Observation Visit,535.16,68,,535.16,percent of total billed charges,All Other Outpatient,98.07,,,98.07,Other,186% Medicaid methodology,629.6,80,,629.6,percent of total billed charges,All Other Outpatient,653.21,83,,653.21,percent of total billed charges,All Other Outpatient,653.21,83,,653.21,percent of total billed charges,All Other Outpatient,629.6,80,,629.6,percent of total billed charges,All Other Outpatient,653.21,83,,653.21,percent of total billed charges,All Other Outpatient,2166,,,2166,Case Rate,ED Visit,550.9,70,,550.9,percent of total billed charges,All Other,7308,,,7308,Case Rate,Observation Visit,6212,,,6212,Case Rate,Observation Visit,2425,,,2425,Case Rate,Observation Visit,5610,,,5610,Case Rate,Observation Visit,5013,,,5013,Case Rate,Observation Visit,5298,,,5298,Case Rate,Observation Visit,52.73,,,52.73,Other,New York Medicaid APG methodology,52.73,,,52.73,Other,100% Medicaid APG methodology,52.73,,,52.73,Other,100% Medicaid APG methodology,52.73,,,52.73,Other,100% Medicaid APG methodology,118.64,,,118.64,Other,225% Medicaid APG methodology,118.64,,,118.64,Other,225% Medicaid APG methodology,80.67,,,80.67,Other,153% Medicaid APG methodology,118.64,,,118.64,Other,225% Medicaid APG methodology,73.82,,,73.82,Other,140% Medicaid APG methodology,118.64,,,118.64,Other,225% Medicaid APG methodology,137.09,,,137.09,Other,260% Medicaid APG methodology,170.83,,,170.83,Other,324% Medicaid APG methodology,113.36,,,113.36,Other,215% Medicaid APG methodology,113.36,,,113.36,Other,215% Medicaid APG methodology,65.91,,,65.91,Other,125% Medicaid APG methodology,0.01,8858,
IMMUNE ADMIN EACH ADD           ,90472,CPT,,40800435,CDM,771,RC,,,both,,,127,50.12,,,50.12,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,63.5,50,,63.5,percent of total billed charges,All Other Outpatient,57.15,45,,57.15,percent of total billed charges,All Other Outpatient,63.5,50,,63.5,percent of total billed charges,All Other Outpatient,57.15,45,,57.15,percent of total billed charges,All Other Outpatient,54.61,43,,54.61,percent of total billed charges,All Other Outpatient,63.5,50,,63.5,percent of total billed charges,All Other,88.9,70,,88.9,percent of total billed charges,All Other,53.11,,,53.11,Fee Schedule,,71.04,,,71.04,Other,186% Medicaid methodology,62.55,,,62.55,Fee Schedule,,78.74,62,,78.74,percent of total billed charges,All Other Outpatient,35.41,,,35.41,Fee Schedule,,62.55,,,62.55,Fee Schedule,,78.74,62,,78.74,percent of total billed charges,All Other Outpatient,114.3,90,,114.3,percent of total billed charges,All Other,88.9,70,,88.9,percent of total billed charges,All Other,61.05,,,61.05,Fee Schedule,,51.8,,,51.8,Fee Schedule,,300,,,300,Case Rate,Vaccine Admin Per Visit,238,,,238,Case Rate,Vaccine Admin Per Visit,263,,,263,Case Rate,Vaccine Admin Per Visit,224,,,224,Case Rate,Vaccine Admin Per Visit,38.19,,,38.19,Other,New York Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,58.44,,,58.44,Other,153% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,53.47,,,53.47,Other,140% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,99.3,,,99.3,Other,260% Medicaid APG methodology,123.75,,,123.75,Other,324% Medicaid APG methodology,82.12,,,82.12,Other,215% Medicaid APG methodology,82.12,,,82.12,Other,215% Medicaid APG methodology,47.74,,,47.74,Other,125% Medicaid APG methodology,0.01,300,
IMMUNE ADMIN                    ,90471,CPT,,40800708,CDM,771,RC,,,both,,,165,133.96,,,133.96,Other,150% of Medicare + 9.63% HCRA Surcharge,81.46,,,81.46,Other,Medicare OPPS methodology,82.5,50,,82.5,percent of total billed charges,All Other Outpatient,74.25,45,,74.25,percent of total billed charges,All Other Outpatient,82.5,50,,82.5,percent of total billed charges,All Other Outpatient,74.25,45,,74.25,percent of total billed charges,All Other Outpatient,70.95,43,,70.95,percent of total billed charges,All Other Outpatient,82.5,50,,82.5,percent of total billed charges,All Other,115.5,70,,115.5,percent of total billed charges,All Other,75.1,,,75.1,Fee Schedule,,71.04,,,71.04,Other,186% Medicaid methodology,88.45,,,88.45,Fee Schedule,,102.3,62,,102.3,percent of total billed charges,All Other Outpatient,50.06,,,50.06,Fee Schedule,,88.45,,,88.45,Fee Schedule,,102.3,62,,102.3,percent of total billed charges,All Other Outpatient,148.5,90,,148.5,percent of total billed charges,All Other,115.5,70,,115.5,percent of total billed charges,All Other,80.85,,,80.85,Fee Schedule,,68.6,,,68.6,Fee Schedule,,300,,,300,Case Rate,Vaccine Admin Per Visit,238,,,238,Case Rate,Vaccine Admin Per Visit,263,,,263,Case Rate,Vaccine Admin Per Visit,224,,,224,Case Rate,Vaccine Admin Per Visit,38.19,,,38.19,Other,New York Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,58.44,,,58.44,Other,153% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,53.47,,,53.47,Other,140% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,99.3,,,99.3,Other,260% Medicaid APG methodology,123.75,,,123.75,Other,324% Medicaid APG methodology,82.12,,,82.12,Other,215% Medicaid APG methodology,82.12,,,82.12,Other,215% Medicaid APG methodology,47.74,,,47.74,Other,125% Medicaid APG methodology,38.19,300,
ADMIN HEPATITIS B VACCINE       ,G0010,HCPCS,,40800880,CDM,771,RC,,,both,,,418,90.33,,,90.33,Other,150% of Medicare + 9.63% HCRA Surcharge,54.93,,,54.93,Other,Medicare OPPS methodology,209,50,,209,percent of total billed charges,All Other Outpatient,188.1,45,,188.1,percent of total billed charges,All Other Outpatient,209,50,,209,percent of total billed charges,All Other Outpatient,188.1,45,,188.1,percent of total billed charges,All Other Outpatient,179.74,43,,179.74,percent of total billed charges,All Other Outpatient,209,50,,209,percent of total billed charges,All Other,292.6,70,,292.6,percent of total billed charges,All Other,284.24,68,,284.24,percent of total billed charges,All Other Outpatient,71.04,,,71.04,Other,186% Medicaid methodology,334.4,80,,334.4,percent of total billed charges,All Other Outpatient,346.94,83,,346.94,percent of total billed charges,All Other Outpatient,346.94,83,,346.94,percent of total billed charges,All Other Outpatient,334.4,80,,334.4,percent of total billed charges,All Other Outpatient,346.94,83,,346.94,percent of total billed charges,All Other Outpatient,376.2,90,,376.2,percent of total billed charges,All Other,292.6,70,,292.6,percent of total billed charges,All Other,209,50,,209,percent of total billed charges,All Other,209,50,,209,percent of total billed charges,All Other,300,,,300,Case Rate,Vaccine Admin Per Visit,238,,,238,Case Rate,Vaccine Admin Per Visit,263,,,263,Case Rate,Vaccine Admin Per Visit,224,,,224,Case Rate,Vaccine Admin Per Visit,38.19,,,38.19,Other,New York Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,58.44,,,58.44,Other,153% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,53.47,,,53.47,Other,140% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,99.3,,,99.3,Other,260% Medicaid APG methodology,123.75,,,123.75,Other,324% Medicaid APG methodology,82.12,,,82.12,Other,215% Medicaid APG methodology,82.12,,,82.12,Other,215% Medicaid APG methodology,47.74,,,47.74,Other,125% Medicaid APG methodology,38.19,376.2,
IMMUNE ADMIN PNEUMOCOCCAL       ,90471,CPT,,40800948,CDM,771,RC,,,both,,,132,90.33,,,90.33,Other,150% of Medicare + 9.63% HCRA Surcharge,54.93,,,54.93,Other,Medicare OPPS methodology,66,50,,66,percent of total billed charges,All Other Outpatient,59.4,45,,59.4,percent of total billed charges,All Other Outpatient,66,50,,66,percent of total billed charges,All Other Outpatient,59.4,45,,59.4,percent of total billed charges,All Other Outpatient,56.76,43,,56.76,percent of total billed charges,All Other Outpatient,66,50,,66,percent of total billed charges,All Other,92.4,70,,92.4,percent of total billed charges,All Other,75.1,,,75.1,Fee Schedule,,71.04,,,71.04,Other,186% Medicaid methodology,88.45,,,88.45,Fee Schedule,,81.84,62,,81.84,percent of total billed charges,All Other Outpatient,50.06,,,50.06,Fee Schedule,,88.45,,,88.45,Fee Schedule,,81.84,62,,81.84,percent of total billed charges,All Other Outpatient,118.8,90,,118.8,percent of total billed charges,All Other,92.4,70,,92.4,percent of total billed charges,All Other,80.85,,,80.85,Fee Schedule,,68.6,,,68.6,Fee Schedule,,300,,,300,Case Rate,Vaccine Admin Per Visit,238,,,238,Case Rate,Vaccine Admin Per Visit,263,,,263,Case Rate,Vaccine Admin Per Visit,224,,,224,Case Rate,Vaccine Admin Per Visit,38.19,,,38.19,Other,New York Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,58.44,,,58.44,Other,153% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,53.47,,,53.47,Other,140% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,99.3,,,99.3,Other,260% Medicaid APG methodology,123.75,,,123.75,Other,324% Medicaid APG methodology,82.12,,,82.12,Other,215% Medicaid APG methodology,82.12,,,82.12,Other,215% Medicaid APG methodology,47.74,,,47.74,Other,125% Medicaid APG methodology,38.19,300,
IMMUNE ADMIN FLU                ,90471,CPT,,40800955,CDM,771,RC,,,both,,,132,90.33,,,90.33,Other,150% of Medicare + 9.63% HCRA Surcharge,54.93,,,54.93,Other,Medicare OPPS methodology,66,50,,66,percent of total billed charges,All Other Outpatient,59.4,45,,59.4,percent of total billed charges,All Other Outpatient,66,50,,66,percent of total billed charges,All Other Outpatient,59.4,45,,59.4,percent of total billed charges,All Other Outpatient,56.76,43,,56.76,percent of total billed charges,All Other Outpatient,66,50,,66,percent of total billed charges,All Other,92.4,70,,92.4,percent of total billed charges,All Other,75.1,,,75.1,Fee Schedule,,71.04,,,71.04,Other,186% Medicaid methodology,88.45,,,88.45,Fee Schedule,,81.84,62,,81.84,percent of total billed charges,All Other Outpatient,50.06,,,50.06,Fee Schedule,,88.45,,,88.45,Fee Schedule,,81.84,62,,81.84,percent of total billed charges,All Other Outpatient,118.8,90,,118.8,percent of total billed charges,All Other,92.4,70,,92.4,percent of total billed charges,All Other,80.85,,,80.85,Fee Schedule,,68.6,,,68.6,Fee Schedule,,300,,,300,Case Rate,Vaccine Admin Per Visit,238,,,238,Case Rate,Vaccine Admin Per Visit,263,,,263,Case Rate,Vaccine Admin Per Visit,224,,,224,Case Rate,Vaccine Admin Per Visit,38.19,,,38.19,Other,New York Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,58.44,,,58.44,Other,153% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,53.47,,,53.47,Other,140% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,99.3,,,99.3,Other,260% Medicaid APG methodology,123.75,,,123.75,Other,324% Medicaid APG methodology,82.12,,,82.12,Other,215% Medicaid APG methodology,82.12,,,82.12,Other,215% Medicaid APG methodology,47.74,,,47.74,Other,125% Medicaid APG methodology,38.19,300,
CASIRIVI AND IMDEVI INFUSION    ,M0243,HCPCS,,40801029,CDM,771,RC,,,both,,,1876,899.14,,,899.14,Other,150% of Medicare + 9.63% HCRA Surcharge,546.77,,,546.77,Other,Medicare OPPS methodology,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,938,50,,938,percent of total billed charges,All Other Outpatient,844.2,45,,844.2,percent of total billed charges,All Other Outpatient,806.68,43,,806.68,percent of total billed charges,All Other Outpatient,938,50,,938,percent of total billed charges,All Other,309.6,,,309.6,Fee Schedule,,1275.68,68,,1275.68,percent of total billed charges,All Other Outpatient,577.69,,,577.69,Other,186% Medicaid methodology,1500.8,80,,1500.8,percent of total billed charges,All Other Outpatient,1557.08,83,,1557.08,percent of total billed charges,All Other Outpatient,1557.08,83,,1557.08,percent of total billed charges,All Other Outpatient,1500.8,80,,1500.8,percent of total billed charges,All Other Outpatient,1557.08,83,,1557.08,percent of total billed charges,All Other Outpatient,1688.4,90,,1688.4,percent of total billed charges,All Other,1313.2,70,,1313.2,percent of total billed charges,All Other,938,50,,938,percent of total billed charges,All Other,938,50,,938,percent of total billed charges,All Other,300,,,300,Case Rate,Vaccine Admin Per Visit,238,,,238,Case Rate,Vaccine Admin Per Visit,263,,,263,Case Rate,Vaccine Admin Per Visit,224,,,224,Case Rate,Vaccine Admin Per Visit,310.58,,,310.58,Other,New York Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,475.19,,,475.19,Other,153% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,434.82,,,434.82,Other,140% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,807.52,,,807.52,Other,260% Medicaid APG methodology,1006.29,,,1006.29,Other,324% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,388.23,,,388.23,Other,125% Medicaid APG methodology,224,1688.4,
BAMLAN AND ETESEV INFUSION      ,M0245,HCPCS,,40801037,CDM,771,RC,,,both,,,1876,899.14,,,899.14,Other,150% of Medicare + 9.63% HCRA Surcharge,546.77,,,546.77,Other,Medicare OPPS methodology,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,450,,,450,Fee Schedule,,450,,,450,Fee Schedule,,450,,,450,Fee Schedule,,938,50,,938,percent of total billed charges,All Other,309.6,,,309.6,Fee Schedule,,1275.68,68,,1275.68,percent of total billed charges,All Other Outpatient,577.69,,,577.69,Other,186% Medicaid methodology,1500.8,80,,1500.8,percent of total billed charges,All Other Outpatient,1557.08,83,,1557.08,percent of total billed charges,All Other Outpatient,1557.08,83,,1557.08,percent of total billed charges,All Other Outpatient,1500.8,80,,1500.8,percent of total billed charges,All Other Outpatient,1557.08,83,,1557.08,percent of total billed charges,All Other Outpatient,1688.4,90,,1688.4,percent of total billed charges,All Other,1313.2,70,,1313.2,percent of total billed charges,All Other,938,50,,938,percent of total billed charges,All Other,938,50,,938,percent of total billed charges,All Other,300,,,300,Case Rate,Vaccine Admin Per Visit,238,,,238,Case Rate,Vaccine Admin Per Visit,263,,,263,Case Rate,Vaccine Admin Per Visit,224,,,224,Case Rate,Vaccine Admin Per Visit,310.58,,,310.58,Other,New York Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,475.19,,,475.19,Other,153% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,434.82,,,434.82,Other,140% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,807.52,,,807.52,Other,260% Medicaid APG methodology,1006.29,,,1006.29,Other,324% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,388.23,,,388.23,Other,125% Medicaid APG methodology,224,1688.4,
ADMIN PNEUMOCOCCAL VACCINE      ,G0009,HCPCS,,48301634,CDM,771,RC,,,both,,,132,90.33,,,90.33,Other,150% of Medicare + 9.63% HCRA Surcharge,54.93,,,54.93,Other,Medicare OPPS methodology,66,50,,66,percent of total billed charges,All Other Outpatient,59.4,45,,59.4,percent of total billed charges,All Other Outpatient,66,50,,66,percent of total billed charges,All Other Outpatient,59.4,45,,59.4,percent of total billed charges,All Other Outpatient,56.76,43,,56.76,percent of total billed charges,All Other Outpatient,66,50,,66,percent of total billed charges,All Other,92.4,70,,92.4,percent of total billed charges,All Other,89.76,68,,89.76,percent of total billed charges,All Other Outpatient,71.04,,,71.04,Other,186% Medicaid methodology,105.6,80,,105.6,percent of total billed charges,All Other Outpatient,109.56,83,,109.56,percent of total billed charges,All Other Outpatient,109.56,83,,109.56,percent of total billed charges,All Other Outpatient,105.6,80,,105.6,percent of total billed charges,All Other Outpatient,109.56,83,,109.56,percent of total billed charges,All Other Outpatient,118.8,90,,118.8,percent of total billed charges,All Other,92.4,70,,92.4,percent of total billed charges,All Other,80.85,,,80.85,Fee Schedule,,68.6,,,68.6,Fee Schedule,,300,,,300,Case Rate,Vaccine Admin Per Visit,238,,,238,Case Rate,Vaccine Admin Per Visit,263,,,263,Case Rate,Vaccine Admin Per Visit,224,,,224,Case Rate,Vaccine Admin Per Visit,38.19,,,38.19,Other,New York Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,58.44,,,58.44,Other,153% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,53.47,,,53.47,Other,140% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,99.3,,,99.3,Other,260% Medicaid APG methodology,123.75,,,123.75,Other,324% Medicaid APG methodology,82.12,,,82.12,Other,215% Medicaid APG methodology,82.12,,,82.12,Other,215% Medicaid APG methodology,47.74,,,47.74,Other,125% Medicaid APG methodology,38.19,300,
ADMIN INFLUENZA VIRUS VAC       ,G0008,HCPCS,,48301642,CDM,771,RC,,,both,,,132,90.33,,,90.33,Other,150% of Medicare + 9.63% HCRA Surcharge,54.93,,,54.93,Other,Medicare OPPS methodology,66,50,,66,percent of total billed charges,All Other Outpatient,59.4,45,,59.4,percent of total billed charges,All Other Outpatient,66,50,,66,percent of total billed charges,All Other Outpatient,59.4,45,,59.4,percent of total billed charges,All Other Outpatient,56.76,43,,56.76,percent of total billed charges,All Other Outpatient,66,50,,66,percent of total billed charges,All Other,92.4,70,,92.4,percent of total billed charges,All Other,89.76,68,,89.76,percent of total billed charges,All Other Outpatient,71.04,,,71.04,Other,186% Medicaid methodology,105.6,80,,105.6,percent of total billed charges,All Other Outpatient,109.56,83,,109.56,percent of total billed charges,All Other Outpatient,109.56,83,,109.56,percent of total billed charges,All Other Outpatient,105.6,80,,105.6,percent of total billed charges,All Other Outpatient,109.56,83,,109.56,percent of total billed charges,All Other Outpatient,118.8,90,,118.8,percent of total billed charges,All Other,92.4,70,,92.4,percent of total billed charges,All Other,80.85,,,80.85,Fee Schedule,,68.6,,,68.6,Fee Schedule,,300,,,300,Case Rate,Vaccine Admin Per Visit,238,,,238,Case Rate,Vaccine Admin Per Visit,263,,,263,Case Rate,Vaccine Admin Per Visit,224,,,224,Case Rate,Vaccine Admin Per Visit,38.19,,,38.19,Other,New York Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,58.44,,,58.44,Other,153% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,53.47,,,53.47,Other,140% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,99.3,,,99.3,Other,260% Medicaid APG methodology,123.75,,,123.75,Other,324% Medicaid APG methodology,82.12,,,82.12,Other,215% Medicaid APG methodology,82.12,,,82.12,Other,215% Medicaid APG methodology,47.74,,,47.74,Other,125% Medicaid APG methodology,38.19,300,
ADMIN HEPATITIS B VACCINE       ,G0010,HCPCS,,48301659,CDM,771,RC,,,both,,,132,90.33,,,90.33,Other,150% of Medicare + 9.63% HCRA Surcharge,54.93,,,54.93,Other,Medicare OPPS methodology,66,50,,66,percent of total billed charges,All Other Outpatient,59.4,45,,59.4,percent of total billed charges,All Other Outpatient,66,50,,66,percent of total billed charges,All Other Outpatient,59.4,45,,59.4,percent of total billed charges,All Other Outpatient,56.76,43,,56.76,percent of total billed charges,All Other Outpatient,66,50,,66,percent of total billed charges,All Other,92.4,70,,92.4,percent of total billed charges,All Other,89.76,68,,89.76,percent of total billed charges,All Other Outpatient,71.04,,,71.04,Other,186% Medicaid methodology,105.6,80,,105.6,percent of total billed charges,All Other Outpatient,109.56,83,,109.56,percent of total billed charges,All Other Outpatient,109.56,83,,109.56,percent of total billed charges,All Other Outpatient,105.6,80,,105.6,percent of total billed charges,All Other Outpatient,109.56,83,,109.56,percent of total billed charges,All Other Outpatient,118.8,90,,118.8,percent of total billed charges,All Other,92.4,70,,92.4,percent of total billed charges,All Other,66,50,,66,percent of total billed charges,All Other,66,50,,66,percent of total billed charges,All Other,300,,,300,Case Rate,Vaccine Admin Per Visit,238,,,238,Case Rate,Vaccine Admin Per Visit,263,,,263,Case Rate,Vaccine Admin Per Visit,224,,,224,Case Rate,Vaccine Admin Per Visit,38.19,,,38.19,Other,New York Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,58.44,,,58.44,Other,153% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,53.47,,,53.47,Other,140% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,99.3,,,99.3,Other,260% Medicaid APG methodology,123.75,,,123.75,Other,324% Medicaid APG methodology,82.12,,,82.12,Other,215% Medicaid APG methodology,82.12,,,82.12,Other,215% Medicaid APG methodology,47.74,,,47.74,Other,125% Medicaid APG methodology,38.19,300,
IMMUNE ADMIN                    ,90471,CPT,,48301667,CDM,771,RC,,,both,,,132,133.96,,,133.96,Other,150% of Medicare + 9.63% HCRA Surcharge,81.46,,,81.46,Other,Medicare OPPS methodology,66,50,,66,percent of total billed charges,All Other Outpatient,59.4,45,,59.4,percent of total billed charges,All Other Outpatient,66,50,,66,percent of total billed charges,All Other Outpatient,59.4,45,,59.4,percent of total billed charges,All Other Outpatient,56.76,43,,56.76,percent of total billed charges,All Other Outpatient,66,50,,66,percent of total billed charges,All Other,92.4,70,,92.4,percent of total billed charges,All Other,75.1,,,75.1,Fee Schedule,,71.04,,,71.04,Other,186% Medicaid methodology,88.45,,,88.45,Fee Schedule,,81.84,62,,81.84,percent of total billed charges,All Other Outpatient,50.06,,,50.06,Fee Schedule,,88.45,,,88.45,Fee Schedule,,81.84,62,,81.84,percent of total billed charges,All Other Outpatient,118.8,90,,118.8,percent of total billed charges,All Other,92.4,70,,92.4,percent of total billed charges,All Other,80.85,,,80.85,Fee Schedule,,68.6,,,68.6,Fee Schedule,,300,,,300,Case Rate,Vaccine Admin Per Visit,238,,,238,Case Rate,Vaccine Admin Per Visit,263,,,263,Case Rate,Vaccine Admin Per Visit,224,,,224,Case Rate,Vaccine Admin Per Visit,38.19,,,38.19,Other,New York Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,58.44,,,58.44,Other,153% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,53.47,,,53.47,Other,140% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,99.3,,,99.3,Other,260% Medicaid APG methodology,123.75,,,123.75,Other,324% Medicaid APG methodology,82.12,,,82.12,Other,215% Medicaid APG methodology,82.12,,,82.12,Other,215% Medicaid APG methodology,47.74,,,47.74,Other,125% Medicaid APG methodology,38.19,300,
IMMUNE ADMIN EACH ADD           ,90472,CPT,,48301824,CDM,771,RC,,,both,,,127,50.12,,,50.12,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,63.5,50,,63.5,percent of total billed charges,All Other Outpatient,57.15,45,,57.15,percent of total billed charges,All Other Outpatient,63.5,50,,63.5,percent of total billed charges,All Other Outpatient,57.15,45,,57.15,percent of total billed charges,All Other Outpatient,54.61,43,,54.61,percent of total billed charges,All Other Outpatient,63.5,50,,63.5,percent of total billed charges,All Other,88.9,70,,88.9,percent of total billed charges,All Other,53.11,,,53.11,Fee Schedule,,71.04,,,71.04,Other,186% Medicaid methodology,62.55,,,62.55,Fee Schedule,,78.74,62,,78.74,percent of total billed charges,All Other Outpatient,35.41,,,35.41,Fee Schedule,,62.55,,,62.55,Fee Schedule,,78.74,62,,78.74,percent of total billed charges,All Other Outpatient,114.3,90,,114.3,percent of total billed charges,All Other,88.9,70,,88.9,percent of total billed charges,All Other,61.05,,,61.05,Fee Schedule,,51.8,,,51.8,Fee Schedule,,300,,,300,Case Rate,Vaccine Admin Per Visit,238,,,238,Case Rate,Vaccine Admin Per Visit,263,,,263,Case Rate,Vaccine Admin Per Visit,224,,,224,Case Rate,Vaccine Admin Per Visit,38.19,,,38.19,Other,New York Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,58.44,,,58.44,Other,153% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,53.47,,,53.47,Other,140% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,99.3,,,99.3,Other,260% Medicaid APG methodology,123.75,,,123.75,Other,324% Medicaid APG methodology,82.12,,,82.12,Other,215% Medicaid APG methodology,82.12,,,82.12,Other,215% Medicaid APG methodology,47.74,,,47.74,Other,125% Medicaid APG methodology,0.01,300,
ADMIN PNEUMOCOCCAL VACCINE      ,G0009,HCPCS,,50054030,CDM,771,RC,,,both,,,132,90.33,,,90.33,Other,150% of Medicare + 9.63% HCRA Surcharge,54.93,,,54.93,Other,Medicare OPPS methodology,66,50,,66,percent of total billed charges,All Other Outpatient,59.4,45,,59.4,percent of total billed charges,All Other Outpatient,66,50,,66,percent of total billed charges,All Other Outpatient,59.4,45,,59.4,percent of total billed charges,All Other Outpatient,56.76,43,,56.76,percent of total billed charges,All Other Outpatient,66,50,,66,percent of total billed charges,All Other,92.4,70,,92.4,percent of total billed charges,All Other,89.76,68,,89.76,percent of total billed charges,All Other Outpatient,71.04,,,71.04,Other,186% Medicaid methodology,105.6,80,,105.6,percent of total billed charges,All Other Outpatient,109.56,83,,109.56,percent of total billed charges,All Other Outpatient,109.56,83,,109.56,percent of total billed charges,All Other Outpatient,105.6,80,,105.6,percent of total billed charges,All Other Outpatient,109.56,83,,109.56,percent of total billed charges,All Other Outpatient,118.8,90,,118.8,percent of total billed charges,All Other,92.4,70,,92.4,percent of total billed charges,All Other,80.85,,,80.85,Fee Schedule,,68.6,,,68.6,Fee Schedule,,300,,,300,Case Rate,Vaccine Admin Per Visit,238,,,238,Case Rate,Vaccine Admin Per Visit,263,,,263,Case Rate,Vaccine Admin Per Visit,224,,,224,Case Rate,Vaccine Admin Per Visit,38.19,,,38.19,Other,New York Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,58.44,,,58.44,Other,153% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,53.47,,,53.47,Other,140% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,99.3,,,99.3,Other,260% Medicaid APG methodology,123.75,,,123.75,Other,324% Medicaid APG methodology,82.12,,,82.12,Other,215% Medicaid APG methodology,82.12,,,82.12,Other,215% Medicaid APG methodology,47.74,,,47.74,Other,125% Medicaid APG methodology,38.19,300,
IMMUNE ADMIN FLU                ,90471,CPT,,50054048,CDM,771,RC,,,both,,,132,90.33,,,90.33,Other,150% of Medicare + 9.63% HCRA Surcharge,54.93,,,54.93,Other,Medicare OPPS methodology,66,50,,66,percent of total billed charges,All Other Outpatient,59.4,45,,59.4,percent of total billed charges,All Other Outpatient,66,50,,66,percent of total billed charges,All Other Outpatient,59.4,45,,59.4,percent of total billed charges,All Other Outpatient,56.76,43,,56.76,percent of total billed charges,All Other Outpatient,66,50,,66,percent of total billed charges,All Other,92.4,70,,92.4,percent of total billed charges,All Other,75.1,,,75.1,Fee Schedule,,71.04,,,71.04,Other,186% Medicaid methodology,88.45,,,88.45,Fee Schedule,,81.84,62,,81.84,percent of total billed charges,All Other Outpatient,50.06,,,50.06,Fee Schedule,,88.45,,,88.45,Fee Schedule,,81.84,62,,81.84,percent of total billed charges,All Other Outpatient,118.8,90,,118.8,percent of total billed charges,All Other,92.4,70,,92.4,percent of total billed charges,All Other,80.85,,,80.85,Fee Schedule,,68.6,,,68.6,Fee Schedule,,300,,,300,Case Rate,Vaccine Admin Per Visit,238,,,238,Case Rate,Vaccine Admin Per Visit,263,,,263,Case Rate,Vaccine Admin Per Visit,224,,,224,Case Rate,Vaccine Admin Per Visit,38.19,,,38.19,Other,New York Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,58.44,,,58.44,Other,153% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,53.47,,,53.47,Other,140% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,99.3,,,99.3,Other,260% Medicaid APG methodology,123.75,,,123.75,Other,324% Medicaid APG methodology,82.12,,,82.12,Other,215% Medicaid APG methodology,82.12,,,82.12,Other,215% Medicaid APG methodology,47.74,,,47.74,Other,125% Medicaid APG methodology,38.19,300,
IMMUNE ADMIN                    ,90471,CPT,,50056803,CDM,771,RC,,,both,,,165,133.96,,,133.96,Other,150% of Medicare + 9.63% HCRA Surcharge,81.46,,,81.46,Other,Medicare OPPS methodology,82.5,50,,82.5,percent of total billed charges,All Other Outpatient,74.25,45,,74.25,percent of total billed charges,All Other Outpatient,82.5,50,,82.5,percent of total billed charges,All Other Outpatient,74.25,45,,74.25,percent of total billed charges,All Other Outpatient,70.95,43,,70.95,percent of total billed charges,All Other Outpatient,82.5,50,,82.5,percent of total billed charges,All Other,115.5,70,,115.5,percent of total billed charges,All Other,75.1,,,75.1,Fee Schedule,,71.04,,,71.04,Other,186% Medicaid methodology,88.45,,,88.45,Fee Schedule,,102.3,62,,102.3,percent of total billed charges,All Other Outpatient,50.06,,,50.06,Fee Schedule,,88.45,,,88.45,Fee Schedule,,102.3,62,,102.3,percent of total billed charges,All Other Outpatient,148.5,90,,148.5,percent of total billed charges,All Other,115.5,70,,115.5,percent of total billed charges,All Other,80.85,,,80.85,Fee Schedule,,68.6,,,68.6,Fee Schedule,,300,,,300,Case Rate,Vaccine Admin Per Visit,238,,,238,Case Rate,Vaccine Admin Per Visit,263,,,263,Case Rate,Vaccine Admin Per Visit,224,,,224,Case Rate,Vaccine Admin Per Visit,38.19,,,38.19,Other,New York Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,58.44,,,58.44,Other,153% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,53.47,,,53.47,Other,140% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,99.3,,,99.3,Other,260% Medicaid APG methodology,123.75,,,123.75,Other,324% Medicaid APG methodology,82.12,,,82.12,Other,215% Medicaid APG methodology,82.12,,,82.12,Other,215% Medicaid APG methodology,47.74,,,47.74,Other,125% Medicaid APG methodology,38.19,300,
ADMIN HEPATITIS B VACCINE       ,G0010,HCPCS,,50056845,CDM,771,RC,,,both,,,132,90.33,,,90.33,Other,150% of Medicare + 9.63% HCRA Surcharge,54.93,,,54.93,Other,Medicare OPPS methodology,66,50,,66,percent of total billed charges,All Other Outpatient,59.4,45,,59.4,percent of total billed charges,All Other Outpatient,66,50,,66,percent of total billed charges,All Other Outpatient,59.4,45,,59.4,percent of total billed charges,All Other Outpatient,56.76,43,,56.76,percent of total billed charges,All Other Outpatient,66,50,,66,percent of total billed charges,All Other,92.4,70,,92.4,percent of total billed charges,All Other,89.76,68,,89.76,percent of total billed charges,All Other Outpatient,71.04,,,71.04,Other,186% Medicaid methodology,105.6,80,,105.6,percent of total billed charges,All Other Outpatient,109.56,83,,109.56,percent of total billed charges,All Other Outpatient,109.56,83,,109.56,percent of total billed charges,All Other Outpatient,105.6,80,,105.6,percent of total billed charges,All Other Outpatient,109.56,83,,109.56,percent of total billed charges,All Other Outpatient,118.8,90,,118.8,percent of total billed charges,All Other,92.4,70,,92.4,percent of total billed charges,All Other,66,50,,66,percent of total billed charges,All Other,66,50,,66,percent of total billed charges,All Other,300,,,300,Case Rate,Vaccine Admin Per Visit,238,,,238,Case Rate,Vaccine Admin Per Visit,263,,,263,Case Rate,Vaccine Admin Per Visit,224,,,224,Case Rate,Vaccine Admin Per Visit,38.19,,,38.19,Other,New York Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,58.44,,,58.44,Other,153% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,53.47,,,53.47,Other,140% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,99.3,,,99.3,Other,260% Medicaid APG methodology,123.75,,,123.75,Other,324% Medicaid APG methodology,82.12,,,82.12,Other,215% Medicaid APG methodology,82.12,,,82.12,Other,215% Medicaid APG methodology,47.74,,,47.74,Other,125% Medicaid APG methodology,38.19,300,
CASIRIVI AND IMDEVI INFUSION    ,M0243,HCPCS,,50057884,CDM,771,RC,,,both,,,1876,899.14,,,899.14,Other,150% of Medicare + 9.63% HCRA Surcharge,546.77,,,546.77,Other,Medicare OPPS methodology,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,938,50,,938,percent of total billed charges,All Other Outpatient,844.2,45,,844.2,percent of total billed charges,All Other Outpatient,806.68,43,,806.68,percent of total billed charges,All Other Outpatient,938,50,,938,percent of total billed charges,All Other,309.6,,,309.6,Fee Schedule,,1275.68,68,,1275.68,percent of total billed charges,All Other Outpatient,577.69,,,577.69,Other,186% Medicaid methodology,1500.8,80,,1500.8,percent of total billed charges,All Other Outpatient,1557.08,83,,1557.08,percent of total billed charges,All Other Outpatient,1557.08,83,,1557.08,percent of total billed charges,All Other Outpatient,1500.8,80,,1500.8,percent of total billed charges,All Other Outpatient,1557.08,83,,1557.08,percent of total billed charges,All Other Outpatient,1688.4,90,,1688.4,percent of total billed charges,All Other,1313.2,70,,1313.2,percent of total billed charges,All Other,938,50,,938,percent of total billed charges,All Other,938,50,,938,percent of total billed charges,All Other,300,,,300,Case Rate,Vaccine Admin Per Visit,238,,,238,Case Rate,Vaccine Admin Per Visit,263,,,263,Case Rate,Vaccine Admin Per Visit,224,,,224,Case Rate,Vaccine Admin Per Visit,310.58,,,310.58,Other,New York Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,475.19,,,475.19,Other,153% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,434.82,,,434.82,Other,140% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,807.52,,,807.52,Other,260% Medicaid APG methodology,1006.29,,,1006.29,Other,324% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,388.23,,,388.23,Other,125% Medicaid APG methodology,224,1688.4,
BAMLAN AND ETESEV INFUSION      ,M0245,HCPCS,,50057892,CDM,771,RC,,,both,,,1876,899.14,,,899.14,Other,150% of Medicare + 9.63% HCRA Surcharge,546.77,,,546.77,Other,Medicare OPPS methodology,309.6,,,309.6,Fee Schedule,,309.6,,,309.6,Fee Schedule,,450,,,450,Fee Schedule,,450,,,450,Fee Schedule,,450,,,450,Fee Schedule,,938,50,,938,percent of total billed charges,All Other,309.6,,,309.6,Fee Schedule,,1275.68,68,,1275.68,percent of total billed charges,All Other Outpatient,577.69,,,577.69,Other,186% Medicaid methodology,1500.8,80,,1500.8,percent of total billed charges,All Other Outpatient,1557.08,83,,1557.08,percent of total billed charges,All Other Outpatient,1557.08,83,,1557.08,percent of total billed charges,All Other Outpatient,1500.8,80,,1500.8,percent of total billed charges,All Other Outpatient,1557.08,83,,1557.08,percent of total billed charges,All Other Outpatient,1688.4,90,,1688.4,percent of total billed charges,All Other,1313.2,70,,1313.2,percent of total billed charges,All Other,938,50,,938,percent of total billed charges,All Other,938,50,,938,percent of total billed charges,All Other,300,,,300,Case Rate,Vaccine Admin Per Visit,238,,,238,Case Rate,Vaccine Admin Per Visit,263,,,263,Case Rate,Vaccine Admin Per Visit,224,,,224,Case Rate,Vaccine Admin Per Visit,310.58,,,310.58,Other,New York Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,475.19,,,475.19,Other,153% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,434.82,,,434.82,Other,140% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,807.52,,,807.52,Other,260% Medicaid APG methodology,1006.29,,,1006.29,Other,324% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,388.23,,,388.23,Other,125% Medicaid APG methodology,224,1688.4,
SOTROVIMAB INFUSION             ,M0247,HCPCS,,50057926,CDM,771,RC,,,both,,,1876,899.14,,,899.14,Other,150% of Medicare + 9.63% HCRA Surcharge,546.77,,,546.77,Other,Medicare OPPS methodology,938,50,,938,percent of total billed charges,All Other Outpatient,844.2,45,,844.2,percent of total billed charges,All Other Outpatient,938,50,,938,percent of total billed charges,All Other Outpatient,844.2,45,,844.2,percent of total billed charges,All Other Outpatient,806.68,43,,806.68,percent of total billed charges,All Other Outpatient,938,50,,938,percent of total billed charges,All Other,1313.2,70,,1313.2,percent of total billed charges,All Other,1275.68,68,,1275.68,percent of total billed charges,All Other Outpatient,577.69,,,577.69,Other,186% Medicaid methodology,1500.8,80,,1500.8,percent of total billed charges,All Other Outpatient,1557.08,83,,1557.08,percent of total billed charges,All Other Outpatient,1557.08,83,,1557.08,percent of total billed charges,All Other Outpatient,1500.8,80,,1500.8,percent of total billed charges,All Other Outpatient,1557.08,83,,1557.08,percent of total billed charges,All Other Outpatient,1688.4,90,,1688.4,percent of total billed charges,All Other,1313.2,70,,1313.2,percent of total billed charges,All Other,938,50,,938,percent of total billed charges,All Other,938,50,,938,percent of total billed charges,All Other,300,,,300,Case Rate,Vaccine Admin Per Visit,238,,,238,Case Rate,Vaccine Admin Per Visit,263,,,263,Case Rate,Vaccine Admin Per Visit,224,,,224,Case Rate,Vaccine Admin Per Visit,310.58,,,310.58,Other,New York Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,475.19,,,475.19,Other,153% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,434.82,,,434.82,Other,140% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,807.52,,,807.52,Other,260% Medicaid APG methodology,1006.29,,,1006.29,Other,324% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,388.23,,,388.23,Other,125% Medicaid APG methodology,224,1688.4,
IMMUNE ADMIN                    ,90471,CPT,,50117357,CDM,771,RC,,,both,,,132,90.33,,,90.33,Other,150% of Medicare + 9.63% HCRA Surcharge,54.93,,,54.93,Other,Medicare OPPS methodology,66,50,,66,percent of total billed charges,All Other Outpatient,59.4,45,,59.4,percent of total billed charges,All Other Outpatient,66,50,,66,percent of total billed charges,All Other Outpatient,59.4,45,,59.4,percent of total billed charges,All Other Outpatient,56.76,43,,56.76,percent of total billed charges,All Other Outpatient,66,50,,66,percent of total billed charges,All Other,92.4,70,,92.4,percent of total billed charges,All Other,75.1,,,75.1,Fee Schedule,,71.04,,,71.04,Other,186% Medicaid methodology,88.45,,,88.45,Fee Schedule,,81.84,62,,81.84,percent of total billed charges,All Other Outpatient,50.06,,,50.06,Fee Schedule,,88.45,,,88.45,Fee Schedule,,81.84,62,,81.84,percent of total billed charges,All Other Outpatient,118.8,90,,118.8,percent of total billed charges,All Other,92.4,70,,92.4,percent of total billed charges,All Other,80.85,,,80.85,Fee Schedule,,68.6,,,68.6,Fee Schedule,,300,,,300,Case Rate,Vaccine Admin Per Visit,238,,,238,Case Rate,Vaccine Admin Per Visit,263,,,263,Case Rate,Vaccine Admin Per Visit,224,,,224,Case Rate,Vaccine Admin Per Visit,38.19,,,38.19,Other,New York Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,38.19,,,38.19,Other,100% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,58.44,,,58.44,Other,153% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,53.47,,,53.47,Other,140% Medicaid APG methodology,85.94,,,85.94,Other,225% Medicaid APG methodology,99.3,,,99.3,Other,260% Medicaid APG methodology,123.75,,,123.75,Other,324% Medicaid APG methodology,82.12,,,82.12,Other,215% Medicaid APG methodology,82.12,,,82.12,Other,215% Medicaid APG methodology,47.74,,,47.74,Other,125% Medicaid APG methodology,38.19,300,
DIALYSIS ONE EVALUATION         ,90945,CPT,,42800086,CDM,809,RC,,,both,,,3489,842.26,,,842.26,Other,150% of Medicare + 9.63% HCRA Surcharge,512.18,,,512.18,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1744.5,50,,1744.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,2372.52,68,,2372.52,percent of total billed charges,All Other Outpatient,541.96,,,541.96,Other,186% Medicaid methodology,2791.2,80,,2791.2,percent of total billed charges,All Other Outpatient,2895.87,83,,2895.87,percent of total billed charges,All Other Outpatient,2895.87,83,,2895.87,percent of total billed charges,All Other Outpatient,2791.2,80,,2791.2,percent of total billed charges,All Other Outpatient,2895.87,83,,2895.87,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,Non-covered service,2442.3,70,,2442.3,percent of total billed charges,All Other,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,0.01,,,0.01,Other,Inclusive of Other Service,291.38,,,291.38,Other,New York Medicaid APG methodology,291.38,,,291.38,Other,100% Medicaid APG methodology,291.38,,,291.38,Other,100% Medicaid APG methodology,291.38,,,291.38,Other,100% Medicaid APG methodology,655.6,,,655.6,Other,225% Medicaid APG methodology,655.6,,,655.6,Other,225% Medicaid APG methodology,445.8,,,445.8,Other,153% Medicaid APG methodology,655.6,,,655.6,Other,225% Medicaid APG methodology,407.93,,,407.93,Other,140% Medicaid APG methodology,655.6,,,655.6,Other,225% Medicaid APG methodology,757.58,,,757.58,Other,260% Medicaid APG methodology,944.06,,,944.06,Other,324% Medicaid APG methodology,626.46,,,626.46,Other,215% Medicaid APG methodology,626.46,,,626.46,Other,215% Medicaid APG methodology,364.22,,,364.22,Other,125% Medicaid APG methodology,0.01,2895.87,
THAW AND WASH                   ,38209,CPT,,40700098,CDM,819,RC,,,both,,,1840,825.51,,,825.51,Other,150% of Medicare + 9.63% HCRA Surcharge,502,,,502,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,920,50,,920,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,1251.2,68,,1251.2,percent of total billed charges,All Other Outpatient,4136.45,,,4136.45,Other,186% Medicaid methodology,1472,80,,1472,percent of total billed charges,All Other Outpatient,1527.2,83,,1527.2,percent of total billed charges,All Other Outpatient,1527.2,83,,1527.2,percent of total billed charges,All Other Outpatient,1472,80,,1472,percent of total billed charges,All Other Outpatient,1527.2,83,,1527.2,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,1288,70,,1288,percent of total billed charges,All Other,57.75,,,57.75,Fee Schedule,,49,,,49,Fee Schedule,,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2223.9,,,2223.9,Other,New York Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,3402.56,,,3402.56,Other,153% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,3113.46,,,3113.46,Other,140% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,5782.13,,,5782.13,Other,260% Medicaid APG methodology,7205.43,,,7205.43,Other,324% Medicaid APG methodology,4781.38,,,4781.38,Other,215% Medicaid APG methodology,4781.38,,,4781.38,Other,215% Medicaid APG methodology,2779.87,,,2779.87,Other,125% Medicaid APG methodology,0.01,7205.43,
THAW STEM CELL NO WASH          ,38208,CPT,,40700148,CDM,819,RC,,,both,,,1840,825.51,,,825.51,Other,150% of Medicare + 9.63% HCRA Surcharge,502,,,502,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,920,50,,920,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,1251.2,68,,1251.2,percent of total billed charges,All Other Outpatient,4136.45,,,4136.45,Other,186% Medicaid methodology,1472,80,,1472,percent of total billed charges,All Other Outpatient,1527.2,83,,1527.2,percent of total billed charges,All Other Outpatient,1527.2,83,,1527.2,percent of total billed charges,All Other Outpatient,1472,80,,1472,percent of total billed charges,All Other Outpatient,1527.2,83,,1527.2,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,1288,70,,1288,percent of total billed charges,All Other,136.95,,,136.95,Fee Schedule,,116.2,,,116.2,Fee Schedule,,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2223.9,,,2223.9,Other,New York Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,3402.56,,,3402.56,Other,153% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,3113.46,,,3113.46,Other,140% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,5782.13,,,5782.13,Other,260% Medicaid APG methodology,7205.43,,,7205.43,Other,324% Medicaid APG methodology,4781.38,,,4781.38,Other,215% Medicaid APG methodology,4781.38,,,4781.38,Other,215% Medicaid APG methodology,2779.87,,,2779.87,Other,125% Medicaid APG methodology,0.01,7205.43,
CRYOPRESERVE STEM CELLS         ,38207,CPT,,40700155,CDM,819,RC,,,both,,,1840,825.51,,,825.51,Other,150% of Medicare + 9.63% HCRA Surcharge,502,,,502,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,920,50,,920,percent of total billed charges,All Other Outpatient,828,45,,828,percent of total billed charges,All Other Outpatient,791.2,43,,791.2,percent of total billed charges,All Other Outpatient,920,50,,920,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,1251.2,68,,1251.2,percent of total billed charges,All Other Outpatient,4136.45,,,4136.45,Other,186% Medicaid methodology,1472,80,,1472,percent of total billed charges,All Other Outpatient,1527.2,83,,1527.2,percent of total billed charges,All Other Outpatient,1527.2,83,,1527.2,percent of total billed charges,All Other Outpatient,1472,80,,1472,percent of total billed charges,All Other Outpatient,1527.2,83,,1527.2,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,1288,70,,1288,percent of total billed charges,All Other,216.15,,,216.15,Fee Schedule,,183.4,,,183.4,Fee Schedule,,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2223.9,,,2223.9,Other,New York Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,3402.56,,,3402.56,Other,153% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,3113.46,,,3113.46,Other,140% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,5782.13,,,5782.13,Other,260% Medicaid APG methodology,7205.43,,,7205.43,Other,324% Medicaid APG methodology,4781.38,,,4781.38,Other,215% Medicaid APG methodology,4781.38,,,4781.38,Other,215% Medicaid APG methodology,2779.87,,,2779.87,Other,125% Medicaid APG methodology,0.01,7205.43,
T-CELL DEPLETION OF HARVEST     ,38210,CPT,,40700171,CDM,819,RC,,,both,,,1840,825.51,,,825.51,Other,150% of Medicare + 9.63% HCRA Surcharge,502,,,502,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,920,50,,920,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,1251.2,68,,1251.2,percent of total billed charges,All Other Outpatient,4136.45,,,4136.45,Other,186% Medicaid methodology,1472,80,,1472,percent of total billed charges,All Other Outpatient,1527.2,83,,1527.2,percent of total billed charges,All Other Outpatient,1527.2,83,,1527.2,percent of total billed charges,All Other Outpatient,1472,80,,1472,percent of total billed charges,All Other Outpatient,1527.2,83,,1527.2,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,1288,70,,1288,percent of total billed charges,All Other,379.5,,,379.5,Fee Schedule,,322,,,322,Fee Schedule,,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2223.9,,,2223.9,Other,New York Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,3402.56,,,3402.56,Other,153% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,3113.46,,,3113.46,Other,140% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,5782.13,,,5782.13,Other,260% Medicaid APG methodology,7205.43,,,7205.43,Other,324% Medicaid APG methodology,4781.38,,,4781.38,Other,215% Medicaid APG methodology,4781.38,,,4781.38,Other,215% Medicaid APG methodology,2779.87,,,2779.87,Other,125% Medicaid APG methodology,0.01,7205.43,
TUMOR CELL DEPLETE OF HARVST    ,38211,CPT,,40700189,CDM,819,RC,,,both,,,1840,825.51,,,825.51,Other,150% of Medicare + 9.63% HCRA Surcharge,502,,,502,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,920,50,,920,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,1251.2,68,,1251.2,percent of total billed charges,All Other Outpatient,4136.45,,,4136.45,Other,186% Medicaid methodology,1472,80,,1472,percent of total billed charges,All Other Outpatient,1527.2,83,,1527.2,percent of total billed charges,All Other Outpatient,1527.2,83,,1527.2,percent of total billed charges,All Other Outpatient,1472,80,,1472,percent of total billed charges,All Other Outpatient,1527.2,83,,1527.2,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,1288,70,,1288,percent of total billed charges,All Other,343.2,,,343.2,Fee Schedule,,291.2,,,291.2,Fee Schedule,,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2223.9,,,2223.9,Other,New York Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,3402.56,,,3402.56,Other,153% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,3113.46,,,3113.46,Other,140% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,5782.13,,,5782.13,Other,260% Medicaid APG methodology,7205.43,,,7205.43,Other,324% Medicaid APG methodology,4781.38,,,4781.38,Other,215% Medicaid APG methodology,4781.38,,,4781.38,Other,215% Medicaid APG methodology,2779.87,,,2779.87,Other,125% Medicaid APG methodology,0.01,7205.43,
RBC DEPLETION OF HARVEST        ,38212,CPT,,40700197,CDM,819,RC,,,both,,,1840,825.51,,,825.51,Other,150% of Medicare + 9.63% HCRA Surcharge,502,,,502,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,920,50,,920,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,1251.2,68,,1251.2,percent of total billed charges,All Other Outpatient,1127.51,,,1127.51,Other,186% Medicaid methodology,1472,80,,1472,percent of total billed charges,All Other Outpatient,1527.2,83,,1527.2,percent of total billed charges,All Other Outpatient,1527.2,83,,1527.2,percent of total billed charges,All Other Outpatient,1472,80,,1472,percent of total billed charges,All Other Outpatient,1527.2,83,,1527.2,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,1288,70,,1288,percent of total billed charges,All Other,229.35,,,229.35,Fee Schedule,,194.6,,,194.6,Fee Schedule,,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,606.19,,,606.19,Other,New York Medicaid APG methodology,606.19,,,606.19,Other,100% Medicaid APG methodology,606.19,,,606.19,Other,100% Medicaid APG methodology,606.19,,,606.19,Other,100% Medicaid APG methodology,1363.92,,,1363.92,Other,225% Medicaid APG methodology,1363.92,,,1363.92,Other,225% Medicaid APG methodology,927.47,,,927.47,Other,153% Medicaid APG methodology,1363.92,,,1363.92,Other,225% Medicaid APG methodology,848.66,,,848.66,Other,140% Medicaid APG methodology,1363.92,,,1363.92,Other,225% Medicaid APG methodology,1576.09,,,1576.09,Other,260% Medicaid APG methodology,1964.05,,,1964.05,Other,324% Medicaid APG methodology,1303.3,,,1303.3,Other,215% Medicaid APG methodology,1303.3,,,1303.3,Other,215% Medicaid APG methodology,757.74,,,757.74,Other,125% Medicaid APG methodology,0.01,1964.05,
PLATELET DEPLETE OF HARVEST     ,38213,CPT,,40700205,CDM,819,RC,,,both,,,1840,825.51,,,825.51,Other,150% of Medicare + 9.63% HCRA Surcharge,502,,,502,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,920,50,,920,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,1251.2,68,,1251.2,percent of total billed charges,All Other Outpatient,4136.45,,,4136.45,Other,186% Medicaid methodology,1472,80,,1472,percent of total billed charges,All Other Outpatient,1527.2,83,,1527.2,percent of total billed charges,All Other Outpatient,1527.2,83,,1527.2,percent of total billed charges,All Other Outpatient,1472,80,,1472,percent of total billed charges,All Other Outpatient,1527.2,83,,1527.2,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,1288,70,,1288,percent of total billed charges,All Other,57.75,,,57.75,Fee Schedule,,49,,,49,Fee Schedule,,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2223.9,,,2223.9,Other,New York Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,3402.56,,,3402.56,Other,153% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,3113.46,,,3113.46,Other,140% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,5782.13,,,5782.13,Other,260% Medicaid APG methodology,7205.43,,,7205.43,Other,324% Medicaid APG methodology,4781.38,,,4781.38,Other,215% Medicaid APG methodology,4781.38,,,4781.38,Other,215% Medicaid APG methodology,2779.87,,,2779.87,Other,125% Medicaid APG methodology,0.01,7205.43,
VOLUME DEPLETE OF HARVEST       ,38214,CPT,,40700213,CDM,819,RC,,,both,,,1840,825.51,,,825.51,Other,150% of Medicare + 9.63% HCRA Surcharge,502,,,502,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,920,50,,920,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,1251.2,68,,1251.2,percent of total billed charges,All Other Outpatient,4136.45,,,4136.45,Other,186% Medicaid methodology,1472,80,,1472,percent of total billed charges,All Other Outpatient,1527.2,83,,1527.2,percent of total billed charges,All Other Outpatient,1527.2,83,,1527.2,percent of total billed charges,All Other Outpatient,1472,80,,1472,percent of total billed charges,All Other Outpatient,1527.2,83,,1527.2,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,1288,70,,1288,percent of total billed charges,All Other,198,,,198,Fee Schedule,,168,,,168,Fee Schedule,,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2223.9,,,2223.9,Other,New York Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,3402.56,,,3402.56,Other,153% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,3113.46,,,3113.46,Other,140% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,5782.13,,,5782.13,Other,260% Medicaid APG methodology,7205.43,,,7205.43,Other,324% Medicaid APG methodology,4781.38,,,4781.38,Other,215% Medicaid APG methodology,4781.38,,,4781.38,Other,215% Medicaid APG methodology,2779.87,,,2779.87,Other,125% Medicaid APG methodology,0.01,7205.43,
HARVEST STEM CELL CONCENTRTE    ,38215,CPT,,40700221,CDM,819,RC,,,both,,,1840,825.51,,,825.51,Other,150% of Medicare + 9.63% HCRA Surcharge,502,,,502,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,920,50,,920,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,1251.2,68,,1251.2,percent of total billed charges,All Other Outpatient,4136.45,,,4136.45,Other,186% Medicaid methodology,1472,80,,1472,percent of total billed charges,All Other Outpatient,1527.2,83,,1527.2,percent of total billed charges,All Other Outpatient,1527.2,83,,1527.2,percent of total billed charges,All Other Outpatient,1472,80,,1472,percent of total billed charges,All Other Outpatient,1527.2,83,,1527.2,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,1288,70,,1288,percent of total billed charges,All Other,229.35,,,229.35,Fee Schedule,,194.6,,,194.6,Fee Schedule,,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2223.9,,,2223.9,Other,New York Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,3402.56,,,3402.56,Other,153% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,3113.46,,,3113.46,Other,140% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,5782.13,,,5782.13,Other,260% Medicaid APG methodology,7205.43,,,7205.43,Other,324% Medicaid APG methodology,4781.38,,,4781.38,Other,215% Medicaid APG methodology,4781.38,,,4781.38,Other,215% Medicaid APG methodology,2779.87,,,2779.87,Other,125% Medicaid APG methodology,0.01,7205.43,
STEMCELL ALLOGENIC              ,38205,CPT,,48401301,CDM,819,RC,,,both,,,5883,2321.83,,,2321.83,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2941.5,50,,2941.5,percent of total billed charges,All Other Outpatient,2647.35,45,,2647.35,percent of total billed charges,All Other Outpatient,2529.69,43,,2529.69,percent of total billed charges,All Other Outpatient,2941.5,50,,2941.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,4000.44,68,,4000.44,percent of total billed charges,All Other Outpatient,4136.45,,,4136.45,Other,186% Medicaid methodology,4706.4,80,,4706.4,percent of total billed charges,All Other Outpatient,4882.89,83,,4882.89,percent of total billed charges,All Other Outpatient,4882.89,83,,4882.89,percent of total billed charges,All Other Outpatient,4706.4,80,,4706.4,percent of total billed charges,All Other Outpatient,4882.89,83,,4882.89,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,Non-covered service,4118.1,70,,4118.1,percent of total billed charges,All Other,414.15,,,414.15,Fee Schedule,,351.4,,,351.4,Fee Schedule,,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,2223.9,,,2223.9,Other,New York Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,2223.9,,,2223.9,Other,100% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,3402.56,,,3402.56,Other,153% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,3113.46,,,3113.46,Other,140% Medicaid APG methodology,5003.77,,,5003.77,Other,225% Medicaid APG methodology,5782.13,,,5782.13,Other,260% Medicaid APG methodology,7205.43,,,7205.43,Other,324% Medicaid APG methodology,4781.38,,,4781.38,Other,215% Medicaid APG methodology,4781.38,,,4781.38,Other,215% Medicaid APG methodology,2779.87,,,2779.87,Other,125% Medicaid APG methodology,0.01,7205.43,
CAR-T CLL ADMN AUTOLOGOUS       ,0540T,HCPCS,,40700346,CDM,874,RC,,,both,,,2101,644.03,,,644.03,Other,150% of Medicare + 9.63% HCRA Surcharge,391.64,,,391.64,Other,Medicare OPPS methodology,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,1050.5,50,,1050.5,percent of total billed charges,All Other Outpatient,945.45,45,,945.45,percent of total billed charges,All Other Outpatient,903.43,43,,903.43,percent of total billed charges,All Other Outpatient,1050.5,50,,1050.5,percent of total billed charges,All Other,1470.7,70,,1470.7,percent of total billed charges,All Other,1428.68,68,,1428.68,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,1680.8,80,,1680.8,percent of total billed charges,All Other Outpatient,1743.83,83,,1743.83,percent of total billed charges,All Other Outpatient,1743.83,83,,1743.83,percent of total billed charges,All Other Outpatient,1680.8,80,,1680.8,percent of total billed charges,All Other Outpatient,1743.83,83,,1743.83,percent of total billed charges,All Other Outpatient,1890.9,90,,1890.9,percent of total billed charges,All Other,1470.7,70,,1470.7,percent of total billed charges,All Other,1050.5,50,,1050.5,percent of total billed charges,All Other,1050.5,50,,1050.5,percent of total billed charges,All Other,1470.7,70,,1470.7,percent of total billed charges,All Other,1470.7,70,,1470.7,percent of total billed charges,All Other,1470.7,70,,1470.7,percent of total billed charges,All Other,1470.7,70,,1470.7,percent of total billed charges,All Other,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1890.9,
PSYCH DIAGNOSTIC EVALUATION     ,90791,CPT,,50720002,CDM,900,RC,,,both,,,898,303.19,,,303.19,Other,150% of Medicare + 9.63% HCRA Surcharge,184.37,,,184.37,Other,Medicare OPPS methodology,583.7,65,,583.7,percent of total billed charges,All Other Outpatient,529.82,59,,529.82,percent of total billed charges,All Other Outpatient,508,,,508,Fee Schedule,Behavioral Health,457,,,457,Fee Schedule,Behavioral Health,432,,,432,Fee Schedule,Behavioral Health,449,50,,449,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,143.31,,,143.31,Fee Schedule,Behavioral Health,420.52,,,420.52,Other,186% Medicaid methodology,122.08,,,122.08,Fee Schedule,Behavioral Health,203.03,,,203.03,Fee Schedule,Behavioral Health,203.03,,,203.03,Fee Schedule,Behavioral Health,122.08,,,122.08,Fee Schedule,Behavioral Health,203.03,,,203.03,Fee Schedule,Behavioral Health,808.2,90,,808.2,percent of total billed charges,All Other,628.6,70,,628.6,percent of total billed charges,All Other,217,,,217,Fee Schedule,Behavioral Health,184,,,184,Fee Schedule,Behavioral Health,142.44,,,142.44,Fee Schedule,Behavioral Health,142.44,,,142.44,Fee Schedule,Behavioral Health,142.44,,,142.44,Fee Schedule,Behavioral Health,142.44,,,142.44,Fee Schedule,Behavioral Health,226.08,,,226.08,Other,New York Medicaid APG methodology,226.08,,,226.08,Other,100% Medicaid APG methodology,226.08,,,226.08,Other,100% Medicaid APG methodology,226.08,,,226.08,Other,100% Medicaid APG methodology,508.69,,,508.69,Other,225% Medicaid APG methodology,508.69,,,508.69,Other,225% Medicaid APG methodology,345.91,,,345.91,Other,153% Medicaid APG methodology,508.69,,,508.69,Other,225% Medicaid APG methodology,316.52,,,316.52,Other,140% Medicaid APG methodology,508.69,,,508.69,Other,225% Medicaid APG methodology,587.82,,,587.82,Other,260% Medicaid APG methodology,732.51,,,732.51,Other,324% Medicaid APG methodology,486.08,,,486.08,Other,215% Medicaid APG methodology,486.08,,,486.08,Other,215% Medicaid APG methodology,282.6,,,282.6,Other,125% Medicaid APG methodology,0.01,808.2,
PSYCH DIAG EVAL W/MED SRVCS     ,90792,CPT,,50720374,CDM,900,RC,,,both,,,699,303.19,,,303.19,Other,150% of Medicare + 9.63% HCRA Surcharge,184.37,,,184.37,Other,Medicare OPPS methodology,454.35,65,,454.35,percent of total billed charges,All Other Outpatient,412.41,59,,412.41,percent of total billed charges,All Other Outpatient,508,,,508,Fee Schedule,Behavioral Health,457,,,457,Fee Schedule,Behavioral Health,432,,,432,Fee Schedule,Behavioral Health,349.5,50,,349.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,143.31,,,143.31,Fee Schedule,Behavioral Health,420.52,,,420.52,Other,186% Medicaid methodology,122.08,,,122.08,Fee Schedule,Behavioral Health,203.03,,,203.03,Fee Schedule,Behavioral Health,203.03,,,203.03,Fee Schedule,Behavioral Health,122.08,,,122.08,Fee Schedule,Behavioral Health,203.03,,,203.03,Fee Schedule,Behavioral Health,629.1,90,,629.1,percent of total billed charges,All Other,489.3,70,,489.3,percent of total billed charges,All Other,217,,,217,Fee Schedule,Behavioral Health,184,,,184,Fee Schedule,Behavioral Health,142.44,,,142.44,Fee Schedule,Behavioral Health,142.44,,,142.44,Fee Schedule,Behavioral Health,142.44,,,142.44,Fee Schedule,Behavioral Health,142.44,,,142.44,Fee Schedule,Behavioral Health,226.08,,,226.08,Other,New York Medicaid APG methodology,226.08,,,226.08,Other,100% Medicaid APG methodology,226.08,,,226.08,Other,100% Medicaid APG methodology,226.08,,,226.08,Other,100% Medicaid APG methodology,508.69,,,508.69,Other,225% Medicaid APG methodology,508.69,,,508.69,Other,225% Medicaid APG methodology,345.91,,,345.91,Other,153% Medicaid APG methodology,508.69,,,508.69,Other,225% Medicaid APG methodology,316.52,,,316.52,Other,140% Medicaid APG methodology,508.69,,,508.69,Other,225% Medicaid APG methodology,587.82,,,587.82,Other,260% Medicaid APG methodology,732.51,,,732.51,Other,324% Medicaid APG methodology,486.08,,,486.08,Other,215% Medicaid APG methodology,486.08,,,486.08,Other,215% Medicaid APG methodology,282.6,,,282.6,Other,125% Medicaid APG methodology,0.01,732.51,
PSYCH DIAGNOSTIC EVALUATION     ,90791,CPT,,50820620,CDM,900,RC,,,both,,,898,303.19,,,303.19,Other,150% of Medicare + 9.63% HCRA Surcharge,184.37,,,184.37,Other,Medicare OPPS methodology,583.7,65,,583.7,percent of total billed charges,All Other Outpatient,529.82,59,,529.82,percent of total billed charges,All Other Outpatient,508,,,508,Fee Schedule,Behavioral Health,457,,,457,Fee Schedule,Behavioral Health,432,,,432,Fee Schedule,Behavioral Health,449,50,,449,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,143.31,,,143.31,Fee Schedule,Behavioral Health,420.52,,,420.52,Other,186% Medicaid methodology,122.08,,,122.08,Fee Schedule,Behavioral Health,203.03,,,203.03,Fee Schedule,Behavioral Health,203.03,,,203.03,Fee Schedule,Behavioral Health,122.08,,,122.08,Fee Schedule,Behavioral Health,203.03,,,203.03,Fee Schedule,Behavioral Health,808.2,90,,808.2,percent of total billed charges,All Other,628.6,70,,628.6,percent of total billed charges,All Other,217,,,217,Fee Schedule,Behavioral Health,184,,,184,Fee Schedule,Behavioral Health,142.44,,,142.44,Fee Schedule,Behavioral Health,142.44,,,142.44,Fee Schedule,Behavioral Health,142.44,,,142.44,Fee Schedule,Behavioral Health,142.44,,,142.44,Fee Schedule,Behavioral Health,226.08,,,226.08,Other,New York Medicaid APG methodology,226.08,,,226.08,Other,100% Medicaid APG methodology,226.08,,,226.08,Other,100% Medicaid APG methodology,226.08,,,226.08,Other,100% Medicaid APG methodology,508.69,,,508.69,Other,225% Medicaid APG methodology,508.69,,,508.69,Other,225% Medicaid APG methodology,345.91,,,345.91,Other,153% Medicaid APG methodology,508.69,,,508.69,Other,225% Medicaid APG methodology,316.52,,,316.52,Other,140% Medicaid APG methodology,508.69,,,508.69,Other,225% Medicaid APG methodology,587.82,,,587.82,Other,260% Medicaid APG methodology,732.51,,,732.51,Other,324% Medicaid APG methodology,486.08,,,486.08,Other,215% Medicaid APG methodology,486.08,,,486.08,Other,215% Medicaid APG methodology,282.6,,,282.6,Other,125% Medicaid APG methodology,0.01,808.2,
PSYCH DIAG EVAL W/MED SRVCS     ,90792,CPT,,50820638,CDM,900,RC,,,both,,,699,303.19,,,303.19,Other,150% of Medicare + 9.63% HCRA Surcharge,184.37,,,184.37,Other,Medicare OPPS methodology,454.35,65,,454.35,percent of total billed charges,All Other Outpatient,412.41,59,,412.41,percent of total billed charges,All Other Outpatient,508,,,508,Fee Schedule,Behavioral Health,457,,,457,Fee Schedule,Behavioral Health,432,,,432,Fee Schedule,Behavioral Health,349.5,50,,349.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,143.31,,,143.31,Fee Schedule,Behavioral Health,420.52,,,420.52,Other,186% Medicaid methodology,122.08,,,122.08,Fee Schedule,Behavioral Health,203.03,,,203.03,Fee Schedule,Behavioral Health,203.03,,,203.03,Fee Schedule,Behavioral Health,122.08,,,122.08,Fee Schedule,Behavioral Health,203.03,,,203.03,Fee Schedule,Behavioral Health,629.1,90,,629.1,percent of total billed charges,All Other,489.3,70,,489.3,percent of total billed charges,All Other,217,,,217,Fee Schedule,Behavioral Health,184,,,184,Fee Schedule,Behavioral Health,142.44,,,142.44,Fee Schedule,Behavioral Health,142.44,,,142.44,Fee Schedule,Behavioral Health,142.44,,,142.44,Fee Schedule,Behavioral Health,142.44,,,142.44,Fee Schedule,Behavioral Health,226.08,,,226.08,Other,New York Medicaid APG methodology,226.08,,,226.08,Other,100% Medicaid APG methodology,226.08,,,226.08,Other,100% Medicaid APG methodology,226.08,,,226.08,Other,100% Medicaid APG methodology,508.69,,,508.69,Other,225% Medicaid APG methodology,508.69,,,508.69,Other,225% Medicaid APG methodology,345.91,,,345.91,Other,153% Medicaid APG methodology,508.69,,,508.69,Other,225% Medicaid APG methodology,316.52,,,316.52,Other,140% Medicaid APG methodology,508.69,,,508.69,Other,225% Medicaid APG methodology,587.82,,,587.82,Other,260% Medicaid APG methodology,732.51,,,732.51,Other,324% Medicaid APG methodology,486.08,,,486.08,Other,215% Medicaid APG methodology,486.08,,,486.08,Other,215% Medicaid APG methodology,282.6,,,282.6,Other,125% Medicaid APG methodology,0.01,732.51,
CRISIS INTERVENTION/HR TH       ,S9484,HCPCS,GT       ,50891860,CDM,900,RC,,,both,,,1235,487.41,,,487.41,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,802.75,65,,802.75,percent of total billed charges,All Other Outpatient,728.65,59,,728.65,percent of total billed charges,All Other Outpatient,617.5,50,,617.5,percent of total billed charges,All Other Outpatient,555.75,45,,555.75,percent of total billed charges,All Other Outpatient,531.05,43,,531.05,percent of total billed charges,All Other Outpatient,617.5,50,,617.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,839.8,68,,839.8,percent of total billed charges,All Other Outpatient,344.55,,,344.55,Other,186% Medicaid methodology,988,80,,988,percent of total billed charges,All Other Outpatient,1025.05,83,,1025.05,percent of total billed charges,All Other Outpatient,1025.05,83,,1025.05,percent of total billed charges,All Other Outpatient,988,80,,988,percent of total billed charges,All Other Outpatient,1025.05,83,,1025.05,percent of total billed charges,All Other Outpatient,1111.5,90,,1111.5,percent of total billed charges,All Other,864.5,70,,864.5,percent of total billed charges,All Other,617.5,50,,617.5,percent of total billed charges,All Other,617.5,50,,617.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,185.24,,,185.24,Other,New York Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,283.42,,,283.42,Other,153% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,259.34,,,259.34,Other,140% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,481.63,,,481.63,Other,260% Medicaid APG methodology,600.18,,,600.18,Other,324% Medicaid APG methodology,398.27,,,398.27,Other,215% Medicaid APG methodology,398.27,,,398.27,Other,215% Medicaid APG methodology,231.55,,,231.55,Other,125% Medicaid APG methodology,0.01,1111.5,
CRISIS INTERVENTION/DIEM TH     ,S9485,HCPCS,GT       ,50891878,CDM,900,RC,,,both,,,3858,1522.63,,,1522.63,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,2507.7,65,,2507.7,percent of total billed charges,All Other Outpatient,2276.22,59,,2276.22,percent of total billed charges,All Other Outpatient,1929,50,,1929,percent of total billed charges,All Other Outpatient,1736.1,45,,1736.1,percent of total billed charges,All Other Outpatient,1658.94,43,,1658.94,percent of total billed charges,All Other Outpatient,1929,50,,1929,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,2623.44,68,,2623.44,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,3086.4,80,,3086.4,percent of total billed charges,All Other Outpatient,3202.14,83,,3202.14,percent of total billed charges,All Other Outpatient,3202.14,83,,3202.14,percent of total billed charges,All Other Outpatient,3086.4,80,,3086.4,percent of total billed charges,All Other Outpatient,3202.14,83,,3202.14,percent of total billed charges,All Other Outpatient,3472.2,90,,3472.2,percent of total billed charges,All Other,2700.6,70,,2700.6,percent of total billed charges,All Other,1929,50,,1929,percent of total billed charges,All Other,1929,50,,1929,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,3472.2,
MED SERV EVE/WKEND/HOLIDAY      ,99051,CPT,,50720093,CDM,914,RC,,,both,,,15,5.92,,,5.92,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,9.75,65,,9.75,percent of total billed charges,All Other Outpatient,8.85,59,,8.85,percent of total billed charges,All Other Outpatient,7.5,50,,7.5,percent of total billed charges,All Other Outpatient,6.75,45,,6.75,percent of total billed charges,All Other Outpatient,6.45,43,,6.45,percent of total billed charges,All Other Outpatient,7.5,50,,7.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,10.2,68,,10.2,percent of total billed charges,All Other Outpatient,68.53,,,68.53,Other,186% Medicaid methodology,12,80,,12,percent of total billed charges,All Other Outpatient,12.45,83,,12.45,percent of total billed charges,All Other Outpatient,12.45,83,,12.45,percent of total billed charges,All Other Outpatient,12,80,,12,percent of total billed charges,All Other Outpatient,12.45,83,,12.45,percent of total billed charges,All Other Outpatient,13.5,90,,13.5,percent of total billed charges,All Other,10.5,70,,10.5,percent of total billed charges,All Other,7.5,50,,7.5,percent of total billed charges,All Other,7.5,50,,7.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,36.85,,,36.85,Other,New York Medicaid APG methodology,36.85,,,36.85,Other,100% Medicaid APG methodology,36.85,,,36.85,Other,100% Medicaid APG methodology,36.85,,,36.85,Other,100% Medicaid APG methodology,82.9,,,82.9,Other,225% Medicaid APG methodology,82.9,,,82.9,Other,225% Medicaid APG methodology,56.37,,,56.37,Other,153% Medicaid APG methodology,82.9,,,82.9,Other,225% Medicaid APG methodology,51.58,,,51.58,Other,140% Medicaid APG methodology,82.9,,,82.9,Other,225% Medicaid APG methodology,95.8,,,95.8,Other,260% Medicaid APG methodology,119.38,,,119.38,Other,324% Medicaid APG methodology,79.22,,,79.22,Other,215% Medicaid APG methodology,79.22,,,79.22,Other,215% Medicaid APG methodology,46.06,,,46.06,Other,125% Medicaid APG methodology,0.01,119.38,
PSYTX W PT 30 MINUTES           ,90832,CPT,,50720101,CDM,914,RC,,,both,,,538,303.19,,,303.19,Other,150% of Medicare + 9.63% HCRA Surcharge,184.37,,,184.37,Other,Medicare OPPS methodology,349.7,65,,349.7,percent of total billed charges,All Other Outpatient,317.42,59,,317.42,percent of total billed charges,All Other Outpatient,214,,,214,Fee Schedule,Behavioral Health,193,,,193,Fee Schedule,Behavioral Health,182,,,182,Fee Schedule,Behavioral Health,269,50,,269,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,65.02,,,65.02,Fee Schedule,Behavioral Health,268.58,,,268.58,Other,186% Medicaid methodology,62.36,,,62.36,Fee Schedule,Behavioral Health,78.29,,,78.29,Fee Schedule,Behavioral Health,78.29,,,78.29,Fee Schedule,Behavioral Health,62.36,,,62.36,Fee Schedule,Behavioral Health,78.29,,,78.29,Fee Schedule,Behavioral Health,484.2,90,,484.2,percent of total billed charges,All Other,376.6,70,,376.6,percent of total billed charges,All Other,99,,,99,Fee Schedule,Behavioral Health,84,,,84,Fee Schedule,Behavioral Health,70.68,,,70.68,Fee Schedule,Behavioral Health,70.68,,,70.68,Fee Schedule,Behavioral Health,70.68,,,70.68,Fee Schedule,Behavioral Health,70.68,,,70.68,Fee Schedule,Behavioral Health,144.4,,,144.4,Other,New York Medicaid APG methodology,144.4,,,144.4,Other,100% Medicaid APG methodology,144.4,,,144.4,Other,100% Medicaid APG methodology,144.4,,,144.4,Other,100% Medicaid APG methodology,324.9,,,324.9,Other,225% Medicaid APG methodology,324.9,,,324.9,Other,225% Medicaid APG methodology,220.93,,,220.93,Other,153% Medicaid APG methodology,324.9,,,324.9,Other,225% Medicaid APG methodology,202.16,,,202.16,Other,140% Medicaid APG methodology,324.9,,,324.9,Other,225% Medicaid APG methodology,375.44,,,375.44,Other,260% Medicaid APG methodology,467.85,,,467.85,Other,324% Medicaid APG methodology,310.46,,,310.46,Other,215% Medicaid APG methodology,310.46,,,310.46,Other,215% Medicaid APG methodology,180.5,,,180.5,Other,125% Medicaid APG methodology,0.01,484.2,
PSYTX W PT 45 MINUTES           ,90834,CPT,,50720119,CDM,914,RC,,,both,,,643,303.19,,,303.19,Other,150% of Medicare + 9.63% HCRA Surcharge,184.37,,,184.37,Other,Medicare OPPS methodology,417.95,65,,417.95,percent of total billed charges,All Other Outpatient,379.37,59,,379.37,percent of total billed charges,All Other Outpatient,383,,,383,Fee Schedule,Behavioral Health,345,,,345,Fee Schedule,Behavioral Health,326,,,326,Fee Schedule,Behavioral Health,321.5,50,,321.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,108.81,,,108.81,Fee Schedule,Behavioral Health,344.55,,,344.55,Other,186% Medicaid methodology,96.87,,,96.87,Fee Schedule,Behavioral Health,147.29,,,147.29,Fee Schedule,Behavioral Health,147.29,,,147.29,Fee Schedule,Behavioral Health,96.87,,,96.87,Fee Schedule,Behavioral Health,147.29,,,147.29,Fee Schedule,Behavioral Health,578.7,90,,578.7,percent of total billed charges,All Other,450.1,70,,450.1,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,106.58,,,106.58,Fee Schedule,Behavioral Health,106.58,,,106.58,Fee Schedule,Behavioral Health,106.58,,,106.58,Fee Schedule,Behavioral Health,106.58,,,106.58,Fee Schedule,Behavioral Health,185.24,,,185.24,Other,New York Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,283.42,,,283.42,Other,153% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,259.34,,,259.34,Other,140% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,481.63,,,481.63,Other,260% Medicaid APG methodology,600.18,,,600.18,Other,324% Medicaid APG methodology,398.27,,,398.27,Other,215% Medicaid APG methodology,398.27,,,398.27,Other,215% Medicaid APG methodology,231.55,,,231.55,Other,125% Medicaid APG methodology,0.01,600.18,
FAMILY PSYTX W/O PT 50 MIN      ,90846,CPT,,50720184,CDM,914,RC,,,both,,,643,303.19,,,303.19,Other,150% of Medicare + 9.63% HCRA Surcharge,184.37,,,184.37,Other,Medicare OPPS methodology,417.95,65,,417.95,percent of total billed charges,All Other Outpatient,379.37,59,,379.37,percent of total billed charges,All Other Outpatient,302,,,302,Fee Schedule,Behavioral Health,272,,,272,Fee Schedule,Behavioral Health,257,,,257,Fee Schedule,Behavioral Health,321.5,50,,321.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,108.81,,,108.81,Fee Schedule,Behavioral Health,268.58,,,268.58,Other,186% Medicaid methodology,96.87,,,96.87,Fee Schedule,Behavioral Health,127.39,,,127.39,Fee Schedule,Behavioral Health,127.39,,,127.39,Fee Schedule,Behavioral Health,96.87,,,96.87,Fee Schedule,Behavioral Health,127.39,,,127.39,Fee Schedule,Behavioral Health,578.7,90,,578.7,percent of total billed charges,All Other,450.1,70,,450.1,percent of total billed charges,All Other,148,,,148,Fee Schedule,Behavioral Health,126,,,126,Fee Schedule,Behavioral Health,107.27,,,107.27,Fee Schedule,Behavioral Health,107.27,,,107.27,Fee Schedule,Behavioral Health,107.27,,,107.27,Fee Schedule,Behavioral Health,107.27,,,107.27,Fee Schedule,Behavioral Health,144.4,,,144.4,Other,New York Medicaid APG methodology,144.4,,,144.4,Other,100% Medicaid APG methodology,144.4,,,144.4,Other,100% Medicaid APG methodology,144.4,,,144.4,Other,100% Medicaid APG methodology,324.9,,,324.9,Other,225% Medicaid APG methodology,324.9,,,324.9,Other,225% Medicaid APG methodology,220.93,,,220.93,Other,153% Medicaid APG methodology,324.9,,,324.9,Other,225% Medicaid APG methodology,202.16,,,202.16,Other,140% Medicaid APG methodology,324.9,,,324.9,Other,225% Medicaid APG methodology,375.44,,,375.44,Other,260% Medicaid APG methodology,467.85,,,467.85,Other,324% Medicaid APG methodology,310.46,,,310.46,Other,215% Medicaid APG methodology,310.46,,,310.46,Other,215% Medicaid APG methodology,180.5,,,180.5,Other,125% Medicaid APG methodology,0.01,578.7,
PSYTX W PT W E/M 30 MIN         ,90833,CPT,,50720382,CDM,914,RC,,,both,,,355,140.11,,,140.11,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,230.75,65,,230.75,percent of total billed charges,All Other Outpatient,209.45,59,,209.45,percent of total billed charges,All Other Outpatient,177.5,50,,177.5,percent of total billed charges,All Other Outpatient,159.75,45,,159.75,percent of total billed charges,All Other Outpatient,152.65,43,,152.65,percent of total billed charges,All Other Outpatient,177.5,50,,177.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,11.95,,,11.95,Fee Schedule,Behavioral Health,268.58,,,268.58,Other,186% Medicaid methodology,15.93,,,15.93,Fee Schedule,Behavioral Health,19.91,,,19.91,Fee Schedule,Behavioral Health,19.91,,,19.91,Fee Schedule,Behavioral Health,15.93,,,15.93,Fee Schedule,Behavioral Health,19.91,,,19.91,Fee Schedule,Behavioral Health,319.5,90,,319.5,percent of total billed charges,All Other,248.5,70,,248.5,percent of total billed charges,All Other,28,,,28,Fee Schedule,Behavioral Health,24,,,24,Fee Schedule,Behavioral Health,53.82,,,53.82,Fee Schedule,Behavioral Health,53.82,,,53.82,Fee Schedule,Behavioral Health,53.82,,,53.82,Fee Schedule,Behavioral Health,53.82,,,53.82,Fee Schedule,Behavioral Health,144.4,,,144.4,Other,New York Medicaid APG methodology,144.4,,,144.4,Other,100% Medicaid APG methodology,144.4,,,144.4,Other,100% Medicaid APG methodology,144.4,,,144.4,Other,100% Medicaid APG methodology,324.9,,,324.9,Other,225% Medicaid APG methodology,324.9,,,324.9,Other,225% Medicaid APG methodology,220.93,,,220.93,Other,153% Medicaid APG methodology,324.9,,,324.9,Other,225% Medicaid APG methodology,202.16,,,202.16,Other,140% Medicaid APG methodology,324.9,,,324.9,Other,225% Medicaid APG methodology,375.44,,,375.44,Other,260% Medicaid APG methodology,467.85,,,467.85,Other,324% Medicaid APG methodology,310.46,,,310.46,Other,215% Medicaid APG methodology,310.46,,,310.46,Other,215% Medicaid APG methodology,180.5,,,180.5,Other,125% Medicaid APG methodology,0.01,467.85,
PSYTX W PT W E/M 45 MIN         ,90836,CPT,,50720408,CDM,914,RC,,,both,,,121,47.75,,,47.75,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,78.65,65,,78.65,percent of total billed charges,All Other Outpatient,71.39,59,,71.39,percent of total billed charges,All Other Outpatient,60.5,50,,60.5,percent of total billed charges,All Other Outpatient,54.45,45,,54.45,percent of total billed charges,All Other Outpatient,52.03,43,,52.03,percent of total billed charges,All Other Outpatient,60.5,50,,60.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,62.36,,,62.36,Fee Schedule,Behavioral Health,344.55,,,344.55,Other,186% Medicaid methodology,55.74,,,55.74,Fee Schedule,Behavioral Health,88.91,,,88.91,Fee Schedule,Behavioral Health,88.91,,,88.91,Fee Schedule,Behavioral Health,55.74,,,55.74,Fee Schedule,Behavioral Health,88.91,,,88.91,Fee Schedule,Behavioral Health,108.9,90,,108.9,percent of total billed charges,All Other,84.7,70,,84.7,percent of total billed charges,All Other,100,,,100,Fee Schedule,Behavioral Health,86,,,86,Fee Schedule,Behavioral Health,81.09,,,81.09,Fee Schedule,Behavioral Health,81.09,,,81.09,Fee Schedule,Behavioral Health,81.09,,,81.09,Fee Schedule,Behavioral Health,81.09,,,81.09,Fee Schedule,Behavioral Health,185.24,,,185.24,Other,New York Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,283.42,,,283.42,Other,153% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,259.34,,,259.34,Other,140% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,481.63,,,481.63,Other,260% Medicaid APG methodology,600.18,,,600.18,Other,324% Medicaid APG methodology,398.27,,,398.27,Other,215% Medicaid APG methodology,398.27,,,398.27,Other,215% Medicaid APG methodology,231.55,,,231.55,Other,125% Medicaid APG methodology,0.01,600.18,
PSYTX CRISIS INITIAL 60 MIN     ,90839,CPT,,50720549,CDM,914,RC,,,both,,,993,303.19,,,303.19,Other,150% of Medicare + 9.63% HCRA Surcharge,184.37,,,184.37,Other,Medicare OPPS methodology,645.45,65,,645.45,percent of total billed charges,All Other Outpatient,585.87,59,,585.87,percent of total billed charges,All Other Outpatient,496.5,50,,496.5,percent of total billed charges,All Other Outpatient,446.85,45,,446.85,percent of total billed charges,All Other Outpatient,426.99,43,,426.99,percent of total billed charges,All Other Outpatient,496.5,50,,496.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,108.81,,,108.81,Fee Schedule,Behavioral Health,344.55,,,344.55,Other,186% Medicaid methodology,96.87,,,96.87,Fee Schedule,Behavioral Health,147.29,,,147.29,Fee Schedule,Behavioral Health,147.29,,,147.29,Fee Schedule,Behavioral Health,96.87,,,96.87,Fee Schedule,Behavioral Health,147.29,,,147.29,Fee Schedule,Behavioral Health,893.7,90,,893.7,percent of total billed charges,All Other,695.1,70,,695.1,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,135.27,,,135.27,Fee Schedule,Behavioral Health,135.27,,,135.27,Fee Schedule,Behavioral Health,135.27,,,135.27,Fee Schedule,Behavioral Health,135.27,,,135.27,Fee Schedule,Behavioral Health,185.24,,,185.24,Other,New York Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,283.42,,,283.42,Other,153% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,259.34,,,259.34,Other,140% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,481.63,,,481.63,Other,260% Medicaid APG methodology,600.18,,,600.18,Other,324% Medicaid APG methodology,398.27,,,398.27,Other,215% Medicaid APG methodology,398.27,,,398.27,Other,215% Medicaid APG methodology,231.55,,,231.55,Other,125% Medicaid APG methodology,0.01,893.7,
PSYTX W PT 60 MINUTES           ,90837,CPT,,50790948,CDM,914,RC,,,both,,,546,303.19,,,303.19,Other,150% of Medicare + 9.63% HCRA Surcharge,184.37,,,184.37,Other,Medicare OPPS methodology,354.9,65,,354.9,percent of total billed charges,All Other Outpatient,322.14,59,,322.14,percent of total billed charges,All Other Outpatient,383,,,383,Fee Schedule,Behavioral Health,345,,,345,Fee Schedule,Behavioral Health,326,,,326,Fee Schedule,Behavioral Health,273,50,,273,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,108.81,,,108.81,Fee Schedule,Behavioral Health,344.55,,,344.55,Other,186% Medicaid methodology,96.87,,,96.87,Fee Schedule,Behavioral Health,147.29,,,147.29,Fee Schedule,Behavioral Health,147.29,,,147.29,Fee Schedule,Behavioral Health,96.87,,,96.87,Fee Schedule,Behavioral Health,147.29,,,147.29,Fee Schedule,Behavioral Health,491.4,90,,491.4,percent of total billed charges,All Other,382.2,70,,382.2,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,113.03,,,113.03,Fee Schedule,Behavioral Health,113.03,,,113.03,Fee Schedule,Behavioral Health,113.03,,,113.03,Fee Schedule,Behavioral Health,113.03,,,113.03,Fee Schedule,Behavioral Health,185.24,,,185.24,Other,New York Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,283.42,,,283.42,Other,153% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,259.34,,,259.34,Other,140% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,481.63,,,481.63,Other,260% Medicaid APG methodology,600.18,,,600.18,Other,324% Medicaid APG methodology,398.27,,,398.27,Other,215% Medicaid APG methodology,398.27,,,398.27,Other,215% Medicaid APG methodology,231.55,,,231.55,Other,125% Medicaid APG methodology,0.01,600.18,
PSYTX CRISIS EA ADDL 30 MIN TH  ,90840,CPT,GT       ,50791094,CDM,914,RC,,,both,,,663,261.66,,,261.66,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,430.95,65,,430.95,percent of total billed charges,All Other Outpatient,391.17,59,,391.17,percent of total billed charges,All Other Outpatient,331.5,50,,331.5,percent of total billed charges,All Other Outpatient,298.35,45,,298.35,percent of total billed charges,All Other Outpatient,285.09,43,,285.09,percent of total billed charges,All Other Outpatient,331.5,50,,331.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,65.02,,,65.02,Fee Schedule,Behavioral Health,344.55,,,344.55,Other,186% Medicaid methodology,62.36,,,62.36,Fee Schedule,Behavioral Health,78.29,,,78.29,Fee Schedule,Behavioral Health,78.29,,,78.29,Fee Schedule,Behavioral Health,62.36,,,62.36,Fee Schedule,Behavioral Health,78.29,,,78.29,Fee Schedule,Behavioral Health,596.7,90,,596.7,percent of total billed charges,All Other,464.1,70,,464.1,percent of total billed charges,All Other,99,,,99,Fee Schedule,Behavioral Health,84,,,84,Fee Schedule,Behavioral Health,6.81,,,6.81,Fee Schedule,Behavioral Health,6.81,,,6.81,Fee Schedule,Behavioral Health,6.81,,,6.81,Fee Schedule,Behavioral Health,6.81,,,6.81,Fee Schedule,Behavioral Health,185.24,,,185.24,Other,New York Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,283.42,,,283.42,Other,153% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,259.34,,,259.34,Other,140% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,481.63,,,481.63,Other,260% Medicaid APG methodology,600.18,,,600.18,Other,324% Medicaid APG methodology,398.27,,,398.27,Other,215% Medicaid APG methodology,398.27,,,398.27,Other,215% Medicaid APG methodology,231.55,,,231.55,Other,125% Medicaid APG methodology,0.01,600.18,
PSYTX W PT W E/M 30 MIN         ,90833,CPT,,50820604,CDM,914,RC,,,both,,,355,140.11,,,140.11,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,230.75,65,,230.75,percent of total billed charges,All Other Outpatient,209.45,59,,209.45,percent of total billed charges,All Other Outpatient,177.5,50,,177.5,percent of total billed charges,All Other Outpatient,159.75,45,,159.75,percent of total billed charges,All Other Outpatient,152.65,43,,152.65,percent of total billed charges,All Other Outpatient,177.5,50,,177.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,11.95,,,11.95,Fee Schedule,Behavioral Health,268.58,,,268.58,Other,186% Medicaid methodology,15.93,,,15.93,Fee Schedule,Behavioral Health,19.91,,,19.91,Fee Schedule,Behavioral Health,19.91,,,19.91,Fee Schedule,Behavioral Health,15.93,,,15.93,Fee Schedule,Behavioral Health,19.91,,,19.91,Fee Schedule,Behavioral Health,319.5,90,,319.5,percent of total billed charges,All Other,248.5,70,,248.5,percent of total billed charges,All Other,28,,,28,Fee Schedule,Behavioral Health,24,,,24,Fee Schedule,Behavioral Health,53.82,,,53.82,Fee Schedule,Behavioral Health,53.82,,,53.82,Fee Schedule,Behavioral Health,53.82,,,53.82,Fee Schedule,Behavioral Health,53.82,,,53.82,Fee Schedule,Behavioral Health,144.4,,,144.4,Other,New York Medicaid APG methodology,144.4,,,144.4,Other,100% Medicaid APG methodology,144.4,,,144.4,Other,100% Medicaid APG methodology,144.4,,,144.4,Other,100% Medicaid APG methodology,324.9,,,324.9,Other,225% Medicaid APG methodology,324.9,,,324.9,Other,225% Medicaid APG methodology,220.93,,,220.93,Other,153% Medicaid APG methodology,324.9,,,324.9,Other,225% Medicaid APG methodology,202.16,,,202.16,Other,140% Medicaid APG methodology,324.9,,,324.9,Other,225% Medicaid APG methodology,375.44,,,375.44,Other,260% Medicaid APG methodology,467.85,,,467.85,Other,324% Medicaid APG methodology,310.46,,,310.46,Other,215% Medicaid APG methodology,310.46,,,310.46,Other,215% Medicaid APG methodology,180.5,,,180.5,Other,125% Medicaid APG methodology,0.01,467.85,
PSYTX W PT W E/M 45 MIN         ,90836,CPT,,50820612,CDM,914,RC,,,both,,,121,47.75,,,47.75,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,78.65,65,,78.65,percent of total billed charges,All Other Outpatient,71.39,59,,71.39,percent of total billed charges,All Other Outpatient,60.5,50,,60.5,percent of total billed charges,All Other Outpatient,54.45,45,,54.45,percent of total billed charges,All Other Outpatient,52.03,43,,52.03,percent of total billed charges,All Other Outpatient,60.5,50,,60.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,62.36,,,62.36,Fee Schedule,Behavioral Health,344.55,,,344.55,Other,186% Medicaid methodology,55.74,,,55.74,Fee Schedule,Behavioral Health,88.91,,,88.91,Fee Schedule,Behavioral Health,88.91,,,88.91,Fee Schedule,Behavioral Health,55.74,,,55.74,Fee Schedule,Behavioral Health,88.91,,,88.91,Fee Schedule,Behavioral Health,108.9,90,,108.9,percent of total billed charges,All Other,84.7,70,,84.7,percent of total billed charges,All Other,100,,,100,Fee Schedule,Behavioral Health,86,,,86,Fee Schedule,Behavioral Health,81.09,,,81.09,Fee Schedule,Behavioral Health,81.09,,,81.09,Fee Schedule,Behavioral Health,81.09,,,81.09,Fee Schedule,Behavioral Health,81.09,,,81.09,Fee Schedule,Behavioral Health,185.24,,,185.24,Other,New York Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,283.42,,,283.42,Other,153% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,259.34,,,259.34,Other,140% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,481.63,,,481.63,Other,260% Medicaid APG methodology,600.18,,,600.18,Other,324% Medicaid APG methodology,398.27,,,398.27,Other,215% Medicaid APG methodology,398.27,,,398.27,Other,215% Medicaid APG methodology,231.55,,,231.55,Other,125% Medicaid APG methodology,0.01,600.18,
PSYTX W PT 30 MINUTES           ,90832,CPT,,50820646,CDM,914,RC,,,both,,,538,303.19,,,303.19,Other,150% of Medicare + 9.63% HCRA Surcharge,184.37,,,184.37,Other,Medicare OPPS methodology,349.7,65,,349.7,percent of total billed charges,All Other Outpatient,317.42,59,,317.42,percent of total billed charges,All Other Outpatient,214,,,214,Fee Schedule,Behavioral Health,193,,,193,Fee Schedule,Behavioral Health,182,,,182,Fee Schedule,Behavioral Health,269,50,,269,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,65.02,,,65.02,Fee Schedule,Behavioral Health,268.58,,,268.58,Other,186% Medicaid methodology,62.36,,,62.36,Fee Schedule,Behavioral Health,78.29,,,78.29,Fee Schedule,Behavioral Health,78.29,,,78.29,Fee Schedule,Behavioral Health,62.36,,,62.36,Fee Schedule,Behavioral Health,78.29,,,78.29,Fee Schedule,Behavioral Health,484.2,90,,484.2,percent of total billed charges,All Other,376.6,70,,376.6,percent of total billed charges,All Other,99,,,99,Fee Schedule,Behavioral Health,84,,,84,Fee Schedule,Behavioral Health,70.68,,,70.68,Fee Schedule,Behavioral Health,70.68,,,70.68,Fee Schedule,Behavioral Health,70.68,,,70.68,Fee Schedule,Behavioral Health,70.68,,,70.68,Fee Schedule,Behavioral Health,144.4,,,144.4,Other,New York Medicaid APG methodology,144.4,,,144.4,Other,100% Medicaid APG methodology,144.4,,,144.4,Other,100% Medicaid APG methodology,144.4,,,144.4,Other,100% Medicaid APG methodology,324.9,,,324.9,Other,225% Medicaid APG methodology,324.9,,,324.9,Other,225% Medicaid APG methodology,220.93,,,220.93,Other,153% Medicaid APG methodology,324.9,,,324.9,Other,225% Medicaid APG methodology,202.16,,,202.16,Other,140% Medicaid APG methodology,324.9,,,324.9,Other,225% Medicaid APG methodology,375.44,,,375.44,Other,260% Medicaid APG methodology,467.85,,,467.85,Other,324% Medicaid APG methodology,310.46,,,310.46,Other,215% Medicaid APG methodology,310.46,,,310.46,Other,215% Medicaid APG methodology,180.5,,,180.5,Other,125% Medicaid APG methodology,0.01,484.2,
PSYTX W PT 45 MINUTES           ,90834,CPT,,50820653,CDM,914,RC,,,both,,,643,303.19,,,303.19,Other,150% of Medicare + 9.63% HCRA Surcharge,184.37,,,184.37,Other,Medicare OPPS methodology,417.95,65,,417.95,percent of total billed charges,All Other Outpatient,379.37,59,,379.37,percent of total billed charges,All Other Outpatient,383,,,383,Fee Schedule,Behavioral Health,345,,,345,Fee Schedule,Behavioral Health,326,,,326,Fee Schedule,Behavioral Health,321.5,50,,321.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,108.81,,,108.81,Fee Schedule,Behavioral Health,344.55,,,344.55,Other,186% Medicaid methodology,96.87,,,96.87,Fee Schedule,Behavioral Health,147.29,,,147.29,Fee Schedule,Behavioral Health,147.29,,,147.29,Fee Schedule,Behavioral Health,96.87,,,96.87,Fee Schedule,Behavioral Health,147.29,,,147.29,Fee Schedule,Behavioral Health,578.7,90,,578.7,percent of total billed charges,All Other,450.1,70,,450.1,percent of total billed charges,All Other,154,,,154,Fee Schedule,Behavioral Health,131,,,131,Fee Schedule,Behavioral Health,106.58,,,106.58,Fee Schedule,Behavioral Health,106.58,,,106.58,Fee Schedule,Behavioral Health,106.58,,,106.58,Fee Schedule,Behavioral Health,106.58,,,106.58,Fee Schedule,Behavioral Health,185.24,,,185.24,Other,New York Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,283.42,,,283.42,Other,153% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,259.34,,,259.34,Other,140% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,481.63,,,481.63,Other,260% Medicaid APG methodology,600.18,,,600.18,Other,324% Medicaid APG methodology,398.27,,,398.27,Other,215% Medicaid APG methodology,398.27,,,398.27,Other,215% Medicaid APG methodology,231.55,,,231.55,Other,125% Medicaid APG methodology,0.01,600.18,
MED SERV EVE/WKEND/HOLIDAY      ,99051,CPT,,50820752,CDM,914,RC,,,both,,,15,5.92,,,5.92,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,9.75,65,,9.75,percent of total billed charges,All Other Outpatient,8.85,59,,8.85,percent of total billed charges,All Other Outpatient,7.5,50,,7.5,percent of total billed charges,All Other Outpatient,6.75,45,,6.75,percent of total billed charges,All Other Outpatient,6.45,43,,6.45,percent of total billed charges,All Other Outpatient,7.5,50,,7.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,10.2,68,,10.2,percent of total billed charges,All Other Outpatient,68.53,,,68.53,Other,186% Medicaid methodology,12,80,,12,percent of total billed charges,All Other Outpatient,12.45,83,,12.45,percent of total billed charges,All Other Outpatient,12.45,83,,12.45,percent of total billed charges,All Other Outpatient,12,80,,12,percent of total billed charges,All Other Outpatient,12.45,83,,12.45,percent of total billed charges,All Other Outpatient,13.5,90,,13.5,percent of total billed charges,All Other,10.5,70,,10.5,percent of total billed charges,All Other,7.5,50,,7.5,percent of total billed charges,All Other,7.5,50,,7.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,0.01,,,0.01,Other,Non-covered service,36.85,,,36.85,Other,New York Medicaid APG methodology,36.85,,,36.85,Other,100% Medicaid APG methodology,36.85,,,36.85,Other,100% Medicaid APG methodology,36.85,,,36.85,Other,100% Medicaid APG methodology,82.9,,,82.9,Other,225% Medicaid APG methodology,82.9,,,82.9,Other,225% Medicaid APG methodology,56.37,,,56.37,Other,153% Medicaid APG methodology,82.9,,,82.9,Other,225% Medicaid APG methodology,51.58,,,51.58,Other,140% Medicaid APG methodology,82.9,,,82.9,Other,225% Medicaid APG methodology,95.8,,,95.8,Other,260% Medicaid APG methodology,119.38,,,119.38,Other,324% Medicaid APG methodology,79.22,,,79.22,Other,215% Medicaid APG methodology,79.22,,,79.22,Other,215% Medicaid APG methodology,46.06,,,46.06,Other,125% Medicaid APG methodology,0.01,119.38,
GROUP PSYCHOTHERAPY             ,90853,CPT,,50720150,CDM,915,RC,,,both,,,1056,169.51,,,169.51,Other,150% of Medicare + 9.63% HCRA Surcharge,103.08,,,103.08,Other,Medicare OPPS methodology,686.4,65,,686.4,percent of total billed charges,All Other Outpatient,623.04,59,,623.04,percent of total billed charges,All Other Outpatient,181,,,181,Fee Schedule,Behavioral Health,163,,,163,Fee Schedule,Behavioral Health,154,,,154,Fee Schedule,Behavioral Health,528,50,,528,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,65.02,,,65.02,Fee Schedule,Behavioral Health,158.43,,,158.43,Other,186% Medicaid methodology,51.75,,,51.75,Fee Schedule,Behavioral Health,67.67,,,67.67,Fee Schedule,Behavioral Health,67.67,,,67.67,Fee Schedule,Behavioral Health,51.75,,,51.75,Fee Schedule,Behavioral Health,67.67,,,67.67,Fee Schedule,Behavioral Health,950.4,90,,950.4,percent of total billed charges,All Other,739.2,70,,739.2,percent of total billed charges,All Other,103,,,103,Fee Schedule,Behavioral Health,88,,,88,Fee Schedule,Behavioral Health,64.59,,,64.59,Fee Schedule,Behavioral Health,64.59,,,64.59,Fee Schedule,Behavioral Health,64.59,,,64.59,Fee Schedule,Behavioral Health,64.59,,,64.59,Fee Schedule,Behavioral Health,85.18,,,85.18,Other,New York Medicaid APG methodology,85.18,,,85.18,Other,100% Medicaid APG methodology,85.18,,,85.18,Other,100% Medicaid APG methodology,85.18,,,85.18,Other,100% Medicaid APG methodology,191.65,,,191.65,Other,225% Medicaid APG methodology,191.65,,,191.65,Other,225% Medicaid APG methodology,130.32,,,130.32,Other,153% Medicaid APG methodology,191.65,,,191.65,Other,225% Medicaid APG methodology,119.25,,,119.25,Other,140% Medicaid APG methodology,191.65,,,191.65,Other,225% Medicaid APG methodology,221.46,,,221.46,Other,260% Medicaid APG methodology,275.97,,,275.97,Other,324% Medicaid APG methodology,183.13,,,183.13,Other,215% Medicaid APG methodology,183.13,,,183.13,Other,215% Medicaid APG methodology,106.47,,,106.47,Other,125% Medicaid APG methodology,0.01,950.4,
FAMILY PSYTX W/PT 50 MIN        ,90847,CPT,,50720168,CDM,916,RC,,,both,,,643,303.19,,,303.19,Other,150% of Medicare + 9.63% HCRA Surcharge,184.37,,,184.37,Other,Medicare OPPS methodology,419.78,,,419.78,Fee Schedule,,378.02,,,378.02,Fee Schedule,,302,,,302,Fee Schedule,Behavioral Health,272,,,272,Fee Schedule,Behavioral Health,257,,,257,Fee Schedule,Behavioral Health,321.5,50,,321.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,108.81,,,108.81,Fee Schedule,Behavioral Health,268.58,,,268.58,Other,186% Medicaid methodology,96.87,,,96.87,Fee Schedule,Behavioral Health,127.39,,,127.39,Fee Schedule,Behavioral Health,127.39,,,127.39,Fee Schedule,Behavioral Health,96.87,,,96.87,Fee Schedule,Behavioral Health,127.39,,,127.39,Fee Schedule,Behavioral Health,578.7,90,,578.7,percent of total billed charges,All Other,450.1,70,,450.1,percent of total billed charges,All Other,170,,,170,Fee Schedule,Behavioral Health,145,,,145,Fee Schedule,Behavioral Health,107.27,,,107.27,Fee Schedule,Behavioral Health,107.27,,,107.27,Fee Schedule,Behavioral Health,107.27,,,107.27,Fee Schedule,Behavioral Health,107.27,,,107.27,Fee Schedule,Behavioral Health,144.4,,,144.4,Other,New York Medicaid APG methodology,144.4,,,144.4,Other,100% Medicaid APG methodology,144.4,,,144.4,Other,100% Medicaid APG methodology,144.4,,,144.4,Other,100% Medicaid APG methodology,324.9,,,324.9,Other,225% Medicaid APG methodology,324.9,,,324.9,Other,225% Medicaid APG methodology,220.93,,,220.93,Other,153% Medicaid APG methodology,324.9,,,324.9,Other,225% Medicaid APG methodology,202.16,,,202.16,Other,140% Medicaid APG methodology,324.9,,,324.9,Other,225% Medicaid APG methodology,375.44,,,375.44,Other,260% Medicaid APG methodology,467.85,,,467.85,Other,324% Medicaid APG methodology,310.46,,,310.46,Other,215% Medicaid APG methodology,310.46,,,310.46,Other,215% Medicaid APG methodology,180.5,,,180.5,Other,125% Medicaid APG methodology,0.01,578.7,
FAMILY PSYTX W/PT 50 MIN        ,90847,CPT,,50820679,CDM,916,RC,,,both,,,643,303.19,,,303.19,Other,150% of Medicare + 9.63% HCRA Surcharge,184.37,,,184.37,Other,Medicare OPPS methodology,419.78,,,419.78,Fee Schedule,,378.02,,,378.02,Fee Schedule,,302,,,302,Fee Schedule,Behavioral Health,272,,,272,Fee Schedule,Behavioral Health,257,,,257,Fee Schedule,Behavioral Health,321.5,50,,321.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,108.81,,,108.81,Fee Schedule,Behavioral Health,268.58,,,268.58,Other,186% Medicaid methodology,96.87,,,96.87,Fee Schedule,Behavioral Health,127.39,,,127.39,Fee Schedule,Behavioral Health,127.39,,,127.39,Fee Schedule,Behavioral Health,96.87,,,96.87,Fee Schedule,Behavioral Health,127.39,,,127.39,Fee Schedule,Behavioral Health,578.7,90,,578.7,percent of total billed charges,All Other,450.1,70,,450.1,percent of total billed charges,All Other,170,,,170,Fee Schedule,Behavioral Health,145,,,145,Fee Schedule,Behavioral Health,107.27,,,107.27,Fee Schedule,Behavioral Health,107.27,,,107.27,Fee Schedule,Behavioral Health,107.27,,,107.27,Fee Schedule,Behavioral Health,107.27,,,107.27,Fee Schedule,Behavioral Health,144.4,,,144.4,Other,New York Medicaid APG methodology,144.4,,,144.4,Other,100% Medicaid APG methodology,144.4,,,144.4,Other,100% Medicaid APG methodology,144.4,,,144.4,Other,100% Medicaid APG methodology,324.9,,,324.9,Other,225% Medicaid APG methodology,324.9,,,324.9,Other,225% Medicaid APG methodology,220.93,,,220.93,Other,153% Medicaid APG methodology,324.9,,,324.9,Other,225% Medicaid APG methodology,202.16,,,202.16,Other,140% Medicaid APG methodology,324.9,,,324.9,Other,225% Medicaid APG methodology,375.44,,,375.44,Other,260% Medicaid APG methodology,467.85,,,467.85,Other,324% Medicaid APG methodology,310.46,,,310.46,Other,215% Medicaid APG methodology,310.46,,,310.46,Other,215% Medicaid APG methodology,180.5,,,180.5,Other,125% Medicaid APG methodology,0.01,578.7,
PSYCHIATRIC SERVICE/THERAPY     ,90899,CPT,,50720127,CDM,919,RC,,,both,,,107,54.57,,,54.57,Other,150% of Medicare + 9.63% HCRA Surcharge,33.18,,,33.18,Other,Medicare OPPS methodology,69.55,65,,69.55,percent of total billed charges,All Other Outpatient,63.13,59,,63.13,percent of total billed charges,All Other Outpatient,53.5,50,,53.5,percent of total billed charges,All Other Outpatient,48.15,45,,48.15,percent of total billed charges,All Other Outpatient,46.01,43,,46.01,percent of total billed charges,All Other Outpatient,53.5,50,,53.5,percent of total billed charges,All Other,0.01,,,0.01,Other,Non-covered service,72.76,68,,72.76,percent of total billed charges,All Other Outpatient,344.55,,,344.55,Other,186% Medicaid methodology,85.6,80,,85.6,percent of total billed charges,All Other Outpatient,88.81,83,,88.81,percent of total billed charges,All Other Outpatient,88.81,83,,88.81,percent of total billed charges,All Other Outpatient,85.6,80,,85.6,percent of total billed charges,All Other Outpatient,88.81,83,,88.81,percent of total billed charges,All Other Outpatient,96.3,90,,96.3,percent of total billed charges,All Other,74.9,70,,74.9,percent of total billed charges,All Other,53.5,50,,53.5,percent of total billed charges,All Other,53.5,50,,53.5,percent of total billed charges,All Other,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,0.01,,,0.01,Fee Schedule,Behavioral Health,185.24,,,185.24,Other,New York Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,185.24,,,185.24,Other,100% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,283.42,,,283.42,Other,153% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,259.34,,,259.34,Other,140% Medicaid APG methodology,416.79,,,416.79,Other,225% Medicaid APG methodology,481.63,,,481.63,Other,260% Medicaid APG methodology,600.18,,,600.18,Other,324% Medicaid APG methodology,398.27,,,398.27,Other,215% Medicaid APG methodology,398.27,,,398.27,Other,215% Medicaid APG methodology,231.55,,,231.55,Other,125% Medicaid APG methodology,0.01,600.18,
MULTIPLE SLEEP LATENCY TEST     ,95805,CPT,,46700027,CDM,920,RC,,,both,,,9683,1019.25,,,1019.25,Other,150% of Medicare + 9.63% HCRA Surcharge,619.81,,,619.81,Other,Medicare OPPS methodology,3746,,,3746,Case Rate,,3371,,,3371,Case Rate,,3199.34,,,3199.34,Fee Schedule,,2878.51,,,2878.51,Fee Schedule,,2718.1,,,2718.1,Fee Schedule,,4841.5,50,,4841.5,percent of total billed charges,All Other,6778.1,70,,6778.1,percent of total billed charges,All Other,6584.44,68,,6584.44,percent of total billed charges,All Other Outpatient,1758.79,,,1758.79,Other,186% Medicaid methodology,7746.4,80,,7746.4,percent of total billed charges,All Other Outpatient,8036.89,83,,8036.89,percent of total billed charges,All Other Outpatient,8036.89,83,,8036.89,percent of total billed charges,All Other Outpatient,7746.4,80,,7746.4,percent of total billed charges,All Other Outpatient,8036.89,83,,8036.89,percent of total billed charges,All Other Outpatient,8714.7,90,,8714.7,percent of total billed charges,All Other,6778.1,70,,6778.1,percent of total billed charges,All Other,1758.9,,,1758.9,Fee Schedule,,1492.4,,,1492.4,Fee Schedule,,2059,,,2059,Case Rate,Sleep Study Case Rate,1886,,,1886,Case Rate,Sleep Study Case Rate,2095,,,2095,Case Rate,Sleep Study Case Rate,1780,,,1780,Case Rate,Sleep Study Case Rate,945.58,,,945.58,Other,New York Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,1446.74,,,1446.74,Other,153% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,1323.82,,,1323.82,Other,140% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,2458.52,,,2458.52,Other,260% Medicaid APG methodology,3063.69,,,3063.69,Other,324% Medicaid APG methodology,2033.01,,,2033.01,Other,215% Medicaid APG methodology,2033.01,,,2033.01,Other,215% Medicaid APG methodology,1181.98,,,1181.98,Other,125% Medicaid APG methodology,619.81,8714.7,
POLYSOM 6/> YRS 4/> PARAM       ,95810,CPT,,46700035,CDM,920,RC,,,both,,,18122,1988.24,,,1988.24,Other,150% of Medicare + 9.63% HCRA Surcharge,1209.06,,,1209.06,Other,Medicare OPPS methodology,3746,,,3746,Case Rate,,3371,,,3371,Case Rate,,5220.51,,,5220.51,Fee Schedule,,4697,,,4697,Fee Schedule,,4435.25,,,4435.25,Fee Schedule,,9061,50,,9061,percent of total billed charges,All Other,12685.4,70,,12685.4,percent of total billed charges,All Other,12322.96,68,,12322.96,percent of total billed charges,All Other Outpatient,1758.79,,,1758.79,Other,186% Medicaid methodology,14497.6,80,,14497.6,percent of total billed charges,All Other Outpatient,15041.26,83,,15041.26,percent of total billed charges,All Other Outpatient,15041.26,83,,15041.26,percent of total billed charges,All Other Outpatient,14497.6,80,,14497.6,percent of total billed charges,All Other Outpatient,15041.26,83,,15041.26,percent of total billed charges,All Other Outpatient,16309.8,90,,16309.8,percent of total billed charges,All Other,12685.4,70,,12685.4,percent of total billed charges,All Other,2390.85,,,2390.85,Fee Schedule,,2028.6,,,2028.6,Fee Schedule,,2059,,,2059,Case Rate,Sleep Study Case Rate,1886,,,1886,Case Rate,Sleep Study Case Rate,2095,,,2095,Case Rate,Sleep Study Case Rate,1780,,,1780,Case Rate,Sleep Study Case Rate,945.58,,,945.58,Other,New York Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,1446.74,,,1446.74,Other,153% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,1323.82,,,1323.82,Other,140% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,2458.52,,,2458.52,Other,260% Medicaid APG methodology,3063.69,,,3063.69,Other,324% Medicaid APG methodology,2033.01,,,2033.01,Other,215% Medicaid APG methodology,2033.01,,,2033.01,Other,215% Medicaid APG methodology,1181.98,,,1181.98,Other,125% Medicaid APG methodology,945.58,16309.8,
POLYSOM 6/> YRS 4/> PARAM       ,95810,CPT,52,46700068,CDM,920,RC,,,both,,,18122,1988.24,,,1988.24,Other,150% of Medicare + 9.63% HCRA Surcharge,1209.06,,,1209.06,Other,Medicare OPPS methodology,3746,,,3746,Case Rate,,3371,,,3371,Case Rate,,5220.51,,,5220.51,Fee Schedule,,4697,,,4697,Fee Schedule,,4435.25,,,4435.25,Fee Schedule,,9061,50,,9061,percent of total billed charges,All Other,12685.4,70,,12685.4,percent of total billed charges,All Other,12322.96,68,,12322.96,percent of total billed charges,All Other Outpatient,1758.79,,,1758.79,Other,186% Medicaid methodology,14497.6,80,,14497.6,percent of total billed charges,All Other Outpatient,15041.26,83,,15041.26,percent of total billed charges,All Other Outpatient,15041.26,83,,15041.26,percent of total billed charges,All Other Outpatient,14497.6,80,,14497.6,percent of total billed charges,All Other Outpatient,15041.26,83,,15041.26,percent of total billed charges,All Other Outpatient,16309.8,90,,16309.8,percent of total billed charges,All Other,12685.4,70,,12685.4,percent of total billed charges,All Other,2390.85,,,2390.85,Fee Schedule,,2028.6,,,2028.6,Fee Schedule,,2059,,,2059,Case Rate,Sleep Study Case Rate,1886,,,1886,Case Rate,Sleep Study Case Rate,2095,,,2095,Case Rate,Sleep Study Case Rate,1780,,,1780,Case Rate,Sleep Study Case Rate,945.58,,,945.58,Other,New York Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,1446.74,,,1446.74,Other,153% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,1323.82,,,1323.82,Other,140% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,2458.52,,,2458.52,Other,260% Medicaid APG methodology,3063.69,,,3063.69,Other,324% Medicaid APG methodology,2033.01,,,2033.01,Other,215% Medicaid APG methodology,2033.01,,,2033.01,Other,215% Medicaid APG methodology,1181.98,,,1181.98,Other,125% Medicaid APG methodology,945.58,16309.8,
POLYSOM 6/>YRS CPAP 4/> PARM    ,95811,CPT,52,46700076,CDM,920,RC,,,both,,,18122,1988.24,,,1988.24,Other,150% of Medicare + 9.63% HCRA Surcharge,1209.06,,,1209.06,Other,Medicare OPPS methodology,3746,,,3746,Case Rate,,3371,,,3371,Case Rate,,5672.77,,,5672.77,Fee Schedule,,5103.92,,,5103.92,Fee Schedule,,4819.49,,,4819.49,Fee Schedule,,9061,50,,9061,percent of total billed charges,All Other,12685.4,70,,12685.4,percent of total billed charges,All Other,12322.96,68,,12322.96,percent of total billed charges,All Other Outpatient,1758.79,,,1758.79,Other,186% Medicaid methodology,14497.6,80,,14497.6,percent of total billed charges,All Other Outpatient,15041.26,83,,15041.26,percent of total billed charges,All Other Outpatient,15041.26,83,,15041.26,percent of total billed charges,All Other Outpatient,14497.6,80,,14497.6,percent of total billed charges,All Other Outpatient,15041.26,83,,15041.26,percent of total billed charges,All Other Outpatient,16309.8,90,,16309.8,percent of total billed charges,All Other,12685.4,70,,12685.4,percent of total billed charges,All Other,2499.75,,,2499.75,Fee Schedule,,2121,,,2121,Fee Schedule,,2059,,,2059,Case Rate,Sleep Study Case Rate,1886,,,1886,Case Rate,Sleep Study Case Rate,2095,,,2095,Case Rate,Sleep Study Case Rate,1780,,,1780,Case Rate,Sleep Study Case Rate,945.58,,,945.58,Other,New York Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,945.58,,,945.58,Other,100% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,1446.74,,,1446.74,Other,153% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,1323.82,,,1323.82,Other,140% Medicaid APG methodology,2127.57,,,2127.57,Other,225% Medicaid APG methodology,2458.52,,,2458.52,Other,260% Medicaid APG methodology,3063.69,,,3063.69,Other,324% Medicaid APG methodology,2033.01,,,2033.01,Other,215% Medicaid APG methodology,2033.01,,,2033.01,Other,215% Medicaid APG methodology,1181.98,,,1181.98,Other,125% Medicaid APG methodology,945.58,16309.8,
UPR/L XTREMITY ART 2 LEVELS     ,93922,CPT,,47900345,CDM,920,RC,,,both,,,2401,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,352.67,,,352.67,Fee Schedule,,317.49,,,317.49,Fee Schedule,,901.16,,,901.16,Fee Schedule,,810.79,,,810.79,Fee Schedule,,765.61,,,765.61,Fee Schedule,,1200.5,50,,1200.5,percent of total billed charges,All Other,328.28,,,328.28,Fee Schedule,,317.49,,,317.49,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,373.61,,,373.61,Fee Schedule,,1488.62,,,1488.62,Fee Schedule,,175.92,,,175.92,Fee Schedule,,373.61,,,373.61,Fee Schedule,,1488.62,,,1488.62,Fee Schedule,,2160.9,90,,2160.9,percent of total billed charges,All Other,1680.7,70,,1680.7,percent of total billed charges,All Other,344.85,,,344.85,Fee Schedule,,292.6,,,292.6,Fee Schedule,,1200.5,50,,1200.5,percent of total billed charges,All Other Outpatient,1200.5,50,,1200.5,percent of total billed charges,All Other Outpatient,1200.5,50,,1200.5,percent of total billed charges,All Other Outpatient,1200.5,50,,1200.5,percent of total billed charges,All Other Outpatient,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,147.72,2160.9,
UPR/LXTR ART STDY 3+ LVLS       ,93923,CPT,,47900352,CDM,920,RC,,,both,,,2623,297.05,,,297.05,Other,150% of Medicare + 9.63% HCRA Surcharge,180.63,,,180.63,Other,Medicare OPPS methodology,543.89,,,543.89,Fee Schedule,,489.63,,,489.63,Fee Schedule,,1359.46,,,1359.46,Fee Schedule,,1223.14,,,1223.14,Fee Schedule,,1154.97,,,1154.97,Fee Schedule,,1311.5,50,,1311.5,percent of total billed charges,All Other,409.21,,,409.21,Fee Schedule,,489.63,,,489.63,Fee Schedule,,374.3,,,374.3,Other,186% Medicaid methodology,576.19,,,576.19,Fee Schedule,,1626.26,,,1626.26,Fee Schedule,,271.3,,,271.3,Fee Schedule,,576.19,,,576.19,Fee Schedule,,1626.26,,,1626.26,Fee Schedule,,2360.7,90,,2360.7,percent of total billed charges,All Other,1836.1,70,,1836.1,percent of total billed charges,All Other,526.35,,,526.35,Fee Schedule,,446.6,,,446.6,Fee Schedule,,1311.5,50,,1311.5,percent of total billed charges,All Other Outpatient,1311.5,50,,1311.5,percent of total billed charges,All Other Outpatient,1311.5,50,,1311.5,percent of total billed charges,All Other Outpatient,1311.5,50,,1311.5,percent of total billed charges,All Other Outpatient,201.24,,,201.24,Other,New York Medicaid APG methodology,201.24,,,201.24,Other,100% Medicaid APG methodology,201.24,,,201.24,Other,100% Medicaid APG methodology,201.24,,,201.24,Other,100% Medicaid APG methodology,452.78,,,452.78,Other,225% Medicaid APG methodology,452.78,,,452.78,Other,225% Medicaid APG methodology,307.89,,,307.89,Other,153% Medicaid APG methodology,452.78,,,452.78,Other,225% Medicaid APG methodology,281.73,,,281.73,Other,140% Medicaid APG methodology,452.78,,,452.78,Other,225% Medicaid APG methodology,523.21,,,523.21,Other,260% Medicaid APG methodology,652,,,652,Other,324% Medicaid APG methodology,432.66,,,432.66,Other,215% Medicaid APG methodology,432.66,,,432.66,Other,215% Medicaid APG methodology,251.54,,,251.54,Other,125% Medicaid APG methodology,180.63,2360.7,
FETAL NON-STRESS TEST           ,59025,CPT,,48300008,CDM,920,RC,,,both,,,2237,378.94,,,378.94,Other,150% of Medicare + 9.63% HCRA Surcharge,230.43,,,230.43,Other,Medicare OPPS methodology,92.44,,,92.44,Fee Schedule,,83.25,,,83.25,Fee Schedule,,159.11,,,159.11,Fee Schedule,,143.15,,,143.15,Fee Schedule,,135.18,,,135.18,Fee Schedule,,1118.5,50,,1118.5,percent of total billed charges,All Other,1565.9,70,,1565.9,percent of total billed charges,All Other,91.72,,,91.72,Fee Schedule,,722.7,,,722.7,Other,186% Medicaid methodology,107.93,,,107.93,Fee Schedule,,1386.94,,,1386.94,Fee Schedule,,50.82,,,50.82,Fee Schedule,,107.93,,,107.93,Fee Schedule,,1386.94,,,1386.94,Fee Schedule,,2013.3,90,,2013.3,percent of total billed charges,All Other,1565.9,70,,1565.9,percent of total billed charges,All Other,95.7,,,95.7,Fee Schedule,,81.2,,,81.2,Fee Schedule,,1118.5,50,,1118.5,percent of total billed charges,All Other Outpatient,1118.5,50,,1118.5,percent of total billed charges,All Other Outpatient,1118.5,50,,1118.5,percent of total billed charges,All Other Outpatient,1118.5,50,,1118.5,percent of total billed charges,All Other Outpatient,388.55,,,388.55,Other,New York Medicaid APG methodology,388.55,,,388.55,Other,100% Medicaid APG methodology,388.55,,,388.55,Other,100% Medicaid APG methodology,388.55,,,388.55,Other,100% Medicaid APG methodology,874.24,,,874.24,Other,225% Medicaid APG methodology,874.24,,,874.24,Other,225% Medicaid APG methodology,594.48,,,594.48,Other,153% Medicaid APG methodology,874.24,,,874.24,Other,225% Medicaid APG methodology,543.97,,,543.97,Other,140% Medicaid APG methodology,874.24,,,874.24,Other,225% Medicaid APG methodology,1010.23,,,1010.23,Other,260% Medicaid APG methodology,1258.91,,,1258.91,Other,324% Medicaid APG methodology,835.38,,,835.38,Other,215% Medicaid APG methodology,835.38,,,835.38,Other,215% Medicaid APG methodology,485.69,,,485.69,Other,125% Medicaid APG methodology,50.82,2013.3,
FETAL CONTRACT STRESS TEST      ,59020,CPT,,48300107,CDM,920,RC,,,both,,,821,378.94,,,378.94,Other,150% of Medicare + 9.63% HCRA Surcharge,230.43,,,230.43,Other,Medicare OPPS methodology,158.49,,,158.49,Fee Schedule,,142.73,,,142.73,Fee Schedule,,410.5,50,,410.5,percent of total billed charges,All Other Outpatient,369.45,45,,369.45,percent of total billed charges,All Other Outpatient,353.03,43,,353.03,percent of total billed charges,All Other Outpatient,410.5,50,,410.5,percent of total billed charges,All Other,574.7,70,,574.7,percent of total billed charges,All Other,157.25,,,157.25,Fee Schedule,,722.7,,,722.7,Other,186% Medicaid methodology,185.05,,,185.05,Fee Schedule,,509.02,,,509.02,Fee Schedule,,87.13,,,87.13,Fee Schedule,,185.05,,,185.05,Fee Schedule,,509.02,,,509.02,Fee Schedule,,738.9,90,,738.9,percent of total billed charges,All Other,574.7,70,,574.7,percent of total billed charges,All Other,163.35,,,163.35,Fee Schedule,,138.6,,,138.6,Fee Schedule,,410.5,50,,410.5,percent of total billed charges,All Other Outpatient,410.5,50,,410.5,percent of total billed charges,All Other Outpatient,410.5,50,,410.5,percent of total billed charges,All Other Outpatient,410.5,50,,410.5,percent of total billed charges,All Other Outpatient,388.55,,,388.55,Other,New York Medicaid APG methodology,388.55,,,388.55,Other,100% Medicaid APG methodology,388.55,,,388.55,Other,100% Medicaid APG methodology,388.55,,,388.55,Other,100% Medicaid APG methodology,874.24,,,874.24,Other,225% Medicaid APG methodology,874.24,,,874.24,Other,225% Medicaid APG methodology,594.48,,,594.48,Other,153% Medicaid APG methodology,874.24,,,874.24,Other,225% Medicaid APG methodology,543.97,,,543.97,Other,140% Medicaid APG methodology,874.24,,,874.24,Other,225% Medicaid APG methodology,1010.23,,,1010.23,Other,260% Medicaid APG methodology,1258.91,,,1258.91,Other,324% Medicaid APG methodology,835.38,,,835.38,Other,215% Medicaid APG methodology,835.38,,,835.38,Other,215% Medicaid APG methodology,485.69,,,485.69,Other,125% Medicaid APG methodology,87.13,1258.91,
FETAL NON-STRESS TEST ADDTL     ,59025,CPT,XS       ,48301741,CDM,920,RC,,,both,,,2237,378.94,,,378.94,Other,150% of Medicare + 9.63% HCRA Surcharge,230.43,,,230.43,Other,Medicare OPPS methodology,92.44,,,92.44,Fee Schedule,,83.25,,,83.25,Fee Schedule,,159.11,,,159.11,Fee Schedule,,143.15,,,143.15,Fee Schedule,,135.18,,,135.18,Fee Schedule,,1118.5,50,,1118.5,percent of total billed charges,All Other,1565.9,70,,1565.9,percent of total billed charges,All Other,91.72,,,91.72,Fee Schedule,,722.7,,,722.7,Other,186% Medicaid methodology,107.93,,,107.93,Fee Schedule,,1386.94,,,1386.94,Fee Schedule,,50.82,,,50.82,Fee Schedule,,107.93,,,107.93,Fee Schedule,,1386.94,,,1386.94,Fee Schedule,,2013.3,90,,2013.3,percent of total billed charges,All Other,1565.9,70,,1565.9,percent of total billed charges,All Other,95.7,,,95.7,Fee Schedule,,81.2,,,81.2,Fee Schedule,,1118.5,50,,1118.5,percent of total billed charges,All Other Outpatient,1118.5,50,,1118.5,percent of total billed charges,All Other Outpatient,1118.5,50,,1118.5,percent of total billed charges,All Other Outpatient,1118.5,50,,1118.5,percent of total billed charges,All Other Outpatient,388.55,,,388.55,Other,New York Medicaid APG methodology,388.55,,,388.55,Other,100% Medicaid APG methodology,388.55,,,388.55,Other,100% Medicaid APG methodology,388.55,,,388.55,Other,100% Medicaid APG methodology,874.24,,,874.24,Other,225% Medicaid APG methodology,874.24,,,874.24,Other,225% Medicaid APG methodology,594.48,,,594.48,Other,153% Medicaid APG methodology,874.24,,,874.24,Other,225% Medicaid APG methodology,543.97,,,543.97,Other,140% Medicaid APG methodology,874.24,,,874.24,Other,225% Medicaid APG methodology,1010.23,,,1010.23,Other,260% Medicaid APG methodology,1258.91,,,1258.91,Other,324% Medicaid APG methodology,835.38,,,835.38,Other,215% Medicaid APG methodology,835.38,,,835.38,Other,215% Medicaid APG methodology,485.69,,,485.69,Other,125% Medicaid APG methodology,50.82,2013.3,
CONT GLUC MNTR PHYS/QHP EQP     ,95250,CPT,,50119676,CDM,920,RC,,,both,,,764,251.38,,,251.38,Other,150% of Medicare + 9.63% HCRA Surcharge,152.87,,,152.87,Other,Medicare OPPS methodology,668.5,,,668.5,Fee Schedule,,602,,,602,Fee Schedule,,1359.46,,,1359.46,Fee Schedule,,1223.14,,,1223.14,Fee Schedule,,1154.97,,,1154.97,Fee Schedule,,382,50,,382,percent of total billed charges,All Other,534.8,70,,534.8,percent of total billed charges,All Other,663.25,,,663.25,Fee Schedule,,412.61,,,412.61,Other,186% Medicaid methodology,780.5,,,780.5,Fee Schedule,,473.68,,,473.68,Fee Schedule,,367.5,,,367.5,Fee Schedule,,780.5,,,780.5,Fee Schedule,,473.68,,,473.68,Fee Schedule,,687.6,90,,687.6,percent of total billed charges,All Other,534.8,70,,534.8,percent of total billed charges,All Other,722.7,,,722.7,Fee Schedule,,613.2,,,613.2,Fee Schedule,,382,50,,382,percent of total billed charges,All Other Outpatient,382,50,,382,percent of total billed charges,All Other Outpatient,382,50,,382,percent of total billed charges,All Other Outpatient,382,50,,382,percent of total billed charges,All Other Outpatient,221.83,,,221.83,Other,New York Medicaid APG methodology,221.83,,,221.83,Other,100% Medicaid APG methodology,221.83,,,221.83,Other,100% Medicaid APG methodology,221.83,,,221.83,Other,100% Medicaid APG methodology,499.12,,,499.12,Other,225% Medicaid APG methodology,499.12,,,499.12,Other,225% Medicaid APG methodology,339.4,,,339.4,Other,153% Medicaid APG methodology,499.12,,,499.12,Other,225% Medicaid APG methodology,310.57,,,310.57,Other,140% Medicaid APG methodology,499.12,,,499.12,Other,225% Medicaid APG methodology,576.77,,,576.77,Other,260% Medicaid APG methodology,718.74,,,718.74,Other,324% Medicaid APG methodology,476.94,,,476.94,Other,215% Medicaid APG methodology,476.94,,,476.94,Other,215% Medicaid APG methodology,277.29,,,277.29,Other,125% Medicaid APG methodology,152.87,1359.46,
CONT GLUC MNTR PT PROV EQP      ,95249,CPT,,50119908,CDM,920,RC,,,both,,,2213,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,297.77,,,297.77,Fee Schedule,,268.15,,,268.15,Fee Schedule,,1106.5,50,,1106.5,percent of total billed charges,All Other Outpatient,995.85,45,,995.85,percent of total billed charges,All Other Outpatient,951.59,43,,951.59,percent of total billed charges,All Other Outpatient,1106.5,50,,1106.5,percent of total billed charges,All Other,1549.1,70,,1549.1,percent of total billed charges,All Other,295.43,,,295.43,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,347.66,,,347.66,Fee Schedule,,1372.06,,,1372.06,Fee Schedule,,163.7,,,163.7,Fee Schedule,,347.66,,,347.66,Fee Schedule,,1372.06,,,1372.06,Fee Schedule,,1991.7,90,,1991.7,percent of total billed charges,All Other,1549.1,70,,1549.1,percent of total billed charges,All Other,285.45,,,285.45,Fee Schedule,,242.2,,,242.2,Fee Schedule,,1106.5,50,,1106.5,percent of total billed charges,All Other Outpatient,1106.5,50,,1106.5,percent of total billed charges,All Other Outpatient,1106.5,50,,1106.5,percent of total billed charges,All Other Outpatient,1106.5,50,,1106.5,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,1991.7,
DUPLEX ARTERIAL FLOW; COMPL     ,93975,CPT,,44400125,CDM,921,RC,,,both,,,6512,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,1047.74,,,1047.74,Fee Schedule,,943.22,,,943.22,Fee Schedule,,1406.35,,,1406.35,Fee Schedule,,1265.32,,,1265.32,Fee Schedule,,1194.81,,,1194.81,Fee Schedule,,3256,50,,3256,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,943.22,,,943.22,Fee Schedule,,1322.89,,,1322.89,Other,186% Medicaid methodology,1109.96,,,1109.96,Fee Schedule,,4037.44,,,4037.44,Fee Schedule,,522.63,,,522.63,Fee Schedule,,1109.96,,,1109.96,Fee Schedule,,4037.44,,,4037.44,Fee Schedule,,5860.8,90,,5860.8,percent of total billed charges,All Other,4558.4,70,,4558.4,percent of total billed charges,All Other,1051.05,,,1051.05,Fee Schedule,,891.8,,,891.8,Fee Schedule,,2263,,,2263,Case Rate,Peripheral Vasc Lab Visit,1457,,,1457,Case Rate,Peripheral Vasc Lab Visit,2515,,,2515,Case Rate,Peripheral Vasc Lab Visit,2138,,,2138,Case Rate,Peripheral Vasc Lab Visit,711.23,,,711.23,Other,New York Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1088.18,,,1088.18,Other,153% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,995.72,,,995.72,Other,140% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1849.2,,,1849.2,Other,260% Medicaid APG methodology,2304.38,,,2304.38,Other,324% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,889.04,,,889.04,Other,125% Medicaid APG methodology,283.36,5860.8,
DUPLEX A IVC IL/BPG; UNIL/LIM   ,93979,CPT,,44400133,CDM,921,RC,,,both,,,2225,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,471.77,,,471.77,Fee Schedule,,424.71,,,424.71,Fee Schedule,,885.58,,,885.58,Fee Schedule,,796.78,,,796.78,Fee Schedule,,752.37,,,752.37,Fee Schedule,,1112.5,50,,1112.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,424.71,,,424.71,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,499.79,,,499.79,Fee Schedule,,1379.5,,,1379.5,Fee Schedule,,235.33,,,235.33,Fee Schedule,,499.79,,,499.79,Fee Schedule,,1379.5,,,1379.5,Fee Schedule,,2002.5,90,,2002.5,percent of total billed charges,All Other,1557.5,70,,1557.5,percent of total billed charges,All Other,468.6,,,468.6,Fee Schedule,,397.6,,,397.6,Fee Schedule,,2263,,,2263,Case Rate,Peripheral Vasc Lab Visit,1457,,,1457,Case Rate,Peripheral Vasc Lab Visit,2515,,,2515,Case Rate,Peripheral Vasc Lab Visit,2138,,,2138,Case Rate,Peripheral Vasc Lab Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,127.14,2515,
EXTRACRANIAL BILAT STUDY        ,93880,CPT,,44400182,CDM,921,RC,,,both,,,5002,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,760.58,,,760.58,Fee Schedule,,684.7,,,684.7,Fee Schedule,,1406.2,,,1406.2,Fee Schedule,,1265.19,,,1265.19,Fee Schedule,,1194.69,,,1194.69,Fee Schedule,,2501,50,,2501,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,684.7,,,684.7,Fee Schedule,,1322.89,,,1322.89,Other,186% Medicaid methodology,805.74,,,805.74,Fee Schedule,,3101.24,,,3101.24,Fee Schedule,,379.39,,,379.39,Fee Schedule,,805.74,,,805.74,Fee Schedule,,3101.24,,,3101.24,Fee Schedule,,4501.8,90,,4501.8,percent of total billed charges,All Other,3501.4,70,,3501.4,percent of total billed charges,All Other,762.3,,,762.3,Fee Schedule,,646.8,,,646.8,Fee Schedule,,2263,,,2263,Case Rate,Peripheral Vasc Lab Visit,1457,,,1457,Case Rate,Peripheral Vasc Lab Visit,2515,,,2515,Case Rate,Peripheral Vasc Lab Visit,2138,,,2138,Case Rate,Peripheral Vasc Lab Visit,711.23,,,711.23,Other,New York Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1088.18,,,1088.18,Other,153% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,995.72,,,995.72,Other,140% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1849.2,,,1849.2,Other,260% Medicaid APG methodology,2304.38,,,2304.38,Other,324% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,889.04,,,889.04,Other,125% Medicaid APG methodology,283.36,4501.8,
EXTRACRANIAL UNI/LTD STUDY      ,93882,CPT,,44400190,CDM,921,RC,,,both,,,2822,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,504.86,,,504.86,Fee Schedule,,454.5,,,454.5,Fee Schedule,,1403.12,,,1403.12,Fee Schedule,,1262.41,,,1262.41,Fee Schedule,,1192.06,,,1192.06,Fee Schedule,,1411,50,,1411,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,454.5,,,454.5,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,534.84,,,534.84,Fee Schedule,,1749.64,,,1749.64,Fee Schedule,,251.83,,,251.83,Fee Schedule,,534.84,,,534.84,Fee Schedule,,1749.64,,,1749.64,Fee Schedule,,2539.8,90,,2539.8,percent of total billed charges,All Other,1975.4,70,,1975.4,percent of total billed charges,All Other,503.25,,,503.25,Fee Schedule,,427,,,427,Fee Schedule,,2263,,,2263,Case Rate,Peripheral Vasc Lab Visit,1457,,,1457,Case Rate,Peripheral Vasc Lab Visit,2515,,,2515,Case Rate,Peripheral Vasc Lab Visit,2138,,,2138,Case Rate,Peripheral Vasc Lab Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,127.14,2539.8,
UPR/L XTREMITY ART 2 LEVELS     ,93922,CPT,,44400208,CDM,921,RC,,,both,,,2401,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,352.67,,,352.67,Fee Schedule,,317.49,,,317.49,Fee Schedule,,901.16,,,901.16,Fee Schedule,,810.79,,,810.79,Fee Schedule,,765.61,,,765.61,Fee Schedule,,1200.5,50,,1200.5,percent of total billed charges,All Other,328.28,,,328.28,Fee Schedule,,317.49,,,317.49,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,373.61,,,373.61,Fee Schedule,,1488.62,,,1488.62,Fee Schedule,,175.92,,,175.92,Fee Schedule,,373.61,,,373.61,Fee Schedule,,1488.62,,,1488.62,Fee Schedule,,2160.9,90,,2160.9,percent of total billed charges,All Other,1680.7,70,,1680.7,percent of total billed charges,All Other,344.85,,,344.85,Fee Schedule,,292.6,,,292.6,Fee Schedule,,2263,,,2263,Case Rate,Peripheral Vasc Lab Visit,1457,,,1457,Case Rate,Peripheral Vasc Lab Visit,2515,,,2515,Case Rate,Peripheral Vasc Lab Visit,2138,,,2138,Case Rate,Peripheral Vasc Lab Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,147.72,2515,
UPR/LXTR ART STDY 3+ LVLS       ,93923,CPT,,44400216,CDM,921,RC,,,both,,,2623,297.05,,,297.05,Other,150% of Medicare + 9.63% HCRA Surcharge,180.63,,,180.63,Other,Medicare OPPS methodology,543.89,,,543.89,Fee Schedule,,489.63,,,489.63,Fee Schedule,,1359.46,,,1359.46,Fee Schedule,,1223.14,,,1223.14,Fee Schedule,,1154.97,,,1154.97,Fee Schedule,,1311.5,50,,1311.5,percent of total billed charges,All Other,409.21,,,409.21,Fee Schedule,,489.63,,,489.63,Fee Schedule,,374.3,,,374.3,Other,186% Medicaid methodology,576.19,,,576.19,Fee Schedule,,1626.26,,,1626.26,Fee Schedule,,271.3,,,271.3,Fee Schedule,,576.19,,,576.19,Fee Schedule,,1626.26,,,1626.26,Fee Schedule,,2360.7,90,,2360.7,percent of total billed charges,All Other,1836.1,70,,1836.1,percent of total billed charges,All Other,526.35,,,526.35,Fee Schedule,,446.6,,,446.6,Fee Schedule,,2263,,,2263,Case Rate,Peripheral Vasc Lab Visit,1457,,,1457,Case Rate,Peripheral Vasc Lab Visit,2515,,,2515,Case Rate,Peripheral Vasc Lab Visit,2138,,,2138,Case Rate,Peripheral Vasc Lab Visit,201.24,,,201.24,Other,New York Medicaid APG methodology,201.24,,,201.24,Other,100% Medicaid APG methodology,201.24,,,201.24,Other,100% Medicaid APG methodology,201.24,,,201.24,Other,100% Medicaid APG methodology,452.78,,,452.78,Other,225% Medicaid APG methodology,452.78,,,452.78,Other,225% Medicaid APG methodology,307.89,,,307.89,Other,153% Medicaid APG methodology,452.78,,,452.78,Other,225% Medicaid APG methodology,281.73,,,281.73,Other,140% Medicaid APG methodology,452.78,,,452.78,Other,225% Medicaid APG methodology,523.21,,,523.21,Other,260% Medicaid APG methodology,652,,,652,Other,324% Medicaid APG methodology,432.66,,,432.66,Other,215% Medicaid APG methodology,432.66,,,432.66,Other,215% Medicaid APG methodology,251.54,,,251.54,Other,125% Medicaid APG methodology,180.63,2515,
DUPLEX LE ART/BPG; BILAT        ,93925,CPT,,44400232,CDM,921,RC,,,both,,,3877,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,1013.01,,,1013.01,Fee Schedule,,911.95,,,911.95,Fee Schedule,,1406.35,,,1406.35,Fee Schedule,,1265.32,,,1265.32,Fee Schedule,,1194.81,,,1194.81,Fee Schedule,,1938.5,50,,1938.5,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,911.95,,,911.95,Fee Schedule,,1322.89,,,1322.89,Other,186% Medicaid methodology,1073.17,,,1073.17,Fee Schedule,,2403.74,,,2403.74,Fee Schedule,,505.3,,,505.3,Fee Schedule,,1073.17,,,1073.17,Fee Schedule,,2403.74,,,2403.74,Fee Schedule,,3489.3,90,,3489.3,percent of total billed charges,All Other,2713.9,70,,2713.9,percent of total billed charges,All Other,1018.05,,,1018.05,Fee Schedule,,863.8,,,863.8,Fee Schedule,,2263,,,2263,Case Rate,Peripheral Vasc Lab Visit,1457,,,1457,Case Rate,Peripheral Vasc Lab Visit,2515,,,2515,Case Rate,Peripheral Vasc Lab Visit,2138,,,2138,Case Rate,Peripheral Vasc Lab Visit,711.23,,,711.23,Other,New York Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1088.18,,,1088.18,Other,153% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,995.72,,,995.72,Other,140% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1849.2,,,1849.2,Other,260% Medicaid APG methodology,2304.38,,,2304.38,Other,324% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,889.04,,,889.04,Other,125% Medicaid APG methodology,283.36,3489.3,
DUPLEX LE ART/BPG; UNIL/LIMIT   ,93926,CPT,,44400240,CDM,921,RC,,,both,,,2890,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,532.31,,,532.31,Fee Schedule,,479.21,,,479.21,Fee Schedule,,885.58,,,885.58,Fee Schedule,,796.78,,,796.78,Fee Schedule,,752.37,,,752.37,Fee Schedule,,1445,50,,1445,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,479.21,,,479.21,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,563.92,,,563.92,Fee Schedule,,1791.8,,,1791.8,Fee Schedule,,265.52,,,265.52,Fee Schedule,,563.92,,,563.92,Fee Schedule,,1791.8,,,1791.8,Fee Schedule,,2601,90,,2601,percent of total billed charges,All Other,2023,70,,2023,percent of total billed charges,All Other,598.95,,,598.95,Fee Schedule,,508.2,,,508.2,Fee Schedule,,2263,,,2263,Case Rate,Peripheral Vasc Lab Visit,1457,,,1457,Case Rate,Peripheral Vasc Lab Visit,2515,,,2515,Case Rate,Peripheral Vasc Lab Visit,2138,,,2138,Case Rate,Peripheral Vasc Lab Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,127.14,2601,
DUPLEX UE ART/BPG; BILAT        ,93930,CPT,,44400257,CDM,921,RC,,,both,,,2314,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,800.28,,,800.28,Fee Schedule,,720.44,,,720.44,Fee Schedule,,1406.2,,,1406.2,Fee Schedule,,1265.19,,,1265.19,Fee Schedule,,1194.69,,,1194.69,Fee Schedule,,1157,50,,1157,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,720.44,,,720.44,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,847.8,,,847.8,Fee Schedule,,1434.68,,,1434.68,Fee Schedule,,399.19,,,399.19,Fee Schedule,,847.8,,,847.8,Fee Schedule,,1434.68,,,1434.68,Fee Schedule,,2082.6,90,,2082.6,percent of total billed charges,All Other,1619.8,70,,1619.8,percent of total billed charges,All Other,788.7,,,788.7,Fee Schedule,,669.2,,,669.2,Fee Schedule,,2263,,,2263,Case Rate,Peripheral Vasc Lab Visit,1457,,,1457,Case Rate,Peripheral Vasc Lab Visit,2515,,,2515,Case Rate,Peripheral Vasc Lab Visit,2138,,,2138,Case Rate,Peripheral Vasc Lab Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,180.79,2515,
DUPLEX UE ART/BPG; UNIL/LIMIT   ,93931,CPT,,44400265,CDM,921,RC,,,both,,,2061,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,501.54,,,501.54,Fee Schedule,,451.5,,,451.5,Fee Schedule,,885.58,,,885.58,Fee Schedule,,796.78,,,796.78,Fee Schedule,,752.37,,,752.37,Fee Schedule,,1030.5,50,,1030.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,451.5,,,451.5,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,531.32,,,531.32,Fee Schedule,,1277.82,,,1277.82,Fee Schedule,,250.17,,,250.17,Fee Schedule,,531.32,,,531.32,Fee Schedule,,1277.82,,,1277.82,Fee Schedule,,1854.9,90,,1854.9,percent of total billed charges,All Other,1442.7,70,,1442.7,percent of total billed charges,All Other,501.6,,,501.6,Fee Schedule,,425.6,,,425.6,Fee Schedule,,2263,,,2263,Case Rate,Peripheral Vasc Lab Visit,1457,,,1457,Case Rate,Peripheral Vasc Lab Visit,2515,,,2515,Case Rate,Peripheral Vasc Lab Visit,2138,,,2138,Case Rate,Peripheral Vasc Lab Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,127.14,2515,
DUPLEX EXT VEINS; BILAT         ,93970,CPT,,44400281,CDM,921,RC,,,both,,,4166,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,770.51,,,770.51,Fee Schedule,,693.65,,,693.65,Fee Schedule,,1406.2,,,1406.2,Fee Schedule,,1265.19,,,1265.19,Fee Schedule,,1194.69,,,1194.69,Fee Schedule,,2083,50,,2083,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,693.65,,,693.65,Fee Schedule,,1322.89,,,1322.89,Other,186% Medicaid methodology,816.27,,,816.27,Fee Schedule,,2582.92,,,2582.92,Fee Schedule,,384.34,,,384.34,Fee Schedule,,816.27,,,816.27,Fee Schedule,,2582.92,,,2582.92,Fee Schedule,,3749.4,90,,3749.4,percent of total billed charges,All Other,2916.2,70,,2916.2,percent of total billed charges,All Other,770.55,,,770.55,Fee Schedule,,653.8,,,653.8,Fee Schedule,,2263,,,2263,Case Rate,Peripheral Vasc Lab Visit,1457,,,1457,Case Rate,Peripheral Vasc Lab Visit,2515,,,2515,Case Rate,Peripheral Vasc Lab Visit,2138,,,2138,Case Rate,Peripheral Vasc Lab Visit,711.23,,,711.23,Other,New York Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1088.18,,,1088.18,Other,153% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,995.72,,,995.72,Other,140% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1849.2,,,1849.2,Other,260% Medicaid APG methodology,2304.38,,,2304.38,Other,324% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,889.04,,,889.04,Other,125% Medicaid APG methodology,283.36,3749.4,
DUPLEX EXT VEINS; UNIL/LIMIT    ,93971,CPT,,44400299,CDM,921,RC,,,both,,,3306,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,489.96,,,489.96,Fee Schedule,,441.08,,,441.08,Fee Schedule,,885.58,,,885.58,Fee Schedule,,796.78,,,796.78,Fee Schedule,,752.37,,,752.37,Fee Schedule,,1653,50,,1653,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,441.08,,,441.08,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,519.05,,,519.05,Fee Schedule,,2049.72,,,2049.72,Fee Schedule,,244.4,,,244.4,Fee Schedule,,519.05,,,519.05,Fee Schedule,,2049.72,,,2049.72,Fee Schedule,,2975.4,90,,2975.4,percent of total billed charges,All Other,2314.2,70,,2314.2,percent of total billed charges,All Other,488.4,,,488.4,Fee Schedule,,414.4,,,414.4,Fee Schedule,,2263,,,2263,Case Rate,Peripheral Vasc Lab Visit,1457,,,1457,Case Rate,Peripheral Vasc Lab Visit,2515,,,2515,Case Rate,Peripheral Vasc Lab Visit,2138,,,2138,Case Rate,Peripheral Vasc Lab Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,127.14,2975.4,
DUPLEX A IVC IL/BPG; COMPL      ,93978,CPT,,44400315,CDM,921,RC,,,both,,,3805,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,712.63,,,712.63,Fee Schedule,,641.53,,,641.53,Fee Schedule,,1406.2,,,1406.2,Fee Schedule,,1265.19,,,1265.19,Fee Schedule,,1194.69,,,1194.69,Fee Schedule,,1902.5,50,,1902.5,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,641.53,,,641.53,Fee Schedule,,1322.89,,,1322.89,Other,186% Medicaid methodology,754.94,,,754.94,Fee Schedule,,2359.1,,,2359.1,Fee Schedule,,355.47,,,355.47,Fee Schedule,,754.94,,,754.94,Fee Schedule,,2359.1,,,2359.1,Fee Schedule,,3424.5,90,,3424.5,percent of total billed charges,All Other,2663.5,70,,2663.5,percent of total billed charges,All Other,712.8,,,712.8,Fee Schedule,,604.8,,,604.8,Fee Schedule,,2263,,,2263,Case Rate,Peripheral Vasc Lab Visit,1457,,,1457,Case Rate,Peripheral Vasc Lab Visit,2515,,,2515,Case Rate,Peripheral Vasc Lab Visit,2138,,,2138,Case Rate,Peripheral Vasc Lab Visit,711.23,,,711.23,Other,New York Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1088.18,,,1088.18,Other,153% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,995.72,,,995.72,Other,140% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1849.2,,,1849.2,Other,260% Medicaid APG methodology,2304.38,,,2304.38,Other,324% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,889.04,,,889.04,Other,125% Medicaid APG methodology,283.36,3424.5,
DUPLEX HEMODIALYSIS ACCESS      ,93990,CPT,,44400323,CDM,921,RC,,,both,,,1192,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,532.31,,,532.31,Fee Schedule,,479.21,,,479.21,Fee Schedule,,882.28,,,882.28,Fee Schedule,,793.8,,,793.8,Fee Schedule,,749.57,,,749.57,Fee Schedule,,596,50,,596,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,479.21,,,479.21,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,563.92,,,563.92,Fee Schedule,,739.04,,,739.04,Fee Schedule,,265.52,,,265.52,Fee Schedule,,563.92,,,563.92,Fee Schedule,,739.04,,,739.04,Fee Schedule,,1072.8,90,,1072.8,percent of total billed charges,All Other,834.4,70,,834.4,percent of total billed charges,All Other,617.1,,,617.1,Fee Schedule,,523.6,,,523.6,Fee Schedule,,2263,,,2263,Case Rate,Peripheral Vasc Lab Visit,1457,,,1457,Case Rate,Peripheral Vasc Lab Visit,2515,,,2515,Case Rate,Peripheral Vasc Lab Visit,2138,,,2138,Case Rate,Peripheral Vasc Lab Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,127.14,2515,
CV Lower Ext Venous Duplex Bilateral (Heart and Vascular Imaging),93970,CPT,,44400364,CDM,921,RC,,,both,,,3637,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,770.51,,,770.51,Fee Schedule,,693.65,,,693.65,Fee Schedule,,1406.2,,,1406.2,Fee Schedule,,1265.19,,,1265.19,Fee Schedule,,1194.69,,,1194.69,Fee Schedule,,1818.5,50,,1818.5,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,693.65,,,693.65,Fee Schedule,,1322.89,,,1322.89,Other,186% Medicaid methodology,816.27,,,816.27,Fee Schedule,,2254.94,,,2254.94,Fee Schedule,,384.34,,,384.34,Fee Schedule,,816.27,,,816.27,Fee Schedule,,2254.94,,,2254.94,Fee Schedule,,3273.3,90,,3273.3,percent of total billed charges,All Other,2545.9,70,,2545.9,percent of total billed charges,All Other,770.55,,,770.55,Fee Schedule,,653.8,,,653.8,Fee Schedule,,2263,,,2263,Case Rate,Peripheral Vasc Lab Visit,1457,,,1457,Case Rate,Peripheral Vasc Lab Visit,2515,,,2515,Case Rate,Peripheral Vasc Lab Visit,2138,,,2138,Case Rate,Peripheral Vasc Lab Visit,711.23,,,711.23,Other,New York Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1088.18,,,1088.18,Other,153% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,995.72,,,995.72,Other,140% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1849.2,,,1849.2,Other,260% Medicaid APG methodology,2304.38,,,2304.38,Other,324% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,889.04,,,889.04,Other,125% Medicaid APG methodology,283.36,3273.3,
INTRACRANIAL COMPLETE STUDY     ,93886,CPT,,46100475,CDM,921,RC,,,both,,,3736,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,1139.39,,,1139.39,Fee Schedule,,1025.73,,,1025.73,Fee Schedule,,1406.2,,,1406.2,Fee Schedule,,1265.19,,,1265.19,Fee Schedule,,1194.69,,,1194.69,Fee Schedule,,1868,50,,1868,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,1025.73,,,1025.73,Fee Schedule,,1322.89,,,1322.89,Other,186% Medicaid methodology,1207.05,,,1207.05,Fee Schedule,,2316.32,,,2316.32,Fee Schedule,,568.34,,,568.34,Fee Schedule,,1207.05,,,1207.05,Fee Schedule,,2316.32,,,2316.32,Fee Schedule,,3362.4,90,,3362.4,percent of total billed charges,All Other,2615.2,70,,2615.2,percent of total billed charges,All Other,1112.1,,,1112.1,Fee Schedule,,943.6,,,943.6,Fee Schedule,,2263,,,2263,Case Rate,Peripheral Vasc Lab Visit,1457,,,1457,Case Rate,Peripheral Vasc Lab Visit,2515,,,2515,Case Rate,Peripheral Vasc Lab Visit,2138,,,2138,Case Rate,Peripheral Vasc Lab Visit,711.23,,,711.23,Other,New York Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1088.18,,,1088.18,Other,153% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,995.72,,,995.72,Other,140% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1849.2,,,1849.2,Other,260% Medicaid APG methodology,2304.38,,,2304.38,Other,324% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,889.04,,,889.04,Other,125% Medicaid APG methodology,283.36,3362.4,
INTRACRANIAL LIMITED STUDY      ,93888,CPT,,46100541,CDM,921,RC,,,both,,,1908,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,531.3,,,531.3,Fee Schedule,,478.3,,,478.3,Fee Schedule,,570.52,,,570.52,Fee Schedule,,513.31,,,513.31,Fee Schedule,,484.71,,,484.71,Fee Schedule,,954,50,,954,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,478.3,,,478.3,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,562.85,,,562.85,Fee Schedule,,1182.96,,,1182.96,Fee Schedule,,265.02,,,265.02,Fee Schedule,,562.85,,,562.85,Fee Schedule,,1182.96,,,1182.96,Fee Schedule,,1717.2,90,,1717.2,percent of total billed charges,All Other,1335.6,70,,1335.6,percent of total billed charges,All Other,673.2,,,673.2,Fee Schedule,,571.2,,,571.2,Fee Schedule,,2263,,,2263,Case Rate,Peripheral Vasc Lab Visit,1457,,,1457,Case Rate,Peripheral Vasc Lab Visit,2515,,,2515,Case Rate,Peripheral Vasc Lab Visit,2138,,,2138,Case Rate,Peripheral Vasc Lab Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,127.14,2515,
DUPLEX EXT VEINS; UNIL/LIMIT    ,93971,CPT,,47100086,CDM,921,RC,,,both,,,3637,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,489.96,,,489.96,Fee Schedule,,441.08,,,441.08,Fee Schedule,,885.58,,,885.58,Fee Schedule,,796.78,,,796.78,Fee Schedule,,752.37,,,752.37,Fee Schedule,,1818.5,50,,1818.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,441.08,,,441.08,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,519.05,,,519.05,Fee Schedule,,2254.94,,,2254.94,Fee Schedule,,244.4,,,244.4,Fee Schedule,,519.05,,,519.05,Fee Schedule,,2254.94,,,2254.94,Fee Schedule,,3273.3,90,,3273.3,percent of total billed charges,All Other,2545.9,70,,2545.9,percent of total billed charges,All Other,488.4,,,488.4,Fee Schedule,,414.4,,,414.4,Fee Schedule,,2263,,,2263,Case Rate,Peripheral Vasc Lab Visit,1457,,,1457,Case Rate,Peripheral Vasc Lab Visit,2515,,,2515,Case Rate,Peripheral Vasc Lab Visit,2138,,,2138,Case Rate,Peripheral Vasc Lab Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,127.14,3273.3,
DUPLEX UE ART/BPG; BILAT        ,93930,CPT,,47100128,CDM,921,RC,,,both,,,2314,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,800.28,,,800.28,Fee Schedule,,720.44,,,720.44,Fee Schedule,,1406.2,,,1406.2,Fee Schedule,,1265.19,,,1265.19,Fee Schedule,,1194.69,,,1194.69,Fee Schedule,,1157,50,,1157,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,720.44,,,720.44,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,847.8,,,847.8,Fee Schedule,,1434.68,,,1434.68,Fee Schedule,,399.19,,,399.19,Fee Schedule,,847.8,,,847.8,Fee Schedule,,1434.68,,,1434.68,Fee Schedule,,2082.6,90,,2082.6,percent of total billed charges,All Other,1619.8,70,,1619.8,percent of total billed charges,All Other,788.7,,,788.7,Fee Schedule,,669.2,,,669.2,Fee Schedule,,2263,,,2263,Case Rate,Peripheral Vasc Lab Visit,1457,,,1457,Case Rate,Peripheral Vasc Lab Visit,2515,,,2515,Case Rate,Peripheral Vasc Lab Visit,2138,,,2138,Case Rate,Peripheral Vasc Lab Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,180.79,2515,
EXTRACRANIAL BILAT STUDY        ,93880,CPT,,47100177,CDM,921,RC,,,both,,,5002,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,760.58,,,760.58,Fee Schedule,,684.7,,,684.7,Fee Schedule,,1406.2,,,1406.2,Fee Schedule,,1265.19,,,1265.19,Fee Schedule,,1194.69,,,1194.69,Fee Schedule,,2501,50,,2501,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,684.7,,,684.7,Fee Schedule,,1322.89,,,1322.89,Other,186% Medicaid methodology,805.74,,,805.74,Fee Schedule,,3101.24,,,3101.24,Fee Schedule,,379.39,,,379.39,Fee Schedule,,805.74,,,805.74,Fee Schedule,,3101.24,,,3101.24,Fee Schedule,,4501.8,90,,4501.8,percent of total billed charges,All Other,3501.4,70,,3501.4,percent of total billed charges,All Other,762.3,,,762.3,Fee Schedule,,646.8,,,646.8,Fee Schedule,,2263,,,2263,Case Rate,Peripheral Vasc Lab Visit,1457,,,1457,Case Rate,Peripheral Vasc Lab Visit,2515,,,2515,Case Rate,Peripheral Vasc Lab Visit,2138,,,2138,Case Rate,Peripheral Vasc Lab Visit,711.23,,,711.23,Other,New York Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1088.18,,,1088.18,Other,153% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,995.72,,,995.72,Other,140% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1849.2,,,1849.2,Other,260% Medicaid APG methodology,2304.38,,,2304.38,Other,324% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,889.04,,,889.04,Other,125% Medicaid APG methodology,283.36,4501.8,
DUPLEX ARTERIAL FLOW; LIMITED   ,93976,CPT,,47100839,CDM,921,RC,,,both,,,4122,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,531.3,,,531.3,Fee Schedule,,478.3,,,478.3,Fee Schedule,,1403.12,,,1403.12,Fee Schedule,,1262.41,,,1262.41,Fee Schedule,,1192.06,,,1192.06,Fee Schedule,,2061,50,,2061,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,478.3,,,478.3,Fee Schedule,,1322.89,,,1322.89,Other,186% Medicaid methodology,562.85,,,562.85,Fee Schedule,,2555.64,,,2555.64,Fee Schedule,,265.02,,,265.02,Fee Schedule,,562.85,,,562.85,Fee Schedule,,2555.64,,,2555.64,Fee Schedule,,3709.8,90,,3709.8,percent of total billed charges,All Other,2885.4,70,,2885.4,percent of total billed charges,All Other,598.95,,,598.95,Fee Schedule,,508.2,,,508.2,Fee Schedule,,2263,,,2263,Case Rate,Peripheral Vasc Lab Visit,1457,,,1457,Case Rate,Peripheral Vasc Lab Visit,2515,,,2515,Case Rate,Peripheral Vasc Lab Visit,2138,,,2138,Case Rate,Peripheral Vasc Lab Visit,711.23,,,711.23,Other,New York Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1088.18,,,1088.18,Other,153% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,995.72,,,995.72,Other,140% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1849.2,,,1849.2,Other,260% Medicaid APG methodology,2304.38,,,2304.38,Other,324% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,889.04,,,889.04,Other,125% Medicaid APG methodology,127.14,3709.8,
DUPLEX A IVC IL/BPG; COMPL      ,93978,CPT,,47100847,CDM,921,RC,,,both,,,3805,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,712.63,,,712.63,Fee Schedule,,641.53,,,641.53,Fee Schedule,,1406.2,,,1406.2,Fee Schedule,,1265.19,,,1265.19,Fee Schedule,,1194.69,,,1194.69,Fee Schedule,,1902.5,50,,1902.5,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,641.53,,,641.53,Fee Schedule,,1322.89,,,1322.89,Other,186% Medicaid methodology,754.94,,,754.94,Fee Schedule,,2359.1,,,2359.1,Fee Schedule,,355.47,,,355.47,Fee Schedule,,754.94,,,754.94,Fee Schedule,,2359.1,,,2359.1,Fee Schedule,,3424.5,90,,3424.5,percent of total billed charges,All Other,2663.5,70,,2663.5,percent of total billed charges,All Other,712.8,,,712.8,Fee Schedule,,604.8,,,604.8,Fee Schedule,,2263,,,2263,Case Rate,Peripheral Vasc Lab Visit,1457,,,1457,Case Rate,Peripheral Vasc Lab Visit,2515,,,2515,Case Rate,Peripheral Vasc Lab Visit,2138,,,2138,Case Rate,Peripheral Vasc Lab Visit,711.23,,,711.23,Other,New York Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1088.18,,,1088.18,Other,153% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,995.72,,,995.72,Other,140% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1849.2,,,1849.2,Other,260% Medicaid APG methodology,2304.38,,,2304.38,Other,324% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,889.04,,,889.04,Other,125% Medicaid APG methodology,283.36,3424.5,
DUPLEX HEMODIALYSIS ACCESS      ,93990,CPT,,47100854,CDM,921,RC,,,both,,,1192,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,532.31,,,532.31,Fee Schedule,,479.21,,,479.21,Fee Schedule,,882.28,,,882.28,Fee Schedule,,793.8,,,793.8,Fee Schedule,,749.57,,,749.57,Fee Schedule,,596,50,,596,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,479.21,,,479.21,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,563.92,,,563.92,Fee Schedule,,739.04,,,739.04,Fee Schedule,,265.52,,,265.52,Fee Schedule,,563.92,,,563.92,Fee Schedule,,739.04,,,739.04,Fee Schedule,,1072.8,90,,1072.8,percent of total billed charges,All Other,834.4,70,,834.4,percent of total billed charges,All Other,617.1,,,617.1,Fee Schedule,,523.6,,,523.6,Fee Schedule,,2263,,,2263,Case Rate,Peripheral Vasc Lab Visit,1457,,,1457,Case Rate,Peripheral Vasc Lab Visit,2515,,,2515,Case Rate,Peripheral Vasc Lab Visit,2138,,,2138,Case Rate,Peripheral Vasc Lab Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,127.14,2515,
DUPLEX LE ART/BPG; UNIL/LIMIT   ,93926,CPT,,47100862,CDM,921,RC,,,both,,,2890,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,532.31,,,532.31,Fee Schedule,,479.21,,,479.21,Fee Schedule,,885.58,,,885.58,Fee Schedule,,796.78,,,796.78,Fee Schedule,,752.37,,,752.37,Fee Schedule,,1445,50,,1445,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,479.21,,,479.21,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,563.92,,,563.92,Fee Schedule,,1791.8,,,1791.8,Fee Schedule,,265.52,,,265.52,Fee Schedule,,563.92,,,563.92,Fee Schedule,,1791.8,,,1791.8,Fee Schedule,,2601,90,,2601,percent of total billed charges,All Other,2023,70,,2023,percent of total billed charges,All Other,598.95,,,598.95,Fee Schedule,,508.2,,,508.2,Fee Schedule,,2263,,,2263,Case Rate,Peripheral Vasc Lab Visit,1457,,,1457,Case Rate,Peripheral Vasc Lab Visit,2515,,,2515,Case Rate,Peripheral Vasc Lab Visit,2138,,,2138,Case Rate,Peripheral Vasc Lab Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,127.14,2601,
EXTRACRANIAL UNI/LTD STUDY      ,93882,CPT,,47100870,CDM,921,RC,,,both,,,2822,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,504.86,,,504.86,Fee Schedule,,454.5,,,454.5,Fee Schedule,,1403.12,,,1403.12,Fee Schedule,,1262.41,,,1262.41,Fee Schedule,,1192.06,,,1192.06,Fee Schedule,,1411,50,,1411,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,454.5,,,454.5,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,534.84,,,534.84,Fee Schedule,,1749.64,,,1749.64,Fee Schedule,,251.83,,,251.83,Fee Schedule,,534.84,,,534.84,Fee Schedule,,1749.64,,,1749.64,Fee Schedule,,2539.8,90,,2539.8,percent of total billed charges,All Other,1975.4,70,,1975.4,percent of total billed charges,All Other,503.25,,,503.25,Fee Schedule,,427,,,427,Fee Schedule,,2263,,,2263,Case Rate,Peripheral Vasc Lab Visit,1457,,,1457,Case Rate,Peripheral Vasc Lab Visit,2515,,,2515,Case Rate,Peripheral Vasc Lab Visit,2138,,,2138,Case Rate,Peripheral Vasc Lab Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,127.14,2539.8,
DUPLEX UE ART/BPG; UNIL/LIMIT   ,93931,CPT,,47100896,CDM,921,RC,,,both,,,2061,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,501.54,,,501.54,Fee Schedule,,451.5,,,451.5,Fee Schedule,,885.58,,,885.58,Fee Schedule,,796.78,,,796.78,Fee Schedule,,752.37,,,752.37,Fee Schedule,,1030.5,50,,1030.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,451.5,,,451.5,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,531.32,,,531.32,Fee Schedule,,1277.82,,,1277.82,Fee Schedule,,250.17,,,250.17,Fee Schedule,,531.32,,,531.32,Fee Schedule,,1277.82,,,1277.82,Fee Schedule,,1854.9,90,,1854.9,percent of total billed charges,All Other,1442.7,70,,1442.7,percent of total billed charges,All Other,501.6,,,501.6,Fee Schedule,,425.6,,,425.6,Fee Schedule,,2263,,,2263,Case Rate,Peripheral Vasc Lab Visit,1457,,,1457,Case Rate,Peripheral Vasc Lab Visit,2515,,,2515,Case Rate,Peripheral Vasc Lab Visit,2138,,,2138,Case Rate,Peripheral Vasc Lab Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,127.14,2515,
DUPLEX EXT VEINS; BILAT         ,93970,CPT,,47100904,CDM,921,RC,,,both,,,4166,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,770.51,,,770.51,Fee Schedule,,693.65,,,693.65,Fee Schedule,,1406.2,,,1406.2,Fee Schedule,,1265.19,,,1265.19,Fee Schedule,,1194.69,,,1194.69,Fee Schedule,,2083,50,,2083,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,693.65,,,693.65,Fee Schedule,,1322.89,,,1322.89,Other,186% Medicaid methodology,816.27,,,816.27,Fee Schedule,,2582.92,,,2582.92,Fee Schedule,,384.34,,,384.34,Fee Schedule,,816.27,,,816.27,Fee Schedule,,2582.92,,,2582.92,Fee Schedule,,3749.4,90,,3749.4,percent of total billed charges,All Other,2916.2,70,,2916.2,percent of total billed charges,All Other,770.55,,,770.55,Fee Schedule,,653.8,,,653.8,Fee Schedule,,2263,,,2263,Case Rate,Peripheral Vasc Lab Visit,1457,,,1457,Case Rate,Peripheral Vasc Lab Visit,2515,,,2515,Case Rate,Peripheral Vasc Lab Visit,2138,,,2138,Case Rate,Peripheral Vasc Lab Visit,711.23,,,711.23,Other,New York Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1088.18,,,1088.18,Other,153% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,995.72,,,995.72,Other,140% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1849.2,,,1849.2,Other,260% Medicaid APG methodology,2304.38,,,2304.38,Other,324% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,889.04,,,889.04,Other,125% Medicaid APG methodology,283.36,3749.4,
UPR/L XTREMITY ART 2 LEVELS     ,93922,CPT,,47100912,CDM,921,RC,,,both,,,2401,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,352.67,,,352.67,Fee Schedule,,317.49,,,317.49,Fee Schedule,,901.16,,,901.16,Fee Schedule,,810.79,,,810.79,Fee Schedule,,765.61,,,765.61,Fee Schedule,,1200.5,50,,1200.5,percent of total billed charges,All Other,328.28,,,328.28,Fee Schedule,,317.49,,,317.49,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,373.61,,,373.61,Fee Schedule,,1488.62,,,1488.62,Fee Schedule,,175.92,,,175.92,Fee Schedule,,373.61,,,373.61,Fee Schedule,,1488.62,,,1488.62,Fee Schedule,,2160.9,90,,2160.9,percent of total billed charges,All Other,1680.7,70,,1680.7,percent of total billed charges,All Other,344.85,,,344.85,Fee Schedule,,292.6,,,292.6,Fee Schedule,,2263,,,2263,Case Rate,Peripheral Vasc Lab Visit,1457,,,1457,Case Rate,Peripheral Vasc Lab Visit,2515,,,2515,Case Rate,Peripheral Vasc Lab Visit,2138,,,2138,Case Rate,Peripheral Vasc Lab Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,147.72,2515,
US Abdomen Aorta,93979,CPT,TC,47100938,CDM,921,RC,,,both,,,2225,209.07,,,209.07,Other,150% of Medicare + 9.63% HCRA Surcharge,127.14,,,127.14,Other,Medicare OPPS methodology,471.77,,,471.77,Fee Schedule,,424.71,,,424.71,Fee Schedule,,885.58,,,885.58,Fee Schedule,,796.78,,,796.78,Fee Schedule,,752.37,,,752.37,Fee Schedule,,1112.5,50,,1112.5,percent of total billed charges,All Other,319.54,,,319.54,Fee Schedule,,424.71,,,424.71,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,499.79,,,499.79,Fee Schedule,,1379.5,,,1379.5,Fee Schedule,,235.33,,,235.33,Fee Schedule,,499.79,,,499.79,Fee Schedule,,1379.5,,,1379.5,Fee Schedule,,2002.5,90,,2002.5,percent of total billed charges,All Other,1557.5,70,,1557.5,percent of total billed charges,All Other,468.6,,,468.6,Fee Schedule,,397.6,,,397.6,Fee Schedule,,2263,,,2263,Case Rate,Peripheral Vasc Lab Visit,1457,,,1457,Case Rate,Peripheral Vasc Lab Visit,2515,,,2515,Case Rate,Peripheral Vasc Lab Visit,2138,,,2138,Case Rate,Peripheral Vasc Lab Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,127.14,2515,
DUPLEX LE ART/BPG; BILAT        ,93925,CPT,,47101035,CDM,921,RC,,,both,,,3877,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,1013.01,,,1013.01,Fee Schedule,,911.95,,,911.95,Fee Schedule,,1406.35,,,1406.35,Fee Schedule,,1265.32,,,1265.32,Fee Schedule,,1194.81,,,1194.81,Fee Schedule,,1938.5,50,,1938.5,percent of total billed charges,All Other,674.83,,,674.83,Fee Schedule,,911.95,,,911.95,Fee Schedule,,1322.89,,,1322.89,Other,186% Medicaid methodology,1073.17,,,1073.17,Fee Schedule,,2403.74,,,2403.74,Fee Schedule,,505.3,,,505.3,Fee Schedule,,1073.17,,,1073.17,Fee Schedule,,2403.74,,,2403.74,Fee Schedule,,3489.3,90,,3489.3,percent of total billed charges,All Other,2713.9,70,,2713.9,percent of total billed charges,All Other,1018.05,,,1018.05,Fee Schedule,,863.8,,,863.8,Fee Schedule,,2263,,,2263,Case Rate,Peripheral Vasc Lab Visit,1457,,,1457,Case Rate,Peripheral Vasc Lab Visit,2515,,,2515,Case Rate,Peripheral Vasc Lab Visit,2138,,,2138,Case Rate,Peripheral Vasc Lab Visit,711.23,,,711.23,Other,New York Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,711.23,,,711.23,Other,100% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1088.18,,,1088.18,Other,153% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,995.72,,,995.72,Other,140% Medicaid APG methodology,1600.27,,,1600.27,Other,225% Medicaid APG methodology,1849.2,,,1849.2,Other,260% Medicaid APG methodology,2304.38,,,2304.38,Other,324% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,1529.14,,,1529.14,Other,215% Medicaid APG methodology,889.04,,,889.04,Other,125% Medicaid APG methodology,283.36,3489.3,
UPR/LXTR ART STDY 3+ LVLS BI    ,93923,CPT,50,47101068,CDM,921,RC,,,both,,,2623,297.05,,,297.05,Other,150% of Medicare + 9.63% HCRA Surcharge,180.63,,,180.63,Other,Medicare OPPS methodology,543.89,,,543.89,Fee Schedule,,489.63,,,489.63,Fee Schedule,,1359.46,,,1359.46,Fee Schedule,,1223.14,,,1223.14,Fee Schedule,,1154.97,,,1154.97,Fee Schedule,,1311.5,50,,1311.5,percent of total billed charges,All Other,409.21,,,409.21,Fee Schedule,,489.63,,,489.63,Fee Schedule,,374.3,,,374.3,Other,186% Medicaid methodology,576.19,,,576.19,Fee Schedule,,1626.26,,,1626.26,Fee Schedule,,271.3,,,271.3,Fee Schedule,,576.19,,,576.19,Fee Schedule,,1626.26,,,1626.26,Fee Schedule,,2360.7,90,,2360.7,percent of total billed charges,All Other,1836.1,70,,1836.1,percent of total billed charges,All Other,526.35,,,526.35,Fee Schedule,,446.6,,,446.6,Fee Schedule,,2263,,,2263,Case Rate,Peripheral Vasc Lab Visit,1457,,,1457,Case Rate,Peripheral Vasc Lab Visit,2515,,,2515,Case Rate,Peripheral Vasc Lab Visit,2138,,,2138,Case Rate,Peripheral Vasc Lab Visit,201.24,,,201.24,Other,New York Medicaid APG methodology,201.24,,,201.24,Other,100% Medicaid APG methodology,201.24,,,201.24,Other,100% Medicaid APG methodology,201.24,,,201.24,Other,100% Medicaid APG methodology,452.78,,,452.78,Other,225% Medicaid APG methodology,452.78,,,452.78,Other,225% Medicaid APG methodology,307.89,,,307.89,Other,153% Medicaid APG methodology,452.78,,,452.78,Other,225% Medicaid APG methodology,281.73,,,281.73,Other,140% Medicaid APG methodology,452.78,,,452.78,Other,225% Medicaid APG methodology,523.21,,,523.21,Other,260% Medicaid APG methodology,652,,,652,Other,324% Medicaid APG methodology,432.66,,,432.66,Other,215% Medicaid APG methodology,432.66,,,432.66,Other,215% Medicaid APG methodology,251.54,,,251.54,Other,125% Medicaid APG methodology,180.63,2515,
UPR/L XTREMITY ART 2 LEVELS BI  ,93922,CPT,50,47101159,CDM,921,RC,,,both,,,2401,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,352.67,,,352.67,Fee Schedule,,317.49,,,317.49,Fee Schedule,,901.16,,,901.16,Fee Schedule,,810.79,,,810.79,Fee Schedule,,765.61,,,765.61,Fee Schedule,,1200.5,50,,1200.5,percent of total billed charges,All Other,328.28,,,328.28,Fee Schedule,,317.49,,,317.49,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,373.61,,,373.61,Fee Schedule,,1488.62,,,1488.62,Fee Schedule,,175.92,,,175.92,Fee Schedule,,373.61,,,373.61,Fee Schedule,,1488.62,,,1488.62,Fee Schedule,,2160.9,90,,2160.9,percent of total billed charges,All Other,1680.7,70,,1680.7,percent of total billed charges,All Other,344.85,,,344.85,Fee Schedule,,292.6,,,292.6,Fee Schedule,,2263,,,2263,Case Rate,Peripheral Vasc Lab Visit,1457,,,1457,Case Rate,Peripheral Vasc Lab Visit,2515,,,2515,Case Rate,Peripheral Vasc Lab Visit,2138,,,2138,Case Rate,Peripheral Vasc Lab Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,147.72,2515,
UPR/L XTREMITY ART 2 LEVELS     ,93922,CPT,,47901301,CDM,921,RC,,,both,,,2401,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,352.67,,,352.67,Fee Schedule,,317.49,,,317.49,Fee Schedule,,901.16,,,901.16,Fee Schedule,,810.79,,,810.79,Fee Schedule,,765.61,,,765.61,Fee Schedule,,1200.5,50,,1200.5,percent of total billed charges,All Other,328.28,,,328.28,Fee Schedule,,317.49,,,317.49,Fee Schedule,,336.27,,,336.27,Other,186% Medicaid methodology,373.61,,,373.61,Fee Schedule,,1488.62,,,1488.62,Fee Schedule,,175.92,,,175.92,Fee Schedule,,373.61,,,373.61,Fee Schedule,,1488.62,,,1488.62,Fee Schedule,,2160.9,90,,2160.9,percent of total billed charges,All Other,1680.7,70,,1680.7,percent of total billed charges,All Other,344.85,,,344.85,Fee Schedule,,292.6,,,292.6,Fee Schedule,,2263,,,2263,Case Rate,Peripheral Vasc Lab Visit,1457,,,1457,Case Rate,Peripheral Vasc Lab Visit,2515,,,2515,Case Rate,Peripheral Vasc Lab Visit,2138,,,2138,Case Rate,Peripheral Vasc Lab Visit,180.79,,,180.79,Other,New York Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,180.79,,,180.79,Other,100% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,276.61,,,276.61,Other,153% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,253.11,,,253.11,Other,140% Medicaid APG methodology,406.78,,,406.78,Other,225% Medicaid APG methodology,470.06,,,470.06,Other,260% Medicaid APG methodology,585.77,,,585.77,Other,324% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,388.7,,,388.7,Other,215% Medicaid APG methodology,225.99,,,225.99,Other,125% Medicaid APG methodology,147.72,2515,
VISUAL EP TEST CNS W/I&R        ,95930,CPT,,46100012,CDM,922,RC,,,both,,,1431,596.88,,,596.88,Other,150% of Medicare + 9.63% HCRA Surcharge,362.97,,,362.97,Other,Medicare OPPS methodology,223.05,,,223.05,Fee Schedule,,200.86,,,200.86,Fee Schedule,,1060.13,,,1060.13,Fee Schedule,,953.82,,,953.82,Fee Schedule,,900.67,,,900.67,Fee Schedule,,715.5,50,,715.5,percent of total billed charges,All Other,1001.7,70,,1001.7,percent of total billed charges,All Other,221.3,,,221.3,Fee Schedule,,315.23,,,315.23,Other,186% Medicaid methodology,260.42,,,260.42,Fee Schedule,,887.22,,,887.22,Fee Schedule,,122.62,,,122.62,Fee Schedule,,260.42,,,260.42,Fee Schedule,,887.22,,,887.22,Fee Schedule,,1287.9,90,,1287.9,percent of total billed charges,All Other,1001.7,70,,1001.7,percent of total billed charges,All Other,231,,,231,Fee Schedule,,196,,,196,Fee Schedule,,1563,,,1563,Case Rate,EMG Per Visit,1332,,,1332,Case Rate,EMG Per Visit,1480,,,1480,Case Rate,EMG Per Visit,1258,,,1258,Case Rate,EMG Per Visit,169.48,,,169.48,Other,New York Medicaid APG methodology,169.48,,,169.48,Other,100% Medicaid APG methodology,169.48,,,169.48,Other,100% Medicaid APG methodology,169.48,,,169.48,Other,100% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,259.31,,,259.31,Other,153% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,237.27,,,237.27,Other,140% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,440.65,,,440.65,Other,260% Medicaid APG methodology,549.12,,,549.12,Other,324% Medicaid APG methodology,364.38,,,364.38,Other,215% Medicaid APG methodology,364.38,,,364.38,Other,215% Medicaid APG methodology,211.85,,,211.85,Other,125% Medicaid APG methodology,122.62,1563,
MUSCLE TEST ONE LIMB            ,95860,CPT,,46100046,CDM,922,RC,,,both,,,570,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,283.06,,,283.06,Fee Schedule,,254.9,,,254.9,Fee Schedule,,374.29,,,374.29,Fee Schedule,,336.76,,,336.76,Fee Schedule,,317.99,,,317.99,Fee Schedule,,285,50,,285,percent of total billed charges,All Other,399,70,,399,percent of total billed charges,All Other,280.84,,,280.84,Fee Schedule,,315.23,,,315.23,Other,186% Medicaid methodology,330.49,,,330.49,Fee Schedule,,353.4,,,353.4,Fee Schedule,,155.61,,,155.61,Fee Schedule,,330.49,,,330.49,Fee Schedule,,353.4,,,353.4,Fee Schedule,,513,90,,513,percent of total billed charges,All Other,399,70,,399,percent of total billed charges,All Other,313.5,,,313.5,Fee Schedule,,266,,,266,Fee Schedule,,1563,,,1563,Case Rate,EMG Per Visit,1332,,,1332,Case Rate,EMG Per Visit,1480,,,1480,Case Rate,EMG Per Visit,1258,,,1258,Case Rate,EMG Per Visit,169.48,,,169.48,Other,New York Medicaid APG methodology,169.48,,,169.48,Other,100% Medicaid APG methodology,169.48,,,169.48,Other,100% Medicaid APG methodology,169.48,,,169.48,Other,100% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,259.31,,,259.31,Other,153% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,237.27,,,237.27,Other,140% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,440.65,,,440.65,Other,260% Medicaid APG methodology,549.12,,,549.12,Other,324% Medicaid APG methodology,364.38,,,364.38,Other,215% Medicaid APG methodology,364.38,,,364.38,Other,215% Medicaid APG methodology,211.85,,,211.85,Other,125% Medicaid APG methodology,147.72,1563,
MUSCLE TEST 2 LIMBS             ,95861,CPT,,46100053,CDM,922,RC,,,both,,,570,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,361.14,,,361.14,Fee Schedule,,325.22,,,325.22,Fee Schedule,,477.11,,,477.11,Fee Schedule,,429.27,,,429.27,Fee Schedule,,405.35,,,405.35,Fee Schedule,,285,50,,285,percent of total billed charges,All Other,399,70,,399,percent of total billed charges,All Other,358.31,,,358.31,Fee Schedule,,315.23,,,315.23,Other,186% Medicaid methodology,421.65,,,421.65,Fee Schedule,,353.4,,,353.4,Fee Schedule,,198.53,,,198.53,Fee Schedule,,421.65,,,421.65,Fee Schedule,,353.4,,,353.4,Fee Schedule,,513,90,,513,percent of total billed charges,All Other,399,70,,399,percent of total billed charges,All Other,414.15,,,414.15,Fee Schedule,,351.4,,,351.4,Fee Schedule,,1563,,,1563,Case Rate,EMG Per Visit,1332,,,1332,Case Rate,EMG Per Visit,1480,,,1480,Case Rate,EMG Per Visit,1258,,,1258,Case Rate,EMG Per Visit,169.48,,,169.48,Other,New York Medicaid APG methodology,169.48,,,169.48,Other,100% Medicaid APG methodology,169.48,,,169.48,Other,100% Medicaid APG methodology,169.48,,,169.48,Other,100% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,259.31,,,259.31,Other,153% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,237.27,,,237.27,Other,140% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,440.65,,,440.65,Other,260% Medicaid APG methodology,549.12,,,549.12,Other,324% Medicaid APG methodology,364.38,,,364.38,Other,215% Medicaid APG methodology,364.38,,,364.38,Other,215% Medicaid APG methodology,211.85,,,211.85,Other,125% Medicaid APG methodology,147.72,1563,
MUSCLE TEST 3 LIMBS             ,95863,CPT,,46100061,CDM,922,RC,,,both,,,570,297.05,,,297.05,Other,150% of Medicare + 9.63% HCRA Surcharge,180.63,,,180.63,Other,Medicare OPPS methodology,497.71,,,497.71,Fee Schedule,,448.2,,,448.2,Fee Schedule,,580,,,580,Fee Schedule,,521.84,,,521.84,Fee Schedule,,492.76,,,492.76,Fee Schedule,,285,50,,285,percent of total billed charges,All Other,399,70,,399,percent of total billed charges,All Other,493.8,,,493.8,Fee Schedule,,315.23,,,315.23,Other,186% Medicaid methodology,581.09,,,581.09,Fee Schedule,,353.4,,,353.4,Fee Schedule,,273.61,,,273.61,Fee Schedule,,581.09,,,581.09,Fee Schedule,,353.4,,,353.4,Fee Schedule,,513,90,,513,percent of total billed charges,All Other,399,70,,399,percent of total billed charges,All Other,577.5,,,577.5,Fee Schedule,,490,,,490,Fee Schedule,,1563,,,1563,Case Rate,EMG Per Visit,1332,,,1332,Case Rate,EMG Per Visit,1480,,,1480,Case Rate,EMG Per Visit,1258,,,1258,Case Rate,EMG Per Visit,169.48,,,169.48,Other,New York Medicaid APG methodology,169.48,,,169.48,Other,100% Medicaid APG methodology,169.48,,,169.48,Other,100% Medicaid APG methodology,169.48,,,169.48,Other,100% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,259.31,,,259.31,Other,153% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,237.27,,,237.27,Other,140% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,440.65,,,440.65,Other,260% Medicaid APG methodology,549.12,,,549.12,Other,324% Medicaid APG methodology,364.38,,,364.38,Other,215% Medicaid APG methodology,364.38,,,364.38,Other,215% Medicaid APG methodology,211.85,,,211.85,Other,125% Medicaid APG methodology,169.48,1563,
MUSCLE TEST 4 LIMBS             ,95864,CPT,,46100079,CDM,922,RC,,,both,,,570,297.05,,,297.05,Other,150% of Medicare + 9.63% HCRA Surcharge,180.63,,,180.63,Other,Medicare OPPS methodology,579.65,,,579.65,Fee Schedule,,521.99,,,521.99,Fee Schedule,,664.22,,,664.22,Fee Schedule,,597.61,,,597.61,Fee Schedule,,564.31,,,564.31,Fee Schedule,,285,50,,285,percent of total billed charges,All Other,399,70,,399,percent of total billed charges,All Other,575.09,,,575.09,Fee Schedule,,315.23,,,315.23,Other,186% Medicaid methodology,676.76,,,676.76,Fee Schedule,,353.4,,,353.4,Fee Schedule,,318.65,,,318.65,Fee Schedule,,676.76,,,676.76,Fee Schedule,,353.4,,,353.4,Fee Schedule,,513,90,,513,percent of total billed charges,All Other,399,70,,399,percent of total billed charges,All Other,668.25,,,668.25,Fee Schedule,,567,,,567,Fee Schedule,,1563,,,1563,Case Rate,EMG Per Visit,1332,,,1332,Case Rate,EMG Per Visit,1480,,,1480,Case Rate,EMG Per Visit,1258,,,1258,Case Rate,EMG Per Visit,169.48,,,169.48,Other,New York Medicaid APG methodology,169.48,,,169.48,Other,100% Medicaid APG methodology,169.48,,,169.48,Other,100% Medicaid APG methodology,169.48,,,169.48,Other,100% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,259.31,,,259.31,Other,153% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,237.27,,,237.27,Other,140% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,440.65,,,440.65,Other,260% Medicaid APG methodology,549.12,,,549.12,Other,324% Medicaid APG methodology,364.38,,,364.38,Other,215% Medicaid APG methodology,364.38,,,364.38,Other,215% Medicaid APG methodology,211.85,,,211.85,Other,125% Medicaid APG methodology,169.48,1563,
NEUROMUSCULAR JNCT TEST EA NRV  ,95937,CPT,,46100103,CDM,922,RC,,,both,,,570,297.05,,,297.05,Other,150% of Medicare + 9.63% HCRA Surcharge,180.63,,,180.63,Other,Medicare OPPS methodology,317.59,,,317.59,Fee Schedule,,286,,,286,Fee Schedule,,286.98,,,286.98,Fee Schedule,,258.21,,,258.21,Fee Schedule,,243.82,,,243.82,Fee Schedule,,285,50,,285,percent of total billed charges,All Other,399,70,,399,percent of total billed charges,All Other,315.1,,,315.1,Fee Schedule,,315.23,,,315.23,Other,186% Medicaid methodology,370.8,,,370.8,Fee Schedule,,353.4,,,353.4,Fee Schedule,,174.59,,,174.59,Fee Schedule,,370.8,,,370.8,Fee Schedule,,353.4,,,353.4,Fee Schedule,,513,90,,513,percent of total billed charges,All Other,399,70,,399,percent of total billed charges,All Other,359.7,,,359.7,Fee Schedule,,305.2,,,305.2,Fee Schedule,,1563,,,1563,Case Rate,EMG Per Visit,1332,,,1332,Case Rate,EMG Per Visit,1480,,,1480,Case Rate,EMG Per Visit,1258,,,1258,Case Rate,EMG Per Visit,169.48,,,169.48,Other,New York Medicaid APG methodology,169.48,,,169.48,Other,100% Medicaid APG methodology,169.48,,,169.48,Other,100% Medicaid APG methodology,169.48,,,169.48,Other,100% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,259.31,,,259.31,Other,153% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,237.27,,,237.27,Other,140% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,440.65,,,440.65,Other,260% Medicaid APG methodology,549.12,,,549.12,Other,324% Medicaid APG methodology,364.38,,,364.38,Other,215% Medicaid APG methodology,364.38,,,364.38,Other,215% Medicaid APG methodology,211.85,,,211.85,Other,125% Medicaid APG methodology,169.48,1563,
MUSCLE TEST CRAN NERV UNILAT    ,95867,CPT,,46100178,CDM,922,RC,,,both,,,570,596.88,,,596.88,Other,150% of Medicare + 9.63% HCRA Surcharge,362.97,,,362.97,Other,Medicare OPPS methodology,296.58,,,296.58,Fee Schedule,,267.08,,,267.08,Fee Schedule,,361.8,,,361.8,Fee Schedule,,325.52,,,325.52,Fee Schedule,,307.38,,,307.38,Fee Schedule,,285,50,,285,percent of total billed charges,All Other,399,70,,399,percent of total billed charges,All Other,294.26,,,294.26,Fee Schedule,,315.23,,,315.23,Other,186% Medicaid methodology,346.27,,,346.27,Fee Schedule,,353.4,,,353.4,Fee Schedule,,163.04,,,163.04,Fee Schedule,,346.27,,,346.27,Fee Schedule,,353.4,,,353.4,Fee Schedule,,513,90,,513,percent of total billed charges,All Other,399,70,,399,percent of total billed charges,All Other,331.65,,,331.65,Fee Schedule,,281.4,,,281.4,Fee Schedule,,1563,,,1563,Case Rate,EMG Per Visit,1332,,,1332,Case Rate,EMG Per Visit,1480,,,1480,Case Rate,EMG Per Visit,1258,,,1258,Case Rate,EMG Per Visit,169.48,,,169.48,Other,New York Medicaid APG methodology,169.48,,,169.48,Other,100% Medicaid APG methodology,169.48,,,169.48,Other,100% Medicaid APG methodology,169.48,,,169.48,Other,100% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,259.31,,,259.31,Other,153% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,237.27,,,237.27,Other,140% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,440.65,,,440.65,Other,260% Medicaid APG methodology,549.12,,,549.12,Other,324% Medicaid APG methodology,364.38,,,364.38,Other,215% Medicaid APG methodology,364.38,,,364.38,Other,215% Medicaid APG methodology,211.85,,,211.85,Other,125% Medicaid APG methodology,163.04,1563,
MUSCLE TEST CRAN NERVE BILAT    ,95868,CPT,,46100186,CDM,922,RC,,,both,,,570,596.88,,,596.88,Other,150% of Medicare + 9.63% HCRA Surcharge,362.97,,,362.97,Other,Medicare OPPS methodology,349.11,,,349.11,Fee Schedule,,314.38,,,314.38,Fee Schedule,,445.95,,,445.95,Fee Schedule,,401.23,,,401.23,Fee Schedule,,378.87,,,378.87,Fee Schedule,,285,50,,285,percent of total billed charges,All Other,399,70,,399,percent of total billed charges,All Other,346.37,,,346.37,Fee Schedule,,315.23,,,315.23,Other,186% Medicaid methodology,407.6,,,407.6,Fee Schedule,,353.4,,,353.4,Fee Schedule,,191.92,,,191.92,Fee Schedule,,407.6,,,407.6,Fee Schedule,,353.4,,,353.4,Fee Schedule,,513,90,,513,percent of total billed charges,All Other,399,70,,399,percent of total billed charges,All Other,404.25,,,404.25,Fee Schedule,,343,,,343,Fee Schedule,,1563,,,1563,Case Rate,EMG Per Visit,1332,,,1332,Case Rate,EMG Per Visit,1480,,,1480,Case Rate,EMG Per Visit,1258,,,1258,Case Rate,EMG Per Visit,169.48,,,169.48,Other,New York Medicaid APG methodology,169.48,,,169.48,Other,100% Medicaid APG methodology,169.48,,,169.48,Other,100% Medicaid APG methodology,169.48,,,169.48,Other,100% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,259.31,,,259.31,Other,153% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,237.27,,,237.27,Other,140% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,440.65,,,440.65,Other,260% Medicaid APG methodology,549.12,,,549.12,Other,324% Medicaid APG methodology,364.38,,,364.38,Other,215% Medicaid APG methodology,364.38,,,364.38,Other,215% Medicaid APG methodology,211.85,,,211.85,Other,125% Medicaid APG methodology,169.48,1563,
MUSCLE TEST THOR PARASPINAL     ,95869,CPT,,46100368,CDM,922,RC,,,both,,,302,596.88,,,596.88,Other,150% of Medicare + 9.63% HCRA Surcharge,362.97,,,362.97,Other,Medicare OPPS methodology,341.62,,,341.62,Fee Schedule,,307.64,,,307.64,Fee Schedule,,361.8,,,361.8,Fee Schedule,,325.52,,,325.52,Fee Schedule,,307.38,,,307.38,Fee Schedule,,151,50,,151,percent of total billed charges,All Other,211.4,70,,211.4,percent of total billed charges,All Other,338.94,,,338.94,Fee Schedule,,315.23,,,315.23,Other,186% Medicaid methodology,398.86,,,398.86,Fee Schedule,,187.24,,,187.24,Fee Schedule,,187.8,,,187.8,Fee Schedule,,398.86,,,398.86,Fee Schedule,,187.24,,,187.24,Fee Schedule,,271.8,90,,271.8,percent of total billed charges,All Other,211.4,70,,211.4,percent of total billed charges,All Other,394.35,,,394.35,Fee Schedule,,334.6,,,334.6,Fee Schedule,,1563,,,1563,Case Rate,EMG Per Visit,1332,,,1332,Case Rate,EMG Per Visit,1480,,,1480,Case Rate,EMG Per Visit,1258,,,1258,Case Rate,EMG Per Visit,169.48,,,169.48,Other,New York Medicaid APG methodology,169.48,,,169.48,Other,100% Medicaid APG methodology,169.48,,,169.48,Other,100% Medicaid APG methodology,169.48,,,169.48,Other,100% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,259.31,,,259.31,Other,153% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,237.27,,,237.27,Other,140% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,440.65,,,440.65,Other,260% Medicaid APG methodology,549.12,,,549.12,Other,324% Medicaid APG methodology,364.38,,,364.38,Other,215% Medicaid APG methodology,364.38,,,364.38,Other,215% Medicaid APG methodology,211.85,,,211.85,Other,125% Medicaid APG methodology,151,1563,
BLINK REFLEX TEST               ,95933,CPT,,46100392,CDM,922,RC,,,both,,,363,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,233.55,,,233.55,Fee Schedule,,210.32,,,210.32,Fee Schedule,,402.3,,,402.3,Fee Schedule,,361.95,,,361.95,Fee Schedule,,341.78,,,341.78,Fee Schedule,,181.5,50,,181.5,percent of total billed charges,All Other,254.1,70,,254.1,percent of total billed charges,All Other,231.72,,,231.72,Fee Schedule,,222.52,,,222.52,Other,186% Medicaid methodology,272.68,,,272.68,Fee Schedule,,225.06,,,225.06,Fee Schedule,,128.39,,,128.39,Fee Schedule,,272.68,,,272.68,Fee Schedule,,225.06,,,225.06,Fee Schedule,,326.7,90,,326.7,percent of total billed charges,All Other,254.1,70,,254.1,percent of total billed charges,All Other,265.65,,,265.65,Fee Schedule,,225.4,,,225.4,Fee Schedule,,1563,,,1563,Case Rate,EMG Per Visit,1332,,,1332,Case Rate,EMG Per Visit,1480,,,1480,Case Rate,EMG Per Visit,1258,,,1258,Case Rate,EMG Per Visit,119.64,,,119.64,Other,New York Medicaid APG methodology,119.64,,,119.64,Other,100% Medicaid APG methodology,119.64,,,119.64,Other,100% Medicaid APG methodology,119.64,,,119.64,Other,100% Medicaid APG methodology,269.18,,,269.18,Other,225% Medicaid APG methodology,269.18,,,269.18,Other,225% Medicaid APG methodology,183.04,,,183.04,Other,153% Medicaid APG methodology,269.18,,,269.18,Other,225% Medicaid APG methodology,167.49,,,167.49,Other,140% Medicaid APG methodology,269.18,,,269.18,Other,225% Medicaid APG methodology,311.05,,,311.05,Other,260% Medicaid APG methodology,387.62,,,387.62,Other,324% Medicaid APG methodology,257.22,,,257.22,Other,215% Medicaid APG methodology,257.22,,,257.22,Other,215% Medicaid APG methodology,149.54,,,149.54,Other,125% Medicaid APG methodology,70.73,1563,
MUSCLE TEST NONPARASPINAL       ,95870,CPT,,46100400,CDM,922,RC,,,both,,,292,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,287.57,,,287.57,Fee Schedule,,258.96,,,258.96,Fee Schedule,,352.47,,,352.47,Fee Schedule,,317.12,,,317.12,Fee Schedule,,299.45,,,299.45,Fee Schedule,,146,50,,146,percent of total billed charges,All Other,204.4,70,,204.4,percent of total billed charges,All Other,285.31,,,285.31,Fee Schedule,,315.23,,,315.23,Other,186% Medicaid methodology,335.75,,,335.75,Fee Schedule,,181.04,,,181.04,Fee Schedule,,158.09,,,158.09,Fee Schedule,,335.75,,,335.75,Fee Schedule,,181.04,,,181.04,Fee Schedule,,262.8,90,,262.8,percent of total billed charges,All Other,204.4,70,,204.4,percent of total billed charges,All Other,330,,,330,Fee Schedule,,280,,,280,Fee Schedule,,1563,,,1563,Case Rate,EMG Per Visit,1332,,,1332,Case Rate,EMG Per Visit,1480,,,1480,Case Rate,EMG Per Visit,1258,,,1258,Case Rate,EMG Per Visit,169.48,,,169.48,Other,New York Medicaid APG methodology,169.48,,,169.48,Other,100% Medicaid APG methodology,169.48,,,169.48,Other,100% Medicaid APG methodology,169.48,,,169.48,Other,100% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,259.31,,,259.31,Other,153% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,237.27,,,237.27,Other,140% Medicaid APG methodology,381.33,,,381.33,Other,225% Medicaid APG methodology,440.65,,,440.65,Other,260% Medicaid APG methodology,549.12,,,549.12,Other,324% Medicaid APG methodology,364.38,,,364.38,Other,215% Medicaid APG methodology,364.38,,,364.38,Other,215% Medicaid APG methodology,211.85,,,211.85,Other,125% Medicaid APG methodology,146,1563,
PHLEBOTOMY THERAPEUTIC          ,99195,CPT,,40800591,CDM,940,RC,,,both,,,797,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,436.13,,,436.13,Fee Schedule,,392.74,,,392.74,Fee Schedule,,398.5,50,,398.5,percent of total billed charges,All Other Outpatient,358.65,45,,358.65,percent of total billed charges,All Other Outpatient,342.71,43,,342.71,percent of total billed charges,All Other Outpatient,398.5,50,,398.5,percent of total billed charges,All Other,557.9,70,,557.9,percent of total billed charges,All Other,541.96,68,,541.96,percent of total billed charges,All Other Outpatient,104.72,,,104.72,Other,186% Medicaid methodology,637.6,80,,637.6,percent of total billed charges,All Other Outpatient,661.51,83,,661.51,percent of total billed charges,All Other Outpatient,661.51,83,,661.51,percent of total billed charges,All Other Outpatient,637.6,80,,637.6,percent of total billed charges,All Other Outpatient,661.51,83,,661.51,percent of total billed charges,All Other Outpatient,717.3,90,,717.3,percent of total billed charges,All Other,557.9,70,,557.9,percent of total billed charges,All Other,496.65,,,496.65,Fee Schedule,,421.4,,,421.4,Fee Schedule,,398.5,50,,398.5,percent of total billed charges,All Other Outpatient,398.5,50,,398.5,percent of total billed charges,All Other Outpatient,398.5,50,,398.5,percent of total billed charges,All Other Outpatient,398.5,50,,398.5,percent of total billed charges,All Other Outpatient,56.3,,,56.3,Other,New York Medicaid APG methodology,56.3,,,56.3,Other,100% Medicaid APG methodology,56.3,,,56.3,Other,100% Medicaid APG methodology,56.3,,,56.3,Other,100% Medicaid APG methodology,126.68,,,126.68,Other,225% Medicaid APG methodology,126.68,,,126.68,Other,225% Medicaid APG methodology,86.14,,,86.14,Other,153% Medicaid APG methodology,126.68,,,126.68,Other,225% Medicaid APG methodology,78.82,,,78.82,Other,140% Medicaid APG methodology,126.68,,,126.68,Other,225% Medicaid APG methodology,146.38,,,146.38,Other,260% Medicaid APG methodology,182.41,,,182.41,Other,324% Medicaid APG methodology,121.05,,,121.05,Other,215% Medicaid APG methodology,121.05,,,121.05,Other,215% Medicaid APG methodology,70.38,,,70.38,Other,125% Medicaid APG methodology,56.3,717.3,
THER/PROPH/DIAG INJ IV PUSH     ,96374,CPT,,44100998,CDM,940,RC,,,both,,,1106,407.6,,,407.6,Other,150% of Medicare + 9.63% HCRA Surcharge,247.86,,,247.86,Other,Medicare OPPS methodology,163.84,,,163.84,Fee Schedule,,147.54,,,147.54,Fee Schedule,,553,50,,553,percent of total billed charges,All Other Outpatient,497.7,45,,497.7,percent of total billed charges,All Other Outpatient,475.58,43,,475.58,percent of total billed charges,All Other Outpatient,553,50,,553,percent of total billed charges,All Other,774.2,70,,774.2,percent of total billed charges,All Other,752.08,68,,752.08,percent of total billed charges,All Other Outpatient,116.47,,,116.47,Other,186% Medicaid methodology,884.8,80,,884.8,percent of total billed charges,All Other Outpatient,917.98,83,,917.98,percent of total billed charges,All Other Outpatient,917.98,83,,917.98,percent of total billed charges,All Other Outpatient,884.8,80,,884.8,percent of total billed charges,All Other Outpatient,917.98,83,,917.98,percent of total billed charges,All Other Outpatient,995.4,90,,995.4,percent of total billed charges,All Other,774.2,70,,774.2,percent of total billed charges,All Other,191.4,,,191.4,Fee Schedule,,162.4,,,162.4,Fee Schedule,,553,50,,553,percent of total billed charges,All Other Outpatient,553,50,,553,percent of total billed charges,All Other Outpatient,553,50,,553,percent of total billed charges,All Other Outpatient,553,50,,553,percent of total billed charges,All Other Outpatient,62.62,,,62.62,Other,New York Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,95.8,,,95.8,Other,153% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,87.66,,,87.66,Other,140% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,162.81,,,162.81,Other,260% Medicaid APG methodology,202.88,,,202.88,Other,324% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,78.27,,,78.27,Other,125% Medicaid APG methodology,62.62,995.4,
THER/PROPH/DIAG INJ SC/IM       ,96372,CPT,,48300222,CDM,940,RC,,,both,,,621,133.96,,,133.96,Other,150% of Medicare + 9.63% HCRA Surcharge,81.46,,,81.46,Other,Medicare OPPS methodology,62.57,,,62.57,Fee Schedule,,56.35,,,56.35,Fee Schedule,,310.5,50,,310.5,percent of total billed charges,All Other Outpatient,279.45,45,,279.45,percent of total billed charges,All Other Outpatient,267.03,43,,267.03,percent of total billed charges,All Other Outpatient,310.5,50,,310.5,percent of total billed charges,All Other,434.7,70,,434.7,percent of total billed charges,All Other,422.28,68,,422.28,percent of total billed charges,All Other Outpatient,116.47,,,116.47,Other,186% Medicaid methodology,496.8,80,,496.8,percent of total billed charges,All Other Outpatient,515.43,83,,515.43,percent of total billed charges,All Other Outpatient,515.43,83,,515.43,percent of total billed charges,All Other Outpatient,496.8,80,,496.8,percent of total billed charges,All Other Outpatient,515.43,83,,515.43,percent of total billed charges,All Other Outpatient,558.9,90,,558.9,percent of total billed charges,All Other,434.7,70,,434.7,percent of total billed charges,All Other,69.3,,,69.3,Fee Schedule,,58.8,,,58.8,Fee Schedule,,310.5,50,,310.5,percent of total billed charges,All Other Outpatient,310.5,50,,310.5,percent of total billed charges,All Other Outpatient,310.5,50,,310.5,percent of total billed charges,All Other Outpatient,310.5,50,,310.5,percent of total billed charges,All Other Outpatient,62.62,,,62.62,Other,New York Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,95.8,,,95.8,Other,153% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,87.66,,,87.66,Other,140% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,162.81,,,162.81,Other,260% Medicaid APG methodology,202.88,,,202.88,Other,324% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,78.27,,,78.27,Other,125% Medicaid APG methodology,56.35,558.9,
PHLEBOTOMY THERAPEUTIC          ,99195,CPT,,48400212,CDM,940,RC,,,both,,,877,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,436.13,,,436.13,Fee Schedule,,392.74,,,392.74,Fee Schedule,,438.5,50,,438.5,percent of total billed charges,All Other Outpatient,394.65,45,,394.65,percent of total billed charges,All Other Outpatient,377.11,43,,377.11,percent of total billed charges,All Other Outpatient,438.5,50,,438.5,percent of total billed charges,All Other,613.9,70,,613.9,percent of total billed charges,All Other,596.36,68,,596.36,percent of total billed charges,All Other Outpatient,104.72,,,104.72,Other,186% Medicaid methodology,701.6,80,,701.6,percent of total billed charges,All Other Outpatient,727.91,83,,727.91,percent of total billed charges,All Other Outpatient,727.91,83,,727.91,percent of total billed charges,All Other Outpatient,701.6,80,,701.6,percent of total billed charges,All Other Outpatient,727.91,83,,727.91,percent of total billed charges,All Other Outpatient,789.3,90,,789.3,percent of total billed charges,All Other,613.9,70,,613.9,percent of total billed charges,All Other,496.65,,,496.65,Fee Schedule,,421.4,,,421.4,Fee Schedule,,438.5,50,,438.5,percent of total billed charges,All Other Outpatient,438.5,50,,438.5,percent of total billed charges,All Other Outpatient,438.5,50,,438.5,percent of total billed charges,All Other Outpatient,438.5,50,,438.5,percent of total billed charges,All Other Outpatient,56.3,,,56.3,Other,New York Medicaid APG methodology,56.3,,,56.3,Other,100% Medicaid APG methodology,56.3,,,56.3,Other,100% Medicaid APG methodology,56.3,,,56.3,Other,100% Medicaid APG methodology,126.68,,,126.68,Other,225% Medicaid APG methodology,126.68,,,126.68,Other,225% Medicaid APG methodology,86.14,,,86.14,Other,153% Medicaid APG methodology,126.68,,,126.68,Other,225% Medicaid APG methodology,78.82,,,78.82,Other,140% Medicaid APG methodology,126.68,,,126.68,Other,225% Medicaid APG methodology,146.38,,,146.38,Other,260% Medicaid APG methodology,182.41,,,182.41,Other,324% Medicaid APG methodology,121.05,,,121.05,Other,215% Medicaid APG methodology,121.05,,,121.05,Other,215% Medicaid APG methodology,70.38,,,70.38,Other,125% Medicaid APG methodology,56.3,789.3,
THER/DIAG CONCURRENT INF        ,96368,CPT,,50054550,CDM,940,RC,,,both,,,327,129.06,,,129.06,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,163.5,50,,163.5,percent of total billed charges,All Other Outpatient,147.15,45,,147.15,percent of total billed charges,All Other Outpatient,1342,,,1342,Case Rate,IV Therapy Per Visit,1208,,,1208,Case Rate,IV Therapy Per Visit,1141,,,1141,Case Rate,IV Therapy Per Visit,163.5,50,,163.5,percent of total billed charges,All Other,228.9,70,,228.9,percent of total billed charges,All Other,222.36,68,,222.36,percent of total billed charges,All Other,577.69,,,577.69,Other,186% Medicaid methodology,261.6,80,,261.6,percent of total billed charges,All Other,271.41,83,,271.41,percent of total billed charges,All Other,271.41,83,,271.41,percent of total billed charges,All Other,261.6,80,,261.6,percent of total billed charges,All Other,271.41,83,,271.41,percent of total billed charges,All Other,294.3,90,,294.3,percent of total billed charges,All Other,228.9,70,,228.9,percent of total billed charges,All Other,99,,,99,Fee Schedule,,84,,,84,Fee Schedule,,824,,,824,Case Rate,IV Therapy Per Visit,748,,,748,Case Rate,IV Therapy Per Visit,831,,,831,Case Rate,IV Therapy Per Visit,706,,,706,Case Rate,IV Therapy Per Visit,310.58,,,310.58,Other,New York Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,475.19,,,475.19,Other,153% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,434.82,,,434.82,Other,140% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,807.52,,,807.52,Other,260% Medicaid APG methodology,1006.29,,,1006.29,Other,324% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,388.23,,,388.23,Other,125% Medicaid APG methodology,0.01,1342,
THER/PROPH/DIAG INJ IV PUSH     ,96374,CPT,,50054568,CDM,940,RC,,,both,,,1106,407.6,,,407.6,Other,150% of Medicare + 9.63% HCRA Surcharge,247.86,,,247.86,Other,Medicare OPPS methodology,163.84,,,163.84,Fee Schedule,,147.54,,,147.54,Fee Schedule,,553,50,,553,percent of total billed charges,All Other Outpatient,497.7,45,,497.7,percent of total billed charges,All Other Outpatient,475.58,43,,475.58,percent of total billed charges,All Other Outpatient,553,50,,553,percent of total billed charges,All Other,774.2,70,,774.2,percent of total billed charges,All Other,752.08,68,,752.08,percent of total billed charges,All Other Outpatient,116.47,,,116.47,Other,186% Medicaid methodology,884.8,80,,884.8,percent of total billed charges,All Other Outpatient,917.98,83,,917.98,percent of total billed charges,All Other Outpatient,917.98,83,,917.98,percent of total billed charges,All Other Outpatient,884.8,80,,884.8,percent of total billed charges,All Other Outpatient,917.98,83,,917.98,percent of total billed charges,All Other Outpatient,995.4,90,,995.4,percent of total billed charges,All Other,774.2,70,,774.2,percent of total billed charges,All Other,191.4,,,191.4,Fee Schedule,,162.4,,,162.4,Fee Schedule,,553,50,,553,percent of total billed charges,All Other Outpatient,553,50,,553,percent of total billed charges,All Other Outpatient,553,50,,553,percent of total billed charges,All Other Outpatient,553,50,,553,percent of total billed charges,All Other Outpatient,62.62,,,62.62,Other,New York Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,62.62,,,62.62,Other,100% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,95.8,,,95.8,Other,153% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,87.66,,,87.66,Other,140% Medicaid APG methodology,140.89,,,140.89,Other,225% Medicaid APG methodology,162.81,,,162.81,Other,260% Medicaid APG methodology,202.88,,,202.88,Other,324% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,134.63,,,134.63,Other,215% Medicaid APG methodology,78.27,,,78.27,Other,125% Medicaid APG methodology,62.62,995.4,
THER/PROPH/DIAG IV INF INIT     ,96365,CPT,,50054584,CDM,940,RC,,,both,,,1928,407.6,,,407.6,Other,150% of Medicare + 9.63% HCRA Surcharge,247.86,,,247.86,Other,Medicare OPPS methodology,964,50,,964,percent of total billed charges,All Other Outpatient,867.6,45,,867.6,percent of total billed charges,All Other Outpatient,1342,,,1342,Case Rate,IV Therapy Per Visit,1208,,,1208,Case Rate,IV Therapy Per Visit,1141,,,1141,Case Rate,IV Therapy Per Visit,964,50,,964,percent of total billed charges,All Other,1349.6,70,,1349.6,percent of total billed charges,All Other,1311.04,68,,1311.04,percent of total billed charges,All Other,577.69,,,577.69,Other,186% Medicaid methodology,1542.4,80,,1542.4,percent of total billed charges,All Other,1600.24,83,,1600.24,percent of total billed charges,All Other,1600.24,83,,1600.24,percent of total billed charges,All Other,1542.4,80,,1542.4,percent of total billed charges,All Other,1600.24,83,,1600.24,percent of total billed charges,All Other,1735.2,90,,1735.2,percent of total billed charges,All Other,1349.6,70,,1349.6,percent of total billed charges,All Other,330,,,330,Fee Schedule,,280,,,280,Fee Schedule,,824,,,824,Case Rate,IV Therapy Per Visit,748,,,748,Case Rate,IV Therapy Per Visit,831,,,831,Case Rate,IV Therapy Per Visit,706,,,706,Case Rate,IV Therapy Per Visit,310.58,,,310.58,Other,New York Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,310.58,,,310.58,Other,100% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,475.19,,,475.19,Other,153% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,434.82,,,434.82,Other,140% Medicaid APG methodology,698.81,,,698.81,Other,225% Medicaid APG methodology,807.52,,,807.52,Other,260% Medicaid APG methodology,1006.29,,,1006.29,Other,324% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,667.75,,,667.75,Other,215% Medicaid APG methodology,388.23,,,388.23,Other,125% Medicaid APG methodology,247.86,1735.2,
THER/PROPH/DIAG IV INF ADDON    ,96366,CPT,,50054774,CDM,940,RC,,,both,,,460,90.33,,,90.33,Other,150% of Medicare + 9.63% HCRA Surcharge,54.93,,,54.93,Other,Medicare OPPS methodology,230,50,,230,percent of total billed charges,All Other Outpatient,207,45,,207,percent of total billed charges,All Other Outpatient,1342,,,1342,Case Rate,IV Therapy Per Visit,1208,,,1208,Case Rate,IV Therapy Per Visit,1141,,,1141,Case Rate,IV Therapy Per Visit,230,50,,230,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,312.8,68,,312.8,percent of total billed charges,All Other,1474.51,,,1474.51,Other,186% Medicaid methodology,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,368,80,,368,percent of total billed charges,All Other,381.8,83,,381.8,percent of total billed charges,All Other,414,90,,414,percent of total billed charges,All Other,322,70,,322,percent of total billed charges,All Other,102.3,,,102.3,Fee Schedule,,86.8,,,86.8,Fee Schedule,,824,,,824,Case Rate,IV Therapy Per Visit,748,,,748,Case Rate,IV Therapy Per Visit,831,,,831,Case Rate,IV Therapy Per Visit,706,,,706,Case Rate,IV Therapy Per Visit,792.75,,,792.75,Other,New York Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,792.75,,,792.75,Other,100% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1212.91,,,1212.91,Other,153% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,1109.85,,,1109.85,Other,140% Medicaid APG methodology,1783.69,,,1783.69,Other,225% Medicaid APG methodology,2061.15,,,2061.15,Other,260% Medicaid APG methodology,2568.51,,,2568.51,Other,324% Medicaid APG methodology,1704.41,,,1704.41,Other,215% Medicaid APG methodology,1704.41,,,1704.41,Other,215% Medicaid APG methodology,990.94,,,990.94,Other,125% Medicaid APG methodology,54.93,2568.51,
SELF-MGMT EDUC & TRAIN 1 PT     ,98960,CPT,GP       ,48600795,CDM,942,RC,,,both,,,114,44.99,,,44.99,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,57,50,,57,percent of total billed charges,All Other Outpatient,51.3,45,,51.3,percent of total billed charges,All Other Outpatient,26.87,,,26.87,Fee Schedule,,26.87,,,26.87,Fee Schedule,,26.87,,,26.87,Fee Schedule,,57,50,,57,percent of total billed charges,All Other,79.8,70,,79.8,percent of total billed charges,All Other,77.52,68,,77.52,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,91.2,80,,91.2,percent of total billed charges,All Other Outpatient,94.62,83,,94.62,percent of total billed charges,All Other Outpatient,94.62,83,,94.62,percent of total billed charges,All Other Outpatient,91.2,80,,91.2,percent of total billed charges,All Other Outpatient,94.62,83,,94.62,percent of total billed charges,All Other Outpatient,102.6,90,,102.6,percent of total billed charges,All Other,79.8,70,,79.8,percent of total billed charges,All Other,140.25,,,140.25,Fee Schedule,,119,,,119,Fee Schedule,,239,,,239,Case Rate,Education & Train Per Visit,188,,,188,Case Rate,Education & Train Per Visit,210,,,210,Case Rate,Education & Train Per Visit,179,,,179,Case Rate,Education & Train Per Visit,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,239,
SELF-MGMT EDUC & TRAIN 1 PT     ,98960,CPT,GO       ,48701015,CDM,942,RC,,,both,,,114,44.99,,,44.99,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,57,50,,57,percent of total billed charges,All Other Outpatient,51.3,45,,51.3,percent of total billed charges,All Other Outpatient,26.87,,,26.87,Fee Schedule,,26.87,,,26.87,Fee Schedule,,26.87,,,26.87,Fee Schedule,,57,50,,57,percent of total billed charges,All Other,79.8,70,,79.8,percent of total billed charges,All Other,77.52,68,,77.52,percent of total billed charges,All Other Outpatient,0.02,,,0.02,Other,186% Medicaid methodology,91.2,80,,91.2,percent of total billed charges,All Other Outpatient,94.62,83,,94.62,percent of total billed charges,All Other Outpatient,94.62,83,,94.62,percent of total billed charges,All Other Outpatient,91.2,80,,91.2,percent of total billed charges,All Other Outpatient,94.62,83,,94.62,percent of total billed charges,All Other Outpatient,102.6,90,,102.6,percent of total billed charges,All Other,79.8,70,,79.8,percent of total billed charges,All Other,140.25,,,140.25,Fee Schedule,,119,,,119,Fee Schedule,,239,,,239,Case Rate,Education & Train Per Visit,188,,,188,Case Rate,Education & Train Per Visit,210,,,210,Case Rate,Education & Train Per Visit,179,,,179,Case Rate,Education & Train Per Visit,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,239,
OT CAREGIVER TRAING 1ST 30 MIN  ,97550,CPT,GO       ,48701858,CDM,942,RC,,,both,,,210,82.88,,,82.88,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,224.43,,,224.43,Fee Schedule,,202.1,,,202.1,Fee Schedule,,105,50,,105,percent of total billed charges,All Other Outpatient,94.5,45,,94.5,percent of total billed charges,All Other Outpatient,90.3,43,,90.3,percent of total billed charges,All Other Outpatient,105,50,,105,percent of total billed charges,All Other,147,70,,147,percent of total billed charges,All Other,185.06,,,185.06,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,217.96,,,217.96,Fee Schedule,,130.2,62,,130.2,percent of total billed charges,All Other Outpatient,123.38,,,123.38,Fee Schedule,,217.96,,,217.96,Fee Schedule,,130.2,62,,130.2,percent of total billed charges,All Other Outpatient,189,90,,189,percent of total billed charges,All Other,147,70,,147,percent of total billed charges,All Other,105,50,,105,percent of total billed charges,All Other,105,50,,105,percent of total billed charges,All Other,105,50,,105,percent of total billed charges,All Other Outpatient,105,50,,105,percent of total billed charges,All Other Outpatient,105,50,,105,percent of total billed charges,All Other Outpatient,105,50,,105,percent of total billed charges,All Other Outpatient,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,224.43,
DM OP SMT INDIV EA 30 MIN       ,G0108,HCPCS,,50119692,CDM,942,RC,,,both,,,85,33.55,,,33.55,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,192.76,,,192.76,Fee Schedule,,173.24,,,173.24,Fee Schedule,,42.5,50,,42.5,percent of total billed charges,All Other Outpatient,38.25,45,,38.25,percent of total billed charges,All Other Outpatient,36.55,43,,36.55,percent of total billed charges,All Other Outpatient,42.5,50,,42.5,percent of total billed charges,All Other,59.5,70,,59.5,percent of total billed charges,All Other,192.15,,,192.15,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,226.31,,,226.31,Fee Schedule,,52.7,62,,52.7,percent of total billed charges,All Other Outpatient,128.1,,,128.1,Fee Schedule,,226.31,,,226.31,Fee Schedule,,52.7,62,,52.7,percent of total billed charges,All Other Outpatient,76.5,90,,76.5,percent of total billed charges,All Other,59.5,70,,59.5,percent of total billed charges,All Other,267.3,,,267.3,Fee Schedule,,226.8,,,226.8,Fee Schedule,,239,,,239,Case Rate,Education & Train Per Visit,188,,,188,Case Rate,Education & Train Per Visit,210,,,210,Case Rate,Education & Train Per Visit,179,,,179,Case Rate,Education & Train Per Visit,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,267.3,
DM OP SMT GRP PER 30 MIN        ,G0109,HCPCS,,50119718,CDM,942,RC,,,both,,,82,32.36,,,32.36,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,55.62,,,55.62,Fee Schedule,,49.98,,,49.98,Fee Schedule,,41,50,,41,percent of total billed charges,All Other Outpatient,36.9,45,,36.9,percent of total billed charges,All Other Outpatient,35.26,43,,35.26,percent of total billed charges,All Other Outpatient,41,50,,41,percent of total billed charges,All Other,57.4,70,,57.4,percent of total billed charges,All Other,55.44,,,55.44,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,65.3,,,65.3,Fee Schedule,,50.84,62,,50.84,percent of total billed charges,All Other Outpatient,36.96,,,36.96,Fee Schedule,,65.3,,,65.3,Fee Schedule,,50.84,62,,50.84,percent of total billed charges,All Other Outpatient,73.8,90,,73.8,percent of total billed charges,All Other,57.4,70,,57.4,percent of total billed charges,All Other,75.9,,,75.9,Fee Schedule,,64.4,,,64.4,Fee Schedule,,239,,,239,Case Rate,Education & Train Per Visit,188,,,188,Case Rate,Education & Train Per Visit,210,,,210,Case Rate,Education & Train Per Visit,179,,,179,Case Rate,Education & Train Per Visit,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,239,
DM OP SMT INDIV EA 30 MIN TH    ,G0108,HCPCS,GT       ,50119890,CDM,942,RC,,,both,,,85,33.55,,,33.55,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Non-covered Service,192.76,,,192.76,Fee Schedule,,173.24,,,173.24,Fee Schedule,,42.5,50,,42.5,percent of total billed charges,All Other Outpatient,38.25,45,,38.25,percent of total billed charges,All Other Outpatient,36.55,43,,36.55,percent of total billed charges,All Other Outpatient,42.5,50,,42.5,percent of total billed charges,All Other,59.5,70,,59.5,percent of total billed charges,All Other,192.15,,,192.15,Fee Schedule,,0.02,,,0.02,Other,186% Medicaid methodology,226.31,,,226.31,Fee Schedule,,52.7,62,,52.7,percent of total billed charges,All Other Outpatient,128.1,,,128.1,Fee Schedule,,226.31,,,226.31,Fee Schedule,,52.7,62,,52.7,percent of total billed charges,All Other Outpatient,76.5,90,,76.5,percent of total billed charges,All Other,59.5,70,,59.5,percent of total billed charges,All Other,267.3,,,267.3,Fee Schedule,,226.8,,,226.8,Fee Schedule,,239,,,239,Case Rate,Education & Train Per Visit,188,,,188,Case Rate,Education & Train Per Visit,210,,,210,Case Rate,Education & Train Per Visit,179,,,179,Case Rate,Education & Train Per Visit,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.01,,,0.01,Other,100% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.02,,,0.02,Other,153% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.01,,,0.01,Other,140% Medicaid APG methodology,0.02,,,0.02,Other,225% Medicaid APG methodology,0.03,,,0.03,Other,260% Medicaid APG methodology,0.03,,,0.03,Other,324% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.02,,,0.02,Other,215% Medicaid APG methodology,0.01,,,0.01,Other,125% Medicaid APG methodology,0.01,267.3,
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,,inpatient,,,70766.77,22971,,,22971,Other,150% of Medicare + 9.63% HCRA Surcharge,13969.06,,,13969.06,Other,Medicare IPPS methodology,38092,,,38092,Case Rate,,34283,,,34283,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35383,50,,35383,Percent of Total Billed Charges,50% of Charges,44147,,"29,096 x DRG Weight",44147,Other,base rate x DRG weight,34083,,"22,463 x DRG Weight",34083,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,40096,,"26,426 x DRG Weight",40096,Other,base rate x DRG weight,58885,,"38,809 x DRG Weight",58885,Other,base rate x DRG weight,58885,,"38,809 x DRG Weight",58885,Other,base rate x DRG weight,40096,,"26,426 x DRG Weight",40096,Other,base rate x DRG weight,58885,,"38,809 x DRG Weight",58885,Other,base rate x DRG weight,53699,,"35,391 x DRG Weight",53699,Other,base rate x DRG weight,49537,70,,49537,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,38260,,"25,216 X DRG Weight",38260,Other,Base Weight X DRG Weight,34435,,"22,695 X DRG Weight",34435,Other,Base Weight X DRG Weight,38260,,"25,216 X DRG Weight",38260,Other,Base Rate x DRG Weight ,32520,,"21,433 x DRG Weight",32520,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,58885,
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,,inpatient,,,326103.8,26746,,,26746,Other,150% of Medicare + 9.63% HCRA Surcharge,16264.26,,,16264.26,Other,Medicare IPPS methodology,24290,,,24290,Case Rate,,21861,,,21861,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,163052,50,,163052,Percent of Total Billed Charges,50% of Charges,51552,,"29,096 x DRG Weight",51552,Other,base rate x DRG weight,15062,,,15062,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,17720,,,17720,Case Rate,,25662,,,25662,Case Rate,,25662,,,25662,Case Rate,,17720,,,17720,Case Rate,,25662,,,25662,Case Rate,,62706,,"35,391 x DRG Weight",62706,Other,base rate x DRG weight,228273,70,,228273,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,15273,,,15273,Case Rate,,13745,,,13745,Case Rate,,15273,,,15273,Case Rate,,12982,,,12982,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,228273,
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,,inpatient,,,136580.72,15657,,,15657,Other,150% of Medicare + 9.63% HCRA Surcharge,9521.15,,,9521.15,Other,Medicare IPPS methodology,24290,,,24290,Case Rate,,21861,,,21861,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,68290,50,,68290,Percent of Total Billed Charges,50% of Charges,29797,,"29,096 x DRG Weight",29797,Other,base rate x DRG weight,15062,,,15062,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,17720,,,17720,Case Rate,,25662,,,25662,Case Rate,,25662,,,25662,Case Rate,,17720,,,17720,Case Rate,,25662,,,25662,Case Rate,,36244,,"35,391 x DRG Weight",36244,Other,base rate x DRG weight,95607,70,,95607,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,15273,,,15273,Case Rate,,13745,,,13745,Case Rate,,15273,,,15273,Case Rate,,12982,,,12982,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,95607,
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,,inpatient,,,129444.36,13317,,,13317,Other,150% of Medicare + 9.63% HCRA Surcharge,8098.03,,,8098.03,Other,Medicare IPPS methodology,21706,,,21706,Case Rate,,19535,,,19535,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,64722,50,,64722,Percent of Total Billed Charges,50% of Charges,25206,,"29,096 x DRG Weight",25206,Other,base rate x DRG weight,15062,,,15062,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,17720,,,17720,Case Rate,,25662,,,25662,Case Rate,,25662,,,25662,Case Rate,,17720,,,17720,Case Rate,,25662,,,25662,Case Rate,,30659,,"35,391 x DRG Weight",30659,Other,base rate x DRG weight,90611,70,,90611,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,15273,,,15273,Case Rate,,13745,,,13745,Case Rate,,15273,,,15273,Case Rate,,12982,,,12982,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,90611,
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,,inpatient,,,180273.63,26415,,,26415,Other,150% of Medicare + 9.63% HCRA Surcharge,16063.15,,,16063.15,Other,Medicare IPPS methodology,24290,,,24290,Case Rate,,21861,,,21861,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,90137,50,,90137,Percent of Total Billed Charges,50% of Charges,50903,,"29,096 x DRG Weight",50903,Other,base rate x DRG weight,15062,,,15062,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,17720,,,17720,Case Rate,,25662,,,25662,Case Rate,,25662,,,25662,Case Rate,,17720,,,17720,Case Rate,,25662,,,25662,Case Rate,,61917,,"35,391 x DRG Weight",61917,Other,base rate x DRG weight,126192,70,,126192,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,15273,,,15273,Case Rate,,13745,,,13745,Case Rate,,15273,,,15273,Case Rate,,12982,,,12982,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,126192,
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,,inpatient,,,152105.02,16057,,,16057,Other,150% of Medicare + 9.63% HCRA Surcharge,9764.64,,,9764.64,Other,Medicare IPPS methodology,24290,,,24290,Case Rate,,21861,,,21861,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,76053,50,,76053,Percent of Total Billed Charges,50% of Charges,30583,,"29,096 x DRG Weight",30583,Other,base rate x DRG weight,15062,,,15062,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,17720,,,17720,Case Rate,,25662,,,25662,Case Rate,,25662,,,25662,Case Rate,,17720,,,17720,Case Rate,,25662,,,25662,Case Rate,,37199,,"35,391 x DRG Weight",37199,Other,base rate x DRG weight,106474,70,,106474,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,15273,,,15273,Case Rate,,13745,,,13745,Case Rate,,15273,,,15273,Case Rate,,12982,,,12982,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,106474,
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,,inpatient,,,117547.07,13149,,,13149,Other,150% of Medicare + 9.63% HCRA Surcharge,7996.12,,,7996.12,Other,Medicare IPPS methodology,21706,,,21706,Case Rate,,19535,,,19535,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,58774,50,,58774,Percent of Total Billed Charges,50% of Charges,24877,,"29,096 x DRG Weight",24877,Other,base rate x DRG weight,15062,,,15062,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,17720,,,17720,Case Rate,,25662,,,25662,Case Rate,,25662,,,25662,Case Rate,,17720,,,17720,Case Rate,,25662,,,25662,Case Rate,,30259,,"35,391 x DRG Weight",30259,Other,base rate x DRG weight,82283,70,,82283,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,15273,,,15273,Case Rate,,13745,,,13745,Case Rate,,15273,,,15273,Case Rate,,12982,,,12982,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,82283,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,,inpatient,,,44703.82,8989,,,8989,Other,150% of Medicare + 9.63% HCRA Surcharge,5466.44,,,5466.44,Other,Medicare IPPS methodology,11910,,"4,107 x patient days",11910,Per diem,,10718,,"3,696 x patient days",10718,Per diem,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22352,50,,22352,Percent of Total Billed Charges,50% of Charges,44703.82,,,44703.82,Other,Non Covered Service,4718,,"1,627 X patient days",4718,Per Diem,,0.01,,,0.01,Other,See APR-DRG information,5504,,"1,898 X patient days",5504,Per Diem,,5504,,1.898 X patients days,5504,Per Diem,,5504,,1.898 X patients days,5504,Per Diem,,4718,,"1,627 X patient days",4718,Per Diem,,4718,,"1,627 X patient days",4718,Per Diem,,7772,,"2,680 x patient days",7772,Per Diem,,31293,70,,31293,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,4588,,"1,582 X patient days",4588,Per Diem,,4588,,"1,582 X patient days",4588,Per Diem,,4588,,"1,582 X patient days",4588,Per Diem,,4588,,"1,582 X patient days",4588,Per Diem,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,44703.82,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,,inpatient,,,156174.86,26839,,,26839,Other,150% of Medicare + 9.63% HCRA Surcharge,16321.08,,,16321.08,Other,Medicare IPPS methodology,30392,,"4,107 x patient days",30392,Per diem,,27350,,"3,696 x patient days",27350,Per diem,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,78087,50,,78087,Percent of Total Billed Charges,50% of Charges,156174.86,,,156174.86,Other,Non Covered Service,12040,,"1,627 X patient days",12040,Per Diem,,0.01,,,0.01,Other,See APR-DRG information,14045,,"1,898 X patient days",14045,Per Diem,,14045,,1.898 X patients days,14045,Per Diem,,14045,,1.898 X patients days,14045,Per Diem,,12040,,"1,627 X patient days",12040,Per Diem,,12040,,"1,627 X patient days",12040,Per Diem,,19832,,"2,680 x patient days",19832,Per Diem,,109322,70,,109322,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,11707,,"1,582 X patient days",11707,Per Diem,,11707,,"1,582 X patient days",11707,Per Diem,,11707,,"1,582 X patient days",11707,Per Diem,,11707,,"1,582 X patient days",11707,Per Diem,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,156174.86,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,,inpatient,,,51639.53,13158,,,13158,Other,150% of Medicare + 9.63% HCRA Surcharge,8001.53,,,8001.53,Other,Medicare IPPS methodology,18071,,"4,107 x patient days",18071,Per diem,,16262,,"3,696 x patient days",16262,Per diem,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25820,50,,25820,Percent of Total Billed Charges,50% of Charges,51639.53,,,51639.53,Other,Non Covered Service,7159,,"1,627 X patient days",7159,Per Diem,,0.01,,,0.01,Other,See APR-DRG information,8351,,"1,898 X patient days",8351,Per Diem,,8351,,1.898 X patients days,8351,Per Diem,,8351,,1.898 X patients days,8351,Per Diem,,7159,,"1,627 X patient days",7159,Per Diem,,7159,,"1,627 X patient days",7159,Per Diem,,11792,,"2,680 x patient days",11792,Per Diem,,36148,70,,36148,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,6961,,"1,582 X patient days",6961,Per Diem,,6961,,"1,582 X patient days",6961,Per Diem,,6961,,"1,582 X patient days",6961,Per Diem,,6961,,"1,582 X patient days",6961,Per Diem,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,51639.53,
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,,inpatient,,,1418836.78,27452,,,27452,Other,150% of Medicare + 9.63% HCRA Surcharge,16693.54,,,16693.54,Other,Medicare IPPS methodology,9432,,"5,240 x patient days",9432,Per diem,,8489,,"4,716 X patient days",8489,Per diem,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,709418,50,,709418,Percent of Total Billed Charges,50% of Charges,52937,,"29,096 x DRG Weight",52937,Other,base rate x DRG weight,11201,,"6,223 X patient days",11201,Per Diem,,0.01,,,0.01,Other,See APR-DRG information,13178,,"7,321 X patient days",13178,Per Diem,,9180,,"5,100 X patient days",9180,Per Diem,,9180,,"5,100 X patient days",9180,Per Diem,,13178,,"7,321 X patient days",13178,Per Diem,,9180,,"5,100 X patient days",9180,Per Diem,,64390,,"35,391 x DRG Weight",64390,Other,base rate x DRG weight,993186,70,,993186,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,10631,,"5,906 X patient day",10631,Per Diem,,9571,,"5,317 X patient days",9571,Per Diem,,10631,,"5,906 x pateint days",10631,Per Diem,,9036,,"5,020 X patient days",9036,Per Diem,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,993186,
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,,inpatient,,,1430505.82,89453,,,89453,Other,150% of Medicare + 9.63% HCRA Surcharge,54397.1,,,54397.1,Other,Medicare IPPS methodology,147407,,"8,235 x patient days",147407,Per diem,,132675,,"7,412 X patient days",132675,Per diem,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,715253,50,,715253,Percent of Total Billed Charges,50% of Charges,174579,,"29,096 x DRG Weight",174579,Other,base rate x DRG weight,111392,,"6,223 X patient days",111392,Per Diem,,0.01,,,0.01,Other,See APR-DRG information,131046,,"7,321 X patient days",131046,Per Diem,,91290,,"5,100 X patient days",91290,Per Diem,,91290,,"5,100 X patient days",91290,Per Diem,,131046,,"7,321 X patient days",131046,Per Diem,,91290,,"5,100 X patient days",91290,Per Diem,,212350,,"35,391 x DRG Weight",212350,Other,base rate x DRG weight,1001354,70,,1001354,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,128504,,"7,179 X patient day",128504,Per Diem,,115634,,"6,460 X patient days",115634,Per Diem,,128504,,"7,179 X patient days",128504,Per Diem,,109208,,"6,101 X patient days",109208,Per Diem,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,1001354,
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,,inpatient,,,467884.73,61240,,,61240,Other,150% of Medicare + 9.63% HCRA Surcharge,37240.35,,,37240.35,Other,Medicare IPPS methodology,109526,,"8,235 x patient days",109526,Per diem,,98580,,"7,412 X patient days",98580,Per diem,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,233942,50,,233942,Percent of Total Billed Charges,50% of Charges,119227,,"29,096 x DRG Weight",119227,Other,base rate x DRG weight,82766,,"6,223 X patient days",82766,Per Diem,,0.01,,,0.01,Other,See APR-DRG information,97369,,"7,321 X patient days",97369,Per Diem,,67830,,"5,100 X patient days",67830,Per Diem,,67830,,"5,100 X patient days",67830,Per Diem,,97369,,"7,321 X patient days",97369,Per Diem,,67830,,"5,100 X patient days",67830,Per Diem,,145022,,"35,391 x DRG Weight",145022,Other,base rate x DRG weight,327519,70,,327519,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,95481,,"7,179 X patient day",95481,Per Diem,,85918,,"6,460 X patient days",85918,Per Diem,,95481,,"7,179 X patient days",95481,Per Diem,,81143,,"6,101 X patient days",81143,Per Diem,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,327519,
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,,inpatient,,,188718.27,37137,,,37137,Other,150% of Medicare + 9.63% HCRA Surcharge,22583.51,,,22583.51,Other,Medicare IPPS methodology,45064,,"5,240 x patient days",45064,Per diem,,40558,,"4,716 X patient days",40558,Per diem,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,94359,50,,94359,Percent of Total Billed Charges,50% of Charges,71940,,"29,096 x DRG Weight",71940,Other,base rate x DRG weight,53518,,"6,223 X patient days",53518,Per Diem,,0.01,,,0.01,Other,See APR-DRG information,62961,,"7,321 X patient days",62961,Per Diem,,43860,,"5,100 X patient days",43860,Per Diem,,43860,,"5,100 X patient days",43860,Per Diem,,62961,,"7,321 X patient days",62961,Per Diem,,43860,,"5,100 X patient days",43860,Per Diem,,87504,,"35,391 x DRG Weight",87504,Other,base rate x DRG weight,132103,70,,132103,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,50792,,"5,906 X patient day",50792,Per Diem,,45726,,"5,317 X patient days",45726,Per Diem,,50792,,"5,906 x pateint days",50792,Per Diem,,43172,,"5,020 X patient days",43172,Per Diem,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,132103,
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,,inpatient,,,267942.92,62895,,,62895,Other,150% of Medicare + 9.63% HCRA Surcharge,38246.81,,,38246.81,Other,Medicare IPPS methodology,38705,,"8,235 x patient days",38705,Per diem,,34836,,"7,412 X patient days",34836,Per diem,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,133971,50,,133971,Percent of Total Billed Charges,50% of Charges,122474,,"29,096 x DRG Weight",122474,Other,base rate x DRG weight,29248,,"6,223 X patient days",29248,Per Diem,,0.01,,,0.01,Other,See APR-DRG information,34409,,"7,321 X patient days",34409,Per Diem,,23970,,"5,100 X patient days",23970,Per Diem,,23970,,"5,100 X patient days",23970,Per Diem,,34409,,"7,321 X patient days",34409,Per Diem,,23970,,"5,100 X patient days",23970,Per Diem,,148971,,"35,391 x DRG Weight",148971,Other,base rate x DRG weight,187560,70,,187560,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,33741,,"7,179 X patient day",33741,Per Diem,,30362,,"6,460 X patient days",30362,Per Diem,,33741,,"7,179 X patient days",33741,Per Diem,,28675,,"6,101 X patient days",28675,Per Diem,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,187560,
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,,inpatient,,,52210.18,22565,,,22565,Other,150% of Medicare + 9.63% HCRA Surcharge,13721.95,,,13721.95,Other,Medicare IPPS methodology,17816,,"5,240 x patient days",17816,Per diem,,25201,,"7,412 X patient days",25201,Per diem,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,26105,50,,26105,Percent of Total Billed Charges,50% of Charges,43350,,"29,096 x DRG Weight",43350,Other,base rate x DRG weight,21158,,"6,223 X patient days",21158,Per Diem,,0.01,,,0.01,Other,See APR-DRG information,24891,,"7,321 X patient days",24891,Per Diem,,17340,,"5,100 X patient days",17340,Per Diem,,17340,,"5,100 X patient days",17340,Per Diem,,24891,,"7,321 X patient days",24891,Per Diem,,17340,,"5,100 X patient days",17340,Per Diem,,52729,,"35,391 x DRG Weight",52729,Other,base rate x DRG weight,36547,70,,36547,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20080,,"5,906 X patient day",20080,Per Diem,,18078,,"5,317 X patient days",18078,Per Diem,,20080,,"5,906 x pateint days",20080,Per Diem,,17068,,"5,020 X patient days",17068,Per Diem,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,52729,
NORMAL NEWBORN,795,MS-DRG,,,,,,,,inpatient,,,22159.76,3460,,,3460,Other,150% of Medicare + 9.63% HCRA Surcharge,2104.35,,,2104.35,Other,Medicare IPPS methodology,10670,,"5,240 x patient days",10670,Per diem,,9604,,"3,098 X patient days",9604,Per diem,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,11080,50,,11080,Percent of Total Billed Charges,50% of Charges,5869,,"29,096 x DRG Weight",5869,Other,base rate x DRG weight,5803,,"1,872 X patient days",5803,Per Diem,,0.01,,,0.01,Other,See APR-DRG information,6826,,"2,202 X patient days",6826,Per Diem,,11777,,"3,799 X patient days",11777,Per Diem,,11777,,"3,799 X patient days",11777,Per Diem,,6826,,"2,202 X patient days",6826,Per Diem,,11777,,"3,799 X patient days",11777,Per Diem,,7138,,"35,391 x DRG Weight",7138,Other,base rate x DRG weight,15512,70,,15512,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,7905,,"2,550 X patient Days",7905,Per Diem,,7111,,"2,294 X patient days",7111,Per Diem,,7905,,"2,550 X patient days",7905,Per Diem,,6718,,"2,167 X patient days",6718,Per Diem,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,15512,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,,,,inpatient,,,110308.21,24328,,,24328,Other,150% of Medicare + 9.63% HCRA Surcharge,14794.25,,,14794.25,Other,Medicare IPPS methodology,47641,,"4,107 x patient days",47641,Per diem,,42874,,"3,696 x patient days",42874,Per diem,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,55154,50,,55154,Percent of Total Billed Charges,50% of Charges,110308.21,,,110308.21,Other,Non Covered Service,18873,,"1,627 X patient days",18873,Per Diem,,0.01,,,0.01,Other,See APR-DRG information,22017,,"1,898 X patient days",22017,Per Diem,,22017,,1.898 X patients days,22017,Per Diem,,22017,,1.898 X patients days,22017,Per Diem,,18873,,"1,627 X patient days",18873,Per Diem,,18873,,"1,627 X patient days",18873,Per Diem,,31088,,"2,680 x patient days",31088,Per Diem,,77216,70,,77216,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18351,,"1,582 X patient days",18351,Per Diem,,18351,,"1,582 X patient days",18351,Per Diem,,18351,,"1,582 X patient days",18351,Per Diem,,18351,,"1,582 X patient days",18351,Per Diem,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,110308.21,
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",3,MS-DRG,,,,,,,,inpatient,,,2142512.18,316659,,,316659,Other,150% of Medicare + 9.63% HCRA Surcharge,192562.02,,,192562.02,Other,Medicare IPPS methodology,548529,,"25,728 x DRG weight",548529,Other,base rate x DRG weight,493672,,"23,155 x DRG weight",493672,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,1071256,50,,1071256,Percent of Total Billed Charges,50% of Charges,620335,,"29,096 x DRG Weight",620335,Other,base rate x DRG weight,478918,,"22,463 x DRG Weight",478918,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,563410,,"26,426 x DRG Weight",563410,Other,base rate x DRG weight,827420,,"38,809 x DRG Weight",827420,Other,base rate x DRG weight,827420,,"38,809 x DRG Weight",827420,Other,base rate x DRG weight,563410,,"26,426 x DRG Weight",563410,Other,base rate x DRG weight,827420,,"38,809 x DRG Weight",827420,Other,base rate x DRG weight,754547,,"35,391 x DRG Weight",754547,Other,base rate x DRG weight,1499759,70,,1499759,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,537613,,"25,216 X DRG Weight",537613,Other,Base Weight X DRG Weight,483864,,"22,695 X DRG Weight",483864,Other,Base Weight X DRG Weight,537613,,"25,216 X DRG Weight",537613,Other,Base Rate x DRG Weight ,456958,,"21,433 x DRG Weight",456958,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,1499759,
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",4,MS-DRG,,,,,,,,inpatient,,,2138389.4,218477,,,218477,Other,150% of Medicare + 9.63% HCRA Surcharge,132856.98,,,132856.98,Other,Medicare IPPS methodology,378202,,"25,728 x DRG weight",378202,Other,base rate x DRG weight,340379,,"23,155 x DRG weight",340379,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,1069195,50,,1069195,Percent of Total Billed Charges,50% of Charges,427711,,"29,096 x DRG Weight",427711,Other,base rate x DRG weight,330206,,"22,463 x DRG Weight",330206,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,388462,,"26,426 x DRG Weight",388462,Other,base rate x DRG weight,570492,,"38,809 x DRG Weight",570492,Other,base rate x DRG weight,570492,,"38,809 x DRG Weight",570492,Other,base rate x DRG weight,388462,,"26,426 x DRG Weight",388462,Other,base rate x DRG weight,570492,,"38,809 x DRG Weight",570492,Other,base rate x DRG weight,520248,,"35,391 x DRG Weight",520248,Other,base rate x DRG weight,1496873,70,,1496873,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,370675,,"25,216 X DRG Weight",370675,Other,Base Weight X DRG Weight,333617,,"22,695 X DRG Weight",333617,Other,Base Weight X DRG Weight,370675,,"25,216 X DRG Weight",370675,Other,Base Rate x DRG Weight ,315065,,"21,433 x DRG Weight",315065,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,1496873,
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,,inpatient,,,94083.98,18534,,,18534,Other,150% of Medicare + 9.63% HCRA Surcharge,11270.73,,,11270.73,Other,Medicare IPPS methodology,19461,,,19461,Case Rate,,17515,,,17515,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,47042,50,,47042,Percent of Total Billed Charges,50% of Charges,35442,,"29,096 x DRG Weight",35442,Other,base rate x DRG weight,10041,,,10041,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,11813,,,11813,Case Rate,,18158,,,18158,Case Rate,,18158,,,18158,Case Rate,,11813,,,11813,Case Rate,,18158,,,18158,Case Rate,,43110,,"35,391 x DRG Weight",43110,Other,base rate x DRG weight,65859,70,,65859,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,11145,,,11145,Case Rate,,10030,,,10030,Case Rate,,11145,,,11145,Case Rate,,9474,,,9474,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,65859,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,MS-DRG,,,,,,,,inpatient,,,116164.8,21505,,,21505,Other,150% of Medicare + 9.63% HCRA Surcharge,13077.13,,,13077.13,Other,Medicare IPPS methodology,23204,,,23204,Case Rate,,20884,,,20884,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,58082,50,,58082,Percent of Total Billed Charges,50% of Charges,41270,,"29,096 x DRG Weight",41270,Other,base rate x DRG weight,10041,,,10041,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,11813,,,11813,Case Rate,,18158,,,18158,Case Rate,,18158,,,18158,Case Rate,,11813,,,11813,Case Rate,,18158,,,18158,Case Rate,,50199,,"35,391 x DRG Weight",50199,Other,base rate x DRG weight,81315,70,,81315,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,11145,,,11145,Case Rate,,10030,,,10030,Case Rate,,11145,,,11145,Case Rate,,9474,,,9474,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,81315,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,,inpatient,,,225725.21,15239,,,15239,Other,150% of Medicare + 9.63% HCRA Surcharge,9266.82,,,9266.82,Other,Medicare IPPS methodology,23204,,,23204,Case Rate,,20884,,,20884,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,112863,50,,112863,Percent of Total Billed Charges,50% of Charges,28977,,"29,096 x DRG Weight",28977,Other,base rate x DRG weight,10041,,,10041,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,11813,,,11813,Case Rate,,18158,,,18158,Case Rate,,18158,,,18158,Case Rate,,11813,,,11813,Case Rate,,18158,,,18158,Case Rate,,35246,,"35,391 x DRG Weight",35246,Other,base rate x DRG weight,158008,70,,158008,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,11145,,,11145,Case Rate,,10030,,,10030,Case Rate,,11145,,,11145,Case Rate,,9474,,,9474,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,158008,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,MS-DRG,,,,,,,,inpatient,,,111119.12,12854,,,12854,Other,150% of Medicare + 9.63% HCRA Surcharge,7816.65,,,7816.65,Other,Medicare IPPS methodology,23204,,,23204,Case Rate,,20884,,,20884,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,55560,50,,55560,Percent of Total Billed Charges,50% of Charges,24298,,"29,096 x DRG Weight",24298,Other,base rate x DRG weight,10041,,,10041,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,11813,,,11813,Case Rate,,18158,,,18158,Case Rate,,18158,,,18158,Case Rate,,11813,,,11813,Case Rate,,18158,,,18158,Case Rate,,29555,,"35,391 x DRG Weight",29555,Other,base rate x DRG weight,77783,70,,77783,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,11145,,,11145,Case Rate,,10030,,,10030,Case Rate,,11145,,,11145,Case Rate,,9474,,,9474,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,77783,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,,inpatient,,,104120.21,15421,,,15421,Other,150% of Medicare + 9.63% HCRA Surcharge,9377.75,,,9377.75,Other,Medicare IPPS methodology,19461,,,19461,Case Rate,,17515,,,17515,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,52060,50,,52060,Percent of Total Billed Charges,50% of Charges,29335,,"29,096 x DRG Weight",29335,Other,base rate x DRG weight,10041,,,10041,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,11813,,,11813,Case Rate,,18158,,,18158,Case Rate,,18158,,,18158,Case Rate,,11813,,,11813,Case Rate,,18158,,,18158,Case Rate,,35681,,"35,391 x DRG Weight",35681,Other,base rate x DRG weight,72884,70,,72884,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,11145,,,11145,Case Rate,,10030,,,10030,Case Rate,,11145,,,11145,Case Rate,,9474,,,9474,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,72884,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,,inpatient,,,81857.31,11543,,,11543,Other,150% of Medicare + 9.63% HCRA Surcharge,7019.42,,,7019.42,Other,Medicare IPPS methodology,19461,,,19461,Case Rate,,17515,,,17515,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40929,50,,40929,Percent of Total Billed Charges,50% of Charges,21726,,"29,096 x DRG Weight",21726,Other,base rate x DRG weight,10041,,,10041,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,11813,,,11813,Case Rate,,18158,,,18158,Case Rate,,18158,,,18158,Case Rate,,11813,,,11813,Case Rate,,18158,,,18158,Case Rate,,26426,,"35,391 x DRG Weight",26426,Other,base rate x DRG weight,57300,70,,57300,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,11145,,,11145,Case Rate,,10030,,,10030,Case Rate,,11145,,,11145,Case Rate,,9474,,,9474,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,57300,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,,inpatient,,,71402.35,10173,,,10173,Other,150% of Medicare + 9.63% HCRA Surcharge,6186.11,,,6186.11,Other,Medicare IPPS methodology,18562,,,18562,Case Rate,,16706,,,16706,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35701,50,,35701,Percent of Total Billed Charges,50% of Charges,19038,,"29,096 x DRG Weight",19038,Other,base rate x DRG weight,10041,,,10041,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,11813,,,11813,Case Rate,,18158,,,18158,Case Rate,,18158,,,18158,Case Rate,,11813,,,11813,Case Rate,,18158,,,18158,Case Rate,,23156,,"35,391 x DRG Weight",23156,Other,base rate x DRG weight,49982,70,,49982,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,11145,,,11145,Case Rate,,10030,,,10030,Case Rate,,11145,,,11145,Case Rate,,9474,,,9474,Case Rate,,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,49982,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",11,MS-DRG,,,,,,,,inpatient,,,1018970.79,76939,,,76939,Other,150% of Medicare + 9.63% HCRA Surcharge,46787.31,,,46787.31,Other,Medicare IPPS methodology,132661,,"25,728 x DRG weight",132661,Other,base rate x DRG weight,119394,,"23,155 x DRG weight",119394,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,509485,50,,509485,Percent of Total Billed Charges,50% of Charges,150028,,"29,096 x DRG Weight",150028,Other,base rate x DRG weight,115826,,"22,463 x DRG Weight",115826,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,136260,,"26,426 x DRG Weight",136260,Other,base rate x DRG weight,200111,,"38,809 x DRG Weight",200111,Other,base rate x DRG weight,200111,,"38,809 x DRG Weight",200111,Other,base rate x DRG weight,136260,,"26,426 x DRG Weight",136260,Other,base rate x DRG weight,200111,,"38,809 x DRG Weight",200111,Other,base rate x DRG weight,182487,,"35,391 x DRG Weight",182487,Other,base rate x DRG weight,713280,70,,713280,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,130021,,"25,216 X DRG Weight",130021,Other,Base Weight X DRG Weight,117022,,"22,695 X DRG Weight",117022,Other,Base Weight X DRG Weight,130021,,"25,216 X DRG Weight",130021,Other,Base Rate x DRG Weight ,110515,,"21,433 x DRG Weight",110515,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,713280,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",12,MS-DRG,,,,,,,,inpatient,,,746089.01,59864,,,59864,Other,150% of Medicare + 9.63% HCRA Surcharge,36403.43,,,36403.43,Other,Medicare IPPS methodology,103038,,"25,728 x DRG weight",103038,Other,base rate x DRG weight,92733,,"23,155 x DRG weight",92733,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,373045,50,,373045,Percent of Total Billed Charges,50% of Charges,116527,,"29,096 x DRG Weight",116527,Other,base rate x DRG weight,89962,,"22,463 x DRG Weight",89962,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,105833,,"26,426 x DRG Weight",105833,Other,base rate x DRG weight,155426,,"38,809 x DRG Weight",155426,Other,base rate x DRG weight,155426,,"38,809 x DRG Weight",155426,Other,base rate x DRG weight,105833,,"26,426 x DRG Weight",105833,Other,base rate x DRG weight,155426,,"38,809 x DRG Weight",155426,Other,base rate x DRG weight,141737,,"35,391 x DRG Weight",141737,Other,base rate x DRG weight,522262,70,,522262,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,100988,,"25,216 X DRG Weight",100988,Other,Base Weight X DRG Weight,90891,,"22,695 X DRG Weight",90891,Other,Base Weight X DRG Weight,100988,,"25,216 X DRG Weight",100988,Other,Base Rate x DRG Weight ,85837,,"21,433 x DRG Weight",85837,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,522262,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",13,MS-DRG,,,,,,,,inpatient,,,640772.94,40299,,,40299,Other,150% of Medicare + 9.63% HCRA Surcharge,24506.25,,,24506.25,Other,Medicare IPPS methodology,69098,,"25,728 x DRG weight",69098,Other,base rate x DRG weight,62187,,"23,155 x DRG weight",62187,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,320386,50,,320386,Percent of Total Billed Charges,50% of Charges,78143,,"29,096 x DRG Weight",78143,Other,base rate x DRG weight,60329,,"22,463 x DRG Weight",60329,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,70972,,"26,426 x DRG Weight",70972,Other,base rate x DRG weight,104229,,"38,809 x DRG Weight",104229,Other,base rate x DRG weight,104229,,"38,809 x DRG Weight",104229,Other,base rate x DRG weight,70972,,"26,426 x DRG Weight",70972,Other,base rate x DRG weight,104229,,"38,809 x DRG Weight",104229,Other,base rate x DRG weight,95050,,"35,391 x DRG Weight",95050,Other,base rate x DRG weight,448541,70,,448541,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,67723,,"25,216 X DRG Weight",67723,Other,Base Weight X DRG Weight,60952,,"22,695 X DRG Weight",60952,Other,Base Weight X DRG Weight,67723,,"25,216 X DRG Weight",67723,Other,Base Rate x DRG Weight ,57563,,"21,433 x DRG Weight",57563,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,448541,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,18,MS-DRG,,,,,,,,inpatient,,,2269653,546863,,,546863,Other,150% of Medicare + 9.63% HCRA Surcharge,332550.47,,,332550.47,Other,Medicare IPPS methodology,947889,,"25,728 x DRG weight",947889,Other,base rate x DRG weight,853093,,"23,155 x DRG weight",853093,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,1134827,50,,1134827,Percent of Total Billed Charges,50% of Charges,1071975,,"29,096 x DRG Weight",1071975,Other,base rate x DRG weight,827598,,"22,463 x DRG Weight",827598,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,973605,,"26,426 x DRG Weight",973605,Other,base rate x DRG weight,1429828,,"38,809 x DRG Weight",1429828,Other,base rate x DRG weight,1429828,,"38,809 x DRG Weight",1429828,Other,base rate x DRG weight,973605,,"26,426 x DRG Weight",973605,Other,base rate x DRG weight,1429828,,"38,809 x DRG Weight",1429828,Other,base rate x DRG weight,1303900,,"35,391 x DRG Weight",1303900,Other,base rate x DRG weight,1588757,70,,1588757,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,929026,,"25,216 X DRG Weight",929026,Other,Base Weight X DRG Weight,836145,,"22,695 X DRG Weight",836145,Other,Base Weight X DRG Weight,929026,,"25,216 X DRG Weight",929026,Other,Base Rate x DRG Weight ,789650,,"21,433 x DRG Weight",789650,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,1588757,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,20,MS-DRG,,,,,,,,inpatient,,,843972.12,125822,,,125822,Other,150% of Medicare + 9.63% HCRA Surcharge,76513.12,,,76513.12,Other,Medicare IPPS methodology,217463,,"25,728 x DRG weight",217463,Other,base rate x DRG weight,195715,,"23,155 x DRG weight",195715,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,421986,50,,421986,Percent of Total Billed Charges,50% of Charges,245931,,"29,096 x DRG Weight",245931,Other,base rate x DRG weight,189866,,"22,463 x DRG Weight",189866,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,223363,,"26,426 x DRG Weight",223363,Other,base rate x DRG weight,328029,,"38,809 x DRG Weight",328029,Other,base rate x DRG weight,328029,,"38,809 x DRG Weight",328029,Other,base rate x DRG weight,223363,,"26,426 x DRG Weight",223363,Other,base rate x DRG weight,328029,,"38,809 x DRG Weight",328029,Other,base rate x DRG weight,299139,,"35,391 x DRG Weight",299139,Other,base rate x DRG weight,590780,70,,590780,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,213136,,"25,216 X DRG Weight",213136,Other,Base Weight X DRG Weight,191827,,"22,695 X DRG Weight",191827,Other,Base Weight X DRG Weight,213136,,"25,216 X DRG Weight",213136,Other,Base Rate x DRG Weight ,181160,,"21,433 x DRG Weight",181160,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,590780,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,21,MS-DRG,,,,,,,,inpatient,,,431596.61,91549,,,91549,Other,150% of Medicare + 9.63% HCRA Surcharge,55671.41,,,55671.41,Other,Medicare IPPS methodology,158006,,"25,728 x DRG weight",158006,Other,base rate x DRG weight,142204,,"23,155 x DRG weight",142204,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,215798,50,,215798,Percent of Total Billed Charges,50% of Charges,178690,,"29,096 x DRG Weight",178690,Other,base rate x DRG weight,137954,,"22,463 x DRG Weight",137954,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,162293,,"26,426 x DRG Weight",162293,Other,base rate x DRG weight,238342,,"38,809 x DRG Weight",238342,Other,base rate x DRG weight,238342,,"38,809 x DRG Weight",238342,Other,base rate x DRG weight,162293,,"26,426 x DRG Weight",162293,Other,base rate x DRG weight,238342,,"38,809 x DRG Weight",238342,Other,base rate x DRG weight,217350,,"35,391 x DRG Weight",217350,Other,base rate x DRG weight,302118,70,,302118,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,154862,,"25,216 X DRG Weight",154862,Other,Base Weight X DRG Weight,139379,,"22,695 X DRG Weight",139379,Other,Base Weight X DRG Weight,154862,,"25,216 X DRG Weight",154862,Other,Base Rate x DRG Weight ,131629,,"21,433 x DRG Weight",131629,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,302118,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,22,MS-DRG,,,,,,,,inpatient,,,383655.44,58645,,,58645,Other,150% of Medicare + 9.63% HCRA Surcharge,35662.11,,,35662.11,Other,Medicare IPPS methodology,100923,,"25,728 x DRG weight",100923,Other,base rate x DRG weight,90830,,"23,155 x DRG weight",90830,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,191828,50,,191828,Percent of Total Billed Charges,50% of Charges,114135,,"29,096 x DRG Weight",114135,Other,base rate x DRG weight,88116,,"22,463 x DRG Weight",88116,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,103661,,"26,426 x DRG Weight",103661,Other,base rate x DRG weight,152236,,"38,809 x DRG Weight",152236,Other,base rate x DRG weight,152236,,"38,809 x DRG Weight",152236,Other,base rate x DRG weight,103661,,"26,426 x DRG Weight",103661,Other,base rate x DRG weight,152236,,"38,809 x DRG Weight",152236,Other,base rate x DRG weight,138828,,"35,391 x DRG Weight",138828,Other,base rate x DRG weight,268559,70,,268559,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,98915,,"25,216 X DRG Weight",98915,Other,Base Weight X DRG Weight,89026,,"22,695 X DRG Weight",89026,Other,Base Weight X DRG Weight,98915,,"25,216 X DRG Weight",98915,Other,Base Rate x DRG Weight ,84075,,"21,433 x DRG Weight",84075,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,268559,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,23,MS-DRG,,,,,,,,inpatient,,,464200.84,84540,,,84540,Other,150% of Medicare + 9.63% HCRA Surcharge,51409.28,,,51409.28,Other,Medicare IPPS methodology,145847,,"25,728 x DRG weight",145847,Other,base rate x DRG weight,131261,,"23,155 x DRG weight",131261,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,232100,50,,232100,Percent of Total Billed Charges,50% of Charges,164939,,"29,096 x DRG Weight",164939,Other,base rate x DRG weight,127338,,"22,463 x DRG Weight",127338,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,149804,,"26,426 x DRG Weight",149804,Other,base rate x DRG weight,220000,,"38,809 x DRG Weight",220000,Other,base rate x DRG weight,220000,,"38,809 x DRG Weight",220000,Other,base rate x DRG weight,149804,,"26,426 x DRG Weight",149804,Other,base rate x DRG weight,220000,,"38,809 x DRG Weight",220000,Other,base rate x DRG weight,200625,,"35,391 x DRG Weight",200625,Other,base rate x DRG weight,324941,70,,324941,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,142944,,"25,216 X DRG Weight",142944,Other,Base Weight X DRG Weight,128653,,"22,695 X DRG Weight",128653,Other,Base Weight X DRG Weight,142944,,"25,216 X DRG Weight",142944,Other,Base Rate x DRG Weight ,121499,,"21,433 x DRG Weight",121499,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,324941,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,24,MS-DRG,,,,,,,,inpatient,,,345432.72,56659,,,56659,Other,150% of Medicare + 9.63% HCRA Surcharge,34454.54,,,34454.54,Other,Medicare IPPS methodology,97478,,"25,728 x DRG weight",97478,Other,base rate x DRG weight,87730,,"23,155 x DRG weight",87730,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,172716,50,,172716,Percent of Total Billed Charges,50% of Charges,110239,,"29,096 x DRG Weight",110239,Other,base rate x DRG weight,85108,,"22,463 x DRG Weight",85108,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,100123,,"26,426 x DRG Weight",100123,Other,base rate x DRG weight,147040,,"38,809 x DRG Weight",147040,Other,base rate x DRG weight,147040,,"38,809 x DRG Weight",147040,Other,base rate x DRG weight,100123,,"26,426 x DRG Weight",100123,Other,base rate x DRG weight,147040,,"38,809 x DRG Weight",147040,Other,base rate x DRG weight,134089,,"35,391 x DRG Weight",134089,Other,base rate x DRG weight,241803,70,,241803,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,95538,,"25,216 X DRG Weight",95538,Other,Base Weight X DRG Weight,85987,,"22,695 X DRG Weight",85987,Other,Base Weight X DRG Weight,95538,,"25,216 X DRG Weight",95538,Other,Base Rate x DRG Weight ,81205,,"21,433 x DRG Weight",81205,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,241803,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,25,MS-DRG,,,,,,,,inpatient,,,461817.62,65960,,,65960,Other,150% of Medicare + 9.63% HCRA Surcharge,40110.93,,,40110.93,Other,Medicare IPPS methodology,113615,,"25,728 x DRG weight",113615,Other,base rate x DRG weight,102252,,"23,155 x DRG weight",102252,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,230909,50,,230909,Percent of Total Billed Charges,50% of Charges,128488,,"29,096 x DRG Weight",128488,Other,base rate x DRG weight,99197,,"22,463 x DRG Weight",99197,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,116697,,"26,426 x DRG Weight",116697,Other,base rate x DRG weight,171381,,"38,809 x DRG Weight",171381,Other,base rate x DRG weight,171381,,"38,809 x DRG Weight",171381,Other,base rate x DRG weight,116697,,"26,426 x DRG Weight",116697,Other,base rate x DRG weight,171381,,"38,809 x DRG Weight",171381,Other,base rate x DRG weight,156287,,"35,391 x DRG Weight",156287,Other,base rate x DRG weight,323272,70,,323272,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,111354,,"25,216 X DRG Weight",111354,Other,Base Weight X DRG Weight,100221,,"22,695 X DRG Weight",100221,Other,Base Weight X DRG Weight,111354,,"25,216 X DRG Weight",111354,Other,Base Rate x DRG Weight ,94648,,"21,433 x DRG Weight",94648,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,323272,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,26,MS-DRG,,,,,,,,inpatient,,,336299.27,44265,,,44265,Other,150% of Medicare + 9.63% HCRA Surcharge,26917.79,,,26917.79,Other,Medicare IPPS methodology,75977,,"25,728 x DRG weight",75977,Other,base rate x DRG weight,68379,,"23,155 x DRG weight",68379,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,168150,50,,168150,Percent of Total Billed Charges,50% of Charges,85923,,"29,096 x DRG Weight",85923,Other,base rate x DRG weight,66335,,"22,463 x DRG Weight",66335,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,78039,,"26,426 x DRG Weight",78039,Other,base rate x DRG weight,114607,,"38,809 x DRG Weight",114607,Other,base rate x DRG weight,114607,,"38,809 x DRG Weight",114607,Other,base rate x DRG weight,78039,,"26,426 x DRG Weight",78039,Other,base rate x DRG weight,114607,,"38,809 x DRG Weight",114607,Other,base rate x DRG weight,104513,,"35,391 x DRG Weight",104513,Other,base rate x DRG weight,235409,70,,235409,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,74465,,"25,216 X DRG Weight",74465,Other,Base Weight X DRG Weight,67021,,"22,695 X DRG Weight",67021,Other,Base Weight X DRG Weight,74465,,"25,216 X DRG Weight",74465,Other,Base Rate x DRG Weight ,63294,,"21,433 x DRG Weight",63294,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,235409,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,27,MS-DRG,,,,,,,,inpatient,,,206391.91,36550,,,36550,Other,150% of Medicare + 9.63% HCRA Surcharge,22226.38,,,22226.38,Other,Medicare IPPS methodology,62594,,"25,728 x DRG weight",62594,Other,base rate x DRG weight,56334,,"23,155 x DRG weight",56334,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,103196,50,,103196,Percent of Total Billed Charges,50% of Charges,70788,,"29,096 x DRG Weight",70788,Other,base rate x DRG weight,54650,,"22,463 x DRG Weight",54650,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,64292,,"26,426 x DRG Weight",64292,Other,base rate x DRG weight,94418,,"38,809 x DRG Weight",94418,Other,base rate x DRG weight,94418,,"38,809 x DRG Weight",94418,Other,base rate x DRG weight,64292,,"26,426 x DRG Weight",64292,Other,base rate x DRG weight,94418,,"38,809 x DRG Weight",94418,Other,base rate x DRG weight,86103,,"35,391 x DRG Weight",86103,Other,base rate x DRG weight,144474,70,,144474,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,61348,,"25,216 X DRG Weight",61348,Other,Base Weight X DRG Weight,55215,,"22,695 X DRG Weight",55215,Other,Base Weight X DRG Weight,61348,,"25,216 X DRG Weight",61348,Other,Base Rate x DRG Weight ,52144,,"21,433 x DRG Weight",52144,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,144474,
SPINAL PROCEDURES WITH MCC,28,MS-DRG,,,,,,,,inpatient,,,524282.81,89839,,,89839,Other,150% of Medicare + 9.63% HCRA Surcharge,54631.58,,,54631.58,Other,Medicare IPPS methodology,155040,,"25,728 x DRG weight",155040,Other,base rate x DRG weight,139534,,"23,155 x DRG weight",139534,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,262141,50,,262141,Percent of Total Billed Charges,50% of Charges,175335,,"29,096 x DRG Weight",175335,Other,base rate x DRG weight,135364,,"22,463 x DRG Weight",135364,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,159246,,"26,426 x DRG Weight",159246,Other,base rate x DRG weight,233867,,"38,809 x DRG Weight",233867,Other,base rate x DRG weight,233867,,"38,809 x DRG Weight",233867,Other,base rate x DRG weight,159246,,"26,426 x DRG Weight",159246,Other,base rate x DRG weight,233867,,"38,809 x DRG Weight",233867,Other,base rate x DRG weight,213270,,"35,391 x DRG Weight",213270,Other,base rate x DRG weight,366998,70,,366998,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,151954,,"25,216 X DRG Weight",151954,Other,Base Weight X DRG Weight,136762,,"22,695 X DRG Weight",136762,Other,Base Weight X DRG Weight,151954,,"25,216 X DRG Weight",151954,Other,Base Rate x DRG Weight ,129157,,"21,433 x DRG Weight",129157,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,366998,
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,29,MS-DRG,,,,,,,,inpatient,,,391448.89,51311,,,51311,Other,150% of Medicare + 9.63% HCRA Surcharge,31202.47,,,31202.47,Other,Medicare IPPS methodology,88201,,"25,728 x DRG weight",88201,Other,base rate x DRG weight,79380,,"23,155 x DRG weight",79380,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,195724,50,,195724,Percent of Total Billed Charges,50% of Charges,99747,,"29,096 x DRG Weight",99747,Other,base rate x DRG weight,77008,,"22,463 x DRG Weight",77008,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,90594,,"26,426 x DRG Weight",90594,Other,base rate x DRG weight,133045,,"38,809 x DRG Weight",133045,Other,base rate x DRG weight,133045,,"38,809 x DRG Weight",133045,Other,base rate x DRG weight,90594,,"26,426 x DRG Weight",90594,Other,base rate x DRG weight,133045,,"38,809 x DRG Weight",133045,Other,base rate x DRG weight,121327,,"35,391 x DRG Weight",121327,Other,base rate x DRG weight,274014,70,,274014,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,86445,,"25,216 X DRG Weight",86445,Other,Base Weight X DRG Weight,77803,,"22,695 X DRG Weight",77803,Other,Base Weight X DRG Weight,86445,,"25,216 X DRG Weight",86445,Other,Base Rate x DRG Weight ,73477,,"21,433 x DRG Weight",73477,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,274014,
SPINAL PROCEDURES WITHOUT CC/MCC,30,MS-DRG,,,,,,,,inpatient,,,216991.21,34861,,,34861,Other,150% of Medicare + 9.63% HCRA Surcharge,21199.18,,,21199.18,Other,Medicare IPPS methodology,59663,,"25,728 x DRG weight",59663,Other,base rate x DRG weight,53696,,"23,155 x DRG weight",53696,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,108496,50,,108496,Percent of Total Billed Charges,50% of Charges,67474,,"29,096 x DRG Weight",67474,Other,base rate x DRG weight,52092,,"22,463 x DRG Weight",52092,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,61282,,"26,426 x DRG Weight",61282,Other,base rate x DRG weight,89998,,"38,809 x DRG Weight",89998,Other,base rate x DRG weight,89998,,"38,809 x DRG Weight",89998,Other,base rate x DRG weight,61282,,"26,426 x DRG Weight",61282,Other,base rate x DRG weight,89998,,"38,809 x DRG Weight",89998,Other,base rate x DRG weight,82072,,"35,391 x DRG Weight",82072,Other,base rate x DRG weight,151894,70,,151894,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,58476,,"25,216 X DRG Weight",58476,Other,Base Weight X DRG Weight,52630,,"22,695 X DRG Weight",52630,Other,Base Weight X DRG Weight,58476,,"25,216 X DRG Weight",58476,Other,Base Rate x DRG Weight ,49703,,"21,433 x DRG Weight",49703,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,151894,
VENTRICULAR SHUNT PROCEDURES WITH MCC,31,MS-DRG,,,,,,,,inpatient,,,307699.13,61520,,,61520,Other,150% of Medicare + 9.63% HCRA Surcharge,37410.79,,,37410.79,Other,Medicare IPPS methodology,105912,,"25,728 x DRG weight",105912,Other,base rate x DRG weight,95320,,"23,155 x DRG weight",95320,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,153850,50,,153850,Percent of Total Billed Charges,50% of Charges,119777,,"29,096 x DRG Weight",119777,Other,base rate x DRG weight,92471,,"22,463 x DRG Weight",92471,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,108785,,"26,426 x DRG Weight",108785,Other,base rate x DRG weight,159761,,"38,809 x DRG Weight",159761,Other,base rate x DRG weight,159761,,"38,809 x DRG Weight",159761,Other,base rate x DRG weight,108785,,"26,426 x DRG Weight",108785,Other,base rate x DRG weight,159761,,"38,809 x DRG Weight",159761,Other,base rate x DRG weight,145691,,"35,391 x DRG Weight",145691,Other,base rate x DRG weight,215389,70,,215389,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,103804,,"25,216 X DRG Weight",103804,Other,Base Weight X DRG Weight,93426,,"22,695 X DRG Weight",93426,Other,Base Weight X DRG Weight,103804,,"25,216 X DRG Weight",103804,Other,Base Rate x DRG Weight ,88231,,"21,433 x DRG Weight",88231,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,215389,
VENTRICULAR SHUNT PROCEDURES WITH CC,32,MS-DRG,,,,,,,,inpatient,,,206595.31,32411,,,32411,Other,150% of Medicare + 9.63% HCRA Surcharge,19709.32,,,19709.32,Other,Medicare IPPS methodology,55413,,"25,728 x DRG weight",55413,Other,base rate x DRG weight,49871,,"23,155 x DRG weight",49871,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,103298,50,,103298,Percent of Total Billed Charges,50% of Charges,62667,,"29,096 x DRG Weight",62667,Other,base rate x DRG weight,48381,,"22,463 x DRG Weight",48381,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,56916,,"26,426 x DRG Weight",56916,Other,base rate x DRG weight,83587,,"38,809 x DRG Weight",83587,Other,base rate x DRG weight,83587,,"38,809 x DRG Weight",83587,Other,base rate x DRG weight,56916,,"26,426 x DRG Weight",56916,Other,base rate x DRG weight,83587,,"38,809 x DRG Weight",83587,Other,base rate x DRG weight,76225,,"35,391 x DRG Weight",76225,Other,base rate x DRG weight,144617,70,,144617,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,54310,,"25,216 X DRG Weight",54310,Other,Base Weight X DRG Weight,48880,,"22,695 X DRG Weight",48880,Other,Base Weight X DRG Weight,54310,,"25,216 X DRG Weight",54310,Other,Base Rate x DRG Weight ,46162,,"21,433 x DRG Weight",46162,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,144617,
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,33,MS-DRG,,,,,,,,inpatient,,,190809.61,24538,,,24538,Other,150% of Medicare + 9.63% HCRA Surcharge,14921.41,,,14921.41,Other,Medicare IPPS methodology,41754,,"25,728 x DRG weight",41754,Other,base rate x DRG weight,37578,,"23,155 x DRG weight",37578,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,95405,50,,95405,Percent of Total Billed Charges,50% of Charges,47220,,"29,096 x DRG Weight",47220,Other,base rate x DRG weight,36455,,"22,463 x DRG Weight",36455,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,42887,,"26,426 x DRG Weight",42887,Other,base rate x DRG weight,62983,,"38,809 x DRG Weight",62983,Other,base rate x DRG weight,62983,,"38,809 x DRG Weight",62983,Other,base rate x DRG weight,42887,,"26,426 x DRG Weight",42887,Other,base rate x DRG weight,62983,,"38,809 x DRG Weight",62983,Other,base rate x DRG weight,57436,,"35,391 x DRG Weight",57436,Other,base rate x DRG weight,133567,70,,133567,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40923,,"25,216 X DRG Weight",40923,Other,Base Weight X DRG Weight,36832,,"22,695 X DRG Weight",36832,Other,Base Weight X DRG Weight,40923,,"25,216 X DRG Weight",40923,Other,Base Rate x DRG Weight ,34784,,"21,433 x DRG Weight",34784,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,133567,
CAROTID ARTERY STENT PROCEDURES WITH MCC,34,MS-DRG,,,,,,,,inpatient,,,474493.8,58329,,,58329,Other,150% of Medicare + 9.63% HCRA Surcharge,35470.02,,,35470.02,Other,Medicare IPPS methodology,100375,,"25,728 x DRG weight",100375,Other,base rate x DRG weight,90337,,"23,155 x DRG weight",90337,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,237247,50,,237247,Percent of Total Billed Charges,50% of Charges,113515,,"29,096 x DRG Weight",113515,Other,base rate x DRG weight,87637,,"22,463 x DRG Weight",87637,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,103098,,"26,426 x DRG Weight",103098,Other,base rate x DRG weight,151409,,"38,809 x DRG Weight",151409,Other,base rate x DRG weight,151409,,"38,809 x DRG Weight",151409,Other,base rate x DRG weight,103098,,"26,426 x DRG Weight",103098,Other,base rate x DRG weight,151409,,"38,809 x DRG Weight",151409,Other,base rate x DRG weight,138074,,"35,391 x DRG Weight",138074,Other,base rate x DRG weight,332146,70,,332146,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,98378,,"25,216 X DRG Weight",98378,Other,Base Weight X DRG Weight,88542,,"22,695 X DRG Weight",88542,Other,Base Weight X DRG Weight,98378,,"25,216 X DRG Weight",98378,Other,Base Rate x DRG Weight ,83619,,"21,433 x DRG Weight",83619,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,332146,
CAROTID ARTERY STENT PROCEDURES WITH CC,35,MS-DRG,,,,,,,,inpatient,,,159638.37,34572,,,34572,Other,150% of Medicare + 9.63% HCRA Surcharge,21023.31,,,21023.31,Other,Medicare IPPS methodology,59162,,"25,728 x DRG weight",59162,Other,base rate x DRG weight,53245,,"23,155 x DRG weight",53245,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,79819,50,,79819,Percent of Total Billed Charges,50% of Charges,66906,,"29,096 x DRG Weight",66906,Other,base rate x DRG weight,51654,,"22,463 x DRG Weight",51654,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,60767,,"26,426 x DRG Weight",60767,Other,base rate x DRG weight,89241,,"38,809 x DRG Weight",89241,Other,base rate x DRG weight,89241,,"38,809 x DRG Weight",89241,Other,base rate x DRG weight,60767,,"26,426 x DRG Weight",60767,Other,base rate x DRG weight,89241,,"38,809 x DRG Weight",89241,Other,base rate x DRG weight,81382,,"35,391 x DRG Weight",81382,Other,base rate x DRG weight,111747,70,,111747,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,57984,,"25,216 X DRG Weight",57984,Other,Base Weight X DRG Weight,52187,,"22,695 X DRG Weight",52187,Other,Base Weight X DRG Weight,57984,,"25,216 X DRG Weight",57984,Other,Base Rate x DRG Weight ,49285,,"21,433 x DRG Weight",49285,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,111747,
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,36,MS-DRG,,,,,,,,inpatient,,,118825.49,27286,,,27286,Other,150% of Medicare + 9.63% HCRA Surcharge,16592.54,,,16592.54,Other,Medicare IPPS methodology,46521,,"25,728 x DRG weight",46521,Other,base rate x DRG weight,41869,,"23,155 x DRG weight",41869,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,59413,50,,59413,Percent of Total Billed Charges,50% of Charges,52611,,"29,096 x DRG Weight",52611,Other,base rate x DRG weight,40618,,"22,463 x DRG Weight",40618,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,47783,,"26,426 x DRG Weight",47783,Other,base rate x DRG weight,70174,,"38,809 x DRG Weight",70174,Other,base rate x DRG weight,70174,,"38,809 x DRG Weight",70174,Other,base rate x DRG weight,47783,,"26,426 x DRG Weight",47783,Other,base rate x DRG weight,70174,,"38,809 x DRG Weight",70174,Other,base rate x DRG weight,63994,,"35,391 x DRG Weight",63994,Other,base rate x DRG weight,83178,70,,83178,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,45596,,"25,216 X DRG Weight",45596,Other,Base Weight X DRG Weight,41037,,"22,695 X DRG Weight",41037,Other,Base Weight X DRG Weight,45596,,"25,216 X DRG Weight",45596,Other,Base Rate x DRG Weight ,38755,,"21,433 x DRG Weight",38755,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,83178,
EXTRACRANIAL PROCEDURES WITH MCC,37,MS-DRG,,,,,,,,inpatient,,,377407.72,50531,,,50531,Other,150% of Medicare + 9.63% HCRA Surcharge,30728.1,,,30728.1,Other,Medicare IPPS methodology,86847,,"25,728 x DRG weight",86847,Other,base rate x DRG weight,78162,,"23,155 x DRG weight",78162,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,188704,50,,188704,Percent of Total Billed Charges,50% of Charges,98216,,"29,096 x DRG Weight",98216,Other,base rate x DRG weight,75826,,"22,463 x DRG Weight",75826,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,89204,,"26,426 x DRG Weight",89204,Other,base rate x DRG weight,131004,,"38,809 x DRG Weight",131004,Other,base rate x DRG weight,131004,,"38,809 x DRG Weight",131004,Other,base rate x DRG weight,89204,,"26,426 x DRG Weight",89204,Other,base rate x DRG weight,131004,,"38,809 x DRG Weight",131004,Other,base rate x DRG weight,119466,,"35,391 x DRG Weight",119466,Other,base rate x DRG weight,264185,70,,264185,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,85119,,"25,216 X DRG Weight",85119,Other,Base Weight X DRG Weight,76609,,"22,695 X DRG Weight",76609,Other,Base Weight X DRG Weight,85119,,"25,216 X DRG Weight",85119,Other,Base Rate x DRG Weight ,72349,,"21,433 x DRG Weight",72349,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,264185,
EXTRACRANIAL PROCEDURES WITH CC,38,MS-DRG,,,,,,,,inpatient,,,218233.89,24196,,,24196,Other,150% of Medicare + 9.63% HCRA Surcharge,14713.99,,,14713.99,Other,Medicare IPPS methodology,41162,,"25,728 x DRG weight",41162,Other,base rate x DRG weight,37046,,"23,155 x DRG weight",37046,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,109117,50,,109117,Percent of Total Billed Charges,50% of Charges,46551,,"29,096 x DRG Weight",46551,Other,base rate x DRG weight,35939,,"22,463 x DRG Weight",35939,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,42279,,"26,426 x DRG Weight",42279,Other,base rate x DRG weight,62091,,"38,809 x DRG Weight",62091,Other,base rate x DRG weight,62091,,"38,809 x DRG Weight",62091,Other,base rate x DRG weight,42279,,"26,426 x DRG Weight",42279,Other,base rate x DRG weight,62091,,"38,809 x DRG Weight",62091,Other,base rate x DRG weight,56622,,"35,391 x DRG Weight",56622,Other,base rate x DRG weight,152764,70,,152764,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40343,,"25,216 X DRG Weight",40343,Other,Base Weight X DRG Weight,36310,,"22,695 X DRG Weight",36310,Other,Base Weight X DRG Weight,40343,,"25,216 X DRG Weight",40343,Other,Base Rate x DRG Weight ,34291,,"21,433 x DRG Weight",34291,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,152764,
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,39,MS-DRG,,,,,,,,inpatient,,,158873.59,17391,,,17391,Other,150% of Medicare + 9.63% HCRA Surcharge,10575.41,,,10575.41,Other,Medicare IPPS methodology,29356,,"25,728 x DRG weight",29356,Other,base rate x DRG weight,26420,,"23,155 x DRG weight",26420,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,79437,50,,79437,Percent of Total Billed Charges,50% of Charges,33199,,"29,096 x DRG Weight",33199,Other,base rate x DRG weight,25630,,"22,463 x DRG Weight",25630,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,30152,,"26,426 x DRG Weight",30152,Other,base rate x DRG weight,44281,,"38,809 x DRG Weight",44281,Other,base rate x DRG weight,44281,,"38,809 x DRG Weight",44281,Other,base rate x DRG weight,30152,,"26,426 x DRG Weight",30152,Other,base rate x DRG weight,44281,,"38,809 x DRG Weight",44281,Other,base rate x DRG weight,40381,,"35,391 x DRG Weight",40381,Other,base rate x DRG weight,111212,70,,111212,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,28771,,"25,216 X DRG Weight",28771,Other,Base Weight X DRG Weight,25895,,"22,695 X DRG Weight",25895,Other,Base Weight X DRG Weight,28771,,"25,216 X DRG Weight",28771,Other,Base Rate x DRG Weight ,24455,,"21,433 x DRG Weight",24455,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,111212,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",40,MS-DRG,,,,,,,,inpatient,,,392203.02,57574,,,57574,Other,150% of Medicare + 9.63% HCRA Surcharge,35010.98,,,35010.98,Other,Medicare IPPS methodology,99066,,"25,728 x DRG weight",99066,Other,base rate x DRG weight,89158,,"23,155 x DRG weight",89158,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,196102,50,,196102,Percent of Total Billed Charges,50% of Charges,112034,,"29,096 x DRG Weight",112034,Other,base rate x DRG weight,86494,,"22,463 x DRG Weight",86494,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,101753,,"26,426 x DRG Weight",101753,Other,base rate x DRG weight,149434,,"38,809 x DRG Weight",149434,Other,base rate x DRG weight,149434,,"38,809 x DRG Weight",149434,Other,base rate x DRG weight,101753,,"26,426 x DRG Weight",101753,Other,base rate x DRG weight,149434,,"38,809 x DRG Weight",149434,Other,base rate x DRG weight,136273,,"35,391 x DRG Weight",136273,Other,base rate x DRG weight,274542,70,,274542,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,97094,,"25,216 X DRG Weight",97094,Other,Base Weight X DRG Weight,87387,,"22,695 X DRG Weight",87387,Other,Base Weight X DRG Weight,97094,,"25,216 X DRG Weight",97094,Other,Base Rate x DRG Weight ,82528,,"21,433 x DRG Weight",82528,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,274542,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",41,MS-DRG,,,,,,,,inpatient,,,281707.97,33551,,,33551,Other,150% of Medicare + 9.63% HCRA Surcharge,20402.84,,,20402.84,Other,Medicare IPPS methodology,57391,,"25,728 x DRG weight",57391,Other,base rate x DRG weight,51652,,"23,155 x DRG weight",51652,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,140854,50,,140854,Percent of Total Billed Charges,50% of Charges,64904,,"29,096 x DRG Weight",64904,Other,base rate x DRG weight,50108,,"22,463 x DRG Weight",50108,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,58948,,"26,426 x DRG Weight",58948,Other,base rate x DRG weight,86571,,"38,809 x DRG Weight",86571,Other,base rate x DRG weight,86571,,"38,809 x DRG Weight",86571,Other,base rate x DRG weight,58948,,"26,426 x DRG Weight",58948,Other,base rate x DRG weight,86571,,"38,809 x DRG Weight",86571,Other,base rate x DRG weight,78947,,"35,391 x DRG Weight",78947,Other,base rate x DRG weight,197196,70,,197196,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,56249,,"25,216 X DRG Weight",56249,Other,Base Weight X DRG Weight,50626,,"22,695 X DRG Weight",50626,Other,Base Weight X DRG Weight,56249,,"25,216 X DRG Weight",56249,Other,Base Rate x DRG Weight ,47811,,"21,433 x DRG Weight",47811,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,197196,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",42,MS-DRG,,,,,,,,inpatient,,,196612.99,26271,,,26271,Other,150% of Medicare + 9.63% HCRA Surcharge,15975.67,,,15975.67,Other,Medicare IPPS methodology,44762,,"25,728 x DRG weight",44762,Other,base rate x DRG weight,40285,,"23,155 x DRG weight",40285,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,98306,50,,98306,Percent of Total Billed Charges,50% of Charges,50621,,"29,096 x DRG Weight",50621,Other,base rate x DRG weight,39081,,"22,463 x DRG Weight",39081,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,45976,,"26,426 x DRG Weight",45976,Other,base rate x DRG weight,67520,,"38,809 x DRG Weight",67520,Other,base rate x DRG weight,67520,,"38,809 x DRG Weight",67520,Other,base rate x DRG weight,45976,,"26,426 x DRG Weight",45976,Other,base rate x DRG weight,67520,,"38,809 x DRG Weight",67520,Other,base rate x DRG weight,61573,,"35,391 x DRG Weight",61573,Other,base rate x DRG weight,137629,70,,137629,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43871,,"25,216 X DRG Weight",43871,Other,Base Weight X DRG Weight,39485,,"22,695 X DRG Weight",39485,Other,Base Weight X DRG Weight,43871,,"25,216 X DRG Weight",43871,Other,Base Rate x DRG Weight ,37289,,"21,433 x DRG Weight",37289,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,137629,
SPINAL DISORDERS AND INJURIES WITH CC/MCC,52,MS-DRG,,,,,,,,inpatient,,,241819.82,29307,,,29307,Other,150% of Medicare + 9.63% HCRA Surcharge,17821.75,,,17821.75,Other,Medicare IPPS methodology,50028,,"25,728 x DRG weight",50028,Other,base rate x DRG weight,45025,,"23,155 x DRG weight",45025,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,120910,50,,120910,Percent of Total Billed Charges,50% of Charges,56577,,"29,096 x DRG Weight",56577,Other,base rate x DRG weight,43679,,"22,463 x DRG Weight",43679,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,51385,,"26,426 x DRG Weight",51385,Other,base rate x DRG weight,75464,,"38,809 x DRG Weight",75464,Other,base rate x DRG weight,75464,,"38,809 x DRG Weight",75464,Other,base rate x DRG weight,51385,,"26,426 x DRG Weight",51385,Other,base rate x DRG weight,75464,,"38,809 x DRG Weight",75464,Other,base rate x DRG weight,68818,,"35,391 x DRG Weight",68818,Other,base rate x DRG weight,169274,70,,169274,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,49033,,"25,216 X DRG Weight",49033,Other,Base Weight X DRG Weight,44130,,"22,695 X DRG Weight",44130,Other,Base Weight X DRG Weight,49033,,"25,216 X DRG Weight",49033,Other,Base Rate x DRG Weight ,41676,,"21,433 x DRG Weight",41676,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,169274,
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,53,MS-DRG,,,,,,,,inpatient,,,259436.94,15059,,,15059,Other,150% of Medicare + 9.63% HCRA Surcharge,9157.7,,,9157.7,Other,Medicare IPPS methodology,25311,,"25,728 x DRG weight",25311,Other,base rate x DRG weight,22780,,"23,155 x DRG weight",22780,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,129718,50,,129718,Percent of Total Billed Charges,50% of Charges,28625,,"29,096 x DRG Weight",28625,Other,base rate x DRG weight,22099,,"22,463 x DRG Weight",22099,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,25998,,"26,426 x DRG Weight",25998,Other,base rate x DRG weight,38180,,"38,809 x DRG Weight",38180,Other,base rate x DRG weight,38180,,"38,809 x DRG Weight",38180,Other,base rate x DRG weight,25998,,"26,426 x DRG Weight",25998,Other,base rate x DRG weight,38180,,"38,809 x DRG Weight",38180,Other,base rate x DRG weight,34818,,"35,391 x DRG Weight",34818,Other,base rate x DRG weight,181606,70,,181606,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24808,,"25,216 X DRG Weight",24808,Other,Base Weight X DRG Weight,22327,,"22,695 X DRG Weight",22327,Other,Base Weight X DRG Weight,24808,,"25,216 X DRG Weight",24808,Other,Base Rate x DRG Weight ,21086,,"21,433 x DRG Weight",21086,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,181606,
NERVOUS SYSTEM NEOPLASMS WITH MCC,54,MS-DRG,,,,,,,,inpatient,,,232111.95,22322,,,22322,Other,150% of Medicare + 9.63% HCRA Surcharge,13574.05,,,13574.05,Other,Medicare IPPS methodology,37910,,"25,728 x DRG weight",37910,Other,base rate x DRG weight,34119,,"23,155 x DRG weight",34119,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,116056,50,,116056,Percent of Total Billed Charges,50% of Charges,42873,,"29,096 x DRG Weight",42873,Other,base rate x DRG weight,33099,,"22,463 x DRG Weight",33099,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,38939,,"26,426 x DRG Weight",38939,Other,base rate x DRG weight,57185,,"38,809 x DRG Weight",57185,Other,base rate x DRG weight,57185,,"38,809 x DRG Weight",57185,Other,base rate x DRG weight,38939,,"26,426 x DRG Weight",38939,Other,base rate x DRG weight,57185,,"38,809 x DRG Weight",57185,Other,base rate x DRG weight,52149,,"35,391 x DRG Weight",52149,Other,base rate x DRG weight,162478,70,,162478,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37156,,"25,216 X DRG Weight",37156,Other,Base Weight X DRG Weight,33441,,"22,695 X DRG Weight",33441,Other,Base Weight X DRG Weight,37156,,"25,216 X DRG Weight",37156,Other,Base Rate x DRG Weight ,31582,,"21,433 x DRG Weight",31582,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,162478,
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,55,MS-DRG,,,,,,,,inpatient,,,191422.93,16385,,,16385,Other,150% of Medicare + 9.63% HCRA Surcharge,9963.95,,,9963.95,Other,Medicare IPPS methodology,27611,,"25,728 x DRG weight",27611,Other,base rate x DRG weight,24850,,"23,155 x DRG weight",24850,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,95711,50,,95711,Percent of Total Billed Charges,50% of Charges,31226,,"29,096 x DRG Weight",31226,Other,base rate x DRG weight,24107,,"22,463 x DRG Weight",24107,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28360,,"26,426 x DRG Weight",28360,Other,base rate x DRG weight,41650,,"38,809 x DRG Weight",41650,Other,base rate x DRG weight,41650,,"38,809 x DRG Weight",41650,Other,base rate x DRG weight,28360,,"26,426 x DRG Weight",28360,Other,base rate x DRG weight,41650,,"38,809 x DRG Weight",41650,Other,base rate x DRG weight,37982,,"35,391 x DRG Weight",37982,Other,base rate x DRG weight,133996,70,,133996,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27062,,"25,216 X DRG Weight",27062,Other,Base Weight X DRG Weight,24356,,"22,695 X DRG Weight",24356,Other,Base Weight X DRG Weight,27062,,"25,216 X DRG Weight",27062,Other,Base Rate x DRG Weight ,23002,,"21,433 x DRG Weight",23002,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,133996,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,56,MS-DRG,,,,,,,,inpatient,,,328732.92,35973,,,35973,Other,150% of Medicare + 9.63% HCRA Surcharge,21875.56,,,21875.56,Other,Medicare IPPS methodology,61593,,"25,728 x DRG weight",61593,Other,base rate x DRG weight,55433,,"23,155 x DRG weight",55433,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,164366,50,,164366,Percent of Total Billed Charges,50% of Charges,69656,,"29,096 x DRG Weight",69656,Other,base rate x DRG weight,53776,,"22,463 x DRG Weight",53776,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,63264,,"26,426 x DRG Weight",63264,Other,base rate x DRG weight,92909,,"38,809 x DRG Weight",92909,Other,base rate x DRG weight,92909,,"38,809 x DRG Weight",92909,Other,base rate x DRG weight,63264,,"26,426 x DRG Weight",63264,Other,base rate x DRG weight,92909,,"38,809 x DRG Weight",92909,Other,base rate x DRG weight,84726,,"35,391 x DRG Weight",84726,Other,base rate x DRG weight,230113,70,,230113,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,60367,,"25,216 X DRG Weight",60367,Other,Base Weight X DRG Weight,54332,,"22,695 X DRG Weight",54332,Other,Base Weight X DRG Weight,60367,,"25,216 X DRG Weight",60367,Other,Base Rate x DRG Weight ,51311,,"21,433 x DRG Weight",51311,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,230113,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,57,MS-DRG,,,,,,,,inpatient,,,207796.84,20686,,,20686,Other,150% of Medicare + 9.63% HCRA Surcharge,12579.31,,,12579.31,Other,Medicare IPPS methodology,35072,,"25,728 x DRG weight",35072,Other,base rate x DRG weight,31565,,"23,155 x DRG weight",31565,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,103898,50,,103898,Percent of Total Billed Charges,50% of Charges,39664,,"29,096 x DRG Weight",39664,Other,base rate x DRG weight,30622,,"22,463 x DRG Weight",30622,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,36024,,"26,426 x DRG Weight",36024,Other,base rate x DRG weight,52904,,"38,809 x DRG Weight",52904,Other,base rate x DRG weight,52904,,"38,809 x DRG Weight",52904,Other,base rate x DRG weight,36024,,"26,426 x DRG Weight",36024,Other,base rate x DRG weight,52904,,"38,809 x DRG Weight",52904,Other,base rate x DRG weight,48245,,"35,391 x DRG Weight",48245,Other,base rate x DRG weight,145458,70,,145458,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,34374,,"25,216 X DRG Weight",34374,Other,Base Weight X DRG Weight,30938,,"22,695 X DRG Weight",30938,Other,Base Weight X DRG Weight,34374,,"25,216 X DRG Weight",34374,Other,Base Rate x DRG Weight ,29217,,"21,433 x DRG Weight",29217,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,145458,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,58,MS-DRG,,,,,,,,inpatient,,,120609,26095,,,26095,Other,150% of Medicare + 9.63% HCRA Surcharge,15868.35,,,15868.35,Other,Medicare IPPS methodology,44455,,"25,728 x DRG weight",44455,Other,base rate x DRG weight,40010,,"23,155 x DRG weight",40010,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,60305,50,,60305,Percent of Total Billed Charges,50% of Charges,50275,,"29,096 x DRG Weight",50275,Other,base rate x DRG weight,38814,,"22,463 x DRG Weight",38814,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,45661,,"26,426 x DRG Weight",45661,Other,base rate x DRG weight,67058,,"38,809 x DRG Weight",67058,Other,base rate x DRG weight,67058,,"38,809 x DRG Weight",67058,Other,base rate x DRG weight,45661,,"26,426 x DRG Weight",45661,Other,base rate x DRG weight,67058,,"38,809 x DRG Weight",67058,Other,base rate x DRG weight,61152,,"35,391 x DRG Weight",61152,Other,base rate x DRG weight,84426,70,,84426,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43571,,"25,216 X DRG Weight",43571,Other,Base Weight X DRG Weight,39215,,"22,695 X DRG Weight",39215,Other,Base Weight X DRG Weight,43571,,"25,216 X DRG Weight",43571,Other,Base Rate x DRG Weight ,37034,,"21,433 x DRG Weight",37034,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,84426,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,59,MS-DRG,,,,,,,,inpatient,,,173761,18076,,,18076,Other,150% of Medicare + 9.63% HCRA Surcharge,10992.06,,,10992.06,Other,Medicare IPPS methodology,30544,,"25,728 x DRG weight",30544,Other,base rate x DRG weight,27490,,"23,155 x DRG weight",27490,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,86880,50,,86880,Percent of Total Billed Charges,50% of Charges,34543,,"29,096 x DRG Weight",34543,Other,base rate x DRG weight,26668,,"22,463 x DRG Weight",26668,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31373,,"26,426 x DRG Weight",31373,Other,base rate x DRG weight,46074,,"38,809 x DRG Weight",46074,Other,base rate x DRG weight,46074,,"38,809 x DRG Weight",46074,Other,base rate x DRG weight,31373,,"26,426 x DRG Weight",31373,Other,base rate x DRG weight,46074,,"38,809 x DRG Weight",46074,Other,base rate x DRG weight,42016,,"35,391 x DRG Weight",42016,Other,base rate x DRG weight,121633,70,,121633,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,29936,,"25,216 X DRG Weight",29936,Other,Base Weight X DRG Weight,26944,,"22,695 X DRG Weight",26944,Other,Base Weight X DRG Weight,29936,,"25,216 X DRG Weight",29936,Other,Base Rate x DRG Weight ,25445,,"21,433 x DRG Weight",25445,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,121633,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,60,MS-DRG,,,,,,,,inpatient,,,96942.45,13778,,,13778,Other,150% of Medicare + 9.63% HCRA Surcharge,8378.5,,,8378.5,Other,Medicare IPPS methodology,23088,,"25,728 x DRG weight",23088,Other,base rate x DRG weight,20779,,"23,155 x DRG weight",20779,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,48471,50,,48471,Percent of Total Billed Charges,50% of Charges,26111,,"29,096 x DRG Weight",26111,Other,base rate x DRG weight,20158,,"22,463 x DRG Weight",20158,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23715,,"26,426 x DRG Weight",23715,Other,base rate x DRG weight,34827,,"38,809 x DRG Weight",34827,Other,base rate x DRG weight,34827,,"38,809 x DRG Weight",34827,Other,base rate x DRG weight,23715,,"26,426 x DRG Weight",23715,Other,base rate x DRG weight,34827,,"38,809 x DRG Weight",34827,Other,base rate x DRG weight,31760,,"35,391 x DRG Weight",31760,Other,base rate x DRG weight,67860,70,,67860,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22629,,"25,216 X DRG Weight",22629,Other,Base Weight X DRG Weight,20366,,"22,695 X DRG Weight",20366,Other,Base Weight X DRG Weight,22629,,"25,216 X DRG Weight",22629,Other,Base Rate x DRG Weight ,19234,,"21,433 x DRG Weight",19234,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,67860,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",61,MS-DRG,,,,,,,,inpatient,,,402567.78,42036,,,42036,Other,150% of Medicare + 9.63% HCRA Surcharge,25562.32,,,25562.32,Other,Medicare IPPS methodology,72110,,"25,728 x DRG weight",72110,Other,base rate x DRG weight,64899,,"23,155 x DRG weight",64899,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,201284,50,,201284,Percent of Total Billed Charges,50% of Charges,81550,,"29,096 x DRG Weight",81550,Other,base rate x DRG weight,62959,,"22,463 x DRG Weight",62959,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,74067,,"26,426 x DRG Weight",74067,Other,base rate x DRG weight,108774,,"38,809 x DRG Weight",108774,Other,base rate x DRG weight,108774,,"38,809 x DRG Weight",108774,Other,base rate x DRG weight,74067,,"26,426 x DRG Weight",74067,Other,base rate x DRG weight,108774,,"38,809 x DRG Weight",108774,Other,base rate x DRG weight,99194,,"35,391 x DRG Weight",99194,Other,base rate x DRG weight,281797,70,,281797,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,70675,,"25,216 X DRG Weight",70675,Other,Base Weight X DRG Weight,63610,,"22,695 X DRG Weight",63610,Other,Base Weight X DRG Weight,70675,,"25,216 X DRG Weight",70675,Other,Base Rate x DRG Weight ,60072,,"21,433 x DRG Weight",60072,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,281797,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",62,MS-DRG,,,,,,,,inpatient,,,187858.06,28227,,,28227,Other,150% of Medicare + 9.63% HCRA Surcharge,17165.21,,,17165.21,Other,Medicare IPPS methodology,48155,,"25,728 x DRG weight",48155,Other,base rate x DRG weight,43339,,"23,155 x DRG weight",43339,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,93929,50,,93929,Percent of Total Billed Charges,50% of Charges,54459,,"29,096 x DRG Weight",54459,Other,base rate x DRG weight,42044,,"22,463 x DRG Weight",42044,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,49462,,"26,426 x DRG Weight",49462,Other,base rate x DRG weight,72639,,"38,809 x DRG Weight",72639,Other,base rate x DRG weight,72639,,"38,809 x DRG Weight",72639,Other,base rate x DRG weight,49462,,"26,426 x DRG Weight",49462,Other,base rate x DRG weight,72639,,"38,809 x DRG Weight",72639,Other,base rate x DRG weight,66241,,"35,391 x DRG Weight",66241,Other,base rate x DRG weight,131501,70,,131501,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,47197,,"25,216 X DRG Weight",47197,Other,Base Weight X DRG Weight,42478,,"22,695 X DRG Weight",42478,Other,Base Weight X DRG Weight,47197,,"25,216 X DRG Weight",47197,Other,Base Rate x DRG Weight ,40116,,"21,433 x DRG Weight",40116,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,131501,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",63,MS-DRG,,,,,,,,inpatient,,,146396.43,22519,,,22519,Other,150% of Medicare + 9.63% HCRA Surcharge,13694,,,13694,Other,Medicare IPPS methodology,38252,,"25,728 x DRG weight",38252,Other,base rate x DRG weight,34427,,"23,155 x DRG weight",34427,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,73198,50,,73198,Percent of Total Billed Charges,50% of Charges,43260,,"29,096 x DRG Weight",43260,Other,base rate x DRG weight,33398,,"22,463 x DRG Weight",33398,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39290,,"26,426 x DRG Weight",39290,Other,base rate x DRG weight,57701,,"38,809 x DRG Weight",57701,Other,base rate x DRG weight,57701,,"38,809 x DRG Weight",57701,Other,base rate x DRG weight,39290,,"26,426 x DRG Weight",39290,Other,base rate x DRG weight,57701,,"38,809 x DRG Weight",57701,Other,base rate x DRG weight,52619,,"35,391 x DRG Weight",52619,Other,base rate x DRG weight,102477,70,,102477,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37491,,"25,216 X DRG Weight",37491,Other,Base Weight X DRG Weight,33743,,"22,695 X DRG Weight",33743,Other,Base Weight X DRG Weight,37491,,"25,216 X DRG Weight",37491,Other,Base Rate x DRG Weight ,31867,,"21,433 x DRG Weight",31867,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,102477,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,64,MS-DRG,,,,,,,,inpatient,,,276477.92,30175,,,30175,Other,150% of Medicare + 9.63% HCRA Surcharge,18349.34,,,18349.34,Other,Medicare IPPS methodology,51533,,"25,728 x DRG weight",51533,Other,base rate x DRG weight,46379,,"23,155 x DRG weight",46379,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,138239,50,,138239,Percent of Total Billed Charges,50% of Charges,58279,,"29,096 x DRG Weight",58279,Other,base rate x DRG weight,44993,,"22,463 x DRG Weight",44993,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,52931,,"26,426 x DRG Weight",52931,Other,base rate x DRG weight,77734,,"38,809 x DRG Weight",77734,Other,base rate x DRG weight,77734,,"38,809 x DRG Weight",77734,Other,base rate x DRG weight,52931,,"26,426 x DRG Weight",52931,Other,base rate x DRG weight,77734,,"38,809 x DRG Weight",77734,Other,base rate x DRG weight,70888,,"35,391 x DRG Weight",70888,Other,base rate x DRG weight,193535,70,,193535,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,50508,,"25,216 X DRG Weight",50508,Other,Base Weight X DRG Weight,45458,,"22,695 X DRG Weight",45458,Other,Base Weight X DRG Weight,50508,,"25,216 X DRG Weight",50508,Other,Base Rate x DRG Weight ,42930,,"21,433 x DRG Weight",42930,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,193535,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,65,MS-DRG,,,,,,,,inpatient,,,180198.81,15543,,,15543,Other,150% of Medicare + 9.63% HCRA Surcharge,9451.7,,,9451.7,Other,Medicare IPPS methodology,26150,,"25,728 x DRG weight",26150,Other,base rate x DRG weight,23535,,"23,155 x DRG weight",23535,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,90099,50,,90099,Percent of Total Billed Charges,50% of Charges,29573,,"29,096 x DRG Weight",29573,Other,base rate x DRG weight,22831,,"22,463 x DRG Weight",22831,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26859,,"26,426 x DRG Weight",26859,Other,base rate x DRG weight,39445,,"38,809 x DRG Weight",39445,Other,base rate x DRG weight,39445,,"38,809 x DRG Weight",39445,Other,base rate x DRG weight,26859,,"26,426 x DRG Weight",26859,Other,base rate x DRG weight,39445,,"38,809 x DRG Weight",39445,Other,base rate x DRG weight,35971,,"35,391 x DRG Weight",35971,Other,base rate x DRG weight,126139,70,,126139,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25630,,"25,216 X DRG Weight",25630,Other,Base Weight X DRG Weight,23067,,"22,695 X DRG Weight",23067,Other,Base Weight X DRG Weight,25630,,"25,216 X DRG Weight",25630,Other,Base Rate x DRG Weight ,21785,,"21,433 x DRG Weight",21785,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,126139,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,66,MS-DRG,,,,,,,,inpatient,,,140690.68,10665,,,10665,Other,150% of Medicare + 9.63% HCRA Surcharge,6485.53,,,6485.53,Other,Medicare IPPS methodology,17688,,"25,728 x DRG weight",17688,Other,base rate x DRG weight,15919,,"23,155 x DRG weight",15919,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,70345,50,,70345,Percent of Total Billed Charges,50% of Charges,20004,,"29,096 x DRG Weight",20004,Other,base rate x DRG weight,15443,,"22,463 x DRG Weight",15443,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18168,,"26,426 x DRG Weight",18168,Other,base rate x DRG weight,26681,,"38,809 x DRG Weight",26681,Other,base rate x DRG weight,26681,,"38,809 x DRG Weight",26681,Other,base rate x DRG weight,18168,,"26,426 x DRG Weight",18168,Other,base rate x DRG weight,26681,,"38,809 x DRG Weight",26681,Other,base rate x DRG weight,24331,,"35,391 x DRG Weight",24331,Other,base rate x DRG weight,98483,70,,98483,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,17336,,"25,216 X DRG Weight",17336,Other,Base Weight X DRG Weight,15603,,"22,695 X DRG Weight",15603,Other,Base Weight X DRG Weight,17336,,"25,216 X DRG Weight",17336,Other,Base Rate x DRG Weight ,14735,,"21,433 x DRG Weight",14735,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,98483,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,67,MS-DRG,,,,,,,,inpatient,,,288204.73,21482,,,21482,Other,150% of Medicare + 9.63% HCRA Surcharge,13063.6,,,13063.6,Other,Medicare IPPS methodology,36454,,"25,728 x DRG weight",36454,Other,base rate x DRG weight,32808,,"23,155 x DRG weight",32808,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,144102,50,,144102,Percent of Total Billed Charges,50% of Charges,41226,,"29,096 x DRG Weight",41226,Other,base rate x DRG weight,31828,,"22,463 x DRG Weight",31828,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,37443,,"26,426 x DRG Weight",37443,Other,base rate x DRG weight,54988,,"38,809 x DRG Weight",54988,Other,base rate x DRG weight,54988,,"38,809 x DRG Weight",54988,Other,base rate x DRG weight,37443,,"26,426 x DRG Weight",37443,Other,base rate x DRG weight,54988,,"38,809 x DRG Weight",54988,Other,base rate x DRG weight,50146,,"35,391 x DRG Weight",50146,Other,base rate x DRG weight,201743,70,,201743,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35729,,"25,216 X DRG Weight",35729,Other,Base Weight X DRG Weight,32157,,"22,695 X DRG Weight",32157,Other,Base Weight X DRG Weight,35729,,"25,216 X DRG Weight",35729,Other,Base Rate x DRG Weight ,30368,,"21,433 x DRG Weight",30368,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,201743,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,68,MS-DRG,,,,,,,,inpatient,,,108189.13,13387,,,13387,Other,150% of Medicare + 9.63% HCRA Surcharge,8140.42,,,8140.42,Other,Medicare IPPS methodology,22409,,"25,728 x DRG weight",22409,Other,base rate x DRG weight,20168,,"23,155 x DRG weight",20168,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,54095,50,,54095,Percent of Total Billed Charges,50% of Charges,25343,,"29,096 x DRG Weight",25343,Other,base rate x DRG weight,19565,,"22,463 x DRG Weight",19565,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23017,,"26,426 x DRG Weight",23017,Other,base rate x DRG weight,33803,,"38,809 x DRG Weight",33803,Other,base rate x DRG weight,33803,,"38,809 x DRG Weight",33803,Other,base rate x DRG weight,23017,,"26,426 x DRG Weight",23017,Other,base rate x DRG weight,33803,,"38,809 x DRG Weight",33803,Other,base rate x DRG weight,30826,,"35,391 x DRG Weight",30826,Other,base rate x DRG weight,75732,70,,75732,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,21963,,"25,216 X DRG Weight",21963,Other,Base Weight X DRG Weight,19767,,"22,695 X DRG Weight",19767,Other,Base Weight X DRG Weight,21963,,"25,216 X DRG Weight",21963,Other,Base Rate x DRG Weight ,18668,,"21,433 x DRG Weight",18668,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,75732,
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,69,MS-DRG,,,,,,,,inpatient,,,111705.66,12314,,,12314,Other,150% of Medicare + 9.63% HCRA Surcharge,7488.38,,,7488.38,Other,Medicare IPPS methodology,20549,,"25,728 x DRG weight",20549,Other,base rate x DRG weight,18494,,"23,155 x DRG weight",18494,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,55853,50,,55853,Percent of Total Billed Charges,50% of Charges,23239,,"29,096 x DRG Weight",23239,Other,base rate x DRG weight,17941,,"22,463 x DRG Weight",17941,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21106,,"26,426 x DRG Weight",21106,Other,base rate x DRG weight,30997,,"38,809 x DRG Weight",30997,Other,base rate x DRG weight,30997,,"38,809 x DRG Weight",30997,Other,base rate x DRG weight,21106,,"26,426 x DRG Weight",21106,Other,base rate x DRG weight,30997,,"38,809 x DRG Weight",30997,Other,base rate x DRG weight,28267,,"35,391 x DRG Weight",28267,Other,base rate x DRG weight,78194,70,,78194,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20140,,"25,216 X DRG Weight",20140,Other,Base Weight X DRG Weight,18126,,"22,695 X DRG Weight",18126,Other,Base Weight X DRG Weight,20140,,"25,216 X DRG Weight",20140,Other,Base Rate x DRG Weight ,17119,,"21,433 x DRG Weight",17119,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,78194,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,70,MS-DRG,,,,,,,,inpatient,,,190249.44,27008,,,27008,Other,150% of Medicare + 9.63% HCRA Surcharge,16423.89,,,16423.89,Other,Medicare IPPS methodology,46040,,"25,728 x DRG weight",46040,Other,base rate x DRG weight,41436,,"23,155 x DRG weight",41436,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,95125,50,,95125,Percent of Total Billed Charges,50% of Charges,52067,,"29,096 x DRG Weight",52067,Other,base rate x DRG weight,40198,,"22,463 x DRG Weight",40198,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,47289,,"26,426 x DRG Weight",47289,Other,base rate x DRG weight,69449,,"38,809 x DRG Weight",69449,Other,base rate x DRG weight,69449,,"38,809 x DRG Weight",69449,Other,base rate x DRG weight,47289,,"26,426 x DRG Weight",47289,Other,base rate x DRG weight,69449,,"38,809 x DRG Weight",69449,Other,base rate x DRG weight,63332,,"35,391 x DRG Weight",63332,Other,base rate x DRG weight,133175,70,,133175,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,45124,,"25,216 X DRG Weight",45124,Other,Base Weight X DRG Weight,40613,,"22,695 X DRG Weight",40613,Other,Base Weight X DRG Weight,45124,,"25,216 X DRG Weight",45124,Other,Base Rate x DRG Weight ,38354,,"21,433 x DRG Weight",38354,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,133175,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,71,MS-DRG,,,,,,,,inpatient,,,184199.33,16216,,,16216,Other,150% of Medicare + 9.63% HCRA Surcharge,9861.14,,,9861.14,Other,Medicare IPPS methodology,27318,,"25,728 x DRG weight",27318,Other,base rate x DRG weight,24586,,"23,155 x DRG weight",24586,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,92100,50,,92100,Percent of Total Billed Charges,50% of Charges,30894,,"29,096 x DRG Weight",30894,Other,base rate x DRG weight,23851,,"22,463 x DRG Weight",23851,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28059,,"26,426 x DRG Weight",28059,Other,base rate x DRG weight,41207,,"38,809 x DRG Weight",41207,Other,base rate x DRG weight,41207,,"38,809 x DRG Weight",41207,Other,base rate x DRG weight,28059,,"26,426 x DRG Weight",28059,Other,base rate x DRG weight,41207,,"38,809 x DRG Weight",41207,Other,base rate x DRG weight,37578,,"35,391 x DRG Weight",37578,Other,base rate x DRG weight,128940,70,,128940,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,26774,,"25,216 X DRG Weight",26774,Other,Base Weight X DRG Weight,24098,,"22,695 X DRG Weight",24098,Other,Base Weight X DRG Weight,26774,,"25,216 X DRG Weight",26774,Other,Base Rate x DRG Weight ,22758,,"21,433 x DRG Weight",22758,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,128940,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,72,MS-DRG,,,,,,,,inpatient,,,66397.16,12081,,,12081,Other,150% of Medicare + 9.63% HCRA Surcharge,7346.79,,,7346.79,Other,Medicare IPPS methodology,20145,,"25,728 x DRG weight",20145,Other,base rate x DRG weight,18130,,"23,155 x DRG weight",18130,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,33199,50,,33199,Percent of Total Billed Charges,50% of Charges,22782,,"29,096 x DRG Weight",22782,Other,base rate x DRG weight,17589,,"22,463 x DRG Weight",17589,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,20692,,"26,426 x DRG Weight",20692,Other,base rate x DRG weight,30387,,"38,809 x DRG Weight",30387,Other,base rate x DRG weight,30387,,"38,809 x DRG Weight",30387,Other,base rate x DRG weight,20692,,"26,426 x DRG Weight",20692,Other,base rate x DRG weight,30387,,"38,809 x DRG Weight",30387,Other,base rate x DRG weight,27711,,"35,391 x DRG Weight",27711,Other,base rate x DRG weight,46478,70,,46478,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19744,,"25,216 X DRG Weight",19744,Other,Base Weight X DRG Weight,17770,,"22,695 X DRG Weight",17770,Other,Base Weight X DRG Weight,19744,,"25,216 X DRG Weight",19744,Other,Base Rate x DRG Weight ,16782,,"21,433 x DRG Weight",16782,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,46478,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,73,MS-DRG,,,,,,,,inpatient,,,195231.93,22908,,,22908,Other,150% of Medicare + 9.63% HCRA Surcharge,13930.28,,,13930.28,Other,Medicare IPPS methodology,38926,,"25,728 x DRG weight",38926,Other,base rate x DRG weight,35034,,"23,155 x DRG weight",35034,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,97616,50,,97616,Percent of Total Billed Charges,50% of Charges,44022,,"29,096 x DRG Weight",44022,Other,base rate x DRG weight,33987,,"22,463 x DRG Weight",33987,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39983,,"26,426 x DRG Weight",39983,Other,base rate x DRG weight,58718,,"38,809 x DRG Weight",58718,Other,base rate x DRG weight,58718,,"38,809 x DRG Weight",58718,Other,base rate x DRG weight,39983,,"26,426 x DRG Weight",39983,Other,base rate x DRG weight,58718,,"38,809 x DRG Weight",58718,Other,base rate x DRG weight,53547,,"35,391 x DRG Weight",53547,Other,base rate x DRG weight,136662,70,,136662,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,38152,,"25,216 X DRG Weight",38152,Other,Base Weight X DRG Weight,34338,,"22,695 X DRG Weight",34338,Other,Base Weight X DRG Weight,38152,,"25,216 X DRG Weight",38152,Other,Base Rate x DRG Weight ,32428,,"21,433 x DRG Weight",32428,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,136662,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,74,MS-DRG,,,,,,,,inpatient,,,176051.52,15688,,,15688,Other,150% of Medicare + 9.63% HCRA Surcharge,9540.08,,,9540.08,Other,Medicare IPPS methodology,26402,,"25,728 x DRG weight",26402,Other,base rate x DRG weight,23762,,"23,155 x DRG weight",23762,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,88026,50,,88026,Percent of Total Billed Charges,50% of Charges,29858,,"29,096 x DRG Weight",29858,Other,base rate x DRG weight,23052,,"22,463 x DRG Weight",23052,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,27118,,"26,426 x DRG Weight",27118,Other,base rate x DRG weight,39826,,"38,809 x DRG Weight",39826,Other,base rate x DRG weight,39826,,"38,809 x DRG Weight",39826,Other,base rate x DRG weight,27118,,"26,426 x DRG Weight",27118,Other,base rate x DRG weight,39826,,"38,809 x DRG Weight",39826,Other,base rate x DRG weight,36318,,"35,391 x DRG Weight",36318,Other,base rate x DRG weight,123236,70,,123236,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25877,,"25,216 X DRG Weight",25877,Other,Base Weight X DRG Weight,23290,,"22,695 X DRG Weight",23290,Other,Base Weight X DRG Weight,25877,,"25,216 X DRG Weight",25877,Other,Base Rate x DRG Weight ,21995,,"21,433 x DRG Weight",21995,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,123236,
VIRAL MENINGITIS WITH CC/MCC,75,MS-DRG,,,,,,,,inpatient,,,166616.58,28852,,,28852,Other,150% of Medicare + 9.63% HCRA Surcharge,17544.89,,,17544.89,Other,Medicare IPPS methodology,49238,,"25,728 x DRG weight",49238,Other,base rate x DRG weight,44314,,"23,155 x DRG weight",44314,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,83308,50,,83308,Percent of Total Billed Charges,50% of Charges,55684,,"29,096 x DRG Weight",55684,Other,base rate x DRG weight,42990,,"22,463 x DRG Weight",42990,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,50574,,"26,426 x DRG Weight",50574,Other,base rate x DRG weight,74273,,"38,809 x DRG Weight",74273,Other,base rate x DRG weight,74273,,"38,809 x DRG Weight",74273,Other,base rate x DRG weight,50574,,"26,426 x DRG Weight",50574,Other,base rate x DRG weight,74273,,"38,809 x DRG Weight",74273,Other,base rate x DRG weight,67731,,"35,391 x DRG Weight",67731,Other,base rate x DRG weight,116632,70,,116632,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,48258,,"25,216 X DRG Weight",48258,Other,Base Weight X DRG Weight,43434,,"22,695 X DRG Weight",43434,Other,Base Weight X DRG Weight,48258,,"25,216 X DRG Weight",48258,Other,Base Rate x DRG Weight ,41018,,"21,433 x DRG Weight",41018,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,116632,
VIRAL MENINGITIS WITHOUT CC/MCC,76,MS-DRG,,,,,,,,inpatient,,,65979.44,14150,,,14150,Other,150% of Medicare + 9.63% HCRA Surcharge,8604.87,,,8604.87,Other,Medicare IPPS methodology,23734,,"25,728 x DRG weight",23734,Other,base rate x DRG weight,21360,,"23,155 x DRG weight",21360,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32990,50,,32990,Percent of Total Billed Charges,50% of Charges,26841,,"29,096 x DRG Weight",26841,Other,base rate x DRG weight,20722,,"22,463 x DRG Weight",20722,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,24378,,"26,426 x DRG Weight",24378,Other,base rate x DRG weight,35801,,"38,809 x DRG Weight",35801,Other,base rate x DRG weight,35801,,"38,809 x DRG Weight",35801,Other,base rate x DRG weight,24378,,"26,426 x DRG Weight",24378,Other,base rate x DRG weight,35801,,"38,809 x DRG Weight",35801,Other,base rate x DRG weight,32648,,"35,391 x DRG Weight",32648,Other,base rate x DRG weight,46186,70,,46186,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,23262,,"25,216 X DRG Weight",23262,Other,Base Weight X DRG Weight,20936,,"22,695 X DRG Weight",20936,Other,Base Weight X DRG Weight,23262,,"25,216 X DRG Weight",23262,Other,Base Rate x DRG Weight ,19772,,"21,433 x DRG Weight",19772,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,46186,
HYPERTENSIVE ENCEPHALOPATHY WITH MCC,77,MS-DRG,,,,,,,,inpatient,,,88267,22877,,,22877,Other,150% of Medicare + 9.63% HCRA Surcharge,13911.34,,,13911.34,Other,Medicare IPPS methodology,38872,,"25,728 x DRG weight",38872,Other,base rate x DRG weight,34985,,"23,155 x DRG weight",34985,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,44134,50,,44134,Percent of Total Billed Charges,50% of Charges,43961,,"29,096 x DRG Weight",43961,Other,base rate x DRG weight,33939,,"22,463 x DRG Weight",33939,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39927,,"26,426 x DRG Weight",39927,Other,base rate x DRG weight,58637,,"38,809 x DRG Weight",58637,Other,base rate x DRG weight,58637,,"38,809 x DRG Weight",58637,Other,base rate x DRG weight,39927,,"26,426 x DRG Weight",39927,Other,base rate x DRG weight,58637,,"38,809 x DRG Weight",58637,Other,base rate x DRG weight,53472,,"35,391 x DRG Weight",53472,Other,base rate x DRG weight,61787,70,,61787,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,38099,,"25,216 X DRG Weight",38099,Other,Base Weight X DRG Weight,34290,,"22,695 X DRG Weight",34290,Other,Base Weight X DRG Weight,38099,,"25,216 X DRG Weight",38099,Other,Base Rate x DRG Weight ,32383,,"21,433 x DRG Weight",32383,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,61787,
HYPERTENSIVE ENCEPHALOPATHY WITH CC,78,MS-DRG,,,,,,,,inpatient,,,181671,15550,,,15550,Other,150% of Medicare + 9.63% HCRA Surcharge,9456.21,,,9456.21,Other,Medicare IPPS methodology,26163,,"25,728 x DRG weight",26163,Other,base rate x DRG weight,23546,,"23,155 x DRG weight",23546,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,90836,50,,90836,Percent of Total Billed Charges,50% of Charges,29588,,"29,096 x DRG Weight",29588,Other,base rate x DRG weight,22843,,"22,463 x DRG Weight",22843,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26873,,"26,426 x DRG Weight",26873,Other,base rate x DRG weight,39465,,"38,809 x DRG Weight",39465,Other,base rate x DRG weight,39465,,"38,809 x DRG Weight",39465,Other,base rate x DRG weight,26873,,"26,426 x DRG Weight",26873,Other,base rate x DRG weight,39465,,"38,809 x DRG Weight",39465,Other,base rate x DRG weight,35989,,"35,391 x DRG Weight",35989,Other,base rate x DRG weight,127170,70,,127170,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25642,,"25,216 X DRG Weight",25642,Other,Base Weight X DRG Weight,23079,,"22,695 X DRG Weight",23079,Other,Base Weight X DRG Weight,25642,,"25,216 X DRG Weight",25642,Other,Base Rate x DRG Weight ,21795,,"21,433 x DRG Weight",21795,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,127170,
HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,79,MS-DRG,,,,,,,,inpatient,,,64503,11456,,,11456,Other,150% of Medicare + 9.63% HCRA Surcharge,6966.21,,,6966.21,Other,Medicare IPPS methodology,19059,,"25,728 x DRG weight",19059,Other,base rate x DRG weight,17153,,"23,155 x DRG weight",17153,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32252,50,,32252,Percent of Total Billed Charges,50% of Charges,21554,,"29,096 x DRG Weight",21554,Other,base rate x DRG weight,16641,,"22,463 x DRG Weight",16641,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,19576,,"26,426 x DRG Weight",19576,Other,base rate x DRG weight,28750,,"38,809 x DRG Weight",28750,Other,base rate x DRG weight,28750,,"38,809 x DRG Weight",28750,Other,base rate x DRG weight,19576,,"26,426 x DRG Weight",19576,Other,base rate x DRG weight,28750,,"38,809 x DRG Weight",28750,Other,base rate x DRG weight,26218,,"35,391 x DRG Weight",26218,Other,base rate x DRG weight,45152,70,,45152,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18680,,"25,216 X DRG Weight",18680,Other,Base Weight X DRG Weight,16812,,"22,695 X DRG Weight",16812,Other,Base Weight X DRG Weight,18680,,"25,216 X DRG Weight",18680,Other,Base Rate x DRG Weight ,15878,,"21,433 x DRG Weight",15878,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,45152,
NONTRAUMATIC STUPOR AND COMA WITH MCC,80,MS-DRG,,,,,,,,inpatient,,,255939.76,33225,,,33225,Other,150% of Medicare + 9.63% HCRA Surcharge,20204.44,,,20204.44,Other,Medicare IPPS methodology,56825,,"25,728 x DRG weight",56825,Other,base rate x DRG weight,51142,,"23,155 x DRG weight",51142,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,127970,50,,127970,Percent of Total Billed Charges,50% of Charges,64264,,"29,096 x DRG Weight",64264,Other,base rate x DRG weight,49614,,"22,463 x DRG Weight",49614,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,58367,,"26,426 x DRG Weight",58367,Other,base rate x DRG weight,85717,,"38,809 x DRG Weight",85717,Other,base rate x DRG weight,85717,,"38,809 x DRG Weight",85717,Other,base rate x DRG weight,58367,,"26,426 x DRG Weight",58367,Other,base rate x DRG weight,85717,,"38,809 x DRG Weight",85717,Other,base rate x DRG weight,78168,,"35,391 x DRG Weight",78168,Other,base rate x DRG weight,179158,70,,179158,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,55695,,"25,216 X DRG Weight",55695,Other,Base Weight X DRG Weight,50126,,"22,695 X DRG Weight",50126,Other,Base Weight X DRG Weight,55695,,"25,216 X DRG Weight",55695,Other,Base Rate x DRG Weight ,47339,,"21,433 x DRG Weight",47339,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,179158,
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,81,MS-DRG,,,,,,,,inpatient,,,121420.68,13957,,,13957,Other,150% of Medicare + 9.63% HCRA Surcharge,8487.63,,,8487.63,Other,Medicare IPPS methodology,23400,,"25,728 x DRG weight",23400,Other,base rate x DRG weight,21059,,"23,155 x DRG weight",21059,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,60710,50,,60710,Percent of Total Billed Charges,50% of Charges,26463,,"29,096 x DRG Weight",26463,Other,base rate x DRG weight,20430,,"22,463 x DRG Weight",20430,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,24034,,"26,426 x DRG Weight",24034,Other,base rate x DRG weight,35297,,"38,809 x DRG Weight",35297,Other,base rate x DRG weight,35297,,"38,809 x DRG Weight",35297,Other,base rate x DRG weight,24034,,"26,426 x DRG Weight",24034,Other,base rate x DRG weight,35297,,"38,809 x DRG Weight",35297,Other,base rate x DRG weight,32188,,"35,391 x DRG Weight",32188,Other,base rate x DRG weight,84994,70,,84994,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22934,,"25,216 X DRG Weight",22934,Other,Base Weight X DRG Weight,20641,,"22,695 X DRG Weight",20641,Other,Base Weight X DRG Weight,22934,,"25,216 X DRG Weight",22934,Other,Base Rate x DRG Weight ,19493,,"21,433 x DRG Weight",19493,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,84994,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,82,MS-DRG,,,,,,,,inpatient,,,283860.77,34257,,,34257,Other,150% of Medicare + 9.63% HCRA Surcharge,20832.12,,,20832.12,Other,Medicare IPPS methodology,58616,,"25,728 x DRG weight",58616,Other,base rate x DRG weight,52754,,"23,155 x DRG weight",52754,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,141930,50,,141930,Percent of Total Billed Charges,50% of Charges,66289,,"29,096 x DRG Weight",66289,Other,base rate x DRG weight,51177,,"22,463 x DRG Weight",51177,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,60206,,"26,426 x DRG Weight",60206,Other,base rate x DRG weight,88419,,"38,809 x DRG Weight",88419,Other,base rate x DRG weight,88419,,"38,809 x DRG Weight",88419,Other,base rate x DRG weight,60206,,"26,426 x DRG Weight",60206,Other,base rate x DRG weight,88419,,"38,809 x DRG Weight",88419,Other,base rate x DRG weight,80631,,"35,391 x DRG Weight",80631,Other,base rate x DRG weight,198703,70,,198703,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,57450,,"25,216 X DRG Weight",57450,Other,Base Weight X DRG Weight,51706,,"22,695 X DRG Weight",51706,Other,Base Weight X DRG Weight,57450,,"25,216 X DRG Weight",57450,Other,Base Rate x DRG Weight ,48831,,"21,433 x DRG Weight",48831,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,198703,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,83,MS-DRG,,,,,,,,inpatient,,,200124.21,20585,,,20585,Other,150% of Medicare + 9.63% HCRA Surcharge,12517.99,,,12517.99,Other,Medicare IPPS methodology,34897,,"25,728 x DRG weight",34897,Other,base rate x DRG weight,31407,,"23,155 x DRG weight",31407,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,100062,50,,100062,Percent of Total Billed Charges,50% of Charges,39466,,"29,096 x DRG Weight",39466,Other,base rate x DRG weight,30469,,"22,463 x DRG Weight",30469,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,35844,,"26,426 x DRG Weight",35844,Other,base rate x DRG weight,52641,,"38,809 x DRG Weight",52641,Other,base rate x DRG weight,52641,,"38,809 x DRG Weight",52641,Other,base rate x DRG weight,35844,,"26,426 x DRG Weight",35844,Other,base rate x DRG weight,52641,,"38,809 x DRG Weight",52641,Other,base rate x DRG weight,48004,,"35,391 x DRG Weight",48004,Other,base rate x DRG weight,140087,70,,140087,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,34203,,"25,216 X DRG Weight",34203,Other,Base Weight X DRG Weight,30783,,"22,695 X DRG Weight",30783,Other,Base Weight X DRG Weight,34203,,"25,216 X DRG Weight",34203,Other,Base Rate x DRG Weight ,29072,,"21,433 x DRG Weight",29072,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,140087,
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,84,MS-DRG,,,,,,,,inpatient,,,117757.53,14109,,,14109,Other,150% of Medicare + 9.63% HCRA Surcharge,8579.62,,,8579.62,Other,Medicare IPPS methodology,23662,,"25,728 x DRG weight",23662,Other,base rate x DRG weight,21296,,"23,155 x DRG weight",21296,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,58879,50,,58879,Percent of Total Billed Charges,50% of Charges,26760,,"29,096 x DRG Weight",26760,Other,base rate x DRG weight,20659,,"22,463 x DRG Weight",20659,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,24304,,"26,426 x DRG Weight",24304,Other,base rate x DRG weight,35693,,"38,809 x DRG Weight",35693,Other,base rate x DRG weight,35693,,"38,809 x DRG Weight",35693,Other,base rate x DRG weight,24304,,"26,426 x DRG Weight",24304,Other,base rate x DRG weight,35693,,"38,809 x DRG Weight",35693,Other,base rate x DRG weight,32549,,"35,391 x DRG Weight",32549,Other,base rate x DRG weight,82430,70,,82430,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,23191,,"25,216 X DRG Weight",23191,Other,Base Weight X DRG Weight,20873,,"22,695 X DRG Weight",20873,Other,Base Weight X DRG Weight,23191,,"25,216 X DRG Weight",23191,Other,Base Rate x DRG Weight ,19712,,"21,433 x DRG Weight",19712,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,82430,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,85,MS-DRG,,,,,,,,inpatient,,,256151.69,34176,,,34176,Other,150% of Medicare + 9.63% HCRA Surcharge,20782.52,,,20782.52,Other,Medicare IPPS methodology,58475,,"25,728 x DRG weight",58475,Other,base rate x DRG weight,52627,,"23,155 x DRG weight",52627,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,128076,50,,128076,Percent of Total Billed Charges,50% of Charges,66129,,"29,096 x DRG Weight",66129,Other,base rate x DRG weight,51054,,"22,463 x DRG Weight",51054,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,60061,,"26,426 x DRG Weight",60061,Other,base rate x DRG weight,88205,,"38,809 x DRG Weight",88205,Other,base rate x DRG weight,88205,,"38,809 x DRG Weight",88205,Other,base rate x DRG weight,60061,,"26,426 x DRG Weight",60061,Other,base rate x DRG weight,88205,,"38,809 x DRG Weight",88205,Other,base rate x DRG weight,80437,,"35,391 x DRG Weight",80437,Other,base rate x DRG weight,179306,70,,179306,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,57311,,"25,216 X DRG Weight",57311,Other,Base Weight X DRG Weight,51581,,"22,695 X DRG Weight",51581,Other,Base Weight X DRG Weight,57311,,"25,216 X DRG Weight",57311,Other,Base Rate x DRG Weight ,48713,,"21,433 x DRG Weight",48713,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,179306,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,86,MS-DRG,,,,,,,,inpatient,,,177275.48,20002,,,20002,Other,150% of Medicare + 9.63% HCRA Surcharge,12163.56,,,12163.56,Other,Medicare IPPS methodology,33886,,"25,728 x DRG weight",33886,Other,base rate x DRG weight,30497,,"23,155 x DRG weight",30497,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,88638,50,,88638,Percent of Total Billed Charges,50% of Charges,38322,,"29,096 x DRG Weight",38322,Other,base rate x DRG weight,29586,,"22,463 x DRG Weight",29586,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,34806,,"26,426 x DRG Weight",34806,Other,base rate x DRG weight,51115,,"38,809 x DRG Weight",51115,Other,base rate x DRG weight,51115,,"38,809 x DRG Weight",51115,Other,base rate x DRG weight,34806,,"26,426 x DRG Weight",34806,Other,base rate x DRG weight,51115,,"38,809 x DRG Weight",51115,Other,base rate x DRG weight,46613,,"35,391 x DRG Weight",46613,Other,base rate x DRG weight,124093,70,,124093,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,33212,,"25,216 X DRG Weight",33212,Other,Base Weight X DRG Weight,29892,,"22,695 X DRG Weight",29892,Other,Base Weight X DRG Weight,33212,,"25,216 X DRG Weight",33212,Other,Base Rate x DRG Weight ,28229,,"21,433 x DRG Weight",28229,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,124093,
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,87,MS-DRG,,,,,,,,inpatient,,,80254.97,13612,,,13612,Other,150% of Medicare + 9.63% HCRA Surcharge,8277.5,,,8277.5,Other,Medicare IPPS methodology,22800,,"25,728 x DRG weight",22800,Other,base rate x DRG weight,20520,,"23,155 x DRG weight",20520,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40127,50,,40127,Percent of Total Billed Charges,50% of Charges,25785,,"29,096 x DRG Weight",25785,Other,base rate x DRG weight,19907,,"22,463 x DRG Weight",19907,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23419,,"26,426 x DRG Weight",23419,Other,base rate x DRG weight,34393,,"38,809 x DRG Weight",34393,Other,base rate x DRG weight,34393,,"38,809 x DRG Weight",34393,Other,base rate x DRG weight,23419,,"26,426 x DRG Weight",23419,Other,base rate x DRG weight,34393,,"38,809 x DRG Weight",34393,Other,base rate x DRG weight,31364,,"35,391 x DRG Weight",31364,Other,base rate x DRG weight,56178,70,,56178,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22346,,"25,216 X DRG Weight",22346,Other,Base Weight X DRG Weight,20112,,"22,695 X DRG Weight",20112,Other,Base Weight X DRG Weight,22346,,"25,216 X DRG Weight",22346,Other,Base Rate x DRG Weight ,18994,,"21,433 x DRG Weight",18994,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,56178,
CONCUSSION WITH MCC,88,MS-DRG,,,,,,,,inpatient,,,131096.93,23216,,,23216,Other,150% of Medicare + 9.63% HCRA Surcharge,14117.86,,,14117.86,Other,Medicare IPPS methodology,39462,,"25,728 x DRG weight",39462,Other,base rate x DRG weight,35515,,"23,155 x DRG weight",35515,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,65548,50,,65548,Percent of Total Billed Charges,50% of Charges,44627,,"29,096 x DRG Weight",44627,Other,base rate x DRG weight,34454,,"22,463 x DRG Weight",34454,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,40532,,"26,426 x DRG Weight",40532,Other,base rate x DRG weight,59525,,"38,809 x DRG Weight",59525,Other,base rate x DRG weight,59525,,"38,809 x DRG Weight",59525,Other,base rate x DRG weight,40532,,"26,426 x DRG Weight",40532,Other,base rate x DRG weight,59525,,"38,809 x DRG Weight",59525,Other,base rate x DRG weight,54283,,"35,391 x DRG Weight",54283,Other,base rate x DRG weight,91768,70,,91768,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,38676,,"25,216 X DRG Weight",38676,Other,Base Weight X DRG Weight,34810,,"22,695 X DRG Weight",34810,Other,Base Weight X DRG Weight,38676,,"25,216 X DRG Weight",38676,Other,Base Rate x DRG Weight ,32874,,"21,433 x DRG Weight",32874,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,91768,
CONCUSSION WITH CC,89,MS-DRG,,,,,,,,inpatient,,,145574.28,17523,,,17523,Other,150% of Medicare + 9.63% HCRA Surcharge,10655.67,,,10655.67,Other,Medicare IPPS methodology,29585,,"25,728 x DRG weight",29585,Other,base rate x DRG weight,26626,,"23,155 x DRG weight",26626,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,72787,50,,72787,Percent of Total Billed Charges,50% of Charges,33457,,"29,096 x DRG Weight",33457,Other,base rate x DRG weight,25830,,"22,463 x DRG Weight",25830,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,30387,,"26,426 x DRG Weight",30387,Other,base rate x DRG weight,44626,,"38,809 x DRG Weight",44626,Other,base rate x DRG weight,44626,,"38,809 x DRG Weight",44626,Other,base rate x DRG weight,30387,,"26,426 x DRG Weight",30387,Other,base rate x DRG weight,44626,,"38,809 x DRG Weight",44626,Other,base rate x DRG weight,40696,,"35,391 x DRG Weight",40696,Other,base rate x DRG weight,101902,70,,101902,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,28996,,"25,216 X DRG Weight",28996,Other,Base Weight X DRG Weight,26097,,"22,695 X DRG Weight",26097,Other,Base Weight X DRG Weight,28996,,"25,216 X DRG Weight",28996,Other,Base Rate x DRG Weight ,24646,,"21,433 x DRG Weight",24646,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,101902,
CONCUSSION WITHOUT CC/MCC,90,MS-DRG,,,,,,,,inpatient,,,91120.84,14333,,,14333,Other,150% of Medicare + 9.63% HCRA Surcharge,8715.8,,,8715.8,Other,Medicare IPPS methodology,24051,,"25,728 x DRG weight",24051,Other,base rate x DRG weight,21645,,"23,155 x DRG weight",21645,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,45560,50,,45560,Percent of Total Billed Charges,50% of Charges,27199,,"29,096 x DRG Weight",27199,Other,base rate x DRG weight,20998,,"22,463 x DRG Weight",20998,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,24703,,"26,426 x DRG Weight",24703,Other,base rate x DRG weight,36279,,"38,809 x DRG Weight",36279,Other,base rate x DRG weight,36279,,"38,809 x DRG Weight",36279,Other,base rate x DRG weight,24703,,"26,426 x DRG Weight",24703,Other,base rate x DRG weight,36279,,"38,809 x DRG Weight",36279,Other,base rate x DRG weight,33084,,"35,391 x DRG Weight",33084,Other,base rate x DRG weight,63785,70,,63785,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,23572,,"25,216 X DRG Weight",23572,Other,Base Weight X DRG Weight,21215,,"22,695 X DRG Weight",21215,Other,Base Weight X DRG Weight,23572,,"25,216 X DRG Weight",23572,Other,Base Rate x DRG Weight ,20036,,"21,433 x DRG Weight",20036,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,63785,
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,91,MS-DRG,,,,,,,,inpatient,,,247322.39,27004,,,27004,Other,150% of Medicare + 9.63% HCRA Surcharge,16421.18,,,16421.18,Other,Medicare IPPS methodology,46033,,"25,728 x DRG weight",46033,Other,base rate x DRG weight,41429,,"23,155 x DRG weight",41429,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,123661,50,,123661,Percent of Total Billed Charges,50% of Charges,52059,,"29,096 x DRG Weight",52059,Other,base rate x DRG weight,40191,,"22,463 x DRG Weight",40191,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,47281,,"26,426 x DRG Weight",47281,Other,base rate x DRG weight,69437,,"38,809 x DRG Weight",69437,Other,base rate x DRG weight,69437,,"38,809 x DRG Weight",69437,Other,base rate x DRG weight,47281,,"26,426 x DRG Weight",47281,Other,base rate x DRG weight,69437,,"38,809 x DRG Weight",69437,Other,base rate x DRG weight,63322,,"35,391 x DRG Weight",63322,Other,base rate x DRG weight,173126,70,,173126,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,45116,,"25,216 X DRG Weight",45116,Other,Base Weight X DRG Weight,40606,,"22,695 X DRG Weight",40606,Other,Base Weight X DRG Weight,45116,,"25,216 X DRG Weight",45116,Other,Base Rate x DRG Weight ,38348,,"21,433 x DRG Weight",38348,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,173126,
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,92,MS-DRG,,,,,,,,inpatient,,,163311.23,15687,,,15687,Other,150% of Medicare + 9.63% HCRA Surcharge,9539.18,,,9539.18,Other,Medicare IPPS methodology,26400,,"25,728 x DRG weight",26400,Other,base rate x DRG weight,23759,,"23,155 x DRG weight",23759,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,81656,50,,81656,Percent of Total Billed Charges,50% of Charges,29855,,"29,096 x DRG Weight",29855,Other,base rate x DRG weight,23049,,"22,463 x DRG Weight",23049,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,27116,,"26,426 x DRG Weight",27116,Other,base rate x DRG weight,39822,,"38,809 x DRG Weight",39822,Other,base rate x DRG weight,39822,,"38,809 x DRG Weight",39822,Other,base rate x DRG weight,27116,,"26,426 x DRG Weight",27116,Other,base rate x DRG weight,39822,,"38,809 x DRG Weight",39822,Other,base rate x DRG weight,36315,,"35,391 x DRG Weight",36315,Other,base rate x DRG weight,114318,70,,114318,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25874,,"25,216 X DRG Weight",25874,Other,Base Weight X DRG Weight,23287,,"22,695 X DRG Weight",23287,Other,Base Weight X DRG Weight,25874,,"25,216 X DRG Weight",25874,Other,Base Rate x DRG Weight ,21992,,"21,433 x DRG Weight",21992,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,114318,
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,93,MS-DRG,,,,,,,,inpatient,,,94602.58,11954,,,11954,Other,150% of Medicare + 9.63% HCRA Surcharge,7269.23,,,7269.23,Other,Medicare IPPS methodology,19924,,"25,728 x DRG weight",19924,Other,base rate x DRG weight,17931,,"23,155 x DRG weight",17931,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,47301,50,,47301,Percent of Total Billed Charges,50% of Charges,22532,,"29,096 x DRG Weight",22532,Other,base rate x DRG weight,17395,,"22,463 x DRG Weight",17395,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,20464,,"26,426 x DRG Weight",20464,Other,base rate x DRG weight,30054,,"38,809 x DRG Weight",30054,Other,base rate x DRG weight,30054,,"38,809 x DRG Weight",30054,Other,base rate x DRG weight,20464,,"26,426 x DRG Weight",20464,Other,base rate x DRG weight,30054,,"38,809 x DRG Weight",30054,Other,base rate x DRG weight,27407,,"35,391 x DRG Weight",27407,Other,base rate x DRG weight,66222,70,,66222,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19527,,"25,216 X DRG Weight",19527,Other,Base Weight X DRG Weight,17575,,"22,695 X DRG Weight",17575,Other,Base Weight X DRG Weight,19527,,"25,216 X DRG Weight",19527,Other,Base Rate x DRG Weight ,16598,,"21,433 x DRG Weight",16598,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,66222,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,94,MS-DRG,,,,,,,,inpatient,,,348015.49,54195,,,54195,Other,150% of Medicare + 9.63% HCRA Surcharge,32956.57,,,32956.57,Other,Medicare IPPS methodology,93205,,"25,728 x DRG weight",93205,Other,base rate x DRG weight,83884,,"23,155 x DRG weight",83884,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,174008,50,,174008,Percent of Total Billed Charges,50% of Charges,105406,,"29,096 x DRG Weight",105406,Other,base rate x DRG weight,81377,,"22,463 x DRG Weight",81377,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,95733,,"26,426 x DRG Weight",95733,Other,base rate x DRG weight,140593,,"38,809 x DRG Weight",140593,Other,base rate x DRG weight,140593,,"38,809 x DRG Weight",140593,Other,base rate x DRG weight,95733,,"26,426 x DRG Weight",95733,Other,base rate x DRG weight,140593,,"38,809 x DRG Weight",140593,Other,base rate x DRG weight,128211,,"35,391 x DRG Weight",128211,Other,base rate x DRG weight,243611,70,,243611,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,91350,,"25,216 X DRG Weight",91350,Other,Base Weight X DRG Weight,82217,,"22,695 X DRG Weight",82217,Other,Base Weight X DRG Weight,91350,,"25,216 X DRG Weight",91350,Other,Base Rate x DRG Weight ,77645,,"21,433 x DRG Weight",77645,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,243611,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,95,MS-DRG,,,,,,,,inpatient,,,251747.23,35828,,,35828,Other,150% of Medicare + 9.63% HCRA Surcharge,21787.18,,,21787.18,Other,Medicare IPPS methodology,61341,,"25,728 x DRG weight",61341,Other,base rate x DRG weight,55206,,"23,155 x DRG weight",55206,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,125874,50,,125874,Percent of Total Billed Charges,50% of Charges,69371,,"29,096 x DRG Weight",69371,Other,base rate x DRG weight,53556,,"22,463 x DRG Weight",53556,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,63005,,"26,426 x DRG Weight",63005,Other,base rate x DRG weight,92528,,"38,809 x DRG Weight",92528,Other,base rate x DRG weight,92528,,"38,809 x DRG Weight",92528,Other,base rate x DRG weight,63005,,"26,426 x DRG Weight",63005,Other,base rate x DRG weight,92528,,"38,809 x DRG Weight",92528,Other,base rate x DRG weight,84379,,"35,391 x DRG Weight",84379,Other,base rate x DRG weight,176223,70,,176223,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,60120,,"25,216 X DRG Weight",60120,Other,Base Weight X DRG Weight,54109,,"22,695 X DRG Weight",54109,Other,Base Weight X DRG Weight,60120,,"25,216 X DRG Weight",60120,Other,Base Rate x DRG Weight ,51101,,"21,433 x DRG Weight",51101,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,176223,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,96,MS-DRG,,,,,,,,inpatient,,,206916.67,32795,,,32795,Other,150% of Medicare + 9.63% HCRA Surcharge,19942.9,,,19942.9,Other,Medicare IPPS methodology,56079,,"25,728 x DRG weight",56079,Other,base rate x DRG weight,50471,,"23,155 x DRG weight",50471,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,103458,50,,103458,Percent of Total Billed Charges,50% of Charges,63421,,"29,096 x DRG Weight",63421,Other,base rate x DRG weight,48963,,"22,463 x DRG Weight",48963,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,57601,,"26,426 x DRG Weight",57601,Other,base rate x DRG weight,84592,,"38,809 x DRG Weight",84592,Other,base rate x DRG weight,84592,,"38,809 x DRG Weight",84592,Other,base rate x DRG weight,57601,,"26,426 x DRG Weight",57601,Other,base rate x DRG weight,84592,,"38,809 x DRG Weight",84592,Other,base rate x DRG weight,77142,,"35,391 x DRG Weight",77142,Other,base rate x DRG weight,144842,70,,144842,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,54963,,"25,216 X DRG Weight",54963,Other,Base Weight X DRG Weight,49468,,"22,695 X DRG Weight",49468,Other,Base Weight X DRG Weight,54963,,"25,216 X DRG Weight",54963,Other,Base Rate x DRG Weight ,46718,,"21,433 x DRG Weight",46718,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,144842,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,97,MS-DRG,,,,,,,,inpatient,,,411465.66,54406,,,54406,Other,150% of Medicare + 9.63% HCRA Surcharge,33084.63,,,33084.63,Other,Medicare IPPS methodology,93570,,"25,728 x DRG weight",93570,Other,base rate x DRG weight,84212,,"23,155 x DRG weight",84212,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,205733,50,,205733,Percent of Total Billed Charges,50% of Charges,105819,,"29,096 x DRG Weight",105819,Other,base rate x DRG weight,81696,,"22,463 x DRG Weight",81696,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,96109,,"26,426 x DRG Weight",96109,Other,base rate x DRG weight,141144,,"38,809 x DRG Weight",141144,Other,base rate x DRG weight,141144,,"38,809 x DRG Weight",141144,Other,base rate x DRG weight,96109,,"26,426 x DRG Weight",96109,Other,base rate x DRG weight,141144,,"38,809 x DRG Weight",141144,Other,base rate x DRG weight,128714,,"35,391 x DRG Weight",128714,Other,base rate x DRG weight,288026,70,,288026,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,91708,,"25,216 X DRG Weight",91708,Other,Base Weight X DRG Weight,82539,,"22,695 X DRG Weight",82539,Other,Base Weight X DRG Weight,91708,,"25,216 X DRG Weight",91708,Other,Base Rate x DRG Weight ,77950,,"21,433 x DRG Weight",77950,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,288026,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,98,MS-DRG,,,,,,,,inpatient,,,305591.59,32421,,,32421,Other,150% of Medicare + 9.63% HCRA Surcharge,19715.64,,,19715.64,Other,Medicare IPPS methodology,55431,,"25,728 x DRG weight",55431,Other,base rate x DRG weight,49887,,"23,155 x DRG weight",49887,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,152796,50,,152796,Percent of Total Billed Charges,50% of Charges,62687,,"29,096 x DRG Weight",62687,Other,base rate x DRG weight,48397,,"22,463 x DRG Weight",48397,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,56935,,"26,426 x DRG Weight",56935,Other,base rate x DRG weight,83614,,"38,809 x DRG Weight",83614,Other,base rate x DRG weight,83614,,"38,809 x DRG Weight",83614,Other,base rate x DRG weight,56935,,"26,426 x DRG Weight",56935,Other,base rate x DRG weight,83614,,"38,809 x DRG Weight",83614,Other,base rate x DRG weight,76250,,"35,391 x DRG Weight",76250,Other,base rate x DRG weight,213914,70,,213914,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,54328,,"25,216 X DRG Weight",54328,Other,Base Weight X DRG Weight,48896,,"22,695 X DRG Weight",48896,Other,Base Weight X DRG Weight,54328,,"25,216 X DRG Weight",54328,Other,Base Rate x DRG Weight ,46177,,"21,433 x DRG Weight",46177,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,213914,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,99,MS-DRG,,,,,,,,inpatient,,,127994.65,20048,,,20048,Other,150% of Medicare + 9.63% HCRA Surcharge,12191.52,,,12191.52,Other,Medicare IPPS methodology,33966,,"25,728 x DRG weight",33966,Other,base rate x DRG weight,30569,,"23,155 x DRG weight",30569,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,63997,50,,63997,Percent of Total Billed Charges,50% of Charges,38413,,"29,096 x DRG Weight",38413,Other,base rate x DRG weight,29656,,"22,463 x DRG Weight",29656,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,34888,,"26,426 x DRG Weight",34888,Other,base rate x DRG weight,51236,,"38,809 x DRG Weight",51236,Other,base rate x DRG weight,51236,,"38,809 x DRG Weight",51236,Other,base rate x DRG weight,34888,,"26,426 x DRG Weight",34888,Other,base rate x DRG weight,51236,,"38,809 x DRG Weight",51236,Other,base rate x DRG weight,46723,,"35,391 x DRG Weight",46723,Other,base rate x DRG weight,89596,70,,89596,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,33290,,"25,216 X DRG Weight",33290,Other,Base Weight X DRG Weight,29962,,"22,695 X DRG Weight",29962,Other,Base Weight X DRG Weight,33290,,"25,216 X DRG Weight",33290,Other,Base Rate x DRG Weight ,28296,,"21,433 x DRG Weight",28296,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,89596,
SEIZURES WITH MCC,100,MS-DRG,,,,,,,,inpatient,,,212740.77,29871,,,29871,Other,150% of Medicare + 9.63% HCRA Surcharge,18164.46,,,18164.46,Other,Medicare IPPS methodology,51006,,"25,728 x DRG weight",51006,Other,base rate x DRG weight,45905,,"23,155 x DRG weight",45905,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,106370,50,,106370,Percent of Total Billed Charges,50% of Charges,57683,,"29,096 x DRG Weight",57683,Other,base rate x DRG weight,44533,,"22,463 x DRG Weight",44533,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,52390,,"26,426 x DRG Weight",52390,Other,base rate x DRG weight,76939,,"38,809 x DRG Weight",76939,Other,base rate x DRG weight,76939,,"38,809 x DRG Weight",76939,Other,base rate x DRG weight,52390,,"26,426 x DRG Weight",52390,Other,base rate x DRG weight,76939,,"38,809 x DRG Weight",76939,Other,base rate x DRG weight,70163,,"35,391 x DRG Weight",70163,Other,base rate x DRG weight,148919,70,,148919,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,49991,,"25,216 X DRG Weight",49991,Other,Base Weight X DRG Weight,44993,,"22,695 X DRG Weight",44993,Other,Base Weight X DRG Weight,49991,,"25,216 X DRG Weight",49991,Other,Base Rate x DRG Weight ,42491,,"21,433 x DRG Weight",42491,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,148919,
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,,inpatient,,,89221.08,13959,,,13959,Other,150% of Medicare + 9.63% HCRA Surcharge,8488.53,,,8488.53,Other,Medicare IPPS methodology,23402,,"25,728 x DRG weight",23402,Other,base rate x DRG weight,21062,,"23,155 x DRG weight",21062,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,44611,50,,44611,Percent of Total Billed Charges,50% of Charges,26466,,"29,096 x DRG Weight",26466,Other,base rate x DRG weight,20432,,"22,463 x DRG Weight",20432,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,24037,,"26,426 x DRG Weight",24037,Other,base rate x DRG weight,35301,,"38,809 x DRG Weight",35301,Other,base rate x DRG weight,35301,,"38,809 x DRG Weight",35301,Other,base rate x DRG weight,24037,,"26,426 x DRG Weight",24037,Other,base rate x DRG weight,35301,,"38,809 x DRG Weight",35301,Other,base rate x DRG weight,32192,,"35,391 x DRG Weight",32192,Other,base rate x DRG weight,62455,70,,62455,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22936,,"25,216 X DRG Weight",22936,Other,Base Weight X DRG Weight,20643,,"22,695 X DRG Weight",20643,Other,Base Weight X DRG Weight,22936,,"25,216 X DRG Weight",22936,Other,Base Rate x DRG Weight ,19495,,"21,433 x DRG Weight",19495,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,62455,
HEADACHES WITH MCC,102,MS-DRG,,,,,,,,inpatient,,,188017.58,18364,,,18364,Other,150% of Medicare + 9.63% HCRA Surcharge,11167.02,,,11167.02,Other,Medicare IPPS methodology,31043,,"25,728 x DRG weight",31043,Other,base rate x DRG weight,27939,,"23,155 x DRG weight",27939,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,94009,50,,94009,Percent of Total Billed Charges,50% of Charges,35107,,"29,096 x DRG Weight",35107,Other,base rate x DRG weight,27104,,"22,463 x DRG Weight",27104,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31886,,"26,426 x DRG Weight",31886,Other,base rate x DRG weight,46827,,"38,809 x DRG Weight",46827,Other,base rate x DRG weight,46827,,"38,809 x DRG Weight",46827,Other,base rate x DRG weight,31886,,"26,426 x DRG Weight",31886,Other,base rate x DRG weight,46827,,"38,809 x DRG Weight",46827,Other,base rate x DRG weight,42703,,"35,391 x DRG Weight",42703,Other,base rate x DRG weight,131612,70,,131612,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,30426,,"25,216 X DRG Weight",30426,Other,Base Weight X DRG Weight,27384,,"22,695 X DRG Weight",27384,Other,Base Weight X DRG Weight,30426,,"25,216 X DRG Weight",30426,Other,Base Rate x DRG Weight ,25861,,"21,433 x DRG Weight",25861,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,131612,
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,,inpatient,,,110728.85,12962,,,12962,Other,150% of Medicare + 9.63% HCRA Surcharge,7882.49,,,7882.49,Other,Medicare IPPS methodology,21673,,"25,728 x DRG weight",21673,Other,base rate x DRG weight,19506,,"23,155 x DRG weight",19506,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,55364,50,,55364,Percent of Total Billed Charges,50% of Charges,24510,,"29,096 x DRG Weight",24510,Other,base rate x DRG weight,18923,,"22,463 x DRG Weight",18923,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,22261,,"26,426 x DRG Weight",22261,Other,base rate x DRG weight,32693,,"38,809 x DRG Weight",32693,Other,base rate x DRG weight,32693,,"38,809 x DRG Weight",32693,Other,base rate x DRG weight,22261,,"26,426 x DRG Weight",22261,Other,base rate x DRG weight,32693,,"38,809 x DRG Weight",32693,Other,base rate x DRG weight,29813,,"35,391 x DRG Weight",29813,Other,base rate x DRG weight,77510,70,,77510,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,21242,,"25,216 X DRG Weight",21242,Other,Base Weight X DRG Weight,19118,,"22,695 X DRG Weight",19118,Other,Base Weight X DRG Weight,21242,,"25,216 X DRG Weight",21242,Other,Base Rate x DRG Weight ,18055,,"21,433 x DRG Weight",18055,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,77510,
ORBITAL PROCEDURES WITH CC/MCC,113,MS-DRG,,,,,,,,inpatient,,,464263.93,37654,,,37654,Other,150% of Medicare + 9.63% HCRA Surcharge,22897.35,,,22897.35,Other,Medicare IPPS methodology,64508,,"25,728 x DRG weight",64508,Other,base rate x DRG weight,58057,,"23,155 x DRG weight",58057,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,232132,50,,232132,Percent of Total Billed Charges,50% of Charges,72952,,"29,096 x DRG Weight",72952,Other,base rate x DRG weight,56321,,"22,463 x DRG Weight",56321,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,66258,,"26,426 x DRG Weight",66258,Other,base rate x DRG weight,97306,,"38,809 x DRG Weight",97306,Other,base rate x DRG weight,97306,,"38,809 x DRG Weight",97306,Other,base rate x DRG weight,66258,,"26,426 x DRG Weight",66258,Other,base rate x DRG weight,97306,,"38,809 x DRG Weight",97306,Other,base rate x DRG weight,88736,,"35,391 x DRG Weight",88736,Other,base rate x DRG weight,324985,70,,324985,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,63224,,"25,216 X DRG Weight",63224,Other,Base Weight X DRG Weight,56903,,"22,695 X DRG Weight",56903,Other,Base Weight X DRG Weight,63224,,"25,216 X DRG Weight",63224,Other,Base Rate x DRG Weight ,53739,,"21,433 x DRG Weight",53739,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,324985,
ORBITAL PROCEDURES WITHOUT CC/MCC,114,MS-DRG,,,,,,,,inpatient,,,92286.06,18737,,,18737,Other,150% of Medicare + 9.63% HCRA Surcharge,11394.28,,,11394.28,Other,Medicare IPPS methodology,31692,,"25,728 x DRG weight",31692,Other,base rate x DRG weight,28522,,"23,155 x DRG weight",28522,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46143,50,,46143,Percent of Total Billed Charges,50% of Charges,35840,,"29,096 x DRG Weight",35840,Other,base rate x DRG weight,27670,,"22,463 x DRG Weight",27670,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,32552,,"26,426 x DRG Weight",32552,Other,base rate x DRG weight,47805,,"38,809 x DRG Weight",47805,Other,base rate x DRG weight,47805,,"38,809 x DRG Weight",47805,Other,base rate x DRG weight,32552,,"26,426 x DRG Weight",32552,Other,base rate x DRG weight,47805,,"38,809 x DRG Weight",47805,Other,base rate x DRG weight,43595,,"35,391 x DRG Weight",43595,Other,base rate x DRG weight,64600,70,,64600,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,31061,,"25,216 X DRG Weight",31061,Other,Base Weight X DRG Weight,27956,,"22,695 X DRG Weight",27956,Other,Base Weight X DRG Weight,31061,,"25,216 X DRG Weight",31061,Other,Base Rate x DRG Weight ,26401,,"21,433 x DRG Weight",26401,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,64600,
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,MS-DRG,,,,,,,,inpatient,,,172972.87,23670,,,23670,Other,150% of Medicare + 9.63% HCRA Surcharge,14393.83,,,14393.83,Other,Medicare IPPS methodology,40249,,"25,728 x DRG weight",40249,Other,base rate x DRG weight,36224,,"23,155 x DRG weight",36224,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,86486,50,,86486,Percent of Total Billed Charges,50% of Charges,45518,,"29,096 x DRG Weight",45518,Other,base rate x DRG weight,35141,,"22,463 x DRG Weight",35141,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41341,,"26,426 x DRG Weight",41341,Other,base rate x DRG weight,60713,,"38,809 x DRG Weight",60713,Other,base rate x DRG weight,60713,,"38,809 x DRG Weight",60713,Other,base rate x DRG weight,41341,,"26,426 x DRG Weight",41341,Other,base rate x DRG weight,60713,,"38,809 x DRG Weight",60713,Other,base rate x DRG weight,55366,,"35,391 x DRG Weight",55366,Other,base rate x DRG weight,121081,70,,121081,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39448,,"25,216 X DRG Weight",39448,Other,Base Weight X DRG Weight,35504,,"22,695 X DRG Weight",35504,Other,Base Weight X DRG Weight,39448,,"25,216 X DRG Weight",39448,Other,Base Rate x DRG Weight ,33530,,"21,433 x DRG Weight",33530,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,121081,
INTRAOCULAR PROCEDURES WITH CC/MCC,116,MS-DRG,,,,,,,,inpatient,,,161700.79,27621,,,27621,Other,150% of Medicare + 9.63% HCRA Surcharge,16796.35,,,16796.35,Other,Medicare IPPS methodology,47103,,"25,728 x DRG weight",47103,Other,base rate x DRG weight,42392,,"23,155 x DRG weight",42392,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,80850,50,,80850,Percent of Total Billed Charges,50% of Charges,53269,,"29,096 x DRG Weight",53269,Other,base rate x DRG weight,41125,,"22,463 x DRG Weight",41125,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,48381,,"26,426 x DRG Weight",48381,Other,base rate x DRG weight,71052,,"38,809 x DRG Weight",71052,Other,base rate x DRG weight,71052,,"38,809 x DRG Weight",71052,Other,base rate x DRG weight,48381,,"26,426 x DRG Weight",48381,Other,base rate x DRG weight,71052,,"38,809 x DRG Weight",71052,Other,base rate x DRG weight,64794,,"35,391 x DRG Weight",64794,Other,base rate x DRG weight,113191,70,,113191,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46165,,"25,216 X DRG Weight",46165,Other,Base Weight X DRG Weight,41550,,"22,695 X DRG Weight",41550,Other,Base Weight X DRG Weight,46165,,"25,216 X DRG Weight",46165,Other,Base Rate x DRG Weight ,39240,,"21,433 x DRG Weight",39240,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,113191,
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,MS-DRG,,,,,,,,inpatient,,,87477.7,18242,,,18242,Other,150% of Medicare + 9.63% HCRA Surcharge,11093.07,,,11093.07,Other,Medicare IPPS methodology,30832,,"25,728 x DRG weight",30832,Other,base rate x DRG weight,27749,,"23,155 x DRG weight",27749,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43739,50,,43739,Percent of Total Billed Charges,50% of Charges,34869,,"29,096 x DRG Weight",34869,Other,base rate x DRG weight,26920,,"22,463 x DRG Weight",26920,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31669,,"26,426 x DRG Weight",31669,Other,base rate x DRG weight,46509,,"38,809 x DRG Weight",46509,Other,base rate x DRG weight,46509,,"38,809 x DRG Weight",46509,Other,base rate x DRG weight,31669,,"26,426 x DRG Weight",31669,Other,base rate x DRG weight,46509,,"38,809 x DRG Weight",46509,Other,base rate x DRG weight,42413,,"35,391 x DRG Weight",42413,Other,base rate x DRG weight,61234,70,,61234,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,30219,,"25,216 X DRG Weight",30219,Other,Base Weight X DRG Weight,27198,,"22,695 X DRG Weight",27198,Other,Base Weight X DRG Weight,30219,,"25,216 X DRG Weight",30219,Other,Base Rate x DRG Weight ,25685,,"21,433 x DRG Weight",25685,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,61234,
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,MS-DRG,,,,,,,,inpatient,,,101124.95,19470,,,19470,Other,150% of Medicare + 9.63% HCRA Surcharge,11839.8,,,11839.8,Other,Medicare IPPS methodology,32963,,"25,728 x DRG weight",32963,Other,base rate x DRG weight,29666,,"23,155 x DRG weight",29666,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,50562,50,,50562,Percent of Total Billed Charges,50% of Charges,37278,,"29,096 x DRG Weight",37278,Other,base rate x DRG weight,28780,,"22,463 x DRG Weight",28780,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,33857,,"26,426 x DRG Weight",33857,Other,base rate x DRG weight,49722,,"38,809 x DRG Weight",49722,Other,base rate x DRG weight,49722,,"38,809 x DRG Weight",49722,Other,base rate x DRG weight,33857,,"26,426 x DRG Weight",33857,Other,base rate x DRG weight,49722,,"38,809 x DRG Weight",49722,Other,base rate x DRG weight,45343,,"35,391 x DRG Weight",45343,Other,base rate x DRG weight,70787,70,,70787,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32307,,"25,216 X DRG Weight",32307,Other,Base Weight X DRG Weight,29077,,"22,695 X DRG Weight",29077,Other,Base Weight X DRG Weight,32307,,"25,216 X DRG Weight",32307,Other,Base Rate x DRG Weight ,27460,,"21,433 x DRG Weight",27460,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,70787,
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,MS-DRG,,,,,,,,inpatient,,,74313.11,11510,,,11510,Other,150% of Medicare + 9.63% HCRA Surcharge,6999.58,,,6999.58,Other,Medicare IPPS methodology,19154,,"25,728 x DRG weight",19154,Other,base rate x DRG weight,17239,,"23,155 x DRG weight",17239,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37157,50,,37157,Percent of Total Billed Charges,50% of Charges,21662,,"29,096 x DRG Weight",21662,Other,base rate x DRG weight,16724,,"22,463 x DRG Weight",16724,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,19674,,"26,426 x DRG Weight",19674,Other,base rate x DRG weight,28893,,"38,809 x DRG Weight",28893,Other,base rate x DRG weight,28893,,"38,809 x DRG Weight",28893,Other,base rate x DRG weight,19674,,"26,426 x DRG Weight",19674,Other,base rate x DRG weight,28893,,"38,809 x DRG Weight",28893,Other,base rate x DRG weight,26349,,"35,391 x DRG Weight",26349,Other,base rate x DRG weight,52019,70,,52019,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18773,,"25,216 X DRG Weight",18773,Other,Base Weight X DRG Weight,16896,,"22,695 X DRG Weight",16896,Other,Base Weight X DRG Weight,18773,,"25,216 X DRG Weight",18773,Other,Base Rate x DRG Weight ,15957,,"21,433 x DRG Weight",15957,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,52019,
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,,inpatient,,,151775.32,12393,,,12393,Other,150% of Medicare + 9.63% HCRA Surcharge,7536.18,,,7536.18,Other,Medicare IPPS methodology,20685,,"25,728 x DRG weight",20685,Other,base rate x DRG weight,18617,,"23,155 x DRG weight",18617,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,75888,50,,75888,Percent of Total Billed Charges,50% of Charges,23393,,"29,096 x DRG Weight",23393,Other,base rate x DRG weight,18060,,"22,463 x DRG Weight",18060,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21247,,"26,426 x DRG Weight",21247,Other,base rate x DRG weight,31202,,"38,809 x DRG Weight",31202,Other,base rate x DRG weight,31202,,"38,809 x DRG Weight",31202,Other,base rate x DRG weight,21247,,"26,426 x DRG Weight",21247,Other,base rate x DRG weight,31202,,"38,809 x DRG Weight",31202,Other,base rate x DRG weight,28454,,"35,391 x DRG Weight",28454,Other,base rate x DRG weight,106243,70,,106243,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20274,,"25,216 X DRG Weight",20274,Other,Base Weight X DRG Weight,18247,,"22,695 X DRG Weight",18247,Other,Base Weight X DRG Weight,20274,,"25,216 X DRG Weight",20274,Other,Base Rate x DRG Weight ,17232,,"21,433 x DRG Weight",17232,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,106243,
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,MS-DRG,,,,,,,,inpatient,,,234515.92,20074,,,20074,Other,150% of Medicare + 9.63% HCRA Surcharge,12206.85,,,12206.85,Other,Medicare IPPS methodology,34010,,"25,728 x DRG weight",34010,Other,base rate x DRG weight,30609,,"23,155 x DRG weight",30609,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,117258,50,,117258,Percent of Total Billed Charges,50% of Charges,38462,,"29,096 x DRG Weight",38462,Other,base rate x DRG weight,29694,,"22,463 x DRG Weight",29694,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,34933,,"26,426 x DRG Weight",34933,Other,base rate x DRG weight,51302,,"38,809 x DRG Weight",51302,Other,base rate x DRG weight,51302,,"38,809 x DRG Weight",51302,Other,base rate x DRG weight,34933,,"26,426 x DRG Weight",34933,Other,base rate x DRG weight,51302,,"38,809 x DRG Weight",51302,Other,base rate x DRG weight,46783,,"35,391 x DRG Weight",46783,Other,base rate x DRG weight,164161,70,,164161,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,33333,,"25,216 X DRG Weight",33333,Other,Base Weight X DRG Weight,30001,,"22,695 X DRG Weight",30001,Other,Base Weight X DRG Weight,33333,,"25,216 X DRG Weight",33333,Other,Base Rate x DRG Weight ,28332,,"21,433 x DRG Weight",28332,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,164161,
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,,inpatient,,,148165.28,12296,,,12296,Other,150% of Medicare + 9.63% HCRA Surcharge,7477.56,,,7477.56,Other,Medicare IPPS methodology,20518,,"25,728 x DRG weight",20518,Other,base rate x DRG weight,18466,,"23,155 x DRG weight",18466,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,74083,50,,74083,Percent of Total Billed Charges,50% of Charges,23204,,"29,096 x DRG Weight",23204,Other,base rate x DRG weight,17914,,"22,463 x DRG Weight",17914,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21075,,"26,426 x DRG Weight",21075,Other,base rate x DRG weight,30950,,"38,809 x DRG Weight",30950,Other,base rate x DRG weight,30950,,"38,809 x DRG Weight",30950,Other,base rate x DRG weight,21075,,"26,426 x DRG Weight",21075,Other,base rate x DRG weight,30950,,"38,809 x DRG Weight",30950,Other,base rate x DRG weight,28224,,"35,391 x DRG Weight",28224,Other,base rate x DRG weight,103716,70,,103716,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20110,,"25,216 X DRG Weight",20110,Other,Base Weight X DRG Weight,18099,,"22,695 X DRG Weight",18099,Other,Base Weight X DRG Weight,20110,,"25,216 X DRG Weight",20110,Other,Base Rate x DRG Weight ,17093,,"21,433 x DRG Weight",17093,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,103716,
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,MS-DRG,,,,,,,,inpatient,,,263085.12,39801,,,39801,Other,150% of Medicare + 9.63% HCRA Surcharge,24203.23,,,24203.23,Other,Medicare IPPS methodology,68233,,"25,728 x DRG weight",68233,Other,base rate x DRG weight,61409,,"23,155 x DRG weight",61409,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,131543,50,,131543,Percent of Total Billed Charges,50% of Charges,77166,,"29,096 x DRG Weight",77166,Other,base rate x DRG weight,59574,,"22,463 x DRG Weight",59574,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,70084,,"26,426 x DRG Weight",70084,Other,base rate x DRG weight,102925,,"38,809 x DRG Weight",102925,Other,base rate x DRG weight,102925,,"38,809 x DRG Weight",102925,Other,base rate x DRG weight,70084,,"26,426 x DRG Weight",70084,Other,base rate x DRG weight,102925,,"38,809 x DRG Weight",102925,Other,base rate x DRG weight,93860,,"35,391 x DRG Weight",93860,Other,base rate x DRG weight,184160,70,,184160,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,66875,,"25,216 X DRG Weight",66875,Other,Base Weight X DRG Weight,60189,,"22,695 X DRG Weight",60189,Other,Base Weight X DRG Weight,66875,,"25,216 X DRG Weight",66875,Other,Base Rate x DRG Weight ,56842,,"21,433 x DRG Weight",56842,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,184160,
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,MS-DRG,,,,,,,,inpatient,,,136004.4,15957,,,15957,Other,150% of Medicare + 9.63% HCRA Surcharge,9703.32,,,9703.32,Other,Medicare IPPS methodology,26868,,"25,728 x DRG weight",26868,Other,base rate x DRG weight,24181,,"23,155 x DRG weight",24181,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,68002,50,,68002,Percent of Total Billed Charges,50% of Charges,30385,,"29,096 x DRG Weight",30385,Other,base rate x DRG weight,23458,,"22,463 x DRG Weight",23458,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,27597,,"26,426 x DRG Weight",27597,Other,base rate x DRG weight,40528,,"38,809 x DRG Weight",40528,Other,base rate x DRG weight,40528,,"38,809 x DRG Weight",40528,Other,base rate x DRG weight,27597,,"26,426 x DRG Weight",27597,Other,base rate x DRG weight,40528,,"38,809 x DRG Weight",40528,Other,base rate x DRG weight,36959,,"35,391 x DRG Weight",36959,Other,base rate x DRG weight,95203,70,,95203,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,26333,,"25,216 X DRG Weight",26333,Other,Base Weight X DRG Weight,23700,,"22,695 X DRG Weight",23700,Other,Base Weight X DRG Weight,26333,,"25,216 X DRG Weight",26333,Other,Base Rate x DRG Weight ,22382,,"21,433 x DRG Weight",22382,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,95203,
MOUTH PROCEDURES WITH CC/MCC,137,MS-DRG,,,,,,,,inpatient,,,174872.07,22785,,,22785,Other,150% of Medicare + 9.63% HCRA Surcharge,13855.43,,,13855.43,Other,Medicare IPPS methodology,38713,,"25,728 x DRG weight",38713,Other,base rate x DRG weight,34841,,"23,155 x DRG weight",34841,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,87436,50,,87436,Percent of Total Billed Charges,50% of Charges,43781,,"29,096 x DRG Weight",43781,Other,base rate x DRG weight,33800,,"22,463 x DRG Weight",33800,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39763,,"26,426 x DRG Weight",39763,Other,base rate x DRG weight,58396,,"38,809 x DRG Weight",58396,Other,base rate x DRG weight,58396,,"38,809 x DRG Weight",58396,Other,base rate x DRG weight,39763,,"26,426 x DRG Weight",39763,Other,base rate x DRG weight,58396,,"38,809 x DRG Weight",58396,Other,base rate x DRG weight,53253,,"35,391 x DRG Weight",53253,Other,base rate x DRG weight,122410,70,,122410,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37943,,"25,216 X DRG Weight",37943,Other,Base Weight X DRG Weight,34149,,"22,695 X DRG Weight",34149,Other,Base Weight X DRG Weight,37943,,"25,216 X DRG Weight",37943,Other,Base Rate x DRG Weight ,32250,,"21,433 x DRG Weight",32250,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,122410,
MOUTH PROCEDURES WITHOUT CC/MCC,138,MS-DRG,,,,,,,,inpatient,,,222907.05,13308,,,13308,Other,150% of Medicare + 9.63% HCRA Surcharge,8092.62,,,8092.62,Other,Medicare IPPS methodology,22273,,"25,728 x DRG weight",22273,Other,base rate x DRG weight,20045,,"23,155 x DRG weight",20045,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,111454,50,,111454,Percent of Total Billed Charges,50% of Charges,25188,,"29,096 x DRG Weight",25188,Other,base rate x DRG weight,19446,,"22,463 x DRG Weight",19446,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,22877,,"26,426 x DRG Weight",22877,Other,base rate x DRG weight,33597,,"38,809 x DRG Weight",33597,Other,base rate x DRG weight,33597,,"38,809 x DRG Weight",33597,Other,base rate x DRG weight,22877,,"26,426 x DRG Weight",22877,Other,base rate x DRG weight,33597,,"38,809 x DRG Weight",33597,Other,base rate x DRG weight,30638,,"35,391 x DRG Weight",30638,Other,base rate x DRG weight,156035,70,,156035,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,21829,,"25,216 X DRG Weight",21829,Other,Base Weight X DRG Weight,19647,,"22,695 X DRG Weight",19647,Other,Base Weight X DRG Weight,21829,,"25,216 X DRG Weight",21829,Other,Base Rate x DRG Weight ,18555,,"21,433 x DRG Weight",18555,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,156035,
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,,inpatient,,,185599.04,18083,,,18083,Other,150% of Medicare + 9.63% HCRA Surcharge,10996.57,,,10996.57,Other,Medicare IPPS methodology,30557,,"25,728 x DRG weight",30557,Other,base rate x DRG weight,27501,,"23,155 x DRG weight",27501,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,92800,50,,92800,Percent of Total Billed Charges,50% of Charges,34557,,"29,096 x DRG Weight",34557,Other,base rate x DRG weight,26679,,"22,463 x DRG Weight",26679,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31386,,"26,426 x DRG Weight",31386,Other,base rate x DRG weight,46093,,"38,809 x DRG Weight",46093,Other,base rate x DRG weight,46093,,"38,809 x DRG Weight",46093,Other,base rate x DRG weight,31386,,"26,426 x DRG Weight",31386,Other,base rate x DRG weight,46093,,"38,809 x DRG Weight",46093,Other,base rate x DRG weight,42034,,"35,391 x DRG Weight",42034,Other,base rate x DRG weight,129919,70,,129919,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,29949,,"25,216 X DRG Weight",29949,Other,Base Weight X DRG Weight,26955,,"22,695 X DRG Weight",26955,Other,Base Weight X DRG Weight,29949,,"25,216 X DRG Weight",29949,Other,Base Rate x DRG Weight ,25456,,"21,433 x DRG Weight",25456,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,129919,
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,MS-DRG,,,,,,,,inpatient,,,540714.02,56500,,,56500,Other,150% of Medicare + 9.63% HCRA Surcharge,34358.04,,,34358.04,Other,Medicare IPPS methodology,97203,,"25,728 x DRG weight",97203,Other,base rate x DRG weight,87482,,"23,155 x DRG weight",87482,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,270357,50,,270357,Percent of Total Billed Charges,50% of Charges,109928,,"29,096 x DRG Weight",109928,Other,base rate x DRG weight,84867,,"22,463 x DRG Weight",84867,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,99840,,"26,426 x DRG Weight",99840,Other,base rate x DRG weight,146624,,"38,809 x DRG Weight",146624,Other,base rate x DRG weight,146624,,"38,809 x DRG Weight",146624,Other,base rate x DRG weight,99840,,"26,426 x DRG Weight",99840,Other,base rate x DRG weight,146624,,"38,809 x DRG Weight",146624,Other,base rate x DRG weight,133711,,"35,391 x DRG Weight",133711,Other,base rate x DRG weight,378500,70,,378500,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,95269,,"25,216 X DRG Weight",95269,Other,Base Weight X DRG Weight,85744,,"22,695 X DRG Weight",85744,Other,Base Weight X DRG Weight,95269,,"25,216 X DRG Weight",95269,Other,Base Rate x DRG Weight ,80976,,"21,433 x DRG Weight",80976,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,378500,
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,MS-DRG,,,,,,,,inpatient,,,305703.48,31193,,,31193,Other,150% of Medicare + 9.63% HCRA Surcharge,18968.91,,,18968.91,Other,Medicare IPPS methodology,53301,,"25,728 x DRG weight",53301,Other,base rate x DRG weight,47970,,"23,155 x DRG weight",47970,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,152852,50,,152852,Percent of Total Billed Charges,50% of Charges,60278,,"29,096 x DRG Weight",60278,Other,base rate x DRG weight,46537,,"22,463 x DRG Weight",46537,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,54747,,"26,426 x DRG Weight",54747,Other,base rate x DRG weight,80401,,"38,809 x DRG Weight",80401,Other,base rate x DRG weight,80401,,"38,809 x DRG Weight",80401,Other,base rate x DRG weight,54747,,"26,426 x DRG Weight",54747,Other,base rate x DRG weight,80401,,"38,809 x DRG Weight",80401,Other,base rate x DRG weight,73320,,"35,391 x DRG Weight",73320,Other,base rate x DRG weight,213992,70,,213992,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,52240,,"25,216 X DRG Weight",52240,Other,Base Weight X DRG Weight,47017,,"22,695 X DRG Weight",47017,Other,Base Weight X DRG Weight,52240,,"25,216 X DRG Weight",52240,Other,Base Rate x DRG Weight ,44403,,"21,433 x DRG Weight",44403,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,213992,
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,MS-DRG,,,,,,,,inpatient,,,151922.26,23382,,,23382,Other,150% of Medicare + 9.63% HCRA Surcharge,14218.87,,,14218.87,Other,Medicare IPPS methodology,39750,,"25,728 x DRG weight",39750,Other,base rate x DRG weight,35774,,"23,155 x DRG weight",35774,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,75961,50,,75961,Percent of Total Billed Charges,50% of Charges,44953,,"29,096 x DRG Weight",44953,Other,base rate x DRG weight,34705,,"22,463 x DRG Weight",34705,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,40828,,"26,426 x DRG Weight",40828,Other,base rate x DRG weight,59960,,"38,809 x DRG Weight",59960,Other,base rate x DRG weight,59960,,"38,809 x DRG Weight",59960,Other,base rate x DRG weight,40828,,"26,426 x DRG Weight",40828,Other,base rate x DRG weight,59960,,"38,809 x DRG Weight",59960,Other,base rate x DRG weight,54679,,"35,391 x DRG Weight",54679,Other,base rate x DRG weight,106346,70,,106346,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,38959,,"25,216 X DRG Weight",38959,Other,Base Weight X DRG Weight,35064,,"22,695 X DRG Weight",35064,Other,Base Weight X DRG Weight,38959,,"25,216 X DRG Weight",38959,Other,Base Rate x DRG Weight ,33114,,"21,433 x DRG Weight",33114,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,106346,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,MS-DRG,,,,,,,,inpatient,,,298063.22,49789,,,49789,Other,150% of Medicare + 9.63% HCRA Surcharge,30277.18,,,30277.18,Other,Medicare IPPS methodology,85561,,"25,728 x DRG weight",85561,Other,base rate x DRG weight,77004,,"23,155 x DRG weight",77004,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,149032,50,,149032,Percent of Total Billed Charges,50% of Charges,96762,,"29,096 x DRG Weight",96762,Other,base rate x DRG weight,74703,,"22,463 x DRG Weight",74703,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,87882,,"26,426 x DRG Weight",87882,Other,base rate x DRG weight,129063,,"38,809 x DRG Weight",129063,Other,base rate x DRG weight,129063,,"38,809 x DRG Weight",129063,Other,base rate x DRG weight,87882,,"26,426 x DRG Weight",87882,Other,base rate x DRG weight,129063,,"38,809 x DRG Weight",129063,Other,base rate x DRG weight,117696,,"35,391 x DRG Weight",117696,Other,base rate x DRG weight,208644,70,,208644,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,83858,,"25,216 X DRG Weight",83858,Other,Base Weight X DRG Weight,75474,,"22,695 X DRG Weight",75474,Other,Base Weight X DRG Weight,83858,,"25,216 X DRG Weight",83858,Other,Base Rate x DRG Weight ,71278,,"21,433 x DRG Weight",71278,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,208644,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,MS-DRG,,,,,,,,inpatient,,,116858.05,26133,,,26133,Other,150% of Medicare + 9.63% HCRA Surcharge,15891.8,,,15891.8,Other,Medicare IPPS methodology,44522,,"25,728 x DRG weight",44522,Other,base rate x DRG weight,40070,,"23,155 x DRG weight",40070,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,58429,50,,58429,Percent of Total Billed Charges,50% of Charges,50351,,"29,096 x DRG Weight",50351,Other,base rate x DRG weight,38872,,"22,463 x DRG Weight",38872,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,45730,,"26,426 x DRG Weight",45730,Other,base rate x DRG weight,67159,,"38,809 x DRG Weight",67159,Other,base rate x DRG weight,67159,,"38,809 x DRG Weight",67159,Other,base rate x DRG weight,45730,,"26,426 x DRG Weight",45730,Other,base rate x DRG weight,67159,,"38,809 x DRG Weight",67159,Other,base rate x DRG weight,61244,,"35,391 x DRG Weight",61244,Other,base rate x DRG weight,81801,70,,81801,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43636,,"25,216 X DRG Weight",43636,Other,Base Weight X DRG Weight,39274,,"22,695 X DRG Weight",39274,Other,Base Weight X DRG Weight,43636,,"25,216 X DRG Weight",43636,Other,Base Rate x DRG Weight ,37090,,"21,433 x DRG Weight",37090,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,81801,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,MS-DRG,,,,,,,,inpatient,,,71466.59,18579,,,18579,Other,150% of Medicare + 9.63% HCRA Surcharge,11297.79,,,11297.79,Other,Medicare IPPS methodology,31416,,"25,728 x DRG weight",31416,Other,base rate x DRG weight,28275,,"23,155 x DRG weight",28275,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35733,50,,35733,Percent of Total Billed Charges,50% of Charges,35529,,"29,096 x DRG Weight",35529,Other,base rate x DRG weight,27430,,"22,463 x DRG Weight",27430,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,32269,,"26,426 x DRG Weight",32269,Other,base rate x DRG weight,47390,,"38,809 x DRG Weight",47390,Other,base rate x DRG weight,47390,,"38,809 x DRG Weight",47390,Other,base rate x DRG weight,32269,,"26,426 x DRG Weight",32269,Other,base rate x DRG weight,47390,,"38,809 x DRG Weight",47390,Other,base rate x DRG weight,43216,,"35,391 x DRG Weight",43216,Other,base rate x DRG weight,50027,70,,50027,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,30791,,"25,216 X DRG Weight",30791,Other,Base Weight X DRG Weight,27713,,"22,695 X DRG Weight",27713,Other,Base Weight X DRG Weight,30791,,"25,216 X DRG Weight",30791,Other,Base Rate x DRG Weight ,26172,,"21,433 x DRG Weight",26172,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,50027,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,,inpatient,,,242841.51,31776,,,31776,Other,150% of Medicare + 9.63% HCRA Surcharge,19323.33,,,19323.33,Other,Medicare IPPS methodology,54312,,"25,728 x DRG weight",54312,Other,base rate x DRG weight,48880,,"23,155 x DRG weight",48880,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,121421,50,,121421,Percent of Total Billed Charges,50% of Charges,61422,,"29,096 x DRG Weight",61422,Other,base rate x DRG weight,47419,,"22,463 x DRG Weight",47419,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,55785,,"26,426 x DRG Weight",55785,Other,base rate x DRG weight,81926,,"38,809 x DRG Weight",81926,Other,base rate x DRG weight,81926,,"38,809 x DRG Weight",81926,Other,base rate x DRG weight,55785,,"26,426 x DRG Weight",55785,Other,base rate x DRG weight,81926,,"38,809 x DRG Weight",81926,Other,base rate x DRG weight,74710,,"35,391 x DRG Weight",74710,Other,base rate x DRG weight,169989,70,,169989,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,53231,,"25,216 X DRG Weight",53231,Other,Base Weight X DRG Weight,47909,,"22,695 X DRG Weight",47909,Other,Base Weight X DRG Weight,53231,,"25,216 X DRG Weight",53231,Other,Base Rate x DRG Weight ,45245,,"21,433 x DRG Weight",45245,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,169989,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,,inpatient,,,195187.52,18797,,,18797,Other,150% of Medicare + 9.63% HCRA Surcharge,11430.36,,,11430.36,Other,Medicare IPPS methodology,31795,,"25,728 x DRG weight",31795,Other,base rate x DRG weight,28615,,"23,155 x DRG weight",28615,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,97594,50,,97594,Percent of Total Billed Charges,50% of Charges,35957,,"29,096 x DRG Weight",35957,Other,base rate x DRG weight,27760,,"22,463 x DRG Weight",27760,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,32657,,"26,426 x DRG Weight",32657,Other,base rate x DRG weight,47960,,"38,809 x DRG Weight",47960,Other,base rate x DRG weight,47960,,"38,809 x DRG Weight",47960,Other,base rate x DRG weight,32657,,"26,426 x DRG Weight",32657,Other,base rate x DRG weight,47960,,"38,809 x DRG Weight",47960,Other,base rate x DRG weight,43736,,"35,391 x DRG Weight",43736,Other,base rate x DRG weight,136631,70,,136631,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,31162,,"25,216 X DRG Weight",31162,Other,Base Weight X DRG Weight,28046,,"22,695 X DRG Weight",28046,Other,Base Weight X DRG Weight,31162,,"25,216 X DRG Weight",31162,Other,Base Rate x DRG Weight ,26487,,"21,433 x DRG Weight",26487,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,136631,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,MS-DRG,,,,,,,,inpatient,,,106260,13664,,,13664,Other,150% of Medicare + 9.63% HCRA Surcharge,8309.06,,,8309.06,Other,Medicare IPPS methodology,22890,,"25,728 x DRG weight",22890,Other,base rate x DRG weight,20601,,"23,155 x DRG weight",20601,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,53130,50,,53130,Percent of Total Billed Charges,50% of Charges,25887,,"29,096 x DRG Weight",25887,Other,base rate x DRG weight,19985,,"22,463 x DRG Weight",19985,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23511,,"26,426 x DRG Weight",23511,Other,base rate x DRG weight,34528,,"38,809 x DRG Weight",34528,Other,base rate x DRG weight,34528,,"38,809 x DRG Weight",34528,Other,base rate x DRG weight,23511,,"26,426 x DRG Weight",23511,Other,base rate x DRG weight,34528,,"38,809 x DRG Weight",34528,Other,base rate x DRG weight,31487,,"35,391 x DRG Weight",31487,Other,base rate x DRG weight,74382,70,,74382,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22435,,"25,216 X DRG Weight",22435,Other,Base Weight X DRG Weight,20192,,"22,695 X DRG Weight",20192,Other,Base Weight X DRG Weight,22435,,"25,216 X DRG Weight",22435,Other,Base Rate x DRG Weight ,19069,,"21,433 x DRG Weight",19069,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,74382,
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,,inpatient,,,119203.93,11513,,,11513,Other,150% of Medicare + 9.63% HCRA Surcharge,7001.38,,,7001.38,Other,Medicare IPPS methodology,19160,,"25,728 x DRG weight",19160,Other,base rate x DRG weight,17244,,"23,155 x DRG weight",17244,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,59602,50,,59602,Percent of Total Billed Charges,50% of Charges,21668,,"29,096 x DRG Weight",21668,Other,base rate x DRG weight,16728,,"22,463 x DRG Weight",16728,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,19679,,"26,426 x DRG Weight",19679,Other,base rate x DRG weight,28901,,"38,809 x DRG Weight",28901,Other,base rate x DRG weight,28901,,"38,809 x DRG Weight",28901,Other,base rate x DRG weight,19679,,"26,426 x DRG Weight",19679,Other,base rate x DRG weight,28901,,"38,809 x DRG Weight",28901,Other,base rate x DRG weight,26356,,"35,391 x DRG Weight",26356,Other,base rate x DRG weight,83443,70,,83443,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18778,,"25,216 X DRG Weight",18778,Other,Base Weight X DRG Weight,16901,,"22,695 X DRG Weight",16901,Other,Base Weight X DRG Weight,18778,,"25,216 X DRG Weight",18778,Other,Base Rate x DRG Weight ,15961,,"21,433 x DRG Weight",15961,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,83443,
EPISTAXIS WITH MCC,150,MS-DRG,,,,,,,,inpatient,,,211777.46,19964,,,19964,Other,150% of Medicare + 9.63% HCRA Surcharge,12140.11,,,12140.11,Other,Medicare IPPS methodology,33819,,"25,728 x DRG weight",33819,Other,base rate x DRG weight,30437,,"23,155 x DRG weight",30437,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,105889,50,,105889,Percent of Total Billed Charges,50% of Charges,38247,,"29,096 x DRG Weight",38247,Other,base rate x DRG weight,29528,,"22,463 x DRG Weight",29528,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,34737,,"26,426 x DRG Weight",34737,Other,base rate x DRG weight,51014,,"38,809 x DRG Weight",51014,Other,base rate x DRG weight,51014,,"38,809 x DRG Weight",51014,Other,base rate x DRG weight,34737,,"26,426 x DRG Weight",34737,Other,base rate x DRG weight,51014,,"38,809 x DRG Weight",51014,Other,base rate x DRG weight,46521,,"35,391 x DRG Weight",46521,Other,base rate x DRG weight,148244,70,,148244,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,33146,,"25,216 X DRG Weight",33146,Other,Base Weight X DRG Weight,29833,,"22,695 X DRG Weight",29833,Other,Base Weight X DRG Weight,33146,,"25,216 X DRG Weight",33146,Other,Base Rate x DRG Weight ,28174,,"21,433 x DRG Weight",28174,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,148244,
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,,inpatient,,,79887.08,11899,,,11899,Other,150% of Medicare + 9.63% HCRA Surcharge,7235.86,,,7235.86,Other,Medicare IPPS methodology,19829,,"25,728 x DRG weight",19829,Other,base rate x DRG weight,17846,,"23,155 x DRG weight",17846,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39944,50,,39944,Percent of Total Billed Charges,50% of Charges,22424,,"29,096 x DRG Weight",22424,Other,base rate x DRG weight,17312,,"22,463 x DRG Weight",17312,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,20367,,"26,426 x DRG Weight",20367,Other,base rate x DRG weight,29910,,"38,809 x DRG Weight",29910,Other,base rate x DRG weight,29910,,"38,809 x DRG Weight",29910,Other,base rate x DRG weight,20367,,"26,426 x DRG Weight",20367,Other,base rate x DRG weight,29910,,"38,809 x DRG Weight",29910,Other,base rate x DRG weight,27276,,"35,391 x DRG Weight",27276,Other,base rate x DRG weight,55921,70,,55921,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19434,,"25,216 X DRG Weight",19434,Other,Base Weight X DRG Weight,17491,,"22,695 X DRG Weight",17491,Other,Base Weight X DRG Weight,19434,,"25,216 X DRG Weight",19434,Other,Base Rate x DRG Weight ,16518,,"21,433 x DRG Weight",16518,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,55921,
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,,inpatient,,,79823.68,18091,,,18091,Other,150% of Medicare + 9.63% HCRA Surcharge,11001.08,,,11001.08,Other,Medicare IPPS methodology,30570,,"25,728 x DRG weight",30570,Other,base rate x DRG weight,27513,,"23,155 x DRG weight",27513,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39912,50,,39912,Percent of Total Billed Charges,50% of Charges,34572,,"29,096 x DRG Weight",34572,Other,base rate x DRG weight,26691,,"22,463 x DRG Weight",26691,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31399,,"26,426 x DRG Weight",31399,Other,base rate x DRG weight,46113,,"38,809 x DRG Weight",46113,Other,base rate x DRG weight,46113,,"38,809 x DRG Weight",46113,Other,base rate x DRG weight,31399,,"26,426 x DRG Weight",31399,Other,base rate x DRG weight,46113,,"38,809 x DRG Weight",46113,Other,base rate x DRG weight,42052,,"35,391 x DRG Weight",42052,Other,base rate x DRG weight,55877,70,,55877,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,29962,,"25,216 X DRG Weight",29962,Other,Base Weight X DRG Weight,26966,,"22,695 X DRG Weight",26966,Other,Base Weight X DRG Weight,29962,,"25,216 X DRG Weight",29962,Other,Base Rate x DRG Weight ,25467,,"21,433 x DRG Weight",25467,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,55877,
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,,inpatient,,,64792.2,11367,,,11367,Other,150% of Medicare + 9.63% HCRA Surcharge,6912.1,,,6912.1,Other,Medicare IPPS methodology,18905,,"25,728 x DRG weight",18905,Other,base rate x DRG weight,17014,,"23,155 x DRG weight",17014,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32396,50,,32396,Percent of Total Billed Charges,50% of Charges,21380,,"29,096 x DRG Weight",21380,Other,base rate x DRG weight,16506,,"22,463 x DRG Weight",16506,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,19418,,"26,426 x DRG Weight",19418,Other,base rate x DRG weight,28517,,"38,809 x DRG Weight",28517,Other,base rate x DRG weight,28517,,"38,809 x DRG Weight",28517,Other,base rate x DRG weight,19418,,"26,426 x DRG Weight",19418,Other,base rate x DRG weight,28517,,"38,809 x DRG Weight",28517,Other,base rate x DRG weight,26005,,"35,391 x DRG Weight",26005,Other,base rate x DRG weight,45355,70,,45355,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18529,,"25,216 X DRG Weight",18529,Other,Base Weight X DRG Weight,16676,,"22,695 X DRG Weight",16676,Other,Base Weight X DRG Weight,18529,,"25,216 X DRG Weight",18529,Other,Base Rate x DRG Weight ,15749,,"21,433 x DRG Weight",15749,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,45355,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,,inpatient,,,260488.17,23281,,,23281,Other,150% of Medicare + 9.63% HCRA Surcharge,14157.55,,,14157.55,Other,Medicare IPPS methodology,39575,,"25,728 x DRG weight",39575,Other,base rate x DRG weight,35617,,"23,155 x DRG weight",35617,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,130244,50,,130244,Percent of Total Billed Charges,50% of Charges,44755,,"29,096 x DRG Weight",44755,Other,base rate x DRG weight,34553,,"22,463 x DRG Weight",34553,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,40648,,"26,426 x DRG Weight",40648,Other,base rate x DRG weight,59696,,"38,809 x DRG Weight",59696,Other,base rate x DRG weight,59696,,"38,809 x DRG Weight",59696,Other,base rate x DRG weight,40648,,"26,426 x DRG Weight",40648,Other,base rate x DRG weight,59696,,"38,809 x DRG Weight",59696,Other,base rate x DRG weight,54438,,"35,391 x DRG Weight",54438,Other,base rate x DRG weight,182342,70,,182342,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,38787,,"25,216 X DRG Weight",38787,Other,Base Weight X DRG Weight,34909,,"22,695 X DRG Weight",34909,Other,Base Weight X DRG Weight,38787,,"25,216 X DRG Weight",38787,Other,Base Rate x DRG Weight ,32968,,"21,433 x DRG Weight",32968,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,182342,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,,inpatient,,,112500.78,14508,,,14508,Other,150% of Medicare + 9.63% HCRA Surcharge,8822.21,,,8822.21,Other,Medicare IPPS methodology,24354,,"25,728 x DRG weight",24354,Other,base rate x DRG weight,21919,,"23,155 x DRG weight",21919,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,56250,50,,56250,Percent of Total Billed Charges,50% of Charges,27542,,"29,096 x DRG Weight",27542,Other,base rate x DRG weight,21263,,"22,463 x DRG Weight",21263,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,25015,,"26,426 x DRG Weight",25015,Other,base rate x DRG weight,36737,,"38,809 x DRG Weight",36737,Other,base rate x DRG weight,36737,,"38,809 x DRG Weight",36737,Other,base rate x DRG weight,25015,,"26,426 x DRG Weight",25015,Other,base rate x DRG weight,36737,,"38,809 x DRG Weight",36737,Other,base rate x DRG weight,33501,,"35,391 x DRG Weight",33501,Other,base rate x DRG weight,78751,70,,78751,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,23869,,"25,216 X DRG Weight",23869,Other,Base Weight X DRG Weight,21483,,"22,695 X DRG Weight",21483,Other,Base Weight X DRG Weight,23869,,"25,216 X DRG Weight",23869,Other,Base Rate x DRG Weight ,20288,,"21,433 x DRG Weight",20288,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,78751,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,,inpatient,,,72738.95,10191,,,10191,Other,150% of Medicare + 9.63% HCRA Surcharge,6196.93,,,6196.93,Other,Medicare IPPS methodology,16865,,"25,728 x DRG weight",16865,Other,base rate x DRG weight,15178,,"23,155 x DRG weight",15178,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,36369,50,,36369,Percent of Total Billed Charges,50% of Charges,19072,,"29,096 x DRG Weight",19072,Other,base rate x DRG weight,14724,,"22,463 x DRG Weight",14724,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,17322,,"26,426 x DRG Weight",17322,Other,base rate x DRG weight,25439,,"38,809 x DRG Weight",25439,Other,base rate x DRG weight,25439,,"38,809 x DRG Weight",25439,Other,base rate x DRG weight,17322,,"26,426 x DRG Weight",17322,Other,base rate x DRG weight,25439,,"38,809 x DRG Weight",25439,Other,base rate x DRG weight,23199,,"35,391 x DRG Weight",23199,Other,base rate x DRG weight,50917,70,,50917,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,16529,,"25,216 X DRG Weight",16529,Other,Base Weight X DRG Weight,14877,,"22,695 X DRG Weight",14877,Other,Base Weight X DRG Weight,16529,,"25,216 X DRG Weight",16529,Other,Base Rate x DRG Weight ,14049,,"21,433 x DRG Weight",14049,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,50917,
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,,inpatient,,,131007.38,25785,,,25785,Other,150% of Medicare + 9.63% HCRA Surcharge,15679.87,,,15679.87,Other,Medicare IPPS methodology,43918,,"25,728 x DRG weight",43918,Other,base rate x DRG weight,39526,,"23,155 x DRG weight",39526,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,65504,50,,65504,Percent of Total Billed Charges,50% of Charges,49667,,"29,096 x DRG Weight",49667,Other,base rate x DRG weight,38344,,"22,463 x DRG Weight",38344,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,45109,,"26,426 x DRG Weight",45109,Other,base rate x DRG weight,66247,,"38,809 x DRG Weight",66247,Other,base rate x DRG weight,66247,,"38,809 x DRG Weight",66247,Other,base rate x DRG weight,45109,,"26,426 x DRG Weight",45109,Other,base rate x DRG weight,66247,,"38,809 x DRG Weight",66247,Other,base rate x DRG weight,60412,,"35,391 x DRG Weight",60412,Other,base rate x DRG weight,91705,70,,91705,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43044,,"25,216 X DRG Weight",43044,Other,Base Weight X DRG Weight,38740,,"22,695 X DRG Weight",38740,Other,Base Weight X DRG Weight,43044,,"25,216 X DRG Weight",43044,Other,Base Rate x DRG Weight ,36586,,"21,433 x DRG Weight",36586,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,91705,
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,,inpatient,,,144648.14,14388,,,14388,Other,150% of Medicare + 9.63% HCRA Surcharge,8749.16,,,8749.16,Other,Medicare IPPS methodology,24146,,"25,728 x DRG weight",24146,Other,base rate x DRG weight,21731,,"23,155 x DRG weight",21731,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,72324,50,,72324,Percent of Total Billed Charges,50% of Charges,27307,,"29,096 x DRG Weight",27307,Other,base rate x DRG weight,21082,,"22,463 x DRG Weight",21082,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,24801,,"26,426 x DRG Weight",24801,Other,base rate x DRG weight,36422,,"38,809 x DRG Weight",36422,Other,base rate x DRG weight,36422,,"38,809 x DRG Weight",36422,Other,base rate x DRG weight,24801,,"26,426 x DRG Weight",24801,Other,base rate x DRG weight,36422,,"38,809 x DRG Weight",36422,Other,base rate x DRG weight,33214,,"35,391 x DRG Weight",33214,Other,base rate x DRG weight,101254,70,,101254,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,23665,,"25,216 X DRG Weight",23665,Other,Base Weight X DRG Weight,21299,,"22,695 X DRG Weight",21299,Other,Base Weight X DRG Weight,23665,,"25,216 X DRG Weight",23665,Other,Base Rate x DRG Weight ,20115,,"21,433 x DRG Weight",20115,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,101254,
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,MS-DRG,,,,,,,,inpatient,,,79825.68,10483,,,10483,Other,150% of Medicare + 9.63% HCRA Surcharge,6374.6,,,6374.6,Other,Medicare IPPS methodology,17372,,"25,728 x DRG weight",17372,Other,base rate x DRG weight,15634,,"23,155 x DRG weight",15634,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39913,50,,39913,Percent of Total Billed Charges,50% of Charges,19646,,"29,096 x DRG Weight",19646,Other,base rate x DRG weight,15167,,"22,463 x DRG Weight",15167,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,17843,,"26,426 x DRG Weight",17843,Other,base rate x DRG weight,26204,,"38,809 x DRG Weight",26204,Other,base rate x DRG weight,26204,,"38,809 x DRG Weight",26204,Other,base rate x DRG weight,17843,,"26,426 x DRG Weight",17843,Other,base rate x DRG weight,26204,,"38,809 x DRG Weight",26204,Other,base rate x DRG weight,23896,,"35,391 x DRG Weight",23896,Other,base rate x DRG weight,55878,70,,55878,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,17026,,"25,216 X DRG Weight",17026,Other,Base Weight X DRG Weight,15324,,"22,695 X DRG Weight",15324,Other,Base Weight X DRG Weight,17026,,"25,216 X DRG Weight",17026,Other,Base Rate x DRG Weight ,14472,,"21,433 x DRG Weight",14472,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,55878,
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,,inpatient,,,582271.14,70374,,,70374,Other,150% of Medicare + 9.63% HCRA Surcharge,42794.83,,,42794.83,Other,Medicare IPPS methodology,121272,,"25,728 x DRG weight",121272,Other,base rate x DRG weight,109143,,"23,155 x DRG weight",109143,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,291136,50,,291136,Percent of Total Billed Charges,50% of Charges,137147,,"29,096 x DRG Weight",137147,Other,base rate x DRG weight,105882,,"22,463 x DRG Weight",105882,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,124562,,"26,426 x DRG Weight",124562,Other,base rate x DRG weight,182930,,"38,809 x DRG Weight",182930,Other,base rate x DRG weight,182930,,"38,809 x DRG Weight",182930,Other,base rate x DRG weight,124562,,"26,426 x DRG Weight",124562,Other,base rate x DRG weight,182930,,"38,809 x DRG Weight",182930,Other,base rate x DRG weight,166819,,"35,391 x DRG Weight",166819,Other,base rate x DRG weight,407590,70,,407590,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,118858,,"25,216 X DRG Weight",118858,Other,Base Weight X DRG Weight,106975,,"22,695 X DRG Weight",106975,Other,Base Weight X DRG Weight,118858,,"25,216 X DRG Weight",118858,Other,Base Rate x DRG Weight ,101027,,"21,433 x DRG Weight",101027,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,407590,
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,,inpatient,,,292149.29,38293,,,38293,Other,150% of Medicare + 9.63% HCRA Surcharge,23286.05,,,23286.05,Other,Medicare IPPS methodology,65617,,"25,728 x DRG weight",65617,Other,base rate x DRG weight,59055,,"23,155 x DRG weight",59055,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,146075,50,,146075,Percent of Total Billed Charges,50% of Charges,74206,,"29,096 x DRG Weight",74206,Other,base rate x DRG weight,57290,,"22,463 x DRG Weight",57290,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,67397,,"26,426 x DRG Weight",67397,Other,base rate x DRG weight,98978,,"38,809 x DRG Weight",98978,Other,base rate x DRG weight,98978,,"38,809 x DRG Weight",98978,Other,base rate x DRG weight,67397,,"26,426 x DRG Weight",67397,Other,base rate x DRG weight,98978,,"38,809 x DRG Weight",98978,Other,base rate x DRG weight,90261,,"35,391 x DRG Weight",90261,Other,base rate x DRG weight,204505,70,,204505,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,64311,,"25,216 X DRG Weight",64311,Other,Base Weight X DRG Weight,57881,,"22,695 X DRG Weight",57881,Other,Base Weight X DRG Weight,64311,,"25,216 X DRG Weight",64311,Other,Base Rate x DRG Weight ,54663,,"21,433 x DRG Weight",54663,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,204505,
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,,inpatient,,,176343.39,28297,,,28297,Other,150% of Medicare + 9.63% HCRA Surcharge,17207.6,,,17207.6,Other,Medicare IPPS methodology,48276,,"25,728 x DRG weight",48276,Other,base rate x DRG weight,43448,,"23,155 x DRG weight",43448,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,88172,50,,88172,Percent of Total Billed Charges,50% of Charges,54596,,"29,096 x DRG Weight",54596,Other,base rate x DRG weight,42150,,"22,463 x DRG Weight",42150,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,49586,,"26,426 x DRG Weight",49586,Other,base rate x DRG weight,72821,,"38,809 x DRG Weight",72821,Other,base rate x DRG weight,72821,,"38,809 x DRG Weight",72821,Other,base rate x DRG weight,49586,,"26,426 x DRG Weight",49586,Other,base rate x DRG weight,72821,,"38,809 x DRG Weight",72821,Other,base rate x DRG weight,66408,,"35,391 x DRG Weight",66408,Other,base rate x DRG weight,123440,70,,123440,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,47315,,"25,216 X DRG Weight",47315,Other,Base Weight X DRG Weight,42585,,"22,695 X DRG Weight",42585,Other,Base Weight X DRG Weight,47315,,"25,216 X DRG Weight",47315,Other,Base Rate x DRG Weight ,40217,,"21,433 x DRG Weight",40217,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,123440,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,,inpatient,,,460006.21,60648,,,60648,Other,150% of Medicare + 9.63% HCRA Surcharge,36880.51,,,36880.51,Other,Medicare IPPS methodology,104399,,"25,728 x DRG weight",104399,Other,base rate x DRG weight,93958,,"23,155 x DRG weight",93958,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,230003,50,,230003,Percent of Total Billed Charges,50% of Charges,118066,,"29,096 x DRG Weight",118066,Other,base rate x DRG weight,91150,,"22,463 x DRG Weight",91150,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,107231,,"26,426 x DRG Weight",107231,Other,base rate x DRG weight,157479,,"38,809 x DRG Weight",157479,Other,base rate x DRG weight,157479,,"38,809 x DRG Weight",157479,Other,base rate x DRG weight,107231,,"26,426 x DRG Weight",107231,Other,base rate x DRG weight,157479,,"38,809 x DRG Weight",157479,Other,base rate x DRG weight,143610,,"35,391 x DRG Weight",143610,Other,base rate x DRG weight,322004,70,,322004,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,102321,,"25,216 X DRG Weight",102321,Other,Base Weight X DRG Weight,92092,,"22,695 X DRG Weight",92092,Other,Base Weight X DRG Weight,102321,,"25,216 X DRG Weight",102321,Other,Base Rate x DRG Weight ,86971,,"21,433 x DRG Weight",86971,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,322004,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,,inpatient,,,225094.23,27458,,,27458,Other,150% of Medicare + 9.63% HCRA Surcharge,16697.15,,,16697.15,Other,Medicare IPPS methodology,46820,,"25,728 x DRG weight",46820,Other,base rate x DRG weight,42137,,"23,155 x DRG weight",42137,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,112547,50,,112547,Percent of Total Billed Charges,50% of Charges,52949,,"29,096 x DRG Weight",52949,Other,base rate x DRG weight,40878,,"22,463 x DRG Weight",40878,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,48090,,"26,426 x DRG Weight",48090,Other,base rate x DRG weight,70625,,"38,809 x DRG Weight",70625,Other,base rate x DRG weight,70625,,"38,809 x DRG Weight",70625,Other,base rate x DRG weight,48090,,"26,426 x DRG Weight",48090,Other,base rate x DRG weight,70625,,"38,809 x DRG Weight",70625,Other,base rate x DRG weight,64405,,"35,391 x DRG Weight",64405,Other,base rate x DRG weight,157566,70,,157566,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,45888,,"25,216 X DRG Weight",45888,Other,Base Weight X DRG Weight,41300,,"22,695 X DRG Weight",41300,Other,Base Weight X DRG Weight,45888,,"25,216 X DRG Weight",45888,Other,Base Rate x DRG Weight ,39004,,"21,433 x DRG Weight",39004,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,157566,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,MS-DRG,,,,,,,,inpatient,,,182152.28,20575,,,20575,Other,150% of Medicare + 9.63% HCRA Surcharge,12511.67,,,12511.67,Other,Medicare IPPS methodology,34879,,"25,728 x DRG weight",34879,Other,base rate x DRG weight,31391,,"23,155 x DRG weight",31391,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,91076,50,,91076,Percent of Total Billed Charges,50% of Charges,39445,,"29,096 x DRG Weight",39445,Other,base rate x DRG weight,30453,,"22,463 x DRG Weight",30453,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,35826,,"26,426 x DRG Weight",35826,Other,base rate x DRG weight,52613,,"38,809 x DRG Weight",52613,Other,base rate x DRG weight,52613,,"38,809 x DRG Weight",52613,Other,base rate x DRG weight,35826,,"26,426 x DRG Weight",35826,Other,base rate x DRG weight,52613,,"38,809 x DRG Weight",52613,Other,base rate x DRG weight,47980,,"35,391 x DRG Weight",47980,Other,base rate x DRG weight,127507,70,,127507,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,34185,,"25,216 X DRG Weight",34185,Other,Base Weight X DRG Weight,30768,,"22,695 X DRG Weight",30768,Other,Base Weight X DRG Weight,34185,,"25,216 X DRG Weight",34185,Other,Base Rate x DRG Weight ,29057,,"21,433 x DRG Weight",29057,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,127507,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,MS-DRG,,,,,,,,inpatient,,,244798.28,46073,,,46073,Other,150% of Medicare + 9.63% HCRA Surcharge,28017.15,,,28017.15,Other,Medicare IPPS methodology,79114,,"25,728 x DRG weight",79114,Other,base rate x DRG weight,71202,,"23,155 x DRG weight",71202,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,122399,50,,122399,Percent of Total Billed Charges,50% of Charges,89470,,"29,096 x DRG Weight",89470,Other,base rate x DRG weight,69074,,"22,463 x DRG Weight",69074,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,81260,,"26,426 x DRG Weight",81260,Other,base rate x DRG weight,119338,,"38,809 x DRG Weight",119338,Other,base rate x DRG weight,119338,,"38,809 x DRG Weight",119338,Other,base rate x DRG weight,81260,,"26,426 x DRG Weight",81260,Other,base rate x DRG weight,119338,,"38,809 x DRG Weight",119338,Other,base rate x DRG weight,108827,,"35,391 x DRG Weight",108827,Other,base rate x DRG weight,171359,70,,171359,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,77539,,"25,216 X DRG Weight",77539,Other,Base Weight X DRG Weight,69787,,"22,695 X DRG Weight",69787,Other,Base Weight X DRG Weight,77539,,"25,216 X DRG Weight",77539,Other,Base Rate x DRG Weight ,65906,,"21,433 x DRG Weight",65906,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,171359,
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,,inpatient,,,216094.4,21276,,,21276,Other,150% of Medicare + 9.63% HCRA Surcharge,12938.25,,,12938.25,Other,Medicare IPPS methodology,36096,,"25,728 x DRG weight",36096,Other,base rate x DRG weight,32486,,"23,155 x DRG weight",32486,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,108047,50,,108047,Percent of Total Billed Charges,50% of Charges,40822,,"29,096 x DRG Weight",40822,Other,base rate x DRG weight,31516,,"22,463 x DRG Weight",31516,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,37076,,"26,426 x DRG Weight",37076,Other,base rate x DRG weight,54449,,"38,809 x DRG Weight",54449,Other,base rate x DRG weight,54449,,"38,809 x DRG Weight",54449,Other,base rate x DRG weight,37076,,"26,426 x DRG Weight",37076,Other,base rate x DRG weight,54449,,"38,809 x DRG Weight",54449,Other,base rate x DRG weight,49654,,"35,391 x DRG Weight",49654,Other,base rate x DRG weight,151266,70,,151266,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35378,,"25,216 X DRG Weight",35378,Other,Base Weight X DRG Weight,31841,,"22,695 X DRG Weight",31841,Other,Base Weight X DRG Weight,35378,,"25,216 X DRG Weight",35378,Other,Base Rate x DRG Weight ,30070,,"21,433 x DRG Weight",30070,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,151266,
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,,inpatient,,,136811.29,12565,,,12565,Other,150% of Medicare + 9.63% HCRA Surcharge,7640.79,,,7640.79,Other,Medicare IPPS methodology,20984,,"25,728 x DRG weight",20984,Other,base rate x DRG weight,18885,,"23,155 x DRG weight",18885,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,68406,50,,68406,Percent of Total Billed Charges,50% of Charges,23731,,"29,096 x DRG Weight",23731,Other,base rate x DRG weight,18321,,"22,463 x DRG Weight",18321,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21553,,"26,426 x DRG Weight",21553,Other,base rate x DRG weight,31653,,"38,809 x DRG Weight",31653,Other,base rate x DRG weight,31653,,"38,809 x DRG Weight",31653,Other,base rate x DRG weight,21553,,"26,426 x DRG Weight",21553,Other,base rate x DRG weight,31653,,"38,809 x DRG Weight",31653,Other,base rate x DRG weight,28865,,"35,391 x DRG Weight",28865,Other,base rate x DRG weight,95768,70,,95768,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20566,,"25,216 X DRG Weight",20566,Other,Base Weight X DRG Weight,18510,,"22,695 X DRG Weight",18510,Other,Base Weight X DRG Weight,20566,,"25,216 X DRG Weight",20566,Other,Base Rate x DRG Weight ,17481,,"21,433 x DRG Weight",17481,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,95768,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,,inpatient,,,205105.76,25628,,,25628,Other,150% of Medicare + 9.63% HCRA Surcharge,15584.27,,,15584.27,Other,Medicare IPPS methodology,43645,,"25,728 x DRG weight",43645,Other,base rate x DRG weight,39280,,"23,155 x DRG weight",39280,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,102553,50,,102553,Percent of Total Billed Charges,50% of Charges,49358,,"29,096 x DRG Weight",49358,Other,base rate x DRG weight,38106,,"22,463 x DRG Weight",38106,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,44829,,"26,426 x DRG Weight",44829,Other,base rate x DRG weight,65836,,"38,809 x DRG Weight",65836,Other,base rate x DRG weight,65836,,"38,809 x DRG Weight",65836,Other,base rate x DRG weight,44829,,"26,426 x DRG Weight",44829,Other,base rate x DRG weight,65836,,"38,809 x DRG Weight",65836,Other,base rate x DRG weight,60037,,"35,391 x DRG Weight",60037,Other,base rate x DRG weight,143574,70,,143574,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,42776,,"25,216 X DRG Weight",42776,Other,Base Weight X DRG Weight,38500,,"22,695 X DRG Weight",38500,Other,Base Weight X DRG Weight,42776,,"25,216 X DRG Weight",42776,Other,Base Rate x DRG Weight ,36359,,"21,433 x DRG Weight",36359,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,143574,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,,inpatient,,,118142.66,15102,,,15102,Other,150% of Medicare + 9.63% HCRA Surcharge,9183.85,,,9183.85,Other,Medicare IPPS methodology,25386,,"25,728 x DRG weight",25386,Other,base rate x DRG weight,22847,,"23,155 x DRG weight",22847,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,59071,50,,59071,Percent of Total Billed Charges,50% of Charges,28709,,"29,096 x DRG Weight",28709,Other,base rate x DRG weight,22164,,"22,463 x DRG Weight",22164,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26075,,"26,426 x DRG Weight",26075,Other,base rate x DRG weight,38293,,"38,809 x DRG Weight",38293,Other,base rate x DRG weight,38293,,"38,809 x DRG Weight",38293,Other,base rate x DRG weight,26075,,"26,426 x DRG Weight",26075,Other,base rate x DRG weight,38293,,"38,809 x DRG Weight",38293,Other,base rate x DRG weight,34920,,"35,391 x DRG Weight",34920,Other,base rate x DRG weight,82700,70,,82700,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24881,,"25,216 X DRG Weight",24881,Other,Base Weight X DRG Weight,22393,,"22,695 X DRG Weight",22393,Other,Base Weight X DRG Weight,24881,,"25,216 X DRG Weight",24881,Other,Base Rate x DRG Weight ,21148,,"21,433 x DRG Weight",21148,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,82700,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,,inpatient,,,78523.2,11789,,,11789,Other,150% of Medicare + 9.63% HCRA Surcharge,7169.13,,,7169.13,Other,Medicare IPPS methodology,19638,,"25,728 x DRG weight",19638,Other,base rate x DRG weight,17674,,"23,155 x DRG weight",17674,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39262,50,,39262,Percent of Total Billed Charges,50% of Charges,22209,,"29,096 x DRG Weight",22209,Other,base rate x DRG weight,17146,,"22,463 x DRG Weight",17146,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,20171,,"26,426 x DRG Weight",20171,Other,base rate x DRG weight,29623,,"38,809 x DRG Weight",29623,Other,base rate x DRG weight,29623,,"38,809 x DRG Weight",29623,Other,base rate x DRG weight,20171,,"26,426 x DRG Weight",20171,Other,base rate x DRG weight,29623,,"38,809 x DRG Weight",29623,Other,base rate x DRG weight,27014,,"35,391 x DRG Weight",27014,Other,base rate x DRG weight,54966,70,,54966,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19247,,"25,216 X DRG Weight",19247,Other,Base Weight X DRG Weight,17323,,"22,695 X DRG Weight",17323,Other,Base Weight X DRG Weight,19247,,"25,216 X DRG Weight",19247,Other,Base Rate x DRG Weight ,16360,,"21,433 x DRG Weight",16360,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,54966,
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,,inpatient,,,278728.13,26247,,,26247,Other,150% of Medicare + 9.63% HCRA Surcharge,15961.24,,,15961.24,Other,Medicare IPPS methodology,44720,,"25,728 x DRG weight",44720,Other,base rate x DRG weight,40248,,"23,155 x DRG weight",40248,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,139364,50,,139364,Percent of Total Billed Charges,50% of Charges,50575,,"29,096 x DRG Weight",50575,Other,base rate x DRG weight,39045,,"22,463 x DRG Weight",39045,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,45934,,"26,426 x DRG Weight",45934,Other,base rate x DRG weight,67458,,"38,809 x DRG Weight",67458,Other,base rate x DRG weight,67458,,"38,809 x DRG Weight",67458,Other,base rate x DRG weight,45934,,"26,426 x DRG Weight",45934,Other,base rate x DRG weight,67458,,"38,809 x DRG Weight",67458,Other,base rate x DRG weight,61517,,"35,391 x DRG Weight",61517,Other,base rate x DRG weight,195110,70,,195110,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43830,,"25,216 X DRG Weight",43830,Other,Base Weight X DRG Weight,39448,,"22,695 X DRG Weight",39448,Other,Base Weight X DRG Weight,43830,,"25,216 X DRG Weight",43830,Other,Base Rate x DRG Weight ,37255,,"21,433 x DRG Weight",37255,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,195110,
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,,inpatient,,,176490.82,16799,,,16799,Other,150% of Medicare + 9.63% HCRA Surcharge,10215.57,,,10215.57,Other,Medicare IPPS methodology,28329,,"25,728 x DRG weight",28329,Other,base rate x DRG weight,25496,,"23,155 x DRG weight",25496,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,88245,50,,88245,Percent of Total Billed Charges,50% of Charges,32038,,"29,096 x DRG Weight",32038,Other,base rate x DRG weight,24734,,"22,463 x DRG Weight",24734,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,29098,,"26,426 x DRG Weight",29098,Other,base rate x DRG weight,42733,,"38,809 x DRG Weight",42733,Other,base rate x DRG weight,42733,,"38,809 x DRG Weight",42733,Other,base rate x DRG weight,29098,,"26,426 x DRG Weight",29098,Other,base rate x DRG weight,42733,,"38,809 x DRG Weight",42733,Other,base rate x DRG weight,38969,,"35,391 x DRG Weight",38969,Other,base rate x DRG weight,123544,70,,123544,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27765,,"25,216 X DRG Weight",27765,Other,Base Weight X DRG Weight,24989,,"22,695 X DRG Weight",24989,Other,Base Weight X DRG Weight,27765,,"25,216 X DRG Weight",27765,Other,Base Rate x DRG Weight ,23600,,"21,433 x DRG Weight",23600,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,123544,
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,,inpatient,,,107644.72,12316,,,12316,Other,150% of Medicare + 9.63% HCRA Surcharge,7489.28,,,7489.28,Other,Medicare IPPS methodology,20552,,"25,728 x DRG weight",20552,Other,base rate x DRG weight,18496,,"23,155 x DRG weight",18496,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,53822,50,,53822,Percent of Total Billed Charges,50% of Charges,23242,,"29,096 x DRG Weight",23242,Other,base rate x DRG weight,17943,,"22,463 x DRG Weight",17943,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21109,,"26,426 x DRG Weight",21109,Other,base rate x DRG weight,31001,,"38,809 x DRG Weight",31001,Other,base rate x DRG weight,31001,,"38,809 x DRG Weight",31001,Other,base rate x DRG weight,21109,,"26,426 x DRG Weight",21109,Other,base rate x DRG weight,31001,,"38,809 x DRG Weight",31001,Other,base rate x DRG weight,28270,,"35,391 x DRG Weight",28270,Other,base rate x DRG weight,75351,70,,75351,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20143,,"25,216 X DRG Weight",20143,Other,Base Weight X DRG Weight,18129,,"22,695 X DRG Weight",18129,Other,Base Weight X DRG Weight,20143,,"25,216 X DRG Weight",20143,Other,Base Rate x DRG Weight ,17121,,"21,433 x DRG Weight",17121,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,75351,
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,,inpatient,,,189879.65,23820,,,23820,Other,150% of Medicare + 9.63% HCRA Surcharge,14484.92,,,14484.92,Other,Medicare IPPS methodology,40509,,"25,728 x DRG weight",40509,Other,base rate x DRG weight,36458,,"23,155 x DRG weight",36458,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,94940,50,,94940,Percent of Total Billed Charges,50% of Charges,45812,,"29,096 x DRG Weight",45812,Other,base rate x DRG weight,35368,,"22,463 x DRG Weight",35368,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41608,,"26,426 x DRG Weight",41608,Other,base rate x DRG weight,61105,,"38,809 x DRG Weight",61105,Other,base rate x DRG weight,61105,,"38,809 x DRG Weight",61105,Other,base rate x DRG weight,41608,,"26,426 x DRG Weight",41608,Other,base rate x DRG weight,61105,,"38,809 x DRG Weight",61105,Other,base rate x DRG weight,55723,,"35,391 x DRG Weight",55723,Other,base rate x DRG weight,132916,70,,132916,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39703,,"25,216 X DRG Weight",39703,Other,Base Weight X DRG Weight,35733,,"22,695 X DRG Weight",35733,Other,Base Weight X DRG Weight,39703,,"25,216 X DRG Weight",39703,Other,Base Rate x DRG Weight ,33746,,"21,433 x DRG Weight",33746,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,132916,
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,,inpatient,,,167982.92,16069,,,16069,Other,150% of Medicare + 9.63% HCRA Surcharge,9771.86,,,9771.86,Other,Medicare IPPS methodology,27063,,"25,728 x DRG weight",27063,Other,base rate x DRG weight,24357,,"23,155 x DRG weight",24357,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,83991,50,,83991,Percent of Total Billed Charges,50% of Charges,30606,,"29,096 x DRG Weight",30606,Other,base rate x DRG weight,23629,,"22,463 x DRG Weight",23629,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,27798,,"26,426 x DRG Weight",27798,Other,base rate x DRG weight,40823,,"38,809 x DRG Weight",40823,Other,base rate x DRG weight,40823,,"38,809 x DRG Weight",40823,Other,base rate x DRG weight,27798,,"26,426 x DRG Weight",27798,Other,base rate x DRG weight,40823,,"38,809 x DRG Weight",40823,Other,base rate x DRG weight,37228,,"35,391 x DRG Weight",37228,Other,base rate x DRG weight,117588,70,,117588,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,26525,,"25,216 X DRG Weight",26525,Other,Base Weight X DRG Weight,23873,,"22,695 X DRG Weight",23873,Other,Base Weight X DRG Weight,26525,,"25,216 X DRG Weight",26525,Other,Base Rate x DRG Weight ,22545,,"21,433 x DRG Weight",22545,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,117588,
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,,inpatient,,,90469.83,11677,,,11677,Other,150% of Medicare + 9.63% HCRA Surcharge,7100.59,,,7100.59,Other,Medicare IPPS methodology,19443,,"25,728 x DRG weight",19443,Other,base rate x DRG weight,17498,,"23,155 x DRG weight",17498,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,45235,50,,45235,Percent of Total Billed Charges,50% of Charges,21988,,"29,096 x DRG Weight",21988,Other,base rate x DRG weight,16975,,"22,463 x DRG Weight",16975,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,19970,,"26,426 x DRG Weight",19970,Other,base rate x DRG weight,29328,,"38,809 x DRG Weight",29328,Other,base rate x DRG weight,29328,,"38,809 x DRG Weight",29328,Other,base rate x DRG weight,19970,,"26,426 x DRG Weight",19970,Other,base rate x DRG weight,29328,,"38,809 x DRG Weight",29328,Other,base rate x DRG weight,26745,,"35,391 x DRG Weight",26745,Other,base rate x DRG weight,63329,70,,63329,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19056,,"25,216 X DRG Weight",19056,Other,Base Weight X DRG Weight,17151,,"22,695 X DRG Weight",17151,Other,Base Weight X DRG Weight,19056,,"25,216 X DRG Weight",19056,Other,Base Rate x DRG Weight ,16197,,"21,433 x DRG Weight",16197,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,63329,
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,,inpatient,,,180027.88,23488,,,23488,Other,150% of Medicare + 9.63% HCRA Surcharge,14282.9,,,14282.9,Other,Medicare IPPS methodology,39932,,"25,728 x DRG weight",39932,Other,base rate x DRG weight,35939,,"23,155 x DRG weight",35939,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,90014,50,,90014,Percent of Total Billed Charges,50% of Charges,45160,,"29,096 x DRG Weight",45160,Other,base rate x DRG weight,34865,,"22,463 x DRG Weight",34865,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41016,,"26,426 x DRG Weight",41016,Other,base rate x DRG weight,60235,,"38,809 x DRG Weight",60235,Other,base rate x DRG weight,60235,,"38,809 x DRG Weight",60235,Other,base rate x DRG weight,41016,,"26,426 x DRG Weight",41016,Other,base rate x DRG weight,60235,,"38,809 x DRG Weight",60235,Other,base rate x DRG weight,54930,,"35,391 x DRG Weight",54930,Other,base rate x DRG weight,126020,70,,126020,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39138,,"25,216 X DRG Weight",39138,Other,Base Weight X DRG Weight,35225,,"22,695 X DRG Weight",35225,Other,Base Weight X DRG Weight,39138,,"25,216 X DRG Weight",39138,Other,Base Rate x DRG Weight ,33266,,"21,433 x DRG Weight",33266,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,126020,
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,,inpatient,,,131722.63,15245,,,15245,Other,150% of Medicare + 9.63% HCRA Surcharge,9270.43,,,9270.43,Other,Medicare IPPS methodology,25633,,"25,728 x DRG weight",25633,Other,base rate x DRG weight,23069,,"23,155 x DRG weight",23069,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,65861,50,,65861,Percent of Total Billed Charges,50% of Charges,28988,,"29,096 x DRG Weight",28988,Other,base rate x DRG weight,22380,,"22,463 x DRG Weight",22380,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26328,,"26,426 x DRG Weight",26328,Other,base rate x DRG weight,38665,,"38,809 x DRG Weight",38665,Other,base rate x DRG weight,38665,,"38,809 x DRG Weight",38665,Other,base rate x DRG weight,26328,,"26,426 x DRG Weight",26328,Other,base rate x DRG weight,38665,,"38,809 x DRG Weight",38665,Other,base rate x DRG weight,35260,,"35,391 x DRG Weight",35260,Other,base rate x DRG weight,92206,70,,92206,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25123,,"25,216 X DRG Weight",25123,Other,Base Weight X DRG Weight,22611,,"22,695 X DRG Weight",22611,Other,Base Weight X DRG Weight,25123,,"25,216 X DRG Weight",25123,Other,Base Rate x DRG Weight ,21354,,"21,433 x DRG Weight",21354,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,92206,
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,,inpatient,,,94434,11540,,,11540,Other,150% of Medicare + 9.63% HCRA Surcharge,7017.62,,,7017.62,Other,Medicare IPPS methodology,19206,,"25,728 x DRG weight",19206,Other,base rate x DRG weight,17285,,"23,155 x DRG weight",17285,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,47217,50,,47217,Percent of Total Billed Charges,50% of Charges,21720,,"29,096 x DRG Weight",21720,Other,base rate x DRG weight,16769,,"22,463 x DRG Weight",16769,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,19727,,"26,426 x DRG Weight",19727,Other,base rate x DRG weight,28971,,"38,809 x DRG Weight",28971,Other,base rate x DRG weight,28971,,"38,809 x DRG Weight",28971,Other,base rate x DRG weight,19727,,"26,426 x DRG Weight",19727,Other,base rate x DRG weight,28971,,"38,809 x DRG Weight",28971,Other,base rate x DRG weight,26419,,"35,391 x DRG Weight",26419,Other,base rate x DRG weight,66104,70,,66104,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18824,,"25,216 X DRG Weight",18824,Other,Base Weight X DRG Weight,16942,,"22,695 X DRG Weight",16942,Other,Base Weight X DRG Weight,18824,,"25,216 X DRG Weight",18824,Other,Base Rate x DRG Weight ,16000,,"21,433 x DRG Weight",16000,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,66104,
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,,inpatient,,,131495.35,18740,,,18740,Other,150% of Medicare + 9.63% HCRA Surcharge,11396.09,,,11396.09,Other,Medicare IPPS methodology,31697,,"25,728 x DRG weight",31697,Other,base rate x DRG weight,28527,,"23,155 x DRG weight",28527,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,65748,50,,65748,Percent of Total Billed Charges,50% of Charges,35846,,"29,096 x DRG Weight",35846,Other,base rate x DRG weight,27674,,"22,463 x DRG Weight",27674,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,32557,,"26,426 x DRG Weight",32557,Other,base rate x DRG weight,47813,,"38,809 x DRG Weight",47813,Other,base rate x DRG weight,47813,,"38,809 x DRG Weight",47813,Other,base rate x DRG weight,32557,,"26,426 x DRG Weight",32557,Other,base rate x DRG weight,47813,,"38,809 x DRG Weight",47813,Other,base rate x DRG weight,43602,,"35,391 x DRG Weight",43602,Other,base rate x DRG weight,92047,70,,92047,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,31066,,"25,216 X DRG Weight",31066,Other,Base Weight X DRG Weight,27960,,"22,695 X DRG Weight",27960,Other,Base Weight X DRG Weight,31066,,"25,216 X DRG Weight",31066,Other,Base Rate x DRG Weight ,26405,,"21,433 x DRG Weight",26405,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,92047,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,,inpatient,,,141350.82,16812,,,16812,Other,150% of Medicare + 9.63% HCRA Surcharge,10223.68,,,10223.68,Other,Medicare IPPS methodology,28352,,"25,728 x DRG weight",28352,Other,base rate x DRG weight,25517,,"23,155 x DRG weight",25517,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,70675,50,,70675,Percent of Total Billed Charges,50% of Charges,32064,,"29,096 x DRG Weight",32064,Other,base rate x DRG weight,24754,,"22,463 x DRG Weight",24754,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,29121,,"26,426 x DRG Weight",29121,Other,base rate x DRG weight,42768,,"38,809 x DRG Weight",42768,Other,base rate x DRG weight,42768,,"38,809 x DRG Weight",42768,Other,base rate x DRG weight,29121,,"26,426 x DRG Weight",29121,Other,base rate x DRG weight,42768,,"38,809 x DRG Weight",42768,Other,base rate x DRG weight,39001,,"35,391 x DRG Weight",39001,Other,base rate x DRG weight,98946,70,,98946,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27788,,"25,216 X DRG Weight",27788,Other,Base Weight X DRG Weight,25010,,"22,695 X DRG Weight",25010,Other,Base Weight X DRG Weight,27788,,"25,216 X DRG Weight",27788,Other,Base Rate x DRG Weight ,23619,,"21,433 x DRG Weight",23619,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,98946,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,,inpatient,,,114478.28,13060,,,13060,Other,150% of Medicare + 9.63% HCRA Surcharge,7942.01,,,7942.01,Other,Medicare IPPS methodology,21843,,"25,728 x DRG weight",21843,Other,base rate x DRG weight,19659,,"23,155 x DRG weight",19659,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,57239,50,,57239,Percent of Total Billed Charges,50% of Charges,24703,,"29,096 x DRG Weight",24703,Other,base rate x DRG weight,19071,,"22,463 x DRG Weight",19071,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,22436,,"26,426 x DRG Weight",22436,Other,base rate x DRG weight,32949,,"38,809 x DRG Weight",32949,Other,base rate x DRG weight,32949,,"38,809 x DRG Weight",32949,Other,base rate x DRG weight,22436,,"26,426 x DRG Weight",22436,Other,base rate x DRG weight,32949,,"38,809 x DRG Weight",32949,Other,base rate x DRG weight,30047,,"35,391 x DRG Weight",30047,Other,base rate x DRG weight,80135,70,,80135,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,21408,,"25,216 X DRG Weight",21408,Other,Base Weight X DRG Weight,19268,,"22,695 X DRG Weight",19268,Other,Base Weight X DRG Weight,21408,,"25,216 X DRG Weight",21408,Other,Base Rate x DRG Weight ,18197,,"21,433 x DRG Weight",18197,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,80135,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,,inpatient,,,68831.45,9987,,,9987,Other,150% of Medicare + 9.63% HCRA Surcharge,6073.38,,,6073.38,Other,Medicare IPPS methodology,16512,,"25,728 x DRG weight",16512,Other,base rate x DRG weight,14861,,"23,155 x DRG weight",14861,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,34416,50,,34416,Percent of Total Billed Charges,50% of Charges,18674,,"29,096 x DRG Weight",18674,Other,base rate x DRG weight,14417,,"22,463 x DRG Weight",14417,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,16960,,"26,426 x DRG Weight",16960,Other,base rate x DRG weight,24908,,"38,809 x DRG Weight",24908,Other,base rate x DRG weight,24908,,"38,809 x DRG Weight",24908,Other,base rate x DRG weight,16960,,"26,426 x DRG Weight",16960,Other,base rate x DRG weight,24908,,"38,809 x DRG Weight",24908,Other,base rate x DRG weight,22714,,"35,391 x DRG Weight",22714,Other,base rate x DRG weight,48182,70,,48182,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,16184,,"25,216 X DRG Weight",16184,Other,Base Weight X DRG Weight,14566,,"22,695 X DRG Weight",14566,Other,Base Weight X DRG Weight,16184,,"25,216 X DRG Weight",16184,Other,Base Rate x DRG Weight ,13756,,"21,433 x DRG Weight",13756,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,48182,
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,,inpatient,,,159275.83,20143,,,20143,Other,150% of Medicare + 9.63% HCRA Surcharge,12249.24,,,12249.24,Other,Medicare IPPS methodology,34131,,"25,728 x DRG weight",34131,Other,base rate x DRG weight,30717,,"23,155 x DRG weight",30717,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,79638,50,,79638,Percent of Total Billed Charges,50% of Charges,38599,,"29,096 x DRG Weight",38599,Other,base rate x DRG weight,29799,,"22,463 x DRG Weight",29799,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,35057,,"26,426 x DRG Weight",35057,Other,base rate x DRG weight,51484,,"38,809 x DRG Weight",51484,Other,base rate x DRG weight,51484,,"38,809 x DRG Weight",51484,Other,base rate x DRG weight,35057,,"26,426 x DRG Weight",35057,Other,base rate x DRG weight,51484,,"38,809 x DRG Weight",51484,Other,base rate x DRG weight,46950,,"35,391 x DRG Weight",46950,Other,base rate x DRG weight,111493,70,,111493,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,33452,,"25,216 X DRG Weight",33452,Other,Base Weight X DRG Weight,30107,,"22,695 X DRG Weight",30107,Other,Base Weight X DRG Weight,33452,,"25,216 X DRG Weight",33452,Other,Base Rate x DRG Weight ,28433,,"21,433 x DRG Weight",28433,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,111493,
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,,inpatient,,,98405.59,12663,,,12663,Other,150% of Medicare + 9.63% HCRA Surcharge,7700.31,,,7700.31,Other,Medicare IPPS methodology,21154,,"25,728 x DRG weight",21154,Other,base rate x DRG weight,19038,,"23,155 x DRG weight",19038,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,49203,50,,49203,Percent of Total Billed Charges,50% of Charges,23923,,"29,096 x DRG Weight",23923,Other,base rate x DRG weight,18469,,"22,463 x DRG Weight",18469,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21727,,"26,426 x DRG Weight",21727,Other,base rate x DRG weight,31909,,"38,809 x DRG Weight",31909,Other,base rate x DRG weight,31909,,"38,809 x DRG Weight",31909,Other,base rate x DRG weight,21727,,"26,426 x DRG Weight",21727,Other,base rate x DRG weight,31909,,"38,809 x DRG Weight",31909,Other,base rate x DRG weight,29098,,"35,391 x DRG Weight",29098,Other,base rate x DRG weight,68884,70,,68884,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20733,,"25,216 X DRG Weight",20733,Other,Base Weight X DRG Weight,18660,,"22,695 X DRG Weight",18660,Other,Base Weight X DRG Weight,20733,,"25,216 X DRG Weight",20733,Other,Base Rate x DRG Weight ,17622,,"21,433 x DRG Weight",17622,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,68884,
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,,inpatient,,,64782.22,9747,,,9747,Other,150% of Medicare + 9.63% HCRA Surcharge,5927.28,,,5927.28,Other,Medicare IPPS methodology,16095,,"25,728 x DRG weight",16095,Other,base rate x DRG weight,14486,,"23,155 x DRG weight",14486,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32391,50,,32391,Percent of Total Billed Charges,50% of Charges,18202,,"29,096 x DRG Weight",18202,Other,base rate x DRG weight,14053,,"22,463 x DRG Weight",14053,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,16532,,"26,426 x DRG Weight",16532,Other,base rate x DRG weight,24279,,"38,809 x DRG Weight",24279,Other,base rate x DRG weight,24279,,"38,809 x DRG Weight",24279,Other,base rate x DRG weight,16532,,"26,426 x DRG Weight",16532,Other,base rate x DRG weight,24279,,"38,809 x DRG Weight",24279,Other,base rate x DRG weight,22141,,"35,391 x DRG Weight",22141,Other,base rate x DRG weight,45348,70,,45348,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,15775,,"25,216 X DRG Weight",15775,Other,Base Weight X DRG Weight,14198,,"22,695 X DRG Weight",14198,Other,Base Weight X DRG Weight,15775,,"25,216 X DRG Weight",15775,Other,Base Rate x DRG Weight ,13408,,"21,433 x DRG Weight",13408,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,45348,
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,,inpatient,,,196429.88,28579,,,28579,Other,150% of Medicare + 9.63% HCRA Surcharge,17378.95,,,17378.95,Other,Medicare IPPS methodology,48765,,"25,728 x DRG weight",48765,Other,base rate x DRG weight,43888,,"23,155 x DRG weight",43888,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,98215,50,,98215,Percent of Total Billed Charges,50% of Charges,55149,,"29,096 x DRG Weight",55149,Other,base rate x DRG weight,42576,,"22,463 x DRG Weight",42576,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,50088,,"26,426 x DRG Weight",50088,Other,base rate x DRG weight,73559,,"38,809 x DRG Weight",73559,Other,base rate x DRG weight,73559,,"38,809 x DRG Weight",73559,Other,base rate x DRG weight,50088,,"26,426 x DRG Weight",50088,Other,base rate x DRG weight,73559,,"38,809 x DRG Weight",73559,Other,base rate x DRG weight,67080,,"35,391 x DRG Weight",67080,Other,base rate x DRG weight,137501,70,,137501,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,47794,,"25,216 X DRG Weight",47794,Other,Base Weight X DRG Weight,43016,,"22,695 X DRG Weight",43016,Other,Base Weight X DRG Weight,47794,,"25,216 X DRG Weight",47794,Other,Base Rate x DRG Weight ,40624,,"21,433 x DRG Weight",40624,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,137501,
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,,inpatient,,,116692.32,15263,,,15263,Other,150% of Medicare + 9.63% HCRA Surcharge,9281.25,,,9281.25,Other,Medicare IPPS methodology,25664,,"25,728 x DRG weight",25664,Other,base rate x DRG weight,23097,,"23,155 x DRG weight",23097,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,58346,50,,58346,Percent of Total Billed Charges,50% of Charges,29023,,"29,096 x DRG Weight",29023,Other,base rate x DRG weight,22407,,"22,463 x DRG Weight",22407,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26360,,"26,426 x DRG Weight",26360,Other,base rate x DRG weight,38712,,"38,809 x DRG Weight",38712,Other,base rate x DRG weight,38712,,"38,809 x DRG Weight",38712,Other,base rate x DRG weight,26360,,"26,426 x DRG Weight",26360,Other,base rate x DRG weight,38712,,"38,809 x DRG Weight",38712,Other,base rate x DRG weight,35303,,"35,391 x DRG Weight",35303,Other,base rate x DRG weight,81685,70,,81685,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25153,,"25,216 X DRG Weight",25153,Other,Base Weight X DRG Weight,22638,,"22,695 X DRG Weight",22638,Other,Base Weight X DRG Weight,25153,,"25,216 X DRG Weight",25153,Other,Base Rate x DRG Weight ,21379,,"21,433 x DRG Weight",21379,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,81685,
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,,inpatient,,,53318,12010,,,12010,Other,150% of Medicare + 9.63% HCRA Surcharge,7303.5,,,7303.5,Other,Medicare IPPS methodology,20022,,"25,728 x DRG weight",20022,Other,base rate x DRG weight,18019,,"23,155 x DRG weight",18019,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,26659,50,,26659,Percent of Total Billed Charges,50% of Charges,22643,,"29,096 x DRG Weight",22643,Other,base rate x DRG weight,17481,,"22,463 x DRG Weight",17481,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,20565,,"26,426 x DRG Weight",20565,Other,base rate x DRG weight,30201,,"38,809 x DRG Weight",30201,Other,base rate x DRG weight,30201,,"38,809 x DRG Weight",30201,Other,base rate x DRG weight,20565,,"26,426 x DRG Weight",20565,Other,base rate x DRG weight,30201,,"38,809 x DRG Weight",30201,Other,base rate x DRG weight,27541,,"35,391 x DRG Weight",27541,Other,base rate x DRG weight,37323,70,,37323,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19623,,"25,216 X DRG Weight",19623,Other,Base Weight X DRG Weight,17661,,"22,695 X DRG Weight",17661,Other,Base Weight X DRG Weight,19623,,"25,216 X DRG Weight",19623,Other,Base Rate x DRG Weight ,16679,,"21,433 x DRG Weight",16679,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,37323,
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,,inpatient,,,183491.29,26780,,,26780,Other,150% of Medicare + 9.63% HCRA Surcharge,16285.01,,,16285.01,Other,Medicare IPPS methodology,45644,,"25,728 x DRG weight",45644,Other,base rate x DRG weight,41079,,"23,155 x DRG weight",41079,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,91746,50,,91746,Percent of Total Billed Charges,50% of Charges,51619,,"29,096 x DRG Weight",51619,Other,base rate x DRG weight,39852,,"22,463 x DRG Weight",39852,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,46882,,"26,426 x DRG Weight",46882,Other,base rate x DRG weight,68851,,"38,809 x DRG Weight",68851,Other,base rate x DRG weight,68851,,"38,809 x DRG Weight",68851,Other,base rate x DRG weight,46882,,"26,426 x DRG Weight",46882,Other,base rate x DRG weight,68851,,"38,809 x DRG Weight",68851,Other,base rate x DRG weight,62787,,"35,391 x DRG Weight",62787,Other,base rate x DRG weight,128444,70,,128444,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,44736,,"25,216 X DRG Weight",44736,Other,Base Weight X DRG Weight,40263,,"22,695 X DRG Weight",40263,Other,Base Weight X DRG Weight,44736,,"25,216 X DRG Weight",44736,Other,Base Rate x DRG Weight ,38024,,"21,433 x DRG Weight",38024,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,128444,
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,,inpatient,,,145711.42,16442,,,16442,Other,150% of Medicare + 9.63% HCRA Surcharge,9998.22,,,9998.22,Other,Medicare IPPS methodology,27709,,"25,728 x DRG weight",27709,Other,base rate x DRG weight,24938,,"23,155 x DRG weight",24938,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,72856,50,,72856,Percent of Total Billed Charges,50% of Charges,31336,,"29,096 x DRG Weight",31336,Other,base rate x DRG weight,24193,,"22,463 x DRG Weight",24193,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28461,,"26,426 x DRG Weight",28461,Other,base rate x DRG weight,41797,,"38,809 x DRG Weight",41797,Other,base rate x DRG weight,41797,,"38,809 x DRG Weight",41797,Other,base rate x DRG weight,28461,,"26,426 x DRG Weight",28461,Other,base rate x DRG weight,41797,,"38,809 x DRG Weight",41797,Other,base rate x DRG weight,38116,,"35,391 x DRG Weight",38116,Other,base rate x DRG weight,101998,70,,101998,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27158,,"25,216 X DRG Weight",27158,Other,Base Weight X DRG Weight,24443,,"22,695 X DRG Weight",24443,Other,Base Weight X DRG Weight,27158,,"25,216 X DRG Weight",27158,Other,Base Rate x DRG Weight ,23083,,"21,433 x DRG Weight",23083,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,101998,
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,,inpatient,,,72268.8,10941,,,10941,Other,150% of Medicare + 9.63% HCRA Surcharge,6653.27,,,6653.27,Other,Medicare IPPS methodology,18167,,"25,728 x DRG weight",18167,Other,base rate x DRG weight,16350,,"23,155 x DRG weight",16350,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,36134,50,,36134,Percent of Total Billed Charges,50% of Charges,20545,,"29,096 x DRG Weight",20545,Other,base rate x DRG weight,15861,,"22,463 x DRG Weight",15861,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18659,,"26,426 x DRG Weight",18659,Other,base rate x DRG weight,27403,,"38,809 x DRG Weight",27403,Other,base rate x DRG weight,27403,,"38,809 x DRG Weight",27403,Other,base rate x DRG weight,18659,,"26,426 x DRG Weight",18659,Other,base rate x DRG weight,27403,,"38,809 x DRG Weight",27403,Other,base rate x DRG weight,24990,,"35,391 x DRG Weight",24990,Other,base rate x DRG weight,50588,70,,50588,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,17805,,"25,216 X DRG Weight",17805,Other,Base Weight X DRG Weight,16025,,"22,695 X DRG Weight",16025,Other,Base Weight X DRG Weight,17805,,"25,216 X DRG Weight",17805,Other,Base Rate x DRG Weight ,15134,,"21,433 x DRG Weight",15134,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,50588,
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,,inpatient,,,91494.19,14669,,,14669,Other,150% of Medicare + 9.63% HCRA Surcharge,8920.51,,,8920.51,Other,Medicare IPPS methodology,24635,,"25,728 x DRG weight",24635,Other,base rate x DRG weight,22171,,"23,155 x DRG weight",22171,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,45747,50,,45747,Percent of Total Billed Charges,50% of Charges,27859,,"29,096 x DRG Weight",27859,Other,base rate x DRG weight,21508,,"22,463 x DRG Weight",21508,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,25303,,"26,426 x DRG Weight",25303,Other,base rate x DRG weight,37160,,"38,809 x DRG Weight",37160,Other,base rate x DRG weight,37160,,"38,809 x DRG Weight",37160,Other,base rate x DRG weight,25303,,"26,426 x DRG Weight",25303,Other,base rate x DRG weight,37160,,"38,809 x DRG Weight",37160,Other,base rate x DRG weight,33887,,"35,391 x DRG Weight",33887,Other,base rate x DRG weight,64046,70,,64046,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24144,,"25,216 X DRG Weight",24144,Other,Base Weight X DRG Weight,21730,,"22,695 X DRG Weight",21730,Other,Base Weight X DRG Weight,24144,,"25,216 X DRG Weight",24144,Other,Base Rate x DRG Weight ,20522,,"21,433 x DRG Weight",20522,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,64046,
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,,inpatient,,,58971.87,10775,,,10775,Other,150% of Medicare + 9.63% HCRA Surcharge,6552.26,,,6552.26,Other,Medicare IPPS methodology,17878,,"25,728 x DRG weight",17878,Other,base rate x DRG weight,16090,,"23,155 x DRG weight",16090,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,29486,50,,29486,Percent of Total Billed Charges,50% of Charges,20219,,"29,096 x DRG Weight",20219,Other,base rate x DRG weight,15610,,"22,463 x DRG Weight",15610,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18363,,"26,426 x DRG Weight",18363,Other,base rate x DRG weight,26968,,"38,809 x DRG Weight",26968,Other,base rate x DRG weight,26968,,"38,809 x DRG Weight",26968,Other,base rate x DRG weight,18363,,"26,426 x DRG Weight",18363,Other,base rate x DRG weight,26968,,"38,809 x DRG Weight",26968,Other,base rate x DRG weight,24593,,"35,391 x DRG Weight",24593,Other,base rate x DRG weight,41280,70,,41280,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,17523,,"25,216 X DRG Weight",17523,Other,Base Weight X DRG Weight,15771,,"22,695 X DRG Weight",15771,Other,Base Weight X DRG Weight,17523,,"25,216 X DRG Weight",17523,Other,Base Rate x DRG Weight ,14894,,"21,433 x DRG Weight",14894,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,41280,
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,,inpatient,,,144451.95,12673,,,12673,Other,150% of Medicare + 9.63% HCRA Surcharge,7706.63,,,7706.63,Other,Medicare IPPS methodology,21172,,"25,728 x DRG weight",21172,Other,base rate x DRG weight,19054,,"23,155 x DRG weight",19054,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,72226,50,,72226,Percent of Total Billed Charges,50% of Charges,23943,,"29,096 x DRG Weight",23943,Other,base rate x DRG weight,18485,,"22,463 x DRG Weight",18485,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21746,,"26,426 x DRG Weight",21746,Other,base rate x DRG weight,31936,,"38,809 x DRG Weight",31936,Other,base rate x DRG weight,31936,,"38,809 x DRG Weight",31936,Other,base rate x DRG weight,21746,,"26,426 x DRG Weight",21746,Other,base rate x DRG weight,31936,,"38,809 x DRG Weight",31936,Other,base rate x DRG weight,29123,,"35,391 x DRG Weight",29123,Other,base rate x DRG weight,101116,70,,101116,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20750,,"25,216 X DRG Weight",20750,Other,Base Weight X DRG Weight,18676,,"22,695 X DRG Weight",18676,Other,Base Weight X DRG Weight,20750,,"25,216 X DRG Weight",20750,Other,Base Rate x DRG Weight ,17637,,"21,433 x DRG Weight",17637,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,101116,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,,inpatient,,,195278.34,27317,,,27317,Other,150% of Medicare + 9.63% HCRA Surcharge,16611.47,,,16611.47,Other,Medicare IPPS methodology,46575,,"25,728 x DRG weight",46575,Other,base rate x DRG weight,41917,,"23,155 x DRG weight",41917,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,97639,50,,97639,Percent of Total Billed Charges,50% of Charges,52672,,"29,096 x DRG Weight",52672,Other,base rate x DRG weight,40665,,"22,463 x DRG Weight",40665,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,47839,,"26,426 x DRG Weight",47839,Other,base rate x DRG weight,70256,,"38,809 x DRG Weight",70256,Other,base rate x DRG weight,70256,,"38,809 x DRG Weight",70256,Other,base rate x DRG weight,47839,,"26,426 x DRG Weight",47839,Other,base rate x DRG weight,70256,,"38,809 x DRG Weight",70256,Other,base rate x DRG weight,64068,,"35,391 x DRG Weight",64068,Other,base rate x DRG weight,136695,70,,136695,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,45649,,"25,216 X DRG Weight",45649,Other,Base Weight X DRG Weight,41085,,"22,695 X DRG Weight",41085,Other,Base Weight X DRG Weight,45649,,"25,216 X DRG Weight",45649,Other,Base Rate x DRG Weight ,38800,,"21,433 x DRG Weight",38800,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,136695,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,,inpatient,,,107739.98,14017,,,14017,Other,150% of Medicare + 9.63% HCRA Surcharge,8523.7,,,8523.7,Other,Medicare IPPS methodology,23503,,"25,728 x DRG weight",23503,Other,base rate x DRG weight,21152,,"23,155 x DRG weight",21152,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,53870,50,,53870,Percent of Total Billed Charges,50% of Charges,26579,,"29,096 x DRG Weight",26579,Other,base rate x DRG weight,20520,,"22,463 x DRG Weight",20520,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,24140,,"26,426 x DRG Weight",24140,Other,base rate x DRG weight,35452,,"38,809 x DRG Weight",35452,Other,base rate x DRG weight,35452,,"38,809 x DRG Weight",35452,Other,base rate x DRG weight,24140,,"26,426 x DRG Weight",24140,Other,base rate x DRG weight,35452,,"38,809 x DRG Weight",35452,Other,base rate x DRG weight,32330,,"35,391 x DRG Weight",32330,Other,base rate x DRG weight,75418,70,,75418,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,23035,,"25,216 X DRG Weight",23035,Other,Base Weight X DRG Weight,20732,,"22,695 X DRG Weight",20732,Other,Base Weight X DRG Weight,23035,,"25,216 X DRG Weight",23035,Other,Base Rate x DRG Weight ,19579,,"21,433 x DRG Weight",19579,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,75418,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,,inpatient,,,585406.73,102918,,,102918,Other,150% of Medicare + 9.63% HCRA Surcharge,62584.98,,,62584.98,Other,Medicare IPPS methodology,177729,,"25,728 x DRG weight",177729,Other,base rate x DRG weight,159955,,"23,155 x DRG weight",159955,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,292703,50,,292703,Percent of Total Billed Charges,50% of Charges,200995,,"29,096 x DRG Weight",200995,Other,base rate x DRG weight,155174,,"22,463 x DRG Weight",155174,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,182551,,"26,426 x DRG Weight",182551,Other,base rate x DRG weight,268093,,"38,809 x DRG Weight",268093,Other,base rate x DRG weight,268093,,"38,809 x DRG Weight",268093,Other,base rate x DRG weight,182551,,"26,426 x DRG Weight",182551,Other,base rate x DRG weight,268093,,"38,809 x DRG Weight",268093,Other,base rate x DRG weight,244481,,"35,391 x DRG Weight",244481,Other,base rate x DRG weight,409785,70,,409785,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,174192,,"25,216 X DRG Weight",174192,Other,Base Weight X DRG Weight,156777,,"22,695 X DRG Weight",156777,Other,Base Weight X DRG Weight,174192,,"25,216 X DRG Weight",174192,Other,Base Rate x DRG Weight ,148059,,"21,433 x DRG Weight",148059,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,409785,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,,inpatient,,,244798.28,40568,,,40568,Other,150% of Medicare + 9.63% HCRA Surcharge,24669.49,,,24669.49,Other,Medicare IPPS methodology,69563,,"25,728 x DRG weight",69563,Other,base rate x DRG weight,62606,,"23,155 x DRG weight",62606,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,122399,50,,122399,Percent of Total Billed Charges,50% of Charges,78670,,"29,096 x DRG Weight",78670,Other,base rate x DRG weight,60735,,"22,463 x DRG Weight",60735,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,71451,,"26,426 x DRG Weight",71451,Other,base rate x DRG weight,104932,,"38,809 x DRG Weight",104932,Other,base rate x DRG weight,104932,,"38,809 x DRG Weight",104932,Other,base rate x DRG weight,71451,,"26,426 x DRG Weight",71451,Other,base rate x DRG weight,104932,,"38,809 x DRG Weight",104932,Other,base rate x DRG weight,95690,,"35,391 x DRG Weight",95690,Other,base rate x DRG weight,171359,70,,171359,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,68179,,"25,216 X DRG Weight",68179,Other,Base Weight X DRG Weight,61363,,"22,695 X DRG Weight",61363,Other,Base Weight X DRG Weight,68179,,"25,216 X DRG Weight",68179,Other,Base Rate x DRG Weight ,57951,,"21,433 x DRG Weight",57951,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,171359,
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES,212,MS-DRG,,,,,,,,inpatient,,,1520385.15,160203,,,160203,Other,150% of Medicare + 9.63% HCRA Surcharge,97420.66,,,97420.66,Other,Medicare IPPS methodology,277109,,"25,728 x DRG weight",277109,Other,base rate x DRG weight,249396,,"23,155 x DRG weight",249396,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,760193,50,,760193,Percent of Total Billed Charges,50% of Charges,313384,,"29,096 x DRG Weight",313384,Other,base rate x DRG weight,241942,,"22,463 x DRG Weight",241942,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,284627,,"26,426 x DRG Weight",284627,Other,base rate x DRG weight,418000,,"38,809 x DRG Weight",418000,Other,base rate x DRG weight,418000,,"38,809 x DRG Weight",418000,Other,base rate x DRG weight,284627,,"26,426 x DRG Weight",284627,Other,base rate x DRG weight,418000,,"38,809 x DRG Weight",418000,Other,base rate x DRG weight,381186,,"35,391 x DRG Weight",381186,Other,base rate x DRG weight,1064270,70,,1064270,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,271594,,"25,216 X DRG Weight",271594,Other,Base Weight X DRG Weight,244441,,"22,695 X DRG Weight",244441,Other,Base Weight X DRG Weight,271594,,"25,216 X DRG Weight",271594,Other,Base Rate x DRG Weight ,230848,,"21,433 x DRG Weight",230848,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,1064270,
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,,inpatient,,,1281378.9,151959,,,151959,Other,150% of Medicare + 9.63% HCRA Surcharge,92407.29,,,92407.29,Other,Medicare IPPS methodology,262806,,"25,728 x DRG weight",262806,Other,base rate x DRG weight,236524,,"23,155 x DRG weight",236524,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,640689,50,,640689,Percent of Total Billed Charges,50% of Charges,297210,,"29,096 x DRG Weight",297210,Other,base rate x DRG weight,229455,,"22,463 x DRG Weight",229455,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,269936,,"26,426 x DRG Weight",269936,Other,base rate x DRG weight,396426,,"38,809 x DRG Weight",396426,Other,base rate x DRG weight,396426,,"38,809 x DRG Weight",396426,Other,base rate x DRG weight,269936,,"26,426 x DRG Weight",269936,Other,base rate x DRG weight,396426,,"38,809 x DRG Weight",396426,Other,base rate x DRG weight,361512,,"35,391 x DRG Weight",361512,Other,base rate x DRG weight,896965,70,,896965,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,257576,,"25,216 X DRG Weight",257576,Other,Base Weight X DRG Weight,231825,,"22,695 X DRG Weight",231825,Other,Base Weight X DRG Weight,257576,,"25,216 X DRG Weight",257576,Other,Base Rate x DRG Weight ,218934,,"21,433 x DRG Weight",218934,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,896965,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,,inpatient,,,953897.27,144403,,,144403,Other,150% of Medicare + 9.63% HCRA Surcharge,87812.37,,,87812.37,Other,Medicare IPPS methodology,249698,,"25,728 x DRG weight",249698,Other,base rate x DRG weight,224726,,"23,155 x DRG weight",224726,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,476949,50,,476949,Percent of Total Billed Charges,50% of Charges,282385,,"29,096 x DRG Weight",282385,Other,base rate x DRG weight,218010,,"22,463 x DRG Weight",218010,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,256472,,"26,426 x DRG Weight",256472,Other,base rate x DRG weight,376653,,"38,809 x DRG Weight",376653,Other,base rate x DRG weight,376653,,"38,809 x DRG Weight",376653,Other,base rate x DRG weight,256472,,"26,426 x DRG Weight",256472,Other,base rate x DRG weight,376653,,"38,809 x DRG Weight",376653,Other,base rate x DRG weight,343480,,"35,391 x DRG Weight",343480,Other,base rate x DRG weight,667728,70,,667728,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,244729,,"25,216 X DRG Weight",244729,Other,Base Weight X DRG Weight,220262,,"22,695 X DRG Weight",220262,Other,Base Weight X DRG Weight,244729,,"25,216 X DRG Weight",244729,Other,Base Rate x DRG Weight ,208014,,"21,433 x DRG Weight",208014,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,667728,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,,inpatient,,,677974.07,94869,,,94869,Other,150% of Medicare + 9.63% HCRA Surcharge,57690.65,,,57690.65,Other,Medicare IPPS methodology,163766,,"25,728 x DRG weight",163766,Other,base rate x DRG weight,147389,,"23,155 x DRG weight",147389,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,338987,50,,338987,Percent of Total Billed Charges,50% of Charges,185205,,"29,096 x DRG Weight",185205,Other,base rate x DRG weight,142984,,"22,463 x DRG Weight",142984,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,168209,,"26,426 x DRG Weight",168209,Other,base rate x DRG weight,247031,,"38,809 x DRG Weight",247031,Other,base rate x DRG weight,247031,,"38,809 x DRG Weight",247031,Other,base rate x DRG weight,168209,,"26,426 x DRG Weight",168209,Other,base rate x DRG weight,247031,,"38,809 x DRG Weight",247031,Other,base rate x DRG weight,225274,,"35,391 x DRG Weight",225274,Other,base rate x DRG weight,474582,70,,474582,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,160507,,"25,216 X DRG Weight",160507,Other,Base Weight X DRG Weight,144460,,"22,695 X DRG Weight",144460,Other,Base Weight X DRG Weight,160507,,"25,216 X DRG Weight",160507,Other,Base Rate x DRG Weight ,136427,,"21,433 x DRG Weight",136427,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,474582,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,,inpatient,,,568710.96,84954,,,84954,Other,150% of Medicare + 9.63% HCRA Surcharge,51660.9,,,51660.9,Other,Medicare IPPS methodology,146565,,"25,728 x DRG weight",146565,Other,base rate x DRG weight,131907,,"23,155 x DRG weight",131907,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,284355,50,,284355,Percent of Total Billed Charges,50% of Charges,165751,,"29,096 x DRG Weight",165751,Other,base rate x DRG weight,127965,,"22,463 x DRG Weight",127965,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,150541,,"26,426 x DRG Weight",150541,Other,base rate x DRG weight,221083,,"38,809 x DRG Weight",221083,Other,base rate x DRG weight,221083,,"38,809 x DRG Weight",221083,Other,base rate x DRG weight,150541,,"26,426 x DRG Weight",150541,Other,base rate x DRG weight,221083,,"38,809 x DRG Weight",221083,Other,base rate x DRG weight,201612,,"35,391 x DRG Weight",201612,Other,base rate x DRG weight,398098,70,,398098,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,143648,,"25,216 X DRG Weight",143648,Other,Base Weight X DRG Weight,129287,,"22,695 X DRG Weight",129287,Other,Base Weight X DRG Weight,143648,,"25,216 X DRG Weight",143648,Other,Base Rate x DRG Weight ,122097,,"21,433 x DRG Weight",122097,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,398098,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,,inpatient,,,779264.3,114830,,,114830,Other,150% of Medicare + 9.63% HCRA Surcharge,69828.62,,,69828.62,Other,Medicare IPPS methodology,198394,,"25,728 x DRG weight",198394,Other,base rate x DRG weight,178553,,"23,155 x DRG weight",178553,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,389632,50,,389632,Percent of Total Billed Charges,50% of Charges,224365,,"29,096 x DRG Weight",224365,Other,base rate x DRG weight,173217,,"22,463 x DRG Weight",173217,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,203776,,"26,426 x DRG Weight",203776,Other,base rate x DRG weight,299264,,"38,809 x DRG Weight",299264,Other,base rate x DRG weight,299264,,"38,809 x DRG Weight",299264,Other,base rate x DRG weight,203776,,"26,426 x DRG Weight",203776,Other,base rate x DRG weight,299264,,"38,809 x DRG Weight",299264,Other,base rate x DRG weight,272907,,"35,391 x DRG Weight",272907,Other,base rate x DRG weight,545485,70,,545485,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,194446,,"25,216 X DRG Weight",194446,Other,Base Weight X DRG Weight,175006,,"22,695 X DRG Weight",175006,Other,Base Weight X DRG Weight,194446,,"25,216 X DRG Weight",194446,Other,Base Rate x DRG Weight ,165274,,"21,433 x DRG Weight",165274,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,545485,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,,inpatient,,,583822.96,78249,,,78249,Other,150% of Medicare + 9.63% HCRA Surcharge,47583.64,,,47583.64,Other,Medicare IPPS methodology,134933,,"25,728 x DRG weight",134933,Other,base rate x DRG weight,121439,,"23,155 x DRG weight",121439,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,291911,50,,291911,Percent of Total Billed Charges,50% of Charges,152597,,"29,096 x DRG Weight",152597,Other,base rate x DRG weight,117809,,"22,463 x DRG Weight",117809,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,138594,,"26,426 x DRG Weight",138594,Other,base rate x DRG weight,203538,,"38,809 x DRG Weight",203538,Other,base rate x DRG weight,203538,,"38,809 x DRG Weight",203538,Other,base rate x DRG weight,138594,,"26,426 x DRG Weight",138594,Other,base rate x DRG weight,203538,,"38,809 x DRG Weight",203538,Other,base rate x DRG weight,185612,,"35,391 x DRG Weight",185612,Other,base rate x DRG weight,408676,70,,408676,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,132248,,"25,216 X DRG Weight",132248,Other,Base Weight X DRG Weight,119026,,"22,695 X DRG Weight",119026,Other,Base Weight X DRG Weight,132248,,"25,216 X DRG Weight",132248,Other,Base Rate x DRG Weight ,112408,,"21,433 x DRG Weight",112408,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,408676,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,,inpatient,,,416384.25,69410,,,69410,Other,150% of Medicare + 9.63% HCRA Surcharge,42208.63,,,42208.63,Other,Medicare IPPS methodology,119599,,"25,728 x DRG weight",119599,Other,base rate x DRG weight,107638,,"23,155 x DRG weight",107638,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,208192,50,,208192,Percent of Total Billed Charges,50% of Charges,135256,,"29,096 x DRG Weight",135256,Other,base rate x DRG weight,104422,,"22,463 x DRG Weight",104422,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,122844,,"26,426 x DRG Weight",122844,Other,base rate x DRG weight,180408,,"38,809 x DRG Weight",180408,Other,base rate x DRG weight,180408,,"38,809 x DRG Weight",180408,Other,base rate x DRG weight,122844,,"26,426 x DRG Weight",122844,Other,base rate x DRG weight,180408,,"38,809 x DRG Weight",180408,Other,base rate x DRG weight,164519,,"35,391 x DRG Weight",164519,Other,base rate x DRG weight,291469,70,,291469,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,117219,,"25,216 X DRG Weight",117219,Other,Base Weight X DRG Weight,105500,,"22,695 X DRG Weight",105500,Other,Base Weight X DRG Weight,117219,,"25,216 X DRG Weight",117219,Other,Base Rate x DRG Weight ,99633,,"21,433 x DRG Weight",99633,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,291469,
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,,inpatient,,,573616.59,75195,,,75195,Other,150% of Medicare + 9.63% HCRA Surcharge,45726.74,,,45726.74,Other,Medicare IPPS methodology,129636,,"25,728 x DRG weight",129636,Other,base rate x DRG weight,116671,,"23,155 x DRG weight",116671,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,286808,50,,286808,Percent of Total Billed Charges,50% of Charges,146606,,"29,096 x DRG Weight",146606,Other,base rate x DRG weight,113184,,"22,463 x DRG Weight",113184,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,133153,,"26,426 x DRG Weight",133153,Other,base rate x DRG weight,195547,,"38,809 x DRG Weight",195547,Other,base rate x DRG weight,195547,,"38,809 x DRG Weight",195547,Other,base rate x DRG weight,133153,,"26,426 x DRG Weight",133153,Other,base rate x DRG weight,195547,,"38,809 x DRG Weight",195547,Other,base rate x DRG weight,178325,,"35,391 x DRG Weight",178325,Other,base rate x DRG weight,401532,70,,401532,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,127056,,"25,216 X DRG Weight",127056,Other,Base Weight X DRG Weight,114353,,"22,695 X DRG Weight",114353,Other,Base Weight X DRG Weight,127056,,"25,216 X DRG Weight",127056,Other,Base Rate x DRG Weight ,107994,,"21,433 x DRG Weight",107994,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,401532,
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,,inpatient,,,301670.68,47624,,,47624,Other,150% of Medicare + 9.63% HCRA Surcharge,28960.48,,,28960.48,Other,Medicare IPPS methodology,81805,,"25,728 x DRG weight",81805,Other,base rate x DRG weight,73624,,"23,155 x DRG weight",73624,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,150835,50,,150835,Percent of Total Billed Charges,50% of Charges,92514,,"29,096 x DRG Weight",92514,Other,base rate x DRG weight,71423,,"22,463 x DRG Weight",71423,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,84024,,"26,426 x DRG Weight",84024,Other,base rate x DRG weight,123397,,"38,809 x DRG Weight",123397,Other,base rate x DRG weight,123397,,"38,809 x DRG Weight",123397,Other,base rate x DRG weight,84024,,"26,426 x DRG Weight",84024,Other,base rate x DRG weight,123397,,"38,809 x DRG Weight",123397,Other,base rate x DRG weight,112529,,"35,391 x DRG Weight",112529,Other,base rate x DRG weight,211169,70,,211169,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,80177,,"25,216 X DRG Weight",80177,Other,Base Weight X DRG Weight,72161,,"22,695 X DRG Weight",72161,Other,Base Weight X DRG Weight,80177,,"25,216 X DRG Weight",80177,Other,Base Rate x DRG Weight ,68148,,"21,433 x DRG Weight",68148,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,211169,
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,,inpatient,,,1154004.57,120821,,,120821,Other,150% of Medicare + 9.63% HCRA Surcharge,73472.09,,,73472.09,Other,Medicare IPPS methodology,208788,,"25,728 x DRG weight",208788,Other,base rate x DRG weight,187907,,"23,155 x DRG weight",187907,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,577002,50,,577002,Percent of Total Billed Charges,50% of Charges,236120,,"29,096 x DRG Weight",236120,Other,base rate x DRG weight,182292,,"22,463 x DRG Weight",182292,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,214452,,"26,426 x DRG Weight",214452,Other,base rate x DRG weight,314943,,"38,809 x DRG Weight",314943,Other,base rate x DRG weight,314943,,"38,809 x DRG Weight",314943,Other,base rate x DRG weight,214452,,"26,426 x DRG Weight",214452,Other,base rate x DRG weight,314943,,"38,809 x DRG Weight",314943,Other,base rate x DRG weight,287205,,"35,391 x DRG Weight",287205,Other,base rate x DRG weight,807803,70,,807803,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,204633,,"25,216 X DRG Weight",204633,Other,Base Weight X DRG Weight,184174,,"22,695 X DRG Weight",184174,Other,Base Weight X DRG Weight,204633,,"25,216 X DRG Weight",204633,Other,Base Rate x DRG Weight ,173933,,"21,433 x DRG Weight",173933,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,807803,
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,,inpatient,,,588002.47,88690,,,88690,Other,150% of Medicare + 9.63% HCRA Surcharge,53932.65,,,53932.65,Other,Medicare IPPS methodology,153046,,"25,728 x DRG weight",153046,Other,base rate x DRG weight,137740,,"23,155 x DRG weight",137740,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,294001,50,,294001,Percent of Total Billed Charges,50% of Charges,173080,,"29,096 x DRG Weight",173080,Other,base rate x DRG weight,133623,,"22,463 x DRG Weight",133623,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,157198,,"26,426 x DRG Weight",157198,Other,base rate x DRG weight,230859,,"38,809 x DRG Weight",230859,Other,base rate x DRG weight,230859,,"38,809 x DRG Weight",230859,Other,base rate x DRG weight,157198,,"26,426 x DRG Weight",157198,Other,base rate x DRG weight,230859,,"38,809 x DRG Weight",230859,Other,base rate x DRG weight,210527,,"35,391 x DRG Weight",210527,Other,base rate x DRG weight,411602,70,,411602,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,150000,,"25,216 X DRG Weight",150000,Other,Base Weight X DRG Weight,135003,,"22,695 X DRG Weight",135003,Other,Base Weight X DRG Weight,150000,,"25,216 X DRG Weight",150000,Other,Base Rate x DRG Weight ,127496,,"21,433 x DRG Weight",127496,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,411602,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,,inpatient,,,764165.03,116141,,,116141,Other,150% of Medicare + 9.63% HCRA Surcharge,70625.86,,,70625.86,Other,Medicare IPPS methodology,200668,,"25,728 x DRG weight",200668,Other,base rate x DRG weight,180600,,"23,155 x DRG weight",180600,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,382083,50,,382083,Percent of Total Billed Charges,50% of Charges,226937,,"29,096 x DRG Weight",226937,Other,base rate x DRG weight,175202,,"22,463 x DRG Weight",175202,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,206112,,"26,426 x DRG Weight",206112,Other,base rate x DRG weight,302695,,"38,809 x DRG Weight",302695,Other,base rate x DRG weight,302695,,"38,809 x DRG Weight",302695,Other,base rate x DRG weight,206112,,"26,426 x DRG Weight",206112,Other,base rate x DRG weight,302695,,"38,809 x DRG Weight",302695,Other,base rate x DRG weight,276036,,"35,391 x DRG Weight",276036,Other,base rate x DRG weight,534916,70,,534916,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,196675,,"25,216 X DRG Weight",196675,Other,Base Weight X DRG Weight,177012,,"22,695 X DRG Weight",177012,Other,Base Weight X DRG Weight,196675,,"25,216 X DRG Weight",196675,Other,Base Rate x DRG Weight ,167169,,"21,433 x DRG Weight",167169,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,534916,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,,inpatient,,,578985.14,77556,,,77556,Other,150% of Medicare + 9.63% HCRA Surcharge,47162.48,,,47162.48,Other,Medicare IPPS methodology,133732,,"25,728 x DRG weight",133732,Other,base rate x DRG weight,120357,,"23,155 x DRG weight",120357,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,289493,50,,289493,Percent of Total Billed Charges,50% of Charges,151238,,"29,096 x DRG Weight",151238,Other,base rate x DRG weight,116760,,"22,463 x DRG Weight",116760,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,137360,,"26,426 x DRG Weight",137360,Other,base rate x DRG weight,201725,,"38,809 x DRG Weight",201725,Other,base rate x DRG weight,201725,,"38,809 x DRG Weight",201725,Other,base rate x DRG weight,137360,,"26,426 x DRG Weight",137360,Other,base rate x DRG weight,201725,,"38,809 x DRG Weight",201725,Other,base rate x DRG weight,183959,,"35,391 x DRG Weight",183959,Other,base rate x DRG weight,405290,70,,405290,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,131070,,"25,216 X DRG Weight",131070,Other,Base Weight X DRG Weight,117966,,"22,695 X DRG Weight",117966,Other,Base Weight X DRG Weight,131070,,"25,216 X DRG Weight",131070,Other,Base Rate x DRG Weight ,111407,,"21,433 x DRG Weight",111407,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,405290,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,,inpatient,,,616184.41,87681,,,87681,Other,150% of Medicare + 9.63% HCRA Surcharge,53319.39,,,53319.39,Other,Medicare IPPS methodology,151296,,"25,728 x DRG weight",151296,Other,base rate x DRG weight,136165,,"23,155 x DRG weight",136165,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,308092,50,,308092,Percent of Total Billed Charges,50% of Charges,171102,,"29,096 x DRG Weight",171102,Other,base rate x DRG weight,132096,,"22,463 x DRG Weight",132096,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,155401,,"26,426 x DRG Weight",155401,Other,base rate x DRG weight,228220,,"38,809 x DRG Weight",228220,Other,base rate x DRG weight,228220,,"38,809 x DRG Weight",228220,Other,base rate x DRG weight,155401,,"26,426 x DRG Weight",155401,Other,base rate x DRG weight,228220,,"38,809 x DRG Weight",228220,Other,base rate x DRG weight,208120,,"35,391 x DRG Weight",208120,Other,base rate x DRG weight,431329,70,,431329,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,148285,,"25,216 X DRG Weight",148285,Other,Base Weight X DRG Weight,133460,,"22,695 X DRG Weight",133460,Other,Base Weight X DRG Weight,148285,,"25,216 X DRG Weight",148285,Other,Base Rate x DRG Weight ,126039,,"21,433 x DRG Weight",126039,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,431329,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,,inpatient,,,486448.72,60402,,,60402,Other,150% of Medicare + 9.63% HCRA Surcharge,36730.8,,,36730.8,Other,Medicare IPPS methodology,103972,,"25,728 x DRG weight",103972,Other,base rate x DRG weight,93574,,"23,155 x DRG weight",93574,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,243224,50,,243224,Percent of Total Billed Charges,50% of Charges,117583,,"29,096 x DRG Weight",117583,Other,base rate x DRG weight,90777,,"22,463 x DRG Weight",90777,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,106793,,"26,426 x DRG Weight",106793,Other,base rate x DRG weight,156835,,"38,809 x DRG Weight",156835,Other,base rate x DRG weight,156835,,"38,809 x DRG Weight",156835,Other,base rate x DRG weight,106793,,"26,426 x DRG Weight",106793,Other,base rate x DRG weight,156835,,"38,809 x DRG Weight",156835,Other,base rate x DRG weight,143022,,"35,391 x DRG Weight",143022,Other,base rate x DRG weight,340514,70,,340514,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,101903,,"25,216 X DRG Weight",101903,Other,Base Weight X DRG Weight,91715,,"22,695 X DRG Weight",91715,Other,Base Weight X DRG Weight,101903,,"25,216 X DRG Weight",101903,Other,Base Rate x DRG Weight ,86615,,"21,433 x DRG Weight",86615,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,340514,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,,inpatient,,,922646.48,71756,,,71756,Other,150% of Medicare + 9.63% HCRA Surcharge,43635.35,,,43635.35,Other,Medicare IPPS methodology,123669,,"25,728 x DRG weight",123669,Other,base rate x DRG weight,111301,,"23,155 x DRG weight",111301,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,461323,50,,461323,Percent of Total Billed Charges,50% of Charges,139859,,"29,096 x DRG Weight",139859,Other,base rate x DRG weight,107975,,"22,463 x DRG Weight",107975,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,127024,,"26,426 x DRG Weight",127024,Other,base rate x DRG weight,186547,,"38,809 x DRG Weight",186547,Other,base rate x DRG weight,186547,,"38,809 x DRG Weight",186547,Other,base rate x DRG weight,127024,,"26,426 x DRG Weight",127024,Other,base rate x DRG weight,186547,,"38,809 x DRG Weight",186547,Other,base rate x DRG weight,170117,,"35,391 x DRG Weight",170117,Other,base rate x DRG weight,645853,70,,645853,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,121208,,"25,216 X DRG Weight",121208,Other,Base Weight X DRG Weight,109090,,"22,695 X DRG Weight",109090,Other,Base Weight X DRG Weight,121208,,"25,216 X DRG Weight",121208,Other,Base Rate x DRG Weight ,103024,,"21,433 x DRG Weight",103024,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,645853,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,,inpatient,,,628646.8,42131,,,42131,Other,150% of Medicare + 9.63% HCRA Surcharge,25620.03,,,25620.03,Other,Medicare IPPS methodology,72275,,"25,728 x DRG weight",72275,Other,base rate x DRG weight,65047,,"23,155 x DRG weight",65047,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,314323,50,,314323,Percent of Total Billed Charges,50% of Charges,81736,,"29,096 x DRG Weight",81736,Other,base rate x DRG weight,63103,,"22,463 x DRG Weight",63103,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,74236,,"26,426 x DRG Weight",74236,Other,base rate x DRG weight,109022,,"38,809 x DRG Weight",109022,Other,base rate x DRG weight,109022,,"38,809 x DRG Weight",109022,Other,base rate x DRG weight,74236,,"26,426 x DRG Weight",74236,Other,base rate x DRG weight,109022,,"38,809 x DRG Weight",109022,Other,base rate x DRG weight,99420,,"35,391 x DRG Weight",99420,Other,base rate x DRG weight,440053,70,,440053,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,70837,,"25,216 X DRG Weight",70837,Other,Base Weight X DRG Weight,63755,,"22,695 X DRG Weight",63755,Other,Base Weight X DRG Weight,70837,,"25,216 X DRG Weight",70837,Other,Base Rate x DRG Weight ,60210,,"21,433 x DRG Weight",60210,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,440053,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,MS-DRG,,,,,,,,inpatient,,,278137.31,21143,,,21143,Other,150% of Medicare + 9.63% HCRA Surcharge,12857.08,,,12857.08,Other,Medicare IPPS methodology,35865,,"25,728 x DRG weight",35865,Other,base rate x DRG weight,32278,,"23,155 x DRG weight",32278,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,139069,50,,139069,Percent of Total Billed Charges,50% of Charges,40560,,"29,096 x DRG Weight",40560,Other,base rate x DRG weight,31313,,"22,463 x DRG Weight",31313,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,36838,,"26,426 x DRG Weight",36838,Other,base rate x DRG weight,54100,,"38,809 x DRG Weight",54100,Other,base rate x DRG weight,54100,,"38,809 x DRG Weight",54100,Other,base rate x DRG weight,36838,,"26,426 x DRG Weight",36838,Other,base rate x DRG weight,54100,,"38,809 x DRG Weight",54100,Other,base rate x DRG weight,49335,,"35,391 x DRG Weight",49335,Other,base rate x DRG weight,194696,70,,194696,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35151,,"25,216 X DRG Weight",35151,Other,Base Weight X DRG Weight,31637,,"22,695 X DRG Weight",31637,Other,Base Weight X DRG Weight,35151,,"25,216 X DRG Weight",35151,Other,Base Rate x DRG Weight ,29878,,"21,433 x DRG Weight",29878,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,194696,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,,inpatient,,,517066.14,51710,,,51710,Other,150% of Medicare + 9.63% HCRA Surcharge,31445.07,,,31445.07,Other,Medicare IPPS methodology,88893,,"25,728 x DRG weight",88893,Other,base rate x DRG weight,80003,,"23,155 x DRG weight",80003,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,258533,50,,258533,Percent of Total Billed Charges,50% of Charges,100530,,"29,096 x DRG Weight",100530,Other,base rate x DRG weight,77612,,"22,463 x DRG Weight",77612,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,91304,,"26,426 x DRG Weight",91304,Other,base rate x DRG weight,134089,,"38,809 x DRG Weight",134089,Other,base rate x DRG weight,134089,,"38,809 x DRG Weight",134089,Other,base rate x DRG weight,91304,,"26,426 x DRG Weight",91304,Other,base rate x DRG weight,134089,,"38,809 x DRG Weight",134089,Other,base rate x DRG weight,122279,,"35,391 x DRG Weight",122279,Other,base rate x DRG weight,361946,70,,361946,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,87124,,"25,216 X DRG Weight",87124,Other,Base Weight X DRG Weight,78413,,"22,695 X DRG Weight",78413,Other,Base Weight X DRG Weight,87124,,"25,216 X DRG Weight",87124,Other,Base Rate x DRG Weight ,74053,,"21,433 x DRG Weight",74053,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,361946,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,,inpatient,,,286481.93,34247,,,34247,Other,150% of Medicare + 9.63% HCRA Surcharge,20825.81,,,20825.81,Other,Medicare IPPS methodology,58598,,"25,728 x DRG weight",58598,Other,base rate x DRG weight,52738,,"23,155 x DRG weight",52738,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,143241,50,,143241,Percent of Total Billed Charges,50% of Charges,66269,,"29,096 x DRG Weight",66269,Other,base rate x DRG weight,51162,,"22,463 x DRG Weight",51162,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,60188,,"26,426 x DRG Weight",60188,Other,base rate x DRG weight,88391,,"38,809 x DRG Weight",88391,Other,base rate x DRG weight,88391,,"38,809 x DRG Weight",88391,Other,base rate x DRG weight,60188,,"26,426 x DRG Weight",60188,Other,base rate x DRG weight,88391,,"38,809 x DRG Weight",88391,Other,base rate x DRG weight,80607,,"35,391 x DRG Weight",80607,Other,base rate x DRG weight,200537,70,,200537,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,57432,,"25,216 X DRG Weight",57432,Other,Base Weight X DRG Weight,51690,,"22,695 X DRG Weight",51690,Other,Base Weight X DRG Weight,57432,,"25,216 X DRG Weight",57432,Other,Base Rate x DRG Weight ,48816,,"21,433 x DRG Weight",48816,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,200537,
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,,inpatient,,,204054.44,27601,,,27601,Other,150% of Medicare + 9.63% HCRA Surcharge,16784.63,,,16784.63,Other,Medicare IPPS methodology,47069,,"25,728 x DRG weight",47069,Other,base rate x DRG weight,42362,,"23,155 x DRG weight",42362,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,102027,50,,102027,Percent of Total Billed Charges,50% of Charges,53231,,"29,096 x DRG Weight",53231,Other,base rate x DRG weight,41096,,"22,463 x DRG Weight",41096,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,48346,,"26,426 x DRG Weight",48346,Other,base rate x DRG weight,71001,,"38,809 x DRG Weight",71001,Other,base rate x DRG weight,71001,,"38,809 x DRG Weight",71001,Other,base rate x DRG weight,48346,,"26,426 x DRG Weight",48346,Other,base rate x DRG weight,71001,,"38,809 x DRG Weight",71001,Other,base rate x DRG weight,64748,,"35,391 x DRG Weight",64748,Other,base rate x DRG weight,142838,70,,142838,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46133,,"25,216 X DRG Weight",46133,Other,Base Weight X DRG Weight,41521,,"22,695 X DRG Weight",41521,Other,Base Weight X DRG Weight,46133,,"25,216 X DRG Weight",46133,Other,Base Rate x DRG Weight ,39212,,"21,433 x DRG Weight",39212,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,142838,
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,,inpatient,,,449127.75,67672,,,67672,Other,150% of Medicare + 9.63% HCRA Surcharge,41151.66,,,41151.66,Other,Medicare IPPS methodology,116584,,"25,728 x DRG weight",116584,Other,base rate x DRG weight,104925,,"23,155 x DRG weight",104925,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,224564,50,,224564,Percent of Total Billed Charges,50% of Charges,131846,,"29,096 x DRG Weight",131846,Other,base rate x DRG weight,101789,,"22,463 x DRG Weight",101789,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,119747,,"26,426 x DRG Weight",119747,Other,base rate x DRG weight,175859,,"38,809 x DRG Weight",175859,Other,base rate x DRG weight,175859,,"38,809 x DRG Weight",175859,Other,base rate x DRG weight,119747,,"26,426 x DRG Weight",119747,Other,base rate x DRG weight,175859,,"38,809 x DRG Weight",175859,Other,base rate x DRG weight,160371,,"35,391 x DRG Weight",160371,Other,base rate x DRG weight,314389,70,,314389,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,114264,,"25,216 X DRG Weight",114264,Other,Base Weight X DRG Weight,102840,,"22,695 X DRG Weight",102840,Other,Base Weight X DRG Weight,114264,,"25,216 X DRG Weight",114264,Other,Base Rate x DRG Weight ,97121,,"21,433 x DRG Weight",97121,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,314389,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,,inpatient,,,338735.7,35333,,,35333,Other,150% of Medicare + 9.63% HCRA Surcharge,21485.96,,,21485.96,Other,Medicare IPPS methodology,60481,,"25,728 x DRG weight",60481,Other,base rate x DRG weight,54433,,"23,155 x DRG weight",54433,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,169368,50,,169368,Percent of Total Billed Charges,50% of Charges,68399,,"29,096 x DRG Weight",68399,Other,base rate x DRG weight,52806,,"22,463 x DRG Weight",52806,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,62122,,"26,426 x DRG Weight",62122,Other,base rate x DRG weight,91232,,"38,809 x DRG Weight",91232,Other,base rate x DRG weight,91232,,"38,809 x DRG Weight",91232,Other,base rate x DRG weight,62122,,"26,426 x DRG Weight",62122,Other,base rate x DRG weight,91232,,"38,809 x DRG Weight",91232,Other,base rate x DRG weight,83197,,"35,391 x DRG Weight",83197,Other,base rate x DRG weight,237115,70,,237115,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,59278,,"25,216 X DRG Weight",59278,Other,Base Weight X DRG Weight,53351,,"22,695 X DRG Weight",53351,Other,Base Weight X DRG Weight,59278,,"25,216 X DRG Weight",59278,Other,Base Rate x DRG Weight ,50385,,"21,433 x DRG Weight",50385,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,237115,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,,inpatient,,,128369.42,24004,,,24004,Other,150% of Medicare + 9.63% HCRA Surcharge,14596.75,,,14596.75,Other,Medicare IPPS methodology,40828,,"25,728 x DRG weight",40828,Other,base rate x DRG weight,36745,,"23,155 x DRG weight",36745,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,64185,50,,64185,Percent of Total Billed Charges,50% of Charges,46172,,"29,096 x DRG Weight",46172,Other,base rate x DRG weight,35647,,"22,463 x DRG Weight",35647,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41935,,"26,426 x DRG Weight",41935,Other,base rate x DRG weight,61586,,"38,809 x DRG Weight",61586,Other,base rate x DRG weight,61586,,"38,809 x DRG Weight",61586,Other,base rate x DRG weight,41935,,"26,426 x DRG Weight",41935,Other,base rate x DRG weight,61586,,"38,809 x DRG Weight",61586,Other,base rate x DRG weight,56162,,"35,391 x DRG Weight",56162,Other,base rate x DRG weight,89859,70,,89859,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40015,,"25,216 X DRG Weight",40015,Other,Base Weight X DRG Weight,36015,,"22,695 X DRG Weight",36015,Other,Base Weight X DRG Weight,40015,,"25,216 X DRG Weight",40015,Other,Base Rate x DRG Weight ,34012,,"21,433 x DRG Weight",34012,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,89859,
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,,inpatient,,,419441.03,50208,,,50208,Other,150% of Medicare + 9.63% HCRA Surcharge,30531.5,,,30531.5,Other,Medicare IPPS methodology,86287,,"25,728 x DRG weight",86287,Other,base rate x DRG weight,77657,,"23,155 x DRG weight",77657,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,209721,50,,209721,Percent of Total Billed Charges,50% of Charges,97582,,"29,096 x DRG Weight",97582,Other,base rate x DRG weight,75336,,"22,463 x DRG Weight",75336,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,88628,,"26,426 x DRG Weight",88628,Other,base rate x DRG weight,130158,,"38,809 x DRG Weight",130158,Other,base rate x DRG weight,130158,,"38,809 x DRG Weight",130158,Other,base rate x DRG weight,88628,,"26,426 x DRG Weight",88628,Other,base rate x DRG weight,130158,,"38,809 x DRG Weight",130158,Other,base rate x DRG weight,118694,,"35,391 x DRG Weight",118694,Other,base rate x DRG weight,293609,70,,293609,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,84569,,"25,216 X DRG Weight",84569,Other,Base Weight X DRG Weight,76114,,"22,695 X DRG Weight",76114,Other,Base Weight X DRG Weight,84569,,"25,216 X DRG Weight",84569,Other,Base Rate x DRG Weight ,71882,,"21,433 x DRG Weight",71882,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,293609,
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,,inpatient,,,373894.59,38303,,,38303,Other,150% of Medicare + 9.63% HCRA Surcharge,23292.36,,,23292.36,Other,Medicare IPPS methodology,65635,,"25,728 x DRG weight",65635,Other,base rate x DRG weight,59071,,"23,155 x DRG weight",59071,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,186947,50,,186947,Percent of Total Billed Charges,50% of Charges,74227,,"29,096 x DRG Weight",74227,Other,base rate x DRG weight,57305,,"22,463 x DRG Weight",57305,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,67415,,"26,426 x DRG Weight",67415,Other,base rate x DRG weight,99006,,"38,809 x DRG Weight",99006,Other,base rate x DRG weight,99006,,"38,809 x DRG Weight",99006,Other,base rate x DRG weight,67415,,"26,426 x DRG Weight",67415,Other,base rate x DRG weight,99006,,"38,809 x DRG Weight",99006,Other,base rate x DRG weight,90286,,"35,391 x DRG Weight",90286,Other,base rate x DRG weight,261726,70,,261726,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,64329,,"25,216 X DRG Weight",64329,Other,Base Weight X DRG Weight,57897,,"22,695 X DRG Weight",57897,Other,Base Weight X DRG Weight,64329,,"25,216 X DRG Weight",64329,Other,Base Rate x DRG Weight ,54678,,"21,433 x DRG Weight",54678,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,261726,
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,,inpatient,,,167941.28,26201,,,26201,Other,150% of Medicare + 9.63% HCRA Surcharge,15933.28,,,15933.28,Other,Medicare IPPS methodology,44641,,"25,728 x DRG weight",44641,Other,base rate x DRG weight,40176,,"23,155 x DRG weight",40176,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,83971,50,,83971,Percent of Total Billed Charges,50% of Charges,50484,,"29,096 x DRG Weight",50484,Other,base rate x DRG weight,38976,,"22,463 x DRG Weight",38976,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,45852,,"26,426 x DRG Weight",45852,Other,base rate x DRG weight,67337,,"38,809 x DRG Weight",67337,Other,base rate x DRG weight,67337,,"38,809 x DRG Weight",67337,Other,base rate x DRG weight,45852,,"26,426 x DRG Weight",45852,Other,base rate x DRG weight,67337,,"38,809 x DRG Weight",67337,Other,base rate x DRG weight,61407,,"35,391 x DRG Weight",61407,Other,base rate x DRG weight,117559,70,,117559,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43752,,"25,216 X DRG Weight",43752,Other,Base Weight X DRG Weight,39378,,"22,695 X DRG Weight",39378,Other,Base Weight X DRG Weight,43752,,"25,216 X DRG Weight",43752,Other,Base Rate x DRG Weight ,37188,,"21,433 x DRG Weight",37188,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,117559,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,,inpatient,,,266996.59,41214,,,41214,Other,150% of Medicare + 9.63% HCRA Surcharge,25062.69,,,25062.69,Other,Medicare IPPS methodology,70685,,"25,728 x DRG weight",70685,Other,base rate x DRG weight,63616,,"23,155 x DRG weight",63616,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,133498,50,,133498,Percent of Total Billed Charges,50% of Charges,79938,,"29,096 x DRG Weight",79938,Other,base rate x DRG weight,61715,,"22,463 x DRG Weight",61715,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,72603,,"26,426 x DRG Weight",72603,Other,base rate x DRG weight,106624,,"38,809 x DRG Weight",106624,Other,base rate x DRG weight,106624,,"38,809 x DRG Weight",106624,Other,base rate x DRG weight,72603,,"26,426 x DRG Weight",72603,Other,base rate x DRG weight,106624,,"38,809 x DRG Weight",106624,Other,base rate x DRG weight,97233,,"35,391 x DRG Weight",97233,Other,base rate x DRG weight,186898,70,,186898,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,69278,,"25,216 X DRG Weight",69278,Other,Base Weight X DRG Weight,62352,,"22,695 X DRG Weight",62352,Other,Base Weight X DRG Weight,69278,,"25,216 X DRG Weight",69278,Other,Base Rate x DRG Weight ,58885,,"21,433 x DRG Weight",58885,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,186898,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,MS-DRG,,,,,,,,inpatient,,,306098.74,24787,,,24787,Other,150% of Medicare + 9.63% HCRA Surcharge,15072.92,,,15072.92,Other,Medicare IPPS methodology,42186,,"25,728 x DRG weight",42186,Other,base rate x DRG weight,37967,,"23,155 x DRG weight",37967,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,153049,50,,153049,Percent of Total Billed Charges,50% of Charges,47709,,"29,096 x DRG Weight",47709,Other,base rate x DRG weight,36833,,"22,463 x DRG Weight",36833,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,43331,,"26,426 x DRG Weight",43331,Other,base rate x DRG weight,63635,,"38,809 x DRG Weight",63635,Other,base rate x DRG weight,63635,,"38,809 x DRG Weight",63635,Other,base rate x DRG weight,43331,,"26,426 x DRG Weight",43331,Other,base rate x DRG weight,63635,,"38,809 x DRG Weight",63635,Other,base rate x DRG weight,58031,,"35,391 x DRG Weight",58031,Other,base rate x DRG weight,214269,70,,214269,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,41347,,"25,216 X DRG Weight",41347,Other,Base Weight X DRG Weight,37213,,"22,695 X DRG Weight",37213,Other,Base Weight X DRG Weight,41347,,"25,216 X DRG Weight",41347,Other,Base Rate x DRG Weight ,35144,,"21,433 x DRG Weight",35144,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,214269,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,MS-DRG,,,,,,,,inpatient,,,131488.65,15166,,,15166,Other,150% of Medicare + 9.63% HCRA Surcharge,9222.63,,,9222.63,Other,Medicare IPPS methodology,25496,,"25,728 x DRG weight",25496,Other,base rate x DRG weight,22947,,"23,155 x DRG weight",22947,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,65744,50,,65744,Percent of Total Billed Charges,50% of Charges,28834,,"29,096 x DRG Weight",28834,Other,base rate x DRG weight,22261,,"22,463 x DRG Weight",22261,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26188,,"26,426 x DRG Weight",26188,Other,base rate x DRG weight,38460,,"38,809 x DRG Weight",38460,Other,base rate x DRG weight,38460,,"38,809 x DRG Weight",38460,Other,base rate x DRG weight,26188,,"26,426 x DRG Weight",26188,Other,base rate x DRG weight,38460,,"38,809 x DRG Weight",38460,Other,base rate x DRG weight,35072,,"35,391 x DRG Weight",35072,Other,base rate x DRG weight,92042,70,,92042,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24989,,"25,216 X DRG Weight",24989,Other,Base Weight X DRG Weight,22491,,"22,695 X DRG Weight",22491,Other,Base Weight X DRG Weight,24989,,"25,216 X DRG Weight",24989,Other,Base Rate x DRG Weight ,21240,,"21,433 x DRG Weight",21240,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,92042,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,MS-DRG,,,,,,,,inpatient,,,324936,40639,,,40639,Other,150% of Medicare + 9.63% HCRA Surcharge,24712.77,,,24712.77,Other,Medicare IPPS methodology,69687,,"25,728 x DRG weight",69687,Other,base rate x DRG weight,62718,,"23,155 x DRG weight",62718,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,162468,50,,162468,Percent of Total Billed Charges,50% of Charges,78809,,"29,096 x DRG Weight",78809,Other,base rate x DRG weight,60843,,"22,463 x DRG Weight",60843,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,71577,,"26,426 x DRG Weight",71577,Other,base rate x DRG weight,105118,,"38,809 x DRG Weight",105118,Other,base rate x DRG weight,105118,,"38,809 x DRG Weight",105118,Other,base rate x DRG weight,71577,,"26,426 x DRG Weight",71577,Other,base rate x DRG weight,105118,,"38,809 x DRG Weight",105118,Other,base rate x DRG weight,95860,,"35,391 x DRG Weight",95860,Other,base rate x DRG weight,227455,70,,227455,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,68300,,"25,216 X DRG Weight",68300,Other,Base Weight X DRG Weight,61472,,"22,695 X DRG Weight",61472,Other,Base Weight X DRG Weight,68300,,"25,216 X DRG Weight",68300,Other,Base Rate x DRG Weight ,58053,,"21,433 x DRG Weight",58053,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,227455,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,MS-DRG,,,,,,,,inpatient,,,163347,28152,,,28152,Other,150% of Medicare + 9.63% HCRA Surcharge,17119.21,,,17119.21,Other,Medicare IPPS methodology,48024,,"25,728 x DRG weight",48024,Other,base rate x DRG weight,43221,,"23,155 x DRG weight",43221,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,81674,50,,81674,Percent of Total Billed Charges,50% of Charges,54311,,"29,096 x DRG Weight",54311,Other,base rate x DRG weight,41929,,"22,463 x DRG Weight",41929,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,49327,,"26,426 x DRG Weight",49327,Other,base rate x DRG weight,72441,,"38,809 x DRG Weight",72441,Other,base rate x DRG weight,72441,,"38,809 x DRG Weight",72441,Other,base rate x DRG weight,49327,,"26,426 x DRG Weight",49327,Other,base rate x DRG weight,72441,,"38,809 x DRG Weight",72441,Other,base rate x DRG weight,66061,,"35,391 x DRG Weight",66061,Other,base rate x DRG weight,114343,70,,114343,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,47068,,"25,216 X DRG Weight",47068,Other,Base Weight X DRG Weight,42362,,"22,695 X DRG Weight",42362,Other,Base Weight X DRG Weight,47068,,"25,216 X DRG Weight",47068,Other,Base Rate x DRG Weight ,40007,,"21,433 x DRG Weight",40007,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,114343,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,,inpatient,,,378802.63,49635,,,49635,Other,150% of Medicare + 9.63% HCRA Surcharge,30183.38,,,30183.38,Other,Medicare IPPS methodology,85293,,"25,728 x DRG weight",85293,Other,base rate x DRG weight,76763,,"23,155 x DRG weight",76763,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,189401,50,,189401,Percent of Total Billed Charges,50% of Charges,96459,,"29,096 x DRG Weight",96459,Other,base rate x DRG weight,74469,,"22,463 x DRG Weight",74469,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,87607,,"26,426 x DRG Weight",87607,Other,base rate x DRG weight,128660,,"38,809 x DRG Weight",128660,Other,base rate x DRG weight,128660,,"38,809 x DRG Weight",128660,Other,base rate x DRG weight,87607,,"26,426 x DRG Weight",87607,Other,base rate x DRG weight,128660,,"38,809 x DRG Weight",128660,Other,base rate x DRG weight,117328,,"35,391 x DRG Weight",117328,Other,base rate x DRG weight,265162,70,,265162,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,83596,,"25,216 X DRG Weight",83596,Other,Base Weight X DRG Weight,75238,,"22,695 X DRG Weight",75238,Other,Base Weight X DRG Weight,83596,,"25,216 X DRG Weight",83596,Other,Base Rate x DRG Weight ,71055,,"21,433 x DRG Weight",71055,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,265162,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,,inpatient,,,247238.56,28377,,,28377,Other,150% of Medicare + 9.63% HCRA Surcharge,17256.3,,,17256.3,Other,Medicare IPPS methodology,48415,,"25,728 x DRG weight",48415,Other,base rate x DRG weight,43573,,"23,155 x DRG weight",43573,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,123619,50,,123619,Percent of Total Billed Charges,50% of Charges,54753,,"29,096 x DRG Weight",54753,Other,base rate x DRG weight,42271,,"22,463 x DRG Weight",42271,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,49728,,"26,426 x DRG Weight",49728,Other,base rate x DRG weight,73031,,"38,809 x DRG Weight",73031,Other,base rate x DRG weight,73031,,"38,809 x DRG Weight",73031,Other,base rate x DRG weight,49728,,"26,426 x DRG Weight",49728,Other,base rate x DRG weight,73031,,"38,809 x DRG Weight",73031,Other,base rate x DRG weight,66599,,"35,391 x DRG Weight",66599,Other,base rate x DRG weight,173067,70,,173067,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,47451,,"25,216 X DRG Weight",47451,Other,Base Weight X DRG Weight,42707,,"22,695 X DRG Weight",42707,Other,Base Weight X DRG Weight,47451,,"25,216 X DRG Weight",47451,Other,Base Rate x DRG Weight ,40333,,"21,433 x DRG Weight",40333,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,173067,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,,inpatient,,,184977.61,24870,,,24870,Other,150% of Medicare + 9.63% HCRA Surcharge,15123.43,,,15123.43,Other,Medicare IPPS methodology,42330,,"25,728 x DRG weight",42330,Other,base rate x DRG weight,38097,,"23,155 x DRG weight",38097,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,92489,50,,92489,Percent of Total Billed Charges,50% of Charges,47872,,"29,096 x DRG Weight",47872,Other,base rate x DRG weight,36958,,"22,463 x DRG Weight",36958,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,43479,,"26,426 x DRG Weight",43479,Other,base rate x DRG weight,63852,,"38,809 x DRG Weight",63852,Other,base rate x DRG weight,63852,,"38,809 x DRG Weight",63852,Other,base rate x DRG weight,43479,,"26,426 x DRG Weight",43479,Other,base rate x DRG weight,63852,,"38,809 x DRG Weight",63852,Other,base rate x DRG weight,58229,,"35,391 x DRG Weight",58229,Other,base rate x DRG weight,129484,70,,129484,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,41488,,"25,216 X DRG Weight",41488,Other,Base Weight X DRG Weight,37340,,"22,695 X DRG Weight",37340,Other,Base Weight X DRG Weight,41488,,"25,216 X DRG Weight",41488,Other,Base Rate x DRG Weight ,35264,,"21,433 x DRG Weight",35264,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,129484,
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,,inpatient,,,720089.09,42368,,,42368,Other,150% of Medicare + 9.63% HCRA Surcharge,25764.33,,,25764.33,Other,Medicare IPPS methodology,72687,,"25,728 x DRG weight",72687,Other,base rate x DRG weight,65418,,"23,155 x DRG weight",65418,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,360045,50,,360045,Percent of Total Billed Charges,50% of Charges,82202,,"29,096 x DRG Weight",82202,Other,base rate x DRG weight,63462,,"22,463 x DRG Weight",63462,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,74659,,"26,426 x DRG Weight",74659,Other,base rate x DRG weight,109643,,"38,809 x DRG Weight",109643,Other,base rate x DRG weight,109643,,"38,809 x DRG Weight",109643,Other,base rate x DRG weight,74659,,"26,426 x DRG Weight",74659,Other,base rate x DRG weight,109643,,"38,809 x DRG Weight",109643,Other,base rate x DRG weight,99987,,"35,391 x DRG Weight",99987,Other,base rate x DRG weight,504062,70,,504062,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,71240,,"25,216 X DRG Weight",71240,Other,Base Weight X DRG Weight,64118,,"22,695 X DRG Weight",64118,Other,Base Weight X DRG Weight,71240,,"25,216 X DRG Weight",71240,Other,Base Rate x DRG Weight ,60553,,"21,433 x DRG Weight",60553,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,504062,
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,,inpatient,,,500471.13,48905,,,48905,Other,150% of Medicare + 9.63% HCRA Surcharge,29739.68,,,29739.68,Other,Medicare IPPS methodology,84028,,"25,728 x DRG weight",84028,Other,base rate x DRG weight,75624,,"23,155 x DRG weight",75624,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,250236,50,,250236,Percent of Total Billed Charges,50% of Charges,95028,,"29,096 x DRG Weight",95028,Other,base rate x DRG weight,73364,,"22,463 x DRG Weight",73364,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,86307,,"26,426 x DRG Weight",86307,Other,base rate x DRG weight,126750,,"38,809 x DRG Weight",126750,Other,base rate x DRG weight,126750,,"38,809 x DRG Weight",126750,Other,base rate x DRG weight,86307,,"26,426 x DRG Weight",86307,Other,base rate x DRG weight,126750,,"38,809 x DRG Weight",126750,Other,base rate x DRG weight,115587,,"35,391 x DRG Weight",115587,Other,base rate x DRG weight,350330,70,,350330,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,82355,,"25,216 X DRG Weight",82355,Other,Base Weight X DRG Weight,74122,,"22,695 X DRG Weight",74122,Other,Base Weight X DRG Weight,82355,,"25,216 X DRG Weight",82355,Other,Base Rate x DRG Weight ,70000,,"21,433 x DRG Weight",70000,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,350330,
AICD LEAD PROCEDURES,265,MS-DRG,,,,,,,,inpatient,,,876391.52,52881,,,52881,Other,150% of Medicare + 9.63% HCRA Surcharge,32157.53,,,32157.53,Other,Medicare IPPS methodology,90925,,"25,728 x DRG weight",90925,Other,base rate x DRG weight,81832,,"23,155 x DRG weight",81832,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,438196,50,,438196,Percent of Total Billed Charges,50% of Charges,102828,,"29,096 x DRG Weight",102828,Other,base rate x DRG weight,79386,,"22,463 x DRG Weight",79386,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,93392,,"26,426 x DRG Weight",93392,Other,base rate x DRG weight,137155,,"38,809 x DRG Weight",137155,Other,base rate x DRG weight,137155,,"38,809 x DRG Weight",137155,Other,base rate x DRG weight,93392,,"26,426 x DRG Weight",93392,Other,base rate x DRG weight,137155,,"38,809 x DRG Weight",137155,Other,base rate x DRG weight,125075,,"35,391 x DRG Weight",125075,Other,base rate x DRG weight,613474,70,,613474,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,89116,,"25,216 X DRG Weight",89116,Other,Base Weight X DRG Weight,80206,,"22,695 X DRG Weight",80206,Other,Base Weight X DRG Weight,89116,,"25,216 X DRG Weight",89116,Other,Base Rate x DRG Weight ,75746,,"21,433 x DRG Weight",75746,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,613474,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,,inpatient,,,567767.19,93102,,,93102,Other,150% of Medicare + 9.63% HCRA Surcharge,56615.65,,,56615.65,Other,Medicare IPPS methodology,160700,,"25,728 x DRG weight",160700,Other,base rate x DRG weight,144628,,"23,155 x DRG weight",144628,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,283884,50,,283884,Percent of Total Billed Charges,50% of Charges,181737,,"29,096 x DRG Weight",181737,Other,base rate x DRG weight,140306,,"22,463 x DRG Weight",140306,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,165059,,"26,426 x DRG Weight",165059,Other,base rate x DRG weight,242405,,"38,809 x DRG Weight",242405,Other,base rate x DRG weight,242405,,"38,809 x DRG Weight",242405,Other,base rate x DRG weight,165059,,"26,426 x DRG Weight",165059,Other,base rate x DRG weight,242405,,"38,809 x DRG Weight",242405,Other,base rate x DRG weight,221056,,"35,391 x DRG Weight",221056,Other,base rate x DRG weight,397437,70,,397437,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,157502,,"25,216 X DRG Weight",157502,Other,Base Weight X DRG Weight,141755,,"22,695 X DRG Weight",141755,Other,Base Weight X DRG Weight,157502,,"25,216 X DRG Weight",157502,Other,Base Rate x DRG Weight ,133873,,"21,433 x DRG Weight",133873,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,397437,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,,inpatient,,,351716.98,72845,,,72845,Other,150% of Medicare + 9.63% HCRA Surcharge,44297.31,,,44297.31,Other,Medicare IPPS methodology,125558,,"25,728 x DRG weight",125558,Other,base rate x DRG weight,113001,,"23,155 x DRG weight",113001,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,175858,50,,175858,Percent of Total Billed Charges,50% of Charges,141994,,"29,096 x DRG Weight",141994,Other,base rate x DRG weight,109624,,"22,463 x DRG Weight",109624,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,128964,,"26,426 x DRG Weight",128964,Other,base rate x DRG weight,189396,,"38,809 x DRG Weight",189396,Other,base rate x DRG weight,189396,,"38,809 x DRG Weight",189396,Other,base rate x DRG weight,128964,,"26,426 x DRG Weight",128964,Other,base rate x DRG weight,189396,,"38,809 x DRG Weight",189396,Other,base rate x DRG weight,172715,,"35,391 x DRG Weight",172715,Other,base rate x DRG weight,246202,70,,246202,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,123059,,"25,216 X DRG Weight",123059,Other,Base Weight X DRG Weight,110756,,"22,695 X DRG Weight",110756,Other,Base Weight X DRG Weight,123059,,"25,216 X DRG Weight",123059,Other,Base Rate x DRG Weight ,104597,,"21,433 x DRG Weight",104597,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,246202,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,,inpatient,,,527800.13,102127,,,102127,Other,150% of Medicare + 9.63% HCRA Surcharge,62104.29,,,62104.29,Other,Medicare IPPS methodology,176358,,"25,728 x DRG weight",176358,Other,base rate x DRG weight,158721,,"23,155 x DRG weight",158721,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,263900,50,,263900,Percent of Total Billed Charges,50% of Charges,199444,,"29,096 x DRG Weight",199444,Other,base rate x DRG weight,153977,,"22,463 x DRG Weight",153977,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,181142,,"26,426 x DRG Weight",181142,Other,base rate x DRG weight,266024,,"38,809 x DRG Weight",266024,Other,base rate x DRG weight,266024,,"38,809 x DRG Weight",266024,Other,base rate x DRG weight,181142,,"26,426 x DRG Weight",181142,Other,base rate x DRG weight,266024,,"38,809 x DRG Weight",266024,Other,base rate x DRG weight,242595,,"35,391 x DRG Weight",242595,Other,base rate x DRG weight,369460,70,,369460,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,172848,,"25,216 X DRG Weight",172848,Other,Base Weight X DRG Weight,155567,,"22,695 X DRG Weight",155567,Other,Base Weight X DRG Weight,172848,,"25,216 X DRG Weight",172848,Other,Base Rate x DRG Weight ,146917,,"21,433 x DRG Weight",146917,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,369460,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,,inpatient,,,238295.27,62143,,,62143,Other,150% of Medicare + 9.63% HCRA Surcharge,37789.57,,,37789.57,Other,Medicare IPPS methodology,106992,,"25,728 x DRG weight",106992,Other,base rate x DRG weight,96292,,"23,155 x DRG weight",96292,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,119148,50,,119148,Percent of Total Billed Charges,50% of Charges,120999,,"29,096 x DRG Weight",120999,Other,base rate x DRG weight,93415,,"22,463 x DRG Weight",93415,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,109895,,"26,426 x DRG Weight",109895,Other,base rate x DRG weight,161391,,"38,809 x DRG Weight",161391,Other,base rate x DRG weight,161391,,"38,809 x DRG Weight",161391,Other,base rate x DRG weight,109895,,"26,426 x DRG Weight",109895,Other,base rate x DRG weight,161391,,"38,809 x DRG Weight",161391,Other,base rate x DRG weight,147177,,"35,391 x DRG Weight",147177,Other,base rate x DRG weight,166807,70,,166807,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,104863,,"25,216 X DRG Weight",104863,Other,Base Weight X DRG Weight,94379,,"22,695 X DRG Weight",94379,Other,Base Weight X DRG Weight,104863,,"25,216 X DRG Weight",104863,Other,Base Rate x DRG Weight ,89131,,"21,433 x DRG Weight",89131,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,166807,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,,inpatient,,,574901.75,75465,,,75465,Other,150% of Medicare + 9.63% HCRA Surcharge,45890.87,,,45890.87,Other,Medicare IPPS methodology,130104,,"25,728 x DRG weight",130104,Other,base rate x DRG weight,117093,,"23,155 x DRG weight",117093,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,287451,50,,287451,Percent of Total Billed Charges,50% of Charges,147136,,"29,096 x DRG Weight",147136,Other,base rate x DRG weight,113593,,"22,463 x DRG Weight",113593,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,133634,,"26,426 x DRG Weight",133634,Other,base rate x DRG weight,196253,,"38,809 x DRG Weight",196253,Other,base rate x DRG weight,196253,,"38,809 x DRG Weight",196253,Other,base rate x DRG weight,133634,,"26,426 x DRG Weight",133634,Other,base rate x DRG weight,196253,,"38,809 x DRG Weight",196253,Other,base rate x DRG weight,178969,,"35,391 x DRG Weight",178969,Other,base rate x DRG weight,402431,70,,402431,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,127515,,"25,216 X DRG Weight",127515,Other,Base Weight X DRG Weight,114766,,"22,695 X DRG Weight",114766,Other,Base Weight X DRG Weight,127515,,"25,216 X DRG Weight",127515,Other,Base Rate x DRG Weight ,108385,,"21,433 x DRG Weight",108385,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,402431,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,,inpatient,,,365025.15,51726,,,51726,Other,150% of Medicare + 9.63% HCRA Surcharge,31454.99,,,31454.99,Other,Medicare IPPS methodology,88921,,"25,728 x DRG weight",88921,Other,base rate x DRG weight,80028,,"23,155 x DRG weight",80028,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,182513,50,,182513,Percent of Total Billed Charges,50% of Charges,100562,,"29,096 x DRG Weight",100562,Other,base rate x DRG weight,77637,,"22,463 x DRG Weight",77637,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,91334,,"26,426 x DRG Weight",91334,Other,base rate x DRG weight,134132,,"38,809 x DRG Weight",134132,Other,base rate x DRG weight,134132,,"38,809 x DRG Weight",134132,Other,base rate x DRG weight,91334,,"26,426 x DRG Weight",91334,Other,base rate x DRG weight,134132,,"38,809 x DRG Weight",134132,Other,base rate x DRG weight,122318,,"35,391 x DRG Weight",122318,Other,base rate x DRG weight,255518,70,,255518,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,87152,,"25,216 X DRG Weight",87152,Other,Base Weight X DRG Weight,78438,,"22,695 X DRG Weight",78438,Other,Base Weight X DRG Weight,87152,,"25,216 X DRG Weight",87152,Other,Base Rate x DRG Weight ,74077,,"21,433 x DRG Weight",74077,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,255518,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,,inpatient,,,234749.99,36648,,,36648,Other,150% of Medicare + 9.63% HCRA Surcharge,22285.9,,,22285.9,Other,Medicare IPPS methodology,62763,,"25,728 x DRG weight",62763,Other,base rate x DRG weight,56487,,"23,155 x DRG weight",56487,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,117375,50,,117375,Percent of Total Billed Charges,50% of Charges,70980,,"29,096 x DRG Weight",70980,Other,base rate x DRG weight,54798,,"22,463 x DRG Weight",54798,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,64466,,"26,426 x DRG Weight",64466,Other,base rate x DRG weight,94675,,"38,809 x DRG Weight",94675,Other,base rate x DRG weight,94675,,"38,809 x DRG Weight",94675,Other,base rate x DRG weight,64466,,"26,426 x DRG Weight",64466,Other,base rate x DRG weight,94675,,"38,809 x DRG Weight",94675,Other,base rate x DRG weight,86336,,"35,391 x DRG Weight",86336,Other,base rate x DRG weight,164325,70,,164325,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,61514,,"25,216 X DRG Weight",61514,Other,Base Weight X DRG Weight,55364,,"22,695 X DRG Weight",55364,Other,Base Weight X DRG Weight,61514,,"25,216 X DRG Weight",61514,Other,Base Rate x DRG Weight ,52286,,"21,433 x DRG Weight",52286,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,164325,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,,inpatient,,,427760.46,58263,,,58263,Other,150% of Medicare + 9.63% HCRA Surcharge,35430.34,,,35430.34,Other,Medicare IPPS methodology,100262,,"25,728 x DRG weight",100262,Other,base rate x DRG weight,90235,,"23,155 x DRG weight",90235,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,213880,50,,213880,Percent of Total Billed Charges,50% of Charges,113387,,"29,096 x DRG Weight",113387,Other,base rate x DRG weight,87538,,"22,463 x DRG Weight",87538,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,102982,,"26,426 x DRG Weight",102982,Other,base rate x DRG weight,151239,,"38,809 x DRG Weight",151239,Other,base rate x DRG weight,151239,,"38,809 x DRG Weight",151239,Other,base rate x DRG weight,102982,,"26,426 x DRG Weight",102982,Other,base rate x DRG weight,151239,,"38,809 x DRG Weight",151239,Other,base rate x DRG weight,137919,,"35,391 x DRG Weight",137919,Other,base rate x DRG weight,299432,70,,299432,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,98267,,"25,216 X DRG Weight",98267,Other,Base Weight X DRG Weight,88442,,"22,695 X DRG Weight",88442,Other,Base Weight X DRG Weight,98267,,"25,216 X DRG Weight",98267,Other,Base Rate x DRG Weight ,83524,,"21,433 x DRG Weight",83524,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,299432,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,,inpatient,,,273708.33,48532,,,48532,Other,150% of Medicare + 9.63% HCRA Surcharge,29512.41,,,29512.41,Other,Medicare IPPS methodology,83379,,"25,728 x DRG weight",83379,Other,base rate x DRG weight,75041,,"23,155 x DRG weight",75041,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,136854,50,,136854,Percent of Total Billed Charges,50% of Charges,94294,,"29,096 x DRG Weight",94294,Other,base rate x DRG weight,72798,,"22,463 x DRG Weight",72798,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,85641,,"26,426 x DRG Weight",85641,Other,base rate x DRG weight,125772,,"38,809 x DRG Weight",125772,Other,base rate x DRG weight,125772,,"38,809 x DRG Weight",125772,Other,base rate x DRG weight,85641,,"26,426 x DRG Weight",85641,Other,base rate x DRG weight,125772,,"38,809 x DRG Weight",125772,Other,base rate x DRG weight,114695,,"35,391 x DRG Weight",114695,Other,base rate x DRG weight,191596,70,,191596,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,81720,,"25,216 X DRG Weight",81720,Other,Base Weight X DRG Weight,73550,,"22,695 X DRG Weight",73550,Other,Base Weight X DRG Weight,81720,,"25,216 X DRG Weight",81720,Other,Base Rate x DRG Weight ,69460,,"21,433 x DRG Weight",69460,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,191596,
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,,inpatient,,,679165.74,104813,,,104813,Other,150% of Medicare + 9.63% HCRA Surcharge,63737.54,,,63737.54,Other,Medicare IPPS methodology,181017,,"25,728 x DRG weight",181017,Other,base rate x DRG weight,162914,,"23,155 x DRG weight",162914,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,339583,50,,339583,Percent of Total Billed Charges,50% of Charges,204714,,"29,096 x DRG Weight",204714,Other,base rate x DRG weight,158045,,"22,463 x DRG Weight",158045,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,185928,,"26,426 x DRG Weight",185928,Other,base rate x DRG weight,273052,,"38,809 x DRG Weight",273052,Other,base rate x DRG weight,273052,,"38,809 x DRG Weight",273052,Other,base rate x DRG weight,185928,,"26,426 x DRG Weight",185928,Other,base rate x DRG weight,273052,,"38,809 x DRG Weight",273052,Other,base rate x DRG weight,249004,,"35,391 x DRG Weight",249004,Other,base rate x DRG weight,475416,70,,475416,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,177415,,"25,216 X DRG Weight",177415,Other,Base Weight X DRG Weight,159677,,"22,695 X DRG Weight",159677,Other,Base Weight X DRG Weight,177415,,"25,216 X DRG Weight",177415,Other,Base Rate x DRG Weight ,150798,,"21,433 x DRG Weight",150798,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,475416,
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC,276,MS-DRG,,,,,,,,inpatient,,,527800.13,92569,,,92569,Other,150% of Medicare + 9.63% HCRA Surcharge,56291.88,,,56291.88,Other,Medicare IPPS methodology,159776,,"25,728 x DRG weight",159776,Other,base rate x DRG weight,143797,,"23,155 x DRG weight",143797,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,263900,50,,263900,Percent of Total Billed Charges,50% of Charges,180692,,"29,096 x DRG Weight",180692,Other,base rate x DRG weight,139500,,"22,463 x DRG Weight",139500,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,164111,,"26,426 x DRG Weight",164111,Other,base rate x DRG weight,241012,,"38,809 x DRG Weight",241012,Other,base rate x DRG weight,241012,,"38,809 x DRG Weight",241012,Other,base rate x DRG weight,164111,,"26,426 x DRG Weight",164111,Other,base rate x DRG weight,241012,,"38,809 x DRG Weight",241012,Other,base rate x DRG weight,219785,,"35,391 x DRG Weight",219785,Other,base rate x DRG weight,369460,70,,369460,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,156596,,"25,216 X DRG Weight",156596,Other,Base Weight X DRG Weight,140940,,"22,695 X DRG Weight",140940,Other,Base Weight X DRG Weight,156596,,"25,216 X DRG Weight",156596,Other,Base Rate x DRG Weight ,133103,,"21,433 x DRG Weight",133103,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,369460,
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,,inpatient,,,396793.25,71394,,,71394,Other,150% of Medicare + 9.63% HCRA Surcharge,43415.3,,,43415.3,Other,Medicare IPPS methodology,123042,,"25,728 x DRG weight",123042,Other,base rate x DRG weight,110736,,"23,155 x DRG weight",110736,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,198397,50,,198397,Percent of Total Billed Charges,50% of Charges,139149,,"29,096 x DRG Weight",139149,Other,base rate x DRG weight,107427,,"22,463 x DRG Weight",107427,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,126380,,"26,426 x DRG Weight",126380,Other,base rate x DRG weight,185600,,"38,809 x DRG Weight",185600,Other,base rate x DRG weight,185600,,"38,809 x DRG Weight",185600,Other,base rate x DRG weight,126380,,"26,426 x DRG Weight",126380,Other,base rate x DRG weight,185600,,"38,809 x DRG Weight",185600,Other,base rate x DRG weight,169254,,"35,391 x DRG Weight",169254,Other,base rate x DRG weight,277755,70,,277755,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,120593,,"25,216 X DRG Weight",120593,Other,Base Weight X DRG Weight,108537,,"22,695 X DRG Weight",108537,Other,Base Weight X DRG Weight,120593,,"25,216 X DRG Weight",120593,Other,Base Rate x DRG Weight ,102501,,"21,433 x DRG Weight",102501,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,277755,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,,inpatient,,,624536.85,66619,,,66619,Other,150% of Medicare + 9.63% HCRA Surcharge,40511.35,,,40511.35,Other,Medicare IPPS methodology,114757,,"25,728 x DRG weight",114757,Other,base rate x DRG weight,103281,,"23,155 x DRG weight",103281,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,312268,50,,312268,Percent of Total Billed Charges,50% of Charges,129780,,"29,096 x DRG Weight",129780,Other,base rate x DRG weight,100194,,"22,463 x DRG Weight",100194,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,117871,,"26,426 x DRG Weight",117871,Other,base rate x DRG weight,173104,,"38,809 x DRG Weight",173104,Other,base rate x DRG weight,173104,,"38,809 x DRG Weight",173104,Other,base rate x DRG weight,117871,,"26,426 x DRG Weight",117871,Other,base rate x DRG weight,173104,,"38,809 x DRG Weight",173104,Other,base rate x DRG weight,157858,,"35,391 x DRG Weight",157858,Other,base rate x DRG weight,437176,70,,437176,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,112473,,"25,216 X DRG Weight",112473,Other,Base Weight X DRG Weight,101229,,"22,695 X DRG Weight",101229,Other,Base Weight X DRG Weight,112473,,"25,216 X DRG Weight",112473,Other,Base Rate x DRG Weight ,95600,,"21,433 x DRG Weight",95600,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,437176,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,,inpatient,,,503452,47935,,,47935,Other,150% of Medicare + 9.63% HCRA Surcharge,29149.87,,,29149.87,Other,Medicare IPPS methodology,82345,,"25,728 x DRG weight",82345,Other,base rate x DRG weight,74110,,"23,155 x DRG weight",74110,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,251726,50,,251726,Percent of Total Billed Charges,50% of Charges,93125,,"29,096 x DRG Weight",93125,Other,base rate x DRG weight,71895,,"22,463 x DRG Weight",71895,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,84579,,"26,426 x DRG Weight",84579,Other,base rate x DRG weight,124212,,"38,809 x DRG Weight",124212,Other,base rate x DRG weight,124212,,"38,809 x DRG Weight",124212,Other,base rate x DRG weight,84579,,"26,426 x DRG Weight",84579,Other,base rate x DRG weight,124212,,"38,809 x DRG Weight",124212,Other,base rate x DRG weight,113272,,"35,391 x DRG Weight",113272,Other,base rate x DRG weight,352416,70,,352416,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,80706,,"25,216 X DRG Weight",80706,Other,Base Weight X DRG Weight,72638,,"22,695 X DRG Weight",72638,Other,Base Weight X DRG Weight,80706,,"25,216 X DRG Weight",80706,Other,Base Rate x DRG Weight ,68598,,"21,433 x DRG Weight",68598,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,352416,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,,inpatient,,,187163.71,23998,,,23998,Other,150% of Medicare + 9.63% HCRA Surcharge,14593.14,,,14593.14,Other,Medicare IPPS methodology,40817,,"25,728 x DRG weight",40817,Other,base rate x DRG weight,36735,,"23,155 x DRG weight",36735,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,93582,50,,93582,Percent of Total Billed Charges,50% of Charges,46161,,"29,096 x DRG Weight",46161,Other,base rate x DRG weight,35638,,"22,463 x DRG Weight",35638,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41925,,"26,426 x DRG Weight",41925,Other,base rate x DRG weight,61570,,"38,809 x DRG Weight",61570,Other,base rate x DRG weight,61570,,"38,809 x DRG Weight",61570,Other,base rate x DRG weight,41925,,"26,426 x DRG Weight",41925,Other,base rate x DRG weight,61570,,"38,809 x DRG Weight",61570,Other,base rate x DRG weight,56148,,"35,391 x DRG Weight",56148,Other,base rate x DRG weight,131015,70,,131015,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40005,,"25,216 X DRG Weight",40005,Other,Base Weight X DRG Weight,36006,,"22,695 X DRG Weight",36006,Other,Base Weight X DRG Weight,40005,,"25,216 X DRG Weight",40005,Other,Base Rate x DRG Weight ,34003,,"21,433 x DRG Weight",34003,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,131015,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,,inpatient,,,165079.79,14009,,,14009,Other,150% of Medicare + 9.63% HCRA Surcharge,8519.19,,,8519.19,Other,Medicare IPPS methodology,23490,,"25,728 x DRG weight",23490,Other,base rate x DRG weight,21141,,"23,155 x DRG weight",21141,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,82540,50,,82540,Percent of Total Billed Charges,50% of Charges,26565,,"29,096 x DRG Weight",26565,Other,base rate x DRG weight,20509,,"22,463 x DRG Weight",20509,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,24127,,"26,426 x DRG Weight",24127,Other,base rate x DRG weight,35433,,"38,809 x DRG Weight",35433,Other,base rate x DRG weight,35433,,"38,809 x DRG Weight",35433,Other,base rate x DRG weight,24127,,"26,426 x DRG Weight",24127,Other,base rate x DRG weight,35433,,"38,809 x DRG Weight",35433,Other,base rate x DRG weight,32312,,"35,391 x DRG Weight",32312,Other,base rate x DRG weight,115556,70,,115556,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,23022,,"25,216 X DRG Weight",23022,Other,Base Weight X DRG Weight,20721,,"22,695 X DRG Weight",20721,Other,Base Weight X DRG Weight,23022,,"25,216 X DRG Weight",23022,Other,Base Rate x DRG Weight ,19568,,"21,433 x DRG Weight",19568,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,115556,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,,inpatient,,,125225.93,11119,,,11119,Other,150% of Medicare + 9.63% HCRA Surcharge,6761.49,,,6761.49,Other,Medicare IPPS methodology,18475,,"25,728 x DRG weight",18475,Other,base rate x DRG weight,16628,,"23,155 x DRG weight",16628,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,62613,50,,62613,Percent of Total Billed Charges,50% of Charges,20894,,"29,096 x DRG Weight",20894,Other,base rate x DRG weight,16131,,"22,463 x DRG Weight",16131,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18977,,"26,426 x DRG Weight",18977,Other,base rate x DRG weight,27869,,"38,809 x DRG Weight",27869,Other,base rate x DRG weight,27869,,"38,809 x DRG Weight",27869,Other,base rate x DRG weight,18977,,"26,426 x DRG Weight",18977,Other,base rate x DRG weight,27869,,"38,809 x DRG Weight",27869,Other,base rate x DRG weight,25414,,"35,391 x DRG Weight",25414,Other,base rate x DRG weight,87658,70,,87658,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18108,,"25,216 X DRG Weight",18108,Other,Base Weight X DRG Weight,16297,,"22,695 X DRG Weight",16297,Other,Base Weight X DRG Weight,18108,,"25,216 X DRG Weight",18108,Other,Base Rate x DRG Weight ,15391,,"21,433 x DRG Weight",15391,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,87658,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,,inpatient,,,325734.2,29706,,,29706,Other,150% of Medicare + 9.63% HCRA Surcharge,18064.35,,,18064.35,Other,Medicare IPPS methodology,50720,,"25,728 x DRG weight",50720,Other,base rate x DRG weight,45648,,"23,155 x DRG weight",45648,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,162867,50,,162867,Percent of Total Billed Charges,50% of Charges,57360,,"29,096 x DRG Weight",57360,Other,base rate x DRG weight,44284,,"22,463 x DRG Weight",44284,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,52096,,"26,426 x DRG Weight",52096,Other,base rate x DRG weight,76508,,"38,809 x DRG Weight",76508,Other,base rate x DRG weight,76508,,"38,809 x DRG Weight",76508,Other,base rate x DRG weight,52096,,"26,426 x DRG Weight",52096,Other,base rate x DRG weight,76508,,"38,809 x DRG Weight",76508,Other,base rate x DRG weight,69770,,"35,391 x DRG Weight",69770,Other,base rate x DRG weight,228014,70,,228014,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,49711,,"25,216 X DRG Weight",49711,Other,Base Weight X DRG Weight,44741,,"22,695 X DRG Weight",44741,Other,Base Weight X DRG Weight,49711,,"25,216 X DRG Weight",49711,Other,Base Rate x DRG Weight ,42253,,"21,433 x DRG Weight",42253,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,228014,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,MS-DRG,,,,,,,,inpatient,,,155313.68,11439,,,11439,Other,150% of Medicare + 9.63% HCRA Surcharge,6956.29,,,6956.29,Other,Medicare IPPS methodology,19031,,"25,728 x DRG weight",19031,Other,base rate x DRG weight,17128,,"23,155 x DRG weight",17128,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,77657,50,,77657,Percent of Total Billed Charges,50% of Charges,21522,,"29,096 x DRG Weight",21522,Other,base rate x DRG weight,16616,,"22,463 x DRG Weight",16616,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,19547,,"26,426 x DRG Weight",19547,Other,base rate x DRG weight,28707,,"38,809 x DRG Weight",28707,Other,base rate x DRG weight,28707,,"38,809 x DRG Weight",28707,Other,base rate x DRG weight,19547,,"26,426 x DRG Weight",19547,Other,base rate x DRG weight,28707,,"38,809 x DRG Weight",28707,Other,base rate x DRG weight,26179,,"35,391 x DRG Weight",26179,Other,base rate x DRG weight,108720,70,,108720,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18652,,"25,216 X DRG Weight",18652,Other,Base Weight X DRG Weight,16787,,"22,695 X DRG Weight",16787,Other,Base Weight X DRG Weight,18652,,"25,216 X DRG Weight",18652,Other,Base Rate x DRG Weight ,15854,,"21,433 x DRG Weight",15854,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,108720,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,MS-DRG,,,,,,,,inpatient,,,62179.52,7717,,,7717,Other,150% of Medicare + 9.63% HCRA Surcharge,4692.65,,,4692.65,Other,Medicare IPPS methodology,12573,,"25,728 x DRG weight",12573,Other,base rate x DRG weight,11316,,"23,155 x DRG weight",11316,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,31090,50,,31090,Percent of Total Billed Charges,50% of Charges,14219,,"29,096 x DRG Weight",14219,Other,base rate x DRG weight,10978,,"22,463 x DRG Weight",10978,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,12914,,"26,426 x DRG Weight",12914,Other,base rate x DRG weight,18966,,"38,809 x DRG Weight",18966,Other,base rate x DRG weight,18966,,"38,809 x DRG Weight",18966,Other,base rate x DRG weight,12914,,"26,426 x DRG Weight",12914,Other,base rate x DRG weight,18966,,"38,809 x DRG Weight",18966,Other,base rate x DRG weight,17296,,"35,391 x DRG Weight",17296,Other,base rate x DRG weight,43526,70,,43526,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,12323,,"25,216 X DRG Weight",12323,Other,Base Weight X DRG Weight,11091,,"22,695 X DRG Weight",11091,Other,Base Weight X DRG Weight,12323,,"25,216 X DRG Weight",12323,Other,Base Rate x DRG Weight ,10474,,"21,433 x DRG Weight",10474,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,43526,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,,inpatient,,,320162.29,32438,,,32438,Other,150% of Medicare + 9.63% HCRA Surcharge,19725.56,,,19725.56,Other,Medicare IPPS methodology,55459,,"25,728 x DRG weight",55459,Other,base rate x DRG weight,49913,,"23,155 x DRG weight",49913,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,160081,50,,160081,Percent of Total Billed Charges,50% of Charges,62719,,"29,096 x DRG Weight",62719,Other,base rate x DRG weight,48421,,"22,463 x DRG Weight",48421,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,56964,,"26,426 x DRG Weight",56964,Other,base rate x DRG weight,83657,,"38,809 x DRG Weight",83657,Other,base rate x DRG weight,83657,,"38,809 x DRG Weight",83657,Other,base rate x DRG weight,56964,,"26,426 x DRG Weight",56964,Other,base rate x DRG weight,83657,,"38,809 x DRG Weight",83657,Other,base rate x DRG weight,76289,,"35,391 x DRG Weight",76289,Other,base rate x DRG weight,224114,70,,224114,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,54356,,"25,216 X DRG Weight",54356,Other,Base Weight X DRG Weight,48921,,"22,695 X DRG Weight",48921,Other,Base Weight X DRG Weight,54356,,"25,216 X DRG Weight",54356,Other,Base Rate x DRG Weight ,46201,,"21,433 x DRG Weight",46201,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,224114,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,,inpatient,,,197727.89,16510,,,16510,Other,150% of Medicare + 9.63% HCRA Surcharge,10039.71,,,10039.71,Other,Medicare IPPS methodology,27827,,"25,728 x DRG weight",27827,Other,base rate x DRG weight,25044,,"23,155 x DRG weight",25044,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,98864,50,,98864,Percent of Total Billed Charges,50% of Charges,31470,,"29,096 x DRG Weight",31470,Other,base rate x DRG weight,24296,,"22,463 x DRG Weight",24296,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28582,,"26,426 x DRG Weight",28582,Other,base rate x DRG weight,41976,,"38,809 x DRG Weight",41976,Other,base rate x DRG weight,41976,,"38,809 x DRG Weight",41976,Other,base rate x DRG weight,28582,,"26,426 x DRG Weight",28582,Other,base rate x DRG weight,41976,,"38,809 x DRG Weight",41976,Other,base rate x DRG weight,38279,,"35,391 x DRG Weight",38279,Other,base rate x DRG weight,138410,70,,138410,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27274,,"25,216 X DRG Weight",27274,Other,Base Weight X DRG Weight,24547,,"22,695 X DRG Weight",24547,Other,Base Weight X DRG Weight,27274,,"25,216 X DRG Weight",27274,Other,Base Rate x DRG Weight ,23182,,"21,433 x DRG Weight",23182,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,138410,
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,MS-DRG,,,,,,,,inpatient,,,234961.3,38925,,,38925,Other,150% of Medicare + 9.63% HCRA Surcharge,23670.24,,,23670.24,Other,Medicare IPPS methodology,66713,,"25,728 x DRG weight",66713,Other,base rate x DRG weight,60041,,"23,155 x DRG weight",60041,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,117481,50,,117481,Percent of Total Billed Charges,50% of Charges,75446,,"29,096 x DRG Weight",75446,Other,base rate x DRG weight,58247,,"22,463 x DRG Weight",58247,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,68523,,"26,426 x DRG Weight",68523,Other,base rate x DRG weight,100632,,"38,809 x DRG Weight",100632,Other,base rate x DRG weight,100632,,"38,809 x DRG Weight",100632,Other,base rate x DRG weight,68523,,"26,426 x DRG Weight",68523,Other,base rate x DRG weight,100632,,"38,809 x DRG Weight",100632,Other,base rate x DRG weight,91769,,"35,391 x DRG Weight",91769,Other,base rate x DRG weight,164473,70,,164473,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,65385,,"25,216 X DRG Weight",65385,Other,Base Weight X DRG Weight,58848,,"22,695 X DRG Weight",58848,Other,Base Weight X DRG Weight,65385,,"25,216 X DRG Weight",65385,Other,Base Rate x DRG Weight ,55576,,"21,433 x DRG Weight",55576,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,164473,
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,MS-DRG,,,,,,,,inpatient,,,75012,22384,,,22384,Other,150% of Medicare + 9.63% HCRA Surcharge,13611.93,,,13611.93,Other,Medicare IPPS methodology,38018,,"25,728 x DRG weight",38018,Other,base rate x DRG weight,34216,,"23,155 x DRG weight",34216,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37506,50,,37506,Percent of Total Billed Charges,50% of Charges,42995,,"29,096 x DRG Weight",42995,Other,base rate x DRG weight,33194,,"22,463 x DRG Weight",33194,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39050,,"26,426 x DRG Weight",39050,Other,base rate x DRG weight,57348,,"38,809 x DRG Weight",57348,Other,base rate x DRG weight,57348,,"38,809 x DRG Weight",57348,Other,base rate x DRG weight,39050,,"26,426 x DRG Weight",39050,Other,base rate x DRG weight,57348,,"38,809 x DRG Weight",57348,Other,base rate x DRG weight,52297,,"35,391 x DRG Weight",52297,Other,base rate x DRG weight,52508,70,,52508,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37262,,"25,216 X DRG Weight",37262,Other,Base Weight X DRG Weight,33536,,"22,695 X DRG Weight",33536,Other,Base Weight X DRG Weight,37262,,"25,216 X DRG Weight",37262,Other,Base Rate x DRG Weight ,31672,,"21,433 x DRG Weight",31672,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,57348,
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,MS-DRG,,,,,,,,inpatient,,,365016,16562,,,16562,Other,150% of Medicare + 9.63% HCRA Surcharge,10071.27,,,10071.27,Other,Medicare IPPS methodology,27917,,"25,728 x DRG weight",27917,Other,base rate x DRG weight,25125,,"23,155 x DRG weight",25125,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,182508,50,,182508,Percent of Total Billed Charges,50% of Charges,31572,,"29,096 x DRG Weight",31572,Other,base rate x DRG weight,24375,,"22,463 x DRG Weight",24375,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28675,,"26,426 x DRG Weight",28675,Other,base rate x DRG weight,42112,,"38,809 x DRG Weight",42112,Other,base rate x DRG weight,42112,,"38,809 x DRG Weight",42112,Other,base rate x DRG weight,28675,,"26,426 x DRG Weight",28675,Other,base rate x DRG weight,42112,,"38,809 x DRG Weight",42112,Other,base rate x DRG weight,38403,,"35,391 x DRG Weight",38403,Other,base rate x DRG weight,255511,70,,255511,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27362,,"25,216 X DRG Weight",27362,Other,Base Weight X DRG Weight,24626,,"22,695 X DRG Weight",24626,Other,Base Weight X DRG Weight,27362,,"25,216 X DRG Weight",27362,Other,Base Rate x DRG Weight ,23257,,"21,433 x DRG Weight",23257,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,255511,
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,,inpatient,,,180437.03,19510,,,19510,Other,150% of Medicare + 9.63% HCRA Surcharge,11864.15,,,11864.15,Other,Medicare IPPS methodology,33032,,"25,728 x DRG weight",33032,Other,base rate x DRG weight,29729,,"23,155 x DRG weight",29729,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,90219,50,,90219,Percent of Total Billed Charges,50% of Charges,37356,,"29,096 x DRG Weight",37356,Other,base rate x DRG weight,28840,,"22,463 x DRG Weight",28840,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,33928,,"26,426 x DRG Weight",33928,Other,base rate x DRG weight,49827,,"38,809 x DRG Weight",49827,Other,base rate x DRG weight,49827,,"38,809 x DRG Weight",49827,Other,base rate x DRG weight,33928,,"26,426 x DRG Weight",33928,Other,base rate x DRG weight,49827,,"38,809 x DRG Weight",49827,Other,base rate x DRG weight,45439,,"35,391 x DRG Weight",45439,Other,base rate x DRG weight,126306,70,,126306,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32375,,"25,216 X DRG Weight",32375,Other,Base Weight X DRG Weight,29138,,"22,695 X DRG Weight",29138,Other,Base Weight X DRG Weight,32375,,"25,216 X DRG Weight",32375,Other,Base Rate x DRG Weight ,27518,,"21,433 x DRG Weight",27518,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,126306,
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,,inpatient,,,140436.83,13171,,,13171,Other,150% of Medicare + 9.63% HCRA Surcharge,8009.65,,,8009.65,Other,Medicare IPPS methodology,22036,,"25,728 x DRG weight",22036,Other,base rate x DRG weight,19832,,"23,155 x DRG weight",19832,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,70218,50,,70218,Percent of Total Billed Charges,50% of Charges,24921,,"29,096 x DRG Weight",24921,Other,base rate x DRG weight,19240,,"22,463 x DRG Weight",19240,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,22634,,"26,426 x DRG Weight",22634,Other,base rate x DRG weight,33240,,"38,809 x DRG Weight",33240,Other,base rate x DRG weight,33240,,"38,809 x DRG Weight",33240,Other,base rate x DRG weight,22634,,"26,426 x DRG Weight",22634,Other,base rate x DRG weight,33240,,"38,809 x DRG Weight",33240,Other,base rate x DRG weight,30312,,"35,391 x DRG Weight",30312,Other,base rate x DRG weight,98306,70,,98306,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,21598,,"25,216 X DRG Weight",21598,Other,Base Weight X DRG Weight,19438,,"22,695 X DRG Weight",19438,Other,Base Weight X DRG Weight,21598,,"25,216 X DRG Weight",21598,Other,Base Rate x DRG Weight ,18357,,"21,433 x DRG Weight",18357,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,98306,
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,,inpatient,,,158996.19,8796,,,8796,Other,150% of Medicare + 9.63% HCRA Surcharge,5349.2,,,5349.2,Other,Medicare IPPS methodology,14446,,"25,728 x DRG weight",14446,Other,base rate x DRG weight,13002,,"23,155 x DRG weight",13002,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,79498,50,,79498,Percent of Total Billed Charges,50% of Charges,16337,,"29,096 x DRG Weight",16337,Other,base rate x DRG weight,12613,,"22,463 x DRG Weight",12613,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,14838,,"26,426 x DRG Weight",14838,Other,base rate x DRG weight,21791,,"38,809 x DRG Weight",21791,Other,base rate x DRG weight,21791,,"38,809 x DRG Weight",21791,Other,base rate x DRG weight,14838,,"26,426 x DRG Weight",14838,Other,base rate x DRG weight,21791,,"38,809 x DRG Weight",21791,Other,base rate x DRG weight,19872,,"35,391 x DRG Weight",19872,Other,base rate x DRG weight,111297,70,,111297,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,14159,,"25,216 X DRG Weight",14159,Other,Base Weight X DRG Weight,12743,,"22,695 X DRG Weight",12743,Other,Base Weight X DRG Weight,14159,,"25,216 X DRG Weight",14159,Other,Base Rate x DRG Weight ,12035,,"21,433 x DRG Weight",12035,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,111297,
DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,294,MS-DRG,,,,,,,,inpatient,,,365016,16689,,,16689,Other,150% of Medicare + 9.63% HCRA Surcharge,10148.83,,,10148.83,Other,Medicare IPPS methodology,28139,,"25,728 x DRG weight",28139,Other,base rate x DRG weight,25325,,"23,155 x DRG weight",25325,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,182508,50,,182508,Percent of Total Billed Charges,50% of Charges,31822,,"29,096 x DRG Weight",31822,Other,base rate x DRG weight,24568,,"22,463 x DRG Weight",24568,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28902,,"26,426 x DRG Weight",28902,Other,base rate x DRG weight,42445,,"38,809 x DRG Weight",42445,Other,base rate x DRG weight,42445,,"38,809 x DRG Weight",42445,Other,base rate x DRG weight,28902,,"26,426 x DRG Weight",28902,Other,base rate x DRG weight,42445,,"38,809 x DRG Weight",42445,Other,base rate x DRG weight,38707,,"35,391 x DRG Weight",38707,Other,base rate x DRG weight,255511,70,,255511,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27579,,"25,216 X DRG Weight",27579,Other,Base Weight X DRG Weight,24822,,"22,695 X DRG Weight",24822,Other,Base Weight X DRG Weight,27579,,"25,216 X DRG Weight",27579,Other,Base Rate x DRG Weight ,23441,,"21,433 x DRG Weight",23441,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,255511,
DEEP VEIN THROMBOPHLEBITIS WITHOUT CC/MCC,295,MS-DRG,,,,,,,,inpatient,,,57778,12291,,,12291,Other,150% of Medicare + 9.63% HCRA Surcharge,7473.95,,,7473.95,Other,Medicare IPPS methodology,20508,,"25,728 x DRG weight",20508,Other,base rate x DRG weight,18457,,"23,155 x DRG weight",18457,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,28889,50,,28889,Percent of Total Billed Charges,50% of Charges,23192,,"29,096 x DRG Weight",23192,Other,base rate x DRG weight,17905,,"22,463 x DRG Weight",17905,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21064,,"26,426 x DRG Weight",21064,Other,base rate x DRG weight,30935,,"38,809 x DRG Weight",30935,Other,base rate x DRG weight,30935,,"38,809 x DRG Weight",30935,Other,base rate x DRG weight,21064,,"26,426 x DRG Weight",21064,Other,base rate x DRG weight,30935,,"38,809 x DRG Weight",30935,Other,base rate x DRG weight,28210,,"35,391 x DRG Weight",28210,Other,base rate x DRG weight,40445,70,,40445,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20100,,"25,216 X DRG Weight",20100,Other,Base Weight X DRG Weight,18090,,"22,695 X DRG Weight",18090,Other,Base Weight X DRG Weight,20100,,"25,216 X DRG Weight",20100,Other,Base Rate x DRG Weight ,17084,,"21,433 x DRG Weight",17084,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,40445,
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,,inpatient,,,302456.76,24245,,,24245,Other,150% of Medicare + 9.63% HCRA Surcharge,14743.75,,,14743.75,Other,Medicare IPPS methodology,41247,,"25,728 x DRG weight",41247,Other,base rate x DRG weight,37122,,"23,155 x DRG weight",37122,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,151228,50,,151228,Percent of Total Billed Charges,50% of Charges,46647,,"29,096 x DRG Weight",46647,Other,base rate x DRG weight,36013,,"22,463 x DRG Weight",36013,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,42366,,"26,426 x DRG Weight",42366,Other,base rate x DRG weight,62219,,"38,809 x DRG Weight",62219,Other,base rate x DRG weight,62219,,"38,809 x DRG Weight",62219,Other,base rate x DRG weight,42366,,"26,426 x DRG Weight",42366,Other,base rate x DRG weight,62219,,"38,809 x DRG Weight",62219,Other,base rate x DRG weight,56739,,"35,391 x DRG Weight",56739,Other,base rate x DRG weight,211720,70,,211720,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40426,,"25,216 X DRG Weight",40426,Other,Base Weight X DRG Weight,36385,,"22,695 X DRG Weight",36385,Other,Base Weight X DRG Weight,40426,,"25,216 X DRG Weight",40426,Other,Base Rate x DRG Weight ,34361,,"21,433 x DRG Weight",34361,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,211720,
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,MS-DRG,,,,,,,,inpatient,,,57778,11275,,,11275,Other,150% of Medicare + 9.63% HCRA Surcharge,6856.18,,,6856.18,Other,Medicare IPPS methodology,18745,,"25,728 x DRG weight",18745,Other,base rate x DRG weight,16871,,"23,155 x DRG weight",16871,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,28889,50,,28889,Percent of Total Billed Charges,50% of Charges,21199,,"29,096 x DRG Weight",21199,Other,base rate x DRG weight,16367,,"22,463 x DRG Weight",16367,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,19254,,"26,426 x DRG Weight",19254,Other,base rate x DRG weight,28276,,"38,809 x DRG Weight",28276,Other,base rate x DRG weight,28276,,"38,809 x DRG Weight",28276,Other,base rate x DRG weight,19254,,"26,426 x DRG Weight",19254,Other,base rate x DRG weight,28276,,"38,809 x DRG Weight",28276,Other,base rate x DRG weight,25786,,"35,391 x DRG Weight",25786,Other,base rate x DRG weight,40445,70,,40445,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18372,,"25,216 X DRG Weight",18372,Other,Base Weight X DRG Weight,16536,,"22,695 X DRG Weight",16536,Other,Base Weight X DRG Weight,18372,,"25,216 X DRG Weight",18372,Other,Base Rate x DRG Weight ,15616,,"21,433 x DRG Weight",15616,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,40445,
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,MS-DRG,,,,,,,,inpatient,,,39243,6990,,,6990,Other,150% of Medicare + 9.63% HCRA Surcharge,4250.75,,,4250.75,Other,Medicare IPPS methodology,11313,,"25,728 x DRG weight",11313,Other,base rate x DRG weight,10181,,"23,155 x DRG weight",10181,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19622,50,,19622,Percent of Total Billed Charges,50% of Charges,12794,,"29,096 x DRG Weight",12794,Other,base rate x DRG weight,9877,,"22,463 x DRG Weight",9877,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,11620,,"26,426 x DRG Weight",11620,Other,base rate x DRG weight,17064,,"38,809 x DRG Weight",17064,Other,base rate x DRG weight,17064,,"38,809 x DRG Weight",17064,Other,base rate x DRG weight,11620,,"26,426 x DRG Weight",11620,Other,base rate x DRG weight,17064,,"38,809 x DRG Weight",17064,Other,base rate x DRG weight,15561,,"35,391 x DRG Weight",15561,Other,base rate x DRG weight,27470,70,,27470,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,11087,,"25,216 X DRG Weight",11087,Other,Base Weight X DRG Weight,9979,,"22,695 X DRG Weight",9979,Other,Base Weight X DRG Weight,11087,,"25,216 X DRG Weight",11087,Other,Base Rate x DRG Weight ,9424,,"21,433 x DRG Weight",9424,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,27470,
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,,inpatient,,,188166.23,23845,,,23845,Other,150% of Medicare + 9.63% HCRA Surcharge,14500.25,,,14500.25,Other,Medicare IPPS methodology,40552,,"25,728 x DRG weight",40552,Other,base rate x DRG weight,36497,,"23,155 x DRG weight",36497,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,94083,50,,94083,Percent of Total Billed Charges,50% of Charges,45861,,"29,096 x DRG Weight",45861,Other,base rate x DRG weight,35406,,"22,463 x DRG Weight",35406,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41653,,"26,426 x DRG Weight",41653,Other,base rate x DRG weight,61171,,"38,809 x DRG Weight",61171,Other,base rate x DRG weight,61171,,"38,809 x DRG Weight",61171,Other,base rate x DRG weight,41653,,"26,426 x DRG Weight",41653,Other,base rate x DRG weight,61171,,"38,809 x DRG Weight",61171,Other,base rate x DRG weight,55783,,"35,391 x DRG Weight",55783,Other,base rate x DRG weight,131716,70,,131716,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39745,,"25,216 X DRG Weight",39745,Other,Base Weight X DRG Weight,35772,,"22,695 X DRG Weight",35772,Other,Base Weight X DRG Weight,39745,,"25,216 X DRG Weight",39745,Other,Base Rate x DRG Weight ,33783,,"21,433 x DRG Weight",33783,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,131716,
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,,inpatient,,,123909.19,16293,,,16293,Other,150% of Medicare + 9.63% HCRA Surcharge,9908.04,,,9908.04,Other,Medicare IPPS methodology,27452,,"25,728 x DRG weight",27452,Other,base rate x DRG weight,24706,,"23,155 x DRG weight",24706,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,61955,50,,61955,Percent of Total Billed Charges,50% of Charges,31045,,"29,096 x DRG Weight",31045,Other,base rate x DRG weight,23968,,"22,463 x DRG Weight",23968,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28197,,"26,426 x DRG Weight",28197,Other,base rate x DRG weight,41409,,"38,809 x DRG Weight",41409,Other,base rate x DRG weight,41409,,"38,809 x DRG Weight",41409,Other,base rate x DRG weight,28197,,"26,426 x DRG Weight",28197,Other,base rate x DRG weight,41409,,"38,809 x DRG Weight",41409,Other,base rate x DRG weight,37762,,"35,391 x DRG Weight",37762,Other,base rate x DRG weight,86736,70,,86736,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,26905,,"25,216 X DRG Weight",26905,Other,Base Weight X DRG Weight,24216,,"22,695 X DRG Weight",24216,Other,Base Weight X DRG Weight,26905,,"25,216 X DRG Weight",26905,Other,Base Rate x DRG Weight ,22869,,"21,433 x DRG Weight",22869,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,86736,
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,,inpatient,,,108696.83,10996,,,10996,Other,150% of Medicare + 9.63% HCRA Surcharge,6686.64,,,6686.64,Other,Medicare IPPS methodology,18262,,"25,728 x DRG weight",18262,Other,base rate x DRG weight,16435,,"23,155 x DRG weight",16435,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,54348,50,,54348,Percent of Total Billed Charges,50% of Charges,20652,,"29,096 x DRG Weight",20652,Other,base rate x DRG weight,15944,,"22,463 x DRG Weight",15944,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18757,,"26,426 x DRG Weight",18757,Other,base rate x DRG weight,27547,,"38,809 x DRG Weight",27547,Other,base rate x DRG weight,27547,,"38,809 x DRG Weight",27547,Other,base rate x DRG weight,18757,,"26,426 x DRG Weight",18757,Other,base rate x DRG weight,27547,,"38,809 x DRG Weight",27547,Other,base rate x DRG weight,25121,,"35,391 x DRG Weight",25121,Other,base rate x DRG weight,76088,70,,76088,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,17898,,"25,216 X DRG Weight",17898,Other,Base Weight X DRG Weight,16109,,"22,695 X DRG Weight",16109,Other,Base Weight X DRG Weight,17898,,"25,216 X DRG Weight",17898,Other,Base Rate x DRG Weight ,15213,,"21,433 x DRG Weight",15213,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,76088,
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,,inpatient,,,118462.97,17096,,,17096,Other,150% of Medicare + 9.63% HCRA Surcharge,10395.94,,,10395.94,Other,Medicare IPPS methodology,28844,,"25,728 x DRG weight",28844,Other,base rate x DRG weight,25959,,"23,155 x DRG weight",25959,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,59231,50,,59231,Percent of Total Billed Charges,50% of Charges,32620,,"29,096 x DRG Weight",32620,Other,base rate x DRG weight,25183,,"22,463 x DRG Weight",25183,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,29626,,"26,426 x DRG Weight",29626,Other,base rate x DRG weight,43509,,"38,809 x DRG Weight",43509,Other,base rate x DRG weight,43509,,"38,809 x DRG Weight",43509,Other,base rate x DRG weight,29626,,"26,426 x DRG Weight",29626,Other,base rate x DRG weight,43509,,"38,809 x DRG Weight",43509,Other,base rate x DRG weight,39677,,"35,391 x DRG Weight",39677,Other,base rate x DRG weight,82924,70,,82924,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,28270,,"25,216 X DRG Weight",28270,Other,Base Weight X DRG Weight,25443,,"22,695 X DRG Weight",25443,Other,Base Weight X DRG Weight,28270,,"25,216 X DRG Weight",28270,Other,Base Rate x DRG Weight ,24029,,"21,433 x DRG Weight",24029,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,82924,
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,,inpatient,,,109760.62,10229,,,10229,Other,150% of Medicare + 9.63% HCRA Surcharge,6220.38,,,6220.38,Other,Medicare IPPS methodology,16932,,"25,728 x DRG weight",16932,Other,base rate x DRG weight,15238,,"23,155 x DRG weight",15238,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,54880,50,,54880,Percent of Total Billed Charges,50% of Charges,19148,,"29,096 x DRG Weight",19148,Other,base rate x DRG weight,14783,,"22,463 x DRG Weight",14783,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,17391,,"26,426 x DRG Weight",17391,Other,base rate x DRG weight,25540,,"38,809 x DRG Weight",25540,Other,base rate x DRG weight,25540,,"38,809 x DRG Weight",25540,Other,base rate x DRG weight,17391,,"26,426 x DRG Weight",17391,Other,base rate x DRG weight,25540,,"38,809 x DRG Weight",25540,Other,base rate x DRG weight,23291,,"35,391 x DRG Weight",23291,Other,base rate x DRG weight,76832,70,,76832,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,16595,,"25,216 X DRG Weight",16595,Other,Base Weight X DRG Weight,14936,,"22,695 X DRG Weight",14936,Other,Base Weight X DRG Weight,16595,,"25,216 X DRG Weight",16595,Other,Base Rate x DRG Weight ,14105,,"21,433 x DRG Weight",14105,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,76832,
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,,inpatient,,,164718.08,17509,,,17509,Other,150% of Medicare + 9.63% HCRA Surcharge,10647.55,,,10647.55,Other,Medicare IPPS methodology,29561,,"25,728 x DRG weight",29561,Other,base rate x DRG weight,26605,,"23,155 x DRG weight",26605,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,82359,50,,82359,Percent of Total Billed Charges,50% of Charges,33431,,"29,096 x DRG Weight",33431,Other,base rate x DRG weight,25810,,"22,463 x DRG Weight",25810,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,30363,,"26,426 x DRG Weight",30363,Other,base rate x DRG weight,44592,,"38,809 x DRG Weight",44592,Other,base rate x DRG weight,44592,,"38,809 x DRG Weight",44592,Other,base rate x DRG weight,30363,,"26,426 x DRG Weight",30363,Other,base rate x DRG weight,44592,,"38,809 x DRG Weight",44592,Other,base rate x DRG weight,40664,,"35,391 x DRG Weight",40664,Other,base rate x DRG weight,115303,70,,115303,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,28973,,"25,216 X DRG Weight",28973,Other,Base Weight X DRG Weight,26077,,"22,695 X DRG Weight",26077,Other,Base Weight X DRG Weight,28973,,"25,216 X DRG Weight",28973,Other,Base Rate x DRG Weight ,24627,,"21,433 x DRG Weight",24627,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,115303,
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,,inpatient,,,116227.06,11644,,,11644,Other,150% of Medicare + 9.63% HCRA Surcharge,7080.74,,,7080.74,Other,Medicare IPPS methodology,19386,,"25,728 x DRG weight",19386,Other,base rate x DRG weight,17447,,"23,155 x DRG weight",17447,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,58114,50,,58114,Percent of Total Billed Charges,50% of Charges,21924,,"29,096 x DRG Weight",21924,Other,base rate x DRG weight,16926,,"22,463 x DRG Weight",16926,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,19912,,"26,426 x DRG Weight",19912,Other,base rate x DRG weight,29243,,"38,809 x DRG Weight",29243,Other,base rate x DRG weight,29243,,"38,809 x DRG Weight",29243,Other,base rate x DRG weight,19912,,"26,426 x DRG Weight",19912,Other,base rate x DRG weight,29243,,"38,809 x DRG Weight",29243,Other,base rate x DRG weight,26667,,"35,391 x DRG Weight",26667,Other,base rate x DRG weight,81359,70,,81359,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19000,,"25,216 X DRG Weight",19000,Other,Base Weight X DRG Weight,17101,,"22,695 X DRG Weight",17101,Other,Base Weight X DRG Weight,19000,,"25,216 X DRG Weight",19000,Other,Base Rate x DRG Weight ,16150,,"21,433 x DRG Weight",16150,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,81359,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,,inpatient,,,546948.46,23261,,,23261,Other,150% of Medicare + 9.63% HCRA Surcharge,14144.92,,,14144.92,Other,Medicare IPPS methodology,39539,,"25,728 x DRG weight",39539,Other,base rate x DRG weight,35585,,"23,155 x DRG weight",35585,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,273474,50,,273474,Percent of Total Billed Charges,50% of Charges,44715,,"29,096 x DRG Weight",44715,Other,base rate x DRG weight,34521,,"22,463 x DRG Weight",34521,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,40611,,"26,426 x DRG Weight",40611,Other,base rate x DRG weight,59642,,"38,809 x DRG Weight",59642,Other,base rate x DRG weight,59642,,"38,809 x DRG Weight",59642,Other,base rate x DRG weight,40611,,"26,426 x DRG Weight",40611,Other,base rate x DRG weight,59642,,"38,809 x DRG Weight",59642,Other,base rate x DRG weight,54389,,"35,391 x DRG Weight",54389,Other,base rate x DRG weight,382864,70,,382864,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,38752,,"25,216 X DRG Weight",38752,Other,Base Weight X DRG Weight,34878,,"22,695 X DRG Weight",34878,Other,Base Weight X DRG Weight,38752,,"25,216 X DRG Weight",38752,Other,Base Rate x DRG Weight ,32938,,"21,433 x DRG Weight",32938,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,382864,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,,inpatient,,,126821.63,14448,,,14448,Other,150% of Medicare + 9.63% HCRA Surcharge,8786.14,,,8786.14,Other,Medicare IPPS methodology,24251,,"25,728 x DRG weight",24251,Other,base rate x DRG weight,21826,,"23,155 x DRG weight",21826,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,63411,50,,63411,Percent of Total Billed Charges,50% of Charges,27426,,"29,096 x DRG Weight",27426,Other,base rate x DRG weight,21174,,"22,463 x DRG Weight",21174,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,24909,,"26,426 x DRG Weight",24909,Other,base rate x DRG weight,36581,,"38,809 x DRG Weight",36581,Other,base rate x DRG weight,36581,,"38,809 x DRG Weight",36581,Other,base rate x DRG weight,24909,,"26,426 x DRG Weight",24909,Other,base rate x DRG weight,36581,,"38,809 x DRG Weight",36581,Other,base rate x DRG weight,33360,,"35,391 x DRG Weight",33360,Other,base rate x DRG weight,88775,70,,88775,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,23769,,"25,216 X DRG Weight",23769,Other,Base Weight X DRG Weight,21392,,"22,695 X DRG Weight",21392,Other,Base Weight X DRG Weight,23769,,"25,216 X DRG Weight",23769,Other,Base Rate x DRG Weight ,20203,,"21,433 x DRG Weight",20203,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,88775,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,,inpatient,,,176568.14,18298,,,18298,Other,150% of Medicare + 9.63% HCRA Surcharge,11127.34,,,11127.34,Other,Medicare IPPS methodology,30930,,"25,728 x DRG weight",30930,Other,base rate x DRG weight,27837,,"23,155 x DRG weight",27837,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,88284,50,,88284,Percent of Total Billed Charges,50% of Charges,34979,,"29,096 x DRG Weight",34979,Other,base rate x DRG weight,27005,,"22,463 x DRG Weight",27005,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31769,,"26,426 x DRG Weight",31769,Other,base rate x DRG weight,46656,,"38,809 x DRG Weight",46656,Other,base rate x DRG weight,46656,,"38,809 x DRG Weight",46656,Other,base rate x DRG weight,31769,,"26,426 x DRG Weight",31769,Other,base rate x DRG weight,46656,,"38,809 x DRG Weight",46656,Other,base rate x DRG weight,42547,,"35,391 x DRG Weight",42547,Other,base rate x DRG weight,123598,70,,123598,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,30315,,"25,216 X DRG Weight",30315,Other,Base Weight X DRG Weight,27284,,"22,695 X DRG Weight",27284,Other,Base Weight X DRG Weight,30315,,"25,216 X DRG Weight",30315,Other,Base Rate x DRG Weight ,25767,,"21,433 x DRG Weight",25767,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,123598,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,,inpatient,,,122201.12,11513,,,11513,Other,150% of Medicare + 9.63% HCRA Surcharge,7001.38,,,7001.38,Other,Medicare IPPS methodology,19160,,"25,728 x DRG weight",19160,Other,base rate x DRG weight,17244,,"23,155 x DRG weight",17244,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,61101,50,,61101,Percent of Total Billed Charges,50% of Charges,21668,,"29,096 x DRG Weight",21668,Other,base rate x DRG weight,16728,,"22,463 x DRG Weight",16728,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,19679,,"26,426 x DRG Weight",19679,Other,base rate x DRG weight,28901,,"38,809 x DRG Weight",28901,Other,base rate x DRG weight,28901,,"38,809 x DRG Weight",28901,Other,base rate x DRG weight,19679,,"26,426 x DRG Weight",19679,Other,base rate x DRG weight,28901,,"38,809 x DRG Weight",28901,Other,base rate x DRG weight,26356,,"35,391 x DRG Weight",26356,Other,base rate x DRG weight,85541,70,,85541,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18778,,"25,216 X DRG Weight",18778,Other,Base Weight X DRG Weight,16901,,"22,695 X DRG Weight",16901,Other,Base Weight X DRG Weight,18778,,"25,216 X DRG Weight",18778,Other,Base Rate x DRG Weight ,15961,,"21,433 x DRG Weight",15961,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,85541,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,,inpatient,,,67364.96,8670,,,8670,Other,150% of Medicare + 9.63% HCRA Surcharge,5272.54,,,5272.54,Other,Medicare IPPS methodology,14228,,"25,728 x DRG weight",14228,Other,base rate x DRG weight,12805,,"23,155 x DRG weight",12805,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,33682,50,,33682,Percent of Total Billed Charges,50% of Charges,16090,,"29,096 x DRG Weight",16090,Other,base rate x DRG weight,12422,,"22,463 x DRG Weight",12422,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,14614,,"26,426 x DRG Weight",14614,Other,base rate x DRG weight,21461,,"38,809 x DRG Weight",21461,Other,base rate x DRG weight,21461,,"38,809 x DRG Weight",21461,Other,base rate x DRG weight,14614,,"26,426 x DRG Weight",14614,Other,base rate x DRG weight,21461,,"38,809 x DRG Weight",21461,Other,base rate x DRG weight,19571,,"35,391 x DRG Weight",19571,Other,base rate x DRG weight,47155,70,,47155,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,13944,,"25,216 X DRG Weight",13944,Other,Base Weight X DRG Weight,12550,,"22,695 X DRG Weight",12550,Other,Base Weight X DRG Weight,13944,,"25,216 X DRG Weight",13944,Other,Base Rate x DRG Weight ,11852,,"21,433 x DRG Weight",11852,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,47155,
ANGINA PECTORIS,311,MS-DRG,,,,,,,,inpatient,,,85151.04,10822,,,10822,Other,150% of Medicare + 9.63% HCRA Surcharge,6581.12,,,6581.12,Other,Medicare IPPS methodology,17961,,"25,728 x DRG weight",17961,Other,base rate x DRG weight,16165,,"23,155 x DRG weight",16165,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,42576,50,,42576,Percent of Total Billed Charges,50% of Charges,20312,,"29,096 x DRG Weight",20312,Other,base rate x DRG weight,15681,,"22,463 x DRG Weight",15681,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18448,,"26,426 x DRG Weight",18448,Other,base rate x DRG weight,27093,,"38,809 x DRG Weight",27093,Other,base rate x DRG weight,27093,,"38,809 x DRG Weight",27093,Other,base rate x DRG weight,18448,,"26,426 x DRG Weight",18448,Other,base rate x DRG weight,27093,,"38,809 x DRG Weight",27093,Other,base rate x DRG weight,24706,,"35,391 x DRG Weight",24706,Other,base rate x DRG weight,59606,70,,59606,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,17603,,"25,216 X DRG Weight",17603,Other,Base Weight X DRG Weight,15843,,"22,695 X DRG Weight",15843,Other,Base Weight X DRG Weight,17603,,"25,216 X DRG Weight",17603,Other,Base Rate x DRG Weight ,14962,,"21,433 x DRG Weight",14962,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,59606,
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,,inpatient,,,135930.04,13275,,,13275,Other,150% of Medicare + 9.63% HCRA Surcharge,8072.78,,,8072.78,Other,Medicare IPPS methodology,22216,,"25,728 x DRG weight",22216,Other,base rate x DRG weight,19994,,"23,155 x DRG weight",19994,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,67965,50,,67965,Percent of Total Billed Charges,50% of Charges,25124,,"29,096 x DRG Weight",25124,Other,base rate x DRG weight,19397,,"22,463 x DRG Weight",19397,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,22819,,"26,426 x DRG Weight",22819,Other,base rate x DRG weight,33512,,"38,809 x DRG Weight",33512,Other,base rate x DRG weight,33512,,"38,809 x DRG Weight",33512,Other,base rate x DRG weight,22819,,"26,426 x DRG Weight",22819,Other,base rate x DRG weight,33512,,"38,809 x DRG Weight",33512,Other,base rate x DRG weight,30560,,"35,391 x DRG Weight",30560,Other,base rate x DRG weight,95151,70,,95151,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,21774,,"25,216 X DRG Weight",21774,Other,Base Weight X DRG Weight,19597,,"22,695 X DRG Weight",19597,Other,Base Weight X DRG Weight,21774,,"25,216 X DRG Weight",21774,Other,Base Rate x DRG Weight ,18507,,"21,433 x DRG Weight",18507,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,95151,
CHEST PAIN,313,MS-DRG,,,,,,,,inpatient,,,100121.91,11201,,,11201,Other,150% of Medicare + 9.63% HCRA Surcharge,6811.09,,,6811.09,Other,Medicare IPPS methodology,18617,,"25,728 x DRG weight",18617,Other,base rate x DRG weight,16755,,"23,155 x DRG weight",16755,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,50061,50,,50061,Percent of Total Billed Charges,50% of Charges,21054,,"29,096 x DRG Weight",21054,Other,base rate x DRG weight,16254,,"22,463 x DRG Weight",16254,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,19122,,"26,426 x DRG Weight",19122,Other,base rate x DRG weight,28082,,"38,809 x DRG Weight",28082,Other,base rate x DRG weight,28082,,"38,809 x DRG Weight",28082,Other,base rate x DRG weight,19122,,"26,426 x DRG Weight",19122,Other,base rate x DRG weight,28082,,"38,809 x DRG Weight",28082,Other,base rate x DRG weight,25609,,"35,391 x DRG Weight",25609,Other,base rate x DRG weight,70085,70,,70085,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18246,,"25,216 X DRG Weight",18246,Other,Base Weight X DRG Weight,16422,,"22,695 X DRG Weight",16422,Other,Base Weight X DRG Weight,18246,,"25,216 X DRG Weight",18246,Other,Base Rate x DRG Weight ,15509,,"21,433 x DRG Weight",15509,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,70085,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,,inpatient,,,310115.72,31517,,,31517,Other,150% of Medicare + 9.63% HCRA Surcharge,19165.51,,,19165.51,Other,Medicare IPPS methodology,53862,,"25,728 x DRG weight",53862,Other,base rate x DRG weight,48475,,"23,155 x DRG weight",48475,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,155058,50,,155058,Percent of Total Billed Charges,50% of Charges,60912,,"29,096 x DRG Weight",60912,Other,base rate x DRG weight,47026,,"22,463 x DRG Weight",47026,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,55323,,"26,426 x DRG Weight",55323,Other,base rate x DRG weight,81247,,"38,809 x DRG Weight",81247,Other,base rate x DRG weight,81247,,"38,809 x DRG Weight",81247,Other,base rate x DRG weight,55323,,"26,426 x DRG Weight",55323,Other,base rate x DRG weight,81247,,"38,809 x DRG Weight",81247,Other,base rate x DRG weight,74091,,"35,391 x DRG Weight",74091,Other,base rate x DRG weight,217081,70,,217081,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,52790,,"25,216 X DRG Weight",52790,Other,Base Weight X DRG Weight,47512,,"22,695 X DRG Weight",47512,Other,Base Weight X DRG Weight,52790,,"25,216 X DRG Weight",52790,Other,Base Rate x DRG Weight ,44870,,"21,433 x DRG Weight",44870,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,217081,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,,inpatient,,,143896.63,14815,,,14815,Other,150% of Medicare + 9.63% HCRA Surcharge,9008.9,,,9008.9,Other,Medicare IPPS methodology,24887,,"25,728 x DRG weight",24887,Other,base rate x DRG weight,22398,,"23,155 x DRG weight",22398,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,71948,50,,71948,Percent of Total Billed Charges,50% of Charges,28145,,"29,096 x DRG Weight",28145,Other,base rate x DRG weight,21728,,"22,463 x DRG Weight",21728,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,25562,,"26,426 x DRG Weight",25562,Other,base rate x DRG weight,37540,,"38,809 x DRG Weight",37540,Other,base rate x DRG weight,37540,,"38,809 x DRG Weight",37540,Other,base rate x DRG weight,25562,,"26,426 x DRG Weight",25562,Other,base rate x DRG weight,37540,,"38,809 x DRG Weight",37540,Other,base rate x DRG weight,34234,,"35,391 x DRG Weight",34234,Other,base rate x DRG weight,100728,70,,100728,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24391,,"25,216 X DRG Weight",24391,Other,Base Weight X DRG Weight,21953,,"22,695 X DRG Weight",21953,Other,Base Weight X DRG Weight,24391,,"25,216 X DRG Weight",24391,Other,Base Rate x DRG Weight ,20732,,"21,433 x DRG Weight",20732,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,100728,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,,inpatient,,,98929.04,10742,,,10742,Other,150% of Medicare + 9.63% HCRA Surcharge,6532.42,,,6532.42,Other,Medicare IPPS methodology,17822,,"25,728 x DRG weight",17822,Other,base rate x DRG weight,16039,,"23,155 x DRG weight",16039,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,49465,50,,49465,Percent of Total Billed Charges,50% of Charges,20155,,"29,096 x DRG Weight",20155,Other,base rate x DRG weight,15560,,"22,463 x DRG Weight",15560,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18305,,"26,426 x DRG Weight",18305,Other,base rate x DRG weight,26883,,"38,809 x DRG Weight",26883,Other,base rate x DRG weight,26883,,"38,809 x DRG Weight",26883,Other,base rate x DRG weight,18305,,"26,426 x DRG Weight",18305,Other,base rate x DRG weight,26883,,"38,809 x DRG Weight",26883,Other,base rate x DRG weight,24515,,"35,391 x DRG Weight",24515,Other,base rate x DRG weight,69250,70,,69250,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,17467,,"25,216 X DRG Weight",17467,Other,Base Weight X DRG Weight,15721,,"22,695 X DRG Weight",15721,Other,Base Weight X DRG Weight,17467,,"25,216 X DRG Weight",17467,Other,Base Rate x DRG Weight ,14847,,"21,433 x DRG Weight",14847,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,69250,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,,inpatient,,,818007.19,65158,,,65158,Other,150% of Medicare + 9.63% HCRA Surcharge,39623.03,,,39623.03,Other,Medicare IPPS methodology,112223,,"25,728 x DRG weight",112223,Other,base rate x DRG weight,101000,,"23,155 x DRG weight",101000,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,409004,50,,409004,Percent of Total Billed Charges,50% of Charges,126914,,"29,096 x DRG Weight",126914,Other,base rate x DRG weight,97981,,"22,463 x DRG Weight",97981,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,115268,,"26,426 x DRG Weight",115268,Other,base rate x DRG weight,169281,,"38,809 x DRG Weight",169281,Other,base rate x DRG weight,169281,,"38,809 x DRG Weight",169281,Other,base rate x DRG weight,115268,,"26,426 x DRG Weight",115268,Other,base rate x DRG weight,169281,,"38,809 x DRG Weight",169281,Other,base rate x DRG weight,154372,,"35,391 x DRG Weight",154372,Other,base rate x DRG weight,572605,70,,572605,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,109990,,"25,216 X DRG Weight",109990,Other,Base Weight X DRG Weight,98993,,"22,695 X DRG Weight",98993,Other,Base Weight X DRG Weight,109990,,"25,216 X DRG Weight",109990,Other,Base Rate x DRG Weight ,93489,,"21,433 x DRG Weight",93489,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,572605,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,,inpatient,,,421986.5,33482,,,33482,Other,150% of Medicare + 9.63% HCRA Surcharge,20360.46,,,20360.46,Other,Medicare IPPS methodology,57271,,"25,728 x DRG weight",57271,Other,base rate x DRG weight,51543,,"23,155 x DRG weight",51543,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,210993,50,,210993,Percent of Total Billed Charges,50% of Charges,64768,,"29,096 x DRG Weight",64768,Other,base rate x DRG weight,50003,,"22,463 x DRG Weight",50003,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,58824,,"26,426 x DRG Weight",58824,Other,base rate x DRG weight,86389,,"38,809 x DRG Weight",86389,Other,base rate x DRG weight,86389,,"38,809 x DRG Weight",86389,Other,base rate x DRG weight,58824,,"26,426 x DRG Weight",58824,Other,base rate x DRG weight,86389,,"38,809 x DRG Weight",86389,Other,base rate x DRG weight,78780,,"35,391 x DRG Weight",78780,Other,base rate x DRG weight,295391,70,,295391,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,56131,,"25,216 X DRG Weight",56131,Other,Base Weight X DRG Weight,50519,,"22,695 X DRG Weight",50519,Other,Base Weight X DRG Weight,56131,,"25,216 X DRG Weight",56131,Other,Base Rate x DRG Weight ,47710,,"21,433 x DRG Weight",47710,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,295391,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,,inpatient,,,345470.51,43102,,,43102,Other,150% of Medicare + 9.63% HCRA Surcharge,26210.74,,,26210.74,Other,Medicare IPPS methodology,73960,,"25,728 x DRG weight",73960,Other,base rate x DRG weight,66564,,"23,155 x DRG weight",66564,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,172735,50,,172735,Percent of Total Billed Charges,50% of Charges,83642,,"29,096 x DRG Weight",83642,Other,base rate x DRG weight,64574,,"22,463 x DRG Weight",64574,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,75967,,"26,426 x DRG Weight",75967,Other,base rate x DRG weight,111564,,"38,809 x DRG Weight",111564,Other,base rate x DRG weight,111564,,"38,809 x DRG Weight",111564,Other,base rate x DRG weight,75967,,"26,426 x DRG Weight",75967,Other,base rate x DRG weight,111564,,"38,809 x DRG Weight",111564,Other,base rate x DRG weight,101739,,"35,391 x DRG Weight",101739,Other,base rate x DRG weight,241829,70,,241829,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,72488,,"25,216 X DRG Weight",72488,Other,Base Weight X DRG Weight,65241,,"22,695 X DRG Weight",65241,Other,Base Weight X DRG Weight,72488,,"25,216 X DRG Weight",72488,Other,Base Rate x DRG Weight ,61613,,"21,433 x DRG Weight",61613,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,241829,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,,inpatient,,,204191.54,27511,,,27511,Other,150% of Medicare + 9.63% HCRA Surcharge,16729.62,,,16729.62,Other,Medicare IPPS methodology,46912,,"25,728 x DRG weight",46912,Other,base rate x DRG weight,42221,,"23,155 x DRG weight",42221,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,102096,50,,102096,Percent of Total Billed Charges,50% of Charges,53054,,"29,096 x DRG Weight",53054,Other,base rate x DRG weight,40959,,"22,463 x DRG Weight",40959,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,48185,,"26,426 x DRG Weight",48185,Other,base rate x DRG weight,70764,,"38,809 x DRG Weight",70764,Other,base rate x DRG weight,70764,,"38,809 x DRG Weight",70764,Other,base rate x DRG weight,48185,,"26,426 x DRG Weight",48185,Other,base rate x DRG weight,70764,,"38,809 x DRG Weight",70764,Other,base rate x DRG weight,64532,,"35,391 x DRG Weight",64532,Other,base rate x DRG weight,142934,70,,142934,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,45979,,"25,216 X DRG Weight",45979,Other,Base Weight X DRG Weight,41382,,"22,695 X DRG Weight",41382,Other,Base Weight X DRG Weight,45979,,"25,216 X DRG Weight",45979,Other,Base Rate x DRG Weight ,39081,,"21,433 x DRG Weight",39081,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,142934,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,,inpatient,,,230036,61867,,,61867,Other,150% of Medicare + 9.63% HCRA Surcharge,37621.83,,,37621.83,Other,Medicare IPPS methodology,106514,,"25,728 x DRG weight",106514,Other,base rate x DRG weight,95862,,"23,155 x DRG weight",95862,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,115018,50,,115018,Percent of Total Billed Charges,50% of Charges,120457,,"29,096 x DRG Weight",120457,Other,base rate x DRG weight,92997,,"22,463 x DRG Weight",92997,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,109404,,"26,426 x DRG Weight",109404,Other,base rate x DRG weight,160669,,"38,809 x DRG Weight",160669,Other,base rate x DRG weight,160669,,"38,809 x DRG Weight",160669,Other,base rate x DRG weight,109404,,"26,426 x DRG Weight",109404,Other,base rate x DRG weight,160669,,"38,809 x DRG Weight",160669,Other,base rate x DRG weight,146519,,"35,391 x DRG Weight",146519,Other,base rate x DRG weight,161025,70,,161025,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,104394,,"25,216 X DRG Weight",104394,Other,Base Weight X DRG Weight,93957,,"22,695 X DRG Weight",93957,Other,Base Weight X DRG Weight,104394,,"25,216 X DRG Weight",104394,Other,Base Rate x DRG Weight ,88733,,"21,433 x DRG Weight",88733,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,161025,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,,inpatient,,,285419.08,44495,,,44495,Other,150% of Medicare + 9.63% HCRA Surcharge,27057.58,,,27057.58,Other,Medicare IPPS methodology,76376,,"25,728 x DRG weight",76376,Other,base rate x DRG weight,68738,,"23,155 x DRG weight",68738,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,142710,50,,142710,Percent of Total Billed Charges,50% of Charges,86374,,"29,096 x DRG Weight",86374,Other,base rate x DRG weight,66684,,"22,463 x DRG Weight",66684,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,78448,,"26,426 x DRG Weight",78448,Other,base rate x DRG weight,115208,,"38,809 x DRG Weight",115208,Other,base rate x DRG weight,115208,,"38,809 x DRG Weight",115208,Other,base rate x DRG weight,78448,,"26,426 x DRG Weight",78448,Other,base rate x DRG weight,115208,,"38,809 x DRG Weight",115208,Other,base rate x DRG weight,105062,,"35,391 x DRG Weight",105062,Other,base rate x DRG weight,199793,70,,199793,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,74856,,"25,216 X DRG Weight",74856,Other,Base Weight X DRG Weight,67372,,"22,695 X DRG Weight",67372,Other,Base Weight X DRG Weight,74856,,"25,216 X DRG Weight",74856,Other,Base Rate x DRG Weight ,63626,,"21,433 x DRG Weight",63626,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,199793,
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,,inpatient,,,421986.5,39685,,,39685,Other,150% of Medicare + 9.63% HCRA Surcharge,24132.89,,,24132.89,Other,Medicare IPPS methodology,68033,,"25,728 x DRG weight",68033,Other,base rate x DRG weight,61229,,"23,155 x DRG weight",61229,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,210993,50,,210993,Percent of Total Billed Charges,50% of Charges,76939,,"29,096 x DRG Weight",76939,Other,base rate x DRG weight,59399,,"22,463 x DRG Weight",59399,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,69878,,"26,426 x DRG Weight",69878,Other,base rate x DRG weight,102623,,"38,809 x DRG Weight",102623,Other,base rate x DRG weight,102623,,"38,809 x DRG Weight",102623,Other,base rate x DRG weight,69878,,"26,426 x DRG Weight",69878,Other,base rate x DRG weight,102623,,"38,809 x DRG Weight",102623,Other,base rate x DRG weight,93584,,"35,391 x DRG Weight",93584,Other,base rate x DRG weight,295391,70,,295391,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,66679,,"25,216 X DRG Weight",66679,Other,Base Weight X DRG Weight,60012,,"22,695 X DRG Weight",60012,Other,Base Weight X DRG Weight,66679,,"25,216 X DRG Weight",66679,Other,Base Rate x DRG Weight ,56675,,"21,433 x DRG Weight",56675,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,295391,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,,inpatient,,,510319.69,75793,,,75793,Other,150% of Medicare + 9.63% HCRA Surcharge,46090.18,,,46090.18,Other,Medicare IPPS methodology,130673,,"25,728 x DRG weight",130673,Other,base rate x DRG weight,117604,,"23,155 x DRG weight",117604,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,255160,50,,255160,Percent of Total Billed Charges,50% of Charges,147779,,"29,096 x DRG Weight",147779,Other,base rate x DRG weight,114090,,"22,463 x DRG Weight",114090,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,134218,,"26,426 x DRG Weight",134218,Other,base rate x DRG weight,197111,,"38,809 x DRG Weight",197111,Other,base rate x DRG weight,197111,,"38,809 x DRG Weight",197111,Other,base rate x DRG weight,134218,,"26,426 x DRG Weight",134218,Other,base rate x DRG weight,197111,,"38,809 x DRG Weight",197111,Other,base rate x DRG weight,179751,,"35,391 x DRG Weight",179751,Other,base rate x DRG weight,357224,70,,357224,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,128072,,"25,216 X DRG Weight",128072,Other,Base Weight X DRG Weight,115268,,"22,695 X DRG Weight",115268,Other,Base Weight X DRG Weight,128072,,"25,216 X DRG Weight",128072,Other,Base Rate x DRG Weight ,108858,,"21,433 x DRG Weight",108858,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,357224,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,,inpatient,,,210636.53,37507,,,37507,Other,150% of Medicare + 9.63% HCRA Surcharge,22808.07,,,22808.07,Other,Medicare IPPS methodology,64253,,"25,728 x DRG weight",64253,Other,base rate x DRG weight,57827,,"23,155 x DRG weight",57827,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,105318,50,,105318,Percent of Total Billed Charges,50% of Charges,72664,,"29,096 x DRG Weight",72664,Other,base rate x DRG weight,56099,,"22,463 x DRG Weight",56099,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,65996,,"26,426 x DRG Weight",65996,Other,base rate x DRG weight,96922,,"38,809 x DRG Weight",96922,Other,base rate x DRG weight,96922,,"38,809 x DRG Weight",96922,Other,base rate x DRG weight,65996,,"26,426 x DRG Weight",65996,Other,base rate x DRG weight,96922,,"38,809 x DRG Weight",96922,Other,base rate x DRG weight,88385,,"35,391 x DRG Weight",88385,Other,base rate x DRG weight,147446,70,,147446,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,62974,,"25,216 X DRG Weight",62974,Other,Base Weight X DRG Weight,56678,,"22,695 X DRG Weight",56678,Other,Base Weight X DRG Weight,62974,,"25,216 X DRG Weight",62974,Other,Base Rate x DRG Weight ,53527,,"21,433 x DRG Weight",53527,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,147446,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,,inpatient,,,104022.57,24158,,,24158,Other,150% of Medicare + 9.63% HCRA Surcharge,14690.54,,,14690.54,Other,Medicare IPPS methodology,41095,,"25,728 x DRG weight",41095,Other,base rate x DRG weight,36985,,"23,155 x DRG weight",36985,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,52011,50,,52011,Percent of Total Billed Charges,50% of Charges,46475,,"29,096 x DRG Weight",46475,Other,base rate x DRG weight,35880,,"22,463 x DRG Weight",35880,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,42210,,"26,426 x DRG Weight",42210,Other,base rate x DRG weight,61990,,"38,809 x DRG Weight",61990,Other,base rate x DRG weight,61990,,"38,809 x DRG Weight",61990,Other,base rate x DRG weight,42210,,"26,426 x DRG Weight",42210,Other,base rate x DRG weight,61990,,"38,809 x DRG Weight",61990,Other,base rate x DRG weight,56530,,"35,391 x DRG Weight",56530,Other,base rate x DRG weight,72816,70,,72816,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40278,,"25,216 X DRG Weight",40278,Other,Base Weight X DRG Weight,36251,,"22,695 X DRG Weight",36251,Other,Base Weight X DRG Weight,40278,,"25,216 X DRG Weight",40278,Other,Base Rate x DRG Weight ,34235,,"21,433 x DRG Weight",34235,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,72816,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,,inpatient,,,541805.78,67455,,,67455,Other,150% of Medicare + 9.63% HCRA Surcharge,41019.99,,,41019.99,Other,Medicare IPPS methodology,116208,,"25,728 x DRG weight",116208,Other,base rate x DRG weight,104587,,"23,155 x DRG weight",104587,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,270903,50,,270903,Percent of Total Billed Charges,50% of Charges,131421,,"29,096 x DRG Weight",131421,Other,base rate x DRG weight,101461,,"22,463 x DRG Weight",101461,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,119361,,"26,426 x DRG Weight",119361,Other,base rate x DRG weight,175292,,"38,809 x DRG Weight",175292,Other,base rate x DRG weight,175292,,"38,809 x DRG Weight",175292,Other,base rate x DRG weight,119361,,"26,426 x DRG Weight",119361,Other,base rate x DRG weight,175292,,"38,809 x DRG Weight",175292,Other,base rate x DRG weight,159854,,"35,391 x DRG Weight",159854,Other,base rate x DRG weight,379264,70,,379264,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,113896,,"25,216 X DRG Weight",113896,Other,Base Weight X DRG Weight,102509,,"22,695 X DRG Weight",102509,Other,Base Weight X DRG Weight,113896,,"25,216 X DRG Weight",113896,Other,Base Rate x DRG Weight ,96809,,"21,433 x DRG Weight",96809,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,379264,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,,inpatient,,,262953.11,35648,,,35648,Other,150% of Medicare + 9.63% HCRA Surcharge,21678.06,,,21678.06,Other,Medicare IPPS methodology,61029,,"25,728 x DRG weight",61029,Other,base rate x DRG weight,54926,,"23,155 x DRG weight",54926,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,131477,50,,131477,Percent of Total Billed Charges,50% of Charges,69019,,"29,096 x DRG Weight",69019,Other,base rate x DRG weight,53284,,"22,463 x DRG Weight",53284,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,62685,,"26,426 x DRG Weight",62685,Other,base rate x DRG weight,92059,,"38,809 x DRG Weight",92059,Other,base rate x DRG weight,92059,,"38,809 x DRG Weight",92059,Other,base rate x DRG weight,62685,,"26,426 x DRG Weight",62685,Other,base rate x DRG weight,92059,,"38,809 x DRG Weight",92059,Other,base rate x DRG weight,83951,,"35,391 x DRG Weight",83951,Other,base rate x DRG weight,184067,70,,184067,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,59815,,"25,216 X DRG Weight",59815,Other,Base Weight X DRG Weight,53835,,"22,695 X DRG Weight",53835,Other,Base Weight X DRG Weight,59815,,"25,216 X DRG Weight",59815,Other,Base Rate x DRG Weight ,50841,,"21,433 x DRG Weight",50841,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,184067,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,,inpatient,,,144011.03,25266,,,25266,Other,150% of Medicare + 9.63% HCRA Surcharge,15364.22,,,15364.22,Other,Medicare IPPS methodology,43017,,"25,728 x DRG weight",43017,Other,base rate x DRG weight,38715,,"23,155 x DRG weight",38715,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,72006,50,,72006,Percent of Total Billed Charges,50% of Charges,48649,,"29,096 x DRG Weight",48649,Other,base rate x DRG weight,37558,,"22,463 x DRG Weight",37558,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,44184,,"26,426 x DRG Weight",44184,Other,base rate x DRG weight,64889,,"38,809 x DRG Weight",64889,Other,base rate x DRG weight,64889,,"38,809 x DRG Weight",64889,Other,base rate x DRG weight,44184,,"26,426 x DRG Weight",44184,Other,base rate x DRG weight,64889,,"38,809 x DRG Weight",64889,Other,base rate x DRG weight,59174,,"35,391 x DRG Weight",59174,Other,base rate x DRG weight,100808,70,,100808,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,42161,,"25,216 X DRG Weight",42161,Other,Base Weight X DRG Weight,37946,,"22,695 X DRG Weight",37946,Other,Base Weight X DRG Weight,42161,,"25,216 X DRG Weight",42161,Other,Base Rate x DRG Weight ,35836,,"21,433 x DRG Weight",35836,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,100808,
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,,inpatient,,,511895.78,54664,,,54664,Other,150% of Medicare + 9.63% HCRA Surcharge,33241.55,,,33241.55,Other,Medicare IPPS methodology,94018,,"25,728 x DRG weight",94018,Other,base rate x DRG weight,84615,,"23,155 x DRG weight",84615,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,255948,50,,255948,Percent of Total Billed Charges,50% of Charges,106326,,"29,096 x DRG Weight",106326,Other,base rate x DRG weight,82087,,"22,463 x DRG Weight",82087,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,96569,,"26,426 x DRG Weight",96569,Other,base rate x DRG weight,141820,,"38,809 x DRG Weight",141820,Other,base rate x DRG weight,141820,,"38,809 x DRG Weight",141820,Other,base rate x DRG weight,96569,,"26,426 x DRG Weight",96569,Other,base rate x DRG weight,141820,,"38,809 x DRG Weight",141820,Other,base rate x DRG weight,129329,,"35,391 x DRG Weight",129329,Other,base rate x DRG weight,358327,70,,358327,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,92147,,"25,216 X DRG Weight",92147,Other,Base Weight X DRG Weight,82934,,"22,695 X DRG Weight",82934,Other,Base Weight X DRG Weight,92147,,"25,216 X DRG Weight",92147,Other,Base Rate x DRG Weight ,78323,,"21,433 x DRG Weight",78323,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,358327,
RECTAL RESECTION WITH CC,333,MS-DRG,,,,,,,,inpatient,,,86800.71,31309,,,31309,Other,150% of Medicare + 9.63% HCRA Surcharge,19039.25,,,19039.25,Other,Medicare IPPS methodology,53501,,"25,728 x DRG weight",53501,Other,base rate x DRG weight,48151,,"23,155 x DRG weight",48151,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43400,50,,43400,Percent of Total Billed Charges,50% of Charges,60505,,"29,096 x DRG Weight",60505,Other,base rate x DRG weight,46712,,"22,463 x DRG Weight",46712,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,54953,,"26,426 x DRG Weight",54953,Other,base rate x DRG weight,80703,,"38,809 x DRG Weight",80703,Other,base rate x DRG weight,80703,,"38,809 x DRG Weight",80703,Other,base rate x DRG weight,54953,,"26,426 x DRG Weight",54953,Other,base rate x DRG weight,80703,,"38,809 x DRG Weight",80703,Other,base rate x DRG weight,73596,,"35,391 x DRG Weight",73596,Other,base rate x DRG weight,60760,70,,60760,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,52437,,"25,216 X DRG Weight",52437,Other,Base Weight X DRG Weight,47194,,"22,695 X DRG Weight",47194,Other,Base Weight X DRG Weight,52437,,"25,216 X DRG Weight",52437,Other,Base Rate x DRG Weight ,44570,,"21,433 x DRG Weight",44570,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,80703,
RECTAL RESECTION WITHOUT CC/MCC,334,MS-DRG,,,,,,,,inpatient,,,126740.94,24274,,,24274,Other,150% of Medicare + 9.63% HCRA Surcharge,14760.88,,,14760.88,Other,Medicare IPPS methodology,41296,,"25,728 x DRG weight",41296,Other,base rate x DRG weight,37166,,"23,155 x DRG weight",37166,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,63370,50,,63370,Percent of Total Billed Charges,50% of Charges,46702,,"29,096 x DRG Weight",46702,Other,base rate x DRG weight,36055,,"22,463 x DRG Weight",36055,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,42416,,"26,426 x DRG Weight",42416,Other,base rate x DRG weight,62292,,"38,809 x DRG Weight",62292,Other,base rate x DRG weight,62292,,"38,809 x DRG Weight",62292,Other,base rate x DRG weight,42416,,"26,426 x DRG Weight",42416,Other,base rate x DRG weight,62292,,"38,809 x DRG Weight",62292,Other,base rate x DRG weight,56806,,"35,391 x DRG Weight",56806,Other,base rate x DRG weight,88719,70,,88719,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40474,,"25,216 X DRG Weight",40474,Other,Base Weight X DRG Weight,36428,,"22,695 X DRG Weight",36428,Other,Base Weight X DRG Weight,40474,,"25,216 X DRG Weight",40474,Other,Base Rate x DRG Weight ,34402,,"21,433 x DRG Weight",34402,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,88719,
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,,inpatient,,,353724.21,53488,,,53488,Other,150% of Medicare + 9.63% HCRA Surcharge,32526.39,,,32526.39,Other,Medicare IPPS methodology,91978,,"25,728 x DRG weight",91978,Other,base rate x DRG weight,82779,,"23,155 x DRG weight",82779,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,176862,50,,176862,Percent of Total Billed Charges,50% of Charges,104018,,"29,096 x DRG Weight",104018,Other,base rate x DRG weight,80305,,"22,463 x DRG Weight",80305,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,94473,,"26,426 x DRG Weight",94473,Other,base rate x DRG weight,138742,,"38,809 x DRG Weight",138742,Other,base rate x DRG weight,138742,,"38,809 x DRG Weight",138742,Other,base rate x DRG weight,94473,,"26,426 x DRG Weight",94473,Other,base rate x DRG weight,138742,,"38,809 x DRG Weight",138742,Other,base rate x DRG weight,126523,,"35,391 x DRG Weight",126523,Other,base rate x DRG weight,247607,70,,247607,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,90147,,"25,216 X DRG Weight",90147,Other,Base Weight X DRG Weight,81135,,"22,695 X DRG Weight",81135,Other,Base Weight X DRG Weight,90147,,"25,216 X DRG Weight",90147,Other,Base Rate x DRG Weight ,76623,,"21,433 x DRG Weight",76623,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,247607,
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,,inpatient,,,240481.91,31692,,,31692,Other,150% of Medicare + 9.63% HCRA Surcharge,19271.93,,,19271.93,Other,Medicare IPPS methodology,54165,,"25,728 x DRG weight",54165,Other,base rate x DRG weight,48748,,"23,155 x DRG weight",48748,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,120241,50,,120241,Percent of Total Billed Charges,50% of Charges,61256,,"29,096 x DRG Weight",61256,Other,base rate x DRG weight,47291,,"22,463 x DRG Weight",47291,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,55635,,"26,426 x DRG Weight",55635,Other,base rate x DRG weight,81705,,"38,809 x DRG Weight",81705,Other,base rate x DRG weight,81705,,"38,809 x DRG Weight",81705,Other,base rate x DRG weight,55635,,"26,426 x DRG Weight",55635,Other,base rate x DRG weight,81705,,"38,809 x DRG Weight",81705,Other,base rate x DRG weight,74509,,"35,391 x DRG Weight",74509,Other,base rate x DRG weight,168337,70,,168337,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,53087,,"25,216 X DRG Weight",53087,Other,Base Weight X DRG Weight,47780,,"22,695 X DRG Weight",47780,Other,Base Weight X DRG Weight,53087,,"25,216 X DRG Weight",53087,Other,Base Rate x DRG Weight ,45123,,"21,433 x DRG Weight",45123,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,168337,
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,,inpatient,,,130269.51,22661,,,22661,Other,150% of Medicare + 9.63% HCRA Surcharge,13780.57,,,13780.57,Other,Medicare IPPS methodology,38499,,"25,728 x DRG weight",38499,Other,base rate x DRG weight,34649,,"23,155 x DRG weight",34649,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,65135,50,,65135,Percent of Total Billed Charges,50% of Charges,43539,,"29,096 x DRG Weight",43539,Other,base rate x DRG weight,33614,,"22,463 x DRG Weight",33614,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39544,,"26,426 x DRG Weight",39544,Other,base rate x DRG weight,58074,,"38,809 x DRG Weight",58074,Other,base rate x DRG weight,58074,,"38,809 x DRG Weight",58074,Other,base rate x DRG weight,39544,,"26,426 x DRG Weight",39544,Other,base rate x DRG weight,58074,,"38,809 x DRG Weight",58074,Other,base rate x DRG weight,52959,,"35,391 x DRG Weight",52959,Other,base rate x DRG weight,91189,70,,91189,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37733,,"25,216 X DRG Weight",37733,Other,Base Weight X DRG Weight,33961,,"22,695 X DRG Weight",33961,Other,Base Weight X DRG Weight,37733,,"25,216 X DRG Weight",37733,Other,Base Rate x DRG Weight ,32072,,"21,433 x DRG Weight",32072,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,91189,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,,inpatient,,,260881.91,41111,,,41111,Other,150% of Medicare + 9.63% HCRA Surcharge,24999.56,,,24999.56,Other,Medicare IPPS methodology,70505,,"25,728 x DRG weight",70505,Other,base rate x DRG weight,63454,,"23,155 x DRG weight",63454,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,130441,50,,130441,Percent of Total Billed Charges,50% of Charges,79735,,"29,096 x DRG Weight",79735,Other,base rate x DRG weight,61558,,"22,463 x DRG Weight",61558,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,72418,,"26,426 x DRG Weight",72418,Other,base rate x DRG weight,106352,,"38,809 x DRG Weight",106352,Other,base rate x DRG weight,106352,,"38,809 x DRG Weight",106352,Other,base rate x DRG weight,72418,,"26,426 x DRG Weight",72418,Other,base rate x DRG weight,106352,,"38,809 x DRG Weight",106352,Other,base rate x DRG weight,96985,,"35,391 x DRG Weight",96985,Other,base rate x DRG weight,182617,70,,182617,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,69102,,"25,216 X DRG Weight",69102,Other,Base Weight X DRG Weight,62193,,"22,695 X DRG Weight",62193,Other,Base Weight X DRG Weight,69102,,"25,216 X DRG Weight",69102,Other,Base Rate x DRG Weight ,58735,,"21,433 x DRG Weight",58735,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,182617,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,,inpatient,,,217741.13,23317,,,23317,Other,150% of Medicare + 9.63% HCRA Surcharge,14179.19,,,14179.19,Other,Medicare IPPS methodology,39637,,"25,728 x DRG weight",39637,Other,base rate x DRG weight,35673,,"23,155 x DRG weight",35673,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,108871,50,,108871,Percent of Total Billed Charges,50% of Charges,44825,,"29,096 x DRG Weight",44825,Other,base rate x DRG weight,34606,,"22,463 x DRG Weight",34606,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,40712,,"26,426 x DRG Weight",40712,Other,base rate x DRG weight,59789,,"38,809 x DRG Weight",59789,Other,base rate x DRG weight,59789,,"38,809 x DRG Weight",59789,Other,base rate x DRG weight,40712,,"26,426 x DRG Weight",40712,Other,base rate x DRG weight,59789,,"38,809 x DRG Weight",59789,Other,base rate x DRG weight,54523,,"35,391 x DRG Weight",54523,Other,base rate x DRG weight,152419,70,,152419,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,38848,,"25,216 X DRG Weight",38848,Other,Base Weight X DRG Weight,34964,,"22,695 X DRG Weight",34964,Other,Base Weight X DRG Weight,38848,,"25,216 X DRG Weight",38848,Other,Base Rate x DRG Weight ,33020,,"21,433 x DRG Weight",33020,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,152419,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,,inpatient,,,124639,19568,,,19568,Other,150% of Medicare + 9.63% HCRA Surcharge,11899.32,,,11899.32,Other,Medicare IPPS methodology,33133,,"25,728 x DRG weight",33133,Other,base rate x DRG weight,29819,,"23,155 x DRG weight",29819,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,62320,50,,62320,Percent of Total Billed Charges,50% of Charges,37470,,"29,096 x DRG Weight",37470,Other,base rate x DRG weight,28928,,"22,463 x DRG Weight",28928,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,34031,,"26,426 x DRG Weight",34031,Other,base rate x DRG weight,49978,,"38,809 x DRG Weight",49978,Other,base rate x DRG weight,49978,,"38,809 x DRG Weight",49978,Other,base rate x DRG weight,34031,,"26,426 x DRG Weight",34031,Other,base rate x DRG weight,49978,,"38,809 x DRG Weight",49978,Other,base rate x DRG weight,45577,,"35,391 x DRG Weight",45577,Other,base rate x DRG weight,87247,70,,87247,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32473,,"25,216 X DRG Weight",32473,Other,Base Weight X DRG Weight,29227,,"22,695 X DRG Weight",29227,Other,Base Weight X DRG Weight,32473,,"25,216 X DRG Weight",32473,Other,Base Rate x DRG Weight ,27601,,"21,433 x DRG Weight",27601,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,87247,
ANAL AND STOMAL PROCEDURES WITH MCC,347,MS-DRG,,,,,,,,inpatient,,,429562.31,38273,,,38273,Other,150% of Medicare + 9.63% HCRA Surcharge,23274.33,,,23274.33,Other,Medicare IPPS methodology,65583,,"25,728 x DRG weight",65583,Other,base rate x DRG weight,59024,,"23,155 x DRG weight",59024,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,214781,50,,214781,Percent of Total Billed Charges,50% of Charges,74169,,"29,096 x DRG Weight",74169,Other,base rate x DRG weight,57260,,"22,463 x DRG Weight",57260,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,67363,,"26,426 x DRG Weight",67363,Other,base rate x DRG weight,98928,,"38,809 x DRG Weight",98928,Other,base rate x DRG weight,98928,,"38,809 x DRG Weight",98928,Other,base rate x DRG weight,67363,,"26,426 x DRG Weight",67363,Other,base rate x DRG weight,98928,,"38,809 x DRG Weight",98928,Other,base rate x DRG weight,90215,,"35,391 x DRG Weight",90215,Other,base rate x DRG weight,300694,70,,300694,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,64278,,"25,216 X DRG Weight",64278,Other,Base Weight X DRG Weight,57852,,"22,695 X DRG Weight",57852,Other,Base Weight X DRG Weight,64278,,"25,216 X DRG Weight",64278,Other,Base Rate x DRG Weight ,54635,,"21,433 x DRG Weight",54635,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,300694,
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,,inpatient,,,139982.84,19770,,,19770,Other,150% of Medicare + 9.63% HCRA Surcharge,12021.97,,,12021.97,Other,Medicare IPPS methodology,33482,,"25,728 x DRG weight",33482,Other,base rate x DRG weight,30134,,"23,155 x DRG weight",30134,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,69991,50,,69991,Percent of Total Billed Charges,50% of Charges,37866,,"29,096 x DRG Weight",37866,Other,base rate x DRG weight,29233,,"22,463 x DRG Weight",29233,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,34391,,"26,426 x DRG Weight",34391,Other,base rate x DRG weight,50506,,"38,809 x DRG Weight",50506,Other,base rate x DRG weight,50506,,"38,809 x DRG Weight",50506,Other,base rate x DRG weight,34391,,"26,426 x DRG Weight",34391,Other,base rate x DRG weight,50506,,"38,809 x DRG Weight",50506,Other,base rate x DRG weight,46058,,"35,391 x DRG Weight",46058,Other,base rate x DRG weight,97988,70,,97988,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32816,,"25,216 X DRG Weight",32816,Other,Base Weight X DRG Weight,29535,,"22,695 X DRG Weight",29535,Other,Base Weight X DRG Weight,32816,,"25,216 X DRG Weight",32816,Other,Base Rate x DRG Weight ,27893,,"21,433 x DRG Weight",27893,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,97988,
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,,inpatient,,,58439.29,14941,,,14941,Other,150% of Medicare + 9.63% HCRA Surcharge,9085.55,,,9085.55,Other,Medicare IPPS methodology,25105,,"25,728 x DRG weight",25105,Other,base rate x DRG weight,22595,,"23,155 x DRG weight",22595,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,29220,50,,29220,Percent of Total Billed Charges,50% of Charges,28392,,"29,096 x DRG Weight",28392,Other,base rate x DRG weight,21919,,"22,463 x DRG Weight",21919,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,25786,,"26,426 x DRG Weight",25786,Other,base rate x DRG weight,37870,,"38,809 x DRG Weight",37870,Other,base rate x DRG weight,37870,,"38,809 x DRG Weight",37870,Other,base rate x DRG weight,25786,,"26,426 x DRG Weight",25786,Other,base rate x DRG weight,37870,,"38,809 x DRG Weight",37870,Other,base rate x DRG weight,34535,,"35,391 x DRG Weight",34535,Other,base rate x DRG weight,40908,70,,40908,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24606,,"25,216 X DRG Weight",24606,Other,Base Weight X DRG Weight,22146,,"22,695 X DRG Weight",22146,Other,Base Weight X DRG Weight,24606,,"25,216 X DRG Weight",24606,Other,Base Rate x DRG Weight ,20914,,"21,433 x DRG Weight",20914,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,40908,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,,inpatient,,,146612.33,36062,,,36062,Other,150% of Medicare + 9.63% HCRA Surcharge,21929.67,,,21929.67,Other,Medicare IPPS methodology,61747,,"25,728 x DRG weight",61747,Other,base rate x DRG weight,55572,,"23,155 x DRG weight",55572,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,73306,50,,73306,Percent of Total Billed Charges,50% of Charges,69830,,"29,096 x DRG Weight",69830,Other,base rate x DRG weight,53911,,"22,463 x DRG Weight",53911,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,63422,,"26,426 x DRG Weight",63422,Other,base rate x DRG weight,93142,,"38,809 x DRG Weight",93142,Other,base rate x DRG weight,93142,,"38,809 x DRG Weight",93142,Other,base rate x DRG weight,63422,,"26,426 x DRG Weight",63422,Other,base rate x DRG weight,93142,,"38,809 x DRG Weight",93142,Other,base rate x DRG weight,84938,,"35,391 x DRG Weight",84938,Other,base rate x DRG weight,102629,70,,102629,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,60518,,"25,216 X DRG Weight",60518,Other,Base Weight X DRG Weight,54468,,"22,695 X DRG Weight",54468,Other,Base Weight X DRG Weight,60518,,"25,216 X DRG Weight",60518,Other,Base Rate x DRG Weight ,51439,,"21,433 x DRG Weight",51439,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,102629,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,,inpatient,,,134953.04,22056,,,22056,Other,150% of Medicare + 9.63% HCRA Surcharge,13412.62,,,13412.62,Other,Medicare IPPS methodology,37450,,"25,728 x DRG weight",37450,Other,base rate x DRG weight,33704,,"23,155 x DRG weight",33704,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,67477,50,,67477,Percent of Total Billed Charges,50% of Charges,42352,,"29,096 x DRG Weight",42352,Other,base rate x DRG weight,32697,,"22,463 x DRG Weight",32697,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,38466,,"26,426 x DRG Weight",38466,Other,base rate x DRG weight,56490,,"38,809 x DRG Weight",56490,Other,base rate x DRG weight,56490,,"38,809 x DRG Weight",56490,Other,base rate x DRG weight,38466,,"26,426 x DRG Weight",38466,Other,base rate x DRG weight,56490,,"38,809 x DRG Weight",56490,Other,base rate x DRG weight,51515,,"35,391 x DRG Weight",51515,Other,base rate x DRG weight,94467,70,,94467,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,36704,,"25,216 X DRG Weight",36704,Other,Base Weight X DRG Weight,33035,,"22,695 X DRG Weight",33035,Other,Base Weight X DRG Weight,36704,,"25,216 X DRG Weight",36704,Other,Base Rate x DRG Weight ,31198,,"21,433 x DRG Weight",31198,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,94467,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,,inpatient,,,111772.39,16916,,,16916,Other,150% of Medicare + 9.63% HCRA Surcharge,10286.81,,,10286.81,Other,Medicare IPPS methodology,28532,,"25,728 x DRG weight",28532,Other,base rate x DRG weight,25679,,"23,155 x DRG weight",25679,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,55886,50,,55886,Percent of Total Billed Charges,50% of Charges,32267,,"29,096 x DRG Weight",32267,Other,base rate x DRG weight,24911,,"22,463 x DRG Weight",24911,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,29306,,"26,426 x DRG Weight",29306,Other,base rate x DRG weight,43039,,"38,809 x DRG Weight",43039,Other,base rate x DRG weight,43039,,"38,809 x DRG Weight",43039,Other,base rate x DRG weight,29306,,"26,426 x DRG Weight",29306,Other,base rate x DRG weight,43039,,"38,809 x DRG Weight",43039,Other,base rate x DRG weight,39249,,"35,391 x DRG Weight",39249,Other,base rate x DRG weight,78241,70,,78241,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27965,,"25,216 X DRG Weight",27965,Other,Base Weight X DRG Weight,25169,,"22,695 X DRG Weight",25169,Other,Base Weight X DRG Weight,27965,,"25,216 X DRG Weight",27965,Other,Base Rate x DRG Weight ,23769,,"21,433 x DRG Weight",23769,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,78241,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,,inpatient,,,253158.37,43838,,,43838,Other,150% of Medicare + 9.63% HCRA Surcharge,26658.06,,,26658.06,Other,Medicare IPPS methodology,75236,,"25,728 x DRG weight",75236,Other,base rate x DRG weight,67712,,"23,155 x DRG weight",67712,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,126579,50,,126579,Percent of Total Billed Charges,50% of Charges,85085,,"29,096 x DRG Weight",85085,Other,base rate x DRG weight,65689,,"22,463 x DRG Weight",65689,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,77278,,"26,426 x DRG Weight",77278,Other,base rate x DRG weight,113489,,"38,809 x DRG Weight",113489,Other,base rate x DRG weight,113489,,"38,809 x DRG Weight",113489,Other,base rate x DRG weight,77278,,"26,426 x DRG Weight",77278,Other,base rate x DRG weight,113489,,"38,809 x DRG Weight",113489,Other,base rate x DRG weight,103494,,"35,391 x DRG Weight",103494,Other,base rate x DRG weight,177211,70,,177211,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,73739,,"25,216 X DRG Weight",73739,Other,Base Weight X DRG Weight,66367,,"22,695 X DRG Weight",66367,Other,Base Weight X DRG Weight,73739,,"25,216 X DRG Weight",73739,Other,Base Rate x DRG Weight ,62677,,"21,433 x DRG Weight",62677,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,177211,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,,inpatient,,,207376.47,25945,,,25945,Other,150% of Medicare + 9.63% HCRA Surcharge,15777.26,,,15777.26,Other,Medicare IPPS methodology,44196,,"25,728 x DRG weight",44196,Other,base rate x DRG weight,39776,,"23,155 x DRG weight",39776,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,103688,50,,103688,Percent of Total Billed Charges,50% of Charges,49981,,"29,096 x DRG Weight",49981,Other,base rate x DRG weight,38587,,"22,463 x DRG Weight",38587,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,45395,,"26,426 x DRG Weight",45395,Other,base rate x DRG weight,66666,,"38,809 x DRG Weight",66666,Other,base rate x DRG weight,66666,,"38,809 x DRG Weight",66666,Other,base rate x DRG weight,45395,,"26,426 x DRG Weight",45395,Other,base rate x DRG weight,66666,,"38,809 x DRG Weight",66666,Other,base rate x DRG weight,60795,,"35,391 x DRG Weight",60795,Other,base rate x DRG weight,145164,70,,145164,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43316,,"25,216 X DRG Weight",43316,Other,Base Weight X DRG Weight,38985,,"22,695 X DRG Weight",38985,Other,Base Weight X DRG Weight,43316,,"25,216 X DRG Weight",43316,Other,Base Rate x DRG Weight ,36818,,"21,433 x DRG Weight",36818,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,145164,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,,inpatient,,,96443.6,20677,,,20677,Other,150% of Medicare + 9.63% HCRA Surcharge,12573.9,,,12573.9,Other,Medicare IPPS methodology,35057,,"25,728 x DRG weight",35057,Other,base rate x DRG weight,31551,,"23,155 x DRG weight",31551,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,48222,50,,48222,Percent of Total Billed Charges,50% of Charges,39646,,"29,096 x DRG Weight",39646,Other,base rate x DRG weight,30608,,"22,463 x DRG Weight",30608,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,36008,,"26,426 x DRG Weight",36008,Other,base rate x DRG weight,52881,,"38,809 x DRG Weight",52881,Other,base rate x DRG weight,52881,,"38,809 x DRG Weight",52881,Other,base rate x DRG weight,36008,,"26,426 x DRG Weight",36008,Other,base rate x DRG weight,52881,,"38,809 x DRG Weight",52881,Other,base rate x DRG weight,48224,,"35,391 x DRG Weight",48224,Other,base rate x DRG weight,67511,70,,67511,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,34359,,"25,216 X DRG Weight",34359,Other,Base Weight X DRG Weight,30924,,"22,695 X DRG Weight",30924,Other,Base Weight X DRG Weight,34359,,"25,216 X DRG Weight",34359,Other,Base Rate x DRG Weight ,29205,,"21,433 x DRG Weight",29205,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,67511,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,,inpatient,,,610805.36,63924,,,63924,Other,150% of Medicare + 9.63% HCRA Surcharge,38872.69,,,38872.69,Other,Medicare IPPS methodology,110082,,"25,728 x DRG weight",110082,Other,base rate x DRG weight,99073,,"23,155 x DRG weight",99073,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,305403,50,,305403,Percent of Total Billed Charges,50% of Charges,124493,,"29,096 x DRG Weight",124493,Other,base rate x DRG weight,96112,,"22,463 x DRG Weight",96112,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,113069,,"26,426 x DRG Weight",113069,Other,base rate x DRG weight,166052,,"38,809 x DRG Weight",166052,Other,base rate x DRG weight,166052,,"38,809 x DRG Weight",166052,Other,base rate x DRG weight,113069,,"26,426 x DRG Weight",113069,Other,base rate x DRG weight,166052,,"38,809 x DRG Weight",166052,Other,base rate x DRG weight,151427,,"35,391 x DRG Weight",151427,Other,base rate x DRG weight,427564,70,,427564,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,107892,,"25,216 X DRG Weight",107892,Other,Base Weight X DRG Weight,97105,,"22,695 X DRG Weight",97105,Other,Base Weight X DRG Weight,107892,,"25,216 X DRG Weight",107892,Other,Base Rate x DRG Weight ,91705,,"21,433 x DRG Weight",91705,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,427564,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,,inpatient,,,250970.93,33049,,,33049,Other,150% of Medicare + 9.63% HCRA Surcharge,20097.12,,,20097.12,Other,Medicare IPPS methodology,56519,,"25,728 x DRG weight",56519,Other,base rate x DRG weight,50867,,"23,155 x DRG weight",50867,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,125485,50,,125485,Percent of Total Billed Charges,50% of Charges,63918,,"29,096 x DRG Weight",63918,Other,base rate x DRG weight,49347,,"22,463 x DRG Weight",49347,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,58053,,"26,426 x DRG Weight",58053,Other,base rate x DRG weight,85256,,"38,809 x DRG Weight",85256,Other,base rate x DRG weight,85256,,"38,809 x DRG Weight",85256,Other,base rate x DRG weight,58053,,"26,426 x DRG Weight",58053,Other,base rate x DRG weight,85256,,"38,809 x DRG Weight",85256,Other,base rate x DRG weight,77747,,"35,391 x DRG Weight",77747,Other,base rate x DRG weight,175680,70,,175680,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,55395,,"25,216 X DRG Weight",55395,Other,Base Weight X DRG Weight,49856,,"22,695 X DRG Weight",49856,Other,Base Weight X DRG Weight,55395,,"25,216 X DRG Weight",55395,Other,Base Rate x DRG Weight ,47084,,"21,433 x DRG Weight",47084,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,175680,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,,inpatient,,,147974.66,19468,,,19468,Other,150% of Medicare + 9.63% HCRA Surcharge,11838.89,,,11838.89,Other,Medicare IPPS methodology,32960,,"25,728 x DRG weight",32960,Other,base rate x DRG weight,29664,,"23,155 x DRG weight",29664,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,73987,50,,73987,Percent of Total Billed Charges,50% of Charges,37275,,"29,096 x DRG Weight",37275,Other,base rate x DRG weight,28777,,"22,463 x DRG Weight",28777,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,33854,,"26,426 x DRG Weight",33854,Other,base rate x DRG weight,49718,,"38,809 x DRG Weight",49718,Other,base rate x DRG weight,49718,,"38,809 x DRG Weight",49718,Other,base rate x DRG weight,33854,,"26,426 x DRG Weight",33854,Other,base rate x DRG weight,49718,,"38,809 x DRG Weight",49718,Other,base rate x DRG weight,45339,,"35,391 x DRG Weight",45339,Other,base rate x DRG weight,103582,70,,103582,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32304,,"25,216 X DRG Weight",32304,Other,Base Weight X DRG Weight,29075,,"22,695 X DRG Weight",29075,Other,Base Weight X DRG Weight,32304,,"25,216 X DRG Weight",32304,Other,Base Rate x DRG Weight ,27458,,"21,433 x DRG Weight",27458,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,103582,
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,,inpatient,,,125057.04,24969,,,24969,Other,150% of Medicare + 9.63% HCRA Surcharge,15183.85,,,15183.85,Other,Medicare IPPS methodology,42503,,"25,728 x DRG weight",42503,Other,base rate x DRG weight,38252,,"23,155 x DRG weight",38252,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,62529,50,,62529,Percent of Total Billed Charges,50% of Charges,48067,,"29,096 x DRG Weight",48067,Other,base rate x DRG weight,37109,,"22,463 x DRG Weight",37109,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,43656,,"26,426 x DRG Weight",43656,Other,base rate x DRG weight,64112,,"38,809 x DRG Weight",64112,Other,base rate x DRG weight,64112,,"38,809 x DRG Weight",64112,Other,base rate x DRG weight,43656,,"26,426 x DRG Weight",43656,Other,base rate x DRG weight,64112,,"38,809 x DRG Weight",64112,Other,base rate x DRG weight,58466,,"35,391 x DRG Weight",58466,Other,base rate x DRG weight,87540,70,,87540,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,41657,,"25,216 X DRG Weight",41657,Other,Base Weight X DRG Weight,37492,,"22,695 X DRG Weight",37492,Other,Base Weight X DRG Weight,41657,,"25,216 X DRG Weight",41657,Other,Base Rate x DRG Weight ,35407,,"21,433 x DRG Weight",35407,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,87540,
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,,inpatient,,,136788.2,15126,,,15126,Other,150% of Medicare + 9.63% HCRA Surcharge,9198.28,,,9198.28,Other,Medicare IPPS methodology,25427,,"25,728 x DRG weight",25427,Other,base rate x DRG weight,22884,,"23,155 x DRG weight",22884,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,68394,50,,68394,Percent of Total Billed Charges,50% of Charges,28756,,"29,096 x DRG Weight",28756,Other,base rate x DRG weight,22200,,"22,463 x DRG Weight",22200,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26117,,"26,426 x DRG Weight",26117,Other,base rate x DRG weight,38355,,"38,809 x DRG Weight",38355,Other,base rate x DRG weight,38355,,"38,809 x DRG Weight",38355,Other,base rate x DRG weight,26117,,"26,426 x DRG Weight",26117,Other,base rate x DRG weight,38355,,"38,809 x DRG Weight",38355,Other,base rate x DRG weight,34977,,"35,391 x DRG Weight",34977,Other,base rate x DRG weight,95752,70,,95752,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24921,,"25,216 X DRG Weight",24921,Other,Base Weight X DRG Weight,22429,,"22,695 X DRG Weight",22429,Other,Base Weight X DRG Weight,24921,,"25,216 X DRG Weight",24921,Other,Base Rate x DRG Weight ,21182,,"21,433 x DRG Weight",21182,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,95752,
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,MS-DRG,,,,,,,,inpatient,,,55938.84,11499,,,11499,Other,150% of Medicare + 9.63% HCRA Surcharge,6992.36,,,6992.36,Other,Medicare IPPS methodology,19134,,"25,728 x DRG weight",19134,Other,base rate x DRG weight,17220,,"23,155 x DRG weight",17220,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27969,50,,27969,Percent of Total Billed Charges,50% of Charges,21639,,"29,096 x DRG Weight",21639,Other,base rate x DRG weight,16706,,"22,463 x DRG Weight",16706,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,19653,,"26,426 x DRG Weight",19653,Other,base rate x DRG weight,28862,,"38,809 x DRG Weight",28862,Other,base rate x DRG weight,28862,,"38,809 x DRG Weight",28862,Other,base rate x DRG weight,19653,,"26,426 x DRG Weight",19653,Other,base rate x DRG weight,28862,,"38,809 x DRG Weight",28862,Other,base rate x DRG weight,26320,,"35,391 x DRG Weight",26320,Other,base rate x DRG weight,39157,70,,39157,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18753,,"25,216 X DRG Weight",18753,Other,Base Weight X DRG Weight,16878,,"22,695 X DRG Weight",16878,Other,Base Weight X DRG Weight,18753,,"25,216 X DRG Weight",18753,Other,Base Rate x DRG Weight ,15940,,"21,433 x DRG Weight",15940,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,39157,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,,inpatient,,,264384.74,26388,,,26388,Other,150% of Medicare + 9.63% HCRA Surcharge,16046.92,,,16046.92,Other,Medicare IPPS methodology,44965,,"25,728 x DRG weight",44965,Other,base rate x DRG weight,40468,,"23,155 x DRG weight",40468,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,132192,50,,132192,Percent of Total Billed Charges,50% of Charges,50851,,"29,096 x DRG Weight",50851,Other,base rate x DRG weight,39259,,"22,463 x DRG Weight",39259,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,46185,,"26,426 x DRG Weight",46185,Other,base rate x DRG weight,67826,,"38,809 x DRG Weight",67826,Other,base rate x DRG weight,67826,,"38,809 x DRG Weight",67826,Other,base rate x DRG weight,46185,,"26,426 x DRG Weight",46185,Other,base rate x DRG weight,67826,,"38,809 x DRG Weight",67826,Other,base rate x DRG weight,61853,,"35,391 x DRG Weight",61853,Other,base rate x DRG weight,185069,70,,185069,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,44070,,"25,216 X DRG Weight",44070,Other,Base Weight X DRG Weight,39664,,"22,695 X DRG Weight",39664,Other,Base Weight X DRG Weight,44070,,"25,216 X DRG Weight",44070,Other,Base Rate x DRG Weight ,37458,,"21,433 x DRG Weight",37458,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,185069,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,,inpatient,,,140654.67,15927,,,15927,Other,150% of Medicare + 9.63% HCRA Surcharge,9685.28,,,9685.28,Other,Medicare IPPS methodology,26816,,"25,728 x DRG weight",26816,Other,base rate x DRG weight,24134,,"23,155 x DRG weight",24134,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,70327,50,,70327,Percent of Total Billed Charges,50% of Charges,30327,,"29,096 x DRG Weight",30327,Other,base rate x DRG weight,23413,,"22,463 x DRG Weight",23413,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,27544,,"26,426 x DRG Weight",27544,Other,base rate x DRG weight,40451,,"38,809 x DRG Weight",40451,Other,base rate x DRG weight,40451,,"38,809 x DRG Weight",40451,Other,base rate x DRG weight,27544,,"26,426 x DRG Weight",27544,Other,base rate x DRG weight,40451,,"38,809 x DRG Weight",40451,Other,base rate x DRG weight,36888,,"35,391 x DRG Weight",36888,Other,base rate x DRG weight,98458,70,,98458,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,26283,,"25,216 X DRG Weight",26283,Other,Base Weight X DRG Weight,23655,,"22,695 X DRG Weight",23655,Other,Base Weight X DRG Weight,26283,,"25,216 X DRG Weight",26283,Other,Base Rate x DRG Weight ,22340,,"21,433 x DRG Weight",22340,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,98458,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,,inpatient,,,87175.27,11095,,,11095,Other,150% of Medicare + 9.63% HCRA Surcharge,6747.06,,,6747.06,Other,Medicare IPPS methodology,18434,,"25,728 x DRG weight",18434,Other,base rate x DRG weight,16591,,"23,155 x DRG weight",16591,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43588,50,,43588,Percent of Total Billed Charges,50% of Charges,20847,,"29,096 x DRG Weight",20847,Other,base rate x DRG weight,16095,,"22,463 x DRG Weight",16095,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18934,,"26,426 x DRG Weight",18934,Other,base rate x DRG weight,27807,,"38,809 x DRG Weight",27807,Other,base rate x DRG weight,27807,,"38,809 x DRG Weight",27807,Other,base rate x DRG weight,18934,,"26,426 x DRG Weight",18934,Other,base rate x DRG weight,27807,,"38,809 x DRG Weight",27807,Other,base rate x DRG weight,25358,,"35,391 x DRG Weight",25358,Other,base rate x DRG weight,61023,70,,61023,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18067,,"25,216 X DRG Weight",18067,Other,Base Weight X DRG Weight,16261,,"22,695 X DRG Weight",16261,Other,Base Weight X DRG Weight,18067,,"25,216 X DRG Weight",18067,Other,Base Rate x DRG Weight ,15357,,"21,433 x DRG Weight",15357,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,61023,
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,,inpatient,,,334803.01,31598,,,31598,Other,150% of Medicare + 9.63% HCRA Surcharge,19215.11,,,19215.11,Other,Medicare IPPS methodology,54003,,"25,728 x DRG weight",54003,Other,base rate x DRG weight,48602,,"23,155 x DRG weight",48602,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,167402,50,,167402,Percent of Total Billed Charges,50% of Charges,61073,,"29,096 x DRG Weight",61073,Other,base rate x DRG weight,47150,,"22,463 x DRG Weight",47150,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,55468,,"26,426 x DRG Weight",55468,Other,base rate x DRG weight,81460,,"38,809 x DRG Weight",81460,Other,base rate x DRG weight,81460,,"38,809 x DRG Weight",81460,Other,base rate x DRG weight,55468,,"26,426 x DRG Weight",55468,Other,base rate x DRG weight,81460,,"38,809 x DRG Weight",81460,Other,base rate x DRG weight,74286,,"35,391 x DRG Weight",74286,Other,base rate x DRG weight,234362,70,,234362,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,52928,,"25,216 X DRG Weight",52928,Other,Base Weight X DRG Weight,47637,,"22,695 X DRG Weight",47637,Other,Base Weight X DRG Weight,52928,,"25,216 X DRG Weight",52928,Other,Base Rate x DRG Weight ,44988,,"21,433 x DRG Weight",44988,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,234362,
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,,inpatient,,,290067.91,18241,,,18241,Other,150% of Medicare + 9.63% HCRA Surcharge,11092.16,,,11092.16,Other,Medicare IPPS methodology,30830,,"25,728 x DRG weight",30830,Other,base rate x DRG weight,27747,,"23,155 x DRG weight",27747,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,145034,50,,145034,Percent of Total Billed Charges,50% of Charges,34866,,"29,096 x DRG Weight",34866,Other,base rate x DRG weight,26917,,"22,463 x DRG Weight",26917,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31666,,"26,426 x DRG Weight",31666,Other,base rate x DRG weight,46505,,"38,809 x DRG Weight",46505,Other,base rate x DRG weight,46505,,"38,809 x DRG Weight",46505,Other,base rate x DRG weight,31666,,"26,426 x DRG Weight",31666,Other,base rate x DRG weight,46505,,"38,809 x DRG Weight",46505,Other,base rate x DRG weight,42409,,"35,391 x DRG Weight",42409,Other,base rate x DRG weight,203048,70,,203048,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,30216,,"25,216 X DRG Weight",30216,Other,Base Weight X DRG Weight,27195,,"22,695 X DRG Weight",27195,Other,Base Weight X DRG Weight,30216,,"25,216 X DRG Weight",30216,Other,Base Rate x DRG Weight ,25683,,"21,433 x DRG Weight",25683,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,203048,
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,MS-DRG,,,,,,,,inpatient,,,154497.32,13689,,,13689,Other,150% of Medicare + 9.63% HCRA Surcharge,8324.39,,,8324.39,Other,Medicare IPPS methodology,22934,,"25,728 x DRG weight",22934,Other,base rate x DRG weight,20640,,"23,155 x DRG weight",20640,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,77249,50,,77249,Percent of Total Billed Charges,50% of Charges,25936,,"29,096 x DRG Weight",25936,Other,base rate x DRG weight,20024,,"22,463 x DRG Weight",20024,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23556,,"26,426 x DRG Weight",23556,Other,base rate x DRG weight,34594,,"38,809 x DRG Weight",34594,Other,base rate x DRG weight,34594,,"38,809 x DRG Weight",34594,Other,base rate x DRG weight,23556,,"26,426 x DRG Weight",23556,Other,base rate x DRG weight,34594,,"38,809 x DRG Weight",34594,Other,base rate x DRG weight,31548,,"35,391 x DRG Weight",31548,Other,base rate x DRG weight,108148,70,,108148,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22478,,"25,216 X DRG Weight",22478,Other,Base Weight X DRG Weight,20230,,"22,695 X DRG Weight",20230,Other,Base Weight X DRG Weight,22478,,"25,216 X DRG Weight",22478,Other,Base Rate x DRG Weight ,19105,,"21,433 x DRG Weight",19105,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,108148,
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,,inpatient,,,267641.88,27020,,,27020,Other,150% of Medicare + 9.63% HCRA Surcharge,16431.1,,,16431.1,Other,Medicare IPPS methodology,46061,,"25,728 x DRG weight",46061,Other,base rate x DRG weight,41454,,"23,155 x DRG weight",41454,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,133821,50,,133821,Percent of Total Billed Charges,50% of Charges,52091,,"29,096 x DRG Weight",52091,Other,base rate x DRG weight,40216,,"22,463 x DRG Weight",40216,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,47310,,"26,426 x DRG Weight",47310,Other,base rate x DRG weight,69480,,"38,809 x DRG Weight",69480,Other,base rate x DRG weight,69480,,"38,809 x DRG Weight",69480,Other,base rate x DRG weight,47310,,"26,426 x DRG Weight",47310,Other,base rate x DRG weight,69480,,"38,809 x DRG Weight",69480,Other,base rate x DRG weight,63361,,"35,391 x DRG Weight",63361,Other,base rate x DRG weight,187349,70,,187349,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,45144,,"25,216 X DRG Weight",45144,Other,Base Weight X DRG Weight,40631,,"22,695 X DRG Weight",40631,Other,Base Weight X DRG Weight,45144,,"25,216 X DRG Weight",45144,Other,Base Rate x DRG Weight ,38371,,"21,433 x DRG Weight",38371,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,187349,
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,,inpatient,,,137968.46,15059,,,15059,Other,150% of Medicare + 9.63% HCRA Surcharge,9157.7,,,9157.7,Other,Medicare IPPS methodology,25311,,"25,728 x DRG weight",25311,Other,base rate x DRG weight,22780,,"23,155 x DRG weight",22780,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,68984,50,,68984,Percent of Total Billed Charges,50% of Charges,28625,,"29,096 x DRG Weight",28625,Other,base rate x DRG weight,22099,,"22,463 x DRG Weight",22099,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,25998,,"26,426 x DRG Weight",25998,Other,base rate x DRG weight,38180,,"38,809 x DRG Weight",38180,Other,base rate x DRG weight,38180,,"38,809 x DRG Weight",38180,Other,base rate x DRG weight,25998,,"26,426 x DRG Weight",25998,Other,base rate x DRG weight,38180,,"38,809 x DRG Weight",38180,Other,base rate x DRG weight,34818,,"35,391 x DRG Weight",34818,Other,base rate x DRG weight,96578,70,,96578,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24808,,"25,216 X DRG Weight",24808,Other,Base Weight X DRG Weight,22327,,"22,695 X DRG Weight",22327,Other,Base Weight X DRG Weight,24808,,"25,216 X DRG Weight",24808,Other,Base Rate x DRG Weight ,21086,,"21,433 x DRG Weight",21086,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,96578,
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,,inpatient,,,99890.04,9860,,,9860,Other,150% of Medicare + 9.63% HCRA Surcharge,5995.82,,,5995.82,Other,Medicare IPPS methodology,16291,,"25,728 x DRG weight",16291,Other,base rate x DRG weight,14662,,"23,155 x DRG weight",14662,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,49945,50,,49945,Percent of Total Billed Charges,50% of Charges,18424,,"29,096 x DRG Weight",18424,Other,base rate x DRG weight,14224,,"22,463 x DRG Weight",14224,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,16733,,"26,426 x DRG Weight",16733,Other,base rate x DRG weight,24574,,"38,809 x DRG Weight",24574,Other,base rate x DRG weight,24574,,"38,809 x DRG Weight",24574,Other,base rate x DRG weight,16733,,"26,426 x DRG Weight",16733,Other,base rate x DRG weight,24574,,"38,809 x DRG Weight",24574,Other,base rate x DRG weight,22410,,"35,391 x DRG Weight",22410,Other,base rate x DRG weight,69923,70,,69923,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,15967,,"25,216 X DRG Weight",15967,Other,Base Weight X DRG Weight,14370,,"22,695 X DRG Weight",14370,Other,Base Weight X DRG Weight,15967,,"25,216 X DRG Weight",15967,Other,Base Rate x DRG Weight ,13571,,"21,433 x DRG Weight",13571,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,69923,
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,,inpatient,,,331567.02,29366,,,29366,Other,150% of Medicare + 9.63% HCRA Surcharge,17857.83,,,17857.83,Other,Medicare IPPS methodology,50131,,"25,728 x DRG weight",50131,Other,base rate x DRG weight,45118,,"23,155 x DRG weight",45118,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,165784,50,,165784,Percent of Total Billed Charges,50% of Charges,56694,,"29,096 x DRG Weight",56694,Other,base rate x DRG weight,43769,,"22,463 x DRG Weight",43769,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,51491,,"26,426 x DRG Weight",51491,Other,base rate x DRG weight,75619,,"38,809 x DRG Weight",75619,Other,base rate x DRG weight,75619,,"38,809 x DRG Weight",75619,Other,base rate x DRG weight,51491,,"26,426 x DRG Weight",51491,Other,base rate x DRG weight,75619,,"38,809 x DRG Weight",75619,Other,base rate x DRG weight,68959,,"35,391 x DRG Weight",68959,Other,base rate x DRG weight,232097,70,,232097,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,49133,,"25,216 X DRG Weight",49133,Other,Base Weight X DRG Weight,44221,,"22,695 X DRG Weight",44221,Other,Base Weight X DRG Weight,49133,,"25,216 X DRG Weight",49133,Other,Base Rate x DRG Weight ,41762,,"21,433 x DRG Weight",41762,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,232097,
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,,inpatient,,,259555.62,16382,,,16382,Other,150% of Medicare + 9.63% HCRA Surcharge,9962.15,,,9962.15,Other,Medicare IPPS methodology,27606,,"25,728 x DRG weight",27606,Other,base rate x DRG weight,24845,,"23,155 x DRG weight",24845,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,129778,50,,129778,Percent of Total Billed Charges,50% of Charges,31220,,"29,096 x DRG Weight",31220,Other,base rate x DRG weight,24103,,"22,463 x DRG Weight",24103,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28355,,"26,426 x DRG Weight",28355,Other,base rate x DRG weight,41642,,"38,809 x DRG Weight",41642,Other,base rate x DRG weight,41642,,"38,809 x DRG Weight",41642,Other,base rate x DRG weight,28355,,"26,426 x DRG Weight",28355,Other,base rate x DRG weight,41642,,"38,809 x DRG Weight",41642,Other,base rate x DRG weight,37975,,"35,391 x DRG Weight",37975,Other,base rate x DRG weight,181689,70,,181689,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27057,,"25,216 X DRG Weight",27057,Other,Base Weight X DRG Weight,24352,,"22,695 X DRG Weight",24352,Other,Base Weight X DRG Weight,27057,,"25,216 X DRG Weight",27057,Other,Base Rate x DRG Weight ,22998,,"21,433 x DRG Weight",22998,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,181689,
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,MS-DRG,,,,,,,,inpatient,,,172009,11697,,,11697,Other,150% of Medicare + 9.63% HCRA Surcharge,7113.21,,,7113.21,Other,Medicare IPPS methodology,19479,,"25,728 x DRG weight",19479,Other,base rate x DRG weight,17531,,"23,155 x DRG weight",17531,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,86005,50,,86005,Percent of Total Billed Charges,50% of Charges,22029,,"29,096 x DRG Weight",22029,Other,base rate x DRG weight,17007,,"22,463 x DRG Weight",17007,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,20007,,"26,426 x DRG Weight",20007,Other,base rate x DRG weight,29382,,"38,809 x DRG Weight",29382,Other,base rate x DRG weight,29382,,"38,809 x DRG Weight",29382,Other,base rate x DRG weight,20007,,"26,426 x DRG Weight",20007,Other,base rate x DRG weight,29382,,"38,809 x DRG Weight",29382,Other,base rate x DRG weight,26795,,"35,391 x DRG Weight",26795,Other,base rate x DRG weight,120406,70,,120406,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19091,,"25,216 X DRG Weight",19091,Other,Base Weight X DRG Weight,17182,,"22,695 X DRG Weight",17182,Other,Base Weight X DRG Weight,19091,,"25,216 X DRG Weight",19091,Other,Base Rate x DRG Weight ,16227,,"21,433 x DRG Weight",16227,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,120406,
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,MS-DRG,,,,,,,,inpatient,,,378280.8,21205,,,21205,Other,150% of Medicare + 9.63% HCRA Surcharge,12894.96,,,12894.96,Other,Medicare IPPS methodology,35973,,"25,728 x DRG weight",35973,Other,base rate x DRG weight,32375,,"23,155 x DRG weight",32375,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,189140,50,,189140,Percent of Total Billed Charges,50% of Charges,40682,,"29,096 x DRG Weight",40682,Other,base rate x DRG weight,31408,,"22,463 x DRG Weight",31408,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,36949,,"26,426 x DRG Weight",36949,Other,base rate x DRG weight,54263,,"38,809 x DRG Weight",54263,Other,base rate x DRG weight,54263,,"38,809 x DRG Weight",54263,Other,base rate x DRG weight,36949,,"26,426 x DRG Weight",36949,Other,base rate x DRG weight,54263,,"38,809 x DRG Weight",54263,Other,base rate x DRG weight,49484,,"35,391 x DRG Weight",49484,Other,base rate x DRG weight,264797,70,,264797,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35257,,"25,216 X DRG Weight",35257,Other,Base Weight X DRG Weight,31732,,"22,695 X DRG Weight",31732,Other,Base Weight X DRG Weight,35257,,"25,216 X DRG Weight",35257,Other,Base Rate x DRG Weight ,29968,,"21,433 x DRG Weight",29968,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,264797,
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,,inpatient,,,101786.77,13456,,,13456,Other,150% of Medicare + 9.63% HCRA Surcharge,8182.8,,,8182.8,Other,Medicare IPPS methodology,22530,,"25,728 x DRG weight",22530,Other,base rate x DRG weight,20277,,"23,155 x DRG weight",20277,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,50893,50,,50893,Percent of Total Billed Charges,50% of Charges,25479,,"29,096 x DRG Weight",25479,Other,base rate x DRG weight,19671,,"22,463 x DRG Weight",19671,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23141,,"26,426 x DRG Weight",23141,Other,base rate x DRG weight,33985,,"38,809 x DRG Weight",33985,Other,base rate x DRG weight,33985,,"38,809 x DRG Weight",33985,Other,base rate x DRG weight,23141,,"26,426 x DRG Weight",23141,Other,base rate x DRG weight,33985,,"38,809 x DRG Weight",33985,Other,base rate x DRG weight,30992,,"35,391 x DRG Weight",30992,Other,base rate x DRG weight,71251,70,,71251,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22082,,"25,216 X DRG Weight",22082,Other,Base Weight X DRG Weight,19874,,"22,695 X DRG Weight",19874,Other,Base Weight X DRG Weight,22082,,"25,216 X DRG Weight",22082,Other,Base Rate x DRG Weight ,18769,,"21,433 x DRG Weight",18769,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,71251,
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,,inpatient,,,270251.77,23707,,,23707,Other,150% of Medicare + 9.63% HCRA Surcharge,14416.38,,,14416.38,Other,Medicare IPPS methodology,40313,,"25,728 x DRG weight",40313,Other,base rate x DRG weight,36282,,"23,155 x DRG weight",36282,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,135126,50,,135126,Percent of Total Billed Charges,50% of Charges,45591,,"29,096 x DRG Weight",45591,Other,base rate x DRG weight,35197,,"22,463 x DRG Weight",35197,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41407,,"26,426 x DRG Weight",41407,Other,base rate x DRG weight,60810,,"38,809 x DRG Weight",60810,Other,base rate x DRG weight,60810,,"38,809 x DRG Weight",60810,Other,base rate x DRG weight,41407,,"26,426 x DRG Weight",41407,Other,base rate x DRG weight,60810,,"38,809 x DRG Weight",60810,Other,base rate x DRG weight,55454,,"35,391 x DRG Weight",55454,Other,base rate x DRG weight,189176,70,,189176,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39511,,"25,216 X DRG Weight",39511,Other,Base Weight X DRG Weight,35561,,"22,695 X DRG Weight",35561,Other,Base Weight X DRG Weight,39511,,"25,216 X DRG Weight",39511,Other,Base Rate x DRG Weight ,33583,,"21,433 x DRG Weight",33583,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,189176,
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,,inpatient,,,176957.37,14878,,,14878,Other,150% of Medicare + 9.63% HCRA Surcharge,9047.68,,,9047.68,Other,Medicare IPPS methodology,24997,,"25,728 x DRG weight",24997,Other,base rate x DRG weight,22497,,"23,155 x DRG weight",22497,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,88479,50,,88479,Percent of Total Billed Charges,50% of Charges,28270,,"29,096 x DRG Weight",28270,Other,base rate x DRG weight,21825,,"22,463 x DRG Weight",21825,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,25676,,"26,426 x DRG Weight",25676,Other,base rate x DRG weight,37707,,"38,809 x DRG Weight",37707,Other,base rate x DRG weight,37707,,"38,809 x DRG Weight",37707,Other,base rate x DRG weight,25676,,"26,426 x DRG Weight",25676,Other,base rate x DRG weight,37707,,"38,809 x DRG Weight",37707,Other,base rate x DRG weight,34386,,"35,391 x DRG Weight",34386,Other,base rate x DRG weight,123870,70,,123870,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24500,,"25,216 X DRG Weight",24500,Other,Base Weight X DRG Weight,22050,,"22,695 X DRG Weight",22050,Other,Base Weight X DRG Weight,24500,,"25,216 X DRG Weight",24500,Other,Base Rate x DRG Weight ,20824,,"21,433 x DRG Weight",20824,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,123870,
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,,inpatient,,,123584.17,10615,,,10615,Other,150% of Medicare + 9.63% HCRA Surcharge,6454.86,,,6454.86,Other,Medicare IPPS methodology,17601,,"25,728 x DRG weight",17601,Other,base rate x DRG weight,15840,,"23,155 x DRG weight",15840,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,61792,50,,61792,Percent of Total Billed Charges,50% of Charges,19905,,"29,096 x DRG Weight",19905,Other,base rate x DRG weight,15367,,"22,463 x DRG Weight",15367,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18078,,"26,426 x DRG Weight",18078,Other,base rate x DRG weight,26549,,"38,809 x DRG Weight",26549,Other,base rate x DRG weight,26549,,"38,809 x DRG Weight",26549,Other,base rate x DRG weight,18078,,"26,426 x DRG Weight",18078,Other,base rate x DRG weight,26549,,"38,809 x DRG Weight",26549,Other,base rate x DRG weight,24211,,"35,391 x DRG Weight",24211,Other,base rate x DRG weight,86509,70,,86509,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,17250,,"25,216 X DRG Weight",17250,Other,Base Weight X DRG Weight,15526,,"22,695 X DRG Weight",15526,Other,Base Weight X DRG Weight,17250,,"25,216 X DRG Weight",17250,Other,Base Rate x DRG Weight ,14662,,"21,433 x DRG Weight",14662,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,86509,
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,,inpatient,,,197166.6,22025,,,22025,Other,150% of Medicare + 9.63% HCRA Surcharge,13393.68,,,13393.68,Other,Medicare IPPS methodology,37396,,"25,728 x DRG weight",37396,Other,base rate x DRG weight,33656,,"23,155 x DRG weight",33656,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,98583,50,,98583,Percent of Total Billed Charges,50% of Charges,42291,,"29,096 x DRG Weight",42291,Other,base rate x DRG weight,32650,,"22,463 x DRG Weight",32650,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,38410,,"26,426 x DRG Weight",38410,Other,base rate x DRG weight,56409,,"38,809 x DRG Weight",56409,Other,base rate x DRG weight,56409,,"38,809 x DRG Weight",56409,Other,base rate x DRG weight,38410,,"26,426 x DRG Weight",38410,Other,base rate x DRG weight,56409,,"38,809 x DRG Weight",56409,Other,base rate x DRG weight,51441,,"35,391 x DRG Weight",51441,Other,base rate x DRG weight,138017,70,,138017,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,36651,,"25,216 X DRG Weight",36651,Other,Base Weight X DRG Weight,32987,,"22,695 X DRG Weight",32987,Other,Base Weight X DRG Weight,36651,,"25,216 X DRG Weight",36651,Other,Base Rate x DRG Weight ,31153,,"21,433 x DRG Weight",31153,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,138017,
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,,inpatient,,,116946.79,12280,,,12280,Other,150% of Medicare + 9.63% HCRA Surcharge,7467.64,,,7467.64,Other,Medicare IPPS methodology,20490,,"25,728 x DRG weight",20490,Other,base rate x DRG weight,18441,,"23,155 x DRG weight",18441,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,58473,50,,58473,Percent of Total Billed Charges,50% of Charges,23172,,"29,096 x DRG Weight",23172,Other,base rate x DRG weight,17890,,"22,463 x DRG Weight",17890,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21046,,"26,426 x DRG Weight",21046,Other,base rate x DRG weight,30907,,"38,809 x DRG Weight",30907,Other,base rate x DRG weight,30907,,"38,809 x DRG Weight",30907,Other,base rate x DRG weight,21046,,"26,426 x DRG Weight",21046,Other,base rate x DRG weight,30907,,"38,809 x DRG Weight",30907,Other,base rate x DRG weight,28185,,"35,391 x DRG Weight",28185,Other,base rate x DRG weight,81863,70,,81863,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20082,,"25,216 X DRG Weight",20082,Other,Base Weight X DRG Weight,18074,,"22,695 X DRG Weight",18074,Other,Base Weight X DRG Weight,20082,,"25,216 X DRG Weight",20082,Other,Base Rate x DRG Weight ,17069,,"21,433 x DRG Weight",17069,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,81863,
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,,inpatient,,,84892.15,8759,,,8759,Other,150% of Medicare + 9.63% HCRA Surcharge,5326.65,,,5326.65,Other,Medicare IPPS methodology,14382,,"25,728 x DRG weight",14382,Other,base rate x DRG weight,12944,,"23,155 x DRG weight",12944,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,42446,50,,42446,Percent of Total Billed Charges,50% of Charges,16265,,"29,096 x DRG Weight",16265,Other,base rate x DRG weight,12557,,"22,463 x DRG Weight",12557,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,14772,,"26,426 x DRG Weight",14772,Other,base rate x DRG weight,21694,,"38,809 x DRG Weight",21694,Other,base rate x DRG weight,21694,,"38,809 x DRG Weight",21694,Other,base rate x DRG weight,14772,,"26,426 x DRG Weight",14772,Other,base rate x DRG weight,21694,,"38,809 x DRG Weight",21694,Other,base rate x DRG weight,19784,,"35,391 x DRG Weight",19784,Other,base rate x DRG weight,59425,70,,59425,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,14096,,"25,216 X DRG Weight",14096,Other,Base Weight X DRG Weight,12687,,"22,695 X DRG Weight",12687,Other,Base Weight X DRG Weight,14096,,"25,216 X DRG Weight",14096,Other,Base Rate x DRG Weight ,11981,,"21,433 x DRG Weight",11981,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,59425,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,,inpatient,,,153223.48,19388,,,19388,Other,150% of Medicare + 9.63% HCRA Surcharge,11790.19,,,11790.19,Other,Medicare IPPS methodology,32821,,"25,728 x DRG weight",32821,Other,base rate x DRG weight,29539,,"23,155 x DRG weight",29539,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,76612,50,,76612,Percent of Total Billed Charges,50% of Charges,37118,,"29,096 x DRG Weight",37118,Other,base rate x DRG weight,28656,,"22,463 x DRG Weight",28656,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,33712,,"26,426 x DRG Weight",33712,Other,base rate x DRG weight,49509,,"38,809 x DRG Weight",49509,Other,base rate x DRG weight,49509,,"38,809 x DRG Weight",49509,Other,base rate x DRG weight,33712,,"26,426 x DRG Weight",33712,Other,base rate x DRG weight,49509,,"38,809 x DRG Weight",49509,Other,base rate x DRG weight,45148,,"35,391 x DRG Weight",45148,Other,base rate x DRG weight,107256,70,,107256,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32168,,"25,216 X DRG Weight",32168,Other,Base Weight X DRG Weight,28952,,"22,695 X DRG Weight",28952,Other,Base Weight X DRG Weight,32168,,"25,216 X DRG Weight",32168,Other,Base Rate x DRG Weight ,27342,,"21,433 x DRG Weight",27342,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,107256,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,,inpatient,,,110388.6,12120,,,12120,Other,150% of Medicare + 9.63% HCRA Surcharge,7370.24,,,7370.24,Other,Medicare IPPS methodology,20212,,"25,728 x DRG weight",20212,Other,base rate x DRG weight,18191,,"23,155 x DRG weight",18191,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,55194,50,,55194,Percent of Total Billed Charges,50% of Charges,22858,,"29,096 x DRG Weight",22858,Other,base rate x DRG weight,17647,,"22,463 x DRG Weight",17647,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,20760,,"26,426 x DRG Weight",20760,Other,base rate x DRG weight,30488,,"38,809 x DRG Weight",30488,Other,base rate x DRG weight,30488,,"38,809 x DRG Weight",30488,Other,base rate x DRG weight,20760,,"26,426 x DRG Weight",20760,Other,base rate x DRG weight,30488,,"38,809 x DRG Weight",30488,Other,base rate x DRG weight,27803,,"35,391 x DRG Weight",27803,Other,base rate x DRG weight,77272,70,,77272,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19810,,"25,216 X DRG Weight",19810,Other,Base Weight X DRG Weight,17829,,"22,695 X DRG Weight",17829,Other,Base Weight X DRG Weight,19810,,"25,216 X DRG Weight",19810,Other,Base Rate x DRG Weight ,16838,,"21,433 x DRG Weight",16838,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,77272,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,,inpatient,,,233240.19,24489,,,24489,Other,150% of Medicare + 9.63% HCRA Surcharge,14891.65,,,14891.65,Other,Medicare IPPS methodology,41669,,"25,728 x DRG weight",41669,Other,base rate x DRG weight,37502,,"23,155 x DRG weight",37502,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,116620,50,,116620,Percent of Total Billed Charges,50% of Charges,47124,,"29,096 x DRG Weight",47124,Other,base rate x DRG weight,36381,,"22,463 x DRG Weight",36381,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,42800,,"26,426 x DRG Weight",42800,Other,base rate x DRG weight,62855,,"38,809 x DRG Weight",62855,Other,base rate x DRG weight,62855,,"38,809 x DRG Weight",62855,Other,base rate x DRG weight,42800,,"26,426 x DRG Weight",42800,Other,base rate x DRG weight,62855,,"38,809 x DRG Weight",62855,Other,base rate x DRG weight,57319,,"35,391 x DRG Weight",57319,Other,base rate x DRG weight,163268,70,,163268,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40840,,"25,216 X DRG Weight",40840,Other,Base Weight X DRG Weight,36757,,"22,695 X DRG Weight",36757,Other,Base Weight X DRG Weight,40840,,"25,216 X DRG Weight",40840,Other,Base Rate x DRG Weight ,34713,,"21,433 x DRG Weight",34713,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,163268,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,,inpatient,,,140935.12,14364,,,14364,Other,150% of Medicare + 9.63% HCRA Surcharge,8734.73,,,8734.73,Other,Medicare IPPS methodology,24105,,"25,728 x DRG weight",24105,Other,base rate x DRG weight,21694,,"23,155 x DRG weight",21694,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,70468,50,,70468,Percent of Total Billed Charges,50% of Charges,27260,,"29,096 x DRG Weight",27260,Other,base rate x DRG weight,21046,,"22,463 x DRG Weight",21046,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,24759,,"26,426 x DRG Weight",24759,Other,base rate x DRG weight,36360,,"38,809 x DRG Weight",36360,Other,base rate x DRG weight,36360,,"38,809 x DRG Weight",36360,Other,base rate x DRG weight,24759,,"26,426 x DRG Weight",24759,Other,base rate x DRG weight,36360,,"38,809 x DRG Weight",36360,Other,base rate x DRG weight,33158,,"35,391 x DRG Weight",33158,Other,base rate x DRG weight,98655,70,,98655,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,23625,,"25,216 X DRG Weight",23625,Other,Base Weight X DRG Weight,21263,,"22,695 X DRG Weight",21263,Other,Base Weight X DRG Weight,23625,,"25,216 X DRG Weight",23625,Other,Base Rate x DRG Weight ,20081,,"21,433 x DRG Weight",20081,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,98655,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,,inpatient,,,93151.05,10072,,,10072,Other,150% of Medicare + 9.63% HCRA Surcharge,6124.79,,,6124.79,Other,Medicare IPPS methodology,16659,,"25,728 x DRG weight",16659,Other,base rate x DRG weight,14993,,"23,155 x DRG weight",14993,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46576,50,,46576,Percent of Total Billed Charges,50% of Charges,18840,,"29,096 x DRG Weight",18840,Other,base rate x DRG weight,14545,,"22,463 x DRG Weight",14545,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,17111,,"26,426 x DRG Weight",17111,Other,base rate x DRG weight,25129,,"38,809 x DRG Weight",25129,Other,base rate x DRG weight,25129,,"38,809 x DRG Weight",25129,Other,base rate x DRG weight,17111,,"26,426 x DRG Weight",17111,Other,base rate x DRG weight,25129,,"38,809 x DRG Weight",25129,Other,base rate x DRG weight,22916,,"35,391 x DRG Weight",22916,Other,base rate x DRG weight,65206,70,,65206,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,16327,,"25,216 X DRG Weight",16327,Other,Base Weight X DRG Weight,14695,,"22,695 X DRG Weight",14695,Other,Base Weight X DRG Weight,16327,,"25,216 X DRG Weight",16327,Other,Base Rate x DRG Weight ,13878,,"21,433 x DRG Weight",13878,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,65206,
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,,inpatient,,,164873.11,33787,,,33787,Other,150% of Medicare + 9.63% HCRA Surcharge,20546.24,,,20546.24,Other,Medicare IPPS methodology,57801,,"25,728 x DRG weight",57801,Other,base rate x DRG weight,52020,,"23,155 x DRG weight",52020,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,82437,50,,82437,Percent of Total Billed Charges,50% of Charges,65367,,"29,096 x DRG Weight",65367,Other,base rate x DRG weight,50465,,"22,463 x DRG Weight",50465,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,59369,,"26,426 x DRG Weight",59369,Other,base rate x DRG weight,87188,,"38,809 x DRG Weight",87188,Other,base rate x DRG weight,87188,,"38,809 x DRG Weight",87188,Other,base rate x DRG weight,59369,,"26,426 x DRG Weight",59369,Other,base rate x DRG weight,87188,,"38,809 x DRG Weight",87188,Other,base rate x DRG weight,79509,,"35,391 x DRG Weight",79509,Other,base rate x DRG weight,115411,70,,115411,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,56650,,"25,216 X DRG Weight",56650,Other,Base Weight X DRG Weight,50987,,"22,695 X DRG Weight",50987,Other,Base Weight X DRG Weight,56650,,"25,216 X DRG Weight",56650,Other,Base Rate x DRG Weight ,48151,,"21,433 x DRG Weight",48151,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,115411,
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,,inpatient,,,103380.07,22912,,,22912,Other,150% of Medicare + 9.63% HCRA Surcharge,13932.99,,,13932.99,Other,Medicare IPPS methodology,38934,,"25,728 x DRG weight",38934,Other,base rate x DRG weight,35040,,"23,155 x DRG weight",35040,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,51690,50,,51690,Percent of Total Billed Charges,50% of Charges,44031,,"29,096 x DRG Weight",44031,Other,base rate x DRG weight,33993,,"22,463 x DRG Weight",33993,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39990,,"26,426 x DRG Weight",39990,Other,base rate x DRG weight,58730,,"38,809 x DRG Weight",58730,Other,base rate x DRG weight,58730,,"38,809 x DRG Weight",58730,Other,base rate x DRG weight,39990,,"26,426 x DRG Weight",39990,Other,base rate x DRG weight,58730,,"38,809 x DRG Weight",58730,Other,base rate x DRG weight,53557,,"35,391 x DRG Weight",53557,Other,base rate x DRG weight,72366,70,,72366,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,38159,,"25,216 X DRG Weight",38159,Other,Base Weight X DRG Weight,34344,,"22,695 X DRG Weight",34344,Other,Base Weight X DRG Weight,38159,,"25,216 X DRG Weight",38159,Other,Base Rate x DRG Weight ,32435,,"21,433 x DRG Weight",32435,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,72366,
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,,inpatient,,,89201.58,16977,,,16977,Other,150% of Medicare + 9.63% HCRA Surcharge,10323.79,,,10323.79,Other,Medicare IPPS methodology,28638,,"25,728 x DRG weight",28638,Other,base rate x DRG weight,25774,,"23,155 x DRG weight",25774,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,44601,50,,44601,Percent of Total Billed Charges,50% of Charges,32387,,"29,096 x DRG Weight",32387,Other,base rate x DRG weight,25004,,"22,463 x DRG Weight",25004,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,29415,,"26,426 x DRG Weight",29415,Other,base rate x DRG weight,43198,,"38,809 x DRG Weight",43198,Other,base rate x DRG weight,43198,,"38,809 x DRG Weight",43198,Other,base rate x DRG weight,29415,,"26,426 x DRG Weight",29415,Other,base rate x DRG weight,43198,,"38,809 x DRG Weight",43198,Other,base rate x DRG weight,39394,,"35,391 x DRG Weight",39394,Other,base rate x DRG weight,62441,70,,62441,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,28068,,"25,216 X DRG Weight",28068,Other,Base Weight X DRG Weight,25262,,"22,695 X DRG Weight",25262,Other,Base Weight X DRG Weight,28068,,"25,216 X DRG Weight",28068,Other,Base Rate x DRG Weight ,23857,,"21,433 x DRG Weight",23857,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,62441,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,,inpatient,,,619797.78,82114,,,82114,Other,150% of Medicare + 9.63% HCRA Surcharge,49933.86,,,49933.86,Other,Medicare IPPS methodology,141638,,"25,728 x DRG weight",141638,Other,base rate x DRG weight,127473,,"23,155 x DRG weight",127473,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,309899,50,,309899,Percent of Total Billed Charges,50% of Charges,160179,,"29,096 x DRG Weight",160179,Other,base rate x DRG weight,123663,,"22,463 x DRG Weight",123663,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,145480,,"26,426 x DRG Weight",145480,Other,base rate x DRG weight,213651,,"38,809 x DRG Weight",213651,Other,base rate x DRG weight,213651,,"38,809 x DRG Weight",213651,Other,base rate x DRG weight,145480,,"26,426 x DRG Weight",145480,Other,base rate x DRG weight,213651,,"38,809 x DRG Weight",213651,Other,base rate x DRG weight,194835,,"35,391 x DRG Weight",194835,Other,base rate x DRG weight,433858,70,,433858,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,138819,,"25,216 X DRG Weight",138819,Other,Base Weight X DRG Weight,124941,,"22,695 X DRG Weight",124941,Other,Base Weight X DRG Weight,138819,,"25,216 X DRG Weight",138819,Other,Base Rate x DRG Weight ,117993,,"21,433 x DRG Weight",117993,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,433858,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,,inpatient,,,260950.29,43291,,,43291,Other,150% of Medicare + 9.63% HCRA Surcharge,26325.28,,,26325.28,Other,Medicare IPPS methodology,74287,,"25,728 x DRG weight",74287,Other,base rate x DRG weight,66858,,"23,155 x DRG weight",66858,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,130475,50,,130475,Percent of Total Billed Charges,50% of Charges,84012,,"29,096 x DRG Weight",84012,Other,base rate x DRG weight,64860,,"22,463 x DRG Weight",64860,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,76302,,"26,426 x DRG Weight",76302,Other,base rate x DRG weight,112057,,"38,809 x DRG Weight",112057,Other,base rate x DRG weight,112057,,"38,809 x DRG Weight",112057,Other,base rate x DRG weight,76302,,"26,426 x DRG Weight",76302,Other,base rate x DRG weight,112057,,"38,809 x DRG Weight",112057,Other,base rate x DRG weight,102188,,"35,391 x DRG Weight",102188,Other,base rate x DRG weight,182665,70,,182665,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,72809,,"25,216 X DRG Weight",72809,Other,Base Weight X DRG Weight,65530,,"22,695 X DRG Weight",65530,Other,Base Weight X DRG Weight,72809,,"25,216 X DRG Weight",72809,Other,Base Rate x DRG Weight ,61886,,"21,433 x DRG Weight",61886,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,182665,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,,inpatient,,,225852.18,32369,,,32369,Other,150% of Medicare + 9.63% HCRA Surcharge,19684.07,,,19684.07,Other,Medicare IPPS methodology,55341,,"25,728 x DRG weight",55341,Other,base rate x DRG weight,49806,,"23,155 x DRG weight",49806,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,112926,50,,112926,Percent of Total Billed Charges,50% of Charges,62585,,"29,096 x DRG Weight",62585,Other,base rate x DRG weight,48318,,"22,463 x DRG Weight",48318,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,56842,,"26,426 x DRG Weight",56842,Other,base rate x DRG weight,83478,,"38,809 x DRG Weight",83478,Other,base rate x DRG weight,83478,,"38,809 x DRG Weight",83478,Other,base rate x DRG weight,56842,,"26,426 x DRG Weight",56842,Other,base rate x DRG weight,83478,,"38,809 x DRG Weight",83478,Other,base rate x DRG weight,76126,,"35,391 x DRG Weight",76126,Other,base rate x DRG weight,158097,70,,158097,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,54240,,"25,216 X DRG Weight",54240,Other,Base Weight X DRG Weight,48817,,"22,695 X DRG Weight",48817,Other,Base Weight X DRG Weight,54240,,"25,216 X DRG Weight",54240,Other,Base Rate x DRG Weight ,46102,,"21,433 x DRG Weight",46102,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,158097,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,,inpatient,,,636079.48,55671,,,55671,Other,150% of Medicare + 9.63% HCRA Surcharge,33853.91,,,33853.91,Other,Medicare IPPS methodology,95765,,"25,728 x DRG weight",95765,Other,base rate x DRG weight,86188,,"23,155 x DRG weight",86188,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,318040,50,,318040,Percent of Total Billed Charges,50% of Charges,108301,,"29,096 x DRG Weight",108301,Other,base rate x DRG weight,83612,,"22,463 x DRG Weight",83612,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,98363,,"26,426 x DRG Weight",98363,Other,base rate x DRG weight,144455,,"38,809 x DRG Weight",144455,Other,base rate x DRG weight,144455,,"38,809 x DRG Weight",144455,Other,base rate x DRG weight,98363,,"26,426 x DRG Weight",98363,Other,base rate x DRG weight,144455,,"38,809 x DRG Weight",144455,Other,base rate x DRG weight,131732,,"35,391 x DRG Weight",131732,Other,base rate x DRG weight,445256,70,,445256,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,93859,,"25,216 X DRG Weight",93859,Other,Base Weight X DRG Weight,84475,,"22,695 X DRG Weight",84475,Other,Base Weight X DRG Weight,93859,,"25,216 X DRG Weight",93859,Other,Base Rate x DRG Weight ,79778,,"21,433 x DRG Weight",79778,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,445256,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,,inpatient,,,297030.96,29497,,,29497,Other,150% of Medicare + 9.63% HCRA Surcharge,17937.19,,,17937.19,Other,Medicare IPPS methodology,50357,,"25,728 x DRG weight",50357,Other,base rate x DRG weight,45321,,"23,155 x DRG weight",45321,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,148515,50,,148515,Percent of Total Billed Charges,50% of Charges,56950,,"29,096 x DRG Weight",56950,Other,base rate x DRG weight,43967,,"22,463 x DRG Weight",43967,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,51724,,"26,426 x DRG Weight",51724,Other,base rate x DRG weight,75961,,"38,809 x DRG Weight",75961,Other,base rate x DRG weight,75961,,"38,809 x DRG Weight",75961,Other,base rate x DRG weight,51724,,"26,426 x DRG Weight",51724,Other,base rate x DRG weight,75961,,"38,809 x DRG Weight",75961,Other,base rate x DRG weight,69271,,"35,391 x DRG Weight",69271,Other,base rate x DRG weight,207922,70,,207922,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,49355,,"25,216 X DRG Weight",49355,Other,Base Weight X DRG Weight,44421,,"22,695 X DRG Weight",44421,Other,Base Weight X DRG Weight,49355,,"25,216 X DRG Weight",49355,Other,Base Rate x DRG Weight ,41951,,"21,433 x DRG Weight",41951,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,207922,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,,inpatient,,,122727.59,23682,,,23682,Other,150% of Medicare + 9.63% HCRA Surcharge,14401.04,,,14401.04,Other,Medicare IPPS methodology,40269,,"25,728 x DRG weight",40269,Other,base rate x DRG weight,36242,,"23,155 x DRG weight",36242,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,61364,50,,61364,Percent of Total Billed Charges,50% of Charges,45541,,"29,096 x DRG Weight",45541,Other,base rate x DRG weight,35159,,"22,463 x DRG Weight",35159,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41362,,"26,426 x DRG Weight",41362,Other,base rate x DRG weight,60744,,"38,809 x DRG Weight",60744,Other,base rate x DRG weight,60744,,"38,809 x DRG Weight",60744,Other,base rate x DRG weight,41362,,"26,426 x DRG Weight",41362,Other,base rate x DRG weight,60744,,"38,809 x DRG Weight",60744,Other,base rate x DRG weight,55394,,"35,391 x DRG Weight",55394,Other,base rate x DRG weight,85909,70,,85909,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39468,,"25,216 X DRG Weight",39468,Other,Base Weight X DRG Weight,35522,,"22,695 X DRG Weight",35522,Other,Base Weight X DRG Weight,39468,,"25,216 X DRG Weight",39468,Other,Base Rate x DRG Weight ,33547,,"21,433 x DRG Weight",33547,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,85909,
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,,inpatient,,,636079.48,45560,,,45560,Other,150% of Medicare + 9.63% HCRA Surcharge,27705.11,,,27705.11,Other,Medicare IPPS methodology,78223,,"25,728 x DRG weight",78223,Other,base rate x DRG weight,70400,,"23,155 x DRG weight",70400,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,318040,50,,318040,Percent of Total Billed Charges,50% of Charges,88463,,"29,096 x DRG Weight",88463,Other,base rate x DRG weight,68297,,"22,463 x DRG Weight",68297,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,80346,,"26,426 x DRG Weight",80346,Other,base rate x DRG weight,117995,,"38,809 x DRG Weight",117995,Other,base rate x DRG weight,117995,,"38,809 x DRG Weight",117995,Other,base rate x DRG weight,80346,,"26,426 x DRG Weight",80346,Other,base rate x DRG weight,117995,,"38,809 x DRG Weight",117995,Other,base rate x DRG weight,107603,,"35,391 x DRG Weight",107603,Other,base rate x DRG weight,445256,70,,445256,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,76667,,"25,216 X DRG Weight",76667,Other,Base Weight X DRG Weight,69002,,"22,695 X DRG Weight",69002,Other,Base Weight X DRG Weight,76667,,"25,216 X DRG Weight",76667,Other,Base Rate x DRG Weight ,65165,,"21,433 x DRG Weight",65165,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,445256,
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,MS-DRG,,,,,,,,inpatient,,,142251.57,31110,,,31110,Other,150% of Medicare + 9.63% HCRA Surcharge,18918.4,,,18918.4,Other,Medicare IPPS methodology,53157,,"25,728 x DRG weight",53157,Other,base rate x DRG weight,47841,,"23,155 x DRG weight",47841,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,71126,50,,71126,Percent of Total Billed Charges,50% of Charges,60115,,"29,096 x DRG Weight",60115,Other,base rate x DRG weight,46411,,"22,463 x DRG Weight",46411,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,54599,,"26,426 x DRG Weight",54599,Other,base rate x DRG weight,80183,,"38,809 x DRG Weight",80183,Other,base rate x DRG weight,80183,,"38,809 x DRG Weight",80183,Other,base rate x DRG weight,54599,,"26,426 x DRG Weight",54599,Other,base rate x DRG weight,80183,,"38,809 x DRG Weight",80183,Other,base rate x DRG weight,73121,,"35,391 x DRG Weight",73121,Other,base rate x DRG weight,99576,70,,99576,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,52099,,"25,216 X DRG Weight",52099,Other,Base Weight X DRG Weight,46890,,"22,695 X DRG Weight",46890,Other,Base Weight X DRG Weight,52099,,"25,216 X DRG Weight",52099,Other,Base Rate x DRG Weight ,44283,,"21,433 x DRG Weight",44283,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,99576,
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,MS-DRG,,,,,,,,inpatient,,,336831.31,22857,,,22857,Other,150% of Medicare + 9.63% HCRA Surcharge,13899.62,,,13899.62,Other,Medicare IPPS methodology,38839,,"25,728 x DRG weight",38839,Other,base rate x DRG weight,34955,,"23,155 x DRG weight",34955,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,168416,50,,168416,Percent of Total Billed Charges,50% of Charges,43923,,"29,096 x DRG Weight",43923,Other,base rate x DRG weight,33910,,"22,463 x DRG Weight",33910,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39893,,"26,426 x DRG Weight",39893,Other,base rate x DRG weight,58586,,"38,809 x DRG Weight",58586,Other,base rate x DRG weight,58586,,"38,809 x DRG Weight",58586,Other,base rate x DRG weight,39893,,"26,426 x DRG Weight",39893,Other,base rate x DRG weight,58586,,"38,809 x DRG Weight",58586,Other,base rate x DRG weight,53426,,"35,391 x DRG Weight",53426,Other,base rate x DRG weight,235782,70,,235782,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,38066,,"25,216 X DRG Weight",38066,Other,Base Weight X DRG Weight,34260,,"22,695 X DRG Weight",34260,Other,Base Weight X DRG Weight,38066,,"25,216 X DRG Weight",38066,Other,Base Rate x DRG Weight ,32355,,"21,433 x DRG Weight",32355,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,235782,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,,inpatient,,,411884.91,52749,,,52749,Other,150% of Medicare + 9.63% HCRA Surcharge,32077.27,,,32077.27,Other,Medicare IPPS methodology,90696,,"25,728 x DRG weight",90696,Other,base rate x DRG weight,81626,,"23,155 x DRG weight",81626,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,205942,50,,205942,Percent of Total Billed Charges,50% of Charges,102569,,"29,096 x DRG Weight",102569,Other,base rate x DRG weight,79187,,"22,463 x DRG Weight",79187,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,93157,,"26,426 x DRG Weight",93157,Other,base rate x DRG weight,136809,,"38,809 x DRG Weight",136809,Other,base rate x DRG weight,136809,,"38,809 x DRG Weight",136809,Other,base rate x DRG weight,93157,,"26,426 x DRG Weight",93157,Other,base rate x DRG weight,136809,,"38,809 x DRG Weight",136809,Other,base rate x DRG weight,124760,,"35,391 x DRG Weight",124760,Other,base rate x DRG weight,288319,70,,288319,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,88891,,"25,216 X DRG Weight",88891,Other,Base Weight X DRG Weight,80004,,"22,695 X DRG Weight",80004,Other,Base Weight X DRG Weight,88891,,"25,216 X DRG Weight",88891,Other,Base Rate x DRG Weight ,75556,,"21,433 x DRG Weight",75556,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,288319,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,,inpatient,,,214840.92,29771,,,29771,Other,150% of Medicare + 9.63% HCRA Surcharge,18104.03,,,18104.03,Other,Medicare IPPS methodology,50833,,"25,728 x DRG weight",50833,Other,base rate x DRG weight,45750,,"23,155 x DRG weight",45750,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,107420,50,,107420,Percent of Total Billed Charges,50% of Charges,57488,,"29,096 x DRG Weight",57488,Other,base rate x DRG weight,44382,,"22,463 x DRG Weight",44382,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,52212,,"26,426 x DRG Weight",52212,Other,base rate x DRG weight,76679,,"38,809 x DRG Weight",76679,Other,base rate x DRG weight,76679,,"38,809 x DRG Weight",76679,Other,base rate x DRG weight,52212,,"26,426 x DRG Weight",52212,Other,base rate x DRG weight,76679,,"38,809 x DRG Weight",76679,Other,base rate x DRG weight,69926,,"35,391 x DRG Weight",69926,Other,base rate x DRG weight,150389,70,,150389,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,49822,,"25,216 X DRG Weight",49822,Other,Base Weight X DRG Weight,44841,,"22,695 X DRG Weight",44841,Other,Base Weight X DRG Weight,49822,,"25,216 X DRG Weight",49822,Other,Base Rate x DRG Weight ,42347,,"21,433 x DRG Weight",42347,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,150389,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,MS-DRG,,,,,,,,inpatient,,,179180.51,20330,,,20330,Other,150% of Medicare + 9.63% HCRA Surcharge,12362.87,,,12362.87,Other,Medicare IPPS methodology,34455,,"25,728 x DRG weight",34455,Other,base rate x DRG weight,31009,,"23,155 x DRG weight",31009,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,89590,50,,89590,Percent of Total Billed Charges,50% of Charges,38965,,"29,096 x DRG Weight",38965,Other,base rate x DRG weight,30082,,"22,463 x DRG Weight",30082,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,35390,,"26,426 x DRG Weight",35390,Other,base rate x DRG weight,51973,,"38,809 x DRG Weight",51973,Other,base rate x DRG weight,51973,,"38,809 x DRG Weight",51973,Other,base rate x DRG weight,35390,,"26,426 x DRG Weight",35390,Other,base rate x DRG weight,51973,,"38,809 x DRG Weight",51973,Other,base rate x DRG weight,47396,,"35,391 x DRG Weight",47396,Other,base rate x DRG weight,125426,70,,125426,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,33769,,"25,216 X DRG Weight",33769,Other,Base Weight X DRG Weight,30393,,"22,695 X DRG Weight",30393,Other,Base Weight X DRG Weight,33769,,"25,216 X DRG Weight",33769,Other,Base Rate x DRG Weight ,28703,,"21,433 x DRG Weight",28703,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,125426,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,,inpatient,,,212879.52,34843,,,34843,Other,150% of Medicare + 9.63% HCRA Surcharge,21188.35,,,21188.35,Other,Medicare IPPS methodology,59632,,"25,728 x DRG weight",59632,Other,base rate x DRG weight,53669,,"23,155 x DRG weight",53669,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,106440,50,,106440,Percent of Total Billed Charges,50% of Charges,67439,,"29,096 x DRG Weight",67439,Other,base rate x DRG weight,52065,,"22,463 x DRG Weight",52065,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,61250,,"26,426 x DRG Weight",61250,Other,base rate x DRG weight,89952,,"38,809 x DRG Weight",89952,Other,base rate x DRG weight,89952,,"38,809 x DRG Weight",89952,Other,base rate x DRG weight,61250,,"26,426 x DRG Weight",61250,Other,base rate x DRG weight,89952,,"38,809 x DRG Weight",89952,Other,base rate x DRG weight,82029,,"35,391 x DRG Weight",82029,Other,base rate x DRG weight,149016,70,,149016,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,58446,,"25,216 X DRG Weight",58446,Other,Base Weight X DRG Weight,52602,,"22,695 X DRG Weight",52602,Other,Base Weight X DRG Weight,58446,,"25,216 X DRG Weight",58446,Other,Base Rate x DRG Weight ,49677,,"21,433 x DRG Weight",49677,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,149016,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,,inpatient,,,182591.62,24713,,,24713,Other,150% of Medicare + 9.63% HCRA Surcharge,15027.83,,,15027.83,Other,Medicare IPPS methodology,42058,,"25,728 x DRG weight",42058,Other,base rate x DRG weight,37851,,"23,155 x DRG weight",37851,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,91296,50,,91296,Percent of Total Billed Charges,50% of Charges,47563,,"29,096 x DRG Weight",47563,Other,base rate x DRG weight,36720,,"22,463 x DRG Weight",36720,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,43199,,"26,426 x DRG Weight",43199,Other,base rate x DRG weight,63441,,"38,809 x DRG Weight",63441,Other,base rate x DRG weight,63441,,"38,809 x DRG Weight",63441,Other,base rate x DRG weight,43199,,"26,426 x DRG Weight",43199,Other,base rate x DRG weight,63441,,"38,809 x DRG Weight",63441,Other,base rate x DRG weight,57854,,"35,391 x DRG Weight",57854,Other,base rate x DRG weight,127814,70,,127814,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,41221,,"25,216 X DRG Weight",41221,Other,Base Weight X DRG Weight,37100,,"22,695 X DRG Weight",37100,Other,Base Weight X DRG Weight,41221,,"25,216 X DRG Weight",41221,Other,Base Rate x DRG Weight ,35037,,"21,433 x DRG Weight",35037,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,127814,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,,inpatient,,,128377.27,19945,,,19945,Other,150% of Medicare + 9.63% HCRA Surcharge,12128.39,,,12128.39,Other,Medicare IPPS methodology,33786,,"25,728 x DRG weight",33786,Other,base rate x DRG weight,30407,,"23,155 x DRG weight",30407,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,64189,50,,64189,Percent of Total Billed Charges,50% of Charges,38209,,"29,096 x DRG Weight",38209,Other,base rate x DRG weight,29498,,"22,463 x DRG Weight",29498,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,34703,,"26,426 x DRG Weight",34703,Other,base rate x DRG weight,50964,,"38,809 x DRG Weight",50964,Other,base rate x DRG weight,50964,,"38,809 x DRG Weight",50964,Other,base rate x DRG weight,34703,,"26,426 x DRG Weight",34703,Other,base rate x DRG weight,50964,,"38,809 x DRG Weight",50964,Other,base rate x DRG weight,46475,,"35,391 x DRG Weight",46475,Other,base rate x DRG weight,89864,70,,89864,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,33114,,"25,216 X DRG Weight",33114,Other,Base Weight X DRG Weight,29803,,"22,695 X DRG Weight",29803,Other,Base Weight X DRG Weight,33114,,"25,216 X DRG Weight",33114,Other,Base Rate x DRG Weight ,28146,,"21,433 x DRG Weight",28146,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,89864,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,,inpatient,,,341777.81,47938,,,47938,Other,150% of Medicare + 9.63% HCRA Surcharge,29151.67,,,29151.67,Other,Medicare IPPS methodology,82350,,"25,728 x DRG weight",82350,Other,base rate x DRG weight,74115,,"23,155 x DRG weight",74115,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,170889,50,,170889,Percent of Total Billed Charges,50% of Charges,93130,,"29,096 x DRG Weight",93130,Other,base rate x DRG weight,71900,,"22,463 x DRG Weight",71900,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,84584,,"26,426 x DRG Weight",84584,Other,base rate x DRG weight,124220,,"38,809 x DRG Weight",124220,Other,base rate x DRG weight,124220,,"38,809 x DRG Weight",124220,Other,base rate x DRG weight,84584,,"26,426 x DRG Weight",84584,Other,base rate x DRG weight,124220,,"38,809 x DRG Weight",124220,Other,base rate x DRG weight,113280,,"35,391 x DRG Weight",113280,Other,base rate x DRG weight,239244,70,,239244,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,80711,,"25,216 X DRG Weight",80711,Other,Base Weight X DRG Weight,72642,,"22,695 X DRG Weight",72642,Other,Base Weight X DRG Weight,80711,,"25,216 X DRG Weight",80711,Other,Base Rate x DRG Weight ,68603,,"21,433 x DRG Weight",68603,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,239244,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,MS-DRG,,,,,,,,inpatient,,,105017.04,25823,,,25823,Other,150% of Medicare + 9.63% HCRA Surcharge,15703.31,,,15703.31,Other,Medicare IPPS methodology,43985,,"25,728 x DRG weight",43985,Other,base rate x DRG weight,39586,,"23,155 x DRG weight",39586,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,52509,50,,52509,Percent of Total Billed Charges,50% of Charges,49743,,"29,096 x DRG Weight",49743,Other,base rate x DRG weight,38403,,"22,463 x DRG Weight",38403,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,45178,,"26,426 x DRG Weight",45178,Other,base rate x DRG weight,66348,,"38,809 x DRG Weight",66348,Other,base rate x DRG weight,66348,,"38,809 x DRG Weight",66348,Other,base rate x DRG weight,45178,,"26,426 x DRG Weight",45178,Other,base rate x DRG weight,66348,,"38,809 x DRG Weight",66348,Other,base rate x DRG weight,60504,,"35,391 x DRG Weight",60504,Other,base rate x DRG weight,73512,70,,73512,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43109,,"25,216 X DRG Weight",43109,Other,Base Weight X DRG Weight,38799,,"22,695 X DRG Weight",38799,Other,Base Weight X DRG Weight,43109,,"25,216 X DRG Weight",43109,Other,Base Rate x DRG Weight ,36642,,"21,433 x DRG Weight",36642,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,73512,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,,inpatient,,,107453.52,21395,,,21395,Other,150% of Medicare + 9.63% HCRA Surcharge,13010.4,,,13010.4,Other,Medicare IPPS methodology,36302,,"25,728 x DRG weight",36302,Other,base rate x DRG weight,32672,,"23,155 x DRG weight",32672,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,53727,50,,53727,Percent of Total Billed Charges,50% of Charges,41054,,"29,096 x DRG Weight",41054,Other,base rate x DRG weight,31695,,"22,463 x DRG Weight",31695,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,37287,,"26,426 x DRG Weight",37287,Other,base rate x DRG weight,54759,,"38,809 x DRG Weight",54759,Other,base rate x DRG weight,54759,,"38,809 x DRG Weight",54759,Other,base rate x DRG weight,37287,,"26,426 x DRG Weight",37287,Other,base rate x DRG weight,54759,,"38,809 x DRG Weight",54759,Other,base rate x DRG weight,49937,,"35,391 x DRG Weight",49937,Other,base rate x DRG weight,75217,70,,75217,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35580,,"25,216 X DRG Weight",35580,Other,Base Weight X DRG Weight,32023,,"22,695 X DRG Weight",32023,Other,Base Weight X DRG Weight,35580,,"25,216 X DRG Weight",35580,Other,Base Rate x DRG Weight ,30242,,"21,433 x DRG Weight",30242,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,75217,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,,inpatient,,,1102167.42,58470,,,58470,Other,150% of Medicare + 9.63% HCRA Surcharge,35555.69,,,35555.69,Other,Medicare IPPS methodology,100620,,"25,728 x DRG weight",100620,Other,base rate x DRG weight,90557,,"23,155 x DRG weight",90557,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,551084,50,,551084,Percent of Total Billed Charges,50% of Charges,113792,,"29,096 x DRG Weight",113792,Other,base rate x DRG weight,87851,,"22,463 x DRG Weight",87851,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,103349,,"26,426 x DRG Weight",103349,Other,base rate x DRG weight,151778,,"38,809 x DRG Weight",151778,Other,base rate x DRG weight,151778,,"38,809 x DRG Weight",151778,Other,base rate x DRG weight,103349,,"26,426 x DRG Weight",103349,Other,base rate x DRG weight,151778,,"38,809 x DRG Weight",151778,Other,base rate x DRG weight,138411,,"35,391 x DRG Weight",138411,Other,base rate x DRG weight,771517,70,,771517,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,98617,,"25,216 X DRG Weight",98617,Other,Base Weight X DRG Weight,88758,,"22,695 X DRG Weight",88758,Other,Base Weight X DRG Weight,98617,,"25,216 X DRG Weight",98617,Other,Base Rate x DRG Weight ,83822,,"21,433 x DRG Weight",83822,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,771517,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,,inpatient,,,233759.2,32083,,,32083,Other,150% of Medicare + 9.63% HCRA Surcharge,19510.01,,,19510.01,Other,Medicare IPPS methodology,54844,,"25,728 x DRG weight",54844,Other,base rate x DRG weight,49360,,"23,155 x DRG weight",49360,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,116880,50,,116880,Percent of Total Billed Charges,50% of Charges,62024,,"29,096 x DRG Weight",62024,Other,base rate x DRG weight,47884,,"22,463 x DRG Weight",47884,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,56332,,"26,426 x DRG Weight",56332,Other,base rate x DRG weight,82729,,"38,809 x DRG Weight",82729,Other,base rate x DRG weight,82729,,"38,809 x DRG Weight",82729,Other,base rate x DRG weight,56332,,"26,426 x DRG Weight",56332,Other,base rate x DRG weight,82729,,"38,809 x DRG Weight",82729,Other,base rate x DRG weight,75443,,"35,391 x DRG Weight",75443,Other,base rate x DRG weight,163631,70,,163631,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,53753,,"25,216 X DRG Weight",53753,Other,Base Weight X DRG Weight,48379,,"22,695 X DRG Weight",48379,Other,Base Weight X DRG Weight,53753,,"25,216 X DRG Weight",53753,Other,Base Rate x DRG Weight ,45689,,"21,433 x DRG Weight",45689,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,163631,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,,inpatient,,,224128.8,24226,,,24226,Other,150% of Medicare + 9.63% HCRA Surcharge,14732.02,,,14732.02,Other,Medicare IPPS methodology,41214,,"25,728 x DRG weight",41214,Other,base rate x DRG weight,37092,,"23,155 x DRG weight",37092,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,112064,50,,112064,Percent of Total Billed Charges,50% of Charges,46609,,"29,096 x DRG Weight",46609,Other,base rate x DRG weight,35983,,"22,463 x DRG Weight",35983,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,42332,,"26,426 x DRG Weight",42332,Other,base rate x DRG weight,62168,,"38,809 x DRG Weight",62168,Other,base rate x DRG weight,62168,,"38,809 x DRG Weight",62168,Other,base rate x DRG weight,42332,,"26,426 x DRG Weight",42332,Other,base rate x DRG weight,62168,,"38,809 x DRG Weight",62168,Other,base rate x DRG weight,56693,,"35,391 x DRG Weight",56693,Other,base rate x DRG weight,156890,70,,156890,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40394,,"25,216 X DRG Weight",40394,Other,Base Weight X DRG Weight,36355,,"22,695 X DRG Weight",36355,Other,Base Weight X DRG Weight,40394,,"25,216 X DRG Weight",40394,Other,Base Rate x DRG Weight ,34334,,"21,433 x DRG Weight",34334,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,156890,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,,inpatient,,,338325.67,28884,,,28884,Other,150% of Medicare + 9.63% HCRA Surcharge,17564.73,,,17564.73,Other,Medicare IPPS methodology,49295,,"25,728 x DRG weight",49295,Other,base rate x DRG weight,44365,,"23,155 x DRG weight",44365,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,169163,50,,169163,Percent of Total Billed Charges,50% of Charges,55748,,"29,096 x DRG Weight",55748,Other,base rate x DRG weight,43039,,"22,463 x DRG Weight",43039,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,50632,,"26,426 x DRG Weight",50632,Other,base rate x DRG weight,74358,,"38,809 x DRG Weight",74358,Other,base rate x DRG weight,74358,,"38,809 x DRG Weight",74358,Other,base rate x DRG weight,50632,,"26,426 x DRG Weight",50632,Other,base rate x DRG weight,74358,,"38,809 x DRG Weight",74358,Other,base rate x DRG weight,67809,,"35,391 x DRG Weight",67809,Other,base rate x DRG weight,236828,70,,236828,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,48314,,"25,216 X DRG Weight",48314,Other,Base Weight X DRG Weight,43484,,"22,695 X DRG Weight",43484,Other,Base Weight X DRG Weight,48314,,"25,216 X DRG Weight",48314,Other,Base Rate x DRG Weight ,41066,,"21,433 x DRG Weight",41066,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,236828,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,,inpatient,,,160499.33,15759,,,15759,Other,150% of Medicare + 9.63% HCRA Surcharge,9583.37,,,9583.37,Other,Medicare IPPS methodology,26526,,"25,728 x DRG weight",26526,Other,base rate x DRG weight,23873,,"23,155 x DRG weight",23873,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,80250,50,,80250,Percent of Total Billed Charges,50% of Charges,29998,,"29,096 x DRG Weight",29998,Other,base rate x DRG weight,23159,,"22,463 x DRG Weight",23159,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,27245,,"26,426 x DRG Weight",27245,Other,base rate x DRG weight,40012,,"38,809 x DRG Weight",40012,Other,base rate x DRG weight,40012,,"38,809 x DRG Weight",40012,Other,base rate x DRG weight,27245,,"26,426 x DRG Weight",27245,Other,base rate x DRG weight,40012,,"38,809 x DRG Weight",40012,Other,base rate x DRG weight,36488,,"35,391 x DRG Weight",36488,Other,base rate x DRG weight,112350,70,,112350,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25998,,"25,216 X DRG Weight",25998,Other,Base Weight X DRG Weight,23399,,"22,695 X DRG Weight",23399,Other,Base Weight X DRG Weight,25998,,"25,216 X DRG Weight",25998,Other,Base Rate x DRG Weight ,22097,,"21,433 x DRG Weight",22097,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,112350,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,,inpatient,,,136029.08,10398,,,10398,Other,150% of Medicare + 9.63% HCRA Surcharge,6323.19,,,6323.19,Other,Medicare IPPS methodology,17225,,"25,728 x DRG weight",17225,Other,base rate x DRG weight,15502,,"23,155 x DRG weight",15502,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,68015,50,,68015,Percent of Total Billed Charges,50% of Charges,19480,,"29,096 x DRG Weight",19480,Other,base rate x DRG weight,15039,,"22,463 x DRG Weight",15039,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,17692,,"26,426 x DRG Weight",17692,Other,base rate x DRG weight,25983,,"38,809 x DRG Weight",25983,Other,base rate x DRG weight,25983,,"38,809 x DRG Weight",25983,Other,base rate x DRG weight,17692,,"26,426 x DRG Weight",17692,Other,base rate x DRG weight,25983,,"38,809 x DRG Weight",25983,Other,base rate x DRG weight,23694,,"35,391 x DRG Weight",23694,Other,base rate x DRG weight,95220,70,,95220,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,16882,,"25,216 X DRG Weight",16882,Other,Base Weight X DRG Weight,15194,,"22,695 X DRG Weight",15194,Other,Base Weight X DRG Weight,16882,,"25,216 X DRG Weight",16882,Other,Base Rate x DRG Weight ,14349,,"21,433 x DRG Weight",14349,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,95220,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,,inpatient,,,260130.32,26569,,,26569,Other,150% of Medicare + 9.63% HCRA Surcharge,16156.94,,,16156.94,Other,Medicare IPPS methodology,45279,,"25,728 x DRG weight",45279,Other,base rate x DRG weight,40750,,"23,155 x DRG weight",40750,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,130065,50,,130065,Percent of Total Billed Charges,50% of Charges,51206,,"29,096 x DRG Weight",51206,Other,base rate x DRG weight,39533,,"22,463 x DRG Weight",39533,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,46507,,"26,426 x DRG Weight",46507,Other,base rate x DRG weight,68300,,"38,809 x DRG Weight",68300,Other,base rate x DRG weight,68300,,"38,809 x DRG Weight",68300,Other,base rate x DRG weight,46507,,"26,426 x DRG Weight",46507,Other,base rate x DRG weight,68300,,"38,809 x DRG Weight",68300,Other,base rate x DRG weight,62285,,"35,391 x DRG Weight",62285,Other,base rate x DRG weight,182091,70,,182091,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,44378,,"25,216 X DRG Weight",44378,Other,Base Weight X DRG Weight,39941,,"22,695 X DRG Weight",39941,Other,Base Weight X DRG Weight,44378,,"25,216 X DRG Weight",44378,Other,Base Rate x DRG Weight ,37720,,"21,433 x DRG Weight",37720,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,182091,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,,inpatient,,,165540.76,16793,,,16793,Other,150% of Medicare + 9.63% HCRA Surcharge,10211.96,,,10211.96,Other,Medicare IPPS methodology,28319,,"25,728 x DRG weight",28319,Other,base rate x DRG weight,25487,,"23,155 x DRG weight",25487,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,82770,50,,82770,Percent of Total Billed Charges,50% of Charges,32026,,"29,096 x DRG Weight",32026,Other,base rate x DRG weight,24725,,"22,463 x DRG Weight",24725,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,29087,,"26,426 x DRG Weight",29087,Other,base rate x DRG weight,42717,,"38,809 x DRG Weight",42717,Other,base rate x DRG weight,42717,,"38,809 x DRG Weight",42717,Other,base rate x DRG weight,29087,,"26,426 x DRG Weight",29087,Other,base rate x DRG weight,42717,,"38,809 x DRG Weight",42717,Other,base rate x DRG weight,38955,,"35,391 x DRG Weight",38955,Other,base rate x DRG weight,115879,70,,115879,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27755,,"25,216 X DRG Weight",27755,Other,Base Weight X DRG Weight,24980,,"22,695 X DRG Weight",24980,Other,Base Weight X DRG Weight,27755,,"25,216 X DRG Weight",27755,Other,Base Rate x DRG Weight ,23591,,"21,433 x DRG Weight",23591,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,115879,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,MS-DRG,,,,,,,,inpatient,,,139705.79,12795,,,12795,Other,150% of Medicare + 9.63% HCRA Surcharge,7780.58,,,7780.58,Other,Medicare IPPS methodology,21383,,"25,728 x DRG weight",21383,Other,base rate x DRG weight,19244,,"23,155 x DRG weight",19244,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,69853,50,,69853,Percent of Total Billed Charges,50% of Charges,24182,,"29,096 x DRG Weight",24182,Other,base rate x DRG weight,18669,,"22,463 x DRG Weight",18669,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21963,,"26,426 x DRG Weight",21963,Other,base rate x DRG weight,32254,,"38,809 x DRG Weight",32254,Other,base rate x DRG weight,32254,,"38,809 x DRG Weight",32254,Other,base rate x DRG weight,21963,,"26,426 x DRG Weight",21963,Other,base rate x DRG weight,32254,,"38,809 x DRG Weight",32254,Other,base rate x DRG weight,29413,,"35,391 x DRG Weight",29413,Other,base rate x DRG weight,97794,70,,97794,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20957,,"25,216 X DRG Weight",20957,Other,Base Weight X DRG Weight,18862,,"22,695 X DRG Weight",18862,Other,Base Weight X DRG Weight,20957,,"25,216 X DRG Weight",20957,Other,Base Rate x DRG Weight ,17813,,"21,433 x DRG Weight",17813,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,97794,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,,inpatient,,,231225.22,25218,,,25218,Other,150% of Medicare + 9.63% HCRA Surcharge,15335.36,,,15335.36,Other,Medicare IPPS methodology,42935,,"25,728 x DRG weight",42935,Other,base rate x DRG weight,38641,,"23,155 x DRG weight",38641,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,115613,50,,115613,Percent of Total Billed Charges,50% of Charges,48555,,"29,096 x DRG Weight",48555,Other,base rate x DRG weight,37486,,"22,463 x DRG Weight",37486,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,44100,,"26,426 x DRG Weight",44100,Other,base rate x DRG weight,64764,,"38,809 x DRG Weight",64764,Other,base rate x DRG weight,64764,,"38,809 x DRG Weight",64764,Other,base rate x DRG weight,44100,,"26,426 x DRG Weight",44100,Other,base rate x DRG weight,64764,,"38,809 x DRG Weight",64764,Other,base rate x DRG weight,59061,,"35,391 x DRG Weight",59061,Other,base rate x DRG weight,161858,70,,161858,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,42080,,"25,216 X DRG Weight",42080,Other,Base Weight X DRG Weight,37873,,"22,695 X DRG Weight",37873,Other,Base Weight X DRG Weight,42080,,"25,216 X DRG Weight",42080,Other,Base Rate x DRG Weight ,35767,,"21,433 x DRG Weight",35767,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,161858,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,,inpatient,,,154774.29,13152,,,13152,Other,150% of Medicare + 9.63% HCRA Surcharge,7997.92,,,7997.92,Other,Medicare IPPS methodology,22003,,"25,728 x DRG weight",22003,Other,base rate x DRG weight,19802,,"23,155 x DRG weight",19802,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,77387,50,,77387,Percent of Total Billed Charges,50% of Charges,24883,,"29,096 x DRG Weight",24883,Other,base rate x DRG weight,19210,,"22,463 x DRG Weight",19210,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,22600,,"26,426 x DRG Weight",22600,Other,base rate x DRG weight,33189,,"38,809 x DRG Weight",33189,Other,base rate x DRG weight,33189,,"38,809 x DRG Weight",33189,Other,base rate x DRG weight,22600,,"26,426 x DRG Weight",22600,Other,base rate x DRG weight,33189,,"38,809 x DRG Weight",33189,Other,base rate x DRG weight,30266,,"35,391 x DRG Weight",30266,Other,base rate x DRG weight,108342,70,,108342,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,21565,,"25,216 X DRG Weight",21565,Other,Base Weight X DRG Weight,19409,,"22,695 X DRG Weight",19409,Other,Base Weight X DRG Weight,21565,,"25,216 X DRG Weight",21565,Other,Base Rate x DRG Weight ,18330,,"21,433 x DRG Weight",18330,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,108342,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,,inpatient,,,93885.21,9599,,,9599,Other,150% of Medicare + 9.63% HCRA Surcharge,5837.1,,,5837.1,Other,Medicare IPPS methodology,15838,,"25,728 x DRG weight",15838,Other,base rate x DRG weight,14254,,"23,155 x DRG weight",14254,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46943,50,,46943,Percent of Total Billed Charges,50% of Charges,17911,,"29,096 x DRG Weight",17911,Other,base rate x DRG weight,13828,,"22,463 x DRG Weight",13828,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,16268,,"26,426 x DRG Weight",16268,Other,base rate x DRG weight,23891,,"38,809 x DRG Weight",23891,Other,base rate x DRG weight,23891,,"38,809 x DRG Weight",23891,Other,base rate x DRG weight,16268,,"26,426 x DRG Weight",16268,Other,base rate x DRG weight,23891,,"38,809 x DRG Weight",23891,Other,base rate x DRG weight,21787,,"35,391 x DRG Weight",21787,Other,base rate x DRG weight,65720,70,,65720,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,15523,,"25,216 X DRG Weight",15523,Other,Base Weight X DRG Weight,13971,,"22,695 X DRG Weight",13971,Other,Base Weight X DRG Weight,15523,,"25,216 X DRG Weight",15523,Other,Base Rate x DRG Weight ,13194,,"21,433 x DRG Weight",13194,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,65720,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,,inpatient,,,292904.11,27582,,,27582,Other,150% of Medicare + 9.63% HCRA Surcharge,16772.91,,,16772.91,Other,Medicare IPPS methodology,47036,,"25,728 x DRG weight",47036,Other,base rate x DRG weight,42332,,"23,155 x DRG weight",42332,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,146452,50,,146452,Percent of Total Billed Charges,50% of Charges,53193,,"29,096 x DRG Weight",53193,Other,base rate x DRG weight,41067,,"22,463 x DRG Weight",41067,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,48312,,"26,426 x DRG Weight",48312,Other,base rate x DRG weight,70951,,"38,809 x DRG Weight",70951,Other,base rate x DRG weight,70951,,"38,809 x DRG Weight",70951,Other,base rate x DRG weight,48312,,"26,426 x DRG Weight",48312,Other,base rate x DRG weight,70951,,"38,809 x DRG Weight",70951,Other,base rate x DRG weight,64702,,"35,391 x DRG Weight",64702,Other,base rate x DRG weight,205033,70,,205033,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46100,,"25,216 X DRG Weight",46100,Other,Base Weight X DRG Weight,41491,,"22,695 X DRG Weight",41491,Other,Base Weight X DRG Weight,46100,,"25,216 X DRG Weight",46100,Other,Base Rate x DRG Weight ,39184,,"21,433 x DRG Weight",39184,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,205033,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,,inpatient,,,154877.1,14580,,,14580,Other,150% of Medicare + 9.63% HCRA Surcharge,8866.4,,,8866.4,Other,Medicare IPPS methodology,24480,,"25,728 x DRG weight",24480,Other,base rate x DRG weight,22032,,"23,155 x DRG weight",22032,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,77439,50,,77439,Percent of Total Billed Charges,50% of Charges,27685,,"29,096 x DRG Weight",27685,Other,base rate x DRG weight,21374,,"22,463 x DRG Weight",21374,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,25144,,"26,426 x DRG Weight",25144,Other,base rate x DRG weight,36927,,"38,809 x DRG Weight",36927,Other,base rate x DRG weight,36927,,"38,809 x DRG Weight",36927,Other,base rate x DRG weight,25144,,"26,426 x DRG Weight",25144,Other,base rate x DRG weight,36927,,"38,809 x DRG Weight",36927,Other,base rate x DRG weight,33675,,"35,391 x DRG Weight",33675,Other,base rate x DRG weight,108414,70,,108414,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,23993,,"25,216 X DRG Weight",23993,Other,Base Weight X DRG Weight,21594,,"22,695 X DRG Weight",21594,Other,Base Weight X DRG Weight,23993,,"25,216 X DRG Weight",23993,Other,Base Rate x DRG Weight ,20393,,"21,433 x DRG Weight",20393,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,108414,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,,inpatient,,,124494.32,11069,,,11069,Other,150% of Medicare + 9.63% HCRA Surcharge,6730.83,,,6730.83,Other,Medicare IPPS methodology,18388,,"25,728 x DRG weight",18388,Other,base rate x DRG weight,16549,,"23,155 x DRG weight",16549,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,62247,50,,62247,Percent of Total Billed Charges,50% of Charges,20795,,"29,096 x DRG Weight",20795,Other,base rate x DRG weight,16054,,"22,463 x DRG Weight",16054,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18887,,"26,426 x DRG Weight",18887,Other,base rate x DRG weight,27737,,"38,809 x DRG Weight",27737,Other,base rate x DRG weight,27737,,"38,809 x DRG Weight",27737,Other,base rate x DRG weight,18887,,"26,426 x DRG Weight",18887,Other,base rate x DRG weight,27737,,"38,809 x DRG Weight",27737,Other,base rate x DRG weight,25294,,"35,391 x DRG Weight",25294,Other,base rate x DRG weight,87146,70,,87146,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18022,,"25,216 X DRG Weight",18022,Other,Base Weight X DRG Weight,16220,,"22,695 X DRG Weight",16220,Other,Base Weight X DRG Weight,18022,,"25,216 X DRG Weight",18022,Other,Base Rate x DRG Weight ,15318,,"21,433 x DRG Weight",15318,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,87146,
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,,inpatient,,,229395.79,24690,,,24690,Other,150% of Medicare + 9.63% HCRA Surcharge,15014.3,,,15014.3,Other,Medicare IPPS methodology,42019,,"25,728 x DRG weight",42019,Other,base rate x DRG weight,37817,,"23,155 x DRG weight",37817,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,114698,50,,114698,Percent of Total Billed Charges,50% of Charges,47520,,"29,096 x DRG Weight",47520,Other,base rate x DRG weight,36687,,"22,463 x DRG Weight",36687,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,43159,,"26,426 x DRG Weight",43159,Other,base rate x DRG weight,63383,,"38,809 x DRG Weight",63383,Other,base rate x DRG weight,63383,,"38,809 x DRG Weight",63383,Other,base rate x DRG weight,43159,,"26,426 x DRG Weight",43159,Other,base rate x DRG weight,63383,,"38,809 x DRG Weight",63383,Other,base rate x DRG weight,57801,,"35,391 x DRG Weight",57801,Other,base rate x DRG weight,160577,70,,160577,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,41183,,"25,216 X DRG Weight",41183,Other,Base Weight X DRG Weight,37065,,"22,695 X DRG Weight",37065,Other,Base Weight X DRG Weight,41183,,"25,216 X DRG Weight",41183,Other,Base Rate x DRG Weight ,35004,,"21,433 x DRG Weight",35004,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,160577,
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,,inpatient,,,155190.87,16587,,,16587,Other,150% of Medicare + 9.63% HCRA Surcharge,10086.6,,,10086.6,Other,Medicare IPPS methodology,27961,,"25,728 x DRG weight",27961,Other,base rate x DRG weight,25165,,"23,155 x DRG weight",25165,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,77595,50,,77595,Percent of Total Billed Charges,50% of Charges,31622,,"29,096 x DRG Weight",31622,Other,base rate x DRG weight,24413,,"22,463 x DRG Weight",24413,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28720,,"26,426 x DRG Weight",28720,Other,base rate x DRG weight,42178,,"38,809 x DRG Weight",42178,Other,base rate x DRG weight,42178,,"38,809 x DRG Weight",42178,Other,base rate x DRG weight,28720,,"26,426 x DRG Weight",28720,Other,base rate x DRG weight,42178,,"38,809 x DRG Weight",42178,Other,base rate x DRG weight,38463,,"35,391 x DRG Weight",38463,Other,base rate x DRG weight,108634,70,,108634,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27405,,"25,216 X DRG Weight",27405,Other,Base Weight X DRG Weight,24665,,"22,695 X DRG Weight",24665,Other,Base Weight X DRG Weight,27405,,"25,216 X DRG Weight",27405,Other,Base Rate x DRG Weight ,23293,,"21,433 x DRG Weight",23293,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,108634,
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,,inpatient,,,90748.1,12356,,,12356,Other,150% of Medicare + 9.63% HCRA Surcharge,7513.63,,,7513.63,Other,Medicare IPPS methodology,20621,,"25,728 x DRG weight",20621,Other,base rate x DRG weight,18559,,"23,155 x DRG weight",18559,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,45374,50,,45374,Percent of Total Billed Charges,50% of Charges,23320,,"29,096 x DRG Weight",23320,Other,base rate x DRG weight,18004,,"22,463 x DRG Weight",18004,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21180,,"26,426 x DRG Weight",21180,Other,base rate x DRG weight,31105,,"38,809 x DRG Weight",31105,Other,base rate x DRG weight,31105,,"38,809 x DRG Weight",31105,Other,base rate x DRG weight,21180,,"26,426 x DRG Weight",21180,Other,base rate x DRG weight,31105,,"38,809 x DRG Weight",31105,Other,base rate x DRG weight,28366,,"35,391 x DRG Weight",28366,Other,base rate x DRG weight,63524,70,,63524,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20211,,"25,216 X DRG Weight",20211,Other,Base Weight X DRG Weight,18190,,"22,695 X DRG Weight",18190,Other,Base Weight X DRG Weight,20211,,"25,216 X DRG Weight",20211,Other,Base Rate x DRG Weight ,17179,,"21,433 x DRG Weight",17179,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,63524,
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH MCC,453,MS-DRG,,,,,,,,inpatient,,,633098.44,131888,,,131888,Other,150% of Medicare + 9.63% HCRA Surcharge,80201.68,,,80201.68,Other,Medicare IPPS methodology,227986,,"25,728 x DRG weight",227986,Other,base rate x DRG weight,205186,,"23,155 x DRG weight",205186,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,316549,50,,316549,Percent of Total Billed Charges,50% of Charges,257831,,"29,096 x DRG Weight",257831,Other,base rate x DRG weight,199054,,"22,463 x DRG Weight",199054,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,234171,,"26,426 x DRG Weight",234171,Other,base rate x DRG weight,343902,,"38,809 x DRG Weight",343902,Other,base rate x DRG weight,343902,,"38,809 x DRG Weight",343902,Other,base rate x DRG weight,234171,,"26,426 x DRG Weight",234171,Other,base rate x DRG weight,343902,,"38,809 x DRG Weight",343902,Other,base rate x DRG weight,313614,,"35,391 x DRG Weight",313614,Other,base rate x DRG weight,443169,70,,443169,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,223449,,"25,216 X DRG Weight",223449,Other,Base Weight X DRG Weight,201109,,"22,695 X DRG Weight",201109,Other,Base Weight X DRG Weight,223449,,"25,216 X DRG Weight",223449,Other,Base Rate x DRG Weight ,189926,,"21,433 x DRG Weight",189926,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,443169,
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,454,MS-DRG,,,,,,,,inpatient,,,567022.09,91177,,,91177,Other,150% of Medicare + 9.63% HCRA Surcharge,55445.05,,,55445.05,Other,Medicare IPPS methodology,157360,,"25,728 x DRG weight",157360,Other,base rate x DRG weight,141623,,"23,155 x DRG weight",141623,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,283511,50,,283511,Percent of Total Billed Charges,50% of Charges,177960,,"29,096 x DRG Weight",177960,Other,base rate x DRG weight,137390,,"22,463 x DRG Weight",137390,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,161629,,"26,426 x DRG Weight",161629,Other,base rate x DRG weight,237367,,"38,809 x DRG Weight",237367,Other,base rate x DRG weight,237367,,"38,809 x DRG Weight",237367,Other,base rate x DRG weight,161629,,"26,426 x DRG Weight",161629,Other,base rate x DRG weight,237367,,"38,809 x DRG Weight",237367,Other,base rate x DRG weight,216462,,"35,391 x DRG Weight",216462,Other,base rate x DRG weight,396915,70,,396915,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,154229,,"25,216 X DRG Weight",154229,Other,Base Weight X DRG Weight,138809,,"22,695 X DRG Weight",138809,Other,Base Weight X DRG Weight,154229,,"25,216 X DRG Weight",154229,Other,Base Rate x DRG Weight ,131091,,"21,433 x DRG Weight",131091,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,396915,
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,455,MS-DRG,,,,,,,,inpatient,,,369111.85,68772,,,68772,Other,150% of Medicare + 9.63% HCRA Surcharge,41820.83,,,41820.83,Other,Medicare IPPS methodology,118493,,"25,728 x DRG weight",118493,Other,base rate x DRG weight,106643,,"23,155 x DRG weight",106643,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,184556,50,,184556,Percent of Total Billed Charges,50% of Charges,134005,,"29,096 x DRG Weight",134005,Other,base rate x DRG weight,103456,,"22,463 x DRG Weight",103456,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,121708,,"26,426 x DRG Weight",121708,Other,base rate x DRG weight,178739,,"38,809 x DRG Weight",178739,Other,base rate x DRG weight,178739,,"38,809 x DRG Weight",178739,Other,base rate x DRG weight,121708,,"26,426 x DRG Weight",121708,Other,base rate x DRG weight,178739,,"38,809 x DRG Weight",178739,Other,base rate x DRG weight,162997,,"35,391 x DRG Weight",162997,Other,base rate x DRG weight,258378,70,,258378,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,116135,,"25,216 X DRG Weight",116135,Other,Base Weight X DRG Weight,104524,,"22,695 X DRG Weight",104524,Other,Base Weight X DRG Weight,116135,,"25,216 X DRG Weight",116135,Other,Base Rate x DRG Weight ,98712,,"21,433 x DRG Weight",98712,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,258378,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,MS-DRG,,,,,,,,inpatient,,,843561.74,125481,,,125481,Other,150% of Medicare + 9.63% HCRA Surcharge,76305.7,,,76305.7,Other,Medicare IPPS methodology,216872,,"25,728 x DRG weight",216872,Other,base rate x DRG weight,195183,,"23,155 x DRG weight",195183,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,421781,50,,421781,Percent of Total Billed Charges,50% of Charges,245262,,"29,096 x DRG Weight",245262,Other,base rate x DRG weight,189350,,"22,463 x DRG Weight",189350,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,222755,,"26,426 x DRG Weight",222755,Other,base rate x DRG weight,327137,,"38,809 x DRG Weight",327137,Other,base rate x DRG weight,327137,,"38,809 x DRG Weight",327137,Other,base rate x DRG weight,222755,,"26,426 x DRG Weight",222755,Other,base rate x DRG weight,327137,,"38,809 x DRG Weight",327137,Other,base rate x DRG weight,298325,,"35,391 x DRG Weight",298325,Other,base rate x DRG weight,590493,70,,590493,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,212556,,"25,216 X DRG Weight",212556,Other,Base Weight X DRG Weight,191305,,"22,695 X DRG Weight",191305,Other,Base Weight X DRG Weight,212556,,"25,216 X DRG Weight",212556,Other,Base Rate x DRG Weight ,180667,,"21,433 x DRG Weight",180667,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,590493,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,,inpatient,,,595047.79,90569,,,90569,Other,150% of Medicare + 9.63% HCRA Surcharge,55075.29,,,55075.29,Other,Medicare IPPS methodology,156305,,"25,728 x DRG weight",156305,Other,base rate x DRG weight,140674,,"23,155 x DRG weight",140674,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,297524,50,,297524,Percent of Total Billed Charges,50% of Charges,176767,,"29,096 x DRG Weight",176767,Other,base rate x DRG weight,136469,,"22,463 x DRG Weight",136469,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,160546,,"26,426 x DRG Weight",160546,Other,base rate x DRG weight,235776,,"38,809 x DRG Weight",235776,Other,base rate x DRG weight,235776,,"38,809 x DRG Weight",235776,Other,base rate x DRG weight,160546,,"26,426 x DRG Weight",160546,Other,base rate x DRG weight,235776,,"38,809 x DRG Weight",235776,Other,base rate x DRG weight,215011,,"35,391 x DRG Weight",215011,Other,base rate x DRG weight,416533,70,,416533,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,153195,,"25,216 X DRG Weight",153195,Other,Base Weight X DRG Weight,137879,,"22,695 X DRG Weight",137879,Other,Base Weight X DRG Weight,153195,,"25,216 X DRG Weight",153195,Other,Base Rate x DRG Weight ,130212,,"21,433 x DRG Weight",130212,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,416533,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,,inpatient,,,361625.58,67666,,,67666,Other,150% of Medicare + 9.63% HCRA Surcharge,41148.05,,,41148.05,Other,Medicare IPPS methodology,116574,,"25,728 x DRG weight",116574,Other,base rate x DRG weight,104915,,"23,155 x DRG weight",104915,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,180813,50,,180813,Percent of Total Billed Charges,50% of Charges,131834,,"29,096 x DRG Weight",131834,Other,base rate x DRG weight,101780,,"22,463 x DRG Weight",101780,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,119736,,"26,426 x DRG Weight",119736,Other,base rate x DRG weight,175844,,"38,809 x DRG Weight",175844,Other,base rate x DRG weight,175844,,"38,809 x DRG Weight",175844,Other,base rate x DRG weight,119736,,"26,426 x DRG Weight",119736,Other,base rate x DRG weight,175844,,"38,809 x DRG Weight",175844,Other,base rate x DRG weight,160357,,"35,391 x DRG Weight",160357,Other,base rate x DRG weight,253138,70,,253138,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,114254,,"25,216 X DRG Weight",114254,Other,Base Weight X DRG Weight,102831,,"22,695 X DRG Weight",102831,Other,Base Weight X DRG Weight,114254,,"25,216 X DRG Weight",114254,Other,Base Rate x DRG Weight ,97113,,"21,433 x DRG Weight",97113,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,253138,
SPINAL FUSION EXCEPT CERVICAL WITH MCC,459,MS-DRG,,,,,,,,inpatient,,,571947.85,98829,,,98829,Other,150% of Medicare + 9.63% HCRA Surcharge,60098.58,,,60098.58,Other,Medicare IPPS methodology,170636,,"25,728 x DRG weight",170636,Other,base rate x DRG weight,153571,,"23,155 x DRG weight",153571,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,285974,50,,285974,Percent of Total Billed Charges,50% of Charges,192973,,"29,096 x DRG Weight",192973,Other,base rate x DRG weight,148981,,"22,463 x DRG Weight",148981,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,175265,,"26,426 x DRG Weight",175265,Other,base rate x DRG weight,257393,,"38,809 x DRG Weight",257393,Other,base rate x DRG weight,257393,,"38,809 x DRG Weight",257393,Other,base rate x DRG weight,175265,,"26,426 x DRG Weight",175265,Other,base rate x DRG weight,257393,,"38,809 x DRG Weight",257393,Other,base rate x DRG weight,234724,,"35,391 x DRG Weight",234724,Other,base rate x DRG weight,400363,70,,400363,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,167240,,"25,216 X DRG Weight",167240,Other,Base Weight X DRG Weight,150520,,"22,695 X DRG Weight",150520,Other,Base Weight X DRG Weight,167240,,"25,216 X DRG Weight",167240,Other,Base Rate x DRG Weight ,142150,,"21,433 x DRG Weight",142150,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,400363,
SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,460,MS-DRG,,,,,,,,inpatient,,,412534.11,54717,,,54717,Other,150% of Medicare + 9.63% HCRA Surcharge,33274.02,,,33274.02,Other,Medicare IPPS methodology,94110,,"25,728 x DRG weight",94110,Other,base rate x DRG weight,84699,,"23,155 x DRG weight",84699,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,206267,50,,206267,Percent of Total Billed Charges,50% of Charges,106430,,"29,096 x DRG Weight",106430,Other,base rate x DRG weight,82167,,"22,463 x DRG Weight",82167,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,96664,,"26,426 x DRG Weight",96664,Other,base rate x DRG weight,141959,,"38,809 x DRG Weight",141959,Other,base rate x DRG weight,141959,,"38,809 x DRG Weight",141959,Other,base rate x DRG weight,96664,,"26,426 x DRG Weight",96664,Other,base rate x DRG weight,141959,,"38,809 x DRG Weight",141959,Other,base rate x DRG weight,129457,,"35,391 x DRG Weight",129457,Other,base rate x DRG weight,288774,70,,288774,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,92238,,"25,216 X DRG Weight",92238,Other,Base Weight X DRG Weight,83016,,"22,695 X DRG Weight",83016,Other,Base Weight X DRG Weight,92238,,"25,216 X DRG Weight",92238,Other,Base Rate x DRG Weight ,78400,,"21,433 x DRG Weight",78400,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,288774,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,MS-DRG,,,,,,,,inpatient,,,375453.95,101591,,,101591,Other,150% of Medicare + 9.63% HCRA Surcharge,61777.83,,,61777.83,Other,Medicare IPPS methodology,175426,,"25,728 x DRG weight",175426,Other,base rate x DRG weight,157882,,"23,155 x DRG weight",157882,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,187727,50,,187727,Percent of Total Billed Charges,50% of Charges,198391,,"29,096 x DRG Weight",198391,Other,base rate x DRG weight,153164,,"22,463 x DRG Weight",153164,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,180186,,"26,426 x DRG Weight",180186,Other,base rate x DRG weight,264619,,"38,809 x DRG Weight",264619,Other,base rate x DRG weight,264619,,"38,809 x DRG Weight",264619,Other,base rate x DRG weight,180186,,"26,426 x DRG Weight",180186,Other,base rate x DRG weight,264619,,"38,809 x DRG Weight",264619,Other,base rate x DRG weight,241314,,"35,391 x DRG Weight",241314,Other,base rate x DRG weight,262818,70,,262818,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,171935,,"25,216 X DRG Weight",171935,Other,Base Weight X DRG Weight,154746,,"22,695 X DRG Weight",154746,Other,Base Weight X DRG Weight,171935,,"25,216 X DRG Weight",171935,Other,Base Rate x DRG Weight ,146141,,"21,433 x DRG Weight",146141,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,264619,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,MS-DRG,,,,,,,,inpatient,,,213954.99,42681,,,42681,Other,150% of Medicare + 9.63% HCRA Surcharge,25954.62,,,25954.62,Other,Medicare IPPS methodology,73230,,"25,728 x DRG weight",73230,Other,base rate x DRG weight,65906,,"23,155 x DRG weight",65906,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,106977,50,,106977,Percent of Total Billed Charges,50% of Charges,82816,,"29,096 x DRG Weight",82816,Other,base rate x DRG weight,63936,,"22,463 x DRG Weight",63936,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,75216,,"26,426 x DRG Weight",75216,Other,base rate x DRG weight,110462,,"38,809 x DRG Weight",110462,Other,base rate x DRG weight,110462,,"38,809 x DRG Weight",110462,Other,base rate x DRG weight,75216,,"26,426 x DRG Weight",75216,Other,base rate x DRG weight,110462,,"38,809 x DRG Weight",110462,Other,base rate x DRG weight,100733,,"35,391 x DRG Weight",100733,Other,base rate x DRG weight,149768,70,,149768,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,71772,,"25,216 X DRG Weight",71772,Other,Base Weight X DRG Weight,64597,,"22,695 X DRG Weight",64597,Other,Base Weight X DRG Weight,71772,,"25,216 X DRG Weight",71772,Other,Base Rate x DRG Weight ,61005,,"21,433 x DRG Weight",61005,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,149768,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,,inpatient,,,848239.31,84464,,,84464,Other,150% of Medicare + 9.63% HCRA Surcharge,51363.29,,,51363.29,Other,Medicare IPPS methodology,145716,,"25,728 x DRG weight",145716,Other,base rate x DRG weight,131143,,"23,155 x DRG weight",131143,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,424120,50,,424120,Percent of Total Billed Charges,50% of Charges,164791,,"29,096 x DRG Weight",164791,Other,base rate x DRG weight,127224,,"22,463 x DRG Weight",127224,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,149669,,"26,426 x DRG Weight",149669,Other,base rate x DRG weight,219803,,"38,809 x DRG Weight",219803,Other,base rate x DRG weight,219803,,"38,809 x DRG Weight",219803,Other,base rate x DRG weight,149669,,"26,426 x DRG Weight",149669,Other,base rate x DRG weight,219803,,"38,809 x DRG Weight",219803,Other,base rate x DRG weight,200444,,"35,391 x DRG Weight",200444,Other,base rate x DRG weight,593768,70,,593768,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,142816,,"25,216 X DRG Weight",142816,Other,Base Weight X DRG Weight,128538,,"22,695 X DRG Weight",128538,Other,Base Weight X DRG Weight,142816,,"25,216 X DRG Weight",142816,Other,Base Rate x DRG Weight ,121390,,"21,433 x DRG Weight",121390,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,593768,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,,inpatient,,,544659.96,44981,,,44981,Other,150% of Medicare + 9.63% HCRA Surcharge,27353.39,,,27353.39,Other,Medicare IPPS methodology,77220,,"25,728 x DRG weight",77220,Other,base rate x DRG weight,69497,,"23,155 x DRG weight",69497,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,272330,50,,272330,Percent of Total Billed Charges,50% of Charges,87329,,"29,096 x DRG Weight",87329,Other,base rate x DRG weight,67420,,"22,463 x DRG Weight",67420,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,79315,,"26,426 x DRG Weight",79315,Other,base rate x DRG weight,116481,,"38,809 x DRG Weight",116481,Other,base rate x DRG weight,116481,,"38,809 x DRG Weight",116481,Other,base rate x DRG weight,79315,,"26,426 x DRG Weight",79315,Other,base rate x DRG weight,116481,,"38,809 x DRG Weight",116481,Other,base rate x DRG weight,106223,,"35,391 x DRG Weight",106223,Other,base rate x DRG weight,381262,70,,381262,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,75683,,"25,216 X DRG Weight",75683,Other,Base Weight X DRG Weight,68117,,"22,695 X DRG Weight",68117,Other,Base Weight X DRG Weight,75683,,"25,216 X DRG Weight",75683,Other,Base Rate x DRG Weight ,64329,,"21,433 x DRG Weight",64329,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,381262,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,,inpatient,,,300547.76,28214,,,28214,Other,150% of Medicare + 9.63% HCRA Surcharge,17157.09,,,17157.09,Other,Medicare IPPS methodology,48132,,"25,728 x DRG weight",48132,Other,base rate x DRG weight,43318,,"23,155 x DRG weight",43318,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,150274,50,,150274,Percent of Total Billed Charges,50% of Charges,54433,,"29,096 x DRG Weight",54433,Other,base rate x DRG weight,42024,,"22,463 x DRG Weight",42024,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,49438,,"26,426 x DRG Weight",49438,Other,base rate x DRG weight,72604,,"38,809 x DRG Weight",72604,Other,base rate x DRG weight,72604,,"38,809 x DRG Weight",72604,Other,base rate x DRG weight,49438,,"26,426 x DRG Weight",49438,Other,base rate x DRG weight,72604,,"38,809 x DRG Weight",72604,Other,base rate x DRG weight,66209,,"35,391 x DRG Weight",66209,Other,base rate x DRG weight,210383,70,,210383,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,47174,,"25,216 X DRG Weight",47174,Other,Base Weight X DRG Weight,42458,,"22,695 X DRG Weight",42458,Other,Base Weight X DRG Weight,47174,,"25,216 X DRG Weight",47174,Other,Base Rate x DRG Weight ,40097,,"21,433 x DRG Weight",40097,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,210383,
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,MS-DRG,,,,,,,,inpatient,,,415619.59,77389,,,77389,Other,150% of Medicare + 9.63% HCRA Surcharge,47060.57,,,47060.57,Other,Medicare IPPS methodology,133441,,"25,728 x DRG weight",133441,Other,base rate x DRG weight,120096,,"23,155 x DRG weight",120096,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,207810,50,,207810,Percent of Total Billed Charges,50% of Charges,150909,,"29,096 x DRG Weight",150909,Other,base rate x DRG weight,116507,,"22,463 x DRG Weight",116507,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,137061,,"26,426 x DRG Weight",137061,Other,base rate x DRG weight,201287,,"38,809 x DRG Weight",201287,Other,base rate x DRG weight,201287,,"38,809 x DRG Weight",201287,Other,base rate x DRG weight,137061,,"26,426 x DRG Weight",137061,Other,base rate x DRG weight,201287,,"38,809 x DRG Weight",201287,Other,base rate x DRG weight,183559,,"35,391 x DRG Weight",183559,Other,base rate x DRG weight,290934,70,,290934,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,130785,,"25,216 X DRG Weight",130785,Other,Base Weight X DRG Weight,117710,,"22,695 X DRG Weight",117710,Other,Base Weight X DRG Weight,130785,,"25,216 X DRG Weight",130785,Other,Base Rate x DRG Weight ,111164,,"21,433 x DRG Weight",111164,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,290934,
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,,inpatient,,,301348.69,52173,,,52173,Other,150% of Medicare + 9.63% HCRA Surcharge,31726.45,,,31726.45,Other,Medicare IPPS methodology,89696,,"25,728 x DRG weight",89696,Other,base rate x DRG weight,80725,,"23,155 x DRG weight",80725,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,150674,50,,150674,Percent of Total Billed Charges,50% of Charges,101437,,"29,096 x DRG Weight",101437,Other,base rate x DRG weight,78313,,"22,463 x DRG Weight",78313,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,92129,,"26,426 x DRG Weight",92129,Other,base rate x DRG weight,135300,,"38,809 x DRG Weight",135300,Other,base rate x DRG weight,135300,,"38,809 x DRG Weight",135300,Other,base rate x DRG weight,92129,,"26,426 x DRG Weight",92129,Other,base rate x DRG weight,135300,,"38,809 x DRG Weight",135300,Other,base rate x DRG weight,123384,,"35,391 x DRG Weight",123384,Other,base rate x DRG weight,210944,70,,210944,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,87911,,"25,216 X DRG Weight",87911,Other,Base Weight X DRG Weight,79122,,"22,695 X DRG Weight",79122,Other,Base Weight X DRG Weight,87911,,"25,216 X DRG Weight",87911,Other,Base Rate x DRG Weight ,74722,,"21,433 x DRG Weight",74722,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,210944,
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,,inpatient,,,176455.89,40061,,,40061,Other,150% of Medicare + 9.63% HCRA Surcharge,24361.05,,,24361.05,Other,Medicare IPPS methodology,68683,,"25,728 x DRG weight",68683,Other,base rate x DRG weight,61815,,"23,155 x DRG weight",61815,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,88228,50,,88228,Percent of Total Billed Charges,50% of Charges,77675,,"29,096 x DRG Weight",77675,Other,base rate x DRG weight,59967,,"22,463 x DRG Weight",59967,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,70547,,"26,426 x DRG Weight",70547,Other,base rate x DRG weight,103605,,"38,809 x DRG Weight",103605,Other,base rate x DRG weight,103605,,"38,809 x DRG Weight",103605,Other,base rate x DRG weight,70547,,"26,426 x DRG Weight",70547,Other,base rate x DRG weight,103605,,"38,809 x DRG Weight",103605,Other,base rate x DRG weight,94480,,"35,391 x DRG Weight",94480,Other,base rate x DRG weight,123519,70,,123519,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,67317,,"25,216 X DRG Weight",67317,Other,Base Weight X DRG Weight,60587,,"22,695 X DRG Weight",60587,Other,Base Weight X DRG Weight,67317,,"25,216 X DRG Weight",67317,Other,Base Rate x DRG Weight ,57218,,"21,433 x DRG Weight",57218,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,123519,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,,inpatient,,,267132.55,49852,,,49852,Other,150% of Medicare + 9.63% HCRA Surcharge,30315.05,,,30315.05,Other,Medicare IPPS methodology,85669,,"25,728 x DRG weight",85669,Other,base rate x DRG weight,77102,,"23,155 x DRG weight",77102,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,133566,50,,133566,Percent of Total Billed Charges,50% of Charges,96884,,"29,096 x DRG Weight",96884,Other,base rate x DRG weight,74797,,"22,463 x DRG Weight",74797,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,87993,,"26,426 x DRG Weight",87993,Other,base rate x DRG weight,129226,,"38,809 x DRG Weight",129226,Other,base rate x DRG weight,129226,,"38,809 x DRG Weight",129226,Other,base rate x DRG weight,87993,,"26,426 x DRG Weight",87993,Other,base rate x DRG weight,129226,,"38,809 x DRG Weight",129226,Other,base rate x DRG weight,117845,,"35,391 x DRG Weight",117845,Other,base rate x DRG weight,186993,70,,186993,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,83964,,"25,216 X DRG Weight",83964,Other,Base Weight X DRG Weight,75570,,"22,695 X DRG Weight",75570,Other,Base Weight X DRG Weight,83964,,"25,216 X DRG Weight",83964,Other,Base Rate x DRG Weight ,71368,,"21,433 x DRG Weight",71368,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,186993,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,,inpatient,,,151090.61,28376,,,28376,Other,150% of Medicare + 9.63% HCRA Surcharge,17255.39,,,17255.39,Other,Medicare IPPS methodology,48412,,"25,728 x DRG weight",48412,Other,base rate x DRG weight,43571,,"23,155 x DRG weight",43571,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,75545,50,,75545,Percent of Total Billed Charges,50% of Charges,54750,,"29,096 x DRG Weight",54750,Other,base rate x DRG weight,42269,,"22,463 x DRG Weight",42269,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,49726,,"26,426 x DRG Weight",49726,Other,base rate x DRG weight,73027,,"38,809 x DRG Weight",73027,Other,base rate x DRG weight,73027,,"38,809 x DRG Weight",73027,Other,base rate x DRG weight,49726,,"26,426 x DRG Weight",49726,Other,base rate x DRG weight,73027,,"38,809 x DRG Weight",73027,Other,base rate x DRG weight,66595,,"35,391 x DRG Weight",66595,Other,base rate x DRG weight,105763,70,,105763,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,47449,,"25,216 X DRG Weight",47449,Other,Base Weight X DRG Weight,42705,,"22,695 X DRG Weight",42705,Other,Base Weight X DRG Weight,47449,,"25,216 X DRG Weight",47449,Other,Base Rate x DRG Weight ,40330,,"21,433 x DRG Weight",40330,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,105763,
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,,inpatient,,,489370.33,73420,,,73420,Other,150% of Medicare + 9.63% HCRA Surcharge,44647.22,,,44647.22,Other,Medicare IPPS methodology,126556,,"25,728 x DRG weight",126556,Other,base rate x DRG weight,113899,,"23,155 x DRG weight",113899,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,244685,50,,244685,Percent of Total Billed Charges,50% of Charges,143123,,"29,096 x DRG Weight",143123,Other,base rate x DRG weight,110495,,"22,463 x DRG Weight",110495,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,129989,,"26,426 x DRG Weight",129989,Other,base rate x DRG weight,190901,,"38,809 x DRG Weight",190901,Other,base rate x DRG weight,190901,,"38,809 x DRG Weight",190901,Other,base rate x DRG weight,129989,,"26,426 x DRG Weight",129989,Other,base rate x DRG weight,190901,,"38,809 x DRG Weight",190901,Other,base rate x DRG weight,174088,,"35,391 x DRG Weight",174088,Other,base rate x DRG weight,342559,70,,342559,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,124038,,"25,216 X DRG Weight",124038,Other,Base Weight X DRG Weight,111637,,"22,695 X DRG Weight",111637,Other,Base Weight X DRG Weight,124038,,"25,216 X DRG Weight",124038,Other,Base Rate x DRG Weight ,105429,,"21,433 x DRG Weight",105429,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,342559,
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,,inpatient,,,288821.42,44299,,,44299,Other,150% of Medicare + 9.63% HCRA Surcharge,26938.54,,,26938.54,Other,Medicare IPPS methodology,76037,,"25,728 x DRG weight",76037,Other,base rate x DRG weight,68432,,"23,155 x DRG weight",68432,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,144411,50,,144411,Percent of Total Billed Charges,50% of Charges,85990,,"29,096 x DRG Weight",85990,Other,base rate x DRG weight,66387,,"22,463 x DRG Weight",66387,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,78099,,"26,426 x DRG Weight",78099,Other,base rate x DRG weight,114696,,"38,809 x DRG Weight",114696,Other,base rate x DRG weight,114696,,"38,809 x DRG Weight",114696,Other,base rate x DRG weight,78099,,"26,426 x DRG Weight",78099,Other,base rate x DRG weight,114696,,"38,809 x DRG Weight",114696,Other,base rate x DRG weight,104595,,"35,391 x DRG Weight",104595,Other,base rate x DRG weight,202175,70,,202175,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,74523,,"25,216 X DRG Weight",74523,Other,Base Weight X DRG Weight,67073,,"22,695 X DRG Weight",67073,Other,Base Weight X DRG Weight,74523,,"25,216 X DRG Weight",74523,Other,Base Rate x DRG Weight ,63343,,"21,433 x DRG Weight",63343,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,202175,
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,,inpatient,,,189159.65,36961,,,36961,Other,150% of Medicare + 9.63% HCRA Surcharge,22476.19,,,22476.19,Other,Medicare IPPS methodology,63306,,"25,728 x DRG weight",63306,Other,base rate x DRG weight,56975,,"23,155 x DRG weight",56975,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,94580,50,,94580,Percent of Total Billed Charges,50% of Charges,71594,,"29,096 x DRG Weight",71594,Other,base rate x DRG weight,55272,,"22,463 x DRG Weight",55272,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,65024,,"26,426 x DRG Weight",65024,Other,base rate x DRG weight,95493,,"38,809 x DRG Weight",95493,Other,base rate x DRG weight,95493,,"38,809 x DRG Weight",95493,Other,base rate x DRG weight,65024,,"26,426 x DRG Weight",65024,Other,base rate x DRG weight,95493,,"38,809 x DRG Weight",95493,Other,base rate x DRG weight,87083,,"35,391 x DRG Weight",87083,Other,base rate x DRG weight,132412,70,,132412,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,62046,,"25,216 X DRG Weight",62046,Other,Base Weight X DRG Weight,55843,,"22,695 X DRG Weight",55843,Other,Base Weight X DRG Weight,62046,,"25,216 X DRG Weight",62046,Other,Base Rate x DRG Weight ,52738,,"21,433 x DRG Weight",52738,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,132412,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,,inpatient,,,544842.37,64282,,,64282,Other,150% of Medicare + 9.63% HCRA Surcharge,39090.04,,,39090.04,Other,Medicare IPPS methodology,110702,,"25,728 x DRG weight",110702,Other,base rate x DRG weight,99631,,"23,155 x DRG weight",99631,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,272421,50,,272421,Percent of Total Billed Charges,50% of Charges,125194,,"29,096 x DRG Weight",125194,Other,base rate x DRG weight,96654,,"22,463 x DRG Weight",96654,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,113706,,"26,426 x DRG Weight",113706,Other,base rate x DRG weight,166987,,"38,809 x DRG Weight",166987,Other,base rate x DRG weight,166987,,"38,809 x DRG Weight",166987,Other,base rate x DRG weight,113706,,"26,426 x DRG Weight",113706,Other,base rate x DRG weight,166987,,"38,809 x DRG Weight",166987,Other,base rate x DRG weight,152280,,"35,391 x DRG Weight",152280,Other,base rate x DRG weight,381390,70,,381390,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,108499,,"25,216 X DRG Weight",108499,Other,Base Weight X DRG Weight,97652,,"22,695 X DRG Weight",97652,Other,Base Weight X DRG Weight,108499,,"25,216 X DRG Weight",108499,Other,Base Rate x DRG Weight ,92222,,"21,433 x DRG Weight",92222,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,381390,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,,inpatient,,,263729.03,32276,,,32276,Other,150% of Medicare + 9.63% HCRA Surcharge,19627.25,,,19627.25,Other,Medicare IPPS methodology,55179,,"25,728 x DRG weight",55179,Other,base rate x DRG weight,49661,,"23,155 x DRG weight",49661,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,131865,50,,131865,Percent of Total Billed Charges,50% of Charges,62402,,"29,096 x DRG Weight",62402,Other,base rate x DRG weight,48176,,"22,463 x DRG Weight",48176,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,56676,,"26,426 x DRG Weight",56676,Other,base rate x DRG weight,83234,,"38,809 x DRG Weight",83234,Other,base rate x DRG weight,83234,,"38,809 x DRG Weight",83234,Other,base rate x DRG weight,56676,,"26,426 x DRG Weight",56676,Other,base rate x DRG weight,83234,,"38,809 x DRG Weight",83234,Other,base rate x DRG weight,75903,,"35,391 x DRG Weight",75903,Other,base rate x DRG weight,184610,70,,184610,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,54081,,"25,216 X DRG Weight",54081,Other,Base Weight X DRG Weight,48674,,"22,695 X DRG Weight",48674,Other,Base Weight X DRG Weight,54081,,"25,216 X DRG Weight",54081,Other,Base Rate x DRG Weight ,45967,,"21,433 x DRG Weight",45967,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,184610,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,MS-DRG,,,,,,,,inpatient,,,139055.76,17923,,,17923,Other,150% of Medicare + 9.63% HCRA Surcharge,10899.17,,,10899.17,Other,Medicare IPPS methodology,30279,,"25,728 x DRG weight",30279,Other,base rate x DRG weight,27251,,"23,155 x DRG weight",27251,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,69528,50,,69528,Percent of Total Billed Charges,50% of Charges,34243,,"29,096 x DRG Weight",34243,Other,base rate x DRG weight,26437,,"22,463 x DRG Weight",26437,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31101,,"26,426 x DRG Weight",31101,Other,base rate x DRG weight,45674,,"38,809 x DRG Weight",45674,Other,base rate x DRG weight,45674,,"38,809 x DRG Weight",45674,Other,base rate x DRG weight,31101,,"26,426 x DRG Weight",31101,Other,base rate x DRG weight,45674,,"38,809 x DRG Weight",45674,Other,base rate x DRG weight,41652,,"35,391 x DRG Weight",41652,Other,base rate x DRG weight,97339,70,,97339,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,29677,,"25,216 X DRG Weight",29677,Other,Base Weight X DRG Weight,26710,,"22,695 X DRG Weight",26710,Other,Base Weight X DRG Weight,29677,,"25,216 X DRG Weight",29677,Other,Base Rate x DRG Weight ,25224,,"21,433 x DRG Weight",25224,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,97339,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,,inpatient,,,534816.66,50433,,,50433,Other,150% of Medicare + 9.63% HCRA Surcharge,30668.58,,,30668.58,Other,Medicare IPPS methodology,86678,,"25,728 x DRG weight",86678,Other,base rate x DRG weight,78009,,"23,155 x DRG weight",78009,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,267408,50,,267408,Percent of Total Billed Charges,50% of Charges,98024,,"29,096 x DRG Weight",98024,Other,base rate x DRG weight,75678,,"22,463 x DRG Weight",75678,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,89029,,"26,426 x DRG Weight",89029,Other,base rate x DRG weight,130748,,"38,809 x DRG Weight",130748,Other,base rate x DRG weight,130748,,"38,809 x DRG Weight",130748,Other,base rate x DRG weight,89029,,"26,426 x DRG Weight",89029,Other,base rate x DRG weight,130748,,"38,809 x DRG Weight",130748,Other,base rate x DRG weight,119232,,"35,391 x DRG Weight",119232,Other,base rate x DRG weight,374372,70,,374372,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,84953,,"25,216 X DRG Weight",84953,Other,Base Weight X DRG Weight,76459,,"22,695 X DRG Weight",76459,Other,Base Weight X DRG Weight,84953,,"25,216 X DRG Weight",84953,Other,Base Rate x DRG Weight ,72208,,"21,433 x DRG Weight",72208,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,374372,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,,inpatient,,,300553.25,35821,,,35821,Other,150% of Medicare + 9.63% HCRA Surcharge,21782.67,,,21782.67,Other,Medicare IPPS methodology,61328,,"25,728 x DRG weight",61328,Other,base rate x DRG weight,55195,,"23,155 x DRG weight",55195,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,150277,50,,150277,Percent of Total Billed Charges,50% of Charges,69356,,"29,096 x DRG Weight",69356,Other,base rate x DRG weight,53545,,"22,463 x DRG Weight",53545,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,62992,,"26,426 x DRG Weight",62992,Other,base rate x DRG weight,92509,,"38,809 x DRG Weight",92509,Other,base rate x DRG weight,92509,,"38,809 x DRG Weight",92509,Other,base rate x DRG weight,62992,,"26,426 x DRG Weight",62992,Other,base rate x DRG weight,92509,,"38,809 x DRG Weight",92509,Other,base rate x DRG weight,84362,,"35,391 x DRG Weight",84362,Other,base rate x DRG weight,210387,70,,210387,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,60107,,"25,216 X DRG Weight",60107,Other,Base Weight X DRG Weight,54098,,"22,695 X DRG Weight",54098,Other,Base Weight X DRG Weight,60107,,"25,216 X DRG Weight",60107,Other,Base Rate x DRG Weight ,51090,,"21,433 x DRG Weight",51090,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,210387,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,,inpatient,,,252720.48,28113,,,28113,Other,150% of Medicare + 9.63% HCRA Surcharge,17095.77,,,17095.77,Other,Medicare IPPS methodology,47957,,"25,728 x DRG weight",47957,Other,base rate x DRG weight,43161,,"23,155 x DRG weight",43161,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,126360,50,,126360,Percent of Total Billed Charges,50% of Charges,54235,,"29,096 x DRG Weight",54235,Other,base rate x DRG weight,41871,,"22,463 x DRG Weight",41871,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,49258,,"26,426 x DRG Weight",49258,Other,base rate x DRG weight,72340,,"38,809 x DRG Weight",72340,Other,base rate x DRG weight,72340,,"38,809 x DRG Weight",72340,Other,base rate x DRG weight,49258,,"26,426 x DRG Weight",49258,Other,base rate x DRG weight,72340,,"38,809 x DRG Weight",72340,Other,base rate x DRG weight,65969,,"35,391 x DRG Weight",65969,Other,base rate x DRG weight,176904,70,,176904,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,47003,,"25,216 X DRG Weight",47003,Other,Base Weight X DRG Weight,42303,,"22,695 X DRG Weight",42303,Other,Base Weight X DRG Weight,47003,,"25,216 X DRG Weight",47003,Other,Base Rate x DRG Weight ,39951,,"21,433 x DRG Weight",39951,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,176904,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,,inpatient,,,332195.9,44203,,,44203,Other,150% of Medicare + 9.63% HCRA Surcharge,26879.92,,,26879.92,Other,Medicare IPPS methodology,75869,,"25,728 x DRG weight",75869,Other,base rate x DRG weight,68282,,"23,155 x DRG weight",68282,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,166098,50,,166098,Percent of Total Billed Charges,50% of Charges,85801,,"29,096 x DRG Weight",85801,Other,base rate x DRG weight,66241,,"22,463 x DRG Weight",66241,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,77928,,"26,426 x DRG Weight",77928,Other,base rate x DRG weight,114444,,"38,809 x DRG Weight",114444,Other,base rate x DRG weight,114444,,"38,809 x DRG Weight",114444,Other,base rate x DRG weight,77928,,"26,426 x DRG Weight",77928,Other,base rate x DRG weight,114444,,"38,809 x DRG Weight",114444,Other,base rate x DRG weight,104365,,"35,391 x DRG Weight",104365,Other,base rate x DRG weight,232537,70,,232537,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,74359,,"25,216 X DRG Weight",74359,Other,Base Weight X DRG Weight,66925,,"22,695 X DRG Weight",66925,Other,Base Weight X DRG Weight,74359,,"25,216 X DRG Weight",74359,Other,Base Rate x DRG Weight ,63204,,"21,433 x DRG Weight",63204,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,232537,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,,inpatient,,,253655.8,31241,,,31241,Other,150% of Medicare + 9.63% HCRA Surcharge,18997.76,,,18997.76,Other,Medicare IPPS methodology,53383,,"25,728 x DRG weight",53383,Other,base rate x DRG weight,48044,,"23,155 x DRG weight",48044,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,126828,50,,126828,Percent of Total Billed Charges,50% of Charges,60371,,"29,096 x DRG Weight",60371,Other,base rate x DRG weight,46608,,"22,463 x DRG Weight",46608,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,54831,,"26,426 x DRG Weight",54831,Other,base rate x DRG weight,80525,,"38,809 x DRG Weight",80525,Other,base rate x DRG weight,80525,,"38,809 x DRG Weight",80525,Other,base rate x DRG weight,54831,,"26,426 x DRG Weight",54831,Other,base rate x DRG weight,80525,,"38,809 x DRG Weight",80525,Other,base rate x DRG weight,73433,,"35,391 x DRG Weight",73433,Other,base rate x DRG weight,177559,70,,177559,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,52321,,"25,216 X DRG Weight",52321,Other,Base Weight X DRG Weight,47090,,"22,695 X DRG Weight",47090,Other,Base Weight X DRG Weight,52321,,"25,216 X DRG Weight",52321,Other,Base Rate x DRG Weight ,44471,,"21,433 x DRG Weight",44471,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,177559,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,,inpatient,,,183953.55,24026,,,24026,Other,150% of Medicare + 9.63% HCRA Surcharge,14610.27,,,14610.27,Other,Medicare IPPS methodology,40866,,"25,728 x DRG weight",40866,Other,base rate x DRG weight,36779,,"23,155 x DRG weight",36779,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,91977,50,,91977,Percent of Total Billed Charges,50% of Charges,46216,,"29,096 x DRG Weight",46216,Other,base rate x DRG weight,35680,,"22,463 x DRG Weight",35680,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41975,,"26,426 x DRG Weight",41975,Other,base rate x DRG weight,61644,,"38,809 x DRG Weight",61644,Other,base rate x DRG weight,61644,,"38,809 x DRG Weight",61644,Other,base rate x DRG weight,41975,,"26,426 x DRG Weight",41975,Other,base rate x DRG weight,61644,,"38,809 x DRG Weight",61644,Other,base rate x DRG weight,56215,,"35,391 x DRG Weight",56215,Other,base rate x DRG weight,128767,70,,128767,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40053,,"25,216 X DRG Weight",40053,Other,Base Weight X DRG Weight,36049,,"22,695 X DRG Weight",36049,Other,Base Weight X DRG Weight,40053,,"25,216 X DRG Weight",40053,Other,Base Rate x DRG Weight ,34044,,"21,433 x DRG Weight",34044,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,128767,
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,,inpatient,,,271272.5,37311,,,37311,Other,150% of Medicare + 9.63% HCRA Surcharge,22689.03,,,22689.03,Other,Medicare IPPS methodology,63913,,"25,728 x DRG weight",63913,Other,base rate x DRG weight,57522,,"23,155 x DRG weight",57522,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,135636,50,,135636,Percent of Total Billed Charges,50% of Charges,72280,,"29,096 x DRG Weight",72280,Other,base rate x DRG weight,55803,,"22,463 x DRG Weight",55803,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,65647,,"26,426 x DRG Weight",65647,Other,base rate x DRG weight,96409,,"38,809 x DRG Weight",96409,Other,base rate x DRG weight,96409,,"38,809 x DRG Weight",96409,Other,base rate x DRG weight,65647,,"26,426 x DRG Weight",65647,Other,base rate x DRG weight,96409,,"38,809 x DRG Weight",96409,Other,base rate x DRG weight,87918,,"35,391 x DRG Weight",87918,Other,base rate x DRG weight,189891,70,,189891,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,62642,,"25,216 X DRG Weight",62642,Other,Base Weight X DRG Weight,56379,,"22,695 X DRG Weight",56379,Other,Base Weight X DRG Weight,62642,,"25,216 X DRG Weight",62642,Other,Base Rate x DRG Weight ,53244,,"21,433 x DRG Weight",53244,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,189891,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,,inpatient,,,502414.13,49321,,,49321,Other,150% of Medicare + 9.63% HCRA Surcharge,29992.19,,,29992.19,Other,Medicare IPPS methodology,84748,,"25,728 x DRG weight",84748,Other,base rate x DRG weight,76273,,"23,155 x DRG weight",76273,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,251207,50,,251207,Percent of Total Billed Charges,50% of Charges,95842,,"29,096 x DRG Weight",95842,Other,base rate x DRG weight,73993,,"22,463 x DRG Weight",73993,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,87047,,"26,426 x DRG Weight",87047,Other,base rate x DRG weight,127837,,"38,809 x DRG Weight",127837,Other,base rate x DRG weight,127837,,"38,809 x DRG Weight",127837,Other,base rate x DRG weight,87047,,"26,426 x DRG Weight",87047,Other,base rate x DRG weight,127837,,"38,809 x DRG Weight",127837,Other,base rate x DRG weight,116578,,"35,391 x DRG Weight",116578,Other,base rate x DRG weight,351690,70,,351690,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,83062,,"25,216 X DRG Weight",83062,Other,Base Weight X DRG Weight,74757,,"22,695 X DRG Weight",74757,Other,Base Weight X DRG Weight,83062,,"25,216 X DRG Weight",83062,Other,Base Rate x DRG Weight ,70600,,"21,433 x DRG Weight",70600,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,351690,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,,inpatient,,,261162.63,30253,,,30253,Other,150% of Medicare + 9.63% HCRA Surcharge,18397.13,,,18397.13,Other,Medicare IPPS methodology,51670,,"25,728 x DRG weight",51670,Other,base rate x DRG weight,46502,,"23,155 x DRG weight",46502,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,130581,50,,130581,Percent of Total Billed Charges,50% of Charges,58433,,"29,096 x DRG Weight",58433,Other,base rate x DRG weight,45112,,"22,463 x DRG Weight",45112,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,53071,,"26,426 x DRG Weight",53071,Other,base rate x DRG weight,77940,,"38,809 x DRG Weight",77940,Other,base rate x DRG weight,77940,,"38,809 x DRG Weight",77940,Other,base rate x DRG weight,53071,,"26,426 x DRG Weight",53071,Other,base rate x DRG weight,77940,,"38,809 x DRG Weight",77940,Other,base rate x DRG weight,71076,,"35,391 x DRG Weight",71076,Other,base rate x DRG weight,182814,70,,182814,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,50641,,"25,216 X DRG Weight",50641,Other,Base Weight X DRG Weight,45578,,"22,695 X DRG Weight",45578,Other,Base Weight X DRG Weight,50641,,"25,216 X DRG Weight",50641,Other,Base Rate x DRG Weight ,43044,,"21,433 x DRG Weight",43044,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,182814,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,,inpatient,,,164039.72,23381,,,23381,Other,150% of Medicare + 9.63% HCRA Surcharge,14217.97,,,14217.97,Other,Medicare IPPS methodology,39747,,"25,728 x DRG weight",39747,Other,base rate x DRG weight,35772,,"23,155 x DRG weight",35772,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,82020,50,,82020,Percent of Total Billed Charges,50% of Charges,44950,,"29,096 x DRG Weight",44950,Other,base rate x DRG weight,34703,,"22,463 x DRG Weight",34703,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,40826,,"26,426 x DRG Weight",40826,Other,base rate x DRG weight,59956,,"38,809 x DRG Weight",59956,Other,base rate x DRG weight,59956,,"38,809 x DRG Weight",59956,Other,base rate x DRG weight,40826,,"26,426 x DRG Weight",40826,Other,base rate x DRG weight,59956,,"38,809 x DRG Weight",59956,Other,base rate x DRG weight,54676,,"35,391 x DRG Weight",54676,Other,base rate x DRG weight,114828,70,,114828,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,38956,,"25,216 X DRG Weight",38956,Other,Base Weight X DRG Weight,35062,,"22,695 X DRG Weight",35062,Other,Base Weight X DRG Weight,38956,,"25,216 X DRG Weight",38956,Other,Base Rate x DRG Weight ,33112,,"21,433 x DRG Weight",33112,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,114828,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,,inpatient,,,322882.32,31711,,,31711,Other,150% of Medicare + 9.63% HCRA Surcharge,19283.65,,,19283.65,Other,Medicare IPPS methodology,54199,,"25,728 x DRG weight",54199,Other,base rate x DRG weight,48778,,"23,155 x DRG weight",48778,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,161441,50,,161441,Percent of Total Billed Charges,50% of Charges,61294,,"29,096 x DRG Weight",61294,Other,base rate x DRG weight,47321,,"22,463 x DRG Weight",47321,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,55669,,"26,426 x DRG Weight",55669,Other,base rate x DRG weight,81755,,"38,809 x DRG Weight",81755,Other,base rate x DRG weight,81755,,"38,809 x DRG Weight",81755,Other,base rate x DRG weight,55669,,"26,426 x DRG Weight",55669,Other,base rate x DRG weight,81755,,"38,809 x DRG Weight",81755,Other,base rate x DRG weight,74555,,"35,391 x DRG Weight",74555,Other,base rate x DRG weight,226018,70,,226018,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,53120,,"25,216 X DRG Weight",53120,Other,Base Weight X DRG Weight,47809,,"22,695 X DRG Weight",47809,Other,Base Weight X DRG Weight,53120,,"25,216 X DRG Weight",53120,Other,Base Rate x DRG Weight ,45151,,"21,433 x DRG Weight",45151,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,226018,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,,inpatient,,,190126.09,18825,,,18825,Other,150% of Medicare + 9.63% HCRA Surcharge,11447.49,,,11447.49,Other,Medicare IPPS methodology,31844,,"25,728 x DRG weight",31844,Other,base rate x DRG weight,28659,,"23,155 x DRG weight",28659,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,95063,50,,95063,Percent of Total Billed Charges,50% of Charges,36012,,"29,096 x DRG Weight",36012,Other,base rate x DRG weight,27802,,"22,463 x DRG Weight",27802,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,32707,,"26,426 x DRG Weight",32707,Other,base rate x DRG weight,48034,,"38,809 x DRG Weight",48034,Other,base rate x DRG weight,48034,,"38,809 x DRG Weight",48034,Other,base rate x DRG weight,32707,,"26,426 x DRG Weight",32707,Other,base rate x DRG weight,48034,,"38,809 x DRG Weight",48034,Other,base rate x DRG weight,43803,,"35,391 x DRG Weight",43803,Other,base rate x DRG weight,133088,70,,133088,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,31210,,"25,216 X DRG Weight",31210,Other,Base Weight X DRG Weight,28090,,"22,695 X DRG Weight",28090,Other,Base Weight X DRG Weight,31210,,"25,216 X DRG Weight",31210,Other,Base Rate x DRG Weight ,26528,,"21,433 x DRG Weight",26528,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,133088,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,,inpatient,,,407050.77,51814,,,51814,Other,150% of Medicare + 9.63% HCRA Surcharge,31508.2,,,31508.2,Other,Medicare IPPS methodology,89073,,"25,728 x DRG weight",89073,Other,base rate x DRG weight,80165,,"23,155 x DRG weight",80165,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,203525,50,,203525,Percent of Total Billed Charges,50% of Charges,100733,,"29,096 x DRG Weight",100733,Other,base rate x DRG weight,77769,,"22,463 x DRG Weight",77769,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,91489,,"26,426 x DRG Weight",91489,Other,base rate x DRG weight,134361,,"38,809 x DRG Weight",134361,Other,base rate x DRG weight,134361,,"38,809 x DRG Weight",134361,Other,base rate x DRG weight,91489,,"26,426 x DRG Weight",91489,Other,base rate x DRG weight,134361,,"38,809 x DRG Weight",134361,Other,base rate x DRG weight,122527,,"35,391 x DRG Weight",122527,Other,base rate x DRG weight,284936,70,,284936,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,87300,,"25,216 X DRG Weight",87300,Other,Base Weight X DRG Weight,78572,,"22,695 X DRG Weight",78572,Other,Base Weight X DRG Weight,87300,,"25,216 X DRG Weight",87300,Other,Base Rate x DRG Weight ,74203,,"21,433 x DRG Weight",74203,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,284936,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,,inpatient,,,277949.72,36087,,,36087,Other,150% of Medicare + 9.63% HCRA Surcharge,21945,,,21945,Other,Medicare IPPS methodology,61791,,"25,728 x DRG weight",61791,Other,base rate x DRG weight,55611,,"23,155 x DRG weight",55611,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,138975,50,,138975,Percent of Total Billed Charges,50% of Charges,69880,,"29,096 x DRG Weight",69880,Other,base rate x DRG weight,53949,,"22,463 x DRG Weight",53949,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,63467,,"26,426 x DRG Weight",63467,Other,base rate x DRG weight,93208,,"38,809 x DRG Weight",93208,Other,base rate x DRG weight,93208,,"38,809 x DRG Weight",93208,Other,base rate x DRG weight,63467,,"26,426 x DRG Weight",63467,Other,base rate x DRG weight,93208,,"38,809 x DRG Weight",93208,Other,base rate x DRG weight,84999,,"35,391 x DRG Weight",84999,Other,base rate x DRG weight,194565,70,,194565,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,60561,,"25,216 X DRG Weight",60561,Other,Base Weight X DRG Weight,54507,,"22,695 X DRG Weight",54507,Other,Base Weight X DRG Weight,60561,,"25,216 X DRG Weight",60561,Other,Base Rate x DRG Weight ,51476,,"21,433 x DRG Weight",51476,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,194565,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,,inpatient,,,207862.3,28190,,,28190,Other,150% of Medicare + 9.63% HCRA Surcharge,17142.66,,,17142.66,Other,Medicare IPPS methodology,48091,,"25,728 x DRG weight",48091,Other,base rate x DRG weight,43281,,"23,155 x DRG weight",43281,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,103931,50,,103931,Percent of Total Billed Charges,50% of Charges,54386,,"29,096 x DRG Weight",54386,Other,base rate x DRG weight,41988,,"22,463 x DRG Weight",41988,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,49395,,"26,426 x DRG Weight",49395,Other,base rate x DRG weight,72542,,"38,809 x DRG Weight",72542,Other,base rate x DRG weight,72542,,"38,809 x DRG Weight",72542,Other,base rate x DRG weight,49395,,"26,426 x DRG Weight",49395,Other,base rate x DRG weight,72542,,"38,809 x DRG Weight",72542,Other,base rate x DRG weight,66153,,"35,391 x DRG Weight",66153,Other,base rate x DRG weight,145504,70,,145504,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,47134,,"25,216 X DRG Weight",47134,Other,Base Weight X DRG Weight,42421,,"22,695 X DRG Weight",42421,Other,Base Weight X DRG Weight,47134,,"25,216 X DRG Weight",47134,Other,Base Rate x DRG Weight ,40063,,"21,433 x DRG Weight",40063,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,145504,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,MS-DRG,,,,,,,,inpatient,,,1130144.9,53580,,,53580,Other,150% of Medicare + 9.63% HCRA Surcharge,32582.3,,,32582.3,Other,Medicare IPPS methodology,92137,,"25,728 x DRG weight",92137,Other,base rate x DRG weight,82923,,"23,155 x DRG weight",82923,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,565072,50,,565072,Percent of Total Billed Charges,50% of Charges,104199,,"29,096 x DRG Weight",104199,Other,base rate x DRG weight,80444,,"22,463 x DRG Weight",80444,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,94637,,"26,426 x DRG Weight",94637,Other,base rate x DRG weight,138983,,"38,809 x DRG Weight",138983,Other,base rate x DRG weight,138983,,"38,809 x DRG Weight",138983,Other,base rate x DRG weight,94637,,"26,426 x DRG Weight",94637,Other,base rate x DRG weight,138983,,"38,809 x DRG Weight",138983,Other,base rate x DRG weight,126742,,"35,391 x DRG Weight",126742,Other,base rate x DRG weight,791101,70,,791101,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,90304,,"25,216 X DRG Weight",90304,Other,Base Weight X DRG Weight,81275,,"22,695 X DRG Weight",81275,Other,Base Weight X DRG Weight,90304,,"25,216 X DRG Weight",90304,Other,Base Rate x DRG Weight ,76756,,"21,433 x DRG Weight",76756,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,791101,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,,inpatient,,,239548.84,29945,,,29945,Other,150% of Medicare + 9.63% HCRA Surcharge,18209.55,,,18209.55,Other,Medicare IPPS methodology,51134,,"25,728 x DRG weight",51134,Other,base rate x DRG weight,46021,,"23,155 x DRG weight",46021,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,119774,50,,119774,Percent of Total Billed Charges,50% of Charges,57828,,"29,096 x DRG Weight",57828,Other,base rate x DRG weight,44645,,"22,463 x DRG Weight",44645,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,52522,,"26,426 x DRG Weight",52522,Other,base rate x DRG weight,77133,,"38,809 x DRG Weight",77133,Other,base rate x DRG weight,77133,,"38,809 x DRG Weight",77133,Other,base rate x DRG weight,52522,,"26,426 x DRG Weight",52522,Other,base rate x DRG weight,77133,,"38,809 x DRG Weight",77133,Other,base rate x DRG weight,70340,,"35,391 x DRG Weight",70340,Other,base rate x DRG weight,167684,70,,167684,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,50117,,"25,216 X DRG Weight",50117,Other,Base Weight X DRG Weight,45106,,"22,695 X DRG Weight",45106,Other,Base Weight X DRG Weight,50117,,"25,216 X DRG Weight",50117,Other,Base Rate x DRG Weight ,42598,,"21,433 x DRG Weight",42598,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,167684,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,,inpatient,,,111107.51,21638,,,21638,Other,150% of Medicare + 9.63% HCRA Surcharge,13158.3,,,13158.3,Other,Medicare IPPS methodology,36724,,"25,728 x DRG weight",36724,Other,base rate x DRG weight,33051,,"23,155 x DRG weight",33051,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,55554,50,,55554,Percent of Total Billed Charges,50% of Charges,41532,,"29,096 x DRG Weight",41532,Other,base rate x DRG weight,32064,,"22,463 x DRG Weight",32064,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,37720,,"26,426 x DRG Weight",37720,Other,base rate x DRG weight,55396,,"38,809 x DRG Weight",55396,Other,base rate x DRG weight,55396,,"38,809 x DRG Weight",55396,Other,base rate x DRG weight,37720,,"26,426 x DRG Weight",37720,Other,base rate x DRG weight,55396,,"38,809 x DRG Weight",55396,Other,base rate x DRG weight,50517,,"35,391 x DRG Weight",50517,Other,base rate x DRG weight,77775,70,,77775,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35993,,"25,216 X DRG Weight",35993,Other,Base Weight X DRG Weight,32395,,"22,695 X DRG Weight",32395,Other,Base Weight X DRG Weight,35993,,"25,216 X DRG Weight",35993,Other,Base Rate x DRG Weight ,30593,,"21,433 x DRG Weight",30593,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,77775,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,,inpatient,,,433070.13,39191,,,39191,Other,150% of Medicare + 9.63% HCRA Surcharge,23832.57,,,23832.57,Other,Medicare IPPS methodology,67176,,"25,728 x DRG weight",67176,Other,base rate x DRG weight,60458,,"23,155 x DRG weight",60458,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,216535,50,,216535,Percent of Total Billed Charges,50% of Charges,75970,,"29,096 x DRG Weight",75970,Other,base rate x DRG weight,58651,,"22,463 x DRG Weight",58651,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,68998,,"26,426 x DRG Weight",68998,Other,base rate x DRG weight,101330,,"38,809 x DRG Weight",101330,Other,base rate x DRG weight,101330,,"38,809 x DRG Weight",101330,Other,base rate x DRG weight,68998,,"26,426 x DRG Weight",68998,Other,base rate x DRG weight,101330,,"38,809 x DRG Weight",101330,Other,base rate x DRG weight,92406,,"35,391 x DRG Weight",92406,Other,base rate x DRG weight,303149,70,,303149,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,65839,,"25,216 X DRG Weight",65839,Other,Base Weight X DRG Weight,59257,,"22,695 X DRG Weight",59257,Other,Base Weight X DRG Weight,65839,,"25,216 X DRG Weight",65839,Other,Base Rate x DRG Weight ,55962,,"21,433 x DRG Weight",55962,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,303149,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,MS-DRG,,,,,,,,inpatient,,,175437.85,19597,,,19597,Other,150% of Medicare + 9.63% HCRA Surcharge,11917.36,,,11917.36,Other,Medicare IPPS methodology,33184,,"25,728 x DRG weight",33184,Other,base rate x DRG weight,29865,,"23,155 x DRG weight",29865,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,87719,50,,87719,Percent of Total Billed Charges,50% of Charges,37528,,"29,096 x DRG Weight",37528,Other,base rate x DRG weight,28973,,"22,463 x DRG Weight",28973,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,34084,,"26,426 x DRG Weight",34084,Other,base rate x DRG weight,50056,,"38,809 x DRG Weight",50056,Other,base rate x DRG weight,50056,,"38,809 x DRG Weight",50056,Other,base rate x DRG weight,34084,,"26,426 x DRG Weight",34084,Other,base rate x DRG weight,50056,,"38,809 x DRG Weight",50056,Other,base rate x DRG weight,45647,,"35,391 x DRG Weight",45647,Other,base rate x DRG weight,122806,70,,122806,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32524,,"25,216 X DRG Weight",32524,Other,Base Weight X DRG Weight,29272,,"22,695 X DRG Weight",29272,Other,Base Weight X DRG Weight,32524,,"25,216 X DRG Weight",32524,Other,Base Rate x DRG Weight ,27644,,"21,433 x DRG Weight",27644,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,122806,
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,,inpatient,,,262912.23,48561,,,48561,Other,150% of Medicare + 9.63% HCRA Surcharge,29530.45,,,29530.45,Other,Medicare IPPS methodology,83431,,"25,728 x DRG weight",83431,Other,base rate x DRG weight,75087,,"23,155 x DRG weight",75087,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,131456,50,,131456,Percent of Total Billed Charges,50% of Charges,94353,,"29,096 x DRG Weight",94353,Other,base rate x DRG weight,72843,,"22,463 x DRG Weight",72843,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,85694,,"26,426 x DRG Weight",85694,Other,base rate x DRG weight,125850,,"38,809 x DRG Weight",125850,Other,base rate x DRG weight,125850,,"38,809 x DRG Weight",125850,Other,base rate x DRG weight,85694,,"26,426 x DRG Weight",85694,Other,base rate x DRG weight,125850,,"38,809 x DRG Weight",125850,Other,base rate x DRG weight,114766,,"35,391 x DRG Weight",114766,Other,base rate x DRG weight,184039,70,,184039,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,81770,,"25,216 X DRG Weight",81770,Other,Base Weight X DRG Weight,73595,,"22,695 X DRG Weight",73595,Other,Base Weight X DRG Weight,81770,,"25,216 X DRG Weight",81770,Other,Base Rate x DRG Weight ,69503,,"21,433 x DRG Weight",69503,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,184039,
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,,inpatient,,,275120.97,26210,,,26210,Other,150% of Medicare + 9.63% HCRA Surcharge,15938.7,,,15938.7,Other,Medicare IPPS methodology,44656,,"25,728 x DRG weight",44656,Other,base rate x DRG weight,40190,,"23,155 x DRG weight",40190,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,137560,50,,137560,Percent of Total Billed Charges,50% of Charges,50502,,"29,096 x DRG Weight",50502,Other,base rate x DRG weight,38989,,"22,463 x DRG Weight",38989,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,45868,,"26,426 x DRG Weight",45868,Other,base rate x DRG weight,67361,,"38,809 x DRG Weight",67361,Other,base rate x DRG weight,67361,,"38,809 x DRG Weight",67361,Other,base rate x DRG weight,45868,,"26,426 x DRG Weight",45868,Other,base rate x DRG weight,67361,,"38,809 x DRG Weight",67361,Other,base rate x DRG weight,61428,,"35,391 x DRG Weight",61428,Other,base rate x DRG weight,192585,70,,192585,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43767,,"25,216 X DRG Weight",43767,Other,Base Weight X DRG Weight,39392,,"22,695 X DRG Weight",39392,Other,Base Weight X DRG Weight,43767,,"25,216 X DRG Weight",43767,Other,Base Rate x DRG Weight ,37201,,"21,433 x DRG Weight",37201,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,192585,
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,,inpatient,,,174345.25,20975,,,20975,Other,150% of Medicare + 9.63% HCRA Surcharge,12755.17,,,12755.17,Other,Medicare IPPS methodology,35574,,"25,728 x DRG weight",35574,Other,base rate x DRG weight,32016,,"23,155 x DRG weight",32016,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,87173,50,,87173,Percent of Total Billed Charges,50% of Charges,40231,,"29,096 x DRG Weight",40231,Other,base rate x DRG weight,31060,,"22,463 x DRG Weight",31060,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,36539,,"26,426 x DRG Weight",36539,Other,base rate x DRG weight,53661,,"38,809 x DRG Weight",53661,Other,base rate x DRG weight,53661,,"38,809 x DRG Weight",53661,Other,base rate x DRG weight,36539,,"26,426 x DRG Weight",36539,Other,base rate x DRG weight,53661,,"38,809 x DRG Weight",53661,Other,base rate x DRG weight,48935,,"35,391 x DRG Weight",48935,Other,base rate x DRG weight,122042,70,,122042,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,34866,,"25,216 X DRG Weight",34866,Other,Base Weight X DRG Weight,31380,,"22,695 X DRG Weight",31380,Other,Base Weight X DRG Weight,34866,,"25,216 X DRG Weight",34866,Other,Base Rate x DRG Weight ,29635,,"21,433 x DRG Weight",29635,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,122042,
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,,inpatient,,,335847.49,40243,,,40243,Other,150% of Medicare + 9.63% HCRA Surcharge,24471.98,,,24471.98,Other,Medicare IPPS methodology,69000,,"25,728 x DRG weight",69000,Other,base rate x DRG weight,62099,,"23,155 x DRG weight",62099,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,167924,50,,167924,Percent of Total Billed Charges,50% of Charges,78033,,"29,096 x DRG Weight",78033,Other,base rate x DRG weight,60244,,"22,463 x DRG Weight",60244,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,70872,,"26,426 x DRG Weight",70872,Other,base rate x DRG weight,104082,,"38,809 x DRG Weight",104082,Other,base rate x DRG weight,104082,,"38,809 x DRG Weight",104082,Other,base rate x DRG weight,70872,,"26,426 x DRG Weight",70872,Other,base rate x DRG weight,104082,,"38,809 x DRG Weight",104082,Other,base rate x DRG weight,94915,,"35,391 x DRG Weight",94915,Other,base rate x DRG weight,235093,70,,235093,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,67627,,"25,216 X DRG Weight",67627,Other,Base Weight X DRG Weight,60866,,"22,695 X DRG Weight",60866,Other,Base Weight X DRG Weight,67627,,"25,216 X DRG Weight",67627,Other,Base Rate x DRG Weight ,57481,,"21,433 x DRG Weight",57481,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,235093,
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,,inpatient,,,217277.38,26083,,,26083,Other,150% of Medicare + 9.63% HCRA Surcharge,15861.14,,,15861.14,Other,Medicare IPPS methodology,44435,,"25,728 x DRG weight",44435,Other,base rate x DRG weight,39991,,"23,155 x DRG weight",39991,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,108639,50,,108639,Percent of Total Billed Charges,50% of Charges,50252,,"29,096 x DRG Weight",50252,Other,base rate x DRG weight,38796,,"22,463 x DRG Weight",38796,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,45640,,"26,426 x DRG Weight",45640,Other,base rate x DRG weight,67027,,"38,809 x DRG Weight",67027,Other,base rate x DRG weight,67027,,"38,809 x DRG Weight",67027,Other,base rate x DRG weight,45640,,"26,426 x DRG Weight",45640,Other,base rate x DRG weight,67027,,"38,809 x DRG Weight",67027,Other,base rate x DRG weight,61124,,"35,391 x DRG Weight",61124,Other,base rate x DRG weight,152094,70,,152094,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43551,,"25,216 X DRG Weight",43551,Other,Base Weight X DRG Weight,39197,,"22,695 X DRG Weight",39197,Other,Base Weight X DRG Weight,43551,,"25,216 X DRG Weight",43551,Other,Base Rate x DRG Weight ,37017,,"21,433 x DRG Weight",37017,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,152094,
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,,inpatient,,,226961.08,25765,,,25765,Other,150% of Medicare + 9.63% HCRA Surcharge,15668.14,,,15668.14,Other,Medicare IPPS methodology,43884,,"25,728 x DRG weight",43884,Other,base rate x DRG weight,39495,,"23,155 x DRG weight",39495,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,113481,50,,113481,Percent of Total Billed Charges,50% of Charges,49629,,"29,096 x DRG Weight",49629,Other,base rate x DRG weight,38315,,"22,463 x DRG Weight",38315,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,45075,,"26,426 x DRG Weight",45075,Other,base rate x DRG weight,66197,,"38,809 x DRG Weight",66197,Other,base rate x DRG weight,66197,,"38,809 x DRG Weight",66197,Other,base rate x DRG weight,45075,,"26,426 x DRG Weight",45075,Other,base rate x DRG weight,66197,,"38,809 x DRG Weight",66197,Other,base rate x DRG weight,60366,,"35,391 x DRG Weight",60366,Other,base rate x DRG weight,158873,70,,158873,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43011,,"25,216 X DRG Weight",43011,Other,Base Weight X DRG Weight,38711,,"22,695 X DRG Weight",38711,Other,Base Weight X DRG Weight,43011,,"25,216 X DRG Weight",43011,Other,Base Rate x DRG Weight ,36558,,"21,433 x DRG Weight",36558,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,158873,
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,,inpatient,,,342220.88,22160,,,22160,Other,150% of Medicare + 9.63% HCRA Surcharge,13475.75,,,13475.75,Other,Medicare IPPS methodology,37630,,"25,728 x DRG weight",37630,Other,base rate x DRG weight,33867,,"23,155 x DRG weight",33867,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,171110,50,,171110,Percent of Total Billed Charges,50% of Charges,42556,,"29,096 x DRG Weight",42556,Other,base rate x DRG weight,32854,,"22,463 x DRG Weight",32854,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,38651,,"26,426 x DRG Weight",38651,Other,base rate x DRG weight,56762,,"38,809 x DRG Weight",56762,Other,base rate x DRG weight,56762,,"38,809 x DRG Weight",56762,Other,base rate x DRG weight,38651,,"26,426 x DRG Weight",38651,Other,base rate x DRG weight,56762,,"38,809 x DRG Weight",56762,Other,base rate x DRG weight,51763,,"35,391 x DRG Weight",51763,Other,base rate x DRG weight,239555,70,,239555,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,36881,,"25,216 X DRG Weight",36881,Other,Base Weight X DRG Weight,33194,,"22,695 X DRG Weight",33194,Other,Base Weight X DRG Weight,36881,,"25,216 X DRG Weight",36881,Other,Base Rate x DRG Weight ,31348,,"21,433 x DRG Weight",31348,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,239555,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,,inpatient,,,398980.37,32083,,,32083,Other,150% of Medicare + 9.63% HCRA Surcharge,19510.01,,,19510.01,Other,Medicare IPPS methodology,54844,,"25,728 x DRG weight",54844,Other,base rate x DRG weight,49360,,"23,155 x DRG weight",49360,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,199490,50,,199490,Percent of Total Billed Charges,50% of Charges,62024,,"29,096 x DRG Weight",62024,Other,base rate x DRG weight,47884,,"22,463 x DRG Weight",47884,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,56332,,"26,426 x DRG Weight",56332,Other,base rate x DRG weight,82729,,"38,809 x DRG Weight",82729,Other,base rate x DRG weight,82729,,"38,809 x DRG Weight",82729,Other,base rate x DRG weight,56332,,"26,426 x DRG Weight",56332,Other,base rate x DRG weight,82729,,"38,809 x DRG Weight",82729,Other,base rate x DRG weight,75443,,"35,391 x DRG Weight",75443,Other,base rate x DRG weight,279286,70,,279286,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,53753,,"25,216 X DRG Weight",53753,Other,Base Weight X DRG Weight,48379,,"22,695 X DRG Weight",48379,Other,Base Weight X DRG Weight,53753,,"25,216 X DRG Weight",53753,Other,Base Rate x DRG Weight ,45689,,"21,433 x DRG Weight",45689,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,279286,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,MS-DRG,,,,,,,,inpatient,,,173438.38,21736,,,21736,Other,150% of Medicare + 9.63% HCRA Surcharge,13217.82,,,13217.82,Other,Medicare IPPS methodology,36894,,"25,728 x DRG weight",36894,Other,base rate x DRG weight,33204,,"23,155 x DRG weight",33204,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,86719,50,,86719,Percent of Total Billed Charges,50% of Charges,41724,,"29,096 x DRG Weight",41724,Other,base rate x DRG weight,32212,,"22,463 x DRG Weight",32212,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,37895,,"26,426 x DRG Weight",37895,Other,base rate x DRG weight,55652,,"38,809 x DRG Weight",55652,Other,base rate x DRG weight,55652,,"38,809 x DRG Weight",55652,Other,base rate x DRG weight,37895,,"26,426 x DRG Weight",37895,Other,base rate x DRG weight,55652,,"38,809 x DRG Weight",55652,Other,base rate x DRG weight,50751,,"35,391 x DRG Weight",50751,Other,base rate x DRG weight,121407,70,,121407,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,36160,,"25,216 X DRG Weight",36160,Other,Base Weight X DRG Weight,32545,,"22,695 X DRG Weight",32545,Other,Base Weight X DRG Weight,36160,,"25,216 X DRG Weight",36160,Other,Base Rate x DRG Weight ,30735,,"21,433 x DRG Weight",30735,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,121407,
ARTHROSCOPY,509,MS-DRG,,,,,,,,inpatient,,,173438.38,20729,,,20729,Other,150% of Medicare + 9.63% HCRA Surcharge,12605.47,,,12605.47,Other,Medicare IPPS methodology,35147,,"25,728 x DRG weight",35147,Other,base rate x DRG weight,31632,,"23,155 x DRG weight",31632,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,86719,50,,86719,Percent of Total Billed Charges,50% of Charges,39748,,"29,096 x DRG Weight",39748,Other,base rate x DRG weight,30687,,"22,463 x DRG Weight",30687,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,36101,,"26,426 x DRG Weight",36101,Other,base rate x DRG weight,53017,,"38,809 x DRG Weight",53017,Other,base rate x DRG weight,53017,,"38,809 x DRG Weight",53017,Other,base rate x DRG weight,36101,,"26,426 x DRG Weight",36101,Other,base rate x DRG weight,53017,,"38,809 x DRG Weight",53017,Other,base rate x DRG weight,48348,,"35,391 x DRG Weight",48348,Other,base rate x DRG weight,121407,70,,121407,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,34448,,"25,216 X DRG Weight",34448,Other,Base Weight X DRG Weight,31004,,"22,695 X DRG Weight",31004,Other,Base Weight X DRG Weight,34448,,"25,216 X DRG Weight",34448,Other,Base Rate x DRG Weight ,29280,,"21,433 x DRG Weight",29280,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,121407,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,,inpatient,,,318283.56,40817,,,40817,Other,150% of Medicare + 9.63% HCRA Surcharge,24821,,,24821,Other,Medicare IPPS methodology,69996,,"25,728 x DRG weight",69996,Other,base rate x DRG weight,62995,,"23,155 x DRG weight",62995,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,159142,50,,159142,Percent of Total Billed Charges,50% of Charges,79159,,"29,096 x DRG Weight",79159,Other,base rate x DRG weight,61113,,"22,463 x DRG Weight",61113,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,71895,,"26,426 x DRG Weight",71895,Other,base rate x DRG weight,105584,,"38,809 x DRG Weight",105584,Other,base rate x DRG weight,105584,,"38,809 x DRG Weight",105584,Other,base rate x DRG weight,71895,,"26,426 x DRG Weight",71895,Other,base rate x DRG weight,105584,,"38,809 x DRG Weight",105584,Other,base rate x DRG weight,96285,,"35,391 x DRG Weight",96285,Other,base rate x DRG weight,222798,70,,222798,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,68603,,"25,216 X DRG Weight",68603,Other,Base Weight X DRG Weight,61744,,"22,695 X DRG Weight",61744,Other,Base Weight X DRG Weight,68603,,"25,216 X DRG Weight",68603,Other,Base Rate x DRG Weight ,58311,,"21,433 x DRG Weight",58311,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,222798,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,,inpatient,,,247003.25,30038,,,30038,Other,150% of Medicare + 9.63% HCRA Surcharge,18266.37,,,18266.37,Other,Medicare IPPS methodology,51296,,"25,728 x DRG weight",51296,Other,base rate x DRG weight,46166,,"23,155 x DRG weight",46166,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,123502,50,,123502,Percent of Total Billed Charges,50% of Charges,58012,,"29,096 x DRG Weight",58012,Other,base rate x DRG weight,44787,,"22,463 x DRG Weight",44787,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,52688,,"26,426 x DRG Weight",52688,Other,base rate x DRG weight,77377,,"38,809 x DRG Weight",77377,Other,base rate x DRG weight,77377,,"38,809 x DRG Weight",77377,Other,base rate x DRG weight,52688,,"26,426 x DRG Weight",52688,Other,base rate x DRG weight,77377,,"38,809 x DRG Weight",77377,Other,base rate x DRG weight,70563,,"35,391 x DRG Weight",70563,Other,base rate x DRG weight,172902,70,,172902,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,50276,,"25,216 X DRG Weight",50276,Other,Base Weight X DRG Weight,45249,,"22,695 X DRG Weight",45249,Other,Base Weight X DRG Weight,50276,,"25,216 X DRG Weight",50276,Other,Base Rate x DRG Weight ,42733,,"21,433 x DRG Weight",42733,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,172902,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,MS-DRG,,,,,,,,inpatient,,,160689.07,24403,,,24403,Other,150% of Medicare + 9.63% HCRA Surcharge,14839.34,,,14839.34,Other,Medicare IPPS methodology,41520,,"25,728 x DRG weight",41520,Other,base rate x DRG weight,37368,,"23,155 x DRG weight",37368,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,80345,50,,80345,Percent of Total Billed Charges,50% of Charges,46955,,"29,096 x DRG Weight",46955,Other,base rate x DRG weight,36251,,"22,463 x DRG Weight",36251,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,42646,,"26,426 x DRG Weight",42646,Other,base rate x DRG weight,62630,,"38,809 x DRG Weight",62630,Other,base rate x DRG weight,62630,,"38,809 x DRG Weight",62630,Other,base rate x DRG weight,42646,,"26,426 x DRG Weight",42646,Other,base rate x DRG weight,62630,,"38,809 x DRG Weight",62630,Other,base rate x DRG weight,57114,,"35,391 x DRG Weight",57114,Other,base rate x DRG weight,112482,70,,112482,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40694,,"25,216 X DRG Weight",40694,Other,Base Weight X DRG Weight,36625,,"22,695 X DRG Weight",36625,Other,Base Weight X DRG Weight,40694,,"25,216 X DRG Weight",40694,Other,Base Rate x DRG Weight ,34589,,"21,433 x DRG Weight",34589,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,112482,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,,inpatient,,,192311.1,24509,,,24509,Other,150% of Medicare + 9.63% HCRA Surcharge,14904.28,,,14904.28,Other,Medicare IPPS methodology,41705,,"25,728 x DRG weight",41705,Other,base rate x DRG weight,37534,,"23,155 x DRG weight",37534,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,96156,50,,96156,Percent of Total Billed Charges,50% of Charges,47165,,"29,096 x DRG Weight",47165,Other,base rate x DRG weight,36413,,"22,463 x DRG Weight",36413,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,42837,,"26,426 x DRG Weight",42837,Other,base rate x DRG weight,62909,,"38,809 x DRG Weight",62909,Other,base rate x DRG weight,62909,,"38,809 x DRG Weight",62909,Other,base rate x DRG weight,42837,,"26,426 x DRG Weight",42837,Other,base rate x DRG weight,62909,,"38,809 x DRG Weight",62909,Other,base rate x DRG weight,57369,,"35,391 x DRG Weight",57369,Other,base rate x DRG weight,134618,70,,134618,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40875,,"25,216 X DRG Weight",40875,Other,Base Weight X DRG Weight,36789,,"22,695 X DRG Weight",36789,Other,Base Weight X DRG Weight,40875,,"25,216 X DRG Weight",40875,Other,Base Rate x DRG Weight ,34743,,"21,433 x DRG Weight",34743,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,134618,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,,inpatient,,,129155.97,15915,,,15915,Other,150% of Medicare + 9.63% HCRA Surcharge,9678.07,,,9678.07,Other,Medicare IPPS methodology,26796,,"25,728 x DRG weight",26796,Other,base rate x DRG weight,24116,,"23,155 x DRG weight",24116,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,64578,50,,64578,Percent of Total Billed Charges,50% of Charges,30303,,"29,096 x DRG Weight",30303,Other,base rate x DRG weight,23395,,"22,463 x DRG Weight",23395,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,27523,,"26,426 x DRG Weight",27523,Other,base rate x DRG weight,40420,,"38,809 x DRG Weight",40420,Other,base rate x DRG weight,40420,,"38,809 x DRG Weight",40420,Other,base rate x DRG weight,27523,,"26,426 x DRG Weight",27523,Other,base rate x DRG weight,40420,,"38,809 x DRG Weight",40420,Other,base rate x DRG weight,36860,,"35,391 x DRG Weight",36860,Other,base rate x DRG weight,90409,70,,90409,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,26262,,"25,216 X DRG Weight",26262,Other,Base Weight X DRG Weight,23637,,"22,695 X DRG Weight",23637,Other,Base Weight X DRG Weight,26262,,"25,216 X DRG Weight",26262,Other,Base Rate x DRG Weight ,22322,,"21,433 x DRG Weight",22322,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,90409,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,,inpatient,,,390024.67,47356,,,47356,Other,150% of Medicare + 9.63% HCRA Surcharge,28797.24,,,28797.24,Other,Medicare IPPS methodology,81339,,"25,728 x DRG weight",81339,Other,base rate x DRG weight,73205,,"23,155 x DRG weight",73205,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,195012,50,,195012,Percent of Total Billed Charges,50% of Charges,91987,,"29,096 x DRG Weight",91987,Other,base rate x DRG weight,71017,,"22,463 x DRG Weight",71017,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,83546,,"26,426 x DRG Weight",83546,Other,base rate x DRG weight,122695,,"38,809 x DRG Weight",122695,Other,base rate x DRG weight,122695,,"38,809 x DRG Weight",122695,Other,base rate x DRG weight,83546,,"26,426 x DRG Weight",83546,Other,base rate x DRG weight,122695,,"38,809 x DRG Weight",122695,Other,base rate x DRG weight,111889,,"35,391 x DRG Weight",111889,Other,base rate x DRG weight,273017,70,,273017,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,79720,,"25,216 X DRG Weight",79720,Other,Base Weight X DRG Weight,71750,,"22,695 X DRG Weight",71750,Other,Base Weight X DRG Weight,79720,,"25,216 X DRG Weight",79720,Other,Base Rate x DRG Weight ,67760,,"21,433 x DRG Weight",67760,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,273017,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,,inpatient,,,265776.1,30735,,,30735,Other,150% of Medicare + 9.63% HCRA Surcharge,18690.23,,,18690.23,Other,Medicare IPPS methodology,52506,,"25,728 x DRG weight",52506,Other,base rate x DRG weight,47255,,"23,155 x DRG weight",47255,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,132888,50,,132888,Percent of Total Billed Charges,50% of Charges,59379,,"29,096 x DRG Weight",59379,Other,base rate x DRG weight,45842,,"22,463 x DRG Weight",45842,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,53930,,"26,426 x DRG Weight",53930,Other,base rate x DRG weight,79201,,"38,809 x DRG Weight",79201,Other,base rate x DRG weight,79201,,"38,809 x DRG Weight",79201,Other,base rate x DRG weight,53930,,"26,426 x DRG Weight",53930,Other,base rate x DRG weight,79201,,"38,809 x DRG Weight",79201,Other,base rate x DRG weight,72226,,"35,391 x DRG Weight",72226,Other,base rate x DRG weight,186043,70,,186043,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,51461,,"25,216 X DRG Weight",51461,Other,Base Weight X DRG Weight,46316,,"22,695 X DRG Weight",46316,Other,Base Weight X DRG Weight,51461,,"25,216 X DRG Weight",51461,Other,Base Rate x DRG Weight ,43740,,"21,433 x DRG Weight",43740,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,186043,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,,,,inpatient,,,202936.2,22632,,,22632,Other,150% of Medicare + 9.63% HCRA Surcharge,13762.54,,,13762.54,Other,Medicare IPPS methodology,38448,,"25,728 x DRG weight",38448,Other,base rate x DRG weight,34603,,"23,155 x DRG weight",34603,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,101468,50,,101468,Percent of Total Billed Charges,50% of Charges,43481,,"29,096 x DRG Weight",43481,Other,base rate x DRG weight,33569,,"22,463 x DRG Weight",33569,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39491,,"26,426 x DRG Weight",39491,Other,base rate x DRG weight,57996,,"38,809 x DRG Weight",57996,Other,base rate x DRG weight,57996,,"38,809 x DRG Weight",57996,Other,base rate x DRG weight,39491,,"26,426 x DRG Weight",39491,Other,base rate x DRG weight,57996,,"38,809 x DRG Weight",57996,Other,base rate x DRG weight,52888,,"35,391 x DRG Weight",52888,Other,base rate x DRG weight,142055,70,,142055,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37683,,"25,216 X DRG Weight",37683,Other,Base Weight X DRG Weight,33915,,"22,695 X DRG Weight",33915,Other,Base Weight X DRG Weight,37683,,"25,216 X DRG Weight",37683,Other,Base Rate x DRG Weight ,32029,,"21,433 x DRG Weight",32029,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,142055,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,,inpatient,,,405596.54,54627,,,54627,Other,150% of Medicare + 9.63% HCRA Surcharge,33219.01,,,33219.01,Other,Medicare IPPS methodology,93954,,"25,728 x DRG weight",93954,Other,base rate x DRG weight,84557,,"23,155 x DRG weight",84557,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,202798,50,,202798,Percent of Total Billed Charges,50% of Charges,106253,,"29,096 x DRG Weight",106253,Other,base rate x DRG weight,82030,,"22,463 x DRG Weight",82030,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,96502,,"26,426 x DRG Weight",96502,Other,base rate x DRG weight,141723,,"38,809 x DRG Weight",141723,Other,base rate x DRG weight,141723,,"38,809 x DRG Weight",141723,Other,base rate x DRG weight,96502,,"26,426 x DRG Weight",96502,Other,base rate x DRG weight,141723,,"38,809 x DRG Weight",141723,Other,base rate x DRG weight,129241,,"35,391 x DRG Weight",129241,Other,base rate x DRG weight,283918,70,,283918,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,92084,,"25,216 X DRG Weight",92084,Other,Base Weight X DRG Weight,82878,,"22,695 X DRG Weight",82878,Other,Base Weight X DRG Weight,92084,,"25,216 X DRG Weight",92084,Other,Base Rate x DRG Weight ,78269,,"21,433 x DRG Weight",78269,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,283918,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,,inpatient,,,306057.09,29664,,,29664,Other,150% of Medicare + 9.63% HCRA Surcharge,18039.1,,,18039.1,Other,Medicare IPPS methodology,50648,,"25,728 x DRG weight",50648,Other,base rate x DRG weight,45583,,"23,155 x DRG weight",45583,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,153029,50,,153029,Percent of Total Billed Charges,50% of Charges,57278,,"29,096 x DRG Weight",57278,Other,base rate x DRG weight,44221,,"22,463 x DRG Weight",44221,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,52022,,"26,426 x DRG Weight",52022,Other,base rate x DRG weight,76399,,"38,809 x DRG Weight",76399,Other,base rate x DRG weight,76399,,"38,809 x DRG Weight",76399,Other,base rate x DRG weight,52022,,"26,426 x DRG Weight",52022,Other,base rate x DRG weight,76399,,"38,809 x DRG Weight",76399,Other,base rate x DRG weight,69671,,"35,391 x DRG Weight",69671,Other,base rate x DRG weight,214240,70,,214240,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,49640,,"25,216 X DRG Weight",49640,Other,Base Weight X DRG Weight,44677,,"22,695 X DRG Weight",44677,Other,Base Weight X DRG Weight,49640,,"25,216 X DRG Weight",49640,Other,Base Rate x DRG Weight ,42193,,"21,433 x DRG Weight",42193,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,214240,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,,inpatient,,,189873.17,21699,,,21699,Other,150% of Medicare + 9.63% HCRA Surcharge,13195.27,,,13195.27,Other,Medicare IPPS methodology,36830,,"25,728 x DRG weight",36830,Other,base rate x DRG weight,33146,,"23,155 x DRG weight",33146,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,94937,50,,94937,Percent of Total Billed Charges,50% of Charges,41651,,"29,096 x DRG Weight",41651,Other,base rate x DRG weight,32156,,"22,463 x DRG Weight",32156,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,37829,,"26,426 x DRG Weight",37829,Other,base rate x DRG weight,55555,,"38,809 x DRG Weight",55555,Other,base rate x DRG weight,55555,,"38,809 x DRG Weight",55555,Other,base rate x DRG weight,37829,,"26,426 x DRG Weight",37829,Other,base rate x DRG weight,55555,,"38,809 x DRG Weight",55555,Other,base rate x DRG weight,50662,,"35,391 x DRG Weight",50662,Other,base rate x DRG weight,132911,70,,132911,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,36097,,"25,216 X DRG Weight",36097,Other,Base Weight X DRG Weight,32488,,"22,695 X DRG Weight",32488,Other,Base Weight X DRG Weight,36097,,"25,216 X DRG Weight",36097,Other,Base Rate x DRG Weight ,30681,,"21,433 x DRG Weight",30681,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,132911,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,,inpatient,,,352051.27,44874,,,44874,Other,150% of Medicare + 9.63% HCRA Surcharge,27288.45,,,27288.45,Other,Medicare IPPS methodology,77035,,"25,728 x DRG weight",77035,Other,base rate x DRG weight,69331,,"23,155 x DRG weight",69331,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,176026,50,,176026,Percent of Total Billed Charges,50% of Charges,87119,,"29,096 x DRG Weight",87119,Other,base rate x DRG weight,67259,,"22,463 x DRG Weight",67259,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,79125,,"26,426 x DRG Weight",79125,Other,base rate x DRG weight,116202,,"38,809 x DRG Weight",116202,Other,base rate x DRG weight,116202,,"38,809 x DRG Weight",116202,Other,base rate x DRG weight,79125,,"26,426 x DRG Weight",79125,Other,base rate x DRG weight,116202,,"38,809 x DRG Weight",116202,Other,base rate x DRG weight,105968,,"35,391 x DRG Weight",105968,Other,base rate x DRG weight,246436,70,,246436,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,75502,,"25,216 X DRG Weight",75502,Other,Base Weight X DRG Weight,67953,,"22,695 X DRG Weight",67953,Other,Base Weight X DRG Weight,75502,,"25,216 X DRG Weight",75502,Other,Base Rate x DRG Weight ,64175,,"21,433 x DRG Weight",64175,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,246436,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,,inpatient,,,229904.83,31794,,,31794,Other,150% of Medicare + 9.63% HCRA Surcharge,19334.15,,,19334.15,Other,Medicare IPPS methodology,54343,,"25,728 x DRG weight",54343,Other,base rate x DRG weight,48908,,"23,155 x DRG weight",48908,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,114952,50,,114952,Percent of Total Billed Charges,50% of Charges,61457,,"29,096 x DRG Weight",61457,Other,base rate x DRG weight,47446,,"22,463 x DRG Weight",47446,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,55817,,"26,426 x DRG Weight",55817,Other,base rate x DRG weight,81972,,"38,809 x DRG Weight",81972,Other,base rate x DRG weight,81972,,"38,809 x DRG Weight",81972,Other,base rate x DRG weight,55817,,"26,426 x DRG Weight",55817,Other,base rate x DRG weight,81972,,"38,809 x DRG Weight",81972,Other,base rate x DRG weight,74753,,"35,391 x DRG Weight",74753,Other,base rate x DRG weight,160933,70,,160933,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,53261,,"25,216 X DRG Weight",53261,Other,Base Weight X DRG Weight,47936,,"22,695 X DRG Weight",47936,Other,Base Weight X DRG Weight,53261,,"25,216 X DRG Weight",53261,Other,Base Rate x DRG Weight ,45271,,"21,433 x DRG Weight",45271,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,160933,
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,,inpatient,,,247711.73,24664,,,24664,Other,150% of Medicare + 9.63% HCRA Surcharge,14998.07,,,14998.07,Other,Medicare IPPS methodology,41973,,"25,728 x DRG weight",41973,Other,base rate x DRG weight,37775,,"23,155 x DRG weight",37775,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,123856,50,,123856,Percent of Total Billed Charges,50% of Charges,47467,,"29,096 x DRG Weight",47467,Other,base rate x DRG weight,36646,,"22,463 x DRG Weight",36646,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,43111,,"26,426 x DRG Weight",43111,Other,base rate x DRG weight,63313,,"38,809 x DRG Weight",63313,Other,base rate x DRG weight,63313,,"38,809 x DRG Weight",63313,Other,base rate x DRG weight,43111,,"26,426 x DRG Weight",43111,Other,base rate x DRG weight,63313,,"38,809 x DRG Weight",63313,Other,base rate x DRG weight,57737,,"35,391 x DRG Weight",57737,Other,base rate x DRG weight,173398,70,,173398,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,41137,,"25,216 X DRG Weight",41137,Other,Base Weight X DRG Weight,37025,,"22,695 X DRG Weight",37025,Other,Base Weight X DRG Weight,41137,,"25,216 X DRG Weight",41137,Other,Base Rate x DRG Weight ,34966,,"21,433 x DRG Weight",34966,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,173398,
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,,inpatient,,,99141.01,12482,,,12482,Other,150% of Medicare + 9.63% HCRA Surcharge,7590.29,,,7590.29,Other,Medicare IPPS methodology,20840,,"25,728 x DRG weight",20840,Other,base rate x DRG weight,18756,,"23,155 x DRG weight",18756,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,49571,50,,49571,Percent of Total Billed Charges,50% of Charges,23568,,"29,096 x DRG Weight",23568,Other,base rate x DRG weight,18195,,"22,463 x DRG Weight",18195,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21405,,"26,426 x DRG Weight",21405,Other,base rate x DRG weight,31435,,"38,809 x DRG Weight",31435,Other,base rate x DRG weight,31435,,"38,809 x DRG Weight",31435,Other,base rate x DRG weight,21405,,"26,426 x DRG Weight",21405,Other,base rate x DRG weight,31435,,"38,809 x DRG Weight",31435,Other,base rate x DRG weight,28667,,"35,391 x DRG Weight",28667,Other,base rate x DRG weight,69399,70,,69399,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20425,,"25,216 X DRG Weight",20425,Other,Base Weight X DRG Weight,18383,,"22,695 X DRG Weight",18383,Other,Base Weight X DRG Weight,20425,,"25,216 X DRG Weight",20425,Other,Base Rate x DRG Weight ,17361,,"21,433 x DRG Weight",17361,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,69399,
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,,inpatient,,,210494.22,19700,,,19700,Other,150% of Medicare + 9.63% HCRA Surcharge,11979.58,,,11979.58,Other,Medicare IPPS methodology,33361,,"25,728 x DRG weight",33361,Other,base rate x DRG weight,30025,,"23,155 x DRG weight",30025,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,105247,50,,105247,Percent of Total Billed Charges,50% of Charges,37729,,"29,096 x DRG Weight",37729,Other,base rate x DRG weight,29128,,"22,463 x DRG Weight",29128,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,34267,,"26,426 x DRG Weight",34267,Other,base rate x DRG weight,50324,,"38,809 x DRG Weight",50324,Other,base rate x DRG weight,50324,,"38,809 x DRG Weight",50324,Other,base rate x DRG weight,34267,,"26,426 x DRG Weight",34267,Other,base rate x DRG weight,50324,,"38,809 x DRG Weight",50324,Other,base rate x DRG weight,45892,,"35,391 x DRG Weight",45892,Other,base rate x DRG weight,147346,70,,147346,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32698,,"25,216 X DRG Weight",32698,Other,Base Weight X DRG Weight,29429,,"22,695 X DRG Weight",29429,Other,Base Weight X DRG Weight,32698,,"25,216 X DRG Weight",32698,Other,Base Rate x DRG Weight ,27792,,"21,433 x DRG Weight",27792,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,147346,
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,,inpatient,,,125096.21,12142,,,12142,Other,150% of Medicare + 9.63% HCRA Surcharge,7383.77,,,7383.77,Other,Medicare IPPS methodology,20251,,"25,728 x DRG weight",20251,Other,base rate x DRG weight,18225,,"23,155 x DRG weight",18225,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,62548,50,,62548,Percent of Total Billed Charges,50% of Charges,22901,,"29,096 x DRG Weight",22901,Other,base rate x DRG weight,17681,,"22,463 x DRG Weight",17681,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,20800,,"26,426 x DRG Weight",20800,Other,base rate x DRG weight,30547,,"38,809 x DRG Weight",30547,Other,base rate x DRG weight,30547,,"38,809 x DRG Weight",30547,Other,base rate x DRG weight,20800,,"26,426 x DRG Weight",20800,Other,base rate x DRG weight,30547,,"38,809 x DRG Weight",30547,Other,base rate x DRG weight,27856,,"35,391 x DRG Weight",27856,Other,base rate x DRG weight,87567,70,,87567,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19848,,"25,216 X DRG Weight",19848,Other,Base Weight X DRG Weight,17863,,"22,695 X DRG Weight",17863,Other,Base Weight X DRG Weight,19848,,"25,216 X DRG Weight",19848,Other,Base Rate x DRG Weight ,16870,,"21,433 x DRG Weight",16870,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,87567,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,,inpatient,,,413970,14810,,,14810,Other,150% of Medicare + 9.63% HCRA Surcharge,9006.19,,,9006.19,Other,Medicare IPPS methodology,24879,,"25,728 x DRG weight",24879,Other,base rate x DRG weight,22391,,"23,155 x DRG weight",22391,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,206985,50,,206985,Percent of Total Billed Charges,50% of Charges,28136,,"29,096 x DRG Weight",28136,Other,base rate x DRG weight,21722,,"22,463 x DRG Weight",21722,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,25554,,"26,426 x DRG Weight",25554,Other,base rate x DRG weight,37528,,"38,809 x DRG Weight",37528,Other,base rate x DRG weight,37528,,"38,809 x DRG Weight",37528,Other,base rate x DRG weight,25554,,"26,426 x DRG Weight",25554,Other,base rate x DRG weight,37528,,"38,809 x DRG Weight",37528,Other,base rate x DRG weight,34223,,"35,391 x DRG Weight",34223,Other,base rate x DRG weight,289779,70,,289779,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24384,,"25,216 X DRG Weight",24384,Other,Base Weight X DRG Weight,21946,,"22,695 X DRG Weight",21946,Other,Base Weight X DRG Weight,24384,,"25,216 X DRG Weight",24384,Other,Base Rate x DRG Weight ,20726,,"21,433 x DRG Weight",20726,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,289779,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,MS-DRG,,,,,,,,inpatient,,,30498,10985,,,10985,Other,150% of Medicare + 9.63% HCRA Surcharge,6680.32,,,6680.32,Other,Medicare IPPS methodology,18244,,"25,728 x DRG weight",18244,Other,base rate x DRG weight,16419,,"23,155 x DRG weight",16419,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,15249,50,,15249,Percent of Total Billed Charges,50% of Charges,20632,,"29,096 x DRG Weight",20632,Other,base rate x DRG weight,15929,,"22,463 x DRG Weight",15929,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18739,,"26,426 x DRG Weight",18739,Other,base rate x DRG weight,27519,,"38,809 x DRG Weight",27519,Other,base rate x DRG weight,27519,,"38,809 x DRG Weight",27519,Other,base rate x DRG weight,18739,,"26,426 x DRG Weight",18739,Other,base rate x DRG weight,27519,,"38,809 x DRG Weight",27519,Other,base rate x DRG weight,25096,,"35,391 x DRG Weight",25096,Other,base rate x DRG weight,21349,70,,21349,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,17881,,"25,216 X DRG Weight",17881,Other,Base Weight X DRG Weight,16093,,"22,695 X DRG Weight",16093,Other,Base Weight X DRG Weight,17881,,"25,216 X DRG Weight",17881,Other,Base Rate x DRG Weight ,15198,,"21,433 x DRG Weight",15198,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,27519,
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,,inpatient,,,445794.23,29899,,,29899,Other,150% of Medicare + 9.63% HCRA Surcharge,18181.59,,,18181.59,Other,Medicare IPPS methodology,51055,,"25,728 x DRG weight",51055,Other,base rate x DRG weight,45949,,"23,155 x DRG weight",45949,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,222897,50,,222897,Percent of Total Billed Charges,50% of Charges,57738,,"29,096 x DRG Weight",57738,Other,base rate x DRG weight,44576,,"22,463 x DRG Weight",44576,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,52440,,"26,426 x DRG Weight",52440,Other,base rate x DRG weight,77013,,"38,809 x DRG Weight",77013,Other,base rate x DRG weight,77013,,"38,809 x DRG Weight",77013,Other,base rate x DRG weight,52440,,"26,426 x DRG Weight",52440,Other,base rate x DRG weight,77013,,"38,809 x DRG Weight",77013,Other,base rate x DRG weight,70230,,"35,391 x DRG Weight",70230,Other,base rate x DRG weight,312056,70,,312056,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,50039,,"25,216 X DRG Weight",50039,Other,Base Weight X DRG Weight,45036,,"22,695 X DRG Weight",45036,Other,Base Weight X DRG Weight,50039,,"25,216 X DRG Weight",50039,Other,Base Rate x DRG Weight ,42532,,"21,433 x DRG Weight",42532,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,312056,
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,,inpatient,,,161586.34,19722,,,19722,Other,150% of Medicare + 9.63% HCRA Surcharge,11993.11,,,11993.11,Other,Medicare IPPS methodology,33400,,"25,728 x DRG weight",33400,Other,base rate x DRG weight,30060,,"23,155 x DRG weight",30060,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,80793,50,,80793,Percent of Total Billed Charges,50% of Charges,37772,,"29,096 x DRG Weight",37772,Other,base rate x DRG weight,29161,,"22,463 x DRG Weight",29161,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,34306,,"26,426 x DRG Weight",34306,Other,base rate x DRG weight,50382,,"38,809 x DRG Weight",50382,Other,base rate x DRG weight,50382,,"38,809 x DRG Weight",50382,Other,base rate x DRG weight,34306,,"26,426 x DRG Weight",34306,Other,base rate x DRG weight,50382,,"38,809 x DRG Weight",50382,Other,base rate x DRG weight,45945,,"35,391 x DRG Weight",45945,Other,base rate x DRG weight,113110,70,,113110,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32735,,"25,216 X DRG Weight",32735,Other,Base Weight X DRG Weight,29463,,"22,695 X DRG Weight",29463,Other,Base Weight X DRG Weight,32735,,"25,216 X DRG Weight",32735,Other,Base Rate x DRG Weight ,27824,,"21,433 x DRG Weight",27824,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,113110,
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,,inpatient,,,95377.2,13192,,,13192,Other,150% of Medicare + 9.63% HCRA Surcharge,8022.27,,,8022.27,Other,Medicare IPPS methodology,22072,,"25,728 x DRG weight",22072,Other,base rate x DRG weight,19865,,"23,155 x DRG weight",19865,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,47689,50,,47689,Percent of Total Billed Charges,50% of Charges,24961,,"29,096 x DRG Weight",24961,Other,base rate x DRG weight,19271,,"22,463 x DRG Weight",19271,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,22671,,"26,426 x DRG Weight",22671,Other,base rate x DRG weight,33294,,"38,809 x DRG Weight",33294,Other,base rate x DRG weight,33294,,"38,809 x DRG Weight",33294,Other,base rate x DRG weight,22671,,"26,426 x DRG Weight",22671,Other,base rate x DRG weight,33294,,"38,809 x DRG Weight",33294,Other,base rate x DRG weight,30362,,"35,391 x DRG Weight",30362,Other,base rate x DRG weight,66764,70,,66764,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,21633,,"25,216 X DRG Weight",21633,Other,Base Weight X DRG Weight,19470,,"22,695 X DRG Weight",19470,Other,Base Weight X DRG Weight,21633,,"25,216 X DRG Weight",21633,Other,Base Rate x DRG Weight ,18387,,"21,433 x DRG Weight",18387,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,66764,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,,inpatient,,,295335.51,27515,,,27515,Other,150% of Medicare + 9.63% HCRA Surcharge,16732.32,,,16732.32,Other,Medicare IPPS methodology,46920,,"25,728 x DRG weight",46920,Other,base rate x DRG weight,42228,,"23,155 x DRG weight",42228,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,147668,50,,147668,Percent of Total Billed Charges,50% of Charges,53062,,"29,096 x DRG Weight",53062,Other,base rate x DRG weight,40966,,"22,463 x DRG Weight",40966,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,48193,,"26,426 x DRG Weight",48193,Other,base rate x DRG weight,70776,,"38,809 x DRG Weight",70776,Other,base rate x DRG weight,70776,,"38,809 x DRG Weight",70776,Other,base rate x DRG weight,48193,,"26,426 x DRG Weight",48193,Other,base rate x DRG weight,70776,,"38,809 x DRG Weight",70776,Other,base rate x DRG weight,64543,,"35,391 x DRG Weight",64543,Other,base rate x DRG weight,206735,70,,206735,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,45986,,"25,216 X DRG Weight",45986,Other,Base Weight X DRG Weight,41389,,"22,695 X DRG Weight",41389,Other,Base Weight X DRG Weight,45986,,"25,216 X DRG Weight",45986,Other,Base Rate x DRG Weight ,39087,,"21,433 x DRG Weight",39087,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,206735,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,,inpatient,,,305965.02,16645,,,16645,Other,150% of Medicare + 9.63% HCRA Surcharge,10121.78,,,10121.78,Other,Medicare IPPS methodology,28062,,"25,728 x DRG weight",28062,Other,base rate x DRG weight,25255,,"23,155 x DRG weight",25255,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,152983,50,,152983,Percent of Total Billed Charges,50% of Charges,31735,,"29,096 x DRG Weight",31735,Other,base rate x DRG weight,24500,,"22,463 x DRG Weight",24500,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28823,,"26,426 x DRG Weight",28823,Other,base rate x DRG weight,42329,,"38,809 x DRG Weight",42329,Other,base rate x DRG weight,42329,,"38,809 x DRG Weight",42329,Other,base rate x DRG weight,28823,,"26,426 x DRG Weight",28823,Other,base rate x DRG weight,42329,,"38,809 x DRG Weight",42329,Other,base rate x DRG weight,38601,,"35,391 x DRG Weight",38601,Other,base rate x DRG weight,214176,70,,214176,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27503,,"25,216 X DRG Weight",27503,Other,Base Weight X DRG Weight,24753,,"22,695 X DRG Weight",24753,Other,Base Weight X DRG Weight,27503,,"25,216 X DRG Weight",27503,Other,Base Rate x DRG Weight ,23377,,"21,433 x DRG Weight",23377,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,214176,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,,inpatient,,,137580.85,11852,,,11852,Other,150% of Medicare + 9.63% HCRA Surcharge,7207,,,7207,Other,Medicare IPPS methodology,19746,,"25,728 x DRG weight",19746,Other,base rate x DRG weight,17771,,"23,155 x DRG weight",17771,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,68790,50,,68790,Percent of Total Billed Charges,50% of Charges,22331,,"29,096 x DRG Weight",22331,Other,base rate x DRG weight,17240,,"22,463 x DRG Weight",17240,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,20282,,"26,426 x DRG Weight",20282,Other,base rate x DRG weight,29786,,"38,809 x DRG Weight",29786,Other,base rate x DRG weight,29786,,"38,809 x DRG Weight",29786,Other,base rate x DRG weight,20282,,"26,426 x DRG Weight",20282,Other,base rate x DRG weight,29786,,"38,809 x DRG Weight",29786,Other,base rate x DRG weight,27163,,"35,391 x DRG Weight",27163,Other,base rate x DRG weight,96307,70,,96307,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19353,,"25,216 X DRG Weight",19353,Other,Base Weight X DRG Weight,17418,,"22,695 X DRG Weight",17418,Other,Base Weight X DRG Weight,19353,,"25,216 X DRG Weight",19353,Other,Base Rate x DRG Weight ,16450,,"21,433 x DRG Weight",16450,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,96307,
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,,inpatient,,,402996.07,37444,,,37444,Other,150% of Medicare + 9.63% HCRA Surcharge,22770.19,,,22770.19,Other,Medicare IPPS methodology,64145,,"25,728 x DRG weight",64145,Other,base rate x DRG weight,57730,,"23,155 x DRG weight",57730,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,201498,50,,201498,Percent of Total Billed Charges,50% of Charges,72542,,"29,096 x DRG Weight",72542,Other,base rate x DRG weight,56005,,"22,463 x DRG Weight",56005,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,65885,,"26,426 x DRG Weight",65885,Other,base rate x DRG weight,96759,,"38,809 x DRG Weight",96759,Other,base rate x DRG weight,96759,,"38,809 x DRG Weight",96759,Other,base rate x DRG weight,65885,,"26,426 x DRG Weight",65885,Other,base rate x DRG weight,96759,,"38,809 x DRG Weight",96759,Other,base rate x DRG weight,88237,,"35,391 x DRG Weight",88237,Other,base rate x DRG weight,282097,70,,282097,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,62869,,"25,216 X DRG Weight",62869,Other,Base Weight X DRG Weight,56583,,"22,695 X DRG Weight",56583,Other,Base Weight X DRG Weight,62869,,"25,216 X DRG Weight",62869,Other,Base Rate x DRG Weight ,53437,,"21,433 x DRG Weight",53437,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,282097,
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,,inpatient,,,171715.72,18255,,,18255,Other,150% of Medicare + 9.63% HCRA Surcharge,11101.18,,,11101.18,Other,Medicare IPPS methodology,30856,,"25,728 x DRG weight",30856,Other,base rate x DRG weight,27770,,"23,155 x DRG weight",27770,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,85858,50,,85858,Percent of Total Billed Charges,50% of Charges,34895,,"29,096 x DRG Weight",34895,Other,base rate x DRG weight,26940,,"22,463 x DRG Weight",26940,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31693,,"26,426 x DRG Weight",31693,Other,base rate x DRG weight,46544,,"38,809 x DRG Weight",46544,Other,base rate x DRG weight,46544,,"38,809 x DRG Weight",46544,Other,base rate x DRG weight,31693,,"26,426 x DRG Weight",31693,Other,base rate x DRG weight,46544,,"38,809 x DRG Weight",46544,Other,base rate x DRG weight,42444,,"35,391 x DRG Weight",42444,Other,base rate x DRG weight,120201,70,,120201,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,30242,,"25,216 X DRG Weight",30242,Other,Base Weight X DRG Weight,27218,,"22,695 X DRG Weight",27218,Other,Base Weight X DRG Weight,30242,,"25,216 X DRG Weight",30242,Other,Base Rate x DRG Weight ,25705,,"21,433 x DRG Weight",25705,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,120201,
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,,inpatient,,,119033.23,12679,,,12679,Other,150% of Medicare + 9.63% HCRA Surcharge,7710.23,,,7710.23,Other,Medicare IPPS methodology,21182,,"25,728 x DRG weight",21182,Other,base rate x DRG weight,19064,,"23,155 x DRG weight",19064,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,59517,50,,59517,Percent of Total Billed Charges,50% of Charges,23955,,"29,096 x DRG Weight",23955,Other,base rate x DRG weight,18494,,"22,463 x DRG Weight",18494,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21757,,"26,426 x DRG Weight",21757,Other,base rate x DRG weight,31951,,"38,809 x DRG Weight",31951,Other,base rate x DRG weight,31951,,"38,809 x DRG Weight",31951,Other,base rate x DRG weight,21757,,"26,426 x DRG Weight",21757,Other,base rate x DRG weight,31951,,"38,809 x DRG Weight",31951,Other,base rate x DRG weight,29137,,"35,391 x DRG Weight",29137,Other,base rate x DRG weight,83323,70,,83323,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20760,,"25,216 X DRG Weight",20760,Other,Base Weight X DRG Weight,18685,,"22,695 X DRG Weight",18685,Other,Base Weight X DRG Weight,20760,,"25,216 X DRG Weight",20760,Other,Base Rate x DRG Weight ,17646,,"21,433 x DRG Weight",17646,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,83323,
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,,inpatient,,,145414.91,29386,,,29386,Other,150% of Medicare + 9.63% HCRA Surcharge,17869.55,,,17869.55,Other,Medicare IPPS methodology,50164,,"25,728 x DRG weight",50164,Other,base rate x DRG weight,45148,,"23,155 x DRG weight",45148,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,72707,50,,72707,Percent of Total Billed Charges,50% of Charges,56731,,"29,096 x DRG Weight",56731,Other,base rate x DRG weight,43798,,"22,463 x DRG Weight",43798,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,51525,,"26,426 x DRG Weight",51525,Other,base rate x DRG weight,75670,,"38,809 x DRG Weight",75670,Other,base rate x DRG weight,75670,,"38,809 x DRG Weight",75670,Other,base rate x DRG weight,51525,,"26,426 x DRG Weight",51525,Other,base rate x DRG weight,75670,,"38,809 x DRG Weight",75670,Other,base rate x DRG weight,69005,,"35,391 x DRG Weight",69005,Other,base rate x DRG weight,101790,70,,101790,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,49166,,"25,216 X DRG Weight",49166,Other,Base Weight X DRG Weight,44251,,"22,695 X DRG Weight",44251,Other,Base Weight X DRG Weight,49166,,"25,216 X DRG Weight",49166,Other,Base Rate x DRG Weight ,41790,,"21,433 x DRG Weight",41790,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,101790,
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,,inpatient,,,153496.95,18358,,,18358,Other,150% of Medicare + 9.63% HCRA Surcharge,11163.41,,,11163.41,Other,Medicare IPPS methodology,31033,,"25,728 x DRG weight",31033,Other,base rate x DRG weight,27930,,"23,155 x DRG weight",27930,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,76748,50,,76748,Percent of Total Billed Charges,50% of Charges,35096,,"29,096 x DRG Weight",35096,Other,base rate x DRG weight,27095,,"22,463 x DRG Weight",27095,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31875,,"26,426 x DRG Weight",31875,Other,base rate x DRG weight,46811,,"38,809 x DRG Weight",46811,Other,base rate x DRG weight,46811,,"38,809 x DRG Weight",46811,Other,base rate x DRG weight,31875,,"26,426 x DRG Weight",31875,Other,base rate x DRG weight,46811,,"38,809 x DRG Weight",46811,Other,base rate x DRG weight,42689,,"35,391 x DRG Weight",42689,Other,base rate x DRG weight,107448,70,,107448,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,30416,,"25,216 X DRG Weight",30416,Other,Base Weight X DRG Weight,27375,,"22,695 X DRG Weight",27375,Other,Base Weight X DRG Weight,30416,,"25,216 X DRG Weight",30416,Other,Base Rate x DRG Weight ,25852,,"21,433 x DRG Weight",25852,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,107448,
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,MS-DRG,,,,,,,,inpatient,,,71104.5,14462,,,14462,Other,150% of Medicare + 9.63% HCRA Surcharge,8794.26,,,8794.26,Other,Medicare IPPS methodology,24274,,"25,728 x DRG weight",24274,Other,base rate x DRG weight,21847,,"23,155 x DRG weight",21847,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35552,50,,35552,Percent of Total Billed Charges,50% of Charges,27452,,"29,096 x DRG Weight",27452,Other,base rate x DRG weight,21194,,"22,463 x DRG Weight",21194,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,24933,,"26,426 x DRG Weight",24933,Other,base rate x DRG weight,36616,,"38,809 x DRG Weight",36616,Other,base rate x DRG weight,36616,,"38,809 x DRG Weight",36616,Other,base rate x DRG weight,24933,,"26,426 x DRG Weight",24933,Other,base rate x DRG weight,36616,,"38,809 x DRG Weight",36616,Other,base rate x DRG weight,33391,,"35,391 x DRG Weight",33391,Other,base rate x DRG weight,49773,70,,49773,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,23791,,"25,216 X DRG Weight",23791,Other,Base Weight X DRG Weight,21413,,"22,695 X DRG Weight",21413,Other,Base Weight X DRG Weight,23791,,"25,216 X DRG Weight",23791,Other,Base Rate x DRG Weight ,20222,,"21,433 x DRG Weight",20222,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,49773,
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,,inpatient,,,222008.27,25709,,,25709,Other,150% of Medicare + 9.63% HCRA Surcharge,15633.87,,,15633.87,Other,Medicare IPPS methodology,43786,,"25,728 x DRG weight",43786,Other,base rate x DRG weight,39407,,"23,155 x DRG weight",39407,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,111004,50,,111004,Percent of Total Billed Charges,50% of Charges,49518,,"29,096 x DRG Weight",49518,Other,base rate x DRG weight,38230,,"22,463 x DRG Weight",38230,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,44974,,"26,426 x DRG Weight",44974,Other,base rate x DRG weight,66049,,"38,809 x DRG Weight",66049,Other,base rate x DRG weight,66049,,"38,809 x DRG Weight",66049,Other,base rate x DRG weight,44974,,"26,426 x DRG Weight",44974,Other,base rate x DRG weight,66049,,"38,809 x DRG Weight",66049,Other,base rate x DRG weight,60232,,"35,391 x DRG Weight",60232,Other,base rate x DRG weight,155406,70,,155406,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,42915,,"25,216 X DRG Weight",42915,Other,Base Weight X DRG Weight,38625,,"22,695 X DRG Weight",38625,Other,Base Weight X DRG Weight,42915,,"25,216 X DRG Weight",42915,Other,Base Rate x DRG Weight ,36477,,"21,433 x DRG Weight",36477,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,155406,
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,,inpatient,,,149351.04,14800,,,14800,Other,150% of Medicare + 9.63% HCRA Surcharge,8999.88,,,8999.88,Other,Medicare IPPS methodology,24861,,"25,728 x DRG weight",24861,Other,base rate x DRG weight,22375,,"23,155 x DRG weight",22375,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,74676,50,,74676,Percent of Total Billed Charges,50% of Charges,28115,,"29,096 x DRG Weight",28115,Other,base rate x DRG weight,21706,,"22,463 x DRG Weight",21706,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,25535,,"26,426 x DRG Weight",25535,Other,base rate x DRG weight,37501,,"38,809 x DRG Weight",37501,Other,base rate x DRG weight,37501,,"38,809 x DRG Weight",37501,Other,base rate x DRG weight,25535,,"26,426 x DRG Weight",25535,Other,base rate x DRG weight,37501,,"38,809 x DRG Weight",37501,Other,base rate x DRG weight,34198,,"35,391 x DRG Weight",34198,Other,base rate x DRG weight,104546,70,,104546,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24366,,"25,216 X DRG Weight",24366,Other,Base Weight X DRG Weight,21930,,"22,695 X DRG Weight",21930,Other,Base Weight X DRG Weight,24366,,"25,216 X DRG Weight",24366,Other,Base Rate x DRG Weight ,20711,,"21,433 x DRG Weight",20711,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,104546,
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,,inpatient,,,154011.39,20513,,,20513,Other,150% of Medicare + 9.63% HCRA Surcharge,12473.8,,,12473.8,Other,Medicare IPPS methodology,34771,,"25,728 x DRG weight",34771,Other,base rate x DRG weight,31294,,"23,155 x DRG weight",31294,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,77006,50,,77006,Percent of Total Billed Charges,50% of Charges,39323,,"29,096 x DRG Weight",39323,Other,base rate x DRG weight,30359,,"22,463 x DRG Weight",30359,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,35715,,"26,426 x DRG Weight",35715,Other,base rate x DRG weight,52450,,"38,809 x DRG Weight",52450,Other,base rate x DRG weight,52450,,"38,809 x DRG Weight",52450,Other,base rate x DRG weight,35715,,"26,426 x DRG Weight",35715,Other,base rate x DRG weight,52450,,"38,809 x DRG Weight",52450,Other,base rate x DRG weight,47831,,"35,391 x DRG Weight",47831,Other,base rate x DRG weight,107808,70,,107808,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,34079,,"25,216 X DRG Weight",34079,Other,Base Weight X DRG Weight,30672,,"22,695 X DRG Weight",30672,Other,Base Weight X DRG Weight,34079,,"25,216 X DRG Weight",34079,Other,Base Rate x DRG Weight ,28967,,"21,433 x DRG Weight",28967,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,107808,
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,,inpatient,,,135978.72,12657,,,12657,Other,150% of Medicare + 9.63% HCRA Surcharge,7696.71,,,7696.71,Other,Medicare IPPS methodology,21143,,"25,728 x DRG weight",21143,Other,base rate x DRG weight,19029,,"23,155 x DRG weight",19029,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,67989,50,,67989,Percent of Total Billed Charges,50% of Charges,23911,,"29,096 x DRG Weight",23911,Other,base rate x DRG weight,18460,,"22,463 x DRG Weight",18460,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21717,,"26,426 x DRG Weight",21717,Other,base rate x DRG weight,31893,,"38,809 x DRG Weight",31893,Other,base rate x DRG weight,31893,,"38,809 x DRG Weight",31893,Other,base rate x DRG weight,21717,,"26,426 x DRG Weight",21717,Other,base rate x DRG weight,31893,,"38,809 x DRG Weight",31893,Other,base rate x DRG weight,29084,,"35,391 x DRG Weight",29084,Other,base rate x DRG weight,95185,70,,95185,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20723,,"25,216 X DRG Weight",20723,Other,Base Weight X DRG Weight,18651,,"22,695 X DRG Weight",18651,Other,Base Weight X DRG Weight,20723,,"25,216 X DRG Weight",20723,Other,Base Rate x DRG Weight ,17614,,"21,433 x DRG Weight",17614,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,95185,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,,inpatient,,,111419.12,21217,,,21217,Other,150% of Medicare + 9.63% HCRA Surcharge,12902.17,,,12902.17,Other,Medicare IPPS methodology,35993,,"25,728 x DRG weight",35993,Other,base rate x DRG weight,32394,,"23,155 x DRG weight",32394,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,55710,50,,55710,Percent of Total Billed Charges,50% of Charges,40705,,"29,096 x DRG Weight",40705,Other,base rate x DRG weight,31426,,"22,463 x DRG Weight",31426,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,36970,,"26,426 x DRG Weight",36970,Other,base rate x DRG weight,54294,,"38,809 x DRG Weight",54294,Other,base rate x DRG weight,54294,,"38,809 x DRG Weight",54294,Other,base rate x DRG weight,36970,,"26,426 x DRG Weight",36970,Other,base rate x DRG weight,54294,,"38,809 x DRG Weight",54294,Other,base rate x DRG weight,49512,,"35,391 x DRG Weight",49512,Other,base rate x DRG weight,77993,70,,77993,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35277,,"25,216 X DRG Weight",35277,Other,Base Weight X DRG Weight,31750,,"22,695 X DRG Weight",31750,Other,Base Weight X DRG Weight,35277,,"25,216 X DRG Weight",35277,Other,Base Rate x DRG Weight ,29985,,"21,433 x DRG Weight",29985,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,77993,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,,inpatient,,,114607.91,12695,,,12695,Other,150% of Medicare + 9.63% HCRA Surcharge,7720.15,,,7720.15,Other,Medicare IPPS methodology,21210,,"25,728 x DRG weight",21210,Other,base rate x DRG weight,19089,,"23,155 x DRG weight",19089,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,57304,50,,57304,Percent of Total Billed Charges,50% of Charges,23987,,"29,096 x DRG Weight",23987,Other,base rate x DRG weight,18518,,"22,463 x DRG Weight",18518,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21786,,"26,426 x DRG Weight",21786,Other,base rate x DRG weight,31994,,"38,809 x DRG Weight",31994,Other,base rate x DRG weight,31994,,"38,809 x DRG Weight",31994,Other,base rate x DRG weight,21786,,"26,426 x DRG Weight",21786,Other,base rate x DRG weight,31994,,"38,809 x DRG Weight",31994,Other,base rate x DRG weight,29176,,"35,391 x DRG Weight",29176,Other,base rate x DRG weight,80226,70,,80226,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20788,,"25,216 X DRG Weight",20788,Other,Base Weight X DRG Weight,18710,,"22,695 X DRG Weight",18710,Other,Base Weight X DRG Weight,20788,,"25,216 X DRG Weight",20788,Other,Base Rate x DRG Weight ,17669,,"21,433 x DRG Weight",17669,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,80226,
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,,inpatient,,,219778.64,23557,,,23557,Other,150% of Medicare + 9.63% HCRA Surcharge,14325.29,,,14325.29,Other,Medicare IPPS methodology,40053,,"25,728 x DRG weight",40053,Other,base rate x DRG weight,36048,,"23,155 x DRG weight",36048,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,109889,50,,109889,Percent of Total Billed Charges,50% of Charges,45297,,"29,096 x DRG Weight",45297,Other,base rate x DRG weight,34970,,"22,463 x DRG Weight",34970,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41140,,"26,426 x DRG Weight",41140,Other,base rate x DRG weight,60418,,"38,809 x DRG Weight",60418,Other,base rate x DRG weight,60418,,"38,809 x DRG Weight",60418,Other,base rate x DRG weight,41140,,"26,426 x DRG Weight",41140,Other,base rate x DRG weight,60418,,"38,809 x DRG Weight",60418,Other,base rate x DRG weight,55097,,"35,391 x DRG Weight",55097,Other,base rate x DRG weight,153845,70,,153845,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39256,,"25,216 X DRG Weight",39256,Other,Base Weight X DRG Weight,35332,,"22,695 X DRG Weight",35332,Other,Base Weight X DRG Weight,39256,,"25,216 X DRG Weight",39256,Other,Base Rate x DRG Weight ,33367,,"21,433 x DRG Weight",33367,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,153845,
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,,inpatient,,,88055.18,13496,,,13496,Other,150% of Medicare + 9.63% HCRA Surcharge,8207.15,,,8207.15,Other,Medicare IPPS methodology,22599,,"25,728 x DRG weight",22599,Other,base rate x DRG weight,20339,,"23,155 x DRG weight",20339,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,44028,50,,44028,Percent of Total Billed Charges,50% of Charges,25558,,"29,096 x DRG Weight",25558,Other,base rate x DRG weight,19731,,"22,463 x DRG Weight",19731,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23213,,"26,426 x DRG Weight",23213,Other,base rate x DRG weight,34090,,"38,809 x DRG Weight",34090,Other,base rate x DRG weight,34090,,"38,809 x DRG Weight",34090,Other,base rate x DRG weight,23213,,"26,426 x DRG Weight",23213,Other,base rate x DRG weight,34090,,"38,809 x DRG Weight",34090,Other,base rate x DRG weight,31087,,"35,391 x DRG Weight",31087,Other,base rate x DRG weight,61639,70,,61639,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22150,,"25,216 X DRG Weight",22150,Other,Base Weight X DRG Weight,19935,,"22,695 X DRG Weight",19935,Other,Base Weight X DRG Weight,22150,,"25,216 X DRG Weight",22150,Other,Base Rate x DRG Weight ,18827,,"21,433 x DRG Weight",18827,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,61639,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,,inpatient,,,185727.45,27913,,,27913,Other,150% of Medicare + 9.63% HCRA Surcharge,16974.02,,,16974.02,Other,Medicare IPPS methodology,47610,,"25,728 x DRG weight",47610,Other,base rate x DRG weight,42848,,"23,155 x DRG weight",42848,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,92864,50,,92864,Percent of Total Billed Charges,50% of Charges,53842,,"29,096 x DRG Weight",53842,Other,base rate x DRG weight,41568,,"22,463 x DRG Weight",41568,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,48901,,"26,426 x DRG Weight",48901,Other,base rate x DRG weight,71816,,"38,809 x DRG Weight",71816,Other,base rate x DRG weight,71816,,"38,809 x DRG Weight",71816,Other,base rate x DRG weight,48901,,"26,426 x DRG Weight",48901,Other,base rate x DRG weight,71816,,"38,809 x DRG Weight",71816,Other,base rate x DRG weight,65491,,"35,391 x DRG Weight",65491,Other,base rate x DRG weight,130009,70,,130009,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46662,,"25,216 X DRG Weight",46662,Other,Base Weight X DRG Weight,41997,,"22,695 X DRG Weight",41997,Other,Base Weight X DRG Weight,46662,,"25,216 X DRG Weight",46662,Other,Base Rate x DRG Weight ,39662,,"21,433 x DRG Weight",39662,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,130009,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,,inpatient,,,150931.77,17259,,,17259,Other,150% of Medicare + 9.63% HCRA Surcharge,10495.14,,,10495.14,Other,Medicare IPPS methodology,29127,,"25,728 x DRG weight",29127,Other,base rate x DRG weight,26214,,"23,155 x DRG weight",26214,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,75466,50,,75466,Percent of Total Billed Charges,50% of Charges,32940,,"29,096 x DRG Weight",32940,Other,base rate x DRG weight,25430,,"22,463 x DRG Weight",25430,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,29917,,"26,426 x DRG Weight",29917,Other,base rate x DRG weight,43936,,"38,809 x DRG Weight",43936,Other,base rate x DRG weight,43936,,"38,809 x DRG Weight",43936,Other,base rate x DRG weight,29917,,"26,426 x DRG Weight",29917,Other,base rate x DRG weight,43936,,"38,809 x DRG Weight",43936,Other,base rate x DRG weight,40066,,"35,391 x DRG Weight",40066,Other,base rate x DRG weight,105652,70,,105652,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,28547,,"25,216 X DRG Weight",28547,Other,Base Weight X DRG Weight,25693,,"22,695 X DRG Weight",25693,Other,Base Weight X DRG Weight,28547,,"25,216 X DRG Weight",28547,Other,Base Rate x DRG Weight ,24264,,"21,433 x DRG Weight",24264,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,105652,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,,inpatient,,,125772.49,12040,,,12040,Other,150% of Medicare + 9.63% HCRA Surcharge,7321.54,,,7321.54,Other,Medicare IPPS methodology,20073,,"25,728 x DRG weight",20073,Other,base rate x DRG weight,18066,,"23,155 x DRG weight",18066,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,62886,50,,62886,Percent of Total Billed Charges,50% of Charges,22701,,"29,096 x DRG Weight",22701,Other,base rate x DRG weight,17526,,"22,463 x DRG Weight",17526,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,20618,,"26,426 x DRG Weight",20618,Other,base rate x DRG weight,30279,,"38,809 x DRG Weight",30279,Other,base rate x DRG weight,30279,,"38,809 x DRG Weight",30279,Other,base rate x DRG weight,20618,,"26,426 x DRG Weight",20618,Other,base rate x DRG weight,30279,,"38,809 x DRG Weight",30279,Other,base rate x DRG weight,27612,,"35,391 x DRG Weight",27612,Other,base rate x DRG weight,88041,70,,88041,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19674,,"25,216 X DRG Weight",19674,Other,Base Weight X DRG Weight,17707,,"22,695 X DRG Weight",17707,Other,Base Weight X DRG Weight,19674,,"25,216 X DRG Weight",19674,Other,Base Rate x DRG Weight ,16722,,"21,433 x DRG Weight",16722,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,88041,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,,inpatient,,,209266.75,23022,,,23022,Other,150% of Medicare + 9.63% HCRA Surcharge,13999.72,,,13999.72,Other,Medicare IPPS methodology,39125,,"25,728 x DRG weight",39125,Other,base rate x DRG weight,35212,,"23,155 x DRG weight",35212,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,104633,50,,104633,Percent of Total Billed Charges,50% of Charges,44246,,"29,096 x DRG Weight",44246,Other,base rate x DRG weight,34159,,"22,463 x DRG Weight",34159,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,40186,,"26,426 x DRG Weight",40186,Other,base rate x DRG weight,59017,,"38,809 x DRG Weight",59017,Other,base rate x DRG weight,59017,,"38,809 x DRG Weight",59017,Other,base rate x DRG weight,40186,,"26,426 x DRG Weight",40186,Other,base rate x DRG weight,59017,,"38,809 x DRG Weight",59017,Other,base rate x DRG weight,53819,,"35,391 x DRG Weight",53819,Other,base rate x DRG weight,146487,70,,146487,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,38346,,"25,216 X DRG Weight",38346,Other,Base Weight X DRG Weight,34512,,"22,695 X DRG Weight",34512,Other,Base Weight X DRG Weight,38346,,"25,216 X DRG Weight",38346,Other,Base Rate x DRG Weight ,32593,,"21,433 x DRG Weight",32593,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,146487,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,,inpatient,,,116010.17,13751,,,13751,Other,150% of Medicare + 9.63% HCRA Surcharge,8362.27,,,8362.27,Other,Medicare IPPS methodology,23042,,"25,728 x DRG weight",23042,Other,base rate x DRG weight,20738,,"23,155 x DRG weight",20738,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,58005,50,,58005,Percent of Total Billed Charges,50% of Charges,26058,,"29,096 x DRG Weight",26058,Other,base rate x DRG weight,20118,,"22,463 x DRG Weight",20118,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23667,,"26,426 x DRG Weight",23667,Other,base rate x DRG weight,34757,,"38,809 x DRG Weight",34757,Other,base rate x DRG weight,34757,,"38,809 x DRG Weight",34757,Other,base rate x DRG weight,23667,,"26,426 x DRG Weight",23667,Other,base rate x DRG weight,34757,,"38,809 x DRG Weight",34757,Other,base rate x DRG weight,31696,,"35,391 x DRG Weight",31696,Other,base rate x DRG weight,81207,70,,81207,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22583,,"25,216 X DRG Weight",22583,Other,Base Weight X DRG Weight,20326,,"22,695 X DRG Weight",20326,Other,Base Weight X DRG Weight,22583,,"25,216 X DRG Weight",22583,Other,Base Rate x DRG Weight ,19195,,"21,433 x DRG Weight",19195,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,81207,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,,inpatient,,,286985.36,23633,,,23633,Other,150% of Medicare + 9.63% HCRA Surcharge,14371.28,,,14371.28,Other,Medicare IPPS methodology,40185,,"25,728 x DRG weight",40185,Other,base rate x DRG weight,36166,,"23,155 x DRG weight",36166,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,143493,50,,143493,Percent of Total Billed Charges,50% of Charges,45445,,"29,096 x DRG Weight",45445,Other,base rate x DRG weight,35085,,"22,463 x DRG Weight",35085,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41275,,"26,426 x DRG Weight",41275,Other,base rate x DRG weight,60616,,"38,809 x DRG Weight",60616,Other,base rate x DRG weight,60616,,"38,809 x DRG Weight",60616,Other,base rate x DRG weight,41275,,"26,426 x DRG Weight",41275,Other,base rate x DRG weight,60616,,"38,809 x DRG Weight",60616,Other,base rate x DRG weight,55277,,"35,391 x DRG Weight",55277,Other,base rate x DRG weight,200890,70,,200890,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39385,,"25,216 X DRG Weight",39385,Other,Base Weight X DRG Weight,35447,,"22,695 X DRG Weight",35447,Other,Base Weight X DRG Weight,39385,,"25,216 X DRG Weight",39385,Other,Base Rate x DRG Weight ,33476,,"21,433 x DRG Weight",33476,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,200890,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,,inpatient,,,146472.21,15291,,,15291,Other,150% of Medicare + 9.63% HCRA Surcharge,9298.39,,,9298.39,Other,Medicare IPPS methodology,25713,,"25,728 x DRG weight",25713,Other,base rate x DRG weight,23141,,"23,155 x DRG weight",23141,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,73236,50,,73236,Percent of Total Billed Charges,50% of Charges,29079,,"29,096 x DRG Weight",29079,Other,base rate x DRG weight,22450,,"22,463 x DRG Weight",22450,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26410,,"26,426 x DRG Weight",26410,Other,base rate x DRG weight,38786,,"38,809 x DRG Weight",38786,Other,base rate x DRG weight,38786,,"38,809 x DRG Weight",38786,Other,base rate x DRG weight,26410,,"26,426 x DRG Weight",26410,Other,base rate x DRG weight,38786,,"38,809 x DRG Weight",38786,Other,base rate x DRG weight,35370,,"35,391 x DRG Weight",35370,Other,base rate x DRG weight,102531,70,,102531,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25201,,"25,216 X DRG Weight",25201,Other,Base Weight X DRG Weight,22681,,"22,695 X DRG Weight",22681,Other,Base Weight X DRG Weight,25201,,"25,216 X DRG Weight",25201,Other,Base Rate x DRG Weight ,21420,,"21,433 x DRG Weight",21420,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,102531,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,,inpatient,,,77997.2,11599,,,11599,Other,150% of Medicare + 9.63% HCRA Surcharge,7053.69,,,7053.69,Other,Medicare IPPS methodology,19309,,"25,728 x DRG weight",19309,Other,base rate x DRG weight,17378,,"23,155 x DRG weight",17378,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,38999,50,,38999,Percent of Total Billed Charges,50% of Charges,21837,,"29,096 x DRG Weight",21837,Other,base rate x DRG weight,16858,,"22,463 x DRG Weight",16858,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,19833,,"26,426 x DRG Weight",19833,Other,base rate x DRG weight,29126,,"38,809 x DRG Weight",29126,Other,base rate x DRG weight,29126,,"38,809 x DRG Weight",29126,Other,base rate x DRG weight,19833,,"26,426 x DRG Weight",19833,Other,base rate x DRG weight,29126,,"38,809 x DRG Weight",29126,Other,base rate x DRG weight,26561,,"35,391 x DRG Weight",26561,Other,base rate x DRG weight,54598,70,,54598,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18925,,"25,216 X DRG Weight",18925,Other,Base Weight X DRG Weight,17033,,"22,695 X DRG Weight",17033,Other,Base Weight X DRG Weight,18925,,"25,216 X DRG Weight",18925,Other,Base Rate x DRG Weight ,16085,,"21,433 x DRG Weight",16085,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,54598,
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,,inpatient,,,296566.47,43807,,,43807,Other,150% of Medicare + 9.63% HCRA Surcharge,26639.12,,,26639.12,Other,Medicare IPPS methodology,75182,,"25,728 x DRG weight",75182,Other,base rate x DRG weight,67664,,"23,155 x DRG weight",67664,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,148283,50,,148283,Percent of Total Billed Charges,50% of Charges,85024,,"29,096 x DRG Weight",85024,Other,base rate x DRG weight,65641,,"22,463 x DRG Weight",65641,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,77222,,"26,426 x DRG Weight",77222,Other,base rate x DRG weight,113408,,"38,809 x DRG Weight",113408,Other,base rate x DRG weight,113408,,"38,809 x DRG Weight",113408,Other,base rate x DRG weight,77222,,"26,426 x DRG Weight",77222,Other,base rate x DRG weight,113408,,"38,809 x DRG Weight",113408,Other,base rate x DRG weight,103420,,"35,391 x DRG Weight",103420,Other,base rate x DRG weight,207597,70,,207597,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,73686,,"25,216 X DRG Weight",73686,Other,Base Weight X DRG Weight,66319,,"22,695 X DRG Weight",66319,Other,Base Weight X DRG Weight,73686,,"25,216 X DRG Weight",73686,Other,Base Rate x DRG Weight ,62632,,"21,433 x DRG Weight",62632,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,207597,
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,,inpatient,,,230034.64,25561,,,25561,Other,150% of Medicare + 9.63% HCRA Surcharge,15543.69,,,15543.69,Other,Medicare IPPS methodology,43529,,"25,728 x DRG weight",43529,Other,base rate x DRG weight,39176,,"23,155 x DRG weight",39176,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,115017,50,,115017,Percent of Total Billed Charges,50% of Charges,49228,,"29,096 x DRG Weight",49228,Other,base rate x DRG weight,38005,,"22,463 x DRG Weight",38005,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,44710,,"26,426 x DRG Weight",44710,Other,base rate x DRG weight,65661,,"38,809 x DRG Weight",65661,Other,base rate x DRG weight,65661,,"38,809 x DRG Weight",65661,Other,base rate x DRG weight,44710,,"26,426 x DRG Weight",44710,Other,base rate x DRG weight,65661,,"38,809 x DRG Weight",65661,Other,base rate x DRG weight,59878,,"35,391 x DRG Weight",59878,Other,base rate x DRG weight,161024,70,,161024,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,42663,,"25,216 X DRG Weight",42663,Other,Base Weight X DRG Weight,38398,,"22,695 X DRG Weight",38398,Other,Base Weight X DRG Weight,42663,,"25,216 X DRG Weight",42663,Other,Base Rate x DRG Weight ,36262,,"21,433 x DRG Weight",36262,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,161024,
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,,inpatient,,,116935.28,17370,,,17370,Other,150% of Medicare + 9.63% HCRA Surcharge,10562.78,,,10562.78,Other,Medicare IPPS methodology,29320,,"25,728 x DRG weight",29320,Other,base rate x DRG weight,26387,,"23,155 x DRG weight",26387,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,58468,50,,58468,Percent of Total Billed Charges,50% of Charges,33158,,"29,096 x DRG Weight",33158,Other,base rate x DRG weight,25599,,"22,463 x DRG Weight",25599,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,30115,,"26,426 x DRG Weight",30115,Other,base rate x DRG weight,44227,,"38,809 x DRG Weight",44227,Other,base rate x DRG weight,44227,,"38,809 x DRG Weight",44227,Other,base rate x DRG weight,30115,,"26,426 x DRG Weight",30115,Other,base rate x DRG weight,44227,,"38,809 x DRG Weight",44227,Other,base rate x DRG weight,40332,,"35,391 x DRG Weight",40332,Other,base rate x DRG weight,81855,70,,81855,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,28736,,"25,216 X DRG Weight",28736,Other,Base Weight X DRG Weight,25863,,"22,695 X DRG Weight",25863,Other,Base Weight X DRG Weight,28736,,"25,216 X DRG Weight",28736,Other,Base Rate x DRG Weight ,24425,,"21,433 x DRG Weight",24425,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,81855,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,MS-DRG,,,,,,,,inpatient,,,990952.69,92686,,,92686,Other,150% of Medicare + 9.63% HCRA Surcharge,56363.13,,,56363.13,Other,Medicare IPPS methodology,159979,,"25,728 x DRG weight",159979,Other,base rate x DRG weight,143980,,"23,155 x DRG weight",143980,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,495476,50,,495476,Percent of Total Billed Charges,50% of Charges,180922,,"29,096 x DRG Weight",180922,Other,base rate x DRG weight,139677,,"22,463 x DRG Weight",139677,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,164320,,"26,426 x DRG Weight",164320,Other,base rate x DRG weight,241318,,"38,809 x DRG Weight",241318,Other,base rate x DRG weight,241318,,"38,809 x DRG Weight",241318,Other,base rate x DRG weight,164320,,"26,426 x DRG Weight",164320,Other,base rate x DRG weight,241318,,"38,809 x DRG Weight",241318,Other,base rate x DRG weight,220065,,"35,391 x DRG Weight",220065,Other,base rate x DRG weight,693667,70,,693667,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,156796,,"25,216 X DRG Weight",156796,Other,Base Weight X DRG Weight,141120,,"22,695 X DRG Weight",141120,Other,Base Weight X DRG Weight,156796,,"25,216 X DRG Weight",156796,Other,Base Rate x DRG Weight ,133273,,"21,433 x DRG Weight",133273,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,693667,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,MS-DRG,,,,,,,,inpatient,,,415535.65,50979,,,50979,Other,150% of Medicare + 9.63% HCRA Surcharge,31000.46,,,31000.46,Other,Medicare IPPS methodology,87624,,"25,728 x DRG weight",87624,Other,base rate x DRG weight,78861,,"23,155 x DRG weight",78861,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,207768,50,,207768,Percent of Total Billed Charges,50% of Charges,99095,,"29,096 x DRG Weight",99095,Other,base rate x DRG weight,76504,,"22,463 x DRG Weight",76504,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,90002,,"26,426 x DRG Weight",90002,Other,base rate x DRG weight,132176,,"38,809 x DRG Weight",132176,Other,base rate x DRG weight,132176,,"38,809 x DRG Weight",132176,Other,base rate x DRG weight,90002,,"26,426 x DRG Weight",90002,Other,base rate x DRG weight,132176,,"38,809 x DRG Weight",132176,Other,base rate x DRG weight,120535,,"35,391 x DRG Weight",120535,Other,base rate x DRG weight,290875,70,,290875,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,85881,,"25,216 X DRG Weight",85881,Other,Base Weight X DRG Weight,77295,,"22,695 X DRG Weight",77295,Other,Base Weight X DRG Weight,85881,,"25,216 X DRG Weight",85881,Other,Base Rate x DRG Weight ,72997,,"21,433 x DRG Weight",72997,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,290875,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,,inpatient,,,126628.96,30812,,,30812,Other,150% of Medicare + 9.63% HCRA Surcharge,18737.13,,,18737.13,Other,Medicare IPPS methodology,52639,,"25,728 x DRG weight",52639,Other,base rate x DRG weight,47375,,"23,155 x DRG weight",47375,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,63314,50,,63314,Percent of Total Billed Charges,50% of Charges,59530,,"29,096 x DRG Weight",59530,Other,base rate x DRG weight,45959,,"22,463 x DRG Weight",45959,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,54068,,"26,426 x DRG Weight",54068,Other,base rate x DRG weight,79403,,"38,809 x DRG Weight",79403,Other,base rate x DRG weight,79403,,"38,809 x DRG Weight",79403,Other,base rate x DRG weight,54068,,"26,426 x DRG Weight",54068,Other,base rate x DRG weight,79403,,"38,809 x DRG Weight",79403,Other,base rate x DRG weight,72410,,"35,391 x DRG Weight",72410,Other,base rate x DRG weight,88640,70,,88640,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,51592,,"25,216 X DRG Weight",51592,Other,Base Weight X DRG Weight,46434,,"22,695 X DRG Weight",46434,Other,Base Weight X DRG Weight,51592,,"25,216 X DRG Weight",51592,Other,Base Rate x DRG Weight ,43852,,"21,433 x DRG Weight",43852,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,88640,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,MS-DRG,,,,,,,,inpatient,,,1204252.37,84752,,,84752,Other,150% of Medicare + 9.63% HCRA Surcharge,51538.24,,,51538.24,Other,Medicare IPPS methodology,146215,,"25,728 x DRG weight",146215,Other,base rate x DRG weight,131592,,"23,155 x DRG weight",131592,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,602126,50,,602126,Percent of Total Billed Charges,50% of Charges,165355,,"29,096 x DRG Weight",165355,Other,base rate x DRG weight,127659,,"22,463 x DRG Weight",127659,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,150182,,"26,426 x DRG Weight",150182,Other,base rate x DRG weight,220555,,"38,809 x DRG Weight",220555,Other,base rate x DRG weight,220555,,"38,809 x DRG Weight",220555,Other,base rate x DRG weight,150182,,"26,426 x DRG Weight",150182,Other,base rate x DRG weight,220555,,"38,809 x DRG Weight",220555,Other,base rate x DRG weight,201131,,"35,391 x DRG Weight",201131,Other,base rate x DRG weight,842977,70,,842977,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,143305,,"25,216 X DRG Weight",143305,Other,Base Weight X DRG Weight,128978,,"22,695 X DRG Weight",128978,Other,Base Weight X DRG Weight,143305,,"25,216 X DRG Weight",143305,Other,Base Rate x DRG Weight ,121806,,"21,433 x DRG Weight",121806,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,842977,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,MS-DRG,,,,,,,,inpatient,,,447661.57,39757,,,39757,Other,150% of Medicare + 9.63% HCRA Surcharge,24176.18,,,24176.18,Other,Medicare IPPS methodology,68156,,"25,728 x DRG weight",68156,Other,base rate x DRG weight,61340,,"23,155 x DRG weight",61340,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,223831,50,,223831,Percent of Total Billed Charges,50% of Charges,77078,,"29,096 x DRG Weight",77078,Other,base rate x DRG weight,59507,,"22,463 x DRG Weight",59507,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,70005,,"26,426 x DRG Weight",70005,Other,base rate x DRG weight,102809,,"38,809 x DRG Weight",102809,Other,base rate x DRG weight,102809,,"38,809 x DRG Weight",102809,Other,base rate x DRG weight,70005,,"26,426 x DRG Weight",70005,Other,base rate x DRG weight,102809,,"38,809 x DRG Weight",102809,Other,base rate x DRG weight,93754,,"35,391 x DRG Weight",93754,Other,base rate x DRG weight,313363,70,,313363,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,66800,,"25,216 X DRG Weight",66800,Other,Base Weight X DRG Weight,60121,,"22,695 X DRG Weight",60121,Other,Base Weight X DRG Weight,66800,,"25,216 X DRG Weight",66800,Other,Base Rate x DRG Weight ,56778,,"21,433 x DRG Weight",56778,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,313363,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,,inpatient,,,107260.28,24354,,,24354,Other,150% of Medicare + 9.63% HCRA Surcharge,14809.58,,,14809.58,Other,Medicare IPPS methodology,41435,,"25,728 x DRG weight",41435,Other,base rate x DRG weight,37291,,"23,155 x DRG weight",37291,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,53630,50,,53630,Percent of Total Billed Charges,50% of Charges,46859,,"29,096 x DRG Weight",46859,Other,base rate x DRG weight,36177,,"22,463 x DRG Weight",36177,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,42559,,"26,426 x DRG Weight",42559,Other,base rate x DRG weight,62502,,"38,809 x DRG Weight",62502,Other,base rate x DRG weight,62502,,"38,809 x DRG Weight",62502,Other,base rate x DRG weight,42559,,"26,426 x DRG Weight",42559,Other,base rate x DRG weight,62502,,"38,809 x DRG Weight",62502,Other,base rate x DRG weight,56997,,"35,391 x DRG Weight",56997,Other,base rate x DRG weight,75082,70,,75082,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40610,,"25,216 X DRG Weight",40610,Other,Base Weight X DRG Weight,36550,,"22,695 X DRG Weight",36550,Other,Base Weight X DRG Weight,40610,,"25,216 X DRG Weight",40610,Other,Base Rate x DRG Weight ,34518,,"21,433 x DRG Weight",34518,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,75082,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,MS-DRG,,,,,,,,inpatient,,,290583.64,50035,,,50035,Other,150% of Medicare + 9.63% HCRA Surcharge,30426.88,,,30426.88,Other,Medicare IPPS methodology,85988,,"25,728 x DRG weight",85988,Other,base rate x DRG weight,77389,,"23,155 x DRG weight",77389,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,145292,50,,145292,Percent of Total Billed Charges,50% of Charges,97245,,"29,096 x DRG Weight",97245,Other,base rate x DRG weight,75076,,"22,463 x DRG Weight",75076,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,88321,,"26,426 x DRG Weight",88321,Other,base rate x DRG weight,129707,,"38,809 x DRG Weight",129707,Other,base rate x DRG weight,129707,,"38,809 x DRG Weight",129707,Other,base rate x DRG weight,88321,,"26,426 x DRG Weight",88321,Other,base rate x DRG weight,129707,,"38,809 x DRG Weight",129707,Other,base rate x DRG weight,118284,,"35,391 x DRG Weight",118284,Other,base rate x DRG weight,203409,70,,203409,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,84277,,"25,216 X DRG Weight",84277,Other,Base Weight X DRG Weight,75851,,"22,695 X DRG Weight",75851,Other,Base Weight X DRG Weight,84277,,"25,216 X DRG Weight",84277,Other,Base Rate x DRG Weight ,71633,,"21,433 x DRG Weight",71633,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,203409,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,,inpatient,,,208980.23,26372,,,26372,Other,150% of Medicare + 9.63% HCRA Surcharge,16037,,,16037,Other,Medicare IPPS methodology,44937,,"25,728 x DRG weight",44937,Other,base rate x DRG weight,40443,,"23,155 x DRG weight",40443,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,104490,50,,104490,Percent of Total Billed Charges,50% of Charges,50819,,"29,096 x DRG Weight",50819,Other,base rate x DRG weight,39234,,"22,463 x DRG Weight",39234,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,46156,,"26,426 x DRG Weight",46156,Other,base rate x DRG weight,67784,,"38,809 x DRG Weight",67784,Other,base rate x DRG weight,67784,,"38,809 x DRG Weight",67784,Other,base rate x DRG weight,46156,,"26,426 x DRG Weight",46156,Other,base rate x DRG weight,67784,,"38,809 x DRG Weight",67784,Other,base rate x DRG weight,61814,,"35,391 x DRG Weight",61814,Other,base rate x DRG weight,146286,70,,146286,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,44042,,"25,216 X DRG Weight",44042,Other,Base Weight X DRG Weight,39639,,"22,695 X DRG Weight",39639,Other,Base Weight X DRG Weight,44042,,"25,216 X DRG Weight",44042,Other,Base Rate x DRG Weight ,37435,,"21,433 x DRG Weight",37435,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,146286,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,,inpatient,,,140192.28,20441,,,20441,Other,150% of Medicare + 9.63% HCRA Surcharge,12430.51,,,12430.51,Other,Medicare IPPS methodology,34648,,"25,728 x DRG weight",34648,Other,base rate x DRG weight,31183,,"23,155 x DRG weight",31183,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,70096,50,,70096,Percent of Total Billed Charges,50% of Charges,39184,,"29,096 x DRG Weight",39184,Other,base rate x DRG weight,30251,,"22,463 x DRG Weight",30251,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,35588,,"26,426 x DRG Weight",35588,Other,base rate x DRG weight,52264,,"38,809 x DRG Weight",52264,Other,base rate x DRG weight,52264,,"38,809 x DRG Weight",52264,Other,base rate x DRG weight,35588,,"26,426 x DRG Weight",35588,Other,base rate x DRG weight,52264,,"38,809 x DRG Weight",52264,Other,base rate x DRG weight,47661,,"35,391 x DRG Weight",47661,Other,base rate x DRG weight,98135,70,,98135,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,33958,,"25,216 X DRG Weight",33958,Other,Base Weight X DRG Weight,30563,,"22,695 X DRG Weight",30563,Other,Base Weight X DRG Weight,33958,,"25,216 X DRG Weight",33958,Other,Base Rate x DRG Weight ,28864,,"21,433 x DRG Weight",28864,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,98135,
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,MS-DRG,,,,,,,,inpatient,,,452655.36,26293,,,26293,Other,150% of Medicare + 9.63% HCRA Surcharge,15989.2,,,15989.2,Other,Medicare IPPS methodology,44800,,"25,728 x DRG weight",44800,Other,base rate x DRG weight,40320,,"23,155 x DRG weight",40320,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,226328,50,,226328,Percent of Total Billed Charges,50% of Charges,50665,,"29,096 x DRG Weight",50665,Other,base rate x DRG weight,39115,,"22,463 x DRG Weight",39115,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,46016,,"26,426 x DRG Weight",46016,Other,base rate x DRG weight,67578,,"38,809 x DRG Weight",67578,Other,base rate x DRG weight,67578,,"38,809 x DRG Weight",67578,Other,base rate x DRG weight,46016,,"26,426 x DRG Weight",46016,Other,base rate x DRG weight,67578,,"38,809 x DRG Weight",67578,Other,base rate x DRG weight,61626,,"35,391 x DRG Weight",61626,Other,base rate x DRG weight,316859,70,,316859,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43909,,"25,216 X DRG Weight",43909,Other,Base Weight X DRG Weight,39519,,"22,695 X DRG Weight",39519,Other,Base Weight X DRG Weight,43909,,"25,216 X DRG Weight",43909,Other,Base Rate x DRG Weight ,37321,,"21,433 x DRG Weight",37321,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,316859,
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,,inpatient,,,262765.06,23040,,,23040,Other,150% of Medicare + 9.63% HCRA Surcharge,14010.54,,,14010.54,Other,Medicare IPPS methodology,39155,,"25,728 x DRG weight",39155,Other,base rate x DRG weight,35240,,"23,155 x DRG weight",35240,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,131383,50,,131383,Percent of Total Billed Charges,50% of Charges,44281,,"29,096 x DRG Weight",44281,Other,base rate x DRG weight,34186,,"22,463 x DRG Weight",34186,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,40218,,"26,426 x DRG Weight",40218,Other,base rate x DRG weight,59063,,"38,809 x DRG Weight",59063,Other,base rate x DRG weight,59063,,"38,809 x DRG Weight",59063,Other,base rate x DRG weight,40218,,"26,426 x DRG Weight",40218,Other,base rate x DRG weight,59063,,"38,809 x DRG Weight",59063,Other,base rate x DRG weight,53862,,"35,391 x DRG Weight",53862,Other,base rate x DRG weight,183936,70,,183936,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,38376,,"25,216 X DRG Weight",38376,Other,Base Weight X DRG Weight,34540,,"22,695 X DRG Weight",34540,Other,Base Weight X DRG Weight,38376,,"25,216 X DRG Weight",38376,Other,Base Rate x DRG Weight ,32619,,"21,433 x DRG Weight",32619,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,183936,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,MS-DRG,,,,,,,,inpatient,,,281117.77,29516,,,29516,Other,150% of Medicare + 9.63% HCRA Surcharge,17948.91,,,17948.91,Other,Medicare IPPS methodology,50391,,"25,728 x DRG weight",50391,Other,base rate x DRG weight,45351,,"23,155 x DRG weight",45351,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,140559,50,,140559,Percent of Total Billed Charges,50% of Charges,56987,,"29,096 x DRG Weight",56987,Other,base rate x DRG weight,43996,,"22,463 x DRG Weight",43996,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,51758,,"26,426 x DRG Weight",51758,Other,base rate x DRG weight,76011,,"38,809 x DRG Weight",76011,Other,base rate x DRG weight,76011,,"38,809 x DRG Weight",76011,Other,base rate x DRG weight,51758,,"26,426 x DRG Weight",51758,Other,base rate x DRG weight,76011,,"38,809 x DRG Weight",76011,Other,base rate x DRG weight,69317,,"35,391 x DRG Weight",69317,Other,base rate x DRG weight,196782,70,,196782,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,49388,,"25,216 X DRG Weight",49388,Other,Base Weight X DRG Weight,44450,,"22,695 X DRG Weight",44450,Other,Base Weight X DRG Weight,49388,,"25,216 X DRG Weight",49388,Other,Base Rate x DRG Weight ,41979,,"21,433 x DRG Weight",41979,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,196782,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,MS-DRG,,,,,,,,inpatient,,,166960.29,25444,,,25444,Other,150% of Medicare + 9.63% HCRA Surcharge,15472.44,,,15472.44,Other,Medicare IPPS methodology,43326,,"25,728 x DRG weight",43326,Other,base rate x DRG weight,38993,,"23,155 x DRG weight",38993,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,83480,50,,83480,Percent of Total Billed Charges,50% of Charges,48998,,"29,096 x DRG Weight",48998,Other,base rate x DRG weight,37828,,"22,463 x DRG Weight",37828,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,44501,,"26,426 x DRG Weight",44501,Other,base rate x DRG weight,65354,,"38,809 x DRG Weight",65354,Other,base rate x DRG weight,65354,,"38,809 x DRG Weight",65354,Other,base rate x DRG weight,44501,,"26,426 x DRG Weight",44501,Other,base rate x DRG weight,65354,,"38,809 x DRG Weight",65354,Other,base rate x DRG weight,59598,,"35,391 x DRG Weight",59598,Other,base rate x DRG weight,116872,70,,116872,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,42464,,"25,216 X DRG Weight",42464,Other,Base Weight X DRG Weight,38218,,"22,695 X DRG Weight",38218,Other,Base Weight X DRG Weight,42464,,"25,216 X DRG Weight",42464,Other,Base Rate x DRG Weight ,36093,,"21,433 x DRG Weight",36093,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,116872,
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,,inpatient,,,154357.17,31466,,,31466,Other,150% of Medicare + 9.63% HCRA Surcharge,19134.85,,,19134.85,Other,Medicare IPPS methodology,53774,,"25,728 x DRG weight",53774,Other,base rate x DRG weight,48396,,"23,155 x DRG weight",48396,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,77179,50,,77179,Percent of Total Billed Charges,50% of Charges,60814,,"29,096 x DRG Weight",60814,Other,base rate x DRG weight,46950,,"22,463 x DRG Weight",46950,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,55233,,"26,426 x DRG Weight",55233,Other,base rate x DRG weight,81115,,"38,809 x DRG Weight",81115,Other,base rate x DRG weight,81115,,"38,809 x DRG Weight",81115,Other,base rate x DRG weight,55233,,"26,426 x DRG Weight",55233,Other,base rate x DRG weight,81115,,"38,809 x DRG Weight",81115,Other,base rate x DRG weight,73971,,"35,391 x DRG Weight",73971,Other,base rate x DRG weight,108050,70,,108050,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,52704,,"25,216 X DRG Weight",52704,Other,Base Weight X DRG Weight,47435,,"22,695 X DRG Weight",47435,Other,Base Weight X DRG Weight,52704,,"25,216 X DRG Weight",52704,Other,Base Rate x DRG Weight ,44797,,"21,433 x DRG Weight",44797,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,108050,
SKIN ULCERS WITH CC,593,MS-DRG,,,,,,,,inpatient,,,75200.5,18413,,,18413,Other,150% of Medicare + 9.63% HCRA Surcharge,11196.78,,,11196.78,Other,Medicare IPPS methodology,31128,,"25,728 x DRG weight",31128,Other,base rate x DRG weight,28015,,"23,155 x DRG weight",28015,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37600,50,,37600,Percent of Total Billed Charges,50% of Charges,35203,,"29,096 x DRG Weight",35203,Other,base rate x DRG weight,27178,,"22,463 x DRG Weight",27178,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31973,,"26,426 x DRG Weight",31973,Other,base rate x DRG weight,46955,,"38,809 x DRG Weight",46955,Other,base rate x DRG weight,46955,,"38,809 x DRG Weight",46955,Other,base rate x DRG weight,31973,,"26,426 x DRG Weight",31973,Other,base rate x DRG weight,46955,,"38,809 x DRG Weight",46955,Other,base rate x DRG weight,42820,,"35,391 x DRG Weight",42820,Other,base rate x DRG weight,52640,70,,52640,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,30509,,"25,216 X DRG Weight",30509,Other,Base Weight X DRG Weight,27459,,"22,695 X DRG Weight",27459,Other,Base Weight X DRG Weight,30509,,"25,216 X DRG Weight",30509,Other,Base Rate x DRG Weight ,25932,,"21,433 x DRG Weight",25932,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,52640,
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,,inpatient,,,41415,12147,,,12147,Other,150% of Medicare + 9.63% HCRA Surcharge,7386.47,,,7386.47,Other,Medicare IPPS methodology,20258,,"25,728 x DRG weight",20258,Other,base rate x DRG weight,18232,,"23,155 x DRG weight",18232,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20708,50,,20708,Percent of Total Billed Charges,50% of Charges,22910,,"29,096 x DRG Weight",22910,Other,base rate x DRG weight,17687,,"22,463 x DRG Weight",17687,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,20808,,"26,426 x DRG Weight",20808,Other,base rate x DRG weight,30558,,"38,809 x DRG Weight",30558,Other,base rate x DRG weight,30558,,"38,809 x DRG Weight",30558,Other,base rate x DRG weight,20808,,"26,426 x DRG Weight",20808,Other,base rate x DRG weight,30558,,"38,809 x DRG Weight",30558,Other,base rate x DRG weight,27867,,"35,391 x DRG Weight",27867,Other,base rate x DRG weight,28991,70,,28991,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19855,,"25,216 X DRG Weight",19855,Other,Base Weight X DRG Weight,17870,,"22,695 X DRG Weight",17870,Other,Base Weight X DRG Weight,19855,,"25,216 X DRG Weight",19855,Other,Base Rate x DRG Weight ,16876,,"21,433 x DRG Weight",16876,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,30558,
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,,inpatient,,,357838.87,32725,,,32725,Other,150% of Medicare + 9.63% HCRA Surcharge,19900.51,,,19900.51,Other,Medicare IPPS methodology,55958,,"25,728 x DRG weight",55958,Other,base rate x DRG weight,50362,,"23,155 x DRG weight",50362,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,178919,50,,178919,Percent of Total Billed Charges,50% of Charges,63284,,"29,096 x DRG Weight",63284,Other,base rate x DRG weight,48857,,"22,463 x DRG Weight",48857,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,57477,,"26,426 x DRG Weight",57477,Other,base rate x DRG weight,84410,,"38,809 x DRG Weight",84410,Other,base rate x DRG weight,84410,,"38,809 x DRG Weight",84410,Other,base rate x DRG weight,57477,,"26,426 x DRG Weight",57477,Other,base rate x DRG weight,84410,,"38,809 x DRG Weight",84410,Other,base rate x DRG weight,76975,,"35,391 x DRG Weight",76975,Other,base rate x DRG weight,250487,70,,250487,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,54845,,"25,216 X DRG Weight",54845,Other,Base Weight X DRG Weight,49362,,"22,695 X DRG Weight",49362,Other,Base Weight X DRG Weight,54845,,"25,216 X DRG Weight",54845,Other,Base Rate x DRG Weight ,46617,,"21,433 x DRG Weight",46617,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,250487,
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,,inpatient,,,121904.89,15433,,,15433,Other,150% of Medicare + 9.63% HCRA Surcharge,9384.97,,,9384.97,Other,Medicare IPPS methodology,25960,,"25,728 x DRG weight",25960,Other,base rate x DRG weight,23363,,"23,155 x DRG weight",23363,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,60952,50,,60952,Percent of Total Billed Charges,50% of Charges,29358,,"29,096 x DRG Weight",29358,Other,base rate x DRG weight,22665,,"22,463 x DRG Weight",22665,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26664,,"26,426 x DRG Weight",26664,Other,base rate x DRG weight,39158,,"38,809 x DRG Weight",39158,Other,base rate x DRG weight,39158,,"38,809 x DRG Weight",39158,Other,base rate x DRG weight,26664,,"26,426 x DRG Weight",26664,Other,base rate x DRG weight,39158,,"38,809 x DRG Weight",39158,Other,base rate x DRG weight,35710,,"35,391 x DRG Weight",35710,Other,base rate x DRG weight,85333,70,,85333,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25443,,"25,216 X DRG Weight",25443,Other,Base Weight X DRG Weight,22899,,"22,695 X DRG Weight",22899,Other,Base Weight X DRG Weight,25443,,"25,216 X DRG Weight",25443,Other,Base Rate x DRG Weight ,21626,,"21,433 x DRG Weight",21626,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,85333,
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,,inpatient,,,231290.93,24205,,,24205,Other,150% of Medicare + 9.63% HCRA Surcharge,14719.4,,,14719.4,Other,Medicare IPPS methodology,41178,,"25,728 x DRG weight",41178,Other,base rate x DRG weight,37060,,"23,155 x DRG weight",37060,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,115645,50,,115645,Percent of Total Billed Charges,50% of Charges,46568,,"29,096 x DRG Weight",46568,Other,base rate x DRG weight,35952,,"22,463 x DRG Weight",35952,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,42295,,"26,426 x DRG Weight",42295,Other,base rate x DRG weight,62114,,"38,809 x DRG Weight",62114,Other,base rate x DRG weight,62114,,"38,809 x DRG Weight",62114,Other,base rate x DRG weight,42295,,"26,426 x DRG Weight",42295,Other,base rate x DRG weight,62114,,"38,809 x DRG Weight",62114,Other,base rate x DRG weight,56643,,"35,391 x DRG Weight",56643,Other,base rate x DRG weight,161904,70,,161904,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40358,,"25,216 X DRG Weight",40358,Other,Base Weight X DRG Weight,36323,,"22,695 X DRG Weight",36323,Other,Base Weight X DRG Weight,40358,,"25,216 X DRG Weight",40358,Other,Base Rate x DRG Weight ,34304,,"21,433 x DRG Weight",34304,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,161904,
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,,inpatient,,,134604.21,18248,,,18248,Other,150% of Medicare + 9.63% HCRA Surcharge,11096.67,,,11096.67,Other,Medicare IPPS methodology,30843,,"25,728 x DRG weight",30843,Other,base rate x DRG weight,27758,,"23,155 x DRG weight",27758,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,67302,50,,67302,Percent of Total Billed Charges,50% of Charges,34880,,"29,096 x DRG Weight",34880,Other,base rate x DRG weight,26929,,"22,463 x DRG Weight",26929,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31679,,"26,426 x DRG Weight",31679,Other,base rate x DRG weight,46524,,"38,809 x DRG Weight",46524,Other,base rate x DRG weight,46524,,"38,809 x DRG Weight",46524,Other,base rate x DRG weight,31679,,"26,426 x DRG Weight",31679,Other,base rate x DRG weight,46524,,"38,809 x DRG Weight",46524,Other,base rate x DRG weight,42427,,"35,391 x DRG Weight",42427,Other,base rate x DRG weight,94223,70,,94223,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,30229,,"25,216 X DRG Weight",30229,Other,Base Weight X DRG Weight,27207,,"22,695 X DRG Weight",27207,Other,Base Weight X DRG Weight,30229,,"25,216 X DRG Weight",30229,Other,Base Rate x DRG Weight ,25694,,"21,433 x DRG Weight",25694,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,94223,
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,MS-DRG,,,,,,,,inpatient,,,121904.89,10447,,,10447,Other,150% of Medicare + 9.63% HCRA Surcharge,6352.95,,,6352.95,Other,Medicare IPPS methodology,17310,,"25,728 x DRG weight",17310,Other,base rate x DRG weight,15579,,"23,155 x DRG weight",15579,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,60952,50,,60952,Percent of Total Billed Charges,50% of Charges,19576,,"29,096 x DRG Weight",19576,Other,base rate x DRG weight,15113,,"22,463 x DRG Weight",15113,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,17779,,"26,426 x DRG Weight",17779,Other,base rate x DRG weight,26111,,"38,809 x DRG Weight",26111,Other,base rate x DRG weight,26111,,"38,809 x DRG Weight",26111,Other,base rate x DRG weight,17779,,"26,426 x DRG Weight",17779,Other,base rate x DRG weight,26111,,"38,809 x DRG Weight",26111,Other,base rate x DRG weight,23811,,"35,391 x DRG Weight",23811,Other,base rate x DRG weight,85333,70,,85333,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,16965,,"25,216 X DRG Weight",16965,Other,Base Weight X DRG Weight,15269,,"22,695 X DRG Weight",15269,Other,Base Weight X DRG Weight,16965,,"25,216 X DRG Weight",16965,Other,Base Rate x DRG Weight ,14420,,"21,433 x DRG Weight",14420,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,85333,
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,,inpatient,,,307554.34,15678,,,15678,Other,150% of Medicare + 9.63% HCRA Surcharge,9533.77,,,9533.77,Other,Medicare IPPS methodology,26384,,"25,728 x DRG weight",26384,Other,base rate x DRG weight,23745,,"23,155 x DRG weight",23745,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,153777,50,,153777,Percent of Total Billed Charges,50% of Charges,29838,,"29,096 x DRG Weight",29838,Other,base rate x DRG weight,23036,,"22,463 x DRG Weight",23036,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,27100,,"26,426 x DRG Weight",27100,Other,base rate x DRG weight,39799,,"38,809 x DRG Weight",39799,Other,base rate x DRG weight,39799,,"38,809 x DRG Weight",39799,Other,base rate x DRG weight,27100,,"26,426 x DRG Weight",27100,Other,base rate x DRG weight,39799,,"38,809 x DRG Weight",39799,Other,base rate x DRG weight,36293,,"35,391 x DRG Weight",36293,Other,base rate x DRG weight,215288,70,,215288,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25859,,"25,216 X DRG Weight",25859,Other,Base Weight X DRG Weight,23274,,"22,695 X DRG Weight",23274,Other,Base Weight X DRG Weight,25859,,"25,216 X DRG Weight",25859,Other,Base Rate x DRG Weight ,21980,,"21,433 x DRG Weight",21980,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,215288,
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,,inpatient,,,54660.52,9864,,,9864,Other,150% of Medicare + 9.63% HCRA Surcharge,5998.53,,,5998.53,Other,Medicare IPPS methodology,16299,,"25,728 x DRG weight",16299,Other,base rate x DRG weight,14669,,"23,155 x DRG weight",14669,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27330,50,,27330,Percent of Total Billed Charges,50% of Charges,18432,,"29,096 x DRG Weight",18432,Other,base rate x DRG weight,14230,,"22,463 x DRG Weight",14230,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,16741,,"26,426 x DRG Weight",16741,Other,base rate x DRG weight,24586,,"38,809 x DRG Weight",24586,Other,base rate x DRG weight,24586,,"38,809 x DRG Weight",24586,Other,base rate x DRG weight,16741,,"26,426 x DRG Weight",16741,Other,base rate x DRG weight,24586,,"38,809 x DRG Weight",24586,Other,base rate x DRG weight,22420,,"35,391 x DRG Weight",22420,Other,base rate x DRG weight,38262,70,,38262,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,15974,,"25,216 X DRG Weight",15974,Other,Base Weight X DRG Weight,14377,,"22,695 X DRG Weight",14377,Other,Base Weight X DRG Weight,15974,,"25,216 X DRG Weight",15974,Other,Base Rate x DRG Weight ,13578,,"21,433 x DRG Weight",13578,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,38262,
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,,inpatient,,,167772.02,22529,,,22529,Other,150% of Medicare + 9.63% HCRA Surcharge,13700.31,,,13700.31,Other,Medicare IPPS methodology,38270,,"25,728 x DRG weight",38270,Other,base rate x DRG weight,34443,,"23,155 x DRG weight",34443,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,83886,50,,83886,Percent of Total Billed Charges,50% of Charges,43280,,"29,096 x DRG Weight",43280,Other,base rate x DRG weight,33414,,"22,463 x DRG Weight",33414,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39309,,"26,426 x DRG Weight",39309,Other,base rate x DRG weight,57728,,"38,809 x DRG Weight",57728,Other,base rate x DRG weight,57728,,"38,809 x DRG Weight",57728,Other,base rate x DRG weight,39309,,"26,426 x DRG Weight",39309,Other,base rate x DRG weight,57728,,"38,809 x DRG Weight",57728,Other,base rate x DRG weight,52644,,"35,391 x DRG Weight",52644,Other,base rate x DRG weight,117440,70,,117440,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37509,,"25,216 X DRG Weight",37509,Other,Base Weight X DRG Weight,33759,,"22,695 X DRG Weight",33759,Other,Base Weight X DRG Weight,37509,,"25,216 X DRG Weight",37509,Other,Base Rate x DRG Weight ,31882,,"21,433 x DRG Weight",31882,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,117440,
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,,inpatient,,,93896.51,13590,,,13590,Other,150% of Medicare + 9.63% HCRA Surcharge,8263.97,,,8263.97,Other,Medicare IPPS methodology,22762,,"25,728 x DRG weight",22762,Other,base rate x DRG weight,20485,,"23,155 x DRG weight",20485,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46948,50,,46948,Percent of Total Billed Charges,50% of Charges,25741,,"29,096 x DRG Weight",25741,Other,base rate x DRG weight,19873,,"22,463 x DRG Weight",19873,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23379,,"26,426 x DRG Weight",23379,Other,base rate x DRG weight,34334,,"38,809 x DRG Weight",34334,Other,base rate x DRG weight,34334,,"38,809 x DRG Weight",34334,Other,base rate x DRG weight,23379,,"26,426 x DRG Weight",23379,Other,base rate x DRG weight,34334,,"38,809 x DRG Weight",34334,Other,base rate x DRG weight,31310,,"35,391 x DRG Weight",31310,Other,base rate x DRG weight,65728,70,,65728,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22309,,"25,216 X DRG Weight",22309,Other,Base Weight X DRG Weight,20078,,"22,695 X DRG Weight",20078,Other,Base Weight X DRG Weight,22309,,"25,216 X DRG Weight",22309,Other,Base Rate x DRG Weight ,18962,,"21,433 x DRG Weight",18962,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,65728,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,,inpatient,,,201464.97,22807,,,22807,Other,150% of Medicare + 9.63% HCRA Surcharge,13868.95,,,13868.95,Other,Medicare IPPS methodology,38752,,"25,728 x DRG weight",38752,Other,base rate x DRG weight,34876,,"23,155 x DRG weight",34876,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,100732,50,,100732,Percent of Total Billed Charges,50% of Charges,43824,,"29,096 x DRG Weight",43824,Other,base rate x DRG weight,33834,,"22,463 x DRG Weight",33834,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39803,,"26,426 x DRG Weight",39803,Other,base rate x DRG weight,58454,,"38,809 x DRG Weight",58454,Other,base rate x DRG weight,58454,,"38,809 x DRG Weight",58454,Other,base rate x DRG weight,39803,,"26,426 x DRG Weight",39803,Other,base rate x DRG weight,58454,,"38,809 x DRG Weight",58454,Other,base rate x DRG weight,53306,,"35,391 x DRG Weight",53306,Other,base rate x DRG weight,141025,70,,141025,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37980,,"25,216 X DRG Weight",37980,Other,Base Weight X DRG Weight,34183,,"22,695 X DRG Weight",34183,Other,Base Weight X DRG Weight,37980,,"25,216 X DRG Weight",37980,Other,Base Rate x DRG Weight ,32282,,"21,433 x DRG Weight",32282,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,141025,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,,inpatient,,,101598.7,13947,,,13947,Other,150% of Medicare + 9.63% HCRA Surcharge,8481.31,,,8481.31,Other,Medicare IPPS methodology,23382,,"25,728 x DRG weight",23382,Other,base rate x DRG weight,21043,,"23,155 x DRG weight",21043,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,50799,50,,50799,Percent of Total Billed Charges,50% of Charges,26442,,"29,096 x DRG Weight",26442,Other,base rate x DRG weight,20414,,"22,463 x DRG Weight",20414,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,24016,,"26,426 x DRG Weight",24016,Other,base rate x DRG weight,35270,,"38,809 x DRG Weight",35270,Other,base rate x DRG weight,35270,,"38,809 x DRG Weight",35270,Other,base rate x DRG weight,24016,,"26,426 x DRG Weight",24016,Other,base rate x DRG weight,35270,,"38,809 x DRG Weight",35270,Other,base rate x DRG weight,32163,,"35,391 x DRG Weight",32163,Other,base rate x DRG weight,71119,70,,71119,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22916,,"25,216 X DRG Weight",22916,Other,Base Weight X DRG Weight,20625,,"22,695 X DRG Weight",20625,Other,Base Weight X DRG Weight,22916,,"25,216 X DRG Weight",22916,Other,Base Rate x DRG Weight ,19478,,"21,433 x DRG Weight",19478,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,71119,
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,,inpatient,,,288867.89,23987,,,23987,Other,150% of Medicare + 9.63% HCRA Surcharge,14586.83,,,14586.83,Other,Medicare IPPS methodology,40799,,"25,728 x DRG weight",40799,Other,base rate x DRG weight,36719,,"23,155 x DRG weight",36719,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,144434,50,,144434,Percent of Total Billed Charges,50% of Charges,46140,,"29,096 x DRG Weight",46140,Other,base rate x DRG weight,35622,,"22,463 x DRG Weight",35622,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41906,,"26,426 x DRG Weight",41906,Other,base rate x DRG weight,61543,,"38,809 x DRG Weight",61543,Other,base rate x DRG weight,61543,,"38,809 x DRG Weight",61543,Other,base rate x DRG weight,41906,,"26,426 x DRG Weight",41906,Other,base rate x DRG weight,61543,,"38,809 x DRG Weight",61543,Other,base rate x DRG weight,56123,,"35,391 x DRG Weight",56123,Other,base rate x DRG weight,202208,70,,202208,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39988,,"25,216 X DRG Weight",39988,Other,Base Weight X DRG Weight,35990,,"22,695 X DRG Weight",35990,Other,Base Weight X DRG Weight,39988,,"25,216 X DRG Weight",39988,Other,Base Rate x DRG Weight ,33988,,"21,433 x DRG Weight",33988,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,202208,
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,,inpatient,,,124704.26,13720,,,13720,Other,150% of Medicare + 9.63% HCRA Surcharge,8343.33,,,8343.33,Other,Medicare IPPS methodology,22988,,"25,728 x DRG weight",22988,Other,base rate x DRG weight,20689,,"23,155 x DRG weight",20689,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,62352,50,,62352,Percent of Total Billed Charges,50% of Charges,25997,,"29,096 x DRG Weight",25997,Other,base rate x DRG weight,20071,,"22,463 x DRG Weight",20071,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23612,,"26,426 x DRG Weight",23612,Other,base rate x DRG weight,34676,,"38,809 x DRG Weight",34676,Other,base rate x DRG weight,34676,,"38,809 x DRG Weight",34676,Other,base rate x DRG weight,23612,,"26,426 x DRG Weight",23612,Other,base rate x DRG weight,34676,,"38,809 x DRG Weight",34676,Other,base rate x DRG weight,31622,,"35,391 x DRG Weight",31622,Other,base rate x DRG weight,87293,70,,87293,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22530,,"25,216 X DRG Weight",22530,Other,Base Weight X DRG Weight,20278,,"22,695 X DRG Weight",20278,Other,Base Weight X DRG Weight,22530,,"25,216 X DRG Weight",22530,Other,Base Rate x DRG Weight ,19150,,"21,433 x DRG Weight",19150,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,87293,
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,,inpatient,,,290925.87,33873,,,33873,Other,150% of Medicare + 9.63% HCRA Surcharge,20598.54,,,20598.54,Other,Medicare IPPS methodology,57950,,"25,728 x DRG weight",57950,Other,base rate x DRG weight,52154,,"23,155 x DRG weight",52154,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,145463,50,,145463,Percent of Total Billed Charges,50% of Charges,65536,,"29,096 x DRG Weight",65536,Other,base rate x DRG weight,50596,,"22,463 x DRG Weight",50596,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,59522,,"26,426 x DRG Weight",59522,Other,base rate x DRG weight,87413,,"38,809 x DRG Weight",87413,Other,base rate x DRG weight,87413,,"38,809 x DRG Weight",87413,Other,base rate x DRG weight,59522,,"26,426 x DRG Weight",59522,Other,base rate x DRG weight,87413,,"38,809 x DRG Weight",87413,Other,base rate x DRG weight,79715,,"35,391 x DRG Weight",79715,Other,base rate x DRG weight,203648,70,,203648,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,56797,,"25,216 X DRG Weight",56797,Other,Base Weight X DRG Weight,51118,,"22,695 X DRG Weight",51118,Other,Base Weight X DRG Weight,56797,,"25,216 X DRG Weight",56797,Other,Base Rate x DRG Weight ,48276,,"21,433 x DRG Weight",48276,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,203648,
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,,inpatient,,,252737.71,22286,,,22286,Other,150% of Medicare + 9.63% HCRA Surcharge,13552.41,,,13552.41,Other,Medicare IPPS methodology,37848,,"25,728 x DRG weight",37848,Other,base rate x DRG weight,34063,,"23,155 x DRG weight",34063,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,126369,50,,126369,Percent of Total Billed Charges,50% of Charges,42803,,"29,096 x DRG Weight",42803,Other,base rate x DRG weight,33045,,"22,463 x DRG Weight",33045,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,38875,,"26,426 x DRG Weight",38875,Other,base rate x DRG weight,57092,,"38,809 x DRG Weight",57092,Other,base rate x DRG weight,57092,,"38,809 x DRG Weight",57092,Other,base rate x DRG weight,38875,,"26,426 x DRG Weight",38875,Other,base rate x DRG weight,57092,,"38,809 x DRG Weight",57092,Other,base rate x DRG weight,52064,,"35,391 x DRG Weight",52064,Other,base rate x DRG weight,176916,70,,176916,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37095,,"25,216 X DRG Weight",37095,Other,Base Weight X DRG Weight,33387,,"22,695 X DRG Weight",33387,Other,Base Weight X DRG Weight,37095,,"25,216 X DRG Weight",37095,Other,Base Rate x DRG Weight ,31530,,"21,433 x DRG Weight",31530,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,176916,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,,inpatient,,,496608.26,59164,,,59164,Other,150% of Medicare + 9.63% HCRA Surcharge,35977.76,,,35977.76,Other,Medicare IPPS methodology,101824,,"25,728 x DRG weight",101824,Other,base rate x DRG weight,91641,,"23,155 x DRG weight",91641,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,248304,50,,248304,Percent of Total Billed Charges,50% of Charges,115153,,"29,096 x DRG Weight",115153,Other,base rate x DRG weight,88902,,"22,463 x DRG Weight",88902,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,104586,,"26,426 x DRG Weight",104586,Other,base rate x DRG weight,153594,,"38,809 x DRG Weight",153594,Other,base rate x DRG weight,153594,,"38,809 x DRG Weight",153594,Other,base rate x DRG weight,104586,,"26,426 x DRG Weight",104586,Other,base rate x DRG weight,153594,,"38,809 x DRG Weight",153594,Other,base rate x DRG weight,140067,,"35,391 x DRG Weight",140067,Other,base rate x DRG weight,347626,70,,347626,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,99797,,"25,216 X DRG Weight",99797,Other,Base Weight X DRG Weight,89820,,"22,695 X DRG Weight",89820,Other,Base Weight X DRG Weight,99797,,"25,216 X DRG Weight",99797,Other,Base Rate x DRG Weight ,84825,,"21,433 x DRG Weight",84825,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,347626,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,,inpatient,,,211436.08,29900,,,29900,Other,150% of Medicare + 9.63% HCRA Surcharge,18182.49,,,18182.49,Other,Medicare IPPS methodology,51057,,"25,728 x DRG weight",51057,Other,base rate x DRG weight,45951,,"23,155 x DRG weight",45951,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,105718,50,,105718,Percent of Total Billed Charges,50% of Charges,57741,,"29,096 x DRG Weight",57741,Other,base rate x DRG weight,44578,,"22,463 x DRG Weight",44578,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,52442,,"26,426 x DRG Weight",52442,Other,base rate x DRG weight,77016,,"38,809 x DRG Weight",77016,Other,base rate x DRG weight,77016,,"38,809 x DRG Weight",77016,Other,base rate x DRG weight,52442,,"26,426 x DRG Weight",52442,Other,base rate x DRG weight,77016,,"38,809 x DRG Weight",77016,Other,base rate x DRG weight,70233,,"35,391 x DRG Weight",70233,Other,base rate x DRG weight,148005,70,,148005,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,50041,,"25,216 X DRG Weight",50041,Other,Base Weight X DRG Weight,45038,,"22,695 X DRG Weight",45038,Other,Base Weight X DRG Weight,50041,,"25,216 X DRG Weight",50041,Other,Base Rate x DRG Weight ,42534,,"21,433 x DRG Weight",42534,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,148005,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,MS-DRG,,,,,,,,inpatient,,,82460.9,17695,,,17695,Other,150% of Medicare + 9.63% HCRA Surcharge,10760.28,,,10760.28,Other,Medicare IPPS methodology,29883,,"25,728 x DRG weight",29883,Other,base rate x DRG weight,26895,,"23,155 x DRG weight",26895,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,41230,50,,41230,Percent of Total Billed Charges,50% of Charges,33795,,"29,096 x DRG Weight",33795,Other,base rate x DRG weight,26091,,"22,463 x DRG Weight",26091,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,30694,,"26,426 x DRG Weight",30694,Other,base rate x DRG weight,45077,,"38,809 x DRG Weight",45077,Other,base rate x DRG weight,45077,,"38,809 x DRG Weight",45077,Other,base rate x DRG weight,30694,,"26,426 x DRG Weight",30694,Other,base rate x DRG weight,45077,,"38,809 x DRG Weight",45077,Other,base rate x DRG weight,41107,,"35,391 x DRG Weight",41107,Other,base rate x DRG weight,57723,70,,57723,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,29288,,"25,216 X DRG Weight",29288,Other,Base Weight X DRG Weight,26360,,"22,695 X DRG Weight",26360,Other,Base Weight X DRG Weight,29288,,"25,216 X DRG Weight",29288,Other,Base Rate x DRG Weight ,24894,,"21,433 x DRG Weight",24894,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,57723,
O.R. PROCEDURES FOR OBESITY WITH MCC,619,MS-DRG,,,,,,,,inpatient,,,65001.95,39065,,,39065,Other,150% of Medicare + 9.63% HCRA Surcharge,23755.91,,,23755.91,Other,Medicare IPPS methodology,66957,,"25,728 x DRG weight",66957,Other,base rate x DRG weight,60261,,"23,155 x DRG weight",60261,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32501,50,,32501,Percent of Total Billed Charges,50% of Charges,75722,,"29,096 x DRG Weight",75722,Other,base rate x DRG weight,58460,,"22,463 x DRG Weight",58460,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,68774,,"26,426 x DRG Weight",68774,Other,base rate x DRG weight,101000,,"38,809 x DRG Weight",101000,Other,base rate x DRG weight,101000,,"38,809 x DRG Weight",101000,Other,base rate x DRG weight,68774,,"26,426 x DRG Weight",68774,Other,base rate x DRG weight,101000,,"38,809 x DRG Weight",101000,Other,base rate x DRG weight,92105,,"35,391 x DRG Weight",92105,Other,base rate x DRG weight,45501,70,,45501,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,65625,,"25,216 X DRG Weight",65625,Other,Base Weight X DRG Weight,59064,,"22,695 X DRG Weight",59064,Other,Base Weight X DRG Weight,65625,,"25,216 X DRG Weight",65625,Other,Base Rate x DRG Weight ,55779,,"21,433 x DRG Weight",55779,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,101000,
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,,inpatient,,,76851.85,24527,,,24527,Other,150% of Medicare + 9.63% HCRA Surcharge,14915.1,,,14915.1,Other,Medicare IPPS methodology,41736,,"25,728 x DRG weight",41736,Other,base rate x DRG weight,37562,,"23,155 x DRG weight",37562,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,38426,50,,38426,Percent of Total Billed Charges,50% of Charges,47200,,"29,096 x DRG Weight",47200,Other,base rate x DRG weight,36439,,"22,463 x DRG Weight",36439,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,42868,,"26,426 x DRG Weight",42868,Other,base rate x DRG weight,62956,,"38,809 x DRG Weight",62956,Other,base rate x DRG weight,62956,,"38,809 x DRG Weight",62956,Other,base rate x DRG weight,42868,,"26,426 x DRG Weight",42868,Other,base rate x DRG weight,62956,,"38,809 x DRG Weight",62956,Other,base rate x DRG weight,57411,,"35,391 x DRG Weight",57411,Other,base rate x DRG weight,53796,70,,53796,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40905,,"25,216 X DRG Weight",40905,Other,Base Weight X DRG Weight,36816,,"22,695 X DRG Weight",36816,Other,Base Weight X DRG Weight,40905,,"25,216 X DRG Weight",40905,Other,Base Rate x DRG Weight ,34769,,"21,433 x DRG Weight",34769,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,62956,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,,inpatient,,,1025121.9,57205,,,57205,Other,150% of Medicare + 9.63% HCRA Surcharge,34786.42,,,34786.42,Other,Medicare IPPS methodology,98425,,"25,728 x DRG weight",98425,Other,base rate x DRG weight,88582,,"23,155 x DRG weight",88582,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,512561,50,,512561,Percent of Total Billed Charges,50% of Charges,111310,,"29,096 x DRG Weight",111310,Other,base rate x DRG weight,85934,,"22,463 x DRG Weight",85934,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,101095,,"26,426 x DRG Weight",101095,Other,base rate x DRG weight,148468,,"38,809 x DRG Weight",148468,Other,base rate x DRG weight,148468,,"38,809 x DRG Weight",148468,Other,base rate x DRG weight,101095,,"26,426 x DRG Weight",101095,Other,base rate x DRG weight,148468,,"38,809 x DRG Weight",148468,Other,base rate x DRG weight,135392,,"35,391 x DRG Weight",135392,Other,base rate x DRG weight,717585,70,,717585,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,96466,,"25,216 X DRG Weight",96466,Other,Base Weight X DRG Weight,86822,,"22,695 X DRG Weight",86822,Other,Base Weight X DRG Weight,96466,,"25,216 X DRG Weight",96466,Other,Base Rate x DRG Weight ,81994,,"21,433 x DRG Weight",81994,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,717585,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,,inpatient,,,335410.92,28075,,,28075,Other,150% of Medicare + 9.63% HCRA Surcharge,17072.32,,,17072.32,Other,Medicare IPPS methodology,47890,,"25,728 x DRG weight",47890,Other,base rate x DRG weight,43101,,"23,155 x DRG weight",43101,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,167705,50,,167705,Percent of Total Billed Charges,50% of Charges,54159,,"29,096 x DRG Weight",54159,Other,base rate x DRG weight,41813,,"22,463 x DRG Weight",41813,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,49189,,"26,426 x DRG Weight",49189,Other,base rate x DRG weight,72239,,"38,809 x DRG Weight",72239,Other,base rate x DRG weight,72239,,"38,809 x DRG Weight",72239,Other,base rate x DRG weight,49189,,"26,426 x DRG Weight",49189,Other,base rate x DRG weight,72239,,"38,809 x DRG Weight",72239,Other,base rate x DRG weight,65877,,"35,391 x DRG Weight",65877,Other,base rate x DRG weight,234788,70,,234788,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46937,,"25,216 X DRG Weight",46937,Other,Base Weight X DRG Weight,42244,,"22,695 X DRG Weight",42244,Other,Base Weight X DRG Weight,46937,,"25,216 X DRG Weight",46937,Other,Base Rate x DRG Weight ,39895,,"21,433 x DRG Weight",39895,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,234788,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,MS-DRG,,,,,,,,inpatient,,,82460.9,16998,,,16998,Other,150% of Medicare + 9.63% HCRA Surcharge,10336.42,,,10336.42,Other,Medicare IPPS methodology,28674,,"25,728 x DRG weight",28674,Other,base rate x DRG weight,25806,,"23,155 x DRG weight",25806,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,41230,50,,41230,Percent of Total Billed Charges,50% of Charges,32427,,"29,096 x DRG Weight",32427,Other,base rate x DRG weight,25035,,"22,463 x DRG Weight",25035,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,29452,,"26,426 x DRG Weight",29452,Other,base rate x DRG weight,43253,,"38,809 x DRG Weight",43253,Other,base rate x DRG weight,43253,,"38,809 x DRG Weight",43253,Other,base rate x DRG weight,29452,,"26,426 x DRG Weight",29452,Other,base rate x DRG weight,43253,,"38,809 x DRG Weight",43253,Other,base rate x DRG weight,39443,,"35,391 x DRG Weight",39443,Other,base rate x DRG weight,57723,70,,57723,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,28103,,"25,216 X DRG Weight",28103,Other,Base Weight X DRG Weight,25294,,"22,695 X DRG Weight",25294,Other,Base Weight X DRG Weight,28103,,"25,216 X DRG Weight",28103,Other,Base Rate x DRG Weight ,23887,,"21,433 x DRG Weight",23887,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,57723,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,MS-DRG,,,,,,,,inpatient,,,458181.8,43792,,,43792,Other,150% of Medicare + 9.63% HCRA Surcharge,26630.1,,,26630.1,Other,Medicare IPPS methodology,75157,,"25,728 x DRG weight",75157,Other,base rate x DRG weight,67640,,"23,155 x DRG weight",67640,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,229091,50,,229091,Percent of Total Billed Charges,50% of Charges,84995,,"29,096 x DRG Weight",84995,Other,base rate x DRG weight,65619,,"22,463 x DRG Weight",65619,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,77196,,"26,426 x DRG Weight",77196,Other,base rate x DRG weight,113369,,"38,809 x DRG Weight",113369,Other,base rate x DRG weight,113369,,"38,809 x DRG Weight",113369,Other,base rate x DRG weight,77196,,"26,426 x DRG Weight",77196,Other,base rate x DRG weight,113369,,"38,809 x DRG Weight",113369,Other,base rate x DRG weight,103384,,"35,391 x DRG Weight",103384,Other,base rate x DRG weight,320727,70,,320727,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,73661,,"25,216 X DRG Weight",73661,Other,Base Weight X DRG Weight,66297,,"22,695 X DRG Weight",66297,Other,Base Weight X DRG Weight,73661,,"25,216 X DRG Weight",73661,Other,Base Rate x DRG Weight ,62610,,"21,433 x DRG Weight",62610,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,320727,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,MS-DRG,,,,,,,,inpatient,,,205070.14,22595,,,22595,Other,150% of Medicare + 9.63% HCRA Surcharge,13739.99,,,13739.99,Other,Medicare IPPS methodology,38384,,"25,728 x DRG weight",38384,Other,base rate x DRG weight,34545,,"23,155 x DRG weight",34545,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,102535,50,,102535,Percent of Total Billed Charges,50% of Charges,43408,,"29,096 x DRG Weight",43408,Other,base rate x DRG weight,33513,,"22,463 x DRG Weight",33513,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39425,,"26,426 x DRG Weight",39425,Other,base rate x DRG weight,57899,,"38,809 x DRG Weight",57899,Other,base rate x DRG weight,57899,,"38,809 x DRG Weight",57899,Other,base rate x DRG weight,39425,,"26,426 x DRG Weight",39425,Other,base rate x DRG weight,57899,,"38,809 x DRG Weight",57899,Other,base rate x DRG weight,52800,,"35,391 x DRG Weight",52800,Other,base rate x DRG weight,143549,70,,143549,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37620,,"25,216 X DRG Weight",37620,Other,Base Weight X DRG Weight,33859,,"22,695 X DRG Weight",33859,Other,Base Weight X DRG Weight,37620,,"25,216 X DRG Weight",37620,Other,Base Rate x DRG Weight ,31976,,"21,433 x DRG Weight",31976,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,143549,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,MS-DRG,,,,,,,,inpatient,,,115715.03,18800,,,18800,Other,150% of Medicare + 9.63% HCRA Surcharge,11432.16,,,11432.16,Other,Medicare IPPS methodology,31800,,"25,728 x DRG weight",31800,Other,base rate x DRG weight,28620,,"23,155 x DRG weight",28620,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,57858,50,,57858,Percent of Total Billed Charges,50% of Charges,35963,,"29,096 x DRG Weight",35963,Other,base rate x DRG weight,27764,,"22,463 x DRG Weight",27764,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,32663,,"26,426 x DRG Weight",32663,Other,base rate x DRG weight,47968,,"38,809 x DRG Weight",47968,Other,base rate x DRG weight,47968,,"38,809 x DRG Weight",47968,Other,base rate x DRG weight,32663,,"26,426 x DRG Weight",32663,Other,base rate x DRG weight,47968,,"38,809 x DRG Weight",47968,Other,base rate x DRG weight,43743,,"35,391 x DRG Weight",43743,Other,base rate x DRG weight,81001,70,,81001,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,31167,,"25,216 X DRG Weight",31167,Other,Base Weight X DRG Weight,28051,,"22,695 X DRG Weight",28051,Other,Base Weight X DRG Weight,31167,,"25,216 X DRG Weight",31167,Other,Base Rate x DRG Weight ,26491,,"21,433 x DRG Weight",26491,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,81001,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,,inpatient,,,493924.97,60006,,,60006,Other,150% of Medicare + 9.63% HCRA Surcharge,36490.01,,,36490.01,Other,Medicare IPPS methodology,103285,,"25,728 x DRG weight",103285,Other,base rate x DRG weight,92956,,"23,155 x DRG weight",92956,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,246962,50,,246962,Percent of Total Billed Charges,50% of Charges,116806,,"29,096 x DRG Weight",116806,Other,base rate x DRG weight,90178,,"22,463 x DRG Weight",90178,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,106087,,"26,426 x DRG Weight",106087,Other,base rate x DRG weight,155799,,"38,809 x DRG Weight",155799,Other,base rate x DRG weight,155799,,"38,809 x DRG Weight",155799,Other,base rate x DRG weight,106087,,"26,426 x DRG Weight",106087,Other,base rate x DRG weight,155799,,"38,809 x DRG Weight",155799,Other,base rate x DRG weight,142077,,"35,391 x DRG Weight",142077,Other,base rate x DRG weight,345747,70,,345747,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,101230,,"25,216 X DRG Weight",101230,Other,Base Weight X DRG Weight,91109,,"22,695 X DRG Weight",91109,Other,Base Weight X DRG Weight,101230,,"25,216 X DRG Weight",101230,Other,Base Rate x DRG Weight ,86043,,"21,433 x DRG Weight",86043,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,345747,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,,inpatient,,,254257.07,34028,,,34028,Other,150% of Medicare + 9.63% HCRA Surcharge,20692.34,,,20692.34,Other,Medicare IPPS methodology,58217,,"25,728 x DRG weight",58217,Other,base rate x DRG weight,52395,,"23,155 x DRG weight",52395,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,127129,50,,127129,Percent of Total Billed Charges,50% of Charges,65838,,"29,096 x DRG Weight",65838,Other,base rate x DRG weight,50829,,"22,463 x DRG Weight",50829,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,59797,,"26,426 x DRG Weight",59797,Other,base rate x DRG weight,87817,,"38,809 x DRG Weight",87817,Other,base rate x DRG weight,87817,,"38,809 x DRG Weight",87817,Other,base rate x DRG weight,59797,,"26,426 x DRG Weight",59797,Other,base rate x DRG weight,87817,,"38,809 x DRG Weight",87817,Other,base rate x DRG weight,80083,,"35,391 x DRG Weight",80083,Other,base rate x DRG weight,177980,70,,177980,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,57059,,"25,216 X DRG Weight",57059,Other,Base Weight X DRG Weight,51354,,"22,695 X DRG Weight",51354,Other,Base Weight X DRG Weight,57059,,"25,216 X DRG Weight",57059,Other,Base Rate x DRG Weight ,48499,,"21,433 x DRG Weight",48499,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,177980,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,,inpatient,,,255914.82,21177,,,21177,Other,150% of Medicare + 9.63% HCRA Surcharge,12877.82,,,12877.82,Other,Medicare IPPS methodology,35924,,"25,728 x DRG weight",35924,Other,base rate x DRG weight,32331,,"23,155 x DRG weight",32331,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,127957,50,,127957,Percent of Total Billed Charges,50% of Charges,40627,,"29,096 x DRG Weight",40627,Other,base rate x DRG weight,31365,,"22,463 x DRG Weight",31365,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,36899,,"26,426 x DRG Weight",36899,Other,base rate x DRG weight,54189,,"38,809 x DRG Weight",54189,Other,base rate x DRG weight,54189,,"38,809 x DRG Weight",54189,Other,base rate x DRG weight,36899,,"26,426 x DRG Weight",36899,Other,base rate x DRG weight,54189,,"38,809 x DRG Weight",54189,Other,base rate x DRG weight,49416,,"35,391 x DRG Weight",49416,Other,base rate x DRG weight,179140,70,,179140,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35209,,"25,216 X DRG Weight",35209,Other,Base Weight X DRG Weight,31689,,"22,695 X DRG Weight",31689,Other,Base Weight X DRG Weight,35209,,"25,216 X DRG Weight",35209,Other,Base Rate x DRG Weight ,29927,,"21,433 x DRG Weight",29927,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,179140,
DIABETES WITH MCC,637,MS-DRG,,,,,,,,inpatient,,,159288.06,21963,,,21963,Other,150% of Medicare + 9.63% HCRA Surcharge,13355.8,,,13355.8,Other,Medicare IPPS methodology,37288,,"25,728 x DRG weight",37288,Other,base rate x DRG weight,33559,,"23,155 x DRG weight",33559,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,79644,50,,79644,Percent of Total Billed Charges,50% of Charges,42169,,"29,096 x DRG Weight",42169,Other,base rate x DRG weight,32556,,"22,463 x DRG Weight",32556,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,38299,,"26,426 x DRG Weight",38299,Other,base rate x DRG weight,56246,,"38,809 x DRG Weight",56246,Other,base rate x DRG weight,56246,,"38,809 x DRG Weight",56246,Other,base rate x DRG weight,38299,,"26,426 x DRG Weight",38299,Other,base rate x DRG weight,56246,,"38,809 x DRG Weight",56246,Other,base rate x DRG weight,51292,,"35,391 x DRG Weight",51292,Other,base rate x DRG weight,111502,70,,111502,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,36546,,"25,216 X DRG Weight",36546,Other,Base Weight X DRG Weight,32892,,"22,695 X DRG Weight",32892,Other,Base Weight X DRG Weight,36546,,"25,216 X DRG Weight",36546,Other,Base Rate x DRG Weight ,31063,,"21,433 x DRG Weight",31063,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,111502,
DIABETES WITH CC,638,MS-DRG,,,,,,,,inpatient,,,110017.24,13808,,,13808,Other,150% of Medicare + 9.63% HCRA Surcharge,8396.54,,,8396.54,Other,Medicare IPPS methodology,23140,,"25,728 x DRG weight",23140,Other,base rate x DRG weight,20826,,"23,155 x DRG weight",20826,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,55009,50,,55009,Percent of Total Billed Charges,50% of Charges,26169,,"29,096 x DRG Weight",26169,Other,base rate x DRG weight,20203,,"22,463 x DRG Weight",20203,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23768,,"26,426 x DRG Weight",23768,Other,base rate x DRG weight,34905,,"38,809 x DRG Weight",34905,Other,base rate x DRG weight,34905,,"38,809 x DRG Weight",34905,Other,base rate x DRG weight,23768,,"26,426 x DRG Weight",23768,Other,base rate x DRG weight,34905,,"38,809 x DRG Weight",34905,Other,base rate x DRG weight,31831,,"35,391 x DRG Weight",31831,Other,base rate x DRG weight,77012,70,,77012,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22679,,"25,216 X DRG Weight",22679,Other,Base Weight X DRG Weight,20412,,"22,695 X DRG Weight",20412,Other,Base Weight X DRG Weight,22679,,"25,216 X DRG Weight",22679,Other,Base Rate x DRG Weight ,19277,,"21,433 x DRG Weight",19277,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,77012,
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,,inpatient,,,69968.93,9701,,,9701,Other,150% of Medicare + 9.63% HCRA Surcharge,5899.32,,,5899.32,Other,Medicare IPPS methodology,16016,,"25,728 x DRG weight",16016,Other,base rate x DRG weight,14414,,"23,155 x DRG weight",14414,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,34984,50,,34984,Percent of Total Billed Charges,50% of Charges,18112,,"29,096 x DRG Weight",18112,Other,base rate x DRG weight,13983,,"22,463 x DRG Weight",13983,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,16450,,"26,426 x DRG Weight",16450,Other,base rate x DRG weight,24159,,"38,809 x DRG Weight",24159,Other,base rate x DRG weight,24159,,"38,809 x DRG Weight",24159,Other,base rate x DRG weight,16450,,"26,426 x DRG Weight",16450,Other,base rate x DRG weight,24159,,"38,809 x DRG Weight",24159,Other,base rate x DRG weight,22031,,"35,391 x DRG Weight",22031,Other,base rate x DRG weight,48978,70,,48978,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,15697,,"25,216 X DRG Weight",15697,Other,Base Weight X DRG Weight,14128,,"22,695 X DRG Weight",14128,Other,Base Weight X DRG Weight,15697,,"25,216 X DRG Weight",15697,Other,Base Rate x DRG Weight ,13342,,"21,433 x DRG Weight",13342,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,48978,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,,inpatient,,,195858.9,19974,,,19974,Other,150% of Medicare + 9.63% HCRA Surcharge,12146.42,,,12146.42,Other,Medicare IPPS methodology,33837,,"25,728 x DRG weight",33837,Other,base rate x DRG weight,30453,,"23,155 x DRG weight",30453,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,97929,50,,97929,Percent of Total Billed Charges,50% of Charges,38267,,"29,096 x DRG Weight",38267,Other,base rate x DRG weight,29543,,"22,463 x DRG Weight",29543,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,34755,,"26,426 x DRG Weight",34755,Other,base rate x DRG weight,51042,,"38,809 x DRG Weight",51042,Other,base rate x DRG weight,51042,,"38,809 x DRG Weight",51042,Other,base rate x DRG weight,34755,,"26,426 x DRG Weight",34755,Other,base rate x DRG weight,51042,,"38,809 x DRG Weight",51042,Other,base rate x DRG weight,46546,,"35,391 x DRG Weight",46546,Other,base rate x DRG weight,137101,70,,137101,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,33164,,"25,216 X DRG Weight",33164,Other,Base Weight X DRG Weight,29848,,"22,695 X DRG Weight",29848,Other,Base Weight X DRG Weight,33164,,"25,216 X DRG Weight",33164,Other,Base Rate x DRG Weight ,28189,,"21,433 x DRG Weight",28189,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,137101,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,,inpatient,,,132454.53,12058,,,12058,Other,150% of Medicare + 9.63% HCRA Surcharge,7332.36,,,7332.36,Other,Medicare IPPS methodology,20104,,"25,728 x DRG weight",20104,Other,base rate x DRG weight,18093,,"23,155 x DRG weight",18093,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,66227,50,,66227,Percent of Total Billed Charges,50% of Charges,22736,,"29,096 x DRG Weight",22736,Other,base rate x DRG weight,17553,,"22,463 x DRG Weight",17553,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,20649,,"26,426 x DRG Weight",20649,Other,base rate x DRG weight,30325,,"38,809 x DRG Weight",30325,Other,base rate x DRG weight,30325,,"38,809 x DRG Weight",30325,Other,base rate x DRG weight,20649,,"26,426 x DRG Weight",20649,Other,base rate x DRG weight,30325,,"38,809 x DRG Weight",30325,Other,base rate x DRG weight,27655,,"35,391 x DRG Weight",27655,Other,base rate x DRG weight,92718,70,,92718,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19704,,"25,216 X DRG Weight",19704,Other,Base Weight X DRG Weight,17734,,"22,695 X DRG Weight",17734,Other,Base Weight X DRG Weight,19704,,"25,216 X DRG Weight",19704,Other,Base Rate x DRG Weight ,16748,,"21,433 x DRG Weight",16748,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,92718,
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,,inpatient,,,93890.09,19798,,,19798,Other,150% of Medicare + 9.63% HCRA Surcharge,12039.1,,,12039.1,Other,Medicare IPPS methodology,33531,,"25,728 x DRG weight",33531,Other,base rate x DRG weight,30178,,"23,155 x DRG weight",30178,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46945,50,,46945,Percent of Total Billed Charges,50% of Charges,37921,,"29,096 x DRG Weight",37921,Other,base rate x DRG weight,29276,,"22,463 x DRG Weight",29276,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,34441,,"26,426 x DRG Weight",34441,Other,base rate x DRG weight,50580,,"38,809 x DRG Weight",50580,Other,base rate x DRG weight,50580,,"38,809 x DRG Weight",50580,Other,base rate x DRG weight,34441,,"26,426 x DRG Weight",34441,Other,base rate x DRG weight,50580,,"38,809 x DRG Weight",50580,Other,base rate x DRG weight,46125,,"35,391 x DRG Weight",46125,Other,base rate x DRG weight,65723,70,,65723,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32864,,"25,216 X DRG Weight",32864,Other,Base Weight X DRG Weight,29578,,"22,695 X DRG Weight",29578,Other,Base Weight X DRG Weight,32864,,"25,216 X DRG Weight",32864,Other,Base Rate x DRG Weight ,27934,,"21,433 x DRG Weight",27934,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,65723,
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,,inpatient,,,190340.66,24867,,,24867,Other,150% of Medicare + 9.63% HCRA Surcharge,15121.62,,,15121.62,Other,Medicare IPPS methodology,42325,,"25,728 x DRG weight",42325,Other,base rate x DRG weight,38092,,"23,155 x DRG weight",38092,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,95170,50,,95170,Percent of Total Billed Charges,50% of Charges,47866,,"29,096 x DRG Weight",47866,Other,base rate x DRG weight,36954,,"22,463 x DRG Weight",36954,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,43473,,"26,426 x DRG Weight",43473,Other,base rate x DRG weight,63845,,"38,809 x DRG Weight",63845,Other,base rate x DRG weight,63845,,"38,809 x DRG Weight",63845,Other,base rate x DRG weight,43473,,"26,426 x DRG Weight",43473,Other,base rate x DRG weight,63845,,"38,809 x DRG Weight",63845,Other,base rate x DRG weight,58222,,"35,391 x DRG Weight",58222,Other,base rate x DRG weight,133238,70,,133238,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,41483,,"25,216 X DRG Weight",41483,Other,Base Weight X DRG Weight,37336,,"22,695 X DRG Weight",37336,Other,Base Weight X DRG Weight,41483,,"25,216 X DRG Weight",41483,Other,Base Rate x DRG Weight ,35259,,"21,433 x DRG Weight",35259,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,133238,
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,,inpatient,,,153940.75,16215,,,16215,Other,150% of Medicare + 9.63% HCRA Surcharge,9860.24,,,9860.24,Other,Medicare IPPS methodology,27315,,"25,728 x DRG weight",27315,Other,base rate x DRG weight,24584,,"23,155 x DRG weight",24584,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,76970,50,,76970,Percent of Total Billed Charges,50% of Charges,30891,,"29,096 x DRG Weight",30891,Other,base rate x DRG weight,23849,,"22,463 x DRG Weight",23849,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28056,,"26,426 x DRG Weight",28056,Other,base rate x DRG weight,41204,,"38,809 x DRG Weight",41204,Other,base rate x DRG weight,41204,,"38,809 x DRG Weight",41204,Other,base rate x DRG weight,28056,,"26,426 x DRG Weight",28056,Other,base rate x DRG weight,41204,,"38,809 x DRG Weight",41204,Other,base rate x DRG weight,37575,,"35,391 x DRG Weight",37575,Other,base rate x DRG weight,107759,70,,107759,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,26772,,"25,216 X DRG Weight",26772,Other,Base Weight X DRG Weight,24095,,"22,695 X DRG Weight",24095,Other,Base Weight X DRG Weight,26772,,"25,216 X DRG Weight",26772,Other,Base Rate x DRG Weight ,22755,,"21,433 x DRG Weight",22755,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,107759,
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,,inpatient,,,82997.27,11754,,,11754,Other,150% of Medicare + 9.63% HCRA Surcharge,7147.48,,,7147.48,Other,Medicare IPPS methodology,19576,,"25,728 x DRG weight",19576,Other,base rate x DRG weight,17619,,"23,155 x DRG weight",17619,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,41499,50,,41499,Percent of Total Billed Charges,50% of Charges,22139,,"29,096 x DRG Weight",22139,Other,base rate x DRG weight,17092,,"22,463 x DRG Weight",17092,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,20108,,"26,426 x DRG Weight",20108,Other,base rate x DRG weight,29530,,"38,809 x DRG Weight",29530,Other,base rate x DRG weight,29530,,"38,809 x DRG Weight",29530,Other,base rate x DRG weight,20108,,"26,426 x DRG Weight",20108,Other,base rate x DRG weight,29530,,"38,809 x DRG Weight",29530,Other,base rate x DRG weight,26929,,"35,391 x DRG Weight",26929,Other,base rate x DRG weight,58098,70,,58098,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19187,,"25,216 X DRG Weight",19187,Other,Base Weight X DRG Weight,17269,,"22,695 X DRG Weight",17269,Other,Base Weight X DRG Weight,19187,,"25,216 X DRG Weight",19187,Other,Base Rate x DRG Weight ,16308,,"21,433 x DRG Weight",16308,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,58098,
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,,inpatient,,,995537.36,80755,,,80755,Other,150% of Medicare + 9.63% HCRA Surcharge,49107.76,,,49107.76,Other,Medicare IPPS methodology,139281,,"25,728 x DRG weight",139281,Other,base rate x DRG weight,125352,,"23,155 x DRG weight",125352,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,497769,50,,497769,Percent of Total Billed Charges,50% of Charges,157514,,"29,096 x DRG Weight",157514,Other,base rate x DRG weight,121606,,"22,463 x DRG Weight",121606,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,143060,,"26,426 x DRG Weight",143060,Other,base rate x DRG weight,210096,,"38,809 x DRG Weight",210096,Other,base rate x DRG weight,210096,,"38,809 x DRG Weight",210096,Other,base rate x DRG weight,143060,,"26,426 x DRG Weight",143060,Other,base rate x DRG weight,210096,,"38,809 x DRG Weight",210096,Other,base rate x DRG weight,191593,,"35,391 x DRG Weight",191593,Other,base rate x DRG weight,696876,70,,696876,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,136509,,"25,216 X DRG Weight",136509,Other,Base Weight X DRG Weight,122862,,"22,695 X DRG Weight",122862,Other,Base Weight X DRG Weight,136509,,"25,216 X DRG Weight",136509,Other,Base Rate x DRG Weight ,116030,,"21,433 x DRG Weight",116030,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,696876,
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,,inpatient,,,341123.2,41068,,,41068,Other,150% of Medicare + 9.63% HCRA Surcharge,24973.41,,,24973.41,Other,Medicare IPPS methodology,70430,,"25,728 x DRG weight",70430,Other,base rate x DRG weight,63387,,"23,155 x DRG weight",63387,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,170562,50,,170562,Percent of Total Billed Charges,50% of Charges,79650,,"29,096 x DRG Weight",79650,Other,base rate x DRG weight,61492,,"22,463 x DRG Weight",61492,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,72341,,"26,426 x DRG Weight",72341,Other,base rate x DRG weight,106240,,"38,809 x DRG Weight",106240,Other,base rate x DRG weight,106240,,"38,809 x DRG Weight",106240,Other,base rate x DRG weight,72341,,"26,426 x DRG Weight",72341,Other,base rate x DRG weight,106240,,"38,809 x DRG Weight",106240,Other,base rate x DRG weight,96883,,"35,391 x DRG Weight",96883,Other,base rate x DRG weight,238786,70,,238786,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,69029,,"25,216 X DRG Weight",69029,Other,Base Weight X DRG Weight,62128,,"22,695 X DRG Weight",62128,Other,Base Weight X DRG Weight,69029,,"25,216 X DRG Weight",69029,Other,Base Rate x DRG Weight ,58673,,"21,433 x DRG Weight",58673,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,238786,
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,MS-DRG,,,,,,,,inpatient,,,232323.22,31729,,,31729,Other,150% of Medicare + 9.63% HCRA Surcharge,19294.47,,,19294.47,Other,Medicare IPPS methodology,54229,,"25,728 x DRG weight",54229,Other,base rate x DRG weight,48806,,"23,155 x DRG weight",48806,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,116162,50,,116162,Percent of Total Billed Charges,50% of Charges,61329,,"29,096 x DRG Weight",61329,Other,base rate x DRG weight,47348,,"22,463 x DRG Weight",47348,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,55701,,"26,426 x DRG Weight",55701,Other,base rate x DRG weight,81802,,"38,809 x DRG Weight",81802,Other,base rate x DRG weight,81802,,"38,809 x DRG Weight",81802,Other,base rate x DRG weight,55701,,"26,426 x DRG Weight",55701,Other,base rate x DRG weight,81802,,"38,809 x DRG Weight",81802,Other,base rate x DRG weight,74597,,"35,391 x DRG Weight",74597,Other,base rate x DRG weight,162626,70,,162626,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,53150,,"25,216 X DRG Weight",53150,Other,Base Weight X DRG Weight,47837,,"22,695 X DRG Weight",47837,Other,Base Weight X DRG Weight,53150,,"25,216 X DRG Weight",53150,Other,Base Rate x DRG Weight ,45176,,"21,433 x DRG Weight",45176,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,162626,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,,inpatient,,,427366.57,47001,,,47001,Other,150% of Medicare + 9.63% HCRA Surcharge,28581.7,,,28581.7,Other,Medicare IPPS methodology,80724,,"25,728 x DRG weight",80724,Other,base rate x DRG weight,72651,,"23,155 x DRG weight",72651,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,213683,50,,213683,Percent of Total Billed Charges,50% of Charges,91292,,"29,096 x DRG Weight",91292,Other,base rate x DRG weight,70480,,"22,463 x DRG Weight",70480,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,82914,,"26,426 x DRG Weight",82914,Other,base rate x DRG weight,121767,,"38,809 x DRG Weight",121767,Other,base rate x DRG weight,121767,,"38,809 x DRG Weight",121767,Other,base rate x DRG weight,82914,,"26,426 x DRG Weight",82914,Other,base rate x DRG weight,121767,,"38,809 x DRG Weight",121767,Other,base rate x DRG weight,111043,,"35,391 x DRG Weight",111043,Other,base rate x DRG weight,299157,70,,299157,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,79118,,"25,216 X DRG Weight",79118,Other,Base Weight X DRG Weight,71208,,"22,695 X DRG Weight",71208,Other,Base Weight X DRG Weight,79118,,"25,216 X DRG Weight",79118,Other,Base Rate x DRG Weight ,67248,,"21,433 x DRG Weight",67248,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,299157,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,,inpatient,,,168435.95,27819,,,27819,Other,150% of Medicare + 9.63% HCRA Surcharge,16917.2,,,16917.2,Other,Medicare IPPS methodology,47448,,"25,728 x DRG weight",47448,Other,base rate x DRG weight,42702,,"23,155 x DRG weight",42702,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,84218,50,,84218,Percent of Total Billed Charges,50% of Charges,53659,,"29,096 x DRG Weight",53659,Other,base rate x DRG weight,41426,,"22,463 x DRG Weight",41426,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,48735,,"26,426 x DRG Weight",48735,Other,base rate x DRG weight,71572,,"38,809 x DRG Weight",71572,Other,base rate x DRG weight,71572,,"38,809 x DRG Weight",71572,Other,base rate x DRG weight,48735,,"26,426 x DRG Weight",48735,Other,base rate x DRG weight,71572,,"38,809 x DRG Weight",71572,Other,base rate x DRG weight,65268,,"35,391 x DRG Weight",65268,Other,base rate x DRG weight,117905,70,,117905,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46503,,"25,216 X DRG Weight",46503,Other,Base Weight X DRG Weight,41854,,"22,695 X DRG Weight",41854,Other,Base Weight X DRG Weight,46503,,"25,216 X DRG Weight",46503,Other,Base Rate x DRG Weight ,39527,,"21,433 x DRG Weight",39527,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,117905,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,,inpatient,,,79976.07,22424,,,22424,Other,150% of Medicare + 9.63% HCRA Surcharge,13636.28,,,13636.28,Other,Medicare IPPS methodology,38088,,"25,728 x DRG weight",38088,Other,base rate x DRG weight,34279,,"23,155 x DRG weight",34279,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39988,50,,39988,Percent of Total Billed Charges,50% of Charges,43074,,"29,096 x DRG Weight",43074,Other,base rate x DRG weight,33254,,"22,463 x DRG Weight",33254,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39121,,"26,426 x DRG Weight",39121,Other,base rate x DRG weight,57453,,"38,809 x DRG Weight",57453,Other,base rate x DRG weight,57453,,"38,809 x DRG Weight",57453,Other,base rate x DRG weight,39121,,"26,426 x DRG Weight",39121,Other,base rate x DRG weight,57453,,"38,809 x DRG Weight",57453,Other,base rate x DRG weight,52393,,"35,391 x DRG Weight",52393,Other,base rate x DRG weight,55983,70,,55983,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37330,,"25,216 X DRG Weight",37330,Other,Base Weight X DRG Weight,33598,,"22,695 X DRG Weight",33598,Other,Base Weight X DRG Weight,37330,,"25,216 X DRG Weight",37330,Other,Base Rate x DRG Weight ,31729,,"21,433 x DRG Weight",31729,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,57453,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,,inpatient,,,388139.55,38864,,,38864,Other,150% of Medicare + 9.63% HCRA Surcharge,23633.26,,,23633.26,Other,Medicare IPPS methodology,66607,,"25,728 x DRG weight",66607,Other,base rate x DRG weight,59946,,"23,155 x DRG weight",59946,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,194070,50,,194070,Percent of Total Billed Charges,50% of Charges,75327,,"29,096 x DRG Weight",75327,Other,base rate x DRG weight,58154,,"22,463 x DRG Weight",58154,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,68414,,"26,426 x DRG Weight",68414,Other,base rate x DRG weight,100473,,"38,809 x DRG Weight",100473,Other,base rate x DRG weight,100473,,"38,809 x DRG Weight",100473,Other,base rate x DRG weight,68414,,"26,426 x DRG Weight",68414,Other,base rate x DRG weight,100473,,"38,809 x DRG Weight",100473,Other,base rate x DRG weight,91624,,"35,391 x DRG Weight",91624,Other,base rate x DRG weight,271698,70,,271698,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,65282,,"25,216 X DRG Weight",65282,Other,Base Weight X DRG Weight,58755,,"22,695 X DRG Weight",58755,Other,Base Weight X DRG Weight,65282,,"25,216 X DRG Weight",65282,Other,Base Rate x DRG Weight ,55488,,"21,433 x DRG Weight",55488,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,271698,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,,inpatient,,,183635.31,20429,,,20429,Other,150% of Medicare + 9.63% HCRA Surcharge,12423.29,,,12423.29,Other,Medicare IPPS methodology,34627,,"25,728 x DRG weight",34627,Other,base rate x DRG weight,31164,,"23,155 x DRG weight",31164,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,91818,50,,91818,Percent of Total Billed Charges,50% of Charges,39160,,"29,096 x DRG Weight",39160,Other,base rate x DRG weight,30233,,"22,463 x DRG Weight",30233,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,35567,,"26,426 x DRG Weight",35567,Other,base rate x DRG weight,52233,,"38,809 x DRG Weight",52233,Other,base rate x DRG weight,52233,,"38,809 x DRG Weight",52233,Other,base rate x DRG weight,35567,,"26,426 x DRG Weight",35567,Other,base rate x DRG weight,52233,,"38,809 x DRG Weight",52233,Other,base rate x DRG weight,47633,,"35,391 x DRG Weight",47633,Other,base rate x DRG weight,128545,70,,128545,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,33938,,"25,216 X DRG Weight",33938,Other,Base Weight X DRG Weight,30545,,"22,695 X DRG Weight",30545,Other,Base Weight X DRG Weight,33938,,"25,216 X DRG Weight",33938,Other,Base Rate x DRG Weight ,28847,,"21,433 x DRG Weight",28847,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,128545,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,,inpatient,,,97671.39,16017,,,16017,Other,150% of Medicare + 9.63% HCRA Surcharge,9740.29,,,9740.29,Other,Medicare IPPS methodology,26973,,"25,728 x DRG weight",26973,Other,base rate x DRG weight,24276,,"23,155 x DRG weight",24276,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,48836,50,,48836,Percent of Total Billed Charges,50% of Charges,30504,,"29,096 x DRG Weight",30504,Other,base rate x DRG weight,23550,,"22,463 x DRG Weight",23550,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,27705,,"26,426 x DRG Weight",27705,Other,base rate x DRG weight,40687,,"38,809 x DRG Weight",40687,Other,base rate x DRG weight,40687,,"38,809 x DRG Weight",40687,Other,base rate x DRG weight,27705,,"26,426 x DRG Weight",27705,Other,base rate x DRG weight,40687,,"38,809 x DRG Weight",40687,Other,base rate x DRG weight,37104,,"35,391 x DRG Weight",37104,Other,base rate x DRG weight,68370,70,,68370,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,26436,,"25,216 X DRG Weight",26436,Other,Base Weight X DRG Weight,23793,,"22,695 X DRG Weight",23793,Other,Base Weight X DRG Weight,26436,,"25,216 X DRG Weight",26436,Other,Base Rate x DRG Weight ,22470,,"21,433 x DRG Weight",22470,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,68370,
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,,inpatient,,,275160.83,44912,,,44912,Other,150% of Medicare + 9.63% HCRA Surcharge,27311,,,27311,Other,Medicare IPPS methodology,77099,,"25,728 x DRG weight",77099,Other,base rate x DRG weight,69389,,"23,155 x DRG weight",69389,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,137580,50,,137580,Percent of Total Billed Charges,50% of Charges,87192,,"29,096 x DRG Weight",87192,Other,base rate x DRG weight,67315,,"22,463 x DRG Weight",67315,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,79191,,"26,426 x DRG Weight",79191,Other,base rate x DRG weight,116299,,"38,809 x DRG Weight",116299,Other,base rate x DRG weight,116299,,"38,809 x DRG Weight",116299,Other,base rate x DRG weight,79191,,"26,426 x DRG Weight",79191,Other,base rate x DRG weight,116299,,"38,809 x DRG Weight",116299,Other,base rate x DRG weight,106056,,"35,391 x DRG Weight",106056,Other,base rate x DRG weight,192613,70,,192613,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,75565,,"25,216 X DRG Weight",75565,Other,Base Weight X DRG Weight,68010,,"22,695 X DRG Weight",68010,Other,Base Weight X DRG Weight,75565,,"25,216 X DRG Weight",75565,Other,Base Rate x DRG Weight ,64228,,"21,433 x DRG Weight",64228,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,192613,
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,,inpatient,,,169235.84,22107,,,22107,Other,150% of Medicare + 9.63% HCRA Surcharge,13443.28,,,13443.28,Other,Medicare IPPS methodology,37537,,"25,728 x DRG weight",37537,Other,base rate x DRG weight,33783,,"23,155 x DRG weight",33783,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,84618,50,,84618,Percent of Total Billed Charges,50% of Charges,42451,,"29,096 x DRG Weight",42451,Other,base rate x DRG weight,32774,,"22,463 x DRG Weight",32774,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,38556,,"26,426 x DRG Weight",38556,Other,base rate x DRG weight,56622,,"38,809 x DRG Weight",56622,Other,base rate x DRG weight,56622,,"38,809 x DRG Weight",56622,Other,base rate x DRG weight,38556,,"26,426 x DRG Weight",38556,Other,base rate x DRG weight,56622,,"38,809 x DRG Weight",56622,Other,base rate x DRG weight,51635,,"35,391 x DRG Weight",51635,Other,base rate x DRG weight,118465,70,,118465,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,36790,,"25,216 X DRG Weight",36790,Other,Base Weight X DRG Weight,33112,,"22,695 X DRG Weight",33112,Other,Base Weight X DRG Weight,36790,,"25,216 X DRG Weight",36790,Other,Base Rate x DRG Weight ,31271,,"21,433 x DRG Weight",31271,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,118465,
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,,inpatient,,,136684.75,16213,,,16213,Other,150% of Medicare + 9.63% HCRA Surcharge,9859.34,,,9859.34,Other,Medicare IPPS methodology,27313,,"25,728 x DRG weight",27313,Other,base rate x DRG weight,24581,,"23,155 x DRG weight",24581,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,68342,50,,68342,Percent of Total Billed Charges,50% of Charges,30888,,"29,096 x DRG Weight",30888,Other,base rate x DRG weight,23847,,"22,463 x DRG Weight",23847,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28054,,"26,426 x DRG Weight",28054,Other,base rate x DRG weight,41200,,"38,809 x DRG Weight",41200,Other,base rate x DRG weight,41200,,"38,809 x DRG Weight",41200,Other,base rate x DRG weight,28054,,"26,426 x DRG Weight",28054,Other,base rate x DRG weight,41200,,"38,809 x DRG Weight",41200,Other,base rate x DRG weight,37571,,"35,391 x DRG Weight",37571,Other,base rate x DRG weight,95679,70,,95679,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,26769,,"25,216 X DRG Weight",26769,Other,Base Weight X DRG Weight,24093,,"22,695 X DRG Weight",24093,Other,Base Weight X DRG Weight,26769,,"25,216 X DRG Weight",26769,Other,Base Rate x DRG Weight ,22753,,"21,433 x DRG Weight",22753,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,95679,
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,,inpatient,,,166503.8,46282,,,46282,Other,150% of Medicare + 9.63% HCRA Surcharge,28144.31,,,28144.31,Other,Medicare IPPS methodology,79476,,"25,728 x DRG weight",79476,Other,base rate x DRG weight,71528,,"23,155 x DRG weight",71528,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,83252,50,,83252,Percent of Total Billed Charges,50% of Charges,89880,,"29,096 x DRG Weight",89880,Other,base rate x DRG weight,69390,,"22,463 x DRG Weight",69390,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,81633,,"26,426 x DRG Weight",81633,Other,base rate x DRG weight,119885,,"38,809 x DRG Weight",119885,Other,base rate x DRG weight,119885,,"38,809 x DRG Weight",119885,Other,base rate x DRG weight,81633,,"26,426 x DRG Weight",81633,Other,base rate x DRG weight,119885,,"38,809 x DRG Weight",119885,Other,base rate x DRG weight,109326,,"35,391 x DRG Weight",109326,Other,base rate x DRG weight,116553,70,,116553,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,77895,,"25,216 X DRG Weight",77895,Other,Base Weight X DRG Weight,70107,,"22,695 X DRG Weight",70107,Other,Base Weight X DRG Weight,77895,,"25,216 X DRG Weight",77895,Other,Base Rate x DRG Weight ,66209,,"21,433 x DRG Weight",66209,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,119885,
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,,inpatient,,,199155.01,25939,,,25939,Other,150% of Medicare + 9.63% HCRA Surcharge,15773.66,,,15773.66,Other,Medicare IPPS methodology,44185,,"25,728 x DRG weight",44185,Other,base rate x DRG weight,39766,,"23,155 x DRG weight",39766,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,99578,50,,99578,Percent of Total Billed Charges,50% of Charges,49969,,"29,096 x DRG Weight",49969,Other,base rate x DRG weight,38578,,"22,463 x DRG Weight",38578,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,45384,,"26,426 x DRG Weight",45384,Other,base rate x DRG weight,66651,,"38,809 x DRG Weight",66651,Other,base rate x DRG weight,66651,,"38,809 x DRG Weight",66651,Other,base rate x DRG weight,45384,,"26,426 x DRG Weight",45384,Other,base rate x DRG weight,66651,,"38,809 x DRG Weight",66651,Other,base rate x DRG weight,60781,,"35,391 x DRG Weight",60781,Other,base rate x DRG weight,139409,70,,139409,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43306,,"25,216 X DRG Weight",43306,Other,Base Weight X DRG Weight,38976,,"22,695 X DRG Weight",38976,Other,Base Weight X DRG Weight,43306,,"25,216 X DRG Weight",43306,Other,Base Rate x DRG Weight ,36809,,"21,433 x DRG Weight",36809,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,139409,
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,,inpatient,,,67691.82,16035,,,16035,Other,150% of Medicare + 9.63% HCRA Surcharge,9751.12,,,9751.12,Other,Medicare IPPS methodology,27004,,"25,728 x DRG weight",27004,Other,base rate x DRG weight,24303,,"23,155 x DRG weight",24303,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,33846,50,,33846,Percent of Total Billed Charges,50% of Charges,30539,,"29,096 x DRG Weight",30539,Other,base rate x DRG weight,23577,,"22,463 x DRG Weight",23577,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,27737,,"26,426 x DRG Weight",27737,Other,base rate x DRG weight,40734,,"38,809 x DRG Weight",40734,Other,base rate x DRG weight,40734,,"38,809 x DRG Weight",40734,Other,base rate x DRG weight,27737,,"26,426 x DRG Weight",27737,Other,base rate x DRG weight,40734,,"38,809 x DRG Weight",40734,Other,base rate x DRG weight,37146,,"35,391 x DRG Weight",37146,Other,base rate x DRG weight,47384,70,,47384,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,26467,,"25,216 X DRG Weight",26467,Other,Base Weight X DRG Weight,23821,,"22,695 X DRG Weight",23821,Other,Base Weight X DRG Weight,26467,,"25,216 X DRG Weight",26467,Other,Base Rate x DRG Weight ,22496,,"21,433 x DRG Weight",22496,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,47384,
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,,inpatient,,,152868.85,42261,,,42261,Other,150% of Medicare + 9.63% HCRA Surcharge,25699.4,,,25699.4,Other,Medicare IPPS methodology,72502,,"25,728 x DRG weight",72502,Other,base rate x DRG weight,65251,,"23,155 x DRG weight",65251,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,76434,50,,76434,Percent of Total Billed Charges,50% of Charges,81993,,"29,096 x DRG Weight",81993,Other,base rate x DRG weight,63301,,"22,463 x DRG Weight",63301,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,74468,,"26,426 x DRG Weight",74468,Other,base rate x DRG weight,109364,,"38,809 x DRG Weight",109364,Other,base rate x DRG weight,109364,,"38,809 x DRG Weight",109364,Other,base rate x DRG weight,74468,,"26,426 x DRG Weight",74468,Other,base rate x DRG weight,109364,,"38,809 x DRG Weight",109364,Other,base rate x DRG weight,99732,,"35,391 x DRG Weight",99732,Other,base rate x DRG weight,107008,70,,107008,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,71059,,"25,216 X DRG Weight",71059,Other,Base Weight X DRG Weight,63955,,"22,695 X DRG Weight",63955,Other,Base Weight X DRG Weight,71059,,"25,216 X DRG Weight",71059,Other,Base Rate x DRG Weight ,60398,,"21,433 x DRG Weight",60398,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,109364,
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,,inpatient,,,213964.49,23228,,,23228,Other,150% of Medicare + 9.63% HCRA Surcharge,14125.08,,,14125.08,Other,Medicare IPPS methodology,39482,,"25,728 x DRG weight",39482,Other,base rate x DRG weight,35534,,"23,155 x DRG weight",35534,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,106982,50,,106982,Percent of Total Billed Charges,50% of Charges,44651,,"29,096 x DRG Weight",44651,Other,base rate x DRG weight,34472,,"22,463 x DRG Weight",34472,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,40553,,"26,426 x DRG Weight",40553,Other,base rate x DRG weight,59556,,"38,809 x DRG Weight",59556,Other,base rate x DRG weight,59556,,"38,809 x DRG Weight",59556,Other,base rate x DRG weight,40553,,"26,426 x DRG Weight",40553,Other,base rate x DRG weight,59556,,"38,809 x DRG Weight",59556,Other,base rate x DRG weight,54311,,"35,391 x DRG Weight",54311,Other,base rate x DRG weight,149775,70,,149775,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,38696,,"25,216 X DRG Weight",38696,Other,Base Weight X DRG Weight,34828,,"22,695 X DRG Weight",34828,Other,Base Weight X DRG Weight,38696,,"25,216 X DRG Weight",38696,Other,Base Rate x DRG Weight ,32891,,"21,433 x DRG Weight",32891,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,149775,
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,,inpatient,,,111634.82,14745,,,14745,Other,150% of Medicare + 9.63% HCRA Surcharge,8966.51,,,8966.51,Other,Medicare IPPS methodology,24766,,"25,728 x DRG weight",24766,Other,base rate x DRG weight,22289,,"23,155 x DRG weight",22289,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,55817,50,,55817,Percent of Total Billed Charges,50% of Charges,28008,,"29,096 x DRG Weight",28008,Other,base rate x DRG weight,21623,,"22,463 x DRG Weight",21623,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,25438,,"26,426 x DRG Weight",25438,Other,base rate x DRG weight,37358,,"38,809 x DRG Weight",37358,Other,base rate x DRG weight,37358,,"38,809 x DRG Weight",37358,Other,base rate x DRG weight,25438,,"26,426 x DRG Weight",25438,Other,base rate x DRG weight,37358,,"38,809 x DRG Weight",37358,Other,base rate x DRG weight,34067,,"35,391 x DRG Weight",34067,Other,base rate x DRG weight,78144,70,,78144,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24273,,"25,216 X DRG Weight",24273,Other,Base Weight X DRG Weight,21846,,"22,695 X DRG Weight",21846,Other,Base Weight X DRG Weight,24273,,"25,216 X DRG Weight",24273,Other,Base Rate x DRG Weight ,20631,,"21,433 x DRG Weight",20631,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,78144,
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,,inpatient,,,1092892.95,25857,,,25857,Other,150% of Medicare + 9.63% HCRA Surcharge,15724.06,,,15724.06,Other,Medicare IPPS methodology,44044,,"25,728 x DRG weight",44044,Other,base rate x DRG weight,39639,,"23,155 x DRG weight",39639,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,546446,50,,546446,Percent of Total Billed Charges,50% of Charges,49809,,"29,096 x DRG Weight",49809,Other,base rate x DRG weight,38454,,"22,463 x DRG Weight",38454,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,45239,,"26,426 x DRG Weight",45239,Other,base rate x DRG weight,66437,,"38,809 x DRG Weight",66437,Other,base rate x DRG weight,66437,,"38,809 x DRG Weight",66437,Other,base rate x DRG weight,45239,,"26,426 x DRG Weight",45239,Other,base rate x DRG weight,66437,,"38,809 x DRG Weight",66437,Other,base rate x DRG weight,60586,,"35,391 x DRG Weight",60586,Other,base rate x DRG weight,765025,70,,765025,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43167,,"25,216 X DRG Weight",43167,Other,Base Weight X DRG Weight,38852,,"22,695 X DRG Weight",38852,Other,Base Weight X DRG Weight,43167,,"25,216 X DRG Weight",43167,Other,Base Rate x DRG Weight ,36691,,"21,433 x DRG Weight",36691,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,765025,
URETHRAL PROCEDURES WITHOUT CC/MCC,672,MS-DRG,,,,,,,,inpatient,,,122264.34,14373,,,14373,Other,150% of Medicare + 9.63% HCRA Surcharge,8740.15,,,8740.15,Other,Medicare IPPS methodology,24120,,"25,728 x DRG weight",24120,Other,base rate x DRG weight,21708,,"23,155 x DRG weight",21708,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,61132,50,,61132,Percent of Total Billed Charges,50% of Charges,27278,,"29,096 x DRG Weight",27278,Other,base rate x DRG weight,21059,,"22,463 x DRG Weight",21059,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,24774,,"26,426 x DRG Weight",24774,Other,base rate x DRG weight,36383,,"38,809 x DRG Weight",36383,Other,base rate x DRG weight,36383,,"38,809 x DRG Weight",36383,Other,base rate x DRG weight,24774,,"26,426 x DRG Weight",24774,Other,base rate x DRG weight,36383,,"38,809 x DRG Weight",36383,Other,base rate x DRG weight,33179,,"35,391 x DRG Weight",33179,Other,base rate x DRG weight,85585,70,,85585,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,23640,,"25,216 X DRG Weight",23640,Other,Base Weight X DRG Weight,21277,,"22,695 X DRG Weight",21277,Other,Base Weight X DRG Weight,23640,,"25,216 X DRG Weight",23640,Other,Base Rate x DRG Weight ,20093,,"21,433 x DRG Weight",20093,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,85585,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,,inpatient,,,547788.05,55312,,,55312,Other,150% of Medicare + 9.63% HCRA Surcharge,33635.66,,,33635.66,Other,Medicare IPPS methodology,95142,,"25,728 x DRG weight",95142,Other,base rate x DRG weight,85627,,"23,155 x DRG weight",85627,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,273894,50,,273894,Percent of Total Billed Charges,50% of Charges,107597,,"29,096 x DRG Weight",107597,Other,base rate x DRG weight,83068,,"22,463 x DRG Weight",83068,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,97723,,"26,426 x DRG Weight",97723,Other,base rate x DRG weight,143516,,"38,809 x DRG Weight",143516,Other,base rate x DRG weight,143516,,"38,809 x DRG Weight",143516,Other,base rate x DRG weight,97723,,"26,426 x DRG Weight",97723,Other,base rate x DRG weight,143516,,"38,809 x DRG Weight",143516,Other,base rate x DRG weight,130876,,"35,391 x DRG Weight",130876,Other,base rate x DRG weight,383452,70,,383452,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,93249,,"25,216 X DRG Weight",93249,Other,Base Weight X DRG Weight,83926,,"22,695 X DRG Weight",83926,Other,Base Weight X DRG Weight,93249,,"25,216 X DRG Weight",93249,Other,Base Rate x DRG Weight ,79259,,"21,433 x DRG Weight",79259,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,383452,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,,inpatient,,,385911.79,35798,,,35798,Other,150% of Medicare + 9.63% HCRA Surcharge,21769.14,,,21769.14,Other,Medicare IPPS methodology,61289,,"25,728 x DRG weight",61289,Other,base rate x DRG weight,55160,,"23,155 x DRG weight",55160,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,192956,50,,192956,Percent of Total Billed Charges,50% of Charges,69312,,"29,096 x DRG Weight",69312,Other,base rate x DRG weight,53511,,"22,463 x DRG Weight",53511,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,62952,,"26,426 x DRG Weight",62952,Other,base rate x DRG weight,92451,,"38,809 x DRG Weight",92451,Other,base rate x DRG weight,92451,,"38,809 x DRG Weight",92451,Other,base rate x DRG weight,62952,,"26,426 x DRG Weight",62952,Other,base rate x DRG weight,92451,,"38,809 x DRG Weight",92451,Other,base rate x DRG weight,84308,,"35,391 x DRG Weight",84308,Other,base rate x DRG weight,270138,70,,270138,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,60070,,"25,216 X DRG Weight",60070,Other,Base Weight X DRG Weight,54064,,"22,695 X DRG Weight",54064,Other,Base Weight X DRG Weight,60070,,"25,216 X DRG Weight",60070,Other,Base Rate x DRG Weight ,51058,,"21,433 x DRG Weight",51058,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,270138,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,,inpatient,,,107041,23998,,,23998,Other,150% of Medicare + 9.63% HCRA Surcharge,14593.14,,,14593.14,Other,Medicare IPPS methodology,40817,,"25,728 x DRG weight",40817,Other,base rate x DRG weight,36735,,"23,155 x DRG weight",36735,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,53521,50,,53521,Percent of Total Billed Charges,50% of Charges,46161,,"29,096 x DRG Weight",46161,Other,base rate x DRG weight,35638,,"22,463 x DRG Weight",35638,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41925,,"26,426 x DRG Weight",41925,Other,base rate x DRG weight,61570,,"38,809 x DRG Weight",61570,Other,base rate x DRG weight,61570,,"38,809 x DRG Weight",61570,Other,base rate x DRG weight,41925,,"26,426 x DRG Weight",41925,Other,base rate x DRG weight,61570,,"38,809 x DRG Weight",61570,Other,base rate x DRG weight,56148,,"35,391 x DRG Weight",56148,Other,base rate x DRG weight,74929,70,,74929,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40005,,"25,216 X DRG Weight",40005,Other,Base Weight X DRG Weight,36006,,"22,695 X DRG Weight",36006,Other,Base Weight X DRG Weight,40005,,"25,216 X DRG Weight",40005,Other,Base Rate x DRG Weight ,34003,,"21,433 x DRG Weight",34003,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,74929,
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,,inpatient,,,237883.59,22727,,,22727,Other,150% of Medicare + 9.63% HCRA Surcharge,13820.25,,,13820.25,Other,Medicare IPPS methodology,38613,,"25,728 x DRG weight",38613,Other,base rate x DRG weight,34751,,"23,155 x DRG weight",34751,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,118942,50,,118942,Percent of Total Billed Charges,50% of Charges,43667,,"29,096 x DRG Weight",43667,Other,base rate x DRG weight,33712,,"22,463 x DRG Weight",33712,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39660,,"26,426 x DRG Weight",39660,Other,base rate x DRG weight,58245,,"38,809 x DRG Weight",58245,Other,base rate x DRG weight,58245,,"38,809 x DRG Weight",58245,Other,base rate x DRG weight,39660,,"26,426 x DRG Weight",39660,Other,base rate x DRG weight,58245,,"38,809 x DRG Weight",58245,Other,base rate x DRG weight,53115,,"35,391 x DRG Weight",53115,Other,base rate x DRG weight,166519,70,,166519,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37844,,"25,216 X DRG Weight",37844,Other,Base Weight X DRG Weight,34061,,"22,695 X DRG Weight",34061,Other,Base Weight X DRG Weight,37844,,"25,216 X DRG Weight",37844,Other,Base Rate x DRG Weight ,32167,,"21,433 x DRG Weight",32167,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,166519,
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,,inpatient,,,135915.06,13828,,,13828,Other,150% of Medicare + 9.63% HCRA Surcharge,8409.17,,,8409.17,Other,Medicare IPPS methodology,23176,,"25,728 x DRG weight",23176,Other,base rate x DRG weight,20858,,"23,155 x DRG weight",20858,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,67958,50,,67958,Percent of Total Billed Charges,50% of Charges,26210,,"29,096 x DRG Weight",26210,Other,base rate x DRG weight,20235,,"22,463 x DRG Weight",20235,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23805,,"26,426 x DRG Weight",23805,Other,base rate x DRG weight,34959,,"38,809 x DRG Weight",34959,Other,base rate x DRG weight,34959,,"38,809 x DRG Weight",34959,Other,base rate x DRG weight,23805,,"26,426 x DRG Weight",23805,Other,base rate x DRG weight,34959,,"38,809 x DRG Weight",34959,Other,base rate x DRG weight,31880,,"35,391 x DRG Weight",31880,Other,base rate x DRG weight,95141,70,,95141,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22715,,"25,216 X DRG Weight",22715,Other,Base Weight X DRG Weight,20444,,"22,695 X DRG Weight",20444,Other,Base Weight X DRG Weight,22715,,"25,216 X DRG Weight",22715,Other,Base Rate x DRG Weight ,19307,,"21,433 x DRG Weight",19307,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,95141,
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,,inpatient,,,87987.72,9494,,,9494,Other,150% of Medicare + 9.63% HCRA Surcharge,5773.07,,,5773.07,Other,Medicare IPPS methodology,15655,,"25,728 x DRG weight",15655,Other,base rate x DRG weight,14090,,"23,155 x DRG weight",14090,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43994,50,,43994,Percent of Total Billed Charges,50% of Charges,17705,,"29,096 x DRG Weight",17705,Other,base rate x DRG weight,13669,,"22,463 x DRG Weight",13669,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,16080,,"26,426 x DRG Weight",16080,Other,base rate x DRG weight,23615,,"38,809 x DRG Weight",23615,Other,base rate x DRG weight,23615,,"38,809 x DRG Weight",23615,Other,base rate x DRG weight,16080,,"26,426 x DRG Weight",16080,Other,base rate x DRG weight,23615,,"38,809 x DRG Weight",23615,Other,base rate x DRG weight,21535,,"35,391 x DRG Weight",21535,Other,base rate x DRG weight,61591,70,,61591,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,15344,,"25,216 X DRG Weight",15344,Other,Base Weight X DRG Weight,13810,,"22,695 X DRG Weight",13810,Other,Base Weight X DRG Weight,15344,,"25,216 X DRG Weight",15344,Other,Base Rate x DRG Weight ,13042,,"21,433 x DRG Weight",13042,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,61591,
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,MS-DRG,,,,,,,,inpatient,,,155268.42,27748,,,27748,Other,150% of Medicare + 9.63% HCRA Surcharge,16873.91,,,16873.91,Other,Medicare IPPS methodology,47324,,"25,728 x DRG weight",47324,Other,base rate x DRG weight,42591,,"23,155 x DRG weight",42591,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,77634,50,,77634,Percent of Total Billed Charges,50% of Charges,53519,,"29,096 x DRG Weight",53519,Other,base rate x DRG weight,41318,,"22,463 x DRG Weight",41318,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,48608,,"26,426 x DRG Weight",48608,Other,base rate x DRG weight,71385,,"38,809 x DRG Weight",71385,Other,base rate x DRG weight,71385,,"38,809 x DRG Weight",71385,Other,base rate x DRG weight,48608,,"26,426 x DRG Weight",48608,Other,base rate x DRG weight,71385,,"38,809 x DRG Weight",71385,Other,base rate x DRG weight,65098,,"35,391 x DRG Weight",65098,Other,base rate x DRG weight,108688,70,,108688,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46382,,"25,216 X DRG Weight",46382,Other,Base Weight X DRG Weight,41745,,"22,695 X DRG Weight",41745,Other,Base Weight X DRG Weight,46382,,"25,216 X DRG Weight",46382,Other,Base Rate x DRG Weight ,39424,,"21,433 x DRG Weight",39424,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,108688,
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,,inpatient,,,263020.16,15971,,,15971,Other,150% of Medicare + 9.63% HCRA Surcharge,9712.34,,,9712.34,Other,Medicare IPPS methodology,26893,,"25,728 x DRG weight",26893,Other,base rate x DRG weight,24204,,"23,155 x DRG weight",24204,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,131510,50,,131510,Percent of Total Billed Charges,50% of Charges,30414,,"29,096 x DRG Weight",30414,Other,base rate x DRG weight,23481,,"22,463 x DRG Weight",23481,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,27623,,"26,426 x DRG Weight",27623,Other,base rate x DRG weight,40567,,"38,809 x DRG Weight",40567,Other,base rate x DRG weight,40567,,"38,809 x DRG Weight",40567,Other,base rate x DRG weight,27623,,"26,426 x DRG Weight",27623,Other,base rate x DRG weight,40567,,"38,809 x DRG Weight",40567,Other,base rate x DRG weight,36994,,"35,391 x DRG Weight",36994,Other,base rate x DRG weight,184114,70,,184114,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,26358,,"25,216 X DRG Weight",26358,Other,Base Weight X DRG Weight,23723,,"22,695 X DRG Weight",23723,Other,Base Weight X DRG Weight,26358,,"25,216 X DRG Weight",26358,Other,Base Rate x DRG Weight ,22404,,"21,433 x DRG Weight",22404,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,184114,
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,MS-DRG,,,,,,,,inpatient,,,96103.05,12050,,,12050,Other,150% of Medicare + 9.63% HCRA Surcharge,7327.85,,,7327.85,Other,Medicare IPPS methodology,20091,,"25,728 x DRG weight",20091,Other,base rate x DRG weight,18082,,"23,155 x DRG weight",18082,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,48052,50,,48052,Percent of Total Billed Charges,50% of Charges,22721,,"29,096 x DRG Weight",22721,Other,base rate x DRG weight,17541,,"22,463 x DRG Weight",17541,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,20636,,"26,426 x DRG Weight",20636,Other,base rate x DRG weight,30306,,"38,809 x DRG Weight",30306,Other,base rate x DRG weight,30306,,"38,809 x DRG Weight",30306,Other,base rate x DRG weight,20636,,"26,426 x DRG Weight",20636,Other,base rate x DRG weight,30306,,"38,809 x DRG Weight",30306,Other,base rate x DRG weight,27637,,"35,391 x DRG Weight",27637,Other,base rate x DRG weight,67272,70,,67272,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19691,,"25,216 X DRG Weight",19691,Other,Base Weight X DRG Weight,17723,,"22,695 X DRG Weight",17723,Other,Base Weight X DRG Weight,19691,,"25,216 X DRG Weight",19691,Other,Base Rate x DRG Weight ,16737,,"21,433 x DRG Weight",16737,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,67272,
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,,inpatient,,,214037.92,17886,,,17886,Other,150% of Medicare + 9.63% HCRA Surcharge,10876.62,,,10876.62,Other,Medicare IPPS methodology,30215,,"25,728 x DRG weight",30215,Other,base rate x DRG weight,27193,,"23,155 x DRG weight",27193,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,107019,50,,107019,Percent of Total Billed Charges,50% of Charges,34170,,"29,096 x DRG Weight",34170,Other,base rate x DRG weight,26381,,"22,463 x DRG Weight",26381,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31035,,"26,426 x DRG Weight",31035,Other,base rate x DRG weight,45577,,"38,809 x DRG Weight",45577,Other,base rate x DRG weight,45577,,"38,809 x DRG Weight",45577,Other,base rate x DRG weight,31035,,"26,426 x DRG Weight",31035,Other,base rate x DRG weight,45577,,"38,809 x DRG Weight",45577,Other,base rate x DRG weight,41563,,"35,391 x DRG Weight",41563,Other,base rate x DRG weight,149827,70,,149827,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,29614,,"25,216 X DRG Weight",29614,Other,Base Weight X DRG Weight,26653,,"22,695 X DRG Weight",26653,Other,Base Weight X DRG Weight,29614,,"25,216 X DRG Weight",29614,Other,Base Rate x DRG Weight ,25171,,"21,433 x DRG Weight",25171,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,149827,
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,,inpatient,,,109233.76,12436,,,12436,Other,150% of Medicare + 9.63% HCRA Surcharge,7562.33,,,7562.33,Other,Medicare IPPS methodology,20760,,"25,728 x DRG weight",20760,Other,base rate x DRG weight,18684,,"23,155 x DRG weight",18684,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,54617,50,,54617,Percent of Total Billed Charges,50% of Charges,23478,,"29,096 x DRG Weight",23478,Other,base rate x DRG weight,18125,,"22,463 x DRG Weight",18125,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21323,,"26,426 x DRG Weight",21323,Other,base rate x DRG weight,31315,,"38,809 x DRG Weight",31315,Other,base rate x DRG weight,31315,,"38,809 x DRG Weight",31315,Other,base rate x DRG weight,21323,,"26,426 x DRG Weight",21323,Other,base rate x DRG weight,31315,,"38,809 x DRG Weight",31315,Other,base rate x DRG weight,28557,,"35,391 x DRG Weight",28557,Other,base rate x DRG weight,76464,70,,76464,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20347,,"25,216 X DRG Weight",20347,Other,Base Weight X DRG Weight,18313,,"22,695 X DRG Weight",18313,Other,Base Weight X DRG Weight,20347,,"25,216 X DRG Weight",20347,Other,Base Rate x DRG Weight ,17294,,"21,433 x DRG Weight",17294,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,76464,
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,,inpatient,,,188718.89,21474,,,21474,Other,150% of Medicare + 9.63% HCRA Surcharge,13058.19,,,13058.19,Other,Medicare IPPS methodology,36439,,"25,728 x DRG weight",36439,Other,base rate x DRG weight,32794,,"23,155 x DRG weight",32794,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,94359,50,,94359,Percent of Total Billed Charges,50% of Charges,41209,,"29,096 x DRG Weight",41209,Other,base rate x DRG weight,31814,,"22,463 x DRG Weight",31814,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,37427,,"26,426 x DRG Weight",37427,Other,base rate x DRG weight,54965,,"38,809 x DRG Weight",54965,Other,base rate x DRG weight,54965,,"38,809 x DRG Weight",54965,Other,base rate x DRG weight,37427,,"26,426 x DRG Weight",37427,Other,base rate x DRG weight,54965,,"38,809 x DRG Weight",54965,Other,base rate x DRG weight,50124,,"35,391 x DRG Weight",50124,Other,base rate x DRG weight,132103,70,,132103,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35713,,"25,216 X DRG Weight",35713,Other,Base Weight X DRG Weight,32143,,"22,695 X DRG Weight",32143,Other,Base Weight X DRG Weight,35713,,"25,216 X DRG Weight",35713,Other,Base Rate x DRG Weight ,30356,,"21,433 x DRG Weight",30356,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,132103,
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,,inpatient,,,71696.51,12077,,,12077,Other,150% of Medicare + 9.63% HCRA Surcharge,7344.08,,,7344.08,Other,Medicare IPPS methodology,20137,,"25,728 x DRG weight",20137,Other,base rate x DRG weight,18123,,"23,155 x DRG weight",18123,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35848,50,,35848,Percent of Total Billed Charges,50% of Charges,22773,,"29,096 x DRG Weight",22773,Other,base rate x DRG weight,17582,,"22,463 x DRG Weight",17582,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,20684,,"26,426 x DRG Weight",20684,Other,base rate x DRG weight,30376,,"38,809 x DRG Weight",30376,Other,base rate x DRG weight,30376,,"38,809 x DRG Weight",30376,Other,base rate x DRG weight,20684,,"26,426 x DRG Weight",20684,Other,base rate x DRG weight,30376,,"38,809 x DRG Weight",30376,Other,base rate x DRG weight,27701,,"35,391 x DRG Weight",27701,Other,base rate x DRG weight,50188,70,,50188,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,19737,,"25,216 X DRG Weight",19737,Other,Base Weight X DRG Weight,17763,,"22,695 X DRG Weight",17763,Other,Base Weight X DRG Weight,19737,,"25,216 X DRG Weight",19737,Other,Base Rate x DRG Weight ,16776,,"21,433 x DRG Weight",16776,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,50188,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,,inpatient,,,171132,18206,,,18206,Other,150% of Medicare + 9.63% HCRA Surcharge,11071.42,,,11071.42,Other,Medicare IPPS methodology,30771,,"25,728 x DRG weight",30771,Other,base rate x DRG weight,27693,,"23,155 x DRG weight",27693,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,85566,50,,85566,Percent of Total Billed Charges,50% of Charges,34799,,"29,096 x DRG Weight",34799,Other,base rate x DRG weight,26866,,"22,463 x DRG Weight",26866,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31605,,"26,426 x DRG Weight",31605,Other,base rate x DRG weight,46416,,"38,809 x DRG Weight",46416,Other,base rate x DRG weight,46416,,"38,809 x DRG Weight",46416,Other,base rate x DRG weight,31605,,"26,426 x DRG Weight",31605,Other,base rate x DRG weight,46416,,"38,809 x DRG Weight",46416,Other,base rate x DRG weight,42328,,"35,391 x DRG Weight",42328,Other,base rate x DRG weight,119792,70,,119792,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,30158,,"25,216 X DRG Weight",30158,Other,Base Weight X DRG Weight,27143,,"22,695 X DRG Weight",27143,Other,Base Weight X DRG Weight,30158,,"25,216 X DRG Weight",30158,Other,Base Rate x DRG Weight ,25634,,"21,433 x DRG Weight",25634,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,119792,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,,inpatient,,,100621.85,10733,,,10733,Other,150% of Medicare + 9.63% HCRA Surcharge,6527.01,,,6527.01,Other,Medicare IPPS methodology,17806,,"25,728 x DRG weight",17806,Other,base rate x DRG weight,16026,,"23,155 x DRG weight",16026,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,50311,50,,50311,Percent of Total Billed Charges,50% of Charges,20137,,"29,096 x DRG Weight",20137,Other,base rate x DRG weight,15547,,"22,463 x DRG Weight",15547,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18289,,"26,426 x DRG Weight",18289,Other,base rate x DRG weight,26860,,"38,809 x DRG Weight",26860,Other,base rate x DRG weight,26860,,"38,809 x DRG Weight",26860,Other,base rate x DRG weight,18289,,"26,426 x DRG Weight",18289,Other,base rate x DRG weight,26860,,"38,809 x DRG Weight",26860,Other,base rate x DRG weight,24494,,"35,391 x DRG Weight",24494,Other,base rate x DRG weight,70435,70,,70435,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,17452,,"25,216 X DRG Weight",17452,Other,Base Weight X DRG Weight,15707,,"22,695 X DRG Weight",15707,Other,Base Weight X DRG Weight,17452,,"25,216 X DRG Weight",17452,Other,Base Rate x DRG Weight ,14834,,"21,433 x DRG Weight",14834,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,70435,
URETHRAL STRICTURE,697,MS-DRG,,,,,,,,inpatient,,,94621.51,16977,,,16977,Other,150% of Medicare + 9.63% HCRA Surcharge,10323.79,,,10323.79,Other,Medicare IPPS methodology,28638,,"25,728 x DRG weight",28638,Other,base rate x DRG weight,25774,,"23,155 x DRG weight",25774,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,47311,50,,47311,Percent of Total Billed Charges,50% of Charges,32387,,"29,096 x DRG Weight",32387,Other,base rate x DRG weight,25004,,"22,463 x DRG Weight",25004,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,29415,,"26,426 x DRG Weight",29415,Other,base rate x DRG weight,43198,,"38,809 x DRG Weight",43198,Other,base rate x DRG weight,43198,,"38,809 x DRG Weight",43198,Other,base rate x DRG weight,29415,,"26,426 x DRG Weight",29415,Other,base rate x DRG weight,43198,,"38,809 x DRG Weight",43198,Other,base rate x DRG weight,39394,,"35,391 x DRG Weight",39394,Other,base rate x DRG weight,66235,70,,66235,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,28068,,"25,216 X DRG Weight",28068,Other,Base Weight X DRG Weight,25262,,"22,695 X DRG Weight",25262,Other,Base Weight X DRG Weight,28068,,"25,216 X DRG Weight",28068,Other,Base Rate x DRG Weight ,23857,,"21,433 x DRG Weight",23857,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,66235,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,,inpatient,,,184205.46,25005,,,25005,Other,150% of Medicare + 9.63% HCRA Surcharge,15205.49,,,15205.49,Other,Medicare IPPS methodology,42564,,"25,728 x DRG weight",42564,Other,base rate x DRG weight,38308,,"23,155 x DRG weight",38308,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,92103,50,,92103,Percent of Total Billed Charges,50% of Charges,48136,,"29,096 x DRG Weight",48136,Other,base rate x DRG weight,37163,,"22,463 x DRG Weight",37163,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,43719,,"26,426 x DRG Weight",43719,Other,base rate x DRG weight,64206,,"38,809 x DRG Weight",64206,Other,base rate x DRG weight,64206,,"38,809 x DRG Weight",64206,Other,base rate x DRG weight,43719,,"26,426 x DRG Weight",43719,Other,base rate x DRG weight,64206,,"38,809 x DRG Weight",64206,Other,base rate x DRG weight,58551,,"35,391 x DRG Weight",58551,Other,base rate x DRG weight,128944,70,,128944,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,41717,,"25,216 X DRG Weight",41717,Other,Base Weight X DRG Weight,37547,,"22,695 X DRG Weight",37547,Other,Base Weight X DRG Weight,41717,,"25,216 X DRG Weight",41717,Other,Base Rate x DRG Weight ,35459,,"21,433 x DRG Weight",35459,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,128944,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,,inpatient,,,140422.98,15608,,,15608,Other,150% of Medicare + 9.63% HCRA Surcharge,9491.38,,,9491.38,Other,Medicare IPPS methodology,26263,,"25,728 x DRG weight",26263,Other,base rate x DRG weight,23637,,"23,155 x DRG weight",23637,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,70211,50,,70211,Percent of Total Billed Charges,50% of Charges,29701,,"29,096 x DRG Weight",29701,Other,base rate x DRG weight,22930,,"22,463 x DRG Weight",22930,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26976,,"26,426 x DRG Weight",26976,Other,base rate x DRG weight,39616,,"38,809 x DRG Weight",39616,Other,base rate x DRG weight,39616,,"38,809 x DRG Weight",39616,Other,base rate x DRG weight,26976,,"26,426 x DRG Weight",26976,Other,base rate x DRG weight,39616,,"38,809 x DRG Weight",39616,Other,base rate x DRG weight,36127,,"35,391 x DRG Weight",36127,Other,base rate x DRG weight,98296,70,,98296,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25740,,"25,216 X DRG Weight",25740,Other,Base Weight X DRG Weight,23167,,"22,695 X DRG Weight",23167,Other,Base Weight X DRG Weight,25740,,"25,216 X DRG Weight",25740,Other,Base Rate x DRG Weight ,21879,,"21,433 x DRG Weight",21879,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,98296,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,,inpatient,,,93081.62,10974,,,10974,Other,150% of Medicare + 9.63% HCRA Surcharge,6673.11,,,6673.11,Other,Medicare IPPS methodology,18223,,"25,728 x DRG weight",18223,Other,base rate x DRG weight,16401,,"23,155 x DRG weight",16401,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46541,50,,46541,Percent of Total Billed Charges,50% of Charges,20609,,"29,096 x DRG Weight",20609,Other,base rate x DRG weight,15911,,"22,463 x DRG Weight",15911,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18718,,"26,426 x DRG Weight",18718,Other,base rate x DRG weight,27488,,"38,809 x DRG Weight",27488,Other,base rate x DRG weight,27488,,"38,809 x DRG Weight",27488,Other,base rate x DRG weight,18718,,"26,426 x DRG Weight",18718,Other,base rate x DRG weight,27488,,"38,809 x DRG Weight",27488,Other,base rate x DRG weight,25067,,"35,391 x DRG Weight",25067,Other,base rate x DRG weight,65157,70,,65157,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,17860,,"25,216 X DRG Weight",17860,Other,Base Weight X DRG Weight,16075,,"22,695 X DRG Weight",16075,Other,Base Weight X DRG Weight,17860,,"25,216 X DRG Weight",17860,Other,Base Rate x DRG Weight ,15181,,"21,433 x DRG Weight",15181,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,65157,
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,,inpatient,,,165828.54,29565,,,29565,Other,150% of Medicare + 9.63% HCRA Surcharge,17978.68,,,17978.68,Other,Medicare IPPS methodology,50476,,"25,728 x DRG weight",50476,Other,base rate x DRG weight,45428,,"23,155 x DRG weight",45428,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,82914,50,,82914,Percent of Total Billed Charges,50% of Charges,57083,,"29,096 x DRG Weight",57083,Other,base rate x DRG weight,44070,,"22,463 x DRG Weight",44070,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,51845,,"26,426 x DRG Weight",51845,Other,base rate x DRG weight,76139,,"38,809 x DRG Weight",76139,Other,base rate x DRG weight,76139,,"38,809 x DRG Weight",76139,Other,base rate x DRG weight,51845,,"26,426 x DRG Weight",51845,Other,base rate x DRG weight,76139,,"38,809 x DRG Weight",76139,Other,base rate x DRG weight,69434,,"35,391 x DRG Weight",69434,Other,base rate x DRG weight,116080,70,,116080,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,49471,,"25,216 X DRG Weight",49471,Other,Base Weight X DRG Weight,44525,,"22,695 X DRG Weight",44525,Other,Base Weight X DRG Weight,49471,,"25,216 X DRG Weight",49471,Other,Base Rate x DRG Weight ,42049,,"21,433 x DRG Weight",42049,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,116080,
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,,inpatient,,,89728.12,22099,,,22099,Other,150% of Medicare + 9.63% HCRA Surcharge,13438.77,,,13438.77,Other,Medicare IPPS methodology,37524,,"25,728 x DRG weight",37524,Other,base rate x DRG weight,33772,,"23,155 x DRG weight",33772,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,44864,50,,44864,Percent of Total Billed Charges,50% of Charges,42437,,"29,096 x DRG Weight",42437,Other,base rate x DRG weight,32762,,"22,463 x DRG Weight",32762,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,38542,,"26,426 x DRG Weight",38542,Other,base rate x DRG weight,56603,,"38,809 x DRG Weight",56603,Other,base rate x DRG weight,56603,,"38,809 x DRG Weight",56603,Other,base rate x DRG weight,38542,,"26,426 x DRG Weight",38542,Other,base rate x DRG weight,56603,,"38,809 x DRG Weight",56603,Other,base rate x DRG weight,51618,,"35,391 x DRG Weight",51618,Other,base rate x DRG weight,62810,70,,62810,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,36778,,"25,216 X DRG Weight",36778,Other,Base Weight X DRG Weight,33101,,"22,695 X DRG Weight",33101,Other,Base Weight X DRG Weight,36778,,"25,216 X DRG Weight",36778,Other,Base Rate x DRG Weight ,31260,,"21,433 x DRG Weight",31260,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,62810,
PENIS PROCEDURES WITH CC/MCC,709,MS-DRG,,,,,,,,inpatient,,,153367.65,32663,,,32663,Other,150% of Medicare + 9.63% HCRA Surcharge,19862.64,,,19862.64,Other,Medicare IPPS methodology,55850,,"25,728 x DRG weight",55850,Other,base rate x DRG weight,50265,,"23,155 x DRG weight",50265,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,76684,50,,76684,Percent of Total Billed Charges,50% of Charges,63162,,"29,096 x DRG Weight",63162,Other,base rate x DRG weight,48763,,"22,463 x DRG Weight",48763,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,57366,,"26,426 x DRG Weight",57366,Other,base rate x DRG weight,84247,,"38,809 x DRG Weight",84247,Other,base rate x DRG weight,84247,,"38,809 x DRG Weight",84247,Other,base rate x DRG weight,57366,,"26,426 x DRG Weight",57366,Other,base rate x DRG weight,84247,,"38,809 x DRG Weight",84247,Other,base rate x DRG weight,76827,,"35,391 x DRG Weight",76827,Other,base rate x DRG weight,107357,70,,107357,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,54739,,"25,216 X DRG Weight",54739,Other,Base Weight X DRG Weight,49266,,"22,695 X DRG Weight",49266,Other,Base Weight X DRG Weight,54739,,"25,216 X DRG Weight",54739,Other,Base Rate x DRG Weight ,46527,,"21,433 x DRG Weight",46527,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,107357,
PENIS PROCEDURES WITHOUT CC/MCC,710,MS-DRG,,,,,,,,inpatient,,,85369.11,19709,,,19709,Other,150% of Medicare + 9.63% HCRA Surcharge,11984.99,,,11984.99,Other,Medicare IPPS methodology,33377,,"25,728 x DRG weight",33377,Other,base rate x DRG weight,30039,,"23,155 x DRG weight",30039,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,42685,50,,42685,Percent of Total Billed Charges,50% of Charges,37746,,"29,096 x DRG Weight",37746,Other,base rate x DRG weight,29141,,"22,463 x DRG Weight",29141,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,34282,,"26,426 x DRG Weight",34282,Other,base rate x DRG weight,50347,,"38,809 x DRG Weight",50347,Other,base rate x DRG weight,50347,,"38,809 x DRG Weight",50347,Other,base rate x DRG weight,34282,,"26,426 x DRG Weight",34282,Other,base rate x DRG weight,50347,,"38,809 x DRG Weight",50347,Other,base rate x DRG weight,45913,,"35,391 x DRG Weight",45913,Other,base rate x DRG weight,59758,70,,59758,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32713,,"25,216 X DRG Weight",32713,Other,Base Weight X DRG Weight,29442,,"22,695 X DRG Weight",29442,Other,Base Weight X DRG Weight,32713,,"25,216 X DRG Weight",32713,Other,Base Rate x DRG Weight ,27805,,"21,433 x DRG Weight",27805,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,59758,
TESTES PROCEDURES WITH CC/MCC,711,MS-DRG,,,,,,,,inpatient,,,73437.13,31953,,,31953,Other,150% of Medicare + 9.63% HCRA Surcharge,19430.65,,,19430.65,Other,Medicare IPPS methodology,54618,,"25,728 x DRG weight",54618,Other,base rate x DRG weight,49156,,"23,155 x DRG weight",49156,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,36719,50,,36719,Percent of Total Billed Charges,50% of Charges,61768,,"29,096 x DRG Weight",61768,Other,base rate x DRG weight,47687,,"22,463 x DRG Weight",47687,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,56100,,"26,426 x DRG Weight",56100,Other,base rate x DRG weight,82388,,"38,809 x DRG Weight",82388,Other,base rate x DRG weight,82388,,"38,809 x DRG Weight",82388,Other,base rate x DRG weight,56100,,"26,426 x DRG Weight",56100,Other,base rate x DRG weight,82388,,"38,809 x DRG Weight",82388,Other,base rate x DRG weight,75132,,"35,391 x DRG Weight",75132,Other,base rate x DRG weight,51406,70,,51406,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,53531,,"25,216 X DRG Weight",53531,Other,Base Weight X DRG Weight,48179,,"22,695 X DRG Weight",48179,Other,Base Weight X DRG Weight,53531,,"25,216 X DRG Weight",53531,Other,Base Rate x DRG Weight ,45500,,"21,433 x DRG Weight",45500,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,82388,
TESTES PROCEDURES WITHOUT CC/MCC,712,MS-DRG,,,,,,,,inpatient,,,73198,18094,,,18094,Other,150% of Medicare + 9.63% HCRA Surcharge,11002.88,,,11002.88,Other,Medicare IPPS methodology,30575,,"25,728 x DRG weight",30575,Other,base rate x DRG weight,27517,,"23,155 x DRG weight",27517,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,36599,50,,36599,Percent of Total Billed Charges,50% of Charges,34578,,"29,096 x DRG Weight",34578,Other,base rate x DRG weight,26695,,"22,463 x DRG Weight",26695,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31405,,"26,426 x DRG Weight",31405,Other,base rate x DRG weight,46121,,"38,809 x DRG Weight",46121,Other,base rate x DRG weight,46121,,"38,809 x DRG Weight",46121,Other,base rate x DRG weight,31405,,"26,426 x DRG Weight",31405,Other,base rate x DRG weight,46121,,"38,809 x DRG Weight",46121,Other,base rate x DRG weight,42059,,"35,391 x DRG Weight",42059,Other,base rate x DRG weight,51239,70,,51239,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,29967,,"25,216 X DRG Weight",29967,Other,Base Weight X DRG Weight,26971,,"22,695 X DRG Weight",26971,Other,Base Weight X DRG Weight,29967,,"25,216 X DRG Weight",29967,Other,Base Rate x DRG Weight ,25471,,"21,433 x DRG Weight",25471,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,51239,
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,,inpatient,,,82123.62,21984,,,21984,Other,150% of Medicare + 9.63% HCRA Surcharge,13368.43,,,13368.43,Other,Medicare IPPS methodology,37324,,"25,728 x DRG weight",37324,Other,base rate x DRG weight,33591,,"23,155 x DRG weight",33591,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,41062,50,,41062,Percent of Total Billed Charges,50% of Charges,42210,,"29,096 x DRG Weight",42210,Other,base rate x DRG weight,32587,,"22,463 x DRG Weight",32587,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,38336,,"26,426 x DRG Weight",38336,Other,base rate x DRG weight,56300,,"38,809 x DRG Weight",56300,Other,base rate x DRG weight,56300,,"38,809 x DRG Weight",56300,Other,base rate x DRG weight,38336,,"26,426 x DRG Weight",38336,Other,base rate x DRG weight,56300,,"38,809 x DRG Weight",56300,Other,base rate x DRG weight,51342,,"35,391 x DRG Weight",51342,Other,base rate x DRG weight,57487,70,,57487,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,36581,,"25,216 X DRG Weight",36581,Other,Base Weight X DRG Weight,32924,,"22,695 X DRG Weight",32924,Other,Base Weight X DRG Weight,36581,,"25,216 X DRG Weight",36581,Other,Base Rate x DRG Weight ,31093,,"21,433 x DRG Weight",31093,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,57487,
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,,inpatient,,,72648.49,14684,,,14684,Other,150% of Medicare + 9.63% HCRA Surcharge,8929.53,,,8929.53,Other,Medicare IPPS methodology,24660,,"25,728 x DRG weight",24660,Other,base rate x DRG weight,22194,,"23,155 x DRG weight",22194,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,36324,50,,36324,Percent of Total Billed Charges,50% of Charges,27889,,"29,096 x DRG Weight",27889,Other,base rate x DRG weight,21531,,"22,463 x DRG Weight",21531,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,25329,,"26,426 x DRG Weight",25329,Other,base rate x DRG weight,37198,,"38,809 x DRG Weight",37198,Other,base rate x DRG weight,37198,,"38,809 x DRG Weight",37198,Other,base rate x DRG weight,25329,,"26,426 x DRG Weight",25329,Other,base rate x DRG weight,37198,,"38,809 x DRG Weight",37198,Other,base rate x DRG weight,33922,,"35,391 x DRG Weight",33922,Other,base rate x DRG weight,50854,70,,50854,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24170,,"25,216 X DRG Weight",24170,Other,Base Weight X DRG Weight,21753,,"22,695 X DRG Weight",21753,Other,Base Weight X DRG Weight,24170,,"25,216 X DRG Weight",24170,Other,Base Rate x DRG Weight ,20544,,"21,433 x DRG Weight",20544,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,50854,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,MS-DRG,,,,,,,,inpatient,,,672810.72,33207,,,33207,Other,150% of Medicare + 9.63% HCRA Surcharge,20193.61,,,20193.61,Other,Medicare IPPS methodology,56795,,"25,728 x DRG weight",56795,Other,base rate x DRG weight,51115,,"23,155 x DRG weight",51115,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,336405,50,,336405,Percent of Total Billed Charges,50% of Charges,64229,,"29,096 x DRG Weight",64229,Other,base rate x DRG weight,49587,,"22,463 x DRG Weight",49587,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,58335,,"26,426 x DRG Weight",58335,Other,base rate x DRG weight,85671,,"38,809 x DRG Weight",85671,Other,base rate x DRG weight,85671,,"38,809 x DRG Weight",85671,Other,base rate x DRG weight,58335,,"26,426 x DRG Weight",58335,Other,base rate x DRG weight,85671,,"38,809 x DRG Weight",85671,Other,base rate x DRG weight,78126,,"35,391 x DRG Weight",78126,Other,base rate x DRG weight,470968,70,,470968,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,55664,,"25,216 X DRG Weight",55664,Other,Base Weight X DRG Weight,50099,,"22,695 X DRG Weight",50099,Other,Base Weight X DRG Weight,55664,,"25,216 X DRG Weight",55664,Other,Base Rate x DRG Weight ,47313,,"21,433 x DRG Weight",47313,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,470968,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,MS-DRG,,,,,,,,inpatient,,,85878.08,21561,,,21561,Other,150% of Medicare + 9.63% HCRA Surcharge,13111.4,,,13111.4,Other,Medicare IPPS methodology,36590,,"25,728 x DRG weight",36590,Other,base rate x DRG weight,32931,,"23,155 x DRG weight",32931,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,42939,50,,42939,Percent of Total Billed Charges,50% of Charges,41380,,"29,096 x DRG Weight",41380,Other,base rate x DRG weight,31947,,"22,463 x DRG Weight",31947,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,37583,,"26,426 x DRG Weight",37583,Other,base rate x DRG weight,55194,,"38,809 x DRG Weight",55194,Other,base rate x DRG weight,55194,,"38,809 x DRG Weight",55194,Other,base rate x DRG weight,37583,,"26,426 x DRG Weight",37583,Other,base rate x DRG weight,55194,,"38,809 x DRG Weight",55194,Other,base rate x DRG weight,50333,,"35,391 x DRG Weight",50333,Other,base rate x DRG weight,60115,70,,60115,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35862,,"25,216 X DRG Weight",35862,Other,Base Weight X DRG Weight,32277,,"22,695 X DRG Weight",32277,Other,Base Weight X DRG Weight,35862,,"25,216 X DRG Weight",35862,Other,Base Rate x DRG Weight ,30482,,"21,433 x DRG Weight",30482,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,60115,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,,inpatient,,,193611.43,27367,,,27367,Other,150% of Medicare + 9.63% HCRA Surcharge,16642.14,,,16642.14,Other,Medicare IPPS methodology,46663,,"25,728 x DRG weight",46663,Other,base rate x DRG weight,41996,,"23,155 x DRG weight",41996,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,96806,50,,96806,Percent of Total Billed Charges,50% of Charges,52771,,"29,096 x DRG Weight",52771,Other,base rate x DRG weight,40741,,"22,463 x DRG Weight",40741,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,47929,,"26,426 x DRG Weight",47929,Other,base rate x DRG weight,70388,,"38,809 x DRG Weight",70388,Other,base rate x DRG weight,70388,,"38,809 x DRG Weight",70388,Other,base rate x DRG weight,47929,,"26,426 x DRG Weight",47929,Other,base rate x DRG weight,70388,,"38,809 x DRG Weight",70388,Other,base rate x DRG weight,64189,,"35,391 x DRG Weight",64189,Other,base rate x DRG weight,135528,70,,135528,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,45734,,"25,216 X DRG Weight",45734,Other,Base Weight X DRG Weight,41162,,"22,695 X DRG Weight",41162,Other,Base Weight X DRG Weight,45734,,"25,216 X DRG Weight",45734,Other,Base Rate x DRG Weight ,38873,,"21,433 x DRG Weight",38873,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,135528,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,MS-DRG,,,,,,,,inpatient,,,86665.45,17907,,,17907,Other,150% of Medicare + 9.63% HCRA Surcharge,10889.25,,,10889.25,Other,Medicare IPPS methodology,30251,,"25,728 x DRG weight",30251,Other,base rate x DRG weight,27226,,"23,155 x DRG weight",27226,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43333,50,,43333,Percent of Total Billed Charges,50% of Charges,34211,,"29,096 x DRG Weight",34211,Other,base rate x DRG weight,26412,,"22,463 x DRG Weight",26412,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31072,,"26,426 x DRG Weight",31072,Other,base rate x DRG weight,45632,,"38,809 x DRG Weight",45632,Other,base rate x DRG weight,45632,,"38,809 x DRG Weight",45632,Other,base rate x DRG weight,31072,,"26,426 x DRG Weight",31072,Other,base rate x DRG weight,45632,,"38,809 x DRG Weight",45632,Other,base rate x DRG weight,41613,,"35,391 x DRG Weight",41613,Other,base rate x DRG weight,60666,70,,60666,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,29649,,"25,216 X DRG Weight",29649,Other,Base Weight X DRG Weight,26685,,"22,695 X DRG Weight",26685,Other,Base Weight X DRG Weight,29649,,"25,216 X DRG Weight",29649,Other,Base Rate x DRG Weight ,25201,,"21,433 x DRG Weight",25201,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,60666,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,,inpatient,,,66917,28273,,,28273,Other,150% of Medicare + 9.63% HCRA Surcharge,17193.17,,,17193.17,Other,Medicare IPPS methodology,48235,,"25,728 x DRG weight",48235,Other,base rate x DRG weight,43411,,"23,155 x DRG weight",43411,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,33459,50,,33459,Percent of Total Billed Charges,50% of Charges,54549,,"29,096 x DRG Weight",54549,Other,base rate x DRG weight,42114,,"22,463 x DRG Weight",42114,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,49543,,"26,426 x DRG Weight",49543,Other,base rate x DRG weight,72759,,"38,809 x DRG Weight",72759,Other,base rate x DRG weight,72759,,"38,809 x DRG Weight",72759,Other,base rate x DRG weight,49543,,"26,426 x DRG Weight",49543,Other,base rate x DRG weight,72759,,"38,809 x DRG Weight",72759,Other,base rate x DRG weight,66351,,"35,391 x DRG Weight",66351,Other,base rate x DRG weight,46842,70,,46842,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,47275,,"25,216 X DRG Weight",47275,Other,Base Weight X DRG Weight,42549,,"22,695 X DRG Weight",42549,Other,Base Weight X DRG Weight,47275,,"25,216 X DRG Weight",47275,Other,Base Rate x DRG Weight ,40183,,"21,433 x DRG Weight",40183,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,72759,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,,inpatient,,,173080.84,16995,,,16995,Other,150% of Medicare + 9.63% HCRA Surcharge,10334.61,,,10334.61,Other,Medicare IPPS methodology,28669,,"25,728 x DRG weight",28669,Other,base rate x DRG weight,25802,,"23,155 x DRG weight",25802,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,86540,50,,86540,Percent of Total Billed Charges,50% of Charges,32422,,"29,096 x DRG Weight",32422,Other,base rate x DRG weight,25031,,"22,463 x DRG Weight",25031,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,29446,,"26,426 x DRG Weight",29446,Other,base rate x DRG weight,43245,,"38,809 x DRG Weight",43245,Other,base rate x DRG weight,43245,,"38,809 x DRG Weight",43245,Other,base rate x DRG weight,29446,,"26,426 x DRG Weight",29446,Other,base rate x DRG weight,43245,,"38,809 x DRG Weight",43245,Other,base rate x DRG weight,39436,,"35,391 x DRG Weight",39436,Other,base rate x DRG weight,121157,70,,121157,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,28098,,"25,216 X DRG Weight",28098,Other,Base Weight X DRG Weight,25289,,"22,695 X DRG Weight",25289,Other,Base Weight X DRG Weight,28098,,"25,216 X DRG Weight",28098,Other,Base Rate x DRG Weight ,23883,,"21,433 x DRG Weight",23883,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,121157,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,MS-DRG,,,,,,,,inpatient,,,19635,12474,,,12474,Other,150% of Medicare + 9.63% HCRA Surcharge,7585.78,,,7585.78,Other,Medicare IPPS methodology,20827,,"25,728 x DRG weight",20827,Other,base rate x DRG weight,18744,,"23,155 x DRG weight",18744,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,9818,50,,9818,Percent of Total Billed Charges,50% of Charges,23553,,"29,096 x DRG Weight",23553,Other,base rate x DRG weight,18184,,"22,463 x DRG Weight",18184,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21392,,"26,426 x DRG Weight",21392,Other,base rate x DRG weight,31416,,"38,809 x DRG Weight",31416,Other,base rate x DRG weight,31416,,"38,809 x DRG Weight",31416,Other,base rate x DRG weight,21392,,"26,426 x DRG Weight",21392,Other,base rate x DRG weight,31416,,"38,809 x DRG Weight",31416,Other,base rate x DRG weight,28649,,"35,391 x DRG Weight",28649,Other,base rate x DRG weight,13745,70,,13745,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20412,,"25,216 X DRG Weight",20412,Other,Base Weight X DRG Weight,18372,,"22,695 X DRG Weight",18372,Other,Base Weight X DRG Weight,20412,,"25,216 X DRG Weight",20412,Other,Base Rate x DRG Weight ,17350,,"21,433 x DRG Weight",17350,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,31416,
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,,inpatient,,,105831,18872,,,18872,Other,150% of Medicare + 9.63% HCRA Surcharge,11476.35,,,11476.35,Other,Medicare IPPS methodology,31926,,"25,728 x DRG weight",31926,Other,base rate x DRG weight,28733,,"23,155 x DRG weight",28733,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,52916,50,,52916,Percent of Total Billed Charges,50% of Charges,36105,,"29,096 x DRG Weight",36105,Other,base rate x DRG weight,27874,,"22,463 x DRG Weight",27874,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,32792,,"26,426 x DRG Weight",32792,Other,base rate x DRG weight,48158,,"38,809 x DRG Weight",48158,Other,base rate x DRG weight,48158,,"38,809 x DRG Weight",48158,Other,base rate x DRG weight,32792,,"26,426 x DRG Weight",32792,Other,base rate x DRG weight,48158,,"38,809 x DRG Weight",48158,Other,base rate x DRG weight,43917,,"35,391 x DRG Weight",43917,Other,base rate x DRG weight,74082,70,,74082,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,31291,,"25,216 X DRG Weight",31291,Other,Base Weight X DRG Weight,28162,,"22,695 X DRG Weight",28162,Other,Base Weight X DRG Weight,31291,,"25,216 X DRG Weight",31291,Other,Base Rate x DRG Weight ,26596,,"21,433 x DRG Weight",26596,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,74082,
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,,inpatient,,,135159.5,11309,,,11309,Other,150% of Medicare + 9.63% HCRA Surcharge,6876.93,,,6876.93,Other,Medicare IPPS methodology,18805,,"25,728 x DRG weight",18805,Other,base rate x DRG weight,16924,,"23,155 x DRG weight",16924,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,67580,50,,67580,Percent of Total Billed Charges,50% of Charges,21266,,"29,096 x DRG Weight",21266,Other,base rate x DRG weight,16418,,"22,463 x DRG Weight",16418,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,19315,,"26,426 x DRG Weight",19315,Other,base rate x DRG weight,28365,,"38,809 x DRG Weight",28365,Other,base rate x DRG weight,28365,,"38,809 x DRG Weight",28365,Other,base rate x DRG weight,19315,,"26,426 x DRG Weight",19315,Other,base rate x DRG weight,28365,,"38,809 x DRG Weight",28365,Other,base rate x DRG weight,25867,,"35,391 x DRG Weight",25867,Other,base rate x DRG weight,94612,70,,94612,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18430,,"25,216 X DRG Weight",18430,Other,Base Weight X DRG Weight,16588,,"22,695 X DRG Weight",16588,Other,Base Weight X DRG Weight,18430,,"25,216 X DRG Weight",18430,Other,Base Rate x DRG Weight ,15665,,"21,433 x DRG Weight",15665,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,94612,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,,inpatient,,,121672.4,24509,,,24509,Other,150% of Medicare + 9.63% HCRA Surcharge,14904.28,,,14904.28,Other,Medicare IPPS methodology,41705,,"25,728 x DRG weight",41705,Other,base rate x DRG weight,37534,,"23,155 x DRG weight",37534,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,60836,50,,60836,Percent of Total Billed Charges,50% of Charges,47165,,"29,096 x DRG Weight",47165,Other,base rate x DRG weight,36413,,"22,463 x DRG Weight",36413,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,42837,,"26,426 x DRG Weight",42837,Other,base rate x DRG weight,62909,,"38,809 x DRG Weight",62909,Other,base rate x DRG weight,62909,,"38,809 x DRG Weight",62909,Other,base rate x DRG weight,42837,,"26,426 x DRG Weight",42837,Other,base rate x DRG weight,62909,,"38,809 x DRG Weight",62909,Other,base rate x DRG weight,57369,,"35,391 x DRG Weight",57369,Other,base rate x DRG weight,85171,70,,85171,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40875,,"25,216 X DRG Weight",40875,Other,Base Weight X DRG Weight,36789,,"22,695 X DRG Weight",36789,Other,Base Weight X DRG Weight,40875,,"25,216 X DRG Weight",40875,Other,Base Rate x DRG Weight ,34743,,"21,433 x DRG Weight",34743,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,85171,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,,inpatient,,,107991.3,12335,,,12335,Other,150% of Medicare + 9.63% HCRA Surcharge,7501.01,,,7501.01,Other,Medicare IPPS methodology,20585,,"25,728 x DRG weight",20585,Other,base rate x DRG weight,18526,,"23,155 x DRG weight",18526,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,53996,50,,53996,Percent of Total Billed Charges,50% of Charges,23280,,"29,096 x DRG Weight",23280,Other,base rate x DRG weight,17973,,"22,463 x DRG Weight",17973,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21143,,"26,426 x DRG Weight",21143,Other,base rate x DRG weight,31051,,"38,809 x DRG Weight",31051,Other,base rate x DRG weight,31051,,"38,809 x DRG Weight",31051,Other,base rate x DRG weight,21143,,"26,426 x DRG Weight",21143,Other,base rate x DRG weight,31051,,"38,809 x DRG Weight",31051,Other,base rate x DRG weight,28316,,"35,391 x DRG Weight",28316,Other,base rate x DRG weight,75594,70,,75594,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20175,,"25,216 X DRG Weight",20175,Other,Base Weight X DRG Weight,18158,,"22,695 X DRG Weight",18158,Other,Base Weight X DRG Weight,20175,,"25,216 X DRG Weight",20175,Other,Base Rate x DRG Weight ,17149,,"21,433 x DRG Weight",17149,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,75594,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,,inpatient,,,150200.13,15357,,,15357,Other,150% of Medicare + 9.63% HCRA Surcharge,9338.97,,,9338.97,Other,Medicare IPPS methodology,25828,,"25,728 x DRG weight",25828,Other,base rate x DRG weight,23245,,"23,155 x DRG weight",23245,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,75100,50,,75100,Percent of Total Billed Charges,50% of Charges,29209,,"29,096 x DRG Weight",29209,Other,base rate x DRG weight,22551,,"22,463 x DRG Weight",22551,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26529,,"26,426 x DRG Weight",26529,Other,base rate x DRG weight,38960,,"38,809 x DRG Weight",38960,Other,base rate x DRG weight,38960,,"38,809 x DRG Weight",38960,Other,base rate x DRG weight,26529,,"26,426 x DRG Weight",26529,Other,base rate x DRG weight,38960,,"38,809 x DRG Weight",38960,Other,base rate x DRG weight,35529,,"35,391 x DRG Weight",35529,Other,base rate x DRG weight,105140,70,,105140,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25314,,"25,216 X DRG Weight",25314,Other,Base Weight X DRG Weight,22784,,"22,695 X DRG Weight",22784,Other,Base Weight X DRG Weight,25314,,"25,216 X DRG Weight",25314,Other,Base Rate x DRG Weight ,21517,,"21,433 x DRG Weight",21517,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,105140,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,MS-DRG,,,,,,,,inpatient,,,45266,9688,,,9688,Other,150% of Medicare + 9.63% HCRA Surcharge,5891.21,,,5891.21,Other,Medicare IPPS methodology,15993,,"25,728 x DRG weight",15993,Other,base rate x DRG weight,14393,,"23,155 x DRG weight",14393,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22633,50,,22633,Percent of Total Billed Charges,50% of Charges,18086,,"29,096 x DRG Weight",18086,Other,base rate x DRG weight,13963,,"22,463 x DRG Weight",13963,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,16426,,"26,426 x DRG Weight",16426,Other,base rate x DRG weight,24124,,"38,809 x DRG Weight",24124,Other,base rate x DRG weight,24124,,"38,809 x DRG Weight",24124,Other,base rate x DRG weight,16426,,"26,426 x DRG Weight",16426,Other,base rate x DRG weight,24124,,"38,809 x DRG Weight",24124,Other,base rate x DRG weight,21999,,"35,391 x DRG Weight",21999,Other,base rate x DRG weight,31686,70,,31686,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,15674,,"25,216 X DRG Weight",15674,Other,Base Weight X DRG Weight,14107,,"22,695 X DRG Weight",14107,Other,Base Weight X DRG Weight,15674,,"25,216 X DRG Weight",15674,Other,Base Rate x DRG Weight ,13323,,"21,433 x DRG Weight",13323,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,31686,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,MS-DRG,,,,,,,,inpatient,,,266811.89,32705,,,32705,Other,150% of Medicare + 9.63% HCRA Surcharge,19887.89,,,19887.89,Other,Medicare IPPS methodology,55922,,"25,728 x DRG weight",55922,Other,base rate x DRG weight,50330,,"23,155 x DRG weight",50330,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,133406,50,,133406,Percent of Total Billed Charges,50% of Charges,63243,,"29,096 x DRG Weight",63243,Other,base rate x DRG weight,48826,,"22,463 x DRG Weight",48826,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,57440,,"26,426 x DRG Weight",57440,Other,base rate x DRG weight,84355,,"38,809 x DRG Weight",84355,Other,base rate x DRG weight,84355,,"38,809 x DRG Weight",84355,Other,base rate x DRG weight,57440,,"26,426 x DRG Weight",57440,Other,base rate x DRG weight,84355,,"38,809 x DRG Weight",84355,Other,base rate x DRG weight,76926,,"35,391 x DRG Weight",76926,Other,base rate x DRG weight,186768,70,,186768,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,54809,,"25,216 X DRG Weight",54809,Other,Base Weight X DRG Weight,49330,,"22,695 X DRG Weight",49330,Other,Base Weight X DRG Weight,54809,,"25,216 X DRG Weight",54809,Other,Base Rate x DRG Weight ,46587,,"21,433 x DRG Weight",46587,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,186768,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,MS-DRG,,,,,,,,inpatient,,,138118.19,19159,,,19159,Other,150% of Medicare + 9.63% HCRA Surcharge,11650.41,,,11650.41,Other,Medicare IPPS methodology,32422,,"25,728 x DRG weight",32422,Other,base rate x DRG weight,29180,,"23,155 x DRG weight",29180,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,69059,50,,69059,Percent of Total Billed Charges,50% of Charges,36667,,"29,096 x DRG Weight",36667,Other,base rate x DRG weight,28308,,"22,463 x DRG Weight",28308,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,33302,,"26,426 x DRG Weight",33302,Other,base rate x DRG weight,48907,,"38,809 x DRG Weight",48907,Other,base rate x DRG weight,48907,,"38,809 x DRG Weight",48907,Other,base rate x DRG weight,33302,,"26,426 x DRG Weight",33302,Other,base rate x DRG weight,48907,,"38,809 x DRG Weight",48907,Other,base rate x DRG weight,44600,,"35,391 x DRG Weight",44600,Other,base rate x DRG weight,96683,70,,96683,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,31777,,"25,216 X DRG Weight",31777,Other,Base Weight X DRG Weight,28600,,"22,695 X DRG Weight",28600,Other,Base Weight X DRG Weight,31777,,"25,216 X DRG Weight",31777,Other,Base Rate x DRG Weight ,27010,,"21,433 x DRG Weight",27010,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,96683,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,,inpatient,,,395451.85,58118,,,58118,Other,150% of Medicare + 9.63% HCRA Surcharge,35341.96,,,35341.96,Other,Medicare IPPS methodology,100010,,"25,728 x DRG weight",100010,Other,base rate x DRG weight,90008,,"23,155 x DRG weight",90008,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,197726,50,,197726,Percent of Total Billed Charges,50% of Charges,113102,,"29,096 x DRG Weight",113102,Other,base rate x DRG weight,87318,,"22,463 x DRG Weight",87318,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,102723,,"26,426 x DRG Weight",102723,Other,base rate x DRG weight,150858,,"38,809 x DRG Weight",150858,Other,base rate x DRG weight,150858,,"38,809 x DRG Weight",150858,Other,base rate x DRG weight,102723,,"26,426 x DRG Weight",102723,Other,base rate x DRG weight,150858,,"38,809 x DRG Weight",150858,Other,base rate x DRG weight,137572,,"35,391 x DRG Weight",137572,Other,base rate x DRG weight,276816,70,,276816,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,98020,,"25,216 X DRG Weight",98020,Other,Base Weight X DRG Weight,88220,,"22,695 X DRG Weight",88220,Other,Base Weight X DRG Weight,98020,,"25,216 X DRG Weight",98020,Other,Base Rate x DRG Weight ,83314,,"21,433 x DRG Weight",83314,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,276816,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,,inpatient,,,230661.41,29742,,,29742,Other,150% of Medicare + 9.63% HCRA Surcharge,18086,,,18086,Other,Medicare IPPS methodology,50782,,"25,728 x DRG weight",50782,Other,base rate x DRG weight,45703,,"23,155 x DRG weight",45703,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,115331,50,,115331,Percent of Total Billed Charges,50% of Charges,57430,,"29,096 x DRG Weight",57430,Other,base rate x DRG weight,44337,,"22,463 x DRG Weight",44337,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,52160,,"26,426 x DRG Weight",52160,Other,base rate x DRG weight,76601,,"38,809 x DRG Weight",76601,Other,base rate x DRG weight,76601,,"38,809 x DRG Weight",76601,Other,base rate x DRG weight,52160,,"26,426 x DRG Weight",52160,Other,base rate x DRG weight,76601,,"38,809 x DRG Weight",76601,Other,base rate x DRG weight,69855,,"35,391 x DRG Weight",69855,Other,base rate x DRG weight,161463,70,,161463,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,49771,,"25,216 X DRG Weight",49771,Other,Base Weight X DRG Weight,44795,,"22,695 X DRG Weight",44795,Other,Base Weight X DRG Weight,49771,,"25,216 X DRG Weight",49771,Other,Base Rate x DRG Weight ,42304,,"21,433 x DRG Weight",42304,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,161463,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,,inpatient,,,154592.47,20707,,,20707,Other,150% of Medicare + 9.63% HCRA Surcharge,12591.94,,,12591.94,Other,Medicare IPPS methodology,35108,,"25,728 x DRG weight",35108,Other,base rate x DRG weight,31597,,"23,155 x DRG weight",31597,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,77296,50,,77296,Percent of Total Billed Charges,50% of Charges,39704,,"29,096 x DRG Weight",39704,Other,base rate x DRG weight,30653,,"22,463 x DRG Weight",30653,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,36061,,"26,426 x DRG Weight",36061,Other,base rate x DRG weight,52959,,"38,809 x DRG Weight",52959,Other,base rate x DRG weight,52959,,"38,809 x DRG Weight",52959,Other,base rate x DRG weight,36061,,"26,426 x DRG Weight",36061,Other,base rate x DRG weight,52959,,"38,809 x DRG Weight",52959,Other,base rate x DRG weight,48295,,"35,391 x DRG Weight",48295,Other,base rate x DRG weight,108215,70,,108215,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,34410,,"25,216 X DRG Weight",34410,Other,Base Weight X DRG Weight,30970,,"22,695 X DRG Weight",30970,Other,Base Weight X DRG Weight,34410,,"25,216 X DRG Weight",34410,Other,Base Rate x DRG Weight ,29247,,"21,433 x DRG Weight",29247,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,108215,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,,inpatient,,,394301.66,54101,,,54101,Other,150% of Medicare + 9.63% HCRA Surcharge,32898.85,,,32898.85,Other,Medicare IPPS methodology,93040,,"25,728 x DRG weight",93040,Other,base rate x DRG weight,83735,,"23,155 x DRG weight",83735,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,197151,50,,197151,Percent of Total Billed Charges,50% of Charges,105220,,"29,096 x DRG Weight",105220,Other,base rate x DRG weight,81233,,"22,463 x DRG Weight",81233,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,95564,,"26,426 x DRG Weight",95564,Other,base rate x DRG weight,140345,,"38,809 x DRG Weight",140345,Other,base rate x DRG weight,140345,,"38,809 x DRG Weight",140345,Other,base rate x DRG weight,95564,,"26,426 x DRG Weight",95564,Other,base rate x DRG weight,140345,,"38,809 x DRG Weight",140345,Other,base rate x DRG weight,127984,,"35,391 x DRG Weight",127984,Other,base rate x DRG weight,276011,70,,276011,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,91189,,"25,216 X DRG Weight",91189,Other,Base Weight X DRG Weight,82072,,"22,695 X DRG Weight",82072,Other,Base Weight X DRG Weight,91189,,"25,216 X DRG Weight",91189,Other,Base Rate x DRG Weight ,77508,,"21,433 x DRG Weight",77508,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,276011,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,,inpatient,,,224338.12,26971,,,26971,Other,150% of Medicare + 9.63% HCRA Surcharge,16401.34,,,16401.34,Other,Medicare IPPS methodology,45976,,"25,728 x DRG weight",45976,Other,base rate x DRG weight,41378,,"23,155 x DRG weight",41378,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,112169,50,,112169,Percent of Total Billed Charges,50% of Charges,51995,,"29,096 x DRG Weight",51995,Other,base rate x DRG weight,40141,,"22,463 x DRG Weight",40141,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,47223,,"26,426 x DRG Weight",47223,Other,base rate x DRG weight,69352,,"38,809 x DRG Weight",69352,Other,base rate x DRG weight,69352,,"38,809 x DRG Weight",69352,Other,base rate x DRG weight,47223,,"26,426 x DRG Weight",47223,Other,base rate x DRG weight,69352,,"38,809 x DRG Weight",69352,Other,base rate x DRG weight,63244,,"35,391 x DRG Weight",63244,Other,base rate x DRG weight,157037,70,,157037,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,45061,,"25,216 X DRG Weight",45061,Other,Base Weight X DRG Weight,40556,,"22,695 X DRG Weight",40556,Other,Base Weight X DRG Weight,45061,,"25,216 X DRG Weight",45061,Other,Base Rate x DRG Weight ,38301,,"21,433 x DRG Weight",38301,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,157037,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,,inpatient,,,119467.87,19738,,,19738,Other,150% of Medicare + 9.63% HCRA Surcharge,12003.03,,,12003.03,Other,Medicare IPPS methodology,33428,,"25,728 x DRG weight",33428,Other,base rate x DRG weight,30085,,"23,155 x DRG weight",30085,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,59734,50,,59734,Percent of Total Billed Charges,50% of Charges,37804,,"29,096 x DRG Weight",37804,Other,base rate x DRG weight,29186,,"22,463 x DRG Weight",29186,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,34335,,"26,426 x DRG Weight",34335,Other,base rate x DRG weight,50425,,"38,809 x DRG Weight",50425,Other,base rate x DRG weight,50425,,"38,809 x DRG Weight",50425,Other,base rate x DRG weight,34335,,"26,426 x DRG Weight",34335,Other,base rate x DRG weight,50425,,"38,809 x DRG Weight",50425,Other,base rate x DRG weight,45984,,"35,391 x DRG Weight",45984,Other,base rate x DRG weight,83628,70,,83628,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32763,,"25,216 X DRG Weight",32763,Other,Base Weight X DRG Weight,29488,,"22,695 X DRG Weight",29488,Other,Base Weight X DRG Weight,32763,,"25,216 X DRG Weight",32763,Other,Base Rate x DRG Weight ,27848,,"21,433 x DRG Weight",27848,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,83628,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,,inpatient,,,143911.13,26896,,,26896,Other,150% of Medicare + 9.63% HCRA Surcharge,16355.35,,,16355.35,Other,Medicare IPPS methodology,45845,,"25,728 x DRG weight",45845,Other,base rate x DRG weight,41260,,"23,155 x DRG weight",41260,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,71956,50,,71956,Percent of Total Billed Charges,50% of Charges,51846,,"29,096 x DRG Weight",51846,Other,base rate x DRG weight,40027,,"22,463 x DRG Weight",40027,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,47088,,"26,426 x DRG Weight",47088,Other,base rate x DRG weight,69154,,"38,809 x DRG Weight",69154,Other,base rate x DRG weight,69154,,"38,809 x DRG Weight",69154,Other,base rate x DRG weight,47088,,"26,426 x DRG Weight",47088,Other,base rate x DRG weight,69154,,"38,809 x DRG Weight",69154,Other,base rate x DRG weight,63063,,"35,391 x DRG Weight",63063,Other,base rate x DRG weight,100738,70,,100738,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,44932,,"25,216 X DRG Weight",44932,Other,Base Weight X DRG Weight,40440,,"22,695 X DRG Weight",40440,Other,Base Weight X DRG Weight,44932,,"25,216 X DRG Weight",44932,Other,Base Rate x DRG Weight ,38191,,"21,433 x DRG Weight",38191,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,100738,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,,inpatient,,,119614.78,17702,,,17702,Other,150% of Medicare + 9.63% HCRA Surcharge,10764.79,,,10764.79,Other,Medicare IPPS methodology,29896,,"25,728 x DRG weight",29896,Other,base rate x DRG weight,26906,,"23,155 x DRG weight",26906,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,59807,50,,59807,Percent of Total Billed Charges,50% of Charges,33810,,"29,096 x DRG Weight",33810,Other,base rate x DRG weight,26102,,"22,463 x DRG Weight",26102,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,30707,,"26,426 x DRG Weight",30707,Other,base rate x DRG weight,45096,,"38,809 x DRG Weight",45096,Other,base rate x DRG weight,45096,,"38,809 x DRG Weight",45096,Other,base rate x DRG weight,30707,,"26,426 x DRG Weight",30707,Other,base rate x DRG weight,45096,,"38,809 x DRG Weight",45096,Other,base rate x DRG weight,41124,,"35,391 x DRG Weight",41124,Other,base rate x DRG weight,83730,70,,83730,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,29301,,"25,216 X DRG Weight",29301,Other,Base Weight X DRG Weight,26372,,"22,695 X DRG Weight",26372,Other,Base Weight X DRG Weight,29301,,"25,216 X DRG Weight",29301,Other,Base Rate x DRG Weight ,24905,,"21,433 x DRG Weight",24905,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,83730,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,,inpatient,,,188345.52,28386,,,28386,Other,150% of Medicare + 9.63% HCRA Surcharge,17261.71,,,17261.71,Other,Medicare IPPS methodology,48430,,"25,728 x DRG weight",48430,Other,base rate x DRG weight,43587,,"23,155 x DRG weight",43587,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,94173,50,,94173,Percent of Total Billed Charges,50% of Charges,54770,,"29,096 x DRG Weight",54770,Other,base rate x DRG weight,42284,,"22,463 x DRG Weight",42284,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,49744,,"26,426 x DRG Weight",49744,Other,base rate x DRG weight,73054,,"38,809 x DRG Weight",73054,Other,base rate x DRG weight,73054,,"38,809 x DRG Weight",73054,Other,base rate x DRG weight,49744,,"26,426 x DRG Weight",49744,Other,base rate x DRG weight,73054,,"38,809 x DRG Weight",73054,Other,base rate x DRG weight,66620,,"35,391 x DRG Weight",66620,Other,base rate x DRG weight,131842,70,,131842,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,47467,,"25,216 X DRG Weight",47467,Other,Base Weight X DRG Weight,42721,,"22,695 X DRG Weight",42721,Other,Base Weight X DRG Weight,47467,,"25,216 X DRG Weight",47467,Other,Base Rate x DRG Weight ,40345,,"21,433 x DRG Weight",40345,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,131842,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,,inpatient,,,105015.35,15832,,,15832,Other,150% of Medicare + 9.63% HCRA Surcharge,9627.56,,,9627.56,Other,Medicare IPPS methodology,26652,,"25,728 x DRG weight",26652,Other,base rate x DRG weight,23986,,"23,155 x DRG weight",23986,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,52508,50,,52508,Percent of Total Billed Charges,50% of Charges,30141,,"29,096 x DRG Weight",30141,Other,base rate x DRG weight,23269,,"22,463 x DRG Weight",23269,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,27375,,"26,426 x DRG Weight",27375,Other,base rate x DRG weight,40202,,"38,809 x DRG Weight",40202,Other,base rate x DRG weight,40202,,"38,809 x DRG Weight",40202,Other,base rate x DRG weight,27375,,"26,426 x DRG Weight",27375,Other,base rate x DRG weight,40202,,"38,809 x DRG Weight",40202,Other,base rate x DRG weight,36662,,"35,391 x DRG Weight",36662,Other,base rate x DRG weight,73511,70,,73511,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,26121,,"25,216 X DRG Weight",26121,Other,Base Weight X DRG Weight,23510,,"22,695 X DRG Weight",23510,Other,Base Weight X DRG Weight,26121,,"25,216 X DRG Weight",26121,Other,Base Rate x DRG Weight ,22202,,"21,433 x DRG Weight",22202,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,73511,
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,,inpatient,,,318480.73,25326,,,25326,Other,150% of Medicare + 9.63% HCRA Surcharge,15401.19,,,15401.19,Other,Medicare IPPS methodology,43123,,"25,728 x DRG weight",43123,Other,base rate x DRG weight,38810,,"23,155 x DRG weight",38810,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,159240,50,,159240,Percent of Total Billed Charges,50% of Charges,48768,,"29,096 x DRG Weight",48768,Other,base rate x DRG weight,37650,,"22,463 x DRG Weight",37650,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,44293,,"26,426 x DRG Weight",44293,Other,base rate x DRG weight,65048,,"38,809 x DRG Weight",65048,Other,base rate x DRG weight,65048,,"38,809 x DRG Weight",65048,Other,base rate x DRG weight,44293,,"26,426 x DRG Weight",44293,Other,base rate x DRG weight,65048,,"38,809 x DRG Weight",65048,Other,base rate x DRG weight,59319,,"35,391 x DRG Weight",59319,Other,base rate x DRG weight,222937,70,,222937,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,42265,,"25,216 X DRG Weight",42265,Other,Base Weight X DRG Weight,38039,,"22,695 X DRG Weight",38039,Other,Base Weight X DRG Weight,42265,,"25,216 X DRG Weight",42265,Other,Base Rate x DRG Weight ,35924,,"21,433 x DRG Weight",35924,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,222937,
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,,inpatient,,,120820.28,13627,,,13627,Other,150% of Medicare + 9.63% HCRA Surcharge,8286.52,,,8286.52,Other,Medicare IPPS methodology,22826,,"25,728 x DRG weight",22826,Other,base rate x DRG weight,20543,,"23,155 x DRG weight",20543,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,60410,50,,60410,Percent of Total Billed Charges,50% of Charges,25814,,"29,096 x DRG Weight",25814,Other,base rate x DRG weight,19929,,"22,463 x DRG Weight",19929,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23445,,"26,426 x DRG Weight",23445,Other,base rate x DRG weight,34431,,"38,809 x DRG Weight",34431,Other,base rate x DRG weight,34431,,"38,809 x DRG Weight",34431,Other,base rate x DRG weight,23445,,"26,426 x DRG Weight",23445,Other,base rate x DRG weight,34431,,"38,809 x DRG Weight",34431,Other,base rate x DRG weight,31399,,"35,391 x DRG Weight",31399,Other,base rate x DRG weight,84574,70,,84574,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22372,,"25,216 X DRG Weight",22372,Other,Base Weight X DRG Weight,20135,,"22,695 X DRG Weight",20135,Other,Base Weight X DRG Weight,22372,,"25,216 X DRG Weight",22372,Other,Base Rate x DRG Weight ,19015,,"21,433 x DRG Weight",19015,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,84574,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,,inpatient,,,117580.68,21304,,,21304,Other,150% of Medicare + 9.63% HCRA Surcharge,12955.38,,,12955.38,Other,Medicare IPPS methodology,36145,,"25,728 x DRG weight",36145,Other,base rate x DRG weight,32530,,"23,155 x DRG weight",32530,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,58790,50,,58790,Percent of Total Billed Charges,50% of Charges,40877,,"29,096 x DRG Weight",40877,Other,base rate x DRG weight,31558,,"22,463 x DRG Weight",31558,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,37126,,"26,426 x DRG Weight",37126,Other,base rate x DRG weight,54523,,"38,809 x DRG Weight",54523,Other,base rate x DRG weight,54523,,"38,809 x DRG Weight",54523,Other,base rate x DRG weight,37126,,"26,426 x DRG Weight",37126,Other,base rate x DRG weight,54523,,"38,809 x DRG Weight",54523,Other,base rate x DRG weight,49721,,"35,391 x DRG Weight",49721,Other,base rate x DRG weight,82306,70,,82306,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35426,,"25,216 X DRG Weight",35426,Other,Base Weight X DRG Weight,31884,,"22,695 X DRG Weight",31884,Other,Base Weight X DRG Weight,35426,,"25,216 X DRG Weight",35426,Other,Base Rate x DRG Weight ,30111,,"21,433 x DRG Weight",30111,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,82306,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,,inpatient,,,154320.11,37800,,,37800,Other,150% of Medicare + 9.63% HCRA Surcharge,22986.64,,,22986.64,Other,Medicare IPPS methodology,64763,,"25,728 x DRG weight",64763,Other,base rate x DRG weight,58286,,"23,155 x DRG weight",58286,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,77160,50,,77160,Percent of Total Billed Charges,50% of Charges,73240,,"29,096 x DRG Weight",73240,Other,base rate x DRG weight,56544,,"22,463 x DRG Weight",56544,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,66520,,"26,426 x DRG Weight",66520,Other,base rate x DRG weight,97690,,"38,809 x DRG Weight",97690,Other,base rate x DRG weight,97690,,"38,809 x DRG Weight",97690,Other,base rate x DRG weight,66520,,"26,426 x DRG Weight",66520,Other,base rate x DRG weight,97690,,"38,809 x DRG Weight",97690,Other,base rate x DRG weight,89086,,"35,391 x DRG Weight",89086,Other,base rate x DRG weight,108024,70,,108024,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,63474,,"25,216 X DRG Weight",63474,Other,Base Weight X DRG Weight,57128,,"22,695 X DRG Weight",57128,Other,Base Weight X DRG Weight,63474,,"25,216 X DRG Weight",63474,Other,Base Rate x DRG Weight ,53951,,"21,433 x DRG Weight",53951,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,108024,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,MS-DRG,,,,,,,,inpatient,,,77672.49,20639,,,20639,Other,150% of Medicare + 9.63% HCRA Surcharge,12550.45,,,12550.45,Other,Medicare IPPS methodology,34990,,"25,728 x DRG weight",34990,Other,base rate x DRG weight,31491,,"23,155 x DRG weight",31491,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,38836,50,,38836,Percent of Total Billed Charges,50% of Charges,39571,,"29,096 x DRG Weight",39571,Other,base rate x DRG weight,30550,,"22,463 x DRG Weight",30550,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,35939,,"26,426 x DRG Weight",35939,Other,base rate x DRG weight,52780,,"38,809 x DRG Weight",52780,Other,base rate x DRG weight,52780,,"38,809 x DRG Weight",52780,Other,base rate x DRG weight,35939,,"26,426 x DRG Weight",35939,Other,base rate x DRG weight,52780,,"38,809 x DRG Weight",52780,Other,base rate x DRG weight,48132,,"35,391 x DRG Weight",48132,Other,base rate x DRG weight,54371,70,,54371,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,34294,,"25,216 X DRG Weight",34294,Other,Base Weight X DRG Weight,30865,,"22,695 X DRG Weight",30865,Other,Base Weight X DRG Weight,34294,,"25,216 X DRG Weight",34294,Other,Base Rate x DRG Weight ,29149,,"21,433 x DRG Weight",29149,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,54371,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,,inpatient,,,223184.5,27943,,,27943,Other,150% of Medicare + 9.63% HCRA Surcharge,16992.05,,,16992.05,Other,Medicare IPPS methodology,47661,,"25,728 x DRG weight",47661,Other,base rate x DRG weight,42895,,"23,155 x DRG weight",42895,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,111592,50,,111592,Percent of Total Billed Charges,50% of Charges,53900,,"29,096 x DRG Weight",53900,Other,base rate x DRG weight,41613,,"22,463 x DRG Weight",41613,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,48954,,"26,426 x DRG Weight",48954,Other,base rate x DRG weight,71894,,"38,809 x DRG Weight",71894,Other,base rate x DRG weight,71894,,"38,809 x DRG Weight",71894,Other,base rate x DRG weight,48954,,"26,426 x DRG Weight",48954,Other,base rate x DRG weight,71894,,"38,809 x DRG Weight",71894,Other,base rate x DRG weight,65562,,"35,391 x DRG Weight",65562,Other,base rate x DRG weight,156229,70,,156229,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46713,,"25,216 X DRG Weight",46713,Other,Base Weight X DRG Weight,42042,,"22,695 X DRG Weight",42042,Other,Base Weight X DRG Weight,46713,,"25,216 X DRG Weight",46713,Other,Base Rate x DRG Weight ,39705,,"21,433 x DRG Weight",39705,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,156229,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,,inpatient,,,225371.75,16556,,,16556,Other,150% of Medicare + 9.63% HCRA Surcharge,10067.67,,,10067.67,Other,Medicare IPPS methodology,27907,,"25,728 x DRG weight",27907,Other,base rate x DRG weight,25116,,"23,155 x DRG weight",25116,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,112686,50,,112686,Percent of Total Billed Charges,50% of Charges,31560,,"29,096 x DRG Weight",31560,Other,base rate x DRG weight,24366,,"22,463 x DRG Weight",24366,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28664,,"26,426 x DRG Weight",28664,Other,base rate x DRG weight,42096,,"38,809 x DRG Weight",42096,Other,base rate x DRG weight,42096,,"38,809 x DRG Weight",42096,Other,base rate x DRG weight,28664,,"26,426 x DRG Weight",28664,Other,base rate x DRG weight,42096,,"38,809 x DRG Weight",42096,Other,base rate x DRG weight,38389,,"35,391 x DRG Weight",38389,Other,base rate x DRG weight,157760,70,,157760,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27352,,"25,216 X DRG Weight",27352,Other,Base Weight X DRG Weight,24617,,"22,695 X DRG Weight",24617,Other,Base Weight X DRG Weight,27352,,"25,216 X DRG Weight",27352,Other,Base Rate x DRG Weight ,23248,,"21,433 x DRG Weight",23248,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,157760,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,,,,,,,,inpatient,,,94960,15147,,,15147,Other,150% of Medicare + 9.63% HCRA Surcharge,9210.91,,,9210.91,Other,Medicare IPPS methodology,25463,,"25,728 x DRG weight",25463,Other,base rate x DRG weight,22917,,"23,155 x DRG weight",22917,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,47480,50,,47480,Percent of Total Billed Charges,50% of Charges,28796,,"29,096 x DRG Weight",28796,Other,base rate x DRG weight,22232,,"22,463 x DRG Weight",22232,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26154,,"26,426 x DRG Weight",26154,Other,base rate x DRG weight,38409,,"38,809 x DRG Weight",38409,Other,base rate x DRG weight,38409,,"38,809 x DRG Weight",38409,Other,base rate x DRG weight,26154,,"26,426 x DRG Weight",26154,Other,base rate x DRG weight,38409,,"38,809 x DRG Weight",38409,Other,base rate x DRG weight,35026,,"35,391 x DRG Weight",35026,Other,base rate x DRG weight,66472,70,,66472,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24956,,"25,216 X DRG Weight",24956,Other,Base Weight X DRG Weight,22461,,"22,695 X DRG Weight",22461,Other,Base Weight X DRG Weight,24956,,"25,216 X DRG Weight",24956,Other,Base Rate x DRG Weight ,21212,,"21,433 x DRG Weight",21212,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,66472,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,,inpatient,,,109570.47,22590,,,22590,Other,150% of Medicare + 9.63% HCRA Surcharge,13737.28,,,13737.28,Other,Medicare IPPS methodology,38376,,"25,728 x DRG weight",38376,Other,base rate x DRG weight,34538,,"23,155 x DRG weight",34538,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,54785,50,,54785,Percent of Total Billed Charges,50% of Charges,43400,,"29,096 x DRG Weight",43400,Other,base rate x DRG weight,33506,,"22,463 x DRG Weight",33506,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39417,,"26,426 x DRG Weight",39417,Other,base rate x DRG weight,57888,,"38,809 x DRG Weight",57888,Other,base rate x DRG weight,57888,,"38,809 x DRG Weight",57888,Other,base rate x DRG weight,39417,,"26,426 x DRG Weight",39417,Other,base rate x DRG weight,57888,,"38,809 x DRG Weight",57888,Other,base rate x DRG weight,52789,,"35,391 x DRG Weight",52789,Other,base rate x DRG weight,76699,70,,76699,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37612,,"25,216 X DRG Weight",37612,Other,Base Weight X DRG Weight,33852,,"22,695 X DRG Weight",33852,Other,Base Weight X DRG Weight,37612,,"25,216 X DRG Weight",37612,Other,Base Rate x DRG Weight ,31969,,"21,433 x DRG Weight",31969,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,76699,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,,inpatient,,,140774.2,15190,,,15190,Other,150% of Medicare + 9.63% HCRA Surcharge,9237.06,,,9237.06,Other,Medicare IPPS methodology,25538,,"25,728 x DRG weight",25538,Other,base rate x DRG weight,22984,,"23,155 x DRG weight",22984,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,70387,50,,70387,Percent of Total Billed Charges,50% of Charges,28881,,"29,096 x DRG Weight",28881,Other,base rate x DRG weight,22297,,"22,463 x DRG Weight",22297,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26230,,"26,426 x DRG Weight",26230,Other,base rate x DRG weight,38522,,"38,809 x DRG Weight",38522,Other,base rate x DRG weight,38522,,"38,809 x DRG Weight",38522,Other,base rate x DRG weight,26230,,"26,426 x DRG Weight",26230,Other,base rate x DRG weight,38522,,"38,809 x DRG Weight",38522,Other,base rate x DRG weight,35129,,"35,391 x DRG Weight",35129,Other,base rate x DRG weight,98542,70,,98542,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25029,,"25,216 X DRG Weight",25029,Other,Base Weight X DRG Weight,22527,,"22,695 X DRG Weight",22527,Other,Base Weight X DRG Weight,25029,,"25,216 X DRG Weight",25029,Other,Base Rate x DRG Weight ,21274,,"21,433 x DRG Weight",21274,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,98542,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,,inpatient,,,80688.03,10053,,,10053,Other,150% of Medicare + 9.63% HCRA Surcharge,6113.06,,,6113.06,Other,Medicare IPPS methodology,16625,,"25,728 x DRG weight",16625,Other,base rate x DRG weight,14963,,"23,155 x DRG weight",14963,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40344,50,,40344,Percent of Total Billed Charges,50% of Charges,18802,,"29,096 x DRG Weight",18802,Other,base rate x DRG weight,14516,,"22,463 x DRG Weight",14516,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,17076,,"26,426 x DRG Weight",17076,Other,base rate x DRG weight,25078,,"38,809 x DRG Weight",25078,Other,base rate x DRG weight,25078,,"38,809 x DRG Weight",25078,Other,base rate x DRG weight,17076,,"26,426 x DRG Weight",17076,Other,base rate x DRG weight,25078,,"38,809 x DRG Weight",25078,Other,base rate x DRG weight,22870,,"35,391 x DRG Weight",22870,Other,base rate x DRG weight,56482,70,,56482,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,16295,,"25,216 X DRG Weight",16295,Other,Base Weight X DRG Weight,14666,,"22,695 X DRG Weight",14666,Other,Base Weight X DRG Weight,16295,,"25,216 X DRG Weight",16295,Other,Base Rate x DRG Weight ,13850,,"21,433 x DRG Weight",13850,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,56482,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,,inpatient,,,75978.04,15231,,,15231,Other,150% of Medicare + 9.63% HCRA Surcharge,9262.31,,,9262.31,Other,Medicare IPPS methodology,25610,,"25,728 x DRG weight",25610,Other,base rate x DRG weight,23048,,"23,155 x DRG weight",23048,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37989,50,,37989,Percent of Total Billed Charges,50% of Charges,28962,,"29,096 x DRG Weight",28962,Other,base rate x DRG weight,22360,,"22,463 x DRG Weight",22360,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26304,,"26,426 x DRG Weight",26304,Other,base rate x DRG weight,38630,,"38,809 x DRG Weight",38630,Other,base rate x DRG weight,38630,,"38,809 x DRG Weight",38630,Other,base rate x DRG weight,26304,,"26,426 x DRG Weight",26304,Other,base rate x DRG weight,38630,,"38,809 x DRG Weight",38630,Other,base rate x DRG weight,35228,,"35,391 x DRG Weight",35228,Other,base rate x DRG weight,53185,70,,53185,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25100,,"25,216 X DRG Weight",25100,Other,Base Weight X DRG Weight,22591,,"22,695 X DRG Weight",22591,Other,Base Weight X DRG Weight,25100,,"25,216 X DRG Weight",25100,Other,Base Rate x DRG Weight ,21334,,"21,433 x DRG Weight",21334,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,53185,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,,inpatient,,,72379.63,9451,,,9451,Other,150% of Medicare + 9.63% HCRA Surcharge,5746.91,,,5746.91,Other,Medicare IPPS methodology,15581,,"25,728 x DRG weight",15581,Other,base rate x DRG weight,14023,,"23,155 x DRG weight",14023,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,36190,50,,36190,Percent of Total Billed Charges,50% of Charges,17621,,"29,096 x DRG Weight",17621,Other,base rate x DRG weight,13604,,"22,463 x DRG Weight",13604,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,16004,,"26,426 x DRG Weight",16004,Other,base rate x DRG weight,23503,,"38,809 x DRG Weight",23503,Other,base rate x DRG weight,23503,,"38,809 x DRG Weight",23503,Other,base rate x DRG weight,16004,,"26,426 x DRG Weight",16004,Other,base rate x DRG weight,23503,,"38,809 x DRG Weight",23503,Other,base rate x DRG weight,21433,,"35,391 x DRG Weight",21433,Other,base rate x DRG weight,50666,70,,50666,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,15271,,"25,216 X DRG Weight",15271,Other,Base Weight X DRG Weight,13744,,"22,695 X DRG Weight",13744,Other,Base Weight X DRG Weight,15271,,"25,216 X DRG Weight",15271,Other,Base Rate x DRG Weight ,12980,,"21,433 x DRG Weight",12980,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,50666,
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,,inpatient,,,204856.68,23366,,,23366,Other,150% of Medicare + 9.63% HCRA Surcharge,14208.95,,,14208.95,Other,Medicare IPPS methodology,39721,,"25,728 x DRG weight",39721,Other,base rate x DRG weight,35749,,"23,155 x DRG weight",35749,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,102428,50,,102428,Percent of Total Billed Charges,50% of Charges,44921,,"29,096 x DRG Weight",44921,Other,base rate x DRG weight,34681,,"22,463 x DRG Weight",34681,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,40799,,"26,426 x DRG Weight",40799,Other,base rate x DRG weight,59917,,"38,809 x DRG Weight",59917,Other,base rate x DRG weight,59917,,"38,809 x DRG Weight",59917,Other,base rate x DRG weight,40799,,"26,426 x DRG Weight",40799,Other,base rate x DRG weight,59917,,"38,809 x DRG Weight",59917,Other,base rate x DRG weight,54640,,"35,391 x DRG Weight",54640,Other,base rate x DRG weight,143400,70,,143400,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,38931,,"25,216 X DRG Weight",38931,Other,Base Weight X DRG Weight,35039,,"22,695 X DRG Weight",35039,Other,Base Weight X DRG Weight,38931,,"25,216 X DRG Weight",38931,Other,Base Rate x DRG Weight ,33090,,"21,433 x DRG Weight",33090,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,143400,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,,inpatient,,,121738.67,12314,,,12314,Other,150% of Medicare + 9.63% HCRA Surcharge,7488.38,,,7488.38,Other,Medicare IPPS methodology,20549,,"25,728 x DRG weight",20549,Other,base rate x DRG weight,18494,,"23,155 x DRG weight",18494,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,60869,50,,60869,Percent of Total Billed Charges,50% of Charges,23239,,"29,096 x DRG Weight",23239,Other,base rate x DRG weight,17941,,"22,463 x DRG Weight",17941,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21106,,"26,426 x DRG Weight",21106,Other,base rate x DRG weight,30997,,"38,809 x DRG Weight",30997,Other,base rate x DRG weight,30997,,"38,809 x DRG Weight",30997,Other,base rate x DRG weight,21106,,"26,426 x DRG Weight",21106,Other,base rate x DRG weight,30997,,"38,809 x DRG Weight",30997,Other,base rate x DRG weight,28267,,"35,391 x DRG Weight",28267,Other,base rate x DRG weight,85217,70,,85217,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20140,,"25,216 X DRG Weight",20140,Other,Base Weight X DRG Weight,18126,,"22,695 X DRG Weight",18126,Other,Base Weight X DRG Weight,20140,,"25,216 X DRG Weight",20140,Other,Base Rate x DRG Weight ,17119,,"21,433 x DRG Weight",17119,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,85217,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,,inpatient,,,80412.78,11098,,,11098,Other,150% of Medicare + 9.63% HCRA Surcharge,6748.86,,,6748.86,Other,Medicare IPPS methodology,18439,,"25,728 x DRG weight",18439,Other,base rate x DRG weight,16595,,"23,155 x DRG weight",16595,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40206,50,,40206,Percent of Total Billed Charges,50% of Charges,20853,,"29,096 x DRG Weight",20853,Other,base rate x DRG weight,16099,,"22,463 x DRG Weight",16099,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18940,,"26,426 x DRG Weight",18940,Other,base rate x DRG weight,27814,,"38,809 x DRG Weight",27814,Other,base rate x DRG weight,27814,,"38,809 x DRG Weight",27814,Other,base rate x DRG weight,18940,,"26,426 x DRG Weight",18940,Other,base rate x DRG weight,27814,,"38,809 x DRG Weight",27814,Other,base rate x DRG weight,25365,,"35,391 x DRG Weight",25365,Other,base rate x DRG weight,56289,70,,56289,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18072,,"25,216 X DRG Weight",18072,Other,Base Weight X DRG Weight,16266,,"22,695 X DRG Weight",16266,Other,Base Weight X DRG Weight,18072,,"25,216 X DRG Weight",18072,Other,Base Rate x DRG Weight ,15361,,"21,433 x DRG Weight",15361,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,56289,
ABORTION WITHOUT D&C,779,MS-DRG,,,,,,,,inpatient,,,161268.53,15139,,,15139,Other,150% of Medicare + 9.63% HCRA Surcharge,9206.4,,,9206.4,Other,Medicare IPPS methodology,25450,,"25,728 x DRG weight",25450,Other,base rate x DRG weight,22905,,"23,155 x DRG weight",22905,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,80634,50,,80634,Percent of Total Billed Charges,50% of Charges,28782,,"29,096 x DRG Weight",28782,Other,base rate x DRG weight,22220,,"22,463 x DRG Weight",22220,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26141,,"26,426 x DRG Weight",26141,Other,base rate x DRG weight,38390,,"38,809 x DRG Weight",38390,Other,base rate x DRG weight,38390,,"38,809 x DRG Weight",38390,Other,base rate x DRG weight,26141,,"26,426 x DRG Weight",26141,Other,base rate x DRG weight,38390,,"38,809 x DRG Weight",38390,Other,base rate x DRG weight,35009,,"35,391 x DRG Weight",35009,Other,base rate x DRG weight,112888,70,,112888,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24944,,"25,216 X DRG Weight",24944,Other,Base Weight X DRG Weight,22450,,"22,695 X DRG Weight",22450,Other,Base Weight X DRG Weight,24944,,"25,216 X DRG Weight",24944,Other,Base Rate x DRG Weight ,21202,,"21,433 x DRG Weight",21202,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,112888,
SPLENIC PROCEDURES WITH MCC,799,MS-DRG,,,,,,,,inpatient,,,201209,73948,,,73948,Other,150% of Medicare + 9.63% HCRA Surcharge,44968.28,,,44968.28,Other,Medicare IPPS methodology,127472,,"25,728 x DRG weight",127472,Other,base rate x DRG weight,114724,,"23,155 x DRG weight",114724,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,100605,50,,100605,Percent of Total Billed Charges,50% of Charges,144159,,"29,096 x DRG Weight",144159,Other,base rate x DRG weight,111295,,"22,463 x DRG Weight",111295,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,130930,,"26,426 x DRG Weight",130930,Other,base rate x DRG weight,192283,,"38,809 x DRG Weight",192283,Other,base rate x DRG weight,192283,,"38,809 x DRG Weight",192283,Other,base rate x DRG weight,130930,,"26,426 x DRG Weight",130930,Other,base rate x DRG weight,192283,,"38,809 x DRG Weight",192283,Other,base rate x DRG weight,175348,,"35,391 x DRG Weight",175348,Other,base rate x DRG weight,140846,70,,140846,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,124935,,"25,216 X DRG Weight",124935,Other,Base Weight X DRG Weight,112445,,"22,695 X DRG Weight",112445,Other,Base Weight X DRG Weight,124935,,"25,216 X DRG Weight",124935,Other,Base Rate x DRG Weight ,106192,,"21,433 x DRG Weight",106192,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,192283,
SPLENIC PROCEDURES WITH CC,800,MS-DRG,,,,,,,,inpatient,,,134326.23,42257,,,42257,Other,150% of Medicare + 9.63% HCRA Surcharge,25696.69,,,25696.69,Other,Medicare IPPS methodology,72494,,"25,728 x DRG weight",72494,Other,base rate x DRG weight,65244,,"23,155 x DRG weight",65244,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,67163,50,,67163,Percent of Total Billed Charges,50% of Charges,81984,,"29,096 x DRG Weight",81984,Other,base rate x DRG weight,63294,,"22,463 x DRG Weight",63294,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,74461,,"26,426 x DRG Weight",74461,Other,base rate x DRG weight,109352,,"38,809 x DRG Weight",109352,Other,base rate x DRG weight,109352,,"38,809 x DRG Weight",109352,Other,base rate x DRG weight,74461,,"26,426 x DRG Weight",74461,Other,base rate x DRG weight,109352,,"38,809 x DRG Weight",109352,Other,base rate x DRG weight,99721,,"35,391 x DRG Weight",99721,Other,base rate x DRG weight,94028,70,,94028,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,71051,,"25,216 X DRG Weight",71051,Other,Base Weight X DRG Weight,63948,,"22,695 X DRG Weight",63948,Other,Base Weight X DRG Weight,71051,,"25,216 X DRG Weight",71051,Other,Base Rate x DRG Weight ,60392,,"21,433 x DRG Weight",60392,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,109352,
SPLENIC PROCEDURES WITHOUT CC/MCC,801,MS-DRG,,,,,,,,inpatient,,,81755.94,27011,,,27011,Other,150% of Medicare + 9.63% HCRA Surcharge,16425.69,,,16425.69,Other,Medicare IPPS methodology,46045,,"25,728 x DRG weight",46045,Other,base rate x DRG weight,41441,,"23,155 x DRG weight",41441,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40878,50,,40878,Percent of Total Billed Charges,50% of Charges,52073,,"29,096 x DRG Weight",52073,Other,base rate x DRG weight,40202,,"22,463 x DRG Weight",40202,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,47295,,"26,426 x DRG Weight",47295,Other,base rate x DRG weight,69456,,"38,809 x DRG Weight",69456,Other,base rate x DRG weight,69456,,"38,809 x DRG Weight",69456,Other,base rate x DRG weight,47295,,"26,426 x DRG Weight",47295,Other,base rate x DRG weight,69456,,"38,809 x DRG Weight",69456,Other,base rate x DRG weight,63339,,"35,391 x DRG Weight",63339,Other,base rate x DRG weight,57229,70,,57229,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,45129,,"25,216 X DRG Weight",45129,Other,Base Weight X DRG Weight,40617,,"22,695 X DRG Weight",40617,Other,Base Weight X DRG Weight,45129,,"25,216 X DRG Weight",45129,Other,Base Rate x DRG Weight ,38359,,"21,433 x DRG Weight",38359,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,69456,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,,inpatient,,,285425.59,51349,,,51349,Other,150% of Medicare + 9.63% HCRA Surcharge,31225.92,,,31225.92,Other,Medicare IPPS methodology,88268,,"25,728 x DRG weight",88268,Other,base rate x DRG weight,79440,,"23,155 x DRG weight",79440,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,142713,50,,142713,Percent of Total Billed Charges,50% of Charges,99823,,"29,096 x DRG Weight",99823,Other,base rate x DRG weight,77066,,"22,463 x DRG Weight",77066,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,90662,,"26,426 x DRG Weight",90662,Other,base rate x DRG weight,133146,,"38,809 x DRG Weight",133146,Other,base rate x DRG weight,133146,,"38,809 x DRG Weight",133146,Other,base rate x DRG weight,90662,,"26,426 x DRG Weight",90662,Other,base rate x DRG weight,133146,,"38,809 x DRG Weight",133146,Other,base rate x DRG weight,121419,,"35,391 x DRG Weight",121419,Other,base rate x DRG weight,199798,70,,199798,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,86511,,"25,216 X DRG Weight",86511,Other,Base Weight X DRG Weight,77862,,"22,695 X DRG Weight",77862,Other,Base Weight X DRG Weight,86511,,"25,216 X DRG Weight",86511,Other,Base Rate x DRG Weight ,73532,,"21,433 x DRG Weight",73532,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,199798,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,,inpatient,,,157504.65,28027,,,28027,Other,150% of Medicare + 9.63% HCRA Surcharge,17043.46,,,17043.46,Other,Medicare IPPS methodology,47808,,"25,728 x DRG weight",47808,Other,base rate x DRG weight,43027,,"23,155 x DRG weight",43027,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,78752,50,,78752,Percent of Total Billed Charges,50% of Charges,54066,,"29,096 x DRG Weight",54066,Other,base rate x DRG weight,41741,,"22,463 x DRG Weight",41741,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,49105,,"26,426 x DRG Weight",49105,Other,base rate x DRG weight,72115,,"38,809 x DRG Weight",72115,Other,base rate x DRG weight,72115,,"38,809 x DRG Weight",72115,Other,base rate x DRG weight,49105,,"26,426 x DRG Weight",49105,Other,base rate x DRG weight,72115,,"38,809 x DRG Weight",72115,Other,base rate x DRG weight,65764,,"35,391 x DRG Weight",65764,Other,base rate x DRG weight,110253,70,,110253,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46856,,"25,216 X DRG Weight",46856,Other,Base Weight X DRG Weight,42172,,"22,695 X DRG Weight",42172,Other,Base Weight X DRG Weight,46856,,"25,216 X DRG Weight",46856,Other,Base Rate x DRG Weight ,39827,,"21,433 x DRG Weight",39827,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,110253,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,MS-DRG,,,,,,,,inpatient,,,172279.15,18420,,,18420,Other,150% of Medicare + 9.63% HCRA Surcharge,11201.29,,,11201.29,Other,Medicare IPPS methodology,31141,,"25,728 x DRG weight",31141,Other,base rate x DRG weight,28027,,"23,155 x DRG weight",28027,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,86140,50,,86140,Percent of Total Billed Charges,50% of Charges,35218,,"29,096 x DRG Weight",35218,Other,base rate x DRG weight,27189,,"22,463 x DRG Weight",27189,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31986,,"26,426 x DRG Weight",31986,Other,base rate x DRG weight,46974,,"38,809 x DRG Weight",46974,Other,base rate x DRG weight,46974,,"38,809 x DRG Weight",46974,Other,base rate x DRG weight,31986,,"26,426 x DRG Weight",31986,Other,base rate x DRG weight,46974,,"38,809 x DRG Weight",46974,Other,base rate x DRG weight,42837,,"35,391 x DRG Weight",42837,Other,base rate x DRG weight,120595,70,,120595,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,30521,,"25,216 X DRG Weight",30521,Other,Base Weight X DRG Weight,27470,,"22,695 X DRG Weight",27470,Other,Base Weight X DRG Weight,30521,,"25,216 X DRG Weight",30521,Other,Base Rate x DRG Weight ,25943,,"21,433 x DRG Weight",25943,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,120595,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,,inpatient,,,320861.91,32949,,,32949,Other,150% of Medicare + 9.63% HCRA Surcharge,20036.69,,,20036.69,Other,Medicare IPPS methodology,56347,,"25,728 x DRG weight",56347,Other,base rate x DRG weight,50712,,"23,155 x DRG weight",50712,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,160431,50,,160431,Percent of Total Billed Charges,50% of Charges,63723,,"29,096 x DRG Weight",63723,Other,base rate x DRG weight,49196,,"22,463 x DRG Weight",49196,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,57876,,"26,426 x DRG Weight",57876,Other,base rate x DRG weight,84996,,"38,809 x DRG Weight",84996,Other,base rate x DRG weight,84996,,"38,809 x DRG Weight",84996,Other,base rate x DRG weight,57876,,"26,426 x DRG Weight",57876,Other,base rate x DRG weight,84996,,"38,809 x DRG Weight",84996,Other,base rate x DRG weight,77510,,"35,391 x DRG Weight",77510,Other,base rate x DRG weight,224603,70,,224603,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,55226,,"25,216 X DRG Weight",55226,Other,Base Weight X DRG Weight,49704,,"22,695 X DRG Weight",49704,Other,Base Weight X DRG Weight,55226,,"25,216 X DRG Weight",55226,Other,Base Rate x DRG Weight ,46940,,"21,433 x DRG Weight",46940,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,224603,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,,inpatient,,,155465.23,18331,,,18331,Other,150% of Medicare + 9.63% HCRA Surcharge,11147.18,,,11147.18,Other,Medicare IPPS methodology,30987,,"25,728 x DRG weight",30987,Other,base rate x DRG weight,27888,,"23,155 x DRG weight",27888,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,77733,50,,77733,Percent of Total Billed Charges,50% of Charges,35043,,"29,096 x DRG Weight",35043,Other,base rate x DRG weight,27054,,"22,463 x DRG Weight",27054,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,31827,,"26,426 x DRG Weight",31827,Other,base rate x DRG weight,46742,,"38,809 x DRG Weight",46742,Other,base rate x DRG weight,46742,,"38,809 x DRG Weight",46742,Other,base rate x DRG weight,31827,,"26,426 x DRG Weight",31827,Other,base rate x DRG weight,46742,,"38,809 x DRG Weight",46742,Other,base rate x DRG weight,42625,,"35,391 x DRG Weight",42625,Other,base rate x DRG weight,108826,70,,108826,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,30370,,"25,216 X DRG Weight",30370,Other,Base Weight X DRG Weight,27334,,"22,695 X DRG Weight",27334,Other,Base Weight X DRG Weight,30370,,"25,216 X DRG Weight",30370,Other,Base Rate x DRG Weight ,25814,,"21,433 x DRG Weight",25814,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,108826,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,,inpatient,,,148218.26,15366,,,15366,Other,150% of Medicare + 9.63% HCRA Surcharge,9344.38,,,9344.38,Other,Medicare IPPS methodology,25844,,"25,728 x DRG weight",25844,Other,base rate x DRG weight,23259,,"23,155 x DRG weight",23259,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,74109,50,,74109,Percent of Total Billed Charges,50% of Charges,29227,,"29,096 x DRG Weight",29227,Other,base rate x DRG weight,22564,,"22,463 x DRG Weight",22564,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26545,,"26,426 x DRG Weight",26545,Other,base rate x DRG weight,38984,,"38,809 x DRG Weight",38984,Other,base rate x DRG weight,38984,,"38,809 x DRG Weight",38984,Other,base rate x DRG weight,26545,,"26,426 x DRG Weight",26545,Other,base rate x DRG weight,38984,,"38,809 x DRG Weight",38984,Other,base rate x DRG weight,35550,,"35,391 x DRG Weight",35550,Other,base rate x DRG weight,103753,70,,103753,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25329,,"25,216 X DRG Weight",25329,Other,Base Weight X DRG Weight,22797,,"22,695 X DRG Weight",22797,Other,Base Weight X DRG Weight,25329,,"25,216 X DRG Weight",25329,Other,Base Rate x DRG Weight ,21529,,"21,433 x DRG Weight",21529,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,103753,
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,,inpatient,,,193444.49,21285,,,21285,Other,150% of Medicare + 9.63% HCRA Surcharge,12943.66,,,12943.66,Other,Medicare IPPS methodology,36112,,"25,728 x DRG weight",36112,Other,base rate x DRG weight,32500,,"23,155 x DRG weight",32500,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,96722,50,,96722,Percent of Total Billed Charges,50% of Charges,40839,,"29,096 x DRG Weight",40839,Other,base rate x DRG weight,31529,,"22,463 x DRG Weight",31529,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,37092,,"26,426 x DRG Weight",37092,Other,base rate x DRG weight,54472,,"38,809 x DRG Weight",54472,Other,base rate x DRG weight,54472,,"38,809 x DRG Weight",54472,Other,base rate x DRG weight,37092,,"26,426 x DRG Weight",37092,Other,base rate x DRG weight,54472,,"38,809 x DRG Weight",54472,Other,base rate x DRG weight,49675,,"35,391 x DRG Weight",49675,Other,base rate x DRG weight,135411,70,,135411,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35393,,"25,216 X DRG Weight",35393,Other,Base Weight X DRG Weight,31855,,"22,695 X DRG Weight",31855,Other,Base Weight X DRG Weight,35393,,"25,216 X DRG Weight",35393,Other,Base Rate x DRG Weight ,30083,,"21,433 x DRG Weight",30083,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,135411,
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,,inpatient,,,136529.49,13827,,,13827,Other,150% of Medicare + 9.63% HCRA Surcharge,8408.26,,,8408.26,Other,Medicare IPPS methodology,23173,,"25,728 x DRG weight",23173,Other,base rate x DRG weight,20856,,"23,155 x DRG weight",20856,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,68265,50,,68265,Percent of Total Billed Charges,50% of Charges,26207,,"29,096 x DRG Weight",26207,Other,base rate x DRG weight,20232,,"22,463 x DRG Weight",20232,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23802,,"26,426 x DRG Weight",23802,Other,base rate x DRG weight,34955,,"38,809 x DRG Weight",34955,Other,base rate x DRG weight,34955,,"38,809 x DRG Weight",34955,Other,base rate x DRG weight,23802,,"26,426 x DRG Weight",23802,Other,base rate x DRG weight,34955,,"38,809 x DRG Weight",34955,Other,base rate x DRG weight,31877,,"35,391 x DRG Weight",31877,Other,base rate x DRG weight,95571,70,,95571,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22712,,"25,216 X DRG Weight",22712,Other,Base Weight X DRG Weight,20441,,"22,695 X DRG Weight",20441,Other,Base Weight X DRG Weight,22712,,"25,216 X DRG Weight",22712,Other,Base Rate x DRG Weight ,19305,,"21,433 x DRG Weight",19305,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,95571,
COAGULATION DISORDERS,813,MS-DRG,,,,,,,,inpatient,,,150549.26,23605,,,23605,Other,150% of Medicare + 9.63% HCRA Surcharge,14354.15,,,14354.15,Other,Medicare IPPS methodology,40136,,"25,728 x DRG weight",40136,Other,base rate x DRG weight,36122,,"23,155 x DRG weight",36122,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,75275,50,,75275,Percent of Total Billed Charges,50% of Charges,45390,,"29,096 x DRG Weight",45390,Other,base rate x DRG weight,35042,,"22,463 x DRG Weight",35042,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41225,,"26,426 x DRG Weight",41225,Other,base rate x DRG weight,60542,,"38,809 x DRG Weight",60542,Other,base rate x DRG weight,60542,,"38,809 x DRG Weight",60542,Other,base rate x DRG weight,41225,,"26,426 x DRG Weight",41225,Other,base rate x DRG weight,60542,,"38,809 x DRG Weight",60542,Other,base rate x DRG weight,55210,,"35,391 x DRG Weight",55210,Other,base rate x DRG weight,105384,70,,105384,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39337,,"25,216 X DRG Weight",39337,Other,Base Weight X DRG Weight,35404,,"22,695 X DRG Weight",35404,Other,Base Weight X DRG Weight,39337,,"25,216 X DRG Weight",39337,Other,Base Rate x DRG Weight ,33435,,"21,433 x DRG Weight",33435,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,105384,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,,inpatient,,,442077.65,32030,,,32030,Other,150% of Medicare + 9.63% HCRA Surcharge,19477.55,,,19477.55,Other,Medicare IPPS methodology,54752,,"25,728 x DRG weight",54752,Other,base rate x DRG weight,49276,,"23,155 x DRG weight",49276,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,221039,50,,221039,Percent of Total Billed Charges,50% of Charges,61919,,"29,096 x DRG Weight",61919,Other,base rate x DRG weight,47804,,"22,463 x DRG Weight",47804,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,56237,,"26,426 x DRG Weight",56237,Other,base rate x DRG weight,82589,,"38,809 x DRG Weight",82589,Other,base rate x DRG weight,82589,,"38,809 x DRG Weight",82589,Other,base rate x DRG weight,56237,,"26,426 x DRG Weight",56237,Other,base rate x DRG weight,82589,,"38,809 x DRG Weight",82589,Other,base rate x DRG weight,75316,,"35,391 x DRG Weight",75316,Other,base rate x DRG weight,309454,70,,309454,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,53662,,"25,216 X DRG Weight",53662,Other,Base Weight X DRG Weight,48297,,"22,695 X DRG Weight",48297,Other,Base Weight X DRG Weight,53662,,"25,216 X DRG Weight",53662,Other,Base Rate x DRG Weight ,45612,,"21,433 x DRG Weight",45612,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,309454,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,,inpatient,,,124895.14,15214,,,15214,Other,150% of Medicare + 9.63% HCRA Surcharge,9251.49,,,9251.49,Other,Medicare IPPS methodology,25579,,"25,728 x DRG weight",25579,Other,base rate x DRG weight,23021,,"23,155 x DRG weight",23021,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,62448,50,,62448,Percent of Total Billed Charges,50% of Charges,28927,,"29,096 x DRG Weight",28927,Other,base rate x DRG weight,22333,,"22,463 x DRG Weight",22333,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26273,,"26,426 x DRG Weight",26273,Other,base rate x DRG weight,38584,,"38,809 x DRG Weight",38584,Other,base rate x DRG weight,38584,,"38,809 x DRG Weight",38584,Other,base rate x DRG weight,26273,,"26,426 x DRG Weight",26273,Other,base rate x DRG weight,38584,,"38,809 x DRG Weight",38584,Other,base rate x DRG weight,35186,,"35,391 x DRG Weight",35186,Other,base rate x DRG weight,87427,70,,87427,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25070,,"25,216 X DRG Weight",25070,Other,Base Weight X DRG Weight,22563,,"22,695 X DRG Weight",22563,Other,Base Weight X DRG Weight,25070,,"25,216 X DRG Weight",25070,Other,Base Rate x DRG Weight ,21309,,"21,433 x DRG Weight",21309,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,87427,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,,inpatient,,,82618.99,11002,,,11002,Other,150% of Medicare + 9.63% HCRA Surcharge,6690.24,,,6690.24,Other,Medicare IPPS methodology,18272,,"25,728 x DRG weight",18272,Other,base rate x DRG weight,16445,,"23,155 x DRG weight",16445,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,41309,50,,41309,Percent of Total Billed Charges,50% of Charges,20664,,"29,096 x DRG Weight",20664,Other,base rate x DRG weight,15953,,"22,463 x DRG Weight",15953,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18768,,"26,426 x DRG Weight",18768,Other,base rate x DRG weight,27562,,"38,809 x DRG Weight",27562,Other,base rate x DRG weight,27562,,"38,809 x DRG Weight",27562,Other,base rate x DRG weight,18768,,"26,426 x DRG Weight",18768,Other,base rate x DRG weight,27562,,"38,809 x DRG Weight",27562,Other,base rate x DRG weight,25135,,"35,391 x DRG Weight",25135,Other,base rate x DRG weight,57833,70,,57833,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,17908,,"25,216 X DRG Weight",17908,Other,Base Weight X DRG Weight,16118,,"22,695 X DRG Weight",16118,Other,Base Weight X DRG Weight,17908,,"25,216 X DRG Weight",17908,Other,Base Rate x DRG Weight ,15222,,"21,433 x DRG Weight",15222,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,57833,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,,inpatient,,,203739,42244,,,42244,Other,150% of Medicare + 9.63% HCRA Surcharge,25688.57,,,25688.57,Other,Medicare IPPS methodology,72471,,"25,728 x DRG weight",72471,Other,base rate x DRG weight,65223,,"23,155 x DRG weight",65223,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,101870,50,,101870,Percent of Total Billed Charges,50% of Charges,81958,,"29,096 x DRG Weight",81958,Other,base rate x DRG weight,63274,,"22,463 x DRG Weight",63274,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,74437,,"26,426 x DRG Weight",74437,Other,base rate x DRG weight,109317,,"38,809 x DRG Weight",109317,Other,base rate x DRG weight,109317,,"38,809 x DRG Weight",109317,Other,base rate x DRG weight,74437,,"26,426 x DRG Weight",74437,Other,base rate x DRG weight,109317,,"38,809 x DRG Weight",109317,Other,base rate x DRG weight,99689,,"35,391 x DRG Weight",99689,Other,base rate x DRG weight,142617,70,,142617,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,71028,,"25,216 X DRG Weight",71028,Other,Base Weight X DRG Weight,63927,,"22,695 X DRG Weight",63927,Other,Base Weight X DRG Weight,71028,,"25,216 X DRG Weight",71028,Other,Base Rate x DRG Weight ,60372,,"21,433 x DRG Weight",60372,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,142617,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,,inpatient,,,171139.33,21693,,,21693,Other,150% of Medicare + 9.63% HCRA Surcharge,13191.67,,,13191.67,Other,Medicare IPPS methodology,36819,,"25,728 x DRG weight",36819,Other,base rate x DRG weight,33137,,"23,155 x DRG weight",33137,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,85570,50,,85570,Percent of Total Billed Charges,50% of Charges,41639,,"29,096 x DRG Weight",41639,Other,base rate x DRG weight,32147,,"22,463 x DRG Weight",32147,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,37818,,"26,426 x DRG Weight",37818,Other,base rate x DRG weight,55540,,"38,809 x DRG Weight",55540,Other,base rate x DRG weight,55540,,"38,809 x DRG Weight",55540,Other,base rate x DRG weight,37818,,"26,426 x DRG Weight",37818,Other,base rate x DRG weight,55540,,"38,809 x DRG Weight",55540,Other,base rate x DRG weight,50648,,"35,391 x DRG Weight",50648,Other,base rate x DRG weight,119798,70,,119798,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,36087,,"25,216 X DRG Weight",36087,Other,Base Weight X DRG Weight,32479,,"22,695 X DRG Weight",32479,Other,Base Weight X DRG Weight,36087,,"25,216 X DRG Weight",36087,Other,Base Rate x DRG Weight ,30673,,"21,433 x DRG Weight",30673,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,119798,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,MS-DRG,,,,,,,,inpatient,,,88619.17,13923,,,13923,Other,150% of Medicare + 9.63% HCRA Surcharge,8466.89,,,8466.89,Other,Medicare IPPS methodology,23340,,"25,728 x DRG weight",23340,Other,base rate x DRG weight,21006,,"23,155 x DRG weight",21006,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,44310,50,,44310,Percent of Total Billed Charges,50% of Charges,26396,,"29,096 x DRG Weight",26396,Other,base rate x DRG weight,20378,,"22,463 x DRG Weight",20378,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23974,,"26,426 x DRG Weight",23974,Other,base rate x DRG weight,35208,,"38,809 x DRG Weight",35208,Other,base rate x DRG weight,35208,,"38,809 x DRG Weight",35208,Other,base rate x DRG weight,23974,,"26,426 x DRG Weight",23974,Other,base rate x DRG weight,35208,,"38,809 x DRG Weight",35208,Other,base rate x DRG weight,32107,,"35,391 x DRG Weight",32107,Other,base rate x DRG weight,62033,70,,62033,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22876,,"25,216 X DRG Weight",22876,Other,Base Weight X DRG Weight,20589,,"22,695 X DRG Weight",20589,Other,Base Weight X DRG Weight,22876,,"25,216 X DRG Weight",22876,Other,Base Rate x DRG Weight ,19444,,"21,433 x DRG Weight",19444,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,62033,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,,inpatient,,,1390777.53,90144,,,90144,Other,150% of Medicare + 9.63% HCRA Surcharge,54817.36,,,54817.36,Other,Medicare IPPS methodology,155569,,"25,728 x DRG weight",155569,Other,base rate x DRG weight,140011,,"23,155 x DRG weight",140011,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,695389,50,,695389,Percent of Total Billed Charges,50% of Charges,175935,,"29,096 x DRG Weight",175935,Other,base rate x DRG weight,135827,,"22,463 x DRG Weight",135827,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,159790,,"26,426 x DRG Weight",159790,Other,base rate x DRG weight,234666,,"38,809 x DRG Weight",234666,Other,base rate x DRG weight,234666,,"38,809 x DRG Weight",234666,Other,base rate x DRG weight,159790,,"26,426 x DRG Weight",159790,Other,base rate x DRG weight,234666,,"38,809 x DRG Weight",234666,Other,base rate x DRG weight,213999,,"35,391 x DRG Weight",213999,Other,base rate x DRG weight,973544,70,,973544,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,152474,,"25,216 X DRG Weight",152474,Other,Base Weight X DRG Weight,137230,,"22,695 X DRG Weight",137230,Other,Base Weight X DRG Weight,152474,,"25,216 X DRG Weight",152474,Other,Base Rate x DRG Weight ,129599,,"21,433 x DRG Weight",129599,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,973544,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,MS-DRG,,,,,,,,inpatient,,,699365.59,33572,,,33572,Other,150% of Medicare + 9.63% HCRA Surcharge,20415.47,,,20415.47,Other,Medicare IPPS methodology,57427,,"25,728 x DRG weight",57427,Other,base rate x DRG weight,51684,,"23,155 x DRG weight",51684,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,349683,50,,349683,Percent of Total Billed Charges,50% of Charges,64945,,"29,096 x DRG Weight",64945,Other,base rate x DRG weight,50140,,"22,463 x DRG Weight",50140,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,58985,,"26,426 x DRG Weight",58985,Other,base rate x DRG weight,86626,,"38,809 x DRG Weight",86626,Other,base rate x DRG weight,86626,,"38,809 x DRG Weight",86626,Other,base rate x DRG weight,58985,,"26,426 x DRG Weight",58985,Other,base rate x DRG weight,86626,,"38,809 x DRG Weight",86626,Other,base rate x DRG weight,78996,,"35,391 x DRG Weight",78996,Other,base rate x DRG weight,489556,70,,489556,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,56285,,"25,216 X DRG Weight",56285,Other,Base Weight X DRG Weight,50658,,"22,695 X DRG Weight",50658,Other,Base Weight X DRG Weight,56285,,"25,216 X DRG Weight",56285,Other,Base Rate x DRG Weight ,47841,,"21,433 x DRG Weight",47841,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,489556,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,,inpatient,,,410703.18,18841,,,18841,Other,150% of Medicare + 9.63% HCRA Surcharge,11457.41,,,11457.41,Other,Medicare IPPS methodology,31872,,"25,728 x DRG weight",31872,Other,base rate x DRG weight,28684,,"23,155 x DRG weight",28684,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,205352,50,,205352,Percent of Total Billed Charges,50% of Charges,36044,,"29,096 x DRG Weight",36044,Other,base rate x DRG weight,27827,,"22,463 x DRG Weight",27827,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,32737,,"26,426 x DRG Weight",32737,Other,base rate x DRG weight,48077,,"38,809 x DRG Weight",48077,Other,base rate x DRG weight,48077,,"38,809 x DRG Weight",48077,Other,base rate x DRG weight,32737,,"26,426 x DRG Weight",32737,Other,base rate x DRG weight,48077,,"38,809 x DRG Weight",48077,Other,base rate x DRG weight,43842,,"35,391 x DRG Weight",43842,Other,base rate x DRG weight,287492,70,,287492,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,31238,,"25,216 X DRG Weight",31238,Other,Base Weight X DRG Weight,28115,,"22,695 X DRG Weight",28115,Other,Base Weight X DRG Weight,31238,,"25,216 X DRG Weight",31238,Other,Base Rate x DRG Weight ,26551,,"21,433 x DRG Weight",26551,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,287492,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,,inpatient,,,637850.16,67234,,,67234,Other,150% of Medicare + 9.63% HCRA Surcharge,40885.62,,,40885.62,Other,Medicare IPPS methodology,115825,,"25,728 x DRG weight",115825,Other,base rate x DRG weight,104241,,"23,155 x DRG weight",104241,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,318925,50,,318925,Percent of Total Billed Charges,50% of Charges,130987,,"29,096 x DRG Weight",130987,Other,base rate x DRG weight,101126,,"22,463 x DRG Weight",101126,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,118967,,"26,426 x DRG Weight",118967,Other,base rate x DRG weight,174714,,"38,809 x DRG Weight",174714,Other,base rate x DRG weight,174714,,"38,809 x DRG Weight",174714,Other,base rate x DRG weight,118967,,"26,426 x DRG Weight",118967,Other,base rate x DRG weight,174714,,"38,809 x DRG Weight",174714,Other,base rate x DRG weight,159327,,"35,391 x DRG Weight",159327,Other,base rate x DRG weight,446495,70,,446495,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,113520,,"25,216 X DRG Weight",113520,Other,Base Weight X DRG Weight,102171,,"22,695 X DRG Weight",102171,Other,Base Weight X DRG Weight,113520,,"25,216 X DRG Weight",113520,Other,Base Rate x DRG Weight ,96489,,"21,433 x DRG Weight",96489,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,446495,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,,inpatient,,,416247.07,33584,,,33584,Other,150% of Medicare + 9.63% HCRA Surcharge,20422.68,,,20422.68,Other,Medicare IPPS methodology,57448,,"25,728 x DRG weight",57448,Other,base rate x DRG weight,51703,,"23,155 x DRG weight",51703,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,208124,50,,208124,Percent of Total Billed Charges,50% of Charges,64968,,"29,096 x DRG Weight",64968,Other,base rate x DRG weight,50158,,"22,463 x DRG Weight",50158,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,59007,,"26,426 x DRG Weight",59007,Other,base rate x DRG weight,86657,,"38,809 x DRG Weight",86657,Other,base rate x DRG weight,86657,,"38,809 x DRG Weight",86657,Other,base rate x DRG weight,59007,,"26,426 x DRG Weight",59007,Other,base rate x DRG weight,86657,,"38,809 x DRG Weight",86657,Other,base rate x DRG weight,79025,,"35,391 x DRG Weight",79025,Other,base rate x DRG weight,291373,70,,291373,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,56305,,"25,216 X DRG Weight",56305,Other,Base Weight X DRG Weight,50676,,"22,695 X DRG Weight",50676,Other,Base Weight X DRG Weight,56305,,"25,216 X DRG Weight",56305,Other,Base Rate x DRG Weight ,47858,,"21,433 x DRG Weight",47858,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,291373,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,MS-DRG,,,,,,,,inpatient,,,181929.93,19621,,,19621,Other,150% of Medicare + 9.63% HCRA Surcharge,11931.79,,,11931.79,Other,Medicare IPPS methodology,33225,,"25,728 x DRG weight",33225,Other,base rate x DRG weight,29902,,"23,155 x DRG weight",29902,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,90965,50,,90965,Percent of Total Billed Charges,50% of Charges,37575,,"29,096 x DRG Weight",37575,Other,base rate x DRG weight,29009,,"22,463 x DRG Weight",29009,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,34127,,"26,426 x DRG Weight",34127,Other,base rate x DRG weight,50118,,"38,809 x DRG Weight",50118,Other,base rate x DRG weight,50118,,"38,809 x DRG Weight",50118,Other,base rate x DRG weight,34127,,"26,426 x DRG Weight",34127,Other,base rate x DRG weight,50118,,"38,809 x DRG Weight",50118,Other,base rate x DRG weight,45704,,"35,391 x DRG Weight",45704,Other,base rate x DRG weight,127351,70,,127351,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32564,,"25,216 X DRG Weight",32564,Other,Base Weight X DRG Weight,29308,,"22,695 X DRG Weight",29308,Other,Base Weight X DRG Weight,32564,,"25,216 X DRG Weight",32564,Other,Base Rate x DRG Weight ,27679,,"21,433 x DRG Weight",27679,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,127351,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,,inpatient,,,949759.67,69100,,,69100,Other,150% of Medicare + 9.63% HCRA Surcharge,42020.14,,,42020.14,Other,Medicare IPPS methodology,119061,,"25,728 x DRG weight",119061,Other,base rate x DRG weight,107154,,"23,155 x DRG weight",107154,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,474880,50,,474880,Percent of Total Billed Charges,50% of Charges,134648,,"29,096 x DRG Weight",134648,Other,base rate x DRG weight,103952,,"22,463 x DRG Weight",103952,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,122292,,"26,426 x DRG Weight",122292,Other,base rate x DRG weight,179596,,"38,809 x DRG Weight",179596,Other,base rate x DRG weight,179596,,"38,809 x DRG Weight",179596,Other,base rate x DRG weight,122292,,"26,426 x DRG Weight",122292,Other,base rate x DRG weight,179596,,"38,809 x DRG Weight",179596,Other,base rate x DRG weight,163779,,"35,391 x DRG Weight",163779,Other,base rate x DRG weight,664832,70,,664832,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,116692,,"25,216 X DRG Weight",116692,Other,Base Weight X DRG Weight,105026,,"22,695 X DRG Weight",105026,Other,Base Weight X DRG Weight,116692,,"25,216 X DRG Weight",116692,Other,Base Rate x DRG Weight ,99185,,"21,433 x DRG Weight",99185,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,664832,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,,inpatient,,,244097.37,34834,,,34834,Other,150% of Medicare + 9.63% HCRA Surcharge,21182.94,,,21182.94,Other,Medicare IPPS methodology,59617,,"25,728 x DRG weight",59617,Other,base rate x DRG weight,53655,,"23,155 x DRG weight",53655,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,122049,50,,122049,Percent of Total Billed Charges,50% of Charges,67421,,"29,096 x DRG Weight",67421,Other,base rate x DRG weight,52051,,"22,463 x DRG Weight",52051,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,61234,,"26,426 x DRG Weight",61234,Other,base rate x DRG weight,89928,,"38,809 x DRG Weight",89928,Other,base rate x DRG weight,89928,,"38,809 x DRG Weight",89928,Other,base rate x DRG weight,61234,,"26,426 x DRG Weight",61234,Other,base rate x DRG weight,89928,,"38,809 x DRG Weight",89928,Other,base rate x DRG weight,82008,,"35,391 x DRG Weight",82008,Other,base rate x DRG weight,170868,70,,170868,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,58431,,"25,216 X DRG Weight",58431,Other,Base Weight X DRG Weight,52589,,"22,695 X DRG Weight",52589,Other,Base Weight X DRG Weight,58431,,"25,216 X DRG Weight",58431,Other,Base Rate x DRG Weight ,49665,,"21,433 x DRG Weight",49665,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,170868,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,,inpatient,,,218325.59,24797,,,24797,Other,150% of Medicare + 9.63% HCRA Surcharge,15079.23,,,15079.23,Other,Medicare IPPS methodology,42204,,"25,728 x DRG weight",42204,Other,base rate x DRG weight,37983,,"23,155 x DRG weight",37983,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,109163,50,,109163,Percent of Total Billed Charges,50% of Charges,47729,,"29,096 x DRG Weight",47729,Other,base rate x DRG weight,36848,,"22,463 x DRG Weight",36848,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,43349,,"26,426 x DRG Weight",43349,Other,base rate x DRG weight,63662,,"38,809 x DRG Weight",63662,Other,base rate x DRG weight,63662,,"38,809 x DRG Weight",63662,Other,base rate x DRG weight,43349,,"26,426 x DRG Weight",43349,Other,base rate x DRG weight,63662,,"38,809 x DRG Weight",63662,Other,base rate x DRG weight,58055,,"35,391 x DRG Weight",58055,Other,base rate x DRG weight,152828,70,,152828,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,41364,,"25,216 X DRG Weight",41364,Other,Base Weight X DRG Weight,37229,,"22,695 X DRG Weight",37229,Other,Base Weight X DRG Weight,41364,,"25,216 X DRG Weight",41364,Other,Base Rate x DRG Weight ,35159,,"21,433 x DRG Weight",35159,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,152828,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,,inpatient,,,430007.92,47241,,,47241,Other,150% of Medicare + 9.63% HCRA Surcharge,28727.8,,,28727.8,Other,Medicare IPPS methodology,81141,,"25,728 x DRG weight",81141,Other,base rate x DRG weight,73026,,"23,155 x DRG weight",73026,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,215004,50,,215004,Percent of Total Billed Charges,50% of Charges,91763,,"29,096 x DRG Weight",91763,Other,base rate x DRG weight,70844,,"22,463 x DRG Weight",70844,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,83342,,"26,426 x DRG Weight",83342,Other,base rate x DRG weight,122396,,"38,809 x DRG Weight",122396,Other,base rate x DRG weight,122396,,"38,809 x DRG Weight",122396,Other,base rate x DRG weight,83342,,"26,426 x DRG Weight",83342,Other,base rate x DRG weight,122396,,"38,809 x DRG Weight",122396,Other,base rate x DRG weight,111616,,"35,391 x DRG Weight",111616,Other,base rate x DRG weight,301006,70,,301006,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,79526,,"25,216 X DRG Weight",79526,Other,Base Weight X DRG Weight,71575,,"22,695 X DRG Weight",71575,Other,Base Weight X DRG Weight,79526,,"25,216 X DRG Weight",79526,Other,Base Rate x DRG Weight ,67595,,"21,433 x DRG Weight",67595,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,301006,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,MS-DRG,,,,,,,,inpatient,,,123797.2,23919,,,23919,Other,150% of Medicare + 9.63% HCRA Surcharge,14545.34,,,14545.34,Other,Medicare IPPS methodology,40681,,"25,728 x DRG weight",40681,Other,base rate x DRG weight,36613,,"23,155 x DRG weight",36613,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,61899,50,,61899,Percent of Total Billed Charges,50% of Charges,46007,,"29,096 x DRG Weight",46007,Other,base rate x DRG weight,35518,,"22,463 x DRG Weight",35518,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41785,,"26,426 x DRG Weight",41785,Other,base rate x DRG weight,61365,,"38,809 x DRG Weight",61365,Other,base rate x DRG weight,61365,,"38,809 x DRG Weight",61365,Other,base rate x DRG weight,41785,,"26,426 x DRG Weight",41785,Other,base rate x DRG weight,61365,,"38,809 x DRG Weight",61365,Other,base rate x DRG weight,55960,,"35,391 x DRG Weight",55960,Other,base rate x DRG weight,86658,70,,86658,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39872,,"25,216 X DRG Weight",39872,Other,Base Weight X DRG Weight,35885,,"22,695 X DRG Weight",35885,Other,Base Weight X DRG Weight,39872,,"25,216 X DRG Weight",39872,Other,Base Rate x DRG Weight ,33890,,"21,433 x DRG Weight",33890,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,86658,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,,inpatient,,,111509.39,16416,,,16416,Other,150% of Medicare + 9.63% HCRA Surcharge,9982.89,,,9982.89,Other,Medicare IPPS methodology,27665,,"25,728 x DRG weight",27665,Other,base rate x DRG weight,24899,,"23,155 x DRG weight",24899,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,55755,50,,55755,Percent of Total Billed Charges,50% of Charges,31287,,"29,096 x DRG Weight",31287,Other,base rate x DRG weight,24154,,"22,463 x DRG Weight",24154,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28416,,"26,426 x DRG Weight",28416,Other,base rate x DRG weight,41731,,"38,809 x DRG Weight",41731,Other,base rate x DRG weight,41731,,"38,809 x DRG Weight",41731,Other,base rate x DRG weight,28416,,"26,426 x DRG Weight",28416,Other,base rate x DRG weight,41731,,"38,809 x DRG Weight",41731,Other,base rate x DRG weight,38056,,"35,391 x DRG Weight",38056,Other,base rate x DRG weight,78057,70,,78057,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27115,,"25,216 X DRG Weight",27115,Other,Base Weight X DRG Weight,24404,,"22,695 X DRG Weight",24404,Other,Base Weight X DRG Weight,27115,,"25,216 X DRG Weight",27115,Other,Base Rate x DRG Weight ,23047,,"21,433 x DRG Weight",23047,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,78057,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,,inpatient,,,106476.69,11410,,,11410,Other,150% of Medicare + 9.63% HCRA Surcharge,6938.25,,,6938.25,Other,Medicare IPPS methodology,18980,,"25,728 x DRG weight",18980,Other,base rate x DRG weight,17081,,"23,155 x DRG weight",17081,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,53238,50,,53238,Percent of Total Billed Charges,50% of Charges,21464,,"29,096 x DRG Weight",21464,Other,base rate x DRG weight,16571,,"22,463 x DRG Weight",16571,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,19494,,"26,426 x DRG Weight",19494,Other,base rate x DRG weight,28629,,"38,809 x DRG Weight",28629,Other,base rate x DRG weight,28629,,"38,809 x DRG Weight",28629,Other,base rate x DRG weight,19494,,"26,426 x DRG Weight",19494,Other,base rate x DRG weight,28629,,"38,809 x DRG Weight",28629,Other,base rate x DRG weight,26108,,"35,391 x DRG Weight",26108,Other,base rate x DRG weight,74534,70,,74534,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,18602,,"25,216 X DRG Weight",18602,Other,Base Weight X DRG Weight,16742,,"22,695 X DRG Weight",16742,Other,Base Weight X DRG Weight,18602,,"25,216 X DRG Weight",18602,Other,Base Rate x DRG Weight ,15811,,"21,433 x DRG Weight",15811,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,74534,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,,inpatient,,,79106,8059,,,8059,Other,150% of Medicare + 9.63% HCRA Surcharge,4900.98,,,4900.98,Other,Medicare IPPS methodology,13168,,"25,728 x DRG weight",13168,Other,base rate x DRG weight,11851,,"23,155 x DRG weight",11851,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39553,50,,39553,Percent of Total Billed Charges,50% of Charges,14891,,"29,096 x DRG Weight",14891,Other,base rate x DRG weight,11497,,"22,463 x DRG Weight",11497,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,13525,,"26,426 x DRG Weight",13525,Other,base rate x DRG weight,19862,,"38,809 x DRG Weight",19862,Other,base rate x DRG weight,19862,,"38,809 x DRG Weight",19862,Other,base rate x DRG weight,13525,,"26,426 x DRG Weight",13525,Other,base rate x DRG weight,19862,,"38,809 x DRG Weight",19862,Other,base rate x DRG weight,18113,,"35,391 x DRG Weight",18113,Other,base rate x DRG weight,55374,70,,55374,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,12906,,"25,216 X DRG Weight",12906,Other,Base Weight X DRG Weight,11615,,"22,695 X DRG Weight",11615,Other,Base Weight X DRG Weight,12906,,"25,216 X DRG Weight",12906,Other,Base Rate x DRG Weight ,10969,,"21,433 x DRG Weight",10969,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,55374,
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH MCC,834,MS-DRG,,,,,,,,inpatient,,,796579.88,83505,,,83505,Other,150% of Medicare + 9.63% HCRA Surcharge,50779.79,,,50779.79,Other,Medicare IPPS methodology,144051,,"25,728 x DRG weight",144051,Other,base rate x DRG weight,129645,,"23,155 x DRG weight",129645,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,398290,50,,398290,Percent of Total Billed Charges,50% of Charges,162909,,"29,096 x DRG Weight",162909,Other,base rate x DRG weight,125770,,"22,463 x DRG Weight",125770,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,147959,,"26,426 x DRG Weight",147959,Other,base rate x DRG weight,217292,,"38,809 x DRG Weight",217292,Other,base rate x DRG weight,217292,,"38,809 x DRG Weight",217292,Other,base rate x DRG weight,147959,,"26,426 x DRG Weight",147959,Other,base rate x DRG weight,217292,,"38,809 x DRG Weight",217292,Other,base rate x DRG weight,198154,,"35,391 x DRG Weight",198154,Other,base rate x DRG weight,557606,70,,557606,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,141184,,"25,216 X DRG Weight",141184,Other,Base Weight X DRG Weight,127069,,"22,695 X DRG Weight",127069,Other,Base Weight X DRG Weight,141184,,"25,216 X DRG Weight",141184,Other,Base Rate x DRG Weight ,120003,,"21,433 x DRG Weight",120003,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,557606,
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,835,MS-DRG,,,,,,,,inpatient,,,623373.46,33623,,,33623,Other,150% of Medicare + 9.63% HCRA Surcharge,20446.13,,,20446.13,Other,Medicare IPPS methodology,57515,,"25,728 x DRG weight",57515,Other,base rate x DRG weight,51763,,"23,155 x DRG weight",51763,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,311687,50,,311687,Percent of Total Billed Charges,50% of Charges,65044,,"29,096 x DRG Weight",65044,Other,base rate x DRG weight,50216,,"22,463 x DRG Weight",50216,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,59075,,"26,426 x DRG Weight",59075,Other,base rate x DRG weight,86758,,"38,809 x DRG Weight",86758,Other,base rate x DRG weight,86758,,"38,809 x DRG Weight",86758,Other,base rate x DRG weight,59075,,"26,426 x DRG Weight",59075,Other,base rate x DRG weight,86758,,"38,809 x DRG Weight",86758,Other,base rate x DRG weight,79117,,"35,391 x DRG Weight",79117,Other,base rate x DRG weight,436361,70,,436361,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,56370,,"25,216 X DRG Weight",56370,Other,Base Weight X DRG Weight,50735,,"22,695 X DRG Weight",50735,Other,Base Weight X DRG Weight,56370,,"25,216 X DRG Weight",56370,Other,Base Rate x DRG Weight ,47913,,"21,433 x DRG Weight",47913,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,436361,
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,836,MS-DRG,,,,,,,,inpatient,,,216729.11,21408,,,21408,Other,150% of Medicare + 9.63% HCRA Surcharge,13018.51,,,13018.51,Other,Medicare IPPS methodology,36325,,"25,728 x DRG weight",36325,Other,base rate x DRG weight,32693,,"23,155 x DRG weight",32693,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,108365,50,,108365,Percent of Total Billed Charges,50% of Charges,41081,,"29,096 x DRG Weight",41081,Other,base rate x DRG weight,31716,,"22,463 x DRG Weight",31716,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,37311,,"26,426 x DRG Weight",37311,Other,base rate x DRG weight,54794,,"38,809 x DRG Weight",54794,Other,base rate x DRG weight,54794,,"38,809 x DRG Weight",54794,Other,base rate x DRG weight,37311,,"26,426 x DRG Weight",37311,Other,base rate x DRG weight,54794,,"38,809 x DRG Weight",54794,Other,base rate x DRG weight,49969,,"35,391 x DRG Weight",49969,Other,base rate x DRG weight,151710,70,,151710,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35602,,"25,216 X DRG Weight",35602,Other,Base Weight X DRG Weight,32043,,"22,695 X DRG Weight",32043,Other,Base Weight X DRG Weight,35602,,"25,216 X DRG Weight",35602,Other,Base Rate x DRG Weight ,30261,,"21,433 x DRG Weight",30261,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,151710,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,,inpatient,,,621914.21,72308,,,72308,Other,150% of Medicare + 9.63% HCRA Surcharge,43970.84,,,43970.84,Other,Medicare IPPS methodology,124626,,"25,728 x DRG weight",124626,Other,base rate x DRG weight,112163,,"23,155 x DRG weight",112163,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,310957,50,,310957,Percent of Total Billed Charges,50% of Charges,140941,,"29,096 x DRG Weight",140941,Other,base rate x DRG weight,108811,,"22,463 x DRG Weight",108811,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,128008,,"26,426 x DRG Weight",128008,Other,base rate x DRG weight,187991,,"38,809 x DRG Weight",187991,Other,base rate x DRG weight,187991,,"38,809 x DRG Weight",187991,Other,base rate x DRG weight,128008,,"26,426 x DRG Weight",128008,Other,base rate x DRG weight,187991,,"38,809 x DRG Weight",187991,Other,base rate x DRG weight,171434,,"35,391 x DRG Weight",171434,Other,base rate x DRG weight,435340,70,,435340,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,122146,,"25,216 X DRG Weight",122146,Other,Base Weight X DRG Weight,109935,,"22,695 X DRG Weight",109935,Other,Base Weight X DRG Weight,122146,,"25,216 X DRG Weight",122146,Other,Base Rate x DRG Weight ,103821,,"21,433 x DRG Weight",103821,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,435340,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,,inpatient,,,283819.16,30155,,,30155,Other,150% of Medicare + 9.63% HCRA Surcharge,18337.61,,,18337.61,Other,Medicare IPPS methodology,51500,,"25,728 x DRG weight",51500,Other,base rate x DRG weight,46349,,"23,155 x DRG weight",46349,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,141910,50,,141910,Percent of Total Billed Charges,50% of Charges,58241,,"29,096 x DRG Weight",58241,Other,base rate x DRG weight,44964,,"22,463 x DRG Weight",44964,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,52897,,"26,426 x DRG Weight",52897,Other,base rate x DRG weight,77684,,"38,809 x DRG Weight",77684,Other,base rate x DRG weight,77684,,"38,809 x DRG Weight",77684,Other,base rate x DRG weight,52897,,"26,426 x DRG Weight",52897,Other,base rate x DRG weight,77684,,"38,809 x DRG Weight",77684,Other,base rate x DRG weight,70842,,"35,391 x DRG Weight",70842,Other,base rate x DRG weight,198673,70,,198673,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,50475,,"25,216 X DRG Weight",50475,Other,Base Weight X DRG Weight,45429,,"22,695 X DRG Weight",45429,Other,Base Weight X DRG Weight,50475,,"25,216 X DRG Weight",50475,Other,Base Rate x DRG Weight ,42902,,"21,433 x DRG Weight",42902,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,198673,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,,inpatient,,,164472.38,19795,,,19795,Other,150% of Medicare + 9.63% HCRA Surcharge,12037.3,,,12037.3,Other,Medicare IPPS methodology,33526,,"25,728 x DRG weight",33526,Other,base rate x DRG weight,30173,,"23,155 x DRG weight",30173,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,82236,50,,82236,Percent of Total Billed Charges,50% of Charges,37915,,"29,096 x DRG Weight",37915,Other,base rate x DRG weight,29272,,"22,463 x DRG Weight",29272,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,34436,,"26,426 x DRG Weight",34436,Other,base rate x DRG weight,50572,,"38,809 x DRG Weight",50572,Other,base rate x DRG weight,50572,,"38,809 x DRG Weight",50572,Other,base rate x DRG weight,34436,,"26,426 x DRG Weight",34436,Other,base rate x DRG weight,50572,,"38,809 x DRG Weight",50572,Other,base rate x DRG weight,46118,,"35,391 x DRG Weight",46118,Other,base rate x DRG weight,115131,70,,115131,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32859,,"25,216 X DRG Weight",32859,Other,Base Weight X DRG Weight,29574,,"22,695 X DRG Weight",29574,Other,Base Weight X DRG Weight,32859,,"25,216 X DRG Weight",32859,Other,Base Rate x DRG Weight ,27929,,"21,433 x DRG Weight",27929,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,115131,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,,inpatient,,,435632.41,46817,,,46817,Other,150% of Medicare + 9.63% HCRA Surcharge,28469.87,,,28469.87,Other,Medicare IPPS methodology,80405,,"25,728 x DRG weight",80405,Other,base rate x DRG weight,72364,,"23,155 x DRG weight",72364,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,217816,50,,217816,Percent of Total Billed Charges,50% of Charges,90931,,"29,096 x DRG Weight",90931,Other,base rate x DRG weight,70201,,"22,463 x DRG Weight",70201,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,82587,,"26,426 x DRG Weight",82587,Other,base rate x DRG weight,121286,,"38,809 x DRG Weight",121286,Other,base rate x DRG weight,121286,,"38,809 x DRG Weight",121286,Other,base rate x DRG weight,82587,,"26,426 x DRG Weight",82587,Other,base rate x DRG weight,121286,,"38,809 x DRG Weight",121286,Other,base rate x DRG weight,110604,,"35,391 x DRG Weight",110604,Other,base rate x DRG weight,304943,70,,304943,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,78805,,"25,216 X DRG Weight",78805,Other,Base Weight X DRG Weight,70926,,"22,695 X DRG Weight",70926,Other,Base Weight X DRG Weight,78805,,"25,216 X DRG Weight",78805,Other,Base Rate x DRG Weight ,66982,,"21,433 x DRG Weight",66982,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,304943,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,,inpatient,,,330332.43,23805,,,23805,Other,150% of Medicare + 9.63% HCRA Surcharge,14475.9,,,14475.9,Other,Medicare IPPS methodology,40483,,"25,728 x DRG weight",40483,Other,base rate x DRG weight,36434,,"23,155 x DRG weight",36434,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,165166,50,,165166,Percent of Total Billed Charges,50% of Charges,45783,,"29,096 x DRG Weight",45783,Other,base rate x DRG weight,35346,,"22,463 x DRG Weight",35346,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41581,,"26,426 x DRG Weight",41581,Other,base rate x DRG weight,61066,,"38,809 x DRG Weight",61066,Other,base rate x DRG weight,61066,,"38,809 x DRG Weight",61066,Other,base rate x DRG weight,41581,,"26,426 x DRG Weight",41581,Other,base rate x DRG weight,61066,,"38,809 x DRG Weight",61066,Other,base rate x DRG weight,55688,,"35,391 x DRG Weight",55688,Other,base rate x DRG weight,231233,70,,231233,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39677,,"25,216 X DRG Weight",39677,Other,Base Weight X DRG Weight,35711,,"22,695 X DRG Weight",35711,Other,Base Weight X DRG Weight,39677,,"25,216 X DRG Weight",39677,Other,Base Rate x DRG Weight ,33725,,"21,433 x DRG Weight",33725,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,231233,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,,inpatient,,,208498.44,16284,,,16284,Other,150% of Medicare + 9.63% HCRA Surcharge,9902.63,,,9902.63,Other,Medicare IPPS methodology,27436,,"25,728 x DRG weight",27436,Other,base rate x DRG weight,24692,,"23,155 x DRG weight",24692,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,104249,50,,104249,Percent of Total Billed Charges,50% of Charges,31028,,"29,096 x DRG Weight",31028,Other,base rate x DRG weight,23955,,"22,463 x DRG Weight",23955,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28181,,"26,426 x DRG Weight",28181,Other,base rate x DRG weight,41386,,"38,809 x DRG Weight",41386,Other,base rate x DRG weight,41386,,"38,809 x DRG Weight",41386,Other,base rate x DRG weight,28181,,"26,426 x DRG Weight",28181,Other,base rate x DRG weight,41386,,"38,809 x DRG Weight",41386,Other,base rate x DRG weight,37741,,"35,391 x DRG Weight",37741,Other,base rate x DRG weight,145949,70,,145949,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,26890,,"25,216 X DRG Weight",26890,Other,Base Weight X DRG Weight,24202,,"22,695 X DRG Weight",24202,Other,Base Weight X DRG Weight,26890,,"25,216 X DRG Weight",26890,Other,Base Rate x DRG Weight ,22856,,"21,433 x DRG Weight",22856,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,145949,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,,inpatient,,,524795.41,28063,,,28063,Other,150% of Medicare + 9.63% HCRA Surcharge,17065.1,,,17065.1,Other,Medicare IPPS methodology,47870,,"25,728 x DRG weight",47870,Other,base rate x DRG weight,43082,,"23,155 x DRG weight",43082,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,262398,50,,262398,Percent of Total Billed Charges,50% of Charges,54136,,"29,096 x DRG Weight",54136,Other,base rate x DRG weight,41795,,"22,463 x DRG Weight",41795,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,49168,,"26,426 x DRG Weight",49168,Other,base rate x DRG weight,72208,,"38,809 x DRG Weight",72208,Other,base rate x DRG weight,72208,,"38,809 x DRG Weight",72208,Other,base rate x DRG weight,49168,,"26,426 x DRG Weight",49168,Other,base rate x DRG weight,72208,,"38,809 x DRG Weight",72208,Other,base rate x DRG weight,65848,,"35,391 x DRG Weight",65848,Other,base rate x DRG weight,367357,70,,367357,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46917,,"25,216 X DRG Weight",46917,Other,Base Weight X DRG Weight,42226,,"22,695 X DRG Weight",42226,Other,Base Weight X DRG Weight,46917,,"25,216 X DRG Weight",46917,Other,Base Rate x DRG Weight ,39878,,"21,433 x DRG Weight",39878,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,367357,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,,inpatient,,,423023.75,17631,,,17631,Other,150% of Medicare + 9.63% HCRA Surcharge,10721.51,,,10721.51,Other,Medicare IPPS methodology,29772,,"25,728 x DRG weight",29772,Other,base rate x DRG weight,26795,,"23,155 x DRG weight",26795,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,211512,50,,211512,Percent of Total Billed Charges,50% of Charges,33670,,"29,096 x DRG Weight",33670,Other,base rate x DRG weight,25994,,"22,463 x DRG Weight",25994,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,30580,,"26,426 x DRG Weight",30580,Other,base rate x DRG weight,44910,,"38,809 x DRG Weight",44910,Other,base rate x DRG weight,44910,,"38,809 x DRG Weight",44910,Other,base rate x DRG weight,30580,,"26,426 x DRG Weight",30580,Other,base rate x DRG weight,44910,,"38,809 x DRG Weight",44910,Other,base rate x DRG weight,40954,,"35,391 x DRG Weight",40954,Other,base rate x DRG weight,296117,70,,296117,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,29180,,"25,216 X DRG Weight",29180,Other,Base Weight X DRG Weight,26263,,"22,695 X DRG Weight",26263,Other,Base Weight X DRG Weight,29180,,"25,216 X DRG Weight",29180,Other,Base Rate x DRG Weight ,24802,,"21,433 x DRG Weight",24802,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,296117,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,MS-DRG,,,,,,,,inpatient,,,80786,13296,,,13296,Other,150% of Medicare + 9.63% HCRA Surcharge,8085.4,,,8085.4,Other,Medicare IPPS methodology,22252,,"25,728 x DRG weight",22252,Other,base rate x DRG weight,20027,,"23,155 x DRG weight",20027,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40393,50,,40393,Percent of Total Billed Charges,50% of Charges,25165,,"29,096 x DRG Weight",25165,Other,base rate x DRG weight,19428,,"22,463 x DRG Weight",19428,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,22856,,"26,426 x DRG Weight",22856,Other,base rate x DRG weight,33566,,"38,809 x DRG Weight",33566,Other,base rate x DRG weight,33566,,"38,809 x DRG Weight",33566,Other,base rate x DRG weight,22856,,"26,426 x DRG Weight",22856,Other,base rate x DRG weight,33566,,"38,809 x DRG Weight",33566,Other,base rate x DRG weight,30610,,"35,391 x DRG Weight",30610,Other,base rate x DRG weight,56550,70,,56550,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,21809,,"25,216 X DRG Weight",21809,Other,Base Weight X DRG Weight,19629,,"22,695 X DRG Weight",19629,Other,Base Weight X DRG Weight,21809,,"25,216 X DRG Weight",21809,Other,Base Rate x DRG Weight ,18537,,"21,433 x DRG Weight",18537,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,56550,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,,inpatient,,,271697,36715,,,36715,Other,150% of Medicare + 9.63% HCRA Surcharge,22326.49,,,22326.49,Other,Medicare IPPS methodology,62879,,"25,728 x DRG weight",62879,Other,base rate x DRG weight,56591,,"23,155 x DRG weight",56591,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,135848,50,,135848,Percent of Total Billed Charges,50% of Charges,71111,,"29,096 x DRG Weight",71111,Other,base rate x DRG weight,54900,,"22,463 x DRG Weight",54900,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,64585,,"26,426 x DRG Weight",64585,Other,base rate x DRG weight,94849,,"38,809 x DRG Weight",94849,Other,base rate x DRG weight,94849,,"38,809 x DRG Weight",94849,Other,base rate x DRG weight,64585,,"26,426 x DRG Weight",64585,Other,base rate x DRG weight,94849,,"38,809 x DRG Weight",94849,Other,base rate x DRG weight,86496,,"35,391 x DRG Weight",86496,Other,base rate x DRG weight,190188,70,,190188,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,61628,,"25,216 X DRG Weight",61628,Other,Base Weight X DRG Weight,55467,,"22,695 X DRG Weight",55467,Other,Base Weight X DRG Weight,61628,,"25,216 X DRG Weight",61628,Other,Base Rate x DRG Weight ,52382,,"21,433 x DRG Weight",52382,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,190188,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,,inpatient,,,110806.33,18453,,,18453,Other,150% of Medicare + 9.63% HCRA Surcharge,11221.13,,,11221.13,Other,Medicare IPPS methodology,31198,,"25,728 x DRG weight",31198,Other,base rate x DRG weight,28078,,"23,155 x DRG weight",28078,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,55403,50,,55403,Percent of Total Billed Charges,50% of Charges,35282,,"29,096 x DRG Weight",35282,Other,base rate x DRG weight,27239,,"22,463 x DRG Weight",27239,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,32044,,"26,426 x DRG Weight",32044,Other,base rate x DRG weight,47060,,"38,809 x DRG Weight",47060,Other,base rate x DRG weight,47060,,"38,809 x DRG Weight",47060,Other,base rate x DRG weight,32044,,"26,426 x DRG Weight",32044,Other,base rate x DRG weight,47060,,"38,809 x DRG Weight",47060,Other,base rate x DRG weight,42915,,"35,391 x DRG Weight",42915,Other,base rate x DRG weight,77564,70,,77564,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,30577,,"25,216 X DRG Weight",30577,Other,Base Weight X DRG Weight,27520,,"22,695 X DRG Weight",27520,Other,Base Weight X DRG Weight,30577,,"25,216 X DRG Weight",30577,Other,Base Rate x DRG Weight ,25990,,"21,433 x DRG Weight",25990,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,77564,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,MS-DRG,,,,,,,,inpatient,,,75000.87,12870,,,12870,Other,150% of Medicare + 9.63% HCRA Surcharge,7826.57,,,7826.57,Other,Medicare IPPS methodology,21514,,"25,728 x DRG weight",21514,Other,base rate x DRG weight,19362,,"23,155 x DRG weight",19362,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37500,50,,37500,Percent of Total Billed Charges,50% of Charges,24330,,"29,096 x DRG Weight",24330,Other,base rate x DRG weight,18784,,"22,463 x DRG Weight",18784,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,22097,,"26,426 x DRG Weight",22097,Other,base rate x DRG weight,32452,,"38,809 x DRG Weight",32452,Other,base rate x DRG weight,32452,,"38,809 x DRG Weight",32452,Other,base rate x DRG weight,22097,,"26,426 x DRG Weight",22097,Other,base rate x DRG weight,32452,,"38,809 x DRG Weight",32452,Other,base rate x DRG weight,29594,,"35,391 x DRG Weight",29594,Other,base rate x DRG weight,52501,70,,52501,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,21086,,"25,216 X DRG Weight",21086,Other,Base Weight X DRG Weight,18978,,"22,695 X DRG Weight",18978,Other,Base Weight X DRG Weight,21086,,"25,216 X DRG Weight",21086,Other,Base Rate x DRG Weight ,17922,,"21,433 x DRG Weight",17922,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,52501,
RADIOTHERAPY,849,MS-DRG,,,,,,,,inpatient,,,177682.96,40384,,,40384,Other,150% of Medicare + 9.63% HCRA Surcharge,24557.66,,,24557.66,Other,Medicare IPPS methodology,69244,,"25,728 x DRG weight",69244,Other,base rate x DRG weight,62319,,"23,155 x DRG weight",62319,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,88841,50,,88841,Percent of Total Billed Charges,50% of Charges,78309,,"29,096 x DRG Weight",78309,Other,base rate x DRG weight,60457,,"22,463 x DRG Weight",60457,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,71123,,"26,426 x DRG Weight",71123,Other,base rate x DRG weight,104451,,"38,809 x DRG Weight",104451,Other,base rate x DRG weight,104451,,"38,809 x DRG Weight",104451,Other,base rate x DRG weight,71123,,"26,426 x DRG Weight",71123,Other,base rate x DRG weight,104451,,"38,809 x DRG Weight",104451,Other,base rate x DRG weight,95251,,"35,391 x DRG Weight",95251,Other,base rate x DRG weight,124378,70,,124378,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,67866,,"25,216 X DRG Weight",67866,Other,Base Weight X DRG Weight,61081,,"22,695 X DRG Weight",61081,Other,Base Weight X DRG Weight,67866,,"25,216 X DRG Weight",67866,Other,Base Rate x DRG Weight ,57685,,"21,433 x DRG Weight",57685,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,124378,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,,inpatient,,,645394.83,74611,,,74611,Other,150% of Medicare + 9.63% HCRA Surcharge,45371.41,,,45371.41,Other,Medicare IPPS methodology,128622,,"25,728 x DRG weight",128622,Other,base rate x DRG weight,115759,,"23,155 x DRG weight",115759,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,322697,50,,322697,Percent of Total Billed Charges,50% of Charges,145460,,"29,096 x DRG Weight",145460,Other,base rate x DRG weight,112299,,"22,463 x DRG Weight",112299,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,132112,,"26,426 x DRG Weight",132112,Other,base rate x DRG weight,194018,,"38,809 x DRG Weight",194018,Other,base rate x DRG weight,194018,,"38,809 x DRG Weight",194018,Other,base rate x DRG weight,132112,,"26,426 x DRG Weight",132112,Other,base rate x DRG weight,194018,,"38,809 x DRG Weight",194018,Other,base rate x DRG weight,176930,,"35,391 x DRG Weight",176930,Other,base rate x DRG weight,451776,70,,451776,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,126062,,"25,216 X DRG Weight",126062,Other,Base Weight X DRG Weight,113459,,"22,695 X DRG Weight",113459,Other,Base Weight X DRG Weight,126062,,"25,216 X DRG Weight",126062,Other,Base Rate x DRG Weight ,107150,,"21,433 x DRG Weight",107150,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,451776,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,,inpatient,,,221748.51,30697,,,30697,Other,150% of Medicare + 9.63% HCRA Surcharge,18666.79,,,18666.79,Other,Medicare IPPS methodology,52439,,"25,728 x DRG weight",52439,Other,base rate x DRG weight,47195,,"23,155 x DRG weight",47195,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,110874,50,,110874,Percent of Total Billed Charges,50% of Charges,59303,,"29,096 x DRG Weight",59303,Other,base rate x DRG weight,45784,,"22,463 x DRG Weight",45784,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,53861,,"26,426 x DRG Weight",53861,Other,base rate x DRG weight,79101,,"38,809 x DRG Weight",79101,Other,base rate x DRG weight,79101,,"38,809 x DRG Weight",79101,Other,base rate x DRG weight,53861,,"26,426 x DRG Weight",53861,Other,base rate x DRG weight,79101,,"38,809 x DRG Weight",79101,Other,base rate x DRG weight,72134,,"35,391 x DRG Weight",72134,Other,base rate x DRG weight,155224,70,,155224,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,51395,,"25,216 X DRG Weight",51395,Other,Base Weight X DRG Weight,46257,,"22,695 X DRG Weight",46257,Other,Base Weight X DRG Weight,51395,,"25,216 X DRG Weight",51395,Other,Base Rate x DRG Weight ,43685,,"21,433 x DRG Weight",43685,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,155224,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,MS-DRG,,,,,,,,inpatient,,,246890.84,25708,,,25708,Other,150% of Medicare + 9.63% HCRA Surcharge,15632.97,,,15632.97,Other,Medicare IPPS methodology,43784,,"25,728 x DRG weight",43784,Other,base rate x DRG weight,39405,,"23,155 x DRG weight",39405,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,123445,50,,123445,Percent of Total Billed Charges,50% of Charges,49516,,"29,096 x DRG Weight",49516,Other,base rate x DRG weight,38228,,"22,463 x DRG Weight",38228,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,44972,,"26,426 x DRG Weight",44972,Other,base rate x DRG weight,66045,,"38,809 x DRG Weight",66045,Other,base rate x DRG weight,66045,,"38,809 x DRG Weight",66045,Other,base rate x DRG weight,44972,,"26,426 x DRG Weight",44972,Other,base rate x DRG weight,66045,,"38,809 x DRG Weight",66045,Other,base rate x DRG weight,60228,,"35,391 x DRG Weight",60228,Other,base rate x DRG weight,172824,70,,172824,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,42913,,"25,216 X DRG Weight",42913,Other,Base Weight X DRG Weight,38622,,"22,695 X DRG Weight",38622,Other,Base Weight X DRG Weight,42913,,"25,216 X DRG Weight",42913,Other,Base Rate x DRG Weight ,36475,,"21,433 x DRG Weight",36475,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,172824,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,,inpatient,,,744269.96,66144,,,66144,Other,150% of Medicare + 9.63% HCRA Surcharge,40222.76,,,40222.76,Other,Medicare IPPS methodology,113934,,"25,728 x DRG weight",113934,Other,base rate x DRG weight,102540,,"23,155 x DRG weight",102540,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,372135,50,,372135,Percent of Total Billed Charges,50% of Charges,128849,,"29,096 x DRG Weight",128849,Other,base rate x DRG weight,99475,,"22,463 x DRG Weight",99475,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,117025,,"26,426 x DRG Weight",117025,Other,base rate x DRG weight,171862,,"38,809 x DRG Weight",171862,Other,base rate x DRG weight,171862,,"38,809 x DRG Weight",171862,Other,base rate x DRG weight,117025,,"26,426 x DRG Weight",117025,Other,base rate x DRG weight,171862,,"38,809 x DRG Weight",171862,Other,base rate x DRG weight,156726,,"35,391 x DRG Weight",156726,Other,base rate x DRG weight,520989,70,,520989,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,111667,,"25,216 X DRG Weight",111667,Other,Base Weight X DRG Weight,100503,,"22,695 X DRG Weight",100503,Other,Base Weight X DRG Weight,111667,,"25,216 X DRG Weight",111667,Other,Base Rate x DRG Weight ,94914,,"21,433 x DRG Weight",94914,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,520989,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,,inpatient,,,276880.94,32143,,,32143,Other,150% of Medicare + 9.63% HCRA Surcharge,19546.09,,,19546.09,Other,Medicare IPPS methodology,54947,,"25,728 x DRG weight",54947,Other,base rate x DRG weight,49452,,"23,155 x DRG weight",49452,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,138440,50,,138440,Percent of Total Billed Charges,50% of Charges,62140,,"29,096 x DRG Weight",62140,Other,base rate x DRG weight,47974,,"22,463 x DRG Weight",47974,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,56438,,"26,426 x DRG Weight",56438,Other,base rate x DRG weight,82884,,"38,809 x DRG Weight",82884,Other,base rate x DRG weight,82884,,"38,809 x DRG Weight",82884,Other,base rate x DRG weight,56438,,"26,426 x DRG Weight",56438,Other,base rate x DRG weight,82884,,"38,809 x DRG Weight",82884,Other,base rate x DRG weight,75585,,"35,391 x DRG Weight",75585,Other,base rate x DRG weight,193817,70,,193817,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,53854,,"25,216 X DRG Weight",53854,Other,Base Weight X DRG Weight,48470,,"22,695 X DRG Weight",48470,Other,Base Weight X DRG Weight,53854,,"25,216 X DRG Weight",53854,Other,Base Rate x DRG Weight ,45774,,"21,433 x DRG Weight",45774,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,193817,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,,inpatient,,,68959.4,19503,,,19503,Other,150% of Medicare + 9.63% HCRA Surcharge,11859.64,,,11859.64,Other,Medicare IPPS methodology,33019,,"25,728 x DRG weight",33019,Other,base rate x DRG weight,29717,,"23,155 x DRG weight",29717,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,34480,50,,34480,Percent of Total Billed Charges,50% of Charges,37342,,"29,096 x DRG Weight",37342,Other,base rate x DRG weight,28829,,"22,463 x DRG Weight",28829,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,33915,,"26,426 x DRG Weight",33915,Other,base rate x DRG weight,49807,,"38,809 x DRG Weight",49807,Other,base rate x DRG weight,49807,,"38,809 x DRG Weight",49807,Other,base rate x DRG weight,33915,,"26,426 x DRG Weight",33915,Other,base rate x DRG weight,49807,,"38,809 x DRG Weight",49807,Other,base rate x DRG weight,45421,,"35,391 x DRG Weight",45421,Other,base rate x DRG weight,48272,70,,48272,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,32362,,"25,216 X DRG Weight",32362,Other,Base Weight X DRG Weight,29127,,"22,695 X DRG Weight",29127,Other,Base Weight X DRG Weight,32362,,"25,216 X DRG Weight",32362,Other,Base Rate x DRG Weight ,27507,,"21,433 x DRG Weight",27507,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,49807,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,,inpatient,,,234292.57,27787,,,27787,Other,150% of Medicare + 9.63% HCRA Surcharge,16897.36,,,16897.36,Other,Medicare IPPS methodology,47391,,"25,728 x DRG weight",47391,Other,base rate x DRG weight,42652,,"23,155 x DRG weight",42652,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,117146,50,,117146,Percent of Total Billed Charges,50% of Charges,53595,,"29,096 x DRG Weight",53595,Other,base rate x DRG weight,41377,,"22,463 x DRG Weight",41377,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,48677,,"26,426 x DRG Weight",48677,Other,base rate x DRG weight,71486,,"38,809 x DRG Weight",71486,Other,base rate x DRG weight,71486,,"38,809 x DRG Weight",71486,Other,base rate x DRG weight,48677,,"26,426 x DRG Weight",48677,Other,base rate x DRG weight,71486,,"38,809 x DRG Weight",71486,Other,base rate x DRG weight,65190,,"35,391 x DRG Weight",65190,Other,base rate x DRG weight,164005,70,,164005,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46448,,"25,216 X DRG Weight",46448,Other,Base Weight X DRG Weight,41804,,"22,695 X DRG Weight",41804,Other,Base Weight X DRG Weight,46448,,"25,216 X DRG Weight",46448,Other,Base Rate x DRG Weight ,39480,,"21,433 x DRG Weight",39480,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,164005,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,,inpatient,,,126665.38,15381,,,15381,Other,150% of Medicare + 9.63% HCRA Surcharge,9353.4,,,9353.4,Other,Medicare IPPS methodology,25870,,"25,728 x DRG weight",25870,Other,base rate x DRG weight,23282,,"23,155 x DRG weight",23282,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,63333,50,,63333,Percent of Total Billed Charges,50% of Charges,29256,,"29,096 x DRG Weight",29256,Other,base rate x DRG weight,22587,,"22,463 x DRG Weight",22587,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26571,,"26,426 x DRG Weight",26571,Other,base rate x DRG weight,39022,,"38,809 x DRG Weight",39022,Other,base rate x DRG weight,39022,,"38,809 x DRG Weight",39022,Other,base rate x DRG weight,26571,,"26,426 x DRG Weight",26571,Other,base rate x DRG weight,39022,,"38,809 x DRG Weight",39022,Other,base rate x DRG weight,35586,,"35,391 x DRG Weight",35586,Other,base rate x DRG weight,88666,70,,88666,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25355,,"25,216 X DRG Weight",25355,Other,Base Weight X DRG Weight,22820,,"22,695 X DRG Weight",22820,Other,Base Weight X DRG Weight,25355,,"25,216 X DRG Weight",25355,Other,Base Rate x DRG Weight ,21551,,"21,433 x DRG Weight",21551,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,88666,
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,,inpatient,,,89742.06,13562,,,13562,Other,150% of Medicare + 9.63% HCRA Surcharge,8246.83,,,8246.83,Other,Medicare IPPS methodology,22713,,"25,728 x DRG weight",22713,Other,base rate x DRG weight,20441,,"23,155 x DRG weight",20441,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,44871,50,,44871,Percent of Total Billed Charges,50% of Charges,25686,,"29,096 x DRG Weight",25686,Other,base rate x DRG weight,19830,,"22,463 x DRG Weight",19830,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23329,,"26,426 x DRG Weight",23329,Other,base rate x DRG weight,34261,,"38,809 x DRG Weight",34261,Other,base rate x DRG weight,34261,,"38,809 x DRG Weight",34261,Other,base rate x DRG weight,23329,,"26,426 x DRG Weight",23329,Other,base rate x DRG weight,34261,,"38,809 x DRG Weight",34261,Other,base rate x DRG weight,31243,,"35,391 x DRG Weight",31243,Other,base rate x DRG weight,62819,70,,62819,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22261,,"25,216 X DRG Weight",22261,Other,Base Weight X DRG Weight,20035,,"22,695 X DRG Weight",20035,Other,Base Weight X DRG Weight,22261,,"25,216 X DRG Weight",22261,Other,Base Rate x DRG Weight ,18921,,"21,433 x DRG Weight",18921,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,62819,
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,,inpatient,,,116548.9,24790,,,24790,Other,150% of Medicare + 9.63% HCRA Surcharge,15074.73,,,15074.73,Other,Medicare IPPS methodology,42191,,"25,728 x DRG weight",42191,Other,base rate x DRG weight,37972,,"23,155 x DRG weight",37972,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,58274,50,,58274,Percent of Total Billed Charges,50% of Charges,47715,,"29,096 x DRG Weight",47715,Other,base rate x DRG weight,36837,,"22,463 x DRG Weight",36837,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,43336,,"26,426 x DRG Weight",43336,Other,base rate x DRG weight,63643,,"38,809 x DRG Weight",63643,Other,base rate x DRG weight,63643,,"38,809 x DRG Weight",63643,Other,base rate x DRG weight,43336,,"26,426 x DRG Weight",43336,Other,base rate x DRG weight,63643,,"38,809 x DRG Weight",63643,Other,base rate x DRG weight,58038,,"35,391 x DRG Weight",58038,Other,base rate x DRG weight,81584,70,,81584,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,41352,,"25,216 X DRG Weight",41352,Other,Base Weight X DRG Weight,37218,,"22,695 X DRG Weight",37218,Other,Base Weight X DRG Weight,41352,,"25,216 X DRG Weight",41352,Other,Base Rate x DRG Weight ,35148,,"21,433 x DRG Weight",35148,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,81584,
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,,inpatient,,,103943.58,14079,,,14079,Other,150% of Medicare + 9.63% HCRA Surcharge,8561.58,,,8561.58,Other,Medicare IPPS methodology,23611,,"25,728 x DRG weight",23611,Other,base rate x DRG weight,21249,,"23,155 x DRG weight",21249,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,51972,50,,51972,Percent of Total Billed Charges,50% of Charges,26701,,"29,096 x DRG Weight",26701,Other,base rate x DRG weight,20614,,"22,463 x DRG Weight",20614,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,24251,,"26,426 x DRG Weight",24251,Other,base rate x DRG weight,35615,,"38,809 x DRG Weight",35615,Other,base rate x DRG weight,35615,,"38,809 x DRG Weight",35615,Other,base rate x DRG weight,24251,,"26,426 x DRG Weight",24251,Other,base rate x DRG weight,35615,,"38,809 x DRG Weight",35615,Other,base rate x DRG weight,32478,,"35,391 x DRG Weight",32478,Other,base rate x DRG weight,72761,70,,72761,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,23141,,"25,216 X DRG Weight",23141,Other,Base Weight X DRG Weight,20827,,"22,695 X DRG Weight",20827,Other,Base Weight X DRG Weight,23141,,"25,216 X DRG Weight",23141,Other,Base Rate x DRG Weight ,19669,,"21,433 x DRG Weight",19669,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,72761,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,,inpatient,,,194621.4,31499,,,31499,Other,150% of Medicare + 9.63% HCRA Surcharge,19154.69,,,19154.69,Other,Medicare IPPS methodology,53831,,"25,728 x DRG weight",53831,Other,base rate x DRG weight,48447,,"23,155 x DRG weight",48447,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,97311,50,,97311,Percent of Total Billed Charges,50% of Charges,60878,,"29,096 x DRG Weight",60878,Other,base rate x DRG weight,46999,,"22,463 x DRG Weight",46999,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,55291,,"26,426 x DRG Weight",55291,Other,base rate x DRG weight,81200,,"38,809 x DRG Weight",81200,Other,base rate x DRG weight,81200,,"38,809 x DRG Weight",81200,Other,base rate x DRG weight,55291,,"26,426 x DRG Weight",55291,Other,base rate x DRG weight,81200,,"38,809 x DRG Weight",81200,Other,base rate x DRG weight,74049,,"35,391 x DRG Weight",74049,Other,base rate x DRG weight,136235,70,,136235,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,52759,,"25,216 X DRG Weight",52759,Other,Base Weight X DRG Weight,47485,,"22,695 X DRG Weight",47485,Other,Base Weight X DRG Weight,52759,,"25,216 X DRG Weight",52759,Other,Base Rate x DRG Weight ,44844,,"21,433 x DRG Weight",44844,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,136235,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,,inpatient,,,101550.82,16568,,,16568,Other,150% of Medicare + 9.63% HCRA Surcharge,10074.88,,,10074.88,Other,Medicare IPPS methodology,27928,,"25,728 x DRG weight",27928,Other,base rate x DRG weight,25135,,"23,155 x DRG weight",25135,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,50775,50,,50775,Percent of Total Billed Charges,50% of Charges,31584,,"29,096 x DRG Weight",31584,Other,base rate x DRG weight,24384,,"22,463 x DRG Weight",24384,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28685,,"26,426 x DRG Weight",28685,Other,base rate x DRG weight,42127,,"38,809 x DRG Weight",42127,Other,base rate x DRG weight,42127,,"38,809 x DRG Weight",42127,Other,base rate x DRG weight,28685,,"26,426 x DRG Weight",28685,Other,base rate x DRG weight,42127,,"38,809 x DRG Weight",42127,Other,base rate x DRG weight,38417,,"35,391 x DRG Weight",38417,Other,base rate x DRG weight,71086,70,,71086,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27372,,"25,216 X DRG Weight",27372,Other,Base Weight X DRG Weight,24635,,"22,695 X DRG Weight",24635,Other,Base Weight X DRG Weight,27372,,"25,216 X DRG Weight",27372,Other,Base Rate x DRG Weight ,23266,,"21,433 x DRG Weight",23266,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,71086,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,,inpatient,,,91651.41,10713,,,10713,Other,150% of Medicare + 9.63% HCRA Surcharge,6514.38,,,6514.38,Other,Medicare IPPS methodology,17770,,"25,728 x DRG weight",17770,Other,base rate x DRG weight,15993,,"23,155 x DRG weight",15993,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,45826,50,,45826,Percent of Total Billed Charges,50% of Charges,20097,,"29,096 x DRG Weight",20097,Other,base rate x DRG weight,15515,,"22,463 x DRG Weight",15515,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18252,,"26,426 x DRG Weight",18252,Other,base rate x DRG weight,26805,,"38,809 x DRG Weight",26805,Other,base rate x DRG weight,26805,,"38,809 x DRG Weight",26805,Other,base rate x DRG weight,18252,,"26,426 x DRG Weight",18252,Other,base rate x DRG weight,26805,,"38,809 x DRG Weight",26805,Other,base rate x DRG weight,24445,,"35,391 x DRG Weight",24445,Other,base rate x DRG weight,64156,70,,64156,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,17417,,"25,216 X DRG Weight",17417,Other,Base Weight X DRG Weight,15675,,"22,695 X DRG Weight",15675,Other,Base Weight X DRG Weight,17417,,"25,216 X DRG Weight",17417,Other,Base Rate x DRG Weight ,14804,,"21,433 x DRG Weight",14804,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,64156,
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,,inpatient,,,800008.95,103762,,,103762,Other,150% of Medicare + 9.63% HCRA Surcharge,63098.13,,,63098.13,Other,Medicare IPPS methodology,179193,,"25,728 x DRG weight",179193,Other,base rate x DRG weight,161272,,"23,155 x DRG weight",161272,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,400004,50,,400004,Percent of Total Billed Charges,50% of Charges,202651,,"29,096 x DRG Weight",202651,Other,base rate x DRG weight,156453,,"22,463 x DRG Weight",156453,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,184054,,"26,426 x DRG Weight",184054,Other,base rate x DRG weight,270301,,"38,809 x DRG Weight",270301,Other,base rate x DRG weight,270301,,"38,809 x DRG Weight",270301,Other,base rate x DRG weight,184054,,"26,426 x DRG Weight",184054,Other,base rate x DRG weight,270301,,"38,809 x DRG Weight",270301,Other,base rate x DRG weight,246495,,"35,391 x DRG Weight",246495,Other,base rate x DRG weight,560006,70,,560006,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,175627,,"25,216 X DRG Weight",175627,Other,Base Weight X DRG Weight,158068,,"22,695 X DRG Weight",158068,Other,Base Weight X DRG Weight,175627,,"25,216 X DRG Weight",175627,Other,Base Rate x DRG Weight ,149279,,"21,433 x DRG Weight",149279,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,560006,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,,inpatient,,,229554.05,29872,,,29872,Other,150% of Medicare + 9.63% HCRA Surcharge,18165.36,,,18165.36,Other,Medicare IPPS methodology,51008,,"25,728 x DRG weight",51008,Other,base rate x DRG weight,45907,,"23,155 x DRG weight",45907,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,114777,50,,114777,Percent of Total Billed Charges,50% of Charges,57686,,"29,096 x DRG Weight",57686,Other,base rate x DRG weight,44535,,"22,463 x DRG Weight",44535,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,52392,,"26,426 x DRG Weight",52392,Other,base rate x DRG weight,76943,,"38,809 x DRG Weight",76943,Other,base rate x DRG weight,76943,,"38,809 x DRG Weight",76943,Other,base rate x DRG weight,52392,,"26,426 x DRG Weight",52392,Other,base rate x DRG weight,76943,,"38,809 x DRG Weight",76943,Other,base rate x DRG weight,70166,,"35,391 x DRG Weight",70166,Other,base rate x DRG weight,160688,70,,160688,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,49993,,"25,216 X DRG Weight",49993,Other,Base Weight X DRG Weight,44995,,"22,695 X DRG Weight",44995,Other,Base Weight X DRG Weight,49993,,"25,216 X DRG Weight",49993,Other,Base Rate x DRG Weight ,42493,,"21,433 x DRG Weight",42493,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,160688,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,,inpatient,,,131995.42,15743,,,15743,Other,150% of Medicare + 9.63% HCRA Surcharge,9573.45,,,9573.45,Other,Medicare IPPS methodology,26497,,"25,728 x DRG weight",26497,Other,base rate x DRG weight,23847,,"23,155 x DRG weight",23847,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,65998,50,,65998,Percent of Total Billed Charges,50% of Charges,29966,,"29,096 x DRG Weight",29966,Other,base rate x DRG weight,23135,,"22,463 x DRG Weight",23135,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,27216,,"26,426 x DRG Weight",27216,Other,base rate x DRG weight,39969,,"38,809 x DRG Weight",39969,Other,base rate x DRG weight,39969,,"38,809 x DRG Weight",39969,Other,base rate x DRG weight,27216,,"26,426 x DRG Weight",27216,Other,base rate x DRG weight,39969,,"38,809 x DRG Weight",39969,Other,base rate x DRG weight,36449,,"35,391 x DRG Weight",36449,Other,base rate x DRG weight,92397,70,,92397,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25970,,"25,216 X DRG Weight",25970,Other,Base Weight X DRG Weight,23374,,"22,695 X DRG Weight",23374,Other,Base Weight X DRG Weight,25970,,"25,216 X DRG Weight",25970,Other,Base Rate x DRG Weight ,22074,,"21,433 x DRG Weight",22074,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,92397,
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,,,,inpatient,,,333359.01,55809,,,55809,Other,150% of Medicare + 9.63% HCRA Surcharge,33937.78,,,33937.78,Other,Medicare IPPS methodology,96004,,"25,728 x DRG weight",96004,Other,base rate x DRG weight,86403,,"23,155 x DRG weight",86403,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,166680,50,,166680,Percent of Total Billed Charges,50% of Charges,108572,,"29,096 x DRG Weight",108572,Other,base rate x DRG weight,83821,,"22,463 x DRG Weight",83821,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,98609,,"26,426 x DRG Weight",98609,Other,base rate x DRG weight,144816,,"38,809 x DRG Weight",144816,Other,base rate x DRG weight,144816,,"38,809 x DRG Weight",144816,Other,base rate x DRG weight,98609,,"26,426 x DRG Weight",98609,Other,base rate x DRG weight,144816,,"38,809 x DRG Weight",144816,Other,base rate x DRG weight,132062,,"35,391 x DRG Weight",132062,Other,base rate x DRG weight,233351,70,,233351,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,94094,,"25,216 X DRG Weight",94094,Other,Base Weight X DRG Weight,84686,,"22,695 X DRG Weight",84686,Other,Base Weight X DRG Weight,94094,,"25,216 X DRG Weight",94094,Other,Base Rate x DRG Weight ,79977,,"21,433 x DRG Weight",79977,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,233351,
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,MS-DRG,,,,,,,,inpatient,,,1190531.27,64652,,,64652,Other,150% of Medicare + 9.63% HCRA Surcharge,39315.5,,,39315.5,Other,Medicare IPPS methodology,111346,,"25,728 x DRG weight",111346,Other,base rate x DRG weight,100210,,"23,155 x DRG weight",100210,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,595266,50,,595266,Percent of Total Billed Charges,50% of Charges,125922,,"29,096 x DRG Weight",125922,Other,base rate x DRG weight,97215,,"22,463 x DRG Weight",97215,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,114366,,"26,426 x DRG Weight",114366,Other,base rate x DRG weight,167958,,"38,809 x DRG Weight",167958,Other,base rate x DRG weight,167958,,"38,809 x DRG Weight",167958,Other,base rate x DRG weight,114366,,"26,426 x DRG Weight",114366,Other,base rate x DRG weight,167958,,"38,809 x DRG Weight",167958,Other,base rate x DRG weight,153165,,"35,391 x DRG Weight",153165,Other,base rate x DRG weight,833372,70,,833372,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,109130,,"25,216 X DRG Weight",109130,Other,Base Weight X DRG Weight,98219,,"22,695 X DRG Weight",98219,Other,Base Weight X DRG Weight,109130,,"25,216 X DRG Weight",109130,Other,Base Rate x DRG Weight ,92758,,"21,433 x DRG Weight",92758,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,833372,
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,MS-DRG,,,,,,,,inpatient,,,101203.96,28420,,,28420,Other,150% of Medicare + 9.63% HCRA Surcharge,17282.45,,,17282.45,Other,Medicare IPPS methodology,48490,,"25,728 x DRG weight",48490,Other,base rate x DRG weight,43640,,"23,155 x DRG weight",43640,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,50602,50,,50602,Percent of Total Billed Charges,50% of Charges,54837,,"29,096 x DRG Weight",54837,Other,base rate x DRG weight,42336,,"22,463 x DRG Weight",42336,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,49805,,"26,426 x DRG Weight",49805,Other,base rate x DRG weight,73143,,"38,809 x DRG Weight",73143,Other,base rate x DRG weight,73143,,"38,809 x DRG Weight",73143,Other,base rate x DRG weight,49805,,"26,426 x DRG Weight",49805,Other,base rate x DRG weight,73143,,"38,809 x DRG Weight",73143,Other,base rate x DRG weight,66701,,"35,391 x DRG Weight",66701,Other,base rate x DRG weight,70843,70,,70843,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,47525,,"25,216 X DRG Weight",47525,Other,Base Weight X DRG Weight,42773,,"22,695 X DRG Weight",42773,Other,Base Weight X DRG Weight,47525,,"25,216 X DRG Weight",47525,Other,Base Rate x DRG Weight ,40395,,"21,433 x DRG Weight",40395,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,73143,
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,,inpatient,,,129098.3,18881,,,18881,Other,150% of Medicare + 9.63% HCRA Surcharge,11481.76,,,11481.76,Other,Medicare IPPS methodology,31941,,"25,728 x DRG weight",31941,Other,base rate x DRG weight,28747,,"23,155 x DRG weight",28747,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,64549,50,,64549,Percent of Total Billed Charges,50% of Charges,36123,,"29,096 x DRG Weight",36123,Other,base rate x DRG weight,27888,,"22,463 x DRG Weight",27888,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,32808,,"26,426 x DRG Weight",32808,Other,base rate x DRG weight,48181,,"38,809 x DRG Weight",48181,Other,base rate x DRG weight,48181,,"38,809 x DRG Weight",48181,Other,base rate x DRG weight,32808,,"26,426 x DRG Weight",32808,Other,base rate x DRG weight,48181,,"38,809 x DRG Weight",48181,Other,base rate x DRG weight,43938,,"35,391 x DRG Weight",43938,Other,base rate x DRG weight,90369,70,,90369,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,31306,,"25,216 X DRG Weight",31306,Other,Base Weight X DRG Weight,28176,,"22,695 X DRG Weight",28176,Other,Base Weight X DRG Weight,31306,,"25,216 X DRG Weight",31306,Other,Base Rate x DRG Weight ,26609,,"21,433 x DRG Weight",26609,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,90369,
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,MS-DRG,,,,,,,,inpatient,,,725620.05,48760,,,48760,Other,150% of Medicare + 9.63% HCRA Surcharge,29651.29,,,29651.29,Other,Medicare IPPS methodology,83776,,"25,728 x DRG weight",83776,Other,base rate x DRG weight,75397,,"23,155 x DRG weight",75397,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,362810,50,,362810,Percent of Total Billed Charges,50% of Charges,94742,,"29,096 x DRG Weight",94742,Other,base rate x DRG weight,73144,,"22,463 x DRG Weight",73144,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,86048,,"26,426 x DRG Weight",86048,Other,base rate x DRG weight,126370,,"38,809 x DRG Weight",126370,Other,base rate x DRG weight,126370,,"38,809 x DRG Weight",126370,Other,base rate x DRG weight,86048,,"26,426 x DRG Weight",86048,Other,base rate x DRG weight,126370,,"38,809 x DRG Weight",126370,Other,base rate x DRG weight,115240,,"35,391 x DRG Weight",115240,Other,base rate x DRG weight,507934,70,,507934,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,82108,,"25,216 X DRG Weight",82108,Other,Base Weight X DRG Weight,73899,,"22,695 X DRG Weight",73899,Other,Base Weight X DRG Weight,82108,,"25,216 X DRG Weight",82108,Other,Base Rate x DRG Weight ,69790,,"21,433 x DRG Weight",69790,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,507934,
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,MS-DRG,,,,,,,,inpatient,,,143321.31,23956,,,23956,Other,150% of Medicare + 9.63% HCRA Surcharge,14567.89,,,14567.89,Other,Medicare IPPS methodology,40745,,"25,728 x DRG weight",40745,Other,base rate x DRG weight,36671,,"23,155 x DRG weight",36671,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,71661,50,,71661,Percent of Total Billed Charges,50% of Charges,46079,,"29,096 x DRG Weight",46079,Other,base rate x DRG weight,35575,,"22,463 x DRG Weight",35575,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,41851,,"26,426 x DRG Weight",41851,Other,base rate x DRG weight,61462,,"38,809 x DRG Weight",61462,Other,base rate x DRG weight,61462,,"38,809 x DRG Weight",61462,Other,base rate x DRG weight,41851,,"26,426 x DRG Weight",41851,Other,base rate x DRG weight,61462,,"38,809 x DRG Weight",61462,Other,base rate x DRG weight,56049,,"35,391 x DRG Weight",56049,Other,base rate x DRG weight,100325,70,,100325,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,39935,,"25,216 X DRG Weight",39935,Other,Base Weight X DRG Weight,35942,,"22,695 X DRG Weight",35942,Other,Base Weight X DRG Weight,39935,,"25,216 X DRG Weight",39935,Other,Base Rate x DRG Weight ,33943,,"21,433 x DRG Weight",33943,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,100325,
HAND PROCEDURES FOR INJURIES,906,MS-DRG,,,,,,,,inpatient,,,145480.88,28374,,,28374,Other,150% of Medicare + 9.63% HCRA Surcharge,17254.49,,,17254.49,Other,Medicare IPPS methodology,48410,,"25,728 x DRG weight",48410,Other,base rate x DRG weight,43568,,"23,155 x DRG weight",43568,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,72740,50,,72740,Percent of Total Billed Charges,50% of Charges,54747,,"29,096 x DRG Weight",54747,Other,base rate x DRG weight,42266,,"22,463 x DRG Weight",42266,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,49723,,"26,426 x DRG Weight",49723,Other,base rate x DRG weight,73023,,"38,809 x DRG Weight",73023,Other,base rate x DRG weight,73023,,"38,809 x DRG Weight",73023,Other,base rate x DRG weight,49723,,"26,426 x DRG Weight",49723,Other,base rate x DRG weight,73023,,"38,809 x DRG Weight",73023,Other,base rate x DRG weight,66592,,"35,391 x DRG Weight",66592,Other,base rate x DRG weight,101837,70,,101837,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,47446,,"25,216 X DRG Weight",47446,Other,Base Weight X DRG Weight,42703,,"22,695 X DRG Weight",42703,Other,Base Weight X DRG Weight,47446,,"25,216 X DRG Weight",47446,Other,Base Rate x DRG Weight ,40328,,"21,433 x DRG Weight",40328,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,101837,
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,,inpatient,,,404436.95,55631,,,55631,Other,150% of Medicare + 9.63% HCRA Surcharge,33829.56,,,33829.56,Other,Medicare IPPS methodology,95695,,"25,728 x DRG weight",95695,Other,base rate x DRG weight,86125,,"23,155 x DRG weight",86125,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,202218,50,,202218,Percent of Total Billed Charges,50% of Charges,108223,,"29,096 x DRG Weight",108223,Other,base rate x DRG weight,83551,,"22,463 x DRG Weight",83551,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,98292,,"26,426 x DRG Weight",98292,Other,base rate x DRG weight,144350,,"38,809 x DRG Weight",144350,Other,base rate x DRG weight,144350,,"38,809 x DRG Weight",144350,Other,base rate x DRG weight,98292,,"26,426 x DRG Weight",98292,Other,base rate x DRG weight,144350,,"38,809 x DRG Weight",144350,Other,base rate x DRG weight,131637,,"35,391 x DRG Weight",131637,Other,base rate x DRG weight,283106,70,,283106,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,93791,,"25,216 X DRG Weight",93791,Other,Base Weight X DRG Weight,84414,,"22,695 X DRG Weight",84414,Other,Base Weight X DRG Weight,93791,,"25,216 X DRG Weight",93791,Other,Base Rate x DRG Weight ,79720,,"21,433 x DRG Weight",79720,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,283106,
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,,inpatient,,,280457.16,30191,,,30191,Other,150% of Medicare + 9.63% HCRA Surcharge,18359.26,,,18359.26,Other,Medicare IPPS methodology,51561,,"25,728 x DRG weight",51561,Other,base rate x DRG weight,46405,,"23,155 x DRG weight",46405,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,140229,50,,140229,Percent of Total Billed Charges,50% of Charges,58311,,"29,096 x DRG Weight",58311,Other,base rate x DRG weight,45018,,"22,463 x DRG Weight",45018,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,52960,,"26,426 x DRG Weight",52960,Other,base rate x DRG weight,77777,,"38,809 x DRG Weight",77777,Other,base rate x DRG weight,77777,,"38,809 x DRG Weight",77777,Other,base rate x DRG weight,52960,,"26,426 x DRG Weight",52960,Other,base rate x DRG weight,77777,,"38,809 x DRG Weight",77777,Other,base rate x DRG weight,70927,,"35,391 x DRG Weight",70927,Other,base rate x DRG weight,196320,70,,196320,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,50535,,"25,216 X DRG Weight",50535,Other,Base Weight X DRG Weight,45483,,"22,695 X DRG Weight",45483,Other,Base Weight X DRG Weight,50535,,"25,216 X DRG Weight",50535,Other,Base Rate x DRG Weight ,42954,,"21,433 x DRG Weight",42954,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,196320,
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,,inpatient,,,151285.75,20584,,,20584,Other,150% of Medicare + 9.63% HCRA Surcharge,12517.08,,,12517.08,Other,Medicare IPPS methodology,34895,,"25,728 x DRG weight",34895,Other,base rate x DRG weight,31405,,"23,155 x DRG weight",31405,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,75643,50,,75643,Percent of Total Billed Charges,50% of Charges,39463,,"29,096 x DRG Weight",39463,Other,base rate x DRG weight,30467,,"22,463 x DRG Weight",30467,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,35842,,"26,426 x DRG Weight",35842,Other,base rate x DRG weight,52637,,"38,809 x DRG Weight",52637,Other,base rate x DRG weight,52637,,"38,809 x DRG Weight",52637,Other,base rate x DRG weight,35842,,"26,426 x DRG Weight",35842,Other,base rate x DRG weight,52637,,"38,809 x DRG Weight",52637,Other,base rate x DRG weight,48001,,"35,391 x DRG Weight",48001,Other,base rate x DRG weight,105900,70,,105900,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,34200,,"25,216 X DRG Weight",34200,Other,Base Weight X DRG Weight,30781,,"22,695 X DRG Weight",30781,Other,Base Weight X DRG Weight,34200,,"25,216 X DRG Weight",34200,Other,Base Rate x DRG Weight ,29070,,"21,433 x DRG Weight",29070,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,105900,
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,,inpatient,,,300873.47,22633,,,22633,Other,150% of Medicare + 9.63% HCRA Surcharge,13763.44,,,13763.44,Other,Medicare IPPS methodology,38450,,"25,728 x DRG weight",38450,Other,base rate x DRG weight,34605,,"23,155 x DRG weight",34605,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,150437,50,,150437,Percent of Total Billed Charges,50% of Charges,43484,,"29,096 x DRG Weight",43484,Other,base rate x DRG weight,33571,,"22,463 x DRG Weight",33571,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39494,,"26,426 x DRG Weight",39494,Other,base rate x DRG weight,58000,,"38,809 x DRG Weight",58000,Other,base rate x DRG weight,58000,,"38,809 x DRG Weight",58000,Other,base rate x DRG weight,39494,,"26,426 x DRG Weight",39494,Other,base rate x DRG weight,58000,,"38,809 x DRG Weight",58000,Other,base rate x DRG weight,52892,,"35,391 x DRG Weight",52892,Other,base rate x DRG weight,210611,70,,210611,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37685,,"25,216 X DRG Weight",37685,Other,Base Weight X DRG Weight,33918,,"22,695 X DRG Weight",33918,Other,Base Weight X DRG Weight,37685,,"25,216 X DRG Weight",37685,Other,Base Rate x DRG Weight ,32032,,"21,433 x DRG Weight",32032,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,210611,
TRAUMATIC INJURY WITHOUT MCC,914,MS-DRG,,,,,,,,inpatient,,,86778.14,13931,,,13931,Other,150% of Medicare + 9.63% HCRA Surcharge,8471.39,,,8471.39,Other,Medicare IPPS methodology,23353,,"25,728 x DRG weight",23353,Other,base rate x DRG weight,21018,,"23,155 x DRG weight",21018,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43389,50,,43389,Percent of Total Billed Charges,50% of Charges,26410,,"29,096 x DRG Weight",26410,Other,base rate x DRG weight,20390,,"22,463 x DRG Weight",20390,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,23987,,"26,426 x DRG Weight",23987,Other,base rate x DRG weight,35227,,"38,809 x DRG Weight",35227,Other,base rate x DRG weight,35227,,"38,809 x DRG Weight",35227,Other,base rate x DRG weight,23987,,"26,426 x DRG Weight",23987,Other,base rate x DRG weight,35227,,"38,809 x DRG Weight",35227,Other,base rate x DRG weight,32124,,"35,391 x DRG Weight",32124,Other,base rate x DRG weight,60745,70,,60745,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,22889,,"25,216 X DRG Weight",22889,Other,Base Weight X DRG Weight,20600,,"22,695 X DRG Weight",20600,Other,Base Weight X DRG Weight,22889,,"25,216 X DRG Weight",22889,Other,Base Rate x DRG Weight ,19455,,"21,433 x DRG Weight",19455,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,60745,
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,,inpatient,,,202183.18,26778,,,26778,Other,150% of Medicare + 9.63% HCRA Surcharge,16284.1,,,16284.1,Other,Medicare IPPS methodology,45641,,"25,728 x DRG weight",45641,Other,base rate x DRG weight,41077,,"23,155 x DRG weight",41077,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,101092,50,,101092,Percent of Total Billed Charges,50% of Charges,51616,,"29,096 x DRG Weight",51616,Other,base rate x DRG weight,39849,,"22,463 x DRG Weight",39849,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,46880,,"26,426 x DRG Weight",46880,Other,base rate x DRG weight,68847,,"38,809 x DRG Weight",68847,Other,base rate x DRG weight,68847,,"38,809 x DRG Weight",68847,Other,base rate x DRG weight,46880,,"26,426 x DRG Weight",46880,Other,base rate x DRG weight,68847,,"38,809 x DRG Weight",68847,Other,base rate x DRG weight,62784,,"35,391 x DRG Weight",62784,Other,base rate x DRG weight,141528,70,,141528,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,44733,,"25,216 X DRG Weight",44733,Other,Base Weight X DRG Weight,40261,,"22,695 X DRG Weight",40261,Other,Base Weight X DRG Weight,44733,,"25,216 X DRG Weight",44733,Other,Base Rate x DRG Weight ,38022,,"21,433 x DRG Weight",38022,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,141528,
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,,inpatient,,,84150.39,10239,,,10239,Other,150% of Medicare + 9.63% HCRA Surcharge,6226.69,,,6226.69,Other,Medicare IPPS methodology,16950,,"25,728 x DRG weight",16950,Other,base rate x DRG weight,15255,,"23,155 x DRG weight",15255,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,42075,50,,42075,Percent of Total Billed Charges,50% of Charges,19168,,"29,096 x DRG Weight",19168,Other,base rate x DRG weight,14799,,"22,463 x DRG Weight",14799,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,17409,,"26,426 x DRG Weight",17409,Other,base rate x DRG weight,25567,,"38,809 x DRG Weight",25567,Other,base rate x DRG weight,25567,,"38,809 x DRG Weight",25567,Other,base rate x DRG weight,17409,,"26,426 x DRG Weight",17409,Other,base rate x DRG weight,25567,,"38,809 x DRG Weight",25567,Other,base rate x DRG weight,23316,,"35,391 x DRG Weight",23316,Other,base rate x DRG weight,58905,70,,58905,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,16612,,"25,216 X DRG Weight",16612,Other,Base Weight X DRG Weight,14951,,"22,695 X DRG Weight",14951,Other,Base Weight X DRG Weight,16612,,"25,216 X DRG Weight",16612,Other,Base Rate x DRG Weight ,14120,,"21,433 x DRG Weight",14120,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,58905,
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,,inpatient,,,189693.48,24137,,,24137,Other,150% of Medicare + 9.63% HCRA Surcharge,14677.91,,,14677.91,Other,Medicare IPPS methodology,41059,,"25,728 x DRG weight",41059,Other,base rate x DRG weight,36953,,"23,155 x DRG weight",36953,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,94847,50,,94847,Percent of Total Billed Charges,50% of Charges,46434,,"29,096 x DRG Weight",46434,Other,base rate x DRG weight,35849,,"22,463 x DRG Weight",35849,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,42173,,"26,426 x DRG Weight",42173,Other,base rate x DRG weight,61935,,"38,809 x DRG Weight",61935,Other,base rate x DRG weight,61935,,"38,809 x DRG Weight",61935,Other,base rate x DRG weight,42173,,"26,426 x DRG Weight",42173,Other,base rate x DRG weight,61935,,"38,809 x DRG Weight",61935,Other,base rate x DRG weight,56480,,"35,391 x DRG Weight",56480,Other,base rate x DRG weight,132785,70,,132785,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,40242,,"25,216 X DRG Weight",40242,Other,Base Weight X DRG Weight,36219,,"22,695 X DRG Weight",36219,Other,Base Weight X DRG Weight,40242,,"25,216 X DRG Weight",40242,Other,Base Rate x DRG Weight ,34205,,"21,433 x DRG Weight",34205,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,132785,
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,,inpatient,,,90526.71,13237,,,13237,Other,150% of Medicare + 9.63% HCRA Surcharge,8049.33,,,8049.33,Other,Medicare IPPS methodology,22149,,"25,728 x DRG weight",22149,Other,base rate x DRG weight,19934,,"23,155 x DRG weight",19934,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,45263,50,,45263,Percent of Total Billed Charges,50% of Charges,25049,,"29,096 x DRG Weight",25049,Other,base rate x DRG weight,19338,,"22,463 x DRG Weight",19338,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,22750,,"26,426 x DRG Weight",22750,Other,base rate x DRG weight,33411,,"38,809 x DRG Weight",33411,Other,base rate x DRG weight,33411,,"38,809 x DRG Weight",33411,Other,base rate x DRG weight,22750,,"26,426 x DRG Weight",22750,Other,base rate x DRG weight,33411,,"38,809 x DRG Weight",33411,Other,base rate x DRG weight,30468,,"35,391 x DRG Weight",30468,Other,base rate x DRG weight,63369,70,,63369,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,21708,,"25,216 X DRG Weight",21708,Other,Base Weight X DRG Weight,19538,,"22,695 X DRG Weight",19538,Other,Base Weight X DRG Weight,21708,,"25,216 X DRG Weight",21708,Other,Base Rate x DRG Weight ,18452,,"21,433 x DRG Weight",18452,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,63369,
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,,inpatient,,,198006.82,27530,,,27530,Other,150% of Medicare + 9.63% HCRA Surcharge,16741.34,,,16741.34,Other,Medicare IPPS methodology,46946,,"25,728 x DRG weight",46946,Other,base rate x DRG weight,42251,,"23,155 x DRG weight",42251,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,99003,50,,99003,Percent of Total Billed Charges,50% of Charges,53091,,"29,096 x DRG Weight",53091,Other,base rate x DRG weight,40988,,"22,463 x DRG Weight",40988,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,48220,,"26,426 x DRG Weight",48220,Other,base rate x DRG weight,70815,,"38,809 x DRG Weight",70815,Other,base rate x DRG weight,70815,,"38,809 x DRG Weight",70815,Other,base rate x DRG weight,48220,,"26,426 x DRG Weight",48220,Other,base rate x DRG weight,70815,,"38,809 x DRG Weight",70815,Other,base rate x DRG weight,64578,,"35,391 x DRG Weight",64578,Other,base rate x DRG weight,138605,70,,138605,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46012,,"25,216 X DRG Weight",46012,Other,Base Weight X DRG Weight,41412,,"22,695 X DRG Weight",41412,Other,Base Weight X DRG Weight,46012,,"25,216 X DRG Weight",46012,Other,Base Rate x DRG Weight ,39109,,"21,433 x DRG Weight",39109,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,138605,
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,,inpatient,,,161505.57,15801,,,15801,Other,150% of Medicare + 9.63% HCRA Surcharge,9608.62,,,9608.62,Other,Medicare IPPS methodology,26598,,"25,728 x DRG weight",26598,Other,base rate x DRG weight,23938,,"23,155 x DRG weight",23938,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,80753,50,,80753,Percent of Total Billed Charges,50% of Charges,30079,,"29,096 x DRG Weight",30079,Other,base rate x DRG weight,23222,,"22,463 x DRG Weight",23222,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,27319,,"26,426 x DRG Weight",27319,Other,base rate x DRG weight,40121,,"38,809 x DRG Weight",40121,Other,base rate x DRG weight,40121,,"38,809 x DRG Weight",40121,Other,base rate x DRG weight,27319,,"26,426 x DRG Weight",27319,Other,base rate x DRG weight,40121,,"38,809 x DRG Weight",40121,Other,base rate x DRG weight,36587,,"35,391 x DRG Weight",36587,Other,base rate x DRG weight,113054,70,,113054,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,26068,,"25,216 X DRG Weight",26068,Other,Base Weight X DRG Weight,23462,,"22,695 X DRG Weight",23462,Other,Base Weight X DRG Weight,26068,,"25,216 X DRG Weight",26068,Other,Base Rate x DRG Weight ,22157,,"21,433 x DRG Weight",22157,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,113054,
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,,inpatient,,,90123.85,10818,,,10818,Other,150% of Medicare + 9.63% HCRA Surcharge,6578.42,,,6578.42,Other,Medicare IPPS methodology,17953,,"25,728 x DRG weight",17953,Other,base rate x DRG weight,16158,,"23,155 x DRG weight",16158,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,45062,50,,45062,Percent of Total Billed Charges,50% of Charges,20303,,"29,096 x DRG Weight",20303,Other,base rate x DRG weight,15675,,"22,463 x DRG Weight",15675,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,18440,,"26,426 x DRG Weight",18440,Other,base rate x DRG weight,27081,,"38,809 x DRG Weight",27081,Other,base rate x DRG weight,27081,,"38,809 x DRG Weight",27081,Other,base rate x DRG weight,18440,,"26,426 x DRG Weight",18440,Other,base rate x DRG weight,27081,,"38,809 x DRG Weight",27081,Other,base rate x DRG weight,24696,,"35,391 x DRG Weight",24696,Other,base rate x DRG weight,63087,70,,63087,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,17596,,"25,216 X DRG Weight",17596,Other,Base Weight X DRG Weight,15837,,"22,695 X DRG Weight",15837,Other,Base Weight X DRG Weight,17596,,"25,216 X DRG Weight",17596,Other,Base Rate x DRG Weight ,14956,,"21,433 x DRG Weight",14956,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,63087,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,,inpatient,,,353327.55,26347,,,26347,Other,150% of Medicare + 9.63% HCRA Surcharge,16021.67,,,16021.67,Other,Medicare IPPS methodology,44893,,"25,728 x DRG weight",44893,Other,base rate x DRG weight,40403,,"23,155 x DRG weight",40403,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,176664,50,,176664,Percent of Total Billed Charges,50% of Charges,50770,,"29,096 x DRG Weight",50770,Other,base rate x DRG weight,39196,,"22,463 x DRG Weight",39196,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,46111,,"26,426 x DRG Weight",46111,Other,base rate x DRG weight,67718,,"38,809 x DRG Weight",67718,Other,base rate x DRG weight,67718,,"38,809 x DRG Weight",67718,Other,base rate x DRG weight,46111,,"26,426 x DRG Weight",46111,Other,base rate x DRG weight,67718,,"38,809 x DRG Weight",67718,Other,base rate x DRG weight,61754,,"35,391 x DRG Weight",61754,Other,base rate x DRG weight,247329,70,,247329,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,43999,,"25,216 X DRG Weight",43999,Other,Base Weight X DRG Weight,39601,,"22,695 X DRG Weight",39601,Other,Base Weight X DRG Weight,43999,,"25,216 X DRG Weight",43999,Other,Base Rate x DRG Weight ,37398,,"21,433 x DRG Weight",37398,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,247329,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,,inpatient,,,232553.09,15469,,,15469,Other,150% of Medicare + 9.63% HCRA Surcharge,9406.61,,,9406.61,Other,Medicare IPPS methodology,26021,,"25,728 x DRG weight",26021,Other,base rate x DRG weight,23419,,"23,155 x DRG weight",23419,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,116277,50,,116277,Percent of Total Billed Charges,50% of Charges,29428,,"29,096 x DRG Weight",29428,Other,base rate x DRG weight,22719,,"22,463 x DRG Weight",22719,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,26727,,"26,426 x DRG Weight",26727,Other,base rate x DRG weight,39251,,"38,809 x DRG Weight",39251,Other,base rate x DRG weight,39251,,"38,809 x DRG Weight",39251,Other,base rate x DRG weight,26727,,"26,426 x DRG Weight",26727,Other,base rate x DRG weight,39251,,"38,809 x DRG Weight",39251,Other,base rate x DRG weight,35794,,"35,391 x DRG Weight",35794,Other,base rate x DRG weight,162787,70,,162787,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,25503,,"25,216 X DRG Weight",25503,Other,Base Weight X DRG Weight,22954,,"22,695 X DRG Weight",22954,Other,Base Weight X DRG Weight,25503,,"25,216 X DRG Weight",25503,Other,Base Rate x DRG Weight ,21677,,"21,433 x DRG Weight",21677,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,162787,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,MS-DRG,,,,,,,,inpatient,,,1868428.79,391380,,,391380,Other,150% of Medicare + 9.63% HCRA Surcharge,238000.73,,,238000.73,Other,Medicare IPPS methodology,678157,,"25,728 x DRG weight",678157,Other,base rate x DRG weight,610336,,"23,155 x DRG weight",610336,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,934214,50,,934214,Percent of Total Billed Charges,50% of Charges,766933,,"29,096 x DRG Weight",766933,Other,base rate x DRG weight,592095,,"22,463 x DRG Weight",592095,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,696555,,"26,426 x DRG Weight",696555,Other,base rate x DRG weight,1022955,,"38,809 x DRG Weight",1022955,Other,base rate x DRG weight,1022955,,"38,809 x DRG Weight",1022955,Other,base rate x DRG weight,696555,,"26,426 x DRG Weight",696555,Other,base rate x DRG weight,1022955,,"38,809 x DRG Weight",1022955,Other,base rate x DRG weight,932861,,"35,391 x DRG Weight",932861,Other,base rate x DRG weight,1307900,70,,1307900,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,664661,,"25,216 X DRG Weight",664661,Other,Base Weight X DRG Weight,598211,,"22,695 X DRG Weight",598211,Other,Base Weight X DRG Weight,664661,,"25,216 X DRG Weight",664661,Other,Base Rate x DRG Weight ,564946,,"21,433 x DRG Weight",564946,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,1307900,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,MS-DRG,,,,,,,,inpatient,,,699323.95,103091,,,103091,Other,150% of Medicare + 9.63% HCRA Surcharge,62690.5,,,62690.5,Other,Medicare IPPS methodology,178030,,"25,728 x DRG weight",178030,Other,base rate x DRG weight,160226,,"23,155 x DRG weight",160226,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,349662,50,,349662,Percent of Total Billed Charges,50% of Charges,201336,,"29,096 x DRG Weight",201336,Other,base rate x DRG weight,155437,,"22,463 x DRG Weight",155437,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,182860,,"26,426 x DRG Weight",182860,Other,base rate x DRG weight,268547,,"38,809 x DRG Weight",268547,Other,base rate x DRG weight,268547,,"38,809 x DRG Weight",268547,Other,base rate x DRG weight,182860,,"26,426 x DRG Weight",182860,Other,base rate x DRG weight,268547,,"38,809 x DRG Weight",268547,Other,base rate x DRG weight,244895,,"35,391 x DRG Weight",244895,Other,base rate x DRG weight,489527,70,,489527,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,174487,,"25,216 X DRG Weight",174487,Other,Base Weight X DRG Weight,157043,,"22,695 X DRG Weight",157043,Other,Base Weight X DRG Weight,174487,,"25,216 X DRG Weight",174487,Other,Base Rate x DRG Weight ,148310,,"21,433 x DRG Weight",148310,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,489527,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,MS-DRG,,,,,,,,inpatient,,,487625.04,48156,,,48156,Other,150% of Medicare + 9.63% HCRA Surcharge,29284.24,,,29284.24,Other,Medicare IPPS methodology,82728,,"25,728 x DRG weight",82728,Other,base rate x DRG weight,74455,,"23,155 x DRG weight",74455,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,243813,50,,243813,Percent of Total Billed Charges,50% of Charges,93558,,"29,096 x DRG Weight",93558,Other,base rate x DRG weight,72230,,"22,463 x DRG Weight",72230,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,84973,,"26,426 x DRG Weight",84973,Other,base rate x DRG weight,124790,,"38,809 x DRG Weight",124790,Other,base rate x DRG weight,124790,,"38,809 x DRG Weight",124790,Other,base rate x DRG weight,84973,,"26,426 x DRG Weight",84973,Other,base rate x DRG weight,124790,,"38,809 x DRG Weight",124790,Other,base rate x DRG weight,113800,,"35,391 x DRG Weight",113800,Other,base rate x DRG weight,341338,70,,341338,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,81082,,"25,216 X DRG Weight",81082,Other,Base Weight X DRG Weight,72976,,"22,695 X DRG Weight",72976,Other,Base Weight X DRG Weight,81082,,"25,216 X DRG Weight",81082,Other,Base Rate x DRG Weight ,68918,,"21,433 x DRG Weight",68918,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,341338,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,MS-DRG,,,,,,,,inpatient,,,250045.33,45435,,,45435,Other,150% of Medicare + 9.63% HCRA Surcharge,27629.35,,,27629.35,Other,Medicare IPPS methodology,78007,,"25,728 x DRG weight",78007,Other,base rate x DRG weight,70206,,"23,155 x DRG weight",70206,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,125023,50,,125023,Percent of Total Billed Charges,50% of Charges,88219,,"29,096 x DRG Weight",88219,Other,base rate x DRG weight,68108,,"22,463 x DRG Weight",68108,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,80124,,"26,426 x DRG Weight",80124,Other,base rate x DRG weight,117669,,"38,809 x DRG Weight",117669,Other,base rate x DRG weight,117669,,"38,809 x DRG Weight",117669,Other,base rate x DRG weight,80124,,"26,426 x DRG Weight",80124,Other,base rate x DRG weight,117669,,"38,809 x DRG Weight",117669,Other,base rate x DRG weight,107306,,"35,391 x DRG Weight",107306,Other,base rate x DRG weight,175032,70,,175032,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,76455,,"25,216 X DRG Weight",76455,Other,Base Weight X DRG Weight,68811,,"22,695 X DRG Weight",68811,Other,Base Weight X DRG Weight,76455,,"25,216 X DRG Weight",76455,Other,Base Rate x DRG Weight ,64985,,"21,433 x DRG Weight",64985,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,175032,
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,MS-DRG,,,,,,,,inpatient,,,402958.87,31502,,,31502,Other,150% of Medicare + 9.63% HCRA Surcharge,19156.49,,,19156.49,Other,Medicare IPPS methodology,53836,,"25,728 x DRG weight",53836,Other,base rate x DRG weight,48452,,"23,155 x DRG weight",48452,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,201479,50,,201479,Percent of Total Billed Charges,50% of Charges,60883,,"29,096 x DRG Weight",60883,Other,base rate x DRG weight,47004,,"22,463 x DRG Weight",47004,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,55296,,"26,426 x DRG Weight",55296,Other,base rate x DRG weight,81208,,"38,809 x DRG Weight",81208,Other,base rate x DRG weight,81208,,"38,809 x DRG Weight",81208,Other,base rate x DRG weight,55296,,"26,426 x DRG Weight",55296,Other,base rate x DRG weight,81208,,"38,809 x DRG Weight",81208,Other,base rate x DRG weight,74056,,"35,391 x DRG Weight",74056,Other,base rate x DRG weight,282071,70,,282071,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,52764,,"25,216 X DRG Weight",52764,Other,Base Weight X DRG Weight,47489,,"22,695 X DRG Weight",47489,Other,Base Weight X DRG Weight,52764,,"25,216 X DRG Weight",52764,Other,Base Rate x DRG Weight ,44849,,"21,433 x DRG Weight",44849,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,282071,
NON-EXTENSIVE BURNS,935,MS-DRG,,,,,,,,inpatient,,,270505.91,30740,,,30740,Other,150% of Medicare + 9.63% HCRA Surcharge,18692.94,,,18692.94,Other,Medicare IPPS methodology,52513,,"25,728 x DRG weight",52513,Other,base rate x DRG weight,47262,,"23,155 x DRG weight",47262,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,135253,50,,135253,Percent of Total Billed Charges,50% of Charges,59388,,"29,096 x DRG Weight",59388,Other,base rate x DRG weight,45849,,"22,463 x DRG Weight",45849,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,53938,,"26,426 x DRG Weight",53938,Other,base rate x DRG weight,79213,,"38,809 x DRG Weight",79213,Other,base rate x DRG weight,79213,,"38,809 x DRG Weight",79213,Other,base rate x DRG weight,53938,,"26,426 x DRG Weight",53938,Other,base rate x DRG weight,79213,,"38,809 x DRG Weight",79213,Other,base rate x DRG weight,72237,,"35,391 x DRG Weight",72237,Other,base rate x DRG weight,189354,70,,189354,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,51468,,"25,216 X DRG Weight",51468,Other,Base Weight X DRG Weight,46323,,"22,695 X DRG Weight",46323,Other,Base Weight X DRG Weight,51468,,"25,216 X DRG Weight",51468,Other,Base Rate x DRG Weight ,43747,,"21,433 x DRG Weight",43747,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,189354,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,,inpatient,,,254493.41,48154,,,48154,Other,150% of Medicare + 9.63% HCRA Surcharge,29282.44,,,29282.44,Other,Medicare IPPS methodology,82723,,"25,728 x DRG weight",82723,Other,base rate x DRG weight,74450,,"23,155 x DRG weight",74450,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,127247,50,,127247,Percent of Total Billed Charges,50% of Charges,93552,,"29,096 x DRG Weight",93552,Other,base rate x DRG weight,72225,,"22,463 x DRG Weight",72225,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,84968,,"26,426 x DRG Weight",84968,Other,base rate x DRG weight,124783,,"38,809 x DRG Weight",124783,Other,base rate x DRG weight,124783,,"38,809 x DRG Weight",124783,Other,base rate x DRG weight,84968,,"26,426 x DRG Weight",84968,Other,base rate x DRG weight,124783,,"38,809 x DRG Weight",124783,Other,base rate x DRG weight,113793,,"35,391 x DRG Weight",113793,Other,base rate x DRG weight,178145,70,,178145,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,81077,,"25,216 X DRG Weight",81077,Other,Base Weight X DRG Weight,72971,,"22,695 X DRG Weight",72971,Other,Base Weight X DRG Weight,81077,,"25,216 X DRG Weight",81077,Other,Base Rate x DRG Weight ,68914,,"21,433 x DRG Weight",68914,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,178145,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,,inpatient,,,250994.14,32601,,,32601,Other,150% of Medicare + 9.63% HCRA Surcharge,19824.76,,,19824.76,Other,Medicare IPPS methodology,55742,,"25,728 x DRG weight",55742,Other,base rate x DRG weight,50168,,"23,155 x DRG weight",50168,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,125497,50,,125497,Percent of Total Billed Charges,50% of Charges,63039,,"29,096 x DRG Weight",63039,Other,base rate x DRG weight,48668,,"22,463 x DRG Weight",48668,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,57255,,"26,426 x DRG Weight",57255,Other,base rate x DRG weight,84084,,"38,809 x DRG Weight",84084,Other,base rate x DRG weight,84084,,"38,809 x DRG Weight",84084,Other,base rate x DRG weight,57255,,"26,426 x DRG Weight",57255,Other,base rate x DRG weight,84084,,"38,809 x DRG Weight",84084,Other,base rate x DRG weight,76678,,"35,391 x DRG Weight",76678,Other,base rate x DRG weight,175696,70,,175696,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,54633,,"25,216 X DRG Weight",54633,Other,Base Weight X DRG Weight,49171,,"22,695 X DRG Weight",49171,Other,Base Weight X DRG Weight,54633,,"25,216 X DRG Weight",54633,Other,Base Rate x DRG Weight ,46437,,"21,433 x DRG Weight",46437,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,175696,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,,inpatient,,,117589.06,27994,,,27994,Other,150% of Medicare + 9.63% HCRA Surcharge,17023.62,,,17023.62,Other,Medicare IPPS methodology,47751,,"25,728 x DRG weight",47751,Other,base rate x DRG weight,42976,,"23,155 x DRG weight",42976,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,58795,50,,58795,Percent of Total Billed Charges,50% of Charges,54002,,"29,096 x DRG Weight",54002,Other,base rate x DRG weight,41691,,"22,463 x DRG Weight",41691,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,49047,,"26,426 x DRG Weight",49047,Other,base rate x DRG weight,72030,,"38,809 x DRG Weight",72030,Other,base rate x DRG weight,72030,,"38,809 x DRG Weight",72030,Other,base rate x DRG weight,49047,,"26,426 x DRG Weight",49047,Other,base rate x DRG weight,72030,,"38,809 x DRG Weight",72030,Other,base rate x DRG weight,65686,,"35,391 x DRG Weight",65686,Other,base rate x DRG weight,82312,70,,82312,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,46801,,"25,216 X DRG Weight",46801,Other,Base Weight X DRG Weight,42122,,"22,695 X DRG Weight",42122,Other,Base Weight X DRG Weight,46801,,"25,216 X DRG Weight",46801,Other,Base Rate x DRG Weight ,39780,,"21,433 x DRG Weight",39780,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,82312,
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,,inpatient,,,315077.54,19031,,,19031,Other,150% of Medicare + 9.63% HCRA Surcharge,11572.85,,,11572.85,Other,Medicare IPPS methodology,32201,,"25,728 x DRG weight",32201,Other,base rate x DRG weight,28981,,"23,155 x DRG weight",28981,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,157539,50,,157539,Percent of Total Billed Charges,50% of Charges,36417,,"29,096 x DRG Weight",36417,Other,base rate x DRG weight,28115,,"22,463 x DRG Weight",28115,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,33075,,"26,426 x DRG Weight",33075,Other,base rate x DRG weight,48573,,"38,809 x DRG Weight",48573,Other,base rate x DRG weight,48573,,"38,809 x DRG Weight",48573,Other,base rate x DRG weight,33075,,"26,426 x DRG Weight",33075,Other,base rate x DRG weight,48573,,"38,809 x DRG Weight",48573,Other,base rate x DRG weight,44295,,"35,391 x DRG Weight",44295,Other,base rate x DRG weight,220554,70,,220554,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,31560,,"25,216 X DRG Weight",31560,Other,Base Weight X DRG Weight,28405,,"22,695 X DRG Weight",28405,Other,Base Weight X DRG Weight,31560,,"25,216 X DRG Weight",31560,Other,Base Rate x DRG Weight ,26826,,"21,433 x DRG Weight",26826,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,220554,
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,,inpatient,,,107235.24,12348,,,12348,Other,150% of Medicare + 9.63% HCRA Surcharge,7509.12,,,7509.12,Other,Medicare IPPS methodology,20608,,"25,728 x DRG weight",20608,Other,base rate x DRG weight,18547,,"23,155 x DRG weight",18547,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,53618,50,,53618,Percent of Total Billed Charges,50% of Charges,23306,,"29,096 x DRG Weight",23306,Other,base rate x DRG weight,17993,,"22,463 x DRG Weight",17993,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,21167,,"26,426 x DRG Weight",21167,Other,base rate x DRG weight,31086,,"38,809 x DRG Weight",31086,Other,base rate x DRG weight,31086,,"38,809 x DRG Weight",31086,Other,base rate x DRG weight,21167,,"26,426 x DRG Weight",21167,Other,base rate x DRG weight,31086,,"38,809 x DRG Weight",31086,Other,base rate x DRG weight,28348,,"35,391 x DRG Weight",28348,Other,base rate x DRG weight,75065,70,,75065,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,20198,,"25,216 X DRG Weight",20198,Other,Base Weight X DRG Weight,18179,,"22,695 X DRG Weight",18179,Other,Base Weight X DRG Weight,20198,,"25,216 X DRG Weight",20198,Other,Base Rate x DRG Weight ,17168,,"21,433 x DRG Weight",17168,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,75065,
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,,inpatient,,,152010.9,16379,,,16379,Other,150% of Medicare + 9.63% HCRA Surcharge,9960.35,,,9960.35,Other,Medicare IPPS methodology,27601,,"25,728 x DRG weight",27601,Other,base rate x DRG weight,24841,,"23,155 x DRG weight",24841,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,76005,50,,76005,Percent of Total Billed Charges,50% of Charges,31214,,"29,096 x DRG Weight",31214,Other,base rate x DRG weight,24098,,"22,463 x DRG Weight",24098,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28350,,"26,426 x DRG Weight",28350,Other,base rate x DRG weight,41634,,"38,809 x DRG Weight",41634,Other,base rate x DRG weight,41634,,"38,809 x DRG Weight",41634,Other,base rate x DRG weight,28350,,"26,426 x DRG Weight",28350,Other,base rate x DRG weight,41634,,"38,809 x DRG Weight",41634,Other,base rate x DRG weight,37967,,"35,391 x DRG Weight",37967,Other,base rate x DRG weight,106408,70,,106408,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27052,,"25,216 X DRG Weight",27052,Other,Base Weight X DRG Weight,24347,,"22,695 X DRG Weight",24347,Other,Base Weight X DRG Weight,27052,,"25,216 X DRG Weight",27052,Other,Base Rate x DRG Weight ,22993,,"21,433 x DRG Weight",22993,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,106408,
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,,inpatient,,,91528.2,9940,,,9940,Other,150% of Medicare + 9.63% HCRA Surcharge,6044.52,,,6044.52,Other,Medicare IPPS methodology,16430,,"25,728 x DRG weight",16430,Other,base rate x DRG weight,14787,,"23,155 x DRG weight",14787,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,45764,50,,45764,Percent of Total Billed Charges,50% of Charges,18581,,"29,096 x DRG Weight",18581,Other,base rate x DRG weight,14345,,"22,463 x DRG Weight",14345,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,16876,,"26,426 x DRG Weight",16876,Other,base rate x DRG weight,24783,,"38,809 x DRG Weight",24783,Other,base rate x DRG weight,24783,,"38,809 x DRG Weight",24783,Other,base rate x DRG weight,16876,,"26,426 x DRG Weight",16876,Other,base rate x DRG weight,24783,,"38,809 x DRG Weight",24783,Other,base rate x DRG weight,22601,,"35,391 x DRG Weight",22601,Other,base rate x DRG weight,64070,70,,64070,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,16103,,"25,216 X DRG Weight",16103,Other,Base Weight X DRG Weight,14493,,"22,695 X DRG Weight",14493,Other,Base Weight X DRG Weight,16103,,"25,216 X DRG Weight",16103,Other,Base Rate x DRG Weight ,13687,,"21,433 x DRG Weight",13687,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,64070,
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,,inpatient,,,103021.31,9219,,,9219,Other,150% of Medicare + 9.63% HCRA Surcharge,5606.22,,,5606.22,Other,Medicare IPPS methodology,15180,,"25,728 x DRG weight",15180,Other,base rate x DRG weight,13661,,"23,155 x DRG weight",13661,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,51511,50,,51511,Percent of Total Billed Charges,50% of Charges,17167,,"29,096 x DRG Weight",17167,Other,base rate x DRG weight,13253,,"22,463 x DRG Weight",13253,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,15591,,"26,426 x DRG Weight",15591,Other,base rate x DRG weight,22897,,"38,809 x DRG Weight",22897,Other,base rate x DRG weight,22897,,"38,809 x DRG Weight",22897,Other,base rate x DRG weight,15591,,"26,426 x DRG Weight",15591,Other,base rate x DRG weight,22897,,"38,809 x DRG Weight",22897,Other,base rate x DRG weight,20881,,"35,391 x DRG Weight",20881,Other,base rate x DRG weight,72115,70,,72115,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,14877,,"25,216 X DRG Weight",14877,Other,Base Weight X DRG Weight,13390,,"22,695 X DRG Weight",13390,Other,Base Weight X DRG Weight,14877,,"25,216 X DRG Weight",14877,Other,Base Rate x DRG Weight ,12645,,"21,433 x DRG Weight",12645,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,72115,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,MS-DRG,,,,,,,,inpatient,,,666307.7,90790,,,90790,Other,150% of Medicare + 9.63% HCRA Surcharge,55209.67,,,55209.67,Other,Medicare IPPS methodology,156689,,"25,728 x DRG weight",156689,Other,base rate x DRG weight,141019,,"23,155 x DRG weight",141019,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,333154,50,,333154,Percent of Total Billed Charges,50% of Charges,177200,,"29,096 x DRG Weight",177200,Other,base rate x DRG weight,136804,,"22,463 x DRG Weight",136804,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,160940,,"26,426 x DRG Weight",160940,Other,base rate x DRG weight,236355,,"38,809 x DRG Weight",236355,Other,base rate x DRG weight,236355,,"38,809 x DRG Weight",236355,Other,base rate x DRG weight,160940,,"26,426 x DRG Weight",160940,Other,base rate x DRG weight,236355,,"38,809 x DRG Weight",236355,Other,base rate x DRG weight,215538,,"35,391 x DRG Weight",215538,Other,base rate x DRG weight,466415,70,,466415,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,153570,,"25,216 X DRG Weight",153570,Other,Base Weight X DRG Weight,138217,,"22,695 X DRG Weight",138217,Other,Base Weight X DRG Weight,153570,,"25,216 X DRG Weight",153570,Other,Base Rate x DRG Weight ,130531,,"21,433 x DRG Weight",130531,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,466415,
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,,inpatient,,,651853.98,57985,,,57985,Other,150% of Medicare + 9.63% HCRA Surcharge,35260.79,,,35260.79,Other,Medicare IPPS methodology,99778,,"25,728 x DRG weight",99778,Other,base rate x DRG weight,89800,,"23,155 x DRG weight",89800,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,325927,50,,325927,Percent of Total Billed Charges,50% of Charges,112840,,"29,096 x DRG Weight",112840,Other,base rate x DRG weight,87116,,"22,463 x DRG Weight",87116,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,102485,,"26,426 x DRG Weight",102485,Other,base rate x DRG weight,150509,,"38,809 x DRG Weight",150509,Other,base rate x DRG weight,150509,,"38,809 x DRG Weight",150509,Other,base rate x DRG weight,102485,,"26,426 x DRG Weight",102485,Other,base rate x DRG weight,150509,,"38,809 x DRG Weight",150509,Other,base rate x DRG weight,137253,,"35,391 x DRG Weight",137253,Other,base rate x DRG weight,456298,70,,456298,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,97793,,"25,216 X DRG Weight",97793,Other,Base Weight X DRG Weight,88016,,"22,695 X DRG Weight",88016,Other,Base Weight X DRG Weight,97793,,"25,216 X DRG Weight",97793,Other,Base Rate x DRG Weight ,83121,,"21,433 x DRG Weight",83121,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,456298,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,MS-DRG,,,,,,,,inpatient,,,644915.06,107730,,,107730,Other,150% of Medicare + 9.63% HCRA Surcharge,65511.48,,,65511.48,Other,Medicare IPPS methodology,186078,,"25,728 x DRG weight",186078,Other,base rate x DRG weight,167469,,"23,155 x DRG weight",167469,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,322458,50,,322458,Percent of Total Billed Charges,50% of Charges,210437,,"29,096 x DRG Weight",210437,Other,base rate x DRG weight,162464,,"22,463 x DRG Weight",162464,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,191126,,"26,426 x DRG Weight",191126,Other,base rate x DRG weight,280686,,"38,809 x DRG Weight",280686,Other,base rate x DRG weight,280686,,"38,809 x DRG Weight",280686,Other,base rate x DRG weight,191126,,"26,426 x DRG Weight",191126,Other,base rate x DRG weight,280686,,"38,809 x DRG Weight",280686,Other,base rate x DRG weight,255965,,"35,391 x DRG Weight",255965,Other,base rate x DRG weight,451441,70,,451441,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,182375,,"25,216 X DRG Weight",182375,Other,Base Weight X DRG Weight,164142,,"22,695 X DRG Weight",164142,Other,Base Weight X DRG Weight,182375,,"25,216 X DRG Weight",182375,Other,Base Rate x DRG Weight ,155014,,"21,433 x DRG Weight",155014,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,451441,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,MS-DRG,,,,,,,,inpatient,,,450638.53,60455,,,60455,Other,150% of Medicare + 9.63% HCRA Surcharge,36763.27,,,36763.27,Other,Medicare IPPS methodology,104065,,"25,728 x DRG weight",104065,Other,base rate x DRG weight,93657,,"23,155 x DRG weight",93657,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,225319,50,,225319,Percent of Total Billed Charges,50% of Charges,117688,,"29,096 x DRG Weight",117688,Other,base rate x DRG weight,90858,,"22,463 x DRG Weight",90858,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,106888,,"26,426 x DRG Weight",106888,Other,base rate x DRG weight,156975,,"38,809 x DRG Weight",156975,Other,base rate x DRG weight,156975,,"38,809 x DRG Weight",156975,Other,base rate x DRG weight,106888,,"26,426 x DRG Weight",106888,Other,base rate x DRG weight,156975,,"38,809 x DRG Weight",156975,Other,base rate x DRG weight,143150,,"35,391 x DRG Weight",143150,Other,base rate x DRG weight,315447,70,,315447,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,101994,,"25,216 X DRG Weight",101994,Other,Base Weight X DRG Weight,91797,,"22,695 X DRG Weight",91797,Other,Base Weight X DRG Weight,101994,,"25,216 X DRG Weight",101994,Other,Base Rate x DRG Weight ,86692,,"21,433 x DRG Weight",86692,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,315447,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,MS-DRG,,,,,,,,inpatient,,,429728.36,38026,,,38026,Other,150% of Medicare + 9.63% HCRA Surcharge,23123.72,,,23123.72,Other,Medicare IPPS methodology,65154,,"25,728 x DRG weight",65154,Other,base rate x DRG weight,58638,,"23,155 x DRG weight",58638,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,214864,50,,214864,Percent of Total Billed Charges,50% of Charges,73683,,"29,096 x DRG Weight",73683,Other,base rate x DRG weight,56885,,"22,463 x DRG Weight",56885,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,66921,,"26,426 x DRG Weight",66921,Other,base rate x DRG weight,98280,,"38,809 x DRG Weight",98280,Other,base rate x DRG weight,98280,,"38,809 x DRG Weight",98280,Other,base rate x DRG weight,66921,,"26,426 x DRG Weight",66921,Other,base rate x DRG weight,98280,,"38,809 x DRG Weight",98280,Other,base rate x DRG weight,89624,,"35,391 x DRG Weight",89624,Other,base rate x DRG weight,300810,70,,300810,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,63857,,"25,216 X DRG Weight",63857,Other,Base Weight X DRG Weight,57473,,"22,695 X DRG Weight",57473,Other,Base Weight X DRG Weight,63857,,"25,216 X DRG Weight",63857,Other,Base Rate x DRG Weight ,54277,,"21,433 x DRG Weight",54277,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,300810,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,MS-DRG,,,,,,,,inpatient,,,288738.68,41020,,,41020,Other,150% of Medicare + 9.63% HCRA Surcharge,24944.55,,,24944.55,Other,Medicare IPPS methodology,70348,,"25,728 x DRG weight",70348,Other,base rate x DRG weight,63313,,"23,155 x DRG weight",63313,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,144369,50,,144369,Percent of Total Billed Charges,50% of Charges,79557,,"29,096 x DRG Weight",79557,Other,base rate x DRG weight,61421,,"22,463 x DRG Weight",61421,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,72257,,"26,426 x DRG Weight",72257,Other,base rate x DRG weight,106115,,"38,809 x DRG Weight",106115,Other,base rate x DRG weight,106115,,"38,809 x DRG Weight",106115,Other,base rate x DRG weight,72257,,"26,426 x DRG Weight",72257,Other,base rate x DRG weight,106115,,"38,809 x DRG Weight",106115,Other,base rate x DRG weight,96770,,"35,391 x DRG Weight",96770,Other,base rate x DRG weight,202117,70,,202117,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,68948,,"25,216 X DRG Weight",68948,Other,Base Weight X DRG Weight,62055,,"22,695 X DRG Weight",62055,Other,Base Weight X DRG Weight,68948,,"25,216 X DRG Weight",68948,Other,Base Rate x DRG Weight ,58604,,"21,433 x DRG Weight",58604,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,202117,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,,inpatient,,,177696.36,22730,,,22730,Other,150% of Medicare + 9.63% HCRA Surcharge,13822.06,,,13822.06,Other,Medicare IPPS methodology,38618,,"25,728 x DRG weight",38618,Other,base rate x DRG weight,34756,,"23,155 x DRG weight",34756,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,88848,50,,88848,Percent of Total Billed Charges,50% of Charges,43673,,"29,096 x DRG Weight",43673,Other,base rate x DRG weight,33717,,"22,463 x DRG Weight",33717,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,39665,,"26,426 x DRG Weight",39665,Other,base rate x DRG weight,58252,,"38,809 x DRG Weight",58252,Other,base rate x DRG weight,58252,,"38,809 x DRG Weight",58252,Other,base rate x DRG weight,39665,,"26,426 x DRG Weight",39665,Other,base rate x DRG weight,58252,,"38,809 x DRG Weight",58252,Other,base rate x DRG weight,53122,,"35,391 x DRG Weight",53122,Other,base rate x DRG weight,124387,70,,124387,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,37849,,"25,216 X DRG Weight",37849,Other,Base Weight X DRG Weight,34065,,"22,695 X DRG Weight",34065,Other,Base Weight X DRG Weight,37849,,"25,216 X DRG Weight",37849,Other,Base Rate x DRG Weight ,32171,,"21,433 x DRG Weight",32171,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,124387,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,MS-DRG,,,,,,,,inpatient,,,136727.25,14646,,,14646,Other,150% of Medicare + 9.63% HCRA Surcharge,8906.09,,,8906.09,Other,Medicare IPPS methodology,24593,,"25,728 x DRG weight",24593,Other,base rate x DRG weight,22134,,"23,155 x DRG weight",22134,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,68364,50,,68364,Percent of Total Billed Charges,50% of Charges,27813,,"29,096 x DRG Weight",27813,Other,base rate x DRG weight,21472,,"22,463 x DRG Weight",21472,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,25261,,"26,426 x DRG Weight",25261,Other,base rate x DRG weight,37098,,"38,809 x DRG Weight",37098,Other,base rate x DRG weight,37098,,"38,809 x DRG Weight",37098,Other,base rate x DRG weight,25261,,"26,426 x DRG Weight",25261,Other,base rate x DRG weight,37098,,"38,809 x DRG Weight",37098,Other,base rate x DRG weight,33830,,"35,391 x DRG Weight",33830,Other,base rate x DRG weight,95709,70,,95709,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,24104,,"25,216 X DRG Weight",24104,Other,Base Weight X DRG Weight,21694,,"22,695 X DRG Weight",21694,Other,Base Weight X DRG Weight,24104,,"25,216 X DRG Weight",24104,Other,Base Rate x DRG Weight ,20488,,"21,433 x DRG Weight",20488,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,95709,
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,,inpatient,,,2067235,102393,,,102393,Other,150% of Medicare + 9.63% HCRA Surcharge,62265.73,,,62265.73,Other,Medicare IPPS methodology,176818,,"25,728 x DRG weight",176818,Other,base rate x DRG weight,159135,,"23,155 x DRG weight",159135,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,1033618,50,,1033618,Percent of Total Billed Charges,50% of Charges,199965,,"29,096 x DRG Weight",199965,Other,base rate x DRG weight,154379,,"22,463 x DRG Weight",154379,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,181615,,"26,426 x DRG Weight",181615,Other,base rate x DRG weight,266719,,"38,809 x DRG Weight",266719,Other,base rate x DRG weight,266719,,"38,809 x DRG Weight",266719,Other,base rate x DRG weight,181615,,"26,426 x DRG Weight",181615,Other,base rate x DRG weight,266719,,"38,809 x DRG Weight",266719,Other,base rate x DRG weight,243228,,"35,391 x DRG Weight",243228,Other,base rate x DRG weight,1447065,70,,1447065,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,173299,,"25,216 X DRG Weight",173299,Other,Base Weight X DRG Weight,155974,,"22,695 X DRG Weight",155974,Other,Base Weight X DRG Weight,173299,,"25,216 X DRG Weight",173299,Other,Base Rate x DRG Weight ,147300,,"21,433 x DRG Weight",147300,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,1447065,
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,MS-DRG,,,,,,,,inpatient,,,2067235,41692,,,41692,Other,150% of Medicare + 9.63% HCRA Surcharge,25353.09,,,25353.09,Other,Medicare IPPS methodology,71514,,"25,728 x DRG weight",71514,Other,base rate x DRG weight,64362,,"23,155 x DRG weight",64362,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,1033618,50,,1033618,Percent of Total Billed Charges,50% of Charges,80875,,"29,096 x DRG Weight",80875,Other,base rate x DRG weight,62438,,"22,463 x DRG Weight",62438,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,73454,,"26,426 x DRG Weight",73454,Other,base rate x DRG weight,107873,,"38,809 x DRG Weight",107873,Other,base rate x DRG weight,107873,,"38,809 x DRG Weight",107873,Other,base rate x DRG weight,73454,,"26,426 x DRG Weight",73454,Other,base rate x DRG weight,107873,,"38,809 x DRG Weight",107873,Other,base rate x DRG weight,98373,,"35,391 x DRG Weight",98373,Other,base rate x DRG weight,1447065,70,,1447065,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,70090,,"25,216 X DRG Weight",70090,Other,Base Weight X DRG Weight,63083,,"22,695 X DRG Weight",63083,Other,Base Weight X DRG Weight,70090,,"25,216 X DRG Weight",70090,Other,Base Rate x DRG Weight ,59575,,"21,433 x DRG Weight",59575,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,1447065,
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,,inpatient,,,720980.75,43722,,,43722,Other,150% of Medicare + 9.63% HCRA Surcharge,26587.72,,,26587.72,Other,Medicare IPPS methodology,75036,,"25,728 x DRG weight",75036,Other,base rate x DRG weight,67532,,"23,155 x DRG weight",67532,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,360490,50,,360490,Percent of Total Billed Charges,50% of Charges,84858,,"29,096 x DRG Weight",84858,Other,base rate x DRG weight,65513,,"22,463 x DRG Weight",65513,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,77071,,"26,426 x DRG Weight",77071,Other,base rate x DRG weight,113186,,"38,809 x DRG Weight",113186,Other,base rate x DRG weight,113186,,"38,809 x DRG Weight",113186,Other,base rate x DRG weight,77071,,"26,426 x DRG Weight",77071,Other,base rate x DRG weight,113186,,"38,809 x DRG Weight",113186,Other,base rate x DRG weight,103218,,"35,391 x DRG Weight",103218,Other,base rate x DRG weight,504687,70,,504687,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,73542,,"25,216 X DRG Weight",73542,Other,Base Weight X DRG Weight,66190,,"22,695 X DRG Weight",66190,Other,Base Weight X DRG Weight,73542,,"25,216 X DRG Weight",73542,Other,Base Rate x DRG Weight ,62509,,"21,433 x DRG Weight",62509,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,504687,
HIV WITH MAJOR RELATED CONDITION WITH CC,975,MS-DRG,,,,,,,,inpatient,,,197222.56,20688,,,20688,Other,150% of Medicare + 9.63% HCRA Surcharge,12580.21,,,12580.21,Other,Medicare IPPS methodology,35075,,"25,728 x DRG weight",35075,Other,base rate x DRG weight,31567,,"23,155 x DRG weight",31567,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,98611,50,,98611,Percent of Total Billed Charges,50% of Charges,39667,,"29,096 x DRG Weight",39667,Other,base rate x DRG weight,30624,,"22,463 x DRG Weight",30624,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,36027,,"26,426 x DRG Weight",36027,Other,base rate x DRG weight,52908,,"38,809 x DRG Weight",52908,Other,base rate x DRG weight,52908,,"38,809 x DRG Weight",52908,Other,base rate x DRG weight,36027,,"26,426 x DRG Weight",36027,Other,base rate x DRG weight,52908,,"38,809 x DRG Weight",52908,Other,base rate x DRG weight,48249,,"35,391 x DRG Weight",48249,Other,base rate x DRG weight,138056,70,,138056,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,34377,,"25,216 X DRG Weight",34377,Other,Base Weight X DRG Weight,30940,,"22,695 X DRG Weight",30940,Other,Base Weight X DRG Weight,34377,,"25,216 X DRG Weight",34377,Other,Base Rate x DRG Weight ,29220,,"21,433 x DRG Weight",29220,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,138056,
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,MS-DRG,,,,,,,,inpatient,,,122280.7,13005,,,13005,Other,150% of Medicare + 9.63% HCRA Surcharge,7908.64,,,7908.64,Other,Medicare IPPS methodology,21748,,"25,728 x DRG weight",21748,Other,base rate x DRG weight,19573,,"23,155 x DRG weight",19573,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,61140,50,,61140,Percent of Total Billed Charges,50% of Charges,24595,,"29,096 x DRG Weight",24595,Other,base rate x DRG weight,18988,,"22,463 x DRG Weight",18988,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,22338,,"26,426 x DRG Weight",22338,Other,base rate x DRG weight,32805,,"38,809 x DRG Weight",32805,Other,base rate x DRG weight,32805,,"38,809 x DRG Weight",32805,Other,base rate x DRG weight,22338,,"26,426 x DRG Weight",22338,Other,base rate x DRG weight,32805,,"38,809 x DRG Weight",32805,Other,base rate x DRG weight,29916,,"35,391 x DRG Weight",29916,Other,base rate x DRG weight,85596,70,,85596,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,21315,,"25,216 X DRG Weight",21315,Other,Base Weight X DRG Weight,19184,,"22,695 X DRG Weight",19184,Other,Base Weight X DRG Weight,21315,,"25,216 X DRG Weight",21315,Other,Base Rate x DRG Weight ,18117,,"21,433 x DRG Weight",18117,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,85596,
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,,inpatient,,,338221.04,21471,,,21471,Other,150% of Medicare + 9.63% HCRA Surcharge,13056.39,,,13056.39,Other,Medicare IPPS methodology,36433,,"25,728 x DRG weight",36433,Other,base rate x DRG weight,32790,,"23,155 x DRG weight",32790,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,169111,50,,169111,Percent of Total Billed Charges,50% of Charges,41203,,"29,096 x DRG Weight",41203,Other,base rate x DRG weight,31810,,"22,463 x DRG Weight",31810,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,37422,,"26,426 x DRG Weight",37422,Other,base rate x DRG weight,54957,,"38,809 x DRG Weight",54957,Other,base rate x DRG weight,54957,,"38,809 x DRG Weight",54957,Other,base rate x DRG weight,37422,,"26,426 x DRG Weight",37422,Other,base rate x DRG weight,54957,,"38,809 x DRG Weight",54957,Other,base rate x DRG weight,50117,,"35,391 x DRG Weight",50117,Other,base rate x DRG weight,236755,70,,236755,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,35708,,"25,216 X DRG Weight",35708,Other,Base Weight X DRG Weight,32138,,"22,695 X DRG Weight",32138,Other,Base Weight X DRG Weight,35708,,"25,216 X DRG Weight",35708,Other,Base Rate x DRG Weight ,30351,,"21,433 x DRG Weight",30351,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,236755,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,,inpatient,,,796330.3,70771,,,70771,Other,150% of Medicare + 9.63% HCRA Surcharge,43036.52,,,43036.52,Other,Medicare IPPS methodology,121961,,"25,728 x DRG weight",121961,Other,base rate x DRG weight,109764,,"23,155 x DRG weight",109764,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,398165,50,,398165,Percent of Total Billed Charges,50% of Charges,137927,,"29,096 x DRG Weight",137927,Other,base rate x DRG weight,106484,,"22,463 x DRG Weight",106484,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,125270,,"26,426 x DRG Weight",125270,Other,base rate x DRG weight,183970,,"38,809 x DRG Weight",183970,Other,base rate x DRG weight,183970,,"38,809 x DRG Weight",183970,Other,base rate x DRG weight,125270,,"26,426 x DRG Weight",125270,Other,base rate x DRG weight,183970,,"38,809 x DRG Weight",183970,Other,base rate x DRG weight,167767,,"35,391 x DRG Weight",167767,Other,base rate x DRG weight,557431,70,,557431,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,119534,,"25,216 X DRG Weight",119534,Other,Base Weight X DRG Weight,107583,,"22,695 X DRG Weight",107583,Other,Base Weight X DRG Weight,119534,,"25,216 X DRG Weight",119534,Other,Base Rate x DRG Weight ,101601,,"21,433 x DRG Weight",101601,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,557431,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,,inpatient,,,273227.72,37338,,,37338,Other,150% of Medicare + 9.63% HCRA Surcharge,22705.26,,,22705.26,Other,Medicare IPPS methodology,63960,,"25,728 x DRG weight",63960,Other,base rate x DRG weight,57563,,"23,155 x DRG weight",57563,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,136614,50,,136614,Percent of Total Billed Charges,50% of Charges,72333,,"29,096 x DRG Weight",72333,Other,base rate x DRG weight,55843,,"22,463 x DRG Weight",55843,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,65695,,"26,426 x DRG Weight",65695,Other,base rate x DRG weight,96479,,"38,809 x DRG Weight",96479,Other,base rate x DRG weight,96479,,"38,809 x DRG Weight",96479,Other,base rate x DRG weight,65695,,"26,426 x DRG Weight",65695,Other,base rate x DRG weight,96479,,"38,809 x DRG Weight",96479,Other,base rate x DRG weight,87982,,"35,391 x DRG Weight",87982,Other,base rate x DRG weight,191259,70,,191259,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,62687,,"25,216 X DRG Weight",62687,Other,Base Weight X DRG Weight,56420,,"22,695 X DRG Weight",56420,Other,Base Weight X DRG Weight,62687,,"25,216 X DRG Weight",62687,Other,Base Rate x DRG Weight ,53282,,"21,433 x DRG Weight",53282,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,191259,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,,inpatient,,,111288.85,24720,,,24720,Other,150% of Medicare + 9.63% HCRA Surcharge,15032.34,,,15032.34,Other,Medicare IPPS methodology,42070,,"25,728 x DRG weight",42070,Other,base rate x DRG weight,37863,,"23,155 x DRG weight",37863,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,55644,50,,55644,Percent of Total Billed Charges,50% of Charges,47578,,"29,096 x DRG Weight",47578,Other,base rate x DRG weight,36731,,"22,463 x DRG Weight",36731,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,43212,,"26,426 x DRG Weight",43212,Other,base rate x DRG weight,63460,,"38,809 x DRG Weight",63460,Other,base rate x DRG weight,63460,,"38,809 x DRG Weight",63460,Other,base rate x DRG weight,43212,,"26,426 x DRG Weight",43212,Other,base rate x DRG weight,63460,,"38,809 x DRG Weight",63460,Other,base rate x DRG weight,57871,,"35,391 x DRG Weight",57871,Other,base rate x DRG weight,77902,70,,77902,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,41233,,"25,216 X DRG Weight",41233,Other,Base Weight X DRG Weight,37111,,"22,695 X DRG Weight",37111,Other,Base Weight X DRG Weight,41233,,"25,216 X DRG Weight",41233,Other,Base Rate x DRG Weight ,35047,,"21,433 x DRG Weight",35047,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,77902,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,,inpatient,,,493854.01,50547,,,50547,Other,150% of Medicare + 9.63% HCRA Surcharge,30738.02,,,30738.02,Other,Medicare IPPS methodology,86876,,"25,728 x DRG weight",86876,Other,base rate x DRG weight,78187,,"23,155 x DRG weight",78187,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,246927,50,,246927,Percent of Total Billed Charges,50% of Charges,98248,,"29,096 x DRG Weight",98248,Other,base rate x DRG weight,75851,,"22,463 x DRG Weight",75851,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,89233,,"26,426 x DRG Weight",89233,Other,base rate x DRG weight,131046,,"38,809 x DRG Weight",131046,Other,base rate x DRG weight,131046,,"38,809 x DRG Weight",131046,Other,base rate x DRG weight,89233,,"26,426 x DRG Weight",89233,Other,base rate x DRG weight,131046,,"38,809 x DRG Weight",131046,Other,base rate x DRG weight,119505,,"35,391 x DRG Weight",119505,Other,base rate x DRG weight,345698,70,,345698,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,85147,,"25,216 X DRG Weight",85147,Other,Base Weight X DRG Weight,76634,,"22,695 X DRG Weight",76634,Other,Base Weight X DRG Weight,85147,,"25,216 X DRG Weight",85147,Other,Base Rate x DRG Weight ,72373,,"21,433 x DRG Weight",72373,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,345698,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,,inpatient,,,272581.15,25636,,,25636,Other,150% of Medicare + 9.63% HCRA Surcharge,15589.68,,,15589.68,Other,Medicare IPPS methodology,43660,,"25,728 x DRG weight",43660,Other,base rate x DRG weight,39294,,"23,155 x DRG weight",39294,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,136291,50,,136291,Percent of Total Billed Charges,50% of Charges,49376,,"29,096 x DRG Weight",49376,Other,base rate x DRG weight,38120,,"22,463 x DRG Weight",38120,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,44845,,"26,426 x DRG Weight",44845,Other,base rate x DRG weight,65859,,"38,809 x DRG Weight",65859,Other,base rate x DRG weight,65859,,"38,809 x DRG Weight",65859,Other,base rate x DRG weight,44845,,"26,426 x DRG Weight",44845,Other,base rate x DRG weight,65859,,"38,809 x DRG Weight",65859,Other,base rate x DRG weight,60059,,"35,391 x DRG Weight",60059,Other,base rate x DRG weight,190807,70,,190807,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,42792,,"25,216 X DRG Weight",42792,Other,Base Weight X DRG Weight,38513,,"22,695 X DRG Weight",38513,Other,Base Weight X DRG Weight,42792,,"25,216 X DRG Weight",42792,Other,Base Rate x DRG Weight ,36372,,"21,433 x DRG Weight",36372,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,190807,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,,inpatient,,,110395.47,16491,,,16491,Other,150% of Medicare + 9.63% HCRA Surcharge,10027.98,,,10027.98,Other,Medicare IPPS methodology,27794,,"25,728 x DRG weight",27794,Other,base rate x DRG weight,25014,,"23,155 x DRG weight",25014,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,55198,50,,55198,Percent of Total Billed Charges,50% of Charges,31432,,"29,096 x DRG Weight",31432,Other,base rate x DRG weight,24267,,"22,463 x DRG Weight",24267,Other,base rate x DRG weight,0.01,,,0.01,Other,See APR-DRG information,28548,,"26,426 x DRG Weight",28548,Other,base rate x DRG weight,41925,,"38,809 x DRG Weight",41925,Other,base rate x DRG weight,41925,,"38,809 x DRG Weight",41925,Other,base rate x DRG weight,28548,,"26,426 x DRG Weight",28548,Other,base rate x DRG weight,41925,,"38,809 x DRG Weight",41925,Other,base rate x DRG weight,38233,,"35,391 x DRG Weight",38233,Other,base rate x DRG weight,77277,70,,77277,Percent of Total Billed Charges,70% of charges,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,27241,,"25,216 X DRG Weight",27241,Other,Base Weight X DRG Weight,24517,,"22,695 X DRG Weight",24517,Other,Base Weight X DRG Weight,27241,,"25,216 X DRG Weight",27241,Other,Base Rate x DRG Weight ,23154,,"21,433 x DRG Weight",23154,Other,Base Rate x DRG Weight ,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,,,0.01,Other,See APR-DRG information,0.01,77277,
Tracheostomy w MV 96+ hours w extensive procedure or ECMO,004-1,APR-DRG,,,,,,,,inpatient,,,578945.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,324407,,"45,128 x DRG weight",324407,Other,base rate x DRG weight,291965,,"40,615 x DRG weight",291965,Other,base rate x DRG weight,275748,,"38,359 x DRG weight",275748,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,105494,,186% x Medicaid HMO amount,105494,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,244966,,"34,077 x DRG weight",244966,Other,base rate x DRG weight,208225,,"28,966 x DRG weight",208225,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56717,,DRG base rate x DRG weight + capital per discharge,56717,Other,100% of NY Medicaid HMO DRG,56717,,100% x Medicaid HMO amount,56717,Other,100% of NY Medicaid HMO DRG,56717,,100% x Medicaid HMO amount,56717,Other,100% of NY Medicaid HMO DRG,56717,,100% x Medicaid HMO amount,56717,Other,100% of NY Medicaid HMO DRG,127613,,225% x Medicaid HMO amount,127613,Other,225% of NY Medicaid HMO DRG,127613,,225% x Medicaid HMO amount,127613,Other,225% of NY Medicaid HMO DRG,127613,,225% x Medicaid HMO amount,127613,Other,225% of NY Medicaid HMO DRG,127613,,225% x Medicaid HMO amount,127613,Other,225% of NY Medicaid HMO DRG,79404,,140% x Medicaid HMO amount,79404,Other,140% of NY Medicaid HMO DRG,127613,,225% x Medicaid HMO amount,127613,Other,225% of NY Medicaid HMO DRG,155972,,275% x Medicaid HMO amount,155972,Other,275% of NY Medicaid HMO DRG,183763,,324% x Medicaid HMO amount,183763,Other,324% of NY Medicaid HMO DRG,121942,,215% x Medicaid HMO amount,121942,Other,215% of NY Medicaid HMO DRG,121942,,215% x Medicaid HMO amount,121942,Other,215% of NY Medicaid HMO DRG,70896,,125% x Medicaid HMO amount,70896,Other,125% of NY Medicaid HMO DRG,0.01,324407,
Tracheostomy w MV 96+ hours w extensive procedure or ECMO,004-2,APR-DRG,,,,,,,,inpatient,,,578945.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,324407,,"45,128 x DRG weight",324407,Other,base rate x DRG weight,291965,,"40,615 x DRG weight",291965,Other,base rate x DRG weight,275748,,"38,359 x DRG weight",275748,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,105494,,186% x Medicaid HMO amount,105494,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,244966,,"34,077 x DRG weight",244966,Other,base rate x DRG weight,208225,,"28,966 x DRG weight",208225,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56717,,DRG base rate x DRG weight + capital per discharge,56717,Other,100% of NY Medicaid HMO DRG,56717,,100% x Medicaid HMO amount,56717,Other,100% of NY Medicaid HMO DRG,56717,,100% x Medicaid HMO amount,56717,Other,100% of NY Medicaid HMO DRG,56717,,100% x Medicaid HMO amount,56717,Other,100% of NY Medicaid HMO DRG,127613,,225% x Medicaid HMO amount,127613,Other,225% of NY Medicaid HMO DRG,127613,,225% x Medicaid HMO amount,127613,Other,225% of NY Medicaid HMO DRG,127613,,225% x Medicaid HMO amount,127613,Other,225% of NY Medicaid HMO DRG,127613,,225% x Medicaid HMO amount,127613,Other,225% of NY Medicaid HMO DRG,79404,,140% x Medicaid HMO amount,79404,Other,140% of NY Medicaid HMO DRG,127613,,225% x Medicaid HMO amount,127613,Other,225% of NY Medicaid HMO DRG,155972,,275% x Medicaid HMO amount,155972,Other,275% of NY Medicaid HMO DRG,183763,,324% x Medicaid HMO amount,183763,Other,324% of NY Medicaid HMO DRG,121942,,215% x Medicaid HMO amount,121942,Other,215% of NY Medicaid HMO DRG,121942,,215% x Medicaid HMO amount,121942,Other,215% of NY Medicaid HMO DRG,70896,,125% x Medicaid HMO amount,70896,Other,125% of NY Medicaid HMO DRG,0.01,324407,
Tracheostomy w MV 96+ hours w extensive procedure or ECMO,004-3,APR-DRG,,,,,,,,inpatient,,,1276065.57,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,454466,,"45,128 x DRG weight",454466,Other,base rate x DRG weight,409017,,"40,615 x DRG weight",409017,Other,base rate x DRG weight,386298,,"38,359 x DRG weight",386298,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,147174,,186% x Medicaid HMO amount,147174,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,343176,,"34,077 x DRG weight",343176,Other,base rate x DRG weight,291705,,"28,966 x DRG weight",291705,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,79126,,DRG base rate x DRG weight + capital per discharge,79126,Other,100% of NY Medicaid HMO DRG,79126,,100% x Medicaid HMO amount,79126,Other,100% of NY Medicaid HMO DRG,79126,,100% x Medicaid HMO amount,79126,Other,100% of NY Medicaid HMO DRG,79126,,100% x Medicaid HMO amount,79126,Other,100% of NY Medicaid HMO DRG,178034,,225% x Medicaid HMO amount,178034,Other,225% of NY Medicaid HMO DRG,178034,,225% x Medicaid HMO amount,178034,Other,225% of NY Medicaid HMO DRG,178034,,225% x Medicaid HMO amount,178034,Other,225% of NY Medicaid HMO DRG,178034,,225% x Medicaid HMO amount,178034,Other,225% of NY Medicaid HMO DRG,110776,,140% x Medicaid HMO amount,110776,Other,140% of NY Medicaid HMO DRG,178034,,225% x Medicaid HMO amount,178034,Other,225% of NY Medicaid HMO DRG,217597,,275% x Medicaid HMO amount,217597,Other,275% of NY Medicaid HMO DRG,256368,,324% x Medicaid HMO amount,256368,Other,324% of NY Medicaid HMO DRG,170121,,215% x Medicaid HMO amount,170121,Other,215% of NY Medicaid HMO DRG,170121,,215% x Medicaid HMO amount,170121,Other,215% of NY Medicaid HMO DRG,98908,,125% x Medicaid HMO amount,98908,Other,125% of NY Medicaid HMO DRG,0.01,454466,
Tracheostomy w MV 96+ hours w extensive procedure or ECMO,004-4,APR-DRG,,,,,,,,inpatient,,,2232524.79,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,815558,,"45,128 x DRG weight",815558,Other,base rate x DRG weight,733998,,"40,615 x DRG weight",733998,Other,base rate x DRG weight,693228,,"38,359 x DRG weight",693228,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,262898,,186% x Medicaid HMO amount,262898,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,615843,,"34,077 x DRG weight",615843,Other,base rate x DRG weight,523476,,"28,966 x DRG weight",523476,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,141343,,DRG base rate x DRG weight + capital per discharge,141343,Other,100% of NY Medicaid HMO DRG,141343,,100% x Medicaid HMO amount,141343,Other,100% of NY Medicaid HMO DRG,141343,,100% x Medicaid HMO amount,141343,Other,100% of NY Medicaid HMO DRG,141343,,100% x Medicaid HMO amount,141343,Other,100% of NY Medicaid HMO DRG,318022,,225% x Medicaid HMO amount,318022,Other,225% of NY Medicaid HMO DRG,318022,,225% x Medicaid HMO amount,318022,Other,225% of NY Medicaid HMO DRG,318022,,225% x Medicaid HMO amount,318022,Other,225% of NY Medicaid HMO DRG,318022,,225% x Medicaid HMO amount,318022,Other,225% of NY Medicaid HMO DRG,197880,,140% x Medicaid HMO amount,197880,Other,140% of NY Medicaid HMO DRG,318022,,225% x Medicaid HMO amount,318022,Other,225% of NY Medicaid HMO DRG,388693,,275% x Medicaid HMO amount,388693,Other,275% of NY Medicaid HMO DRG,457951,,324% x Medicaid HMO amount,457951,Other,324% of NY Medicaid HMO DRG,303887,,215% x Medicaid HMO amount,303887,Other,215% of NY Medicaid HMO DRG,303887,,215% x Medicaid HMO amount,303887,Other,215% of NY Medicaid HMO DRG,176679,,125% x Medicaid HMO amount,176679,Other,125% of NY Medicaid HMO DRG,0.01,815558,
Tracheostomy w MV 96+ hours w/o extensive procedure,005-1,APR-DRG,,,,,,,,inpatient,,,843405.03,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,257054,,"45,128 x DRG weight",257054,Other,base rate x DRG weight,231347,,"40,615 x DRG weight",231347,Other,base rate x DRG weight,218497,,"38,359 x DRG weight",218497,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,83908,,186% x Medicaid HMO amount,83908,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,194106,,"34,077 x DRG weight",194106,Other,base rate x DRG weight,164993,,"28,966 x DRG weight",164993,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45112,,DRG base rate x DRG weight + capital per discharge,45112,Other,100% of NY Medicaid HMO DRG,45112,,100% x Medicaid HMO amount,45112,Other,100% of NY Medicaid HMO DRG,45112,,100% x Medicaid HMO amount,45112,Other,100% of NY Medicaid HMO DRG,45112,,100% x Medicaid HMO amount,45112,Other,100% of NY Medicaid HMO DRG,101502,,225% x Medicaid HMO amount,101502,Other,225% of NY Medicaid HMO DRG,101502,,225% x Medicaid HMO amount,101502,Other,225% of NY Medicaid HMO DRG,101502,,225% x Medicaid HMO amount,101502,Other,225% of NY Medicaid HMO DRG,101502,,225% x Medicaid HMO amount,101502,Other,225% of NY Medicaid HMO DRG,63157,,140% x Medicaid HMO amount,63157,Other,140% of NY Medicaid HMO DRG,101502,,225% x Medicaid HMO amount,101502,Other,225% of NY Medicaid HMO DRG,124058,,275% x Medicaid HMO amount,124058,Other,275% of NY Medicaid HMO DRG,146163,,324% x Medicaid HMO amount,146163,Other,324% of NY Medicaid HMO DRG,96991,,215% x Medicaid HMO amount,96991,Other,215% of NY Medicaid HMO DRG,96991,,215% x Medicaid HMO amount,96991,Other,215% of NY Medicaid HMO DRG,56390,,125% x Medicaid HMO amount,56390,Other,125% of NY Medicaid HMO DRG,0.01,257054,
Tracheostomy w MV 96+ hours w/o extensive procedure,005-2,APR-DRG,,,,,,,,inpatient,,,843405.03,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,263710,,"45,128 x DRG weight",263710,Other,base rate x DRG weight,237338,,"40,615 x DRG weight",237338,Other,base rate x DRG weight,224155,,"38,359 x DRG weight",224155,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,86040,,186% x Medicaid HMO amount,86040,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,199132,,"34,077 x DRG weight",199132,Other,base rate x DRG weight,169266,,"28,966 x DRG weight",169266,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46258,,DRG base rate x DRG weight + capital per discharge,46258,Other,100% of NY Medicaid HMO DRG,46258,,100% x Medicaid HMO amount,46258,Other,100% of NY Medicaid HMO DRG,46258,,100% x Medicaid HMO amount,46258,Other,100% of NY Medicaid HMO DRG,46258,,100% x Medicaid HMO amount,46258,Other,100% of NY Medicaid HMO DRG,104081,,225% x Medicaid HMO amount,104081,Other,225% of NY Medicaid HMO DRG,104081,,225% x Medicaid HMO amount,104081,Other,225% of NY Medicaid HMO DRG,104081,,225% x Medicaid HMO amount,104081,Other,225% of NY Medicaid HMO DRG,104081,,225% x Medicaid HMO amount,104081,Other,225% of NY Medicaid HMO DRG,64761,,140% x Medicaid HMO amount,64761,Other,140% of NY Medicaid HMO DRG,104081,,225% x Medicaid HMO amount,104081,Other,225% of NY Medicaid HMO DRG,127210,,275% x Medicaid HMO amount,127210,Other,275% of NY Medicaid HMO DRG,149876,,324% x Medicaid HMO amount,149876,Other,324% of NY Medicaid HMO DRG,99455,,215% x Medicaid HMO amount,99455,Other,215% of NY Medicaid HMO DRG,99455,,215% x Medicaid HMO amount,99455,Other,215% of NY Medicaid HMO DRG,57823,,125% x Medicaid HMO amount,57823,Other,125% of NY Medicaid HMO DRG,0.01,263710,
Tracheostomy w MV 96+ hours w/o extensive procedure,005-3,APR-DRG,,,,,,,,inpatient,,,1220871.77,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,416653,,"45,128 x DRG weight",416653,Other,base rate x DRG weight,374986,,"40,615 x DRG weight",374986,Other,base rate x DRG weight,354157,,"38,359 x DRG weight",354157,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,135056,,186% x Medicaid HMO amount,135056,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,314623,,"34,077 x DRG weight",314623,Other,base rate x DRG weight,267434,,"28,966 x DRG weight",267434,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,72611,,DRG base rate x DRG weight + capital per discharge,72611,Other,100% of NY Medicaid HMO DRG,72611,,100% x Medicaid HMO amount,72611,Other,100% of NY Medicaid HMO DRG,72611,,100% x Medicaid HMO amount,72611,Other,100% of NY Medicaid HMO DRG,72611,,100% x Medicaid HMO amount,72611,Other,100% of NY Medicaid HMO DRG,163375,,225% x Medicaid HMO amount,163375,Other,225% of NY Medicaid HMO DRG,163375,,225% x Medicaid HMO amount,163375,Other,225% of NY Medicaid HMO DRG,163375,,225% x Medicaid HMO amount,163375,Other,225% of NY Medicaid HMO DRG,163375,,225% x Medicaid HMO amount,163375,Other,225% of NY Medicaid HMO DRG,101655,,140% x Medicaid HMO amount,101655,Other,140% of NY Medicaid HMO DRG,163375,,225% x Medicaid HMO amount,163375,Other,225% of NY Medicaid HMO DRG,199680,,275% x Medicaid HMO amount,199680,Other,275% of NY Medicaid HMO DRG,235260,,324% x Medicaid HMO amount,235260,Other,324% of NY Medicaid HMO DRG,156114,,215% x Medicaid HMO amount,156114,Other,215% of NY Medicaid HMO DRG,156114,,215% x Medicaid HMO amount,156114,Other,215% of NY Medicaid HMO DRG,90764,,125% x Medicaid HMO amount,90764,Other,125% of NY Medicaid HMO DRG,0.01,416653,
Tracheostomy w MV 96+ hours w/o extensive procedure,005-4,APR-DRG,,,,,,,,inpatient,,,1735098.49,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,622293,,"45,128 x DRG weight",622293,Other,base rate x DRG weight,560061,,"40,615 x DRG weight",560061,Other,base rate x DRG weight,528951,,"38,359 x DRG weight",528951,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,200960,,186% x Medicaid HMO amount,200960,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,469905,,"34,077 x DRG weight",469905,Other,base rate x DRG weight,399427,,"28,966 x DRG weight",399427,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,108043,,DRG base rate x DRG weight + capital per discharge,108043,Other,100% of NY Medicaid HMO DRG,108043,,100% x Medicaid HMO amount,108043,Other,100% of NY Medicaid HMO DRG,108043,,100% x Medicaid HMO amount,108043,Other,100% of NY Medicaid HMO DRG,108043,,100% x Medicaid HMO amount,108043,Other,100% of NY Medicaid HMO DRG,243097,,225% x Medicaid HMO amount,243097,Other,225% of NY Medicaid HMO DRG,243097,,225% x Medicaid HMO amount,243097,Other,225% of NY Medicaid HMO DRG,243097,,225% x Medicaid HMO amount,243097,Other,225% of NY Medicaid HMO DRG,243097,,225% x Medicaid HMO amount,243097,Other,225% of NY Medicaid HMO DRG,151260,,140% x Medicaid HMO amount,151260,Other,140% of NY Medicaid HMO DRG,243097,,225% x Medicaid HMO amount,243097,Other,225% of NY Medicaid HMO DRG,297118,,275% x Medicaid HMO amount,297118,Other,275% of NY Medicaid HMO DRG,350059,,324% x Medicaid HMO amount,350059,Other,324% of NY Medicaid HMO DRG,232292,,215% x Medicaid HMO amount,232292,Other,215% of NY Medicaid HMO DRG,232292,,215% x Medicaid HMO amount,232292,Other,215% of NY Medicaid HMO DRG,135054,,125% x Medicaid HMO amount,135054,Other,125% of NY Medicaid HMO DRG,0.01,622293,
Craniotomy for trauma,020-1,APR-DRG,,,,,,,,inpatient,,,172052.26,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,80581,,"45,128 x DRG weight",80581,Other,base rate x DRG weight,72522,,"40,615 x DRG weight",72522,Other,base rate x DRG weight,68494,,"38,359 x DRG weight",68494,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27351,,186% x Medicaid HMO amount,27351,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60848,,"34,077 x DRG weight",60848,Other,base rate x DRG weight,51722,,"28,966 x DRG weight",51722,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14705,,DRG base rate x DRG weight + capital per discharge,14705,Other,100% of NY Medicaid HMO DRG,14705,,100% x Medicaid HMO amount,14705,Other,100% of NY Medicaid HMO DRG,14705,,100% x Medicaid HMO amount,14705,Other,100% of NY Medicaid HMO DRG,14705,,100% x Medicaid HMO amount,14705,Other,100% of NY Medicaid HMO DRG,33086,,225% x Medicaid HMO amount,33086,Other,225% of NY Medicaid HMO DRG,33086,,225% x Medicaid HMO amount,33086,Other,225% of NY Medicaid HMO DRG,33086,,225% x Medicaid HMO amount,33086,Other,225% of NY Medicaid HMO DRG,33086,,225% x Medicaid HMO amount,33086,Other,225% of NY Medicaid HMO DRG,20587,,140% x Medicaid HMO amount,20587,Other,140% of NY Medicaid HMO DRG,33086,,225% x Medicaid HMO amount,33086,Other,225% of NY Medicaid HMO DRG,40439,,275% x Medicaid HMO amount,40439,Other,275% of NY Medicaid HMO DRG,47644,,324% x Medicaid HMO amount,47644,Other,324% of NY Medicaid HMO DRG,31616,,215% x Medicaid HMO amount,31616,Other,215% of NY Medicaid HMO DRG,31616,,215% x Medicaid HMO amount,31616,Other,215% of NY Medicaid HMO DRG,18381,,125% x Medicaid HMO amount,18381,Other,125% of NY Medicaid HMO DRG,0.01,80581,
Craniotomy for trauma,020-2,APR-DRG,,,,,,,,inpatient,,,193932.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,101782,,"45,128 x DRG weight",101782,Other,base rate x DRG weight,91603,,"40,615 x DRG weight",91603,Other,base rate x DRG weight,86515,,"38,359 x DRG weight",86515,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34146,,186% x Medicaid HMO amount,34146,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,76857,,"34,077 x DRG weight",76857,Other,base rate x DRG weight,65330,,"28,966 x DRG weight",65330,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18358,,DRG base rate x DRG weight + capital per discharge,18358,Other,100% of NY Medicaid HMO DRG,18358,,100% x Medicaid HMO amount,18358,Other,100% of NY Medicaid HMO DRG,18358,,100% x Medicaid HMO amount,18358,Other,100% of NY Medicaid HMO DRG,18358,,100% x Medicaid HMO amount,18358,Other,100% of NY Medicaid HMO DRG,41306,,225% x Medicaid HMO amount,41306,Other,225% of NY Medicaid HMO DRG,41306,,225% x Medicaid HMO amount,41306,Other,225% of NY Medicaid HMO DRG,41306,,225% x Medicaid HMO amount,41306,Other,225% of NY Medicaid HMO DRG,41306,,225% x Medicaid HMO amount,41306,Other,225% of NY Medicaid HMO DRG,25701,,140% x Medicaid HMO amount,25701,Other,140% of NY Medicaid HMO DRG,41306,,225% x Medicaid HMO amount,41306,Other,225% of NY Medicaid HMO DRG,50485,,275% x Medicaid HMO amount,50485,Other,275% of NY Medicaid HMO DRG,59480,,324% x Medicaid HMO amount,59480,Other,324% of NY Medicaid HMO DRG,39470,,215% x Medicaid HMO amount,39470,Other,215% of NY Medicaid HMO DRG,39470,,215% x Medicaid HMO amount,39470,Other,215% of NY Medicaid HMO DRG,22948,,125% x Medicaid HMO amount,22948,Other,125% of NY Medicaid HMO DRG,0.01,101782,
Craniotomy for trauma,020-3,APR-DRG,,,,,,,,inpatient,,,496264.4,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,159861,,"45,128 x DRG weight",159861,Other,base rate x DRG weight,143875,,"40,615 x DRG weight",143875,Other,base rate x DRG weight,135883,,"38,359 x DRG weight",135883,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52759,,186% x Medicaid HMO amount,52759,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,120714,,"34,077 x DRG weight",120714,Other,base rate x DRG weight,102609,,"28,966 x DRG weight",102609,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28365,,DRG base rate x DRG weight + capital per discharge,28365,Other,100% of NY Medicaid HMO DRG,28365,,100% x Medicaid HMO amount,28365,Other,100% of NY Medicaid HMO DRG,28365,,100% x Medicaid HMO amount,28365,Other,100% of NY Medicaid HMO DRG,28365,,100% x Medicaid HMO amount,28365,Other,100% of NY Medicaid HMO DRG,63821,,225% x Medicaid HMO amount,63821,Other,225% of NY Medicaid HMO DRG,63821,,225% x Medicaid HMO amount,63821,Other,225% of NY Medicaid HMO DRG,63821,,225% x Medicaid HMO amount,63821,Other,225% of NY Medicaid HMO DRG,63821,,225% x Medicaid HMO amount,63821,Other,225% of NY Medicaid HMO DRG,39711,,140% x Medicaid HMO amount,39711,Other,140% of NY Medicaid HMO DRG,63821,,225% x Medicaid HMO amount,63821,Other,225% of NY Medicaid HMO DRG,78004,,275% x Medicaid HMO amount,78004,Other,275% of NY Medicaid HMO DRG,91903,,324% x Medicaid HMO amount,91903,Other,324% of NY Medicaid HMO DRG,60985,,215% x Medicaid HMO amount,60985,Other,215% of NY Medicaid HMO DRG,60985,,215% x Medicaid HMO amount,60985,Other,215% of NY Medicaid HMO DRG,35456,,125% x Medicaid HMO amount,35456,Other,125% of NY Medicaid HMO DRG,0.01,159861,
Craniotomy for trauma,020-4,APR-DRG,,,,,,,,inpatient,,,914478.38,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,301906,,"45,128 x DRG weight",301906,Other,base rate x DRG weight,271714,,"40,615 x DRG weight",271714,Other,base rate x DRG weight,256622,,"38,359 x DRG weight",256622,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,98282,,186% x Medicaid HMO amount,98282,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,227975,,"34,077 x DRG weight",227975,Other,base rate x DRG weight,193783,,"28,966 x DRG weight",193783,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52840,,DRG base rate x DRG weight + capital per discharge,52840,Other,100% of NY Medicaid HMO DRG,52840,,100% x Medicaid HMO amount,52840,Other,100% of NY Medicaid HMO DRG,52840,,100% x Medicaid HMO amount,52840,Other,100% of NY Medicaid HMO DRG,52840,,100% x Medicaid HMO amount,52840,Other,100% of NY Medicaid HMO DRG,118890,,225% x Medicaid HMO amount,118890,Other,225% of NY Medicaid HMO DRG,118890,,225% x Medicaid HMO amount,118890,Other,225% of NY Medicaid HMO DRG,118890,,225% x Medicaid HMO amount,118890,Other,225% of NY Medicaid HMO DRG,118890,,225% x Medicaid HMO amount,118890,Other,225% of NY Medicaid HMO DRG,73976,,140% x Medicaid HMO amount,73976,Other,140% of NY Medicaid HMO DRG,118890,,225% x Medicaid HMO amount,118890,Other,225% of NY Medicaid HMO DRG,145310,,275% x Medicaid HMO amount,145310,Other,275% of NY Medicaid HMO DRG,171202,,324% x Medicaid HMO amount,171202,Other,324% of NY Medicaid HMO DRG,113606,,215% x Medicaid HMO amount,113606,Other,215% of NY Medicaid HMO DRG,113606,,215% x Medicaid HMO amount,113606,Other,215% of NY Medicaid HMO DRG,66050,,125% x Medicaid HMO amount,66050,Other,125% of NY Medicaid HMO DRG,0.01,301906,
Craniotomy except for trauma,021-1,APR-DRG,,,,,,,,inpatient,,,289033.37,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,85477,,"45,128 x DRG weight",85477,Other,base rate x DRG weight,76929,,"40,615 x DRG weight",76929,Other,base rate x DRG weight,72656,,"38,359 x DRG weight",72656,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28921,,186% x Medicaid HMO amount,28921,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,64545,,"34,077 x DRG weight",64545,Other,base rate x DRG weight,54865,,"28,966 x DRG weight",54865,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15549,,DRG base rate x DRG weight + capital per discharge,15549,Other,100% of NY Medicaid HMO DRG,15549,,100% x Medicaid HMO amount,15549,Other,100% of NY Medicaid HMO DRG,15549,,100% x Medicaid HMO amount,15549,Other,100% of NY Medicaid HMO DRG,15549,,100% x Medicaid HMO amount,15549,Other,100% of NY Medicaid HMO DRG,34985,,225% x Medicaid HMO amount,34985,Other,225% of NY Medicaid HMO DRG,34985,,225% x Medicaid HMO amount,34985,Other,225% of NY Medicaid HMO DRG,34985,,225% x Medicaid HMO amount,34985,Other,225% of NY Medicaid HMO DRG,34985,,225% x Medicaid HMO amount,34985,Other,225% of NY Medicaid HMO DRG,21769,,140% x Medicaid HMO amount,21769,Other,140% of NY Medicaid HMO DRG,34985,,225% x Medicaid HMO amount,34985,Other,225% of NY Medicaid HMO DRG,42760,,275% x Medicaid HMO amount,42760,Other,275% of NY Medicaid HMO DRG,50379,,324% x Medicaid HMO amount,50379,Other,324% of NY Medicaid HMO DRG,33430,,215% x Medicaid HMO amount,33430,Other,215% of NY Medicaid HMO DRG,33430,,215% x Medicaid HMO amount,33430,Other,215% of NY Medicaid HMO DRG,19436,,125% x Medicaid HMO amount,19436,Other,125% of NY Medicaid HMO DRG,0.01,85477,
Craniotomy except for trauma,021-2,APR-DRG,,,,,,,,inpatient,,,292310.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,120817,,"45,128 x DRG weight",120817,Other,base rate x DRG weight,108734,,"40,615 x DRG weight",108734,Other,base rate x DRG weight,102695,,"38,359 x DRG weight",102695,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40247,,186% x Medicaid HMO amount,40247,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,91231,,"34,077 x DRG weight",91231,Other,base rate x DRG weight,77548,,"28,966 x DRG weight",77548,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21638,,DRG base rate x DRG weight + capital per discharge,21638,Other,100% of NY Medicaid HMO DRG,21638,,100% x Medicaid HMO amount,21638,Other,100% of NY Medicaid HMO DRG,21638,,100% x Medicaid HMO amount,21638,Other,100% of NY Medicaid HMO DRG,21638,,100% x Medicaid HMO amount,21638,Other,100% of NY Medicaid HMO DRG,48686,,225% x Medicaid HMO amount,48686,Other,225% of NY Medicaid HMO DRG,48686,,225% x Medicaid HMO amount,48686,Other,225% of NY Medicaid HMO DRG,48686,,225% x Medicaid HMO amount,48686,Other,225% of NY Medicaid HMO DRG,48686,,225% x Medicaid HMO amount,48686,Other,225% of NY Medicaid HMO DRG,30293,,140% x Medicaid HMO amount,30293,Other,140% of NY Medicaid HMO DRG,48686,,225% x Medicaid HMO amount,48686,Other,225% of NY Medicaid HMO DRG,59505,,275% x Medicaid HMO amount,59505,Other,275% of NY Medicaid HMO DRG,70107,,324% x Medicaid HMO amount,70107,Other,324% of NY Medicaid HMO DRG,46522,,215% x Medicaid HMO amount,46522,Other,215% of NY Medicaid HMO DRG,46522,,215% x Medicaid HMO amount,46522,Other,215% of NY Medicaid HMO DRG,27048,,125% x Medicaid HMO amount,27048,Other,125% of NY Medicaid HMO DRG,0.01,120817,
Craniotomy except for trauma,021-3,APR-DRG,,,,,,,,inpatient,,,429083.55,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,195490,,"45,128 x DRG weight",195490,Other,base rate x DRG weight,175940,,"40,615 x DRG weight",175940,Other,base rate x DRG weight,166167,,"38,359 x DRG weight",166167,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,64177,,186% x Medicaid HMO amount,64177,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,147618,,"34,077 x DRG weight",147618,Other,base rate x DRG weight,125478,,"28,966 x DRG weight",125478,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34504,,DRG base rate x DRG weight + capital per discharge,34504,Other,100% of NY Medicaid HMO DRG,34504,,100% x Medicaid HMO amount,34504,Other,100% of NY Medicaid HMO DRG,34504,,100% x Medicaid HMO amount,34504,Other,100% of NY Medicaid HMO DRG,34504,,100% x Medicaid HMO amount,34504,Other,100% of NY Medicaid HMO DRG,77634,,225% x Medicaid HMO amount,77634,Other,225% of NY Medicaid HMO DRG,77634,,225% x Medicaid HMO amount,77634,Other,225% of NY Medicaid HMO DRG,77634,,225% x Medicaid HMO amount,77634,Other,225% of NY Medicaid HMO DRG,77634,,225% x Medicaid HMO amount,77634,Other,225% of NY Medicaid HMO DRG,48306,,140% x Medicaid HMO amount,48306,Other,140% of NY Medicaid HMO DRG,77634,,225% x Medicaid HMO amount,77634,Other,225% of NY Medicaid HMO DRG,94886,,275% x Medicaid HMO amount,94886,Other,275% of NY Medicaid HMO DRG,111793,,324% x Medicaid HMO amount,111793,Other,324% of NY Medicaid HMO DRG,74184,,215% x Medicaid HMO amount,74184,Other,215% of NY Medicaid HMO DRG,74184,,215% x Medicaid HMO amount,74184,Other,215% of NY Medicaid HMO DRG,43130,,125% x Medicaid HMO amount,43130,Other,125% of NY Medicaid HMO DRG,0.01,195490,
Craniotomy except for trauma,021-4,APR-DRG,,,,,,,,inpatient,,,747089.04,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,326790,,"45,128 x DRG weight",326790,Other,base rate x DRG weight,294109,,"40,615 x DRG weight",294109,Other,base rate x DRG weight,277773,,"38,359 x DRG weight",277773,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,106256,,186% x Medicaid HMO amount,106256,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,246765,,"34,077 x DRG weight",246765,Other,base rate x DRG weight,209754,,"28,966 x DRG weight",209754,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,57127,,DRG base rate x DRG weight + capital per discharge,57127,Other,100% of NY Medicaid HMO DRG,57127,,100% x Medicaid HMO amount,57127,Other,100% of NY Medicaid HMO DRG,57127,,100% x Medicaid HMO amount,57127,Other,100% of NY Medicaid HMO DRG,57127,,100% x Medicaid HMO amount,57127,Other,100% of NY Medicaid HMO DRG,128536,,225% x Medicaid HMO amount,128536,Other,225% of NY Medicaid HMO DRG,128536,,225% x Medicaid HMO amount,128536,Other,225% of NY Medicaid HMO DRG,128536,,225% x Medicaid HMO amount,128536,Other,225% of NY Medicaid HMO DRG,128536,,225% x Medicaid HMO amount,128536,Other,225% of NY Medicaid HMO DRG,79978,,140% x Medicaid HMO amount,79978,Other,140% of NY Medicaid HMO DRG,128536,,225% x Medicaid HMO amount,128536,Other,225% of NY Medicaid HMO DRG,157099,,275% x Medicaid HMO amount,157099,Other,275% of NY Medicaid HMO DRG,185091,,324% x Medicaid HMO amount,185091,Other,324% of NY Medicaid HMO DRG,122823,,215% x Medicaid HMO amount,122823,Other,215% of NY Medicaid HMO DRG,122823,,215% x Medicaid HMO amount,122823,Other,215% of NY Medicaid HMO DRG,71409,,125% x Medicaid HMO amount,71409,Other,125% of NY Medicaid HMO DRG,0.01,326790,
Ventricular shunt procedures,022-1,APR-DRG,,,,,,,,inpatient,,,202387.4,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,57529,,"45,128 x DRG weight",57529,Other,base rate x DRG weight,51776,,"40,615 x DRG weight",51776,Other,base rate x DRG weight,48900,,"38,359 x DRG weight",48900,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19963,,186% x Medicaid HMO amount,19963,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43441,,"34,077 x DRG weight",43441,Other,base rate x DRG weight,36926,,"28,966 x DRG weight",36926,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10733,,DRG base rate x DRG weight + capital per discharge,10733,Other,100% of NY Medicaid HMO DRG,10733,,100% x Medicaid HMO amount,10733,Other,100% of NY Medicaid HMO DRG,10733,,100% x Medicaid HMO amount,10733,Other,100% of NY Medicaid HMO DRG,10733,,100% x Medicaid HMO amount,10733,Other,100% of NY Medicaid HMO DRG,24149,,225% x Medicaid HMO amount,24149,Other,225% of NY Medicaid HMO DRG,24149,,225% x Medicaid HMO amount,24149,Other,225% of NY Medicaid HMO DRG,24149,,225% x Medicaid HMO amount,24149,Other,225% of NY Medicaid HMO DRG,24149,,225% x Medicaid HMO amount,24149,Other,225% of NY Medicaid HMO DRG,15026,,140% x Medicaid HMO amount,15026,Other,140% of NY Medicaid HMO DRG,24149,,225% x Medicaid HMO amount,24149,Other,225% of NY Medicaid HMO DRG,29516,,275% x Medicaid HMO amount,29516,Other,275% of NY Medicaid HMO DRG,34775,,324% x Medicaid HMO amount,34775,Other,324% of NY Medicaid HMO DRG,23076,,215% x Medicaid HMO amount,23076,Other,215% of NY Medicaid HMO DRG,23076,,215% x Medicaid HMO amount,23076,Other,215% of NY Medicaid HMO DRG,13416,,125% x Medicaid HMO amount,13416,Other,125% of NY Medicaid HMO DRG,0.01,57529,
Ventricular shunt procedures,022-2,APR-DRG,,,,,,,,inpatient,,,268233.96,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73559,,"45,128 x DRG weight",73559,Other,base rate x DRG weight,66202,,"40,615 x DRG weight",66202,Other,base rate x DRG weight,62525,,"38,359 x DRG weight",62525,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25101,,186% x Medicaid HMO amount,25101,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55546,,"34,077 x DRG weight",55546,Other,base rate x DRG weight,47215,,"28,966 x DRG weight",47215,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13495,,DRG base rate x DRG weight + capital per discharge,13495,Other,100% of NY Medicaid HMO DRG,13495,,100% x Medicaid HMO amount,13495,Other,100% of NY Medicaid HMO DRG,13495,,100% x Medicaid HMO amount,13495,Other,100% of NY Medicaid HMO DRG,13495,,100% x Medicaid HMO amount,13495,Other,100% of NY Medicaid HMO DRG,30364,,225% x Medicaid HMO amount,30364,Other,225% of NY Medicaid HMO DRG,30364,,225% x Medicaid HMO amount,30364,Other,225% of NY Medicaid HMO DRG,30364,,225% x Medicaid HMO amount,30364,Other,225% of NY Medicaid HMO DRG,30364,,225% x Medicaid HMO amount,30364,Other,225% of NY Medicaid HMO DRG,18893,,140% x Medicaid HMO amount,18893,Other,140% of NY Medicaid HMO DRG,30364,,225% x Medicaid HMO amount,30364,Other,225% of NY Medicaid HMO DRG,37111,,275% x Medicaid HMO amount,37111,Other,275% of NY Medicaid HMO DRG,43724,,324% x Medicaid HMO amount,43724,Other,324% of NY Medicaid HMO DRG,29014,,215% x Medicaid HMO amount,29014,Other,215% of NY Medicaid HMO DRG,29014,,215% x Medicaid HMO amount,29014,Other,215% of NY Medicaid HMO DRG,16869,,125% x Medicaid HMO amount,16869,Other,125% of NY Medicaid HMO DRG,0.01,73559,
Ventricular shunt procedures,022-3,APR-DRG,,,,,,,,inpatient,,,234390.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,120582,,"45,128 x DRG weight",120582,Other,base rate x DRG weight,108523,,"40,615 x DRG weight",108523,Other,base rate x DRG weight,102495,,"38,359 x DRG weight",102495,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40170,,186% x Medicaid HMO amount,40170,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,91054,,"34,077 x DRG weight",91054,Other,base rate x DRG weight,77397,,"28,966 x DRG weight",77397,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21597,,DRG base rate x DRG weight + capital per discharge,21597,Other,100% of NY Medicaid HMO DRG,21597,,100% x Medicaid HMO amount,21597,Other,100% of NY Medicaid HMO DRG,21597,,100% x Medicaid HMO amount,21597,Other,100% of NY Medicaid HMO DRG,21597,,100% x Medicaid HMO amount,21597,Other,100% of NY Medicaid HMO DRG,48593,,225% x Medicaid HMO amount,48593,Other,225% of NY Medicaid HMO DRG,48593,,225% x Medicaid HMO amount,48593,Other,225% of NY Medicaid HMO DRG,48593,,225% x Medicaid HMO amount,48593,Other,225% of NY Medicaid HMO DRG,48593,,225% x Medicaid HMO amount,48593,Other,225% of NY Medicaid HMO DRG,30236,,140% x Medicaid HMO amount,30236,Other,140% of NY Medicaid HMO DRG,48593,,225% x Medicaid HMO amount,48593,Other,225% of NY Medicaid HMO DRG,59392,,275% x Medicaid HMO amount,59392,Other,275% of NY Medicaid HMO DRG,69974,,324% x Medicaid HMO amount,69974,Other,324% of NY Medicaid HMO DRG,46434,,215% x Medicaid HMO amount,46434,Other,215% of NY Medicaid HMO DRG,46434,,215% x Medicaid HMO amount,46434,Other,215% of NY Medicaid HMO DRG,26996,,125% x Medicaid HMO amount,26996,Other,125% of NY Medicaid HMO DRG,0.01,120582,
Ventricular shunt procedures,022-4,APR-DRG,,,,,,,,inpatient,,,1031318.43,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,243127,,"45,128 x DRG weight",243127,Other,base rate x DRG weight,218813,,"40,615 x DRG weight",218813,Other,base rate x DRG weight,206659,,"38,359 x DRG weight",206659,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,79444,,186% x Medicaid HMO amount,79444,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,183590,,"34,077 x DRG weight",183590,Other,base rate x DRG weight,156054,,"28,966 x DRG weight",156054,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42712,,DRG base rate x DRG weight + capital per discharge,42712,Other,100% of NY Medicaid HMO DRG,42712,,100% x Medicaid HMO amount,42712,Other,100% of NY Medicaid HMO DRG,42712,,100% x Medicaid HMO amount,42712,Other,100% of NY Medicaid HMO DRG,42712,,100% x Medicaid HMO amount,42712,Other,100% of NY Medicaid HMO DRG,96102,,225% x Medicaid HMO amount,96102,Other,225% of NY Medicaid HMO DRG,96102,,225% x Medicaid HMO amount,96102,Other,225% of NY Medicaid HMO DRG,96102,,225% x Medicaid HMO amount,96102,Other,225% of NY Medicaid HMO DRG,96102,,225% x Medicaid HMO amount,96102,Other,225% of NY Medicaid HMO DRG,59797,,140% x Medicaid HMO amount,59797,Other,140% of NY Medicaid HMO DRG,96102,,225% x Medicaid HMO amount,96102,Other,225% of NY Medicaid HMO DRG,117458,,275% x Medicaid HMO amount,117458,Other,275% of NY Medicaid HMO DRG,138387,,324% x Medicaid HMO amount,138387,Other,324% of NY Medicaid HMO DRG,91831,,215% x Medicaid HMO amount,91831,Other,215% of NY Medicaid HMO DRG,91831,,215% x Medicaid HMO amount,91831,Other,215% of NY Medicaid HMO DRG,53390,,125% x Medicaid HMO amount,53390,Other,125% of NY Medicaid HMO DRG,0.01,243127,
Spinal procedures,023-1,APR-DRG,,,,,,,,inpatient,,,164749.12,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,74055,,"45,128 x DRG weight",74055,Other,base rate x DRG weight,66649,,"40,615 x DRG weight",66649,Other,base rate x DRG weight,62947,,"38,359 x DRG weight",62947,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25261,,186% x Medicaid HMO amount,25261,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55920,,"34,077 x DRG weight",55920,Other,base rate x DRG weight,47533,,"28,966 x DRG weight",47533,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13581,,DRG base rate x DRG weight + capital per discharge,13581,Other,100% of NY Medicaid HMO DRG,13581,,100% x Medicaid HMO amount,13581,Other,100% of NY Medicaid HMO DRG,13581,,100% x Medicaid HMO amount,13581,Other,100% of NY Medicaid HMO DRG,13581,,100% x Medicaid HMO amount,13581,Other,100% of NY Medicaid HMO DRG,30557,,225% x Medicaid HMO amount,30557,Other,225% of NY Medicaid HMO DRG,30557,,225% x Medicaid HMO amount,30557,Other,225% of NY Medicaid HMO DRG,30557,,225% x Medicaid HMO amount,30557,Other,225% of NY Medicaid HMO DRG,30557,,225% x Medicaid HMO amount,30557,Other,225% of NY Medicaid HMO DRG,19013,,140% x Medicaid HMO amount,19013,Other,140% of NY Medicaid HMO DRG,30557,,225% x Medicaid HMO amount,30557,Other,225% of NY Medicaid HMO DRG,37348,,275% x Medicaid HMO amount,37348,Other,275% of NY Medicaid HMO DRG,44002,,324% x Medicaid HMO amount,44002,Other,324% of NY Medicaid HMO DRG,29199,,215% x Medicaid HMO amount,29199,Other,215% of NY Medicaid HMO DRG,29199,,215% x Medicaid HMO amount,29199,Other,215% of NY Medicaid HMO DRG,16976,,125% x Medicaid HMO amount,16976,Other,125% of NY Medicaid HMO DRG,0.01,74055,
Spinal procedures,023-2,APR-DRG,,,,,,,,inpatient,,,294874.08,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,99552,,"45,128 x DRG weight",99552,Other,base rate x DRG weight,89597,,"40,615 x DRG weight",89597,Other,base rate x DRG weight,84620,,"38,359 x DRG weight",84620,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33432,,186% x Medicaid HMO amount,33432,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,75174,,"34,077 x DRG weight",75174,Other,base rate x DRG weight,63899,,"28,966 x DRG weight",63899,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17974,,DRG base rate x DRG weight + capital per discharge,17974,Other,100% of NY Medicaid HMO DRG,17974,,100% x Medicaid HMO amount,17974,Other,100% of NY Medicaid HMO DRG,17974,,100% x Medicaid HMO amount,17974,Other,100% of NY Medicaid HMO DRG,17974,,100% x Medicaid HMO amount,17974,Other,100% of NY Medicaid HMO DRG,40442,,225% x Medicaid HMO amount,40442,Other,225% of NY Medicaid HMO DRG,40442,,225% x Medicaid HMO amount,40442,Other,225% of NY Medicaid HMO DRG,40442,,225% x Medicaid HMO amount,40442,Other,225% of NY Medicaid HMO DRG,40442,,225% x Medicaid HMO amount,40442,Other,225% of NY Medicaid HMO DRG,25164,,140% x Medicaid HMO amount,25164,Other,140% of NY Medicaid HMO DRG,40442,,225% x Medicaid HMO amount,40442,Other,225% of NY Medicaid HMO DRG,49429,,275% x Medicaid HMO amount,49429,Other,275% of NY Medicaid HMO DRG,58236,,324% x Medicaid HMO amount,58236,Other,324% of NY Medicaid HMO DRG,38644,,215% x Medicaid HMO amount,38644,Other,215% of NY Medicaid HMO DRG,38644,,215% x Medicaid HMO amount,38644,Other,215% of NY Medicaid HMO DRG,22468,,125% x Medicaid HMO amount,22468,Other,125% of NY Medicaid HMO DRG,0.01,99552,
Spinal procedures,023-3,APR-DRG,,,,,,,,inpatient,,,550176.99,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,193888,,"45,128 x DRG weight",193888,Other,base rate x DRG weight,174498,,"40,615 x DRG weight",174498,Other,base rate x DRG weight,164806,,"38,359 x DRG weight",164806,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,63664,,186% x Medicaid HMO amount,63664,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,146408,,"34,077 x DRG weight",146408,Other,base rate x DRG weight,124450,,"28,966 x DRG weight",124450,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34228,,DRG base rate x DRG weight + capital per discharge,34228,Other,100% of NY Medicaid HMO DRG,34228,,100% x Medicaid HMO amount,34228,Other,100% of NY Medicaid HMO DRG,34228,,100% x Medicaid HMO amount,34228,Other,100% of NY Medicaid HMO DRG,34228,,100% x Medicaid HMO amount,34228,Other,100% of NY Medicaid HMO DRG,77013,,225% x Medicaid HMO amount,77013,Other,225% of NY Medicaid HMO DRG,77013,,225% x Medicaid HMO amount,77013,Other,225% of NY Medicaid HMO DRG,77013,,225% x Medicaid HMO amount,77013,Other,225% of NY Medicaid HMO DRG,77013,,225% x Medicaid HMO amount,77013,Other,225% of NY Medicaid HMO DRG,47919,,140% x Medicaid HMO amount,47919,Other,140% of NY Medicaid HMO DRG,77013,,225% x Medicaid HMO amount,77013,Other,225% of NY Medicaid HMO DRG,94127,,275% x Medicaid HMO amount,94127,Other,275% of NY Medicaid HMO DRG,110899,,324% x Medicaid HMO amount,110899,Other,324% of NY Medicaid HMO DRG,73590,,215% x Medicaid HMO amount,73590,Other,215% of NY Medicaid HMO DRG,73590,,215% x Medicaid HMO amount,73590,Other,215% of NY Medicaid HMO DRG,42785,,125% x Medicaid HMO amount,42785,Other,125% of NY Medicaid HMO DRG,0.01,193888,
Spinal procedures,023-4,APR-DRG,,,,,,,,inpatient,,,309827.1,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,364729,,"45,128 x DRG weight",364729,Other,base rate x DRG weight,328254,,"40,615 x DRG weight",328254,Other,base rate x DRG weight,310021,,"38,359 x DRG weight",310021,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,118415,,186% x Medicaid HMO amount,118415,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,275414,,"34,077 x DRG weight",275414,Other,base rate x DRG weight,234106,,"28,966 x DRG weight",234106,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,63664,,DRG base rate x DRG weight + capital per discharge,63664,Other,100% of NY Medicaid HMO DRG,63664,,100% x Medicaid HMO amount,63664,Other,100% of NY Medicaid HMO DRG,63664,,100% x Medicaid HMO amount,63664,Other,100% of NY Medicaid HMO DRG,63664,,100% x Medicaid HMO amount,63664,Other,100% of NY Medicaid HMO DRG,143244,,225% x Medicaid HMO amount,143244,Other,225% of NY Medicaid HMO DRG,143244,,225% x Medicaid HMO amount,143244,Other,225% of NY Medicaid HMO DRG,143244,,225% x Medicaid HMO amount,143244,Other,225% of NY Medicaid HMO DRG,143244,,225% x Medicaid HMO amount,143244,Other,225% of NY Medicaid HMO DRG,89130,,140% x Medicaid HMO amount,89130,Other,140% of NY Medicaid HMO DRG,143244,,225% x Medicaid HMO amount,143244,Other,225% of NY Medicaid HMO DRG,175076,,275% x Medicaid HMO amount,175076,Other,275% of NY Medicaid HMO DRG,206271,,324% x Medicaid HMO amount,206271,Other,324% of NY Medicaid HMO DRG,136878,,215% x Medicaid HMO amount,136878,Other,215% of NY Medicaid HMO DRG,136878,,215% x Medicaid HMO amount,136878,Other,215% of NY Medicaid HMO DRG,79580,,125% x Medicaid HMO amount,79580,Other,125% of NY Medicaid HMO DRG,0.01,364729,
Extracranial vascular procedures,024-1,APR-DRG,,,,,,,,inpatient,,,162208.3,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,67769,,"45,128 x DRG weight",67769,Other,base rate x DRG weight,60992,,"40,615 x DRG weight",60992,Other,base rate x DRG weight,57604,,"38,359 x DRG weight",57604,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23246,,186% x Medicaid HMO amount,23246,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51173,,"34,077 x DRG weight",51173,Other,base rate x DRG weight,43498,,"28,966 x DRG weight",43498,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12498,,DRG base rate x DRG weight + capital per discharge,12498,Other,100% of NY Medicaid HMO DRG,12498,,100% x Medicaid HMO amount,12498,Other,100% of NY Medicaid HMO DRG,12498,,100% x Medicaid HMO amount,12498,Other,100% of NY Medicaid HMO DRG,12498,,100% x Medicaid HMO amount,12498,Other,100% of NY Medicaid HMO DRG,28121,,225% x Medicaid HMO amount,28121,Other,225% of NY Medicaid HMO DRG,28121,,225% x Medicaid HMO amount,28121,Other,225% of NY Medicaid HMO DRG,28121,,225% x Medicaid HMO amount,28121,Other,225% of NY Medicaid HMO DRG,28121,,225% x Medicaid HMO amount,28121,Other,225% of NY Medicaid HMO DRG,17497,,140% x Medicaid HMO amount,17497,Other,140% of NY Medicaid HMO DRG,28121,,225% x Medicaid HMO amount,28121,Other,225% of NY Medicaid HMO DRG,34370,,275% x Medicaid HMO amount,34370,Other,275% of NY Medicaid HMO DRG,40494,,324% x Medicaid HMO amount,40494,Other,324% of NY Medicaid HMO DRG,26871,,215% x Medicaid HMO amount,26871,Other,215% of NY Medicaid HMO DRG,26871,,215% x Medicaid HMO amount,26871,Other,215% of NY Medicaid HMO DRG,15623,,125% x Medicaid HMO amount,15623,Other,125% of NY Medicaid HMO DRG,0.01,67769,
Extracranial vascular procedures,024-2,APR-DRG,,,,,,,,inpatient,,,330447.13,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,96145,,"45,128 x DRG weight",96145,Other,base rate x DRG weight,86530,,"40,615 x DRG weight",86530,Other,base rate x DRG weight,81724,,"38,359 x DRG weight",81724,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32340,,186% x Medicaid HMO amount,32340,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,72601,,"34,077 x DRG weight",72601,Other,base rate x DRG weight,61712,,"28,966 x DRG weight",61712,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17387,,DRG base rate x DRG weight + capital per discharge,17387,Other,100% of NY Medicaid HMO DRG,17387,,100% x Medicaid HMO amount,17387,Other,100% of NY Medicaid HMO DRG,17387,,100% x Medicaid HMO amount,17387,Other,100% of NY Medicaid HMO DRG,17387,,100% x Medicaid HMO amount,17387,Other,100% of NY Medicaid HMO DRG,39121,,225% x Medicaid HMO amount,39121,Other,225% of NY Medicaid HMO DRG,39121,,225% x Medicaid HMO amount,39121,Other,225% of NY Medicaid HMO DRG,39121,,225% x Medicaid HMO amount,39121,Other,225% of NY Medicaid HMO DRG,39121,,225% x Medicaid HMO amount,39121,Other,225% of NY Medicaid HMO DRG,24342,,140% x Medicaid HMO amount,24342,Other,140% of NY Medicaid HMO DRG,39121,,225% x Medicaid HMO amount,39121,Other,225% of NY Medicaid HMO DRG,47814,,275% x Medicaid HMO amount,47814,Other,275% of NY Medicaid HMO DRG,56334,,324% x Medicaid HMO amount,56334,Other,324% of NY Medicaid HMO DRG,37382,,215% x Medicaid HMO amount,37382,Other,215% of NY Medicaid HMO DRG,37382,,215% x Medicaid HMO amount,37382,Other,215% of NY Medicaid HMO DRG,21734,,125% x Medicaid HMO amount,21734,Other,125% of NY Medicaid HMO DRG,0.01,96145,
Extracranial vascular procedures,024-3,APR-DRG,,,,,,,,inpatient,,,524773.59,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,166536,,"45,128 x DRG weight",166536,Other,base rate x DRG weight,149882,,"40,615 x DRG weight",149882,Other,base rate x DRG weight,141556,,"38,359 x DRG weight",141556,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54898,,186% x Medicaid HMO amount,54898,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,125754,,"34,077 x DRG weight",125754,Other,base rate x DRG weight,106893,,"28,966 x DRG weight",106893,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29515,,DRG base rate x DRG weight + capital per discharge,29515,Other,100% of NY Medicaid HMO DRG,29515,,100% x Medicaid HMO amount,29515,Other,100% of NY Medicaid HMO DRG,29515,,100% x Medicaid HMO amount,29515,Other,100% of NY Medicaid HMO DRG,29515,,100% x Medicaid HMO amount,29515,Other,100% of NY Medicaid HMO DRG,66409,,225% x Medicaid HMO amount,66409,Other,225% of NY Medicaid HMO DRG,66409,,225% x Medicaid HMO amount,66409,Other,225% of NY Medicaid HMO DRG,66409,,225% x Medicaid HMO amount,66409,Other,225% of NY Medicaid HMO DRG,66409,,225% x Medicaid HMO amount,66409,Other,225% of NY Medicaid HMO DRG,41321,,140% x Medicaid HMO amount,41321,Other,140% of NY Medicaid HMO DRG,66409,,225% x Medicaid HMO amount,66409,Other,225% of NY Medicaid HMO DRG,81166,,275% x Medicaid HMO amount,81166,Other,275% of NY Medicaid HMO DRG,95629,,324% x Medicaid HMO amount,95629,Other,324% of NY Medicaid HMO DRG,63457,,215% x Medicaid HMO amount,63457,Other,215% of NY Medicaid HMO DRG,63457,,215% x Medicaid HMO amount,63457,Other,215% of NY Medicaid HMO DRG,36894,,125% x Medicaid HMO amount,36894,Other,125% of NY Medicaid HMO DRG,0.01,166536,
Extracranial vascular procedures,024-4,APR-DRG,,,,,,,,inpatient,,,516288.78,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,306582,,"45,128 x DRG weight",306582,Other,base rate x DRG weight,275922,,"40,615 x DRG weight",275922,Other,base rate x DRG weight,260596,,"38,359 x DRG weight",260596,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,99780,,186% x Medicaid HMO amount,99780,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,231506,,"34,077 x DRG weight",231506,Other,base rate x DRG weight,196783,,"28,966 x DRG weight",196783,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53645,,DRG base rate x DRG weight + capital per discharge,53645,Other,100% of NY Medicaid HMO DRG,53645,,100% x Medicaid HMO amount,53645,Other,100% of NY Medicaid HMO DRG,53645,,100% x Medicaid HMO amount,53645,Other,100% of NY Medicaid HMO DRG,53645,,100% x Medicaid HMO amount,53645,Other,100% of NY Medicaid HMO DRG,120701,,225% x Medicaid HMO amount,120701,Other,225% of NY Medicaid HMO DRG,120701,,225% x Medicaid HMO amount,120701,Other,225% of NY Medicaid HMO DRG,120701,,225% x Medicaid HMO amount,120701,Other,225% of NY Medicaid HMO DRG,120701,,225% x Medicaid HMO amount,120701,Other,225% of NY Medicaid HMO DRG,75103,,140% x Medicaid HMO amount,75103,Other,140% of NY Medicaid HMO DRG,120701,,225% x Medicaid HMO amount,120701,Other,225% of NY Medicaid HMO DRG,147524,,275% x Medicaid HMO amount,147524,Other,275% of NY Medicaid HMO DRG,173810,,324% x Medicaid HMO amount,173810,Other,324% of NY Medicaid HMO DRG,115337,,215% x Medicaid HMO amount,115337,Other,215% of NY Medicaid HMO DRG,115337,,215% x Medicaid HMO amount,115337,Other,215% of NY Medicaid HMO DRG,67056,,125% x Medicaid HMO amount,67056,Other,125% of NY Medicaid HMO DRG,0.01,306582,
Other nervous system & related procedures,026-1,APR-DRG,,,,,,,,inpatient,,,159967.32,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55359,,"45,128 x DRG weight",55359,Other,base rate x DRG weight,49822,,"40,615 x DRG weight",49822,Other,base rate x DRG weight,47055,,"38,359 x DRG weight",47055,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19268,,186% x Medicaid HMO amount,19268,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41802,,"34,077 x DRG weight",41802,Other,base rate x DRG weight,35533,,"28,966 x DRG weight",35533,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10359,,DRG base rate x DRG weight + capital per discharge,10359,Other,100% of NY Medicaid HMO DRG,10359,,100% x Medicaid HMO amount,10359,Other,100% of NY Medicaid HMO DRG,10359,,100% x Medicaid HMO amount,10359,Other,100% of NY Medicaid HMO DRG,10359,,100% x Medicaid HMO amount,10359,Other,100% of NY Medicaid HMO DRG,23308,,225% x Medicaid HMO amount,23308,Other,225% of NY Medicaid HMO DRG,23308,,225% x Medicaid HMO amount,23308,Other,225% of NY Medicaid HMO DRG,23308,,225% x Medicaid HMO amount,23308,Other,225% of NY Medicaid HMO DRG,23308,,225% x Medicaid HMO amount,23308,Other,225% of NY Medicaid HMO DRG,14503,,140% x Medicaid HMO amount,14503,Other,140% of NY Medicaid HMO DRG,23308,,225% x Medicaid HMO amount,23308,Other,225% of NY Medicaid HMO DRG,28487,,275% x Medicaid HMO amount,28487,Other,275% of NY Medicaid HMO DRG,33563,,324% x Medicaid HMO amount,33563,Other,324% of NY Medicaid HMO DRG,22272,,215% x Medicaid HMO amount,22272,Other,215% of NY Medicaid HMO DRG,22272,,215% x Medicaid HMO amount,22272,Other,215% of NY Medicaid HMO DRG,12949,,125% x Medicaid HMO amount,12949,Other,125% of NY Medicaid HMO DRG,0.01,55359,
Other nervous system & related procedures,026-2,APR-DRG,,,,,,,,inpatient,,,273933.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,81050,,"45,128 x DRG weight",81050,Other,base rate x DRG weight,72945,,"40,615 x DRG weight",72945,Other,base rate x DRG weight,68893,,"38,359 x DRG weight",68893,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27502,,186% x Medicaid HMO amount,27502,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,61202,,"34,077 x DRG weight",61202,Other,base rate x DRG weight,52023,,"28,966 x DRG weight",52023,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14786,,DRG base rate x DRG weight + capital per discharge,14786,Other,100% of NY Medicaid HMO DRG,14786,,100% x Medicaid HMO amount,14786,Other,100% of NY Medicaid HMO DRG,14786,,100% x Medicaid HMO amount,14786,Other,100% of NY Medicaid HMO DRG,14786,,100% x Medicaid HMO amount,14786,Other,100% of NY Medicaid HMO DRG,33269,,225% x Medicaid HMO amount,33269,Other,225% of NY Medicaid HMO DRG,33269,,225% x Medicaid HMO amount,33269,Other,225% of NY Medicaid HMO DRG,33269,,225% x Medicaid HMO amount,33269,Other,225% of NY Medicaid HMO DRG,33269,,225% x Medicaid HMO amount,33269,Other,225% of NY Medicaid HMO DRG,20700,,140% x Medicaid HMO amount,20700,Other,140% of NY Medicaid HMO DRG,33269,,225% x Medicaid HMO amount,33269,Other,225% of NY Medicaid HMO DRG,40662,,275% x Medicaid HMO amount,40662,Other,275% of NY Medicaid HMO DRG,47907,,324% x Medicaid HMO amount,47907,Other,324% of NY Medicaid HMO DRG,31790,,215% x Medicaid HMO amount,31790,Other,215% of NY Medicaid HMO DRG,31790,,215% x Medicaid HMO amount,31790,Other,215% of NY Medicaid HMO DRG,18483,,125% x Medicaid HMO amount,18483,Other,125% of NY Medicaid HMO DRG,0.01,81050,
Other nervous system & related procedures,026-3,APR-DRG,,,,,,,,inpatient,,,252795.91,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,120420,,"45,128 x DRG weight",120420,Other,base rate x DRG weight,108377,,"40,615 x DRG weight",108377,Other,base rate x DRG weight,102357,,"38,359 x DRG weight",102357,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40118,,186% x Medicaid HMO amount,40118,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,90931,,"34,077 x DRG weight",90931,Other,base rate x DRG weight,77293,,"28,966 x DRG weight",77293,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21569,,DRG base rate x DRG weight + capital per discharge,21569,Other,100% of NY Medicaid HMO DRG,21569,,100% x Medicaid HMO amount,21569,Other,100% of NY Medicaid HMO DRG,21569,,100% x Medicaid HMO amount,21569,Other,100% of NY Medicaid HMO DRG,21569,,100% x Medicaid HMO amount,21569,Other,100% of NY Medicaid HMO DRG,48530,,225% x Medicaid HMO amount,48530,Other,225% of NY Medicaid HMO DRG,48530,,225% x Medicaid HMO amount,48530,Other,225% of NY Medicaid HMO DRG,48530,,225% x Medicaid HMO amount,48530,Other,225% of NY Medicaid HMO DRG,48530,,225% x Medicaid HMO amount,48530,Other,225% of NY Medicaid HMO DRG,30197,,140% x Medicaid HMO amount,30197,Other,140% of NY Medicaid HMO DRG,48530,,225% x Medicaid HMO amount,48530,Other,225% of NY Medicaid HMO DRG,59315,,275% x Medicaid HMO amount,59315,Other,275% of NY Medicaid HMO DRG,69884,,324% x Medicaid HMO amount,69884,Other,324% of NY Medicaid HMO DRG,46373,,215% x Medicaid HMO amount,46373,Other,215% of NY Medicaid HMO DRG,46373,,215% x Medicaid HMO amount,46373,Other,215% of NY Medicaid HMO DRG,26961,,125% x Medicaid HMO amount,26961,Other,125% of NY Medicaid HMO DRG,0.01,120420,
Other nervous system & related procedures,026-4,APR-DRG,,,,,,,,inpatient,,,1599828.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,283219,,"45,128 x DRG weight",283219,Other,base rate x DRG weight,254896,,"40,615 x DRG weight",254896,Other,base rate x DRG weight,240737,,"38,359 x DRG weight",240737,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,92293,,186% x Medicaid HMO amount,92293,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,213864,,"34,077 x DRG weight",213864,Other,base rate x DRG weight,181788,,"28,966 x DRG weight",181788,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49620,,DRG base rate x DRG weight + capital per discharge,49620,Other,100% of NY Medicaid HMO DRG,49620,,100% x Medicaid HMO amount,49620,Other,100% of NY Medicaid HMO DRG,49620,,100% x Medicaid HMO amount,49620,Other,100% of NY Medicaid HMO DRG,49620,,100% x Medicaid HMO amount,49620,Other,100% of NY Medicaid HMO DRG,111645,,225% x Medicaid HMO amount,111645,Other,225% of NY Medicaid HMO DRG,111645,,225% x Medicaid HMO amount,111645,Other,225% of NY Medicaid HMO DRG,111645,,225% x Medicaid HMO amount,111645,Other,225% of NY Medicaid HMO DRG,111645,,225% x Medicaid HMO amount,111645,Other,225% of NY Medicaid HMO DRG,69468,,140% x Medicaid HMO amount,69468,Other,140% of NY Medicaid HMO DRG,111645,,225% x Medicaid HMO amount,111645,Other,225% of NY Medicaid HMO DRG,136455,,275% x Medicaid HMO amount,136455,Other,275% of NY Medicaid HMO DRG,160769,,324% x Medicaid HMO amount,160769,Other,324% of NY Medicaid HMO DRG,106683,,215% x Medicaid HMO amount,106683,Other,215% of NY Medicaid HMO DRG,106683,,215% x Medicaid HMO amount,106683,Other,215% of NY Medicaid HMO DRG,62025,,125% x Medicaid HMO amount,62025,Other,125% of NY Medicaid HMO DRG,0.01,283219,
Spinal disorders & injuries,040-1,APR-DRG,,,,,,,,inpatient,,,87432.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36820,,"45,128 x DRG weight",36820,Other,base rate x DRG weight,33138,,"40,615 x DRG weight",33138,Other,base rate x DRG weight,31297,,"38,359 x DRG weight",31297,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13327,,186% x Medicaid HMO amount,13327,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27803,,"34,077 x DRG weight",27803,Other,base rate x DRG weight,23633,,"28,966 x DRG weight",23633,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7165,,DRG base rate x DRG weight + capital per discharge,7165,Other,100% of NY Medicaid HMO DRG,7165,,100% x Medicaid HMO amount,7165,Other,100% of NY Medicaid HMO DRG,7165,,100% x Medicaid HMO amount,7165,Other,100% of NY Medicaid HMO DRG,7165,,100% x Medicaid HMO amount,7165,Other,100% of NY Medicaid HMO DRG,16121,,225% x Medicaid HMO amount,16121,Other,225% of NY Medicaid HMO DRG,16121,,225% x Medicaid HMO amount,16121,Other,225% of NY Medicaid HMO DRG,16121,,225% x Medicaid HMO amount,16121,Other,225% of NY Medicaid HMO DRG,16121,,225% x Medicaid HMO amount,16121,Other,225% of NY Medicaid HMO DRG,10031,,140% x Medicaid HMO amount,10031,Other,140% of NY Medicaid HMO DRG,16121,,225% x Medicaid HMO amount,16121,Other,225% of NY Medicaid HMO DRG,19704,,275% x Medicaid HMO amount,19704,Other,275% of NY Medicaid HMO DRG,23215,,324% x Medicaid HMO amount,23215,Other,324% of NY Medicaid HMO DRG,15405,,215% x Medicaid HMO amount,15405,Other,215% of NY Medicaid HMO DRG,15405,,215% x Medicaid HMO amount,15405,Other,215% of NY Medicaid HMO DRG,8956,,125% x Medicaid HMO amount,8956,Other,125% of NY Medicaid HMO DRG,0.01,36820,
Spinal disorders & injuries,040-2,APR-DRG,,,,,,,,inpatient,,,153585.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,57958,,"45,128 x DRG weight",57958,Other,base rate x DRG weight,52162,,"40,615 x DRG weight",52162,Other,base rate x DRG weight,49264,,"38,359 x DRG weight",49264,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20101,,186% x Medicaid HMO amount,20101,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43765,,"34,077 x DRG weight",43765,Other,base rate x DRG weight,37201,,"28,966 x DRG weight",37201,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10807,,DRG base rate x DRG weight + capital per discharge,10807,Other,100% of NY Medicaid HMO DRG,10807,,100% x Medicaid HMO amount,10807,Other,100% of NY Medicaid HMO DRG,10807,,100% x Medicaid HMO amount,10807,Other,100% of NY Medicaid HMO DRG,10807,,100% x Medicaid HMO amount,10807,Other,100% of NY Medicaid HMO DRG,24316,,225% x Medicaid HMO amount,24316,Other,225% of NY Medicaid HMO DRG,24316,,225% x Medicaid HMO amount,24316,Other,225% of NY Medicaid HMO DRG,24316,,225% x Medicaid HMO amount,24316,Other,225% of NY Medicaid HMO DRG,24316,,225% x Medicaid HMO amount,24316,Other,225% of NY Medicaid HMO DRG,15130,,140% x Medicaid HMO amount,15130,Other,140% of NY Medicaid HMO DRG,24316,,225% x Medicaid HMO amount,24316,Other,225% of NY Medicaid HMO DRG,29719,,275% x Medicaid HMO amount,29719,Other,275% of NY Medicaid HMO DRG,35015,,324% x Medicaid HMO amount,35015,Other,324% of NY Medicaid HMO DRG,23235,,215% x Medicaid HMO amount,23235,Other,215% of NY Medicaid HMO DRG,23235,,215% x Medicaid HMO amount,23235,Other,215% of NY Medicaid HMO DRG,13509,,125% x Medicaid HMO amount,13509,Other,125% of NY Medicaid HMO DRG,0.01,57958,
Spinal disorders & injuries,040-3,APR-DRG,,,,,,,,inpatient,,,350638.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,103636,,"45,128 x DRG weight",103636,Other,base rate x DRG weight,93272,,"40,615 x DRG weight",93272,Other,base rate x DRG weight,88091,,"38,359 x DRG weight",88091,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34741,,186% x Medicaid HMO amount,34741,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,78258,,"34,077 x DRG weight",78258,Other,base rate x DRG weight,66520,,"28,966 x DRG weight",66520,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18678,,DRG base rate x DRG weight + capital per discharge,18678,Other,100% of NY Medicaid HMO DRG,18678,,100% x Medicaid HMO amount,18678,Other,100% of NY Medicaid HMO DRG,18678,,100% x Medicaid HMO amount,18678,Other,100% of NY Medicaid HMO DRG,18678,,100% x Medicaid HMO amount,18678,Other,100% of NY Medicaid HMO DRG,42026,,225% x Medicaid HMO amount,42026,Other,225% of NY Medicaid HMO DRG,42026,,225% x Medicaid HMO amount,42026,Other,225% of NY Medicaid HMO DRG,42026,,225% x Medicaid HMO amount,42026,Other,225% of NY Medicaid HMO DRG,42026,,225% x Medicaid HMO amount,42026,Other,225% of NY Medicaid HMO DRG,26149,,140% x Medicaid HMO amount,26149,Other,140% of NY Medicaid HMO DRG,42026,,225% x Medicaid HMO amount,42026,Other,225% of NY Medicaid HMO DRG,51365,,275% x Medicaid HMO amount,51365,Other,275% of NY Medicaid HMO DRG,60517,,324% x Medicaid HMO amount,60517,Other,324% of NY Medicaid HMO DRG,40158,,215% x Medicaid HMO amount,40158,Other,215% of NY Medicaid HMO DRG,40158,,215% x Medicaid HMO amount,40158,Other,215% of NY Medicaid HMO DRG,23348,,125% x Medicaid HMO amount,23348,Other,125% of NY Medicaid HMO DRG,0.01,103636,
Spinal disorders & injuries,040-4,APR-DRG,,,,,,,,inpatient,,,350638.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,122568,,"45,128 x DRG weight",122568,Other,base rate x DRG weight,110310,,"40,615 x DRG weight",110310,Other,base rate x DRG weight,104183,,"38,359 x DRG weight",104183,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40807,,186% x Medicaid HMO amount,40807,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,92553,,"34,077 x DRG weight",92553,Other,base rate x DRG weight,78672,,"28,966 x DRG weight",78672,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21939,,DRG base rate x DRG weight + capital per discharge,21939,Other,100% of NY Medicaid HMO DRG,21939,,100% x Medicaid HMO amount,21939,Other,100% of NY Medicaid HMO DRG,21939,,100% x Medicaid HMO amount,21939,Other,100% of NY Medicaid HMO DRG,21939,,100% x Medicaid HMO amount,21939,Other,100% of NY Medicaid HMO DRG,49363,,225% x Medicaid HMO amount,49363,Other,225% of NY Medicaid HMO DRG,49363,,225% x Medicaid HMO amount,49363,Other,225% of NY Medicaid HMO DRG,49363,,225% x Medicaid HMO amount,49363,Other,225% of NY Medicaid HMO DRG,49363,,225% x Medicaid HMO amount,49363,Other,225% of NY Medicaid HMO DRG,30715,,140% x Medicaid HMO amount,30715,Other,140% of NY Medicaid HMO DRG,49363,,225% x Medicaid HMO amount,49363,Other,225% of NY Medicaid HMO DRG,60332,,275% x Medicaid HMO amount,60332,Other,275% of NY Medicaid HMO DRG,71082,,324% x Medicaid HMO amount,71082,Other,324% of NY Medicaid HMO DRG,47169,,215% x Medicaid HMO amount,47169,Other,215% of NY Medicaid HMO DRG,47169,,215% x Medicaid HMO amount,47169,Other,215% of NY Medicaid HMO DRG,27424,,125% x Medicaid HMO amount,27424,Other,125% of NY Medicaid HMO DRG,0.01,122568,
Nervous system malignancy,041-1,APR-DRG,,,,,,,,inpatient,,,60218.14,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33882,,"45,128 x DRG weight",33882,Other,base rate x DRG weight,30494,,"40,615 x DRG weight",30494,Other,base rate x DRG weight,28800,,"38,359 x DRG weight",28800,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12386,,186% x Medicaid HMO amount,12386,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25585,,"34,077 x DRG weight",25585,Other,base rate x DRG weight,21748,,"28,966 x DRG weight",21748,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6659,,DRG base rate x DRG weight + capital per discharge,6659,Other,100% of NY Medicaid HMO DRG,6659,,100% x Medicaid HMO amount,6659,Other,100% of NY Medicaid HMO DRG,6659,,100% x Medicaid HMO amount,6659,Other,100% of NY Medicaid HMO DRG,6659,,100% x Medicaid HMO amount,6659,Other,100% of NY Medicaid HMO DRG,14983,,225% x Medicaid HMO amount,14983,Other,225% of NY Medicaid HMO DRG,14983,,225% x Medicaid HMO amount,14983,Other,225% of NY Medicaid HMO DRG,14983,,225% x Medicaid HMO amount,14983,Other,225% of NY Medicaid HMO DRG,14983,,225% x Medicaid HMO amount,14983,Other,225% of NY Medicaid HMO DRG,9323,,140% x Medicaid HMO amount,9323,Other,140% of NY Medicaid HMO DRG,14983,,225% x Medicaid HMO amount,14983,Other,225% of NY Medicaid HMO DRG,18312,,275% x Medicaid HMO amount,18312,Other,275% of NY Medicaid HMO DRG,21575,,324% x Medicaid HMO amount,21575,Other,324% of NY Medicaid HMO DRG,14317,,215% x Medicaid HMO amount,14317,Other,215% of NY Medicaid HMO DRG,14317,,215% x Medicaid HMO amount,14317,Other,215% of NY Medicaid HMO DRG,8324,,125% x Medicaid HMO amount,8324,Other,125% of NY Medicaid HMO DRG,0.01,33882,
Nervous system malignancy,041-2,APR-DRG,,,,,,,,inpatient,,,70598.89,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39099,,"45,128 x DRG weight",39099,Other,base rate x DRG weight,35189,,"40,615 x DRG weight",35189,Other,base rate x DRG weight,33234,,"38,359 x DRG weight",33234,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14058,,186% x Medicaid HMO amount,14058,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29524,,"34,077 x DRG weight",29524,Other,base rate x DRG weight,25096,,"28,966 x DRG weight",25096,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7558,,DRG base rate x DRG weight + capital per discharge,7558,Other,100% of NY Medicaid HMO DRG,7558,,100% x Medicaid HMO amount,7558,Other,100% of NY Medicaid HMO DRG,7558,,100% x Medicaid HMO amount,7558,Other,100% of NY Medicaid HMO DRG,7558,,100% x Medicaid HMO amount,7558,Other,100% of NY Medicaid HMO DRG,17006,,225% x Medicaid HMO amount,17006,Other,225% of NY Medicaid HMO DRG,17006,,225% x Medicaid HMO amount,17006,Other,225% of NY Medicaid HMO DRG,17006,,225% x Medicaid HMO amount,17006,Other,225% of NY Medicaid HMO DRG,17006,,225% x Medicaid HMO amount,17006,Other,225% of NY Medicaid HMO DRG,10581,,140% x Medicaid HMO amount,10581,Other,140% of NY Medicaid HMO DRG,17006,,225% x Medicaid HMO amount,17006,Other,225% of NY Medicaid HMO DRG,20785,,275% x Medicaid HMO amount,20785,Other,275% of NY Medicaid HMO DRG,24488,,324% x Medicaid HMO amount,24488,Other,324% of NY Medicaid HMO DRG,16250,,215% x Medicaid HMO amount,16250,Other,215% of NY Medicaid HMO DRG,16250,,215% x Medicaid HMO amount,16250,Other,215% of NY Medicaid HMO DRG,9448,,125% x Medicaid HMO amount,9448,Other,125% of NY Medicaid HMO DRG,0.01,39099,
Nervous system malignancy,041-3,APR-DRG,,,,,,,,inpatient,,,263831.69,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,66514,,"45,128 x DRG weight",66514,Other,base rate x DRG weight,59862,,"40,615 x DRG weight",59862,Other,base rate x DRG weight,56537,,"38,359 x DRG weight",56537,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22843,,186% x Medicaid HMO amount,22843,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50226,,"34,077 x DRG weight",50226,Other,base rate x DRG weight,42693,,"28,966 x DRG weight",42693,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12281,,DRG base rate x DRG weight + capital per discharge,12281,Other,100% of NY Medicaid HMO DRG,12281,,100% x Medicaid HMO amount,12281,Other,100% of NY Medicaid HMO DRG,12281,,100% x Medicaid HMO amount,12281,Other,100% of NY Medicaid HMO DRG,12281,,100% x Medicaid HMO amount,12281,Other,100% of NY Medicaid HMO DRG,27632,,225% x Medicaid HMO amount,27632,Other,225% of NY Medicaid HMO DRG,27632,,225% x Medicaid HMO amount,27632,Other,225% of NY Medicaid HMO DRG,27632,,225% x Medicaid HMO amount,27632,Other,225% of NY Medicaid HMO DRG,27632,,225% x Medicaid HMO amount,27632,Other,225% of NY Medicaid HMO DRG,17193,,140% x Medicaid HMO amount,17193,Other,140% of NY Medicaid HMO DRG,27632,,225% x Medicaid HMO amount,27632,Other,225% of NY Medicaid HMO DRG,33773,,275% x Medicaid HMO amount,33773,Other,275% of NY Medicaid HMO DRG,39790,,324% x Medicaid HMO amount,39790,Other,324% of NY Medicaid HMO DRG,26404,,215% x Medicaid HMO amount,26404,Other,215% of NY Medicaid HMO DRG,26404,,215% x Medicaid HMO amount,26404,Other,215% of NY Medicaid HMO DRG,15351,,125% x Medicaid HMO amount,15351,Other,125% of NY Medicaid HMO DRG,0.01,66514,
Nervous system malignancy,041-4,APR-DRG,,,,,,,,inpatient,,,133503.72,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,123258,,"45,128 x DRG weight",123258,Other,base rate x DRG weight,110932,,"40,615 x DRG weight",110932,Other,base rate x DRG weight,104770,,"38,359 x DRG weight",104770,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41028,,186% x Medicaid HMO amount,41028,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,93075,,"34,077 x DRG weight",93075,Other,base rate x DRG weight,79115,,"28,966 x DRG weight",79115,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22058,,DRG base rate x DRG weight + capital per discharge,22058,Other,100% of NY Medicaid HMO DRG,22058,,100% x Medicaid HMO amount,22058,Other,100% of NY Medicaid HMO DRG,22058,,100% x Medicaid HMO amount,22058,Other,100% of NY Medicaid HMO DRG,22058,,100% x Medicaid HMO amount,22058,Other,100% of NY Medicaid HMO DRG,49631,,225% x Medicaid HMO amount,49631,Other,225% of NY Medicaid HMO DRG,49631,,225% x Medicaid HMO amount,49631,Other,225% of NY Medicaid HMO DRG,49631,,225% x Medicaid HMO amount,49631,Other,225% of NY Medicaid HMO DRG,49631,,225% x Medicaid HMO amount,49631,Other,225% of NY Medicaid HMO DRG,30881,,140% x Medicaid HMO amount,30881,Other,140% of NY Medicaid HMO DRG,49631,,225% x Medicaid HMO amount,49631,Other,225% of NY Medicaid HMO DRG,60660,,275% x Medicaid HMO amount,60660,Other,275% of NY Medicaid HMO DRG,71468,,324% x Medicaid HMO amount,71468,Other,324% of NY Medicaid HMO DRG,47425,,215% x Medicaid HMO amount,47425,Other,215% of NY Medicaid HMO DRG,47425,,215% x Medicaid HMO amount,47425,Other,215% of NY Medicaid HMO DRG,27573,,125% x Medicaid HMO amount,27573,Other,125% of NY Medicaid HMO DRG,0.01,123258,
Degenerative nervous system disorders exc mult sclerosis,042-1,APR-DRG,,,,,,,,inpatient,,,106754.16,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28756,,"45,128 x DRG weight",28756,Other,base rate x DRG weight,25880,,"40,615 x DRG weight",25880,Other,base rate x DRG weight,24442,,"38,359 x DRG weight",24442,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10742,,186% x Medicaid HMO amount,10742,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21714,,"34,077 x DRG weight",21714,Other,base rate x DRG weight,18457,,"28,966 x DRG weight",18457,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5775,,DRG base rate x DRG weight + capital per discharge,5775,Other,100% of NY Medicaid HMO DRG,5775,,100% x Medicaid HMO amount,5775,Other,100% of NY Medicaid HMO DRG,5775,,100% x Medicaid HMO amount,5775,Other,100% of NY Medicaid HMO DRG,5775,,100% x Medicaid HMO amount,5775,Other,100% of NY Medicaid HMO DRG,12994,,225% x Medicaid HMO amount,12994,Other,225% of NY Medicaid HMO DRG,12994,,225% x Medicaid HMO amount,12994,Other,225% of NY Medicaid HMO DRG,12994,,225% x Medicaid HMO amount,12994,Other,225% of NY Medicaid HMO DRG,12994,,225% x Medicaid HMO amount,12994,Other,225% of NY Medicaid HMO DRG,8085,,140% x Medicaid HMO amount,8085,Other,140% of NY Medicaid HMO DRG,12994,,225% x Medicaid HMO amount,12994,Other,225% of NY Medicaid HMO DRG,15881,,275% x Medicaid HMO amount,15881,Other,275% of NY Medicaid HMO DRG,18711,,324% x Medicaid HMO amount,18711,Other,324% of NY Medicaid HMO DRG,12416,,215% x Medicaid HMO amount,12416,Other,215% of NY Medicaid HMO DRG,12416,,215% x Medicaid HMO amount,12416,Other,215% of NY Medicaid HMO DRG,7219,,125% x Medicaid HMO amount,7219,Other,125% of NY Medicaid HMO DRG,0.01,28756,
Degenerative nervous system disorders exc mult sclerosis,042-2,APR-DRG,,,,,,,,inpatient,,,173922.63,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39834,,"45,128 x DRG weight",39834,Other,base rate x DRG weight,35851,,"40,615 x DRG weight",35851,Other,base rate x DRG weight,33859,,"38,359 x DRG weight",33859,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14292,,186% x Medicaid HMO amount,14292,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30080,,"34,077 x DRG weight",30080,Other,base rate x DRG weight,25568,,"28,966 x DRG weight",25568,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7684,,DRG base rate x DRG weight + capital per discharge,7684,Other,100% of NY Medicaid HMO DRG,7684,,100% x Medicaid HMO amount,7684,Other,100% of NY Medicaid HMO DRG,7684,,100% x Medicaid HMO amount,7684,Other,100% of NY Medicaid HMO DRG,7684,,100% x Medicaid HMO amount,7684,Other,100% of NY Medicaid HMO DRG,17289,,225% x Medicaid HMO amount,17289,Other,225% of NY Medicaid HMO DRG,17289,,225% x Medicaid HMO amount,17289,Other,225% of NY Medicaid HMO DRG,17289,,225% x Medicaid HMO amount,17289,Other,225% of NY Medicaid HMO DRG,17289,,225% x Medicaid HMO amount,17289,Other,225% of NY Medicaid HMO DRG,10758,,140% x Medicaid HMO amount,10758,Other,140% of NY Medicaid HMO DRG,17289,,225% x Medicaid HMO amount,17289,Other,225% of NY Medicaid HMO DRG,21131,,275% x Medicaid HMO amount,21131,Other,275% of NY Medicaid HMO DRG,24896,,324% x Medicaid HMO amount,24896,Other,324% of NY Medicaid HMO DRG,16521,,215% x Medicaid HMO amount,16521,Other,215% of NY Medicaid HMO DRG,16521,,215% x Medicaid HMO amount,16521,Other,215% of NY Medicaid HMO DRG,9605,,125% x Medicaid HMO amount,9605,Other,125% of NY Medicaid HMO DRG,0.01,39834,
Degenerative nervous system disorders exc mult sclerosis,042-3,APR-DRG,,,,,,,,inpatient,,,130034.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,82390,,"45,128 x DRG weight",82390,Other,base rate x DRG weight,74151,,"40,615 x DRG weight",74151,Other,base rate x DRG weight,70032,,"38,359 x DRG weight",70032,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27932,,186% x Medicaid HMO amount,27932,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,62214,,"34,077 x DRG weight",62214,Other,base rate x DRG weight,52883,,"28,966 x DRG weight",52883,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15017,,DRG base rate x DRG weight + capital per discharge,15017,Other,100% of NY Medicaid HMO DRG,15017,,100% x Medicaid HMO amount,15017,Other,100% of NY Medicaid HMO DRG,15017,,100% x Medicaid HMO amount,15017,Other,100% of NY Medicaid HMO DRG,15017,,100% x Medicaid HMO amount,15017,Other,100% of NY Medicaid HMO DRG,33788,,225% x Medicaid HMO amount,33788,Other,225% of NY Medicaid HMO DRG,33788,,225% x Medicaid HMO amount,33788,Other,225% of NY Medicaid HMO DRG,33788,,225% x Medicaid HMO amount,33788,Other,225% of NY Medicaid HMO DRG,33788,,225% x Medicaid HMO amount,33788,Other,225% of NY Medicaid HMO DRG,21024,,140% x Medicaid HMO amount,21024,Other,140% of NY Medicaid HMO DRG,33788,,225% x Medicaid HMO amount,33788,Other,225% of NY Medicaid HMO DRG,41297,,275% x Medicaid HMO amount,41297,Other,275% of NY Medicaid HMO DRG,48655,,324% x Medicaid HMO amount,48655,Other,324% of NY Medicaid HMO DRG,32287,,215% x Medicaid HMO amount,32287,Other,215% of NY Medicaid HMO DRG,32287,,215% x Medicaid HMO amount,32287,Other,215% of NY Medicaid HMO DRG,18771,,125% x Medicaid HMO amount,18771,Other,125% of NY Medicaid HMO DRG,0.01,82390,
Degenerative nervous system disorders exc mult sclerosis,042-4,APR-DRG,,,,,,,,inpatient,,,411649.05,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,87702,,"45,128 x DRG weight",87702,Other,base rate x DRG weight,78931,,"40,615 x DRG weight",78931,Other,base rate x DRG weight,74547,,"38,359 x DRG weight",74547,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29634,,186% x Medicaid HMO amount,29634,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,66225,,"34,077 x DRG weight",66225,Other,base rate x DRG weight,56293,,"28,966 x DRG weight",56293,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15932,,DRG base rate x DRG weight + capital per discharge,15932,Other,100% of NY Medicaid HMO DRG,15932,,100% x Medicaid HMO amount,15932,Other,100% of NY Medicaid HMO DRG,15932,,100% x Medicaid HMO amount,15932,Other,100% of NY Medicaid HMO DRG,15932,,100% x Medicaid HMO amount,15932,Other,100% of NY Medicaid HMO DRG,35847,,225% x Medicaid HMO amount,35847,Other,225% of NY Medicaid HMO DRG,35847,,225% x Medicaid HMO amount,35847,Other,225% of NY Medicaid HMO DRG,35847,,225% x Medicaid HMO amount,35847,Other,225% of NY Medicaid HMO DRG,35847,,225% x Medicaid HMO amount,35847,Other,225% of NY Medicaid HMO DRG,22305,,140% x Medicaid HMO amount,22305,Other,140% of NY Medicaid HMO DRG,35847,,225% x Medicaid HMO amount,35847,Other,225% of NY Medicaid HMO DRG,43813,,275% x Medicaid HMO amount,43813,Other,275% of NY Medicaid HMO DRG,51620,,324% x Medicaid HMO amount,51620,Other,324% of NY Medicaid HMO DRG,34254,,215% x Medicaid HMO amount,34254,Other,215% of NY Medicaid HMO DRG,34254,,215% x Medicaid HMO amount,34254,Other,215% of NY Medicaid HMO DRG,19915,,125% x Medicaid HMO amount,19915,Other,125% of NY Medicaid HMO DRG,0.01,87702,
Multiple sclerosis & other demyelinating diseases,043-1,APR-DRG,,,,,,,,inpatient,,,63962,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35376,,"45,128 x DRG weight",35376,Other,base rate x DRG weight,31838,,"40,615 x DRG weight",31838,Other,base rate x DRG weight,30070,,"38,359 x DRG weight",30070,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12864,,186% x Medicaid HMO amount,12864,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26713,,"34,077 x DRG weight",26713,Other,base rate x DRG weight,22706,,"28,966 x DRG weight",22706,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6916,,DRG base rate x DRG weight + capital per discharge,6916,Other,100% of NY Medicaid HMO DRG,6916,,100% x Medicaid HMO amount,6916,Other,100% of NY Medicaid HMO DRG,6916,,100% x Medicaid HMO amount,6916,Other,100% of NY Medicaid HMO DRG,6916,,100% x Medicaid HMO amount,6916,Other,100% of NY Medicaid HMO DRG,15561,,225% x Medicaid HMO amount,15561,Other,225% of NY Medicaid HMO DRG,15561,,225% x Medicaid HMO amount,15561,Other,225% of NY Medicaid HMO DRG,15561,,225% x Medicaid HMO amount,15561,Other,225% of NY Medicaid HMO DRG,15561,,225% x Medicaid HMO amount,15561,Other,225% of NY Medicaid HMO DRG,9682,,140% x Medicaid HMO amount,9682,Other,140% of NY Medicaid HMO DRG,15561,,225% x Medicaid HMO amount,15561,Other,225% of NY Medicaid HMO DRG,19019,,275% x Medicaid HMO amount,19019,Other,275% of NY Medicaid HMO DRG,22408,,324% x Medicaid HMO amount,22408,Other,324% of NY Medicaid HMO DRG,14869,,215% x Medicaid HMO amount,14869,Other,215% of NY Medicaid HMO DRG,14869,,215% x Medicaid HMO amount,14869,Other,215% of NY Medicaid HMO DRG,8645,,125% x Medicaid HMO amount,8645,Other,125% of NY Medicaid HMO DRG,0.01,35376,
Multiple sclerosis & other demyelinating diseases,043-2,APR-DRG,,,,,,,,inpatient,,,100947.22,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48504,,"45,128 x DRG weight",48504,Other,base rate x DRG weight,43653,,"40,615 x DRG weight",43653,Other,base rate x DRG weight,41228,,"38,359 x DRG weight",41228,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17071,,186% x Medicaid HMO amount,17071,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36626,,"34,077 x DRG weight",36626,Other,base rate x DRG weight,31133,,"28,966 x DRG weight",31133,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9178,,DRG base rate x DRG weight + capital per discharge,9178,Other,100% of NY Medicaid HMO DRG,9178,,100% x Medicaid HMO amount,9178,Other,100% of NY Medicaid HMO DRG,9178,,100% x Medicaid HMO amount,9178,Other,100% of NY Medicaid HMO DRG,9178,,100% x Medicaid HMO amount,9178,Other,100% of NY Medicaid HMO DRG,20651,,225% x Medicaid HMO amount,20651,Other,225% of NY Medicaid HMO DRG,20651,,225% x Medicaid HMO amount,20651,Other,225% of NY Medicaid HMO DRG,20651,,225% x Medicaid HMO amount,20651,Other,225% of NY Medicaid HMO DRG,20651,,225% x Medicaid HMO amount,20651,Other,225% of NY Medicaid HMO DRG,12849,,140% x Medicaid HMO amount,12849,Other,140% of NY Medicaid HMO DRG,20651,,225% x Medicaid HMO amount,20651,Other,225% of NY Medicaid HMO DRG,25240,,275% x Medicaid HMO amount,25240,Other,275% of NY Medicaid HMO DRG,29737,,324% x Medicaid HMO amount,29737,Other,324% of NY Medicaid HMO DRG,19733,,215% x Medicaid HMO amount,19733,Other,215% of NY Medicaid HMO DRG,19733,,215% x Medicaid HMO amount,19733,Other,215% of NY Medicaid HMO DRG,11473,,125% x Medicaid HMO amount,11473,Other,125% of NY Medicaid HMO DRG,0.01,48504,
Multiple sclerosis & other demyelinating diseases,043-3,APR-DRG,,,,,,,,inpatient,,,138710.01,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,101904,,"45,128 x DRG weight",101904,Other,base rate x DRG weight,91713,,"40,615 x DRG weight",91713,Other,base rate x DRG weight,86618,,"38,359 x DRG weight",86618,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34185,,186% x Medicaid HMO amount,34185,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,76949,,"34,077 x DRG weight",76949,Other,base rate x DRG weight,65408,,"28,966 x DRG weight",65408,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18379,,DRG base rate x DRG weight + capital per discharge,18379,Other,100% of NY Medicaid HMO DRG,18379,,100% x Medicaid HMO amount,18379,Other,100% of NY Medicaid HMO DRG,18379,,100% x Medicaid HMO amount,18379,Other,100% of NY Medicaid HMO DRG,18379,,100% x Medicaid HMO amount,18379,Other,100% of NY Medicaid HMO DRG,41353,,225% x Medicaid HMO amount,41353,Other,225% of NY Medicaid HMO DRG,41353,,225% x Medicaid HMO amount,41353,Other,225% of NY Medicaid HMO DRG,41353,,225% x Medicaid HMO amount,41353,Other,225% of NY Medicaid HMO DRG,41353,,225% x Medicaid HMO amount,41353,Other,225% of NY Medicaid HMO DRG,25731,,140% x Medicaid HMO amount,25731,Other,140% of NY Medicaid HMO DRG,41353,,225% x Medicaid HMO amount,41353,Other,225% of NY Medicaid HMO DRG,50542,,275% x Medicaid HMO amount,50542,Other,275% of NY Medicaid HMO DRG,59548,,324% x Medicaid HMO amount,59548,Other,324% of NY Medicaid HMO DRG,39515,,215% x Medicaid HMO amount,39515,Other,215% of NY Medicaid HMO DRG,39515,,215% x Medicaid HMO amount,39515,Other,215% of NY Medicaid HMO DRG,22974,,125% x Medicaid HMO amount,22974,Other,125% of NY Medicaid HMO DRG,0.01,101904,
Multiple sclerosis & other demyelinating diseases,043-4,APR-DRG,,,,,,,,inpatient,,,366821.02,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,267054,,"45,128 x DRG weight",267054,Other,base rate x DRG weight,240347,,"40,615 x DRG weight",240347,Other,base rate x DRG weight,226997,,"38,359 x DRG weight",226997,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,87113,,186% x Medicaid HMO amount,87113,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,201657,,"34,077 x DRG weight",201657,Other,base rate x DRG weight,171412,,"28,966 x DRG weight",171412,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46835,,DRG base rate x DRG weight + capital per discharge,46835,Other,100% of NY Medicaid HMO DRG,46835,,100% x Medicaid HMO amount,46835,Other,100% of NY Medicaid HMO DRG,46835,,100% x Medicaid HMO amount,46835,Other,100% of NY Medicaid HMO DRG,46835,,100% x Medicaid HMO amount,46835,Other,100% of NY Medicaid HMO DRG,105379,,225% x Medicaid HMO amount,105379,Other,225% of NY Medicaid HMO DRG,105379,,225% x Medicaid HMO amount,105379,Other,225% of NY Medicaid HMO DRG,105379,,225% x Medicaid HMO amount,105379,Other,225% of NY Medicaid HMO DRG,105379,,225% x Medicaid HMO amount,105379,Other,225% of NY Medicaid HMO DRG,65569,,140% x Medicaid HMO amount,65569,Other,140% of NY Medicaid HMO DRG,105379,,225% x Medicaid HMO amount,105379,Other,225% of NY Medicaid HMO DRG,128796,,275% x Medicaid HMO amount,128796,Other,275% of NY Medicaid HMO DRG,151745,,324% x Medicaid HMO amount,151745,Other,324% of NY Medicaid HMO DRG,100695,,215% x Medicaid HMO amount,100695,Other,215% of NY Medicaid HMO DRG,100695,,215% x Medicaid HMO amount,100695,Other,215% of NY Medicaid HMO DRG,58544,,125% x Medicaid HMO amount,58544,Other,125% of NY Medicaid HMO DRG,0.01,267054,
Intracranial hemorrhage,044-1,APR-DRG,,,,,,,,inpatient,,,143706.99,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45133,,"45,128 x DRG weight",45133,Other,base rate x DRG weight,40619,,"40,615 x DRG weight",40619,Other,base rate x DRG weight,38363,,"38,359 x DRG weight",38363,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15990,,186% x Medicaid HMO amount,15990,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34080,,"34,077 x DRG weight",34080,Other,base rate x DRG weight,28969,,"28,966 x DRG weight",28969,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8597,,DRG base rate x DRG weight + capital per discharge,8597,Other,100% of NY Medicaid HMO DRG,8597,,100% x Medicaid HMO amount,8597,Other,100% of NY Medicaid HMO DRG,8597,,100% x Medicaid HMO amount,8597,Other,100% of NY Medicaid HMO DRG,8597,,100% x Medicaid HMO amount,8597,Other,100% of NY Medicaid HMO DRG,19343,,225% x Medicaid HMO amount,19343,Other,225% of NY Medicaid HMO DRG,19343,,225% x Medicaid HMO amount,19343,Other,225% of NY Medicaid HMO DRG,19343,,225% x Medicaid HMO amount,19343,Other,225% of NY Medicaid HMO DRG,19343,,225% x Medicaid HMO amount,19343,Other,225% of NY Medicaid HMO DRG,12036,,140% x Medicaid HMO amount,12036,Other,140% of NY Medicaid HMO DRG,19343,,225% x Medicaid HMO amount,19343,Other,225% of NY Medicaid HMO DRG,23642,,275% x Medicaid HMO amount,23642,Other,275% of NY Medicaid HMO DRG,27854,,324% x Medicaid HMO amount,27854,Other,324% of NY Medicaid HMO DRG,18484,,215% x Medicaid HMO amount,18484,Other,215% of NY Medicaid HMO DRG,18484,,215% x Medicaid HMO amount,18484,Other,215% of NY Medicaid HMO DRG,10746,,125% x Medicaid HMO amount,10746,Other,125% of NY Medicaid HMO DRG,0.01,45133,
Intracranial hemorrhage,044-2,APR-DRG,,,,,,,,inpatient,,,134232.85,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,66027,,"45,128 x DRG weight",66027,Other,base rate x DRG weight,59424,,"40,615 x DRG weight",59424,Other,base rate x DRG weight,56123,,"38,359 x DRG weight",56123,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22686,,186% x Medicaid HMO amount,22686,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49858,,"34,077 x DRG weight",49858,Other,base rate x DRG weight,42380,,"28,966 x DRG weight",42380,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12197,,DRG base rate x DRG weight + capital per discharge,12197,Other,100% of NY Medicaid HMO DRG,12197,,100% x Medicaid HMO amount,12197,Other,100% of NY Medicaid HMO DRG,12197,,100% x Medicaid HMO amount,12197,Other,100% of NY Medicaid HMO DRG,12197,,100% x Medicaid HMO amount,12197,Other,100% of NY Medicaid HMO DRG,27443,,225% x Medicaid HMO amount,27443,Other,225% of NY Medicaid HMO DRG,27443,,225% x Medicaid HMO amount,27443,Other,225% of NY Medicaid HMO DRG,27443,,225% x Medicaid HMO amount,27443,Other,225% of NY Medicaid HMO DRG,27443,,225% x Medicaid HMO amount,27443,Other,225% of NY Medicaid HMO DRG,17076,,140% x Medicaid HMO amount,17076,Other,140% of NY Medicaid HMO DRG,27443,,225% x Medicaid HMO amount,27443,Other,225% of NY Medicaid HMO DRG,33542,,275% x Medicaid HMO amount,33542,Other,275% of NY Medicaid HMO DRG,39518,,324% x Medicaid HMO amount,39518,Other,324% of NY Medicaid HMO DRG,26224,,215% x Medicaid HMO amount,26224,Other,215% of NY Medicaid HMO DRG,26224,,215% x Medicaid HMO amount,26224,Other,215% of NY Medicaid HMO DRG,15246,,125% x Medicaid HMO amount,15246,Other,125% of NY Medicaid HMO DRG,0.01,66027,
Intracranial hemorrhage,044-3,APR-DRG,,,,,,,,inpatient,,,275985.91,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,95468,,"45,128 x DRG weight",95468,Other,base rate x DRG weight,85921,,"40,615 x DRG weight",85921,Other,base rate x DRG weight,81148,,"38,359 x DRG weight",81148,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32122,,186% x Medicaid HMO amount,32122,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,72090,,"34,077 x DRG weight",72090,Other,base rate x DRG weight,61278,,"28,966 x DRG weight",61278,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17270,,DRG base rate x DRG weight + capital per discharge,17270,Other,100% of NY Medicaid HMO DRG,17270,,100% x Medicaid HMO amount,17270,Other,100% of NY Medicaid HMO DRG,17270,,100% x Medicaid HMO amount,17270,Other,100% of NY Medicaid HMO DRG,17270,,100% x Medicaid HMO amount,17270,Other,100% of NY Medicaid HMO DRG,38858,,225% x Medicaid HMO amount,38858,Other,225% of NY Medicaid HMO DRG,38858,,225% x Medicaid HMO amount,38858,Other,225% of NY Medicaid HMO DRG,38858,,225% x Medicaid HMO amount,38858,Other,225% of NY Medicaid HMO DRG,38858,,225% x Medicaid HMO amount,38858,Other,225% of NY Medicaid HMO DRG,24178,,140% x Medicaid HMO amount,24178,Other,140% of NY Medicaid HMO DRG,38858,,225% x Medicaid HMO amount,38858,Other,225% of NY Medicaid HMO DRG,47493,,275% x Medicaid HMO amount,47493,Other,275% of NY Medicaid HMO DRG,55955,,324% x Medicaid HMO amount,55955,Other,324% of NY Medicaid HMO DRG,37131,,215% x Medicaid HMO amount,37131,Other,215% of NY Medicaid HMO DRG,37131,,215% x Medicaid HMO amount,37131,Other,215% of NY Medicaid HMO DRG,21588,,125% x Medicaid HMO amount,21588,Other,125% of NY Medicaid HMO DRG,0.01,95468,
Intracranial hemorrhage,044-4,APR-DRG,,,,,,,,inpatient,,,479134.32,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,125397,,"45,128 x DRG weight",125397,Other,base rate x DRG weight,112857,,"40,615 x DRG weight",112857,Other,base rate x DRG weight,106588,,"38,359 x DRG weight",106588,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41714,,186% x Medicaid HMO amount,41714,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,94690,,"34,077 x DRG weight",94690,Other,base rate x DRG weight,80488,,"28,966 x DRG weight",80488,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22427,,DRG base rate x DRG weight + capital per discharge,22427,Other,100% of NY Medicaid HMO DRG,22427,,100% x Medicaid HMO amount,22427,Other,100% of NY Medicaid HMO DRG,22427,,100% x Medicaid HMO amount,22427,Other,100% of NY Medicaid HMO DRG,22427,,100% x Medicaid HMO amount,22427,Other,100% of NY Medicaid HMO DRG,50461,,225% x Medicaid HMO amount,50461,Other,225% of NY Medicaid HMO DRG,50461,,225% x Medicaid HMO amount,50461,Other,225% of NY Medicaid HMO DRG,50461,,225% x Medicaid HMO amount,50461,Other,225% of NY Medicaid HMO DRG,50461,,225% x Medicaid HMO amount,50461,Other,225% of NY Medicaid HMO DRG,31398,,140% x Medicaid HMO amount,31398,Other,140% of NY Medicaid HMO DRG,50461,,225% x Medicaid HMO amount,50461,Other,225% of NY Medicaid HMO DRG,61674,,275% x Medicaid HMO amount,61674,Other,275% of NY Medicaid HMO DRG,72663,,324% x Medicaid HMO amount,72663,Other,324% of NY Medicaid HMO DRG,48218,,215% x Medicaid HMO amount,48218,Other,215% of NY Medicaid HMO DRG,48218,,215% x Medicaid HMO amount,48218,Other,215% of NY Medicaid HMO DRG,28034,,125% x Medicaid HMO amount,28034,Other,125% of NY Medicaid HMO DRG,0.01,125397,
CVA & precerebral occlusion w infarct,045-1,APR-DRG,,,,,,,,inpatient,,,109772.6,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35981,,"45,128 x DRG weight",35981,Other,base rate x DRG weight,32382,,"40,615 x DRG weight",32382,Other,base rate x DRG weight,30584,,"38,359 x DRG weight",30584,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13057,,186% x Medicaid HMO amount,13057,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27170,,"34,077 x DRG weight",27170,Other,base rate x DRG weight,23095,,"28,966 x DRG weight",23095,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7020,,DRG base rate x DRG weight + capital per discharge,7020,Other,100% of NY Medicaid HMO DRG,7020,,100% x Medicaid HMO amount,7020,Other,100% of NY Medicaid HMO DRG,7020,,100% x Medicaid HMO amount,7020,Other,100% of NY Medicaid HMO DRG,7020,,100% x Medicaid HMO amount,7020,Other,100% of NY Medicaid HMO DRG,15795,,225% x Medicaid HMO amount,15795,Other,225% of NY Medicaid HMO DRG,15795,,225% x Medicaid HMO amount,15795,Other,225% of NY Medicaid HMO DRG,15795,,225% x Medicaid HMO amount,15795,Other,225% of NY Medicaid HMO DRG,15795,,225% x Medicaid HMO amount,15795,Other,225% of NY Medicaid HMO DRG,9828,,140% x Medicaid HMO amount,9828,Other,140% of NY Medicaid HMO DRG,15795,,225% x Medicaid HMO amount,15795,Other,225% of NY Medicaid HMO DRG,19305,,275% x Medicaid HMO amount,19305,Other,275% of NY Medicaid HMO DRG,22745,,324% x Medicaid HMO amount,22745,Other,324% of NY Medicaid HMO DRG,15093,,215% x Medicaid HMO amount,15093,Other,215% of NY Medicaid HMO DRG,15093,,215% x Medicaid HMO amount,15093,Other,215% of NY Medicaid HMO DRG,8775,,125% x Medicaid HMO amount,8775,Other,125% of NY Medicaid HMO DRG,0.01,35981,
CVA & precerebral occlusion w infarct,045-2,APR-DRG,,,,,,,,inpatient,,,210289.76,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50151,,"45,128 x DRG weight",50151,Other,base rate x DRG weight,45135,,"40,615 x DRG weight",45135,Other,base rate x DRG weight,42628,,"38,359 x DRG weight",42628,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17599,,186% x Medicaid HMO amount,17599,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37870,,"34,077 x DRG weight",37870,Other,base rate x DRG weight,32190,,"28,966 x DRG weight",32190,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9462,,DRG base rate x DRG weight + capital per discharge,9462,Other,100% of NY Medicaid HMO DRG,9462,,100% x Medicaid HMO amount,9462,Other,100% of NY Medicaid HMO DRG,9462,,100% x Medicaid HMO amount,9462,Other,100% of NY Medicaid HMO DRG,9462,,100% x Medicaid HMO amount,9462,Other,100% of NY Medicaid HMO DRG,21290,,225% x Medicaid HMO amount,21290,Other,225% of NY Medicaid HMO DRG,21290,,225% x Medicaid HMO amount,21290,Other,225% of NY Medicaid HMO DRG,21290,,225% x Medicaid HMO amount,21290,Other,225% of NY Medicaid HMO DRG,21290,,225% x Medicaid HMO amount,21290,Other,225% of NY Medicaid HMO DRG,13247,,140% x Medicaid HMO amount,13247,Other,140% of NY Medicaid HMO DRG,21290,,225% x Medicaid HMO amount,21290,Other,225% of NY Medicaid HMO DRG,26021,,275% x Medicaid HMO amount,26021,Other,275% of NY Medicaid HMO DRG,30657,,324% x Medicaid HMO amount,30657,Other,324% of NY Medicaid HMO DRG,20343,,215% x Medicaid HMO amount,20343,Other,215% of NY Medicaid HMO DRG,20343,,215% x Medicaid HMO amount,20343,Other,215% of NY Medicaid HMO DRG,11828,,125% x Medicaid HMO amount,11828,Other,125% of NY Medicaid HMO DRG,0.01,50151,
CVA & precerebral occlusion w infarct,045-3,APR-DRG,,,,,,,,inpatient,,,205432.59,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,77679,,"45,128 x DRG weight",77679,Other,base rate x DRG weight,69911,,"40,615 x DRG weight",69911,Other,base rate x DRG weight,66027,,"38,359 x DRG weight",66027,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26421,,186% x Medicaid HMO amount,26421,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,58657,,"34,077 x DRG weight",58657,Other,base rate x DRG weight,49859,,"28,966 x DRG weight",49859,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14205,,DRG base rate x DRG weight + capital per discharge,14205,Other,100% of NY Medicaid HMO DRG,14205,,100% x Medicaid HMO amount,14205,Other,100% of NY Medicaid HMO DRG,14205,,100% x Medicaid HMO amount,14205,Other,100% of NY Medicaid HMO DRG,14205,,100% x Medicaid HMO amount,14205,Other,100% of NY Medicaid HMO DRG,31961,,225% x Medicaid HMO amount,31961,Other,225% of NY Medicaid HMO DRG,31961,,225% x Medicaid HMO amount,31961,Other,225% of NY Medicaid HMO DRG,31961,,225% x Medicaid HMO amount,31961,Other,225% of NY Medicaid HMO DRG,31961,,225% x Medicaid HMO amount,31961,Other,225% of NY Medicaid HMO DRG,19887,,140% x Medicaid HMO amount,19887,Other,140% of NY Medicaid HMO DRG,31961,,225% x Medicaid HMO amount,31961,Other,225% of NY Medicaid HMO DRG,39064,,275% x Medicaid HMO amount,39064,Other,275% of NY Medicaid HMO DRG,46024,,324% x Medicaid HMO amount,46024,Other,324% of NY Medicaid HMO DRG,30541,,215% x Medicaid HMO amount,30541,Other,215% of NY Medicaid HMO DRG,30541,,215% x Medicaid HMO amount,30541,Other,215% of NY Medicaid HMO DRG,17756,,125% x Medicaid HMO amount,17756,Other,125% of NY Medicaid HMO DRG,0.01,77679,
CVA & precerebral occlusion w infarct,045-4,APR-DRG,,,,,,,,inpatient,,,592370.68,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,154347,,"45,128 x DRG weight",154347,Other,base rate x DRG weight,138911,,"40,615 x DRG weight",138911,Other,base rate x DRG weight,131195,,"38,359 x DRG weight",131195,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50992,,186% x Medicaid HMO amount,50992,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,116550,,"34,077 x DRG weight",116550,Other,base rate x DRG weight,99070,,"28,966 x DRG weight",99070,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27415,,DRG base rate x DRG weight + capital per discharge,27415,Other,100% of NY Medicaid HMO DRG,27415,,100% x Medicaid HMO amount,27415,Other,100% of NY Medicaid HMO DRG,27415,,100% x Medicaid HMO amount,27415,Other,100% of NY Medicaid HMO DRG,27415,,100% x Medicaid HMO amount,27415,Other,100% of NY Medicaid HMO DRG,61684,,225% x Medicaid HMO amount,61684,Other,225% of NY Medicaid HMO DRG,61684,,225% x Medicaid HMO amount,61684,Other,225% of NY Medicaid HMO DRG,61684,,225% x Medicaid HMO amount,61684,Other,225% of NY Medicaid HMO DRG,61684,,225% x Medicaid HMO amount,61684,Other,225% of NY Medicaid HMO DRG,38381,,140% x Medicaid HMO amount,38381,Other,140% of NY Medicaid HMO DRG,61684,,225% x Medicaid HMO amount,61684,Other,225% of NY Medicaid HMO DRG,75391,,275% x Medicaid HMO amount,75391,Other,275% of NY Medicaid HMO DRG,88825,,324% x Medicaid HMO amount,88825,Other,324% of NY Medicaid HMO DRG,58942,,215% x Medicaid HMO amount,58942,Other,215% of NY Medicaid HMO DRG,58942,,215% x Medicaid HMO amount,58942,Other,215% of NY Medicaid HMO DRG,34269,,125% x Medicaid HMO amount,34269,Other,125% of NY Medicaid HMO DRG,0.01,154347,
Nonspecific CVA & precerebral occlusion w/o infarct,046-1,APR-DRG,,,,,,,,inpatient,,,63313.52,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28498,,"45,128 x DRG weight",28498,Other,base rate x DRG weight,25648,,"40,615 x DRG weight",25648,Other,base rate x DRG weight,24224,,"38,359 x DRG weight",24224,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10660,,186% x Medicaid HMO amount,10660,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21520,,"34,077 x DRG weight",21520,Other,base rate x DRG weight,18292,,"28,966 x DRG weight",18292,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5731,,DRG base rate x DRG weight + capital per discharge,5731,Other,100% of NY Medicaid HMO DRG,5731,,100% x Medicaid HMO amount,5731,Other,100% of NY Medicaid HMO DRG,5731,,100% x Medicaid HMO amount,5731,Other,100% of NY Medicaid HMO DRG,5731,,100% x Medicaid HMO amount,5731,Other,100% of NY Medicaid HMO DRG,12895,,225% x Medicaid HMO amount,12895,Other,225% of NY Medicaid HMO DRG,12895,,225% x Medicaid HMO amount,12895,Other,225% of NY Medicaid HMO DRG,12895,,225% x Medicaid HMO amount,12895,Other,225% of NY Medicaid HMO DRG,12895,,225% x Medicaid HMO amount,12895,Other,225% of NY Medicaid HMO DRG,8023,,140% x Medicaid HMO amount,8023,Other,140% of NY Medicaid HMO DRG,12895,,225% x Medicaid HMO amount,12895,Other,225% of NY Medicaid HMO DRG,15760,,275% x Medicaid HMO amount,15760,Other,275% of NY Medicaid HMO DRG,18568,,324% x Medicaid HMO amount,18568,Other,324% of NY Medicaid HMO DRG,12322,,215% x Medicaid HMO amount,12322,Other,215% of NY Medicaid HMO DRG,12322,,215% x Medicaid HMO amount,12322,Other,215% of NY Medicaid HMO DRG,7164,,125% x Medicaid HMO amount,7164,Other,125% of NY Medicaid HMO DRG,0.01,28498,
Nonspecific CVA & precerebral occlusion w/o infarct,046-2,APR-DRG,,,,,,,,inpatient,,,125107.23,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38287,,"45,128 x DRG weight",38287,Other,base rate x DRG weight,34458,,"40,615 x DRG weight",34458,Other,base rate x DRG weight,32544,,"38,359 x DRG weight",32544,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13797,,186% x Medicaid HMO amount,13797,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28911,,"34,077 x DRG weight",28911,Other,base rate x DRG weight,24575,,"28,966 x DRG weight",24575,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7418,,DRG base rate x DRG weight + capital per discharge,7418,Other,100% of NY Medicaid HMO DRG,7418,,100% x Medicaid HMO amount,7418,Other,100% of NY Medicaid HMO DRG,7418,,100% x Medicaid HMO amount,7418,Other,100% of NY Medicaid HMO DRG,7418,,100% x Medicaid HMO amount,7418,Other,100% of NY Medicaid HMO DRG,16691,,225% x Medicaid HMO amount,16691,Other,225% of NY Medicaid HMO DRG,16691,,225% x Medicaid HMO amount,16691,Other,225% of NY Medicaid HMO DRG,16691,,225% x Medicaid HMO amount,16691,Other,225% of NY Medicaid HMO DRG,16691,,225% x Medicaid HMO amount,16691,Other,225% of NY Medicaid HMO DRG,10385,,140% x Medicaid HMO amount,10385,Other,140% of NY Medicaid HMO DRG,16691,,225% x Medicaid HMO amount,16691,Other,225% of NY Medicaid HMO DRG,20400,,275% x Medicaid HMO amount,20400,Other,275% of NY Medicaid HMO DRG,24034,,324% x Medicaid HMO amount,24034,Other,324% of NY Medicaid HMO DRG,15949,,215% x Medicaid HMO amount,15949,Other,215% of NY Medicaid HMO DRG,15949,,215% x Medicaid HMO amount,15949,Other,215% of NY Medicaid HMO DRG,9273,,125% x Medicaid HMO amount,9273,Other,125% of NY Medicaid HMO DRG,0.01,38287,
Nonspecific CVA & precerebral occlusion w/o infarct,046-3,APR-DRG,,,,,,,,inpatient,,,91913.6,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49903,,"45,128 x DRG weight",49903,Other,base rate x DRG weight,44912,,"40,615 x DRG weight",44912,Other,base rate x DRG weight,42417,,"38,359 x DRG weight",42417,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17519,,186% x Medicaid HMO amount,17519,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37682,,"34,077 x DRG weight",37682,Other,base rate x DRG weight,32031,,"28,966 x DRG weight",32031,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9419,,DRG base rate x DRG weight + capital per discharge,9419,Other,100% of NY Medicaid HMO DRG,9419,,100% x Medicaid HMO amount,9419,Other,100% of NY Medicaid HMO DRG,9419,,100% x Medicaid HMO amount,9419,Other,100% of NY Medicaid HMO DRG,9419,,100% x Medicaid HMO amount,9419,Other,100% of NY Medicaid HMO DRG,21193,,225% x Medicaid HMO amount,21193,Other,225% of NY Medicaid HMO DRG,21193,,225% x Medicaid HMO amount,21193,Other,225% of NY Medicaid HMO DRG,21193,,225% x Medicaid HMO amount,21193,Other,225% of NY Medicaid HMO DRG,21193,,225% x Medicaid HMO amount,21193,Other,225% of NY Medicaid HMO DRG,13187,,140% x Medicaid HMO amount,13187,Other,140% of NY Medicaid HMO DRG,21193,,225% x Medicaid HMO amount,21193,Other,225% of NY Medicaid HMO DRG,25902,,275% x Medicaid HMO amount,25902,Other,275% of NY Medicaid HMO DRG,30518,,324% x Medicaid HMO amount,30518,Other,324% of NY Medicaid HMO DRG,20251,,215% x Medicaid HMO amount,20251,Other,215% of NY Medicaid HMO DRG,20251,,215% x Medicaid HMO amount,20251,Other,215% of NY Medicaid HMO DRG,11774,,125% x Medicaid HMO amount,11774,Other,125% of NY Medicaid HMO DRG,0.01,49903,
Nonspecific CVA & precerebral occlusion w/o infarct,046-4,APR-DRG,,,,,,,,inpatient,,,170256,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52145,,"45,128 x DRG weight",52145,Other,base rate x DRG weight,46931,,"40,615 x DRG weight",46931,Other,base rate x DRG weight,44324,,"38,359 x DRG weight",44324,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18239,,186% x Medicaid HMO amount,18239,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39376,,"34,077 x DRG weight",39376,Other,base rate x DRG weight,33470,,"28,966 x DRG weight",33470,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9806,,DRG base rate x DRG weight + capital per discharge,9806,Other,100% of NY Medicaid HMO DRG,9806,,100% x Medicaid HMO amount,9806,Other,100% of NY Medicaid HMO DRG,9806,,100% x Medicaid HMO amount,9806,Other,100% of NY Medicaid HMO DRG,9806,,100% x Medicaid HMO amount,9806,Other,100% of NY Medicaid HMO DRG,22064,,225% x Medicaid HMO amount,22064,Other,225% of NY Medicaid HMO DRG,22064,,225% x Medicaid HMO amount,22064,Other,225% of NY Medicaid HMO DRG,22064,,225% x Medicaid HMO amount,22064,Other,225% of NY Medicaid HMO DRG,22064,,225% x Medicaid HMO amount,22064,Other,225% of NY Medicaid HMO DRG,13728,,140% x Medicaid HMO amount,13728,Other,140% of NY Medicaid HMO DRG,22064,,225% x Medicaid HMO amount,22064,Other,225% of NY Medicaid HMO DRG,26967,,275% x Medicaid HMO amount,26967,Other,275% of NY Medicaid HMO DRG,31771,,324% x Medicaid HMO amount,31771,Other,324% of NY Medicaid HMO DRG,21083,,215% x Medicaid HMO amount,21083,Other,215% of NY Medicaid HMO DRG,21083,,215% x Medicaid HMO amount,21083,Other,215% of NY Medicaid HMO DRG,12258,,125% x Medicaid HMO amount,12258,Other,125% of NY Medicaid HMO DRG,0.01,52145,
Transient ischemia,047-1,APR-DRG,,,,,,,,inpatient,,,92888.52,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23169,,"45,128 x DRG weight",23169,Other,base rate x DRG weight,20852,,"40,615 x DRG weight",20852,Other,base rate x DRG weight,19694,,"38,359 x DRG weight",19694,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8952,,186% x Medicaid HMO amount,8952,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17495,,"34,077 x DRG weight",17495,Other,base rate x DRG weight,14871,,"28,966 x DRG weight",14871,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4813,,DRG base rate x DRG weight + capital per discharge,4813,Other,100% of NY Medicaid HMO DRG,4813,,100% x Medicaid HMO amount,4813,Other,100% of NY Medicaid HMO DRG,4813,,100% x Medicaid HMO amount,4813,Other,100% of NY Medicaid HMO DRG,4813,,100% x Medicaid HMO amount,4813,Other,100% of NY Medicaid HMO DRG,10829,,225% x Medicaid HMO amount,10829,Other,225% of NY Medicaid HMO DRG,10829,,225% x Medicaid HMO amount,10829,Other,225% of NY Medicaid HMO DRG,10829,,225% x Medicaid HMO amount,10829,Other,225% of NY Medicaid HMO DRG,10829,,225% x Medicaid HMO amount,10829,Other,225% of NY Medicaid HMO DRG,6738,,140% x Medicaid HMO amount,6738,Other,140% of NY Medicaid HMO DRG,10829,,225% x Medicaid HMO amount,10829,Other,225% of NY Medicaid HMO DRG,13236,,275% x Medicaid HMO amount,13236,Other,275% of NY Medicaid HMO DRG,15594,,324% x Medicaid HMO amount,15594,Other,324% of NY Medicaid HMO DRG,10348,,215% x Medicaid HMO amount,10348,Other,215% of NY Medicaid HMO DRG,10348,,215% x Medicaid HMO amount,10348,Other,215% of NY Medicaid HMO DRG,6016,,125% x Medicaid HMO amount,6016,Other,125% of NY Medicaid HMO DRG,0.01,23169,
Transient ischemia,047-2,APR-DRG,,,,,,,,inpatient,,,114868.04,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28562,,"45,128 x DRG weight",28562,Other,base rate x DRG weight,25705,,"40,615 x DRG weight",25705,Other,base rate x DRG weight,24277,,"38,359 x DRG weight",24277,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10680,,186% x Medicaid HMO amount,10680,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21567,,"34,077 x DRG weight",21567,Other,base rate x DRG weight,18333,,"28,966 x DRG weight",18333,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5742,,DRG base rate x DRG weight + capital per discharge,5742,Other,100% of NY Medicaid HMO DRG,5742,,100% x Medicaid HMO amount,5742,Other,100% of NY Medicaid HMO DRG,5742,,100% x Medicaid HMO amount,5742,Other,100% of NY Medicaid HMO DRG,5742,,100% x Medicaid HMO amount,5742,Other,100% of NY Medicaid HMO DRG,12920,,225% x Medicaid HMO amount,12920,Other,225% of NY Medicaid HMO DRG,12920,,225% x Medicaid HMO amount,12920,Other,225% of NY Medicaid HMO DRG,12920,,225% x Medicaid HMO amount,12920,Other,225% of NY Medicaid HMO DRG,12920,,225% x Medicaid HMO amount,12920,Other,225% of NY Medicaid HMO DRG,8039,,140% x Medicaid HMO amount,8039,Other,140% of NY Medicaid HMO DRG,12920,,225% x Medicaid HMO amount,12920,Other,225% of NY Medicaid HMO DRG,15791,,275% x Medicaid HMO amount,15791,Other,275% of NY Medicaid HMO DRG,18604,,324% x Medicaid HMO amount,18604,Other,324% of NY Medicaid HMO DRG,12345,,215% x Medicaid HMO amount,12345,Other,215% of NY Medicaid HMO DRG,12345,,215% x Medicaid HMO amount,12345,Other,215% of NY Medicaid HMO DRG,7178,,125% x Medicaid HMO amount,7178,Other,125% of NY Medicaid HMO DRG,0.01,28562,
Transient ischemia,047-3,APR-DRG,,,,,,,,inpatient,,,86204.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39514,,"45,128 x DRG weight",39514,Other,base rate x DRG weight,35562,,"40,615 x DRG weight",35562,Other,base rate x DRG weight,33587,,"38,359 x DRG weight",33587,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14190,,186% x Medicaid HMO amount,14190,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29838,,"34,077 x DRG weight",29838,Other,base rate x DRG weight,25363,,"28,966 x DRG weight",25363,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7629,,DRG base rate x DRG weight + capital per discharge,7629,Other,100% of NY Medicaid HMO DRG,7629,,100% x Medicaid HMO amount,7629,Other,100% of NY Medicaid HMO DRG,7629,,100% x Medicaid HMO amount,7629,Other,100% of NY Medicaid HMO DRG,7629,,100% x Medicaid HMO amount,7629,Other,100% of NY Medicaid HMO DRG,17165,,225% x Medicaid HMO amount,17165,Other,225% of NY Medicaid HMO DRG,17165,,225% x Medicaid HMO amount,17165,Other,225% of NY Medicaid HMO DRG,17165,,225% x Medicaid HMO amount,17165,Other,225% of NY Medicaid HMO DRG,17165,,225% x Medicaid HMO amount,17165,Other,225% of NY Medicaid HMO DRG,10681,,140% x Medicaid HMO amount,10681,Other,140% of NY Medicaid HMO DRG,17165,,225% x Medicaid HMO amount,17165,Other,225% of NY Medicaid HMO DRG,20980,,275% x Medicaid HMO amount,20980,Other,275% of NY Medicaid HMO DRG,24718,,324% x Medicaid HMO amount,24718,Other,324% of NY Medicaid HMO DRG,16402,,215% x Medicaid HMO amount,16402,Other,215% of NY Medicaid HMO DRG,16402,,215% x Medicaid HMO amount,16402,Other,215% of NY Medicaid HMO DRG,9536,,125% x Medicaid HMO amount,9536,Other,125% of NY Medicaid HMO DRG,0.01,39514,
Transient ischemia,047-4,APR-DRG,,,,,,,,inpatient,,,114868.04,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40457,,"45,128 x DRG weight",40457,Other,base rate x DRG weight,36411,,"40,615 x DRG weight",36411,Other,base rate x DRG weight,34389,,"38,359 x DRG weight",34389,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14493,,186% x Medicaid HMO amount,14493,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30550,,"34,077 x DRG weight",30550,Other,base rate x DRG weight,25968,,"28,966 x DRG weight",25968,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7792,,DRG base rate x DRG weight + capital per discharge,7792,Other,100% of NY Medicaid HMO DRG,7792,,100% x Medicaid HMO amount,7792,Other,100% of NY Medicaid HMO DRG,7792,,100% x Medicaid HMO amount,7792,Other,100% of NY Medicaid HMO DRG,7792,,100% x Medicaid HMO amount,7792,Other,100% of NY Medicaid HMO DRG,17532,,225% x Medicaid HMO amount,17532,Other,225% of NY Medicaid HMO DRG,17532,,225% x Medicaid HMO amount,17532,Other,225% of NY Medicaid HMO DRG,17532,,225% x Medicaid HMO amount,17532,Other,225% of NY Medicaid HMO DRG,17532,,225% x Medicaid HMO amount,17532,Other,225% of NY Medicaid HMO DRG,10909,,140% x Medicaid HMO amount,10909,Other,140% of NY Medicaid HMO DRG,17532,,225% x Medicaid HMO amount,17532,Other,225% of NY Medicaid HMO DRG,21428,,275% x Medicaid HMO amount,21428,Other,275% of NY Medicaid HMO DRG,25246,,324% x Medicaid HMO amount,25246,Other,324% of NY Medicaid HMO DRG,16753,,215% x Medicaid HMO amount,16753,Other,215% of NY Medicaid HMO DRG,16753,,215% x Medicaid HMO amount,16753,Other,215% of NY Medicaid HMO DRG,9740,,125% x Medicaid HMO amount,9740,Other,125% of NY Medicaid HMO DRG,0.01,40457,
"Peripheral, cranial & autonomic nerve disorders",048-1,APR-DRG,,,,,,,,inpatient,,,146144.94,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24992,,"45,128 x DRG weight",24992,Other,base rate x DRG weight,22493,,"40,615 x DRG weight",22493,Other,base rate x DRG weight,21243,,"38,359 x DRG weight",21243,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9536,,186% x Medicaid HMO amount,9536,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18872,,"34,077 x DRG weight",18872,Other,base rate x DRG weight,16041,,"28,966 x DRG weight",16041,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5127,,DRG base rate x DRG weight + capital per discharge,5127,Other,100% of NY Medicaid HMO DRG,5127,,100% x Medicaid HMO amount,5127,Other,100% of NY Medicaid HMO DRG,5127,,100% x Medicaid HMO amount,5127,Other,100% of NY Medicaid HMO DRG,5127,,100% x Medicaid HMO amount,5127,Other,100% of NY Medicaid HMO DRG,11536,,225% x Medicaid HMO amount,11536,Other,225% of NY Medicaid HMO DRG,11536,,225% x Medicaid HMO amount,11536,Other,225% of NY Medicaid HMO DRG,11536,,225% x Medicaid HMO amount,11536,Other,225% of NY Medicaid HMO DRG,11536,,225% x Medicaid HMO amount,11536,Other,225% of NY Medicaid HMO DRG,7178,,140% x Medicaid HMO amount,7178,Other,140% of NY Medicaid HMO DRG,11536,,225% x Medicaid HMO amount,11536,Other,225% of NY Medicaid HMO DRG,14099,,275% x Medicaid HMO amount,14099,Other,275% of NY Medicaid HMO DRG,16611,,324% x Medicaid HMO amount,16611,Other,324% of NY Medicaid HMO DRG,11023,,215% x Medicaid HMO amount,11023,Other,215% of NY Medicaid HMO DRG,11023,,215% x Medicaid HMO amount,11023,Other,215% of NY Medicaid HMO DRG,6409,,125% x Medicaid HMO amount,6409,Other,125% of NY Medicaid HMO DRG,0.01,24992,
"Peripheral, cranial & autonomic nerve disorders",048-2,APR-DRG,,,,,,,,inpatient,,,250051.21,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33363,,"45,128 x DRG weight",33363,Other,base rate x DRG weight,30027,,"40,615 x DRG weight",30027,Other,base rate x DRG weight,28359,,"38,359 x DRG weight",28359,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12218,,186% x Medicaid HMO amount,12218,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25193,,"34,077 x DRG weight",25193,Other,base rate x DRG weight,21415,,"28,966 x DRG weight",21415,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6569,,DRG base rate x DRG weight + capital per discharge,6569,Other,100% of NY Medicaid HMO DRG,6569,,100% x Medicaid HMO amount,6569,Other,100% of NY Medicaid HMO DRG,6569,,100% x Medicaid HMO amount,6569,Other,100% of NY Medicaid HMO DRG,6569,,100% x Medicaid HMO amount,6569,Other,100% of NY Medicaid HMO DRG,14780,,225% x Medicaid HMO amount,14780,Other,225% of NY Medicaid HMO DRG,14780,,225% x Medicaid HMO amount,14780,Other,225% of NY Medicaid HMO DRG,14780,,225% x Medicaid HMO amount,14780,Other,225% of NY Medicaid HMO DRG,14780,,225% x Medicaid HMO amount,14780,Other,225% of NY Medicaid HMO DRG,9197,,140% x Medicaid HMO amount,9197,Other,140% of NY Medicaid HMO DRG,14780,,225% x Medicaid HMO amount,14780,Other,225% of NY Medicaid HMO DRG,18065,,275% x Medicaid HMO amount,18065,Other,275% of NY Medicaid HMO DRG,21284,,324% x Medicaid HMO amount,21284,Other,324% of NY Medicaid HMO DRG,14123,,215% x Medicaid HMO amount,14123,Other,215% of NY Medicaid HMO DRG,14123,,215% x Medicaid HMO amount,14123,Other,215% of NY Medicaid HMO DRG,8211,,125% x Medicaid HMO amount,8211,Other,125% of NY Medicaid HMO DRG,0.01,33363,
"Peripheral, cranial & autonomic nerve disorders",048-3,APR-DRG,,,,,,,,inpatient,,,137867.03,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49916,,"45,128 x DRG weight",49916,Other,base rate x DRG weight,44924,,"40,615 x DRG weight",44924,Other,base rate x DRG weight,42429,,"38,359 x DRG weight",42429,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17523,,186% x Medicaid HMO amount,17523,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37693,,"34,077 x DRG weight",37693,Other,base rate x DRG weight,32039,,"28,966 x DRG weight",32039,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9421,,DRG base rate x DRG weight + capital per discharge,9421,Other,100% of NY Medicaid HMO DRG,9421,,100% x Medicaid HMO amount,9421,Other,100% of NY Medicaid HMO DRG,9421,,100% x Medicaid HMO amount,9421,Other,100% of NY Medicaid HMO DRG,9421,,100% x Medicaid HMO amount,9421,Other,100% of NY Medicaid HMO DRG,21197,,225% x Medicaid HMO amount,21197,Other,225% of NY Medicaid HMO DRG,21197,,225% x Medicaid HMO amount,21197,Other,225% of NY Medicaid HMO DRG,21197,,225% x Medicaid HMO amount,21197,Other,225% of NY Medicaid HMO DRG,21197,,225% x Medicaid HMO amount,21197,Other,225% of NY Medicaid HMO DRG,13189,,140% x Medicaid HMO amount,13189,Other,140% of NY Medicaid HMO DRG,21197,,225% x Medicaid HMO amount,21197,Other,225% of NY Medicaid HMO DRG,25908,,275% x Medicaid HMO amount,25908,Other,275% of NY Medicaid HMO DRG,30524,,324% x Medicaid HMO amount,30524,Other,324% of NY Medicaid HMO DRG,20255,,215% x Medicaid HMO amount,20255,Other,215% of NY Medicaid HMO DRG,20255,,215% x Medicaid HMO amount,20255,Other,215% of NY Medicaid HMO DRG,11776,,125% x Medicaid HMO amount,11776,Other,125% of NY Medicaid HMO DRG,0.01,49916,
"Peripheral, cranial & autonomic nerve disorders",048-4,APR-DRG,,,,,,,,inpatient,,,240670.21,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,157239,,"45,128 x DRG weight",157239,Other,base rate x DRG weight,141515,,"40,615 x DRG weight",141515,Other,base rate x DRG weight,133654,,"38,359 x DRG weight",133654,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51918,,186% x Medicaid HMO amount,51918,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,118734,,"34,077 x DRG weight",118734,Other,base rate x DRG weight,100926,,"28,966 x DRG weight",100926,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27913,,DRG base rate x DRG weight + capital per discharge,27913,Other,100% of NY Medicaid HMO DRG,27913,,100% x Medicaid HMO amount,27913,Other,100% of NY Medicaid HMO DRG,27913,,100% x Medicaid HMO amount,27913,Other,100% of NY Medicaid HMO DRG,27913,,100% x Medicaid HMO amount,27913,Other,100% of NY Medicaid HMO DRG,62804,,225% x Medicaid HMO amount,62804,Other,225% of NY Medicaid HMO DRG,62804,,225% x Medicaid HMO amount,62804,Other,225% of NY Medicaid HMO DRG,62804,,225% x Medicaid HMO amount,62804,Other,225% of NY Medicaid HMO DRG,62804,,225% x Medicaid HMO amount,62804,Other,225% of NY Medicaid HMO DRG,39078,,140% x Medicaid HMO amount,39078,Other,140% of NY Medicaid HMO DRG,62804,,225% x Medicaid HMO amount,62804,Other,225% of NY Medicaid HMO DRG,76761,,275% x Medicaid HMO amount,76761,Other,275% of NY Medicaid HMO DRG,90438,,324% x Medicaid HMO amount,90438,Other,324% of NY Medicaid HMO DRG,60013,,215% x Medicaid HMO amount,60013,Other,215% of NY Medicaid HMO DRG,60013,,215% x Medicaid HMO amount,60013,Other,215% of NY Medicaid HMO DRG,34891,,125% x Medicaid HMO amount,34891,Other,125% of NY Medicaid HMO DRG,0.01,157239,
Bacterial & tuberculous infections of nervous system,049-1,APR-DRG,,,,,,,,inpatient,,,238126.44,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52565,,"45,128 x DRG weight",52565,Other,base rate x DRG weight,47308,,"40,615 x DRG weight",47308,Other,base rate x DRG weight,44681,,"38,359 x DRG weight",44681,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18373,,186% x Medicaid HMO amount,18373,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39693,,"34,077 x DRG weight",39693,Other,base rate x DRG weight,33740,,"28,966 x DRG weight",33740,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9878,,DRG base rate x DRG weight + capital per discharge,9878,Other,100% of NY Medicaid HMO DRG,9878,,100% x Medicaid HMO amount,9878,Other,100% of NY Medicaid HMO DRG,9878,,100% x Medicaid HMO amount,9878,Other,100% of NY Medicaid HMO DRG,9878,,100% x Medicaid HMO amount,9878,Other,100% of NY Medicaid HMO DRG,22226,,225% x Medicaid HMO amount,22226,Other,225% of NY Medicaid HMO DRG,22226,,225% x Medicaid HMO amount,22226,Other,225% of NY Medicaid HMO DRG,22226,,225% x Medicaid HMO amount,22226,Other,225% of NY Medicaid HMO DRG,22226,,225% x Medicaid HMO amount,22226,Other,225% of NY Medicaid HMO DRG,13829,,140% x Medicaid HMO amount,13829,Other,140% of NY Medicaid HMO DRG,22226,,225% x Medicaid HMO amount,22226,Other,225% of NY Medicaid HMO DRG,27165,,275% x Medicaid HMO amount,27165,Other,275% of NY Medicaid HMO DRG,32005,,324% x Medicaid HMO amount,32005,Other,324% of NY Medicaid HMO DRG,21238,,215% x Medicaid HMO amount,21238,Other,215% of NY Medicaid HMO DRG,21238,,215% x Medicaid HMO amount,21238,Other,215% of NY Medicaid HMO DRG,12348,,125% x Medicaid HMO amount,12348,Other,125% of NY Medicaid HMO DRG,0.01,52565,
Bacterial & tuberculous infections of nervous system,049-2,APR-DRG,,,,,,,,inpatient,,,201766.55,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,112328,,"45,128 x DRG weight",112328,Other,base rate x DRG weight,101095,,"40,615 x DRG weight",101095,Other,base rate x DRG weight,95479,,"38,359 x DRG weight",95479,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37526,,186% x Medicaid HMO amount,37526,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,84821,,"34,077 x DRG weight",84821,Other,base rate x DRG weight,72099,,"28,966 x DRG weight",72099,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20175,,DRG base rate x DRG weight + capital per discharge,20175,Other,100% of NY Medicaid HMO DRG,20175,,100% x Medicaid HMO amount,20175,Other,100% of NY Medicaid HMO DRG,20175,,100% x Medicaid HMO amount,20175,Other,100% of NY Medicaid HMO DRG,20175,,100% x Medicaid HMO amount,20175,Other,100% of NY Medicaid HMO DRG,45394,,225% x Medicaid HMO amount,45394,Other,225% of NY Medicaid HMO DRG,45394,,225% x Medicaid HMO amount,45394,Other,225% of NY Medicaid HMO DRG,45394,,225% x Medicaid HMO amount,45394,Other,225% of NY Medicaid HMO DRG,45394,,225% x Medicaid HMO amount,45394,Other,225% of NY Medicaid HMO DRG,28245,,140% x Medicaid HMO amount,28245,Other,140% of NY Medicaid HMO DRG,45394,,225% x Medicaid HMO amount,45394,Other,225% of NY Medicaid HMO DRG,55481,,275% x Medicaid HMO amount,55481,Other,275% of NY Medicaid HMO DRG,65367,,324% x Medicaid HMO amount,65367,Other,324% of NY Medicaid HMO DRG,43376,,215% x Medicaid HMO amount,43376,Other,215% of NY Medicaid HMO DRG,43376,,215% x Medicaid HMO amount,43376,Other,215% of NY Medicaid HMO DRG,25219,,125% x Medicaid HMO amount,25219,Other,125% of NY Medicaid HMO DRG,0.01,112328,
Bacterial & tuberculous infections of nervous system,049-3,APR-DRG,,,,,,,,inpatient,,,393665.33,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,144432,,"45,128 x DRG weight",144432,Other,base rate x DRG weight,129988,,"40,615 x DRG weight",129988,Other,base rate x DRG weight,122768,,"38,359 x DRG weight",122768,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47815,,186% x Medicaid HMO amount,47815,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,109063,,"34,077 x DRG weight",109063,Other,base rate x DRG weight,92706,,"28,966 x DRG weight",92706,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25707,,DRG base rate x DRG weight + capital per discharge,25707,Other,100% of NY Medicaid HMO DRG,25707,,100% x Medicaid HMO amount,25707,Other,100% of NY Medicaid HMO DRG,25707,,100% x Medicaid HMO amount,25707,Other,100% of NY Medicaid HMO DRG,25707,,100% x Medicaid HMO amount,25707,Other,100% of NY Medicaid HMO DRG,57841,,225% x Medicaid HMO amount,57841,Other,225% of NY Medicaid HMO DRG,57841,,225% x Medicaid HMO amount,57841,Other,225% of NY Medicaid HMO DRG,57841,,225% x Medicaid HMO amount,57841,Other,225% of NY Medicaid HMO DRG,57841,,225% x Medicaid HMO amount,57841,Other,225% of NY Medicaid HMO DRG,35990,,140% x Medicaid HMO amount,35990,Other,140% of NY Medicaid HMO DRG,57841,,225% x Medicaid HMO amount,57841,Other,225% of NY Medicaid HMO DRG,70694,,275% x Medicaid HMO amount,70694,Other,275% of NY Medicaid HMO DRG,83291,,324% x Medicaid HMO amount,83291,Other,324% of NY Medicaid HMO DRG,55270,,215% x Medicaid HMO amount,55270,Other,215% of NY Medicaid HMO DRG,55270,,215% x Medicaid HMO amount,55270,Other,215% of NY Medicaid HMO DRG,32134,,125% x Medicaid HMO amount,32134,Other,125% of NY Medicaid HMO DRG,0.01,144432,
Bacterial & tuberculous infections of nervous system,049-4,APR-DRG,,,,,,,,inpatient,,,401539.38,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,269301,,"45,128 x DRG weight",269301,Other,base rate x DRG weight,242370,,"40,615 x DRG weight",242370,Other,base rate x DRG weight,228907,,"38,359 x DRG weight",228907,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,87833,,186% x Medicaid HMO amount,87833,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,203354,,"34,077 x DRG weight",203354,Other,base rate x DRG weight,172855,,"28,966 x DRG weight",172855,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47222,,DRG base rate x DRG weight + capital per discharge,47222,Other,100% of NY Medicaid HMO DRG,47222,,100% x Medicaid HMO amount,47222,Other,100% of NY Medicaid HMO DRG,47222,,100% x Medicaid HMO amount,47222,Other,100% of NY Medicaid HMO DRG,47222,,100% x Medicaid HMO amount,47222,Other,100% of NY Medicaid HMO DRG,106250,,225% x Medicaid HMO amount,106250,Other,225% of NY Medicaid HMO DRG,106250,,225% x Medicaid HMO amount,106250,Other,225% of NY Medicaid HMO DRG,106250,,225% x Medicaid HMO amount,106250,Other,225% of NY Medicaid HMO DRG,106250,,225% x Medicaid HMO amount,106250,Other,225% of NY Medicaid HMO DRG,66111,,140% x Medicaid HMO amount,66111,Other,140% of NY Medicaid HMO DRG,106250,,225% x Medicaid HMO amount,106250,Other,225% of NY Medicaid HMO DRG,129861,,275% x Medicaid HMO amount,129861,Other,275% of NY Medicaid HMO DRG,152999,,324% x Medicaid HMO amount,152999,Other,324% of NY Medicaid HMO DRG,101527,,215% x Medicaid HMO amount,101527,Other,215% of NY Medicaid HMO DRG,101527,,215% x Medicaid HMO amount,101527,Other,215% of NY Medicaid HMO DRG,59028,,125% x Medicaid HMO amount,59028,Other,125% of NY Medicaid HMO DRG,0.01,269301,
Non-bacterial infections of nervous system exc viral meningitis,050-1,APR-DRG,,,,,,,,inpatient,,,135796,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33869,,"45,128 x DRG weight",33869,Other,base rate x DRG weight,30482,,"40,615 x DRG weight",30482,Other,base rate x DRG weight,28788,,"38,359 x DRG weight",28788,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12380,,186% x Medicaid HMO amount,12380,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25575,,"34,077 x DRG weight",25575,Other,base rate x DRG weight,21739,,"28,966 x DRG weight",21739,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6656,,DRG base rate x DRG weight + capital per discharge,6656,Other,100% of NY Medicaid HMO DRG,6656,,100% x Medicaid HMO amount,6656,Other,100% of NY Medicaid HMO DRG,6656,,100% x Medicaid HMO amount,6656,Other,100% of NY Medicaid HMO DRG,6656,,100% x Medicaid HMO amount,6656,Other,100% of NY Medicaid HMO DRG,14976,,225% x Medicaid HMO amount,14976,Other,225% of NY Medicaid HMO DRG,14976,,225% x Medicaid HMO amount,14976,Other,225% of NY Medicaid HMO DRG,14976,,225% x Medicaid HMO amount,14976,Other,225% of NY Medicaid HMO DRG,14976,,225% x Medicaid HMO amount,14976,Other,225% of NY Medicaid HMO DRG,9318,,140% x Medicaid HMO amount,9318,Other,140% of NY Medicaid HMO DRG,14976,,225% x Medicaid HMO amount,14976,Other,225% of NY Medicaid HMO DRG,18304,,275% x Medicaid HMO amount,18304,Other,275% of NY Medicaid HMO DRG,21565,,324% x Medicaid HMO amount,21565,Other,324% of NY Medicaid HMO DRG,14310,,215% x Medicaid HMO amount,14310,Other,215% of NY Medicaid HMO DRG,14310,,215% x Medicaid HMO amount,14310,Other,215% of NY Medicaid HMO DRG,8320,,125% x Medicaid HMO amount,8320,Other,125% of NY Medicaid HMO DRG,0.01,33869,
Non-bacterial infections of nervous system exc viral meningitis,050-2,APR-DRG,,,,,,,,inpatient,,,287236.16,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,61036,,"45,128 x DRG weight",61036,Other,base rate x DRG weight,54932,,"40,615 x DRG weight",54932,Other,base rate x DRG weight,51881,,"38,359 x DRG weight",51881,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21087,,186% x Medicaid HMO amount,21087,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46089,,"34,077 x DRG weight",46089,Other,base rate x DRG weight,39177,,"28,966 x DRG weight",39177,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11337,,DRG base rate x DRG weight + capital per discharge,11337,Other,100% of NY Medicaid HMO DRG,11337,,100% x Medicaid HMO amount,11337,Other,100% of NY Medicaid HMO DRG,11337,,100% x Medicaid HMO amount,11337,Other,100% of NY Medicaid HMO DRG,11337,,100% x Medicaid HMO amount,11337,Other,100% of NY Medicaid HMO DRG,25508,,225% x Medicaid HMO amount,25508,Other,225% of NY Medicaid HMO DRG,25508,,225% x Medicaid HMO amount,25508,Other,225% of NY Medicaid HMO DRG,25508,,225% x Medicaid HMO amount,25508,Other,225% of NY Medicaid HMO DRG,25508,,225% x Medicaid HMO amount,25508,Other,225% of NY Medicaid HMO DRG,15872,,140% x Medicaid HMO amount,15872,Other,140% of NY Medicaid HMO DRG,25508,,225% x Medicaid HMO amount,25508,Other,225% of NY Medicaid HMO DRG,31177,,275% x Medicaid HMO amount,31177,Other,275% of NY Medicaid HMO DRG,36732,,324% x Medicaid HMO amount,36732,Other,324% of NY Medicaid HMO DRG,24375,,215% x Medicaid HMO amount,24375,Other,215% of NY Medicaid HMO DRG,24375,,215% x Medicaid HMO amount,24375,Other,215% of NY Medicaid HMO DRG,14171,,125% x Medicaid HMO amount,14171,Other,125% of NY Medicaid HMO DRG,0.01,61036,
Non-bacterial infections of nervous system exc viral meningitis,050-3,APR-DRG,,,,,,,,inpatient,,,289045.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,99489,,"45,128 x DRG weight",99489,Other,base rate x DRG weight,89540,,"40,615 x DRG weight",89540,Other,base rate x DRG weight,84566,,"38,359 x DRG weight",84566,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33411,,186% x Medicaid HMO amount,33411,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,75126,,"34,077 x DRG weight",75126,Other,base rate x DRG weight,63858,,"28,966 x DRG weight",63858,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17963,,DRG base rate x DRG weight + capital per discharge,17963,Other,100% of NY Medicaid HMO DRG,17963,,100% x Medicaid HMO amount,17963,Other,100% of NY Medicaid HMO DRG,17963,,100% x Medicaid HMO amount,17963,Other,100% of NY Medicaid HMO DRG,17963,,100% x Medicaid HMO amount,17963,Other,100% of NY Medicaid HMO DRG,40417,,225% x Medicaid HMO amount,40417,Other,225% of NY Medicaid HMO DRG,40417,,225% x Medicaid HMO amount,40417,Other,225% of NY Medicaid HMO DRG,40417,,225% x Medicaid HMO amount,40417,Other,225% of NY Medicaid HMO DRG,40417,,225% x Medicaid HMO amount,40417,Other,225% of NY Medicaid HMO DRG,25148,,140% x Medicaid HMO amount,25148,Other,140% of NY Medicaid HMO DRG,40417,,225% x Medicaid HMO amount,40417,Other,225% of NY Medicaid HMO DRG,49398,,275% x Medicaid HMO amount,49398,Other,275% of NY Medicaid HMO DRG,58200,,324% x Medicaid HMO amount,58200,Other,324% of NY Medicaid HMO DRG,38620,,215% x Medicaid HMO amount,38620,Other,215% of NY Medicaid HMO DRG,38620,,215% x Medicaid HMO amount,38620,Other,215% of NY Medicaid HMO DRG,22454,,125% x Medicaid HMO amount,22454,Other,125% of NY Medicaid HMO DRG,0.01,99489,
Non-bacterial infections of nervous system exc viral meningitis,050-4,APR-DRG,,,,,,,,inpatient,,,785355.87,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,241277,,"45,128 x DRG weight",241277,Other,base rate x DRG weight,217148,,"40,615 x DRG weight",217148,Other,base rate x DRG weight,205086,,"38,359 x DRG weight",205086,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,78851,,186% x Medicaid HMO amount,78851,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,182193,,"34,077 x DRG weight",182193,Other,base rate x DRG weight,154867,,"28,966 x DRG weight",154867,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42393,,DRG base rate x DRG weight + capital per discharge,42393,Other,100% of NY Medicaid HMO DRG,42393,,100% x Medicaid HMO amount,42393,Other,100% of NY Medicaid HMO DRG,42393,,100% x Medicaid HMO amount,42393,Other,100% of NY Medicaid HMO DRG,42393,,100% x Medicaid HMO amount,42393,Other,100% of NY Medicaid HMO DRG,95384,,225% x Medicaid HMO amount,95384,Other,225% of NY Medicaid HMO DRG,95384,,225% x Medicaid HMO amount,95384,Other,225% of NY Medicaid HMO DRG,95384,,225% x Medicaid HMO amount,95384,Other,225% of NY Medicaid HMO DRG,95384,,225% x Medicaid HMO amount,95384,Other,225% of NY Medicaid HMO DRG,59350,,140% x Medicaid HMO amount,59350,Other,140% of NY Medicaid HMO DRG,95384,,225% x Medicaid HMO amount,95384,Other,225% of NY Medicaid HMO DRG,116581,,275% x Medicaid HMO amount,116581,Other,275% of NY Medicaid HMO DRG,137353,,324% x Medicaid HMO amount,137353,Other,324% of NY Medicaid HMO DRG,91145,,215% x Medicaid HMO amount,91145,Other,215% of NY Medicaid HMO DRG,91145,,215% x Medicaid HMO amount,91145,Other,215% of NY Medicaid HMO DRG,52991,,125% x Medicaid HMO amount,52991,Other,125% of NY Medicaid HMO DRG,0.01,241277,
Viral meningitis,051-1,APR-DRG,,,,,,,,inpatient,,,99340.16,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27853,,"45,128 x DRG weight",27853,Other,base rate x DRG weight,25068,,"40,615 x DRG weight",25068,Other,base rate x DRG weight,23675,,"38,359 x DRG weight",23675,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10453,,186% x Medicaid HMO amount,10453,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21032,,"34,077 x DRG weight",21032,Other,base rate x DRG weight,17878,,"28,966 x DRG weight",17878,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5620,,DRG base rate x DRG weight + capital per discharge,5620,Other,100% of NY Medicaid HMO DRG,5620,,100% x Medicaid HMO amount,5620,Other,100% of NY Medicaid HMO DRG,5620,,100% x Medicaid HMO amount,5620,Other,100% of NY Medicaid HMO DRG,5620,,100% x Medicaid HMO amount,5620,Other,100% of NY Medicaid HMO DRG,12645,,225% x Medicaid HMO amount,12645,Other,225% of NY Medicaid HMO DRG,12645,,225% x Medicaid HMO amount,12645,Other,225% of NY Medicaid HMO DRG,12645,,225% x Medicaid HMO amount,12645,Other,225% of NY Medicaid HMO DRG,12645,,225% x Medicaid HMO amount,12645,Other,225% of NY Medicaid HMO DRG,7868,,140% x Medicaid HMO amount,7868,Other,140% of NY Medicaid HMO DRG,12645,,225% x Medicaid HMO amount,12645,Other,225% of NY Medicaid HMO DRG,15455,,275% x Medicaid HMO amount,15455,Other,275% of NY Medicaid HMO DRG,18209,,324% x Medicaid HMO amount,18209,Other,324% of NY Medicaid HMO DRG,12083,,215% x Medicaid HMO amount,12083,Other,215% of NY Medicaid HMO DRG,12083,,215% x Medicaid HMO amount,12083,Other,215% of NY Medicaid HMO DRG,7025,,125% x Medicaid HMO amount,7025,Other,125% of NY Medicaid HMO DRG,0.01,27853,
Viral meningitis,051-2,APR-DRG,,,,,,,,inpatient,,,68612.95,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35344,,"45,128 x DRG weight",35344,Other,base rate x DRG weight,31810,,"40,615 x DRG weight",31810,Other,base rate x DRG weight,30043,,"38,359 x DRG weight",30043,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12854,,186% x Medicaid HMO amount,12854,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26689,,"34,077 x DRG weight",26689,Other,base rate x DRG weight,22686,,"28,966 x DRG weight",22686,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6911,,DRG base rate x DRG weight + capital per discharge,6911,Other,100% of NY Medicaid HMO DRG,6911,,100% x Medicaid HMO amount,6911,Other,100% of NY Medicaid HMO DRG,6911,,100% x Medicaid HMO amount,6911,Other,100% of NY Medicaid HMO DRG,6911,,100% x Medicaid HMO amount,6911,Other,100% of NY Medicaid HMO DRG,15550,,225% x Medicaid HMO amount,15550,Other,225% of NY Medicaid HMO DRG,15550,,225% x Medicaid HMO amount,15550,Other,225% of NY Medicaid HMO DRG,15550,,225% x Medicaid HMO amount,15550,Other,225% of NY Medicaid HMO DRG,15550,,225% x Medicaid HMO amount,15550,Other,225% of NY Medicaid HMO DRG,9675,,140% x Medicaid HMO amount,9675,Other,140% of NY Medicaid HMO DRG,15550,,225% x Medicaid HMO amount,15550,Other,225% of NY Medicaid HMO DRG,19005,,275% x Medicaid HMO amount,19005,Other,275% of NY Medicaid HMO DRG,22392,,324% x Medicaid HMO amount,22392,Other,324% of NY Medicaid HMO DRG,14859,,215% x Medicaid HMO amount,14859,Other,215% of NY Medicaid HMO DRG,14859,,215% x Medicaid HMO amount,14859,Other,215% of NY Medicaid HMO DRG,8639,,125% x Medicaid HMO amount,8639,Other,125% of NY Medicaid HMO DRG,0.01,35344,
Viral meningitis,051-3,APR-DRG,,,,,,,,inpatient,,,110348.54,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,68450,,"45,128 x DRG weight",68450,Other,base rate x DRG weight,61605,,"40,615 x DRG weight",61605,Other,base rate x DRG weight,58183,,"38,359 x DRG weight",58183,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23464,,186% x Medicaid HMO amount,23464,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51688,,"34,077 x DRG weight",51688,Other,base rate x DRG weight,43936,,"28,966 x DRG weight",43936,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12615,,DRG base rate x DRG weight + capital per discharge,12615,Other,100% of NY Medicaid HMO DRG,12615,,100% x Medicaid HMO amount,12615,Other,100% of NY Medicaid HMO DRG,12615,,100% x Medicaid HMO amount,12615,Other,100% of NY Medicaid HMO DRG,12615,,100% x Medicaid HMO amount,12615,Other,100% of NY Medicaid HMO DRG,28384,,225% x Medicaid HMO amount,28384,Other,225% of NY Medicaid HMO DRG,28384,,225% x Medicaid HMO amount,28384,Other,225% of NY Medicaid HMO DRG,28384,,225% x Medicaid HMO amount,28384,Other,225% of NY Medicaid HMO DRG,28384,,225% x Medicaid HMO amount,28384,Other,225% of NY Medicaid HMO DRG,17661,,140% x Medicaid HMO amount,17661,Other,140% of NY Medicaid HMO DRG,28384,,225% x Medicaid HMO amount,28384,Other,225% of NY Medicaid HMO DRG,34691,,275% x Medicaid HMO amount,34691,Other,275% of NY Medicaid HMO DRG,40873,,324% x Medicaid HMO amount,40873,Other,324% of NY Medicaid HMO DRG,27122,,215% x Medicaid HMO amount,27122,Other,215% of NY Medicaid HMO DRG,27122,,215% x Medicaid HMO amount,27122,Other,215% of NY Medicaid HMO DRG,15769,,125% x Medicaid HMO amount,15769,Other,125% of NY Medicaid HMO DRG,0.01,68450,
Viral meningitis,051-4,APR-DRG,,,,,,,,inpatient,,,356085.28,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,78112,,"45,128 x DRG weight",78112,Other,base rate x DRG weight,70301,,"40,615 x DRG weight",70301,Other,base rate x DRG weight,66396,,"38,359 x DRG weight",66396,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26561,,186% x Medicaid HMO amount,26561,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,58984,,"34,077 x DRG weight",58984,Other,base rate x DRG weight,50137,,"28,966 x DRG weight",50137,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14280,,DRG base rate x DRG weight + capital per discharge,14280,Other,100% of NY Medicaid HMO DRG,14280,,100% x Medicaid HMO amount,14280,Other,100% of NY Medicaid HMO DRG,14280,,100% x Medicaid HMO amount,14280,Other,100% of NY Medicaid HMO DRG,14280,,100% x Medicaid HMO amount,14280,Other,100% of NY Medicaid HMO DRG,32130,,225% x Medicaid HMO amount,32130,Other,225% of NY Medicaid HMO DRG,32130,,225% x Medicaid HMO amount,32130,Other,225% of NY Medicaid HMO DRG,32130,,225% x Medicaid HMO amount,32130,Other,225% of NY Medicaid HMO DRG,32130,,225% x Medicaid HMO amount,32130,Other,225% of NY Medicaid HMO DRG,19992,,140% x Medicaid HMO amount,19992,Other,140% of NY Medicaid HMO DRG,32130,,225% x Medicaid HMO amount,32130,Other,225% of NY Medicaid HMO DRG,39270,,275% x Medicaid HMO amount,39270,Other,275% of NY Medicaid HMO DRG,46267,,324% x Medicaid HMO amount,46267,Other,324% of NY Medicaid HMO DRG,30702,,215% x Medicaid HMO amount,30702,Other,215% of NY Medicaid HMO DRG,30702,,215% x Medicaid HMO amount,30702,Other,215% of NY Medicaid HMO DRG,17850,,125% x Medicaid HMO amount,17850,Other,125% of NY Medicaid HMO DRG,0.01,78112,
Nontraumatic stupor & coma,052-1,APR-DRG,,,,,,,,inpatient,,,102492.98,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25060,,"45,128 x DRG weight",25060,Other,base rate x DRG weight,22554,,"40,615 x DRG weight",22554,Other,base rate x DRG weight,21301,,"38,359 x DRG weight",21301,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9559,,186% x Medicaid HMO amount,9559,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18923,,"34,077 x DRG weight",18923,Other,base rate x DRG weight,16085,,"28,966 x DRG weight",16085,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5139,,DRG base rate x DRG weight + capital per discharge,5139,Other,100% of NY Medicaid HMO DRG,5139,,100% x Medicaid HMO amount,5139,Other,100% of NY Medicaid HMO DRG,5139,,100% x Medicaid HMO amount,5139,Other,100% of NY Medicaid HMO DRG,5139,,100% x Medicaid HMO amount,5139,Other,100% of NY Medicaid HMO DRG,11563,,225% x Medicaid HMO amount,11563,Other,225% of NY Medicaid HMO DRG,11563,,225% x Medicaid HMO amount,11563,Other,225% of NY Medicaid HMO DRG,11563,,225% x Medicaid HMO amount,11563,Other,225% of NY Medicaid HMO DRG,11563,,225% x Medicaid HMO amount,11563,Other,225% of NY Medicaid HMO DRG,7195,,140% x Medicaid HMO amount,7195,Other,140% of NY Medicaid HMO DRG,11563,,225% x Medicaid HMO amount,11563,Other,225% of NY Medicaid HMO DRG,14132,,275% x Medicaid HMO amount,14132,Other,275% of NY Medicaid HMO DRG,16650,,324% x Medicaid HMO amount,16650,Other,324% of NY Medicaid HMO DRG,11049,,215% x Medicaid HMO amount,11049,Other,215% of NY Medicaid HMO DRG,11049,,215% x Medicaid HMO amount,11049,Other,215% of NY Medicaid HMO DRG,6424,,125% x Medicaid HMO amount,6424,Other,125% of NY Medicaid HMO DRG,0.01,25060,
Nontraumatic stupor & coma,052-2,APR-DRG,,,,,,,,inpatient,,,92078.95,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32799,,"45,128 x DRG weight",32799,Other,base rate x DRG weight,29519,,"40,615 x DRG weight",29519,Other,base rate x DRG weight,27879,,"38,359 x DRG weight",27879,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12038,,186% x Medicaid HMO amount,12038,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24767,,"34,077 x DRG weight",24767,Other,base rate x DRG weight,21052,,"28,966 x DRG weight",21052,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6472,,DRG base rate x DRG weight + capital per discharge,6472,Other,100% of NY Medicaid HMO DRG,6472,,100% x Medicaid HMO amount,6472,Other,100% of NY Medicaid HMO DRG,6472,,100% x Medicaid HMO amount,6472,Other,100% of NY Medicaid HMO DRG,6472,,100% x Medicaid HMO amount,6472,Other,100% of NY Medicaid HMO DRG,14562,,225% x Medicaid HMO amount,14562,Other,225% of NY Medicaid HMO DRG,14562,,225% x Medicaid HMO amount,14562,Other,225% of NY Medicaid HMO DRG,14562,,225% x Medicaid HMO amount,14562,Other,225% of NY Medicaid HMO DRG,14562,,225% x Medicaid HMO amount,14562,Other,225% of NY Medicaid HMO DRG,9061,,140% x Medicaid HMO amount,9061,Other,140% of NY Medicaid HMO DRG,14562,,225% x Medicaid HMO amount,14562,Other,225% of NY Medicaid HMO DRG,17798,,275% x Medicaid HMO amount,17798,Other,275% of NY Medicaid HMO DRG,20969,,324% x Medicaid HMO amount,20969,Other,324% of NY Medicaid HMO DRG,13915,,215% x Medicaid HMO amount,13915,Other,215% of NY Medicaid HMO DRG,13915,,215% x Medicaid HMO amount,13915,Other,215% of NY Medicaid HMO DRG,8090,,125% x Medicaid HMO amount,8090,Other,125% of NY Medicaid HMO DRG,0.01,32799,
Nontraumatic stupor & coma,052-3,APR-DRG,,,,,,,,inpatient,,,133418.37,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45232,,"45,128 x DRG weight",45232,Other,base rate x DRG weight,40708,,"40,615 x DRG weight",40708,Other,base rate x DRG weight,38447,,"38,359 x DRG weight",38447,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16022,,186% x Medicaid HMO amount,16022,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34155,,"34,077 x DRG weight",34155,Other,base rate x DRG weight,29033,,"28,966 x DRG weight",29033,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8614,,DRG base rate x DRG weight + capital per discharge,8614,Other,100% of NY Medicaid HMO DRG,8614,,100% x Medicaid HMO amount,8614,Other,100% of NY Medicaid HMO DRG,8614,,100% x Medicaid HMO amount,8614,Other,100% of NY Medicaid HMO DRG,8614,,100% x Medicaid HMO amount,8614,Other,100% of NY Medicaid HMO DRG,19382,,225% x Medicaid HMO amount,19382,Other,225% of NY Medicaid HMO DRG,19382,,225% x Medicaid HMO amount,19382,Other,225% of NY Medicaid HMO DRG,19382,,225% x Medicaid HMO amount,19382,Other,225% of NY Medicaid HMO DRG,19382,,225% x Medicaid HMO amount,19382,Other,225% of NY Medicaid HMO DRG,12060,,140% x Medicaid HMO amount,12060,Other,140% of NY Medicaid HMO DRG,19382,,225% x Medicaid HMO amount,19382,Other,225% of NY Medicaid HMO DRG,23689,,275% x Medicaid HMO amount,23689,Other,275% of NY Medicaid HMO DRG,27909,,324% x Medicaid HMO amount,27909,Other,324% of NY Medicaid HMO DRG,18520,,215% x Medicaid HMO amount,18520,Other,215% of NY Medicaid HMO DRG,18520,,215% x Medicaid HMO amount,18520,Other,215% of NY Medicaid HMO DRG,10768,,125% x Medicaid HMO amount,10768,Other,125% of NY Medicaid HMO DRG,0.01,45232,
Nontraumatic stupor & coma,052-4,APR-DRG,,,,,,,,inpatient,,,393684.57,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,102765,,"45,128 x DRG weight",102765,Other,base rate x DRG weight,92488,,"40,615 x DRG weight",92488,Other,base rate x DRG weight,87351,,"38,359 x DRG weight",87351,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34462,,186% x Medicaid HMO amount,34462,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,77600,,"34,077 x DRG weight",77600,Other,base rate x DRG weight,65961,,"28,966 x DRG weight",65961,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18528,,DRG base rate x DRG weight + capital per discharge,18528,Other,100% of NY Medicaid HMO DRG,18528,,100% x Medicaid HMO amount,18528,Other,100% of NY Medicaid HMO DRG,18528,,100% x Medicaid HMO amount,18528,Other,100% of NY Medicaid HMO DRG,18528,,100% x Medicaid HMO amount,18528,Other,100% of NY Medicaid HMO DRG,41688,,225% x Medicaid HMO amount,41688,Other,225% of NY Medicaid HMO DRG,41688,,225% x Medicaid HMO amount,41688,Other,225% of NY Medicaid HMO DRG,41688,,225% x Medicaid HMO amount,41688,Other,225% of NY Medicaid HMO DRG,41688,,225% x Medicaid HMO amount,41688,Other,225% of NY Medicaid HMO DRG,25939,,140% x Medicaid HMO amount,25939,Other,140% of NY Medicaid HMO DRG,41688,,225% x Medicaid HMO amount,41688,Other,225% of NY Medicaid HMO DRG,50952,,275% x Medicaid HMO amount,50952,Other,275% of NY Medicaid HMO DRG,60031,,324% x Medicaid HMO amount,60031,Other,324% of NY Medicaid HMO DRG,39835,,215% x Medicaid HMO amount,39835,Other,215% of NY Medicaid HMO DRG,39835,,215% x Medicaid HMO amount,39835,Other,215% of NY Medicaid HMO DRG,23160,,125% x Medicaid HMO amount,23160,Other,125% of NY Medicaid HMO DRG,0.01,102765,
Seizure,053-1,APR-DRG,,,,,,,,inpatient,,,72041.55,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22022,,"45,128 x DRG weight",22022,Other,base rate x DRG weight,19820,,"40,615 x DRG weight",19820,Other,base rate x DRG weight,18719,,"38,359 x DRG weight",18719,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8584,,186% x Medicaid HMO amount,8584,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16630,,"34,077 x DRG weight",16630,Other,base rate x DRG weight,14135,,"28,966 x DRG weight",14135,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4615,,DRG base rate x DRG weight + capital per discharge,4615,Other,100% of NY Medicaid HMO DRG,4615,,100% x Medicaid HMO amount,4615,Other,100% of NY Medicaid HMO DRG,4615,,100% x Medicaid HMO amount,4615,Other,100% of NY Medicaid HMO DRG,4615,,100% x Medicaid HMO amount,4615,Other,100% of NY Medicaid HMO DRG,10384,,225% x Medicaid HMO amount,10384,Other,225% of NY Medicaid HMO DRG,10384,,225% x Medicaid HMO amount,10384,Other,225% of NY Medicaid HMO DRG,10384,,225% x Medicaid HMO amount,10384,Other,225% of NY Medicaid HMO DRG,10384,,225% x Medicaid HMO amount,10384,Other,225% of NY Medicaid HMO DRG,6461,,140% x Medicaid HMO amount,6461,Other,140% of NY Medicaid HMO DRG,10384,,225% x Medicaid HMO amount,10384,Other,225% of NY Medicaid HMO DRG,12691,,275% x Medicaid HMO amount,12691,Other,275% of NY Medicaid HMO DRG,14953,,324% x Medicaid HMO amount,14953,Other,324% of NY Medicaid HMO DRG,9922,,215% x Medicaid HMO amount,9922,Other,215% of NY Medicaid HMO DRG,9922,,215% x Medicaid HMO amount,9922,Other,215% of NY Medicaid HMO DRG,5769,,125% x Medicaid HMO amount,5769,Other,125% of NY Medicaid HMO DRG,0.01,22022,
Seizure,053-2,APR-DRG,,,,,,,,inpatient,,,83092.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26269,,"45,128 x DRG weight",26269,Other,base rate x DRG weight,23642,,"40,615 x DRG weight",23642,Other,base rate x DRG weight,22329,,"38,359 x DRG weight",22329,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9945,,186% x Medicaid HMO amount,9945,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19836,,"34,077 x DRG weight",19836,Other,base rate x DRG weight,16861,,"28,966 x DRG weight",16861,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5347,,DRG base rate x DRG weight + capital per discharge,5347,Other,100% of NY Medicaid HMO DRG,5347,,100% x Medicaid HMO amount,5347,Other,100% of NY Medicaid HMO DRG,5347,,100% x Medicaid HMO amount,5347,Other,100% of NY Medicaid HMO DRG,5347,,100% x Medicaid HMO amount,5347,Other,100% of NY Medicaid HMO DRG,12031,,225% x Medicaid HMO amount,12031,Other,225% of NY Medicaid HMO DRG,12031,,225% x Medicaid HMO amount,12031,Other,225% of NY Medicaid HMO DRG,12031,,225% x Medicaid HMO amount,12031,Other,225% of NY Medicaid HMO DRG,12031,,225% x Medicaid HMO amount,12031,Other,225% of NY Medicaid HMO DRG,7486,,140% x Medicaid HMO amount,7486,Other,140% of NY Medicaid HMO DRG,12031,,225% x Medicaid HMO amount,12031,Other,225% of NY Medicaid HMO DRG,14704,,275% x Medicaid HMO amount,14704,Other,275% of NY Medicaid HMO DRG,17324,,324% x Medicaid HMO amount,17324,Other,324% of NY Medicaid HMO DRG,11496,,215% x Medicaid HMO amount,11496,Other,215% of NY Medicaid HMO DRG,11496,,215% x Medicaid HMO amount,11496,Other,215% of NY Medicaid HMO DRG,6684,,125% x Medicaid HMO amount,6684,Other,125% of NY Medicaid HMO DRG,0.01,26269,
Seizure,053-3,APR-DRG,,,,,,,,inpatient,,,116588.04,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37000,,"45,128 x DRG weight",37000,Other,base rate x DRG weight,33300,,"40,615 x DRG weight",33300,Other,base rate x DRG weight,31451,,"38,359 x DRG weight",31451,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13385,,186% x Medicaid HMO amount,13385,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27940,,"34,077 x DRG weight",27940,Other,base rate x DRG weight,23749,,"28,966 x DRG weight",23749,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7196,,DRG base rate x DRG weight + capital per discharge,7196,Other,100% of NY Medicaid HMO DRG,7196,,100% x Medicaid HMO amount,7196,Other,100% of NY Medicaid HMO DRG,7196,,100% x Medicaid HMO amount,7196,Other,100% of NY Medicaid HMO DRG,7196,,100% x Medicaid HMO amount,7196,Other,100% of NY Medicaid HMO DRG,16191,,225% x Medicaid HMO amount,16191,Other,225% of NY Medicaid HMO DRG,16191,,225% x Medicaid HMO amount,16191,Other,225% of NY Medicaid HMO DRG,16191,,225% x Medicaid HMO amount,16191,Other,225% of NY Medicaid HMO DRG,16191,,225% x Medicaid HMO amount,16191,Other,225% of NY Medicaid HMO DRG,10074,,140% x Medicaid HMO amount,10074,Other,140% of NY Medicaid HMO DRG,16191,,225% x Medicaid HMO amount,16191,Other,225% of NY Medicaid HMO DRG,19789,,275% x Medicaid HMO amount,19789,Other,275% of NY Medicaid HMO DRG,23315,,324% x Medicaid HMO amount,23315,Other,324% of NY Medicaid HMO DRG,15471,,215% x Medicaid HMO amount,15471,Other,215% of NY Medicaid HMO DRG,15471,,215% x Medicaid HMO amount,15471,Other,215% of NY Medicaid HMO DRG,8995,,125% x Medicaid HMO amount,8995,Other,125% of NY Medicaid HMO DRG,0.01,37000,
Seizure,053-4,APR-DRG,,,,,,,,inpatient,,,293200.96,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,120803,,"45,128 x DRG weight",120803,Other,base rate x DRG weight,108722,,"40,615 x DRG weight",108722,Other,base rate x DRG weight,102683,,"38,359 x DRG weight",102683,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40241,,186% x Medicaid HMO amount,40241,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,91221,,"34,077 x DRG weight",91221,Other,base rate x DRG weight,77539,,"28,966 x DRG weight",77539,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21635,,DRG base rate x DRG weight + capital per discharge,21635,Other,100% of NY Medicaid HMO DRG,21635,,100% x Medicaid HMO amount,21635,Other,100% of NY Medicaid HMO DRG,21635,,100% x Medicaid HMO amount,21635,Other,100% of NY Medicaid HMO DRG,21635,,100% x Medicaid HMO amount,21635,Other,100% of NY Medicaid HMO DRG,48679,,225% x Medicaid HMO amount,48679,Other,225% of NY Medicaid HMO DRG,48679,,225% x Medicaid HMO amount,48679,Other,225% of NY Medicaid HMO DRG,48679,,225% x Medicaid HMO amount,48679,Other,225% of NY Medicaid HMO DRG,48679,,225% x Medicaid HMO amount,48679,Other,225% of NY Medicaid HMO DRG,30289,,140% x Medicaid HMO amount,30289,Other,140% of NY Medicaid HMO DRG,48679,,225% x Medicaid HMO amount,48679,Other,225% of NY Medicaid HMO DRG,59496,,275% x Medicaid HMO amount,59496,Other,275% of NY Medicaid HMO DRG,70097,,324% x Medicaid HMO amount,70097,Other,324% of NY Medicaid HMO DRG,46515,,215% x Medicaid HMO amount,46515,Other,215% of NY Medicaid HMO DRG,46515,,215% x Medicaid HMO amount,46515,Other,215% of NY Medicaid HMO DRG,27044,,125% x Medicaid HMO amount,27044,Other,125% of NY Medicaid HMO DRG,0.01,120803,
Migraine & other headaches,054-1,APR-DRG,,,,,,,,inpatient,,,83169.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22207,,"45,128 x DRG weight",22207,Other,base rate x DRG weight,19987,,"40,615 x DRG weight",19987,Other,base rate x DRG weight,18876,,"38,359 x DRG weight",18876,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8643,,186% x Medicaid HMO amount,8643,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16769,,"34,077 x DRG weight",16769,Other,base rate x DRG weight,14254,,"28,966 x DRG weight",14254,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4647,,DRG base rate x DRG weight + capital per discharge,4647,Other,100% of NY Medicaid HMO DRG,4647,,100% x Medicaid HMO amount,4647,Other,100% of NY Medicaid HMO DRG,4647,,100% x Medicaid HMO amount,4647,Other,100% of NY Medicaid HMO DRG,4647,,100% x Medicaid HMO amount,4647,Other,100% of NY Medicaid HMO DRG,10456,,225% x Medicaid HMO amount,10456,Other,225% of NY Medicaid HMO DRG,10456,,225% x Medicaid HMO amount,10456,Other,225% of NY Medicaid HMO DRG,10456,,225% x Medicaid HMO amount,10456,Other,225% of NY Medicaid HMO DRG,10456,,225% x Medicaid HMO amount,10456,Other,225% of NY Medicaid HMO DRG,6506,,140% x Medicaid HMO amount,6506,Other,140% of NY Medicaid HMO DRG,10456,,225% x Medicaid HMO amount,10456,Other,225% of NY Medicaid HMO DRG,12779,,275% x Medicaid HMO amount,12779,Other,275% of NY Medicaid HMO DRG,15056,,324% x Medicaid HMO amount,15056,Other,324% of NY Medicaid HMO DRG,9991,,215% x Medicaid HMO amount,9991,Other,215% of NY Medicaid HMO DRG,9991,,215% x Medicaid HMO amount,9991,Other,215% of NY Medicaid HMO DRG,5809,,125% x Medicaid HMO amount,5809,Other,125% of NY Medicaid HMO DRG,0.01,22207,
Migraine & other headaches,054-2,APR-DRG,,,,,,,,inpatient,,,106107.34,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27627,,"45,128 x DRG weight",27627,Other,base rate x DRG weight,24865,,"40,615 x DRG weight",24865,Other,base rate x DRG weight,23483,,"38,359 x DRG weight",23483,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10381,,186% x Medicaid HMO amount,10381,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20862,,"34,077 x DRG weight",20862,Other,base rate x DRG weight,17733,,"28,966 x DRG weight",17733,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5581,,DRG base rate x DRG weight + capital per discharge,5581,Other,100% of NY Medicaid HMO DRG,5581,,100% x Medicaid HMO amount,5581,Other,100% of NY Medicaid HMO DRG,5581,,100% x Medicaid HMO amount,5581,Other,100% of NY Medicaid HMO DRG,5581,,100% x Medicaid HMO amount,5581,Other,100% of NY Medicaid HMO DRG,12557,,225% x Medicaid HMO amount,12557,Other,225% of NY Medicaid HMO DRG,12557,,225% x Medicaid HMO amount,12557,Other,225% of NY Medicaid HMO DRG,12557,,225% x Medicaid HMO amount,12557,Other,225% of NY Medicaid HMO DRG,12557,,225% x Medicaid HMO amount,12557,Other,225% of NY Medicaid HMO DRG,7813,,140% x Medicaid HMO amount,7813,Other,140% of NY Medicaid HMO DRG,12557,,225% x Medicaid HMO amount,12557,Other,225% of NY Medicaid HMO DRG,15348,,275% x Medicaid HMO amount,15348,Other,275% of NY Medicaid HMO DRG,18082,,324% x Medicaid HMO amount,18082,Other,324% of NY Medicaid HMO DRG,11999,,215% x Medicaid HMO amount,11999,Other,215% of NY Medicaid HMO DRG,11999,,215% x Medicaid HMO amount,11999,Other,215% of NY Medicaid HMO DRG,6976,,125% x Medicaid HMO amount,6976,Other,125% of NY Medicaid HMO DRG,0.01,27627,
Migraine & other headaches,054-3,APR-DRG,,,,,,,,inpatient,,,106098.11,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35647,,"45,128 x DRG weight",35647,Other,base rate x DRG weight,32082,,"40,615 x DRG weight",32082,Other,base rate x DRG weight,30300,,"38,359 x DRG weight",30300,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12951,,186% x Medicaid HMO amount,12951,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26917,,"34,077 x DRG weight",26917,Other,base rate x DRG weight,22880,,"28,966 x DRG weight",22880,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6963,,DRG base rate x DRG weight + capital per discharge,6963,Other,100% of NY Medicaid HMO DRG,6963,,100% x Medicaid HMO amount,6963,Other,100% of NY Medicaid HMO DRG,6963,,100% x Medicaid HMO amount,6963,Other,100% of NY Medicaid HMO DRG,6963,,100% x Medicaid HMO amount,6963,Other,100% of NY Medicaid HMO DRG,15667,,225% x Medicaid HMO amount,15667,Other,225% of NY Medicaid HMO DRG,15667,,225% x Medicaid HMO amount,15667,Other,225% of NY Medicaid HMO DRG,15667,,225% x Medicaid HMO amount,15667,Other,225% of NY Medicaid HMO DRG,15667,,225% x Medicaid HMO amount,15667,Other,225% of NY Medicaid HMO DRG,9748,,140% x Medicaid HMO amount,9748,Other,140% of NY Medicaid HMO DRG,15667,,225% x Medicaid HMO amount,15667,Other,225% of NY Medicaid HMO DRG,19148,,275% x Medicaid HMO amount,19148,Other,275% of NY Medicaid HMO DRG,22560,,324% x Medicaid HMO amount,22560,Other,324% of NY Medicaid HMO DRG,14970,,215% x Medicaid HMO amount,14970,Other,215% of NY Medicaid HMO DRG,14970,,215% x Medicaid HMO amount,14970,Other,215% of NY Medicaid HMO DRG,8704,,125% x Medicaid HMO amount,8704,Other,125% of NY Medicaid HMO DRG,0.01,35647,
Migraine & other headaches,054-4,APR-DRG,,,,,,,,inpatient,,,137275.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36301,,"45,128 x DRG weight",36301,Other,base rate x DRG weight,32671,,"40,615 x DRG weight",32671,Other,base rate x DRG weight,30856,,"38,359 x DRG weight",30856,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13161,,186% x Medicaid HMO amount,13161,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27412,,"34,077 x DRG weight",27412,Other,base rate x DRG weight,23300,,"28,966 x DRG weight",23300,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7076,,DRG base rate x DRG weight + capital per discharge,7076,Other,100% of NY Medicaid HMO DRG,7076,,100% x Medicaid HMO amount,7076,Other,100% of NY Medicaid HMO DRG,7076,,100% x Medicaid HMO amount,7076,Other,100% of NY Medicaid HMO DRG,7076,,100% x Medicaid HMO amount,7076,Other,100% of NY Medicaid HMO DRG,15921,,225% x Medicaid HMO amount,15921,Other,225% of NY Medicaid HMO DRG,15921,,225% x Medicaid HMO amount,15921,Other,225% of NY Medicaid HMO DRG,15921,,225% x Medicaid HMO amount,15921,Other,225% of NY Medicaid HMO DRG,15921,,225% x Medicaid HMO amount,15921,Other,225% of NY Medicaid HMO DRG,9906,,140% x Medicaid HMO amount,9906,Other,140% of NY Medicaid HMO DRG,15921,,225% x Medicaid HMO amount,15921,Other,225% of NY Medicaid HMO DRG,19459,,275% x Medicaid HMO amount,19459,Other,275% of NY Medicaid HMO DRG,22926,,324% x Medicaid HMO amount,22926,Other,324% of NY Medicaid HMO DRG,15213,,215% x Medicaid HMO amount,15213,Other,215% of NY Medicaid HMO DRG,15213,,215% x Medicaid HMO amount,15213,Other,215% of NY Medicaid HMO DRG,8845,,125% x Medicaid HMO amount,8845,Other,125% of NY Medicaid HMO DRG,0.01,36301,
Head trauma w coma >1 hr or hemorrhage,055-1,APR-DRG,,,,,,,,inpatient,,,77715.73,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25132,,"45,128 x DRG weight",25132,Other,base rate x DRG weight,22618,,"40,615 x DRG weight",22618,Other,base rate x DRG weight,21362,,"38,359 x DRG weight",21362,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9581,,186% x Medicaid HMO amount,9581,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18977,,"34,077 x DRG weight",18977,Other,base rate x DRG weight,16131,,"28,966 x DRG weight",16131,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5151,,DRG base rate x DRG weight + capital per discharge,5151,Other,100% of NY Medicaid HMO DRG,5151,,100% x Medicaid HMO amount,5151,Other,100% of NY Medicaid HMO DRG,5151,,100% x Medicaid HMO amount,5151,Other,100% of NY Medicaid HMO DRG,5151,,100% x Medicaid HMO amount,5151,Other,100% of NY Medicaid HMO DRG,11590,,225% x Medicaid HMO amount,11590,Other,225% of NY Medicaid HMO DRG,11590,,225% x Medicaid HMO amount,11590,Other,225% of NY Medicaid HMO DRG,11590,,225% x Medicaid HMO amount,11590,Other,225% of NY Medicaid HMO DRG,11590,,225% x Medicaid HMO amount,11590,Other,225% of NY Medicaid HMO DRG,7211,,140% x Medicaid HMO amount,7211,Other,140% of NY Medicaid HMO DRG,11590,,225% x Medicaid HMO amount,11590,Other,225% of NY Medicaid HMO DRG,14165,,275% x Medicaid HMO amount,14165,Other,275% of NY Medicaid HMO DRG,16689,,324% x Medicaid HMO amount,16689,Other,324% of NY Medicaid HMO DRG,11075,,215% x Medicaid HMO amount,11075,Other,215% of NY Medicaid HMO DRG,11075,,215% x Medicaid HMO amount,11075,Other,215% of NY Medicaid HMO DRG,6439,,125% x Medicaid HMO amount,6439,Other,125% of NY Medicaid HMO DRG,0.01,25132,
Head trauma w coma >1 hr or hemorrhage,055-2,APR-DRG,,,,,,,,inpatient,,,141938.68,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39600,,"45,128 x DRG weight",39600,Other,base rate x DRG weight,35640,,"40,615 x DRG weight",35640,Other,base rate x DRG weight,33660,,"38,359 x DRG weight",33660,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14218,,186% x Medicaid HMO amount,14218,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29903,,"34,077 x DRG weight",29903,Other,base rate x DRG weight,25418,,"28,966 x DRG weight",25418,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7644,,DRG base rate x DRG weight + capital per discharge,7644,Other,100% of NY Medicaid HMO DRG,7644,,100% x Medicaid HMO amount,7644,Other,100% of NY Medicaid HMO DRG,7644,,100% x Medicaid HMO amount,7644,Other,100% of NY Medicaid HMO DRG,7644,,100% x Medicaid HMO amount,7644,Other,100% of NY Medicaid HMO DRG,17199,,225% x Medicaid HMO amount,17199,Other,225% of NY Medicaid HMO DRG,17199,,225% x Medicaid HMO amount,17199,Other,225% of NY Medicaid HMO DRG,17199,,225% x Medicaid HMO amount,17199,Other,225% of NY Medicaid HMO DRG,17199,,225% x Medicaid HMO amount,17199,Other,225% of NY Medicaid HMO DRG,10702,,140% x Medicaid HMO amount,10702,Other,140% of NY Medicaid HMO DRG,17199,,225% x Medicaid HMO amount,17199,Other,225% of NY Medicaid HMO DRG,21021,,275% x Medicaid HMO amount,21021,Other,275% of NY Medicaid HMO DRG,24767,,324% x Medicaid HMO amount,24767,Other,324% of NY Medicaid HMO DRG,16435,,215% x Medicaid HMO amount,16435,Other,215% of NY Medicaid HMO DRG,16435,,215% x Medicaid HMO amount,16435,Other,215% of NY Medicaid HMO DRG,9555,,125% x Medicaid HMO amount,9555,Other,125% of NY Medicaid HMO DRG,0.01,39600,
Head trauma w coma >1 hr or hemorrhage,055-3,APR-DRG,,,,,,,,inpatient,,,224219.58,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,67728,,"45,128 x DRG weight",67728,Other,base rate x DRG weight,60955,,"40,615 x DRG weight",60955,Other,base rate x DRG weight,57569,,"38,359 x DRG weight",57569,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23233,,186% x Medicaid HMO amount,23233,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51143,,"34,077 x DRG weight",51143,Other,base rate x DRG weight,43472,,"28,966 x DRG weight",43472,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12491,,DRG base rate x DRG weight + capital per discharge,12491,Other,100% of NY Medicaid HMO DRG,12491,,100% x Medicaid HMO amount,12491,Other,100% of NY Medicaid HMO DRG,12491,,100% x Medicaid HMO amount,12491,Other,100% of NY Medicaid HMO DRG,12491,,100% x Medicaid HMO amount,12491,Other,100% of NY Medicaid HMO DRG,28105,,225% x Medicaid HMO amount,28105,Other,225% of NY Medicaid HMO DRG,28105,,225% x Medicaid HMO amount,28105,Other,225% of NY Medicaid HMO DRG,28105,,225% x Medicaid HMO amount,28105,Other,225% of NY Medicaid HMO DRG,28105,,225% x Medicaid HMO amount,28105,Other,225% of NY Medicaid HMO DRG,17487,,140% x Medicaid HMO amount,17487,Other,140% of NY Medicaid HMO DRG,28105,,225% x Medicaid HMO amount,28105,Other,225% of NY Medicaid HMO DRG,34350,,275% x Medicaid HMO amount,34350,Other,275% of NY Medicaid HMO DRG,40471,,324% x Medicaid HMO amount,40471,Other,324% of NY Medicaid HMO DRG,26856,,215% x Medicaid HMO amount,26856,Other,215% of NY Medicaid HMO DRG,26856,,215% x Medicaid HMO amount,26856,Other,215% of NY Medicaid HMO DRG,15614,,125% x Medicaid HMO amount,15614,Other,125% of NY Medicaid HMO DRG,0.01,67728,
Head trauma w coma >1 hr or hemorrhage,055-4,APR-DRG,,,,,,,,inpatient,,,556386.4,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,152677,,"45,128 x DRG weight",152677,Other,base rate x DRG weight,137409,,"40,615 x DRG weight",137409,Other,base rate x DRG weight,129776,,"38,359 x DRG weight",129776,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50456,,186% x Medicaid HMO amount,50456,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,115289,,"34,077 x DRG weight",115289,Other,base rate x DRG weight,97998,,"28,966 x DRG weight",97998,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27127,,DRG base rate x DRG weight + capital per discharge,27127,Other,100% of NY Medicaid HMO DRG,27127,,100% x Medicaid HMO amount,27127,Other,100% of NY Medicaid HMO DRG,27127,,100% x Medicaid HMO amount,27127,Other,100% of NY Medicaid HMO DRG,27127,,100% x Medicaid HMO amount,27127,Other,100% of NY Medicaid HMO DRG,61036,,225% x Medicaid HMO amount,61036,Other,225% of NY Medicaid HMO DRG,61036,,225% x Medicaid HMO amount,61036,Other,225% of NY Medicaid HMO DRG,61036,,225% x Medicaid HMO amount,61036,Other,225% of NY Medicaid HMO DRG,61036,,225% x Medicaid HMO amount,61036,Other,225% of NY Medicaid HMO DRG,37978,,140% x Medicaid HMO amount,37978,Other,140% of NY Medicaid HMO DRG,61036,,225% x Medicaid HMO amount,61036,Other,225% of NY Medicaid HMO DRG,74599,,275% x Medicaid HMO amount,74599,Other,275% of NY Medicaid HMO DRG,87891,,324% x Medicaid HMO amount,87891,Other,324% of NY Medicaid HMO DRG,58323,,215% x Medicaid HMO amount,58323,Other,215% of NY Medicaid HMO DRG,58323,,215% x Medicaid HMO amount,58323,Other,215% of NY Medicaid HMO DRG,33909,,125% x Medicaid HMO amount,33909,Other,125% of NY Medicaid HMO DRG,0.01,152677,
"Brain contusion/laceration & complicated skull Fx, coma < 1 hr or no coma",056-1,APR-DRG,,,,,,,,inpatient,,,77715.73,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23435,,"45,128 x DRG weight",23435,Other,base rate x DRG weight,21091,,"40,615 x DRG weight",21091,Other,base rate x DRG weight,19920,,"38,359 x DRG weight",19920,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9038,,186% x Medicaid HMO amount,9038,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17696,,"34,077 x DRG weight",17696,Other,base rate x DRG weight,15042,,"28,966 x DRG weight",15042,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4859,,DRG base rate x DRG weight + capital per discharge,4859,Other,100% of NY Medicaid HMO DRG,4859,,100% x Medicaid HMO amount,4859,Other,100% of NY Medicaid HMO DRG,4859,,100% x Medicaid HMO amount,4859,Other,100% of NY Medicaid HMO DRG,4859,,100% x Medicaid HMO amount,4859,Other,100% of NY Medicaid HMO DRG,10933,,225% x Medicaid HMO amount,10933,Other,225% of NY Medicaid HMO DRG,10933,,225% x Medicaid HMO amount,10933,Other,225% of NY Medicaid HMO DRG,10933,,225% x Medicaid HMO amount,10933,Other,225% of NY Medicaid HMO DRG,10933,,225% x Medicaid HMO amount,10933,Other,225% of NY Medicaid HMO DRG,6803,,140% x Medicaid HMO amount,6803,Other,140% of NY Medicaid HMO DRG,10933,,225% x Medicaid HMO amount,10933,Other,225% of NY Medicaid HMO DRG,13362,,275% x Medicaid HMO amount,13362,Other,275% of NY Medicaid HMO DRG,15743,,324% x Medicaid HMO amount,15743,Other,324% of NY Medicaid HMO DRG,10447,,215% x Medicaid HMO amount,10447,Other,215% of NY Medicaid HMO DRG,10447,,215% x Medicaid HMO amount,10447,Other,215% of NY Medicaid HMO DRG,6074,,125% x Medicaid HMO amount,6074,Other,125% of NY Medicaid HMO DRG,0.01,23435,
"Brain contusion/laceration & complicated skull Fx, coma < 1 hr or no coma",056-2,APR-DRG,,,,,,,,inpatient,,,129437.02,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36175,,"45,128 x DRG weight",36175,Other,base rate x DRG weight,32557,,"40,615 x DRG weight",32557,Other,base rate x DRG weight,30749,,"38,359 x DRG weight",30749,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13120,,186% x Medicaid HMO amount,13120,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27316,,"34,077 x DRG weight",27316,Other,base rate x DRG weight,23219,,"28,966 x DRG weight",23219,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7054,,DRG base rate x DRG weight + capital per discharge,7054,Other,100% of NY Medicaid HMO DRG,7054,,100% x Medicaid HMO amount,7054,Other,100% of NY Medicaid HMO DRG,7054,,100% x Medicaid HMO amount,7054,Other,100% of NY Medicaid HMO DRG,7054,,100% x Medicaid HMO amount,7054,Other,100% of NY Medicaid HMO DRG,15872,,225% x Medicaid HMO amount,15872,Other,225% of NY Medicaid HMO DRG,15872,,225% x Medicaid HMO amount,15872,Other,225% of NY Medicaid HMO DRG,15872,,225% x Medicaid HMO amount,15872,Other,225% of NY Medicaid HMO DRG,15872,,225% x Medicaid HMO amount,15872,Other,225% of NY Medicaid HMO DRG,9876,,140% x Medicaid HMO amount,9876,Other,140% of NY Medicaid HMO DRG,15872,,225% x Medicaid HMO amount,15872,Other,225% of NY Medicaid HMO DRG,19399,,275% x Medicaid HMO amount,19399,Other,275% of NY Medicaid HMO DRG,22855,,324% x Medicaid HMO amount,22855,Other,324% of NY Medicaid HMO DRG,15166,,215% x Medicaid HMO amount,15166,Other,215% of NY Medicaid HMO DRG,15166,,215% x Medicaid HMO amount,15166,Other,215% of NY Medicaid HMO DRG,8818,,125% x Medicaid HMO amount,8818,Other,125% of NY Medicaid HMO DRG,0.01,36175,
"Brain contusion/laceration & complicated skull Fx, coma < 1 hr or no coma",056-3,APR-DRG,,,,,,,,inpatient,,,33187.55,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,64384,,"45,128 x DRG weight",64384,Other,base rate x DRG weight,57945,,"40,615 x DRG weight",57945,Other,base rate x DRG weight,54727,,"38,359 x DRG weight",54727,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22160,,186% x Medicaid HMO amount,22160,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48618,,"34,077 x DRG weight",48618,Other,base rate x DRG weight,41326,,"28,966 x DRG weight",41326,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11914,,DRG base rate x DRG weight + capital per discharge,11914,Other,100% of NY Medicaid HMO DRG,11914,,100% x Medicaid HMO amount,11914,Other,100% of NY Medicaid HMO DRG,11914,,100% x Medicaid HMO amount,11914,Other,100% of NY Medicaid HMO DRG,11914,,100% x Medicaid HMO amount,11914,Other,100% of NY Medicaid HMO DRG,26807,,225% x Medicaid HMO amount,26807,Other,225% of NY Medicaid HMO DRG,26807,,225% x Medicaid HMO amount,26807,Other,225% of NY Medicaid HMO DRG,26807,,225% x Medicaid HMO amount,26807,Other,225% of NY Medicaid HMO DRG,26807,,225% x Medicaid HMO amount,26807,Other,225% of NY Medicaid HMO DRG,16680,,140% x Medicaid HMO amount,16680,Other,140% of NY Medicaid HMO DRG,26807,,225% x Medicaid HMO amount,26807,Other,225% of NY Medicaid HMO DRG,32764,,275% x Medicaid HMO amount,32764,Other,275% of NY Medicaid HMO DRG,38601,,324% x Medicaid HMO amount,38601,Other,324% of NY Medicaid HMO DRG,25615,,215% x Medicaid HMO amount,25615,Other,215% of NY Medicaid HMO DRG,25615,,215% x Medicaid HMO amount,25615,Other,215% of NY Medicaid HMO DRG,14893,,125% x Medicaid HMO amount,14893,Other,125% of NY Medicaid HMO DRG,0.01,64384,
"Brain contusion/laceration & complicated skull Fx, coma < 1 hr or no coma",056-4,APR-DRG,,,,,,,,inpatient,,,296222.6,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,171667,,"45,128 x DRG weight",171667,Other,base rate x DRG weight,154499,,"40,615 x DRG weight",154499,Other,base rate x DRG weight,145918,,"38,359 x DRG weight",145918,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56542,,186% x Medicaid HMO amount,56542,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,129629,,"34,077 x DRG weight",129629,Other,base rate x DRG weight,110187,,"28,966 x DRG weight",110187,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30399,,DRG base rate x DRG weight + capital per discharge,30399,Other,100% of NY Medicaid HMO DRG,30399,,100% x Medicaid HMO amount,30399,Other,100% of NY Medicaid HMO DRG,30399,,100% x Medicaid HMO amount,30399,Other,100% of NY Medicaid HMO DRG,30399,,100% x Medicaid HMO amount,30399,Other,100% of NY Medicaid HMO DRG,68398,,225% x Medicaid HMO amount,68398,Other,225% of NY Medicaid HMO DRG,68398,,225% x Medicaid HMO amount,68398,Other,225% of NY Medicaid HMO DRG,68398,,225% x Medicaid HMO amount,68398,Other,225% of NY Medicaid HMO DRG,68398,,225% x Medicaid HMO amount,68398,Other,225% of NY Medicaid HMO DRG,42559,,140% x Medicaid HMO amount,42559,Other,140% of NY Medicaid HMO DRG,68398,,225% x Medicaid HMO amount,68398,Other,225% of NY Medicaid HMO DRG,83597,,275% x Medicaid HMO amount,83597,Other,275% of NY Medicaid HMO DRG,98493,,324% x Medicaid HMO amount,98493,Other,324% of NY Medicaid HMO DRG,65358,,215% x Medicaid HMO amount,65358,Other,215% of NY Medicaid HMO DRG,65358,,215% x Medicaid HMO amount,65358,Other,215% of NY Medicaid HMO DRG,37999,,125% x Medicaid HMO amount,37999,Other,125% of NY Medicaid HMO DRG,0.01,171667,
"Concussion, closed skull Fx nos,uncomplicated intracranial injury, coma < 1 hr or no coma",057-1,APR-DRG,,,,,,,,inpatient,,,87457.34,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17911,,"45,128 x DRG weight",17911,Other,base rate x DRG weight,16120,,"40,615 x DRG weight",16120,Other,base rate x DRG weight,15225,,"38,359 x DRG weight",15225,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7267,,186% x Medicaid HMO amount,7267,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13525,,"34,077 x DRG weight",13525,Other,base rate x DRG weight,11497,,"28,966 x DRG weight",11497,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3907,,DRG base rate x DRG weight + capital per discharge,3907,Other,100% of NY Medicaid HMO DRG,3907,,100% x Medicaid HMO amount,3907,Other,100% of NY Medicaid HMO DRG,3907,,100% x Medicaid HMO amount,3907,Other,100% of NY Medicaid HMO DRG,3907,,100% x Medicaid HMO amount,3907,Other,100% of NY Medicaid HMO DRG,8791,,225% x Medicaid HMO amount,8791,Other,225% of NY Medicaid HMO DRG,8791,,225% x Medicaid HMO amount,8791,Other,225% of NY Medicaid HMO DRG,8791,,225% x Medicaid HMO amount,8791,Other,225% of NY Medicaid HMO DRG,8791,,225% x Medicaid HMO amount,8791,Other,225% of NY Medicaid HMO DRG,5470,,140% x Medicaid HMO amount,5470,Other,140% of NY Medicaid HMO DRG,8791,,225% x Medicaid HMO amount,8791,Other,225% of NY Medicaid HMO DRG,10744,,275% x Medicaid HMO amount,10744,Other,275% of NY Medicaid HMO DRG,12659,,324% x Medicaid HMO amount,12659,Other,324% of NY Medicaid HMO DRG,8400,,215% x Medicaid HMO amount,8400,Other,215% of NY Medicaid HMO DRG,8400,,215% x Medicaid HMO amount,8400,Other,215% of NY Medicaid HMO DRG,4884,,125% x Medicaid HMO amount,4884,Other,125% of NY Medicaid HMO DRG,0.01,17911,
"Concussion, closed skull Fx nos,uncomplicated intracranial injury, coma < 1 hr or no coma",057-2,APR-DRG,,,,,,,,inpatient,,,82004.88,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24365,,"45,128 x DRG weight",24365,Other,base rate x DRG weight,21928,,"40,615 x DRG weight",21928,Other,base rate x DRG weight,20710,,"38,359 x DRG weight",20710,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9335,,186% x Medicaid HMO amount,9335,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18398,,"34,077 x DRG weight",18398,Other,base rate x DRG weight,15639,,"28,966 x DRG weight",15639,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5019,,DRG base rate x DRG weight + capital per discharge,5019,Other,100% of NY Medicaid HMO DRG,5019,,100% x Medicaid HMO amount,5019,Other,100% of NY Medicaid HMO DRG,5019,,100% x Medicaid HMO amount,5019,Other,100% of NY Medicaid HMO DRG,5019,,100% x Medicaid HMO amount,5019,Other,100% of NY Medicaid HMO DRG,11293,,225% x Medicaid HMO amount,11293,Other,225% of NY Medicaid HMO DRG,11293,,225% x Medicaid HMO amount,11293,Other,225% of NY Medicaid HMO DRG,11293,,225% x Medicaid HMO amount,11293,Other,225% of NY Medicaid HMO DRG,11293,,225% x Medicaid HMO amount,11293,Other,225% of NY Medicaid HMO DRG,7027,,140% x Medicaid HMO amount,7027,Other,140% of NY Medicaid HMO DRG,11293,,225% x Medicaid HMO amount,11293,Other,225% of NY Medicaid HMO DRG,13802,,275% x Medicaid HMO amount,13802,Other,275% of NY Medicaid HMO DRG,16262,,324% x Medicaid HMO amount,16262,Other,324% of NY Medicaid HMO DRG,10791,,215% x Medicaid HMO amount,10791,Other,215% of NY Medicaid HMO DRG,10791,,215% x Medicaid HMO amount,10791,Other,215% of NY Medicaid HMO DRG,6274,,125% x Medicaid HMO amount,6274,Other,125% of NY Medicaid HMO DRG,0.01,24365,
"Concussion, closed skull Fx nos,uncomplicated intracranial injury, coma < 1 hr or no coma",057-3,APR-DRG,,,,,,,,inpatient,,,109547.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43702,,"45,128 x DRG weight",43702,Other,base rate x DRG weight,39332,,"40,615 x DRG weight",39332,Other,base rate x DRG weight,37147,,"38,359 x DRG weight",37147,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15533,,186% x Medicaid HMO amount,15533,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33000,,"34,077 x DRG weight",33000,Other,base rate x DRG weight,28051,,"28,966 x DRG weight",28051,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8351,,DRG base rate x DRG weight + capital per discharge,8351,Other,100% of NY Medicaid HMO DRG,8351,,100% x Medicaid HMO amount,8351,Other,100% of NY Medicaid HMO DRG,8351,,100% x Medicaid HMO amount,8351,Other,100% of NY Medicaid HMO DRG,8351,,100% x Medicaid HMO amount,8351,Other,100% of NY Medicaid HMO DRG,18790,,225% x Medicaid HMO amount,18790,Other,225% of NY Medicaid HMO DRG,18790,,225% x Medicaid HMO amount,18790,Other,225% of NY Medicaid HMO DRG,18790,,225% x Medicaid HMO amount,18790,Other,225% of NY Medicaid HMO DRG,18790,,225% x Medicaid HMO amount,18790,Other,225% of NY Medicaid HMO DRG,11691,,140% x Medicaid HMO amount,11691,Other,140% of NY Medicaid HMO DRG,18790,,225% x Medicaid HMO amount,18790,Other,225% of NY Medicaid HMO DRG,22965,,275% x Medicaid HMO amount,22965,Other,275% of NY Medicaid HMO DRG,27057,,324% x Medicaid HMO amount,27057,Other,324% of NY Medicaid HMO DRG,17955,,215% x Medicaid HMO amount,17955,Other,215% of NY Medicaid HMO DRG,17955,,215% x Medicaid HMO amount,17955,Other,215% of NY Medicaid HMO DRG,10439,,125% x Medicaid HMO amount,10439,Other,125% of NY Medicaid HMO DRG,0.01,43702,
"Concussion, closed skull Fx nos,uncomplicated intracranial injury, coma < 1 hr or no coma",057-4,APR-DRG,,,,,,,,inpatient,,,160983.2,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,133299,,"45,128 x DRG weight",133299,Other,base rate x DRG weight,119969,,"40,615 x DRG weight",119969,Other,base rate x DRG weight,113305,,"38,359 x DRG weight",113305,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44246,,186% x Medicaid HMO amount,44246,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,100657,,"34,077 x DRG weight",100657,Other,base rate x DRG weight,85560,,"28,966 x DRG weight",85560,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23788,,DRG base rate x DRG weight + capital per discharge,23788,Other,100% of NY Medicaid HMO DRG,23788,,100% x Medicaid HMO amount,23788,Other,100% of NY Medicaid HMO DRG,23788,,100% x Medicaid HMO amount,23788,Other,100% of NY Medicaid HMO DRG,23788,,100% x Medicaid HMO amount,23788,Other,100% of NY Medicaid HMO DRG,53523,,225% x Medicaid HMO amount,53523,Other,225% of NY Medicaid HMO DRG,53523,,225% x Medicaid HMO amount,53523,Other,225% of NY Medicaid HMO DRG,53523,,225% x Medicaid HMO amount,53523,Other,225% of NY Medicaid HMO DRG,53523,,225% x Medicaid HMO amount,53523,Other,225% of NY Medicaid HMO DRG,33303,,140% x Medicaid HMO amount,33303,Other,140% of NY Medicaid HMO DRG,53523,,225% x Medicaid HMO amount,53523,Other,225% of NY Medicaid HMO DRG,65417,,275% x Medicaid HMO amount,65417,Other,275% of NY Medicaid HMO DRG,77073,,324% x Medicaid HMO amount,77073,Other,324% of NY Medicaid HMO DRG,51144,,215% x Medicaid HMO amount,51144,Other,215% of NY Medicaid HMO DRG,51144,,215% x Medicaid HMO amount,51144,Other,215% of NY Medicaid HMO DRG,29735,,125% x Medicaid HMO amount,29735,Other,125% of NY Medicaid HMO DRG,0.01,133299,
Other disorders of nervous system,058-1,APR-DRG,,,,,,,,inpatient,,,101846.62,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24301,,"45,128 x DRG weight",24301,Other,base rate x DRG weight,21871,,"40,615 x DRG weight",21871,Other,base rate x DRG weight,20656,,"38,359 x DRG weight",20656,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9315,,186% x Medicaid HMO amount,9315,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18350,,"34,077 x DRG weight",18350,Other,base rate x DRG weight,15598,,"28,966 x DRG weight",15598,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5008,,DRG base rate x DRG weight + capital per discharge,5008,Other,100% of NY Medicaid HMO DRG,5008,,100% x Medicaid HMO amount,5008,Other,100% of NY Medicaid HMO DRG,5008,,100% x Medicaid HMO amount,5008,Other,100% of NY Medicaid HMO DRG,5008,,100% x Medicaid HMO amount,5008,Other,100% of NY Medicaid HMO DRG,11268,,225% x Medicaid HMO amount,11268,Other,225% of NY Medicaid HMO DRG,11268,,225% x Medicaid HMO amount,11268,Other,225% of NY Medicaid HMO DRG,11268,,225% x Medicaid HMO amount,11268,Other,225% of NY Medicaid HMO DRG,11268,,225% x Medicaid HMO amount,11268,Other,225% of NY Medicaid HMO DRG,7011,,140% x Medicaid HMO amount,7011,Other,140% of NY Medicaid HMO DRG,11268,,225% x Medicaid HMO amount,11268,Other,225% of NY Medicaid HMO DRG,13772,,275% x Medicaid HMO amount,13772,Other,275% of NY Medicaid HMO DRG,16226,,324% x Medicaid HMO amount,16226,Other,324% of NY Medicaid HMO DRG,10767,,215% x Medicaid HMO amount,10767,Other,215% of NY Medicaid HMO DRG,10767,,215% x Medicaid HMO amount,10767,Other,215% of NY Medicaid HMO DRG,6260,,125% x Medicaid HMO amount,6260,Other,125% of NY Medicaid HMO DRG,0.01,24301,
Other disorders of nervous system,058-2,APR-DRG,,,,,,,,inpatient,,,137387.77,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35331,,"45,128 x DRG weight",35331,Other,base rate x DRG weight,31797,,"40,615 x DRG weight",31797,Other,base rate x DRG weight,30031,,"38,359 x DRG weight",30031,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12849,,186% x Medicaid HMO amount,12849,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26679,,"34,077 x DRG weight",26679,Other,base rate x DRG weight,22677,,"28,966 x DRG weight",22677,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6908,,DRG base rate x DRG weight + capital per discharge,6908,Other,100% of NY Medicaid HMO DRG,6908,,100% x Medicaid HMO amount,6908,Other,100% of NY Medicaid HMO DRG,6908,,100% x Medicaid HMO amount,6908,Other,100% of NY Medicaid HMO DRG,6908,,100% x Medicaid HMO amount,6908,Other,100% of NY Medicaid HMO DRG,15543,,225% x Medicaid HMO amount,15543,Other,225% of NY Medicaid HMO DRG,15543,,225% x Medicaid HMO amount,15543,Other,225% of NY Medicaid HMO DRG,15543,,225% x Medicaid HMO amount,15543,Other,225% of NY Medicaid HMO DRG,15543,,225% x Medicaid HMO amount,15543,Other,225% of NY Medicaid HMO DRG,9671,,140% x Medicaid HMO amount,9671,Other,140% of NY Medicaid HMO DRG,15543,,225% x Medicaid HMO amount,15543,Other,225% of NY Medicaid HMO DRG,18997,,275% x Medicaid HMO amount,18997,Other,275% of NY Medicaid HMO DRG,22382,,324% x Medicaid HMO amount,22382,Other,324% of NY Medicaid HMO DRG,14852,,215% x Medicaid HMO amount,14852,Other,215% of NY Medicaid HMO DRG,14852,,215% x Medicaid HMO amount,14852,Other,215% of NY Medicaid HMO DRG,8635,,125% x Medicaid HMO amount,8635,Other,125% of NY Medicaid HMO DRG,0.01,35331,
Other disorders of nervous system,058-3,APR-DRG,,,,,,,,inpatient,,,232142.62,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,57055,,"45,128 x DRG weight",57055,Other,base rate x DRG weight,51350,,"40,615 x DRG weight",51350,Other,base rate x DRG weight,48497,,"38,359 x DRG weight",48497,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19813,,186% x Medicaid HMO amount,19813,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43084,,"34,077 x DRG weight",43084,Other,base rate x DRG weight,36622,,"28,966 x DRG weight",36622,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10652,,DRG base rate x DRG weight + capital per discharge,10652,Other,100% of NY Medicaid HMO DRG,10652,,100% x Medicaid HMO amount,10652,Other,100% of NY Medicaid HMO DRG,10652,,100% x Medicaid HMO amount,10652,Other,100% of NY Medicaid HMO DRG,10652,,100% x Medicaid HMO amount,10652,Other,100% of NY Medicaid HMO DRG,23967,,225% x Medicaid HMO amount,23967,Other,225% of NY Medicaid HMO DRG,23967,,225% x Medicaid HMO amount,23967,Other,225% of NY Medicaid HMO DRG,23967,,225% x Medicaid HMO amount,23967,Other,225% of NY Medicaid HMO DRG,23967,,225% x Medicaid HMO amount,23967,Other,225% of NY Medicaid HMO DRG,14913,,140% x Medicaid HMO amount,14913,Other,140% of NY Medicaid HMO DRG,23967,,225% x Medicaid HMO amount,23967,Other,225% of NY Medicaid HMO DRG,29293,,275% x Medicaid HMO amount,29293,Other,275% of NY Medicaid HMO DRG,34512,,324% x Medicaid HMO amount,34512,Other,324% of NY Medicaid HMO DRG,22902,,215% x Medicaid HMO amount,22902,Other,215% of NY Medicaid HMO DRG,22902,,215% x Medicaid HMO amount,22902,Other,215% of NY Medicaid HMO DRG,13315,,125% x Medicaid HMO amount,13315,Other,125% of NY Medicaid HMO DRG,0.01,57055,
Other disorders of nervous system,058-4,APR-DRG,,,,,,,,inpatient,,,214088.32,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,152907,,"45,128 x DRG weight",152907,Other,base rate x DRG weight,137616,,"40,615 x DRG weight",137616,Other,base rate x DRG weight,129972,,"38,359 x DRG weight",129972,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50531,,186% x Medicaid HMO amount,50531,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,115463,,"34,077 x DRG weight",115463,Other,base rate x DRG weight,98145,,"28,966 x DRG weight",98145,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27167,,DRG base rate x DRG weight + capital per discharge,27167,Other,100% of NY Medicaid HMO DRG,27167,,100% x Medicaid HMO amount,27167,Other,100% of NY Medicaid HMO DRG,27167,,100% x Medicaid HMO amount,27167,Other,100% of NY Medicaid HMO DRG,27167,,100% x Medicaid HMO amount,27167,Other,100% of NY Medicaid HMO DRG,61126,,225% x Medicaid HMO amount,61126,Other,225% of NY Medicaid HMO DRG,61126,,225% x Medicaid HMO amount,61126,Other,225% of NY Medicaid HMO DRG,61126,,225% x Medicaid HMO amount,61126,Other,225% of NY Medicaid HMO DRG,61126,,225% x Medicaid HMO amount,61126,Other,225% of NY Medicaid HMO DRG,38034,,140% x Medicaid HMO amount,38034,Other,140% of NY Medicaid HMO DRG,61126,,225% x Medicaid HMO amount,61126,Other,225% of NY Medicaid HMO DRG,74709,,275% x Medicaid HMO amount,74709,Other,275% of NY Medicaid HMO DRG,88021,,324% x Medicaid HMO amount,88021,Other,324% of NY Medicaid HMO DRG,58409,,215% x Medicaid HMO amount,58409,Other,215% of NY Medicaid HMO DRG,58409,,215% x Medicaid HMO amount,58409,Other,215% of NY Medicaid HMO DRG,33959,,125% x Medicaid HMO amount,33959,Other,125% of NY Medicaid HMO DRG,0.01,152907,
Orbital procedures,070-1,APR-DRG,,,,,,,,inpatient,,,86402.55,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36292,,"45,128 x DRG weight",36292,Other,base rate x DRG weight,32663,,"40,615 x DRG weight",32663,Other,base rate x DRG weight,30848,,"38,359 x DRG weight",30848,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13158,,186% x Medicaid HMO amount,13158,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27405,,"34,077 x DRG weight",27405,Other,base rate x DRG weight,23294,,"28,966 x DRG weight",23294,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7074,,DRG base rate x DRG weight + capital per discharge,7074,Other,100% of NY Medicaid HMO DRG,7074,,100% x Medicaid HMO amount,7074,Other,100% of NY Medicaid HMO DRG,7074,,100% x Medicaid HMO amount,7074,Other,100% of NY Medicaid HMO DRG,7074,,100% x Medicaid HMO amount,7074,Other,100% of NY Medicaid HMO DRG,15917,,225% x Medicaid HMO amount,15917,Other,225% of NY Medicaid HMO DRG,15917,,225% x Medicaid HMO amount,15917,Other,225% of NY Medicaid HMO DRG,15917,,225% x Medicaid HMO amount,15917,Other,225% of NY Medicaid HMO DRG,15917,,225% x Medicaid HMO amount,15917,Other,225% of NY Medicaid HMO DRG,9904,,140% x Medicaid HMO amount,9904,Other,140% of NY Medicaid HMO DRG,15917,,225% x Medicaid HMO amount,15917,Other,225% of NY Medicaid HMO DRG,19454,,275% x Medicaid HMO amount,19454,Other,275% of NY Medicaid HMO DRG,22920,,324% x Medicaid HMO amount,22920,Other,324% of NY Medicaid HMO DRG,15209,,215% x Medicaid HMO amount,15209,Other,215% of NY Medicaid HMO DRG,15209,,215% x Medicaid HMO amount,15209,Other,215% of NY Medicaid HMO DRG,8843,,125% x Medicaid HMO amount,8843,Other,125% of NY Medicaid HMO DRG,0.01,36292,
Orbital procedures,070-2,APR-DRG,,,,,,,,inpatient,,,134182.94,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55679,,"45,128 x DRG weight",55679,Other,base rate x DRG weight,50111,,"40,615 x DRG weight",50111,Other,base rate x DRG weight,47327,,"38,359 x DRG weight",47327,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19370,,186% x Medicaid HMO amount,19370,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42044,,"34,077 x DRG weight",42044,Other,base rate x DRG weight,35738,,"28,966 x DRG weight",35738,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10414,,DRG base rate x DRG weight + capital per discharge,10414,Other,100% of NY Medicaid HMO DRG,10414,,100% x Medicaid HMO amount,10414,Other,100% of NY Medicaid HMO DRG,10414,,100% x Medicaid HMO amount,10414,Other,100% of NY Medicaid HMO DRG,10414,,100% x Medicaid HMO amount,10414,Other,100% of NY Medicaid HMO DRG,23432,,225% x Medicaid HMO amount,23432,Other,225% of NY Medicaid HMO DRG,23432,,225% x Medicaid HMO amount,23432,Other,225% of NY Medicaid HMO DRG,23432,,225% x Medicaid HMO amount,23432,Other,225% of NY Medicaid HMO DRG,23432,,225% x Medicaid HMO amount,23432,Other,225% of NY Medicaid HMO DRG,14580,,140% x Medicaid HMO amount,14580,Other,140% of NY Medicaid HMO DRG,23432,,225% x Medicaid HMO amount,23432,Other,225% of NY Medicaid HMO DRG,28639,,275% x Medicaid HMO amount,28639,Other,275% of NY Medicaid HMO DRG,33741,,324% x Medicaid HMO amount,33741,Other,324% of NY Medicaid HMO DRG,22390,,215% x Medicaid HMO amount,22390,Other,215% of NY Medicaid HMO DRG,22390,,215% x Medicaid HMO amount,22390,Other,215% of NY Medicaid HMO DRG,13018,,125% x Medicaid HMO amount,13018,Other,125% of NY Medicaid HMO DRG,0.01,55679,
Orbital procedures,070-3,APR-DRG,,,,,,,,inpatient,,,541419.85,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,92011,,"45,128 x DRG weight",92011,Other,base rate x DRG weight,82810,,"40,615 x DRG weight",82810,Other,base rate x DRG weight,78210,,"38,359 x DRG weight",78210,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31016,,186% x Medicaid HMO amount,31016,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,69480,,"34,077 x DRG weight",69480,Other,base rate x DRG weight,59059,,"28,966 x DRG weight",59059,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16675,,DRG base rate x DRG weight + capital per discharge,16675,Other,100% of NY Medicaid HMO DRG,16675,,100% x Medicaid HMO amount,16675,Other,100% of NY Medicaid HMO DRG,16675,,100% x Medicaid HMO amount,16675,Other,100% of NY Medicaid HMO DRG,16675,,100% x Medicaid HMO amount,16675,Other,100% of NY Medicaid HMO DRG,37519,,225% x Medicaid HMO amount,37519,Other,225% of NY Medicaid HMO DRG,37519,,225% x Medicaid HMO amount,37519,Other,225% of NY Medicaid HMO DRG,37519,,225% x Medicaid HMO amount,37519,Other,225% of NY Medicaid HMO DRG,37519,,225% x Medicaid HMO amount,37519,Other,225% of NY Medicaid HMO DRG,23345,,140% x Medicaid HMO amount,23345,Other,140% of NY Medicaid HMO DRG,37519,,225% x Medicaid HMO amount,37519,Other,225% of NY Medicaid HMO DRG,45856,,275% x Medicaid HMO amount,45856,Other,275% of NY Medicaid HMO DRG,54027,,324% x Medicaid HMO amount,54027,Other,324% of NY Medicaid HMO DRG,35851,,215% x Medicaid HMO amount,35851,Other,215% of NY Medicaid HMO DRG,35851,,215% x Medicaid HMO amount,35851,Other,215% of NY Medicaid HMO DRG,20844,,125% x Medicaid HMO amount,20844,Other,125% of NY Medicaid HMO DRG,0.01,92011,
Orbital procedures,070-4,APR-DRG,,,,,,,,inpatient,,,541419.85,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,104729,,"45,128 x DRG weight",104729,Other,base rate x DRG weight,94255,,"40,615 x DRG weight",94255,Other,base rate x DRG weight,89020,,"38,359 x DRG weight",89020,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35091,,186% x Medicaid HMO amount,35091,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,79082,,"34,077 x DRG weight",79082,Other,base rate x DRG weight,67221,,"28,966 x DRG weight",67221,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18866,,DRG base rate x DRG weight + capital per discharge,18866,Other,100% of NY Medicaid HMO DRG,18866,,100% x Medicaid HMO amount,18866,Other,100% of NY Medicaid HMO DRG,18866,,100% x Medicaid HMO amount,18866,Other,100% of NY Medicaid HMO DRG,18866,,100% x Medicaid HMO amount,18866,Other,100% of NY Medicaid HMO DRG,42449,,225% x Medicaid HMO amount,42449,Other,225% of NY Medicaid HMO DRG,42449,,225% x Medicaid HMO amount,42449,Other,225% of NY Medicaid HMO DRG,42449,,225% x Medicaid HMO amount,42449,Other,225% of NY Medicaid HMO DRG,42449,,225% x Medicaid HMO amount,42449,Other,225% of NY Medicaid HMO DRG,26412,,140% x Medicaid HMO amount,26412,Other,140% of NY Medicaid HMO DRG,42449,,225% x Medicaid HMO amount,42449,Other,225% of NY Medicaid HMO DRG,51882,,275% x Medicaid HMO amount,51882,Other,275% of NY Medicaid HMO DRG,61126,,324% x Medicaid HMO amount,61126,Other,324% of NY Medicaid HMO DRG,40562,,215% x Medicaid HMO amount,40562,Other,215% of NY Medicaid HMO DRG,40562,,215% x Medicaid HMO amount,40562,Other,215% of NY Medicaid HMO DRG,23583,,125% x Medicaid HMO amount,23583,Other,125% of NY Medicaid HMO DRG,0.01,104729,
Eye procedures except orbit,073-1,APR-DRG,,,,,,,,inpatient,,,120793.18,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29739,,"45,128 x DRG weight",29739,Other,base rate x DRG weight,26765,,"40,615 x DRG weight",26765,Other,base rate x DRG weight,25279,,"38,359 x DRG weight",25279,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11058,,186% x Medicaid HMO amount,11058,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22457,,"34,077 x DRG weight",22457,Other,base rate x DRG weight,19089,,"28,966 x DRG weight",19089,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5945,,DRG base rate x DRG weight + capital per discharge,5945,Other,100% of NY Medicaid HMO DRG,5945,,100% x Medicaid HMO amount,5945,Other,100% of NY Medicaid HMO DRG,5945,,100% x Medicaid HMO amount,5945,Other,100% of NY Medicaid HMO DRG,5945,,100% x Medicaid HMO amount,5945,Other,100% of NY Medicaid HMO DRG,13376,,225% x Medicaid HMO amount,13376,Other,225% of NY Medicaid HMO DRG,13376,,225% x Medicaid HMO amount,13376,Other,225% of NY Medicaid HMO DRG,13376,,225% x Medicaid HMO amount,13376,Other,225% of NY Medicaid HMO DRG,13376,,225% x Medicaid HMO amount,13376,Other,225% of NY Medicaid HMO DRG,8323,,140% x Medicaid HMO amount,8323,Other,140% of NY Medicaid HMO DRG,13376,,225% x Medicaid HMO amount,13376,Other,225% of NY Medicaid HMO DRG,16349,,275% x Medicaid HMO amount,16349,Other,275% of NY Medicaid HMO DRG,19262,,324% x Medicaid HMO amount,19262,Other,324% of NY Medicaid HMO DRG,12782,,215% x Medicaid HMO amount,12782,Other,215% of NY Medicaid HMO DRG,12782,,215% x Medicaid HMO amount,12782,Other,215% of NY Medicaid HMO DRG,7431,,125% x Medicaid HMO amount,7431,Other,125% of NY Medicaid HMO DRG,0.01,29739,
Eye procedures except orbit,073-2,APR-DRG,,,,,,,,inpatient,,,129700.15,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38178,,"45,128 x DRG weight",38178,Other,base rate x DRG weight,34360,,"40,615 x DRG weight",34360,Other,base rate x DRG weight,32452,,"38,359 x DRG weight",32452,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13762,,186% x Medicaid HMO amount,13762,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28829,,"34,077 x DRG weight",28829,Other,base rate x DRG weight,24505,,"28,966 x DRG weight",24505,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7399,,DRG base rate x DRG weight + capital per discharge,7399,Other,100% of NY Medicaid HMO DRG,7399,,100% x Medicaid HMO amount,7399,Other,100% of NY Medicaid HMO DRG,7399,,100% x Medicaid HMO amount,7399,Other,100% of NY Medicaid HMO DRG,7399,,100% x Medicaid HMO amount,7399,Other,100% of NY Medicaid HMO DRG,16648,,225% x Medicaid HMO amount,16648,Other,225% of NY Medicaid HMO DRG,16648,,225% x Medicaid HMO amount,16648,Other,225% of NY Medicaid HMO DRG,16648,,225% x Medicaid HMO amount,16648,Other,225% of NY Medicaid HMO DRG,16648,,225% x Medicaid HMO amount,16648,Other,225% of NY Medicaid HMO DRG,10359,,140% x Medicaid HMO amount,10359,Other,140% of NY Medicaid HMO DRG,16648,,225% x Medicaid HMO amount,16648,Other,225% of NY Medicaid HMO DRG,20347,,275% x Medicaid HMO amount,20347,Other,275% of NY Medicaid HMO DRG,23973,,324% x Medicaid HMO amount,23973,Other,324% of NY Medicaid HMO DRG,15908,,215% x Medicaid HMO amount,15908,Other,215% of NY Medicaid HMO DRG,15908,,215% x Medicaid HMO amount,15908,Other,215% of NY Medicaid HMO DRG,9249,,125% x Medicaid HMO amount,9249,Other,125% of NY Medicaid HMO DRG,0.01,38178,
Eye procedures except orbit,073-3,APR-DRG,,,,,,,,inpatient,,,721787.24,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,111231,,"45,128 x DRG weight",111231,Other,base rate x DRG weight,100108,,"40,615 x DRG weight",100108,Other,base rate x DRG weight,94547,,"38,359 x DRG weight",94547,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37174,,186% x Medicaid HMO amount,37174,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,83993,,"34,077 x DRG weight",83993,Other,base rate x DRG weight,71395,,"28,966 x DRG weight",71395,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19986,,DRG base rate x DRG weight + capital per discharge,19986,Other,100% of NY Medicaid HMO DRG,19986,,100% x Medicaid HMO amount,19986,Other,100% of NY Medicaid HMO DRG,19986,,100% x Medicaid HMO amount,19986,Other,100% of NY Medicaid HMO DRG,19986,,100% x Medicaid HMO amount,19986,Other,100% of NY Medicaid HMO DRG,44969,,225% x Medicaid HMO amount,44969,Other,225% of NY Medicaid HMO DRG,44969,,225% x Medicaid HMO amount,44969,Other,225% of NY Medicaid HMO DRG,44969,,225% x Medicaid HMO amount,44969,Other,225% of NY Medicaid HMO DRG,44969,,225% x Medicaid HMO amount,44969,Other,225% of NY Medicaid HMO DRG,27980,,140% x Medicaid HMO amount,27980,Other,140% of NY Medicaid HMO DRG,44969,,225% x Medicaid HMO amount,44969,Other,225% of NY Medicaid HMO DRG,54962,,275% x Medicaid HMO amount,54962,Other,275% of NY Medicaid HMO DRG,64755,,324% x Medicaid HMO amount,64755,Other,324% of NY Medicaid HMO DRG,42970,,215% x Medicaid HMO amount,42970,Other,215% of NY Medicaid HMO DRG,42970,,215% x Medicaid HMO amount,42970,Other,215% of NY Medicaid HMO DRG,24983,,125% x Medicaid HMO amount,24983,Other,125% of NY Medicaid HMO DRG,0.01,111231,
Eye procedures except orbit,073-4,APR-DRG,,,,,,,,inpatient,,,285207.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,116277,,"45,128 x DRG weight",116277,Other,base rate x DRG weight,104649,,"40,615 x DRG weight",104649,Other,base rate x DRG weight,98836,,"38,359 x DRG weight",98836,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38792,,186% x Medicaid HMO amount,38792,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,87803,,"34,077 x DRG weight",87803,Other,base rate x DRG weight,74634,,"28,966 x DRG weight",74634,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20856,,DRG base rate x DRG weight + capital per discharge,20856,Other,100% of NY Medicaid HMO DRG,20856,,100% x Medicaid HMO amount,20856,Other,100% of NY Medicaid HMO DRG,20856,,100% x Medicaid HMO amount,20856,Other,100% of NY Medicaid HMO DRG,20856,,100% x Medicaid HMO amount,20856,Other,100% of NY Medicaid HMO DRG,46926,,225% x Medicaid HMO amount,46926,Other,225% of NY Medicaid HMO DRG,46926,,225% x Medicaid HMO amount,46926,Other,225% of NY Medicaid HMO DRG,46926,,225% x Medicaid HMO amount,46926,Other,225% of NY Medicaid HMO DRG,46926,,225% x Medicaid HMO amount,46926,Other,225% of NY Medicaid HMO DRG,29198,,140% x Medicaid HMO amount,29198,Other,140% of NY Medicaid HMO DRG,46926,,225% x Medicaid HMO amount,46926,Other,225% of NY Medicaid HMO DRG,57354,,275% x Medicaid HMO amount,57354,Other,275% of NY Medicaid HMO DRG,67573,,324% x Medicaid HMO amount,67573,Other,324% of NY Medicaid HMO DRG,44840,,215% x Medicaid HMO amount,44840,Other,215% of NY Medicaid HMO DRG,44840,,215% x Medicaid HMO amount,44840,Other,215% of NY Medicaid HMO DRG,26070,,125% x Medicaid HMO amount,26070,Other,125% of NY Medicaid HMO DRG,0.01,116277,
Acute major eye infections,080-1,APR-DRG,,,,,,,,inpatient,,,62248.42,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24807,,"45,128 x DRG weight",24807,Other,base rate x DRG weight,22326,,"40,615 x DRG weight",22326,Other,base rate x DRG weight,21086,,"38,359 x DRG weight",21086,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9477,,186% x Medicaid HMO amount,9477,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18732,,"34,077 x DRG weight",18732,Other,base rate x DRG weight,15923,,"28,966 x DRG weight",15923,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5095,,DRG base rate x DRG weight + capital per discharge,5095,Other,100% of NY Medicaid HMO DRG,5095,,100% x Medicaid HMO amount,5095,Other,100% of NY Medicaid HMO DRG,5095,,100% x Medicaid HMO amount,5095,Other,100% of NY Medicaid HMO DRG,5095,,100% x Medicaid HMO amount,5095,Other,100% of NY Medicaid HMO DRG,11464,,225% x Medicaid HMO amount,11464,Other,225% of NY Medicaid HMO DRG,11464,,225% x Medicaid HMO amount,11464,Other,225% of NY Medicaid HMO DRG,11464,,225% x Medicaid HMO amount,11464,Other,225% of NY Medicaid HMO DRG,11464,,225% x Medicaid HMO amount,11464,Other,225% of NY Medicaid HMO DRG,7133,,140% x Medicaid HMO amount,7133,Other,140% of NY Medicaid HMO DRG,11464,,225% x Medicaid HMO amount,11464,Other,225% of NY Medicaid HMO DRG,14011,,275% x Medicaid HMO amount,14011,Other,275% of NY Medicaid HMO DRG,16508,,324% x Medicaid HMO amount,16508,Other,324% of NY Medicaid HMO DRG,10954,,215% x Medicaid HMO amount,10954,Other,215% of NY Medicaid HMO DRG,10954,,215% x Medicaid HMO amount,10954,Other,215% of NY Medicaid HMO DRG,6369,,125% x Medicaid HMO amount,6369,Other,125% of NY Medicaid HMO DRG,0.01,24807,
Acute major eye infections,080-2,APR-DRG,,,,,,,,inpatient,,,75862.99,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31693,,"45,128 x DRG weight",31693,Other,base rate x DRG weight,28524,,"40,615 x DRG weight",28524,Other,base rate x DRG weight,26940,,"38,359 x DRG weight",26940,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11685,,186% x Medicaid HMO amount,11685,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23932,,"34,077 x DRG weight",23932,Other,base rate x DRG weight,20343,,"28,966 x DRG weight",20343,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6282,,DRG base rate x DRG weight + capital per discharge,6282,Other,100% of NY Medicaid HMO DRG,6282,,100% x Medicaid HMO amount,6282,Other,100% of NY Medicaid HMO DRG,6282,,100% x Medicaid HMO amount,6282,Other,100% of NY Medicaid HMO DRG,6282,,100% x Medicaid HMO amount,6282,Other,100% of NY Medicaid HMO DRG,14135,,225% x Medicaid HMO amount,14135,Other,225% of NY Medicaid HMO DRG,14135,,225% x Medicaid HMO amount,14135,Other,225% of NY Medicaid HMO DRG,14135,,225% x Medicaid HMO amount,14135,Other,225% of NY Medicaid HMO DRG,14135,,225% x Medicaid HMO amount,14135,Other,225% of NY Medicaid HMO DRG,8795,,140% x Medicaid HMO amount,8795,Other,140% of NY Medicaid HMO DRG,14135,,225% x Medicaid HMO amount,14135,Other,225% of NY Medicaid HMO DRG,17276,,275% x Medicaid HMO amount,17276,Other,275% of NY Medicaid HMO DRG,20354,,324% x Medicaid HMO amount,20354,Other,324% of NY Medicaid HMO DRG,13506,,215% x Medicaid HMO amount,13506,Other,215% of NY Medicaid HMO DRG,13506,,215% x Medicaid HMO amount,13506,Other,215% of NY Medicaid HMO DRG,7853,,125% x Medicaid HMO amount,7853,Other,125% of NY Medicaid HMO DRG,0.01,31693,
Acute major eye infections,080-3,APR-DRG,,,,,,,,inpatient,,,189423,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54659,,"45,128 x DRG weight",54659,Other,base rate x DRG weight,49193,,"40,615 x DRG weight",49193,Other,base rate x DRG weight,46460,,"38,359 x DRG weight",46460,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19045,,186% x Medicaid HMO amount,19045,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41274,,"34,077 x DRG weight",41274,Other,base rate x DRG weight,35084,,"28,966 x DRG weight",35084,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10239,,DRG base rate x DRG weight + capital per discharge,10239,Other,100% of NY Medicaid HMO DRG,10239,,100% x Medicaid HMO amount,10239,Other,100% of NY Medicaid HMO DRG,10239,,100% x Medicaid HMO amount,10239,Other,100% of NY Medicaid HMO DRG,10239,,100% x Medicaid HMO amount,10239,Other,100% of NY Medicaid HMO DRG,23038,,225% x Medicaid HMO amount,23038,Other,225% of NY Medicaid HMO DRG,23038,,225% x Medicaid HMO amount,23038,Other,225% of NY Medicaid HMO DRG,23038,,225% x Medicaid HMO amount,23038,Other,225% of NY Medicaid HMO DRG,23038,,225% x Medicaid HMO amount,23038,Other,225% of NY Medicaid HMO DRG,14335,,140% x Medicaid HMO amount,14335,Other,140% of NY Medicaid HMO DRG,23038,,225% x Medicaid HMO amount,23038,Other,225% of NY Medicaid HMO DRG,28157,,275% x Medicaid HMO amount,28157,Other,275% of NY Medicaid HMO DRG,33174,,324% x Medicaid HMO amount,33174,Other,324% of NY Medicaid HMO DRG,22014,,215% x Medicaid HMO amount,22014,Other,215% of NY Medicaid HMO DRG,22014,,215% x Medicaid HMO amount,22014,Other,215% of NY Medicaid HMO DRG,12799,,125% x Medicaid HMO amount,12799,Other,125% of NY Medicaid HMO DRG,0.01,54659,
Acute major eye infections,080-4,APR-DRG,,,,,,,,inpatient,,,189423,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,61013,,"45,128 x DRG weight",61013,Other,base rate x DRG weight,54911,,"40,615 x DRG weight",54911,Other,base rate x DRG weight,51861,,"38,359 x DRG weight",51861,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21081,,186% x Medicaid HMO amount,21081,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46072,,"34,077 x DRG weight",46072,Other,base rate x DRG weight,39162,,"28,966 x DRG weight",39162,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11334,,DRG base rate x DRG weight + capital per discharge,11334,Other,100% of NY Medicaid HMO DRG,11334,,100% x Medicaid HMO amount,11334,Other,100% of NY Medicaid HMO DRG,11334,,100% x Medicaid HMO amount,11334,Other,100% of NY Medicaid HMO DRG,11334,,100% x Medicaid HMO amount,11334,Other,100% of NY Medicaid HMO DRG,25502,,225% x Medicaid HMO amount,25502,Other,225% of NY Medicaid HMO DRG,25502,,225% x Medicaid HMO amount,25502,Other,225% of NY Medicaid HMO DRG,25502,,225% x Medicaid HMO amount,25502,Other,225% of NY Medicaid HMO DRG,25502,,225% x Medicaid HMO amount,25502,Other,225% of NY Medicaid HMO DRG,15868,,140% x Medicaid HMO amount,15868,Other,140% of NY Medicaid HMO DRG,25502,,225% x Medicaid HMO amount,25502,Other,225% of NY Medicaid HMO DRG,31169,,275% x Medicaid HMO amount,31169,Other,275% of NY Medicaid HMO DRG,36722,,324% x Medicaid HMO amount,36722,Other,324% of NY Medicaid HMO DRG,24368,,215% x Medicaid HMO amount,24368,Other,215% of NY Medicaid HMO DRG,24368,,215% x Medicaid HMO amount,24368,Other,215% of NY Medicaid HMO DRG,14168,,125% x Medicaid HMO amount,14168,Other,125% of NY Medicaid HMO DRG,0.01,61013,
Eye disorders except major infections,082-1,APR-DRG,,,,,,,,inpatient,,,92331.8,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22090,,"45,128 x DRG weight",22090,Other,base rate x DRG weight,19881,,"40,615 x DRG weight",19881,Other,base rate x DRG weight,18777,,"38,359 x DRG weight",18777,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8606,,186% x Medicaid HMO amount,8606,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16681,,"34,077 x DRG weight",16681,Other,base rate x DRG weight,14179,,"28,966 x DRG weight",14179,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4627,,DRG base rate x DRG weight + capital per discharge,4627,Other,100% of NY Medicaid HMO DRG,4627,,100% x Medicaid HMO amount,4627,Other,100% of NY Medicaid HMO DRG,4627,,100% x Medicaid HMO amount,4627,Other,100% of NY Medicaid HMO DRG,4627,,100% x Medicaid HMO amount,4627,Other,100% of NY Medicaid HMO DRG,10411,,225% x Medicaid HMO amount,10411,Other,225% of NY Medicaid HMO DRG,10411,,225% x Medicaid HMO amount,10411,Other,225% of NY Medicaid HMO DRG,10411,,225% x Medicaid HMO amount,10411,Other,225% of NY Medicaid HMO DRG,10411,,225% x Medicaid HMO amount,10411,Other,225% of NY Medicaid HMO DRG,6478,,140% x Medicaid HMO amount,6478,Other,140% of NY Medicaid HMO DRG,10411,,225% x Medicaid HMO amount,10411,Other,225% of NY Medicaid HMO DRG,12724,,275% x Medicaid HMO amount,12724,Other,275% of NY Medicaid HMO DRG,14991,,324% x Medicaid HMO amount,14991,Other,324% of NY Medicaid HMO DRG,9948,,215% x Medicaid HMO amount,9948,Other,215% of NY Medicaid HMO DRG,9948,,215% x Medicaid HMO amount,9948,Other,215% of NY Medicaid HMO DRG,5784,,125% x Medicaid HMO amount,5784,Other,125% of NY Medicaid HMO DRG,0.01,22090,
Eye disorders except major infections,082-2,APR-DRG,,,,,,,,inpatient,,,117692.58,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26783,,"45,128 x DRG weight",26783,Other,base rate x DRG weight,24105,,"40,615 x DRG weight",24105,Other,base rate x DRG weight,22766,,"38,359 x DRG weight",22766,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10111,,186% x Medicaid HMO amount,10111,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20225,,"34,077 x DRG weight",20225,Other,base rate x DRG weight,17191,,"28,966 x DRG weight",17191,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5436,,DRG base rate x DRG weight + capital per discharge,5436,Other,100% of NY Medicaid HMO DRG,5436,,100% x Medicaid HMO amount,5436,Other,100% of NY Medicaid HMO DRG,5436,,100% x Medicaid HMO amount,5436,Other,100% of NY Medicaid HMO DRG,5436,,100% x Medicaid HMO amount,5436,Other,100% of NY Medicaid HMO DRG,12231,,225% x Medicaid HMO amount,12231,Other,225% of NY Medicaid HMO DRG,12231,,225% x Medicaid HMO amount,12231,Other,225% of NY Medicaid HMO DRG,12231,,225% x Medicaid HMO amount,12231,Other,225% of NY Medicaid HMO DRG,12231,,225% x Medicaid HMO amount,12231,Other,225% of NY Medicaid HMO DRG,7610,,140% x Medicaid HMO amount,7610,Other,140% of NY Medicaid HMO DRG,12231,,225% x Medicaid HMO amount,12231,Other,225% of NY Medicaid HMO DRG,14949,,275% x Medicaid HMO amount,14949,Other,275% of NY Medicaid HMO DRG,17613,,324% x Medicaid HMO amount,17613,Other,324% of NY Medicaid HMO DRG,11687,,215% x Medicaid HMO amount,11687,Other,215% of NY Medicaid HMO DRG,11687,,215% x Medicaid HMO amount,11687,Other,215% of NY Medicaid HMO DRG,6795,,125% x Medicaid HMO amount,6795,Other,125% of NY Medicaid HMO DRG,0.01,26783,
Eye disorders except major infections,082-3,APR-DRG,,,,,,,,inpatient,,,271037.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46306,,"45,128 x DRG weight",46306,Other,base rate x DRG weight,41675,,"40,615 x DRG weight",41675,Other,base rate x DRG weight,39360,,"38,359 x DRG weight",39360,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16366,,186% x Medicaid HMO amount,16366,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34966,,"34,077 x DRG weight",34966,Other,base rate x DRG weight,29722,,"28,966 x DRG weight",29722,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8799,,DRG base rate x DRG weight + capital per discharge,8799,Other,100% of NY Medicaid HMO DRG,8799,,100% x Medicaid HMO amount,8799,Other,100% of NY Medicaid HMO DRG,8799,,100% x Medicaid HMO amount,8799,Other,100% of NY Medicaid HMO DRG,8799,,100% x Medicaid HMO amount,8799,Other,100% of NY Medicaid HMO DRG,19798,,225% x Medicaid HMO amount,19798,Other,225% of NY Medicaid HMO DRG,19798,,225% x Medicaid HMO amount,19798,Other,225% of NY Medicaid HMO DRG,19798,,225% x Medicaid HMO amount,19798,Other,225% of NY Medicaid HMO DRG,19798,,225% x Medicaid HMO amount,19798,Other,225% of NY Medicaid HMO DRG,12319,,140% x Medicaid HMO amount,12319,Other,140% of NY Medicaid HMO DRG,19798,,225% x Medicaid HMO amount,19798,Other,225% of NY Medicaid HMO DRG,24197,,275% x Medicaid HMO amount,24197,Other,275% of NY Medicaid HMO DRG,28509,,324% x Medicaid HMO amount,28509,Other,324% of NY Medicaid HMO DRG,18918,,215% x Medicaid HMO amount,18918,Other,215% of NY Medicaid HMO DRG,18918,,215% x Medicaid HMO amount,18918,Other,215% of NY Medicaid HMO DRG,10999,,125% x Medicaid HMO amount,10999,Other,125% of NY Medicaid HMO DRG,0.01,46306,
Eye disorders except major infections,082-4,APR-DRG,,,,,,,,inpatient,,,271037.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47606,,"45,128 x DRG weight",47606,Other,base rate x DRG weight,42845,,"40,615 x DRG weight",42845,Other,base rate x DRG weight,40465,,"38,359 x DRG weight",40465,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16783,,186% x Medicaid HMO amount,16783,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35948,,"34,077 x DRG weight",35948,Other,base rate x DRG weight,30556,,"28,966 x DRG weight",30556,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9023,,DRG base rate x DRG weight + capital per discharge,9023,Other,100% of NY Medicaid HMO DRG,9023,,100% x Medicaid HMO amount,9023,Other,100% of NY Medicaid HMO DRG,9023,,100% x Medicaid HMO amount,9023,Other,100% of NY Medicaid HMO DRG,9023,,100% x Medicaid HMO amount,9023,Other,100% of NY Medicaid HMO DRG,20302,,225% x Medicaid HMO amount,20302,Other,225% of NY Medicaid HMO DRG,20302,,225% x Medicaid HMO amount,20302,Other,225% of NY Medicaid HMO DRG,20302,,225% x Medicaid HMO amount,20302,Other,225% of NY Medicaid HMO DRG,20302,,225% x Medicaid HMO amount,20302,Other,225% of NY Medicaid HMO DRG,12632,,140% x Medicaid HMO amount,12632,Other,140% of NY Medicaid HMO DRG,20302,,225% x Medicaid HMO amount,20302,Other,225% of NY Medicaid HMO DRG,24813,,275% x Medicaid HMO amount,24813,Other,275% of NY Medicaid HMO DRG,29235,,324% x Medicaid HMO amount,29235,Other,324% of NY Medicaid HMO DRG,19399,,215% x Medicaid HMO amount,19399,Other,215% of NY Medicaid HMO DRG,19399,,215% x Medicaid HMO amount,19399,Other,215% of NY Medicaid HMO DRG,11279,,125% x Medicaid HMO amount,11279,Other,125% of NY Medicaid HMO DRG,0.01,47606,
Major cranial/facial bone procedures,089-1,APR-DRG,,,,,,,,inpatient,,,163032.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,61528,,"45,128 x DRG weight",61528,Other,base rate x DRG weight,55374,,"40,615 x DRG weight",55374,Other,base rate x DRG weight,52299,,"38,359 x DRG weight",52299,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21245,,186% x Medicaid HMO amount,21245,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46461,,"34,077 x DRG weight",46461,Other,base rate x DRG weight,39492,,"28,966 x DRG weight",39492,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11422,,DRG base rate x DRG weight + capital per discharge,11422,Other,100% of NY Medicaid HMO DRG,11422,,100% x Medicaid HMO amount,11422,Other,100% of NY Medicaid HMO DRG,11422,,100% x Medicaid HMO amount,11422,Other,100% of NY Medicaid HMO DRG,11422,,100% x Medicaid HMO amount,11422,Other,100% of NY Medicaid HMO DRG,25700,,225% x Medicaid HMO amount,25700,Other,225% of NY Medicaid HMO DRG,25700,,225% x Medicaid HMO amount,25700,Other,225% of NY Medicaid HMO DRG,25700,,225% x Medicaid HMO amount,25700,Other,225% of NY Medicaid HMO DRG,25700,,225% x Medicaid HMO amount,25700,Other,225% of NY Medicaid HMO DRG,15991,,140% x Medicaid HMO amount,15991,Other,140% of NY Medicaid HMO DRG,25700,,225% x Medicaid HMO amount,25700,Other,225% of NY Medicaid HMO DRG,31411,,275% x Medicaid HMO amount,31411,Other,275% of NY Medicaid HMO DRG,37007,,324% x Medicaid HMO amount,37007,Other,324% of NY Medicaid HMO DRG,24557,,215% x Medicaid HMO amount,24557,Other,215% of NY Medicaid HMO DRG,24557,,215% x Medicaid HMO amount,24557,Other,215% of NY Medicaid HMO DRG,14278,,125% x Medicaid HMO amount,14278,Other,125% of NY Medicaid HMO DRG,0.01,61528,
Major cranial/facial bone procedures,089-2,APR-DRG,,,,,,,,inpatient,,,248871.79,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,97576,,"45,128 x DRG weight",97576,Other,base rate x DRG weight,87818,,"40,615 x DRG weight",87818,Other,base rate x DRG weight,82940,,"38,359 x DRG weight",82940,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32797,,186% x Medicaid HMO amount,32797,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73681,,"34,077 x DRG weight",73681,Other,base rate x DRG weight,62630,,"28,966 x DRG weight",62630,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17633,,DRG base rate x DRG weight + capital per discharge,17633,Other,100% of NY Medicaid HMO DRG,17633,,100% x Medicaid HMO amount,17633,Other,100% of NY Medicaid HMO DRG,17633,,100% x Medicaid HMO amount,17633,Other,100% of NY Medicaid HMO DRG,17633,,100% x Medicaid HMO amount,17633,Other,100% of NY Medicaid HMO DRG,39674,,225% x Medicaid HMO amount,39674,Other,225% of NY Medicaid HMO DRG,39674,,225% x Medicaid HMO amount,39674,Other,225% of NY Medicaid HMO DRG,39674,,225% x Medicaid HMO amount,39674,Other,225% of NY Medicaid HMO DRG,39674,,225% x Medicaid HMO amount,39674,Other,225% of NY Medicaid HMO DRG,24686,,140% x Medicaid HMO amount,24686,Other,140% of NY Medicaid HMO DRG,39674,,225% x Medicaid HMO amount,39674,Other,225% of NY Medicaid HMO DRG,48491,,275% x Medicaid HMO amount,48491,Other,275% of NY Medicaid HMO DRG,57131,,324% x Medicaid HMO amount,57131,Other,324% of NY Medicaid HMO DRG,37911,,215% x Medicaid HMO amount,37911,Other,215% of NY Medicaid HMO DRG,37911,,215% x Medicaid HMO amount,37911,Other,215% of NY Medicaid HMO DRG,22041,,125% x Medicaid HMO amount,22041,Other,125% of NY Medicaid HMO DRG,0.01,97576,
Major cranial/facial bone procedures,089-3,APR-DRG,,,,,,,,inpatient,,,509390.85,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,171938,,"45,128 x DRG weight",171938,Other,base rate x DRG weight,154743,,"40,615 x DRG weight",154743,Other,base rate x DRG weight,146148,,"38,359 x DRG weight",146148,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56630,,186% x Medicaid HMO amount,56630,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,129833,,"34,077 x DRG weight",129833,Other,base rate x DRG weight,110360,,"28,966 x DRG weight",110360,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30446,,DRG base rate x DRG weight + capital per discharge,30446,Other,100% of NY Medicaid HMO DRG,30446,,100% x Medicaid HMO amount,30446,Other,100% of NY Medicaid HMO DRG,30446,,100% x Medicaid HMO amount,30446,Other,100% of NY Medicaid HMO DRG,30446,,100% x Medicaid HMO amount,30446,Other,100% of NY Medicaid HMO DRG,68504,,225% x Medicaid HMO amount,68504,Other,225% of NY Medicaid HMO DRG,68504,,225% x Medicaid HMO amount,68504,Other,225% of NY Medicaid HMO DRG,68504,,225% x Medicaid HMO amount,68504,Other,225% of NY Medicaid HMO DRG,68504,,225% x Medicaid HMO amount,68504,Other,225% of NY Medicaid HMO DRG,42624,,140% x Medicaid HMO amount,42624,Other,140% of NY Medicaid HMO DRG,68504,,225% x Medicaid HMO amount,68504,Other,225% of NY Medicaid HMO DRG,83727,,275% x Medicaid HMO amount,83727,Other,275% of NY Medicaid HMO DRG,98645,,324% x Medicaid HMO amount,98645,Other,324% of NY Medicaid HMO DRG,65459,,215% x Medicaid HMO amount,65459,Other,215% of NY Medicaid HMO DRG,65459,,215% x Medicaid HMO amount,65459,Other,215% of NY Medicaid HMO DRG,38058,,125% x Medicaid HMO amount,38058,Other,125% of NY Medicaid HMO DRG,0.01,171938,
Major cranial/facial bone procedures,089-4,APR-DRG,,,,,,,,inpatient,,,1100723.23,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,307710,,"45,128 x DRG weight",307710,Other,base rate x DRG weight,276937,,"40,615 x DRG weight",276937,Other,base rate x DRG weight,261555,,"38,359 x DRG weight",261555,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,100142,,186% x Medicaid HMO amount,100142,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,232357,,"34,077 x DRG weight",232357,Other,base rate x DRG weight,197508,,"28,966 x DRG weight",197508,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53840,,DRG base rate x DRG weight + capital per discharge,53840,Other,100% of NY Medicaid HMO DRG,53840,,100% x Medicaid HMO amount,53840,Other,100% of NY Medicaid HMO DRG,53840,,100% x Medicaid HMO amount,53840,Other,100% of NY Medicaid HMO DRG,53840,,100% x Medicaid HMO amount,53840,Other,100% of NY Medicaid HMO DRG,121140,,225% x Medicaid HMO amount,121140,Other,225% of NY Medicaid HMO DRG,121140,,225% x Medicaid HMO amount,121140,Other,225% of NY Medicaid HMO DRG,121140,,225% x Medicaid HMO amount,121140,Other,225% of NY Medicaid HMO DRG,121140,,225% x Medicaid HMO amount,121140,Other,225% of NY Medicaid HMO DRG,75376,,140% x Medicaid HMO amount,75376,Other,140% of NY Medicaid HMO DRG,121140,,225% x Medicaid HMO amount,121140,Other,225% of NY Medicaid HMO DRG,148060,,275% x Medicaid HMO amount,148060,Other,275% of NY Medicaid HMO DRG,174442,,324% x Medicaid HMO amount,174442,Other,324% of NY Medicaid HMO DRG,115756,,215% x Medicaid HMO amount,115756,Other,215% of NY Medicaid HMO DRG,115756,,215% x Medicaid HMO amount,115756,Other,215% of NY Medicaid HMO DRG,67300,,125% x Medicaid HMO amount,67300,Other,125% of NY Medicaid HMO DRG,0.01,307710,
Major larynx & trachea procedures,090-1,APR-DRG,,,,,,,,inpatient,,,111215.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34234,,"45,128 x DRG weight",34234,Other,base rate x DRG weight,30811,,"40,615 x DRG weight",30811,Other,base rate x DRG weight,29099,,"38,359 x DRG weight",29099,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12497,,186% x Medicaid HMO amount,12497,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25851,,"34,077 x DRG weight",25851,Other,base rate x DRG weight,21974,,"28,966 x DRG weight",21974,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6719,,DRG base rate x DRG weight + capital per discharge,6719,Other,100% of NY Medicaid HMO DRG,6719,,100% x Medicaid HMO amount,6719,Other,100% of NY Medicaid HMO DRG,6719,,100% x Medicaid HMO amount,6719,Other,100% of NY Medicaid HMO DRG,6719,,100% x Medicaid HMO amount,6719,Other,100% of NY Medicaid HMO DRG,15118,,225% x Medicaid HMO amount,15118,Other,225% of NY Medicaid HMO DRG,15118,,225% x Medicaid HMO amount,15118,Other,225% of NY Medicaid HMO DRG,15118,,225% x Medicaid HMO amount,15118,Other,225% of NY Medicaid HMO DRG,15118,,225% x Medicaid HMO amount,15118,Other,225% of NY Medicaid HMO DRG,9407,,140% x Medicaid HMO amount,9407,Other,140% of NY Medicaid HMO DRG,15118,,225% x Medicaid HMO amount,15118,Other,225% of NY Medicaid HMO DRG,18477,,275% x Medicaid HMO amount,18477,Other,275% of NY Medicaid HMO DRG,21770,,324% x Medicaid HMO amount,21770,Other,324% of NY Medicaid HMO DRG,14446,,215% x Medicaid HMO amount,14446,Other,215% of NY Medicaid HMO DRG,14446,,215% x Medicaid HMO amount,14446,Other,215% of NY Medicaid HMO DRG,8399,,125% x Medicaid HMO amount,8399,Other,125% of NY Medicaid HMO DRG,0.01,34234,
Major larynx & trachea procedures,090-2,APR-DRG,,,,,,,,inpatient,,,357205.01,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,102535,,"45,128 x DRG weight",102535,Other,base rate x DRG weight,92281,,"40,615 x DRG weight",92281,Other,base rate x DRG weight,87155,,"38,359 x DRG weight",87155,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34388,,186% x Medicaid HMO amount,34388,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,77426,,"34,077 x DRG weight",77426,Other,base rate x DRG weight,65814,,"28,966 x DRG weight",65814,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18488,,DRG base rate x DRG weight + capital per discharge,18488,Other,100% of NY Medicaid HMO DRG,18488,,100% x Medicaid HMO amount,18488,Other,100% of NY Medicaid HMO DRG,18488,,100% x Medicaid HMO amount,18488,Other,100% of NY Medicaid HMO DRG,18488,,100% x Medicaid HMO amount,18488,Other,100% of NY Medicaid HMO DRG,41598,,225% x Medicaid HMO amount,41598,Other,225% of NY Medicaid HMO DRG,41598,,225% x Medicaid HMO amount,41598,Other,225% of NY Medicaid HMO DRG,41598,,225% x Medicaid HMO amount,41598,Other,225% of NY Medicaid HMO DRG,41598,,225% x Medicaid HMO amount,41598,Other,225% of NY Medicaid HMO DRG,25883,,140% x Medicaid HMO amount,25883,Other,140% of NY Medicaid HMO DRG,41598,,225% x Medicaid HMO amount,41598,Other,225% of NY Medicaid HMO DRG,50842,,275% x Medicaid HMO amount,50842,Other,275% of NY Medicaid HMO DRG,59901,,324% x Medicaid HMO amount,59901,Other,324% of NY Medicaid HMO DRG,39749,,215% x Medicaid HMO amount,39749,Other,215% of NY Medicaid HMO DRG,39749,,215% x Medicaid HMO amount,39749,Other,215% of NY Medicaid HMO DRG,23110,,125% x Medicaid HMO amount,23110,Other,125% of NY Medicaid HMO DRG,0.01,102535,
Major larynx & trachea procedures,090-3,APR-DRG,,,,,,,,inpatient,,,300761.19,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,184420,,"45,128 x DRG weight",184420,Other,base rate x DRG weight,165977,,"40,615 x DRG weight",165977,Other,base rate x DRG weight,156758,,"38,359 x DRG weight",156758,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60630,,186% x Medicaid HMO amount,60630,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,139259,,"34,077 x DRG weight",139259,Other,base rate x DRG weight,118372,,"28,966 x DRG weight",118372,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32597,,DRG base rate x DRG weight + capital per discharge,32597,Other,100% of NY Medicaid HMO DRG,32597,,100% x Medicaid HMO amount,32597,Other,100% of NY Medicaid HMO DRG,32597,,100% x Medicaid HMO amount,32597,Other,100% of NY Medicaid HMO DRG,32597,,100% x Medicaid HMO amount,32597,Other,100% of NY Medicaid HMO DRG,73343,,225% x Medicaid HMO amount,73343,Other,225% of NY Medicaid HMO DRG,73343,,225% x Medicaid HMO amount,73343,Other,225% of NY Medicaid HMO DRG,73343,,225% x Medicaid HMO amount,73343,Other,225% of NY Medicaid HMO DRG,73343,,225% x Medicaid HMO amount,73343,Other,225% of NY Medicaid HMO DRG,45636,,140% x Medicaid HMO amount,45636,Other,140% of NY Medicaid HMO DRG,73343,,225% x Medicaid HMO amount,73343,Other,225% of NY Medicaid HMO DRG,89642,,275% x Medicaid HMO amount,89642,Other,275% of NY Medicaid HMO DRG,105614,,324% x Medicaid HMO amount,105614,Other,324% of NY Medicaid HMO DRG,70084,,215% x Medicaid HMO amount,70084,Other,215% of NY Medicaid HMO DRG,70084,,215% x Medicaid HMO amount,70084,Other,215% of NY Medicaid HMO DRG,40746,,125% x Medicaid HMO amount,40746,Other,125% of NY Medicaid HMO DRG,0.01,184420,
Major larynx & trachea procedures,090-4,APR-DRG,,,,,,,,inpatient,,,1517996.77,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,506805,,"45,128 x DRG weight",506805,Other,base rate x DRG weight,456123,,"40,615 x DRG weight",456123,Other,base rate x DRG weight,430787,,"38,359 x DRG weight",430787,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,163948,,186% x Medicaid HMO amount,163948,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,382698,,"34,077 x DRG weight",382698,Other,base rate x DRG weight,325300,,"28,966 x DRG weight",325300,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,88144,,DRG base rate x DRG weight + capital per discharge,88144,Other,100% of NY Medicaid HMO DRG,88144,,100% x Medicaid HMO amount,88144,Other,100% of NY Medicaid HMO DRG,88144,,100% x Medicaid HMO amount,88144,Other,100% of NY Medicaid HMO DRG,88144,,100% x Medicaid HMO amount,88144,Other,100% of NY Medicaid HMO DRG,198324,,225% x Medicaid HMO amount,198324,Other,225% of NY Medicaid HMO DRG,198324,,225% x Medicaid HMO amount,198324,Other,225% of NY Medicaid HMO DRG,198324,,225% x Medicaid HMO amount,198324,Other,225% of NY Medicaid HMO DRG,198324,,225% x Medicaid HMO amount,198324,Other,225% of NY Medicaid HMO DRG,123402,,140% x Medicaid HMO amount,123402,Other,140% of NY Medicaid HMO DRG,198324,,225% x Medicaid HMO amount,198324,Other,225% of NY Medicaid HMO DRG,242396,,275% x Medicaid HMO amount,242396,Other,275% of NY Medicaid HMO DRG,285587,,324% x Medicaid HMO amount,285587,Other,324% of NY Medicaid HMO DRG,189510,,215% x Medicaid HMO amount,189510,Other,215% of NY Medicaid HMO DRG,189510,,215% x Medicaid HMO amount,189510,Other,215% of NY Medicaid HMO DRG,110180,,125% x Medicaid HMO amount,110180,Other,125% of NY Medicaid HMO DRG,0.01,506805,
Other major head & neck procedures,091-1,APR-DRG,,,,,,,,inpatient,,,591656.53,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60228,,"45,128 x DRG weight",60228,Other,base rate x DRG weight,54205,,"40,615 x DRG weight",54205,Other,base rate x DRG weight,51194,,"38,359 x DRG weight",51194,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20828,,186% x Medicaid HMO amount,20828,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45479,,"34,077 x DRG weight",45479,Other,base rate x DRG weight,38658,,"28,966 x DRG weight",38658,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11198,,DRG base rate x DRG weight + capital per discharge,11198,Other,100% of NY Medicaid HMO DRG,11198,,100% x Medicaid HMO amount,11198,Other,100% of NY Medicaid HMO DRG,11198,,100% x Medicaid HMO amount,11198,Other,100% of NY Medicaid HMO DRG,11198,,100% x Medicaid HMO amount,11198,Other,100% of NY Medicaid HMO DRG,25196,,225% x Medicaid HMO amount,25196,Other,225% of NY Medicaid HMO DRG,25196,,225% x Medicaid HMO amount,25196,Other,225% of NY Medicaid HMO DRG,25196,,225% x Medicaid HMO amount,25196,Other,225% of NY Medicaid HMO DRG,25196,,225% x Medicaid HMO amount,25196,Other,225% of NY Medicaid HMO DRG,15677,,140% x Medicaid HMO amount,15677,Other,140% of NY Medicaid HMO DRG,25196,,225% x Medicaid HMO amount,25196,Other,225% of NY Medicaid HMO DRG,30795,,275% x Medicaid HMO amount,30795,Other,275% of NY Medicaid HMO DRG,36282,,324% x Medicaid HMO amount,36282,Other,324% of NY Medicaid HMO DRG,24076,,215% x Medicaid HMO amount,24076,Other,215% of NY Medicaid HMO DRG,24076,,215% x Medicaid HMO amount,24076,Other,215% of NY Medicaid HMO DRG,13998,,125% x Medicaid HMO amount,13998,Other,125% of NY Medicaid HMO DRG,0.01,60228,
Other major head & neck procedures,091-2,APR-DRG,,,,,,,,inpatient,,,591656.53,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,128570,,"45,128 x DRG weight",128570,Other,base rate x DRG weight,115712,,"40,615 x DRG weight",115712,Other,base rate x DRG weight,109285,,"38,359 x DRG weight",109285,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42732,,186% x Medicaid HMO amount,42732,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,97085,,"34,077 x DRG weight",97085,Other,base rate x DRG weight,82524,,"28,966 x DRG weight",82524,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22974,,DRG base rate x DRG weight + capital per discharge,22974,Other,100% of NY Medicaid HMO DRG,22974,,100% x Medicaid HMO amount,22974,Other,100% of NY Medicaid HMO DRG,22974,,100% x Medicaid HMO amount,22974,Other,100% of NY Medicaid HMO DRG,22974,,100% x Medicaid HMO amount,22974,Other,100% of NY Medicaid HMO DRG,51692,,225% x Medicaid HMO amount,51692,Other,225% of NY Medicaid HMO DRG,51692,,225% x Medicaid HMO amount,51692,Other,225% of NY Medicaid HMO DRG,51692,,225% x Medicaid HMO amount,51692,Other,225% of NY Medicaid HMO DRG,51692,,225% x Medicaid HMO amount,51692,Other,225% of NY Medicaid HMO DRG,32164,,140% x Medicaid HMO amount,32164,Other,140% of NY Medicaid HMO DRG,51692,,225% x Medicaid HMO amount,51692,Other,225% of NY Medicaid HMO DRG,63179,,275% x Medicaid HMO amount,63179,Other,275% of NY Medicaid HMO DRG,74436,,324% x Medicaid HMO amount,74436,Other,324% of NY Medicaid HMO DRG,49394,,215% x Medicaid HMO amount,49394,Other,215% of NY Medicaid HMO DRG,49394,,215% x Medicaid HMO amount,49394,Other,215% of NY Medicaid HMO DRG,28718,,125% x Medicaid HMO amount,28718,Other,125% of NY Medicaid HMO DRG,0.01,128570,
Other major head & neck procedures,091-3,APR-DRG,,,,,,,,inpatient,,,553354.16,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,166279,,"45,128 x DRG weight",166279,Other,base rate x DRG weight,149650,,"40,615 x DRG weight",149650,Other,base rate x DRG weight,141338,,"38,359 x DRG weight",141338,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54816,,186% x Medicaid HMO amount,54816,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,125560,,"34,077 x DRG weight",125560,Other,base rate x DRG weight,106728,,"28,966 x DRG weight",106728,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29471,,DRG base rate x DRG weight + capital per discharge,29471,Other,100% of NY Medicaid HMO DRG,29471,,100% x Medicaid HMO amount,29471,Other,100% of NY Medicaid HMO DRG,29471,,100% x Medicaid HMO amount,29471,Other,100% of NY Medicaid HMO DRG,29471,,100% x Medicaid HMO amount,29471,Other,100% of NY Medicaid HMO DRG,66310,,225% x Medicaid HMO amount,66310,Other,225% of NY Medicaid HMO DRG,66310,,225% x Medicaid HMO amount,66310,Other,225% of NY Medicaid HMO DRG,66310,,225% x Medicaid HMO amount,66310,Other,225% of NY Medicaid HMO DRG,66310,,225% x Medicaid HMO amount,66310,Other,225% of NY Medicaid HMO DRG,41259,,140% x Medicaid HMO amount,41259,Other,140% of NY Medicaid HMO DRG,66310,,225% x Medicaid HMO amount,66310,Other,225% of NY Medicaid HMO DRG,81045,,275% x Medicaid HMO amount,81045,Other,275% of NY Medicaid HMO DRG,95486,,324% x Medicaid HMO amount,95486,Other,324% of NY Medicaid HMO DRG,63363,,215% x Medicaid HMO amount,63363,Other,215% of NY Medicaid HMO DRG,63363,,215% x Medicaid HMO amount,63363,Other,215% of NY Medicaid HMO DRG,36839,,125% x Medicaid HMO amount,36839,Other,125% of NY Medicaid HMO DRG,0.01,166279,
Other major head & neck procedures,091-4,APR-DRG,,,,,,,,inpatient,,,591656.53,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,186952,,"45,128 x DRG weight",186952,Other,base rate x DRG weight,168256,,"40,615 x DRG weight",168256,Other,base rate x DRG weight,158910,,"38,359 x DRG weight",158910,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,61441,,186% x Medicaid HMO amount,61441,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,141171,,"34,077 x DRG weight",141171,Other,base rate x DRG weight,119997,,"28,966 x DRG weight",119997,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33033,,DRG base rate x DRG weight + capital per discharge,33033,Other,100% of NY Medicaid HMO DRG,33033,,100% x Medicaid HMO amount,33033,Other,100% of NY Medicaid HMO DRG,33033,,100% x Medicaid HMO amount,33033,Other,100% of NY Medicaid HMO DRG,33033,,100% x Medicaid HMO amount,33033,Other,100% of NY Medicaid HMO DRG,74324,,225% x Medicaid HMO amount,74324,Other,225% of NY Medicaid HMO DRG,74324,,225% x Medicaid HMO amount,74324,Other,225% of NY Medicaid HMO DRG,74324,,225% x Medicaid HMO amount,74324,Other,225% of NY Medicaid HMO DRG,74324,,225% x Medicaid HMO amount,74324,Other,225% of NY Medicaid HMO DRG,46246,,140% x Medicaid HMO amount,46246,Other,140% of NY Medicaid HMO DRG,74324,,225% x Medicaid HMO amount,74324,Other,225% of NY Medicaid HMO DRG,90841,,275% x Medicaid HMO amount,90841,Other,275% of NY Medicaid HMO DRG,107027,,324% x Medicaid HMO amount,107027,Other,324% of NY Medicaid HMO DRG,71021,,215% x Medicaid HMO amount,71021,Other,215% of NY Medicaid HMO DRG,71021,,215% x Medicaid HMO amount,71021,Other,215% of NY Medicaid HMO DRG,41291,,125% x Medicaid HMO amount,41291,Other,125% of NY Medicaid HMO DRG,0.01,186952,
Facial bone procedures except major cranial/facial bone procedures,092-1,APR-DRG,,,,,,,,inpatient,,,144089.34,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47457,,"45,128 x DRG weight",47457,Other,base rate x DRG weight,42711,,"40,615 x DRG weight",42711,Other,base rate x DRG weight,40338,,"38,359 x DRG weight",40338,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16736,,186% x Medicaid HMO amount,16736,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35835,,"34,077 x DRG weight",35835,Other,base rate x DRG weight,30461,,"28,966 x DRG weight",30461,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8998,,DRG base rate x DRG weight + capital per discharge,8998,Other,100% of NY Medicaid HMO DRG,8998,,100% x Medicaid HMO amount,8998,Other,100% of NY Medicaid HMO DRG,8998,,100% x Medicaid HMO amount,8998,Other,100% of NY Medicaid HMO DRG,8998,,100% x Medicaid HMO amount,8998,Other,100% of NY Medicaid HMO DRG,20246,,225% x Medicaid HMO amount,20246,Other,225% of NY Medicaid HMO DRG,20246,,225% x Medicaid HMO amount,20246,Other,225% of NY Medicaid HMO DRG,20246,,225% x Medicaid HMO amount,20246,Other,225% of NY Medicaid HMO DRG,20246,,225% x Medicaid HMO amount,20246,Other,225% of NY Medicaid HMO DRG,12597,,140% x Medicaid HMO amount,12597,Other,140% of NY Medicaid HMO DRG,20246,,225% x Medicaid HMO amount,20246,Other,225% of NY Medicaid HMO DRG,24745,,275% x Medicaid HMO amount,24745,Other,275% of NY Medicaid HMO DRG,29154,,324% x Medicaid HMO amount,29154,Other,324% of NY Medicaid HMO DRG,19346,,215% x Medicaid HMO amount,19346,Other,215% of NY Medicaid HMO DRG,19346,,215% x Medicaid HMO amount,19346,Other,215% of NY Medicaid HMO DRG,11248,,125% x Medicaid HMO amount,11248,Other,125% of NY Medicaid HMO DRG,0.01,47457,
Facial bone procedures except major cranial/facial bone procedures,092-2,APR-DRG,,,,,,,,inpatient,,,228573.82,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,61577,,"45,128 x DRG weight",61577,Other,base rate x DRG weight,55419,,"40,615 x DRG weight",55419,Other,base rate x DRG weight,52341,,"38,359 x DRG weight",52341,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21262,,186% x Medicaid HMO amount,21262,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46498,,"34,077 x DRG weight",46498,Other,base rate x DRG weight,39524,,"28,966 x DRG weight",39524,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11431,,DRG base rate x DRG weight + capital per discharge,11431,Other,100% of NY Medicaid HMO DRG,11431,,100% x Medicaid HMO amount,11431,Other,100% of NY Medicaid HMO DRG,11431,,100% x Medicaid HMO amount,11431,Other,100% of NY Medicaid HMO DRG,11431,,100% x Medicaid HMO amount,11431,Other,100% of NY Medicaid HMO DRG,25720,,225% x Medicaid HMO amount,25720,Other,225% of NY Medicaid HMO DRG,25720,,225% x Medicaid HMO amount,25720,Other,225% of NY Medicaid HMO DRG,25720,,225% x Medicaid HMO amount,25720,Other,225% of NY Medicaid HMO DRG,25720,,225% x Medicaid HMO amount,25720,Other,225% of NY Medicaid HMO DRG,16003,,140% x Medicaid HMO amount,16003,Other,140% of NY Medicaid HMO DRG,25720,,225% x Medicaid HMO amount,25720,Other,225% of NY Medicaid HMO DRG,31435,,275% x Medicaid HMO amount,31435,Other,275% of NY Medicaid HMO DRG,37036,,324% x Medicaid HMO amount,37036,Other,324% of NY Medicaid HMO DRG,24577,,215% x Medicaid HMO amount,24577,Other,215% of NY Medicaid HMO DRG,24577,,215% x Medicaid HMO amount,24577,Other,215% of NY Medicaid HMO DRG,14289,,125% x Medicaid HMO amount,14289,Other,125% of NY Medicaid HMO DRG,0.01,61577,
Facial bone procedures except major cranial/facial bone procedures,092-3,APR-DRG,,,,,,,,inpatient,,,358636.71,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,98343,,"45,128 x DRG weight",98343,Other,base rate x DRG weight,88508,,"40,615 x DRG weight",88508,Other,base rate x DRG weight,83592,,"38,359 x DRG weight",83592,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33045,,186% x Medicaid HMO amount,33045,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,74261,,"34,077 x DRG weight",74261,Other,base rate x DRG weight,63123,,"28,966 x DRG weight",63123,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17766,,DRG base rate x DRG weight + capital per discharge,17766,Other,100% of NY Medicaid HMO DRG,17766,,100% x Medicaid HMO amount,17766,Other,100% of NY Medicaid HMO DRG,17766,,100% x Medicaid HMO amount,17766,Other,100% of NY Medicaid HMO DRG,17766,,100% x Medicaid HMO amount,17766,Other,100% of NY Medicaid HMO DRG,39974,,225% x Medicaid HMO amount,39974,Other,225% of NY Medicaid HMO DRG,39974,,225% x Medicaid HMO amount,39974,Other,225% of NY Medicaid HMO DRG,39974,,225% x Medicaid HMO amount,39974,Other,225% of NY Medicaid HMO DRG,39974,,225% x Medicaid HMO amount,39974,Other,225% of NY Medicaid HMO DRG,24872,,140% x Medicaid HMO amount,24872,Other,140% of NY Medicaid HMO DRG,39974,,225% x Medicaid HMO amount,39974,Other,225% of NY Medicaid HMO DRG,48857,,275% x Medicaid HMO amount,48857,Other,275% of NY Medicaid HMO DRG,57562,,324% x Medicaid HMO amount,57562,Other,324% of NY Medicaid HMO DRG,38197,,215% x Medicaid HMO amount,38197,Other,215% of NY Medicaid HMO DRG,38197,,215% x Medicaid HMO amount,38197,Other,215% of NY Medicaid HMO DRG,22208,,125% x Medicaid HMO amount,22208,Other,125% of NY Medicaid HMO DRG,0.01,98343,
Facial bone procedures except major cranial/facial bone procedures,092-4,APR-DRG,,,,,,,,inpatient,,,957722.22,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,331844,,"45,128 x DRG weight",331844,Other,base rate x DRG weight,298658,,"40,615 x DRG weight",298658,Other,base rate x DRG weight,282069,,"38,359 x DRG weight",282069,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,107876,,186% x Medicaid HMO amount,107876,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,250582,,"34,077 x DRG weight",250582,Other,base rate x DRG weight,212999,,"28,966 x DRG weight",212999,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,57998,,DRG base rate x DRG weight + capital per discharge,57998,Other,100% of NY Medicaid HMO DRG,57998,,100% x Medicaid HMO amount,57998,Other,100% of NY Medicaid HMO DRG,57998,,100% x Medicaid HMO amount,57998,Other,100% of NY Medicaid HMO DRG,57998,,100% x Medicaid HMO amount,57998,Other,100% of NY Medicaid HMO DRG,130496,,225% x Medicaid HMO amount,130496,Other,225% of NY Medicaid HMO DRG,130496,,225% x Medicaid HMO amount,130496,Other,225% of NY Medicaid HMO DRG,130496,,225% x Medicaid HMO amount,130496,Other,225% of NY Medicaid HMO DRG,130496,,225% x Medicaid HMO amount,130496,Other,225% of NY Medicaid HMO DRG,81197,,140% x Medicaid HMO amount,81197,Other,140% of NY Medicaid HMO DRG,130496,,225% x Medicaid HMO amount,130496,Other,225% of NY Medicaid HMO DRG,159495,,275% x Medicaid HMO amount,159495,Other,275% of NY Medicaid HMO DRG,187914,,324% x Medicaid HMO amount,187914,Other,324% of NY Medicaid HMO DRG,124696,,215% x Medicaid HMO amount,124696,Other,215% of NY Medicaid HMO DRG,124696,,215% x Medicaid HMO amount,124696,Other,215% of NY Medicaid HMO DRG,72498,,125% x Medicaid HMO amount,72498,Other,125% of NY Medicaid HMO DRG,0.01,331844,
Sinus & mastoid procedures,093-1,APR-DRG,,,,,,,,inpatient,,,92659.22,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40480,,"45,128 x DRG weight",40480,Other,base rate x DRG weight,36432,,"40,615 x DRG weight",36432,Other,base rate x DRG weight,34408,,"38,359 x DRG weight",34408,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14501,,186% x Medicaid HMO amount,14501,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30567,,"34,077 x DRG weight",30567,Other,base rate x DRG weight,25983,,"28,966 x DRG weight",25983,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7796,,DRG base rate x DRG weight + capital per discharge,7796,Other,100% of NY Medicaid HMO DRG,7796,,100% x Medicaid HMO amount,7796,Other,100% of NY Medicaid HMO DRG,7796,,100% x Medicaid HMO amount,7796,Other,100% of NY Medicaid HMO DRG,7796,,100% x Medicaid HMO amount,7796,Other,100% of NY Medicaid HMO DRG,17541,,225% x Medicaid HMO amount,17541,Other,225% of NY Medicaid HMO DRG,17541,,225% x Medicaid HMO amount,17541,Other,225% of NY Medicaid HMO DRG,17541,,225% x Medicaid HMO amount,17541,Other,225% of NY Medicaid HMO DRG,17541,,225% x Medicaid HMO amount,17541,Other,225% of NY Medicaid HMO DRG,10914,,140% x Medicaid HMO amount,10914,Other,140% of NY Medicaid HMO DRG,17541,,225% x Medicaid HMO amount,17541,Other,225% of NY Medicaid HMO DRG,21439,,275% x Medicaid HMO amount,21439,Other,275% of NY Medicaid HMO DRG,25259,,324% x Medicaid HMO amount,25259,Other,324% of NY Medicaid HMO DRG,16761,,215% x Medicaid HMO amount,16761,Other,215% of NY Medicaid HMO DRG,16761,,215% x Medicaid HMO amount,16761,Other,215% of NY Medicaid HMO DRG,9745,,125% x Medicaid HMO amount,9745,Other,125% of NY Medicaid HMO DRG,0.01,40480,
Sinus & mastoid procedures,093-2,APR-DRG,,,,,,,,inpatient,,,168159.59,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55679,,"45,128 x DRG weight",55679,Other,base rate x DRG weight,50111,,"40,615 x DRG weight",50111,Other,base rate x DRG weight,47327,,"38,359 x DRG weight",47327,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19370,,186% x Medicaid HMO amount,19370,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42044,,"34,077 x DRG weight",42044,Other,base rate x DRG weight,35738,,"28,966 x DRG weight",35738,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10414,,DRG base rate x DRG weight + capital per discharge,10414,Other,100% of NY Medicaid HMO DRG,10414,,100% x Medicaid HMO amount,10414,Other,100% of NY Medicaid HMO DRG,10414,,100% x Medicaid HMO amount,10414,Other,100% of NY Medicaid HMO DRG,10414,,100% x Medicaid HMO amount,10414,Other,100% of NY Medicaid HMO DRG,23432,,225% x Medicaid HMO amount,23432,Other,225% of NY Medicaid HMO DRG,23432,,225% x Medicaid HMO amount,23432,Other,225% of NY Medicaid HMO DRG,23432,,225% x Medicaid HMO amount,23432,Other,225% of NY Medicaid HMO DRG,23432,,225% x Medicaid HMO amount,23432,Other,225% of NY Medicaid HMO DRG,14580,,140% x Medicaid HMO amount,14580,Other,140% of NY Medicaid HMO DRG,23432,,225% x Medicaid HMO amount,23432,Other,225% of NY Medicaid HMO DRG,28639,,275% x Medicaid HMO amount,28639,Other,275% of NY Medicaid HMO DRG,33741,,324% x Medicaid HMO amount,33741,Other,324% of NY Medicaid HMO DRG,22390,,215% x Medicaid HMO amount,22390,Other,215% of NY Medicaid HMO DRG,22390,,215% x Medicaid HMO amount,22390,Other,215% of NY Medicaid HMO DRG,13018,,125% x Medicaid HMO amount,13018,Other,125% of NY Medicaid HMO DRG,0.01,55679,
Sinus & mastoid procedures,093-3,APR-DRG,,,,,,,,inpatient,,,320080.1,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,106868,,"45,128 x DRG weight",106868,Other,base rate x DRG weight,96180,,"40,615 x DRG weight",96180,Other,base rate x DRG weight,90838,,"38,359 x DRG weight",90838,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35775,,186% x Medicaid HMO amount,35775,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,80698,,"34,077 x DRG weight",80698,Other,base rate x DRG weight,68594,,"28,966 x DRG weight",68594,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19234,,DRG base rate x DRG weight + capital per discharge,19234,Other,100% of NY Medicaid HMO DRG,19234,,100% x Medicaid HMO amount,19234,Other,100% of NY Medicaid HMO DRG,19234,,100% x Medicaid HMO amount,19234,Other,100% of NY Medicaid HMO DRG,19234,,100% x Medicaid HMO amount,19234,Other,100% of NY Medicaid HMO DRG,43277,,225% x Medicaid HMO amount,43277,Other,225% of NY Medicaid HMO DRG,43277,,225% x Medicaid HMO amount,43277,Other,225% of NY Medicaid HMO DRG,43277,,225% x Medicaid HMO amount,43277,Other,225% of NY Medicaid HMO DRG,43277,,225% x Medicaid HMO amount,43277,Other,225% of NY Medicaid HMO DRG,26928,,140% x Medicaid HMO amount,26928,Other,140% of NY Medicaid HMO DRG,43277,,225% x Medicaid HMO amount,43277,Other,225% of NY Medicaid HMO DRG,52894,,275% x Medicaid HMO amount,52894,Other,275% of NY Medicaid HMO DRG,62318,,324% x Medicaid HMO amount,62318,Other,324% of NY Medicaid HMO DRG,41353,,215% x Medicaid HMO amount,41353,Other,215% of NY Medicaid HMO DRG,41353,,215% x Medicaid HMO amount,41353,Other,215% of NY Medicaid HMO DRG,24043,,125% x Medicaid HMO amount,24043,Other,125% of NY Medicaid HMO DRG,0.01,106868,
Sinus & mastoid procedures,093-4,APR-DRG,,,,,,,,inpatient,,,350155.65,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,125501,,"45,128 x DRG weight",125501,Other,base rate x DRG weight,112950,,"40,615 x DRG weight",112950,Other,base rate x DRG weight,106676,,"38,359 x DRG weight",106676,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41748,,186% x Medicaid HMO amount,41748,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,94768,,"34,077 x DRG weight",94768,Other,base rate x DRG weight,80554,,"28,966 x DRG weight",80554,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22445,,DRG base rate x DRG weight + capital per discharge,22445,Other,100% of NY Medicaid HMO DRG,22445,,100% x Medicaid HMO amount,22445,Other,100% of NY Medicaid HMO DRG,22445,,100% x Medicaid HMO amount,22445,Other,100% of NY Medicaid HMO DRG,22445,,100% x Medicaid HMO amount,22445,Other,100% of NY Medicaid HMO DRG,50501,,225% x Medicaid HMO amount,50501,Other,225% of NY Medicaid HMO DRG,50501,,225% x Medicaid HMO amount,50501,Other,225% of NY Medicaid HMO DRG,50501,,225% x Medicaid HMO amount,50501,Other,225% of NY Medicaid HMO DRG,50501,,225% x Medicaid HMO amount,50501,Other,225% of NY Medicaid HMO DRG,31423,,140% x Medicaid HMO amount,31423,Other,140% of NY Medicaid HMO DRG,50501,,225% x Medicaid HMO amount,50501,Other,225% of NY Medicaid HMO DRG,61724,,275% x Medicaid HMO amount,61724,Other,275% of NY Medicaid HMO DRG,72722,,324% x Medicaid HMO amount,72722,Other,324% of NY Medicaid HMO DRG,48257,,215% x Medicaid HMO amount,48257,Other,215% of NY Medicaid HMO DRG,48257,,215% x Medicaid HMO amount,48257,Other,215% of NY Medicaid HMO DRG,28056,,125% x Medicaid HMO amount,28056,Other,125% of NY Medicaid HMO DRG,0.01,125501,
Cleft lip & palate repair,095-1,APR-DRG,,,,,,,,inpatient,,,93293.69,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32352,,"45,128 x DRG weight",32352,Other,base rate x DRG weight,29117,,"40,615 x DRG weight",29117,Other,base rate x DRG weight,27500,,"38,359 x DRG weight",27500,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11895,,186% x Medicaid HMO amount,11895,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24430,,"34,077 x DRG weight",24430,Other,base rate x DRG weight,20766,,"28,966 x DRG weight",20766,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6395,,DRG base rate x DRG weight + capital per discharge,6395,Other,100% of NY Medicaid HMO DRG,6395,,100% x Medicaid HMO amount,6395,Other,100% of NY Medicaid HMO DRG,6395,,100% x Medicaid HMO amount,6395,Other,100% of NY Medicaid HMO DRG,6395,,100% x Medicaid HMO amount,6395,Other,100% of NY Medicaid HMO DRG,14389,,225% x Medicaid HMO amount,14389,Other,225% of NY Medicaid HMO DRG,14389,,225% x Medicaid HMO amount,14389,Other,225% of NY Medicaid HMO DRG,14389,,225% x Medicaid HMO amount,14389,Other,225% of NY Medicaid HMO DRG,14389,,225% x Medicaid HMO amount,14389,Other,225% of NY Medicaid HMO DRG,8953,,140% x Medicaid HMO amount,8953,Other,140% of NY Medicaid HMO DRG,14389,,225% x Medicaid HMO amount,14389,Other,225% of NY Medicaid HMO DRG,17586,,275% x Medicaid HMO amount,17586,Other,275% of NY Medicaid HMO DRG,20720,,324% x Medicaid HMO amount,20720,Other,324% of NY Medicaid HMO DRG,13749,,215% x Medicaid HMO amount,13749,Other,215% of NY Medicaid HMO DRG,13749,,215% x Medicaid HMO amount,13749,Other,215% of NY Medicaid HMO DRG,7994,,125% x Medicaid HMO amount,7994,Other,125% of NY Medicaid HMO DRG,0.01,32352,
Cleft lip & palate repair,095-2,APR-DRG,,,,,,,,inpatient,,,70312.7,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40931,,"45,128 x DRG weight",40931,Other,base rate x DRG weight,36838,,"40,615 x DRG weight",36838,Other,base rate x DRG weight,34792,,"38,359 x DRG weight",34792,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14644,,186% x Medicaid HMO amount,14644,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30908,,"34,077 x DRG weight",30908,Other,base rate x DRG weight,26272,,"28,966 x DRG weight",26272,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7873,,DRG base rate x DRG weight + capital per discharge,7873,Other,100% of NY Medicaid HMO DRG,7873,,100% x Medicaid HMO amount,7873,Other,100% of NY Medicaid HMO DRG,7873,,100% x Medicaid HMO amount,7873,Other,100% of NY Medicaid HMO DRG,7873,,100% x Medicaid HMO amount,7873,Other,100% of NY Medicaid HMO DRG,17714,,225% x Medicaid HMO amount,17714,Other,225% of NY Medicaid HMO DRG,17714,,225% x Medicaid HMO amount,17714,Other,225% of NY Medicaid HMO DRG,17714,,225% x Medicaid HMO amount,17714,Other,225% of NY Medicaid HMO DRG,17714,,225% x Medicaid HMO amount,17714,Other,225% of NY Medicaid HMO DRG,11022,,140% x Medicaid HMO amount,11022,Other,140% of NY Medicaid HMO DRG,17714,,225% x Medicaid HMO amount,17714,Other,225% of NY Medicaid HMO DRG,21651,,275% x Medicaid HMO amount,21651,Other,275% of NY Medicaid HMO DRG,25509,,324% x Medicaid HMO amount,25509,Other,324% of NY Medicaid HMO DRG,16927,,215% x Medicaid HMO amount,16927,Other,215% of NY Medicaid HMO DRG,16927,,215% x Medicaid HMO amount,16927,Other,215% of NY Medicaid HMO DRG,9841,,125% x Medicaid HMO amount,9841,Other,125% of NY Medicaid HMO DRG,0.01,40931,
Cleft lip & palate repair,095-3,APR-DRG,,,,,,,,inpatient,,,93293.69,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,62565,,"45,128 x DRG weight",62565,Other,base rate x DRG weight,56309,,"40,615 x DRG weight",56309,Other,base rate x DRG weight,53181,,"38,359 x DRG weight",53181,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21578,,186% x Medicaid HMO amount,21578,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47244,,"34,077 x DRG weight",47244,Other,base rate x DRG weight,40158,,"28,966 x DRG weight",40158,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11601,,DRG base rate x DRG weight + capital per discharge,11601,Other,100% of NY Medicaid HMO DRG,11601,,100% x Medicaid HMO amount,11601,Other,100% of NY Medicaid HMO DRG,11601,,100% x Medicaid HMO amount,11601,Other,100% of NY Medicaid HMO DRG,11601,,100% x Medicaid HMO amount,11601,Other,100% of NY Medicaid HMO DRG,26102,,225% x Medicaid HMO amount,26102,Other,225% of NY Medicaid HMO DRG,26102,,225% x Medicaid HMO amount,26102,Other,225% of NY Medicaid HMO DRG,26102,,225% x Medicaid HMO amount,26102,Other,225% of NY Medicaid HMO DRG,26102,,225% x Medicaid HMO amount,26102,Other,225% of NY Medicaid HMO DRG,16241,,140% x Medicaid HMO amount,16241,Other,140% of NY Medicaid HMO DRG,26102,,225% x Medicaid HMO amount,26102,Other,225% of NY Medicaid HMO DRG,31903,,275% x Medicaid HMO amount,31903,Other,275% of NY Medicaid HMO DRG,37587,,324% x Medicaid HMO amount,37587,Other,324% of NY Medicaid HMO DRG,24942,,215% x Medicaid HMO amount,24942,Other,215% of NY Medicaid HMO DRG,24942,,215% x Medicaid HMO amount,24942,Other,215% of NY Medicaid HMO DRG,14501,,125% x Medicaid HMO amount,14501,Other,125% of NY Medicaid HMO DRG,0.01,62565,
Cleft lip & palate repair,095-4,APR-DRG,,,,,,,,inpatient,,,93293.69,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,114783,,"45,128 x DRG weight",114783,Other,base rate x DRG weight,103304,,"40,615 x DRG weight",103304,Other,base rate x DRG weight,97566,,"38,359 x DRG weight",97566,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38312,,186% x Medicaid HMO amount,38312,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,86675,,"34,077 x DRG weight",86675,Other,base rate x DRG weight,73675,,"28,966 x DRG weight",73675,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20598,,DRG base rate x DRG weight + capital per discharge,20598,Other,100% of NY Medicaid HMO DRG,20598,,100% x Medicaid HMO amount,20598,Other,100% of NY Medicaid HMO DRG,20598,,100% x Medicaid HMO amount,20598,Other,100% of NY Medicaid HMO DRG,20598,,100% x Medicaid HMO amount,20598,Other,100% of NY Medicaid HMO DRG,46346,,225% x Medicaid HMO amount,46346,Other,225% of NY Medicaid HMO DRG,46346,,225% x Medicaid HMO amount,46346,Other,225% of NY Medicaid HMO DRG,46346,,225% x Medicaid HMO amount,46346,Other,225% of NY Medicaid HMO DRG,46346,,225% x Medicaid HMO amount,46346,Other,225% of NY Medicaid HMO DRG,28837,,140% x Medicaid HMO amount,28837,Other,140% of NY Medicaid HMO DRG,46346,,225% x Medicaid HMO amount,46346,Other,225% of NY Medicaid HMO DRG,56645,,275% x Medicaid HMO amount,56645,Other,275% of NY Medicaid HMO DRG,66738,,324% x Medicaid HMO amount,66738,Other,324% of NY Medicaid HMO DRG,44286,,215% x Medicaid HMO amount,44286,Other,215% of NY Medicaid HMO DRG,44286,,215% x Medicaid HMO amount,44286,Other,215% of NY Medicaid HMO DRG,25748,,125% x Medicaid HMO amount,25748,Other,125% of NY Medicaid HMO DRG,0.01,114783,
Tonsil & adenoid procedures,097-1,APR-DRG,,,,,,,,inpatient,,,59099.59,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21851,,"45,128 x DRG weight",21851,Other,base rate x DRG weight,19666,,"40,615 x DRG weight",19666,Other,base rate x DRG weight,18573,,"38,359 x DRG weight",18573,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8530,,186% x Medicaid HMO amount,8530,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16500,,"34,077 x DRG weight",16500,Other,base rate x DRG weight,14025,,"28,966 x DRG weight",14025,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4586,,DRG base rate x DRG weight + capital per discharge,4586,Other,100% of NY Medicaid HMO DRG,4586,,100% x Medicaid HMO amount,4586,Other,100% of NY Medicaid HMO DRG,4586,,100% x Medicaid HMO amount,4586,Other,100% of NY Medicaid HMO DRG,4586,,100% x Medicaid HMO amount,4586,Other,100% of NY Medicaid HMO DRG,10319,,225% x Medicaid HMO amount,10319,Other,225% of NY Medicaid HMO DRG,10319,,225% x Medicaid HMO amount,10319,Other,225% of NY Medicaid HMO DRG,10319,,225% x Medicaid HMO amount,10319,Other,225% of NY Medicaid HMO DRG,10319,,225% x Medicaid HMO amount,10319,Other,225% of NY Medicaid HMO DRG,6420,,140% x Medicaid HMO amount,6420,Other,140% of NY Medicaid HMO DRG,10319,,225% x Medicaid HMO amount,10319,Other,225% of NY Medicaid HMO DRG,12612,,275% x Medicaid HMO amount,12612,Other,275% of NY Medicaid HMO DRG,14859,,324% x Medicaid HMO amount,14859,Other,324% of NY Medicaid HMO DRG,9860,,215% x Medicaid HMO amount,9860,Other,215% of NY Medicaid HMO DRG,9860,,215% x Medicaid HMO amount,9860,Other,215% of NY Medicaid HMO DRG,5733,,125% x Medicaid HMO amount,5733,Other,125% of NY Medicaid HMO DRG,0.01,21851,
Tonsil & adenoid procedures,097-2,APR-DRG,,,,,,,,inpatient,,,85499.55,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31165,,"45,128 x DRG weight",31165,Other,base rate x DRG weight,28049,,"40,615 x DRG weight",28049,Other,base rate x DRG weight,26491,,"38,359 x DRG weight",26491,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11515,,186% x Medicaid HMO amount,11515,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23534,,"34,077 x DRG weight",23534,Other,base rate x DRG weight,20004,,"28,966 x DRG weight",20004,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6191,,DRG base rate x DRG weight + capital per discharge,6191,Other,100% of NY Medicaid HMO DRG,6191,,100% x Medicaid HMO amount,6191,Other,100% of NY Medicaid HMO DRG,6191,,100% x Medicaid HMO amount,6191,Other,100% of NY Medicaid HMO DRG,6191,,100% x Medicaid HMO amount,6191,Other,100% of NY Medicaid HMO DRG,13930,,225% x Medicaid HMO amount,13930,Other,225% of NY Medicaid HMO DRG,13930,,225% x Medicaid HMO amount,13930,Other,225% of NY Medicaid HMO DRG,13930,,225% x Medicaid HMO amount,13930,Other,225% of NY Medicaid HMO DRG,13930,,225% x Medicaid HMO amount,13930,Other,225% of NY Medicaid HMO DRG,8667,,140% x Medicaid HMO amount,8667,Other,140% of NY Medicaid HMO DRG,13930,,225% x Medicaid HMO amount,13930,Other,225% of NY Medicaid HMO DRG,17025,,275% x Medicaid HMO amount,17025,Other,275% of NY Medicaid HMO DRG,20059,,324% x Medicaid HMO amount,20059,Other,324% of NY Medicaid HMO DRG,13311,,215% x Medicaid HMO amount,13311,Other,215% of NY Medicaid HMO DRG,13311,,215% x Medicaid HMO amount,13311,Other,215% of NY Medicaid HMO DRG,7739,,125% x Medicaid HMO amount,7739,Other,125% of NY Medicaid HMO DRG,0.01,31165,
Tonsil & adenoid procedures,097-3,APR-DRG,,,,,,,,inpatient,,,121239.26,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,66749,,"45,128 x DRG weight",66749,Other,base rate x DRG weight,60074,,"40,615 x DRG weight",60074,Other,base rate x DRG weight,56737,,"38,359 x DRG weight",56737,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22919,,186% x Medicaid HMO amount,22919,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50403,,"34,077 x DRG weight",50403,Other,base rate x DRG weight,42844,,"28,966 x DRG weight",42844,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12322,,DRG base rate x DRG weight + capital per discharge,12322,Other,100% of NY Medicaid HMO DRG,12322,,100% x Medicaid HMO amount,12322,Other,100% of NY Medicaid HMO DRG,12322,,100% x Medicaid HMO amount,12322,Other,100% of NY Medicaid HMO DRG,12322,,100% x Medicaid HMO amount,12322,Other,100% of NY Medicaid HMO DRG,27725,,225% x Medicaid HMO amount,27725,Other,225% of NY Medicaid HMO DRG,27725,,225% x Medicaid HMO amount,27725,Other,225% of NY Medicaid HMO DRG,27725,,225% x Medicaid HMO amount,27725,Other,225% of NY Medicaid HMO DRG,27725,,225% x Medicaid HMO amount,27725,Other,225% of NY Medicaid HMO DRG,17251,,140% x Medicaid HMO amount,17251,Other,140% of NY Medicaid HMO DRG,27725,,225% x Medicaid HMO amount,27725,Other,225% of NY Medicaid HMO DRG,33886,,275% x Medicaid HMO amount,33886,Other,275% of NY Medicaid HMO DRG,39923,,324% x Medicaid HMO amount,39923,Other,324% of NY Medicaid HMO DRG,26492,,215% x Medicaid HMO amount,26492,Other,215% of NY Medicaid HMO DRG,26492,,215% x Medicaid HMO amount,26492,Other,215% of NY Medicaid HMO DRG,15403,,125% x Medicaid HMO amount,15403,Other,125% of NY Medicaid HMO DRG,0.01,66749,
Tonsil & adenoid procedures,097-4,APR-DRG,,,,,,,,inpatient,,,200632.02,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,179348,,"45,128 x DRG weight",179348,Other,base rate x DRG weight,161412,,"40,615 x DRG weight",161412,Other,base rate x DRG weight,152446,,"38,359 x DRG weight",152446,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59005,,186% x Medicaid HMO amount,59005,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,135429,,"34,077 x DRG weight",135429,Other,base rate x DRG weight,115117,,"28,966 x DRG weight",115117,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31723,,DRG base rate x DRG weight + capital per discharge,31723,Other,100% of NY Medicaid HMO DRG,31723,,100% x Medicaid HMO amount,31723,Other,100% of NY Medicaid HMO DRG,31723,,100% x Medicaid HMO amount,31723,Other,100% of NY Medicaid HMO DRG,31723,,100% x Medicaid HMO amount,31723,Other,100% of NY Medicaid HMO DRG,71377,,225% x Medicaid HMO amount,71377,Other,225% of NY Medicaid HMO DRG,71377,,225% x Medicaid HMO amount,71377,Other,225% of NY Medicaid HMO DRG,71377,,225% x Medicaid HMO amount,71377,Other,225% of NY Medicaid HMO DRG,71377,,225% x Medicaid HMO amount,71377,Other,225% of NY Medicaid HMO DRG,44412,,140% x Medicaid HMO amount,44412,Other,140% of NY Medicaid HMO DRG,71377,,225% x Medicaid HMO amount,71377,Other,225% of NY Medicaid HMO DRG,87238,,275% x Medicaid HMO amount,87238,Other,275% of NY Medicaid HMO DRG,102783,,324% x Medicaid HMO amount,102783,Other,324% of NY Medicaid HMO DRG,68204,,215% x Medicaid HMO amount,68204,Other,215% of NY Medicaid HMO DRG,68204,,215% x Medicaid HMO amount,68204,Other,215% of NY Medicaid HMO DRG,39654,,125% x Medicaid HMO amount,39654,Other,125% of NY Medicaid HMO DRG,0.01,179348,
"Other ear, nose, mouth & throat procedures",098-1,APR-DRG,,,,,,,,inpatient,,,92389.93,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30899,,"45,128 x DRG weight",30899,Other,base rate x DRG weight,27809,,"40,615 x DRG weight",27809,Other,base rate x DRG weight,26264,,"38,359 x DRG weight",26264,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11430,,186% x Medicaid HMO amount,11430,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23333,,"34,077 x DRG weight",23333,Other,base rate x DRG weight,19833,,"28,966 x DRG weight",19833,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6145,,DRG base rate x DRG weight + capital per discharge,6145,Other,100% of NY Medicaid HMO DRG,6145,,100% x Medicaid HMO amount,6145,Other,100% of NY Medicaid HMO DRG,6145,,100% x Medicaid HMO amount,6145,Other,100% of NY Medicaid HMO DRG,6145,,100% x Medicaid HMO amount,6145,Other,100% of NY Medicaid HMO DRG,13826,,225% x Medicaid HMO amount,13826,Other,225% of NY Medicaid HMO DRG,13826,,225% x Medicaid HMO amount,13826,Other,225% of NY Medicaid HMO DRG,13826,,225% x Medicaid HMO amount,13826,Other,225% of NY Medicaid HMO DRG,13826,,225% x Medicaid HMO amount,13826,Other,225% of NY Medicaid HMO DRG,8603,,140% x Medicaid HMO amount,8603,Other,140% of NY Medicaid HMO DRG,13826,,225% x Medicaid HMO amount,13826,Other,225% of NY Medicaid HMO DRG,16899,,275% x Medicaid HMO amount,16899,Other,275% of NY Medicaid HMO DRG,19910,,324% x Medicaid HMO amount,19910,Other,324% of NY Medicaid HMO DRG,13212,,215% x Medicaid HMO amount,13212,Other,215% of NY Medicaid HMO DRG,13212,,215% x Medicaid HMO amount,13212,Other,215% of NY Medicaid HMO DRG,7681,,125% x Medicaid HMO amount,7681,Other,125% of NY Medicaid HMO DRG,0.01,30899,
"Other ear, nose, mouth & throat procedures",098-2,APR-DRG,,,,,,,,inpatient,,,124969.05,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44013,,"45,128 x DRG weight",44013,Other,base rate x DRG weight,39612,,"40,615 x DRG weight",39612,Other,base rate x DRG weight,37412,,"38,359 x DRG weight",37412,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15631,,186% x Medicaid HMO amount,15631,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33235,,"34,077 x DRG weight",33235,Other,base rate x DRG weight,28251,,"28,966 x DRG weight",28251,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8404,,DRG base rate x DRG weight + capital per discharge,8404,Other,100% of NY Medicaid HMO DRG,8404,,100% x Medicaid HMO amount,8404,Other,100% of NY Medicaid HMO DRG,8404,,100% x Medicaid HMO amount,8404,Other,100% of NY Medicaid HMO DRG,8404,,100% x Medicaid HMO amount,8404,Other,100% of NY Medicaid HMO DRG,18909,,225% x Medicaid HMO amount,18909,Other,225% of NY Medicaid HMO DRG,18909,,225% x Medicaid HMO amount,18909,Other,225% of NY Medicaid HMO DRG,18909,,225% x Medicaid HMO amount,18909,Other,225% of NY Medicaid HMO DRG,18909,,225% x Medicaid HMO amount,18909,Other,225% of NY Medicaid HMO DRG,11766,,140% x Medicaid HMO amount,11766,Other,140% of NY Medicaid HMO DRG,18909,,225% x Medicaid HMO amount,18909,Other,225% of NY Medicaid HMO DRG,23111,,275% x Medicaid HMO amount,23111,Other,275% of NY Medicaid HMO DRG,27229,,324% x Medicaid HMO amount,27229,Other,324% of NY Medicaid HMO DRG,18069,,215% x Medicaid HMO amount,18069,Other,215% of NY Medicaid HMO DRG,18069,,215% x Medicaid HMO amount,18069,Other,215% of NY Medicaid HMO DRG,10505,,125% x Medicaid HMO amount,10505,Other,125% of NY Medicaid HMO DRG,0.01,44013,
"Other ear, nose, mouth & throat procedures",098-3,APR-DRG,,,,,,,,inpatient,,,273103.8,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,84087,,"45,128 x DRG weight",84087,Other,base rate x DRG weight,75678,,"40,615 x DRG weight",75678,Other,base rate x DRG weight,71474,,"38,359 x DRG weight",71474,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28475,,186% x Medicaid HMO amount,28475,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,63496,,"34,077 x DRG weight",63496,Other,base rate x DRG weight,53972,,"28,966 x DRG weight",53972,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15309,,DRG base rate x DRG weight + capital per discharge,15309,Other,100% of NY Medicaid HMO DRG,15309,,100% x Medicaid HMO amount,15309,Other,100% of NY Medicaid HMO DRG,15309,,100% x Medicaid HMO amount,15309,Other,100% of NY Medicaid HMO DRG,15309,,100% x Medicaid HMO amount,15309,Other,100% of NY Medicaid HMO DRG,34445,,225% x Medicaid HMO amount,34445,Other,225% of NY Medicaid HMO DRG,34445,,225% x Medicaid HMO amount,34445,Other,225% of NY Medicaid HMO DRG,34445,,225% x Medicaid HMO amount,34445,Other,225% of NY Medicaid HMO DRG,34445,,225% x Medicaid HMO amount,34445,Other,225% of NY Medicaid HMO DRG,21433,,140% x Medicaid HMO amount,21433,Other,140% of NY Medicaid HMO DRG,34445,,225% x Medicaid HMO amount,34445,Other,225% of NY Medicaid HMO DRG,42100,,275% x Medicaid HMO amount,42100,Other,275% of NY Medicaid HMO DRG,49601,,324% x Medicaid HMO amount,49601,Other,324% of NY Medicaid HMO DRG,32914,,215% x Medicaid HMO amount,32914,Other,215% of NY Medicaid HMO DRG,32914,,215% x Medicaid HMO amount,32914,Other,215% of NY Medicaid HMO DRG,19136,,125% x Medicaid HMO amount,19136,Other,125% of NY Medicaid HMO DRG,0.01,84087,
"Other ear, nose, mouth & throat procedures",098-4,APR-DRG,,,,,,,,inpatient,,,813558.95,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,187800,,"45,128 x DRG weight",187800,Other,base rate x DRG weight,169019,,"40,615 x DRG weight",169019,Other,base rate x DRG weight,159631,,"38,359 x DRG weight",159631,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,61713,,186% x Medicaid HMO amount,61713,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,141811,,"34,077 x DRG weight",141811,Other,base rate x DRG weight,120542,,"28,966 x DRG weight",120542,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33179,,DRG base rate x DRG weight + capital per discharge,33179,Other,100% of NY Medicaid HMO DRG,33179,,100% x Medicaid HMO amount,33179,Other,100% of NY Medicaid HMO DRG,33179,,100% x Medicaid HMO amount,33179,Other,100% of NY Medicaid HMO DRG,33179,,100% x Medicaid HMO amount,33179,Other,100% of NY Medicaid HMO DRG,74653,,225% x Medicaid HMO amount,74653,Other,225% of NY Medicaid HMO DRG,74653,,225% x Medicaid HMO amount,74653,Other,225% of NY Medicaid HMO DRG,74653,,225% x Medicaid HMO amount,74653,Other,225% of NY Medicaid HMO DRG,74653,,225% x Medicaid HMO amount,74653,Other,225% of NY Medicaid HMO DRG,46451,,140% x Medicaid HMO amount,46451,Other,140% of NY Medicaid HMO DRG,74653,,225% x Medicaid HMO amount,74653,Other,225% of NY Medicaid HMO DRG,91242,,275% x Medicaid HMO amount,91242,Other,275% of NY Medicaid HMO DRG,107500,,324% x Medicaid HMO amount,107500,Other,324% of NY Medicaid HMO DRG,71335,,215% x Medicaid HMO amount,71335,Other,215% of NY Medicaid HMO DRG,71335,,215% x Medicaid HMO amount,71335,Other,215% of NY Medicaid HMO DRG,41474,,125% x Medicaid HMO amount,41474,Other,125% of NY Medicaid HMO DRG,0.01,187800,
"Ear, nose, mouth, throat, cranial/facial malignancies",110-1,APR-DRG,,,,,,,,inpatient,,,106260,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32366,,"45,128 x DRG weight",32366,Other,base rate x DRG weight,29129,,"40,615 x DRG weight",29129,Other,base rate x DRG weight,27511,,"38,359 x DRG weight",27511,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11900,,186% x Medicaid HMO amount,11900,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24440,,"34,077 x DRG weight",24440,Other,base rate x DRG weight,20774,,"28,966 x DRG weight",20774,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6398,,DRG base rate x DRG weight + capital per discharge,6398,Other,100% of NY Medicaid HMO DRG,6398,,100% x Medicaid HMO amount,6398,Other,100% of NY Medicaid HMO DRG,6398,,100% x Medicaid HMO amount,6398,Other,100% of NY Medicaid HMO DRG,6398,,100% x Medicaid HMO amount,6398,Other,100% of NY Medicaid HMO DRG,14396,,225% x Medicaid HMO amount,14396,Other,225% of NY Medicaid HMO DRG,14396,,225% x Medicaid HMO amount,14396,Other,225% of NY Medicaid HMO DRG,14396,,225% x Medicaid HMO amount,14396,Other,225% of NY Medicaid HMO DRG,14396,,225% x Medicaid HMO amount,14396,Other,225% of NY Medicaid HMO DRG,8957,,140% x Medicaid HMO amount,8957,Other,140% of NY Medicaid HMO DRG,14396,,225% x Medicaid HMO amount,14396,Other,225% of NY Medicaid HMO DRG,17595,,275% x Medicaid HMO amount,17595,Other,275% of NY Medicaid HMO DRG,20730,,324% x Medicaid HMO amount,20730,Other,324% of NY Medicaid HMO DRG,13756,,215% x Medicaid HMO amount,13756,Other,215% of NY Medicaid HMO DRG,13756,,215% x Medicaid HMO amount,13756,Other,215% of NY Medicaid HMO DRG,7998,,125% x Medicaid HMO amount,7998,Other,125% of NY Medicaid HMO DRG,0.01,32366,
"Ear, nose, mouth, throat, cranial/facial malignancies",110-2,APR-DRG,,,,,,,,inpatient,,,79162,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40728,,"45,128 x DRG weight",40728,Other,base rate x DRG weight,36655,,"40,615 x DRG weight",36655,Other,base rate x DRG weight,34619,,"38,359 x DRG weight",34619,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14579,,186% x Medicaid HMO amount,14579,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30754,,"34,077 x DRG weight",30754,Other,base rate x DRG weight,26142,,"28,966 x DRG weight",26142,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7838,,DRG base rate x DRG weight + capital per discharge,7838,Other,100% of NY Medicaid HMO DRG,7838,,100% x Medicaid HMO amount,7838,Other,100% of NY Medicaid HMO DRG,7838,,100% x Medicaid HMO amount,7838,Other,100% of NY Medicaid HMO DRG,7838,,100% x Medicaid HMO amount,7838,Other,100% of NY Medicaid HMO DRG,17636,,225% x Medicaid HMO amount,17636,Other,225% of NY Medicaid HMO DRG,17636,,225% x Medicaid HMO amount,17636,Other,225% of NY Medicaid HMO DRG,17636,,225% x Medicaid HMO amount,17636,Other,225% of NY Medicaid HMO DRG,17636,,225% x Medicaid HMO amount,17636,Other,225% of NY Medicaid HMO DRG,10973,,140% x Medicaid HMO amount,10973,Other,140% of NY Medicaid HMO DRG,17636,,225% x Medicaid HMO amount,17636,Other,225% of NY Medicaid HMO DRG,21555,,275% x Medicaid HMO amount,21555,Other,275% of NY Medicaid HMO DRG,25395,,324% x Medicaid HMO amount,25395,Other,324% of NY Medicaid HMO DRG,16852,,215% x Medicaid HMO amount,16852,Other,215% of NY Medicaid HMO DRG,16852,,215% x Medicaid HMO amount,16852,Other,215% of NY Medicaid HMO DRG,9798,,125% x Medicaid HMO amount,9798,Other,125% of NY Medicaid HMO DRG,0.01,40728,
"Ear, nose, mouth, throat, cranial/facial malignancies",110-3,APR-DRG,,,,,,,,inpatient,,,175765.11,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,80035,,"45,128 x DRG weight",80035,Other,base rate x DRG weight,72031,,"40,615 x DRG weight",72031,Other,base rate x DRG weight,68030,,"38,359 x DRG weight",68030,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27176,,186% x Medicaid HMO amount,27176,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60436,,"34,077 x DRG weight",60436,Other,base rate x DRG weight,51371,,"28,966 x DRG weight",51371,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14611,,DRG base rate x DRG weight + capital per discharge,14611,Other,100% of NY Medicaid HMO DRG,14611,,100% x Medicaid HMO amount,14611,Other,100% of NY Medicaid HMO DRG,14611,,100% x Medicaid HMO amount,14611,Other,100% of NY Medicaid HMO DRG,14611,,100% x Medicaid HMO amount,14611,Other,100% of NY Medicaid HMO DRG,32875,,225% x Medicaid HMO amount,32875,Other,225% of NY Medicaid HMO DRG,32875,,225% x Medicaid HMO amount,32875,Other,225% of NY Medicaid HMO DRG,32875,,225% x Medicaid HMO amount,32875,Other,225% of NY Medicaid HMO DRG,32875,,225% x Medicaid HMO amount,32875,Other,225% of NY Medicaid HMO DRG,20455,,140% x Medicaid HMO amount,20455,Other,140% of NY Medicaid HMO DRG,32875,,225% x Medicaid HMO amount,32875,Other,225% of NY Medicaid HMO DRG,40180,,275% x Medicaid HMO amount,40180,Other,275% of NY Medicaid HMO DRG,47340,,324% x Medicaid HMO amount,47340,Other,324% of NY Medicaid HMO DRG,31414,,215% x Medicaid HMO amount,31414,Other,215% of NY Medicaid HMO DRG,31414,,215% x Medicaid HMO amount,31414,Other,215% of NY Medicaid HMO DRG,18264,,125% x Medicaid HMO amount,18264,Other,125% of NY Medicaid HMO DRG,0.01,80035,
"Ear, nose, mouth, throat, cranial/facial malignancies",110-4,APR-DRG,,,,,,,,inpatient,,,609618.43,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,163711,,"45,128 x DRG weight",163711,Other,base rate x DRG weight,147339,,"40,615 x DRG weight",147339,Other,base rate x DRG weight,139155,,"38,359 x DRG weight",139155,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53992,,186% x Medicaid HMO amount,53992,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,123621,,"34,077 x DRG weight",123621,Other,base rate x DRG weight,105080,,"28,966 x DRG weight",105080,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29028,,DRG base rate x DRG weight + capital per discharge,29028,Other,100% of NY Medicaid HMO DRG,29028,,100% x Medicaid HMO amount,29028,Other,100% of NY Medicaid HMO DRG,29028,,100% x Medicaid HMO amount,29028,Other,100% of NY Medicaid HMO DRG,29028,,100% x Medicaid HMO amount,29028,Other,100% of NY Medicaid HMO DRG,65313,,225% x Medicaid HMO amount,65313,Other,225% of NY Medicaid HMO DRG,65313,,225% x Medicaid HMO amount,65313,Other,225% of NY Medicaid HMO DRG,65313,,225% x Medicaid HMO amount,65313,Other,225% of NY Medicaid HMO DRG,65313,,225% x Medicaid HMO amount,65313,Other,225% of NY Medicaid HMO DRG,40639,,140% x Medicaid HMO amount,40639,Other,140% of NY Medicaid HMO DRG,65313,,225% x Medicaid HMO amount,65313,Other,225% of NY Medicaid HMO DRG,79827,,275% x Medicaid HMO amount,79827,Other,275% of NY Medicaid HMO DRG,94051,,324% x Medicaid HMO amount,94051,Other,324% of NY Medicaid HMO DRG,62410,,215% x Medicaid HMO amount,62410,Other,215% of NY Medicaid HMO DRG,62410,,215% x Medicaid HMO amount,62410,Other,215% of NY Medicaid HMO DRG,36285,,125% x Medicaid HMO amount,36285,Other,125% of NY Medicaid HMO DRG,0.01,163711,
Vertigo & other labyrinth disorders,111-1,APR-DRG,,,,,,,,inpatient,,,94223.81,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19757,,"45,128 x DRG weight",19757,Other,base rate x DRG weight,17781,,"40,615 x DRG weight",17781,Other,base rate x DRG weight,16794,,"38,359 x DRG weight",16794,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7859,,186% x Medicaid HMO amount,7859,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14919,,"34,077 x DRG weight",14919,Other,base rate x DRG weight,12681,,"28,966 x DRG weight",12681,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4225,,DRG base rate x DRG weight + capital per discharge,4225,Other,100% of NY Medicaid HMO DRG,4225,,100% x Medicaid HMO amount,4225,Other,100% of NY Medicaid HMO DRG,4225,,100% x Medicaid HMO amount,4225,Other,100% of NY Medicaid HMO DRG,4225,,100% x Medicaid HMO amount,4225,Other,100% of NY Medicaid HMO DRG,9506,,225% x Medicaid HMO amount,9506,Other,225% of NY Medicaid HMO DRG,9506,,225% x Medicaid HMO amount,9506,Other,225% of NY Medicaid HMO DRG,9506,,225% x Medicaid HMO amount,9506,Other,225% of NY Medicaid HMO DRG,9506,,225% x Medicaid HMO amount,9506,Other,225% of NY Medicaid HMO DRG,5915,,140% x Medicaid HMO amount,5915,Other,140% of NY Medicaid HMO DRG,9506,,225% x Medicaid HMO amount,9506,Other,225% of NY Medicaid HMO DRG,11619,,275% x Medicaid HMO amount,11619,Other,275% of NY Medicaid HMO DRG,13689,,324% x Medicaid HMO amount,13689,Other,324% of NY Medicaid HMO DRG,9084,,215% x Medicaid HMO amount,9084,Other,215% of NY Medicaid HMO DRG,9084,,215% x Medicaid HMO amount,9084,Other,215% of NY Medicaid HMO DRG,5281,,125% x Medicaid HMO amount,5281,Other,125% of NY Medicaid HMO DRG,0.01,19757,
Vertigo & other labyrinth disorders,111-2,APR-DRG,,,,,,,,inpatient,,,130338.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24446,,"45,128 x DRG weight",24446,Other,base rate x DRG weight,22001,,"40,615 x DRG weight",22001,Other,base rate x DRG weight,20779,,"38,359 x DRG weight",20779,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9361,,186% x Medicaid HMO amount,9361,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18460,,"34,077 x DRG weight",18460,Other,base rate x DRG weight,15691,,"28,966 x DRG weight",15691,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5033,,DRG base rate x DRG weight + capital per discharge,5033,Other,100% of NY Medicaid HMO DRG,5033,,100% x Medicaid HMO amount,5033,Other,100% of NY Medicaid HMO DRG,5033,,100% x Medicaid HMO amount,5033,Other,100% of NY Medicaid HMO DRG,5033,,100% x Medicaid HMO amount,5033,Other,100% of NY Medicaid HMO DRG,11324,,225% x Medicaid HMO amount,11324,Other,225% of NY Medicaid HMO DRG,11324,,225% x Medicaid HMO amount,11324,Other,225% of NY Medicaid HMO DRG,11324,,225% x Medicaid HMO amount,11324,Other,225% of NY Medicaid HMO DRG,11324,,225% x Medicaid HMO amount,11324,Other,225% of NY Medicaid HMO DRG,7046,,140% x Medicaid HMO amount,7046,Other,140% of NY Medicaid HMO DRG,11324,,225% x Medicaid HMO amount,11324,Other,225% of NY Medicaid HMO DRG,13841,,275% x Medicaid HMO amount,13841,Other,275% of NY Medicaid HMO DRG,16307,,324% x Medicaid HMO amount,16307,Other,324% of NY Medicaid HMO DRG,10821,,215% x Medicaid HMO amount,10821,Other,215% of NY Medicaid HMO DRG,10821,,215% x Medicaid HMO amount,10821,Other,215% of NY Medicaid HMO DRG,6291,,125% x Medicaid HMO amount,6291,Other,125% of NY Medicaid HMO DRG,0.01,24446,
Vertigo & other labyrinth disorders,111-3,APR-DRG,,,,,,,,inpatient,,,121320.4,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34415,,"45,128 x DRG weight",34415,Other,base rate x DRG weight,30973,,"40,615 x DRG weight",30973,Other,base rate x DRG weight,29253,,"38,359 x DRG weight",29253,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12557,,186% x Medicaid HMO amount,12557,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25987,,"34,077 x DRG weight",25987,Other,base rate x DRG weight,22089,,"28,966 x DRG weight",22089,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6751,,DRG base rate x DRG weight + capital per discharge,6751,Other,100% of NY Medicaid HMO DRG,6751,,100% x Medicaid HMO amount,6751,Other,100% of NY Medicaid HMO DRG,6751,,100% x Medicaid HMO amount,6751,Other,100% of NY Medicaid HMO DRG,6751,,100% x Medicaid HMO amount,6751,Other,100% of NY Medicaid HMO DRG,15190,,225% x Medicaid HMO amount,15190,Other,225% of NY Medicaid HMO DRG,15190,,225% x Medicaid HMO amount,15190,Other,225% of NY Medicaid HMO DRG,15190,,225% x Medicaid HMO amount,15190,Other,225% of NY Medicaid HMO DRG,15190,,225% x Medicaid HMO amount,15190,Other,225% of NY Medicaid HMO DRG,9451,,140% x Medicaid HMO amount,9451,Other,140% of NY Medicaid HMO DRG,15190,,225% x Medicaid HMO amount,15190,Other,225% of NY Medicaid HMO DRG,18565,,275% x Medicaid HMO amount,18565,Other,275% of NY Medicaid HMO DRG,21873,,324% x Medicaid HMO amount,21873,Other,324% of NY Medicaid HMO DRG,14515,,215% x Medicaid HMO amount,14515,Other,215% of NY Medicaid HMO DRG,14515,,215% x Medicaid HMO amount,14515,Other,215% of NY Medicaid HMO DRG,8439,,125% x Medicaid HMO amount,8439,Other,125% of NY Medicaid HMO DRG,0.01,34415,
Vertigo & other labyrinth disorders,111-4,APR-DRG,,,,,,,,inpatient,,,130338.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35042,,"45,128 x DRG weight",35042,Other,base rate x DRG weight,31538,,"40,615 x DRG weight",31538,Other,base rate x DRG weight,29786,,"38,359 x DRG weight",29786,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12758,,186% x Medicaid HMO amount,12758,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26461,,"34,077 x DRG weight",26461,Other,base rate x DRG weight,22492,,"28,966 x DRG weight",22492,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6859,,DRG base rate x DRG weight + capital per discharge,6859,Other,100% of NY Medicaid HMO DRG,6859,,100% x Medicaid HMO amount,6859,Other,100% of NY Medicaid HMO DRG,6859,,100% x Medicaid HMO amount,6859,Other,100% of NY Medicaid HMO DRG,6859,,100% x Medicaid HMO amount,6859,Other,100% of NY Medicaid HMO DRG,15433,,225% x Medicaid HMO amount,15433,Other,225% of NY Medicaid HMO DRG,15433,,225% x Medicaid HMO amount,15433,Other,225% of NY Medicaid HMO DRG,15433,,225% x Medicaid HMO amount,15433,Other,225% of NY Medicaid HMO DRG,15433,,225% x Medicaid HMO amount,15433,Other,225% of NY Medicaid HMO DRG,9603,,140% x Medicaid HMO amount,9603,Other,140% of NY Medicaid HMO DRG,15433,,225% x Medicaid HMO amount,15433,Other,225% of NY Medicaid HMO DRG,18862,,275% x Medicaid HMO amount,18862,Other,275% of NY Medicaid HMO DRG,22223,,324% x Medicaid HMO amount,22223,Other,324% of NY Medicaid HMO DRG,14747,,215% x Medicaid HMO amount,14747,Other,215% of NY Medicaid HMO DRG,14747,,215% x Medicaid HMO amount,14747,Other,215% of NY Medicaid HMO DRG,8574,,125% x Medicaid HMO amount,8574,Other,125% of NY Medicaid HMO DRG,0.01,35042,
Infections of upper respiratory tract,113-1,APR-DRG,,,,,,,,inpatient,,,47537.13,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17514,,"45,128 x DRG weight",17514,Other,base rate x DRG weight,15763,,"40,615 x DRG weight",15763,Other,base rate x DRG weight,14887,,"38,359 x DRG weight",14887,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7141,,186% x Medicaid HMO amount,7141,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13225,,"34,077 x DRG weight",13225,Other,base rate x DRG weight,11242,,"28,966 x DRG weight",11242,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3839,,DRG base rate x DRG weight + capital per discharge,3839,Other,100% of NY Medicaid HMO DRG,3839,,100% x Medicaid HMO amount,3839,Other,100% of NY Medicaid HMO DRG,3839,,100% x Medicaid HMO amount,3839,Other,100% of NY Medicaid HMO DRG,3839,,100% x Medicaid HMO amount,3839,Other,100% of NY Medicaid HMO DRG,8638,,225% x Medicaid HMO amount,8638,Other,225% of NY Medicaid HMO DRG,8638,,225% x Medicaid HMO amount,8638,Other,225% of NY Medicaid HMO DRG,8638,,225% x Medicaid HMO amount,8638,Other,225% of NY Medicaid HMO DRG,8638,,225% x Medicaid HMO amount,8638,Other,225% of NY Medicaid HMO DRG,5375,,140% x Medicaid HMO amount,5375,Other,140% of NY Medicaid HMO DRG,8638,,225% x Medicaid HMO amount,8638,Other,225% of NY Medicaid HMO DRG,10557,,275% x Medicaid HMO amount,10557,Other,275% of NY Medicaid HMO DRG,12438,,324% x Medicaid HMO amount,12438,Other,324% of NY Medicaid HMO DRG,8254,,215% x Medicaid HMO amount,8254,Other,215% of NY Medicaid HMO DRG,8254,,215% x Medicaid HMO amount,8254,Other,215% of NY Medicaid HMO DRG,4799,,125% x Medicaid HMO amount,4799,Other,125% of NY Medicaid HMO DRG,0.01,17514,
Infections of upper respiratory tract,113-2,APR-DRG,,,,,,,,inpatient,,,65903.7,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22447,,"45,128 x DRG weight",22447,Other,base rate x DRG weight,20202,,"40,615 x DRG weight",20202,Other,base rate x DRG weight,19080,,"38,359 x DRG weight",19080,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8720,,186% x Medicaid HMO amount,8720,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16950,,"34,077 x DRG weight",16950,Other,base rate x DRG weight,14408,,"28,966 x DRG weight",14408,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4688,,DRG base rate x DRG weight + capital per discharge,4688,Other,100% of NY Medicaid HMO DRG,4688,,100% x Medicaid HMO amount,4688,Other,100% of NY Medicaid HMO DRG,4688,,100% x Medicaid HMO amount,4688,Other,100% of NY Medicaid HMO DRG,4688,,100% x Medicaid HMO amount,4688,Other,100% of NY Medicaid HMO DRG,10548,,225% x Medicaid HMO amount,10548,Other,225% of NY Medicaid HMO DRG,10548,,225% x Medicaid HMO amount,10548,Other,225% of NY Medicaid HMO DRG,10548,,225% x Medicaid HMO amount,10548,Other,225% of NY Medicaid HMO DRG,10548,,225% x Medicaid HMO amount,10548,Other,225% of NY Medicaid HMO DRG,6563,,140% x Medicaid HMO amount,6563,Other,140% of NY Medicaid HMO DRG,10548,,225% x Medicaid HMO amount,10548,Other,225% of NY Medicaid HMO DRG,12892,,275% x Medicaid HMO amount,12892,Other,275% of NY Medicaid HMO DRG,15189,,324% x Medicaid HMO amount,15189,Other,324% of NY Medicaid HMO DRG,10079,,215% x Medicaid HMO amount,10079,Other,215% of NY Medicaid HMO DRG,10079,,215% x Medicaid HMO amount,10079,Other,215% of NY Medicaid HMO DRG,5860,,125% x Medicaid HMO amount,5860,Other,125% of NY Medicaid HMO DRG,0.01,22447,
Infections of upper respiratory tract,113-3,APR-DRG,,,,,,,,inpatient,,,98363.09,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35137,,"45,128 x DRG weight",35137,Other,base rate x DRG weight,31623,,"40,615 x DRG weight",31623,Other,base rate x DRG weight,29866,,"38,359 x DRG weight",29866,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12788,,186% x Medicaid HMO amount,12788,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26532,,"34,077 x DRG weight",26532,Other,base rate x DRG weight,22553,,"28,966 x DRG weight",22553,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6875,,DRG base rate x DRG weight + capital per discharge,6875,Other,100% of NY Medicaid HMO DRG,6875,,100% x Medicaid HMO amount,6875,Other,100% of NY Medicaid HMO DRG,6875,,100% x Medicaid HMO amount,6875,Other,100% of NY Medicaid HMO DRG,6875,,100% x Medicaid HMO amount,6875,Other,100% of NY Medicaid HMO DRG,15469,,225% x Medicaid HMO amount,15469,Other,225% of NY Medicaid HMO DRG,15469,,225% x Medicaid HMO amount,15469,Other,225% of NY Medicaid HMO DRG,15469,,225% x Medicaid HMO amount,15469,Other,225% of NY Medicaid HMO DRG,15469,,225% x Medicaid HMO amount,15469,Other,225% of NY Medicaid HMO DRG,9625,,140% x Medicaid HMO amount,9625,Other,140% of NY Medicaid HMO DRG,15469,,225% x Medicaid HMO amount,15469,Other,225% of NY Medicaid HMO DRG,18906,,275% x Medicaid HMO amount,18906,Other,275% of NY Medicaid HMO DRG,22275,,324% x Medicaid HMO amount,22275,Other,324% of NY Medicaid HMO DRG,14781,,215% x Medicaid HMO amount,14781,Other,215% of NY Medicaid HMO DRG,14781,,215% x Medicaid HMO amount,14781,Other,215% of NY Medicaid HMO DRG,8594,,125% x Medicaid HMO amount,8594,Other,125% of NY Medicaid HMO DRG,0.01,35137,
Infections of upper respiratory tract,113-4,APR-DRG,,,,,,,,inpatient,,,131847,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,94155,,"45,128 x DRG weight",94155,Other,base rate x DRG weight,84739,,"40,615 x DRG weight",84739,Other,base rate x DRG weight,80032,,"38,359 x DRG weight",80032,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31702,,186% x Medicaid HMO amount,31702,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,71098,,"34,077 x DRG weight",71098,Other,base rate x DRG weight,60435,,"28,966 x DRG weight",60435,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17044,,DRG base rate x DRG weight + capital per discharge,17044,Other,100% of NY Medicaid HMO DRG,17044,,100% x Medicaid HMO amount,17044,Other,100% of NY Medicaid HMO DRG,17044,,100% x Medicaid HMO amount,17044,Other,100% of NY Medicaid HMO DRG,17044,,100% x Medicaid HMO amount,17044,Other,100% of NY Medicaid HMO DRG,38349,,225% x Medicaid HMO amount,38349,Other,225% of NY Medicaid HMO DRG,38349,,225% x Medicaid HMO amount,38349,Other,225% of NY Medicaid HMO DRG,38349,,225% x Medicaid HMO amount,38349,Other,225% of NY Medicaid HMO DRG,38349,,225% x Medicaid HMO amount,38349,Other,225% of NY Medicaid HMO DRG,23862,,140% x Medicaid HMO amount,23862,Other,140% of NY Medicaid HMO DRG,38349,,225% x Medicaid HMO amount,38349,Other,225% of NY Medicaid HMO DRG,46871,,275% x Medicaid HMO amount,46871,Other,275% of NY Medicaid HMO DRG,55223,,324% x Medicaid HMO amount,55223,Other,324% of NY Medicaid HMO DRG,36645,,215% x Medicaid HMO amount,36645,Other,215% of NY Medicaid HMO DRG,36645,,215% x Medicaid HMO amount,36645,Other,215% of NY Medicaid HMO DRG,21305,,125% x Medicaid HMO amount,21305,Other,125% of NY Medicaid HMO DRG,0.01,94155,
Dental & oral diseases & injuries,114-1,APR-DRG,,,,,,,,inpatient,,,57194.42,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21603,,"45,128 x DRG weight",21603,Other,base rate x DRG weight,19442,,"40,615 x DRG weight",19442,Other,base rate x DRG weight,18362,,"38,359 x DRG weight",18362,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8450,,186% x Medicaid HMO amount,8450,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16313,,"34,077 x DRG weight",16313,Other,base rate x DRG weight,13866,,"28,966 x DRG weight",13866,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4543,,DRG base rate x DRG weight + capital per discharge,4543,Other,100% of NY Medicaid HMO DRG,4543,,100% x Medicaid HMO amount,4543,Other,100% of NY Medicaid HMO DRG,4543,,100% x Medicaid HMO amount,4543,Other,100% of NY Medicaid HMO DRG,4543,,100% x Medicaid HMO amount,4543,Other,100% of NY Medicaid HMO DRG,10222,,225% x Medicaid HMO amount,10222,Other,225% of NY Medicaid HMO DRG,10222,,225% x Medicaid HMO amount,10222,Other,225% of NY Medicaid HMO DRG,10222,,225% x Medicaid HMO amount,10222,Other,225% of NY Medicaid HMO DRG,10222,,225% x Medicaid HMO amount,10222,Other,225% of NY Medicaid HMO DRG,6360,,140% x Medicaid HMO amount,6360,Other,140% of NY Medicaid HMO DRG,10222,,225% x Medicaid HMO amount,10222,Other,225% of NY Medicaid HMO DRG,12493,,275% x Medicaid HMO amount,12493,Other,275% of NY Medicaid HMO DRG,14719,,324% x Medicaid HMO amount,14719,Other,324% of NY Medicaid HMO DRG,9767,,215% x Medicaid HMO amount,9767,Other,215% of NY Medicaid HMO DRG,9767,,215% x Medicaid HMO amount,9767,Other,215% of NY Medicaid HMO DRG,5679,,125% x Medicaid HMO amount,5679,Other,125% of NY Medicaid HMO DRG,0.01,21603,
Dental & oral diseases & injuries,114-2,APR-DRG,,,,,,,,inpatient,,,94020.35,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27320,,"45,128 x DRG weight",27320,Other,base rate x DRG weight,24588,,"40,615 x DRG weight",24588,Other,base rate x DRG weight,23223,,"38,359 x DRG weight",23223,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10282,,186% x Medicaid HMO amount,10282,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20630,,"34,077 x DRG weight",20630,Other,base rate x DRG weight,17536,,"28,966 x DRG weight",17536,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5528,,DRG base rate x DRG weight + capital per discharge,5528,Other,100% of NY Medicaid HMO DRG,5528,,100% x Medicaid HMO amount,5528,Other,100% of NY Medicaid HMO DRG,5528,,100% x Medicaid HMO amount,5528,Other,100% of NY Medicaid HMO DRG,5528,,100% x Medicaid HMO amount,5528,Other,100% of NY Medicaid HMO DRG,12438,,225% x Medicaid HMO amount,12438,Other,225% of NY Medicaid HMO DRG,12438,,225% x Medicaid HMO amount,12438,Other,225% of NY Medicaid HMO DRG,12438,,225% x Medicaid HMO amount,12438,Other,225% of NY Medicaid HMO DRG,12438,,225% x Medicaid HMO amount,12438,Other,225% of NY Medicaid HMO DRG,7739,,140% x Medicaid HMO amount,7739,Other,140% of NY Medicaid HMO DRG,12438,,225% x Medicaid HMO amount,12438,Other,225% of NY Medicaid HMO DRG,15202,,275% x Medicaid HMO amount,15202,Other,275% of NY Medicaid HMO DRG,17911,,324% x Medicaid HMO amount,17911,Other,324% of NY Medicaid HMO DRG,11885,,215% x Medicaid HMO amount,11885,Other,215% of NY Medicaid HMO DRG,11885,,215% x Medicaid HMO amount,11885,Other,215% of NY Medicaid HMO DRG,6910,,125% x Medicaid HMO amount,6910,Other,125% of NY Medicaid HMO DRG,0.01,27320,
Dental & oral diseases & injuries,114-3,APR-DRG,,,,,,,,inpatient,,,237822.49,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54145,,"45,128 x DRG weight",54145,Other,base rate x DRG weight,48730,,"40,615 x DRG weight",48730,Other,base rate x DRG weight,46023,,"38,359 x DRG weight",46023,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18879,,186% x Medicaid HMO amount,18879,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40886,,"34,077 x DRG weight",40886,Other,base rate x DRG weight,34753,,"28,966 x DRG weight",34753,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10150,,DRG base rate x DRG weight + capital per discharge,10150,Other,100% of NY Medicaid HMO DRG,10150,,100% x Medicaid HMO amount,10150,Other,100% of NY Medicaid HMO DRG,10150,,100% x Medicaid HMO amount,10150,Other,100% of NY Medicaid HMO DRG,10150,,100% x Medicaid HMO amount,10150,Other,100% of NY Medicaid HMO DRG,22838,,225% x Medicaid HMO amount,22838,Other,225% of NY Medicaid HMO DRG,22838,,225% x Medicaid HMO amount,22838,Other,225% of NY Medicaid HMO DRG,22838,,225% x Medicaid HMO amount,22838,Other,225% of NY Medicaid HMO DRG,22838,,225% x Medicaid HMO amount,22838,Other,225% of NY Medicaid HMO DRG,14210,,140% x Medicaid HMO amount,14210,Other,140% of NY Medicaid HMO DRG,22838,,225% x Medicaid HMO amount,22838,Other,225% of NY Medicaid HMO DRG,27913,,275% x Medicaid HMO amount,27913,Other,275% of NY Medicaid HMO DRG,32886,,324% x Medicaid HMO amount,32886,Other,324% of NY Medicaid HMO DRG,21823,,215% x Medicaid HMO amount,21823,Other,215% of NY Medicaid HMO DRG,21823,,215% x Medicaid HMO amount,21823,Other,215% of NY Medicaid HMO DRG,12688,,125% x Medicaid HMO amount,12688,Other,125% of NY Medicaid HMO DRG,0.01,54145,
Dental & oral diseases & injuries,114-4,APR-DRG,,,,,,,,inpatient,,,32501,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,111358,,"45,128 x DRG weight",111358,Other,base rate x DRG weight,100222,,"40,615 x DRG weight",100222,Other,base rate x DRG weight,94655,,"38,359 x DRG weight",94655,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37215,,186% x Medicaid HMO amount,37215,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,84088,,"34,077 x DRG weight",84088,Other,base rate x DRG weight,71477,,"28,966 x DRG weight",71477,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20008,,DRG base rate x DRG weight + capital per discharge,20008,Other,100% of NY Medicaid HMO DRG,20008,,100% x Medicaid HMO amount,20008,Other,100% of NY Medicaid HMO DRG,20008,,100% x Medicaid HMO amount,20008,Other,100% of NY Medicaid HMO DRG,20008,,100% x Medicaid HMO amount,20008,Other,100% of NY Medicaid HMO DRG,45018,,225% x Medicaid HMO amount,45018,Other,225% of NY Medicaid HMO DRG,45018,,225% x Medicaid HMO amount,45018,Other,225% of NY Medicaid HMO DRG,45018,,225% x Medicaid HMO amount,45018,Other,225% of NY Medicaid HMO DRG,45018,,225% x Medicaid HMO amount,45018,Other,225% of NY Medicaid HMO DRG,28011,,140% x Medicaid HMO amount,28011,Other,140% of NY Medicaid HMO DRG,45018,,225% x Medicaid HMO amount,45018,Other,225% of NY Medicaid HMO DRG,55022,,275% x Medicaid HMO amount,55022,Other,275% of NY Medicaid HMO DRG,64826,,324% x Medicaid HMO amount,64826,Other,324% of NY Medicaid HMO DRG,43017,,215% x Medicaid HMO amount,43017,Other,215% of NY Medicaid HMO DRG,43017,,215% x Medicaid HMO amount,43017,Other,215% of NY Medicaid HMO DRG,25010,,125% x Medicaid HMO amount,25010,Other,125% of NY Medicaid HMO DRG,0.01,111358,
"Other ear, nose, mouth,throat & cranial/facial diagnoses",115-1,APR-DRG,,,,,,,,inpatient,,,62696.36,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19929,,"45,128 x DRG weight",19929,Other,base rate x DRG weight,17936,,"40,615 x DRG weight",17936,Other,base rate x DRG weight,16939,,"38,359 x DRG weight",16939,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7914,,186% x Medicaid HMO amount,7914,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15048,,"34,077 x DRG weight",15048,Other,base rate x DRG weight,12791,,"28,966 x DRG weight",12791,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4255,,DRG base rate x DRG weight + capital per discharge,4255,Other,100% of NY Medicaid HMO DRG,4255,,100% x Medicaid HMO amount,4255,Other,100% of NY Medicaid HMO DRG,4255,,100% x Medicaid HMO amount,4255,Other,100% of NY Medicaid HMO DRG,4255,,100% x Medicaid HMO amount,4255,Other,100% of NY Medicaid HMO DRG,9574,,225% x Medicaid HMO amount,9574,Other,225% of NY Medicaid HMO DRG,9574,,225% x Medicaid HMO amount,9574,Other,225% of NY Medicaid HMO DRG,9574,,225% x Medicaid HMO amount,9574,Other,225% of NY Medicaid HMO DRG,9574,,225% x Medicaid HMO amount,9574,Other,225% of NY Medicaid HMO DRG,5957,,140% x Medicaid HMO amount,5957,Other,140% of NY Medicaid HMO DRG,9574,,225% x Medicaid HMO amount,9574,Other,225% of NY Medicaid HMO DRG,11701,,275% x Medicaid HMO amount,11701,Other,275% of NY Medicaid HMO DRG,13786,,324% x Medicaid HMO amount,13786,Other,324% of NY Medicaid HMO DRG,9148,,215% x Medicaid HMO amount,9148,Other,215% of NY Medicaid HMO DRG,9148,,215% x Medicaid HMO amount,9148,Other,215% of NY Medicaid HMO DRG,5319,,125% x Medicaid HMO amount,5319,Other,125% of NY Medicaid HMO DRG,0.01,19929,
"Other ear, nose, mouth,throat & cranial/facial diagnoses",115-2,APR-DRG,,,,,,,,inpatient,,,109849.93,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27140,,"45,128 x DRG weight",27140,Other,base rate x DRG weight,24426,,"40,615 x DRG weight",24426,Other,base rate x DRG weight,23069,,"38,359 x DRG weight",23069,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10224,,186% x Medicaid HMO amount,10224,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20494,,"34,077 x DRG weight",20494,Other,base rate x DRG weight,17420,,"28,966 x DRG weight",17420,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5497,,DRG base rate x DRG weight + capital per discharge,5497,Other,100% of NY Medicaid HMO DRG,5497,,100% x Medicaid HMO amount,5497,Other,100% of NY Medicaid HMO DRG,5497,,100% x Medicaid HMO amount,5497,Other,100% of NY Medicaid HMO DRG,5497,,100% x Medicaid HMO amount,5497,Other,100% of NY Medicaid HMO DRG,12368,,225% x Medicaid HMO amount,12368,Other,225% of NY Medicaid HMO DRG,12368,,225% x Medicaid HMO amount,12368,Other,225% of NY Medicaid HMO DRG,12368,,225% x Medicaid HMO amount,12368,Other,225% of NY Medicaid HMO DRG,12368,,225% x Medicaid HMO amount,12368,Other,225% of NY Medicaid HMO DRG,7696,,140% x Medicaid HMO amount,7696,Other,140% of NY Medicaid HMO DRG,12368,,225% x Medicaid HMO amount,12368,Other,225% of NY Medicaid HMO DRG,15117,,275% x Medicaid HMO amount,15117,Other,275% of NY Medicaid HMO DRG,17810,,324% x Medicaid HMO amount,17810,Other,324% of NY Medicaid HMO DRG,11819,,215% x Medicaid HMO amount,11819,Other,215% of NY Medicaid HMO DRG,11819,,215% x Medicaid HMO amount,11819,Other,215% of NY Medicaid HMO DRG,6871,,125% x Medicaid HMO amount,6871,Other,125% of NY Medicaid HMO DRG,0.01,27140,
"Other ear, nose, mouth,throat & cranial/facial diagnoses",115-3,APR-DRG,,,,,,,,inpatient,,,97821.52,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44812,,"45,128 x DRG weight",44812,Other,base rate x DRG weight,40331,,"40,615 x DRG weight",40331,Other,base rate x DRG weight,38090,,"38,359 x DRG weight",38090,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15888,,186% x Medicaid HMO amount,15888,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33838,,"34,077 x DRG weight",33838,Other,base rate x DRG weight,28763,,"28,966 x DRG weight",28763,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8542,,DRG base rate x DRG weight + capital per discharge,8542,Other,100% of NY Medicaid HMO DRG,8542,,100% x Medicaid HMO amount,8542,Other,100% of NY Medicaid HMO DRG,8542,,100% x Medicaid HMO amount,8542,Other,100% of NY Medicaid HMO DRG,8542,,100% x Medicaid HMO amount,8542,Other,100% of NY Medicaid HMO DRG,19220,,225% x Medicaid HMO amount,19220,Other,225% of NY Medicaid HMO DRG,19220,,225% x Medicaid HMO amount,19220,Other,225% of NY Medicaid HMO DRG,19220,,225% x Medicaid HMO amount,19220,Other,225% of NY Medicaid HMO DRG,19220,,225% x Medicaid HMO amount,19220,Other,225% of NY Medicaid HMO DRG,11959,,140% x Medicaid HMO amount,11959,Other,140% of NY Medicaid HMO DRG,19220,,225% x Medicaid HMO amount,19220,Other,225% of NY Medicaid HMO DRG,23491,,275% x Medicaid HMO amount,23491,Other,275% of NY Medicaid HMO DRG,27676,,324% x Medicaid HMO amount,27676,Other,324% of NY Medicaid HMO DRG,18365,,215% x Medicaid HMO amount,18365,Other,215% of NY Medicaid HMO DRG,18365,,215% x Medicaid HMO amount,18365,Other,215% of NY Medicaid HMO DRG,10678,,125% x Medicaid HMO amount,10678,Other,125% of NY Medicaid HMO DRG,0.01,44812,
"Other ear, nose, mouth,throat & cranial/facial diagnoses",115-4,APR-DRG,,,,,,,,inpatient,,,341570.76,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,118317,,"45,128 x DRG weight",118317,Other,base rate x DRG weight,106484,,"40,615 x DRG weight",106484,Other,base rate x DRG weight,100570,,"38,359 x DRG weight",100570,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39445,,186% x Medicaid HMO amount,39445,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,89343,,"34,077 x DRG weight",89343,Other,base rate x DRG weight,75943,,"28,966 x DRG weight",75943,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21207,,DRG base rate x DRG weight + capital per discharge,21207,Other,100% of NY Medicaid HMO DRG,21207,,100% x Medicaid HMO amount,21207,Other,100% of NY Medicaid HMO DRG,21207,,100% x Medicaid HMO amount,21207,Other,100% of NY Medicaid HMO DRG,21207,,100% x Medicaid HMO amount,21207,Other,100% of NY Medicaid HMO DRG,47716,,225% x Medicaid HMO amount,47716,Other,225% of NY Medicaid HMO DRG,47716,,225% x Medicaid HMO amount,47716,Other,225% of NY Medicaid HMO DRG,47716,,225% x Medicaid HMO amount,47716,Other,225% of NY Medicaid HMO DRG,47716,,225% x Medicaid HMO amount,47716,Other,225% of NY Medicaid HMO DRG,29690,,140% x Medicaid HMO amount,29690,Other,140% of NY Medicaid HMO DRG,47716,,225% x Medicaid HMO amount,47716,Other,225% of NY Medicaid HMO DRG,58319,,275% x Medicaid HMO amount,58319,Other,275% of NY Medicaid HMO DRG,68711,,324% x Medicaid HMO amount,68711,Other,324% of NY Medicaid HMO DRG,45595,,215% x Medicaid HMO amount,45595,Other,215% of NY Medicaid HMO DRG,45595,,215% x Medicaid HMO amount,45595,Other,215% of NY Medicaid HMO DRG,26509,,125% x Medicaid HMO amount,26509,Other,125% of NY Medicaid HMO DRG,0.01,118317,
Major respiratory & chest procedures,120-1,APR-DRG,,,,,,,,inpatient,,,176767.21,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,78193,,"45,128 x DRG weight",78193,Other,base rate x DRG weight,70374,,"40,615 x DRG weight",70374,Other,base rate x DRG weight,66465,,"38,359 x DRG weight",66465,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26587,,186% x Medicaid HMO amount,26587,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59045,,"34,077 x DRG weight",59045,Other,base rate x DRG weight,50189,,"28,966 x DRG weight",50189,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14294,,DRG base rate x DRG weight + capital per discharge,14294,Other,100% of NY Medicaid HMO DRG,14294,,100% x Medicaid HMO amount,14294,Other,100% of NY Medicaid HMO DRG,14294,,100% x Medicaid HMO amount,14294,Other,100% of NY Medicaid HMO DRG,14294,,100% x Medicaid HMO amount,14294,Other,100% of NY Medicaid HMO DRG,32162,,225% x Medicaid HMO amount,32162,Other,225% of NY Medicaid HMO DRG,32162,,225% x Medicaid HMO amount,32162,Other,225% of NY Medicaid HMO DRG,32162,,225% x Medicaid HMO amount,32162,Other,225% of NY Medicaid HMO DRG,32162,,225% x Medicaid HMO amount,32162,Other,225% of NY Medicaid HMO DRG,20012,,140% x Medicaid HMO amount,20012,Other,140% of NY Medicaid HMO DRG,32162,,225% x Medicaid HMO amount,32162,Other,225% of NY Medicaid HMO DRG,39309,,275% x Medicaid HMO amount,39309,Other,275% of NY Medicaid HMO DRG,46313,,324% x Medicaid HMO amount,46313,Other,324% of NY Medicaid HMO DRG,30732,,215% x Medicaid HMO amount,30732,Other,215% of NY Medicaid HMO DRG,30732,,215% x Medicaid HMO amount,30732,Other,215% of NY Medicaid HMO DRG,17868,,125% x Medicaid HMO amount,17868,Other,125% of NY Medicaid HMO DRG,0.01,78193,
Major respiratory & chest procedures,120-2,APR-DRG,,,,,,,,inpatient,,,209877.51,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,95270,,"45,128 x DRG weight",95270,Other,base rate x DRG weight,85742,,"40,615 x DRG weight",85742,Other,base rate x DRG weight,80980,,"38,359 x DRG weight",80980,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32059,,186% x Medicaid HMO amount,32059,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,71940,,"34,077 x DRG weight",71940,Other,base rate x DRG weight,61150,,"28,966 x DRG weight",61150,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17236,,DRG base rate x DRG weight + capital per discharge,17236,Other,100% of NY Medicaid HMO DRG,17236,,100% x Medicaid HMO amount,17236,Other,100% of NY Medicaid HMO DRG,17236,,100% x Medicaid HMO amount,17236,Other,100% of NY Medicaid HMO DRG,17236,,100% x Medicaid HMO amount,17236,Other,100% of NY Medicaid HMO DRG,38781,,225% x Medicaid HMO amount,38781,Other,225% of NY Medicaid HMO DRG,38781,,225% x Medicaid HMO amount,38781,Other,225% of NY Medicaid HMO DRG,38781,,225% x Medicaid HMO amount,38781,Other,225% of NY Medicaid HMO DRG,38781,,225% x Medicaid HMO amount,38781,Other,225% of NY Medicaid HMO DRG,24130,,140% x Medicaid HMO amount,24130,Other,140% of NY Medicaid HMO DRG,38781,,225% x Medicaid HMO amount,38781,Other,225% of NY Medicaid HMO DRG,47399,,275% x Medicaid HMO amount,47399,Other,275% of NY Medicaid HMO DRG,55845,,324% x Medicaid HMO amount,55845,Other,324% of NY Medicaid HMO DRG,37057,,215% x Medicaid HMO amount,37057,Other,215% of NY Medicaid HMO DRG,37057,,215% x Medicaid HMO amount,37057,Other,215% of NY Medicaid HMO DRG,21545,,125% x Medicaid HMO amount,21545,Other,125% of NY Medicaid HMO DRG,0.01,95270,
Major respiratory & chest procedures,120-3,APR-DRG,,,,,,,,inpatient,,,513444.58,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,151824,,"45,128 x DRG weight",151824,Other,base rate x DRG weight,136641,,"40,615 x DRG weight",136641,Other,base rate x DRG weight,129051,,"38,359 x DRG weight",129051,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50183,,186% x Medicaid HMO amount,50183,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,114645,,"34,077 x DRG weight",114645,Other,base rate x DRG weight,97450,,"28,966 x DRG weight",97450,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26980,,DRG base rate x DRG weight + capital per discharge,26980,Other,100% of NY Medicaid HMO DRG,26980,,100% x Medicaid HMO amount,26980,Other,100% of NY Medicaid HMO DRG,26980,,100% x Medicaid HMO amount,26980,Other,100% of NY Medicaid HMO DRG,26980,,100% x Medicaid HMO amount,26980,Other,100% of NY Medicaid HMO DRG,60705,,225% x Medicaid HMO amount,60705,Other,225% of NY Medicaid HMO DRG,60705,,225% x Medicaid HMO amount,60705,Other,225% of NY Medicaid HMO DRG,60705,,225% x Medicaid HMO amount,60705,Other,225% of NY Medicaid HMO DRG,60705,,225% x Medicaid HMO amount,60705,Other,225% of NY Medicaid HMO DRG,37772,,140% x Medicaid HMO amount,37772,Other,140% of NY Medicaid HMO DRG,60705,,225% x Medicaid HMO amount,60705,Other,225% of NY Medicaid HMO DRG,74195,,275% x Medicaid HMO amount,74195,Other,275% of NY Medicaid HMO DRG,87415,,324% x Medicaid HMO amount,87415,Other,324% of NY Medicaid HMO DRG,58007,,215% x Medicaid HMO amount,58007,Other,215% of NY Medicaid HMO DRG,58007,,215% x Medicaid HMO amount,58007,Other,215% of NY Medicaid HMO DRG,33725,,125% x Medicaid HMO amount,33725,Other,125% of NY Medicaid HMO DRG,0.01,151824,
Major respiratory & chest procedures,120-4,APR-DRG,,,,,,,,inpatient,,,618420.87,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,274866,,"45,128 x DRG weight",274866,Other,base rate x DRG weight,247378,,"40,615 x DRG weight",247378,Other,base rate x DRG weight,233637,,"38,359 x DRG weight",233637,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,89617,,186% x Medicaid HMO amount,89617,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,207556,,"34,077 x DRG weight",207556,Other,base rate x DRG weight,176426,,"28,966 x DRG weight",176426,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48181,,DRG base rate x DRG weight + capital per discharge,48181,Other,100% of NY Medicaid HMO DRG,48181,,100% x Medicaid HMO amount,48181,Other,100% of NY Medicaid HMO DRG,48181,,100% x Medicaid HMO amount,48181,Other,100% of NY Medicaid HMO DRG,48181,,100% x Medicaid HMO amount,48181,Other,100% of NY Medicaid HMO DRG,108407,,225% x Medicaid HMO amount,108407,Other,225% of NY Medicaid HMO DRG,108407,,225% x Medicaid HMO amount,108407,Other,225% of NY Medicaid HMO DRG,108407,,225% x Medicaid HMO amount,108407,Other,225% of NY Medicaid HMO DRG,108407,,225% x Medicaid HMO amount,108407,Other,225% of NY Medicaid HMO DRG,67453,,140% x Medicaid HMO amount,67453,Other,140% of NY Medicaid HMO DRG,108407,,225% x Medicaid HMO amount,108407,Other,225% of NY Medicaid HMO DRG,132498,,275% x Medicaid HMO amount,132498,Other,275% of NY Medicaid HMO DRG,156106,,324% x Medicaid HMO amount,156106,Other,324% of NY Medicaid HMO DRG,103589,,215% x Medicaid HMO amount,103589,Other,215% of NY Medicaid HMO DRG,103589,,215% x Medicaid HMO amount,103589,Other,215% of NY Medicaid HMO DRG,60226,,125% x Medicaid HMO amount,60226,Other,125% of NY Medicaid HMO DRG,0.01,274866,
Other respiratory & chest procedures,121-1,APR-DRG,,,,,,,,inpatient,,,105207.12,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54546,,"45,128 x DRG weight",54546,Other,base rate x DRG weight,49091,,"40,615 x DRG weight",49091,Other,base rate x DRG weight,46365,,"38,359 x DRG weight",46365,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19007,,186% x Medicaid HMO amount,19007,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41189,,"34,077 x DRG weight",41189,Other,base rate x DRG weight,35011,,"28,966 x DRG weight",35011,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10219,,DRG base rate x DRG weight + capital per discharge,10219,Other,100% of NY Medicaid HMO DRG,10219,,100% x Medicaid HMO amount,10219,Other,100% of NY Medicaid HMO DRG,10219,,100% x Medicaid HMO amount,10219,Other,100% of NY Medicaid HMO DRG,10219,,100% x Medicaid HMO amount,10219,Other,100% of NY Medicaid HMO DRG,22993,,225% x Medicaid HMO amount,22993,Other,225% of NY Medicaid HMO DRG,22993,,225% x Medicaid HMO amount,22993,Other,225% of NY Medicaid HMO DRG,22993,,225% x Medicaid HMO amount,22993,Other,225% of NY Medicaid HMO DRG,22993,,225% x Medicaid HMO amount,22993,Other,225% of NY Medicaid HMO DRG,14307,,140% x Medicaid HMO amount,14307,Other,140% of NY Medicaid HMO DRG,22993,,225% x Medicaid HMO amount,22993,Other,225% of NY Medicaid HMO DRG,28102,,275% x Medicaid HMO amount,28102,Other,275% of NY Medicaid HMO DRG,33110,,324% x Medicaid HMO amount,33110,Other,324% of NY Medicaid HMO DRG,21971,,215% x Medicaid HMO amount,21971,Other,215% of NY Medicaid HMO DRG,21971,,215% x Medicaid HMO amount,21971,Other,215% of NY Medicaid HMO DRG,12774,,125% x Medicaid HMO amount,12774,Other,125% of NY Medicaid HMO DRG,0.01,54546,
Other respiratory & chest procedures,121-2,APR-DRG,,,,,,,,inpatient,,,325454.56,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73441,,"45,128 x DRG weight",73441,Other,base rate x DRG weight,66097,,"40,615 x DRG weight",66097,Other,base rate x DRG weight,62425,,"38,359 x DRG weight",62425,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25064,,186% x Medicaid HMO amount,25064,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55457,,"34,077 x DRG weight",55457,Other,base rate x DRG weight,47139,,"28,966 x DRG weight",47139,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13475,,DRG base rate x DRG weight + capital per discharge,13475,Other,100% of NY Medicaid HMO DRG,13475,,100% x Medicaid HMO amount,13475,Other,100% of NY Medicaid HMO DRG,13475,,100% x Medicaid HMO amount,13475,Other,100% of NY Medicaid HMO DRG,13475,,100% x Medicaid HMO amount,13475,Other,100% of NY Medicaid HMO DRG,30319,,225% x Medicaid HMO amount,30319,Other,225% of NY Medicaid HMO DRG,30319,,225% x Medicaid HMO amount,30319,Other,225% of NY Medicaid HMO DRG,30319,,225% x Medicaid HMO amount,30319,Other,225% of NY Medicaid HMO DRG,30319,,225% x Medicaid HMO amount,30319,Other,225% of NY Medicaid HMO DRG,18865,,140% x Medicaid HMO amount,18865,Other,140% of NY Medicaid HMO DRG,30319,,225% x Medicaid HMO amount,30319,Other,225% of NY Medicaid HMO DRG,37056,,275% x Medicaid HMO amount,37056,Other,275% of NY Medicaid HMO DRG,43659,,324% x Medicaid HMO amount,43659,Other,324% of NY Medicaid HMO DRG,28971,,215% x Medicaid HMO amount,28971,Other,215% of NY Medicaid HMO DRG,28971,,215% x Medicaid HMO amount,28971,Other,215% of NY Medicaid HMO DRG,16844,,125% x Medicaid HMO amount,16844,Other,125% of NY Medicaid HMO DRG,0.01,73441,
Other respiratory & chest procedures,121-3,APR-DRG,,,,,,,,inpatient,,,560210.09,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,128326,,"45,128 x DRG weight",128326,Other,base rate x DRG weight,115493,,"40,615 x DRG weight",115493,Other,base rate x DRG weight,109078,,"38,359 x DRG weight",109078,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42654,,186% x Medicaid HMO amount,42654,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,96901,,"34,077 x DRG weight",96901,Other,base rate x DRG weight,82368,,"28,966 x DRG weight",82368,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22932,,DRG base rate x DRG weight + capital per discharge,22932,Other,100% of NY Medicaid HMO DRG,22932,,100% x Medicaid HMO amount,22932,Other,100% of NY Medicaid HMO DRG,22932,,100% x Medicaid HMO amount,22932,Other,100% of NY Medicaid HMO DRG,22932,,100% x Medicaid HMO amount,22932,Other,100% of NY Medicaid HMO DRG,51597,,225% x Medicaid HMO amount,51597,Other,225% of NY Medicaid HMO DRG,51597,,225% x Medicaid HMO amount,51597,Other,225% of NY Medicaid HMO DRG,51597,,225% x Medicaid HMO amount,51597,Other,225% of NY Medicaid HMO DRG,51597,,225% x Medicaid HMO amount,51597,Other,225% of NY Medicaid HMO DRG,32105,,140% x Medicaid HMO amount,32105,Other,140% of NY Medicaid HMO DRG,51597,,225% x Medicaid HMO amount,51597,Other,225% of NY Medicaid HMO DRG,63063,,275% x Medicaid HMO amount,63063,Other,275% of NY Medicaid HMO DRG,74300,,324% x Medicaid HMO amount,74300,Other,324% of NY Medicaid HMO DRG,49304,,215% x Medicaid HMO amount,49304,Other,215% of NY Medicaid HMO DRG,49304,,215% x Medicaid HMO amount,49304,Other,215% of NY Medicaid HMO DRG,28665,,125% x Medicaid HMO amount,28665,Other,125% of NY Medicaid HMO DRG,0.01,128326,
Other respiratory & chest procedures,121-4,APR-DRG,,,,,,,,inpatient,,,933405.05,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,273345,,"45,128 x DRG weight",273345,Other,base rate x DRG weight,246009,,"40,615 x DRG weight",246009,Other,base rate x DRG weight,232344,,"38,359 x DRG weight",232344,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,89129,,186% x Medicaid HMO amount,89129,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,206408,,"34,077 x DRG weight",206408,Other,base rate x DRG weight,175450,,"28,966 x DRG weight",175450,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47919,,DRG base rate x DRG weight + capital per discharge,47919,Other,100% of NY Medicaid HMO DRG,47919,,100% x Medicaid HMO amount,47919,Other,100% of NY Medicaid HMO DRG,47919,,100% x Medicaid HMO amount,47919,Other,100% of NY Medicaid HMO DRG,47919,,100% x Medicaid HMO amount,47919,Other,100% of NY Medicaid HMO DRG,107818,,225% x Medicaid HMO amount,107818,Other,225% of NY Medicaid HMO DRG,107818,,225% x Medicaid HMO amount,107818,Other,225% of NY Medicaid HMO DRG,107818,,225% x Medicaid HMO amount,107818,Other,225% of NY Medicaid HMO DRG,107818,,225% x Medicaid HMO amount,107818,Other,225% of NY Medicaid HMO DRG,67087,,140% x Medicaid HMO amount,67087,Other,140% of NY Medicaid HMO DRG,107818,,225% x Medicaid HMO amount,107818,Other,225% of NY Medicaid HMO DRG,131777,,275% x Medicaid HMO amount,131777,Other,275% of NY Medicaid HMO DRG,155258,,324% x Medicaid HMO amount,155258,Other,324% of NY Medicaid HMO DRG,103026,,215% x Medicaid HMO amount,103026,Other,215% of NY Medicaid HMO DRG,103026,,215% x Medicaid HMO amount,103026,Other,215% of NY Medicaid HMO DRG,59899,,125% x Medicaid HMO amount,59899,Other,125% of NY Medicaid HMO DRG,0.01,273345,
Respiratory system diagnosis w ventilator support 96+ hours,130-1,APR-DRG,,,,,,,,inpatient,,,116711,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,154798,,"45,128 x DRG weight",154798,Other,base rate x DRG weight,139318,,"40,615 x DRG weight",139318,Other,base rate x DRG weight,131579,,"38,359 x DRG weight",131579,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51137,,186% x Medicaid HMO amount,51137,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,116891,,"34,077 x DRG weight",116891,Other,base rate x DRG weight,99359,,"28,966 x DRG weight",99359,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27493,,DRG base rate x DRG weight + capital per discharge,27493,Other,100% of NY Medicaid HMO DRG,27493,,100% x Medicaid HMO amount,27493,Other,100% of NY Medicaid HMO DRG,27493,,100% x Medicaid HMO amount,27493,Other,100% of NY Medicaid HMO DRG,27493,,100% x Medicaid HMO amount,27493,Other,100% of NY Medicaid HMO DRG,61859,,225% x Medicaid HMO amount,61859,Other,225% of NY Medicaid HMO DRG,61859,,225% x Medicaid HMO amount,61859,Other,225% of NY Medicaid HMO DRG,61859,,225% x Medicaid HMO amount,61859,Other,225% of NY Medicaid HMO DRG,61859,,225% x Medicaid HMO amount,61859,Other,225% of NY Medicaid HMO DRG,38490,,140% x Medicaid HMO amount,38490,Other,140% of NY Medicaid HMO DRG,61859,,225% x Medicaid HMO amount,61859,Other,225% of NY Medicaid HMO DRG,75606,,275% x Medicaid HMO amount,75606,Other,275% of NY Medicaid HMO DRG,89077,,324% x Medicaid HMO amount,89077,Other,324% of NY Medicaid HMO DRG,59110,,215% x Medicaid HMO amount,59110,Other,215% of NY Medicaid HMO DRG,59110,,215% x Medicaid HMO amount,59110,Other,215% of NY Medicaid HMO DRG,34366,,125% x Medicaid HMO amount,34366,Other,125% of NY Medicaid HMO DRG,0.01,154798,
Respiratory system diagnosis w ventilator support 96+ hours,130-2,APR-DRG,,,,,,,,inpatient,,,296886,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,154798,,"45,128 x DRG weight",154798,Other,base rate x DRG weight,139318,,"40,615 x DRG weight",139318,Other,base rate x DRG weight,131579,,"38,359 x DRG weight",131579,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51137,,186% x Medicaid HMO amount,51137,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,116891,,"34,077 x DRG weight",116891,Other,base rate x DRG weight,99359,,"28,966 x DRG weight",99359,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27493,,DRG base rate x DRG weight + capital per discharge,27493,Other,100% of NY Medicaid HMO DRG,27493,,100% x Medicaid HMO amount,27493,Other,100% of NY Medicaid HMO DRG,27493,,100% x Medicaid HMO amount,27493,Other,100% of NY Medicaid HMO DRG,27493,,100% x Medicaid HMO amount,27493,Other,100% of NY Medicaid HMO DRG,61859,,225% x Medicaid HMO amount,61859,Other,225% of NY Medicaid HMO DRG,61859,,225% x Medicaid HMO amount,61859,Other,225% of NY Medicaid HMO DRG,61859,,225% x Medicaid HMO amount,61859,Other,225% of NY Medicaid HMO DRG,61859,,225% x Medicaid HMO amount,61859,Other,225% of NY Medicaid HMO DRG,38490,,140% x Medicaid HMO amount,38490,Other,140% of NY Medicaid HMO DRG,61859,,225% x Medicaid HMO amount,61859,Other,225% of NY Medicaid HMO DRG,75606,,275% x Medicaid HMO amount,75606,Other,275% of NY Medicaid HMO DRG,89077,,324% x Medicaid HMO amount,89077,Other,324% of NY Medicaid HMO DRG,59110,,215% x Medicaid HMO amount,59110,Other,215% of NY Medicaid HMO DRG,59110,,215% x Medicaid HMO amount,59110,Other,215% of NY Medicaid HMO DRG,34366,,125% x Medicaid HMO amount,34366,Other,125% of NY Medicaid HMO DRG,0.01,154798,
Respiratory system diagnosis w ventilator support 96+ hours,130-3,APR-DRG,,,,,,,,inpatient,,,481963.13,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,193121,,"45,128 x DRG weight",193121,Other,base rate x DRG weight,173808,,"40,615 x DRG weight",173808,Other,base rate x DRG weight,164154,,"38,359 x DRG weight",164154,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,63419,,186% x Medicaid HMO amount,63419,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,145829,,"34,077 x DRG weight",145829,Other,base rate x DRG weight,123957,,"28,966 x DRG weight",123957,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34096,,DRG base rate x DRG weight + capital per discharge,34096,Other,100% of NY Medicaid HMO DRG,34096,,100% x Medicaid HMO amount,34096,Other,100% of NY Medicaid HMO DRG,34096,,100% x Medicaid HMO amount,34096,Other,100% of NY Medicaid HMO DRG,34096,,100% x Medicaid HMO amount,34096,Other,100% of NY Medicaid HMO DRG,76716,,225% x Medicaid HMO amount,76716,Other,225% of NY Medicaid HMO DRG,76716,,225% x Medicaid HMO amount,76716,Other,225% of NY Medicaid HMO DRG,76716,,225% x Medicaid HMO amount,76716,Other,225% of NY Medicaid HMO DRG,76716,,225% x Medicaid HMO amount,76716,Other,225% of NY Medicaid HMO DRG,47734,,140% x Medicaid HMO amount,47734,Other,140% of NY Medicaid HMO DRG,76716,,225% x Medicaid HMO amount,76716,Other,225% of NY Medicaid HMO DRG,93764,,275% x Medicaid HMO amount,93764,Other,275% of NY Medicaid HMO DRG,110471,,324% x Medicaid HMO amount,110471,Other,324% of NY Medicaid HMO DRG,73306,,215% x Medicaid HMO amount,73306,Other,215% of NY Medicaid HMO DRG,73306,,215% x Medicaid HMO amount,73306,Other,215% of NY Medicaid HMO DRG,42620,,125% x Medicaid HMO amount,42620,Other,125% of NY Medicaid HMO DRG,0.01,193121,
Respiratory system diagnosis w ventilator support 96+ hours,130-4,APR-DRG,,,,,,,,inpatient,,,1565318.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,274053,,"45,128 x DRG weight",274053,Other,base rate x DRG weight,246647,,"40,615 x DRG weight",246647,Other,base rate x DRG weight,232947,,"38,359 x DRG weight",232947,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,89356,,186% x Medicaid HMO amount,89356,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,206943,,"34,077 x DRG weight",206943,Other,base rate x DRG weight,175905,,"28,966 x DRG weight",175905,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48041,,DRG base rate x DRG weight + capital per discharge,48041,Other,100% of NY Medicaid HMO DRG,48041,,100% x Medicaid HMO amount,48041,Other,100% of NY Medicaid HMO DRG,48041,,100% x Medicaid HMO amount,48041,Other,100% of NY Medicaid HMO DRG,48041,,100% x Medicaid HMO amount,48041,Other,100% of NY Medicaid HMO DRG,108092,,225% x Medicaid HMO amount,108092,Other,225% of NY Medicaid HMO DRG,108092,,225% x Medicaid HMO amount,108092,Other,225% of NY Medicaid HMO DRG,108092,,225% x Medicaid HMO amount,108092,Other,225% of NY Medicaid HMO DRG,108092,,225% x Medicaid HMO amount,108092,Other,225% of NY Medicaid HMO DRG,67257,,140% x Medicaid HMO amount,67257,Other,140% of NY Medicaid HMO DRG,108092,,225% x Medicaid HMO amount,108092,Other,225% of NY Medicaid HMO DRG,132113,,275% x Medicaid HMO amount,132113,Other,275% of NY Medicaid HMO DRG,155653,,324% x Medicaid HMO amount,155653,Other,324% of NY Medicaid HMO DRG,103288,,215% x Medicaid HMO amount,103288,Other,215% of NY Medicaid HMO DRG,103288,,215% x Medicaid HMO amount,103288,Other,215% of NY Medicaid HMO DRG,60051,,125% x Medicaid HMO amount,60051,Other,125% of NY Medicaid HMO DRG,0.01,274053,
Cystic fibrosis - pulmonary disease,131-1,APR-DRG,,,,,,,,inpatient,,,101263.02,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,62277,,"45,128 x DRG weight",62277,Other,base rate x DRG weight,56049,,"40,615 x DRG weight",56049,Other,base rate x DRG weight,52935,,"38,359 x DRG weight",52935,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21485,,186% x Medicaid HMO amount,21485,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47026,,"34,077 x DRG weight",47026,Other,base rate x DRG weight,39973,,"28,966 x DRG weight",39973,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11551,,DRG base rate x DRG weight + capital per discharge,11551,Other,100% of NY Medicaid HMO DRG,11551,,100% x Medicaid HMO amount,11551,Other,100% of NY Medicaid HMO DRG,11551,,100% x Medicaid HMO amount,11551,Other,100% of NY Medicaid HMO DRG,11551,,100% x Medicaid HMO amount,11551,Other,100% of NY Medicaid HMO DRG,25990,,225% x Medicaid HMO amount,25990,Other,225% of NY Medicaid HMO DRG,25990,,225% x Medicaid HMO amount,25990,Other,225% of NY Medicaid HMO DRG,25990,,225% x Medicaid HMO amount,25990,Other,225% of NY Medicaid HMO DRG,25990,,225% x Medicaid HMO amount,25990,Other,225% of NY Medicaid HMO DRG,16171,,140% x Medicaid HMO amount,16171,Other,140% of NY Medicaid HMO DRG,25990,,225% x Medicaid HMO amount,25990,Other,225% of NY Medicaid HMO DRG,31765,,275% x Medicaid HMO amount,31765,Other,275% of NY Medicaid HMO DRG,37425,,324% x Medicaid HMO amount,37425,Other,324% of NY Medicaid HMO DRG,24835,,215% x Medicaid HMO amount,24835,Other,215% of NY Medicaid HMO DRG,24835,,215% x Medicaid HMO amount,24835,Other,215% of NY Medicaid HMO DRG,14439,,125% x Medicaid HMO amount,14439,Other,125% of NY Medicaid HMO DRG,0.01,62277,
Cystic fibrosis - pulmonary disease,131-2,APR-DRG,,,,,,,,inpatient,,,115061.18,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,78062,,"45,128 x DRG weight",78062,Other,base rate x DRG weight,70256,,"40,615 x DRG weight",70256,Other,base rate x DRG weight,66353,,"38,359 x DRG weight",66353,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26544,,186% x Medicaid HMO amount,26544,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,58946,,"34,077 x DRG weight",58946,Other,base rate x DRG weight,50105,,"28,966 x DRG weight",50105,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14271,,DRG base rate x DRG weight + capital per discharge,14271,Other,100% of NY Medicaid HMO DRG,14271,,100% x Medicaid HMO amount,14271,Other,100% of NY Medicaid HMO DRG,14271,,100% x Medicaid HMO amount,14271,Other,100% of NY Medicaid HMO DRG,14271,,100% x Medicaid HMO amount,14271,Other,100% of NY Medicaid HMO DRG,32110,,225% x Medicaid HMO amount,32110,Other,225% of NY Medicaid HMO DRG,32110,,225% x Medicaid HMO amount,32110,Other,225% of NY Medicaid HMO DRG,32110,,225% x Medicaid HMO amount,32110,Other,225% of NY Medicaid HMO DRG,32110,,225% x Medicaid HMO amount,32110,Other,225% of NY Medicaid HMO DRG,19979,,140% x Medicaid HMO amount,19979,Other,140% of NY Medicaid HMO DRG,32110,,225% x Medicaid HMO amount,32110,Other,225% of NY Medicaid HMO DRG,39245,,275% x Medicaid HMO amount,39245,Other,275% of NY Medicaid HMO DRG,46238,,324% x Medicaid HMO amount,46238,Other,324% of NY Medicaid HMO DRG,30683,,215% x Medicaid HMO amount,30683,Other,215% of NY Medicaid HMO DRG,30683,,215% x Medicaid HMO amount,30683,Other,215% of NY Medicaid HMO DRG,17839,,125% x Medicaid HMO amount,17839,Other,125% of NY Medicaid HMO DRG,0.01,78062,
Cystic fibrosis - pulmonary disease,131-3,APR-DRG,,,,,,,,inpatient,,,173087.03,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,115230,,"45,128 x DRG weight",115230,Other,base rate x DRG weight,103706,,"40,615 x DRG weight",103706,Other,base rate x DRG weight,97946,,"38,359 x DRG weight",97946,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38456,,186% x Medicaid HMO amount,38456,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,87012,,"34,077 x DRG weight",87012,Other,base rate x DRG weight,73962,,"28,966 x DRG weight",73962,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20675,,DRG base rate x DRG weight + capital per discharge,20675,Other,100% of NY Medicaid HMO DRG,20675,,100% x Medicaid HMO amount,20675,Other,100% of NY Medicaid HMO DRG,20675,,100% x Medicaid HMO amount,20675,Other,100% of NY Medicaid HMO DRG,20675,,100% x Medicaid HMO amount,20675,Other,100% of NY Medicaid HMO DRG,46519,,225% x Medicaid HMO amount,46519,Other,225% of NY Medicaid HMO DRG,46519,,225% x Medicaid HMO amount,46519,Other,225% of NY Medicaid HMO DRG,46519,,225% x Medicaid HMO amount,46519,Other,225% of NY Medicaid HMO DRG,46519,,225% x Medicaid HMO amount,46519,Other,225% of NY Medicaid HMO DRG,28945,,140% x Medicaid HMO amount,28945,Other,140% of NY Medicaid HMO DRG,46519,,225% x Medicaid HMO amount,46519,Other,225% of NY Medicaid HMO DRG,56856,,275% x Medicaid HMO amount,56856,Other,275% of NY Medicaid HMO DRG,66987,,324% x Medicaid HMO amount,66987,Other,324% of NY Medicaid HMO DRG,44451,,215% x Medicaid HMO amount,44451,Other,215% of NY Medicaid HMO DRG,44451,,215% x Medicaid HMO amount,44451,Other,215% of NY Medicaid HMO DRG,25844,,125% x Medicaid HMO amount,25844,Other,125% of NY Medicaid HMO DRG,0.01,115230,
Cystic fibrosis - pulmonary disease,131-4,APR-DRG,,,,,,,,inpatient,,,259723.18,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,123357,,"45,128 x DRG weight",123357,Other,base rate x DRG weight,111021,,"40,615 x DRG weight",111021,Other,base rate x DRG weight,104854,,"38,359 x DRG weight",104854,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41061,,186% x Medicaid HMO amount,41061,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,93149,,"34,077 x DRG weight",93149,Other,base rate x DRG weight,79179,,"28,966 x DRG weight",79179,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22076,,DRG base rate x DRG weight + capital per discharge,22076,Other,100% of NY Medicaid HMO DRG,22076,,100% x Medicaid HMO amount,22076,Other,100% of NY Medicaid HMO DRG,22076,,100% x Medicaid HMO amount,22076,Other,100% of NY Medicaid HMO DRG,22076,,100% x Medicaid HMO amount,22076,Other,100% of NY Medicaid HMO DRG,49671,,225% x Medicaid HMO amount,49671,Other,225% of NY Medicaid HMO DRG,49671,,225% x Medicaid HMO amount,49671,Other,225% of NY Medicaid HMO DRG,49671,,225% x Medicaid HMO amount,49671,Other,225% of NY Medicaid HMO DRG,49671,,225% x Medicaid HMO amount,49671,Other,225% of NY Medicaid HMO DRG,30906,,140% x Medicaid HMO amount,30906,Other,140% of NY Medicaid HMO DRG,49671,,225% x Medicaid HMO amount,49671,Other,225% of NY Medicaid HMO DRG,60709,,275% x Medicaid HMO amount,60709,Other,275% of NY Medicaid HMO DRG,71526,,324% x Medicaid HMO amount,71526,Other,324% of NY Medicaid HMO DRG,47463,,215% x Medicaid HMO amount,47463,Other,215% of NY Medicaid HMO DRG,47463,,215% x Medicaid HMO amount,47463,Other,215% of NY Medicaid HMO DRG,27595,,125% x Medicaid HMO amount,27595,Other,125% of NY Medicaid HMO DRG,0.01,123357,
BPD & oth chronic respiratory diseases arising in perinatal period,132-1,APR-DRG,,,,,,,,inpatient,,,134363.12,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26635,,"45,128 x DRG weight",26635,Other,base rate x DRG weight,23971,,"40,615 x DRG weight",23971,Other,base rate x DRG weight,22639,,"38,359 x DRG weight",22639,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10063,,186% x Medicaid HMO amount,10063,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20112,,"34,077 x DRG weight",20112,Other,base rate x DRG weight,17096,,"28,966 x DRG weight",17096,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5410,,DRG base rate x DRG weight + capital per discharge,5410,Other,100% of NY Medicaid HMO DRG,5410,,100% x Medicaid HMO amount,5410,Other,100% of NY Medicaid HMO DRG,5410,,100% x Medicaid HMO amount,5410,Other,100% of NY Medicaid HMO DRG,5410,,100% x Medicaid HMO amount,5410,Other,100% of NY Medicaid HMO DRG,12173,,225% x Medicaid HMO amount,12173,Other,225% of NY Medicaid HMO DRG,12173,,225% x Medicaid HMO amount,12173,Other,225% of NY Medicaid HMO DRG,12173,,225% x Medicaid HMO amount,12173,Other,225% of NY Medicaid HMO DRG,12173,,225% x Medicaid HMO amount,12173,Other,225% of NY Medicaid HMO DRG,7574,,140% x Medicaid HMO amount,7574,Other,140% of NY Medicaid HMO DRG,12173,,225% x Medicaid HMO amount,12173,Other,225% of NY Medicaid HMO DRG,14878,,275% x Medicaid HMO amount,14878,Other,275% of NY Medicaid HMO DRG,17528,,324% x Medicaid HMO amount,17528,Other,324% of NY Medicaid HMO DRG,11632,,215% x Medicaid HMO amount,11632,Other,215% of NY Medicaid HMO DRG,11632,,215% x Medicaid HMO amount,11632,Other,215% of NY Medicaid HMO DRG,6763,,125% x Medicaid HMO amount,6763,Other,125% of NY Medicaid HMO DRG,0.01,26635,
BPD & oth chronic respiratory diseases arising in perinatal period,132-2,APR-DRG,,,,,,,,inpatient,,,130750.55,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35394,,"45,128 x DRG weight",35394,Other,base rate x DRG weight,31854,,"40,615 x DRG weight",31854,Other,base rate x DRG weight,30085,,"38,359 x DRG weight",30085,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12869,,186% x Medicaid HMO amount,12869,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26727,,"34,077 x DRG weight",26727,Other,base rate x DRG weight,22718,,"28,966 x DRG weight",22718,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6919,,DRG base rate x DRG weight + capital per discharge,6919,Other,100% of NY Medicaid HMO DRG,6919,,100% x Medicaid HMO amount,6919,Other,100% of NY Medicaid HMO DRG,6919,,100% x Medicaid HMO amount,6919,Other,100% of NY Medicaid HMO DRG,6919,,100% x Medicaid HMO amount,6919,Other,100% of NY Medicaid HMO DRG,15568,,225% x Medicaid HMO amount,15568,Other,225% of NY Medicaid HMO DRG,15568,,225% x Medicaid HMO amount,15568,Other,225% of NY Medicaid HMO DRG,15568,,225% x Medicaid HMO amount,15568,Other,225% of NY Medicaid HMO DRG,15568,,225% x Medicaid HMO amount,15568,Other,225% of NY Medicaid HMO DRG,9687,,140% x Medicaid HMO amount,9687,Other,140% of NY Medicaid HMO DRG,15568,,225% x Medicaid HMO amount,15568,Other,225% of NY Medicaid HMO DRG,19027,,275% x Medicaid HMO amount,19027,Other,275% of NY Medicaid HMO DRG,22418,,324% x Medicaid HMO amount,22418,Other,324% of NY Medicaid HMO DRG,14876,,215% x Medicaid HMO amount,14876,Other,215% of NY Medicaid HMO DRG,14876,,215% x Medicaid HMO amount,14876,Other,215% of NY Medicaid HMO DRG,8649,,125% x Medicaid HMO amount,8649,Other,125% of NY Medicaid HMO DRG,0.01,35394,
BPD & oth chronic respiratory diseases arising in perinatal period,132-3,APR-DRG,,,,,,,,inpatient,,,99357.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59465,,"45,128 x DRG weight",59465,Other,base rate x DRG weight,53518,,"40,615 x DRG weight",53518,Other,base rate x DRG weight,50546,,"38,359 x DRG weight",50546,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20585,,186% x Medicaid HMO amount,20585,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44903,,"34,077 x DRG weight",44903,Other,base rate x DRG weight,38168,,"28,966 x DRG weight",38168,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11067,,DRG base rate x DRG weight + capital per discharge,11067,Other,100% of NY Medicaid HMO DRG,11067,,100% x Medicaid HMO amount,11067,Other,100% of NY Medicaid HMO DRG,11067,,100% x Medicaid HMO amount,11067,Other,100% of NY Medicaid HMO DRG,11067,,100% x Medicaid HMO amount,11067,Other,100% of NY Medicaid HMO DRG,24901,,225% x Medicaid HMO amount,24901,Other,225% of NY Medicaid HMO DRG,24901,,225% x Medicaid HMO amount,24901,Other,225% of NY Medicaid HMO DRG,24901,,225% x Medicaid HMO amount,24901,Other,225% of NY Medicaid HMO DRG,24901,,225% x Medicaid HMO amount,24901,Other,225% of NY Medicaid HMO DRG,15494,,140% x Medicaid HMO amount,15494,Other,140% of NY Medicaid HMO DRG,24901,,225% x Medicaid HMO amount,24901,Other,225% of NY Medicaid HMO DRG,30434,,275% x Medicaid HMO amount,30434,Other,275% of NY Medicaid HMO DRG,35857,,324% x Medicaid HMO amount,35857,Other,324% of NY Medicaid HMO DRG,23794,,215% x Medicaid HMO amount,23794,Other,215% of NY Medicaid HMO DRG,23794,,215% x Medicaid HMO amount,23794,Other,215% of NY Medicaid HMO DRG,13834,,125% x Medicaid HMO amount,13834,Other,125% of NY Medicaid HMO DRG,0.01,59465,
BPD & oth chronic respiratory diseases arising in perinatal period,132-4,APR-DRG,,,,,,,,inpatient,,,222809.96,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,108343,,"45,128 x DRG weight",108343,Other,base rate x DRG weight,97508,,"40,615 x DRG weight",97508,Other,base rate x DRG weight,92092,,"38,359 x DRG weight",92092,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36250,,186% x Medicaid HMO amount,36250,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,81812,,"34,077 x DRG weight",81812,Other,base rate x DRG weight,69542,,"28,966 x DRG weight",69542,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19489,,DRG base rate x DRG weight + capital per discharge,19489,Other,100% of NY Medicaid HMO DRG,19489,,100% x Medicaid HMO amount,19489,Other,100% of NY Medicaid HMO DRG,19489,,100% x Medicaid HMO amount,19489,Other,100% of NY Medicaid HMO DRG,19489,,100% x Medicaid HMO amount,19489,Other,100% of NY Medicaid HMO DRG,43850,,225% x Medicaid HMO amount,43850,Other,225% of NY Medicaid HMO DRG,43850,,225% x Medicaid HMO amount,43850,Other,225% of NY Medicaid HMO DRG,43850,,225% x Medicaid HMO amount,43850,Other,225% of NY Medicaid HMO DRG,43850,,225% x Medicaid HMO amount,43850,Other,225% of NY Medicaid HMO DRG,27285,,140% x Medicaid HMO amount,27285,Other,140% of NY Medicaid HMO DRG,43850,,225% x Medicaid HMO amount,43850,Other,225% of NY Medicaid HMO DRG,53595,,275% x Medicaid HMO amount,53595,Other,275% of NY Medicaid HMO DRG,63144,,324% x Medicaid HMO amount,63144,Other,324% of NY Medicaid HMO DRG,41901,,215% x Medicaid HMO amount,41901,Other,215% of NY Medicaid HMO DRG,41901,,215% x Medicaid HMO amount,41901,Other,215% of NY Medicaid HMO DRG,24361,,125% x Medicaid HMO amount,24361,Other,125% of NY Medicaid HMO DRG,0.01,108343,
Respiratory Failure,133-1,APR-DRG,,,,,,,,inpatient,,,93911,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41585,,"45,128 x DRG weight",41585,Other,base rate x DRG weight,37427,,"40,615 x DRG weight",37427,Other,base rate x DRG weight,35348,,"38,359 x DRG weight",35348,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14854,,186% x Medicaid HMO amount,14854,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31402,,"34,077 x DRG weight",31402,Other,base rate x DRG weight,26692,,"28,966 x DRG weight",26692,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7986,,DRG base rate x DRG weight + capital per discharge,7986,Other,100% of NY Medicaid HMO DRG,7986,,100% x Medicaid HMO amount,7986,Other,100% of NY Medicaid HMO DRG,7986,,100% x Medicaid HMO amount,7986,Other,100% of NY Medicaid HMO DRG,7986,,100% x Medicaid HMO amount,7986,Other,100% of NY Medicaid HMO DRG,17969,,225% x Medicaid HMO amount,17969,Other,225% of NY Medicaid HMO DRG,17969,,225% x Medicaid HMO amount,17969,Other,225% of NY Medicaid HMO DRG,17969,,225% x Medicaid HMO amount,17969,Other,225% of NY Medicaid HMO DRG,17969,,225% x Medicaid HMO amount,17969,Other,225% of NY Medicaid HMO DRG,11180,,140% x Medicaid HMO amount,11180,Other,140% of NY Medicaid HMO DRG,17969,,225% x Medicaid HMO amount,17969,Other,225% of NY Medicaid HMO DRG,21962,,275% x Medicaid HMO amount,21962,Other,275% of NY Medicaid HMO DRG,25875,,324% x Medicaid HMO amount,25875,Other,324% of NY Medicaid HMO DRG,17170,,215% x Medicaid HMO amount,17170,Other,215% of NY Medicaid HMO DRG,17170,,215% x Medicaid HMO amount,17170,Other,215% of NY Medicaid HMO DRG,9983,,125% x Medicaid HMO amount,9983,Other,125% of NY Medicaid HMO DRG,0.01,41585,
Respiratory Failure,133-2,APR-DRG,,,,,,,,inpatient,,,93911,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41671,,"45,128 x DRG weight",41671,Other,base rate x DRG weight,37504,,"40,615 x DRG weight",37504,Other,base rate x DRG weight,35421,,"38,359 x DRG weight",35421,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14882,,186% x Medicaid HMO amount,14882,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31467,,"34,077 x DRG weight",31467,Other,base rate x DRG weight,26747,,"28,966 x DRG weight",26747,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8001,,DRG base rate x DRG weight + capital per discharge,8001,Other,100% of NY Medicaid HMO DRG,8001,,100% x Medicaid HMO amount,8001,Other,100% of NY Medicaid HMO DRG,8001,,100% x Medicaid HMO amount,8001,Other,100% of NY Medicaid HMO DRG,8001,,100% x Medicaid HMO amount,8001,Other,100% of NY Medicaid HMO DRG,18002,,225% x Medicaid HMO amount,18002,Other,225% of NY Medicaid HMO DRG,18002,,225% x Medicaid HMO amount,18002,Other,225% of NY Medicaid HMO DRG,18002,,225% x Medicaid HMO amount,18002,Other,225% of NY Medicaid HMO DRG,18002,,225% x Medicaid HMO amount,18002,Other,225% of NY Medicaid HMO DRG,11201,,140% x Medicaid HMO amount,11201,Other,140% of NY Medicaid HMO DRG,18002,,225% x Medicaid HMO amount,18002,Other,225% of NY Medicaid HMO DRG,22003,,275% x Medicaid HMO amount,22003,Other,275% of NY Medicaid HMO DRG,25923,,324% x Medicaid HMO amount,25923,Other,324% of NY Medicaid HMO DRG,17202,,215% x Medicaid HMO amount,17202,Other,215% of NY Medicaid HMO DRG,17202,,215% x Medicaid HMO amount,17202,Other,215% of NY Medicaid HMO DRG,10001,,125% x Medicaid HMO amount,10001,Other,125% of NY Medicaid HMO DRG,0.01,41671,
Respiratory Failure,133-3,APR-DRG,,,,,,,,inpatient,,,121549.43,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,61681,,"45,128 x DRG weight",61681,Other,base rate x DRG weight,55513,,"40,615 x DRG weight",55513,Other,base rate x DRG weight,52429,,"38,359 x DRG weight",52429,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21295,,186% x Medicaid HMO amount,21295,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46576,,"34,077 x DRG weight",46576,Other,base rate x DRG weight,39591,,"28,966 x DRG weight",39591,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11449,,DRG base rate x DRG weight + capital per discharge,11449,Other,100% of NY Medicaid HMO DRG,11449,,100% x Medicaid HMO amount,11449,Other,100% of NY Medicaid HMO DRG,11449,,100% x Medicaid HMO amount,11449,Other,100% of NY Medicaid HMO DRG,11449,,100% x Medicaid HMO amount,11449,Other,100% of NY Medicaid HMO DRG,25760,,225% x Medicaid HMO amount,25760,Other,225% of NY Medicaid HMO DRG,25760,,225% x Medicaid HMO amount,25760,Other,225% of NY Medicaid HMO DRG,25760,,225% x Medicaid HMO amount,25760,Other,225% of NY Medicaid HMO DRG,25760,,225% x Medicaid HMO amount,25760,Other,225% of NY Medicaid HMO DRG,16029,,140% x Medicaid HMO amount,16029,Other,140% of NY Medicaid HMO DRG,25760,,225% x Medicaid HMO amount,25760,Other,225% of NY Medicaid HMO DRG,31485,,275% x Medicaid HMO amount,31485,Other,275% of NY Medicaid HMO DRG,37095,,324% x Medicaid HMO amount,37095,Other,324% of NY Medicaid HMO DRG,24615,,215% x Medicaid HMO amount,24615,Other,215% of NY Medicaid HMO DRG,24615,,215% x Medicaid HMO amount,24615,Other,215% of NY Medicaid HMO DRG,14311,,125% x Medicaid HMO amount,14311,Other,125% of NY Medicaid HMO DRG,0.01,61681,
Respiratory Failure,133-4,APR-DRG,,,,,,,,inpatient,,,153146.39,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,91028,,"45,128 x DRG weight",91028,Other,base rate x DRG weight,81925,,"40,615 x DRG weight",81925,Other,base rate x DRG weight,77374,,"38,359 x DRG weight",77374,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30699,,186% x Medicaid HMO amount,30699,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,68737,,"34,077 x DRG weight",68737,Other,base rate x DRG weight,58427,,"28,966 x DRG weight",58427,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16505,,DRG base rate x DRG weight + capital per discharge,16505,Other,100% of NY Medicaid HMO DRG,16505,,100% x Medicaid HMO amount,16505,Other,100% of NY Medicaid HMO DRG,16505,,100% x Medicaid HMO amount,16505,Other,100% of NY Medicaid HMO DRG,16505,,100% x Medicaid HMO amount,16505,Other,100% of NY Medicaid HMO DRG,37136,,225% x Medicaid HMO amount,37136,Other,225% of NY Medicaid HMO DRG,37136,,225% x Medicaid HMO amount,37136,Other,225% of NY Medicaid HMO DRG,37136,,225% x Medicaid HMO amount,37136,Other,225% of NY Medicaid HMO DRG,37136,,225% x Medicaid HMO amount,37136,Other,225% of NY Medicaid HMO DRG,23107,,140% x Medicaid HMO amount,23107,Other,140% of NY Medicaid HMO DRG,37136,,225% x Medicaid HMO amount,37136,Other,225% of NY Medicaid HMO DRG,45389,,275% x Medicaid HMO amount,45389,Other,275% of NY Medicaid HMO DRG,53476,,324% x Medicaid HMO amount,53476,Other,324% of NY Medicaid HMO DRG,35486,,215% x Medicaid HMO amount,35486,Other,215% of NY Medicaid HMO DRG,35486,,215% x Medicaid HMO amount,35486,Other,215% of NY Medicaid HMO DRG,20631,,125% x Medicaid HMO amount,20631,Other,125% of NY Medicaid HMO DRG,0.01,91028,
Pulmonary embolism,134-1,APR-DRG,,,,,,,,inpatient,,,83186.91,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31802,,"45,128 x DRG weight",31802,Other,base rate x DRG weight,28621,,"40,615 x DRG weight",28621,Other,base rate x DRG weight,27032,,"38,359 x DRG weight",27032,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11718,,186% x Medicaid HMO amount,11718,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24014,,"34,077 x DRG weight",24014,Other,base rate x DRG weight,20412,,"28,966 x DRG weight",20412,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6300,,DRG base rate x DRG weight + capital per discharge,6300,Other,100% of NY Medicaid HMO DRG,6300,,100% x Medicaid HMO amount,6300,Other,100% of NY Medicaid HMO DRG,6300,,100% x Medicaid HMO amount,6300,Other,100% of NY Medicaid HMO DRG,6300,,100% x Medicaid HMO amount,6300,Other,100% of NY Medicaid HMO DRG,14175,,225% x Medicaid HMO amount,14175,Other,225% of NY Medicaid HMO DRG,14175,,225% x Medicaid HMO amount,14175,Other,225% of NY Medicaid HMO DRG,14175,,225% x Medicaid HMO amount,14175,Other,225% of NY Medicaid HMO DRG,14175,,225% x Medicaid HMO amount,14175,Other,225% of NY Medicaid HMO DRG,8820,,140% x Medicaid HMO amount,8820,Other,140% of NY Medicaid HMO DRG,14175,,225% x Medicaid HMO amount,14175,Other,225% of NY Medicaid HMO DRG,17325,,275% x Medicaid HMO amount,17325,Other,275% of NY Medicaid HMO DRG,20412,,324% x Medicaid HMO amount,20412,Other,324% of NY Medicaid HMO DRG,13545,,215% x Medicaid HMO amount,13545,Other,215% of NY Medicaid HMO DRG,13545,,215% x Medicaid HMO amount,13545,Other,215% of NY Medicaid HMO DRG,7875,,125% x Medicaid HMO amount,7875,Other,125% of NY Medicaid HMO DRG,0.01,31802,
Pulmonary embolism,134-2,APR-DRG,,,,,,,,inpatient,,,141942.08,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42199,,"45,128 x DRG weight",42199,Other,base rate x DRG weight,37979,,"40,615 x DRG weight",37979,Other,base rate x DRG weight,35870,,"38,359 x DRG weight",35870,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15051,,186% x Medicaid HMO amount,15051,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31865,,"34,077 x DRG weight",31865,Other,base rate x DRG weight,27086,,"28,966 x DRG weight",27086,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8092,,DRG base rate x DRG weight + capital per discharge,8092,Other,100% of NY Medicaid HMO DRG,8092,,100% x Medicaid HMO amount,8092,Other,100% of NY Medicaid HMO DRG,8092,,100% x Medicaid HMO amount,8092,Other,100% of NY Medicaid HMO DRG,8092,,100% x Medicaid HMO amount,8092,Other,100% of NY Medicaid HMO DRG,18207,,225% x Medicaid HMO amount,18207,Other,225% of NY Medicaid HMO DRG,18207,,225% x Medicaid HMO amount,18207,Other,225% of NY Medicaid HMO DRG,18207,,225% x Medicaid HMO amount,18207,Other,225% of NY Medicaid HMO DRG,18207,,225% x Medicaid HMO amount,18207,Other,225% of NY Medicaid HMO DRG,11329,,140% x Medicaid HMO amount,11329,Other,140% of NY Medicaid HMO DRG,18207,,225% x Medicaid HMO amount,18207,Other,225% of NY Medicaid HMO DRG,22253,,275% x Medicaid HMO amount,22253,Other,275% of NY Medicaid HMO DRG,26218,,324% x Medicaid HMO amount,26218,Other,324% of NY Medicaid HMO DRG,17398,,215% x Medicaid HMO amount,17398,Other,215% of NY Medicaid HMO DRG,17398,,215% x Medicaid HMO amount,17398,Other,215% of NY Medicaid HMO DRG,10115,,125% x Medicaid HMO amount,10115,Other,125% of NY Medicaid HMO DRG,0.01,42199,
Pulmonary embolism,134-3,APR-DRG,,,,,,,,inpatient,,,218830.2,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,68116,,"45,128 x DRG weight",68116,Other,base rate x DRG weight,61304,,"40,615 x DRG weight",61304,Other,base rate x DRG weight,57899,,"38,359 x DRG weight",57899,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23356,,186% x Medicaid HMO amount,23356,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51436,,"34,077 x DRG weight",51436,Other,base rate x DRG weight,43721,,"28,966 x DRG weight",43721,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12557,,DRG base rate x DRG weight + capital per discharge,12557,Other,100% of NY Medicaid HMO DRG,12557,,100% x Medicaid HMO amount,12557,Other,100% of NY Medicaid HMO DRG,12557,,100% x Medicaid HMO amount,12557,Other,100% of NY Medicaid HMO DRG,12557,,100% x Medicaid HMO amount,12557,Other,100% of NY Medicaid HMO DRG,28253,,225% x Medicaid HMO amount,28253,Other,225% of NY Medicaid HMO DRG,28253,,225% x Medicaid HMO amount,28253,Other,225% of NY Medicaid HMO DRG,28253,,225% x Medicaid HMO amount,28253,Other,225% of NY Medicaid HMO DRG,28253,,225% x Medicaid HMO amount,28253,Other,225% of NY Medicaid HMO DRG,17580,,140% x Medicaid HMO amount,17580,Other,140% of NY Medicaid HMO DRG,28253,,225% x Medicaid HMO amount,28253,Other,225% of NY Medicaid HMO DRG,34532,,275% x Medicaid HMO amount,34532,Other,275% of NY Medicaid HMO DRG,40685,,324% x Medicaid HMO amount,40685,Other,324% of NY Medicaid HMO DRG,26998,,215% x Medicaid HMO amount,26998,Other,215% of NY Medicaid HMO DRG,26998,,215% x Medicaid HMO amount,26998,Other,215% of NY Medicaid HMO DRG,15696,,125% x Medicaid HMO amount,15696,Other,125% of NY Medicaid HMO DRG,0.01,68116,
Pulmonary embolism,134-4,APR-DRG,,,,,,,,inpatient,,,673798.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,115365,,"45,128 x DRG weight",115365,Other,base rate x DRG weight,103828,,"40,615 x DRG weight",103828,Other,base rate x DRG weight,98061,,"38,359 x DRG weight",98061,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38498,,186% x Medicaid HMO amount,38498,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,87114,,"34,077 x DRG weight",87114,Other,base rate x DRG weight,74049,,"28,966 x DRG weight",74049,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20698,,DRG base rate x DRG weight + capital per discharge,20698,Other,100% of NY Medicaid HMO DRG,20698,,100% x Medicaid HMO amount,20698,Other,100% of NY Medicaid HMO DRG,20698,,100% x Medicaid HMO amount,20698,Other,100% of NY Medicaid HMO DRG,20698,,100% x Medicaid HMO amount,20698,Other,100% of NY Medicaid HMO DRG,46571,,225% x Medicaid HMO amount,46571,Other,225% of NY Medicaid HMO DRG,46571,,225% x Medicaid HMO amount,46571,Other,225% of NY Medicaid HMO DRG,46571,,225% x Medicaid HMO amount,46571,Other,225% of NY Medicaid HMO DRG,46571,,225% x Medicaid HMO amount,46571,Other,225% of NY Medicaid HMO DRG,28977,,140% x Medicaid HMO amount,28977,Other,140% of NY Medicaid HMO DRG,46571,,225% x Medicaid HMO amount,46571,Other,225% of NY Medicaid HMO DRG,56920,,275% x Medicaid HMO amount,56920,Other,275% of NY Medicaid HMO DRG,67062,,324% x Medicaid HMO amount,67062,Other,324% of NY Medicaid HMO DRG,44501,,215% x Medicaid HMO amount,44501,Other,215% of NY Medicaid HMO DRG,44501,,215% x Medicaid HMO amount,44501,Other,215% of NY Medicaid HMO DRG,25873,,125% x Medicaid HMO amount,25873,Other,125% of NY Medicaid HMO DRG,0.01,115365,
Major chest & respiratory trauma,135-1,APR-DRG,,,,,,,,inpatient,,,112165.56,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23358,,"45,128 x DRG weight",23358,Other,base rate x DRG weight,21022,,"40,615 x DRG weight",21022,Other,base rate x DRG weight,19855,,"38,359 x DRG weight",19855,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9014,,186% x Medicaid HMO amount,9014,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17638,,"34,077 x DRG weight",17638,Other,base rate x DRG weight,14993,,"28,966 x DRG weight",14993,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4846,,DRG base rate x DRG weight + capital per discharge,4846,Other,100% of NY Medicaid HMO DRG,4846,,100% x Medicaid HMO amount,4846,Other,100% of NY Medicaid HMO DRG,4846,,100% x Medicaid HMO amount,4846,Other,100% of NY Medicaid HMO DRG,4846,,100% x Medicaid HMO amount,4846,Other,100% of NY Medicaid HMO DRG,10904,,225% x Medicaid HMO amount,10904,Other,225% of NY Medicaid HMO DRG,10904,,225% x Medicaid HMO amount,10904,Other,225% of NY Medicaid HMO DRG,10904,,225% x Medicaid HMO amount,10904,Other,225% of NY Medicaid HMO DRG,10904,,225% x Medicaid HMO amount,10904,Other,225% of NY Medicaid HMO DRG,6784,,140% x Medicaid HMO amount,6784,Other,140% of NY Medicaid HMO DRG,10904,,225% x Medicaid HMO amount,10904,Other,225% of NY Medicaid HMO DRG,13327,,275% x Medicaid HMO amount,13327,Other,275% of NY Medicaid HMO DRG,15701,,324% x Medicaid HMO amount,15701,Other,324% of NY Medicaid HMO DRG,10419,,215% x Medicaid HMO amount,10419,Other,215% of NY Medicaid HMO DRG,10419,,215% x Medicaid HMO amount,10419,Other,215% of NY Medicaid HMO DRG,6058,,125% x Medicaid HMO amount,6058,Other,125% of NY Medicaid HMO DRG,0.01,23358,
Major chest & respiratory trauma,135-2,APR-DRG,,,,,,,,inpatient,,,152828.66,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32533,,"45,128 x DRG weight",32533,Other,base rate x DRG weight,29279,,"40,615 x DRG weight",29279,Other,base rate x DRG weight,27653,,"38,359 x DRG weight",27653,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11952,,186% x Medicaid HMO amount,11952,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24566,,"34,077 x DRG weight",24566,Other,base rate x DRG weight,20882,,"28,966 x DRG weight",20882,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6426,,DRG base rate x DRG weight + capital per discharge,6426,Other,100% of NY Medicaid HMO DRG,6426,,100% x Medicaid HMO amount,6426,Other,100% of NY Medicaid HMO DRG,6426,,100% x Medicaid HMO amount,6426,Other,100% of NY Medicaid HMO DRG,6426,,100% x Medicaid HMO amount,6426,Other,100% of NY Medicaid HMO DRG,14459,,225% x Medicaid HMO amount,14459,Other,225% of NY Medicaid HMO DRG,14459,,225% x Medicaid HMO amount,14459,Other,225% of NY Medicaid HMO DRG,14459,,225% x Medicaid HMO amount,14459,Other,225% of NY Medicaid HMO DRG,14459,,225% x Medicaid HMO amount,14459,Other,225% of NY Medicaid HMO DRG,8996,,140% x Medicaid HMO amount,8996,Other,140% of NY Medicaid HMO DRG,14459,,225% x Medicaid HMO amount,14459,Other,225% of NY Medicaid HMO DRG,17672,,275% x Medicaid HMO amount,17672,Other,275% of NY Medicaid HMO DRG,20820,,324% x Medicaid HMO amount,20820,Other,324% of NY Medicaid HMO DRG,13816,,215% x Medicaid HMO amount,13816,Other,215% of NY Medicaid HMO DRG,13816,,215% x Medicaid HMO amount,13816,Other,215% of NY Medicaid HMO DRG,8033,,125% x Medicaid HMO amount,8033,Other,125% of NY Medicaid HMO DRG,0.01,32533,
Major chest & respiratory trauma,135-3,APR-DRG,,,,,,,,inpatient,,,198307.37,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55359,,"45,128 x DRG weight",55359,Other,base rate x DRG weight,49822,,"40,615 x DRG weight",49822,Other,base rate x DRG weight,47055,,"38,359 x DRG weight",47055,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19268,,186% x Medicaid HMO amount,19268,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41802,,"34,077 x DRG weight",41802,Other,base rate x DRG weight,35533,,"28,966 x DRG weight",35533,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10359,,DRG base rate x DRG weight + capital per discharge,10359,Other,100% of NY Medicaid HMO DRG,10359,,100% x Medicaid HMO amount,10359,Other,100% of NY Medicaid HMO DRG,10359,,100% x Medicaid HMO amount,10359,Other,100% of NY Medicaid HMO DRG,10359,,100% x Medicaid HMO amount,10359,Other,100% of NY Medicaid HMO DRG,23308,,225% x Medicaid HMO amount,23308,Other,225% of NY Medicaid HMO DRG,23308,,225% x Medicaid HMO amount,23308,Other,225% of NY Medicaid HMO DRG,23308,,225% x Medicaid HMO amount,23308,Other,225% of NY Medicaid HMO DRG,23308,,225% x Medicaid HMO amount,23308,Other,225% of NY Medicaid HMO DRG,14503,,140% x Medicaid HMO amount,14503,Other,140% of NY Medicaid HMO DRG,23308,,225% x Medicaid HMO amount,23308,Other,225% of NY Medicaid HMO DRG,28487,,275% x Medicaid HMO amount,28487,Other,275% of NY Medicaid HMO DRG,33563,,324% x Medicaid HMO amount,33563,Other,324% of NY Medicaid HMO DRG,22272,,215% x Medicaid HMO amount,22272,Other,215% of NY Medicaid HMO DRG,22272,,215% x Medicaid HMO amount,22272,Other,215% of NY Medicaid HMO DRG,12949,,125% x Medicaid HMO amount,12949,Other,125% of NY Medicaid HMO DRG,0.01,55359,
Major chest & respiratory trauma,135-4,APR-DRG,,,,,,,,inpatient,,,181349.84,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,81939,,"45,128 x DRG weight",81939,Other,base rate x DRG weight,73745,,"40,615 x DRG weight",73745,Other,base rate x DRG weight,69648,,"38,359 x DRG weight",69648,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27787,,186% x Medicaid HMO amount,27787,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,61874,,"34,077 x DRG weight",61874,Other,base rate x DRG weight,52594,,"28,966 x DRG weight",52594,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14939,,DRG base rate x DRG weight + capital per discharge,14939,Other,100% of NY Medicaid HMO DRG,14939,,100% x Medicaid HMO amount,14939,Other,100% of NY Medicaid HMO DRG,14939,,100% x Medicaid HMO amount,14939,Other,100% of NY Medicaid HMO DRG,14939,,100% x Medicaid HMO amount,14939,Other,100% of NY Medicaid HMO DRG,33613,,225% x Medicaid HMO amount,33613,Other,225% of NY Medicaid HMO DRG,33613,,225% x Medicaid HMO amount,33613,Other,225% of NY Medicaid HMO DRG,33613,,225% x Medicaid HMO amount,33613,Other,225% of NY Medicaid HMO DRG,33613,,225% x Medicaid HMO amount,33613,Other,225% of NY Medicaid HMO DRG,20915,,140% x Medicaid HMO amount,20915,Other,140% of NY Medicaid HMO DRG,33613,,225% x Medicaid HMO amount,33613,Other,225% of NY Medicaid HMO DRG,41082,,275% x Medicaid HMO amount,41082,Other,275% of NY Medicaid HMO DRG,48402,,324% x Medicaid HMO amount,48402,Other,324% of NY Medicaid HMO DRG,32119,,215% x Medicaid HMO amount,32119,Other,215% of NY Medicaid HMO DRG,32119,,215% x Medicaid HMO amount,32119,Other,215% of NY Medicaid HMO DRG,18674,,125% x Medicaid HMO amount,18674,Other,125% of NY Medicaid HMO DRG,0.01,81939,
Respiratory malignancy,136-1,APR-DRG,,,,,,,,inpatient,,,140050,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25678,,"45,128 x DRG weight",25678,Other,base rate x DRG weight,23110,,"40,615 x DRG weight",23110,Other,base rate x DRG weight,21826,,"38,359 x DRG weight",21826,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9756,,186% x Medicaid HMO amount,9756,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19390,,"34,077 x DRG weight",19390,Other,base rate x DRG weight,16482,,"28,966 x DRG weight",16482,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5245,,DRG base rate x DRG weight + capital per discharge,5245,Other,100% of NY Medicaid HMO DRG,5245,,100% x Medicaid HMO amount,5245,Other,100% of NY Medicaid HMO DRG,5245,,100% x Medicaid HMO amount,5245,Other,100% of NY Medicaid HMO DRG,5245,,100% x Medicaid HMO amount,5245,Other,100% of NY Medicaid HMO DRG,11801,,225% x Medicaid HMO amount,11801,Other,225% of NY Medicaid HMO DRG,11801,,225% x Medicaid HMO amount,11801,Other,225% of NY Medicaid HMO DRG,11801,,225% x Medicaid HMO amount,11801,Other,225% of NY Medicaid HMO DRG,11801,,225% x Medicaid HMO amount,11801,Other,225% of NY Medicaid HMO DRG,7343,,140% x Medicaid HMO amount,7343,Other,140% of NY Medicaid HMO DRG,11801,,225% x Medicaid HMO amount,11801,Other,225% of NY Medicaid HMO DRG,14424,,275% x Medicaid HMO amount,14424,Other,275% of NY Medicaid HMO DRG,16994,,324% x Medicaid HMO amount,16994,Other,324% of NY Medicaid HMO DRG,11277,,215% x Medicaid HMO amount,11277,Other,215% of NY Medicaid HMO DRG,11277,,215% x Medicaid HMO amount,11277,Other,215% of NY Medicaid HMO DRG,6556,,125% x Medicaid HMO amount,6556,Other,125% of NY Medicaid HMO DRG,0.01,25678,
Respiratory malignancy,136-2,APR-DRG,,,,,,,,inpatient,,,193028.83,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40791,,"45,128 x DRG weight",40791,Other,base rate x DRG weight,36712,,"40,615 x DRG weight",36712,Other,base rate x DRG weight,34673,,"38,359 x DRG weight",34673,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14599,,186% x Medicaid HMO amount,14599,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30802,,"34,077 x DRG weight",30802,Other,base rate x DRG weight,26182,,"28,966 x DRG weight",26182,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7849,,DRG base rate x DRG weight + capital per discharge,7849,Other,100% of NY Medicaid HMO DRG,7849,,100% x Medicaid HMO amount,7849,Other,100% of NY Medicaid HMO DRG,7849,,100% x Medicaid HMO amount,7849,Other,100% of NY Medicaid HMO DRG,7849,,100% x Medicaid HMO amount,7849,Other,100% of NY Medicaid HMO DRG,17660,,225% x Medicaid HMO amount,17660,Other,225% of NY Medicaid HMO DRG,17660,,225% x Medicaid HMO amount,17660,Other,225% of NY Medicaid HMO DRG,17660,,225% x Medicaid HMO amount,17660,Other,225% of NY Medicaid HMO DRG,17660,,225% x Medicaid HMO amount,17660,Other,225% of NY Medicaid HMO DRG,10989,,140% x Medicaid HMO amount,10989,Other,140% of NY Medicaid HMO DRG,17660,,225% x Medicaid HMO amount,17660,Other,225% of NY Medicaid HMO DRG,21585,,275% x Medicaid HMO amount,21585,Other,275% of NY Medicaid HMO DRG,25431,,324% x Medicaid HMO amount,25431,Other,324% of NY Medicaid HMO DRG,16875,,215% x Medicaid HMO amount,16875,Other,215% of NY Medicaid HMO DRG,16875,,215% x Medicaid HMO amount,16875,Other,215% of NY Medicaid HMO DRG,9811,,125% x Medicaid HMO amount,9811,Other,125% of NY Medicaid HMO DRG,0.01,40791,
Respiratory malignancy,136-3,APR-DRG,,,,,,,,inpatient,,,278808.17,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,70386,,"45,128 x DRG weight",70386,Other,base rate x DRG weight,63347,,"40,615 x DRG weight",63347,Other,base rate x DRG weight,59829,,"38,359 x DRG weight",59829,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24085,,186% x Medicaid HMO amount,24085,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53150,,"34,077 x DRG weight",53150,Other,base rate x DRG weight,45178,,"28,966 x DRG weight",45178,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12949,,DRG base rate x DRG weight + capital per discharge,12949,Other,100% of NY Medicaid HMO DRG,12949,,100% x Medicaid HMO amount,12949,Other,100% of NY Medicaid HMO DRG,12949,,100% x Medicaid HMO amount,12949,Other,100% of NY Medicaid HMO DRG,12949,,100% x Medicaid HMO amount,12949,Other,100% of NY Medicaid HMO DRG,29135,,225% x Medicaid HMO amount,29135,Other,225% of NY Medicaid HMO DRG,29135,,225% x Medicaid HMO amount,29135,Other,225% of NY Medicaid HMO DRG,29135,,225% x Medicaid HMO amount,29135,Other,225% of NY Medicaid HMO DRG,29135,,225% x Medicaid HMO amount,29135,Other,225% of NY Medicaid HMO DRG,18129,,140% x Medicaid HMO amount,18129,Other,140% of NY Medicaid HMO DRG,29135,,225% x Medicaid HMO amount,29135,Other,225% of NY Medicaid HMO DRG,35610,,275% x Medicaid HMO amount,35610,Other,275% of NY Medicaid HMO DRG,41955,,324% x Medicaid HMO amount,41955,Other,324% of NY Medicaid HMO DRG,27840,,215% x Medicaid HMO amount,27840,Other,215% of NY Medicaid HMO DRG,27840,,215% x Medicaid HMO amount,27840,Other,215% of NY Medicaid HMO DRG,16186,,125% x Medicaid HMO amount,16186,Other,125% of NY Medicaid HMO DRG,0.01,70386,
Respiratory malignancy,136-4,APR-DRG,,,,,,,,inpatient,,,278808.17,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,103506,,"45,128 x DRG weight",103506,Other,base rate x DRG weight,93155,,"40,615 x DRG weight",93155,Other,base rate x DRG weight,87980,,"38,359 x DRG weight",87980,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34698,,186% x Medicaid HMO amount,34698,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,78159,,"34,077 x DRG weight",78159,Other,base rate x DRG weight,66436,,"28,966 x DRG weight",66436,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18655,,DRG base rate x DRG weight + capital per discharge,18655,Other,100% of NY Medicaid HMO DRG,18655,,100% x Medicaid HMO amount,18655,Other,100% of NY Medicaid HMO DRG,18655,,100% x Medicaid HMO amount,18655,Other,100% of NY Medicaid HMO DRG,18655,,100% x Medicaid HMO amount,18655,Other,100% of NY Medicaid HMO DRG,41974,,225% x Medicaid HMO amount,41974,Other,225% of NY Medicaid HMO DRG,41974,,225% x Medicaid HMO amount,41974,Other,225% of NY Medicaid HMO DRG,41974,,225% x Medicaid HMO amount,41974,Other,225% of NY Medicaid HMO DRG,41974,,225% x Medicaid HMO amount,41974,Other,225% of NY Medicaid HMO DRG,26117,,140% x Medicaid HMO amount,26117,Other,140% of NY Medicaid HMO DRG,41974,,225% x Medicaid HMO amount,41974,Other,225% of NY Medicaid HMO DRG,51301,,275% x Medicaid HMO amount,51301,Other,275% of NY Medicaid HMO DRG,60442,,324% x Medicaid HMO amount,60442,Other,324% of NY Medicaid HMO DRG,40108,,215% x Medicaid HMO amount,40108,Other,215% of NY Medicaid HMO DRG,40108,,215% x Medicaid HMO amount,40108,Other,215% of NY Medicaid HMO DRG,23319,,125% x Medicaid HMO amount,23319,Other,125% of NY Medicaid HMO DRG,0.01,103506,
Major respiratory infections & inflammations,137-1,APR-DRG,,,,,,,,inpatient,,,58081,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31400,,"45,128 x DRG weight",31400,Other,base rate x DRG weight,28260,,"40,615 x DRG weight",28260,Other,base rate x DRG weight,26690,,"38,359 x DRG weight",26690,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11590,,186% x Medicaid HMO amount,11590,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23711,,"34,077 x DRG weight",23711,Other,base rate x DRG weight,20155,,"28,966 x DRG weight",20155,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6231,,DRG base rate x DRG weight + capital per discharge,6231,Other,100% of NY Medicaid HMO DRG,6231,,100% x Medicaid HMO amount,6231,Other,100% of NY Medicaid HMO DRG,6231,,100% x Medicaid HMO amount,6231,Other,100% of NY Medicaid HMO DRG,6231,,100% x Medicaid HMO amount,6231,Other,100% of NY Medicaid HMO DRG,14020,,225% x Medicaid HMO amount,14020,Other,225% of NY Medicaid HMO DRG,14020,,225% x Medicaid HMO amount,14020,Other,225% of NY Medicaid HMO DRG,14020,,225% x Medicaid HMO amount,14020,Other,225% of NY Medicaid HMO DRG,14020,,225% x Medicaid HMO amount,14020,Other,225% of NY Medicaid HMO DRG,8723,,140% x Medicaid HMO amount,8723,Other,140% of NY Medicaid HMO DRG,14020,,225% x Medicaid HMO amount,14020,Other,225% of NY Medicaid HMO DRG,17135,,275% x Medicaid HMO amount,17135,Other,275% of NY Medicaid HMO DRG,20188,,324% x Medicaid HMO amount,20188,Other,324% of NY Medicaid HMO DRG,13397,,215% x Medicaid HMO amount,13397,Other,215% of NY Medicaid HMO DRG,13397,,215% x Medicaid HMO amount,13397,Other,215% of NY Medicaid HMO DRG,7789,,125% x Medicaid HMO amount,7789,Other,125% of NY Medicaid HMO DRG,0.01,31400,
Major respiratory infections & inflammations,137-2,APR-DRG,,,,,,,,inpatient,,,97455.91,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46518,,"45,128 x DRG weight",46518,Other,base rate x DRG weight,41866,,"40,615 x DRG weight",41866,Other,base rate x DRG weight,39540,,"38,359 x DRG weight",39540,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16435,,186% x Medicaid HMO amount,16435,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35127,,"34,077 x DRG weight",35127,Other,base rate x DRG weight,29858,,"28,966 x DRG weight",29858,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8836,,DRG base rate x DRG weight + capital per discharge,8836,Other,100% of NY Medicaid HMO DRG,8836,,100% x Medicaid HMO amount,8836,Other,100% of NY Medicaid HMO DRG,8836,,100% x Medicaid HMO amount,8836,Other,100% of NY Medicaid HMO DRG,8836,,100% x Medicaid HMO amount,8836,Other,100% of NY Medicaid HMO DRG,19881,,225% x Medicaid HMO amount,19881,Other,225% of NY Medicaid HMO DRG,19881,,225% x Medicaid HMO amount,19881,Other,225% of NY Medicaid HMO DRG,19881,,225% x Medicaid HMO amount,19881,Other,225% of NY Medicaid HMO DRG,19881,,225% x Medicaid HMO amount,19881,Other,225% of NY Medicaid HMO DRG,12370,,140% x Medicaid HMO amount,12370,Other,140% of NY Medicaid HMO DRG,19881,,225% x Medicaid HMO amount,19881,Other,225% of NY Medicaid HMO DRG,24299,,275% x Medicaid HMO amount,24299,Other,275% of NY Medicaid HMO DRG,28629,,324% x Medicaid HMO amount,28629,Other,324% of NY Medicaid HMO DRG,18997,,215% x Medicaid HMO amount,18997,Other,215% of NY Medicaid HMO DRG,18997,,215% x Medicaid HMO amount,18997,Other,215% of NY Medicaid HMO DRG,11045,,125% x Medicaid HMO amount,11045,Other,125% of NY Medicaid HMO DRG,0.01,46518,
Major respiratory infections & inflammations,137-3,APR-DRG,,,,,,,,inpatient,,,138466.37,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,75671,,"45,128 x DRG weight",75671,Other,base rate x DRG weight,68103,,"40,615 x DRG weight",68103,Other,base rate x DRG weight,64320,,"38,359 x DRG weight",64320,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25778,,186% x Medicaid HMO amount,25778,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,57140,,"34,077 x DRG weight",57140,Other,base rate x DRG weight,48570,,"28,966 x DRG weight",48570,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13859,,DRG base rate x DRG weight + capital per discharge,13859,Other,100% of NY Medicaid HMO DRG,13859,,100% x Medicaid HMO amount,13859,Other,100% of NY Medicaid HMO DRG,13859,,100% x Medicaid HMO amount,13859,Other,100% of NY Medicaid HMO DRG,13859,,100% x Medicaid HMO amount,13859,Other,100% of NY Medicaid HMO DRG,31183,,225% x Medicaid HMO amount,31183,Other,225% of NY Medicaid HMO DRG,31183,,225% x Medicaid HMO amount,31183,Other,225% of NY Medicaid HMO DRG,31183,,225% x Medicaid HMO amount,31183,Other,225% of NY Medicaid HMO DRG,31183,,225% x Medicaid HMO amount,31183,Other,225% of NY Medicaid HMO DRG,19403,,140% x Medicaid HMO amount,19403,Other,140% of NY Medicaid HMO DRG,31183,,225% x Medicaid HMO amount,31183,Other,225% of NY Medicaid HMO DRG,38112,,275% x Medicaid HMO amount,38112,Other,275% of NY Medicaid HMO DRG,44903,,324% x Medicaid HMO amount,44903,Other,324% of NY Medicaid HMO DRG,29797,,215% x Medicaid HMO amount,29797,Other,215% of NY Medicaid HMO DRG,29797,,215% x Medicaid HMO amount,29797,Other,215% of NY Medicaid HMO DRG,17324,,125% x Medicaid HMO amount,17324,Other,125% of NY Medicaid HMO DRG,0.01,75671,
Major respiratory infections & inflammations,137-4,APR-DRG,,,,,,,,inpatient,,,439858.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,117879,,"45,128 x DRG weight",117879,Other,base rate x DRG weight,106090,,"40,615 x DRG weight",106090,Other,base rate x DRG weight,100198,,"38,359 x DRG weight",100198,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39306,,186% x Medicaid HMO amount,39306,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,89013,,"34,077 x DRG weight",89013,Other,base rate x DRG weight,75662,,"28,966 x DRG weight",75662,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21132,,DRG base rate x DRG weight + capital per discharge,21132,Other,100% of NY Medicaid HMO DRG,21132,,100% x Medicaid HMO amount,21132,Other,100% of NY Medicaid HMO DRG,21132,,100% x Medicaid HMO amount,21132,Other,100% of NY Medicaid HMO DRG,21132,,100% x Medicaid HMO amount,21132,Other,100% of NY Medicaid HMO DRG,47547,,225% x Medicaid HMO amount,47547,Other,225% of NY Medicaid HMO DRG,47547,,225% x Medicaid HMO amount,47547,Other,225% of NY Medicaid HMO DRG,47547,,225% x Medicaid HMO amount,47547,Other,225% of NY Medicaid HMO DRG,47547,,225% x Medicaid HMO amount,47547,Other,225% of NY Medicaid HMO DRG,29585,,140% x Medicaid HMO amount,29585,Other,140% of NY Medicaid HMO DRG,47547,,225% x Medicaid HMO amount,47547,Other,225% of NY Medicaid HMO DRG,58113,,275% x Medicaid HMO amount,58113,Other,275% of NY Medicaid HMO DRG,68468,,324% x Medicaid HMO amount,68468,Other,324% of NY Medicaid HMO DRG,45434,,215% x Medicaid HMO amount,45434,Other,215% of NY Medicaid HMO DRG,45434,,215% x Medicaid HMO amount,45434,Other,215% of NY Medicaid HMO DRG,26415,,125% x Medicaid HMO amount,26415,Other,125% of NY Medicaid HMO DRG,0.01,117879,
Bronchiolitis & RSV pneumonia,138-1,APR-DRG,,,,,,,,inpatient,,,49164.88,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22009,,"45,128 x DRG weight",22009,Other,base rate x DRG weight,19808,,"40,615 x DRG weight",19808,Other,base rate x DRG weight,18708,,"38,359 x DRG weight",18708,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8580,,186% x Medicaid HMO amount,8580,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16619,,"34,077 x DRG weight",16619,Other,base rate x DRG weight,14127,,"28,966 x DRG weight",14127,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4613,,DRG base rate x DRG weight + capital per discharge,4613,Other,100% of NY Medicaid HMO DRG,4613,,100% x Medicaid HMO amount,4613,Other,100% of NY Medicaid HMO DRG,4613,,100% x Medicaid HMO amount,4613,Other,100% of NY Medicaid HMO DRG,4613,,100% x Medicaid HMO amount,4613,Other,100% of NY Medicaid HMO DRG,10379,,225% x Medicaid HMO amount,10379,Other,225% of NY Medicaid HMO DRG,10379,,225% x Medicaid HMO amount,10379,Other,225% of NY Medicaid HMO DRG,10379,,225% x Medicaid HMO amount,10379,Other,225% of NY Medicaid HMO DRG,10379,,225% x Medicaid HMO amount,10379,Other,225% of NY Medicaid HMO DRG,6458,,140% x Medicaid HMO amount,6458,Other,140% of NY Medicaid HMO DRG,10379,,225% x Medicaid HMO amount,10379,Other,225% of NY Medicaid HMO DRG,12686,,275% x Medicaid HMO amount,12686,Other,275% of NY Medicaid HMO DRG,14946,,324% x Medicaid HMO amount,14946,Other,324% of NY Medicaid HMO DRG,9918,,215% x Medicaid HMO amount,9918,Other,215% of NY Medicaid HMO DRG,9918,,215% x Medicaid HMO amount,9918,Other,215% of NY Medicaid HMO DRG,5766,,125% x Medicaid HMO amount,5766,Other,125% of NY Medicaid HMO DRG,0.01,22009,
Bronchiolitis & RSV pneumonia,138-2,APR-DRG,,,,,,,,inpatient,,,75374.07,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28444,,"45,128 x DRG weight",28444,Other,base rate x DRG weight,25600,,"40,615 x DRG weight",25600,Other,base rate x DRG weight,24178,,"38,359 x DRG weight",24178,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10643,,186% x Medicaid HMO amount,10643,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21479,,"34,077 x DRG weight",21479,Other,base rate x DRG weight,18257,,"28,966 x DRG weight",18257,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5722,,DRG base rate x DRG weight + capital per discharge,5722,Other,100% of NY Medicaid HMO DRG,5722,,100% x Medicaid HMO amount,5722,Other,100% of NY Medicaid HMO DRG,5722,,100% x Medicaid HMO amount,5722,Other,100% of NY Medicaid HMO DRG,5722,,100% x Medicaid HMO amount,5722,Other,100% of NY Medicaid HMO DRG,12875,,225% x Medicaid HMO amount,12875,Other,225% of NY Medicaid HMO DRG,12875,,225% x Medicaid HMO amount,12875,Other,225% of NY Medicaid HMO DRG,12875,,225% x Medicaid HMO amount,12875,Other,225% of NY Medicaid HMO DRG,12875,,225% x Medicaid HMO amount,12875,Other,225% of NY Medicaid HMO DRG,8011,,140% x Medicaid HMO amount,8011,Other,140% of NY Medicaid HMO DRG,12875,,225% x Medicaid HMO amount,12875,Other,225% of NY Medicaid HMO DRG,15736,,275% x Medicaid HMO amount,15736,Other,275% of NY Medicaid HMO DRG,18539,,324% x Medicaid HMO amount,18539,Other,324% of NY Medicaid HMO DRG,12302,,215% x Medicaid HMO amount,12302,Other,215% of NY Medicaid HMO DRG,12302,,215% x Medicaid HMO amount,12302,Other,215% of NY Medicaid HMO DRG,7153,,125% x Medicaid HMO amount,7153,Other,125% of NY Medicaid HMO DRG,0.01,28444,
Bronchiolitis & RSV pneumonia,138-3,APR-DRG,,,,,,,,inpatient,,,121433.97,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,61591,,"45,128 x DRG weight",61591,Other,base rate x DRG weight,55431,,"40,615 x DRG weight",55431,Other,base rate x DRG weight,52352,,"38,359 x DRG weight",52352,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21265,,186% x Medicaid HMO amount,21265,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46508,,"34,077 x DRG weight",46508,Other,base rate x DRG weight,39533,,"28,966 x DRG weight",39533,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11433,,DRG base rate x DRG weight + capital per discharge,11433,Other,100% of NY Medicaid HMO DRG,11433,,100% x Medicaid HMO amount,11433,Other,100% of NY Medicaid HMO DRG,11433,,100% x Medicaid HMO amount,11433,Other,100% of NY Medicaid HMO DRG,11433,,100% x Medicaid HMO amount,11433,Other,100% of NY Medicaid HMO DRG,25724,,225% x Medicaid HMO amount,25724,Other,225% of NY Medicaid HMO DRG,25724,,225% x Medicaid HMO amount,25724,Other,225% of NY Medicaid HMO DRG,25724,,225% x Medicaid HMO amount,25724,Other,225% of NY Medicaid HMO DRG,25724,,225% x Medicaid HMO amount,25724,Other,225% of NY Medicaid HMO DRG,16006,,140% x Medicaid HMO amount,16006,Other,140% of NY Medicaid HMO DRG,25724,,225% x Medicaid HMO amount,25724,Other,225% of NY Medicaid HMO DRG,31441,,275% x Medicaid HMO amount,31441,Other,275% of NY Medicaid HMO DRG,37043,,324% x Medicaid HMO amount,37043,Other,324% of NY Medicaid HMO DRG,24581,,215% x Medicaid HMO amount,24581,Other,215% of NY Medicaid HMO DRG,24581,,215% x Medicaid HMO amount,24581,Other,215% of NY Medicaid HMO DRG,14291,,125% x Medicaid HMO amount,14291,Other,125% of NY Medicaid HMO DRG,0.01,61591,
Bronchiolitis & RSV pneumonia,138-4,APR-DRG,,,,,,,,inpatient,,,114746.81,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,136454,,"45,128 x DRG weight",136454,Other,base rate x DRG weight,122808,,"40,615 x DRG weight",122808,Other,base rate x DRG weight,115986,,"38,359 x DRG weight",115986,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45258,,186% x Medicaid HMO amount,45258,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,103039,,"34,077 x DRG weight",103039,Other,base rate x DRG weight,87584,,"28,966 x DRG weight",87584,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24332,,DRG base rate x DRG weight + capital per discharge,24332,Other,100% of NY Medicaid HMO DRG,24332,,100% x Medicaid HMO amount,24332,Other,100% of NY Medicaid HMO DRG,24332,,100% x Medicaid HMO amount,24332,Other,100% of NY Medicaid HMO DRG,24332,,100% x Medicaid HMO amount,24332,Other,100% of NY Medicaid HMO DRG,54747,,225% x Medicaid HMO amount,54747,Other,225% of NY Medicaid HMO DRG,54747,,225% x Medicaid HMO amount,54747,Other,225% of NY Medicaid HMO DRG,54747,,225% x Medicaid HMO amount,54747,Other,225% of NY Medicaid HMO DRG,54747,,225% x Medicaid HMO amount,54747,Other,225% of NY Medicaid HMO DRG,34065,,140% x Medicaid HMO amount,34065,Other,140% of NY Medicaid HMO DRG,54747,,225% x Medicaid HMO amount,54747,Other,225% of NY Medicaid HMO DRG,66913,,275% x Medicaid HMO amount,66913,Other,275% of NY Medicaid HMO DRG,78836,,324% x Medicaid HMO amount,78836,Other,324% of NY Medicaid HMO DRG,52314,,215% x Medicaid HMO amount,52314,Other,215% of NY Medicaid HMO DRG,52314,,215% x Medicaid HMO amount,52314,Other,215% of NY Medicaid HMO DRG,30415,,125% x Medicaid HMO amount,30415,Other,125% of NY Medicaid HMO DRG,0.01,136454,
Other pneumonia,139-1,APR-DRG,,,,,,,,inpatient,,,65208.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23182,,"45,128 x DRG weight",23182,Other,base rate x DRG weight,20864,,"40,615 x DRG weight",20864,Other,base rate x DRG weight,19705,,"38,359 x DRG weight",19705,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8956,,186% x Medicaid HMO amount,8956,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17505,,"34,077 x DRG weight",17505,Other,base rate x DRG weight,14880,,"28,966 x DRG weight",14880,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4815,,DRG base rate x DRG weight + capital per discharge,4815,Other,100% of NY Medicaid HMO DRG,4815,,100% x Medicaid HMO amount,4815,Other,100% of NY Medicaid HMO DRG,4815,,100% x Medicaid HMO amount,4815,Other,100% of NY Medicaid HMO DRG,4815,,100% x Medicaid HMO amount,4815,Other,100% of NY Medicaid HMO DRG,10834,,225% x Medicaid HMO amount,10834,Other,225% of NY Medicaid HMO DRG,10834,,225% x Medicaid HMO amount,10834,Other,225% of NY Medicaid HMO DRG,10834,,225% x Medicaid HMO amount,10834,Other,225% of NY Medicaid HMO DRG,10834,,225% x Medicaid HMO amount,10834,Other,225% of NY Medicaid HMO DRG,6741,,140% x Medicaid HMO amount,6741,Other,140% of NY Medicaid HMO DRG,10834,,225% x Medicaid HMO amount,10834,Other,225% of NY Medicaid HMO DRG,13241,,275% x Medicaid HMO amount,13241,Other,275% of NY Medicaid HMO DRG,15601,,324% x Medicaid HMO amount,15601,Other,324% of NY Medicaid HMO DRG,10352,,215% x Medicaid HMO amount,10352,Other,215% of NY Medicaid HMO DRG,10352,,215% x Medicaid HMO amount,10352,Other,215% of NY Medicaid HMO DRG,6019,,125% x Medicaid HMO amount,6019,Other,125% of NY Medicaid HMO DRG,0.01,23182,
Other pneumonia,139-2,APR-DRG,,,,,,,,inpatient,,,78521.38,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30610,,"45,128 x DRG weight",30610,Other,base rate x DRG weight,27549,,"40,615 x DRG weight",27549,Other,base rate x DRG weight,26019,,"38,359 x DRG weight",26019,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11337,,186% x Medicaid HMO amount,11337,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23114,,"34,077 x DRG weight",23114,Other,base rate x DRG weight,19648,,"28,966 x DRG weight",19648,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6095,,DRG base rate x DRG weight + capital per discharge,6095,Other,100% of NY Medicaid HMO DRG,6095,,100% x Medicaid HMO amount,6095,Other,100% of NY Medicaid HMO DRG,6095,,100% x Medicaid HMO amount,6095,Other,100% of NY Medicaid HMO DRG,6095,,100% x Medicaid HMO amount,6095,Other,100% of NY Medicaid HMO DRG,13714,,225% x Medicaid HMO amount,13714,Other,225% of NY Medicaid HMO DRG,13714,,225% x Medicaid HMO amount,13714,Other,225% of NY Medicaid HMO DRG,13714,,225% x Medicaid HMO amount,13714,Other,225% of NY Medicaid HMO DRG,13714,,225% x Medicaid HMO amount,13714,Other,225% of NY Medicaid HMO DRG,8533,,140% x Medicaid HMO amount,8533,Other,140% of NY Medicaid HMO DRG,13714,,225% x Medicaid HMO amount,13714,Other,225% of NY Medicaid HMO DRG,16761,,275% x Medicaid HMO amount,16761,Other,275% of NY Medicaid HMO DRG,19748,,324% x Medicaid HMO amount,19748,Other,324% of NY Medicaid HMO DRG,13104,,215% x Medicaid HMO amount,13104,Other,215% of NY Medicaid HMO DRG,13104,,215% x Medicaid HMO amount,13104,Other,215% of NY Medicaid HMO DRG,7619,,125% x Medicaid HMO amount,7619,Other,125% of NY Medicaid HMO DRG,0.01,30610,
Other pneumonia,139-3,APR-DRG,,,,,,,,inpatient,,,157119.86,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51360,,"45,128 x DRG weight",51360,Other,base rate x DRG weight,46224,,"40,615 x DRG weight",46224,Other,base rate x DRG weight,43656,,"38,359 x DRG weight",43656,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17986,,186% x Medicaid HMO amount,17986,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38783,,"34,077 x DRG weight",38783,Other,base rate x DRG weight,32966,,"28,966 x DRG weight",32966,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9670,,DRG base rate x DRG weight + capital per discharge,9670,Other,100% of NY Medicaid HMO DRG,9670,,100% x Medicaid HMO amount,9670,Other,100% of NY Medicaid HMO DRG,9670,,100% x Medicaid HMO amount,9670,Other,100% of NY Medicaid HMO DRG,9670,,100% x Medicaid HMO amount,9670,Other,100% of NY Medicaid HMO DRG,21758,,225% x Medicaid HMO amount,21758,Other,225% of NY Medicaid HMO DRG,21758,,225% x Medicaid HMO amount,21758,Other,225% of NY Medicaid HMO DRG,21758,,225% x Medicaid HMO amount,21758,Other,225% of NY Medicaid HMO DRG,21758,,225% x Medicaid HMO amount,21758,Other,225% of NY Medicaid HMO DRG,13538,,140% x Medicaid HMO amount,13538,Other,140% of NY Medicaid HMO DRG,21758,,225% x Medicaid HMO amount,21758,Other,225% of NY Medicaid HMO DRG,26593,,275% x Medicaid HMO amount,26593,Other,275% of NY Medicaid HMO DRG,31331,,324% x Medicaid HMO amount,31331,Other,324% of NY Medicaid HMO DRG,20791,,215% x Medicaid HMO amount,20791,Other,215% of NY Medicaid HMO DRG,20791,,215% x Medicaid HMO amount,20791,Other,215% of NY Medicaid HMO DRG,12088,,125% x Medicaid HMO amount,12088,Other,125% of NY Medicaid HMO DRG,0.01,51360,
Other pneumonia,139-4,APR-DRG,,,,,,,,inpatient,,,257249.45,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,97919,,"45,128 x DRG weight",97919,Other,base rate x DRG weight,88126,,"40,615 x DRG weight",88126,Other,base rate x DRG weight,83231,,"38,359 x DRG weight",83231,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32907,,186% x Medicaid HMO amount,32907,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73940,,"34,077 x DRG weight",73940,Other,base rate x DRG weight,62850,,"28,966 x DRG weight",62850,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17692,,DRG base rate x DRG weight + capital per discharge,17692,Other,100% of NY Medicaid HMO DRG,17692,,100% x Medicaid HMO amount,17692,Other,100% of NY Medicaid HMO DRG,17692,,100% x Medicaid HMO amount,17692,Other,100% of NY Medicaid HMO DRG,17692,,100% x Medicaid HMO amount,17692,Other,100% of NY Medicaid HMO DRG,39807,,225% x Medicaid HMO amount,39807,Other,225% of NY Medicaid HMO DRG,39807,,225% x Medicaid HMO amount,39807,Other,225% of NY Medicaid HMO DRG,39807,,225% x Medicaid HMO amount,39807,Other,225% of NY Medicaid HMO DRG,39807,,225% x Medicaid HMO amount,39807,Other,225% of NY Medicaid HMO DRG,24769,,140% x Medicaid HMO amount,24769,Other,140% of NY Medicaid HMO DRG,39807,,225% x Medicaid HMO amount,39807,Other,225% of NY Medicaid HMO DRG,48653,,275% x Medicaid HMO amount,48653,Other,275% of NY Medicaid HMO DRG,57322,,324% x Medicaid HMO amount,57322,Other,324% of NY Medicaid HMO DRG,38038,,215% x Medicaid HMO amount,38038,Other,215% of NY Medicaid HMO DRG,38038,,215% x Medicaid HMO amount,38038,Other,215% of NY Medicaid HMO DRG,22115,,125% x Medicaid HMO amount,22115,Other,125% of NY Medicaid HMO DRG,0.01,97919,
Chronic obstructive pulmonary disease,140-1,APR-DRG,,,,,,,,inpatient,,,70974.51,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25953,,"45,128 x DRG weight",25953,Other,base rate x DRG weight,23358,,"40,615 x DRG weight",23358,Other,base rate x DRG weight,22060,,"38,359 x DRG weight",22060,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9845,,186% x Medicaid HMO amount,9845,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19598,,"34,077 x DRG weight",19598,Other,base rate x DRG weight,16658,,"28,966 x DRG weight",16658,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5293,,DRG base rate x DRG weight + capital per discharge,5293,Other,100% of NY Medicaid HMO DRG,5293,,100% x Medicaid HMO amount,5293,Other,100% of NY Medicaid HMO DRG,5293,,100% x Medicaid HMO amount,5293,Other,100% of NY Medicaid HMO DRG,5293,,100% x Medicaid HMO amount,5293,Other,100% of NY Medicaid HMO DRG,11909,,225% x Medicaid HMO amount,11909,Other,225% of NY Medicaid HMO DRG,11909,,225% x Medicaid HMO amount,11909,Other,225% of NY Medicaid HMO DRG,11909,,225% x Medicaid HMO amount,11909,Other,225% of NY Medicaid HMO DRG,11909,,225% x Medicaid HMO amount,11909,Other,225% of NY Medicaid HMO DRG,7410,,140% x Medicaid HMO amount,7410,Other,140% of NY Medicaid HMO DRG,11909,,225% x Medicaid HMO amount,11909,Other,225% of NY Medicaid HMO DRG,14556,,275% x Medicaid HMO amount,14556,Other,275% of NY Medicaid HMO DRG,17149,,324% x Medicaid HMO amount,17149,Other,324% of NY Medicaid HMO DRG,11380,,215% x Medicaid HMO amount,11380,Other,215% of NY Medicaid HMO DRG,11380,,215% x Medicaid HMO amount,11380,Other,215% of NY Medicaid HMO DRG,6616,,125% x Medicaid HMO amount,6616,Other,125% of NY Medicaid HMO DRG,0.01,25953,
Chronic obstructive pulmonary disease,140-2,APR-DRG,,,,,,,,inpatient,,,80328.69,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32582,,"45,128 x DRG weight",32582,Other,base rate x DRG weight,29324,,"40,615 x DRG weight",29324,Other,base rate x DRG weight,27695,,"38,359 x DRG weight",27695,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11969,,186% x Medicaid HMO amount,11969,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24604,,"34,077 x DRG weight",24604,Other,base rate x DRG weight,20913,,"28,966 x DRG weight",20913,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6435,,DRG base rate x DRG weight + capital per discharge,6435,Other,100% of NY Medicaid HMO DRG,6435,,100% x Medicaid HMO amount,6435,Other,100% of NY Medicaid HMO DRG,6435,,100% x Medicaid HMO amount,6435,Other,100% of NY Medicaid HMO DRG,6435,,100% x Medicaid HMO amount,6435,Other,100% of NY Medicaid HMO DRG,14479,,225% x Medicaid HMO amount,14479,Other,225% of NY Medicaid HMO DRG,14479,,225% x Medicaid HMO amount,14479,Other,225% of NY Medicaid HMO DRG,14479,,225% x Medicaid HMO amount,14479,Other,225% of NY Medicaid HMO DRG,14479,,225% x Medicaid HMO amount,14479,Other,225% of NY Medicaid HMO DRG,9009,,140% x Medicaid HMO amount,9009,Other,140% of NY Medicaid HMO DRG,14479,,225% x Medicaid HMO amount,14479,Other,225% of NY Medicaid HMO DRG,17696,,275% x Medicaid HMO amount,17696,Other,275% of NY Medicaid HMO DRG,20849,,324% x Medicaid HMO amount,20849,Other,324% of NY Medicaid HMO DRG,13835,,215% x Medicaid HMO amount,13835,Other,215% of NY Medicaid HMO DRG,13835,,215% x Medicaid HMO amount,13835,Other,215% of NY Medicaid HMO DRG,8044,,125% x Medicaid HMO amount,8044,Other,125% of NY Medicaid HMO DRG,0.01,32582,
Chronic obstructive pulmonary disease,140-3,APR-DRG,,,,,,,,inpatient,,,105230.1,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45683,,"45,128 x DRG weight",45683,Other,base rate x DRG weight,41115,,"40,615 x DRG weight",41115,Other,base rate x DRG weight,38831,,"38,359 x DRG weight",38831,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16167,,186% x Medicaid HMO amount,16167,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34496,,"34,077 x DRG weight",34496,Other,base rate x DRG weight,29322,,"28,966 x DRG weight",29322,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8692,,DRG base rate x DRG weight + capital per discharge,8692,Other,100% of NY Medicaid HMO DRG,8692,,100% x Medicaid HMO amount,8692,Other,100% of NY Medicaid HMO DRG,8692,,100% x Medicaid HMO amount,8692,Other,100% of NY Medicaid HMO DRG,8692,,100% x Medicaid HMO amount,8692,Other,100% of NY Medicaid HMO DRG,19557,,225% x Medicaid HMO amount,19557,Other,225% of NY Medicaid HMO DRG,19557,,225% x Medicaid HMO amount,19557,Other,225% of NY Medicaid HMO DRG,19557,,225% x Medicaid HMO amount,19557,Other,225% of NY Medicaid HMO DRG,19557,,225% x Medicaid HMO amount,19557,Other,225% of NY Medicaid HMO DRG,12169,,140% x Medicaid HMO amount,12169,Other,140% of NY Medicaid HMO DRG,19557,,225% x Medicaid HMO amount,19557,Other,225% of NY Medicaid HMO DRG,23903,,275% x Medicaid HMO amount,23903,Other,275% of NY Medicaid HMO DRG,28162,,324% x Medicaid HMO amount,28162,Other,324% of NY Medicaid HMO DRG,18688,,215% x Medicaid HMO amount,18688,Other,215% of NY Medicaid HMO DRG,18688,,215% x Medicaid HMO amount,18688,Other,215% of NY Medicaid HMO DRG,10865,,125% x Medicaid HMO amount,10865,Other,125% of NY Medicaid HMO DRG,0.01,45683,
Chronic obstructive pulmonary disease,140-4,APR-DRG,,,,,,,,inpatient,,,212102.07,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,88920,,"45,128 x DRG weight",88920,Other,base rate x DRG weight,80028,,"40,615 x DRG weight",80028,Other,base rate x DRG weight,75583,,"38,359 x DRG weight",75583,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30024,,186% x Medicaid HMO amount,30024,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,67145,,"34,077 x DRG weight",67145,Other,base rate x DRG weight,57075,,"28,966 x DRG weight",57075,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16142,,DRG base rate x DRG weight + capital per discharge,16142,Other,100% of NY Medicaid HMO DRG,16142,,100% x Medicaid HMO amount,16142,Other,100% of NY Medicaid HMO DRG,16142,,100% x Medicaid HMO amount,16142,Other,100% of NY Medicaid HMO DRG,16142,,100% x Medicaid HMO amount,16142,Other,100% of NY Medicaid HMO DRG,36320,,225% x Medicaid HMO amount,36320,Other,225% of NY Medicaid HMO DRG,36320,,225% x Medicaid HMO amount,36320,Other,225% of NY Medicaid HMO DRG,36320,,225% x Medicaid HMO amount,36320,Other,225% of NY Medicaid HMO DRG,36320,,225% x Medicaid HMO amount,36320,Other,225% of NY Medicaid HMO DRG,22599,,140% x Medicaid HMO amount,22599,Other,140% of NY Medicaid HMO DRG,36320,,225% x Medicaid HMO amount,36320,Other,225% of NY Medicaid HMO DRG,44391,,275% x Medicaid HMO amount,44391,Other,275% of NY Medicaid HMO DRG,52300,,324% x Medicaid HMO amount,52300,Other,324% of NY Medicaid HMO DRG,34705,,215% x Medicaid HMO amount,34705,Other,215% of NY Medicaid HMO DRG,34705,,215% x Medicaid HMO amount,34705,Other,215% of NY Medicaid HMO DRG,20178,,125% x Medicaid HMO amount,20178,Other,125% of NY Medicaid HMO DRG,0.01,88920,
Asthma,141-1,APR-DRG,,,,,,,,inpatient,,,60338.58,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21373,,"45,128 x DRG weight",21373,Other,base rate x DRG weight,19235,,"40,615 x DRG weight",19235,Other,base rate x DRG weight,18167,,"38,359 x DRG weight",18167,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8376,,186% x Medicaid HMO amount,8376,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16139,,"34,077 x DRG weight",16139,Other,base rate x DRG weight,13718,,"28,966 x DRG weight",13718,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4503,,DRG base rate x DRG weight + capital per discharge,4503,Other,100% of NY Medicaid HMO DRG,4503,,100% x Medicaid HMO amount,4503,Other,100% of NY Medicaid HMO DRG,4503,,100% x Medicaid HMO amount,4503,Other,100% of NY Medicaid HMO DRG,4503,,100% x Medicaid HMO amount,4503,Other,100% of NY Medicaid HMO DRG,10132,,225% x Medicaid HMO amount,10132,Other,225% of NY Medicaid HMO DRG,10132,,225% x Medicaid HMO amount,10132,Other,225% of NY Medicaid HMO DRG,10132,,225% x Medicaid HMO amount,10132,Other,225% of NY Medicaid HMO DRG,10132,,225% x Medicaid HMO amount,10132,Other,225% of NY Medicaid HMO DRG,6304,,140% x Medicaid HMO amount,6304,Other,140% of NY Medicaid HMO DRG,10132,,225% x Medicaid HMO amount,10132,Other,225% of NY Medicaid HMO DRG,12383,,275% x Medicaid HMO amount,12383,Other,275% of NY Medicaid HMO DRG,14590,,324% x Medicaid HMO amount,14590,Other,324% of NY Medicaid HMO DRG,9681,,215% x Medicaid HMO amount,9681,Other,215% of NY Medicaid HMO DRG,9681,,215% x Medicaid HMO amount,9681,Other,215% of NY Medicaid HMO DRG,5629,,125% x Medicaid HMO amount,5629,Other,125% of NY Medicaid HMO DRG,0.01,21373,
Asthma,141-2,APR-DRG,,,,,,,,inpatient,,,70052.89,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27858,,"45,128 x DRG weight",27858,Other,base rate x DRG weight,25072,,"40,615 x DRG weight",25072,Other,base rate x DRG weight,23679,,"38,359 x DRG weight",23679,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10455,,186% x Medicaid HMO amount,10455,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21036,,"34,077 x DRG weight",21036,Other,base rate x DRG weight,17881,,"28,966 x DRG weight",17881,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5621,,DRG base rate x DRG weight + capital per discharge,5621,Other,100% of NY Medicaid HMO DRG,5621,,100% x Medicaid HMO amount,5621,Other,100% of NY Medicaid HMO DRG,5621,,100% x Medicaid HMO amount,5621,Other,100% of NY Medicaid HMO DRG,5621,,100% x Medicaid HMO amount,5621,Other,100% of NY Medicaid HMO DRG,12647,,225% x Medicaid HMO amount,12647,Other,225% of NY Medicaid HMO DRG,12647,,225% x Medicaid HMO amount,12647,Other,225% of NY Medicaid HMO DRG,12647,,225% x Medicaid HMO amount,12647,Other,225% of NY Medicaid HMO DRG,12647,,225% x Medicaid HMO amount,12647,Other,225% of NY Medicaid HMO DRG,7869,,140% x Medicaid HMO amount,7869,Other,140% of NY Medicaid HMO DRG,12647,,225% x Medicaid HMO amount,12647,Other,225% of NY Medicaid HMO DRG,15458,,275% x Medicaid HMO amount,15458,Other,275% of NY Medicaid HMO DRG,18212,,324% x Medicaid HMO amount,18212,Other,324% of NY Medicaid HMO DRG,12085,,215% x Medicaid HMO amount,12085,Other,215% of NY Medicaid HMO DRG,12085,,215% x Medicaid HMO amount,12085,Other,215% of NY Medicaid HMO DRG,7026,,125% x Medicaid HMO amount,7026,Other,125% of NY Medicaid HMO DRG,0.01,27858,
Asthma,141-3,APR-DRG,,,,,,,,inpatient,,,92648.53,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42317,,"45,128 x DRG weight",42317,Other,base rate x DRG weight,38085,,"40,615 x DRG weight",38085,Other,base rate x DRG weight,35969,,"38,359 x DRG weight",35969,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15088,,186% x Medicaid HMO amount,15088,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31954,,"34,077 x DRG weight",31954,Other,base rate x DRG weight,27161,,"28,966 x DRG weight",27161,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8112,,DRG base rate x DRG weight + capital per discharge,8112,Other,100% of NY Medicaid HMO DRG,8112,,100% x Medicaid HMO amount,8112,Other,100% of NY Medicaid HMO DRG,8112,,100% x Medicaid HMO amount,8112,Other,100% of NY Medicaid HMO DRG,8112,,100% x Medicaid HMO amount,8112,Other,100% of NY Medicaid HMO DRG,18252,,225% x Medicaid HMO amount,18252,Other,225% of NY Medicaid HMO DRG,18252,,225% x Medicaid HMO amount,18252,Other,225% of NY Medicaid HMO DRG,18252,,225% x Medicaid HMO amount,18252,Other,225% of NY Medicaid HMO DRG,18252,,225% x Medicaid HMO amount,18252,Other,225% of NY Medicaid HMO DRG,11357,,140% x Medicaid HMO amount,11357,Other,140% of NY Medicaid HMO DRG,18252,,225% x Medicaid HMO amount,18252,Other,225% of NY Medicaid HMO DRG,22308,,275% x Medicaid HMO amount,22308,Other,275% of NY Medicaid HMO DRG,26283,,324% x Medicaid HMO amount,26283,Other,324% of NY Medicaid HMO DRG,17441,,215% x Medicaid HMO amount,17441,Other,215% of NY Medicaid HMO DRG,17441,,215% x Medicaid HMO amount,17441,Other,215% of NY Medicaid HMO DRG,10140,,125% x Medicaid HMO amount,10140,Other,125% of NY Medicaid HMO DRG,0.01,42317,
Asthma,141-4,APR-DRG,,,,,,,,inpatient,,,123003.7,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,74547,,"45,128 x DRG weight",74547,Other,base rate x DRG weight,67092,,"40,615 x DRG weight",67092,Other,base rate x DRG weight,63365,,"38,359 x DRG weight",63365,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25417,,186% x Medicaid HMO amount,25417,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56292,,"34,077 x DRG weight",56292,Other,base rate x DRG weight,47849,,"28,966 x DRG weight",47849,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13665,,DRG base rate x DRG weight + capital per discharge,13665,Other,100% of NY Medicaid HMO DRG,13665,,100% x Medicaid HMO amount,13665,Other,100% of NY Medicaid HMO DRG,13665,,100% x Medicaid HMO amount,13665,Other,100% of NY Medicaid HMO DRG,13665,,100% x Medicaid HMO amount,13665,Other,100% of NY Medicaid HMO DRG,30746,,225% x Medicaid HMO amount,30746,Other,225% of NY Medicaid HMO DRG,30746,,225% x Medicaid HMO amount,30746,Other,225% of NY Medicaid HMO DRG,30746,,225% x Medicaid HMO amount,30746,Other,225% of NY Medicaid HMO DRG,30746,,225% x Medicaid HMO amount,30746,Other,225% of NY Medicaid HMO DRG,19131,,140% x Medicaid HMO amount,19131,Other,140% of NY Medicaid HMO DRG,30746,,225% x Medicaid HMO amount,30746,Other,225% of NY Medicaid HMO DRG,37579,,275% x Medicaid HMO amount,37579,Other,275% of NY Medicaid HMO DRG,44275,,324% x Medicaid HMO amount,44275,Other,324% of NY Medicaid HMO DRG,29380,,215% x Medicaid HMO amount,29380,Other,215% of NY Medicaid HMO DRG,29380,,215% x Medicaid HMO amount,29380,Other,215% of NY Medicaid HMO DRG,17081,,125% x Medicaid HMO amount,17081,Other,125% of NY Medicaid HMO DRG,0.01,74547,
Interstitial & alveolar lung diseases,142-1,APR-DRG,,,,,,,,inpatient,,,320544.88,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30105,,"45,128 x DRG weight",30105,Other,base rate x DRG weight,27094,,"40,615 x DRG weight",27094,Other,base rate x DRG weight,25589,,"38,359 x DRG weight",25589,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11175,,186% x Medicaid HMO amount,11175,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22733,,"34,077 x DRG weight",22733,Other,base rate x DRG weight,19323,,"28,966 x DRG weight",19323,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6008,,DRG base rate x DRG weight + capital per discharge,6008,Other,100% of NY Medicaid HMO DRG,6008,,100% x Medicaid HMO amount,6008,Other,100% of NY Medicaid HMO DRG,6008,,100% x Medicaid HMO amount,6008,Other,100% of NY Medicaid HMO DRG,6008,,100% x Medicaid HMO amount,6008,Other,100% of NY Medicaid HMO DRG,13518,,225% x Medicaid HMO amount,13518,Other,225% of NY Medicaid HMO DRG,13518,,225% x Medicaid HMO amount,13518,Other,225% of NY Medicaid HMO DRG,13518,,225% x Medicaid HMO amount,13518,Other,225% of NY Medicaid HMO DRG,13518,,225% x Medicaid HMO amount,13518,Other,225% of NY Medicaid HMO DRG,8411,,140% x Medicaid HMO amount,8411,Other,140% of NY Medicaid HMO DRG,13518,,225% x Medicaid HMO amount,13518,Other,225% of NY Medicaid HMO DRG,16522,,275% x Medicaid HMO amount,16522,Other,275% of NY Medicaid HMO DRG,19466,,324% x Medicaid HMO amount,19466,Other,324% of NY Medicaid HMO DRG,12917,,215% x Medicaid HMO amount,12917,Other,215% of NY Medicaid HMO DRG,12917,,215% x Medicaid HMO amount,12917,Other,215% of NY Medicaid HMO DRG,7510,,125% x Medicaid HMO amount,7510,Other,125% of NY Medicaid HMO DRG,0.01,30105,
Interstitial & alveolar lung diseases,142-2,APR-DRG,,,,,,,,inpatient,,,167842.71,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38769,,"45,128 x DRG weight",38769,Other,base rate x DRG weight,34892,,"40,615 x DRG weight",34892,Other,base rate x DRG weight,32954,,"38,359 x DRG weight",32954,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13952,,186% x Medicaid HMO amount,13952,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29276,,"34,077 x DRG weight",29276,Other,base rate x DRG weight,24885,,"28,966 x DRG weight",24885,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7501,,DRG base rate x DRG weight + capital per discharge,7501,Other,100% of NY Medicaid HMO DRG,7501,,100% x Medicaid HMO amount,7501,Other,100% of NY Medicaid HMO DRG,7501,,100% x Medicaid HMO amount,7501,Other,100% of NY Medicaid HMO DRG,7501,,100% x Medicaid HMO amount,7501,Other,100% of NY Medicaid HMO DRG,16877,,225% x Medicaid HMO amount,16877,Other,225% of NY Medicaid HMO DRG,16877,,225% x Medicaid HMO amount,16877,Other,225% of NY Medicaid HMO DRG,16877,,225% x Medicaid HMO amount,16877,Other,225% of NY Medicaid HMO DRG,16877,,225% x Medicaid HMO amount,16877,Other,225% of NY Medicaid HMO DRG,10501,,140% x Medicaid HMO amount,10501,Other,140% of NY Medicaid HMO DRG,16877,,225% x Medicaid HMO amount,16877,Other,225% of NY Medicaid HMO DRG,20628,,275% x Medicaid HMO amount,20628,Other,275% of NY Medicaid HMO DRG,24303,,324% x Medicaid HMO amount,24303,Other,324% of NY Medicaid HMO DRG,16127,,215% x Medicaid HMO amount,16127,Other,215% of NY Medicaid HMO DRG,16127,,215% x Medicaid HMO amount,16127,Other,215% of NY Medicaid HMO DRG,9376,,125% x Medicaid HMO amount,9376,Other,125% of NY Medicaid HMO DRG,0.01,38769,
Interstitial & alveolar lung diseases,142-3,APR-DRG,,,,,,,,inpatient,,,212654.14,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60056,,"45,128 x DRG weight",60056,Other,base rate x DRG weight,54050,,"40,615 x DRG weight",54050,Other,base rate x DRG weight,51048,,"38,359 x DRG weight",51048,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20774,,186% x Medicaid HMO amount,20774,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45350,,"34,077 x DRG weight",45350,Other,base rate x DRG weight,38548,,"28,966 x DRG weight",38548,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11169,,DRG base rate x DRG weight + capital per discharge,11169,Other,100% of NY Medicaid HMO DRG,11169,,100% x Medicaid HMO amount,11169,Other,100% of NY Medicaid HMO DRG,11169,,100% x Medicaid HMO amount,11169,Other,100% of NY Medicaid HMO DRG,11169,,100% x Medicaid HMO amount,11169,Other,100% of NY Medicaid HMO DRG,25130,,225% x Medicaid HMO amount,25130,Other,225% of NY Medicaid HMO DRG,25130,,225% x Medicaid HMO amount,25130,Other,225% of NY Medicaid HMO DRG,25130,,225% x Medicaid HMO amount,25130,Other,225% of NY Medicaid HMO DRG,25130,,225% x Medicaid HMO amount,25130,Other,225% of NY Medicaid HMO DRG,15637,,140% x Medicaid HMO amount,15637,Other,140% of NY Medicaid HMO DRG,25130,,225% x Medicaid HMO amount,25130,Other,225% of NY Medicaid HMO DRG,30715,,275% x Medicaid HMO amount,30715,Other,275% of NY Medicaid HMO DRG,36188,,324% x Medicaid HMO amount,36188,Other,324% of NY Medicaid HMO DRG,24013,,215% x Medicaid HMO amount,24013,Other,215% of NY Medicaid HMO DRG,24013,,215% x Medicaid HMO amount,24013,Other,215% of NY Medicaid HMO DRG,13961,,125% x Medicaid HMO amount,13961,Other,125% of NY Medicaid HMO DRG,0.01,60056,
Interstitial & alveolar lung diseases,142-4,APR-DRG,,,,,,,,inpatient,,,415838,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,125528,,"45,128 x DRG weight",125528,Other,base rate x DRG weight,112975,,"40,615 x DRG weight",112975,Other,base rate x DRG weight,106699,,"38,359 x DRG weight",106699,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41757,,186% x Medicaid HMO amount,41757,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,94789,,"34,077 x DRG weight",94789,Other,base rate x DRG weight,80572,,"28,966 x DRG weight",80572,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22450,,DRG base rate x DRG weight + capital per discharge,22450,Other,100% of NY Medicaid HMO DRG,22450,,100% x Medicaid HMO amount,22450,Other,100% of NY Medicaid HMO DRG,22450,,100% x Medicaid HMO amount,22450,Other,100% of NY Medicaid HMO DRG,22450,,100% x Medicaid HMO amount,22450,Other,100% of NY Medicaid HMO DRG,50513,,225% x Medicaid HMO amount,50513,Other,225% of NY Medicaid HMO DRG,50513,,225% x Medicaid HMO amount,50513,Other,225% of NY Medicaid HMO DRG,50513,,225% x Medicaid HMO amount,50513,Other,225% of NY Medicaid HMO DRG,50513,,225% x Medicaid HMO amount,50513,Other,225% of NY Medicaid HMO DRG,31430,,140% x Medicaid HMO amount,31430,Other,140% of NY Medicaid HMO DRG,50513,,225% x Medicaid HMO amount,50513,Other,225% of NY Medicaid HMO DRG,61738,,275% x Medicaid HMO amount,61738,Other,275% of NY Medicaid HMO DRG,72738,,324% x Medicaid HMO amount,72738,Other,324% of NY Medicaid HMO DRG,48268,,215% x Medicaid HMO amount,48268,Other,215% of NY Medicaid HMO DRG,48268,,215% x Medicaid HMO amount,48268,Other,215% of NY Medicaid HMO DRG,28063,,125% x Medicaid HMO amount,28063,Other,125% of NY Medicaid HMO DRG,0.01,125528,
"Other respiratory diagnoses except signs, symptoms & minor diagnoses",143-1,APR-DRG,,,,,,,,inpatient,,,64108.13,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23967,,"45,128 x DRG weight",23967,Other,base rate x DRG weight,21571,,"40,615 x DRG weight",21571,Other,base rate x DRG weight,20372,,"38,359 x DRG weight",20372,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9209,,186% x Medicaid HMO amount,9209,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18098,,"34,077 x DRG weight",18098,Other,base rate x DRG weight,15384,,"28,966 x DRG weight",15384,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4951,,DRG base rate x DRG weight + capital per discharge,4951,Other,100% of NY Medicaid HMO DRG,4951,,100% x Medicaid HMO amount,4951,Other,100% of NY Medicaid HMO DRG,4951,,100% x Medicaid HMO amount,4951,Other,100% of NY Medicaid HMO DRG,4951,,100% x Medicaid HMO amount,4951,Other,100% of NY Medicaid HMO DRG,11140,,225% x Medicaid HMO amount,11140,Other,225% of NY Medicaid HMO DRG,11140,,225% x Medicaid HMO amount,11140,Other,225% of NY Medicaid HMO DRG,11140,,225% x Medicaid HMO amount,11140,Other,225% of NY Medicaid HMO DRG,11140,,225% x Medicaid HMO amount,11140,Other,225% of NY Medicaid HMO DRG,6931,,140% x Medicaid HMO amount,6931,Other,140% of NY Medicaid HMO DRG,11140,,225% x Medicaid HMO amount,11140,Other,225% of NY Medicaid HMO DRG,13615,,275% x Medicaid HMO amount,13615,Other,275% of NY Medicaid HMO DRG,16041,,324% x Medicaid HMO amount,16041,Other,324% of NY Medicaid HMO DRG,10645,,215% x Medicaid HMO amount,10645,Other,215% of NY Medicaid HMO DRG,10645,,215% x Medicaid HMO amount,10645,Other,215% of NY Medicaid HMO DRG,6189,,125% x Medicaid HMO amount,6189,Other,125% of NY Medicaid HMO DRG,0.01,23967,
"Other respiratory diagnoses except signs, symptoms & minor diagnoses",143-2,APR-DRG,,,,,,,,inpatient,,,110654.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34252,,"45,128 x DRG weight",34252,Other,base rate x DRG weight,30827,,"40,615 x DRG weight",30827,Other,base rate x DRG weight,29114,,"38,359 x DRG weight",29114,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12505,,186% x Medicaid HMO amount,12505,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25864,,"34,077 x DRG weight",25864,Other,base rate x DRG weight,21985,,"28,966 x DRG weight",21985,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6723,,DRG base rate x DRG weight + capital per discharge,6723,Other,100% of NY Medicaid HMO DRG,6723,,100% x Medicaid HMO amount,6723,Other,100% of NY Medicaid HMO DRG,6723,,100% x Medicaid HMO amount,6723,Other,100% of NY Medicaid HMO DRG,6723,,100% x Medicaid HMO amount,6723,Other,100% of NY Medicaid HMO DRG,15127,,225% x Medicaid HMO amount,15127,Other,225% of NY Medicaid HMO DRG,15127,,225% x Medicaid HMO amount,15127,Other,225% of NY Medicaid HMO DRG,15127,,225% x Medicaid HMO amount,15127,Other,225% of NY Medicaid HMO DRG,15127,,225% x Medicaid HMO amount,15127,Other,225% of NY Medicaid HMO DRG,9412,,140% x Medicaid HMO amount,9412,Other,140% of NY Medicaid HMO DRG,15127,,225% x Medicaid HMO amount,15127,Other,225% of NY Medicaid HMO DRG,18488,,275% x Medicaid HMO amount,18488,Other,275% of NY Medicaid HMO DRG,21783,,324% x Medicaid HMO amount,21783,Other,324% of NY Medicaid HMO DRG,14454,,215% x Medicaid HMO amount,14454,Other,215% of NY Medicaid HMO DRG,14454,,215% x Medicaid HMO amount,14454,Other,215% of NY Medicaid HMO DRG,8404,,125% x Medicaid HMO amount,8404,Other,125% of NY Medicaid HMO DRG,0.01,34252,
"Other respiratory diagnoses except signs, symptoms & minor diagnoses",143-3,APR-DRG,,,,,,,,inpatient,,,155647.11,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,57890,,"45,128 x DRG weight",57890,Other,base rate x DRG weight,52101,,"40,615 x DRG weight",52101,Other,base rate x DRG weight,49207,,"38,359 x DRG weight",49207,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20079,,186% x Medicaid HMO amount,20079,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43714,,"34,077 x DRG weight",43714,Other,base rate x DRG weight,37158,,"28,966 x DRG weight",37158,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10795,,DRG base rate x DRG weight + capital per discharge,10795,Other,100% of NY Medicaid HMO DRG,10795,,100% x Medicaid HMO amount,10795,Other,100% of NY Medicaid HMO DRG,10795,,100% x Medicaid HMO amount,10795,Other,100% of NY Medicaid HMO DRG,10795,,100% x Medicaid HMO amount,10795,Other,100% of NY Medicaid HMO DRG,24289,,225% x Medicaid HMO amount,24289,Other,225% of NY Medicaid HMO DRG,24289,,225% x Medicaid HMO amount,24289,Other,225% of NY Medicaid HMO DRG,24289,,225% x Medicaid HMO amount,24289,Other,225% of NY Medicaid HMO DRG,24289,,225% x Medicaid HMO amount,24289,Other,225% of NY Medicaid HMO DRG,15113,,140% x Medicaid HMO amount,15113,Other,140% of NY Medicaid HMO DRG,24289,,225% x Medicaid HMO amount,24289,Other,225% of NY Medicaid HMO DRG,29686,,275% x Medicaid HMO amount,29686,Other,275% of NY Medicaid HMO DRG,34976,,324% x Medicaid HMO amount,34976,Other,324% of NY Medicaid HMO DRG,23209,,215% x Medicaid HMO amount,23209,Other,215% of NY Medicaid HMO DRG,23209,,215% x Medicaid HMO amount,23209,Other,215% of NY Medicaid HMO DRG,13494,,125% x Medicaid HMO amount,13494,Other,125% of NY Medicaid HMO DRG,0.01,57890,
"Other respiratory diagnoses except signs, symptoms & minor diagnoses",143-4,APR-DRG,,,,,,,,inpatient,,,136025.18,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,92860,,"45,128 x DRG weight",92860,Other,base rate x DRG weight,83573,,"40,615 x DRG weight",83573,Other,base rate x DRG weight,78931,,"38,359 x DRG weight",78931,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31287,,186% x Medicaid HMO amount,31287,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,70120,,"34,077 x DRG weight",70120,Other,base rate x DRG weight,59603,,"28,966 x DRG weight",59603,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16821,,DRG base rate x DRG weight + capital per discharge,16821,Other,100% of NY Medicaid HMO DRG,16821,,100% x Medicaid HMO amount,16821,Other,100% of NY Medicaid HMO DRG,16821,,100% x Medicaid HMO amount,16821,Other,100% of NY Medicaid HMO DRG,16821,,100% x Medicaid HMO amount,16821,Other,100% of NY Medicaid HMO DRG,37847,,225% x Medicaid HMO amount,37847,Other,225% of NY Medicaid HMO DRG,37847,,225% x Medicaid HMO amount,37847,Other,225% of NY Medicaid HMO DRG,37847,,225% x Medicaid HMO amount,37847,Other,225% of NY Medicaid HMO DRG,37847,,225% x Medicaid HMO amount,37847,Other,225% of NY Medicaid HMO DRG,23549,,140% x Medicaid HMO amount,23549,Other,140% of NY Medicaid HMO DRG,37847,,225% x Medicaid HMO amount,37847,Other,225% of NY Medicaid HMO DRG,46258,,275% x Medicaid HMO amount,46258,Other,275% of NY Medicaid HMO DRG,54500,,324% x Medicaid HMO amount,54500,Other,324% of NY Medicaid HMO DRG,36165,,215% x Medicaid HMO amount,36165,Other,215% of NY Medicaid HMO DRG,36165,,215% x Medicaid HMO amount,36165,Other,215% of NY Medicaid HMO DRG,21026,,125% x Medicaid HMO amount,21026,Other,125% of NY Medicaid HMO DRG,0.01,92860,
"Respiratory signs, symptoms & minor diagnoses",144-1,APR-DRG,,,,,,,,inpatient,,,73692.76,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20429,,"45,128 x DRG weight",20429,Other,base rate x DRG weight,18386,,"40,615 x DRG weight",18386,Other,base rate x DRG weight,17365,,"38,359 x DRG weight",17365,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8074,,186% x Medicaid HMO amount,8074,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15427,,"34,077 x DRG weight",15427,Other,base rate x DRG weight,13113,,"28,966 x DRG weight",13113,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4341,,DRG base rate x DRG weight + capital per discharge,4341,Other,100% of NY Medicaid HMO DRG,4341,,100% x Medicaid HMO amount,4341,Other,100% of NY Medicaid HMO DRG,4341,,100% x Medicaid HMO amount,4341,Other,100% of NY Medicaid HMO DRG,4341,,100% x Medicaid HMO amount,4341,Other,100% of NY Medicaid HMO DRG,9767,,225% x Medicaid HMO amount,9767,Other,225% of NY Medicaid HMO DRG,9767,,225% x Medicaid HMO amount,9767,Other,225% of NY Medicaid HMO DRG,9767,,225% x Medicaid HMO amount,9767,Other,225% of NY Medicaid HMO DRG,9767,,225% x Medicaid HMO amount,9767,Other,225% of NY Medicaid HMO DRG,6077,,140% x Medicaid HMO amount,6077,Other,140% of NY Medicaid HMO DRG,9767,,225% x Medicaid HMO amount,9767,Other,225% of NY Medicaid HMO DRG,11938,,275% x Medicaid HMO amount,11938,Other,275% of NY Medicaid HMO DRG,14065,,324% x Medicaid HMO amount,14065,Other,324% of NY Medicaid HMO DRG,9333,,215% x Medicaid HMO amount,9333,Other,215% of NY Medicaid HMO DRG,9333,,215% x Medicaid HMO amount,9333,Other,215% of NY Medicaid HMO DRG,5426,,125% x Medicaid HMO amount,5426,Other,125% of NY Medicaid HMO DRG,0.01,20429,
"Respiratory signs, symptoms & minor diagnoses",144-2,APR-DRG,,,,,,,,inpatient,,,94240.84,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25673,,"45,128 x DRG weight",25673,Other,base rate x DRG weight,23106,,"40,615 x DRG weight",23106,Other,base rate x DRG weight,21822,,"38,359 x DRG weight",21822,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9754,,186% x Medicaid HMO amount,9754,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19386,,"34,077 x DRG weight",19386,Other,base rate x DRG weight,16479,,"28,966 x DRG weight",16479,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5244,,DRG base rate x DRG weight + capital per discharge,5244,Other,100% of NY Medicaid HMO DRG,5244,,100% x Medicaid HMO amount,5244,Other,100% of NY Medicaid HMO DRG,5244,,100% x Medicaid HMO amount,5244,Other,100% of NY Medicaid HMO DRG,5244,,100% x Medicaid HMO amount,5244,Other,100% of NY Medicaid HMO DRG,11799,,225% x Medicaid HMO amount,11799,Other,225% of NY Medicaid HMO DRG,11799,,225% x Medicaid HMO amount,11799,Other,225% of NY Medicaid HMO DRG,11799,,225% x Medicaid HMO amount,11799,Other,225% of NY Medicaid HMO DRG,11799,,225% x Medicaid HMO amount,11799,Other,225% of NY Medicaid HMO DRG,7342,,140% x Medicaid HMO amount,7342,Other,140% of NY Medicaid HMO DRG,11799,,225% x Medicaid HMO amount,11799,Other,225% of NY Medicaid HMO DRG,14421,,275% x Medicaid HMO amount,14421,Other,275% of NY Medicaid HMO DRG,16991,,324% x Medicaid HMO amount,16991,Other,324% of NY Medicaid HMO DRG,11275,,215% x Medicaid HMO amount,11275,Other,215% of NY Medicaid HMO DRG,11275,,215% x Medicaid HMO amount,11275,Other,215% of NY Medicaid HMO DRG,6555,,125% x Medicaid HMO amount,6555,Other,125% of NY Medicaid HMO DRG,0.01,25673,
"Respiratory signs, symptoms & minor diagnoses",144-3,APR-DRG,,,,,,,,inpatient,,,120079.79,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39000,,"45,128 x DRG weight",39000,Other,base rate x DRG weight,35099,,"40,615 x DRG weight",35099,Other,base rate x DRG weight,33150,,"38,359 x DRG weight",33150,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14026,,186% x Medicaid HMO amount,14026,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29449,,"34,077 x DRG weight",29449,Other,base rate x DRG weight,25032,,"28,966 x DRG weight",25032,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7541,,DRG base rate x DRG weight + capital per discharge,7541,Other,100% of NY Medicaid HMO DRG,7541,,100% x Medicaid HMO amount,7541,Other,100% of NY Medicaid HMO DRG,7541,,100% x Medicaid HMO amount,7541,Other,100% of NY Medicaid HMO DRG,7541,,100% x Medicaid HMO amount,7541,Other,100% of NY Medicaid HMO DRG,16967,,225% x Medicaid HMO amount,16967,Other,225% of NY Medicaid HMO DRG,16967,,225% x Medicaid HMO amount,16967,Other,225% of NY Medicaid HMO DRG,16967,,225% x Medicaid HMO amount,16967,Other,225% of NY Medicaid HMO DRG,16967,,225% x Medicaid HMO amount,16967,Other,225% of NY Medicaid HMO DRG,10557,,140% x Medicaid HMO amount,10557,Other,140% of NY Medicaid HMO DRG,16967,,225% x Medicaid HMO amount,16967,Other,225% of NY Medicaid HMO DRG,20738,,275% x Medicaid HMO amount,20738,Other,275% of NY Medicaid HMO DRG,24433,,324% x Medicaid HMO amount,24433,Other,324% of NY Medicaid HMO DRG,16213,,215% x Medicaid HMO amount,16213,Other,215% of NY Medicaid HMO DRG,16213,,215% x Medicaid HMO amount,16213,Other,215% of NY Medicaid HMO DRG,9426,,125% x Medicaid HMO amount,9426,Other,125% of NY Medicaid HMO DRG,0.01,39000,
"Respiratory signs, symptoms & minor diagnoses",144-4,APR-DRG,,,,,,,,inpatient,,,169840.16,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,76668,,"45,128 x DRG weight",76668,Other,base rate x DRG weight,69001,,"40,615 x DRG weight",69001,Other,base rate x DRG weight,65168,,"38,359 x DRG weight",65168,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26098,,186% x Medicaid HMO amount,26098,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,57893,,"34,077 x DRG weight",57893,Other,base rate x DRG weight,49210,,"28,966 x DRG weight",49210,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14031,,DRG base rate x DRG weight + capital per discharge,14031,Other,100% of NY Medicaid HMO DRG,14031,,100% x Medicaid HMO amount,14031,Other,100% of NY Medicaid HMO DRG,14031,,100% x Medicaid HMO amount,14031,Other,100% of NY Medicaid HMO DRG,14031,,100% x Medicaid HMO amount,14031,Other,100% of NY Medicaid HMO DRG,31570,,225% x Medicaid HMO amount,31570,Other,225% of NY Medicaid HMO DRG,31570,,225% x Medicaid HMO amount,31570,Other,225% of NY Medicaid HMO DRG,31570,,225% x Medicaid HMO amount,31570,Other,225% of NY Medicaid HMO DRG,31570,,225% x Medicaid HMO amount,31570,Other,225% of NY Medicaid HMO DRG,19643,,140% x Medicaid HMO amount,19643,Other,140% of NY Medicaid HMO DRG,31570,,225% x Medicaid HMO amount,31570,Other,225% of NY Medicaid HMO DRG,38585,,275% x Medicaid HMO amount,38585,Other,275% of NY Medicaid HMO DRG,45460,,324% x Medicaid HMO amount,45460,Other,324% of NY Medicaid HMO DRG,30167,,215% x Medicaid HMO amount,30167,Other,215% of NY Medicaid HMO DRG,30167,,215% x Medicaid HMO amount,30167,Other,215% of NY Medicaid HMO DRG,17539,,125% x Medicaid HMO amount,17539,Other,125% of NY Medicaid HMO DRG,0.01,76668,
Major cardiothoracic repair of heart anomaly,160-1,APR-DRG,,,,,,,,inpatient,,,586096.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,141982,,"45,128 x DRG weight",141982,Other,base rate x DRG weight,127783,,"40,615 x DRG weight",127783,Other,base rate x DRG weight,120685,,"38,359 x DRG weight",120685,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47030,,186% x Medicaid HMO amount,47030,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,107213,,"34,077 x DRG weight",107213,Other,base rate x DRG weight,91133,,"28,966 x DRG weight",91133,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25285,,DRG base rate x DRG weight + capital per discharge,25285,Other,100% of NY Medicaid HMO DRG,25285,,100% x Medicaid HMO amount,25285,Other,100% of NY Medicaid HMO DRG,25285,,100% x Medicaid HMO amount,25285,Other,100% of NY Medicaid HMO DRG,25285,,100% x Medicaid HMO amount,25285,Other,100% of NY Medicaid HMO DRG,56891,,225% x Medicaid HMO amount,56891,Other,225% of NY Medicaid HMO DRG,56891,,225% x Medicaid HMO amount,56891,Other,225% of NY Medicaid HMO DRG,56891,,225% x Medicaid HMO amount,56891,Other,225% of NY Medicaid HMO DRG,56891,,225% x Medicaid HMO amount,56891,Other,225% of NY Medicaid HMO DRG,35399,,140% x Medicaid HMO amount,35399,Other,140% of NY Medicaid HMO DRG,56891,,225% x Medicaid HMO amount,56891,Other,225% of NY Medicaid HMO DRG,69534,,275% x Medicaid HMO amount,69534,Other,275% of NY Medicaid HMO DRG,81923,,324% x Medicaid HMO amount,81923,Other,324% of NY Medicaid HMO DRG,54363,,215% x Medicaid HMO amount,54363,Other,215% of NY Medicaid HMO DRG,54363,,215% x Medicaid HMO amount,54363,Other,215% of NY Medicaid HMO DRG,31606,,125% x Medicaid HMO amount,31606,Other,125% of NY Medicaid HMO DRG,0.01,141982,
Major cardiothoracic repair of heart anomaly,160-2,APR-DRG,,,,,,,,inpatient,,,586096.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,153336,,"45,128 x DRG weight",153336,Other,base rate x DRG weight,138002,,"40,615 x DRG weight",138002,Other,base rate x DRG weight,130336,,"38,359 x DRG weight",130336,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50668,,186% x Medicaid HMO amount,50668,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,115787,,"34,077 x DRG weight",115787,Other,base rate x DRG weight,98421,,"28,966 x DRG weight",98421,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27241,,DRG base rate x DRG weight + capital per discharge,27241,Other,100% of NY Medicaid HMO DRG,27241,,100% x Medicaid HMO amount,27241,Other,100% of NY Medicaid HMO DRG,27241,,100% x Medicaid HMO amount,27241,Other,100% of NY Medicaid HMO DRG,27241,,100% x Medicaid HMO amount,27241,Other,100% of NY Medicaid HMO DRG,61292,,225% x Medicaid HMO amount,61292,Other,225% of NY Medicaid HMO DRG,61292,,225% x Medicaid HMO amount,61292,Other,225% of NY Medicaid HMO DRG,61292,,225% x Medicaid HMO amount,61292,Other,225% of NY Medicaid HMO DRG,61292,,225% x Medicaid HMO amount,61292,Other,225% of NY Medicaid HMO DRG,38137,,140% x Medicaid HMO amount,38137,Other,140% of NY Medicaid HMO DRG,61292,,225% x Medicaid HMO amount,61292,Other,225% of NY Medicaid HMO DRG,74913,,275% x Medicaid HMO amount,74913,Other,275% of NY Medicaid HMO DRG,88261,,324% x Medicaid HMO amount,88261,Other,324% of NY Medicaid HMO DRG,58568,,215% x Medicaid HMO amount,58568,Other,215% of NY Medicaid HMO DRG,58568,,215% x Medicaid HMO amount,58568,Other,215% of NY Medicaid HMO DRG,34051,,125% x Medicaid HMO amount,34051,Other,125% of NY Medicaid HMO DRG,0.01,153336,
Major cardiothoracic repair of heart anomaly,160-3,APR-DRG,,,,,,,,inpatient,,,843071.64,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,215716,,"45,128 x DRG weight",215716,Other,base rate x DRG weight,194144,,"40,615 x DRG weight",194144,Other,base rate x DRG weight,183360,,"38,359 x DRG weight",183360,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,70660,,186% x Medicaid HMO amount,70660,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,162891,,"34,077 x DRG weight",162891,Other,base rate x DRG weight,138460,,"28,966 x DRG weight",138460,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37989,,DRG base rate x DRG weight + capital per discharge,37989,Other,100% of NY Medicaid HMO DRG,37989,,100% x Medicaid HMO amount,37989,Other,100% of NY Medicaid HMO DRG,37989,,100% x Medicaid HMO amount,37989,Other,100% of NY Medicaid HMO DRG,37989,,100% x Medicaid HMO amount,37989,Other,100% of NY Medicaid HMO DRG,85475,,225% x Medicaid HMO amount,85475,Other,225% of NY Medicaid HMO DRG,85475,,225% x Medicaid HMO amount,85475,Other,225% of NY Medicaid HMO DRG,85475,,225% x Medicaid HMO amount,85475,Other,225% of NY Medicaid HMO DRG,85475,,225% x Medicaid HMO amount,85475,Other,225% of NY Medicaid HMO DRG,53185,,140% x Medicaid HMO amount,53185,Other,140% of NY Medicaid HMO DRG,85475,,225% x Medicaid HMO amount,85475,Other,225% of NY Medicaid HMO DRG,104470,,275% x Medicaid HMO amount,104470,Other,275% of NY Medicaid HMO DRG,123084,,324% x Medicaid HMO amount,123084,Other,324% of NY Medicaid HMO DRG,81676,,215% x Medicaid HMO amount,81676,Other,215% of NY Medicaid HMO DRG,81676,,215% x Medicaid HMO amount,81676,Other,215% of NY Medicaid HMO DRG,47486,,125% x Medicaid HMO amount,47486,Other,125% of NY Medicaid HMO DRG,0.01,215716,
Major cardiothoracic repair of heart anomaly,160-4,APR-DRG,,,,,,,,inpatient,,,586096.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,448748,,"45,128 x DRG weight",448748,Other,base rate x DRG weight,403871,,"40,615 x DRG weight",403871,Other,base rate x DRG weight,381438,,"38,359 x DRG weight",381438,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,145342,,186% x Medicaid HMO amount,145342,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,338858,,"34,077 x DRG weight",338858,Other,base rate x DRG weight,288035,,"28,966 x DRG weight",288035,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,78141,,DRG base rate x DRG weight + capital per discharge,78141,Other,100% of NY Medicaid HMO DRG,78141,,100% x Medicaid HMO amount,78141,Other,100% of NY Medicaid HMO DRG,78141,,100% x Medicaid HMO amount,78141,Other,100% of NY Medicaid HMO DRG,78141,,100% x Medicaid HMO amount,78141,Other,100% of NY Medicaid HMO DRG,175817,,225% x Medicaid HMO amount,175817,Other,225% of NY Medicaid HMO DRG,175817,,225% x Medicaid HMO amount,175817,Other,225% of NY Medicaid HMO DRG,175817,,225% x Medicaid HMO amount,175817,Other,225% of NY Medicaid HMO DRG,175817,,225% x Medicaid HMO amount,175817,Other,225% of NY Medicaid HMO DRG,109397,,140% x Medicaid HMO amount,109397,Other,140% of NY Medicaid HMO DRG,175817,,225% x Medicaid HMO amount,175817,Other,225% of NY Medicaid HMO DRG,214888,,275% x Medicaid HMO amount,214888,Other,275% of NY Medicaid HMO DRG,253177,,324% x Medicaid HMO amount,253177,Other,324% of NY Medicaid HMO DRG,168003,,215% x Medicaid HMO amount,168003,Other,215% of NY Medicaid HMO DRG,168003,,215% x Medicaid HMO amount,168003,Other,215% of NY Medicaid HMO DRG,97676,,125% x Medicaid HMO amount,97676,Other,125% of NY Medicaid HMO DRG,0.01,448748,
Cardiac defibrillator & heart assist implant,161-1,APR-DRG,,,,,,,,inpatient,,,284329.4,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,181157,,"45,128 x DRG weight",181157,Other,base rate x DRG weight,163041,,"40,615 x DRG weight",163041,Other,base rate x DRG weight,153985,,"38,359 x DRG weight",153985,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59585,,186% x Medicaid HMO amount,59585,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,136795,,"34,077 x DRG weight",136795,Other,base rate x DRG weight,116278,,"28,966 x DRG weight",116278,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32035,,DRG base rate x DRG weight + capital per discharge,32035,Other,100% of NY Medicaid HMO DRG,32035,,100% x Medicaid HMO amount,32035,Other,100% of NY Medicaid HMO DRG,32035,,100% x Medicaid HMO amount,32035,Other,100% of NY Medicaid HMO DRG,32035,,100% x Medicaid HMO amount,32035,Other,100% of NY Medicaid HMO DRG,72079,,225% x Medicaid HMO amount,72079,Other,225% of NY Medicaid HMO DRG,72079,,225% x Medicaid HMO amount,72079,Other,225% of NY Medicaid HMO DRG,72079,,225% x Medicaid HMO amount,72079,Other,225% of NY Medicaid HMO DRG,72079,,225% x Medicaid HMO amount,72079,Other,225% of NY Medicaid HMO DRG,44849,,140% x Medicaid HMO amount,44849,Other,140% of NY Medicaid HMO DRG,72079,,225% x Medicaid HMO amount,72079,Other,225% of NY Medicaid HMO DRG,88096,,275% x Medicaid HMO amount,88096,Other,275% of NY Medicaid HMO DRG,103793,,324% x Medicaid HMO amount,103793,Other,324% of NY Medicaid HMO DRG,68875,,215% x Medicaid HMO amount,68875,Other,215% of NY Medicaid HMO DRG,68875,,215% x Medicaid HMO amount,68875,Other,215% of NY Medicaid HMO DRG,40044,,125% x Medicaid HMO amount,40044,Other,125% of NY Medicaid HMO DRG,0.01,181157,
Cardiac defibrillator & heart assist implant,161-2,APR-DRG,,,,,,,,inpatient,,,538737.24,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,276526,,"45,128 x DRG weight",276526,Other,base rate x DRG weight,248872,,"40,615 x DRG weight",248872,Other,base rate x DRG weight,235049,,"38,359 x DRG weight",235049,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,90149,,186% x Medicaid HMO amount,90149,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,208810,,"34,077 x DRG weight",208810,Other,base rate x DRG weight,177492,,"28,966 x DRG weight",177492,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48467,,DRG base rate x DRG weight + capital per discharge,48467,Other,100% of NY Medicaid HMO DRG,48467,,100% x Medicaid HMO amount,48467,Other,100% of NY Medicaid HMO DRG,48467,,100% x Medicaid HMO amount,48467,Other,100% of NY Medicaid HMO DRG,48467,,100% x Medicaid HMO amount,48467,Other,100% of NY Medicaid HMO DRG,109051,,225% x Medicaid HMO amount,109051,Other,225% of NY Medicaid HMO DRG,109051,,225% x Medicaid HMO amount,109051,Other,225% of NY Medicaid HMO DRG,109051,,225% x Medicaid HMO amount,109051,Other,225% of NY Medicaid HMO DRG,109051,,225% x Medicaid HMO amount,109051,Other,225% of NY Medicaid HMO DRG,67854,,140% x Medicaid HMO amount,67854,Other,140% of NY Medicaid HMO DRG,109051,,225% x Medicaid HMO amount,109051,Other,225% of NY Medicaid HMO DRG,133284,,275% x Medicaid HMO amount,133284,Other,275% of NY Medicaid HMO DRG,157033,,324% x Medicaid HMO amount,157033,Other,324% of NY Medicaid HMO DRG,104204,,215% x Medicaid HMO amount,104204,Other,215% of NY Medicaid HMO DRG,104204,,215% x Medicaid HMO amount,104204,Other,215% of NY Medicaid HMO DRG,60584,,125% x Medicaid HMO amount,60584,Other,125% of NY Medicaid HMO DRG,0.01,276526,
Cardiac defibrillator & heart assist implant,161-3,APR-DRG,,,,,,,,inpatient,,,494301.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,444041,,"45,128 x DRG weight",444041,Other,base rate x DRG weight,399635,,"40,615 x DRG weight",399635,Other,base rate x DRG weight,377437,,"38,359 x DRG weight",377437,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,143834,,186% x Medicaid HMO amount,143834,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,335304,,"34,077 x DRG weight",335304,Other,base rate x DRG weight,285014,,"28,966 x DRG weight",285014,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,77330,,DRG base rate x DRG weight + capital per discharge,77330,Other,100% of NY Medicaid HMO DRG,77330,,100% x Medicaid HMO amount,77330,Other,100% of NY Medicaid HMO DRG,77330,,100% x Medicaid HMO amount,77330,Other,100% of NY Medicaid HMO DRG,77330,,100% x Medicaid HMO amount,77330,Other,100% of NY Medicaid HMO DRG,173993,,225% x Medicaid HMO amount,173993,Other,225% of NY Medicaid HMO DRG,173993,,225% x Medicaid HMO amount,173993,Other,225% of NY Medicaid HMO DRG,173993,,225% x Medicaid HMO amount,173993,Other,225% of NY Medicaid HMO DRG,173993,,225% x Medicaid HMO amount,173993,Other,225% of NY Medicaid HMO DRG,108262,,140% x Medicaid HMO amount,108262,Other,140% of NY Medicaid HMO DRG,173993,,225% x Medicaid HMO amount,173993,Other,225% of NY Medicaid HMO DRG,212658,,275% x Medicaid HMO amount,212658,Other,275% of NY Medicaid HMO DRG,250549,,324% x Medicaid HMO amount,250549,Other,324% of NY Medicaid HMO DRG,166260,,215% x Medicaid HMO amount,166260,Other,215% of NY Medicaid HMO DRG,166260,,215% x Medicaid HMO amount,166260,Other,215% of NY Medicaid HMO DRG,96663,,125% x Medicaid HMO amount,96663,Other,125% of NY Medicaid HMO DRG,0.01,444041,
Cardiac defibrillator & heart assist implant,161-4,APR-DRG,,,,,,,,inpatient,,,1641477.14,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,1041590,,"45,128 x DRG weight",1041590,Other,base rate x DRG weight,937427,,"40,615 x DRG weight",937427,Other,base rate x DRG weight,885356,,"38,359 x DRG weight",885356,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,335336,,186% x Medicaid HMO amount,335336,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,786524,,"34,077 x DRG weight",786524,Other,base rate x DRG weight,668558,,"28,966 x DRG weight",668558,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,180288,,DRG base rate x DRG weight + capital per discharge,180288,Other,100% of NY Medicaid HMO DRG,180288,,100% x Medicaid HMO amount,180288,Other,100% of NY Medicaid HMO DRG,180288,,100% x Medicaid HMO amount,180288,Other,100% of NY Medicaid HMO DRG,180288,,100% x Medicaid HMO amount,180288,Other,100% of NY Medicaid HMO DRG,405648,,225% x Medicaid HMO amount,405648,Other,225% of NY Medicaid HMO DRG,405648,,225% x Medicaid HMO amount,405648,Other,225% of NY Medicaid HMO DRG,405648,,225% x Medicaid HMO amount,405648,Other,225% of NY Medicaid HMO DRG,405648,,225% x Medicaid HMO amount,405648,Other,225% of NY Medicaid HMO DRG,252403,,140% x Medicaid HMO amount,252403,Other,140% of NY Medicaid HMO DRG,405648,,225% x Medicaid HMO amount,405648,Other,225% of NY Medicaid HMO DRG,495792,,275% x Medicaid HMO amount,495792,Other,275% of NY Medicaid HMO DRG,584133,,324% x Medicaid HMO amount,584133,Other,324% of NY Medicaid HMO DRG,387619,,215% x Medicaid HMO amount,387619,Other,215% of NY Medicaid HMO DRG,387619,,215% x Medicaid HMO amount,387619,Other,215% of NY Medicaid HMO DRG,225360,,125% x Medicaid HMO amount,225360,Other,125% of NY Medicaid HMO DRG,0.01,1041590,
Cardiac valve procedures w AMI or complex PDX,162-1,APR-DRG,,,,,,,,inpatient,,,497337.94,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,156238,,"45,128 x DRG weight",156238,Other,base rate x DRG weight,140613,,"40,615 x DRG weight",140613,Other,base rate x DRG weight,132803,,"38,359 x DRG weight",132803,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51598,,186% x Medicaid HMO amount,51598,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,117978,,"34,077 x DRG weight",117978,Other,base rate x DRG weight,100283,,"28,966 x DRG weight",100283,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27741,,DRG base rate x DRG weight + capital per discharge,27741,Other,100% of NY Medicaid HMO DRG,27741,,100% x Medicaid HMO amount,27741,Other,100% of NY Medicaid HMO DRG,27741,,100% x Medicaid HMO amount,27741,Other,100% of NY Medicaid HMO DRG,27741,,100% x Medicaid HMO amount,27741,Other,100% of NY Medicaid HMO DRG,62417,,225% x Medicaid HMO amount,62417,Other,225% of NY Medicaid HMO DRG,62417,,225% x Medicaid HMO amount,62417,Other,225% of NY Medicaid HMO DRG,62417,,225% x Medicaid HMO amount,62417,Other,225% of NY Medicaid HMO DRG,62417,,225% x Medicaid HMO amount,62417,Other,225% of NY Medicaid HMO DRG,38837,,140% x Medicaid HMO amount,38837,Other,140% of NY Medicaid HMO DRG,62417,,225% x Medicaid HMO amount,62417,Other,225% of NY Medicaid HMO DRG,76288,,275% x Medicaid HMO amount,76288,Other,275% of NY Medicaid HMO DRG,89881,,324% x Medicaid HMO amount,89881,Other,324% of NY Medicaid HMO DRG,59643,,215% x Medicaid HMO amount,59643,Other,215% of NY Medicaid HMO DRG,59643,,215% x Medicaid HMO amount,59643,Other,215% of NY Medicaid HMO DRG,34676,,125% x Medicaid HMO amount,34676,Other,125% of NY Medicaid HMO DRG,0.01,156238,
Cardiac valve procedures w AMI or complex PDX,162-2,APR-DRG,,,,,,,,inpatient,,,446594.87,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,202268,,"45,128 x DRG weight",202268,Other,base rate x DRG weight,182040,,"40,615 x DRG weight",182040,Other,base rate x DRG weight,171929,,"38,359 x DRG weight",171929,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,66350,,186% x Medicaid HMO amount,66350,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,152737,,"34,077 x DRG weight",152737,Other,base rate x DRG weight,129829,,"28,966 x DRG weight",129829,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35672,,DRG base rate x DRG weight + capital per discharge,35672,Other,100% of NY Medicaid HMO DRG,35672,,100% x Medicaid HMO amount,35672,Other,100% of NY Medicaid HMO DRG,35672,,100% x Medicaid HMO amount,35672,Other,100% of NY Medicaid HMO DRG,35672,,100% x Medicaid HMO amount,35672,Other,100% of NY Medicaid HMO DRG,80262,,225% x Medicaid HMO amount,80262,Other,225% of NY Medicaid HMO DRG,80262,,225% x Medicaid HMO amount,80262,Other,225% of NY Medicaid HMO DRG,80262,,225% x Medicaid HMO amount,80262,Other,225% of NY Medicaid HMO DRG,80262,,225% x Medicaid HMO amount,80262,Other,225% of NY Medicaid HMO DRG,49941,,140% x Medicaid HMO amount,49941,Other,140% of NY Medicaid HMO DRG,80262,,225% x Medicaid HMO amount,80262,Other,225% of NY Medicaid HMO DRG,98098,,275% x Medicaid HMO amount,98098,Other,275% of NY Medicaid HMO DRG,115577,,324% x Medicaid HMO amount,115577,Other,324% of NY Medicaid HMO DRG,76695,,215% x Medicaid HMO amount,76695,Other,215% of NY Medicaid HMO DRG,76695,,215% x Medicaid HMO amount,76695,Other,215% of NY Medicaid HMO DRG,44590,,125% x Medicaid HMO amount,44590,Other,125% of NY Medicaid HMO DRG,0.01,202268,
Cardiac valve procedures w AMI or complex PDX,162-3,APR-DRG,,,,,,,,inpatient,,,666539.54,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,258886,,"45,128 x DRG weight",258886,Other,base rate x DRG weight,232996,,"40,615 x DRG weight",232996,Other,base rate x DRG weight,220054,,"38,359 x DRG weight",220054,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,84494,,186% x Medicaid HMO amount,84494,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,195490,,"34,077 x DRG weight",195490,Other,base rate x DRG weight,166169,,"28,966 x DRG weight",166169,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45427,,DRG base rate x DRG weight + capital per discharge,45427,Other,100% of NY Medicaid HMO DRG,45427,,100% x Medicaid HMO amount,45427,Other,100% of NY Medicaid HMO DRG,45427,,100% x Medicaid HMO amount,45427,Other,100% of NY Medicaid HMO DRG,45427,,100% x Medicaid HMO amount,45427,Other,100% of NY Medicaid HMO DRG,102211,,225% x Medicaid HMO amount,102211,Other,225% of NY Medicaid HMO DRG,102211,,225% x Medicaid HMO amount,102211,Other,225% of NY Medicaid HMO DRG,102211,,225% x Medicaid HMO amount,102211,Other,225% of NY Medicaid HMO DRG,102211,,225% x Medicaid HMO amount,102211,Other,225% of NY Medicaid HMO DRG,63598,,140% x Medicaid HMO amount,63598,Other,140% of NY Medicaid HMO DRG,102211,,225% x Medicaid HMO amount,102211,Other,225% of NY Medicaid HMO DRG,124924,,275% x Medicaid HMO amount,124924,Other,275% of NY Medicaid HMO DRG,147183,,324% x Medicaid HMO amount,147183,Other,324% of NY Medicaid HMO DRG,97668,,215% x Medicaid HMO amount,97668,Other,215% of NY Medicaid HMO DRG,97668,,215% x Medicaid HMO amount,97668,Other,215% of NY Medicaid HMO DRG,56784,,125% x Medicaid HMO amount,56784,Other,125% of NY Medicaid HMO DRG,0.01,258886,
Cardiac valve procedures w AMI or complex PDX,162-4,APR-DRG,,,,,,,,inpatient,,,1293079.92,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,423513,,"45,128 x DRG weight",423513,Other,base rate x DRG weight,381160,,"40,615 x DRG weight",381160,Other,base rate x DRG weight,359988,,"38,359 x DRG weight",359988,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,137255,,186% x Medicaid HMO amount,137255,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,319802,,"34,077 x DRG weight",319802,Other,base rate x DRG weight,271837,,"28,966 x DRG weight",271837,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73793,,DRG base rate x DRG weight + capital per discharge,73793,Other,100% of NY Medicaid HMO DRG,73793,,100% x Medicaid HMO amount,73793,Other,100% of NY Medicaid HMO DRG,73793,,100% x Medicaid HMO amount,73793,Other,100% of NY Medicaid HMO DRG,73793,,100% x Medicaid HMO amount,73793,Other,100% of NY Medicaid HMO DRG,166034,,225% x Medicaid HMO amount,166034,Other,225% of NY Medicaid HMO DRG,166034,,225% x Medicaid HMO amount,166034,Other,225% of NY Medicaid HMO DRG,166034,,225% x Medicaid HMO amount,166034,Other,225% of NY Medicaid HMO DRG,166034,,225% x Medicaid HMO amount,166034,Other,225% of NY Medicaid HMO DRG,103310,,140% x Medicaid HMO amount,103310,Other,140% of NY Medicaid HMO DRG,166034,,225% x Medicaid HMO amount,166034,Other,225% of NY Medicaid HMO DRG,202931,,275% x Medicaid HMO amount,202931,Other,275% of NY Medicaid HMO DRG,239089,,324% x Medicaid HMO amount,239089,Other,324% of NY Medicaid HMO DRG,158655,,215% x Medicaid HMO amount,158655,Other,215% of NY Medicaid HMO DRG,158655,,215% x Medicaid HMO amount,158655,Other,215% of NY Medicaid HMO DRG,92241,,125% x Medicaid HMO amount,92241,Other,125% of NY Medicaid HMO DRG,0.01,423513,
Cardiac valve procedures w/o AMI or complex PDX,163-1,APR-DRG,,,,,,,,inpatient,,,368680.69,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,136499,,"45,128 x DRG weight",136499,Other,base rate x DRG weight,122848,,"40,615 x DRG weight",122848,Other,base rate x DRG weight,116024,,"38,359 x DRG weight",116024,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45272,,186% x Medicaid HMO amount,45272,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,103073,,"34,077 x DRG weight",103073,Other,base rate x DRG weight,87613,,"28,966 x DRG weight",87613,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24340,,DRG base rate x DRG weight + capital per discharge,24340,Other,100% of NY Medicaid HMO DRG,24340,,100% x Medicaid HMO amount,24340,Other,100% of NY Medicaid HMO DRG,24340,,100% x Medicaid HMO amount,24340,Other,100% of NY Medicaid HMO DRG,24340,,100% x Medicaid HMO amount,24340,Other,100% of NY Medicaid HMO DRG,54765,,225% x Medicaid HMO amount,54765,Other,225% of NY Medicaid HMO DRG,54765,,225% x Medicaid HMO amount,54765,Other,225% of NY Medicaid HMO DRG,54765,,225% x Medicaid HMO amount,54765,Other,225% of NY Medicaid HMO DRG,54765,,225% x Medicaid HMO amount,54765,Other,225% of NY Medicaid HMO DRG,34076,,140% x Medicaid HMO amount,34076,Other,140% of NY Medicaid HMO DRG,54765,,225% x Medicaid HMO amount,54765,Other,225% of NY Medicaid HMO DRG,66935,,275% x Medicaid HMO amount,66935,Other,275% of NY Medicaid HMO DRG,78862,,324% x Medicaid HMO amount,78862,Other,324% of NY Medicaid HMO DRG,52331,,215% x Medicaid HMO amount,52331,Other,215% of NY Medicaid HMO DRG,52331,,215% x Medicaid HMO amount,52331,Other,215% of NY Medicaid HMO DRG,30425,,125% x Medicaid HMO amount,30425,Other,125% of NY Medicaid HMO DRG,0.01,136499,
Cardiac valve procedures w/o AMI or complex PDX,163-2,APR-DRG,,,,,,,,inpatient,,,426385.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,166978,,"45,128 x DRG weight",166978,Other,base rate x DRG weight,150280,,"40,615 x DRG weight",150280,Other,base rate x DRG weight,141932,,"38,359 x DRG weight",141932,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55039,,186% x Medicaid HMO amount,55039,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,126088,,"34,077 x DRG weight",126088,Other,base rate x DRG weight,107177,,"28,966 x DRG weight",107177,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29591,,DRG base rate x DRG weight + capital per discharge,29591,Other,100% of NY Medicaid HMO DRG,29591,,100% x Medicaid HMO amount,29591,Other,100% of NY Medicaid HMO DRG,29591,,100% x Medicaid HMO amount,29591,Other,100% of NY Medicaid HMO DRG,29591,,100% x Medicaid HMO amount,29591,Other,100% of NY Medicaid HMO DRG,66580,,225% x Medicaid HMO amount,66580,Other,225% of NY Medicaid HMO DRG,66580,,225% x Medicaid HMO amount,66580,Other,225% of NY Medicaid HMO DRG,66580,,225% x Medicaid HMO amount,66580,Other,225% of NY Medicaid HMO DRG,66580,,225% x Medicaid HMO amount,66580,Other,225% of NY Medicaid HMO DRG,41427,,140% x Medicaid HMO amount,41427,Other,140% of NY Medicaid HMO DRG,66580,,225% x Medicaid HMO amount,66580,Other,225% of NY Medicaid HMO DRG,81375,,275% x Medicaid HMO amount,81375,Other,275% of NY Medicaid HMO DRG,95875,,324% x Medicaid HMO amount,95875,Other,324% of NY Medicaid HMO DRG,63621,,215% x Medicaid HMO amount,63621,Other,215% of NY Medicaid HMO DRG,63621,,215% x Medicaid HMO amount,63621,Other,215% of NY Medicaid HMO DRG,36989,,125% x Medicaid HMO amount,36989,Other,125% of NY Medicaid HMO DRG,0.01,166978,
Cardiac valve procedures w/o AMI or complex PDX,163-3,APR-DRG,,,,,,,,inpatient,,,770325.98,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,205134,,"45,128 x DRG weight",205134,Other,base rate x DRG weight,184620,,"40,615 x DRG weight",184620,Other,base rate x DRG weight,174365,,"38,359 x DRG weight",174365,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,67269,,186% x Medicaid HMO amount,67269,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,154900,,"34,077 x DRG weight",154900,Other,base rate x DRG weight,131668,,"28,966 x DRG weight",131668,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36166,,DRG base rate x DRG weight + capital per discharge,36166,Other,100% of NY Medicaid HMO DRG,36166,,100% x Medicaid HMO amount,36166,Other,100% of NY Medicaid HMO DRG,36166,,100% x Medicaid HMO amount,36166,Other,100% of NY Medicaid HMO DRG,36166,,100% x Medicaid HMO amount,36166,Other,100% of NY Medicaid HMO DRG,81374,,225% x Medicaid HMO amount,81374,Other,225% of NY Medicaid HMO DRG,81374,,225% x Medicaid HMO amount,81374,Other,225% of NY Medicaid HMO DRG,81374,,225% x Medicaid HMO amount,81374,Other,225% of NY Medicaid HMO DRG,81374,,225% x Medicaid HMO amount,81374,Other,225% of NY Medicaid HMO DRG,50632,,140% x Medicaid HMO amount,50632,Other,140% of NY Medicaid HMO DRG,81374,,225% x Medicaid HMO amount,81374,Other,225% of NY Medicaid HMO DRG,99457,,275% x Medicaid HMO amount,99457,Other,275% of NY Medicaid HMO DRG,117178,,324% x Medicaid HMO amount,117178,Other,324% of NY Medicaid HMO DRG,77757,,215% x Medicaid HMO amount,77757,Other,215% of NY Medicaid HMO DRG,77757,,215% x Medicaid HMO amount,77757,Other,215% of NY Medicaid HMO DRG,45208,,125% x Medicaid HMO amount,45208,Other,125% of NY Medicaid HMO DRG,0.01,205134,
Cardiac valve procedures w/o AMI or complex PDX,163-4,APR-DRG,,,,,,,,inpatient,,,922959.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,318017,,"45,128 x DRG weight",318017,Other,base rate x DRG weight,286214,,"40,615 x DRG weight",286214,Other,base rate x DRG weight,270316,,"38,359 x DRG weight",270316,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,103446,,186% x Medicaid HMO amount,103446,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,240141,,"34,077 x DRG weight",240141,Other,base rate x DRG weight,204123,,"28,966 x DRG weight",204123,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55616,,DRG base rate x DRG weight + capital per discharge,55616,Other,100% of NY Medicaid HMO DRG,55616,,100% x Medicaid HMO amount,55616,Other,100% of NY Medicaid HMO DRG,55616,,100% x Medicaid HMO amount,55616,Other,100% of NY Medicaid HMO DRG,55616,,100% x Medicaid HMO amount,55616,Other,100% of NY Medicaid HMO DRG,125136,,225% x Medicaid HMO amount,125136,Other,225% of NY Medicaid HMO DRG,125136,,225% x Medicaid HMO amount,125136,Other,225% of NY Medicaid HMO DRG,125136,,225% x Medicaid HMO amount,125136,Other,225% of NY Medicaid HMO DRG,125136,,225% x Medicaid HMO amount,125136,Other,225% of NY Medicaid HMO DRG,77862,,140% x Medicaid HMO amount,77862,Other,140% of NY Medicaid HMO DRG,125136,,225% x Medicaid HMO amount,125136,Other,225% of NY Medicaid HMO DRG,152944,,275% x Medicaid HMO amount,152944,Other,275% of NY Medicaid HMO DRG,180196,,324% x Medicaid HMO amount,180196,Other,324% of NY Medicaid HMO DRG,119574,,215% x Medicaid HMO amount,119574,Other,215% of NY Medicaid HMO DRG,119574,,215% x Medicaid HMO amount,119574,Other,215% of NY Medicaid HMO DRG,69520,,125% x Medicaid HMO amount,69520,Other,125% of NY Medicaid HMO DRG,0.01,318017,
Coronary bypass w AMI or complex PDX,165-1,APR-DRG,,,,,,,,inpatient,,,498912.47,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,177511,,"45,128 x DRG weight",177511,Other,base rate x DRG weight,159759,,"40,615 x DRG weight",159759,Other,base rate x DRG weight,150885,,"38,359 x DRG weight",150885,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,58415,,186% x Medicaid HMO amount,58415,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,134042,,"34,077 x DRG weight",134042,Other,base rate x DRG weight,113938,,"28,966 x DRG weight",113938,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31406,,DRG base rate x DRG weight + capital per discharge,31406,Other,100% of NY Medicaid HMO DRG,31406,,100% x Medicaid HMO amount,31406,Other,100% of NY Medicaid HMO DRG,31406,,100% x Medicaid HMO amount,31406,Other,100% of NY Medicaid HMO DRG,31406,,100% x Medicaid HMO amount,31406,Other,100% of NY Medicaid HMO DRG,70664,,225% x Medicaid HMO amount,70664,Other,225% of NY Medicaid HMO DRG,70664,,225% x Medicaid HMO amount,70664,Other,225% of NY Medicaid HMO DRG,70664,,225% x Medicaid HMO amount,70664,Other,225% of NY Medicaid HMO DRG,70664,,225% x Medicaid HMO amount,70664,Other,225% of NY Medicaid HMO DRG,43968,,140% x Medicaid HMO amount,43968,Other,140% of NY Medicaid HMO DRG,70664,,225% x Medicaid HMO amount,70664,Other,225% of NY Medicaid HMO DRG,86367,,275% x Medicaid HMO amount,86367,Other,275% of NY Medicaid HMO DRG,101755,,324% x Medicaid HMO amount,101755,Other,324% of NY Medicaid HMO DRG,67523,,215% x Medicaid HMO amount,67523,Other,215% of NY Medicaid HMO DRG,67523,,215% x Medicaid HMO amount,67523,Other,215% of NY Medicaid HMO DRG,39258,,125% x Medicaid HMO amount,39258,Other,125% of NY Medicaid HMO DRG,0.01,177511,
Coronary bypass w AMI or complex PDX,165-2,APR-DRG,,,,,,,,inpatient,,,498912.47,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,178120,,"45,128 x DRG weight",178120,Other,base rate x DRG weight,160307,,"40,615 x DRG weight",160307,Other,base rate x DRG weight,151403,,"38,359 x DRG weight",151403,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,58610,,186% x Medicaid HMO amount,58610,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,134502,,"34,077 x DRG weight",134502,Other,base rate x DRG weight,114329,,"28,966 x DRG weight",114329,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31511,,DRG base rate x DRG weight + capital per discharge,31511,Other,100% of NY Medicaid HMO DRG,31511,,100% x Medicaid HMO amount,31511,Other,100% of NY Medicaid HMO DRG,31511,,100% x Medicaid HMO amount,31511,Other,100% of NY Medicaid HMO DRG,31511,,100% x Medicaid HMO amount,31511,Other,100% of NY Medicaid HMO DRG,70900,,225% x Medicaid HMO amount,70900,Other,225% of NY Medicaid HMO DRG,70900,,225% x Medicaid HMO amount,70900,Other,225% of NY Medicaid HMO DRG,70900,,225% x Medicaid HMO amount,70900,Other,225% of NY Medicaid HMO DRG,70900,,225% x Medicaid HMO amount,70900,Other,225% of NY Medicaid HMO DRG,44115,,140% x Medicaid HMO amount,44115,Other,140% of NY Medicaid HMO DRG,70900,,225% x Medicaid HMO amount,70900,Other,225% of NY Medicaid HMO DRG,86655,,275% x Medicaid HMO amount,86655,Other,275% of NY Medicaid HMO DRG,102096,,324% x Medicaid HMO amount,102096,Other,324% of NY Medicaid HMO DRG,67749,,215% x Medicaid HMO amount,67749,Other,215% of NY Medicaid HMO DRG,67749,,215% x Medicaid HMO amount,67749,Other,215% of NY Medicaid HMO DRG,39389,,125% x Medicaid HMO amount,39389,Other,125% of NY Medicaid HMO DRG,0.01,178120,
Coronary bypass w AMI or complex PDX,165-3,APR-DRG,,,,,,,,inpatient,,,722596.53,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,219385,,"45,128 x DRG weight",219385,Other,base rate x DRG weight,197446,,"40,615 x DRG weight",197446,Other,base rate x DRG weight,186478,,"38,359 x DRG weight",186478,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,71835,,186% x Medicaid HMO amount,71835,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,165662,,"34,077 x DRG weight",165662,Other,base rate x DRG weight,140815,,"28,966 x DRG weight",140815,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38621,,DRG base rate x DRG weight + capital per discharge,38621,Other,100% of NY Medicaid HMO DRG,38621,,100% x Medicaid HMO amount,38621,Other,100% of NY Medicaid HMO DRG,38621,,100% x Medicaid HMO amount,38621,Other,100% of NY Medicaid HMO DRG,38621,,100% x Medicaid HMO amount,38621,Other,100% of NY Medicaid HMO DRG,86897,,225% x Medicaid HMO amount,86897,Other,225% of NY Medicaid HMO DRG,86897,,225% x Medicaid HMO amount,86897,Other,225% of NY Medicaid HMO DRG,86897,,225% x Medicaid HMO amount,86897,Other,225% of NY Medicaid HMO DRG,86897,,225% x Medicaid HMO amount,86897,Other,225% of NY Medicaid HMO DRG,54069,,140% x Medicaid HMO amount,54069,Other,140% of NY Medicaid HMO DRG,86897,,225% x Medicaid HMO amount,86897,Other,225% of NY Medicaid HMO DRG,106208,,275% x Medicaid HMO amount,106208,Other,275% of NY Medicaid HMO DRG,125132,,324% x Medicaid HMO amount,125132,Other,324% of NY Medicaid HMO DRG,83035,,215% x Medicaid HMO amount,83035,Other,215% of NY Medicaid HMO DRG,83035,,215% x Medicaid HMO amount,83035,Other,215% of NY Medicaid HMO DRG,48276,,125% x Medicaid HMO amount,48276,Other,125% of NY Medicaid HMO DRG,0.01,219385,
Coronary bypass w AMI or complex PDX,165-4,APR-DRG,,,,,,,,inpatient,,,1510877.43,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,319353,,"45,128 x DRG weight",319353,Other,base rate x DRG weight,287416,,"40,615 x DRG weight",287416,Other,base rate x DRG weight,271451,,"38,359 x DRG weight",271451,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,103874,,186% x Medicaid HMO amount,103874,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,241149,,"34,077 x DRG weight",241149,Other,base rate x DRG weight,204981,,"28,966 x DRG weight",204981,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55846,,DRG base rate x DRG weight + capital per discharge,55846,Other,100% of NY Medicaid HMO DRG,55846,,100% x Medicaid HMO amount,55846,Other,100% of NY Medicaid HMO DRG,55846,,100% x Medicaid HMO amount,55846,Other,100% of NY Medicaid HMO DRG,55846,,100% x Medicaid HMO amount,55846,Other,100% of NY Medicaid HMO DRG,125654,,225% x Medicaid HMO amount,125654,Other,225% of NY Medicaid HMO DRG,125654,,225% x Medicaid HMO amount,125654,Other,225% of NY Medicaid HMO DRG,125654,,225% x Medicaid HMO amount,125654,Other,225% of NY Medicaid HMO DRG,125654,,225% x Medicaid HMO amount,125654,Other,225% of NY Medicaid HMO DRG,78184,,140% x Medicaid HMO amount,78184,Other,140% of NY Medicaid HMO DRG,125654,,225% x Medicaid HMO amount,125654,Other,225% of NY Medicaid HMO DRG,153577,,275% x Medicaid HMO amount,153577,Other,275% of NY Medicaid HMO DRG,180941,,324% x Medicaid HMO amount,180941,Other,324% of NY Medicaid HMO DRG,120069,,215% x Medicaid HMO amount,120069,Other,215% of NY Medicaid HMO DRG,120069,,215% x Medicaid HMO amount,120069,Other,215% of NY Medicaid HMO DRG,69808,,125% x Medicaid HMO amount,69808,Other,125% of NY Medicaid HMO DRG,0.01,319353,
Coronary bypass w/o AMI or complex PDX,166-1,APR-DRG,,,,,,,,inpatient,,,355089.76,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,135551,,"45,128 x DRG weight",135551,Other,base rate x DRG weight,121995,,"40,615 x DRG weight",121995,Other,base rate x DRG weight,115219,,"38,359 x DRG weight",115219,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44967,,186% x Medicaid HMO amount,44967,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,102357,,"34,077 x DRG weight",102357,Other,base rate x DRG weight,87005,,"28,966 x DRG weight",87005,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24176,,DRG base rate x DRG weight + capital per discharge,24176,Other,100% of NY Medicaid HMO DRG,24176,,100% x Medicaid HMO amount,24176,Other,100% of NY Medicaid HMO DRG,24176,,100% x Medicaid HMO amount,24176,Other,100% of NY Medicaid HMO DRG,24176,,100% x Medicaid HMO amount,24176,Other,100% of NY Medicaid HMO DRG,54396,,225% x Medicaid HMO amount,54396,Other,225% of NY Medicaid HMO DRG,54396,,225% x Medicaid HMO amount,54396,Other,225% of NY Medicaid HMO DRG,54396,,225% x Medicaid HMO amount,54396,Other,225% of NY Medicaid HMO DRG,54396,,225% x Medicaid HMO amount,54396,Other,225% of NY Medicaid HMO DRG,33846,,140% x Medicaid HMO amount,33846,Other,140% of NY Medicaid HMO DRG,54396,,225% x Medicaid HMO amount,54396,Other,225% of NY Medicaid HMO DRG,66484,,275% x Medicaid HMO amount,66484,Other,275% of NY Medicaid HMO DRG,78330,,324% x Medicaid HMO amount,78330,Other,324% of NY Medicaid HMO DRG,51978,,215% x Medicaid HMO amount,51978,Other,215% of NY Medicaid HMO DRG,51978,,215% x Medicaid HMO amount,51978,Other,215% of NY Medicaid HMO DRG,30220,,125% x Medicaid HMO amount,30220,Other,125% of NY Medicaid HMO DRG,0.01,135551,
Coronary bypass w/o AMI or complex PDX,166-2,APR-DRG,,,,,,,,inpatient,,,541172.91,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,147189,,"45,128 x DRG weight",147189,Other,base rate x DRG weight,132470,,"40,615 x DRG weight",132470,Other,base rate x DRG weight,125112,,"38,359 x DRG weight",125112,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48699,,186% x Medicaid HMO amount,48699,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,111146,,"34,077 x DRG weight",111146,Other,base rate x DRG weight,94476,,"28,966 x DRG weight",94476,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26182,,DRG base rate x DRG weight + capital per discharge,26182,Other,100% of NY Medicaid HMO DRG,26182,,100% x Medicaid HMO amount,26182,Other,100% of NY Medicaid HMO DRG,26182,,100% x Medicaid HMO amount,26182,Other,100% of NY Medicaid HMO DRG,26182,,100% x Medicaid HMO amount,26182,Other,100% of NY Medicaid HMO DRG,58910,,225% x Medicaid HMO amount,58910,Other,225% of NY Medicaid HMO DRG,58910,,225% x Medicaid HMO amount,58910,Other,225% of NY Medicaid HMO DRG,58910,,225% x Medicaid HMO amount,58910,Other,225% of NY Medicaid HMO DRG,58910,,225% x Medicaid HMO amount,58910,Other,225% of NY Medicaid HMO DRG,36655,,140% x Medicaid HMO amount,36655,Other,140% of NY Medicaid HMO DRG,58910,,225% x Medicaid HMO amount,58910,Other,225% of NY Medicaid HMO DRG,72001,,275% x Medicaid HMO amount,72001,Other,275% of NY Medicaid HMO DRG,84830,,324% x Medicaid HMO amount,84830,Other,324% of NY Medicaid HMO DRG,56291,,215% x Medicaid HMO amount,56291,Other,215% of NY Medicaid HMO DRG,56291,,215% x Medicaid HMO amount,56291,Other,215% of NY Medicaid HMO DRG,32728,,125% x Medicaid HMO amount,32728,Other,125% of NY Medicaid HMO DRG,0.01,147189,
Coronary bypass w/o AMI or complex PDX,166-3,APR-DRG,,,,,,,,inpatient,,,482321.88,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,181225,,"45,128 x DRG weight",181225,Other,base rate x DRG weight,163102,,"40,615 x DRG weight",163102,Other,base rate x DRG weight,154042,,"38,359 x DRG weight",154042,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59606,,186% x Medicaid HMO amount,59606,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,136846,,"34,077 x DRG weight",136846,Other,base rate x DRG weight,116322,,"28,966 x DRG weight",116322,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32046,,DRG base rate x DRG weight + capital per discharge,32046,Other,100% of NY Medicaid HMO DRG,32046,,100% x Medicaid HMO amount,32046,Other,100% of NY Medicaid HMO DRG,32046,,100% x Medicaid HMO amount,32046,Other,100% of NY Medicaid HMO DRG,32046,,100% x Medicaid HMO amount,32046,Other,100% of NY Medicaid HMO DRG,72104,,225% x Medicaid HMO amount,72104,Other,225% of NY Medicaid HMO DRG,72104,,225% x Medicaid HMO amount,72104,Other,225% of NY Medicaid HMO DRG,72104,,225% x Medicaid HMO amount,72104,Other,225% of NY Medicaid HMO DRG,72104,,225% x Medicaid HMO amount,72104,Other,225% of NY Medicaid HMO DRG,44864,,140% x Medicaid HMO amount,44864,Other,140% of NY Medicaid HMO DRG,72104,,225% x Medicaid HMO amount,72104,Other,225% of NY Medicaid HMO DRG,88127,,275% x Medicaid HMO amount,88127,Other,275% of NY Medicaid HMO DRG,103829,,324% x Medicaid HMO amount,103829,Other,324% of NY Medicaid HMO DRG,68899,,215% x Medicaid HMO amount,68899,Other,215% of NY Medicaid HMO DRG,68899,,215% x Medicaid HMO amount,68899,Other,215% of NY Medicaid HMO DRG,40058,,125% x Medicaid HMO amount,40058,Other,125% of NY Medicaid HMO DRG,0.01,181225,
Coronary bypass w/o AMI or complex PDX,166-4,APR-DRG,,,,,,,,inpatient,,,614887.93,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,281202,,"45,128 x DRG weight",281202,Other,base rate x DRG weight,253080,,"40,615 x DRG weight",253080,Other,base rate x DRG weight,239023,,"38,359 x DRG weight",239023,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,91646,,186% x Medicaid HMO amount,91646,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,212341,,"34,077 x DRG weight",212341,Other,base rate x DRG weight,180493,,"28,966 x DRG weight",180493,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49272,,DRG base rate x DRG weight + capital per discharge,49272,Other,100% of NY Medicaid HMO DRG,49272,,100% x Medicaid HMO amount,49272,Other,100% of NY Medicaid HMO DRG,49272,,100% x Medicaid HMO amount,49272,Other,100% of NY Medicaid HMO DRG,49272,,100% x Medicaid HMO amount,49272,Other,100% of NY Medicaid HMO DRG,110862,,225% x Medicaid HMO amount,110862,Other,225% of NY Medicaid HMO DRG,110862,,225% x Medicaid HMO amount,110862,Other,225% of NY Medicaid HMO DRG,110862,,225% x Medicaid HMO amount,110862,Other,225% of NY Medicaid HMO DRG,110862,,225% x Medicaid HMO amount,110862,Other,225% of NY Medicaid HMO DRG,68981,,140% x Medicaid HMO amount,68981,Other,140% of NY Medicaid HMO DRG,110862,,225% x Medicaid HMO amount,110862,Other,225% of NY Medicaid HMO DRG,135498,,275% x Medicaid HMO amount,135498,Other,275% of NY Medicaid HMO DRG,159641,,324% x Medicaid HMO amount,159641,Other,324% of NY Medicaid HMO DRG,105935,,215% x Medicaid HMO amount,105935,Other,215% of NY Medicaid HMO DRG,105935,,215% x Medicaid HMO amount,105935,Other,215% of NY Medicaid HMO DRG,61590,,125% x Medicaid HMO amount,61590,Other,125% of NY Medicaid HMO DRG,0.01,281202,
Other cardiothoracic & thoracic vascular procedures,167-1,APR-DRG,,,,,,,,inpatient,,,196915.88,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,109467,,"45,128 x DRG weight",109467,Other,base rate x DRG weight,98520,,"40,615 x DRG weight",98520,Other,base rate x DRG weight,93047,,"38,359 x DRG weight",93047,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36609,,186% x Medicaid HMO amount,36609,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,82661,,"34,077 x DRG weight",82661,Other,base rate x DRG weight,70263,,"28,966 x DRG weight",70263,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19682,,DRG base rate x DRG weight + capital per discharge,19682,Other,100% of NY Medicaid HMO DRG,19682,,100% x Medicaid HMO amount,19682,Other,100% of NY Medicaid HMO DRG,19682,,100% x Medicaid HMO amount,19682,Other,100% of NY Medicaid HMO DRG,19682,,100% x Medicaid HMO amount,19682,Other,100% of NY Medicaid HMO DRG,44285,,225% x Medicaid HMO amount,44285,Other,225% of NY Medicaid HMO DRG,44285,,225% x Medicaid HMO amount,44285,Other,225% of NY Medicaid HMO DRG,44285,,225% x Medicaid HMO amount,44285,Other,225% of NY Medicaid HMO DRG,44285,,225% x Medicaid HMO amount,44285,Other,225% of NY Medicaid HMO DRG,27555,,140% x Medicaid HMO amount,27555,Other,140% of NY Medicaid HMO DRG,44285,,225% x Medicaid HMO amount,44285,Other,225% of NY Medicaid HMO DRG,54126,,275% x Medicaid HMO amount,54126,Other,275% of NY Medicaid HMO DRG,63770,,324% x Medicaid HMO amount,63770,Other,324% of NY Medicaid HMO DRG,42316,,215% x Medicaid HMO amount,42316,Other,215% of NY Medicaid HMO DRG,42316,,215% x Medicaid HMO amount,42316,Other,215% of NY Medicaid HMO DRG,24603,,125% x Medicaid HMO amount,24603,Other,125% of NY Medicaid HMO DRG,0.01,109467,
Other cardiothoracic & thoracic vascular procedures,167-2,APR-DRG,,,,,,,,inpatient,,,369975.64,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,128150,,"45,128 x DRG weight",128150,Other,base rate x DRG weight,115334,,"40,615 x DRG weight",115334,Other,base rate x DRG weight,108928,,"38,359 x DRG weight",108928,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42596,,186% x Medicaid HMO amount,42596,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,96768,,"34,077 x DRG weight",96768,Other,base rate x DRG weight,82255,,"28,966 x DRG weight",82255,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22901,,DRG base rate x DRG weight + capital per discharge,22901,Other,100% of NY Medicaid HMO DRG,22901,,100% x Medicaid HMO amount,22901,Other,100% of NY Medicaid HMO DRG,22901,,100% x Medicaid HMO amount,22901,Other,100% of NY Medicaid HMO DRG,22901,,100% x Medicaid HMO amount,22901,Other,100% of NY Medicaid HMO DRG,51527,,225% x Medicaid HMO amount,51527,Other,225% of NY Medicaid HMO DRG,51527,,225% x Medicaid HMO amount,51527,Other,225% of NY Medicaid HMO DRG,51527,,225% x Medicaid HMO amount,51527,Other,225% of NY Medicaid HMO DRG,51527,,225% x Medicaid HMO amount,51527,Other,225% of NY Medicaid HMO DRG,32061,,140% x Medicaid HMO amount,32061,Other,140% of NY Medicaid HMO DRG,51527,,225% x Medicaid HMO amount,51527,Other,225% of NY Medicaid HMO DRG,62978,,275% x Medicaid HMO amount,62978,Other,275% of NY Medicaid HMO DRG,74199,,324% x Medicaid HMO amount,74199,Other,324% of NY Medicaid HMO DRG,49237,,215% x Medicaid HMO amount,49237,Other,215% of NY Medicaid HMO DRG,49237,,215% x Medicaid HMO amount,49237,Other,215% of NY Medicaid HMO DRG,28626,,125% x Medicaid HMO amount,28626,Other,125% of NY Medicaid HMO DRG,0.01,128150,
Other cardiothoracic & thoracic vascular procedures,167-3,APR-DRG,,,,,,,,inpatient,,,565606.14,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,166125,,"45,128 x DRG weight",166125,Other,base rate x DRG weight,149512,,"40,615 x DRG weight",149512,Other,base rate x DRG weight,141207,,"38,359 x DRG weight",141207,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54766,,186% x Medicaid HMO amount,54766,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,125444,,"34,077 x DRG weight",125444,Other,base rate x DRG weight,106630,,"28,966 x DRG weight",106630,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29444,,DRG base rate x DRG weight + capital per discharge,29444,Other,100% of NY Medicaid HMO DRG,29444,,100% x Medicaid HMO amount,29444,Other,100% of NY Medicaid HMO DRG,29444,,100% x Medicaid HMO amount,29444,Other,100% of NY Medicaid HMO DRG,29444,,100% x Medicaid HMO amount,29444,Other,100% of NY Medicaid HMO DRG,66249,,225% x Medicaid HMO amount,66249,Other,225% of NY Medicaid HMO DRG,66249,,225% x Medicaid HMO amount,66249,Other,225% of NY Medicaid HMO DRG,66249,,225% x Medicaid HMO amount,66249,Other,225% of NY Medicaid HMO DRG,66249,,225% x Medicaid HMO amount,66249,Other,225% of NY Medicaid HMO DRG,41222,,140% x Medicaid HMO amount,41222,Other,140% of NY Medicaid HMO DRG,66249,,225% x Medicaid HMO amount,66249,Other,225% of NY Medicaid HMO DRG,80971,,275% x Medicaid HMO amount,80971,Other,275% of NY Medicaid HMO DRG,95399,,324% x Medicaid HMO amount,95399,Other,324% of NY Medicaid HMO DRG,63305,,215% x Medicaid HMO amount,63305,Other,215% of NY Medicaid HMO DRG,63305,,215% x Medicaid HMO amount,63305,Other,215% of NY Medicaid HMO DRG,36805,,125% x Medicaid HMO amount,36805,Other,125% of NY Medicaid HMO DRG,0.01,166125,
Other cardiothoracic & thoracic vascular procedures,167-4,APR-DRG,,,,,,,,inpatient,,,1019180.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,299253,,"45,128 x DRG weight",299253,Other,base rate x DRG weight,269326,,"40,615 x DRG weight",269326,Other,base rate x DRG weight,254366,,"38,359 x DRG weight",254366,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,97432,,186% x Medicaid HMO amount,97432,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,225971,,"34,077 x DRG weight",225971,Other,base rate x DRG weight,192079,,"28,966 x DRG weight",192079,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52383,,DRG base rate x DRG weight + capital per discharge,52383,Other,100% of NY Medicaid HMO DRG,52383,,100% x Medicaid HMO amount,52383,Other,100% of NY Medicaid HMO DRG,52383,,100% x Medicaid HMO amount,52383,Other,100% of NY Medicaid HMO DRG,52383,,100% x Medicaid HMO amount,52383,Other,100% of NY Medicaid HMO DRG,117862,,225% x Medicaid HMO amount,117862,Other,225% of NY Medicaid HMO DRG,117862,,225% x Medicaid HMO amount,117862,Other,225% of NY Medicaid HMO DRG,117862,,225% x Medicaid HMO amount,117862,Other,225% of NY Medicaid HMO DRG,117862,,225% x Medicaid HMO amount,117862,Other,225% of NY Medicaid HMO DRG,73336,,140% x Medicaid HMO amount,73336,Other,140% of NY Medicaid HMO DRG,117862,,225% x Medicaid HMO amount,117862,Other,225% of NY Medicaid HMO DRG,144053,,275% x Medicaid HMO amount,144053,Other,275% of NY Medicaid HMO DRG,169721,,324% x Medicaid HMO amount,169721,Other,324% of NY Medicaid HMO DRG,112623,,215% x Medicaid HMO amount,112623,Other,215% of NY Medicaid HMO DRG,112623,,215% x Medicaid HMO amount,112623,Other,215% of NY Medicaid HMO DRG,65479,,125% x Medicaid HMO amount,65479,Other,125% of NY Medicaid HMO DRG,0.01,299253,
Major abdominal vascular procedures,169-1,APR-DRG,,,,,,,,inpatient,,,224037.16,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,80477,,"45,128 x DRG weight",80477,Other,base rate x DRG weight,72429,,"40,615 x DRG weight",72429,Other,base rate x DRG weight,68406,,"38,359 x DRG weight",68406,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27318,,186% x Medicaid HMO amount,27318,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60770,,"34,077 x DRG weight",60770,Other,base rate x DRG weight,51655,,"28,966 x DRG weight",51655,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14687,,DRG base rate x DRG weight + capital per discharge,14687,Other,100% of NY Medicaid HMO DRG,14687,,100% x Medicaid HMO amount,14687,Other,100% of NY Medicaid HMO DRG,14687,,100% x Medicaid HMO amount,14687,Other,100% of NY Medicaid HMO DRG,14687,,100% x Medicaid HMO amount,14687,Other,100% of NY Medicaid HMO DRG,33046,,225% x Medicaid HMO amount,33046,Other,225% of NY Medicaid HMO DRG,33046,,225% x Medicaid HMO amount,33046,Other,225% of NY Medicaid HMO DRG,33046,,225% x Medicaid HMO amount,33046,Other,225% of NY Medicaid HMO DRG,33046,,225% x Medicaid HMO amount,33046,Other,225% of NY Medicaid HMO DRG,20562,,140% x Medicaid HMO amount,20562,Other,140% of NY Medicaid HMO DRG,33046,,225% x Medicaid HMO amount,33046,Other,225% of NY Medicaid HMO DRG,40389,,275% x Medicaid HMO amount,40389,Other,275% of NY Medicaid HMO DRG,47586,,324% x Medicaid HMO amount,47586,Other,324% of NY Medicaid HMO DRG,31577,,215% x Medicaid HMO amount,31577,Other,215% of NY Medicaid HMO DRG,31577,,215% x Medicaid HMO amount,31577,Other,215% of NY Medicaid HMO DRG,18359,,125% x Medicaid HMO amount,18359,Other,125% of NY Medicaid HMO DRG,0.01,80477,
Major abdominal vascular procedures,169-2,APR-DRG,,,,,,,,inpatient,,,320855.16,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,103271,,"45,128 x DRG weight",103271,Other,base rate x DRG weight,92943,,"40,615 x DRG weight",92943,Other,base rate x DRG weight,87781,,"38,359 x DRG weight",87781,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34624,,186% x Medicaid HMO amount,34624,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,77982,,"34,077 x DRG weight",77982,Other,base rate x DRG weight,66286,,"28,966 x DRG weight",66286,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18615,,DRG base rate x DRG weight + capital per discharge,18615,Other,100% of NY Medicaid HMO DRG,18615,,100% x Medicaid HMO amount,18615,Other,100% of NY Medicaid HMO DRG,18615,,100% x Medicaid HMO amount,18615,Other,100% of NY Medicaid HMO DRG,18615,,100% x Medicaid HMO amount,18615,Other,100% of NY Medicaid HMO DRG,41884,,225% x Medicaid HMO amount,41884,Other,225% of NY Medicaid HMO DRG,41884,,225% x Medicaid HMO amount,41884,Other,225% of NY Medicaid HMO DRG,41884,,225% x Medicaid HMO amount,41884,Other,225% of NY Medicaid HMO DRG,41884,,225% x Medicaid HMO amount,41884,Other,225% of NY Medicaid HMO DRG,26061,,140% x Medicaid HMO amount,26061,Other,140% of NY Medicaid HMO DRG,41884,,225% x Medicaid HMO amount,41884,Other,225% of NY Medicaid HMO DRG,51191,,275% x Medicaid HMO amount,51191,Other,275% of NY Medicaid HMO DRG,60313,,324% x Medicaid HMO amount,60313,Other,324% of NY Medicaid HMO DRG,40022,,215% x Medicaid HMO amount,40022,Other,215% of NY Medicaid HMO DRG,40022,,215% x Medicaid HMO amount,40022,Other,215% of NY Medicaid HMO DRG,23269,,125% x Medicaid HMO amount,23269,Other,125% of NY Medicaid HMO DRG,0.01,103271,
Major abdominal vascular procedures,169-3,APR-DRG,,,,,,,,inpatient,,,471431.61,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,167669,,"45,128 x DRG weight",167669,Other,base rate x DRG weight,150901,,"40,615 x DRG weight",150901,Other,base rate x DRG weight,142519,,"38,359 x DRG weight",142519,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55261,,186% x Medicaid HMO amount,55261,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,126610,,"34,077 x DRG weight",126610,Other,base rate x DRG weight,107620,,"28,966 x DRG weight",107620,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29710,,DRG base rate x DRG weight + capital per discharge,29710,Other,100% of NY Medicaid HMO DRG,29710,,100% x Medicaid HMO amount,29710,Other,100% of NY Medicaid HMO DRG,29710,,100% x Medicaid HMO amount,29710,Other,100% of NY Medicaid HMO DRG,29710,,100% x Medicaid HMO amount,29710,Other,100% of NY Medicaid HMO DRG,66848,,225% x Medicaid HMO amount,66848,Other,225% of NY Medicaid HMO DRG,66848,,225% x Medicaid HMO amount,66848,Other,225% of NY Medicaid HMO DRG,66848,,225% x Medicaid HMO amount,66848,Other,225% of NY Medicaid HMO DRG,66848,,225% x Medicaid HMO amount,66848,Other,225% of NY Medicaid HMO DRG,41594,,140% x Medicaid HMO amount,41594,Other,140% of NY Medicaid HMO DRG,66848,,225% x Medicaid HMO amount,66848,Other,225% of NY Medicaid HMO DRG,81703,,275% x Medicaid HMO amount,81703,Other,275% of NY Medicaid HMO DRG,96260,,324% x Medicaid HMO amount,96260,Other,324% of NY Medicaid HMO DRG,63877,,215% x Medicaid HMO amount,63877,Other,215% of NY Medicaid HMO DRG,63877,,215% x Medicaid HMO amount,63877,Other,215% of NY Medicaid HMO DRG,37138,,125% x Medicaid HMO amount,37138,Other,125% of NY Medicaid HMO DRG,0.01,167669,
Major abdominal vascular procedures,169-4,APR-DRG,,,,,,,,inpatient,,,1233181.37,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,324150,,"45,128 x DRG weight",324150,Other,base rate x DRG weight,291733,,"40,615 x DRG weight",291733,Other,base rate x DRG weight,275529,,"38,359 x DRG weight",275529,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,105410,,186% x Medicaid HMO amount,105410,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,244772,,"34,077 x DRG weight",244772,Other,base rate x DRG weight,208060,,"28,966 x DRG weight",208060,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56672,,DRG base rate x DRG weight + capital per discharge,56672,Other,100% of NY Medicaid HMO DRG,56672,,100% x Medicaid HMO amount,56672,Other,100% of NY Medicaid HMO DRG,56672,,100% x Medicaid HMO amount,56672,Other,100% of NY Medicaid HMO DRG,56672,,100% x Medicaid HMO amount,56672,Other,100% of NY Medicaid HMO DRG,127512,,225% x Medicaid HMO amount,127512,Other,225% of NY Medicaid HMO DRG,127512,,225% x Medicaid HMO amount,127512,Other,225% of NY Medicaid HMO DRG,127512,,225% x Medicaid HMO amount,127512,Other,225% of NY Medicaid HMO DRG,127512,,225% x Medicaid HMO amount,127512,Other,225% of NY Medicaid HMO DRG,79341,,140% x Medicaid HMO amount,79341,Other,140% of NY Medicaid HMO DRG,127512,,225% x Medicaid HMO amount,127512,Other,225% of NY Medicaid HMO DRG,155848,,275% x Medicaid HMO amount,155848,Other,275% of NY Medicaid HMO DRG,183617,,324% x Medicaid HMO amount,183617,Other,324% of NY Medicaid HMO DRG,121845,,215% x Medicaid HMO amount,121845,Other,215% of NY Medicaid HMO DRG,121845,,215% x Medicaid HMO amount,121845,Other,215% of NY Medicaid HMO DRG,70840,,125% x Medicaid HMO amount,70840,Other,125% of NY Medicaid HMO DRG,0.01,324150,
"Permanent cardiac pacemaker implant w AMI, heart failure or shock",170-1,APR-DRG,,,,,,,,inpatient,,,272579,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,122098,,"45,128 x DRG weight",122098,Other,base rate x DRG weight,109888,,"40,615 x DRG weight",109888,Other,base rate x DRG weight,103784,,"38,359 x DRG weight",103784,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40658,,186% x Medicaid HMO amount,40658,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,92199,,"34,077 x DRG weight",92199,Other,base rate x DRG weight,78370,,"28,966 x DRG weight",78370,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21859,,DRG base rate x DRG weight + capital per discharge,21859,Other,100% of NY Medicaid HMO DRG,21859,,100% x Medicaid HMO amount,21859,Other,100% of NY Medicaid HMO DRG,21859,,100% x Medicaid HMO amount,21859,Other,100% of NY Medicaid HMO DRG,21859,,100% x Medicaid HMO amount,21859,Other,100% of NY Medicaid HMO DRG,49183,,225% x Medicaid HMO amount,49183,Other,225% of NY Medicaid HMO DRG,49183,,225% x Medicaid HMO amount,49183,Other,225% of NY Medicaid HMO DRG,49183,,225% x Medicaid HMO amount,49183,Other,225% of NY Medicaid HMO DRG,49183,,225% x Medicaid HMO amount,49183,Other,225% of NY Medicaid HMO DRG,30603,,140% x Medicaid HMO amount,30603,Other,140% of NY Medicaid HMO DRG,49183,,225% x Medicaid HMO amount,49183,Other,225% of NY Medicaid HMO DRG,60112,,275% x Medicaid HMO amount,60112,Other,275% of NY Medicaid HMO DRG,70823,,324% x Medicaid HMO amount,70823,Other,324% of NY Medicaid HMO DRG,46997,,215% x Medicaid HMO amount,46997,Other,215% of NY Medicaid HMO DRG,46997,,215% x Medicaid HMO amount,46997,Other,215% of NY Medicaid HMO DRG,27324,,125% x Medicaid HMO amount,27324,Other,125% of NY Medicaid HMO DRG,0.01,122098,
"Permanent cardiac pacemaker implant w AMI, heart failure or shock",170-2,APR-DRG,,,,,,,,inpatient,,,256944.8,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,123443,,"45,128 x DRG weight",123443,Other,base rate x DRG weight,111098,,"40,615 x DRG weight",111098,Other,base rate x DRG weight,104927,,"38,359 x DRG weight",104927,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41087,,186% x Medicaid HMO amount,41087,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,93214,,"34,077 x DRG weight",93214,Other,base rate x DRG weight,79234,,"28,966 x DRG weight",79234,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22090,,DRG base rate x DRG weight + capital per discharge,22090,Other,100% of NY Medicaid HMO DRG,22090,,100% x Medicaid HMO amount,22090,Other,100% of NY Medicaid HMO DRG,22090,,100% x Medicaid HMO amount,22090,Other,100% of NY Medicaid HMO DRG,22090,,100% x Medicaid HMO amount,22090,Other,100% of NY Medicaid HMO DRG,49703,,225% x Medicaid HMO amount,49703,Other,225% of NY Medicaid HMO DRG,49703,,225% x Medicaid HMO amount,49703,Other,225% of NY Medicaid HMO DRG,49703,,225% x Medicaid HMO amount,49703,Other,225% of NY Medicaid HMO DRG,49703,,225% x Medicaid HMO amount,49703,Other,225% of NY Medicaid HMO DRG,30926,,140% x Medicaid HMO amount,30926,Other,140% of NY Medicaid HMO DRG,49703,,225% x Medicaid HMO amount,49703,Other,225% of NY Medicaid HMO DRG,60748,,275% x Medicaid HMO amount,60748,Other,275% of NY Medicaid HMO DRG,71572,,324% x Medicaid HMO amount,71572,Other,324% of NY Medicaid HMO DRG,47494,,215% x Medicaid HMO amount,47494,Other,215% of NY Medicaid HMO DRG,47494,,215% x Medicaid HMO amount,47494,Other,215% of NY Medicaid HMO DRG,27613,,125% x Medicaid HMO amount,27613,Other,125% of NY Medicaid HMO DRG,0.01,123443,
"Permanent cardiac pacemaker implant w AMI, heart failure or shock",170-3,APR-DRG,,,,,,,,inpatient,,,406911.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,162596,,"45,128 x DRG weight",162596,Other,base rate x DRG weight,146336,,"40,615 x DRG weight",146336,Other,base rate x DRG weight,138207,,"38,359 x DRG weight",138207,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53635,,186% x Medicaid HMO amount,53635,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,122779,,"34,077 x DRG weight",122779,Other,base rate x DRG weight,104364,,"28,966 x DRG weight",104364,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28836,,DRG base rate x DRG weight + capital per discharge,28836,Other,100% of NY Medicaid HMO DRG,28836,,100% x Medicaid HMO amount,28836,Other,100% of NY Medicaid HMO DRG,28836,,100% x Medicaid HMO amount,28836,Other,100% of NY Medicaid HMO DRG,28836,,100% x Medicaid HMO amount,28836,Other,100% of NY Medicaid HMO DRG,64881,,225% x Medicaid HMO amount,64881,Other,225% of NY Medicaid HMO DRG,64881,,225% x Medicaid HMO amount,64881,Other,225% of NY Medicaid HMO DRG,64881,,225% x Medicaid HMO amount,64881,Other,225% of NY Medicaid HMO DRG,64881,,225% x Medicaid HMO amount,64881,Other,225% of NY Medicaid HMO DRG,40370,,140% x Medicaid HMO amount,40370,Other,140% of NY Medicaid HMO DRG,64881,,225% x Medicaid HMO amount,64881,Other,225% of NY Medicaid HMO DRG,79299,,275% x Medicaid HMO amount,79299,Other,275% of NY Medicaid HMO DRG,93429,,324% x Medicaid HMO amount,93429,Other,324% of NY Medicaid HMO DRG,61997,,215% x Medicaid HMO amount,61997,Other,215% of NY Medicaid HMO DRG,61997,,215% x Medicaid HMO amount,61997,Other,215% of NY Medicaid HMO DRG,36045,,125% x Medicaid HMO amount,36045,Other,125% of NY Medicaid HMO DRG,0.01,162596,
"Permanent cardiac pacemaker implant w AMI, heart failure or shock",170-4,APR-DRG,,,,,,,,inpatient,,,406911.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,217179,,"45,128 x DRG weight",217179,Other,base rate x DRG weight,195460,,"40,615 x DRG weight",195460,Other,base rate x DRG weight,184603,,"38,359 x DRG weight",184603,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,71128,,186% x Medicaid HMO amount,71128,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,163996,,"34,077 x DRG weight",163996,Other,base rate x DRG weight,139399,,"28,966 x DRG weight",139399,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38241,,DRG base rate x DRG weight + capital per discharge,38241,Other,100% of NY Medicaid HMO DRG,38241,,100% x Medicaid HMO amount,38241,Other,100% of NY Medicaid HMO DRG,38241,,100% x Medicaid HMO amount,38241,Other,100% of NY Medicaid HMO DRG,38241,,100% x Medicaid HMO amount,38241,Other,100% of NY Medicaid HMO DRG,86042,,225% x Medicaid HMO amount,86042,Other,225% of NY Medicaid HMO DRG,86042,,225% x Medicaid HMO amount,86042,Other,225% of NY Medicaid HMO DRG,86042,,225% x Medicaid HMO amount,86042,Other,225% of NY Medicaid HMO DRG,86042,,225% x Medicaid HMO amount,86042,Other,225% of NY Medicaid HMO DRG,53537,,140% x Medicaid HMO amount,53537,Other,140% of NY Medicaid HMO DRG,86042,,225% x Medicaid HMO amount,86042,Other,225% of NY Medicaid HMO DRG,105163,,275% x Medicaid HMO amount,105163,Other,275% of NY Medicaid HMO DRG,123901,,324% x Medicaid HMO amount,123901,Other,324% of NY Medicaid HMO DRG,82218,,215% x Medicaid HMO amount,82218,Other,215% of NY Medicaid HMO DRG,82218,,215% x Medicaid HMO amount,82218,Other,215% of NY Medicaid HMO DRG,47801,,125% x Medicaid HMO amount,47801,Other,125% of NY Medicaid HMO DRG,0.01,217179,
"Perm cardiac pacemaker implant w/o AMI, heart failure or shock",171-1,APR-DRG,,,,,,,,inpatient,,,272579,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,78514,,"45,128 x DRG weight",78514,Other,base rate x DRG weight,70662,,"40,615 x DRG weight",70662,Other,base rate x DRG weight,66737,,"38,359 x DRG weight",66737,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26689,,186% x Medicaid HMO amount,26689,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59287,,"34,077 x DRG weight",59287,Other,base rate x DRG weight,50395,,"28,966 x DRG weight",50395,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14349,,DRG base rate x DRG weight + capital per discharge,14349,Other,100% of NY Medicaid HMO DRG,14349,,100% x Medicaid HMO amount,14349,Other,100% of NY Medicaid HMO DRG,14349,,100% x Medicaid HMO amount,14349,Other,100% of NY Medicaid HMO DRG,14349,,100% x Medicaid HMO amount,14349,Other,100% of NY Medicaid HMO DRG,32285,,225% x Medicaid HMO amount,32285,Other,225% of NY Medicaid HMO DRG,32285,,225% x Medicaid HMO amount,32285,Other,225% of NY Medicaid HMO DRG,32285,,225% x Medicaid HMO amount,32285,Other,225% of NY Medicaid HMO DRG,32285,,225% x Medicaid HMO amount,32285,Other,225% of NY Medicaid HMO DRG,20089,,140% x Medicaid HMO amount,20089,Other,140% of NY Medicaid HMO DRG,32285,,225% x Medicaid HMO amount,32285,Other,225% of NY Medicaid HMO DRG,39460,,275% x Medicaid HMO amount,39460,Other,275% of NY Medicaid HMO DRG,46491,,324% x Medicaid HMO amount,46491,Other,324% of NY Medicaid HMO DRG,30850,,215% x Medicaid HMO amount,30850,Other,215% of NY Medicaid HMO DRG,30850,,215% x Medicaid HMO amount,30850,Other,215% of NY Medicaid HMO DRG,17936,,125% x Medicaid HMO amount,17936,Other,125% of NY Medicaid HMO DRG,0.01,78514,
"Perm cardiac pacemaker implant w/o AMI, heart failure or shock",171-2,APR-DRG,,,,,,,,inpatient,,,256944.8,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,96754,,"45,128 x DRG weight",96754,Other,base rate x DRG weight,87079,,"40,615 x DRG weight",87079,Other,base rate x DRG weight,82242,,"38,359 x DRG weight",82242,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32535,,186% x Medicaid HMO amount,32535,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73061,,"34,077 x DRG weight",73061,Other,base rate x DRG weight,62103,,"28,966 x DRG weight",62103,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17492,,DRG base rate x DRG weight + capital per discharge,17492,Other,100% of NY Medicaid HMO DRG,17492,,100% x Medicaid HMO amount,17492,Other,100% of NY Medicaid HMO DRG,17492,,100% x Medicaid HMO amount,17492,Other,100% of NY Medicaid HMO DRG,17492,,100% x Medicaid HMO amount,17492,Other,100% of NY Medicaid HMO DRG,39357,,225% x Medicaid HMO amount,39357,Other,225% of NY Medicaid HMO DRG,39357,,225% x Medicaid HMO amount,39357,Other,225% of NY Medicaid HMO DRG,39357,,225% x Medicaid HMO amount,39357,Other,225% of NY Medicaid HMO DRG,39357,,225% x Medicaid HMO amount,39357,Other,225% of NY Medicaid HMO DRG,24489,,140% x Medicaid HMO amount,24489,Other,140% of NY Medicaid HMO DRG,39357,,225% x Medicaid HMO amount,39357,Other,225% of NY Medicaid HMO DRG,48103,,275% x Medicaid HMO amount,48103,Other,275% of NY Medicaid HMO DRG,56674,,324% x Medicaid HMO amount,56674,Other,324% of NY Medicaid HMO DRG,37608,,215% x Medicaid HMO amount,37608,Other,215% of NY Medicaid HMO DRG,37608,,215% x Medicaid HMO amount,37608,Other,215% of NY Medicaid HMO DRG,21865,,125% x Medicaid HMO amount,21865,Other,125% of NY Medicaid HMO DRG,0.01,96754,
"Perm cardiac pacemaker implant w/o AMI, heart failure or shock",171-3,APR-DRG,,,,,,,,inpatient,,,406911.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,134838,,"45,128 x DRG weight",134838,Other,base rate x DRG weight,121354,,"40,615 x DRG weight",121354,Other,base rate x DRG weight,114613,,"38,359 x DRG weight",114613,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44740,,186% x Medicaid HMO amount,44740,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,101819,,"34,077 x DRG weight",101819,Other,base rate x DRG weight,86548,,"28,966 x DRG weight",86548,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24054,,DRG base rate x DRG weight + capital per discharge,24054,Other,100% of NY Medicaid HMO DRG,24054,,100% x Medicaid HMO amount,24054,Other,100% of NY Medicaid HMO DRG,24054,,100% x Medicaid HMO amount,24054,Other,100% of NY Medicaid HMO DRG,24054,,100% x Medicaid HMO amount,24054,Other,100% of NY Medicaid HMO DRG,54122,,225% x Medicaid HMO amount,54122,Other,225% of NY Medicaid HMO DRG,54122,,225% x Medicaid HMO amount,54122,Other,225% of NY Medicaid HMO DRG,54122,,225% x Medicaid HMO amount,54122,Other,225% of NY Medicaid HMO DRG,54122,,225% x Medicaid HMO amount,54122,Other,225% of NY Medicaid HMO DRG,33676,,140% x Medicaid HMO amount,33676,Other,140% of NY Medicaid HMO DRG,54122,,225% x Medicaid HMO amount,54122,Other,225% of NY Medicaid HMO DRG,66149,,275% x Medicaid HMO amount,66149,Other,275% of NY Medicaid HMO DRG,77935,,324% x Medicaid HMO amount,77935,Other,324% of NY Medicaid HMO DRG,51716,,215% x Medicaid HMO amount,51716,Other,215% of NY Medicaid HMO DRG,51716,,215% x Medicaid HMO amount,51716,Other,215% of NY Medicaid HMO DRG,30068,,125% x Medicaid HMO amount,30068,Other,125% of NY Medicaid HMO DRG,0.01,134838,
"Perm cardiac pacemaker implant w/o AMI, heart failure or shock",171-4,APR-DRG,,,,,,,,inpatient,,,406911.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,269134,,"45,128 x DRG weight",269134,Other,base rate x DRG weight,242220,,"40,615 x DRG weight",242220,Other,base rate x DRG weight,228765,,"38,359 x DRG weight",228765,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,87779,,186% x Medicaid HMO amount,87779,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,203228,,"34,077 x DRG weight",203228,Other,base rate x DRG weight,172747,,"28,966 x DRG weight",172747,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47193,,DRG base rate x DRG weight + capital per discharge,47193,Other,100% of NY Medicaid HMO DRG,47193,,100% x Medicaid HMO amount,47193,Other,100% of NY Medicaid HMO DRG,47193,,100% x Medicaid HMO amount,47193,Other,100% of NY Medicaid HMO DRG,47193,,100% x Medicaid HMO amount,47193,Other,100% of NY Medicaid HMO DRG,106184,,225% x Medicaid HMO amount,106184,Other,225% of NY Medicaid HMO DRG,106184,,225% x Medicaid HMO amount,106184,Other,225% of NY Medicaid HMO DRG,106184,,225% x Medicaid HMO amount,106184,Other,225% of NY Medicaid HMO DRG,106184,,225% x Medicaid HMO amount,106184,Other,225% of NY Medicaid HMO DRG,66070,,140% x Medicaid HMO amount,66070,Other,140% of NY Medicaid HMO DRG,106184,,225% x Medicaid HMO amount,106184,Other,225% of NY Medicaid HMO DRG,129781,,275% x Medicaid HMO amount,129781,Other,275% of NY Medicaid HMO DRG,152905,,324% x Medicaid HMO amount,152905,Other,324% of NY Medicaid HMO DRG,101465,,215% x Medicaid HMO amount,101465,Other,215% of NY Medicaid HMO DRG,101465,,215% x Medicaid HMO amount,101465,Other,215% of NY Medicaid HMO DRG,58991,,125% x Medicaid HMO amount,58991,Other,125% of NY Medicaid HMO DRG,0.01,269134,
Percutaneous coronary intervention w AMI,174-1,APR-DRG,,,,,,,,inpatient,,,179858.95,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,79651,,"45,128 x DRG weight",79651,Other,base rate x DRG weight,71685,,"40,615 x DRG weight",71685,Other,base rate x DRG weight,67704,,"38,359 x DRG weight",67704,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27054,,186% x Medicaid HMO amount,27054,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60146,,"34,077 x DRG weight",60146,Other,base rate x DRG weight,51125,,"28,966 x DRG weight",51125,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14545,,DRG base rate x DRG weight + capital per discharge,14545,Other,100% of NY Medicaid HMO DRG,14545,,100% x Medicaid HMO amount,14545,Other,100% of NY Medicaid HMO DRG,14545,,100% x Medicaid HMO amount,14545,Other,100% of NY Medicaid HMO DRG,14545,,100% x Medicaid HMO amount,14545,Other,100% of NY Medicaid HMO DRG,32726,,225% x Medicaid HMO amount,32726,Other,225% of NY Medicaid HMO DRG,32726,,225% x Medicaid HMO amount,32726,Other,225% of NY Medicaid HMO DRG,32726,,225% x Medicaid HMO amount,32726,Other,225% of NY Medicaid HMO DRG,32726,,225% x Medicaid HMO amount,32726,Other,225% of NY Medicaid HMO DRG,20363,,140% x Medicaid HMO amount,20363,Other,140% of NY Medicaid HMO DRG,32726,,225% x Medicaid HMO amount,32726,Other,225% of NY Medicaid HMO DRG,39999,,275% x Medicaid HMO amount,39999,Other,275% of NY Medicaid HMO DRG,47126,,324% x Medicaid HMO amount,47126,Other,324% of NY Medicaid HMO DRG,31272,,215% x Medicaid HMO amount,31272,Other,215% of NY Medicaid HMO DRG,31272,,215% x Medicaid HMO amount,31272,Other,215% of NY Medicaid HMO DRG,18181,,125% x Medicaid HMO amount,18181,Other,125% of NY Medicaid HMO DRG,0.01,79651,
Percutaneous coronary intervention w AMI,174-2,APR-DRG,,,,,,,,inpatient,,,212603.48,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,87652,,"45,128 x DRG weight",87652,Other,base rate x DRG weight,78887,,"40,615 x DRG weight",78887,Other,base rate x DRG weight,74505,,"38,359 x DRG weight",74505,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29617,,186% x Medicaid HMO amount,29617,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,66188,,"34,077 x DRG weight",66188,Other,base rate x DRG weight,56261,,"28,966 x DRG weight",56261,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15923,,DRG base rate x DRG weight + capital per discharge,15923,Other,100% of NY Medicaid HMO DRG,15923,,100% x Medicaid HMO amount,15923,Other,100% of NY Medicaid HMO DRG,15923,,100% x Medicaid HMO amount,15923,Other,100% of NY Medicaid HMO DRG,15923,,100% x Medicaid HMO amount,15923,Other,100% of NY Medicaid HMO DRG,35827,,225% x Medicaid HMO amount,35827,Other,225% of NY Medicaid HMO DRG,35827,,225% x Medicaid HMO amount,35827,Other,225% of NY Medicaid HMO DRG,35827,,225% x Medicaid HMO amount,35827,Other,225% of NY Medicaid HMO DRG,35827,,225% x Medicaid HMO amount,35827,Other,225% of NY Medicaid HMO DRG,22292,,140% x Medicaid HMO amount,22292,Other,140% of NY Medicaid HMO DRG,35827,,225% x Medicaid HMO amount,35827,Other,225% of NY Medicaid HMO DRG,43788,,275% x Medicaid HMO amount,43788,Other,275% of NY Medicaid HMO DRG,51591,,324% x Medicaid HMO amount,51591,Other,324% of NY Medicaid HMO DRG,34234,,215% x Medicaid HMO amount,34234,Other,215% of NY Medicaid HMO DRG,34234,,215% x Medicaid HMO amount,34234,Other,215% of NY Medicaid HMO DRG,19904,,125% x Medicaid HMO amount,19904,Other,125% of NY Medicaid HMO DRG,0.01,87652,
Percutaneous coronary intervention w AMI,174-3,APR-DRG,,,,,,,,inpatient,,,313907.53,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,113109,,"45,128 x DRG weight",113109,Other,base rate x DRG weight,101797,,"40,615 x DRG weight",101797,Other,base rate x DRG weight,96143,,"38,359 x DRG weight",96143,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37777,,186% x Medicaid HMO amount,37777,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,85411,,"34,077 x DRG weight",85411,Other,base rate x DRG weight,72600,,"28,966 x DRG weight",72600,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20310,,DRG base rate x DRG weight + capital per discharge,20310,Other,100% of NY Medicaid HMO DRG,20310,,100% x Medicaid HMO amount,20310,Other,100% of NY Medicaid HMO DRG,20310,,100% x Medicaid HMO amount,20310,Other,100% of NY Medicaid HMO DRG,20310,,100% x Medicaid HMO amount,20310,Other,100% of NY Medicaid HMO DRG,45698,,225% x Medicaid HMO amount,45698,Other,225% of NY Medicaid HMO DRG,45698,,225% x Medicaid HMO amount,45698,Other,225% of NY Medicaid HMO DRG,45698,,225% x Medicaid HMO amount,45698,Other,225% of NY Medicaid HMO DRG,45698,,225% x Medicaid HMO amount,45698,Other,225% of NY Medicaid HMO DRG,28434,,140% x Medicaid HMO amount,28434,Other,140% of NY Medicaid HMO DRG,45698,,225% x Medicaid HMO amount,45698,Other,225% of NY Medicaid HMO DRG,55853,,275% x Medicaid HMO amount,55853,Other,275% of NY Medicaid HMO DRG,65804,,324% x Medicaid HMO amount,65804,Other,324% of NY Medicaid HMO DRG,43667,,215% x Medicaid HMO amount,43667,Other,215% of NY Medicaid HMO DRG,43667,,215% x Medicaid HMO amount,43667,Other,215% of NY Medicaid HMO DRG,25388,,125% x Medicaid HMO amount,25388,Other,125% of NY Medicaid HMO DRG,0.01,113109,
Percutaneous coronary intervention w AMI,174-4,APR-DRG,,,,,,,,inpatient,,,632784.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,172786,,"45,128 x DRG weight",172786,Other,base rate x DRG weight,155507,,"40,615 x DRG weight",155507,Other,base rate x DRG weight,146869,,"38,359 x DRG weight",146869,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56901,,186% x Medicaid HMO amount,56901,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,130474,,"34,077 x DRG weight",130474,Other,base rate x DRG weight,110905,,"28,966 x DRG weight",110905,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30592,,DRG base rate x DRG weight + capital per discharge,30592,Other,100% of NY Medicaid HMO DRG,30592,,100% x Medicaid HMO amount,30592,Other,100% of NY Medicaid HMO DRG,30592,,100% x Medicaid HMO amount,30592,Other,100% of NY Medicaid HMO DRG,30592,,100% x Medicaid HMO amount,30592,Other,100% of NY Medicaid HMO DRG,68832,,225% x Medicaid HMO amount,68832,Other,225% of NY Medicaid HMO DRG,68832,,225% x Medicaid HMO amount,68832,Other,225% of NY Medicaid HMO DRG,68832,,225% x Medicaid HMO amount,68832,Other,225% of NY Medicaid HMO DRG,68832,,225% x Medicaid HMO amount,68832,Other,225% of NY Medicaid HMO DRG,42829,,140% x Medicaid HMO amount,42829,Other,140% of NY Medicaid HMO DRG,68832,,225% x Medicaid HMO amount,68832,Other,225% of NY Medicaid HMO DRG,84128,,275% x Medicaid HMO amount,84128,Other,275% of NY Medicaid HMO DRG,99118,,324% x Medicaid HMO amount,99118,Other,324% of NY Medicaid HMO DRG,65773,,215% x Medicaid HMO amount,65773,Other,215% of NY Medicaid HMO DRG,65773,,215% x Medicaid HMO amount,65773,Other,215% of NY Medicaid HMO DRG,38240,,125% x Medicaid HMO amount,38240,Other,125% of NY Medicaid HMO DRG,0.01,172786,
Percutaneous coronary intervention w/o AMI,175-1,APR-DRG,,,,,,,,inpatient,,,201004.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,66582,,"45,128 x DRG weight",66582,Other,base rate x DRG weight,59923,,"40,615 x DRG weight",59923,Other,base rate x DRG weight,56595,,"38,359 x DRG weight",56595,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22865,,186% x Medicaid HMO amount,22865,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50277,,"34,077 x DRG weight",50277,Other,base rate x DRG weight,42736,,"28,966 x DRG weight",42736,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12293,,DRG base rate x DRG weight + capital per discharge,12293,Other,100% of NY Medicaid HMO DRG,12293,,100% x Medicaid HMO amount,12293,Other,100% of NY Medicaid HMO DRG,12293,,100% x Medicaid HMO amount,12293,Other,100% of NY Medicaid HMO DRG,12293,,100% x Medicaid HMO amount,12293,Other,100% of NY Medicaid HMO DRG,27659,,225% x Medicaid HMO amount,27659,Other,225% of NY Medicaid HMO DRG,27659,,225% x Medicaid HMO amount,27659,Other,225% of NY Medicaid HMO DRG,27659,,225% x Medicaid HMO amount,27659,Other,225% of NY Medicaid HMO DRG,27659,,225% x Medicaid HMO amount,27659,Other,225% of NY Medicaid HMO DRG,17210,,140% x Medicaid HMO amount,17210,Other,140% of NY Medicaid HMO DRG,27659,,225% x Medicaid HMO amount,27659,Other,225% of NY Medicaid HMO DRG,33806,,275% x Medicaid HMO amount,33806,Other,275% of NY Medicaid HMO DRG,39829,,324% x Medicaid HMO amount,39829,Other,324% of NY Medicaid HMO DRG,26430,,215% x Medicaid HMO amount,26430,Other,215% of NY Medicaid HMO DRG,26430,,215% x Medicaid HMO amount,26430,Other,215% of NY Medicaid HMO DRG,15366,,125% x Medicaid HMO amount,15366,Other,125% of NY Medicaid HMO DRG,0.01,66582,
Percutaneous coronary intervention w/o AMI,175-2,APR-DRG,,,,,,,,inpatient,,,455540.26,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,75549,,"45,128 x DRG weight",75549,Other,base rate x DRG weight,67994,,"40,615 x DRG weight",67994,Other,base rate x DRG weight,64217,,"38,359 x DRG weight",64217,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25739,,186% x Medicaid HMO amount,25739,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,57048,,"34,077 x DRG weight",57048,Other,base rate x DRG weight,48492,,"28,966 x DRG weight",48492,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13838,,DRG base rate x DRG weight + capital per discharge,13838,Other,100% of NY Medicaid HMO DRG,13838,,100% x Medicaid HMO amount,13838,Other,100% of NY Medicaid HMO DRG,13838,,100% x Medicaid HMO amount,13838,Other,100% of NY Medicaid HMO DRG,13838,,100% x Medicaid HMO amount,13838,Other,100% of NY Medicaid HMO DRG,31136,,225% x Medicaid HMO amount,31136,Other,225% of NY Medicaid HMO DRG,31136,,225% x Medicaid HMO amount,31136,Other,225% of NY Medicaid HMO DRG,31136,,225% x Medicaid HMO amount,31136,Other,225% of NY Medicaid HMO DRG,31136,,225% x Medicaid HMO amount,31136,Other,225% of NY Medicaid HMO DRG,19373,,140% x Medicaid HMO amount,19373,Other,140% of NY Medicaid HMO DRG,31136,,225% x Medicaid HMO amount,31136,Other,225% of NY Medicaid HMO DRG,38055,,275% x Medicaid HMO amount,38055,Other,275% of NY Medicaid HMO DRG,44835,,324% x Medicaid HMO amount,44835,Other,324% of NY Medicaid HMO DRG,29752,,215% x Medicaid HMO amount,29752,Other,215% of NY Medicaid HMO DRG,29752,,215% x Medicaid HMO amount,29752,Other,215% of NY Medicaid HMO DRG,17298,,125% x Medicaid HMO amount,17298,Other,125% of NY Medicaid HMO DRG,0.01,75549,
Percutaneous coronary intervention w/o AMI,175-3,APR-DRG,,,,,,,,inpatient,,,339435.21,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,109138,,"45,128 x DRG weight",109138,Other,base rate x DRG weight,98223,,"40,615 x DRG weight",98223,Other,base rate x DRG weight,92767,,"38,359 x DRG weight",92767,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36503,,186% x Medicaid HMO amount,36503,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,82412,,"34,077 x DRG weight",82412,Other,base rate x DRG weight,70051,,"28,966 x DRG weight",70051,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19625,,DRG base rate x DRG weight + capital per discharge,19625,Other,100% of NY Medicaid HMO DRG,19625,,100% x Medicaid HMO amount,19625,Other,100% of NY Medicaid HMO DRG,19625,,100% x Medicaid HMO amount,19625,Other,100% of NY Medicaid HMO DRG,19625,,100% x Medicaid HMO amount,19625,Other,100% of NY Medicaid HMO DRG,44156,,225% x Medicaid HMO amount,44156,Other,225% of NY Medicaid HMO DRG,44156,,225% x Medicaid HMO amount,44156,Other,225% of NY Medicaid HMO DRG,44156,,225% x Medicaid HMO amount,44156,Other,225% of NY Medicaid HMO DRG,44156,,225% x Medicaid HMO amount,44156,Other,225% of NY Medicaid HMO DRG,27475,,140% x Medicaid HMO amount,27475,Other,140% of NY Medicaid HMO DRG,44156,,225% x Medicaid HMO amount,44156,Other,225% of NY Medicaid HMO DRG,53969,,275% x Medicaid HMO amount,53969,Other,275% of NY Medicaid HMO DRG,63585,,324% x Medicaid HMO amount,63585,Other,324% of NY Medicaid HMO DRG,42194,,215% x Medicaid HMO amount,42194,Other,215% of NY Medicaid HMO DRG,42194,,215% x Medicaid HMO amount,42194,Other,215% of NY Medicaid HMO DRG,24531,,125% x Medicaid HMO amount,24531,Other,125% of NY Medicaid HMO DRG,0.01,109138,
Percutaneous coronary intervention w/o AMI,175-4,APR-DRG,,,,,,,,inpatient,,,658090.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,221610,,"45,128 x DRG weight",221610,Other,base rate x DRG weight,199448,,"40,615 x DRG weight",199448,Other,base rate x DRG weight,188370,,"38,359 x DRG weight",188370,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,72549,,186% x Medicaid HMO amount,72549,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,167342,,"34,077 x DRG weight",167342,Other,base rate x DRG weight,142243,,"28,966 x DRG weight",142243,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39005,,DRG base rate x DRG weight + capital per discharge,39005,Other,100% of NY Medicaid HMO DRG,39005,,100% x Medicaid HMO amount,39005,Other,100% of NY Medicaid HMO DRG,39005,,100% x Medicaid HMO amount,39005,Other,100% of NY Medicaid HMO DRG,39005,,100% x Medicaid HMO amount,39005,Other,100% of NY Medicaid HMO DRG,87761,,225% x Medicaid HMO amount,87761,Other,225% of NY Medicaid HMO DRG,87761,,225% x Medicaid HMO amount,87761,Other,225% of NY Medicaid HMO DRG,87761,,225% x Medicaid HMO amount,87761,Other,225% of NY Medicaid HMO DRG,87761,,225% x Medicaid HMO amount,87761,Other,225% of NY Medicaid HMO DRG,54607,,140% x Medicaid HMO amount,54607,Other,140% of NY Medicaid HMO DRG,87761,,225% x Medicaid HMO amount,87761,Other,225% of NY Medicaid HMO DRG,107264,,275% x Medicaid HMO amount,107264,Other,275% of NY Medicaid HMO DRG,126376,,324% x Medicaid HMO amount,126376,Other,324% of NY Medicaid HMO DRG,83861,,215% x Medicaid HMO amount,83861,Other,215% of NY Medicaid HMO DRG,83861,,215% x Medicaid HMO amount,83861,Other,215% of NY Medicaid HMO DRG,48756,,125% x Medicaid HMO amount,48756,Other,125% of NY Medicaid HMO DRG,0.01,221610,
Cardiac pacemaker & defibrillator device replacement,176-1,APR-DRG,,,,,,,,inpatient,,,449127.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,64664,,"45,128 x DRG weight",64664,Other,base rate x DRG weight,58197,,"40,615 x DRG weight",58197,Other,base rate x DRG weight,54965,,"38,359 x DRG weight",54965,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22251,,186% x Medicaid HMO amount,22251,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48829,,"34,077 x DRG weight",48829,Other,base rate x DRG weight,41505,,"28,966 x DRG weight",41505,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11963,,DRG base rate x DRG weight + capital per discharge,11963,Other,100% of NY Medicaid HMO DRG,11963,,100% x Medicaid HMO amount,11963,Other,100% of NY Medicaid HMO DRG,11963,,100% x Medicaid HMO amount,11963,Other,100% of NY Medicaid HMO DRG,11963,,100% x Medicaid HMO amount,11963,Other,100% of NY Medicaid HMO DRG,26917,,225% x Medicaid HMO amount,26917,Other,225% of NY Medicaid HMO DRG,26917,,225% x Medicaid HMO amount,26917,Other,225% of NY Medicaid HMO DRG,26917,,225% x Medicaid HMO amount,26917,Other,225% of NY Medicaid HMO DRG,26917,,225% x Medicaid HMO amount,26917,Other,225% of NY Medicaid HMO DRG,16748,,140% x Medicaid HMO amount,16748,Other,140% of NY Medicaid HMO DRG,26917,,225% x Medicaid HMO amount,26917,Other,225% of NY Medicaid HMO DRG,32898,,275% x Medicaid HMO amount,32898,Other,275% of NY Medicaid HMO DRG,38760,,324% x Medicaid HMO amount,38760,Other,324% of NY Medicaid HMO DRG,25720,,215% x Medicaid HMO amount,25720,Other,215% of NY Medicaid HMO DRG,25720,,215% x Medicaid HMO amount,25720,Other,215% of NY Medicaid HMO DRG,14954,,125% x Medicaid HMO amount,14954,Other,125% of NY Medicaid HMO DRG,0.01,64664,
Cardiac pacemaker & defibrillator device replacement,176-2,APR-DRG,,,,,,,,inpatient,,,449127.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,119156,,"45,128 x DRG weight",119156,Other,base rate x DRG weight,107240,,"40,615 x DRG weight",107240,Other,base rate x DRG weight,101283,,"38,359 x DRG weight",101283,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39715,,186% x Medicaid HMO amount,39715,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,89977,,"34,077 x DRG weight",89977,Other,base rate x DRG weight,76482,,"28,966 x DRG weight",76482,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21352,,DRG base rate x DRG weight + capital per discharge,21352,Other,100% of NY Medicaid HMO DRG,21352,,100% x Medicaid HMO amount,21352,Other,100% of NY Medicaid HMO DRG,21352,,100% x Medicaid HMO amount,21352,Other,100% of NY Medicaid HMO DRG,21352,,100% x Medicaid HMO amount,21352,Other,100% of NY Medicaid HMO DRG,48042,,225% x Medicaid HMO amount,48042,Other,225% of NY Medicaid HMO DRG,48042,,225% x Medicaid HMO amount,48042,Other,225% of NY Medicaid HMO DRG,48042,,225% x Medicaid HMO amount,48042,Other,225% of NY Medicaid HMO DRG,48042,,225% x Medicaid HMO amount,48042,Other,225% of NY Medicaid HMO DRG,29893,,140% x Medicaid HMO amount,29893,Other,140% of NY Medicaid HMO DRG,48042,,225% x Medicaid HMO amount,48042,Other,225% of NY Medicaid HMO DRG,58718,,275% x Medicaid HMO amount,58718,Other,275% of NY Medicaid HMO DRG,69180,,324% x Medicaid HMO amount,69180,Other,324% of NY Medicaid HMO DRG,45907,,215% x Medicaid HMO amount,45907,Other,215% of NY Medicaid HMO DRG,45907,,215% x Medicaid HMO amount,45907,Other,215% of NY Medicaid HMO DRG,26690,,125% x Medicaid HMO amount,26690,Other,125% of NY Medicaid HMO DRG,0.01,119156,
Cardiac pacemaker & defibrillator device replacement,176-3,APR-DRG,,,,,,,,inpatient,,,500234,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,151838,,"45,128 x DRG weight",151838,Other,base rate x DRG weight,136653,,"40,615 x DRG weight",136653,Other,base rate x DRG weight,129063,,"38,359 x DRG weight",129063,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50188,,186% x Medicaid HMO amount,50188,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,114655,,"34,077 x DRG weight",114655,Other,base rate x DRG weight,97459,,"28,966 x DRG weight",97459,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26983,,DRG base rate x DRG weight + capital per discharge,26983,Other,100% of NY Medicaid HMO DRG,26983,,100% x Medicaid HMO amount,26983,Other,100% of NY Medicaid HMO DRG,26983,,100% x Medicaid HMO amount,26983,Other,100% of NY Medicaid HMO DRG,26983,,100% x Medicaid HMO amount,26983,Other,100% of NY Medicaid HMO DRG,60712,,225% x Medicaid HMO amount,60712,Other,225% of NY Medicaid HMO DRG,60712,,225% x Medicaid HMO amount,60712,Other,225% of NY Medicaid HMO DRG,60712,,225% x Medicaid HMO amount,60712,Other,225% of NY Medicaid HMO DRG,60712,,225% x Medicaid HMO amount,60712,Other,225% of NY Medicaid HMO DRG,37776,,140% x Medicaid HMO amount,37776,Other,140% of NY Medicaid HMO DRG,60712,,225% x Medicaid HMO amount,60712,Other,225% of NY Medicaid HMO DRG,74203,,275% x Medicaid HMO amount,74203,Other,275% of NY Medicaid HMO DRG,87425,,324% x Medicaid HMO amount,87425,Other,324% of NY Medicaid HMO DRG,58013,,215% x Medicaid HMO amount,58013,Other,215% of NY Medicaid HMO DRG,58013,,215% x Medicaid HMO amount,58013,Other,215% of NY Medicaid HMO DRG,33729,,125% x Medicaid HMO amount,33729,Other,125% of NY Medicaid HMO DRG,0.01,151838,
Cardiac pacemaker & defibrillator device replacement,176-4,APR-DRG,,,,,,,,inpatient,,,901458.74,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,160254,,"45,128 x DRG weight",160254,Other,base rate x DRG weight,144228,,"40,615 x DRG weight",144228,Other,base rate x DRG weight,136217,,"38,359 x DRG weight",136217,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52885,,186% x Medicaid HMO amount,52885,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,121011,,"34,077 x DRG weight",121011,Other,base rate x DRG weight,102861,,"28,966 x DRG weight",102861,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28433,,DRG base rate x DRG weight + capital per discharge,28433,Other,100% of NY Medicaid HMO DRG,28433,,100% x Medicaid HMO amount,28433,Other,100% of NY Medicaid HMO DRG,28433,,100% x Medicaid HMO amount,28433,Other,100% of NY Medicaid HMO DRG,28433,,100% x Medicaid HMO amount,28433,Other,100% of NY Medicaid HMO DRG,63974,,225% x Medicaid HMO amount,63974,Other,225% of NY Medicaid HMO DRG,63974,,225% x Medicaid HMO amount,63974,Other,225% of NY Medicaid HMO DRG,63974,,225% x Medicaid HMO amount,63974,Other,225% of NY Medicaid HMO DRG,63974,,225% x Medicaid HMO amount,63974,Other,225% of NY Medicaid HMO DRG,39806,,140% x Medicaid HMO amount,39806,Other,140% of NY Medicaid HMO DRG,63974,,225% x Medicaid HMO amount,63974,Other,225% of NY Medicaid HMO DRG,78191,,275% x Medicaid HMO amount,78191,Other,275% of NY Medicaid HMO DRG,92123,,324% x Medicaid HMO amount,92123,Other,324% of NY Medicaid HMO DRG,61131,,215% x Medicaid HMO amount,61131,Other,215% of NY Medicaid HMO DRG,61131,,215% x Medicaid HMO amount,61131,Other,215% of NY Medicaid HMO DRG,35541,,125% x Medicaid HMO amount,35541,Other,125% of NY Medicaid HMO DRG,0.01,160254,
Cardiac pacemaker & defibrillator revision except device replacement,177-1,APR-DRG,,,,,,,,inpatient,,,157007,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,62917,,"45,128 x DRG weight",62917,Other,base rate x DRG weight,56625,,"40,615 x DRG weight",56625,Other,base rate x DRG weight,53480,,"38,359 x DRG weight",53480,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21691,,186% x Medicaid HMO amount,21691,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47510,,"34,077 x DRG weight",47510,Other,base rate x DRG weight,40384,,"28,966 x DRG weight",40384,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11662,,DRG base rate x DRG weight + capital per discharge,11662,Other,100% of NY Medicaid HMO DRG,11662,,100% x Medicaid HMO amount,11662,Other,100% of NY Medicaid HMO DRG,11662,,100% x Medicaid HMO amount,11662,Other,100% of NY Medicaid HMO DRG,11662,,100% x Medicaid HMO amount,11662,Other,100% of NY Medicaid HMO DRG,26240,,225% x Medicaid HMO amount,26240,Other,225% of NY Medicaid HMO DRG,26240,,225% x Medicaid HMO amount,26240,Other,225% of NY Medicaid HMO DRG,26240,,225% x Medicaid HMO amount,26240,Other,225% of NY Medicaid HMO DRG,26240,,225% x Medicaid HMO amount,26240,Other,225% of NY Medicaid HMO DRG,16327,,140% x Medicaid HMO amount,16327,Other,140% of NY Medicaid HMO DRG,26240,,225% x Medicaid HMO amount,26240,Other,225% of NY Medicaid HMO DRG,32071,,275% x Medicaid HMO amount,32071,Other,275% of NY Medicaid HMO DRG,37785,,324% x Medicaid HMO amount,37785,Other,324% of NY Medicaid HMO DRG,25073,,215% x Medicaid HMO amount,25073,Other,215% of NY Medicaid HMO DRG,25073,,215% x Medicaid HMO amount,25073,Other,215% of NY Medicaid HMO DRG,14578,,125% x Medicaid HMO amount,14578,Other,125% of NY Medicaid HMO DRG,0.01,62917,
Cardiac pacemaker & defibrillator revision except device replacement,177-2,APR-DRG,,,,,,,,inpatient,,,157007,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,78848,,"45,128 x DRG weight",78848,Other,base rate x DRG weight,70963,,"40,615 x DRG weight",70963,Other,base rate x DRG weight,67021,,"38,359 x DRG weight",67021,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26795,,186% x Medicaid HMO amount,26795,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59539,,"34,077 x DRG weight",59539,Other,base rate x DRG weight,50609,,"28,966 x DRG weight",50609,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14406,,DRG base rate x DRG weight + capital per discharge,14406,Other,100% of NY Medicaid HMO DRG,14406,,100% x Medicaid HMO amount,14406,Other,100% of NY Medicaid HMO DRG,14406,,100% x Medicaid HMO amount,14406,Other,100% of NY Medicaid HMO DRG,14406,,100% x Medicaid HMO amount,14406,Other,100% of NY Medicaid HMO DRG,32414,,225% x Medicaid HMO amount,32414,Other,225% of NY Medicaid HMO DRG,32414,,225% x Medicaid HMO amount,32414,Other,225% of NY Medicaid HMO DRG,32414,,225% x Medicaid HMO amount,32414,Other,225% of NY Medicaid HMO DRG,32414,,225% x Medicaid HMO amount,32414,Other,225% of NY Medicaid HMO DRG,20168,,140% x Medicaid HMO amount,20168,Other,140% of NY Medicaid HMO DRG,32414,,225% x Medicaid HMO amount,32414,Other,225% of NY Medicaid HMO DRG,39617,,275% x Medicaid HMO amount,39617,Other,275% of NY Medicaid HMO DRG,46675,,324% x Medicaid HMO amount,46675,Other,324% of NY Medicaid HMO DRG,30973,,215% x Medicaid HMO amount,30973,Other,215% of NY Medicaid HMO DRG,30973,,215% x Medicaid HMO amount,30973,Other,215% of NY Medicaid HMO DRG,18008,,125% x Medicaid HMO amount,18008,Other,125% of NY Medicaid HMO DRG,0.01,78848,
Cardiac pacemaker & defibrillator revision except device replacement,177-3,APR-DRG,,,,,,,,inpatient,,,348888.27,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,120970,,"45,128 x DRG weight",120970,Other,base rate x DRG weight,108873,,"40,615 x DRG weight",108873,Other,base rate x DRG weight,102825,,"38,359 x DRG weight",102825,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40295,,186% x Medicaid HMO amount,40295,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,91347,,"34,077 x DRG weight",91347,Other,base rate x DRG weight,77646,,"28,966 x DRG weight",77646,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21664,,DRG base rate x DRG weight + capital per discharge,21664,Other,100% of NY Medicaid HMO DRG,21664,,100% x Medicaid HMO amount,21664,Other,100% of NY Medicaid HMO DRG,21664,,100% x Medicaid HMO amount,21664,Other,100% of NY Medicaid HMO DRG,21664,,100% x Medicaid HMO amount,21664,Other,100% of NY Medicaid HMO DRG,48744,,225% x Medicaid HMO amount,48744,Other,225% of NY Medicaid HMO DRG,48744,,225% x Medicaid HMO amount,48744,Other,225% of NY Medicaid HMO DRG,48744,,225% x Medicaid HMO amount,48744,Other,225% of NY Medicaid HMO DRG,48744,,225% x Medicaid HMO amount,48744,Other,225% of NY Medicaid HMO DRG,30330,,140% x Medicaid HMO amount,30330,Other,140% of NY Medicaid HMO DRG,48744,,225% x Medicaid HMO amount,48744,Other,225% of NY Medicaid HMO DRG,59576,,275% x Medicaid HMO amount,59576,Other,275% of NY Medicaid HMO DRG,70191,,324% x Medicaid HMO amount,70191,Other,324% of NY Medicaid HMO DRG,46578,,215% x Medicaid HMO amount,46578,Other,215% of NY Medicaid HMO DRG,46578,,215% x Medicaid HMO amount,46578,Other,215% of NY Medicaid HMO DRG,27080,,125% x Medicaid HMO amount,27080,Other,125% of NY Medicaid HMO DRG,0.01,120970,
Cardiac pacemaker & defibrillator revision except device replacement,177-4,APR-DRG,,,,,,,,inpatient,,,170896,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,285868,,"45,128 x DRG weight",285868,Other,base rate x DRG weight,257280,,"40,615 x DRG weight",257280,Other,base rate x DRG weight,242989,,"38,359 x DRG weight",242989,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,93141,,186% x Medicaid HMO amount,93141,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,215864,,"34,077 x DRG weight",215864,Other,base rate x DRG weight,183488,,"28,966 x DRG weight",183488,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50076,,DRG base rate x DRG weight + capital per discharge,50076,Other,100% of NY Medicaid HMO DRG,50076,,100% x Medicaid HMO amount,50076,Other,100% of NY Medicaid HMO DRG,50076,,100% x Medicaid HMO amount,50076,Other,100% of NY Medicaid HMO DRG,50076,,100% x Medicaid HMO amount,50076,Other,100% of NY Medicaid HMO DRG,112671,,225% x Medicaid HMO amount,112671,Other,225% of NY Medicaid HMO DRG,112671,,225% x Medicaid HMO amount,112671,Other,225% of NY Medicaid HMO DRG,112671,,225% x Medicaid HMO amount,112671,Other,225% of NY Medicaid HMO DRG,112671,,225% x Medicaid HMO amount,112671,Other,225% of NY Medicaid HMO DRG,70106,,140% x Medicaid HMO amount,70106,Other,140% of NY Medicaid HMO DRG,112671,,225% x Medicaid HMO amount,112671,Other,225% of NY Medicaid HMO DRG,137709,,275% x Medicaid HMO amount,137709,Other,275% of NY Medicaid HMO DRG,162246,,324% x Medicaid HMO amount,162246,Other,324% of NY Medicaid HMO DRG,107663,,215% x Medicaid HMO amount,107663,Other,215% of NY Medicaid HMO DRG,107663,,215% x Medicaid HMO amount,107663,Other,215% of NY Medicaid HMO DRG,62595,,125% x Medicaid HMO amount,62595,Other,125% of NY Medicaid HMO DRG,0.01,285868,
Other circulatory system procedures,180-1,APR-DRG,,,,,,,,inpatient,,,333865.32,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51401,,"45,128 x DRG weight",51401,Other,base rate x DRG weight,46260,,"40,615 x DRG weight",46260,Other,base rate x DRG weight,43691,,"38,359 x DRG weight",43691,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17999,,186% x Medicaid HMO amount,17999,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38814,,"34,077 x DRG weight",38814,Other,base rate x DRG weight,32992,,"28,966 x DRG weight",32992,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9677,,DRG base rate x DRG weight + capital per discharge,9677,Other,100% of NY Medicaid HMO DRG,9677,,100% x Medicaid HMO amount,9677,Other,100% of NY Medicaid HMO DRG,9677,,100% x Medicaid HMO amount,9677,Other,100% of NY Medicaid HMO DRG,9677,,100% x Medicaid HMO amount,9677,Other,100% of NY Medicaid HMO DRG,21773,,225% x Medicaid HMO amount,21773,Other,225% of NY Medicaid HMO DRG,21773,,225% x Medicaid HMO amount,21773,Other,225% of NY Medicaid HMO DRG,21773,,225% x Medicaid HMO amount,21773,Other,225% of NY Medicaid HMO DRG,21773,,225% x Medicaid HMO amount,21773,Other,225% of NY Medicaid HMO DRG,13548,,140% x Medicaid HMO amount,13548,Other,140% of NY Medicaid HMO DRG,21773,,225% x Medicaid HMO amount,21773,Other,225% of NY Medicaid HMO DRG,26612,,275% x Medicaid HMO amount,26612,Other,275% of NY Medicaid HMO DRG,31353,,324% x Medicaid HMO amount,31353,Other,324% of NY Medicaid HMO DRG,20806,,215% x Medicaid HMO amount,20806,Other,215% of NY Medicaid HMO DRG,20806,,215% x Medicaid HMO amount,20806,Other,215% of NY Medicaid HMO DRG,12096,,125% x Medicaid HMO amount,12096,Other,125% of NY Medicaid HMO DRG,0.01,51401,
Other circulatory system procedures,180-2,APR-DRG,,,,,,,,inpatient,,,333865.32,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,74290,,"45,128 x DRG weight",74290,Other,base rate x DRG weight,66860,,"40,615 x DRG weight",66860,Other,base rate x DRG weight,63147,,"38,359 x DRG weight",63147,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25335,,186% x Medicaid HMO amount,25335,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56098,,"34,077 x DRG weight",56098,Other,base rate x DRG weight,47684,,"28,966 x DRG weight",47684,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13621,,DRG base rate x DRG weight + capital per discharge,13621,Other,100% of NY Medicaid HMO DRG,13621,,100% x Medicaid HMO amount,13621,Other,100% of NY Medicaid HMO DRG,13621,,100% x Medicaid HMO amount,13621,Other,100% of NY Medicaid HMO DRG,13621,,100% x Medicaid HMO amount,13621,Other,100% of NY Medicaid HMO DRG,30647,,225% x Medicaid HMO amount,30647,Other,225% of NY Medicaid HMO DRG,30647,,225% x Medicaid HMO amount,30647,Other,225% of NY Medicaid HMO DRG,30647,,225% x Medicaid HMO amount,30647,Other,225% of NY Medicaid HMO DRG,30647,,225% x Medicaid HMO amount,30647,Other,225% of NY Medicaid HMO DRG,19069,,140% x Medicaid HMO amount,19069,Other,140% of NY Medicaid HMO DRG,30647,,225% x Medicaid HMO amount,30647,Other,225% of NY Medicaid HMO DRG,37458,,275% x Medicaid HMO amount,37458,Other,275% of NY Medicaid HMO DRG,44132,,324% x Medicaid HMO amount,44132,Other,324% of NY Medicaid HMO DRG,29285,,215% x Medicaid HMO amount,29285,Other,215% of NY Medicaid HMO DRG,29285,,215% x Medicaid HMO amount,29285,Other,215% of NY Medicaid HMO DRG,17026,,125% x Medicaid HMO amount,17026,Other,125% of NY Medicaid HMO DRG,0.01,74290,
Other circulatory system procedures,180-3,APR-DRG,,,,,,,,inpatient,,,305442.72,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,109187,,"45,128 x DRG weight",109187,Other,base rate x DRG weight,98268,,"40,615 x DRG weight",98268,Other,base rate x DRG weight,92810,,"38,359 x DRG weight",92810,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36519,,186% x Medicaid HMO amount,36519,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,82449,,"34,077 x DRG weight",82449,Other,base rate x DRG weight,70083,,"28,966 x DRG weight",70083,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19634,,DRG base rate x DRG weight + capital per discharge,19634,Other,100% of NY Medicaid HMO DRG,19634,,100% x Medicaid HMO amount,19634,Other,100% of NY Medicaid HMO DRG,19634,,100% x Medicaid HMO amount,19634,Other,100% of NY Medicaid HMO DRG,19634,,100% x Medicaid HMO amount,19634,Other,100% of NY Medicaid HMO DRG,44177,,225% x Medicaid HMO amount,44177,Other,225% of NY Medicaid HMO DRG,44177,,225% x Medicaid HMO amount,44177,Other,225% of NY Medicaid HMO DRG,44177,,225% x Medicaid HMO amount,44177,Other,225% of NY Medicaid HMO DRG,44177,,225% x Medicaid HMO amount,44177,Other,225% of NY Medicaid HMO DRG,27488,,140% x Medicaid HMO amount,27488,Other,140% of NY Medicaid HMO DRG,44177,,225% x Medicaid HMO amount,44177,Other,225% of NY Medicaid HMO DRG,53994,,275% x Medicaid HMO amount,53994,Other,275% of NY Medicaid HMO DRG,63614,,324% x Medicaid HMO amount,63614,Other,324% of NY Medicaid HMO DRG,42213,,215% x Medicaid HMO amount,42213,Other,215% of NY Medicaid HMO DRG,42213,,215% x Medicaid HMO amount,42213,Other,215% of NY Medicaid HMO DRG,24543,,125% x Medicaid HMO amount,24543,Other,125% of NY Medicaid HMO DRG,0.01,109187,
Other circulatory system procedures,180-4,APR-DRG,,,,,,,,inpatient,,,617103.78,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,217476,,"45,128 x DRG weight",217476,Other,base rate x DRG weight,195728,,"40,615 x DRG weight",195728,Other,base rate x DRG weight,184856,,"38,359 x DRG weight",184856,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,71223,,186% x Medicaid HMO amount,71223,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,164220,,"34,077 x DRG weight",164220,Other,base rate x DRG weight,139590,,"28,966 x DRG weight",139590,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38292,,DRG base rate x DRG weight + capital per discharge,38292,Other,100% of NY Medicaid HMO DRG,38292,,100% x Medicaid HMO amount,38292,Other,100% of NY Medicaid HMO DRG,38292,,100% x Medicaid HMO amount,38292,Other,100% of NY Medicaid HMO DRG,38292,,100% x Medicaid HMO amount,38292,Other,100% of NY Medicaid HMO DRG,86157,,225% x Medicaid HMO amount,86157,Other,225% of NY Medicaid HMO DRG,86157,,225% x Medicaid HMO amount,86157,Other,225% of NY Medicaid HMO DRG,86157,,225% x Medicaid HMO amount,86157,Other,225% of NY Medicaid HMO DRG,86157,,225% x Medicaid HMO amount,86157,Other,225% of NY Medicaid HMO DRG,53609,,140% x Medicaid HMO amount,53609,Other,140% of NY Medicaid HMO DRG,86157,,225% x Medicaid HMO amount,86157,Other,225% of NY Medicaid HMO DRG,105303,,275% x Medicaid HMO amount,105303,Other,275% of NY Medicaid HMO DRG,124066,,324% x Medicaid HMO amount,124066,Other,324% of NY Medicaid HMO DRG,82328,,215% x Medicaid HMO amount,82328,Other,215% of NY Medicaid HMO DRG,82328,,215% x Medicaid HMO amount,82328,Other,215% of NY Medicaid HMO DRG,47865,,125% x Medicaid HMO amount,47865,Other,125% of NY Medicaid HMO DRG,0.01,217476,
Lower extremity arterial procedures #,181-1,APR-DRG,,,,,,,,inpatient,,,274129.69,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,64759,,"45,128 x DRG weight",64759,Other,base rate x DRG weight,58283,,"40,615 x DRG weight",58283,Other,base rate x DRG weight,55045,,"38,359 x DRG weight",55045,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22281,,186% x Medicaid HMO amount,22281,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48900,,"34,077 x DRG weight",48900,Other,base rate x DRG weight,41566,,"28,966 x DRG weight",41566,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11979,,DRG base rate x DRG weight + capital per discharge,11979,Other,100% of NY Medicaid HMO DRG,11979,,100% x Medicaid HMO amount,11979,Other,100% of NY Medicaid HMO DRG,11979,,100% x Medicaid HMO amount,11979,Other,100% of NY Medicaid HMO DRG,11979,,100% x Medicaid HMO amount,11979,Other,100% of NY Medicaid HMO DRG,26953,,225% x Medicaid HMO amount,26953,Other,225% of NY Medicaid HMO DRG,26953,,225% x Medicaid HMO amount,26953,Other,225% of NY Medicaid HMO DRG,26953,,225% x Medicaid HMO amount,26953,Other,225% of NY Medicaid HMO DRG,26953,,225% x Medicaid HMO amount,26953,Other,225% of NY Medicaid HMO DRG,16771,,140% x Medicaid HMO amount,16771,Other,140% of NY Medicaid HMO DRG,26953,,225% x Medicaid HMO amount,26953,Other,225% of NY Medicaid HMO DRG,32942,,275% x Medicaid HMO amount,32942,Other,275% of NY Medicaid HMO DRG,38812,,324% x Medicaid HMO amount,38812,Other,324% of NY Medicaid HMO DRG,25755,,215% x Medicaid HMO amount,25755,Other,215% of NY Medicaid HMO DRG,25755,,215% x Medicaid HMO amount,25755,Other,215% of NY Medicaid HMO DRG,14974,,125% x Medicaid HMO amount,14974,Other,125% of NY Medicaid HMO DRG,0.01,64759,
Lower extremity arterial procedures #,181-2,APR-DRG,,,,,,,,inpatient,,,245632.8,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,102788,,"45,128 x DRG weight",102788,Other,base rate x DRG weight,92509,,"40,615 x DRG weight",92509,Other,base rate x DRG weight,87370,,"38,359 x DRG weight",87370,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34468,,186% x Medicaid HMO amount,34468,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,77617,,"34,077 x DRG weight",77617,Other,base rate x DRG weight,65976,,"28,966 x DRG weight",65976,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18531,,DRG base rate x DRG weight + capital per discharge,18531,Other,100% of NY Medicaid HMO DRG,18531,,100% x Medicaid HMO amount,18531,Other,100% of NY Medicaid HMO DRG,18531,,100% x Medicaid HMO amount,18531,Other,100% of NY Medicaid HMO DRG,18531,,100% x Medicaid HMO amount,18531,Other,100% of NY Medicaid HMO DRG,41695,,225% x Medicaid HMO amount,41695,Other,225% of NY Medicaid HMO DRG,41695,,225% x Medicaid HMO amount,41695,Other,225% of NY Medicaid HMO DRG,41695,,225% x Medicaid HMO amount,41695,Other,225% of NY Medicaid HMO DRG,41695,,225% x Medicaid HMO amount,41695,Other,225% of NY Medicaid HMO DRG,25943,,140% x Medicaid HMO amount,25943,Other,140% of NY Medicaid HMO DRG,41695,,225% x Medicaid HMO amount,41695,Other,225% of NY Medicaid HMO DRG,50960,,275% x Medicaid HMO amount,50960,Other,275% of NY Medicaid HMO DRG,60040,,324% x Medicaid HMO amount,60040,Other,324% of NY Medicaid HMO DRG,39842,,215% x Medicaid HMO amount,39842,Other,215% of NY Medicaid HMO DRG,39842,,215% x Medicaid HMO amount,39842,Other,215% of NY Medicaid HMO DRG,23164,,125% x Medicaid HMO amount,23164,Other,125% of NY Medicaid HMO DRG,0.01,102788,
Lower extremity arterial procedures #,181-3,APR-DRG,,,,,,,,inpatient,,,733088.12,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,184587,,"45,128 x DRG weight",184587,Other,base rate x DRG weight,166128,,"40,615 x DRG weight",166128,Other,base rate x DRG weight,156900,,"38,359 x DRG weight",156900,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60683,,186% x Medicaid HMO amount,60683,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,139385,,"34,077 x DRG weight",139385,Other,base rate x DRG weight,118480,,"28,966 x DRG weight",118480,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32625,,DRG base rate x DRG weight + capital per discharge,32625,Other,100% of NY Medicaid HMO DRG,32625,,100% x Medicaid HMO amount,32625,Other,100% of NY Medicaid HMO DRG,32625,,100% x Medicaid HMO amount,32625,Other,100% of NY Medicaid HMO DRG,32625,,100% x Medicaid HMO amount,32625,Other,100% of NY Medicaid HMO DRG,73406,,225% x Medicaid HMO amount,73406,Other,225% of NY Medicaid HMO DRG,73406,,225% x Medicaid HMO amount,73406,Other,225% of NY Medicaid HMO DRG,73406,,225% x Medicaid HMO amount,73406,Other,225% of NY Medicaid HMO DRG,73406,,225% x Medicaid HMO amount,73406,Other,225% of NY Medicaid HMO DRG,45675,,140% x Medicaid HMO amount,45675,Other,140% of NY Medicaid HMO DRG,73406,,225% x Medicaid HMO amount,73406,Other,225% of NY Medicaid HMO DRG,89719,,275% x Medicaid HMO amount,89719,Other,275% of NY Medicaid HMO DRG,105705,,324% x Medicaid HMO amount,105705,Other,324% of NY Medicaid HMO DRG,70144,,215% x Medicaid HMO amount,70144,Other,215% of NY Medicaid HMO DRG,70144,,215% x Medicaid HMO amount,70144,Other,215% of NY Medicaid HMO DRG,40781,,125% x Medicaid HMO amount,40781,Other,125% of NY Medicaid HMO DRG,0.01,184587,
Lower extremity arterial procedures #,181-4,APR-DRG,,,,,,,,inpatient,,,854967.03,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,298589,,"45,128 x DRG weight",298589,Other,base rate x DRG weight,268729,,"40,615 x DRG weight",268729,Other,base rate x DRG weight,253802,,"38,359 x DRG weight",253802,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,97218,,186% x Medicaid HMO amount,97218,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,225470,,"34,077 x DRG weight",225470,Other,base rate x DRG weight,191654,,"28,966 x DRG weight",191654,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52268,,DRG base rate x DRG weight + capital per discharge,52268,Other,100% of NY Medicaid HMO DRG,52268,,100% x Medicaid HMO amount,52268,Other,100% of NY Medicaid HMO DRG,52268,,100% x Medicaid HMO amount,52268,Other,100% of NY Medicaid HMO DRG,52268,,100% x Medicaid HMO amount,52268,Other,100% of NY Medicaid HMO DRG,117603,,225% x Medicaid HMO amount,117603,Other,225% of NY Medicaid HMO DRG,117603,,225% x Medicaid HMO amount,117603,Other,225% of NY Medicaid HMO DRG,117603,,225% x Medicaid HMO amount,117603,Other,225% of NY Medicaid HMO DRG,117603,,225% x Medicaid HMO amount,117603,Other,225% of NY Medicaid HMO DRG,73175,,140% x Medicaid HMO amount,73175,Other,140% of NY Medicaid HMO DRG,117603,,225% x Medicaid HMO amount,117603,Other,225% of NY Medicaid HMO DRG,143737,,275% x Medicaid HMO amount,143737,Other,275% of NY Medicaid HMO DRG,169348,,324% x Medicaid HMO amount,169348,Other,324% of NY Medicaid HMO DRG,112376,,215% x Medicaid HMO amount,112376,Other,215% of NY Medicaid HMO DRG,112376,,215% x Medicaid HMO amount,112376,Other,215% of NY Medicaid HMO DRG,65335,,125% x Medicaid HMO amount,65335,Other,125% of NY Medicaid HMO DRG,0.01,298589,
Other peripheral vascular procedures #,182-1,APR-DRG,,,,,,,,inpatient,,,119359.66,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,67710,,"45,128 x DRG weight",67710,Other,base rate x DRG weight,60939,,"40,615 x DRG weight",60939,Other,base rate x DRG weight,57554,,"38,359 x DRG weight",57554,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23226,,186% x Medicaid HMO amount,23226,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51129,,"34,077 x DRG weight",51129,Other,base rate x DRG weight,43461,,"28,966 x DRG weight",43461,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12487,,DRG base rate x DRG weight + capital per discharge,12487,Other,100% of NY Medicaid HMO DRG,12487,,100% x Medicaid HMO amount,12487,Other,100% of NY Medicaid HMO DRG,12487,,100% x Medicaid HMO amount,12487,Other,100% of NY Medicaid HMO DRG,12487,,100% x Medicaid HMO amount,12487,Other,100% of NY Medicaid HMO DRG,28096,,225% x Medicaid HMO amount,28096,Other,225% of NY Medicaid HMO DRG,28096,,225% x Medicaid HMO amount,28096,Other,225% of NY Medicaid HMO DRG,28096,,225% x Medicaid HMO amount,28096,Other,225% of NY Medicaid HMO DRG,28096,,225% x Medicaid HMO amount,28096,Other,225% of NY Medicaid HMO DRG,17482,,140% x Medicaid HMO amount,17482,Other,140% of NY Medicaid HMO DRG,28096,,225% x Medicaid HMO amount,28096,Other,225% of NY Medicaid HMO DRG,34339,,275% x Medicaid HMO amount,34339,Other,275% of NY Medicaid HMO DRG,40458,,324% x Medicaid HMO amount,40458,Other,324% of NY Medicaid HMO DRG,26847,,215% x Medicaid HMO amount,26847,Other,215% of NY Medicaid HMO DRG,26847,,215% x Medicaid HMO amount,26847,Other,215% of NY Medicaid HMO DRG,15609,,125% x Medicaid HMO amount,15609,Other,125% of NY Medicaid HMO DRG,0.01,67710,
Other peripheral vascular procedures #,182-2,APR-DRG,,,,,,,,inpatient,,,401770.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,95581,,"45,128 x DRG weight",95581,Other,base rate x DRG weight,86023,,"40,615 x DRG weight",86023,Other,base rate x DRG weight,81244,,"38,359 x DRG weight",81244,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32159,,186% x Medicaid HMO amount,32159,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,72175,,"34,077 x DRG weight",72175,Other,base rate x DRG weight,61350,,"28,966 x DRG weight",61350,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17290,,DRG base rate x DRG weight + capital per discharge,17290,Other,100% of NY Medicaid HMO DRG,17290,,100% x Medicaid HMO amount,17290,Other,100% of NY Medicaid HMO DRG,17290,,100% x Medicaid HMO amount,17290,Other,100% of NY Medicaid HMO DRG,17290,,100% x Medicaid HMO amount,17290,Other,100% of NY Medicaid HMO DRG,38903,,225% x Medicaid HMO amount,38903,Other,225% of NY Medicaid HMO DRG,38903,,225% x Medicaid HMO amount,38903,Other,225% of NY Medicaid HMO DRG,38903,,225% x Medicaid HMO amount,38903,Other,225% of NY Medicaid HMO DRG,38903,,225% x Medicaid HMO amount,38903,Other,225% of NY Medicaid HMO DRG,24206,,140% x Medicaid HMO amount,24206,Other,140% of NY Medicaid HMO DRG,38903,,225% x Medicaid HMO amount,38903,Other,225% of NY Medicaid HMO DRG,47548,,275% x Medicaid HMO amount,47548,Other,275% of NY Medicaid HMO DRG,56020,,324% x Medicaid HMO amount,56020,Other,324% of NY Medicaid HMO DRG,37174,,215% x Medicaid HMO amount,37174,Other,215% of NY Medicaid HMO DRG,37174,,215% x Medicaid HMO amount,37174,Other,215% of NY Medicaid HMO DRG,21613,,125% x Medicaid HMO amount,21613,Other,125% of NY Medicaid HMO DRG,0.01,95581,
Other peripheral vascular procedures #,182-3,APR-DRG,,,,,,,,inpatient,,,658418.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,145493,,"45,128 x DRG weight",145493,Other,base rate x DRG weight,130943,,"40,615 x DRG weight",130943,Other,base rate x DRG weight,123669,,"38,359 x DRG weight",123669,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48154,,186% x Medicaid HMO amount,48154,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,109864,,"34,077 x DRG weight",109864,Other,base rate x DRG weight,93386,,"28,966 x DRG weight",93386,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25889,,DRG base rate x DRG weight + capital per discharge,25889,Other,100% of NY Medicaid HMO DRG,25889,,100% x Medicaid HMO amount,25889,Other,100% of NY Medicaid HMO DRG,25889,,100% x Medicaid HMO amount,25889,Other,100% of NY Medicaid HMO DRG,25889,,100% x Medicaid HMO amount,25889,Other,100% of NY Medicaid HMO DRG,58250,,225% x Medicaid HMO amount,58250,Other,225% of NY Medicaid HMO DRG,58250,,225% x Medicaid HMO amount,58250,Other,225% of NY Medicaid HMO DRG,58250,,225% x Medicaid HMO amount,58250,Other,225% of NY Medicaid HMO DRG,58250,,225% x Medicaid HMO amount,58250,Other,225% of NY Medicaid HMO DRG,36245,,140% x Medicaid HMO amount,36245,Other,140% of NY Medicaid HMO DRG,58250,,225% x Medicaid HMO amount,58250,Other,225% of NY Medicaid HMO DRG,71195,,275% x Medicaid HMO amount,71195,Other,275% of NY Medicaid HMO DRG,83880,,324% x Medicaid HMO amount,83880,Other,324% of NY Medicaid HMO DRG,55661,,215% x Medicaid HMO amount,55661,Other,215% of NY Medicaid HMO DRG,55661,,215% x Medicaid HMO amount,55661,Other,215% of NY Medicaid HMO DRG,32361,,125% x Medicaid HMO amount,32361,Other,125% of NY Medicaid HMO DRG,0.01,145493,
Other peripheral vascular procedures #,182-4,APR-DRG,,,,,,,,inpatient,,,611609.16,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,283043,,"45,128 x DRG weight",283043,Other,base rate x DRG weight,254737,,"40,615 x DRG weight",254737,Other,base rate x DRG weight,240588,,"38,359 x DRG weight",240588,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,92237,,186% x Medicaid HMO amount,92237,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,213731,,"34,077 x DRG weight",213731,Other,base rate x DRG weight,181675,,"28,966 x DRG weight",181675,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49590,,DRG base rate x DRG weight + capital per discharge,49590,Other,100% of NY Medicaid HMO DRG,49590,,100% x Medicaid HMO amount,49590,Other,100% of NY Medicaid HMO DRG,49590,,100% x Medicaid HMO amount,49590,Other,100% of NY Medicaid HMO DRG,49590,,100% x Medicaid HMO amount,49590,Other,100% of NY Medicaid HMO DRG,111578,,225% x Medicaid HMO amount,111578,Other,225% of NY Medicaid HMO DRG,111578,,225% x Medicaid HMO amount,111578,Other,225% of NY Medicaid HMO DRG,111578,,225% x Medicaid HMO amount,111578,Other,225% of NY Medicaid HMO DRG,111578,,225% x Medicaid HMO amount,111578,Other,225% of NY Medicaid HMO DRG,69426,,140% x Medicaid HMO amount,69426,Other,140% of NY Medicaid HMO DRG,111578,,225% x Medicaid HMO amount,111578,Other,225% of NY Medicaid HMO DRG,136373,,275% x Medicaid HMO amount,136373,Other,275% of NY Medicaid HMO DRG,160672,,324% x Medicaid HMO amount,160672,Other,324% of NY Medicaid HMO DRG,106619,,215% x Medicaid HMO amount,106619,Other,215% of NY Medicaid HMO DRG,106619,,215% x Medicaid HMO amount,106619,Other,215% of NY Medicaid HMO DRG,61988,,125% x Medicaid HMO amount,61988,Other,125% of NY Medicaid HMO DRG,0.01,283043,
Acute myocardial infarction,190-1,APR-DRG,,,,,,,,inpatient,,,121278.26,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33201,,"45,128 x DRG weight",33201,Other,base rate x DRG weight,29880,,"40,615 x DRG weight",29880,Other,base rate x DRG weight,28221,,"38,359 x DRG weight",28221,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12166,,186% x Medicaid HMO amount,12166,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25070,,"34,077 x DRG weight",25070,Other,base rate x DRG weight,21310,,"28,966 x DRG weight",21310,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6541,,DRG base rate x DRG weight + capital per discharge,6541,Other,100% of NY Medicaid HMO DRG,6541,,100% x Medicaid HMO amount,6541,Other,100% of NY Medicaid HMO DRG,6541,,100% x Medicaid HMO amount,6541,Other,100% of NY Medicaid HMO DRG,6541,,100% x Medicaid HMO amount,6541,Other,100% of NY Medicaid HMO DRG,14717,,225% x Medicaid HMO amount,14717,Other,225% of NY Medicaid HMO DRG,14717,,225% x Medicaid HMO amount,14717,Other,225% of NY Medicaid HMO DRG,14717,,225% x Medicaid HMO amount,14717,Other,225% of NY Medicaid HMO DRG,14717,,225% x Medicaid HMO amount,14717,Other,225% of NY Medicaid HMO DRG,9157,,140% x Medicaid HMO amount,9157,Other,140% of NY Medicaid HMO DRG,14717,,225% x Medicaid HMO amount,14717,Other,225% of NY Medicaid HMO DRG,17988,,275% x Medicaid HMO amount,17988,Other,275% of NY Medicaid HMO DRG,21193,,324% x Medicaid HMO amount,21193,Other,324% of NY Medicaid HMO DRG,14063,,215% x Medicaid HMO amount,14063,Other,215% of NY Medicaid HMO DRG,14063,,215% x Medicaid HMO amount,14063,Other,215% of NY Medicaid HMO DRG,8176,,125% x Medicaid HMO amount,8176,Other,125% of NY Medicaid HMO DRG,0.01,33201,
Acute myocardial infarction,190-2,APR-DRG,,,,,,,,inpatient,,,113366.49,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43246,,"45,128 x DRG weight",43246,Other,base rate x DRG weight,38921,,"40,615 x DRG weight",38921,Other,base rate x DRG weight,36759,,"38,359 x DRG weight",36759,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15386,,186% x Medicaid HMO amount,15386,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32656,,"34,077 x DRG weight",32656,Other,base rate x DRG weight,27758,,"28,966 x DRG weight",27758,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8272,,DRG base rate x DRG weight + capital per discharge,8272,Other,100% of NY Medicaid HMO DRG,8272,,100% x Medicaid HMO amount,8272,Other,100% of NY Medicaid HMO DRG,8272,,100% x Medicaid HMO amount,8272,Other,100% of NY Medicaid HMO DRG,8272,,100% x Medicaid HMO amount,8272,Other,100% of NY Medicaid HMO DRG,18612,,225% x Medicaid HMO amount,18612,Other,225% of NY Medicaid HMO DRG,18612,,225% x Medicaid HMO amount,18612,Other,225% of NY Medicaid HMO DRG,18612,,225% x Medicaid HMO amount,18612,Other,225% of NY Medicaid HMO DRG,18612,,225% x Medicaid HMO amount,18612,Other,225% of NY Medicaid HMO DRG,11581,,140% x Medicaid HMO amount,11581,Other,140% of NY Medicaid HMO DRG,18612,,225% x Medicaid HMO amount,18612,Other,225% of NY Medicaid HMO DRG,22748,,275% x Medicaid HMO amount,22748,Other,275% of NY Medicaid HMO DRG,26801,,324% x Medicaid HMO amount,26801,Other,324% of NY Medicaid HMO DRG,17785,,215% x Medicaid HMO amount,17785,Other,215% of NY Medicaid HMO DRG,17785,,215% x Medicaid HMO amount,17785,Other,215% of NY Medicaid HMO DRG,10340,,125% x Medicaid HMO amount,10340,Other,125% of NY Medicaid HMO DRG,0.01,43246,
Acute myocardial infarction,190-3,APR-DRG,,,,,,,,inpatient,,,161463.7,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,65472,,"45,128 x DRG weight",65472,Other,base rate x DRG weight,58924,,"40,615 x DRG weight",58924,Other,base rate x DRG weight,55651,,"38,359 x DRG weight",55651,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22510,,186% x Medicaid HMO amount,22510,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49439,,"34,077 x DRG weight",49439,Other,base rate x DRG weight,42024,,"28,966 x DRG weight",42024,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12102,,DRG base rate x DRG weight + capital per discharge,12102,Other,100% of NY Medicaid HMO DRG,12102,,100% x Medicaid HMO amount,12102,Other,100% of NY Medicaid HMO DRG,12102,,100% x Medicaid HMO amount,12102,Other,100% of NY Medicaid HMO DRG,12102,,100% x Medicaid HMO amount,12102,Other,100% of NY Medicaid HMO DRG,27230,,225% x Medicaid HMO amount,27230,Other,225% of NY Medicaid HMO DRG,27230,,225% x Medicaid HMO amount,27230,Other,225% of NY Medicaid HMO DRG,27230,,225% x Medicaid HMO amount,27230,Other,225% of NY Medicaid HMO DRG,27230,,225% x Medicaid HMO amount,27230,Other,225% of NY Medicaid HMO DRG,16943,,140% x Medicaid HMO amount,16943,Other,140% of NY Medicaid HMO DRG,27230,,225% x Medicaid HMO amount,27230,Other,225% of NY Medicaid HMO DRG,33281,,275% x Medicaid HMO amount,33281,Other,275% of NY Medicaid HMO DRG,39210,,324% x Medicaid HMO amount,39210,Other,324% of NY Medicaid HMO DRG,26019,,215% x Medicaid HMO amount,26019,Other,215% of NY Medicaid HMO DRG,26019,,215% x Medicaid HMO amount,26019,Other,215% of NY Medicaid HMO DRG,15128,,125% x Medicaid HMO amount,15128,Other,125% of NY Medicaid HMO DRG,0.01,65472,
Acute myocardial infarction,190-4,APR-DRG,,,,,,,,inpatient,,,350968.47,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,126954,,"45,128 x DRG weight",126954,Other,base rate x DRG weight,114258,,"40,615 x DRG weight",114258,Other,base rate x DRG weight,107912,,"38,359 x DRG weight",107912,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42213,,186% x Medicaid HMO amount,42213,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,95865,,"34,077 x DRG weight",95865,Other,base rate x DRG weight,81487,,"28,966 x DRG weight",81487,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22695,,DRG base rate x DRG weight + capital per discharge,22695,Other,100% of NY Medicaid HMO DRG,22695,,100% x Medicaid HMO amount,22695,Other,100% of NY Medicaid HMO DRG,22695,,100% x Medicaid HMO amount,22695,Other,100% of NY Medicaid HMO DRG,22695,,100% x Medicaid HMO amount,22695,Other,100% of NY Medicaid HMO DRG,51064,,225% x Medicaid HMO amount,51064,Other,225% of NY Medicaid HMO DRG,51064,,225% x Medicaid HMO amount,51064,Other,225% of NY Medicaid HMO DRG,51064,,225% x Medicaid HMO amount,51064,Other,225% of NY Medicaid HMO DRG,51064,,225% x Medicaid HMO amount,51064,Other,225% of NY Medicaid HMO DRG,31773,,140% x Medicaid HMO amount,31773,Other,140% of NY Medicaid HMO DRG,51064,,225% x Medicaid HMO amount,51064,Other,225% of NY Medicaid HMO DRG,62411,,275% x Medicaid HMO amount,62411,Other,275% of NY Medicaid HMO DRG,73532,,324% x Medicaid HMO amount,73532,Other,324% of NY Medicaid HMO DRG,48794,,215% x Medicaid HMO amount,48794,Other,215% of NY Medicaid HMO DRG,48794,,215% x Medicaid HMO amount,48794,Other,215% of NY Medicaid HMO DRG,28369,,125% x Medicaid HMO amount,28369,Other,125% of NY Medicaid HMO DRG,0.01,126954,
Cardiac catheterization for coronary artery disease,191-1,APR-DRG,,,,,,,,inpatient,,,161517.61,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32357,,"45,128 x DRG weight",32357,Other,base rate x DRG weight,29121,,"40,615 x DRG weight",29121,Other,base rate x DRG weight,27503,,"38,359 x DRG weight",27503,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11897,,186% x Medicaid HMO amount,11897,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24433,,"34,077 x DRG weight",24433,Other,base rate x DRG weight,20769,,"28,966 x DRG weight",20769,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6396,,DRG base rate x DRG weight + capital per discharge,6396,Other,100% of NY Medicaid HMO DRG,6396,,100% x Medicaid HMO amount,6396,Other,100% of NY Medicaid HMO DRG,6396,,100% x Medicaid HMO amount,6396,Other,100% of NY Medicaid HMO DRG,6396,,100% x Medicaid HMO amount,6396,Other,100% of NY Medicaid HMO DRG,14391,,225% x Medicaid HMO amount,14391,Other,225% of NY Medicaid HMO DRG,14391,,225% x Medicaid HMO amount,14391,Other,225% of NY Medicaid HMO DRG,14391,,225% x Medicaid HMO amount,14391,Other,225% of NY Medicaid HMO DRG,14391,,225% x Medicaid HMO amount,14391,Other,225% of NY Medicaid HMO DRG,8954,,140% x Medicaid HMO amount,8954,Other,140% of NY Medicaid HMO DRG,14391,,225% x Medicaid HMO amount,14391,Other,225% of NY Medicaid HMO DRG,17589,,275% x Medicaid HMO amount,17589,Other,275% of NY Medicaid HMO DRG,20723,,324% x Medicaid HMO amount,20723,Other,324% of NY Medicaid HMO DRG,13751,,215% x Medicaid HMO amount,13751,Other,215% of NY Medicaid HMO DRG,13751,,215% x Medicaid HMO amount,13751,Other,215% of NY Medicaid HMO DRG,7995,,125% x Medicaid HMO amount,7995,Other,125% of NY Medicaid HMO DRG,0.01,32357,
Cardiac catheterization for coronary artery disease,191-2,APR-DRG,,,,,,,,inpatient,,,285660.87,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39541,,"45,128 x DRG weight",39541,Other,base rate x DRG weight,35587,,"40,615 x DRG weight",35587,Other,base rate x DRG weight,33610,,"38,359 x DRG weight",33610,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14199,,186% x Medicaid HMO amount,14199,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29858,,"34,077 x DRG weight",29858,Other,base rate x DRG weight,25380,,"28,966 x DRG weight",25380,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7634,,DRG base rate x DRG weight + capital per discharge,7634,Other,100% of NY Medicaid HMO DRG,7634,,100% x Medicaid HMO amount,7634,Other,100% of NY Medicaid HMO DRG,7634,,100% x Medicaid HMO amount,7634,Other,100% of NY Medicaid HMO DRG,7634,,100% x Medicaid HMO amount,7634,Other,100% of NY Medicaid HMO DRG,17177,,225% x Medicaid HMO amount,17177,Other,225% of NY Medicaid HMO DRG,17177,,225% x Medicaid HMO amount,17177,Other,225% of NY Medicaid HMO DRG,17177,,225% x Medicaid HMO amount,17177,Other,225% of NY Medicaid HMO DRG,17177,,225% x Medicaid HMO amount,17177,Other,225% of NY Medicaid HMO DRG,10688,,140% x Medicaid HMO amount,10688,Other,140% of NY Medicaid HMO DRG,17177,,225% x Medicaid HMO amount,17177,Other,225% of NY Medicaid HMO DRG,20994,,275% x Medicaid HMO amount,20994,Other,275% of NY Medicaid HMO DRG,24734,,324% x Medicaid HMO amount,24734,Other,324% of NY Medicaid HMO DRG,16413,,215% x Medicaid HMO amount,16413,Other,215% of NY Medicaid HMO DRG,16413,,215% x Medicaid HMO amount,16413,Other,215% of NY Medicaid HMO DRG,9543,,125% x Medicaid HMO amount,9543,Other,125% of NY Medicaid HMO DRG,0.01,39541,
Cardiac catheterization for coronary artery disease,191-3,APR-DRG,,,,,,,,inpatient,,,378281.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,64384,,"45,128 x DRG weight",64384,Other,base rate x DRG weight,57945,,"40,615 x DRG weight",57945,Other,base rate x DRG weight,54727,,"38,359 x DRG weight",54727,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22160,,186% x Medicaid HMO amount,22160,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48618,,"34,077 x DRG weight",48618,Other,base rate x DRG weight,41326,,"28,966 x DRG weight",41326,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11914,,DRG base rate x DRG weight + capital per discharge,11914,Other,100% of NY Medicaid HMO DRG,11914,,100% x Medicaid HMO amount,11914,Other,100% of NY Medicaid HMO DRG,11914,,100% x Medicaid HMO amount,11914,Other,100% of NY Medicaid HMO DRG,11914,,100% x Medicaid HMO amount,11914,Other,100% of NY Medicaid HMO DRG,26807,,225% x Medicaid HMO amount,26807,Other,225% of NY Medicaid HMO DRG,26807,,225% x Medicaid HMO amount,26807,Other,225% of NY Medicaid HMO DRG,26807,,225% x Medicaid HMO amount,26807,Other,225% of NY Medicaid HMO DRG,26807,,225% x Medicaid HMO amount,26807,Other,225% of NY Medicaid HMO DRG,16680,,140% x Medicaid HMO amount,16680,Other,140% of NY Medicaid HMO DRG,26807,,225% x Medicaid HMO amount,26807,Other,225% of NY Medicaid HMO DRG,32764,,275% x Medicaid HMO amount,32764,Other,275% of NY Medicaid HMO DRG,38601,,324% x Medicaid HMO amount,38601,Other,324% of NY Medicaid HMO DRG,25615,,215% x Medicaid HMO amount,25615,Other,215% of NY Medicaid HMO DRG,25615,,215% x Medicaid HMO amount,25615,Other,215% of NY Medicaid HMO DRG,14893,,125% x Medicaid HMO amount,14893,Other,125% of NY Medicaid HMO DRG,0.01,64384,
Cardiac catheterization for coronary artery disease,191-4,APR-DRG,,,,,,,,inpatient,,,378281.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,119476,,"45,128 x DRG weight",119476,Other,base rate x DRG weight,107528,,"40,615 x DRG weight",107528,Other,base rate x DRG weight,101555,,"38,359 x DRG weight",101555,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39817,,186% x Medicaid HMO amount,39817,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,90219,,"34,077 x DRG weight",90219,Other,base rate x DRG weight,76687,,"28,966 x DRG weight",76687,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21407,,DRG base rate x DRG weight + capital per discharge,21407,Other,100% of NY Medicaid HMO DRG,21407,,100% x Medicaid HMO amount,21407,Other,100% of NY Medicaid HMO DRG,21407,,100% x Medicaid HMO amount,21407,Other,100% of NY Medicaid HMO DRG,21407,,100% x Medicaid HMO amount,21407,Other,100% of NY Medicaid HMO DRG,48166,,225% x Medicaid HMO amount,48166,Other,225% of NY Medicaid HMO DRG,48166,,225% x Medicaid HMO amount,48166,Other,225% of NY Medicaid HMO DRG,48166,,225% x Medicaid HMO amount,48166,Other,225% of NY Medicaid HMO DRG,48166,,225% x Medicaid HMO amount,48166,Other,225% of NY Medicaid HMO DRG,29970,,140% x Medicaid HMO amount,29970,Other,140% of NY Medicaid HMO DRG,48166,,225% x Medicaid HMO amount,48166,Other,225% of NY Medicaid HMO DRG,58869,,275% x Medicaid HMO amount,58869,Other,275% of NY Medicaid HMO DRG,69359,,324% x Medicaid HMO amount,69359,Other,324% of NY Medicaid HMO DRG,46025,,215% x Medicaid HMO amount,46025,Other,215% of NY Medicaid HMO DRG,46025,,215% x Medicaid HMO amount,46025,Other,215% of NY Medicaid HMO DRG,26759,,125% x Medicaid HMO amount,26759,Other,125% of NY Medicaid HMO DRG,0.01,119476,
Cardiac catheterization for other non-coronary conditions,192-1,APR-DRG,,,,,,,,inpatient,,,161036.98,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32406,,"45,128 x DRG weight",32406,Other,base rate x DRG weight,29166,,"40,615 x DRG weight",29166,Other,base rate x DRG weight,27546,,"38,359 x DRG weight",27546,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11913,,186% x Medicaid HMO amount,11913,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24471,,"34,077 x DRG weight",24471,Other,base rate x DRG weight,20800,,"28,966 x DRG weight",20800,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6405,,DRG base rate x DRG weight + capital per discharge,6405,Other,100% of NY Medicaid HMO DRG,6405,,100% x Medicaid HMO amount,6405,Other,100% of NY Medicaid HMO DRG,6405,,100% x Medicaid HMO amount,6405,Other,100% of NY Medicaid HMO DRG,6405,,100% x Medicaid HMO amount,6405,Other,100% of NY Medicaid HMO DRG,14411,,225% x Medicaid HMO amount,14411,Other,225% of NY Medicaid HMO DRG,14411,,225% x Medicaid HMO amount,14411,Other,225% of NY Medicaid HMO DRG,14411,,225% x Medicaid HMO amount,14411,Other,225% of NY Medicaid HMO DRG,14411,,225% x Medicaid HMO amount,14411,Other,225% of NY Medicaid HMO DRG,8967,,140% x Medicaid HMO amount,8967,Other,140% of NY Medicaid HMO DRG,14411,,225% x Medicaid HMO amount,14411,Other,225% of NY Medicaid HMO DRG,17614,,275% x Medicaid HMO amount,17614,Other,275% of NY Medicaid HMO DRG,20752,,324% x Medicaid HMO amount,20752,Other,324% of NY Medicaid HMO DRG,13771,,215% x Medicaid HMO amount,13771,Other,215% of NY Medicaid HMO DRG,13771,,215% x Medicaid HMO amount,13771,Other,215% of NY Medicaid HMO DRG,8006,,125% x Medicaid HMO amount,8006,Other,125% of NY Medicaid HMO DRG,0.01,32406,
Cardiac catheterization for other non-coronary conditions,192-2,APR-DRG,,,,,,,,inpatient,,,226320.14,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46003,,"45,128 x DRG weight",46003,Other,base rate x DRG weight,41403,,"40,615 x DRG weight",41403,Other,base rate x DRG weight,39103,,"38,359 x DRG weight",39103,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16269,,186% x Medicaid HMO amount,16269,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34738,,"34,077 x DRG weight",34738,Other,base rate x DRG weight,29528,,"28,966 x DRG weight",29528,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8747,,DRG base rate x DRG weight + capital per discharge,8747,Other,100% of NY Medicaid HMO DRG,8747,,100% x Medicaid HMO amount,8747,Other,100% of NY Medicaid HMO DRG,8747,,100% x Medicaid HMO amount,8747,Other,100% of NY Medicaid HMO DRG,8747,,100% x Medicaid HMO amount,8747,Other,100% of NY Medicaid HMO DRG,19681,,225% x Medicaid HMO amount,19681,Other,225% of NY Medicaid HMO DRG,19681,,225% x Medicaid HMO amount,19681,Other,225% of NY Medicaid HMO DRG,19681,,225% x Medicaid HMO amount,19681,Other,225% of NY Medicaid HMO DRG,19681,,225% x Medicaid HMO amount,19681,Other,225% of NY Medicaid HMO DRG,12246,,140% x Medicaid HMO amount,12246,Other,140% of NY Medicaid HMO DRG,19681,,225% x Medicaid HMO amount,19681,Other,225% of NY Medicaid HMO DRG,24054,,275% x Medicaid HMO amount,24054,Other,275% of NY Medicaid HMO DRG,28340,,324% x Medicaid HMO amount,28340,Other,324% of NY Medicaid HMO DRG,18806,,215% x Medicaid HMO amount,18806,Other,215% of NY Medicaid HMO DRG,18806,,215% x Medicaid HMO amount,18806,Other,215% of NY Medicaid HMO DRG,10934,,125% x Medicaid HMO amount,10934,Other,125% of NY Medicaid HMO DRG,0.01,46003,
Cardiac catheterization for other non-coronary conditions,192-3,APR-DRG,,,,,,,,inpatient,,,270443.38,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,82128,,"45,128 x DRG weight",82128,Other,base rate x DRG weight,73915,,"40,615 x DRG weight",73915,Other,base rate x DRG weight,69810,,"38,359 x DRG weight",69810,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27848,,186% x Medicaid HMO amount,27848,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,62017,,"34,077 x DRG weight",62017,Other,base rate x DRG weight,52715,,"28,966 x DRG weight",52715,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14972,,DRG base rate x DRG weight + capital per discharge,14972,Other,100% of NY Medicaid HMO DRG,14972,,100% x Medicaid HMO amount,14972,Other,100% of NY Medicaid HMO DRG,14972,,100% x Medicaid HMO amount,14972,Other,100% of NY Medicaid HMO DRG,14972,,100% x Medicaid HMO amount,14972,Other,100% of NY Medicaid HMO DRG,33687,,225% x Medicaid HMO amount,33687,Other,225% of NY Medicaid HMO DRG,33687,,225% x Medicaid HMO amount,33687,Other,225% of NY Medicaid HMO DRG,33687,,225% x Medicaid HMO amount,33687,Other,225% of NY Medicaid HMO DRG,33687,,225% x Medicaid HMO amount,33687,Other,225% of NY Medicaid HMO DRG,20961,,140% x Medicaid HMO amount,20961,Other,140% of NY Medicaid HMO DRG,33687,,225% x Medicaid HMO amount,33687,Other,225% of NY Medicaid HMO DRG,41173,,275% x Medicaid HMO amount,41173,Other,275% of NY Medicaid HMO DRG,48509,,324% x Medicaid HMO amount,48509,Other,324% of NY Medicaid HMO DRG,32190,,215% x Medicaid HMO amount,32190,Other,215% of NY Medicaid HMO DRG,32190,,215% x Medicaid HMO amount,32190,Other,215% of NY Medicaid HMO DRG,18715,,125% x Medicaid HMO amount,18715,Other,125% of NY Medicaid HMO DRG,0.01,82128,
Cardiac catheterization for other non-coronary conditions,192-4,APR-DRG,,,,,,,,inpatient,,,566014.56,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,185806,,"45,128 x DRG weight",185806,Other,base rate x DRG weight,167224,,"40,615 x DRG weight",167224,Other,base rate x DRG weight,157936,,"38,359 x DRG weight",157936,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,61073,,186% x Medicaid HMO amount,61073,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,140305,,"34,077 x DRG weight",140305,Other,base rate x DRG weight,119262,,"28,966 x DRG weight",119262,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32835,,DRG base rate x DRG weight + capital per discharge,32835,Other,100% of NY Medicaid HMO DRG,32835,,100% x Medicaid HMO amount,32835,Other,100% of NY Medicaid HMO DRG,32835,,100% x Medicaid HMO amount,32835,Other,100% of NY Medicaid HMO DRG,32835,,100% x Medicaid HMO amount,32835,Other,100% of NY Medicaid HMO DRG,73879,,225% x Medicaid HMO amount,73879,Other,225% of NY Medicaid HMO DRG,73879,,225% x Medicaid HMO amount,73879,Other,225% of NY Medicaid HMO DRG,73879,,225% x Medicaid HMO amount,73879,Other,225% of NY Medicaid HMO DRG,73879,,225% x Medicaid HMO amount,73879,Other,225% of NY Medicaid HMO DRG,45969,,140% x Medicaid HMO amount,45969,Other,140% of NY Medicaid HMO DRG,73879,,225% x Medicaid HMO amount,73879,Other,225% of NY Medicaid HMO DRG,90296,,275% x Medicaid HMO amount,90296,Other,275% of NY Medicaid HMO DRG,106385,,324% x Medicaid HMO amount,106385,Other,324% of NY Medicaid HMO DRG,70595,,215% x Medicaid HMO amount,70595,Other,215% of NY Medicaid HMO DRG,70595,,215% x Medicaid HMO amount,70595,Other,215% of NY Medicaid HMO DRG,41044,,125% x Medicaid HMO amount,41044,Other,125% of NY Medicaid HMO DRG,0.01,185806,
Acute & subacute endocarditis,193-1,APR-DRG,,,,,,,,inpatient,,,75012,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46563,,"45,128 x DRG weight",46563,Other,base rate x DRG weight,41907,,"40,615 x DRG weight",41907,Other,base rate x DRG weight,39579,,"38,359 x DRG weight",39579,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16450,,186% x Medicaid HMO amount,16450,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35161,,"34,077 x DRG weight",35161,Other,base rate x DRG weight,29887,,"28,966 x DRG weight",29887,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8844,,DRG base rate x DRG weight + capital per discharge,8844,Other,100% of NY Medicaid HMO DRG,8844,,100% x Medicaid HMO amount,8844,Other,100% of NY Medicaid HMO DRG,8844,,100% x Medicaid HMO amount,8844,Other,100% of NY Medicaid HMO DRG,8844,,100% x Medicaid HMO amount,8844,Other,100% of NY Medicaid HMO DRG,19899,,225% x Medicaid HMO amount,19899,Other,225% of NY Medicaid HMO DRG,19899,,225% x Medicaid HMO amount,19899,Other,225% of NY Medicaid HMO DRG,19899,,225% x Medicaid HMO amount,19899,Other,225% of NY Medicaid HMO DRG,19899,,225% x Medicaid HMO amount,19899,Other,225% of NY Medicaid HMO DRG,12382,,140% x Medicaid HMO amount,12382,Other,140% of NY Medicaid HMO DRG,19899,,225% x Medicaid HMO amount,19899,Other,225% of NY Medicaid HMO DRG,24321,,275% x Medicaid HMO amount,24321,Other,275% of NY Medicaid HMO DRG,28655,,324% x Medicaid HMO amount,28655,Other,324% of NY Medicaid HMO DRG,19015,,215% x Medicaid HMO amount,19015,Other,215% of NY Medicaid HMO DRG,19015,,215% x Medicaid HMO amount,19015,Other,215% of NY Medicaid HMO DRG,11055,,125% x Medicaid HMO amount,11055,Other,125% of NY Medicaid HMO DRG,0.01,46563,
Acute & subacute endocarditis,193-2,APR-DRG,,,,,,,,inpatient,,,75012,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,62191,,"45,128 x DRG weight",62191,Other,base rate x DRG weight,55972,,"40,615 x DRG weight",55972,Other,base rate x DRG weight,52863,,"38,359 x DRG weight",52863,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21457,,186% x Medicaid HMO amount,21457,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46962,,"34,077 x DRG weight",46962,Other,base rate x DRG weight,39918,,"28,966 x DRG weight",39918,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11536,,DRG base rate x DRG weight + capital per discharge,11536,Other,100% of NY Medicaid HMO DRG,11536,,100% x Medicaid HMO amount,11536,Other,100% of NY Medicaid HMO DRG,11536,,100% x Medicaid HMO amount,11536,Other,100% of NY Medicaid HMO DRG,11536,,100% x Medicaid HMO amount,11536,Other,100% of NY Medicaid HMO DRG,25956,,225% x Medicaid HMO amount,25956,Other,225% of NY Medicaid HMO DRG,25956,,225% x Medicaid HMO amount,25956,Other,225% of NY Medicaid HMO DRG,25956,,225% x Medicaid HMO amount,25956,Other,225% of NY Medicaid HMO DRG,25956,,225% x Medicaid HMO amount,25956,Other,225% of NY Medicaid HMO DRG,16150,,140% x Medicaid HMO amount,16150,Other,140% of NY Medicaid HMO DRG,25956,,225% x Medicaid HMO amount,25956,Other,225% of NY Medicaid HMO DRG,31724,,275% x Medicaid HMO amount,31724,Other,275% of NY Medicaid HMO DRG,37377,,324% x Medicaid HMO amount,37377,Other,324% of NY Medicaid HMO DRG,24802,,215% x Medicaid HMO amount,24802,Other,215% of NY Medicaid HMO DRG,24802,,215% x Medicaid HMO amount,24802,Other,215% of NY Medicaid HMO DRG,14420,,125% x Medicaid HMO amount,14420,Other,125% of NY Medicaid HMO DRG,0.01,62191,
Acute & subacute endocarditis,193-3,APR-DRG,,,,,,,,inpatient,,,75012,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,97170,,"45,128 x DRG weight",97170,Other,base rate x DRG weight,87452,,"40,615 x DRG weight",87452,Other,base rate x DRG weight,82595,,"38,359 x DRG weight",82595,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32667,,186% x Medicaid HMO amount,32667,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73375,,"34,077 x DRG weight",73375,Other,base rate x DRG weight,62370,,"28,966 x DRG weight",62370,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17563,,DRG base rate x DRG weight + capital per discharge,17563,Other,100% of NY Medicaid HMO DRG,17563,,100% x Medicaid HMO amount,17563,Other,100% of NY Medicaid HMO DRG,17563,,100% x Medicaid HMO amount,17563,Other,100% of NY Medicaid HMO DRG,17563,,100% x Medicaid HMO amount,17563,Other,100% of NY Medicaid HMO DRG,39517,,225% x Medicaid HMO amount,39517,Other,225% of NY Medicaid HMO DRG,39517,,225% x Medicaid HMO amount,39517,Other,225% of NY Medicaid HMO DRG,39517,,225% x Medicaid HMO amount,39517,Other,225% of NY Medicaid HMO DRG,39517,,225% x Medicaid HMO amount,39517,Other,225% of NY Medicaid HMO DRG,24588,,140% x Medicaid HMO amount,24588,Other,140% of NY Medicaid HMO DRG,39517,,225% x Medicaid HMO amount,39517,Other,225% of NY Medicaid HMO DRG,48298,,275% x Medicaid HMO amount,48298,Other,275% of NY Medicaid HMO DRG,56904,,324% x Medicaid HMO amount,56904,Other,324% of NY Medicaid HMO DRG,37760,,215% x Medicaid HMO amount,37760,Other,215% of NY Medicaid HMO DRG,37760,,215% x Medicaid HMO amount,37760,Other,215% of NY Medicaid HMO DRG,21954,,125% x Medicaid HMO amount,21954,Other,125% of NY Medicaid HMO DRG,0.01,97170,
Acute & subacute endocarditis,193-4,APR-DRG,,,,,,,,inpatient,,,836588.15,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,201460,,"45,128 x DRG weight",201460,Other,base rate x DRG weight,181313,,"40,615 x DRG weight",181313,Other,base rate x DRG weight,171242,,"38,359 x DRG weight",171242,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,66091,,186% x Medicaid HMO amount,66091,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,152127,,"34,077 x DRG weight",152127,Other,base rate x DRG weight,129310,,"28,966 x DRG weight",129310,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35533,,DRG base rate x DRG weight + capital per discharge,35533,Other,100% of NY Medicaid HMO DRG,35533,,100% x Medicaid HMO amount,35533,Other,100% of NY Medicaid HMO DRG,35533,,100% x Medicaid HMO amount,35533,Other,100% of NY Medicaid HMO DRG,35533,,100% x Medicaid HMO amount,35533,Other,100% of NY Medicaid HMO DRG,79949,,225% x Medicaid HMO amount,79949,Other,225% of NY Medicaid HMO DRG,79949,,225% x Medicaid HMO amount,79949,Other,225% of NY Medicaid HMO DRG,79949,,225% x Medicaid HMO amount,79949,Other,225% of NY Medicaid HMO DRG,79949,,225% x Medicaid HMO amount,79949,Other,225% of NY Medicaid HMO DRG,49746,,140% x Medicaid HMO amount,49746,Other,140% of NY Medicaid HMO DRG,79949,,225% x Medicaid HMO amount,79949,Other,225% of NY Medicaid HMO DRG,97716,,275% x Medicaid HMO amount,97716,Other,275% of NY Medicaid HMO DRG,115127,,324% x Medicaid HMO amount,115127,Other,324% of NY Medicaid HMO DRG,76396,,215% x Medicaid HMO amount,76396,Other,215% of NY Medicaid HMO DRG,76396,,215% x Medicaid HMO amount,76396,Other,215% of NY Medicaid HMO DRG,44416,,125% x Medicaid HMO amount,44416,Other,125% of NY Medicaid HMO DRG,0.01,201460,
Heart failure,194-1,APR-DRG,,,,,,,,inpatient,,,98706.13,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25714,,"45,128 x DRG weight",25714,Other,base rate x DRG weight,23142,,"40,615 x DRG weight",23142,Other,base rate x DRG weight,21857,,"38,359 x DRG weight",21857,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9767,,186% x Medicaid HMO amount,9767,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19417,,"34,077 x DRG weight",19417,Other,base rate x DRG weight,16505,,"28,966 x DRG weight",16505,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5251,,DRG base rate x DRG weight + capital per discharge,5251,Other,100% of NY Medicaid HMO DRG,5251,,100% x Medicaid HMO amount,5251,Other,100% of NY Medicaid HMO DRG,5251,,100% x Medicaid HMO amount,5251,Other,100% of NY Medicaid HMO DRG,5251,,100% x Medicaid HMO amount,5251,Other,100% of NY Medicaid HMO DRG,11815,,225% x Medicaid HMO amount,11815,Other,225% of NY Medicaid HMO DRG,11815,,225% x Medicaid HMO amount,11815,Other,225% of NY Medicaid HMO DRG,11815,,225% x Medicaid HMO amount,11815,Other,225% of NY Medicaid HMO DRG,11815,,225% x Medicaid HMO amount,11815,Other,225% of NY Medicaid HMO DRG,7351,,140% x Medicaid HMO amount,7351,Other,140% of NY Medicaid HMO DRG,11815,,225% x Medicaid HMO amount,11815,Other,225% of NY Medicaid HMO DRG,14440,,275% x Medicaid HMO amount,14440,Other,275% of NY Medicaid HMO DRG,17013,,324% x Medicaid HMO amount,17013,Other,324% of NY Medicaid HMO DRG,11290,,215% x Medicaid HMO amount,11290,Other,215% of NY Medicaid HMO DRG,11290,,215% x Medicaid HMO amount,11290,Other,215% of NY Medicaid HMO DRG,6564,,125% x Medicaid HMO amount,6564,Other,125% of NY Medicaid HMO DRG,0.01,25714,
Heart failure,194-2,APR-DRG,,,,,,,,inpatient,,,140073.61,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35705,,"45,128 x DRG weight",35705,Other,base rate x DRG weight,32135,,"40,615 x DRG weight",32135,Other,base rate x DRG weight,30350,,"38,359 x DRG weight",30350,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12970,,186% x Medicaid HMO amount,12970,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26962,,"34,077 x DRG weight",26962,Other,base rate x DRG weight,22918,,"28,966 x DRG weight",22918,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6973,,DRG base rate x DRG weight + capital per discharge,6973,Other,100% of NY Medicaid HMO DRG,6973,,100% x Medicaid HMO amount,6973,Other,100% of NY Medicaid HMO DRG,6973,,100% x Medicaid HMO amount,6973,Other,100% of NY Medicaid HMO DRG,6973,,100% x Medicaid HMO amount,6973,Other,100% of NY Medicaid HMO DRG,15689,,225% x Medicaid HMO amount,15689,Other,225% of NY Medicaid HMO DRG,15689,,225% x Medicaid HMO amount,15689,Other,225% of NY Medicaid HMO DRG,15689,,225% x Medicaid HMO amount,15689,Other,225% of NY Medicaid HMO DRG,15689,,225% x Medicaid HMO amount,15689,Other,225% of NY Medicaid HMO DRG,9762,,140% x Medicaid HMO amount,9762,Other,140% of NY Medicaid HMO DRG,15689,,225% x Medicaid HMO amount,15689,Other,225% of NY Medicaid HMO DRG,19176,,275% x Medicaid HMO amount,19176,Other,275% of NY Medicaid HMO DRG,22593,,324% x Medicaid HMO amount,22593,Other,324% of NY Medicaid HMO DRG,14992,,215% x Medicaid HMO amount,14992,Other,215% of NY Medicaid HMO DRG,14992,,215% x Medicaid HMO amount,14992,Other,215% of NY Medicaid HMO DRG,8716,,125% x Medicaid HMO amount,8716,Other,125% of NY Medicaid HMO DRG,0.01,35705,
Heart failure,194-3,APR-DRG,,,,,,,,inpatient,,,160572.79,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,58382,,"45,128 x DRG weight",58382,Other,base rate x DRG weight,52544,,"40,615 x DRG weight",52544,Other,base rate x DRG weight,49625,,"38,359 x DRG weight",49625,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20237,,186% x Medicaid HMO amount,20237,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44085,,"34,077 x DRG weight",44085,Other,base rate x DRG weight,37473,,"28,966 x DRG weight",37473,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10880,,DRG base rate x DRG weight + capital per discharge,10880,Other,100% of NY Medicaid HMO DRG,10880,,100% x Medicaid HMO amount,10880,Other,100% of NY Medicaid HMO DRG,10880,,100% x Medicaid HMO amount,10880,Other,100% of NY Medicaid HMO DRG,10880,,100% x Medicaid HMO amount,10880,Other,100% of NY Medicaid HMO DRG,24480,,225% x Medicaid HMO amount,24480,Other,225% of NY Medicaid HMO DRG,24480,,225% x Medicaid HMO amount,24480,Other,225% of NY Medicaid HMO DRG,24480,,225% x Medicaid HMO amount,24480,Other,225% of NY Medicaid HMO DRG,24480,,225% x Medicaid HMO amount,24480,Other,225% of NY Medicaid HMO DRG,15232,,140% x Medicaid HMO amount,15232,Other,140% of NY Medicaid HMO DRG,24480,,225% x Medicaid HMO amount,24480,Other,225% of NY Medicaid HMO DRG,29920,,275% x Medicaid HMO amount,29920,Other,275% of NY Medicaid HMO DRG,35251,,324% x Medicaid HMO amount,35251,Other,324% of NY Medicaid HMO DRG,23392,,215% x Medicaid HMO amount,23392,Other,215% of NY Medicaid HMO DRG,23392,,215% x Medicaid HMO amount,23392,Other,215% of NY Medicaid HMO DRG,13600,,125% x Medicaid HMO amount,13600,Other,125% of NY Medicaid HMO DRG,0.01,58382,
Heart failure,194-4,APR-DRG,,,,,,,,inpatient,,,310713.52,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,130348,,"45,128 x DRG weight",130348,Other,base rate x DRG weight,117312,,"40,615 x DRG weight",117312,Other,base rate x DRG weight,110796,,"38,359 x DRG weight",110796,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43301,,186% x Medicaid HMO amount,43301,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,98428,,"34,077 x DRG weight",98428,Other,base rate x DRG weight,83665,,"28,966 x DRG weight",83665,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23280,,DRG base rate x DRG weight + capital per discharge,23280,Other,100% of NY Medicaid HMO DRG,23280,,100% x Medicaid HMO amount,23280,Other,100% of NY Medicaid HMO DRG,23280,,100% x Medicaid HMO amount,23280,Other,100% of NY Medicaid HMO DRG,23280,,100% x Medicaid HMO amount,23280,Other,100% of NY Medicaid HMO DRG,52380,,225% x Medicaid HMO amount,52380,Other,225% of NY Medicaid HMO DRG,52380,,225% x Medicaid HMO amount,52380,Other,225% of NY Medicaid HMO DRG,52380,,225% x Medicaid HMO amount,52380,Other,225% of NY Medicaid HMO DRG,52380,,225% x Medicaid HMO amount,52380,Other,225% of NY Medicaid HMO DRG,32592,,140% x Medicaid HMO amount,32592,Other,140% of NY Medicaid HMO DRG,52380,,225% x Medicaid HMO amount,52380,Other,225% of NY Medicaid HMO DRG,64020,,275% x Medicaid HMO amount,64020,Other,275% of NY Medicaid HMO DRG,75427,,324% x Medicaid HMO amount,75427,Other,324% of NY Medicaid HMO DRG,50052,,215% x Medicaid HMO amount,50052,Other,215% of NY Medicaid HMO DRG,50052,,215% x Medicaid HMO amount,50052,Other,215% of NY Medicaid HMO DRG,29100,,125% x Medicaid HMO amount,29100,Other,125% of NY Medicaid HMO DRG,0.01,130348,
Cardiac arrest and shock,196-1,APR-DRG,,,,,,,,inpatient,,,39243,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26431,,"45,128 x DRG weight",26431,Other,base rate x DRG weight,23788,,"40,615 x DRG weight",23788,Other,base rate x DRG weight,22467,,"38,359 x DRG weight",22467,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9998,,186% x Medicaid HMO amount,9998,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19959,,"34,077 x DRG weight",19959,Other,base rate x DRG weight,16965,,"28,966 x DRG weight",16965,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5375,,DRG base rate x DRG weight + capital per discharge,5375,Other,100% of NY Medicaid HMO DRG,5375,,100% x Medicaid HMO amount,5375,Other,100% of NY Medicaid HMO DRG,5375,,100% x Medicaid HMO amount,5375,Other,100% of NY Medicaid HMO DRG,5375,,100% x Medicaid HMO amount,5375,Other,100% of NY Medicaid HMO DRG,12094,,225% x Medicaid HMO amount,12094,Other,225% of NY Medicaid HMO DRG,12094,,225% x Medicaid HMO amount,12094,Other,225% of NY Medicaid HMO DRG,12094,,225% x Medicaid HMO amount,12094,Other,225% of NY Medicaid HMO DRG,12094,,225% x Medicaid HMO amount,12094,Other,225% of NY Medicaid HMO DRG,7525,,140% x Medicaid HMO amount,7525,Other,140% of NY Medicaid HMO DRG,12094,,225% x Medicaid HMO amount,12094,Other,225% of NY Medicaid HMO DRG,14781,,275% x Medicaid HMO amount,14781,Other,275% of NY Medicaid HMO DRG,17415,,324% x Medicaid HMO amount,17415,Other,324% of NY Medicaid HMO DRG,11556,,215% x Medicaid HMO amount,11556,Other,215% of NY Medicaid HMO DRG,11556,,215% x Medicaid HMO amount,11556,Other,215% of NY Medicaid HMO DRG,6719,,125% x Medicaid HMO amount,6719,Other,125% of NY Medicaid HMO DRG,0.01,26431,
Cardiac arrest and shock,196-2,APR-DRG,,,,,,,,inpatient,,,39243,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28521,,"45,128 x DRG weight",28521,Other,base rate x DRG weight,25669,,"40,615 x DRG weight",25669,Other,base rate x DRG weight,24243,,"38,359 x DRG weight",24243,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10667,,186% x Medicaid HMO amount,10667,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21537,,"34,077 x DRG weight",21537,Other,base rate x DRG weight,18307,,"28,966 x DRG weight",18307,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5735,,DRG base rate x DRG weight + capital per discharge,5735,Other,100% of NY Medicaid HMO DRG,5735,,100% x Medicaid HMO amount,5735,Other,100% of NY Medicaid HMO DRG,5735,,100% x Medicaid HMO amount,5735,Other,100% of NY Medicaid HMO DRG,5735,,100% x Medicaid HMO amount,5735,Other,100% of NY Medicaid HMO DRG,12904,,225% x Medicaid HMO amount,12904,Other,225% of NY Medicaid HMO DRG,12904,,225% x Medicaid HMO amount,12904,Other,225% of NY Medicaid HMO DRG,12904,,225% x Medicaid HMO amount,12904,Other,225% of NY Medicaid HMO DRG,12904,,225% x Medicaid HMO amount,12904,Other,225% of NY Medicaid HMO DRG,8029,,140% x Medicaid HMO amount,8029,Other,140% of NY Medicaid HMO DRG,12904,,225% x Medicaid HMO amount,12904,Other,225% of NY Medicaid HMO DRG,15771,,275% x Medicaid HMO amount,15771,Other,275% of NY Medicaid HMO DRG,18581,,324% x Medicaid HMO amount,18581,Other,324% of NY Medicaid HMO DRG,12330,,215% x Medicaid HMO amount,12330,Other,215% of NY Medicaid HMO DRG,12330,,215% x Medicaid HMO amount,12330,Other,215% of NY Medicaid HMO DRG,7169,,125% x Medicaid HMO amount,7169,Other,125% of NY Medicaid HMO DRG,0.01,28521,
Cardiac arrest and shock,196-3,APR-DRG,,,,,,,,inpatient,,,58926,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31657,,"45,128 x DRG weight",31657,Other,base rate x DRG weight,28491,,"40,615 x DRG weight",28491,Other,base rate x DRG weight,26909,,"38,359 x DRG weight",26909,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11672,,186% x Medicaid HMO amount,11672,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23905,,"34,077 x DRG weight",23905,Other,base rate x DRG weight,20320,,"28,966 x DRG weight",20320,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6275,,DRG base rate x DRG weight + capital per discharge,6275,Other,100% of NY Medicaid HMO DRG,6275,,100% x Medicaid HMO amount,6275,Other,100% of NY Medicaid HMO DRG,6275,,100% x Medicaid HMO amount,6275,Other,100% of NY Medicaid HMO DRG,6275,,100% x Medicaid HMO amount,6275,Other,100% of NY Medicaid HMO DRG,14119,,225% x Medicaid HMO amount,14119,Other,225% of NY Medicaid HMO DRG,14119,,225% x Medicaid HMO amount,14119,Other,225% of NY Medicaid HMO DRG,14119,,225% x Medicaid HMO amount,14119,Other,225% of NY Medicaid HMO DRG,14119,,225% x Medicaid HMO amount,14119,Other,225% of NY Medicaid HMO DRG,8785,,140% x Medicaid HMO amount,8785,Other,140% of NY Medicaid HMO DRG,14119,,225% x Medicaid HMO amount,14119,Other,225% of NY Medicaid HMO DRG,17256,,275% x Medicaid HMO amount,17256,Other,275% of NY Medicaid HMO DRG,20331,,324% x Medicaid HMO amount,20331,Other,324% of NY Medicaid HMO DRG,13491,,215% x Medicaid HMO amount,13491,Other,215% of NY Medicaid HMO DRG,13491,,215% x Medicaid HMO amount,13491,Other,215% of NY Medicaid HMO DRG,7844,,125% x Medicaid HMO amount,7844,Other,125% of NY Medicaid HMO DRG,0.01,31657,
Cardiac arrest and shock,196-4,APR-DRG,,,,,,,,inpatient,,,436026.47,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,94354,,"45,128 x DRG weight",94354,Other,base rate x DRG weight,84918,,"40,615 x DRG weight",84918,Other,base rate x DRG weight,80201,,"38,359 x DRG weight",80201,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31765,,186% x Medicaid HMO amount,31765,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,71248,,"34,077 x DRG weight",71248,Other,base rate x DRG weight,60562,,"28,966 x DRG weight",60562,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17078,,DRG base rate x DRG weight + capital per discharge,17078,Other,100% of NY Medicaid HMO DRG,17078,,100% x Medicaid HMO amount,17078,Other,100% of NY Medicaid HMO DRG,17078,,100% x Medicaid HMO amount,17078,Other,100% of NY Medicaid HMO DRG,17078,,100% x Medicaid HMO amount,17078,Other,100% of NY Medicaid HMO DRG,38426,,225% x Medicaid HMO amount,38426,Other,225% of NY Medicaid HMO DRG,38426,,225% x Medicaid HMO amount,38426,Other,225% of NY Medicaid HMO DRG,38426,,225% x Medicaid HMO amount,38426,Other,225% of NY Medicaid HMO DRG,38426,,225% x Medicaid HMO amount,38426,Other,225% of NY Medicaid HMO DRG,23909,,140% x Medicaid HMO amount,23909,Other,140% of NY Medicaid HMO DRG,38426,,225% x Medicaid HMO amount,38426,Other,225% of NY Medicaid HMO DRG,46965,,275% x Medicaid HMO amount,46965,Other,275% of NY Medicaid HMO DRG,55333,,324% x Medicaid HMO amount,55333,Other,324% of NY Medicaid HMO DRG,36718,,215% x Medicaid HMO amount,36718,Other,215% of NY Medicaid HMO DRG,36718,,215% x Medicaid HMO amount,36718,Other,215% of NY Medicaid HMO DRG,21348,,125% x Medicaid HMO amount,21348,Other,125% of NY Medicaid HMO DRG,0.01,94354,
Peripheral & other vascular disorders,197-1,APR-DRG,,,,,,,,inpatient,,,67963.56,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26445,,"45,128 x DRG weight",26445,Other,base rate x DRG weight,23800,,"40,615 x DRG weight",23800,Other,base rate x DRG weight,22478,,"38,359 x DRG weight",22478,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10001,,186% x Medicaid HMO amount,10001,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19969,,"34,077 x DRG weight",19969,Other,base rate x DRG weight,16974,,"28,966 x DRG weight",16974,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5377,,DRG base rate x DRG weight + capital per discharge,5377,Other,100% of NY Medicaid HMO DRG,5377,,100% x Medicaid HMO amount,5377,Other,100% of NY Medicaid HMO DRG,5377,,100% x Medicaid HMO amount,5377,Other,100% of NY Medicaid HMO DRG,5377,,100% x Medicaid HMO amount,5377,Other,100% of NY Medicaid HMO DRG,12098,,225% x Medicaid HMO amount,12098,Other,225% of NY Medicaid HMO DRG,12098,,225% x Medicaid HMO amount,12098,Other,225% of NY Medicaid HMO DRG,12098,,225% x Medicaid HMO amount,12098,Other,225% of NY Medicaid HMO DRG,12098,,225% x Medicaid HMO amount,12098,Other,225% of NY Medicaid HMO DRG,7528,,140% x Medicaid HMO amount,7528,Other,140% of NY Medicaid HMO DRG,12098,,225% x Medicaid HMO amount,12098,Other,225% of NY Medicaid HMO DRG,14787,,275% x Medicaid HMO amount,14787,Other,275% of NY Medicaid HMO DRG,17421,,324% x Medicaid HMO amount,17421,Other,324% of NY Medicaid HMO DRG,11561,,215% x Medicaid HMO amount,11561,Other,215% of NY Medicaid HMO DRG,11561,,215% x Medicaid HMO amount,11561,Other,215% of NY Medicaid HMO DRG,6721,,125% x Medicaid HMO amount,6721,Other,125% of NY Medicaid HMO DRG,0.01,26445,
Peripheral & other vascular disorders,197-2,APR-DRG,,,,,,,,inpatient,,,188289.28,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35755,,"45,128 x DRG weight",35755,Other,base rate x DRG weight,32179,,"40,615 x DRG weight",32179,Other,base rate x DRG weight,30392,,"38,359 x DRG weight",30392,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12985,,186% x Medicaid HMO amount,12985,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26999,,"34,077 x DRG weight",26999,Other,base rate x DRG weight,22950,,"28,966 x DRG weight",22950,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6981,,DRG base rate x DRG weight + capital per discharge,6981,Other,100% of NY Medicaid HMO DRG,6981,,100% x Medicaid HMO amount,6981,Other,100% of NY Medicaid HMO DRG,6981,,100% x Medicaid HMO amount,6981,Other,100% of NY Medicaid HMO DRG,6981,,100% x Medicaid HMO amount,6981,Other,100% of NY Medicaid HMO DRG,15707,,225% x Medicaid HMO amount,15707,Other,225% of NY Medicaid HMO DRG,15707,,225% x Medicaid HMO amount,15707,Other,225% of NY Medicaid HMO DRG,15707,,225% x Medicaid HMO amount,15707,Other,225% of NY Medicaid HMO DRG,15707,,225% x Medicaid HMO amount,15707,Other,225% of NY Medicaid HMO DRG,9773,,140% x Medicaid HMO amount,9773,Other,140% of NY Medicaid HMO DRG,15707,,225% x Medicaid HMO amount,15707,Other,225% of NY Medicaid HMO DRG,19198,,275% x Medicaid HMO amount,19198,Other,275% of NY Medicaid HMO DRG,22618,,324% x Medicaid HMO amount,22618,Other,324% of NY Medicaid HMO DRG,15009,,215% x Medicaid HMO amount,15009,Other,215% of NY Medicaid HMO DRG,15009,,215% x Medicaid HMO amount,15009,Other,215% of NY Medicaid HMO DRG,8726,,125% x Medicaid HMO amount,8726,Other,125% of NY Medicaid HMO DRG,0.01,35755,
Peripheral & other vascular disorders,197-3,APR-DRG,,,,,,,,inpatient,,,141771.2,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53292,,"45,128 x DRG weight",53292,Other,base rate x DRG weight,47962,,"40,615 x DRG weight",47962,Other,base rate x DRG weight,45298,,"38,359 x DRG weight",45298,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18606,,186% x Medicaid HMO amount,18606,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40242,,"34,077 x DRG weight",40242,Other,base rate x DRG weight,34206,,"28,966 x DRG weight",34206,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10003,,DRG base rate x DRG weight + capital per discharge,10003,Other,100% of NY Medicaid HMO DRG,10003,,100% x Medicaid HMO amount,10003,Other,100% of NY Medicaid HMO DRG,10003,,100% x Medicaid HMO amount,10003,Other,100% of NY Medicaid HMO DRG,10003,,100% x Medicaid HMO amount,10003,Other,100% of NY Medicaid HMO DRG,22507,,225% x Medicaid HMO amount,22507,Other,225% of NY Medicaid HMO DRG,22507,,225% x Medicaid HMO amount,22507,Other,225% of NY Medicaid HMO DRG,22507,,225% x Medicaid HMO amount,22507,Other,225% of NY Medicaid HMO DRG,22507,,225% x Medicaid HMO amount,22507,Other,225% of NY Medicaid HMO DRG,14004,,140% x Medicaid HMO amount,14004,Other,140% of NY Medicaid HMO DRG,22507,,225% x Medicaid HMO amount,22507,Other,225% of NY Medicaid HMO DRG,27508,,275% x Medicaid HMO amount,27508,Other,275% of NY Medicaid HMO DRG,32410,,324% x Medicaid HMO amount,32410,Other,324% of NY Medicaid HMO DRG,21506,,215% x Medicaid HMO amount,21506,Other,215% of NY Medicaid HMO DRG,21506,,215% x Medicaid HMO amount,21506,Other,215% of NY Medicaid HMO DRG,12504,,125% x Medicaid HMO amount,12504,Other,125% of NY Medicaid HMO DRG,0.01,53292,
Peripheral & other vascular disorders,197-4,APR-DRG,,,,,,,,inpatient,,,249807.56,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,129242,,"45,128 x DRG weight",129242,Other,base rate x DRG weight,116317,,"40,615 x DRG weight",116317,Other,base rate x DRG weight,109856,,"38,359 x DRG weight",109856,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42946,,186% x Medicaid HMO amount,42946,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,97593,,"34,077 x DRG weight",97593,Other,base rate x DRG weight,82956,,"28,966 x DRG weight",82956,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23089,,DRG base rate x DRG weight + capital per discharge,23089,Other,100% of NY Medicaid HMO DRG,23089,,100% x Medicaid HMO amount,23089,Other,100% of NY Medicaid HMO DRG,23089,,100% x Medicaid HMO amount,23089,Other,100% of NY Medicaid HMO DRG,23089,,100% x Medicaid HMO amount,23089,Other,100% of NY Medicaid HMO DRG,51950,,225% x Medicaid HMO amount,51950,Other,225% of NY Medicaid HMO DRG,51950,,225% x Medicaid HMO amount,51950,Other,225% of NY Medicaid HMO DRG,51950,,225% x Medicaid HMO amount,51950,Other,225% of NY Medicaid HMO DRG,51950,,225% x Medicaid HMO amount,51950,Other,225% of NY Medicaid HMO DRG,32325,,140% x Medicaid HMO amount,32325,Other,140% of NY Medicaid HMO DRG,51950,,225% x Medicaid HMO amount,51950,Other,225% of NY Medicaid HMO DRG,63495,,275% x Medicaid HMO amount,63495,Other,275% of NY Medicaid HMO DRG,74808,,324% x Medicaid HMO amount,74808,Other,324% of NY Medicaid HMO DRG,49641,,215% x Medicaid HMO amount,49641,Other,215% of NY Medicaid HMO DRG,49641,,215% x Medicaid HMO amount,49641,Other,215% of NY Medicaid HMO DRG,28861,,125% x Medicaid HMO amount,28861,Other,125% of NY Medicaid HMO DRG,0.01,129242,
Angina pectoris & coronary atherosclerosis,198-1,APR-DRG,,,,,,,,inpatient,,,102325.47,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18426,,"45,128 x DRG weight",18426,Other,base rate x DRG weight,16583,,"40,615 x DRG weight",16583,Other,base rate x DRG weight,15662,,"38,359 x DRG weight",15662,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7433,,186% x Medicaid HMO amount,7433,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13914,,"34,077 x DRG weight",13914,Other,base rate x DRG weight,11827,,"28,966 x DRG weight",11827,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3996,,DRG base rate x DRG weight + capital per discharge,3996,Other,100% of NY Medicaid HMO DRG,3996,,100% x Medicaid HMO amount,3996,Other,100% of NY Medicaid HMO DRG,3996,,100% x Medicaid HMO amount,3996,Other,100% of NY Medicaid HMO DRG,3996,,100% x Medicaid HMO amount,3996,Other,100% of NY Medicaid HMO DRG,8991,,225% x Medicaid HMO amount,8991,Other,225% of NY Medicaid HMO DRG,8991,,225% x Medicaid HMO amount,8991,Other,225% of NY Medicaid HMO DRG,8991,,225% x Medicaid HMO amount,8991,Other,225% of NY Medicaid HMO DRG,8991,,225% x Medicaid HMO amount,8991,Other,225% of NY Medicaid HMO DRG,5594,,140% x Medicaid HMO amount,5594,Other,140% of NY Medicaid HMO DRG,8991,,225% x Medicaid HMO amount,8991,Other,225% of NY Medicaid HMO DRG,10989,,275% x Medicaid HMO amount,10989,Other,275% of NY Medicaid HMO DRG,12947,,324% x Medicaid HMO amount,12947,Other,324% of NY Medicaid HMO DRG,8591,,215% x Medicaid HMO amount,8591,Other,215% of NY Medicaid HMO DRG,8591,,215% x Medicaid HMO amount,8591,Other,215% of NY Medicaid HMO DRG,4995,,125% x Medicaid HMO amount,4995,Other,125% of NY Medicaid HMO DRG,0.01,18426,
Angina pectoris & coronary atherosclerosis,198-2,APR-DRG,,,,,,,,inpatient,,,85033.92,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24112,,"45,128 x DRG weight",24112,Other,base rate x DRG weight,21701,,"40,615 x DRG weight",21701,Other,base rate x DRG weight,20495,,"38,359 x DRG weight",20495,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9254,,186% x Medicaid HMO amount,9254,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18207,,"34,077 x DRG weight",18207,Other,base rate x DRG weight,15477,,"28,966 x DRG weight",15477,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4975,,DRG base rate x DRG weight + capital per discharge,4975,Other,100% of NY Medicaid HMO DRG,4975,,100% x Medicaid HMO amount,4975,Other,100% of NY Medicaid HMO DRG,4975,,100% x Medicaid HMO amount,4975,Other,100% of NY Medicaid HMO DRG,4975,,100% x Medicaid HMO amount,4975,Other,100% of NY Medicaid HMO DRG,11194,,225% x Medicaid HMO amount,11194,Other,225% of NY Medicaid HMO DRG,11194,,225% x Medicaid HMO amount,11194,Other,225% of NY Medicaid HMO DRG,11194,,225% x Medicaid HMO amount,11194,Other,225% of NY Medicaid HMO DRG,11194,,225% x Medicaid HMO amount,11194,Other,225% of NY Medicaid HMO DRG,6965,,140% x Medicaid HMO amount,6965,Other,140% of NY Medicaid HMO DRG,11194,,225% x Medicaid HMO amount,11194,Other,225% of NY Medicaid HMO DRG,13681,,275% x Medicaid HMO amount,13681,Other,275% of NY Medicaid HMO DRG,16119,,324% x Medicaid HMO amount,16119,Other,324% of NY Medicaid HMO DRG,10696,,215% x Medicaid HMO amount,10696,Other,215% of NY Medicaid HMO DRG,10696,,215% x Medicaid HMO amount,10696,Other,215% of NY Medicaid HMO DRG,6219,,125% x Medicaid HMO amount,6219,Other,125% of NY Medicaid HMO DRG,0.01,24112,
Angina pectoris & coronary atherosclerosis,198-3,APR-DRG,,,,,,,,inpatient,,,81012.79,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36901,,"45,128 x DRG weight",36901,Other,base rate x DRG weight,33211,,"40,615 x DRG weight",33211,Other,base rate x DRG weight,31366,,"38,359 x DRG weight",31366,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13353,,186% x Medicaid HMO amount,13353,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27865,,"34,077 x DRG weight",27865,Other,base rate x DRG weight,23685,,"28,966 x DRG weight",23685,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7179,,DRG base rate x DRG weight + capital per discharge,7179,Other,100% of NY Medicaid HMO DRG,7179,,100% x Medicaid HMO amount,7179,Other,100% of NY Medicaid HMO DRG,7179,,100% x Medicaid HMO amount,7179,Other,100% of NY Medicaid HMO DRG,7179,,100% x Medicaid HMO amount,7179,Other,100% of NY Medicaid HMO DRG,16153,,225% x Medicaid HMO amount,16153,Other,225% of NY Medicaid HMO DRG,16153,,225% x Medicaid HMO amount,16153,Other,225% of NY Medicaid HMO DRG,16153,,225% x Medicaid HMO amount,16153,Other,225% of NY Medicaid HMO DRG,16153,,225% x Medicaid HMO amount,16153,Other,225% of NY Medicaid HMO DRG,10051,,140% x Medicaid HMO amount,10051,Other,140% of NY Medicaid HMO DRG,16153,,225% x Medicaid HMO amount,16153,Other,225% of NY Medicaid HMO DRG,19742,,275% x Medicaid HMO amount,19742,Other,275% of NY Medicaid HMO DRG,23260,,324% x Medicaid HMO amount,23260,Other,324% of NY Medicaid HMO DRG,15435,,215% x Medicaid HMO amount,15435,Other,215% of NY Medicaid HMO DRG,15435,,215% x Medicaid HMO amount,15435,Other,215% of NY Medicaid HMO DRG,8974,,125% x Medicaid HMO amount,8974,Other,125% of NY Medicaid HMO DRG,0.01,36901,
Angina pectoris & coronary atherosclerosis,198-4,APR-DRG,,,,,,,,inpatient,,,90536,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,109241,,"45,128 x DRG weight",109241,Other,base rate x DRG weight,98317,,"40,615 x DRG weight",98317,Other,base rate x DRG weight,92856,,"38,359 x DRG weight",92856,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36536,,186% x Medicaid HMO amount,36536,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,82490,,"34,077 x DRG weight",82490,Other,base rate x DRG weight,70118,,"28,966 x DRG weight",70118,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19643,,DRG base rate x DRG weight + capital per discharge,19643,Other,100% of NY Medicaid HMO DRG,19643,,100% x Medicaid HMO amount,19643,Other,100% of NY Medicaid HMO DRG,19643,,100% x Medicaid HMO amount,19643,Other,100% of NY Medicaid HMO DRG,19643,,100% x Medicaid HMO amount,19643,Other,100% of NY Medicaid HMO DRG,44197,,225% x Medicaid HMO amount,44197,Other,225% of NY Medicaid HMO DRG,44197,,225% x Medicaid HMO amount,44197,Other,225% of NY Medicaid HMO DRG,44197,,225% x Medicaid HMO amount,44197,Other,225% of NY Medicaid HMO DRG,44197,,225% x Medicaid HMO amount,44197,Other,225% of NY Medicaid HMO DRG,27500,,140% x Medicaid HMO amount,27500,Other,140% of NY Medicaid HMO DRG,44197,,225% x Medicaid HMO amount,44197,Other,225% of NY Medicaid HMO DRG,54018,,275% x Medicaid HMO amount,54018,Other,275% of NY Medicaid HMO DRG,63643,,324% x Medicaid HMO amount,63643,Other,324% of NY Medicaid HMO DRG,42232,,215% x Medicaid HMO amount,42232,Other,215% of NY Medicaid HMO DRG,42232,,215% x Medicaid HMO amount,42232,Other,215% of NY Medicaid HMO DRG,24554,,125% x Medicaid HMO amount,24554,Other,125% of NY Medicaid HMO DRG,0.01,109241,
Hypertension,199-1,APR-DRG,,,,,,,,inpatient,,,92242.65,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20420,,"45,128 x DRG weight",20420,Other,base rate x DRG weight,18378,,"40,615 x DRG weight",18378,Other,base rate x DRG weight,17357,,"38,359 x DRG weight",17357,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8071,,186% x Medicaid HMO amount,8071,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15420,,"34,077 x DRG weight",15420,Other,base rate x DRG weight,13107,,"28,966 x DRG weight",13107,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4339,,DRG base rate x DRG weight + capital per discharge,4339,Other,100% of NY Medicaid HMO DRG,4339,,100% x Medicaid HMO amount,4339,Other,100% of NY Medicaid HMO DRG,4339,,100% x Medicaid HMO amount,4339,Other,100% of NY Medicaid HMO DRG,4339,,100% x Medicaid HMO amount,4339,Other,100% of NY Medicaid HMO DRG,9763,,225% x Medicaid HMO amount,9763,Other,225% of NY Medicaid HMO DRG,9763,,225% x Medicaid HMO amount,9763,Other,225% of NY Medicaid HMO DRG,9763,,225% x Medicaid HMO amount,9763,Other,225% of NY Medicaid HMO DRG,9763,,225% x Medicaid HMO amount,9763,Other,225% of NY Medicaid HMO DRG,6075,,140% x Medicaid HMO amount,6075,Other,140% of NY Medicaid HMO DRG,9763,,225% x Medicaid HMO amount,9763,Other,225% of NY Medicaid HMO DRG,11932,,275% x Medicaid HMO amount,11932,Other,275% of NY Medicaid HMO DRG,14058,,324% x Medicaid HMO amount,14058,Other,324% of NY Medicaid HMO DRG,9329,,215% x Medicaid HMO amount,9329,Other,215% of NY Medicaid HMO DRG,9329,,215% x Medicaid HMO amount,9329,Other,215% of NY Medicaid HMO DRG,5424,,125% x Medicaid HMO amount,5424,Other,125% of NY Medicaid HMO DRG,0.01,20420,
Hypertension,199-2,APR-DRG,,,,,,,,inpatient,,,80019.84,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26734,,"45,128 x DRG weight",26734,Other,base rate x DRG weight,24060,,"40,615 x DRG weight",24060,Other,base rate x DRG weight,22724,,"38,359 x DRG weight",22724,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10094,,186% x Medicaid HMO amount,10094,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20187,,"34,077 x DRG weight",20187,Other,base rate x DRG weight,17159,,"28,966 x DRG weight",17159,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5427,,DRG base rate x DRG weight + capital per discharge,5427,Other,100% of NY Medicaid HMO DRG,5427,,100% x Medicaid HMO amount,5427,Other,100% of NY Medicaid HMO DRG,5427,,100% x Medicaid HMO amount,5427,Other,100% of NY Medicaid HMO DRG,5427,,100% x Medicaid HMO amount,5427,Other,100% of NY Medicaid HMO DRG,12211,,225% x Medicaid HMO amount,12211,Other,225% of NY Medicaid HMO DRG,12211,,225% x Medicaid HMO amount,12211,Other,225% of NY Medicaid HMO DRG,12211,,225% x Medicaid HMO amount,12211,Other,225% of NY Medicaid HMO DRG,12211,,225% x Medicaid HMO amount,12211,Other,225% of NY Medicaid HMO DRG,7598,,140% x Medicaid HMO amount,7598,Other,140% of NY Medicaid HMO DRG,12211,,225% x Medicaid HMO amount,12211,Other,225% of NY Medicaid HMO DRG,14924,,275% x Medicaid HMO amount,14924,Other,275% of NY Medicaid HMO DRG,17583,,324% x Medicaid HMO amount,17583,Other,324% of NY Medicaid HMO DRG,11668,,215% x Medicaid HMO amount,11668,Other,215% of NY Medicaid HMO DRG,11668,,215% x Medicaid HMO amount,11668,Other,215% of NY Medicaid HMO DRG,6784,,125% x Medicaid HMO amount,6784,Other,125% of NY Medicaid HMO DRG,0.01,26734,
Hypertension,199-3,APR-DRG,,,,,,,,inpatient,,,143572.32,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42055,,"45,128 x DRG weight",42055,Other,base rate x DRG weight,37849,,"40,615 x DRG weight",37849,Other,base rate x DRG weight,35747,,"38,359 x DRG weight",35747,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15005,,186% x Medicaid HMO amount,15005,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31756,,"34,077 x DRG weight",31756,Other,base rate x DRG weight,26993,,"28,966 x DRG weight",26993,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8067,,DRG base rate x DRG weight + capital per discharge,8067,Other,100% of NY Medicaid HMO DRG,8067,,100% x Medicaid HMO amount,8067,Other,100% of NY Medicaid HMO DRG,8067,,100% x Medicaid HMO amount,8067,Other,100% of NY Medicaid HMO DRG,8067,,100% x Medicaid HMO amount,8067,Other,100% of NY Medicaid HMO DRG,18151,,225% x Medicaid HMO amount,18151,Other,225% of NY Medicaid HMO DRG,18151,,225% x Medicaid HMO amount,18151,Other,225% of NY Medicaid HMO DRG,18151,,225% x Medicaid HMO amount,18151,Other,225% of NY Medicaid HMO DRG,18151,,225% x Medicaid HMO amount,18151,Other,225% of NY Medicaid HMO DRG,11294,,140% x Medicaid HMO amount,11294,Other,140% of NY Medicaid HMO DRG,18151,,225% x Medicaid HMO amount,18151,Other,225% of NY Medicaid HMO DRG,22184,,275% x Medicaid HMO amount,22184,Other,275% of NY Medicaid HMO DRG,26137,,324% x Medicaid HMO amount,26137,Other,324% of NY Medicaid HMO DRG,17344,,215% x Medicaid HMO amount,17344,Other,215% of NY Medicaid HMO DRG,17344,,215% x Medicaid HMO amount,17344,Other,215% of NY Medicaid HMO DRG,10084,,125% x Medicaid HMO amount,10084,Other,125% of NY Medicaid HMO DRG,0.01,42055,
Hypertension,199-4,APR-DRG,,,,,,,,inpatient,,,229473.45,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,110848,,"45,128 x DRG weight",110848,Other,base rate x DRG weight,99763,,"40,615 x DRG weight",99763,Other,base rate x DRG weight,94221,,"38,359 x DRG weight",94221,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37051,,186% x Medicaid HMO amount,37051,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,83703,,"34,077 x DRG weight",83703,Other,base rate x DRG weight,71149,,"28,966 x DRG weight",71149,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19920,,DRG base rate x DRG weight + capital per discharge,19920,Other,100% of NY Medicaid HMO DRG,19920,,100% x Medicaid HMO amount,19920,Other,100% of NY Medicaid HMO DRG,19920,,100% x Medicaid HMO amount,19920,Other,100% of NY Medicaid HMO DRG,19920,,100% x Medicaid HMO amount,19920,Other,100% of NY Medicaid HMO DRG,44820,,225% x Medicaid HMO amount,44820,Other,225% of NY Medicaid HMO DRG,44820,,225% x Medicaid HMO amount,44820,Other,225% of NY Medicaid HMO DRG,44820,,225% x Medicaid HMO amount,44820,Other,225% of NY Medicaid HMO DRG,44820,,225% x Medicaid HMO amount,44820,Other,225% of NY Medicaid HMO DRG,27888,,140% x Medicaid HMO amount,27888,Other,140% of NY Medicaid HMO DRG,44820,,225% x Medicaid HMO amount,44820,Other,225% of NY Medicaid HMO DRG,54780,,275% x Medicaid HMO amount,54780,Other,275% of NY Medicaid HMO DRG,64541,,324% x Medicaid HMO amount,64541,Other,324% of NY Medicaid HMO DRG,42828,,215% x Medicaid HMO amount,42828,Other,215% of NY Medicaid HMO DRG,42828,,215% x Medicaid HMO amount,42828,Other,215% of NY Medicaid HMO DRG,24900,,125% x Medicaid HMO amount,24900,Other,125% of NY Medicaid HMO DRG,0.01,110848,
Cardiac structural & valvular disorders,200-1,APR-DRG,,,,,,,,inpatient,,,47277.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22893,,"45,128 x DRG weight",22893,Other,base rate x DRG weight,20604,,"40,615 x DRG weight",20604,Other,base rate x DRG weight,19460,,"38,359 x DRG weight",19460,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8863,,186% x Medicaid HMO amount,8863,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17287,,"34,077 x DRG weight",17287,Other,base rate x DRG weight,14694,,"28,966 x DRG weight",14694,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4765,,DRG base rate x DRG weight + capital per discharge,4765,Other,100% of NY Medicaid HMO DRG,4765,,100% x Medicaid HMO amount,4765,Other,100% of NY Medicaid HMO DRG,4765,,100% x Medicaid HMO amount,4765,Other,100% of NY Medicaid HMO DRG,4765,,100% x Medicaid HMO amount,4765,Other,100% of NY Medicaid HMO DRG,10721,,225% x Medicaid HMO amount,10721,Other,225% of NY Medicaid HMO DRG,10721,,225% x Medicaid HMO amount,10721,Other,225% of NY Medicaid HMO DRG,10721,,225% x Medicaid HMO amount,10721,Other,225% of NY Medicaid HMO DRG,10721,,225% x Medicaid HMO amount,10721,Other,225% of NY Medicaid HMO DRG,6671,,140% x Medicaid HMO amount,6671,Other,140% of NY Medicaid HMO DRG,10721,,225% x Medicaid HMO amount,10721,Other,225% of NY Medicaid HMO DRG,13104,,275% x Medicaid HMO amount,13104,Other,275% of NY Medicaid HMO DRG,15439,,324% x Medicaid HMO amount,15439,Other,324% of NY Medicaid HMO DRG,10245,,215% x Medicaid HMO amount,10245,Other,215% of NY Medicaid HMO DRG,10245,,215% x Medicaid HMO amount,10245,Other,215% of NY Medicaid HMO DRG,5956,,125% x Medicaid HMO amount,5956,Other,125% of NY Medicaid HMO DRG,0.01,22893,
Cardiac structural & valvular disorders,200-2,APR-DRG,,,,,,,,inpatient,,,85847.83,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31409,,"45,128 x DRG weight",31409,Other,base rate x DRG weight,28268,,"40,615 x DRG weight",28268,Other,base rate x DRG weight,26698,,"38,359 x DRG weight",26698,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11593,,186% x Medicaid HMO amount,11593,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23718,,"34,077 x DRG weight",23718,Other,base rate x DRG weight,20160,,"28,966 x DRG weight",20160,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6233,,DRG base rate x DRG weight + capital per discharge,6233,Other,100% of NY Medicaid HMO DRG,6233,,100% x Medicaid HMO amount,6233,Other,100% of NY Medicaid HMO DRG,6233,,100% x Medicaid HMO amount,6233,Other,100% of NY Medicaid HMO DRG,6233,,100% x Medicaid HMO amount,6233,Other,100% of NY Medicaid HMO DRG,14024,,225% x Medicaid HMO amount,14024,Other,225% of NY Medicaid HMO DRG,14024,,225% x Medicaid HMO amount,14024,Other,225% of NY Medicaid HMO DRG,14024,,225% x Medicaid HMO amount,14024,Other,225% of NY Medicaid HMO DRG,14024,,225% x Medicaid HMO amount,14024,Other,225% of NY Medicaid HMO DRG,8726,,140% x Medicaid HMO amount,8726,Other,140% of NY Medicaid HMO DRG,14024,,225% x Medicaid HMO amount,14024,Other,225% of NY Medicaid HMO DRG,17141,,275% x Medicaid HMO amount,17141,Other,275% of NY Medicaid HMO DRG,20195,,324% x Medicaid HMO amount,20195,Other,324% of NY Medicaid HMO DRG,13401,,215% x Medicaid HMO amount,13401,Other,215% of NY Medicaid HMO DRG,13401,,215% x Medicaid HMO amount,13401,Other,215% of NY Medicaid HMO DRG,7791,,125% x Medicaid HMO amount,7791,Other,125% of NY Medicaid HMO DRG,0.01,31409,
Cardiac structural & valvular disorders,200-3,APR-DRG,,,,,,,,inpatient,,,219955.13,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56482,,"45,128 x DRG weight",56482,Other,base rate x DRG weight,50834,,"40,615 x DRG weight",50834,Other,base rate x DRG weight,48010,,"38,359 x DRG weight",48010,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19629,,186% x Medicaid HMO amount,19629,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42651,,"34,077 x DRG weight",42651,Other,base rate x DRG weight,36254,,"28,966 x DRG weight",36254,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10553,,DRG base rate x DRG weight + capital per discharge,10553,Other,100% of NY Medicaid HMO DRG,10553,,100% x Medicaid HMO amount,10553,Other,100% of NY Medicaid HMO DRG,10553,,100% x Medicaid HMO amount,10553,Other,100% of NY Medicaid HMO DRG,10553,,100% x Medicaid HMO amount,10553,Other,100% of NY Medicaid HMO DRG,23744,,225% x Medicaid HMO amount,23744,Other,225% of NY Medicaid HMO DRG,23744,,225% x Medicaid HMO amount,23744,Other,225% of NY Medicaid HMO DRG,23744,,225% x Medicaid HMO amount,23744,Other,225% of NY Medicaid HMO DRG,23744,,225% x Medicaid HMO amount,23744,Other,225% of NY Medicaid HMO DRG,14774,,140% x Medicaid HMO amount,14774,Other,140% of NY Medicaid HMO DRG,23744,,225% x Medicaid HMO amount,23744,Other,225% of NY Medicaid HMO DRG,29021,,275% x Medicaid HMO amount,29021,Other,275% of NY Medicaid HMO DRG,34192,,324% x Medicaid HMO amount,34192,Other,324% of NY Medicaid HMO DRG,22689,,215% x Medicaid HMO amount,22689,Other,215% of NY Medicaid HMO DRG,22689,,215% x Medicaid HMO amount,22689,Other,215% of NY Medicaid HMO DRG,13191,,125% x Medicaid HMO amount,13191,Other,125% of NY Medicaid HMO DRG,0.01,56482,
Cardiac structural & valvular disorders,200-4,APR-DRG,,,,,,,,inpatient,,,36093,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,177782,,"45,128 x DRG weight",177782,Other,base rate x DRG weight,160003,,"40,615 x DRG weight",160003,Other,base rate x DRG weight,151115,,"38,359 x DRG weight",151115,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,58503,,186% x Medicaid HMO amount,58503,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,134246,,"34,077 x DRG weight",134246,Other,base rate x DRG weight,114112,,"28,966 x DRG weight",114112,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31453,,DRG base rate x DRG weight + capital per discharge,31453,Other,100% of NY Medicaid HMO DRG,31453,,100% x Medicaid HMO amount,31453,Other,100% of NY Medicaid HMO DRG,31453,,100% x Medicaid HMO amount,31453,Other,100% of NY Medicaid HMO DRG,31453,,100% x Medicaid HMO amount,31453,Other,100% of NY Medicaid HMO DRG,70769,,225% x Medicaid HMO amount,70769,Other,225% of NY Medicaid HMO DRG,70769,,225% x Medicaid HMO amount,70769,Other,225% of NY Medicaid HMO DRG,70769,,225% x Medicaid HMO amount,70769,Other,225% of NY Medicaid HMO DRG,70769,,225% x Medicaid HMO amount,70769,Other,225% of NY Medicaid HMO DRG,44034,,140% x Medicaid HMO amount,44034,Other,140% of NY Medicaid HMO DRG,70769,,225% x Medicaid HMO amount,70769,Other,225% of NY Medicaid HMO DRG,86496,,275% x Medicaid HMO amount,86496,Other,275% of NY Medicaid HMO DRG,101908,,324% x Medicaid HMO amount,101908,Other,324% of NY Medicaid HMO DRG,67624,,215% x Medicaid HMO amount,67624,Other,215% of NY Medicaid HMO DRG,67624,,215% x Medicaid HMO amount,67624,Other,215% of NY Medicaid HMO DRG,39316,,125% x Medicaid HMO amount,39316,Other,125% of NY Medicaid HMO DRG,0.01,177782,
Cardiac arrhythmia & conduction disorders,201-1,APR-DRG,,,,,,,,inpatient,,,116319.68,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19518,,"45,128 x DRG weight",19518,Other,base rate x DRG weight,17566,,"40,615 x DRG weight",17566,Other,base rate x DRG weight,16590,,"38,359 x DRG weight",16590,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7782,,186% x Medicaid HMO amount,7782,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14738,,"34,077 x DRG weight",14738,Other,base rate x DRG weight,12528,,"28,966 x DRG weight",12528,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4184,,DRG base rate x DRG weight + capital per discharge,4184,Other,100% of NY Medicaid HMO DRG,4184,,100% x Medicaid HMO amount,4184,Other,100% of NY Medicaid HMO DRG,4184,,100% x Medicaid HMO amount,4184,Other,100% of NY Medicaid HMO DRG,4184,,100% x Medicaid HMO amount,4184,Other,100% of NY Medicaid HMO DRG,9414,,225% x Medicaid HMO amount,9414,Other,225% of NY Medicaid HMO DRG,9414,,225% x Medicaid HMO amount,9414,Other,225% of NY Medicaid HMO DRG,9414,,225% x Medicaid HMO amount,9414,Other,225% of NY Medicaid HMO DRG,9414,,225% x Medicaid HMO amount,9414,Other,225% of NY Medicaid HMO DRG,5858,,140% x Medicaid HMO amount,5858,Other,140% of NY Medicaid HMO DRG,9414,,225% x Medicaid HMO amount,9414,Other,225% of NY Medicaid HMO DRG,11506,,275% x Medicaid HMO amount,11506,Other,275% of NY Medicaid HMO DRG,13556,,324% x Medicaid HMO amount,13556,Other,324% of NY Medicaid HMO DRG,8996,,215% x Medicaid HMO amount,8996,Other,215% of NY Medicaid HMO DRG,8996,,215% x Medicaid HMO amount,8996,Other,215% of NY Medicaid HMO DRG,5230,,125% x Medicaid HMO amount,5230,Other,125% of NY Medicaid HMO DRG,0.01,19518,
Cardiac arrhythmia & conduction disorders,201-2,APR-DRG,,,,,,,,inpatient,,,107906.78,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28191,,"45,128 x DRG weight",28191,Other,base rate x DRG weight,25372,,"40,615 x DRG weight",25372,Other,base rate x DRG weight,23963,,"38,359 x DRG weight",23963,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10561,,186% x Medicaid HMO amount,10561,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21288,,"34,077 x DRG weight",21288,Other,base rate x DRG weight,18095,,"28,966 x DRG weight",18095,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5678,,DRG base rate x DRG weight + capital per discharge,5678,Other,100% of NY Medicaid HMO DRG,5678,,100% x Medicaid HMO amount,5678,Other,100% of NY Medicaid HMO DRG,5678,,100% x Medicaid HMO amount,5678,Other,100% of NY Medicaid HMO DRG,5678,,100% x Medicaid HMO amount,5678,Other,100% of NY Medicaid HMO DRG,12776,,225% x Medicaid HMO amount,12776,Other,225% of NY Medicaid HMO DRG,12776,,225% x Medicaid HMO amount,12776,Other,225% of NY Medicaid HMO DRG,12776,,225% x Medicaid HMO amount,12776,Other,225% of NY Medicaid HMO DRG,12776,,225% x Medicaid HMO amount,12776,Other,225% of NY Medicaid HMO DRG,7949,,140% x Medicaid HMO amount,7949,Other,140% of NY Medicaid HMO DRG,12776,,225% x Medicaid HMO amount,12776,Other,225% of NY Medicaid HMO DRG,15615,,275% x Medicaid HMO amount,15615,Other,275% of NY Medicaid HMO DRG,18397,,324% x Medicaid HMO amount,18397,Other,324% of NY Medicaid HMO DRG,12208,,215% x Medicaid HMO amount,12208,Other,215% of NY Medicaid HMO DRG,12208,,215% x Medicaid HMO amount,12208,Other,215% of NY Medicaid HMO DRG,7098,,125% x Medicaid HMO amount,7098,Other,125% of NY Medicaid HMO DRG,0.01,28191,
Cardiac arrhythmia & conduction disorders,201-3,APR-DRG,,,,,,,,inpatient,,,113020.64,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48959,,"45,128 x DRG weight",48959,Other,base rate x DRG weight,44063,,"40,615 x DRG weight",44063,Other,base rate x DRG weight,41616,,"38,359 x DRG weight",41616,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17218,,186% x Medicaid HMO amount,17218,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36970,,"34,077 x DRG weight",36970,Other,base rate x DRG weight,31425,,"28,966 x DRG weight",31425,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9257,,DRG base rate x DRG weight + capital per discharge,9257,Other,100% of NY Medicaid HMO DRG,9257,,100% x Medicaid HMO amount,9257,Other,100% of NY Medicaid HMO DRG,9257,,100% x Medicaid HMO amount,9257,Other,100% of NY Medicaid HMO DRG,9257,,100% x Medicaid HMO amount,9257,Other,100% of NY Medicaid HMO DRG,20828,,225% x Medicaid HMO amount,20828,Other,225% of NY Medicaid HMO DRG,20828,,225% x Medicaid HMO amount,20828,Other,225% of NY Medicaid HMO DRG,20828,,225% x Medicaid HMO amount,20828,Other,225% of NY Medicaid HMO DRG,20828,,225% x Medicaid HMO amount,20828,Other,225% of NY Medicaid HMO DRG,12960,,140% x Medicaid HMO amount,12960,Other,140% of NY Medicaid HMO DRG,20828,,225% x Medicaid HMO amount,20828,Other,225% of NY Medicaid HMO DRG,25457,,275% x Medicaid HMO amount,25457,Other,275% of NY Medicaid HMO DRG,29993,,324% x Medicaid HMO amount,29993,Other,324% of NY Medicaid HMO DRG,19903,,215% x Medicaid HMO amount,19903,Other,215% of NY Medicaid HMO DRG,19903,,215% x Medicaid HMO amount,19903,Other,215% of NY Medicaid HMO DRG,11571,,125% x Medicaid HMO amount,11571,Other,125% of NY Medicaid HMO DRG,0.01,48959,
Cardiac arrhythmia & conduction disorders,201-4,APR-DRG,,,,,,,,inpatient,,,158033,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,114625,,"45,128 x DRG weight",114625,Other,base rate x DRG weight,103162,,"40,615 x DRG weight",103162,Other,base rate x DRG weight,97432,,"38,359 x DRG weight",97432,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38262,,186% x Medicaid HMO amount,38262,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,86556,,"34,077 x DRG weight",86556,Other,base rate x DRG weight,73574,,"28,966 x DRG weight",73574,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20571,,DRG base rate x DRG weight + capital per discharge,20571,Other,100% of NY Medicaid HMO DRG,20571,,100% x Medicaid HMO amount,20571,Other,100% of NY Medicaid HMO DRG,20571,,100% x Medicaid HMO amount,20571,Other,100% of NY Medicaid HMO DRG,20571,,100% x Medicaid HMO amount,20571,Other,100% of NY Medicaid HMO DRG,46285,,225% x Medicaid HMO amount,46285,Other,225% of NY Medicaid HMO DRG,46285,,225% x Medicaid HMO amount,46285,Other,225% of NY Medicaid HMO DRG,46285,,225% x Medicaid HMO amount,46285,Other,225% of NY Medicaid HMO DRG,46285,,225% x Medicaid HMO amount,46285,Other,225% of NY Medicaid HMO DRG,28799,,140% x Medicaid HMO amount,28799,Other,140% of NY Medicaid HMO DRG,46285,,225% x Medicaid HMO amount,46285,Other,225% of NY Medicaid HMO DRG,56570,,275% x Medicaid HMO amount,56570,Other,275% of NY Medicaid HMO DRG,66650,,324% x Medicaid HMO amount,66650,Other,324% of NY Medicaid HMO DRG,44228,,215% x Medicaid HMO amount,44228,Other,215% of NY Medicaid HMO DRG,44228,,215% x Medicaid HMO amount,44228,Other,215% of NY Medicaid HMO DRG,25714,,125% x Medicaid HMO amount,25714,Other,125% of NY Medicaid HMO DRG,0.01,114625,
Chest pain,203-1,APR-DRG,,,,,,,,inpatient,,,115321.97,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17771,,"45,128 x DRG weight",17771,Other,base rate x DRG weight,15994,,"40,615 x DRG weight",15994,Other,base rate x DRG weight,15106,,"38,359 x DRG weight",15106,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7222,,186% x Medicaid HMO amount,7222,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13420,,"34,077 x DRG weight",13420,Other,base rate x DRG weight,11407,,"28,966 x DRG weight",11407,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3883,,DRG base rate x DRG weight + capital per discharge,3883,Other,100% of NY Medicaid HMO DRG,3883,,100% x Medicaid HMO amount,3883,Other,100% of NY Medicaid HMO DRG,3883,,100% x Medicaid HMO amount,3883,Other,100% of NY Medicaid HMO DRG,3883,,100% x Medicaid HMO amount,3883,Other,100% of NY Medicaid HMO DRG,8737,,225% x Medicaid HMO amount,8737,Other,225% of NY Medicaid HMO DRG,8737,,225% x Medicaid HMO amount,8737,Other,225% of NY Medicaid HMO DRG,8737,,225% x Medicaid HMO amount,8737,Other,225% of NY Medicaid HMO DRG,8737,,225% x Medicaid HMO amount,8737,Other,225% of NY Medicaid HMO DRG,5436,,140% x Medicaid HMO amount,5436,Other,140% of NY Medicaid HMO DRG,8737,,225% x Medicaid HMO amount,8737,Other,225% of NY Medicaid HMO DRG,10678,,275% x Medicaid HMO amount,10678,Other,275% of NY Medicaid HMO DRG,12581,,324% x Medicaid HMO amount,12581,Other,324% of NY Medicaid HMO DRG,8348,,215% x Medicaid HMO amount,8348,Other,215% of NY Medicaid HMO DRG,8348,,215% x Medicaid HMO amount,8348,Other,215% of NY Medicaid HMO DRG,4854,,125% x Medicaid HMO amount,4854,Other,125% of NY Medicaid HMO DRG,0.01,17771,
Chest pain,203-2,APR-DRG,,,,,,,,inpatient,,,102165.3,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22171,,"45,128 x DRG weight",22171,Other,base rate x DRG weight,19954,,"40,615 x DRG weight",19954,Other,base rate x DRG weight,18846,,"38,359 x DRG weight",18846,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8632,,186% x Medicaid HMO amount,8632,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16742,,"34,077 x DRG weight",16742,Other,base rate x DRG weight,14231,,"28,966 x DRG weight",14231,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4641,,DRG base rate x DRG weight + capital per discharge,4641,Other,100% of NY Medicaid HMO DRG,4641,,100% x Medicaid HMO amount,4641,Other,100% of NY Medicaid HMO DRG,4641,,100% x Medicaid HMO amount,4641,Other,100% of NY Medicaid HMO DRG,4641,,100% x Medicaid HMO amount,4641,Other,100% of NY Medicaid HMO DRG,10442,,225% x Medicaid HMO amount,10442,Other,225% of NY Medicaid HMO DRG,10442,,225% x Medicaid HMO amount,10442,Other,225% of NY Medicaid HMO DRG,10442,,225% x Medicaid HMO amount,10442,Other,225% of NY Medicaid HMO DRG,10442,,225% x Medicaid HMO amount,10442,Other,225% of NY Medicaid HMO DRG,6497,,140% x Medicaid HMO amount,6497,Other,140% of NY Medicaid HMO DRG,10442,,225% x Medicaid HMO amount,10442,Other,225% of NY Medicaid HMO DRG,12763,,275% x Medicaid HMO amount,12763,Other,275% of NY Medicaid HMO DRG,15037,,324% x Medicaid HMO amount,15037,Other,324% of NY Medicaid HMO DRG,9978,,215% x Medicaid HMO amount,9978,Other,215% of NY Medicaid HMO DRG,9978,,215% x Medicaid HMO amount,9978,Other,215% of NY Medicaid HMO DRG,5801,,125% x Medicaid HMO amount,5801,Other,125% of NY Medicaid HMO DRG,0.01,22171,
Chest pain,203-3,APR-DRG,,,,,,,,inpatient,,,123261,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31856,,"45,128 x DRG weight",31856,Other,base rate x DRG weight,28670,,"40,615 x DRG weight",28670,Other,base rate x DRG weight,27078,,"38,359 x DRG weight",27078,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11737,,186% x Medicaid HMO amount,11737,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24055,,"34,077 x DRG weight",24055,Other,base rate x DRG weight,20447,,"28,966 x DRG weight",20447,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6310,,DRG base rate x DRG weight + capital per discharge,6310,Other,100% of NY Medicaid HMO DRG,6310,,100% x Medicaid HMO amount,6310,Other,100% of NY Medicaid HMO DRG,6310,,100% x Medicaid HMO amount,6310,Other,100% of NY Medicaid HMO DRG,6310,,100% x Medicaid HMO amount,6310,Other,100% of NY Medicaid HMO DRG,14198,,225% x Medicaid HMO amount,14198,Other,225% of NY Medicaid HMO DRG,14198,,225% x Medicaid HMO amount,14198,Other,225% of NY Medicaid HMO DRG,14198,,225% x Medicaid HMO amount,14198,Other,225% of NY Medicaid HMO DRG,14198,,225% x Medicaid HMO amount,14198,Other,225% of NY Medicaid HMO DRG,8834,,140% x Medicaid HMO amount,8834,Other,140% of NY Medicaid HMO DRG,14198,,225% x Medicaid HMO amount,14198,Other,225% of NY Medicaid HMO DRG,17353,,275% x Medicaid HMO amount,17353,Other,275% of NY Medicaid HMO DRG,20444,,324% x Medicaid HMO amount,20444,Other,324% of NY Medicaid HMO DRG,13567,,215% x Medicaid HMO amount,13567,Other,215% of NY Medicaid HMO DRG,13567,,215% x Medicaid HMO amount,13567,Other,215% of NY Medicaid HMO DRG,7888,,125% x Medicaid HMO amount,7888,Other,125% of NY Medicaid HMO DRG,0.01,31856,
Chest pain,203-4,APR-DRG,,,,,,,,inpatient,,,123261,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,106285,,"45,128 x DRG weight",106285,Other,base rate x DRG weight,95656,,"40,615 x DRG weight",95656,Other,base rate x DRG weight,90343,,"38,359 x DRG weight",90343,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35589,,186% x Medicaid HMO amount,35589,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,80258,,"34,077 x DRG weight",80258,Other,base rate x DRG weight,68221,,"28,966 x DRG weight",68221,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19134,,DRG base rate x DRG weight + capital per discharge,19134,Other,100% of NY Medicaid HMO DRG,19134,,100% x Medicaid HMO amount,19134,Other,100% of NY Medicaid HMO DRG,19134,,100% x Medicaid HMO amount,19134,Other,100% of NY Medicaid HMO DRG,19134,,100% x Medicaid HMO amount,19134,Other,100% of NY Medicaid HMO DRG,43052,,225% x Medicaid HMO amount,43052,Other,225% of NY Medicaid HMO DRG,43052,,225% x Medicaid HMO amount,43052,Other,225% of NY Medicaid HMO DRG,43052,,225% x Medicaid HMO amount,43052,Other,225% of NY Medicaid HMO DRG,43052,,225% x Medicaid HMO amount,43052,Other,225% of NY Medicaid HMO DRG,26788,,140% x Medicaid HMO amount,26788,Other,140% of NY Medicaid HMO DRG,43052,,225% x Medicaid HMO amount,43052,Other,225% of NY Medicaid HMO DRG,52619,,275% x Medicaid HMO amount,52619,Other,275% of NY Medicaid HMO DRG,61994,,324% x Medicaid HMO amount,61994,Other,324% of NY Medicaid HMO DRG,41138,,215% x Medicaid HMO amount,41138,Other,215% of NY Medicaid HMO DRG,41138,,215% x Medicaid HMO amount,41138,Other,215% of NY Medicaid HMO DRG,23918,,125% x Medicaid HMO amount,23918,Other,125% of NY Medicaid HMO DRG,0.01,106285,
Syncope & collapse,204-1,APR-DRG,,,,,,,,inpatient,,,92229.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20772,,"45,128 x DRG weight",20772,Other,base rate x DRG weight,18695,,"40,615 x DRG weight",18695,Other,base rate x DRG weight,17657,,"38,359 x DRG weight",17657,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8184,,186% x Medicaid HMO amount,8184,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15686,,"34,077 x DRG weight",15686,Other,base rate x DRG weight,13333,,"28,966 x DRG weight",13333,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4400,,DRG base rate x DRG weight + capital per discharge,4400,Other,100% of NY Medicaid HMO DRG,4400,,100% x Medicaid HMO amount,4400,Other,100% of NY Medicaid HMO DRG,4400,,100% x Medicaid HMO amount,4400,Other,100% of NY Medicaid HMO DRG,4400,,100% x Medicaid HMO amount,4400,Other,100% of NY Medicaid HMO DRG,9900,,225% x Medicaid HMO amount,9900,Other,225% of NY Medicaid HMO DRG,9900,,225% x Medicaid HMO amount,9900,Other,225% of NY Medicaid HMO DRG,9900,,225% x Medicaid HMO amount,9900,Other,225% of NY Medicaid HMO DRG,9900,,225% x Medicaid HMO amount,9900,Other,225% of NY Medicaid HMO DRG,6160,,140% x Medicaid HMO amount,6160,Other,140% of NY Medicaid HMO DRG,9900,,225% x Medicaid HMO amount,9900,Other,225% of NY Medicaid HMO DRG,12100,,275% x Medicaid HMO amount,12100,Other,275% of NY Medicaid HMO DRG,14256,,324% x Medicaid HMO amount,14256,Other,324% of NY Medicaid HMO DRG,9460,,215% x Medicaid HMO amount,9460,Other,215% of NY Medicaid HMO DRG,9460,,215% x Medicaid HMO amount,9460,Other,215% of NY Medicaid HMO DRG,5500,,125% x Medicaid HMO amount,5500,Other,125% of NY Medicaid HMO DRG,0.01,20772,
Syncope & collapse,204-2,APR-DRG,,,,,,,,inpatient,,,150563.03,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25949,,"45,128 x DRG weight",25949,Other,base rate x DRG weight,23354,,"40,615 x DRG weight",23354,Other,base rate x DRG weight,22056,,"38,359 x DRG weight",22056,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9843,,186% x Medicaid HMO amount,9843,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19594,,"34,077 x DRG weight",19594,Other,base rate x DRG weight,16655,,"28,966 x DRG weight",16655,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5292,,DRG base rate x DRG weight + capital per discharge,5292,Other,100% of NY Medicaid HMO DRG,5292,,100% x Medicaid HMO amount,5292,Other,100% of NY Medicaid HMO DRG,5292,,100% x Medicaid HMO amount,5292,Other,100% of NY Medicaid HMO DRG,5292,,100% x Medicaid HMO amount,5292,Other,100% of NY Medicaid HMO DRG,11907,,225% x Medicaid HMO amount,11907,Other,225% of NY Medicaid HMO DRG,11907,,225% x Medicaid HMO amount,11907,Other,225% of NY Medicaid HMO DRG,11907,,225% x Medicaid HMO amount,11907,Other,225% of NY Medicaid HMO DRG,11907,,225% x Medicaid HMO amount,11907,Other,225% of NY Medicaid HMO DRG,7409,,140% x Medicaid HMO amount,7409,Other,140% of NY Medicaid HMO DRG,11907,,225% x Medicaid HMO amount,11907,Other,225% of NY Medicaid HMO DRG,14553,,275% x Medicaid HMO amount,14553,Other,275% of NY Medicaid HMO DRG,17146,,324% x Medicaid HMO amount,17146,Other,324% of NY Medicaid HMO DRG,11378,,215% x Medicaid HMO amount,11378,Other,215% of NY Medicaid HMO DRG,11378,,215% x Medicaid HMO amount,11378,Other,215% of NY Medicaid HMO DRG,6615,,125% x Medicaid HMO amount,6615,Other,125% of NY Medicaid HMO DRG,0.01,25949,
Syncope & collapse,204-3,APR-DRG,,,,,,,,inpatient,,,189869.65,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38783,,"45,128 x DRG weight",38783,Other,base rate x DRG weight,34905,,"40,615 x DRG weight",34905,Other,base rate x DRG weight,32966,,"38,359 x DRG weight",32966,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13956,,186% x Medicaid HMO amount,13956,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29286,,"34,077 x DRG weight",29286,Other,base rate x DRG weight,24893,,"28,966 x DRG weight",24893,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7503,,DRG base rate x DRG weight + capital per discharge,7503,Other,100% of NY Medicaid HMO DRG,7503,,100% x Medicaid HMO amount,7503,Other,100% of NY Medicaid HMO DRG,7503,,100% x Medicaid HMO amount,7503,Other,100% of NY Medicaid HMO DRG,7503,,100% x Medicaid HMO amount,7503,Other,100% of NY Medicaid HMO DRG,16882,,225% x Medicaid HMO amount,16882,Other,225% of NY Medicaid HMO DRG,16882,,225% x Medicaid HMO amount,16882,Other,225% of NY Medicaid HMO DRG,16882,,225% x Medicaid HMO amount,16882,Other,225% of NY Medicaid HMO DRG,16882,,225% x Medicaid HMO amount,16882,Other,225% of NY Medicaid HMO DRG,10504,,140% x Medicaid HMO amount,10504,Other,140% of NY Medicaid HMO DRG,16882,,225% x Medicaid HMO amount,16882,Other,225% of NY Medicaid HMO DRG,20633,,275% x Medicaid HMO amount,20633,Other,275% of NY Medicaid HMO DRG,24310,,324% x Medicaid HMO amount,24310,Other,324% of NY Medicaid HMO DRG,16131,,215% x Medicaid HMO amount,16131,Other,215% of NY Medicaid HMO DRG,16131,,215% x Medicaid HMO amount,16131,Other,215% of NY Medicaid HMO DRG,9379,,125% x Medicaid HMO amount,9379,Other,125% of NY Medicaid HMO DRG,0.01,38783,
Syncope & collapse,204-4,APR-DRG,,,,,,,,inpatient,,,118084.71,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,95703,,"45,128 x DRG weight",95703,Other,base rate x DRG weight,86132,,"40,615 x DRG weight",86132,Other,base rate x DRG weight,81348,,"38,359 x DRG weight",81348,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32198,,186% x Medicaid HMO amount,32198,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,72267,,"34,077 x DRG weight",72267,Other,base rate x DRG weight,61428,,"28,966 x DRG weight",61428,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17311,,DRG base rate x DRG weight + capital per discharge,17311,Other,100% of NY Medicaid HMO DRG,17311,,100% x Medicaid HMO amount,17311,Other,100% of NY Medicaid HMO DRG,17311,,100% x Medicaid HMO amount,17311,Other,100% of NY Medicaid HMO DRG,17311,,100% x Medicaid HMO amount,17311,Other,100% of NY Medicaid HMO DRG,38950,,225% x Medicaid HMO amount,38950,Other,225% of NY Medicaid HMO DRG,38950,,225% x Medicaid HMO amount,38950,Other,225% of NY Medicaid HMO DRG,38950,,225% x Medicaid HMO amount,38950,Other,225% of NY Medicaid HMO DRG,38950,,225% x Medicaid HMO amount,38950,Other,225% of NY Medicaid HMO DRG,24235,,140% x Medicaid HMO amount,24235,Other,140% of NY Medicaid HMO DRG,38950,,225% x Medicaid HMO amount,38950,Other,225% of NY Medicaid HMO DRG,47605,,275% x Medicaid HMO amount,47605,Other,275% of NY Medicaid HMO DRG,56088,,324% x Medicaid HMO amount,56088,Other,324% of NY Medicaid HMO DRG,37219,,215% x Medicaid HMO amount,37219,Other,215% of NY Medicaid HMO DRG,37219,,215% x Medicaid HMO amount,37219,Other,215% of NY Medicaid HMO DRG,21639,,125% x Medicaid HMO amount,21639,Other,125% of NY Medicaid HMO DRG,0.01,95703,
Cardiomyopathy,205-1,APR-DRG,,,,,,,,inpatient,,,36299.23,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26517,,"45,128 x DRG weight",26517,Other,base rate x DRG weight,23865,,"40,615 x DRG weight",23865,Other,base rate x DRG weight,22540,,"38,359 x DRG weight",22540,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10025,,186% x Medicaid HMO amount,10025,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20024,,"34,077 x DRG weight",20024,Other,base rate x DRG weight,17020,,"28,966 x DRG weight",17020,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5390,,DRG base rate x DRG weight + capital per discharge,5390,Other,100% of NY Medicaid HMO DRG,5390,,100% x Medicaid HMO amount,5390,Other,100% of NY Medicaid HMO DRG,5390,,100% x Medicaid HMO amount,5390,Other,100% of NY Medicaid HMO DRG,5390,,100% x Medicaid HMO amount,5390,Other,100% of NY Medicaid HMO DRG,12128,,225% x Medicaid HMO amount,12128,Other,225% of NY Medicaid HMO DRG,12128,,225% x Medicaid HMO amount,12128,Other,225% of NY Medicaid HMO DRG,12128,,225% x Medicaid HMO amount,12128,Other,225% of NY Medicaid HMO DRG,12128,,225% x Medicaid HMO amount,12128,Other,225% of NY Medicaid HMO DRG,7546,,140% x Medicaid HMO amount,7546,Other,140% of NY Medicaid HMO DRG,12128,,225% x Medicaid HMO amount,12128,Other,225% of NY Medicaid HMO DRG,14823,,275% x Medicaid HMO amount,14823,Other,275% of NY Medicaid HMO DRG,17464,,324% x Medicaid HMO amount,17464,Other,324% of NY Medicaid HMO DRG,11589,,215% x Medicaid HMO amount,11589,Other,215% of NY Medicaid HMO DRG,11589,,215% x Medicaid HMO amount,11589,Other,215% of NY Medicaid HMO DRG,6738,,125% x Medicaid HMO amount,6738,Other,125% of NY Medicaid HMO DRG,0.01,26517,
Cardiomyopathy,205-2,APR-DRG,,,,,,,,inpatient,,,133924.12,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33679,,"45,128 x DRG weight",33679,Other,base rate x DRG weight,30311,,"40,615 x DRG weight",30311,Other,base rate x DRG weight,28627,,"38,359 x DRG weight",28627,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12321,,186% x Medicaid HMO amount,12321,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25432,,"34,077 x DRG weight",25432,Other,base rate x DRG weight,21617,,"28,966 x DRG weight",21617,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6624,,DRG base rate x DRG weight + capital per discharge,6624,Other,100% of NY Medicaid HMO DRG,6624,,100% x Medicaid HMO amount,6624,Other,100% of NY Medicaid HMO DRG,6624,,100% x Medicaid HMO amount,6624,Other,100% of NY Medicaid HMO DRG,6624,,100% x Medicaid HMO amount,6624,Other,100% of NY Medicaid HMO DRG,14904,,225% x Medicaid HMO amount,14904,Other,225% of NY Medicaid HMO DRG,14904,,225% x Medicaid HMO amount,14904,Other,225% of NY Medicaid HMO DRG,14904,,225% x Medicaid HMO amount,14904,Other,225% of NY Medicaid HMO DRG,14904,,225% x Medicaid HMO amount,14904,Other,225% of NY Medicaid HMO DRG,9274,,140% x Medicaid HMO amount,9274,Other,140% of NY Medicaid HMO DRG,14904,,225% x Medicaid HMO amount,14904,Other,225% of NY Medicaid HMO DRG,18216,,275% x Medicaid HMO amount,18216,Other,275% of NY Medicaid HMO DRG,21462,,324% x Medicaid HMO amount,21462,Other,324% of NY Medicaid HMO DRG,14242,,215% x Medicaid HMO amount,14242,Other,215% of NY Medicaid HMO DRG,14242,,215% x Medicaid HMO amount,14242,Other,215% of NY Medicaid HMO DRG,8280,,125% x Medicaid HMO amount,8280,Other,125% of NY Medicaid HMO DRG,0.01,33679,
Cardiomyopathy,205-3,APR-DRG,,,,,,,,inpatient,,,121963.73,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,65589,,"45,128 x DRG weight",65589,Other,base rate x DRG weight,59030,,"40,615 x DRG weight",59030,Other,base rate x DRG weight,55751,,"38,359 x DRG weight",55751,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22547,,186% x Medicaid HMO amount,22547,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49528,,"34,077 x DRG weight",49528,Other,base rate x DRG weight,42099,,"28,966 x DRG weight",42099,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12122,,DRG base rate x DRG weight + capital per discharge,12122,Other,100% of NY Medicaid HMO DRG,12122,,100% x Medicaid HMO amount,12122,Other,100% of NY Medicaid HMO DRG,12122,,100% x Medicaid HMO amount,12122,Other,100% of NY Medicaid HMO DRG,12122,,100% x Medicaid HMO amount,12122,Other,100% of NY Medicaid HMO DRG,27275,,225% x Medicaid HMO amount,27275,Other,225% of NY Medicaid HMO DRG,27275,,225% x Medicaid HMO amount,27275,Other,225% of NY Medicaid HMO DRG,27275,,225% x Medicaid HMO amount,27275,Other,225% of NY Medicaid HMO DRG,27275,,225% x Medicaid HMO amount,27275,Other,225% of NY Medicaid HMO DRG,16971,,140% x Medicaid HMO amount,16971,Other,140% of NY Medicaid HMO DRG,27275,,225% x Medicaid HMO amount,27275,Other,225% of NY Medicaid HMO DRG,33336,,275% x Medicaid HMO amount,33336,Other,275% of NY Medicaid HMO DRG,39275,,324% x Medicaid HMO amount,39275,Other,324% of NY Medicaid HMO DRG,26062,,215% x Medicaid HMO amount,26062,Other,215% of NY Medicaid HMO DRG,26062,,215% x Medicaid HMO amount,26062,Other,215% of NY Medicaid HMO DRG,15153,,125% x Medicaid HMO amount,15153,Other,125% of NY Medicaid HMO DRG,0.01,65589,
Cardiomyopathy,205-4,APR-DRG,,,,,,,,inpatient,,,133924.12,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,79971,,"45,128 x DRG weight",79971,Other,base rate x DRG weight,71974,,"40,615 x DRG weight",71974,Other,base rate x DRG weight,67976,,"38,359 x DRG weight",67976,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27156,,186% x Medicaid HMO amount,27156,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60388,,"34,077 x DRG weight",60388,Other,base rate x DRG weight,51331,,"28,966 x DRG weight",51331,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14600,,DRG base rate x DRG weight + capital per discharge,14600,Other,100% of NY Medicaid HMO DRG,14600,,100% x Medicaid HMO amount,14600,Other,100% of NY Medicaid HMO DRG,14600,,100% x Medicaid HMO amount,14600,Other,100% of NY Medicaid HMO DRG,14600,,100% x Medicaid HMO amount,14600,Other,100% of NY Medicaid HMO DRG,32850,,225% x Medicaid HMO amount,32850,Other,225% of NY Medicaid HMO DRG,32850,,225% x Medicaid HMO amount,32850,Other,225% of NY Medicaid HMO DRG,32850,,225% x Medicaid HMO amount,32850,Other,225% of NY Medicaid HMO DRG,32850,,225% x Medicaid HMO amount,32850,Other,225% of NY Medicaid HMO DRG,20440,,140% x Medicaid HMO amount,20440,Other,140% of NY Medicaid HMO DRG,32850,,225% x Medicaid HMO amount,32850,Other,225% of NY Medicaid HMO DRG,40150,,275% x Medicaid HMO amount,40150,Other,275% of NY Medicaid HMO DRG,47304,,324% x Medicaid HMO amount,47304,Other,324% of NY Medicaid HMO DRG,31390,,215% x Medicaid HMO amount,31390,Other,215% of NY Medicaid HMO DRG,31390,,215% x Medicaid HMO amount,31390,Other,215% of NY Medicaid HMO DRG,18250,,125% x Medicaid HMO amount,18250,Other,125% of NY Medicaid HMO DRG,0.01,79971,
"Malfunction,reaction,complication of cardiac/vasc device or procedure",206-1,APR-DRG,,,,,,,,inpatient,,,135654.44,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24811,,"45,128 x DRG weight",24811,Other,base rate x DRG weight,22330,,"40,615 x DRG weight",22330,Other,base rate x DRG weight,21090,,"38,359 x DRG weight",21090,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9479,,186% x Medicaid HMO amount,9479,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18736,,"34,077 x DRG weight",18736,Other,base rate x DRG weight,15926,,"28,966 x DRG weight",15926,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5096,,DRG base rate x DRG weight + capital per discharge,5096,Other,100% of NY Medicaid HMO DRG,5096,,100% x Medicaid HMO amount,5096,Other,100% of NY Medicaid HMO DRG,5096,,100% x Medicaid HMO amount,5096,Other,100% of NY Medicaid HMO DRG,5096,,100% x Medicaid HMO amount,5096,Other,100% of NY Medicaid HMO DRG,11466,,225% x Medicaid HMO amount,11466,Other,225% of NY Medicaid HMO DRG,11466,,225% x Medicaid HMO amount,11466,Other,225% of NY Medicaid HMO DRG,11466,,225% x Medicaid HMO amount,11466,Other,225% of NY Medicaid HMO DRG,11466,,225% x Medicaid HMO amount,11466,Other,225% of NY Medicaid HMO DRG,7134,,140% x Medicaid HMO amount,7134,Other,140% of NY Medicaid HMO DRG,11466,,225% x Medicaid HMO amount,11466,Other,225% of NY Medicaid HMO DRG,14014,,275% x Medicaid HMO amount,14014,Other,275% of NY Medicaid HMO DRG,16511,,324% x Medicaid HMO amount,16511,Other,324% of NY Medicaid HMO DRG,10956,,215% x Medicaid HMO amount,10956,Other,215% of NY Medicaid HMO DRG,10956,,215% x Medicaid HMO amount,10956,Other,215% of NY Medicaid HMO DRG,6370,,125% x Medicaid HMO amount,6370,Other,125% of NY Medicaid HMO DRG,0.01,24811,
"Malfunction,reaction,complication of cardiac/vasc device or procedure",206-2,APR-DRG,,,,,,,,inpatient,,,76262.3,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32840,,"45,128 x DRG weight",32840,Other,base rate x DRG weight,29556,,"40,615 x DRG weight",29556,Other,base rate x DRG weight,27914,,"38,359 x DRG weight",27914,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12051,,186% x Medicaid HMO amount,12051,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24798,,"34,077 x DRG weight",24798,Other,base rate x DRG weight,21079,,"28,966 x DRG weight",21079,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6479,,DRG base rate x DRG weight + capital per discharge,6479,Other,100% of NY Medicaid HMO DRG,6479,,100% x Medicaid HMO amount,6479,Other,100% of NY Medicaid HMO DRG,6479,,100% x Medicaid HMO amount,6479,Other,100% of NY Medicaid HMO DRG,6479,,100% x Medicaid HMO amount,6479,Other,100% of NY Medicaid HMO DRG,14578,,225% x Medicaid HMO amount,14578,Other,225% of NY Medicaid HMO DRG,14578,,225% x Medicaid HMO amount,14578,Other,225% of NY Medicaid HMO DRG,14578,,225% x Medicaid HMO amount,14578,Other,225% of NY Medicaid HMO DRG,14578,,225% x Medicaid HMO amount,14578,Other,225% of NY Medicaid HMO DRG,9071,,140% x Medicaid HMO amount,9071,Other,140% of NY Medicaid HMO DRG,14578,,225% x Medicaid HMO amount,14578,Other,225% of NY Medicaid HMO DRG,17817,,275% x Medicaid HMO amount,17817,Other,275% of NY Medicaid HMO DRG,20992,,324% x Medicaid HMO amount,20992,Other,324% of NY Medicaid HMO DRG,13930,,215% x Medicaid HMO amount,13930,Other,215% of NY Medicaid HMO DRG,13930,,215% x Medicaid HMO amount,13930,Other,215% of NY Medicaid HMO DRG,8099,,125% x Medicaid HMO amount,8099,Other,125% of NY Medicaid HMO DRG,0.01,32840,
"Malfunction,reaction,complication of cardiac/vasc device or procedure",206-3,APR-DRG,,,,,,,,inpatient,,,213020.68,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56148,,"45,128 x DRG weight",56148,Other,base rate x DRG weight,50533,,"40,615 x DRG weight",50533,Other,base rate x DRG weight,47726,,"38,359 x DRG weight",47726,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19521,,186% x Medicaid HMO amount,19521,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42399,,"34,077 x DRG weight",42399,Other,base rate x DRG weight,36039,,"28,966 x DRG weight",36039,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10495,,DRG base rate x DRG weight + capital per discharge,10495,Other,100% of NY Medicaid HMO DRG,10495,,100% x Medicaid HMO amount,10495,Other,100% of NY Medicaid HMO DRG,10495,,100% x Medicaid HMO amount,10495,Other,100% of NY Medicaid HMO DRG,10495,,100% x Medicaid HMO amount,10495,Other,100% of NY Medicaid HMO DRG,23614,,225% x Medicaid HMO amount,23614,Other,225% of NY Medicaid HMO DRG,23614,,225% x Medicaid HMO amount,23614,Other,225% of NY Medicaid HMO DRG,23614,,225% x Medicaid HMO amount,23614,Other,225% of NY Medicaid HMO DRG,23614,,225% x Medicaid HMO amount,23614,Other,225% of NY Medicaid HMO DRG,14693,,140% x Medicaid HMO amount,14693,Other,140% of NY Medicaid HMO DRG,23614,,225% x Medicaid HMO amount,23614,Other,225% of NY Medicaid HMO DRG,28861,,275% x Medicaid HMO amount,28861,Other,275% of NY Medicaid HMO DRG,34004,,324% x Medicaid HMO amount,34004,Other,324% of NY Medicaid HMO DRG,22564,,215% x Medicaid HMO amount,22564,Other,215% of NY Medicaid HMO DRG,22564,,215% x Medicaid HMO amount,22564,Other,215% of NY Medicaid HMO DRG,13119,,125% x Medicaid HMO amount,13119,Other,125% of NY Medicaid HMO DRG,0.01,56148,
"Malfunction,reaction,complication of cardiac/vasc device or procedure",206-4,APR-DRG,,,,,,,,inpatient,,,264277.07,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,153638,,"45,128 x DRG weight",153638,Other,base rate x DRG weight,138274,,"40,615 x DRG weight",138274,Other,base rate x DRG weight,130593,,"38,359 x DRG weight",130593,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50765,,186% x Medicaid HMO amount,50765,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,116015,,"34,077 x DRG weight",116015,Other,base rate x DRG weight,98615,,"28,966 x DRG weight",98615,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27293,,DRG base rate x DRG weight + capital per discharge,27293,Other,100% of NY Medicaid HMO DRG,27293,,100% x Medicaid HMO amount,27293,Other,100% of NY Medicaid HMO DRG,27293,,100% x Medicaid HMO amount,27293,Other,100% of NY Medicaid HMO DRG,27293,,100% x Medicaid HMO amount,27293,Other,100% of NY Medicaid HMO DRG,61409,,225% x Medicaid HMO amount,61409,Other,225% of NY Medicaid HMO DRG,61409,,225% x Medicaid HMO amount,61409,Other,225% of NY Medicaid HMO DRG,61409,,225% x Medicaid HMO amount,61409,Other,225% of NY Medicaid HMO DRG,61409,,225% x Medicaid HMO amount,61409,Other,225% of NY Medicaid HMO DRG,38210,,140% x Medicaid HMO amount,38210,Other,140% of NY Medicaid HMO DRG,61409,,225% x Medicaid HMO amount,61409,Other,225% of NY Medicaid HMO DRG,75056,,275% x Medicaid HMO amount,75056,Other,275% of NY Medicaid HMO DRG,88429,,324% x Medicaid HMO amount,88429,Other,324% of NY Medicaid HMO DRG,58680,,215% x Medicaid HMO amount,58680,Other,215% of NY Medicaid HMO DRG,58680,,215% x Medicaid HMO amount,58680,Other,215% of NY Medicaid HMO DRG,34116,,125% x Medicaid HMO amount,34116,Other,125% of NY Medicaid HMO DRG,0.01,153638,
Other circulatory system diagnoses,207-1,APR-DRG,,,,,,,,inpatient,,,64898.43,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22063,,"45,128 x DRG weight",22063,Other,base rate x DRG weight,19857,,"40,615 x DRG weight",19857,Other,base rate x DRG weight,18754,,"38,359 x DRG weight",18754,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8597,,186% x Medicaid HMO amount,8597,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16660,,"34,077 x DRG weight",16660,Other,base rate x DRG weight,14161,,"28,966 x DRG weight",14161,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4622,,DRG base rate x DRG weight + capital per discharge,4622,Other,100% of NY Medicaid HMO DRG,4622,,100% x Medicaid HMO amount,4622,Other,100% of NY Medicaid HMO DRG,4622,,100% x Medicaid HMO amount,4622,Other,100% of NY Medicaid HMO DRG,4622,,100% x Medicaid HMO amount,4622,Other,100% of NY Medicaid HMO DRG,10400,,225% x Medicaid HMO amount,10400,Other,225% of NY Medicaid HMO DRG,10400,,225% x Medicaid HMO amount,10400,Other,225% of NY Medicaid HMO DRG,10400,,225% x Medicaid HMO amount,10400,Other,225% of NY Medicaid HMO DRG,10400,,225% x Medicaid HMO amount,10400,Other,225% of NY Medicaid HMO DRG,6471,,140% x Medicaid HMO amount,6471,Other,140% of NY Medicaid HMO DRG,10400,,225% x Medicaid HMO amount,10400,Other,225% of NY Medicaid HMO DRG,12711,,275% x Medicaid HMO amount,12711,Other,275% of NY Medicaid HMO DRG,14975,,324% x Medicaid HMO amount,14975,Other,324% of NY Medicaid HMO DRG,9937,,215% x Medicaid HMO amount,9937,Other,215% of NY Medicaid HMO DRG,9937,,215% x Medicaid HMO amount,9937,Other,215% of NY Medicaid HMO DRG,5778,,125% x Medicaid HMO amount,5778,Other,125% of NY Medicaid HMO DRG,0.01,22063,
Other circulatory system diagnoses,207-2,APR-DRG,,,,,,,,inpatient,,,137783.15,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32361,,"45,128 x DRG weight",32361,Other,base rate x DRG weight,29125,,"40,615 x DRG weight",29125,Other,base rate x DRG weight,27507,,"38,359 x DRG weight",27507,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11898,,186% x Medicaid HMO amount,11898,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24437,,"34,077 x DRG weight",24437,Other,base rate x DRG weight,20772,,"28,966 x DRG weight",20772,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6397,,DRG base rate x DRG weight + capital per discharge,6397,Other,100% of NY Medicaid HMO DRG,6397,,100% x Medicaid HMO amount,6397,Other,100% of NY Medicaid HMO DRG,6397,,100% x Medicaid HMO amount,6397,Other,100% of NY Medicaid HMO DRG,6397,,100% x Medicaid HMO amount,6397,Other,100% of NY Medicaid HMO DRG,14393,,225% x Medicaid HMO amount,14393,Other,225% of NY Medicaid HMO DRG,14393,,225% x Medicaid HMO amount,14393,Other,225% of NY Medicaid HMO DRG,14393,,225% x Medicaid HMO amount,14393,Other,225% of NY Medicaid HMO DRG,14393,,225% x Medicaid HMO amount,14393,Other,225% of NY Medicaid HMO DRG,8956,,140% x Medicaid HMO amount,8956,Other,140% of NY Medicaid HMO DRG,14393,,225% x Medicaid HMO amount,14393,Other,225% of NY Medicaid HMO DRG,17592,,275% x Medicaid HMO amount,17592,Other,275% of NY Medicaid HMO DRG,20726,,324% x Medicaid HMO amount,20726,Other,324% of NY Medicaid HMO DRG,13754,,215% x Medicaid HMO amount,13754,Other,215% of NY Medicaid HMO DRG,13754,,215% x Medicaid HMO amount,13754,Other,215% of NY Medicaid HMO DRG,7996,,125% x Medicaid HMO amount,7996,Other,125% of NY Medicaid HMO DRG,0.01,32361,
Other circulatory system diagnoses,207-3,APR-DRG,,,,,,,,inpatient,,,190779.16,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54284,,"45,128 x DRG weight",54284,Other,base rate x DRG weight,48856,,"40,615 x DRG weight",48856,Other,base rate x DRG weight,46142,,"38,359 x DRG weight",46142,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18924,,186% x Medicaid HMO amount,18924,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40991,,"34,077 x DRG weight",40991,Other,base rate x DRG weight,34843,,"28,966 x DRG weight",34843,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10174,,DRG base rate x DRG weight + capital per discharge,10174,Other,100% of NY Medicaid HMO DRG,10174,,100% x Medicaid HMO amount,10174,Other,100% of NY Medicaid HMO DRG,10174,,100% x Medicaid HMO amount,10174,Other,100% of NY Medicaid HMO DRG,10174,,100% x Medicaid HMO amount,10174,Other,100% of NY Medicaid HMO DRG,22892,,225% x Medicaid HMO amount,22892,Other,225% of NY Medicaid HMO DRG,22892,,225% x Medicaid HMO amount,22892,Other,225% of NY Medicaid HMO DRG,22892,,225% x Medicaid HMO amount,22892,Other,225% of NY Medicaid HMO DRG,22892,,225% x Medicaid HMO amount,22892,Other,225% of NY Medicaid HMO DRG,14244,,140% x Medicaid HMO amount,14244,Other,140% of NY Medicaid HMO DRG,22892,,225% x Medicaid HMO amount,22892,Other,225% of NY Medicaid HMO DRG,27979,,275% x Medicaid HMO amount,27979,Other,275% of NY Medicaid HMO DRG,32964,,324% x Medicaid HMO amount,32964,Other,324% of NY Medicaid HMO DRG,21874,,215% x Medicaid HMO amount,21874,Other,215% of NY Medicaid HMO DRG,21874,,215% x Medicaid HMO amount,21874,Other,215% of NY Medicaid HMO DRG,12718,,125% x Medicaid HMO amount,12718,Other,125% of NY Medicaid HMO DRG,0.01,54284,
Other circulatory system diagnoses,207-4,APR-DRG,,,,,,,,inpatient,,,350200.53,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,114038,,"45,128 x DRG weight",114038,Other,base rate x DRG weight,102634,,"40,615 x DRG weight",102634,Other,base rate x DRG weight,96933,,"38,359 x DRG weight",96933,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38074,,186% x Medicaid HMO amount,38074,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,86113,,"34,077 x DRG weight",86113,Other,base rate x DRG weight,73197,,"28,966 x DRG weight",73197,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20470,,DRG base rate x DRG weight + capital per discharge,20470,Other,100% of NY Medicaid HMO DRG,20470,,100% x Medicaid HMO amount,20470,Other,100% of NY Medicaid HMO DRG,20470,,100% x Medicaid HMO amount,20470,Other,100% of NY Medicaid HMO DRG,20470,,100% x Medicaid HMO amount,20470,Other,100% of NY Medicaid HMO DRG,46058,,225% x Medicaid HMO amount,46058,Other,225% of NY Medicaid HMO DRG,46058,,225% x Medicaid HMO amount,46058,Other,225% of NY Medicaid HMO DRG,46058,,225% x Medicaid HMO amount,46058,Other,225% of NY Medicaid HMO DRG,46058,,225% x Medicaid HMO amount,46058,Other,225% of NY Medicaid HMO DRG,28658,,140% x Medicaid HMO amount,28658,Other,140% of NY Medicaid HMO DRG,46058,,225% x Medicaid HMO amount,46058,Other,225% of NY Medicaid HMO DRG,56293,,275% x Medicaid HMO amount,56293,Other,275% of NY Medicaid HMO DRG,66323,,324% x Medicaid HMO amount,66323,Other,324% of NY Medicaid HMO DRG,44011,,215% x Medicaid HMO amount,44011,Other,215% of NY Medicaid HMO DRG,44011,,215% x Medicaid HMO amount,44011,Other,215% of NY Medicaid HMO DRG,25588,,125% x Medicaid HMO amount,25588,Other,125% of NY Medicaid HMO DRG,0.01,114038,
"Major stomach, esophageal & duodenal procedures",220-1,APR-DRG,,,,,,,,inpatient,,,126137.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52285,,"45,128 x DRG weight",52285,Other,base rate x DRG weight,47057,,"40,615 x DRG weight",47057,Other,base rate x DRG weight,44443,,"38,359 x DRG weight",44443,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18284,,186% x Medicaid HMO amount,18284,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39482,,"34,077 x DRG weight",39482,Other,base rate x DRG weight,33560,,"28,966 x DRG weight",33560,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9830,,DRG base rate x DRG weight + capital per discharge,9830,Other,100% of NY Medicaid HMO DRG,9830,,100% x Medicaid HMO amount,9830,Other,100% of NY Medicaid HMO DRG,9830,,100% x Medicaid HMO amount,9830,Other,100% of NY Medicaid HMO DRG,9830,,100% x Medicaid HMO amount,9830,Other,100% of NY Medicaid HMO DRG,22118,,225% x Medicaid HMO amount,22118,Other,225% of NY Medicaid HMO DRG,22118,,225% x Medicaid HMO amount,22118,Other,225% of NY Medicaid HMO DRG,22118,,225% x Medicaid HMO amount,22118,Other,225% of NY Medicaid HMO DRG,22118,,225% x Medicaid HMO amount,22118,Other,225% of NY Medicaid HMO DRG,13762,,140% x Medicaid HMO amount,13762,Other,140% of NY Medicaid HMO DRG,22118,,225% x Medicaid HMO amount,22118,Other,225% of NY Medicaid HMO DRG,27033,,275% x Medicaid HMO amount,27033,Other,275% of NY Medicaid HMO DRG,31849,,324% x Medicaid HMO amount,31849,Other,324% of NY Medicaid HMO DRG,21135,,215% x Medicaid HMO amount,21135,Other,215% of NY Medicaid HMO DRG,21135,,215% x Medicaid HMO amount,21135,Other,215% of NY Medicaid HMO DRG,12288,,125% x Medicaid HMO amount,12288,Other,125% of NY Medicaid HMO DRG,0.01,52285,
"Major stomach, esophageal & duodenal procedures",220-2,APR-DRG,,,,,,,,inpatient,,,83452.34,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,83270,,"45,128 x DRG weight",83270,Other,base rate x DRG weight,74943,,"40,615 x DRG weight",74943,Other,base rate x DRG weight,70780,,"38,359 x DRG weight",70780,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28212,,186% x Medicaid HMO amount,28212,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,62879,,"34,077 x DRG weight",62879,Other,base rate x DRG weight,53448,,"28,966 x DRG weight",53448,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15168,,DRG base rate x DRG weight + capital per discharge,15168,Other,100% of NY Medicaid HMO DRG,15168,,100% x Medicaid HMO amount,15168,Other,100% of NY Medicaid HMO DRG,15168,,100% x Medicaid HMO amount,15168,Other,100% of NY Medicaid HMO DRG,15168,,100% x Medicaid HMO amount,15168,Other,100% of NY Medicaid HMO DRG,34128,,225% x Medicaid HMO amount,34128,Other,225% of NY Medicaid HMO DRG,34128,,225% x Medicaid HMO amount,34128,Other,225% of NY Medicaid HMO DRG,34128,,225% x Medicaid HMO amount,34128,Other,225% of NY Medicaid HMO DRG,34128,,225% x Medicaid HMO amount,34128,Other,225% of NY Medicaid HMO DRG,21235,,140% x Medicaid HMO amount,21235,Other,140% of NY Medicaid HMO DRG,34128,,225% x Medicaid HMO amount,34128,Other,225% of NY Medicaid HMO DRG,41712,,275% x Medicaid HMO amount,41712,Other,275% of NY Medicaid HMO DRG,49144,,324% x Medicaid HMO amount,49144,Other,324% of NY Medicaid HMO DRG,32611,,215% x Medicaid HMO amount,32611,Other,215% of NY Medicaid HMO DRG,32611,,215% x Medicaid HMO amount,32611,Other,215% of NY Medicaid HMO DRG,18960,,125% x Medicaid HMO amount,18960,Other,125% of NY Medicaid HMO DRG,0.01,83270,
"Major stomach, esophageal & duodenal procedures",220-3,APR-DRG,,,,,,,,inpatient,,,232708.83,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,153562,,"45,128 x DRG weight",153562,Other,base rate x DRG weight,138205,,"40,615 x DRG weight",138205,Other,base rate x DRG weight,130528,,"38,359 x DRG weight",130528,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50741,,186% x Medicaid HMO amount,50741,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,115957,,"34,077 x DRG weight",115957,Other,base rate x DRG weight,98566,,"28,966 x DRG weight",98566,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27280,,DRG base rate x DRG weight + capital per discharge,27280,Other,100% of NY Medicaid HMO DRG,27280,,100% x Medicaid HMO amount,27280,Other,100% of NY Medicaid HMO DRG,27280,,100% x Medicaid HMO amount,27280,Other,100% of NY Medicaid HMO DRG,27280,,100% x Medicaid HMO amount,27280,Other,100% of NY Medicaid HMO DRG,61380,,225% x Medicaid HMO amount,61380,Other,225% of NY Medicaid HMO DRG,61380,,225% x Medicaid HMO amount,61380,Other,225% of NY Medicaid HMO DRG,61380,,225% x Medicaid HMO amount,61380,Other,225% of NY Medicaid HMO DRG,61380,,225% x Medicaid HMO amount,61380,Other,225% of NY Medicaid HMO DRG,38192,,140% x Medicaid HMO amount,38192,Other,140% of NY Medicaid HMO DRG,61380,,225% x Medicaid HMO amount,61380,Other,225% of NY Medicaid HMO DRG,75020,,275% x Medicaid HMO amount,75020,Other,275% of NY Medicaid HMO DRG,88387,,324% x Medicaid HMO amount,88387,Other,324% of NY Medicaid HMO DRG,58652,,215% x Medicaid HMO amount,58652,Other,215% of NY Medicaid HMO DRG,58652,,215% x Medicaid HMO amount,58652,Other,215% of NY Medicaid HMO DRG,34100,,125% x Medicaid HMO amount,34100,Other,125% of NY Medicaid HMO DRG,0.01,153562,
"Major stomach, esophageal & duodenal procedures",220-4,APR-DRG,,,,,,,,inpatient,,,1103905.49,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,319854,,"45,128 x DRG weight",319854,Other,base rate x DRG weight,287867,,"40,615 x DRG weight",287867,Other,base rate x DRG weight,271877,,"38,359 x DRG weight",271877,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,104034,,186% x Medicaid HMO amount,104034,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,241528,,"34,077 x DRG weight",241528,Other,base rate x DRG weight,205302,,"28,966 x DRG weight",205302,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55932,,DRG base rate x DRG weight + capital per discharge,55932,Other,100% of NY Medicaid HMO DRG,55932,,100% x Medicaid HMO amount,55932,Other,100% of NY Medicaid HMO DRG,55932,,100% x Medicaid HMO amount,55932,Other,100% of NY Medicaid HMO DRG,55932,,100% x Medicaid HMO amount,55932,Other,100% of NY Medicaid HMO DRG,125847,,225% x Medicaid HMO amount,125847,Other,225% of NY Medicaid HMO DRG,125847,,225% x Medicaid HMO amount,125847,Other,225% of NY Medicaid HMO DRG,125847,,225% x Medicaid HMO amount,125847,Other,225% of NY Medicaid HMO DRG,125847,,225% x Medicaid HMO amount,125847,Other,225% of NY Medicaid HMO DRG,78305,,140% x Medicaid HMO amount,78305,Other,140% of NY Medicaid HMO DRG,125847,,225% x Medicaid HMO amount,125847,Other,225% of NY Medicaid HMO DRG,153813,,275% x Medicaid HMO amount,153813,Other,275% of NY Medicaid HMO DRG,181220,,324% x Medicaid HMO amount,181220,Other,324% of NY Medicaid HMO DRG,120254,,215% x Medicaid HMO amount,120254,Other,215% of NY Medicaid HMO DRG,120254,,215% x Medicaid HMO amount,120254,Other,215% of NY Medicaid HMO DRG,69915,,125% x Medicaid HMO amount,69915,Other,125% of NY Medicaid HMO DRG,0.01,319854,
Major small & large bowel procedures,221-1,APR-DRG,,,,,,,,inpatient,,,161782.59,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,67087,,"45,128 x DRG weight",67087,Other,base rate x DRG weight,60378,,"40,615 x DRG weight",60378,Other,base rate x DRG weight,57024,,"38,359 x DRG weight",57024,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23027,,186% x Medicaid HMO amount,23027,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50659,,"34,077 x DRG weight",50659,Other,base rate x DRG weight,43061,,"28,966 x DRG weight",43061,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12380,,DRG base rate x DRG weight + capital per discharge,12380,Other,100% of NY Medicaid HMO DRG,12380,,100% x Medicaid HMO amount,12380,Other,100% of NY Medicaid HMO DRG,12380,,100% x Medicaid HMO amount,12380,Other,100% of NY Medicaid HMO DRG,12380,,100% x Medicaid HMO amount,12380,Other,100% of NY Medicaid HMO DRG,27855,,225% x Medicaid HMO amount,27855,Other,225% of NY Medicaid HMO DRG,27855,,225% x Medicaid HMO amount,27855,Other,225% of NY Medicaid HMO DRG,27855,,225% x Medicaid HMO amount,27855,Other,225% of NY Medicaid HMO DRG,27855,,225% x Medicaid HMO amount,27855,Other,225% of NY Medicaid HMO DRG,17332,,140% x Medicaid HMO amount,17332,Other,140% of NY Medicaid HMO DRG,27855,,225% x Medicaid HMO amount,27855,Other,225% of NY Medicaid HMO DRG,34045,,275% x Medicaid HMO amount,34045,Other,275% of NY Medicaid HMO DRG,40111,,324% x Medicaid HMO amount,40111,Other,324% of NY Medicaid HMO DRG,26617,,215% x Medicaid HMO amount,26617,Other,215% of NY Medicaid HMO DRG,26617,,215% x Medicaid HMO amount,26617,Other,215% of NY Medicaid HMO DRG,15475,,125% x Medicaid HMO amount,15475,Other,125% of NY Medicaid HMO DRG,0.01,67087,
Major small & large bowel procedures,221-2,APR-DRG,,,,,,,,inpatient,,,207501.99,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,84962,,"45,128 x DRG weight",84962,Other,base rate x DRG weight,76466,,"40,615 x DRG weight",76466,Other,base rate x DRG weight,72218,,"38,359 x DRG weight",72218,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28756,,186% x Medicaid HMO amount,28756,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,64157,,"34,077 x DRG weight",64157,Other,base rate x DRG weight,54534,,"28,966 x DRG weight",54534,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15460,,DRG base rate x DRG weight + capital per discharge,15460,Other,100% of NY Medicaid HMO DRG,15460,,100% x Medicaid HMO amount,15460,Other,100% of NY Medicaid HMO DRG,15460,,100% x Medicaid HMO amount,15460,Other,100% of NY Medicaid HMO DRG,15460,,100% x Medicaid HMO amount,15460,Other,100% of NY Medicaid HMO DRG,34785,,225% x Medicaid HMO amount,34785,Other,225% of NY Medicaid HMO DRG,34785,,225% x Medicaid HMO amount,34785,Other,225% of NY Medicaid HMO DRG,34785,,225% x Medicaid HMO amount,34785,Other,225% of NY Medicaid HMO DRG,34785,,225% x Medicaid HMO amount,34785,Other,225% of NY Medicaid HMO DRG,21644,,140% x Medicaid HMO amount,21644,Other,140% of NY Medicaid HMO DRG,34785,,225% x Medicaid HMO amount,34785,Other,225% of NY Medicaid HMO DRG,42515,,275% x Medicaid HMO amount,42515,Other,275% of NY Medicaid HMO DRG,50090,,324% x Medicaid HMO amount,50090,Other,324% of NY Medicaid HMO DRG,33239,,215% x Medicaid HMO amount,33239,Other,215% of NY Medicaid HMO DRG,33239,,215% x Medicaid HMO amount,33239,Other,215% of NY Medicaid HMO DRG,19325,,125% x Medicaid HMO amount,19325,Other,125% of NY Medicaid HMO DRG,0.01,84962,
Major small & large bowel procedures,221-3,APR-DRG,,,,,,,,inpatient,,,414882.92,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,139960,,"45,128 x DRG weight",139960,Other,base rate x DRG weight,125963,,"40,615 x DRG weight",125963,Other,base rate x DRG weight,118967,,"38,359 x DRG weight",118967,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46381,,186% x Medicaid HMO amount,46381,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,105686,,"34,077 x DRG weight",105686,Other,base rate x DRG weight,89835,,"28,966 x DRG weight",89835,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24936,,DRG base rate x DRG weight + capital per discharge,24936,Other,100% of NY Medicaid HMO DRG,24936,,100% x Medicaid HMO amount,24936,Other,100% of NY Medicaid HMO DRG,24936,,100% x Medicaid HMO amount,24936,Other,100% of NY Medicaid HMO DRG,24936,,100% x Medicaid HMO amount,24936,Other,100% of NY Medicaid HMO DRG,56106,,225% x Medicaid HMO amount,56106,Other,225% of NY Medicaid HMO DRG,56106,,225% x Medicaid HMO amount,56106,Other,225% of NY Medicaid HMO DRG,56106,,225% x Medicaid HMO amount,56106,Other,225% of NY Medicaid HMO DRG,56106,,225% x Medicaid HMO amount,56106,Other,225% of NY Medicaid HMO DRG,34910,,140% x Medicaid HMO amount,34910,Other,140% of NY Medicaid HMO DRG,56106,,225% x Medicaid HMO amount,56106,Other,225% of NY Medicaid HMO DRG,68574,,275% x Medicaid HMO amount,68574,Other,275% of NY Medicaid HMO DRG,80793,,324% x Medicaid HMO amount,80793,Other,324% of NY Medicaid HMO DRG,53612,,215% x Medicaid HMO amount,53612,Other,215% of NY Medicaid HMO DRG,53612,,215% x Medicaid HMO amount,53612,Other,215% of NY Medicaid HMO DRG,31170,,125% x Medicaid HMO amount,31170,Other,125% of NY Medicaid HMO DRG,0.01,139960,
Major small & large bowel procedures,221-4,APR-DRG,,,,,,,,inpatient,,,605283.98,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,298219,,"45,128 x DRG weight",298219,Other,base rate x DRG weight,268396,,"40,615 x DRG weight",268396,Other,base rate x DRG weight,253488,,"38,359 x DRG weight",253488,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,97099,,186% x Medicaid HMO amount,97099,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,225191,,"34,077 x DRG weight",225191,Other,base rate x DRG weight,191416,,"28,966 x DRG weight",191416,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52204,,DRG base rate x DRG weight + capital per discharge,52204,Other,100% of NY Medicaid HMO DRG,52204,,100% x Medicaid HMO amount,52204,Other,100% of NY Medicaid HMO DRG,52204,,100% x Medicaid HMO amount,52204,Other,100% of NY Medicaid HMO DRG,52204,,100% x Medicaid HMO amount,52204,Other,100% of NY Medicaid HMO DRG,117459,,225% x Medicaid HMO amount,117459,Other,225% of NY Medicaid HMO DRG,117459,,225% x Medicaid HMO amount,117459,Other,225% of NY Medicaid HMO DRG,117459,,225% x Medicaid HMO amount,117459,Other,225% of NY Medicaid HMO DRG,117459,,225% x Medicaid HMO amount,117459,Other,225% of NY Medicaid HMO DRG,73086,,140% x Medicaid HMO amount,73086,Other,140% of NY Medicaid HMO DRG,117459,,225% x Medicaid HMO amount,117459,Other,225% of NY Medicaid HMO DRG,143561,,275% x Medicaid HMO amount,143561,Other,275% of NY Medicaid HMO DRG,169141,,324% x Medicaid HMO amount,169141,Other,324% of NY Medicaid HMO DRG,112239,,215% x Medicaid HMO amount,112239,Other,215% of NY Medicaid HMO DRG,112239,,215% x Medicaid HMO amount,112239,Other,215% of NY Medicaid HMO DRG,65255,,125% x Medicaid HMO amount,65255,Other,125% of NY Medicaid HMO DRG,0.01,298219,
"Other stomach, esophageal & duodenal procedures",222-1,APR-DRG,,,,,,,,inpatient,,,106756.77,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37136,,"45,128 x DRG weight",37136,Other,base rate x DRG weight,33422,,"40,615 x DRG weight",33422,Other,base rate x DRG weight,31566,,"38,359 x DRG weight",31566,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13427,,186% x Medicaid HMO amount,13427,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28042,,"34,077 x DRG weight",28042,Other,base rate x DRG weight,23836,,"28,966 x DRG weight",23836,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7219,,DRG base rate x DRG weight + capital per discharge,7219,Other,100% of NY Medicaid HMO DRG,7219,,100% x Medicaid HMO amount,7219,Other,100% of NY Medicaid HMO DRG,7219,,100% x Medicaid HMO amount,7219,Other,100% of NY Medicaid HMO DRG,7219,,100% x Medicaid HMO amount,7219,Other,100% of NY Medicaid HMO DRG,16243,,225% x Medicaid HMO amount,16243,Other,225% of NY Medicaid HMO DRG,16243,,225% x Medicaid HMO amount,16243,Other,225% of NY Medicaid HMO DRG,16243,,225% x Medicaid HMO amount,16243,Other,225% of NY Medicaid HMO DRG,16243,,225% x Medicaid HMO amount,16243,Other,225% of NY Medicaid HMO DRG,10107,,140% x Medicaid HMO amount,10107,Other,140% of NY Medicaid HMO DRG,16243,,225% x Medicaid HMO amount,16243,Other,225% of NY Medicaid HMO DRG,19852,,275% x Medicaid HMO amount,19852,Other,275% of NY Medicaid HMO DRG,23390,,324% x Medicaid HMO amount,23390,Other,324% of NY Medicaid HMO DRG,15521,,215% x Medicaid HMO amount,15521,Other,215% of NY Medicaid HMO DRG,15521,,215% x Medicaid HMO amount,15521,Other,215% of NY Medicaid HMO DRG,9024,,125% x Medicaid HMO amount,9024,Other,125% of NY Medicaid HMO DRG,0.01,37136,
"Other stomach, esophageal & duodenal procedures",222-2,APR-DRG,,,,,,,,inpatient,,,185488.46,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51171,,"45,128 x DRG weight",51171,Other,base rate x DRG weight,46053,,"40,615 x DRG weight",46053,Other,base rate x DRG weight,43495,,"38,359 x DRG weight",43495,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17927,,186% x Medicaid HMO amount,17927,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38640,,"34,077 x DRG weight",38640,Other,base rate x DRG weight,32845,,"28,966 x DRG weight",32845,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9638,,DRG base rate x DRG weight + capital per discharge,9638,Other,100% of NY Medicaid HMO DRG,9638,,100% x Medicaid HMO amount,9638,Other,100% of NY Medicaid HMO DRG,9638,,100% x Medicaid HMO amount,9638,Other,100% of NY Medicaid HMO DRG,9638,,100% x Medicaid HMO amount,9638,Other,100% of NY Medicaid HMO DRG,21686,,225% x Medicaid HMO amount,21686,Other,225% of NY Medicaid HMO DRG,21686,,225% x Medicaid HMO amount,21686,Other,225% of NY Medicaid HMO DRG,21686,,225% x Medicaid HMO amount,21686,Other,225% of NY Medicaid HMO DRG,21686,,225% x Medicaid HMO amount,21686,Other,225% of NY Medicaid HMO DRG,13493,,140% x Medicaid HMO amount,13493,Other,140% of NY Medicaid HMO DRG,21686,,225% x Medicaid HMO amount,21686,Other,225% of NY Medicaid HMO DRG,26505,,275% x Medicaid HMO amount,26505,Other,275% of NY Medicaid HMO DRG,31227,,324% x Medicaid HMO amount,31227,Other,324% of NY Medicaid HMO DRG,20722,,215% x Medicaid HMO amount,20722,Other,215% of NY Medicaid HMO DRG,20722,,215% x Medicaid HMO amount,20722,Other,215% of NY Medicaid HMO DRG,12048,,125% x Medicaid HMO amount,12048,Other,125% of NY Medicaid HMO DRG,0.01,51171,
"Other stomach, esophageal & duodenal procedures",222-3,APR-DRG,,,,,,,,inpatient,,,188404.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,92409,,"45,128 x DRG weight",92409,Other,base rate x DRG weight,83167,,"40,615 x DRG weight",83167,Other,base rate x DRG weight,78548,,"38,359 x DRG weight",78548,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31142,,186% x Medicaid HMO amount,31142,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,69779,,"34,077 x DRG weight",69779,Other,base rate x DRG weight,59314,,"28,966 x DRG weight",59314,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16743,,DRG base rate x DRG weight + capital per discharge,16743,Other,100% of NY Medicaid HMO DRG,16743,,100% x Medicaid HMO amount,16743,Other,100% of NY Medicaid HMO DRG,16743,,100% x Medicaid HMO amount,16743,Other,100% of NY Medicaid HMO DRG,16743,,100% x Medicaid HMO amount,16743,Other,100% of NY Medicaid HMO DRG,37672,,225% x Medicaid HMO amount,37672,Other,225% of NY Medicaid HMO DRG,37672,,225% x Medicaid HMO amount,37672,Other,225% of NY Medicaid HMO DRG,37672,,225% x Medicaid HMO amount,37672,Other,225% of NY Medicaid HMO DRG,37672,,225% x Medicaid HMO amount,37672,Other,225% of NY Medicaid HMO DRG,23440,,140% x Medicaid HMO amount,23440,Other,140% of NY Medicaid HMO DRG,37672,,225% x Medicaid HMO amount,37672,Other,225% of NY Medicaid HMO DRG,46043,,275% x Medicaid HMO amount,46043,Other,275% of NY Medicaid HMO DRG,54247,,324% x Medicaid HMO amount,54247,Other,324% of NY Medicaid HMO DRG,35997,,215% x Medicaid HMO amount,35997,Other,215% of NY Medicaid HMO DRG,35997,,215% x Medicaid HMO amount,35997,Other,215% of NY Medicaid HMO DRG,20929,,125% x Medicaid HMO amount,20929,Other,125% of NY Medicaid HMO DRG,0.01,92409,
"Other stomach, esophageal & duodenal procedures",222-4,APR-DRG,,,,,,,,inpatient,,,249880.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,249738,,"45,128 x DRG weight",249738,Other,base rate x DRG weight,224763,,"40,615 x DRG weight",224763,Other,base rate x DRG weight,212279,,"38,359 x DRG weight",212279,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,81563,,186% x Medicaid HMO amount,81563,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,188582,,"34,077 x DRG weight",188582,Other,base rate x DRG weight,160298,,"28,966 x DRG weight",160298,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43851,,DRG base rate x DRG weight + capital per discharge,43851,Other,100% of NY Medicaid HMO DRG,43851,,100% x Medicaid HMO amount,43851,Other,100% of NY Medicaid HMO DRG,43851,,100% x Medicaid HMO amount,43851,Other,100% of NY Medicaid HMO DRG,43851,,100% x Medicaid HMO amount,43851,Other,100% of NY Medicaid HMO DRG,98665,,225% x Medicaid HMO amount,98665,Other,225% of NY Medicaid HMO DRG,98665,,225% x Medicaid HMO amount,98665,Other,225% of NY Medicaid HMO DRG,98665,,225% x Medicaid HMO amount,98665,Other,225% of NY Medicaid HMO DRG,98665,,225% x Medicaid HMO amount,98665,Other,225% of NY Medicaid HMO DRG,61391,,140% x Medicaid HMO amount,61391,Other,140% of NY Medicaid HMO DRG,98665,,225% x Medicaid HMO amount,98665,Other,225% of NY Medicaid HMO DRG,120590,,275% x Medicaid HMO amount,120590,Other,275% of NY Medicaid HMO DRG,142077,,324% x Medicaid HMO amount,142077,Other,324% of NY Medicaid HMO DRG,94280,,215% x Medicaid HMO amount,94280,Other,215% of NY Medicaid HMO DRG,94280,,215% x Medicaid HMO amount,94280,Other,215% of NY Medicaid HMO DRG,54814,,125% x Medicaid HMO amount,54814,Other,125% of NY Medicaid HMO DRG,0.01,249738,
Other small & large bowel procedures,223-1,APR-DRG,,,,,,,,inpatient,,,116815.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53111,,"45,128 x DRG weight",53111,Other,base rate x DRG weight,47800,,"40,615 x DRG weight",47800,Other,base rate x DRG weight,45145,,"38,359 x DRG weight",45145,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18548,,186% x Medicaid HMO amount,18548,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40105,,"34,077 x DRG weight",40105,Other,base rate x DRG weight,34090,,"28,966 x DRG weight",34090,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9972,,DRG base rate x DRG weight + capital per discharge,9972,Other,100% of NY Medicaid HMO DRG,9972,,100% x Medicaid HMO amount,9972,Other,100% of NY Medicaid HMO DRG,9972,,100% x Medicaid HMO amount,9972,Other,100% of NY Medicaid HMO DRG,9972,,100% x Medicaid HMO amount,9972,Other,100% of NY Medicaid HMO DRG,22437,,225% x Medicaid HMO amount,22437,Other,225% of NY Medicaid HMO DRG,22437,,225% x Medicaid HMO amount,22437,Other,225% of NY Medicaid HMO DRG,22437,,225% x Medicaid HMO amount,22437,Other,225% of NY Medicaid HMO DRG,22437,,225% x Medicaid HMO amount,22437,Other,225% of NY Medicaid HMO DRG,13961,,140% x Medicaid HMO amount,13961,Other,140% of NY Medicaid HMO DRG,22437,,225% x Medicaid HMO amount,22437,Other,225% of NY Medicaid HMO DRG,27423,,275% x Medicaid HMO amount,27423,Other,275% of NY Medicaid HMO DRG,32309,,324% x Medicaid HMO amount,32309,Other,324% of NY Medicaid HMO DRG,21440,,215% x Medicaid HMO amount,21440,Other,215% of NY Medicaid HMO DRG,21440,,215% x Medicaid HMO amount,21440,Other,215% of NY Medicaid HMO DRG,12465,,125% x Medicaid HMO amount,12465,Other,125% of NY Medicaid HMO DRG,0.01,53111,
Other small & large bowel procedures,223-2,APR-DRG,,,,,,,,inpatient,,,192783.69,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,71059,,"45,128 x DRG weight",71059,Other,base rate x DRG weight,63952,,"40,615 x DRG weight",63952,Other,base rate x DRG weight,60400,,"38,359 x DRG weight",60400,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24299,,186% x Medicaid HMO amount,24299,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53658,,"34,077 x DRG weight",53658,Other,base rate x DRG weight,45610,,"28,966 x DRG weight",45610,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13064,,DRG base rate x DRG weight + capital per discharge,13064,Other,100% of NY Medicaid HMO DRG,13064,,100% x Medicaid HMO amount,13064,Other,100% of NY Medicaid HMO DRG,13064,,100% x Medicaid HMO amount,13064,Other,100% of NY Medicaid HMO DRG,13064,,100% x Medicaid HMO amount,13064,Other,100% of NY Medicaid HMO DRG,29394,,225% x Medicaid HMO amount,29394,Other,225% of NY Medicaid HMO DRG,29394,,225% x Medicaid HMO amount,29394,Other,225% of NY Medicaid HMO DRG,29394,,225% x Medicaid HMO amount,29394,Other,225% of NY Medicaid HMO DRG,29394,,225% x Medicaid HMO amount,29394,Other,225% of NY Medicaid HMO DRG,18290,,140% x Medicaid HMO amount,18290,Other,140% of NY Medicaid HMO DRG,29394,,225% x Medicaid HMO amount,29394,Other,225% of NY Medicaid HMO DRG,35926,,275% x Medicaid HMO amount,35926,Other,275% of NY Medicaid HMO DRG,42327,,324% x Medicaid HMO amount,42327,Other,324% of NY Medicaid HMO DRG,28088,,215% x Medicaid HMO amount,28088,Other,215% of NY Medicaid HMO DRG,28088,,215% x Medicaid HMO amount,28088,Other,215% of NY Medicaid HMO DRG,16330,,125% x Medicaid HMO amount,16330,Other,125% of NY Medicaid HMO DRG,0.01,71059,
Other small & large bowel procedures,223-3,APR-DRG,,,,,,,,inpatient,,,334628.89,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,120054,,"45,128 x DRG weight",120054,Other,base rate x DRG weight,108048,,"40,615 x DRG weight",108048,Other,base rate x DRG weight,102046,,"38,359 x DRG weight",102046,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40001,,186% x Medicaid HMO amount,40001,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,90655,,"34,077 x DRG weight",90655,Other,base rate x DRG weight,77058,,"28,966 x DRG weight",77058,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21506,,DRG base rate x DRG weight + capital per discharge,21506,Other,100% of NY Medicaid HMO DRG,21506,,100% x Medicaid HMO amount,21506,Other,100% of NY Medicaid HMO DRG,21506,,100% x Medicaid HMO amount,21506,Other,100% of NY Medicaid HMO DRG,21506,,100% x Medicaid HMO amount,21506,Other,100% of NY Medicaid HMO DRG,48389,,225% x Medicaid HMO amount,48389,Other,225% of NY Medicaid HMO DRG,48389,,225% x Medicaid HMO amount,48389,Other,225% of NY Medicaid HMO DRG,48389,,225% x Medicaid HMO amount,48389,Other,225% of NY Medicaid HMO DRG,48389,,225% x Medicaid HMO amount,48389,Other,225% of NY Medicaid HMO DRG,30108,,140% x Medicaid HMO amount,30108,Other,140% of NY Medicaid HMO DRG,48389,,225% x Medicaid HMO amount,48389,Other,225% of NY Medicaid HMO DRG,59142,,275% x Medicaid HMO amount,59142,Other,275% of NY Medicaid HMO DRG,69679,,324% x Medicaid HMO amount,69679,Other,324% of NY Medicaid HMO DRG,46238,,215% x Medicaid HMO amount,46238,Other,215% of NY Medicaid HMO DRG,46238,,215% x Medicaid HMO amount,46238,Other,215% of NY Medicaid HMO DRG,26883,,125% x Medicaid HMO amount,26883,Other,125% of NY Medicaid HMO DRG,0.01,120054,
Other small & large bowel procedures,223-4,APR-DRG,,,,,,,,inpatient,,,283345.2,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,251747,,"45,128 x DRG weight",251747,Other,base rate x DRG weight,226571,,"40,615 x DRG weight",226571,Other,base rate x DRG weight,213986,,"38,359 x DRG weight",213986,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,82206,,186% x Medicaid HMO amount,82206,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,190099,,"34,077 x DRG weight",190099,Other,base rate x DRG weight,161587,,"28,966 x DRG weight",161587,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44197,,DRG base rate x DRG weight + capital per discharge,44197,Other,100% of NY Medicaid HMO DRG,44197,,100% x Medicaid HMO amount,44197,Other,100% of NY Medicaid HMO DRG,44197,,100% x Medicaid HMO amount,44197,Other,100% of NY Medicaid HMO DRG,44197,,100% x Medicaid HMO amount,44197,Other,100% of NY Medicaid HMO DRG,99443,,225% x Medicaid HMO amount,99443,Other,225% of NY Medicaid HMO DRG,99443,,225% x Medicaid HMO amount,99443,Other,225% of NY Medicaid HMO DRG,99443,,225% x Medicaid HMO amount,99443,Other,225% of NY Medicaid HMO DRG,99443,,225% x Medicaid HMO amount,99443,Other,225% of NY Medicaid HMO DRG,61876,,140% x Medicaid HMO amount,61876,Other,140% of NY Medicaid HMO DRG,99443,,225% x Medicaid HMO amount,99443,Other,225% of NY Medicaid HMO DRG,121542,,275% x Medicaid HMO amount,121542,Other,275% of NY Medicaid HMO DRG,143198,,324% x Medicaid HMO amount,143198,Other,324% of NY Medicaid HMO DRG,95024,,215% x Medicaid HMO amount,95024,Other,215% of NY Medicaid HMO DRG,95024,,215% x Medicaid HMO amount,95024,Other,215% of NY Medicaid HMO DRG,55246,,125% x Medicaid HMO amount,55246,Other,125% of NY Medicaid HMO DRG,0.01,251747,
Peritoneal adhesiolysis,224-1,APR-DRG,,,,,,,,inpatient,,,124158.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54235,,"45,128 x DRG weight",54235,Other,base rate x DRG weight,48811,,"40,615 x DRG weight",48811,Other,base rate x DRG weight,46100,,"38,359 x DRG weight",46100,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18909,,186% x Medicaid HMO amount,18909,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40954,,"34,077 x DRG weight",40954,Other,base rate x DRG weight,34811,,"28,966 x DRG weight",34811,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10166,,DRG base rate x DRG weight + capital per discharge,10166,Other,100% of NY Medicaid HMO DRG,10166,,100% x Medicaid HMO amount,10166,Other,100% of NY Medicaid HMO DRG,10166,,100% x Medicaid HMO amount,10166,Other,100% of NY Medicaid HMO DRG,10166,,100% x Medicaid HMO amount,10166,Other,100% of NY Medicaid HMO DRG,22874,,225% x Medicaid HMO amount,22874,Other,225% of NY Medicaid HMO DRG,22874,,225% x Medicaid HMO amount,22874,Other,225% of NY Medicaid HMO DRG,22874,,225% x Medicaid HMO amount,22874,Other,225% of NY Medicaid HMO DRG,22874,,225% x Medicaid HMO amount,22874,Other,225% of NY Medicaid HMO DRG,14232,,140% x Medicaid HMO amount,14232,Other,140% of NY Medicaid HMO DRG,22874,,225% x Medicaid HMO amount,22874,Other,225% of NY Medicaid HMO DRG,27957,,275% x Medicaid HMO amount,27957,Other,275% of NY Medicaid HMO DRG,32938,,324% x Medicaid HMO amount,32938,Other,324% of NY Medicaid HMO DRG,21857,,215% x Medicaid HMO amount,21857,Other,215% of NY Medicaid HMO DRG,21857,,215% x Medicaid HMO amount,21857,Other,215% of NY Medicaid HMO DRG,12708,,125% x Medicaid HMO amount,12708,Other,125% of NY Medicaid HMO DRG,0.01,54235,
Peritoneal adhesiolysis,224-2,APR-DRG,,,,,,,,inpatient,,,177502.78,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,72263,,"45,128 x DRG weight",72263,Other,base rate x DRG weight,65037,,"40,615 x DRG weight",65037,Other,base rate x DRG weight,61424,,"38,359 x DRG weight",61424,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24686,,186% x Medicaid HMO amount,24686,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54568,,"34,077 x DRG weight",54568,Other,base rate x DRG weight,46383,,"28,966 x DRG weight",46383,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13272,,DRG base rate x DRG weight + capital per discharge,13272,Other,100% of NY Medicaid HMO DRG,13272,,100% x Medicaid HMO amount,13272,Other,100% of NY Medicaid HMO DRG,13272,,100% x Medicaid HMO amount,13272,Other,100% of NY Medicaid HMO DRG,13272,,100% x Medicaid HMO amount,13272,Other,100% of NY Medicaid HMO DRG,29862,,225% x Medicaid HMO amount,29862,Other,225% of NY Medicaid HMO DRG,29862,,225% x Medicaid HMO amount,29862,Other,225% of NY Medicaid HMO DRG,29862,,225% x Medicaid HMO amount,29862,Other,225% of NY Medicaid HMO DRG,29862,,225% x Medicaid HMO amount,29862,Other,225% of NY Medicaid HMO DRG,18581,,140% x Medicaid HMO amount,18581,Other,140% of NY Medicaid HMO DRG,29862,,225% x Medicaid HMO amount,29862,Other,225% of NY Medicaid HMO DRG,36498,,275% x Medicaid HMO amount,36498,Other,275% of NY Medicaid HMO DRG,43001,,324% x Medicaid HMO amount,43001,Other,324% of NY Medicaid HMO DRG,28535,,215% x Medicaid HMO amount,28535,Other,215% of NY Medicaid HMO DRG,28535,,215% x Medicaid HMO amount,28535,Other,215% of NY Medicaid HMO DRG,16590,,125% x Medicaid HMO amount,16590,Other,125% of NY Medicaid HMO DRG,0.01,72263,
Peritoneal adhesiolysis,224-3,APR-DRG,,,,,,,,inpatient,,,605898.02,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,119761,,"45,128 x DRG weight",119761,Other,base rate x DRG weight,107784,,"40,615 x DRG weight",107784,Other,base rate x DRG weight,101797,,"38,359 x DRG weight",101797,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39908,,186% x Medicaid HMO amount,39908,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,90434,,"34,077 x DRG weight",90434,Other,base rate x DRG weight,76870,,"28,966 x DRG weight",76870,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21456,,DRG base rate x DRG weight + capital per discharge,21456,Other,100% of NY Medicaid HMO DRG,21456,,100% x Medicaid HMO amount,21456,Other,100% of NY Medicaid HMO DRG,21456,,100% x Medicaid HMO amount,21456,Other,100% of NY Medicaid HMO DRG,21456,,100% x Medicaid HMO amount,21456,Other,100% of NY Medicaid HMO DRG,48276,,225% x Medicaid HMO amount,48276,Other,225% of NY Medicaid HMO DRG,48276,,225% x Medicaid HMO amount,48276,Other,225% of NY Medicaid HMO DRG,48276,,225% x Medicaid HMO amount,48276,Other,225% of NY Medicaid HMO DRG,48276,,225% x Medicaid HMO amount,48276,Other,225% of NY Medicaid HMO DRG,30038,,140% x Medicaid HMO amount,30038,Other,140% of NY Medicaid HMO DRG,48276,,225% x Medicaid HMO amount,48276,Other,225% of NY Medicaid HMO DRG,59004,,275% x Medicaid HMO amount,59004,Other,275% of NY Medicaid HMO DRG,69517,,324% x Medicaid HMO amount,69517,Other,324% of NY Medicaid HMO DRG,46130,,215% x Medicaid HMO amount,46130,Other,215% of NY Medicaid HMO DRG,46130,,215% x Medicaid HMO amount,46130,Other,215% of NY Medicaid HMO DRG,26820,,125% x Medicaid HMO amount,26820,Other,125% of NY Medicaid HMO DRG,0.01,119761,
Peritoneal adhesiolysis,224-4,APR-DRG,,,,,,,,inpatient,,,631151.13,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,251300,,"45,128 x DRG weight",251300,Other,base rate x DRG weight,226169,,"40,615 x DRG weight",226169,Other,base rate x DRG weight,213606,,"38,359 x DRG weight",213606,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,82063,,186% x Medicaid HMO amount,82063,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,189761,,"34,077 x DRG weight",189761,Other,base rate x DRG weight,161300,,"28,966 x DRG weight",161300,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44120,,DRG base rate x DRG weight + capital per discharge,44120,Other,100% of NY Medicaid HMO DRG,44120,,100% x Medicaid HMO amount,44120,Other,100% of NY Medicaid HMO DRG,44120,,100% x Medicaid HMO amount,44120,Other,100% of NY Medicaid HMO DRG,44120,,100% x Medicaid HMO amount,44120,Other,100% of NY Medicaid HMO DRG,99270,,225% x Medicaid HMO amount,99270,Other,225% of NY Medicaid HMO DRG,99270,,225% x Medicaid HMO amount,99270,Other,225% of NY Medicaid HMO DRG,99270,,225% x Medicaid HMO amount,99270,Other,225% of NY Medicaid HMO DRG,99270,,225% x Medicaid HMO amount,99270,Other,225% of NY Medicaid HMO DRG,61768,,140% x Medicaid HMO amount,61768,Other,140% of NY Medicaid HMO DRG,99270,,225% x Medicaid HMO amount,99270,Other,225% of NY Medicaid HMO DRG,121330,,275% x Medicaid HMO amount,121330,Other,275% of NY Medicaid HMO DRG,142949,,324% x Medicaid HMO amount,142949,Other,324% of NY Medicaid HMO DRG,94858,,215% x Medicaid HMO amount,94858,Other,215% of NY Medicaid HMO DRG,94858,,215% x Medicaid HMO amount,94858,Other,215% of NY Medicaid HMO DRG,55150,,125% x Medicaid HMO amount,55150,Other,125% of NY Medicaid HMO DRG,0.01,251300,
Appendectomy,225-1,APR-DRG,,,,,,,,inpatient,,,74424.07,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32492,,"45,128 x DRG weight",32492,Other,base rate x DRG weight,29243,,"40,615 x DRG weight",29243,Other,base rate x DRG weight,27618,,"38,359 x DRG weight",27618,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11939,,186% x Medicaid HMO amount,11939,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24535,,"34,077 x DRG weight",24535,Other,base rate x DRG weight,20856,,"28,966 x DRG weight",20856,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6419,,DRG base rate x DRG weight + capital per discharge,6419,Other,100% of NY Medicaid HMO DRG,6419,,100% x Medicaid HMO amount,6419,Other,100% of NY Medicaid HMO DRG,6419,,100% x Medicaid HMO amount,6419,Other,100% of NY Medicaid HMO DRG,6419,,100% x Medicaid HMO amount,6419,Other,100% of NY Medicaid HMO DRG,14443,,225% x Medicaid HMO amount,14443,Other,225% of NY Medicaid HMO DRG,14443,,225% x Medicaid HMO amount,14443,Other,225% of NY Medicaid HMO DRG,14443,,225% x Medicaid HMO amount,14443,Other,225% of NY Medicaid HMO DRG,14443,,225% x Medicaid HMO amount,14443,Other,225% of NY Medicaid HMO DRG,8987,,140% x Medicaid HMO amount,8987,Other,140% of NY Medicaid HMO DRG,14443,,225% x Medicaid HMO amount,14443,Other,225% of NY Medicaid HMO DRG,17652,,275% x Medicaid HMO amount,17652,Other,275% of NY Medicaid HMO DRG,20798,,324% x Medicaid HMO amount,20798,Other,324% of NY Medicaid HMO DRG,13801,,215% x Medicaid HMO amount,13801,Other,215% of NY Medicaid HMO DRG,13801,,215% x Medicaid HMO amount,13801,Other,215% of NY Medicaid HMO DRG,8024,,125% x Medicaid HMO amount,8024,Other,125% of NY Medicaid HMO DRG,0.01,32492,
Appendectomy,225-2,APR-DRG,,,,,,,,inpatient,,,121347.09,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49839,,"45,128 x DRG weight",49839,Other,base rate x DRG weight,44855,,"40,615 x DRG weight",44855,Other,base rate x DRG weight,42364,,"38,359 x DRG weight",42364,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17499,,186% x Medicaid HMO amount,17499,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37635,,"34,077 x DRG weight",37635,Other,base rate x DRG weight,31990,,"28,966 x DRG weight",31990,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9408,,DRG base rate x DRG weight + capital per discharge,9408,Other,100% of NY Medicaid HMO DRG,9408,,100% x Medicaid HMO amount,9408,Other,100% of NY Medicaid HMO DRG,9408,,100% x Medicaid HMO amount,9408,Other,100% of NY Medicaid HMO DRG,9408,,100% x Medicaid HMO amount,9408,Other,100% of NY Medicaid HMO DRG,21168,,225% x Medicaid HMO amount,21168,Other,225% of NY Medicaid HMO DRG,21168,,225% x Medicaid HMO amount,21168,Other,225% of NY Medicaid HMO DRG,21168,,225% x Medicaid HMO amount,21168,Other,225% of NY Medicaid HMO DRG,21168,,225% x Medicaid HMO amount,21168,Other,225% of NY Medicaid HMO DRG,13171,,140% x Medicaid HMO amount,13171,Other,140% of NY Medicaid HMO DRG,21168,,225% x Medicaid HMO amount,21168,Other,225% of NY Medicaid HMO DRG,25872,,275% x Medicaid HMO amount,25872,Other,275% of NY Medicaid HMO DRG,30482,,324% x Medicaid HMO amount,30482,Other,324% of NY Medicaid HMO DRG,20227,,215% x Medicaid HMO amount,20227,Other,215% of NY Medicaid HMO DRG,20227,,215% x Medicaid HMO amount,20227,Other,215% of NY Medicaid HMO DRG,11760,,125% x Medicaid HMO amount,11760,Other,125% of NY Medicaid HMO DRG,0.01,49839,
Appendectomy,225-3,APR-DRG,,,,,,,,inpatient,,,241930.68,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,91556,,"45,128 x DRG weight",91556,Other,base rate x DRG weight,82400,,"40,615 x DRG weight",82400,Other,base rate x DRG weight,77823,,"38,359 x DRG weight",77823,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30869,,186% x Medicaid HMO amount,30869,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,69135,,"34,077 x DRG weight",69135,Other,base rate x DRG weight,58766,,"28,966 x DRG weight",58766,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16596,,DRG base rate x DRG weight + capital per discharge,16596,Other,100% of NY Medicaid HMO DRG,16596,,100% x Medicaid HMO amount,16596,Other,100% of NY Medicaid HMO DRG,16596,,100% x Medicaid HMO amount,16596,Other,100% of NY Medicaid HMO DRG,16596,,100% x Medicaid HMO amount,16596,Other,100% of NY Medicaid HMO DRG,37341,,225% x Medicaid HMO amount,37341,Other,225% of NY Medicaid HMO DRG,37341,,225% x Medicaid HMO amount,37341,Other,225% of NY Medicaid HMO DRG,37341,,225% x Medicaid HMO amount,37341,Other,225% of NY Medicaid HMO DRG,37341,,225% x Medicaid HMO amount,37341,Other,225% of NY Medicaid HMO DRG,23234,,140% x Medicaid HMO amount,23234,Other,140% of NY Medicaid HMO DRG,37341,,225% x Medicaid HMO amount,37341,Other,225% of NY Medicaid HMO DRG,45639,,275% x Medicaid HMO amount,45639,Other,275% of NY Medicaid HMO DRG,53771,,324% x Medicaid HMO amount,53771,Other,324% of NY Medicaid HMO DRG,35681,,215% x Medicaid HMO amount,35681,Other,215% of NY Medicaid HMO DRG,35681,,215% x Medicaid HMO amount,35681,Other,215% of NY Medicaid HMO DRG,20745,,125% x Medicaid HMO amount,20745,Other,125% of NY Medicaid HMO DRG,0.01,91556,
Appendectomy,225-4,APR-DRG,,,,,,,,inpatient,,,285684.07,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,183319,,"45,128 x DRG weight",183319,Other,base rate x DRG weight,164986,,"40,615 x DRG weight",164986,Other,base rate x DRG weight,155822,,"38,359 x DRG weight",155822,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60277,,186% x Medicaid HMO amount,60277,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,138428,,"34,077 x DRG weight",138428,Other,base rate x DRG weight,117666,,"28,966 x DRG weight",117666,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32407,,DRG base rate x DRG weight + capital per discharge,32407,Other,100% of NY Medicaid HMO DRG,32407,,100% x Medicaid HMO amount,32407,Other,100% of NY Medicaid HMO DRG,32407,,100% x Medicaid HMO amount,32407,Other,100% of NY Medicaid HMO DRG,32407,,100% x Medicaid HMO amount,32407,Other,100% of NY Medicaid HMO DRG,72916,,225% x Medicaid HMO amount,72916,Other,225% of NY Medicaid HMO DRG,72916,,225% x Medicaid HMO amount,72916,Other,225% of NY Medicaid HMO DRG,72916,,225% x Medicaid HMO amount,72916,Other,225% of NY Medicaid HMO DRG,72916,,225% x Medicaid HMO amount,72916,Other,225% of NY Medicaid HMO DRG,45370,,140% x Medicaid HMO amount,45370,Other,140% of NY Medicaid HMO DRG,72916,,225% x Medicaid HMO amount,72916,Other,225% of NY Medicaid HMO DRG,89119,,275% x Medicaid HMO amount,89119,Other,275% of NY Medicaid HMO DRG,104999,,324% x Medicaid HMO amount,104999,Other,324% of NY Medicaid HMO DRG,69675,,215% x Medicaid HMO amount,69675,Other,215% of NY Medicaid HMO DRG,69675,,215% x Medicaid HMO amount,69675,Other,215% of NY Medicaid HMO DRG,40509,,125% x Medicaid HMO amount,40509,Other,125% of NY Medicaid HMO DRG,0.01,183319,
Anal procedures,226-1,APR-DRG,,,,,,,,inpatient,,,81392.18,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27930,,"45,128 x DRG weight",27930,Other,base rate x DRG weight,25137,,"40,615 x DRG weight",25137,Other,base rate x DRG weight,23740,,"38,359 x DRG weight",23740,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10477,,186% x Medicaid HMO amount,10477,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21090,,"34,077 x DRG weight",21090,Other,base rate x DRG weight,17927,,"28,966 x DRG weight",17927,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5633,,DRG base rate x DRG weight + capital per discharge,5633,Other,100% of NY Medicaid HMO DRG,5633,,100% x Medicaid HMO amount,5633,Other,100% of NY Medicaid HMO DRG,5633,,100% x Medicaid HMO amount,5633,Other,100% of NY Medicaid HMO DRG,5633,,100% x Medicaid HMO amount,5633,Other,100% of NY Medicaid HMO DRG,12674,,225% x Medicaid HMO amount,12674,Other,225% of NY Medicaid HMO DRG,12674,,225% x Medicaid HMO amount,12674,Other,225% of NY Medicaid HMO DRG,12674,,225% x Medicaid HMO amount,12674,Other,225% of NY Medicaid HMO DRG,12674,,225% x Medicaid HMO amount,12674,Other,225% of NY Medicaid HMO DRG,7886,,140% x Medicaid HMO amount,7886,Other,140% of NY Medicaid HMO DRG,12674,,225% x Medicaid HMO amount,12674,Other,225% of NY Medicaid HMO DRG,15491,,275% x Medicaid HMO amount,15491,Other,275% of NY Medicaid HMO DRG,18251,,324% x Medicaid HMO amount,18251,Other,324% of NY Medicaid HMO DRG,12111,,215% x Medicaid HMO amount,12111,Other,215% of NY Medicaid HMO DRG,12111,,215% x Medicaid HMO amount,12111,Other,215% of NY Medicaid HMO DRG,7041,,125% x Medicaid HMO amount,7041,Other,125% of NY Medicaid HMO DRG,0.01,27930,
Anal procedures,226-2,APR-DRG,,,,,,,,inpatient,,,126614.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39848,,"45,128 x DRG weight",39848,Other,base rate x DRG weight,35863,,"40,615 x DRG weight",35863,Other,base rate x DRG weight,33871,,"38,359 x DRG weight",33871,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14298,,186% x Medicaid HMO amount,14298,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30090,,"34,077 x DRG weight",30090,Other,base rate x DRG weight,25577,,"28,966 x DRG weight",25577,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7687,,DRG base rate x DRG weight + capital per discharge,7687,Other,100% of NY Medicaid HMO DRG,7687,,100% x Medicaid HMO amount,7687,Other,100% of NY Medicaid HMO DRG,7687,,100% x Medicaid HMO amount,7687,Other,100% of NY Medicaid HMO DRG,7687,,100% x Medicaid HMO amount,7687,Other,100% of NY Medicaid HMO DRG,17296,,225% x Medicaid HMO amount,17296,Other,225% of NY Medicaid HMO DRG,17296,,225% x Medicaid HMO amount,17296,Other,225% of NY Medicaid HMO DRG,17296,,225% x Medicaid HMO amount,17296,Other,225% of NY Medicaid HMO DRG,17296,,225% x Medicaid HMO amount,17296,Other,225% of NY Medicaid HMO DRG,10762,,140% x Medicaid HMO amount,10762,Other,140% of NY Medicaid HMO DRG,17296,,225% x Medicaid HMO amount,17296,Other,225% of NY Medicaid HMO DRG,21139,,275% x Medicaid HMO amount,21139,Other,275% of NY Medicaid HMO DRG,24906,,324% x Medicaid HMO amount,24906,Other,324% of NY Medicaid HMO DRG,16527,,215% x Medicaid HMO amount,16527,Other,215% of NY Medicaid HMO DRG,16527,,215% x Medicaid HMO amount,16527,Other,215% of NY Medicaid HMO DRG,9609,,125% x Medicaid HMO amount,9609,Other,125% of NY Medicaid HMO DRG,0.01,39848,
Anal procedures,226-3,APR-DRG,,,,,,,,inpatient,,,356419.86,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,67620,,"45,128 x DRG weight",67620,Other,base rate x DRG weight,60858,,"40,615 x DRG weight",60858,Other,base rate x DRG weight,57477,,"38,359 x DRG weight",57477,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23198,,186% x Medicaid HMO amount,23198,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51061,,"34,077 x DRG weight",51061,Other,base rate x DRG weight,43403,,"28,966 x DRG weight",43403,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12472,,DRG base rate x DRG weight + capital per discharge,12472,Other,100% of NY Medicaid HMO DRG,12472,,100% x Medicaid HMO amount,12472,Other,100% of NY Medicaid HMO DRG,12472,,100% x Medicaid HMO amount,12472,Other,100% of NY Medicaid HMO DRG,12472,,100% x Medicaid HMO amount,12472,Other,100% of NY Medicaid HMO DRG,28062,,225% x Medicaid HMO amount,28062,Other,225% of NY Medicaid HMO DRG,28062,,225% x Medicaid HMO amount,28062,Other,225% of NY Medicaid HMO DRG,28062,,225% x Medicaid HMO amount,28062,Other,225% of NY Medicaid HMO DRG,28062,,225% x Medicaid HMO amount,28062,Other,225% of NY Medicaid HMO DRG,17461,,140% x Medicaid HMO amount,17461,Other,140% of NY Medicaid HMO DRG,28062,,225% x Medicaid HMO amount,28062,Other,225% of NY Medicaid HMO DRG,34298,,275% x Medicaid HMO amount,34298,Other,275% of NY Medicaid HMO DRG,40409,,324% x Medicaid HMO amount,40409,Other,324% of NY Medicaid HMO DRG,26815,,215% x Medicaid HMO amount,26815,Other,215% of NY Medicaid HMO DRG,26815,,215% x Medicaid HMO amount,26815,Other,215% of NY Medicaid HMO DRG,15590,,125% x Medicaid HMO amount,15590,Other,125% of NY Medicaid HMO DRG,0.01,67620,
Anal procedures,226-4,APR-DRG,,,,,,,,inpatient,,,1092437.37,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,163765,,"45,128 x DRG weight",163765,Other,base rate x DRG weight,147388,,"40,615 x DRG weight",147388,Other,base rate x DRG weight,139201,,"38,359 x DRG weight",139201,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54011,,186% x Medicaid HMO amount,54011,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,123662,,"34,077 x DRG weight",123662,Other,base rate x DRG weight,105115,,"28,966 x DRG weight",105115,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29038,,DRG base rate x DRG weight + capital per discharge,29038,Other,100% of NY Medicaid HMO DRG,29038,,100% x Medicaid HMO amount,29038,Other,100% of NY Medicaid HMO DRG,29038,,100% x Medicaid HMO amount,29038,Other,100% of NY Medicaid HMO DRG,29038,,100% x Medicaid HMO amount,29038,Other,100% of NY Medicaid HMO DRG,65336,,225% x Medicaid HMO amount,65336,Other,225% of NY Medicaid HMO DRG,65336,,225% x Medicaid HMO amount,65336,Other,225% of NY Medicaid HMO DRG,65336,,225% x Medicaid HMO amount,65336,Other,225% of NY Medicaid HMO DRG,65336,,225% x Medicaid HMO amount,65336,Other,225% of NY Medicaid HMO DRG,40653,,140% x Medicaid HMO amount,40653,Other,140% of NY Medicaid HMO DRG,65336,,225% x Medicaid HMO amount,65336,Other,225% of NY Medicaid HMO DRG,79855,,275% x Medicaid HMO amount,79855,Other,275% of NY Medicaid HMO DRG,94083,,324% x Medicaid HMO amount,94083,Other,324% of NY Medicaid HMO DRG,62432,,215% x Medicaid HMO amount,62432,Other,215% of NY Medicaid HMO DRG,62432,,215% x Medicaid HMO amount,62432,Other,215% of NY Medicaid HMO DRG,36298,,125% x Medicaid HMO amount,36298,Other,125% of NY Medicaid HMO DRG,0.01,163765,
"Hernia procedures except inguinal, femoral & umbilical",227-1,APR-DRG,,,,,,,,inpatient,,,161537.48,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46906,,"45,128 x DRG weight",46906,Other,base rate x DRG weight,42215,,"40,615 x DRG weight",42215,Other,base rate x DRG weight,39870,,"38,359 x DRG weight",39870,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16560,,186% x Medicaid HMO amount,16560,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35420,,"34,077 x DRG weight",35420,Other,base rate x DRG weight,30107,,"28,966 x DRG weight",30107,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8903,,DRG base rate x DRG weight + capital per discharge,8903,Other,100% of NY Medicaid HMO DRG,8903,,100% x Medicaid HMO amount,8903,Other,100% of NY Medicaid HMO DRG,8903,,100% x Medicaid HMO amount,8903,Other,100% of NY Medicaid HMO DRG,8903,,100% x Medicaid HMO amount,8903,Other,100% of NY Medicaid HMO DRG,20032,,225% x Medicaid HMO amount,20032,Other,225% of NY Medicaid HMO DRG,20032,,225% x Medicaid HMO amount,20032,Other,225% of NY Medicaid HMO DRG,20032,,225% x Medicaid HMO amount,20032,Other,225% of NY Medicaid HMO DRG,20032,,225% x Medicaid HMO amount,20032,Other,225% of NY Medicaid HMO DRG,12464,,140% x Medicaid HMO amount,12464,Other,140% of NY Medicaid HMO DRG,20032,,225% x Medicaid HMO amount,20032,Other,225% of NY Medicaid HMO DRG,24483,,275% x Medicaid HMO amount,24483,Other,275% of NY Medicaid HMO DRG,28846,,324% x Medicaid HMO amount,28846,Other,324% of NY Medicaid HMO DRG,19141,,215% x Medicaid HMO amount,19141,Other,215% of NY Medicaid HMO DRG,19141,,215% x Medicaid HMO amount,19141,Other,215% of NY Medicaid HMO DRG,11129,,125% x Medicaid HMO amount,11129,Other,125% of NY Medicaid HMO DRG,0.01,46906,
"Hernia procedures except inguinal, femoral & umbilical",227-2,APR-DRG,,,,,,,,inpatient,,,233346.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60941,,"45,128 x DRG weight",60941,Other,base rate x DRG weight,54846,,"40,615 x DRG weight",54846,Other,base rate x DRG weight,51800,,"38,359 x DRG weight",51800,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21057,,186% x Medicaid HMO amount,21057,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46018,,"34,077 x DRG weight",46018,Other,base rate x DRG weight,39116,,"28,966 x DRG weight",39116,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11321,,DRG base rate x DRG weight + capital per discharge,11321,Other,100% of NY Medicaid HMO DRG,11321,,100% x Medicaid HMO amount,11321,Other,100% of NY Medicaid HMO DRG,11321,,100% x Medicaid HMO amount,11321,Other,100% of NY Medicaid HMO DRG,11321,,100% x Medicaid HMO amount,11321,Other,100% of NY Medicaid HMO DRG,25472,,225% x Medicaid HMO amount,25472,Other,225% of NY Medicaid HMO DRG,25472,,225% x Medicaid HMO amount,25472,Other,225% of NY Medicaid HMO DRG,25472,,225% x Medicaid HMO amount,25472,Other,225% of NY Medicaid HMO DRG,25472,,225% x Medicaid HMO amount,25472,Other,225% of NY Medicaid HMO DRG,15849,,140% x Medicaid HMO amount,15849,Other,140% of NY Medicaid HMO DRG,25472,,225% x Medicaid HMO amount,25472,Other,225% of NY Medicaid HMO DRG,31133,,275% x Medicaid HMO amount,31133,Other,275% of NY Medicaid HMO DRG,36680,,324% x Medicaid HMO amount,36680,Other,324% of NY Medicaid HMO DRG,24340,,215% x Medicaid HMO amount,24340,Other,215% of NY Medicaid HMO DRG,24340,,215% x Medicaid HMO amount,24340,Other,215% of NY Medicaid HMO DRG,14151,,125% x Medicaid HMO amount,14151,Other,125% of NY Medicaid HMO DRG,0.01,60941,
"Hernia procedures except inguinal, femoral & umbilical",227-3,APR-DRG,,,,,,,,inpatient,,,242045.54,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,104625,,"45,128 x DRG weight",104625,Other,base rate x DRG weight,94162,,"40,615 x DRG weight",94162,Other,base rate x DRG weight,88932,,"38,359 x DRG weight",88932,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35057,,186% x Medicaid HMO amount,35057,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,79004,,"34,077 x DRG weight",79004,Other,base rate x DRG weight,67155,,"28,966 x DRG weight",67155,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18848,,DRG base rate x DRG weight + capital per discharge,18848,Other,100% of NY Medicaid HMO DRG,18848,,100% x Medicaid HMO amount,18848,Other,100% of NY Medicaid HMO DRG,18848,,100% x Medicaid HMO amount,18848,Other,100% of NY Medicaid HMO DRG,18848,,100% x Medicaid HMO amount,18848,Other,100% of NY Medicaid HMO DRG,42408,,225% x Medicaid HMO amount,42408,Other,225% of NY Medicaid HMO DRG,42408,,225% x Medicaid HMO amount,42408,Other,225% of NY Medicaid HMO DRG,42408,,225% x Medicaid HMO amount,42408,Other,225% of NY Medicaid HMO DRG,42408,,225% x Medicaid HMO amount,42408,Other,225% of NY Medicaid HMO DRG,26387,,140% x Medicaid HMO amount,26387,Other,140% of NY Medicaid HMO DRG,42408,,225% x Medicaid HMO amount,42408,Other,225% of NY Medicaid HMO DRG,51832,,275% x Medicaid HMO amount,51832,Other,275% of NY Medicaid HMO DRG,61068,,324% x Medicaid HMO amount,61068,Other,324% of NY Medicaid HMO DRG,40523,,215% x Medicaid HMO amount,40523,Other,215% of NY Medicaid HMO DRG,40523,,215% x Medicaid HMO amount,40523,Other,215% of NY Medicaid HMO DRG,23560,,125% x Medicaid HMO amount,23560,Other,125% of NY Medicaid HMO DRG,0.01,104625,
"Hernia procedures except inguinal, femoral & umbilical",227-4,APR-DRG,,,,,,,,inpatient,,,95511.63,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,237992,,"45,128 x DRG weight",237992,Other,base rate x DRG weight,214191,,"40,615 x DRG weight",214191,Other,base rate x DRG weight,202294,,"38,359 x DRG weight",202294,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,77798,,186% x Medicaid HMO amount,77798,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,179712,,"34,077 x DRG weight",179712,Other,base rate x DRG weight,152758,,"28,966 x DRG weight",152758,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41827,,DRG base rate x DRG weight + capital per discharge,41827,Other,100% of NY Medicaid HMO DRG,41827,,100% x Medicaid HMO amount,41827,Other,100% of NY Medicaid HMO DRG,41827,,100% x Medicaid HMO amount,41827,Other,100% of NY Medicaid HMO DRG,41827,,100% x Medicaid HMO amount,41827,Other,100% of NY Medicaid HMO DRG,94111,,225% x Medicaid HMO amount,94111,Other,225% of NY Medicaid HMO DRG,94111,,225% x Medicaid HMO amount,94111,Other,225% of NY Medicaid HMO DRG,94111,,225% x Medicaid HMO amount,94111,Other,225% of NY Medicaid HMO DRG,94111,,225% x Medicaid HMO amount,94111,Other,225% of NY Medicaid HMO DRG,58558,,140% x Medicaid HMO amount,58558,Other,140% of NY Medicaid HMO DRG,94111,,225% x Medicaid HMO amount,94111,Other,225% of NY Medicaid HMO DRG,115024,,275% x Medicaid HMO amount,115024,Other,275% of NY Medicaid HMO DRG,135519,,324% x Medicaid HMO amount,135519,Other,324% of NY Medicaid HMO DRG,89928,,215% x Medicaid HMO amount,89928,Other,215% of NY Medicaid HMO DRG,89928,,215% x Medicaid HMO amount,89928,Other,215% of NY Medicaid HMO DRG,52284,,125% x Medicaid HMO amount,52284,Other,125% of NY Medicaid HMO DRG,0.01,237992,
"Inguinal, femoral & umbilical hernia procedures",228-1,APR-DRG,,,,,,,,inpatient,,,81869.87,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31463,,"45,128 x DRG weight",31463,Other,base rate x DRG weight,28317,,"40,615 x DRG weight",28317,Other,base rate x DRG weight,26744,,"38,359 x DRG weight",26744,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11610,,186% x Medicaid HMO amount,11610,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23758,,"34,077 x DRG weight",23758,Other,base rate x DRG weight,20195,,"28,966 x DRG weight",20195,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6242,,DRG base rate x DRG weight + capital per discharge,6242,Other,100% of NY Medicaid HMO DRG,6242,,100% x Medicaid HMO amount,6242,Other,100% of NY Medicaid HMO DRG,6242,,100% x Medicaid HMO amount,6242,Other,100% of NY Medicaid HMO DRG,6242,,100% x Medicaid HMO amount,6242,Other,100% of NY Medicaid HMO DRG,14045,,225% x Medicaid HMO amount,14045,Other,225% of NY Medicaid HMO DRG,14045,,225% x Medicaid HMO amount,14045,Other,225% of NY Medicaid HMO DRG,14045,,225% x Medicaid HMO amount,14045,Other,225% of NY Medicaid HMO DRG,14045,,225% x Medicaid HMO amount,14045,Other,225% of NY Medicaid HMO DRG,8739,,140% x Medicaid HMO amount,8739,Other,140% of NY Medicaid HMO DRG,14045,,225% x Medicaid HMO amount,14045,Other,225% of NY Medicaid HMO DRG,17166,,275% x Medicaid HMO amount,17166,Other,275% of NY Medicaid HMO DRG,20224,,324% x Medicaid HMO amount,20224,Other,324% of NY Medicaid HMO DRG,13420,,215% x Medicaid HMO amount,13420,Other,215% of NY Medicaid HMO DRG,13420,,215% x Medicaid HMO amount,13420,Other,215% of NY Medicaid HMO DRG,7803,,125% x Medicaid HMO amount,7803,Other,125% of NY Medicaid HMO DRG,0.01,31463,
"Inguinal, femoral & umbilical hernia procedures",228-2,APR-DRG,,,,,,,,inpatient,,,161105.35,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43021,,"45,128 x DRG weight",43021,Other,base rate x DRG weight,38718,,"40,615 x DRG weight",38718,Other,base rate x DRG weight,36568,,"38,359 x DRG weight",36568,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15313,,186% x Medicaid HMO amount,15313,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32486,,"34,077 x DRG weight",32486,Other,base rate x DRG weight,27613,,"28,966 x DRG weight",27613,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8233,,DRG base rate x DRG weight + capital per discharge,8233,Other,100% of NY Medicaid HMO DRG,8233,,100% x Medicaid HMO amount,8233,Other,100% of NY Medicaid HMO DRG,8233,,100% x Medicaid HMO amount,8233,Other,100% of NY Medicaid HMO DRG,8233,,100% x Medicaid HMO amount,8233,Other,100% of NY Medicaid HMO DRG,18524,,225% x Medicaid HMO amount,18524,Other,225% of NY Medicaid HMO DRG,18524,,225% x Medicaid HMO amount,18524,Other,225% of NY Medicaid HMO DRG,18524,,225% x Medicaid HMO amount,18524,Other,225% of NY Medicaid HMO DRG,18524,,225% x Medicaid HMO amount,18524,Other,225% of NY Medicaid HMO DRG,11526,,140% x Medicaid HMO amount,11526,Other,140% of NY Medicaid HMO DRG,18524,,225% x Medicaid HMO amount,18524,Other,225% of NY Medicaid HMO DRG,22641,,275% x Medicaid HMO amount,22641,Other,275% of NY Medicaid HMO DRG,26675,,324% x Medicaid HMO amount,26675,Other,324% of NY Medicaid HMO DRG,17701,,215% x Medicaid HMO amount,17701,Other,215% of NY Medicaid HMO DRG,17701,,215% x Medicaid HMO amount,17701,Other,215% of NY Medicaid HMO DRG,10291,,125% x Medicaid HMO amount,10291,Other,125% of NY Medicaid HMO DRG,0.01,43021,
"Inguinal, femoral & umbilical hernia procedures",228-3,APR-DRG,,,,,,,,inpatient,,,78257.78,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,72819,,"45,128 x DRG weight",72819,Other,base rate x DRG weight,65536,,"40,615 x DRG weight",65536,Other,base rate x DRG weight,61896,,"38,359 x DRG weight",61896,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24864,,186% x Medicaid HMO amount,24864,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54987,,"34,077 x DRG weight",54987,Other,base rate x DRG weight,46740,,"28,966 x DRG weight",46740,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13368,,DRG base rate x DRG weight + capital per discharge,13368,Other,100% of NY Medicaid HMO DRG,13368,,100% x Medicaid HMO amount,13368,Other,100% of NY Medicaid HMO DRG,13368,,100% x Medicaid HMO amount,13368,Other,100% of NY Medicaid HMO DRG,13368,,100% x Medicaid HMO amount,13368,Other,100% of NY Medicaid HMO DRG,30078,,225% x Medicaid HMO amount,30078,Other,225% of NY Medicaid HMO DRG,30078,,225% x Medicaid HMO amount,30078,Other,225% of NY Medicaid HMO DRG,30078,,225% x Medicaid HMO amount,30078,Other,225% of NY Medicaid HMO DRG,30078,,225% x Medicaid HMO amount,30078,Other,225% of NY Medicaid HMO DRG,18715,,140% x Medicaid HMO amount,18715,Other,140% of NY Medicaid HMO DRG,30078,,225% x Medicaid HMO amount,30078,Other,225% of NY Medicaid HMO DRG,36762,,275% x Medicaid HMO amount,36762,Other,275% of NY Medicaid HMO DRG,43312,,324% x Medicaid HMO amount,43312,Other,324% of NY Medicaid HMO DRG,28741,,215% x Medicaid HMO amount,28741,Other,215% of NY Medicaid HMO DRG,28741,,215% x Medicaid HMO amount,28741,Other,215% of NY Medicaid HMO DRG,16710,,125% x Medicaid HMO amount,16710,Other,125% of NY Medicaid HMO DRG,0.01,72819,
"Inguinal, femoral & umbilical hernia procedures",228-4,APR-DRG,,,,,,,,inpatient,,,454616.93,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,201081,,"45,128 x DRG weight",201081,Other,base rate x DRG weight,180972,,"40,615 x DRG weight",180972,Other,base rate x DRG weight,170920,,"38,359 x DRG weight",170920,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,65969,,186% x Medicaid HMO amount,65969,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,151840,,"34,077 x DRG weight",151840,Other,base rate x DRG weight,129067,,"28,966 x DRG weight",129067,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35467,,DRG base rate x DRG weight + capital per discharge,35467,Other,100% of NY Medicaid HMO DRG,35467,,100% x Medicaid HMO amount,35467,Other,100% of NY Medicaid HMO DRG,35467,,100% x Medicaid HMO amount,35467,Other,100% of NY Medicaid HMO DRG,35467,,100% x Medicaid HMO amount,35467,Other,100% of NY Medicaid HMO DRG,79801,,225% x Medicaid HMO amount,79801,Other,225% of NY Medicaid HMO DRG,79801,,225% x Medicaid HMO amount,79801,Other,225% of NY Medicaid HMO DRG,79801,,225% x Medicaid HMO amount,79801,Other,225% of NY Medicaid HMO DRG,79801,,225% x Medicaid HMO amount,79801,Other,225% of NY Medicaid HMO DRG,49654,,140% x Medicaid HMO amount,49654,Other,140% of NY Medicaid HMO DRG,79801,,225% x Medicaid HMO amount,79801,Other,225% of NY Medicaid HMO DRG,97534,,275% x Medicaid HMO amount,97534,Other,275% of NY Medicaid HMO DRG,114913,,324% x Medicaid HMO amount,114913,Other,324% of NY Medicaid HMO DRG,76254,,215% x Medicaid HMO amount,76254,Other,215% of NY Medicaid HMO DRG,76254,,215% x Medicaid HMO amount,76254,Other,215% of NY Medicaid HMO DRG,44334,,125% x Medicaid HMO amount,44334,Other,125% of NY Medicaid HMO DRG,0.01,201081,
Other digestive system & abdominal procedures,229-1,APR-DRG,,,,,,,,inpatient,,,209990.27,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46089,,"45,128 x DRG weight",46089,Other,base rate x DRG weight,41480,,"40,615 x DRG weight",41480,Other,base rate x DRG weight,39176,,"38,359 x DRG weight",39176,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16297,,186% x Medicaid HMO amount,16297,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34803,,"34,077 x DRG weight",34803,Other,base rate x DRG weight,29583,,"28,966 x DRG weight",29583,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8762,,DRG base rate x DRG weight + capital per discharge,8762,Other,100% of NY Medicaid HMO DRG,8762,,100% x Medicaid HMO amount,8762,Other,100% of NY Medicaid HMO DRG,8762,,100% x Medicaid HMO amount,8762,Other,100% of NY Medicaid HMO DRG,8762,,100% x Medicaid HMO amount,8762,Other,100% of NY Medicaid HMO DRG,19715,,225% x Medicaid HMO amount,19715,Other,225% of NY Medicaid HMO DRG,19715,,225% x Medicaid HMO amount,19715,Other,225% of NY Medicaid HMO DRG,19715,,225% x Medicaid HMO amount,19715,Other,225% of NY Medicaid HMO DRG,19715,,225% x Medicaid HMO amount,19715,Other,225% of NY Medicaid HMO DRG,12267,,140% x Medicaid HMO amount,12267,Other,140% of NY Medicaid HMO DRG,19715,,225% x Medicaid HMO amount,19715,Other,225% of NY Medicaid HMO DRG,24096,,275% x Medicaid HMO amount,24096,Other,275% of NY Medicaid HMO DRG,28389,,324% x Medicaid HMO amount,28389,Other,324% of NY Medicaid HMO DRG,18838,,215% x Medicaid HMO amount,18838,Other,215% of NY Medicaid HMO DRG,18838,,215% x Medicaid HMO amount,18838,Other,215% of NY Medicaid HMO DRG,10953,,125% x Medicaid HMO amount,10953,Other,125% of NY Medicaid HMO DRG,0.01,46089,
Other digestive system & abdominal procedures,229-2,APR-DRG,,,,,,,,inpatient,,,158747.34,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,66798,,"45,128 x DRG weight",66798,Other,base rate x DRG weight,60118,,"40,615 x DRG weight",60118,Other,base rate x DRG weight,56779,,"38,359 x DRG weight",56779,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22934,,186% x Medicaid HMO amount,22934,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50441,,"34,077 x DRG weight",50441,Other,base rate x DRG weight,42875,,"28,966 x DRG weight",42875,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12330,,DRG base rate x DRG weight + capital per discharge,12330,Other,100% of NY Medicaid HMO DRG,12330,,100% x Medicaid HMO amount,12330,Other,100% of NY Medicaid HMO DRG,12330,,100% x Medicaid HMO amount,12330,Other,100% of NY Medicaid HMO DRG,12330,,100% x Medicaid HMO amount,12330,Other,100% of NY Medicaid HMO DRG,27743,,225% x Medicaid HMO amount,27743,Other,225% of NY Medicaid HMO DRG,27743,,225% x Medicaid HMO amount,27743,Other,225% of NY Medicaid HMO DRG,27743,,225% x Medicaid HMO amount,27743,Other,225% of NY Medicaid HMO DRG,27743,,225% x Medicaid HMO amount,27743,Other,225% of NY Medicaid HMO DRG,17262,,140% x Medicaid HMO amount,17262,Other,140% of NY Medicaid HMO DRG,27743,,225% x Medicaid HMO amount,27743,Other,225% of NY Medicaid HMO DRG,33908,,275% x Medicaid HMO amount,33908,Other,275% of NY Medicaid HMO DRG,39949,,324% x Medicaid HMO amount,39949,Other,324% of NY Medicaid HMO DRG,26510,,215% x Medicaid HMO amount,26510,Other,215% of NY Medicaid HMO DRG,26510,,215% x Medicaid HMO amount,26510,Other,215% of NY Medicaid HMO DRG,15413,,125% x Medicaid HMO amount,15413,Other,125% of NY Medicaid HMO DRG,0.01,66798,
Other digestive system & abdominal procedures,229-3,APR-DRG,,,,,,,,inpatient,,,364897.14,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,117590,,"45,128 x DRG weight",117590,Other,base rate x DRG weight,105831,,"40,615 x DRG weight",105831,Other,base rate x DRG weight,99952,,"38,359 x DRG weight",99952,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39213,,186% x Medicaid HMO amount,39213,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,88794,,"34,077 x DRG weight",88794,Other,base rate x DRG weight,75477,,"28,966 x DRG weight",75477,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21082,,DRG base rate x DRG weight + capital per discharge,21082,Other,100% of NY Medicaid HMO DRG,21082,,100% x Medicaid HMO amount,21082,Other,100% of NY Medicaid HMO DRG,21082,,100% x Medicaid HMO amount,21082,Other,100% of NY Medicaid HMO DRG,21082,,100% x Medicaid HMO amount,21082,Other,100% of NY Medicaid HMO DRG,47435,,225% x Medicaid HMO amount,47435,Other,225% of NY Medicaid HMO DRG,47435,,225% x Medicaid HMO amount,47435,Other,225% of NY Medicaid HMO DRG,47435,,225% x Medicaid HMO amount,47435,Other,225% of NY Medicaid HMO DRG,47435,,225% x Medicaid HMO amount,47435,Other,225% of NY Medicaid HMO DRG,29515,,140% x Medicaid HMO amount,29515,Other,140% of NY Medicaid HMO DRG,47435,,225% x Medicaid HMO amount,47435,Other,225% of NY Medicaid HMO DRG,57976,,275% x Medicaid HMO amount,57976,Other,275% of NY Medicaid HMO DRG,68306,,324% x Medicaid HMO amount,68306,Other,324% of NY Medicaid HMO DRG,45326,,215% x Medicaid HMO amount,45326,Other,215% of NY Medicaid HMO DRG,45326,,215% x Medicaid HMO amount,45326,Other,215% of NY Medicaid HMO DRG,26353,,125% x Medicaid HMO amount,26353,Other,125% of NY Medicaid HMO DRG,0.01,117590,
Other digestive system & abdominal procedures,229-4,APR-DRG,,,,,,,,inpatient,,,723373.83,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,261147,,"45,128 x DRG weight",261147,Other,base rate x DRG weight,235031,,"40,615 x DRG weight",235031,Other,base rate x DRG weight,221976,,"38,359 x DRG weight",221976,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,85220,,186% x Medicaid HMO amount,85220,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,197197,,"34,077 x DRG weight",197197,Other,base rate x DRG weight,167620,,"28,966 x DRG weight",167620,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45817,,DRG base rate x DRG weight + capital per discharge,45817,Other,100% of NY Medicaid HMO DRG,45817,,100% x Medicaid HMO amount,45817,Other,100% of NY Medicaid HMO DRG,45817,,100% x Medicaid HMO amount,45817,Other,100% of NY Medicaid HMO DRG,45817,,100% x Medicaid HMO amount,45817,Other,100% of NY Medicaid HMO DRG,103088,,225% x Medicaid HMO amount,103088,Other,225% of NY Medicaid HMO DRG,103088,,225% x Medicaid HMO amount,103088,Other,225% of NY Medicaid HMO DRG,103088,,225% x Medicaid HMO amount,103088,Other,225% of NY Medicaid HMO DRG,103088,,225% x Medicaid HMO amount,103088,Other,225% of NY Medicaid HMO DRG,64144,,140% x Medicaid HMO amount,64144,Other,140% of NY Medicaid HMO DRG,103088,,225% x Medicaid HMO amount,103088,Other,225% of NY Medicaid HMO DRG,125997,,275% x Medicaid HMO amount,125997,Other,275% of NY Medicaid HMO DRG,148447,,324% x Medicaid HMO amount,148447,Other,324% of NY Medicaid HMO DRG,98507,,215% x Medicaid HMO amount,98507,Other,215% of NY Medicaid HMO DRG,98507,,215% x Medicaid HMO amount,98507,Other,215% of NY Medicaid HMO DRG,57271,,125% x Medicaid HMO amount,57271,Other,125% of NY Medicaid HMO DRG,0.01,261147,
Digestive malignancy,240-1,APR-DRG,,,,,,,,inpatient,,,175015.63,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31581,,"45,128 x DRG weight",31581,Other,base rate x DRG weight,28422,,"40,615 x DRG weight",28422,Other,base rate x DRG weight,26844,,"38,359 x DRG weight",26844,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11647,,186% x Medicaid HMO amount,11647,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23847,,"34,077 x DRG weight",23847,Other,base rate x DRG weight,20270,,"28,966 x DRG weight",20270,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6262,,DRG base rate x DRG weight + capital per discharge,6262,Other,100% of NY Medicaid HMO DRG,6262,,100% x Medicaid HMO amount,6262,Other,100% of NY Medicaid HMO DRG,6262,,100% x Medicaid HMO amount,6262,Other,100% of NY Medicaid HMO DRG,6262,,100% x Medicaid HMO amount,6262,Other,100% of NY Medicaid HMO DRG,14090,,225% x Medicaid HMO amount,14090,Other,225% of NY Medicaid HMO DRG,14090,,225% x Medicaid HMO amount,14090,Other,225% of NY Medicaid HMO DRG,14090,,225% x Medicaid HMO amount,14090,Other,225% of NY Medicaid HMO DRG,14090,,225% x Medicaid HMO amount,14090,Other,225% of NY Medicaid HMO DRG,8767,,140% x Medicaid HMO amount,8767,Other,140% of NY Medicaid HMO DRG,14090,,225% x Medicaid HMO amount,14090,Other,225% of NY Medicaid HMO DRG,17221,,275% x Medicaid HMO amount,17221,Other,275% of NY Medicaid HMO DRG,20289,,324% x Medicaid HMO amount,20289,Other,324% of NY Medicaid HMO DRG,13463,,215% x Medicaid HMO amount,13463,Other,215% of NY Medicaid HMO DRG,13463,,215% x Medicaid HMO amount,13463,Other,215% of NY Medicaid HMO DRG,7828,,125% x Medicaid HMO amount,7828,Other,125% of NY Medicaid HMO DRG,0.01,31581,
Digestive malignancy,240-2,APR-DRG,,,,,,,,inpatient,,,363554.48,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42840,,"45,128 x DRG weight",42840,Other,base rate x DRG weight,38556,,"40,615 x DRG weight",38556,Other,base rate x DRG weight,36414,,"38,359 x DRG weight",36414,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15256,,186% x Medicaid HMO amount,15256,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32349,,"34,077 x DRG weight",32349,Other,base rate x DRG weight,27497,,"28,966 x DRG weight",27497,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8202,,DRG base rate x DRG weight + capital per discharge,8202,Other,100% of NY Medicaid HMO DRG,8202,,100% x Medicaid HMO amount,8202,Other,100% of NY Medicaid HMO DRG,8202,,100% x Medicaid HMO amount,8202,Other,100% of NY Medicaid HMO DRG,8202,,100% x Medicaid HMO amount,8202,Other,100% of NY Medicaid HMO DRG,18455,,225% x Medicaid HMO amount,18455,Other,225% of NY Medicaid HMO DRG,18455,,225% x Medicaid HMO amount,18455,Other,225% of NY Medicaid HMO DRG,18455,,225% x Medicaid HMO amount,18455,Other,225% of NY Medicaid HMO DRG,18455,,225% x Medicaid HMO amount,18455,Other,225% of NY Medicaid HMO DRG,11483,,140% x Medicaid HMO amount,11483,Other,140% of NY Medicaid HMO DRG,18455,,225% x Medicaid HMO amount,18455,Other,225% of NY Medicaid HMO DRG,22556,,275% x Medicaid HMO amount,22556,Other,275% of NY Medicaid HMO DRG,26574,,324% x Medicaid HMO amount,26574,Other,324% of NY Medicaid HMO DRG,17634,,215% x Medicaid HMO amount,17634,Other,215% of NY Medicaid HMO DRG,17634,,215% x Medicaid HMO amount,17634,Other,215% of NY Medicaid HMO DRG,10253,,125% x Medicaid HMO amount,10253,Other,125% of NY Medicaid HMO DRG,0.01,42840,
Digestive malignancy,240-3,APR-DRG,,,,,,,,inpatient,,,394722.98,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,71456,,"45,128 x DRG weight",71456,Other,base rate x DRG weight,64310,,"40,615 x DRG weight",64310,Other,base rate x DRG weight,60738,,"38,359 x DRG weight",60738,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24427,,186% x Medicaid HMO amount,24427,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53958,,"34,077 x DRG weight",53958,Other,base rate x DRG weight,45865,,"28,966 x DRG weight",45865,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13133,,DRG base rate x DRG weight + capital per discharge,13133,Other,100% of NY Medicaid HMO DRG,13133,,100% x Medicaid HMO amount,13133,Other,100% of NY Medicaid HMO DRG,13133,,100% x Medicaid HMO amount,13133,Other,100% of NY Medicaid HMO DRG,13133,,100% x Medicaid HMO amount,13133,Other,100% of NY Medicaid HMO DRG,29549,,225% x Medicaid HMO amount,29549,Other,225% of NY Medicaid HMO DRG,29549,,225% x Medicaid HMO amount,29549,Other,225% of NY Medicaid HMO DRG,29549,,225% x Medicaid HMO amount,29549,Other,225% of NY Medicaid HMO DRG,29549,,225% x Medicaid HMO amount,29549,Other,225% of NY Medicaid HMO DRG,18386,,140% x Medicaid HMO amount,18386,Other,140% of NY Medicaid HMO DRG,29549,,225% x Medicaid HMO amount,29549,Other,225% of NY Medicaid HMO DRG,36116,,275% x Medicaid HMO amount,36116,Other,275% of NY Medicaid HMO DRG,42551,,324% x Medicaid HMO amount,42551,Other,324% of NY Medicaid HMO DRG,28236,,215% x Medicaid HMO amount,28236,Other,215% of NY Medicaid HMO DRG,28236,,215% x Medicaid HMO amount,28236,Other,215% of NY Medicaid HMO DRG,16416,,125% x Medicaid HMO amount,16416,Other,125% of NY Medicaid HMO DRG,0.01,71456,
Digestive malignancy,240-4,APR-DRG,,,,,,,,inpatient,,,508662.69,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,134206,,"45,128 x DRG weight",134206,Other,base rate x DRG weight,120785,,"40,615 x DRG weight",120785,Other,base rate x DRG weight,114076,,"38,359 x DRG weight",114076,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44538,,186% x Medicaid HMO amount,44538,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,101342,,"34,077 x DRG weight",101342,Other,base rate x DRG weight,86142,,"28,966 x DRG weight",86142,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23945,,DRG base rate x DRG weight + capital per discharge,23945,Other,100% of NY Medicaid HMO DRG,23945,,100% x Medicaid HMO amount,23945,Other,100% of NY Medicaid HMO DRG,23945,,100% x Medicaid HMO amount,23945,Other,100% of NY Medicaid HMO DRG,23945,,100% x Medicaid HMO amount,23945,Other,100% of NY Medicaid HMO DRG,53876,,225% x Medicaid HMO amount,53876,Other,225% of NY Medicaid HMO DRG,53876,,225% x Medicaid HMO amount,53876,Other,225% of NY Medicaid HMO DRG,53876,,225% x Medicaid HMO amount,53876,Other,225% of NY Medicaid HMO DRG,53876,,225% x Medicaid HMO amount,53876,Other,225% of NY Medicaid HMO DRG,33523,,140% x Medicaid HMO amount,33523,Other,140% of NY Medicaid HMO DRG,53876,,225% x Medicaid HMO amount,53876,Other,225% of NY Medicaid HMO DRG,65849,,275% x Medicaid HMO amount,65849,Other,275% of NY Medicaid HMO DRG,77582,,324% x Medicaid HMO amount,77582,Other,324% of NY Medicaid HMO DRG,51482,,215% x Medicaid HMO amount,51482,Other,215% of NY Medicaid HMO DRG,51482,,215% x Medicaid HMO amount,51482,Other,215% of NY Medicaid HMO DRG,29931,,125% x Medicaid HMO amount,29931,Other,125% of NY Medicaid HMO DRG,0.01,134206,
Peptic ulcer & gastritis,241-1,APR-DRG,,,,,,,,inpatient,,,98652.05,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24392,,"45,128 x DRG weight",24392,Other,base rate x DRG weight,21952,,"40,615 x DRG weight",21952,Other,base rate x DRG weight,20733,,"38,359 x DRG weight",20733,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9345,,186% x Medicaid HMO amount,9345,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18419,,"34,077 x DRG weight",18419,Other,base rate x DRG weight,15656,,"28,966 x DRG weight",15656,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5024,,DRG base rate x DRG weight + capital per discharge,5024,Other,100% of NY Medicaid HMO DRG,5024,,100% x Medicaid HMO amount,5024,Other,100% of NY Medicaid HMO DRG,5024,,100% x Medicaid HMO amount,5024,Other,100% of NY Medicaid HMO DRG,5024,,100% x Medicaid HMO amount,5024,Other,100% of NY Medicaid HMO DRG,11304,,225% x Medicaid HMO amount,11304,Other,225% of NY Medicaid HMO DRG,11304,,225% x Medicaid HMO amount,11304,Other,225% of NY Medicaid HMO DRG,11304,,225% x Medicaid HMO amount,11304,Other,225% of NY Medicaid HMO DRG,11304,,225% x Medicaid HMO amount,11304,Other,225% of NY Medicaid HMO DRG,7034,,140% x Medicaid HMO amount,7034,Other,140% of NY Medicaid HMO DRG,11304,,225% x Medicaid HMO amount,11304,Other,225% of NY Medicaid HMO DRG,13816,,275% x Medicaid HMO amount,13816,Other,275% of NY Medicaid HMO DRG,16278,,324% x Medicaid HMO amount,16278,Other,324% of NY Medicaid HMO DRG,10802,,215% x Medicaid HMO amount,10802,Other,215% of NY Medicaid HMO DRG,10802,,215% x Medicaid HMO amount,10802,Other,215% of NY Medicaid HMO DRG,6280,,125% x Medicaid HMO amount,6280,Other,125% of NY Medicaid HMO DRG,0.01,24392,
Peptic ulcer & gastritis,241-2,APR-DRG,,,,,,,,inpatient,,,130688.37,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35006,,"45,128 x DRG weight",35006,Other,base rate x DRG weight,31505,,"40,615 x DRG weight",31505,Other,base rate x DRG weight,29755,,"38,359 x DRG weight",29755,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12745,,186% x Medicaid HMO amount,12745,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26434,,"34,077 x DRG weight",26434,Other,base rate x DRG weight,22469,,"28,966 x DRG weight",22469,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6852,,DRG base rate x DRG weight + capital per discharge,6852,Other,100% of NY Medicaid HMO DRG,6852,,100% x Medicaid HMO amount,6852,Other,100% of NY Medicaid HMO DRG,6852,,100% x Medicaid HMO amount,6852,Other,100% of NY Medicaid HMO DRG,6852,,100% x Medicaid HMO amount,6852,Other,100% of NY Medicaid HMO DRG,15417,,225% x Medicaid HMO amount,15417,Other,225% of NY Medicaid HMO DRG,15417,,225% x Medicaid HMO amount,15417,Other,225% of NY Medicaid HMO DRG,15417,,225% x Medicaid HMO amount,15417,Other,225% of NY Medicaid HMO DRG,15417,,225% x Medicaid HMO amount,15417,Other,225% of NY Medicaid HMO DRG,9593,,140% x Medicaid HMO amount,9593,Other,140% of NY Medicaid HMO DRG,15417,,225% x Medicaid HMO amount,15417,Other,225% of NY Medicaid HMO DRG,18843,,275% x Medicaid HMO amount,18843,Other,275% of NY Medicaid HMO DRG,22200,,324% x Medicaid HMO amount,22200,Other,324% of NY Medicaid HMO DRG,14732,,215% x Medicaid HMO amount,14732,Other,215% of NY Medicaid HMO DRG,14732,,215% x Medicaid HMO amount,14732,Other,215% of NY Medicaid HMO DRG,8565,,125% x Medicaid HMO amount,8565,Other,125% of NY Medicaid HMO DRG,0.01,35006,
Peptic ulcer & gastritis,241-3,APR-DRG,,,,,,,,inpatient,,,152371.82,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56081,,"45,128 x DRG weight",56081,Other,base rate x DRG weight,50472,,"40,615 x DRG weight",50472,Other,base rate x DRG weight,47669,,"38,359 x DRG weight",47669,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19500,,186% x Medicaid HMO amount,19500,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42347,,"34,077 x DRG weight",42347,Other,base rate x DRG weight,35996,,"28,966 x DRG weight",35996,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10484,,DRG base rate x DRG weight + capital per discharge,10484,Other,100% of NY Medicaid HMO DRG,10484,,100% x Medicaid HMO amount,10484,Other,100% of NY Medicaid HMO DRG,10484,,100% x Medicaid HMO amount,10484,Other,100% of NY Medicaid HMO DRG,10484,,100% x Medicaid HMO amount,10484,Other,100% of NY Medicaid HMO DRG,23589,,225% x Medicaid HMO amount,23589,Other,225% of NY Medicaid HMO DRG,23589,,225% x Medicaid HMO amount,23589,Other,225% of NY Medicaid HMO DRG,23589,,225% x Medicaid HMO amount,23589,Other,225% of NY Medicaid HMO DRG,23589,,225% x Medicaid HMO amount,23589,Other,225% of NY Medicaid HMO DRG,14678,,140% x Medicaid HMO amount,14678,Other,140% of NY Medicaid HMO DRG,23589,,225% x Medicaid HMO amount,23589,Other,225% of NY Medicaid HMO DRG,28831,,275% x Medicaid HMO amount,28831,Other,275% of NY Medicaid HMO DRG,33968,,324% x Medicaid HMO amount,33968,Other,324% of NY Medicaid HMO DRG,22541,,215% x Medicaid HMO amount,22541,Other,215% of NY Medicaid HMO DRG,22541,,215% x Medicaid HMO amount,22541,Other,215% of NY Medicaid HMO DRG,13105,,125% x Medicaid HMO amount,13105,Other,125% of NY Medicaid HMO DRG,0.01,56081,
Peptic ulcer & gastritis,241-4,APR-DRG,,,,,,,,inpatient,,,346158.03,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,141237,,"45,128 x DRG weight",141237,Other,base rate x DRG weight,127113,,"40,615 x DRG weight",127113,Other,base rate x DRG weight,120052,,"38,359 x DRG weight",120052,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46790,,186% x Medicaid HMO amount,46790,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,106651,,"34,077 x DRG weight",106651,Other,base rate x DRG weight,90655,,"28,966 x DRG weight",90655,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25156,,DRG base rate x DRG weight + capital per discharge,25156,Other,100% of NY Medicaid HMO DRG,25156,,100% x Medicaid HMO amount,25156,Other,100% of NY Medicaid HMO DRG,25156,,100% x Medicaid HMO amount,25156,Other,100% of NY Medicaid HMO DRG,25156,,100% x Medicaid HMO amount,25156,Other,100% of NY Medicaid HMO DRG,56601,,225% x Medicaid HMO amount,56601,Other,225% of NY Medicaid HMO DRG,56601,,225% x Medicaid HMO amount,56601,Other,225% of NY Medicaid HMO DRG,56601,,225% x Medicaid HMO amount,56601,Other,225% of NY Medicaid HMO DRG,56601,,225% x Medicaid HMO amount,56601,Other,225% of NY Medicaid HMO DRG,35218,,140% x Medicaid HMO amount,35218,Other,140% of NY Medicaid HMO DRG,56601,,225% x Medicaid HMO amount,56601,Other,225% of NY Medicaid HMO DRG,69179,,275% x Medicaid HMO amount,69179,Other,275% of NY Medicaid HMO DRG,81505,,324% x Medicaid HMO amount,81505,Other,324% of NY Medicaid HMO DRG,54085,,215% x Medicaid HMO amount,54085,Other,215% of NY Medicaid HMO DRG,54085,,215% x Medicaid HMO amount,54085,Other,215% of NY Medicaid HMO DRG,31445,,125% x Medicaid HMO amount,31445,Other,125% of NY Medicaid HMO DRG,0.01,141237,
Major esophageal disorders,242-1,APR-DRG,,,,,,,,inpatient,,,49854,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24933,,"45,128 x DRG weight",24933,Other,base rate x DRG weight,22440,,"40,615 x DRG weight",22440,Other,base rate x DRG weight,21193,,"38,359 x DRG weight",21193,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9518,,186% x Medicaid HMO amount,9518,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18828,,"34,077 x DRG weight",18828,Other,base rate x DRG weight,16004,,"28,966 x DRG weight",16004,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5117,,DRG base rate x DRG weight + capital per discharge,5117,Other,100% of NY Medicaid HMO DRG,5117,,100% x Medicaid HMO amount,5117,Other,100% of NY Medicaid HMO DRG,5117,,100% x Medicaid HMO amount,5117,Other,100% of NY Medicaid HMO DRG,5117,,100% x Medicaid HMO amount,5117,Other,100% of NY Medicaid HMO DRG,11513,,225% x Medicaid HMO amount,11513,Other,225% of NY Medicaid HMO DRG,11513,,225% x Medicaid HMO amount,11513,Other,225% of NY Medicaid HMO DRG,11513,,225% x Medicaid HMO amount,11513,Other,225% of NY Medicaid HMO DRG,11513,,225% x Medicaid HMO amount,11513,Other,225% of NY Medicaid HMO DRG,7164,,140% x Medicaid HMO amount,7164,Other,140% of NY Medicaid HMO DRG,11513,,225% x Medicaid HMO amount,11513,Other,225% of NY Medicaid HMO DRG,14072,,275% x Medicaid HMO amount,14072,Other,275% of NY Medicaid HMO DRG,16579,,324% x Medicaid HMO amount,16579,Other,324% of NY Medicaid HMO DRG,11002,,215% x Medicaid HMO amount,11002,Other,215% of NY Medicaid HMO DRG,11002,,215% x Medicaid HMO amount,11002,Other,215% of NY Medicaid HMO DRG,6396,,125% x Medicaid HMO amount,6396,Other,125% of NY Medicaid HMO DRG,0.01,24933,
Major esophageal disorders,242-2,APR-DRG,,,,,,,,inpatient,,,57789.91,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35850,,"45,128 x DRG weight",35850,Other,base rate x DRG weight,32265,,"40,615 x DRG weight",32265,Other,base rate x DRG weight,30472,,"38,359 x DRG weight",30472,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13016,,186% x Medicaid HMO amount,13016,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27071,,"34,077 x DRG weight",27071,Other,base rate x DRG weight,23011,,"28,966 x DRG weight",23011,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6998,,DRG base rate x DRG weight + capital per discharge,6998,Other,100% of NY Medicaid HMO DRG,6998,,100% x Medicaid HMO amount,6998,Other,100% of NY Medicaid HMO DRG,6998,,100% x Medicaid HMO amount,6998,Other,100% of NY Medicaid HMO DRG,6998,,100% x Medicaid HMO amount,6998,Other,100% of NY Medicaid HMO DRG,15746,,225% x Medicaid HMO amount,15746,Other,225% of NY Medicaid HMO DRG,15746,,225% x Medicaid HMO amount,15746,Other,225% of NY Medicaid HMO DRG,15746,,225% x Medicaid HMO amount,15746,Other,225% of NY Medicaid HMO DRG,15746,,225% x Medicaid HMO amount,15746,Other,225% of NY Medicaid HMO DRG,9797,,140% x Medicaid HMO amount,9797,Other,140% of NY Medicaid HMO DRG,15746,,225% x Medicaid HMO amount,15746,Other,225% of NY Medicaid HMO DRG,19245,,275% x Medicaid HMO amount,19245,Other,275% of NY Medicaid HMO DRG,22674,,324% x Medicaid HMO amount,22674,Other,324% of NY Medicaid HMO DRG,15046,,215% x Medicaid HMO amount,15046,Other,215% of NY Medicaid HMO DRG,15046,,215% x Medicaid HMO amount,15046,Other,215% of NY Medicaid HMO DRG,8748,,125% x Medicaid HMO amount,8748,Other,125% of NY Medicaid HMO DRG,0.01,35850,
Major esophageal disorders,242-3,APR-DRG,,,,,,,,inpatient,,,95020.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56333,,"45,128 x DRG weight",56333,Other,base rate x DRG weight,50700,,"40,615 x DRG weight",50700,Other,base rate x DRG weight,47884,,"38,359 x DRG weight",47884,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19580,,186% x Medicaid HMO amount,19580,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42538,,"34,077 x DRG weight",42538,Other,base rate x DRG weight,36158,,"28,966 x DRG weight",36158,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10527,,DRG base rate x DRG weight + capital per discharge,10527,Other,100% of NY Medicaid HMO DRG,10527,,100% x Medicaid HMO amount,10527,Other,100% of NY Medicaid HMO DRG,10527,,100% x Medicaid HMO amount,10527,Other,100% of NY Medicaid HMO DRG,10527,,100% x Medicaid HMO amount,10527,Other,100% of NY Medicaid HMO DRG,23686,,225% x Medicaid HMO amount,23686,Other,225% of NY Medicaid HMO DRG,23686,,225% x Medicaid HMO amount,23686,Other,225% of NY Medicaid HMO DRG,23686,,225% x Medicaid HMO amount,23686,Other,225% of NY Medicaid HMO DRG,23686,,225% x Medicaid HMO amount,23686,Other,225% of NY Medicaid HMO DRG,14738,,140% x Medicaid HMO amount,14738,Other,140% of NY Medicaid HMO DRG,23686,,225% x Medicaid HMO amount,23686,Other,225% of NY Medicaid HMO DRG,28949,,275% x Medicaid HMO amount,28949,Other,275% of NY Medicaid HMO DRG,34107,,324% x Medicaid HMO amount,34107,Other,324% of NY Medicaid HMO DRG,22633,,215% x Medicaid HMO amount,22633,Other,215% of NY Medicaid HMO DRG,22633,,215% x Medicaid HMO amount,22633,Other,215% of NY Medicaid HMO DRG,13159,,125% x Medicaid HMO amount,13159,Other,125% of NY Medicaid HMO DRG,0.01,56333,
Major esophageal disorders,242-4,APR-DRG,,,,,,,,inpatient,,,152089.88,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,142388,,"45,128 x DRG weight",142388,Other,base rate x DRG weight,128148,,"40,615 x DRG weight",128148,Other,base rate x DRG weight,121030,,"38,359 x DRG weight",121030,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47160,,186% x Medicaid HMO amount,47160,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,107520,,"34,077 x DRG weight",107520,Other,base rate x DRG weight,91394,,"28,966 x DRG weight",91394,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25355,,DRG base rate x DRG weight + capital per discharge,25355,Other,100% of NY Medicaid HMO DRG,25355,,100% x Medicaid HMO amount,25355,Other,100% of NY Medicaid HMO DRG,25355,,100% x Medicaid HMO amount,25355,Other,100% of NY Medicaid HMO DRG,25355,,100% x Medicaid HMO amount,25355,Other,100% of NY Medicaid HMO DRG,57049,,225% x Medicaid HMO amount,57049,Other,225% of NY Medicaid HMO DRG,57049,,225% x Medicaid HMO amount,57049,Other,225% of NY Medicaid HMO DRG,57049,,225% x Medicaid HMO amount,57049,Other,225% of NY Medicaid HMO DRG,57049,,225% x Medicaid HMO amount,57049,Other,225% of NY Medicaid HMO DRG,35497,,140% x Medicaid HMO amount,35497,Other,140% of NY Medicaid HMO DRG,57049,,225% x Medicaid HMO amount,57049,Other,225% of NY Medicaid HMO DRG,69726,,275% x Medicaid HMO amount,69726,Other,275% of NY Medicaid HMO DRG,82150,,324% x Medicaid HMO amount,82150,Other,324% of NY Medicaid HMO DRG,54513,,215% x Medicaid HMO amount,54513,Other,215% of NY Medicaid HMO DRG,54513,,215% x Medicaid HMO amount,54513,Other,215% of NY Medicaid HMO DRG,31694,,125% x Medicaid HMO amount,31694,Other,125% of NY Medicaid HMO DRG,0.01,142388,
Other esophageal disorders,243-1,APR-DRG,,,,,,,,inpatient,,,70883.52,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19613,,"45,128 x DRG weight",19613,Other,base rate x DRG weight,17651,,"40,615 x DRG weight",17651,Other,base rate x DRG weight,16671,,"38,359 x DRG weight",16671,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7812,,186% x Medicaid HMO amount,7812,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14810,,"34,077 x DRG weight",14810,Other,base rate x DRG weight,12589,,"28,966 x DRG weight",12589,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4200,,DRG base rate x DRG weight + capital per discharge,4200,Other,100% of NY Medicaid HMO DRG,4200,,100% x Medicaid HMO amount,4200,Other,100% of NY Medicaid HMO DRG,4200,,100% x Medicaid HMO amount,4200,Other,100% of NY Medicaid HMO DRG,4200,,100% x Medicaid HMO amount,4200,Other,100% of NY Medicaid HMO DRG,9450,,225% x Medicaid HMO amount,9450,Other,225% of NY Medicaid HMO DRG,9450,,225% x Medicaid HMO amount,9450,Other,225% of NY Medicaid HMO DRG,9450,,225% x Medicaid HMO amount,9450,Other,225% of NY Medicaid HMO DRG,9450,,225% x Medicaid HMO amount,9450,Other,225% of NY Medicaid HMO DRG,5880,,140% x Medicaid HMO amount,5880,Other,140% of NY Medicaid HMO DRG,9450,,225% x Medicaid HMO amount,9450,Other,225% of NY Medicaid HMO DRG,11550,,275% x Medicaid HMO amount,11550,Other,275% of NY Medicaid HMO DRG,13608,,324% x Medicaid HMO amount,13608,Other,324% of NY Medicaid HMO DRG,9030,,215% x Medicaid HMO amount,9030,Other,215% of NY Medicaid HMO DRG,9030,,215% x Medicaid HMO amount,9030,Other,215% of NY Medicaid HMO DRG,5250,,125% x Medicaid HMO amount,5250,Other,125% of NY Medicaid HMO DRG,0.01,19613,
Other esophageal disorders,243-2,APR-DRG,,,,,,,,inpatient,,,138448.13,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28386,,"45,128 x DRG weight",28386,Other,base rate x DRG weight,25547,,"40,615 x DRG weight",25547,Other,base rate x DRG weight,24128,,"38,359 x DRG weight",24128,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10624,,186% x Medicaid HMO amount,10624,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21434,,"34,077 x DRG weight",21434,Other,base rate x DRG weight,18220,,"28,966 x DRG weight",18220,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5712,,DRG base rate x DRG weight + capital per discharge,5712,Other,100% of NY Medicaid HMO DRG,5712,,100% x Medicaid HMO amount,5712,Other,100% of NY Medicaid HMO DRG,5712,,100% x Medicaid HMO amount,5712,Other,100% of NY Medicaid HMO DRG,5712,,100% x Medicaid HMO amount,5712,Other,100% of NY Medicaid HMO DRG,12852,,225% x Medicaid HMO amount,12852,Other,225% of NY Medicaid HMO DRG,12852,,225% x Medicaid HMO amount,12852,Other,225% of NY Medicaid HMO DRG,12852,,225% x Medicaid HMO amount,12852,Other,225% of NY Medicaid HMO DRG,12852,,225% x Medicaid HMO amount,12852,Other,225% of NY Medicaid HMO DRG,7997,,140% x Medicaid HMO amount,7997,Other,140% of NY Medicaid HMO DRG,12852,,225% x Medicaid HMO amount,12852,Other,225% of NY Medicaid HMO DRG,15708,,275% x Medicaid HMO amount,15708,Other,275% of NY Medicaid HMO DRG,18507,,324% x Medicaid HMO amount,18507,Other,324% of NY Medicaid HMO DRG,12281,,215% x Medicaid HMO amount,12281,Other,215% of NY Medicaid HMO DRG,12281,,215% x Medicaid HMO amount,12281,Other,215% of NY Medicaid HMO DRG,7140,,125% x Medicaid HMO amount,7140,Other,125% of NY Medicaid HMO DRG,0.01,28386,
Other esophageal disorders,243-3,APR-DRG,,,,,,,,inpatient,,,157721.23,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47615,,"45,128 x DRG weight",47615,Other,base rate x DRG weight,42853,,"40,615 x DRG weight",42853,Other,base rate x DRG weight,40473,,"38,359 x DRG weight",40473,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16787,,186% x Medicaid HMO amount,16787,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35955,,"34,077 x DRG weight",35955,Other,base rate x DRG weight,30562,,"28,966 x DRG weight",30562,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9025,,DRG base rate x DRG weight + capital per discharge,9025,Other,100% of NY Medicaid HMO DRG,9025,,100% x Medicaid HMO amount,9025,Other,100% of NY Medicaid HMO DRG,9025,,100% x Medicaid HMO amount,9025,Other,100% of NY Medicaid HMO DRG,9025,,100% x Medicaid HMO amount,9025,Other,100% of NY Medicaid HMO DRG,20306,,225% x Medicaid HMO amount,20306,Other,225% of NY Medicaid HMO DRG,20306,,225% x Medicaid HMO amount,20306,Other,225% of NY Medicaid HMO DRG,20306,,225% x Medicaid HMO amount,20306,Other,225% of NY Medicaid HMO DRG,20306,,225% x Medicaid HMO amount,20306,Other,225% of NY Medicaid HMO DRG,12635,,140% x Medicaid HMO amount,12635,Other,140% of NY Medicaid HMO DRG,20306,,225% x Medicaid HMO amount,20306,Other,225% of NY Medicaid HMO DRG,24819,,275% x Medicaid HMO amount,24819,Other,275% of NY Medicaid HMO DRG,29241,,324% x Medicaid HMO amount,29241,Other,324% of NY Medicaid HMO DRG,19404,,215% x Medicaid HMO amount,19404,Other,215% of NY Medicaid HMO DRG,19404,,215% x Medicaid HMO amount,19404,Other,215% of NY Medicaid HMO DRG,11281,,125% x Medicaid HMO amount,11281,Other,125% of NY Medicaid HMO DRG,0.01,47615,
Other esophageal disorders,243-4,APR-DRG,,,,,,,,inpatient,,,580126.69,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,103736,,"45,128 x DRG weight",103736,Other,base rate x DRG weight,93362,,"40,615 x DRG weight",93362,Other,base rate x DRG weight,88176,,"38,359 x DRG weight",88176,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34773,,186% x Medicaid HMO amount,34773,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,78333,,"34,077 x DRG weight",78333,Other,base rate x DRG weight,66584,,"28,966 x DRG weight",66584,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18695,,DRG base rate x DRG weight + capital per discharge,18695,Other,100% of NY Medicaid HMO DRG,18695,,100% x Medicaid HMO amount,18695,Other,100% of NY Medicaid HMO DRG,18695,,100% x Medicaid HMO amount,18695,Other,100% of NY Medicaid HMO DRG,18695,,100% x Medicaid HMO amount,18695,Other,100% of NY Medicaid HMO DRG,42064,,225% x Medicaid HMO amount,42064,Other,225% of NY Medicaid HMO DRG,42064,,225% x Medicaid HMO amount,42064,Other,225% of NY Medicaid HMO DRG,42064,,225% x Medicaid HMO amount,42064,Other,225% of NY Medicaid HMO DRG,42064,,225% x Medicaid HMO amount,42064,Other,225% of NY Medicaid HMO DRG,26173,,140% x Medicaid HMO amount,26173,Other,140% of NY Medicaid HMO DRG,42064,,225% x Medicaid HMO amount,42064,Other,225% of NY Medicaid HMO DRG,51411,,275% x Medicaid HMO amount,51411,Other,275% of NY Medicaid HMO DRG,60572,,324% x Medicaid HMO amount,60572,Other,324% of NY Medicaid HMO DRG,40194,,215% x Medicaid HMO amount,40194,Other,215% of NY Medicaid HMO DRG,40194,,215% x Medicaid HMO amount,40194,Other,215% of NY Medicaid HMO DRG,23369,,125% x Medicaid HMO amount,23369,Other,125% of NY Medicaid HMO DRG,0.01,103736,
Diverticulitis & diverticulosis,244-1,APR-DRG,,,,,,,,inpatient,,,75251.49,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23476,,"45,128 x DRG weight",23476,Other,base rate x DRG weight,21128,,"40,615 x DRG weight",21128,Other,base rate x DRG weight,19954,,"38,359 x DRG weight",19954,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9051,,186% x Medicaid HMO amount,9051,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17727,,"34,077 x DRG weight",17727,Other,base rate x DRG weight,15068,,"28,966 x DRG weight",15068,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4866,,DRG base rate x DRG weight + capital per discharge,4866,Other,100% of NY Medicaid HMO DRG,4866,,100% x Medicaid HMO amount,4866,Other,100% of NY Medicaid HMO DRG,4866,,100% x Medicaid HMO amount,4866,Other,100% of NY Medicaid HMO DRG,4866,,100% x Medicaid HMO amount,4866,Other,100% of NY Medicaid HMO DRG,10949,,225% x Medicaid HMO amount,10949,Other,225% of NY Medicaid HMO DRG,10949,,225% x Medicaid HMO amount,10949,Other,225% of NY Medicaid HMO DRG,10949,,225% x Medicaid HMO amount,10949,Other,225% of NY Medicaid HMO DRG,10949,,225% x Medicaid HMO amount,10949,Other,225% of NY Medicaid HMO DRG,6812,,140% x Medicaid HMO amount,6812,Other,140% of NY Medicaid HMO DRG,10949,,225% x Medicaid HMO amount,10949,Other,225% of NY Medicaid HMO DRG,13382,,275% x Medicaid HMO amount,13382,Other,275% of NY Medicaid HMO DRG,15766,,324% x Medicaid HMO amount,15766,Other,324% of NY Medicaid HMO DRG,10462,,215% x Medicaid HMO amount,10462,Other,215% of NY Medicaid HMO DRG,10462,,215% x Medicaid HMO amount,10462,Other,215% of NY Medicaid HMO DRG,6083,,125% x Medicaid HMO amount,6083,Other,125% of NY Medicaid HMO DRG,0.01,23476,
Diverticulitis & diverticulosis,244-2,APR-DRG,,,,,,,,inpatient,,,66037.3,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31296,,"45,128 x DRG weight",31296,Other,base rate x DRG weight,28167,,"40,615 x DRG weight",28167,Other,base rate x DRG weight,26602,,"38,359 x DRG weight",26602,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11556,,186% x Medicaid HMO amount,11556,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23632,,"34,077 x DRG weight",23632,Other,base rate x DRG weight,20088,,"28,966 x DRG weight",20088,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6213,,DRG base rate x DRG weight + capital per discharge,6213,Other,100% of NY Medicaid HMO DRG,6213,,100% x Medicaid HMO amount,6213,Other,100% of NY Medicaid HMO DRG,6213,,100% x Medicaid HMO amount,6213,Other,100% of NY Medicaid HMO DRG,6213,,100% x Medicaid HMO amount,6213,Other,100% of NY Medicaid HMO DRG,13979,,225% x Medicaid HMO amount,13979,Other,225% of NY Medicaid HMO DRG,13979,,225% x Medicaid HMO amount,13979,Other,225% of NY Medicaid HMO DRG,13979,,225% x Medicaid HMO amount,13979,Other,225% of NY Medicaid HMO DRG,13979,,225% x Medicaid HMO amount,13979,Other,225% of NY Medicaid HMO DRG,8698,,140% x Medicaid HMO amount,8698,Other,140% of NY Medicaid HMO DRG,13979,,225% x Medicaid HMO amount,13979,Other,225% of NY Medicaid HMO DRG,17086,,275% x Medicaid HMO amount,17086,Other,275% of NY Medicaid HMO DRG,20130,,324% x Medicaid HMO amount,20130,Other,324% of NY Medicaid HMO DRG,13358,,215% x Medicaid HMO amount,13358,Other,215% of NY Medicaid HMO DRG,13358,,215% x Medicaid HMO amount,13358,Other,215% of NY Medicaid HMO DRG,7766,,125% x Medicaid HMO amount,7766,Other,125% of NY Medicaid HMO DRG,0.01,31296,
Diverticulitis & diverticulosis,244-3,APR-DRG,,,,,,,,inpatient,,,141395.87,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52425,,"45,128 x DRG weight",52425,Other,base rate x DRG weight,47182,,"40,615 x DRG weight",47182,Other,base rate x DRG weight,44562,,"38,359 x DRG weight",44562,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18328,,186% x Medicaid HMO amount,18328,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39587,,"34,077 x DRG weight",39587,Other,base rate x DRG weight,33650,,"28,966 x DRG weight",33650,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9854,,DRG base rate x DRG weight + capital per discharge,9854,Other,100% of NY Medicaid HMO DRG,9854,,100% x Medicaid HMO amount,9854,Other,100% of NY Medicaid HMO DRG,9854,,100% x Medicaid HMO amount,9854,Other,100% of NY Medicaid HMO DRG,9854,,100% x Medicaid HMO amount,9854,Other,100% of NY Medicaid HMO DRG,22172,,225% x Medicaid HMO amount,22172,Other,225% of NY Medicaid HMO DRG,22172,,225% x Medicaid HMO amount,22172,Other,225% of NY Medicaid HMO DRG,22172,,225% x Medicaid HMO amount,22172,Other,225% of NY Medicaid HMO DRG,22172,,225% x Medicaid HMO amount,22172,Other,225% of NY Medicaid HMO DRG,13796,,140% x Medicaid HMO amount,13796,Other,140% of NY Medicaid HMO DRG,22172,,225% x Medicaid HMO amount,22172,Other,225% of NY Medicaid HMO DRG,27099,,275% x Medicaid HMO amount,27099,Other,275% of NY Medicaid HMO DRG,31927,,324% x Medicaid HMO amount,31927,Other,324% of NY Medicaid HMO DRG,21186,,215% x Medicaid HMO amount,21186,Other,215% of NY Medicaid HMO DRG,21186,,215% x Medicaid HMO amount,21186,Other,215% of NY Medicaid HMO DRG,12318,,125% x Medicaid HMO amount,12318,Other,125% of NY Medicaid HMO DRG,0.01,52425,
Diverticulitis & diverticulosis,244-4,APR-DRG,,,,,,,,inpatient,,,141395.87,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,138674,,"45,128 x DRG weight",138674,Other,base rate x DRG weight,124806,,"40,615 x DRG weight",124806,Other,base rate x DRG weight,117873,,"38,359 x DRG weight",117873,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45970,,186% x Medicaid HMO amount,45970,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,104715,,"34,077 x DRG weight",104715,Other,base rate x DRG weight,89010,,"28,966 x DRG weight",89010,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24715,,DRG base rate x DRG weight + capital per discharge,24715,Other,100% of NY Medicaid HMO DRG,24715,,100% x Medicaid HMO amount,24715,Other,100% of NY Medicaid HMO DRG,24715,,100% x Medicaid HMO amount,24715,Other,100% of NY Medicaid HMO DRG,24715,,100% x Medicaid HMO amount,24715,Other,100% of NY Medicaid HMO DRG,55609,,225% x Medicaid HMO amount,55609,Other,225% of NY Medicaid HMO DRG,55609,,225% x Medicaid HMO amount,55609,Other,225% of NY Medicaid HMO DRG,55609,,225% x Medicaid HMO amount,55609,Other,225% of NY Medicaid HMO DRG,55609,,225% x Medicaid HMO amount,55609,Other,225% of NY Medicaid HMO DRG,34601,,140% x Medicaid HMO amount,34601,Other,140% of NY Medicaid HMO DRG,55609,,225% x Medicaid HMO amount,55609,Other,225% of NY Medicaid HMO DRG,67966,,275% x Medicaid HMO amount,67966,Other,275% of NY Medicaid HMO DRG,80077,,324% x Medicaid HMO amount,80077,Other,324% of NY Medicaid HMO DRG,53137,,215% x Medicaid HMO amount,53137,Other,215% of NY Medicaid HMO DRG,53137,,215% x Medicaid HMO amount,53137,Other,215% of NY Medicaid HMO DRG,30894,,125% x Medicaid HMO amount,30894,Other,125% of NY Medicaid HMO DRG,0.01,138674,
Inflammatory bowel disease,245-1,APR-DRG,,,,,,,,inpatient,,,108866.14,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28191,,"45,128 x DRG weight",28191,Other,base rate x DRG weight,25372,,"40,615 x DRG weight",25372,Other,base rate x DRG weight,23963,,"38,359 x DRG weight",23963,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10561,,186% x Medicaid HMO amount,10561,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21288,,"34,077 x DRG weight",21288,Other,base rate x DRG weight,18095,,"28,966 x DRG weight",18095,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5678,,DRG base rate x DRG weight + capital per discharge,5678,Other,100% of NY Medicaid HMO DRG,5678,,100% x Medicaid HMO amount,5678,Other,100% of NY Medicaid HMO DRG,5678,,100% x Medicaid HMO amount,5678,Other,100% of NY Medicaid HMO DRG,5678,,100% x Medicaid HMO amount,5678,Other,100% of NY Medicaid HMO DRG,12776,,225% x Medicaid HMO amount,12776,Other,225% of NY Medicaid HMO DRG,12776,,225% x Medicaid HMO amount,12776,Other,225% of NY Medicaid HMO DRG,12776,,225% x Medicaid HMO amount,12776,Other,225% of NY Medicaid HMO DRG,12776,,225% x Medicaid HMO amount,12776,Other,225% of NY Medicaid HMO DRG,7949,,140% x Medicaid HMO amount,7949,Other,140% of NY Medicaid HMO DRG,12776,,225% x Medicaid HMO amount,12776,Other,225% of NY Medicaid HMO DRG,15615,,275% x Medicaid HMO amount,15615,Other,275% of NY Medicaid HMO DRG,18397,,324% x Medicaid HMO amount,18397,Other,324% of NY Medicaid HMO DRG,12208,,215% x Medicaid HMO amount,12208,Other,215% of NY Medicaid HMO DRG,12208,,215% x Medicaid HMO amount,12208,Other,215% of NY Medicaid HMO DRG,7098,,125% x Medicaid HMO amount,7098,Other,125% of NY Medicaid HMO DRG,0.01,28191,
Inflammatory bowel disease,245-2,APR-DRG,,,,,,,,inpatient,,,153893.34,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34997,,"45,128 x DRG weight",34997,Other,base rate x DRG weight,31497,,"40,615 x DRG weight",31497,Other,base rate x DRG weight,29747,,"38,359 x DRG weight",29747,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12743,,186% x Medicaid HMO amount,12743,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26427,,"34,077 x DRG weight",26427,Other,base rate x DRG weight,22463,,"28,966 x DRG weight",22463,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6851,,DRG base rate x DRG weight + capital per discharge,6851,Other,100% of NY Medicaid HMO DRG,6851,,100% x Medicaid HMO amount,6851,Other,100% of NY Medicaid HMO DRG,6851,,100% x Medicaid HMO amount,6851,Other,100% of NY Medicaid HMO DRG,6851,,100% x Medicaid HMO amount,6851,Other,100% of NY Medicaid HMO DRG,15415,,225% x Medicaid HMO amount,15415,Other,225% of NY Medicaid HMO DRG,15415,,225% x Medicaid HMO amount,15415,Other,225% of NY Medicaid HMO DRG,15415,,225% x Medicaid HMO amount,15415,Other,225% of NY Medicaid HMO DRG,15415,,225% x Medicaid HMO amount,15415,Other,225% of NY Medicaid HMO DRG,9591,,140% x Medicaid HMO amount,9591,Other,140% of NY Medicaid HMO DRG,15415,,225% x Medicaid HMO amount,15415,Other,225% of NY Medicaid HMO DRG,18840,,275% x Medicaid HMO amount,18840,Other,275% of NY Medicaid HMO DRG,22197,,324% x Medicaid HMO amount,22197,Other,324% of NY Medicaid HMO DRG,14730,,215% x Medicaid HMO amount,14730,Other,215% of NY Medicaid HMO DRG,14730,,215% x Medicaid HMO amount,14730,Other,215% of NY Medicaid HMO DRG,8564,,125% x Medicaid HMO amount,8564,Other,125% of NY Medicaid HMO DRG,0.01,34997,
Inflammatory bowel disease,245-3,APR-DRG,,,,,,,,inpatient,,,172569.03,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54970,,"45,128 x DRG weight",54970,Other,base rate x DRG weight,49473,,"40,615 x DRG weight",49473,Other,base rate x DRG weight,46725,,"38,359 x DRG weight",46725,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19143,,186% x Medicaid HMO amount,19143,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41509,,"34,077 x DRG weight",41509,Other,base rate x DRG weight,35283,,"28,966 x DRG weight",35283,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10292,,DRG base rate x DRG weight + capital per discharge,10292,Other,100% of NY Medicaid HMO DRG,10292,,100% x Medicaid HMO amount,10292,Other,100% of NY Medicaid HMO DRG,10292,,100% x Medicaid HMO amount,10292,Other,100% of NY Medicaid HMO DRG,10292,,100% x Medicaid HMO amount,10292,Other,100% of NY Medicaid HMO DRG,23157,,225% x Medicaid HMO amount,23157,Other,225% of NY Medicaid HMO DRG,23157,,225% x Medicaid HMO amount,23157,Other,225% of NY Medicaid HMO DRG,23157,,225% x Medicaid HMO amount,23157,Other,225% of NY Medicaid HMO DRG,23157,,225% x Medicaid HMO amount,23157,Other,225% of NY Medicaid HMO DRG,14409,,140% x Medicaid HMO amount,14409,Other,140% of NY Medicaid HMO DRG,23157,,225% x Medicaid HMO amount,23157,Other,225% of NY Medicaid HMO DRG,28303,,275% x Medicaid HMO amount,28303,Other,275% of NY Medicaid HMO DRG,33346,,324% x Medicaid HMO amount,33346,Other,324% of NY Medicaid HMO DRG,22128,,215% x Medicaid HMO amount,22128,Other,215% of NY Medicaid HMO DRG,22128,,215% x Medicaid HMO amount,22128,Other,215% of NY Medicaid HMO DRG,12865,,125% x Medicaid HMO amount,12865,Other,125% of NY Medicaid HMO DRG,0.01,54970,
Inflammatory bowel disease,245-4,APR-DRG,,,,,,,,inpatient,,,198353.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,97269,,"45,128 x DRG weight",97269,Other,base rate x DRG weight,87542,,"40,615 x DRG weight",87542,Other,base rate x DRG weight,82679,,"38,359 x DRG weight",82679,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32699,,186% x Medicaid HMO amount,32699,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73450,,"34,077 x DRG weight",73450,Other,base rate x DRG weight,62433,,"28,966 x DRG weight",62433,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17580,,DRG base rate x DRG weight + capital per discharge,17580,Other,100% of NY Medicaid HMO DRG,17580,,100% x Medicaid HMO amount,17580,Other,100% of NY Medicaid HMO DRG,17580,,100% x Medicaid HMO amount,17580,Other,100% of NY Medicaid HMO DRG,17580,,100% x Medicaid HMO amount,17580,Other,100% of NY Medicaid HMO DRG,39555,,225% x Medicaid HMO amount,39555,Other,225% of NY Medicaid HMO DRG,39555,,225% x Medicaid HMO amount,39555,Other,225% of NY Medicaid HMO DRG,39555,,225% x Medicaid HMO amount,39555,Other,225% of NY Medicaid HMO DRG,39555,,225% x Medicaid HMO amount,39555,Other,225% of NY Medicaid HMO DRG,24612,,140% x Medicaid HMO amount,24612,Other,140% of NY Medicaid HMO DRG,39555,,225% x Medicaid HMO amount,39555,Other,225% of NY Medicaid HMO DRG,48345,,275% x Medicaid HMO amount,48345,Other,275% of NY Medicaid HMO DRG,56959,,324% x Medicaid HMO amount,56959,Other,324% of NY Medicaid HMO DRG,37797,,215% x Medicaid HMO amount,37797,Other,215% of NY Medicaid HMO DRG,37797,,215% x Medicaid HMO amount,37797,Other,215% of NY Medicaid HMO DRG,21975,,125% x Medicaid HMO amount,21975,Other,125% of NY Medicaid HMO DRG,0.01,97269,
Gastrointestinal vascular insufficiency,246-1,APR-DRG,,,,,,,,inpatient,,,124504.2,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28119,,"45,128 x DRG weight",28119,Other,base rate x DRG weight,25307,,"40,615 x DRG weight",25307,Other,base rate x DRG weight,23901,,"38,359 x DRG weight",23901,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10539,,186% x Medicaid HMO amount,10539,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21233,,"34,077 x DRG weight",21233,Other,base rate x DRG weight,18049,,"28,966 x DRG weight",18049,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5666,,DRG base rate x DRG weight + capital per discharge,5666,Other,100% of NY Medicaid HMO DRG,5666,,100% x Medicaid HMO amount,5666,Other,100% of NY Medicaid HMO DRG,5666,,100% x Medicaid HMO amount,5666,Other,100% of NY Medicaid HMO DRG,5666,,100% x Medicaid HMO amount,5666,Other,100% of NY Medicaid HMO DRG,12749,,225% x Medicaid HMO amount,12749,Other,225% of NY Medicaid HMO DRG,12749,,225% x Medicaid HMO amount,12749,Other,225% of NY Medicaid HMO DRG,12749,,225% x Medicaid HMO amount,12749,Other,225% of NY Medicaid HMO DRG,12749,,225% x Medicaid HMO amount,12749,Other,225% of NY Medicaid HMO DRG,7932,,140% x Medicaid HMO amount,7932,Other,140% of NY Medicaid HMO DRG,12749,,225% x Medicaid HMO amount,12749,Other,225% of NY Medicaid HMO DRG,15582,,275% x Medicaid HMO amount,15582,Other,275% of NY Medicaid HMO DRG,18358,,324% x Medicaid HMO amount,18358,Other,324% of NY Medicaid HMO DRG,12182,,215% x Medicaid HMO amount,12182,Other,215% of NY Medicaid HMO DRG,12182,,215% x Medicaid HMO amount,12182,Other,215% of NY Medicaid HMO DRG,7083,,125% x Medicaid HMO amount,7083,Other,125% of NY Medicaid HMO DRG,0.01,28119,
Gastrointestinal vascular insufficiency,246-2,APR-DRG,,,,,,,,inpatient,,,148396.93,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35407,,"45,128 x DRG weight",35407,Other,base rate x DRG weight,31867,,"40,615 x DRG weight",31867,Other,base rate x DRG weight,30096,,"38,359 x DRG weight",30096,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12875,,186% x Medicaid HMO amount,12875,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26737,,"34,077 x DRG weight",26737,Other,base rate x DRG weight,22727,,"28,966 x DRG weight",22727,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6922,,DRG base rate x DRG weight + capital per discharge,6922,Other,100% of NY Medicaid HMO DRG,6922,,100% x Medicaid HMO amount,6922,Other,100% of NY Medicaid HMO DRG,6922,,100% x Medicaid HMO amount,6922,Other,100% of NY Medicaid HMO DRG,6922,,100% x Medicaid HMO amount,6922,Other,100% of NY Medicaid HMO DRG,15575,,225% x Medicaid HMO amount,15575,Other,225% of NY Medicaid HMO DRG,15575,,225% x Medicaid HMO amount,15575,Other,225% of NY Medicaid HMO DRG,15575,,225% x Medicaid HMO amount,15575,Other,225% of NY Medicaid HMO DRG,15575,,225% x Medicaid HMO amount,15575,Other,225% of NY Medicaid HMO DRG,9691,,140% x Medicaid HMO amount,9691,Other,140% of NY Medicaid HMO DRG,15575,,225% x Medicaid HMO amount,15575,Other,225% of NY Medicaid HMO DRG,19036,,275% x Medicaid HMO amount,19036,Other,275% of NY Medicaid HMO DRG,22427,,324% x Medicaid HMO amount,22427,Other,324% of NY Medicaid HMO DRG,14882,,215% x Medicaid HMO amount,14882,Other,215% of NY Medicaid HMO DRG,14882,,215% x Medicaid HMO amount,14882,Other,215% of NY Medicaid HMO DRG,8653,,125% x Medicaid HMO amount,8653,Other,125% of NY Medicaid HMO DRG,0.01,35407,
Gastrointestinal vascular insufficiency,246-3,APR-DRG,,,,,,,,inpatient,,,226363.48,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,58337,,"45,128 x DRG weight",58337,Other,base rate x DRG weight,52503,,"40,615 x DRG weight",52503,Other,base rate x DRG weight,49587,,"38,359 x DRG weight",49587,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20222,,186% x Medicaid HMO amount,20222,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44051,,"34,077 x DRG weight",44051,Other,base rate x DRG weight,37444,,"28,966 x DRG weight",37444,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10872,,DRG base rate x DRG weight + capital per discharge,10872,Other,100% of NY Medicaid HMO DRG,10872,,100% x Medicaid HMO amount,10872,Other,100% of NY Medicaid HMO DRG,10872,,100% x Medicaid HMO amount,10872,Other,100% of NY Medicaid HMO DRG,10872,,100% x Medicaid HMO amount,10872,Other,100% of NY Medicaid HMO DRG,24462,,225% x Medicaid HMO amount,24462,Other,225% of NY Medicaid HMO DRG,24462,,225% x Medicaid HMO amount,24462,Other,225% of NY Medicaid HMO DRG,24462,,225% x Medicaid HMO amount,24462,Other,225% of NY Medicaid HMO DRG,24462,,225% x Medicaid HMO amount,24462,Other,225% of NY Medicaid HMO DRG,15221,,140% x Medicaid HMO amount,15221,Other,140% of NY Medicaid HMO DRG,24462,,225% x Medicaid HMO amount,24462,Other,225% of NY Medicaid HMO DRG,29898,,275% x Medicaid HMO amount,29898,Other,275% of NY Medicaid HMO DRG,35225,,324% x Medicaid HMO amount,35225,Other,324% of NY Medicaid HMO DRG,23375,,215% x Medicaid HMO amount,23375,Other,215% of NY Medicaid HMO DRG,23375,,215% x Medicaid HMO amount,23375,Other,215% of NY Medicaid HMO DRG,13590,,125% x Medicaid HMO amount,13590,Other,125% of NY Medicaid HMO DRG,0.01,58337,
Gastrointestinal vascular insufficiency,246-4,APR-DRG,,,,,,,,inpatient,,,189923.74,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,128682,,"45,128 x DRG weight",128682,Other,base rate x DRG weight,115814,,"40,615 x DRG weight",115814,Other,base rate x DRG weight,109381,,"38,359 x DRG weight",109381,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42767,,186% x Medicaid HMO amount,42767,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,97171,,"34,077 x DRG weight",97171,Other,base rate x DRG weight,82597,,"28,966 x DRG weight",82597,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22993,,DRG base rate x DRG weight + capital per discharge,22993,Other,100% of NY Medicaid HMO DRG,22993,,100% x Medicaid HMO amount,22993,Other,100% of NY Medicaid HMO DRG,22993,,100% x Medicaid HMO amount,22993,Other,100% of NY Medicaid HMO DRG,22993,,100% x Medicaid HMO amount,22993,Other,100% of NY Medicaid HMO DRG,51734,,225% x Medicaid HMO amount,51734,Other,225% of NY Medicaid HMO DRG,51734,,225% x Medicaid HMO amount,51734,Other,225% of NY Medicaid HMO DRG,51734,,225% x Medicaid HMO amount,51734,Other,225% of NY Medicaid HMO DRG,51734,,225% x Medicaid HMO amount,51734,Other,225% of NY Medicaid HMO DRG,32190,,140% x Medicaid HMO amount,32190,Other,140% of NY Medicaid HMO DRG,51734,,225% x Medicaid HMO amount,51734,Other,225% of NY Medicaid HMO DRG,63231,,275% x Medicaid HMO amount,63231,Other,275% of NY Medicaid HMO DRG,74497,,324% x Medicaid HMO amount,74497,Other,324% of NY Medicaid HMO DRG,49435,,215% x Medicaid HMO amount,49435,Other,215% of NY Medicaid HMO DRG,49435,,215% x Medicaid HMO amount,49435,Other,215% of NY Medicaid HMO DRG,28741,,125% x Medicaid HMO amount,28741,Other,125% of NY Medicaid HMO DRG,0.01,128682,
Intestinal obstruction,247-1,APR-DRG,,,,,,,,inpatient,,,137358.07,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22135,,"45,128 x DRG weight",22135,Other,base rate x DRG weight,19922,,"40,615 x DRG weight",19922,Other,base rate x DRG weight,18815,,"38,359 x DRG weight",18815,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8621,,186% x Medicaid HMO amount,8621,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16715,,"34,077 x DRG weight",16715,Other,base rate x DRG weight,14208,,"28,966 x DRG weight",14208,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4635,,DRG base rate x DRG weight + capital per discharge,4635,Other,100% of NY Medicaid HMO DRG,4635,,100% x Medicaid HMO amount,4635,Other,100% of NY Medicaid HMO DRG,4635,,100% x Medicaid HMO amount,4635,Other,100% of NY Medicaid HMO DRG,4635,,100% x Medicaid HMO amount,4635,Other,100% of NY Medicaid HMO DRG,10429,,225% x Medicaid HMO amount,10429,Other,225% of NY Medicaid HMO DRG,10429,,225% x Medicaid HMO amount,10429,Other,225% of NY Medicaid HMO DRG,10429,,225% x Medicaid HMO amount,10429,Other,225% of NY Medicaid HMO DRG,10429,,225% x Medicaid HMO amount,10429,Other,225% of NY Medicaid HMO DRG,6489,,140% x Medicaid HMO amount,6489,Other,140% of NY Medicaid HMO DRG,10429,,225% x Medicaid HMO amount,10429,Other,225% of NY Medicaid HMO DRG,12746,,275% x Medicaid HMO amount,12746,Other,275% of NY Medicaid HMO DRG,15017,,324% x Medicaid HMO amount,15017,Other,324% of NY Medicaid HMO DRG,9965,,215% x Medicaid HMO amount,9965,Other,215% of NY Medicaid HMO DRG,9965,,215% x Medicaid HMO amount,9965,Other,215% of NY Medicaid HMO DRG,5794,,125% x Medicaid HMO amount,5794,Other,125% of NY Medicaid HMO DRG,0.01,22135,
Intestinal obstruction,247-2,APR-DRG,,,,,,,,inpatient,,,86834.82,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30371,,"45,128 x DRG weight",30371,Other,base rate x DRG weight,27334,,"40,615 x DRG weight",27334,Other,base rate x DRG weight,25816,,"38,359 x DRG weight",25816,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11260,,186% x Medicaid HMO amount,11260,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22934,,"34,077 x DRG weight",22934,Other,base rate x DRG weight,19494,,"28,966 x DRG weight",19494,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6054,,DRG base rate x DRG weight + capital per discharge,6054,Other,100% of NY Medicaid HMO DRG,6054,,100% x Medicaid HMO amount,6054,Other,100% of NY Medicaid HMO DRG,6054,,100% x Medicaid HMO amount,6054,Other,100% of NY Medicaid HMO DRG,6054,,100% x Medicaid HMO amount,6054,Other,100% of NY Medicaid HMO DRG,13622,,225% x Medicaid HMO amount,13622,Other,225% of NY Medicaid HMO DRG,13622,,225% x Medicaid HMO amount,13622,Other,225% of NY Medicaid HMO DRG,13622,,225% x Medicaid HMO amount,13622,Other,225% of NY Medicaid HMO DRG,13622,,225% x Medicaid HMO amount,13622,Other,225% of NY Medicaid HMO DRG,8476,,140% x Medicaid HMO amount,8476,Other,140% of NY Medicaid HMO DRG,13622,,225% x Medicaid HMO amount,13622,Other,225% of NY Medicaid HMO DRG,16649,,275% x Medicaid HMO amount,16649,Other,275% of NY Medicaid HMO DRG,19615,,324% x Medicaid HMO amount,19615,Other,324% of NY Medicaid HMO DRG,13016,,215% x Medicaid HMO amount,13016,Other,215% of NY Medicaid HMO DRG,13016,,215% x Medicaid HMO amount,13016,Other,215% of NY Medicaid HMO DRG,7568,,125% x Medicaid HMO amount,7568,Other,125% of NY Medicaid HMO DRG,0.01,30371,
Intestinal obstruction,247-3,APR-DRG,,,,,,,,inpatient,,,205820.56,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54348,,"45,128 x DRG weight",54348,Other,base rate x DRG weight,48913,,"40,615 x DRG weight",48913,Other,base rate x DRG weight,46196,,"38,359 x DRG weight",46196,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18944,,186% x Medicaid HMO amount,18944,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41039,,"34,077 x DRG weight",41039,Other,base rate x DRG weight,34884,,"28,966 x DRG weight",34884,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10185,,DRG base rate x DRG weight + capital per discharge,10185,Other,100% of NY Medicaid HMO DRG,10185,,100% x Medicaid HMO amount,10185,Other,100% of NY Medicaid HMO DRG,10185,,100% x Medicaid HMO amount,10185,Other,100% of NY Medicaid HMO DRG,10185,,100% x Medicaid HMO amount,10185,Other,100% of NY Medicaid HMO DRG,22916,,225% x Medicaid HMO amount,22916,Other,225% of NY Medicaid HMO DRG,22916,,225% x Medicaid HMO amount,22916,Other,225% of NY Medicaid HMO DRG,22916,,225% x Medicaid HMO amount,22916,Other,225% of NY Medicaid HMO DRG,22916,,225% x Medicaid HMO amount,22916,Other,225% of NY Medicaid HMO DRG,14259,,140% x Medicaid HMO amount,14259,Other,140% of NY Medicaid HMO DRG,22916,,225% x Medicaid HMO amount,22916,Other,225% of NY Medicaid HMO DRG,28009,,275% x Medicaid HMO amount,28009,Other,275% of NY Medicaid HMO DRG,32999,,324% x Medicaid HMO amount,32999,Other,324% of NY Medicaid HMO DRG,21898,,215% x Medicaid HMO amount,21898,Other,215% of NY Medicaid HMO DRG,21898,,215% x Medicaid HMO amount,21898,Other,215% of NY Medicaid HMO DRG,12731,,125% x Medicaid HMO amount,12731,Other,125% of NY Medicaid HMO DRG,0.01,54348,
Intestinal obstruction,247-4,APR-DRG,,,,,,,,inpatient,,,138423.16,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,115334,,"45,128 x DRG weight",115334,Other,base rate x DRG weight,103800,,"40,615 x DRG weight",103800,Other,base rate x DRG weight,98034,,"38,359 x DRG weight",98034,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38489,,186% x Medicaid HMO amount,38489,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,87091,,"34,077 x DRG weight",87091,Other,base rate x DRG weight,74028,,"28,966 x DRG weight",74028,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20693,,DRG base rate x DRG weight + capital per discharge,20693,Other,100% of NY Medicaid HMO DRG,20693,,100% x Medicaid HMO amount,20693,Other,100% of NY Medicaid HMO DRG,20693,,100% x Medicaid HMO amount,20693,Other,100% of NY Medicaid HMO DRG,20693,,100% x Medicaid HMO amount,20693,Other,100% of NY Medicaid HMO DRG,46559,,225% x Medicaid HMO amount,46559,Other,225% of NY Medicaid HMO DRG,46559,,225% x Medicaid HMO amount,46559,Other,225% of NY Medicaid HMO DRG,46559,,225% x Medicaid HMO amount,46559,Other,225% of NY Medicaid HMO DRG,46559,,225% x Medicaid HMO amount,46559,Other,225% of NY Medicaid HMO DRG,28970,,140% x Medicaid HMO amount,28970,Other,140% of NY Medicaid HMO DRG,46559,,225% x Medicaid HMO amount,46559,Other,225% of NY Medicaid HMO DRG,56906,,275% x Medicaid HMO amount,56906,Other,275% of NY Medicaid HMO DRG,67045,,324% x Medicaid HMO amount,67045,Other,324% of NY Medicaid HMO DRG,44490,,215% x Medicaid HMO amount,44490,Other,215% of NY Medicaid HMO DRG,44490,,215% x Medicaid HMO amount,44490,Other,215% of NY Medicaid HMO DRG,25866,,125% x Medicaid HMO amount,25866,Other,125% of NY Medicaid HMO DRG,0.01,115334,
Major gastrointestinal & peritoneal infections,248-1,APR-DRG,,,,,,,,inpatient,,,69893.42,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26856,,"45,128 x DRG weight",26856,Other,base rate x DRG weight,24170,,"40,615 x DRG weight",24170,Other,base rate x DRG weight,22827,,"38,359 x DRG weight",22827,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10133,,186% x Medicaid HMO amount,10133,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20279,,"34,077 x DRG weight",20279,Other,base rate x DRG weight,17238,,"28,966 x DRG weight",17238,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5448,,DRG base rate x DRG weight + capital per discharge,5448,Other,100% of NY Medicaid HMO DRG,5448,,100% x Medicaid HMO amount,5448,Other,100% of NY Medicaid HMO DRG,5448,,100% x Medicaid HMO amount,5448,Other,100% of NY Medicaid HMO DRG,5448,,100% x Medicaid HMO amount,5448,Other,100% of NY Medicaid HMO DRG,12258,,225% x Medicaid HMO amount,12258,Other,225% of NY Medicaid HMO DRG,12258,,225% x Medicaid HMO amount,12258,Other,225% of NY Medicaid HMO DRG,12258,,225% x Medicaid HMO amount,12258,Other,225% of NY Medicaid HMO DRG,12258,,225% x Medicaid HMO amount,12258,Other,225% of NY Medicaid HMO DRG,7627,,140% x Medicaid HMO amount,7627,Other,140% of NY Medicaid HMO DRG,12258,,225% x Medicaid HMO amount,12258,Other,225% of NY Medicaid HMO DRG,14982,,275% x Medicaid HMO amount,14982,Other,275% of NY Medicaid HMO DRG,17652,,324% x Medicaid HMO amount,17652,Other,324% of NY Medicaid HMO DRG,11713,,215% x Medicaid HMO amount,11713,Other,215% of NY Medicaid HMO DRG,11713,,215% x Medicaid HMO amount,11713,Other,215% of NY Medicaid HMO DRG,6810,,125% x Medicaid HMO amount,6810,Other,125% of NY Medicaid HMO DRG,0.01,26856,
Major gastrointestinal & peritoneal infections,248-2,APR-DRG,,,,,,,,inpatient,,,125491.92,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38196,,"45,128 x DRG weight",38196,Other,base rate x DRG weight,34377,,"40,615 x DRG weight",34377,Other,base rate x DRG weight,32467,,"38,359 x DRG weight",32467,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13768,,186% x Medicaid HMO amount,13768,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28843,,"34,077 x DRG weight",28843,Other,base rate x DRG weight,24517,,"28,966 x DRG weight",24517,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7402,,DRG base rate x DRG weight + capital per discharge,7402,Other,100% of NY Medicaid HMO DRG,7402,,100% x Medicaid HMO amount,7402,Other,100% of NY Medicaid HMO DRG,7402,,100% x Medicaid HMO amount,7402,Other,100% of NY Medicaid HMO DRG,7402,,100% x Medicaid HMO amount,7402,Other,100% of NY Medicaid HMO DRG,16655,,225% x Medicaid HMO amount,16655,Other,225% of NY Medicaid HMO DRG,16655,,225% x Medicaid HMO amount,16655,Other,225% of NY Medicaid HMO DRG,16655,,225% x Medicaid HMO amount,16655,Other,225% of NY Medicaid HMO DRG,16655,,225% x Medicaid HMO amount,16655,Other,225% of NY Medicaid HMO DRG,10363,,140% x Medicaid HMO amount,10363,Other,140% of NY Medicaid HMO DRG,16655,,225% x Medicaid HMO amount,16655,Other,225% of NY Medicaid HMO DRG,20356,,275% x Medicaid HMO amount,20356,Other,275% of NY Medicaid HMO DRG,23982,,324% x Medicaid HMO amount,23982,Other,324% of NY Medicaid HMO DRG,15914,,215% x Medicaid HMO amount,15914,Other,215% of NY Medicaid HMO DRG,15914,,215% x Medicaid HMO amount,15914,Other,215% of NY Medicaid HMO DRG,9253,,125% x Medicaid HMO amount,9253,Other,125% of NY Medicaid HMO DRG,0.01,38196,
Major gastrointestinal & peritoneal infections,248-3,APR-DRG,,,,,,,,inpatient,,,160443.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59519,,"45,128 x DRG weight",59519,Other,base rate x DRG weight,53567,,"40,615 x DRG weight",53567,Other,base rate x DRG weight,50592,,"38,359 x DRG weight",50592,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20601,,186% x Medicaid HMO amount,20601,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44944,,"34,077 x DRG weight",44944,Other,base rate x DRG weight,38203,,"28,966 x DRG weight",38203,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11076,,DRG base rate x DRG weight + capital per discharge,11076,Other,100% of NY Medicaid HMO DRG,11076,,100% x Medicaid HMO amount,11076,Other,100% of NY Medicaid HMO DRG,11076,,100% x Medicaid HMO amount,11076,Other,100% of NY Medicaid HMO DRG,11076,,100% x Medicaid HMO amount,11076,Other,100% of NY Medicaid HMO DRG,24921,,225% x Medicaid HMO amount,24921,Other,225% of NY Medicaid HMO DRG,24921,,225% x Medicaid HMO amount,24921,Other,225% of NY Medicaid HMO DRG,24921,,225% x Medicaid HMO amount,24921,Other,225% of NY Medicaid HMO DRG,24921,,225% x Medicaid HMO amount,24921,Other,225% of NY Medicaid HMO DRG,15506,,140% x Medicaid HMO amount,15506,Other,140% of NY Medicaid HMO DRG,24921,,225% x Medicaid HMO amount,24921,Other,225% of NY Medicaid HMO DRG,30459,,275% x Medicaid HMO amount,30459,Other,275% of NY Medicaid HMO DRG,35886,,324% x Medicaid HMO amount,35886,Other,324% of NY Medicaid HMO DRG,23813,,215% x Medicaid HMO amount,23813,Other,215% of NY Medicaid HMO DRG,23813,,215% x Medicaid HMO amount,23813,Other,215% of NY Medicaid HMO DRG,13845,,125% x Medicaid HMO amount,13845,Other,125% of NY Medicaid HMO DRG,0.01,59519,
Major gastrointestinal & peritoneal infections,248-4,APR-DRG,,,,,,,,inpatient,,,526142.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,146057,,"45,128 x DRG weight",146057,Other,base rate x DRG weight,131450,,"40,615 x DRG weight",131450,Other,base rate x DRG weight,124149,,"38,359 x DRG weight",124149,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48336,,186% x Medicaid HMO amount,48336,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,110290,,"34,077 x DRG weight",110290,Other,base rate x DRG weight,93748,,"28,966 x DRG weight",93748,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25987,,DRG base rate x DRG weight + capital per discharge,25987,Other,100% of NY Medicaid HMO DRG,25987,,100% x Medicaid HMO amount,25987,Other,100% of NY Medicaid HMO DRG,25987,,100% x Medicaid HMO amount,25987,Other,100% of NY Medicaid HMO DRG,25987,,100% x Medicaid HMO amount,25987,Other,100% of NY Medicaid HMO DRG,58471,,225% x Medicaid HMO amount,58471,Other,225% of NY Medicaid HMO DRG,58471,,225% x Medicaid HMO amount,58471,Other,225% of NY Medicaid HMO DRG,58471,,225% x Medicaid HMO amount,58471,Other,225% of NY Medicaid HMO DRG,58471,,225% x Medicaid HMO amount,58471,Other,225% of NY Medicaid HMO DRG,36382,,140% x Medicaid HMO amount,36382,Other,140% of NY Medicaid HMO DRG,58471,,225% x Medicaid HMO amount,58471,Other,225% of NY Medicaid HMO DRG,71464,,275% x Medicaid HMO amount,71464,Other,275% of NY Medicaid HMO DRG,84198,,324% x Medicaid HMO amount,84198,Other,324% of NY Medicaid HMO DRG,55872,,215% x Medicaid HMO amount,55872,Other,215% of NY Medicaid HMO DRG,55872,,215% x Medicaid HMO amount,55872,Other,215% of NY Medicaid HMO DRG,32484,,125% x Medicaid HMO amount,32484,Other,125% of NY Medicaid HMO DRG,0.01,146057,
"Other gastroenteritis, nausa & vomiting",249-1,APR-DRG,,,,,,,,inpatient,,,69371.71,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19184,,"45,128 x DRG weight",19184,Other,base rate x DRG weight,17265,,"40,615 x DRG weight",17265,Other,base rate x DRG weight,16306,,"38,359 x DRG weight",16306,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7674,,186% x Medicaid HMO amount,7674,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14486,,"34,077 x DRG weight",14486,Other,base rate x DRG weight,12313,,"28,966 x DRG weight",12313,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4126,,DRG base rate x DRG weight + capital per discharge,4126,Other,100% of NY Medicaid HMO DRG,4126,,100% x Medicaid HMO amount,4126,Other,100% of NY Medicaid HMO DRG,4126,,100% x Medicaid HMO amount,4126,Other,100% of NY Medicaid HMO DRG,4126,,100% x Medicaid HMO amount,4126,Other,100% of NY Medicaid HMO DRG,9284,,225% x Medicaid HMO amount,9284,Other,225% of NY Medicaid HMO DRG,9284,,225% x Medicaid HMO amount,9284,Other,225% of NY Medicaid HMO DRG,9284,,225% x Medicaid HMO amount,9284,Other,225% of NY Medicaid HMO DRG,9284,,225% x Medicaid HMO amount,9284,Other,225% of NY Medicaid HMO DRG,5776,,140% x Medicaid HMO amount,5776,Other,140% of NY Medicaid HMO DRG,9284,,225% x Medicaid HMO amount,9284,Other,225% of NY Medicaid HMO DRG,11347,,275% x Medicaid HMO amount,11347,Other,275% of NY Medicaid HMO DRG,13368,,324% x Medicaid HMO amount,13368,Other,324% of NY Medicaid HMO DRG,8871,,215% x Medicaid HMO amount,8871,Other,215% of NY Medicaid HMO DRG,8871,,215% x Medicaid HMO amount,8871,Other,215% of NY Medicaid HMO DRG,5158,,125% x Medicaid HMO amount,5158,Other,125% of NY Medicaid HMO DRG,0.01,19184,
"Other gastroenteritis, nausa & vomiting",249-2,APR-DRG,,,,,,,,inpatient,,,87768.62,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24112,,"45,128 x DRG weight",24112,Other,base rate x DRG weight,21701,,"40,615 x DRG weight",21701,Other,base rate x DRG weight,20495,,"38,359 x DRG weight",20495,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9254,,186% x Medicaid HMO amount,9254,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18207,,"34,077 x DRG weight",18207,Other,base rate x DRG weight,15477,,"28,966 x DRG weight",15477,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4975,,DRG base rate x DRG weight + capital per discharge,4975,Other,100% of NY Medicaid HMO DRG,4975,,100% x Medicaid HMO amount,4975,Other,100% of NY Medicaid HMO DRG,4975,,100% x Medicaid HMO amount,4975,Other,100% of NY Medicaid HMO DRG,4975,,100% x Medicaid HMO amount,4975,Other,100% of NY Medicaid HMO DRG,11194,,225% x Medicaid HMO amount,11194,Other,225% of NY Medicaid HMO DRG,11194,,225% x Medicaid HMO amount,11194,Other,225% of NY Medicaid HMO DRG,11194,,225% x Medicaid HMO amount,11194,Other,225% of NY Medicaid HMO DRG,11194,,225% x Medicaid HMO amount,11194,Other,225% of NY Medicaid HMO DRG,6965,,140% x Medicaid HMO amount,6965,Other,140% of NY Medicaid HMO DRG,11194,,225% x Medicaid HMO amount,11194,Other,225% of NY Medicaid HMO DRG,13681,,275% x Medicaid HMO amount,13681,Other,275% of NY Medicaid HMO DRG,16119,,324% x Medicaid HMO amount,16119,Other,324% of NY Medicaid HMO DRG,10696,,215% x Medicaid HMO amount,10696,Other,215% of NY Medicaid HMO DRG,10696,,215% x Medicaid HMO amount,10696,Other,215% of NY Medicaid HMO DRG,6219,,125% x Medicaid HMO amount,6219,Other,125% of NY Medicaid HMO DRG,0.01,24112,
"Other gastroenteritis, nausa & vomiting",249-3,APR-DRG,,,,,,,,inpatient,,,99367.64,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37700,,"45,128 x DRG weight",37700,Other,base rate x DRG weight,33930,,"40,615 x DRG weight",33930,Other,base rate x DRG weight,32045,,"38,359 x DRG weight",32045,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13610,,186% x Medicaid HMO amount,13610,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28468,,"34,077 x DRG weight",28468,Other,base rate x DRG weight,24198,,"28,966 x DRG weight",24198,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7317,,DRG base rate x DRG weight + capital per discharge,7317,Other,100% of NY Medicaid HMO DRG,7317,,100% x Medicaid HMO amount,7317,Other,100% of NY Medicaid HMO DRG,7317,,100% x Medicaid HMO amount,7317,Other,100% of NY Medicaid HMO DRG,7317,,100% x Medicaid HMO amount,7317,Other,100% of NY Medicaid HMO DRG,16463,,225% x Medicaid HMO amount,16463,Other,225% of NY Medicaid HMO DRG,16463,,225% x Medicaid HMO amount,16463,Other,225% of NY Medicaid HMO DRG,16463,,225% x Medicaid HMO amount,16463,Other,225% of NY Medicaid HMO DRG,16463,,225% x Medicaid HMO amount,16463,Other,225% of NY Medicaid HMO DRG,10244,,140% x Medicaid HMO amount,10244,Other,140% of NY Medicaid HMO DRG,16463,,225% x Medicaid HMO amount,16463,Other,225% of NY Medicaid HMO DRG,20122,,275% x Medicaid HMO amount,20122,Other,275% of NY Medicaid HMO DRG,23707,,324% x Medicaid HMO amount,23707,Other,324% of NY Medicaid HMO DRG,15732,,215% x Medicaid HMO amount,15732,Other,215% of NY Medicaid HMO DRG,15732,,215% x Medicaid HMO amount,15732,Other,215% of NY Medicaid HMO DRG,9146,,125% x Medicaid HMO amount,9146,Other,125% of NY Medicaid HMO DRG,0.01,37700,
"Other gastroenteritis, nausa & vomiting",249-4,APR-DRG,,,,,,,,inpatient,,,338050.61,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,91280,,"45,128 x DRG weight",91280,Other,base rate x DRG weight,82152,,"40,615 x DRG weight",82152,Other,base rate x DRG weight,77589,,"38,359 x DRG weight",77589,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30781,,186% x Medicaid HMO amount,30781,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,68928,,"34,077 x DRG weight",68928,Other,base rate x DRG weight,58590,,"28,966 x DRG weight",58590,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16549,,DRG base rate x DRG weight + capital per discharge,16549,Other,100% of NY Medicaid HMO DRG,16549,,100% x Medicaid HMO amount,16549,Other,100% of NY Medicaid HMO DRG,16549,,100% x Medicaid HMO amount,16549,Other,100% of NY Medicaid HMO DRG,16549,,100% x Medicaid HMO amount,16549,Other,100% of NY Medicaid HMO DRG,37235,,225% x Medicaid HMO amount,37235,Other,225% of NY Medicaid HMO DRG,37235,,225% x Medicaid HMO amount,37235,Other,225% of NY Medicaid HMO DRG,37235,,225% x Medicaid HMO amount,37235,Other,225% of NY Medicaid HMO DRG,37235,,225% x Medicaid HMO amount,37235,Other,225% of NY Medicaid HMO DRG,23169,,140% x Medicaid HMO amount,23169,Other,140% of NY Medicaid HMO DRG,37235,,225% x Medicaid HMO amount,37235,Other,225% of NY Medicaid HMO DRG,45510,,275% x Medicaid HMO amount,45510,Other,275% of NY Medicaid HMO DRG,53619,,324% x Medicaid HMO amount,53619,Other,324% of NY Medicaid HMO DRG,35580,,215% x Medicaid HMO amount,35580,Other,215% of NY Medicaid HMO DRG,35580,,215% x Medicaid HMO amount,35580,Other,215% of NY Medicaid HMO DRG,20686,,125% x Medicaid HMO amount,20686,Other,125% of NY Medicaid HMO DRG,0.01,91280,
Abdominal pain,251-1,APR-DRG,,,,,,,,inpatient,,,109406.27,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19328,,"45,128 x DRG weight",19328,Other,base rate x DRG weight,17395,,"40,615 x DRG weight",17395,Other,base rate x DRG weight,16429,,"38,359 x DRG weight",16429,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7721,,186% x Medicaid HMO amount,7721,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14595,,"34,077 x DRG weight",14595,Other,base rate x DRG weight,12406,,"28,966 x DRG weight",12406,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4151,,DRG base rate x DRG weight + capital per discharge,4151,Other,100% of NY Medicaid HMO DRG,4151,,100% x Medicaid HMO amount,4151,Other,100% of NY Medicaid HMO DRG,4151,,100% x Medicaid HMO amount,4151,Other,100% of NY Medicaid HMO DRG,4151,,100% x Medicaid HMO amount,4151,Other,100% of NY Medicaid HMO DRG,9340,,225% x Medicaid HMO amount,9340,Other,225% of NY Medicaid HMO DRG,9340,,225% x Medicaid HMO amount,9340,Other,225% of NY Medicaid HMO DRG,9340,,225% x Medicaid HMO amount,9340,Other,225% of NY Medicaid HMO DRG,9340,,225% x Medicaid HMO amount,9340,Other,225% of NY Medicaid HMO DRG,5811,,140% x Medicaid HMO amount,5811,Other,140% of NY Medicaid HMO DRG,9340,,225% x Medicaid HMO amount,9340,Other,225% of NY Medicaid HMO DRG,11415,,275% x Medicaid HMO amount,11415,Other,275% of NY Medicaid HMO DRG,13449,,324% x Medicaid HMO amount,13449,Other,324% of NY Medicaid HMO DRG,8925,,215% x Medicaid HMO amount,8925,Other,215% of NY Medicaid HMO DRG,8925,,215% x Medicaid HMO amount,8925,Other,215% of NY Medicaid HMO DRG,5189,,125% x Medicaid HMO amount,5189,Other,125% of NY Medicaid HMO DRG,0.01,19328,
Abdominal pain,251-2,APR-DRG,,,,,,,,inpatient,,,114457.78,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25583,,"45,128 x DRG weight",25583,Other,base rate x DRG weight,23025,,"40,615 x DRG weight",23025,Other,base rate x DRG weight,21746,,"38,359 x DRG weight",21746,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9726,,186% x Medicaid HMO amount,9726,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19318,,"34,077 x DRG weight",19318,Other,base rate x DRG weight,16421,,"28,966 x DRG weight",16421,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5229,,DRG base rate x DRG weight + capital per discharge,5229,Other,100% of NY Medicaid HMO DRG,5229,,100% x Medicaid HMO amount,5229,Other,100% of NY Medicaid HMO DRG,5229,,100% x Medicaid HMO amount,5229,Other,100% of NY Medicaid HMO DRG,5229,,100% x Medicaid HMO amount,5229,Other,100% of NY Medicaid HMO DRG,11765,,225% x Medicaid HMO amount,11765,Other,225% of NY Medicaid HMO DRG,11765,,225% x Medicaid HMO amount,11765,Other,225% of NY Medicaid HMO DRG,11765,,225% x Medicaid HMO amount,11765,Other,225% of NY Medicaid HMO DRG,11765,,225% x Medicaid HMO amount,11765,Other,225% of NY Medicaid HMO DRG,7321,,140% x Medicaid HMO amount,7321,Other,140% of NY Medicaid HMO DRG,11765,,225% x Medicaid HMO amount,11765,Other,225% of NY Medicaid HMO DRG,14380,,275% x Medicaid HMO amount,14380,Other,275% of NY Medicaid HMO DRG,16942,,324% x Medicaid HMO amount,16942,Other,324% of NY Medicaid HMO DRG,11242,,215% x Medicaid HMO amount,11242,Other,215% of NY Medicaid HMO DRG,11242,,215% x Medicaid HMO amount,11242,Other,215% of NY Medicaid HMO DRG,6536,,125% x Medicaid HMO amount,6536,Other,125% of NY Medicaid HMO DRG,0.01,25583,
Abdominal pain,251-3,APR-DRG,,,,,,,,inpatient,,,199796.19,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38241,,"45,128 x DRG weight",38241,Other,base rate x DRG weight,34417,,"40,615 x DRG weight",34417,Other,base rate x DRG weight,32505,,"38,359 x DRG weight",32505,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13783,,186% x Medicaid HMO amount,13783,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28877,,"34,077 x DRG weight",28877,Other,base rate x DRG weight,24546,,"28,966 x DRG weight",24546,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7410,,DRG base rate x DRG weight + capital per discharge,7410,Other,100% of NY Medicaid HMO DRG,7410,,100% x Medicaid HMO amount,7410,Other,100% of NY Medicaid HMO DRG,7410,,100% x Medicaid HMO amount,7410,Other,100% of NY Medicaid HMO DRG,7410,,100% x Medicaid HMO amount,7410,Other,100% of NY Medicaid HMO DRG,16673,,225% x Medicaid HMO amount,16673,Other,225% of NY Medicaid HMO DRG,16673,,225% x Medicaid HMO amount,16673,Other,225% of NY Medicaid HMO DRG,16673,,225% x Medicaid HMO amount,16673,Other,225% of NY Medicaid HMO DRG,16673,,225% x Medicaid HMO amount,16673,Other,225% of NY Medicaid HMO DRG,10374,,140% x Medicaid HMO amount,10374,Other,140% of NY Medicaid HMO DRG,16673,,225% x Medicaid HMO amount,16673,Other,225% of NY Medicaid HMO DRG,20378,,275% x Medicaid HMO amount,20378,Other,275% of NY Medicaid HMO DRG,24008,,324% x Medicaid HMO amount,24008,Other,324% of NY Medicaid HMO DRG,15932,,215% x Medicaid HMO amount,15932,Other,215% of NY Medicaid HMO DRG,15932,,215% x Medicaid HMO amount,15932,Other,215% of NY Medicaid HMO DRG,9263,,125% x Medicaid HMO amount,9263,Other,125% of NY Medicaid HMO DRG,0.01,38241,
Abdominal pain,251-4,APR-DRG,,,,,,,,inpatient,,,234267.8,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,87381,,"45,128 x DRG weight",87381,Other,base rate x DRG weight,78643,,"40,615 x DRG weight",78643,Other,base rate x DRG weight,74275,,"38,359 x DRG weight",74275,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29531,,186% x Medicaid HMO amount,29531,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,65983,,"34,077 x DRG weight",65983,Other,base rate x DRG weight,56087,,"28,966 x DRG weight",56087,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15877,,DRG base rate x DRG weight + capital per discharge,15877,Other,100% of NY Medicaid HMO DRG,15877,,100% x Medicaid HMO amount,15877,Other,100% of NY Medicaid HMO DRG,15877,,100% x Medicaid HMO amount,15877,Other,100% of NY Medicaid HMO DRG,15877,,100% x Medicaid HMO amount,15877,Other,100% of NY Medicaid HMO DRG,35723,,225% x Medicaid HMO amount,35723,Other,225% of NY Medicaid HMO DRG,35723,,225% x Medicaid HMO amount,35723,Other,225% of NY Medicaid HMO DRG,35723,,225% x Medicaid HMO amount,35723,Other,225% of NY Medicaid HMO DRG,35723,,225% x Medicaid HMO amount,35723,Other,225% of NY Medicaid HMO DRG,22228,,140% x Medicaid HMO amount,22228,Other,140% of NY Medicaid HMO DRG,35723,,225% x Medicaid HMO amount,35723,Other,225% of NY Medicaid HMO DRG,43662,,275% x Medicaid HMO amount,43662,Other,275% of NY Medicaid HMO DRG,51441,,324% x Medicaid HMO amount,51441,Other,324% of NY Medicaid HMO DRG,34136,,215% x Medicaid HMO amount,34136,Other,215% of NY Medicaid HMO DRG,34136,,215% x Medicaid HMO amount,34136,Other,215% of NY Medicaid HMO DRG,19846,,125% x Medicaid HMO amount,19846,Other,125% of NY Medicaid HMO DRG,0.01,87381,
"Malfunction, reaction & complication of GI device or procedure",252-1,APR-DRG,,,,,,,,inpatient,,,54933.73,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27496,,"45,128 x DRG weight",27496,Other,base rate x DRG weight,24747,,"40,615 x DRG weight",24747,Other,base rate x DRG weight,23372,,"38,359 x DRG weight",23372,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10340,,186% x Medicaid HMO amount,10340,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20763,,"34,077 x DRG weight",20763,Other,base rate x DRG weight,17649,,"28,966 x DRG weight",17649,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5559,,DRG base rate x DRG weight + capital per discharge,5559,Other,100% of NY Medicaid HMO DRG,5559,,100% x Medicaid HMO amount,5559,Other,100% of NY Medicaid HMO DRG,5559,,100% x Medicaid HMO amount,5559,Other,100% of NY Medicaid HMO DRG,5559,,100% x Medicaid HMO amount,5559,Other,100% of NY Medicaid HMO DRG,12508,,225% x Medicaid HMO amount,12508,Other,225% of NY Medicaid HMO DRG,12508,,225% x Medicaid HMO amount,12508,Other,225% of NY Medicaid HMO DRG,12508,,225% x Medicaid HMO amount,12508,Other,225% of NY Medicaid HMO DRG,12508,,225% x Medicaid HMO amount,12508,Other,225% of NY Medicaid HMO DRG,7783,,140% x Medicaid HMO amount,7783,Other,140% of NY Medicaid HMO DRG,12508,,225% x Medicaid HMO amount,12508,Other,225% of NY Medicaid HMO DRG,15287,,275% x Medicaid HMO amount,15287,Other,275% of NY Medicaid HMO DRG,18011,,324% x Medicaid HMO amount,18011,Other,324% of NY Medicaid HMO DRG,11952,,215% x Medicaid HMO amount,11952,Other,215% of NY Medicaid HMO DRG,11952,,215% x Medicaid HMO amount,11952,Other,215% of NY Medicaid HMO DRG,6949,,125% x Medicaid HMO amount,6949,Other,125% of NY Medicaid HMO DRG,0.01,27496,
"Malfunction, reaction & complication of GI device or procedure",252-2,APR-DRG,,,,,,,,inpatient,,,111395.84,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35236,,"45,128 x DRG weight",35236,Other,base rate x DRG weight,31712,,"40,615 x DRG weight",31712,Other,base rate x DRG weight,29951,,"38,359 x DRG weight",29951,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12819,,186% x Medicaid HMO amount,12819,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26607,,"34,077 x DRG weight",26607,Other,base rate x DRG weight,22617,,"28,966 x DRG weight",22617,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6892,,DRG base rate x DRG weight + capital per discharge,6892,Other,100% of NY Medicaid HMO DRG,6892,,100% x Medicaid HMO amount,6892,Other,100% of NY Medicaid HMO DRG,6892,,100% x Medicaid HMO amount,6892,Other,100% of NY Medicaid HMO DRG,6892,,100% x Medicaid HMO amount,6892,Other,100% of NY Medicaid HMO DRG,15507,,225% x Medicaid HMO amount,15507,Other,225% of NY Medicaid HMO DRG,15507,,225% x Medicaid HMO amount,15507,Other,225% of NY Medicaid HMO DRG,15507,,225% x Medicaid HMO amount,15507,Other,225% of NY Medicaid HMO DRG,15507,,225% x Medicaid HMO amount,15507,Other,225% of NY Medicaid HMO DRG,9649,,140% x Medicaid HMO amount,9649,Other,140% of NY Medicaid HMO DRG,15507,,225% x Medicaid HMO amount,15507,Other,225% of NY Medicaid HMO DRG,18953,,275% x Medicaid HMO amount,18953,Other,275% of NY Medicaid HMO DRG,22330,,324% x Medicaid HMO amount,22330,Other,324% of NY Medicaid HMO DRG,14818,,215% x Medicaid HMO amount,14818,Other,215% of NY Medicaid HMO DRG,14818,,215% x Medicaid HMO amount,14818,Other,215% of NY Medicaid HMO DRG,8615,,125% x Medicaid HMO amount,8615,Other,125% of NY Medicaid HMO DRG,0.01,35236,
"Malfunction, reaction & complication of GI device or procedure",252-3,APR-DRG,,,,,,,,inpatient,,,156639.95,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56049,,"45,128 x DRG weight",56049,Other,base rate x DRG weight,50444,,"40,615 x DRG weight",50444,Other,base rate x DRG weight,47642,,"38,359 x DRG weight",47642,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19489,,186% x Medicaid HMO amount,19489,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42324,,"34,077 x DRG weight",42324,Other,base rate x DRG weight,35976,,"28,966 x DRG weight",35976,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10478,,DRG base rate x DRG weight + capital per discharge,10478,Other,100% of NY Medicaid HMO DRG,10478,,100% x Medicaid HMO amount,10478,Other,100% of NY Medicaid HMO DRG,10478,,100% x Medicaid HMO amount,10478,Other,100% of NY Medicaid HMO DRG,10478,,100% x Medicaid HMO amount,10478,Other,100% of NY Medicaid HMO DRG,23576,,225% x Medicaid HMO amount,23576,Other,225% of NY Medicaid HMO DRG,23576,,225% x Medicaid HMO amount,23576,Other,225% of NY Medicaid HMO DRG,23576,,225% x Medicaid HMO amount,23576,Other,225% of NY Medicaid HMO DRG,23576,,225% x Medicaid HMO amount,23576,Other,225% of NY Medicaid HMO DRG,14669,,140% x Medicaid HMO amount,14669,Other,140% of NY Medicaid HMO DRG,23576,,225% x Medicaid HMO amount,23576,Other,225% of NY Medicaid HMO DRG,28815,,275% x Medicaid HMO amount,28815,Other,275% of NY Medicaid HMO DRG,33949,,324% x Medicaid HMO amount,33949,Other,324% of NY Medicaid HMO DRG,22528,,215% x Medicaid HMO amount,22528,Other,215% of NY Medicaid HMO DRG,22528,,215% x Medicaid HMO amount,22528,Other,215% of NY Medicaid HMO DRG,13098,,125% x Medicaid HMO amount,13098,Other,125% of NY Medicaid HMO DRG,0.01,56049,
"Malfunction, reaction & complication of GI device or procedure",252-4,APR-DRG,,,,,,,,inpatient,,,817997.36,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,127902,,"45,128 x DRG weight",127902,Other,base rate x DRG weight,115111,,"40,615 x DRG weight",115111,Other,base rate x DRG weight,108717,,"38,359 x DRG weight",108717,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42518,,186% x Medicaid HMO amount,42518,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,96581,,"34,077 x DRG weight",96581,Other,base rate x DRG weight,82095,,"28,966 x DRG weight",82095,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22859,,DRG base rate x DRG weight + capital per discharge,22859,Other,100% of NY Medicaid HMO DRG,22859,,100% x Medicaid HMO amount,22859,Other,100% of NY Medicaid HMO DRG,22859,,100% x Medicaid HMO amount,22859,Other,100% of NY Medicaid HMO DRG,22859,,100% x Medicaid HMO amount,22859,Other,100% of NY Medicaid HMO DRG,51433,,225% x Medicaid HMO amount,51433,Other,225% of NY Medicaid HMO DRG,51433,,225% x Medicaid HMO amount,51433,Other,225% of NY Medicaid HMO DRG,51433,,225% x Medicaid HMO amount,51433,Other,225% of NY Medicaid HMO DRG,51433,,225% x Medicaid HMO amount,51433,Other,225% of NY Medicaid HMO DRG,32003,,140% x Medicaid HMO amount,32003,Other,140% of NY Medicaid HMO DRG,51433,,225% x Medicaid HMO amount,51433,Other,225% of NY Medicaid HMO DRG,62862,,275% x Medicaid HMO amount,62862,Other,275% of NY Medicaid HMO DRG,74063,,324% x Medicaid HMO amount,74063,Other,324% of NY Medicaid HMO DRG,49147,,215% x Medicaid HMO amount,49147,Other,215% of NY Medicaid HMO DRG,49147,,215% x Medicaid HMO amount,49147,Other,215% of NY Medicaid HMO DRG,28574,,125% x Medicaid HMO amount,28574,Other,125% of NY Medicaid HMO DRG,0.01,127902,
Other & unspecified gastrointestinal hemorrhage,253-1,APR-DRG,,,,,,,,inpatient,,,93809.8,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27546,,"45,128 x DRG weight",27546,Other,base rate x DRG weight,24791,,"40,615 x DRG weight",24791,Other,base rate x DRG weight,23414,,"38,359 x DRG weight",23414,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10355,,186% x Medicaid HMO amount,10355,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20801,,"34,077 x DRG weight",20801,Other,base rate x DRG weight,17681,,"28,966 x DRG weight",17681,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5567,,DRG base rate x DRG weight + capital per discharge,5567,Other,100% of NY Medicaid HMO DRG,5567,,100% x Medicaid HMO amount,5567,Other,100% of NY Medicaid HMO DRG,5567,,100% x Medicaid HMO amount,5567,Other,100% of NY Medicaid HMO DRG,5567,,100% x Medicaid HMO amount,5567,Other,100% of NY Medicaid HMO DRG,12526,,225% x Medicaid HMO amount,12526,Other,225% of NY Medicaid HMO DRG,12526,,225% x Medicaid HMO amount,12526,Other,225% of NY Medicaid HMO DRG,12526,,225% x Medicaid HMO amount,12526,Other,225% of NY Medicaid HMO DRG,12526,,225% x Medicaid HMO amount,12526,Other,225% of NY Medicaid HMO DRG,7794,,140% x Medicaid HMO amount,7794,Other,140% of NY Medicaid HMO DRG,12526,,225% x Medicaid HMO amount,12526,Other,225% of NY Medicaid HMO DRG,15309,,275% x Medicaid HMO amount,15309,Other,275% of NY Medicaid HMO DRG,18037,,324% x Medicaid HMO amount,18037,Other,324% of NY Medicaid HMO DRG,11969,,215% x Medicaid HMO amount,11969,Other,215% of NY Medicaid HMO DRG,11969,,215% x Medicaid HMO amount,11969,Other,215% of NY Medicaid HMO DRG,6959,,125% x Medicaid HMO amount,6959,Other,125% of NY Medicaid HMO DRG,0.01,27546,
Other & unspecified gastrointestinal hemorrhage,253-2,APR-DRG,,,,,,,,inpatient,,,101111.68,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36793,,"45,128 x DRG weight",36793,Other,base rate x DRG weight,33113,,"40,615 x DRG weight",33113,Other,base rate x DRG weight,31274,,"38,359 x DRG weight",31274,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13318,,186% x Medicaid HMO amount,13318,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27783,,"34,077 x DRG weight",27783,Other,base rate x DRG weight,23616,,"28,966 x DRG weight",23616,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7160,,DRG base rate x DRG weight + capital per discharge,7160,Other,100% of NY Medicaid HMO DRG,7160,,100% x Medicaid HMO amount,7160,Other,100% of NY Medicaid HMO DRG,7160,,100% x Medicaid HMO amount,7160,Other,100% of NY Medicaid HMO DRG,7160,,100% x Medicaid HMO amount,7160,Other,100% of NY Medicaid HMO DRG,16110,,225% x Medicaid HMO amount,16110,Other,225% of NY Medicaid HMO DRG,16110,,225% x Medicaid HMO amount,16110,Other,225% of NY Medicaid HMO DRG,16110,,225% x Medicaid HMO amount,16110,Other,225% of NY Medicaid HMO DRG,16110,,225% x Medicaid HMO amount,16110,Other,225% of NY Medicaid HMO DRG,10024,,140% x Medicaid HMO amount,10024,Other,140% of NY Medicaid HMO DRG,16110,,225% x Medicaid HMO amount,16110,Other,225% of NY Medicaid HMO DRG,19690,,275% x Medicaid HMO amount,19690,Other,275% of NY Medicaid HMO DRG,23198,,324% x Medicaid HMO amount,23198,Other,324% of NY Medicaid HMO DRG,15394,,215% x Medicaid HMO amount,15394,Other,215% of NY Medicaid HMO DRG,15394,,215% x Medicaid HMO amount,15394,Other,215% of NY Medicaid HMO DRG,8950,,125% x Medicaid HMO amount,8950,Other,125% of NY Medicaid HMO DRG,0.01,36793,
Other & unspecified gastrointestinal hemorrhage,253-3,APR-DRG,,,,,,,,inpatient,,,231917.58,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60323,,"45,128 x DRG weight",60323,Other,base rate x DRG weight,54290,,"40,615 x DRG weight",54290,Other,base rate x DRG weight,51274,,"38,359 x DRG weight",51274,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20860,,186% x Medicaid HMO amount,20860,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45551,,"34,077 x DRG weight",45551,Other,base rate x DRG weight,38719,,"28,966 x DRG weight",38719,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11215,,DRG base rate x DRG weight + capital per discharge,11215,Other,100% of NY Medicaid HMO DRG,11215,,100% x Medicaid HMO amount,11215,Other,100% of NY Medicaid HMO DRG,11215,,100% x Medicaid HMO amount,11215,Other,100% of NY Medicaid HMO DRG,11215,,100% x Medicaid HMO amount,11215,Other,100% of NY Medicaid HMO DRG,25234,,225% x Medicaid HMO amount,25234,Other,225% of NY Medicaid HMO DRG,25234,,225% x Medicaid HMO amount,25234,Other,225% of NY Medicaid HMO DRG,25234,,225% x Medicaid HMO amount,25234,Other,225% of NY Medicaid HMO DRG,25234,,225% x Medicaid HMO amount,25234,Other,225% of NY Medicaid HMO DRG,15701,,140% x Medicaid HMO amount,15701,Other,140% of NY Medicaid HMO DRG,25234,,225% x Medicaid HMO amount,25234,Other,225% of NY Medicaid HMO DRG,30841,,275% x Medicaid HMO amount,30841,Other,275% of NY Medicaid HMO DRG,36337,,324% x Medicaid HMO amount,36337,Other,324% of NY Medicaid HMO DRG,24112,,215% x Medicaid HMO amount,24112,Other,215% of NY Medicaid HMO DRG,24112,,215% x Medicaid HMO amount,24112,Other,215% of NY Medicaid HMO DRG,14019,,125% x Medicaid HMO amount,14019,Other,125% of NY Medicaid HMO DRG,0.01,60323,
Other & unspecified gastrointestinal hemorrhage,253-4,APR-DRG,,,,,,,,inpatient,,,242914.42,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,106768,,"45,128 x DRG weight",106768,Other,base rate x DRG weight,96091,,"40,615 x DRG weight",96091,Other,base rate x DRG weight,90754,,"38,359 x DRG weight",90754,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35744,,186% x Medicaid HMO amount,35744,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,80623,,"34,077 x DRG weight",80623,Other,base rate x DRG weight,68531,,"28,966 x DRG weight",68531,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19217,,DRG base rate x DRG weight + capital per discharge,19217,Other,100% of NY Medicaid HMO DRG,19217,,100% x Medicaid HMO amount,19217,Other,100% of NY Medicaid HMO DRG,19217,,100% x Medicaid HMO amount,19217,Other,100% of NY Medicaid HMO DRG,19217,,100% x Medicaid HMO amount,19217,Other,100% of NY Medicaid HMO DRG,43238,,225% x Medicaid HMO amount,43238,Other,225% of NY Medicaid HMO DRG,43238,,225% x Medicaid HMO amount,43238,Other,225% of NY Medicaid HMO DRG,43238,,225% x Medicaid HMO amount,43238,Other,225% of NY Medicaid HMO DRG,43238,,225% x Medicaid HMO amount,43238,Other,225% of NY Medicaid HMO DRG,26904,,140% x Medicaid HMO amount,26904,Other,140% of NY Medicaid HMO DRG,43238,,225% x Medicaid HMO amount,43238,Other,225% of NY Medicaid HMO DRG,52847,,275% x Medicaid HMO amount,52847,Other,275% of NY Medicaid HMO DRG,62263,,324% x Medicaid HMO amount,62263,Other,324% of NY Medicaid HMO DRG,41317,,215% x Medicaid HMO amount,41317,Other,215% of NY Medicaid HMO DRG,41317,,215% x Medicaid HMO amount,41317,Other,215% of NY Medicaid HMO DRG,24021,,125% x Medicaid HMO amount,24021,Other,125% of NY Medicaid HMO DRG,0.01,106768,
Other digestive system diagnoses,254-1,APR-DRG,,,,,,,,inpatient,,,93265.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22537,,"45,128 x DRG weight",22537,Other,base rate x DRG weight,20283,,"40,615 x DRG weight",20283,Other,base rate x DRG weight,19156,,"38,359 x DRG weight",19156,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8749,,186% x Medicaid HMO amount,8749,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17018,,"34,077 x DRG weight",17018,Other,base rate x DRG weight,14466,,"28,966 x DRG weight",14466,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4704,,DRG base rate x DRG weight + capital per discharge,4704,Other,100% of NY Medicaid HMO DRG,4704,,100% x Medicaid HMO amount,4704,Other,100% of NY Medicaid HMO DRG,4704,,100% x Medicaid HMO amount,4704,Other,100% of NY Medicaid HMO DRG,4704,,100% x Medicaid HMO amount,4704,Other,100% of NY Medicaid HMO DRG,10584,,225% x Medicaid HMO amount,10584,Other,225% of NY Medicaid HMO DRG,10584,,225% x Medicaid HMO amount,10584,Other,225% of NY Medicaid HMO DRG,10584,,225% x Medicaid HMO amount,10584,Other,225% of NY Medicaid HMO DRG,10584,,225% x Medicaid HMO amount,10584,Other,225% of NY Medicaid HMO DRG,6586,,140% x Medicaid HMO amount,6586,Other,140% of NY Medicaid HMO DRG,10584,,225% x Medicaid HMO amount,10584,Other,225% of NY Medicaid HMO DRG,12936,,275% x Medicaid HMO amount,12936,Other,275% of NY Medicaid HMO DRG,15241,,324% x Medicaid HMO amount,15241,Other,324% of NY Medicaid HMO DRG,10114,,215% x Medicaid HMO amount,10114,Other,215% of NY Medicaid HMO DRG,10114,,215% x Medicaid HMO amount,10114,Other,215% of NY Medicaid HMO DRG,5880,,125% x Medicaid HMO amount,5880,Other,125% of NY Medicaid HMO DRG,0.01,22537,
Other digestive system diagnoses,254-2,APR-DRG,,,,,,,,inpatient,,,139161.81,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32569,,"45,128 x DRG weight",32569,Other,base rate x DRG weight,29312,,"40,615 x DRG weight",29312,Other,base rate x DRG weight,27684,,"38,359 x DRG weight",27684,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11965,,186% x Medicaid HMO amount,11965,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24593,,"34,077 x DRG weight",24593,Other,base rate x DRG weight,20905,,"28,966 x DRG weight",20905,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6433,,DRG base rate x DRG weight + capital per discharge,6433,Other,100% of NY Medicaid HMO DRG,6433,,100% x Medicaid HMO amount,6433,Other,100% of NY Medicaid HMO DRG,6433,,100% x Medicaid HMO amount,6433,Other,100% of NY Medicaid HMO DRG,6433,,100% x Medicaid HMO amount,6433,Other,100% of NY Medicaid HMO DRG,14474,,225% x Medicaid HMO amount,14474,Other,225% of NY Medicaid HMO DRG,14474,,225% x Medicaid HMO amount,14474,Other,225% of NY Medicaid HMO DRG,14474,,225% x Medicaid HMO amount,14474,Other,225% of NY Medicaid HMO DRG,14474,,225% x Medicaid HMO amount,14474,Other,225% of NY Medicaid HMO DRG,9006,,140% x Medicaid HMO amount,9006,Other,140% of NY Medicaid HMO DRG,14474,,225% x Medicaid HMO amount,14474,Other,225% of NY Medicaid HMO DRG,17691,,275% x Medicaid HMO amount,17691,Other,275% of NY Medicaid HMO DRG,20843,,324% x Medicaid HMO amount,20843,Other,324% of NY Medicaid HMO DRG,13831,,215% x Medicaid HMO amount,13831,Other,215% of NY Medicaid HMO DRG,13831,,215% x Medicaid HMO amount,13831,Other,215% of NY Medicaid HMO DRG,8041,,125% x Medicaid HMO amount,8041,Other,125% of NY Medicaid HMO DRG,0.01,32569,
Other digestive system diagnoses,254-3,APR-DRG,,,,,,,,inpatient,,,175379.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54722,,"45,128 x DRG weight",54722,Other,base rate x DRG weight,49250,,"40,615 x DRG weight",49250,Other,base rate x DRG weight,46514,,"38,359 x DRG weight",46514,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19065,,186% x Medicaid HMO amount,19065,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41322,,"34,077 x DRG weight",41322,Other,base rate x DRG weight,35124,,"28,966 x DRG weight",35124,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10250,,DRG base rate x DRG weight + capital per discharge,10250,Other,100% of NY Medicaid HMO DRG,10250,,100% x Medicaid HMO amount,10250,Other,100% of NY Medicaid HMO DRG,10250,,100% x Medicaid HMO amount,10250,Other,100% of NY Medicaid HMO DRG,10250,,100% x Medicaid HMO amount,10250,Other,100% of NY Medicaid HMO DRG,23063,,225% x Medicaid HMO amount,23063,Other,225% of NY Medicaid HMO DRG,23063,,225% x Medicaid HMO amount,23063,Other,225% of NY Medicaid HMO DRG,23063,,225% x Medicaid HMO amount,23063,Other,225% of NY Medicaid HMO DRG,23063,,225% x Medicaid HMO amount,23063,Other,225% of NY Medicaid HMO DRG,14350,,140% x Medicaid HMO amount,14350,Other,140% of NY Medicaid HMO DRG,23063,,225% x Medicaid HMO amount,23063,Other,225% of NY Medicaid HMO DRG,28188,,275% x Medicaid HMO amount,28188,Other,275% of NY Medicaid HMO DRG,33210,,324% x Medicaid HMO amount,33210,Other,324% of NY Medicaid HMO DRG,22038,,215% x Medicaid HMO amount,22038,Other,215% of NY Medicaid HMO DRG,22038,,215% x Medicaid HMO amount,22038,Other,215% of NY Medicaid HMO DRG,12813,,125% x Medicaid HMO amount,12813,Other,125% of NY Medicaid HMO DRG,0.01,54722,
Other digestive system diagnoses,254-4,APR-DRG,,,,,,,,inpatient,,,168762.38,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,117698,,"45,128 x DRG weight",117698,Other,base rate x DRG weight,105928,,"40,615 x DRG weight",105928,Other,base rate x DRG weight,100044,,"38,359 x DRG weight",100044,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39246,,186% x Medicaid HMO amount,39246,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,88876,,"34,077 x DRG weight",88876,Other,base rate x DRG weight,75546,,"28,966 x DRG weight",75546,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21100,,DRG base rate x DRG weight + capital per discharge,21100,Other,100% of NY Medicaid HMO DRG,21100,,100% x Medicaid HMO amount,21100,Other,100% of NY Medicaid HMO DRG,21100,,100% x Medicaid HMO amount,21100,Other,100% of NY Medicaid HMO DRG,21100,,100% x Medicaid HMO amount,21100,Other,100% of NY Medicaid HMO DRG,47475,,225% x Medicaid HMO amount,47475,Other,225% of NY Medicaid HMO DRG,47475,,225% x Medicaid HMO amount,47475,Other,225% of NY Medicaid HMO DRG,47475,,225% x Medicaid HMO amount,47475,Other,225% of NY Medicaid HMO DRG,47475,,225% x Medicaid HMO amount,47475,Other,225% of NY Medicaid HMO DRG,29540,,140% x Medicaid HMO amount,29540,Other,140% of NY Medicaid HMO DRG,47475,,225% x Medicaid HMO amount,47475,Other,225% of NY Medicaid HMO DRG,58025,,275% x Medicaid HMO amount,58025,Other,275% of NY Medicaid HMO DRG,68364,,324% x Medicaid HMO amount,68364,Other,324% of NY Medicaid HMO DRG,45365,,215% x Medicaid HMO amount,45365,Other,215% of NY Medicaid HMO DRG,45365,,215% x Medicaid HMO amount,45365,Other,215% of NY Medicaid HMO DRG,26375,,125% x Medicaid HMO amount,26375,Other,125% of NY Medicaid HMO DRG,0.01,117698,
"Major pancreas, liver & shunt procedures",260-1,APR-DRG,,,,,,,,inpatient,,,269874.03,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,65878,,"45,128 x DRG weight",65878,Other,base rate x DRG weight,59290,,"40,615 x DRG weight",59290,Other,base rate x DRG weight,55996,,"38,359 x DRG weight",55996,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22640,,186% x Medicaid HMO amount,22640,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49746,,"34,077 x DRG weight",49746,Other,base rate x DRG weight,42285,,"28,966 x DRG weight",42285,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12172,,DRG base rate x DRG weight + capital per discharge,12172,Other,100% of NY Medicaid HMO DRG,12172,,100% x Medicaid HMO amount,12172,Other,100% of NY Medicaid HMO DRG,12172,,100% x Medicaid HMO amount,12172,Other,100% of NY Medicaid HMO DRG,12172,,100% x Medicaid HMO amount,12172,Other,100% of NY Medicaid HMO DRG,27387,,225% x Medicaid HMO amount,27387,Other,225% of NY Medicaid HMO DRG,27387,,225% x Medicaid HMO amount,27387,Other,225% of NY Medicaid HMO DRG,27387,,225% x Medicaid HMO amount,27387,Other,225% of NY Medicaid HMO DRG,27387,,225% x Medicaid HMO amount,27387,Other,225% of NY Medicaid HMO DRG,17041,,140% x Medicaid HMO amount,17041,Other,140% of NY Medicaid HMO DRG,27387,,225% x Medicaid HMO amount,27387,Other,225% of NY Medicaid HMO DRG,33473,,275% x Medicaid HMO amount,33473,Other,275% of NY Medicaid HMO DRG,39437,,324% x Medicaid HMO amount,39437,Other,324% of NY Medicaid HMO DRG,26170,,215% x Medicaid HMO amount,26170,Other,215% of NY Medicaid HMO DRG,26170,,215% x Medicaid HMO amount,26170,Other,215% of NY Medicaid HMO DRG,15215,,125% x Medicaid HMO amount,15215,Other,125% of NY Medicaid HMO DRG,0.01,65878,
"Major pancreas, liver & shunt procedures",260-2,APR-DRG,,,,,,,,inpatient,,,234321.88,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,89909,,"45,128 x DRG weight",89909,Other,base rate x DRG weight,80917,,"40,615 x DRG weight",80917,Other,base rate x DRG weight,76423,,"38,359 x DRG weight",76423,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30340,,186% x Medicaid HMO amount,30340,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,67892,,"34,077 x DRG weight",67892,Other,base rate x DRG weight,57709,,"28,966 x DRG weight",57709,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16312,,DRG base rate x DRG weight + capital per discharge,16312,Other,100% of NY Medicaid HMO DRG,16312,,100% x Medicaid HMO amount,16312,Other,100% of NY Medicaid HMO DRG,16312,,100% x Medicaid HMO amount,16312,Other,100% of NY Medicaid HMO DRG,16312,,100% x Medicaid HMO amount,16312,Other,100% of NY Medicaid HMO DRG,36702,,225% x Medicaid HMO amount,36702,Other,225% of NY Medicaid HMO DRG,36702,,225% x Medicaid HMO amount,36702,Other,225% of NY Medicaid HMO DRG,36702,,225% x Medicaid HMO amount,36702,Other,225% of NY Medicaid HMO DRG,36702,,225% x Medicaid HMO amount,36702,Other,225% of NY Medicaid HMO DRG,22837,,140% x Medicaid HMO amount,22837,Other,140% of NY Medicaid HMO DRG,36702,,225% x Medicaid HMO amount,36702,Other,225% of NY Medicaid HMO DRG,44858,,275% x Medicaid HMO amount,44858,Other,275% of NY Medicaid HMO DRG,52851,,324% x Medicaid HMO amount,52851,Other,324% of NY Medicaid HMO DRG,35071,,215% x Medicaid HMO amount,35071,Other,215% of NY Medicaid HMO DRG,35071,,215% x Medicaid HMO amount,35071,Other,215% of NY Medicaid HMO DRG,20390,,125% x Medicaid HMO amount,20390,Other,125% of NY Medicaid HMO DRG,0.01,89909,
"Major pancreas, liver & shunt procedures",260-3,APR-DRG,,,,,,,,inpatient,,,272459.86,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,141937,,"45,128 x DRG weight",141937,Other,base rate x DRG weight,127742,,"40,615 x DRG weight",127742,Other,base rate x DRG weight,120647,,"38,359 x DRG weight",120647,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47015,,186% x Medicaid HMO amount,47015,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,107179,,"34,077 x DRG weight",107179,Other,base rate x DRG weight,91104,,"28,966 x DRG weight",91104,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25277,,DRG base rate x DRG weight + capital per discharge,25277,Other,100% of NY Medicaid HMO DRG,25277,,100% x Medicaid HMO amount,25277,Other,100% of NY Medicaid HMO DRG,25277,,100% x Medicaid HMO amount,25277,Other,100% of NY Medicaid HMO DRG,25277,,100% x Medicaid HMO amount,25277,Other,100% of NY Medicaid HMO DRG,56873,,225% x Medicaid HMO amount,56873,Other,225% of NY Medicaid HMO DRG,56873,,225% x Medicaid HMO amount,56873,Other,225% of NY Medicaid HMO DRG,56873,,225% x Medicaid HMO amount,56873,Other,225% of NY Medicaid HMO DRG,56873,,225% x Medicaid HMO amount,56873,Other,225% of NY Medicaid HMO DRG,35388,,140% x Medicaid HMO amount,35388,Other,140% of NY Medicaid HMO DRG,56873,,225% x Medicaid HMO amount,56873,Other,225% of NY Medicaid HMO DRG,69512,,275% x Medicaid HMO amount,69512,Other,275% of NY Medicaid HMO DRG,81897,,324% x Medicaid HMO amount,81897,Other,324% of NY Medicaid HMO DRG,54346,,215% x Medicaid HMO amount,54346,Other,215% of NY Medicaid HMO DRG,54346,,215% x Medicaid HMO amount,54346,Other,215% of NY Medicaid HMO DRG,31596,,125% x Medicaid HMO amount,31596,Other,125% of NY Medicaid HMO DRG,0.01,141937,
"Major pancreas, liver & shunt procedures",260-4,APR-DRG,,,,,,,,inpatient,,,791173,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,335143,,"45,128 x DRG weight",335143,Other,base rate x DRG weight,301627,,"40,615 x DRG weight",301627,Other,base rate x DRG weight,284873,,"38,359 x DRG weight",284873,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,108935,,186% x Medicaid HMO amount,108935,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,253073,,"34,077 x DRG weight",253073,Other,base rate x DRG weight,215116,,"28,966 x DRG weight",215116,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,58567,,DRG base rate x DRG weight + capital per discharge,58567,Other,100% of NY Medicaid HMO DRG,58567,,100% x Medicaid HMO amount,58567,Other,100% of NY Medicaid HMO DRG,58567,,100% x Medicaid HMO amount,58567,Other,100% of NY Medicaid HMO DRG,58567,,100% x Medicaid HMO amount,58567,Other,100% of NY Medicaid HMO DRG,131776,,225% x Medicaid HMO amount,131776,Other,225% of NY Medicaid HMO DRG,131776,,225% x Medicaid HMO amount,131776,Other,225% of NY Medicaid HMO DRG,131776,,225% x Medicaid HMO amount,131776,Other,225% of NY Medicaid HMO DRG,131776,,225% x Medicaid HMO amount,131776,Other,225% of NY Medicaid HMO DRG,81994,,140% x Medicaid HMO amount,81994,Other,140% of NY Medicaid HMO DRG,131776,,225% x Medicaid HMO amount,131776,Other,225% of NY Medicaid HMO DRG,161059,,275% x Medicaid HMO amount,161059,Other,275% of NY Medicaid HMO DRG,189757,,324% x Medicaid HMO amount,189757,Other,324% of NY Medicaid HMO DRG,125919,,215% x Medicaid HMO amount,125919,Other,215% of NY Medicaid HMO DRG,125919,,215% x Medicaid HMO amount,125919,Other,215% of NY Medicaid HMO DRG,73209,,125% x Medicaid HMO amount,73209,Other,125% of NY Medicaid HMO DRG,0.01,335143,
Major biliary tract procedures,261-1,APR-DRG,,,,,,,,inpatient,,,102145.51,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,63102,,"45,128 x DRG weight",63102,Other,base rate x DRG weight,56792,,"40,615 x DRG weight",56792,Other,base rate x DRG weight,53637,,"38,359 x DRG weight",53637,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21751,,186% x Medicaid HMO amount,21751,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47650,,"34,077 x DRG weight",47650,Other,base rate x DRG weight,40503,,"28,966 x DRG weight",40503,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11694,,DRG base rate x DRG weight + capital per discharge,11694,Other,100% of NY Medicaid HMO DRG,11694,,100% x Medicaid HMO amount,11694,Other,100% of NY Medicaid HMO DRG,11694,,100% x Medicaid HMO amount,11694,Other,100% of NY Medicaid HMO DRG,11694,,100% x Medicaid HMO amount,11694,Other,100% of NY Medicaid HMO DRG,26312,,225% x Medicaid HMO amount,26312,Other,225% of NY Medicaid HMO DRG,26312,,225% x Medicaid HMO amount,26312,Other,225% of NY Medicaid HMO DRG,26312,,225% x Medicaid HMO amount,26312,Other,225% of NY Medicaid HMO DRG,26312,,225% x Medicaid HMO amount,26312,Other,225% of NY Medicaid HMO DRG,16372,,140% x Medicaid HMO amount,16372,Other,140% of NY Medicaid HMO DRG,26312,,225% x Medicaid HMO amount,26312,Other,225% of NY Medicaid HMO DRG,32159,,275% x Medicaid HMO amount,32159,Other,275% of NY Medicaid HMO DRG,37889,,324% x Medicaid HMO amount,37889,Other,324% of NY Medicaid HMO DRG,25142,,215% x Medicaid HMO amount,25142,Other,215% of NY Medicaid HMO DRG,25142,,215% x Medicaid HMO amount,25142,Other,215% of NY Medicaid HMO DRG,14618,,125% x Medicaid HMO amount,14618,Other,125% of NY Medicaid HMO DRG,0.01,63102,
Major biliary tract procedures,261-2,APR-DRG,,,,,,,,inpatient,,,184103.12,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,90346,,"45,128 x DRG weight",90346,Other,base rate x DRG weight,81311,,"40,615 x DRG weight",81311,Other,base rate x DRG weight,76795,,"38,359 x DRG weight",76795,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30482,,186% x Medicaid HMO amount,30482,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,68222,,"34,077 x DRG weight",68222,Other,base rate x DRG weight,57990,,"28,966 x DRG weight",57990,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16388,,DRG base rate x DRG weight + capital per discharge,16388,Other,100% of NY Medicaid HMO DRG,16388,,100% x Medicaid HMO amount,16388,Other,100% of NY Medicaid HMO DRG,16388,,100% x Medicaid HMO amount,16388,Other,100% of NY Medicaid HMO DRG,16388,,100% x Medicaid HMO amount,16388,Other,100% of NY Medicaid HMO DRG,36873,,225% x Medicaid HMO amount,36873,Other,225% of NY Medicaid HMO DRG,36873,,225% x Medicaid HMO amount,36873,Other,225% of NY Medicaid HMO DRG,36873,,225% x Medicaid HMO amount,36873,Other,225% of NY Medicaid HMO DRG,36873,,225% x Medicaid HMO amount,36873,Other,225% of NY Medicaid HMO DRG,22943,,140% x Medicaid HMO amount,22943,Other,140% of NY Medicaid HMO DRG,36873,,225% x Medicaid HMO amount,36873,Other,225% of NY Medicaid HMO DRG,45067,,275% x Medicaid HMO amount,45067,Other,275% of NY Medicaid HMO DRG,53097,,324% x Medicaid HMO amount,53097,Other,324% of NY Medicaid HMO DRG,35234,,215% x Medicaid HMO amount,35234,Other,215% of NY Medicaid HMO DRG,35234,,215% x Medicaid HMO amount,35234,Other,215% of NY Medicaid HMO DRG,20485,,125% x Medicaid HMO amount,20485,Other,125% of NY Medicaid HMO DRG,0.01,90346,
Major biliary tract procedures,261-3,APR-DRG,,,,,,,,inpatient,,,300116.27,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,139369,,"45,128 x DRG weight",139369,Other,base rate x DRG weight,125431,,"40,615 x DRG weight",125431,Other,base rate x DRG weight,118464,,"38,359 x DRG weight",118464,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46191,,186% x Medicaid HMO amount,46191,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,105240,,"34,077 x DRG weight",105240,Other,base rate x DRG weight,89456,,"28,966 x DRG weight",89456,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24834,,DRG base rate x DRG weight + capital per discharge,24834,Other,100% of NY Medicaid HMO DRG,24834,,100% x Medicaid HMO amount,24834,Other,100% of NY Medicaid HMO DRG,24834,,100% x Medicaid HMO amount,24834,Other,100% of NY Medicaid HMO DRG,24834,,100% x Medicaid HMO amount,24834,Other,100% of NY Medicaid HMO DRG,55877,,225% x Medicaid HMO amount,55877,Other,225% of NY Medicaid HMO DRG,55877,,225% x Medicaid HMO amount,55877,Other,225% of NY Medicaid HMO DRG,55877,,225% x Medicaid HMO amount,55877,Other,225% of NY Medicaid HMO DRG,55877,,225% x Medicaid HMO amount,55877,Other,225% of NY Medicaid HMO DRG,34768,,140% x Medicaid HMO amount,34768,Other,140% of NY Medicaid HMO DRG,55877,,225% x Medicaid HMO amount,55877,Other,225% of NY Medicaid HMO DRG,68294,,275% x Medicaid HMO amount,68294,Other,275% of NY Medicaid HMO DRG,80462,,324% x Medicaid HMO amount,80462,Other,324% of NY Medicaid HMO DRG,53393,,215% x Medicaid HMO amount,53393,Other,215% of NY Medicaid HMO DRG,53393,,215% x Medicaid HMO amount,53393,Other,215% of NY Medicaid HMO DRG,31043,,125% x Medicaid HMO amount,31043,Other,125% of NY Medicaid HMO DRG,0.01,139369,
Major biliary tract procedures,261-4,APR-DRG,,,,,,,,inpatient,,,832933.17,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,277113,,"45,128 x DRG weight",277113,Other,base rate x DRG weight,249400,,"40,615 x DRG weight",249400,Other,base rate x DRG weight,235547,,"38,359 x DRG weight",235547,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,90336,,186% x Medicaid HMO amount,90336,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,209253,,"34,077 x DRG weight",209253,Other,base rate x DRG weight,177869,,"28,966 x DRG weight",177869,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48568,,DRG base rate x DRG weight + capital per discharge,48568,Other,100% of NY Medicaid HMO DRG,48568,,100% x Medicaid HMO amount,48568,Other,100% of NY Medicaid HMO DRG,48568,,100% x Medicaid HMO amount,48568,Other,100% of NY Medicaid HMO DRG,48568,,100% x Medicaid HMO amount,48568,Other,100% of NY Medicaid HMO DRG,109278,,225% x Medicaid HMO amount,109278,Other,225% of NY Medicaid HMO DRG,109278,,225% x Medicaid HMO amount,109278,Other,225% of NY Medicaid HMO DRG,109278,,225% x Medicaid HMO amount,109278,Other,225% of NY Medicaid HMO DRG,109278,,225% x Medicaid HMO amount,109278,Other,225% of NY Medicaid HMO DRG,67995,,140% x Medicaid HMO amount,67995,Other,140% of NY Medicaid HMO DRG,109278,,225% x Medicaid HMO amount,109278,Other,225% of NY Medicaid HMO DRG,133562,,275% x Medicaid HMO amount,133562,Other,275% of NY Medicaid HMO DRG,157360,,324% x Medicaid HMO amount,157360,Other,324% of NY Medicaid HMO DRG,104421,,215% x Medicaid HMO amount,104421,Other,215% of NY Medicaid HMO DRG,104421,,215% x Medicaid HMO amount,104421,Other,215% of NY Medicaid HMO DRG,60710,,125% x Medicaid HMO amount,60710,Other,125% of NY Medicaid HMO DRG,0.01,277113,
Cholecystectomy except laparoscopic,262-1,APR-DRG,,,,,,,,inpatient,,,133070.01,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59285,,"45,128 x DRG weight",59285,Other,base rate x DRG weight,53356,,"40,615 x DRG weight",53356,Other,base rate x DRG weight,50392,,"38,359 x DRG weight",50392,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20527,,186% x Medicaid HMO amount,20527,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44767,,"34,077 x DRG weight",44767,Other,base rate x DRG weight,38053,,"28,966 x DRG weight",38053,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11036,,DRG base rate x DRG weight + capital per discharge,11036,Other,100% of NY Medicaid HMO DRG,11036,,100% x Medicaid HMO amount,11036,Other,100% of NY Medicaid HMO DRG,11036,,100% x Medicaid HMO amount,11036,Other,100% of NY Medicaid HMO DRG,11036,,100% x Medicaid HMO amount,11036,Other,100% of NY Medicaid HMO DRG,24831,,225% x Medicaid HMO amount,24831,Other,225% of NY Medicaid HMO DRG,24831,,225% x Medicaid HMO amount,24831,Other,225% of NY Medicaid HMO DRG,24831,,225% x Medicaid HMO amount,24831,Other,225% of NY Medicaid HMO DRG,24831,,225% x Medicaid HMO amount,24831,Other,225% of NY Medicaid HMO DRG,15450,,140% x Medicaid HMO amount,15450,Other,140% of NY Medicaid HMO DRG,24831,,225% x Medicaid HMO amount,24831,Other,225% of NY Medicaid HMO DRG,30349,,275% x Medicaid HMO amount,30349,Other,275% of NY Medicaid HMO DRG,35757,,324% x Medicaid HMO amount,35757,Other,324% of NY Medicaid HMO DRG,23727,,215% x Medicaid HMO amount,23727,Other,215% of NY Medicaid HMO DRG,23727,,215% x Medicaid HMO amount,23727,Other,215% of NY Medicaid HMO DRG,13795,,125% x Medicaid HMO amount,13795,Other,125% of NY Medicaid HMO DRG,0.01,59285,
Cholecystectomy except laparoscopic,262-2,APR-DRG,,,,,,,,inpatient,,,177590.92,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,72453,,"45,128 x DRG weight",72453,Other,base rate x DRG weight,65207,,"40,615 x DRG weight",65207,Other,base rate x DRG weight,61585,,"38,359 x DRG weight",61585,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24747,,186% x Medicaid HMO amount,24747,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54711,,"34,077 x DRG weight",54711,Other,base rate x DRG weight,46505,,"28,966 x DRG weight",46505,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13305,,DRG base rate x DRG weight + capital per discharge,13305,Other,100% of NY Medicaid HMO DRG,13305,,100% x Medicaid HMO amount,13305,Other,100% of NY Medicaid HMO DRG,13305,,100% x Medicaid HMO amount,13305,Other,100% of NY Medicaid HMO DRG,13305,,100% x Medicaid HMO amount,13305,Other,100% of NY Medicaid HMO DRG,29936,,225% x Medicaid HMO amount,29936,Other,225% of NY Medicaid HMO DRG,29936,,225% x Medicaid HMO amount,29936,Other,225% of NY Medicaid HMO DRG,29936,,225% x Medicaid HMO amount,29936,Other,225% of NY Medicaid HMO DRG,29936,,225% x Medicaid HMO amount,29936,Other,225% of NY Medicaid HMO DRG,18627,,140% x Medicaid HMO amount,18627,Other,140% of NY Medicaid HMO DRG,29936,,225% x Medicaid HMO amount,29936,Other,225% of NY Medicaid HMO DRG,36589,,275% x Medicaid HMO amount,36589,Other,275% of NY Medicaid HMO DRG,43108,,324% x Medicaid HMO amount,43108,Other,324% of NY Medicaid HMO DRG,28606,,215% x Medicaid HMO amount,28606,Other,215% of NY Medicaid HMO DRG,28606,,215% x Medicaid HMO amount,28606,Other,215% of NY Medicaid HMO DRG,16631,,125% x Medicaid HMO amount,16631,Other,125% of NY Medicaid HMO DRG,0.01,72453,
Cholecystectomy except laparoscopic,262-3,APR-DRG,,,,,,,,inpatient,,,334695.61,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,123515,,"45,128 x DRG weight",123515,Other,base rate x DRG weight,111163,,"40,615 x DRG weight",111163,Other,base rate x DRG weight,104989,,"38,359 x DRG weight",104989,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41112,,186% x Medicaid HMO amount,41112,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,93269,,"34,077 x DRG weight",93269,Other,base rate x DRG weight,79280,,"28,966 x DRG weight",79280,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22103,,DRG base rate x DRG weight + capital per discharge,22103,Other,100% of NY Medicaid HMO DRG,22103,,100% x Medicaid HMO amount,22103,Other,100% of NY Medicaid HMO DRG,22103,,100% x Medicaid HMO amount,22103,Other,100% of NY Medicaid HMO DRG,22103,,100% x Medicaid HMO amount,22103,Other,100% of NY Medicaid HMO DRG,49732,,225% x Medicaid HMO amount,49732,Other,225% of NY Medicaid HMO DRG,49732,,225% x Medicaid HMO amount,49732,Other,225% of NY Medicaid HMO DRG,49732,,225% x Medicaid HMO amount,49732,Other,225% of NY Medicaid HMO DRG,49732,,225% x Medicaid HMO amount,49732,Other,225% of NY Medicaid HMO DRG,30944,,140% x Medicaid HMO amount,30944,Other,140% of NY Medicaid HMO DRG,49732,,225% x Medicaid HMO amount,49732,Other,225% of NY Medicaid HMO DRG,60783,,275% x Medicaid HMO amount,60783,Other,275% of NY Medicaid HMO DRG,71614,,324% x Medicaid HMO amount,71614,Other,324% of NY Medicaid HMO DRG,47521,,215% x Medicaid HMO amount,47521,Other,215% of NY Medicaid HMO DRG,47521,,215% x Medicaid HMO amount,47521,Other,215% of NY Medicaid HMO DRG,27629,,125% x Medicaid HMO amount,27629,Other,125% of NY Medicaid HMO DRG,0.01,123515,
Cholecystectomy except laparoscopic,262-4,APR-DRG,,,,,,,,inpatient,,,334695.61,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,273187,,"45,128 x DRG weight",273187,Other,base rate x DRG weight,245867,,"40,615 x DRG weight",245867,Other,base rate x DRG weight,232210,,"38,359 x DRG weight",232210,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,89077,,186% x Medicaid HMO amount,89077,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,206289,,"34,077 x DRG weight",206289,Other,base rate x DRG weight,175349,,"28,966 x DRG weight",175349,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47891,,DRG base rate x DRG weight + capital per discharge,47891,Other,100% of NY Medicaid HMO DRG,47891,,100% x Medicaid HMO amount,47891,Other,100% of NY Medicaid HMO DRG,47891,,100% x Medicaid HMO amount,47891,Other,100% of NY Medicaid HMO DRG,47891,,100% x Medicaid HMO amount,47891,Other,100% of NY Medicaid HMO DRG,107755,,225% x Medicaid HMO amount,107755,Other,225% of NY Medicaid HMO DRG,107755,,225% x Medicaid HMO amount,107755,Other,225% of NY Medicaid HMO DRG,107755,,225% x Medicaid HMO amount,107755,Other,225% of NY Medicaid HMO DRG,107755,,225% x Medicaid HMO amount,107755,Other,225% of NY Medicaid HMO DRG,67047,,140% x Medicaid HMO amount,67047,Other,140% of NY Medicaid HMO DRG,107755,,225% x Medicaid HMO amount,107755,Other,225% of NY Medicaid HMO DRG,131700,,275% x Medicaid HMO amount,131700,Other,275% of NY Medicaid HMO DRG,155167,,324% x Medicaid HMO amount,155167,Other,324% of NY Medicaid HMO DRG,102966,,215% x Medicaid HMO amount,102966,Other,215% of NY Medicaid HMO DRG,102966,,215% x Medicaid HMO amount,102966,Other,215% of NY Medicaid HMO DRG,59864,,125% x Medicaid HMO amount,59864,Other,125% of NY Medicaid HMO DRG,0.01,273187,
Laparoscopic cholecystectomy,263-1,APR-DRG,,,,,,,,inpatient,,,125328.27,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39920,,"45,128 x DRG weight",39920,Other,base rate x DRG weight,35928,,"40,615 x DRG weight",35928,Other,base rate x DRG weight,33932,,"38,359 x DRG weight",33932,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14320,,186% x Medicaid HMO amount,14320,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30145,,"34,077 x DRG weight",30145,Other,base rate x DRG weight,25623,,"28,966 x DRG weight",25623,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7699,,DRG base rate x DRG weight + capital per discharge,7699,Other,100% of NY Medicaid HMO DRG,7699,,100% x Medicaid HMO amount,7699,Other,100% of NY Medicaid HMO DRG,7699,,100% x Medicaid HMO amount,7699,Other,100% of NY Medicaid HMO DRG,7699,,100% x Medicaid HMO amount,7699,Other,100% of NY Medicaid HMO DRG,17323,,225% x Medicaid HMO amount,17323,Other,225% of NY Medicaid HMO DRG,17323,,225% x Medicaid HMO amount,17323,Other,225% of NY Medicaid HMO DRG,17323,,225% x Medicaid HMO amount,17323,Other,225% of NY Medicaid HMO DRG,17323,,225% x Medicaid HMO amount,17323,Other,225% of NY Medicaid HMO DRG,10779,,140% x Medicaid HMO amount,10779,Other,140% of NY Medicaid HMO DRG,17323,,225% x Medicaid HMO amount,17323,Other,225% of NY Medicaid HMO DRG,21172,,275% x Medicaid HMO amount,21172,Other,275% of NY Medicaid HMO DRG,24945,,324% x Medicaid HMO amount,24945,Other,324% of NY Medicaid HMO DRG,16553,,215% x Medicaid HMO amount,16553,Other,215% of NY Medicaid HMO DRG,16553,,215% x Medicaid HMO amount,16553,Other,215% of NY Medicaid HMO DRG,9624,,125% x Medicaid HMO amount,9624,Other,125% of NY Medicaid HMO DRG,0.01,39920,
Laparoscopic cholecystectomy,263-2,APR-DRG,,,,,,,,inpatient,,,151224.13,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52876,,"45,128 x DRG weight",52876,Other,base rate x DRG weight,47589,,"40,615 x DRG weight",47589,Other,base rate x DRG weight,44945,,"38,359 x DRG weight",44945,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18474,,186% x Medicaid HMO amount,18474,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39928,,"34,077 x DRG weight",39928,Other,base rate x DRG weight,33939,,"28,966 x DRG weight",33939,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9932,,DRG base rate x DRG weight + capital per discharge,9932,Other,100% of NY Medicaid HMO DRG,9932,,100% x Medicaid HMO amount,9932,Other,100% of NY Medicaid HMO DRG,9932,,100% x Medicaid HMO amount,9932,Other,100% of NY Medicaid HMO DRG,9932,,100% x Medicaid HMO amount,9932,Other,100% of NY Medicaid HMO DRG,22347,,225% x Medicaid HMO amount,22347,Other,225% of NY Medicaid HMO DRG,22347,,225% x Medicaid HMO amount,22347,Other,225% of NY Medicaid HMO DRG,22347,,225% x Medicaid HMO amount,22347,Other,225% of NY Medicaid HMO DRG,22347,,225% x Medicaid HMO amount,22347,Other,225% of NY Medicaid HMO DRG,13905,,140% x Medicaid HMO amount,13905,Other,140% of NY Medicaid HMO DRG,22347,,225% x Medicaid HMO amount,22347,Other,225% of NY Medicaid HMO DRG,27313,,275% x Medicaid HMO amount,27313,Other,275% of NY Medicaid HMO DRG,32180,,324% x Medicaid HMO amount,32180,Other,324% of NY Medicaid HMO DRG,21354,,215% x Medicaid HMO amount,21354,Other,215% of NY Medicaid HMO DRG,21354,,215% x Medicaid HMO amount,21354,Other,215% of NY Medicaid HMO DRG,12415,,125% x Medicaid HMO amount,12415,Other,125% of NY Medicaid HMO DRG,0.01,52876,
Laparoscopic cholecystectomy,263-3,APR-DRG,,,,,,,,inpatient,,,183923.21,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,72900,,"45,128 x DRG weight",72900,Other,base rate x DRG weight,65609,,"40,615 x DRG weight",65609,Other,base rate x DRG weight,61965,,"38,359 x DRG weight",61965,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24891,,186% x Medicaid HMO amount,24891,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55048,,"34,077 x DRG weight",55048,Other,base rate x DRG weight,46792,,"28,966 x DRG weight",46792,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13382,,DRG base rate x DRG weight + capital per discharge,13382,Other,100% of NY Medicaid HMO DRG,13382,,100% x Medicaid HMO amount,13382,Other,100% of NY Medicaid HMO DRG,13382,,100% x Medicaid HMO amount,13382,Other,100% of NY Medicaid HMO DRG,13382,,100% x Medicaid HMO amount,13382,Other,100% of NY Medicaid HMO DRG,30110,,225% x Medicaid HMO amount,30110,Other,225% of NY Medicaid HMO DRG,30110,,225% x Medicaid HMO amount,30110,Other,225% of NY Medicaid HMO DRG,30110,,225% x Medicaid HMO amount,30110,Other,225% of NY Medicaid HMO DRG,30110,,225% x Medicaid HMO amount,30110,Other,225% of NY Medicaid HMO DRG,18735,,140% x Medicaid HMO amount,18735,Other,140% of NY Medicaid HMO DRG,30110,,225% x Medicaid HMO amount,30110,Other,225% of NY Medicaid HMO DRG,36801,,275% x Medicaid HMO amount,36801,Other,275% of NY Medicaid HMO DRG,43358,,324% x Medicaid HMO amount,43358,Other,324% of NY Medicaid HMO DRG,28771,,215% x Medicaid HMO amount,28771,Other,215% of NY Medicaid HMO DRG,28771,,215% x Medicaid HMO amount,28771,Other,215% of NY Medicaid HMO DRG,16728,,125% x Medicaid HMO amount,16728,Other,125% of NY Medicaid HMO DRG,0.01,72900,
Laparoscopic cholecystectomy,263-4,APR-DRG,,,,,,,,inpatient,,,386814.04,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,165606,,"45,128 x DRG weight",165606,Other,base rate x DRG weight,149045,,"40,615 x DRG weight",149045,Other,base rate x DRG weight,140766,,"38,359 x DRG weight",140766,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54600,,186% x Medicaid HMO amount,54600,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,125052,,"34,077 x DRG weight",125052,Other,base rate x DRG weight,106297,,"28,966 x DRG weight",106297,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29355,,DRG base rate x DRG weight + capital per discharge,29355,Other,100% of NY Medicaid HMO DRG,29355,,100% x Medicaid HMO amount,29355,Other,100% of NY Medicaid HMO DRG,29355,,100% x Medicaid HMO amount,29355,Other,100% of NY Medicaid HMO DRG,29355,,100% x Medicaid HMO amount,29355,Other,100% of NY Medicaid HMO DRG,66049,,225% x Medicaid HMO amount,66049,Other,225% of NY Medicaid HMO DRG,66049,,225% x Medicaid HMO amount,66049,Other,225% of NY Medicaid HMO DRG,66049,,225% x Medicaid HMO amount,66049,Other,225% of NY Medicaid HMO DRG,66049,,225% x Medicaid HMO amount,66049,Other,225% of NY Medicaid HMO DRG,41097,,140% x Medicaid HMO amount,41097,Other,140% of NY Medicaid HMO DRG,66049,,225% x Medicaid HMO amount,66049,Other,225% of NY Medicaid HMO DRG,80726,,275% x Medicaid HMO amount,80726,Other,275% of NY Medicaid HMO DRG,95110,,324% x Medicaid HMO amount,95110,Other,324% of NY Medicaid HMO DRG,63113,,215% x Medicaid HMO amount,63113,Other,215% of NY Medicaid HMO DRG,63113,,215% x Medicaid HMO amount,63113,Other,215% of NY Medicaid HMO DRG,36694,,125% x Medicaid HMO amount,36694,Other,125% of NY Medicaid HMO DRG,0.01,165606,
"Other hepatobiliary, pancreas & abdominal procedures",264-1,APR-DRG,,,,,,,,inpatient,,,116577.44,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60196,,"45,128 x DRG weight",60196,Other,base rate x DRG weight,54176,,"40,615 x DRG weight",54176,Other,base rate x DRG weight,51167,,"38,359 x DRG weight",51167,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20819,,186% x Medicaid HMO amount,20819,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45455,,"34,077 x DRG weight",45455,Other,base rate x DRG weight,38638,,"28,966 x DRG weight",38638,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11193,,DRG base rate x DRG weight + capital per discharge,11193,Other,100% of NY Medicaid HMO DRG,11193,,100% x Medicaid HMO amount,11193,Other,100% of NY Medicaid HMO DRG,11193,,100% x Medicaid HMO amount,11193,Other,100% of NY Medicaid HMO DRG,11193,,100% x Medicaid HMO amount,11193,Other,100% of NY Medicaid HMO DRG,25184,,225% x Medicaid HMO amount,25184,Other,225% of NY Medicaid HMO DRG,25184,,225% x Medicaid HMO amount,25184,Other,225% of NY Medicaid HMO DRG,25184,,225% x Medicaid HMO amount,25184,Other,225% of NY Medicaid HMO DRG,25184,,225% x Medicaid HMO amount,25184,Other,225% of NY Medicaid HMO DRG,15670,,140% x Medicaid HMO amount,15670,Other,140% of NY Medicaid HMO DRG,25184,,225% x Medicaid HMO amount,25184,Other,225% of NY Medicaid HMO DRG,30781,,275% x Medicaid HMO amount,30781,Other,275% of NY Medicaid HMO DRG,36265,,324% x Medicaid HMO amount,36265,Other,324% of NY Medicaid HMO DRG,24065,,215% x Medicaid HMO amount,24065,Other,215% of NY Medicaid HMO DRG,24065,,215% x Medicaid HMO amount,24065,Other,215% of NY Medicaid HMO DRG,13991,,125% x Medicaid HMO amount,13991,Other,125% of NY Medicaid HMO DRG,0.01,60196,
"Other hepatobiliary, pancreas & abdominal procedures",264-2,APR-DRG,,,,,,,,inpatient,,,248042.73,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,68238,,"45,128 x DRG weight",68238,Other,base rate x DRG weight,61414,,"40,615 x DRG weight",61414,Other,base rate x DRG weight,58003,,"38,359 x DRG weight",58003,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23395,,186% x Medicaid HMO amount,23395,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51528,,"34,077 x DRG weight",51528,Other,base rate x DRG weight,43799,,"28,966 x DRG weight",43799,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12578,,DRG base rate x DRG weight + capital per discharge,12578,Other,100% of NY Medicaid HMO DRG,12578,,100% x Medicaid HMO amount,12578,Other,100% of NY Medicaid HMO DRG,12578,,100% x Medicaid HMO amount,12578,Other,100% of NY Medicaid HMO DRG,12578,,100% x Medicaid HMO amount,12578,Other,100% of NY Medicaid HMO DRG,28301,,225% x Medicaid HMO amount,28301,Other,225% of NY Medicaid HMO DRG,28301,,225% x Medicaid HMO amount,28301,Other,225% of NY Medicaid HMO DRG,28301,,225% x Medicaid HMO amount,28301,Other,225% of NY Medicaid HMO DRG,28301,,225% x Medicaid HMO amount,28301,Other,225% of NY Medicaid HMO DRG,17609,,140% x Medicaid HMO amount,17609,Other,140% of NY Medicaid HMO DRG,28301,,225% x Medicaid HMO amount,28301,Other,225% of NY Medicaid HMO DRG,34590,,275% x Medicaid HMO amount,34590,Other,275% of NY Medicaid HMO DRG,40753,,324% x Medicaid HMO amount,40753,Other,324% of NY Medicaid HMO DRG,27043,,215% x Medicaid HMO amount,27043,Other,215% of NY Medicaid HMO DRG,27043,,215% x Medicaid HMO amount,27043,Other,215% of NY Medicaid HMO DRG,15723,,125% x Medicaid HMO amount,15723,Other,125% of NY Medicaid HMO DRG,0.01,68238,
"Other hepatobiliary, pancreas & abdominal procedures",264-3,APR-DRG,,,,,,,,inpatient,,,193423.85,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,128908,,"45,128 x DRG weight",128908,Other,base rate x DRG weight,116017,,"40,615 x DRG weight",116017,Other,base rate x DRG weight,109572,,"38,359 x DRG weight",109572,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42840,,186% x Medicaid HMO amount,42840,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,97341,,"34,077 x DRG weight",97341,Other,base rate x DRG weight,82741,,"28,966 x DRG weight",82741,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23032,,DRG base rate x DRG weight + capital per discharge,23032,Other,100% of NY Medicaid HMO DRG,23032,,100% x Medicaid HMO amount,23032,Other,100% of NY Medicaid HMO DRG,23032,,100% x Medicaid HMO amount,23032,Other,100% of NY Medicaid HMO DRG,23032,,100% x Medicaid HMO amount,23032,Other,100% of NY Medicaid HMO DRG,51822,,225% x Medicaid HMO amount,51822,Other,225% of NY Medicaid HMO DRG,51822,,225% x Medicaid HMO amount,51822,Other,225% of NY Medicaid HMO DRG,51822,,225% x Medicaid HMO amount,51822,Other,225% of NY Medicaid HMO DRG,51822,,225% x Medicaid HMO amount,51822,Other,225% of NY Medicaid HMO DRG,32245,,140% x Medicaid HMO amount,32245,Other,140% of NY Medicaid HMO DRG,51822,,225% x Medicaid HMO amount,51822,Other,225% of NY Medicaid HMO DRG,63338,,275% x Medicaid HMO amount,63338,Other,275% of NY Medicaid HMO DRG,74624,,324% x Medicaid HMO amount,74624,Other,324% of NY Medicaid HMO DRG,49519,,215% x Medicaid HMO amount,49519,Other,215% of NY Medicaid HMO DRG,49519,,215% x Medicaid HMO amount,49519,Other,215% of NY Medicaid HMO DRG,28790,,125% x Medicaid HMO amount,28790,Other,125% of NY Medicaid HMO DRG,0.01,128908,
"Other hepatobiliary, pancreas & abdominal procedures",264-4,APR-DRG,,,,,,,,inpatient,,,753257.14,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,277745,,"45,128 x DRG weight",277745,Other,base rate x DRG weight,249969,,"40,615 x DRG weight",249969,Other,base rate x DRG weight,236084,,"38,359 x DRG weight",236084,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,90539,,186% x Medicaid HMO amount,90539,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,209730,,"34,077 x DRG weight",209730,Other,base rate x DRG weight,178274,,"28,966 x DRG weight",178274,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48677,,DRG base rate x DRG weight + capital per discharge,48677,Other,100% of NY Medicaid HMO DRG,48677,,100% x Medicaid HMO amount,48677,Other,100% of NY Medicaid HMO DRG,48677,,100% x Medicaid HMO amount,48677,Other,100% of NY Medicaid HMO DRG,48677,,100% x Medicaid HMO amount,48677,Other,100% of NY Medicaid HMO DRG,109523,,225% x Medicaid HMO amount,109523,Other,225% of NY Medicaid HMO DRG,109523,,225% x Medicaid HMO amount,109523,Other,225% of NY Medicaid HMO DRG,109523,,225% x Medicaid HMO amount,109523,Other,225% of NY Medicaid HMO DRG,109523,,225% x Medicaid HMO amount,109523,Other,225% of NY Medicaid HMO DRG,68148,,140% x Medicaid HMO amount,68148,Other,140% of NY Medicaid HMO DRG,109523,,225% x Medicaid HMO amount,109523,Other,225% of NY Medicaid HMO DRG,133862,,275% x Medicaid HMO amount,133862,Other,275% of NY Medicaid HMO DRG,157713,,324% x Medicaid HMO amount,157713,Other,324% of NY Medicaid HMO DRG,104656,,215% x Medicaid HMO amount,104656,Other,215% of NY Medicaid HMO DRG,104656,,215% x Medicaid HMO amount,104656,Other,215% of NY Medicaid HMO DRG,60846,,125% x Medicaid HMO amount,60846,Other,125% of NY Medicaid HMO DRG,0.01,277745,
Hepatic coma & other major acute liver disorders,279-1,APR-DRG,,,,,,,,inpatient,,,104262,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24802,,"45,128 x DRG weight",24802,Other,base rate x DRG weight,22322,,"40,615 x DRG weight",22322,Other,base rate x DRG weight,21082,,"38,359 x DRG weight",21082,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9475,,186% x Medicaid HMO amount,9475,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18729,,"34,077 x DRG weight",18729,Other,base rate x DRG weight,15920,,"28,966 x DRG weight",15920,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5094,,DRG base rate x DRG weight + capital per discharge,5094,Other,100% of NY Medicaid HMO DRG,5094,,100% x Medicaid HMO amount,5094,Other,100% of NY Medicaid HMO DRG,5094,,100% x Medicaid HMO amount,5094,Other,100% of NY Medicaid HMO DRG,5094,,100% x Medicaid HMO amount,5094,Other,100% of NY Medicaid HMO DRG,11462,,225% x Medicaid HMO amount,11462,Other,225% of NY Medicaid HMO DRG,11462,,225% x Medicaid HMO amount,11462,Other,225% of NY Medicaid HMO DRG,11462,,225% x Medicaid HMO amount,11462,Other,225% of NY Medicaid HMO DRG,11462,,225% x Medicaid HMO amount,11462,Other,225% of NY Medicaid HMO DRG,7132,,140% x Medicaid HMO amount,7132,Other,140% of NY Medicaid HMO DRG,11462,,225% x Medicaid HMO amount,11462,Other,225% of NY Medicaid HMO DRG,14009,,275% x Medicaid HMO amount,14009,Other,275% of NY Medicaid HMO DRG,16505,,324% x Medicaid HMO amount,16505,Other,324% of NY Medicaid HMO DRG,10952,,215% x Medicaid HMO amount,10952,Other,215% of NY Medicaid HMO DRG,10952,,215% x Medicaid HMO amount,10952,Other,215% of NY Medicaid HMO DRG,6368,,125% x Medicaid HMO amount,6368,Other,125% of NY Medicaid HMO DRG,0.01,24802,
Hepatic coma & other major acute liver disorders,279-2,APR-DRG,,,,,,,,inpatient,,,136931.56,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35304,,"45,128 x DRG weight",35304,Other,base rate x DRG weight,31773,,"40,615 x DRG weight",31773,Other,base rate x DRG weight,30008,,"38,359 x DRG weight",30008,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12841,,186% x Medicaid HMO amount,12841,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26658,,"34,077 x DRG weight",26658,Other,base rate x DRG weight,22660,,"28,966 x DRG weight",22660,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6904,,DRG base rate x DRG weight + capital per discharge,6904,Other,100% of NY Medicaid HMO DRG,6904,,100% x Medicaid HMO amount,6904,Other,100% of NY Medicaid HMO DRG,6904,,100% x Medicaid HMO amount,6904,Other,100% of NY Medicaid HMO DRG,6904,,100% x Medicaid HMO amount,6904,Other,100% of NY Medicaid HMO DRG,15534,,225% x Medicaid HMO amount,15534,Other,225% of NY Medicaid HMO DRG,15534,,225% x Medicaid HMO amount,15534,Other,225% of NY Medicaid HMO DRG,15534,,225% x Medicaid HMO amount,15534,Other,225% of NY Medicaid HMO DRG,15534,,225% x Medicaid HMO amount,15534,Other,225% of NY Medicaid HMO DRG,9666,,140% x Medicaid HMO amount,9666,Other,140% of NY Medicaid HMO DRG,15534,,225% x Medicaid HMO amount,15534,Other,225% of NY Medicaid HMO DRG,18986,,275% x Medicaid HMO amount,18986,Other,275% of NY Medicaid HMO DRG,22369,,324% x Medicaid HMO amount,22369,Other,324% of NY Medicaid HMO DRG,14844,,215% x Medicaid HMO amount,14844,Other,215% of NY Medicaid HMO DRG,14844,,215% x Medicaid HMO amount,14844,Other,215% of NY Medicaid HMO DRG,8630,,125% x Medicaid HMO amount,8630,Other,125% of NY Medicaid HMO DRG,0.01,35304,
Hepatic coma & other major acute liver disorders,279-3,APR-DRG,,,,,,,,inpatient,,,281532.38,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,61270,,"45,128 x DRG weight",61270,Other,base rate x DRG weight,55143,,"40,615 x DRG weight",55143,Other,base rate x DRG weight,52080,,"38,359 x DRG weight",52080,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21163,,186% x Medicaid HMO amount,21163,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46266,,"34,077 x DRG weight",46266,Other,base rate x DRG weight,39327,,"28,966 x DRG weight",39327,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11378,,DRG base rate x DRG weight + capital per discharge,11378,Other,100% of NY Medicaid HMO DRG,11378,,100% x Medicaid HMO amount,11378,Other,100% of NY Medicaid HMO DRG,11378,,100% x Medicaid HMO amount,11378,Other,100% of NY Medicaid HMO DRG,11378,,100% x Medicaid HMO amount,11378,Other,100% of NY Medicaid HMO DRG,25601,,225% x Medicaid HMO amount,25601,Other,225% of NY Medicaid HMO DRG,25601,,225% x Medicaid HMO amount,25601,Other,225% of NY Medicaid HMO DRG,25601,,225% x Medicaid HMO amount,25601,Other,225% of NY Medicaid HMO DRG,25601,,225% x Medicaid HMO amount,25601,Other,225% of NY Medicaid HMO DRG,15929,,140% x Medicaid HMO amount,15929,Other,140% of NY Medicaid HMO DRG,25601,,225% x Medicaid HMO amount,25601,Other,225% of NY Medicaid HMO DRG,31290,,275% x Medicaid HMO amount,31290,Other,275% of NY Medicaid HMO DRG,36865,,324% x Medicaid HMO amount,36865,Other,324% of NY Medicaid HMO DRG,24463,,215% x Medicaid HMO amount,24463,Other,215% of NY Medicaid HMO DRG,24463,,215% x Medicaid HMO amount,24463,Other,215% of NY Medicaid HMO DRG,14223,,125% x Medicaid HMO amount,14223,Other,125% of NY Medicaid HMO DRG,0.01,61270,
Hepatic coma & other major acute liver disorders,279-4,APR-DRG,,,,,,,,inpatient,,,269612.32,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,167199,,"45,128 x DRG weight",167199,Other,base rate x DRG weight,150479,,"40,615 x DRG weight",150479,Other,base rate x DRG weight,142120,,"38,359 x DRG weight",142120,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55112,,186% x Medicaid HMO amount,55112,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,126255,,"34,077 x DRG weight",126255,Other,base rate x DRG weight,107319,,"28,966 x DRG weight",107319,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29630,,DRG base rate x DRG weight + capital per discharge,29630,Other,100% of NY Medicaid HMO DRG,29630,,100% x Medicaid HMO amount,29630,Other,100% of NY Medicaid HMO DRG,29630,,100% x Medicaid HMO amount,29630,Other,100% of NY Medicaid HMO DRG,29630,,100% x Medicaid HMO amount,29630,Other,100% of NY Medicaid HMO DRG,66668,,225% x Medicaid HMO amount,66668,Other,225% of NY Medicaid HMO DRG,66668,,225% x Medicaid HMO amount,66668,Other,225% of NY Medicaid HMO DRG,66668,,225% x Medicaid HMO amount,66668,Other,225% of NY Medicaid HMO DRG,66668,,225% x Medicaid HMO amount,66668,Other,225% of NY Medicaid HMO DRG,41482,,140% x Medicaid HMO amount,41482,Other,140% of NY Medicaid HMO DRG,66668,,225% x Medicaid HMO amount,66668,Other,225% of NY Medicaid HMO DRG,81483,,275% x Medicaid HMO amount,81483,Other,275% of NY Medicaid HMO DRG,96001,,324% x Medicaid HMO amount,96001,Other,324% of NY Medicaid HMO DRG,63705,,215% x Medicaid HMO amount,63705,Other,215% of NY Medicaid HMO DRG,63705,,215% x Medicaid HMO amount,63705,Other,215% of NY Medicaid HMO DRG,37038,,125% x Medicaid HMO amount,37038,Other,125% of NY Medicaid HMO DRG,0.01,167199,
Alcoholic liver disease,280-1,APR-DRG,,,,,,,,inpatient,,,112061.4,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24184,,"45,128 x DRG weight",24184,Other,base rate x DRG weight,21766,,"40,615 x DRG weight",21766,Other,base rate x DRG weight,20557,,"38,359 x DRG weight",20557,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9278,,186% x Medicaid HMO amount,9278,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18262,,"34,077 x DRG weight",18262,Other,base rate x DRG weight,15523,,"28,966 x DRG weight",15523,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4988,,DRG base rate x DRG weight + capital per discharge,4988,Other,100% of NY Medicaid HMO DRG,4988,,100% x Medicaid HMO amount,4988,Other,100% of NY Medicaid HMO DRG,4988,,100% x Medicaid HMO amount,4988,Other,100% of NY Medicaid HMO DRG,4988,,100% x Medicaid HMO amount,4988,Other,100% of NY Medicaid HMO DRG,11223,,225% x Medicaid HMO amount,11223,Other,225% of NY Medicaid HMO DRG,11223,,225% x Medicaid HMO amount,11223,Other,225% of NY Medicaid HMO DRG,11223,,225% x Medicaid HMO amount,11223,Other,225% of NY Medicaid HMO DRG,11223,,225% x Medicaid HMO amount,11223,Other,225% of NY Medicaid HMO DRG,6983,,140% x Medicaid HMO amount,6983,Other,140% of NY Medicaid HMO DRG,11223,,225% x Medicaid HMO amount,11223,Other,225% of NY Medicaid HMO DRG,13717,,275% x Medicaid HMO amount,13717,Other,275% of NY Medicaid HMO DRG,16161,,324% x Medicaid HMO amount,16161,Other,324% of NY Medicaid HMO DRG,10724,,215% x Medicaid HMO amount,10724,Other,215% of NY Medicaid HMO DRG,10724,,215% x Medicaid HMO amount,10724,Other,215% of NY Medicaid HMO DRG,6235,,125% x Medicaid HMO amount,6235,Other,125% of NY Medicaid HMO DRG,0.01,24184,
Alcoholic liver disease,280-2,APR-DRG,,,,,,,,inpatient,,,131466.98,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33981,,"45,128 x DRG weight",33981,Other,base rate x DRG weight,30583,,"40,615 x DRG weight",30583,Other,base rate x DRG weight,28884,,"38,359 x DRG weight",28884,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12417,,186% x Medicaid HMO amount,12417,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25660,,"34,077 x DRG weight",25660,Other,base rate x DRG weight,21811,,"28,966 x DRG weight",21811,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6676,,DRG base rate x DRG weight + capital per discharge,6676,Other,100% of NY Medicaid HMO DRG,6676,,100% x Medicaid HMO amount,6676,Other,100% of NY Medicaid HMO DRG,6676,,100% x Medicaid HMO amount,6676,Other,100% of NY Medicaid HMO DRG,6676,,100% x Medicaid HMO amount,6676,Other,100% of NY Medicaid HMO DRG,15021,,225% x Medicaid HMO amount,15021,Other,225% of NY Medicaid HMO DRG,15021,,225% x Medicaid HMO amount,15021,Other,225% of NY Medicaid HMO DRG,15021,,225% x Medicaid HMO amount,15021,Other,225% of NY Medicaid HMO DRG,15021,,225% x Medicaid HMO amount,15021,Other,225% of NY Medicaid HMO DRG,9346,,140% x Medicaid HMO amount,9346,Other,140% of NY Medicaid HMO DRG,15021,,225% x Medicaid HMO amount,15021,Other,225% of NY Medicaid HMO DRG,18359,,275% x Medicaid HMO amount,18359,Other,275% of NY Medicaid HMO DRG,21630,,324% x Medicaid HMO amount,21630,Other,324% of NY Medicaid HMO DRG,14353,,215% x Medicaid HMO amount,14353,Other,215% of NY Medicaid HMO DRG,14353,,215% x Medicaid HMO amount,14353,Other,215% of NY Medicaid HMO DRG,8345,,125% x Medicaid HMO amount,8345,Other,125% of NY Medicaid HMO DRG,0.01,33981,
Alcoholic liver disease,280-3,APR-DRG,,,,,,,,inpatient,,,176449.92,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,57186,,"45,128 x DRG weight",57186,Other,base rate x DRG weight,51467,,"40,615 x DRG weight",51467,Other,base rate x DRG weight,48609,,"38,359 x DRG weight",48609,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19854,,186% x Medicaid HMO amount,19854,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43182,,"34,077 x DRG weight",43182,Other,base rate x DRG weight,36706,,"28,966 x DRG weight",36706,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10674,,DRG base rate x DRG weight + capital per discharge,10674,Other,100% of NY Medicaid HMO DRG,10674,,100% x Medicaid HMO amount,10674,Other,100% of NY Medicaid HMO DRG,10674,,100% x Medicaid HMO amount,10674,Other,100% of NY Medicaid HMO DRG,10674,,100% x Medicaid HMO amount,10674,Other,100% of NY Medicaid HMO DRG,24017,,225% x Medicaid HMO amount,24017,Other,225% of NY Medicaid HMO DRG,24017,,225% x Medicaid HMO amount,24017,Other,225% of NY Medicaid HMO DRG,24017,,225% x Medicaid HMO amount,24017,Other,225% of NY Medicaid HMO DRG,24017,,225% x Medicaid HMO amount,24017,Other,225% of NY Medicaid HMO DRG,14944,,140% x Medicaid HMO amount,14944,Other,140% of NY Medicaid HMO DRG,24017,,225% x Medicaid HMO amount,24017,Other,225% of NY Medicaid HMO DRG,29354,,275% x Medicaid HMO amount,29354,Other,275% of NY Medicaid HMO DRG,34584,,324% x Medicaid HMO amount,34584,Other,324% of NY Medicaid HMO DRG,22949,,215% x Medicaid HMO amount,22949,Other,215% of NY Medicaid HMO DRG,22949,,215% x Medicaid HMO amount,22949,Other,215% of NY Medicaid HMO DRG,13343,,125% x Medicaid HMO amount,13343,Other,125% of NY Medicaid HMO DRG,0.01,57186,
Alcoholic liver disease,280-4,APR-DRG,,,,,,,,inpatient,,,394717.61,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,153990,,"45,128 x DRG weight",153990,Other,base rate x DRG weight,138591,,"40,615 x DRG weight",138591,Other,base rate x DRG weight,130892,,"38,359 x DRG weight",130892,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50878,,186% x Medicaid HMO amount,50878,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,116281,,"34,077 x DRG weight",116281,Other,base rate x DRG weight,98841,,"28,966 x DRG weight",98841,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27354,,DRG base rate x DRG weight + capital per discharge,27354,Other,100% of NY Medicaid HMO DRG,27354,,100% x Medicaid HMO amount,27354,Other,100% of NY Medicaid HMO DRG,27354,,100% x Medicaid HMO amount,27354,Other,100% of NY Medicaid HMO DRG,27354,,100% x Medicaid HMO amount,27354,Other,100% of NY Medicaid HMO DRG,61547,,225% x Medicaid HMO amount,61547,Other,225% of NY Medicaid HMO DRG,61547,,225% x Medicaid HMO amount,61547,Other,225% of NY Medicaid HMO DRG,61547,,225% x Medicaid HMO amount,61547,Other,225% of NY Medicaid HMO DRG,61547,,225% x Medicaid HMO amount,61547,Other,225% of NY Medicaid HMO DRG,38296,,140% x Medicaid HMO amount,38296,Other,140% of NY Medicaid HMO DRG,61547,,225% x Medicaid HMO amount,61547,Other,225% of NY Medicaid HMO DRG,75224,,275% x Medicaid HMO amount,75224,Other,275% of NY Medicaid HMO DRG,88627,,324% x Medicaid HMO amount,88627,Other,324% of NY Medicaid HMO DRG,58811,,215% x Medicaid HMO amount,58811,Other,215% of NY Medicaid HMO DRG,58811,,215% x Medicaid HMO amount,58811,Other,215% of NY Medicaid HMO DRG,34193,,125% x Medicaid HMO amount,34193,Other,125% of NY Medicaid HMO DRG,0.01,153990,
Malignancy of hepatobiliary system & pancreas,281-1,APR-DRG,,,,,,,,inpatient,,,140808.99,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30105,,"45,128 x DRG weight",30105,Other,base rate x DRG weight,27094,,"40,615 x DRG weight",27094,Other,base rate x DRG weight,25589,,"38,359 x DRG weight",25589,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11175,,186% x Medicaid HMO amount,11175,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22733,,"34,077 x DRG weight",22733,Other,base rate x DRG weight,19323,,"28,966 x DRG weight",19323,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6008,,DRG base rate x DRG weight + capital per discharge,6008,Other,100% of NY Medicaid HMO DRG,6008,,100% x Medicaid HMO amount,6008,Other,100% of NY Medicaid HMO DRG,6008,,100% x Medicaid HMO amount,6008,Other,100% of NY Medicaid HMO DRG,6008,,100% x Medicaid HMO amount,6008,Other,100% of NY Medicaid HMO DRG,13518,,225% x Medicaid HMO amount,13518,Other,225% of NY Medicaid HMO DRG,13518,,225% x Medicaid HMO amount,13518,Other,225% of NY Medicaid HMO DRG,13518,,225% x Medicaid HMO amount,13518,Other,225% of NY Medicaid HMO DRG,13518,,225% x Medicaid HMO amount,13518,Other,225% of NY Medicaid HMO DRG,8411,,140% x Medicaid HMO amount,8411,Other,140% of NY Medicaid HMO DRG,13518,,225% x Medicaid HMO amount,13518,Other,225% of NY Medicaid HMO DRG,16522,,275% x Medicaid HMO amount,16522,Other,275% of NY Medicaid HMO DRG,19466,,324% x Medicaid HMO amount,19466,Other,324% of NY Medicaid HMO DRG,12917,,215% x Medicaid HMO amount,12917,Other,215% of NY Medicaid HMO DRG,12917,,215% x Medicaid HMO amount,12917,Other,215% of NY Medicaid HMO DRG,7510,,125% x Medicaid HMO amount,7510,Other,125% of NY Medicaid HMO DRG,0.01,30105,
Malignancy of hepatobiliary system & pancreas,281-2,APR-DRG,,,,,,,,inpatient,,,140808.99,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42429,,"45,128 x DRG weight",42429,Other,base rate x DRG weight,38186,,"40,615 x DRG weight",38186,Other,base rate x DRG weight,36065,,"38,359 x DRG weight",36065,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15126,,186% x Medicaid HMO amount,15126,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32039,,"34,077 x DRG weight",32039,Other,base rate x DRG weight,27234,,"28,966 x DRG weight",27234,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8132,,DRG base rate x DRG weight + capital per discharge,8132,Other,100% of NY Medicaid HMO DRG,8132,,100% x Medicaid HMO amount,8132,Other,100% of NY Medicaid HMO DRG,8132,,100% x Medicaid HMO amount,8132,Other,100% of NY Medicaid HMO DRG,8132,,100% x Medicaid HMO amount,8132,Other,100% of NY Medicaid HMO DRG,18297,,225% x Medicaid HMO amount,18297,Other,225% of NY Medicaid HMO DRG,18297,,225% x Medicaid HMO amount,18297,Other,225% of NY Medicaid HMO DRG,18297,,225% x Medicaid HMO amount,18297,Other,225% of NY Medicaid HMO DRG,18297,,225% x Medicaid HMO amount,18297,Other,225% of NY Medicaid HMO DRG,11385,,140% x Medicaid HMO amount,11385,Other,140% of NY Medicaid HMO DRG,18297,,225% x Medicaid HMO amount,18297,Other,225% of NY Medicaid HMO DRG,22363,,275% x Medicaid HMO amount,22363,Other,275% of NY Medicaid HMO DRG,26348,,324% x Medicaid HMO amount,26348,Other,324% of NY Medicaid HMO DRG,17484,,215% x Medicaid HMO amount,17484,Other,215% of NY Medicaid HMO DRG,17484,,215% x Medicaid HMO amount,17484,Other,215% of NY Medicaid HMO DRG,10165,,125% x Medicaid HMO amount,10165,Other,125% of NY Medicaid HMO DRG,0.01,42429,
Malignancy of hepatobiliary system & pancreas,281-3,APR-DRG,,,,,,,,inpatient,,,144959.85,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,62191,,"45,128 x DRG weight",62191,Other,base rate x DRG weight,55972,,"40,615 x DRG weight",55972,Other,base rate x DRG weight,52863,,"38,359 x DRG weight",52863,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21457,,186% x Medicaid HMO amount,21457,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46962,,"34,077 x DRG weight",46962,Other,base rate x DRG weight,39918,,"28,966 x DRG weight",39918,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11536,,DRG base rate x DRG weight + capital per discharge,11536,Other,100% of NY Medicaid HMO DRG,11536,,100% x Medicaid HMO amount,11536,Other,100% of NY Medicaid HMO DRG,11536,,100% x Medicaid HMO amount,11536,Other,100% of NY Medicaid HMO DRG,11536,,100% x Medicaid HMO amount,11536,Other,100% of NY Medicaid HMO DRG,25956,,225% x Medicaid HMO amount,25956,Other,225% of NY Medicaid HMO DRG,25956,,225% x Medicaid HMO amount,25956,Other,225% of NY Medicaid HMO DRG,25956,,225% x Medicaid HMO amount,25956,Other,225% of NY Medicaid HMO DRG,25956,,225% x Medicaid HMO amount,25956,Other,225% of NY Medicaid HMO DRG,16150,,140% x Medicaid HMO amount,16150,Other,140% of NY Medicaid HMO DRG,25956,,225% x Medicaid HMO amount,25956,Other,225% of NY Medicaid HMO DRG,31724,,275% x Medicaid HMO amount,31724,Other,275% of NY Medicaid HMO DRG,37377,,324% x Medicaid HMO amount,37377,Other,324% of NY Medicaid HMO DRG,24802,,215% x Medicaid HMO amount,24802,Other,215% of NY Medicaid HMO DRG,24802,,215% x Medicaid HMO amount,24802,Other,215% of NY Medicaid HMO DRG,14420,,125% x Medicaid HMO amount,14420,Other,125% of NY Medicaid HMO DRG,0.01,62191,
Malignancy of hepatobiliary system & pancreas,281-4,APR-DRG,,,,,,,,inpatient,,,394655.48,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,109142,,"45,128 x DRG weight",109142,Other,base rate x DRG weight,98227,,"40,615 x DRG weight",98227,Other,base rate x DRG weight,92771,,"38,359 x DRG weight",92771,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36504,,186% x Medicaid HMO amount,36504,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,82415,,"34,077 x DRG weight",82415,Other,base rate x DRG weight,70054,,"28,966 x DRG weight",70054,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19626,,DRG base rate x DRG weight + capital per discharge,19626,Other,100% of NY Medicaid HMO DRG,19626,,100% x Medicaid HMO amount,19626,Other,100% of NY Medicaid HMO DRG,19626,,100% x Medicaid HMO amount,19626,Other,100% of NY Medicaid HMO DRG,19626,,100% x Medicaid HMO amount,19626,Other,100% of NY Medicaid HMO DRG,44159,,225% x Medicaid HMO amount,44159,Other,225% of NY Medicaid HMO DRG,44159,,225% x Medicaid HMO amount,44159,Other,225% of NY Medicaid HMO DRG,44159,,225% x Medicaid HMO amount,44159,Other,225% of NY Medicaid HMO DRG,44159,,225% x Medicaid HMO amount,44159,Other,225% of NY Medicaid HMO DRG,27476,,140% x Medicaid HMO amount,27476,Other,140% of NY Medicaid HMO DRG,44159,,225% x Medicaid HMO amount,44159,Other,225% of NY Medicaid HMO DRG,53972,,275% x Medicaid HMO amount,53972,Other,275% of NY Medicaid HMO DRG,63588,,324% x Medicaid HMO amount,63588,Other,324% of NY Medicaid HMO DRG,42196,,215% x Medicaid HMO amount,42196,Other,215% of NY Medicaid HMO DRG,42196,,215% x Medicaid HMO amount,42196,Other,215% of NY Medicaid HMO DRG,24533,,125% x Medicaid HMO amount,24533,Other,125% of NY Medicaid HMO DRG,0.01,109142,
Disorders of pancreas except malignancy,282-1,APR-DRG,,,,,,,,inpatient,,,72804.21,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24911,,"45,128 x DRG weight",24911,Other,base rate x DRG weight,22419,,"40,615 x DRG weight",22419,Other,base rate x DRG weight,21174,,"38,359 x DRG weight",21174,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9510,,186% x Medicaid HMO amount,9510,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18811,,"34,077 x DRG weight",18811,Other,base rate x DRG weight,15989,,"28,966 x DRG weight",15989,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5113,,DRG base rate x DRG weight + capital per discharge,5113,Other,100% of NY Medicaid HMO DRG,5113,,100% x Medicaid HMO amount,5113,Other,100% of NY Medicaid HMO DRG,5113,,100% x Medicaid HMO amount,5113,Other,100% of NY Medicaid HMO DRG,5113,,100% x Medicaid HMO amount,5113,Other,100% of NY Medicaid HMO DRG,11504,,225% x Medicaid HMO amount,11504,Other,225% of NY Medicaid HMO DRG,11504,,225% x Medicaid HMO amount,11504,Other,225% of NY Medicaid HMO DRG,11504,,225% x Medicaid HMO amount,11504,Other,225% of NY Medicaid HMO DRG,11504,,225% x Medicaid HMO amount,11504,Other,225% of NY Medicaid HMO DRG,7158,,140% x Medicaid HMO amount,7158,Other,140% of NY Medicaid HMO DRG,11504,,225% x Medicaid HMO amount,11504,Other,225% of NY Medicaid HMO DRG,14061,,275% x Medicaid HMO amount,14061,Other,275% of NY Medicaid HMO DRG,16566,,324% x Medicaid HMO amount,16566,Other,324% of NY Medicaid HMO DRG,10993,,215% x Medicaid HMO amount,10993,Other,215% of NY Medicaid HMO DRG,10993,,215% x Medicaid HMO amount,10993,Other,215% of NY Medicaid HMO DRG,6391,,125% x Medicaid HMO amount,6391,Other,125% of NY Medicaid HMO DRG,0.01,24911,
Disorders of pancreas except malignancy,282-2,APR-DRG,,,,,,,,inpatient,,,106860.64,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33706,,"45,128 x DRG weight",33706,Other,base rate x DRG weight,30335,,"40,615 x DRG weight",30335,Other,base rate x DRG weight,28650,,"38,359 x DRG weight",28650,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12328,,186% x Medicaid HMO amount,12328,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25452,,"34,077 x DRG weight",25452,Other,base rate x DRG weight,21635,,"28,966 x DRG weight",21635,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6628,,DRG base rate x DRG weight + capital per discharge,6628,Other,100% of NY Medicaid HMO DRG,6628,,100% x Medicaid HMO amount,6628,Other,100% of NY Medicaid HMO DRG,6628,,100% x Medicaid HMO amount,6628,Other,100% of NY Medicaid HMO DRG,6628,,100% x Medicaid HMO amount,6628,Other,100% of NY Medicaid HMO DRG,14913,,225% x Medicaid HMO amount,14913,Other,225% of NY Medicaid HMO DRG,14913,,225% x Medicaid HMO amount,14913,Other,225% of NY Medicaid HMO DRG,14913,,225% x Medicaid HMO amount,14913,Other,225% of NY Medicaid HMO DRG,14913,,225% x Medicaid HMO amount,14913,Other,225% of NY Medicaid HMO DRG,9279,,140% x Medicaid HMO amount,9279,Other,140% of NY Medicaid HMO DRG,14913,,225% x Medicaid HMO amount,14913,Other,225% of NY Medicaid HMO DRG,18227,,275% x Medicaid HMO amount,18227,Other,275% of NY Medicaid HMO DRG,21475,,324% x Medicaid HMO amount,21475,Other,324% of NY Medicaid HMO DRG,14250,,215% x Medicaid HMO amount,14250,Other,215% of NY Medicaid HMO DRG,14250,,215% x Medicaid HMO amount,14250,Other,215% of NY Medicaid HMO DRG,8285,,125% x Medicaid HMO amount,8285,Other,125% of NY Medicaid HMO DRG,0.01,33706,
Disorders of pancreas except malignancy,282-3,APR-DRG,,,,,,,,inpatient,,,161341.38,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,61460,,"45,128 x DRG weight",61460,Other,base rate x DRG weight,55314,,"40,615 x DRG weight",55314,Other,base rate x DRG weight,52241,,"38,359 x DRG weight",52241,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21223,,186% x Medicaid HMO amount,21223,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46409,,"34,077 x DRG weight",46409,Other,base rate x DRG weight,39449,,"28,966 x DRG weight",39449,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11410,,DRG base rate x DRG weight + capital per discharge,11410,Other,100% of NY Medicaid HMO DRG,11410,,100% x Medicaid HMO amount,11410,Other,100% of NY Medicaid HMO DRG,11410,,100% x Medicaid HMO amount,11410,Other,100% of NY Medicaid HMO DRG,11410,,100% x Medicaid HMO amount,11410,Other,100% of NY Medicaid HMO DRG,25673,,225% x Medicaid HMO amount,25673,Other,225% of NY Medicaid HMO DRG,25673,,225% x Medicaid HMO amount,25673,Other,225% of NY Medicaid HMO DRG,25673,,225% x Medicaid HMO amount,25673,Other,225% of NY Medicaid HMO DRG,25673,,225% x Medicaid HMO amount,25673,Other,225% of NY Medicaid HMO DRG,15974,,140% x Medicaid HMO amount,15974,Other,140% of NY Medicaid HMO DRG,25673,,225% x Medicaid HMO amount,25673,Other,225% of NY Medicaid HMO DRG,31378,,275% x Medicaid HMO amount,31378,Other,275% of NY Medicaid HMO DRG,36968,,324% x Medicaid HMO amount,36968,Other,324% of NY Medicaid HMO DRG,24532,,215% x Medicaid HMO amount,24532,Other,215% of NY Medicaid HMO DRG,24532,,215% x Medicaid HMO amount,24532,Other,215% of NY Medicaid HMO DRG,14263,,125% x Medicaid HMO amount,14263,Other,125% of NY Medicaid HMO DRG,0.01,61460,
Disorders of pancreas except malignancy,282-4,APR-DRG,,,,,,,,inpatient,,,386058.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,155998,,"45,128 x DRG weight",155998,Other,base rate x DRG weight,140398,,"40,615 x DRG weight",140398,Other,base rate x DRG weight,132599,,"38,359 x DRG weight",132599,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51522,,186% x Medicaid HMO amount,51522,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,117797,,"34,077 x DRG weight",117797,Other,base rate x DRG weight,100130,,"28,966 x DRG weight",100130,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27700,,DRG base rate x DRG weight + capital per discharge,27700,Other,100% of NY Medicaid HMO DRG,27700,,100% x Medicaid HMO amount,27700,Other,100% of NY Medicaid HMO DRG,27700,,100% x Medicaid HMO amount,27700,Other,100% of NY Medicaid HMO DRG,27700,,100% x Medicaid HMO amount,27700,Other,100% of NY Medicaid HMO DRG,62325,,225% x Medicaid HMO amount,62325,Other,225% of NY Medicaid HMO DRG,62325,,225% x Medicaid HMO amount,62325,Other,225% of NY Medicaid HMO DRG,62325,,225% x Medicaid HMO amount,62325,Other,225% of NY Medicaid HMO DRG,62325,,225% x Medicaid HMO amount,62325,Other,225% of NY Medicaid HMO DRG,38780,,140% x Medicaid HMO amount,38780,Other,140% of NY Medicaid HMO DRG,62325,,225% x Medicaid HMO amount,62325,Other,225% of NY Medicaid HMO DRG,76175,,275% x Medicaid HMO amount,76175,Other,275% of NY Medicaid HMO DRG,89748,,324% x Medicaid HMO amount,89748,Other,324% of NY Medicaid HMO DRG,59555,,215% x Medicaid HMO amount,59555,Other,215% of NY Medicaid HMO DRG,59555,,215% x Medicaid HMO amount,59555,Other,215% of NY Medicaid HMO DRG,34625,,125% x Medicaid HMO amount,34625,Other,125% of NY Medicaid HMO DRG,0.01,155998,
Other disorders of the liver,283-1,APR-DRG,,,,,,,,inpatient,,,52012.6,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25434,,"45,128 x DRG weight",25434,Other,base rate x DRG weight,22891,,"40,615 x DRG weight",22891,Other,base rate x DRG weight,21619,,"38,359 x DRG weight",21619,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9678,,186% x Medicaid HMO amount,9678,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19206,,"34,077 x DRG weight",19206,Other,base rate x DRG weight,16325,,"28,966 x DRG weight",16325,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5203,,DRG base rate x DRG weight + capital per discharge,5203,Other,100% of NY Medicaid HMO DRG,5203,,100% x Medicaid HMO amount,5203,Other,100% of NY Medicaid HMO DRG,5203,,100% x Medicaid HMO amount,5203,Other,100% of NY Medicaid HMO DRG,5203,,100% x Medicaid HMO amount,5203,Other,100% of NY Medicaid HMO DRG,11707,,225% x Medicaid HMO amount,11707,Other,225% of NY Medicaid HMO DRG,11707,,225% x Medicaid HMO amount,11707,Other,225% of NY Medicaid HMO DRG,11707,,225% x Medicaid HMO amount,11707,Other,225% of NY Medicaid HMO DRG,11707,,225% x Medicaid HMO amount,11707,Other,225% of NY Medicaid HMO DRG,7284,,140% x Medicaid HMO amount,7284,Other,140% of NY Medicaid HMO DRG,11707,,225% x Medicaid HMO amount,11707,Other,225% of NY Medicaid HMO DRG,14308,,275% x Medicaid HMO amount,14308,Other,275% of NY Medicaid HMO DRG,16858,,324% x Medicaid HMO amount,16858,Other,324% of NY Medicaid HMO DRG,11186,,215% x Medicaid HMO amount,11186,Other,215% of NY Medicaid HMO DRG,11186,,215% x Medicaid HMO amount,11186,Other,215% of NY Medicaid HMO DRG,6504,,125% x Medicaid HMO amount,6504,Other,125% of NY Medicaid HMO DRG,0.01,25434,
Other disorders of the liver,283-2,APR-DRG,,,,,,,,inpatient,,,147359.35,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33724,,"45,128 x DRG weight",33724,Other,base rate x DRG weight,30352,,"40,615 x DRG weight",30352,Other,base rate x DRG weight,28666,,"38,359 x DRG weight",28666,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12336,,186% x Medicaid HMO amount,12336,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25466,,"34,077 x DRG weight",25466,Other,base rate x DRG weight,21646,,"28,966 x DRG weight",21646,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6632,,DRG base rate x DRG weight + capital per discharge,6632,Other,100% of NY Medicaid HMO DRG,6632,,100% x Medicaid HMO amount,6632,Other,100% of NY Medicaid HMO DRG,6632,,100% x Medicaid HMO amount,6632,Other,100% of NY Medicaid HMO DRG,6632,,100% x Medicaid HMO amount,6632,Other,100% of NY Medicaid HMO DRG,14922,,225% x Medicaid HMO amount,14922,Other,225% of NY Medicaid HMO DRG,14922,,225% x Medicaid HMO amount,14922,Other,225% of NY Medicaid HMO DRG,14922,,225% x Medicaid HMO amount,14922,Other,225% of NY Medicaid HMO DRG,14922,,225% x Medicaid HMO amount,14922,Other,225% of NY Medicaid HMO DRG,9285,,140% x Medicaid HMO amount,9285,Other,140% of NY Medicaid HMO DRG,14922,,225% x Medicaid HMO amount,14922,Other,225% of NY Medicaid HMO DRG,18238,,275% x Medicaid HMO amount,18238,Other,275% of NY Medicaid HMO DRG,21488,,324% x Medicaid HMO amount,21488,Other,324% of NY Medicaid HMO DRG,14259,,215% x Medicaid HMO amount,14259,Other,215% of NY Medicaid HMO DRG,14259,,215% x Medicaid HMO amount,14259,Other,215% of NY Medicaid HMO DRG,8290,,125% x Medicaid HMO amount,8290,Other,125% of NY Medicaid HMO DRG,0.01,33724,
Other disorders of the liver,283-3,APR-DRG,,,,,,,,inpatient,,,170913.92,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54357,,"45,128 x DRG weight",54357,Other,base rate x DRG weight,48921,,"40,615 x DRG weight",48921,Other,base rate x DRG weight,46203,,"38,359 x DRG weight",46203,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18948,,186% x Medicaid HMO amount,18948,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41046,,"34,077 x DRG weight",41046,Other,base rate x DRG weight,34890,,"28,966 x DRG weight",34890,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10187,,DRG base rate x DRG weight + capital per discharge,10187,Other,100% of NY Medicaid HMO DRG,10187,,100% x Medicaid HMO amount,10187,Other,100% of NY Medicaid HMO DRG,10187,,100% x Medicaid HMO amount,10187,Other,100% of NY Medicaid HMO DRG,10187,,100% x Medicaid HMO amount,10187,Other,100% of NY Medicaid HMO DRG,22921,,225% x Medicaid HMO amount,22921,Other,225% of NY Medicaid HMO DRG,22921,,225% x Medicaid HMO amount,22921,Other,225% of NY Medicaid HMO DRG,22921,,225% x Medicaid HMO amount,22921,Other,225% of NY Medicaid HMO DRG,22921,,225% x Medicaid HMO amount,22921,Other,225% of NY Medicaid HMO DRG,14262,,140% x Medicaid HMO amount,14262,Other,140% of NY Medicaid HMO DRG,22921,,225% x Medicaid HMO amount,22921,Other,225% of NY Medicaid HMO DRG,28014,,275% x Medicaid HMO amount,28014,Other,275% of NY Medicaid HMO DRG,33006,,324% x Medicaid HMO amount,33006,Other,324% of NY Medicaid HMO DRG,21902,,215% x Medicaid HMO amount,21902,Other,215% of NY Medicaid HMO DRG,21902,,215% x Medicaid HMO amount,21902,Other,215% of NY Medicaid HMO DRG,12734,,125% x Medicaid HMO amount,12734,Other,125% of NY Medicaid HMO DRG,0.01,54357,
Other disorders of the liver,283-4,APR-DRG,,,,,,,,inpatient,,,287184.28,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,116868,,"45,128 x DRG weight",116868,Other,base rate x DRG weight,105181,,"40,615 x DRG weight",105181,Other,base rate x DRG weight,99338,,"38,359 x DRG weight",99338,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38980,,186% x Medicaid HMO amount,38980,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,88249,,"34,077 x DRG weight",88249,Other,base rate x DRG weight,75013,,"28,966 x DRG weight",75013,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20957,,DRG base rate x DRG weight + capital per discharge,20957,Other,100% of NY Medicaid HMO DRG,20957,,100% x Medicaid HMO amount,20957,Other,100% of NY Medicaid HMO DRG,20957,,100% x Medicaid HMO amount,20957,Other,100% of NY Medicaid HMO DRG,20957,,100% x Medicaid HMO amount,20957,Other,100% of NY Medicaid HMO DRG,47153,,225% x Medicaid HMO amount,47153,Other,225% of NY Medicaid HMO DRG,47153,,225% x Medicaid HMO amount,47153,Other,225% of NY Medicaid HMO DRG,47153,,225% x Medicaid HMO amount,47153,Other,225% of NY Medicaid HMO DRG,47153,,225% x Medicaid HMO amount,47153,Other,225% of NY Medicaid HMO DRG,29340,,140% x Medicaid HMO amount,29340,Other,140% of NY Medicaid HMO DRG,47153,,225% x Medicaid HMO amount,47153,Other,225% of NY Medicaid HMO DRG,57632,,275% x Medicaid HMO amount,57632,Other,275% of NY Medicaid HMO DRG,67901,,324% x Medicaid HMO amount,67901,Other,324% of NY Medicaid HMO DRG,45058,,215% x Medicaid HMO amount,45058,Other,215% of NY Medicaid HMO DRG,45058,,215% x Medicaid HMO amount,45058,Other,215% of NY Medicaid HMO DRG,26196,,125% x Medicaid HMO amount,26196,Other,125% of NY Medicaid HMO DRG,0.01,116868,
Disorders of gallbladder & biliary tract,284-1,APR-DRG,,,,,,,,inpatient,,,104250.23,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26066,,"45,128 x DRG weight",26066,Other,base rate x DRG weight,23459,,"40,615 x DRG weight",23459,Other,base rate x DRG weight,22156,,"38,359 x DRG weight",22156,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9880,,186% x Medicaid HMO amount,9880,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19683,,"34,077 x DRG weight",19683,Other,base rate x DRG weight,16731,,"28,966 x DRG weight",16731,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5312,,DRG base rate x DRG weight + capital per discharge,5312,Other,100% of NY Medicaid HMO DRG,5312,,100% x Medicaid HMO amount,5312,Other,100% of NY Medicaid HMO DRG,5312,,100% x Medicaid HMO amount,5312,Other,100% of NY Medicaid HMO DRG,5312,,100% x Medicaid HMO amount,5312,Other,100% of NY Medicaid HMO DRG,11952,,225% x Medicaid HMO amount,11952,Other,225% of NY Medicaid HMO DRG,11952,,225% x Medicaid HMO amount,11952,Other,225% of NY Medicaid HMO DRG,11952,,225% x Medicaid HMO amount,11952,Other,225% of NY Medicaid HMO DRG,11952,,225% x Medicaid HMO amount,11952,Other,225% of NY Medicaid HMO DRG,7437,,140% x Medicaid HMO amount,7437,Other,140% of NY Medicaid HMO DRG,11952,,225% x Medicaid HMO amount,11952,Other,225% of NY Medicaid HMO DRG,14608,,275% x Medicaid HMO amount,14608,Other,275% of NY Medicaid HMO DRG,17211,,324% x Medicaid HMO amount,17211,Other,324% of NY Medicaid HMO DRG,11421,,215% x Medicaid HMO amount,11421,Other,215% of NY Medicaid HMO DRG,11421,,215% x Medicaid HMO amount,11421,Other,215% of NY Medicaid HMO DRG,6640,,125% x Medicaid HMO amount,6640,Other,125% of NY Medicaid HMO DRG,0.01,26066,
Disorders of gallbladder & biliary tract,284-2,APR-DRG,,,,,,,,inpatient,,,119435.12,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37348,,"45,128 x DRG weight",37348,Other,base rate x DRG weight,33613,,"40,615 x DRG weight",33613,Other,base rate x DRG weight,31746,,"38,359 x DRG weight",31746,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13496,,186% x Medicaid HMO amount,13496,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28202,,"34,077 x DRG weight",28202,Other,base rate x DRG weight,23972,,"28,966 x DRG weight",23972,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7256,,DRG base rate x DRG weight + capital per discharge,7256,Other,100% of NY Medicaid HMO DRG,7256,,100% x Medicaid HMO amount,7256,Other,100% of NY Medicaid HMO DRG,7256,,100% x Medicaid HMO amount,7256,Other,100% of NY Medicaid HMO DRG,7256,,100% x Medicaid HMO amount,7256,Other,100% of NY Medicaid HMO DRG,16326,,225% x Medicaid HMO amount,16326,Other,225% of NY Medicaid HMO DRG,16326,,225% x Medicaid HMO amount,16326,Other,225% of NY Medicaid HMO DRG,16326,,225% x Medicaid HMO amount,16326,Other,225% of NY Medicaid HMO DRG,16326,,225% x Medicaid HMO amount,16326,Other,225% of NY Medicaid HMO DRG,10158,,140% x Medicaid HMO amount,10158,Other,140% of NY Medicaid HMO DRG,16326,,225% x Medicaid HMO amount,16326,Other,225% of NY Medicaid HMO DRG,19954,,275% x Medicaid HMO amount,19954,Other,275% of NY Medicaid HMO DRG,23509,,324% x Medicaid HMO amount,23509,Other,324% of NY Medicaid HMO DRG,15600,,215% x Medicaid HMO amount,15600,Other,215% of NY Medicaid HMO DRG,15600,,215% x Medicaid HMO amount,15600,Other,215% of NY Medicaid HMO DRG,9070,,125% x Medicaid HMO amount,9070,Other,125% of NY Medicaid HMO DRG,0.01,37348,
Disorders of gallbladder & biliary tract,284-3,APR-DRG,,,,,,,,inpatient,,,161164.14,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59474,,"45,128 x DRG weight",59474,Other,base rate x DRG weight,53527,,"40,615 x DRG weight",53527,Other,base rate x DRG weight,50553,,"38,359 x DRG weight",50553,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20586,,186% x Medicaid HMO amount,20586,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44910,,"34,077 x DRG weight",44910,Other,base rate x DRG weight,38174,,"28,966 x DRG weight",38174,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11068,,DRG base rate x DRG weight + capital per discharge,11068,Other,100% of NY Medicaid HMO DRG,11068,,100% x Medicaid HMO amount,11068,Other,100% of NY Medicaid HMO DRG,11068,,100% x Medicaid HMO amount,11068,Other,100% of NY Medicaid HMO DRG,11068,,100% x Medicaid HMO amount,11068,Other,100% of NY Medicaid HMO DRG,24903,,225% x Medicaid HMO amount,24903,Other,225% of NY Medicaid HMO DRG,24903,,225% x Medicaid HMO amount,24903,Other,225% of NY Medicaid HMO DRG,24903,,225% x Medicaid HMO amount,24903,Other,225% of NY Medicaid HMO DRG,24903,,225% x Medicaid HMO amount,24903,Other,225% of NY Medicaid HMO DRG,15495,,140% x Medicaid HMO amount,15495,Other,140% of NY Medicaid HMO DRG,24903,,225% x Medicaid HMO amount,24903,Other,225% of NY Medicaid HMO DRG,30437,,275% x Medicaid HMO amount,30437,Other,275% of NY Medicaid HMO DRG,35860,,324% x Medicaid HMO amount,35860,Other,324% of NY Medicaid HMO DRG,23796,,215% x Medicaid HMO amount,23796,Other,215% of NY Medicaid HMO DRG,23796,,215% x Medicaid HMO amount,23796,Other,215% of NY Medicaid HMO DRG,13835,,125% x Medicaid HMO amount,13835,Other,125% of NY Medicaid HMO DRG,0.01,59474,
Disorders of gallbladder & biliary tract,284-4,APR-DRG,,,,,,,,inpatient,,,138819.13,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,133768,,"45,128 x DRG weight",133768,Other,base rate x DRG weight,120391,,"40,615 x DRG weight",120391,Other,base rate x DRG weight,113704,,"38,359 x DRG weight",113704,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44396,,186% x Medicaid HMO amount,44396,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,101011,,"34,077 x DRG weight",101011,Other,base rate x DRG weight,85861,,"28,966 x DRG weight",85861,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23869,,DRG base rate x DRG weight + capital per discharge,23869,Other,100% of NY Medicaid HMO DRG,23869,,100% x Medicaid HMO amount,23869,Other,100% of NY Medicaid HMO DRG,23869,,100% x Medicaid HMO amount,23869,Other,100% of NY Medicaid HMO DRG,23869,,100% x Medicaid HMO amount,23869,Other,100% of NY Medicaid HMO DRG,53705,,225% x Medicaid HMO amount,53705,Other,225% of NY Medicaid HMO DRG,53705,,225% x Medicaid HMO amount,53705,Other,225% of NY Medicaid HMO DRG,53705,,225% x Medicaid HMO amount,53705,Other,225% of NY Medicaid HMO DRG,53705,,225% x Medicaid HMO amount,53705,Other,225% of NY Medicaid HMO DRG,33417,,140% x Medicaid HMO amount,33417,Other,140% of NY Medicaid HMO DRG,53705,,225% x Medicaid HMO amount,53705,Other,225% of NY Medicaid HMO DRG,65640,,275% x Medicaid HMO amount,65640,Other,275% of NY Medicaid HMO DRG,77336,,324% x Medicaid HMO amount,77336,Other,324% of NY Medicaid HMO DRG,51318,,215% x Medicaid HMO amount,51318,Other,215% of NY Medicaid HMO DRG,51318,,215% x Medicaid HMO amount,51318,Other,215% of NY Medicaid HMO DRG,29836,,125% x Medicaid HMO amount,29836,Other,125% of NY Medicaid HMO DRG,0.01,133768,
Hip joint replacement,301-1,APR-DRG,,,,,,,,inpatient,,,205313.51,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,83279,,"45,128 x DRG weight",83279,Other,base rate x DRG weight,74951,,"40,615 x DRG weight",74951,Other,base rate x DRG weight,70788,,"38,359 x DRG weight",70788,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28216,,186% x Medicaid HMO amount,28216,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,62886,,"34,077 x DRG weight",62886,Other,base rate x DRG weight,53454,,"28,966 x DRG weight",53454,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15170,,DRG base rate x DRG weight + capital per discharge,15170,Other,100% of NY Medicaid HMO DRG,15170,,100% x Medicaid HMO amount,15170,Other,100% of NY Medicaid HMO DRG,15170,,100% x Medicaid HMO amount,15170,Other,100% of NY Medicaid HMO DRG,15170,,100% x Medicaid HMO amount,15170,Other,100% of NY Medicaid HMO DRG,34133,,225% x Medicaid HMO amount,34133,Other,225% of NY Medicaid HMO DRG,34133,,225% x Medicaid HMO amount,34133,Other,225% of NY Medicaid HMO DRG,34133,,225% x Medicaid HMO amount,34133,Other,225% of NY Medicaid HMO DRG,34133,,225% x Medicaid HMO amount,34133,Other,225% of NY Medicaid HMO DRG,21238,,140% x Medicaid HMO amount,21238,Other,140% of NY Medicaid HMO DRG,34133,,225% x Medicaid HMO amount,34133,Other,225% of NY Medicaid HMO DRG,41718,,275% x Medicaid HMO amount,41718,Other,275% of NY Medicaid HMO DRG,49151,,324% x Medicaid HMO amount,49151,Other,324% of NY Medicaid HMO DRG,32616,,215% x Medicaid HMO amount,32616,Other,215% of NY Medicaid HMO DRG,32616,,215% x Medicaid HMO amount,32616,Other,215% of NY Medicaid HMO DRG,18963,,125% x Medicaid HMO amount,18963,Other,125% of NY Medicaid HMO DRG,0.01,83279,
Hip joint replacement,301-2,APR-DRG,,,,,,,,inpatient,,,206062.91,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,86551,,"45,128 x DRG weight",86551,Other,base rate x DRG weight,77896,,"40,615 x DRG weight",77896,Other,base rate x DRG weight,73569,,"38,359 x DRG weight",73569,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29265,,186% x Medicaid HMO amount,29265,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,65356,,"34,077 x DRG weight",65356,Other,base rate x DRG weight,55554,,"28,966 x DRG weight",55554,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15734,,DRG base rate x DRG weight + capital per discharge,15734,Other,100% of NY Medicaid HMO DRG,15734,,100% x Medicaid HMO amount,15734,Other,100% of NY Medicaid HMO DRG,15734,,100% x Medicaid HMO amount,15734,Other,100% of NY Medicaid HMO DRG,15734,,100% x Medicaid HMO amount,15734,Other,100% of NY Medicaid HMO DRG,35402,,225% x Medicaid HMO amount,35402,Other,225% of NY Medicaid HMO DRG,35402,,225% x Medicaid HMO amount,35402,Other,225% of NY Medicaid HMO DRG,35402,,225% x Medicaid HMO amount,35402,Other,225% of NY Medicaid HMO DRG,35402,,225% x Medicaid HMO amount,35402,Other,225% of NY Medicaid HMO DRG,22028,,140% x Medicaid HMO amount,22028,Other,140% of NY Medicaid HMO DRG,35402,,225% x Medicaid HMO amount,35402,Other,225% of NY Medicaid HMO DRG,43269,,275% x Medicaid HMO amount,43269,Other,275% of NY Medicaid HMO DRG,50978,,324% x Medicaid HMO amount,50978,Other,324% of NY Medicaid HMO DRG,33828,,215% x Medicaid HMO amount,33828,Other,215% of NY Medicaid HMO DRG,33828,,215% x Medicaid HMO amount,33828,Other,215% of NY Medicaid HMO DRG,19668,,125% x Medicaid HMO amount,19668,Other,125% of NY Medicaid HMO DRG,0.01,86551,
Hip joint replacement,301-3,APR-DRG,,,,,,,,inpatient,,,534583.85,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,114476,,"45,128 x DRG weight",114476,Other,base rate x DRG weight,103028,,"40,615 x DRG weight",103028,Other,base rate x DRG weight,97305,,"38,359 x DRG weight",97305,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38214,,186% x Medicaid HMO amount,38214,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,86443,,"34,077 x DRG weight",86443,Other,base rate x DRG weight,73478,,"28,966 x DRG weight",73478,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20545,,DRG base rate x DRG weight + capital per discharge,20545,Other,100% of NY Medicaid HMO DRG,20545,,100% x Medicaid HMO amount,20545,Other,100% of NY Medicaid HMO DRG,20545,,100% x Medicaid HMO amount,20545,Other,100% of NY Medicaid HMO DRG,20545,,100% x Medicaid HMO amount,20545,Other,100% of NY Medicaid HMO DRG,46226,,225% x Medicaid HMO amount,46226,Other,225% of NY Medicaid HMO DRG,46226,,225% x Medicaid HMO amount,46226,Other,225% of NY Medicaid HMO DRG,46226,,225% x Medicaid HMO amount,46226,Other,225% of NY Medicaid HMO DRG,46226,,225% x Medicaid HMO amount,46226,Other,225% of NY Medicaid HMO DRG,28763,,140% x Medicaid HMO amount,28763,Other,140% of NY Medicaid HMO DRG,46226,,225% x Medicaid HMO amount,46226,Other,225% of NY Medicaid HMO DRG,56499,,275% x Medicaid HMO amount,56499,Other,275% of NY Medicaid HMO DRG,66566,,324% x Medicaid HMO amount,66566,Other,324% of NY Medicaid HMO DRG,44172,,215% x Medicaid HMO amount,44172,Other,215% of NY Medicaid HMO DRG,44172,,215% x Medicaid HMO amount,44172,Other,215% of NY Medicaid HMO DRG,25681,,125% x Medicaid HMO amount,25681,Other,125% of NY Medicaid HMO DRG,0.01,114476,
Hip joint replacement,301-4,APR-DRG,,,,,,,,inpatient,,,1017525.91,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,273191,,"45,128 x DRG weight",273191,Other,base rate x DRG weight,245871,,"40,615 x DRG weight",245871,Other,base rate x DRG weight,232214,,"38,359 x DRG weight",232214,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,89079,,186% x Medicaid HMO amount,89079,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,206292,,"34,077 x DRG weight",206292,Other,base rate x DRG weight,175351,,"28,966 x DRG weight",175351,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47892,,DRG base rate x DRG weight + capital per discharge,47892,Other,100% of NY Medicaid HMO DRG,47892,,100% x Medicaid HMO amount,47892,Other,100% of NY Medicaid HMO DRG,47892,,100% x Medicaid HMO amount,47892,Other,100% of NY Medicaid HMO DRG,47892,,100% x Medicaid HMO amount,47892,Other,100% of NY Medicaid HMO DRG,107757,,225% x Medicaid HMO amount,107757,Other,225% of NY Medicaid HMO DRG,107757,,225% x Medicaid HMO amount,107757,Other,225% of NY Medicaid HMO DRG,107757,,225% x Medicaid HMO amount,107757,Other,225% of NY Medicaid HMO DRG,107757,,225% x Medicaid HMO amount,107757,Other,225% of NY Medicaid HMO DRG,67049,,140% x Medicaid HMO amount,67049,Other,140% of NY Medicaid HMO DRG,107757,,225% x Medicaid HMO amount,107757,Other,225% of NY Medicaid HMO DRG,131703,,275% x Medicaid HMO amount,131703,Other,275% of NY Medicaid HMO DRG,155170,,324% x Medicaid HMO amount,155170,Other,324% of NY Medicaid HMO DRG,102968,,215% x Medicaid HMO amount,102968,Other,215% of NY Medicaid HMO DRG,102968,,215% x Medicaid HMO amount,102968,Other,215% of NY Medicaid HMO DRG,59865,,125% x Medicaid HMO amount,59865,Other,125% of NY Medicaid HMO DRG,0.01,273191,
Knee joint replacement,302-1,APR-DRG,,,,,,,,inpatient,,,156533.17,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,80016,,"45,128 x DRG weight",80016,Other,base rate x DRG weight,72014,,"40,615 x DRG weight",72014,Other,base rate x DRG weight,68014,,"38,359 x DRG weight",68014,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27171,,186% x Medicaid HMO amount,27171,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60422,,"34,077 x DRG weight",60422,Other,base rate x DRG weight,51360,,"28,966 x DRG weight",51360,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14608,,DRG base rate x DRG weight + capital per discharge,14608,Other,100% of NY Medicaid HMO DRG,14608,,100% x Medicaid HMO amount,14608,Other,100% of NY Medicaid HMO DRG,14608,,100% x Medicaid HMO amount,14608,Other,100% of NY Medicaid HMO DRG,14608,,100% x Medicaid HMO amount,14608,Other,100% of NY Medicaid HMO DRG,32868,,225% x Medicaid HMO amount,32868,Other,225% of NY Medicaid HMO DRG,32868,,225% x Medicaid HMO amount,32868,Other,225% of NY Medicaid HMO DRG,32868,,225% x Medicaid HMO amount,32868,Other,225% of NY Medicaid HMO DRG,32868,,225% x Medicaid HMO amount,32868,Other,225% of NY Medicaid HMO DRG,20451,,140% x Medicaid HMO amount,20451,Other,140% of NY Medicaid HMO DRG,32868,,225% x Medicaid HMO amount,32868,Other,225% of NY Medicaid HMO DRG,40172,,275% x Medicaid HMO amount,40172,Other,275% of NY Medicaid HMO DRG,47330,,324% x Medicaid HMO amount,47330,Other,324% of NY Medicaid HMO DRG,31407,,215% x Medicaid HMO amount,31407,Other,215% of NY Medicaid HMO DRG,31407,,215% x Medicaid HMO amount,31407,Other,215% of NY Medicaid HMO DRG,18260,,125% x Medicaid HMO amount,18260,Other,125% of NY Medicaid HMO DRG,0.01,80016,
Knee joint replacement,302-2,APR-DRG,,,,,,,,inpatient,,,205346.99,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,90283,,"45,128 x DRG weight",90283,Other,base rate x DRG weight,81254,,"40,615 x DRG weight",81254,Other,base rate x DRG weight,76741,,"38,359 x DRG weight",76741,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30461,,186% x Medicaid HMO amount,30461,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,68174,,"34,077 x DRG weight",68174,Other,base rate x DRG weight,57949,,"28,966 x DRG weight",57949,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16377,,DRG base rate x DRG weight + capital per discharge,16377,Other,100% of NY Medicaid HMO DRG,16377,,100% x Medicaid HMO amount,16377,Other,100% of NY Medicaid HMO DRG,16377,,100% x Medicaid HMO amount,16377,Other,100% of NY Medicaid HMO DRG,16377,,100% x Medicaid HMO amount,16377,Other,100% of NY Medicaid HMO DRG,36848,,225% x Medicaid HMO amount,36848,Other,225% of NY Medicaid HMO DRG,36848,,225% x Medicaid HMO amount,36848,Other,225% of NY Medicaid HMO DRG,36848,,225% x Medicaid HMO amount,36848,Other,225% of NY Medicaid HMO DRG,36848,,225% x Medicaid HMO amount,36848,Other,225% of NY Medicaid HMO DRG,22928,,140% x Medicaid HMO amount,22928,Other,140% of NY Medicaid HMO DRG,36848,,225% x Medicaid HMO amount,36848,Other,225% of NY Medicaid HMO DRG,45037,,275% x Medicaid HMO amount,45037,Other,275% of NY Medicaid HMO DRG,53061,,324% x Medicaid HMO amount,53061,Other,324% of NY Medicaid HMO DRG,35211,,215% x Medicaid HMO amount,35211,Other,215% of NY Medicaid HMO DRG,35211,,215% x Medicaid HMO amount,35211,Other,215% of NY Medicaid HMO DRG,20471,,125% x Medicaid HMO amount,20471,Other,125% of NY Medicaid HMO DRG,0.01,90283,
Knee joint replacement,302-3,APR-DRG,,,,,,,,inpatient,,,326053.32,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,121557,,"45,128 x DRG weight",121557,Other,base rate x DRG weight,109401,,"40,615 x DRG weight",109401,Other,base rate x DRG weight,103324,,"38,359 x DRG weight",103324,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40483,,186% x Medicaid HMO amount,40483,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,91790,,"34,077 x DRG weight",91790,Other,base rate x DRG weight,78023,,"28,966 x DRG weight",78023,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21765,,DRG base rate x DRG weight + capital per discharge,21765,Other,100% of NY Medicaid HMO DRG,21765,,100% x Medicaid HMO amount,21765,Other,100% of NY Medicaid HMO DRG,21765,,100% x Medicaid HMO amount,21765,Other,100% of NY Medicaid HMO DRG,21765,,100% x Medicaid HMO amount,21765,Other,100% of NY Medicaid HMO DRG,48971,,225% x Medicaid HMO amount,48971,Other,225% of NY Medicaid HMO DRG,48971,,225% x Medicaid HMO amount,48971,Other,225% of NY Medicaid HMO DRG,48971,,225% x Medicaid HMO amount,48971,Other,225% of NY Medicaid HMO DRG,48971,,225% x Medicaid HMO amount,48971,Other,225% of NY Medicaid HMO DRG,30471,,140% x Medicaid HMO amount,30471,Other,140% of NY Medicaid HMO DRG,48971,,225% x Medicaid HMO amount,48971,Other,225% of NY Medicaid HMO DRG,59854,,275% x Medicaid HMO amount,59854,Other,275% of NY Medicaid HMO DRG,70519,,324% x Medicaid HMO amount,70519,Other,324% of NY Medicaid HMO DRG,46795,,215% x Medicaid HMO amount,46795,Other,215% of NY Medicaid HMO DRG,46795,,215% x Medicaid HMO amount,46795,Other,215% of NY Medicaid HMO DRG,27206,,125% x Medicaid HMO amount,27206,Other,125% of NY Medicaid HMO DRG,0.01,121557,
Knee joint replacement,302-4,APR-DRG,,,,,,,,inpatient,,,326053.32,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,245623,,"45,128 x DRG weight",245623,Other,base rate x DRG weight,221059,,"40,615 x DRG weight",221059,Other,base rate x DRG weight,208780,,"38,359 x DRG weight",208780,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,80244,,186% x Medicaid HMO amount,80244,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,185474,,"34,077 x DRG weight",185474,Other,base rate x DRG weight,157656,,"28,966 x DRG weight",157656,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43142,,DRG base rate x DRG weight + capital per discharge,43142,Other,100% of NY Medicaid HMO DRG,43142,,100% x Medicaid HMO amount,43142,Other,100% of NY Medicaid HMO DRG,43142,,100% x Medicaid HMO amount,43142,Other,100% of NY Medicaid HMO DRG,43142,,100% x Medicaid HMO amount,43142,Other,100% of NY Medicaid HMO DRG,97070,,225% x Medicaid HMO amount,97070,Other,225% of NY Medicaid HMO DRG,97070,,225% x Medicaid HMO amount,97070,Other,225% of NY Medicaid HMO DRG,97070,,225% x Medicaid HMO amount,97070,Other,225% of NY Medicaid HMO DRG,97070,,225% x Medicaid HMO amount,97070,Other,225% of NY Medicaid HMO DRG,60399,,140% x Medicaid HMO amount,60399,Other,140% of NY Medicaid HMO DRG,97070,,225% x Medicaid HMO amount,97070,Other,225% of NY Medicaid HMO DRG,118641,,275% x Medicaid HMO amount,118641,Other,275% of NY Medicaid HMO DRG,139780,,324% x Medicaid HMO amount,139780,Other,324% of NY Medicaid HMO DRG,92755,,215% x Medicaid HMO amount,92755,Other,215% of NY Medicaid HMO DRG,92755,,215% x Medicaid HMO amount,92755,Other,215% of NY Medicaid HMO DRG,53928,,125% x Medicaid HMO amount,53928,Other,125% of NY Medicaid HMO DRG,0.01,245623,
Dorsal & lumbar fusion proc for curvature of back,303-1,APR-DRG,,,,,,,,inpatient,,,381245.87,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,199457,,"45,128 x DRG weight",199457,Other,base rate x DRG weight,179510,,"40,615 x DRG weight",179510,Other,base rate x DRG weight,169539,,"38,359 x DRG weight",169539,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,65450,,186% x Medicaid HMO amount,65450,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,150614,,"34,077 x DRG weight",150614,Other,base rate x DRG weight,128024,,"28,966 x DRG weight",128024,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35188,,DRG base rate x DRG weight + capital per discharge,35188,Other,100% of NY Medicaid HMO DRG,35188,,100% x Medicaid HMO amount,35188,Other,100% of NY Medicaid HMO DRG,35188,,100% x Medicaid HMO amount,35188,Other,100% of NY Medicaid HMO DRG,35188,,100% x Medicaid HMO amount,35188,Other,100% of NY Medicaid HMO DRG,79173,,225% x Medicaid HMO amount,79173,Other,225% of NY Medicaid HMO DRG,79173,,225% x Medicaid HMO amount,79173,Other,225% of NY Medicaid HMO DRG,79173,,225% x Medicaid HMO amount,79173,Other,225% of NY Medicaid HMO DRG,79173,,225% x Medicaid HMO amount,79173,Other,225% of NY Medicaid HMO DRG,49263,,140% x Medicaid HMO amount,49263,Other,140% of NY Medicaid HMO DRG,79173,,225% x Medicaid HMO amount,79173,Other,225% of NY Medicaid HMO DRG,96767,,275% x Medicaid HMO amount,96767,Other,275% of NY Medicaid HMO DRG,114009,,324% x Medicaid HMO amount,114009,Other,324% of NY Medicaid HMO DRG,75654,,215% x Medicaid HMO amount,75654,Other,215% of NY Medicaid HMO DRG,75654,,215% x Medicaid HMO amount,75654,Other,215% of NY Medicaid HMO DRG,43985,,125% x Medicaid HMO amount,43985,Other,125% of NY Medicaid HMO DRG,0.01,199457,
Dorsal & lumbar fusion proc for curvature of back,303-2,APR-DRG,,,,,,,,inpatient,,,475680.86,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,238655,,"45,128 x DRG weight",238655,Other,base rate x DRG weight,214788,,"40,615 x DRG weight",214788,Other,base rate x DRG weight,202858,,"38,359 x DRG weight",202858,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,78010,,186% x Medicaid HMO amount,78010,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,180213,,"34,077 x DRG weight",180213,Other,base rate x DRG weight,153184,,"28,966 x DRG weight",153184,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41941,,DRG base rate x DRG weight + capital per discharge,41941,Other,100% of NY Medicaid HMO DRG,41941,,100% x Medicaid HMO amount,41941,Other,100% of NY Medicaid HMO DRG,41941,,100% x Medicaid HMO amount,41941,Other,100% of NY Medicaid HMO DRG,41941,,100% x Medicaid HMO amount,41941,Other,100% of NY Medicaid HMO DRG,94367,,225% x Medicaid HMO amount,94367,Other,225% of NY Medicaid HMO DRG,94367,,225% x Medicaid HMO amount,94367,Other,225% of NY Medicaid HMO DRG,94367,,225% x Medicaid HMO amount,94367,Other,225% of NY Medicaid HMO DRG,94367,,225% x Medicaid HMO amount,94367,Other,225% of NY Medicaid HMO DRG,58717,,140% x Medicaid HMO amount,58717,Other,140% of NY Medicaid HMO DRG,94367,,225% x Medicaid HMO amount,94367,Other,225% of NY Medicaid HMO DRG,115338,,275% x Medicaid HMO amount,115338,Other,275% of NY Medicaid HMO DRG,135889,,324% x Medicaid HMO amount,135889,Other,324% of NY Medicaid HMO DRG,90173,,215% x Medicaid HMO amount,90173,Other,215% of NY Medicaid HMO DRG,90173,,215% x Medicaid HMO amount,90173,Other,215% of NY Medicaid HMO DRG,52426,,125% x Medicaid HMO amount,52426,Other,125% of NY Medicaid HMO DRG,0.01,238655,
Dorsal & lumbar fusion proc for curvature of back,303-3,APR-DRG,,,,,,,,inpatient,,,920228.23,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,315354,,"45,128 x DRG weight",315354,Other,base rate x DRG weight,283818,,"40,615 x DRG weight",283818,Other,base rate x DRG weight,268053,,"38,359 x DRG weight",268053,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,102592,,186% x Medicaid HMO amount,102592,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,238130,,"34,077 x DRG weight",238130,Other,base rate x DRG weight,202414,,"28,966 x DRG weight",202414,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55157,,DRG base rate x DRG weight + capital per discharge,55157,Other,100% of NY Medicaid HMO DRG,55157,,100% x Medicaid HMO amount,55157,Other,100% of NY Medicaid HMO DRG,55157,,100% x Medicaid HMO amount,55157,Other,100% of NY Medicaid HMO DRG,55157,,100% x Medicaid HMO amount,55157,Other,100% of NY Medicaid HMO DRG,124103,,225% x Medicaid HMO amount,124103,Other,225% of NY Medicaid HMO DRG,124103,,225% x Medicaid HMO amount,124103,Other,225% of NY Medicaid HMO DRG,124103,,225% x Medicaid HMO amount,124103,Other,225% of NY Medicaid HMO DRG,124103,,225% x Medicaid HMO amount,124103,Other,225% of NY Medicaid HMO DRG,77220,,140% x Medicaid HMO amount,77220,Other,140% of NY Medicaid HMO DRG,124103,,225% x Medicaid HMO amount,124103,Other,225% of NY Medicaid HMO DRG,151682,,275% x Medicaid HMO amount,151682,Other,275% of NY Medicaid HMO DRG,178709,,324% x Medicaid HMO amount,178709,Other,324% of NY Medicaid HMO DRG,118588,,215% x Medicaid HMO amount,118588,Other,215% of NY Medicaid HMO DRG,118588,,215% x Medicaid HMO amount,118588,Other,215% of NY Medicaid HMO DRG,68946,,125% x Medicaid HMO amount,68946,Other,125% of NY Medicaid HMO DRG,0.01,315354,
Dorsal & lumbar fusion proc for curvature of back,303-4,APR-DRG,,,,,,,,inpatient,,,720917.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,491647,,"45,128 x DRG weight",491647,Other,base rate x DRG weight,442480,,"40,615 x DRG weight",442480,Other,base rate x DRG weight,417902,,"38,359 x DRG weight",417902,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,159090,,186% x Medicaid HMO amount,159090,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,371252,,"34,077 x DRG weight",371252,Other,base rate x DRG weight,315570,,"28,966 x DRG weight",315570,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,85532,,DRG base rate x DRG weight + capital per discharge,85532,Other,100% of NY Medicaid HMO DRG,85532,,100% x Medicaid HMO amount,85532,Other,100% of NY Medicaid HMO DRG,85532,,100% x Medicaid HMO amount,85532,Other,100% of NY Medicaid HMO DRG,85532,,100% x Medicaid HMO amount,85532,Other,100% of NY Medicaid HMO DRG,192447,,225% x Medicaid HMO amount,192447,Other,225% of NY Medicaid HMO DRG,192447,,225% x Medicaid HMO amount,192447,Other,225% of NY Medicaid HMO DRG,192447,,225% x Medicaid HMO amount,192447,Other,225% of NY Medicaid HMO DRG,192447,,225% x Medicaid HMO amount,192447,Other,225% of NY Medicaid HMO DRG,119745,,140% x Medicaid HMO amount,119745,Other,140% of NY Medicaid HMO DRG,192447,,225% x Medicaid HMO amount,192447,Other,225% of NY Medicaid HMO DRG,235213,,275% x Medicaid HMO amount,235213,Other,275% of NY Medicaid HMO DRG,277124,,324% x Medicaid HMO amount,277124,Other,324% of NY Medicaid HMO DRG,183894,,215% x Medicaid HMO amount,183894,Other,215% of NY Medicaid HMO DRG,183894,,215% x Medicaid HMO amount,183894,Other,215% of NY Medicaid HMO DRG,106915,,125% x Medicaid HMO amount,106915,Other,125% of NY Medicaid HMO DRG,0.01,491647,
Dorsal & lumbar fusion proc except for curvature of back,304-1,APR-DRG,,,,,,,,inpatient,,,370295.15,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,138367,,"45,128 x DRG weight",138367,Other,base rate x DRG weight,124530,,"40,615 x DRG weight",124530,Other,base rate x DRG weight,117613,,"38,359 x DRG weight",117613,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45871,,186% x Medicaid HMO amount,45871,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,104483,,"34,077 x DRG weight",104483,Other,base rate x DRG weight,88813,,"28,966 x DRG weight",88813,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24662,,DRG base rate x DRG weight + capital per discharge,24662,Other,100% of NY Medicaid HMO DRG,24662,,100% x Medicaid HMO amount,24662,Other,100% of NY Medicaid HMO DRG,24662,,100% x Medicaid HMO amount,24662,Other,100% of NY Medicaid HMO DRG,24662,,100% x Medicaid HMO amount,24662,Other,100% of NY Medicaid HMO DRG,55490,,225% x Medicaid HMO amount,55490,Other,225% of NY Medicaid HMO DRG,55490,,225% x Medicaid HMO amount,55490,Other,225% of NY Medicaid HMO DRG,55490,,225% x Medicaid HMO amount,55490,Other,225% of NY Medicaid HMO DRG,55490,,225% x Medicaid HMO amount,55490,Other,225% of NY Medicaid HMO DRG,34527,,140% x Medicaid HMO amount,34527,Other,140% of NY Medicaid HMO DRG,55490,,225% x Medicaid HMO amount,55490,Other,225% of NY Medicaid HMO DRG,67821,,275% x Medicaid HMO amount,67821,Other,275% of NY Medicaid HMO DRG,79905,,324% x Medicaid HMO amount,79905,Other,324% of NY Medicaid HMO DRG,53023,,215% x Medicaid HMO amount,53023,Other,215% of NY Medicaid HMO DRG,53023,,215% x Medicaid HMO amount,53023,Other,215% of NY Medicaid HMO DRG,30828,,125% x Medicaid HMO amount,30828,Other,125% of NY Medicaid HMO DRG,0.01,138367,
Dorsal & lumbar fusion proc except for curvature of back,304-2,APR-DRG,,,,,,,,inpatient,,,431640.21,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,168544,,"45,128 x DRG weight",168544,Other,base rate x DRG weight,151689,,"40,615 x DRG weight",151689,Other,base rate x DRG weight,143263,,"38,359 x DRG weight",143263,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55541,,186% x Medicaid HMO amount,55541,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,127271,,"34,077 x DRG weight",127271,Other,base rate x DRG weight,108182,,"28,966 x DRG weight",108182,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29861,,DRG base rate x DRG weight + capital per discharge,29861,Other,100% of NY Medicaid HMO DRG,29861,,100% x Medicaid HMO amount,29861,Other,100% of NY Medicaid HMO DRG,29861,,100% x Medicaid HMO amount,29861,Other,100% of NY Medicaid HMO DRG,29861,,100% x Medicaid HMO amount,29861,Other,100% of NY Medicaid HMO DRG,67187,,225% x Medicaid HMO amount,67187,Other,225% of NY Medicaid HMO DRG,67187,,225% x Medicaid HMO amount,67187,Other,225% of NY Medicaid HMO DRG,67187,,225% x Medicaid HMO amount,67187,Other,225% of NY Medicaid HMO DRG,67187,,225% x Medicaid HMO amount,67187,Other,225% of NY Medicaid HMO DRG,41805,,140% x Medicaid HMO amount,41805,Other,140% of NY Medicaid HMO DRG,67187,,225% x Medicaid HMO amount,67187,Other,225% of NY Medicaid HMO DRG,82118,,275% x Medicaid HMO amount,82118,Other,275% of NY Medicaid HMO DRG,96750,,324% x Medicaid HMO amount,96750,Other,324% of NY Medicaid HMO DRG,64201,,215% x Medicaid HMO amount,64201,Other,215% of NY Medicaid HMO DRG,64201,,215% x Medicaid HMO amount,64201,Other,215% of NY Medicaid HMO DRG,37326,,125% x Medicaid HMO amount,37326,Other,125% of NY Medicaid HMO DRG,0.01,168544,
Dorsal & lumbar fusion proc except for curvature of back,304-3,APR-DRG,,,,,,,,inpatient,,,556856,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,240424,,"45,128 x DRG weight",240424,Other,base rate x DRG weight,216380,,"40,615 x DRG weight",216380,Other,base rate x DRG weight,204361,,"38,359 x DRG weight",204361,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,78578,,186% x Medicaid HMO amount,78578,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,181549,,"34,077 x DRG weight",181549,Other,base rate x DRG weight,154319,,"28,966 x DRG weight",154319,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42246,,DRG base rate x DRG weight + capital per discharge,42246,Other,100% of NY Medicaid HMO DRG,42246,,100% x Medicaid HMO amount,42246,Other,100% of NY Medicaid HMO DRG,42246,,100% x Medicaid HMO amount,42246,Other,100% of NY Medicaid HMO DRG,42246,,100% x Medicaid HMO amount,42246,Other,100% of NY Medicaid HMO DRG,95054,,225% x Medicaid HMO amount,95054,Other,225% of NY Medicaid HMO DRG,95054,,225% x Medicaid HMO amount,95054,Other,225% of NY Medicaid HMO DRG,95054,,225% x Medicaid HMO amount,95054,Other,225% of NY Medicaid HMO DRG,95054,,225% x Medicaid HMO amount,95054,Other,225% of NY Medicaid HMO DRG,59144,,140% x Medicaid HMO amount,59144,Other,140% of NY Medicaid HMO DRG,95054,,225% x Medicaid HMO amount,95054,Other,225% of NY Medicaid HMO DRG,116177,,275% x Medicaid HMO amount,116177,Other,275% of NY Medicaid HMO DRG,136877,,324% x Medicaid HMO amount,136877,Other,324% of NY Medicaid HMO DRG,90829,,215% x Medicaid HMO amount,90829,Other,215% of NY Medicaid HMO DRG,90829,,215% x Medicaid HMO amount,90829,Other,215% of NY Medicaid HMO DRG,52808,,125% x Medicaid HMO amount,52808,Other,125% of NY Medicaid HMO DRG,0.01,240424,
Dorsal & lumbar fusion proc except for curvature of back,304-4,APR-DRG,,,,,,,,inpatient,,,853371.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,414374,,"45,128 x DRG weight",414374,Other,base rate x DRG weight,372935,,"40,615 x DRG weight",372935,Other,base rate x DRG weight,352220,,"38,359 x DRG weight",352220,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,134325,,186% x Medicaid HMO amount,134325,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,312902,,"34,077 x DRG weight",312902,Other,base rate x DRG weight,265972,,"28,966 x DRG weight",265972,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,72218,,DRG base rate x DRG weight + capital per discharge,72218,Other,100% of NY Medicaid HMO DRG,72218,,100% x Medicaid HMO amount,72218,Other,100% of NY Medicaid HMO DRG,72218,,100% x Medicaid HMO amount,72218,Other,100% of NY Medicaid HMO DRG,72218,,100% x Medicaid HMO amount,72218,Other,100% of NY Medicaid HMO DRG,162491,,225% x Medicaid HMO amount,162491,Other,225% of NY Medicaid HMO DRG,162491,,225% x Medicaid HMO amount,162491,Other,225% of NY Medicaid HMO DRG,162491,,225% x Medicaid HMO amount,162491,Other,225% of NY Medicaid HMO DRG,162491,,225% x Medicaid HMO amount,162491,Other,225% of NY Medicaid HMO DRG,101105,,140% x Medicaid HMO amount,101105,Other,140% of NY Medicaid HMO DRG,162491,,225% x Medicaid HMO amount,162491,Other,225% of NY Medicaid HMO DRG,198600,,275% x Medicaid HMO amount,198600,Other,275% of NY Medicaid HMO DRG,233986,,324% x Medicaid HMO amount,233986,Other,324% of NY Medicaid HMO DRG,155269,,215% x Medicaid HMO amount,155269,Other,215% of NY Medicaid HMO DRG,155269,,215% x Medicaid HMO amount,155269,Other,215% of NY Medicaid HMO DRG,90273,,125% x Medicaid HMO amount,90273,Other,125% of NY Medicaid HMO DRG,0.01,414374,
Amputation of lower limb except toes,305-1,APR-DRG,,,,,,,,inpatient,,,201582.53,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,61428,,"45,128 x DRG weight",61428,Other,base rate x DRG weight,55285,,"40,615 x DRG weight",55285,Other,base rate x DRG weight,52214,,"38,359 x DRG weight",52214,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21213,,186% x Medicaid HMO amount,21213,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46386,,"34,077 x DRG weight",46386,Other,base rate x DRG weight,39429,,"28,966 x DRG weight",39429,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11405,,DRG base rate x DRG weight + capital per discharge,11405,Other,100% of NY Medicaid HMO DRG,11405,,100% x Medicaid HMO amount,11405,Other,100% of NY Medicaid HMO DRG,11405,,100% x Medicaid HMO amount,11405,Other,100% of NY Medicaid HMO DRG,11405,,100% x Medicaid HMO amount,11405,Other,100% of NY Medicaid HMO DRG,25661,,225% x Medicaid HMO amount,25661,Other,225% of NY Medicaid HMO DRG,25661,,225% x Medicaid HMO amount,25661,Other,225% of NY Medicaid HMO DRG,25661,,225% x Medicaid HMO amount,25661,Other,225% of NY Medicaid HMO DRG,25661,,225% x Medicaid HMO amount,25661,Other,225% of NY Medicaid HMO DRG,15967,,140% x Medicaid HMO amount,15967,Other,140% of NY Medicaid HMO DRG,25661,,225% x Medicaid HMO amount,25661,Other,225% of NY Medicaid HMO DRG,31364,,275% x Medicaid HMO amount,31364,Other,275% of NY Medicaid HMO DRG,36952,,324% x Medicaid HMO amount,36952,Other,324% of NY Medicaid HMO DRG,24521,,215% x Medicaid HMO amount,24521,Other,215% of NY Medicaid HMO DRG,24521,,215% x Medicaid HMO amount,24521,Other,215% of NY Medicaid HMO DRG,14256,,125% x Medicaid HMO amount,14256,Other,125% of NY Medicaid HMO DRG,0.01,61428,
Amputation of lower limb except toes,305-2,APR-DRG,,,,,,,,inpatient,,,503908.58,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,86515,,"45,128 x DRG weight",86515,Other,base rate x DRG weight,77863,,"40,615 x DRG weight",77863,Other,base rate x DRG weight,73538,,"38,359 x DRG weight",73538,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29254,,186% x Medicaid HMO amount,29254,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,65329,,"34,077 x DRG weight",65329,Other,base rate x DRG weight,55531,,"28,966 x DRG weight",55531,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15728,,DRG base rate x DRG weight + capital per discharge,15728,Other,100% of NY Medicaid HMO DRG,15728,,100% x Medicaid HMO amount,15728,Other,100% of NY Medicaid HMO DRG,15728,,100% x Medicaid HMO amount,15728,Other,100% of NY Medicaid HMO DRG,15728,,100% x Medicaid HMO amount,15728,Other,100% of NY Medicaid HMO DRG,35388,,225% x Medicaid HMO amount,35388,Other,225% of NY Medicaid HMO DRG,35388,,225% x Medicaid HMO amount,35388,Other,225% of NY Medicaid HMO DRG,35388,,225% x Medicaid HMO amount,35388,Other,225% of NY Medicaid HMO DRG,35388,,225% x Medicaid HMO amount,35388,Other,225% of NY Medicaid HMO DRG,22019,,140% x Medicaid HMO amount,22019,Other,140% of NY Medicaid HMO DRG,35388,,225% x Medicaid HMO amount,35388,Other,225% of NY Medicaid HMO DRG,43252,,275% x Medicaid HMO amount,43252,Other,275% of NY Medicaid HMO DRG,50959,,324% x Medicaid HMO amount,50959,Other,324% of NY Medicaid HMO DRG,33815,,215% x Medicaid HMO amount,33815,Other,215% of NY Medicaid HMO DRG,33815,,215% x Medicaid HMO amount,33815,Other,215% of NY Medicaid HMO DRG,19660,,125% x Medicaid HMO amount,19660,Other,125% of NY Medicaid HMO DRG,0.01,86515,
Amputation of lower limb except toes,305-3,APR-DRG,,,,,,,,inpatient,,,482034.2,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,152618,,"45,128 x DRG weight",152618,Other,base rate x DRG weight,137356,,"40,615 x DRG weight",137356,Other,base rate x DRG weight,129726,,"38,359 x DRG weight",129726,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50438,,186% x Medicaid HMO amount,50438,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,115245,,"34,077 x DRG weight",115245,Other,base rate x DRG weight,97960,,"28,966 x DRG weight",97960,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27117,,DRG base rate x DRG weight + capital per discharge,27117,Other,100% of NY Medicaid HMO DRG,27117,,100% x Medicaid HMO amount,27117,Other,100% of NY Medicaid HMO DRG,27117,,100% x Medicaid HMO amount,27117,Other,100% of NY Medicaid HMO DRG,27117,,100% x Medicaid HMO amount,27117,Other,100% of NY Medicaid HMO DRG,61013,,225% x Medicaid HMO amount,61013,Other,225% of NY Medicaid HMO DRG,61013,,225% x Medicaid HMO amount,61013,Other,225% of NY Medicaid HMO DRG,61013,,225% x Medicaid HMO amount,61013,Other,225% of NY Medicaid HMO DRG,61013,,225% x Medicaid HMO amount,61013,Other,225% of NY Medicaid HMO DRG,37964,,140% x Medicaid HMO amount,37964,Other,140% of NY Medicaid HMO DRG,61013,,225% x Medicaid HMO amount,61013,Other,225% of NY Medicaid HMO DRG,74572,,275% x Medicaid HMO amount,74572,Other,275% of NY Medicaid HMO DRG,87859,,324% x Medicaid HMO amount,87859,Other,324% of NY Medicaid HMO DRG,58302,,215% x Medicaid HMO amount,58302,Other,215% of NY Medicaid HMO DRG,58302,,215% x Medicaid HMO amount,58302,Other,215% of NY Medicaid HMO DRG,33896,,125% x Medicaid HMO amount,33896,Other,125% of NY Medicaid HMO DRG,0.01,152618,
Amputation of lower limb except toes,305-4,APR-DRG,,,,,,,,inpatient,,,684953.3,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,284388,,"45,128 x DRG weight",284388,Other,base rate x DRG weight,255948,,"40,615 x DRG weight",255948,Other,base rate x DRG weight,241731,,"38,359 x DRG weight",241731,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,92667,,186% x Medicaid HMO amount,92667,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,214746,,"34,077 x DRG weight",214746,Other,base rate x DRG weight,182538,,"28,966 x DRG weight",182538,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49821,,DRG base rate x DRG weight + capital per discharge,49821,Other,100% of NY Medicaid HMO DRG,49821,,100% x Medicaid HMO amount,49821,Other,100% of NY Medicaid HMO DRG,49821,,100% x Medicaid HMO amount,49821,Other,100% of NY Medicaid HMO DRG,49821,,100% x Medicaid HMO amount,49821,Other,100% of NY Medicaid HMO DRG,112097,,225% x Medicaid HMO amount,112097,Other,225% of NY Medicaid HMO DRG,112097,,225% x Medicaid HMO amount,112097,Other,225% of NY Medicaid HMO DRG,112097,,225% x Medicaid HMO amount,112097,Other,225% of NY Medicaid HMO DRG,112097,,225% x Medicaid HMO amount,112097,Other,225% of NY Medicaid HMO DRG,69749,,140% x Medicaid HMO amount,69749,Other,140% of NY Medicaid HMO DRG,112097,,225% x Medicaid HMO amount,112097,Other,225% of NY Medicaid HMO DRG,137008,,275% x Medicaid HMO amount,137008,Other,275% of NY Medicaid HMO DRG,161420,,324% x Medicaid HMO amount,161420,Other,324% of NY Medicaid HMO DRG,107115,,215% x Medicaid HMO amount,107115,Other,215% of NY Medicaid HMO DRG,107115,,215% x Medicaid HMO amount,107115,Other,215% of NY Medicaid HMO DRG,62276,,125% x Medicaid HMO amount,62276,Other,125% of NY Medicaid HMO DRG,0.01,284388,
Hip and femur fracture repair,308-1,APR-DRG,,,,,,,,inpatient,,,178777.39,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60273,,"45,128 x DRG weight",60273,Other,base rate x DRG weight,54245,,"40,615 x DRG weight",54245,Other,base rate x DRG weight,51232,,"38,359 x DRG weight",51232,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20843,,186% x Medicaid HMO amount,20843,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45513,,"34,077 x DRG weight",45513,Other,base rate x DRG weight,38687,,"28,966 x DRG weight",38687,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11206,,DRG base rate x DRG weight + capital per discharge,11206,Other,100% of NY Medicaid HMO DRG,11206,,100% x Medicaid HMO amount,11206,Other,100% of NY Medicaid HMO DRG,11206,,100% x Medicaid HMO amount,11206,Other,100% of NY Medicaid HMO DRG,11206,,100% x Medicaid HMO amount,11206,Other,100% of NY Medicaid HMO DRG,25214,,225% x Medicaid HMO amount,25214,Other,225% of NY Medicaid HMO DRG,25214,,225% x Medicaid HMO amount,25214,Other,225% of NY Medicaid HMO DRG,25214,,225% x Medicaid HMO amount,25214,Other,225% of NY Medicaid HMO DRG,25214,,225% x Medicaid HMO amount,25214,Other,225% of NY Medicaid HMO DRG,15688,,140% x Medicaid HMO amount,15688,Other,140% of NY Medicaid HMO DRG,25214,,225% x Medicaid HMO amount,25214,Other,225% of NY Medicaid HMO DRG,30817,,275% x Medicaid HMO amount,30817,Other,275% of NY Medicaid HMO DRG,36307,,324% x Medicaid HMO amount,36307,Other,324% of NY Medicaid HMO DRG,24093,,215% x Medicaid HMO amount,24093,Other,215% of NY Medicaid HMO DRG,24093,,215% x Medicaid HMO amount,24093,Other,215% of NY Medicaid HMO DRG,14008,,125% x Medicaid HMO amount,14008,Other,125% of NY Medicaid HMO DRG,0.01,60273,
Hip and femur fracture repair,308-2,APR-DRG,,,,,,,,inpatient,,,202004.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,82981,,"45,128 x DRG weight",82981,Other,base rate x DRG weight,74683,,"40,615 x DRG weight",74683,Other,base rate x DRG weight,70535,,"38,359 x DRG weight",70535,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28121,,186% x Medicaid HMO amount,28121,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,62661,,"34,077 x DRG weight",62661,Other,base rate x DRG weight,53263,,"28,966 x DRG weight",53263,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15119,,DRG base rate x DRG weight + capital per discharge,15119,Other,100% of NY Medicaid HMO DRG,15119,,100% x Medicaid HMO amount,15119,Other,100% of NY Medicaid HMO DRG,15119,,100% x Medicaid HMO amount,15119,Other,100% of NY Medicaid HMO DRG,15119,,100% x Medicaid HMO amount,15119,Other,100% of NY Medicaid HMO DRG,34018,,225% x Medicaid HMO amount,34018,Other,225% of NY Medicaid HMO DRG,34018,,225% x Medicaid HMO amount,34018,Other,225% of NY Medicaid HMO DRG,34018,,225% x Medicaid HMO amount,34018,Other,225% of NY Medicaid HMO DRG,34018,,225% x Medicaid HMO amount,34018,Other,225% of NY Medicaid HMO DRG,21167,,140% x Medicaid HMO amount,21167,Other,140% of NY Medicaid HMO DRG,34018,,225% x Medicaid HMO amount,34018,Other,225% of NY Medicaid HMO DRG,41577,,275% x Medicaid HMO amount,41577,Other,275% of NY Medicaid HMO DRG,48986,,324% x Medicaid HMO amount,48986,Other,324% of NY Medicaid HMO DRG,32506,,215% x Medicaid HMO amount,32506,Other,215% of NY Medicaid HMO DRG,32506,,215% x Medicaid HMO amount,32506,Other,215% of NY Medicaid HMO DRG,18899,,125% x Medicaid HMO amount,18899,Other,125% of NY Medicaid HMO DRG,0.01,82981,
Hip and femur fracture repair,308-3,APR-DRG,,,,,,,,inpatient,,,349123.33,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,123908,,"45,128 x DRG weight",123908,Other,base rate x DRG weight,111517,,"40,615 x DRG weight",111517,Other,base rate x DRG weight,105322,,"38,359 x DRG weight",105322,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41236,,186% x Medicaid HMO amount,41236,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,93565,,"34,077 x DRG weight",93565,Other,base rate x DRG weight,79532,,"28,966 x DRG weight",79532,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22170,,DRG base rate x DRG weight + capital per discharge,22170,Other,100% of NY Medicaid HMO DRG,22170,,100% x Medicaid HMO amount,22170,Other,100% of NY Medicaid HMO DRG,22170,,100% x Medicaid HMO amount,22170,Other,100% of NY Medicaid HMO DRG,22170,,100% x Medicaid HMO amount,22170,Other,100% of NY Medicaid HMO DRG,49883,,225% x Medicaid HMO amount,49883,Other,225% of NY Medicaid HMO DRG,49883,,225% x Medicaid HMO amount,49883,Other,225% of NY Medicaid HMO DRG,49883,,225% x Medicaid HMO amount,49883,Other,225% of NY Medicaid HMO DRG,49883,,225% x Medicaid HMO amount,49883,Other,225% of NY Medicaid HMO DRG,31038,,140% x Medicaid HMO amount,31038,Other,140% of NY Medicaid HMO DRG,49883,,225% x Medicaid HMO amount,49883,Other,225% of NY Medicaid HMO DRG,60968,,275% x Medicaid HMO amount,60968,Other,275% of NY Medicaid HMO DRG,71831,,324% x Medicaid HMO amount,71831,Other,324% of NY Medicaid HMO DRG,47666,,215% x Medicaid HMO amount,47666,Other,215% of NY Medicaid HMO DRG,47666,,215% x Medicaid HMO amount,47666,Other,215% of NY Medicaid HMO DRG,27713,,125% x Medicaid HMO amount,27713,Other,125% of NY Medicaid HMO DRG,0.01,123908,
Hip and femur fracture repair,308-4,APR-DRG,,,,,,,,inpatient,,,493957.53,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,260334,,"45,128 x DRG weight",260334,Other,base rate x DRG weight,234300,,"40,615 x DRG weight",234300,Other,base rate x DRG weight,221285,,"38,359 x DRG weight",221285,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,84959,,186% x Medicaid HMO amount,84959,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,196583,,"34,077 x DRG weight",196583,Other,base rate x DRG weight,167099,,"28,966 x DRG weight",167099,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45677,,DRG base rate x DRG weight + capital per discharge,45677,Other,100% of NY Medicaid HMO DRG,45677,,100% x Medicaid HMO amount,45677,Other,100% of NY Medicaid HMO DRG,45677,,100% x Medicaid HMO amount,45677,Other,100% of NY Medicaid HMO DRG,45677,,100% x Medicaid HMO amount,45677,Other,100% of NY Medicaid HMO DRG,102773,,225% x Medicaid HMO amount,102773,Other,225% of NY Medicaid HMO DRG,102773,,225% x Medicaid HMO amount,102773,Other,225% of NY Medicaid HMO DRG,102773,,225% x Medicaid HMO amount,102773,Other,225% of NY Medicaid HMO DRG,102773,,225% x Medicaid HMO amount,102773,Other,225% of NY Medicaid HMO DRG,63948,,140% x Medicaid HMO amount,63948,Other,140% of NY Medicaid HMO DRG,102773,,225% x Medicaid HMO amount,102773,Other,225% of NY Medicaid HMO DRG,125612,,275% x Medicaid HMO amount,125612,Other,275% of NY Medicaid HMO DRG,147993,,324% x Medicaid HMO amount,147993,Other,324% of NY Medicaid HMO DRG,98206,,215% x Medicaid HMO amount,98206,Other,215% of NY Medicaid HMO DRG,98206,,215% x Medicaid HMO amount,98206,Other,215% of NY Medicaid HMO DRG,57096,,125% x Medicaid HMO amount,57096,Other,125% of NY Medicaid HMO DRG,0.01,260334,
Other significant hip and femur surgery,309-1,APR-DRG,,,,,,,,inpatient,,,188202.96,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56202,,"45,128 x DRG weight",56202,Other,base rate x DRG weight,50582,,"40,615 x DRG weight",50582,Other,base rate x DRG weight,47772,,"38,359 x DRG weight",47772,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19539,,186% x Medicaid HMO amount,19539,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42439,,"34,077 x DRG weight",42439,Other,base rate x DRG weight,36074,,"28,966 x DRG weight",36074,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10505,,DRG base rate x DRG weight + capital per discharge,10505,Other,100% of NY Medicaid HMO DRG,10505,,100% x Medicaid HMO amount,10505,Other,100% of NY Medicaid HMO DRG,10505,,100% x Medicaid HMO amount,10505,Other,100% of NY Medicaid HMO DRG,10505,,100% x Medicaid HMO amount,10505,Other,100% of NY Medicaid HMO DRG,23636,,225% x Medicaid HMO amount,23636,Other,225% of NY Medicaid HMO DRG,23636,,225% x Medicaid HMO amount,23636,Other,225% of NY Medicaid HMO DRG,23636,,225% x Medicaid HMO amount,23636,Other,225% of NY Medicaid HMO DRG,23636,,225% x Medicaid HMO amount,23636,Other,225% of NY Medicaid HMO DRG,14707,,140% x Medicaid HMO amount,14707,Other,140% of NY Medicaid HMO DRG,23636,,225% x Medicaid HMO amount,23636,Other,225% of NY Medicaid HMO DRG,28889,,275% x Medicaid HMO amount,28889,Other,275% of NY Medicaid HMO DRG,34036,,324% x Medicaid HMO amount,34036,Other,324% of NY Medicaid HMO DRG,22586,,215% x Medicaid HMO amount,22586,Other,215% of NY Medicaid HMO DRG,22586,,215% x Medicaid HMO amount,22586,Other,215% of NY Medicaid HMO DRG,13131,,125% x Medicaid HMO amount,13131,Other,125% of NY Medicaid HMO DRG,0.01,56202,
Other significant hip and femur surgery,309-2,APR-DRG,,,,,,,,inpatient,,,202463.54,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,84606,,"45,128 x DRG weight",84606,Other,base rate x DRG weight,76145,,"40,615 x DRG weight",76145,Other,base rate x DRG weight,71915,,"38,359 x DRG weight",71915,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28642,,186% x Medicaid HMO amount,28642,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,63888,,"34,077 x DRG weight",63888,Other,base rate x DRG weight,54305,,"28,966 x DRG weight",54305,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15399,,DRG base rate x DRG weight + capital per discharge,15399,Other,100% of NY Medicaid HMO DRG,15399,,100% x Medicaid HMO amount,15399,Other,100% of NY Medicaid HMO DRG,15399,,100% x Medicaid HMO amount,15399,Other,100% of NY Medicaid HMO DRG,15399,,100% x Medicaid HMO amount,15399,Other,100% of NY Medicaid HMO DRG,34648,,225% x Medicaid HMO amount,34648,Other,225% of NY Medicaid HMO DRG,34648,,225% x Medicaid HMO amount,34648,Other,225% of NY Medicaid HMO DRG,34648,,225% x Medicaid HMO amount,34648,Other,225% of NY Medicaid HMO DRG,34648,,225% x Medicaid HMO amount,34648,Other,225% of NY Medicaid HMO DRG,21559,,140% x Medicaid HMO amount,21559,Other,140% of NY Medicaid HMO DRG,34648,,225% x Medicaid HMO amount,34648,Other,225% of NY Medicaid HMO DRG,42347,,275% x Medicaid HMO amount,42347,Other,275% of NY Medicaid HMO DRG,49893,,324% x Medicaid HMO amount,49893,Other,324% of NY Medicaid HMO DRG,33108,,215% x Medicaid HMO amount,33108,Other,215% of NY Medicaid HMO DRG,33108,,215% x Medicaid HMO amount,33108,Other,215% of NY Medicaid HMO DRG,19249,,125% x Medicaid HMO amount,19249,Other,125% of NY Medicaid HMO DRG,0.01,84606,
Other significant hip and femur surgery,309-3,APR-DRG,,,,,,,,inpatient,,,714745.36,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,136372,,"45,128 x DRG weight",136372,Other,base rate x DRG weight,122734,,"40,615 x DRG weight",122734,Other,base rate x DRG weight,115917,,"38,359 x DRG weight",115917,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45231,,186% x Medicaid HMO amount,45231,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,102977,,"34,077 x DRG weight",102977,Other,base rate x DRG weight,87532,,"28,966 x DRG weight",87532,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24318,,DRG base rate x DRG weight + capital per discharge,24318,Other,100% of NY Medicaid HMO DRG,24318,,100% x Medicaid HMO amount,24318,Other,100% of NY Medicaid HMO DRG,24318,,100% x Medicaid HMO amount,24318,Other,100% of NY Medicaid HMO DRG,24318,,100% x Medicaid HMO amount,24318,Other,100% of NY Medicaid HMO DRG,54716,,225% x Medicaid HMO amount,54716,Other,225% of NY Medicaid HMO DRG,54716,,225% x Medicaid HMO amount,54716,Other,225% of NY Medicaid HMO DRG,54716,,225% x Medicaid HMO amount,54716,Other,225% of NY Medicaid HMO DRG,54716,,225% x Medicaid HMO amount,54716,Other,225% of NY Medicaid HMO DRG,34045,,140% x Medicaid HMO amount,34045,Other,140% of NY Medicaid HMO DRG,54716,,225% x Medicaid HMO amount,54716,Other,225% of NY Medicaid HMO DRG,66875,,275% x Medicaid HMO amount,66875,Other,275% of NY Medicaid HMO DRG,78790,,324% x Medicaid HMO amount,78790,Other,324% of NY Medicaid HMO DRG,52284,,215% x Medicaid HMO amount,52284,Other,215% of NY Medicaid HMO DRG,52284,,215% x Medicaid HMO amount,52284,Other,215% of NY Medicaid HMO DRG,30398,,125% x Medicaid HMO amount,30398,Other,125% of NY Medicaid HMO DRG,0.01,136372,
Other significant hip and femur surgery,309-4,APR-DRG,,,,,,,,inpatient,,,1173105.65,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,259265,,"45,128 x DRG weight",259265,Other,base rate x DRG weight,233337,,"40,615 x DRG weight",233337,Other,base rate x DRG weight,220376,,"38,359 x DRG weight",220376,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,84617,,186% x Medicaid HMO amount,84617,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,195776,,"34,077 x DRG weight",195776,Other,base rate x DRG weight,166413,,"28,966 x DRG weight",166413,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45493,,DRG base rate x DRG weight + capital per discharge,45493,Other,100% of NY Medicaid HMO DRG,45493,,100% x Medicaid HMO amount,45493,Other,100% of NY Medicaid HMO DRG,45493,,100% x Medicaid HMO amount,45493,Other,100% of NY Medicaid HMO DRG,45493,,100% x Medicaid HMO amount,45493,Other,100% of NY Medicaid HMO DRG,102359,,225% x Medicaid HMO amount,102359,Other,225% of NY Medicaid HMO DRG,102359,,225% x Medicaid HMO amount,102359,Other,225% of NY Medicaid HMO DRG,102359,,225% x Medicaid HMO amount,102359,Other,225% of NY Medicaid HMO DRG,102359,,225% x Medicaid HMO amount,102359,Other,225% of NY Medicaid HMO DRG,63690,,140% x Medicaid HMO amount,63690,Other,140% of NY Medicaid HMO DRG,102359,,225% x Medicaid HMO amount,102359,Other,225% of NY Medicaid HMO DRG,125106,,275% x Medicaid HMO amount,125106,Other,275% of NY Medicaid HMO DRG,147397,,324% x Medicaid HMO amount,147397,Other,324% of NY Medicaid HMO DRG,97810,,215% x Medicaid HMO amount,97810,Other,215% of NY Medicaid HMO DRG,97810,,215% x Medicaid HMO amount,97810,Other,215% of NY Medicaid HMO DRG,56866,,125% x Medicaid HMO amount,56866,Other,125% of NY Medicaid HMO DRG,0.01,259265,
Intervertebral disc excision & decompression,310-1,APR-DRG,,,,,,,,inpatient,,,186742.28,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38896,,"45,128 x DRG weight",38896,Other,base rate x DRG weight,35006,,"40,615 x DRG weight",35006,Other,base rate x DRG weight,33062,,"38,359 x DRG weight",33062,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13993,,186% x Medicaid HMO amount,13993,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29371,,"34,077 x DRG weight",29371,Other,base rate x DRG weight,24966,,"28,966 x DRG weight",24966,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7523,,DRG base rate x DRG weight + capital per discharge,7523,Other,100% of NY Medicaid HMO DRG,7523,,100% x Medicaid HMO amount,7523,Other,100% of NY Medicaid HMO DRG,7523,,100% x Medicaid HMO amount,7523,Other,100% of NY Medicaid HMO DRG,7523,,100% x Medicaid HMO amount,7523,Other,100% of NY Medicaid HMO DRG,16927,,225% x Medicaid HMO amount,16927,Other,225% of NY Medicaid HMO DRG,16927,,225% x Medicaid HMO amount,16927,Other,225% of NY Medicaid HMO DRG,16927,,225% x Medicaid HMO amount,16927,Other,225% of NY Medicaid HMO DRG,16927,,225% x Medicaid HMO amount,16927,Other,225% of NY Medicaid HMO DRG,10532,,140% x Medicaid HMO amount,10532,Other,140% of NY Medicaid HMO DRG,16927,,225% x Medicaid HMO amount,16927,Other,225% of NY Medicaid HMO DRG,20688,,275% x Medicaid HMO amount,20688,Other,275% of NY Medicaid HMO DRG,24375,,324% x Medicaid HMO amount,24375,Other,324% of NY Medicaid HMO DRG,16174,,215% x Medicaid HMO amount,16174,Other,215% of NY Medicaid HMO DRG,16174,,215% x Medicaid HMO amount,16174,Other,215% of NY Medicaid HMO DRG,9404,,125% x Medicaid HMO amount,9404,Other,125% of NY Medicaid HMO DRG,0.01,38896,
Intervertebral disc excision & decompression,310-2,APR-DRG,,,,,,,,inpatient,,,268237.65,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55146,,"45,128 x DRG weight",55146,Other,base rate x DRG weight,49632,,"40,615 x DRG weight",49632,Other,base rate x DRG weight,46875,,"38,359 x DRG weight",46875,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19201,,186% x Medicaid HMO amount,19201,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41642,,"34,077 x DRG weight",41642,Other,base rate x DRG weight,35396,,"28,966 x DRG weight",35396,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10323,,DRG base rate x DRG weight + capital per discharge,10323,Other,100% of NY Medicaid HMO DRG,10323,,100% x Medicaid HMO amount,10323,Other,100% of NY Medicaid HMO DRG,10323,,100% x Medicaid HMO amount,10323,Other,100% of NY Medicaid HMO DRG,10323,,100% x Medicaid HMO amount,10323,Other,100% of NY Medicaid HMO DRG,23227,,225% x Medicaid HMO amount,23227,Other,225% of NY Medicaid HMO DRG,23227,,225% x Medicaid HMO amount,23227,Other,225% of NY Medicaid HMO DRG,23227,,225% x Medicaid HMO amount,23227,Other,225% of NY Medicaid HMO DRG,23227,,225% x Medicaid HMO amount,23227,Other,225% of NY Medicaid HMO DRG,14452,,140% x Medicaid HMO amount,14452,Other,140% of NY Medicaid HMO DRG,23227,,225% x Medicaid HMO amount,23227,Other,225% of NY Medicaid HMO DRG,28388,,275% x Medicaid HMO amount,28388,Other,275% of NY Medicaid HMO DRG,33447,,324% x Medicaid HMO amount,33447,Other,324% of NY Medicaid HMO DRG,22194,,215% x Medicaid HMO amount,22194,Other,215% of NY Medicaid HMO DRG,22194,,215% x Medicaid HMO amount,22194,Other,215% of NY Medicaid HMO DRG,12904,,125% x Medicaid HMO amount,12904,Other,125% of NY Medicaid HMO DRG,0.01,55146,
Intervertebral disc excision & decompression,310-3,APR-DRG,,,,,,,,inpatient,,,396901.71,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,114851,,"45,128 x DRG weight",114851,Other,base rate x DRG weight,103365,,"40,615 x DRG weight",103365,Other,base rate x DRG weight,97624,,"38,359 x DRG weight",97624,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38335,,186% x Medicaid HMO amount,38335,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,86726,,"34,077 x DRG weight",86726,Other,base rate x DRG weight,73718,,"28,966 x DRG weight",73718,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20610,,DRG base rate x DRG weight + capital per discharge,20610,Other,100% of NY Medicaid HMO DRG,20610,,100% x Medicaid HMO amount,20610,Other,100% of NY Medicaid HMO DRG,20610,,100% x Medicaid HMO amount,20610,Other,100% of NY Medicaid HMO DRG,20610,,100% x Medicaid HMO amount,20610,Other,100% of NY Medicaid HMO DRG,46373,,225% x Medicaid HMO amount,46373,Other,225% of NY Medicaid HMO DRG,46373,,225% x Medicaid HMO amount,46373,Other,225% of NY Medicaid HMO DRG,46373,,225% x Medicaid HMO amount,46373,Other,225% of NY Medicaid HMO DRG,46373,,225% x Medicaid HMO amount,46373,Other,225% of NY Medicaid HMO DRG,28854,,140% x Medicaid HMO amount,28854,Other,140% of NY Medicaid HMO DRG,46373,,225% x Medicaid HMO amount,46373,Other,225% of NY Medicaid HMO DRG,56678,,275% x Medicaid HMO amount,56678,Other,275% of NY Medicaid HMO DRG,66776,,324% x Medicaid HMO amount,66776,Other,324% of NY Medicaid HMO DRG,44312,,215% x Medicaid HMO amount,44312,Other,215% of NY Medicaid HMO DRG,44312,,215% x Medicaid HMO amount,44312,Other,215% of NY Medicaid HMO DRG,25763,,125% x Medicaid HMO amount,25763,Other,125% of NY Medicaid HMO DRG,0.01,114851,
Intervertebral disc excision & decompression,310-4,APR-DRG,,,,,,,,inpatient,,,594634.01,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,308775,,"45,128 x DRG weight",308775,Other,base rate x DRG weight,277896,,"40,615 x DRG weight",277896,Other,base rate x DRG weight,262460,,"38,359 x DRG weight",262460,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,100483,,186% x Medicaid HMO amount,100483,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,233162,,"34,077 x DRG weight",233162,Other,base rate x DRG weight,198191,,"28,966 x DRG weight",198191,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54023,,DRG base rate x DRG weight + capital per discharge,54023,Other,100% of NY Medicaid HMO DRG,54023,,100% x Medicaid HMO amount,54023,Other,100% of NY Medicaid HMO DRG,54023,,100% x Medicaid HMO amount,54023,Other,100% of NY Medicaid HMO DRG,54023,,100% x Medicaid HMO amount,54023,Other,100% of NY Medicaid HMO DRG,121552,,225% x Medicaid HMO amount,121552,Other,225% of NY Medicaid HMO DRG,121552,,225% x Medicaid HMO amount,121552,Other,225% of NY Medicaid HMO DRG,121552,,225% x Medicaid HMO amount,121552,Other,225% of NY Medicaid HMO DRG,121552,,225% x Medicaid HMO amount,121552,Other,225% of NY Medicaid HMO DRG,75632,,140% x Medicaid HMO amount,75632,Other,140% of NY Medicaid HMO DRG,121552,,225% x Medicaid HMO amount,121552,Other,225% of NY Medicaid HMO DRG,148563,,275% x Medicaid HMO amount,148563,Other,275% of NY Medicaid HMO DRG,175035,,324% x Medicaid HMO amount,175035,Other,324% of NY Medicaid HMO DRG,116149,,215% x Medicaid HMO amount,116149,Other,215% of NY Medicaid HMO DRG,116149,,215% x Medicaid HMO amount,116149,Other,215% of NY Medicaid HMO DRG,67529,,125% x Medicaid HMO amount,67529,Other,125% of NY Medicaid HMO DRG,0.01,308775,
"Skin graft, except hand, for musculoskeletal & connective tissue diagnoses",312-1,APR-DRG,,,,,,,,inpatient,,,195262.7,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55007,,"45,128 x DRG weight",55007,Other,base rate x DRG weight,49506,,"40,615 x DRG weight",49506,Other,base rate x DRG weight,46756,,"38,359 x DRG weight",46756,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19156,,186% x Medicaid HMO amount,19156,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41536,,"34,077 x DRG weight",41536,Other,base rate x DRG weight,35307,,"28,966 x DRG weight",35307,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10299,,DRG base rate x DRG weight + capital per discharge,10299,Other,100% of NY Medicaid HMO DRG,10299,,100% x Medicaid HMO amount,10299,Other,100% of NY Medicaid HMO DRG,10299,,100% x Medicaid HMO amount,10299,Other,100% of NY Medicaid HMO DRG,10299,,100% x Medicaid HMO amount,10299,Other,100% of NY Medicaid HMO DRG,23173,,225% x Medicaid HMO amount,23173,Other,225% of NY Medicaid HMO DRG,23173,,225% x Medicaid HMO amount,23173,Other,225% of NY Medicaid HMO DRG,23173,,225% x Medicaid HMO amount,23173,Other,225% of NY Medicaid HMO DRG,23173,,225% x Medicaid HMO amount,23173,Other,225% of NY Medicaid HMO DRG,14419,,140% x Medicaid HMO amount,14419,Other,140% of NY Medicaid HMO DRG,23173,,225% x Medicaid HMO amount,23173,Other,225% of NY Medicaid HMO DRG,28322,,275% x Medicaid HMO amount,28322,Other,275% of NY Medicaid HMO DRG,33369,,324% x Medicaid HMO amount,33369,Other,324% of NY Medicaid HMO DRG,22143,,215% x Medicaid HMO amount,22143,Other,215% of NY Medicaid HMO DRG,22143,,215% x Medicaid HMO amount,22143,Other,215% of NY Medicaid HMO DRG,12874,,125% x Medicaid HMO amount,12874,Other,125% of NY Medicaid HMO DRG,0.01,55007,
"Skin graft, except hand, for musculoskeletal & connective tissue diagnoses",312-2,APR-DRG,,,,,,,,inpatient,,,523226.19,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,101687,,"45,128 x DRG weight",101687,Other,base rate x DRG weight,91518,,"40,615 x DRG weight",91518,Other,base rate x DRG weight,86434,,"38,359 x DRG weight",86434,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34116,,186% x Medicaid HMO amount,34116,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,76786,,"34,077 x DRG weight",76786,Other,base rate x DRG weight,65269,,"28,966 x DRG weight",65269,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18342,,DRG base rate x DRG weight + capital per discharge,18342,Other,100% of NY Medicaid HMO DRG,18342,,100% x Medicaid HMO amount,18342,Other,100% of NY Medicaid HMO DRG,18342,,100% x Medicaid HMO amount,18342,Other,100% of NY Medicaid HMO DRG,18342,,100% x Medicaid HMO amount,18342,Other,100% of NY Medicaid HMO DRG,41270,,225% x Medicaid HMO amount,41270,Other,225% of NY Medicaid HMO DRG,41270,,225% x Medicaid HMO amount,41270,Other,225% of NY Medicaid HMO DRG,41270,,225% x Medicaid HMO amount,41270,Other,225% of NY Medicaid HMO DRG,41270,,225% x Medicaid HMO amount,41270,Other,225% of NY Medicaid HMO DRG,25679,,140% x Medicaid HMO amount,25679,Other,140% of NY Medicaid HMO DRG,41270,,225% x Medicaid HMO amount,41270,Other,225% of NY Medicaid HMO DRG,50441,,275% x Medicaid HMO amount,50441,Other,275% of NY Medicaid HMO DRG,59428,,324% x Medicaid HMO amount,59428,Other,324% of NY Medicaid HMO DRG,39435,,215% x Medicaid HMO amount,39435,Other,215% of NY Medicaid HMO DRG,39435,,215% x Medicaid HMO amount,39435,Other,215% of NY Medicaid HMO DRG,22928,,125% x Medicaid HMO amount,22928,Other,125% of NY Medicaid HMO DRG,0.01,101687,
"Skin graft, except hand, for musculoskeletal & connective tissue diagnoses",312-3,APR-DRG,,,,,,,,inpatient,,,239553.8,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,204326,,"45,128 x DRG weight",204326,Other,base rate x DRG weight,183893,,"40,615 x DRG weight",183893,Other,base rate x DRG weight,173678,,"38,359 x DRG weight",173678,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,67010,,186% x Medicaid HMO amount,67010,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,154290,,"34,077 x DRG weight",154290,Other,base rate x DRG weight,131149,,"28,966 x DRG weight",131149,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36027,,DRG base rate x DRG weight + capital per discharge,36027,Other,100% of NY Medicaid HMO DRG,36027,,100% x Medicaid HMO amount,36027,Other,100% of NY Medicaid HMO DRG,36027,,100% x Medicaid HMO amount,36027,Other,100% of NY Medicaid HMO DRG,36027,,100% x Medicaid HMO amount,36027,Other,100% of NY Medicaid HMO DRG,81061,,225% x Medicaid HMO amount,81061,Other,225% of NY Medicaid HMO DRG,81061,,225% x Medicaid HMO amount,81061,Other,225% of NY Medicaid HMO DRG,81061,,225% x Medicaid HMO amount,81061,Other,225% of NY Medicaid HMO DRG,81061,,225% x Medicaid HMO amount,81061,Other,225% of NY Medicaid HMO DRG,50438,,140% x Medicaid HMO amount,50438,Other,140% of NY Medicaid HMO DRG,81061,,225% x Medicaid HMO amount,81061,Other,225% of NY Medicaid HMO DRG,99074,,275% x Medicaid HMO amount,99074,Other,275% of NY Medicaid HMO DRG,116727,,324% x Medicaid HMO amount,116727,Other,324% of NY Medicaid HMO DRG,77458,,215% x Medicaid HMO amount,77458,Other,215% of NY Medicaid HMO DRG,77458,,215% x Medicaid HMO amount,77458,Other,215% of NY Medicaid HMO DRG,45034,,125% x Medicaid HMO amount,45034,Other,125% of NY Medicaid HMO DRG,0.01,204326,
"Skin graft, except hand, for musculoskeletal & connective tissue diagnoses",312-4,APR-DRG,,,,,,,,inpatient,,,1431548.96,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,406256,,"45,128 x DRG weight",406256,Other,base rate x DRG weight,365628,,"40,615 x DRG weight",365628,Other,base rate x DRG weight,345319,,"38,359 x DRG weight",345319,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,131723,,186% x Medicaid HMO amount,131723,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,306771,,"34,077 x DRG weight",306771,Other,base rate x DRG weight,260761,,"28,966 x DRG weight",260761,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,70819,,DRG base rate x DRG weight + capital per discharge,70819,Other,100% of NY Medicaid HMO DRG,70819,,100% x Medicaid HMO amount,70819,Other,100% of NY Medicaid HMO DRG,70819,,100% x Medicaid HMO amount,70819,Other,100% of NY Medicaid HMO DRG,70819,,100% x Medicaid HMO amount,70819,Other,100% of NY Medicaid HMO DRG,159343,,225% x Medicaid HMO amount,159343,Other,225% of NY Medicaid HMO DRG,159343,,225% x Medicaid HMO amount,159343,Other,225% of NY Medicaid HMO DRG,159343,,225% x Medicaid HMO amount,159343,Other,225% of NY Medicaid HMO DRG,159343,,225% x Medicaid HMO amount,159343,Other,225% of NY Medicaid HMO DRG,99147,,140% x Medicaid HMO amount,99147,Other,140% of NY Medicaid HMO DRG,159343,,225% x Medicaid HMO amount,159343,Other,225% of NY Medicaid HMO DRG,194752,,275% x Medicaid HMO amount,194752,Other,275% of NY Medicaid HMO DRG,229454,,324% x Medicaid HMO amount,229454,Other,324% of NY Medicaid HMO DRG,152261,,215% x Medicaid HMO amount,152261,Other,215% of NY Medicaid HMO DRG,152261,,215% x Medicaid HMO amount,152261,Other,215% of NY Medicaid HMO DRG,88524,,125% x Medicaid HMO amount,88524,Other,125% of NY Medicaid HMO DRG,0.01,406256,
Knee & lower leg procedures except foot,313-1,APR-DRG,,,,,,,,inpatient,,,218809.15,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53987,,"45,128 x DRG weight",53987,Other,base rate x DRG weight,48588,,"40,615 x DRG weight",48588,Other,base rate x DRG weight,45889,,"38,359 x DRG weight",45889,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18829,,186% x Medicaid HMO amount,18829,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40766,,"34,077 x DRG weight",40766,Other,base rate x DRG weight,34652,,"28,966 x DRG weight",34652,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10123,,DRG base rate x DRG weight + capital per discharge,10123,Other,100% of NY Medicaid HMO DRG,10123,,100% x Medicaid HMO amount,10123,Other,100% of NY Medicaid HMO DRG,10123,,100% x Medicaid HMO amount,10123,Other,100% of NY Medicaid HMO DRG,10123,,100% x Medicaid HMO amount,10123,Other,100% of NY Medicaid HMO DRG,22777,,225% x Medicaid HMO amount,22777,Other,225% of NY Medicaid HMO DRG,22777,,225% x Medicaid HMO amount,22777,Other,225% of NY Medicaid HMO DRG,22777,,225% x Medicaid HMO amount,22777,Other,225% of NY Medicaid HMO DRG,22777,,225% x Medicaid HMO amount,22777,Other,225% of NY Medicaid HMO DRG,14172,,140% x Medicaid HMO amount,14172,Other,140% of NY Medicaid HMO DRG,22777,,225% x Medicaid HMO amount,22777,Other,225% of NY Medicaid HMO DRG,27838,,275% x Medicaid HMO amount,27838,Other,275% of NY Medicaid HMO DRG,32799,,324% x Medicaid HMO amount,32799,Other,324% of NY Medicaid HMO DRG,21764,,215% x Medicaid HMO amount,21764,Other,215% of NY Medicaid HMO DRG,21764,,215% x Medicaid HMO amount,21764,Other,215% of NY Medicaid HMO DRG,12654,,125% x Medicaid HMO amount,12654,Other,125% of NY Medicaid HMO DRG,0.01,53987,
Knee & lower leg procedures except foot,313-2,APR-DRG,,,,,,,,inpatient,,,264676.63,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,79227,,"45,128 x DRG weight",79227,Other,base rate x DRG weight,71304,,"40,615 x DRG weight",71304,Other,base rate x DRG weight,67343,,"38,359 x DRG weight",67343,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26918,,186% x Medicaid HMO amount,26918,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59826,,"34,077 x DRG weight",59826,Other,base rate x DRG weight,50853,,"28,966 x DRG weight",50853,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14472,,DRG base rate x DRG weight + capital per discharge,14472,Other,100% of NY Medicaid HMO DRG,14472,,100% x Medicaid HMO amount,14472,Other,100% of NY Medicaid HMO DRG,14472,,100% x Medicaid HMO amount,14472,Other,100% of NY Medicaid HMO DRG,14472,,100% x Medicaid HMO amount,14472,Other,100% of NY Medicaid HMO DRG,32562,,225% x Medicaid HMO amount,32562,Other,225% of NY Medicaid HMO DRG,32562,,225% x Medicaid HMO amount,32562,Other,225% of NY Medicaid HMO DRG,32562,,225% x Medicaid HMO amount,32562,Other,225% of NY Medicaid HMO DRG,32562,,225% x Medicaid HMO amount,32562,Other,225% of NY Medicaid HMO DRG,20261,,140% x Medicaid HMO amount,20261,Other,140% of NY Medicaid HMO DRG,32562,,225% x Medicaid HMO amount,32562,Other,225% of NY Medicaid HMO DRG,39798,,275% x Medicaid HMO amount,39798,Other,275% of NY Medicaid HMO DRG,46889,,324% x Medicaid HMO amount,46889,Other,324% of NY Medicaid HMO DRG,31115,,215% x Medicaid HMO amount,31115,Other,215% of NY Medicaid HMO DRG,31115,,215% x Medicaid HMO amount,31115,Other,215% of NY Medicaid HMO DRG,18090,,125% x Medicaid HMO amount,18090,Other,125% of NY Medicaid HMO DRG,0.01,79227,
Knee & lower leg procedures except foot,313-3,APR-DRG,,,,,,,,inpatient,,,667069.93,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,129743,,"45,128 x DRG weight",129743,Other,base rate x DRG weight,116768,,"40,615 x DRG weight",116768,Other,base rate x DRG weight,110282,,"38,359 x DRG weight",110282,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43107,,186% x Medicaid HMO amount,43107,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,97971,,"34,077 x DRG weight",97971,Other,base rate x DRG weight,83277,,"28,966 x DRG weight",83277,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23176,,DRG base rate x DRG weight + capital per discharge,23176,Other,100% of NY Medicaid HMO DRG,23176,,100% x Medicaid HMO amount,23176,Other,100% of NY Medicaid HMO DRG,23176,,100% x Medicaid HMO amount,23176,Other,100% of NY Medicaid HMO DRG,23176,,100% x Medicaid HMO amount,23176,Other,100% of NY Medicaid HMO DRG,52146,,225% x Medicaid HMO amount,52146,Other,225% of NY Medicaid HMO DRG,52146,,225% x Medicaid HMO amount,52146,Other,225% of NY Medicaid HMO DRG,52146,,225% x Medicaid HMO amount,52146,Other,225% of NY Medicaid HMO DRG,52146,,225% x Medicaid HMO amount,52146,Other,225% of NY Medicaid HMO DRG,32446,,140% x Medicaid HMO amount,32446,Other,140% of NY Medicaid HMO DRG,52146,,225% x Medicaid HMO amount,52146,Other,225% of NY Medicaid HMO DRG,63734,,275% x Medicaid HMO amount,63734,Other,275% of NY Medicaid HMO DRG,75090,,324% x Medicaid HMO amount,75090,Other,324% of NY Medicaid HMO DRG,49828,,215% x Medicaid HMO amount,49828,Other,215% of NY Medicaid HMO DRG,49828,,215% x Medicaid HMO amount,49828,Other,215% of NY Medicaid HMO DRG,28970,,125% x Medicaid HMO amount,28970,Other,125% of NY Medicaid HMO DRG,0.01,129743,
Knee & lower leg procedures except foot,313-4,APR-DRG,,,,,,,,inpatient,,,637267.49,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,292037,,"45,128 x DRG weight",292037,Other,base rate x DRG weight,262832,,"40,615 x DRG weight",262832,Other,base rate x DRG weight,248233,,"38,359 x DRG weight",248233,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,95119,,186% x Medicaid HMO amount,95119,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,220522,,"34,077 x DRG weight",220522,Other,base rate x DRG weight,187448,,"28,966 x DRG weight",187448,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51139,,DRG base rate x DRG weight + capital per discharge,51139,Other,100% of NY Medicaid HMO DRG,51139,,100% x Medicaid HMO amount,51139,Other,100% of NY Medicaid HMO DRG,51139,,100% x Medicaid HMO amount,51139,Other,100% of NY Medicaid HMO DRG,51139,,100% x Medicaid HMO amount,51139,Other,100% of NY Medicaid HMO DRG,115063,,225% x Medicaid HMO amount,115063,Other,225% of NY Medicaid HMO DRG,115063,,225% x Medicaid HMO amount,115063,Other,225% of NY Medicaid HMO DRG,115063,,225% x Medicaid HMO amount,115063,Other,225% of NY Medicaid HMO DRG,115063,,225% x Medicaid HMO amount,115063,Other,225% of NY Medicaid HMO DRG,71595,,140% x Medicaid HMO amount,71595,Other,140% of NY Medicaid HMO DRG,115063,,225% x Medicaid HMO amount,115063,Other,225% of NY Medicaid HMO DRG,140632,,275% x Medicaid HMO amount,140632,Other,275% of NY Medicaid HMO DRG,165690,,324% x Medicaid HMO amount,165690,Other,324% of NY Medicaid HMO DRG,109949,,215% x Medicaid HMO amount,109949,Other,215% of NY Medicaid HMO DRG,109949,,215% x Medicaid HMO amount,109949,Other,215% of NY Medicaid HMO DRG,63924,,125% x Medicaid HMO amount,63924,Other,125% of NY Medicaid HMO DRG,0.01,292037,
Foot & toe procedures,314-1,APR-DRG,,,,,,,,inpatient,,,151017.04,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47763,,"45,128 x DRG weight",47763,Other,base rate x DRG weight,42987,,"40,615 x DRG weight",42987,Other,base rate x DRG weight,40599,,"38,359 x DRG weight",40599,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16835,,186% x Medicaid HMO amount,16835,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36067,,"34,077 x DRG weight",36067,Other,base rate x DRG weight,30658,,"28,966 x DRG weight",30658,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9051,,DRG base rate x DRG weight + capital per discharge,9051,Other,100% of NY Medicaid HMO DRG,9051,,100% x Medicaid HMO amount,9051,Other,100% of NY Medicaid HMO DRG,9051,,100% x Medicaid HMO amount,9051,Other,100% of NY Medicaid HMO DRG,9051,,100% x Medicaid HMO amount,9051,Other,100% of NY Medicaid HMO DRG,20365,,225% x Medicaid HMO amount,20365,Other,225% of NY Medicaid HMO DRG,20365,,225% x Medicaid HMO amount,20365,Other,225% of NY Medicaid HMO DRG,20365,,225% x Medicaid HMO amount,20365,Other,225% of NY Medicaid HMO DRG,20365,,225% x Medicaid HMO amount,20365,Other,225% of NY Medicaid HMO DRG,12671,,140% x Medicaid HMO amount,12671,Other,140% of NY Medicaid HMO DRG,20365,,225% x Medicaid HMO amount,20365,Other,225% of NY Medicaid HMO DRG,24890,,275% x Medicaid HMO amount,24890,Other,275% of NY Medicaid HMO DRG,29325,,324% x Medicaid HMO amount,29325,Other,324% of NY Medicaid HMO DRG,19460,,215% x Medicaid HMO amount,19460,Other,215% of NY Medicaid HMO DRG,19460,,215% x Medicaid HMO amount,19460,Other,215% of NY Medicaid HMO DRG,11314,,125% x Medicaid HMO amount,11314,Other,125% of NY Medicaid HMO DRG,0.01,47763,
Foot & toe procedures,314-2,APR-DRG,,,,,,,,inpatient,,,229184.58,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,61117,,"45,128 x DRG weight",61117,Other,base rate x DRG weight,55005,,"40,615 x DRG weight",55005,Other,base rate x DRG weight,51950,,"38,359 x DRG weight",51950,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21113,,186% x Medicaid HMO amount,21113,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46150,,"34,077 x DRG weight",46150,Other,base rate x DRG weight,39229,,"28,966 x DRG weight",39229,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11351,,DRG base rate x DRG weight + capital per discharge,11351,Other,100% of NY Medicaid HMO DRG,11351,,100% x Medicaid HMO amount,11351,Other,100% of NY Medicaid HMO DRG,11351,,100% x Medicaid HMO amount,11351,Other,100% of NY Medicaid HMO DRG,11351,,100% x Medicaid HMO amount,11351,Other,100% of NY Medicaid HMO DRG,25540,,225% x Medicaid HMO amount,25540,Other,225% of NY Medicaid HMO DRG,25540,,225% x Medicaid HMO amount,25540,Other,225% of NY Medicaid HMO DRG,25540,,225% x Medicaid HMO amount,25540,Other,225% of NY Medicaid HMO DRG,25540,,225% x Medicaid HMO amount,25540,Other,225% of NY Medicaid HMO DRG,15891,,140% x Medicaid HMO amount,15891,Other,140% of NY Medicaid HMO DRG,25540,,225% x Medicaid HMO amount,25540,Other,225% of NY Medicaid HMO DRG,31215,,275% x Medicaid HMO amount,31215,Other,275% of NY Medicaid HMO DRG,36777,,324% x Medicaid HMO amount,36777,Other,324% of NY Medicaid HMO DRG,24405,,215% x Medicaid HMO amount,24405,Other,215% of NY Medicaid HMO DRG,24405,,215% x Medicaid HMO amount,24405,Other,215% of NY Medicaid HMO DRG,14189,,125% x Medicaid HMO amount,14189,Other,125% of NY Medicaid HMO DRG,0.01,61117,
Foot & toe procedures,314-3,APR-DRG,,,,,,,,inpatient,,,353637.26,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,91727,,"45,128 x DRG weight",91727,Other,base rate x DRG weight,82554,,"40,615 x DRG weight",82554,Other,base rate x DRG weight,77969,,"38,359 x DRG weight",77969,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30924,,186% x Medicaid HMO amount,30924,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,69265,,"34,077 x DRG weight",69265,Other,base rate x DRG weight,58876,,"28,966 x DRG weight",58876,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16626,,DRG base rate x DRG weight + capital per discharge,16626,Other,100% of NY Medicaid HMO DRG,16626,,100% x Medicaid HMO amount,16626,Other,100% of NY Medicaid HMO DRG,16626,,100% x Medicaid HMO amount,16626,Other,100% of NY Medicaid HMO DRG,16626,,100% x Medicaid HMO amount,16626,Other,100% of NY Medicaid HMO DRG,37409,,225% x Medicaid HMO amount,37409,Other,225% of NY Medicaid HMO DRG,37409,,225% x Medicaid HMO amount,37409,Other,225% of NY Medicaid HMO DRG,37409,,225% x Medicaid HMO amount,37409,Other,225% of NY Medicaid HMO DRG,37409,,225% x Medicaid HMO amount,37409,Other,225% of NY Medicaid HMO DRG,23276,,140% x Medicaid HMO amount,23276,Other,140% of NY Medicaid HMO DRG,37409,,225% x Medicaid HMO amount,37409,Other,225% of NY Medicaid HMO DRG,45722,,275% x Medicaid HMO amount,45722,Other,275% of NY Medicaid HMO DRG,53868,,324% x Medicaid HMO amount,53868,Other,324% of NY Medicaid HMO DRG,35746,,215% x Medicaid HMO amount,35746,Other,215% of NY Medicaid HMO DRG,35746,,215% x Medicaid HMO amount,35746,Other,215% of NY Medicaid HMO DRG,20783,,125% x Medicaid HMO amount,20783,Other,125% of NY Medicaid HMO DRG,0.01,91727,
Foot & toe procedures,314-4,APR-DRG,,,,,,,,inpatient,,,380835.16,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,173517,,"45,128 x DRG weight",173517,Other,base rate x DRG weight,156165,,"40,615 x DRG weight",156165,Other,base rate x DRG weight,147490,,"38,359 x DRG weight",147490,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,57135,,186% x Medicaid HMO amount,57135,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,131026,,"34,077 x DRG weight",131026,Other,base rate x DRG weight,111374,,"28,966 x DRG weight",111374,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30718,,DRG base rate x DRG weight + capital per discharge,30718,Other,100% of NY Medicaid HMO DRG,30718,,100% x Medicaid HMO amount,30718,Other,100% of NY Medicaid HMO DRG,30718,,100% x Medicaid HMO amount,30718,Other,100% of NY Medicaid HMO DRG,30718,,100% x Medicaid HMO amount,30718,Other,100% of NY Medicaid HMO DRG,69116,,225% x Medicaid HMO amount,69116,Other,225% of NY Medicaid HMO DRG,69116,,225% x Medicaid HMO amount,69116,Other,225% of NY Medicaid HMO DRG,69116,,225% x Medicaid HMO amount,69116,Other,225% of NY Medicaid HMO DRG,69116,,225% x Medicaid HMO amount,69116,Other,225% of NY Medicaid HMO DRG,43005,,140% x Medicaid HMO amount,43005,Other,140% of NY Medicaid HMO DRG,69116,,225% x Medicaid HMO amount,69116,Other,225% of NY Medicaid HMO DRG,84475,,275% x Medicaid HMO amount,84475,Other,275% of NY Medicaid HMO DRG,99526,,324% x Medicaid HMO amount,99526,Other,324% of NY Medicaid HMO DRG,66044,,215% x Medicaid HMO amount,66044,Other,215% of NY Medicaid HMO DRG,66044,,215% x Medicaid HMO amount,66044,Other,215% of NY Medicaid HMO DRG,38398,,125% x Medicaid HMO amount,38398,Other,125% of NY Medicaid HMO DRG,0.01,173517,
"Shoulder, upper arm & forearm procedures except joint replacement",315-1,APR-DRG,,,,,,,,inpatient,,,127992.88,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36495,,"45,128 x DRG weight",36495,Other,base rate x DRG weight,32845,,"40,615 x DRG weight",32845,Other,base rate x DRG weight,31021,,"38,359 x DRG weight",31021,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13223,,186% x Medicaid HMO amount,13223,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27558,,"34,077 x DRG weight",27558,Other,base rate x DRG weight,23425,,"28,966 x DRG weight",23425,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7109,,DRG base rate x DRG weight + capital per discharge,7109,Other,100% of NY Medicaid HMO DRG,7109,,100% x Medicaid HMO amount,7109,Other,100% of NY Medicaid HMO DRG,7109,,100% x Medicaid HMO amount,7109,Other,100% of NY Medicaid HMO DRG,7109,,100% x Medicaid HMO amount,7109,Other,100% of NY Medicaid HMO DRG,15995,,225% x Medicaid HMO amount,15995,Other,225% of NY Medicaid HMO DRG,15995,,225% x Medicaid HMO amount,15995,Other,225% of NY Medicaid HMO DRG,15995,,225% x Medicaid HMO amount,15995,Other,225% of NY Medicaid HMO DRG,15995,,225% x Medicaid HMO amount,15995,Other,225% of NY Medicaid HMO DRG,9953,,140% x Medicaid HMO amount,9953,Other,140% of NY Medicaid HMO DRG,15995,,225% x Medicaid HMO amount,15995,Other,225% of NY Medicaid HMO DRG,19550,,275% x Medicaid HMO amount,19550,Other,275% of NY Medicaid HMO DRG,23033,,324% x Medicaid HMO amount,23033,Other,324% of NY Medicaid HMO DRG,15284,,215% x Medicaid HMO amount,15284,Other,215% of NY Medicaid HMO DRG,15284,,215% x Medicaid HMO amount,15284,Other,215% of NY Medicaid HMO DRG,8886,,125% x Medicaid HMO amount,8886,Other,125% of NY Medicaid HMO DRG,0.01,36495,
"Shoulder, upper arm & forearm procedures except joint replacement",315-2,APR-DRG,,,,,,,,inpatient,,,232920.76,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,62412,,"45,128 x DRG weight",62412,Other,base rate x DRG weight,56171,,"40,615 x DRG weight",56171,Other,base rate x DRG weight,53050,,"38,359 x DRG weight",53050,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21530,,186% x Medicaid HMO amount,21530,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47128,,"34,077 x DRG weight",47128,Other,base rate x DRG weight,40060,,"28,966 x DRG weight",40060,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11575,,DRG base rate x DRG weight + capital per discharge,11575,Other,100% of NY Medicaid HMO DRG,11575,,100% x Medicaid HMO amount,11575,Other,100% of NY Medicaid HMO DRG,11575,,100% x Medicaid HMO amount,11575,Other,100% of NY Medicaid HMO DRG,11575,,100% x Medicaid HMO amount,11575,Other,100% of NY Medicaid HMO DRG,26044,,225% x Medicaid HMO amount,26044,Other,225% of NY Medicaid HMO DRG,26044,,225% x Medicaid HMO amount,26044,Other,225% of NY Medicaid HMO DRG,26044,,225% x Medicaid HMO amount,26044,Other,225% of NY Medicaid HMO DRG,26044,,225% x Medicaid HMO amount,26044,Other,225% of NY Medicaid HMO DRG,16205,,140% x Medicaid HMO amount,16205,Other,140% of NY Medicaid HMO DRG,26044,,225% x Medicaid HMO amount,26044,Other,225% of NY Medicaid HMO DRG,31831,,275% x Medicaid HMO amount,31831,Other,275% of NY Medicaid HMO DRG,37503,,324% x Medicaid HMO amount,37503,Other,324% of NY Medicaid HMO DRG,24886,,215% x Medicaid HMO amount,24886,Other,215% of NY Medicaid HMO DRG,24886,,215% x Medicaid HMO amount,24886,Other,215% of NY Medicaid HMO DRG,14469,,125% x Medicaid HMO amount,14469,Other,125% of NY Medicaid HMO DRG,0.01,62412,
"Shoulder, upper arm & forearm procedures except joint replacement",315-3,APR-DRG,,,,,,,,inpatient,,,367391.1,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,120411,,"45,128 x DRG weight",120411,Other,base rate x DRG weight,108369,,"40,615 x DRG weight",108369,Other,base rate x DRG weight,102349,,"38,359 x DRG weight",102349,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40116,,186% x Medicaid HMO amount,40116,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,90924,,"34,077 x DRG weight",90924,Other,base rate x DRG weight,77287,,"28,966 x DRG weight",77287,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21568,,DRG base rate x DRG weight + capital per discharge,21568,Other,100% of NY Medicaid HMO DRG,21568,,100% x Medicaid HMO amount,21568,Other,100% of NY Medicaid HMO DRG,21568,,100% x Medicaid HMO amount,21568,Other,100% of NY Medicaid HMO DRG,21568,,100% x Medicaid HMO amount,21568,Other,100% of NY Medicaid HMO DRG,48528,,225% x Medicaid HMO amount,48528,Other,225% of NY Medicaid HMO DRG,48528,,225% x Medicaid HMO amount,48528,Other,225% of NY Medicaid HMO DRG,48528,,225% x Medicaid HMO amount,48528,Other,225% of NY Medicaid HMO DRG,48528,,225% x Medicaid HMO amount,48528,Other,225% of NY Medicaid HMO DRG,30195,,140% x Medicaid HMO amount,30195,Other,140% of NY Medicaid HMO DRG,48528,,225% x Medicaid HMO amount,48528,Other,225% of NY Medicaid HMO DRG,59312,,275% x Medicaid HMO amount,59312,Other,275% of NY Medicaid HMO DRG,69880,,324% x Medicaid HMO amount,69880,Other,324% of NY Medicaid HMO DRG,46371,,215% x Medicaid HMO amount,46371,Other,215% of NY Medicaid HMO DRG,46371,,215% x Medicaid HMO amount,46371,Other,215% of NY Medicaid HMO DRG,26960,,125% x Medicaid HMO amount,26960,Other,125% of NY Medicaid HMO DRG,0.01,120411,
"Shoulder, upper arm & forearm procedures except joint replacement",315-4,APR-DRG,,,,,,,,inpatient,,,549334.44,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,231660,,"45,128 x DRG weight",231660,Other,base rate x DRG weight,208493,,"40,615 x DRG weight",208493,Other,base rate x DRG weight,196912,,"38,359 x DRG weight",196912,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,75769,,186% x Medicaid HMO amount,75769,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,174931,,"34,077 x DRG weight",174931,Other,base rate x DRG weight,148694,,"28,966 x DRG weight",148694,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40736,,DRG base rate x DRG weight + capital per discharge,40736,Other,100% of NY Medicaid HMO DRG,40736,,100% x Medicaid HMO amount,40736,Other,100% of NY Medicaid HMO DRG,40736,,100% x Medicaid HMO amount,40736,Other,100% of NY Medicaid HMO DRG,40736,,100% x Medicaid HMO amount,40736,Other,100% of NY Medicaid HMO DRG,91656,,225% x Medicaid HMO amount,91656,Other,225% of NY Medicaid HMO DRG,91656,,225% x Medicaid HMO amount,91656,Other,225% of NY Medicaid HMO DRG,91656,,225% x Medicaid HMO amount,91656,Other,225% of NY Medicaid HMO DRG,91656,,225% x Medicaid HMO amount,91656,Other,225% of NY Medicaid HMO DRG,57030,,140% x Medicaid HMO amount,57030,Other,140% of NY Medicaid HMO DRG,91656,,225% x Medicaid HMO amount,91656,Other,225% of NY Medicaid HMO DRG,112024,,275% x Medicaid HMO amount,112024,Other,275% of NY Medicaid HMO DRG,131985,,324% x Medicaid HMO amount,131985,Other,324% of NY Medicaid HMO DRG,87582,,215% x Medicaid HMO amount,87582,Other,215% of NY Medicaid HMO DRG,87582,,215% x Medicaid HMO amount,87582,Other,215% of NY Medicaid HMO DRG,50920,,125% x Medicaid HMO amount,50920,Other,125% of NY Medicaid HMO DRG,0.01,231660,
Hand & wrist procedures,316-1,APR-DRG,,,,,,,,inpatient,,,128483.42,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32334,,"45,128 x DRG weight",32334,Other,base rate x DRG weight,29101,,"40,615 x DRG weight",29101,Other,base rate x DRG weight,27484,,"38,359 x DRG weight",27484,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11889,,186% x Medicaid HMO amount,11889,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24416,,"34,077 x DRG weight",24416,Other,base rate x DRG weight,20754,,"28,966 x DRG weight",20754,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6392,,DRG base rate x DRG weight + capital per discharge,6392,Other,100% of NY Medicaid HMO DRG,6392,,100% x Medicaid HMO amount,6392,Other,100% of NY Medicaid HMO DRG,6392,,100% x Medicaid HMO amount,6392,Other,100% of NY Medicaid HMO DRG,6392,,100% x Medicaid HMO amount,6392,Other,100% of NY Medicaid HMO DRG,14382,,225% x Medicaid HMO amount,14382,Other,225% of NY Medicaid HMO DRG,14382,,225% x Medicaid HMO amount,14382,Other,225% of NY Medicaid HMO DRG,14382,,225% x Medicaid HMO amount,14382,Other,225% of NY Medicaid HMO DRG,14382,,225% x Medicaid HMO amount,14382,Other,225% of NY Medicaid HMO DRG,8949,,140% x Medicaid HMO amount,8949,Other,140% of NY Medicaid HMO DRG,14382,,225% x Medicaid HMO amount,14382,Other,225% of NY Medicaid HMO DRG,17578,,275% x Medicaid HMO amount,17578,Other,275% of NY Medicaid HMO DRG,20710,,324% x Medicaid HMO amount,20710,Other,324% of NY Medicaid HMO DRG,13743,,215% x Medicaid HMO amount,13743,Other,215% of NY Medicaid HMO DRG,13743,,215% x Medicaid HMO amount,13743,Other,215% of NY Medicaid HMO DRG,7990,,125% x Medicaid HMO amount,7990,Other,125% of NY Medicaid HMO DRG,0.01,32334,
Hand & wrist procedures,316-2,APR-DRG,,,,,,,,inpatient,,,216293.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53278,,"45,128 x DRG weight",53278,Other,base rate x DRG weight,47950,,"40,615 x DRG weight",47950,Other,base rate x DRG weight,45287,,"38,359 x DRG weight",45287,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18602,,186% x Medicaid HMO amount,18602,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40231,,"34,077 x DRG weight",40231,Other,base rate x DRG weight,34197,,"28,966 x DRG weight",34197,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10001,,DRG base rate x DRG weight + capital per discharge,10001,Other,100% of NY Medicaid HMO DRG,10001,,100% x Medicaid HMO amount,10001,Other,100% of NY Medicaid HMO DRG,10001,,100% x Medicaid HMO amount,10001,Other,100% of NY Medicaid HMO DRG,10001,,100% x Medicaid HMO amount,10001,Other,100% of NY Medicaid HMO DRG,22502,,225% x Medicaid HMO amount,22502,Other,225% of NY Medicaid HMO DRG,22502,,225% x Medicaid HMO amount,22502,Other,225% of NY Medicaid HMO DRG,22502,,225% x Medicaid HMO amount,22502,Other,225% of NY Medicaid HMO DRG,22502,,225% x Medicaid HMO amount,22502,Other,225% of NY Medicaid HMO DRG,14001,,140% x Medicaid HMO amount,14001,Other,140% of NY Medicaid HMO DRG,22502,,225% x Medicaid HMO amount,22502,Other,225% of NY Medicaid HMO DRG,27503,,275% x Medicaid HMO amount,27503,Other,275% of NY Medicaid HMO DRG,32403,,324% x Medicaid HMO amount,32403,Other,324% of NY Medicaid HMO DRG,21502,,215% x Medicaid HMO amount,21502,Other,215% of NY Medicaid HMO DRG,21502,,215% x Medicaid HMO amount,21502,Other,215% of NY Medicaid HMO DRG,12501,,125% x Medicaid HMO amount,12501,Other,125% of NY Medicaid HMO DRG,0.01,53278,
Hand & wrist procedures,316-3,APR-DRG,,,,,,,,inpatient,,,132593.33,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,96263,,"45,128 x DRG weight",96263,Other,base rate x DRG weight,86636,,"40,615 x DRG weight",86636,Other,base rate x DRG weight,81824,,"38,359 x DRG weight",81824,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32377,,186% x Medicaid HMO amount,32377,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,72690,,"34,077 x DRG weight",72690,Other,base rate x DRG weight,61787,,"28,966 x DRG weight",61787,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17407,,DRG base rate x DRG weight + capital per discharge,17407,Other,100% of NY Medicaid HMO DRG,17407,,100% x Medicaid HMO amount,17407,Other,100% of NY Medicaid HMO DRG,17407,,100% x Medicaid HMO amount,17407,Other,100% of NY Medicaid HMO DRG,17407,,100% x Medicaid HMO amount,17407,Other,100% of NY Medicaid HMO DRG,39166,,225% x Medicaid HMO amount,39166,Other,225% of NY Medicaid HMO DRG,39166,,225% x Medicaid HMO amount,39166,Other,225% of NY Medicaid HMO DRG,39166,,225% x Medicaid HMO amount,39166,Other,225% of NY Medicaid HMO DRG,39166,,225% x Medicaid HMO amount,39166,Other,225% of NY Medicaid HMO DRG,24370,,140% x Medicaid HMO amount,24370,Other,140% of NY Medicaid HMO DRG,39166,,225% x Medicaid HMO amount,39166,Other,225% of NY Medicaid HMO DRG,47869,,275% x Medicaid HMO amount,47869,Other,275% of NY Medicaid HMO DRG,56399,,324% x Medicaid HMO amount,56399,Other,324% of NY Medicaid HMO DRG,37425,,215% x Medicaid HMO amount,37425,Other,215% of NY Medicaid HMO DRG,37425,,215% x Medicaid HMO amount,37425,Other,215% of NY Medicaid HMO DRG,21759,,125% x Medicaid HMO amount,21759,Other,125% of NY Medicaid HMO DRG,0.01,96263,
Hand & wrist procedures,316-4,APR-DRG,,,,,,,,inpatient,,,132593.33,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,107739,,"45,128 x DRG weight",107739,Other,base rate x DRG weight,96964,,"40,615 x DRG weight",96964,Other,base rate x DRG weight,91578,,"38,359 x DRG weight",91578,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36054,,186% x Medicaid HMO amount,36054,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,81355,,"34,077 x DRG weight",81355,Other,base rate x DRG weight,69153,,"28,966 x DRG weight",69153,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19384,,DRG base rate x DRG weight + capital per discharge,19384,Other,100% of NY Medicaid HMO DRG,19384,,100% x Medicaid HMO amount,19384,Other,100% of NY Medicaid HMO DRG,19384,,100% x Medicaid HMO amount,19384,Other,100% of NY Medicaid HMO DRG,19384,,100% x Medicaid HMO amount,19384,Other,100% of NY Medicaid HMO DRG,43614,,225% x Medicaid HMO amount,43614,Other,225% of NY Medicaid HMO DRG,43614,,225% x Medicaid HMO amount,43614,Other,225% of NY Medicaid HMO DRG,43614,,225% x Medicaid HMO amount,43614,Other,225% of NY Medicaid HMO DRG,43614,,225% x Medicaid HMO amount,43614,Other,225% of NY Medicaid HMO DRG,27138,,140% x Medicaid HMO amount,27138,Other,140% of NY Medicaid HMO DRG,43614,,225% x Medicaid HMO amount,43614,Other,225% of NY Medicaid HMO DRG,53306,,275% x Medicaid HMO amount,53306,Other,275% of NY Medicaid HMO DRG,62804,,324% x Medicaid HMO amount,62804,Other,324% of NY Medicaid HMO DRG,41676,,215% x Medicaid HMO amount,41676,Other,215% of NY Medicaid HMO DRG,41676,,215% x Medicaid HMO amount,41676,Other,215% of NY Medicaid HMO DRG,24230,,125% x Medicaid HMO amount,24230,Other,125% of NY Medicaid HMO DRG,0.01,107739,
"Tendon, muscle & other soft tissue procedures",317-1,APR-DRG,,,,,,,,inpatient,,,170931.89,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40606,,"45,128 x DRG weight",40606,Other,base rate x DRG weight,36545,,"40,615 x DRG weight",36545,Other,base rate x DRG weight,34515,,"38,359 x DRG weight",34515,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14540,,186% x Medicaid HMO amount,14540,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30662,,"34,077 x DRG weight",30662,Other,base rate x DRG weight,26064,,"28,966 x DRG weight",26064,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7817,,DRG base rate x DRG weight + capital per discharge,7817,Other,100% of NY Medicaid HMO DRG,7817,,100% x Medicaid HMO amount,7817,Other,100% of NY Medicaid HMO DRG,7817,,100% x Medicaid HMO amount,7817,Other,100% of NY Medicaid HMO DRG,7817,,100% x Medicaid HMO amount,7817,Other,100% of NY Medicaid HMO DRG,17588,,225% x Medicaid HMO amount,17588,Other,225% of NY Medicaid HMO DRG,17588,,225% x Medicaid HMO amount,17588,Other,225% of NY Medicaid HMO DRG,17588,,225% x Medicaid HMO amount,17588,Other,225% of NY Medicaid HMO DRG,17588,,225% x Medicaid HMO amount,17588,Other,225% of NY Medicaid HMO DRG,10944,,140% x Medicaid HMO amount,10944,Other,140% of NY Medicaid HMO DRG,17588,,225% x Medicaid HMO amount,17588,Other,225% of NY Medicaid HMO DRG,21497,,275% x Medicaid HMO amount,21497,Other,275% of NY Medicaid HMO DRG,25327,,324% x Medicaid HMO amount,25327,Other,324% of NY Medicaid HMO DRG,16807,,215% x Medicaid HMO amount,16807,Other,215% of NY Medicaid HMO DRG,16807,,215% x Medicaid HMO amount,16807,Other,215% of NY Medicaid HMO DRG,9771,,125% x Medicaid HMO amount,9771,Other,125% of NY Medicaid HMO DRG,0.01,40606,
"Tendon, muscle & other soft tissue procedures",317-2,APR-DRG,,,,,,,,inpatient,,,122473.26,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,64754,,"45,128 x DRG weight",64754,Other,base rate x DRG weight,58278,,"40,615 x DRG weight",58278,Other,base rate x DRG weight,55041,,"38,359 x DRG weight",55041,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22279,,186% x Medicaid HMO amount,22279,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48897,,"34,077 x DRG weight",48897,Other,base rate x DRG weight,41563,,"28,966 x DRG weight",41563,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11978,,DRG base rate x DRG weight + capital per discharge,11978,Other,100% of NY Medicaid HMO DRG,11978,,100% x Medicaid HMO amount,11978,Other,100% of NY Medicaid HMO DRG,11978,,100% x Medicaid HMO amount,11978,Other,100% of NY Medicaid HMO DRG,11978,,100% x Medicaid HMO amount,11978,Other,100% of NY Medicaid HMO DRG,26951,,225% x Medicaid HMO amount,26951,Other,225% of NY Medicaid HMO DRG,26951,,225% x Medicaid HMO amount,26951,Other,225% of NY Medicaid HMO DRG,26951,,225% x Medicaid HMO amount,26951,Other,225% of NY Medicaid HMO DRG,26951,,225% x Medicaid HMO amount,26951,Other,225% of NY Medicaid HMO DRG,16769,,140% x Medicaid HMO amount,16769,Other,140% of NY Medicaid HMO DRG,26951,,225% x Medicaid HMO amount,26951,Other,225% of NY Medicaid HMO DRG,32940,,275% x Medicaid HMO amount,32940,Other,275% of NY Medicaid HMO DRG,38809,,324% x Medicaid HMO amount,38809,Other,324% of NY Medicaid HMO DRG,25753,,215% x Medicaid HMO amount,25753,Other,215% of NY Medicaid HMO DRG,25753,,215% x Medicaid HMO amount,25753,Other,215% of NY Medicaid HMO DRG,14973,,125% x Medicaid HMO amount,14973,Other,125% of NY Medicaid HMO DRG,0.01,64754,
"Tendon, muscle & other soft tissue procedures",317-3,APR-DRG,,,,,,,,inpatient,,,350866.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,117685,,"45,128 x DRG weight",117685,Other,base rate x DRG weight,105916,,"40,615 x DRG weight",105916,Other,base rate x DRG weight,100033,,"38,359 x DRG weight",100033,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39242,,186% x Medicaid HMO amount,39242,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,88866,,"34,077 x DRG weight",88866,Other,base rate x DRG weight,75538,,"28,966 x DRG weight",75538,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21098,,DRG base rate x DRG weight + capital per discharge,21098,Other,100% of NY Medicaid HMO DRG,21098,,100% x Medicaid HMO amount,21098,Other,100% of NY Medicaid HMO DRG,21098,,100% x Medicaid HMO amount,21098,Other,100% of NY Medicaid HMO DRG,21098,,100% x Medicaid HMO amount,21098,Other,100% of NY Medicaid HMO DRG,47471,,225% x Medicaid HMO amount,47471,Other,225% of NY Medicaid HMO DRG,47471,,225% x Medicaid HMO amount,47471,Other,225% of NY Medicaid HMO DRG,47471,,225% x Medicaid HMO amount,47471,Other,225% of NY Medicaid HMO DRG,47471,,225% x Medicaid HMO amount,47471,Other,225% of NY Medicaid HMO DRG,29537,,140% x Medicaid HMO amount,29537,Other,140% of NY Medicaid HMO DRG,47471,,225% x Medicaid HMO amount,47471,Other,225% of NY Medicaid HMO DRG,58020,,275% x Medicaid HMO amount,58020,Other,275% of NY Medicaid HMO DRG,68358,,324% x Medicaid HMO amount,68358,Other,324% of NY Medicaid HMO DRG,45361,,215% x Medicaid HMO amount,45361,Other,215% of NY Medicaid HMO DRG,45361,,215% x Medicaid HMO amount,45361,Other,215% of NY Medicaid HMO DRG,26373,,125% x Medicaid HMO amount,26373,Other,125% of NY Medicaid HMO DRG,0.01,117685,
"Tendon, muscle & other soft tissue procedures",317-4,APR-DRG,,,,,,,,inpatient,,,438312.39,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,285119,,"45,128 x DRG weight",285119,Other,base rate x DRG weight,256606,,"40,615 x DRG weight",256606,Other,base rate x DRG weight,242352,,"38,359 x DRG weight",242352,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,92901,,186% x Medicaid HMO amount,92901,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,215298,,"34,077 x DRG weight",215298,Other,base rate x DRG weight,183007,,"28,966 x DRG weight",183007,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49947,,DRG base rate x DRG weight + capital per discharge,49947,Other,100% of NY Medicaid HMO DRG,49947,,100% x Medicaid HMO amount,49947,Other,100% of NY Medicaid HMO DRG,49947,,100% x Medicaid HMO amount,49947,Other,100% of NY Medicaid HMO DRG,49947,,100% x Medicaid HMO amount,49947,Other,100% of NY Medicaid HMO DRG,112381,,225% x Medicaid HMO amount,112381,Other,225% of NY Medicaid HMO DRG,112381,,225% x Medicaid HMO amount,112381,Other,225% of NY Medicaid HMO DRG,112381,,225% x Medicaid HMO amount,112381,Other,225% of NY Medicaid HMO DRG,112381,,225% x Medicaid HMO amount,112381,Other,225% of NY Medicaid HMO DRG,69926,,140% x Medicaid HMO amount,69926,Other,140% of NY Medicaid HMO DRG,112381,,225% x Medicaid HMO amount,112381,Other,225% of NY Medicaid HMO DRG,137354,,275% x Medicaid HMO amount,137354,Other,275% of NY Medicaid HMO DRG,161828,,324% x Medicaid HMO amount,161828,Other,324% of NY Medicaid HMO DRG,107386,,215% x Medicaid HMO amount,107386,Other,215% of NY Medicaid HMO DRG,107386,,215% x Medicaid HMO amount,107386,Other,215% of NY Medicaid HMO DRG,62434,,125% x Medicaid HMO amount,62434,Other,125% of NY Medicaid HMO DRG,0.01,285119,
Other musculoskeletal system & connective tissue procedures,320-1,APR-DRG,,,,,,,,inpatient,,,155382.99,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46274,,"45,128 x DRG weight",46274,Other,base rate x DRG weight,41647,,"40,615 x DRG weight",41647,Other,base rate x DRG weight,39333,,"38,359 x DRG weight",39333,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16357,,186% x Medicaid HMO amount,16357,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34943,,"34,077 x DRG weight",34943,Other,base rate x DRG weight,29702,,"28,966 x DRG weight",29702,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8794,,DRG base rate x DRG weight + capital per discharge,8794,Other,100% of NY Medicaid HMO DRG,8794,,100% x Medicaid HMO amount,8794,Other,100% of NY Medicaid HMO DRG,8794,,100% x Medicaid HMO amount,8794,Other,100% of NY Medicaid HMO DRG,8794,,100% x Medicaid HMO amount,8794,Other,100% of NY Medicaid HMO DRG,19787,,225% x Medicaid HMO amount,19787,Other,225% of NY Medicaid HMO DRG,19787,,225% x Medicaid HMO amount,19787,Other,225% of NY Medicaid HMO DRG,19787,,225% x Medicaid HMO amount,19787,Other,225% of NY Medicaid HMO DRG,19787,,225% x Medicaid HMO amount,19787,Other,225% of NY Medicaid HMO DRG,12312,,140% x Medicaid HMO amount,12312,Other,140% of NY Medicaid HMO DRG,19787,,225% x Medicaid HMO amount,19787,Other,225% of NY Medicaid HMO DRG,24184,,275% x Medicaid HMO amount,24184,Other,275% of NY Medicaid HMO DRG,28493,,324% x Medicaid HMO amount,28493,Other,324% of NY Medicaid HMO DRG,18907,,215% x Medicaid HMO amount,18907,Other,215% of NY Medicaid HMO DRG,18907,,215% x Medicaid HMO amount,18907,Other,215% of NY Medicaid HMO DRG,10993,,125% x Medicaid HMO amount,10993,Other,125% of NY Medicaid HMO DRG,0.01,46274,
Other musculoskeletal system & connective tissue procedures,320-2,APR-DRG,,,,,,,,inpatient,,,384955.42,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73459,,"45,128 x DRG weight",73459,Other,base rate x DRG weight,66113,,"40,615 x DRG weight",66113,Other,base rate x DRG weight,62441,,"38,359 x DRG weight",62441,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25069,,186% x Medicaid HMO amount,25069,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55471,,"34,077 x DRG weight",55471,Other,base rate x DRG weight,47151,,"28,966 x DRG weight",47151,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13478,,DRG base rate x DRG weight + capital per discharge,13478,Other,100% of NY Medicaid HMO DRG,13478,,100% x Medicaid HMO amount,13478,Other,100% of NY Medicaid HMO DRG,13478,,100% x Medicaid HMO amount,13478,Other,100% of NY Medicaid HMO DRG,13478,,100% x Medicaid HMO amount,13478,Other,100% of NY Medicaid HMO DRG,30326,,225% x Medicaid HMO amount,30326,Other,225% of NY Medicaid HMO DRG,30326,,225% x Medicaid HMO amount,30326,Other,225% of NY Medicaid HMO DRG,30326,,225% x Medicaid HMO amount,30326,Other,225% of NY Medicaid HMO DRG,30326,,225% x Medicaid HMO amount,30326,Other,225% of NY Medicaid HMO DRG,18869,,140% x Medicaid HMO amount,18869,Other,140% of NY Medicaid HMO DRG,30326,,225% x Medicaid HMO amount,30326,Other,225% of NY Medicaid HMO DRG,37065,,275% x Medicaid HMO amount,37065,Other,275% of NY Medicaid HMO DRG,43669,,324% x Medicaid HMO amount,43669,Other,324% of NY Medicaid HMO DRG,28978,,215% x Medicaid HMO amount,28978,Other,215% of NY Medicaid HMO DRG,28978,,215% x Medicaid HMO amount,28978,Other,215% of NY Medicaid HMO DRG,16848,,125% x Medicaid HMO amount,16848,Other,125% of NY Medicaid HMO DRG,0.01,73459,
Other musculoskeletal system & connective tissue procedures,320-3,APR-DRG,,,,,,,,inpatient,,,270615.38,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,113492,,"45,128 x DRG weight",113492,Other,base rate x DRG weight,102143,,"40,615 x DRG weight",102143,Other,base rate x DRG weight,96469,,"38,359 x DRG weight",96469,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37899,,186% x Medicaid HMO amount,37899,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,85700,,"34,077 x DRG weight",85700,Other,base rate x DRG weight,72847,,"28,966 x DRG weight",72847,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20376,,DRG base rate x DRG weight + capital per discharge,20376,Other,100% of NY Medicaid HMO DRG,20376,,100% x Medicaid HMO amount,20376,Other,100% of NY Medicaid HMO DRG,20376,,100% x Medicaid HMO amount,20376,Other,100% of NY Medicaid HMO DRG,20376,,100% x Medicaid HMO amount,20376,Other,100% of NY Medicaid HMO DRG,45846,,225% x Medicaid HMO amount,45846,Other,225% of NY Medicaid HMO DRG,45846,,225% x Medicaid HMO amount,45846,Other,225% of NY Medicaid HMO DRG,45846,,225% x Medicaid HMO amount,45846,Other,225% of NY Medicaid HMO DRG,45846,,225% x Medicaid HMO amount,45846,Other,225% of NY Medicaid HMO DRG,28526,,140% x Medicaid HMO amount,28526,Other,140% of NY Medicaid HMO DRG,45846,,225% x Medicaid HMO amount,45846,Other,225% of NY Medicaid HMO DRG,56034,,275% x Medicaid HMO amount,56034,Other,275% of NY Medicaid HMO DRG,66018,,324% x Medicaid HMO amount,66018,Other,324% of NY Medicaid HMO DRG,43808,,215% x Medicaid HMO amount,43808,Other,215% of NY Medicaid HMO DRG,43808,,215% x Medicaid HMO amount,43808,Other,215% of NY Medicaid HMO DRG,25470,,125% x Medicaid HMO amount,25470,Other,125% of NY Medicaid HMO DRG,0.01,113492,
Other musculoskeletal system & connective tissue procedures,320-4,APR-DRG,,,,,,,,inpatient,,,809801.38,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,225802,,"45,128 x DRG weight",225802,Other,base rate x DRG weight,203221,,"40,615 x DRG weight",203221,Other,base rate x DRG weight,191933,,"38,359 x DRG weight",191933,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73892,,186% x Medicaid HMO amount,73892,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,170508,,"34,077 x DRG weight",170508,Other,base rate x DRG weight,144934,,"28,966 x DRG weight",144934,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39727,,DRG base rate x DRG weight + capital per discharge,39727,Other,100% of NY Medicaid HMO DRG,39727,,100% x Medicaid HMO amount,39727,Other,100% of NY Medicaid HMO DRG,39727,,100% x Medicaid HMO amount,39727,Other,100% of NY Medicaid HMO DRG,39727,,100% x Medicaid HMO amount,39727,Other,100% of NY Medicaid HMO DRG,89386,,225% x Medicaid HMO amount,89386,Other,225% of NY Medicaid HMO DRG,89386,,225% x Medicaid HMO amount,89386,Other,225% of NY Medicaid HMO DRG,89386,,225% x Medicaid HMO amount,89386,Other,225% of NY Medicaid HMO DRG,89386,,225% x Medicaid HMO amount,89386,Other,225% of NY Medicaid HMO DRG,55618,,140% x Medicaid HMO amount,55618,Other,140% of NY Medicaid HMO DRG,89386,,225% x Medicaid HMO amount,89386,Other,225% of NY Medicaid HMO DRG,109249,,275% x Medicaid HMO amount,109249,Other,275% of NY Medicaid HMO DRG,128715,,324% x Medicaid HMO amount,128715,Other,324% of NY Medicaid HMO DRG,85413,,215% x Medicaid HMO amount,85413,Other,215% of NY Medicaid HMO DRG,85413,,215% x Medicaid HMO amount,85413,Other,215% of NY Medicaid HMO DRG,49659,,125% x Medicaid HMO amount,49659,Other,125% of NY Medicaid HMO DRG,0.01,225802,
Cervical spinal fusion & other back/neck proc exc disc excis/decomp,321-1,APR-DRG,,,,,,,,inpatient,,,242825.56,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73635,,"45,128 x DRG weight",73635,Other,base rate x DRG weight,66271,,"40,615 x DRG weight",66271,Other,base rate x DRG weight,62590,,"38,359 x DRG weight",62590,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25125,,186% x Medicaid HMO amount,25125,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55603,,"34,077 x DRG weight",55603,Other,base rate x DRG weight,47264,,"28,966 x DRG weight",47264,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13508,,DRG base rate x DRG weight + capital per discharge,13508,Other,100% of NY Medicaid HMO DRG,13508,,100% x Medicaid HMO amount,13508,Other,100% of NY Medicaid HMO DRG,13508,,100% x Medicaid HMO amount,13508,Other,100% of NY Medicaid HMO DRG,13508,,100% x Medicaid HMO amount,13508,Other,100% of NY Medicaid HMO DRG,30393,,225% x Medicaid HMO amount,30393,Other,225% of NY Medicaid HMO DRG,30393,,225% x Medicaid HMO amount,30393,Other,225% of NY Medicaid HMO DRG,30393,,225% x Medicaid HMO amount,30393,Other,225% of NY Medicaid HMO DRG,30393,,225% x Medicaid HMO amount,30393,Other,225% of NY Medicaid HMO DRG,18911,,140% x Medicaid HMO amount,18911,Other,140% of NY Medicaid HMO DRG,30393,,225% x Medicaid HMO amount,30393,Other,225% of NY Medicaid HMO DRG,37147,,275% x Medicaid HMO amount,37147,Other,275% of NY Medicaid HMO DRG,43766,,324% x Medicaid HMO amount,43766,Other,324% of NY Medicaid HMO DRG,29042,,215% x Medicaid HMO amount,29042,Other,215% of NY Medicaid HMO DRG,29042,,215% x Medicaid HMO amount,29042,Other,215% of NY Medicaid HMO DRG,16885,,125% x Medicaid HMO amount,16885,Other,125% of NY Medicaid HMO DRG,0.01,73635,
Cervical spinal fusion & other back/neck proc exc disc excis/decomp,321-2,APR-DRG,,,,,,,,inpatient,,,290126.87,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,96894,,"45,128 x DRG weight",96894,Other,base rate x DRG weight,87204,,"40,615 x DRG weight",87204,Other,base rate x DRG weight,82361,,"38,359 x DRG weight",82361,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32580,,186% x Medicaid HMO amount,32580,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73167,,"34,077 x DRG weight",73167,Other,base rate x DRG weight,62193,,"28,966 x DRG weight",62193,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17516,,DRG base rate x DRG weight + capital per discharge,17516,Other,100% of NY Medicaid HMO DRG,17516,,100% x Medicaid HMO amount,17516,Other,100% of NY Medicaid HMO DRG,17516,,100% x Medicaid HMO amount,17516,Other,100% of NY Medicaid HMO DRG,17516,,100% x Medicaid HMO amount,17516,Other,100% of NY Medicaid HMO DRG,39411,,225% x Medicaid HMO amount,39411,Other,225% of NY Medicaid HMO DRG,39411,,225% x Medicaid HMO amount,39411,Other,225% of NY Medicaid HMO DRG,39411,,225% x Medicaid HMO amount,39411,Other,225% of NY Medicaid HMO DRG,39411,,225% x Medicaid HMO amount,39411,Other,225% of NY Medicaid HMO DRG,24522,,140% x Medicaid HMO amount,24522,Other,140% of NY Medicaid HMO DRG,39411,,225% x Medicaid HMO amount,39411,Other,225% of NY Medicaid HMO DRG,48169,,275% x Medicaid HMO amount,48169,Other,275% of NY Medicaid HMO DRG,56752,,324% x Medicaid HMO amount,56752,Other,324% of NY Medicaid HMO DRG,37659,,215% x Medicaid HMO amount,37659,Other,215% of NY Medicaid HMO DRG,37659,,215% x Medicaid HMO amount,37659,Other,215% of NY Medicaid HMO DRG,21895,,125% x Medicaid HMO amount,21895,Other,125% of NY Medicaid HMO DRG,0.01,96894,
Cervical spinal fusion & other back/neck proc exc disc excis/decomp,321-3,APR-DRG,,,,,,,,inpatient,,,628457.4,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,167091,,"45,128 x DRG weight",167091,Other,base rate x DRG weight,150381,,"40,615 x DRG weight",150381,Other,base rate x DRG weight,142028,,"38,359 x DRG weight",142028,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55076,,186% x Medicaid HMO amount,55076,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,126174,,"34,077 x DRG weight",126174,Other,base rate x DRG weight,107250,,"28,966 x DRG weight",107250,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29611,,DRG base rate x DRG weight + capital per discharge,29611,Other,100% of NY Medicaid HMO DRG,29611,,100% x Medicaid HMO amount,29611,Other,100% of NY Medicaid HMO DRG,29611,,100% x Medicaid HMO amount,29611,Other,100% of NY Medicaid HMO DRG,29611,,100% x Medicaid HMO amount,29611,Other,100% of NY Medicaid HMO DRG,66625,,225% x Medicaid HMO amount,66625,Other,225% of NY Medicaid HMO DRG,66625,,225% x Medicaid HMO amount,66625,Other,225% of NY Medicaid HMO DRG,66625,,225% x Medicaid HMO amount,66625,Other,225% of NY Medicaid HMO DRG,66625,,225% x Medicaid HMO amount,66625,Other,225% of NY Medicaid HMO DRG,41455,,140% x Medicaid HMO amount,41455,Other,140% of NY Medicaid HMO DRG,66625,,225% x Medicaid HMO amount,66625,Other,225% of NY Medicaid HMO DRG,81430,,275% x Medicaid HMO amount,81430,Other,275% of NY Medicaid HMO DRG,95940,,324% x Medicaid HMO amount,95940,Other,324% of NY Medicaid HMO DRG,63664,,215% x Medicaid HMO amount,63664,Other,215% of NY Medicaid HMO DRG,63664,,215% x Medicaid HMO amount,63664,Other,215% of NY Medicaid HMO DRG,37014,,125% x Medicaid HMO amount,37014,Other,125% of NY Medicaid HMO DRG,0.01,167091,
Cervical spinal fusion & other back/neck proc exc disc excis/decomp,321-4,APR-DRG,,,,,,,,inpatient,,,526735.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,318793,,"45,128 x DRG weight",318793,Other,base rate x DRG weight,286912,,"40,615 x DRG weight",286912,Other,base rate x DRG weight,270976,,"38,359 x DRG weight",270976,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,103693,,186% x Medicaid HMO amount,103693,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,240727,,"34,077 x DRG weight",240727,Other,base rate x DRG weight,204622,,"28,966 x DRG weight",204622,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55749,,DRG base rate x DRG weight + capital per discharge,55749,Other,100% of NY Medicaid HMO DRG,55749,,100% x Medicaid HMO amount,55749,Other,100% of NY Medicaid HMO DRG,55749,,100% x Medicaid HMO amount,55749,Other,100% of NY Medicaid HMO DRG,55749,,100% x Medicaid HMO amount,55749,Other,100% of NY Medicaid HMO DRG,125435,,225% x Medicaid HMO amount,125435,Other,225% of NY Medicaid HMO DRG,125435,,225% x Medicaid HMO amount,125435,Other,225% of NY Medicaid HMO DRG,125435,,225% x Medicaid HMO amount,125435,Other,225% of NY Medicaid HMO DRG,125435,,225% x Medicaid HMO amount,125435,Other,225% of NY Medicaid HMO DRG,78049,,140% x Medicaid HMO amount,78049,Other,140% of NY Medicaid HMO DRG,125435,,225% x Medicaid HMO amount,125435,Other,225% of NY Medicaid HMO DRG,153310,,275% x Medicaid HMO amount,153310,Other,275% of NY Medicaid HMO DRG,180627,,324% x Medicaid HMO amount,180627,Other,324% of NY Medicaid HMO DRG,119860,,215% x Medicaid HMO amount,119860,Other,215% of NY Medicaid HMO DRG,119860,,215% x Medicaid HMO amount,119860,Other,215% of NY Medicaid HMO DRG,69686,,125% x Medicaid HMO amount,69686,Other,125% of NY Medicaid HMO DRG,0.01,318793,
Shoulder & elbow joint replacement #,322-1,APR-DRG,,,,,,,,inpatient,,,309470.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,71316,,"45,128 x DRG weight",71316,Other,base rate x DRG weight,64184,,"40,615 x DRG weight",64184,Other,base rate x DRG weight,60619,,"38,359 x DRG weight",60619,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24383,,186% x Medicaid HMO amount,24383,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53852,,"34,077 x DRG weight",53852,Other,base rate x DRG weight,45775,,"28,966 x DRG weight",45775,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13109,,DRG base rate x DRG weight + capital per discharge,13109,Other,100% of NY Medicaid HMO DRG,13109,,100% x Medicaid HMO amount,13109,Other,100% of NY Medicaid HMO DRG,13109,,100% x Medicaid HMO amount,13109,Other,100% of NY Medicaid HMO DRG,13109,,100% x Medicaid HMO amount,13109,Other,100% of NY Medicaid HMO DRG,29495,,225% x Medicaid HMO amount,29495,Other,225% of NY Medicaid HMO DRG,29495,,225% x Medicaid HMO amount,29495,Other,225% of NY Medicaid HMO DRG,29495,,225% x Medicaid HMO amount,29495,Other,225% of NY Medicaid HMO DRG,29495,,225% x Medicaid HMO amount,29495,Other,225% of NY Medicaid HMO DRG,18353,,140% x Medicaid HMO amount,18353,Other,140% of NY Medicaid HMO DRG,29495,,225% x Medicaid HMO amount,29495,Other,225% of NY Medicaid HMO DRG,36050,,275% x Medicaid HMO amount,36050,Other,275% of NY Medicaid HMO DRG,42473,,324% x Medicaid HMO amount,42473,Other,324% of NY Medicaid HMO DRG,28184,,215% x Medicaid HMO amount,28184,Other,215% of NY Medicaid HMO DRG,28184,,215% x Medicaid HMO amount,28184,Other,215% of NY Medicaid HMO DRG,16386,,125% x Medicaid HMO amount,16386,Other,125% of NY Medicaid HMO DRG,0.01,71316,
Shoulder & elbow joint replacement #,322-2,APR-DRG,,,,,,,,inpatient,,,267760.84,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,78775,,"45,128 x DRG weight",78775,Other,base rate x DRG weight,70898,,"40,615 x DRG weight",70898,Other,base rate x DRG weight,66959,,"38,359 x DRG weight",66959,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26773,,186% x Medicaid HMO amount,26773,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59485,,"34,077 x DRG weight",59485,Other,base rate x DRG weight,50563,,"28,966 x DRG weight",50563,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14394,,DRG base rate x DRG weight + capital per discharge,14394,Other,100% of NY Medicaid HMO DRG,14394,,100% x Medicaid HMO amount,14394,Other,100% of NY Medicaid HMO DRG,14394,,100% x Medicaid HMO amount,14394,Other,100% of NY Medicaid HMO DRG,14394,,100% x Medicaid HMO amount,14394,Other,100% of NY Medicaid HMO DRG,32387,,225% x Medicaid HMO amount,32387,Other,225% of NY Medicaid HMO DRG,32387,,225% x Medicaid HMO amount,32387,Other,225% of NY Medicaid HMO DRG,32387,,225% x Medicaid HMO amount,32387,Other,225% of NY Medicaid HMO DRG,32387,,225% x Medicaid HMO amount,32387,Other,225% of NY Medicaid HMO DRG,20152,,140% x Medicaid HMO amount,20152,Other,140% of NY Medicaid HMO DRG,32387,,225% x Medicaid HMO amount,32387,Other,225% of NY Medicaid HMO DRG,39584,,275% x Medicaid HMO amount,39584,Other,275% of NY Medicaid HMO DRG,46637,,324% x Medicaid HMO amount,46637,Other,324% of NY Medicaid HMO DRG,30947,,215% x Medicaid HMO amount,30947,Other,215% of NY Medicaid HMO DRG,30947,,215% x Medicaid HMO amount,30947,Other,215% of NY Medicaid HMO DRG,17993,,125% x Medicaid HMO amount,17993,Other,125% of NY Medicaid HMO DRG,0.01,78775,
Shoulder & elbow joint replacement #,322-3,APR-DRG,,,,,,,,inpatient,,,309470.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,131936,,"45,128 x DRG weight",131936,Other,base rate x DRG weight,118742,,"40,615 x DRG weight",118742,Other,base rate x DRG weight,112146,,"38,359 x DRG weight",112146,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43810,,186% x Medicaid HMO amount,43810,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,99628,,"34,077 x DRG weight",99628,Other,base rate x DRG weight,84685,,"28,966 x DRG weight",84685,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23554,,DRG base rate x DRG weight + capital per discharge,23554,Other,100% of NY Medicaid HMO DRG,23554,,100% x Medicaid HMO amount,23554,Other,100% of NY Medicaid HMO DRG,23554,,100% x Medicaid HMO amount,23554,Other,100% of NY Medicaid HMO DRG,23554,,100% x Medicaid HMO amount,23554,Other,100% of NY Medicaid HMO DRG,52997,,225% x Medicaid HMO amount,52997,Other,225% of NY Medicaid HMO DRG,52997,,225% x Medicaid HMO amount,52997,Other,225% of NY Medicaid HMO DRG,52997,,225% x Medicaid HMO amount,52997,Other,225% of NY Medicaid HMO DRG,52997,,225% x Medicaid HMO amount,52997,Other,225% of NY Medicaid HMO DRG,32976,,140% x Medicaid HMO amount,32976,Other,140% of NY Medicaid HMO DRG,52997,,225% x Medicaid HMO amount,52997,Other,225% of NY Medicaid HMO DRG,64774,,275% x Medicaid HMO amount,64774,Other,275% of NY Medicaid HMO DRG,76315,,324% x Medicaid HMO amount,76315,Other,324% of NY Medicaid HMO DRG,50641,,215% x Medicaid HMO amount,50641,Other,215% of NY Medicaid HMO DRG,50641,,215% x Medicaid HMO amount,50641,Other,215% of NY Medicaid HMO DRG,29443,,125% x Medicaid HMO amount,29443,Other,125% of NY Medicaid HMO DRG,0.01,131936,
Shoulder & elbow joint replacement #,322-4,APR-DRG,,,,,,,,inpatient,,,309470.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,154266,,"45,128 x DRG weight",154266,Other,base rate x DRG weight,138838,,"40,615 x DRG weight",138838,Other,base rate x DRG weight,131126,,"38,359 x DRG weight",131126,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50966,,186% x Medicaid HMO amount,50966,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,116489,,"34,077 x DRG weight",116489,Other,base rate x DRG weight,99017,,"28,966 x DRG weight",99017,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27401,,DRG base rate x DRG weight + capital per discharge,27401,Other,100% of NY Medicaid HMO DRG,27401,,100% x Medicaid HMO amount,27401,Other,100% of NY Medicaid HMO DRG,27401,,100% x Medicaid HMO amount,27401,Other,100% of NY Medicaid HMO DRG,27401,,100% x Medicaid HMO amount,27401,Other,100% of NY Medicaid HMO DRG,61652,,225% x Medicaid HMO amount,61652,Other,225% of NY Medicaid HMO DRG,61652,,225% x Medicaid HMO amount,61652,Other,225% of NY Medicaid HMO DRG,61652,,225% x Medicaid HMO amount,61652,Other,225% of NY Medicaid HMO DRG,61652,,225% x Medicaid HMO amount,61652,Other,225% of NY Medicaid HMO DRG,38361,,140% x Medicaid HMO amount,38361,Other,140% of NY Medicaid HMO DRG,61652,,225% x Medicaid HMO amount,61652,Other,225% of NY Medicaid HMO DRG,75353,,275% x Medicaid HMO amount,75353,Other,275% of NY Medicaid HMO DRG,88779,,324% x Medicaid HMO amount,88779,Other,324% of NY Medicaid HMO DRG,58912,,215% x Medicaid HMO amount,58912,Other,215% of NY Medicaid HMO DRG,58912,,215% x Medicaid HMO amount,58912,Other,215% of NY Medicaid HMO DRG,34251,,125% x Medicaid HMO amount,34251,Other,125% of NY Medicaid HMO DRG,0.01,154266,
Fracture of femur,340-1,APR-DRG,,,,,,,,inpatient,,,87567.03,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23859,,"45,128 x DRG weight",23859,Other,base rate x DRG weight,21473,,"40,615 x DRG weight",21473,Other,base rate x DRG weight,20280,,"38,359 x DRG weight",20280,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9174,,186% x Medicaid HMO amount,9174,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18017,,"34,077 x DRG weight",18017,Other,base rate x DRG weight,15314,,"28,966 x DRG weight",15314,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4932,,DRG base rate x DRG weight + capital per discharge,4932,Other,100% of NY Medicaid HMO DRG,4932,,100% x Medicaid HMO amount,4932,Other,100% of NY Medicaid HMO DRG,4932,,100% x Medicaid HMO amount,4932,Other,100% of NY Medicaid HMO DRG,4932,,100% x Medicaid HMO amount,4932,Other,100% of NY Medicaid HMO DRG,11097,,225% x Medicaid HMO amount,11097,Other,225% of NY Medicaid HMO DRG,11097,,225% x Medicaid HMO amount,11097,Other,225% of NY Medicaid HMO DRG,11097,,225% x Medicaid HMO amount,11097,Other,225% of NY Medicaid HMO DRG,11097,,225% x Medicaid HMO amount,11097,Other,225% of NY Medicaid HMO DRG,6905,,140% x Medicaid HMO amount,6905,Other,140% of NY Medicaid HMO DRG,11097,,225% x Medicaid HMO amount,11097,Other,225% of NY Medicaid HMO DRG,13563,,275% x Medicaid HMO amount,13563,Other,275% of NY Medicaid HMO DRG,15980,,324% x Medicaid HMO amount,15980,Other,324% of NY Medicaid HMO DRG,10604,,215% x Medicaid HMO amount,10604,Other,215% of NY Medicaid HMO DRG,10604,,215% x Medicaid HMO amount,10604,Other,215% of NY Medicaid HMO DRG,6165,,125% x Medicaid HMO amount,6165,Other,125% of NY Medicaid HMO DRG,0.01,23859,
Fracture of femur,340-2,APR-DRG,,,,,,,,inpatient,,,29468,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31955,,"45,128 x DRG weight",31955,Other,base rate x DRG weight,28759,,"40,615 x DRG weight",28759,Other,base rate x DRG weight,27162,,"38,359 x DRG weight",27162,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11768,,186% x Medicaid HMO amount,11768,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24130,,"34,077 x DRG weight",24130,Other,base rate x DRG weight,20511,,"28,966 x DRG weight",20511,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6327,,DRG base rate x DRG weight + capital per discharge,6327,Other,100% of NY Medicaid HMO DRG,6327,,100% x Medicaid HMO amount,6327,Other,100% of NY Medicaid HMO DRG,6327,,100% x Medicaid HMO amount,6327,Other,100% of NY Medicaid HMO DRG,6327,,100% x Medicaid HMO amount,6327,Other,100% of NY Medicaid HMO DRG,14236,,225% x Medicaid HMO amount,14236,Other,225% of NY Medicaid HMO DRG,14236,,225% x Medicaid HMO amount,14236,Other,225% of NY Medicaid HMO DRG,14236,,225% x Medicaid HMO amount,14236,Other,225% of NY Medicaid HMO DRG,14236,,225% x Medicaid HMO amount,14236,Other,225% of NY Medicaid HMO DRG,8858,,140% x Medicaid HMO amount,8858,Other,140% of NY Medicaid HMO DRG,14236,,225% x Medicaid HMO amount,14236,Other,225% of NY Medicaid HMO DRG,17399,,275% x Medicaid HMO amount,17399,Other,275% of NY Medicaid HMO DRG,20499,,324% x Medicaid HMO amount,20499,Other,324% of NY Medicaid HMO DRG,13603,,215% x Medicaid HMO amount,13603,Other,215% of NY Medicaid HMO DRG,13603,,215% x Medicaid HMO amount,13603,Other,215% of NY Medicaid HMO DRG,7909,,125% x Medicaid HMO amount,7909,Other,125% of NY Medicaid HMO DRG,0.01,31955,
Fracture of femur,340-3,APR-DRG,,,,,,,,inpatient,,,169647.97,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,76876,,"45,128 x DRG weight",76876,Other,base rate x DRG weight,69188,,"40,615 x DRG weight",69188,Other,base rate x DRG weight,65345,,"38,359 x DRG weight",65345,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26165,,186% x Medicaid HMO amount,26165,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,58050,,"34,077 x DRG weight",58050,Other,base rate x DRG weight,49344,,"28,966 x DRG weight",49344,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14067,,DRG base rate x DRG weight + capital per discharge,14067,Other,100% of NY Medicaid HMO DRG,14067,,100% x Medicaid HMO amount,14067,Other,100% of NY Medicaid HMO DRG,14067,,100% x Medicaid HMO amount,14067,Other,100% of NY Medicaid HMO DRG,14067,,100% x Medicaid HMO amount,14067,Other,100% of NY Medicaid HMO DRG,31651,,225% x Medicaid HMO amount,31651,Other,225% of NY Medicaid HMO DRG,31651,,225% x Medicaid HMO amount,31651,Other,225% of NY Medicaid HMO DRG,31651,,225% x Medicaid HMO amount,31651,Other,225% of NY Medicaid HMO DRG,31651,,225% x Medicaid HMO amount,31651,Other,225% of NY Medicaid HMO DRG,19694,,140% x Medicaid HMO amount,19694,Other,140% of NY Medicaid HMO DRG,31651,,225% x Medicaid HMO amount,31651,Other,225% of NY Medicaid HMO DRG,38684,,275% x Medicaid HMO amount,38684,Other,275% of NY Medicaid HMO DRG,45577,,324% x Medicaid HMO amount,45577,Other,324% of NY Medicaid HMO DRG,30244,,215% x Medicaid HMO amount,30244,Other,215% of NY Medicaid HMO DRG,30244,,215% x Medicaid HMO amount,30244,Other,215% of NY Medicaid HMO DRG,17584,,125% x Medicaid HMO amount,17584,Other,125% of NY Medicaid HMO DRG,0.01,76876,
Fracture of femur,340-4,APR-DRG,,,,,,,,inpatient,,,65287.86,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,104611,,"45,128 x DRG weight",104611,Other,base rate x DRG weight,94150,,"40,615 x DRG weight",94150,Other,base rate x DRG weight,88920,,"38,359 x DRG weight",88920,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35054,,186% x Medicaid HMO amount,35054,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,78994,,"34,077 x DRG weight",78994,Other,base rate x DRG weight,67146,,"28,966 x DRG weight",67146,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18846,,DRG base rate x DRG weight + capital per discharge,18846,Other,100% of NY Medicaid HMO DRG,18846,,100% x Medicaid HMO amount,18846,Other,100% of NY Medicaid HMO DRG,18846,,100% x Medicaid HMO amount,18846,Other,100% of NY Medicaid HMO DRG,18846,,100% x Medicaid HMO amount,18846,Other,100% of NY Medicaid HMO DRG,42404,,225% x Medicaid HMO amount,42404,Other,225% of NY Medicaid HMO DRG,42404,,225% x Medicaid HMO amount,42404,Other,225% of NY Medicaid HMO DRG,42404,,225% x Medicaid HMO amount,42404,Other,225% of NY Medicaid HMO DRG,42404,,225% x Medicaid HMO amount,42404,Other,225% of NY Medicaid HMO DRG,26384,,140% x Medicaid HMO amount,26384,Other,140% of NY Medicaid HMO DRG,42404,,225% x Medicaid HMO amount,42404,Other,225% of NY Medicaid HMO DRG,51827,,275% x Medicaid HMO amount,51827,Other,275% of NY Medicaid HMO DRG,61061,,324% x Medicaid HMO amount,61061,Other,324% of NY Medicaid HMO DRG,40519,,215% x Medicaid HMO amount,40519,Other,215% of NY Medicaid HMO DRG,40519,,215% x Medicaid HMO amount,40519,Other,215% of NY Medicaid HMO DRG,23558,,125% x Medicaid HMO amount,23558,Other,125% of NY Medicaid HMO DRG,0.01,104611,
Fracture of pelvis or dislocation of hip,341-1,APR-DRG,,,,,,,,inpatient,,,78139.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25836,,"45,128 x DRG weight",25836,Other,base rate x DRG weight,23252,,"40,615 x DRG weight",23252,Other,base rate x DRG weight,21961,,"38,359 x DRG weight",21961,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9806,,186% x Medicaid HMO amount,9806,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19509,,"34,077 x DRG weight",19509,Other,base rate x DRG weight,16583,,"28,966 x DRG weight",16583,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5272,,DRG base rate x DRG weight + capital per discharge,5272,Other,100% of NY Medicaid HMO DRG,5272,,100% x Medicaid HMO amount,5272,Other,100% of NY Medicaid HMO DRG,5272,,100% x Medicaid HMO amount,5272,Other,100% of NY Medicaid HMO DRG,5272,,100% x Medicaid HMO amount,5272,Other,100% of NY Medicaid HMO DRG,11862,,225% x Medicaid HMO amount,11862,Other,225% of NY Medicaid HMO DRG,11862,,225% x Medicaid HMO amount,11862,Other,225% of NY Medicaid HMO DRG,11862,,225% x Medicaid HMO amount,11862,Other,225% of NY Medicaid HMO DRG,11862,,225% x Medicaid HMO amount,11862,Other,225% of NY Medicaid HMO DRG,7381,,140% x Medicaid HMO amount,7381,Other,140% of NY Medicaid HMO DRG,11862,,225% x Medicaid HMO amount,11862,Other,225% of NY Medicaid HMO DRG,14498,,275% x Medicaid HMO amount,14498,Other,275% of NY Medicaid HMO DRG,17081,,324% x Medicaid HMO amount,17081,Other,324% of NY Medicaid HMO DRG,11335,,215% x Medicaid HMO amount,11335,Other,215% of NY Medicaid HMO DRG,11335,,215% x Medicaid HMO amount,11335,Other,215% of NY Medicaid HMO DRG,6590,,125% x Medicaid HMO amount,6590,Other,125% of NY Medicaid HMO DRG,0.01,25836,
Fracture of pelvis or dislocation of hip,341-2,APR-DRG,,,,,,,,inpatient,,,114028.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32212,,"45,128 x DRG weight",32212,Other,base rate x DRG weight,28991,,"40,615 x DRG weight",28991,Other,base rate x DRG weight,27381,,"38,359 x DRG weight",27381,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11850,,186% x Medicaid HMO amount,11850,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24324,,"34,077 x DRG weight",24324,Other,base rate x DRG weight,20676,,"28,966 x DRG weight",20676,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6371,,DRG base rate x DRG weight + capital per discharge,6371,Other,100% of NY Medicaid HMO DRG,6371,,100% x Medicaid HMO amount,6371,Other,100% of NY Medicaid HMO DRG,6371,,100% x Medicaid HMO amount,6371,Other,100% of NY Medicaid HMO DRG,6371,,100% x Medicaid HMO amount,6371,Other,100% of NY Medicaid HMO DRG,14335,,225% x Medicaid HMO amount,14335,Other,225% of NY Medicaid HMO DRG,14335,,225% x Medicaid HMO amount,14335,Other,225% of NY Medicaid HMO DRG,14335,,225% x Medicaid HMO amount,14335,Other,225% of NY Medicaid HMO DRG,14335,,225% x Medicaid HMO amount,14335,Other,225% of NY Medicaid HMO DRG,8919,,140% x Medicaid HMO amount,8919,Other,140% of NY Medicaid HMO DRG,14335,,225% x Medicaid HMO amount,14335,Other,225% of NY Medicaid HMO DRG,17520,,275% x Medicaid HMO amount,17520,Other,275% of NY Medicaid HMO DRG,20642,,324% x Medicaid HMO amount,20642,Other,324% of NY Medicaid HMO DRG,13698,,215% x Medicaid HMO amount,13698,Other,215% of NY Medicaid HMO DRG,13698,,215% x Medicaid HMO amount,13698,Other,215% of NY Medicaid HMO DRG,7964,,125% x Medicaid HMO amount,7964,Other,125% of NY Medicaid HMO DRG,0.01,32212,
Fracture of pelvis or dislocation of hip,341-3,APR-DRG,,,,,,,,inpatient,,,188391.01,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43418,,"45,128 x DRG weight",43418,Other,base rate x DRG weight,39076,,"40,615 x DRG weight",39076,Other,base rate x DRG weight,36905,,"38,359 x DRG weight",36905,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15442,,186% x Medicaid HMO amount,15442,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32785,,"34,077 x DRG weight",32785,Other,base rate x DRG weight,27868,,"28,966 x DRG weight",27868,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8302,,DRG base rate x DRG weight + capital per discharge,8302,Other,100% of NY Medicaid HMO DRG,8302,,100% x Medicaid HMO amount,8302,Other,100% of NY Medicaid HMO DRG,8302,,100% x Medicaid HMO amount,8302,Other,100% of NY Medicaid HMO DRG,8302,,100% x Medicaid HMO amount,8302,Other,100% of NY Medicaid HMO DRG,18680,,225% x Medicaid HMO amount,18680,Other,225% of NY Medicaid HMO DRG,18680,,225% x Medicaid HMO amount,18680,Other,225% of NY Medicaid HMO DRG,18680,,225% x Medicaid HMO amount,18680,Other,225% of NY Medicaid HMO DRG,18680,,225% x Medicaid HMO amount,18680,Other,225% of NY Medicaid HMO DRG,11623,,140% x Medicaid HMO amount,11623,Other,140% of NY Medicaid HMO DRG,18680,,225% x Medicaid HMO amount,18680,Other,225% of NY Medicaid HMO DRG,22831,,275% x Medicaid HMO amount,22831,Other,275% of NY Medicaid HMO DRG,26898,,324% x Medicaid HMO amount,26898,Other,324% of NY Medicaid HMO DRG,17849,,215% x Medicaid HMO amount,17849,Other,215% of NY Medicaid HMO DRG,17849,,215% x Medicaid HMO amount,17849,Other,215% of NY Medicaid HMO DRG,10378,,125% x Medicaid HMO amount,10378,Other,125% of NY Medicaid HMO DRG,0.01,43418,
Fracture of pelvis or dislocation of hip,341-4,APR-DRG,,,,,,,,inpatient,,,413970,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46202,,"45,128 x DRG weight",46202,Other,base rate x DRG weight,41582,,"40,615 x DRG weight",41582,Other,base rate x DRG weight,39272,,"38,359 x DRG weight",39272,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16335,,186% x Medicaid HMO amount,16335,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34888,,"34,077 x DRG weight",34888,Other,base rate x DRG weight,29655,,"28,966 x DRG weight",29655,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8782,,DRG base rate x DRG weight + capital per discharge,8782,Other,100% of NY Medicaid HMO DRG,8782,,100% x Medicaid HMO amount,8782,Other,100% of NY Medicaid HMO DRG,8782,,100% x Medicaid HMO amount,8782,Other,100% of NY Medicaid HMO DRG,8782,,100% x Medicaid HMO amount,8782,Other,100% of NY Medicaid HMO DRG,19760,,225% x Medicaid HMO amount,19760,Other,225% of NY Medicaid HMO DRG,19760,,225% x Medicaid HMO amount,19760,Other,225% of NY Medicaid HMO DRG,19760,,225% x Medicaid HMO amount,19760,Other,225% of NY Medicaid HMO DRG,19760,,225% x Medicaid HMO amount,19760,Other,225% of NY Medicaid HMO DRG,12295,,140% x Medicaid HMO amount,12295,Other,140% of NY Medicaid HMO DRG,19760,,225% x Medicaid HMO amount,19760,Other,225% of NY Medicaid HMO DRG,24151,,275% x Medicaid HMO amount,24151,Other,275% of NY Medicaid HMO DRG,28454,,324% x Medicaid HMO amount,28454,Other,324% of NY Medicaid HMO DRG,18881,,215% x Medicaid HMO amount,18881,Other,215% of NY Medicaid HMO DRG,18881,,215% x Medicaid HMO amount,18881,Other,215% of NY Medicaid HMO DRG,10978,,125% x Medicaid HMO amount,10978,Other,125% of NY Medicaid HMO DRG,0.01,46202,
"Fractures & dislocations except femur, pelvis & back",342-1,APR-DRG,,,,,,,,inpatient,,,92965.78,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20064,,"45,128 x DRG weight",20064,Other,base rate x DRG weight,18057,,"40,615 x DRG weight",18057,Other,base rate x DRG weight,17054,,"38,359 x DRG weight",17054,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7957,,186% x Medicaid HMO amount,7957,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15151,,"34,077 x DRG weight",15151,Other,base rate x DRG weight,12878,,"28,966 x DRG weight",12878,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4278,,DRG base rate x DRG weight + capital per discharge,4278,Other,100% of NY Medicaid HMO DRG,4278,,100% x Medicaid HMO amount,4278,Other,100% of NY Medicaid HMO DRG,4278,,100% x Medicaid HMO amount,4278,Other,100% of NY Medicaid HMO DRG,4278,,100% x Medicaid HMO amount,4278,Other,100% of NY Medicaid HMO DRG,9626,,225% x Medicaid HMO amount,9626,Other,225% of NY Medicaid HMO DRG,9626,,225% x Medicaid HMO amount,9626,Other,225% of NY Medicaid HMO DRG,9626,,225% x Medicaid HMO amount,9626,Other,225% of NY Medicaid HMO DRG,9626,,225% x Medicaid HMO amount,9626,Other,225% of NY Medicaid HMO DRG,5989,,140% x Medicaid HMO amount,5989,Other,140% of NY Medicaid HMO DRG,9626,,225% x Medicaid HMO amount,9626,Other,225% of NY Medicaid HMO DRG,11765,,275% x Medicaid HMO amount,11765,Other,275% of NY Medicaid HMO DRG,13861,,324% x Medicaid HMO amount,13861,Other,324% of NY Medicaid HMO DRG,9198,,215% x Medicaid HMO amount,9198,Other,215% of NY Medicaid HMO DRG,9198,,215% x Medicaid HMO amount,9198,Other,215% of NY Medicaid HMO DRG,5348,,125% x Medicaid HMO amount,5348,Other,125% of NY Medicaid HMO DRG,0.01,20064,
"Fractures & dislocations except femur, pelvis & back",342-2,APR-DRG,,,,,,,,inpatient,,,120322.77,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29753,,"45,128 x DRG weight",29753,Other,base rate x DRG weight,26777,,"40,615 x DRG weight",26777,Other,base rate x DRG weight,25290,,"38,359 x DRG weight",25290,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11061,,186% x Medicaid HMO amount,11061,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22467,,"34,077 x DRG weight",22467,Other,base rate x DRG weight,19097,,"28,966 x DRG weight",19097,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5947,,DRG base rate x DRG weight + capital per discharge,5947,Other,100% of NY Medicaid HMO DRG,5947,,100% x Medicaid HMO amount,5947,Other,100% of NY Medicaid HMO DRG,5947,,100% x Medicaid HMO amount,5947,Other,100% of NY Medicaid HMO DRG,5947,,100% x Medicaid HMO amount,5947,Other,100% of NY Medicaid HMO DRG,13381,,225% x Medicaid HMO amount,13381,Other,225% of NY Medicaid HMO DRG,13381,,225% x Medicaid HMO amount,13381,Other,225% of NY Medicaid HMO DRG,13381,,225% x Medicaid HMO amount,13381,Other,225% of NY Medicaid HMO DRG,13381,,225% x Medicaid HMO amount,13381,Other,225% of NY Medicaid HMO DRG,8326,,140% x Medicaid HMO amount,8326,Other,140% of NY Medicaid HMO DRG,13381,,225% x Medicaid HMO amount,13381,Other,225% of NY Medicaid HMO DRG,16354,,275% x Medicaid HMO amount,16354,Other,275% of NY Medicaid HMO DRG,19268,,324% x Medicaid HMO amount,19268,Other,324% of NY Medicaid HMO DRG,12786,,215% x Medicaid HMO amount,12786,Other,215% of NY Medicaid HMO DRG,12786,,215% x Medicaid HMO amount,12786,Other,215% of NY Medicaid HMO DRG,7434,,125% x Medicaid HMO amount,7434,Other,125% of NY Medicaid HMO DRG,0.01,29753,
"Fractures & dislocations except femur, pelvis & back",342-3,APR-DRG,,,,,,,,inpatient,,,192130.05,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48892,,"45,128 x DRG weight",48892,Other,base rate x DRG weight,44002,,"40,615 x DRG weight",44002,Other,base rate x DRG weight,41558,,"38,359 x DRG weight",41558,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17196,,186% x Medicaid HMO amount,17196,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36919,,"34,077 x DRG weight",36919,Other,base rate x DRG weight,31382,,"28,966 x DRG weight",31382,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9245,,DRG base rate x DRG weight + capital per discharge,9245,Other,100% of NY Medicaid HMO DRG,9245,,100% x Medicaid HMO amount,9245,Other,100% of NY Medicaid HMO DRG,9245,,100% x Medicaid HMO amount,9245,Other,100% of NY Medicaid HMO DRG,9245,,100% x Medicaid HMO amount,9245,Other,100% of NY Medicaid HMO DRG,20801,,225% x Medicaid HMO amount,20801,Other,225% of NY Medicaid HMO DRG,20801,,225% x Medicaid HMO amount,20801,Other,225% of NY Medicaid HMO DRG,20801,,225% x Medicaid HMO amount,20801,Other,225% of NY Medicaid HMO DRG,20801,,225% x Medicaid HMO amount,20801,Other,225% of NY Medicaid HMO DRG,12943,,140% x Medicaid HMO amount,12943,Other,140% of NY Medicaid HMO DRG,20801,,225% x Medicaid HMO amount,20801,Other,225% of NY Medicaid HMO DRG,25424,,275% x Medicaid HMO amount,25424,Other,275% of NY Medicaid HMO DRG,29954,,324% x Medicaid HMO amount,29954,Other,324% of NY Medicaid HMO DRG,19877,,215% x Medicaid HMO amount,19877,Other,215% of NY Medicaid HMO DRG,19877,,215% x Medicaid HMO amount,19877,Other,215% of NY Medicaid HMO DRG,11556,,125% x Medicaid HMO amount,11556,Other,125% of NY Medicaid HMO DRG,0.01,48892,
"Fractures & dislocations except femur, pelvis & back",342-4,APR-DRG,,,,,,,,inpatient,,,240902.52,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,119436,,"45,128 x DRG weight",119436,Other,base rate x DRG weight,107492,,"40,615 x DRG weight",107492,Other,base rate x DRG weight,101521,,"38,359 x DRG weight",101521,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39804,,186% x Medicaid HMO amount,39804,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,90188,,"34,077 x DRG weight",90188,Other,base rate x DRG weight,76661,,"28,966 x DRG weight",76661,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21400,,DRG base rate x DRG weight + capital per discharge,21400,Other,100% of NY Medicaid HMO DRG,21400,,100% x Medicaid HMO amount,21400,Other,100% of NY Medicaid HMO DRG,21400,,100% x Medicaid HMO amount,21400,Other,100% of NY Medicaid HMO DRG,21400,,100% x Medicaid HMO amount,21400,Other,100% of NY Medicaid HMO DRG,48150,,225% x Medicaid HMO amount,48150,Other,225% of NY Medicaid HMO DRG,48150,,225% x Medicaid HMO amount,48150,Other,225% of NY Medicaid HMO DRG,48150,,225% x Medicaid HMO amount,48150,Other,225% of NY Medicaid HMO DRG,48150,,225% x Medicaid HMO amount,48150,Other,225% of NY Medicaid HMO DRG,29960,,140% x Medicaid HMO amount,29960,Other,140% of NY Medicaid HMO DRG,48150,,225% x Medicaid HMO amount,48150,Other,225% of NY Medicaid HMO DRG,58850,,275% x Medicaid HMO amount,58850,Other,275% of NY Medicaid HMO DRG,69336,,324% x Medicaid HMO amount,69336,Other,324% of NY Medicaid HMO DRG,46010,,215% x Medicaid HMO amount,46010,Other,215% of NY Medicaid HMO DRG,46010,,215% x Medicaid HMO amount,46010,Other,215% of NY Medicaid HMO DRG,26750,,125% x Medicaid HMO amount,26750,Other,125% of NY Medicaid HMO DRG,0.01,119436,
Musculoskeletal malignancy & pathol fracture d/t muscskel malig,343-1,APR-DRG,,,,,,,,inpatient,,,305795.62,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37443,,"45,128 x DRG weight",37443,Other,base rate x DRG weight,33698,,"40,615 x DRG weight",33698,Other,base rate x DRG weight,31826,,"38,359 x DRG weight",31826,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13526,,186% x Medicaid HMO amount,13526,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28274,,"34,077 x DRG weight",28274,Other,base rate x DRG weight,24033,,"28,966 x DRG weight",24033,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7272,,DRG base rate x DRG weight + capital per discharge,7272,Other,100% of NY Medicaid HMO DRG,7272,,100% x Medicaid HMO amount,7272,Other,100% of NY Medicaid HMO DRG,7272,,100% x Medicaid HMO amount,7272,Other,100% of NY Medicaid HMO DRG,7272,,100% x Medicaid HMO amount,7272,Other,100% of NY Medicaid HMO DRG,16362,,225% x Medicaid HMO amount,16362,Other,225% of NY Medicaid HMO DRG,16362,,225% x Medicaid HMO amount,16362,Other,225% of NY Medicaid HMO DRG,16362,,225% x Medicaid HMO amount,16362,Other,225% of NY Medicaid HMO DRG,16362,,225% x Medicaid HMO amount,16362,Other,225% of NY Medicaid HMO DRG,10181,,140% x Medicaid HMO amount,10181,Other,140% of NY Medicaid HMO DRG,16362,,225% x Medicaid HMO amount,16362,Other,225% of NY Medicaid HMO DRG,19998,,275% x Medicaid HMO amount,19998,Other,275% of NY Medicaid HMO DRG,23561,,324% x Medicaid HMO amount,23561,Other,324% of NY Medicaid HMO DRG,15635,,215% x Medicaid HMO amount,15635,Other,215% of NY Medicaid HMO DRG,15635,,215% x Medicaid HMO amount,15635,Other,215% of NY Medicaid HMO DRG,9090,,125% x Medicaid HMO amount,9090,Other,125% of NY Medicaid HMO DRG,0.01,37443,
Musculoskeletal malignancy & pathol fracture d/t muscskel malig,343-2,APR-DRG,,,,,,,,inpatient,,,423823.32,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45020,,"45,128 x DRG weight",45020,Other,base rate x DRG weight,40518,,"40,615 x DRG weight",40518,Other,base rate x DRG weight,38267,,"38,359 x DRG weight",38267,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15955,,186% x Medicaid HMO amount,15955,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33995,,"34,077 x DRG weight",33995,Other,base rate x DRG weight,28896,,"28,966 x DRG weight",28896,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8578,,DRG base rate x DRG weight + capital per discharge,8578,Other,100% of NY Medicaid HMO DRG,8578,,100% x Medicaid HMO amount,8578,Other,100% of NY Medicaid HMO DRG,8578,,100% x Medicaid HMO amount,8578,Other,100% of NY Medicaid HMO DRG,8578,,100% x Medicaid HMO amount,8578,Other,100% of NY Medicaid HMO DRG,19301,,225% x Medicaid HMO amount,19301,Other,225% of NY Medicaid HMO DRG,19301,,225% x Medicaid HMO amount,19301,Other,225% of NY Medicaid HMO DRG,19301,,225% x Medicaid HMO amount,19301,Other,225% of NY Medicaid HMO DRG,19301,,225% x Medicaid HMO amount,19301,Other,225% of NY Medicaid HMO DRG,12009,,140% x Medicaid HMO amount,12009,Other,140% of NY Medicaid HMO DRG,19301,,225% x Medicaid HMO amount,19301,Other,225% of NY Medicaid HMO DRG,23590,,275% x Medicaid HMO amount,23590,Other,275% of NY Medicaid HMO DRG,27793,,324% x Medicaid HMO amount,27793,Other,324% of NY Medicaid HMO DRG,18443,,215% x Medicaid HMO amount,18443,Other,215% of NY Medicaid HMO DRG,18443,,215% x Medicaid HMO amount,18443,Other,215% of NY Medicaid HMO DRG,10723,,125% x Medicaid HMO amount,10723,Other,125% of NY Medicaid HMO DRG,0.01,45020,
Musculoskeletal malignancy & pathol fracture d/t muscskel malig,343-3,APR-DRG,,,,,,,,inpatient,,,479363.79,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,96872,,"45,128 x DRG weight",96872,Other,base rate x DRG weight,87184,,"40,615 x DRG weight",87184,Other,base rate x DRG weight,82341,,"38,359 x DRG weight",82341,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32572,,186% x Medicaid HMO amount,32572,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73150,,"34,077 x DRG weight",73150,Other,base rate x DRG weight,62178,,"28,966 x DRG weight",62178,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17512,,DRG base rate x DRG weight + capital per discharge,17512,Other,100% of NY Medicaid HMO DRG,17512,,100% x Medicaid HMO amount,17512,Other,100% of NY Medicaid HMO DRG,17512,,100% x Medicaid HMO amount,17512,Other,100% of NY Medicaid HMO DRG,17512,,100% x Medicaid HMO amount,17512,Other,100% of NY Medicaid HMO DRG,39402,,225% x Medicaid HMO amount,39402,Other,225% of NY Medicaid HMO DRG,39402,,225% x Medicaid HMO amount,39402,Other,225% of NY Medicaid HMO DRG,39402,,225% x Medicaid HMO amount,39402,Other,225% of NY Medicaid HMO DRG,39402,,225% x Medicaid HMO amount,39402,Other,225% of NY Medicaid HMO DRG,24517,,140% x Medicaid HMO amount,24517,Other,140% of NY Medicaid HMO DRG,39402,,225% x Medicaid HMO amount,39402,Other,225% of NY Medicaid HMO DRG,48158,,275% x Medicaid HMO amount,48158,Other,275% of NY Medicaid HMO DRG,56739,,324% x Medicaid HMO amount,56739,Other,324% of NY Medicaid HMO DRG,37651,,215% x Medicaid HMO amount,37651,Other,215% of NY Medicaid HMO DRG,37651,,215% x Medicaid HMO amount,37651,Other,215% of NY Medicaid HMO DRG,21890,,125% x Medicaid HMO amount,21890,Other,125% of NY Medicaid HMO DRG,0.01,96872,
Musculoskeletal malignancy & pathol fracture d/t muscskel malig,343-4,APR-DRG,,,,,,,,inpatient,,,325773,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,173824,,"45,128 x DRG weight",173824,Other,base rate x DRG weight,156441,,"40,615 x DRG weight",156441,Other,base rate x DRG weight,147751,,"38,359 x DRG weight",147751,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,57234,,186% x Medicaid HMO amount,57234,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,131258,,"34,077 x DRG weight",131258,Other,base rate x DRG weight,111571,,"28,966 x DRG weight",111571,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30771,,DRG base rate x DRG weight + capital per discharge,30771,Other,100% of NY Medicaid HMO DRG,30771,,100% x Medicaid HMO amount,30771,Other,100% of NY Medicaid HMO DRG,30771,,100% x Medicaid HMO amount,30771,Other,100% of NY Medicaid HMO DRG,30771,,100% x Medicaid HMO amount,30771,Other,100% of NY Medicaid HMO DRG,69235,,225% x Medicaid HMO amount,69235,Other,225% of NY Medicaid HMO DRG,69235,,225% x Medicaid HMO amount,69235,Other,225% of NY Medicaid HMO DRG,69235,,225% x Medicaid HMO amount,69235,Other,225% of NY Medicaid HMO DRG,69235,,225% x Medicaid HMO amount,69235,Other,225% of NY Medicaid HMO DRG,43079,,140% x Medicaid HMO amount,43079,Other,140% of NY Medicaid HMO DRG,69235,,225% x Medicaid HMO amount,69235,Other,225% of NY Medicaid HMO DRG,84620,,275% x Medicaid HMO amount,84620,Other,275% of NY Medicaid HMO DRG,99698,,324% x Medicaid HMO amount,99698,Other,324% of NY Medicaid HMO DRG,66158,,215% x Medicaid HMO amount,66158,Other,215% of NY Medicaid HMO DRG,66158,,215% x Medicaid HMO amount,66158,Other,215% of NY Medicaid HMO DRG,38464,,125% x Medicaid HMO amount,38464,Other,125% of NY Medicaid HMO DRG,0.01,173824,
"Osteomyelitis, septic arthritis & other musculoskeletal infections",344-1,APR-DRG,,,,,,,,inpatient,,,57913.98,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36287,,"45,128 x DRG weight",36287,Other,base rate x DRG weight,32659,,"40,615 x DRG weight",32659,Other,base rate x DRG weight,30844,,"38,359 x DRG weight",30844,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13156,,186% x Medicaid HMO amount,13156,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27401,,"34,077 x DRG weight",27401,Other,base rate x DRG weight,23292,,"28,966 x DRG weight",23292,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7073,,DRG base rate x DRG weight + capital per discharge,7073,Other,100% of NY Medicaid HMO DRG,7073,,100% x Medicaid HMO amount,7073,Other,100% of NY Medicaid HMO DRG,7073,,100% x Medicaid HMO amount,7073,Other,100% of NY Medicaid HMO DRG,7073,,100% x Medicaid HMO amount,7073,Other,100% of NY Medicaid HMO DRG,15914,,225% x Medicaid HMO amount,15914,Other,225% of NY Medicaid HMO DRG,15914,,225% x Medicaid HMO amount,15914,Other,225% of NY Medicaid HMO DRG,15914,,225% x Medicaid HMO amount,15914,Other,225% of NY Medicaid HMO DRG,15914,,225% x Medicaid HMO amount,15914,Other,225% of NY Medicaid HMO DRG,9902,,140% x Medicaid HMO amount,9902,Other,140% of NY Medicaid HMO DRG,15914,,225% x Medicaid HMO amount,15914,Other,225% of NY Medicaid HMO DRG,19451,,275% x Medicaid HMO amount,19451,Other,275% of NY Medicaid HMO DRG,22917,,324% x Medicaid HMO amount,22917,Other,324% of NY Medicaid HMO DRG,15207,,215% x Medicaid HMO amount,15207,Other,215% of NY Medicaid HMO DRG,15207,,215% x Medicaid HMO amount,15207,Other,215% of NY Medicaid HMO DRG,8841,,125% x Medicaid HMO amount,8841,Other,125% of NY Medicaid HMO DRG,0.01,36287,
"Osteomyelitis, septic arthritis & other musculoskeletal infections",344-2,APR-DRG,,,,,,,,inpatient,,,142328.16,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51888,,"45,128 x DRG weight",51888,Other,base rate x DRG weight,46699,,"40,615 x DRG weight",46699,Other,base rate x DRG weight,44105,,"38,359 x DRG weight",44105,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18155,,186% x Medicaid HMO amount,18155,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39182,,"34,077 x DRG weight",39182,Other,base rate x DRG weight,33305,,"28,966 x DRG weight",33305,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9761,,DRG base rate x DRG weight + capital per discharge,9761,Other,100% of NY Medicaid HMO DRG,9761,,100% x Medicaid HMO amount,9761,Other,100% of NY Medicaid HMO DRG,9761,,100% x Medicaid HMO amount,9761,Other,100% of NY Medicaid HMO DRG,9761,,100% x Medicaid HMO amount,9761,Other,100% of NY Medicaid HMO DRG,21962,,225% x Medicaid HMO amount,21962,Other,225% of NY Medicaid HMO DRG,21962,,225% x Medicaid HMO amount,21962,Other,225% of NY Medicaid HMO DRG,21962,,225% x Medicaid HMO amount,21962,Other,225% of NY Medicaid HMO DRG,21962,,225% x Medicaid HMO amount,21962,Other,225% of NY Medicaid HMO DRG,13665,,140% x Medicaid HMO amount,13665,Other,140% of NY Medicaid HMO DRG,21962,,225% x Medicaid HMO amount,21962,Other,225% of NY Medicaid HMO DRG,26843,,275% x Medicaid HMO amount,26843,Other,275% of NY Medicaid HMO DRG,31626,,324% x Medicaid HMO amount,31626,Other,324% of NY Medicaid HMO DRG,20986,,215% x Medicaid HMO amount,20986,Other,215% of NY Medicaid HMO DRG,20986,,215% x Medicaid HMO amount,20986,Other,215% of NY Medicaid HMO DRG,12201,,125% x Medicaid HMO amount,12201,Other,125% of NY Medicaid HMO DRG,0.01,51888,
"Osteomyelitis, septic arthritis & other musculoskeletal infections",344-3,APR-DRG,,,,,,,,inpatient,,,235243.34,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,80481,,"45,128 x DRG weight",80481,Other,base rate x DRG weight,72433,,"40,615 x DRG weight",72433,Other,base rate x DRG weight,68409,,"38,359 x DRG weight",68409,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27320,,186% x Medicaid HMO amount,27320,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60773,,"34,077 x DRG weight",60773,Other,base rate x DRG weight,51658,,"28,966 x DRG weight",51658,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14688,,DRG base rate x DRG weight + capital per discharge,14688,Other,100% of NY Medicaid HMO DRG,14688,,100% x Medicaid HMO amount,14688,Other,100% of NY Medicaid HMO DRG,14688,,100% x Medicaid HMO amount,14688,Other,100% of NY Medicaid HMO DRG,14688,,100% x Medicaid HMO amount,14688,Other,100% of NY Medicaid HMO DRG,33048,,225% x Medicaid HMO amount,33048,Other,225% of NY Medicaid HMO DRG,33048,,225% x Medicaid HMO amount,33048,Other,225% of NY Medicaid HMO DRG,33048,,225% x Medicaid HMO amount,33048,Other,225% of NY Medicaid HMO DRG,33048,,225% x Medicaid HMO amount,33048,Other,225% of NY Medicaid HMO DRG,20563,,140% x Medicaid HMO amount,20563,Other,140% of NY Medicaid HMO DRG,33048,,225% x Medicaid HMO amount,33048,Other,225% of NY Medicaid HMO DRG,40392,,275% x Medicaid HMO amount,40392,Other,275% of NY Medicaid HMO DRG,47589,,324% x Medicaid HMO amount,47589,Other,324% of NY Medicaid HMO DRG,31579,,215% x Medicaid HMO amount,31579,Other,215% of NY Medicaid HMO DRG,31579,,215% x Medicaid HMO amount,31579,Other,215% of NY Medicaid HMO DRG,18360,,125% x Medicaid HMO amount,18360,Other,125% of NY Medicaid HMO DRG,0.01,80481,
"Osteomyelitis, septic arthritis & other musculoskeletal infections",344-4,APR-DRG,,,,,,,,inpatient,,,347789.16,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,154915,,"45,128 x DRG weight",154915,Other,base rate x DRG weight,139423,,"40,615 x DRG weight",139423,Other,base rate x DRG weight,131679,,"38,359 x DRG weight",131679,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51174,,186% x Medicaid HMO amount,51174,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,116980,,"34,077 x DRG weight",116980,Other,base rate x DRG weight,99434,,"28,966 x DRG weight",99434,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27513,,DRG base rate x DRG weight + capital per discharge,27513,Other,100% of NY Medicaid HMO DRG,27513,,100% x Medicaid HMO amount,27513,Other,100% of NY Medicaid HMO DRG,27513,,100% x Medicaid HMO amount,27513,Other,100% of NY Medicaid HMO DRG,27513,,100% x Medicaid HMO amount,27513,Other,100% of NY Medicaid HMO DRG,61904,,225% x Medicaid HMO amount,61904,Other,225% of NY Medicaid HMO DRG,61904,,225% x Medicaid HMO amount,61904,Other,225% of NY Medicaid HMO DRG,61904,,225% x Medicaid HMO amount,61904,Other,225% of NY Medicaid HMO DRG,61904,,225% x Medicaid HMO amount,61904,Other,225% of NY Medicaid HMO DRG,38518,,140% x Medicaid HMO amount,38518,Other,140% of NY Medicaid HMO DRG,61904,,225% x Medicaid HMO amount,61904,Other,225% of NY Medicaid HMO DRG,75661,,275% x Medicaid HMO amount,75661,Other,275% of NY Medicaid HMO DRG,89142,,324% x Medicaid HMO amount,89142,Other,324% of NY Medicaid HMO DRG,59153,,215% x Medicaid HMO amount,59153,Other,215% of NY Medicaid HMO DRG,59153,,215% x Medicaid HMO amount,59153,Other,215% of NY Medicaid HMO DRG,34391,,125% x Medicaid HMO amount,34391,Other,125% of NY Medicaid HMO DRG,0.01,154915,
Connective tissue disorders,346-1,APR-DRG,,,,,,,,inpatient,,,98482.73,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33011,,"45,128 x DRG weight",33011,Other,base rate x DRG weight,29710,,"40,615 x DRG weight",29710,Other,base rate x DRG weight,28060,,"38,359 x DRG weight",28060,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12107,,186% x Medicaid HMO amount,12107,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24927,,"34,077 x DRG weight",24927,Other,base rate x DRG weight,21189,,"28,966 x DRG weight",21189,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6509,,DRG base rate x DRG weight + capital per discharge,6509,Other,100% of NY Medicaid HMO DRG,6509,,100% x Medicaid HMO amount,6509,Other,100% of NY Medicaid HMO DRG,6509,,100% x Medicaid HMO amount,6509,Other,100% of NY Medicaid HMO DRG,6509,,100% x Medicaid HMO amount,6509,Other,100% of NY Medicaid HMO DRG,14645,,225% x Medicaid HMO amount,14645,Other,225% of NY Medicaid HMO DRG,14645,,225% x Medicaid HMO amount,14645,Other,225% of NY Medicaid HMO DRG,14645,,225% x Medicaid HMO amount,14645,Other,225% of NY Medicaid HMO DRG,14645,,225% x Medicaid HMO amount,14645,Other,225% of NY Medicaid HMO DRG,9113,,140% x Medicaid HMO amount,9113,Other,140% of NY Medicaid HMO DRG,14645,,225% x Medicaid HMO amount,14645,Other,225% of NY Medicaid HMO DRG,17900,,275% x Medicaid HMO amount,17900,Other,275% of NY Medicaid HMO DRG,21089,,324% x Medicaid HMO amount,21089,Other,324% of NY Medicaid HMO DRG,13994,,215% x Medicaid HMO amount,13994,Other,215% of NY Medicaid HMO DRG,13994,,215% x Medicaid HMO amount,13994,Other,215% of NY Medicaid HMO DRG,8136,,125% x Medicaid HMO amount,8136,Other,125% of NY Medicaid HMO DRG,0.01,33011,
Connective tissue disorders,346-2,APR-DRG,,,,,,,,inpatient,,,147716.18,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43422,,"45,128 x DRG weight",43422,Other,base rate x DRG weight,39080,,"40,615 x DRG weight",39080,Other,base rate x DRG weight,36909,,"38,359 x DRG weight",36909,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15444,,186% x Medicaid HMO amount,15444,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32789,,"34,077 x DRG weight",32789,Other,base rate x DRG weight,27871,,"28,966 x DRG weight",27871,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8303,,DRG base rate x DRG weight + capital per discharge,8303,Other,100% of NY Medicaid HMO DRG,8303,,100% x Medicaid HMO amount,8303,Other,100% of NY Medicaid HMO DRG,8303,,100% x Medicaid HMO amount,8303,Other,100% of NY Medicaid HMO DRG,8303,,100% x Medicaid HMO amount,8303,Other,100% of NY Medicaid HMO DRG,18682,,225% x Medicaid HMO amount,18682,Other,225% of NY Medicaid HMO DRG,18682,,225% x Medicaid HMO amount,18682,Other,225% of NY Medicaid HMO DRG,18682,,225% x Medicaid HMO amount,18682,Other,225% of NY Medicaid HMO DRG,18682,,225% x Medicaid HMO amount,18682,Other,225% of NY Medicaid HMO DRG,11624,,140% x Medicaid HMO amount,11624,Other,140% of NY Medicaid HMO DRG,18682,,225% x Medicaid HMO amount,18682,Other,225% of NY Medicaid HMO DRG,22833,,275% x Medicaid HMO amount,22833,Other,275% of NY Medicaid HMO DRG,26902,,324% x Medicaid HMO amount,26902,Other,324% of NY Medicaid HMO DRG,17851,,215% x Medicaid HMO amount,17851,Other,215% of NY Medicaid HMO DRG,17851,,215% x Medicaid HMO amount,17851,Other,215% of NY Medicaid HMO DRG,10379,,125% x Medicaid HMO amount,10379,Other,125% of NY Medicaid HMO DRG,0.01,43422,
Connective tissue disorders,346-3,APR-DRG,,,,,,,,inpatient,,,174289.57,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,75043,,"45,128 x DRG weight",75043,Other,base rate x DRG weight,67539,,"40,615 x DRG weight",67539,Other,base rate x DRG weight,63787,,"38,359 x DRG weight",63787,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25577,,186% x Medicaid HMO amount,25577,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56667,,"34,077 x DRG weight",56667,Other,base rate x DRG weight,48168,,"28,966 x DRG weight",48168,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13751,,DRG base rate x DRG weight + capital per discharge,13751,Other,100% of NY Medicaid HMO DRG,13751,,100% x Medicaid HMO amount,13751,Other,100% of NY Medicaid HMO DRG,13751,,100% x Medicaid HMO amount,13751,Other,100% of NY Medicaid HMO DRG,13751,,100% x Medicaid HMO amount,13751,Other,100% of NY Medicaid HMO DRG,30940,,225% x Medicaid HMO amount,30940,Other,225% of NY Medicaid HMO DRG,30940,,225% x Medicaid HMO amount,30940,Other,225% of NY Medicaid HMO DRG,30940,,225% x Medicaid HMO amount,30940,Other,225% of NY Medicaid HMO DRG,30940,,225% x Medicaid HMO amount,30940,Other,225% of NY Medicaid HMO DRG,19251,,140% x Medicaid HMO amount,19251,Other,140% of NY Medicaid HMO DRG,30940,,225% x Medicaid HMO amount,30940,Other,225% of NY Medicaid HMO DRG,37815,,275% x Medicaid HMO amount,37815,Other,275% of NY Medicaid HMO DRG,44553,,324% x Medicaid HMO amount,44553,Other,324% of NY Medicaid HMO DRG,29565,,215% x Medicaid HMO amount,29565,Other,215% of NY Medicaid HMO DRG,29565,,215% x Medicaid HMO amount,29565,Other,215% of NY Medicaid HMO DRG,17189,,125% x Medicaid HMO amount,17189,Other,125% of NY Medicaid HMO DRG,0.01,75043,
Connective tissue disorders,346-4,APR-DRG,,,,,,,,inpatient,,,414074.24,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,219976,,"45,128 x DRG weight",219976,Other,base rate x DRG weight,197978,,"40,615 x DRG weight",197978,Other,base rate x DRG weight,186981,,"38,359 x DRG weight",186981,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,72025,,186% x Medicaid HMO amount,72025,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,166108,,"34,077 x DRG weight",166108,Other,base rate x DRG weight,141195,,"28,966 x DRG weight",141195,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38723,,DRG base rate x DRG weight + capital per discharge,38723,Other,100% of NY Medicaid HMO DRG,38723,,100% x Medicaid HMO amount,38723,Other,100% of NY Medicaid HMO DRG,38723,,100% x Medicaid HMO amount,38723,Other,100% of NY Medicaid HMO DRG,38723,,100% x Medicaid HMO amount,38723,Other,100% of NY Medicaid HMO DRG,87127,,225% x Medicaid HMO amount,87127,Other,225% of NY Medicaid HMO DRG,87127,,225% x Medicaid HMO amount,87127,Other,225% of NY Medicaid HMO DRG,87127,,225% x Medicaid HMO amount,87127,Other,225% of NY Medicaid HMO DRG,87127,,225% x Medicaid HMO amount,87127,Other,225% of NY Medicaid HMO DRG,54212,,140% x Medicaid HMO amount,54212,Other,140% of NY Medicaid HMO DRG,87127,,225% x Medicaid HMO amount,87127,Other,225% of NY Medicaid HMO DRG,106488,,275% x Medicaid HMO amount,106488,Other,275% of NY Medicaid HMO DRG,125463,,324% x Medicaid HMO amount,125463,Other,324% of NY Medicaid HMO DRG,83254,,215% x Medicaid HMO amount,83254,Other,215% of NY Medicaid HMO DRG,83254,,215% x Medicaid HMO amount,83254,Other,215% of NY Medicaid HMO DRG,48404,,125% x Medicaid HMO amount,48404,Other,125% of NY Medicaid HMO DRG,0.01,219976,
"Other back & neck disorders, fractures & injuries",347-1,APR-DRG,,,,,,,,inpatient,,,112218.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24780,,"45,128 x DRG weight",24780,Other,base rate x DRG weight,22302,,"40,615 x DRG weight",22302,Other,base rate x DRG weight,21063,,"38,359 x DRG weight",21063,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9467,,186% x Medicaid HMO amount,9467,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18712,,"34,077 x DRG weight",18712,Other,base rate x DRG weight,15905,,"28,966 x DRG weight",15905,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5090,,DRG base rate x DRG weight + capital per discharge,5090,Other,100% of NY Medicaid HMO DRG,5090,,100% x Medicaid HMO amount,5090,Other,100% of NY Medicaid HMO DRG,5090,,100% x Medicaid HMO amount,5090,Other,100% of NY Medicaid HMO DRG,5090,,100% x Medicaid HMO amount,5090,Other,100% of NY Medicaid HMO DRG,11453,,225% x Medicaid HMO amount,11453,Other,225% of NY Medicaid HMO DRG,11453,,225% x Medicaid HMO amount,11453,Other,225% of NY Medicaid HMO DRG,11453,,225% x Medicaid HMO amount,11453,Other,225% of NY Medicaid HMO DRG,11453,,225% x Medicaid HMO amount,11453,Other,225% of NY Medicaid HMO DRG,7126,,140% x Medicaid HMO amount,7126,Other,140% of NY Medicaid HMO DRG,11453,,225% x Medicaid HMO amount,11453,Other,225% of NY Medicaid HMO DRG,13998,,275% x Medicaid HMO amount,13998,Other,275% of NY Medicaid HMO DRG,16492,,324% x Medicaid HMO amount,16492,Other,324% of NY Medicaid HMO DRG,10944,,215% x Medicaid HMO amount,10944,Other,215% of NY Medicaid HMO DRG,10944,,215% x Medicaid HMO amount,10944,Other,215% of NY Medicaid HMO DRG,6363,,125% x Medicaid HMO amount,6363,Other,125% of NY Medicaid HMO DRG,0.01,24780,
"Other back & neck disorders, fractures & injuries",347-2,APR-DRG,,,,,,,,inpatient,,,155698.86,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33607,,"45,128 x DRG weight",33607,Other,base rate x DRG weight,30246,,"40,615 x DRG weight",30246,Other,base rate x DRG weight,28566,,"38,359 x DRG weight",28566,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12296,,186% x Medicaid HMO amount,12296,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25377,,"34,077 x DRG weight",25377,Other,base rate x DRG weight,21571,,"28,966 x DRG weight",21571,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6611,,DRG base rate x DRG weight + capital per discharge,6611,Other,100% of NY Medicaid HMO DRG,6611,,100% x Medicaid HMO amount,6611,Other,100% of NY Medicaid HMO DRG,6611,,100% x Medicaid HMO amount,6611,Other,100% of NY Medicaid HMO DRG,6611,,100% x Medicaid HMO amount,6611,Other,100% of NY Medicaid HMO DRG,14875,,225% x Medicaid HMO amount,14875,Other,225% of NY Medicaid HMO DRG,14875,,225% x Medicaid HMO amount,14875,Other,225% of NY Medicaid HMO DRG,14875,,225% x Medicaid HMO amount,14875,Other,225% of NY Medicaid HMO DRG,14875,,225% x Medicaid HMO amount,14875,Other,225% of NY Medicaid HMO DRG,9255,,140% x Medicaid HMO amount,9255,Other,140% of NY Medicaid HMO DRG,14875,,225% x Medicaid HMO amount,14875,Other,225% of NY Medicaid HMO DRG,18180,,275% x Medicaid HMO amount,18180,Other,275% of NY Medicaid HMO DRG,21420,,324% x Medicaid HMO amount,21420,Other,324% of NY Medicaid HMO DRG,14214,,215% x Medicaid HMO amount,14214,Other,215% of NY Medicaid HMO DRG,14214,,215% x Medicaid HMO amount,14214,Other,215% of NY Medicaid HMO DRG,8264,,125% x Medicaid HMO amount,8264,Other,125% of NY Medicaid HMO DRG,0.01,33607,
"Other back & neck disorders, fractures & injuries",347-3,APR-DRG,,,,,,,,inpatient,,,157162.23,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50710,,"45,128 x DRG weight",50710,Other,base rate x DRG weight,45639,,"40,615 x DRG weight",45639,Other,base rate x DRG weight,43104,,"38,359 x DRG weight",43104,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17778,,186% x Medicaid HMO amount,17778,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38292,,"34,077 x DRG weight",38292,Other,base rate x DRG weight,32549,,"28,966 x DRG weight",32549,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9558,,DRG base rate x DRG weight + capital per discharge,9558,Other,100% of NY Medicaid HMO DRG,9558,,100% x Medicaid HMO amount,9558,Other,100% of NY Medicaid HMO DRG,9558,,100% x Medicaid HMO amount,9558,Other,100% of NY Medicaid HMO DRG,9558,,100% x Medicaid HMO amount,9558,Other,100% of NY Medicaid HMO DRG,21506,,225% x Medicaid HMO amount,21506,Other,225% of NY Medicaid HMO DRG,21506,,225% x Medicaid HMO amount,21506,Other,225% of NY Medicaid HMO DRG,21506,,225% x Medicaid HMO amount,21506,Other,225% of NY Medicaid HMO DRG,21506,,225% x Medicaid HMO amount,21506,Other,225% of NY Medicaid HMO DRG,13381,,140% x Medicaid HMO amount,13381,Other,140% of NY Medicaid HMO DRG,21506,,225% x Medicaid HMO amount,21506,Other,225% of NY Medicaid HMO DRG,26285,,275% x Medicaid HMO amount,26285,Other,275% of NY Medicaid HMO DRG,30968,,324% x Medicaid HMO amount,30968,Other,324% of NY Medicaid HMO DRG,20550,,215% x Medicaid HMO amount,20550,Other,215% of NY Medicaid HMO DRG,20550,,215% x Medicaid HMO amount,20550,Other,215% of NY Medicaid HMO DRG,11948,,125% x Medicaid HMO amount,11948,Other,125% of NY Medicaid HMO DRG,0.01,50710,
"Other back & neck disorders, fractures & injuries",347-4,APR-DRG,,,,,,,,inpatient,,,298192,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,142392,,"45,128 x DRG weight",142392,Other,base rate x DRG weight,128153,,"40,615 x DRG weight",128153,Other,base rate x DRG weight,121034,,"38,359 x DRG weight",121034,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47160,,186% x Medicaid HMO amount,47160,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,107523,,"34,077 x DRG weight",107523,Other,base rate x DRG weight,91396,,"28,966 x DRG weight",91396,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25355,,DRG base rate x DRG weight + capital per discharge,25355,Other,100% of NY Medicaid HMO DRG,25355,,100% x Medicaid HMO amount,25355,Other,100% of NY Medicaid HMO DRG,25355,,100% x Medicaid HMO amount,25355,Other,100% of NY Medicaid HMO DRG,25355,,100% x Medicaid HMO amount,25355,Other,100% of NY Medicaid HMO DRG,57049,,225% x Medicaid HMO amount,57049,Other,225% of NY Medicaid HMO DRG,57049,,225% x Medicaid HMO amount,57049,Other,225% of NY Medicaid HMO DRG,57049,,225% x Medicaid HMO amount,57049,Other,225% of NY Medicaid HMO DRG,57049,,225% x Medicaid HMO amount,57049,Other,225% of NY Medicaid HMO DRG,35497,,140% x Medicaid HMO amount,35497,Other,140% of NY Medicaid HMO DRG,57049,,225% x Medicaid HMO amount,57049,Other,225% of NY Medicaid HMO DRG,69726,,275% x Medicaid HMO amount,69726,Other,275% of NY Medicaid HMO DRG,82150,,324% x Medicaid HMO amount,82150,Other,324% of NY Medicaid HMO DRG,54513,,215% x Medicaid HMO amount,54513,Other,215% of NY Medicaid HMO DRG,54513,,215% x Medicaid HMO amount,54513,Other,215% of NY Medicaid HMO DRG,31694,,125% x Medicaid HMO amount,31694,Other,125% of NY Medicaid HMO DRG,0.01,142392,
"Malfunction, reaction, complic of orthopedic device or procedure",349-1,APR-DRG,,,,,,,,inpatient,,,36523.08,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24545,,"45,128 x DRG weight",24545,Other,base rate x DRG weight,22090,,"40,615 x DRG weight",22090,Other,base rate x DRG weight,20863,,"38,359 x DRG weight",20863,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9393,,186% x Medicaid HMO amount,9393,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18534,,"34,077 x DRG weight",18534,Other,base rate x DRG weight,15755,,"28,966 x DRG weight",15755,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5050,,DRG base rate x DRG weight + capital per discharge,5050,Other,100% of NY Medicaid HMO DRG,5050,,100% x Medicaid HMO amount,5050,Other,100% of NY Medicaid HMO DRG,5050,,100% x Medicaid HMO amount,5050,Other,100% of NY Medicaid HMO DRG,5050,,100% x Medicaid HMO amount,5050,Other,100% of NY Medicaid HMO DRG,11363,,225% x Medicaid HMO amount,11363,Other,225% of NY Medicaid HMO DRG,11363,,225% x Medicaid HMO amount,11363,Other,225% of NY Medicaid HMO DRG,11363,,225% x Medicaid HMO amount,11363,Other,225% of NY Medicaid HMO DRG,11363,,225% x Medicaid HMO amount,11363,Other,225% of NY Medicaid HMO DRG,7070,,140% x Medicaid HMO amount,7070,Other,140% of NY Medicaid HMO DRG,11363,,225% x Medicaid HMO amount,11363,Other,225% of NY Medicaid HMO DRG,13888,,275% x Medicaid HMO amount,13888,Other,275% of NY Medicaid HMO DRG,16362,,324% x Medicaid HMO amount,16362,Other,324% of NY Medicaid HMO DRG,10858,,215% x Medicaid HMO amount,10858,Other,215% of NY Medicaid HMO DRG,10858,,215% x Medicaid HMO amount,10858,Other,215% of NY Medicaid HMO DRG,6313,,125% x Medicaid HMO amount,6313,Other,125% of NY Medicaid HMO DRG,0.01,24545,
"Malfunction, reaction, complic of orthopedic device or procedure",349-2,APR-DRG,,,,,,,,inpatient,,,71132.71,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39677,,"45,128 x DRG weight",39677,Other,base rate x DRG weight,35709,,"40,615 x DRG weight",35709,Other,base rate x DRG weight,33725,,"38,359 x DRG weight",33725,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14242,,186% x Medicaid HMO amount,14242,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29960,,"34,077 x DRG weight",29960,Other,base rate x DRG weight,25467,,"28,966 x DRG weight",25467,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7657,,DRG base rate x DRG weight + capital per discharge,7657,Other,100% of NY Medicaid HMO DRG,7657,,100% x Medicaid HMO amount,7657,Other,100% of NY Medicaid HMO DRG,7657,,100% x Medicaid HMO amount,7657,Other,100% of NY Medicaid HMO DRG,7657,,100% x Medicaid HMO amount,7657,Other,100% of NY Medicaid HMO DRG,17228,,225% x Medicaid HMO amount,17228,Other,225% of NY Medicaid HMO DRG,17228,,225% x Medicaid HMO amount,17228,Other,225% of NY Medicaid HMO DRG,17228,,225% x Medicaid HMO amount,17228,Other,225% of NY Medicaid HMO DRG,17228,,225% x Medicaid HMO amount,17228,Other,225% of NY Medicaid HMO DRG,10720,,140% x Medicaid HMO amount,10720,Other,140% of NY Medicaid HMO DRG,17228,,225% x Medicaid HMO amount,17228,Other,225% of NY Medicaid HMO DRG,21057,,275% x Medicaid HMO amount,21057,Other,275% of NY Medicaid HMO DRG,24809,,324% x Medicaid HMO amount,24809,Other,324% of NY Medicaid HMO DRG,16463,,215% x Medicaid HMO amount,16463,Other,215% of NY Medicaid HMO DRG,16463,,215% x Medicaid HMO amount,16463,Other,215% of NY Medicaid HMO DRG,9571,,125% x Medicaid HMO amount,9571,Other,125% of NY Medicaid HMO DRG,0.01,39677,
"Malfunction, reaction, complic of orthopedic device or procedure",349-3,APR-DRG,,,,,,,,inpatient,,,278226.59,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,70309,,"45,128 x DRG weight",70309,Other,base rate x DRG weight,63278,,"40,615 x DRG weight",63278,Other,base rate x DRG weight,59763,,"38,359 x DRG weight",59763,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24059,,186% x Medicaid HMO amount,24059,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53092,,"34,077 x DRG weight",53092,Other,base rate x DRG weight,45129,,"28,966 x DRG weight",45129,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12935,,DRG base rate x DRG weight + capital per discharge,12935,Other,100% of NY Medicaid HMO DRG,12935,,100% x Medicaid HMO amount,12935,Other,100% of NY Medicaid HMO DRG,12935,,100% x Medicaid HMO amount,12935,Other,100% of NY Medicaid HMO DRG,12935,,100% x Medicaid HMO amount,12935,Other,100% of NY Medicaid HMO DRG,29104,,225% x Medicaid HMO amount,29104,Other,225% of NY Medicaid HMO DRG,29104,,225% x Medicaid HMO amount,29104,Other,225% of NY Medicaid HMO DRG,29104,,225% x Medicaid HMO amount,29104,Other,225% of NY Medicaid HMO DRG,29104,,225% x Medicaid HMO amount,29104,Other,225% of NY Medicaid HMO DRG,18109,,140% x Medicaid HMO amount,18109,Other,140% of NY Medicaid HMO DRG,29104,,225% x Medicaid HMO amount,29104,Other,225% of NY Medicaid HMO DRG,35571,,275% x Medicaid HMO amount,35571,Other,275% of NY Medicaid HMO DRG,41909,,324% x Medicaid HMO amount,41909,Other,324% of NY Medicaid HMO DRG,27810,,215% x Medicaid HMO amount,27810,Other,215% of NY Medicaid HMO DRG,27810,,215% x Medicaid HMO amount,27810,Other,215% of NY Medicaid HMO DRG,16169,,125% x Medicaid HMO amount,16169,Other,125% of NY Medicaid HMO DRG,0.01,70309,
"Malfunction, reaction, complic of orthopedic device or procedure",349-4,APR-DRG,,,,,,,,inpatient,,,278226.59,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,161170,,"45,128 x DRG weight",161170,Other,base rate x DRG weight,145052,,"40,615 x DRG weight",145052,Other,base rate x DRG weight,136995,,"38,359 x DRG weight",136995,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53179,,186% x Medicaid HMO amount,53179,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,121703,,"34,077 x DRG weight",121703,Other,base rate x DRG weight,103449,,"28,966 x DRG weight",103449,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28591,,DRG base rate x DRG weight + capital per discharge,28591,Other,100% of NY Medicaid HMO DRG,28591,,100% x Medicaid HMO amount,28591,Other,100% of NY Medicaid HMO DRG,28591,,100% x Medicaid HMO amount,28591,Other,100% of NY Medicaid HMO DRG,28591,,100% x Medicaid HMO amount,28591,Other,100% of NY Medicaid HMO DRG,64330,,225% x Medicaid HMO amount,64330,Other,225% of NY Medicaid HMO DRG,64330,,225% x Medicaid HMO amount,64330,Other,225% of NY Medicaid HMO DRG,64330,,225% x Medicaid HMO amount,64330,Other,225% of NY Medicaid HMO DRG,64330,,225% x Medicaid HMO amount,64330,Other,225% of NY Medicaid HMO DRG,40027,,140% x Medicaid HMO amount,40027,Other,140% of NY Medicaid HMO DRG,64330,,225% x Medicaid HMO amount,64330,Other,225% of NY Medicaid HMO DRG,78625,,275% x Medicaid HMO amount,78625,Other,275% of NY Medicaid HMO DRG,92635,,324% x Medicaid HMO amount,92635,Other,324% of NY Medicaid HMO DRG,61471,,215% x Medicaid HMO amount,61471,Other,215% of NY Medicaid HMO DRG,61471,,215% x Medicaid HMO amount,61471,Other,215% of NY Medicaid HMO DRG,35739,,125% x Medicaid HMO amount,35739,Other,125% of NY Medicaid HMO DRG,0.01,161170,
Other musculoskeletal system & connective tissue diagnoses,351-1,APR-DRG,,,,,,,,inpatient,,,91941.21,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22153,,"45,128 x DRG weight",22153,Other,base rate x DRG weight,19938,,"40,615 x DRG weight",19938,Other,base rate x DRG weight,18830,,"38,359 x DRG weight",18830,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8627,,186% x Medicaid HMO amount,8627,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16728,,"34,077 x DRG weight",16728,Other,base rate x DRG weight,14219,,"28,966 x DRG weight",14219,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4638,,DRG base rate x DRG weight + capital per discharge,4638,Other,100% of NY Medicaid HMO DRG,4638,,100% x Medicaid HMO amount,4638,Other,100% of NY Medicaid HMO DRG,4638,,100% x Medicaid HMO amount,4638,Other,100% of NY Medicaid HMO DRG,4638,,100% x Medicaid HMO amount,4638,Other,100% of NY Medicaid HMO DRG,10436,,225% x Medicaid HMO amount,10436,Other,225% of NY Medicaid HMO DRG,10436,,225% x Medicaid HMO amount,10436,Other,225% of NY Medicaid HMO DRG,10436,,225% x Medicaid HMO amount,10436,Other,225% of NY Medicaid HMO DRG,10436,,225% x Medicaid HMO amount,10436,Other,225% of NY Medicaid HMO DRG,6493,,140% x Medicaid HMO amount,6493,Other,140% of NY Medicaid HMO DRG,10436,,225% x Medicaid HMO amount,10436,Other,225% of NY Medicaid HMO DRG,12755,,275% x Medicaid HMO amount,12755,Other,275% of NY Medicaid HMO DRG,15027,,324% x Medicaid HMO amount,15027,Other,324% of NY Medicaid HMO DRG,9972,,215% x Medicaid HMO amount,9972,Other,215% of NY Medicaid HMO DRG,9972,,215% x Medicaid HMO amount,9972,Other,215% of NY Medicaid HMO DRG,5798,,125% x Medicaid HMO amount,5798,Other,125% of NY Medicaid HMO DRG,0.01,22153,
Other musculoskeletal system & connective tissue diagnoses,351-2,APR-DRG,,,,,,,,inpatient,,,119058.79,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28828,,"45,128 x DRG weight",28828,Other,base rate x DRG weight,25945,,"40,615 x DRG weight",25945,Other,base rate x DRG weight,24504,,"38,359 x DRG weight",24504,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10766,,186% x Medicaid HMO amount,10766,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21768,,"34,077 x DRG weight",21768,Other,base rate x DRG weight,18503,,"28,966 x DRG weight",18503,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5788,,DRG base rate x DRG weight + capital per discharge,5788,Other,100% of NY Medicaid HMO DRG,5788,,100% x Medicaid HMO amount,5788,Other,100% of NY Medicaid HMO DRG,5788,,100% x Medicaid HMO amount,5788,Other,100% of NY Medicaid HMO DRG,5788,,100% x Medicaid HMO amount,5788,Other,100% of NY Medicaid HMO DRG,13023,,225% x Medicaid HMO amount,13023,Other,225% of NY Medicaid HMO DRG,13023,,225% x Medicaid HMO amount,13023,Other,225% of NY Medicaid HMO DRG,13023,,225% x Medicaid HMO amount,13023,Other,225% of NY Medicaid HMO DRG,13023,,225% x Medicaid HMO amount,13023,Other,225% of NY Medicaid HMO DRG,8103,,140% x Medicaid HMO amount,8103,Other,140% of NY Medicaid HMO DRG,13023,,225% x Medicaid HMO amount,13023,Other,225% of NY Medicaid HMO DRG,15917,,275% x Medicaid HMO amount,15917,Other,275% of NY Medicaid HMO DRG,18753,,324% x Medicaid HMO amount,18753,Other,324% of NY Medicaid HMO DRG,12444,,215% x Medicaid HMO amount,12444,Other,215% of NY Medicaid HMO DRG,12444,,215% x Medicaid HMO amount,12444,Other,215% of NY Medicaid HMO DRG,7235,,125% x Medicaid HMO amount,7235,Other,125% of NY Medicaid HMO DRG,0.01,28828,
Other musculoskeletal system & connective tissue diagnoses,351-3,APR-DRG,,,,,,,,inpatient,,,143633.73,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52109,,"45,128 x DRG weight",52109,Other,base rate x DRG weight,46898,,"40,615 x DRG weight",46898,Other,base rate x DRG weight,44293,,"38,359 x DRG weight",44293,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18226,,186% x Medicaid HMO amount,18226,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39349,,"34,077 x DRG weight",39349,Other,base rate x DRG weight,33447,,"28,966 x DRG weight",33447,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9799,,DRG base rate x DRG weight + capital per discharge,9799,Other,100% of NY Medicaid HMO DRG,9799,,100% x Medicaid HMO amount,9799,Other,100% of NY Medicaid HMO DRG,9799,,100% x Medicaid HMO amount,9799,Other,100% of NY Medicaid HMO DRG,9799,,100% x Medicaid HMO amount,9799,Other,100% of NY Medicaid HMO DRG,22048,,225% x Medicaid HMO amount,22048,Other,225% of NY Medicaid HMO DRG,22048,,225% x Medicaid HMO amount,22048,Other,225% of NY Medicaid HMO DRG,22048,,225% x Medicaid HMO amount,22048,Other,225% of NY Medicaid HMO DRG,22048,,225% x Medicaid HMO amount,22048,Other,225% of NY Medicaid HMO DRG,13719,,140% x Medicaid HMO amount,13719,Other,140% of NY Medicaid HMO DRG,22048,,225% x Medicaid HMO amount,22048,Other,225% of NY Medicaid HMO DRG,26947,,275% x Medicaid HMO amount,26947,Other,275% of NY Medicaid HMO DRG,31749,,324% x Medicaid HMO amount,31749,Other,324% of NY Medicaid HMO DRG,21068,,215% x Medicaid HMO amount,21068,Other,215% of NY Medicaid HMO DRG,21068,,215% x Medicaid HMO amount,21068,Other,215% of NY Medicaid HMO DRG,12249,,125% x Medicaid HMO amount,12249,Other,125% of NY Medicaid HMO DRG,0.01,52109,
Other musculoskeletal system & connective tissue diagnoses,351-4,APR-DRG,,,,,,,,inpatient,,,129634.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,139017,,"45,128 x DRG weight",139017,Other,base rate x DRG weight,125115,,"40,615 x DRG weight",125115,Other,base rate x DRG weight,118165,,"38,359 x DRG weight",118165,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46080,,186% x Medicaid HMO amount,46080,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,104974,,"34,077 x DRG weight",104974,Other,base rate x DRG weight,89230,,"28,966 x DRG weight",89230,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24774,,DRG base rate x DRG weight + capital per discharge,24774,Other,100% of NY Medicaid HMO DRG,24774,,100% x Medicaid HMO amount,24774,Other,100% of NY Medicaid HMO DRG,24774,,100% x Medicaid HMO amount,24774,Other,100% of NY Medicaid HMO DRG,24774,,100% x Medicaid HMO amount,24774,Other,100% of NY Medicaid HMO DRG,55742,,225% x Medicaid HMO amount,55742,Other,225% of NY Medicaid HMO DRG,55742,,225% x Medicaid HMO amount,55742,Other,225% of NY Medicaid HMO DRG,55742,,225% x Medicaid HMO amount,55742,Other,225% of NY Medicaid HMO DRG,55742,,225% x Medicaid HMO amount,55742,Other,225% of NY Medicaid HMO DRG,34684,,140% x Medicaid HMO amount,34684,Other,140% of NY Medicaid HMO DRG,55742,,225% x Medicaid HMO amount,55742,Other,225% of NY Medicaid HMO DRG,68129,,275% x Medicaid HMO amount,68129,Other,275% of NY Medicaid HMO DRG,80268,,324% x Medicaid HMO amount,80268,Other,324% of NY Medicaid HMO DRG,53264,,215% x Medicaid HMO amount,53264,Other,215% of NY Medicaid HMO DRG,53264,,215% x Medicaid HMO amount,53264,Other,215% of NY Medicaid HMO DRG,30968,,125% x Medicaid HMO amount,30968,Other,125% of NY Medicaid HMO DRG,0.01,139017,
Skin graft for skin & subcutaneous tissue diagnoses,361-1,APR-DRG,,,,,,,,inpatient,,,73123.42,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59853,,"45,128 x DRG weight",59853,Other,base rate x DRG weight,53868,,"40,615 x DRG weight",53868,Other,base rate x DRG weight,50876,,"38,359 x DRG weight",50876,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20709,,186% x Medicaid HMO amount,20709,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45196,,"34,077 x DRG weight",45196,Other,base rate x DRG weight,38418,,"28,966 x DRG weight",38418,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11134,,DRG base rate x DRG weight + capital per discharge,11134,Other,100% of NY Medicaid HMO DRG,11134,,100% x Medicaid HMO amount,11134,Other,100% of NY Medicaid HMO DRG,11134,,100% x Medicaid HMO amount,11134,Other,100% of NY Medicaid HMO DRG,11134,,100% x Medicaid HMO amount,11134,Other,100% of NY Medicaid HMO DRG,25052,,225% x Medicaid HMO amount,25052,Other,225% of NY Medicaid HMO DRG,25052,,225% x Medicaid HMO amount,25052,Other,225% of NY Medicaid HMO DRG,25052,,225% x Medicaid HMO amount,25052,Other,225% of NY Medicaid HMO DRG,25052,,225% x Medicaid HMO amount,25052,Other,225% of NY Medicaid HMO DRG,15588,,140% x Medicaid HMO amount,15588,Other,140% of NY Medicaid HMO DRG,25052,,225% x Medicaid HMO amount,25052,Other,225% of NY Medicaid HMO DRG,30619,,275% x Medicaid HMO amount,30619,Other,275% of NY Medicaid HMO DRG,36074,,324% x Medicaid HMO amount,36074,Other,324% of NY Medicaid HMO DRG,23938,,215% x Medicaid HMO amount,23938,Other,215% of NY Medicaid HMO DRG,23938,,215% x Medicaid HMO amount,23938,Other,215% of NY Medicaid HMO DRG,13918,,125% x Medicaid HMO amount,13918,Other,125% of NY Medicaid HMO DRG,0.01,59853,
Skin graft for skin & subcutaneous tissue diagnoses,361-2,APR-DRG,,,,,,,,inpatient,,,339404.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,84746,,"45,128 x DRG weight",84746,Other,base rate x DRG weight,76271,,"40,615 x DRG weight",76271,Other,base rate x DRG weight,72034,,"38,359 x DRG weight",72034,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28687,,186% x Medicaid HMO amount,28687,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,63993,,"34,077 x DRG weight",63993,Other,base rate x DRG weight,54395,,"28,966 x DRG weight",54395,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15423,,DRG base rate x DRG weight + capital per discharge,15423,Other,100% of NY Medicaid HMO DRG,15423,,100% x Medicaid HMO amount,15423,Other,100% of NY Medicaid HMO DRG,15423,,100% x Medicaid HMO amount,15423,Other,100% of NY Medicaid HMO DRG,15423,,100% x Medicaid HMO amount,15423,Other,100% of NY Medicaid HMO DRG,34702,,225% x Medicaid HMO amount,34702,Other,225% of NY Medicaid HMO DRG,34702,,225% x Medicaid HMO amount,34702,Other,225% of NY Medicaid HMO DRG,34702,,225% x Medicaid HMO amount,34702,Other,225% of NY Medicaid HMO DRG,34702,,225% x Medicaid HMO amount,34702,Other,225% of NY Medicaid HMO DRG,21592,,140% x Medicaid HMO amount,21592,Other,140% of NY Medicaid HMO DRG,34702,,225% x Medicaid HMO amount,34702,Other,225% of NY Medicaid HMO DRG,42413,,275% x Medicaid HMO amount,42413,Other,275% of NY Medicaid HMO DRG,49971,,324% x Medicaid HMO amount,49971,Other,324% of NY Medicaid HMO DRG,33159,,215% x Medicaid HMO amount,33159,Other,215% of NY Medicaid HMO DRG,33159,,215% x Medicaid HMO amount,33159,Other,215% of NY Medicaid HMO DRG,19279,,125% x Medicaid HMO amount,19279,Other,125% of NY Medicaid HMO DRG,0.01,84746,
Skin graft for skin & subcutaneous tissue diagnoses,361-3,APR-DRG,,,,,,,,inpatient,,,532079.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,150718,,"45,128 x DRG weight",150718,Other,base rate x DRG weight,135646,,"40,615 x DRG weight",135646,Other,base rate x DRG weight,128111,,"38,359 x DRG weight",128111,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49829,,186% x Medicaid HMO amount,49829,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,113810,,"34,077 x DRG weight",113810,Other,base rate x DRG weight,96741,,"28,966 x DRG weight",96741,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26790,,DRG base rate x DRG weight + capital per discharge,26790,Other,100% of NY Medicaid HMO DRG,26790,,100% x Medicaid HMO amount,26790,Other,100% of NY Medicaid HMO DRG,26790,,100% x Medicaid HMO amount,26790,Other,100% of NY Medicaid HMO DRG,26790,,100% x Medicaid HMO amount,26790,Other,100% of NY Medicaid HMO DRG,60278,,225% x Medicaid HMO amount,60278,Other,225% of NY Medicaid HMO DRG,60278,,225% x Medicaid HMO amount,60278,Other,225% of NY Medicaid HMO DRG,60278,,225% x Medicaid HMO amount,60278,Other,225% of NY Medicaid HMO DRG,60278,,225% x Medicaid HMO amount,60278,Other,225% of NY Medicaid HMO DRG,37506,,140% x Medicaid HMO amount,37506,Other,140% of NY Medicaid HMO DRG,60278,,225% x Medicaid HMO amount,60278,Other,225% of NY Medicaid HMO DRG,73673,,275% x Medicaid HMO amount,73673,Other,275% of NY Medicaid HMO DRG,86800,,324% x Medicaid HMO amount,86800,Other,324% of NY Medicaid HMO DRG,57599,,215% x Medicaid HMO amount,57599,Other,215% of NY Medicaid HMO DRG,57599,,215% x Medicaid HMO amount,57599,Other,215% of NY Medicaid HMO DRG,33488,,125% x Medicaid HMO amount,33488,Other,125% of NY Medicaid HMO DRG,0.01,150718,
Skin graft for skin & subcutaneous tissue diagnoses,361-4,APR-DRG,,,,,,,,inpatient,,,2455045.84,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,433251,,"45,128 x DRG weight",433251,Other,base rate x DRG weight,389924,,"40,615 x DRG weight",389924,Other,base rate x DRG weight,368266,,"38,359 x DRG weight",368266,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,140376,,186% x Medicaid HMO amount,140376,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,327156,,"34,077 x DRG weight",327156,Other,base rate x DRG weight,278088,,"28,966 x DRG weight",278088,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,75471,,DRG base rate x DRG weight + capital per discharge,75471,Other,100% of NY Medicaid HMO DRG,75471,,100% x Medicaid HMO amount,75471,Other,100% of NY Medicaid HMO DRG,75471,,100% x Medicaid HMO amount,75471,Other,100% of NY Medicaid HMO DRG,75471,,100% x Medicaid HMO amount,75471,Other,100% of NY Medicaid HMO DRG,169810,,225% x Medicaid HMO amount,169810,Other,225% of NY Medicaid HMO DRG,169810,,225% x Medicaid HMO amount,169810,Other,225% of NY Medicaid HMO DRG,169810,,225% x Medicaid HMO amount,169810,Other,225% of NY Medicaid HMO DRG,169810,,225% x Medicaid HMO amount,169810,Other,225% of NY Medicaid HMO DRG,105659,,140% x Medicaid HMO amount,105659,Other,140% of NY Medicaid HMO DRG,169810,,225% x Medicaid HMO amount,169810,Other,225% of NY Medicaid HMO DRG,207545,,275% x Medicaid HMO amount,207545,Other,275% of NY Medicaid HMO DRG,244526,,324% x Medicaid HMO amount,244526,Other,324% of NY Medicaid HMO DRG,162263,,215% x Medicaid HMO amount,162263,Other,215% of NY Medicaid HMO DRG,162263,,215% x Medicaid HMO amount,162263,Other,215% of NY Medicaid HMO DRG,94339,,125% x Medicaid HMO amount,94339,Other,125% of NY Medicaid HMO DRG,0.01,433251,
Mastectomy procedures,362-1,APR-DRG,,,,,,,,inpatient,,,148774.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,61541,,"45,128 x DRG weight",61541,Other,base rate x DRG weight,55387,,"40,615 x DRG weight",55387,Other,base rate x DRG weight,52310,,"38,359 x DRG weight",52310,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21249,,186% x Medicaid HMO amount,21249,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46471,,"34,077 x DRG weight",46471,Other,base rate x DRG weight,39501,,"28,966 x DRG weight",39501,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11424,,DRG base rate x DRG weight + capital per discharge,11424,Other,100% of NY Medicaid HMO DRG,11424,,100% x Medicaid HMO amount,11424,Other,100% of NY Medicaid HMO DRG,11424,,100% x Medicaid HMO amount,11424,Other,100% of NY Medicaid HMO DRG,11424,,100% x Medicaid HMO amount,11424,Other,100% of NY Medicaid HMO DRG,25704,,225% x Medicaid HMO amount,25704,Other,225% of NY Medicaid HMO DRG,25704,,225% x Medicaid HMO amount,25704,Other,225% of NY Medicaid HMO DRG,25704,,225% x Medicaid HMO amount,25704,Other,225% of NY Medicaid HMO DRG,25704,,225% x Medicaid HMO amount,25704,Other,225% of NY Medicaid HMO DRG,15994,,140% x Medicaid HMO amount,15994,Other,140% of NY Medicaid HMO DRG,25704,,225% x Medicaid HMO amount,25704,Other,225% of NY Medicaid HMO DRG,31416,,275% x Medicaid HMO amount,31416,Other,275% of NY Medicaid HMO DRG,37014,,324% x Medicaid HMO amount,37014,Other,324% of NY Medicaid HMO DRG,24562,,215% x Medicaid HMO amount,24562,Other,215% of NY Medicaid HMO DRG,24562,,215% x Medicaid HMO amount,24562,Other,215% of NY Medicaid HMO DRG,14280,,125% x Medicaid HMO amount,14280,Other,125% of NY Medicaid HMO DRG,0.01,61541,
Mastectomy procedures,362-2,APR-DRG,,,,,,,,inpatient,,,276151.19,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,81470,,"45,128 x DRG weight",81470,Other,base rate x DRG weight,73322,,"40,615 x DRG weight",73322,Other,base rate x DRG weight,69250,,"38,359 x DRG weight",69250,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27636,,186% x Medicaid HMO amount,27636,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,61519,,"34,077 x DRG weight",61519,Other,base rate x DRG weight,52292,,"28,966 x DRG weight",52292,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14858,,DRG base rate x DRG weight + capital per discharge,14858,Other,100% of NY Medicaid HMO DRG,14858,,100% x Medicaid HMO amount,14858,Other,100% of NY Medicaid HMO DRG,14858,,100% x Medicaid HMO amount,14858,Other,100% of NY Medicaid HMO DRG,14858,,100% x Medicaid HMO amount,14858,Other,100% of NY Medicaid HMO DRG,33431,,225% x Medicaid HMO amount,33431,Other,225% of NY Medicaid HMO DRG,33431,,225% x Medicaid HMO amount,33431,Other,225% of NY Medicaid HMO DRG,33431,,225% x Medicaid HMO amount,33431,Other,225% of NY Medicaid HMO DRG,33431,,225% x Medicaid HMO amount,33431,Other,225% of NY Medicaid HMO DRG,20801,,140% x Medicaid HMO amount,20801,Other,140% of NY Medicaid HMO DRG,33431,,225% x Medicaid HMO amount,33431,Other,225% of NY Medicaid HMO DRG,40860,,275% x Medicaid HMO amount,40860,Other,275% of NY Medicaid HMO DRG,48140,,324% x Medicaid HMO amount,48140,Other,324% of NY Medicaid HMO DRG,31945,,215% x Medicaid HMO amount,31945,Other,215% of NY Medicaid HMO DRG,31945,,215% x Medicaid HMO amount,31945,Other,215% of NY Medicaid HMO DRG,18573,,125% x Medicaid HMO amount,18573,Other,125% of NY Medicaid HMO DRG,0.01,81470,
Mastectomy procedures,362-3,APR-DRG,,,,,,,,inpatient,,,148774.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,125379,,"45,128 x DRG weight",125379,Other,base rate x DRG weight,112841,,"40,615 x DRG weight",112841,Other,base rate x DRG weight,106573,,"38,359 x DRG weight",106573,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41709,,186% x Medicaid HMO amount,41709,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,94676,,"34,077 x DRG weight",94676,Other,base rate x DRG weight,80476,,"28,966 x DRG weight",80476,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22424,,DRG base rate x DRG weight + capital per discharge,22424,Other,100% of NY Medicaid HMO DRG,22424,,100% x Medicaid HMO amount,22424,Other,100% of NY Medicaid HMO DRG,22424,,100% x Medicaid HMO amount,22424,Other,100% of NY Medicaid HMO DRG,22424,,100% x Medicaid HMO amount,22424,Other,100% of NY Medicaid HMO DRG,50454,,225% x Medicaid HMO amount,50454,Other,225% of NY Medicaid HMO DRG,50454,,225% x Medicaid HMO amount,50454,Other,225% of NY Medicaid HMO DRG,50454,,225% x Medicaid HMO amount,50454,Other,225% of NY Medicaid HMO DRG,50454,,225% x Medicaid HMO amount,50454,Other,225% of NY Medicaid HMO DRG,31394,,140% x Medicaid HMO amount,31394,Other,140% of NY Medicaid HMO DRG,50454,,225% x Medicaid HMO amount,50454,Other,225% of NY Medicaid HMO DRG,61666,,275% x Medicaid HMO amount,61666,Other,275% of NY Medicaid HMO DRG,72654,,324% x Medicaid HMO amount,72654,Other,324% of NY Medicaid HMO DRG,48212,,215% x Medicaid HMO amount,48212,Other,215% of NY Medicaid HMO DRG,48212,,215% x Medicaid HMO amount,48212,Other,215% of NY Medicaid HMO DRG,28030,,125% x Medicaid HMO amount,28030,Other,125% of NY Medicaid HMO DRG,0.01,125379,
Mastectomy procedures,362-4,APR-DRG,,,,,,,,inpatient,,,148774.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,131038,,"45,128 x DRG weight",131038,Other,base rate x DRG weight,117934,,"40,615 x DRG weight",117934,Other,base rate x DRG weight,111383,,"38,359 x DRG weight",111383,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43522,,186% x Medicaid HMO amount,43522,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,98949,,"34,077 x DRG weight",98949,Other,base rate x DRG weight,84109,,"28,966 x DRG weight",84109,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23399,,DRG base rate x DRG weight + capital per discharge,23399,Other,100% of NY Medicaid HMO DRG,23399,,100% x Medicaid HMO amount,23399,Other,100% of NY Medicaid HMO DRG,23399,,100% x Medicaid HMO amount,23399,Other,100% of NY Medicaid HMO DRG,23399,,100% x Medicaid HMO amount,23399,Other,100% of NY Medicaid HMO DRG,52648,,225% x Medicaid HMO amount,52648,Other,225% of NY Medicaid HMO DRG,52648,,225% x Medicaid HMO amount,52648,Other,225% of NY Medicaid HMO DRG,52648,,225% x Medicaid HMO amount,52648,Other,225% of NY Medicaid HMO DRG,52648,,225% x Medicaid HMO amount,52648,Other,225% of NY Medicaid HMO DRG,32759,,140% x Medicaid HMO amount,32759,Other,140% of NY Medicaid HMO DRG,52648,,225% x Medicaid HMO amount,52648,Other,225% of NY Medicaid HMO DRG,64347,,275% x Medicaid HMO amount,64347,Other,275% of NY Medicaid HMO DRG,75813,,324% x Medicaid HMO amount,75813,Other,324% of NY Medicaid HMO DRG,50308,,215% x Medicaid HMO amount,50308,Other,215% of NY Medicaid HMO DRG,50308,,215% x Medicaid HMO amount,50308,Other,215% of NY Medicaid HMO DRG,29249,,125% x Medicaid HMO amount,29249,Other,125% of NY Medicaid HMO DRG,0.01,131038,
Breast procedures except mastectomy,363-1,APR-DRG,,,,,,,,inpatient,,,92974.07,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40854,,"45,128 x DRG weight",40854,Other,base rate x DRG weight,36769,,"40,615 x DRG weight",36769,Other,base rate x DRG weight,34726,,"38,359 x DRG weight",34726,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14620,,186% x Medicaid HMO amount,14620,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30850,,"34,077 x DRG weight",30850,Other,base rate x DRG weight,26223,,"28,966 x DRG weight",26223,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7860,,DRG base rate x DRG weight + capital per discharge,7860,Other,100% of NY Medicaid HMO DRG,7860,,100% x Medicaid HMO amount,7860,Other,100% of NY Medicaid HMO DRG,7860,,100% x Medicaid HMO amount,7860,Other,100% of NY Medicaid HMO DRG,7860,,100% x Medicaid HMO amount,7860,Other,100% of NY Medicaid HMO DRG,17685,,225% x Medicaid HMO amount,17685,Other,225% of NY Medicaid HMO DRG,17685,,225% x Medicaid HMO amount,17685,Other,225% of NY Medicaid HMO DRG,17685,,225% x Medicaid HMO amount,17685,Other,225% of NY Medicaid HMO DRG,17685,,225% x Medicaid HMO amount,17685,Other,225% of NY Medicaid HMO DRG,11004,,140% x Medicaid HMO amount,11004,Other,140% of NY Medicaid HMO DRG,17685,,225% x Medicaid HMO amount,17685,Other,225% of NY Medicaid HMO DRG,21615,,275% x Medicaid HMO amount,21615,Other,275% of NY Medicaid HMO DRG,25466,,324% x Medicaid HMO amount,25466,Other,324% of NY Medicaid HMO DRG,16899,,215% x Medicaid HMO amount,16899,Other,215% of NY Medicaid HMO DRG,16899,,215% x Medicaid HMO amount,16899,Other,215% of NY Medicaid HMO DRG,9825,,125% x Medicaid HMO amount,9825,Other,125% of NY Medicaid HMO DRG,0.01,40854,
Breast procedures except mastectomy,363-2,APR-DRG,,,,,,,,inpatient,,,185533.18,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,68522,,"45,128 x DRG weight",68522,Other,base rate x DRG weight,61670,,"40,615 x DRG weight",61670,Other,base rate x DRG weight,58244,,"38,359 x DRG weight",58244,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23486,,186% x Medicaid HMO amount,23486,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51743,,"34,077 x DRG weight",51743,Other,base rate x DRG weight,43982,,"28,966 x DRG weight",43982,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12627,,DRG base rate x DRG weight + capital per discharge,12627,Other,100% of NY Medicaid HMO DRG,12627,,100% x Medicaid HMO amount,12627,Other,100% of NY Medicaid HMO DRG,12627,,100% x Medicaid HMO amount,12627,Other,100% of NY Medicaid HMO DRG,12627,,100% x Medicaid HMO amount,12627,Other,100% of NY Medicaid HMO DRG,28411,,225% x Medicaid HMO amount,28411,Other,225% of NY Medicaid HMO DRG,28411,,225% x Medicaid HMO amount,28411,Other,225% of NY Medicaid HMO DRG,28411,,225% x Medicaid HMO amount,28411,Other,225% of NY Medicaid HMO DRG,28411,,225% x Medicaid HMO amount,28411,Other,225% of NY Medicaid HMO DRG,17678,,140% x Medicaid HMO amount,17678,Other,140% of NY Medicaid HMO DRG,28411,,225% x Medicaid HMO amount,28411,Other,225% of NY Medicaid HMO DRG,34724,,275% x Medicaid HMO amount,34724,Other,275% of NY Medicaid HMO DRG,40911,,324% x Medicaid HMO amount,40911,Other,324% of NY Medicaid HMO DRG,27148,,215% x Medicaid HMO amount,27148,Other,215% of NY Medicaid HMO DRG,27148,,215% x Medicaid HMO amount,27148,Other,215% of NY Medicaid HMO DRG,15784,,125% x Medicaid HMO amount,15784,Other,125% of NY Medicaid HMO DRG,0.01,68522,
Breast procedures except mastectomy,363-3,APR-DRG,,,,,,,,inpatient,,,185533.18,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,103582,,"45,128 x DRG weight",103582,Other,base rate x DRG weight,93224,,"40,615 x DRG weight",93224,Other,base rate x DRG weight,88045,,"38,359 x DRG weight",88045,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34722,,186% x Medicaid HMO amount,34722,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,78217,,"34,077 x DRG weight",78217,Other,base rate x DRG weight,66486,,"28,966 x DRG weight",66486,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18668,,DRG base rate x DRG weight + capital per discharge,18668,Other,100% of NY Medicaid HMO DRG,18668,,100% x Medicaid HMO amount,18668,Other,100% of NY Medicaid HMO DRG,18668,,100% x Medicaid HMO amount,18668,Other,100% of NY Medicaid HMO DRG,18668,,100% x Medicaid HMO amount,18668,Other,100% of NY Medicaid HMO DRG,42003,,225% x Medicaid HMO amount,42003,Other,225% of NY Medicaid HMO DRG,42003,,225% x Medicaid HMO amount,42003,Other,225% of NY Medicaid HMO DRG,42003,,225% x Medicaid HMO amount,42003,Other,225% of NY Medicaid HMO DRG,42003,,225% x Medicaid HMO amount,42003,Other,225% of NY Medicaid HMO DRG,26135,,140% x Medicaid HMO amount,26135,Other,140% of NY Medicaid HMO DRG,42003,,225% x Medicaid HMO amount,42003,Other,225% of NY Medicaid HMO DRG,51337,,275% x Medicaid HMO amount,51337,Other,275% of NY Medicaid HMO DRG,60484,,324% x Medicaid HMO amount,60484,Other,324% of NY Medicaid HMO DRG,40136,,215% x Medicaid HMO amount,40136,Other,215% of NY Medicaid HMO DRG,40136,,215% x Medicaid HMO amount,40136,Other,215% of NY Medicaid HMO DRG,23335,,125% x Medicaid HMO amount,23335,Other,125% of NY Medicaid HMO DRG,0.01,103582,
Breast procedures except mastectomy,363-4,APR-DRG,,,,,,,,inpatient,,,185533.18,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,106516,,"45,128 x DRG weight",106516,Other,base rate x DRG weight,95864,,"40,615 x DRG weight",95864,Other,base rate x DRG weight,90539,,"38,359 x DRG weight",90539,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35664,,186% x Medicaid HMO amount,35664,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,80432,,"34,077 x DRG weight",80432,Other,base rate x DRG weight,68368,,"28,966 x DRG weight",68368,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19174,,DRG base rate x DRG weight + capital per discharge,19174,Other,100% of NY Medicaid HMO DRG,19174,,100% x Medicaid HMO amount,19174,Other,100% of NY Medicaid HMO DRG,19174,,100% x Medicaid HMO amount,19174,Other,100% of NY Medicaid HMO DRG,19174,,100% x Medicaid HMO amount,19174,Other,100% of NY Medicaid HMO DRG,43142,,225% x Medicaid HMO amount,43142,Other,225% of NY Medicaid HMO DRG,43142,,225% x Medicaid HMO amount,43142,Other,225% of NY Medicaid HMO DRG,43142,,225% x Medicaid HMO amount,43142,Other,225% of NY Medicaid HMO DRG,43142,,225% x Medicaid HMO amount,43142,Other,225% of NY Medicaid HMO DRG,26844,,140% x Medicaid HMO amount,26844,Other,140% of NY Medicaid HMO DRG,43142,,225% x Medicaid HMO amount,43142,Other,225% of NY Medicaid HMO DRG,52729,,275% x Medicaid HMO amount,52729,Other,275% of NY Medicaid HMO DRG,62124,,324% x Medicaid HMO amount,62124,Other,324% of NY Medicaid HMO DRG,41224,,215% x Medicaid HMO amount,41224,Other,215% of NY Medicaid HMO DRG,41224,,215% x Medicaid HMO amount,41224,Other,215% of NY Medicaid HMO DRG,23968,,125% x Medicaid HMO amount,23968,Other,125% of NY Medicaid HMO DRG,0.01,106516,
"Other skin, subcutaneous tissue & related procedures",364-1,APR-DRG,,,,,,,,inpatient,,,100955.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34726,,"45,128 x DRG weight",34726,Other,base rate x DRG weight,31253,,"40,615 x DRG weight",31253,Other,base rate x DRG weight,29517,,"38,359 x DRG weight",29517,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12655,,186% x Medicaid HMO amount,12655,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26222,,"34,077 x DRG weight",26222,Other,base rate x DRG weight,22289,,"28,966 x DRG weight",22289,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6804,,DRG base rate x DRG weight + capital per discharge,6804,Other,100% of NY Medicaid HMO DRG,6804,,100% x Medicaid HMO amount,6804,Other,100% of NY Medicaid HMO DRG,6804,,100% x Medicaid HMO amount,6804,Other,100% of NY Medicaid HMO DRG,6804,,100% x Medicaid HMO amount,6804,Other,100% of NY Medicaid HMO DRG,15309,,225% x Medicaid HMO amount,15309,Other,225% of NY Medicaid HMO DRG,15309,,225% x Medicaid HMO amount,15309,Other,225% of NY Medicaid HMO DRG,15309,,225% x Medicaid HMO amount,15309,Other,225% of NY Medicaid HMO DRG,15309,,225% x Medicaid HMO amount,15309,Other,225% of NY Medicaid HMO DRG,9526,,140% x Medicaid HMO amount,9526,Other,140% of NY Medicaid HMO DRG,15309,,225% x Medicaid HMO amount,15309,Other,225% of NY Medicaid HMO DRG,18711,,275% x Medicaid HMO amount,18711,Other,275% of NY Medicaid HMO DRG,22045,,324% x Medicaid HMO amount,22045,Other,324% of NY Medicaid HMO DRG,14629,,215% x Medicaid HMO amount,14629,Other,215% of NY Medicaid HMO DRG,14629,,215% x Medicaid HMO amount,14629,Other,215% of NY Medicaid HMO DRG,8505,,125% x Medicaid HMO amount,8505,Other,125% of NY Medicaid HMO DRG,0.01,34726,
"Other skin, subcutaneous tissue & related procedures",364-2,APR-DRG,,,,,,,,inpatient,,,164365.11,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50083,,"45,128 x DRG weight",50083,Other,base rate x DRG weight,45075,,"40,615 x DRG weight",45075,Other,base rate x DRG weight,42571,,"38,359 x DRG weight",42571,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17577,,186% x Medicaid HMO amount,17577,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37819,,"34,077 x DRG weight",37819,Other,base rate x DRG weight,32146,,"28,966 x DRG weight",32146,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9450,,DRG base rate x DRG weight + capital per discharge,9450,Other,100% of NY Medicaid HMO DRG,9450,,100% x Medicaid HMO amount,9450,Other,100% of NY Medicaid HMO DRG,9450,,100% x Medicaid HMO amount,9450,Other,100% of NY Medicaid HMO DRG,9450,,100% x Medicaid HMO amount,9450,Other,100% of NY Medicaid HMO DRG,21263,,225% x Medicaid HMO amount,21263,Other,225% of NY Medicaid HMO DRG,21263,,225% x Medicaid HMO amount,21263,Other,225% of NY Medicaid HMO DRG,21263,,225% x Medicaid HMO amount,21263,Other,225% of NY Medicaid HMO DRG,21263,,225% x Medicaid HMO amount,21263,Other,225% of NY Medicaid HMO DRG,13230,,140% x Medicaid HMO amount,13230,Other,140% of NY Medicaid HMO DRG,21263,,225% x Medicaid HMO amount,21263,Other,225% of NY Medicaid HMO DRG,25988,,275% x Medicaid HMO amount,25988,Other,275% of NY Medicaid HMO DRG,30618,,324% x Medicaid HMO amount,30618,Other,324% of NY Medicaid HMO DRG,20318,,215% x Medicaid HMO amount,20318,Other,215% of NY Medicaid HMO DRG,20318,,215% x Medicaid HMO amount,20318,Other,215% of NY Medicaid HMO DRG,11813,,125% x Medicaid HMO amount,11813,Other,125% of NY Medicaid HMO DRG,0.01,50083,
"Other skin, subcutaneous tissue & related procedures",364-3,APR-DRG,,,,,,,,inpatient,,,354842.22,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,91298,,"45,128 x DRG weight",91298,Other,base rate x DRG weight,82168,,"40,615 x DRG weight",82168,Other,base rate x DRG weight,77604,,"38,359 x DRG weight",77604,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30787,,186% x Medicaid HMO amount,30787,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,68941,,"34,077 x DRG weight",68941,Other,base rate x DRG weight,58601,,"28,966 x DRG weight",58601,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16552,,DRG base rate x DRG weight + capital per discharge,16552,Other,100% of NY Medicaid HMO DRG,16552,,100% x Medicaid HMO amount,16552,Other,100% of NY Medicaid HMO DRG,16552,,100% x Medicaid HMO amount,16552,Other,100% of NY Medicaid HMO DRG,16552,,100% x Medicaid HMO amount,16552,Other,100% of NY Medicaid HMO DRG,37242,,225% x Medicaid HMO amount,37242,Other,225% of NY Medicaid HMO DRG,37242,,225% x Medicaid HMO amount,37242,Other,225% of NY Medicaid HMO DRG,37242,,225% x Medicaid HMO amount,37242,Other,225% of NY Medicaid HMO DRG,37242,,225% x Medicaid HMO amount,37242,Other,225% of NY Medicaid HMO DRG,23173,,140% x Medicaid HMO amount,23173,Other,140% of NY Medicaid HMO DRG,37242,,225% x Medicaid HMO amount,37242,Other,225% of NY Medicaid HMO DRG,45518,,275% x Medicaid HMO amount,45518,Other,275% of NY Medicaid HMO DRG,53628,,324% x Medicaid HMO amount,53628,Other,324% of NY Medicaid HMO DRG,35587,,215% x Medicaid HMO amount,35587,Other,215% of NY Medicaid HMO DRG,35587,,215% x Medicaid HMO amount,35587,Other,215% of NY Medicaid HMO DRG,20690,,125% x Medicaid HMO amount,20690,Other,125% of NY Medicaid HMO DRG,0.01,91298,
"Other skin, subcutaneous tissue & related procedures",364-4,APR-DRG,,,,,,,,inpatient,,,328437.61,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,239598,,"45,128 x DRG weight",239598,Other,base rate x DRG weight,215637,,"40,615 x DRG weight",215637,Other,base rate x DRG weight,203659,,"38,359 x DRG weight",203659,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,78313,,186% x Medicaid HMO amount,78313,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,180925,,"34,077 x DRG weight",180925,Other,base rate x DRG weight,153789,,"28,966 x DRG weight",153789,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42104,,DRG base rate x DRG weight + capital per discharge,42104,Other,100% of NY Medicaid HMO DRG,42104,,100% x Medicaid HMO amount,42104,Other,100% of NY Medicaid HMO DRG,42104,,100% x Medicaid HMO amount,42104,Other,100% of NY Medicaid HMO DRG,42104,,100% x Medicaid HMO amount,42104,Other,100% of NY Medicaid HMO DRG,94734,,225% x Medicaid HMO amount,94734,Other,225% of NY Medicaid HMO DRG,94734,,225% x Medicaid HMO amount,94734,Other,225% of NY Medicaid HMO DRG,94734,,225% x Medicaid HMO amount,94734,Other,225% of NY Medicaid HMO DRG,94734,,225% x Medicaid HMO amount,94734,Other,225% of NY Medicaid HMO DRG,58946,,140% x Medicaid HMO amount,58946,Other,140% of NY Medicaid HMO DRG,94734,,225% x Medicaid HMO amount,94734,Other,225% of NY Medicaid HMO DRG,115786,,275% x Medicaid HMO amount,115786,Other,275% of NY Medicaid HMO DRG,136417,,324% x Medicaid HMO amount,136417,Other,324% of NY Medicaid HMO DRG,90524,,215% x Medicaid HMO amount,90524,Other,215% of NY Medicaid HMO DRG,90524,,215% x Medicaid HMO amount,90524,Other,215% of NY Medicaid HMO DRG,52630,,125% x Medicaid HMO amount,52630,Other,125% of NY Medicaid HMO DRG,0.01,239598,
Skin ulcers,380-1,APR-DRG,,,,,,,,inpatient,,,60201.94,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30980,,"45,128 x DRG weight",30980,Other,base rate x DRG weight,27882,,"40,615 x DRG weight",27882,Other,base rate x DRG weight,26333,,"38,359 x DRG weight",26333,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11456,,186% x Medicaid HMO amount,11456,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23394,,"34,077 x DRG weight",23394,Other,base rate x DRG weight,19885,,"28,966 x DRG weight",19885,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6159,,DRG base rate x DRG weight + capital per discharge,6159,Other,100% of NY Medicaid HMO DRG,6159,,100% x Medicaid HMO amount,6159,Other,100% of NY Medicaid HMO DRG,6159,,100% x Medicaid HMO amount,6159,Other,100% of NY Medicaid HMO DRG,6159,,100% x Medicaid HMO amount,6159,Other,100% of NY Medicaid HMO DRG,13858,,225% x Medicaid HMO amount,13858,Other,225% of NY Medicaid HMO DRG,13858,,225% x Medicaid HMO amount,13858,Other,225% of NY Medicaid HMO DRG,13858,,225% x Medicaid HMO amount,13858,Other,225% of NY Medicaid HMO DRG,13858,,225% x Medicaid HMO amount,13858,Other,225% of NY Medicaid HMO DRG,8623,,140% x Medicaid HMO amount,8623,Other,140% of NY Medicaid HMO DRG,13858,,225% x Medicaid HMO amount,13858,Other,225% of NY Medicaid HMO DRG,16937,,275% x Medicaid HMO amount,16937,Other,275% of NY Medicaid HMO DRG,19955,,324% x Medicaid HMO amount,19955,Other,324% of NY Medicaid HMO DRG,13242,,215% x Medicaid HMO amount,13242,Other,215% of NY Medicaid HMO DRG,13242,,215% x Medicaid HMO amount,13242,Other,215% of NY Medicaid HMO DRG,7699,,125% x Medicaid HMO amount,7699,Other,125% of NY Medicaid HMO DRG,0.01,30980,
Skin ulcers,380-2,APR-DRG,,,,,,,,inpatient,,,102054.89,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37650,,"45,128 x DRG weight",37650,Other,base rate x DRG weight,33885,,"40,615 x DRG weight",33885,Other,base rate x DRG weight,32003,,"38,359 x DRG weight",32003,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13593,,186% x Medicaid HMO amount,13593,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28430,,"34,077 x DRG weight",28430,Other,base rate x DRG weight,24166,,"28,966 x DRG weight",24166,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7308,,DRG base rate x DRG weight + capital per discharge,7308,Other,100% of NY Medicaid HMO DRG,7308,,100% x Medicaid HMO amount,7308,Other,100% of NY Medicaid HMO DRG,7308,,100% x Medicaid HMO amount,7308,Other,100% of NY Medicaid HMO DRG,7308,,100% x Medicaid HMO amount,7308,Other,100% of NY Medicaid HMO DRG,16443,,225% x Medicaid HMO amount,16443,Other,225% of NY Medicaid HMO DRG,16443,,225% x Medicaid HMO amount,16443,Other,225% of NY Medicaid HMO DRG,16443,,225% x Medicaid HMO amount,16443,Other,225% of NY Medicaid HMO DRG,16443,,225% x Medicaid HMO amount,16443,Other,225% of NY Medicaid HMO DRG,10231,,140% x Medicaid HMO amount,10231,Other,140% of NY Medicaid HMO DRG,16443,,225% x Medicaid HMO amount,16443,Other,225% of NY Medicaid HMO DRG,20097,,275% x Medicaid HMO amount,20097,Other,275% of NY Medicaid HMO DRG,23678,,324% x Medicaid HMO amount,23678,Other,324% of NY Medicaid HMO DRG,15712,,215% x Medicaid HMO amount,15712,Other,215% of NY Medicaid HMO DRG,15712,,215% x Medicaid HMO amount,15712,Other,215% of NY Medicaid HMO DRG,9135,,125% x Medicaid HMO amount,9135,Other,125% of NY Medicaid HMO DRG,0.01,37650,
Skin ulcers,380-3,APR-DRG,,,,,,,,inpatient,,,232571.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,58567,,"45,128 x DRG weight",58567,Other,base rate x DRG weight,52710,,"40,615 x DRG weight",52710,Other,base rate x DRG weight,49782,,"38,359 x DRG weight",49782,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20296,,186% x Medicaid HMO amount,20296,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44225,,"34,077 x DRG weight",44225,Other,base rate x DRG weight,37592,,"28,966 x DRG weight",37592,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10912,,DRG base rate x DRG weight + capital per discharge,10912,Other,100% of NY Medicaid HMO DRG,10912,,100% x Medicaid HMO amount,10912,Other,100% of NY Medicaid HMO DRG,10912,,100% x Medicaid HMO amount,10912,Other,100% of NY Medicaid HMO DRG,10912,,100% x Medicaid HMO amount,10912,Other,100% of NY Medicaid HMO DRG,24552,,225% x Medicaid HMO amount,24552,Other,225% of NY Medicaid HMO DRG,24552,,225% x Medicaid HMO amount,24552,Other,225% of NY Medicaid HMO DRG,24552,,225% x Medicaid HMO amount,24552,Other,225% of NY Medicaid HMO DRG,24552,,225% x Medicaid HMO amount,24552,Other,225% of NY Medicaid HMO DRG,15277,,140% x Medicaid HMO amount,15277,Other,140% of NY Medicaid HMO DRG,24552,,225% x Medicaid HMO amount,24552,Other,225% of NY Medicaid HMO DRG,30008,,275% x Medicaid HMO amount,30008,Other,275% of NY Medicaid HMO DRG,35355,,324% x Medicaid HMO amount,35355,Other,324% of NY Medicaid HMO DRG,23461,,215% x Medicaid HMO amount,23461,Other,215% of NY Medicaid HMO DRG,23461,,215% x Medicaid HMO amount,23461,Other,215% of NY Medicaid HMO DRG,13640,,125% x Medicaid HMO amount,13640,Other,125% of NY Medicaid HMO DRG,0.01,58567,
Skin ulcers,380-4,APR-DRG,,,,,,,,inpatient,,,232571.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,112473,,"45,128 x DRG weight",112473,Other,base rate x DRG weight,101225,,"40,615 x DRG weight",101225,Other,base rate x DRG weight,95602,,"38,359 x DRG weight",95602,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37572,,186% x Medicaid HMO amount,37572,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,84930,,"34,077 x DRG weight",84930,Other,base rate x DRG weight,72192,,"28,966 x DRG weight",72192,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20200,,DRG base rate x DRG weight + capital per discharge,20200,Other,100% of NY Medicaid HMO DRG,20200,,100% x Medicaid HMO amount,20200,Other,100% of NY Medicaid HMO DRG,20200,,100% x Medicaid HMO amount,20200,Other,100% of NY Medicaid HMO DRG,20200,,100% x Medicaid HMO amount,20200,Other,100% of NY Medicaid HMO DRG,45450,,225% x Medicaid HMO amount,45450,Other,225% of NY Medicaid HMO DRG,45450,,225% x Medicaid HMO amount,45450,Other,225% of NY Medicaid HMO DRG,45450,,225% x Medicaid HMO amount,45450,Other,225% of NY Medicaid HMO DRG,45450,,225% x Medicaid HMO amount,45450,Other,225% of NY Medicaid HMO DRG,28280,,140% x Medicaid HMO amount,28280,Other,140% of NY Medicaid HMO DRG,45450,,225% x Medicaid HMO amount,45450,Other,225% of NY Medicaid HMO DRG,55550,,275% x Medicaid HMO amount,55550,Other,275% of NY Medicaid HMO DRG,65448,,324% x Medicaid HMO amount,65448,Other,324% of NY Medicaid HMO DRG,43430,,215% x Medicaid HMO amount,43430,Other,215% of NY Medicaid HMO DRG,43430,,215% x Medicaid HMO amount,43430,Other,215% of NY Medicaid HMO DRG,25250,,125% x Medicaid HMO amount,25250,Other,125% of NY Medicaid HMO DRG,0.01,112473,
Major skin disorders,381-1,APR-DRG,,,,,,,,inpatient,,,108112.07,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26829,,"45,128 x DRG weight",26829,Other,base rate x DRG weight,24146,,"40,615 x DRG weight",24146,Other,base rate x DRG weight,22804,,"38,359 x DRG weight",22804,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10124,,186% x Medicaid HMO amount,10124,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20259,,"34,077 x DRG weight",20259,Other,base rate x DRG weight,17220,,"28,966 x DRG weight",17220,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5443,,DRG base rate x DRG weight + capital per discharge,5443,Other,100% of NY Medicaid HMO DRG,5443,,100% x Medicaid HMO amount,5443,Other,100% of NY Medicaid HMO DRG,5443,,100% x Medicaid HMO amount,5443,Other,100% of NY Medicaid HMO DRG,5443,,100% x Medicaid HMO amount,5443,Other,100% of NY Medicaid HMO DRG,12247,,225% x Medicaid HMO amount,12247,Other,225% of NY Medicaid HMO DRG,12247,,225% x Medicaid HMO amount,12247,Other,225% of NY Medicaid HMO DRG,12247,,225% x Medicaid HMO amount,12247,Other,225% of NY Medicaid HMO DRG,12247,,225% x Medicaid HMO amount,12247,Other,225% of NY Medicaid HMO DRG,7620,,140% x Medicaid HMO amount,7620,Other,140% of NY Medicaid HMO DRG,12247,,225% x Medicaid HMO amount,12247,Other,225% of NY Medicaid HMO DRG,14968,,275% x Medicaid HMO amount,14968,Other,275% of NY Medicaid HMO DRG,17635,,324% x Medicaid HMO amount,17635,Other,324% of NY Medicaid HMO DRG,11702,,215% x Medicaid HMO amount,11702,Other,215% of NY Medicaid HMO DRG,11702,,215% x Medicaid HMO amount,11702,Other,215% of NY Medicaid HMO DRG,6804,,125% x Medicaid HMO amount,6804,Other,125% of NY Medicaid HMO DRG,0.01,26829,
Major skin disorders,381-2,APR-DRG,,,,,,,,inpatient,,,98673.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39740,,"45,128 x DRG weight",39740,Other,base rate x DRG weight,35766,,"40,615 x DRG weight",35766,Other,base rate x DRG weight,33779,,"38,359 x DRG weight",33779,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14262,,186% x Medicaid HMO amount,14262,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30008,,"34,077 x DRG weight",30008,Other,base rate x DRG weight,25507,,"28,966 x DRG weight",25507,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7668,,DRG base rate x DRG weight + capital per discharge,7668,Other,100% of NY Medicaid HMO DRG,7668,,100% x Medicaid HMO amount,7668,Other,100% of NY Medicaid HMO DRG,7668,,100% x Medicaid HMO amount,7668,Other,100% of NY Medicaid HMO DRG,7668,,100% x Medicaid HMO amount,7668,Other,100% of NY Medicaid HMO DRG,17253,,225% x Medicaid HMO amount,17253,Other,225% of NY Medicaid HMO DRG,17253,,225% x Medicaid HMO amount,17253,Other,225% of NY Medicaid HMO DRG,17253,,225% x Medicaid HMO amount,17253,Other,225% of NY Medicaid HMO DRG,17253,,225% x Medicaid HMO amount,17253,Other,225% of NY Medicaid HMO DRG,10735,,140% x Medicaid HMO amount,10735,Other,140% of NY Medicaid HMO DRG,17253,,225% x Medicaid HMO amount,17253,Other,225% of NY Medicaid HMO DRG,21087,,275% x Medicaid HMO amount,21087,Other,275% of NY Medicaid HMO DRG,24844,,324% x Medicaid HMO amount,24844,Other,324% of NY Medicaid HMO DRG,16486,,215% x Medicaid HMO amount,16486,Other,215% of NY Medicaid HMO DRG,16486,,215% x Medicaid HMO amount,16486,Other,215% of NY Medicaid HMO DRG,9585,,125% x Medicaid HMO amount,9585,Other,125% of NY Medicaid HMO DRG,0.01,39740,
Major skin disorders,381-3,APR-DRG,,,,,,,,inpatient,,,394675.08,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,86966,,"45,128 x DRG weight",86966,Other,base rate x DRG weight,78269,,"40,615 x DRG weight",78269,Other,base rate x DRG weight,73922,,"38,359 x DRG weight",73922,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29397,,186% x Medicaid HMO amount,29397,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,65670,,"34,077 x DRG weight",65670,Other,base rate x DRG weight,55820,,"28,966 x DRG weight",55820,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15805,,DRG base rate x DRG weight + capital per discharge,15805,Other,100% of NY Medicaid HMO DRG,15805,,100% x Medicaid HMO amount,15805,Other,100% of NY Medicaid HMO DRG,15805,,100% x Medicaid HMO amount,15805,Other,100% of NY Medicaid HMO DRG,15805,,100% x Medicaid HMO amount,15805,Other,100% of NY Medicaid HMO DRG,35561,,225% x Medicaid HMO amount,35561,Other,225% of NY Medicaid HMO DRG,35561,,225% x Medicaid HMO amount,35561,Other,225% of NY Medicaid HMO DRG,35561,,225% x Medicaid HMO amount,35561,Other,225% of NY Medicaid HMO DRG,35561,,225% x Medicaid HMO amount,35561,Other,225% of NY Medicaid HMO DRG,22127,,140% x Medicaid HMO amount,22127,Other,140% of NY Medicaid HMO DRG,35561,,225% x Medicaid HMO amount,35561,Other,225% of NY Medicaid HMO DRG,43464,,275% x Medicaid HMO amount,43464,Other,275% of NY Medicaid HMO DRG,51208,,324% x Medicaid HMO amount,51208,Other,324% of NY Medicaid HMO DRG,33981,,215% x Medicaid HMO amount,33981,Other,215% of NY Medicaid HMO DRG,33981,,215% x Medicaid HMO amount,33981,Other,215% of NY Medicaid HMO DRG,19756,,125% x Medicaid HMO amount,19756,Other,125% of NY Medicaid HMO DRG,0.01,86966,
Major skin disorders,381-4,APR-DRG,,,,,,,,inpatient,,,1427628.2,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,266382,,"45,128 x DRG weight",266382,Other,base rate x DRG weight,239742,,"40,615 x DRG weight",239742,Other,base rate x DRG weight,226426,,"38,359 x DRG weight",226426,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,86897,,186% x Medicaid HMO amount,86897,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,201150,,"34,077 x DRG weight",201150,Other,base rate x DRG weight,170981,,"28,966 x DRG weight",170981,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46719,,DRG base rate x DRG weight + capital per discharge,46719,Other,100% of NY Medicaid HMO DRG,46719,,100% x Medicaid HMO amount,46719,Other,100% of NY Medicaid HMO DRG,46719,,100% x Medicaid HMO amount,46719,Other,100% of NY Medicaid HMO DRG,46719,,100% x Medicaid HMO amount,46719,Other,100% of NY Medicaid HMO DRG,105118,,225% x Medicaid HMO amount,105118,Other,225% of NY Medicaid HMO DRG,105118,,225% x Medicaid HMO amount,105118,Other,225% of NY Medicaid HMO DRG,105118,,225% x Medicaid HMO amount,105118,Other,225% of NY Medicaid HMO DRG,105118,,225% x Medicaid HMO amount,105118,Other,225% of NY Medicaid HMO DRG,65407,,140% x Medicaid HMO amount,65407,Other,140% of NY Medicaid HMO DRG,105118,,225% x Medicaid HMO amount,105118,Other,225% of NY Medicaid HMO DRG,128477,,275% x Medicaid HMO amount,128477,Other,275% of NY Medicaid HMO DRG,151370,,324% x Medicaid HMO amount,151370,Other,324% of NY Medicaid HMO DRG,100446,,215% x Medicaid HMO amount,100446,Other,215% of NY Medicaid HMO DRG,100446,,215% x Medicaid HMO amount,100446,Other,215% of NY Medicaid HMO DRG,58399,,125% x Medicaid HMO amount,58399,Other,125% of NY Medicaid HMO DRG,0.01,266382,
Malignant breast disorders,382-1,APR-DRG,,,,,,,,inpatient,,,56201,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28092,,"45,128 x DRG weight",28092,Other,base rate x DRG weight,25283,,"40,615 x DRG weight",25283,Other,base rate x DRG weight,23878,,"38,359 x DRG weight",23878,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10529,,186% x Medicaid HMO amount,10529,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21213,,"34,077 x DRG weight",21213,Other,base rate x DRG weight,18031,,"28,966 x DRG weight",18031,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5661,,DRG base rate x DRG weight + capital per discharge,5661,Other,100% of NY Medicaid HMO DRG,5661,,100% x Medicaid HMO amount,5661,Other,100% of NY Medicaid HMO DRG,5661,,100% x Medicaid HMO amount,5661,Other,100% of NY Medicaid HMO DRG,5661,,100% x Medicaid HMO amount,5661,Other,100% of NY Medicaid HMO DRG,12737,,225% x Medicaid HMO amount,12737,Other,225% of NY Medicaid HMO DRG,12737,,225% x Medicaid HMO amount,12737,Other,225% of NY Medicaid HMO DRG,12737,,225% x Medicaid HMO amount,12737,Other,225% of NY Medicaid HMO DRG,12737,,225% x Medicaid HMO amount,12737,Other,225% of NY Medicaid HMO DRG,7925,,140% x Medicaid HMO amount,7925,Other,140% of NY Medicaid HMO DRG,12737,,225% x Medicaid HMO amount,12737,Other,225% of NY Medicaid HMO DRG,15568,,275% x Medicaid HMO amount,15568,Other,275% of NY Medicaid HMO DRG,18342,,324% x Medicaid HMO amount,18342,Other,324% of NY Medicaid HMO DRG,12171,,215% x Medicaid HMO amount,12171,Other,215% of NY Medicaid HMO DRG,12171,,215% x Medicaid HMO amount,12171,Other,215% of NY Medicaid HMO DRG,7076,,125% x Medicaid HMO amount,7076,Other,125% of NY Medicaid HMO DRG,0.01,28092,
Malignant breast disorders,382-2,APR-DRG,,,,,,,,inpatient,,,56201,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37610,,"45,128 x DRG weight",37610,Other,base rate x DRG weight,33849,,"40,615 x DRG weight",33849,Other,base rate x DRG weight,31968,,"38,359 x DRG weight",31968,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13580,,186% x Medicaid HMO amount,13580,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28400,,"34,077 x DRG weight",28400,Other,base rate x DRG weight,24140,,"28,966 x DRG weight",24140,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7301,,DRG base rate x DRG weight + capital per discharge,7301,Other,100% of NY Medicaid HMO DRG,7301,,100% x Medicaid HMO amount,7301,Other,100% of NY Medicaid HMO DRG,7301,,100% x Medicaid HMO amount,7301,Other,100% of NY Medicaid HMO DRG,7301,,100% x Medicaid HMO amount,7301,Other,100% of NY Medicaid HMO DRG,16427,,225% x Medicaid HMO amount,16427,Other,225% of NY Medicaid HMO DRG,16427,,225% x Medicaid HMO amount,16427,Other,225% of NY Medicaid HMO DRG,16427,,225% x Medicaid HMO amount,16427,Other,225% of NY Medicaid HMO DRG,16427,,225% x Medicaid HMO amount,16427,Other,225% of NY Medicaid HMO DRG,10221,,140% x Medicaid HMO amount,10221,Other,140% of NY Medicaid HMO DRG,16427,,225% x Medicaid HMO amount,16427,Other,225% of NY Medicaid HMO DRG,20078,,275% x Medicaid HMO amount,20078,Other,275% of NY Medicaid HMO DRG,23655,,324% x Medicaid HMO amount,23655,Other,324% of NY Medicaid HMO DRG,15697,,215% x Medicaid HMO amount,15697,Other,215% of NY Medicaid HMO DRG,15697,,215% x Medicaid HMO amount,15697,Other,215% of NY Medicaid HMO DRG,9126,,125% x Medicaid HMO amount,9126,Other,125% of NY Medicaid HMO DRG,0.01,37610,
Malignant breast disorders,382-3,APR-DRG,,,,,,,,inpatient,,,175779,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,67967,,"45,128 x DRG weight",67967,Other,base rate x DRG weight,61170,,"40,615 x DRG weight",61170,Other,base rate x DRG weight,57772,,"38,359 x DRG weight",57772,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23310,,186% x Medicaid HMO amount,23310,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51323,,"34,077 x DRG weight",51323,Other,base rate x DRG weight,43626,,"28,966 x DRG weight",43626,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12532,,DRG base rate x DRG weight + capital per discharge,12532,Other,100% of NY Medicaid HMO DRG,12532,,100% x Medicaid HMO amount,12532,Other,100% of NY Medicaid HMO DRG,12532,,100% x Medicaid HMO amount,12532,Other,100% of NY Medicaid HMO DRG,12532,,100% x Medicaid HMO amount,12532,Other,100% of NY Medicaid HMO DRG,28197,,225% x Medicaid HMO amount,28197,Other,225% of NY Medicaid HMO DRG,28197,,225% x Medicaid HMO amount,28197,Other,225% of NY Medicaid HMO DRG,28197,,225% x Medicaid HMO amount,28197,Other,225% of NY Medicaid HMO DRG,28197,,225% x Medicaid HMO amount,28197,Other,225% of NY Medicaid HMO DRG,17545,,140% x Medicaid HMO amount,17545,Other,140% of NY Medicaid HMO DRG,28197,,225% x Medicaid HMO amount,28197,Other,225% of NY Medicaid HMO DRG,34463,,275% x Medicaid HMO amount,34463,Other,275% of NY Medicaid HMO DRG,40604,,324% x Medicaid HMO amount,40604,Other,324% of NY Medicaid HMO DRG,26944,,215% x Medicaid HMO amount,26944,Other,215% of NY Medicaid HMO DRG,26944,,215% x Medicaid HMO amount,26944,Other,215% of NY Medicaid HMO DRG,15665,,125% x Medicaid HMO amount,15665,Other,125% of NY Medicaid HMO DRG,0.01,67967,
Malignant breast disorders,382-4,APR-DRG,,,,,,,,inpatient,,,189087.2,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,130587,,"45,128 x DRG weight",130587,Other,base rate x DRG weight,117528,,"40,615 x DRG weight",117528,Other,base rate x DRG weight,110999,,"38,359 x DRG weight",110999,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43377,,186% x Medicaid HMO amount,43377,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,98609,,"34,077 x DRG weight",98609,Other,base rate x DRG weight,83819,,"28,966 x DRG weight",83819,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23321,,DRG base rate x DRG weight + capital per discharge,23321,Other,100% of NY Medicaid HMO DRG,23321,,100% x Medicaid HMO amount,23321,Other,100% of NY Medicaid HMO DRG,23321,,100% x Medicaid HMO amount,23321,Other,100% of NY Medicaid HMO DRG,23321,,100% x Medicaid HMO amount,23321,Other,100% of NY Medicaid HMO DRG,52472,,225% x Medicaid HMO amount,52472,Other,225% of NY Medicaid HMO DRG,52472,,225% x Medicaid HMO amount,52472,Other,225% of NY Medicaid HMO DRG,52472,,225% x Medicaid HMO amount,52472,Other,225% of NY Medicaid HMO DRG,52472,,225% x Medicaid HMO amount,52472,Other,225% of NY Medicaid HMO DRG,32649,,140% x Medicaid HMO amount,32649,Other,140% of NY Medicaid HMO DRG,52472,,225% x Medicaid HMO amount,52472,Other,225% of NY Medicaid HMO DRG,64133,,275% x Medicaid HMO amount,64133,Other,275% of NY Medicaid HMO DRG,75560,,324% x Medicaid HMO amount,75560,Other,324% of NY Medicaid HMO DRG,50140,,215% x Medicaid HMO amount,50140,Other,215% of NY Medicaid HMO DRG,50140,,215% x Medicaid HMO amount,50140,Other,215% of NY Medicaid HMO DRG,29151,,125% x Medicaid HMO amount,29151,Other,125% of NY Medicaid HMO DRG,0.01,130587,
Cellulitis & other skin infections,383-1,APR-DRG,,,,,,,,inpatient,,,70147.56,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22794,,"45,128 x DRG weight",22794,Other,base rate x DRG weight,20515,,"40,615 x DRG weight",20515,Other,base rate x DRG weight,19375,,"38,359 x DRG weight",19375,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8831,,186% x Medicaid HMO amount,8831,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17212,,"34,077 x DRG weight",17212,Other,base rate x DRG weight,14631,,"28,966 x DRG weight",14631,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4748,,DRG base rate x DRG weight + capital per discharge,4748,Other,100% of NY Medicaid HMO DRG,4748,,100% x Medicaid HMO amount,4748,Other,100% of NY Medicaid HMO DRG,4748,,100% x Medicaid HMO amount,4748,Other,100% of NY Medicaid HMO DRG,4748,,100% x Medicaid HMO amount,4748,Other,100% of NY Medicaid HMO DRG,10683,,225% x Medicaid HMO amount,10683,Other,225% of NY Medicaid HMO DRG,10683,,225% x Medicaid HMO amount,10683,Other,225% of NY Medicaid HMO DRG,10683,,225% x Medicaid HMO amount,10683,Other,225% of NY Medicaid HMO DRG,10683,,225% x Medicaid HMO amount,10683,Other,225% of NY Medicaid HMO DRG,6647,,140% x Medicaid HMO amount,6647,Other,140% of NY Medicaid HMO DRG,10683,,225% x Medicaid HMO amount,10683,Other,225% of NY Medicaid HMO DRG,13057,,275% x Medicaid HMO amount,13057,Other,275% of NY Medicaid HMO DRG,15384,,324% x Medicaid HMO amount,15384,Other,324% of NY Medicaid HMO DRG,10208,,215% x Medicaid HMO amount,10208,Other,215% of NY Medicaid HMO DRG,10208,,215% x Medicaid HMO amount,10208,Other,215% of NY Medicaid HMO DRG,5935,,125% x Medicaid HMO amount,5935,Other,125% of NY Medicaid HMO DRG,0.01,22794,
Cellulitis & other skin infections,383-2,APR-DRG,,,,,,,,inpatient,,,88425.26,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30877,,"45,128 x DRG weight",30877,Other,base rate x DRG weight,27789,,"40,615 x DRG weight",27789,Other,base rate x DRG weight,26245,,"38,359 x DRG weight",26245,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11422,,186% x Medicaid HMO amount,11422,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23315,,"34,077 x DRG weight",23315,Other,base rate x DRG weight,19819,,"28,966 x DRG weight",19819,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6141,,DRG base rate x DRG weight + capital per discharge,6141,Other,100% of NY Medicaid HMO DRG,6141,,100% x Medicaid HMO amount,6141,Other,100% of NY Medicaid HMO DRG,6141,,100% x Medicaid HMO amount,6141,Other,100% of NY Medicaid HMO DRG,6141,,100% x Medicaid HMO amount,6141,Other,100% of NY Medicaid HMO DRG,13817,,225% x Medicaid HMO amount,13817,Other,225% of NY Medicaid HMO DRG,13817,,225% x Medicaid HMO amount,13817,Other,225% of NY Medicaid HMO DRG,13817,,225% x Medicaid HMO amount,13817,Other,225% of NY Medicaid HMO DRG,13817,,225% x Medicaid HMO amount,13817,Other,225% of NY Medicaid HMO DRG,8597,,140% x Medicaid HMO amount,8597,Other,140% of NY Medicaid HMO DRG,13817,,225% x Medicaid HMO amount,13817,Other,225% of NY Medicaid HMO DRG,16888,,275% x Medicaid HMO amount,16888,Other,275% of NY Medicaid HMO DRG,19897,,324% x Medicaid HMO amount,19897,Other,324% of NY Medicaid HMO DRG,13203,,215% x Medicaid HMO amount,13203,Other,215% of NY Medicaid HMO DRG,13203,,215% x Medicaid HMO amount,13203,Other,215% of NY Medicaid HMO DRG,7676,,125% x Medicaid HMO amount,7676,Other,125% of NY Medicaid HMO DRG,0.01,30877,
Cellulitis & other skin infections,383-3,APR-DRG,,,,,,,,inpatient,,,150076.12,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53337,,"45,128 x DRG weight",53337,Other,base rate x DRG weight,48003,,"40,615 x DRG weight",48003,Other,base rate x DRG weight,45337,,"38,359 x DRG weight",45337,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18620,,186% x Medicaid HMO amount,18620,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40276,,"34,077 x DRG weight",40276,Other,base rate x DRG weight,34235,,"28,966 x DRG weight",34235,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10011,,DRG base rate x DRG weight + capital per discharge,10011,Other,100% of NY Medicaid HMO DRG,10011,,100% x Medicaid HMO amount,10011,Other,100% of NY Medicaid HMO DRG,10011,,100% x Medicaid HMO amount,10011,Other,100% of NY Medicaid HMO DRG,10011,,100% x Medicaid HMO amount,10011,Other,100% of NY Medicaid HMO DRG,22525,,225% x Medicaid HMO amount,22525,Other,225% of NY Medicaid HMO DRG,22525,,225% x Medicaid HMO amount,22525,Other,225% of NY Medicaid HMO DRG,22525,,225% x Medicaid HMO amount,22525,Other,225% of NY Medicaid HMO DRG,22525,,225% x Medicaid HMO amount,22525,Other,225% of NY Medicaid HMO DRG,14015,,140% x Medicaid HMO amount,14015,Other,140% of NY Medicaid HMO DRG,22525,,225% x Medicaid HMO amount,22525,Other,225% of NY Medicaid HMO DRG,27530,,275% x Medicaid HMO amount,27530,Other,275% of NY Medicaid HMO DRG,32436,,324% x Medicaid HMO amount,32436,Other,324% of NY Medicaid HMO DRG,21524,,215% x Medicaid HMO amount,21524,Other,215% of NY Medicaid HMO DRG,21524,,215% x Medicaid HMO amount,21524,Other,215% of NY Medicaid HMO DRG,12514,,125% x Medicaid HMO amount,12514,Other,125% of NY Medicaid HMO DRG,0.01,53337,
Cellulitis & other skin infections,383-4,APR-DRG,,,,,,,,inpatient,,,334963.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,126070,,"45,128 x DRG weight",126070,Other,base rate x DRG weight,113462,,"40,615 x DRG weight",113462,Other,base rate x DRG weight,107160,,"38,359 x DRG weight",107160,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41930,,186% x Medicaid HMO amount,41930,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,95198,,"34,077 x DRG weight",95198,Other,base rate x DRG weight,80919,,"28,966 x DRG weight",80919,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22543,,DRG base rate x DRG weight + capital per discharge,22543,Other,100% of NY Medicaid HMO DRG,22543,,100% x Medicaid HMO amount,22543,Other,100% of NY Medicaid HMO DRG,22543,,100% x Medicaid HMO amount,22543,Other,100% of NY Medicaid HMO DRG,22543,,100% x Medicaid HMO amount,22543,Other,100% of NY Medicaid HMO DRG,50722,,225% x Medicaid HMO amount,50722,Other,225% of NY Medicaid HMO DRG,50722,,225% x Medicaid HMO amount,50722,Other,225% of NY Medicaid HMO DRG,50722,,225% x Medicaid HMO amount,50722,Other,225% of NY Medicaid HMO DRG,50722,,225% x Medicaid HMO amount,50722,Other,225% of NY Medicaid HMO DRG,31560,,140% x Medicaid HMO amount,31560,Other,140% of NY Medicaid HMO DRG,50722,,225% x Medicaid HMO amount,50722,Other,225% of NY Medicaid HMO DRG,61993,,275% x Medicaid HMO amount,61993,Other,275% of NY Medicaid HMO DRG,73039,,324% x Medicaid HMO amount,73039,Other,324% of NY Medicaid HMO DRG,48467,,215% x Medicaid HMO amount,48467,Other,215% of NY Medicaid HMO DRG,48467,,215% x Medicaid HMO amount,48467,Other,215% of NY Medicaid HMO DRG,28179,,125% x Medicaid HMO amount,28179,Other,125% of NY Medicaid HMO DRG,0.01,126070,
"Contusion, open wound & other trauma to skin & subcutaneous tissue",384-1,APR-DRG,,,,,,,,inpatient,,,71053.7,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18629,,"45,128 x DRG weight",18629,Other,base rate x DRG weight,16766,,"40,615 x DRG weight",16766,Other,base rate x DRG weight,15835,,"38,359 x DRG weight",15835,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7498,,186% x Medicaid HMO amount,7498,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14067,,"34,077 x DRG weight",14067,Other,base rate x DRG weight,11957,,"28,966 x DRG weight",11957,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4031,,DRG base rate x DRG weight + capital per discharge,4031,Other,100% of NY Medicaid HMO DRG,4031,,100% x Medicaid HMO amount,4031,Other,100% of NY Medicaid HMO DRG,4031,,100% x Medicaid HMO amount,4031,Other,100% of NY Medicaid HMO DRG,4031,,100% x Medicaid HMO amount,4031,Other,100% of NY Medicaid HMO DRG,9070,,225% x Medicaid HMO amount,9070,Other,225% of NY Medicaid HMO DRG,9070,,225% x Medicaid HMO amount,9070,Other,225% of NY Medicaid HMO DRG,9070,,225% x Medicaid HMO amount,9070,Other,225% of NY Medicaid HMO DRG,9070,,225% x Medicaid HMO amount,9070,Other,225% of NY Medicaid HMO DRG,5643,,140% x Medicaid HMO amount,5643,Other,140% of NY Medicaid HMO DRG,9070,,225% x Medicaid HMO amount,9070,Other,225% of NY Medicaid HMO DRG,11085,,275% x Medicaid HMO amount,11085,Other,275% of NY Medicaid HMO DRG,13060,,324% x Medicaid HMO amount,13060,Other,324% of NY Medicaid HMO DRG,8667,,215% x Medicaid HMO amount,8667,Other,215% of NY Medicaid HMO DRG,8667,,215% x Medicaid HMO amount,8667,Other,215% of NY Medicaid HMO DRG,5039,,125% x Medicaid HMO amount,5039,Other,125% of NY Medicaid HMO DRG,0.01,18629,
"Contusion, open wound & other trauma to skin & subcutaneous tissue",384-2,APR-DRG,,,,,,,,inpatient,,,104747.59,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26138,,"45,128 x DRG weight",26138,Other,base rate x DRG weight,23524,,"40,615 x DRG weight",23524,Other,base rate x DRG weight,22218,,"38,359 x DRG weight",22218,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9905,,186% x Medicaid HMO amount,9905,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19737,,"34,077 x DRG weight",19737,Other,base rate x DRG weight,16777,,"28,966 x DRG weight",16777,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5325,,DRG base rate x DRG weight + capital per discharge,5325,Other,100% of NY Medicaid HMO DRG,5325,,100% x Medicaid HMO amount,5325,Other,100% of NY Medicaid HMO DRG,5325,,100% x Medicaid HMO amount,5325,Other,100% of NY Medicaid HMO DRG,5325,,100% x Medicaid HMO amount,5325,Other,100% of NY Medicaid HMO DRG,11981,,225% x Medicaid HMO amount,11981,Other,225% of NY Medicaid HMO DRG,11981,,225% x Medicaid HMO amount,11981,Other,225% of NY Medicaid HMO DRG,11981,,225% x Medicaid HMO amount,11981,Other,225% of NY Medicaid HMO DRG,11981,,225% x Medicaid HMO amount,11981,Other,225% of NY Medicaid HMO DRG,7455,,140% x Medicaid HMO amount,7455,Other,140% of NY Medicaid HMO DRG,11981,,225% x Medicaid HMO amount,11981,Other,225% of NY Medicaid HMO DRG,14644,,275% x Medicaid HMO amount,14644,Other,275% of NY Medicaid HMO DRG,17253,,324% x Medicaid HMO amount,17253,Other,324% of NY Medicaid HMO DRG,11449,,215% x Medicaid HMO amount,11449,Other,215% of NY Medicaid HMO DRG,11449,,215% x Medicaid HMO amount,11449,Other,215% of NY Medicaid HMO DRG,6656,,125% x Medicaid HMO amount,6656,Other,125% of NY Medicaid HMO DRG,0.01,26138,
"Contusion, open wound & other trauma to skin & subcutaneous tissue",384-3,APR-DRG,,,,,,,,inpatient,,,71480.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45724,,"45,128 x DRG weight",45724,Other,base rate x DRG weight,41151,,"40,615 x DRG weight",41151,Other,base rate x DRG weight,38865,,"38,359 x DRG weight",38865,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16180,,186% x Medicaid HMO amount,16180,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34527,,"34,077 x DRG weight",34527,Other,base rate x DRG weight,29348,,"28,966 x DRG weight",29348,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8699,,DRG base rate x DRG weight + capital per discharge,8699,Other,100% of NY Medicaid HMO DRG,8699,,100% x Medicaid HMO amount,8699,Other,100% of NY Medicaid HMO DRG,8699,,100% x Medicaid HMO amount,8699,Other,100% of NY Medicaid HMO DRG,8699,,100% x Medicaid HMO amount,8699,Other,100% of NY Medicaid HMO DRG,19573,,225% x Medicaid HMO amount,19573,Other,225% of NY Medicaid HMO DRG,19573,,225% x Medicaid HMO amount,19573,Other,225% of NY Medicaid HMO DRG,19573,,225% x Medicaid HMO amount,19573,Other,225% of NY Medicaid HMO DRG,19573,,225% x Medicaid HMO amount,19573,Other,225% of NY Medicaid HMO DRG,12179,,140% x Medicaid HMO amount,12179,Other,140% of NY Medicaid HMO DRG,19573,,225% x Medicaid HMO amount,19573,Other,225% of NY Medicaid HMO DRG,23922,,275% x Medicaid HMO amount,23922,Other,275% of NY Medicaid HMO DRG,28185,,324% x Medicaid HMO amount,28185,Other,324% of NY Medicaid HMO DRG,18703,,215% x Medicaid HMO amount,18703,Other,215% of NY Medicaid HMO DRG,18703,,215% x Medicaid HMO amount,18703,Other,215% of NY Medicaid HMO DRG,10874,,125% x Medicaid HMO amount,10874,Other,125% of NY Medicaid HMO DRG,0.01,45724,
"Contusion, open wound & other trauma to skin & subcutaneous tissue",384-4,APR-DRG,,,,,,,,inpatient,,,152701,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,83022,,"45,128 x DRG weight",83022,Other,base rate x DRG weight,74719,,"40,615 x DRG weight",74719,Other,base rate x DRG weight,70569,,"38,359 x DRG weight",70569,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28134,,186% x Medicaid HMO amount,28134,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,62691,,"34,077 x DRG weight",62691,Other,base rate x DRG weight,53289,,"28,966 x DRG weight",53289,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15126,,DRG base rate x DRG weight + capital per discharge,15126,Other,100% of NY Medicaid HMO DRG,15126,,100% x Medicaid HMO amount,15126,Other,100% of NY Medicaid HMO DRG,15126,,100% x Medicaid HMO amount,15126,Other,100% of NY Medicaid HMO DRG,15126,,100% x Medicaid HMO amount,15126,Other,100% of NY Medicaid HMO DRG,34034,,225% x Medicaid HMO amount,34034,Other,225% of NY Medicaid HMO DRG,34034,,225% x Medicaid HMO amount,34034,Other,225% of NY Medicaid HMO DRG,34034,,225% x Medicaid HMO amount,34034,Other,225% of NY Medicaid HMO DRG,34034,,225% x Medicaid HMO amount,34034,Other,225% of NY Medicaid HMO DRG,21176,,140% x Medicaid HMO amount,21176,Other,140% of NY Medicaid HMO DRG,34034,,225% x Medicaid HMO amount,34034,Other,225% of NY Medicaid HMO DRG,41597,,275% x Medicaid HMO amount,41597,Other,275% of NY Medicaid HMO DRG,49008,,324% x Medicaid HMO amount,49008,Other,324% of NY Medicaid HMO DRG,32521,,215% x Medicaid HMO amount,32521,Other,215% of NY Medicaid HMO DRG,32521,,215% x Medicaid HMO amount,32521,Other,215% of NY Medicaid HMO DRG,18908,,125% x Medicaid HMO amount,18908,Other,125% of NY Medicaid HMO DRG,0.01,83022,
"Other skin, subcutaneous tissue & breast disorders",385-1,APR-DRG,,,,,,,,inpatient,,,83964.44,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21630,,"45,128 x DRG weight",21630,Other,base rate x DRG weight,19467,,"40,615 x DRG weight",19467,Other,base rate x DRG weight,18385,,"38,359 x DRG weight",18385,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8459,,186% x Medicaid HMO amount,8459,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16333,,"34,077 x DRG weight",16333,Other,base rate x DRG weight,13883,,"28,966 x DRG weight",13883,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4548,,DRG base rate x DRG weight + capital per discharge,4548,Other,100% of NY Medicaid HMO DRG,4548,,100% x Medicaid HMO amount,4548,Other,100% of NY Medicaid HMO DRG,4548,,100% x Medicaid HMO amount,4548,Other,100% of NY Medicaid HMO DRG,4548,,100% x Medicaid HMO amount,4548,Other,100% of NY Medicaid HMO DRG,10233,,225% x Medicaid HMO amount,10233,Other,225% of NY Medicaid HMO DRG,10233,,225% x Medicaid HMO amount,10233,Other,225% of NY Medicaid HMO DRG,10233,,225% x Medicaid HMO amount,10233,Other,225% of NY Medicaid HMO DRG,10233,,225% x Medicaid HMO amount,10233,Other,225% of NY Medicaid HMO DRG,6367,,140% x Medicaid HMO amount,6367,Other,140% of NY Medicaid HMO DRG,10233,,225% x Medicaid HMO amount,10233,Other,225% of NY Medicaid HMO DRG,12507,,275% x Medicaid HMO amount,12507,Other,275% of NY Medicaid HMO DRG,14736,,324% x Medicaid HMO amount,14736,Other,324% of NY Medicaid HMO DRG,9778,,215% x Medicaid HMO amount,9778,Other,215% of NY Medicaid HMO DRG,9778,,215% x Medicaid HMO amount,9778,Other,215% of NY Medicaid HMO DRG,5685,,125% x Medicaid HMO amount,5685,Other,125% of NY Medicaid HMO DRG,0.01,21630,
"Other skin, subcutaneous tissue & breast disorders",385-2,APR-DRG,,,,,,,,inpatient,,,90574.6,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29595,,"45,128 x DRG weight",29595,Other,base rate x DRG weight,26635,,"40,615 x DRG weight",26635,Other,base rate x DRG weight,25156,,"38,359 x DRG weight",25156,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11011,,186% x Medicaid HMO amount,11011,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22348,,"34,077 x DRG weight",22348,Other,base rate x DRG weight,18996,,"28,966 x DRG weight",18996,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5920,,DRG base rate x DRG weight + capital per discharge,5920,Other,100% of NY Medicaid HMO DRG,5920,,100% x Medicaid HMO amount,5920,Other,100% of NY Medicaid HMO DRG,5920,,100% x Medicaid HMO amount,5920,Other,100% of NY Medicaid HMO DRG,5920,,100% x Medicaid HMO amount,5920,Other,100% of NY Medicaid HMO DRG,13320,,225% x Medicaid HMO amount,13320,Other,225% of NY Medicaid HMO DRG,13320,,225% x Medicaid HMO amount,13320,Other,225% of NY Medicaid HMO DRG,13320,,225% x Medicaid HMO amount,13320,Other,225% of NY Medicaid HMO DRG,13320,,225% x Medicaid HMO amount,13320,Other,225% of NY Medicaid HMO DRG,8288,,140% x Medicaid HMO amount,8288,Other,140% of NY Medicaid HMO DRG,13320,,225% x Medicaid HMO amount,13320,Other,225% of NY Medicaid HMO DRG,16280,,275% x Medicaid HMO amount,16280,Other,275% of NY Medicaid HMO DRG,19181,,324% x Medicaid HMO amount,19181,Other,324% of NY Medicaid HMO DRG,12728,,215% x Medicaid HMO amount,12728,Other,215% of NY Medicaid HMO DRG,12728,,215% x Medicaid HMO amount,12728,Other,215% of NY Medicaid HMO DRG,7400,,125% x Medicaid HMO amount,7400,Other,125% of NY Medicaid HMO DRG,0.01,29595,
"Other skin, subcutaneous tissue & breast disorders",385-3,APR-DRG,,,,,,,,inpatient,,,171031.94,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48874,,"45,128 x DRG weight",48874,Other,base rate x DRG weight,43986,,"40,615 x DRG weight",43986,Other,base rate x DRG weight,41543,,"38,359 x DRG weight",41543,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17190,,186% x Medicaid HMO amount,17190,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36905,,"34,077 x DRG weight",36905,Other,base rate x DRG weight,31370,,"28,966 x DRG weight",31370,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9242,,DRG base rate x DRG weight + capital per discharge,9242,Other,100% of NY Medicaid HMO DRG,9242,,100% x Medicaid HMO amount,9242,Other,100% of NY Medicaid HMO DRG,9242,,100% x Medicaid HMO amount,9242,Other,100% of NY Medicaid HMO DRG,9242,,100% x Medicaid HMO amount,9242,Other,100% of NY Medicaid HMO DRG,20795,,225% x Medicaid HMO amount,20795,Other,225% of NY Medicaid HMO DRG,20795,,225% x Medicaid HMO amount,20795,Other,225% of NY Medicaid HMO DRG,20795,,225% x Medicaid HMO amount,20795,Other,225% of NY Medicaid HMO DRG,20795,,225% x Medicaid HMO amount,20795,Other,225% of NY Medicaid HMO DRG,12939,,140% x Medicaid HMO amount,12939,Other,140% of NY Medicaid HMO DRG,20795,,225% x Medicaid HMO amount,20795,Other,225% of NY Medicaid HMO DRG,25416,,275% x Medicaid HMO amount,25416,Other,275% of NY Medicaid HMO DRG,29944,,324% x Medicaid HMO amount,29944,Other,324% of NY Medicaid HMO DRG,19870,,215% x Medicaid HMO amount,19870,Other,215% of NY Medicaid HMO DRG,19870,,215% x Medicaid HMO amount,19870,Other,215% of NY Medicaid HMO DRG,11553,,125% x Medicaid HMO amount,11553,Other,125% of NY Medicaid HMO DRG,0.01,48874,
"Other skin, subcutaneous tissue & breast disorders",385-4,APR-DRG,,,,,,,,inpatient,,,462863.09,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,130632,,"45,128 x DRG weight",130632,Other,base rate x DRG weight,117568,,"40,615 x DRG weight",117568,Other,base rate x DRG weight,111038,,"38,359 x DRG weight",111038,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43392,,186% x Medicaid HMO amount,43392,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,98643,,"34,077 x DRG weight",98643,Other,base rate x DRG weight,83848,,"28,966 x DRG weight",83848,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23329,,DRG base rate x DRG weight + capital per discharge,23329,Other,100% of NY Medicaid HMO DRG,23329,,100% x Medicaid HMO amount,23329,Other,100% of NY Medicaid HMO DRG,23329,,100% x Medicaid HMO amount,23329,Other,100% of NY Medicaid HMO DRG,23329,,100% x Medicaid HMO amount,23329,Other,100% of NY Medicaid HMO DRG,52490,,225% x Medicaid HMO amount,52490,Other,225% of NY Medicaid HMO DRG,52490,,225% x Medicaid HMO amount,52490,Other,225% of NY Medicaid HMO DRG,52490,,225% x Medicaid HMO amount,52490,Other,225% of NY Medicaid HMO DRG,52490,,225% x Medicaid HMO amount,52490,Other,225% of NY Medicaid HMO DRG,32661,,140% x Medicaid HMO amount,32661,Other,140% of NY Medicaid HMO DRG,52490,,225% x Medicaid HMO amount,52490,Other,225% of NY Medicaid HMO DRG,64155,,275% x Medicaid HMO amount,64155,Other,275% of NY Medicaid HMO DRG,75586,,324% x Medicaid HMO amount,75586,Other,324% of NY Medicaid HMO DRG,50157,,215% x Medicaid HMO amount,50157,Other,215% of NY Medicaid HMO DRG,50157,,215% x Medicaid HMO amount,50157,Other,215% of NY Medicaid HMO DRG,29161,,125% x Medicaid HMO amount,29161,Other,125% of NY Medicaid HMO DRG,0.01,130632,
Pituitary & adrenal procedures,401-1,APR-DRG,,,,,,,,inpatient,,,274171.94,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55828,,"45,128 x DRG weight",55828,Other,base rate x DRG weight,50245,,"40,615 x DRG weight",50245,Other,base rate x DRG weight,47454,,"38,359 x DRG weight",47454,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19418,,186% x Medicaid HMO amount,19418,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42157,,"34,077 x DRG weight",42157,Other,base rate x DRG weight,35834,,"28,966 x DRG weight",35834,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10440,,DRG base rate x DRG weight + capital per discharge,10440,Other,100% of NY Medicaid HMO DRG,10440,,100% x Medicaid HMO amount,10440,Other,100% of NY Medicaid HMO DRG,10440,,100% x Medicaid HMO amount,10440,Other,100% of NY Medicaid HMO DRG,10440,,100% x Medicaid HMO amount,10440,Other,100% of NY Medicaid HMO DRG,23490,,225% x Medicaid HMO amount,23490,Other,225% of NY Medicaid HMO DRG,23490,,225% x Medicaid HMO amount,23490,Other,225% of NY Medicaid HMO DRG,23490,,225% x Medicaid HMO amount,23490,Other,225% of NY Medicaid HMO DRG,23490,,225% x Medicaid HMO amount,23490,Other,225% of NY Medicaid HMO DRG,14616,,140% x Medicaid HMO amount,14616,Other,140% of NY Medicaid HMO DRG,23490,,225% x Medicaid HMO amount,23490,Other,225% of NY Medicaid HMO DRG,28710,,275% x Medicaid HMO amount,28710,Other,275% of NY Medicaid HMO DRG,33826,,324% x Medicaid HMO amount,33826,Other,324% of NY Medicaid HMO DRG,22446,,215% x Medicaid HMO amount,22446,Other,215% of NY Medicaid HMO DRG,22446,,215% x Medicaid HMO amount,22446,Other,215% of NY Medicaid HMO DRG,13050,,125% x Medicaid HMO amount,13050,Other,125% of NY Medicaid HMO DRG,0.01,55828,
Pituitary & adrenal procedures,401-2,APR-DRG,,,,,,,,inpatient,,,266531.56,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,76393,,"45,128 x DRG weight",76393,Other,base rate x DRG weight,68753,,"40,615 x DRG weight",68753,Other,base rate x DRG weight,64934,,"38,359 x DRG weight",64934,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26008,,186% x Medicaid HMO amount,26008,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,57686,,"34,077 x DRG weight",57686,Other,base rate x DRG weight,49034,,"28,966 x DRG weight",49034,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13983,,DRG base rate x DRG weight + capital per discharge,13983,Other,100% of NY Medicaid HMO DRG,13983,,100% x Medicaid HMO amount,13983,Other,100% of NY Medicaid HMO DRG,13983,,100% x Medicaid HMO amount,13983,Other,100% of NY Medicaid HMO DRG,13983,,100% x Medicaid HMO amount,13983,Other,100% of NY Medicaid HMO DRG,31462,,225% x Medicaid HMO amount,31462,Other,225% of NY Medicaid HMO DRG,31462,,225% x Medicaid HMO amount,31462,Other,225% of NY Medicaid HMO DRG,31462,,225% x Medicaid HMO amount,31462,Other,225% of NY Medicaid HMO DRG,31462,,225% x Medicaid HMO amount,31462,Other,225% of NY Medicaid HMO DRG,19576,,140% x Medicaid HMO amount,19576,Other,140% of NY Medicaid HMO DRG,31462,,225% x Medicaid HMO amount,31462,Other,225% of NY Medicaid HMO DRG,38453,,275% x Medicaid HMO amount,38453,Other,275% of NY Medicaid HMO DRG,45305,,324% x Medicaid HMO amount,45305,Other,324% of NY Medicaid HMO DRG,30063,,215% x Medicaid HMO amount,30063,Other,215% of NY Medicaid HMO DRG,30063,,215% x Medicaid HMO amount,30063,Other,215% of NY Medicaid HMO DRG,17479,,125% x Medicaid HMO amount,17479,Other,125% of NY Medicaid HMO DRG,0.01,76393,
Pituitary & adrenal procedures,401-3,APR-DRG,,,,,,,,inpatient,,,244178.54,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,139847,,"45,128 x DRG weight",139847,Other,base rate x DRG weight,125862,,"40,615 x DRG weight",125862,Other,base rate x DRG weight,118871,,"38,359 x DRG weight",118871,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46346,,186% x Medicaid HMO amount,46346,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,105601,,"34,077 x DRG weight",105601,Other,base rate x DRG weight,89763,,"28,966 x DRG weight",89763,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24917,,DRG base rate x DRG weight + capital per discharge,24917,Other,100% of NY Medicaid HMO DRG,24917,,100% x Medicaid HMO amount,24917,Other,100% of NY Medicaid HMO DRG,24917,,100% x Medicaid HMO amount,24917,Other,100% of NY Medicaid HMO DRG,24917,,100% x Medicaid HMO amount,24917,Other,100% of NY Medicaid HMO DRG,56063,,225% x Medicaid HMO amount,56063,Other,225% of NY Medicaid HMO DRG,56063,,225% x Medicaid HMO amount,56063,Other,225% of NY Medicaid HMO DRG,56063,,225% x Medicaid HMO amount,56063,Other,225% of NY Medicaid HMO DRG,56063,,225% x Medicaid HMO amount,56063,Other,225% of NY Medicaid HMO DRG,34884,,140% x Medicaid HMO amount,34884,Other,140% of NY Medicaid HMO DRG,56063,,225% x Medicaid HMO amount,56063,Other,225% of NY Medicaid HMO DRG,68522,,275% x Medicaid HMO amount,68522,Other,275% of NY Medicaid HMO DRG,80731,,324% x Medicaid HMO amount,80731,Other,324% of NY Medicaid HMO DRG,53572,,215% x Medicaid HMO amount,53572,Other,215% of NY Medicaid HMO DRG,53572,,215% x Medicaid HMO amount,53572,Other,215% of NY Medicaid HMO DRG,31146,,125% x Medicaid HMO amount,31146,Other,125% of NY Medicaid HMO DRG,0.01,139847,
Pituitary & adrenal procedures,401-4,APR-DRG,,,,,,,,inpatient,,,1215138.73,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,315341,,"45,128 x DRG weight",315341,Other,base rate x DRG weight,283805,,"40,615 x DRG weight",283805,Other,base rate x DRG weight,268041,,"38,359 x DRG weight",268041,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,102588,,186% x Medicaid HMO amount,102588,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,238120,,"34,077 x DRG weight",238120,Other,base rate x DRG weight,202406,,"28,966 x DRG weight",202406,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55155,,DRG base rate x DRG weight + capital per discharge,55155,Other,100% of NY Medicaid HMO DRG,55155,,100% x Medicaid HMO amount,55155,Other,100% of NY Medicaid HMO DRG,55155,,100% x Medicaid HMO amount,55155,Other,100% of NY Medicaid HMO DRG,55155,,100% x Medicaid HMO amount,55155,Other,100% of NY Medicaid HMO DRG,124099,,225% x Medicaid HMO amount,124099,Other,225% of NY Medicaid HMO DRG,124099,,225% x Medicaid HMO amount,124099,Other,225% of NY Medicaid HMO DRG,124099,,225% x Medicaid HMO amount,124099,Other,225% of NY Medicaid HMO DRG,124099,,225% x Medicaid HMO amount,124099,Other,225% of NY Medicaid HMO DRG,77217,,140% x Medicaid HMO amount,77217,Other,140% of NY Medicaid HMO DRG,124099,,225% x Medicaid HMO amount,124099,Other,225% of NY Medicaid HMO DRG,151676,,275% x Medicaid HMO amount,151676,Other,275% of NY Medicaid HMO DRG,178702,,324% x Medicaid HMO amount,178702,Other,324% of NY Medicaid HMO DRG,118583,,215% x Medicaid HMO amount,118583,Other,215% of NY Medicaid HMO DRG,118583,,215% x Medicaid HMO amount,118583,Other,215% of NY Medicaid HMO DRG,68944,,125% x Medicaid HMO amount,68944,Other,125% of NY Medicaid HMO DRG,0.01,315341,
Procedures for obesity,403-1,APR-DRG,,,,,,,,inpatient,,,71703.71,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51446,,"45,128 x DRG weight",51446,Other,base rate x DRG weight,46301,,"40,615 x DRG weight",46301,Other,base rate x DRG weight,43729,,"38,359 x DRG weight",43729,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18014,,186% x Medicaid HMO amount,18014,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22162,,,22162,Case Rate,,18838,,,18838,Case Rate,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9685,,DRG base rate x DRG weight + capital per discharge,9685,Other,100% of NY Medicaid HMO DRG,9685,,100% x Medicaid HMO amount,9685,Other,100% of NY Medicaid HMO DRG,9685,,100% x Medicaid HMO amount,9685,Other,100% of NY Medicaid HMO DRG,9685,,100% x Medicaid HMO amount,9685,Other,100% of NY Medicaid HMO DRG,21791,,225% x Medicaid HMO amount,21791,Other,225% of NY Medicaid HMO DRG,21791,,225% x Medicaid HMO amount,21791,Other,225% of NY Medicaid HMO DRG,21791,,225% x Medicaid HMO amount,21791,Other,225% of NY Medicaid HMO DRG,21791,,225% x Medicaid HMO amount,21791,Other,225% of NY Medicaid HMO DRG,13559,,140% x Medicaid HMO amount,13559,Other,140% of NY Medicaid HMO DRG,21791,,225% x Medicaid HMO amount,21791,Other,225% of NY Medicaid HMO DRG,26634,,275% x Medicaid HMO amount,26634,Other,275% of NY Medicaid HMO DRG,31379,,324% x Medicaid HMO amount,31379,Other,324% of NY Medicaid HMO DRG,20823,,215% x Medicaid HMO amount,20823,Other,215% of NY Medicaid HMO DRG,20823,,215% x Medicaid HMO amount,20823,Other,215% of NY Medicaid HMO DRG,12106,,125% x Medicaid HMO amount,12106,Other,125% of NY Medicaid HMO DRG,0.01,51446,
Procedures for obesity,403-2,APR-DRG,,,,,,,,inpatient,,,69036.47,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,57836,,"45,128 x DRG weight",57836,Other,base rate x DRG weight,52052,,"40,615 x DRG weight",52052,Other,base rate x DRG weight,49161,,"38,359 x DRG weight",49161,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20062,,186% x Medicaid HMO amount,20062,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22162,,,22162,Case Rate,,18838,,,18838,Case Rate,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10786,,DRG base rate x DRG weight + capital per discharge,10786,Other,100% of NY Medicaid HMO DRG,10786,,100% x Medicaid HMO amount,10786,Other,100% of NY Medicaid HMO DRG,10786,,100% x Medicaid HMO amount,10786,Other,100% of NY Medicaid HMO DRG,10786,,100% x Medicaid HMO amount,10786,Other,100% of NY Medicaid HMO DRG,24269,,225% x Medicaid HMO amount,24269,Other,225% of NY Medicaid HMO DRG,24269,,225% x Medicaid HMO amount,24269,Other,225% of NY Medicaid HMO DRG,24269,,225% x Medicaid HMO amount,24269,Other,225% of NY Medicaid HMO DRG,24269,,225% x Medicaid HMO amount,24269,Other,225% of NY Medicaid HMO DRG,15100,,140% x Medicaid HMO amount,15100,Other,140% of NY Medicaid HMO DRG,24269,,225% x Medicaid HMO amount,24269,Other,225% of NY Medicaid HMO DRG,29662,,275% x Medicaid HMO amount,29662,Other,275% of NY Medicaid HMO DRG,34947,,324% x Medicaid HMO amount,34947,Other,324% of NY Medicaid HMO DRG,23190,,215% x Medicaid HMO amount,23190,Other,215% of NY Medicaid HMO DRG,23190,,215% x Medicaid HMO amount,23190,Other,215% of NY Medicaid HMO DRG,13483,,125% x Medicaid HMO amount,13483,Other,125% of NY Medicaid HMO DRG,0.01,57836,
Procedures for obesity,403-3,APR-DRG,,,,,,,,inpatient,,,91864.96,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,94796,,"45,128 x DRG weight",94796,Other,base rate x DRG weight,85316,,"40,615 x DRG weight",85316,Other,base rate x DRG weight,80577,,"38,359 x DRG weight",80577,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31906,,186% x Medicaid HMO amount,31906,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22162,,,22162,Case Rate,,18838,,,18838,Case Rate,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17154,,DRG base rate x DRG weight + capital per discharge,17154,Other,100% of NY Medicaid HMO DRG,17154,,100% x Medicaid HMO amount,17154,Other,100% of NY Medicaid HMO DRG,17154,,100% x Medicaid HMO amount,17154,Other,100% of NY Medicaid HMO DRG,17154,,100% x Medicaid HMO amount,17154,Other,100% of NY Medicaid HMO DRG,38597,,225% x Medicaid HMO amount,38597,Other,225% of NY Medicaid HMO DRG,38597,,225% x Medicaid HMO amount,38597,Other,225% of NY Medicaid HMO DRG,38597,,225% x Medicaid HMO amount,38597,Other,225% of NY Medicaid HMO DRG,38597,,225% x Medicaid HMO amount,38597,Other,225% of NY Medicaid HMO DRG,24016,,140% x Medicaid HMO amount,24016,Other,140% of NY Medicaid HMO DRG,38597,,225% x Medicaid HMO amount,38597,Other,225% of NY Medicaid HMO DRG,47174,,275% x Medicaid HMO amount,47174,Other,275% of NY Medicaid HMO DRG,55579,,324% x Medicaid HMO amount,55579,Other,324% of NY Medicaid HMO DRG,36881,,215% x Medicaid HMO amount,36881,Other,215% of NY Medicaid HMO DRG,36881,,215% x Medicaid HMO amount,36881,Other,215% of NY Medicaid HMO DRG,21443,,125% x Medicaid HMO amount,21443,Other,125% of NY Medicaid HMO DRG,0.01,94796,
Procedures for obesity,403-4,APR-DRG,,,,,,,,inpatient,,,71703.71,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,296793,,"45,128 x DRG weight",296793,Other,base rate x DRG weight,267113,,"40,615 x DRG weight",267113,Other,base rate x DRG weight,252276,,"38,359 x DRG weight",252276,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,96644,,186% x Medicaid HMO amount,96644,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22162,,,22162,Case Rate,,18838,,,18838,Case Rate,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51959,,DRG base rate x DRG weight + capital per discharge,51959,Other,100% of NY Medicaid HMO DRG,51959,,100% x Medicaid HMO amount,51959,Other,100% of NY Medicaid HMO DRG,51959,,100% x Medicaid HMO amount,51959,Other,100% of NY Medicaid HMO DRG,51959,,100% x Medicaid HMO amount,51959,Other,100% of NY Medicaid HMO DRG,116908,,225% x Medicaid HMO amount,116908,Other,225% of NY Medicaid HMO DRG,116908,,225% x Medicaid HMO amount,116908,Other,225% of NY Medicaid HMO DRG,116908,,225% x Medicaid HMO amount,116908,Other,225% of NY Medicaid HMO DRG,116908,,225% x Medicaid HMO amount,116908,Other,225% of NY Medicaid HMO DRG,72743,,140% x Medicaid HMO amount,72743,Other,140% of NY Medicaid HMO DRG,116908,,225% x Medicaid HMO amount,116908,Other,225% of NY Medicaid HMO DRG,142887,,275% x Medicaid HMO amount,142887,Other,275% of NY Medicaid HMO DRG,168347,,324% x Medicaid HMO amount,168347,Other,324% of NY Medicaid HMO DRG,111712,,215% x Medicaid HMO amount,111712,Other,215% of NY Medicaid HMO DRG,111712,,215% x Medicaid HMO amount,111712,Other,215% of NY Medicaid HMO DRG,64949,,125% x Medicaid HMO amount,64949,Other,125% of NY Medicaid HMO DRG,0.01,296793,
"Thyroid, parathyroid & thyroglossal procedures",404-1,APR-DRG,,,,,,,,inpatient,,,129539.14,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30164,,"45,128 x DRG weight",30164,Other,base rate x DRG weight,27147,,"40,615 x DRG weight",27147,Other,base rate x DRG weight,25639,,"38,359 x DRG weight",25639,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11193,,186% x Medicaid HMO amount,11193,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22777,,"34,077 x DRG weight",22777,Other,base rate x DRG weight,19361,,"28,966 x DRG weight",19361,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6018,,DRG base rate x DRG weight + capital per discharge,6018,Other,100% of NY Medicaid HMO DRG,6018,,100% x Medicaid HMO amount,6018,Other,100% of NY Medicaid HMO DRG,6018,,100% x Medicaid HMO amount,6018,Other,100% of NY Medicaid HMO DRG,6018,,100% x Medicaid HMO amount,6018,Other,100% of NY Medicaid HMO DRG,13541,,225% x Medicaid HMO amount,13541,Other,225% of NY Medicaid HMO DRG,13541,,225% x Medicaid HMO amount,13541,Other,225% of NY Medicaid HMO DRG,13541,,225% x Medicaid HMO amount,13541,Other,225% of NY Medicaid HMO DRG,13541,,225% x Medicaid HMO amount,13541,Other,225% of NY Medicaid HMO DRG,8425,,140% x Medicaid HMO amount,8425,Other,140% of NY Medicaid HMO DRG,13541,,225% x Medicaid HMO amount,13541,Other,225% of NY Medicaid HMO DRG,16550,,275% x Medicaid HMO amount,16550,Other,275% of NY Medicaid HMO DRG,19498,,324% x Medicaid HMO amount,19498,Other,324% of NY Medicaid HMO DRG,12939,,215% x Medicaid HMO amount,12939,Other,215% of NY Medicaid HMO DRG,12939,,215% x Medicaid HMO amount,12939,Other,215% of NY Medicaid HMO DRG,7523,,125% x Medicaid HMO amount,7523,Other,125% of NY Medicaid HMO DRG,0.01,30164,
"Thyroid, parathyroid & thyroglossal procedures",404-2,APR-DRG,,,,,,,,inpatient,,,163820.98,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39180,,"45,128 x DRG weight",39180,Other,base rate x DRG weight,35262,,"40,615 x DRG weight",35262,Other,base rate x DRG weight,33303,,"38,359 x DRG weight",33303,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14084,,186% x Medicaid HMO amount,14084,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29586,,"34,077 x DRG weight",29586,Other,base rate x DRG weight,25148,,"28,966 x DRG weight",25148,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7572,,DRG base rate x DRG weight + capital per discharge,7572,Other,100% of NY Medicaid HMO DRG,7572,,100% x Medicaid HMO amount,7572,Other,100% of NY Medicaid HMO DRG,7572,,100% x Medicaid HMO amount,7572,Other,100% of NY Medicaid HMO DRG,7572,,100% x Medicaid HMO amount,7572,Other,100% of NY Medicaid HMO DRG,17037,,225% x Medicaid HMO amount,17037,Other,225% of NY Medicaid HMO DRG,17037,,225% x Medicaid HMO amount,17037,Other,225% of NY Medicaid HMO DRG,17037,,225% x Medicaid HMO amount,17037,Other,225% of NY Medicaid HMO DRG,17037,,225% x Medicaid HMO amount,17037,Other,225% of NY Medicaid HMO DRG,10601,,140% x Medicaid HMO amount,10601,Other,140% of NY Medicaid HMO DRG,17037,,225% x Medicaid HMO amount,17037,Other,225% of NY Medicaid HMO DRG,20823,,275% x Medicaid HMO amount,20823,Other,275% of NY Medicaid HMO DRG,24533,,324% x Medicaid HMO amount,24533,Other,324% of NY Medicaid HMO DRG,16280,,215% x Medicaid HMO amount,16280,Other,215% of NY Medicaid HMO DRG,16280,,215% x Medicaid HMO amount,16280,Other,215% of NY Medicaid HMO DRG,9465,,125% x Medicaid HMO amount,9465,Other,125% of NY Medicaid HMO DRG,0.01,39180,
"Thyroid, parathyroid & thyroglossal procedures",404-3,APR-DRG,,,,,,,,inpatient,,,282536.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,100613,,"45,128 x DRG weight",100613,Other,base rate x DRG weight,90551,,"40,615 x DRG weight",90551,Other,base rate x DRG weight,85521,,"38,359 x DRG weight",85521,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33772,,186% x Medicaid HMO amount,33772,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,75975,,"34,077 x DRG weight",75975,Other,base rate x DRG weight,64580,,"28,966 x DRG weight",64580,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18157,,DRG base rate x DRG weight + capital per discharge,18157,Other,100% of NY Medicaid HMO DRG,18157,,100% x Medicaid HMO amount,18157,Other,100% of NY Medicaid HMO DRG,18157,,100% x Medicaid HMO amount,18157,Other,100% of NY Medicaid HMO DRG,18157,,100% x Medicaid HMO amount,18157,Other,100% of NY Medicaid HMO DRG,40853,,225% x Medicaid HMO amount,40853,Other,225% of NY Medicaid HMO DRG,40853,,225% x Medicaid HMO amount,40853,Other,225% of NY Medicaid HMO DRG,40853,,225% x Medicaid HMO amount,40853,Other,225% of NY Medicaid HMO DRG,40853,,225% x Medicaid HMO amount,40853,Other,225% of NY Medicaid HMO DRG,25420,,140% x Medicaid HMO amount,25420,Other,140% of NY Medicaid HMO DRG,40853,,225% x Medicaid HMO amount,40853,Other,225% of NY Medicaid HMO DRG,49932,,275% x Medicaid HMO amount,49932,Other,275% of NY Medicaid HMO DRG,58829,,324% x Medicaid HMO amount,58829,Other,324% of NY Medicaid HMO DRG,39038,,215% x Medicaid HMO amount,39038,Other,215% of NY Medicaid HMO DRG,39038,,215% x Medicaid HMO amount,39038,Other,215% of NY Medicaid HMO DRG,22696,,125% x Medicaid HMO amount,22696,Other,125% of NY Medicaid HMO DRG,0.01,100613,
"Thyroid, parathyroid & thyroglossal procedures",404-4,APR-DRG,,,,,,,,inpatient,,,755383.56,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,120343,,"45,128 x DRG weight",120343,Other,base rate x DRG weight,108308,,"40,615 x DRG weight",108308,Other,base rate x DRG weight,102292,,"38,359 x DRG weight",102292,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40094,,186% x Medicaid HMO amount,40094,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,90873,,"34,077 x DRG weight",90873,Other,base rate x DRG weight,77244,,"28,966 x DRG weight",77244,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21556,,DRG base rate x DRG weight + capital per discharge,21556,Other,100% of NY Medicaid HMO DRG,21556,,100% x Medicaid HMO amount,21556,Other,100% of NY Medicaid HMO DRG,21556,,100% x Medicaid HMO amount,21556,Other,100% of NY Medicaid HMO DRG,21556,,100% x Medicaid HMO amount,21556,Other,100% of NY Medicaid HMO DRG,48501,,225% x Medicaid HMO amount,48501,Other,225% of NY Medicaid HMO DRG,48501,,225% x Medicaid HMO amount,48501,Other,225% of NY Medicaid HMO DRG,48501,,225% x Medicaid HMO amount,48501,Other,225% of NY Medicaid HMO DRG,48501,,225% x Medicaid HMO amount,48501,Other,225% of NY Medicaid HMO DRG,30178,,140% x Medicaid HMO amount,30178,Other,140% of NY Medicaid HMO DRG,48501,,225% x Medicaid HMO amount,48501,Other,225% of NY Medicaid HMO DRG,59279,,275% x Medicaid HMO amount,59279,Other,275% of NY Medicaid HMO DRG,69841,,324% x Medicaid HMO amount,69841,Other,324% of NY Medicaid HMO DRG,46345,,215% x Medicaid HMO amount,46345,Other,215% of NY Medicaid HMO DRG,46345,,215% x Medicaid HMO amount,46345,Other,215% of NY Medicaid HMO DRG,26945,,125% x Medicaid HMO amount,26945,Other,125% of NY Medicaid HMO DRG,0.01,120343,
"Other procedures for endocrine, nutritional & metabolic disorders",405-1,APR-DRG,,,,,,,,inpatient,,,296577.89,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52610,,"45,128 x DRG weight",52610,Other,base rate x DRG weight,47349,,"40,615 x DRG weight",47349,Other,base rate x DRG weight,44719,,"38,359 x DRG weight",44719,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18388,,186% x Medicaid HMO amount,18388,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39727,,"34,077 x DRG weight",39727,Other,base rate x DRG weight,33769,,"28,966 x DRG weight",33769,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9886,,DRG base rate x DRG weight + capital per discharge,9886,Other,100% of NY Medicaid HMO DRG,9886,,100% x Medicaid HMO amount,9886,Other,100% of NY Medicaid HMO DRG,9886,,100% x Medicaid HMO amount,9886,Other,100% of NY Medicaid HMO DRG,9886,,100% x Medicaid HMO amount,9886,Other,100% of NY Medicaid HMO DRG,22244,,225% x Medicaid HMO amount,22244,Other,225% of NY Medicaid HMO DRG,22244,,225% x Medicaid HMO amount,22244,Other,225% of NY Medicaid HMO DRG,22244,,225% x Medicaid HMO amount,22244,Other,225% of NY Medicaid HMO DRG,22244,,225% x Medicaid HMO amount,22244,Other,225% of NY Medicaid HMO DRG,13840,,140% x Medicaid HMO amount,13840,Other,140% of NY Medicaid HMO DRG,22244,,225% x Medicaid HMO amount,22244,Other,225% of NY Medicaid HMO DRG,27187,,275% x Medicaid HMO amount,27187,Other,275% of NY Medicaid HMO DRG,32031,,324% x Medicaid HMO amount,32031,Other,324% of NY Medicaid HMO DRG,21255,,215% x Medicaid HMO amount,21255,Other,215% of NY Medicaid HMO DRG,21255,,215% x Medicaid HMO amount,21255,Other,215% of NY Medicaid HMO DRG,12358,,125% x Medicaid HMO amount,12358,Other,125% of NY Medicaid HMO DRG,0.01,52610,
"Other procedures for endocrine, nutritional & metabolic disorders",405-2,APR-DRG,,,,,,,,inpatient,,,206668.07,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,76429,,"45,128 x DRG weight",76429,Other,base rate x DRG weight,68786,,"40,615 x DRG weight",68786,Other,base rate x DRG weight,64965,,"38,359 x DRG weight",64965,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26021,,186% x Medicaid HMO amount,26021,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,57713,,"34,077 x DRG weight",57713,Other,base rate x DRG weight,49057,,"28,966 x DRG weight",49057,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13990,,DRG base rate x DRG weight + capital per discharge,13990,Other,100% of NY Medicaid HMO DRG,13990,,100% x Medicaid HMO amount,13990,Other,100% of NY Medicaid HMO DRG,13990,,100% x Medicaid HMO amount,13990,Other,100% of NY Medicaid HMO DRG,13990,,100% x Medicaid HMO amount,13990,Other,100% of NY Medicaid HMO DRG,31478,,225% x Medicaid HMO amount,31478,Other,225% of NY Medicaid HMO DRG,31478,,225% x Medicaid HMO amount,31478,Other,225% of NY Medicaid HMO DRG,31478,,225% x Medicaid HMO amount,31478,Other,225% of NY Medicaid HMO DRG,31478,,225% x Medicaid HMO amount,31478,Other,225% of NY Medicaid HMO DRG,19586,,140% x Medicaid HMO amount,19586,Other,140% of NY Medicaid HMO DRG,31478,,225% x Medicaid HMO amount,31478,Other,225% of NY Medicaid HMO DRG,38473,,275% x Medicaid HMO amount,38473,Other,275% of NY Medicaid HMO DRG,45328,,324% x Medicaid HMO amount,45328,Other,324% of NY Medicaid HMO DRG,30079,,215% x Medicaid HMO amount,30079,Other,215% of NY Medicaid HMO DRG,30079,,215% x Medicaid HMO amount,30079,Other,215% of NY Medicaid HMO DRG,17488,,125% x Medicaid HMO amount,17488,Other,125% of NY Medicaid HMO DRG,0.01,76429,
"Other procedures for endocrine, nutritional & metabolic disorders",405-3,APR-DRG,,,,,,,,inpatient,,,615415.96,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,132906,,"45,128 x DRG weight",132906,Other,base rate x DRG weight,119615,,"40,615 x DRG weight",119615,Other,base rate x DRG weight,112971,,"38,359 x DRG weight",112971,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44121,,186% x Medicaid HMO amount,44121,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,100360,,"34,077 x DRG weight",100360,Other,base rate x DRG weight,85308,,"28,966 x DRG weight",85308,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23721,,DRG base rate x DRG weight + capital per discharge,23721,Other,100% of NY Medicaid HMO DRG,23721,,100% x Medicaid HMO amount,23721,Other,100% of NY Medicaid HMO DRG,23721,,100% x Medicaid HMO amount,23721,Other,100% of NY Medicaid HMO DRG,23721,,100% x Medicaid HMO amount,23721,Other,100% of NY Medicaid HMO DRG,53372,,225% x Medicaid HMO amount,53372,Other,225% of NY Medicaid HMO DRG,53372,,225% x Medicaid HMO amount,53372,Other,225% of NY Medicaid HMO DRG,53372,,225% x Medicaid HMO amount,53372,Other,225% of NY Medicaid HMO DRG,53372,,225% x Medicaid HMO amount,53372,Other,225% of NY Medicaid HMO DRG,33209,,140% x Medicaid HMO amount,33209,Other,140% of NY Medicaid HMO DRG,53372,,225% x Medicaid HMO amount,53372,Other,225% of NY Medicaid HMO DRG,65233,,275% x Medicaid HMO amount,65233,Other,275% of NY Medicaid HMO DRG,76856,,324% x Medicaid HMO amount,76856,Other,324% of NY Medicaid HMO DRG,51000,,215% x Medicaid HMO amount,51000,Other,215% of NY Medicaid HMO DRG,51000,,215% x Medicaid HMO amount,51000,Other,215% of NY Medicaid HMO DRG,29651,,125% x Medicaid HMO amount,29651,Other,125% of NY Medicaid HMO DRG,0.01,132906,
"Other procedures for endocrine, nutritional & metabolic disorders",405-4,APR-DRG,,,,,,,,inpatient,,,213344.02,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,378538,,"45,128 x DRG weight",378538,Other,base rate x DRG weight,340683,,"40,615 x DRG weight",340683,Other,base rate x DRG weight,321759,,"38,359 x DRG weight",321759,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,122842,,186% x Medicaid HMO amount,122842,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,285841,,"34,077 x DRG weight",285841,Other,base rate x DRG weight,242970,,"28,966 x DRG weight",242970,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,66044,,DRG base rate x DRG weight + capital per discharge,66044,Other,100% of NY Medicaid HMO DRG,66044,,100% x Medicaid HMO amount,66044,Other,100% of NY Medicaid HMO DRG,66044,,100% x Medicaid HMO amount,66044,Other,100% of NY Medicaid HMO DRG,66044,,100% x Medicaid HMO amount,66044,Other,100% of NY Medicaid HMO DRG,148599,,225% x Medicaid HMO amount,148599,Other,225% of NY Medicaid HMO DRG,148599,,225% x Medicaid HMO amount,148599,Other,225% of NY Medicaid HMO DRG,148599,,225% x Medicaid HMO amount,148599,Other,225% of NY Medicaid HMO DRG,148599,,225% x Medicaid HMO amount,148599,Other,225% of NY Medicaid HMO DRG,92462,,140% x Medicaid HMO amount,92462,Other,140% of NY Medicaid HMO DRG,148599,,225% x Medicaid HMO amount,148599,Other,225% of NY Medicaid HMO DRG,181621,,275% x Medicaid HMO amount,181621,Other,275% of NY Medicaid HMO DRG,213983,,324% x Medicaid HMO amount,213983,Other,324% of NY Medicaid HMO DRG,141995,,215% x Medicaid HMO amount,141995,Other,215% of NY Medicaid HMO DRG,141995,,215% x Medicaid HMO amount,141995,Other,215% of NY Medicaid HMO DRG,82555,,125% x Medicaid HMO amount,82555,Other,125% of NY Medicaid HMO DRG,0.01,378538,
Diabetes,420-1,APR-DRG,,,,,,,,inpatient,,,62847.81,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20560,,"45,128 x DRG weight",20560,Other,base rate x DRG weight,18504,,"40,615 x DRG weight",18504,Other,base rate x DRG weight,17476,,"38,359 x DRG weight",17476,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8115,,186% x Medicaid HMO amount,8115,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15525,,"34,077 x DRG weight",15525,Other,base rate x DRG weight,13197,,"28,966 x DRG weight",13197,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4363,,DRG base rate x DRG weight + capital per discharge,4363,Other,100% of NY Medicaid HMO DRG,4363,,100% x Medicaid HMO amount,4363,Other,100% of NY Medicaid HMO DRG,4363,,100% x Medicaid HMO amount,4363,Other,100% of NY Medicaid HMO DRG,4363,,100% x Medicaid HMO amount,4363,Other,100% of NY Medicaid HMO DRG,9817,,225% x Medicaid HMO amount,9817,Other,225% of NY Medicaid HMO DRG,9817,,225% x Medicaid HMO amount,9817,Other,225% of NY Medicaid HMO DRG,9817,,225% x Medicaid HMO amount,9817,Other,225% of NY Medicaid HMO DRG,9817,,225% x Medicaid HMO amount,9817,Other,225% of NY Medicaid HMO DRG,6108,,140% x Medicaid HMO amount,6108,Other,140% of NY Medicaid HMO DRG,9817,,225% x Medicaid HMO amount,9817,Other,225% of NY Medicaid HMO DRG,11998,,275% x Medicaid HMO amount,11998,Other,275% of NY Medicaid HMO DRG,14136,,324% x Medicaid HMO amount,14136,Other,324% of NY Medicaid HMO DRG,9380,,215% x Medicaid HMO amount,9380,Other,215% of NY Medicaid HMO DRG,9380,,215% x Medicaid HMO amount,9380,Other,215% of NY Medicaid HMO DRG,5454,,125% x Medicaid HMO amount,5454,Other,125% of NY Medicaid HMO DRG,0.01,20560,
Diabetes,420-2,APR-DRG,,,,,,,,inpatient,,,75207.28,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28480,,"45,128 x DRG weight",28480,Other,base rate x DRG weight,25632,,"40,615 x DRG weight",25632,Other,base rate x DRG weight,24208,,"38,359 x DRG weight",24208,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10654,,186% x Medicaid HMO amount,10654,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21506,,"34,077 x DRG weight",21506,Other,base rate x DRG weight,18280,,"28,966 x DRG weight",18280,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5728,,DRG base rate x DRG weight + capital per discharge,5728,Other,100% of NY Medicaid HMO DRG,5728,,100% x Medicaid HMO amount,5728,Other,100% of NY Medicaid HMO DRG,5728,,100% x Medicaid HMO amount,5728,Other,100% of NY Medicaid HMO DRG,5728,,100% x Medicaid HMO amount,5728,Other,100% of NY Medicaid HMO DRG,12888,,225% x Medicaid HMO amount,12888,Other,225% of NY Medicaid HMO DRG,12888,,225% x Medicaid HMO amount,12888,Other,225% of NY Medicaid HMO DRG,12888,,225% x Medicaid HMO amount,12888,Other,225% of NY Medicaid HMO DRG,12888,,225% x Medicaid HMO amount,12888,Other,225% of NY Medicaid HMO DRG,8019,,140% x Medicaid HMO amount,8019,Other,140% of NY Medicaid HMO DRG,12888,,225% x Medicaid HMO amount,12888,Other,225% of NY Medicaid HMO DRG,15752,,275% x Medicaid HMO amount,15752,Other,275% of NY Medicaid HMO DRG,18559,,324% x Medicaid HMO amount,18559,Other,324% of NY Medicaid HMO DRG,12315,,215% x Medicaid HMO amount,12315,Other,215% of NY Medicaid HMO DRG,12315,,215% x Medicaid HMO amount,12315,Other,215% of NY Medicaid HMO DRG,7160,,125% x Medicaid HMO amount,7160,Other,125% of NY Medicaid HMO DRG,0.01,28480,
Diabetes,420-3,APR-DRG,,,,,,,,inpatient,,,133976.81,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44104,,"45,128 x DRG weight",44104,Other,base rate x DRG weight,39693,,"40,615 x DRG weight",39693,Other,base rate x DRG weight,37488,,"38,359 x DRG weight",37488,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15661,,186% x Medicaid HMO amount,15661,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33303,,"34,077 x DRG weight",33303,Other,base rate x DRG weight,28308,,"28,966 x DRG weight",28308,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8420,,DRG base rate x DRG weight + capital per discharge,8420,Other,100% of NY Medicaid HMO DRG,8420,,100% x Medicaid HMO amount,8420,Other,100% of NY Medicaid HMO DRG,8420,,100% x Medicaid HMO amount,8420,Other,100% of NY Medicaid HMO DRG,8420,,100% x Medicaid HMO amount,8420,Other,100% of NY Medicaid HMO DRG,18945,,225% x Medicaid HMO amount,18945,Other,225% of NY Medicaid HMO DRG,18945,,225% x Medicaid HMO amount,18945,Other,225% of NY Medicaid HMO DRG,18945,,225% x Medicaid HMO amount,18945,Other,225% of NY Medicaid HMO DRG,18945,,225% x Medicaid HMO amount,18945,Other,225% of NY Medicaid HMO DRG,11788,,140% x Medicaid HMO amount,11788,Other,140% of NY Medicaid HMO DRG,18945,,225% x Medicaid HMO amount,18945,Other,225% of NY Medicaid HMO DRG,23155,,275% x Medicaid HMO amount,23155,Other,275% of NY Medicaid HMO DRG,27281,,324% x Medicaid HMO amount,27281,Other,324% of NY Medicaid HMO DRG,18103,,215% x Medicaid HMO amount,18103,Other,215% of NY Medicaid HMO DRG,18103,,215% x Medicaid HMO amount,18103,Other,215% of NY Medicaid HMO DRG,10525,,125% x Medicaid HMO amount,10525,Other,125% of NY Medicaid HMO DRG,0.01,44104,
Diabetes,420-4,APR-DRG,,,,,,,,inpatient,,,223694.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,114625,,"45,128 x DRG weight",114625,Other,base rate x DRG weight,103162,,"40,615 x DRG weight",103162,Other,base rate x DRG weight,97432,,"38,359 x DRG weight",97432,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38262,,186% x Medicaid HMO amount,38262,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,86556,,"34,077 x DRG weight",86556,Other,base rate x DRG weight,73574,,"28,966 x DRG weight",73574,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20571,,DRG base rate x DRG weight + capital per discharge,20571,Other,100% of NY Medicaid HMO DRG,20571,,100% x Medicaid HMO amount,20571,Other,100% of NY Medicaid HMO DRG,20571,,100% x Medicaid HMO amount,20571,Other,100% of NY Medicaid HMO DRG,20571,,100% x Medicaid HMO amount,20571,Other,100% of NY Medicaid HMO DRG,46285,,225% x Medicaid HMO amount,46285,Other,225% of NY Medicaid HMO DRG,46285,,225% x Medicaid HMO amount,46285,Other,225% of NY Medicaid HMO DRG,46285,,225% x Medicaid HMO amount,46285,Other,225% of NY Medicaid HMO DRG,46285,,225% x Medicaid HMO amount,46285,Other,225% of NY Medicaid HMO DRG,28799,,140% x Medicaid HMO amount,28799,Other,140% of NY Medicaid HMO DRG,46285,,225% x Medicaid HMO amount,46285,Other,225% of NY Medicaid HMO DRG,56570,,275% x Medicaid HMO amount,56570,Other,275% of NY Medicaid HMO DRG,66650,,324% x Medicaid HMO amount,66650,Other,324% of NY Medicaid HMO DRG,44228,,215% x Medicaid HMO amount,44228,Other,215% of NY Medicaid HMO DRG,44228,,215% x Medicaid HMO amount,44228,Other,215% of NY Medicaid HMO DRG,25714,,125% x Medicaid HMO amount,25714,Other,125% of NY Medicaid HMO DRG,0.01,114625,
"Malnutrition, failure to thrive & other nutritional disorders",421-1,APR-DRG,,,,,,,,inpatient,,,127625.58,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28205,,"45,128 x DRG weight",28205,Other,base rate x DRG weight,25384,,"40,615 x DRG weight",25384,Other,base rate x DRG weight,23974,,"38,359 x DRG weight",23974,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10567,,186% x Medicaid HMO amount,10567,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21298,,"34,077 x DRG weight",21298,Other,base rate x DRG weight,18104,,"28,966 x DRG weight",18104,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5681,,DRG base rate x DRG weight + capital per discharge,5681,Other,100% of NY Medicaid HMO DRG,5681,,100% x Medicaid HMO amount,5681,Other,100% of NY Medicaid HMO DRG,5681,,100% x Medicaid HMO amount,5681,Other,100% of NY Medicaid HMO DRG,5681,,100% x Medicaid HMO amount,5681,Other,100% of NY Medicaid HMO DRG,12782,,225% x Medicaid HMO amount,12782,Other,225% of NY Medicaid HMO DRG,12782,,225% x Medicaid HMO amount,12782,Other,225% of NY Medicaid HMO DRG,12782,,225% x Medicaid HMO amount,12782,Other,225% of NY Medicaid HMO DRG,12782,,225% x Medicaid HMO amount,12782,Other,225% of NY Medicaid HMO DRG,7953,,140% x Medicaid HMO amount,7953,Other,140% of NY Medicaid HMO DRG,12782,,225% x Medicaid HMO amount,12782,Other,225% of NY Medicaid HMO DRG,15623,,275% x Medicaid HMO amount,15623,Other,275% of NY Medicaid HMO DRG,18406,,324% x Medicaid HMO amount,18406,Other,324% of NY Medicaid HMO DRG,12214,,215% x Medicaid HMO amount,12214,Other,215% of NY Medicaid HMO DRG,12214,,215% x Medicaid HMO amount,12214,Other,215% of NY Medicaid HMO DRG,7101,,125% x Medicaid HMO amount,7101,Other,125% of NY Medicaid HMO DRG,0.01,28205,
"Malnutrition, failure to thrive & other nutritional disorders",421-2,APR-DRG,,,,,,,,inpatient,,,121725.63,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41215,,"45,128 x DRG weight",41215,Other,base rate x DRG weight,37094,,"40,615 x DRG weight",37094,Other,base rate x DRG weight,35033,,"38,359 x DRG weight",35033,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14735,,186% x Medicaid HMO amount,14735,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31123,,"34,077 x DRG weight",31123,Other,base rate x DRG weight,26455,,"28,966 x DRG weight",26455,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7922,,DRG base rate x DRG weight + capital per discharge,7922,Other,100% of NY Medicaid HMO DRG,7922,,100% x Medicaid HMO amount,7922,Other,100% of NY Medicaid HMO DRG,7922,,100% x Medicaid HMO amount,7922,Other,100% of NY Medicaid HMO DRG,7922,,100% x Medicaid HMO amount,7922,Other,100% of NY Medicaid HMO DRG,17825,,225% x Medicaid HMO amount,17825,Other,225% of NY Medicaid HMO DRG,17825,,225% x Medicaid HMO amount,17825,Other,225% of NY Medicaid HMO DRG,17825,,225% x Medicaid HMO amount,17825,Other,225% of NY Medicaid HMO DRG,17825,,225% x Medicaid HMO amount,17825,Other,225% of NY Medicaid HMO DRG,11091,,140% x Medicaid HMO amount,11091,Other,140% of NY Medicaid HMO DRG,17825,,225% x Medicaid HMO amount,17825,Other,225% of NY Medicaid HMO DRG,21786,,275% x Medicaid HMO amount,21786,Other,275% of NY Medicaid HMO DRG,25667,,324% x Medicaid HMO amount,25667,Other,324% of NY Medicaid HMO DRG,17032,,215% x Medicaid HMO amount,17032,Other,215% of NY Medicaid HMO DRG,17032,,215% x Medicaid HMO amount,17032,Other,215% of NY Medicaid HMO DRG,9903,,125% x Medicaid HMO amount,9903,Other,125% of NY Medicaid HMO DRG,0.01,41215,
"Malnutrition, failure to thrive & other nutritional disorders",421-3,APR-DRG,,,,,,,,inpatient,,,355059.19,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,62620,,"45,128 x DRG weight",62620,Other,base rate x DRG weight,56357,,"40,615 x DRG weight",56357,Other,base rate x DRG weight,53227,,"38,359 x DRG weight",53227,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21595,,186% x Medicaid HMO amount,21595,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47285,,"34,077 x DRG weight",47285,Other,base rate x DRG weight,40193,,"28,966 x DRG weight",40193,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11610,,DRG base rate x DRG weight + capital per discharge,11610,Other,100% of NY Medicaid HMO DRG,11610,,100% x Medicaid HMO amount,11610,Other,100% of NY Medicaid HMO DRG,11610,,100% x Medicaid HMO amount,11610,Other,100% of NY Medicaid HMO DRG,11610,,100% x Medicaid HMO amount,11610,Other,100% of NY Medicaid HMO DRG,26123,,225% x Medicaid HMO amount,26123,Other,225% of NY Medicaid HMO DRG,26123,,225% x Medicaid HMO amount,26123,Other,225% of NY Medicaid HMO DRG,26123,,225% x Medicaid HMO amount,26123,Other,225% of NY Medicaid HMO DRG,26123,,225% x Medicaid HMO amount,26123,Other,225% of NY Medicaid HMO DRG,16254,,140% x Medicaid HMO amount,16254,Other,140% of NY Medicaid HMO DRG,26123,,225% x Medicaid HMO amount,26123,Other,225% of NY Medicaid HMO DRG,31928,,275% x Medicaid HMO amount,31928,Other,275% of NY Medicaid HMO DRG,37616,,324% x Medicaid HMO amount,37616,Other,324% of NY Medicaid HMO DRG,24962,,215% x Medicaid HMO amount,24962,Other,215% of NY Medicaid HMO DRG,24962,,215% x Medicaid HMO amount,24962,Other,215% of NY Medicaid HMO DRG,14513,,125% x Medicaid HMO amount,14513,Other,125% of NY Medicaid HMO DRG,0.01,62620,
"Malnutrition, failure to thrive & other nutritional disorders",421-4,APR-DRG,,,,,,,,inpatient,,,205682.34,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,144468,,"45,128 x DRG weight",144468,Other,base rate x DRG weight,130021,,"40,615 x DRG weight",130021,Other,base rate x DRG weight,122799,,"38,359 x DRG weight",122799,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47826,,186% x Medicaid HMO amount,47826,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,109091,,"34,077 x DRG weight",109091,Other,base rate x DRG weight,92729,,"28,966 x DRG weight",92729,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25713,,DRG base rate x DRG weight + capital per discharge,25713,Other,100% of NY Medicaid HMO DRG,25713,,100% x Medicaid HMO amount,25713,Other,100% of NY Medicaid HMO DRG,25713,,100% x Medicaid HMO amount,25713,Other,100% of NY Medicaid HMO DRG,25713,,100% x Medicaid HMO amount,25713,Other,100% of NY Medicaid HMO DRG,57854,,225% x Medicaid HMO amount,57854,Other,225% of NY Medicaid HMO DRG,57854,,225% x Medicaid HMO amount,57854,Other,225% of NY Medicaid HMO DRG,57854,,225% x Medicaid HMO amount,57854,Other,225% of NY Medicaid HMO DRG,57854,,225% x Medicaid HMO amount,57854,Other,225% of NY Medicaid HMO DRG,35998,,140% x Medicaid HMO amount,35998,Other,140% of NY Medicaid HMO DRG,57854,,225% x Medicaid HMO amount,57854,Other,225% of NY Medicaid HMO DRG,70711,,275% x Medicaid HMO amount,70711,Other,275% of NY Medicaid HMO DRG,83310,,324% x Medicaid HMO amount,83310,Other,324% of NY Medicaid HMO DRG,55283,,215% x Medicaid HMO amount,55283,Other,215% of NY Medicaid HMO DRG,55283,,215% x Medicaid HMO amount,55283,Other,215% of NY Medicaid HMO DRG,32141,,125% x Medicaid HMO amount,32141,Other,125% of NY Medicaid HMO DRG,0.01,144468,
Hypovolemia & related electrolyte disorders,422-1,APR-DRG,,,,,,,,inpatient,,,85262.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17063,,"45,128 x DRG weight",17063,Other,base rate x DRG weight,15357,,"40,615 x DRG weight",15357,Other,base rate x DRG weight,14504,,"38,359 x DRG weight",14504,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6995,,186% x Medicaid HMO amount,6995,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12885,,"34,077 x DRG weight",12885,Other,base rate x DRG weight,10952,,"28,966 x DRG weight",10952,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3761,,DRG base rate x DRG weight + capital per discharge,3761,Other,100% of NY Medicaid HMO DRG,3761,,100% x Medicaid HMO amount,3761,Other,100% of NY Medicaid HMO DRG,3761,,100% x Medicaid HMO amount,3761,Other,100% of NY Medicaid HMO DRG,3761,,100% x Medicaid HMO amount,3761,Other,100% of NY Medicaid HMO DRG,8462,,225% x Medicaid HMO amount,8462,Other,225% of NY Medicaid HMO DRG,8462,,225% x Medicaid HMO amount,8462,Other,225% of NY Medicaid HMO DRG,8462,,225% x Medicaid HMO amount,8462,Other,225% of NY Medicaid HMO DRG,8462,,225% x Medicaid HMO amount,8462,Other,225% of NY Medicaid HMO DRG,5265,,140% x Medicaid HMO amount,5265,Other,140% of NY Medicaid HMO DRG,8462,,225% x Medicaid HMO amount,8462,Other,225% of NY Medicaid HMO DRG,10343,,275% x Medicaid HMO amount,10343,Other,275% of NY Medicaid HMO DRG,12186,,324% x Medicaid HMO amount,12186,Other,324% of NY Medicaid HMO DRG,8086,,215% x Medicaid HMO amount,8086,Other,215% of NY Medicaid HMO DRG,8086,,215% x Medicaid HMO amount,8086,Other,215% of NY Medicaid HMO DRG,4701,,125% x Medicaid HMO amount,4701,Other,125% of NY Medicaid HMO DRG,0.01,17063,
Hypovolemia & related electrolyte disorders,422-2,APR-DRG,,,,,,,,inpatient,,,81502.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23737,,"45,128 x DRG weight",23737,Other,base rate x DRG weight,21363,,"40,615 x DRG weight",21363,Other,base rate x DRG weight,20177,,"38,359 x DRG weight",20177,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9134,,186% x Medicaid HMO amount,9134,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17925,,"34,077 x DRG weight",17925,Other,base rate x DRG weight,15236,,"28,966 x DRG weight",15236,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4911,,DRG base rate x DRG weight + capital per discharge,4911,Other,100% of NY Medicaid HMO DRG,4911,,100% x Medicaid HMO amount,4911,Other,100% of NY Medicaid HMO DRG,4911,,100% x Medicaid HMO amount,4911,Other,100% of NY Medicaid HMO DRG,4911,,100% x Medicaid HMO amount,4911,Other,100% of NY Medicaid HMO DRG,11050,,225% x Medicaid HMO amount,11050,Other,225% of NY Medicaid HMO DRG,11050,,225% x Medicaid HMO amount,11050,Other,225% of NY Medicaid HMO DRG,11050,,225% x Medicaid HMO amount,11050,Other,225% of NY Medicaid HMO DRG,11050,,225% x Medicaid HMO amount,11050,Other,225% of NY Medicaid HMO DRG,6875,,140% x Medicaid HMO amount,6875,Other,140% of NY Medicaid HMO DRG,11050,,225% x Medicaid HMO amount,11050,Other,225% of NY Medicaid HMO DRG,13505,,275% x Medicaid HMO amount,13505,Other,275% of NY Medicaid HMO DRG,15912,,324% x Medicaid HMO amount,15912,Other,324% of NY Medicaid HMO DRG,10559,,215% x Medicaid HMO amount,10559,Other,215% of NY Medicaid HMO DRG,10559,,215% x Medicaid HMO amount,10559,Other,215% of NY Medicaid HMO DRG,6139,,125% x Medicaid HMO amount,6139,Other,125% of NY Medicaid HMO DRG,0.01,23737,
Hypovolemia & related electrolyte disorders,422-3,APR-DRG,,,,,,,,inpatient,,,115102.3,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40705,,"45,128 x DRG weight",40705,Other,base rate x DRG weight,36635,,"40,615 x DRG weight",36635,Other,base rate x DRG weight,34600,,"38,359 x DRG weight",34600,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14571,,186% x Medicaid HMO amount,14571,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30737,,"34,077 x DRG weight",30737,Other,base rate x DRG weight,26127,,"28,966 x DRG weight",26127,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7834,,DRG base rate x DRG weight + capital per discharge,7834,Other,100% of NY Medicaid HMO DRG,7834,,100% x Medicaid HMO amount,7834,Other,100% of NY Medicaid HMO DRG,7834,,100% x Medicaid HMO amount,7834,Other,100% of NY Medicaid HMO DRG,7834,,100% x Medicaid HMO amount,7834,Other,100% of NY Medicaid HMO DRG,17627,,225% x Medicaid HMO amount,17627,Other,225% of NY Medicaid HMO DRG,17627,,225% x Medicaid HMO amount,17627,Other,225% of NY Medicaid HMO DRG,17627,,225% x Medicaid HMO amount,17627,Other,225% of NY Medicaid HMO DRG,17627,,225% x Medicaid HMO amount,17627,Other,225% of NY Medicaid HMO DRG,10968,,140% x Medicaid HMO amount,10968,Other,140% of NY Medicaid HMO DRG,17627,,225% x Medicaid HMO amount,17627,Other,225% of NY Medicaid HMO DRG,21544,,275% x Medicaid HMO amount,21544,Other,275% of NY Medicaid HMO DRG,25382,,324% x Medicaid HMO amount,25382,Other,324% of NY Medicaid HMO DRG,16843,,215% x Medicaid HMO amount,16843,Other,215% of NY Medicaid HMO DRG,16843,,215% x Medicaid HMO amount,16843,Other,215% of NY Medicaid HMO DRG,9793,,125% x Medicaid HMO amount,9793,Other,125% of NY Medicaid HMO DRG,0.01,40705,
Hypovolemia & related electrolyte disorders,422-4,APR-DRG,,,,,,,,inpatient,,,105920.44,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,102454,,"45,128 x DRG weight",102454,Other,base rate x DRG weight,92208,,"40,615 x DRG weight",92208,Other,base rate x DRG weight,87086,,"38,359 x DRG weight",87086,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34362,,186% x Medicaid HMO amount,34362,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,77365,,"34,077 x DRG weight",77365,Other,base rate x DRG weight,65762,,"28,966 x DRG weight",65762,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18474,,DRG base rate x DRG weight + capital per discharge,18474,Other,100% of NY Medicaid HMO DRG,18474,,100% x Medicaid HMO amount,18474,Other,100% of NY Medicaid HMO DRG,18474,,100% x Medicaid HMO amount,18474,Other,100% of NY Medicaid HMO DRG,18474,,100% x Medicaid HMO amount,18474,Other,100% of NY Medicaid HMO DRG,41567,,225% x Medicaid HMO amount,41567,Other,225% of NY Medicaid HMO DRG,41567,,225% x Medicaid HMO amount,41567,Other,225% of NY Medicaid HMO DRG,41567,,225% x Medicaid HMO amount,41567,Other,225% of NY Medicaid HMO DRG,41567,,225% x Medicaid HMO amount,41567,Other,225% of NY Medicaid HMO DRG,25864,,140% x Medicaid HMO amount,25864,Other,140% of NY Medicaid HMO DRG,41567,,225% x Medicaid HMO amount,41567,Other,225% of NY Medicaid HMO DRG,50804,,275% x Medicaid HMO amount,50804,Other,275% of NY Medicaid HMO DRG,59856,,324% x Medicaid HMO amount,59856,Other,324% of NY Medicaid HMO DRG,39719,,215% x Medicaid HMO amount,39719,Other,215% of NY Medicaid HMO DRG,39719,,215% x Medicaid HMO amount,39719,Other,215% of NY Medicaid HMO DRG,23093,,125% x Medicaid HMO amount,23093,Other,125% of NY Medicaid HMO DRG,0.01,102454,
Inborn errors of metabolism,423-1,APR-DRG,,,,,,,,inpatient,,,50691.92,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27727,,"45,128 x DRG weight",27727,Other,base rate x DRG weight,24954,,"40,615 x DRG weight",24954,Other,base rate x DRG weight,23568,,"38,359 x DRG weight",23568,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10412,,186% x Medicaid HMO amount,10412,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20937,,"34,077 x DRG weight",20937,Other,base rate x DRG weight,17797,,"28,966 x DRG weight",17797,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5598,,DRG base rate x DRG weight + capital per discharge,5598,Other,100% of NY Medicaid HMO DRG,5598,,100% x Medicaid HMO amount,5598,Other,100% of NY Medicaid HMO DRG,5598,,100% x Medicaid HMO amount,5598,Other,100% of NY Medicaid HMO DRG,5598,,100% x Medicaid HMO amount,5598,Other,100% of NY Medicaid HMO DRG,12596,,225% x Medicaid HMO amount,12596,Other,225% of NY Medicaid HMO DRG,12596,,225% x Medicaid HMO amount,12596,Other,225% of NY Medicaid HMO DRG,12596,,225% x Medicaid HMO amount,12596,Other,225% of NY Medicaid HMO DRG,12596,,225% x Medicaid HMO amount,12596,Other,225% of NY Medicaid HMO DRG,7837,,140% x Medicaid HMO amount,7837,Other,140% of NY Medicaid HMO DRG,12596,,225% x Medicaid HMO amount,12596,Other,225% of NY Medicaid HMO DRG,15395,,275% x Medicaid HMO amount,15395,Other,275% of NY Medicaid HMO DRG,18138,,324% x Medicaid HMO amount,18138,Other,324% of NY Medicaid HMO DRG,12036,,215% x Medicaid HMO amount,12036,Other,215% of NY Medicaid HMO DRG,12036,,215% x Medicaid HMO amount,12036,Other,215% of NY Medicaid HMO DRG,6998,,125% x Medicaid HMO amount,6998,Other,125% of NY Medicaid HMO DRG,0.01,27727,
Inborn errors of metabolism,423-2,APR-DRG,,,,,,,,inpatient,,,93533.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45638,,"45,128 x DRG weight",45638,Other,base rate x DRG weight,41074,,"40,615 x DRG weight",41074,Other,base rate x DRG weight,38792,,"38,359 x DRG weight",38792,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16152,,186% x Medicaid HMO amount,16152,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34462,,"34,077 x DRG weight",34462,Other,base rate x DRG weight,29293,,"28,966 x DRG weight",29293,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8684,,DRG base rate x DRG weight + capital per discharge,8684,Other,100% of NY Medicaid HMO DRG,8684,,100% x Medicaid HMO amount,8684,Other,100% of NY Medicaid HMO DRG,8684,,100% x Medicaid HMO amount,8684,Other,100% of NY Medicaid HMO DRG,8684,,100% x Medicaid HMO amount,8684,Other,100% of NY Medicaid HMO DRG,19539,,225% x Medicaid HMO amount,19539,Other,225% of NY Medicaid HMO DRG,19539,,225% x Medicaid HMO amount,19539,Other,225% of NY Medicaid HMO DRG,19539,,225% x Medicaid HMO amount,19539,Other,225% of NY Medicaid HMO DRG,19539,,225% x Medicaid HMO amount,19539,Other,225% of NY Medicaid HMO DRG,12158,,140% x Medicaid HMO amount,12158,Other,140% of NY Medicaid HMO DRG,19539,,225% x Medicaid HMO amount,19539,Other,225% of NY Medicaid HMO DRG,23881,,275% x Medicaid HMO amount,23881,Other,275% of NY Medicaid HMO DRG,28136,,324% x Medicaid HMO amount,28136,Other,324% of NY Medicaid HMO DRG,18671,,215% x Medicaid HMO amount,18671,Other,215% of NY Medicaid HMO DRG,18671,,215% x Medicaid HMO amount,18671,Other,215% of NY Medicaid HMO DRG,10855,,125% x Medicaid HMO amount,10855,Other,125% of NY Medicaid HMO DRG,0.01,45638,
Inborn errors of metabolism,423-3,APR-DRG,,,,,,,,inpatient,,,74556.86,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,72196,,"45,128 x DRG weight",72196,Other,base rate x DRG weight,64976,,"40,615 x DRG weight",64976,Other,base rate x DRG weight,61367,,"38,359 x DRG weight",61367,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24664,,186% x Medicaid HMO amount,24664,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54516,,"34,077 x DRG weight",54516,Other,base rate x DRG weight,46340,,"28,966 x DRG weight",46340,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13260,,DRG base rate x DRG weight + capital per discharge,13260,Other,100% of NY Medicaid HMO DRG,13260,,100% x Medicaid HMO amount,13260,Other,100% of NY Medicaid HMO DRG,13260,,100% x Medicaid HMO amount,13260,Other,100% of NY Medicaid HMO DRG,13260,,100% x Medicaid HMO amount,13260,Other,100% of NY Medicaid HMO DRG,29835,,225% x Medicaid HMO amount,29835,Other,225% of NY Medicaid HMO DRG,29835,,225% x Medicaid HMO amount,29835,Other,225% of NY Medicaid HMO DRG,29835,,225% x Medicaid HMO amount,29835,Other,225% of NY Medicaid HMO DRG,29835,,225% x Medicaid HMO amount,29835,Other,225% of NY Medicaid HMO DRG,18564,,140% x Medicaid HMO amount,18564,Other,140% of NY Medicaid HMO DRG,29835,,225% x Medicaid HMO amount,29835,Other,225% of NY Medicaid HMO DRG,36465,,275% x Medicaid HMO amount,36465,Other,275% of NY Medicaid HMO DRG,42962,,324% x Medicaid HMO amount,42962,Other,324% of NY Medicaid HMO DRG,28509,,215% x Medicaid HMO amount,28509,Other,215% of NY Medicaid HMO DRG,28509,,215% x Medicaid HMO amount,28509,Other,215% of NY Medicaid HMO DRG,16575,,125% x Medicaid HMO amount,16575,Other,125% of NY Medicaid HMO DRG,0.01,72196,
Inborn errors of metabolism,423-4,APR-DRG,,,,,,,,inpatient,,,93533.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,245420,,"45,128 x DRG weight",245420,Other,base rate x DRG weight,220877,,"40,615 x DRG weight",220877,Other,base rate x DRG weight,208608,,"38,359 x DRG weight",208608,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,80179,,186% x Medicaid HMO amount,80179,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,185321,,"34,077 x DRG weight",185321,Other,base rate x DRG weight,157526,,"28,966 x DRG weight",157526,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43107,,DRG base rate x DRG weight + capital per discharge,43107,Other,100% of NY Medicaid HMO DRG,43107,,100% x Medicaid HMO amount,43107,Other,100% of NY Medicaid HMO DRG,43107,,100% x Medicaid HMO amount,43107,Other,100% of NY Medicaid HMO DRG,43107,,100% x Medicaid HMO amount,43107,Other,100% of NY Medicaid HMO DRG,96991,,225% x Medicaid HMO amount,96991,Other,225% of NY Medicaid HMO DRG,96991,,225% x Medicaid HMO amount,96991,Other,225% of NY Medicaid HMO DRG,96991,,225% x Medicaid HMO amount,96991,Other,225% of NY Medicaid HMO DRG,96991,,225% x Medicaid HMO amount,96991,Other,225% of NY Medicaid HMO DRG,60350,,140% x Medicaid HMO amount,60350,Other,140% of NY Medicaid HMO DRG,96991,,225% x Medicaid HMO amount,96991,Other,225% of NY Medicaid HMO DRG,118544,,275% x Medicaid HMO amount,118544,Other,275% of NY Medicaid HMO DRG,139667,,324% x Medicaid HMO amount,139667,Other,324% of NY Medicaid HMO DRG,92680,,215% x Medicaid HMO amount,92680,Other,215% of NY Medicaid HMO DRG,92680,,215% x Medicaid HMO amount,92680,Other,215% of NY Medicaid HMO DRG,53884,,125% x Medicaid HMO amount,53884,Other,125% of NY Medicaid HMO DRG,0.01,245420,
Other endocrine disorders,424-1,APR-DRG,,,,,,,,inpatient,,,68263.39,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22514,,"45,128 x DRG weight",22514,Other,base rate x DRG weight,20263,,"40,615 x DRG weight",20263,Other,base rate x DRG weight,19137,,"38,359 x DRG weight",19137,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8742,,186% x Medicaid HMO amount,8742,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17001,,"34,077 x DRG weight",17001,Other,base rate x DRG weight,14451,,"28,966 x DRG weight",14451,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4700,,DRG base rate x DRG weight + capital per discharge,4700,Other,100% of NY Medicaid HMO DRG,4700,,100% x Medicaid HMO amount,4700,Other,100% of NY Medicaid HMO DRG,4700,,100% x Medicaid HMO amount,4700,Other,100% of NY Medicaid HMO DRG,4700,,100% x Medicaid HMO amount,4700,Other,100% of NY Medicaid HMO DRG,10575,,225% x Medicaid HMO amount,10575,Other,225% of NY Medicaid HMO DRG,10575,,225% x Medicaid HMO amount,10575,Other,225% of NY Medicaid HMO DRG,10575,,225% x Medicaid HMO amount,10575,Other,225% of NY Medicaid HMO DRG,10575,,225% x Medicaid HMO amount,10575,Other,225% of NY Medicaid HMO DRG,6580,,140% x Medicaid HMO amount,6580,Other,140% of NY Medicaid HMO DRG,10575,,225% x Medicaid HMO amount,10575,Other,225% of NY Medicaid HMO DRG,12925,,275% x Medicaid HMO amount,12925,Other,275% of NY Medicaid HMO DRG,15228,,324% x Medicaid HMO amount,15228,Other,324% of NY Medicaid HMO DRG,10105,,215% x Medicaid HMO amount,10105,Other,215% of NY Medicaid HMO DRG,10105,,215% x Medicaid HMO amount,10105,Other,215% of NY Medicaid HMO DRG,5875,,125% x Medicaid HMO amount,5875,Other,125% of NY Medicaid HMO DRG,0.01,22514,
Other endocrine disorders,424-2,APR-DRG,,,,,,,,inpatient,,,95654.15,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34270,,"45,128 x DRG weight",34270,Other,base rate x DRG weight,30843,,"40,615 x DRG weight",30843,Other,base rate x DRG weight,29130,,"38,359 x DRG weight",29130,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12510,,186% x Medicaid HMO amount,12510,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25878,,"34,077 x DRG weight",25878,Other,base rate x DRG weight,21997,,"28,966 x DRG weight",21997,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6726,,DRG base rate x DRG weight + capital per discharge,6726,Other,100% of NY Medicaid HMO DRG,6726,,100% x Medicaid HMO amount,6726,Other,100% of NY Medicaid HMO DRG,6726,,100% x Medicaid HMO amount,6726,Other,100% of NY Medicaid HMO DRG,6726,,100% x Medicaid HMO amount,6726,Other,100% of NY Medicaid HMO DRG,15134,,225% x Medicaid HMO amount,15134,Other,225% of NY Medicaid HMO DRG,15134,,225% x Medicaid HMO amount,15134,Other,225% of NY Medicaid HMO DRG,15134,,225% x Medicaid HMO amount,15134,Other,225% of NY Medicaid HMO DRG,15134,,225% x Medicaid HMO amount,15134,Other,225% of NY Medicaid HMO DRG,9416,,140% x Medicaid HMO amount,9416,Other,140% of NY Medicaid HMO DRG,15134,,225% x Medicaid HMO amount,15134,Other,225% of NY Medicaid HMO DRG,18497,,275% x Medicaid HMO amount,18497,Other,275% of NY Medicaid HMO DRG,21792,,324% x Medicaid HMO amount,21792,Other,324% of NY Medicaid HMO DRG,14461,,215% x Medicaid HMO amount,14461,Other,215% of NY Medicaid HMO DRG,14461,,215% x Medicaid HMO amount,14461,Other,215% of NY Medicaid HMO DRG,8408,,125% x Medicaid HMO amount,8408,Other,125% of NY Medicaid HMO DRG,0.01,34270,
Other endocrine disorders,424-3,APR-DRG,,,,,,,,inpatient,,,207825.95,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53490,,"45,128 x DRG weight",53490,Other,base rate x DRG weight,48141,,"40,615 x DRG weight",48141,Other,base rate x DRG weight,45467,,"38,359 x DRG weight",45467,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18669,,186% x Medicaid HMO amount,18669,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40391,,"34,077 x DRG weight",40391,Other,base rate x DRG weight,34333,,"28,966 x DRG weight",34333,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10037,,DRG base rate x DRG weight + capital per discharge,10037,Other,100% of NY Medicaid HMO DRG,10037,,100% x Medicaid HMO amount,10037,Other,100% of NY Medicaid HMO DRG,10037,,100% x Medicaid HMO amount,10037,Other,100% of NY Medicaid HMO DRG,10037,,100% x Medicaid HMO amount,10037,Other,100% of NY Medicaid HMO DRG,22583,,225% x Medicaid HMO amount,22583,Other,225% of NY Medicaid HMO DRG,22583,,225% x Medicaid HMO amount,22583,Other,225% of NY Medicaid HMO DRG,22583,,225% x Medicaid HMO amount,22583,Other,225% of NY Medicaid HMO DRG,22583,,225% x Medicaid HMO amount,22583,Other,225% of NY Medicaid HMO DRG,14052,,140% x Medicaid HMO amount,14052,Other,140% of NY Medicaid HMO DRG,22583,,225% x Medicaid HMO amount,22583,Other,225% of NY Medicaid HMO DRG,27602,,275% x Medicaid HMO amount,27602,Other,275% of NY Medicaid HMO DRG,32520,,324% x Medicaid HMO amount,32520,Other,324% of NY Medicaid HMO DRG,21580,,215% x Medicaid HMO amount,21580,Other,215% of NY Medicaid HMO DRG,21580,,215% x Medicaid HMO amount,21580,Other,215% of NY Medicaid HMO DRG,12546,,125% x Medicaid HMO amount,12546,Other,125% of NY Medicaid HMO DRG,0.01,53490,
Other endocrine disorders,424-4,APR-DRG,,,,,,,,inpatient,,,388170.69,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,125596,,"45,128 x DRG weight",125596,Other,base rate x DRG weight,113036,,"40,615 x DRG weight",113036,Other,base rate x DRG weight,106757,,"38,359 x DRG weight",106757,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41777,,186% x Medicaid HMO amount,41777,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,94840,,"34,077 x DRG weight",94840,Other,base rate x DRG weight,80615,,"28,966 x DRG weight",80615,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22461,,DRG base rate x DRG weight + capital per discharge,22461,Other,100% of NY Medicaid HMO DRG,22461,,100% x Medicaid HMO amount,22461,Other,100% of NY Medicaid HMO DRG,22461,,100% x Medicaid HMO amount,22461,Other,100% of NY Medicaid HMO DRG,22461,,100% x Medicaid HMO amount,22461,Other,100% of NY Medicaid HMO DRG,50537,,225% x Medicaid HMO amount,50537,Other,225% of NY Medicaid HMO DRG,50537,,225% x Medicaid HMO amount,50537,Other,225% of NY Medicaid HMO DRG,50537,,225% x Medicaid HMO amount,50537,Other,225% of NY Medicaid HMO DRG,50537,,225% x Medicaid HMO amount,50537,Other,225% of NY Medicaid HMO DRG,31445,,140% x Medicaid HMO amount,31445,Other,140% of NY Medicaid HMO DRG,50537,,225% x Medicaid HMO amount,50537,Other,225% of NY Medicaid HMO DRG,61768,,275% x Medicaid HMO amount,61768,Other,275% of NY Medicaid HMO DRG,72774,,324% x Medicaid HMO amount,72774,Other,324% of NY Medicaid HMO DRG,48291,,215% x Medicaid HMO amount,48291,Other,215% of NY Medicaid HMO DRG,48291,,215% x Medicaid HMO amount,48291,Other,215% of NY Medicaid HMO DRG,28076,,125% x Medicaid HMO amount,28076,Other,125% of NY Medicaid HMO DRG,0.01,125596,
Electrolyte disorders except hypovolemia related,425-1,APR-DRG,,,,,,,,inpatient,,,105839.05,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19441,,"45,128 x DRG weight",19441,Other,base rate x DRG weight,17497,,"40,615 x DRG weight",17497,Other,base rate x DRG weight,16525,,"38,359 x DRG weight",16525,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7758,,186% x Medicaid HMO amount,7758,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14680,,"34,077 x DRG weight",14680,Other,base rate x DRG weight,12479,,"28,966 x DRG weight",12479,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4171,,DRG base rate x DRG weight + capital per discharge,4171,Other,100% of NY Medicaid HMO DRG,4171,,100% x Medicaid HMO amount,4171,Other,100% of NY Medicaid HMO DRG,4171,,100% x Medicaid HMO amount,4171,Other,100% of NY Medicaid HMO DRG,4171,,100% x Medicaid HMO amount,4171,Other,100% of NY Medicaid HMO DRG,9385,,225% x Medicaid HMO amount,9385,Other,225% of NY Medicaid HMO DRG,9385,,225% x Medicaid HMO amount,9385,Other,225% of NY Medicaid HMO DRG,9385,,225% x Medicaid HMO amount,9385,Other,225% of NY Medicaid HMO DRG,9385,,225% x Medicaid HMO amount,9385,Other,225% of NY Medicaid HMO DRG,5839,,140% x Medicaid HMO amount,5839,Other,140% of NY Medicaid HMO DRG,9385,,225% x Medicaid HMO amount,9385,Other,225% of NY Medicaid HMO DRG,11470,,275% x Medicaid HMO amount,11470,Other,275% of NY Medicaid HMO DRG,13514,,324% x Medicaid HMO amount,13514,Other,324% of NY Medicaid HMO DRG,8968,,215% x Medicaid HMO amount,8968,Other,215% of NY Medicaid HMO DRG,8968,,215% x Medicaid HMO amount,8968,Other,215% of NY Medicaid HMO DRG,5214,,125% x Medicaid HMO amount,5214,Other,125% of NY Medicaid HMO DRG,0.01,19441,
Electrolyte disorders except hypovolemia related,425-2,APR-DRG,,,,,,,,inpatient,,,120854.7,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27113,,"45,128 x DRG weight",27113,Other,base rate x DRG weight,24401,,"40,615 x DRG weight",24401,Other,base rate x DRG weight,23046,,"38,359 x DRG weight",23046,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10215,,186% x Medicaid HMO amount,10215,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20473,,"34,077 x DRG weight",20473,Other,base rate x DRG weight,17403,,"28,966 x DRG weight",17403,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5492,,DRG base rate x DRG weight + capital per discharge,5492,Other,100% of NY Medicaid HMO DRG,5492,,100% x Medicaid HMO amount,5492,Other,100% of NY Medicaid HMO DRG,5492,,100% x Medicaid HMO amount,5492,Other,100% of NY Medicaid HMO DRG,5492,,100% x Medicaid HMO amount,5492,Other,100% of NY Medicaid HMO DRG,12357,,225% x Medicaid HMO amount,12357,Other,225% of NY Medicaid HMO DRG,12357,,225% x Medicaid HMO amount,12357,Other,225% of NY Medicaid HMO DRG,12357,,225% x Medicaid HMO amount,12357,Other,225% of NY Medicaid HMO DRG,12357,,225% x Medicaid HMO amount,12357,Other,225% of NY Medicaid HMO DRG,7689,,140% x Medicaid HMO amount,7689,Other,140% of NY Medicaid HMO DRG,12357,,225% x Medicaid HMO amount,12357,Other,225% of NY Medicaid HMO DRG,15103,,275% x Medicaid HMO amount,15103,Other,275% of NY Medicaid HMO DRG,17794,,324% x Medicaid HMO amount,17794,Other,324% of NY Medicaid HMO DRG,11808,,215% x Medicaid HMO amount,11808,Other,215% of NY Medicaid HMO DRG,11808,,215% x Medicaid HMO amount,11808,Other,215% of NY Medicaid HMO DRG,6865,,125% x Medicaid HMO amount,6865,Other,125% of NY Medicaid HMO DRG,0.01,27113,
Electrolyte disorders except hypovolemia related,425-3,APR-DRG,,,,,,,,inpatient,,,159337.12,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45056,,"45,128 x DRG weight",45056,Other,base rate x DRG weight,40550,,"40,615 x DRG weight",40550,Other,base rate x DRG weight,38298,,"38,359 x DRG weight",38298,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15966,,186% x Medicaid HMO amount,15966,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34022,,"34,077 x DRG weight",34022,Other,base rate x DRG weight,28920,,"28,966 x DRG weight",28920,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8584,,DRG base rate x DRG weight + capital per discharge,8584,Other,100% of NY Medicaid HMO DRG,8584,,100% x Medicaid HMO amount,8584,Other,100% of NY Medicaid HMO DRG,8584,,100% x Medicaid HMO amount,8584,Other,100% of NY Medicaid HMO DRG,8584,,100% x Medicaid HMO amount,8584,Other,100% of NY Medicaid HMO DRG,19314,,225% x Medicaid HMO amount,19314,Other,225% of NY Medicaid HMO DRG,19314,,225% x Medicaid HMO amount,19314,Other,225% of NY Medicaid HMO DRG,19314,,225% x Medicaid HMO amount,19314,Other,225% of NY Medicaid HMO DRG,19314,,225% x Medicaid HMO amount,19314,Other,225% of NY Medicaid HMO DRG,12018,,140% x Medicaid HMO amount,12018,Other,140% of NY Medicaid HMO DRG,19314,,225% x Medicaid HMO amount,19314,Other,225% of NY Medicaid HMO DRG,23606,,275% x Medicaid HMO amount,23606,Other,275% of NY Medicaid HMO DRG,27812,,324% x Medicaid HMO amount,27812,Other,324% of NY Medicaid HMO DRG,18456,,215% x Medicaid HMO amount,18456,Other,215% of NY Medicaid HMO DRG,18456,,215% x Medicaid HMO amount,18456,Other,215% of NY Medicaid HMO DRG,10730,,125% x Medicaid HMO amount,10730,Other,125% of NY Medicaid HMO DRG,0.01,45056,
Electrolyte disorders except hypovolemia related,425-4,APR-DRG,,,,,,,,inpatient,,,303475.19,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,112414,,"45,128 x DRG weight",112414,Other,base rate x DRG weight,101172,,"40,615 x DRG weight",101172,Other,base rate x DRG weight,95552,,"38,359 x DRG weight",95552,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37553,,186% x Medicaid HMO amount,37553,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,84886,,"34,077 x DRG weight",84886,Other,base rate x DRG weight,72154,,"28,966 x DRG weight",72154,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20190,,DRG base rate x DRG weight + capital per discharge,20190,Other,100% of NY Medicaid HMO DRG,20190,,100% x Medicaid HMO amount,20190,Other,100% of NY Medicaid HMO DRG,20190,,100% x Medicaid HMO amount,20190,Other,100% of NY Medicaid HMO DRG,20190,,100% x Medicaid HMO amount,20190,Other,100% of NY Medicaid HMO DRG,45428,,225% x Medicaid HMO amount,45428,Other,225% of NY Medicaid HMO DRG,45428,,225% x Medicaid HMO amount,45428,Other,225% of NY Medicaid HMO DRG,45428,,225% x Medicaid HMO amount,45428,Other,225% of NY Medicaid HMO DRG,45428,,225% x Medicaid HMO amount,45428,Other,225% of NY Medicaid HMO DRG,28266,,140% x Medicaid HMO amount,28266,Other,140% of NY Medicaid HMO DRG,45428,,225% x Medicaid HMO amount,45428,Other,225% of NY Medicaid HMO DRG,55523,,275% x Medicaid HMO amount,55523,Other,275% of NY Medicaid HMO DRG,65416,,324% x Medicaid HMO amount,65416,Other,324% of NY Medicaid HMO DRG,43409,,215% x Medicaid HMO amount,43409,Other,215% of NY Medicaid HMO DRG,43409,,215% x Medicaid HMO amount,43409,Other,215% of NY Medicaid HMO DRG,25238,,125% x Medicaid HMO amount,25238,Other,125% of NY Medicaid HMO DRG,0.01,112414,
Major bladder procedures,441-1,APR-DRG,,,,,,,,inpatient,,,180473.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,57782,,"45,128 x DRG weight",57782,Other,base rate x DRG weight,52003,,"40,615 x DRG weight",52003,Other,base rate x DRG weight,49115,,"38,359 x DRG weight",49115,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20045,,186% x Medicaid HMO amount,20045,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43632,,"34,077 x DRG weight",43632,Other,base rate x DRG weight,37088,,"28,966 x DRG weight",37088,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10777,,DRG base rate x DRG weight + capital per discharge,10777,Other,100% of NY Medicaid HMO DRG,10777,,100% x Medicaid HMO amount,10777,Other,100% of NY Medicaid HMO DRG,10777,,100% x Medicaid HMO amount,10777,Other,100% of NY Medicaid HMO DRG,10777,,100% x Medicaid HMO amount,10777,Other,100% of NY Medicaid HMO DRG,24248,,225% x Medicaid HMO amount,24248,Other,225% of NY Medicaid HMO DRG,24248,,225% x Medicaid HMO amount,24248,Other,225% of NY Medicaid HMO DRG,24248,,225% x Medicaid HMO amount,24248,Other,225% of NY Medicaid HMO DRG,24248,,225% x Medicaid HMO amount,24248,Other,225% of NY Medicaid HMO DRG,15088,,140% x Medicaid HMO amount,15088,Other,140% of NY Medicaid HMO DRG,24248,,225% x Medicaid HMO amount,24248,Other,225% of NY Medicaid HMO DRG,29637,,275% x Medicaid HMO amount,29637,Other,275% of NY Medicaid HMO DRG,34917,,324% x Medicaid HMO amount,34917,Other,324% of NY Medicaid HMO DRG,23171,,215% x Medicaid HMO amount,23171,Other,215% of NY Medicaid HMO DRG,23171,,215% x Medicaid HMO amount,23171,Other,215% of NY Medicaid HMO DRG,13471,,125% x Medicaid HMO amount,13471,Other,125% of NY Medicaid HMO DRG,0.01,57782,
Major bladder procedures,441-2,APR-DRG,,,,,,,,inpatient,,,340110.47,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,100468,,"45,128 x DRG weight",100468,Other,base rate x DRG weight,90421,,"40,615 x DRG weight",90421,Other,base rate x DRG weight,85399,,"38,359 x DRG weight",85399,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33726,,186% x Medicaid HMO amount,33726,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,75866,,"34,077 x DRG weight",75866,Other,base rate x DRG weight,64487,,"28,966 x DRG weight",64487,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18132,,DRG base rate x DRG weight + capital per discharge,18132,Other,100% of NY Medicaid HMO DRG,18132,,100% x Medicaid HMO amount,18132,Other,100% of NY Medicaid HMO DRG,18132,,100% x Medicaid HMO amount,18132,Other,100% of NY Medicaid HMO DRG,18132,,100% x Medicaid HMO amount,18132,Other,100% of NY Medicaid HMO DRG,40797,,225% x Medicaid HMO amount,40797,Other,225% of NY Medicaid HMO DRG,40797,,225% x Medicaid HMO amount,40797,Other,225% of NY Medicaid HMO DRG,40797,,225% x Medicaid HMO amount,40797,Other,225% of NY Medicaid HMO DRG,40797,,225% x Medicaid HMO amount,40797,Other,225% of NY Medicaid HMO DRG,25385,,140% x Medicaid HMO amount,25385,Other,140% of NY Medicaid HMO DRG,40797,,225% x Medicaid HMO amount,40797,Other,225% of NY Medicaid HMO DRG,49863,,275% x Medicaid HMO amount,49863,Other,275% of NY Medicaid HMO DRG,58748,,324% x Medicaid HMO amount,58748,Other,324% of NY Medicaid HMO DRG,38984,,215% x Medicaid HMO amount,38984,Other,215% of NY Medicaid HMO DRG,38984,,215% x Medicaid HMO amount,38984,Other,215% of NY Medicaid HMO DRG,22665,,125% x Medicaid HMO amount,22665,Other,125% of NY Medicaid HMO DRG,0.01,100468,
Major bladder procedures,441-3,APR-DRG,,,,,,,,inpatient,,,322830.08,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,142049,,"45,128 x DRG weight",142049,Other,base rate x DRG weight,127844,,"40,615 x DRG weight",127844,Other,base rate x DRG weight,120743,,"38,359 x DRG weight",120743,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47051,,186% x Medicaid HMO amount,47051,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,107264,,"34,077 x DRG weight",107264,Other,base rate x DRG weight,91176,,"28,966 x DRG weight",91176,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25296,,DRG base rate x DRG weight + capital per discharge,25296,Other,100% of NY Medicaid HMO DRG,25296,,100% x Medicaid HMO amount,25296,Other,100% of NY Medicaid HMO DRG,25296,,100% x Medicaid HMO amount,25296,Other,100% of NY Medicaid HMO DRG,25296,,100% x Medicaid HMO amount,25296,Other,100% of NY Medicaid HMO DRG,56916,,225% x Medicaid HMO amount,56916,Other,225% of NY Medicaid HMO DRG,56916,,225% x Medicaid HMO amount,56916,Other,225% of NY Medicaid HMO DRG,56916,,225% x Medicaid HMO amount,56916,Other,225% of NY Medicaid HMO DRG,56916,,225% x Medicaid HMO amount,56916,Other,225% of NY Medicaid HMO DRG,35414,,140% x Medicaid HMO amount,35414,Other,140% of NY Medicaid HMO DRG,56916,,225% x Medicaid HMO amount,56916,Other,225% of NY Medicaid HMO DRG,69564,,275% x Medicaid HMO amount,69564,Other,275% of NY Medicaid HMO DRG,81959,,324% x Medicaid HMO amount,81959,Other,324% of NY Medicaid HMO DRG,54386,,215% x Medicaid HMO amount,54386,Other,215% of NY Medicaid HMO DRG,54386,,215% x Medicaid HMO amount,54386,Other,215% of NY Medicaid HMO DRG,31620,,125% x Medicaid HMO amount,31620,Other,125% of NY Medicaid HMO DRG,0.01,142049,
Major bladder procedures,441-4,APR-DRG,,,,,,,,inpatient,,,1688756.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,305214,,"45,128 x DRG weight",305214,Other,base rate x DRG weight,274691,,"40,615 x DRG weight",274691,Other,base rate x DRG weight,259433,,"38,359 x DRG weight",259433,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,99343,,186% x Medicaid HMO amount,99343,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,230473,,"34,077 x DRG weight",230473,Other,base rate x DRG weight,195906,,"28,966 x DRG weight",195906,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53410,,DRG base rate x DRG weight + capital per discharge,53410,Other,100% of NY Medicaid HMO DRG,53410,,100% x Medicaid HMO amount,53410,Other,100% of NY Medicaid HMO DRG,53410,,100% x Medicaid HMO amount,53410,Other,100% of NY Medicaid HMO DRG,53410,,100% x Medicaid HMO amount,53410,Other,100% of NY Medicaid HMO DRG,120173,,225% x Medicaid HMO amount,120173,Other,225% of NY Medicaid HMO DRG,120173,,225% x Medicaid HMO amount,120173,Other,225% of NY Medicaid HMO DRG,120173,,225% x Medicaid HMO amount,120173,Other,225% of NY Medicaid HMO DRG,120173,,225% x Medicaid HMO amount,120173,Other,225% of NY Medicaid HMO DRG,74774,,140% x Medicaid HMO amount,74774,Other,140% of NY Medicaid HMO DRG,120173,,225% x Medicaid HMO amount,120173,Other,225% of NY Medicaid HMO DRG,146878,,275% x Medicaid HMO amount,146878,Other,275% of NY Medicaid HMO DRG,173048,,324% x Medicaid HMO amount,173048,Other,324% of NY Medicaid HMO DRG,114832,,215% x Medicaid HMO amount,114832,Other,215% of NY Medicaid HMO DRG,114832,,215% x Medicaid HMO amount,114832,Other,215% of NY Medicaid HMO DRG,66763,,125% x Medicaid HMO amount,66763,Other,125% of NY Medicaid HMO DRG,0.01,305214,
Kidney & urinary tract procedures for malignancy,442-1,APR-DRG,,,,,,,,inpatient,,,102373.65,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,58396,,"45,128 x DRG weight",58396,Other,base rate x DRG weight,52556,,"40,615 x DRG weight",52556,Other,base rate x DRG weight,49637,,"38,359 x DRG weight",49637,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20242,,186% x Medicaid HMO amount,20242,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44096,,"34,077 x DRG weight",44096,Other,base rate x DRG weight,37482,,"28,966 x DRG weight",37482,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10883,,DRG base rate x DRG weight + capital per discharge,10883,Other,100% of NY Medicaid HMO DRG,10883,,100% x Medicaid HMO amount,10883,Other,100% of NY Medicaid HMO DRG,10883,,100% x Medicaid HMO amount,10883,Other,100% of NY Medicaid HMO DRG,10883,,100% x Medicaid HMO amount,10883,Other,100% of NY Medicaid HMO DRG,24487,,225% x Medicaid HMO amount,24487,Other,225% of NY Medicaid HMO DRG,24487,,225% x Medicaid HMO amount,24487,Other,225% of NY Medicaid HMO DRG,24487,,225% x Medicaid HMO amount,24487,Other,225% of NY Medicaid HMO DRG,24487,,225% x Medicaid HMO amount,24487,Other,225% of NY Medicaid HMO DRG,15236,,140% x Medicaid HMO amount,15236,Other,140% of NY Medicaid HMO DRG,24487,,225% x Medicaid HMO amount,24487,Other,225% of NY Medicaid HMO DRG,29928,,275% x Medicaid HMO amount,29928,Other,275% of NY Medicaid HMO DRG,35261,,324% x Medicaid HMO amount,35261,Other,324% of NY Medicaid HMO DRG,23398,,215% x Medicaid HMO amount,23398,Other,215% of NY Medicaid HMO DRG,23398,,215% x Medicaid HMO amount,23398,Other,215% of NY Medicaid HMO DRG,13604,,125% x Medicaid HMO amount,13604,Other,125% of NY Medicaid HMO DRG,0.01,58396,
Kidney & urinary tract procedures for malignancy,442-2,APR-DRG,,,,,,,,inpatient,,,590501.21,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,69375,,"45,128 x DRG weight",69375,Other,base rate x DRG weight,62437,,"40,615 x DRG weight",62437,Other,base rate x DRG weight,58969,,"38,359 x DRG weight",58969,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23760,,186% x Medicaid HMO amount,23760,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52387,,"34,077 x DRG weight",52387,Other,base rate x DRG weight,44529,,"28,966 x DRG weight",44529,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12774,,DRG base rate x DRG weight + capital per discharge,12774,Other,100% of NY Medicaid HMO DRG,12774,,100% x Medicaid HMO amount,12774,Other,100% of NY Medicaid HMO DRG,12774,,100% x Medicaid HMO amount,12774,Other,100% of NY Medicaid HMO DRG,12774,,100% x Medicaid HMO amount,12774,Other,100% of NY Medicaid HMO DRG,28742,,225% x Medicaid HMO amount,28742,Other,225% of NY Medicaid HMO DRG,28742,,225% x Medicaid HMO amount,28742,Other,225% of NY Medicaid HMO DRG,28742,,225% x Medicaid HMO amount,28742,Other,225% of NY Medicaid HMO DRG,28742,,225% x Medicaid HMO amount,28742,Other,225% of NY Medicaid HMO DRG,17884,,140% x Medicaid HMO amount,17884,Other,140% of NY Medicaid HMO DRG,28742,,225% x Medicaid HMO amount,28742,Other,225% of NY Medicaid HMO DRG,35129,,275% x Medicaid HMO amount,35129,Other,275% of NY Medicaid HMO DRG,41388,,324% x Medicaid HMO amount,41388,Other,324% of NY Medicaid HMO DRG,27464,,215% x Medicaid HMO amount,27464,Other,215% of NY Medicaid HMO DRG,27464,,215% x Medicaid HMO amount,27464,Other,215% of NY Medicaid HMO DRG,15968,,125% x Medicaid HMO amount,15968,Other,125% of NY Medicaid HMO DRG,0.01,69375,
Kidney & urinary tract procedures for malignancy,442-3,APR-DRG,,,,,,,,inpatient,,,76036.4,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,127067,,"45,128 x DRG weight",127067,Other,base rate x DRG weight,114360,,"40,615 x DRG weight",114360,Other,base rate x DRG weight,108007,,"38,359 x DRG weight",108007,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42250,,186% x Medicaid HMO amount,42250,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,95951,,"34,077 x DRG weight",95951,Other,base rate x DRG weight,81560,,"28,966 x DRG weight",81560,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22715,,DRG base rate x DRG weight + capital per discharge,22715,Other,100% of NY Medicaid HMO DRG,22715,,100% x Medicaid HMO amount,22715,Other,100% of NY Medicaid HMO DRG,22715,,100% x Medicaid HMO amount,22715,Other,100% of NY Medicaid HMO DRG,22715,,100% x Medicaid HMO amount,22715,Other,100% of NY Medicaid HMO DRG,51109,,225% x Medicaid HMO amount,51109,Other,225% of NY Medicaid HMO DRG,51109,,225% x Medicaid HMO amount,51109,Other,225% of NY Medicaid HMO DRG,51109,,225% x Medicaid HMO amount,51109,Other,225% of NY Medicaid HMO DRG,51109,,225% x Medicaid HMO amount,51109,Other,225% of NY Medicaid HMO DRG,31801,,140% x Medicaid HMO amount,31801,Other,140% of NY Medicaid HMO DRG,51109,,225% x Medicaid HMO amount,51109,Other,225% of NY Medicaid HMO DRG,62466,,275% x Medicaid HMO amount,62466,Other,275% of NY Medicaid HMO DRG,73597,,324% x Medicaid HMO amount,73597,Other,324% of NY Medicaid HMO DRG,48837,,215% x Medicaid HMO amount,48837,Other,215% of NY Medicaid HMO DRG,48837,,215% x Medicaid HMO amount,48837,Other,215% of NY Medicaid HMO DRG,28394,,125% x Medicaid HMO amount,28394,Other,125% of NY Medicaid HMO DRG,0.01,127067,
Kidney & urinary tract procedures for malignancy,442-4,APR-DRG,,,,,,,,inpatient,,,988215.49,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,287732,,"45,128 x DRG weight",287732,Other,base rate x DRG weight,258957,,"40,615 x DRG weight",258957,Other,base rate x DRG weight,244573,,"38,359 x DRG weight",244573,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,93738,,186% x Medicaid HMO amount,93738,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,217272,,"34,077 x DRG weight",217272,Other,base rate x DRG weight,184684,,"28,966 x DRG weight",184684,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50397,,DRG base rate x DRG weight + capital per discharge,50397,Other,100% of NY Medicaid HMO DRG,50397,,100% x Medicaid HMO amount,50397,Other,100% of NY Medicaid HMO DRG,50397,,100% x Medicaid HMO amount,50397,Other,100% of NY Medicaid HMO DRG,50397,,100% x Medicaid HMO amount,50397,Other,100% of NY Medicaid HMO DRG,113393,,225% x Medicaid HMO amount,113393,Other,225% of NY Medicaid HMO DRG,113393,,225% x Medicaid HMO amount,113393,Other,225% of NY Medicaid HMO DRG,113393,,225% x Medicaid HMO amount,113393,Other,225% of NY Medicaid HMO DRG,113393,,225% x Medicaid HMO amount,113393,Other,225% of NY Medicaid HMO DRG,70556,,140% x Medicaid HMO amount,70556,Other,140% of NY Medicaid HMO DRG,113393,,225% x Medicaid HMO amount,113393,Other,225% of NY Medicaid HMO DRG,138592,,275% x Medicaid HMO amount,138592,Other,275% of NY Medicaid HMO DRG,163286,,324% x Medicaid HMO amount,163286,Other,324% of NY Medicaid HMO DRG,108354,,215% x Medicaid HMO amount,108354,Other,215% of NY Medicaid HMO DRG,108354,,215% x Medicaid HMO amount,108354,Other,215% of NY Medicaid HMO DRG,62996,,125% x Medicaid HMO amount,62996,Other,125% of NY Medicaid HMO DRG,0.01,287732,
Kidney & urinary tract procedures for nonmalignancy,443-1,APR-DRG,,,,,,,,inpatient,,,104003.82,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48400,,"45,128 x DRG weight",48400,Other,base rate x DRG weight,43560,,"40,615 x DRG weight",43560,Other,base rate x DRG weight,41140,,"38,359 x DRG weight",41140,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17038,,186% x Medicaid HMO amount,17038,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36548,,"34,077 x DRG weight",36548,Other,base rate x DRG weight,31066,,"28,966 x DRG weight",31066,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9160,,DRG base rate x DRG weight + capital per discharge,9160,Other,100% of NY Medicaid HMO DRG,9160,,100% x Medicaid HMO amount,9160,Other,100% of NY Medicaid HMO DRG,9160,,100% x Medicaid HMO amount,9160,Other,100% of NY Medicaid HMO DRG,9160,,100% x Medicaid HMO amount,9160,Other,100% of NY Medicaid HMO DRG,20610,,225% x Medicaid HMO amount,20610,Other,225% of NY Medicaid HMO DRG,20610,,225% x Medicaid HMO amount,20610,Other,225% of NY Medicaid HMO DRG,20610,,225% x Medicaid HMO amount,20610,Other,225% of NY Medicaid HMO DRG,20610,,225% x Medicaid HMO amount,20610,Other,225% of NY Medicaid HMO DRG,12824,,140% x Medicaid HMO amount,12824,Other,140% of NY Medicaid HMO DRG,20610,,225% x Medicaid HMO amount,20610,Other,225% of NY Medicaid HMO DRG,25190,,275% x Medicaid HMO amount,25190,Other,275% of NY Medicaid HMO DRG,29678,,324% x Medicaid HMO amount,29678,Other,324% of NY Medicaid HMO DRG,19694,,215% x Medicaid HMO amount,19694,Other,215% of NY Medicaid HMO DRG,19694,,215% x Medicaid HMO amount,19694,Other,215% of NY Medicaid HMO DRG,11450,,125% x Medicaid HMO amount,11450,Other,125% of NY Medicaid HMO DRG,0.01,48400,
Kidney & urinary tract procedures for nonmalignancy,443-2,APR-DRG,,,,,,,,inpatient,,,167322.68,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53788,,"45,128 x DRG weight",53788,Other,base rate x DRG weight,48409,,"40,615 x DRG weight",48409,Other,base rate x DRG weight,45720,,"38,359 x DRG weight",45720,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18766,,186% x Medicaid HMO amount,18766,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40616,,"34,077 x DRG weight",40616,Other,base rate x DRG weight,34525,,"28,966 x DRG weight",34525,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10089,,DRG base rate x DRG weight + capital per discharge,10089,Other,100% of NY Medicaid HMO DRG,10089,,100% x Medicaid HMO amount,10089,Other,100% of NY Medicaid HMO DRG,10089,,100% x Medicaid HMO amount,10089,Other,100% of NY Medicaid HMO DRG,10089,,100% x Medicaid HMO amount,10089,Other,100% of NY Medicaid HMO DRG,22700,,225% x Medicaid HMO amount,22700,Other,225% of NY Medicaid HMO DRG,22700,,225% x Medicaid HMO amount,22700,Other,225% of NY Medicaid HMO DRG,22700,,225% x Medicaid HMO amount,22700,Other,225% of NY Medicaid HMO DRG,22700,,225% x Medicaid HMO amount,22700,Other,225% of NY Medicaid HMO DRG,14125,,140% x Medicaid HMO amount,14125,Other,140% of NY Medicaid HMO DRG,22700,,225% x Medicaid HMO amount,22700,Other,225% of NY Medicaid HMO DRG,27745,,275% x Medicaid HMO amount,27745,Other,275% of NY Medicaid HMO DRG,32688,,324% x Medicaid HMO amount,32688,Other,324% of NY Medicaid HMO DRG,21691,,215% x Medicaid HMO amount,21691,Other,215% of NY Medicaid HMO DRG,21691,,215% x Medicaid HMO amount,21691,Other,215% of NY Medicaid HMO DRG,12611,,125% x Medicaid HMO amount,12611,Other,125% of NY Medicaid HMO DRG,0.01,53788,
Kidney & urinary tract procedures for nonmalignancy,443-3,APR-DRG,,,,,,,,inpatient,,,388033.07,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,102522,,"45,128 x DRG weight",102522,Other,base rate x DRG weight,92269,,"40,615 x DRG weight",92269,Other,base rate x DRG weight,87144,,"38,359 x DRG weight",87144,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34384,,186% x Medicaid HMO amount,34384,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,77416,,"34,077 x DRG weight",77416,Other,base rate x DRG weight,65805,,"28,966 x DRG weight",65805,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18486,,DRG base rate x DRG weight + capital per discharge,18486,Other,100% of NY Medicaid HMO DRG,18486,,100% x Medicaid HMO amount,18486,Other,100% of NY Medicaid HMO DRG,18486,,100% x Medicaid HMO amount,18486,Other,100% of NY Medicaid HMO DRG,18486,,100% x Medicaid HMO amount,18486,Other,100% of NY Medicaid HMO DRG,41594,,225% x Medicaid HMO amount,41594,Other,225% of NY Medicaid HMO DRG,41594,,225% x Medicaid HMO amount,41594,Other,225% of NY Medicaid HMO DRG,41594,,225% x Medicaid HMO amount,41594,Other,225% of NY Medicaid HMO DRG,41594,,225% x Medicaid HMO amount,41594,Other,225% of NY Medicaid HMO DRG,25880,,140% x Medicaid HMO amount,25880,Other,140% of NY Medicaid HMO DRG,41594,,225% x Medicaid HMO amount,41594,Other,225% of NY Medicaid HMO DRG,50837,,275% x Medicaid HMO amount,50837,Other,275% of NY Medicaid HMO DRG,59895,,324% x Medicaid HMO amount,59895,Other,324% of NY Medicaid HMO DRG,39745,,215% x Medicaid HMO amount,39745,Other,215% of NY Medicaid HMO DRG,39745,,215% x Medicaid HMO amount,39745,Other,215% of NY Medicaid HMO DRG,23108,,125% x Medicaid HMO amount,23108,Other,125% of NY Medicaid HMO DRG,0.01,102522,
Kidney & urinary tract procedures for nonmalignancy,443-4,APR-DRG,,,,,,,,inpatient,,,689506.03,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,228700,,"45,128 x DRG weight",228700,Other,base rate x DRG weight,205829,,"40,615 x DRG weight",205829,Other,base rate x DRG weight,194396,,"38,359 x DRG weight",194396,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,74820,,186% x Medicaid HMO amount,74820,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,172695,,"34,077 x DRG weight",172695,Other,base rate x DRG weight,146794,,"28,966 x DRG weight",146794,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40226,,DRG base rate x DRG weight + capital per discharge,40226,Other,100% of NY Medicaid HMO DRG,40226,,100% x Medicaid HMO amount,40226,Other,100% of NY Medicaid HMO DRG,40226,,100% x Medicaid HMO amount,40226,Other,100% of NY Medicaid HMO DRG,40226,,100% x Medicaid HMO amount,40226,Other,100% of NY Medicaid HMO DRG,90509,,225% x Medicaid HMO amount,90509,Other,225% of NY Medicaid HMO DRG,90509,,225% x Medicaid HMO amount,90509,Other,225% of NY Medicaid HMO DRG,90509,,225% x Medicaid HMO amount,90509,Other,225% of NY Medicaid HMO DRG,90509,,225% x Medicaid HMO amount,90509,Other,225% of NY Medicaid HMO DRG,56316,,140% x Medicaid HMO amount,56316,Other,140% of NY Medicaid HMO DRG,90509,,225% x Medicaid HMO amount,90509,Other,225% of NY Medicaid HMO DRG,110622,,275% x Medicaid HMO amount,110622,Other,275% of NY Medicaid HMO DRG,130332,,324% x Medicaid HMO amount,130332,Other,324% of NY Medicaid HMO DRG,86486,,215% x Medicaid HMO amount,86486,Other,215% of NY Medicaid HMO DRG,86486,,215% x Medicaid HMO amount,86486,Other,215% of NY Medicaid HMO DRG,50283,,125% x Medicaid HMO amount,50283,Other,125% of NY Medicaid HMO DRG,0.01,228700,
Renal dialysis access device procedure only,444-1,APR-DRG,,,,,,,,inpatient,,,321039.32,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44334,,"45,128 x DRG weight",44334,Other,base rate x DRG weight,39900,,"40,615 x DRG weight",39900,Other,base rate x DRG weight,37684,,"38,359 x DRG weight",37684,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15736,,186% x Medicaid HMO amount,15736,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33477,,"34,077 x DRG weight",33477,Other,base rate x DRG weight,28456,,"28,966 x DRG weight",28456,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8460,,DRG base rate x DRG weight + capital per discharge,8460,Other,100% of NY Medicaid HMO DRG,8460,,100% x Medicaid HMO amount,8460,Other,100% of NY Medicaid HMO DRG,8460,,100% x Medicaid HMO amount,8460,Other,100% of NY Medicaid HMO DRG,8460,,100% x Medicaid HMO amount,8460,Other,100% of NY Medicaid HMO DRG,19035,,225% x Medicaid HMO amount,19035,Other,225% of NY Medicaid HMO DRG,19035,,225% x Medicaid HMO amount,19035,Other,225% of NY Medicaid HMO DRG,19035,,225% x Medicaid HMO amount,19035,Other,225% of NY Medicaid HMO DRG,19035,,225% x Medicaid HMO amount,19035,Other,225% of NY Medicaid HMO DRG,11844,,140% x Medicaid HMO amount,11844,Other,140% of NY Medicaid HMO DRG,19035,,225% x Medicaid HMO amount,19035,Other,225% of NY Medicaid HMO DRG,23265,,275% x Medicaid HMO amount,23265,Other,275% of NY Medicaid HMO DRG,27410,,324% x Medicaid HMO amount,27410,Other,324% of NY Medicaid HMO DRG,18189,,215% x Medicaid HMO amount,18189,Other,215% of NY Medicaid HMO DRG,18189,,215% x Medicaid HMO amount,18189,Other,215% of NY Medicaid HMO DRG,10575,,125% x Medicaid HMO amount,10575,Other,125% of NY Medicaid HMO DRG,0.01,44334,
Renal dialysis access device procedure only,444-2,APR-DRG,,,,,,,,inpatient,,,321039.32,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,78834,,"45,128 x DRG weight",78834,Other,base rate x DRG weight,70950,,"40,615 x DRG weight",70950,Other,base rate x DRG weight,67009,,"38,359 x DRG weight",67009,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26791,,186% x Medicaid HMO amount,26791,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59529,,"34,077 x DRG weight",59529,Other,base rate x DRG weight,50601,,"28,966 x DRG weight",50601,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14404,,DRG base rate x DRG weight + capital per discharge,14404,Other,100% of NY Medicaid HMO DRG,14404,,100% x Medicaid HMO amount,14404,Other,100% of NY Medicaid HMO DRG,14404,,100% x Medicaid HMO amount,14404,Other,100% of NY Medicaid HMO DRG,14404,,100% x Medicaid HMO amount,14404,Other,100% of NY Medicaid HMO DRG,32409,,225% x Medicaid HMO amount,32409,Other,225% of NY Medicaid HMO DRG,32409,,225% x Medicaid HMO amount,32409,Other,225% of NY Medicaid HMO DRG,32409,,225% x Medicaid HMO amount,32409,Other,225% of NY Medicaid HMO DRG,32409,,225% x Medicaid HMO amount,32409,Other,225% of NY Medicaid HMO DRG,20166,,140% x Medicaid HMO amount,20166,Other,140% of NY Medicaid HMO DRG,32409,,225% x Medicaid HMO amount,32409,Other,225% of NY Medicaid HMO DRG,39611,,275% x Medicaid HMO amount,39611,Other,275% of NY Medicaid HMO DRG,46669,,324% x Medicaid HMO amount,46669,Other,324% of NY Medicaid HMO DRG,30969,,215% x Medicaid HMO amount,30969,Other,215% of NY Medicaid HMO DRG,30969,,215% x Medicaid HMO amount,30969,Other,215% of NY Medicaid HMO DRG,18005,,125% x Medicaid HMO amount,18005,Other,125% of NY Medicaid HMO DRG,0.01,78834,
Renal dialysis access device procedure only,444-3,APR-DRG,,,,,,,,inpatient,,,556534.6,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,145881,,"45,128 x DRG weight",145881,Other,base rate x DRG weight,131292,,"40,615 x DRG weight",131292,Other,base rate x DRG weight,123999,,"38,359 x DRG weight",123999,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48278,,186% x Medicaid HMO amount,48278,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,110157,,"34,077 x DRG weight",110157,Other,base rate x DRG weight,93635,,"28,966 x DRG weight",93635,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25956,,DRG base rate x DRG weight + capital per discharge,25956,Other,100% of NY Medicaid HMO DRG,25956,,100% x Medicaid HMO amount,25956,Other,100% of NY Medicaid HMO DRG,25956,,100% x Medicaid HMO amount,25956,Other,100% of NY Medicaid HMO DRG,25956,,100% x Medicaid HMO amount,25956,Other,100% of NY Medicaid HMO DRG,58401,,225% x Medicaid HMO amount,58401,Other,225% of NY Medicaid HMO DRG,58401,,225% x Medicaid HMO amount,58401,Other,225% of NY Medicaid HMO DRG,58401,,225% x Medicaid HMO amount,58401,Other,225% of NY Medicaid HMO DRG,58401,,225% x Medicaid HMO amount,58401,Other,225% of NY Medicaid HMO DRG,36338,,140% x Medicaid HMO amount,36338,Other,140% of NY Medicaid HMO DRG,58401,,225% x Medicaid HMO amount,58401,Other,225% of NY Medicaid HMO DRG,71379,,275% x Medicaid HMO amount,71379,Other,275% of NY Medicaid HMO DRG,84097,,324% x Medicaid HMO amount,84097,Other,324% of NY Medicaid HMO DRG,55805,,215% x Medicaid HMO amount,55805,Other,215% of NY Medicaid HMO DRG,55805,,215% x Medicaid HMO amount,55805,Other,215% of NY Medicaid HMO DRG,32445,,125% x Medicaid HMO amount,32445,Other,125% of NY Medicaid HMO DRG,0.01,145881,
Renal dialysis access device procedure only,444-4,APR-DRG,,,,,,,,inpatient,,,1163823.62,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,279157,,"45,128 x DRG weight",279157,Other,base rate x DRG weight,251240,,"40,615 x DRG weight",251240,Other,base rate x DRG weight,237285,,"38,359 x DRG weight",237285,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,90991,,186% x Medicaid HMO amount,90991,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,210797,,"34,077 x DRG weight",210797,Other,base rate x DRG weight,179181,,"28,966 x DRG weight",179181,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48920,,DRG base rate x DRG weight + capital per discharge,48920,Other,100% of NY Medicaid HMO DRG,48920,,100% x Medicaid HMO amount,48920,Other,100% of NY Medicaid HMO DRG,48920,,100% x Medicaid HMO amount,48920,Other,100% of NY Medicaid HMO DRG,48920,,100% x Medicaid HMO amount,48920,Other,100% of NY Medicaid HMO DRG,110070,,225% x Medicaid HMO amount,110070,Other,225% of NY Medicaid HMO DRG,110070,,225% x Medicaid HMO amount,110070,Other,225% of NY Medicaid HMO DRG,110070,,225% x Medicaid HMO amount,110070,Other,225% of NY Medicaid HMO DRG,110070,,225% x Medicaid HMO amount,110070,Other,225% of NY Medicaid HMO DRG,68488,,140% x Medicaid HMO amount,68488,Other,140% of NY Medicaid HMO DRG,110070,,225% x Medicaid HMO amount,110070,Other,225% of NY Medicaid HMO DRG,134530,,275% x Medicaid HMO amount,134530,Other,275% of NY Medicaid HMO DRG,158501,,324% x Medicaid HMO amount,158501,Other,324% of NY Medicaid HMO DRG,105178,,215% x Medicaid HMO amount,105178,Other,215% of NY Medicaid HMO DRG,105178,,215% x Medicaid HMO amount,105178,Other,215% of NY Medicaid HMO DRG,61150,,125% x Medicaid HMO amount,61150,Other,125% of NY Medicaid HMO DRG,0.01,279157,
Other bladder procedures,445-1,APR-DRG,,,,,,,,inpatient,,,101955.17,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37068,,"45,128 x DRG weight",37068,Other,base rate x DRG weight,33361,,"40,615 x DRG weight",33361,Other,base rate x DRG weight,31508,,"38,359 x DRG weight",31508,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13407,,186% x Medicaid HMO amount,13407,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27991,,"34,077 x DRG weight",27991,Other,base rate x DRG weight,23793,,"28,966 x DRG weight",23793,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7208,,DRG base rate x DRG weight + capital per discharge,7208,Other,100% of NY Medicaid HMO DRG,7208,,100% x Medicaid HMO amount,7208,Other,100% of NY Medicaid HMO DRG,7208,,100% x Medicaid HMO amount,7208,Other,100% of NY Medicaid HMO DRG,7208,,100% x Medicaid HMO amount,7208,Other,100% of NY Medicaid HMO DRG,16218,,225% x Medicaid HMO amount,16218,Other,225% of NY Medicaid HMO DRG,16218,,225% x Medicaid HMO amount,16218,Other,225% of NY Medicaid HMO DRG,16218,,225% x Medicaid HMO amount,16218,Other,225% of NY Medicaid HMO DRG,16218,,225% x Medicaid HMO amount,16218,Other,225% of NY Medicaid HMO DRG,10091,,140% x Medicaid HMO amount,10091,Other,140% of NY Medicaid HMO DRG,16218,,225% x Medicaid HMO amount,16218,Other,225% of NY Medicaid HMO DRG,19822,,275% x Medicaid HMO amount,19822,Other,275% of NY Medicaid HMO DRG,23354,,324% x Medicaid HMO amount,23354,Other,324% of NY Medicaid HMO DRG,15497,,215% x Medicaid HMO amount,15497,Other,215% of NY Medicaid HMO DRG,15497,,215% x Medicaid HMO amount,15497,Other,215% of NY Medicaid HMO DRG,9010,,125% x Medicaid HMO amount,9010,Other,125% of NY Medicaid HMO DRG,0.01,37068,
Other bladder procedures,445-2,APR-DRG,,,,,,,,inpatient,,,205189.97,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,57272,,"45,128 x DRG weight",57272,Other,base rate x DRG weight,51544,,"40,615 x DRG weight",51544,Other,base rate x DRG weight,48681,,"38,359 x DRG weight",48681,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19882,,186% x Medicaid HMO amount,19882,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43247,,"34,077 x DRG weight",43247,Other,base rate x DRG weight,36761,,"28,966 x DRG weight",36761,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10689,,DRG base rate x DRG weight + capital per discharge,10689,Other,100% of NY Medicaid HMO DRG,10689,,100% x Medicaid HMO amount,10689,Other,100% of NY Medicaid HMO DRG,10689,,100% x Medicaid HMO amount,10689,Other,100% of NY Medicaid HMO DRG,10689,,100% x Medicaid HMO amount,10689,Other,100% of NY Medicaid HMO DRG,24050,,225% x Medicaid HMO amount,24050,Other,225% of NY Medicaid HMO DRG,24050,,225% x Medicaid HMO amount,24050,Other,225% of NY Medicaid HMO DRG,24050,,225% x Medicaid HMO amount,24050,Other,225% of NY Medicaid HMO DRG,24050,,225% x Medicaid HMO amount,24050,Other,225% of NY Medicaid HMO DRG,14965,,140% x Medicaid HMO amount,14965,Other,140% of NY Medicaid HMO DRG,24050,,225% x Medicaid HMO amount,24050,Other,225% of NY Medicaid HMO DRG,29395,,275% x Medicaid HMO amount,29395,Other,275% of NY Medicaid HMO DRG,34632,,324% x Medicaid HMO amount,34632,Other,324% of NY Medicaid HMO DRG,22981,,215% x Medicaid HMO amount,22981,Other,215% of NY Medicaid HMO DRG,22981,,215% x Medicaid HMO amount,22981,Other,215% of NY Medicaid HMO DRG,13361,,125% x Medicaid HMO amount,13361,Other,125% of NY Medicaid HMO DRG,0.01,57272,
Other bladder procedures,445-3,APR-DRG,,,,,,,,inpatient,,,132329.99,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,84516,,"45,128 x DRG weight",84516,Other,base rate x DRG weight,76064,,"40,615 x DRG weight",76064,Other,base rate x DRG weight,71839,,"38,359 x DRG weight",71839,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28612,,186% x Medicaid HMO amount,28612,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,63819,,"34,077 x DRG weight",63819,Other,base rate x DRG weight,54248,,"28,966 x DRG weight",54248,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15383,,DRG base rate x DRG weight + capital per discharge,15383,Other,100% of NY Medicaid HMO DRG,15383,,100% x Medicaid HMO amount,15383,Other,100% of NY Medicaid HMO DRG,15383,,100% x Medicaid HMO amount,15383,Other,100% of NY Medicaid HMO DRG,15383,,100% x Medicaid HMO amount,15383,Other,100% of NY Medicaid HMO DRG,34612,,225% x Medicaid HMO amount,34612,Other,225% of NY Medicaid HMO DRG,34612,,225% x Medicaid HMO amount,34612,Other,225% of NY Medicaid HMO DRG,34612,,225% x Medicaid HMO amount,34612,Other,225% of NY Medicaid HMO DRG,34612,,225% x Medicaid HMO amount,34612,Other,225% of NY Medicaid HMO DRG,21536,,140% x Medicaid HMO amount,21536,Other,140% of NY Medicaid HMO DRG,34612,,225% x Medicaid HMO amount,34612,Other,225% of NY Medicaid HMO DRG,42303,,275% x Medicaid HMO amount,42303,Other,275% of NY Medicaid HMO DRG,49841,,324% x Medicaid HMO amount,49841,Other,324% of NY Medicaid HMO DRG,33073,,215% x Medicaid HMO amount,33073,Other,215% of NY Medicaid HMO DRG,33073,,215% x Medicaid HMO amount,33073,Other,215% of NY Medicaid HMO DRG,19229,,125% x Medicaid HMO amount,19229,Other,125% of NY Medicaid HMO DRG,0.01,84516,
Other bladder procedures,445-4,APR-DRG,,,,,,,,inpatient,,,196057.95,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,110546,,"45,128 x DRG weight",110546,Other,base rate x DRG weight,99491,,"40,615 x DRG weight",99491,Other,base rate x DRG weight,93964,,"38,359 x DRG weight",93964,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36954,,186% x Medicaid HMO amount,36954,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,83475,,"34,077 x DRG weight",83475,Other,base rate x DRG weight,70955,,"28,966 x DRG weight",70955,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19868,,DRG base rate x DRG weight + capital per discharge,19868,Other,100% of NY Medicaid HMO DRG,19868,,100% x Medicaid HMO amount,19868,Other,100% of NY Medicaid HMO DRG,19868,,100% x Medicaid HMO amount,19868,Other,100% of NY Medicaid HMO DRG,19868,,100% x Medicaid HMO amount,19868,Other,100% of NY Medicaid HMO DRG,44703,,225% x Medicaid HMO amount,44703,Other,225% of NY Medicaid HMO DRG,44703,,225% x Medicaid HMO amount,44703,Other,225% of NY Medicaid HMO DRG,44703,,225% x Medicaid HMO amount,44703,Other,225% of NY Medicaid HMO DRG,44703,,225% x Medicaid HMO amount,44703,Other,225% of NY Medicaid HMO DRG,27815,,140% x Medicaid HMO amount,27815,Other,140% of NY Medicaid HMO DRG,44703,,225% x Medicaid HMO amount,44703,Other,225% of NY Medicaid HMO DRG,54637,,275% x Medicaid HMO amount,54637,Other,275% of NY Medicaid HMO DRG,64372,,324% x Medicaid HMO amount,64372,Other,324% of NY Medicaid HMO DRG,42716,,215% x Medicaid HMO amount,42716,Other,215% of NY Medicaid HMO DRG,42716,,215% x Medicaid HMO amount,42716,Other,215% of NY Medicaid HMO DRG,24835,,125% x Medicaid HMO amount,24835,Other,125% of NY Medicaid HMO DRG,0.01,110546,
Urethral & transurethral procedures,446-1,APR-DRG,,,,,,,,inpatient,,,66444.71,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30890,,"45,128 x DRG weight",30890,Other,base rate x DRG weight,27801,,"40,615 x DRG weight",27801,Other,base rate x DRG weight,26257,,"38,359 x DRG weight",26257,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11426,,186% x Medicaid HMO amount,11426,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23326,,"34,077 x DRG weight",23326,Other,base rate x DRG weight,19827,,"28,966 x DRG weight",19827,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6143,,DRG base rate x DRG weight + capital per discharge,6143,Other,100% of NY Medicaid HMO DRG,6143,,100% x Medicaid HMO amount,6143,Other,100% of NY Medicaid HMO DRG,6143,,100% x Medicaid HMO amount,6143,Other,100% of NY Medicaid HMO DRG,6143,,100% x Medicaid HMO amount,6143,Other,100% of NY Medicaid HMO DRG,13822,,225% x Medicaid HMO amount,13822,Other,225% of NY Medicaid HMO DRG,13822,,225% x Medicaid HMO amount,13822,Other,225% of NY Medicaid HMO DRG,13822,,225% x Medicaid HMO amount,13822,Other,225% of NY Medicaid HMO DRG,13822,,225% x Medicaid HMO amount,13822,Other,225% of NY Medicaid HMO DRG,8600,,140% x Medicaid HMO amount,8600,Other,140% of NY Medicaid HMO DRG,13822,,225% x Medicaid HMO amount,13822,Other,225% of NY Medicaid HMO DRG,16893,,275% x Medicaid HMO amount,16893,Other,275% of NY Medicaid HMO DRG,19903,,324% x Medicaid HMO amount,19903,Other,324% of NY Medicaid HMO DRG,13207,,215% x Medicaid HMO amount,13207,Other,215% of NY Medicaid HMO DRG,13207,,215% x Medicaid HMO amount,13207,Other,215% of NY Medicaid HMO DRG,7679,,125% x Medicaid HMO amount,7679,Other,125% of NY Medicaid HMO DRG,0.01,30890,
Urethral & transurethral procedures,446-2,APR-DRG,,,,,,,,inpatient,,,205189.97,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35660,,"45,128 x DRG weight",35660,Other,base rate x DRG weight,32094,,"40,615 x DRG weight",32094,Other,base rate x DRG weight,30311,,"38,359 x DRG weight",30311,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12955,,186% x Medicaid HMO amount,12955,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26928,,"34,077 x DRG weight",26928,Other,base rate x DRG weight,22889,,"28,966 x DRG weight",22889,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6965,,DRG base rate x DRG weight + capital per discharge,6965,Other,100% of NY Medicaid HMO DRG,6965,,100% x Medicaid HMO amount,6965,Other,100% of NY Medicaid HMO DRG,6965,,100% x Medicaid HMO amount,6965,Other,100% of NY Medicaid HMO DRG,6965,,100% x Medicaid HMO amount,6965,Other,100% of NY Medicaid HMO DRG,15671,,225% x Medicaid HMO amount,15671,Other,225% of NY Medicaid HMO DRG,15671,,225% x Medicaid HMO amount,15671,Other,225% of NY Medicaid HMO DRG,15671,,225% x Medicaid HMO amount,15671,Other,225% of NY Medicaid HMO DRG,15671,,225% x Medicaid HMO amount,15671,Other,225% of NY Medicaid HMO DRG,9751,,140% x Medicaid HMO amount,9751,Other,140% of NY Medicaid HMO DRG,15671,,225% x Medicaid HMO amount,15671,Other,225% of NY Medicaid HMO DRG,19154,,275% x Medicaid HMO amount,19154,Other,275% of NY Medicaid HMO DRG,22567,,324% x Medicaid HMO amount,22567,Other,324% of NY Medicaid HMO DRG,14975,,215% x Medicaid HMO amount,14975,Other,215% of NY Medicaid HMO DRG,14975,,215% x Medicaid HMO amount,14975,Other,215% of NY Medicaid HMO DRG,8706,,125% x Medicaid HMO amount,8706,Other,125% of NY Medicaid HMO DRG,0.01,35660,
Urethral & transurethral procedures,446-3,APR-DRG,,,,,,,,inpatient,,,196057.95,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,68044,,"45,128 x DRG weight",68044,Other,base rate x DRG weight,61239,,"40,615 x DRG weight",61239,Other,base rate x DRG weight,57838,,"38,359 x DRG weight",57838,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23334,,186% x Medicaid HMO amount,23334,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51381,,"34,077 x DRG weight",51381,Other,base rate x DRG weight,43675,,"28,966 x DRG weight",43675,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12545,,DRG base rate x DRG weight + capital per discharge,12545,Other,100% of NY Medicaid HMO DRG,12545,,100% x Medicaid HMO amount,12545,Other,100% of NY Medicaid HMO DRG,12545,,100% x Medicaid HMO amount,12545,Other,100% of NY Medicaid HMO DRG,12545,,100% x Medicaid HMO amount,12545,Other,100% of NY Medicaid HMO DRG,28226,,225% x Medicaid HMO amount,28226,Other,225% of NY Medicaid HMO DRG,28226,,225% x Medicaid HMO amount,28226,Other,225% of NY Medicaid HMO DRG,28226,,225% x Medicaid HMO amount,28226,Other,225% of NY Medicaid HMO DRG,28226,,225% x Medicaid HMO amount,28226,Other,225% of NY Medicaid HMO DRG,17563,,140% x Medicaid HMO amount,17563,Other,140% of NY Medicaid HMO DRG,28226,,225% x Medicaid HMO amount,28226,Other,225% of NY Medicaid HMO DRG,34499,,275% x Medicaid HMO amount,34499,Other,275% of NY Medicaid HMO DRG,40646,,324% x Medicaid HMO amount,40646,Other,324% of NY Medicaid HMO DRG,26972,,215% x Medicaid HMO amount,26972,Other,215% of NY Medicaid HMO DRG,26972,,215% x Medicaid HMO amount,26972,Other,215% of NY Medicaid HMO DRG,15681,,125% x Medicaid HMO amount,15681,Other,125% of NY Medicaid HMO DRG,0.01,68044,
Urethral & transurethral procedures,446-4,APR-DRG,,,,,,,,inpatient,,,196057.95,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,148421,,"45,128 x DRG weight",148421,Other,base rate x DRG weight,133579,,"40,615 x DRG weight",133579,Other,base rate x DRG weight,126159,,"38,359 x DRG weight",126159,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49093,,186% x Medicaid HMO amount,49093,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,112076,,"34,077 x DRG weight",112076,Other,base rate x DRG weight,95266,,"28,966 x DRG weight",95266,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26394,,DRG base rate x DRG weight + capital per discharge,26394,Other,100% of NY Medicaid HMO DRG,26394,,100% x Medicaid HMO amount,26394,Other,100% of NY Medicaid HMO DRG,26394,,100% x Medicaid HMO amount,26394,Other,100% of NY Medicaid HMO DRG,26394,,100% x Medicaid HMO amount,26394,Other,100% of NY Medicaid HMO DRG,59387,,225% x Medicaid HMO amount,59387,Other,225% of NY Medicaid HMO DRG,59387,,225% x Medicaid HMO amount,59387,Other,225% of NY Medicaid HMO DRG,59387,,225% x Medicaid HMO amount,59387,Other,225% of NY Medicaid HMO DRG,59387,,225% x Medicaid HMO amount,59387,Other,225% of NY Medicaid HMO DRG,36952,,140% x Medicaid HMO amount,36952,Other,140% of NY Medicaid HMO DRG,59387,,225% x Medicaid HMO amount,59387,Other,225% of NY Medicaid HMO DRG,72584,,275% x Medicaid HMO amount,72584,Other,275% of NY Medicaid HMO DRG,85517,,324% x Medicaid HMO amount,85517,Other,324% of NY Medicaid HMO DRG,56747,,215% x Medicaid HMO amount,56747,Other,215% of NY Medicaid HMO DRG,56747,,215% x Medicaid HMO amount,56747,Other,215% of NY Medicaid HMO DRG,32993,,125% x Medicaid HMO amount,32993,Other,125% of NY Medicaid HMO DRG,0.01,148421,
"Other kidney, urinary tract & related procedures",447-1,APR-DRG,,,,,,,,inpatient,,,107041,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54005,,"45,128 x DRG weight",54005,Other,base rate x DRG weight,48604,,"40,615 x DRG weight",48604,Other,base rate x DRG weight,45904,,"38,359 x DRG weight",45904,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18834,,186% x Medicaid HMO amount,18834,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40780,,"34,077 x DRG weight",40780,Other,base rate x DRG weight,34664,,"28,966 x DRG weight",34664,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10126,,DRG base rate x DRG weight + capital per discharge,10126,Other,100% of NY Medicaid HMO DRG,10126,,100% x Medicaid HMO amount,10126,Other,100% of NY Medicaid HMO DRG,10126,,100% x Medicaid HMO amount,10126,Other,100% of NY Medicaid HMO DRG,10126,,100% x Medicaid HMO amount,10126,Other,100% of NY Medicaid HMO DRG,22784,,225% x Medicaid HMO amount,22784,Other,225% of NY Medicaid HMO DRG,22784,,225% x Medicaid HMO amount,22784,Other,225% of NY Medicaid HMO DRG,22784,,225% x Medicaid HMO amount,22784,Other,225% of NY Medicaid HMO DRG,22784,,225% x Medicaid HMO amount,22784,Other,225% of NY Medicaid HMO DRG,14176,,140% x Medicaid HMO amount,14176,Other,140% of NY Medicaid HMO DRG,22784,,225% x Medicaid HMO amount,22784,Other,225% of NY Medicaid HMO DRG,27847,,275% x Medicaid HMO amount,27847,Other,275% of NY Medicaid HMO DRG,32808,,324% x Medicaid HMO amount,32808,Other,324% of NY Medicaid HMO DRG,21771,,215% x Medicaid HMO amount,21771,Other,215% of NY Medicaid HMO DRG,21771,,215% x Medicaid HMO amount,21771,Other,215% of NY Medicaid HMO DRG,12658,,125% x Medicaid HMO amount,12658,Other,125% of NY Medicaid HMO DRG,0.01,54005,
"Other kidney, urinary tract & related procedures",447-2,APR-DRG,,,,,,,,inpatient,,,162930.24,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,58775,,"45,128 x DRG weight",58775,Other,base rate x DRG weight,52897,,"40,615 x DRG weight",52897,Other,base rate x DRG weight,49959,,"38,359 x DRG weight",49959,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20363,,186% x Medicaid HMO amount,20363,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44382,,"34,077 x DRG weight",44382,Other,base rate x DRG weight,37725,,"28,966 x DRG weight",37725,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10948,,DRG base rate x DRG weight + capital per discharge,10948,Other,100% of NY Medicaid HMO DRG,10948,,100% x Medicaid HMO amount,10948,Other,100% of NY Medicaid HMO DRG,10948,,100% x Medicaid HMO amount,10948,Other,100% of NY Medicaid HMO DRG,10948,,100% x Medicaid HMO amount,10948,Other,100% of NY Medicaid HMO DRG,24633,,225% x Medicaid HMO amount,24633,Other,225% of NY Medicaid HMO DRG,24633,,225% x Medicaid HMO amount,24633,Other,225% of NY Medicaid HMO DRG,24633,,225% x Medicaid HMO amount,24633,Other,225% of NY Medicaid HMO DRG,24633,,225% x Medicaid HMO amount,24633,Other,225% of NY Medicaid HMO DRG,15327,,140% x Medicaid HMO amount,15327,Other,140% of NY Medicaid HMO DRG,24633,,225% x Medicaid HMO amount,24633,Other,225% of NY Medicaid HMO DRG,30107,,275% x Medicaid HMO amount,30107,Other,275% of NY Medicaid HMO DRG,35472,,324% x Medicaid HMO amount,35472,Other,324% of NY Medicaid HMO DRG,23538,,215% x Medicaid HMO amount,23538,Other,215% of NY Medicaid HMO DRG,23538,,215% x Medicaid HMO amount,23538,Other,215% of NY Medicaid HMO DRG,13685,,125% x Medicaid HMO amount,13685,Other,125% of NY Medicaid HMO DRG,0.01,58775,
"Other kidney, urinary tract & related procedures",447-3,APR-DRG,,,,,,,,inpatient,,,442194.01,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,132279,,"45,128 x DRG weight",132279,Other,base rate x DRG weight,119051,,"40,615 x DRG weight",119051,Other,base rate x DRG weight,112438,,"38,359 x DRG weight",112438,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43920,,186% x Medicaid HMO amount,43920,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,99887,,"34,077 x DRG weight",99887,Other,base rate x DRG weight,84905,,"28,966 x DRG weight",84905,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23613,,DRG base rate x DRG weight + capital per discharge,23613,Other,100% of NY Medicaid HMO DRG,23613,,100% x Medicaid HMO amount,23613,Other,100% of NY Medicaid HMO DRG,23613,,100% x Medicaid HMO amount,23613,Other,100% of NY Medicaid HMO DRG,23613,,100% x Medicaid HMO amount,23613,Other,100% of NY Medicaid HMO DRG,53129,,225% x Medicaid HMO amount,53129,Other,225% of NY Medicaid HMO DRG,53129,,225% x Medicaid HMO amount,53129,Other,225% of NY Medicaid HMO DRG,53129,,225% x Medicaid HMO amount,53129,Other,225% of NY Medicaid HMO DRG,53129,,225% x Medicaid HMO amount,53129,Other,225% of NY Medicaid HMO DRG,33058,,140% x Medicaid HMO amount,33058,Other,140% of NY Medicaid HMO DRG,53129,,225% x Medicaid HMO amount,53129,Other,225% of NY Medicaid HMO DRG,64936,,275% x Medicaid HMO amount,64936,Other,275% of NY Medicaid HMO DRG,76506,,324% x Medicaid HMO amount,76506,Other,324% of NY Medicaid HMO DRG,50768,,215% x Medicaid HMO amount,50768,Other,215% of NY Medicaid HMO DRG,50768,,215% x Medicaid HMO amount,50768,Other,215% of NY Medicaid HMO DRG,29516,,125% x Medicaid HMO amount,29516,Other,125% of NY Medicaid HMO DRG,0.01,132279,
"Other kidney, urinary tract & related procedures",447-4,APR-DRG,,,,,,,,inpatient,,,851118.64,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,344354,,"45,128 x DRG weight",344354,Other,base rate x DRG weight,309917,,"40,615 x DRG weight",309917,Other,base rate x DRG weight,292702,,"38,359 x DRG weight",292702,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,111886,,186% x Medicaid HMO amount,111886,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,260028,,"34,077 x DRG weight",260028,Other,base rate x DRG weight,221028,,"28,966 x DRG weight",221028,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60154,,DRG base rate x DRG weight + capital per discharge,60154,Other,100% of NY Medicaid HMO DRG,60154,,100% x Medicaid HMO amount,60154,Other,100% of NY Medicaid HMO DRG,60154,,100% x Medicaid HMO amount,60154,Other,100% of NY Medicaid HMO DRG,60154,,100% x Medicaid HMO amount,60154,Other,100% of NY Medicaid HMO DRG,135347,,225% x Medicaid HMO amount,135347,Other,225% of NY Medicaid HMO DRG,135347,,225% x Medicaid HMO amount,135347,Other,225% of NY Medicaid HMO DRG,135347,,225% x Medicaid HMO amount,135347,Other,225% of NY Medicaid HMO DRG,135347,,225% x Medicaid HMO amount,135347,Other,225% of NY Medicaid HMO DRG,84216,,140% x Medicaid HMO amount,84216,Other,140% of NY Medicaid HMO DRG,135347,,225% x Medicaid HMO amount,135347,Other,225% of NY Medicaid HMO DRG,165424,,275% x Medicaid HMO amount,165424,Other,275% of NY Medicaid HMO DRG,194899,,324% x Medicaid HMO amount,194899,Other,324% of NY Medicaid HMO DRG,129331,,215% x Medicaid HMO amount,129331,Other,215% of NY Medicaid HMO DRG,129331,,215% x Medicaid HMO amount,129331,Other,215% of NY Medicaid HMO DRG,75193,,125% x Medicaid HMO amount,75193,Other,125% of NY Medicaid HMO DRG,0.01,344354,
Kidney & urinary tract malignancy,461-1,APR-DRG,,,,,,,,inpatient,,,107211.87,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20515,,"45,128 x DRG weight",20515,Other,base rate x DRG weight,18464,,"40,615 x DRG weight",18464,Other,base rate x DRG weight,17438,,"38,359 x DRG weight",17438,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8102,,186% x Medicaid HMO amount,8102,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15491,,"34,077 x DRG weight",15491,Other,base rate x DRG weight,13168,,"28,966 x DRG weight",13168,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4356,,DRG base rate x DRG weight + capital per discharge,4356,Other,100% of NY Medicaid HMO DRG,4356,,100% x Medicaid HMO amount,4356,Other,100% of NY Medicaid HMO DRG,4356,,100% x Medicaid HMO amount,4356,Other,100% of NY Medicaid HMO DRG,4356,,100% x Medicaid HMO amount,4356,Other,100% of NY Medicaid HMO DRG,9801,,225% x Medicaid HMO amount,9801,Other,225% of NY Medicaid HMO DRG,9801,,225% x Medicaid HMO amount,9801,Other,225% of NY Medicaid HMO DRG,9801,,225% x Medicaid HMO amount,9801,Other,225% of NY Medicaid HMO DRG,9801,,225% x Medicaid HMO amount,9801,Other,225% of NY Medicaid HMO DRG,6098,,140% x Medicaid HMO amount,6098,Other,140% of NY Medicaid HMO DRG,9801,,225% x Medicaid HMO amount,9801,Other,225% of NY Medicaid HMO DRG,11979,,275% x Medicaid HMO amount,11979,Other,275% of NY Medicaid HMO DRG,14113,,324% x Medicaid HMO amount,14113,Other,324% of NY Medicaid HMO DRG,9365,,215% x Medicaid HMO amount,9365,Other,215% of NY Medicaid HMO DRG,9365,,215% x Medicaid HMO amount,9365,Other,215% of NY Medicaid HMO DRG,5445,,125% x Medicaid HMO amount,5445,Other,125% of NY Medicaid HMO DRG,0.01,20515,
Kidney & urinary tract malignancy,461-2,APR-DRG,,,,,,,,inpatient,,,270287.21,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36337,,"45,128 x DRG weight",36337,Other,base rate x DRG weight,32703,,"40,615 x DRG weight",32703,Other,base rate x DRG weight,30887,,"38,359 x DRG weight",30887,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13173,,186% x Medicaid HMO amount,13173,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27439,,"34,077 x DRG weight",27439,Other,base rate x DRG weight,23323,,"28,966 x DRG weight",23323,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7082,,DRG base rate x DRG weight + capital per discharge,7082,Other,100% of NY Medicaid HMO DRG,7082,,100% x Medicaid HMO amount,7082,Other,100% of NY Medicaid HMO DRG,7082,,100% x Medicaid HMO amount,7082,Other,100% of NY Medicaid HMO DRG,7082,,100% x Medicaid HMO amount,7082,Other,100% of NY Medicaid HMO DRG,15935,,225% x Medicaid HMO amount,15935,Other,225% of NY Medicaid HMO DRG,15935,,225% x Medicaid HMO amount,15935,Other,225% of NY Medicaid HMO DRG,15935,,225% x Medicaid HMO amount,15935,Other,225% of NY Medicaid HMO DRG,15935,,225% x Medicaid HMO amount,15935,Other,225% of NY Medicaid HMO DRG,9915,,140% x Medicaid HMO amount,9915,Other,140% of NY Medicaid HMO DRG,15935,,225% x Medicaid HMO amount,15935,Other,225% of NY Medicaid HMO DRG,19476,,275% x Medicaid HMO amount,19476,Other,275% of NY Medicaid HMO DRG,22946,,324% x Medicaid HMO amount,22946,Other,324% of NY Medicaid HMO DRG,15226,,215% x Medicaid HMO amount,15226,Other,215% of NY Medicaid HMO DRG,15226,,215% x Medicaid HMO amount,15226,Other,215% of NY Medicaid HMO DRG,8853,,125% x Medicaid HMO amount,8853,Other,125% of NY Medicaid HMO DRG,0.01,36337,
Kidney & urinary tract malignancy,461-3,APR-DRG,,,,,,,,inpatient,,,107211.87,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,67823,,"45,128 x DRG weight",67823,Other,base rate x DRG weight,61040,,"40,615 x DRG weight",61040,Other,base rate x DRG weight,57650,,"38,359 x DRG weight",57650,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23263,,186% x Medicaid HMO amount,23263,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51214,,"34,077 x DRG weight",51214,Other,base rate x DRG weight,43533,,"28,966 x DRG weight",43533,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12507,,DRG base rate x DRG weight + capital per discharge,12507,Other,100% of NY Medicaid HMO DRG,12507,,100% x Medicaid HMO amount,12507,Other,100% of NY Medicaid HMO DRG,12507,,100% x Medicaid HMO amount,12507,Other,100% of NY Medicaid HMO DRG,12507,,100% x Medicaid HMO amount,12507,Other,100% of NY Medicaid HMO DRG,28141,,225% x Medicaid HMO amount,28141,Other,225% of NY Medicaid HMO DRG,28141,,225% x Medicaid HMO amount,28141,Other,225% of NY Medicaid HMO DRG,28141,,225% x Medicaid HMO amount,28141,Other,225% of NY Medicaid HMO DRG,28141,,225% x Medicaid HMO amount,28141,Other,225% of NY Medicaid HMO DRG,17510,,140% x Medicaid HMO amount,17510,Other,140% of NY Medicaid HMO DRG,28141,,225% x Medicaid HMO amount,28141,Other,225% of NY Medicaid HMO DRG,34394,,275% x Medicaid HMO amount,34394,Other,275% of NY Medicaid HMO DRG,40523,,324% x Medicaid HMO amount,40523,Other,324% of NY Medicaid HMO DRG,26890,,215% x Medicaid HMO amount,26890,Other,215% of NY Medicaid HMO DRG,26890,,215% x Medicaid HMO amount,26890,Other,215% of NY Medicaid HMO DRG,15634,,125% x Medicaid HMO amount,15634,Other,125% of NY Medicaid HMO DRG,0.01,67823,
Kidney & urinary tract malignancy,461-4,APR-DRG,,,,,,,,inpatient,,,165176,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,105062,,"45,128 x DRG weight",105062,Other,base rate x DRG weight,94556,,"40,615 x DRG weight",94556,Other,base rate x DRG weight,89304,,"38,359 x DRG weight",89304,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35197,,186% x Medicaid HMO amount,35197,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,79335,,"34,077 x DRG weight",79335,Other,base rate x DRG weight,67436,,"28,966 x DRG weight",67436,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18923,,DRG base rate x DRG weight + capital per discharge,18923,Other,100% of NY Medicaid HMO DRG,18923,,100% x Medicaid HMO amount,18923,Other,100% of NY Medicaid HMO DRG,18923,,100% x Medicaid HMO amount,18923,Other,100% of NY Medicaid HMO DRG,18923,,100% x Medicaid HMO amount,18923,Other,100% of NY Medicaid HMO DRG,42577,,225% x Medicaid HMO amount,42577,Other,225% of NY Medicaid HMO DRG,42577,,225% x Medicaid HMO amount,42577,Other,225% of NY Medicaid HMO DRG,42577,,225% x Medicaid HMO amount,42577,Other,225% of NY Medicaid HMO DRG,42577,,225% x Medicaid HMO amount,42577,Other,225% of NY Medicaid HMO DRG,26492,,140% x Medicaid HMO amount,26492,Other,140% of NY Medicaid HMO DRG,42577,,225% x Medicaid HMO amount,42577,Other,225% of NY Medicaid HMO DRG,52038,,275% x Medicaid HMO amount,52038,Other,275% of NY Medicaid HMO DRG,61311,,324% x Medicaid HMO amount,61311,Other,324% of NY Medicaid HMO DRG,40684,,215% x Medicaid HMO amount,40684,Other,215% of NY Medicaid HMO DRG,40684,,215% x Medicaid HMO amount,40684,Other,215% of NY Medicaid HMO DRG,23654,,125% x Medicaid HMO amount,23654,Other,125% of NY Medicaid HMO DRG,0.01,105062,
Nephritis & nephrosis,462-1,APR-DRG,,,,,,,,inpatient,,,101527,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26635,,"45,128 x DRG weight",26635,Other,base rate x DRG weight,23971,,"40,615 x DRG weight",23971,Other,base rate x DRG weight,22639,,"38,359 x DRG weight",22639,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10063,,186% x Medicaid HMO amount,10063,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20112,,"34,077 x DRG weight",20112,Other,base rate x DRG weight,17096,,"28,966 x DRG weight",17096,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5410,,DRG base rate x DRG weight + capital per discharge,5410,Other,100% of NY Medicaid HMO DRG,5410,,100% x Medicaid HMO amount,5410,Other,100% of NY Medicaid HMO DRG,5410,,100% x Medicaid HMO amount,5410,Other,100% of NY Medicaid HMO DRG,5410,,100% x Medicaid HMO amount,5410,Other,100% of NY Medicaid HMO DRG,12173,,225% x Medicaid HMO amount,12173,Other,225% of NY Medicaid HMO DRG,12173,,225% x Medicaid HMO amount,12173,Other,225% of NY Medicaid HMO DRG,12173,,225% x Medicaid HMO amount,12173,Other,225% of NY Medicaid HMO DRG,12173,,225% x Medicaid HMO amount,12173,Other,225% of NY Medicaid HMO DRG,7574,,140% x Medicaid HMO amount,7574,Other,140% of NY Medicaid HMO DRG,12173,,225% x Medicaid HMO amount,12173,Other,225% of NY Medicaid HMO DRG,14878,,275% x Medicaid HMO amount,14878,Other,275% of NY Medicaid HMO DRG,17528,,324% x Medicaid HMO amount,17528,Other,324% of NY Medicaid HMO DRG,11632,,215% x Medicaid HMO amount,11632,Other,215% of NY Medicaid HMO DRG,11632,,215% x Medicaid HMO amount,11632,Other,215% of NY Medicaid HMO DRG,6763,,125% x Medicaid HMO amount,6763,Other,125% of NY Medicaid HMO DRG,0.01,26635,
Nephritis & nephrosis,462-2,APR-DRG,,,,,,,,inpatient,,,118283.36,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32352,,"45,128 x DRG weight",32352,Other,base rate x DRG weight,29117,,"40,615 x DRG weight",29117,Other,base rate x DRG weight,27500,,"38,359 x DRG weight",27500,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11895,,186% x Medicaid HMO amount,11895,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24430,,"34,077 x DRG weight",24430,Other,base rate x DRG weight,20766,,"28,966 x DRG weight",20766,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6395,,DRG base rate x DRG weight + capital per discharge,6395,Other,100% of NY Medicaid HMO DRG,6395,,100% x Medicaid HMO amount,6395,Other,100% of NY Medicaid HMO DRG,6395,,100% x Medicaid HMO amount,6395,Other,100% of NY Medicaid HMO DRG,6395,,100% x Medicaid HMO amount,6395,Other,100% of NY Medicaid HMO DRG,14389,,225% x Medicaid HMO amount,14389,Other,225% of NY Medicaid HMO DRG,14389,,225% x Medicaid HMO amount,14389,Other,225% of NY Medicaid HMO DRG,14389,,225% x Medicaid HMO amount,14389,Other,225% of NY Medicaid HMO DRG,14389,,225% x Medicaid HMO amount,14389,Other,225% of NY Medicaid HMO DRG,8953,,140% x Medicaid HMO amount,8953,Other,140% of NY Medicaid HMO DRG,14389,,225% x Medicaid HMO amount,14389,Other,225% of NY Medicaid HMO DRG,17586,,275% x Medicaid HMO amount,17586,Other,275% of NY Medicaid HMO DRG,20720,,324% x Medicaid HMO amount,20720,Other,324% of NY Medicaid HMO DRG,13749,,215% x Medicaid HMO amount,13749,Other,215% of NY Medicaid HMO DRG,13749,,215% x Medicaid HMO amount,13749,Other,215% of NY Medicaid HMO DRG,7994,,125% x Medicaid HMO amount,7994,Other,125% of NY Medicaid HMO DRG,0.01,32352,
Nephritis & nephrosis,462-3,APR-DRG,,,,,,,,inpatient,,,159974.86,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,57078,,"45,128 x DRG weight",57078,Other,base rate x DRG weight,51370,,"40,615 x DRG weight",51370,Other,base rate x DRG weight,48516,,"38,359 x DRG weight",48516,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19818,,186% x Medicaid HMO amount,19818,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43101,,"34,077 x DRG weight",43101,Other,base rate x DRG weight,36636,,"28,966 x DRG weight",36636,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10655,,DRG base rate x DRG weight + capital per discharge,10655,Other,100% of NY Medicaid HMO DRG,10655,,100% x Medicaid HMO amount,10655,Other,100% of NY Medicaid HMO DRG,10655,,100% x Medicaid HMO amount,10655,Other,100% of NY Medicaid HMO DRG,10655,,100% x Medicaid HMO amount,10655,Other,100% of NY Medicaid HMO DRG,23974,,225% x Medicaid HMO amount,23974,Other,225% of NY Medicaid HMO DRG,23974,,225% x Medicaid HMO amount,23974,Other,225% of NY Medicaid HMO DRG,23974,,225% x Medicaid HMO amount,23974,Other,225% of NY Medicaid HMO DRG,23974,,225% x Medicaid HMO amount,23974,Other,225% of NY Medicaid HMO DRG,14917,,140% x Medicaid HMO amount,14917,Other,140% of NY Medicaid HMO DRG,23974,,225% x Medicaid HMO amount,23974,Other,225% of NY Medicaid HMO DRG,29301,,275% x Medicaid HMO amount,29301,Other,275% of NY Medicaid HMO DRG,34522,,324% x Medicaid HMO amount,34522,Other,324% of NY Medicaid HMO DRG,22908,,215% x Medicaid HMO amount,22908,Other,215% of NY Medicaid HMO DRG,22908,,215% x Medicaid HMO amount,22908,Other,215% of NY Medicaid HMO DRG,13319,,125% x Medicaid HMO amount,13319,Other,125% of NY Medicaid HMO DRG,0.01,57078,
Nephritis & nephrosis,462-4,APR-DRG,,,,,,,,inpatient,,,528355,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,181329,,"45,128 x DRG weight",181329,Other,base rate x DRG weight,163195,,"40,615 x DRG weight",163195,Other,base rate x DRG weight,154130,,"38,359 x DRG weight",154130,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59639,,186% x Medicaid HMO amount,59639,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,136925,,"34,077 x DRG weight",136925,Other,base rate x DRG weight,116388,,"28,966 x DRG weight",116388,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32064,,DRG base rate x DRG weight + capital per discharge,32064,Other,100% of NY Medicaid HMO DRG,32064,,100% x Medicaid HMO amount,32064,Other,100% of NY Medicaid HMO DRG,32064,,100% x Medicaid HMO amount,32064,Other,100% of NY Medicaid HMO DRG,32064,,100% x Medicaid HMO amount,32064,Other,100% of NY Medicaid HMO DRG,72144,,225% x Medicaid HMO amount,72144,Other,225% of NY Medicaid HMO DRG,72144,,225% x Medicaid HMO amount,72144,Other,225% of NY Medicaid HMO DRG,72144,,225% x Medicaid HMO amount,72144,Other,225% of NY Medicaid HMO DRG,72144,,225% x Medicaid HMO amount,72144,Other,225% of NY Medicaid HMO DRG,44890,,140% x Medicaid HMO amount,44890,Other,140% of NY Medicaid HMO DRG,72144,,225% x Medicaid HMO amount,72144,Other,225% of NY Medicaid HMO DRG,88176,,275% x Medicaid HMO amount,88176,Other,275% of NY Medicaid HMO DRG,103887,,324% x Medicaid HMO amount,103887,Other,324% of NY Medicaid HMO DRG,68938,,215% x Medicaid HMO amount,68938,Other,215% of NY Medicaid HMO DRG,68938,,215% x Medicaid HMO amount,68938,Other,215% of NY Medicaid HMO DRG,40080,,125% x Medicaid HMO amount,40080,Other,125% of NY Medicaid HMO DRG,0.01,181329,
Kidney & urinary tract infections,463-1,APR-DRG,,,,,,,,inpatient,,,88371.52,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22424,,"45,128 x DRG weight",22424,Other,base rate x DRG weight,20182,,"40,615 x DRG weight",20182,Other,base rate x DRG weight,19061,,"38,359 x DRG weight",19061,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8714,,186% x Medicaid HMO amount,8714,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16933,,"34,077 x DRG weight",16933,Other,base rate x DRG weight,14393,,"28,966 x DRG weight",14393,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4685,,DRG base rate x DRG weight + capital per discharge,4685,Other,100% of NY Medicaid HMO DRG,4685,,100% x Medicaid HMO amount,4685,Other,100% of NY Medicaid HMO DRG,4685,,100% x Medicaid HMO amount,4685,Other,100% of NY Medicaid HMO DRG,4685,,100% x Medicaid HMO amount,4685,Other,100% of NY Medicaid HMO DRG,10541,,225% x Medicaid HMO amount,10541,Other,225% of NY Medicaid HMO DRG,10541,,225% x Medicaid HMO amount,10541,Other,225% of NY Medicaid HMO DRG,10541,,225% x Medicaid HMO amount,10541,Other,225% of NY Medicaid HMO DRG,10541,,225% x Medicaid HMO amount,10541,Other,225% of NY Medicaid HMO DRG,6559,,140% x Medicaid HMO amount,6559,Other,140% of NY Medicaid HMO DRG,10541,,225% x Medicaid HMO amount,10541,Other,225% of NY Medicaid HMO DRG,12884,,275% x Medicaid HMO amount,12884,Other,275% of NY Medicaid HMO DRG,15179,,324% x Medicaid HMO amount,15179,Other,324% of NY Medicaid HMO DRG,10073,,215% x Medicaid HMO amount,10073,Other,215% of NY Medicaid HMO DRG,10073,,215% x Medicaid HMO amount,10073,Other,215% of NY Medicaid HMO DRG,5856,,125% x Medicaid HMO amount,5856,Other,125% of NY Medicaid HMO DRG,0.01,22424,
Kidney & urinary tract infections,463-2,APR-DRG,,,,,,,,inpatient,,,98305.73,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28440,,"45,128 x DRG weight",28440,Other,base rate x DRG weight,25596,,"40,615 x DRG weight",25596,Other,base rate x DRG weight,24174,,"38,359 x DRG weight",24174,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10641,,186% x Medicaid HMO amount,10641,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21475,,"34,077 x DRG weight",21475,Other,base rate x DRG weight,18254,,"28,966 x DRG weight",18254,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5721,,DRG base rate x DRG weight + capital per discharge,5721,Other,100% of NY Medicaid HMO DRG,5721,,100% x Medicaid HMO amount,5721,Other,100% of NY Medicaid HMO DRG,5721,,100% x Medicaid HMO amount,5721,Other,100% of NY Medicaid HMO DRG,5721,,100% x Medicaid HMO amount,5721,Other,100% of NY Medicaid HMO DRG,12872,,225% x Medicaid HMO amount,12872,Other,225% of NY Medicaid HMO DRG,12872,,225% x Medicaid HMO amount,12872,Other,225% of NY Medicaid HMO DRG,12872,,225% x Medicaid HMO amount,12872,Other,225% of NY Medicaid HMO DRG,12872,,225% x Medicaid HMO amount,12872,Other,225% of NY Medicaid HMO DRG,8009,,140% x Medicaid HMO amount,8009,Other,140% of NY Medicaid HMO DRG,12872,,225% x Medicaid HMO amount,12872,Other,225% of NY Medicaid HMO DRG,15733,,275% x Medicaid HMO amount,15733,Other,275% of NY Medicaid HMO DRG,18536,,324% x Medicaid HMO amount,18536,Other,324% of NY Medicaid HMO DRG,12300,,215% x Medicaid HMO amount,12300,Other,215% of NY Medicaid HMO DRG,12300,,215% x Medicaid HMO amount,12300,Other,215% of NY Medicaid HMO DRG,7151,,125% x Medicaid HMO amount,7151,Other,125% of NY Medicaid HMO DRG,0.01,28440,
Kidney & urinary tract infections,463-3,APR-DRG,,,,,,,,inpatient,,,133813.3,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44546,,"45,128 x DRG weight",44546,Other,base rate x DRG weight,40091,,"40,615 x DRG weight",40091,Other,base rate x DRG weight,37864,,"38,359 x DRG weight",37864,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15803,,186% x Medicaid HMO amount,15803,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33637,,"34,077 x DRG weight",33637,Other,base rate x DRG weight,28592,,"28,966 x DRG weight",28592,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8496,,DRG base rate x DRG weight + capital per discharge,8496,Other,100% of NY Medicaid HMO DRG,8496,,100% x Medicaid HMO amount,8496,Other,100% of NY Medicaid HMO DRG,8496,,100% x Medicaid HMO amount,8496,Other,100% of NY Medicaid HMO DRG,8496,,100% x Medicaid HMO amount,8496,Other,100% of NY Medicaid HMO DRG,19116,,225% x Medicaid HMO amount,19116,Other,225% of NY Medicaid HMO DRG,19116,,225% x Medicaid HMO amount,19116,Other,225% of NY Medicaid HMO DRG,19116,,225% x Medicaid HMO amount,19116,Other,225% of NY Medicaid HMO DRG,19116,,225% x Medicaid HMO amount,19116,Other,225% of NY Medicaid HMO DRG,11894,,140% x Medicaid HMO amount,11894,Other,140% of NY Medicaid HMO DRG,19116,,225% x Medicaid HMO amount,19116,Other,225% of NY Medicaid HMO DRG,23364,,275% x Medicaid HMO amount,23364,Other,275% of NY Medicaid HMO DRG,27527,,324% x Medicaid HMO amount,27527,Other,324% of NY Medicaid HMO DRG,18266,,215% x Medicaid HMO amount,18266,Other,215% of NY Medicaid HMO DRG,18266,,215% x Medicaid HMO amount,18266,Other,215% of NY Medicaid HMO DRG,10620,,125% x Medicaid HMO amount,10620,Other,125% of NY Medicaid HMO DRG,0.01,44546,
Kidney & urinary tract infections,463-4,APR-DRG,,,,,,,,inpatient,,,201354.28,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,98424,,"45,128 x DRG weight",98424,Other,base rate x DRG weight,88581,,"40,615 x DRG weight",88581,Other,base rate x DRG weight,83661,,"38,359 x DRG weight",83661,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33069,,186% x Medicaid HMO amount,33069,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,74322,,"34,077 x DRG weight",74322,Other,base rate x DRG weight,63175,,"28,966 x DRG weight",63175,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17779,,DRG base rate x DRG weight + capital per discharge,17779,Other,100% of NY Medicaid HMO DRG,17779,,100% x Medicaid HMO amount,17779,Other,100% of NY Medicaid HMO DRG,17779,,100% x Medicaid HMO amount,17779,Other,100% of NY Medicaid HMO DRG,17779,,100% x Medicaid HMO amount,17779,Other,100% of NY Medicaid HMO DRG,40003,,225% x Medicaid HMO amount,40003,Other,225% of NY Medicaid HMO DRG,40003,,225% x Medicaid HMO amount,40003,Other,225% of NY Medicaid HMO DRG,40003,,225% x Medicaid HMO amount,40003,Other,225% of NY Medicaid HMO DRG,40003,,225% x Medicaid HMO amount,40003,Other,225% of NY Medicaid HMO DRG,24891,,140% x Medicaid HMO amount,24891,Other,140% of NY Medicaid HMO DRG,40003,,225% x Medicaid HMO amount,40003,Other,225% of NY Medicaid HMO DRG,48892,,275% x Medicaid HMO amount,48892,Other,275% of NY Medicaid HMO DRG,57604,,324% x Medicaid HMO amount,57604,Other,324% of NY Medicaid HMO DRG,38225,,215% x Medicaid HMO amount,38225,Other,215% of NY Medicaid HMO DRG,38225,,215% x Medicaid HMO amount,38225,Other,215% of NY Medicaid HMO DRG,22224,,125% x Medicaid HMO amount,22224,Other,125% of NY Medicaid HMO DRG,0.01,98424,
Urinary stones & acquired upper urinary tract obstruction,465-1,APR-DRG,,,,,,,,inpatient,,,77236.57,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20226,,"45,128 x DRG weight",20226,Other,base rate x DRG weight,18204,,"40,615 x DRG weight",18204,Other,base rate x DRG weight,17193,,"38,359 x DRG weight",17193,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8009,,186% x Medicaid HMO amount,8009,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15273,,"34,077 x DRG weight",15273,Other,base rate x DRG weight,12983,,"28,966 x DRG weight",12983,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4306,,DRG base rate x DRG weight + capital per discharge,4306,Other,100% of NY Medicaid HMO DRG,4306,,100% x Medicaid HMO amount,4306,Other,100% of NY Medicaid HMO DRG,4306,,100% x Medicaid HMO amount,4306,Other,100% of NY Medicaid HMO DRG,4306,,100% x Medicaid HMO amount,4306,Other,100% of NY Medicaid HMO DRG,9689,,225% x Medicaid HMO amount,9689,Other,225% of NY Medicaid HMO DRG,9689,,225% x Medicaid HMO amount,9689,Other,225% of NY Medicaid HMO DRG,9689,,225% x Medicaid HMO amount,9689,Other,225% of NY Medicaid HMO DRG,9689,,225% x Medicaid HMO amount,9689,Other,225% of NY Medicaid HMO DRG,6028,,140% x Medicaid HMO amount,6028,Other,140% of NY Medicaid HMO DRG,9689,,225% x Medicaid HMO amount,9689,Other,225% of NY Medicaid HMO DRG,11842,,275% x Medicaid HMO amount,11842,Other,275% of NY Medicaid HMO DRG,13951,,324% x Medicaid HMO amount,13951,Other,324% of NY Medicaid HMO DRG,9258,,215% x Medicaid HMO amount,9258,Other,215% of NY Medicaid HMO DRG,9258,,215% x Medicaid HMO amount,9258,Other,215% of NY Medicaid HMO DRG,5383,,125% x Medicaid HMO amount,5383,Other,125% of NY Medicaid HMO DRG,0.01,20226,
Urinary stones & acquired upper urinary tract obstruction,465-2,APR-DRG,,,,,,,,inpatient,,,66276.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23570,,"45,128 x DRG weight",23570,Other,base rate x DRG weight,21213,,"40,615 x DRG weight",21213,Other,base rate x DRG weight,20035,,"38,359 x DRG weight",20035,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9081,,186% x Medicaid HMO amount,9081,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17798,,"34,077 x DRG weight",17798,Other,base rate x DRG weight,15129,,"28,966 x DRG weight",15129,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4882,,DRG base rate x DRG weight + capital per discharge,4882,Other,100% of NY Medicaid HMO DRG,4882,,100% x Medicaid HMO amount,4882,Other,100% of NY Medicaid HMO DRG,4882,,100% x Medicaid HMO amount,4882,Other,100% of NY Medicaid HMO DRG,4882,,100% x Medicaid HMO amount,4882,Other,100% of NY Medicaid HMO DRG,10985,,225% x Medicaid HMO amount,10985,Other,225% of NY Medicaid HMO DRG,10985,,225% x Medicaid HMO amount,10985,Other,225% of NY Medicaid HMO DRG,10985,,225% x Medicaid HMO amount,10985,Other,225% of NY Medicaid HMO DRG,10985,,225% x Medicaid HMO amount,10985,Other,225% of NY Medicaid HMO DRG,6835,,140% x Medicaid HMO amount,6835,Other,140% of NY Medicaid HMO DRG,10985,,225% x Medicaid HMO amount,10985,Other,225% of NY Medicaid HMO DRG,13426,,275% x Medicaid HMO amount,13426,Other,275% of NY Medicaid HMO DRG,15818,,324% x Medicaid HMO amount,15818,Other,324% of NY Medicaid HMO DRG,10496,,215% x Medicaid HMO amount,10496,Other,215% of NY Medicaid HMO DRG,10496,,215% x Medicaid HMO amount,10496,Other,215% of NY Medicaid HMO DRG,6103,,125% x Medicaid HMO amount,6103,Other,125% of NY Medicaid HMO DRG,0.01,23570,
Urinary stones & acquired upper urinary tract obstruction,465-3,APR-DRG,,,,,,,,inpatient,,,55073.64,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39288,,"45,128 x DRG weight",39288,Other,base rate x DRG weight,35359,,"40,615 x DRG weight",35359,Other,base rate x DRG weight,33395,,"38,359 x DRG weight",33395,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14117,,186% x Medicaid HMO amount,14117,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29667,,"34,077 x DRG weight",29667,Other,base rate x DRG weight,25218,,"28,966 x DRG weight",25218,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7590,,DRG base rate x DRG weight + capital per discharge,7590,Other,100% of NY Medicaid HMO DRG,7590,,100% x Medicaid HMO amount,7590,Other,100% of NY Medicaid HMO DRG,7590,,100% x Medicaid HMO amount,7590,Other,100% of NY Medicaid HMO DRG,7590,,100% x Medicaid HMO amount,7590,Other,100% of NY Medicaid HMO DRG,17078,,225% x Medicaid HMO amount,17078,Other,225% of NY Medicaid HMO DRG,17078,,225% x Medicaid HMO amount,17078,Other,225% of NY Medicaid HMO DRG,17078,,225% x Medicaid HMO amount,17078,Other,225% of NY Medicaid HMO DRG,17078,,225% x Medicaid HMO amount,17078,Other,225% of NY Medicaid HMO DRG,10626,,140% x Medicaid HMO amount,10626,Other,140% of NY Medicaid HMO DRG,17078,,225% x Medicaid HMO amount,17078,Other,225% of NY Medicaid HMO DRG,20873,,275% x Medicaid HMO amount,20873,Other,275% of NY Medicaid HMO DRG,24592,,324% x Medicaid HMO amount,24592,Other,324% of NY Medicaid HMO DRG,16319,,215% x Medicaid HMO amount,16319,Other,215% of NY Medicaid HMO DRG,16319,,215% x Medicaid HMO amount,16319,Other,215% of NY Medicaid HMO DRG,9488,,125% x Medicaid HMO amount,9488,Other,125% of NY Medicaid HMO DRG,0.01,39288,
Urinary stones & acquired upper urinary tract obstruction,465-4,APR-DRG,,,,,,,,inpatient,,,66276.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,97883,,"45,128 x DRG weight",97883,Other,base rate x DRG weight,88094,,"40,615 x DRG weight",88094,Other,base rate x DRG weight,83201,,"38,359 x DRG weight",83201,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32896,,186% x Medicaid HMO amount,32896,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73913,,"34,077 x DRG weight",73913,Other,base rate x DRG weight,62827,,"28,966 x DRG weight",62827,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17686,,DRG base rate x DRG weight + capital per discharge,17686,Other,100% of NY Medicaid HMO DRG,17686,,100% x Medicaid HMO amount,17686,Other,100% of NY Medicaid HMO DRG,17686,,100% x Medicaid HMO amount,17686,Other,100% of NY Medicaid HMO DRG,17686,,100% x Medicaid HMO amount,17686,Other,100% of NY Medicaid HMO DRG,39794,,225% x Medicaid HMO amount,39794,Other,225% of NY Medicaid HMO DRG,39794,,225% x Medicaid HMO amount,39794,Other,225% of NY Medicaid HMO DRG,39794,,225% x Medicaid HMO amount,39794,Other,225% of NY Medicaid HMO DRG,39794,,225% x Medicaid HMO amount,39794,Other,225% of NY Medicaid HMO DRG,24760,,140% x Medicaid HMO amount,24760,Other,140% of NY Medicaid HMO DRG,39794,,225% x Medicaid HMO amount,39794,Other,225% of NY Medicaid HMO DRG,48637,,275% x Medicaid HMO amount,48637,Other,275% of NY Medicaid HMO DRG,57303,,324% x Medicaid HMO amount,57303,Other,324% of NY Medicaid HMO DRG,38025,,215% x Medicaid HMO amount,38025,Other,215% of NY Medicaid HMO DRG,38025,,215% x Medicaid HMO amount,38025,Other,215% of NY Medicaid HMO DRG,22108,,125% x Medicaid HMO amount,22108,Other,125% of NY Medicaid HMO DRG,0.01,97883,
"Malfunction, reaction, complic of genitourinary device or proc",466-1,APR-DRG,,,,,,,,inpatient,,,74000.35,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22668,,"45,128 x DRG weight",22668,Other,base rate x DRG weight,20401,,"40,615 x DRG weight",20401,Other,base rate x DRG weight,19268,,"38,359 x DRG weight",19268,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8792,,186% x Medicaid HMO amount,8792,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17117,,"34,077 x DRG weight",17117,Other,base rate x DRG weight,14550,,"28,966 x DRG weight",14550,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4727,,DRG base rate x DRG weight + capital per discharge,4727,Other,100% of NY Medicaid HMO DRG,4727,,100% x Medicaid HMO amount,4727,Other,100% of NY Medicaid HMO DRG,4727,,100% x Medicaid HMO amount,4727,Other,100% of NY Medicaid HMO DRG,4727,,100% x Medicaid HMO amount,4727,Other,100% of NY Medicaid HMO DRG,10636,,225% x Medicaid HMO amount,10636,Other,225% of NY Medicaid HMO DRG,10636,,225% x Medicaid HMO amount,10636,Other,225% of NY Medicaid HMO DRG,10636,,225% x Medicaid HMO amount,10636,Other,225% of NY Medicaid HMO DRG,10636,,225% x Medicaid HMO amount,10636,Other,225% of NY Medicaid HMO DRG,6618,,140% x Medicaid HMO amount,6618,Other,140% of NY Medicaid HMO DRG,10636,,225% x Medicaid HMO amount,10636,Other,225% of NY Medicaid HMO DRG,12999,,275% x Medicaid HMO amount,12999,Other,275% of NY Medicaid HMO DRG,15315,,324% x Medicaid HMO amount,15315,Other,324% of NY Medicaid HMO DRG,10163,,215% x Medicaid HMO amount,10163,Other,215% of NY Medicaid HMO DRG,10163,,215% x Medicaid HMO amount,10163,Other,215% of NY Medicaid HMO DRG,5909,,125% x Medicaid HMO amount,5909,Other,125% of NY Medicaid HMO DRG,0.01,22668,
"Malfunction, reaction, complic of genitourinary device or proc",466-2,APR-DRG,,,,,,,,inpatient,,,142265.55,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31495,,"45,128 x DRG weight",31495,Other,base rate x DRG weight,28345,,"40,615 x DRG weight",28345,Other,base rate x DRG weight,26771,,"38,359 x DRG weight",26771,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11619,,186% x Medicaid HMO amount,11619,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23782,,"34,077 x DRG weight",23782,Other,base rate x DRG weight,20215,,"28,966 x DRG weight",20215,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6247,,DRG base rate x DRG weight + capital per discharge,6247,Other,100% of NY Medicaid HMO DRG,6247,,100% x Medicaid HMO amount,6247,Other,100% of NY Medicaid HMO DRG,6247,,100% x Medicaid HMO amount,6247,Other,100% of NY Medicaid HMO DRG,6247,,100% x Medicaid HMO amount,6247,Other,100% of NY Medicaid HMO DRG,14056,,225% x Medicaid HMO amount,14056,Other,225% of NY Medicaid HMO DRG,14056,,225% x Medicaid HMO amount,14056,Other,225% of NY Medicaid HMO DRG,14056,,225% x Medicaid HMO amount,14056,Other,225% of NY Medicaid HMO DRG,14056,,225% x Medicaid HMO amount,14056,Other,225% of NY Medicaid HMO DRG,8746,,140% x Medicaid HMO amount,8746,Other,140% of NY Medicaid HMO DRG,14056,,225% x Medicaid HMO amount,14056,Other,225% of NY Medicaid HMO DRG,17179,,275% x Medicaid HMO amount,17179,Other,275% of NY Medicaid HMO DRG,20240,,324% x Medicaid HMO amount,20240,Other,324% of NY Medicaid HMO DRG,13431,,215% x Medicaid HMO amount,13431,Other,215% of NY Medicaid HMO DRG,13431,,215% x Medicaid HMO amount,13431,Other,215% of NY Medicaid HMO DRG,7809,,125% x Medicaid HMO amount,7809,Other,125% of NY Medicaid HMO DRG,0.01,31495,
"Malfunction, reaction, complic of genitourinary device or proc",466-3,APR-DRG,,,,,,,,inpatient,,,126134.28,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52506,,"45,128 x DRG weight",52506,Other,base rate x DRG weight,47256,,"40,615 x DRG weight",47256,Other,base rate x DRG weight,44631,,"38,359 x DRG weight",44631,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18354,,186% x Medicaid HMO amount,18354,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39649,,"34,077 x DRG weight",39649,Other,base rate x DRG weight,33702,,"28,966 x DRG weight",33702,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9868,,DRG base rate x DRG weight + capital per discharge,9868,Other,100% of NY Medicaid HMO DRG,9868,,100% x Medicaid HMO amount,9868,Other,100% of NY Medicaid HMO DRG,9868,,100% x Medicaid HMO amount,9868,Other,100% of NY Medicaid HMO DRG,9868,,100% x Medicaid HMO amount,9868,Other,100% of NY Medicaid HMO DRG,22203,,225% x Medicaid HMO amount,22203,Other,225% of NY Medicaid HMO DRG,22203,,225% x Medicaid HMO amount,22203,Other,225% of NY Medicaid HMO DRG,22203,,225% x Medicaid HMO amount,22203,Other,225% of NY Medicaid HMO DRG,22203,,225% x Medicaid HMO amount,22203,Other,225% of NY Medicaid HMO DRG,13815,,140% x Medicaid HMO amount,13815,Other,140% of NY Medicaid HMO DRG,22203,,225% x Medicaid HMO amount,22203,Other,225% of NY Medicaid HMO DRG,27137,,275% x Medicaid HMO amount,27137,Other,275% of NY Medicaid HMO DRG,31972,,324% x Medicaid HMO amount,31972,Other,324% of NY Medicaid HMO DRG,21216,,215% x Medicaid HMO amount,21216,Other,215% of NY Medicaid HMO DRG,21216,,215% x Medicaid HMO amount,21216,Other,215% of NY Medicaid HMO DRG,12335,,125% x Medicaid HMO amount,12335,Other,125% of NY Medicaid HMO DRG,0.01,52506,
"Malfunction, reaction, complic of genitourinary device or proc",466-4,APR-DRG,,,,,,,,inpatient,,,252134.1,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,105044,,"45,128 x DRG weight",105044,Other,base rate x DRG weight,94540,,"40,615 x DRG weight",94540,Other,base rate x DRG weight,89288,,"38,359 x DRG weight",89288,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35191,,186% x Medicaid HMO amount,35191,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,79321,,"34,077 x DRG weight",79321,Other,base rate x DRG weight,67424,,"28,966 x DRG weight",67424,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18920,,DRG base rate x DRG weight + capital per discharge,18920,Other,100% of NY Medicaid HMO DRG,18920,,100% x Medicaid HMO amount,18920,Other,100% of NY Medicaid HMO DRG,18920,,100% x Medicaid HMO amount,18920,Other,100% of NY Medicaid HMO DRG,18920,,100% x Medicaid HMO amount,18920,Other,100% of NY Medicaid HMO DRG,42570,,225% x Medicaid HMO amount,42570,Other,225% of NY Medicaid HMO DRG,42570,,225% x Medicaid HMO amount,42570,Other,225% of NY Medicaid HMO DRG,42570,,225% x Medicaid HMO amount,42570,Other,225% of NY Medicaid HMO DRG,42570,,225% x Medicaid HMO amount,42570,Other,225% of NY Medicaid HMO DRG,26488,,140% x Medicaid HMO amount,26488,Other,140% of NY Medicaid HMO DRG,42570,,225% x Medicaid HMO amount,42570,Other,225% of NY Medicaid HMO DRG,52030,,275% x Medicaid HMO amount,52030,Other,275% of NY Medicaid HMO DRG,61301,,324% x Medicaid HMO amount,61301,Other,324% of NY Medicaid HMO DRG,40678,,215% x Medicaid HMO amount,40678,Other,215% of NY Medicaid HMO DRG,40678,,215% x Medicaid HMO amount,40678,Other,215% of NY Medicaid HMO DRG,23650,,125% x Medicaid HMO amount,23650,Other,125% of NY Medicaid HMO DRG,0.01,105044,
"Other kidney & urinary tract diagnoses, signs & symptoms",468-1,APR-DRG,,,,,,,,inpatient,,,104668.6,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22726,,"45,128 x DRG weight",22726,Other,base rate x DRG weight,20454,,"40,615 x DRG weight",20454,Other,base rate x DRG weight,19318,,"38,359 x DRG weight",19318,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8811,,186% x Medicaid HMO amount,8811,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17161,,"34,077 x DRG weight",17161,Other,base rate x DRG weight,14587,,"28,966 x DRG weight",14587,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4737,,DRG base rate x DRG weight + capital per discharge,4737,Other,100% of NY Medicaid HMO DRG,4737,,100% x Medicaid HMO amount,4737,Other,100% of NY Medicaid HMO DRG,4737,,100% x Medicaid HMO amount,4737,Other,100% of NY Medicaid HMO DRG,4737,,100% x Medicaid HMO amount,4737,Other,100% of NY Medicaid HMO DRG,10658,,225% x Medicaid HMO amount,10658,Other,225% of NY Medicaid HMO DRG,10658,,225% x Medicaid HMO amount,10658,Other,225% of NY Medicaid HMO DRG,10658,,225% x Medicaid HMO amount,10658,Other,225% of NY Medicaid HMO DRG,10658,,225% x Medicaid HMO amount,10658,Other,225% of NY Medicaid HMO DRG,6632,,140% x Medicaid HMO amount,6632,Other,140% of NY Medicaid HMO DRG,10658,,225% x Medicaid HMO amount,10658,Other,225% of NY Medicaid HMO DRG,13027,,275% x Medicaid HMO amount,13027,Other,275% of NY Medicaid HMO DRG,15348,,324% x Medicaid HMO amount,15348,Other,324% of NY Medicaid HMO DRG,10185,,215% x Medicaid HMO amount,10185,Other,215% of NY Medicaid HMO DRG,10185,,215% x Medicaid HMO amount,10185,Other,215% of NY Medicaid HMO DRG,5921,,125% x Medicaid HMO amount,5921,Other,125% of NY Medicaid HMO DRG,0.01,22726,
"Other kidney & urinary tract diagnoses, signs & symptoms",468-2,APR-DRG,,,,,,,,inpatient,,,163686.63,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32804,,"45,128 x DRG weight",32804,Other,base rate x DRG weight,29523,,"40,615 x DRG weight",29523,Other,base rate x DRG weight,27883,,"38,359 x DRG weight",27883,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12040,,186% x Medicaid HMO amount,12040,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24771,,"34,077 x DRG weight",24771,Other,base rate x DRG weight,21055,,"28,966 x DRG weight",21055,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6473,,DRG base rate x DRG weight + capital per discharge,6473,Other,100% of NY Medicaid HMO DRG,6473,,100% x Medicaid HMO amount,6473,Other,100% of NY Medicaid HMO DRG,6473,,100% x Medicaid HMO amount,6473,Other,100% of NY Medicaid HMO DRG,6473,,100% x Medicaid HMO amount,6473,Other,100% of NY Medicaid HMO DRG,14564,,225% x Medicaid HMO amount,14564,Other,225% of NY Medicaid HMO DRG,14564,,225% x Medicaid HMO amount,14564,Other,225% of NY Medicaid HMO DRG,14564,,225% x Medicaid HMO amount,14564,Other,225% of NY Medicaid HMO DRG,14564,,225% x Medicaid HMO amount,14564,Other,225% of NY Medicaid HMO DRG,9062,,140% x Medicaid HMO amount,9062,Other,140% of NY Medicaid HMO DRG,14564,,225% x Medicaid HMO amount,14564,Other,225% of NY Medicaid HMO DRG,17801,,275% x Medicaid HMO amount,17801,Other,275% of NY Medicaid HMO DRG,20973,,324% x Medicaid HMO amount,20973,Other,324% of NY Medicaid HMO DRG,13917,,215% x Medicaid HMO amount,13917,Other,215% of NY Medicaid HMO DRG,13917,,215% x Medicaid HMO amount,13917,Other,215% of NY Medicaid HMO DRG,8091,,125% x Medicaid HMO amount,8091,Other,125% of NY Medicaid HMO DRG,0.01,32804,
"Other kidney & urinary tract diagnoses, signs & symptoms",468-3,APR-DRG,,,,,,,,inpatient,,,137408,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53675,,"45,128 x DRG weight",53675,Other,base rate x DRG weight,48307,,"40,615 x DRG weight",48307,Other,base rate x DRG weight,45624,,"38,359 x DRG weight",45624,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18728,,186% x Medicaid HMO amount,18728,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40531,,"34,077 x DRG weight",40531,Other,base rate x DRG weight,34452,,"28,966 x DRG weight",34452,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10069,,DRG base rate x DRG weight + capital per discharge,10069,Other,100% of NY Medicaid HMO DRG,10069,,100% x Medicaid HMO amount,10069,Other,100% of NY Medicaid HMO DRG,10069,,100% x Medicaid HMO amount,10069,Other,100% of NY Medicaid HMO DRG,10069,,100% x Medicaid HMO amount,10069,Other,100% of NY Medicaid HMO DRG,22655,,225% x Medicaid HMO amount,22655,Other,225% of NY Medicaid HMO DRG,22655,,225% x Medicaid HMO amount,22655,Other,225% of NY Medicaid HMO DRG,22655,,225% x Medicaid HMO amount,22655,Other,225% of NY Medicaid HMO DRG,22655,,225% x Medicaid HMO amount,22655,Other,225% of NY Medicaid HMO DRG,14097,,140% x Medicaid HMO amount,14097,Other,140% of NY Medicaid HMO DRG,22655,,225% x Medicaid HMO amount,22655,Other,225% of NY Medicaid HMO DRG,27690,,275% x Medicaid HMO amount,27690,Other,275% of NY Medicaid HMO DRG,32624,,324% x Medicaid HMO amount,32624,Other,324% of NY Medicaid HMO DRG,21648,,215% x Medicaid HMO amount,21648,Other,215% of NY Medicaid HMO DRG,21648,,215% x Medicaid HMO amount,21648,Other,215% of NY Medicaid HMO DRG,12586,,125% x Medicaid HMO amount,12586,Other,125% of NY Medicaid HMO DRG,0.01,53675,
"Other kidney & urinary tract diagnoses, signs & symptoms",468-4,APR-DRG,,,,,,,,inpatient,,,274508.99,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,126751,,"45,128 x DRG weight",126751,Other,base rate x DRG weight,114075,,"40,615 x DRG weight",114075,Other,base rate x DRG weight,107739,,"38,359 x DRG weight",107739,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42148,,186% x Medicaid HMO amount,42148,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,95712,,"34,077 x DRG weight",95712,Other,base rate x DRG weight,81357,,"28,966 x DRG weight",81357,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22660,,DRG base rate x DRG weight + capital per discharge,22660,Other,100% of NY Medicaid HMO DRG,22660,,100% x Medicaid HMO amount,22660,Other,100% of NY Medicaid HMO DRG,22660,,100% x Medicaid HMO amount,22660,Other,100% of NY Medicaid HMO DRG,22660,,100% x Medicaid HMO amount,22660,Other,100% of NY Medicaid HMO DRG,50985,,225% x Medicaid HMO amount,50985,Other,225% of NY Medicaid HMO DRG,50985,,225% x Medicaid HMO amount,50985,Other,225% of NY Medicaid HMO DRG,50985,,225% x Medicaid HMO amount,50985,Other,225% of NY Medicaid HMO DRG,50985,,225% x Medicaid HMO amount,50985,Other,225% of NY Medicaid HMO DRG,31724,,140% x Medicaid HMO amount,31724,Other,140% of NY Medicaid HMO DRG,50985,,225% x Medicaid HMO amount,50985,Other,225% of NY Medicaid HMO DRG,62315,,275% x Medicaid HMO amount,62315,Other,275% of NY Medicaid HMO DRG,73418,,324% x Medicaid HMO amount,73418,Other,324% of NY Medicaid HMO DRG,48719,,215% x Medicaid HMO amount,48719,Other,215% of NY Medicaid HMO DRG,48719,,215% x Medicaid HMO amount,48719,Other,215% of NY Medicaid HMO DRG,28325,,125% x Medicaid HMO amount,28325,Other,125% of NY Medicaid HMO DRG,0.01,126751,
Acute Kidney Injury #,469-1,APR-DRG,,,,,,,,inpatient,,,29936.1,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23760,,"45,128 x DRG weight",23760,Other,base rate x DRG weight,21384,,"40,615 x DRG weight",21384,Other,base rate x DRG weight,20196,,"38,359 x DRG weight",20196,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9142,,186% x Medicaid HMO amount,9142,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17942,,"34,077 x DRG weight",17942,Other,base rate x DRG weight,15251,,"28,966 x DRG weight",15251,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4915,,DRG base rate x DRG weight + capital per discharge,4915,Other,100% of NY Medicaid HMO DRG,4915,,100% x Medicaid HMO amount,4915,Other,100% of NY Medicaid HMO DRG,4915,,100% x Medicaid HMO amount,4915,Other,100% of NY Medicaid HMO DRG,4915,,100% x Medicaid HMO amount,4915,Other,100% of NY Medicaid HMO DRG,11059,,225% x Medicaid HMO amount,11059,Other,225% of NY Medicaid HMO DRG,11059,,225% x Medicaid HMO amount,11059,Other,225% of NY Medicaid HMO DRG,11059,,225% x Medicaid HMO amount,11059,Other,225% of NY Medicaid HMO DRG,11059,,225% x Medicaid HMO amount,11059,Other,225% of NY Medicaid HMO DRG,6881,,140% x Medicaid HMO amount,6881,Other,140% of NY Medicaid HMO DRG,11059,,225% x Medicaid HMO amount,11059,Other,225% of NY Medicaid HMO DRG,13516,,275% x Medicaid HMO amount,13516,Other,275% of NY Medicaid HMO DRG,15925,,324% x Medicaid HMO amount,15925,Other,324% of NY Medicaid HMO DRG,10567,,215% x Medicaid HMO amount,10567,Other,215% of NY Medicaid HMO DRG,10567,,215% x Medicaid HMO amount,10567,Other,215% of NY Medicaid HMO DRG,6144,,125% x Medicaid HMO amount,6144,Other,125% of NY Medicaid HMO DRG,0.01,23760,
Acute Kidney Injury #,469-2,APR-DRG,,,,,,,,inpatient,,,120863.12,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33598,,"45,128 x DRG weight",33598,Other,base rate x DRG weight,30238,,"40,615 x DRG weight",30238,Other,base rate x DRG weight,28558,,"38,359 x DRG weight",28558,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12295,,186% x Medicaid HMO amount,12295,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25370,,"34,077 x DRG weight",25370,Other,base rate x DRG weight,21565,,"28,966 x DRG weight",21565,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6610,,DRG base rate x DRG weight + capital per discharge,6610,Other,100% of NY Medicaid HMO DRG,6610,,100% x Medicaid HMO amount,6610,Other,100% of NY Medicaid HMO DRG,6610,,100% x Medicaid HMO amount,6610,Other,100% of NY Medicaid HMO DRG,6610,,100% x Medicaid HMO amount,6610,Other,100% of NY Medicaid HMO DRG,14873,,225% x Medicaid HMO amount,14873,Other,225% of NY Medicaid HMO DRG,14873,,225% x Medicaid HMO amount,14873,Other,225% of NY Medicaid HMO DRG,14873,,225% x Medicaid HMO amount,14873,Other,225% of NY Medicaid HMO DRG,14873,,225% x Medicaid HMO amount,14873,Other,225% of NY Medicaid HMO DRG,9254,,140% x Medicaid HMO amount,9254,Other,140% of NY Medicaid HMO DRG,14873,,225% x Medicaid HMO amount,14873,Other,225% of NY Medicaid HMO DRG,18178,,275% x Medicaid HMO amount,18178,Other,275% of NY Medicaid HMO DRG,21416,,324% x Medicaid HMO amount,21416,Other,324% of NY Medicaid HMO DRG,14212,,215% x Medicaid HMO amount,14212,Other,215% of NY Medicaid HMO DRG,14212,,215% x Medicaid HMO amount,14212,Other,215% of NY Medicaid HMO DRG,8263,,125% x Medicaid HMO amount,8263,Other,125% of NY Medicaid HMO DRG,0.01,33598,
Acute Kidney Injury #,469-3,APR-DRG,,,,,,,,inpatient,,,161358.66,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,61293,,"45,128 x DRG weight",61293,Other,base rate x DRG weight,55163,,"40,615 x DRG weight",55163,Other,base rate x DRG weight,52099,,"38,359 x DRG weight",52099,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21171,,186% x Medicaid HMO amount,21171,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46283,,"34,077 x DRG weight",46283,Other,base rate x DRG weight,39342,,"28,966 x DRG weight",39342,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11382,,DRG base rate x DRG weight + capital per discharge,11382,Other,100% of NY Medicaid HMO DRG,11382,,100% x Medicaid HMO amount,11382,Other,100% of NY Medicaid HMO DRG,11382,,100% x Medicaid HMO amount,11382,Other,100% of NY Medicaid HMO DRG,11382,,100% x Medicaid HMO amount,11382,Other,100% of NY Medicaid HMO DRG,25610,,225% x Medicaid HMO amount,25610,Other,225% of NY Medicaid HMO DRG,25610,,225% x Medicaid HMO amount,25610,Other,225% of NY Medicaid HMO DRG,25610,,225% x Medicaid HMO amount,25610,Other,225% of NY Medicaid HMO DRG,25610,,225% x Medicaid HMO amount,25610,Other,225% of NY Medicaid HMO DRG,15935,,140% x Medicaid HMO amount,15935,Other,140% of NY Medicaid HMO DRG,25610,,225% x Medicaid HMO amount,25610,Other,225% of NY Medicaid HMO DRG,31301,,275% x Medicaid HMO amount,31301,Other,275% of NY Medicaid HMO DRG,36878,,324% x Medicaid HMO amount,36878,Other,324% of NY Medicaid HMO DRG,24471,,215% x Medicaid HMO amount,24471,Other,215% of NY Medicaid HMO DRG,24471,,215% x Medicaid HMO amount,24471,Other,215% of NY Medicaid HMO DRG,14228,,125% x Medicaid HMO amount,14228,Other,125% of NY Medicaid HMO DRG,0.01,61293,
Acute Kidney Injury #,469-4,APR-DRG,,,,,,,,inpatient,,,543360.57,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,148981,,"45,128 x DRG weight",148981,Other,base rate x DRG weight,134082,,"40,615 x DRG weight",134082,Other,base rate x DRG weight,126635,,"38,359 x DRG weight",126635,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49273,,186% x Medicaid HMO amount,49273,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,112498,,"34,077 x DRG weight",112498,Other,base rate x DRG weight,95625,,"28,966 x DRG weight",95625,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26491,,DRG base rate x DRG weight + capital per discharge,26491,Other,100% of NY Medicaid HMO DRG,26491,,100% x Medicaid HMO amount,26491,Other,100% of NY Medicaid HMO DRG,26491,,100% x Medicaid HMO amount,26491,Other,100% of NY Medicaid HMO DRG,26491,,100% x Medicaid HMO amount,26491,Other,100% of NY Medicaid HMO DRG,59605,,225% x Medicaid HMO amount,59605,Other,225% of NY Medicaid HMO DRG,59605,,225% x Medicaid HMO amount,59605,Other,225% of NY Medicaid HMO DRG,59605,,225% x Medicaid HMO amount,59605,Other,225% of NY Medicaid HMO DRG,59605,,225% x Medicaid HMO amount,59605,Other,225% of NY Medicaid HMO DRG,37087,,140% x Medicaid HMO amount,37087,Other,140% of NY Medicaid HMO DRG,59605,,225% x Medicaid HMO amount,59605,Other,225% of NY Medicaid HMO DRG,72850,,275% x Medicaid HMO amount,72850,Other,275% of NY Medicaid HMO DRG,85831,,324% x Medicaid HMO amount,85831,Other,324% of NY Medicaid HMO DRG,56956,,215% x Medicaid HMO amount,56956,Other,215% of NY Medicaid HMO DRG,56956,,215% x Medicaid HMO amount,56956,Other,215% of NY Medicaid HMO DRG,33114,,125% x Medicaid HMO amount,33114,Other,125% of NY Medicaid HMO DRG,0.01,148981,
Chronic Kidney Disease #,470-1,APR-DRG,,,,,,,,inpatient,,,174642.65,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21603,,"45,128 x DRG weight",21603,Other,base rate x DRG weight,19442,,"40,615 x DRG weight",19442,Other,base rate x DRG weight,18362,,"38,359 x DRG weight",18362,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8450,,186% x Medicaid HMO amount,8450,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16313,,"34,077 x DRG weight",16313,Other,base rate x DRG weight,13866,,"28,966 x DRG weight",13866,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4543,,DRG base rate x DRG weight + capital per discharge,4543,Other,100% of NY Medicaid HMO DRG,4543,,100% x Medicaid HMO amount,4543,Other,100% of NY Medicaid HMO DRG,4543,,100% x Medicaid HMO amount,4543,Other,100% of NY Medicaid HMO DRG,4543,,100% x Medicaid HMO amount,4543,Other,100% of NY Medicaid HMO DRG,10222,,225% x Medicaid HMO amount,10222,Other,225% of NY Medicaid HMO DRG,10222,,225% x Medicaid HMO amount,10222,Other,225% of NY Medicaid HMO DRG,10222,,225% x Medicaid HMO amount,10222,Other,225% of NY Medicaid HMO DRG,10222,,225% x Medicaid HMO amount,10222,Other,225% of NY Medicaid HMO DRG,6360,,140% x Medicaid HMO amount,6360,Other,140% of NY Medicaid HMO DRG,10222,,225% x Medicaid HMO amount,10222,Other,225% of NY Medicaid HMO DRG,12493,,275% x Medicaid HMO amount,12493,Other,275% of NY Medicaid HMO DRG,14719,,324% x Medicaid HMO amount,14719,Other,324% of NY Medicaid HMO DRG,9767,,215% x Medicaid HMO amount,9767,Other,215% of NY Medicaid HMO DRG,9767,,215% x Medicaid HMO amount,9767,Other,215% of NY Medicaid HMO DRG,5679,,125% x Medicaid HMO amount,5679,Other,125% of NY Medicaid HMO DRG,0.01,21603,
Chronic Kidney Disease #,470-2,APR-DRG,,,,,,,,inpatient,,,262208.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30836,,"45,128 x DRG weight",30836,Other,base rate x DRG weight,27752,,"40,615 x DRG weight",27752,Other,base rate x DRG weight,26211,,"38,359 x DRG weight",26211,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11409,,186% x Medicaid HMO amount,11409,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23285,,"34,077 x DRG weight",23285,Other,base rate x DRG weight,19792,,"28,966 x DRG weight",19792,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6134,,DRG base rate x DRG weight + capital per discharge,6134,Other,100% of NY Medicaid HMO DRG,6134,,100% x Medicaid HMO amount,6134,Other,100% of NY Medicaid HMO DRG,6134,,100% x Medicaid HMO amount,6134,Other,100% of NY Medicaid HMO DRG,6134,,100% x Medicaid HMO amount,6134,Other,100% of NY Medicaid HMO DRG,13802,,225% x Medicaid HMO amount,13802,Other,225% of NY Medicaid HMO DRG,13802,,225% x Medicaid HMO amount,13802,Other,225% of NY Medicaid HMO DRG,13802,,225% x Medicaid HMO amount,13802,Other,225% of NY Medicaid HMO DRG,13802,,225% x Medicaid HMO amount,13802,Other,225% of NY Medicaid HMO DRG,8588,,140% x Medicaid HMO amount,8588,Other,140% of NY Medicaid HMO DRG,13802,,225% x Medicaid HMO amount,13802,Other,225% of NY Medicaid HMO DRG,16869,,275% x Medicaid HMO amount,16869,Other,275% of NY Medicaid HMO DRG,19874,,324% x Medicaid HMO amount,19874,Other,324% of NY Medicaid HMO DRG,13188,,215% x Medicaid HMO amount,13188,Other,215% of NY Medicaid HMO DRG,13188,,215% x Medicaid HMO amount,13188,Other,215% of NY Medicaid HMO DRG,7668,,125% x Medicaid HMO amount,7668,Other,125% of NY Medicaid HMO DRG,0.01,30836,
Chronic Kidney Disease #,470-3,APR-DRG,,,,,,,,inpatient,,,174642.65,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53797,,"45,128 x DRG weight",53797,Other,base rate x DRG weight,48417,,"40,615 x DRG weight",48417,Other,base rate x DRG weight,45728,,"38,359 x DRG weight",45728,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18767,,186% x Medicaid HMO amount,18767,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40623,,"34,077 x DRG weight",40623,Other,base rate x DRG weight,34530,,"28,966 x DRG weight",34530,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10090,,DRG base rate x DRG weight + capital per discharge,10090,Other,100% of NY Medicaid HMO DRG,10090,,100% x Medicaid HMO amount,10090,Other,100% of NY Medicaid HMO DRG,10090,,100% x Medicaid HMO amount,10090,Other,100% of NY Medicaid HMO DRG,10090,,100% x Medicaid HMO amount,10090,Other,100% of NY Medicaid HMO DRG,22703,,225% x Medicaid HMO amount,22703,Other,225% of NY Medicaid HMO DRG,22703,,225% x Medicaid HMO amount,22703,Other,225% of NY Medicaid HMO DRG,22703,,225% x Medicaid HMO amount,22703,Other,225% of NY Medicaid HMO DRG,22703,,225% x Medicaid HMO amount,22703,Other,225% of NY Medicaid HMO DRG,14126,,140% x Medicaid HMO amount,14126,Other,140% of NY Medicaid HMO DRG,22703,,225% x Medicaid HMO amount,22703,Other,225% of NY Medicaid HMO DRG,27748,,275% x Medicaid HMO amount,27748,Other,275% of NY Medicaid HMO DRG,32692,,324% x Medicaid HMO amount,32692,Other,324% of NY Medicaid HMO DRG,21694,,215% x Medicaid HMO amount,21694,Other,215% of NY Medicaid HMO DRG,21694,,215% x Medicaid HMO amount,21694,Other,215% of NY Medicaid HMO DRG,12613,,125% x Medicaid HMO amount,12613,Other,125% of NY Medicaid HMO DRG,0.01,53797,
Chronic Kidney Disease #,470-4,APR-DRG,,,,,,,,inpatient,,,617227.05,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,119869,,"45,128 x DRG weight",119869,Other,base rate x DRG weight,107882,,"40,615 x DRG weight",107882,Other,base rate x DRG weight,101889,,"38,359 x DRG weight",101889,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39942,,186% x Medicaid HMO amount,39942,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,90515,,"34,077 x DRG weight",90515,Other,base rate x DRG weight,76939,,"28,966 x DRG weight",76939,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21474,,DRG base rate x DRG weight + capital per discharge,21474,Other,100% of NY Medicaid HMO DRG,21474,,100% x Medicaid HMO amount,21474,Other,100% of NY Medicaid HMO DRG,21474,,100% x Medicaid HMO amount,21474,Other,100% of NY Medicaid HMO DRG,21474,,100% x Medicaid HMO amount,21474,Other,100% of NY Medicaid HMO DRG,48317,,225% x Medicaid HMO amount,48317,Other,225% of NY Medicaid HMO DRG,48317,,225% x Medicaid HMO amount,48317,Other,225% of NY Medicaid HMO DRG,48317,,225% x Medicaid HMO amount,48317,Other,225% of NY Medicaid HMO DRG,48317,,225% x Medicaid HMO amount,48317,Other,225% of NY Medicaid HMO DRG,30064,,140% x Medicaid HMO amount,30064,Other,140% of NY Medicaid HMO DRG,48317,,225% x Medicaid HMO amount,48317,Other,225% of NY Medicaid HMO DRG,59054,,275% x Medicaid HMO amount,59054,Other,275% of NY Medicaid HMO DRG,69576,,324% x Medicaid HMO amount,69576,Other,324% of NY Medicaid HMO DRG,46169,,215% x Medicaid HMO amount,46169,Other,215% of NY Medicaid HMO DRG,46169,,215% x Medicaid HMO amount,46169,Other,215% of NY Medicaid HMO DRG,26843,,125% x Medicaid HMO amount,26843,Other,125% of NY Medicaid HMO DRG,0.01,119869,
Major male pelvic procedures,480-1,APR-DRG,,,,,,,,inpatient,,,155333.36,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49578,,"45,128 x DRG weight",49578,Other,base rate x DRG weight,44620,,"40,615 x DRG weight",44620,Other,base rate x DRG weight,42141,,"38,359 x DRG weight",42141,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17415,,186% x Medicaid HMO amount,17415,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37437,,"34,077 x DRG weight",37437,Other,base rate x DRG weight,31822,,"28,966 x DRG weight",31822,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9363,,DRG base rate x DRG weight + capital per discharge,9363,Other,100% of NY Medicaid HMO DRG,9363,,100% x Medicaid HMO amount,9363,Other,100% of NY Medicaid HMO DRG,9363,,100% x Medicaid HMO amount,9363,Other,100% of NY Medicaid HMO DRG,9363,,100% x Medicaid HMO amount,9363,Other,100% of NY Medicaid HMO DRG,21067,,225% x Medicaid HMO amount,21067,Other,225% of NY Medicaid HMO DRG,21067,,225% x Medicaid HMO amount,21067,Other,225% of NY Medicaid HMO DRG,21067,,225% x Medicaid HMO amount,21067,Other,225% of NY Medicaid HMO DRG,21067,,225% x Medicaid HMO amount,21067,Other,225% of NY Medicaid HMO DRG,13108,,140% x Medicaid HMO amount,13108,Other,140% of NY Medicaid HMO DRG,21067,,225% x Medicaid HMO amount,21067,Other,225% of NY Medicaid HMO DRG,25748,,275% x Medicaid HMO amount,25748,Other,275% of NY Medicaid HMO DRG,30336,,324% x Medicaid HMO amount,30336,Other,324% of NY Medicaid HMO DRG,20130,,215% x Medicaid HMO amount,20130,Other,215% of NY Medicaid HMO DRG,20130,,215% x Medicaid HMO amount,20130,Other,215% of NY Medicaid HMO DRG,11704,,125% x Medicaid HMO amount,11704,Other,125% of NY Medicaid HMO DRG,0.01,49578,
Major male pelvic procedures,480-2,APR-DRG,,,,,,,,inpatient,,,155333.36,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56604,,"45,128 x DRG weight",56604,Other,base rate x DRG weight,50943,,"40,615 x DRG weight",50943,Other,base rate x DRG weight,48114,,"38,359 x DRG weight",48114,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19668,,186% x Medicaid HMO amount,19668,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42743,,"34,077 x DRG weight",42743,Other,base rate x DRG weight,36332,,"28,966 x DRG weight",36332,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10574,,DRG base rate x DRG weight + capital per discharge,10574,Other,100% of NY Medicaid HMO DRG,10574,,100% x Medicaid HMO amount,10574,Other,100% of NY Medicaid HMO DRG,10574,,100% x Medicaid HMO amount,10574,Other,100% of NY Medicaid HMO DRG,10574,,100% x Medicaid HMO amount,10574,Other,100% of NY Medicaid HMO DRG,23792,,225% x Medicaid HMO amount,23792,Other,225% of NY Medicaid HMO DRG,23792,,225% x Medicaid HMO amount,23792,Other,225% of NY Medicaid HMO DRG,23792,,225% x Medicaid HMO amount,23792,Other,225% of NY Medicaid HMO DRG,23792,,225% x Medicaid HMO amount,23792,Other,225% of NY Medicaid HMO DRG,14804,,140% x Medicaid HMO amount,14804,Other,140% of NY Medicaid HMO DRG,23792,,225% x Medicaid HMO amount,23792,Other,225% of NY Medicaid HMO DRG,29079,,275% x Medicaid HMO amount,29079,Other,275% of NY Medicaid HMO DRG,34260,,324% x Medicaid HMO amount,34260,Other,324% of NY Medicaid HMO DRG,22734,,215% x Medicaid HMO amount,22734,Other,215% of NY Medicaid HMO DRG,22734,,215% x Medicaid HMO amount,22734,Other,215% of NY Medicaid HMO DRG,13218,,125% x Medicaid HMO amount,13218,Other,125% of NY Medicaid HMO DRG,0.01,56604,
Major male pelvic procedures,480-3,APR-DRG,,,,,,,,inpatient,,,155333.36,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,97355,,"45,128 x DRG weight",97355,Other,base rate x DRG weight,87619,,"40,615 x DRG weight",87619,Other,base rate x DRG weight,82752,,"38,359 x DRG weight",82752,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32727,,186% x Medicaid HMO amount,32727,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73514,,"34,077 x DRG weight",73514,Other,base rate x DRG weight,62488,,"28,966 x DRG weight",62488,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17595,,DRG base rate x DRG weight + capital per discharge,17595,Other,100% of NY Medicaid HMO DRG,17595,,100% x Medicaid HMO amount,17595,Other,100% of NY Medicaid HMO DRG,17595,,100% x Medicaid HMO amount,17595,Other,100% of NY Medicaid HMO DRG,17595,,100% x Medicaid HMO amount,17595,Other,100% of NY Medicaid HMO DRG,39589,,225% x Medicaid HMO amount,39589,Other,225% of NY Medicaid HMO DRG,39589,,225% x Medicaid HMO amount,39589,Other,225% of NY Medicaid HMO DRG,39589,,225% x Medicaid HMO amount,39589,Other,225% of NY Medicaid HMO DRG,39589,,225% x Medicaid HMO amount,39589,Other,225% of NY Medicaid HMO DRG,24633,,140% x Medicaid HMO amount,24633,Other,140% of NY Medicaid HMO DRG,39589,,225% x Medicaid HMO amount,39589,Other,225% of NY Medicaid HMO DRG,48386,,275% x Medicaid HMO amount,48386,Other,275% of NY Medicaid HMO DRG,57008,,324% x Medicaid HMO amount,57008,Other,324% of NY Medicaid HMO DRG,37829,,215% x Medicaid HMO amount,37829,Other,215% of NY Medicaid HMO DRG,37829,,215% x Medicaid HMO amount,37829,Other,215% of NY Medicaid HMO DRG,21994,,125% x Medicaid HMO amount,21994,Other,125% of NY Medicaid HMO DRG,0.01,97355,
Major male pelvic procedures,480-4,APR-DRG,,,,,,,,inpatient,,,155333.36,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,117220,,"45,128 x DRG weight",117220,Other,base rate x DRG weight,105497,,"40,615 x DRG weight",105497,Other,base rate x DRG weight,99638,,"38,359 x DRG weight",99638,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39093,,186% x Medicaid HMO amount,39093,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,88515,,"34,077 x DRG weight",88515,Other,base rate x DRG weight,75239,,"28,966 x DRG weight",75239,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21018,,DRG base rate x DRG weight + capital per discharge,21018,Other,100% of NY Medicaid HMO DRG,21018,,100% x Medicaid HMO amount,21018,Other,100% of NY Medicaid HMO DRG,21018,,100% x Medicaid HMO amount,21018,Other,100% of NY Medicaid HMO DRG,21018,,100% x Medicaid HMO amount,21018,Other,100% of NY Medicaid HMO DRG,47291,,225% x Medicaid HMO amount,47291,Other,225% of NY Medicaid HMO DRG,47291,,225% x Medicaid HMO amount,47291,Other,225% of NY Medicaid HMO DRG,47291,,225% x Medicaid HMO amount,47291,Other,225% of NY Medicaid HMO DRG,47291,,225% x Medicaid HMO amount,47291,Other,225% of NY Medicaid HMO DRG,29425,,140% x Medicaid HMO amount,29425,Other,140% of NY Medicaid HMO DRG,47291,,225% x Medicaid HMO amount,47291,Other,225% of NY Medicaid HMO DRG,57800,,275% x Medicaid HMO amount,57800,Other,275% of NY Medicaid HMO DRG,68098,,324% x Medicaid HMO amount,68098,Other,324% of NY Medicaid HMO DRG,45189,,215% x Medicaid HMO amount,45189,Other,215% of NY Medicaid HMO DRG,45189,,215% x Medicaid HMO amount,45189,Other,215% of NY Medicaid HMO DRG,26273,,125% x Medicaid HMO amount,26273,Other,125% of NY Medicaid HMO DRG,0.01,117220,
Penis procedures,481-1,APR-DRG,,,,,,,,inpatient,,,76497.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33489,,"45,128 x DRG weight",33489,Other,base rate x DRG weight,30140,,"40,615 x DRG weight",30140,Other,base rate x DRG weight,28466,,"38,359 x DRG weight",28466,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12259,,186% x Medicaid HMO amount,12259,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25289,,"34,077 x DRG weight",25289,Other,base rate x DRG weight,21496,,"28,966 x DRG weight",21496,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6591,,DRG base rate x DRG weight + capital per discharge,6591,Other,100% of NY Medicaid HMO DRG,6591,,100% x Medicaid HMO amount,6591,Other,100% of NY Medicaid HMO DRG,6591,,100% x Medicaid HMO amount,6591,Other,100% of NY Medicaid HMO DRG,6591,,100% x Medicaid HMO amount,6591,Other,100% of NY Medicaid HMO DRG,14830,,225% x Medicaid HMO amount,14830,Other,225% of NY Medicaid HMO DRG,14830,,225% x Medicaid HMO amount,14830,Other,225% of NY Medicaid HMO DRG,14830,,225% x Medicaid HMO amount,14830,Other,225% of NY Medicaid HMO DRG,14830,,225% x Medicaid HMO amount,14830,Other,225% of NY Medicaid HMO DRG,9227,,140% x Medicaid HMO amount,9227,Other,140% of NY Medicaid HMO DRG,14830,,225% x Medicaid HMO amount,14830,Other,225% of NY Medicaid HMO DRG,18125,,275% x Medicaid HMO amount,18125,Other,275% of NY Medicaid HMO DRG,21355,,324% x Medicaid HMO amount,21355,Other,324% of NY Medicaid HMO DRG,14171,,215% x Medicaid HMO amount,14171,Other,215% of NY Medicaid HMO DRG,14171,,215% x Medicaid HMO amount,14171,Other,215% of NY Medicaid HMO DRG,8239,,125% x Medicaid HMO amount,8239,Other,125% of NY Medicaid HMO DRG,0.01,33489,
Penis procedures,481-2,APR-DRG,,,,,,,,inpatient,,,103094.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55034,,"45,128 x DRG weight",55034,Other,base rate x DRG weight,49530,,"40,615 x DRG weight",49530,Other,base rate x DRG weight,46779,,"38,359 x DRG weight",46779,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19164,,186% x Medicaid HMO amount,19164,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41557,,"34,077 x DRG weight",41557,Other,base rate x DRG weight,35324,,"28,966 x DRG weight",35324,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10303,,DRG base rate x DRG weight + capital per discharge,10303,Other,100% of NY Medicaid HMO DRG,10303,,100% x Medicaid HMO amount,10303,Other,100% of NY Medicaid HMO DRG,10303,,100% x Medicaid HMO amount,10303,Other,100% of NY Medicaid HMO DRG,10303,,100% x Medicaid HMO amount,10303,Other,100% of NY Medicaid HMO DRG,23182,,225% x Medicaid HMO amount,23182,Other,225% of NY Medicaid HMO DRG,23182,,225% x Medicaid HMO amount,23182,Other,225% of NY Medicaid HMO DRG,23182,,225% x Medicaid HMO amount,23182,Other,225% of NY Medicaid HMO DRG,23182,,225% x Medicaid HMO amount,23182,Other,225% of NY Medicaid HMO DRG,14424,,140% x Medicaid HMO amount,14424,Other,140% of NY Medicaid HMO DRG,23182,,225% x Medicaid HMO amount,23182,Other,225% of NY Medicaid HMO DRG,28333,,275% x Medicaid HMO amount,28333,Other,275% of NY Medicaid HMO DRG,33382,,324% x Medicaid HMO amount,33382,Other,324% of NY Medicaid HMO DRG,22151,,215% x Medicaid HMO amount,22151,Other,215% of NY Medicaid HMO DRG,22151,,215% x Medicaid HMO amount,22151,Other,215% of NY Medicaid HMO DRG,12879,,125% x Medicaid HMO amount,12879,Other,125% of NY Medicaid HMO DRG,0.01,55034,
Penis procedures,481-3,APR-DRG,,,,,,,,inpatient,,,103094.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,88207,,"45,128 x DRG weight",88207,Other,base rate x DRG weight,79386,,"40,615 x DRG weight",79386,Other,base rate x DRG weight,74977,,"38,359 x DRG weight",74977,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29795,,186% x Medicaid HMO amount,29795,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,66607,,"34,077 x DRG weight",66607,Other,base rate x DRG weight,56617,,"28,966 x DRG weight",56617,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16019,,DRG base rate x DRG weight + capital per discharge,16019,Other,100% of NY Medicaid HMO DRG,16019,,100% x Medicaid HMO amount,16019,Other,100% of NY Medicaid HMO DRG,16019,,100% x Medicaid HMO amount,16019,Other,100% of NY Medicaid HMO DRG,16019,,100% x Medicaid HMO amount,16019,Other,100% of NY Medicaid HMO DRG,36043,,225% x Medicaid HMO amount,36043,Other,225% of NY Medicaid HMO DRG,36043,,225% x Medicaid HMO amount,36043,Other,225% of NY Medicaid HMO DRG,36043,,225% x Medicaid HMO amount,36043,Other,225% of NY Medicaid HMO DRG,36043,,225% x Medicaid HMO amount,36043,Other,225% of NY Medicaid HMO DRG,22427,,140% x Medicaid HMO amount,22427,Other,140% of NY Medicaid HMO DRG,36043,,225% x Medicaid HMO amount,36043,Other,225% of NY Medicaid HMO DRG,44052,,275% x Medicaid HMO amount,44052,Other,275% of NY Medicaid HMO DRG,51902,,324% x Medicaid HMO amount,51902,Other,324% of NY Medicaid HMO DRG,34441,,215% x Medicaid HMO amount,34441,Other,215% of NY Medicaid HMO DRG,34441,,215% x Medicaid HMO amount,34441,Other,215% of NY Medicaid HMO DRG,20024,,125% x Medicaid HMO amount,20024,Other,125% of NY Medicaid HMO DRG,0.01,88207,
Penis procedures,481-4,APR-DRG,,,,,,,,inpatient,,,103094.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,93252,,"45,128 x DRG weight",93252,Other,base rate x DRG weight,83927,,"40,615 x DRG weight",83927,Other,base rate x DRG weight,79265,,"38,359 x DRG weight",79265,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31412,,186% x Medicaid HMO amount,31412,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,70417,,"34,077 x DRG weight",70417,Other,base rate x DRG weight,59855,,"28,966 x DRG weight",59855,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16888,,DRG base rate x DRG weight + capital per discharge,16888,Other,100% of NY Medicaid HMO DRG,16888,,100% x Medicaid HMO amount,16888,Other,100% of NY Medicaid HMO DRG,16888,,100% x Medicaid HMO amount,16888,Other,100% of NY Medicaid HMO DRG,16888,,100% x Medicaid HMO amount,16888,Other,100% of NY Medicaid HMO DRG,37998,,225% x Medicaid HMO amount,37998,Other,225% of NY Medicaid HMO DRG,37998,,225% x Medicaid HMO amount,37998,Other,225% of NY Medicaid HMO DRG,37998,,225% x Medicaid HMO amount,37998,Other,225% of NY Medicaid HMO DRG,37998,,225% x Medicaid HMO amount,37998,Other,225% of NY Medicaid HMO DRG,23643,,140% x Medicaid HMO amount,23643,Other,140% of NY Medicaid HMO DRG,37998,,225% x Medicaid HMO amount,37998,Other,225% of NY Medicaid HMO DRG,46442,,275% x Medicaid HMO amount,46442,Other,275% of NY Medicaid HMO DRG,54717,,324% x Medicaid HMO amount,54717,Other,324% of NY Medicaid HMO DRG,36309,,215% x Medicaid HMO amount,36309,Other,215% of NY Medicaid HMO DRG,36309,,215% x Medicaid HMO amount,36309,Other,215% of NY Medicaid HMO DRG,21110,,125% x Medicaid HMO amount,21110,Other,125% of NY Medicaid HMO DRG,0.01,93252,
Transurethral prostatectomy,482-1,APR-DRG,,,,,,,,inpatient,,,65399.53,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27302,,"45,128 x DRG weight",27302,Other,base rate x DRG weight,24572,,"40,615 x DRG weight",24572,Other,base rate x DRG weight,23207,,"38,359 x DRG weight",23207,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10277,,186% x Medicaid HMO amount,10277,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20617,,"34,077 x DRG weight",20617,Other,base rate x DRG weight,17524,,"28,966 x DRG weight",17524,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5525,,DRG base rate x DRG weight + capital per discharge,5525,Other,100% of NY Medicaid HMO DRG,5525,,100% x Medicaid HMO amount,5525,Other,100% of NY Medicaid HMO DRG,5525,,100% x Medicaid HMO amount,5525,Other,100% of NY Medicaid HMO DRG,5525,,100% x Medicaid HMO amount,5525,Other,100% of NY Medicaid HMO DRG,12431,,225% x Medicaid HMO amount,12431,Other,225% of NY Medicaid HMO DRG,12431,,225% x Medicaid HMO amount,12431,Other,225% of NY Medicaid HMO DRG,12431,,225% x Medicaid HMO amount,12431,Other,225% of NY Medicaid HMO DRG,12431,,225% x Medicaid HMO amount,12431,Other,225% of NY Medicaid HMO DRG,7735,,140% x Medicaid HMO amount,7735,Other,140% of NY Medicaid HMO DRG,12431,,225% x Medicaid HMO amount,12431,Other,225% of NY Medicaid HMO DRG,15194,,275% x Medicaid HMO amount,15194,Other,275% of NY Medicaid HMO DRG,17901,,324% x Medicaid HMO amount,17901,Other,324% of NY Medicaid HMO DRG,11879,,215% x Medicaid HMO amount,11879,Other,215% of NY Medicaid HMO DRG,11879,,215% x Medicaid HMO amount,11879,Other,215% of NY Medicaid HMO DRG,6906,,125% x Medicaid HMO amount,6906,Other,125% of NY Medicaid HMO DRG,0.01,27302,
Transurethral prostatectomy,482-2,APR-DRG,,,,,,,,inpatient,,,60783.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38260,,"45,128 x DRG weight",38260,Other,base rate x DRG weight,34433,,"40,615 x DRG weight",34433,Other,base rate x DRG weight,32521,,"38,359 x DRG weight",32521,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13788,,186% x Medicaid HMO amount,13788,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28890,,"34,077 x DRG weight",28890,Other,base rate x DRG weight,24557,,"28,966 x DRG weight",24557,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7413,,DRG base rate x DRG weight + capital per discharge,7413,Other,100% of NY Medicaid HMO DRG,7413,,100% x Medicaid HMO amount,7413,Other,100% of NY Medicaid HMO DRG,7413,,100% x Medicaid HMO amount,7413,Other,100% of NY Medicaid HMO DRG,7413,,100% x Medicaid HMO amount,7413,Other,100% of NY Medicaid HMO DRG,16679,,225% x Medicaid HMO amount,16679,Other,225% of NY Medicaid HMO DRG,16679,,225% x Medicaid HMO amount,16679,Other,225% of NY Medicaid HMO DRG,16679,,225% x Medicaid HMO amount,16679,Other,225% of NY Medicaid HMO DRG,16679,,225% x Medicaid HMO amount,16679,Other,225% of NY Medicaid HMO DRG,10378,,140% x Medicaid HMO amount,10378,Other,140% of NY Medicaid HMO DRG,16679,,225% x Medicaid HMO amount,16679,Other,225% of NY Medicaid HMO DRG,20386,,275% x Medicaid HMO amount,20386,Other,275% of NY Medicaid HMO DRG,24018,,324% x Medicaid HMO amount,24018,Other,324% of NY Medicaid HMO DRG,15938,,215% x Medicaid HMO amount,15938,Other,215% of NY Medicaid HMO DRG,15938,,215% x Medicaid HMO amount,15938,Other,215% of NY Medicaid HMO DRG,9266,,125% x Medicaid HMO amount,9266,Other,125% of NY Medicaid HMO DRG,0.01,38260,
Transurethral prostatectomy,482-3,APR-DRG,,,,,,,,inpatient,,,220449.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,106227,,"45,128 x DRG weight",106227,Other,base rate x DRG weight,95604,,"40,615 x DRG weight",95604,Other,base rate x DRG weight,90293,,"38,359 x DRG weight",90293,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35571,,186% x Medicaid HMO amount,35571,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,80214,,"34,077 x DRG weight",80214,Other,base rate x DRG weight,68183,,"28,966 x DRG weight",68183,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19124,,DRG base rate x DRG weight + capital per discharge,19124,Other,100% of NY Medicaid HMO DRG,19124,,100% x Medicaid HMO amount,19124,Other,100% of NY Medicaid HMO DRG,19124,,100% x Medicaid HMO amount,19124,Other,100% of NY Medicaid HMO DRG,19124,,100% x Medicaid HMO amount,19124,Other,100% of NY Medicaid HMO DRG,43029,,225% x Medicaid HMO amount,43029,Other,225% of NY Medicaid HMO DRG,43029,,225% x Medicaid HMO amount,43029,Other,225% of NY Medicaid HMO DRG,43029,,225% x Medicaid HMO amount,43029,Other,225% of NY Medicaid HMO DRG,43029,,225% x Medicaid HMO amount,43029,Other,225% of NY Medicaid HMO DRG,26774,,140% x Medicaid HMO amount,26774,Other,140% of NY Medicaid HMO DRG,43029,,225% x Medicaid HMO amount,43029,Other,225% of NY Medicaid HMO DRG,52591,,275% x Medicaid HMO amount,52591,Other,275% of NY Medicaid HMO DRG,61962,,324% x Medicaid HMO amount,61962,Other,324% of NY Medicaid HMO DRG,41117,,215% x Medicaid HMO amount,41117,Other,215% of NY Medicaid HMO DRG,41117,,215% x Medicaid HMO amount,41117,Other,215% of NY Medicaid HMO DRG,23905,,125% x Medicaid HMO amount,23905,Other,125% of NY Medicaid HMO DRG,0.01,106227,
Transurethral prostatectomy,482-4,APR-DRG,,,,,,,,inpatient,,,220449.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,122103,,"45,128 x DRG weight",122103,Other,base rate x DRG weight,109892,,"40,615 x DRG weight",109892,Other,base rate x DRG weight,103788,,"38,359 x DRG weight",103788,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40658,,186% x Medicaid HMO amount,40658,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,92202,,"34,077 x DRG weight",92202,Other,base rate x DRG weight,78373,,"28,966 x DRG weight",78373,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21859,,DRG base rate x DRG weight + capital per discharge,21859,Other,100% of NY Medicaid HMO DRG,21859,,100% x Medicaid HMO amount,21859,Other,100% of NY Medicaid HMO DRG,21859,,100% x Medicaid HMO amount,21859,Other,100% of NY Medicaid HMO DRG,21859,,100% x Medicaid HMO amount,21859,Other,100% of NY Medicaid HMO DRG,49183,,225% x Medicaid HMO amount,49183,Other,225% of NY Medicaid HMO DRG,49183,,225% x Medicaid HMO amount,49183,Other,225% of NY Medicaid HMO DRG,49183,,225% x Medicaid HMO amount,49183,Other,225% of NY Medicaid HMO DRG,49183,,225% x Medicaid HMO amount,49183,Other,225% of NY Medicaid HMO DRG,30603,,140% x Medicaid HMO amount,30603,Other,140% of NY Medicaid HMO DRG,49183,,225% x Medicaid HMO amount,49183,Other,225% of NY Medicaid HMO DRG,60112,,275% x Medicaid HMO amount,60112,Other,275% of NY Medicaid HMO DRG,70823,,324% x Medicaid HMO amount,70823,Other,324% of NY Medicaid HMO DRG,46997,,215% x Medicaid HMO amount,46997,Other,215% of NY Medicaid HMO DRG,46997,,215% x Medicaid HMO amount,46997,Other,215% of NY Medicaid HMO DRG,27324,,125% x Medicaid HMO amount,27324,Other,125% of NY Medicaid HMO DRG,0.01,122103,
Testes & scrotal procedures,483-1,APR-DRG,,,,,,,,inpatient,,,64859.42,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28507,,"45,128 x DRG weight",28507,Other,base rate x DRG weight,25656,,"40,615 x DRG weight",25656,Other,base rate x DRG weight,24231,,"38,359 x DRG weight",24231,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10663,,186% x Medicaid HMO amount,10663,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21526,,"34,077 x DRG weight",21526,Other,base rate x DRG weight,18298,,"28,966 x DRG weight",18298,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5733,,DRG base rate x DRG weight + capital per discharge,5733,Other,100% of NY Medicaid HMO DRG,5733,,100% x Medicaid HMO amount,5733,Other,100% of NY Medicaid HMO DRG,5733,,100% x Medicaid HMO amount,5733,Other,100% of NY Medicaid HMO DRG,5733,,100% x Medicaid HMO amount,5733,Other,100% of NY Medicaid HMO DRG,12899,,225% x Medicaid HMO amount,12899,Other,225% of NY Medicaid HMO DRG,12899,,225% x Medicaid HMO amount,12899,Other,225% of NY Medicaid HMO DRG,12899,,225% x Medicaid HMO amount,12899,Other,225% of NY Medicaid HMO DRG,12899,,225% x Medicaid HMO amount,12899,Other,225% of NY Medicaid HMO DRG,8026,,140% x Medicaid HMO amount,8026,Other,140% of NY Medicaid HMO DRG,12899,,225% x Medicaid HMO amount,12899,Other,225% of NY Medicaid HMO DRG,15766,,275% x Medicaid HMO amount,15766,Other,275% of NY Medicaid HMO DRG,18575,,324% x Medicaid HMO amount,18575,Other,324% of NY Medicaid HMO DRG,12326,,215% x Medicaid HMO amount,12326,Other,215% of NY Medicaid HMO DRG,12326,,215% x Medicaid HMO amount,12326,Other,215% of NY Medicaid HMO DRG,7166,,125% x Medicaid HMO amount,7166,Other,125% of NY Medicaid HMO DRG,0.01,28507,
Testes & scrotal procedures,483-2,APR-DRG,,,,,,,,inpatient,,,454050.94,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,57809,,"45,128 x DRG weight",57809,Other,base rate x DRG weight,52028,,"40,615 x DRG weight",52028,Other,base rate x DRG weight,49138,,"38,359 x DRG weight",49138,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20053,,186% x Medicaid HMO amount,20053,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43653,,"34,077 x DRG weight",43653,Other,base rate x DRG weight,37105,,"28,966 x DRG weight",37105,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10781,,DRG base rate x DRG weight + capital per discharge,10781,Other,100% of NY Medicaid HMO DRG,10781,,100% x Medicaid HMO amount,10781,Other,100% of NY Medicaid HMO DRG,10781,,100% x Medicaid HMO amount,10781,Other,100% of NY Medicaid HMO DRG,10781,,100% x Medicaid HMO amount,10781,Other,100% of NY Medicaid HMO DRG,24257,,225% x Medicaid HMO amount,24257,Other,225% of NY Medicaid HMO DRG,24257,,225% x Medicaid HMO amount,24257,Other,225% of NY Medicaid HMO DRG,24257,,225% x Medicaid HMO amount,24257,Other,225% of NY Medicaid HMO DRG,24257,,225% x Medicaid HMO amount,24257,Other,225% of NY Medicaid HMO DRG,15093,,140% x Medicaid HMO amount,15093,Other,140% of NY Medicaid HMO DRG,24257,,225% x Medicaid HMO amount,24257,Other,225% of NY Medicaid HMO DRG,29648,,275% x Medicaid HMO amount,29648,Other,275% of NY Medicaid HMO DRG,34930,,324% x Medicaid HMO amount,34930,Other,324% of NY Medicaid HMO DRG,23179,,215% x Medicaid HMO amount,23179,Other,215% of NY Medicaid HMO DRG,23179,,215% x Medicaid HMO amount,23179,Other,215% of NY Medicaid HMO DRG,13476,,125% x Medicaid HMO amount,13476,Other,125% of NY Medicaid HMO DRG,0.01,57809,
Testes & scrotal procedures,483-3,APR-DRG,,,,,,,,inpatient,,,75664.11,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,143575,,"45,128 x DRG weight",143575,Other,base rate x DRG weight,129217,,"40,615 x DRG weight",129217,Other,base rate x DRG weight,122039,,"38,359 x DRG weight",122039,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47540,,186% x Medicaid HMO amount,47540,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,108416,,"34,077 x DRG weight",108416,Other,base rate x DRG weight,92155,,"28,966 x DRG weight",92155,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25559,,DRG base rate x DRG weight + capital per discharge,25559,Other,100% of NY Medicaid HMO DRG,25559,,100% x Medicaid HMO amount,25559,Other,100% of NY Medicaid HMO DRG,25559,,100% x Medicaid HMO amount,25559,Other,100% of NY Medicaid HMO DRG,25559,,100% x Medicaid HMO amount,25559,Other,100% of NY Medicaid HMO DRG,57508,,225% x Medicaid HMO amount,57508,Other,225% of NY Medicaid HMO DRG,57508,,225% x Medicaid HMO amount,57508,Other,225% of NY Medicaid HMO DRG,57508,,225% x Medicaid HMO amount,57508,Other,225% of NY Medicaid HMO DRG,57508,,225% x Medicaid HMO amount,57508,Other,225% of NY Medicaid HMO DRG,35783,,140% x Medicaid HMO amount,35783,Other,140% of NY Medicaid HMO DRG,57508,,225% x Medicaid HMO amount,57508,Other,225% of NY Medicaid HMO DRG,70287,,275% x Medicaid HMO amount,70287,Other,275% of NY Medicaid HMO DRG,82811,,324% x Medicaid HMO amount,82811,Other,324% of NY Medicaid HMO DRG,54952,,215% x Medicaid HMO amount,54952,Other,215% of NY Medicaid HMO DRG,54952,,215% x Medicaid HMO amount,54952,Other,215% of NY Medicaid HMO DRG,31949,,125% x Medicaid HMO amount,31949,Other,125% of NY Medicaid HMO DRG,0.01,143575,
Testes & scrotal procedures,483-4,APR-DRG,,,,,,,,inpatient,,,75664.11,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,193058,,"45,128 x DRG weight",193058,Other,base rate x DRG weight,173751,,"40,615 x DRG weight",173751,Other,base rate x DRG weight,164100,,"38,359 x DRG weight",164100,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,63398,,186% x Medicaid HMO amount,63398,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,145781,,"34,077 x DRG weight",145781,Other,base rate x DRG weight,123917,,"28,966 x DRG weight",123917,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34085,,DRG base rate x DRG weight + capital per discharge,34085,Other,100% of NY Medicaid HMO DRG,34085,,100% x Medicaid HMO amount,34085,Other,100% of NY Medicaid HMO DRG,34085,,100% x Medicaid HMO amount,34085,Other,100% of NY Medicaid HMO DRG,34085,,100% x Medicaid HMO amount,34085,Other,100% of NY Medicaid HMO DRG,76691,,225% x Medicaid HMO amount,76691,Other,225% of NY Medicaid HMO DRG,76691,,225% x Medicaid HMO amount,76691,Other,225% of NY Medicaid HMO DRG,76691,,225% x Medicaid HMO amount,76691,Other,225% of NY Medicaid HMO DRG,76691,,225% x Medicaid HMO amount,76691,Other,225% of NY Medicaid HMO DRG,47719,,140% x Medicaid HMO amount,47719,Other,140% of NY Medicaid HMO DRG,76691,,225% x Medicaid HMO amount,76691,Other,225% of NY Medicaid HMO DRG,93734,,275% x Medicaid HMO amount,93734,Other,275% of NY Medicaid HMO DRG,110435,,324% x Medicaid HMO amount,110435,Other,324% of NY Medicaid HMO DRG,73283,,215% x Medicaid HMO amount,73283,Other,215% of NY Medicaid HMO DRG,73283,,215% x Medicaid HMO amount,73283,Other,215% of NY Medicaid HMO DRG,42606,,125% x Medicaid HMO amount,42606,Other,125% of NY Medicaid HMO DRG,0.01,193058,
Other male reproductive system & related procedures,484-1,APR-DRG,,,,,,,,inpatient,,,87760.87,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39640,,"45,128 x DRG weight",39640,Other,base rate x DRG weight,35676,,"40,615 x DRG weight",35676,Other,base rate x DRG weight,33695,,"38,359 x DRG weight",33695,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14231,,186% x Medicaid HMO amount,14231,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29933,,"34,077 x DRG weight",29933,Other,base rate x DRG weight,25444,,"28,966 x DRG weight",25444,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7651,,DRG base rate x DRG weight + capital per discharge,7651,Other,100% of NY Medicaid HMO DRG,7651,,100% x Medicaid HMO amount,7651,Other,100% of NY Medicaid HMO DRG,7651,,100% x Medicaid HMO amount,7651,Other,100% of NY Medicaid HMO DRG,7651,,100% x Medicaid HMO amount,7651,Other,100% of NY Medicaid HMO DRG,17215,,225% x Medicaid HMO amount,17215,Other,225% of NY Medicaid HMO DRG,17215,,225% x Medicaid HMO amount,17215,Other,225% of NY Medicaid HMO DRG,17215,,225% x Medicaid HMO amount,17215,Other,225% of NY Medicaid HMO DRG,17215,,225% x Medicaid HMO amount,17215,Other,225% of NY Medicaid HMO DRG,10711,,140% x Medicaid HMO amount,10711,Other,140% of NY Medicaid HMO DRG,17215,,225% x Medicaid HMO amount,17215,Other,225% of NY Medicaid HMO DRG,21040,,275% x Medicaid HMO amount,21040,Other,275% of NY Medicaid HMO DRG,24789,,324% x Medicaid HMO amount,24789,Other,324% of NY Medicaid HMO DRG,16450,,215% x Medicaid HMO amount,16450,Other,215% of NY Medicaid HMO DRG,16450,,215% x Medicaid HMO amount,16450,Other,215% of NY Medicaid HMO DRG,9564,,125% x Medicaid HMO amount,9564,Other,125% of NY Medicaid HMO DRG,0.01,39640,
Other male reproductive system & related procedures,484-2,APR-DRG,,,,,,,,inpatient,,,87760.87,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53098,,"45,128 x DRG weight",53098,Other,base rate x DRG weight,47788,,"40,615 x DRG weight",47788,Other,base rate x DRG weight,45133,,"38,359 x DRG weight",45133,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18544,,186% x Medicaid HMO amount,18544,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40095,,"34,077 x DRG weight",40095,Other,base rate x DRG weight,34081,,"28,966 x DRG weight",34081,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9970,,DRG base rate x DRG weight + capital per discharge,9970,Other,100% of NY Medicaid HMO DRG,9970,,100% x Medicaid HMO amount,9970,Other,100% of NY Medicaid HMO DRG,9970,,100% x Medicaid HMO amount,9970,Other,100% of NY Medicaid HMO DRG,9970,,100% x Medicaid HMO amount,9970,Other,100% of NY Medicaid HMO DRG,22433,,225% x Medicaid HMO amount,22433,Other,225% of NY Medicaid HMO DRG,22433,,225% x Medicaid HMO amount,22433,Other,225% of NY Medicaid HMO DRG,22433,,225% x Medicaid HMO amount,22433,Other,225% of NY Medicaid HMO DRG,22433,,225% x Medicaid HMO amount,22433,Other,225% of NY Medicaid HMO DRG,13958,,140% x Medicaid HMO amount,13958,Other,140% of NY Medicaid HMO DRG,22433,,225% x Medicaid HMO amount,22433,Other,225% of NY Medicaid HMO DRG,27418,,275% x Medicaid HMO amount,27418,Other,275% of NY Medicaid HMO DRG,32303,,324% x Medicaid HMO amount,32303,Other,324% of NY Medicaid HMO DRG,21436,,215% x Medicaid HMO amount,21436,Other,215% of NY Medicaid HMO DRG,21436,,215% x Medicaid HMO amount,21436,Other,215% of NY Medicaid HMO DRG,12463,,125% x Medicaid HMO amount,12463,Other,125% of NY Medicaid HMO DRG,0.01,53098,
Other male reproductive system & related procedures,484-3,APR-DRG,,,,,,,,inpatient,,,110586.17,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,88992,,"45,128 x DRG weight",88992,Other,base rate x DRG weight,80093,,"40,615 x DRG weight",80093,Other,base rate x DRG weight,75644,,"38,359 x DRG weight",75644,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30046,,186% x Medicaid HMO amount,30046,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,67200,,"34,077 x DRG weight",67200,Other,base rate x DRG weight,57121,,"28,966 x DRG weight",57121,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16154,,DRG base rate x DRG weight + capital per discharge,16154,Other,100% of NY Medicaid HMO DRG,16154,,100% x Medicaid HMO amount,16154,Other,100% of NY Medicaid HMO DRG,16154,,100% x Medicaid HMO amount,16154,Other,100% of NY Medicaid HMO DRG,16154,,100% x Medicaid HMO amount,16154,Other,100% of NY Medicaid HMO DRG,36347,,225% x Medicaid HMO amount,36347,Other,225% of NY Medicaid HMO DRG,36347,,225% x Medicaid HMO amount,36347,Other,225% of NY Medicaid HMO DRG,36347,,225% x Medicaid HMO amount,36347,Other,225% of NY Medicaid HMO DRG,36347,,225% x Medicaid HMO amount,36347,Other,225% of NY Medicaid HMO DRG,22616,,140% x Medicaid HMO amount,22616,Other,140% of NY Medicaid HMO DRG,36347,,225% x Medicaid HMO amount,36347,Other,225% of NY Medicaid HMO DRG,44424,,275% x Medicaid HMO amount,44424,Other,275% of NY Medicaid HMO DRG,52339,,324% x Medicaid HMO amount,52339,Other,324% of NY Medicaid HMO DRG,34731,,215% x Medicaid HMO amount,34731,Other,215% of NY Medicaid HMO DRG,34731,,215% x Medicaid HMO amount,34731,Other,215% of NY Medicaid HMO DRG,20193,,125% x Medicaid HMO amount,20193,Other,125% of NY Medicaid HMO DRG,0.01,88992,
Other male reproductive system & related procedures,484-4,APR-DRG,,,,,,,,inpatient,,,1687755.95,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,96930,,"45,128 x DRG weight",96930,Other,base rate x DRG weight,87237,,"40,615 x DRG weight",87237,Other,base rate x DRG weight,82391,,"38,359 x DRG weight",82391,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32591,,186% x Medicaid HMO amount,32591,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73194,,"34,077 x DRG weight",73194,Other,base rate x DRG weight,62216,,"28,966 x DRG weight",62216,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17522,,DRG base rate x DRG weight + capital per discharge,17522,Other,100% of NY Medicaid HMO DRG,17522,,100% x Medicaid HMO amount,17522,Other,100% of NY Medicaid HMO DRG,17522,,100% x Medicaid HMO amount,17522,Other,100% of NY Medicaid HMO DRG,17522,,100% x Medicaid HMO amount,17522,Other,100% of NY Medicaid HMO DRG,39425,,225% x Medicaid HMO amount,39425,Other,225% of NY Medicaid HMO DRG,39425,,225% x Medicaid HMO amount,39425,Other,225% of NY Medicaid HMO DRG,39425,,225% x Medicaid HMO amount,39425,Other,225% of NY Medicaid HMO DRG,39425,,225% x Medicaid HMO amount,39425,Other,225% of NY Medicaid HMO DRG,24531,,140% x Medicaid HMO amount,24531,Other,140% of NY Medicaid HMO DRG,39425,,225% x Medicaid HMO amount,39425,Other,225% of NY Medicaid HMO DRG,48186,,275% x Medicaid HMO amount,48186,Other,275% of NY Medicaid HMO DRG,56771,,324% x Medicaid HMO amount,56771,Other,324% of NY Medicaid HMO DRG,37672,,215% x Medicaid HMO amount,37672,Other,215% of NY Medicaid HMO DRG,37672,,215% x Medicaid HMO amount,37672,Other,215% of NY Medicaid HMO DRG,21903,,125% x Medicaid HMO amount,21903,Other,125% of NY Medicaid HMO DRG,0.01,96930,
"Malignancy, male reproductive system",500-1,APR-DRG,,,,,,,,inpatient,,,19635,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19040,,"45,128 x DRG weight",19040,Other,base rate x DRG weight,17135,,"40,615 x DRG weight",17135,Other,base rate x DRG weight,16184,,"38,359 x DRG weight",16184,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7628,,186% x Medicaid HMO amount,7628,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14377,,"34,077 x DRG weight",14377,Other,base rate x DRG weight,12221,,"28,966 x DRG weight",12221,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4101,,DRG base rate x DRG weight + capital per discharge,4101,Other,100% of NY Medicaid HMO DRG,4101,,100% x Medicaid HMO amount,4101,Other,100% of NY Medicaid HMO DRG,4101,,100% x Medicaid HMO amount,4101,Other,100% of NY Medicaid HMO DRG,4101,,100% x Medicaid HMO amount,4101,Other,100% of NY Medicaid HMO DRG,9227,,225% x Medicaid HMO amount,9227,Other,225% of NY Medicaid HMO DRG,9227,,225% x Medicaid HMO amount,9227,Other,225% of NY Medicaid HMO DRG,9227,,225% x Medicaid HMO amount,9227,Other,225% of NY Medicaid HMO DRG,9227,,225% x Medicaid HMO amount,9227,Other,225% of NY Medicaid HMO DRG,5741,,140% x Medicaid HMO amount,5741,Other,140% of NY Medicaid HMO DRG,9227,,225% x Medicaid HMO amount,9227,Other,225% of NY Medicaid HMO DRG,11278,,275% x Medicaid HMO amount,11278,Other,275% of NY Medicaid HMO DRG,13287,,324% x Medicaid HMO amount,13287,Other,324% of NY Medicaid HMO DRG,8817,,215% x Medicaid HMO amount,8817,Other,215% of NY Medicaid HMO DRG,8817,,215% x Medicaid HMO amount,8817,Other,215% of NY Medicaid HMO DRG,5126,,125% x Medicaid HMO amount,5126,Other,125% of NY Medicaid HMO DRG,0.01,19040,
"Malignancy, male reproductive system",500-2,APR-DRG,,,,,,,,inpatient,,,236688.78,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42542,,"45,128 x DRG weight",42542,Other,base rate x DRG weight,38288,,"40,615 x DRG weight",38288,Other,base rate x DRG weight,36161,,"38,359 x DRG weight",36161,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15161,,186% x Medicaid HMO amount,15161,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32124,,"34,077 x DRG weight",32124,Other,base rate x DRG weight,27306,,"28,966 x DRG weight",27306,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8151,,DRG base rate x DRG weight + capital per discharge,8151,Other,100% of NY Medicaid HMO DRG,8151,,100% x Medicaid HMO amount,8151,Other,100% of NY Medicaid HMO DRG,8151,,100% x Medicaid HMO amount,8151,Other,100% of NY Medicaid HMO DRG,8151,,100% x Medicaid HMO amount,8151,Other,100% of NY Medicaid HMO DRG,18340,,225% x Medicaid HMO amount,18340,Other,225% of NY Medicaid HMO DRG,18340,,225% x Medicaid HMO amount,18340,Other,225% of NY Medicaid HMO DRG,18340,,225% x Medicaid HMO amount,18340,Other,225% of NY Medicaid HMO DRG,18340,,225% x Medicaid HMO amount,18340,Other,225% of NY Medicaid HMO DRG,11411,,140% x Medicaid HMO amount,11411,Other,140% of NY Medicaid HMO DRG,18340,,225% x Medicaid HMO amount,18340,Other,225% of NY Medicaid HMO DRG,22415,,275% x Medicaid HMO amount,22415,Other,275% of NY Medicaid HMO DRG,26409,,324% x Medicaid HMO amount,26409,Other,324% of NY Medicaid HMO DRG,17525,,215% x Medicaid HMO amount,17525,Other,215% of NY Medicaid HMO DRG,17525,,215% x Medicaid HMO amount,17525,Other,215% of NY Medicaid HMO DRG,10189,,125% x Medicaid HMO amount,10189,Other,125% of NY Medicaid HMO DRG,0.01,42542,
"Malignancy, male reproductive system",500-3,APR-DRG,,,,,,,,inpatient,,,265957.21,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,71289,,"45,128 x DRG weight",71289,Other,base rate x DRG weight,64160,,"40,615 x DRG weight",64160,Other,base rate x DRG weight,60596,,"38,359 x DRG weight",60596,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24373,,186% x Medicaid HMO amount,24373,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53831,,"34,077 x DRG weight",53831,Other,base rate x DRG weight,45758,,"28,966 x DRG weight",45758,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13104,,DRG base rate x DRG weight + capital per discharge,13104,Other,100% of NY Medicaid HMO DRG,13104,,100% x Medicaid HMO amount,13104,Other,100% of NY Medicaid HMO DRG,13104,,100% x Medicaid HMO amount,13104,Other,100% of NY Medicaid HMO DRG,13104,,100% x Medicaid HMO amount,13104,Other,100% of NY Medicaid HMO DRG,29484,,225% x Medicaid HMO amount,29484,Other,225% of NY Medicaid HMO DRG,29484,,225% x Medicaid HMO amount,29484,Other,225% of NY Medicaid HMO DRG,29484,,225% x Medicaid HMO amount,29484,Other,225% of NY Medicaid HMO DRG,29484,,225% x Medicaid HMO amount,29484,Other,225% of NY Medicaid HMO DRG,18346,,140% x Medicaid HMO amount,18346,Other,140% of NY Medicaid HMO DRG,29484,,225% x Medicaid HMO amount,29484,Other,225% of NY Medicaid HMO DRG,36036,,275% x Medicaid HMO amount,36036,Other,275% of NY Medicaid HMO DRG,42457,,324% x Medicaid HMO amount,42457,Other,324% of NY Medicaid HMO DRG,28174,,215% x Medicaid HMO amount,28174,Other,215% of NY Medicaid HMO DRG,28174,,215% x Medicaid HMO amount,28174,Other,215% of NY Medicaid HMO DRG,16380,,125% x Medicaid HMO amount,16380,Other,125% of NY Medicaid HMO DRG,0.01,71289,
"Malignancy, male reproductive system",500-4,APR-DRG,,,,,,,,inpatient,,,265957.21,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,83117,,"45,128 x DRG weight",83117,Other,base rate x DRG weight,74805,,"40,615 x DRG weight",74805,Other,base rate x DRG weight,70650,,"38,359 x DRG weight",70650,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28164,,186% x Medicaid HMO amount,28164,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,62763,,"34,077 x DRG weight",62763,Other,base rate x DRG weight,53350,,"28,966 x DRG weight",53350,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15142,,DRG base rate x DRG weight + capital per discharge,15142,Other,100% of NY Medicaid HMO DRG,15142,,100% x Medicaid HMO amount,15142,Other,100% of NY Medicaid HMO DRG,15142,,100% x Medicaid HMO amount,15142,Other,100% of NY Medicaid HMO DRG,15142,,100% x Medicaid HMO amount,15142,Other,100% of NY Medicaid HMO DRG,34070,,225% x Medicaid HMO amount,34070,Other,225% of NY Medicaid HMO DRG,34070,,225% x Medicaid HMO amount,34070,Other,225% of NY Medicaid HMO DRG,34070,,225% x Medicaid HMO amount,34070,Other,225% of NY Medicaid HMO DRG,34070,,225% x Medicaid HMO amount,34070,Other,225% of NY Medicaid HMO DRG,21199,,140% x Medicaid HMO amount,21199,Other,140% of NY Medicaid HMO DRG,34070,,225% x Medicaid HMO amount,34070,Other,225% of NY Medicaid HMO DRG,41641,,275% x Medicaid HMO amount,41641,Other,275% of NY Medicaid HMO DRG,49060,,324% x Medicaid HMO amount,49060,Other,324% of NY Medicaid HMO DRG,32555,,215% x Medicaid HMO amount,32555,Other,215% of NY Medicaid HMO DRG,32555,,215% x Medicaid HMO amount,32555,Other,215% of NY Medicaid HMO DRG,18928,,125% x Medicaid HMO amount,18928,Other,125% of NY Medicaid HMO DRG,0.01,83117,
Male reproductive system diagnoses except malignancy,501-1,APR-DRG,,,,,,,,inpatient,,,77365.68,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21815,,"45,128 x DRG weight",21815,Other,base rate x DRG weight,19633,,"40,615 x DRG weight",19633,Other,base rate x DRG weight,18543,,"38,359 x DRG weight",18543,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8519,,186% x Medicaid HMO amount,8519,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16473,,"34,077 x DRG weight",16473,Other,base rate x DRG weight,14002,,"28,966 x DRG weight",14002,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4580,,DRG base rate x DRG weight + capital per discharge,4580,Other,100% of NY Medicaid HMO DRG,4580,,100% x Medicaid HMO amount,4580,Other,100% of NY Medicaid HMO DRG,4580,,100% x Medicaid HMO amount,4580,Other,100% of NY Medicaid HMO DRG,4580,,100% x Medicaid HMO amount,4580,Other,100% of NY Medicaid HMO DRG,10305,,225% x Medicaid HMO amount,10305,Other,225% of NY Medicaid HMO DRG,10305,,225% x Medicaid HMO amount,10305,Other,225% of NY Medicaid HMO DRG,10305,,225% x Medicaid HMO amount,10305,Other,225% of NY Medicaid HMO DRG,10305,,225% x Medicaid HMO amount,10305,Other,225% of NY Medicaid HMO DRG,6412,,140% x Medicaid HMO amount,6412,Other,140% of NY Medicaid HMO DRG,10305,,225% x Medicaid HMO amount,10305,Other,225% of NY Medicaid HMO DRG,12595,,275% x Medicaid HMO amount,12595,Other,275% of NY Medicaid HMO DRG,14839,,324% x Medicaid HMO amount,14839,Other,324% of NY Medicaid HMO DRG,9847,,215% x Medicaid HMO amount,9847,Other,215% of NY Medicaid HMO DRG,9847,,215% x Medicaid HMO amount,9847,Other,215% of NY Medicaid HMO DRG,5725,,125% x Medicaid HMO amount,5725,Other,125% of NY Medicaid HMO DRG,0.01,21815,
Male reproductive system diagnoses except malignancy,501-2,APR-DRG,,,,,,,,inpatient,,,127380.27,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30953,,"45,128 x DRG weight",30953,Other,base rate x DRG weight,27858,,"40,615 x DRG weight",27858,Other,base rate x DRG weight,26310,,"38,359 x DRG weight",26310,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11446,,186% x Medicaid HMO amount,11446,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23373,,"34,077 x DRG weight",23373,Other,base rate x DRG weight,19868,,"28,966 x DRG weight",19868,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6154,,DRG base rate x DRG weight + capital per discharge,6154,Other,100% of NY Medicaid HMO DRG,6154,,100% x Medicaid HMO amount,6154,Other,100% of NY Medicaid HMO DRG,6154,,100% x Medicaid HMO amount,6154,Other,100% of NY Medicaid HMO DRG,6154,,100% x Medicaid HMO amount,6154,Other,100% of NY Medicaid HMO DRG,13847,,225% x Medicaid HMO amount,13847,Other,225% of NY Medicaid HMO DRG,13847,,225% x Medicaid HMO amount,13847,Other,225% of NY Medicaid HMO DRG,13847,,225% x Medicaid HMO amount,13847,Other,225% of NY Medicaid HMO DRG,13847,,225% x Medicaid HMO amount,13847,Other,225% of NY Medicaid HMO DRG,8616,,140% x Medicaid HMO amount,8616,Other,140% of NY Medicaid HMO DRG,13847,,225% x Medicaid HMO amount,13847,Other,225% of NY Medicaid HMO DRG,16924,,275% x Medicaid HMO amount,16924,Other,275% of NY Medicaid HMO DRG,19939,,324% x Medicaid HMO amount,19939,Other,324% of NY Medicaid HMO DRG,13231,,215% x Medicaid HMO amount,13231,Other,215% of NY Medicaid HMO DRG,13231,,215% x Medicaid HMO amount,13231,Other,215% of NY Medicaid HMO DRG,7693,,125% x Medicaid HMO amount,7693,Other,125% of NY Medicaid HMO DRG,0.01,30953,
Male reproductive system diagnoses except malignancy,501-3,APR-DRG,,,,,,,,inpatient,,,179314.82,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50665,,"45,128 x DRG weight",50665,Other,base rate x DRG weight,45598,,"40,615 x DRG weight",45598,Other,base rate x DRG weight,43066,,"38,359 x DRG weight",43066,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17765,,186% x Medicaid HMO amount,17765,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38258,,"34,077 x DRG weight",38258,Other,base rate x DRG weight,32520,,"28,966 x DRG weight",32520,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9551,,DRG base rate x DRG weight + capital per discharge,9551,Other,100% of NY Medicaid HMO DRG,9551,,100% x Medicaid HMO amount,9551,Other,100% of NY Medicaid HMO DRG,9551,,100% x Medicaid HMO amount,9551,Other,100% of NY Medicaid HMO DRG,9551,,100% x Medicaid HMO amount,9551,Other,100% of NY Medicaid HMO DRG,21490,,225% x Medicaid HMO amount,21490,Other,225% of NY Medicaid HMO DRG,21490,,225% x Medicaid HMO amount,21490,Other,225% of NY Medicaid HMO DRG,21490,,225% x Medicaid HMO amount,21490,Other,225% of NY Medicaid HMO DRG,21490,,225% x Medicaid HMO amount,21490,Other,225% of NY Medicaid HMO DRG,13371,,140% x Medicaid HMO amount,13371,Other,140% of NY Medicaid HMO DRG,21490,,225% x Medicaid HMO amount,21490,Other,225% of NY Medicaid HMO DRG,26265,,275% x Medicaid HMO amount,26265,Other,275% of NY Medicaid HMO DRG,30945,,324% x Medicaid HMO amount,30945,Other,324% of NY Medicaid HMO DRG,20535,,215% x Medicaid HMO amount,20535,Other,215% of NY Medicaid HMO DRG,20535,,215% x Medicaid HMO amount,20535,Other,215% of NY Medicaid HMO DRG,11939,,125% x Medicaid HMO amount,11939,Other,125% of NY Medicaid HMO DRG,0.01,50665,
Male reproductive system diagnoses except malignancy,501-4,APR-DRG,,,,,,,,inpatient,,,121672.4,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,96240,,"45,128 x DRG weight",96240,Other,base rate x DRG weight,86616,,"40,615 x DRG weight",86616,Other,base rate x DRG weight,81804,,"38,359 x DRG weight",81804,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32370,,186% x Medicaid HMO amount,32370,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,72673,,"34,077 x DRG weight",72673,Other,base rate x DRG weight,61773,,"28,966 x DRG weight",61773,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17403,,DRG base rate x DRG weight + capital per discharge,17403,Other,100% of NY Medicaid HMO DRG,17403,,100% x Medicaid HMO amount,17403,Other,100% of NY Medicaid HMO DRG,17403,,100% x Medicaid HMO amount,17403,Other,100% of NY Medicaid HMO DRG,17403,,100% x Medicaid HMO amount,17403,Other,100% of NY Medicaid HMO DRG,39157,,225% x Medicaid HMO amount,39157,Other,225% of NY Medicaid HMO DRG,39157,,225% x Medicaid HMO amount,39157,Other,225% of NY Medicaid HMO DRG,39157,,225% x Medicaid HMO amount,39157,Other,225% of NY Medicaid HMO DRG,39157,,225% x Medicaid HMO amount,39157,Other,225% of NY Medicaid HMO DRG,24364,,140% x Medicaid HMO amount,24364,Other,140% of NY Medicaid HMO DRG,39157,,225% x Medicaid HMO amount,39157,Other,225% of NY Medicaid HMO DRG,47858,,275% x Medicaid HMO amount,47858,Other,275% of NY Medicaid HMO DRG,56386,,324% x Medicaid HMO amount,56386,Other,324% of NY Medicaid HMO DRG,37416,,215% x Medicaid HMO amount,37416,Other,215% of NY Medicaid HMO DRG,37416,,215% x Medicaid HMO amount,37416,Other,215% of NY Medicaid HMO DRG,21754,,125% x Medicaid HMO amount,21754,Other,125% of NY Medicaid HMO DRG,0.01,96240,
"Pelvic evisceration, radical hysterectomy & other radical GYN procs",510-1,APR-DRG,,,,,,,,inpatient,,,136847.81,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50742,,"45,128 x DRG weight",50742,Other,base rate x DRG weight,45668,,"40,615 x DRG weight",45668,Other,base rate x DRG weight,43131,,"38,359 x DRG weight",43131,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17789,,186% x Medicaid HMO amount,17789,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38316,,"34,077 x DRG weight",38316,Other,base rate x DRG weight,32569,,"28,966 x DRG weight",32569,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9564,,DRG base rate x DRG weight + capital per discharge,9564,Other,100% of NY Medicaid HMO DRG,9564,,100% x Medicaid HMO amount,9564,Other,100% of NY Medicaid HMO DRG,9564,,100% x Medicaid HMO amount,9564,Other,100% of NY Medicaid HMO DRG,9564,,100% x Medicaid HMO amount,9564,Other,100% of NY Medicaid HMO DRG,21519,,225% x Medicaid HMO amount,21519,Other,225% of NY Medicaid HMO DRG,21519,,225% x Medicaid HMO amount,21519,Other,225% of NY Medicaid HMO DRG,21519,,225% x Medicaid HMO amount,21519,Other,225% of NY Medicaid HMO DRG,21519,,225% x Medicaid HMO amount,21519,Other,225% of NY Medicaid HMO DRG,13390,,140% x Medicaid HMO amount,13390,Other,140% of NY Medicaid HMO DRG,21519,,225% x Medicaid HMO amount,21519,Other,225% of NY Medicaid HMO DRG,26301,,275% x Medicaid HMO amount,26301,Other,275% of NY Medicaid HMO DRG,30987,,324% x Medicaid HMO amount,30987,Other,324% of NY Medicaid HMO DRG,20563,,215% x Medicaid HMO amount,20563,Other,215% of NY Medicaid HMO DRG,20563,,215% x Medicaid HMO amount,20563,Other,215% of NY Medicaid HMO DRG,11955,,125% x Medicaid HMO amount,11955,Other,125% of NY Medicaid HMO DRG,0.01,50742,
"Pelvic evisceration, radical hysterectomy & other radical GYN procs",510-2,APR-DRG,,,,,,,,inpatient,,,362405.56,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,64705,,"45,128 x DRG weight",64705,Other,base rate x DRG weight,58234,,"40,615 x DRG weight",58234,Other,base rate x DRG weight,54999,,"38,359 x DRG weight",54999,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22264,,186% x Medicaid HMO amount,22264,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48860,,"34,077 x DRG weight",48860,Other,base rate x DRG weight,41531,,"28,966 x DRG weight",41531,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11970,,DRG base rate x DRG weight + capital per discharge,11970,Other,100% of NY Medicaid HMO DRG,11970,,100% x Medicaid HMO amount,11970,Other,100% of NY Medicaid HMO DRG,11970,,100% x Medicaid HMO amount,11970,Other,100% of NY Medicaid HMO DRG,11970,,100% x Medicaid HMO amount,11970,Other,100% of NY Medicaid HMO DRG,26933,,225% x Medicaid HMO amount,26933,Other,225% of NY Medicaid HMO DRG,26933,,225% x Medicaid HMO amount,26933,Other,225% of NY Medicaid HMO DRG,26933,,225% x Medicaid HMO amount,26933,Other,225% of NY Medicaid HMO DRG,26933,,225% x Medicaid HMO amount,26933,Other,225% of NY Medicaid HMO DRG,16758,,140% x Medicaid HMO amount,16758,Other,140% of NY Medicaid HMO DRG,26933,,225% x Medicaid HMO amount,26933,Other,225% of NY Medicaid HMO DRG,32918,,275% x Medicaid HMO amount,32918,Other,275% of NY Medicaid HMO DRG,38783,,324% x Medicaid HMO amount,38783,Other,324% of NY Medicaid HMO DRG,25736,,215% x Medicaid HMO amount,25736,Other,215% of NY Medicaid HMO DRG,25736,,215% x Medicaid HMO amount,25736,Other,215% of NY Medicaid HMO DRG,14963,,125% x Medicaid HMO amount,14963,Other,125% of NY Medicaid HMO DRG,0.01,64705,
"Pelvic evisceration, radical hysterectomy & other radical GYN procs",510-3,APR-DRG,,,,,,,,inpatient,,,257184.01,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,118745,,"45,128 x DRG weight",118745,Other,base rate x DRG weight,106870,,"40,615 x DRG weight",106870,Other,base rate x DRG weight,100934,,"38,359 x DRG weight",100934,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39583,,186% x Medicaid HMO amount,39583,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,89667,,"34,077 x DRG weight",89667,Other,base rate x DRG weight,76218,,"28,966 x DRG weight",76218,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21281,,DRG base rate x DRG weight + capital per discharge,21281,Other,100% of NY Medicaid HMO DRG,21281,,100% x Medicaid HMO amount,21281,Other,100% of NY Medicaid HMO DRG,21281,,100% x Medicaid HMO amount,21281,Other,100% of NY Medicaid HMO DRG,21281,,100% x Medicaid HMO amount,21281,Other,100% of NY Medicaid HMO DRG,47882,,225% x Medicaid HMO amount,47882,Other,225% of NY Medicaid HMO DRG,47882,,225% x Medicaid HMO amount,47882,Other,225% of NY Medicaid HMO DRG,47882,,225% x Medicaid HMO amount,47882,Other,225% of NY Medicaid HMO DRG,47882,,225% x Medicaid HMO amount,47882,Other,225% of NY Medicaid HMO DRG,29793,,140% x Medicaid HMO amount,29793,Other,140% of NY Medicaid HMO DRG,47882,,225% x Medicaid HMO amount,47882,Other,225% of NY Medicaid HMO DRG,58523,,275% x Medicaid HMO amount,58523,Other,275% of NY Medicaid HMO DRG,68950,,324% x Medicaid HMO amount,68950,Other,324% of NY Medicaid HMO DRG,45754,,215% x Medicaid HMO amount,45754,Other,215% of NY Medicaid HMO DRG,45754,,215% x Medicaid HMO amount,45754,Other,215% of NY Medicaid HMO DRG,26601,,125% x Medicaid HMO amount,26601,Other,125% of NY Medicaid HMO DRG,0.01,118745,
"Pelvic evisceration, radical hysterectomy & other radical GYN procs",510-4,APR-DRG,,,,,,,,inpatient,,,1688756.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,289239,,"45,128 x DRG weight",289239,Other,base rate x DRG weight,260314,,"40,615 x DRG weight",260314,Other,base rate x DRG weight,245854,,"38,359 x DRG weight",245854,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,94222,,186% x Medicaid HMO amount,94222,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,218410,,"34,077 x DRG weight",218410,Other,base rate x DRG weight,185652,,"28,966 x DRG weight",185652,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50657,,DRG base rate x DRG weight + capital per discharge,50657,Other,100% of NY Medicaid HMO DRG,50657,,100% x Medicaid HMO amount,50657,Other,100% of NY Medicaid HMO DRG,50657,,100% x Medicaid HMO amount,50657,Other,100% of NY Medicaid HMO DRG,50657,,100% x Medicaid HMO amount,50657,Other,100% of NY Medicaid HMO DRG,113978,,225% x Medicaid HMO amount,113978,Other,225% of NY Medicaid HMO DRG,113978,,225% x Medicaid HMO amount,113978,Other,225% of NY Medicaid HMO DRG,113978,,225% x Medicaid HMO amount,113978,Other,225% of NY Medicaid HMO DRG,113978,,225% x Medicaid HMO amount,113978,Other,225% of NY Medicaid HMO DRG,70920,,140% x Medicaid HMO amount,70920,Other,140% of NY Medicaid HMO DRG,113978,,225% x Medicaid HMO amount,113978,Other,225% of NY Medicaid HMO DRG,139307,,275% x Medicaid HMO amount,139307,Other,275% of NY Medicaid HMO DRG,164129,,324% x Medicaid HMO amount,164129,Other,324% of NY Medicaid HMO DRG,108913,,215% x Medicaid HMO amount,108913,Other,215% of NY Medicaid HMO DRG,108913,,215% x Medicaid HMO amount,108913,Other,215% of NY Medicaid HMO DRG,63321,,125% x Medicaid HMO amount,63321,Other,125% of NY Medicaid HMO DRG,0.01,289239,
Uterine & adnexa procedures for ovarian & adnexal malignancy,511-1,APR-DRG,,,,,,,,inpatient,,,126877.95,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,57804,,"45,128 x DRG weight",57804,Other,base rate x DRG weight,52024,,"40,615 x DRG weight",52024,Other,base rate x DRG weight,49134,,"38,359 x DRG weight",49134,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20053,,186% x Medicaid HMO amount,20053,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43649,,"34,077 x DRG weight",43649,Other,base rate x DRG weight,37103,,"28,966 x DRG weight",37103,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10781,,DRG base rate x DRG weight + capital per discharge,10781,Other,100% of NY Medicaid HMO DRG,10781,,100% x Medicaid HMO amount,10781,Other,100% of NY Medicaid HMO DRG,10781,,100% x Medicaid HMO amount,10781,Other,100% of NY Medicaid HMO DRG,10781,,100% x Medicaid HMO amount,10781,Other,100% of NY Medicaid HMO DRG,24257,,225% x Medicaid HMO amount,24257,Other,225% of NY Medicaid HMO DRG,24257,,225% x Medicaid HMO amount,24257,Other,225% of NY Medicaid HMO DRG,24257,,225% x Medicaid HMO amount,24257,Other,225% of NY Medicaid HMO DRG,24257,,225% x Medicaid HMO amount,24257,Other,225% of NY Medicaid HMO DRG,15093,,140% x Medicaid HMO amount,15093,Other,140% of NY Medicaid HMO DRG,24257,,225% x Medicaid HMO amount,24257,Other,225% of NY Medicaid HMO DRG,29648,,275% x Medicaid HMO amount,29648,Other,275% of NY Medicaid HMO DRG,34930,,324% x Medicaid HMO amount,34930,Other,324% of NY Medicaid HMO DRG,23179,,215% x Medicaid HMO amount,23179,Other,215% of NY Medicaid HMO DRG,23179,,215% x Medicaid HMO amount,23179,Other,215% of NY Medicaid HMO DRG,13476,,125% x Medicaid HMO amount,13476,Other,125% of NY Medicaid HMO DRG,0.01,57804,
Uterine & adnexa procedures for ovarian & adnexal malignancy,511-2,APR-DRG,,,,,,,,inpatient,,,191633.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,69488,,"45,128 x DRG weight",69488,Other,base rate x DRG weight,62539,,"40,615 x DRG weight",62539,Other,base rate x DRG weight,59065,,"38,359 x DRG weight",59065,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23797,,186% x Medicaid HMO amount,23797,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52472,,"34,077 x DRG weight",52472,Other,base rate x DRG weight,44602,,"28,966 x DRG weight",44602,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12794,,DRG base rate x DRG weight + capital per discharge,12794,Other,100% of NY Medicaid HMO DRG,12794,,100% x Medicaid HMO amount,12794,Other,100% of NY Medicaid HMO DRG,12794,,100% x Medicaid HMO amount,12794,Other,100% of NY Medicaid HMO DRG,12794,,100% x Medicaid HMO amount,12794,Other,100% of NY Medicaid HMO DRG,28787,,225% x Medicaid HMO amount,28787,Other,225% of NY Medicaid HMO DRG,28787,,225% x Medicaid HMO amount,28787,Other,225% of NY Medicaid HMO DRG,28787,,225% x Medicaid HMO amount,28787,Other,225% of NY Medicaid HMO DRG,28787,,225% x Medicaid HMO amount,28787,Other,225% of NY Medicaid HMO DRG,17912,,140% x Medicaid HMO amount,17912,Other,140% of NY Medicaid HMO DRG,28787,,225% x Medicaid HMO amount,28787,Other,225% of NY Medicaid HMO DRG,35184,,275% x Medicaid HMO amount,35184,Other,275% of NY Medicaid HMO DRG,41453,,324% x Medicaid HMO amount,41453,Other,324% of NY Medicaid HMO DRG,27507,,215% x Medicaid HMO amount,27507,Other,215% of NY Medicaid HMO DRG,27507,,215% x Medicaid HMO amount,27507,Other,215% of NY Medicaid HMO DRG,15993,,125% x Medicaid HMO amount,15993,Other,125% of NY Medicaid HMO DRG,0.01,69488,
Uterine & adnexa procedures for ovarian & adnexal malignancy,511-3,APR-DRG,,,,,,,,inpatient,,,440293.76,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,115257,,"45,128 x DRG weight",115257,Other,base rate x DRG weight,103731,,"40,615 x DRG weight",103731,Other,base rate x DRG weight,97969,,"38,359 x DRG weight",97969,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38465,,186% x Medicaid HMO amount,38465,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,87033,,"34,077 x DRG weight",87033,Other,base rate x DRG weight,73979,,"28,966 x DRG weight",73979,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20680,,DRG base rate x DRG weight + capital per discharge,20680,Other,100% of NY Medicaid HMO DRG,20680,,100% x Medicaid HMO amount,20680,Other,100% of NY Medicaid HMO DRG,20680,,100% x Medicaid HMO amount,20680,Other,100% of NY Medicaid HMO DRG,20680,,100% x Medicaid HMO amount,20680,Other,100% of NY Medicaid HMO DRG,46530,,225% x Medicaid HMO amount,46530,Other,225% of NY Medicaid HMO DRG,46530,,225% x Medicaid HMO amount,46530,Other,225% of NY Medicaid HMO DRG,46530,,225% x Medicaid HMO amount,46530,Other,225% of NY Medicaid HMO DRG,46530,,225% x Medicaid HMO amount,46530,Other,225% of NY Medicaid HMO DRG,28952,,140% x Medicaid HMO amount,28952,Other,140% of NY Medicaid HMO DRG,46530,,225% x Medicaid HMO amount,46530,Other,225% of NY Medicaid HMO DRG,56870,,275% x Medicaid HMO amount,56870,Other,275% of NY Medicaid HMO DRG,67003,,324% x Medicaid HMO amount,67003,Other,324% of NY Medicaid HMO DRG,44462,,215% x Medicaid HMO amount,44462,Other,215% of NY Medicaid HMO DRG,44462,,215% x Medicaid HMO amount,44462,Other,215% of NY Medicaid HMO DRG,25850,,125% x Medicaid HMO amount,25850,Other,125% of NY Medicaid HMO DRG,0.01,115257,
Uterine & adnexa procedures for ovarian & adnexal malignancy,511-4,APR-DRG,,,,,,,,inpatient,,,504078.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,280985,,"45,128 x DRG weight",280985,Other,base rate x DRG weight,252885,,"40,615 x DRG weight",252885,Other,base rate x DRG weight,238838,,"38,359 x DRG weight",238838,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,91577,,186% x Medicaid HMO amount,91577,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,212177,,"34,077 x DRG weight",212177,Other,base rate x DRG weight,180354,,"28,966 x DRG weight",180354,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49235,,DRG base rate x DRG weight + capital per discharge,49235,Other,100% of NY Medicaid HMO DRG,49235,,100% x Medicaid HMO amount,49235,Other,100% of NY Medicaid HMO DRG,49235,,100% x Medicaid HMO amount,49235,Other,100% of NY Medicaid HMO DRG,49235,,100% x Medicaid HMO amount,49235,Other,100% of NY Medicaid HMO DRG,110779,,225% x Medicaid HMO amount,110779,Other,225% of NY Medicaid HMO DRG,110779,,225% x Medicaid HMO amount,110779,Other,225% of NY Medicaid HMO DRG,110779,,225% x Medicaid HMO amount,110779,Other,225% of NY Medicaid HMO DRG,110779,,225% x Medicaid HMO amount,110779,Other,225% of NY Medicaid HMO DRG,68929,,140% x Medicaid HMO amount,68929,Other,140% of NY Medicaid HMO DRG,110779,,225% x Medicaid HMO amount,110779,Other,225% of NY Medicaid HMO DRG,135396,,275% x Medicaid HMO amount,135396,Other,275% of NY Medicaid HMO DRG,159521,,324% x Medicaid HMO amount,159521,Other,324% of NY Medicaid HMO DRG,105855,,215% x Medicaid HMO amount,105855,Other,215% of NY Medicaid HMO DRG,105855,,215% x Medicaid HMO amount,105855,Other,215% of NY Medicaid HMO DRG,61544,,125% x Medicaid HMO amount,61544,Other,125% of NY Medicaid HMO DRG,0.01,280985,
Uterine & adnexa procedures for non-ovarian & non-adnexal malig,512-1,APR-DRG,,,,,,,,inpatient,,,239707.23,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49420,,"45,128 x DRG weight",49420,Other,base rate x DRG weight,44477,,"40,615 x DRG weight",44477,Other,base rate x DRG weight,42007,,"38,359 x DRG weight",42007,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17365,,186% x Medicaid HMO amount,17365,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37318,,"34,077 x DRG weight",37318,Other,base rate x DRG weight,31721,,"28,966 x DRG weight",31721,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9336,,DRG base rate x DRG weight + capital per discharge,9336,Other,100% of NY Medicaid HMO DRG,9336,,100% x Medicaid HMO amount,9336,Other,100% of NY Medicaid HMO DRG,9336,,100% x Medicaid HMO amount,9336,Other,100% of NY Medicaid HMO DRG,9336,,100% x Medicaid HMO amount,9336,Other,100% of NY Medicaid HMO DRG,21006,,225% x Medicaid HMO amount,21006,Other,225% of NY Medicaid HMO DRG,21006,,225% x Medicaid HMO amount,21006,Other,225% of NY Medicaid HMO DRG,21006,,225% x Medicaid HMO amount,21006,Other,225% of NY Medicaid HMO DRG,21006,,225% x Medicaid HMO amount,21006,Other,225% of NY Medicaid HMO DRG,13070,,140% x Medicaid HMO amount,13070,Other,140% of NY Medicaid HMO DRG,21006,,225% x Medicaid HMO amount,21006,Other,225% of NY Medicaid HMO DRG,25674,,275% x Medicaid HMO amount,25674,Other,275% of NY Medicaid HMO DRG,30249,,324% x Medicaid HMO amount,30249,Other,324% of NY Medicaid HMO DRG,20072,,215% x Medicaid HMO amount,20072,Other,215% of NY Medicaid HMO DRG,20072,,215% x Medicaid HMO amount,20072,Other,215% of NY Medicaid HMO DRG,11670,,125% x Medicaid HMO amount,11670,Other,125% of NY Medicaid HMO DRG,0.01,49420,
Uterine & adnexa procedures for non-ovarian & non-adnexal malig,512-2,APR-DRG,,,,,,,,inpatient,,,210970.38,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,61221,,"45,128 x DRG weight",61221,Other,base rate x DRG weight,55098,,"40,615 x DRG weight",55098,Other,base rate x DRG weight,52038,,"38,359 x DRG weight",52038,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21146,,186% x Medicaid HMO amount,21146,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46229,,"34,077 x DRG weight",46229,Other,base rate x DRG weight,39295,,"28,966 x DRG weight",39295,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11369,,DRG base rate x DRG weight + capital per discharge,11369,Other,100% of NY Medicaid HMO DRG,11369,,100% x Medicaid HMO amount,11369,Other,100% of NY Medicaid HMO DRG,11369,,100% x Medicaid HMO amount,11369,Other,100% of NY Medicaid HMO DRG,11369,,100% x Medicaid HMO amount,11369,Other,100% of NY Medicaid HMO DRG,25580,,225% x Medicaid HMO amount,25580,Other,225% of NY Medicaid HMO DRG,25580,,225% x Medicaid HMO amount,25580,Other,225% of NY Medicaid HMO DRG,25580,,225% x Medicaid HMO amount,25580,Other,225% of NY Medicaid HMO DRG,25580,,225% x Medicaid HMO amount,25580,Other,225% of NY Medicaid HMO DRG,15917,,140% x Medicaid HMO amount,15917,Other,140% of NY Medicaid HMO DRG,25580,,225% x Medicaid HMO amount,25580,Other,225% of NY Medicaid HMO DRG,31265,,275% x Medicaid HMO amount,31265,Other,275% of NY Medicaid HMO DRG,36836,,324% x Medicaid HMO amount,36836,Other,324% of NY Medicaid HMO DRG,24443,,215% x Medicaid HMO amount,24443,Other,215% of NY Medicaid HMO DRG,24443,,215% x Medicaid HMO amount,24443,Other,215% of NY Medicaid HMO DRG,14211,,125% x Medicaid HMO amount,14211,Other,125% of NY Medicaid HMO DRG,0.01,61221,
Uterine & adnexa procedures for non-ovarian & non-adnexal malig,512-3,APR-DRG,,,,,,,,inpatient,,,315251.96,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,104002,,"45,128 x DRG weight",104002,Other,base rate x DRG weight,93601,,"40,615 x DRG weight",93601,Other,base rate x DRG weight,88402,,"38,359 x DRG weight",88402,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34858,,186% x Medicaid HMO amount,34858,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,78534,,"34,077 x DRG weight",78534,Other,base rate x DRG weight,66755,,"28,966 x DRG weight",66755,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18741,,DRG base rate x DRG weight + capital per discharge,18741,Other,100% of NY Medicaid HMO DRG,18741,,100% x Medicaid HMO amount,18741,Other,100% of NY Medicaid HMO DRG,18741,,100% x Medicaid HMO amount,18741,Other,100% of NY Medicaid HMO DRG,18741,,100% x Medicaid HMO amount,18741,Other,100% of NY Medicaid HMO DRG,42167,,225% x Medicaid HMO amount,42167,Other,225% of NY Medicaid HMO DRG,42167,,225% x Medicaid HMO amount,42167,Other,225% of NY Medicaid HMO DRG,42167,,225% x Medicaid HMO amount,42167,Other,225% of NY Medicaid HMO DRG,42167,,225% x Medicaid HMO amount,42167,Other,225% of NY Medicaid HMO DRG,26237,,140% x Medicaid HMO amount,26237,Other,140% of NY Medicaid HMO DRG,42167,,225% x Medicaid HMO amount,42167,Other,225% of NY Medicaid HMO DRG,51538,,275% x Medicaid HMO amount,51538,Other,275% of NY Medicaid HMO DRG,60721,,324% x Medicaid HMO amount,60721,Other,324% of NY Medicaid HMO DRG,40293,,215% x Medicaid HMO amount,40293,Other,215% of NY Medicaid HMO DRG,40293,,215% x Medicaid HMO amount,40293,Other,215% of NY Medicaid HMO DRG,23426,,125% x Medicaid HMO amount,23426,Other,125% of NY Medicaid HMO DRG,0.01,104002,
Uterine & adnexa procedures for non-ovarian & non-adnexal malig,512-4,APR-DRG,,,,,,,,inpatient,,,315251.96,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,338613,,"45,128 x DRG weight",338613,Other,base rate x DRG weight,304751,,"40,615 x DRG weight",304751,Other,base rate x DRG weight,287823,,"38,359 x DRG weight",287823,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,110045,,186% x Medicaid HMO amount,110045,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,255693,,"34,077 x DRG weight",255693,Other,base rate x DRG weight,217343,,"28,966 x DRG weight",217343,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59164,,DRG base rate x DRG weight + capital per discharge,59164,Other,100% of NY Medicaid HMO DRG,59164,,100% x Medicaid HMO amount,59164,Other,100% of NY Medicaid HMO DRG,59164,,100% x Medicaid HMO amount,59164,Other,100% of NY Medicaid HMO DRG,59164,,100% x Medicaid HMO amount,59164,Other,100% of NY Medicaid HMO DRG,133119,,225% x Medicaid HMO amount,133119,Other,225% of NY Medicaid HMO DRG,133119,,225% x Medicaid HMO amount,133119,Other,225% of NY Medicaid HMO DRG,133119,,225% x Medicaid HMO amount,133119,Other,225% of NY Medicaid HMO DRG,133119,,225% x Medicaid HMO amount,133119,Other,225% of NY Medicaid HMO DRG,82830,,140% x Medicaid HMO amount,82830,Other,140% of NY Medicaid HMO DRG,133119,,225% x Medicaid HMO amount,133119,Other,225% of NY Medicaid HMO DRG,162701,,275% x Medicaid HMO amount,162701,Other,275% of NY Medicaid HMO DRG,191691,,324% x Medicaid HMO amount,191691,Other,324% of NY Medicaid HMO DRG,127203,,215% x Medicaid HMO amount,127203,Other,215% of NY Medicaid HMO DRG,127203,,215% x Medicaid HMO amount,127203,Other,215% of NY Medicaid HMO DRG,73955,,125% x Medicaid HMO amount,73955,Other,125% of NY Medicaid HMO DRG,0.01,338613,
Uterine & adnexa procedures for non-malignancy except leiomyoma,513-1,APR-DRG,,,,,,,,inpatient,,,108883.19,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39383,,"45,128 x DRG weight",39383,Other,base rate x DRG weight,35445,,"40,615 x DRG weight",35445,Other,base rate x DRG weight,33476,,"38,359 x DRG weight",33476,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14149,,186% x Medicaid HMO amount,14149,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29739,,"34,077 x DRG weight",29739,Other,base rate x DRG weight,25279,,"28,966 x DRG weight",25279,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7607,,DRG base rate x DRG weight + capital per discharge,7607,Other,100% of NY Medicaid HMO DRG,7607,,100% x Medicaid HMO amount,7607,Other,100% of NY Medicaid HMO DRG,7607,,100% x Medicaid HMO amount,7607,Other,100% of NY Medicaid HMO DRG,7607,,100% x Medicaid HMO amount,7607,Other,100% of NY Medicaid HMO DRG,17116,,225% x Medicaid HMO amount,17116,Other,225% of NY Medicaid HMO DRG,17116,,225% x Medicaid HMO amount,17116,Other,225% of NY Medicaid HMO DRG,17116,,225% x Medicaid HMO amount,17116,Other,225% of NY Medicaid HMO DRG,17116,,225% x Medicaid HMO amount,17116,Other,225% of NY Medicaid HMO DRG,10650,,140% x Medicaid HMO amount,10650,Other,140% of NY Medicaid HMO DRG,17116,,225% x Medicaid HMO amount,17116,Other,225% of NY Medicaid HMO DRG,20919,,275% x Medicaid HMO amount,20919,Other,275% of NY Medicaid HMO DRG,24647,,324% x Medicaid HMO amount,24647,Other,324% of NY Medicaid HMO DRG,16355,,215% x Medicaid HMO amount,16355,Other,215% of NY Medicaid HMO DRG,16355,,215% x Medicaid HMO amount,16355,Other,215% of NY Medicaid HMO DRG,9509,,125% x Medicaid HMO amount,9509,Other,125% of NY Medicaid HMO DRG,0.01,39383,
Uterine & adnexa procedures for non-malignancy except leiomyoma,513-2,APR-DRG,,,,,,,,inpatient,,,127769.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46852,,"45,128 x DRG weight",46852,Other,base rate x DRG weight,42166,,"40,615 x DRG weight",42166,Other,base rate x DRG weight,39824,,"38,359 x DRG weight",39824,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16543,,186% x Medicaid HMO amount,16543,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35379,,"34,077 x DRG weight",35379,Other,base rate x DRG weight,30073,,"28,966 x DRG weight",30073,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8894,,DRG base rate x DRG weight + capital per discharge,8894,Other,100% of NY Medicaid HMO DRG,8894,,100% x Medicaid HMO amount,8894,Other,100% of NY Medicaid HMO DRG,8894,,100% x Medicaid HMO amount,8894,Other,100% of NY Medicaid HMO DRG,8894,,100% x Medicaid HMO amount,8894,Other,100% of NY Medicaid HMO DRG,20012,,225% x Medicaid HMO amount,20012,Other,225% of NY Medicaid HMO DRG,20012,,225% x Medicaid HMO amount,20012,Other,225% of NY Medicaid HMO DRG,20012,,225% x Medicaid HMO amount,20012,Other,225% of NY Medicaid HMO DRG,20012,,225% x Medicaid HMO amount,20012,Other,225% of NY Medicaid HMO DRG,12452,,140% x Medicaid HMO amount,12452,Other,140% of NY Medicaid HMO DRG,20012,,225% x Medicaid HMO amount,20012,Other,225% of NY Medicaid HMO DRG,24459,,275% x Medicaid HMO amount,24459,Other,275% of NY Medicaid HMO DRG,28817,,324% x Medicaid HMO amount,28817,Other,324% of NY Medicaid HMO DRG,19122,,215% x Medicaid HMO amount,19122,Other,215% of NY Medicaid HMO DRG,19122,,215% x Medicaid HMO amount,19122,Other,215% of NY Medicaid HMO DRG,11118,,125% x Medicaid HMO amount,11118,Other,125% of NY Medicaid HMO DRG,0.01,46852,
Uterine & adnexa procedures for non-malignancy except leiomyoma,513-3,APR-DRG,,,,,,,,inpatient,,,156746.53,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,83496,,"45,128 x DRG weight",83496,Other,base rate x DRG weight,75146,,"40,615 x DRG weight",75146,Other,base rate x DRG weight,70972,,"38,359 x DRG weight",70972,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28285,,186% x Medicaid HMO amount,28285,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,63049,,"34,077 x DRG weight",63049,Other,base rate x DRG weight,53593,,"28,966 x DRG weight",53593,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15207,,DRG base rate x DRG weight + capital per discharge,15207,Other,100% of NY Medicaid HMO DRG,15207,,100% x Medicaid HMO amount,15207,Other,100% of NY Medicaid HMO DRG,15207,,100% x Medicaid HMO amount,15207,Other,100% of NY Medicaid HMO DRG,15207,,100% x Medicaid HMO amount,15207,Other,100% of NY Medicaid HMO DRG,34216,,225% x Medicaid HMO amount,34216,Other,225% of NY Medicaid HMO DRG,34216,,225% x Medicaid HMO amount,34216,Other,225% of NY Medicaid HMO DRG,34216,,225% x Medicaid HMO amount,34216,Other,225% of NY Medicaid HMO DRG,34216,,225% x Medicaid HMO amount,34216,Other,225% of NY Medicaid HMO DRG,21290,,140% x Medicaid HMO amount,21290,Other,140% of NY Medicaid HMO DRG,34216,,225% x Medicaid HMO amount,34216,Other,225% of NY Medicaid HMO DRG,41819,,275% x Medicaid HMO amount,41819,Other,275% of NY Medicaid HMO DRG,49271,,324% x Medicaid HMO amount,49271,Other,324% of NY Medicaid HMO DRG,32695,,215% x Medicaid HMO amount,32695,Other,215% of NY Medicaid HMO DRG,32695,,215% x Medicaid HMO amount,32695,Other,215% of NY Medicaid HMO DRG,19009,,125% x Medicaid HMO amount,19009,Other,125% of NY Medicaid HMO DRG,0.01,83496,
Uterine & adnexa procedures for non-malignancy except leiomyoma,513-4,APR-DRG,,,,,,,,inpatient,,,156746.53,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,216687,,"45,128 x DRG weight",216687,Other,base rate x DRG weight,195017,,"40,615 x DRG weight",195017,Other,base rate x DRG weight,184185,,"38,359 x DRG weight",184185,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,70970,,186% x Medicaid HMO amount,70970,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,163624,,"34,077 x DRG weight",163624,Other,base rate x DRG weight,139083,,"28,966 x DRG weight",139083,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38156,,DRG base rate x DRG weight + capital per discharge,38156,Other,100% of NY Medicaid HMO DRG,38156,,100% x Medicaid HMO amount,38156,Other,100% of NY Medicaid HMO DRG,38156,,100% x Medicaid HMO amount,38156,Other,100% of NY Medicaid HMO DRG,38156,,100% x Medicaid HMO amount,38156,Other,100% of NY Medicaid HMO DRG,85851,,225% x Medicaid HMO amount,85851,Other,225% of NY Medicaid HMO DRG,85851,,225% x Medicaid HMO amount,85851,Other,225% of NY Medicaid HMO DRG,85851,,225% x Medicaid HMO amount,85851,Other,225% of NY Medicaid HMO DRG,85851,,225% x Medicaid HMO amount,85851,Other,225% of NY Medicaid HMO DRG,53418,,140% x Medicaid HMO amount,53418,Other,140% of NY Medicaid HMO DRG,85851,,225% x Medicaid HMO amount,85851,Other,225% of NY Medicaid HMO DRG,104929,,275% x Medicaid HMO amount,104929,Other,275% of NY Medicaid HMO DRG,123625,,324% x Medicaid HMO amount,123625,Other,324% of NY Medicaid HMO DRG,82035,,215% x Medicaid HMO amount,82035,Other,215% of NY Medicaid HMO DRG,82035,,215% x Medicaid HMO amount,82035,Other,215% of NY Medicaid HMO DRG,47695,,125% x Medicaid HMO amount,47695,Other,125% of NY Medicaid HMO DRG,0.01,216687,
Female reproductive system reconstructive procedures,514-1,APR-DRG,,,,,,,,inpatient,,,136418.46,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44866,,"45,128 x DRG weight",44866,Other,base rate x DRG weight,40379,,"40,615 x DRG weight",40379,Other,base rate x DRG weight,38137,,"38,359 x DRG weight",38137,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15905,,186% x Medicaid HMO amount,15905,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33879,,"34,077 x DRG weight",33879,Other,base rate x DRG weight,28798,,"28,966 x DRG weight",28798,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8551,,DRG base rate x DRG weight + capital per discharge,8551,Other,100% of NY Medicaid HMO DRG,8551,,100% x Medicaid HMO amount,8551,Other,100% of NY Medicaid HMO DRG,8551,,100% x Medicaid HMO amount,8551,Other,100% of NY Medicaid HMO DRG,8551,,100% x Medicaid HMO amount,8551,Other,100% of NY Medicaid HMO DRG,19240,,225% x Medicaid HMO amount,19240,Other,225% of NY Medicaid HMO DRG,19240,,225% x Medicaid HMO amount,19240,Other,225% of NY Medicaid HMO DRG,19240,,225% x Medicaid HMO amount,19240,Other,225% of NY Medicaid HMO DRG,19240,,225% x Medicaid HMO amount,19240,Other,225% of NY Medicaid HMO DRG,11971,,140% x Medicaid HMO amount,11971,Other,140% of NY Medicaid HMO DRG,19240,,225% x Medicaid HMO amount,19240,Other,225% of NY Medicaid HMO DRG,23515,,275% x Medicaid HMO amount,23515,Other,275% of NY Medicaid HMO DRG,27705,,324% x Medicaid HMO amount,27705,Other,324% of NY Medicaid HMO DRG,18385,,215% x Medicaid HMO amount,18385,Other,215% of NY Medicaid HMO DRG,18385,,215% x Medicaid HMO amount,18385,Other,215% of NY Medicaid HMO DRG,10689,,125% x Medicaid HMO amount,10689,Other,125% of NY Medicaid HMO DRG,0.01,44866,
Female reproductive system reconstructive procedures,514-2,APR-DRG,,,,,,,,inpatient,,,394980.59,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44866,,"45,128 x DRG weight",44866,Other,base rate x DRG weight,40379,,"40,615 x DRG weight",40379,Other,base rate x DRG weight,38137,,"38,359 x DRG weight",38137,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15905,,186% x Medicaid HMO amount,15905,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33879,,"34,077 x DRG weight",33879,Other,base rate x DRG weight,28798,,"28,966 x DRG weight",28798,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8551,,DRG base rate x DRG weight + capital per discharge,8551,Other,100% of NY Medicaid HMO DRG,8551,,100% x Medicaid HMO amount,8551,Other,100% of NY Medicaid HMO DRG,8551,,100% x Medicaid HMO amount,8551,Other,100% of NY Medicaid HMO DRG,8551,,100% x Medicaid HMO amount,8551,Other,100% of NY Medicaid HMO DRG,19240,,225% x Medicaid HMO amount,19240,Other,225% of NY Medicaid HMO DRG,19240,,225% x Medicaid HMO amount,19240,Other,225% of NY Medicaid HMO DRG,19240,,225% x Medicaid HMO amount,19240,Other,225% of NY Medicaid HMO DRG,19240,,225% x Medicaid HMO amount,19240,Other,225% of NY Medicaid HMO DRG,11971,,140% x Medicaid HMO amount,11971,Other,140% of NY Medicaid HMO DRG,19240,,225% x Medicaid HMO amount,19240,Other,225% of NY Medicaid HMO DRG,23515,,275% x Medicaid HMO amount,23515,Other,275% of NY Medicaid HMO DRG,27705,,324% x Medicaid HMO amount,27705,Other,324% of NY Medicaid HMO DRG,18385,,215% x Medicaid HMO amount,18385,Other,215% of NY Medicaid HMO DRG,18385,,215% x Medicaid HMO amount,18385,Other,215% of NY Medicaid HMO DRG,10689,,125% x Medicaid HMO amount,10689,Other,125% of NY Medicaid HMO DRG,0.01,44866,
Female reproductive system reconstructive procedures,514-3,APR-DRG,,,,,,,,inpatient,,,394980.59,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44866,,"45,128 x DRG weight",44866,Other,base rate x DRG weight,40379,,"40,615 x DRG weight",40379,Other,base rate x DRG weight,38137,,"38,359 x DRG weight",38137,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15905,,186% x Medicaid HMO amount,15905,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33879,,"34,077 x DRG weight",33879,Other,base rate x DRG weight,28798,,"28,966 x DRG weight",28798,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8551,,DRG base rate x DRG weight + capital per discharge,8551,Other,100% of NY Medicaid HMO DRG,8551,,100% x Medicaid HMO amount,8551,Other,100% of NY Medicaid HMO DRG,8551,,100% x Medicaid HMO amount,8551,Other,100% of NY Medicaid HMO DRG,8551,,100% x Medicaid HMO amount,8551,Other,100% of NY Medicaid HMO DRG,19240,,225% x Medicaid HMO amount,19240,Other,225% of NY Medicaid HMO DRG,19240,,225% x Medicaid HMO amount,19240,Other,225% of NY Medicaid HMO DRG,19240,,225% x Medicaid HMO amount,19240,Other,225% of NY Medicaid HMO DRG,19240,,225% x Medicaid HMO amount,19240,Other,225% of NY Medicaid HMO DRG,11971,,140% x Medicaid HMO amount,11971,Other,140% of NY Medicaid HMO DRG,19240,,225% x Medicaid HMO amount,19240,Other,225% of NY Medicaid HMO DRG,23515,,275% x Medicaid HMO amount,23515,Other,275% of NY Medicaid HMO DRG,27705,,324% x Medicaid HMO amount,27705,Other,324% of NY Medicaid HMO DRG,18385,,215% x Medicaid HMO amount,18385,Other,215% of NY Medicaid HMO DRG,18385,,215% x Medicaid HMO amount,18385,Other,215% of NY Medicaid HMO DRG,10689,,125% x Medicaid HMO amount,10689,Other,125% of NY Medicaid HMO DRG,0.01,44866,
Female reproductive system reconstructive procedures,514-4,APR-DRG,,,,,,,,inpatient,,,394980.59,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,141030,,"45,128 x DRG weight",141030,Other,base rate x DRG weight,126926,,"40,615 x DRG weight",126926,Other,base rate x DRG weight,119876,,"38,359 x DRG weight",119876,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46723,,186% x Medicaid HMO amount,46723,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,106494,,"34,077 x DRG weight",106494,Other,base rate x DRG weight,90522,,"28,966 x DRG weight",90522,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25120,,DRG base rate x DRG weight + capital per discharge,25120,Other,100% of NY Medicaid HMO DRG,25120,,100% x Medicaid HMO amount,25120,Other,100% of NY Medicaid HMO DRG,25120,,100% x Medicaid HMO amount,25120,Other,100% of NY Medicaid HMO DRG,25120,,100% x Medicaid HMO amount,25120,Other,100% of NY Medicaid HMO DRG,56520,,225% x Medicaid HMO amount,56520,Other,225% of NY Medicaid HMO DRG,56520,,225% x Medicaid HMO amount,56520,Other,225% of NY Medicaid HMO DRG,56520,,225% x Medicaid HMO amount,56520,Other,225% of NY Medicaid HMO DRG,56520,,225% x Medicaid HMO amount,56520,Other,225% of NY Medicaid HMO DRG,35168,,140% x Medicaid HMO amount,35168,Other,140% of NY Medicaid HMO DRG,56520,,225% x Medicaid HMO amount,56520,Other,225% of NY Medicaid HMO DRG,69080,,275% x Medicaid HMO amount,69080,Other,275% of NY Medicaid HMO DRG,81389,,324% x Medicaid HMO amount,81389,Other,324% of NY Medicaid HMO DRG,54008,,215% x Medicaid HMO amount,54008,Other,215% of NY Medicaid HMO DRG,54008,,215% x Medicaid HMO amount,54008,Other,215% of NY Medicaid HMO DRG,31400,,125% x Medicaid HMO amount,31400,Other,125% of NY Medicaid HMO DRG,0.01,141030,
Dilation & curettage for non-obstetric diagnoses,517-1,APR-DRG,,,,,,,,inpatient,,,163703.79,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30132,,"45,128 x DRG weight",30132,Other,base rate x DRG weight,27119,,"40,615 x DRG weight",27119,Other,base rate x DRG weight,25612,,"38,359 x DRG weight",25612,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11184,,186% x Medicaid HMO amount,11184,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22753,,"34,077 x DRG weight",22753,Other,base rate x DRG weight,19341,,"28,966 x DRG weight",19341,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6013,,DRG base rate x DRG weight + capital per discharge,6013,Other,100% of NY Medicaid HMO DRG,6013,,100% x Medicaid HMO amount,6013,Other,100% of NY Medicaid HMO DRG,6013,,100% x Medicaid HMO amount,6013,Other,100% of NY Medicaid HMO DRG,6013,,100% x Medicaid HMO amount,6013,Other,100% of NY Medicaid HMO DRG,13529,,225% x Medicaid HMO amount,13529,Other,225% of NY Medicaid HMO DRG,13529,,225% x Medicaid HMO amount,13529,Other,225% of NY Medicaid HMO DRG,13529,,225% x Medicaid HMO amount,13529,Other,225% of NY Medicaid HMO DRG,13529,,225% x Medicaid HMO amount,13529,Other,225% of NY Medicaid HMO DRG,8418,,140% x Medicaid HMO amount,8418,Other,140% of NY Medicaid HMO DRG,13529,,225% x Medicaid HMO amount,13529,Other,225% of NY Medicaid HMO DRG,16536,,275% x Medicaid HMO amount,16536,Other,275% of NY Medicaid HMO DRG,19482,,324% x Medicaid HMO amount,19482,Other,324% of NY Medicaid HMO DRG,12928,,215% x Medicaid HMO amount,12928,Other,215% of NY Medicaid HMO DRG,12928,,215% x Medicaid HMO amount,12928,Other,215% of NY Medicaid HMO DRG,7516,,125% x Medicaid HMO amount,7516,Other,125% of NY Medicaid HMO DRG,0.01,30132,
Dilation & curettage for non-obstetric diagnoses,517-2,APR-DRG,,,,,,,,inpatient,,,163703.79,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42172,,"45,128 x DRG weight",42172,Other,base rate x DRG weight,37955,,"40,615 x DRG weight",37955,Other,base rate x DRG weight,35846,,"38,359 x DRG weight",35846,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15042,,186% x Medicaid HMO amount,15042,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31845,,"34,077 x DRG weight",31845,Other,base rate x DRG weight,27069,,"28,966 x DRG weight",27069,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8087,,DRG base rate x DRG weight + capital per discharge,8087,Other,100% of NY Medicaid HMO DRG,8087,,100% x Medicaid HMO amount,8087,Other,100% of NY Medicaid HMO DRG,8087,,100% x Medicaid HMO amount,8087,Other,100% of NY Medicaid HMO DRG,8087,,100% x Medicaid HMO amount,8087,Other,100% of NY Medicaid HMO DRG,18196,,225% x Medicaid HMO amount,18196,Other,225% of NY Medicaid HMO DRG,18196,,225% x Medicaid HMO amount,18196,Other,225% of NY Medicaid HMO DRG,18196,,225% x Medicaid HMO amount,18196,Other,225% of NY Medicaid HMO DRG,18196,,225% x Medicaid HMO amount,18196,Other,225% of NY Medicaid HMO DRG,11322,,140% x Medicaid HMO amount,11322,Other,140% of NY Medicaid HMO DRG,18196,,225% x Medicaid HMO amount,18196,Other,225% of NY Medicaid HMO DRG,22239,,275% x Medicaid HMO amount,22239,Other,275% of NY Medicaid HMO DRG,26202,,324% x Medicaid HMO amount,26202,Other,324% of NY Medicaid HMO DRG,17387,,215% x Medicaid HMO amount,17387,Other,215% of NY Medicaid HMO DRG,17387,,215% x Medicaid HMO amount,17387,Other,215% of NY Medicaid HMO DRG,10109,,125% x Medicaid HMO amount,10109,Other,125% of NY Medicaid HMO DRG,0.01,42172,
Dilation & curettage for non-obstetric diagnoses,517-3,APR-DRG,,,,,,,,inpatient,,,488129.7,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,91876,,"45,128 x DRG weight",91876,Other,base rate x DRG weight,82688,,"40,615 x DRG weight",82688,Other,base rate x DRG weight,78095,,"38,359 x DRG weight",78095,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30971,,186% x Medicaid HMO amount,30971,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,69377,,"34,077 x DRG weight",69377,Other,base rate x DRG weight,58972,,"28,966 x DRG weight",58972,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16651,,DRG base rate x DRG weight + capital per discharge,16651,Other,100% of NY Medicaid HMO DRG,16651,,100% x Medicaid HMO amount,16651,Other,100% of NY Medicaid HMO DRG,16651,,100% x Medicaid HMO amount,16651,Other,100% of NY Medicaid HMO DRG,16651,,100% x Medicaid HMO amount,16651,Other,100% of NY Medicaid HMO DRG,37465,,225% x Medicaid HMO amount,37465,Other,225% of NY Medicaid HMO DRG,37465,,225% x Medicaid HMO amount,37465,Other,225% of NY Medicaid HMO DRG,37465,,225% x Medicaid HMO amount,37465,Other,225% of NY Medicaid HMO DRG,37465,,225% x Medicaid HMO amount,37465,Other,225% of NY Medicaid HMO DRG,23311,,140% x Medicaid HMO amount,23311,Other,140% of NY Medicaid HMO DRG,37465,,225% x Medicaid HMO amount,37465,Other,225% of NY Medicaid HMO DRG,45790,,275% x Medicaid HMO amount,45790,Other,275% of NY Medicaid HMO DRG,53949,,324% x Medicaid HMO amount,53949,Other,324% of NY Medicaid HMO DRG,35800,,215% x Medicaid HMO amount,35800,Other,215% of NY Medicaid HMO DRG,35800,,215% x Medicaid HMO amount,35800,Other,215% of NY Medicaid HMO DRG,20814,,125% x Medicaid HMO amount,20814,Other,125% of NY Medicaid HMO DRG,0.01,91876,
Dilation & curettage for non-obstetric diagnoses,517-4,APR-DRG,,,,,,,,inpatient,,,194724,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,97021,,"45,128 x DRG weight",97021,Other,base rate x DRG weight,87318,,"40,615 x DRG weight",87318,Other,base rate x DRG weight,82468,,"38,359 x DRG weight",82468,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32621,,186% x Medicaid HMO amount,32621,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73262,,"34,077 x DRG weight",73262,Other,base rate x DRG weight,62274,,"28,966 x DRG weight",62274,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17538,,DRG base rate x DRG weight + capital per discharge,17538,Other,100% of NY Medicaid HMO DRG,17538,,100% x Medicaid HMO amount,17538,Other,100% of NY Medicaid HMO DRG,17538,,100% x Medicaid HMO amount,17538,Other,100% of NY Medicaid HMO DRG,17538,,100% x Medicaid HMO amount,17538,Other,100% of NY Medicaid HMO DRG,39461,,225% x Medicaid HMO amount,39461,Other,225% of NY Medicaid HMO DRG,39461,,225% x Medicaid HMO amount,39461,Other,225% of NY Medicaid HMO DRG,39461,,225% x Medicaid HMO amount,39461,Other,225% of NY Medicaid HMO DRG,39461,,225% x Medicaid HMO amount,39461,Other,225% of NY Medicaid HMO DRG,24553,,140% x Medicaid HMO amount,24553,Other,140% of NY Medicaid HMO DRG,39461,,225% x Medicaid HMO amount,39461,Other,225% of NY Medicaid HMO DRG,48230,,275% x Medicaid HMO amount,48230,Other,275% of NY Medicaid HMO DRG,56823,,324% x Medicaid HMO amount,56823,Other,324% of NY Medicaid HMO DRG,37707,,215% x Medicaid HMO amount,37707,Other,215% of NY Medicaid HMO DRG,37707,,215% x Medicaid HMO amount,37707,Other,215% of NY Medicaid HMO DRG,21923,,125% x Medicaid HMO amount,21923,Other,125% of NY Medicaid HMO DRG,0.01,97021,
Other female reproductive system & related procedures,518-1,APR-DRG,,,,,,,,inpatient,,,95382.64,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34112,,"45,128 x DRG weight",34112,Other,base rate x DRG weight,30701,,"40,615 x DRG weight",30701,Other,base rate x DRG weight,28996,,"38,359 x DRG weight",28996,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12458,,186% x Medicaid HMO amount,12458,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25759,,"34,077 x DRG weight",25759,Other,base rate x DRG weight,21895,,"28,966 x DRG weight",21895,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6698,,DRG base rate x DRG weight + capital per discharge,6698,Other,100% of NY Medicaid HMO DRG,6698,,100% x Medicaid HMO amount,6698,Other,100% of NY Medicaid HMO DRG,6698,,100% x Medicaid HMO amount,6698,Other,100% of NY Medicaid HMO DRG,6698,,100% x Medicaid HMO amount,6698,Other,100% of NY Medicaid HMO DRG,15071,,225% x Medicaid HMO amount,15071,Other,225% of NY Medicaid HMO DRG,15071,,225% x Medicaid HMO amount,15071,Other,225% of NY Medicaid HMO DRG,15071,,225% x Medicaid HMO amount,15071,Other,225% of NY Medicaid HMO DRG,15071,,225% x Medicaid HMO amount,15071,Other,225% of NY Medicaid HMO DRG,9377,,140% x Medicaid HMO amount,9377,Other,140% of NY Medicaid HMO DRG,15071,,225% x Medicaid HMO amount,15071,Other,225% of NY Medicaid HMO DRG,18420,,275% x Medicaid HMO amount,18420,Other,275% of NY Medicaid HMO DRG,21702,,324% x Medicaid HMO amount,21702,Other,324% of NY Medicaid HMO DRG,14401,,215% x Medicaid HMO amount,14401,Other,215% of NY Medicaid HMO DRG,14401,,215% x Medicaid HMO amount,14401,Other,215% of NY Medicaid HMO DRG,8373,,125% x Medicaid HMO amount,8373,Other,125% of NY Medicaid HMO DRG,0.01,34112,
Other female reproductive system & related procedures,518-2,APR-DRG,,,,,,,,inpatient,,,91113.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48851,,"45,128 x DRG weight",48851,Other,base rate x DRG weight,43966,,"40,615 x DRG weight",43966,Other,base rate x DRG weight,41524,,"38,359 x DRG weight",41524,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17183,,186% x Medicaid HMO amount,17183,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36888,,"34,077 x DRG weight",36888,Other,base rate x DRG weight,31356,,"28,966 x DRG weight",31356,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9238,,DRG base rate x DRG weight + capital per discharge,9238,Other,100% of NY Medicaid HMO DRG,9238,,100% x Medicaid HMO amount,9238,Other,100% of NY Medicaid HMO DRG,9238,,100% x Medicaid HMO amount,9238,Other,100% of NY Medicaid HMO DRG,9238,,100% x Medicaid HMO amount,9238,Other,100% of NY Medicaid HMO DRG,20786,,225% x Medicaid HMO amount,20786,Other,225% of NY Medicaid HMO DRG,20786,,225% x Medicaid HMO amount,20786,Other,225% of NY Medicaid HMO DRG,20786,,225% x Medicaid HMO amount,20786,Other,225% of NY Medicaid HMO DRG,20786,,225% x Medicaid HMO amount,20786,Other,225% of NY Medicaid HMO DRG,12933,,140% x Medicaid HMO amount,12933,Other,140% of NY Medicaid HMO DRG,20786,,225% x Medicaid HMO amount,20786,Other,225% of NY Medicaid HMO DRG,25405,,275% x Medicaid HMO amount,25405,Other,275% of NY Medicaid HMO DRG,29931,,324% x Medicaid HMO amount,29931,Other,324% of NY Medicaid HMO DRG,19862,,215% x Medicaid HMO amount,19862,Other,215% of NY Medicaid HMO DRG,19862,,215% x Medicaid HMO amount,19862,Other,215% of NY Medicaid HMO DRG,11548,,125% x Medicaid HMO amount,11548,Other,125% of NY Medicaid HMO DRG,0.01,48851,
Other female reproductive system & related procedures,518-3,APR-DRG,,,,,,,,inpatient,,,599314.63,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,95617,,"45,128 x DRG weight",95617,Other,base rate x DRG weight,86055,,"40,615 x DRG weight",86055,Other,base rate x DRG weight,81275,,"38,359 x DRG weight",81275,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32171,,186% x Medicaid HMO amount,32171,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,72202,,"34,077 x DRG weight",72202,Other,base rate x DRG weight,61373,,"28,966 x DRG weight",61373,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17296,,DRG base rate x DRG weight + capital per discharge,17296,Other,100% of NY Medicaid HMO DRG,17296,,100% x Medicaid HMO amount,17296,Other,100% of NY Medicaid HMO DRG,17296,,100% x Medicaid HMO amount,17296,Other,100% of NY Medicaid HMO DRG,17296,,100% x Medicaid HMO amount,17296,Other,100% of NY Medicaid HMO DRG,38916,,225% x Medicaid HMO amount,38916,Other,225% of NY Medicaid HMO DRG,38916,,225% x Medicaid HMO amount,38916,Other,225% of NY Medicaid HMO DRG,38916,,225% x Medicaid HMO amount,38916,Other,225% of NY Medicaid HMO DRG,38916,,225% x Medicaid HMO amount,38916,Other,225% of NY Medicaid HMO DRG,24214,,140% x Medicaid HMO amount,24214,Other,140% of NY Medicaid HMO DRG,38916,,225% x Medicaid HMO amount,38916,Other,225% of NY Medicaid HMO DRG,47564,,275% x Medicaid HMO amount,47564,Other,275% of NY Medicaid HMO DRG,56039,,324% x Medicaid HMO amount,56039,Other,324% of NY Medicaid HMO DRG,37186,,215% x Medicaid HMO amount,37186,Other,215% of NY Medicaid HMO DRG,37186,,215% x Medicaid HMO amount,37186,Other,215% of NY Medicaid HMO DRG,21620,,125% x Medicaid HMO amount,21620,Other,125% of NY Medicaid HMO DRG,0.01,95617,
Other female reproductive system & related procedures,518-4,APR-DRG,,,,,,,,inpatient,,,599314.63,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,269771,,"45,128 x DRG weight",269771,Other,base rate x DRG weight,242792,,"40,615 x DRG weight",242792,Other,base rate x DRG weight,229306,,"38,359 x DRG weight",229306,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,87984,,186% x Medicaid HMO amount,87984,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,203709,,"34,077 x DRG weight",203709,Other,base rate x DRG weight,173156,,"28,966 x DRG weight",173156,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47303,,DRG base rate x DRG weight + capital per discharge,47303,Other,100% of NY Medicaid HMO DRG,47303,,100% x Medicaid HMO amount,47303,Other,100% of NY Medicaid HMO DRG,47303,,100% x Medicaid HMO amount,47303,Other,100% of NY Medicaid HMO DRG,47303,,100% x Medicaid HMO amount,47303,Other,100% of NY Medicaid HMO DRG,106432,,225% x Medicaid HMO amount,106432,Other,225% of NY Medicaid HMO DRG,106432,,225% x Medicaid HMO amount,106432,Other,225% of NY Medicaid HMO DRG,106432,,225% x Medicaid HMO amount,106432,Other,225% of NY Medicaid HMO DRG,106432,,225% x Medicaid HMO amount,106432,Other,225% of NY Medicaid HMO DRG,66224,,140% x Medicaid HMO amount,66224,Other,140% of NY Medicaid HMO DRG,106432,,225% x Medicaid HMO amount,106432,Other,225% of NY Medicaid HMO DRG,130083,,275% x Medicaid HMO amount,130083,Other,275% of NY Medicaid HMO DRG,153262,,324% x Medicaid HMO amount,153262,Other,324% of NY Medicaid HMO DRG,101701,,215% x Medicaid HMO amount,101701,Other,215% of NY Medicaid HMO DRG,101701,,215% x Medicaid HMO amount,101701,Other,215% of NY Medicaid HMO DRG,59129,,125% x Medicaid HMO amount,59129,Other,125% of NY Medicaid HMO DRG,0.01,269771,
Uterine & adnexa procedures for leiomyoma,519-1,APR-DRG,,,,,,,,inpatient,,,144735.82,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38756,,"45,128 x DRG weight",38756,Other,base rate x DRG weight,34880,,"40,615 x DRG weight",34880,Other,base rate x DRG weight,32943,,"38,359 x DRG weight",32943,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13948,,186% x Medicaid HMO amount,13948,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29265,,"34,077 x DRG weight",29265,Other,base rate x DRG weight,24876,,"28,966 x DRG weight",24876,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7499,,DRG base rate x DRG weight + capital per discharge,7499,Other,100% of NY Medicaid HMO DRG,7499,,100% x Medicaid HMO amount,7499,Other,100% of NY Medicaid HMO DRG,7499,,100% x Medicaid HMO amount,7499,Other,100% of NY Medicaid HMO DRG,7499,,100% x Medicaid HMO amount,7499,Other,100% of NY Medicaid HMO DRG,16873,,225% x Medicaid HMO amount,16873,Other,225% of NY Medicaid HMO DRG,16873,,225% x Medicaid HMO amount,16873,Other,225% of NY Medicaid HMO DRG,16873,,225% x Medicaid HMO amount,16873,Other,225% of NY Medicaid HMO DRG,16873,,225% x Medicaid HMO amount,16873,Other,225% of NY Medicaid HMO DRG,10499,,140% x Medicaid HMO amount,10499,Other,140% of NY Medicaid HMO DRG,16873,,225% x Medicaid HMO amount,16873,Other,225% of NY Medicaid HMO DRG,20622,,275% x Medicaid HMO amount,20622,Other,275% of NY Medicaid HMO DRG,24297,,324% x Medicaid HMO amount,24297,Other,324% of NY Medicaid HMO DRG,16123,,215% x Medicaid HMO amount,16123,Other,215% of NY Medicaid HMO DRG,16123,,215% x Medicaid HMO amount,16123,Other,215% of NY Medicaid HMO DRG,9374,,125% x Medicaid HMO amount,9374,Other,125% of NY Medicaid HMO DRG,0.01,38756,
Uterine & adnexa procedures for leiomyoma,519-2,APR-DRG,,,,,,,,inpatient,,,77003.59,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48517,,"45,128 x DRG weight",48517,Other,base rate x DRG weight,43665,,"40,615 x DRG weight",43665,Other,base rate x DRG weight,41240,,"38,359 x DRG weight",41240,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17075,,186% x Medicaid HMO amount,17075,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36636,,"34,077 x DRG weight",36636,Other,base rate x DRG weight,31141,,"28,966 x DRG weight",31141,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9180,,DRG base rate x DRG weight + capital per discharge,9180,Other,100% of NY Medicaid HMO DRG,9180,,100% x Medicaid HMO amount,9180,Other,100% of NY Medicaid HMO DRG,9180,,100% x Medicaid HMO amount,9180,Other,100% of NY Medicaid HMO DRG,9180,,100% x Medicaid HMO amount,9180,Other,100% of NY Medicaid HMO DRG,20655,,225% x Medicaid HMO amount,20655,Other,225% of NY Medicaid HMO DRG,20655,,225% x Medicaid HMO amount,20655,Other,225% of NY Medicaid HMO DRG,20655,,225% x Medicaid HMO amount,20655,Other,225% of NY Medicaid HMO DRG,20655,,225% x Medicaid HMO amount,20655,Other,225% of NY Medicaid HMO DRG,12852,,140% x Medicaid HMO amount,12852,Other,140% of NY Medicaid HMO DRG,20655,,225% x Medicaid HMO amount,20655,Other,225% of NY Medicaid HMO DRG,25245,,275% x Medicaid HMO amount,25245,Other,275% of NY Medicaid HMO DRG,29743,,324% x Medicaid HMO amount,29743,Other,324% of NY Medicaid HMO DRG,19737,,215% x Medicaid HMO amount,19737,Other,215% of NY Medicaid HMO DRG,19737,,215% x Medicaid HMO amount,19737,Other,215% of NY Medicaid HMO DRG,11475,,125% x Medicaid HMO amount,11475,Other,125% of NY Medicaid HMO DRG,0.01,48517,
Uterine & adnexa procedures for leiomyoma,519-3,APR-DRG,,,,,,,,inpatient,,,289488.83,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,89322,,"45,128 x DRG weight",89322,Other,base rate x DRG weight,80389,,"40,615 x DRG weight",80389,Other,base rate x DRG weight,75924,,"38,359 x DRG weight",75924,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30152,,186% x Medicaid HMO amount,30152,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,67449,,"34,077 x DRG weight",67449,Other,base rate x DRG weight,57332,,"28,966 x DRG weight",57332,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16211,,DRG base rate x DRG weight + capital per discharge,16211,Other,100% of NY Medicaid HMO DRG,16211,,100% x Medicaid HMO amount,16211,Other,100% of NY Medicaid HMO DRG,16211,,100% x Medicaid HMO amount,16211,Other,100% of NY Medicaid HMO DRG,16211,,100% x Medicaid HMO amount,16211,Other,100% of NY Medicaid HMO DRG,36475,,225% x Medicaid HMO amount,36475,Other,225% of NY Medicaid HMO DRG,36475,,225% x Medicaid HMO amount,36475,Other,225% of NY Medicaid HMO DRG,36475,,225% x Medicaid HMO amount,36475,Other,225% of NY Medicaid HMO DRG,36475,,225% x Medicaid HMO amount,36475,Other,225% of NY Medicaid HMO DRG,22695,,140% x Medicaid HMO amount,22695,Other,140% of NY Medicaid HMO DRG,36475,,225% x Medicaid HMO amount,36475,Other,225% of NY Medicaid HMO DRG,44580,,275% x Medicaid HMO amount,44580,Other,275% of NY Medicaid HMO DRG,52524,,324% x Medicaid HMO amount,52524,Other,324% of NY Medicaid HMO DRG,34854,,215% x Medicaid HMO amount,34854,Other,215% of NY Medicaid HMO DRG,34854,,215% x Medicaid HMO amount,34854,Other,215% of NY Medicaid HMO DRG,20264,,125% x Medicaid HMO amount,20264,Other,125% of NY Medicaid HMO DRG,0.01,89322,
Uterine & adnexa procedures for leiomyoma,519-4,APR-DRG,,,,,,,,inpatient,,,144735.82,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,272970,,"45,128 x DRG weight",272970,Other,base rate x DRG weight,245672,,"40,615 x DRG weight",245672,Other,base rate x DRG weight,232026,,"38,359 x DRG weight",232026,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,89008,,186% x Medicaid HMO amount,89008,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,206125,,"34,077 x DRG weight",206125,Other,base rate x DRG weight,175210,,"28,966 x DRG weight",175210,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47854,,DRG base rate x DRG weight + capital per discharge,47854,Other,100% of NY Medicaid HMO DRG,47854,,100% x Medicaid HMO amount,47854,Other,100% of NY Medicaid HMO DRG,47854,,100% x Medicaid HMO amount,47854,Other,100% of NY Medicaid HMO DRG,47854,,100% x Medicaid HMO amount,47854,Other,100% of NY Medicaid HMO DRG,107672,,225% x Medicaid HMO amount,107672,Other,225% of NY Medicaid HMO DRG,107672,,225% x Medicaid HMO amount,107672,Other,225% of NY Medicaid HMO DRG,107672,,225% x Medicaid HMO amount,107672,Other,225% of NY Medicaid HMO DRG,107672,,225% x Medicaid HMO amount,107672,Other,225% of NY Medicaid HMO DRG,66996,,140% x Medicaid HMO amount,66996,Other,140% of NY Medicaid HMO DRG,107672,,225% x Medicaid HMO amount,107672,Other,225% of NY Medicaid HMO DRG,131599,,275% x Medicaid HMO amount,131599,Other,275% of NY Medicaid HMO DRG,155047,,324% x Medicaid HMO amount,155047,Other,324% of NY Medicaid HMO DRG,102886,,215% x Medicaid HMO amount,102886,Other,215% of NY Medicaid HMO DRG,102886,,215% x Medicaid HMO amount,102886,Other,215% of NY Medicaid HMO DRG,59818,,125% x Medicaid HMO amount,59818,Other,125% of NY Medicaid HMO DRG,0.01,272970,
Female reproductive system malignancy,530-1,APR-DRG,,,,,,,,inpatient,,,210556.88,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27537,,"45,128 x DRG weight",27537,Other,base rate x DRG weight,24783,,"40,615 x DRG weight",24783,Other,base rate x DRG weight,23407,,"38,359 x DRG weight",23407,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10353,,186% x Medicaid HMO amount,10353,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20794,,"34,077 x DRG weight",20794,Other,base rate x DRG weight,17675,,"28,966 x DRG weight",17675,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5566,,DRG base rate x DRG weight + capital per discharge,5566,Other,100% of NY Medicaid HMO DRG,5566,,100% x Medicaid HMO amount,5566,Other,100% of NY Medicaid HMO DRG,5566,,100% x Medicaid HMO amount,5566,Other,100% of NY Medicaid HMO DRG,5566,,100% x Medicaid HMO amount,5566,Other,100% of NY Medicaid HMO DRG,12524,,225% x Medicaid HMO amount,12524,Other,225% of NY Medicaid HMO DRG,12524,,225% x Medicaid HMO amount,12524,Other,225% of NY Medicaid HMO DRG,12524,,225% x Medicaid HMO amount,12524,Other,225% of NY Medicaid HMO DRG,12524,,225% x Medicaid HMO amount,12524,Other,225% of NY Medicaid HMO DRG,7792,,140% x Medicaid HMO amount,7792,Other,140% of NY Medicaid HMO DRG,12524,,225% x Medicaid HMO amount,12524,Other,225% of NY Medicaid HMO DRG,15307,,275% x Medicaid HMO amount,15307,Other,275% of NY Medicaid HMO DRG,18034,,324% x Medicaid HMO amount,18034,Other,324% of NY Medicaid HMO DRG,11967,,215% x Medicaid HMO amount,11967,Other,215% of NY Medicaid HMO DRG,11967,,215% x Medicaid HMO amount,11967,Other,215% of NY Medicaid HMO DRG,6958,,125% x Medicaid HMO amount,6958,Other,125% of NY Medicaid HMO DRG,0.01,27537,
Female reproductive system malignancy,530-2,APR-DRG,,,,,,,,inpatient,,,155050.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35304,,"45,128 x DRG weight",35304,Other,base rate x DRG weight,31773,,"40,615 x DRG weight",31773,Other,base rate x DRG weight,30008,,"38,359 x DRG weight",30008,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12841,,186% x Medicaid HMO amount,12841,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26658,,"34,077 x DRG weight",26658,Other,base rate x DRG weight,22660,,"28,966 x DRG weight",22660,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6904,,DRG base rate x DRG weight + capital per discharge,6904,Other,100% of NY Medicaid HMO DRG,6904,,100% x Medicaid HMO amount,6904,Other,100% of NY Medicaid HMO DRG,6904,,100% x Medicaid HMO amount,6904,Other,100% of NY Medicaid HMO DRG,6904,,100% x Medicaid HMO amount,6904,Other,100% of NY Medicaid HMO DRG,15534,,225% x Medicaid HMO amount,15534,Other,225% of NY Medicaid HMO DRG,15534,,225% x Medicaid HMO amount,15534,Other,225% of NY Medicaid HMO DRG,15534,,225% x Medicaid HMO amount,15534,Other,225% of NY Medicaid HMO DRG,15534,,225% x Medicaid HMO amount,15534,Other,225% of NY Medicaid HMO DRG,9666,,140% x Medicaid HMO amount,9666,Other,140% of NY Medicaid HMO DRG,15534,,225% x Medicaid HMO amount,15534,Other,225% of NY Medicaid HMO DRG,18986,,275% x Medicaid HMO amount,18986,Other,275% of NY Medicaid HMO DRG,22369,,324% x Medicaid HMO amount,22369,Other,324% of NY Medicaid HMO DRG,14844,,215% x Medicaid HMO amount,14844,Other,215% of NY Medicaid HMO DRG,14844,,215% x Medicaid HMO amount,14844,Other,215% of NY Medicaid HMO DRG,8630,,125% x Medicaid HMO amount,8630,Other,125% of NY Medicaid HMO DRG,0.01,35304,
Female reproductive system malignancy,530-3,APR-DRG,,,,,,,,inpatient,,,223676.53,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,65521,,"45,128 x DRG weight",65521,Other,base rate x DRG weight,58969,,"40,615 x DRG weight",58969,Other,base rate x DRG weight,55693,,"38,359 x DRG weight",55693,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22525,,186% x Medicaid HMO amount,22525,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49476,,"34,077 x DRG weight",49476,Other,base rate x DRG weight,42056,,"28,966 x DRG weight",42056,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12110,,DRG base rate x DRG weight + capital per discharge,12110,Other,100% of NY Medicaid HMO DRG,12110,,100% x Medicaid HMO amount,12110,Other,100% of NY Medicaid HMO DRG,12110,,100% x Medicaid HMO amount,12110,Other,100% of NY Medicaid HMO DRG,12110,,100% x Medicaid HMO amount,12110,Other,100% of NY Medicaid HMO DRG,27248,,225% x Medicaid HMO amount,27248,Other,225% of NY Medicaid HMO DRG,27248,,225% x Medicaid HMO amount,27248,Other,225% of NY Medicaid HMO DRG,27248,,225% x Medicaid HMO amount,27248,Other,225% of NY Medicaid HMO DRG,27248,,225% x Medicaid HMO amount,27248,Other,225% of NY Medicaid HMO DRG,16954,,140% x Medicaid HMO amount,16954,Other,140% of NY Medicaid HMO DRG,27248,,225% x Medicaid HMO amount,27248,Other,225% of NY Medicaid HMO DRG,33303,,275% x Medicaid HMO amount,33303,Other,275% of NY Medicaid HMO DRG,39236,,324% x Medicaid HMO amount,39236,Other,324% of NY Medicaid HMO DRG,26037,,215% x Medicaid HMO amount,26037,Other,215% of NY Medicaid HMO DRG,26037,,215% x Medicaid HMO amount,26037,Other,215% of NY Medicaid HMO DRG,15138,,125% x Medicaid HMO amount,15138,Other,125% of NY Medicaid HMO DRG,0.01,65521,
Female reproductive system malignancy,530-4,APR-DRG,,,,,,,,inpatient,,,166942.36,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,113140,,"45,128 x DRG weight",113140,Other,base rate x DRG weight,101826,,"40,615 x DRG weight",101826,Other,base rate x DRG weight,96170,,"38,359 x DRG weight",96170,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37786,,186% x Medicaid HMO amount,37786,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,85434,,"34,077 x DRG weight",85434,Other,base rate x DRG weight,72621,,"28,966 x DRG weight",72621,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20315,,DRG base rate x DRG weight + capital per discharge,20315,Other,100% of NY Medicaid HMO DRG,20315,,100% x Medicaid HMO amount,20315,Other,100% of NY Medicaid HMO DRG,20315,,100% x Medicaid HMO amount,20315,Other,100% of NY Medicaid HMO DRG,20315,,100% x Medicaid HMO amount,20315,Other,100% of NY Medicaid HMO DRG,45709,,225% x Medicaid HMO amount,45709,Other,225% of NY Medicaid HMO DRG,45709,,225% x Medicaid HMO amount,45709,Other,225% of NY Medicaid HMO DRG,45709,,225% x Medicaid HMO amount,45709,Other,225% of NY Medicaid HMO DRG,45709,,225% x Medicaid HMO amount,45709,Other,225% of NY Medicaid HMO DRG,28441,,140% x Medicaid HMO amount,28441,Other,140% of NY Medicaid HMO DRG,45709,,225% x Medicaid HMO amount,45709,Other,225% of NY Medicaid HMO DRG,55866,,275% x Medicaid HMO amount,55866,Other,275% of NY Medicaid HMO DRG,65821,,324% x Medicaid HMO amount,65821,Other,324% of NY Medicaid HMO DRG,43677,,215% x Medicaid HMO amount,43677,Other,215% of NY Medicaid HMO DRG,43677,,215% x Medicaid HMO amount,43677,Other,215% of NY Medicaid HMO DRG,25394,,125% x Medicaid HMO amount,25394,Other,125% of NY Medicaid HMO DRG,0.01,113140,
Female reproductive system infections,531-1,APR-DRG,,,,,,,,inpatient,,,81959.58,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24369,,"45,128 x DRG weight",24369,Other,base rate x DRG weight,21932,,"40,615 x DRG weight",21932,Other,base rate x DRG weight,20714,,"38,359 x DRG weight",20714,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9337,,186% x Medicaid HMO amount,9337,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18402,,"34,077 x DRG weight",18402,Other,base rate x DRG weight,15642,,"28,966 x DRG weight",15642,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5020,,DRG base rate x DRG weight + capital per discharge,5020,Other,100% of NY Medicaid HMO DRG,5020,,100% x Medicaid HMO amount,5020,Other,100% of NY Medicaid HMO DRG,5020,,100% x Medicaid HMO amount,5020,Other,100% of NY Medicaid HMO DRG,5020,,100% x Medicaid HMO amount,5020,Other,100% of NY Medicaid HMO DRG,11295,,225% x Medicaid HMO amount,11295,Other,225% of NY Medicaid HMO DRG,11295,,225% x Medicaid HMO amount,11295,Other,225% of NY Medicaid HMO DRG,11295,,225% x Medicaid HMO amount,11295,Other,225% of NY Medicaid HMO DRG,11295,,225% x Medicaid HMO amount,11295,Other,225% of NY Medicaid HMO DRG,7028,,140% x Medicaid HMO amount,7028,Other,140% of NY Medicaid HMO DRG,11295,,225% x Medicaid HMO amount,11295,Other,225% of NY Medicaid HMO DRG,13805,,275% x Medicaid HMO amount,13805,Other,275% of NY Medicaid HMO DRG,16265,,324% x Medicaid HMO amount,16265,Other,324% of NY Medicaid HMO DRG,10793,,215% x Medicaid HMO amount,10793,Other,215% of NY Medicaid HMO DRG,10793,,215% x Medicaid HMO amount,10793,Other,215% of NY Medicaid HMO DRG,6275,,125% x Medicaid HMO amount,6275,Other,125% of NY Medicaid HMO DRG,0.01,24369,
Female reproductive system infections,531-2,APR-DRG,,,,,,,,inpatient,,,139796.04,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32957,,"45,128 x DRG weight",32957,Other,base rate x DRG weight,29661,,"40,615 x DRG weight",29661,Other,base rate x DRG weight,28014,,"38,359 x DRG weight",28014,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12088,,186% x Medicaid HMO amount,12088,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24886,,"34,077 x DRG weight",24886,Other,base rate x DRG weight,21154,,"28,966 x DRG weight",21154,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6499,,DRG base rate x DRG weight + capital per discharge,6499,Other,100% of NY Medicaid HMO DRG,6499,,100% x Medicaid HMO amount,6499,Other,100% of NY Medicaid HMO DRG,6499,,100% x Medicaid HMO amount,6499,Other,100% of NY Medicaid HMO DRG,6499,,100% x Medicaid HMO amount,6499,Other,100% of NY Medicaid HMO DRG,14623,,225% x Medicaid HMO amount,14623,Other,225% of NY Medicaid HMO DRG,14623,,225% x Medicaid HMO amount,14623,Other,225% of NY Medicaid HMO DRG,14623,,225% x Medicaid HMO amount,14623,Other,225% of NY Medicaid HMO DRG,14623,,225% x Medicaid HMO amount,14623,Other,225% of NY Medicaid HMO DRG,9099,,140% x Medicaid HMO amount,9099,Other,140% of NY Medicaid HMO DRG,14623,,225% x Medicaid HMO amount,14623,Other,225% of NY Medicaid HMO DRG,17872,,275% x Medicaid HMO amount,17872,Other,275% of NY Medicaid HMO DRG,21057,,324% x Medicaid HMO amount,21057,Other,324% of NY Medicaid HMO DRG,13973,,215% x Medicaid HMO amount,13973,Other,215% of NY Medicaid HMO DRG,13973,,215% x Medicaid HMO amount,13973,Other,215% of NY Medicaid HMO DRG,8124,,125% x Medicaid HMO amount,8124,Other,125% of NY Medicaid HMO DRG,0.01,32957,
Female reproductive system infections,531-3,APR-DRG,,,,,,,,inpatient,,,109572.96,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52303,,"45,128 x DRG weight",52303,Other,base rate x DRG weight,47073,,"40,615 x DRG weight",47073,Other,base rate x DRG weight,44458,,"38,359 x DRG weight",44458,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18289,,186% x Medicaid HMO amount,18289,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39495,,"34,077 x DRG weight",39495,Other,base rate x DRG weight,33572,,"28,966 x DRG weight",33572,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9833,,DRG base rate x DRG weight + capital per discharge,9833,Other,100% of NY Medicaid HMO DRG,9833,,100% x Medicaid HMO amount,9833,Other,100% of NY Medicaid HMO DRG,9833,,100% x Medicaid HMO amount,9833,Other,100% of NY Medicaid HMO DRG,9833,,100% x Medicaid HMO amount,9833,Other,100% of NY Medicaid HMO DRG,22124,,225% x Medicaid HMO amount,22124,Other,225% of NY Medicaid HMO DRG,22124,,225% x Medicaid HMO amount,22124,Other,225% of NY Medicaid HMO DRG,22124,,225% x Medicaid HMO amount,22124,Other,225% of NY Medicaid HMO DRG,22124,,225% x Medicaid HMO amount,22124,Other,225% of NY Medicaid HMO DRG,13766,,140% x Medicaid HMO amount,13766,Other,140% of NY Medicaid HMO DRG,22124,,225% x Medicaid HMO amount,22124,Other,225% of NY Medicaid HMO DRG,27041,,275% x Medicaid HMO amount,27041,Other,275% of NY Medicaid HMO DRG,31859,,324% x Medicaid HMO amount,31859,Other,324% of NY Medicaid HMO DRG,21141,,215% x Medicaid HMO amount,21141,Other,215% of NY Medicaid HMO DRG,21141,,215% x Medicaid HMO amount,21141,Other,215% of NY Medicaid HMO DRG,12291,,125% x Medicaid HMO amount,12291,Other,125% of NY Medicaid HMO DRG,0.01,52303,
Female reproductive system infections,531-4,APR-DRG,,,,,,,,inpatient,,,139796.04,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,58752,,"45,128 x DRG weight",58752,Other,base rate x DRG weight,52877,,"40,615 x DRG weight",52877,Other,base rate x DRG weight,49940,,"38,359 x DRG weight",49940,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20356,,186% x Medicaid HMO amount,20356,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44365,,"34,077 x DRG weight",44365,Other,base rate x DRG weight,37711,,"28,966 x DRG weight",37711,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10944,,DRG base rate x DRG weight + capital per discharge,10944,Other,100% of NY Medicaid HMO DRG,10944,,100% x Medicaid HMO amount,10944,Other,100% of NY Medicaid HMO DRG,10944,,100% x Medicaid HMO amount,10944,Other,100% of NY Medicaid HMO DRG,10944,,100% x Medicaid HMO amount,10944,Other,100% of NY Medicaid HMO DRG,24624,,225% x Medicaid HMO amount,24624,Other,225% of NY Medicaid HMO DRG,24624,,225% x Medicaid HMO amount,24624,Other,225% of NY Medicaid HMO DRG,24624,,225% x Medicaid HMO amount,24624,Other,225% of NY Medicaid HMO DRG,24624,,225% x Medicaid HMO amount,24624,Other,225% of NY Medicaid HMO DRG,15322,,140% x Medicaid HMO amount,15322,Other,140% of NY Medicaid HMO DRG,24624,,225% x Medicaid HMO amount,24624,Other,225% of NY Medicaid HMO DRG,30096,,275% x Medicaid HMO amount,30096,Other,275% of NY Medicaid HMO DRG,35459,,324% x Medicaid HMO amount,35459,Other,324% of NY Medicaid HMO DRG,23530,,215% x Medicaid HMO amount,23530,Other,215% of NY Medicaid HMO DRG,23530,,215% x Medicaid HMO amount,23530,Other,215% of NY Medicaid HMO DRG,13680,,125% x Medicaid HMO amount,13680,Other,125% of NY Medicaid HMO DRG,0.01,58752,
Menstrual & other female reproductive system disorders,532-1,APR-DRG,,,,,,,,inpatient,,,46782.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18218,,"45,128 x DRG weight",18218,Other,base rate x DRG weight,16396,,"40,615 x DRG weight",16396,Other,base rate x DRG weight,15486,,"38,359 x DRG weight",15486,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7366,,186% x Medicaid HMO amount,7366,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13757,,"34,077 x DRG weight",13757,Other,base rate x DRG weight,11694,,"28,966 x DRG weight",11694,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3960,,DRG base rate x DRG weight + capital per discharge,3960,Other,100% of NY Medicaid HMO DRG,3960,,100% x Medicaid HMO amount,3960,Other,100% of NY Medicaid HMO DRG,3960,,100% x Medicaid HMO amount,3960,Other,100% of NY Medicaid HMO DRG,3960,,100% x Medicaid HMO amount,3960,Other,100% of NY Medicaid HMO DRG,8910,,225% x Medicaid HMO amount,8910,Other,225% of NY Medicaid HMO DRG,8910,,225% x Medicaid HMO amount,8910,Other,225% of NY Medicaid HMO DRG,8910,,225% x Medicaid HMO amount,8910,Other,225% of NY Medicaid HMO DRG,8910,,225% x Medicaid HMO amount,8910,Other,225% of NY Medicaid HMO DRG,5544,,140% x Medicaid HMO amount,5544,Other,140% of NY Medicaid HMO DRG,8910,,225% x Medicaid HMO amount,8910,Other,225% of NY Medicaid HMO DRG,10890,,275% x Medicaid HMO amount,10890,Other,275% of NY Medicaid HMO DRG,12830,,324% x Medicaid HMO amount,12830,Other,324% of NY Medicaid HMO DRG,8514,,215% x Medicaid HMO amount,8514,Other,215% of NY Medicaid HMO DRG,8514,,215% x Medicaid HMO amount,8514,Other,215% of NY Medicaid HMO DRG,4950,,125% x Medicaid HMO amount,4950,Other,125% of NY Medicaid HMO DRG,0.01,18218,
Menstrual & other female reproductive system disorders,532-2,APR-DRG,,,,,,,,inpatient,,,67751.58,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25213,,"45,128 x DRG weight",25213,Other,base rate x DRG weight,22692,,"40,615 x DRG weight",22692,Other,base rate x DRG weight,21431,,"38,359 x DRG weight",21431,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9607,,186% x Medicaid HMO amount,9607,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19039,,"34,077 x DRG weight",19039,Other,base rate x DRG weight,16183,,"28,966 x DRG weight",16183,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5165,,DRG base rate x DRG weight + capital per discharge,5165,Other,100% of NY Medicaid HMO DRG,5165,,100% x Medicaid HMO amount,5165,Other,100% of NY Medicaid HMO DRG,5165,,100% x Medicaid HMO amount,5165,Other,100% of NY Medicaid HMO DRG,5165,,100% x Medicaid HMO amount,5165,Other,100% of NY Medicaid HMO DRG,11621,,225% x Medicaid HMO amount,11621,Other,225% of NY Medicaid HMO DRG,11621,,225% x Medicaid HMO amount,11621,Other,225% of NY Medicaid HMO DRG,11621,,225% x Medicaid HMO amount,11621,Other,225% of NY Medicaid HMO DRG,11621,,225% x Medicaid HMO amount,11621,Other,225% of NY Medicaid HMO DRG,7231,,140% x Medicaid HMO amount,7231,Other,140% of NY Medicaid HMO DRG,11621,,225% x Medicaid HMO amount,11621,Other,225% of NY Medicaid HMO DRG,14204,,275% x Medicaid HMO amount,14204,Other,275% of NY Medicaid HMO DRG,16735,,324% x Medicaid HMO amount,16735,Other,324% of NY Medicaid HMO DRG,11105,,215% x Medicaid HMO amount,11105,Other,215% of NY Medicaid HMO DRG,11105,,215% x Medicaid HMO amount,11105,Other,215% of NY Medicaid HMO DRG,6456,,125% x Medicaid HMO amount,6456,Other,125% of NY Medicaid HMO DRG,0.01,25213,
Menstrual & other female reproductive system disorders,532-3,APR-DRG,,,,,,,,inpatient,,,128400.55,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43806,,"45,128 x DRG weight",43806,Other,base rate x DRG weight,39425,,"40,615 x DRG weight",39425,Other,base rate x DRG weight,37235,,"38,359 x DRG weight",37235,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15566,,186% x Medicaid HMO amount,15566,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33079,,"34,077 x DRG weight",33079,Other,base rate x DRG weight,28117,,"28,966 x DRG weight",28117,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8369,,DRG base rate x DRG weight + capital per discharge,8369,Other,100% of NY Medicaid HMO DRG,8369,,100% x Medicaid HMO amount,8369,Other,100% of NY Medicaid HMO DRG,8369,,100% x Medicaid HMO amount,8369,Other,100% of NY Medicaid HMO DRG,8369,,100% x Medicaid HMO amount,8369,Other,100% of NY Medicaid HMO DRG,18830,,225% x Medicaid HMO amount,18830,Other,225% of NY Medicaid HMO DRG,18830,,225% x Medicaid HMO amount,18830,Other,225% of NY Medicaid HMO DRG,18830,,225% x Medicaid HMO amount,18830,Other,225% of NY Medicaid HMO DRG,18830,,225% x Medicaid HMO amount,18830,Other,225% of NY Medicaid HMO DRG,11717,,140% x Medicaid HMO amount,11717,Other,140% of NY Medicaid HMO DRG,18830,,225% x Medicaid HMO amount,18830,Other,225% of NY Medicaid HMO DRG,23015,,275% x Medicaid HMO amount,23015,Other,275% of NY Medicaid HMO DRG,27116,,324% x Medicaid HMO amount,27116,Other,324% of NY Medicaid HMO DRG,17993,,215% x Medicaid HMO amount,17993,Other,215% of NY Medicaid HMO DRG,17993,,215% x Medicaid HMO amount,17993,Other,215% of NY Medicaid HMO DRG,10461,,125% x Medicaid HMO amount,10461,Other,125% of NY Medicaid HMO DRG,0.01,43806,
Menstrual & other female reproductive system disorders,532-4,APR-DRG,,,,,,,,inpatient,,,321608.2,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46428,,"45,128 x DRG weight",46428,Other,base rate x DRG weight,41785,,"40,615 x DRG weight",41785,Other,base rate x DRG weight,39464,,"38,359 x DRG weight",39464,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16405,,186% x Medicaid HMO amount,16405,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35058,,"34,077 x DRG weight",35058,Other,base rate x DRG weight,29800,,"28,966 x DRG weight",29800,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8820,,DRG base rate x DRG weight + capital per discharge,8820,Other,100% of NY Medicaid HMO DRG,8820,,100% x Medicaid HMO amount,8820,Other,100% of NY Medicaid HMO DRG,8820,,100% x Medicaid HMO amount,8820,Other,100% of NY Medicaid HMO DRG,8820,,100% x Medicaid HMO amount,8820,Other,100% of NY Medicaid HMO DRG,19845,,225% x Medicaid HMO amount,19845,Other,225% of NY Medicaid HMO DRG,19845,,225% x Medicaid HMO amount,19845,Other,225% of NY Medicaid HMO DRG,19845,,225% x Medicaid HMO amount,19845,Other,225% of NY Medicaid HMO DRG,19845,,225% x Medicaid HMO amount,19845,Other,225% of NY Medicaid HMO DRG,12348,,140% x Medicaid HMO amount,12348,Other,140% of NY Medicaid HMO DRG,19845,,225% x Medicaid HMO amount,19845,Other,225% of NY Medicaid HMO DRG,24255,,275% x Medicaid HMO amount,24255,Other,275% of NY Medicaid HMO DRG,28577,,324% x Medicaid HMO amount,28577,Other,324% of NY Medicaid HMO DRG,18963,,215% x Medicaid HMO amount,18963,Other,215% of NY Medicaid HMO DRG,18963,,215% x Medicaid HMO amount,18963,Other,215% of NY Medicaid HMO DRG,11025,,125% x Medicaid HMO amount,11025,Other,125% of NY Medicaid HMO DRG,0.01,46428,
Cesarean delivery,540-1,APR-DRG,,,,,,,,inpatient,,,105530.65,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36152,,"45,128 x DRG weight",36152,Other,base rate x DRG weight,32537,,"40,615 x DRG weight",32537,Other,base rate x DRG weight,30729,,"38,359 x DRG weight",30729,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13113,,186% x Medicaid HMO amount,13113,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27299,,"34,077 x DRG weight",27299,Other,base rate x DRG weight,23205,,"28,966 x DRG weight",23205,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7050,,DRG base rate x DRG weight + capital per discharge,7050,Other,100% of NY Medicaid HMO DRG,7050,,100% x Medicaid HMO amount,7050,Other,100% of NY Medicaid HMO DRG,7050,,100% x Medicaid HMO amount,7050,Other,100% of NY Medicaid HMO DRG,7050,,100% x Medicaid HMO amount,7050,Other,100% of NY Medicaid HMO DRG,15863,,225% x Medicaid HMO amount,15863,Other,225% of NY Medicaid HMO DRG,15863,,225% x Medicaid HMO amount,15863,Other,225% of NY Medicaid HMO DRG,15863,,225% x Medicaid HMO amount,15863,Other,225% of NY Medicaid HMO DRG,15863,,225% x Medicaid HMO amount,15863,Other,225% of NY Medicaid HMO DRG,9870,,140% x Medicaid HMO amount,9870,Other,140% of NY Medicaid HMO DRG,15863,,225% x Medicaid HMO amount,15863,Other,225% of NY Medicaid HMO DRG,19388,,275% x Medicaid HMO amount,19388,Other,275% of NY Medicaid HMO DRG,22842,,324% x Medicaid HMO amount,22842,Other,324% of NY Medicaid HMO DRG,15158,,215% x Medicaid HMO amount,15158,Other,215% of NY Medicaid HMO DRG,15158,,215% x Medicaid HMO amount,15158,Other,215% of NY Medicaid HMO DRG,8813,,125% x Medicaid HMO amount,8813,Other,125% of NY Medicaid HMO DRG,0.01,36152,
Cesarean delivery,540-2,APR-DRG,,,,,,,,inpatient,,,140809.14,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41459,,"45,128 x DRG weight",41459,Other,base rate x DRG weight,37313,,"40,615 x DRG weight",37313,Other,base rate x DRG weight,35240,,"38,359 x DRG weight",35240,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14813,,186% x Medicaid HMO amount,14813,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31307,,"34,077 x DRG weight",31307,Other,base rate x DRG weight,26611,,"28,966 x DRG weight",26611,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7964,,DRG base rate x DRG weight + capital per discharge,7964,Other,100% of NY Medicaid HMO DRG,7964,,100% x Medicaid HMO amount,7964,Other,100% of NY Medicaid HMO DRG,7964,,100% x Medicaid HMO amount,7964,Other,100% of NY Medicaid HMO DRG,7964,,100% x Medicaid HMO amount,7964,Other,100% of NY Medicaid HMO DRG,17919,,225% x Medicaid HMO amount,17919,Other,225% of NY Medicaid HMO DRG,17919,,225% x Medicaid HMO amount,17919,Other,225% of NY Medicaid HMO DRG,17919,,225% x Medicaid HMO amount,17919,Other,225% of NY Medicaid HMO DRG,17919,,225% x Medicaid HMO amount,17919,Other,225% of NY Medicaid HMO DRG,11150,,140% x Medicaid HMO amount,11150,Other,140% of NY Medicaid HMO DRG,17919,,225% x Medicaid HMO amount,17919,Other,225% of NY Medicaid HMO DRG,21901,,275% x Medicaid HMO amount,21901,Other,275% of NY Medicaid HMO DRG,25803,,324% x Medicaid HMO amount,25803,Other,324% of NY Medicaid HMO DRG,17123,,215% x Medicaid HMO amount,17123,Other,215% of NY Medicaid HMO DRG,17123,,215% x Medicaid HMO amount,17123,Other,215% of NY Medicaid HMO DRG,9955,,125% x Medicaid HMO amount,9955,Other,125% of NY Medicaid HMO DRG,0.01,41459,
Cesarean delivery,540-3,APR-DRG,,,,,,,,inpatient,,,185138.55,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53089,,"45,128 x DRG weight",53089,Other,base rate x DRG weight,47779,,"40,615 x DRG weight",47779,Other,base rate x DRG weight,45126,,"38,359 x DRG weight",45126,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18540,,186% x Medicaid HMO amount,18540,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40088,,"34,077 x DRG weight",40088,Other,base rate x DRG weight,34076,,"28,966 x DRG weight",34076,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9968,,DRG base rate x DRG weight + capital per discharge,9968,Other,100% of NY Medicaid HMO DRG,9968,,100% x Medicaid HMO amount,9968,Other,100% of NY Medicaid HMO DRG,9968,,100% x Medicaid HMO amount,9968,Other,100% of NY Medicaid HMO DRG,9968,,100% x Medicaid HMO amount,9968,Other,100% of NY Medicaid HMO DRG,22428,,225% x Medicaid HMO amount,22428,Other,225% of NY Medicaid HMO DRG,22428,,225% x Medicaid HMO amount,22428,Other,225% of NY Medicaid HMO DRG,22428,,225% x Medicaid HMO amount,22428,Other,225% of NY Medicaid HMO DRG,22428,,225% x Medicaid HMO amount,22428,Other,225% of NY Medicaid HMO DRG,13955,,140% x Medicaid HMO amount,13955,Other,140% of NY Medicaid HMO DRG,22428,,225% x Medicaid HMO amount,22428,Other,225% of NY Medicaid HMO DRG,27412,,275% x Medicaid HMO amount,27412,Other,275% of NY Medicaid HMO DRG,32296,,324% x Medicaid HMO amount,32296,Other,324% of NY Medicaid HMO DRG,21431,,215% x Medicaid HMO amount,21431,Other,215% of NY Medicaid HMO DRG,21431,,215% x Medicaid HMO amount,21431,Other,215% of NY Medicaid HMO DRG,12460,,125% x Medicaid HMO amount,12460,Other,125% of NY Medicaid HMO DRG,0.01,53089,
Cesarean delivery,540-4,APR-DRG,,,,,,,,inpatient,,,334973.51,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,122098,,"45,128 x DRG weight",122098,Other,base rate x DRG weight,109888,,"40,615 x DRG weight",109888,Other,base rate x DRG weight,103784,,"38,359 x DRG weight",103784,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40658,,186% x Medicaid HMO amount,40658,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,92199,,"34,077 x DRG weight",92199,Other,base rate x DRG weight,78370,,"28,966 x DRG weight",78370,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21859,,DRG base rate x DRG weight + capital per discharge,21859,Other,100% of NY Medicaid HMO DRG,21859,,100% x Medicaid HMO amount,21859,Other,100% of NY Medicaid HMO DRG,21859,,100% x Medicaid HMO amount,21859,Other,100% of NY Medicaid HMO DRG,21859,,100% x Medicaid HMO amount,21859,Other,100% of NY Medicaid HMO DRG,49183,,225% x Medicaid HMO amount,49183,Other,225% of NY Medicaid HMO DRG,49183,,225% x Medicaid HMO amount,49183,Other,225% of NY Medicaid HMO DRG,49183,,225% x Medicaid HMO amount,49183,Other,225% of NY Medicaid HMO DRG,49183,,225% x Medicaid HMO amount,49183,Other,225% of NY Medicaid HMO DRG,30603,,140% x Medicaid HMO amount,30603,Other,140% of NY Medicaid HMO DRG,49183,,225% x Medicaid HMO amount,49183,Other,225% of NY Medicaid HMO DRG,60112,,275% x Medicaid HMO amount,60112,Other,275% of NY Medicaid HMO DRG,70823,,324% x Medicaid HMO amount,70823,Other,324% of NY Medicaid HMO DRG,46997,,215% x Medicaid HMO amount,46997,Other,215% of NY Medicaid HMO DRG,46997,,215% x Medicaid HMO amount,46997,Other,215% of NY Medicaid HMO DRG,27324,,125% x Medicaid HMO amount,27324,Other,125% of NY Medicaid HMO DRG,0.01,122098,
Vaginal delivery w sterilization &/or D&C,541-1,APR-DRG,,,,,,,,inpatient,,,108561.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31729,,"45,128 x DRG weight",31729,Other,base rate x DRG weight,28556,,"40,615 x DRG weight",28556,Other,base rate x DRG weight,26970,,"38,359 x DRG weight",26970,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11696,,186% x Medicaid HMO amount,11696,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23960,,"34,077 x DRG weight",23960,Other,base rate x DRG weight,20366,,"28,966 x DRG weight",20366,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6288,,DRG base rate x DRG weight + capital per discharge,6288,Other,100% of NY Medicaid HMO DRG,6288,,100% x Medicaid HMO amount,6288,Other,100% of NY Medicaid HMO DRG,6288,,100% x Medicaid HMO amount,6288,Other,100% of NY Medicaid HMO DRG,6288,,100% x Medicaid HMO amount,6288,Other,100% of NY Medicaid HMO DRG,14148,,225% x Medicaid HMO amount,14148,Other,225% of NY Medicaid HMO DRG,14148,,225% x Medicaid HMO amount,14148,Other,225% of NY Medicaid HMO DRG,14148,,225% x Medicaid HMO amount,14148,Other,225% of NY Medicaid HMO DRG,14148,,225% x Medicaid HMO amount,14148,Other,225% of NY Medicaid HMO DRG,8803,,140% x Medicaid HMO amount,8803,Other,140% of NY Medicaid HMO DRG,14148,,225% x Medicaid HMO amount,14148,Other,225% of NY Medicaid HMO DRG,17292,,275% x Medicaid HMO amount,17292,Other,275% of NY Medicaid HMO DRG,20373,,324% x Medicaid HMO amount,20373,Other,324% of NY Medicaid HMO DRG,13519,,215% x Medicaid HMO amount,13519,Other,215% of NY Medicaid HMO DRG,13519,,215% x Medicaid HMO amount,13519,Other,215% of NY Medicaid HMO DRG,7860,,125% x Medicaid HMO amount,7860,Other,125% of NY Medicaid HMO DRG,0.01,31729,
Vaginal delivery w sterilization &/or D&C,541-2,APR-DRG,,,,,,,,inpatient,,,107615.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34302,,"45,128 x DRG weight",34302,Other,base rate x DRG weight,30871,,"40,615 x DRG weight",30871,Other,base rate x DRG weight,29157,,"38,359 x DRG weight",29157,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12520,,186% x Medicaid HMO amount,12520,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25902,,"34,077 x DRG weight",25902,Other,base rate x DRG weight,22017,,"28,966 x DRG weight",22017,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6731,,DRG base rate x DRG weight + capital per discharge,6731,Other,100% of NY Medicaid HMO DRG,6731,,100% x Medicaid HMO amount,6731,Other,100% of NY Medicaid HMO DRG,6731,,100% x Medicaid HMO amount,6731,Other,100% of NY Medicaid HMO DRG,6731,,100% x Medicaid HMO amount,6731,Other,100% of NY Medicaid HMO DRG,15145,,225% x Medicaid HMO amount,15145,Other,225% of NY Medicaid HMO DRG,15145,,225% x Medicaid HMO amount,15145,Other,225% of NY Medicaid HMO DRG,15145,,225% x Medicaid HMO amount,15145,Other,225% of NY Medicaid HMO DRG,15145,,225% x Medicaid HMO amount,15145,Other,225% of NY Medicaid HMO DRG,9423,,140% x Medicaid HMO amount,9423,Other,140% of NY Medicaid HMO DRG,15145,,225% x Medicaid HMO amount,15145,Other,225% of NY Medicaid HMO DRG,18510,,275% x Medicaid HMO amount,18510,Other,275% of NY Medicaid HMO DRG,21808,,324% x Medicaid HMO amount,21808,Other,324% of NY Medicaid HMO DRG,14472,,215% x Medicaid HMO amount,14472,Other,215% of NY Medicaid HMO DRG,14472,,215% x Medicaid HMO amount,14472,Other,215% of NY Medicaid HMO DRG,8414,,125% x Medicaid HMO amount,8414,Other,125% of NY Medicaid HMO DRG,0.01,34302,
Vaginal delivery w sterilization &/or D&C,541-3,APR-DRG,,,,,,,,inpatient,,,258103.07,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44938,,"45,128 x DRG weight",44938,Other,base rate x DRG weight,40444,,"40,615 x DRG weight",40444,Other,base rate x DRG weight,38198,,"38,359 x DRG weight",38198,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15929,,186% x Medicaid HMO amount,15929,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33934,,"34,077 x DRG weight",33934,Other,base rate x DRG weight,28844,,"28,966 x DRG weight",28844,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8564,,DRG base rate x DRG weight + capital per discharge,8564,Other,100% of NY Medicaid HMO DRG,8564,,100% x Medicaid HMO amount,8564,Other,100% of NY Medicaid HMO DRG,8564,,100% x Medicaid HMO amount,8564,Other,100% of NY Medicaid HMO DRG,8564,,100% x Medicaid HMO amount,8564,Other,100% of NY Medicaid HMO DRG,19269,,225% x Medicaid HMO amount,19269,Other,225% of NY Medicaid HMO DRG,19269,,225% x Medicaid HMO amount,19269,Other,225% of NY Medicaid HMO DRG,19269,,225% x Medicaid HMO amount,19269,Other,225% of NY Medicaid HMO DRG,19269,,225% x Medicaid HMO amount,19269,Other,225% of NY Medicaid HMO DRG,11990,,140% x Medicaid HMO amount,11990,Other,140% of NY Medicaid HMO DRG,19269,,225% x Medicaid HMO amount,19269,Other,225% of NY Medicaid HMO DRG,23551,,275% x Medicaid HMO amount,23551,Other,275% of NY Medicaid HMO DRG,27747,,324% x Medicaid HMO amount,27747,Other,324% of NY Medicaid HMO DRG,18413,,215% x Medicaid HMO amount,18413,Other,215% of NY Medicaid HMO DRG,18413,,215% x Medicaid HMO amount,18413,Other,215% of NY Medicaid HMO DRG,10705,,125% x Medicaid HMO amount,10705,Other,125% of NY Medicaid HMO DRG,0.01,44938,
Vaginal delivery w sterilization &/or D&C,541-4,APR-DRG,,,,,,,,inpatient,,,258103.07,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49230,,"45,128 x DRG weight",49230,Other,base rate x DRG weight,44307,,"40,615 x DRG weight",44307,Other,base rate x DRG weight,41846,,"38,359 x DRG weight",41846,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17304,,186% x Medicaid HMO amount,17304,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37175,,"34,077 x DRG weight",37175,Other,base rate x DRG weight,31599,,"28,966 x DRG weight",31599,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9303,,DRG base rate x DRG weight + capital per discharge,9303,Other,100% of NY Medicaid HMO DRG,9303,,100% x Medicaid HMO amount,9303,Other,100% of NY Medicaid HMO DRG,9303,,100% x Medicaid HMO amount,9303,Other,100% of NY Medicaid HMO DRG,9303,,100% x Medicaid HMO amount,9303,Other,100% of NY Medicaid HMO DRG,20932,,225% x Medicaid HMO amount,20932,Other,225% of NY Medicaid HMO DRG,20932,,225% x Medicaid HMO amount,20932,Other,225% of NY Medicaid HMO DRG,20932,,225% x Medicaid HMO amount,20932,Other,225% of NY Medicaid HMO DRG,20932,,225% x Medicaid HMO amount,20932,Other,225% of NY Medicaid HMO DRG,13024,,140% x Medicaid HMO amount,13024,Other,140% of NY Medicaid HMO DRG,20932,,225% x Medicaid HMO amount,20932,Other,225% of NY Medicaid HMO DRG,25583,,275% x Medicaid HMO amount,25583,Other,275% of NY Medicaid HMO DRG,30142,,324% x Medicaid HMO amount,30142,Other,324% of NY Medicaid HMO DRG,20001,,215% x Medicaid HMO amount,20001,Other,215% of NY Medicaid HMO DRG,20001,,215% x Medicaid HMO amount,20001,Other,215% of NY Medicaid HMO DRG,11629,,125% x Medicaid HMO amount,11629,Other,125% of NY Medicaid HMO DRG,0.01,49230,
Vaginal delivery w complicating procedures exc sterilization &/or D&C,542-1,APR-DRG,,,,,,,,inpatient,,,87122,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26856,,"45,128 x DRG weight",26856,Other,base rate x DRG weight,24170,,"40,615 x DRG weight",24170,Other,base rate x DRG weight,22827,,"38,359 x DRG weight",22827,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10133,,186% x Medicaid HMO amount,10133,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20279,,"34,077 x DRG weight",20279,Other,base rate x DRG weight,17238,,"28,966 x DRG weight",17238,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5448,,DRG base rate x DRG weight + capital per discharge,5448,Other,100% of NY Medicaid HMO DRG,5448,,100% x Medicaid HMO amount,5448,Other,100% of NY Medicaid HMO DRG,5448,,100% x Medicaid HMO amount,5448,Other,100% of NY Medicaid HMO DRG,5448,,100% x Medicaid HMO amount,5448,Other,100% of NY Medicaid HMO DRG,12258,,225% x Medicaid HMO amount,12258,Other,225% of NY Medicaid HMO DRG,12258,,225% x Medicaid HMO amount,12258,Other,225% of NY Medicaid HMO DRG,12258,,225% x Medicaid HMO amount,12258,Other,225% of NY Medicaid HMO DRG,12258,,225% x Medicaid HMO amount,12258,Other,225% of NY Medicaid HMO DRG,7627,,140% x Medicaid HMO amount,7627,Other,140% of NY Medicaid HMO DRG,12258,,225% x Medicaid HMO amount,12258,Other,225% of NY Medicaid HMO DRG,14982,,275% x Medicaid HMO amount,14982,Other,275% of NY Medicaid HMO DRG,17652,,324% x Medicaid HMO amount,17652,Other,324% of NY Medicaid HMO DRG,11713,,215% x Medicaid HMO amount,11713,Other,215% of NY Medicaid HMO DRG,11713,,215% x Medicaid HMO amount,11713,Other,215% of NY Medicaid HMO DRG,6810,,125% x Medicaid HMO amount,6810,Other,125% of NY Medicaid HMO DRG,0.01,26856,
Vaginal delivery w complicating procedures exc sterilization &/or D&C,542-2,APR-DRG,,,,,,,,inpatient,,,79363.09,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30606,,"45,128 x DRG weight",30606,Other,base rate x DRG weight,27545,,"40,615 x DRG weight",27545,Other,base rate x DRG weight,26015,,"38,359 x DRG weight",26015,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11335,,186% x Medicaid HMO amount,11335,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23111,,"34,077 x DRG weight",23111,Other,base rate x DRG weight,19645,,"28,966 x DRG weight",19645,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6094,,DRG base rate x DRG weight + capital per discharge,6094,Other,100% of NY Medicaid HMO DRG,6094,,100% x Medicaid HMO amount,6094,Other,100% of NY Medicaid HMO DRG,6094,,100% x Medicaid HMO amount,6094,Other,100% of NY Medicaid HMO DRG,6094,,100% x Medicaid HMO amount,6094,Other,100% of NY Medicaid HMO DRG,13712,,225% x Medicaid HMO amount,13712,Other,225% of NY Medicaid HMO DRG,13712,,225% x Medicaid HMO amount,13712,Other,225% of NY Medicaid HMO DRG,13712,,225% x Medicaid HMO amount,13712,Other,225% of NY Medicaid HMO DRG,13712,,225% x Medicaid HMO amount,13712,Other,225% of NY Medicaid HMO DRG,8532,,140% x Medicaid HMO amount,8532,Other,140% of NY Medicaid HMO DRG,13712,,225% x Medicaid HMO amount,13712,Other,225% of NY Medicaid HMO DRG,16759,,275% x Medicaid HMO amount,16759,Other,275% of NY Medicaid HMO DRG,19745,,324% x Medicaid HMO amount,19745,Other,324% of NY Medicaid HMO DRG,13102,,215% x Medicaid HMO amount,13102,Other,215% of NY Medicaid HMO DRG,13102,,215% x Medicaid HMO amount,13102,Other,215% of NY Medicaid HMO DRG,7618,,125% x Medicaid HMO amount,7618,Other,125% of NY Medicaid HMO DRG,0.01,30606,
Vaginal delivery w complicating procedures exc sterilization &/or D&C,542-3,APR-DRG,,,,,,,,inpatient,,,100826.77,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55128,,"45,128 x DRG weight",55128,Other,base rate x DRG weight,49615,,"40,615 x DRG weight",49615,Other,base rate x DRG weight,46859,,"38,359 x DRG weight",46859,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19195,,186% x Medicaid HMO amount,19195,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41628,,"34,077 x DRG weight",41628,Other,base rate x DRG weight,35385,,"28,966 x DRG weight",35385,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10320,,DRG base rate x DRG weight + capital per discharge,10320,Other,100% of NY Medicaid HMO DRG,10320,,100% x Medicaid HMO amount,10320,Other,100% of NY Medicaid HMO DRG,10320,,100% x Medicaid HMO amount,10320,Other,100% of NY Medicaid HMO DRG,10320,,100% x Medicaid HMO amount,10320,Other,100% of NY Medicaid HMO DRG,23220,,225% x Medicaid HMO amount,23220,Other,225% of NY Medicaid HMO DRG,23220,,225% x Medicaid HMO amount,23220,Other,225% of NY Medicaid HMO DRG,23220,,225% x Medicaid HMO amount,23220,Other,225% of NY Medicaid HMO DRG,23220,,225% x Medicaid HMO amount,23220,Other,225% of NY Medicaid HMO DRG,14448,,140% x Medicaid HMO amount,14448,Other,140% of NY Medicaid HMO DRG,23220,,225% x Medicaid HMO amount,23220,Other,225% of NY Medicaid HMO DRG,28380,,275% x Medicaid HMO amount,28380,Other,275% of NY Medicaid HMO DRG,33437,,324% x Medicaid HMO amount,33437,Other,324% of NY Medicaid HMO DRG,22188,,215% x Medicaid HMO amount,22188,Other,215% of NY Medicaid HMO DRG,22188,,215% x Medicaid HMO amount,22188,Other,215% of NY Medicaid HMO DRG,12900,,125% x Medicaid HMO amount,12900,Other,125% of NY Medicaid HMO DRG,0.01,55128,
Vaginal delivery w complicating procedures exc sterilization &/or D&C,542-4,APR-DRG,,,,,,,,inpatient,,,100826.77,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,69538,,"45,128 x DRG weight",69538,Other,base rate x DRG weight,62584,,"40,615 x DRG weight",62584,Other,base rate x DRG weight,59107,,"38,359 x DRG weight",59107,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23812,,186% x Medicaid HMO amount,23812,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52509,,"34,077 x DRG weight",52509,Other,base rate x DRG weight,44634,,"28,966 x DRG weight",44634,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12802,,DRG base rate x DRG weight + capital per discharge,12802,Other,100% of NY Medicaid HMO DRG,12802,,100% x Medicaid HMO amount,12802,Other,100% of NY Medicaid HMO DRG,12802,,100% x Medicaid HMO amount,12802,Other,100% of NY Medicaid HMO DRG,12802,,100% x Medicaid HMO amount,12802,Other,100% of NY Medicaid HMO DRG,28805,,225% x Medicaid HMO amount,28805,Other,225% of NY Medicaid HMO DRG,28805,,225% x Medicaid HMO amount,28805,Other,225% of NY Medicaid HMO DRG,28805,,225% x Medicaid HMO amount,28805,Other,225% of NY Medicaid HMO DRG,28805,,225% x Medicaid HMO amount,28805,Other,225% of NY Medicaid HMO DRG,17923,,140% x Medicaid HMO amount,17923,Other,140% of NY Medicaid HMO DRG,28805,,225% x Medicaid HMO amount,28805,Other,225% of NY Medicaid HMO DRG,35206,,275% x Medicaid HMO amount,35206,Other,275% of NY Medicaid HMO DRG,41478,,324% x Medicaid HMO amount,41478,Other,324% of NY Medicaid HMO DRG,27524,,215% x Medicaid HMO amount,27524,Other,215% of NY Medicaid HMO DRG,27524,,215% x Medicaid HMO amount,27524,Other,215% of NY Medicaid HMO DRG,16003,,125% x Medicaid HMO amount,16003,Other,125% of NY Medicaid HMO DRG,0.01,69538,
"D&C, aspiration curettage or hysterotomy for obstetric diagnoses",544-1,APR-DRG,,,,,,,,inpatient,,,84340.4,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21657,,"45,128 x DRG weight",21657,Other,base rate x DRG weight,19491,,"40,615 x DRG weight",19491,Other,base rate x DRG weight,18408,,"38,359 x DRG weight",18408,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8467,,186% x Medicaid HMO amount,8467,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16354,,"34,077 x DRG weight",16354,Other,base rate x DRG weight,13901,,"28,966 x DRG weight",13901,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4552,,DRG base rate x DRG weight + capital per discharge,4552,Other,100% of NY Medicaid HMO DRG,4552,,100% x Medicaid HMO amount,4552,Other,100% of NY Medicaid HMO DRG,4552,,100% x Medicaid HMO amount,4552,Other,100% of NY Medicaid HMO DRG,4552,,100% x Medicaid HMO amount,4552,Other,100% of NY Medicaid HMO DRG,10242,,225% x Medicaid HMO amount,10242,Other,225% of NY Medicaid HMO DRG,10242,,225% x Medicaid HMO amount,10242,Other,225% of NY Medicaid HMO DRG,10242,,225% x Medicaid HMO amount,10242,Other,225% of NY Medicaid HMO DRG,10242,,225% x Medicaid HMO amount,10242,Other,225% of NY Medicaid HMO DRG,6373,,140% x Medicaid HMO amount,6373,Other,140% of NY Medicaid HMO DRG,10242,,225% x Medicaid HMO amount,10242,Other,225% of NY Medicaid HMO DRG,12518,,275% x Medicaid HMO amount,12518,Other,275% of NY Medicaid HMO DRG,14748,,324% x Medicaid HMO amount,14748,Other,324% of NY Medicaid HMO DRG,9787,,215% x Medicaid HMO amount,9787,Other,215% of NY Medicaid HMO DRG,9787,,215% x Medicaid HMO amount,9787,Other,215% of NY Medicaid HMO DRG,5690,,125% x Medicaid HMO amount,5690,Other,125% of NY Medicaid HMO DRG,0.01,21657,
"D&C, aspiration curettage or hysterotomy for obstetric diagnoses",544-2,APR-DRG,,,,,,,,inpatient,,,121236.15,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27930,,"45,128 x DRG weight",27930,Other,base rate x DRG weight,25137,,"40,615 x DRG weight",25137,Other,base rate x DRG weight,23740,,"38,359 x DRG weight",23740,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10477,,186% x Medicaid HMO amount,10477,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21090,,"34,077 x DRG weight",21090,Other,base rate x DRG weight,17927,,"28,966 x DRG weight",17927,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5633,,DRG base rate x DRG weight + capital per discharge,5633,Other,100% of NY Medicaid HMO DRG,5633,,100% x Medicaid HMO amount,5633,Other,100% of NY Medicaid HMO DRG,5633,,100% x Medicaid HMO amount,5633,Other,100% of NY Medicaid HMO DRG,5633,,100% x Medicaid HMO amount,5633,Other,100% of NY Medicaid HMO DRG,12674,,225% x Medicaid HMO amount,12674,Other,225% of NY Medicaid HMO DRG,12674,,225% x Medicaid HMO amount,12674,Other,225% of NY Medicaid HMO DRG,12674,,225% x Medicaid HMO amount,12674,Other,225% of NY Medicaid HMO DRG,12674,,225% x Medicaid HMO amount,12674,Other,225% of NY Medicaid HMO DRG,7886,,140% x Medicaid HMO amount,7886,Other,140% of NY Medicaid HMO DRG,12674,,225% x Medicaid HMO amount,12674,Other,225% of NY Medicaid HMO DRG,15491,,275% x Medicaid HMO amount,15491,Other,275% of NY Medicaid HMO DRG,18251,,324% x Medicaid HMO amount,18251,Other,324% of NY Medicaid HMO DRG,12111,,215% x Medicaid HMO amount,12111,Other,215% of NY Medicaid HMO DRG,12111,,215% x Medicaid HMO amount,12111,Other,215% of NY Medicaid HMO DRG,7041,,125% x Medicaid HMO amount,7041,Other,125% of NY Medicaid HMO DRG,0.01,27930,
"D&C, aspiration curettage or hysterotomy for obstetric diagnoses",544-3,APR-DRG,,,,,,,,inpatient,,,160697,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49614,,"45,128 x DRG weight",49614,Other,base rate x DRG weight,44652,,"40,615 x DRG weight",44652,Other,base rate x DRG weight,42172,,"38,359 x DRG weight",42172,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17426,,186% x Medicaid HMO amount,17426,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37464,,"34,077 x DRG weight",37464,Other,base rate x DRG weight,31845,,"28,966 x DRG weight",31845,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9369,,DRG base rate x DRG weight + capital per discharge,9369,Other,100% of NY Medicaid HMO DRG,9369,,100% x Medicaid HMO amount,9369,Other,100% of NY Medicaid HMO DRG,9369,,100% x Medicaid HMO amount,9369,Other,100% of NY Medicaid HMO DRG,9369,,100% x Medicaid HMO amount,9369,Other,100% of NY Medicaid HMO DRG,21080,,225% x Medicaid HMO amount,21080,Other,225% of NY Medicaid HMO DRG,21080,,225% x Medicaid HMO amount,21080,Other,225% of NY Medicaid HMO DRG,21080,,225% x Medicaid HMO amount,21080,Other,225% of NY Medicaid HMO DRG,21080,,225% x Medicaid HMO amount,21080,Other,225% of NY Medicaid HMO DRG,13117,,140% x Medicaid HMO amount,13117,Other,140% of NY Medicaid HMO DRG,21080,,225% x Medicaid HMO amount,21080,Other,225% of NY Medicaid HMO DRG,25765,,275% x Medicaid HMO amount,25765,Other,275% of NY Medicaid HMO DRG,30356,,324% x Medicaid HMO amount,30356,Other,324% of NY Medicaid HMO DRG,20143,,215% x Medicaid HMO amount,20143,Other,215% of NY Medicaid HMO DRG,20143,,215% x Medicaid HMO amount,20143,Other,215% of NY Medicaid HMO DRG,11711,,125% x Medicaid HMO amount,11711,Other,125% of NY Medicaid HMO DRG,0.01,49614,
"D&C, aspiration curettage or hysterotomy for obstetric diagnoses",544-4,APR-DRG,,,,,,,,inpatient,,,160697,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,129544,,"45,128 x DRG weight",129544,Other,base rate x DRG weight,116589,,"40,615 x DRG weight",116589,Other,base rate x DRG weight,110113,,"38,359 x DRG weight",110113,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43044,,186% x Medicaid HMO amount,43044,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,97821,,"34,077 x DRG weight",97821,Other,base rate x DRG weight,83150,,"28,966 x DRG weight",83150,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23142,,DRG base rate x DRG weight + capital per discharge,23142,Other,100% of NY Medicaid HMO DRG,23142,,100% x Medicaid HMO amount,23142,Other,100% of NY Medicaid HMO DRG,23142,,100% x Medicaid HMO amount,23142,Other,100% of NY Medicaid HMO DRG,23142,,100% x Medicaid HMO amount,23142,Other,100% of NY Medicaid HMO DRG,52070,,225% x Medicaid HMO amount,52070,Other,225% of NY Medicaid HMO DRG,52070,,225% x Medicaid HMO amount,52070,Other,225% of NY Medicaid HMO DRG,52070,,225% x Medicaid HMO amount,52070,Other,225% of NY Medicaid HMO DRG,52070,,225% x Medicaid HMO amount,52070,Other,225% of NY Medicaid HMO DRG,32399,,140% x Medicaid HMO amount,32399,Other,140% of NY Medicaid HMO DRG,52070,,225% x Medicaid HMO amount,52070,Other,225% of NY Medicaid HMO DRG,63641,,275% x Medicaid HMO amount,63641,Other,275% of NY Medicaid HMO DRG,74980,,324% x Medicaid HMO amount,74980,Other,324% of NY Medicaid HMO DRG,49755,,215% x Medicaid HMO amount,49755,Other,215% of NY Medicaid HMO DRG,49755,,215% x Medicaid HMO amount,49755,Other,215% of NY Medicaid HMO DRG,28928,,125% x Medicaid HMO amount,28928,Other,125% of NY Medicaid HMO DRG,0.01,129544,
Ectopic pregnancy procedure,545-1,APR-DRG,,,,,,,,inpatient,,,169587.19,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31368,,"45,128 x DRG weight",31368,Other,base rate x DRG weight,28231,,"40,615 x DRG weight",28231,Other,base rate x DRG weight,26663,,"38,359 x DRG weight",26663,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11580,,186% x Medicaid HMO amount,11580,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23687,,"34,077 x DRG weight",23687,Other,base rate x DRG weight,20134,,"28,966 x DRG weight",20134,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6226,,DRG base rate x DRG weight + capital per discharge,6226,Other,100% of NY Medicaid HMO DRG,6226,,100% x Medicaid HMO amount,6226,Other,100% of NY Medicaid HMO DRG,6226,,100% x Medicaid HMO amount,6226,Other,100% of NY Medicaid HMO DRG,6226,,100% x Medicaid HMO amount,6226,Other,100% of NY Medicaid HMO DRG,14009,,225% x Medicaid HMO amount,14009,Other,225% of NY Medicaid HMO DRG,14009,,225% x Medicaid HMO amount,14009,Other,225% of NY Medicaid HMO DRG,14009,,225% x Medicaid HMO amount,14009,Other,225% of NY Medicaid HMO DRG,14009,,225% x Medicaid HMO amount,14009,Other,225% of NY Medicaid HMO DRG,8716,,140% x Medicaid HMO amount,8716,Other,140% of NY Medicaid HMO DRG,14009,,225% x Medicaid HMO amount,14009,Other,225% of NY Medicaid HMO DRG,17122,,275% x Medicaid HMO amount,17122,Other,275% of NY Medicaid HMO DRG,20172,,324% x Medicaid HMO amount,20172,Other,324% of NY Medicaid HMO DRG,13386,,215% x Medicaid HMO amount,13386,Other,215% of NY Medicaid HMO DRG,13386,,215% x Medicaid HMO amount,13386,Other,215% of NY Medicaid HMO DRG,7783,,125% x Medicaid HMO amount,7783,Other,125% of NY Medicaid HMO DRG,0.01,31368,
Ectopic pregnancy procedure,545-2,APR-DRG,,,,,,,,inpatient,,,85244.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35425,,"45,128 x DRG weight",35425,Other,base rate x DRG weight,31883,,"40,615 x DRG weight",31883,Other,base rate x DRG weight,30112,,"38,359 x DRG weight",30112,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12881,,186% x Medicaid HMO amount,12881,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26750,,"34,077 x DRG weight",26750,Other,base rate x DRG weight,22738,,"28,966 x DRG weight",22738,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6925,,DRG base rate x DRG weight + capital per discharge,6925,Other,100% of NY Medicaid HMO DRG,6925,,100% x Medicaid HMO amount,6925,Other,100% of NY Medicaid HMO DRG,6925,,100% x Medicaid HMO amount,6925,Other,100% of NY Medicaid HMO DRG,6925,,100% x Medicaid HMO amount,6925,Other,100% of NY Medicaid HMO DRG,15581,,225% x Medicaid HMO amount,15581,Other,225% of NY Medicaid HMO DRG,15581,,225% x Medicaid HMO amount,15581,Other,225% of NY Medicaid HMO DRG,15581,,225% x Medicaid HMO amount,15581,Other,225% of NY Medicaid HMO DRG,15581,,225% x Medicaid HMO amount,15581,Other,225% of NY Medicaid HMO DRG,9695,,140% x Medicaid HMO amount,9695,Other,140% of NY Medicaid HMO DRG,15581,,225% x Medicaid HMO amount,15581,Other,225% of NY Medicaid HMO DRG,19044,,275% x Medicaid HMO amount,19044,Other,275% of NY Medicaid HMO DRG,22437,,324% x Medicaid HMO amount,22437,Other,324% of NY Medicaid HMO DRG,14889,,215% x Medicaid HMO amount,14889,Other,215% of NY Medicaid HMO DRG,14889,,215% x Medicaid HMO amount,14889,Other,215% of NY Medicaid HMO DRG,8656,,125% x Medicaid HMO amount,8656,Other,125% of NY Medicaid HMO DRG,0.01,35425,
Ectopic pregnancy procedure,545-3,APR-DRG,,,,,,,,inpatient,,,128311.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49699,,"45,128 x DRG weight",49699,Other,base rate x DRG weight,44729,,"40,615 x DRG weight",44729,Other,base rate x DRG weight,42245,,"38,359 x DRG weight",42245,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17454,,186% x Medicaid HMO amount,17454,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37529,,"34,077 x DRG weight",37529,Other,base rate x DRG weight,31900,,"28,966 x DRG weight",31900,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9384,,DRG base rate x DRG weight + capital per discharge,9384,Other,100% of NY Medicaid HMO DRG,9384,,100% x Medicaid HMO amount,9384,Other,100% of NY Medicaid HMO DRG,9384,,100% x Medicaid HMO amount,9384,Other,100% of NY Medicaid HMO DRG,9384,,100% x Medicaid HMO amount,9384,Other,100% of NY Medicaid HMO DRG,21114,,225% x Medicaid HMO amount,21114,Other,225% of NY Medicaid HMO DRG,21114,,225% x Medicaid HMO amount,21114,Other,225% of NY Medicaid HMO DRG,21114,,225% x Medicaid HMO amount,21114,Other,225% of NY Medicaid HMO DRG,21114,,225% x Medicaid HMO amount,21114,Other,225% of NY Medicaid HMO DRG,13138,,140% x Medicaid HMO amount,13138,Other,140% of NY Medicaid HMO DRG,21114,,225% x Medicaid HMO amount,21114,Other,225% of NY Medicaid HMO DRG,25806,,275% x Medicaid HMO amount,25806,Other,275% of NY Medicaid HMO DRG,30404,,324% x Medicaid HMO amount,30404,Other,324% of NY Medicaid HMO DRG,20176,,215% x Medicaid HMO amount,20176,Other,215% of NY Medicaid HMO DRG,20176,,215% x Medicaid HMO amount,20176,Other,215% of NY Medicaid HMO DRG,11730,,125% x Medicaid HMO amount,11730,Other,125% of NY Medicaid HMO DRG,0.01,49699,
Ectopic pregnancy procedure,545-4,APR-DRG,,,,,,,,inpatient,,,128311.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53030,,"45,128 x DRG weight",53030,Other,base rate x DRG weight,47727,,"40,615 x DRG weight",47727,Other,base rate x DRG weight,45076,,"38,359 x DRG weight",45076,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18522,,186% x Medicaid HMO amount,18522,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40044,,"34,077 x DRG weight",40044,Other,base rate x DRG weight,34038,,"28,966 x DRG weight",34038,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9958,,DRG base rate x DRG weight + capital per discharge,9958,Other,100% of NY Medicaid HMO DRG,9958,,100% x Medicaid HMO amount,9958,Other,100% of NY Medicaid HMO DRG,9958,,100% x Medicaid HMO amount,9958,Other,100% of NY Medicaid HMO DRG,9958,,100% x Medicaid HMO amount,9958,Other,100% of NY Medicaid HMO DRG,22406,,225% x Medicaid HMO amount,22406,Other,225% of NY Medicaid HMO DRG,22406,,225% x Medicaid HMO amount,22406,Other,225% of NY Medicaid HMO DRG,22406,,225% x Medicaid HMO amount,22406,Other,225% of NY Medicaid HMO DRG,22406,,225% x Medicaid HMO amount,22406,Other,225% of NY Medicaid HMO DRG,13941,,140% x Medicaid HMO amount,13941,Other,140% of NY Medicaid HMO DRG,22406,,225% x Medicaid HMO amount,22406,Other,225% of NY Medicaid HMO DRG,27385,,275% x Medicaid HMO amount,27385,Other,275% of NY Medicaid HMO DRG,32264,,324% x Medicaid HMO amount,32264,Other,324% of NY Medicaid HMO DRG,21410,,215% x Medicaid HMO amount,21410,Other,215% of NY Medicaid HMO DRG,21410,,215% x Medicaid HMO amount,21410,Other,215% of NY Medicaid HMO DRG,12448,,125% x Medicaid HMO amount,12448,Other,125% of NY Medicaid HMO DRG,0.01,53030,
Other O.R. proc for obstetric diagnoses except delivery diagnoses,546-1,APR-DRG,,,,,,,,inpatient,,,68684.62,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25967,,"45,128 x DRG weight",25967,Other,base rate x DRG weight,23370,,"40,615 x DRG weight",23370,Other,base rate x DRG weight,22072,,"38,359 x DRG weight",22072,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9849,,186% x Medicaid HMO amount,9849,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19608,,"34,077 x DRG weight",19608,Other,base rate x DRG weight,16667,,"28,966 x DRG weight",16667,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5295,,DRG base rate x DRG weight + capital per discharge,5295,Other,100% of NY Medicaid HMO DRG,5295,,100% x Medicaid HMO amount,5295,Other,100% of NY Medicaid HMO DRG,5295,,100% x Medicaid HMO amount,5295,Other,100% of NY Medicaid HMO DRG,5295,,100% x Medicaid HMO amount,5295,Other,100% of NY Medicaid HMO DRG,11914,,225% x Medicaid HMO amount,11914,Other,225% of NY Medicaid HMO DRG,11914,,225% x Medicaid HMO amount,11914,Other,225% of NY Medicaid HMO DRG,11914,,225% x Medicaid HMO amount,11914,Other,225% of NY Medicaid HMO DRG,11914,,225% x Medicaid HMO amount,11914,Other,225% of NY Medicaid HMO DRG,7413,,140% x Medicaid HMO amount,7413,Other,140% of NY Medicaid HMO DRG,11914,,225% x Medicaid HMO amount,11914,Other,225% of NY Medicaid HMO DRG,14561,,275% x Medicaid HMO amount,14561,Other,275% of NY Medicaid HMO DRG,17156,,324% x Medicaid HMO amount,17156,Other,324% of NY Medicaid HMO DRG,11384,,215% x Medicaid HMO amount,11384,Other,215% of NY Medicaid HMO DRG,11384,,215% x Medicaid HMO amount,11384,Other,215% of NY Medicaid HMO DRG,6619,,125% x Medicaid HMO amount,6619,Other,125% of NY Medicaid HMO DRG,0.01,25967,
Other O.R. proc for obstetric diagnoses except delivery diagnoses,546-2,APR-DRG,,,,,,,,inpatient,,,85260.13,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35177,,"45,128 x DRG weight",35177,Other,base rate x DRG weight,31659,,"40,615 x DRG weight",31659,Other,base rate x DRG weight,29901,,"38,359 x DRG weight",29901,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12801,,186% x Medicaid HMO amount,12801,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26563,,"34,077 x DRG weight",26563,Other,base rate x DRG weight,22579,,"28,966 x DRG weight",22579,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6882,,DRG base rate x DRG weight + capital per discharge,6882,Other,100% of NY Medicaid HMO DRG,6882,,100% x Medicaid HMO amount,6882,Other,100% of NY Medicaid HMO DRG,6882,,100% x Medicaid HMO amount,6882,Other,100% of NY Medicaid HMO DRG,6882,,100% x Medicaid HMO amount,6882,Other,100% of NY Medicaid HMO DRG,15485,,225% x Medicaid HMO amount,15485,Other,225% of NY Medicaid HMO DRG,15485,,225% x Medicaid HMO amount,15485,Other,225% of NY Medicaid HMO DRG,15485,,225% x Medicaid HMO amount,15485,Other,225% of NY Medicaid HMO DRG,15485,,225% x Medicaid HMO amount,15485,Other,225% of NY Medicaid HMO DRG,9635,,140% x Medicaid HMO amount,9635,Other,140% of NY Medicaid HMO DRG,15485,,225% x Medicaid HMO amount,15485,Other,225% of NY Medicaid HMO DRG,18926,,275% x Medicaid HMO amount,18926,Other,275% of NY Medicaid HMO DRG,22298,,324% x Medicaid HMO amount,22298,Other,324% of NY Medicaid HMO DRG,14796,,215% x Medicaid HMO amount,14796,Other,215% of NY Medicaid HMO DRG,14796,,215% x Medicaid HMO amount,14796,Other,215% of NY Medicaid HMO DRG,8603,,125% x Medicaid HMO amount,8603,Other,125% of NY Medicaid HMO DRG,0.01,35177,
Other O.R. proc for obstetric diagnoses except delivery diagnoses,546-3,APR-DRG,,,,,,,,inpatient,,,144112.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,75540,,"45,128 x DRG weight",75540,Other,base rate x DRG weight,67985,,"40,615 x DRG weight",67985,Other,base rate x DRG weight,64209,,"38,359 x DRG weight",64209,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25735,,186% x Medicaid HMO amount,25735,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,57041,,"34,077 x DRG weight",57041,Other,base rate x DRG weight,48486,,"28,966 x DRG weight",48486,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13836,,DRG base rate x DRG weight + capital per discharge,13836,Other,100% of NY Medicaid HMO DRG,13836,,100% x Medicaid HMO amount,13836,Other,100% of NY Medicaid HMO DRG,13836,,100% x Medicaid HMO amount,13836,Other,100% of NY Medicaid HMO DRG,13836,,100% x Medicaid HMO amount,13836,Other,100% of NY Medicaid HMO DRG,31131,,225% x Medicaid HMO amount,31131,Other,225% of NY Medicaid HMO DRG,31131,,225% x Medicaid HMO amount,31131,Other,225% of NY Medicaid HMO DRG,31131,,225% x Medicaid HMO amount,31131,Other,225% of NY Medicaid HMO DRG,31131,,225% x Medicaid HMO amount,31131,Other,225% of NY Medicaid HMO DRG,19370,,140% x Medicaid HMO amount,19370,Other,140% of NY Medicaid HMO DRG,31131,,225% x Medicaid HMO amount,31131,Other,225% of NY Medicaid HMO DRG,38049,,275% x Medicaid HMO amount,38049,Other,275% of NY Medicaid HMO DRG,44829,,324% x Medicaid HMO amount,44829,Other,324% of NY Medicaid HMO DRG,29747,,215% x Medicaid HMO amount,29747,Other,215% of NY Medicaid HMO DRG,29747,,215% x Medicaid HMO amount,29747,Other,215% of NY Medicaid HMO DRG,17295,,125% x Medicaid HMO amount,17295,Other,125% of NY Medicaid HMO DRG,0.01,75540,
Other O.R. proc for obstetric diagnoses except delivery diagnoses,546-4,APR-DRG,,,,,,,,inpatient,,,144112.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,194398,,"45,128 x DRG weight",194398,Other,base rate x DRG weight,174957,,"40,615 x DRG weight",174957,Other,base rate x DRG weight,165239,,"38,359 x DRG weight",165239,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,63828,,186% x Medicaid HMO amount,63828,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,146793,,"34,077 x DRG weight",146793,Other,base rate x DRG weight,124777,,"28,966 x DRG weight",124777,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34316,,DRG base rate x DRG weight + capital per discharge,34316,Other,100% of NY Medicaid HMO DRG,34316,,100% x Medicaid HMO amount,34316,Other,100% of NY Medicaid HMO DRG,34316,,100% x Medicaid HMO amount,34316,Other,100% of NY Medicaid HMO DRG,34316,,100% x Medicaid HMO amount,34316,Other,100% of NY Medicaid HMO DRG,77211,,225% x Medicaid HMO amount,77211,Other,225% of NY Medicaid HMO DRG,77211,,225% x Medicaid HMO amount,77211,Other,225% of NY Medicaid HMO DRG,77211,,225% x Medicaid HMO amount,77211,Other,225% of NY Medicaid HMO DRG,77211,,225% x Medicaid HMO amount,77211,Other,225% of NY Medicaid HMO DRG,48042,,140% x Medicaid HMO amount,48042,Other,140% of NY Medicaid HMO DRG,77211,,225% x Medicaid HMO amount,77211,Other,225% of NY Medicaid HMO DRG,94369,,275% x Medicaid HMO amount,94369,Other,275% of NY Medicaid HMO DRG,111184,,324% x Medicaid HMO amount,111184,Other,324% of NY Medicaid HMO DRG,73779,,215% x Medicaid HMO amount,73779,Other,215% of NY Medicaid HMO DRG,73779,,215% x Medicaid HMO amount,73779,Other,215% of NY Medicaid HMO DRG,42895,,125% x Medicaid HMO amount,42895,Other,125% of NY Medicaid HMO DRG,0.01,194398,
Vaginal delivery,560-1,APR-DRG,,,,,,,,inpatient,,,66519.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23895,,"45,128 x DRG weight",23895,Other,base rate x DRG weight,21506,,"40,615 x DRG weight",21506,Other,base rate x DRG weight,20311,,"38,359 x DRG weight",20311,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9185,,186% x Medicaid HMO amount,9185,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18044,,"34,077 x DRG weight",18044,Other,base rate x DRG weight,15337,,"28,966 x DRG weight",15337,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4938,,DRG base rate x DRG weight + capital per discharge,4938,Other,100% of NY Medicaid HMO DRG,4938,,100% x Medicaid HMO amount,4938,Other,100% of NY Medicaid HMO DRG,4938,,100% x Medicaid HMO amount,4938,Other,100% of NY Medicaid HMO DRG,4938,,100% x Medicaid HMO amount,4938,Other,100% of NY Medicaid HMO DRG,11111,,225% x Medicaid HMO amount,11111,Other,225% of NY Medicaid HMO DRG,11111,,225% x Medicaid HMO amount,11111,Other,225% of NY Medicaid HMO DRG,11111,,225% x Medicaid HMO amount,11111,Other,225% of NY Medicaid HMO DRG,11111,,225% x Medicaid HMO amount,11111,Other,225% of NY Medicaid HMO DRG,6913,,140% x Medicaid HMO amount,6913,Other,140% of NY Medicaid HMO DRG,11111,,225% x Medicaid HMO amount,11111,Other,225% of NY Medicaid HMO DRG,13580,,275% x Medicaid HMO amount,13580,Other,275% of NY Medicaid HMO DRG,15999,,324% x Medicaid HMO amount,15999,Other,324% of NY Medicaid HMO DRG,10617,,215% x Medicaid HMO amount,10617,Other,215% of NY Medicaid HMO DRG,10617,,215% x Medicaid HMO amount,10617,Other,215% of NY Medicaid HMO DRG,6173,,125% x Medicaid HMO amount,6173,Other,125% of NY Medicaid HMO DRG,0.01,23895,
Vaginal delivery,560-2,APR-DRG,,,,,,,,inpatient,,,75829.33,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26409,,"45,128 x DRG weight",26409,Other,base rate x DRG weight,23768,,"40,615 x DRG weight",23768,Other,base rate x DRG weight,22448,,"38,359 x DRG weight",22448,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9990,,186% x Medicaid HMO amount,9990,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19942,,"34,077 x DRG weight",19942,Other,base rate x DRG weight,16951,,"28,966 x DRG weight",16951,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5371,,DRG base rate x DRG weight + capital per discharge,5371,Other,100% of NY Medicaid HMO DRG,5371,,100% x Medicaid HMO amount,5371,Other,100% of NY Medicaid HMO DRG,5371,,100% x Medicaid HMO amount,5371,Other,100% of NY Medicaid HMO DRG,5371,,100% x Medicaid HMO amount,5371,Other,100% of NY Medicaid HMO DRG,12085,,225% x Medicaid HMO amount,12085,Other,225% of NY Medicaid HMO DRG,12085,,225% x Medicaid HMO amount,12085,Other,225% of NY Medicaid HMO DRG,12085,,225% x Medicaid HMO amount,12085,Other,225% of NY Medicaid HMO DRG,12085,,225% x Medicaid HMO amount,12085,Other,225% of NY Medicaid HMO DRG,7519,,140% x Medicaid HMO amount,7519,Other,140% of NY Medicaid HMO DRG,12085,,225% x Medicaid HMO amount,12085,Other,225% of NY Medicaid HMO DRG,14770,,275% x Medicaid HMO amount,14770,Other,275% of NY Medicaid HMO DRG,17402,,324% x Medicaid HMO amount,17402,Other,324% of NY Medicaid HMO DRG,11548,,215% x Medicaid HMO amount,11548,Other,215% of NY Medicaid HMO DRG,11548,,215% x Medicaid HMO amount,11548,Other,215% of NY Medicaid HMO DRG,6714,,125% x Medicaid HMO amount,6714,Other,125% of NY Medicaid HMO DRG,0.01,26409,
Vaginal delivery,560-3,APR-DRG,,,,,,,,inpatient,,,118877.66,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32781,,"45,128 x DRG weight",32781,Other,base rate x DRG weight,29503,,"40,615 x DRG weight",29503,Other,base rate x DRG weight,27864,,"38,359 x DRG weight",27864,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12032,,186% x Medicaid HMO amount,12032,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24754,,"34,077 x DRG weight",24754,Other,base rate x DRG weight,21041,,"28,966 x DRG weight",21041,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6469,,DRG base rate x DRG weight + capital per discharge,6469,Other,100% of NY Medicaid HMO DRG,6469,,100% x Medicaid HMO amount,6469,Other,100% of NY Medicaid HMO DRG,6469,,100% x Medicaid HMO amount,6469,Other,100% of NY Medicaid HMO DRG,6469,,100% x Medicaid HMO amount,6469,Other,100% of NY Medicaid HMO DRG,14555,,225% x Medicaid HMO amount,14555,Other,225% of NY Medicaid HMO DRG,14555,,225% x Medicaid HMO amount,14555,Other,225% of NY Medicaid HMO DRG,14555,,225% x Medicaid HMO amount,14555,Other,225% of NY Medicaid HMO DRG,14555,,225% x Medicaid HMO amount,14555,Other,225% of NY Medicaid HMO DRG,9057,,140% x Medicaid HMO amount,9057,Other,140% of NY Medicaid HMO DRG,14555,,225% x Medicaid HMO amount,14555,Other,225% of NY Medicaid HMO DRG,17790,,275% x Medicaid HMO amount,17790,Other,275% of NY Medicaid HMO DRG,20960,,324% x Medicaid HMO amount,20960,Other,324% of NY Medicaid HMO DRG,13908,,215% x Medicaid HMO amount,13908,Other,215% of NY Medicaid HMO DRG,13908,,215% x Medicaid HMO amount,13908,Other,215% of NY Medicaid HMO DRG,8086,,125% x Medicaid HMO amount,8086,Other,125% of NY Medicaid HMO DRG,0.01,32781,
Vaginal delivery,560-4,APR-DRG,,,,,,,,inpatient,,,366963.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,76564,,"45,128 x DRG weight",76564,Other,base rate x DRG weight,68907,,"40,615 x DRG weight",68907,Other,base rate x DRG weight,65080,,"38,359 x DRG weight",65080,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26064,,186% x Medicaid HMO amount,26064,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,57815,,"34,077 x DRG weight",57815,Other,base rate x DRG weight,49144,,"28,966 x DRG weight",49144,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14013,,DRG base rate x DRG weight + capital per discharge,14013,Other,100% of NY Medicaid HMO DRG,14013,,100% x Medicaid HMO amount,14013,Other,100% of NY Medicaid HMO DRG,14013,,100% x Medicaid HMO amount,14013,Other,100% of NY Medicaid HMO DRG,14013,,100% x Medicaid HMO amount,14013,Other,100% of NY Medicaid HMO DRG,31529,,225% x Medicaid HMO amount,31529,Other,225% of NY Medicaid HMO DRG,31529,,225% x Medicaid HMO amount,31529,Other,225% of NY Medicaid HMO DRG,31529,,225% x Medicaid HMO amount,31529,Other,225% of NY Medicaid HMO DRG,31529,,225% x Medicaid HMO amount,31529,Other,225% of NY Medicaid HMO DRG,19618,,140% x Medicaid HMO amount,19618,Other,140% of NY Medicaid HMO DRG,31529,,225% x Medicaid HMO amount,31529,Other,225% of NY Medicaid HMO DRG,38536,,275% x Medicaid HMO amount,38536,Other,275% of NY Medicaid HMO DRG,45402,,324% x Medicaid HMO amount,45402,Other,324% of NY Medicaid HMO DRG,30128,,215% x Medicaid HMO amount,30128,Other,215% of NY Medicaid HMO DRG,30128,,215% x Medicaid HMO amount,30128,Other,215% of NY Medicaid HMO DRG,17516,,125% x Medicaid HMO amount,17516,Other,125% of NY Medicaid HMO DRG,0.01,76564,
Postpartum & post abortion diagnoses w/o procedure,561-1,APR-DRG,,,,,,,,inpatient,,,55444.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17104,,"45,128 x DRG weight",17104,Other,base rate x DRG weight,15393,,"40,615 x DRG weight",15393,Other,base rate x DRG weight,14538,,"38,359 x DRG weight",14538,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7008,,186% x Medicaid HMO amount,7008,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12915,,"34,077 x DRG weight",12915,Other,base rate x DRG weight,10978,,"28,966 x DRG weight",10978,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3768,,DRG base rate x DRG weight + capital per discharge,3768,Other,100% of NY Medicaid HMO DRG,3768,,100% x Medicaid HMO amount,3768,Other,100% of NY Medicaid HMO DRG,3768,,100% x Medicaid HMO amount,3768,Other,100% of NY Medicaid HMO DRG,3768,,100% x Medicaid HMO amount,3768,Other,100% of NY Medicaid HMO DRG,8478,,225% x Medicaid HMO amount,8478,Other,225% of NY Medicaid HMO DRG,8478,,225% x Medicaid HMO amount,8478,Other,225% of NY Medicaid HMO DRG,8478,,225% x Medicaid HMO amount,8478,Other,225% of NY Medicaid HMO DRG,8478,,225% x Medicaid HMO amount,8478,Other,225% of NY Medicaid HMO DRG,5275,,140% x Medicaid HMO amount,5275,Other,140% of NY Medicaid HMO DRG,8478,,225% x Medicaid HMO amount,8478,Other,225% of NY Medicaid HMO DRG,10362,,275% x Medicaid HMO amount,10362,Other,275% of NY Medicaid HMO DRG,12208,,324% x Medicaid HMO amount,12208,Other,324% of NY Medicaid HMO DRG,8101,,215% x Medicaid HMO amount,8101,Other,215% of NY Medicaid HMO DRG,8101,,215% x Medicaid HMO amount,8101,Other,215% of NY Medicaid HMO DRG,4710,,125% x Medicaid HMO amount,4710,Other,125% of NY Medicaid HMO DRG,0.01,17104,
Postpartum & post abortion diagnoses w/o procedure,561-2,APR-DRG,,,,,,,,inpatient,,,74019.48,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20244,,"45,128 x DRG weight",20244,Other,base rate x DRG weight,18220,,"40,615 x DRG weight",18220,Other,base rate x DRG weight,17208,,"38,359 x DRG weight",17208,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8015,,186% x Medicaid HMO amount,8015,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15287,,"34,077 x DRG weight",15287,Other,base rate x DRG weight,12994,,"28,966 x DRG weight",12994,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4309,,DRG base rate x DRG weight + capital per discharge,4309,Other,100% of NY Medicaid HMO DRG,4309,,100% x Medicaid HMO amount,4309,Other,100% of NY Medicaid HMO DRG,4309,,100% x Medicaid HMO amount,4309,Other,100% of NY Medicaid HMO DRG,4309,,100% x Medicaid HMO amount,4309,Other,100% of NY Medicaid HMO DRG,9695,,225% x Medicaid HMO amount,9695,Other,225% of NY Medicaid HMO DRG,9695,,225% x Medicaid HMO amount,9695,Other,225% of NY Medicaid HMO DRG,9695,,225% x Medicaid HMO amount,9695,Other,225% of NY Medicaid HMO DRG,9695,,225% x Medicaid HMO amount,9695,Other,225% of NY Medicaid HMO DRG,6033,,140% x Medicaid HMO amount,6033,Other,140% of NY Medicaid HMO DRG,9695,,225% x Medicaid HMO amount,9695,Other,225% of NY Medicaid HMO DRG,11850,,275% x Medicaid HMO amount,11850,Other,275% of NY Medicaid HMO DRG,13961,,324% x Medicaid HMO amount,13961,Other,324% of NY Medicaid HMO DRG,9264,,215% x Medicaid HMO amount,9264,Other,215% of NY Medicaid HMO DRG,9264,,215% x Medicaid HMO amount,9264,Other,215% of NY Medicaid HMO DRG,5386,,125% x Medicaid HMO amount,5386,Other,125% of NY Medicaid HMO DRG,0.01,20244,
Postpartum & post abortion diagnoses w/o procedure,561-3,APR-DRG,,,,,,,,inpatient,,,86038.74,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30403,,"45,128 x DRG weight",30403,Other,base rate x DRG weight,27362,,"40,615 x DRG weight",27362,Other,base rate x DRG weight,25842,,"38,359 x DRG weight",25842,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11270,,186% x Medicaid HMO amount,11270,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22958,,"34,077 x DRG weight",22958,Other,base rate x DRG weight,19514,,"28,966 x DRG weight",19514,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6059,,DRG base rate x DRG weight + capital per discharge,6059,Other,100% of NY Medicaid HMO DRG,6059,,100% x Medicaid HMO amount,6059,Other,100% of NY Medicaid HMO DRG,6059,,100% x Medicaid HMO amount,6059,Other,100% of NY Medicaid HMO DRG,6059,,100% x Medicaid HMO amount,6059,Other,100% of NY Medicaid HMO DRG,13633,,225% x Medicaid HMO amount,13633,Other,225% of NY Medicaid HMO DRG,13633,,225% x Medicaid HMO amount,13633,Other,225% of NY Medicaid HMO DRG,13633,,225% x Medicaid HMO amount,13633,Other,225% of NY Medicaid HMO DRG,13633,,225% x Medicaid HMO amount,13633,Other,225% of NY Medicaid HMO DRG,8483,,140% x Medicaid HMO amount,8483,Other,140% of NY Medicaid HMO DRG,13633,,225% x Medicaid HMO amount,13633,Other,225% of NY Medicaid HMO DRG,16662,,275% x Medicaid HMO amount,16662,Other,275% of NY Medicaid HMO DRG,19631,,324% x Medicaid HMO amount,19631,Other,324% of NY Medicaid HMO DRG,13027,,215% x Medicaid HMO amount,13027,Other,215% of NY Medicaid HMO DRG,13027,,215% x Medicaid HMO amount,13027,Other,215% of NY Medicaid HMO DRG,7574,,125% x Medicaid HMO amount,7574,Other,125% of NY Medicaid HMO DRG,0.01,30403,
Postpartum & post abortion diagnoses w/o procedure,561-4,APR-DRG,,,,,,,,inpatient,,,86038.74,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,65788,,"45,128 x DRG weight",65788,Other,base rate x DRG weight,59209,,"40,615 x DRG weight",59209,Other,base rate x DRG weight,55920,,"38,359 x DRG weight",55920,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22610,,186% x Medicaid HMO amount,22610,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49677,,"34,077 x DRG weight",49677,Other,base rate x DRG weight,42227,,"28,966 x DRG weight",42227,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12156,,DRG base rate x DRG weight + capital per discharge,12156,Other,100% of NY Medicaid HMO DRG,12156,,100% x Medicaid HMO amount,12156,Other,100% of NY Medicaid HMO DRG,12156,,100% x Medicaid HMO amount,12156,Other,100% of NY Medicaid HMO DRG,12156,,100% x Medicaid HMO amount,12156,Other,100% of NY Medicaid HMO DRG,27351,,225% x Medicaid HMO amount,27351,Other,225% of NY Medicaid HMO DRG,27351,,225% x Medicaid HMO amount,27351,Other,225% of NY Medicaid HMO DRG,27351,,225% x Medicaid HMO amount,27351,Other,225% of NY Medicaid HMO DRG,27351,,225% x Medicaid HMO amount,27351,Other,225% of NY Medicaid HMO DRG,17018,,140% x Medicaid HMO amount,17018,Other,140% of NY Medicaid HMO DRG,27351,,225% x Medicaid HMO amount,27351,Other,225% of NY Medicaid HMO DRG,33429,,275% x Medicaid HMO amount,33429,Other,275% of NY Medicaid HMO DRG,39385,,324% x Medicaid HMO amount,39385,Other,324% of NY Medicaid HMO DRG,26135,,215% x Medicaid HMO amount,26135,Other,215% of NY Medicaid HMO DRG,26135,,215% x Medicaid HMO amount,26135,Other,215% of NY Medicaid HMO DRG,15195,,125% x Medicaid HMO amount,15195,Other,125% of NY Medicaid HMO DRG,0.01,65788,
Preterm labor,563-1,APR-DRG,,,,,,,,inpatient,,,59757.84,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15705,,"45,128 x DRG weight",15705,Other,base rate x DRG weight,14134,,"40,615 x DRG weight",14134,Other,base rate x DRG weight,13349,,"38,359 x DRG weight",13349,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6560,,186% x Medicaid HMO amount,6560,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11859,,"34,077 x DRG weight",11859,Other,base rate x DRG weight,10080,,"28,966 x DRG weight",10080,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3527,,DRG base rate x DRG weight + capital per discharge,3527,Other,100% of NY Medicaid HMO DRG,3527,,100% x Medicaid HMO amount,3527,Other,100% of NY Medicaid HMO DRG,3527,,100% x Medicaid HMO amount,3527,Other,100% of NY Medicaid HMO DRG,3527,,100% x Medicaid HMO amount,3527,Other,100% of NY Medicaid HMO DRG,7936,,225% x Medicaid HMO amount,7936,Other,225% of NY Medicaid HMO DRG,7936,,225% x Medicaid HMO amount,7936,Other,225% of NY Medicaid HMO DRG,7936,,225% x Medicaid HMO amount,7936,Other,225% of NY Medicaid HMO DRG,7936,,225% x Medicaid HMO amount,7936,Other,225% of NY Medicaid HMO DRG,4938,,140% x Medicaid HMO amount,4938,Other,140% of NY Medicaid HMO DRG,7936,,225% x Medicaid HMO amount,7936,Other,225% of NY Medicaid HMO DRG,9699,,275% x Medicaid HMO amount,9699,Other,275% of NY Medicaid HMO DRG,11427,,324% x Medicaid HMO amount,11427,Other,324% of NY Medicaid HMO DRG,7583,,215% x Medicaid HMO amount,7583,Other,215% of NY Medicaid HMO DRG,7583,,215% x Medicaid HMO amount,7583,Other,215% of NY Medicaid HMO DRG,4409,,125% x Medicaid HMO amount,4409,Other,125% of NY Medicaid HMO DRG,0.01,15705,
Preterm labor,563-2,APR-DRG,,,,,,,,inpatient,,,62096.28,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18900,,"45,128 x DRG weight",18900,Other,base rate x DRG weight,17010,,"40,615 x DRG weight",17010,Other,base rate x DRG weight,16065,,"38,359 x DRG weight",16065,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7583,,186% x Medicaid HMO amount,7583,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14271,,"34,077 x DRG weight",14271,Other,base rate x DRG weight,12131,,"28,966 x DRG weight",12131,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4077,,DRG base rate x DRG weight + capital per discharge,4077,Other,100% of NY Medicaid HMO DRG,4077,,100% x Medicaid HMO amount,4077,Other,100% of NY Medicaid HMO DRG,4077,,100% x Medicaid HMO amount,4077,Other,100% of NY Medicaid HMO DRG,4077,,100% x Medicaid HMO amount,4077,Other,100% of NY Medicaid HMO DRG,9173,,225% x Medicaid HMO amount,9173,Other,225% of NY Medicaid HMO DRG,9173,,225% x Medicaid HMO amount,9173,Other,225% of NY Medicaid HMO DRG,9173,,225% x Medicaid HMO amount,9173,Other,225% of NY Medicaid HMO DRG,9173,,225% x Medicaid HMO amount,9173,Other,225% of NY Medicaid HMO DRG,5708,,140% x Medicaid HMO amount,5708,Other,140% of NY Medicaid HMO DRG,9173,,225% x Medicaid HMO amount,9173,Other,225% of NY Medicaid HMO DRG,11212,,275% x Medicaid HMO amount,11212,Other,275% of NY Medicaid HMO DRG,13209,,324% x Medicaid HMO amount,13209,Other,324% of NY Medicaid HMO DRG,8766,,215% x Medicaid HMO amount,8766,Other,215% of NY Medicaid HMO DRG,8766,,215% x Medicaid HMO amount,8766,Other,215% of NY Medicaid HMO DRG,5096,,125% x Medicaid HMO amount,5096,Other,125% of NY Medicaid HMO DRG,0.01,18900,
Preterm labor,563-3,APR-DRG,,,,,,,,inpatient,,,46332.08,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26833,,"45,128 x DRG weight",26833,Other,base rate x DRG weight,24150,,"40,615 x DRG weight",24150,Other,base rate x DRG weight,22808,,"38,359 x DRG weight",22808,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10126,,186% x Medicaid HMO amount,10126,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20262,,"34,077 x DRG weight",20262,Other,base rate x DRG weight,17223,,"28,966 x DRG weight",17223,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5444,,DRG base rate x DRG weight + capital per discharge,5444,Other,100% of NY Medicaid HMO DRG,5444,,100% x Medicaid HMO amount,5444,Other,100% of NY Medicaid HMO DRG,5444,,100% x Medicaid HMO amount,5444,Other,100% of NY Medicaid HMO DRG,5444,,100% x Medicaid HMO amount,5444,Other,100% of NY Medicaid HMO DRG,12249,,225% x Medicaid HMO amount,12249,Other,225% of NY Medicaid HMO DRG,12249,,225% x Medicaid HMO amount,12249,Other,225% of NY Medicaid HMO DRG,12249,,225% x Medicaid HMO amount,12249,Other,225% of NY Medicaid HMO DRG,12249,,225% x Medicaid HMO amount,12249,Other,225% of NY Medicaid HMO DRG,7622,,140% x Medicaid HMO amount,7622,Other,140% of NY Medicaid HMO DRG,12249,,225% x Medicaid HMO amount,12249,Other,225% of NY Medicaid HMO DRG,14971,,275% x Medicaid HMO amount,14971,Other,275% of NY Medicaid HMO DRG,17639,,324% x Medicaid HMO amount,17639,Other,324% of NY Medicaid HMO DRG,11705,,215% x Medicaid HMO amount,11705,Other,215% of NY Medicaid HMO DRG,11705,,215% x Medicaid HMO amount,11705,Other,215% of NY Medicaid HMO DRG,6805,,125% x Medicaid HMO amount,6805,Other,125% of NY Medicaid HMO DRG,0.01,26833,
Preterm labor,563-4,APR-DRG,,,,,,,,inpatient,,,62096.28,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26833,,"45,128 x DRG weight",26833,Other,base rate x DRG weight,24150,,"40,615 x DRG weight",24150,Other,base rate x DRG weight,22808,,"38,359 x DRG weight",22808,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10126,,186% x Medicaid HMO amount,10126,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20262,,"34,077 x DRG weight",20262,Other,base rate x DRG weight,17223,,"28,966 x DRG weight",17223,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5444,,DRG base rate x DRG weight + capital per discharge,5444,Other,100% of NY Medicaid HMO DRG,5444,,100% x Medicaid HMO amount,5444,Other,100% of NY Medicaid HMO DRG,5444,,100% x Medicaid HMO amount,5444,Other,100% of NY Medicaid HMO DRG,5444,,100% x Medicaid HMO amount,5444,Other,100% of NY Medicaid HMO DRG,12249,,225% x Medicaid HMO amount,12249,Other,225% of NY Medicaid HMO DRG,12249,,225% x Medicaid HMO amount,12249,Other,225% of NY Medicaid HMO DRG,12249,,225% x Medicaid HMO amount,12249,Other,225% of NY Medicaid HMO DRG,12249,,225% x Medicaid HMO amount,12249,Other,225% of NY Medicaid HMO DRG,7622,,140% x Medicaid HMO amount,7622,Other,140% of NY Medicaid HMO DRG,12249,,225% x Medicaid HMO amount,12249,Other,225% of NY Medicaid HMO DRG,14971,,275% x Medicaid HMO amount,14971,Other,275% of NY Medicaid HMO DRG,17639,,324% x Medicaid HMO amount,17639,Other,324% of NY Medicaid HMO DRG,11705,,215% x Medicaid HMO amount,11705,Other,215% of NY Medicaid HMO DRG,11705,,215% x Medicaid HMO amount,11705,Other,215% of NY Medicaid HMO DRG,6805,,125% x Medicaid HMO amount,6805,Other,125% of NY Medicaid HMO DRG,0.01,26833,
"Abortion w/o D&C, aspiration curettage or hysterotomy",564-1,APR-DRG,,,,,,,,inpatient,,,39420,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16467,,"45,128 x DRG weight",16467,Other,base rate x DRG weight,14820,,"40,615 x DRG weight",14820,Other,base rate x DRG weight,13997,,"38,359 x DRG weight",13997,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6804,,186% x Medicaid HMO amount,6804,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12435,,"34,077 x DRG weight",12435,Other,base rate x DRG weight,10570,,"28,966 x DRG weight",10570,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3658,,DRG base rate x DRG weight + capital per discharge,3658,Other,100% of NY Medicaid HMO DRG,3658,,100% x Medicaid HMO amount,3658,Other,100% of NY Medicaid HMO DRG,3658,,100% x Medicaid HMO amount,3658,Other,100% of NY Medicaid HMO DRG,3658,,100% x Medicaid HMO amount,3658,Other,100% of NY Medicaid HMO DRG,8231,,225% x Medicaid HMO amount,8231,Other,225% of NY Medicaid HMO DRG,8231,,225% x Medicaid HMO amount,8231,Other,225% of NY Medicaid HMO DRG,8231,,225% x Medicaid HMO amount,8231,Other,225% of NY Medicaid HMO DRG,8231,,225% x Medicaid HMO amount,8231,Other,225% of NY Medicaid HMO DRG,5121,,140% x Medicaid HMO amount,5121,Other,140% of NY Medicaid HMO DRG,8231,,225% x Medicaid HMO amount,8231,Other,225% of NY Medicaid HMO DRG,10060,,275% x Medicaid HMO amount,10060,Other,275% of NY Medicaid HMO DRG,11852,,324% x Medicaid HMO amount,11852,Other,324% of NY Medicaid HMO DRG,7865,,215% x Medicaid HMO amount,7865,Other,215% of NY Medicaid HMO DRG,7865,,215% x Medicaid HMO amount,7865,Other,215% of NY Medicaid HMO DRG,4573,,125% x Medicaid HMO amount,4573,Other,125% of NY Medicaid HMO DRG,0.01,16467,
"Abortion w/o D&C, aspiration curettage or hysterotomy",564-2,APR-DRG,,,,,,,,inpatient,,,49448.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19058,,"45,128 x DRG weight",19058,Other,base rate x DRG weight,17152,,"40,615 x DRG weight",17152,Other,base rate x DRG weight,16199,,"38,359 x DRG weight",16199,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7635,,186% x Medicaid HMO amount,7635,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14391,,"34,077 x DRG weight",14391,Other,base rate x DRG weight,12232,,"28,966 x DRG weight",12232,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4105,,DRG base rate x DRG weight + capital per discharge,4105,Other,100% of NY Medicaid HMO DRG,4105,,100% x Medicaid HMO amount,4105,Other,100% of NY Medicaid HMO DRG,4105,,100% x Medicaid HMO amount,4105,Other,100% of NY Medicaid HMO DRG,4105,,100% x Medicaid HMO amount,4105,Other,100% of NY Medicaid HMO DRG,9236,,225% x Medicaid HMO amount,9236,Other,225% of NY Medicaid HMO DRG,9236,,225% x Medicaid HMO amount,9236,Other,225% of NY Medicaid HMO DRG,9236,,225% x Medicaid HMO amount,9236,Other,225% of NY Medicaid HMO DRG,9236,,225% x Medicaid HMO amount,9236,Other,225% of NY Medicaid HMO DRG,5747,,140% x Medicaid HMO amount,5747,Other,140% of NY Medicaid HMO DRG,9236,,225% x Medicaid HMO amount,9236,Other,225% of NY Medicaid HMO DRG,11289,,275% x Medicaid HMO amount,11289,Other,275% of NY Medicaid HMO DRG,13300,,324% x Medicaid HMO amount,13300,Other,324% of NY Medicaid HMO DRG,8826,,215% x Medicaid HMO amount,8826,Other,215% of NY Medicaid HMO DRG,8826,,215% x Medicaid HMO amount,8826,Other,215% of NY Medicaid HMO DRG,5131,,125% x Medicaid HMO amount,5131,Other,125% of NY Medicaid HMO DRG,0.01,19058,
"Abortion w/o D&C, aspiration curettage or hysterotomy",564-3,APR-DRG,,,,,,,,inpatient,,,90792.44,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27230,,"45,128 x DRG weight",27230,Other,base rate x DRG weight,24507,,"40,615 x DRG weight",24507,Other,base rate x DRG weight,23146,,"38,359 x DRG weight",23146,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10254,,186% x Medicaid HMO amount,10254,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20562,,"34,077 x DRG weight",20562,Other,base rate x DRG weight,17478,,"28,966 x DRG weight",17478,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5513,,DRG base rate x DRG weight + capital per discharge,5513,Other,100% of NY Medicaid HMO DRG,5513,,100% x Medicaid HMO amount,5513,Other,100% of NY Medicaid HMO DRG,5513,,100% x Medicaid HMO amount,5513,Other,100% of NY Medicaid HMO DRG,5513,,100% x Medicaid HMO amount,5513,Other,100% of NY Medicaid HMO DRG,12404,,225% x Medicaid HMO amount,12404,Other,225% of NY Medicaid HMO DRG,12404,,225% x Medicaid HMO amount,12404,Other,225% of NY Medicaid HMO DRG,12404,,225% x Medicaid HMO amount,12404,Other,225% of NY Medicaid HMO DRG,12404,,225% x Medicaid HMO amount,12404,Other,225% of NY Medicaid HMO DRG,7718,,140% x Medicaid HMO amount,7718,Other,140% of NY Medicaid HMO DRG,12404,,225% x Medicaid HMO amount,12404,Other,225% of NY Medicaid HMO DRG,15161,,275% x Medicaid HMO amount,15161,Other,275% of NY Medicaid HMO DRG,17862,,324% x Medicaid HMO amount,17862,Other,324% of NY Medicaid HMO DRG,11853,,215% x Medicaid HMO amount,11853,Other,215% of NY Medicaid HMO DRG,11853,,215% x Medicaid HMO amount,11853,Other,215% of NY Medicaid HMO DRG,6891,,125% x Medicaid HMO amount,6891,Other,125% of NY Medicaid HMO DRG,0.01,27230,
"Abortion w/o D&C, aspiration curettage or hysterotomy",564-4,APR-DRG,,,,,,,,inpatient,,,90792.44,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32731,,"45,128 x DRG weight",32731,Other,base rate x DRG weight,29458,,"40,615 x DRG weight",29458,Other,base rate x DRG weight,27822,,"38,359 x DRG weight",27822,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12017,,186% x Medicaid HMO amount,12017,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24716,,"34,077 x DRG weight",24716,Other,base rate x DRG weight,21009,,"28,966 x DRG weight",21009,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6461,,DRG base rate x DRG weight + capital per discharge,6461,Other,100% of NY Medicaid HMO DRG,6461,,100% x Medicaid HMO amount,6461,Other,100% of NY Medicaid HMO DRG,6461,,100% x Medicaid HMO amount,6461,Other,100% of NY Medicaid HMO DRG,6461,,100% x Medicaid HMO amount,6461,Other,100% of NY Medicaid HMO DRG,14537,,225% x Medicaid HMO amount,14537,Other,225% of NY Medicaid HMO DRG,14537,,225% x Medicaid HMO amount,14537,Other,225% of NY Medicaid HMO DRG,14537,,225% x Medicaid HMO amount,14537,Other,225% of NY Medicaid HMO DRG,14537,,225% x Medicaid HMO amount,14537,Other,225% of NY Medicaid HMO DRG,9045,,140% x Medicaid HMO amount,9045,Other,140% of NY Medicaid HMO DRG,14537,,225% x Medicaid HMO amount,14537,Other,225% of NY Medicaid HMO DRG,17768,,275% x Medicaid HMO amount,17768,Other,275% of NY Medicaid HMO DRG,20934,,324% x Medicaid HMO amount,20934,Other,324% of NY Medicaid HMO DRG,13891,,215% x Medicaid HMO amount,13891,Other,215% of NY Medicaid HMO DRG,13891,,215% x Medicaid HMO amount,13891,Other,215% of NY Medicaid HMO DRG,8076,,125% x Medicaid HMO amount,8076,Other,125% of NY Medicaid HMO DRG,0.01,32731,
False labor,565-1,APR-DRG,,,,,,,,inpatient,,,25446,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10271,,"45,128 x DRG weight",10271,Other,base rate x DRG weight,9244,,"40,615 x DRG weight",9244,Other,base rate x DRG weight,8731,,"38,359 x DRG weight",8731,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4819,,186% x Medicaid HMO amount,4819,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7756,,"34,077 x DRG weight",7756,Other,base rate x DRG weight,6593,,"28,966 x DRG weight",6593,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,2591,,DRG base rate x DRG weight + capital per discharge,2591,Other,100% of NY Medicaid HMO DRG,2591,,100% x Medicaid HMO amount,2591,Other,100% of NY Medicaid HMO DRG,2591,,100% x Medicaid HMO amount,2591,Other,100% of NY Medicaid HMO DRG,2591,,100% x Medicaid HMO amount,2591,Other,100% of NY Medicaid HMO DRG,5830,,225% x Medicaid HMO amount,5830,Other,225% of NY Medicaid HMO DRG,5830,,225% x Medicaid HMO amount,5830,Other,225% of NY Medicaid HMO DRG,5830,,225% x Medicaid HMO amount,5830,Other,225% of NY Medicaid HMO DRG,5830,,225% x Medicaid HMO amount,5830,Other,225% of NY Medicaid HMO DRG,3627,,140% x Medicaid HMO amount,3627,Other,140% of NY Medicaid HMO DRG,5830,,225% x Medicaid HMO amount,5830,Other,225% of NY Medicaid HMO DRG,7125,,275% x Medicaid HMO amount,7125,Other,275% of NY Medicaid HMO DRG,8395,,324% x Medicaid HMO amount,8395,Other,324% of NY Medicaid HMO DRG,5571,,215% x Medicaid HMO amount,5571,Other,215% of NY Medicaid HMO DRG,5571,,215% x Medicaid HMO amount,5571,Other,215% of NY Medicaid HMO DRG,3239,,125% x Medicaid HMO amount,3239,Other,125% of NY Medicaid HMO DRG,0.01,10271,
False labor,565-2,APR-DRG,,,,,,,,inpatient,,,27853.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12744,,"45,128 x DRG weight",12744,Other,base rate x DRG weight,11470,,"40,615 x DRG weight",11470,Other,base rate x DRG weight,10833,,"38,359 x DRG weight",10833,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5612,,186% x Medicaid HMO amount,5612,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9623,,"34,077 x DRG weight",9623,Other,base rate x DRG weight,8180,,"28,966 x DRG weight",8180,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3017,,DRG base rate x DRG weight + capital per discharge,3017,Other,100% of NY Medicaid HMO DRG,3017,,100% x Medicaid HMO amount,3017,Other,100% of NY Medicaid HMO DRG,3017,,100% x Medicaid HMO amount,3017,Other,100% of NY Medicaid HMO DRG,3017,,100% x Medicaid HMO amount,3017,Other,100% of NY Medicaid HMO DRG,6788,,225% x Medicaid HMO amount,6788,Other,225% of NY Medicaid HMO DRG,6788,,225% x Medicaid HMO amount,6788,Other,225% of NY Medicaid HMO DRG,6788,,225% x Medicaid HMO amount,6788,Other,225% of NY Medicaid HMO DRG,6788,,225% x Medicaid HMO amount,6788,Other,225% of NY Medicaid HMO DRG,4224,,140% x Medicaid HMO amount,4224,Other,140% of NY Medicaid HMO DRG,6788,,225% x Medicaid HMO amount,6788,Other,225% of NY Medicaid HMO DRG,8297,,275% x Medicaid HMO amount,8297,Other,275% of NY Medicaid HMO DRG,9775,,324% x Medicaid HMO amount,9775,Other,324% of NY Medicaid HMO DRG,6487,,215% x Medicaid HMO amount,6487,Other,215% of NY Medicaid HMO DRG,6487,,215% x Medicaid HMO amount,6487,Other,215% of NY Medicaid HMO DRG,3771,,125% x Medicaid HMO amount,3771,Other,125% of NY Medicaid HMO DRG,0.01,12744,
False labor,565-3,APR-DRG,,,,,,,,inpatient,,,126573.8,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12970,,"45,128 x DRG weight",12970,Other,base rate x DRG weight,11673,,"40,615 x DRG weight",11673,Other,base rate x DRG weight,11024,,"38,359 x DRG weight",11024,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5684,,186% x Medicaid HMO amount,5684,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9794,,"34,077 x DRG weight",9794,Other,base rate x DRG weight,8325,,"28,966 x DRG weight",8325,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3056,,DRG base rate x DRG weight + capital per discharge,3056,Other,100% of NY Medicaid HMO DRG,3056,,100% x Medicaid HMO amount,3056,Other,100% of NY Medicaid HMO DRG,3056,,100% x Medicaid HMO amount,3056,Other,100% of NY Medicaid HMO DRG,3056,,100% x Medicaid HMO amount,3056,Other,100% of NY Medicaid HMO DRG,6876,,225% x Medicaid HMO amount,6876,Other,225% of NY Medicaid HMO DRG,6876,,225% x Medicaid HMO amount,6876,Other,225% of NY Medicaid HMO DRG,6876,,225% x Medicaid HMO amount,6876,Other,225% of NY Medicaid HMO DRG,6876,,225% x Medicaid HMO amount,6876,Other,225% of NY Medicaid HMO DRG,4278,,140% x Medicaid HMO amount,4278,Other,140% of NY Medicaid HMO DRG,6876,,225% x Medicaid HMO amount,6876,Other,225% of NY Medicaid HMO DRG,8404,,275% x Medicaid HMO amount,8404,Other,275% of NY Medicaid HMO DRG,9901,,324% x Medicaid HMO amount,9901,Other,324% of NY Medicaid HMO DRG,6570,,215% x Medicaid HMO amount,6570,Other,215% of NY Medicaid HMO DRG,6570,,215% x Medicaid HMO amount,6570,Other,215% of NY Medicaid HMO DRG,3820,,125% x Medicaid HMO amount,3820,Other,125% of NY Medicaid HMO DRG,0.01,12970,
False labor,565-4,APR-DRG,,,,,,,,inpatient,,,126573.8,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12970,,"45,128 x DRG weight",12970,Other,base rate x DRG weight,11673,,"40,615 x DRG weight",11673,Other,base rate x DRG weight,11024,,"38,359 x DRG weight",11024,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5684,,186% x Medicaid HMO amount,5684,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9794,,"34,077 x DRG weight",9794,Other,base rate x DRG weight,8325,,"28,966 x DRG weight",8325,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3056,,DRG base rate x DRG weight + capital per discharge,3056,Other,100% of NY Medicaid HMO DRG,3056,,100% x Medicaid HMO amount,3056,Other,100% of NY Medicaid HMO DRG,3056,,100% x Medicaid HMO amount,3056,Other,100% of NY Medicaid HMO DRG,3056,,100% x Medicaid HMO amount,3056,Other,100% of NY Medicaid HMO DRG,6876,,225% x Medicaid HMO amount,6876,Other,225% of NY Medicaid HMO DRG,6876,,225% x Medicaid HMO amount,6876,Other,225% of NY Medicaid HMO DRG,6876,,225% x Medicaid HMO amount,6876,Other,225% of NY Medicaid HMO DRG,6876,,225% x Medicaid HMO amount,6876,Other,225% of NY Medicaid HMO DRG,4278,,140% x Medicaid HMO amount,4278,Other,140% of NY Medicaid HMO DRG,6876,,225% x Medicaid HMO amount,6876,Other,225% of NY Medicaid HMO DRG,8404,,275% x Medicaid HMO amount,8404,Other,275% of NY Medicaid HMO DRG,9901,,324% x Medicaid HMO amount,9901,Other,324% of NY Medicaid HMO DRG,6570,,215% x Medicaid HMO amount,6570,Other,215% of NY Medicaid HMO DRG,6570,,215% x Medicaid HMO amount,6570,Other,215% of NY Medicaid HMO DRG,3820,,125% x Medicaid HMO amount,3820,Other,125% of NY Medicaid HMO DRG,0.01,12970,
Other antepartum diagnoses,566-1,APR-DRG,,,,,,,,inpatient,,,53309.78,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15375,,"45,128 x DRG weight",15375,Other,base rate x DRG weight,13838,,"40,615 x DRG weight",13838,Other,base rate x DRG weight,13069,,"38,359 x DRG weight",13069,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6454,,186% x Medicaid HMO amount,6454,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11610,,"34,077 x DRG weight",11610,Other,base rate x DRG weight,9869,,"28,966 x DRG weight",9869,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3470,,DRG base rate x DRG weight + capital per discharge,3470,Other,100% of NY Medicaid HMO DRG,3470,,100% x Medicaid HMO amount,3470,Other,100% of NY Medicaid HMO DRG,3470,,100% x Medicaid HMO amount,3470,Other,100% of NY Medicaid HMO DRG,3470,,100% x Medicaid HMO amount,3470,Other,100% of NY Medicaid HMO DRG,7808,,225% x Medicaid HMO amount,7808,Other,225% of NY Medicaid HMO DRG,7808,,225% x Medicaid HMO amount,7808,Other,225% of NY Medicaid HMO DRG,7808,,225% x Medicaid HMO amount,7808,Other,225% of NY Medicaid HMO DRG,7808,,225% x Medicaid HMO amount,7808,Other,225% of NY Medicaid HMO DRG,4858,,140% x Medicaid HMO amount,4858,Other,140% of NY Medicaid HMO DRG,7808,,225% x Medicaid HMO amount,7808,Other,225% of NY Medicaid HMO DRG,9543,,275% x Medicaid HMO amount,9543,Other,275% of NY Medicaid HMO DRG,11243,,324% x Medicaid HMO amount,11243,Other,324% of NY Medicaid HMO DRG,7461,,215% x Medicaid HMO amount,7461,Other,215% of NY Medicaid HMO DRG,7461,,215% x Medicaid HMO amount,7461,Other,215% of NY Medicaid HMO DRG,4338,,125% x Medicaid HMO amount,4338,Other,125% of NY Medicaid HMO DRG,0.01,15375,
Other antepartum diagnoses,566-2,APR-DRG,,,,,,,,inpatient,,,93972.09,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20123,,"45,128 x DRG weight",20123,Other,base rate x DRG weight,18110,,"40,615 x DRG weight",18110,Other,base rate x DRG weight,17104,,"38,359 x DRG weight",17104,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7976,,186% x Medicaid HMO amount,7976,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15195,,"34,077 x DRG weight",15195,Other,base rate x DRG weight,12916,,"28,966 x DRG weight",12916,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4288,,DRG base rate x DRG weight + capital per discharge,4288,Other,100% of NY Medicaid HMO DRG,4288,,100% x Medicaid HMO amount,4288,Other,100% of NY Medicaid HMO DRG,4288,,100% x Medicaid HMO amount,4288,Other,100% of NY Medicaid HMO DRG,4288,,100% x Medicaid HMO amount,4288,Other,100% of NY Medicaid HMO DRG,9648,,225% x Medicaid HMO amount,9648,Other,225% of NY Medicaid HMO DRG,9648,,225% x Medicaid HMO amount,9648,Other,225% of NY Medicaid HMO DRG,9648,,225% x Medicaid HMO amount,9648,Other,225% of NY Medicaid HMO DRG,9648,,225% x Medicaid HMO amount,9648,Other,225% of NY Medicaid HMO DRG,6003,,140% x Medicaid HMO amount,6003,Other,140% of NY Medicaid HMO DRG,9648,,225% x Medicaid HMO amount,9648,Other,225% of NY Medicaid HMO DRG,11792,,275% x Medicaid HMO amount,11792,Other,275% of NY Medicaid HMO DRG,13893,,324% x Medicaid HMO amount,13893,Other,324% of NY Medicaid HMO DRG,9219,,215% x Medicaid HMO amount,9219,Other,215% of NY Medicaid HMO DRG,9219,,215% x Medicaid HMO amount,9219,Other,215% of NY Medicaid HMO DRG,5360,,125% x Medicaid HMO amount,5360,Other,125% of NY Medicaid HMO DRG,0.01,20123,
Other antepartum diagnoses,566-3,APR-DRG,,,,,,,,inpatient,,,124232.33,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29608,,"45,128 x DRG weight",29608,Other,base rate x DRG weight,26648,,"40,615 x DRG weight",26648,Other,base rate x DRG weight,25167,,"38,359 x DRG weight",25167,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11015,,186% x Medicaid HMO amount,11015,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22358,,"34,077 x DRG weight",22358,Other,base rate x DRG weight,19005,,"28,966 x DRG weight",19005,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5922,,DRG base rate x DRG weight + capital per discharge,5922,Other,100% of NY Medicaid HMO DRG,5922,,100% x Medicaid HMO amount,5922,Other,100% of NY Medicaid HMO DRG,5922,,100% x Medicaid HMO amount,5922,Other,100% of NY Medicaid HMO DRG,5922,,100% x Medicaid HMO amount,5922,Other,100% of NY Medicaid HMO DRG,13325,,225% x Medicaid HMO amount,13325,Other,225% of NY Medicaid HMO DRG,13325,,225% x Medicaid HMO amount,13325,Other,225% of NY Medicaid HMO DRG,13325,,225% x Medicaid HMO amount,13325,Other,225% of NY Medicaid HMO DRG,13325,,225% x Medicaid HMO amount,13325,Other,225% of NY Medicaid HMO DRG,8291,,140% x Medicaid HMO amount,8291,Other,140% of NY Medicaid HMO DRG,13325,,225% x Medicaid HMO amount,13325,Other,225% of NY Medicaid HMO DRG,16286,,275% x Medicaid HMO amount,16286,Other,275% of NY Medicaid HMO DRG,19187,,324% x Medicaid HMO amount,19187,Other,324% of NY Medicaid HMO DRG,12732,,215% x Medicaid HMO amount,12732,Other,215% of NY Medicaid HMO DRG,12732,,215% x Medicaid HMO amount,12732,Other,215% of NY Medicaid HMO DRG,7403,,125% x Medicaid HMO amount,7403,Other,125% of NY Medicaid HMO DRG,0.01,29608,
Other antepartum diagnoses,566-4,APR-DRG,,,,,,,,inpatient,,,114510.91,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,61455,,"45,128 x DRG weight",61455,Other,base rate x DRG weight,55310,,"40,615 x DRG weight",55310,Other,base rate x DRG weight,52237,,"38,359 x DRG weight",52237,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21223,,186% x Medicaid HMO amount,21223,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46406,,"34,077 x DRG weight",46406,Other,base rate x DRG weight,39446,,"28,966 x DRG weight",39446,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11410,,DRG base rate x DRG weight + capital per discharge,11410,Other,100% of NY Medicaid HMO DRG,11410,,100% x Medicaid HMO amount,11410,Other,100% of NY Medicaid HMO DRG,11410,,100% x Medicaid HMO amount,11410,Other,100% of NY Medicaid HMO DRG,11410,,100% x Medicaid HMO amount,11410,Other,100% of NY Medicaid HMO DRG,25673,,225% x Medicaid HMO amount,25673,Other,225% of NY Medicaid HMO DRG,25673,,225% x Medicaid HMO amount,25673,Other,225% of NY Medicaid HMO DRG,25673,,225% x Medicaid HMO amount,25673,Other,225% of NY Medicaid HMO DRG,25673,,225% x Medicaid HMO amount,25673,Other,225% of NY Medicaid HMO DRG,15974,,140% x Medicaid HMO amount,15974,Other,140% of NY Medicaid HMO DRG,25673,,225% x Medicaid HMO amount,25673,Other,225% of NY Medicaid HMO DRG,31378,,275% x Medicaid HMO amount,31378,Other,275% of NY Medicaid HMO DRG,36968,,324% x Medicaid HMO amount,36968,Other,324% of NY Medicaid HMO DRG,24532,,215% x Medicaid HMO amount,24532,Other,215% of NY Medicaid HMO DRG,24532,,215% x Medicaid HMO amount,24532,Other,215% of NY Medicaid HMO DRG,14263,,125% x Medicaid HMO amount,14263,Other,125% of NY Medicaid HMO DRG,0.01,61455,
"Neonate, transferred <5 days old, not born here",580-1,APR-DRG,,,,,,,,inpatient,,,16942.33,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13760,,"45,128 x DRG weight",13760,Other,base rate x DRG weight,12384,,"40,615 x DRG weight",12384,Other,base rate x DRG weight,11696,,"38,359 x DRG weight",11696,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5937,,186% x Medicaid HMO amount,5937,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10390,,"34,077 x DRG weight",10390,Other,base rate x DRG weight,8832,,"28,966 x DRG weight",8832,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3192,,DRG base rate x DRG weight + capital per discharge,3192,Other,100% of NY Medicaid HMO DRG,3192,,100% x Medicaid HMO amount,3192,Other,100% of NY Medicaid HMO DRG,3192,,100% x Medicaid HMO amount,3192,Other,100% of NY Medicaid HMO DRG,3192,,100% x Medicaid HMO amount,3192,Other,100% of NY Medicaid HMO DRG,7182,,225% x Medicaid HMO amount,7182,Other,225% of NY Medicaid HMO DRG,7182,,225% x Medicaid HMO amount,7182,Other,225% of NY Medicaid HMO DRG,7182,,225% x Medicaid HMO amount,7182,Other,225% of NY Medicaid HMO DRG,7182,,225% x Medicaid HMO amount,7182,Other,225% of NY Medicaid HMO DRG,4469,,140% x Medicaid HMO amount,4469,Other,140% of NY Medicaid HMO DRG,7182,,225% x Medicaid HMO amount,7182,Other,225% of NY Medicaid HMO DRG,8778,,275% x Medicaid HMO amount,8778,Other,275% of NY Medicaid HMO DRG,10342,,324% x Medicaid HMO amount,10342,Other,324% of NY Medicaid HMO DRG,6863,,215% x Medicaid HMO amount,6863,Other,215% of NY Medicaid HMO DRG,6863,,215% x Medicaid HMO amount,6863,Other,215% of NY Medicaid HMO DRG,3990,,125% x Medicaid HMO amount,3990,Other,125% of NY Medicaid HMO DRG,0.01,13760,
"Neonate, transferred <5 days old, not born here",580-2,APR-DRG,,,,,,,,inpatient,,,70194.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17419,,"45,128 x DRG weight",17419,Other,base rate x DRG weight,15677,,"40,615 x DRG weight",15677,Other,base rate x DRG weight,14807,,"38,359 x DRG weight",14807,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7109,,186% x Medicaid HMO amount,7109,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13154,,"34,077 x DRG weight",13154,Other,base rate x DRG weight,11181,,"28,966 x DRG weight",11181,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3822,,DRG base rate x DRG weight + capital per discharge,3822,Other,100% of NY Medicaid HMO DRG,3822,,100% x Medicaid HMO amount,3822,Other,100% of NY Medicaid HMO DRG,3822,,100% x Medicaid HMO amount,3822,Other,100% of NY Medicaid HMO DRG,3822,,100% x Medicaid HMO amount,3822,Other,100% of NY Medicaid HMO DRG,8600,,225% x Medicaid HMO amount,8600,Other,225% of NY Medicaid HMO DRG,8600,,225% x Medicaid HMO amount,8600,Other,225% of NY Medicaid HMO DRG,8600,,225% x Medicaid HMO amount,8600,Other,225% of NY Medicaid HMO DRG,8600,,225% x Medicaid HMO amount,8600,Other,225% of NY Medicaid HMO DRG,5351,,140% x Medicaid HMO amount,5351,Other,140% of NY Medicaid HMO DRG,8600,,225% x Medicaid HMO amount,8600,Other,225% of NY Medicaid HMO DRG,10511,,275% x Medicaid HMO amount,10511,Other,275% of NY Medicaid HMO DRG,12383,,324% x Medicaid HMO amount,12383,Other,324% of NY Medicaid HMO DRG,8217,,215% x Medicaid HMO amount,8217,Other,215% of NY Medicaid HMO DRG,8217,,215% x Medicaid HMO amount,8217,Other,215% of NY Medicaid HMO DRG,4778,,125% x Medicaid HMO amount,4778,Other,125% of NY Medicaid HMO DRG,0.01,17419,
"Neonate, transferred <5 days old, not born here",580-3,APR-DRG,,,,,,,,inpatient,,,161498.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24450,,"45,128 x DRG weight",24450,Other,base rate x DRG weight,22005,,"40,615 x DRG weight",22005,Other,base rate x DRG weight,20783,,"38,359 x DRG weight",20783,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9363,,186% x Medicaid HMO amount,9363,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18463,,"34,077 x DRG weight",18463,Other,base rate x DRG weight,15694,,"28,966 x DRG weight",15694,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5034,,DRG base rate x DRG weight + capital per discharge,5034,Other,100% of NY Medicaid HMO DRG,5034,,100% x Medicaid HMO amount,5034,Other,100% of NY Medicaid HMO DRG,5034,,100% x Medicaid HMO amount,5034,Other,100% of NY Medicaid HMO DRG,5034,,100% x Medicaid HMO amount,5034,Other,100% of NY Medicaid HMO DRG,11327,,225% x Medicaid HMO amount,11327,Other,225% of NY Medicaid HMO DRG,11327,,225% x Medicaid HMO amount,11327,Other,225% of NY Medicaid HMO DRG,11327,,225% x Medicaid HMO amount,11327,Other,225% of NY Medicaid HMO DRG,11327,,225% x Medicaid HMO amount,11327,Other,225% of NY Medicaid HMO DRG,7048,,140% x Medicaid HMO amount,7048,Other,140% of NY Medicaid HMO DRG,11327,,225% x Medicaid HMO amount,11327,Other,225% of NY Medicaid HMO DRG,13844,,275% x Medicaid HMO amount,13844,Other,275% of NY Medicaid HMO DRG,16310,,324% x Medicaid HMO amount,16310,Other,324% of NY Medicaid HMO DRG,10823,,215% x Medicaid HMO amount,10823,Other,215% of NY Medicaid HMO DRG,10823,,215% x Medicaid HMO amount,10823,Other,215% of NY Medicaid HMO DRG,6293,,125% x Medicaid HMO amount,6293,Other,125% of NY Medicaid HMO DRG,0.01,24450,
"Neonate, transferred <5 days old, not born here",580-4,APR-DRG,,,,,,,,inpatient,,,161498.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50236,,"45,128 x DRG weight",50236,Other,base rate x DRG weight,45213,,"40,615 x DRG weight",45213,Other,base rate x DRG weight,42701,,"38,359 x DRG weight",42701,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17627,,186% x Medicaid HMO amount,17627,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37935,,"34,077 x DRG weight",37935,Other,base rate x DRG weight,32245,,"28,966 x DRG weight",32245,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9477,,DRG base rate x DRG weight + capital per discharge,9477,Other,100% of NY Medicaid HMO DRG,9477,,100% x Medicaid HMO amount,9477,Other,100% of NY Medicaid HMO DRG,9477,,100% x Medicaid HMO amount,9477,Other,100% of NY Medicaid HMO DRG,9477,,100% x Medicaid HMO amount,9477,Other,100% of NY Medicaid HMO DRG,21323,,225% x Medicaid HMO amount,21323,Other,225% of NY Medicaid HMO DRG,21323,,225% x Medicaid HMO amount,21323,Other,225% of NY Medicaid HMO DRG,21323,,225% x Medicaid HMO amount,21323,Other,225% of NY Medicaid HMO DRG,21323,,225% x Medicaid HMO amount,21323,Other,225% of NY Medicaid HMO DRG,13268,,140% x Medicaid HMO amount,13268,Other,140% of NY Medicaid HMO DRG,21323,,225% x Medicaid HMO amount,21323,Other,225% of NY Medicaid HMO DRG,26062,,275% x Medicaid HMO amount,26062,Other,275% of NY Medicaid HMO DRG,30705,,324% x Medicaid HMO amount,30705,Other,324% of NY Medicaid HMO DRG,20376,,215% x Medicaid HMO amount,20376,Other,215% of NY Medicaid HMO DRG,20376,,215% x Medicaid HMO amount,20376,Other,215% of NY Medicaid HMO DRG,11846,,125% x Medicaid HMO amount,11846,Other,125% of NY Medicaid HMO DRG,0.01,50236,
"Neonate, transferred < 5 days old, born here",581-1,APR-DRG,,,,,,,,inpatient,,,22137.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6160,,"45,128 x DRG weight",6160,Other,base rate x DRG weight,5544,,"40,615 x DRG weight",5544,Other,base rate x DRG weight,5236,,"38,359 x DRG weight",5236,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3501,,186% x Medicaid HMO amount,3501,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4652,,"34,077 x DRG weight",4652,Other,base rate x DRG weight,3954,,"28,966 x DRG weight",3954,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,1882,,DRG base rate x DRG weight + capital per discharge,1882,Other,100% of NY Medicaid HMO DRG,1882,,100% x Medicaid HMO amount,1882,Other,100% of NY Medicaid HMO DRG,1882,,100% x Medicaid HMO amount,1882,Other,100% of NY Medicaid HMO DRG,1882,,100% x Medicaid HMO amount,1882,Other,100% of NY Medicaid HMO DRG,4235,,225% x Medicaid HMO amount,4235,Other,225% of NY Medicaid HMO DRG,4235,,225% x Medicaid HMO amount,4235,Other,225% of NY Medicaid HMO DRG,4235,,225% x Medicaid HMO amount,4235,Other,225% of NY Medicaid HMO DRG,4235,,225% x Medicaid HMO amount,4235,Other,225% of NY Medicaid HMO DRG,2635,,140% x Medicaid HMO amount,2635,Other,140% of NY Medicaid HMO DRG,4235,,225% x Medicaid HMO amount,4235,Other,225% of NY Medicaid HMO DRG,5176,,275% x Medicaid HMO amount,5176,Other,275% of NY Medicaid HMO DRG,6098,,324% x Medicaid HMO amount,6098,Other,324% of NY Medicaid HMO DRG,4046,,215% x Medicaid HMO amount,4046,Other,215% of NY Medicaid HMO DRG,4046,,215% x Medicaid HMO amount,4046,Other,215% of NY Medicaid HMO DRG,2353,,125% x Medicaid HMO amount,2353,Other,125% of NY Medicaid HMO DRG,0.01,6160,
"Neonate, transferred < 5 days old, born here",581-2,APR-DRG,,,,,,,,inpatient,,,37661,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8385,,"45,128 x DRG weight",8385,Other,base rate x DRG weight,7546,,"40,615 x DRG weight",7546,Other,base rate x DRG weight,7127,,"38,359 x DRG weight",7127,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4215,,186% x Medicaid HMO amount,4215,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6332,,"34,077 x DRG weight",6332,Other,base rate x DRG weight,5382,,"28,966 x DRG weight",5382,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,2266,,DRG base rate x DRG weight + capital per discharge,2266,Other,100% of NY Medicaid HMO DRG,2266,,100% x Medicaid HMO amount,2266,Other,100% of NY Medicaid HMO DRG,2266,,100% x Medicaid HMO amount,2266,Other,100% of NY Medicaid HMO DRG,2266,,100% x Medicaid HMO amount,2266,Other,100% of NY Medicaid HMO DRG,5099,,225% x Medicaid HMO amount,5099,Other,225% of NY Medicaid HMO DRG,5099,,225% x Medicaid HMO amount,5099,Other,225% of NY Medicaid HMO DRG,5099,,225% x Medicaid HMO amount,5099,Other,225% of NY Medicaid HMO DRG,5099,,225% x Medicaid HMO amount,5099,Other,225% of NY Medicaid HMO DRG,3172,,140% x Medicaid HMO amount,3172,Other,140% of NY Medicaid HMO DRG,5099,,225% x Medicaid HMO amount,5099,Other,225% of NY Medicaid HMO DRG,6232,,275% x Medicaid HMO amount,6232,Other,275% of NY Medicaid HMO DRG,7342,,324% x Medicaid HMO amount,7342,Other,324% of NY Medicaid HMO DRG,4872,,215% x Medicaid HMO amount,4872,Other,215% of NY Medicaid HMO DRG,4872,,215% x Medicaid HMO amount,4872,Other,215% of NY Medicaid HMO DRG,2833,,125% x Medicaid HMO amount,2833,Other,125% of NY Medicaid HMO DRG,0.01,8385,
"Neonate, transferred < 5 days old, born here",581-3,APR-DRG,,,,,,,,inpatient,,,130270.39,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12365,,"45,128 x DRG weight",12365,Other,base rate x DRG weight,11129,,"40,615 x DRG weight",11129,Other,base rate x DRG weight,10510,,"38,359 x DRG weight",10510,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5489,,186% x Medicaid HMO amount,5489,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9337,,"34,077 x DRG weight",9337,Other,base rate x DRG weight,7937,,"28,966 x DRG weight",7937,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,2951,,DRG base rate x DRG weight + capital per discharge,2951,Other,100% of NY Medicaid HMO DRG,2951,,100% x Medicaid HMO amount,2951,Other,100% of NY Medicaid HMO DRG,2951,,100% x Medicaid HMO amount,2951,Other,100% of NY Medicaid HMO DRG,2951,,100% x Medicaid HMO amount,2951,Other,100% of NY Medicaid HMO DRG,6640,,225% x Medicaid HMO amount,6640,Other,225% of NY Medicaid HMO DRG,6640,,225% x Medicaid HMO amount,6640,Other,225% of NY Medicaid HMO DRG,6640,,225% x Medicaid HMO amount,6640,Other,225% of NY Medicaid HMO DRG,6640,,225% x Medicaid HMO amount,6640,Other,225% of NY Medicaid HMO DRG,4131,,140% x Medicaid HMO amount,4131,Other,140% of NY Medicaid HMO DRG,6640,,225% x Medicaid HMO amount,6640,Other,225% of NY Medicaid HMO DRG,8115,,275% x Medicaid HMO amount,8115,Other,275% of NY Medicaid HMO DRG,9561,,324% x Medicaid HMO amount,9561,Other,324% of NY Medicaid HMO DRG,6345,,215% x Medicaid HMO amount,6345,Other,215% of NY Medicaid HMO DRG,6345,,215% x Medicaid HMO amount,6345,Other,215% of NY Medicaid HMO DRG,3689,,125% x Medicaid HMO amount,3689,Other,125% of NY Medicaid HMO DRG,0.01,12365,
"Neonate, transferred < 5 days old, born here",581-4,APR-DRG,,,,,,,,inpatient,,,130270.39,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22320,,"45,128 x DRG weight",22320,Other,base rate x DRG weight,20088,,"40,615 x DRG weight",20088,Other,base rate x DRG weight,18972,,"38,359 x DRG weight",18972,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8681,,186% x Medicaid HMO amount,8681,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16854,,"34,077 x DRG weight",16854,Other,base rate x DRG weight,14327,,"28,966 x DRG weight",14327,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4667,,DRG base rate x DRG weight + capital per discharge,4667,Other,100% of NY Medicaid HMO DRG,4667,,100% x Medicaid HMO amount,4667,Other,100% of NY Medicaid HMO DRG,4667,,100% x Medicaid HMO amount,4667,Other,100% of NY Medicaid HMO DRG,4667,,100% x Medicaid HMO amount,4667,Other,100% of NY Medicaid HMO DRG,10501,,225% x Medicaid HMO amount,10501,Other,225% of NY Medicaid HMO DRG,10501,,225% x Medicaid HMO amount,10501,Other,225% of NY Medicaid HMO DRG,10501,,225% x Medicaid HMO amount,10501,Other,225% of NY Medicaid HMO DRG,10501,,225% x Medicaid HMO amount,10501,Other,225% of NY Medicaid HMO DRG,6534,,140% x Medicaid HMO amount,6534,Other,140% of NY Medicaid HMO DRG,10501,,225% x Medicaid HMO amount,10501,Other,225% of NY Medicaid HMO DRG,12834,,275% x Medicaid HMO amount,12834,Other,275% of NY Medicaid HMO DRG,15121,,324% x Medicaid HMO amount,15121,Other,324% of NY Medicaid HMO DRG,10034,,215% x Medicaid HMO amount,10034,Other,215% of NY Medicaid HMO DRG,10034,,215% x Medicaid HMO amount,10034,Other,215% of NY Medicaid HMO DRG,5834,,125% x Medicaid HMO amount,5834,Other,125% of NY Medicaid HMO DRG,0.01,22320,
Neonate w ECMO,583-1,APR-DRG,,,,,,,,inpatient,,,819584.95,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,646210,,"45,128 x DRG weight",646210,Other,base rate x DRG weight,581586,,"40,615 x DRG weight",581586,Other,base rate x DRG weight,549282,,"38,359 x DRG weight",549282,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,208625,,186% x Medicaid HMO amount,208625,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,487966,,"34,077 x DRG weight",487966,Other,base rate x DRG weight,414779,,"28,966 x DRG weight",414779,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,112164,,DRG base rate x DRG weight + capital per discharge,112164,Other,100% of NY Medicaid HMO DRG,112164,,100% x Medicaid HMO amount,112164,Other,100% of NY Medicaid HMO DRG,112164,,100% x Medicaid HMO amount,112164,Other,100% of NY Medicaid HMO DRG,112164,,100% x Medicaid HMO amount,112164,Other,100% of NY Medicaid HMO DRG,252369,,225% x Medicaid HMO amount,252369,Other,225% of NY Medicaid HMO DRG,252369,,225% x Medicaid HMO amount,252369,Other,225% of NY Medicaid HMO DRG,252369,,225% x Medicaid HMO amount,252369,Other,225% of NY Medicaid HMO DRG,252369,,225% x Medicaid HMO amount,252369,Other,225% of NY Medicaid HMO DRG,157030,,140% x Medicaid HMO amount,157030,Other,140% of NY Medicaid HMO DRG,252369,,225% x Medicaid HMO amount,252369,Other,225% of NY Medicaid HMO DRG,308451,,275% x Medicaid HMO amount,308451,Other,275% of NY Medicaid HMO DRG,363411,,324% x Medicaid HMO amount,363411,Other,324% of NY Medicaid HMO DRG,241153,,215% x Medicaid HMO amount,241153,Other,215% of NY Medicaid HMO DRG,241153,,215% x Medicaid HMO amount,241153,Other,215% of NY Medicaid HMO DRG,140205,,125% x Medicaid HMO amount,140205,Other,125% of NY Medicaid HMO DRG,0.01,646210,
Neonate w ECMO,583-2,APR-DRG,,,,,,,,inpatient,,,819584.95,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,646210,,"45,128 x DRG weight",646210,Other,base rate x DRG weight,581586,,"40,615 x DRG weight",581586,Other,base rate x DRG weight,549282,,"38,359 x DRG weight",549282,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,208625,,186% x Medicaid HMO amount,208625,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,487966,,"34,077 x DRG weight",487966,Other,base rate x DRG weight,414779,,"28,966 x DRG weight",414779,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,112164,,DRG base rate x DRG weight + capital per discharge,112164,Other,100% of NY Medicaid HMO DRG,112164,,100% x Medicaid HMO amount,112164,Other,100% of NY Medicaid HMO DRG,112164,,100% x Medicaid HMO amount,112164,Other,100% of NY Medicaid HMO DRG,112164,,100% x Medicaid HMO amount,112164,Other,100% of NY Medicaid HMO DRG,252369,,225% x Medicaid HMO amount,252369,Other,225% of NY Medicaid HMO DRG,252369,,225% x Medicaid HMO amount,252369,Other,225% of NY Medicaid HMO DRG,252369,,225% x Medicaid HMO amount,252369,Other,225% of NY Medicaid HMO DRG,252369,,225% x Medicaid HMO amount,252369,Other,225% of NY Medicaid HMO DRG,157030,,140% x Medicaid HMO amount,157030,Other,140% of NY Medicaid HMO DRG,252369,,225% x Medicaid HMO amount,252369,Other,225% of NY Medicaid HMO DRG,308451,,275% x Medicaid HMO amount,308451,Other,275% of NY Medicaid HMO DRG,363411,,324% x Medicaid HMO amount,363411,Other,324% of NY Medicaid HMO DRG,241153,,215% x Medicaid HMO amount,241153,Other,215% of NY Medicaid HMO DRG,241153,,215% x Medicaid HMO amount,241153,Other,215% of NY Medicaid HMO DRG,140205,,125% x Medicaid HMO amount,140205,Other,125% of NY Medicaid HMO DRG,0.01,646210,
Neonate w ECMO,583-3,APR-DRG,,,,,,,,inpatient,,,819584.95,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,658526,,"45,128 x DRG weight",658526,Other,base rate x DRG weight,592670,,"40,615 x DRG weight",592670,Other,base rate x DRG weight,559750,,"38,359 x DRG weight",559750,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,212572,,186% x Medicaid HMO amount,212572,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,497265,,"34,077 x DRG weight",497265,Other,base rate x DRG weight,422683,,"28,966 x DRG weight",422683,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,114286,,DRG base rate x DRG weight + capital per discharge,114286,Other,100% of NY Medicaid HMO DRG,114286,,100% x Medicaid HMO amount,114286,Other,100% of NY Medicaid HMO DRG,114286,,100% x Medicaid HMO amount,114286,Other,100% of NY Medicaid HMO DRG,114286,,100% x Medicaid HMO amount,114286,Other,100% of NY Medicaid HMO DRG,257144,,225% x Medicaid HMO amount,257144,Other,225% of NY Medicaid HMO DRG,257144,,225% x Medicaid HMO amount,257144,Other,225% of NY Medicaid HMO DRG,257144,,225% x Medicaid HMO amount,257144,Other,225% of NY Medicaid HMO DRG,257144,,225% x Medicaid HMO amount,257144,Other,225% of NY Medicaid HMO DRG,160000,,140% x Medicaid HMO amount,160000,Other,140% of NY Medicaid HMO DRG,257144,,225% x Medicaid HMO amount,257144,Other,225% of NY Medicaid HMO DRG,314287,,275% x Medicaid HMO amount,314287,Other,275% of NY Medicaid HMO DRG,370287,,324% x Medicaid HMO amount,370287,Other,324% of NY Medicaid HMO DRG,245715,,215% x Medicaid HMO amount,245715,Other,215% of NY Medicaid HMO DRG,245715,,215% x Medicaid HMO amount,245715,Other,215% of NY Medicaid HMO DRG,142858,,125% x Medicaid HMO amount,142858,Other,125% of NY Medicaid HMO DRG,0.01,658526,
Neonate w ECMO,583-4,APR-DRG,,,,,,,,inpatient,,,2948357.83,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,1159144,,"45,128 x DRG weight",1159144,Other,base rate x DRG weight,1043225,,"40,615 x DRG weight",1043225,Other,base rate x DRG weight,985278,,"38,359 x DRG weight",985278,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,373010,,186% x Medicaid HMO amount,373010,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,875292,,"34,077 x DRG weight",875292,Other,base rate x DRG weight,744012,,"28,966 x DRG weight",744012,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,200543,,DRG base rate x DRG weight + capital per discharge,200543,Other,100% of NY Medicaid HMO DRG,200543,,100% x Medicaid HMO amount,200543,Other,100% of NY Medicaid HMO DRG,200543,,100% x Medicaid HMO amount,200543,Other,100% of NY Medicaid HMO DRG,200543,,100% x Medicaid HMO amount,200543,Other,100% of NY Medicaid HMO DRG,451222,,225% x Medicaid HMO amount,451222,Other,225% of NY Medicaid HMO DRG,451222,,225% x Medicaid HMO amount,451222,Other,225% of NY Medicaid HMO DRG,451222,,225% x Medicaid HMO amount,451222,Other,225% of NY Medicaid HMO DRG,451222,,225% x Medicaid HMO amount,451222,Other,225% of NY Medicaid HMO DRG,280760,,140% x Medicaid HMO amount,280760,Other,140% of NY Medicaid HMO DRG,451222,,225% x Medicaid HMO amount,451222,Other,225% of NY Medicaid HMO DRG,551493,,275% x Medicaid HMO amount,551493,Other,275% of NY Medicaid HMO DRG,649759,,324% x Medicaid HMO amount,649759,Other,324% of NY Medicaid HMO DRG,431167,,215% x Medicaid HMO amount,431167,Other,215% of NY Medicaid HMO DRG,431167,,215% x Medicaid HMO amount,431167,Other,215% of NY Medicaid HMO DRG,250679,,125% x Medicaid HMO amount,250679,Other,125% of NY Medicaid HMO DRG,0.01,1159144,
Neonate bwt <1500g w major procedure,588-1,APR-DRG,,,,,,,,inpatient,,,1630601.47,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,871173,,"45,128 x DRG weight",871173,Other,base rate x DRG weight,784052,,"40,615 x DRG weight",784052,Other,base rate x DRG weight,740501,,"38,359 x DRG weight",740501,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,280721,,186% x Medicaid HMO amount,280721,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,657839,,"34,077 x DRG weight",657839,Other,base rate x DRG weight,559174,,"28,966 x DRG weight",559174,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,150925,,DRG base rate x DRG weight + capital per discharge,150925,Other,100% of NY Medicaid HMO DRG,150925,,100% x Medicaid HMO amount,150925,Other,100% of NY Medicaid HMO DRG,150925,,100% x Medicaid HMO amount,150925,Other,100% of NY Medicaid HMO DRG,150925,,100% x Medicaid HMO amount,150925,Other,100% of NY Medicaid HMO DRG,339581,,225% x Medicaid HMO amount,339581,Other,225% of NY Medicaid HMO DRG,339581,,225% x Medicaid HMO amount,339581,Other,225% of NY Medicaid HMO DRG,339581,,225% x Medicaid HMO amount,339581,Other,225% of NY Medicaid HMO DRG,339581,,225% x Medicaid HMO amount,339581,Other,225% of NY Medicaid HMO DRG,211295,,140% x Medicaid HMO amount,211295,Other,140% of NY Medicaid HMO DRG,339581,,225% x Medicaid HMO amount,339581,Other,225% of NY Medicaid HMO DRG,415044,,275% x Medicaid HMO amount,415044,Other,275% of NY Medicaid HMO DRG,488997,,324% x Medicaid HMO amount,488997,Other,324% of NY Medicaid HMO DRG,324489,,215% x Medicaid HMO amount,324489,Other,215% of NY Medicaid HMO DRG,324489,,215% x Medicaid HMO amount,324489,Other,215% of NY Medicaid HMO DRG,188656,,125% x Medicaid HMO amount,188656,Other,125% of NY Medicaid HMO DRG,0.01,871173,
Neonate bwt <1500g w major procedure,588-2,APR-DRG,,,,,,,,inpatient,,,1630601.47,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,871173,,"45,128 x DRG weight",871173,Other,base rate x DRG weight,784052,,"40,615 x DRG weight",784052,Other,base rate x DRG weight,740501,,"38,359 x DRG weight",740501,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,280721,,186% x Medicaid HMO amount,280721,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,657839,,"34,077 x DRG weight",657839,Other,base rate x DRG weight,559174,,"28,966 x DRG weight",559174,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,150925,,DRG base rate x DRG weight + capital per discharge,150925,Other,100% of NY Medicaid HMO DRG,150925,,100% x Medicaid HMO amount,150925,Other,100% of NY Medicaid HMO DRG,150925,,100% x Medicaid HMO amount,150925,Other,100% of NY Medicaid HMO DRG,150925,,100% x Medicaid HMO amount,150925,Other,100% of NY Medicaid HMO DRG,339581,,225% x Medicaid HMO amount,339581,Other,225% of NY Medicaid HMO DRG,339581,,225% x Medicaid HMO amount,339581,Other,225% of NY Medicaid HMO DRG,339581,,225% x Medicaid HMO amount,339581,Other,225% of NY Medicaid HMO DRG,339581,,225% x Medicaid HMO amount,339581,Other,225% of NY Medicaid HMO DRG,211295,,140% x Medicaid HMO amount,211295,Other,140% of NY Medicaid HMO DRG,339581,,225% x Medicaid HMO amount,339581,Other,225% of NY Medicaid HMO DRG,415044,,275% x Medicaid HMO amount,415044,Other,275% of NY Medicaid HMO DRG,488997,,324% x Medicaid HMO amount,488997,Other,324% of NY Medicaid HMO DRG,324489,,215% x Medicaid HMO amount,324489,Other,215% of NY Medicaid HMO DRG,324489,,215% x Medicaid HMO amount,324489,Other,215% of NY Medicaid HMO DRG,188656,,125% x Medicaid HMO amount,188656,Other,125% of NY Medicaid HMO DRG,0.01,871173,
Neonate bwt <1500g w major procedure,588-3,APR-DRG,,,,,,,,inpatient,,,3057311.12,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,1138769,,"45,128 x DRG weight",1138769,Other,base rate x DRG weight,1024887,,"40,615 x DRG weight",1024887,Other,base rate x DRG weight,967959,,"38,359 x DRG weight",967959,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,366480,,186% x Medicaid HMO amount,366480,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,859906,,"34,077 x DRG weight",859906,Other,base rate x DRG weight,730934,,"28,966 x DRG weight",730934,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,197032,,DRG base rate x DRG weight + capital per discharge,197032,Other,100% of NY Medicaid HMO DRG,197032,,100% x Medicaid HMO amount,197032,Other,100% of NY Medicaid HMO DRG,197032,,100% x Medicaid HMO amount,197032,Other,100% of NY Medicaid HMO DRG,197032,,100% x Medicaid HMO amount,197032,Other,100% of NY Medicaid HMO DRG,443322,,225% x Medicaid HMO amount,443322,Other,225% of NY Medicaid HMO DRG,443322,,225% x Medicaid HMO amount,443322,Other,225% of NY Medicaid HMO DRG,443322,,225% x Medicaid HMO amount,443322,Other,225% of NY Medicaid HMO DRG,443322,,225% x Medicaid HMO amount,443322,Other,225% of NY Medicaid HMO DRG,275845,,140% x Medicaid HMO amount,275845,Other,140% of NY Medicaid HMO DRG,443322,,225% x Medicaid HMO amount,443322,Other,225% of NY Medicaid HMO DRG,541838,,275% x Medicaid HMO amount,541838,Other,275% of NY Medicaid HMO DRG,638384,,324% x Medicaid HMO amount,638384,Other,324% of NY Medicaid HMO DRG,423619,,215% x Medicaid HMO amount,423619,Other,215% of NY Medicaid HMO DRG,423619,,215% x Medicaid HMO amount,423619,Other,215% of NY Medicaid HMO DRG,246290,,125% x Medicaid HMO amount,246290,Other,125% of NY Medicaid HMO DRG,0.01,1138769,
Neonate bwt <1500g w major procedure,588-4,APR-DRG,,,,,,,,inpatient,,,4190879.74,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,1138769,,"45,128 x DRG weight",1138769,Other,base rate x DRG weight,1024887,,"40,615 x DRG weight",1024887,Other,base rate x DRG weight,967959,,"38,359 x DRG weight",967959,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,366480,,186% x Medicaid HMO amount,366480,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,859906,,"34,077 x DRG weight",859906,Other,base rate x DRG weight,730934,,"28,966 x DRG weight",730934,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,197032,,DRG base rate x DRG weight + capital per discharge,197032,Other,100% of NY Medicaid HMO DRG,197032,,100% x Medicaid HMO amount,197032,Other,100% of NY Medicaid HMO DRG,197032,,100% x Medicaid HMO amount,197032,Other,100% of NY Medicaid HMO DRG,197032,,100% x Medicaid HMO amount,197032,Other,100% of NY Medicaid HMO DRG,443322,,225% x Medicaid HMO amount,443322,Other,225% of NY Medicaid HMO DRG,443322,,225% x Medicaid HMO amount,443322,Other,225% of NY Medicaid HMO DRG,443322,,225% x Medicaid HMO amount,443322,Other,225% of NY Medicaid HMO DRG,443322,,225% x Medicaid HMO amount,443322,Other,225% of NY Medicaid HMO DRG,275845,,140% x Medicaid HMO amount,275845,Other,140% of NY Medicaid HMO DRG,443322,,225% x Medicaid HMO amount,443322,Other,225% of NY Medicaid HMO DRG,541838,,275% x Medicaid HMO amount,541838,Other,275% of NY Medicaid HMO DRG,638384,,324% x Medicaid HMO amount,638384,Other,324% of NY Medicaid HMO DRG,423619,,215% x Medicaid HMO amount,423619,Other,215% of NY Medicaid HMO DRG,423619,,215% x Medicaid HMO amount,423619,Other,215% of NY Medicaid HMO DRG,246290,,125% x Medicaid HMO amount,246290,Other,125% of NY Medicaid HMO DRG,0.01,1138769,
Neonate bwt <500g or GA <24 weeks,589-1,APR-DRG,,,,,,,,inpatient,,,3723435,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,547804,,"45,128 x DRG weight",547804,Other,base rate x DRG weight,493021,,"40,615 x DRG weight",493021,Other,base rate x DRG weight,465636,,"38,359 x DRG weight",465636,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,177087,,186% x Medicaid HMO amount,177087,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,413657,,"34,077 x DRG weight",413657,Other,base rate x DRG weight,351615,,"28,966 x DRG weight",351615,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,95208,,DRG base rate x DRG weight + capital per discharge,95208,Other,100% of NY Medicaid HMO DRG,95208,,100% x Medicaid HMO amount,95208,Other,100% of NY Medicaid HMO DRG,95208,,100% x Medicaid HMO amount,95208,Other,100% of NY Medicaid HMO DRG,95208,,100% x Medicaid HMO amount,95208,Other,100% of NY Medicaid HMO DRG,214218,,225% x Medicaid HMO amount,214218,Other,225% of NY Medicaid HMO DRG,214218,,225% x Medicaid HMO amount,214218,Other,225% of NY Medicaid HMO DRG,214218,,225% x Medicaid HMO amount,214218,Other,225% of NY Medicaid HMO DRG,214218,,225% x Medicaid HMO amount,214218,Other,225% of NY Medicaid HMO DRG,133291,,140% x Medicaid HMO amount,133291,Other,140% of NY Medicaid HMO DRG,214218,,225% x Medicaid HMO amount,214218,Other,225% of NY Medicaid HMO DRG,261822,,275% x Medicaid HMO amount,261822,Other,275% of NY Medicaid HMO DRG,308474,,324% x Medicaid HMO amount,308474,Other,324% of NY Medicaid HMO DRG,204697,,215% x Medicaid HMO amount,204697,Other,215% of NY Medicaid HMO DRG,204697,,215% x Medicaid HMO amount,204697,Other,215% of NY Medicaid HMO DRG,119010,,125% x Medicaid HMO amount,119010,Other,125% of NY Medicaid HMO DRG,0.01,547804,
Neonate bwt <500g or GA <24 weeks,589-2,APR-DRG,,,,,,,,inpatient,,,3632622.96,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,547804,,"45,128 x DRG weight",547804,Other,base rate x DRG weight,493021,,"40,615 x DRG weight",493021,Other,base rate x DRG weight,465636,,"38,359 x DRG weight",465636,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,177087,,186% x Medicaid HMO amount,177087,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,413657,,"34,077 x DRG weight",413657,Other,base rate x DRG weight,351615,,"28,966 x DRG weight",351615,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,95208,,DRG base rate x DRG weight + capital per discharge,95208,Other,100% of NY Medicaid HMO DRG,95208,,100% x Medicaid HMO amount,95208,Other,100% of NY Medicaid HMO DRG,95208,,100% x Medicaid HMO amount,95208,Other,100% of NY Medicaid HMO DRG,95208,,100% x Medicaid HMO amount,95208,Other,100% of NY Medicaid HMO DRG,214218,,225% x Medicaid HMO amount,214218,Other,225% of NY Medicaid HMO DRG,214218,,225% x Medicaid HMO amount,214218,Other,225% of NY Medicaid HMO DRG,214218,,225% x Medicaid HMO amount,214218,Other,225% of NY Medicaid HMO DRG,214218,,225% x Medicaid HMO amount,214218,Other,225% of NY Medicaid HMO DRG,133291,,140% x Medicaid HMO amount,133291,Other,140% of NY Medicaid HMO DRG,214218,,225% x Medicaid HMO amount,214218,Other,225% of NY Medicaid HMO DRG,261822,,275% x Medicaid HMO amount,261822,Other,275% of NY Medicaid HMO DRG,308474,,324% x Medicaid HMO amount,308474,Other,324% of NY Medicaid HMO DRG,204697,,215% x Medicaid HMO amount,204697,Other,215% of NY Medicaid HMO DRG,204697,,215% x Medicaid HMO amount,204697,Other,215% of NY Medicaid HMO DRG,119010,,125% x Medicaid HMO amount,119010,Other,125% of NY Medicaid HMO DRG,0.01,547804,
Neonate bwt <500g or GA <24 weeks,589-3,APR-DRG,,,,,,,,inpatient,,,4659798.87,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,198559,,"45,128 x DRG weight",198559,Other,base rate x DRG weight,178702,,"40,615 x DRG weight",178702,Other,base rate x DRG weight,168776,,"38,359 x DRG weight",168776,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,65161,,186% x Medicaid HMO amount,65161,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,149935,,"34,077 x DRG weight",149935,Other,base rate x DRG weight,127448,,"28,966 x DRG weight",127448,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35033,,DRG base rate x DRG weight + capital per discharge,35033,Other,100% of NY Medicaid HMO DRG,35033,,100% x Medicaid HMO amount,35033,Other,100% of NY Medicaid HMO DRG,35033,,100% x Medicaid HMO amount,35033,Other,100% of NY Medicaid HMO DRG,35033,,100% x Medicaid HMO amount,35033,Other,100% of NY Medicaid HMO DRG,78824,,225% x Medicaid HMO amount,78824,Other,225% of NY Medicaid HMO DRG,78824,,225% x Medicaid HMO amount,78824,Other,225% of NY Medicaid HMO DRG,78824,,225% x Medicaid HMO amount,78824,Other,225% of NY Medicaid HMO DRG,78824,,225% x Medicaid HMO amount,78824,Other,225% of NY Medicaid HMO DRG,49046,,140% x Medicaid HMO amount,49046,Other,140% of NY Medicaid HMO DRG,78824,,225% x Medicaid HMO amount,78824,Other,225% of NY Medicaid HMO DRG,96341,,275% x Medicaid HMO amount,96341,Other,275% of NY Medicaid HMO DRG,113507,,324% x Medicaid HMO amount,113507,Other,324% of NY Medicaid HMO DRG,75321,,215% x Medicaid HMO amount,75321,Other,215% of NY Medicaid HMO DRG,75321,,215% x Medicaid HMO amount,75321,Other,215% of NY Medicaid HMO DRG,43791,,125% x Medicaid HMO amount,43791,Other,125% of NY Medicaid HMO DRG,0.01,198559,
Neonate bwt <500g or GA <24 weeks,589-4,APR-DRG,,,,,,,,inpatient,,,6068,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5122,,"45,128 x DRG weight",5122,Other,base rate x DRG weight,4610,,"40,615 x DRG weight",4610,Other,base rate x DRG weight,4354,,"38,359 x DRG weight",4354,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3168,,186% x Medicaid HMO amount,3168,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3868,,"34,077 x DRG weight",3868,Other,base rate x DRG weight,3288,,"28,966 x DRG weight",3288,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,1703,,DRG base rate x DRG weight + capital per discharge,1703,Other,100% of NY Medicaid HMO DRG,1703,,100% x Medicaid HMO amount,1703,Other,100% of NY Medicaid HMO DRG,1703,,100% x Medicaid HMO amount,1703,Other,100% of NY Medicaid HMO DRG,1703,,100% x Medicaid HMO amount,1703,Other,100% of NY Medicaid HMO DRG,3832,,225% x Medicaid HMO amount,3832,Other,225% of NY Medicaid HMO DRG,3832,,225% x Medicaid HMO amount,3832,Other,225% of NY Medicaid HMO DRG,3832,,225% x Medicaid HMO amount,3832,Other,225% of NY Medicaid HMO DRG,3832,,225% x Medicaid HMO amount,3832,Other,225% of NY Medicaid HMO DRG,2384,,140% x Medicaid HMO amount,2384,Other,140% of NY Medicaid HMO DRG,3832,,225% x Medicaid HMO amount,3832,Other,225% of NY Medicaid HMO DRG,4683,,275% x Medicaid HMO amount,4683,Other,275% of NY Medicaid HMO DRG,5518,,324% x Medicaid HMO amount,5518,Other,324% of NY Medicaid HMO DRG,3661,,215% x Medicaid HMO amount,3661,Other,215% of NY Medicaid HMO DRG,3661,,215% x Medicaid HMO amount,3661,Other,215% of NY Medicaid HMO DRG,2129,,125% x Medicaid HMO amount,2129,Other,125% of NY Medicaid HMO DRG,0.01,5518,
Neonate birthwt 500-749g w/o major procedure,591-1,APR-DRG,,,,,,,,inpatient,,,29712,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,401161,,"45,128 x DRG weight",401161,Other,base rate x DRG weight,361043,,"40,615 x DRG weight",361043,Other,base rate x DRG weight,340988,,"38,359 x DRG weight",340988,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,130090,,186% x Medicaid HMO amount,130090,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,302924,,"34,077 x DRG weight",302924,Other,base rate x DRG weight,257490,,"28,966 x DRG weight",257490,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,69941,,DRG base rate x DRG weight + capital per discharge,69941,Other,100% of NY Medicaid HMO DRG,69941,,100% x Medicaid HMO amount,69941,Other,100% of NY Medicaid HMO DRG,69941,,100% x Medicaid HMO amount,69941,Other,100% of NY Medicaid HMO DRG,69941,,100% x Medicaid HMO amount,69941,Other,100% of NY Medicaid HMO DRG,157367,,225% x Medicaid HMO amount,157367,Other,225% of NY Medicaid HMO DRG,157367,,225% x Medicaid HMO amount,157367,Other,225% of NY Medicaid HMO DRG,157367,,225% x Medicaid HMO amount,157367,Other,225% of NY Medicaid HMO DRG,157367,,225% x Medicaid HMO amount,157367,Other,225% of NY Medicaid HMO DRG,97917,,140% x Medicaid HMO amount,97917,Other,140% of NY Medicaid HMO DRG,157367,,225% x Medicaid HMO amount,157367,Other,225% of NY Medicaid HMO DRG,192338,,275% x Medicaid HMO amount,192338,Other,275% of NY Medicaid HMO DRG,226609,,324% x Medicaid HMO amount,226609,Other,324% of NY Medicaid HMO DRG,150373,,215% x Medicaid HMO amount,150373,Other,215% of NY Medicaid HMO DRG,150373,,215% x Medicaid HMO amount,150373,Other,215% of NY Medicaid HMO DRG,87426,,125% x Medicaid HMO amount,87426,Other,125% of NY Medicaid HMO DRG,0.01,401161,
Neonate birthwt 500-749g w/o major procedure,591-2,APR-DRG,,,,,,,,inpatient,,,2735357.94,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,497396,,"45,128 x DRG weight",497396,Other,base rate x DRG weight,447654,,"40,615 x DRG weight",447654,Other,base rate x DRG weight,422789,,"38,359 x DRG weight",422789,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,160933,,186% x Medicaid HMO amount,160933,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,375593,,"34,077 x DRG weight",375593,Other,base rate x DRG weight,319260,,"28,966 x DRG weight",319260,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,86523,,DRG base rate x DRG weight + capital per discharge,86523,Other,100% of NY Medicaid HMO DRG,86523,,100% x Medicaid HMO amount,86523,Other,100% of NY Medicaid HMO DRG,86523,,100% x Medicaid HMO amount,86523,Other,100% of NY Medicaid HMO DRG,86523,,100% x Medicaid HMO amount,86523,Other,100% of NY Medicaid HMO DRG,194677,,225% x Medicaid HMO amount,194677,Other,225% of NY Medicaid HMO DRG,194677,,225% x Medicaid HMO amount,194677,Other,225% of NY Medicaid HMO DRG,194677,,225% x Medicaid HMO amount,194677,Other,225% of NY Medicaid HMO DRG,194677,,225% x Medicaid HMO amount,194677,Other,225% of NY Medicaid HMO DRG,121132,,140% x Medicaid HMO amount,121132,Other,140% of NY Medicaid HMO DRG,194677,,225% x Medicaid HMO amount,194677,Other,225% of NY Medicaid HMO DRG,237938,,275% x Medicaid HMO amount,237938,Other,275% of NY Medicaid HMO DRG,280335,,324% x Medicaid HMO amount,280335,Other,324% of NY Medicaid HMO DRG,186024,,215% x Medicaid HMO amount,186024,Other,215% of NY Medicaid HMO DRG,186024,,215% x Medicaid HMO amount,186024,Other,215% of NY Medicaid HMO DRG,108154,,125% x Medicaid HMO amount,108154,Other,125% of NY Medicaid HMO DRG,0.01,497396,
Neonate birthwt 500-749g w/o major procedure,591-3,APR-DRG,,,,,,,,inpatient,,,232053,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,533178,,"45,128 x DRG weight",533178,Other,base rate x DRG weight,479858,,"40,615 x DRG weight",479858,Other,base rate x DRG weight,453204,,"38,359 x DRG weight",453204,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,172400,,186% x Medicaid HMO amount,172400,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,402613,,"34,077 x DRG weight",402613,Other,base rate x DRG weight,342227,,"28,966 x DRG weight",342227,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,92688,,DRG base rate x DRG weight + capital per discharge,92688,Other,100% of NY Medicaid HMO DRG,92688,,100% x Medicaid HMO amount,92688,Other,100% of NY Medicaid HMO DRG,92688,,100% x Medicaid HMO amount,92688,Other,100% of NY Medicaid HMO DRG,92688,,100% x Medicaid HMO amount,92688,Other,100% of NY Medicaid HMO DRG,208548,,225% x Medicaid HMO amount,208548,Other,225% of NY Medicaid HMO DRG,208548,,225% x Medicaid HMO amount,208548,Other,225% of NY Medicaid HMO DRG,208548,,225% x Medicaid HMO amount,208548,Other,225% of NY Medicaid HMO DRG,208548,,225% x Medicaid HMO amount,208548,Other,225% of NY Medicaid HMO DRG,129763,,140% x Medicaid HMO amount,129763,Other,140% of NY Medicaid HMO DRG,208548,,225% x Medicaid HMO amount,208548,Other,225% of NY Medicaid HMO DRG,254892,,275% x Medicaid HMO amount,254892,Other,275% of NY Medicaid HMO DRG,300309,,324% x Medicaid HMO amount,300309,Other,324% of NY Medicaid HMO DRG,199279,,215% x Medicaid HMO amount,199279,Other,215% of NY Medicaid HMO DRG,199279,,215% x Medicaid HMO amount,199279,Other,215% of NY Medicaid HMO DRG,115860,,125% x Medicaid HMO amount,115860,Other,125% of NY Medicaid HMO DRG,0.01,533178,
Neonate birthwt 500-749g w/o major procedure,591-4,APR-DRG,,,,,,,,inpatient,,,4269592.92,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,874332,,"45,128 x DRG weight",874332,Other,base rate x DRG weight,786895,,"40,615 x DRG weight",786895,Other,base rate x DRG weight,743186,,"38,359 x DRG weight",743186,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,281734,,186% x Medicaid HMO amount,281734,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,660225,,"34,077 x DRG weight",660225,Other,base rate x DRG weight,561202,,"28,966 x DRG weight",561202,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,151470,,DRG base rate x DRG weight + capital per discharge,151470,Other,100% of NY Medicaid HMO DRG,151470,,100% x Medicaid HMO amount,151470,Other,100% of NY Medicaid HMO DRG,151470,,100% x Medicaid HMO amount,151470,Other,100% of NY Medicaid HMO DRG,151470,,100% x Medicaid HMO amount,151470,Other,100% of NY Medicaid HMO DRG,340808,,225% x Medicaid HMO amount,340808,Other,225% of NY Medicaid HMO DRG,340808,,225% x Medicaid HMO amount,340808,Other,225% of NY Medicaid HMO DRG,340808,,225% x Medicaid HMO amount,340808,Other,225% of NY Medicaid HMO DRG,340808,,225% x Medicaid HMO amount,340808,Other,225% of NY Medicaid HMO DRG,212058,,140% x Medicaid HMO amount,212058,Other,140% of NY Medicaid HMO DRG,340808,,225% x Medicaid HMO amount,340808,Other,225% of NY Medicaid HMO DRG,416543,,275% x Medicaid HMO amount,416543,Other,275% of NY Medicaid HMO DRG,490763,,324% x Medicaid HMO amount,490763,Other,324% of NY Medicaid HMO DRG,325661,,215% x Medicaid HMO amount,325661,Other,215% of NY Medicaid HMO DRG,325661,,215% x Medicaid HMO amount,325661,Other,215% of NY Medicaid HMO DRG,189338,,125% x Medicaid HMO amount,189338,Other,125% of NY Medicaid HMO DRG,0.01,874332,
Neonate birthwt 750-999g w/o major procedure,593-1,APR-DRG,,,,,,,,inpatient,,,1816271.51,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,487509,,"45,128 x DRG weight",487509,Other,base rate x DRG weight,438756,,"40,615 x DRG weight",438756,Other,base rate x DRG weight,414385,,"38,359 x DRG weight",414385,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,157763,,186% x Medicaid HMO amount,157763,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,368127,,"34,077 x DRG weight",368127,Other,base rate x DRG weight,312914,,"28,966 x DRG weight",312914,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,84819,,DRG base rate x DRG weight + capital per discharge,84819,Other,100% of NY Medicaid HMO DRG,84819,,100% x Medicaid HMO amount,84819,Other,100% of NY Medicaid HMO DRG,84819,,100% x Medicaid HMO amount,84819,Other,100% of NY Medicaid HMO DRG,84819,,100% x Medicaid HMO amount,84819,Other,100% of NY Medicaid HMO DRG,190843,,225% x Medicaid HMO amount,190843,Other,225% of NY Medicaid HMO DRG,190843,,225% x Medicaid HMO amount,190843,Other,225% of NY Medicaid HMO DRG,190843,,225% x Medicaid HMO amount,190843,Other,225% of NY Medicaid HMO DRG,190843,,225% x Medicaid HMO amount,190843,Other,225% of NY Medicaid HMO DRG,118747,,140% x Medicaid HMO amount,118747,Other,140% of NY Medicaid HMO DRG,190843,,225% x Medicaid HMO amount,190843,Other,225% of NY Medicaid HMO DRG,233252,,275% x Medicaid HMO amount,233252,Other,275% of NY Medicaid HMO DRG,274814,,324% x Medicaid HMO amount,274814,Other,324% of NY Medicaid HMO DRG,182361,,215% x Medicaid HMO amount,182361,Other,215% of NY Medicaid HMO DRG,182361,,215% x Medicaid HMO amount,182361,Other,215% of NY Medicaid HMO DRG,106024,,125% x Medicaid HMO amount,106024,Other,125% of NY Medicaid HMO DRG,0.01,487509,
Neonate birthwt 750-999g w/o major procedure,593-2,APR-DRG,,,,,,,,inpatient,,,1816271.51,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,502821,,"45,128 x DRG weight",502821,Other,base rate x DRG weight,452536,,"40,615 x DRG weight",452536,Other,base rate x DRG weight,427400,,"38,359 x DRG weight",427400,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,162672,,186% x Medicaid HMO amount,162672,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,379689,,"34,077 x DRG weight",379689,Other,base rate x DRG weight,322742,,"28,966 x DRG weight",322742,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,87458,,DRG base rate x DRG weight + capital per discharge,87458,Other,100% of NY Medicaid HMO DRG,87458,,100% x Medicaid HMO amount,87458,Other,100% of NY Medicaid HMO DRG,87458,,100% x Medicaid HMO amount,87458,Other,100% of NY Medicaid HMO DRG,87458,,100% x Medicaid HMO amount,87458,Other,100% of NY Medicaid HMO DRG,196781,,225% x Medicaid HMO amount,196781,Other,225% of NY Medicaid HMO DRG,196781,,225% x Medicaid HMO amount,196781,Other,225% of NY Medicaid HMO DRG,196781,,225% x Medicaid HMO amount,196781,Other,225% of NY Medicaid HMO DRG,196781,,225% x Medicaid HMO amount,196781,Other,225% of NY Medicaid HMO DRG,122441,,140% x Medicaid HMO amount,122441,Other,140% of NY Medicaid HMO DRG,196781,,225% x Medicaid HMO amount,196781,Other,225% of NY Medicaid HMO DRG,240510,,275% x Medicaid HMO amount,240510,Other,275% of NY Medicaid HMO DRG,283364,,324% x Medicaid HMO amount,283364,Other,324% of NY Medicaid HMO DRG,188035,,215% x Medicaid HMO amount,188035,Other,215% of NY Medicaid HMO DRG,188035,,215% x Medicaid HMO amount,188035,Other,215% of NY Medicaid HMO DRG,109323,,125% x Medicaid HMO amount,109323,Other,125% of NY Medicaid HMO DRG,0.01,502821,
Neonate birthwt 750-999g w/o major procedure,593-3,APR-DRG,,,,,,,,inpatient,,,2109601,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,614553,,"45,128 x DRG weight",614553,Other,base rate x DRG weight,553095,,"40,615 x DRG weight",553095,Other,base rate x DRG weight,522373,,"38,359 x DRG weight",522373,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,198479,,186% x Medicaid HMO amount,198479,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,464061,,"34,077 x DRG weight",464061,Other,base rate x DRG weight,394459,,"28,966 x DRG weight",394459,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,106709,,DRG base rate x DRG weight + capital per discharge,106709,Other,100% of NY Medicaid HMO DRG,106709,,100% x Medicaid HMO amount,106709,Other,100% of NY Medicaid HMO DRG,106709,,100% x Medicaid HMO amount,106709,Other,100% of NY Medicaid HMO DRG,106709,,100% x Medicaid HMO amount,106709,Other,100% of NY Medicaid HMO DRG,240095,,225% x Medicaid HMO amount,240095,Other,225% of NY Medicaid HMO DRG,240095,,225% x Medicaid HMO amount,240095,Other,225% of NY Medicaid HMO DRG,240095,,225% x Medicaid HMO amount,240095,Other,225% of NY Medicaid HMO DRG,240095,,225% x Medicaid HMO amount,240095,Other,225% of NY Medicaid HMO DRG,149393,,140% x Medicaid HMO amount,149393,Other,140% of NY Medicaid HMO DRG,240095,,225% x Medicaid HMO amount,240095,Other,225% of NY Medicaid HMO DRG,293450,,275% x Medicaid HMO amount,293450,Other,275% of NY Medicaid HMO DRG,345737,,324% x Medicaid HMO amount,345737,Other,324% of NY Medicaid HMO DRG,229424,,215% x Medicaid HMO amount,229424,Other,215% of NY Medicaid HMO DRG,229424,,215% x Medicaid HMO amount,229424,Other,215% of NY Medicaid HMO DRG,133386,,125% x Medicaid HMO amount,133386,Other,125% of NY Medicaid HMO DRG,0.01,614553,
Neonate birthwt 750-999g w/o major procedure,593-4,APR-DRG,,,,,,,,inpatient,,,2882995.51,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,786847,,"45,128 x DRG weight",786847,Other,base rate x DRG weight,708159,,"40,615 x DRG weight",708159,Other,base rate x DRG weight,668824,,"38,359 x DRG weight",668824,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,253697,,186% x Medicaid HMO amount,253697,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,594163,,"34,077 x DRG weight",594163,Other,base rate x DRG weight,505048,,"28,966 x DRG weight",505048,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,136396,,DRG base rate x DRG weight + capital per discharge,136396,Other,100% of NY Medicaid HMO DRG,136396,,100% x Medicaid HMO amount,136396,Other,100% of NY Medicaid HMO DRG,136396,,100% x Medicaid HMO amount,136396,Other,100% of NY Medicaid HMO DRG,136396,,100% x Medicaid HMO amount,136396,Other,100% of NY Medicaid HMO DRG,306891,,225% x Medicaid HMO amount,306891,Other,225% of NY Medicaid HMO DRG,306891,,225% x Medicaid HMO amount,306891,Other,225% of NY Medicaid HMO DRG,306891,,225% x Medicaid HMO amount,306891,Other,225% of NY Medicaid HMO DRG,306891,,225% x Medicaid HMO amount,306891,Other,225% of NY Medicaid HMO DRG,190954,,140% x Medicaid HMO amount,190954,Other,140% of NY Medicaid HMO DRG,306891,,225% x Medicaid HMO amount,306891,Other,225% of NY Medicaid HMO DRG,375089,,275% x Medicaid HMO amount,375089,Other,275% of NY Medicaid HMO DRG,441923,,324% x Medicaid HMO amount,441923,Other,324% of NY Medicaid HMO DRG,293251,,215% x Medicaid HMO amount,293251,Other,215% of NY Medicaid HMO DRG,293251,,215% x Medicaid HMO amount,293251,Other,215% of NY Medicaid HMO DRG,170495,,125% x Medicaid HMO amount,170495,Other,125% of NY Medicaid HMO DRG,0.01,786847,
Neonate bwt 1000-1249g w resp dist synd/oth maj resp or maj anom,602-1,APR-DRG,,,,,,,,inpatient,,,1630353.76,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,293003,,"45,128 x DRG weight",293003,Other,base rate x DRG weight,263701,,"40,615 x DRG weight",263701,Other,base rate x DRG weight,249053,,"38,359 x DRG weight",249053,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,95429,,186% x Medicaid HMO amount,95429,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,221252,,"34,077 x DRG weight",221252,Other,base rate x DRG weight,188068,,"28,966 x DRG weight",188068,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51306,,DRG base rate x DRG weight + capital per discharge,51306,Other,100% of NY Medicaid HMO DRG,51306,,100% x Medicaid HMO amount,51306,Other,100% of NY Medicaid HMO DRG,51306,,100% x Medicaid HMO amount,51306,Other,100% of NY Medicaid HMO DRG,51306,,100% x Medicaid HMO amount,51306,Other,100% of NY Medicaid HMO DRG,115439,,225% x Medicaid HMO amount,115439,Other,225% of NY Medicaid HMO DRG,115439,,225% x Medicaid HMO amount,115439,Other,225% of NY Medicaid HMO DRG,115439,,225% x Medicaid HMO amount,115439,Other,225% of NY Medicaid HMO DRG,115439,,225% x Medicaid HMO amount,115439,Other,225% of NY Medicaid HMO DRG,71828,,140% x Medicaid HMO amount,71828,Other,140% of NY Medicaid HMO DRG,115439,,225% x Medicaid HMO amount,115439,Other,225% of NY Medicaid HMO DRG,141092,,275% x Medicaid HMO amount,141092,Other,275% of NY Medicaid HMO DRG,166231,,324% x Medicaid HMO amount,166231,Other,324% of NY Medicaid HMO DRG,110308,,215% x Medicaid HMO amount,110308,Other,215% of NY Medicaid HMO DRG,110308,,215% x Medicaid HMO amount,110308,Other,215% of NY Medicaid HMO DRG,64133,,125% x Medicaid HMO amount,64133,Other,125% of NY Medicaid HMO DRG,0.01,293003,
Neonate bwt 1000-1249g w resp dist synd/oth maj resp or maj anom,602-2,APR-DRG,,,,,,,,inpatient,,,1630353.76,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,427994,,"45,128 x DRG weight",427994,Other,base rate x DRG weight,385193,,"40,615 x DRG weight",385193,Other,base rate x DRG weight,363797,,"38,359 x DRG weight",363797,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,138691,,186% x Medicaid HMO amount,138691,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,323186,,"34,077 x DRG weight",323186,Other,base rate x DRG weight,274714,,"28,966 x DRG weight",274714,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,74565,,DRG base rate x DRG weight + capital per discharge,74565,Other,100% of NY Medicaid HMO DRG,74565,,100% x Medicaid HMO amount,74565,Other,100% of NY Medicaid HMO DRG,74565,,100% x Medicaid HMO amount,74565,Other,100% of NY Medicaid HMO DRG,74565,,100% x Medicaid HMO amount,74565,Other,100% of NY Medicaid HMO DRG,167771,,225% x Medicaid HMO amount,167771,Other,225% of NY Medicaid HMO DRG,167771,,225% x Medicaid HMO amount,167771,Other,225% of NY Medicaid HMO DRG,167771,,225% x Medicaid HMO amount,167771,Other,225% of NY Medicaid HMO DRG,167771,,225% x Medicaid HMO amount,167771,Other,225% of NY Medicaid HMO DRG,104391,,140% x Medicaid HMO amount,104391,Other,140% of NY Medicaid HMO DRG,167771,,225% x Medicaid HMO amount,167771,Other,225% of NY Medicaid HMO DRG,205054,,275% x Medicaid HMO amount,205054,Other,275% of NY Medicaid HMO DRG,241591,,324% x Medicaid HMO amount,241591,Other,324% of NY Medicaid HMO DRG,160315,,215% x Medicaid HMO amount,160315,Other,215% of NY Medicaid HMO DRG,160315,,215% x Medicaid HMO amount,160315,Other,215% of NY Medicaid HMO DRG,93206,,125% x Medicaid HMO amount,93206,Other,125% of NY Medicaid HMO DRG,0.01,427994,
Neonate bwt 1000-1249g w resp dist synd/oth maj resp or maj anom,602-3,APR-DRG,,,,,,,,inpatient,,,1653465.22,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,503723,,"45,128 x DRG weight",503723,Other,base rate x DRG weight,453349,,"40,615 x DRG weight",453349,Other,base rate x DRG weight,428167,,"38,359 x DRG weight",428167,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,162960,,186% x Medicaid HMO amount,162960,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,380371,,"34,077 x DRG weight",380371,Other,base rate x DRG weight,323321,,"28,966 x DRG weight",323321,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,87613,,DRG base rate x DRG weight + capital per discharge,87613,Other,100% of NY Medicaid HMO DRG,87613,,100% x Medicaid HMO amount,87613,Other,100% of NY Medicaid HMO DRG,87613,,100% x Medicaid HMO amount,87613,Other,100% of NY Medicaid HMO DRG,87613,,100% x Medicaid HMO amount,87613,Other,100% of NY Medicaid HMO DRG,197129,,225% x Medicaid HMO amount,197129,Other,225% of NY Medicaid HMO DRG,197129,,225% x Medicaid HMO amount,197129,Other,225% of NY Medicaid HMO DRG,197129,,225% x Medicaid HMO amount,197129,Other,225% of NY Medicaid HMO DRG,197129,,225% x Medicaid HMO amount,197129,Other,225% of NY Medicaid HMO DRG,122658,,140% x Medicaid HMO amount,122658,Other,140% of NY Medicaid HMO DRG,197129,,225% x Medicaid HMO amount,197129,Other,225% of NY Medicaid HMO DRG,240936,,275% x Medicaid HMO amount,240936,Other,275% of NY Medicaid HMO DRG,283866,,324% x Medicaid HMO amount,283866,Other,324% of NY Medicaid HMO DRG,188368,,215% x Medicaid HMO amount,188368,Other,215% of NY Medicaid HMO DRG,188368,,215% x Medicaid HMO amount,188368,Other,215% of NY Medicaid HMO DRG,109516,,125% x Medicaid HMO amount,109516,Other,125% of NY Medicaid HMO DRG,0.01,503723,
Neonate bwt 1000-1249g w resp dist synd/oth maj resp or maj anom,602-4,APR-DRG,,,,,,,,inpatient,,,3217411.26,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,682408,,"45,128 x DRG weight",682408,Other,base rate x DRG weight,614164,,"40,615 x DRG weight",614164,Other,base rate x DRG weight,580049,,"38,359 x DRG weight",580049,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,220226,,186% x Medicaid HMO amount,220226,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,515299,,"34,077 x DRG weight",515299,Other,base rate x DRG weight,438012,,"28,966 x DRG weight",438012,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,118401,,DRG base rate x DRG weight + capital per discharge,118401,Other,100% of NY Medicaid HMO DRG,118401,,100% x Medicaid HMO amount,118401,Other,100% of NY Medicaid HMO DRG,118401,,100% x Medicaid HMO amount,118401,Other,100% of NY Medicaid HMO DRG,118401,,100% x Medicaid HMO amount,118401,Other,100% of NY Medicaid HMO DRG,266402,,225% x Medicaid HMO amount,266402,Other,225% of NY Medicaid HMO DRG,266402,,225% x Medicaid HMO amount,266402,Other,225% of NY Medicaid HMO DRG,266402,,225% x Medicaid HMO amount,266402,Other,225% of NY Medicaid HMO DRG,266402,,225% x Medicaid HMO amount,266402,Other,225% of NY Medicaid HMO DRG,165761,,140% x Medicaid HMO amount,165761,Other,140% of NY Medicaid HMO DRG,266402,,225% x Medicaid HMO amount,266402,Other,225% of NY Medicaid HMO DRG,325603,,275% x Medicaid HMO amount,325603,Other,275% of NY Medicaid HMO DRG,383619,,324% x Medicaid HMO amount,383619,Other,324% of NY Medicaid HMO DRG,254562,,215% x Medicaid HMO amount,254562,Other,215% of NY Medicaid HMO DRG,254562,,215% x Medicaid HMO amount,254562,Other,215% of NY Medicaid HMO DRG,148001,,125% x Medicaid HMO amount,148001,Other,125% of NY Medicaid HMO DRG,0.01,682408,
Neonate birthwt 1000-1249g w or w/o other significant condition,603-1,APR-DRG,,,,,,,,inpatient,,,1630353.76,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,233501,,"45,128 x DRG weight",233501,Other,base rate x DRG weight,210150,,"40,615 x DRG weight",210150,Other,base rate x DRG weight,198477,,"38,359 x DRG weight",198477,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,76359,,186% x Medicaid HMO amount,76359,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,176321,,"34,077 x DRG weight",176321,Other,base rate x DRG weight,149876,,"28,966 x DRG weight",149876,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41053,,DRG base rate x DRG weight + capital per discharge,41053,Other,100% of NY Medicaid HMO DRG,41053,,100% x Medicaid HMO amount,41053,Other,100% of NY Medicaid HMO DRG,41053,,100% x Medicaid HMO amount,41053,Other,100% of NY Medicaid HMO DRG,41053,,100% x Medicaid HMO amount,41053,Other,100% of NY Medicaid HMO DRG,92369,,225% x Medicaid HMO amount,92369,Other,225% of NY Medicaid HMO DRG,92369,,225% x Medicaid HMO amount,92369,Other,225% of NY Medicaid HMO DRG,92369,,225% x Medicaid HMO amount,92369,Other,225% of NY Medicaid HMO DRG,92369,,225% x Medicaid HMO amount,92369,Other,225% of NY Medicaid HMO DRG,57474,,140% x Medicaid HMO amount,57474,Other,140% of NY Medicaid HMO DRG,92369,,225% x Medicaid HMO amount,92369,Other,225% of NY Medicaid HMO DRG,112896,,275% x Medicaid HMO amount,112896,Other,275% of NY Medicaid HMO DRG,133012,,324% x Medicaid HMO amount,133012,Other,324% of NY Medicaid HMO DRG,88264,,215% x Medicaid HMO amount,88264,Other,215% of NY Medicaid HMO DRG,88264,,215% x Medicaid HMO amount,88264,Other,215% of NY Medicaid HMO DRG,51316,,125% x Medicaid HMO amount,51316,Other,125% of NY Medicaid HMO DRG,0.01,233501,
Neonate birthwt 1000-1249g w or w/o other significant condition,603-2,APR-DRG,,,,,,,,inpatient,,,1050935.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,311316,,"45,128 x DRG weight",311316,Other,base rate x DRG weight,280183,,"40,615 x DRG weight",280183,Other,base rate x DRG weight,264620,,"38,359 x DRG weight",264620,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,101297,,186% x Medicaid HMO amount,101297,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,235080,,"34,077 x DRG weight",235080,Other,base rate x DRG weight,199822,,"28,966 x DRG weight",199822,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54461,,DRG base rate x DRG weight + capital per discharge,54461,Other,100% of NY Medicaid HMO DRG,54461,,100% x Medicaid HMO amount,54461,Other,100% of NY Medicaid HMO DRG,54461,,100% x Medicaid HMO amount,54461,Other,100% of NY Medicaid HMO DRG,54461,,100% x Medicaid HMO amount,54461,Other,100% of NY Medicaid HMO DRG,122537,,225% x Medicaid HMO amount,122537,Other,225% of NY Medicaid HMO DRG,122537,,225% x Medicaid HMO amount,122537,Other,225% of NY Medicaid HMO DRG,122537,,225% x Medicaid HMO amount,122537,Other,225% of NY Medicaid HMO DRG,122537,,225% x Medicaid HMO amount,122537,Other,225% of NY Medicaid HMO DRG,76245,,140% x Medicaid HMO amount,76245,Other,140% of NY Medicaid HMO DRG,122537,,225% x Medicaid HMO amount,122537,Other,225% of NY Medicaid HMO DRG,149768,,275% x Medicaid HMO amount,149768,Other,275% of NY Medicaid HMO DRG,176454,,324% x Medicaid HMO amount,176454,Other,324% of NY Medicaid HMO DRG,117091,,215% x Medicaid HMO amount,117091,Other,215% of NY Medicaid HMO DRG,117091,,215% x Medicaid HMO amount,117091,Other,215% of NY Medicaid HMO DRG,68076,,125% x Medicaid HMO amount,68076,Other,125% of NY Medicaid HMO DRG,0.01,311316,
Neonate birthwt 1000-1249g w or w/o other significant condition,603-3,APR-DRG,,,,,,,,inpatient,,,1987695,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,405182,,"45,128 x DRG weight",405182,Other,base rate x DRG weight,364662,,"40,615 x DRG weight",364662,Other,base rate x DRG weight,344406,,"38,359 x DRG weight",344406,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,131379,,186% x Medicaid HMO amount,131379,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,305960,,"34,077 x DRG weight",305960,Other,base rate x DRG weight,260071,,"28,966 x DRG weight",260071,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,70634,,DRG base rate x DRG weight + capital per discharge,70634,Other,100% of NY Medicaid HMO DRG,70634,,100% x Medicaid HMO amount,70634,Other,100% of NY Medicaid HMO DRG,70634,,100% x Medicaid HMO amount,70634,Other,100% of NY Medicaid HMO DRG,70634,,100% x Medicaid HMO amount,70634,Other,100% of NY Medicaid HMO DRG,158927,,225% x Medicaid HMO amount,158927,Other,225% of NY Medicaid HMO DRG,158927,,225% x Medicaid HMO amount,158927,Other,225% of NY Medicaid HMO DRG,158927,,225% x Medicaid HMO amount,158927,Other,225% of NY Medicaid HMO DRG,158927,,225% x Medicaid HMO amount,158927,Other,225% of NY Medicaid HMO DRG,98888,,140% x Medicaid HMO amount,98888,Other,140% of NY Medicaid HMO DRG,158927,,225% x Medicaid HMO amount,158927,Other,225% of NY Medicaid HMO DRG,194244,,275% x Medicaid HMO amount,194244,Other,275% of NY Medicaid HMO DRG,228854,,324% x Medicaid HMO amount,228854,Other,324% of NY Medicaid HMO DRG,151863,,215% x Medicaid HMO amount,151863,Other,215% of NY Medicaid HMO DRG,151863,,215% x Medicaid HMO amount,151863,Other,215% of NY Medicaid HMO DRG,88293,,125% x Medicaid HMO amount,88293,Other,125% of NY Medicaid HMO DRG,0.01,405182,
Neonate birthwt 1000-1249g w or w/o other significant condition,603-4,APR-DRG,,,,,,,,inpatient,,,3217411.26,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,628624,,"45,128 x DRG weight",628624,Other,base rate x DRG weight,565759,,"40,615 x DRG weight",565759,Other,base rate x DRG weight,534333,,"38,359 x DRG weight",534333,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,202989,,186% x Medicaid HMO amount,202989,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,474686,,"34,077 x DRG weight",474686,Other,base rate x DRG weight,403491,,"28,966 x DRG weight",403491,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,109134,,DRG base rate x DRG weight + capital per discharge,109134,Other,100% of NY Medicaid HMO DRG,109134,,100% x Medicaid HMO amount,109134,Other,100% of NY Medicaid HMO DRG,109134,,100% x Medicaid HMO amount,109134,Other,100% of NY Medicaid HMO DRG,109134,,100% x Medicaid HMO amount,109134,Other,100% of NY Medicaid HMO DRG,245552,,225% x Medicaid HMO amount,245552,Other,225% of NY Medicaid HMO DRG,245552,,225% x Medicaid HMO amount,245552,Other,225% of NY Medicaid HMO DRG,245552,,225% x Medicaid HMO amount,245552,Other,225% of NY Medicaid HMO DRG,245552,,225% x Medicaid HMO amount,245552,Other,225% of NY Medicaid HMO DRG,152788,,140% x Medicaid HMO amount,152788,Other,140% of NY Medicaid HMO DRG,245552,,225% x Medicaid HMO amount,245552,Other,225% of NY Medicaid HMO DRG,300119,,275% x Medicaid HMO amount,300119,Other,275% of NY Medicaid HMO DRG,353594,,324% x Medicaid HMO amount,353594,Other,324% of NY Medicaid HMO DRG,234638,,215% x Medicaid HMO amount,234638,Other,215% of NY Medicaid HMO DRG,234638,,215% x Medicaid HMO amount,234638,Other,215% of NY Medicaid HMO DRG,136418,,125% x Medicaid HMO amount,136418,Other,125% of NY Medicaid HMO DRG,0.01,628624,
Neonate bwt 1250-1499g w resp dist synd/oth maj resp or maj anom,607-1,APR-DRG,,,,,,,,inpatient,,,977492.2,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,272627,,"45,128 x DRG weight",272627,Other,base rate x DRG weight,245363,,"40,615 x DRG weight",245363,Other,base rate x DRG weight,231734,,"38,359 x DRG weight",231734,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,88899,,186% x Medicaid HMO amount,88899,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,205866,,"34,077 x DRG weight",205866,Other,base rate x DRG weight,174989,,"28,966 x DRG weight",174989,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47795,,DRG base rate x DRG weight + capital per discharge,47795,Other,100% of NY Medicaid HMO DRG,47795,,100% x Medicaid HMO amount,47795,Other,100% of NY Medicaid HMO DRG,47795,,100% x Medicaid HMO amount,47795,Other,100% of NY Medicaid HMO DRG,47795,,100% x Medicaid HMO amount,47795,Other,100% of NY Medicaid HMO DRG,107539,,225% x Medicaid HMO amount,107539,Other,225% of NY Medicaid HMO DRG,107539,,225% x Medicaid HMO amount,107539,Other,225% of NY Medicaid HMO DRG,107539,,225% x Medicaid HMO amount,107539,Other,225% of NY Medicaid HMO DRG,107539,,225% x Medicaid HMO amount,107539,Other,225% of NY Medicaid HMO DRG,66913,,140% x Medicaid HMO amount,66913,Other,140% of NY Medicaid HMO DRG,107539,,225% x Medicaid HMO amount,107539,Other,225% of NY Medicaid HMO DRG,131436,,275% x Medicaid HMO amount,131436,Other,275% of NY Medicaid HMO DRG,154856,,324% x Medicaid HMO amount,154856,Other,324% of NY Medicaid HMO DRG,102759,,215% x Medicaid HMO amount,102759,Other,215% of NY Medicaid HMO DRG,102759,,215% x Medicaid HMO amount,102759,Other,215% of NY Medicaid HMO DRG,59744,,125% x Medicaid HMO amount,59744,Other,125% of NY Medicaid HMO DRG,0.01,272627,
Neonate bwt 1250-1499g w resp dist synd/oth maj resp or maj anom,607-2,APR-DRG,,,,,,,,inpatient,,,1190888.43,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,337485,,"45,128 x DRG weight",337485,Other,base rate x DRG weight,303735,,"40,615 x DRG weight",303735,Other,base rate x DRG weight,286864,,"38,359 x DRG weight",286864,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,109684,,186% x Medicaid HMO amount,109684,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,254841,,"34,077 x DRG weight",254841,Other,base rate x DRG weight,216619,,"28,966 x DRG weight",216619,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,58970,,DRG base rate x DRG weight + capital per discharge,58970,Other,100% of NY Medicaid HMO DRG,58970,,100% x Medicaid HMO amount,58970,Other,100% of NY Medicaid HMO DRG,58970,,100% x Medicaid HMO amount,58970,Other,100% of NY Medicaid HMO DRG,58970,,100% x Medicaid HMO amount,58970,Other,100% of NY Medicaid HMO DRG,132683,,225% x Medicaid HMO amount,132683,Other,225% of NY Medicaid HMO DRG,132683,,225% x Medicaid HMO amount,132683,Other,225% of NY Medicaid HMO DRG,132683,,225% x Medicaid HMO amount,132683,Other,225% of NY Medicaid HMO DRG,132683,,225% x Medicaid HMO amount,132683,Other,225% of NY Medicaid HMO DRG,82558,,140% x Medicaid HMO amount,82558,Other,140% of NY Medicaid HMO DRG,132683,,225% x Medicaid HMO amount,132683,Other,225% of NY Medicaid HMO DRG,162168,,275% x Medicaid HMO amount,162168,Other,275% of NY Medicaid HMO DRG,191063,,324% x Medicaid HMO amount,191063,Other,324% of NY Medicaid HMO DRG,126786,,215% x Medicaid HMO amount,126786,Other,215% of NY Medicaid HMO DRG,126786,,215% x Medicaid HMO amount,126786,Other,215% of NY Medicaid HMO DRG,73713,,125% x Medicaid HMO amount,73713,Other,125% of NY Medicaid HMO DRG,0.01,337485,
Neonate bwt 1250-1499g w resp dist synd/oth maj resp or maj anom,607-3,APR-DRG,,,,,,,,inpatient,,,977492.2,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,412881,,"45,128 x DRG weight",412881,Other,base rate x DRG weight,371591,,"40,615 x DRG weight",371591,Other,base rate x DRG weight,350950,,"38,359 x DRG weight",350950,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,133847,,186% x Medicaid HMO amount,133847,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,311774,,"34,077 x DRG weight",311774,Other,base rate x DRG weight,265013,,"28,966 x DRG weight",265013,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,71961,,DRG base rate x DRG weight + capital per discharge,71961,Other,100% of NY Medicaid HMO DRG,71961,,100% x Medicaid HMO amount,71961,Other,100% of NY Medicaid HMO DRG,71961,,100% x Medicaid HMO amount,71961,Other,100% of NY Medicaid HMO DRG,71961,,100% x Medicaid HMO amount,71961,Other,100% of NY Medicaid HMO DRG,161912,,225% x Medicaid HMO amount,161912,Other,225% of NY Medicaid HMO DRG,161912,,225% x Medicaid HMO amount,161912,Other,225% of NY Medicaid HMO DRG,161912,,225% x Medicaid HMO amount,161912,Other,225% of NY Medicaid HMO DRG,161912,,225% x Medicaid HMO amount,161912,Other,225% of NY Medicaid HMO DRG,100745,,140% x Medicaid HMO amount,100745,Other,140% of NY Medicaid HMO DRG,161912,,225% x Medicaid HMO amount,161912,Other,225% of NY Medicaid HMO DRG,197893,,275% x Medicaid HMO amount,197893,Other,275% of NY Medicaid HMO DRG,233154,,324% x Medicaid HMO amount,233154,Other,324% of NY Medicaid HMO DRG,154716,,215% x Medicaid HMO amount,154716,Other,215% of NY Medicaid HMO DRG,154716,,215% x Medicaid HMO amount,154716,Other,215% of NY Medicaid HMO DRG,89951,,125% x Medicaid HMO amount,89951,Other,125% of NY Medicaid HMO DRG,0.01,412881,
Neonate bwt 1250-1499g w resp dist synd/oth maj resp or maj anom,607-4,APR-DRG,,,,,,,,inpatient,,,2843505.91,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,557132,,"45,128 x DRG weight",557132,Other,base rate x DRG weight,501417,,"40,615 x DRG weight",501417,Other,base rate x DRG weight,473565,,"38,359 x DRG weight",473565,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,180078,,186% x Medicaid HMO amount,180078,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,420701,,"34,077 x DRG weight",420701,Other,base rate x DRG weight,357603,,"28,966 x DRG weight",357603,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,96816,,DRG base rate x DRG weight + capital per discharge,96816,Other,100% of NY Medicaid HMO DRG,96816,,100% x Medicaid HMO amount,96816,Other,100% of NY Medicaid HMO DRG,96816,,100% x Medicaid HMO amount,96816,Other,100% of NY Medicaid HMO DRG,96816,,100% x Medicaid HMO amount,96816,Other,100% of NY Medicaid HMO DRG,217836,,225% x Medicaid HMO amount,217836,Other,225% of NY Medicaid HMO DRG,217836,,225% x Medicaid HMO amount,217836,Other,225% of NY Medicaid HMO DRG,217836,,225% x Medicaid HMO amount,217836,Other,225% of NY Medicaid HMO DRG,217836,,225% x Medicaid HMO amount,217836,Other,225% of NY Medicaid HMO DRG,135542,,140% x Medicaid HMO amount,135542,Other,140% of NY Medicaid HMO DRG,217836,,225% x Medicaid HMO amount,217836,Other,225% of NY Medicaid HMO DRG,266244,,275% x Medicaid HMO amount,266244,Other,275% of NY Medicaid HMO DRG,313684,,324% x Medicaid HMO amount,313684,Other,324% of NY Medicaid HMO DRG,208154,,215% x Medicaid HMO amount,208154,Other,215% of NY Medicaid HMO DRG,208154,,215% x Medicaid HMO amount,208154,Other,215% of NY Medicaid HMO DRG,121020,,125% x Medicaid HMO amount,121020,Other,125% of NY Medicaid HMO DRG,0.01,557132,
Neonate bwt 1250-1499g w or w/o other significant condition,608-1,APR-DRG,,,,,,,,inpatient,,,840356,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,191541,,"45,128 x DRG weight",191541,Other,base rate x DRG weight,172386,,"40,615 x DRG weight",172386,Other,base rate x DRG weight,162811,,"38,359 x DRG weight",162811,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,62913,,186% x Medicaid HMO amount,62913,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,144636,,"34,077 x DRG weight",144636,Other,base rate x DRG weight,122943,,"28,966 x DRG weight",122943,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33824,,DRG base rate x DRG weight + capital per discharge,33824,Other,100% of NY Medicaid HMO DRG,33824,,100% x Medicaid HMO amount,33824,Other,100% of NY Medicaid HMO DRG,33824,,100% x Medicaid HMO amount,33824,Other,100% of NY Medicaid HMO DRG,33824,,100% x Medicaid HMO amount,33824,Other,100% of NY Medicaid HMO DRG,76104,,225% x Medicaid HMO amount,76104,Other,225% of NY Medicaid HMO DRG,76104,,225% x Medicaid HMO amount,76104,Other,225% of NY Medicaid HMO DRG,76104,,225% x Medicaid HMO amount,76104,Other,225% of NY Medicaid HMO DRG,76104,,225% x Medicaid HMO amount,76104,Other,225% of NY Medicaid HMO DRG,47354,,140% x Medicaid HMO amount,47354,Other,140% of NY Medicaid HMO DRG,76104,,225% x Medicaid HMO amount,76104,Other,225% of NY Medicaid HMO DRG,93016,,275% x Medicaid HMO amount,93016,Other,275% of NY Medicaid HMO DRG,109590,,324% x Medicaid HMO amount,109590,Other,324% of NY Medicaid HMO DRG,72722,,215% x Medicaid HMO amount,72722,Other,215% of NY Medicaid HMO DRG,72722,,215% x Medicaid HMO amount,72722,Other,215% of NY Medicaid HMO DRG,42280,,125% x Medicaid HMO amount,42280,Other,125% of NY Medicaid HMO DRG,0.01,191541,
Neonate bwt 1250-1499g w or w/o other significant condition,608-2,APR-DRG,,,,,,,,inpatient,,,840356,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,256598,,"45,128 x DRG weight",256598,Other,base rate x DRG weight,230937,,"40,615 x DRG weight",230937,Other,base rate x DRG weight,218109,,"38,359 x DRG weight",218109,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,83761,,186% x Medicaid HMO amount,83761,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,193762,,"34,077 x DRG weight",193762,Other,base rate x DRG weight,164701,,"28,966 x DRG weight",164701,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45033,,DRG base rate x DRG weight + capital per discharge,45033,Other,100% of NY Medicaid HMO DRG,45033,,100% x Medicaid HMO amount,45033,Other,100% of NY Medicaid HMO DRG,45033,,100% x Medicaid HMO amount,45033,Other,100% of NY Medicaid HMO DRG,45033,,100% x Medicaid HMO amount,45033,Other,100% of NY Medicaid HMO DRG,101324,,225% x Medicaid HMO amount,101324,Other,225% of NY Medicaid HMO DRG,101324,,225% x Medicaid HMO amount,101324,Other,225% of NY Medicaid HMO DRG,101324,,225% x Medicaid HMO amount,101324,Other,225% of NY Medicaid HMO DRG,101324,,225% x Medicaid HMO amount,101324,Other,225% of NY Medicaid HMO DRG,63046,,140% x Medicaid HMO amount,63046,Other,140% of NY Medicaid HMO DRG,101324,,225% x Medicaid HMO amount,101324,Other,225% of NY Medicaid HMO DRG,123841,,275% x Medicaid HMO amount,123841,Other,275% of NY Medicaid HMO DRG,145907,,324% x Medicaid HMO amount,145907,Other,324% of NY Medicaid HMO DRG,96821,,215% x Medicaid HMO amount,96821,Other,215% of NY Medicaid HMO DRG,96821,,215% x Medicaid HMO amount,96821,Other,215% of NY Medicaid HMO DRG,56291,,125% x Medicaid HMO amount,56291,Other,125% of NY Medicaid HMO DRG,0.01,256598,
Neonate bwt 1250-1499g w or w/o other significant condition,608-3,APR-DRG,,,,,,,,inpatient,,,977492.2,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,307935,,"45,128 x DRG weight",307935,Other,base rate x DRG weight,277141,,"40,615 x DRG weight",277141,Other,base rate x DRG weight,261746,,"38,359 x DRG weight",261746,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,100215,,186% x Medicaid HMO amount,100215,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,232528,,"34,077 x DRG weight",232528,Other,base rate x DRG weight,197652,,"28,966 x DRG weight",197652,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53879,,DRG base rate x DRG weight + capital per discharge,53879,Other,100% of NY Medicaid HMO DRG,53879,,100% x Medicaid HMO amount,53879,Other,100% of NY Medicaid HMO DRG,53879,,100% x Medicaid HMO amount,53879,Other,100% of NY Medicaid HMO DRG,53879,,100% x Medicaid HMO amount,53879,Other,100% of NY Medicaid HMO DRG,121228,,225% x Medicaid HMO amount,121228,Other,225% of NY Medicaid HMO DRG,121228,,225% x Medicaid HMO amount,121228,Other,225% of NY Medicaid HMO DRG,121228,,225% x Medicaid HMO amount,121228,Other,225% of NY Medicaid HMO DRG,121228,,225% x Medicaid HMO amount,121228,Other,225% of NY Medicaid HMO DRG,75431,,140% x Medicaid HMO amount,75431,Other,140% of NY Medicaid HMO DRG,121228,,225% x Medicaid HMO amount,121228,Other,225% of NY Medicaid HMO DRG,148167,,275% x Medicaid HMO amount,148167,Other,275% of NY Medicaid HMO DRG,174568,,324% x Medicaid HMO amount,174568,Other,324% of NY Medicaid HMO DRG,115840,,215% x Medicaid HMO amount,115840,Other,215% of NY Medicaid HMO DRG,115840,,215% x Medicaid HMO amount,115840,Other,215% of NY Medicaid HMO DRG,67349,,125% x Medicaid HMO amount,67349,Other,125% of NY Medicaid HMO DRG,0.01,307935,
Neonate bwt 1250-1499g w or w/o other significant condition,608-4,APR-DRG,,,,,,,,inpatient,,,1190888.43,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,324127,,"45,128 x DRG weight",324127,Other,base rate x DRG weight,291713,,"40,615 x DRG weight",291713,Other,base rate x DRG weight,275510,,"38,359 x DRG weight",275510,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,105402,,186% x Medicaid HMO amount,105402,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,244755,,"34,077 x DRG weight",244755,Other,base rate x DRG weight,208045,,"28,966 x DRG weight",208045,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56668,,DRG base rate x DRG weight + capital per discharge,56668,Other,100% of NY Medicaid HMO DRG,56668,,100% x Medicaid HMO amount,56668,Other,100% of NY Medicaid HMO DRG,56668,,100% x Medicaid HMO amount,56668,Other,100% of NY Medicaid HMO DRG,56668,,100% x Medicaid HMO amount,56668,Other,100% of NY Medicaid HMO DRG,127503,,225% x Medicaid HMO amount,127503,Other,225% of NY Medicaid HMO DRG,127503,,225% x Medicaid HMO amount,127503,Other,225% of NY Medicaid HMO DRG,127503,,225% x Medicaid HMO amount,127503,Other,225% of NY Medicaid HMO DRG,127503,,225% x Medicaid HMO amount,127503,Other,225% of NY Medicaid HMO DRG,79335,,140% x Medicaid HMO amount,79335,Other,140% of NY Medicaid HMO DRG,127503,,225% x Medicaid HMO amount,127503,Other,225% of NY Medicaid HMO DRG,155837,,275% x Medicaid HMO amount,155837,Other,275% of NY Medicaid HMO DRG,183604,,324% x Medicaid HMO amount,183604,Other,324% of NY Medicaid HMO DRG,121836,,215% x Medicaid HMO amount,121836,Other,215% of NY Medicaid HMO DRG,121836,,215% x Medicaid HMO amount,121836,Other,215% of NY Medicaid HMO DRG,70835,,125% x Medicaid HMO amount,70835,Other,125% of NY Medicaid HMO DRG,0.01,324127,
Neonate bwt 1500-2499g w major procedure,609-1,APR-DRG,,,,,,,,inpatient,,,430675,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,161003,,"45,128 x DRG weight",161003,Other,base rate x DRG weight,144902,,"40,615 x DRG weight",144902,Other,base rate x DRG weight,136853,,"38,359 x DRG weight",136853,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53125,,186% x Medicaid HMO amount,53125,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,121577,,"34,077 x DRG weight",121577,Other,base rate x DRG weight,103342,,"28,966 x DRG weight",103342,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28562,,DRG base rate x DRG weight + capital per discharge,28562,Other,100% of NY Medicaid HMO DRG,28562,,100% x Medicaid HMO amount,28562,Other,100% of NY Medicaid HMO DRG,28562,,100% x Medicaid HMO amount,28562,Other,100% of NY Medicaid HMO DRG,28562,,100% x Medicaid HMO amount,28562,Other,100% of NY Medicaid HMO DRG,64265,,225% x Medicaid HMO amount,64265,Other,225% of NY Medicaid HMO DRG,64265,,225% x Medicaid HMO amount,64265,Other,225% of NY Medicaid HMO DRG,64265,,225% x Medicaid HMO amount,64265,Other,225% of NY Medicaid HMO DRG,64265,,225% x Medicaid HMO amount,64265,Other,225% of NY Medicaid HMO DRG,39987,,140% x Medicaid HMO amount,39987,Other,140% of NY Medicaid HMO DRG,64265,,225% x Medicaid HMO amount,64265,Other,225% of NY Medicaid HMO DRG,78546,,275% x Medicaid HMO amount,78546,Other,275% of NY Medicaid HMO DRG,92541,,324% x Medicaid HMO amount,92541,Other,324% of NY Medicaid HMO DRG,61408,,215% x Medicaid HMO amount,61408,Other,215% of NY Medicaid HMO DRG,61408,,215% x Medicaid HMO amount,61408,Other,215% of NY Medicaid HMO DRG,35703,,125% x Medicaid HMO amount,35703,Other,125% of NY Medicaid HMO DRG,0.01,161003,
Neonate bwt 1500-2499g w major procedure,609-2,APR-DRG,,,,,,,,inpatient,,,430675,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,162240,,"45,128 x DRG weight",162240,Other,base rate x DRG weight,146015,,"40,615 x DRG weight",146015,Other,base rate x DRG weight,137904,,"38,359 x DRG weight",137904,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53522,,186% x Medicaid HMO amount,53522,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,122510,,"34,077 x DRG weight",122510,Other,base rate x DRG weight,104136,,"28,966 x DRG weight",104136,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28775,,DRG base rate x DRG weight + capital per discharge,28775,Other,100% of NY Medicaid HMO DRG,28775,,100% x Medicaid HMO amount,28775,Other,100% of NY Medicaid HMO DRG,28775,,100% x Medicaid HMO amount,28775,Other,100% of NY Medicaid HMO DRG,28775,,100% x Medicaid HMO amount,28775,Other,100% of NY Medicaid HMO DRG,64744,,225% x Medicaid HMO amount,64744,Other,225% of NY Medicaid HMO DRG,64744,,225% x Medicaid HMO amount,64744,Other,225% of NY Medicaid HMO DRG,64744,,225% x Medicaid HMO amount,64744,Other,225% of NY Medicaid HMO DRG,64744,,225% x Medicaid HMO amount,64744,Other,225% of NY Medicaid HMO DRG,40285,,140% x Medicaid HMO amount,40285,Other,140% of NY Medicaid HMO DRG,64744,,225% x Medicaid HMO amount,64744,Other,225% of NY Medicaid HMO DRG,79131,,275% x Medicaid HMO amount,79131,Other,275% of NY Medicaid HMO DRG,93231,,324% x Medicaid HMO amount,93231,Other,324% of NY Medicaid HMO DRG,61866,,215% x Medicaid HMO amount,61866,Other,215% of NY Medicaid HMO DRG,61866,,215% x Medicaid HMO amount,61866,Other,215% of NY Medicaid HMO DRG,35969,,125% x Medicaid HMO amount,35969,Other,125% of NY Medicaid HMO DRG,0.01,162240,
Neonate bwt 1500-2499g w major procedure,609-3,APR-DRG,,,,,,,,inpatient,,,1250219.15,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,328672,,"45,128 x DRG weight",328672,Other,base rate x DRG weight,295803,,"40,615 x DRG weight",295803,Other,base rate x DRG weight,279372,,"38,359 x DRG weight",279372,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,106859,,186% x Medicaid HMO amount,106859,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,248186,,"34,077 x DRG weight",248186,Other,base rate x DRG weight,210962,,"28,966 x DRG weight",210962,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,57451,,DRG base rate x DRG weight + capital per discharge,57451,Other,100% of NY Medicaid HMO DRG,57451,,100% x Medicaid HMO amount,57451,Other,100% of NY Medicaid HMO DRG,57451,,100% x Medicaid HMO amount,57451,Other,100% of NY Medicaid HMO DRG,57451,,100% x Medicaid HMO amount,57451,Other,100% of NY Medicaid HMO DRG,129265,,225% x Medicaid HMO amount,129265,Other,225% of NY Medicaid HMO DRG,129265,,225% x Medicaid HMO amount,129265,Other,225% of NY Medicaid HMO DRG,129265,,225% x Medicaid HMO amount,129265,Other,225% of NY Medicaid HMO DRG,129265,,225% x Medicaid HMO amount,129265,Other,225% of NY Medicaid HMO DRG,80431,,140% x Medicaid HMO amount,80431,Other,140% of NY Medicaid HMO DRG,129265,,225% x Medicaid HMO amount,129265,Other,225% of NY Medicaid HMO DRG,157990,,275% x Medicaid HMO amount,157990,Other,275% of NY Medicaid HMO DRG,186141,,324% x Medicaid HMO amount,186141,Other,324% of NY Medicaid HMO DRG,123520,,215% x Medicaid HMO amount,123520,Other,215% of NY Medicaid HMO DRG,123520,,215% x Medicaid HMO amount,123520,Other,215% of NY Medicaid HMO DRG,71814,,125% x Medicaid HMO amount,71814,Other,125% of NY Medicaid HMO DRG,0.01,328672,
Neonate bwt 1500-2499g w major procedure,609-4,APR-DRG,,,,,,,,inpatient,,,3369237.47,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,720432,,"45,128 x DRG weight",720432,Other,base rate x DRG weight,648386,,"40,615 x DRG weight",648386,Other,base rate x DRG weight,612371,,"38,359 x DRG weight",612371,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,232411,,186% x Medicaid HMO amount,232411,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,544012,,"34,077 x DRG weight",544012,Other,base rate x DRG weight,462419,,"28,966 x DRG weight",462419,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,124952,,DRG base rate x DRG weight + capital per discharge,124952,Other,100% of NY Medicaid HMO DRG,124952,,100% x Medicaid HMO amount,124952,Other,100% of NY Medicaid HMO DRG,124952,,100% x Medicaid HMO amount,124952,Other,100% of NY Medicaid HMO DRG,124952,,100% x Medicaid HMO amount,124952,Other,100% of NY Medicaid HMO DRG,281142,,225% x Medicaid HMO amount,281142,Other,225% of NY Medicaid HMO DRG,281142,,225% x Medicaid HMO amount,281142,Other,225% of NY Medicaid HMO DRG,281142,,225% x Medicaid HMO amount,281142,Other,225% of NY Medicaid HMO DRG,281142,,225% x Medicaid HMO amount,281142,Other,225% of NY Medicaid HMO DRG,174933,,140% x Medicaid HMO amount,174933,Other,140% of NY Medicaid HMO DRG,281142,,225% x Medicaid HMO amount,281142,Other,225% of NY Medicaid HMO DRG,343618,,275% x Medicaid HMO amount,343618,Other,275% of NY Medicaid HMO DRG,404844,,324% x Medicaid HMO amount,404844,Other,324% of NY Medicaid HMO DRG,268647,,215% x Medicaid HMO amount,268647,Other,215% of NY Medicaid HMO DRG,268647,,215% x Medicaid HMO amount,268647,Other,215% of NY Medicaid HMO DRG,156190,,125% x Medicaid HMO amount,156190,Other,125% of NY Medicaid HMO DRG,0.01,720432,
Neonate birthwt 1500-1999g w major anomaly,611-1,APR-DRG,,,,,,,,inpatient,,,279695.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,113046,,"45,128 x DRG weight",113046,Other,base rate x DRG weight,101741,,"40,615 x DRG weight",101741,Other,base rate x DRG weight,96089,,"38,359 x DRG weight",96089,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37756,,186% x Medicaid HMO amount,37756,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,85363,,"34,077 x DRG weight",85363,Other,base rate x DRG weight,72560,,"28,966 x DRG weight",72560,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20299,,DRG base rate x DRG weight + capital per discharge,20299,Other,100% of NY Medicaid HMO DRG,20299,,100% x Medicaid HMO amount,20299,Other,100% of NY Medicaid HMO DRG,20299,,100% x Medicaid HMO amount,20299,Other,100% of NY Medicaid HMO DRG,20299,,100% x Medicaid HMO amount,20299,Other,100% of NY Medicaid HMO DRG,45673,,225% x Medicaid HMO amount,45673,Other,225% of NY Medicaid HMO DRG,45673,,225% x Medicaid HMO amount,45673,Other,225% of NY Medicaid HMO DRG,45673,,225% x Medicaid HMO amount,45673,Other,225% of NY Medicaid HMO DRG,45673,,225% x Medicaid HMO amount,45673,Other,225% of NY Medicaid HMO DRG,28419,,140% x Medicaid HMO amount,28419,Other,140% of NY Medicaid HMO DRG,45673,,225% x Medicaid HMO amount,45673,Other,225% of NY Medicaid HMO DRG,55822,,275% x Medicaid HMO amount,55822,Other,275% of NY Medicaid HMO DRG,65769,,324% x Medicaid HMO amount,65769,Other,324% of NY Medicaid HMO DRG,43643,,215% x Medicaid HMO amount,43643,Other,215% of NY Medicaid HMO DRG,43643,,215% x Medicaid HMO amount,43643,Other,215% of NY Medicaid HMO DRG,25374,,125% x Medicaid HMO amount,25374,Other,125% of NY Medicaid HMO DRG,0.01,113046,
Neonate birthwt 1500-1999g w major anomaly,611-2,APR-DRG,,,,,,,,inpatient,,,172652.22,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,182087,,"45,128 x DRG weight",182087,Other,base rate x DRG weight,163877,,"40,615 x DRG weight",163877,Other,base rate x DRG weight,154775,,"38,359 x DRG weight",154775,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59883,,186% x Medicaid HMO amount,59883,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,137497,,"34,077 x DRG weight",137497,Other,base rate x DRG weight,116875,,"28,966 x DRG weight",116875,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32195,,DRG base rate x DRG weight + capital per discharge,32195,Other,100% of NY Medicaid HMO DRG,32195,,100% x Medicaid HMO amount,32195,Other,100% of NY Medicaid HMO DRG,32195,,100% x Medicaid HMO amount,32195,Other,100% of NY Medicaid HMO DRG,32195,,100% x Medicaid HMO amount,32195,Other,100% of NY Medicaid HMO DRG,72439,,225% x Medicaid HMO amount,72439,Other,225% of NY Medicaid HMO DRG,72439,,225% x Medicaid HMO amount,72439,Other,225% of NY Medicaid HMO DRG,72439,,225% x Medicaid HMO amount,72439,Other,225% of NY Medicaid HMO DRG,72439,,225% x Medicaid HMO amount,72439,Other,225% of NY Medicaid HMO DRG,45073,,140% x Medicaid HMO amount,45073,Other,140% of NY Medicaid HMO DRG,72439,,225% x Medicaid HMO amount,72439,Other,225% of NY Medicaid HMO DRG,88536,,275% x Medicaid HMO amount,88536,Other,275% of NY Medicaid HMO DRG,104312,,324% x Medicaid HMO amount,104312,Other,324% of NY Medicaid HMO DRG,69219,,215% x Medicaid HMO amount,69219,Other,215% of NY Medicaid HMO DRG,69219,,215% x Medicaid HMO amount,69219,Other,215% of NY Medicaid HMO DRG,40244,,125% x Medicaid HMO amount,40244,Other,125% of NY Medicaid HMO DRG,0.01,182087,
Neonate birthwt 1500-1999g w major anomaly,611-3,APR-DRG,,,,,,,,inpatient,,,1210512.11,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,282763,,"45,128 x DRG weight",282763,Other,base rate x DRG weight,254485,,"40,615 x DRG weight",254485,Other,base rate x DRG weight,240350,,"38,359 x DRG weight",240350,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,92146,,186% x Medicaid HMO amount,92146,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,213520,,"34,077 x DRG weight",213520,Other,base rate x DRG weight,181495,,"28,966 x DRG weight",181495,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49541,,DRG base rate x DRG weight + capital per discharge,49541,Other,100% of NY Medicaid HMO DRG,49541,,100% x Medicaid HMO amount,49541,Other,100% of NY Medicaid HMO DRG,49541,,100% x Medicaid HMO amount,49541,Other,100% of NY Medicaid HMO DRG,49541,,100% x Medicaid HMO amount,49541,Other,100% of NY Medicaid HMO DRG,111467,,225% x Medicaid HMO amount,111467,Other,225% of NY Medicaid HMO DRG,111467,,225% x Medicaid HMO amount,111467,Other,225% of NY Medicaid HMO DRG,111467,,225% x Medicaid HMO amount,111467,Other,225% of NY Medicaid HMO DRG,111467,,225% x Medicaid HMO amount,111467,Other,225% of NY Medicaid HMO DRG,69357,,140% x Medicaid HMO amount,69357,Other,140% of NY Medicaid HMO DRG,111467,,225% x Medicaid HMO amount,111467,Other,225% of NY Medicaid HMO DRG,136238,,275% x Medicaid HMO amount,136238,Other,275% of NY Medicaid HMO DRG,160513,,324% x Medicaid HMO amount,160513,Other,324% of NY Medicaid HMO DRG,106513,,215% x Medicaid HMO amount,106513,Other,215% of NY Medicaid HMO DRG,106513,,215% x Medicaid HMO amount,106513,Other,215% of NY Medicaid HMO DRG,61926,,125% x Medicaid HMO amount,61926,Other,125% of NY Medicaid HMO DRG,0.01,282763,
Neonate birthwt 1500-1999g w major anomaly,611-4,APR-DRG,,,,,,,,inpatient,,,337029.34,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,370668,,"45,128 x DRG weight",370668,Other,base rate x DRG weight,333599,,"40,615 x DRG weight",333599,Other,base rate x DRG weight,315069,,"38,359 x DRG weight",315069,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,120318,,186% x Medicaid HMO amount,120318,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,279898,,"34,077 x DRG weight",279898,Other,base rate x DRG weight,237918,,"28,966 x DRG weight",237918,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,64687,,DRG base rate x DRG weight + capital per discharge,64687,Other,100% of NY Medicaid HMO DRG,64687,,100% x Medicaid HMO amount,64687,Other,100% of NY Medicaid HMO DRG,64687,,100% x Medicaid HMO amount,64687,Other,100% of NY Medicaid HMO DRG,64687,,100% x Medicaid HMO amount,64687,Other,100% of NY Medicaid HMO DRG,145546,,225% x Medicaid HMO amount,145546,Other,225% of NY Medicaid HMO DRG,145546,,225% x Medicaid HMO amount,145546,Other,225% of NY Medicaid HMO DRG,145546,,225% x Medicaid HMO amount,145546,Other,225% of NY Medicaid HMO DRG,145546,,225% x Medicaid HMO amount,145546,Other,225% of NY Medicaid HMO DRG,90562,,140% x Medicaid HMO amount,90562,Other,140% of NY Medicaid HMO DRG,145546,,225% x Medicaid HMO amount,145546,Other,225% of NY Medicaid HMO DRG,177889,,275% x Medicaid HMO amount,177889,Other,275% of NY Medicaid HMO DRG,209586,,324% x Medicaid HMO amount,209586,Other,324% of NY Medicaid HMO DRG,139077,,215% x Medicaid HMO amount,139077,Other,215% of NY Medicaid HMO DRG,139077,,215% x Medicaid HMO amount,139077,Other,215% of NY Medicaid HMO DRG,80859,,125% x Medicaid HMO amount,80859,Other,125% of NY Medicaid HMO DRG,0.01,370668,
Neonate bwt 1500-1999g w resp dist synd/oth maj resp cond,612-1,APR-DRG,,,,,,,,inpatient,,,529544,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,158769,,"45,128 x DRG weight",158769,Other,base rate x DRG weight,142892,,"40,615 x DRG weight",142892,Other,base rate x DRG weight,134955,,"38,359 x DRG weight",134955,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52409,,186% x Medicaid HMO amount,52409,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,119890,,"34,077 x DRG weight",119890,Other,base rate x DRG weight,101908,,"28,966 x DRG weight",101908,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28177,,DRG base rate x DRG weight + capital per discharge,28177,Other,100% of NY Medicaid HMO DRG,28177,,100% x Medicaid HMO amount,28177,Other,100% of NY Medicaid HMO DRG,28177,,100% x Medicaid HMO amount,28177,Other,100% of NY Medicaid HMO DRG,28177,,100% x Medicaid HMO amount,28177,Other,100% of NY Medicaid HMO DRG,63398,,225% x Medicaid HMO amount,63398,Other,225% of NY Medicaid HMO DRG,63398,,225% x Medicaid HMO amount,63398,Other,225% of NY Medicaid HMO DRG,63398,,225% x Medicaid HMO amount,63398,Other,225% of NY Medicaid HMO DRG,63398,,225% x Medicaid HMO amount,63398,Other,225% of NY Medicaid HMO DRG,39448,,140% x Medicaid HMO amount,39448,Other,140% of NY Medicaid HMO DRG,63398,,225% x Medicaid HMO amount,63398,Other,225% of NY Medicaid HMO DRG,77487,,275% x Medicaid HMO amount,77487,Other,275% of NY Medicaid HMO DRG,91293,,324% x Medicaid HMO amount,91293,Other,324% of NY Medicaid HMO DRG,60581,,215% x Medicaid HMO amount,60581,Other,215% of NY Medicaid HMO DRG,60581,,215% x Medicaid HMO amount,60581,Other,215% of NY Medicaid HMO DRG,35221,,125% x Medicaid HMO amount,35221,Other,125% of NY Medicaid HMO DRG,0.01,158769,
Neonate bwt 1500-1999g w resp dist synd/oth maj resp cond,612-2,APR-DRG,,,,,,,,inpatient,,,1012716.45,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,205337,,"45,128 x DRG weight",205337,Other,base rate x DRG weight,184802,,"40,615 x DRG weight",184802,Other,base rate x DRG weight,174537,,"38,359 x DRG weight",174537,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,67334,,186% x Medicaid HMO amount,67334,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,155054,,"34,077 x DRG weight",155054,Other,base rate x DRG weight,131798,,"28,966 x DRG weight",131798,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36201,,DRG base rate x DRG weight + capital per discharge,36201,Other,100% of NY Medicaid HMO DRG,36201,,100% x Medicaid HMO amount,36201,Other,100% of NY Medicaid HMO DRG,36201,,100% x Medicaid HMO amount,36201,Other,100% of NY Medicaid HMO DRG,36201,,100% x Medicaid HMO amount,36201,Other,100% of NY Medicaid HMO DRG,81452,,225% x Medicaid HMO amount,81452,Other,225% of NY Medicaid HMO DRG,81452,,225% x Medicaid HMO amount,81452,Other,225% of NY Medicaid HMO DRG,81452,,225% x Medicaid HMO amount,81452,Other,225% of NY Medicaid HMO DRG,81452,,225% x Medicaid HMO amount,81452,Other,225% of NY Medicaid HMO DRG,50681,,140% x Medicaid HMO amount,50681,Other,140% of NY Medicaid HMO DRG,81452,,225% x Medicaid HMO amount,81452,Other,225% of NY Medicaid HMO DRG,99553,,275% x Medicaid HMO amount,99553,Other,275% of NY Medicaid HMO DRG,117291,,324% x Medicaid HMO amount,117291,Other,324% of NY Medicaid HMO DRG,77832,,215% x Medicaid HMO amount,77832,Other,215% of NY Medicaid HMO DRG,77832,,215% x Medicaid HMO amount,77832,Other,215% of NY Medicaid HMO DRG,45251,,125% x Medicaid HMO amount,45251,Other,125% of NY Medicaid HMO DRG,0.01,205337,
Neonate bwt 1500-1999g w resp dist synd/oth maj resp cond,612-3,APR-DRG,,,,,,,,inpatient,,,1436069.17,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,286247,,"45,128 x DRG weight",286247,Other,base rate x DRG weight,257621,,"40,615 x DRG weight",257621,Other,base rate x DRG weight,243311,,"38,359 x DRG weight",243311,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,93264,,186% x Medicaid HMO amount,93264,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,216150,,"34,077 x DRG weight",216150,Other,base rate x DRG weight,183731,,"28,966 x DRG weight",183731,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50142,,DRG base rate x DRG weight + capital per discharge,50142,Other,100% of NY Medicaid HMO DRG,50142,,100% x Medicaid HMO amount,50142,Other,100% of NY Medicaid HMO DRG,50142,,100% x Medicaid HMO amount,50142,Other,100% of NY Medicaid HMO DRG,50142,,100% x Medicaid HMO amount,50142,Other,100% of NY Medicaid HMO DRG,112820,,225% x Medicaid HMO amount,112820,Other,225% of NY Medicaid HMO DRG,112820,,225% x Medicaid HMO amount,112820,Other,225% of NY Medicaid HMO DRG,112820,,225% x Medicaid HMO amount,112820,Other,225% of NY Medicaid HMO DRG,112820,,225% x Medicaid HMO amount,112820,Other,225% of NY Medicaid HMO DRG,70199,,140% x Medicaid HMO amount,70199,Other,140% of NY Medicaid HMO DRG,112820,,225% x Medicaid HMO amount,112820,Other,225% of NY Medicaid HMO DRG,137891,,275% x Medicaid HMO amount,137891,Other,275% of NY Medicaid HMO DRG,162460,,324% x Medicaid HMO amount,162460,Other,324% of NY Medicaid HMO DRG,107805,,215% x Medicaid HMO amount,107805,Other,215% of NY Medicaid HMO DRG,107805,,215% x Medicaid HMO amount,107805,Other,215% of NY Medicaid HMO DRG,62678,,125% x Medicaid HMO amount,62678,Other,125% of NY Medicaid HMO DRG,0.01,286247,
Neonate bwt 1500-1999g w resp dist synd/oth maj resp cond,612-4,APR-DRG,,,,,,,,inpatient,,,1436069.17,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,382397,,"45,128 x DRG weight",382397,Other,base rate x DRG weight,344155,,"40,615 x DRG weight",344155,Other,base rate x DRG weight,325039,,"38,359 x DRG weight",325039,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,124077,,186% x Medicaid HMO amount,124077,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,288755,,"34,077 x DRG weight",288755,Other,base rate x DRG weight,245446,,"28,966 x DRG weight",245446,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,66708,,DRG base rate x DRG weight + capital per discharge,66708,Other,100% of NY Medicaid HMO DRG,66708,,100% x Medicaid HMO amount,66708,Other,100% of NY Medicaid HMO DRG,66708,,100% x Medicaid HMO amount,66708,Other,100% of NY Medicaid HMO DRG,66708,,100% x Medicaid HMO amount,66708,Other,100% of NY Medicaid HMO DRG,150093,,225% x Medicaid HMO amount,150093,Other,225% of NY Medicaid HMO DRG,150093,,225% x Medicaid HMO amount,150093,Other,225% of NY Medicaid HMO DRG,150093,,225% x Medicaid HMO amount,150093,Other,225% of NY Medicaid HMO DRG,150093,,225% x Medicaid HMO amount,150093,Other,225% of NY Medicaid HMO DRG,93391,,140% x Medicaid HMO amount,93391,Other,140% of NY Medicaid HMO DRG,150093,,225% x Medicaid HMO amount,150093,Other,225% of NY Medicaid HMO DRG,183447,,275% x Medicaid HMO amount,183447,Other,275% of NY Medicaid HMO DRG,216134,,324% x Medicaid HMO amount,216134,Other,324% of NY Medicaid HMO DRG,143422,,215% x Medicaid HMO amount,143422,Other,215% of NY Medicaid HMO DRG,143422,,215% x Medicaid HMO amount,143422,Other,215% of NY Medicaid HMO DRG,83385,,125% x Medicaid HMO amount,83385,Other,125% of NY Medicaid HMO DRG,0.01,382397,
Neonate birthwt 1500-1999g w congenital/perinatal infection,613-1,APR-DRG,,,,,,,,inpatient,,,362914,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,120226,,"45,128 x DRG weight",120226,Other,base rate x DRG weight,108202,,"40,615 x DRG weight",108202,Other,base rate x DRG weight,102192,,"38,359 x DRG weight",102192,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40057,,186% x Medicaid HMO amount,40057,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,90785,,"34,077 x DRG weight",90785,Other,base rate x DRG weight,77168,,"28,966 x DRG weight",77168,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21536,,DRG base rate x DRG weight + capital per discharge,21536,Other,100% of NY Medicaid HMO DRG,21536,,100% x Medicaid HMO amount,21536,Other,100% of NY Medicaid HMO DRG,21536,,100% x Medicaid HMO amount,21536,Other,100% of NY Medicaid HMO DRG,21536,,100% x Medicaid HMO amount,21536,Other,100% of NY Medicaid HMO DRG,48456,,225% x Medicaid HMO amount,48456,Other,225% of NY Medicaid HMO DRG,48456,,225% x Medicaid HMO amount,48456,Other,225% of NY Medicaid HMO DRG,48456,,225% x Medicaid HMO amount,48456,Other,225% of NY Medicaid HMO DRG,48456,,225% x Medicaid HMO amount,48456,Other,225% of NY Medicaid HMO DRG,30150,,140% x Medicaid HMO amount,30150,Other,140% of NY Medicaid HMO DRG,48456,,225% x Medicaid HMO amount,48456,Other,225% of NY Medicaid HMO DRG,59224,,275% x Medicaid HMO amount,59224,Other,275% of NY Medicaid HMO DRG,69777,,324% x Medicaid HMO amount,69777,Other,324% of NY Medicaid HMO DRG,46302,,215% x Medicaid HMO amount,46302,Other,215% of NY Medicaid HMO DRG,46302,,215% x Medicaid HMO amount,46302,Other,215% of NY Medicaid HMO DRG,26920,,125% x Medicaid HMO amount,26920,Other,125% of NY Medicaid HMO DRG,0.01,120226,
Neonate birthwt 1500-1999g w congenital/perinatal infection,613-2,APR-DRG,,,,,,,,inpatient,,,1361680,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,181758,,"45,128 x DRG weight",181758,Other,base rate x DRG weight,163581,,"40,615 x DRG weight",163581,Other,base rate x DRG weight,154495,,"38,359 x DRG weight",154495,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59777,,186% x Medicaid HMO amount,59777,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,137249,,"34,077 x DRG weight",137249,Other,base rate x DRG weight,116663,,"28,966 x DRG weight",116663,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32138,,DRG base rate x DRG weight + capital per discharge,32138,Other,100% of NY Medicaid HMO DRG,32138,,100% x Medicaid HMO amount,32138,Other,100% of NY Medicaid HMO DRG,32138,,100% x Medicaid HMO amount,32138,Other,100% of NY Medicaid HMO DRG,32138,,100% x Medicaid HMO amount,32138,Other,100% of NY Medicaid HMO DRG,72311,,225% x Medicaid HMO amount,72311,Other,225% of NY Medicaid HMO DRG,72311,,225% x Medicaid HMO amount,72311,Other,225% of NY Medicaid HMO DRG,72311,,225% x Medicaid HMO amount,72311,Other,225% of NY Medicaid HMO DRG,72311,,225% x Medicaid HMO amount,72311,Other,225% of NY Medicaid HMO DRG,44993,,140% x Medicaid HMO amount,44993,Other,140% of NY Medicaid HMO DRG,72311,,225% x Medicaid HMO amount,72311,Other,225% of NY Medicaid HMO DRG,88380,,275% x Medicaid HMO amount,88380,Other,275% of NY Medicaid HMO DRG,104127,,324% x Medicaid HMO amount,104127,Other,324% of NY Medicaid HMO DRG,69097,,215% x Medicaid HMO amount,69097,Other,215% of NY Medicaid HMO DRG,69097,,215% x Medicaid HMO amount,69097,Other,215% of NY Medicaid HMO DRG,40173,,125% x Medicaid HMO amount,40173,Other,125% of NY Medicaid HMO DRG,0.01,181758,
Neonate birthwt 1500-1999g w congenital/perinatal infection,613-3,APR-DRG,,,,,,,,inpatient,,,814185.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,227793,,"45,128 x DRG weight",227793,Other,base rate x DRG weight,205012,,"40,615 x DRG weight",205012,Other,base rate x DRG weight,193625,,"38,359 x DRG weight",193625,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,74530,,186% x Medicaid HMO amount,74530,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,172010,,"34,077 x DRG weight",172010,Other,base rate x DRG weight,146212,,"28,966 x DRG weight",146212,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40070,,DRG base rate x DRG weight + capital per discharge,40070,Other,100% of NY Medicaid HMO DRG,40070,,100% x Medicaid HMO amount,40070,Other,100% of NY Medicaid HMO DRG,40070,,100% x Medicaid HMO amount,40070,Other,100% of NY Medicaid HMO DRG,40070,,100% x Medicaid HMO amount,40070,Other,100% of NY Medicaid HMO DRG,90158,,225% x Medicaid HMO amount,90158,Other,225% of NY Medicaid HMO DRG,90158,,225% x Medicaid HMO amount,90158,Other,225% of NY Medicaid HMO DRG,90158,,225% x Medicaid HMO amount,90158,Other,225% of NY Medicaid HMO DRG,90158,,225% x Medicaid HMO amount,90158,Other,225% of NY Medicaid HMO DRG,56098,,140% x Medicaid HMO amount,56098,Other,140% of NY Medicaid HMO DRG,90158,,225% x Medicaid HMO amount,90158,Other,225% of NY Medicaid HMO DRG,110193,,275% x Medicaid HMO amount,110193,Other,275% of NY Medicaid HMO DRG,129827,,324% x Medicaid HMO amount,129827,Other,324% of NY Medicaid HMO DRG,86151,,215% x Medicaid HMO amount,86151,Other,215% of NY Medicaid HMO DRG,86151,,215% x Medicaid HMO amount,86151,Other,215% of NY Medicaid HMO DRG,50088,,125% x Medicaid HMO amount,50088,Other,125% of NY Medicaid HMO DRG,0.01,227793,
Neonate birthwt 1500-1999g w congenital/perinatal infection,613-4,APR-DRG,,,,,,,,inpatient,,,752150,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,233677,,"45,128 x DRG weight",233677,Other,base rate x DRG weight,210309,,"40,615 x DRG weight",210309,Other,base rate x DRG weight,198627,,"38,359 x DRG weight",198627,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,76416,,186% x Medicaid HMO amount,76416,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,176454,,"34,077 x DRG weight",176454,Other,base rate x DRG weight,149989,,"28,966 x DRG weight",149989,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41084,,DRG base rate x DRG weight + capital per discharge,41084,Other,100% of NY Medicaid HMO DRG,41084,,100% x Medicaid HMO amount,41084,Other,100% of NY Medicaid HMO DRG,41084,,100% x Medicaid HMO amount,41084,Other,100% of NY Medicaid HMO DRG,41084,,100% x Medicaid HMO amount,41084,Other,100% of NY Medicaid HMO DRG,92439,,225% x Medicaid HMO amount,92439,Other,225% of NY Medicaid HMO DRG,92439,,225% x Medicaid HMO amount,92439,Other,225% of NY Medicaid HMO DRG,92439,,225% x Medicaid HMO amount,92439,Other,225% of NY Medicaid HMO DRG,92439,,225% x Medicaid HMO amount,92439,Other,225% of NY Medicaid HMO DRG,57518,,140% x Medicaid HMO amount,57518,Other,140% of NY Medicaid HMO DRG,92439,,225% x Medicaid HMO amount,92439,Other,225% of NY Medicaid HMO DRG,112981,,275% x Medicaid HMO amount,112981,Other,275% of NY Medicaid HMO DRG,133112,,324% x Medicaid HMO amount,133112,Other,324% of NY Medicaid HMO DRG,88331,,215% x Medicaid HMO amount,88331,Other,215% of NY Medicaid HMO DRG,88331,,215% x Medicaid HMO amount,88331,Other,215% of NY Medicaid HMO DRG,51355,,125% x Medicaid HMO amount,51355,Other,125% of NY Medicaid HMO DRG,0.01,233677,
Neonate bwt 1500-1999g w or w/o other significant condition,614-1,APR-DRG,,,,,,,,inpatient,,,236221,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,90012,,"45,128 x DRG weight",90012,Other,base rate x DRG weight,81011,,"40,615 x DRG weight",81011,Other,base rate x DRG weight,76511,,"38,359 x DRG weight",76511,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30374,,186% x Medicaid HMO amount,30374,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,67970,,"34,077 x DRG weight",67970,Other,base rate x DRG weight,57776,,"28,966 x DRG weight",57776,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16330,,DRG base rate x DRG weight + capital per discharge,16330,Other,100% of NY Medicaid HMO DRG,16330,,100% x Medicaid HMO amount,16330,Other,100% of NY Medicaid HMO DRG,16330,,100% x Medicaid HMO amount,16330,Other,100% of NY Medicaid HMO DRG,16330,,100% x Medicaid HMO amount,16330,Other,100% of NY Medicaid HMO DRG,36743,,225% x Medicaid HMO amount,36743,Other,225% of NY Medicaid HMO DRG,36743,,225% x Medicaid HMO amount,36743,Other,225% of NY Medicaid HMO DRG,36743,,225% x Medicaid HMO amount,36743,Other,225% of NY Medicaid HMO DRG,36743,,225% x Medicaid HMO amount,36743,Other,225% of NY Medicaid HMO DRG,22862,,140% x Medicaid HMO amount,22862,Other,140% of NY Medicaid HMO DRG,36743,,225% x Medicaid HMO amount,36743,Other,225% of NY Medicaid HMO DRG,44908,,275% x Medicaid HMO amount,44908,Other,275% of NY Medicaid HMO DRG,52909,,324% x Medicaid HMO amount,52909,Other,324% of NY Medicaid HMO DRG,35110,,215% x Medicaid HMO amount,35110,Other,215% of NY Medicaid HMO DRG,35110,,215% x Medicaid HMO amount,35110,Other,215% of NY Medicaid HMO DRG,20413,,125% x Medicaid HMO amount,20413,Other,125% of NY Medicaid HMO DRG,0.01,90012,
Neonate bwt 1500-1999g w or w/o other significant condition,614-2,APR-DRG,,,,,,,,inpatient,,,643544.69,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,148846,,"45,128 x DRG weight",148846,Other,base rate x DRG weight,133960,,"40,615 x DRG weight",133960,Other,base rate x DRG weight,126519,,"38,359 x DRG weight",126519,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49229,,186% x Medicaid HMO amount,49229,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,112396,,"34,077 x DRG weight",112396,Other,base rate x DRG weight,95539,,"28,966 x DRG weight",95539,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26467,,DRG base rate x DRG weight + capital per discharge,26467,Other,100% of NY Medicaid HMO DRG,26467,,100% x Medicaid HMO amount,26467,Other,100% of NY Medicaid HMO DRG,26467,,100% x Medicaid HMO amount,26467,Other,100% of NY Medicaid HMO DRG,26467,,100% x Medicaid HMO amount,26467,Other,100% of NY Medicaid HMO DRG,59551,,225% x Medicaid HMO amount,59551,Other,225% of NY Medicaid HMO DRG,59551,,225% x Medicaid HMO amount,59551,Other,225% of NY Medicaid HMO DRG,59551,,225% x Medicaid HMO amount,59551,Other,225% of NY Medicaid HMO DRG,59551,,225% x Medicaid HMO amount,59551,Other,225% of NY Medicaid HMO DRG,37054,,140% x Medicaid HMO amount,37054,Other,140% of NY Medicaid HMO DRG,59551,,225% x Medicaid HMO amount,59551,Other,225% of NY Medicaid HMO DRG,72784,,275% x Medicaid HMO amount,72784,Other,275% of NY Medicaid HMO DRG,85753,,324% x Medicaid HMO amount,85753,Other,324% of NY Medicaid HMO DRG,56904,,215% x Medicaid HMO amount,56904,Other,215% of NY Medicaid HMO DRG,56904,,215% x Medicaid HMO amount,56904,Other,215% of NY Medicaid HMO DRG,33084,,125% x Medicaid HMO amount,33084,Other,125% of NY Medicaid HMO DRG,0.01,148846,
Neonate bwt 1500-1999g w or w/o other significant condition,614-3,APR-DRG,,,,,,,,inpatient,,,1187147,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,227269,,"45,128 x DRG weight",227269,Other,base rate x DRG weight,204541,,"40,615 x DRG weight",204541,Other,base rate x DRG weight,193180,,"38,359 x DRG weight",193180,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,74363,,186% x Medicaid HMO amount,74363,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,171615,,"34,077 x DRG weight",171615,Other,base rate x DRG weight,145876,,"28,966 x DRG weight",145876,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39980,,DRG base rate x DRG weight + capital per discharge,39980,Other,100% of NY Medicaid HMO DRG,39980,,100% x Medicaid HMO amount,39980,Other,100% of NY Medicaid HMO DRG,39980,,100% x Medicaid HMO amount,39980,Other,100% of NY Medicaid HMO DRG,39980,,100% x Medicaid HMO amount,39980,Other,100% of NY Medicaid HMO DRG,89955,,225% x Medicaid HMO amount,89955,Other,225% of NY Medicaid HMO DRG,89955,,225% x Medicaid HMO amount,89955,Other,225% of NY Medicaid HMO DRG,89955,,225% x Medicaid HMO amount,89955,Other,225% of NY Medicaid HMO DRG,89955,,225% x Medicaid HMO amount,89955,Other,225% of NY Medicaid HMO DRG,55972,,140% x Medicaid HMO amount,55972,Other,140% of NY Medicaid HMO DRG,89955,,225% x Medicaid HMO amount,89955,Other,225% of NY Medicaid HMO DRG,109945,,275% x Medicaid HMO amount,109945,Other,275% of NY Medicaid HMO DRG,129535,,324% x Medicaid HMO amount,129535,Other,324% of NY Medicaid HMO DRG,85957,,215% x Medicaid HMO amount,85957,Other,215% of NY Medicaid HMO DRG,85957,,215% x Medicaid HMO amount,85957,Other,215% of NY Medicaid HMO DRG,49975,,125% x Medicaid HMO amount,49975,Other,125% of NY Medicaid HMO DRG,0.01,227269,
Neonate bwt 1500-1999g w or w/o other significant condition,614-4,APR-DRG,,,,,,,,inpatient,,,31433,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,227269,,"45,128 x DRG weight",227269,Other,base rate x DRG weight,204541,,"40,615 x DRG weight",204541,Other,base rate x DRG weight,193180,,"38,359 x DRG weight",193180,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,74363,,186% x Medicaid HMO amount,74363,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,171615,,"34,077 x DRG weight",171615,Other,base rate x DRG weight,145876,,"28,966 x DRG weight",145876,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39980,,DRG base rate x DRG weight + capital per discharge,39980,Other,100% of NY Medicaid HMO DRG,39980,,100% x Medicaid HMO amount,39980,Other,100% of NY Medicaid HMO DRG,39980,,100% x Medicaid HMO amount,39980,Other,100% of NY Medicaid HMO DRG,39980,,100% x Medicaid HMO amount,39980,Other,100% of NY Medicaid HMO DRG,89955,,225% x Medicaid HMO amount,89955,Other,225% of NY Medicaid HMO DRG,89955,,225% x Medicaid HMO amount,89955,Other,225% of NY Medicaid HMO DRG,89955,,225% x Medicaid HMO amount,89955,Other,225% of NY Medicaid HMO DRG,89955,,225% x Medicaid HMO amount,89955,Other,225% of NY Medicaid HMO DRG,55972,,140% x Medicaid HMO amount,55972,Other,140% of NY Medicaid HMO DRG,89955,,225% x Medicaid HMO amount,89955,Other,225% of NY Medicaid HMO DRG,109945,,275% x Medicaid HMO amount,109945,Other,275% of NY Medicaid HMO DRG,129535,,324% x Medicaid HMO amount,129535,Other,324% of NY Medicaid HMO DRG,85957,,215% x Medicaid HMO amount,85957,Other,215% of NY Medicaid HMO DRG,85957,,215% x Medicaid HMO amount,85957,Other,215% of NY Medicaid HMO DRG,49975,,125% x Medicaid HMO amount,49975,Other,125% of NY Medicaid HMO DRG,0.01,227269,
Neonate bwt 2000-2499g w major anomaly,621-1,APR-DRG,,,,,,,,inpatient,,,109375.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40963,,"45,128 x DRG weight",40963,Other,base rate x DRG weight,36866,,"40,615 x DRG weight",36866,Other,base rate x DRG weight,34818,,"38,359 x DRG weight",34818,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14655,,186% x Medicaid HMO amount,14655,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30932,,"34,077 x DRG weight",30932,Other,base rate x DRG weight,26292,,"28,966 x DRG weight",26292,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7879,,DRG base rate x DRG weight + capital per discharge,7879,Other,100% of NY Medicaid HMO DRG,7879,,100% x Medicaid HMO amount,7879,Other,100% of NY Medicaid HMO DRG,7879,,100% x Medicaid HMO amount,7879,Other,100% of NY Medicaid HMO DRG,7879,,100% x Medicaid HMO amount,7879,Other,100% of NY Medicaid HMO DRG,17728,,225% x Medicaid HMO amount,17728,Other,225% of NY Medicaid HMO DRG,17728,,225% x Medicaid HMO amount,17728,Other,225% of NY Medicaid HMO DRG,17728,,225% x Medicaid HMO amount,17728,Other,225% of NY Medicaid HMO DRG,17728,,225% x Medicaid HMO amount,17728,Other,225% of NY Medicaid HMO DRG,11031,,140% x Medicaid HMO amount,11031,Other,140% of NY Medicaid HMO DRG,17728,,225% x Medicaid HMO amount,17728,Other,225% of NY Medicaid HMO DRG,21667,,275% x Medicaid HMO amount,21667,Other,275% of NY Medicaid HMO DRG,25528,,324% x Medicaid HMO amount,25528,Other,324% of NY Medicaid HMO DRG,16940,,215% x Medicaid HMO amount,16940,Other,215% of NY Medicaid HMO DRG,16940,,215% x Medicaid HMO amount,16940,Other,215% of NY Medicaid HMO DRG,9849,,125% x Medicaid HMO amount,9849,Other,125% of NY Medicaid HMO DRG,0.01,40963,
Neonate bwt 2000-2499g w major anomaly,621-2,APR-DRG,,,,,,,,inpatient,,,575261.4,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,94498,,"45,128 x DRG weight",94498,Other,base rate x DRG weight,85048,,"40,615 x DRG weight",85048,Other,base rate x DRG weight,80324,,"38,359 x DRG weight",80324,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31812,,186% x Medicaid HMO amount,31812,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,71357,,"34,077 x DRG weight",71357,Other,base rate x DRG weight,60655,,"28,966 x DRG weight",60655,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17103,,DRG base rate x DRG weight + capital per discharge,17103,Other,100% of NY Medicaid HMO DRG,17103,,100% x Medicaid HMO amount,17103,Other,100% of NY Medicaid HMO DRG,17103,,100% x Medicaid HMO amount,17103,Other,100% of NY Medicaid HMO DRG,17103,,100% x Medicaid HMO amount,17103,Other,100% of NY Medicaid HMO DRG,38482,,225% x Medicaid HMO amount,38482,Other,225% of NY Medicaid HMO DRG,38482,,225% x Medicaid HMO amount,38482,Other,225% of NY Medicaid HMO DRG,38482,,225% x Medicaid HMO amount,38482,Other,225% of NY Medicaid HMO DRG,38482,,225% x Medicaid HMO amount,38482,Other,225% of NY Medicaid HMO DRG,23944,,140% x Medicaid HMO amount,23944,Other,140% of NY Medicaid HMO DRG,38482,,225% x Medicaid HMO amount,38482,Other,225% of NY Medicaid HMO DRG,47033,,275% x Medicaid HMO amount,47033,Other,275% of NY Medicaid HMO DRG,55414,,324% x Medicaid HMO amount,55414,Other,324% of NY Medicaid HMO DRG,36771,,215% x Medicaid HMO amount,36771,Other,215% of NY Medicaid HMO DRG,36771,,215% x Medicaid HMO amount,36771,Other,215% of NY Medicaid HMO DRG,21379,,125% x Medicaid HMO amount,21379,Other,125% of NY Medicaid HMO DRG,0.01,94498,
Neonate bwt 2000-2499g w major anomaly,621-3,APR-DRG,,,,,,,,inpatient,,,814185.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,179533,,"45,128 x DRG weight",179533,Other,base rate x DRG weight,161579,,"40,615 x DRG weight",161579,Other,base rate x DRG weight,152604,,"38,359 x DRG weight",152604,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59064,,186% x Medicaid HMO amount,59064,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,135569,,"34,077 x DRG weight",135569,Other,base rate x DRG weight,115235,,"28,966 x DRG weight",115235,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31755,,DRG base rate x DRG weight + capital per discharge,31755,Other,100% of NY Medicaid HMO DRG,31755,,100% x Medicaid HMO amount,31755,Other,100% of NY Medicaid HMO DRG,31755,,100% x Medicaid HMO amount,31755,Other,100% of NY Medicaid HMO DRG,31755,,100% x Medicaid HMO amount,31755,Other,100% of NY Medicaid HMO DRG,71449,,225% x Medicaid HMO amount,71449,Other,225% of NY Medicaid HMO DRG,71449,,225% x Medicaid HMO amount,71449,Other,225% of NY Medicaid HMO DRG,71449,,225% x Medicaid HMO amount,71449,Other,225% of NY Medicaid HMO DRG,71449,,225% x Medicaid HMO amount,71449,Other,225% of NY Medicaid HMO DRG,44457,,140% x Medicaid HMO amount,44457,Other,140% of NY Medicaid HMO DRG,71449,,225% x Medicaid HMO amount,71449,Other,225% of NY Medicaid HMO DRG,87326,,275% x Medicaid HMO amount,87326,Other,275% of NY Medicaid HMO DRG,102886,,324% x Medicaid HMO amount,102886,Other,324% of NY Medicaid HMO DRG,68273,,215% x Medicaid HMO amount,68273,Other,215% of NY Medicaid HMO DRG,68273,,215% x Medicaid HMO amount,68273,Other,215% of NY Medicaid HMO DRG,39694,,125% x Medicaid HMO amount,39694,Other,125% of NY Medicaid HMO DRG,0.01,179533,
Neonate bwt 2000-2499g w major anomaly,621-4,APR-DRG,,,,,,,,inpatient,,,752150,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,306514,,"45,128 x DRG weight",306514,Other,base rate x DRG weight,275861,,"40,615 x DRG weight",275861,Other,base rate x DRG weight,260538,,"38,359 x DRG weight",260538,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,99759,,186% x Medicaid HMO amount,99759,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,231454,,"34,077 x DRG weight",231454,Other,base rate x DRG weight,196740,,"28,966 x DRG weight",196740,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53634,,DRG base rate x DRG weight + capital per discharge,53634,Other,100% of NY Medicaid HMO DRG,53634,,100% x Medicaid HMO amount,53634,Other,100% of NY Medicaid HMO DRG,53634,,100% x Medicaid HMO amount,53634,Other,100% of NY Medicaid HMO DRG,53634,,100% x Medicaid HMO amount,53634,Other,100% of NY Medicaid HMO DRG,120677,,225% x Medicaid HMO amount,120677,Other,225% of NY Medicaid HMO DRG,120677,,225% x Medicaid HMO amount,120677,Other,225% of NY Medicaid HMO DRG,120677,,225% x Medicaid HMO amount,120677,Other,225% of NY Medicaid HMO DRG,120677,,225% x Medicaid HMO amount,120677,Other,225% of NY Medicaid HMO DRG,75088,,140% x Medicaid HMO amount,75088,Other,140% of NY Medicaid HMO DRG,120677,,225% x Medicaid HMO amount,120677,Other,225% of NY Medicaid HMO DRG,147494,,275% x Medicaid HMO amount,147494,Other,275% of NY Medicaid HMO DRG,173774,,324% x Medicaid HMO amount,173774,Other,324% of NY Medicaid HMO DRG,115313,,215% x Medicaid HMO amount,115313,Other,215% of NY Medicaid HMO DRG,115313,,215% x Medicaid HMO amount,115313,Other,215% of NY Medicaid HMO DRG,67043,,125% x Medicaid HMO amount,67043,Other,125% of NY Medicaid HMO DRG,0.01,306514,
Neonate bwt 2000-2499g w resp dist synd/oth maj resp cond,622-1,APR-DRG,,,,,,,,inpatient,,,307909.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,87426,,"45,128 x DRG weight",87426,Other,base rate x DRG weight,78683,,"40,615 x DRG weight",78683,Other,base rate x DRG weight,74313,,"38,359 x DRG weight",74313,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29546,,186% x Medicaid HMO amount,29546,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,66017,,"34,077 x DRG weight",66017,Other,base rate x DRG weight,56116,,"28,966 x DRG weight",56116,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15885,,DRG base rate x DRG weight + capital per discharge,15885,Other,100% of NY Medicaid HMO DRG,15885,,100% x Medicaid HMO amount,15885,Other,100% of NY Medicaid HMO DRG,15885,,100% x Medicaid HMO amount,15885,Other,100% of NY Medicaid HMO DRG,15885,,100% x Medicaid HMO amount,15885,Other,100% of NY Medicaid HMO DRG,35741,,225% x Medicaid HMO amount,35741,Other,225% of NY Medicaid HMO DRG,35741,,225% x Medicaid HMO amount,35741,Other,225% of NY Medicaid HMO DRG,35741,,225% x Medicaid HMO amount,35741,Other,225% of NY Medicaid HMO DRG,35741,,225% x Medicaid HMO amount,35741,Other,225% of NY Medicaid HMO DRG,22239,,140% x Medicaid HMO amount,22239,Other,140% of NY Medicaid HMO DRG,35741,,225% x Medicaid HMO amount,35741,Other,225% of NY Medicaid HMO DRG,43684,,275% x Medicaid HMO amount,43684,Other,275% of NY Medicaid HMO DRG,51467,,324% x Medicaid HMO amount,51467,Other,324% of NY Medicaid HMO DRG,34153,,215% x Medicaid HMO amount,34153,Other,215% of NY Medicaid HMO DRG,34153,,215% x Medicaid HMO amount,34153,Other,215% of NY Medicaid HMO DRG,19856,,125% x Medicaid HMO amount,19856,Other,125% of NY Medicaid HMO DRG,0.01,87426,
Neonate bwt 2000-2499g w resp dist synd/oth maj resp cond,622-2,APR-DRG,,,,,,,,inpatient,,,519174,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,118705,,"45,128 x DRG weight",118705,Other,base rate x DRG weight,106834,,"40,615 x DRG weight",106834,Other,base rate x DRG weight,100900,,"38,359 x DRG weight",100900,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39570,,186% x Medicaid HMO amount,39570,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,89636,,"34,077 x DRG weight",89636,Other,base rate x DRG weight,76192,,"28,966 x DRG weight",76192,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21274,,DRG base rate x DRG weight + capital per discharge,21274,Other,100% of NY Medicaid HMO DRG,21274,,100% x Medicaid HMO amount,21274,Other,100% of NY Medicaid HMO DRG,21274,,100% x Medicaid HMO amount,21274,Other,100% of NY Medicaid HMO DRG,21274,,100% x Medicaid HMO amount,21274,Other,100% of NY Medicaid HMO DRG,47867,,225% x Medicaid HMO amount,47867,Other,225% of NY Medicaid HMO DRG,47867,,225% x Medicaid HMO amount,47867,Other,225% of NY Medicaid HMO DRG,47867,,225% x Medicaid HMO amount,47867,Other,225% of NY Medicaid HMO DRG,47867,,225% x Medicaid HMO amount,47867,Other,225% of NY Medicaid HMO DRG,29784,,140% x Medicaid HMO amount,29784,Other,140% of NY Medicaid HMO DRG,47867,,225% x Medicaid HMO amount,47867,Other,225% of NY Medicaid HMO DRG,58504,,275% x Medicaid HMO amount,58504,Other,275% of NY Medicaid HMO DRG,68928,,324% x Medicaid HMO amount,68928,Other,324% of NY Medicaid HMO DRG,45739,,215% x Medicaid HMO amount,45739,Other,215% of NY Medicaid HMO DRG,45739,,215% x Medicaid HMO amount,45739,Other,215% of NY Medicaid HMO DRG,26593,,125% x Medicaid HMO amount,26593,Other,125% of NY Medicaid HMO DRG,0.01,118705,
Neonate bwt 2000-2499g w resp dist synd/oth maj resp cond,622-3,APR-DRG,,,,,,,,inpatient,,,810939.13,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,162723,,"45,128 x DRG weight",162723,Other,base rate x DRG weight,146450,,"40,615 x DRG weight",146450,Other,base rate x DRG weight,138315,,"38,359 x DRG weight",138315,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53676,,186% x Medicaid HMO amount,53676,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,122875,,"34,077 x DRG weight",122875,Other,base rate x DRG weight,104446,,"28,966 x DRG weight",104446,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28858,,DRG base rate x DRG weight + capital per discharge,28858,Other,100% of NY Medicaid HMO DRG,28858,,100% x Medicaid HMO amount,28858,Other,100% of NY Medicaid HMO DRG,28858,,100% x Medicaid HMO amount,28858,Other,100% of NY Medicaid HMO DRG,28858,,100% x Medicaid HMO amount,28858,Other,100% of NY Medicaid HMO DRG,64931,,225% x Medicaid HMO amount,64931,Other,225% of NY Medicaid HMO DRG,64931,,225% x Medicaid HMO amount,64931,Other,225% of NY Medicaid HMO DRG,64931,,225% x Medicaid HMO amount,64931,Other,225% of NY Medicaid HMO DRG,64931,,225% x Medicaid HMO amount,64931,Other,225% of NY Medicaid HMO DRG,40401,,140% x Medicaid HMO amount,40401,Other,140% of NY Medicaid HMO DRG,64931,,225% x Medicaid HMO amount,64931,Other,225% of NY Medicaid HMO DRG,79360,,275% x Medicaid HMO amount,79360,Other,275% of NY Medicaid HMO DRG,93500,,324% x Medicaid HMO amount,93500,Other,324% of NY Medicaid HMO DRG,62045,,215% x Medicaid HMO amount,62045,Other,215% of NY Medicaid HMO DRG,62045,,215% x Medicaid HMO amount,62045,Other,215% of NY Medicaid HMO DRG,36073,,125% x Medicaid HMO amount,36073,Other,125% of NY Medicaid HMO DRG,0.01,162723,
Neonate bwt 2000-2499g w resp dist synd/oth maj resp cond,622-4,APR-DRG,,,,,,,,inpatient,,,579822.01,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,233267,,"45,128 x DRG weight",233267,Other,base rate x DRG weight,209939,,"40,615 x DRG weight",209939,Other,base rate x DRG weight,198278,,"38,359 x DRG weight",198278,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,76284,,186% x Medicaid HMO amount,76284,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,176144,,"34,077 x DRG weight",176144,Other,base rate x DRG weight,149725,,"28,966 x DRG weight",149725,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41013,,DRG base rate x DRG weight + capital per discharge,41013,Other,100% of NY Medicaid HMO DRG,41013,,100% x Medicaid HMO amount,41013,Other,100% of NY Medicaid HMO DRG,41013,,100% x Medicaid HMO amount,41013,Other,100% of NY Medicaid HMO DRG,41013,,100% x Medicaid HMO amount,41013,Other,100% of NY Medicaid HMO DRG,92279,,225% x Medicaid HMO amount,92279,Other,225% of NY Medicaid HMO DRG,92279,,225% x Medicaid HMO amount,92279,Other,225% of NY Medicaid HMO DRG,92279,,225% x Medicaid HMO amount,92279,Other,225% of NY Medicaid HMO DRG,92279,,225% x Medicaid HMO amount,92279,Other,225% of NY Medicaid HMO DRG,57418,,140% x Medicaid HMO amount,57418,Other,140% of NY Medicaid HMO DRG,92279,,225% x Medicaid HMO amount,92279,Other,225% of NY Medicaid HMO DRG,112786,,275% x Medicaid HMO amount,112786,Other,275% of NY Medicaid HMO DRG,132882,,324% x Medicaid HMO amount,132882,Other,324% of NY Medicaid HMO DRG,88178,,215% x Medicaid HMO amount,88178,Other,215% of NY Medicaid HMO DRG,88178,,215% x Medicaid HMO amount,88178,Other,215% of NY Medicaid HMO DRG,51266,,125% x Medicaid HMO amount,51266,Other,125% of NY Medicaid HMO DRG,0.01,233267,
Neonate bwt 2000-2499g w congenital/perinatal infection,623-1,APR-DRG,,,,,,,,inpatient,,,316312.8,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,65657,,"45,128 x DRG weight",65657,Other,base rate x DRG weight,59091,,"40,615 x DRG weight",59091,Other,base rate x DRG weight,55809,,"38,359 x DRG weight",55809,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22569,,186% x Medicaid HMO amount,22569,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49579,,"34,077 x DRG weight",49579,Other,base rate x DRG weight,42143,,"28,966 x DRG weight",42143,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12134,,DRG base rate x DRG weight + capital per discharge,12134,Other,100% of NY Medicaid HMO DRG,12134,,100% x Medicaid HMO amount,12134,Other,100% of NY Medicaid HMO DRG,12134,,100% x Medicaid HMO amount,12134,Other,100% of NY Medicaid HMO DRG,12134,,100% x Medicaid HMO amount,12134,Other,100% of NY Medicaid HMO DRG,27302,,225% x Medicaid HMO amount,27302,Other,225% of NY Medicaid HMO DRG,27302,,225% x Medicaid HMO amount,27302,Other,225% of NY Medicaid HMO DRG,27302,,225% x Medicaid HMO amount,27302,Other,225% of NY Medicaid HMO DRG,27302,,225% x Medicaid HMO amount,27302,Other,225% of NY Medicaid HMO DRG,16988,,140% x Medicaid HMO amount,16988,Other,140% of NY Medicaid HMO DRG,27302,,225% x Medicaid HMO amount,27302,Other,225% of NY Medicaid HMO DRG,33369,,275% x Medicaid HMO amount,33369,Other,275% of NY Medicaid HMO DRG,39314,,324% x Medicaid HMO amount,39314,Other,324% of NY Medicaid HMO DRG,26088,,215% x Medicaid HMO amount,26088,Other,215% of NY Medicaid HMO DRG,26088,,215% x Medicaid HMO amount,26088,Other,215% of NY Medicaid HMO DRG,15168,,125% x Medicaid HMO amount,15168,Other,125% of NY Medicaid HMO DRG,0.01,65657,
Neonate bwt 2000-2499g w congenital/perinatal infection,623-2,APR-DRG,,,,,,,,inpatient,,,472011.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,97395,,"45,128 x DRG weight",97395,Other,base rate x DRG weight,87655,,"40,615 x DRG weight",87655,Other,base rate x DRG weight,82786,,"38,359 x DRG weight",82786,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32740,,186% x Medicaid HMO amount,32740,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73545,,"34,077 x DRG weight",73545,Other,base rate x DRG weight,62514,,"28,966 x DRG weight",62514,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17602,,DRG base rate x DRG weight + capital per discharge,17602,Other,100% of NY Medicaid HMO DRG,17602,,100% x Medicaid HMO amount,17602,Other,100% of NY Medicaid HMO DRG,17602,,100% x Medicaid HMO amount,17602,Other,100% of NY Medicaid HMO DRG,17602,,100% x Medicaid HMO amount,17602,Other,100% of NY Medicaid HMO DRG,39605,,225% x Medicaid HMO amount,39605,Other,225% of NY Medicaid HMO DRG,39605,,225% x Medicaid HMO amount,39605,Other,225% of NY Medicaid HMO DRG,39605,,225% x Medicaid HMO amount,39605,Other,225% of NY Medicaid HMO DRG,39605,,225% x Medicaid HMO amount,39605,Other,225% of NY Medicaid HMO DRG,24643,,140% x Medicaid HMO amount,24643,Other,140% of NY Medicaid HMO DRG,39605,,225% x Medicaid HMO amount,39605,Other,225% of NY Medicaid HMO DRG,48406,,275% x Medicaid HMO amount,48406,Other,275% of NY Medicaid HMO DRG,57030,,324% x Medicaid HMO amount,57030,Other,324% of NY Medicaid HMO DRG,37844,,215% x Medicaid HMO amount,37844,Other,215% of NY Medicaid HMO DRG,37844,,215% x Medicaid HMO amount,37844,Other,215% of NY Medicaid HMO DRG,22003,,125% x Medicaid HMO amount,22003,Other,125% of NY Medicaid HMO DRG,0.01,97395,
Neonate bwt 2000-2499g w congenital/perinatal infection,623-3,APR-DRG,,,,,,,,inpatient,,,549076,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,141030,,"45,128 x DRG weight",141030,Other,base rate x DRG weight,126926,,"40,615 x DRG weight",126926,Other,base rate x DRG weight,119876,,"38,359 x DRG weight",119876,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46723,,186% x Medicaid HMO amount,46723,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,106494,,"34,077 x DRG weight",106494,Other,base rate x DRG weight,90522,,"28,966 x DRG weight",90522,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25120,,DRG base rate x DRG weight + capital per discharge,25120,Other,100% of NY Medicaid HMO DRG,25120,,100% x Medicaid HMO amount,25120,Other,100% of NY Medicaid HMO DRG,25120,,100% x Medicaid HMO amount,25120,Other,100% of NY Medicaid HMO DRG,25120,,100% x Medicaid HMO amount,25120,Other,100% of NY Medicaid HMO DRG,56520,,225% x Medicaid HMO amount,56520,Other,225% of NY Medicaid HMO DRG,56520,,225% x Medicaid HMO amount,56520,Other,225% of NY Medicaid HMO DRG,56520,,225% x Medicaid HMO amount,56520,Other,225% of NY Medicaid HMO DRG,56520,,225% x Medicaid HMO amount,56520,Other,225% of NY Medicaid HMO DRG,35168,,140% x Medicaid HMO amount,35168,Other,140% of NY Medicaid HMO DRG,56520,,225% x Medicaid HMO amount,56520,Other,225% of NY Medicaid HMO DRG,69080,,275% x Medicaid HMO amount,69080,Other,275% of NY Medicaid HMO DRG,81389,,324% x Medicaid HMO amount,81389,Other,324% of NY Medicaid HMO DRG,54008,,215% x Medicaid HMO amount,54008,Other,215% of NY Medicaid HMO DRG,54008,,215% x Medicaid HMO amount,54008,Other,215% of NY Medicaid HMO DRG,31400,,125% x Medicaid HMO amount,31400,Other,125% of NY Medicaid HMO DRG,0.01,141030,
Neonate bwt 2000-2499g w congenital/perinatal infection,623-4,APR-DRG,,,,,,,,inpatient,,,549076,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,141030,,"45,128 x DRG weight",141030,Other,base rate x DRG weight,126926,,"40,615 x DRG weight",126926,Other,base rate x DRG weight,119876,,"38,359 x DRG weight",119876,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46723,,186% x Medicaid HMO amount,46723,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,106494,,"34,077 x DRG weight",106494,Other,base rate x DRG weight,90522,,"28,966 x DRG weight",90522,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25120,,DRG base rate x DRG weight + capital per discharge,25120,Other,100% of NY Medicaid HMO DRG,25120,,100% x Medicaid HMO amount,25120,Other,100% of NY Medicaid HMO DRG,25120,,100% x Medicaid HMO amount,25120,Other,100% of NY Medicaid HMO DRG,25120,,100% x Medicaid HMO amount,25120,Other,100% of NY Medicaid HMO DRG,56520,,225% x Medicaid HMO amount,56520,Other,225% of NY Medicaid HMO DRG,56520,,225% x Medicaid HMO amount,56520,Other,225% of NY Medicaid HMO DRG,56520,,225% x Medicaid HMO amount,56520,Other,225% of NY Medicaid HMO DRG,56520,,225% x Medicaid HMO amount,56520,Other,225% of NY Medicaid HMO DRG,35168,,140% x Medicaid HMO amount,35168,Other,140% of NY Medicaid HMO DRG,56520,,225% x Medicaid HMO amount,56520,Other,225% of NY Medicaid HMO DRG,69080,,275% x Medicaid HMO amount,69080,Other,275% of NY Medicaid HMO DRG,81389,,324% x Medicaid HMO amount,81389,Other,324% of NY Medicaid HMO DRG,54008,,215% x Medicaid HMO amount,54008,Other,215% of NY Medicaid HMO DRG,54008,,215% x Medicaid HMO amount,54008,Other,215% of NY Medicaid HMO DRG,31400,,125% x Medicaid HMO amount,31400,Other,125% of NY Medicaid HMO DRG,0.01,141030,
Neonate bwt 2000-2499g w other significant condition,625-1,APR-DRG,,,,,,,,inpatient,,,316312.8,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,72196,,"45,128 x DRG weight",72196,Other,base rate x DRG weight,64976,,"40,615 x DRG weight",64976,Other,base rate x DRG weight,61367,,"38,359 x DRG weight",61367,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24664,,186% x Medicaid HMO amount,24664,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54516,,"34,077 x DRG weight",54516,Other,base rate x DRG weight,46340,,"28,966 x DRG weight",46340,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13260,,DRG base rate x DRG weight + capital per discharge,13260,Other,100% of NY Medicaid HMO DRG,13260,,100% x Medicaid HMO amount,13260,Other,100% of NY Medicaid HMO DRG,13260,,100% x Medicaid HMO amount,13260,Other,100% of NY Medicaid HMO DRG,13260,,100% x Medicaid HMO amount,13260,Other,100% of NY Medicaid HMO DRG,29835,,225% x Medicaid HMO amount,29835,Other,225% of NY Medicaid HMO DRG,29835,,225% x Medicaid HMO amount,29835,Other,225% of NY Medicaid HMO DRG,29835,,225% x Medicaid HMO amount,29835,Other,225% of NY Medicaid HMO DRG,29835,,225% x Medicaid HMO amount,29835,Other,225% of NY Medicaid HMO DRG,18564,,140% x Medicaid HMO amount,18564,Other,140% of NY Medicaid HMO DRG,29835,,225% x Medicaid HMO amount,29835,Other,225% of NY Medicaid HMO DRG,36465,,275% x Medicaid HMO amount,36465,Other,275% of NY Medicaid HMO DRG,42962,,324% x Medicaid HMO amount,42962,Other,324% of NY Medicaid HMO DRG,28509,,215% x Medicaid HMO amount,28509,Other,215% of NY Medicaid HMO DRG,28509,,215% x Medicaid HMO amount,28509,Other,215% of NY Medicaid HMO DRG,16575,,125% x Medicaid HMO amount,16575,Other,125% of NY Medicaid HMO DRG,0.01,72196,
Neonate bwt 2000-2499g w other significant condition,625-2,APR-DRG,,,,,,,,inpatient,,,472011.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,116760,,"45,128 x DRG weight",116760,Other,base rate x DRG weight,105083,,"40,615 x DRG weight",105083,Other,base rate x DRG weight,99246,,"38,359 x DRG weight",99246,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38947,,186% x Medicaid HMO amount,38947,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,88167,,"34,077 x DRG weight",88167,Other,base rate x DRG weight,74944,,"28,966 x DRG weight",74944,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20939,,DRG base rate x DRG weight + capital per discharge,20939,Other,100% of NY Medicaid HMO DRG,20939,,100% x Medicaid HMO amount,20939,Other,100% of NY Medicaid HMO DRG,20939,,100% x Medicaid HMO amount,20939,Other,100% of NY Medicaid HMO DRG,20939,,100% x Medicaid HMO amount,20939,Other,100% of NY Medicaid HMO DRG,47113,,225% x Medicaid HMO amount,47113,Other,225% of NY Medicaid HMO DRG,47113,,225% x Medicaid HMO amount,47113,Other,225% of NY Medicaid HMO DRG,47113,,225% x Medicaid HMO amount,47113,Other,225% of NY Medicaid HMO DRG,47113,,225% x Medicaid HMO amount,47113,Other,225% of NY Medicaid HMO DRG,29315,,140% x Medicaid HMO amount,29315,Other,140% of NY Medicaid HMO DRG,47113,,225% x Medicaid HMO amount,47113,Other,225% of NY Medicaid HMO DRG,57582,,275% x Medicaid HMO amount,57582,Other,275% of NY Medicaid HMO DRG,67842,,324% x Medicaid HMO amount,67842,Other,324% of NY Medicaid HMO DRG,45019,,215% x Medicaid HMO amount,45019,Other,215% of NY Medicaid HMO DRG,45019,,215% x Medicaid HMO amount,45019,Other,215% of NY Medicaid HMO DRG,26174,,125% x Medicaid HMO amount,26174,Other,125% of NY Medicaid HMO DRG,0.01,116760,
Neonate bwt 2000-2499g w other significant condition,625-3,APR-DRG,,,,,,,,inpatient,,,549076,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,148665,,"45,128 x DRG weight",148665,Other,base rate x DRG weight,133798,,"40,615 x DRG weight",133798,Other,base rate x DRG weight,126366,,"38,359 x DRG weight",126366,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49171,,186% x Medicaid HMO amount,49171,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,112260,,"34,077 x DRG weight",112260,Other,base rate x DRG weight,95423,,"28,966 x DRG weight",95423,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26436,,DRG base rate x DRG weight + capital per discharge,26436,Other,100% of NY Medicaid HMO DRG,26436,,100% x Medicaid HMO amount,26436,Other,100% of NY Medicaid HMO DRG,26436,,100% x Medicaid HMO amount,26436,Other,100% of NY Medicaid HMO DRG,26436,,100% x Medicaid HMO amount,26436,Other,100% of NY Medicaid HMO DRG,59481,,225% x Medicaid HMO amount,59481,Other,225% of NY Medicaid HMO DRG,59481,,225% x Medicaid HMO amount,59481,Other,225% of NY Medicaid HMO DRG,59481,,225% x Medicaid HMO amount,59481,Other,225% of NY Medicaid HMO DRG,59481,,225% x Medicaid HMO amount,59481,Other,225% of NY Medicaid HMO DRG,37010,,140% x Medicaid HMO amount,37010,Other,140% of NY Medicaid HMO DRG,59481,,225% x Medicaid HMO amount,59481,Other,225% of NY Medicaid HMO DRG,72699,,275% x Medicaid HMO amount,72699,Other,275% of NY Medicaid HMO DRG,85653,,324% x Medicaid HMO amount,85653,Other,324% of NY Medicaid HMO DRG,56837,,215% x Medicaid HMO amount,56837,Other,215% of NY Medicaid HMO DRG,56837,,215% x Medicaid HMO amount,56837,Other,215% of NY Medicaid HMO DRG,33045,,125% x Medicaid HMO amount,33045,Other,125% of NY Medicaid HMO DRG,0.01,148665,
Neonate bwt 2000-2499g w other significant condition,625-4,APR-DRG,,,,,,,,inpatient,,,549076,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,148665,,"45,128 x DRG weight",148665,Other,base rate x DRG weight,133798,,"40,615 x DRG weight",133798,Other,base rate x DRG weight,126366,,"38,359 x DRG weight",126366,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49171,,186% x Medicaid HMO amount,49171,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,112260,,"34,077 x DRG weight",112260,Other,base rate x DRG weight,95423,,"28,966 x DRG weight",95423,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26436,,DRG base rate x DRG weight + capital per discharge,26436,Other,100% of NY Medicaid HMO DRG,26436,,100% x Medicaid HMO amount,26436,Other,100% of NY Medicaid HMO DRG,26436,,100% x Medicaid HMO amount,26436,Other,100% of NY Medicaid HMO DRG,26436,,100% x Medicaid HMO amount,26436,Other,100% of NY Medicaid HMO DRG,59481,,225% x Medicaid HMO amount,59481,Other,225% of NY Medicaid HMO DRG,59481,,225% x Medicaid HMO amount,59481,Other,225% of NY Medicaid HMO DRG,59481,,225% x Medicaid HMO amount,59481,Other,225% of NY Medicaid HMO DRG,59481,,225% x Medicaid HMO amount,59481,Other,225% of NY Medicaid HMO DRG,37010,,140% x Medicaid HMO amount,37010,Other,140% of NY Medicaid HMO DRG,59481,,225% x Medicaid HMO amount,59481,Other,225% of NY Medicaid HMO DRG,72699,,275% x Medicaid HMO amount,72699,Other,275% of NY Medicaid HMO DRG,85653,,324% x Medicaid HMO amount,85653,Other,324% of NY Medicaid HMO DRG,56837,,215% x Medicaid HMO amount,56837,Other,215% of NY Medicaid HMO DRG,56837,,215% x Medicaid HMO amount,56837,Other,215% of NY Medicaid HMO DRG,33045,,125% x Medicaid HMO amount,33045,Other,125% of NY Medicaid HMO DRG,0.01,148665,
"Neonate bwt 2000-2499g, normal newborn or neonate w other problem",626-1,APR-DRG,,,,,,,,inpatient,,,16942.33,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9400,,"45,128 x DRG weight",9400,Other,base rate x DRG weight,8460,,"40,615 x DRG weight",8460,Other,base rate x DRG weight,7990,,"38,359 x DRG weight",7990,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4540,,186% x Medicaid HMO amount,4540,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7098,,"34,077 x DRG weight",7098,Other,base rate x DRG weight,6034,,"28,966 x DRG weight",6034,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,2441,,DRG base rate x DRG weight + capital per discharge,2441,Other,100% of NY Medicaid HMO DRG,2441,,100% x Medicaid HMO amount,2441,Other,100% of NY Medicaid HMO DRG,2441,,100% x Medicaid HMO amount,2441,Other,100% of NY Medicaid HMO DRG,2441,,100% x Medicaid HMO amount,2441,Other,100% of NY Medicaid HMO DRG,5492,,225% x Medicaid HMO amount,5492,Other,225% of NY Medicaid HMO DRG,5492,,225% x Medicaid HMO amount,5492,Other,225% of NY Medicaid HMO DRG,5492,,225% x Medicaid HMO amount,5492,Other,225% of NY Medicaid HMO DRG,5492,,225% x Medicaid HMO amount,5492,Other,225% of NY Medicaid HMO DRG,3417,,140% x Medicaid HMO amount,3417,Other,140% of NY Medicaid HMO DRG,5492,,225% x Medicaid HMO amount,5492,Other,225% of NY Medicaid HMO DRG,6713,,275% x Medicaid HMO amount,6713,Other,275% of NY Medicaid HMO DRG,7909,,324% x Medicaid HMO amount,7909,Other,324% of NY Medicaid HMO DRG,5248,,215% x Medicaid HMO amount,5248,Other,215% of NY Medicaid HMO DRG,5248,,215% x Medicaid HMO amount,5248,Other,215% of NY Medicaid HMO DRG,3051,,125% x Medicaid HMO amount,3051,Other,125% of NY Medicaid HMO DRG,0.01,9400,
"Neonate bwt 2000-2499g, normal newborn or neonate w other problem",626-2,APR-DRG,,,,,,,,inpatient,,,70194.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18800,,"45,128 x DRG weight",18800,Other,base rate x DRG weight,16920,,"40,615 x DRG weight",16920,Other,base rate x DRG weight,15980,,"38,359 x DRG weight",15980,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7552,,186% x Medicaid HMO amount,7552,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14196,,"34,077 x DRG weight",14196,Other,base rate x DRG weight,12067,,"28,966 x DRG weight",12067,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4060,,DRG base rate x DRG weight + capital per discharge,4060,Other,100% of NY Medicaid HMO DRG,4060,,100% x Medicaid HMO amount,4060,Other,100% of NY Medicaid HMO DRG,4060,,100% x Medicaid HMO amount,4060,Other,100% of NY Medicaid HMO DRG,4060,,100% x Medicaid HMO amount,4060,Other,100% of NY Medicaid HMO DRG,9135,,225% x Medicaid HMO amount,9135,Other,225% of NY Medicaid HMO DRG,9135,,225% x Medicaid HMO amount,9135,Other,225% of NY Medicaid HMO DRG,9135,,225% x Medicaid HMO amount,9135,Other,225% of NY Medicaid HMO DRG,9135,,225% x Medicaid HMO amount,9135,Other,225% of NY Medicaid HMO DRG,5684,,140% x Medicaid HMO amount,5684,Other,140% of NY Medicaid HMO DRG,9135,,225% x Medicaid HMO amount,9135,Other,225% of NY Medicaid HMO DRG,11165,,275% x Medicaid HMO amount,11165,Other,275% of NY Medicaid HMO DRG,13154,,324% x Medicaid HMO amount,13154,Other,324% of NY Medicaid HMO DRG,8729,,215% x Medicaid HMO amount,8729,Other,215% of NY Medicaid HMO DRG,8729,,215% x Medicaid HMO amount,8729,Other,215% of NY Medicaid HMO DRG,5075,,125% x Medicaid HMO amount,5075,Other,125% of NY Medicaid HMO DRG,0.01,18800,
"Neonate bwt 2000-2499g, normal newborn or neonate w other problem",626-3,APR-DRG,,,,,,,,inpatient,,,161498.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60377,,"45,128 x DRG weight",60377,Other,base rate x DRG weight,54339,,"40,615 x DRG weight",54339,Other,base rate x DRG weight,51321,,"38,359 x DRG weight",51321,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20877,,186% x Medicaid HMO amount,20877,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45592,,"34,077 x DRG weight",45592,Other,base rate x DRG weight,38754,,"28,966 x DRG weight",38754,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11224,,DRG base rate x DRG weight + capital per discharge,11224,Other,100% of NY Medicaid HMO DRG,11224,,100% x Medicaid HMO amount,11224,Other,100% of NY Medicaid HMO DRG,11224,,100% x Medicaid HMO amount,11224,Other,100% of NY Medicaid HMO DRG,11224,,100% x Medicaid HMO amount,11224,Other,100% of NY Medicaid HMO DRG,25254,,225% x Medicaid HMO amount,25254,Other,225% of NY Medicaid HMO DRG,25254,,225% x Medicaid HMO amount,25254,Other,225% of NY Medicaid HMO DRG,25254,,225% x Medicaid HMO amount,25254,Other,225% of NY Medicaid HMO DRG,25254,,225% x Medicaid HMO amount,25254,Other,225% of NY Medicaid HMO DRG,15714,,140% x Medicaid HMO amount,15714,Other,140% of NY Medicaid HMO DRG,25254,,225% x Medicaid HMO amount,25254,Other,225% of NY Medicaid HMO DRG,30866,,275% x Medicaid HMO amount,30866,Other,275% of NY Medicaid HMO DRG,36366,,324% x Medicaid HMO amount,36366,Other,324% of NY Medicaid HMO DRG,24132,,215% x Medicaid HMO amount,24132,Other,215% of NY Medicaid HMO DRG,24132,,215% x Medicaid HMO amount,24132,Other,215% of NY Medicaid HMO DRG,14030,,125% x Medicaid HMO amount,14030,Other,125% of NY Medicaid HMO DRG,0.01,60377,
"Neonate bwt 2000-2499g, normal newborn or neonate w other problem",626-4,APR-DRG,,,,,,,,inpatient,,,161498.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60444,,"45,128 x DRG weight",60444,Other,base rate x DRG weight,54400,,"40,615 x DRG weight",54400,Other,base rate x DRG weight,51378,,"38,359 x DRG weight",51378,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20899,,186% x Medicaid HMO amount,20899,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45643,,"34,077 x DRG weight",45643,Other,base rate x DRG weight,38797,,"28,966 x DRG weight",38797,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11236,,DRG base rate x DRG weight + capital per discharge,11236,Other,100% of NY Medicaid HMO DRG,11236,,100% x Medicaid HMO amount,11236,Other,100% of NY Medicaid HMO DRG,11236,,100% x Medicaid HMO amount,11236,Other,100% of NY Medicaid HMO DRG,11236,,100% x Medicaid HMO amount,11236,Other,100% of NY Medicaid HMO DRG,25281,,225% x Medicaid HMO amount,25281,Other,225% of NY Medicaid HMO DRG,25281,,225% x Medicaid HMO amount,25281,Other,225% of NY Medicaid HMO DRG,25281,,225% x Medicaid HMO amount,25281,Other,225% of NY Medicaid HMO DRG,25281,,225% x Medicaid HMO amount,25281,Other,225% of NY Medicaid HMO DRG,15730,,140% x Medicaid HMO amount,15730,Other,140% of NY Medicaid HMO DRG,25281,,225% x Medicaid HMO amount,25281,Other,225% of NY Medicaid HMO DRG,30899,,275% x Medicaid HMO amount,30899,Other,275% of NY Medicaid HMO DRG,36405,,324% x Medicaid HMO amount,36405,Other,324% of NY Medicaid HMO DRG,24157,,215% x Medicaid HMO amount,24157,Other,215% of NY Medicaid HMO DRG,24157,,215% x Medicaid HMO amount,24157,Other,215% of NY Medicaid HMO DRG,14045,,125% x Medicaid HMO amount,14045,Other,125% of NY Medicaid HMO DRG,0.01,60444,
Neonate birthwt >2499g w major cardiovascular procedure,630-1,APR-DRG,,,,,,,,inpatient,,,318250,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,155637,,"45,128 x DRG weight",155637,Other,base rate x DRG weight,140073,,"40,615 x DRG weight",140073,Other,base rate x DRG weight,132293,,"38,359 x DRG weight",132293,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51405,,186% x Medicaid HMO amount,51405,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,117525,,"34,077 x DRG weight",117525,Other,base rate x DRG weight,99898,,"28,966 x DRG weight",99898,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27637,,DRG base rate x DRG weight + capital per discharge,27637,Other,100% of NY Medicaid HMO DRG,27637,,100% x Medicaid HMO amount,27637,Other,100% of NY Medicaid HMO DRG,27637,,100% x Medicaid HMO amount,27637,Other,100% of NY Medicaid HMO DRG,27637,,100% x Medicaid HMO amount,27637,Other,100% of NY Medicaid HMO DRG,62183,,225% x Medicaid HMO amount,62183,Other,225% of NY Medicaid HMO DRG,62183,,225% x Medicaid HMO amount,62183,Other,225% of NY Medicaid HMO DRG,62183,,225% x Medicaid HMO amount,62183,Other,225% of NY Medicaid HMO DRG,62183,,225% x Medicaid HMO amount,62183,Other,225% of NY Medicaid HMO DRG,38692,,140% x Medicaid HMO amount,38692,Other,140% of NY Medicaid HMO DRG,62183,,225% x Medicaid HMO amount,62183,Other,225% of NY Medicaid HMO DRG,76002,,275% x Medicaid HMO amount,76002,Other,275% of NY Medicaid HMO DRG,89544,,324% x Medicaid HMO amount,89544,Other,324% of NY Medicaid HMO DRG,59420,,215% x Medicaid HMO amount,59420,Other,215% of NY Medicaid HMO DRG,59420,,215% x Medicaid HMO amount,59420,Other,215% of NY Medicaid HMO DRG,34546,,125% x Medicaid HMO amount,34546,Other,125% of NY Medicaid HMO DRG,0.01,155637,
Neonate birthwt >2499g w major cardiovascular procedure,630-2,APR-DRG,,,,,,,,inpatient,,,519875,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,161861,,"45,128 x DRG weight",161861,Other,base rate x DRG weight,145674,,"40,615 x DRG weight",145674,Other,base rate x DRG weight,137582,,"38,359 x DRG weight",137582,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53401,,186% x Medicaid HMO amount,53401,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,122224,,"34,077 x DRG weight",122224,Other,base rate x DRG weight,103892,,"28,966 x DRG weight",103892,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28710,,DRG base rate x DRG weight + capital per discharge,28710,Other,100% of NY Medicaid HMO DRG,28710,,100% x Medicaid HMO amount,28710,Other,100% of NY Medicaid HMO DRG,28710,,100% x Medicaid HMO amount,28710,Other,100% of NY Medicaid HMO DRG,28710,,100% x Medicaid HMO amount,28710,Other,100% of NY Medicaid HMO DRG,64598,,225% x Medicaid HMO amount,64598,Other,225% of NY Medicaid HMO DRG,64598,,225% x Medicaid HMO amount,64598,Other,225% of NY Medicaid HMO DRG,64598,,225% x Medicaid HMO amount,64598,Other,225% of NY Medicaid HMO DRG,64598,,225% x Medicaid HMO amount,64598,Other,225% of NY Medicaid HMO DRG,40194,,140% x Medicaid HMO amount,40194,Other,140% of NY Medicaid HMO DRG,64598,,225% x Medicaid HMO amount,64598,Other,225% of NY Medicaid HMO DRG,78953,,275% x Medicaid HMO amount,78953,Other,275% of NY Medicaid HMO DRG,93020,,324% x Medicaid HMO amount,93020,Other,324% of NY Medicaid HMO DRG,61727,,215% x Medicaid HMO amount,61727,Other,215% of NY Medicaid HMO DRG,61727,,215% x Medicaid HMO amount,61727,Other,215% of NY Medicaid HMO DRG,35888,,125% x Medicaid HMO amount,35888,Other,125% of NY Medicaid HMO DRG,0.01,161861,
Neonate birthwt >2499g w major cardiovascular procedure,630-3,APR-DRG,,,,,,,,inpatient,,,868033.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,267406,,"45,128 x DRG weight",267406,Other,base rate x DRG weight,240664,,"40,615 x DRG weight",240664,Other,base rate x DRG weight,227296,,"38,359 x DRG weight",227296,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,87225,,186% x Medicaid HMO amount,87225,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,201923,,"34,077 x DRG weight",201923,Other,base rate x DRG weight,171638,,"28,966 x DRG weight",171638,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46895,,DRG base rate x DRG weight + capital per discharge,46895,Other,100% of NY Medicaid HMO DRG,46895,,100% x Medicaid HMO amount,46895,Other,100% of NY Medicaid HMO DRG,46895,,100% x Medicaid HMO amount,46895,Other,100% of NY Medicaid HMO DRG,46895,,100% x Medicaid HMO amount,46895,Other,100% of NY Medicaid HMO DRG,105514,,225% x Medicaid HMO amount,105514,Other,225% of NY Medicaid HMO DRG,105514,,225% x Medicaid HMO amount,105514,Other,225% of NY Medicaid HMO DRG,105514,,225% x Medicaid HMO amount,105514,Other,225% of NY Medicaid HMO DRG,105514,,225% x Medicaid HMO amount,105514,Other,225% of NY Medicaid HMO DRG,65653,,140% x Medicaid HMO amount,65653,Other,140% of NY Medicaid HMO DRG,105514,,225% x Medicaid HMO amount,105514,Other,225% of NY Medicaid HMO DRG,128961,,275% x Medicaid HMO amount,128961,Other,275% of NY Medicaid HMO DRG,151940,,324% x Medicaid HMO amount,151940,Other,324% of NY Medicaid HMO DRG,100824,,215% x Medicaid HMO amount,100824,Other,215% of NY Medicaid HMO DRG,100824,,215% x Medicaid HMO amount,100824,Other,215% of NY Medicaid HMO DRG,58619,,125% x Medicaid HMO amount,58619,Other,125% of NY Medicaid HMO DRG,0.01,267406,
Neonate birthwt >2499g w major cardiovascular procedure,630-4,APR-DRG,,,,,,,,inpatient,,,809175.1,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,551893,,"45,128 x DRG weight",551893,Other,base rate x DRG weight,496701,,"40,615 x DRG weight",496701,Other,base rate x DRG weight,469111,,"38,359 x DRG weight",469111,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,178398,,186% x Medicaid HMO amount,178398,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,416745,,"34,077 x DRG weight",416745,Other,base rate x DRG weight,354240,,"28,966 x DRG weight",354240,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,95913,,DRG base rate x DRG weight + capital per discharge,95913,Other,100% of NY Medicaid HMO DRG,95913,,100% x Medicaid HMO amount,95913,Other,100% of NY Medicaid HMO DRG,95913,,100% x Medicaid HMO amount,95913,Other,100% of NY Medicaid HMO DRG,95913,,100% x Medicaid HMO amount,95913,Other,100% of NY Medicaid HMO DRG,215804,,225% x Medicaid HMO amount,215804,Other,225% of NY Medicaid HMO DRG,215804,,225% x Medicaid HMO amount,215804,Other,225% of NY Medicaid HMO DRG,215804,,225% x Medicaid HMO amount,215804,Other,225% of NY Medicaid HMO DRG,215804,,225% x Medicaid HMO amount,215804,Other,225% of NY Medicaid HMO DRG,134278,,140% x Medicaid HMO amount,134278,Other,140% of NY Medicaid HMO DRG,215804,,225% x Medicaid HMO amount,215804,Other,225% of NY Medicaid HMO DRG,263761,,275% x Medicaid HMO amount,263761,Other,275% of NY Medicaid HMO DRG,310758,,324% x Medicaid HMO amount,310758,Other,324% of NY Medicaid HMO DRG,206213,,215% x Medicaid HMO amount,206213,Other,215% of NY Medicaid HMO DRG,206213,,215% x Medicaid HMO amount,206213,Other,215% of NY Medicaid HMO DRG,119891,,125% x Medicaid HMO amount,119891,Other,125% of NY Medicaid HMO DRG,0.01,551893,
Neonate birthwt >2499g w other major procedure,631-1,APR-DRG,,,,,,,,inpatient,,,137924.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73473,,"45,128 x DRG weight",73473,Other,base rate x DRG weight,66125,,"40,615 x DRG weight",66125,Other,base rate x DRG weight,62452,,"38,359 x DRG weight",62452,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25073,,186% x Medicaid HMO amount,25073,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55481,,"34,077 x DRG weight",55481,Other,base rate x DRG weight,47160,,"28,966 x DRG weight",47160,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13480,,DRG base rate x DRG weight + capital per discharge,13480,Other,100% of NY Medicaid HMO DRG,13480,,100% x Medicaid HMO amount,13480,Other,100% of NY Medicaid HMO DRG,13480,,100% x Medicaid HMO amount,13480,Other,100% of NY Medicaid HMO DRG,13480,,100% x Medicaid HMO amount,13480,Other,100% of NY Medicaid HMO DRG,30330,,225% x Medicaid HMO amount,30330,Other,225% of NY Medicaid HMO DRG,30330,,225% x Medicaid HMO amount,30330,Other,225% of NY Medicaid HMO DRG,30330,,225% x Medicaid HMO amount,30330,Other,225% of NY Medicaid HMO DRG,30330,,225% x Medicaid HMO amount,30330,Other,225% of NY Medicaid HMO DRG,18872,,140% x Medicaid HMO amount,18872,Other,140% of NY Medicaid HMO DRG,30330,,225% x Medicaid HMO amount,30330,Other,225% of NY Medicaid HMO DRG,37070,,275% x Medicaid HMO amount,37070,Other,275% of NY Medicaid HMO DRG,43675,,324% x Medicaid HMO amount,43675,Other,324% of NY Medicaid HMO DRG,28982,,215% x Medicaid HMO amount,28982,Other,215% of NY Medicaid HMO DRG,28982,,215% x Medicaid HMO amount,28982,Other,215% of NY Medicaid HMO DRG,16850,,125% x Medicaid HMO amount,16850,Other,125% of NY Medicaid HMO DRG,0.01,73473,
Neonate birthwt >2499g w other major procedure,631-2,APR-DRG,,,,,,,,inpatient,,,513418.93,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,132406,,"45,128 x DRG weight",132406,Other,base rate x DRG weight,119164,,"40,615 x DRG weight",119164,Other,base rate x DRG weight,112545,,"38,359 x DRG weight",112545,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43961,,186% x Medicaid HMO amount,43961,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,99982,,"34,077 x DRG weight",99982,Other,base rate x DRG weight,84986,,"28,966 x DRG weight",84986,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23635,,DRG base rate x DRG weight + capital per discharge,23635,Other,100% of NY Medicaid HMO DRG,23635,,100% x Medicaid HMO amount,23635,Other,100% of NY Medicaid HMO DRG,23635,,100% x Medicaid HMO amount,23635,Other,100% of NY Medicaid HMO DRG,23635,,100% x Medicaid HMO amount,23635,Other,100% of NY Medicaid HMO DRG,53179,,225% x Medicaid HMO amount,53179,Other,225% of NY Medicaid HMO DRG,53179,,225% x Medicaid HMO amount,53179,Other,225% of NY Medicaid HMO DRG,53179,,225% x Medicaid HMO amount,53179,Other,225% of NY Medicaid HMO DRG,53179,,225% x Medicaid HMO amount,53179,Other,225% of NY Medicaid HMO DRG,33089,,140% x Medicaid HMO amount,33089,Other,140% of NY Medicaid HMO DRG,53179,,225% x Medicaid HMO amount,53179,Other,225% of NY Medicaid HMO DRG,64996,,275% x Medicaid HMO amount,64996,Other,275% of NY Medicaid HMO DRG,76577,,324% x Medicaid HMO amount,76577,Other,324% of NY Medicaid HMO DRG,50815,,215% x Medicaid HMO amount,50815,Other,215% of NY Medicaid HMO DRG,50815,,215% x Medicaid HMO amount,50815,Other,215% of NY Medicaid HMO DRG,29544,,125% x Medicaid HMO amount,29544,Other,125% of NY Medicaid HMO DRG,0.01,132406,
Neonate birthwt >2499g w other major procedure,631-3,APR-DRG,,,,,,,,inpatient,,,468154.86,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,220044,,"45,128 x DRG weight",220044,Other,base rate x DRG weight,198039,,"40,615 x DRG weight",198039,Other,base rate x DRG weight,187038,,"38,359 x DRG weight",187038,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,72047,,186% x Medicaid HMO amount,72047,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,166159,,"34,077 x DRG weight",166159,Other,base rate x DRG weight,141238,,"28,966 x DRG weight",141238,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38735,,DRG base rate x DRG weight + capital per discharge,38735,Other,100% of NY Medicaid HMO DRG,38735,,100% x Medicaid HMO amount,38735,Other,100% of NY Medicaid HMO DRG,38735,,100% x Medicaid HMO amount,38735,Other,100% of NY Medicaid HMO DRG,38735,,100% x Medicaid HMO amount,38735,Other,100% of NY Medicaid HMO DRG,87154,,225% x Medicaid HMO amount,87154,Other,225% of NY Medicaid HMO DRG,87154,,225% x Medicaid HMO amount,87154,Other,225% of NY Medicaid HMO DRG,87154,,225% x Medicaid HMO amount,87154,Other,225% of NY Medicaid HMO DRG,87154,,225% x Medicaid HMO amount,87154,Other,225% of NY Medicaid HMO DRG,54229,,140% x Medicaid HMO amount,54229,Other,140% of NY Medicaid HMO DRG,87154,,225% x Medicaid HMO amount,87154,Other,225% of NY Medicaid HMO DRG,106521,,275% x Medicaid HMO amount,106521,Other,275% of NY Medicaid HMO DRG,125501,,324% x Medicaid HMO amount,125501,Other,324% of NY Medicaid HMO DRG,83280,,215% x Medicaid HMO amount,83280,Other,215% of NY Medicaid HMO DRG,83280,,215% x Medicaid HMO amount,83280,Other,215% of NY Medicaid HMO DRG,48419,,125% x Medicaid HMO amount,48419,Other,125% of NY Medicaid HMO DRG,0.01,220044,
Neonate birthwt >2499g w other major procedure,631-4,APR-DRG,,,,,,,,inpatient,,,4292618.39,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,474449,,"45,128 x DRG weight",474449,Other,base rate x DRG weight,427002,,"40,615 x DRG weight",427002,Other,base rate x DRG weight,403284,,"38,359 x DRG weight",403284,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,153578,,186% x Medicaid HMO amount,153578,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,358265,,"34,077 x DRG weight",358265,Other,base rate x DRG weight,304531,,"28,966 x DRG weight",304531,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,82569,,DRG base rate x DRG weight + capital per discharge,82569,Other,100% of NY Medicaid HMO DRG,82569,,100% x Medicaid HMO amount,82569,Other,100% of NY Medicaid HMO DRG,82569,,100% x Medicaid HMO amount,82569,Other,100% of NY Medicaid HMO DRG,82569,,100% x Medicaid HMO amount,82569,Other,100% of NY Medicaid HMO DRG,185780,,225% x Medicaid HMO amount,185780,Other,225% of NY Medicaid HMO DRG,185780,,225% x Medicaid HMO amount,185780,Other,225% of NY Medicaid HMO DRG,185780,,225% x Medicaid HMO amount,185780,Other,225% of NY Medicaid HMO DRG,185780,,225% x Medicaid HMO amount,185780,Other,225% of NY Medicaid HMO DRG,115597,,140% x Medicaid HMO amount,115597,Other,140% of NY Medicaid HMO DRG,185780,,225% x Medicaid HMO amount,185780,Other,225% of NY Medicaid HMO DRG,227065,,275% x Medicaid HMO amount,227065,Other,275% of NY Medicaid HMO DRG,267524,,324% x Medicaid HMO amount,267524,Other,324% of NY Medicaid HMO DRG,177523,,215% x Medicaid HMO amount,177523,Other,215% of NY Medicaid HMO DRG,177523,,215% x Medicaid HMO amount,177523,Other,215% of NY Medicaid HMO DRG,103211,,125% x Medicaid HMO amount,103211,Other,125% of NY Medicaid HMO DRG,0.01,474449,
Neonate birthwt >2499g w major anomaly,633-1,APR-DRG,,,,,,,,inpatient,,,80935.35,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12717,,"45,128 x DRG weight",12717,Other,base rate x DRG weight,11445,,"40,615 x DRG weight",11445,Other,base rate x DRG weight,10810,,"38,359 x DRG weight",10810,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5602,,186% x Medicaid HMO amount,5602,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9603,,"34,077 x DRG weight",9603,Other,base rate x DRG weight,8163,,"28,966 x DRG weight",8163,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3012,,DRG base rate x DRG weight + capital per discharge,3012,Other,100% of NY Medicaid HMO DRG,3012,,100% x Medicaid HMO amount,3012,Other,100% of NY Medicaid HMO DRG,3012,,100% x Medicaid HMO amount,3012,Other,100% of NY Medicaid HMO DRG,3012,,100% x Medicaid HMO amount,3012,Other,100% of NY Medicaid HMO DRG,6777,,225% x Medicaid HMO amount,6777,Other,225% of NY Medicaid HMO DRG,6777,,225% x Medicaid HMO amount,6777,Other,225% of NY Medicaid HMO DRG,6777,,225% x Medicaid HMO amount,6777,Other,225% of NY Medicaid HMO DRG,6777,,225% x Medicaid HMO amount,6777,Other,225% of NY Medicaid HMO DRG,4217,,140% x Medicaid HMO amount,4217,Other,140% of NY Medicaid HMO DRG,6777,,225% x Medicaid HMO amount,6777,Other,225% of NY Medicaid HMO DRG,8283,,275% x Medicaid HMO amount,8283,Other,275% of NY Medicaid HMO DRG,9759,,324% x Medicaid HMO amount,9759,Other,324% of NY Medicaid HMO DRG,6476,,215% x Medicaid HMO amount,6476,Other,215% of NY Medicaid HMO DRG,6476,,215% x Medicaid HMO amount,6476,Other,215% of NY Medicaid HMO DRG,3765,,125% x Medicaid HMO amount,3765,Other,125% of NY Medicaid HMO DRG,0.01,12717,
Neonate birthwt >2499g w major anomaly,633-2,APR-DRG,,,,,,,,inpatient,,,187603.02,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41089,,"45,128 x DRG weight",41089,Other,base rate x DRG weight,36980,,"40,615 x DRG weight",36980,Other,base rate x DRG weight,34926,,"38,359 x DRG weight",34926,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14696,,186% x Medicaid HMO amount,14696,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31027,,"34,077 x DRG weight",31027,Other,base rate x DRG weight,26374,,"28,966 x DRG weight",26374,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7901,,DRG base rate x DRG weight + capital per discharge,7901,Other,100% of NY Medicaid HMO DRG,7901,,100% x Medicaid HMO amount,7901,Other,100% of NY Medicaid HMO DRG,7901,,100% x Medicaid HMO amount,7901,Other,100% of NY Medicaid HMO DRG,7901,,100% x Medicaid HMO amount,7901,Other,100% of NY Medicaid HMO DRG,17777,,225% x Medicaid HMO amount,17777,Other,225% of NY Medicaid HMO DRG,17777,,225% x Medicaid HMO amount,17777,Other,225% of NY Medicaid HMO DRG,17777,,225% x Medicaid HMO amount,17777,Other,225% of NY Medicaid HMO DRG,17777,,225% x Medicaid HMO amount,17777,Other,225% of NY Medicaid HMO DRG,11061,,140% x Medicaid HMO amount,11061,Other,140% of NY Medicaid HMO DRG,17777,,225% x Medicaid HMO amount,17777,Other,225% of NY Medicaid HMO DRG,21728,,275% x Medicaid HMO amount,21728,Other,275% of NY Medicaid HMO DRG,25599,,324% x Medicaid HMO amount,25599,Other,324% of NY Medicaid HMO DRG,16987,,215% x Medicaid HMO amount,16987,Other,215% of NY Medicaid HMO DRG,16987,,215% x Medicaid HMO amount,16987,Other,215% of NY Medicaid HMO DRG,9876,,125% x Medicaid HMO amount,9876,Other,125% of NY Medicaid HMO DRG,0.01,41089,
Neonate birthwt >2499g w major anomaly,633-3,APR-DRG,,,,,,,,inpatient,,,888642.07,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,108145,,"45,128 x DRG weight",108145,Other,base rate x DRG weight,97330,,"40,615 x DRG weight",97330,Other,base rate x DRG weight,91924,,"38,359 x DRG weight",91924,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36184,,186% x Medicaid HMO amount,36184,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,81662,,"34,077 x DRG weight",81662,Other,base rate x DRG weight,69414,,"28,966 x DRG weight",69414,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19454,,DRG base rate x DRG weight + capital per discharge,19454,Other,100% of NY Medicaid HMO DRG,19454,,100% x Medicaid HMO amount,19454,Other,100% of NY Medicaid HMO DRG,19454,,100% x Medicaid HMO amount,19454,Other,100% of NY Medicaid HMO DRG,19454,,100% x Medicaid HMO amount,19454,Other,100% of NY Medicaid HMO DRG,43772,,225% x Medicaid HMO amount,43772,Other,225% of NY Medicaid HMO DRG,43772,,225% x Medicaid HMO amount,43772,Other,225% of NY Medicaid HMO DRG,43772,,225% x Medicaid HMO amount,43772,Other,225% of NY Medicaid HMO DRG,43772,,225% x Medicaid HMO amount,43772,Other,225% of NY Medicaid HMO DRG,27236,,140% x Medicaid HMO amount,27236,Other,140% of NY Medicaid HMO DRG,43772,,225% x Medicaid HMO amount,43772,Other,225% of NY Medicaid HMO DRG,53499,,275% x Medicaid HMO amount,53499,Other,275% of NY Medicaid HMO DRG,63031,,324% x Medicaid HMO amount,63031,Other,324% of NY Medicaid HMO DRG,41826,,215% x Medicaid HMO amount,41826,Other,215% of NY Medicaid HMO DRG,41826,,215% x Medicaid HMO amount,41826,Other,215% of NY Medicaid HMO DRG,24318,,125% x Medicaid HMO amount,24318,Other,125% of NY Medicaid HMO DRG,0.01,108145,
Neonate birthwt >2499g w major anomaly,633-4,APR-DRG,,,,,,,,inpatient,,,1280483.78,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,241611,,"45,128 x DRG weight",241611,Other,base rate x DRG weight,217449,,"40,615 x DRG weight",217449,Other,base rate x DRG weight,205370,,"38,359 x DRG weight",205370,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,78959,,186% x Medicaid HMO amount,78959,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,182445,,"34,077 x DRG weight",182445,Other,base rate x DRG weight,155081,,"28,966 x DRG weight",155081,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42451,,DRG base rate x DRG weight + capital per discharge,42451,Other,100% of NY Medicaid HMO DRG,42451,,100% x Medicaid HMO amount,42451,Other,100% of NY Medicaid HMO DRG,42451,,100% x Medicaid HMO amount,42451,Other,100% of NY Medicaid HMO DRG,42451,,100% x Medicaid HMO amount,42451,Other,100% of NY Medicaid HMO DRG,95515,,225% x Medicaid HMO amount,95515,Other,225% of NY Medicaid HMO DRG,95515,,225% x Medicaid HMO amount,95515,Other,225% of NY Medicaid HMO DRG,95515,,225% x Medicaid HMO amount,95515,Other,225% of NY Medicaid HMO DRG,95515,,225% x Medicaid HMO amount,95515,Other,225% of NY Medicaid HMO DRG,59431,,140% x Medicaid HMO amount,59431,Other,140% of NY Medicaid HMO DRG,95515,,225% x Medicaid HMO amount,95515,Other,225% of NY Medicaid HMO DRG,116740,,275% x Medicaid HMO amount,116740,Other,275% of NY Medicaid HMO DRG,137541,,324% x Medicaid HMO amount,137541,Other,324% of NY Medicaid HMO DRG,91270,,215% x Medicaid HMO amount,91270,Other,215% of NY Medicaid HMO DRG,91270,,215% x Medicaid HMO amount,91270,Other,215% of NY Medicaid HMO DRG,53064,,125% x Medicaid HMO amount,53064,Other,125% of NY Medicaid HMO DRG,0.01,241611,
"Neonate, birthwt >2499g w resp dist synd/oth maj resp cond",634-1,APR-DRG,,,,,,,,inpatient,,,150597,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36287,,"45,128 x DRG weight",36287,Other,base rate x DRG weight,32659,,"40,615 x DRG weight",32659,Other,base rate x DRG weight,30844,,"38,359 x DRG weight",30844,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13156,,186% x Medicaid HMO amount,13156,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27401,,"34,077 x DRG weight",27401,Other,base rate x DRG weight,23292,,"28,966 x DRG weight",23292,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7073,,DRG base rate x DRG weight + capital per discharge,7073,Other,100% of NY Medicaid HMO DRG,7073,,100% x Medicaid HMO amount,7073,Other,100% of NY Medicaid HMO DRG,7073,,100% x Medicaid HMO amount,7073,Other,100% of NY Medicaid HMO DRG,7073,,100% x Medicaid HMO amount,7073,Other,100% of NY Medicaid HMO DRG,15914,,225% x Medicaid HMO amount,15914,Other,225% of NY Medicaid HMO DRG,15914,,225% x Medicaid HMO amount,15914,Other,225% of NY Medicaid HMO DRG,15914,,225% x Medicaid HMO amount,15914,Other,225% of NY Medicaid HMO DRG,15914,,225% x Medicaid HMO amount,15914,Other,225% of NY Medicaid HMO DRG,9902,,140% x Medicaid HMO amount,9902,Other,140% of NY Medicaid HMO DRG,15914,,225% x Medicaid HMO amount,15914,Other,225% of NY Medicaid HMO DRG,19451,,275% x Medicaid HMO amount,19451,Other,275% of NY Medicaid HMO DRG,22917,,324% x Medicaid HMO amount,22917,Other,324% of NY Medicaid HMO DRG,15207,,215% x Medicaid HMO amount,15207,Other,215% of NY Medicaid HMO DRG,15207,,215% x Medicaid HMO amount,15207,Other,215% of NY Medicaid HMO DRG,8841,,125% x Medicaid HMO amount,8841,Other,125% of NY Medicaid HMO DRG,0.01,36287,
"Neonate, birthwt >2499g w resp dist synd/oth maj resp cond",634-2,APR-DRG,,,,,,,,inpatient,,,224452.26,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60160,,"45,128 x DRG weight",60160,Other,base rate x DRG weight,54144,,"40,615 x DRG weight",54144,Other,base rate x DRG weight,51136,,"38,359 x DRG weight",51136,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20808,,186% x Medicaid HMO amount,20808,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45428,,"34,077 x DRG weight",45428,Other,base rate x DRG weight,38615,,"28,966 x DRG weight",38615,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11187,,DRG base rate x DRG weight + capital per discharge,11187,Other,100% of NY Medicaid HMO DRG,11187,,100% x Medicaid HMO amount,11187,Other,100% of NY Medicaid HMO DRG,11187,,100% x Medicaid HMO amount,11187,Other,100% of NY Medicaid HMO DRG,11187,,100% x Medicaid HMO amount,11187,Other,100% of NY Medicaid HMO DRG,25171,,225% x Medicaid HMO amount,25171,Other,225% of NY Medicaid HMO DRG,25171,,225% x Medicaid HMO amount,25171,Other,225% of NY Medicaid HMO DRG,25171,,225% x Medicaid HMO amount,25171,Other,225% of NY Medicaid HMO DRG,25171,,225% x Medicaid HMO amount,25171,Other,225% of NY Medicaid HMO DRG,15662,,140% x Medicaid HMO amount,15662,Other,140% of NY Medicaid HMO DRG,25171,,225% x Medicaid HMO amount,25171,Other,225% of NY Medicaid HMO DRG,30764,,275% x Medicaid HMO amount,30764,Other,275% of NY Medicaid HMO DRG,36246,,324% x Medicaid HMO amount,36246,Other,324% of NY Medicaid HMO DRG,24052,,215% x Medicaid HMO amount,24052,Other,215% of NY Medicaid HMO DRG,24052,,215% x Medicaid HMO amount,24052,Other,215% of NY Medicaid HMO DRG,13984,,125% x Medicaid HMO amount,13984,Other,125% of NY Medicaid HMO DRG,0.01,60160,
"Neonate, birthwt >2499g w resp dist synd/oth maj resp cond",634-3,APR-DRG,,,,,,,,inpatient,,,563011.08,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,101637,,"45,128 x DRG weight",101637,Other,base rate x DRG weight,91473,,"40,615 x DRG weight",91473,Other,base rate x DRG weight,86392,,"38,359 x DRG weight",86392,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34099,,186% x Medicaid HMO amount,34099,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,76748,,"34,077 x DRG weight",76748,Other,base rate x DRG weight,65237,,"28,966 x DRG weight",65237,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18333,,DRG base rate x DRG weight + capital per discharge,18333,Other,100% of NY Medicaid HMO DRG,18333,,100% x Medicaid HMO amount,18333,Other,100% of NY Medicaid HMO DRG,18333,,100% x Medicaid HMO amount,18333,Other,100% of NY Medicaid HMO DRG,18333,,100% x Medicaid HMO amount,18333,Other,100% of NY Medicaid HMO DRG,41249,,225% x Medicaid HMO amount,41249,Other,225% of NY Medicaid HMO DRG,41249,,225% x Medicaid HMO amount,41249,Other,225% of NY Medicaid HMO DRG,41249,,225% x Medicaid HMO amount,41249,Other,225% of NY Medicaid HMO DRG,41249,,225% x Medicaid HMO amount,41249,Other,225% of NY Medicaid HMO DRG,25666,,140% x Medicaid HMO amount,25666,Other,140% of NY Medicaid HMO DRG,41249,,225% x Medicaid HMO amount,41249,Other,225% of NY Medicaid HMO DRG,50416,,275% x Medicaid HMO amount,50416,Other,275% of NY Medicaid HMO DRG,59399,,324% x Medicaid HMO amount,59399,Other,324% of NY Medicaid HMO DRG,39416,,215% x Medicaid HMO amount,39416,Other,215% of NY Medicaid HMO DRG,39416,,215% x Medicaid HMO amount,39416,Other,215% of NY Medicaid HMO DRG,22916,,125% x Medicaid HMO amount,22916,Other,125% of NY Medicaid HMO DRG,0.01,101637,
"Neonate, birthwt >2499g w resp dist synd/oth maj resp cond",634-4,APR-DRG,,,,,,,,inpatient,,,1081304.96,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,182024,,"45,128 x DRG weight",182024,Other,base rate x DRG weight,163821,,"40,615 x DRG weight",163821,Other,base rate x DRG weight,154721,,"38,359 x DRG weight",154721,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59862,,186% x Medicaid HMO amount,59862,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,137450,,"34,077 x DRG weight",137450,Other,base rate x DRG weight,116834,,"28,966 x DRG weight",116834,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32184,,DRG base rate x DRG weight + capital per discharge,32184,Other,100% of NY Medicaid HMO DRG,32184,,100% x Medicaid HMO amount,32184,Other,100% of NY Medicaid HMO DRG,32184,,100% x Medicaid HMO amount,32184,Other,100% of NY Medicaid HMO DRG,32184,,100% x Medicaid HMO amount,32184,Other,100% of NY Medicaid HMO DRG,72414,,225% x Medicaid HMO amount,72414,Other,225% of NY Medicaid HMO DRG,72414,,225% x Medicaid HMO amount,72414,Other,225% of NY Medicaid HMO DRG,72414,,225% x Medicaid HMO amount,72414,Other,225% of NY Medicaid HMO DRG,72414,,225% x Medicaid HMO amount,72414,Other,225% of NY Medicaid HMO DRG,45058,,140% x Medicaid HMO amount,45058,Other,140% of NY Medicaid HMO DRG,72414,,225% x Medicaid HMO amount,72414,Other,225% of NY Medicaid HMO DRG,88506,,275% x Medicaid HMO amount,88506,Other,275% of NY Medicaid HMO DRG,104276,,324% x Medicaid HMO amount,104276,Other,324% of NY Medicaid HMO DRG,69196,,215% x Medicaid HMO amount,69196,Other,215% of NY Medicaid HMO DRG,69196,,215% x Medicaid HMO amount,69196,Other,215% of NY Medicaid HMO DRG,40230,,125% x Medicaid HMO amount,40230,Other,125% of NY Medicaid HMO DRG,0.01,182024,
Neonate birthwt >2499g w congenital/perinatal infection,636-1,APR-DRG,,,,,,,,inpatient,,,104221.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44559,,"45,128 x DRG weight",44559,Other,base rate x DRG weight,40103,,"40,615 x DRG weight",40103,Other,base rate x DRG weight,37876,,"38,359 x DRG weight",37876,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15808,,186% x Medicaid HMO amount,15808,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33648,,"34,077 x DRG weight",33648,Other,base rate x DRG weight,28601,,"28,966 x DRG weight",28601,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8499,,DRG base rate x DRG weight + capital per discharge,8499,Other,100% of NY Medicaid HMO DRG,8499,,100% x Medicaid HMO amount,8499,Other,100% of NY Medicaid HMO DRG,8499,,100% x Medicaid HMO amount,8499,Other,100% of NY Medicaid HMO DRG,8499,,100% x Medicaid HMO amount,8499,Other,100% of NY Medicaid HMO DRG,19123,,225% x Medicaid HMO amount,19123,Other,225% of NY Medicaid HMO DRG,19123,,225% x Medicaid HMO amount,19123,Other,225% of NY Medicaid HMO DRG,19123,,225% x Medicaid HMO amount,19123,Other,225% of NY Medicaid HMO DRG,19123,,225% x Medicaid HMO amount,19123,Other,225% of NY Medicaid HMO DRG,11899,,140% x Medicaid HMO amount,11899,Other,140% of NY Medicaid HMO DRG,19123,,225% x Medicaid HMO amount,19123,Other,225% of NY Medicaid HMO DRG,23372,,275% x Medicaid HMO amount,23372,Other,275% of NY Medicaid HMO DRG,27537,,324% x Medicaid HMO amount,27537,Other,324% of NY Medicaid HMO DRG,18273,,215% x Medicaid HMO amount,18273,Other,215% of NY Medicaid HMO DRG,18273,,215% x Medicaid HMO amount,18273,Other,215% of NY Medicaid HMO DRG,10624,,125% x Medicaid HMO amount,10624,Other,125% of NY Medicaid HMO DRG,0.01,44559,
Neonate birthwt >2499g w congenital/perinatal infection,636-2,APR-DRG,,,,,,,,inpatient,,,109625,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60472,,"45,128 x DRG weight",60472,Other,base rate x DRG weight,54424,,"40,615 x DRG weight",54424,Other,base rate x DRG weight,51401,,"38,359 x DRG weight",51401,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20906,,186% x Medicaid HMO amount,20906,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45663,,"34,077 x DRG weight",45663,Other,base rate x DRG weight,38814,,"28,966 x DRG weight",38814,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11240,,DRG base rate x DRG weight + capital per discharge,11240,Other,100% of NY Medicaid HMO DRG,11240,,100% x Medicaid HMO amount,11240,Other,100% of NY Medicaid HMO DRG,11240,,100% x Medicaid HMO amount,11240,Other,100% of NY Medicaid HMO DRG,11240,,100% x Medicaid HMO amount,11240,Other,100% of NY Medicaid HMO DRG,25290,,225% x Medicaid HMO amount,25290,Other,225% of NY Medicaid HMO DRG,25290,,225% x Medicaid HMO amount,25290,Other,225% of NY Medicaid HMO DRG,25290,,225% x Medicaid HMO amount,25290,Other,225% of NY Medicaid HMO DRG,25290,,225% x Medicaid HMO amount,25290,Other,225% of NY Medicaid HMO DRG,15736,,140% x Medicaid HMO amount,15736,Other,140% of NY Medicaid HMO DRG,25290,,225% x Medicaid HMO amount,25290,Other,225% of NY Medicaid HMO DRG,30910,,275% x Medicaid HMO amount,30910,Other,275% of NY Medicaid HMO DRG,36418,,324% x Medicaid HMO amount,36418,Other,324% of NY Medicaid HMO DRG,24166,,215% x Medicaid HMO amount,24166,Other,215% of NY Medicaid HMO DRG,24166,,215% x Medicaid HMO amount,24166,Other,215% of NY Medicaid HMO DRG,14050,,125% x Medicaid HMO amount,14050,Other,125% of NY Medicaid HMO DRG,0.01,60472,
Neonate birthwt >2499g w congenital/perinatal infection,636-3,APR-DRG,,,,,,,,inpatient,,,558449.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,92833,,"45,128 x DRG weight",92833,Other,base rate x DRG weight,83549,,"40,615 x DRG weight",83549,Other,base rate x DRG weight,78908,,"38,359 x DRG weight",78908,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31278,,186% x Medicaid HMO amount,31278,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,70100,,"34,077 x DRG weight",70100,Other,base rate x DRG weight,59586,,"28,966 x DRG weight",59586,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16816,,DRG base rate x DRG weight + capital per discharge,16816,Other,100% of NY Medicaid HMO DRG,16816,,100% x Medicaid HMO amount,16816,Other,100% of NY Medicaid HMO DRG,16816,,100% x Medicaid HMO amount,16816,Other,100% of NY Medicaid HMO DRG,16816,,100% x Medicaid HMO amount,16816,Other,100% of NY Medicaid HMO DRG,37836,,225% x Medicaid HMO amount,37836,Other,225% of NY Medicaid HMO DRG,37836,,225% x Medicaid HMO amount,37836,Other,225% of NY Medicaid HMO DRG,37836,,225% x Medicaid HMO amount,37836,Other,225% of NY Medicaid HMO DRG,37836,,225% x Medicaid HMO amount,37836,Other,225% of NY Medicaid HMO DRG,23542,,140% x Medicaid HMO amount,23542,Other,140% of NY Medicaid HMO DRG,37836,,225% x Medicaid HMO amount,37836,Other,225% of NY Medicaid HMO DRG,46244,,275% x Medicaid HMO amount,46244,Other,275% of NY Medicaid HMO DRG,54484,,324% x Medicaid HMO amount,54484,Other,324% of NY Medicaid HMO DRG,36154,,215% x Medicaid HMO amount,36154,Other,215% of NY Medicaid HMO DRG,36154,,215% x Medicaid HMO amount,36154,Other,215% of NY Medicaid HMO DRG,21020,,125% x Medicaid HMO amount,21020,Other,125% of NY Medicaid HMO DRG,0.01,92833,
Neonate birthwt >2499g w congenital/perinatal infection,636-4,APR-DRG,,,,,,,,inpatient,,,558449.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,121020,,"45,128 x DRG weight",121020,Other,base rate x DRG weight,108917,,"40,615 x DRG weight",108917,Other,base rate x DRG weight,102867,,"38,359 x DRG weight",102867,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40312,,186% x Medicaid HMO amount,40312,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,91384,,"34,077 x DRG weight",91384,Other,base rate x DRG weight,77678,,"28,966 x DRG weight",77678,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21673,,DRG base rate x DRG weight + capital per discharge,21673,Other,100% of NY Medicaid HMO DRG,21673,,100% x Medicaid HMO amount,21673,Other,100% of NY Medicaid HMO DRG,21673,,100% x Medicaid HMO amount,21673,Other,100% of NY Medicaid HMO DRG,21673,,100% x Medicaid HMO amount,21673,Other,100% of NY Medicaid HMO DRG,48764,,225% x Medicaid HMO amount,48764,Other,225% of NY Medicaid HMO DRG,48764,,225% x Medicaid HMO amount,48764,Other,225% of NY Medicaid HMO DRG,48764,,225% x Medicaid HMO amount,48764,Other,225% of NY Medicaid HMO DRG,48764,,225% x Medicaid HMO amount,48764,Other,225% of NY Medicaid HMO DRG,30342,,140% x Medicaid HMO amount,30342,Other,140% of NY Medicaid HMO DRG,48764,,225% x Medicaid HMO amount,48764,Other,225% of NY Medicaid HMO DRG,59601,,275% x Medicaid HMO amount,59601,Other,275% of NY Medicaid HMO DRG,70221,,324% x Medicaid HMO amount,70221,Other,324% of NY Medicaid HMO DRG,46597,,215% x Medicaid HMO amount,46597,Other,215% of NY Medicaid HMO DRG,46597,,215% x Medicaid HMO amount,46597,Other,215% of NY Medicaid HMO DRG,27091,,125% x Medicaid HMO amount,27091,Other,125% of NY Medicaid HMO DRG,0.01,121020,
Neonate birthwt >2499g w other significant condition,639-1,APR-DRG,,,,,,,,inpatient,,,151058.21,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23273,,"45,128 x DRG weight",23273,Other,base rate x DRG weight,20945,,"40,615 x DRG weight",20945,Other,base rate x DRG weight,19782,,"38,359 x DRG weight",19782,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8986,,186% x Medicaid HMO amount,8986,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17574,,"34,077 x DRG weight",17574,Other,base rate x DRG weight,14938,,"28,966 x DRG weight",14938,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4831,,DRG base rate x DRG weight + capital per discharge,4831,Other,100% of NY Medicaid HMO DRG,4831,,100% x Medicaid HMO amount,4831,Other,100% of NY Medicaid HMO DRG,4831,,100% x Medicaid HMO amount,4831,Other,100% of NY Medicaid HMO DRG,4831,,100% x Medicaid HMO amount,4831,Other,100% of NY Medicaid HMO DRG,10870,,225% x Medicaid HMO amount,10870,Other,225% of NY Medicaid HMO DRG,10870,,225% x Medicaid HMO amount,10870,Other,225% of NY Medicaid HMO DRG,10870,,225% x Medicaid HMO amount,10870,Other,225% of NY Medicaid HMO DRG,10870,,225% x Medicaid HMO amount,10870,Other,225% of NY Medicaid HMO DRG,6763,,140% x Medicaid HMO amount,6763,Other,140% of NY Medicaid HMO DRG,10870,,225% x Medicaid HMO amount,10870,Other,225% of NY Medicaid HMO DRG,13285,,275% x Medicaid HMO amount,13285,Other,275% of NY Medicaid HMO DRG,15652,,324% x Medicaid HMO amount,15652,Other,324% of NY Medicaid HMO DRG,10387,,215% x Medicaid HMO amount,10387,Other,215% of NY Medicaid HMO DRG,10387,,215% x Medicaid HMO amount,10387,Other,215% of NY Medicaid HMO DRG,6039,,125% x Medicaid HMO amount,6039,Other,125% of NY Medicaid HMO DRG,0.01,23273,
Neonate birthwt >2499g w other significant condition,639-2,APR-DRG,,,,,,,,inpatient,,,441914.76,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,58513,,"45,128 x DRG weight",58513,Other,base rate x DRG weight,52661,,"40,615 x DRG weight",52661,Other,base rate x DRG weight,49736,,"38,359 x DRG weight",49736,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20280,,186% x Medicaid HMO amount,20280,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44184,,"34,077 x DRG weight",44184,Other,base rate x DRG weight,37557,,"28,966 x DRG weight",37557,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10903,,DRG base rate x DRG weight + capital per discharge,10903,Other,100% of NY Medicaid HMO DRG,10903,,100% x Medicaid HMO amount,10903,Other,100% of NY Medicaid HMO DRG,10903,,100% x Medicaid HMO amount,10903,Other,100% of NY Medicaid HMO DRG,10903,,100% x Medicaid HMO amount,10903,Other,100% of NY Medicaid HMO DRG,24532,,225% x Medicaid HMO amount,24532,Other,225% of NY Medicaid HMO DRG,24532,,225% x Medicaid HMO amount,24532,Other,225% of NY Medicaid HMO DRG,24532,,225% x Medicaid HMO amount,24532,Other,225% of NY Medicaid HMO DRG,24532,,225% x Medicaid HMO amount,24532,Other,225% of NY Medicaid HMO DRG,15264,,140% x Medicaid HMO amount,15264,Other,140% of NY Medicaid HMO DRG,24532,,225% x Medicaid HMO amount,24532,Other,225% of NY Medicaid HMO DRG,29983,,275% x Medicaid HMO amount,29983,Other,275% of NY Medicaid HMO DRG,35326,,324% x Medicaid HMO amount,35326,Other,324% of NY Medicaid HMO DRG,23441,,215% x Medicaid HMO amount,23441,Other,215% of NY Medicaid HMO DRG,23441,,215% x Medicaid HMO amount,23441,Other,215% of NY Medicaid HMO DRG,13629,,125% x Medicaid HMO amount,13629,Other,125% of NY Medicaid HMO DRG,0.01,58513,
Neonate birthwt >2499g w other significant condition,639-3,APR-DRG,,,,,,,,inpatient,,,433889.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,84105,,"45,128 x DRG weight",84105,Other,base rate x DRG weight,75694,,"40,615 x DRG weight",75694,Other,base rate x DRG weight,71490,,"38,359 x DRG weight",71490,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28480,,186% x Medicaid HMO amount,28480,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,63509,,"34,077 x DRG weight",63509,Other,base rate x DRG weight,53984,,"28,966 x DRG weight",53984,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15312,,DRG base rate x DRG weight + capital per discharge,15312,Other,100% of NY Medicaid HMO DRG,15312,,100% x Medicaid HMO amount,15312,Other,100% of NY Medicaid HMO DRG,15312,,100% x Medicaid HMO amount,15312,Other,100% of NY Medicaid HMO DRG,15312,,100% x Medicaid HMO amount,15312,Other,100% of NY Medicaid HMO DRG,34452,,225% x Medicaid HMO amount,34452,Other,225% of NY Medicaid HMO DRG,34452,,225% x Medicaid HMO amount,34452,Other,225% of NY Medicaid HMO DRG,34452,,225% x Medicaid HMO amount,34452,Other,225% of NY Medicaid HMO DRG,34452,,225% x Medicaid HMO amount,34452,Other,225% of NY Medicaid HMO DRG,21437,,140% x Medicaid HMO amount,21437,Other,140% of NY Medicaid HMO DRG,34452,,225% x Medicaid HMO amount,34452,Other,225% of NY Medicaid HMO DRG,42108,,275% x Medicaid HMO amount,42108,Other,275% of NY Medicaid HMO DRG,49611,,324% x Medicaid HMO amount,49611,Other,324% of NY Medicaid HMO DRG,32921,,215% x Medicaid HMO amount,32921,Other,215% of NY Medicaid HMO DRG,32921,,215% x Medicaid HMO amount,32921,Other,215% of NY Medicaid HMO DRG,19140,,125% x Medicaid HMO amount,19140,Other,125% of NY Medicaid HMO DRG,0.01,84105,
Neonate birthwt >2499g w other significant condition,639-4,APR-DRG,,,,,,,,inpatient,,,3810096.82,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,173034,,"45,128 x DRG weight",173034,Other,base rate x DRG weight,155730,,"40,615 x DRG weight",155730,Other,base rate x DRG weight,147080,,"38,359 x DRG weight",147080,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56981,,186% x Medicaid HMO amount,56981,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,130661,,"34,077 x DRG weight",130661,Other,base rate x DRG weight,111064,,"28,966 x DRG weight",111064,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30635,,DRG base rate x DRG weight + capital per discharge,30635,Other,100% of NY Medicaid HMO DRG,30635,,100% x Medicaid HMO amount,30635,Other,100% of NY Medicaid HMO DRG,30635,,100% x Medicaid HMO amount,30635,Other,100% of NY Medicaid HMO DRG,30635,,100% x Medicaid HMO amount,30635,Other,100% of NY Medicaid HMO DRG,68929,,225% x Medicaid HMO amount,68929,Other,225% of NY Medicaid HMO DRG,68929,,225% x Medicaid HMO amount,68929,Other,225% of NY Medicaid HMO DRG,68929,,225% x Medicaid HMO amount,68929,Other,225% of NY Medicaid HMO DRG,68929,,225% x Medicaid HMO amount,68929,Other,225% of NY Medicaid HMO DRG,42889,,140% x Medicaid HMO amount,42889,Other,140% of NY Medicaid HMO DRG,68929,,225% x Medicaid HMO amount,68929,Other,225% of NY Medicaid HMO DRG,84246,,275% x Medicaid HMO amount,84246,Other,275% of NY Medicaid HMO DRG,99257,,324% x Medicaid HMO amount,99257,Other,324% of NY Medicaid HMO DRG,65865,,215% x Medicaid HMO amount,65865,Other,215% of NY Medicaid HMO DRG,65865,,215% x Medicaid HMO amount,65865,Other,215% of NY Medicaid HMO DRG,38294,,125% x Medicaid HMO amount,38294,Other,125% of NY Medicaid HMO DRG,0.01,173034,
"Neonate birthwt >2499g, normal newborn or neonate w other problem",640-1,APR-DRG,,,,,,,,inpatient,,,22137.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7893,,"45,128 x DRG weight",7893,Other,base rate x DRG weight,7104,,"40,615 x DRG weight",7104,Other,base rate x DRG weight,6709,,"38,359 x DRG weight",6709,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4057,,186% x Medicaid HMO amount,4057,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5960,,"34,077 x DRG weight",5960,Other,base rate x DRG weight,5066,,"28,966 x DRG weight",5066,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,2181,,DRG base rate x DRG weight + capital per discharge,2181,Other,100% of NY Medicaid HMO DRG,2181,,100% x Medicaid HMO amount,2181,Other,100% of NY Medicaid HMO DRG,2181,,100% x Medicaid HMO amount,2181,Other,100% of NY Medicaid HMO DRG,2181,,100% x Medicaid HMO amount,2181,Other,100% of NY Medicaid HMO DRG,4907,,225% x Medicaid HMO amount,4907,Other,225% of NY Medicaid HMO DRG,4907,,225% x Medicaid HMO amount,4907,Other,225% of NY Medicaid HMO DRG,4907,,225% x Medicaid HMO amount,4907,Other,225% of NY Medicaid HMO DRG,4907,,225% x Medicaid HMO amount,4907,Other,225% of NY Medicaid HMO DRG,3053,,140% x Medicaid HMO amount,3053,Other,140% of NY Medicaid HMO DRG,4907,,225% x Medicaid HMO amount,4907,Other,225% of NY Medicaid HMO DRG,5998,,275% x Medicaid HMO amount,5998,Other,275% of NY Medicaid HMO DRG,7066,,324% x Medicaid HMO amount,7066,Other,324% of NY Medicaid HMO DRG,4689,,215% x Medicaid HMO amount,4689,Other,215% of NY Medicaid HMO DRG,4689,,215% x Medicaid HMO amount,4689,Other,215% of NY Medicaid HMO DRG,2726,,125% x Medicaid HMO amount,2726,Other,125% of NY Medicaid HMO DRG,0.01,7893,
"Neonate birthwt >2499g, normal newborn or neonate w other problem",640-2,APR-DRG,,,,,,,,inpatient,,,37661,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10966,,"45,128 x DRG weight",10966,Other,base rate x DRG weight,9869,,"40,615 x DRG weight",9869,Other,base rate x DRG weight,9321,,"38,359 x DRG weight",9321,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5041,,186% x Medicaid HMO amount,5041,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8281,,"34,077 x DRG weight",8281,Other,base rate x DRG weight,7039,,"28,966 x DRG weight",7039,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,2710,,DRG base rate x DRG weight + capital per discharge,2710,Other,100% of NY Medicaid HMO DRG,2710,,100% x Medicaid HMO amount,2710,Other,100% of NY Medicaid HMO DRG,2710,,100% x Medicaid HMO amount,2710,Other,100% of NY Medicaid HMO DRG,2710,,100% x Medicaid HMO amount,2710,Other,100% of NY Medicaid HMO DRG,6098,,225% x Medicaid HMO amount,6098,Other,225% of NY Medicaid HMO DRG,6098,,225% x Medicaid HMO amount,6098,Other,225% of NY Medicaid HMO DRG,6098,,225% x Medicaid HMO amount,6098,Other,225% of NY Medicaid HMO DRG,6098,,225% x Medicaid HMO amount,6098,Other,225% of NY Medicaid HMO DRG,3794,,140% x Medicaid HMO amount,3794,Other,140% of NY Medicaid HMO DRG,6098,,225% x Medicaid HMO amount,6098,Other,225% of NY Medicaid HMO DRG,7453,,275% x Medicaid HMO amount,7453,Other,275% of NY Medicaid HMO DRG,8780,,324% x Medicaid HMO amount,8780,Other,324% of NY Medicaid HMO DRG,5827,,215% x Medicaid HMO amount,5827,Other,215% of NY Medicaid HMO DRG,5827,,215% x Medicaid HMO amount,5827,Other,215% of NY Medicaid HMO DRG,3388,,125% x Medicaid HMO amount,3388,Other,125% of NY Medicaid HMO DRG,0.01,10966,
"Neonate birthwt >2499g, normal newborn or neonate w other problem",640-3,APR-DRG,,,,,,,,inpatient,,,130270.39,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24374,,"45,128 x DRG weight",24374,Other,base rate x DRG weight,21936,,"40,615 x DRG weight",21936,Other,base rate x DRG weight,20718,,"38,359 x DRG weight",20718,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9337,,186% x Medicaid HMO amount,9337,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18405,,"34,077 x DRG weight",18405,Other,base rate x DRG weight,15645,,"28,966 x DRG weight",15645,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5020,,DRG base rate x DRG weight + capital per discharge,5020,Other,100% of NY Medicaid HMO DRG,5020,,100% x Medicaid HMO amount,5020,Other,100% of NY Medicaid HMO DRG,5020,,100% x Medicaid HMO amount,5020,Other,100% of NY Medicaid HMO DRG,5020,,100% x Medicaid HMO amount,5020,Other,100% of NY Medicaid HMO DRG,11295,,225% x Medicaid HMO amount,11295,Other,225% of NY Medicaid HMO DRG,11295,,225% x Medicaid HMO amount,11295,Other,225% of NY Medicaid HMO DRG,11295,,225% x Medicaid HMO amount,11295,Other,225% of NY Medicaid HMO DRG,11295,,225% x Medicaid HMO amount,11295,Other,225% of NY Medicaid HMO DRG,7028,,140% x Medicaid HMO amount,7028,Other,140% of NY Medicaid HMO DRG,11295,,225% x Medicaid HMO amount,11295,Other,225% of NY Medicaid HMO DRG,13805,,275% x Medicaid HMO amount,13805,Other,275% of NY Medicaid HMO DRG,16265,,324% x Medicaid HMO amount,16265,Other,324% of NY Medicaid HMO DRG,10793,,215% x Medicaid HMO amount,10793,Other,215% of NY Medicaid HMO DRG,10793,,215% x Medicaid HMO amount,10793,Other,215% of NY Medicaid HMO DRG,6275,,125% x Medicaid HMO amount,6275,Other,125% of NY Medicaid HMO DRG,0.01,24374,
"Neonate birthwt >2499g, normal newborn or neonate w other problem",640-4,APR-DRG,,,,,,,,inpatient,,,130270.39,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24401,,"45,128 x DRG weight",24401,Other,base rate x DRG weight,21961,,"40,615 x DRG weight",21961,Other,base rate x DRG weight,20741,,"38,359 x DRG weight",20741,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9347,,186% x Medicaid HMO amount,9347,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18425,,"34,077 x DRG weight",18425,Other,base rate x DRG weight,15662,,"28,966 x DRG weight",15662,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5025,,DRG base rate x DRG weight + capital per discharge,5025,Other,100% of NY Medicaid HMO DRG,5025,,100% x Medicaid HMO amount,5025,Other,100% of NY Medicaid HMO DRG,5025,,100% x Medicaid HMO amount,5025,Other,100% of NY Medicaid HMO DRG,5025,,100% x Medicaid HMO amount,5025,Other,100% of NY Medicaid HMO DRG,11306,,225% x Medicaid HMO amount,11306,Other,225% of NY Medicaid HMO DRG,11306,,225% x Medicaid HMO amount,11306,Other,225% of NY Medicaid HMO DRG,11306,,225% x Medicaid HMO amount,11306,Other,225% of NY Medicaid HMO DRG,11306,,225% x Medicaid HMO amount,11306,Other,225% of NY Medicaid HMO DRG,7035,,140% x Medicaid HMO amount,7035,Other,140% of NY Medicaid HMO DRG,11306,,225% x Medicaid HMO amount,11306,Other,225% of NY Medicaid HMO DRG,13819,,275% x Medicaid HMO amount,13819,Other,275% of NY Medicaid HMO DRG,16281,,324% x Medicaid HMO amount,16281,Other,324% of NY Medicaid HMO DRG,10804,,215% x Medicaid HMO amount,10804,Other,215% of NY Medicaid HMO DRG,10804,,215% x Medicaid HMO amount,10804,Other,215% of NY Medicaid HMO DRG,6281,,125% x Medicaid HMO amount,6281,Other,125% of NY Medicaid HMO DRG,0.01,24401,
Splenectomy,650-1,APR-DRG,,,,,,,,inpatient,,,81755.94,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,58635,,"45,128 x DRG weight",58635,Other,base rate x DRG weight,52771,,"40,615 x DRG weight",52771,Other,base rate x DRG weight,49840,,"38,359 x DRG weight",49840,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20319,,186% x Medicaid HMO amount,20319,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44276,,"34,077 x DRG weight",44276,Other,base rate x DRG weight,37636,,"28,966 x DRG weight",37636,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10924,,DRG base rate x DRG weight + capital per discharge,10924,Other,100% of NY Medicaid HMO DRG,10924,,100% x Medicaid HMO amount,10924,Other,100% of NY Medicaid HMO DRG,10924,,100% x Medicaid HMO amount,10924,Other,100% of NY Medicaid HMO DRG,10924,,100% x Medicaid HMO amount,10924,Other,100% of NY Medicaid HMO DRG,24579,,225% x Medicaid HMO amount,24579,Other,225% of NY Medicaid HMO DRG,24579,,225% x Medicaid HMO amount,24579,Other,225% of NY Medicaid HMO DRG,24579,,225% x Medicaid HMO amount,24579,Other,225% of NY Medicaid HMO DRG,24579,,225% x Medicaid HMO amount,24579,Other,225% of NY Medicaid HMO DRG,15294,,140% x Medicaid HMO amount,15294,Other,140% of NY Medicaid HMO DRG,24579,,225% x Medicaid HMO amount,24579,Other,225% of NY Medicaid HMO DRG,30041,,275% x Medicaid HMO amount,30041,Other,275% of NY Medicaid HMO DRG,35394,,324% x Medicaid HMO amount,35394,Other,324% of NY Medicaid HMO DRG,23487,,215% x Medicaid HMO amount,23487,Other,215% of NY Medicaid HMO DRG,23487,,215% x Medicaid HMO amount,23487,Other,215% of NY Medicaid HMO DRG,13655,,125% x Medicaid HMO amount,13655,Other,125% of NY Medicaid HMO DRG,0.01,58635,
Splenectomy,650-2,APR-DRG,,,,,,,,inpatient,,,134326.23,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,89552,,"45,128 x DRG weight",89552,Other,base rate x DRG weight,80596,,"40,615 x DRG weight",80596,Other,base rate x DRG weight,76120,,"38,359 x DRG weight",76120,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30227,,186% x Medicaid HMO amount,30227,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,67622,,"34,077 x DRG weight",67622,Other,base rate x DRG weight,57480,,"28,966 x DRG weight",57480,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16251,,DRG base rate x DRG weight + capital per discharge,16251,Other,100% of NY Medicaid HMO DRG,16251,,100% x Medicaid HMO amount,16251,Other,100% of NY Medicaid HMO DRG,16251,,100% x Medicaid HMO amount,16251,Other,100% of NY Medicaid HMO DRG,16251,,100% x Medicaid HMO amount,16251,Other,100% of NY Medicaid HMO DRG,36565,,225% x Medicaid HMO amount,36565,Other,225% of NY Medicaid HMO DRG,36565,,225% x Medicaid HMO amount,36565,Other,225% of NY Medicaid HMO DRG,36565,,225% x Medicaid HMO amount,36565,Other,225% of NY Medicaid HMO DRG,36565,,225% x Medicaid HMO amount,36565,Other,225% of NY Medicaid HMO DRG,22751,,140% x Medicaid HMO amount,22751,Other,140% of NY Medicaid HMO DRG,36565,,225% x Medicaid HMO amount,36565,Other,225% of NY Medicaid HMO DRG,44690,,275% x Medicaid HMO amount,44690,Other,275% of NY Medicaid HMO DRG,52653,,324% x Medicaid HMO amount,52653,Other,324% of NY Medicaid HMO DRG,34940,,215% x Medicaid HMO amount,34940,Other,215% of NY Medicaid HMO DRG,34940,,215% x Medicaid HMO amount,34940,Other,215% of NY Medicaid HMO DRG,20314,,125% x Medicaid HMO amount,20314,Other,125% of NY Medicaid HMO DRG,0.01,89552,
Splenectomy,650-3,APR-DRG,,,,,,,,inpatient,,,245187.35,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,107915,,"45,128 x DRG weight",107915,Other,base rate x DRG weight,97123,,"40,615 x DRG weight",97123,Other,base rate x DRG weight,91728,,"38,359 x DRG weight",91728,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36112,,186% x Medicaid HMO amount,36112,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,81488,,"34,077 x DRG weight",81488,Other,base rate x DRG weight,69266,,"28,966 x DRG weight",69266,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19415,,DRG base rate x DRG weight + capital per discharge,19415,Other,100% of NY Medicaid HMO DRG,19415,,100% x Medicaid HMO amount,19415,Other,100% of NY Medicaid HMO DRG,19415,,100% x Medicaid HMO amount,19415,Other,100% of NY Medicaid HMO DRG,19415,,100% x Medicaid HMO amount,19415,Other,100% of NY Medicaid HMO DRG,43684,,225% x Medicaid HMO amount,43684,Other,225% of NY Medicaid HMO DRG,43684,,225% x Medicaid HMO amount,43684,Other,225% of NY Medicaid HMO DRG,43684,,225% x Medicaid HMO amount,43684,Other,225% of NY Medicaid HMO DRG,43684,,225% x Medicaid HMO amount,43684,Other,225% of NY Medicaid HMO DRG,27181,,140% x Medicaid HMO amount,27181,Other,140% of NY Medicaid HMO DRG,43684,,225% x Medicaid HMO amount,43684,Other,225% of NY Medicaid HMO DRG,53391,,275% x Medicaid HMO amount,53391,Other,275% of NY Medicaid HMO DRG,62905,,324% x Medicaid HMO amount,62905,Other,324% of NY Medicaid HMO DRG,41742,,215% x Medicaid HMO amount,41742,Other,215% of NY Medicaid HMO DRG,41742,,215% x Medicaid HMO amount,41742,Other,215% of NY Medicaid HMO DRG,24269,,125% x Medicaid HMO amount,24269,Other,125% of NY Medicaid HMO DRG,0.01,107915,
Splenectomy,650-4,APR-DRG,,,,,,,,inpatient,,,526890.28,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,257365,,"45,128 x DRG weight",257365,Other,base rate x DRG weight,231627,,"40,615 x DRG weight",231627,Other,base rate x DRG weight,218761,,"38,359 x DRG weight",218761,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,84007,,186% x Medicaid HMO amount,84007,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,194341,,"34,077 x DRG weight",194341,Other,base rate x DRG weight,165193,,"28,966 x DRG weight",165193,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45165,,DRG base rate x DRG weight + capital per discharge,45165,Other,100% of NY Medicaid HMO DRG,45165,,100% x Medicaid HMO amount,45165,Other,100% of NY Medicaid HMO DRG,45165,,100% x Medicaid HMO amount,45165,Other,100% of NY Medicaid HMO DRG,45165,,100% x Medicaid HMO amount,45165,Other,100% of NY Medicaid HMO DRG,101621,,225% x Medicaid HMO amount,101621,Other,225% of NY Medicaid HMO DRG,101621,,225% x Medicaid HMO amount,101621,Other,225% of NY Medicaid HMO DRG,101621,,225% x Medicaid HMO amount,101621,Other,225% of NY Medicaid HMO DRG,101621,,225% x Medicaid HMO amount,101621,Other,225% of NY Medicaid HMO DRG,63231,,140% x Medicaid HMO amount,63231,Other,140% of NY Medicaid HMO DRG,101621,,225% x Medicaid HMO amount,101621,Other,225% of NY Medicaid HMO DRG,124204,,275% x Medicaid HMO amount,124204,Other,275% of NY Medicaid HMO DRG,146335,,324% x Medicaid HMO amount,146335,Other,324% of NY Medicaid HMO DRG,97105,,215% x Medicaid HMO amount,97105,Other,215% of NY Medicaid HMO DRG,97105,,215% x Medicaid HMO amount,97105,Other,215% of NY Medicaid HMO DRG,56456,,125% x Medicaid HMO amount,56456,Other,125% of NY Medicaid HMO DRG,0.01,257365,
Other procedures of blood & blood-forming organs,651-1,APR-DRG,,,,,,,,inpatient,,,149993.23,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46992,,"45,128 x DRG weight",46992,Other,base rate x DRG weight,42292,,"40,615 x DRG weight",42292,Other,base rate x DRG weight,39943,,"38,359 x DRG weight",39943,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16587,,186% x Medicaid HMO amount,16587,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35484,,"34,077 x DRG weight",35484,Other,base rate x DRG weight,30162,,"28,966 x DRG weight",30162,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8918,,DRG base rate x DRG weight + capital per discharge,8918,Other,100% of NY Medicaid HMO DRG,8918,,100% x Medicaid HMO amount,8918,Other,100% of NY Medicaid HMO DRG,8918,,100% x Medicaid HMO amount,8918,Other,100% of NY Medicaid HMO DRG,8918,,100% x Medicaid HMO amount,8918,Other,100% of NY Medicaid HMO DRG,20066,,225% x Medicaid HMO amount,20066,Other,225% of NY Medicaid HMO DRG,20066,,225% x Medicaid HMO amount,20066,Other,225% of NY Medicaid HMO DRG,20066,,225% x Medicaid HMO amount,20066,Other,225% of NY Medicaid HMO DRG,20066,,225% x Medicaid HMO amount,20066,Other,225% of NY Medicaid HMO DRG,12485,,140% x Medicaid HMO amount,12485,Other,140% of NY Medicaid HMO DRG,20066,,225% x Medicaid HMO amount,20066,Other,225% of NY Medicaid HMO DRG,24525,,275% x Medicaid HMO amount,24525,Other,275% of NY Medicaid HMO DRG,28894,,324% x Medicaid HMO amount,28894,Other,324% of NY Medicaid HMO DRG,19174,,215% x Medicaid HMO amount,19174,Other,215% of NY Medicaid HMO DRG,19174,,215% x Medicaid HMO amount,19174,Other,215% of NY Medicaid HMO DRG,11148,,125% x Medicaid HMO amount,11148,Other,125% of NY Medicaid HMO DRG,0.01,46992,
Other procedures of blood & blood-forming organs,651-2,APR-DRG,,,,,,,,inpatient,,,138054.72,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,62317,,"45,128 x DRG weight",62317,Other,base rate x DRG weight,56085,,"40,615 x DRG weight",56085,Other,base rate x DRG weight,52970,,"38,359 x DRG weight",52970,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21498,,186% x Medicaid HMO amount,21498,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47057,,"34,077 x DRG weight",47057,Other,base rate x DRG weight,39999,,"28,966 x DRG weight",39999,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11558,,DRG base rate x DRG weight + capital per discharge,11558,Other,100% of NY Medicaid HMO DRG,11558,,100% x Medicaid HMO amount,11558,Other,100% of NY Medicaid HMO DRG,11558,,100% x Medicaid HMO amount,11558,Other,100% of NY Medicaid HMO DRG,11558,,100% x Medicaid HMO amount,11558,Other,100% of NY Medicaid HMO DRG,26006,,225% x Medicaid HMO amount,26006,Other,225% of NY Medicaid HMO DRG,26006,,225% x Medicaid HMO amount,26006,Other,225% of NY Medicaid HMO DRG,26006,,225% x Medicaid HMO amount,26006,Other,225% of NY Medicaid HMO DRG,26006,,225% x Medicaid HMO amount,26006,Other,225% of NY Medicaid HMO DRG,16181,,140% x Medicaid HMO amount,16181,Other,140% of NY Medicaid HMO DRG,26006,,225% x Medicaid HMO amount,26006,Other,225% of NY Medicaid HMO DRG,31785,,275% x Medicaid HMO amount,31785,Other,275% of NY Medicaid HMO DRG,37448,,324% x Medicaid HMO amount,37448,Other,324% of NY Medicaid HMO DRG,24850,,215% x Medicaid HMO amount,24850,Other,215% of NY Medicaid HMO DRG,24850,,215% x Medicaid HMO amount,24850,Other,215% of NY Medicaid HMO DRG,14448,,125% x Medicaid HMO amount,14448,Other,125% of NY Medicaid HMO DRG,0.01,62317,
Other procedures of blood & blood-forming organs,651-3,APR-DRG,,,,,,,,inpatient,,,470320.8,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,117653,,"45,128 x DRG weight",117653,Other,base rate x DRG weight,105887,,"40,615 x DRG weight",105887,Other,base rate x DRG weight,100006,,"38,359 x DRG weight",100006,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39233,,186% x Medicaid HMO amount,39233,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,88842,,"34,077 x DRG weight",88842,Other,base rate x DRG weight,75517,,"28,966 x DRG weight",75517,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21093,,DRG base rate x DRG weight + capital per discharge,21093,Other,100% of NY Medicaid HMO DRG,21093,,100% x Medicaid HMO amount,21093,Other,100% of NY Medicaid HMO DRG,21093,,100% x Medicaid HMO amount,21093,Other,100% of NY Medicaid HMO DRG,21093,,100% x Medicaid HMO amount,21093,Other,100% of NY Medicaid HMO DRG,47459,,225% x Medicaid HMO amount,47459,Other,225% of NY Medicaid HMO DRG,47459,,225% x Medicaid HMO amount,47459,Other,225% of NY Medicaid HMO DRG,47459,,225% x Medicaid HMO amount,47459,Other,225% of NY Medicaid HMO DRG,47459,,225% x Medicaid HMO amount,47459,Other,225% of NY Medicaid HMO DRG,29530,,140% x Medicaid HMO amount,29530,Other,140% of NY Medicaid HMO DRG,47459,,225% x Medicaid HMO amount,47459,Other,225% of NY Medicaid HMO DRG,58006,,275% x Medicaid HMO amount,58006,Other,275% of NY Medicaid HMO DRG,68341,,324% x Medicaid HMO amount,68341,Other,324% of NY Medicaid HMO DRG,45350,,215% x Medicaid HMO amount,45350,Other,215% of NY Medicaid HMO DRG,45350,,215% x Medicaid HMO amount,45350,Other,215% of NY Medicaid HMO DRG,26366,,125% x Medicaid HMO amount,26366,Other,125% of NY Medicaid HMO DRG,0.01,117653,
Other procedures of blood & blood-forming organs,651-4,APR-DRG,,,,,,,,inpatient,,,5226480.17,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,170218,,"45,128 x DRG weight",170218,Other,base rate x DRG weight,153196,,"40,615 x DRG weight",153196,Other,base rate x DRG weight,144686,,"38,359 x DRG weight",144686,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56079,,186% x Medicaid HMO amount,56079,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,128535,,"34,077 x DRG weight",128535,Other,base rate x DRG weight,109257,,"28,966 x DRG weight",109257,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30150,,DRG base rate x DRG weight + capital per discharge,30150,Other,100% of NY Medicaid HMO DRG,30150,,100% x Medicaid HMO amount,30150,Other,100% of NY Medicaid HMO DRG,30150,,100% x Medicaid HMO amount,30150,Other,100% of NY Medicaid HMO DRG,30150,,100% x Medicaid HMO amount,30150,Other,100% of NY Medicaid HMO DRG,67838,,225% x Medicaid HMO amount,67838,Other,225% of NY Medicaid HMO DRG,67838,,225% x Medicaid HMO amount,67838,Other,225% of NY Medicaid HMO DRG,67838,,225% x Medicaid HMO amount,67838,Other,225% of NY Medicaid HMO DRG,67838,,225% x Medicaid HMO amount,67838,Other,225% of NY Medicaid HMO DRG,42210,,140% x Medicaid HMO amount,42210,Other,140% of NY Medicaid HMO DRG,67838,,225% x Medicaid HMO amount,67838,Other,225% of NY Medicaid HMO DRG,82913,,275% x Medicaid HMO amount,82913,Other,275% of NY Medicaid HMO DRG,97686,,324% x Medicaid HMO amount,97686,Other,324% of NY Medicaid HMO DRG,64823,,215% x Medicaid HMO amount,64823,Other,215% of NY Medicaid HMO DRG,64823,,215% x Medicaid HMO amount,64823,Other,215% of NY Medicaid HMO DRG,37688,,125% x Medicaid HMO amount,37688,Other,125% of NY Medicaid HMO DRG,0.01,170218,
Major hematologic/immunologic diag exc sickle cell crisis & coagul,660-1,APR-DRG,,,,,,,,inpatient,,,252504.02,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31468,,"45,128 x DRG weight",31468,Other,base rate x DRG weight,28321,,"40,615 x DRG weight",28321,Other,base rate x DRG weight,26748,,"38,359 x DRG weight",26748,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11612,,186% x Medicaid HMO amount,11612,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23762,,"34,077 x DRG weight",23762,Other,base rate x DRG weight,20198,,"28,966 x DRG weight",20198,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6243,,DRG base rate x DRG weight + capital per discharge,6243,Other,100% of NY Medicaid HMO DRG,6243,,100% x Medicaid HMO amount,6243,Other,100% of NY Medicaid HMO DRG,6243,,100% x Medicaid HMO amount,6243,Other,100% of NY Medicaid HMO DRG,6243,,100% x Medicaid HMO amount,6243,Other,100% of NY Medicaid HMO DRG,14047,,225% x Medicaid HMO amount,14047,Other,225% of NY Medicaid HMO DRG,14047,,225% x Medicaid HMO amount,14047,Other,225% of NY Medicaid HMO DRG,14047,,225% x Medicaid HMO amount,14047,Other,225% of NY Medicaid HMO DRG,14047,,225% x Medicaid HMO amount,14047,Other,225% of NY Medicaid HMO DRG,8740,,140% x Medicaid HMO amount,8740,Other,140% of NY Medicaid HMO DRG,14047,,225% x Medicaid HMO amount,14047,Other,225% of NY Medicaid HMO DRG,17168,,275% x Medicaid HMO amount,17168,Other,275% of NY Medicaid HMO DRG,20227,,324% x Medicaid HMO amount,20227,Other,324% of NY Medicaid HMO DRG,13422,,215% x Medicaid HMO amount,13422,Other,215% of NY Medicaid HMO DRG,13422,,215% x Medicaid HMO amount,13422,Other,215% of NY Medicaid HMO DRG,7804,,125% x Medicaid HMO amount,7804,Other,125% of NY Medicaid HMO DRG,0.01,31468,
Major hematologic/immunologic diag exc sickle cell crisis & coagul,660-2,APR-DRG,,,,,,,,inpatient,,,171773.58,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40611,,"45,128 x DRG weight",40611,Other,base rate x DRG weight,36549,,"40,615 x DRG weight",36549,Other,base rate x DRG weight,34519,,"38,359 x DRG weight",34519,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14541,,186% x Medicaid HMO amount,14541,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30666,,"34,077 x DRG weight",30666,Other,base rate x DRG weight,26067,,"28,966 x DRG weight",26067,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7818,,DRG base rate x DRG weight + capital per discharge,7818,Other,100% of NY Medicaid HMO DRG,7818,,100% x Medicaid HMO amount,7818,Other,100% of NY Medicaid HMO DRG,7818,,100% x Medicaid HMO amount,7818,Other,100% of NY Medicaid HMO DRG,7818,,100% x Medicaid HMO amount,7818,Other,100% of NY Medicaid HMO DRG,17591,,225% x Medicaid HMO amount,17591,Other,225% of NY Medicaid HMO DRG,17591,,225% x Medicaid HMO amount,17591,Other,225% of NY Medicaid HMO DRG,17591,,225% x Medicaid HMO amount,17591,Other,225% of NY Medicaid HMO DRG,17591,,225% x Medicaid HMO amount,17591,Other,225% of NY Medicaid HMO DRG,10945,,140% x Medicaid HMO amount,10945,Other,140% of NY Medicaid HMO DRG,17591,,225% x Medicaid HMO amount,17591,Other,225% of NY Medicaid HMO DRG,21500,,275% x Medicaid HMO amount,21500,Other,275% of NY Medicaid HMO DRG,25330,,324% x Medicaid HMO amount,25330,Other,324% of NY Medicaid HMO DRG,16809,,215% x Medicaid HMO amount,16809,Other,215% of NY Medicaid HMO DRG,16809,,215% x Medicaid HMO amount,16809,Other,215% of NY Medicaid HMO DRG,9773,,125% x Medicaid HMO amount,9773,Other,125% of NY Medicaid HMO DRG,0.01,40611,
Major hematologic/immunologic diag exc sickle cell crisis & coagul,660-3,APR-DRG,,,,,,,,inpatient,,,208287.4,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,68671,,"45,128 x DRG weight",68671,Other,base rate x DRG weight,61804,,"40,615 x DRG weight",61804,Other,base rate x DRG weight,58371,,"38,359 x DRG weight",58371,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23535,,186% x Medicaid HMO amount,23535,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51855,,"34,077 x DRG weight",51855,Other,base rate x DRG weight,44078,,"28,966 x DRG weight",44078,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12653,,DRG base rate x DRG weight + capital per discharge,12653,Other,100% of NY Medicaid HMO DRG,12653,,100% x Medicaid HMO amount,12653,Other,100% of NY Medicaid HMO DRG,12653,,100% x Medicaid HMO amount,12653,Other,100% of NY Medicaid HMO DRG,12653,,100% x Medicaid HMO amount,12653,Other,100% of NY Medicaid HMO DRG,28469,,225% x Medicaid HMO amount,28469,Other,225% of NY Medicaid HMO DRG,28469,,225% x Medicaid HMO amount,28469,Other,225% of NY Medicaid HMO DRG,28469,,225% x Medicaid HMO amount,28469,Other,225% of NY Medicaid HMO DRG,28469,,225% x Medicaid HMO amount,28469,Other,225% of NY Medicaid HMO DRG,17714,,140% x Medicaid HMO amount,17714,Other,140% of NY Medicaid HMO DRG,28469,,225% x Medicaid HMO amount,28469,Other,225% of NY Medicaid HMO DRG,34796,,275% x Medicaid HMO amount,34796,Other,275% of NY Medicaid HMO DRG,40996,,324% x Medicaid HMO amount,40996,Other,324% of NY Medicaid HMO DRG,27204,,215% x Medicaid HMO amount,27204,Other,215% of NY Medicaid HMO DRG,27204,,215% x Medicaid HMO amount,27204,Other,215% of NY Medicaid HMO DRG,15816,,125% x Medicaid HMO amount,15816,Other,125% of NY Medicaid HMO DRG,0.01,68671,
Major hematologic/immunologic diag exc sickle cell crisis & coagul,660-4,APR-DRG,,,,,,,,inpatient,,,344483.25,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,224647,,"45,128 x DRG weight",224647,Other,base rate x DRG weight,202181,,"40,615 x DRG weight",202181,Other,base rate x DRG weight,190951,,"38,359 x DRG weight",190951,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73522,,186% x Medicaid HMO amount,73522,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,169635,,"34,077 x DRG weight",169635,Other,base rate x DRG weight,144193,,"28,966 x DRG weight",144193,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39528,,DRG base rate x DRG weight + capital per discharge,39528,Other,100% of NY Medicaid HMO DRG,39528,,100% x Medicaid HMO amount,39528,Other,100% of NY Medicaid HMO DRG,39528,,100% x Medicaid HMO amount,39528,Other,100% of NY Medicaid HMO DRG,39528,,100% x Medicaid HMO amount,39528,Other,100% of NY Medicaid HMO DRG,88938,,225% x Medicaid HMO amount,88938,Other,225% of NY Medicaid HMO DRG,88938,,225% x Medicaid HMO amount,88938,Other,225% of NY Medicaid HMO DRG,88938,,225% x Medicaid HMO amount,88938,Other,225% of NY Medicaid HMO DRG,88938,,225% x Medicaid HMO amount,88938,Other,225% of NY Medicaid HMO DRG,55339,,140% x Medicaid HMO amount,55339,Other,140% of NY Medicaid HMO DRG,88938,,225% x Medicaid HMO amount,88938,Other,225% of NY Medicaid HMO DRG,108702,,275% x Medicaid HMO amount,108702,Other,275% of NY Medicaid HMO DRG,128071,,324% x Medicaid HMO amount,128071,Other,324% of NY Medicaid HMO DRG,84985,,215% x Medicaid HMO amount,84985,Other,215% of NY Medicaid HMO DRG,84985,,215% x Medicaid HMO amount,84985,Other,215% of NY Medicaid HMO DRG,49410,,125% x Medicaid HMO amount,49410,Other,125% of NY Medicaid HMO DRG,0.01,224647,
Coagulation & platelet disorders,661-1,APR-DRG,,,,,,,,inpatient,,,63070.67,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45561,,"45,128 x DRG weight",45561,Other,base rate x DRG weight,41005,,"40,615 x DRG weight",41005,Other,base rate x DRG weight,38727,,"38,359 x DRG weight",38727,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16128,,186% x Medicaid HMO amount,16128,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34404,,"34,077 x DRG weight",34404,Other,base rate x DRG weight,29244,,"28,966 x DRG weight",29244,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8671,,DRG base rate x DRG weight + capital per discharge,8671,Other,100% of NY Medicaid HMO DRG,8671,,100% x Medicaid HMO amount,8671,Other,100% of NY Medicaid HMO DRG,8671,,100% x Medicaid HMO amount,8671,Other,100% of NY Medicaid HMO DRG,8671,,100% x Medicaid HMO amount,8671,Other,100% of NY Medicaid HMO DRG,19510,,225% x Medicaid HMO amount,19510,Other,225% of NY Medicaid HMO DRG,19510,,225% x Medicaid HMO amount,19510,Other,225% of NY Medicaid HMO DRG,19510,,225% x Medicaid HMO amount,19510,Other,225% of NY Medicaid HMO DRG,19510,,225% x Medicaid HMO amount,19510,Other,225% of NY Medicaid HMO DRG,12139,,140% x Medicaid HMO amount,12139,Other,140% of NY Medicaid HMO DRG,19510,,225% x Medicaid HMO amount,19510,Other,225% of NY Medicaid HMO DRG,23845,,275% x Medicaid HMO amount,23845,Other,275% of NY Medicaid HMO DRG,28094,,324% x Medicaid HMO amount,28094,Other,324% of NY Medicaid HMO DRG,18643,,215% x Medicaid HMO amount,18643,Other,215% of NY Medicaid HMO DRG,18643,,215% x Medicaid HMO amount,18643,Other,215% of NY Medicaid HMO DRG,10839,,125% x Medicaid HMO amount,10839,Other,125% of NY Medicaid HMO DRG,0.01,45561,
Coagulation & platelet disorders,661-2,APR-DRG,,,,,,,,inpatient,,,105753.81,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53513,,"45,128 x DRG weight",53513,Other,base rate x DRG weight,48161,,"40,615 x DRG weight",48161,Other,base rate x DRG weight,45486,,"38,359 x DRG weight",45486,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18676,,186% x Medicaid HMO amount,18676,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40409,,"34,077 x DRG weight",40409,Other,base rate x DRG weight,34348,,"28,966 x DRG weight",34348,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10041,,DRG base rate x DRG weight + capital per discharge,10041,Other,100% of NY Medicaid HMO DRG,10041,,100% x Medicaid HMO amount,10041,Other,100% of NY Medicaid HMO DRG,10041,,100% x Medicaid HMO amount,10041,Other,100% of NY Medicaid HMO DRG,10041,,100% x Medicaid HMO amount,10041,Other,100% of NY Medicaid HMO DRG,22592,,225% x Medicaid HMO amount,22592,Other,225% of NY Medicaid HMO DRG,22592,,225% x Medicaid HMO amount,22592,Other,225% of NY Medicaid HMO DRG,22592,,225% x Medicaid HMO amount,22592,Other,225% of NY Medicaid HMO DRG,22592,,225% x Medicaid HMO amount,22592,Other,225% of NY Medicaid HMO DRG,14057,,140% x Medicaid HMO amount,14057,Other,140% of NY Medicaid HMO DRG,22592,,225% x Medicaid HMO amount,22592,Other,225% of NY Medicaid HMO DRG,27613,,275% x Medicaid HMO amount,27613,Other,275% of NY Medicaid HMO DRG,32533,,324% x Medicaid HMO amount,32533,Other,324% of NY Medicaid HMO DRG,21588,,215% x Medicaid HMO amount,21588,Other,215% of NY Medicaid HMO DRG,21588,,215% x Medicaid HMO amount,21588,Other,215% of NY Medicaid HMO DRG,12551,,125% x Medicaid HMO amount,12551,Other,125% of NY Medicaid HMO DRG,0.01,53513,
Coagulation & platelet disorders,661-3,APR-DRG,,,,,,,,inpatient,,,154412.12,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,88261,,"45,128 x DRG weight",88261,Other,base rate x DRG weight,79435,,"40,615 x DRG weight",79435,Other,base rate x DRG weight,75023,,"38,359 x DRG weight",75023,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29812,,186% x Medicaid HMO amount,29812,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,66648,,"34,077 x DRG weight",66648,Other,base rate x DRG weight,56652,,"28,966 x DRG weight",56652,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16028,,DRG base rate x DRG weight + capital per discharge,16028,Other,100% of NY Medicaid HMO DRG,16028,,100% x Medicaid HMO amount,16028,Other,100% of NY Medicaid HMO DRG,16028,,100% x Medicaid HMO amount,16028,Other,100% of NY Medicaid HMO DRG,16028,,100% x Medicaid HMO amount,16028,Other,100% of NY Medicaid HMO DRG,36063,,225% x Medicaid HMO amount,36063,Other,225% of NY Medicaid HMO DRG,36063,,225% x Medicaid HMO amount,36063,Other,225% of NY Medicaid HMO DRG,36063,,225% x Medicaid HMO amount,36063,Other,225% of NY Medicaid HMO DRG,36063,,225% x Medicaid HMO amount,36063,Other,225% of NY Medicaid HMO DRG,22439,,140% x Medicaid HMO amount,22439,Other,140% of NY Medicaid HMO DRG,36063,,225% x Medicaid HMO amount,36063,Other,225% of NY Medicaid HMO DRG,44077,,275% x Medicaid HMO amount,44077,Other,275% of NY Medicaid HMO DRG,51931,,324% x Medicaid HMO amount,51931,Other,324% of NY Medicaid HMO DRG,34460,,215% x Medicaid HMO amount,34460,Other,215% of NY Medicaid HMO DRG,34460,,215% x Medicaid HMO amount,34460,Other,215% of NY Medicaid HMO DRG,20035,,125% x Medicaid HMO amount,20035,Other,125% of NY Medicaid HMO DRG,0.01,88261,
Coagulation & platelet disorders,661-4,APR-DRG,,,,,,,,inpatient,,,801302.4,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,206059,,"45,128 x DRG weight",206059,Other,base rate x DRG weight,185452,,"40,615 x DRG weight",185452,Other,base rate x DRG weight,175151,,"38,359 x DRG weight",175151,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,67565,,186% x Medicaid HMO amount,67565,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,155599,,"34,077 x DRG weight",155599,Other,base rate x DRG weight,132262,,"28,966 x DRG weight",132262,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36325,,DRG base rate x DRG weight + capital per discharge,36325,Other,100% of NY Medicaid HMO DRG,36325,,100% x Medicaid HMO amount,36325,Other,100% of NY Medicaid HMO DRG,36325,,100% x Medicaid HMO amount,36325,Other,100% of NY Medicaid HMO DRG,36325,,100% x Medicaid HMO amount,36325,Other,100% of NY Medicaid HMO DRG,81731,,225% x Medicaid HMO amount,81731,Other,225% of NY Medicaid HMO DRG,81731,,225% x Medicaid HMO amount,81731,Other,225% of NY Medicaid HMO DRG,81731,,225% x Medicaid HMO amount,81731,Other,225% of NY Medicaid HMO DRG,81731,,225% x Medicaid HMO amount,81731,Other,225% of NY Medicaid HMO DRG,50855,,140% x Medicaid HMO amount,50855,Other,140% of NY Medicaid HMO DRG,81731,,225% x Medicaid HMO amount,81731,Other,225% of NY Medicaid HMO DRG,99894,,275% x Medicaid HMO amount,99894,Other,275% of NY Medicaid HMO DRG,117693,,324% x Medicaid HMO amount,117693,Other,324% of NY Medicaid HMO DRG,78099,,215% x Medicaid HMO amount,78099,Other,215% of NY Medicaid HMO DRG,78099,,215% x Medicaid HMO amount,78099,Other,215% of NY Medicaid HMO DRG,45406,,125% x Medicaid HMO amount,45406,Other,125% of NY Medicaid HMO DRG,0.01,206059,
Sickle cell anemia crisis,662-1,APR-DRG,,,,,,,,inpatient,,,104438.37,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30182,,"45,128 x DRG weight",30182,Other,base rate x DRG weight,27163,,"40,615 x DRG weight",27163,Other,base rate x DRG weight,25654,,"38,359 x DRG weight",25654,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11199,,186% x Medicaid HMO amount,11199,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22791,,"34,077 x DRG weight",22791,Other,base rate x DRG weight,19372,,"28,966 x DRG weight",19372,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6021,,DRG base rate x DRG weight + capital per discharge,6021,Other,100% of NY Medicaid HMO DRG,6021,,100% x Medicaid HMO amount,6021,Other,100% of NY Medicaid HMO DRG,6021,,100% x Medicaid HMO amount,6021,Other,100% of NY Medicaid HMO DRG,6021,,100% x Medicaid HMO amount,6021,Other,100% of NY Medicaid HMO DRG,13547,,225% x Medicaid HMO amount,13547,Other,225% of NY Medicaid HMO DRG,13547,,225% x Medicaid HMO amount,13547,Other,225% of NY Medicaid HMO DRG,13547,,225% x Medicaid HMO amount,13547,Other,225% of NY Medicaid HMO DRG,13547,,225% x Medicaid HMO amount,13547,Other,225% of NY Medicaid HMO DRG,8429,,140% x Medicaid HMO amount,8429,Other,140% of NY Medicaid HMO DRG,13547,,225% x Medicaid HMO amount,13547,Other,225% of NY Medicaid HMO DRG,16558,,275% x Medicaid HMO amount,16558,Other,275% of NY Medicaid HMO DRG,19508,,324% x Medicaid HMO amount,19508,Other,324% of NY Medicaid HMO DRG,12945,,215% x Medicaid HMO amount,12945,Other,215% of NY Medicaid HMO DRG,12945,,215% x Medicaid HMO amount,12945,Other,215% of NY Medicaid HMO DRG,7526,,125% x Medicaid HMO amount,7526,Other,125% of NY Medicaid HMO DRG,0.01,30182,
Sickle cell anemia crisis,662-2,APR-DRG,,,,,,,,inpatient,,,170158.57,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43558,,"45,128 x DRG weight",43558,Other,base rate x DRG weight,39202,,"40,615 x DRG weight",39202,Other,base rate x DRG weight,37024,,"38,359 x DRG weight",37024,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15486,,186% x Medicaid HMO amount,15486,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32891,,"34,077 x DRG weight",32891,Other,base rate x DRG weight,27958,,"28,966 x DRG weight",27958,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8326,,DRG base rate x DRG weight + capital per discharge,8326,Other,100% of NY Medicaid HMO DRG,8326,,100% x Medicaid HMO amount,8326,Other,100% of NY Medicaid HMO DRG,8326,,100% x Medicaid HMO amount,8326,Other,100% of NY Medicaid HMO DRG,8326,,100% x Medicaid HMO amount,8326,Other,100% of NY Medicaid HMO DRG,18734,,225% x Medicaid HMO amount,18734,Other,225% of NY Medicaid HMO DRG,18734,,225% x Medicaid HMO amount,18734,Other,225% of NY Medicaid HMO DRG,18734,,225% x Medicaid HMO amount,18734,Other,225% of NY Medicaid HMO DRG,18734,,225% x Medicaid HMO amount,18734,Other,225% of NY Medicaid HMO DRG,11656,,140% x Medicaid HMO amount,11656,Other,140% of NY Medicaid HMO DRG,18734,,225% x Medicaid HMO amount,18734,Other,225% of NY Medicaid HMO DRG,22897,,275% x Medicaid HMO amount,22897,Other,275% of NY Medicaid HMO DRG,26976,,324% x Medicaid HMO amount,26976,Other,324% of NY Medicaid HMO DRG,17901,,215% x Medicaid HMO amount,17901,Other,215% of NY Medicaid HMO DRG,17901,,215% x Medicaid HMO amount,17901,Other,215% of NY Medicaid HMO DRG,10408,,125% x Medicaid HMO amount,10408,Other,125% of NY Medicaid HMO DRG,0.01,43558,
Sickle cell anemia crisis,662-3,APR-DRG,,,,,,,,inpatient,,,231736.07,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,69529,,"45,128 x DRG weight",69529,Other,base rate x DRG weight,62576,,"40,615 x DRG weight",62576,Other,base rate x DRG weight,59100,,"38,359 x DRG weight",59100,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23810,,186% x Medicaid HMO amount,23810,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52502,,"34,077 x DRG weight",52502,Other,base rate x DRG weight,44628,,"28,966 x DRG weight",44628,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12801,,DRG base rate x DRG weight + capital per discharge,12801,Other,100% of NY Medicaid HMO DRG,12801,,100% x Medicaid HMO amount,12801,Other,100% of NY Medicaid HMO DRG,12801,,100% x Medicaid HMO amount,12801,Other,100% of NY Medicaid HMO DRG,12801,,100% x Medicaid HMO amount,12801,Other,100% of NY Medicaid HMO DRG,28802,,225% x Medicaid HMO amount,28802,Other,225% of NY Medicaid HMO DRG,28802,,225% x Medicaid HMO amount,28802,Other,225% of NY Medicaid HMO DRG,28802,,225% x Medicaid HMO amount,28802,Other,225% of NY Medicaid HMO DRG,28802,,225% x Medicaid HMO amount,28802,Other,225% of NY Medicaid HMO DRG,17921,,140% x Medicaid HMO amount,17921,Other,140% of NY Medicaid HMO DRG,28802,,225% x Medicaid HMO amount,28802,Other,225% of NY Medicaid HMO DRG,35203,,275% x Medicaid HMO amount,35203,Other,275% of NY Medicaid HMO DRG,41475,,324% x Medicaid HMO amount,41475,Other,324% of NY Medicaid HMO DRG,27522,,215% x Medicaid HMO amount,27522,Other,215% of NY Medicaid HMO DRG,27522,,215% x Medicaid HMO amount,27522,Other,215% of NY Medicaid HMO DRG,16001,,125% x Medicaid HMO amount,16001,Other,125% of NY Medicaid HMO DRG,0.01,69529,
Sickle cell anemia crisis,662-4,APR-DRG,,,,,,,,inpatient,,,510760.39,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,149477,,"45,128 x DRG weight",149477,Other,base rate x DRG weight,134529,,"40,615 x DRG weight",134529,Other,base rate x DRG weight,127057,,"38,359 x DRG weight",127057,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49431,,186% x Medicaid HMO amount,49431,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,112873,,"34,077 x DRG weight",112873,Other,base rate x DRG weight,95944,,"28,966 x DRG weight",95944,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26576,,DRG base rate x DRG weight + capital per discharge,26576,Other,100% of NY Medicaid HMO DRG,26576,,100% x Medicaid HMO amount,26576,Other,100% of NY Medicaid HMO DRG,26576,,100% x Medicaid HMO amount,26576,Other,100% of NY Medicaid HMO DRG,26576,,100% x Medicaid HMO amount,26576,Other,100% of NY Medicaid HMO DRG,59796,,225% x Medicaid HMO amount,59796,Other,225% of NY Medicaid HMO DRG,59796,,225% x Medicaid HMO amount,59796,Other,225% of NY Medicaid HMO DRG,59796,,225% x Medicaid HMO amount,59796,Other,225% of NY Medicaid HMO DRG,59796,,225% x Medicaid HMO amount,59796,Other,225% of NY Medicaid HMO DRG,37206,,140% x Medicaid HMO amount,37206,Other,140% of NY Medicaid HMO DRG,59796,,225% x Medicaid HMO amount,59796,Other,225% of NY Medicaid HMO DRG,73084,,275% x Medicaid HMO amount,73084,Other,275% of NY Medicaid HMO DRG,86106,,324% x Medicaid HMO amount,86106,Other,324% of NY Medicaid HMO DRG,57138,,215% x Medicaid HMO amount,57138,Other,215% of NY Medicaid HMO DRG,57138,,215% x Medicaid HMO amount,57138,Other,215% of NY Medicaid HMO DRG,33220,,125% x Medicaid HMO amount,33220,Other,125% of NY Medicaid HMO DRG,0.01,149477,
Other anemia & disorders of blood & blood-forming organs,663-1,APR-DRG,,,,,,,,inpatient,,,71386.2,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23164,,"45,128 x DRG weight",23164,Other,base rate x DRG weight,20848,,"40,615 x DRG weight",20848,Other,base rate x DRG weight,19690,,"38,359 x DRG weight",19690,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8950,,186% x Medicaid HMO amount,8950,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17492,,"34,077 x DRG weight",17492,Other,base rate x DRG weight,14868,,"28,966 x DRG weight",14868,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4812,,DRG base rate x DRG weight + capital per discharge,4812,Other,100% of NY Medicaid HMO DRG,4812,,100% x Medicaid HMO amount,4812,Other,100% of NY Medicaid HMO DRG,4812,,100% x Medicaid HMO amount,4812,Other,100% of NY Medicaid HMO DRG,4812,,100% x Medicaid HMO amount,4812,Other,100% of NY Medicaid HMO DRG,10827,,225% x Medicaid HMO amount,10827,Other,225% of NY Medicaid HMO DRG,10827,,225% x Medicaid HMO amount,10827,Other,225% of NY Medicaid HMO DRG,10827,,225% x Medicaid HMO amount,10827,Other,225% of NY Medicaid HMO DRG,10827,,225% x Medicaid HMO amount,10827,Other,225% of NY Medicaid HMO DRG,6737,,140% x Medicaid HMO amount,6737,Other,140% of NY Medicaid HMO DRG,10827,,225% x Medicaid HMO amount,10827,Other,225% of NY Medicaid HMO DRG,13233,,275% x Medicaid HMO amount,13233,Other,275% of NY Medicaid HMO DRG,15591,,324% x Medicaid HMO amount,15591,Other,324% of NY Medicaid HMO DRG,10346,,215% x Medicaid HMO amount,10346,Other,215% of NY Medicaid HMO DRG,10346,,215% x Medicaid HMO amount,10346,Other,215% of NY Medicaid HMO DRG,6015,,125% x Medicaid HMO amount,6015,Other,125% of NY Medicaid HMO DRG,0.01,23164,
Other anemia & disorders of blood & blood-forming organs,663-2,APR-DRG,,,,,,,,inpatient,,,99629.92,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31797,,"45,128 x DRG weight",31797,Other,base rate x DRG weight,28617,,"40,615 x DRG weight",28617,Other,base rate x DRG weight,27028,,"38,359 x DRG weight",27028,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11718,,186% x Medicaid HMO amount,11718,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24011,,"34,077 x DRG weight",24011,Other,base rate x DRG weight,20409,,"28,966 x DRG weight",20409,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6300,,DRG base rate x DRG weight + capital per discharge,6300,Other,100% of NY Medicaid HMO DRG,6300,,100% x Medicaid HMO amount,6300,Other,100% of NY Medicaid HMO DRG,6300,,100% x Medicaid HMO amount,6300,Other,100% of NY Medicaid HMO DRG,6300,,100% x Medicaid HMO amount,6300,Other,100% of NY Medicaid HMO DRG,14175,,225% x Medicaid HMO amount,14175,Other,225% of NY Medicaid HMO DRG,14175,,225% x Medicaid HMO amount,14175,Other,225% of NY Medicaid HMO DRG,14175,,225% x Medicaid HMO amount,14175,Other,225% of NY Medicaid HMO DRG,14175,,225% x Medicaid HMO amount,14175,Other,225% of NY Medicaid HMO DRG,8820,,140% x Medicaid HMO amount,8820,Other,140% of NY Medicaid HMO DRG,14175,,225% x Medicaid HMO amount,14175,Other,225% of NY Medicaid HMO DRG,17325,,275% x Medicaid HMO amount,17325,Other,275% of NY Medicaid HMO DRG,20412,,324% x Medicaid HMO amount,20412,Other,324% of NY Medicaid HMO DRG,13545,,215% x Medicaid HMO amount,13545,Other,215% of NY Medicaid HMO DRG,13545,,215% x Medicaid HMO amount,13545,Other,215% of NY Medicaid HMO DRG,7875,,125% x Medicaid HMO amount,7875,Other,125% of NY Medicaid HMO DRG,0.01,31797,
Other anemia & disorders of blood & blood-forming organs,663-3,APR-DRG,,,,,,,,inpatient,,,162030.83,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50110,,"45,128 x DRG weight",50110,Other,base rate x DRG weight,45099,,"40,615 x DRG weight",45099,Other,base rate x DRG weight,42594,,"38,359 x DRG weight",42594,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17586,,186% x Medicaid HMO amount,17586,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37839,,"34,077 x DRG weight",37839,Other,base rate x DRG weight,32164,,"28,966 x DRG weight",32164,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9455,,DRG base rate x DRG weight + capital per discharge,9455,Other,100% of NY Medicaid HMO DRG,9455,,100% x Medicaid HMO amount,9455,Other,100% of NY Medicaid HMO DRG,9455,,100% x Medicaid HMO amount,9455,Other,100% of NY Medicaid HMO DRG,9455,,100% x Medicaid HMO amount,9455,Other,100% of NY Medicaid HMO DRG,21274,,225% x Medicaid HMO amount,21274,Other,225% of NY Medicaid HMO DRG,21274,,225% x Medicaid HMO amount,21274,Other,225% of NY Medicaid HMO DRG,21274,,225% x Medicaid HMO amount,21274,Other,225% of NY Medicaid HMO DRG,21274,,225% x Medicaid HMO amount,21274,Other,225% of NY Medicaid HMO DRG,13237,,140% x Medicaid HMO amount,13237,Other,140% of NY Medicaid HMO DRG,21274,,225% x Medicaid HMO amount,21274,Other,225% of NY Medicaid HMO DRG,26001,,275% x Medicaid HMO amount,26001,Other,275% of NY Medicaid HMO DRG,30634,,324% x Medicaid HMO amount,30634,Other,324% of NY Medicaid HMO DRG,20328,,215% x Medicaid HMO amount,20328,Other,215% of NY Medicaid HMO DRG,20328,,215% x Medicaid HMO amount,20328,Other,215% of NY Medicaid HMO DRG,11819,,125% x Medicaid HMO amount,11819,Other,125% of NY Medicaid HMO DRG,0.01,50110,
Other anemia & disorders of blood & blood-forming organs,663-4,APR-DRG,,,,,,,,inpatient,,,575292.01,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,106294,,"45,128 x DRG weight",106294,Other,base rate x DRG weight,95665,,"40,615 x DRG weight",95665,Other,base rate x DRG weight,90351,,"38,359 x DRG weight",90351,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35593,,186% x Medicaid HMO amount,35593,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,80265,,"34,077 x DRG weight",80265,Other,base rate x DRG weight,68227,,"28,966 x DRG weight",68227,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19136,,DRG base rate x DRG weight + capital per discharge,19136,Other,100% of NY Medicaid HMO DRG,19136,,100% x Medicaid HMO amount,19136,Other,100% of NY Medicaid HMO DRG,19136,,100% x Medicaid HMO amount,19136,Other,100% of NY Medicaid HMO DRG,19136,,100% x Medicaid HMO amount,19136,Other,100% of NY Medicaid HMO DRG,43056,,225% x Medicaid HMO amount,43056,Other,225% of NY Medicaid HMO DRG,43056,,225% x Medicaid HMO amount,43056,Other,225% of NY Medicaid HMO DRG,43056,,225% x Medicaid HMO amount,43056,Other,225% of NY Medicaid HMO DRG,43056,,225% x Medicaid HMO amount,43056,Other,225% of NY Medicaid HMO DRG,26790,,140% x Medicaid HMO amount,26790,Other,140% of NY Medicaid HMO DRG,43056,,225% x Medicaid HMO amount,43056,Other,225% of NY Medicaid HMO DRG,52624,,275% x Medicaid HMO amount,52624,Other,275% of NY Medicaid HMO DRG,62001,,324% x Medicaid HMO amount,62001,Other,324% of NY Medicaid HMO DRG,41142,,215% x Medicaid HMO amount,41142,Other,215% of NY Medicaid HMO DRG,41142,,215% x Medicaid HMO amount,41142,Other,215% of NY Medicaid HMO DRG,23920,,125% x Medicaid HMO amount,23920,Other,125% of NY Medicaid HMO DRG,0.01,106294,
Major O.R. procedures for lymphatic/hematopoietic/other neoplasms,680-1,APR-DRG,,,,,,,,inpatient,,,81015.57,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,62457,,"45,128 x DRG weight",62457,Other,base rate x DRG weight,56211,,"40,615 x DRG weight",56211,Other,base rate x DRG weight,53089,,"38,359 x DRG weight",53089,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21543,,186% x Medicaid HMO amount,21543,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47163,,"34,077 x DRG weight",47163,Other,base rate x DRG weight,40089,,"28,966 x DRG weight",40089,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11582,,DRG base rate x DRG weight + capital per discharge,11582,Other,100% of NY Medicaid HMO DRG,11582,,100% x Medicaid HMO amount,11582,Other,100% of NY Medicaid HMO DRG,11582,,100% x Medicaid HMO amount,11582,Other,100% of NY Medicaid HMO DRG,11582,,100% x Medicaid HMO amount,11582,Other,100% of NY Medicaid HMO DRG,26060,,225% x Medicaid HMO amount,26060,Other,225% of NY Medicaid HMO DRG,26060,,225% x Medicaid HMO amount,26060,Other,225% of NY Medicaid HMO DRG,26060,,225% x Medicaid HMO amount,26060,Other,225% of NY Medicaid HMO DRG,26060,,225% x Medicaid HMO amount,26060,Other,225% of NY Medicaid HMO DRG,16215,,140% x Medicaid HMO amount,16215,Other,140% of NY Medicaid HMO DRG,26060,,225% x Medicaid HMO amount,26060,Other,225% of NY Medicaid HMO DRG,31851,,275% x Medicaid HMO amount,31851,Other,275% of NY Medicaid HMO DRG,37526,,324% x Medicaid HMO amount,37526,Other,324% of NY Medicaid HMO DRG,24901,,215% x Medicaid HMO amount,24901,Other,215% of NY Medicaid HMO DRG,24901,,215% x Medicaid HMO amount,24901,Other,215% of NY Medicaid HMO DRG,14478,,125% x Medicaid HMO amount,14478,Other,125% of NY Medicaid HMO DRG,0.01,62457,
Major O.R. procedures for lymphatic/hematopoietic/other neoplasms,680-2,APR-DRG,,,,,,,,inpatient,,,570412.22,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,98456,,"45,128 x DRG weight",98456,Other,base rate x DRG weight,88610,,"40,615 x DRG weight",88610,Other,base rate x DRG weight,83688,,"38,359 x DRG weight",83688,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33080,,186% x Medicaid HMO amount,33080,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,74346,,"34,077 x DRG weight",74346,Other,base rate x DRG weight,63195,,"28,966 x DRG weight",63195,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17785,,DRG base rate x DRG weight + capital per discharge,17785,Other,100% of NY Medicaid HMO DRG,17785,,100% x Medicaid HMO amount,17785,Other,100% of NY Medicaid HMO DRG,17785,,100% x Medicaid HMO amount,17785,Other,100% of NY Medicaid HMO DRG,17785,,100% x Medicaid HMO amount,17785,Other,100% of NY Medicaid HMO DRG,40016,,225% x Medicaid HMO amount,40016,Other,225% of NY Medicaid HMO DRG,40016,,225% x Medicaid HMO amount,40016,Other,225% of NY Medicaid HMO DRG,40016,,225% x Medicaid HMO amount,40016,Other,225% of NY Medicaid HMO DRG,40016,,225% x Medicaid HMO amount,40016,Other,225% of NY Medicaid HMO DRG,24899,,140% x Medicaid HMO amount,24899,Other,140% of NY Medicaid HMO DRG,40016,,225% x Medicaid HMO amount,40016,Other,225% of NY Medicaid HMO DRG,48909,,275% x Medicaid HMO amount,48909,Other,275% of NY Medicaid HMO DRG,57623,,324% x Medicaid HMO amount,57623,Other,324% of NY Medicaid HMO DRG,38238,,215% x Medicaid HMO amount,38238,Other,215% of NY Medicaid HMO DRG,38238,,215% x Medicaid HMO amount,38238,Other,215% of NY Medicaid HMO DRG,22231,,125% x Medicaid HMO amount,22231,Other,125% of NY Medicaid HMO DRG,0.01,98456,
Major O.R. procedures for lymphatic/hematopoietic/other neoplasms,680-3,APR-DRG,,,,,,,,inpatient,,,456927.81,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,174587,,"45,128 x DRG weight",174587,Other,base rate x DRG weight,157127,,"40,615 x DRG weight",157127,Other,base rate x DRG weight,148399,,"38,359 x DRG weight",148399,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,57478,,186% x Medicaid HMO amount,57478,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,131834,,"34,077 x DRG weight",131834,Other,base rate x DRG weight,112061,,"28,966 x DRG weight",112061,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30902,,DRG base rate x DRG weight + capital per discharge,30902,Other,100% of NY Medicaid HMO DRG,30902,,100% x Medicaid HMO amount,30902,Other,100% of NY Medicaid HMO DRG,30902,,100% x Medicaid HMO amount,30902,Other,100% of NY Medicaid HMO DRG,30902,,100% x Medicaid HMO amount,30902,Other,100% of NY Medicaid HMO DRG,69530,,225% x Medicaid HMO amount,69530,Other,225% of NY Medicaid HMO DRG,69530,,225% x Medicaid HMO amount,69530,Other,225% of NY Medicaid HMO DRG,69530,,225% x Medicaid HMO amount,69530,Other,225% of NY Medicaid HMO DRG,69530,,225% x Medicaid HMO amount,69530,Other,225% of NY Medicaid HMO DRG,43263,,140% x Medicaid HMO amount,43263,Other,140% of NY Medicaid HMO DRG,69530,,225% x Medicaid HMO amount,69530,Other,225% of NY Medicaid HMO DRG,84981,,275% x Medicaid HMO amount,84981,Other,275% of NY Medicaid HMO DRG,100122,,324% x Medicaid HMO amount,100122,Other,324% of NY Medicaid HMO DRG,66439,,215% x Medicaid HMO amount,66439,Other,215% of NY Medicaid HMO DRG,66439,,215% x Medicaid HMO amount,66439,Other,215% of NY Medicaid HMO DRG,38628,,125% x Medicaid HMO amount,38628,Other,125% of NY Medicaid HMO DRG,0.01,174587,
Major O.R. procedures for lymphatic/hematopoietic/other neoplasms,680-4,APR-DRG,,,,,,,,inpatient,,,1626126.18,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,403729,,"45,128 x DRG weight",403729,Other,base rate x DRG weight,363354,,"40,615 x DRG weight",363354,Other,base rate x DRG weight,343171,,"38,359 x DRG weight",343171,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,130914,,186% x Medicaid HMO amount,130914,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,304863,,"34,077 x DRG weight",304863,Other,base rate x DRG weight,259139,,"28,966 x DRG weight",259139,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,70384,,DRG base rate x DRG weight + capital per discharge,70384,Other,100% of NY Medicaid HMO DRG,70384,,100% x Medicaid HMO amount,70384,Other,100% of NY Medicaid HMO DRG,70384,,100% x Medicaid HMO amount,70384,Other,100% of NY Medicaid HMO DRG,70384,,100% x Medicaid HMO amount,70384,Other,100% of NY Medicaid HMO DRG,158364,,225% x Medicaid HMO amount,158364,Other,225% of NY Medicaid HMO DRG,158364,,225% x Medicaid HMO amount,158364,Other,225% of NY Medicaid HMO DRG,158364,,225% x Medicaid HMO amount,158364,Other,225% of NY Medicaid HMO DRG,158364,,225% x Medicaid HMO amount,158364,Other,225% of NY Medicaid HMO DRG,98538,,140% x Medicaid HMO amount,98538,Other,140% of NY Medicaid HMO DRG,158364,,225% x Medicaid HMO amount,158364,Other,225% of NY Medicaid HMO DRG,193556,,275% x Medicaid HMO amount,193556,Other,275% of NY Medicaid HMO DRG,228044,,324% x Medicaid HMO amount,228044,Other,324% of NY Medicaid HMO DRG,151326,,215% x Medicaid HMO amount,151326,Other,215% of NY Medicaid HMO DRG,151326,,215% x Medicaid HMO amount,151326,Other,215% of NY Medicaid HMO DRG,87980,,125% x Medicaid HMO amount,87980,Other,125% of NY Medicaid HMO DRG,0.01,403729,
Other O.R. procedures for lymphatic/hematopoietic/other neoplasms,681-1,APR-DRG,,,,,,,,inpatient,,,306613.95,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42790,,"45,128 x DRG weight",42790,Other,base rate x DRG weight,38511,,"40,615 x DRG weight",38511,Other,base rate x DRG weight,36372,,"38,359 x DRG weight",36372,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15241,,186% x Medicaid HMO amount,15241,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32312,,"34,077 x DRG weight",32312,Other,base rate x DRG weight,27466,,"28,966 x DRG weight",27466,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8194,,DRG base rate x DRG weight + capital per discharge,8194,Other,100% of NY Medicaid HMO DRG,8194,,100% x Medicaid HMO amount,8194,Other,100% of NY Medicaid HMO DRG,8194,,100% x Medicaid HMO amount,8194,Other,100% of NY Medicaid HMO DRG,8194,,100% x Medicaid HMO amount,8194,Other,100% of NY Medicaid HMO DRG,18437,,225% x Medicaid HMO amount,18437,Other,225% of NY Medicaid HMO DRG,18437,,225% x Medicaid HMO amount,18437,Other,225% of NY Medicaid HMO DRG,18437,,225% x Medicaid HMO amount,18437,Other,225% of NY Medicaid HMO DRG,18437,,225% x Medicaid HMO amount,18437,Other,225% of NY Medicaid HMO DRG,11472,,140% x Medicaid HMO amount,11472,Other,140% of NY Medicaid HMO DRG,18437,,225% x Medicaid HMO amount,18437,Other,225% of NY Medicaid HMO DRG,22534,,275% x Medicaid HMO amount,22534,Other,275% of NY Medicaid HMO DRG,26549,,324% x Medicaid HMO amount,26549,Other,324% of NY Medicaid HMO DRG,17617,,215% x Medicaid HMO amount,17617,Other,215% of NY Medicaid HMO DRG,17617,,215% x Medicaid HMO amount,17617,Other,215% of NY Medicaid HMO DRG,10243,,125% x Medicaid HMO amount,10243,Other,125% of NY Medicaid HMO DRG,0.01,42790,
Other O.R. procedures for lymphatic/hematopoietic/other neoplasms,681-2,APR-DRG,,,,,,,,inpatient,,,535313.46,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,71550,,"45,128 x DRG weight",71550,Other,base rate x DRG weight,64395,,"40,615 x DRG weight",64395,Other,base rate x DRG weight,60818,,"38,359 x DRG weight",60818,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24457,,186% x Medicaid HMO amount,24457,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54029,,"34,077 x DRG weight",54029,Other,base rate x DRG weight,45926,,"28,966 x DRG weight",45926,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13149,,DRG base rate x DRG weight + capital per discharge,13149,Other,100% of NY Medicaid HMO DRG,13149,,100% x Medicaid HMO amount,13149,Other,100% of NY Medicaid HMO DRG,13149,,100% x Medicaid HMO amount,13149,Other,100% of NY Medicaid HMO DRG,13149,,100% x Medicaid HMO amount,13149,Other,100% of NY Medicaid HMO DRG,29585,,225% x Medicaid HMO amount,29585,Other,225% of NY Medicaid HMO DRG,29585,,225% x Medicaid HMO amount,29585,Other,225% of NY Medicaid HMO DRG,29585,,225% x Medicaid HMO amount,29585,Other,225% of NY Medicaid HMO DRG,29585,,225% x Medicaid HMO amount,29585,Other,225% of NY Medicaid HMO DRG,18409,,140% x Medicaid HMO amount,18409,Other,140% of NY Medicaid HMO DRG,29585,,225% x Medicaid HMO amount,29585,Other,225% of NY Medicaid HMO DRG,36160,,275% x Medicaid HMO amount,36160,Other,275% of NY Medicaid HMO DRG,42603,,324% x Medicaid HMO amount,42603,Other,324% of NY Medicaid HMO DRG,28270,,215% x Medicaid HMO amount,28270,Other,215% of NY Medicaid HMO DRG,28270,,215% x Medicaid HMO amount,28270,Other,215% of NY Medicaid HMO DRG,16436,,125% x Medicaid HMO amount,16436,Other,125% of NY Medicaid HMO DRG,0.01,71550,
Other O.R. procedures for lymphatic/hematopoietic/other neoplasms,681-3,APR-DRG,,,,,,,,inpatient,,,1036518.43,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,172357,,"45,128 x DRG weight",172357,Other,base rate x DRG weight,155121,,"40,615 x DRG weight",155121,Other,base rate x DRG weight,146505,,"38,359 x DRG weight",146505,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56763,,186% x Medicaid HMO amount,56763,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,130150,,"34,077 x DRG weight",130150,Other,base rate x DRG weight,110630,,"28,966 x DRG weight",110630,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30518,,DRG base rate x DRG weight + capital per discharge,30518,Other,100% of NY Medicaid HMO DRG,30518,,100% x Medicaid HMO amount,30518,Other,100% of NY Medicaid HMO DRG,30518,,100% x Medicaid HMO amount,30518,Other,100% of NY Medicaid HMO DRG,30518,,100% x Medicaid HMO amount,30518,Other,100% of NY Medicaid HMO DRG,68666,,225% x Medicaid HMO amount,68666,Other,225% of NY Medicaid HMO DRG,68666,,225% x Medicaid HMO amount,68666,Other,225% of NY Medicaid HMO DRG,68666,,225% x Medicaid HMO amount,68666,Other,225% of NY Medicaid HMO DRG,68666,,225% x Medicaid HMO amount,68666,Other,225% of NY Medicaid HMO DRG,42725,,140% x Medicaid HMO amount,42725,Other,140% of NY Medicaid HMO DRG,68666,,225% x Medicaid HMO amount,68666,Other,225% of NY Medicaid HMO DRG,83925,,275% x Medicaid HMO amount,83925,Other,275% of NY Medicaid HMO DRG,98878,,324% x Medicaid HMO amount,98878,Other,324% of NY Medicaid HMO DRG,65614,,215% x Medicaid HMO amount,65614,Other,215% of NY Medicaid HMO DRG,65614,,215% x Medicaid HMO amount,65614,Other,215% of NY Medicaid HMO DRG,38148,,125% x Medicaid HMO amount,38148,Other,125% of NY Medicaid HMO DRG,0.01,172357,
Other O.R. procedures for lymphatic/hematopoietic/other neoplasms,681-4,APR-DRG,,,,,,,,inpatient,,,1888179.27,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,404852,,"45,128 x DRG weight",404852,Other,base rate x DRG weight,364365,,"40,615 x DRG weight",364365,Other,base rate x DRG weight,344126,,"38,359 x DRG weight",344126,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,131275,,186% x Medicaid HMO amount,131275,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,305712,,"34,077 x DRG weight",305712,Other,base rate x DRG weight,259860,,"28,966 x DRG weight",259860,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,70578,,DRG base rate x DRG weight + capital per discharge,70578,Other,100% of NY Medicaid HMO DRG,70578,,100% x Medicaid HMO amount,70578,Other,100% of NY Medicaid HMO DRG,70578,,100% x Medicaid HMO amount,70578,Other,100% of NY Medicaid HMO DRG,70578,,100% x Medicaid HMO amount,70578,Other,100% of NY Medicaid HMO DRG,158801,,225% x Medicaid HMO amount,158801,Other,225% of NY Medicaid HMO DRG,158801,,225% x Medicaid HMO amount,158801,Other,225% of NY Medicaid HMO DRG,158801,,225% x Medicaid HMO amount,158801,Other,225% of NY Medicaid HMO DRG,158801,,225% x Medicaid HMO amount,158801,Other,225% of NY Medicaid HMO DRG,98809,,140% x Medicaid HMO amount,98809,Other,140% of NY Medicaid HMO DRG,158801,,225% x Medicaid HMO amount,158801,Other,225% of NY Medicaid HMO DRG,194090,,275% x Medicaid HMO amount,194090,Other,275% of NY Medicaid HMO DRG,228673,,324% x Medicaid HMO amount,228673,Other,324% of NY Medicaid HMO DRG,151743,,215% x Medicaid HMO amount,151743,Other,215% of NY Medicaid HMO DRG,151743,,215% x Medicaid HMO amount,151743,Other,215% of NY Medicaid HMO DRG,88223,,125% x Medicaid HMO amount,88223,Other,125% of NY Medicaid HMO DRG,0.01,404852,
Acute leukemia,690-1,APR-DRG,,,,,,,,inpatient,,,52522,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60323,,"45,128 x DRG weight",60323,Other,base rate x DRG weight,54290,,"40,615 x DRG weight",54290,Other,base rate x DRG weight,51274,,"38,359 x DRG weight",51274,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20860,,186% x Medicaid HMO amount,20860,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45551,,"34,077 x DRG weight",45551,Other,base rate x DRG weight,38719,,"28,966 x DRG weight",38719,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11215,,DRG base rate x DRG weight + capital per discharge,11215,Other,100% of NY Medicaid HMO DRG,11215,,100% x Medicaid HMO amount,11215,Other,100% of NY Medicaid HMO DRG,11215,,100% x Medicaid HMO amount,11215,Other,100% of NY Medicaid HMO DRG,11215,,100% x Medicaid HMO amount,11215,Other,100% of NY Medicaid HMO DRG,25234,,225% x Medicaid HMO amount,25234,Other,225% of NY Medicaid HMO DRG,25234,,225% x Medicaid HMO amount,25234,Other,225% of NY Medicaid HMO DRG,25234,,225% x Medicaid HMO amount,25234,Other,225% of NY Medicaid HMO DRG,25234,,225% x Medicaid HMO amount,25234,Other,225% of NY Medicaid HMO DRG,15701,,140% x Medicaid HMO amount,15701,Other,140% of NY Medicaid HMO DRG,25234,,225% x Medicaid HMO amount,25234,Other,225% of NY Medicaid HMO DRG,30841,,275% x Medicaid HMO amount,30841,Other,275% of NY Medicaid HMO DRG,36337,,324% x Medicaid HMO amount,36337,Other,324% of NY Medicaid HMO DRG,24112,,215% x Medicaid HMO amount,24112,Other,215% of NY Medicaid HMO DRG,24112,,215% x Medicaid HMO amount,24112,Other,215% of NY Medicaid HMO DRG,14019,,125% x Medicaid HMO amount,14019,Other,125% of NY Medicaid HMO DRG,0.01,60323,
Acute leukemia,690-2,APR-DRG,,,,,,,,inpatient,,,634081.05,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,122689,,"45,128 x DRG weight",122689,Other,base rate x DRG weight,110420,,"40,615 x DRG weight",110420,Other,base rate x DRG weight,104287,,"38,359 x DRG weight",104287,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40846,,186% x Medicaid HMO amount,40846,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,92645,,"34,077 x DRG weight",92645,Other,base rate x DRG weight,78750,,"28,966 x DRG weight",78750,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21960,,DRG base rate x DRG weight + capital per discharge,21960,Other,100% of NY Medicaid HMO DRG,21960,,100% x Medicaid HMO amount,21960,Other,100% of NY Medicaid HMO DRG,21960,,100% x Medicaid HMO amount,21960,Other,100% of NY Medicaid HMO DRG,21960,,100% x Medicaid HMO amount,21960,Other,100% of NY Medicaid HMO DRG,49410,,225% x Medicaid HMO amount,49410,Other,225% of NY Medicaid HMO DRG,49410,,225% x Medicaid HMO amount,49410,Other,225% of NY Medicaid HMO DRG,49410,,225% x Medicaid HMO amount,49410,Other,225% of NY Medicaid HMO DRG,49410,,225% x Medicaid HMO amount,49410,Other,225% of NY Medicaid HMO DRG,30744,,140% x Medicaid HMO amount,30744,Other,140% of NY Medicaid HMO DRG,49410,,225% x Medicaid HMO amount,49410,Other,225% of NY Medicaid HMO DRG,60390,,275% x Medicaid HMO amount,60390,Other,275% of NY Medicaid HMO DRG,71150,,324% x Medicaid HMO amount,71150,Other,324% of NY Medicaid HMO DRG,47214,,215% x Medicaid HMO amount,47214,Other,215% of NY Medicaid HMO DRG,47214,,215% x Medicaid HMO amount,47214,Other,215% of NY Medicaid HMO DRG,27450,,125% x Medicaid HMO amount,27450,Other,125% of NY Medicaid HMO DRG,0.01,122689,
Acute leukemia,690-3,APR-DRG,,,,,,,,inpatient,,,702609.28,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,273607,,"45,128 x DRG weight",273607,Other,base rate x DRG weight,246245,,"40,615 x DRG weight",246245,Other,base rate x DRG weight,232567,,"38,359 x DRG weight",232567,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,89213,,186% x Medicaid HMO amount,89213,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,206605,,"34,077 x DRG weight",206605,Other,base rate x DRG weight,175618,,"28,966 x DRG weight",175618,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47964,,DRG base rate x DRG weight + capital per discharge,47964,Other,100% of NY Medicaid HMO DRG,47964,,100% x Medicaid HMO amount,47964,Other,100% of NY Medicaid HMO DRG,47964,,100% x Medicaid HMO amount,47964,Other,100% of NY Medicaid HMO DRG,47964,,100% x Medicaid HMO amount,47964,Other,100% of NY Medicaid HMO DRG,107919,,225% x Medicaid HMO amount,107919,Other,225% of NY Medicaid HMO DRG,107919,,225% x Medicaid HMO amount,107919,Other,225% of NY Medicaid HMO DRG,107919,,225% x Medicaid HMO amount,107919,Other,225% of NY Medicaid HMO DRG,107919,,225% x Medicaid HMO amount,107919,Other,225% of NY Medicaid HMO DRG,67150,,140% x Medicaid HMO amount,67150,Other,140% of NY Medicaid HMO DRG,107919,,225% x Medicaid HMO amount,107919,Other,225% of NY Medicaid HMO DRG,131901,,275% x Medicaid HMO amount,131901,Other,275% of NY Medicaid HMO DRG,155403,,324% x Medicaid HMO amount,155403,Other,324% of NY Medicaid HMO DRG,103123,,215% x Medicaid HMO amount,103123,Other,215% of NY Medicaid HMO DRG,103123,,215% x Medicaid HMO amount,103123,Other,215% of NY Medicaid HMO DRG,59955,,125% x Medicaid HMO amount,59955,Other,125% of NY Medicaid HMO DRG,0.01,273607,
Acute leukemia,690-4,APR-DRG,,,,,,,,inpatient,,,1803817.34,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,395010,,"45,128 x DRG weight",395010,Other,base rate x DRG weight,355507,,"40,615 x DRG weight",355507,Other,base rate x DRG weight,335760,,"38,359 x DRG weight",335760,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,128121,,186% x Medicaid HMO amount,128121,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,298279,,"34,077 x DRG weight",298279,Other,base rate x DRG weight,253542,,"28,966 x DRG weight",253542,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,68882,,DRG base rate x DRG weight + capital per discharge,68882,Other,100% of NY Medicaid HMO DRG,68882,,100% x Medicaid HMO amount,68882,Other,100% of NY Medicaid HMO DRG,68882,,100% x Medicaid HMO amount,68882,Other,100% of NY Medicaid HMO DRG,68882,,100% x Medicaid HMO amount,68882,Other,100% of NY Medicaid HMO DRG,154985,,225% x Medicaid HMO amount,154985,Other,225% of NY Medicaid HMO DRG,154985,,225% x Medicaid HMO amount,154985,Other,225% of NY Medicaid HMO DRG,154985,,225% x Medicaid HMO amount,154985,Other,225% of NY Medicaid HMO DRG,154985,,225% x Medicaid HMO amount,154985,Other,225% of NY Medicaid HMO DRG,96435,,140% x Medicaid HMO amount,96435,Other,140% of NY Medicaid HMO DRG,154985,,225% x Medicaid HMO amount,154985,Other,225% of NY Medicaid HMO DRG,189426,,275% x Medicaid HMO amount,189426,Other,275% of NY Medicaid HMO DRG,223178,,324% x Medicaid HMO amount,223178,Other,324% of NY Medicaid HMO DRG,148096,,215% x Medicaid HMO amount,148096,Other,215% of NY Medicaid HMO DRG,148096,,215% x Medicaid HMO amount,148096,Other,215% of NY Medicaid HMO DRG,86103,,125% x Medicaid HMO amount,86103,Other,125% of NY Medicaid HMO DRG,0.01,395010,
"Lymphoma, myeloma & non-acute leukemia",691-1,APR-DRG,,,,,,,,inpatient,,,65923,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46152,,"45,128 x DRG weight",46152,Other,base rate x DRG weight,41537,,"40,615 x DRG weight",41537,Other,base rate x DRG weight,39230,,"38,359 x DRG weight",39230,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16318,,186% x Medicaid HMO amount,16318,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34851,,"34,077 x DRG weight",34851,Other,base rate x DRG weight,29624,,"28,966 x DRG weight",29624,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8773,,DRG base rate x DRG weight + capital per discharge,8773,Other,100% of NY Medicaid HMO DRG,8773,,100% x Medicaid HMO amount,8773,Other,100% of NY Medicaid HMO DRG,8773,,100% x Medicaid HMO amount,8773,Other,100% of NY Medicaid HMO DRG,8773,,100% x Medicaid HMO amount,8773,Other,100% of NY Medicaid HMO DRG,19739,,225% x Medicaid HMO amount,19739,Other,225% of NY Medicaid HMO DRG,19739,,225% x Medicaid HMO amount,19739,Other,225% of NY Medicaid HMO DRG,19739,,225% x Medicaid HMO amount,19739,Other,225% of NY Medicaid HMO DRG,19739,,225% x Medicaid HMO amount,19739,Other,225% of NY Medicaid HMO DRG,12282,,140% x Medicaid HMO amount,12282,Other,140% of NY Medicaid HMO DRG,19739,,225% x Medicaid HMO amount,19739,Other,225% of NY Medicaid HMO DRG,24126,,275% x Medicaid HMO amount,24126,Other,275% of NY Medicaid HMO DRG,28425,,324% x Medicaid HMO amount,28425,Other,324% of NY Medicaid HMO DRG,18862,,215% x Medicaid HMO amount,18862,Other,215% of NY Medicaid HMO DRG,18862,,215% x Medicaid HMO amount,18862,Other,215% of NY Medicaid HMO DRG,10966,,125% x Medicaid HMO amount,10966,Other,125% of NY Medicaid HMO DRG,0.01,46152,
"Lymphoma, myeloma & non-acute leukemia",691-2,APR-DRG,,,,,,,,inpatient,,,179939.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,66970,,"45,128 x DRG weight",66970,Other,base rate x DRG weight,60273,,"40,615 x DRG weight",60273,Other,base rate x DRG weight,56925,,"38,359 x DRG weight",56925,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22990,,186% x Medicaid HMO amount,22990,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50570,,"34,077 x DRG weight",50570,Other,base rate x DRG weight,42986,,"28,966 x DRG weight",42986,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12360,,DRG base rate x DRG weight + capital per discharge,12360,Other,100% of NY Medicaid HMO DRG,12360,,100% x Medicaid HMO amount,12360,Other,100% of NY Medicaid HMO DRG,12360,,100% x Medicaid HMO amount,12360,Other,100% of NY Medicaid HMO DRG,12360,,100% x Medicaid HMO amount,12360,Other,100% of NY Medicaid HMO DRG,27810,,225% x Medicaid HMO amount,27810,Other,225% of NY Medicaid HMO DRG,27810,,225% x Medicaid HMO amount,27810,Other,225% of NY Medicaid HMO DRG,27810,,225% x Medicaid HMO amount,27810,Other,225% of NY Medicaid HMO DRG,27810,,225% x Medicaid HMO amount,27810,Other,225% of NY Medicaid HMO DRG,17304,,140% x Medicaid HMO amount,17304,Other,140% of NY Medicaid HMO DRG,27810,,225% x Medicaid HMO amount,27810,Other,225% of NY Medicaid HMO DRG,33990,,275% x Medicaid HMO amount,33990,Other,275% of NY Medicaid HMO DRG,40046,,324% x Medicaid HMO amount,40046,Other,324% of NY Medicaid HMO DRG,26574,,215% x Medicaid HMO amount,26574,Other,215% of NY Medicaid HMO DRG,26574,,215% x Medicaid HMO amount,26574,Other,215% of NY Medicaid HMO DRG,15450,,125% x Medicaid HMO amount,15450,Other,125% of NY Medicaid HMO DRG,0.01,66970,
"Lymphoma, myeloma & non-acute leukemia",691-3,APR-DRG,,,,,,,,inpatient,,,301956.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,113393,,"45,128 x DRG weight",113393,Other,base rate x DRG weight,102053,,"40,615 x DRG weight",102053,Other,base rate x DRG weight,96385,,"38,359 x DRG weight",96385,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37868,,186% x Medicaid HMO amount,37868,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,85625,,"34,077 x DRG weight",85625,Other,base rate x DRG weight,72783,,"28,966 x DRG weight",72783,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20359,,DRG base rate x DRG weight + capital per discharge,20359,Other,100% of NY Medicaid HMO DRG,20359,,100% x Medicaid HMO amount,20359,Other,100% of NY Medicaid HMO DRG,20359,,100% x Medicaid HMO amount,20359,Other,100% of NY Medicaid HMO DRG,20359,,100% x Medicaid HMO amount,20359,Other,100% of NY Medicaid HMO DRG,45808,,225% x Medicaid HMO amount,45808,Other,225% of NY Medicaid HMO DRG,45808,,225% x Medicaid HMO amount,45808,Other,225% of NY Medicaid HMO DRG,45808,,225% x Medicaid HMO amount,45808,Other,225% of NY Medicaid HMO DRG,45808,,225% x Medicaid HMO amount,45808,Other,225% of NY Medicaid HMO DRG,28503,,140% x Medicaid HMO amount,28503,Other,140% of NY Medicaid HMO DRG,45808,,225% x Medicaid HMO amount,45808,Other,225% of NY Medicaid HMO DRG,55987,,275% x Medicaid HMO amount,55987,Other,275% of NY Medicaid HMO DRG,65963,,324% x Medicaid HMO amount,65963,Other,324% of NY Medicaid HMO DRG,43772,,215% x Medicaid HMO amount,43772,Other,215% of NY Medicaid HMO DRG,43772,,215% x Medicaid HMO amount,43772,Other,215% of NY Medicaid HMO DRG,25449,,125% x Medicaid HMO amount,25449,Other,125% of NY Medicaid HMO DRG,0.01,113393,
"Lymphoma, myeloma & non-acute leukemia",691-4,APR-DRG,,,,,,,,inpatient,,,807135.86,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,285787,,"45,128 x DRG weight",285787,Other,base rate x DRG weight,257207,,"40,615 x DRG weight",257207,Other,base rate x DRG weight,242920,,"38,359 x DRG weight",242920,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,93115,,186% x Medicaid HMO amount,93115,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,215803,,"34,077 x DRG weight",215803,Other,base rate x DRG weight,183436,,"28,966 x DRG weight",183436,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50062,,DRG base rate x DRG weight + capital per discharge,50062,Other,100% of NY Medicaid HMO DRG,50062,,100% x Medicaid HMO amount,50062,Other,100% of NY Medicaid HMO DRG,50062,,100% x Medicaid HMO amount,50062,Other,100% of NY Medicaid HMO DRG,50062,,100% x Medicaid HMO amount,50062,Other,100% of NY Medicaid HMO DRG,112640,,225% x Medicaid HMO amount,112640,Other,225% of NY Medicaid HMO DRG,112640,,225% x Medicaid HMO amount,112640,Other,225% of NY Medicaid HMO DRG,112640,,225% x Medicaid HMO amount,112640,Other,225% of NY Medicaid HMO DRG,112640,,225% x Medicaid HMO amount,112640,Other,225% of NY Medicaid HMO DRG,70087,,140% x Medicaid HMO amount,70087,Other,140% of NY Medicaid HMO DRG,112640,,225% x Medicaid HMO amount,112640,Other,225% of NY Medicaid HMO DRG,137671,,275% x Medicaid HMO amount,137671,Other,275% of NY Medicaid HMO DRG,162201,,324% x Medicaid HMO amount,162201,Other,324% of NY Medicaid HMO DRG,107633,,215% x Medicaid HMO amount,107633,Other,215% of NY Medicaid HMO DRG,107633,,215% x Medicaid HMO amount,107633,Other,215% of NY Medicaid HMO DRG,62578,,125% x Medicaid HMO amount,62578,Other,125% of NY Medicaid HMO DRG,0.01,285787,
Radiotherapy,692-1,APR-DRG,,,,,,,,inpatient,,,121868.82,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26892,,"45,128 x DRG weight",26892,Other,base rate x DRG weight,24202,,"40,615 x DRG weight",24202,Other,base rate x DRG weight,22858,,"38,359 x DRG weight",22858,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10144,,186% x Medicaid HMO amount,10144,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20306,,"34,077 x DRG weight",20306,Other,base rate x DRG weight,17261,,"28,966 x DRG weight",17261,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5454,,DRG base rate x DRG weight + capital per discharge,5454,Other,100% of NY Medicaid HMO DRG,5454,,100% x Medicaid HMO amount,5454,Other,100% of NY Medicaid HMO DRG,5454,,100% x Medicaid HMO amount,5454,Other,100% of NY Medicaid HMO DRG,5454,,100% x Medicaid HMO amount,5454,Other,100% of NY Medicaid HMO DRG,12272,,225% x Medicaid HMO amount,12272,Other,225% of NY Medicaid HMO DRG,12272,,225% x Medicaid HMO amount,12272,Other,225% of NY Medicaid HMO DRG,12272,,225% x Medicaid HMO amount,12272,Other,225% of NY Medicaid HMO DRG,12272,,225% x Medicaid HMO amount,12272,Other,225% of NY Medicaid HMO DRG,7636,,140% x Medicaid HMO amount,7636,Other,140% of NY Medicaid HMO DRG,12272,,225% x Medicaid HMO amount,12272,Other,225% of NY Medicaid HMO DRG,14999,,275% x Medicaid HMO amount,14999,Other,275% of NY Medicaid HMO DRG,17671,,324% x Medicaid HMO amount,17671,Other,324% of NY Medicaid HMO DRG,11726,,215% x Medicaid HMO amount,11726,Other,215% of NY Medicaid HMO DRG,11726,,215% x Medicaid HMO amount,11726,Other,215% of NY Medicaid HMO DRG,6818,,125% x Medicaid HMO amount,6818,Other,125% of NY Medicaid HMO DRG,0.01,26892,
Radiotherapy,692-2,APR-DRG,,,,,,,,inpatient,,,95287,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,58707,,"45,128 x DRG weight",58707,Other,base rate x DRG weight,52836,,"40,615 x DRG weight",52836,Other,base rate x DRG weight,49901,,"38,359 x DRG weight",49901,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20341,,186% x Medicaid HMO amount,20341,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44331,,"34,077 x DRG weight",44331,Other,base rate x DRG weight,37682,,"28,966 x DRG weight",37682,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10936,,DRG base rate x DRG weight + capital per discharge,10936,Other,100% of NY Medicaid HMO DRG,10936,,100% x Medicaid HMO amount,10936,Other,100% of NY Medicaid HMO DRG,10936,,100% x Medicaid HMO amount,10936,Other,100% of NY Medicaid HMO DRG,10936,,100% x Medicaid HMO amount,10936,Other,100% of NY Medicaid HMO DRG,24606,,225% x Medicaid HMO amount,24606,Other,225% of NY Medicaid HMO DRG,24606,,225% x Medicaid HMO amount,24606,Other,225% of NY Medicaid HMO DRG,24606,,225% x Medicaid HMO amount,24606,Other,225% of NY Medicaid HMO DRG,24606,,225% x Medicaid HMO amount,24606,Other,225% of NY Medicaid HMO DRG,15310,,140% x Medicaid HMO amount,15310,Other,140% of NY Medicaid HMO DRG,24606,,225% x Medicaid HMO amount,24606,Other,225% of NY Medicaid HMO DRG,30074,,275% x Medicaid HMO amount,30074,Other,275% of NY Medicaid HMO DRG,35433,,324% x Medicaid HMO amount,35433,Other,324% of NY Medicaid HMO DRG,23512,,215% x Medicaid HMO amount,23512,Other,215% of NY Medicaid HMO DRG,23512,,215% x Medicaid HMO amount,23512,Other,215% of NY Medicaid HMO DRG,13670,,125% x Medicaid HMO amount,13670,Other,125% of NY Medicaid HMO DRG,0.01,58707,
Radiotherapy,692-3,APR-DRG,,,,,,,,inpatient,,,653583.84,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,125627,,"45,128 x DRG weight",125627,Other,base rate x DRG weight,113064,,"40,615 x DRG weight",113064,Other,base rate x DRG weight,106784,,"38,359 x DRG weight",106784,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41789,,186% x Medicaid HMO amount,41789,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,94864,,"34,077 x DRG weight",94864,Other,base rate x DRG weight,80636,,"28,966 x DRG weight",80636,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22467,,DRG base rate x DRG weight + capital per discharge,22467,Other,100% of NY Medicaid HMO DRG,22467,,100% x Medicaid HMO amount,22467,Other,100% of NY Medicaid HMO DRG,22467,,100% x Medicaid HMO amount,22467,Other,100% of NY Medicaid HMO DRG,22467,,100% x Medicaid HMO amount,22467,Other,100% of NY Medicaid HMO DRG,50551,,225% x Medicaid HMO amount,50551,Other,225% of NY Medicaid HMO DRG,50551,,225% x Medicaid HMO amount,50551,Other,225% of NY Medicaid HMO DRG,50551,,225% x Medicaid HMO amount,50551,Other,225% of NY Medicaid HMO DRG,50551,,225% x Medicaid HMO amount,50551,Other,225% of NY Medicaid HMO DRG,31454,,140% x Medicaid HMO amount,31454,Other,140% of NY Medicaid HMO DRG,50551,,225% x Medicaid HMO amount,50551,Other,225% of NY Medicaid HMO DRG,61784,,275% x Medicaid HMO amount,61784,Other,275% of NY Medicaid HMO DRG,72793,,324% x Medicaid HMO amount,72793,Other,324% of NY Medicaid HMO DRG,48304,,215% x Medicaid HMO amount,48304,Other,215% of NY Medicaid HMO DRG,48304,,215% x Medicaid HMO amount,48304,Other,215% of NY Medicaid HMO DRG,28084,,125% x Medicaid HMO amount,28084,Other,125% of NY Medicaid HMO DRG,0.01,125627,
Radiotherapy,692-4,APR-DRG,,,,,,,,inpatient,,,653583.84,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,140966,,"45,128 x DRG weight",140966,Other,base rate x DRG weight,126869,,"40,615 x DRG weight",126869,Other,base rate x DRG weight,119822,,"38,359 x DRG weight",119822,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46705,,186% x Medicaid HMO amount,46705,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,106446,,"34,077 x DRG weight",106446,Other,base rate x DRG weight,90481,,"28,966 x DRG weight",90481,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25110,,DRG base rate x DRG weight + capital per discharge,25110,Other,100% of NY Medicaid HMO DRG,25110,,100% x Medicaid HMO amount,25110,Other,100% of NY Medicaid HMO DRG,25110,,100% x Medicaid HMO amount,25110,Other,100% of NY Medicaid HMO DRG,25110,,100% x Medicaid HMO amount,25110,Other,100% of NY Medicaid HMO DRG,56498,,225% x Medicaid HMO amount,56498,Other,225% of NY Medicaid HMO DRG,56498,,225% x Medicaid HMO amount,56498,Other,225% of NY Medicaid HMO DRG,56498,,225% x Medicaid HMO amount,56498,Other,225% of NY Medicaid HMO DRG,56498,,225% x Medicaid HMO amount,56498,Other,225% of NY Medicaid HMO DRG,35154,,140% x Medicaid HMO amount,35154,Other,140% of NY Medicaid HMO DRG,56498,,225% x Medicaid HMO amount,56498,Other,225% of NY Medicaid HMO DRG,69053,,275% x Medicaid HMO amount,69053,Other,275% of NY Medicaid HMO DRG,81356,,324% x Medicaid HMO amount,81356,Other,324% of NY Medicaid HMO DRG,53987,,215% x Medicaid HMO amount,53987,Other,215% of NY Medicaid HMO DRG,53987,,215% x Medicaid HMO amount,53987,Other,215% of NY Medicaid HMO DRG,31388,,125% x Medicaid HMO amount,31388,Other,125% of NY Medicaid HMO DRG,0.01,140966,
Lymphatic & other malignancies & neoplasms of uncertain behavior,694-1,APR-DRG,,,,,,,,inpatient,,,54228,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28101,,"45,128 x DRG weight",28101,Other,base rate x DRG weight,25291,,"40,615 x DRG weight",25291,Other,base rate x DRG weight,23886,,"38,359 x DRG weight",23886,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10533,,186% x Medicaid HMO amount,10533,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21220,,"34,077 x DRG weight",21220,Other,base rate x DRG weight,18037,,"28,966 x DRG weight",18037,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5663,,DRG base rate x DRG weight + capital per discharge,5663,Other,100% of NY Medicaid HMO DRG,5663,,100% x Medicaid HMO amount,5663,Other,100% of NY Medicaid HMO DRG,5663,,100% x Medicaid HMO amount,5663,Other,100% of NY Medicaid HMO DRG,5663,,100% x Medicaid HMO amount,5663,Other,100% of NY Medicaid HMO DRG,12742,,225% x Medicaid HMO amount,12742,Other,225% of NY Medicaid HMO DRG,12742,,225% x Medicaid HMO amount,12742,Other,225% of NY Medicaid HMO DRG,12742,,225% x Medicaid HMO amount,12742,Other,225% of NY Medicaid HMO DRG,12742,,225% x Medicaid HMO amount,12742,Other,225% of NY Medicaid HMO DRG,7928,,140% x Medicaid HMO amount,7928,Other,140% of NY Medicaid HMO DRG,12742,,225% x Medicaid HMO amount,12742,Other,225% of NY Medicaid HMO DRG,15573,,275% x Medicaid HMO amount,15573,Other,275% of NY Medicaid HMO DRG,18348,,324% x Medicaid HMO amount,18348,Other,324% of NY Medicaid HMO DRG,12175,,215% x Medicaid HMO amount,12175,Other,215% of NY Medicaid HMO DRG,12175,,215% x Medicaid HMO amount,12175,Other,215% of NY Medicaid HMO DRG,7079,,125% x Medicaid HMO amount,7079,Other,125% of NY Medicaid HMO DRG,0.01,28101,
Lymphatic & other malignancies & neoplasms of uncertain behavior,694-2,APR-DRG,,,,,,,,inpatient,,,133835.9,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44293,,"45,128 x DRG weight",44293,Other,base rate x DRG weight,39864,,"40,615 x DRG weight",39864,Other,base rate x DRG weight,37649,,"38,359 x DRG weight",37649,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15723,,186% x Medicaid HMO amount,15723,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33447,,"34,077 x DRG weight",33447,Other,base rate x DRG weight,28430,,"28,966 x DRG weight",28430,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8453,,DRG base rate x DRG weight + capital per discharge,8453,Other,100% of NY Medicaid HMO DRG,8453,,100% x Medicaid HMO amount,8453,Other,100% of NY Medicaid HMO DRG,8453,,100% x Medicaid HMO amount,8453,Other,100% of NY Medicaid HMO DRG,8453,,100% x Medicaid HMO amount,8453,Other,100% of NY Medicaid HMO DRG,19019,,225% x Medicaid HMO amount,19019,Other,225% of NY Medicaid HMO DRG,19019,,225% x Medicaid HMO amount,19019,Other,225% of NY Medicaid HMO DRG,19019,,225% x Medicaid HMO amount,19019,Other,225% of NY Medicaid HMO DRG,19019,,225% x Medicaid HMO amount,19019,Other,225% of NY Medicaid HMO DRG,11834,,140% x Medicaid HMO amount,11834,Other,140% of NY Medicaid HMO DRG,19019,,225% x Medicaid HMO amount,19019,Other,225% of NY Medicaid HMO DRG,23246,,275% x Medicaid HMO amount,23246,Other,275% of NY Medicaid HMO DRG,27388,,324% x Medicaid HMO amount,27388,Other,324% of NY Medicaid HMO DRG,18174,,215% x Medicaid HMO amount,18174,Other,215% of NY Medicaid HMO DRG,18174,,215% x Medicaid HMO amount,18174,Other,215% of NY Medicaid HMO DRG,10566,,125% x Medicaid HMO amount,10566,Other,125% of NY Medicaid HMO DRG,0.01,44293,
Lymphatic & other malignancies & neoplasms of uncertain behavior,694-3,APR-DRG,,,,,,,,inpatient,,,362205.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73148,,"45,128 x DRG weight",73148,Other,base rate x DRG weight,65833,,"40,615 x DRG weight",65833,Other,base rate x DRG weight,62176,,"38,359 x DRG weight",62176,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24969,,186% x Medicaid HMO amount,24969,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55235,,"34,077 x DRG weight",55235,Other,base rate x DRG weight,46951,,"28,966 x DRG weight",46951,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13424,,DRG base rate x DRG weight + capital per discharge,13424,Other,100% of NY Medicaid HMO DRG,13424,,100% x Medicaid HMO amount,13424,Other,100% of NY Medicaid HMO DRG,13424,,100% x Medicaid HMO amount,13424,Other,100% of NY Medicaid HMO DRG,13424,,100% x Medicaid HMO amount,13424,Other,100% of NY Medicaid HMO DRG,30204,,225% x Medicaid HMO amount,30204,Other,225% of NY Medicaid HMO DRG,30204,,225% x Medicaid HMO amount,30204,Other,225% of NY Medicaid HMO DRG,30204,,225% x Medicaid HMO amount,30204,Other,225% of NY Medicaid HMO DRG,30204,,225% x Medicaid HMO amount,30204,Other,225% of NY Medicaid HMO DRG,18794,,140% x Medicaid HMO amount,18794,Other,140% of NY Medicaid HMO DRG,30204,,225% x Medicaid HMO amount,30204,Other,225% of NY Medicaid HMO DRG,36916,,275% x Medicaid HMO amount,36916,Other,275% of NY Medicaid HMO DRG,43494,,324% x Medicaid HMO amount,43494,Other,324% of NY Medicaid HMO DRG,28862,,215% x Medicaid HMO amount,28862,Other,215% of NY Medicaid HMO DRG,28862,,215% x Medicaid HMO amount,28862,Other,215% of NY Medicaid HMO DRG,16780,,125% x Medicaid HMO amount,16780,Other,125% of NY Medicaid HMO DRG,0.01,73148,
Lymphatic & other malignancies & neoplasms of uncertain behavior,694-4,APR-DRG,,,,,,,,inpatient,,,569300.42,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,152596,,"45,128 x DRG weight",152596,Other,base rate x DRG weight,137336,,"40,615 x DRG weight",137336,Other,base rate x DRG weight,129707,,"38,359 x DRG weight",129707,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50430,,186% x Medicaid HMO amount,50430,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,115228,,"34,077 x DRG weight",115228,Other,base rate x DRG weight,97946,,"28,966 x DRG weight",97946,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27113,,DRG base rate x DRG weight + capital per discharge,27113,Other,100% of NY Medicaid HMO DRG,27113,,100% x Medicaid HMO amount,27113,Other,100% of NY Medicaid HMO DRG,27113,,100% x Medicaid HMO amount,27113,Other,100% of NY Medicaid HMO DRG,27113,,100% x Medicaid HMO amount,27113,Other,100% of NY Medicaid HMO DRG,61004,,225% x Medicaid HMO amount,61004,Other,225% of NY Medicaid HMO DRG,61004,,225% x Medicaid HMO amount,61004,Other,225% of NY Medicaid HMO DRG,61004,,225% x Medicaid HMO amount,61004,Other,225% of NY Medicaid HMO DRG,61004,,225% x Medicaid HMO amount,61004,Other,225% of NY Medicaid HMO DRG,37958,,140% x Medicaid HMO amount,37958,Other,140% of NY Medicaid HMO DRG,61004,,225% x Medicaid HMO amount,61004,Other,225% of NY Medicaid HMO DRG,74561,,275% x Medicaid HMO amount,74561,Other,275% of NY Medicaid HMO DRG,87846,,324% x Medicaid HMO amount,87846,Other,324% of NY Medicaid HMO DRG,58293,,215% x Medicaid HMO amount,58293,Other,215% of NY Medicaid HMO DRG,58293,,215% x Medicaid HMO amount,58293,Other,215% of NY Medicaid HMO DRG,33891,,125% x Medicaid HMO amount,33891,Other,125% of NY Medicaid HMO DRG,0.01,152596,
Chemotherapy for acute leukemia #,695-1,APR-DRG,,,,,,,,inpatient,,,125942.66,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40836,,"45,128 x DRG weight",40836,Other,base rate x DRG weight,36753,,"40,615 x DRG weight",36753,Other,base rate x DRG weight,34711,,"38,359 x DRG weight",34711,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14614,,186% x Medicaid HMO amount,14614,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30836,,"34,077 x DRG weight",30836,Other,base rate x DRG weight,26211,,"28,966 x DRG weight",26211,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7857,,DRG base rate x DRG weight + capital per discharge,7857,Other,100% of NY Medicaid HMO DRG,7857,,100% x Medicaid HMO amount,7857,Other,100% of NY Medicaid HMO DRG,7857,,100% x Medicaid HMO amount,7857,Other,100% of NY Medicaid HMO DRG,7857,,100% x Medicaid HMO amount,7857,Other,100% of NY Medicaid HMO DRG,17678,,225% x Medicaid HMO amount,17678,Other,225% of NY Medicaid HMO DRG,17678,,225% x Medicaid HMO amount,17678,Other,225% of NY Medicaid HMO DRG,17678,,225% x Medicaid HMO amount,17678,Other,225% of NY Medicaid HMO DRG,17678,,225% x Medicaid HMO amount,17678,Other,225% of NY Medicaid HMO DRG,11000,,140% x Medicaid HMO amount,11000,Other,140% of NY Medicaid HMO DRG,17678,,225% x Medicaid HMO amount,17678,Other,225% of NY Medicaid HMO DRG,21607,,275% x Medicaid HMO amount,21607,Other,275% of NY Medicaid HMO DRG,25457,,324% x Medicaid HMO amount,25457,Other,324% of NY Medicaid HMO DRG,16893,,215% x Medicaid HMO amount,16893,Other,215% of NY Medicaid HMO DRG,16893,,215% x Medicaid HMO amount,16893,Other,215% of NY Medicaid HMO DRG,9821,,125% x Medicaid HMO amount,9821,Other,125% of NY Medicaid HMO DRG,0.01,40836,
Chemotherapy for acute leukemia #,695-2,APR-DRG,,,,,,,,inpatient,,,125942.66,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40895,,"45,128 x DRG weight",40895,Other,base rate x DRG weight,36805,,"40,615 x DRG weight",36805,Other,base rate x DRG weight,34761,,"38,359 x DRG weight",34761,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14633,,186% x Medicaid HMO amount,14633,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30881,,"34,077 x DRG weight",30881,Other,base rate x DRG weight,26249,,"28,966 x DRG weight",26249,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7867,,DRG base rate x DRG weight + capital per discharge,7867,Other,100% of NY Medicaid HMO DRG,7867,,100% x Medicaid HMO amount,7867,Other,100% of NY Medicaid HMO DRG,7867,,100% x Medicaid HMO amount,7867,Other,100% of NY Medicaid HMO DRG,7867,,100% x Medicaid HMO amount,7867,Other,100% of NY Medicaid HMO DRG,17701,,225% x Medicaid HMO amount,17701,Other,225% of NY Medicaid HMO DRG,17701,,225% x Medicaid HMO amount,17701,Other,225% of NY Medicaid HMO DRG,17701,,225% x Medicaid HMO amount,17701,Other,225% of NY Medicaid HMO DRG,17701,,225% x Medicaid HMO amount,17701,Other,225% of NY Medicaid HMO DRG,11014,,140% x Medicaid HMO amount,11014,Other,140% of NY Medicaid HMO DRG,17701,,225% x Medicaid HMO amount,17701,Other,225% of NY Medicaid HMO DRG,21634,,275% x Medicaid HMO amount,21634,Other,275% of NY Medicaid HMO DRG,25489,,324% x Medicaid HMO amount,25489,Other,324% of NY Medicaid HMO DRG,16914,,215% x Medicaid HMO amount,16914,Other,215% of NY Medicaid HMO DRG,16914,,215% x Medicaid HMO amount,16914,Other,215% of NY Medicaid HMO DRG,9834,,125% x Medicaid HMO amount,9834,Other,125% of NY Medicaid HMO DRG,0.01,40895,
Chemotherapy for acute leukemia #,695-3,APR-DRG,,,,,,,,inpatient,,,354439.73,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,110022,,"45,128 x DRG weight",110022,Other,base rate x DRG weight,99019,,"40,615 x DRG weight",99019,Other,base rate x DRG weight,93519,,"38,359 x DRG weight",93519,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36787,,186% x Medicaid HMO amount,36787,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,83080,,"34,077 x DRG weight",83080,Other,base rate x DRG weight,70619,,"28,966 x DRG weight",70619,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19778,,DRG base rate x DRG weight + capital per discharge,19778,Other,100% of NY Medicaid HMO DRG,19778,,100% x Medicaid HMO amount,19778,Other,100% of NY Medicaid HMO DRG,19778,,100% x Medicaid HMO amount,19778,Other,100% of NY Medicaid HMO DRG,19778,,100% x Medicaid HMO amount,19778,Other,100% of NY Medicaid HMO DRG,44501,,225% x Medicaid HMO amount,44501,Other,225% of NY Medicaid HMO DRG,44501,,225% x Medicaid HMO amount,44501,Other,225% of NY Medicaid HMO DRG,44501,,225% x Medicaid HMO amount,44501,Other,225% of NY Medicaid HMO DRG,44501,,225% x Medicaid HMO amount,44501,Other,225% of NY Medicaid HMO DRG,27689,,140% x Medicaid HMO amount,27689,Other,140% of NY Medicaid HMO DRG,44501,,225% x Medicaid HMO amount,44501,Other,225% of NY Medicaid HMO DRG,54390,,275% x Medicaid HMO amount,54390,Other,275% of NY Medicaid HMO DRG,64081,,324% x Medicaid HMO amount,64081,Other,324% of NY Medicaid HMO DRG,42523,,215% x Medicaid HMO amount,42523,Other,215% of NY Medicaid HMO DRG,42523,,215% x Medicaid HMO amount,42523,Other,215% of NY Medicaid HMO DRG,24723,,125% x Medicaid HMO amount,24723,Other,125% of NY Medicaid HMO DRG,0.01,110022,
Chemotherapy for acute leukemia #,695-4,APR-DRG,,,,,,,,inpatient,,,391086.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,333352,,"45,128 x DRG weight",333352,Other,base rate x DRG weight,300015,,"40,615 x DRG weight",300015,Other,base rate x DRG weight,283350,,"38,359 x DRG weight",283350,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,108360,,186% x Medicaid HMO amount,108360,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,251720,,"34,077 x DRG weight",251720,Other,base rate x DRG weight,213966,,"28,966 x DRG weight",213966,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,58258,,DRG base rate x DRG weight + capital per discharge,58258,Other,100% of NY Medicaid HMO DRG,58258,,100% x Medicaid HMO amount,58258,Other,100% of NY Medicaid HMO DRG,58258,,100% x Medicaid HMO amount,58258,Other,100% of NY Medicaid HMO DRG,58258,,100% x Medicaid HMO amount,58258,Other,100% of NY Medicaid HMO DRG,131081,,225% x Medicaid HMO amount,131081,Other,225% of NY Medicaid HMO DRG,131081,,225% x Medicaid HMO amount,131081,Other,225% of NY Medicaid HMO DRG,131081,,225% x Medicaid HMO amount,131081,Other,225% of NY Medicaid HMO DRG,131081,,225% x Medicaid HMO amount,131081,Other,225% of NY Medicaid HMO DRG,81561,,140% x Medicaid HMO amount,81561,Other,140% of NY Medicaid HMO DRG,131081,,225% x Medicaid HMO amount,131081,Other,225% of NY Medicaid HMO DRG,160210,,275% x Medicaid HMO amount,160210,Other,275% of NY Medicaid HMO DRG,188756,,324% x Medicaid HMO amount,188756,Other,324% of NY Medicaid HMO DRG,125255,,215% x Medicaid HMO amount,125255,Other,215% of NY Medicaid HMO DRG,125255,,215% x Medicaid HMO amount,125255,Other,215% of NY Medicaid HMO DRG,72823,,125% x Medicaid HMO amount,72823,Other,125% of NY Medicaid HMO DRG,0.01,333352,
Other Chemotherapy #,696-1,APR-DRG,,,,,,,,inpatient,,,79950.62,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33706,,"45,128 x DRG weight",33706,Other,base rate x DRG weight,30335,,"40,615 x DRG weight",30335,Other,base rate x DRG weight,28650,,"38,359 x DRG weight",28650,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12328,,186% x Medicaid HMO amount,12328,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25452,,"34,077 x DRG weight",25452,Other,base rate x DRG weight,21635,,"28,966 x DRG weight",21635,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6628,,DRG base rate x DRG weight + capital per discharge,6628,Other,100% of NY Medicaid HMO DRG,6628,,100% x Medicaid HMO amount,6628,Other,100% of NY Medicaid HMO DRG,6628,,100% x Medicaid HMO amount,6628,Other,100% of NY Medicaid HMO DRG,6628,,100% x Medicaid HMO amount,6628,Other,100% of NY Medicaid HMO DRG,14913,,225% x Medicaid HMO amount,14913,Other,225% of NY Medicaid HMO DRG,14913,,225% x Medicaid HMO amount,14913,Other,225% of NY Medicaid HMO DRG,14913,,225% x Medicaid HMO amount,14913,Other,225% of NY Medicaid HMO DRG,14913,,225% x Medicaid HMO amount,14913,Other,225% of NY Medicaid HMO DRG,9279,,140% x Medicaid HMO amount,9279,Other,140% of NY Medicaid HMO DRG,14913,,225% x Medicaid HMO amount,14913,Other,225% of NY Medicaid HMO DRG,18227,,275% x Medicaid HMO amount,18227,Other,275% of NY Medicaid HMO DRG,21475,,324% x Medicaid HMO amount,21475,Other,324% of NY Medicaid HMO DRG,14250,,215% x Medicaid HMO amount,14250,Other,215% of NY Medicaid HMO DRG,14250,,215% x Medicaid HMO amount,14250,Other,215% of NY Medicaid HMO DRG,8285,,125% x Medicaid HMO amount,8285,Other,125% of NY Medicaid HMO DRG,0.01,33706,
Other Chemotherapy #,696-2,APR-DRG,,,,,,,,inpatient,,,105337.83,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,45327,,"45,128 x DRG weight",45327,Other,base rate x DRG weight,40794,,"40,615 x DRG weight",40794,Other,base rate x DRG weight,38528,,"38,359 x DRG weight",38528,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16054,,186% x Medicaid HMO amount,16054,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34227,,"34,077 x DRG weight",34227,Other,base rate x DRG weight,29093,,"28,966 x DRG weight",29093,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8631,,DRG base rate x DRG weight + capital per discharge,8631,Other,100% of NY Medicaid HMO DRG,8631,,100% x Medicaid HMO amount,8631,Other,100% of NY Medicaid HMO DRG,8631,,100% x Medicaid HMO amount,8631,Other,100% of NY Medicaid HMO DRG,8631,,100% x Medicaid HMO amount,8631,Other,100% of NY Medicaid HMO DRG,19420,,225% x Medicaid HMO amount,19420,Other,225% of NY Medicaid HMO DRG,19420,,225% x Medicaid HMO amount,19420,Other,225% of NY Medicaid HMO DRG,19420,,225% x Medicaid HMO amount,19420,Other,225% of NY Medicaid HMO DRG,19420,,225% x Medicaid HMO amount,19420,Other,225% of NY Medicaid HMO DRG,12083,,140% x Medicaid HMO amount,12083,Other,140% of NY Medicaid HMO DRG,19420,,225% x Medicaid HMO amount,19420,Other,225% of NY Medicaid HMO DRG,23735,,275% x Medicaid HMO amount,23735,Other,275% of NY Medicaid HMO DRG,27964,,324% x Medicaid HMO amount,27964,Other,324% of NY Medicaid HMO DRG,18557,,215% x Medicaid HMO amount,18557,Other,215% of NY Medicaid HMO DRG,18557,,215% x Medicaid HMO amount,18557,Other,215% of NY Medicaid HMO DRG,10789,,125% x Medicaid HMO amount,10789,Other,125% of NY Medicaid HMO DRG,0.01,45327,
Other Chemotherapy #,696-3,APR-DRG,,,,,,,,inpatient,,,269183.02,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,68369,,"45,128 x DRG weight",68369,Other,base rate x DRG weight,61532,,"40,615 x DRG weight",61532,Other,base rate x DRG weight,58114,,"38,359 x DRG weight",58114,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23438,,186% x Medicaid HMO amount,23438,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51627,,"34,077 x DRG weight",51627,Other,base rate x DRG weight,43883,,"28,966 x DRG weight",43883,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12601,,DRG base rate x DRG weight + capital per discharge,12601,Other,100% of NY Medicaid HMO DRG,12601,,100% x Medicaid HMO amount,12601,Other,100% of NY Medicaid HMO DRG,12601,,100% x Medicaid HMO amount,12601,Other,100% of NY Medicaid HMO DRG,12601,,100% x Medicaid HMO amount,12601,Other,100% of NY Medicaid HMO DRG,28352,,225% x Medicaid HMO amount,28352,Other,225% of NY Medicaid HMO DRG,28352,,225% x Medicaid HMO amount,28352,Other,225% of NY Medicaid HMO DRG,28352,,225% x Medicaid HMO amount,28352,Other,225% of NY Medicaid HMO DRG,28352,,225% x Medicaid HMO amount,28352,Other,225% of NY Medicaid HMO DRG,17641,,140% x Medicaid HMO amount,17641,Other,140% of NY Medicaid HMO DRG,28352,,225% x Medicaid HMO amount,28352,Other,225% of NY Medicaid HMO DRG,34653,,275% x Medicaid HMO amount,34653,Other,275% of NY Medicaid HMO DRG,40827,,324% x Medicaid HMO amount,40827,Other,324% of NY Medicaid HMO DRG,27092,,215% x Medicaid HMO amount,27092,Other,215% of NY Medicaid HMO DRG,27092,,215% x Medicaid HMO amount,27092,Other,215% of NY Medicaid HMO DRG,15751,,125% x Medicaid HMO amount,15751,Other,125% of NY Medicaid HMO DRG,0.01,68369,
Other Chemotherapy #,696-4,APR-DRG,,,,,,,,inpatient,,,637148.33,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,198310,,"45,128 x DRG weight",198310,Other,base rate x DRG weight,178479,,"40,615 x DRG weight",178479,Other,base rate x DRG weight,168565,,"38,359 x DRG weight",168565,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,65081,,186% x Medicaid HMO amount,65081,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,149748,,"34,077 x DRG weight",149748,Other,base rate x DRG weight,127288,,"28,966 x DRG weight",127288,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34990,,DRG base rate x DRG weight + capital per discharge,34990,Other,100% of NY Medicaid HMO DRG,34990,,100% x Medicaid HMO amount,34990,Other,100% of NY Medicaid HMO DRG,34990,,100% x Medicaid HMO amount,34990,Other,100% of NY Medicaid HMO DRG,34990,,100% x Medicaid HMO amount,34990,Other,100% of NY Medicaid HMO DRG,78728,,225% x Medicaid HMO amount,78728,Other,225% of NY Medicaid HMO DRG,78728,,225% x Medicaid HMO amount,78728,Other,225% of NY Medicaid HMO DRG,78728,,225% x Medicaid HMO amount,78728,Other,225% of NY Medicaid HMO DRG,78728,,225% x Medicaid HMO amount,78728,Other,225% of NY Medicaid HMO DRG,48986,,140% x Medicaid HMO amount,48986,Other,140% of NY Medicaid HMO DRG,78728,,225% x Medicaid HMO amount,78728,Other,225% of NY Medicaid HMO DRG,96223,,275% x Medicaid HMO amount,96223,Other,275% of NY Medicaid HMO DRG,113368,,324% x Medicaid HMO amount,113368,Other,324% of NY Medicaid HMO DRG,75229,,215% x Medicaid HMO amount,75229,Other,215% of NY Medicaid HMO DRG,75229,,215% x Medicaid HMO amount,75229,Other,215% of NY Medicaid HMO DRG,43738,,125% x Medicaid HMO amount,43738,Other,125% of NY Medicaid HMO DRG,0.01,198310,
Infectious & parasitic diseases including HIV w O.R. procedure,710-1,APR-DRG,,,,,,,,inpatient,,,147260.52,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48914,,"45,128 x DRG weight",48914,Other,base rate x DRG weight,44023,,"40,615 x DRG weight",44023,Other,base rate x DRG weight,41577,,"38,359 x DRG weight",41577,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17203,,186% x Medicaid HMO amount,17203,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36936,,"34,077 x DRG weight",36936,Other,base rate x DRG weight,31396,,"28,966 x DRG weight",31396,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9249,,DRG base rate x DRG weight + capital per discharge,9249,Other,100% of NY Medicaid HMO DRG,9249,,100% x Medicaid HMO amount,9249,Other,100% of NY Medicaid HMO DRG,9249,,100% x Medicaid HMO amount,9249,Other,100% of NY Medicaid HMO DRG,9249,,100% x Medicaid HMO amount,9249,Other,100% of NY Medicaid HMO DRG,20810,,225% x Medicaid HMO amount,20810,Other,225% of NY Medicaid HMO DRG,20810,,225% x Medicaid HMO amount,20810,Other,225% of NY Medicaid HMO DRG,20810,,225% x Medicaid HMO amount,20810,Other,225% of NY Medicaid HMO DRG,20810,,225% x Medicaid HMO amount,20810,Other,225% of NY Medicaid HMO DRG,12949,,140% x Medicaid HMO amount,12949,Other,140% of NY Medicaid HMO DRG,20810,,225% x Medicaid HMO amount,20810,Other,225% of NY Medicaid HMO DRG,25435,,275% x Medicaid HMO amount,25435,Other,275% of NY Medicaid HMO DRG,29967,,324% x Medicaid HMO amount,29967,Other,324% of NY Medicaid HMO DRG,19885,,215% x Medicaid HMO amount,19885,Other,215% of NY Medicaid HMO DRG,19885,,215% x Medicaid HMO amount,19885,Other,215% of NY Medicaid HMO DRG,11561,,125% x Medicaid HMO amount,11561,Other,125% of NY Medicaid HMO DRG,0.01,48914,
Infectious & parasitic diseases including HIV w O.R. procedure,710-2,APR-DRG,,,,,,,,inpatient,,,148121.49,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,75188,,"45,128 x DRG weight",75188,Other,base rate x DRG weight,67669,,"40,615 x DRG weight",67669,Other,base rate x DRG weight,63910,,"38,359 x DRG weight",63910,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25623,,186% x Medicaid HMO amount,25623,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56776,,"34,077 x DRG weight",56776,Other,base rate x DRG weight,48260,,"28,966 x DRG weight",48260,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13776,,DRG base rate x DRG weight + capital per discharge,13776,Other,100% of NY Medicaid HMO DRG,13776,,100% x Medicaid HMO amount,13776,Other,100% of NY Medicaid HMO DRG,13776,,100% x Medicaid HMO amount,13776,Other,100% of NY Medicaid HMO DRG,13776,,100% x Medicaid HMO amount,13776,Other,100% of NY Medicaid HMO DRG,30996,,225% x Medicaid HMO amount,30996,Other,225% of NY Medicaid HMO DRG,30996,,225% x Medicaid HMO amount,30996,Other,225% of NY Medicaid HMO DRG,30996,,225% x Medicaid HMO amount,30996,Other,225% of NY Medicaid HMO DRG,30996,,225% x Medicaid HMO amount,30996,Other,225% of NY Medicaid HMO DRG,19286,,140% x Medicaid HMO amount,19286,Other,140% of NY Medicaid HMO DRG,30996,,225% x Medicaid HMO amount,30996,Other,225% of NY Medicaid HMO DRG,37884,,275% x Medicaid HMO amount,37884,Other,275% of NY Medicaid HMO DRG,44634,,324% x Medicaid HMO amount,44634,Other,324% of NY Medicaid HMO DRG,29618,,215% x Medicaid HMO amount,29618,Other,215% of NY Medicaid HMO DRG,29618,,215% x Medicaid HMO amount,29618,Other,215% of NY Medicaid HMO DRG,17220,,125% x Medicaid HMO amount,17220,Other,125% of NY Medicaid HMO DRG,0.01,75188,
Infectious & parasitic diseases including HIV w O.R. procedure,710-3,APR-DRG,,,,,,,,inpatient,,,317633.24,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,134283,,"45,128 x DRG weight",134283,Other,base rate x DRG weight,120854,,"40,615 x DRG weight",120854,Other,base rate x DRG weight,114141,,"38,359 x DRG weight",114141,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44562,,186% x Medicaid HMO amount,44562,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,101400,,"34,077 x DRG weight",101400,Other,base rate x DRG weight,86191,,"28,966 x DRG weight",86191,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23958,,DRG base rate x DRG weight + capital per discharge,23958,Other,100% of NY Medicaid HMO DRG,23958,,100% x Medicaid HMO amount,23958,Other,100% of NY Medicaid HMO DRG,23958,,100% x Medicaid HMO amount,23958,Other,100% of NY Medicaid HMO DRG,23958,,100% x Medicaid HMO amount,23958,Other,100% of NY Medicaid HMO DRG,53906,,225% x Medicaid HMO amount,53906,Other,225% of NY Medicaid HMO DRG,53906,,225% x Medicaid HMO amount,53906,Other,225% of NY Medicaid HMO DRG,53906,,225% x Medicaid HMO amount,53906,Other,225% of NY Medicaid HMO DRG,53906,,225% x Medicaid HMO amount,53906,Other,225% of NY Medicaid HMO DRG,33541,,140% x Medicaid HMO amount,33541,Other,140% of NY Medicaid HMO DRG,53906,,225% x Medicaid HMO amount,53906,Other,225% of NY Medicaid HMO DRG,65885,,275% x Medicaid HMO amount,65885,Other,275% of NY Medicaid HMO DRG,77624,,324% x Medicaid HMO amount,77624,Other,324% of NY Medicaid HMO DRG,51510,,215% x Medicaid HMO amount,51510,Other,215% of NY Medicaid HMO DRG,51510,,215% x Medicaid HMO amount,51510,Other,215% of NY Medicaid HMO DRG,29948,,125% x Medicaid HMO amount,29948,Other,125% of NY Medicaid HMO DRG,0.01,134283,
Infectious & parasitic diseases including HIV w O.R. procedure,710-4,APR-DRG,,,,,,,,inpatient,,,891593.23,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,285227,,"45,128 x DRG weight",285227,Other,base rate x DRG weight,256703,,"40,615 x DRG weight",256703,Other,base rate x DRG weight,242444,,"38,359 x DRG weight",242444,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,92937,,186% x Medicaid HMO amount,92937,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,215380,,"34,077 x DRG weight",215380,Other,base rate x DRG weight,183077,,"28,966 x DRG weight",183077,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49966,,DRG base rate x DRG weight + capital per discharge,49966,Other,100% of NY Medicaid HMO DRG,49966,,100% x Medicaid HMO amount,49966,Other,100% of NY Medicaid HMO DRG,49966,,100% x Medicaid HMO amount,49966,Other,100% of NY Medicaid HMO DRG,49966,,100% x Medicaid HMO amount,49966,Other,100% of NY Medicaid HMO DRG,112424,,225% x Medicaid HMO amount,112424,Other,225% of NY Medicaid HMO DRG,112424,,225% x Medicaid HMO amount,112424,Other,225% of NY Medicaid HMO DRG,112424,,225% x Medicaid HMO amount,112424,Other,225% of NY Medicaid HMO DRG,112424,,225% x Medicaid HMO amount,112424,Other,225% of NY Medicaid HMO DRG,69952,,140% x Medicaid HMO amount,69952,Other,140% of NY Medicaid HMO DRG,112424,,225% x Medicaid HMO amount,112424,Other,225% of NY Medicaid HMO DRG,137407,,275% x Medicaid HMO amount,137407,Other,275% of NY Medicaid HMO DRG,161890,,324% x Medicaid HMO amount,161890,Other,324% of NY Medicaid HMO DRG,107427,,215% x Medicaid HMO amount,107427,Other,215% of NY Medicaid HMO DRG,107427,,215% x Medicaid HMO amount,107427,Other,215% of NY Medicaid HMO DRG,62458,,125% x Medicaid HMO amount,62458,Other,125% of NY Medicaid HMO DRG,0.01,285227,
"Post-op, post-trauma, other device infections w O.R. procedure",711-1,APR-DRG,,,,,,,,inpatient,,,41655.17,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52272,,"45,128 x DRG weight",52272,Other,base rate x DRG weight,47044,,"40,615 x DRG weight",47044,Other,base rate x DRG weight,44431,,"38,359 x DRG weight",44431,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18278,,186% x Medicaid HMO amount,18278,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39471,,"34,077 x DRG weight",39471,Other,base rate x DRG weight,33551,,"28,966 x DRG weight",33551,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9827,,DRG base rate x DRG weight + capital per discharge,9827,Other,100% of NY Medicaid HMO DRG,9827,,100% x Medicaid HMO amount,9827,Other,100% of NY Medicaid HMO DRG,9827,,100% x Medicaid HMO amount,9827,Other,100% of NY Medicaid HMO DRG,9827,,100% x Medicaid HMO amount,9827,Other,100% of NY Medicaid HMO DRG,22111,,225% x Medicaid HMO amount,22111,Other,225% of NY Medicaid HMO DRG,22111,,225% x Medicaid HMO amount,22111,Other,225% of NY Medicaid HMO DRG,22111,,225% x Medicaid HMO amount,22111,Other,225% of NY Medicaid HMO DRG,22111,,225% x Medicaid HMO amount,22111,Other,225% of NY Medicaid HMO DRG,13758,,140% x Medicaid HMO amount,13758,Other,140% of NY Medicaid HMO DRG,22111,,225% x Medicaid HMO amount,22111,Other,225% of NY Medicaid HMO DRG,27024,,275% x Medicaid HMO amount,27024,Other,275% of NY Medicaid HMO DRG,31839,,324% x Medicaid HMO amount,31839,Other,324% of NY Medicaid HMO DRG,21128,,215% x Medicaid HMO amount,21128,Other,215% of NY Medicaid HMO DRG,21128,,215% x Medicaid HMO amount,21128,Other,215% of NY Medicaid HMO DRG,12284,,125% x Medicaid HMO amount,12284,Other,125% of NY Medicaid HMO DRG,0.01,52272,
"Post-op, post-trauma, other device infections w O.R. procedure",711-2,APR-DRG,,,,,,,,inpatient,,,311510.38,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,71505,,"45,128 x DRG weight",71505,Other,base rate x DRG weight,64354,,"40,615 x DRG weight",64354,Other,base rate x DRG weight,60780,,"38,359 x DRG weight",60780,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24442,,186% x Medicaid HMO amount,24442,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53995,,"34,077 x DRG weight",53995,Other,base rate x DRG weight,45897,,"28,966 x DRG weight",45897,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13141,,DRG base rate x DRG weight + capital per discharge,13141,Other,100% of NY Medicaid HMO DRG,13141,,100% x Medicaid HMO amount,13141,Other,100% of NY Medicaid HMO DRG,13141,,100% x Medicaid HMO amount,13141,Other,100% of NY Medicaid HMO DRG,13141,,100% x Medicaid HMO amount,13141,Other,100% of NY Medicaid HMO DRG,29567,,225% x Medicaid HMO amount,29567,Other,225% of NY Medicaid HMO DRG,29567,,225% x Medicaid HMO amount,29567,Other,225% of NY Medicaid HMO DRG,29567,,225% x Medicaid HMO amount,29567,Other,225% of NY Medicaid HMO DRG,29567,,225% x Medicaid HMO amount,29567,Other,225% of NY Medicaid HMO DRG,18397,,140% x Medicaid HMO amount,18397,Other,140% of NY Medicaid HMO DRG,29567,,225% x Medicaid HMO amount,29567,Other,225% of NY Medicaid HMO DRG,36138,,275% x Medicaid HMO amount,36138,Other,275% of NY Medicaid HMO DRG,42577,,324% x Medicaid HMO amount,42577,Other,324% of NY Medicaid HMO DRG,28253,,215% x Medicaid HMO amount,28253,Other,215% of NY Medicaid HMO DRG,28253,,215% x Medicaid HMO amount,28253,Other,215% of NY Medicaid HMO DRG,16426,,125% x Medicaid HMO amount,16426,Other,125% of NY Medicaid HMO DRG,0.01,71505,
"Post-op, post-trauma, other device infections w O.R. procedure",711-3,APR-DRG,,,,,,,,inpatient,,,328470.08,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,129738,,"45,128 x DRG weight",129738,Other,base rate x DRG weight,116764,,"40,615 x DRG weight",116764,Other,base rate x DRG weight,110278,,"38,359 x DRG weight",110278,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,43106,,186% x Medicaid HMO amount,43106,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,97968,,"34,077 x DRG weight",97968,Other,base rate x DRG weight,83274,,"28,966 x DRG weight",83274,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23175,,DRG base rate x DRG weight + capital per discharge,23175,Other,100% of NY Medicaid HMO DRG,23175,,100% x Medicaid HMO amount,23175,Other,100% of NY Medicaid HMO DRG,23175,,100% x Medicaid HMO amount,23175,Other,100% of NY Medicaid HMO DRG,23175,,100% x Medicaid HMO amount,23175,Other,100% of NY Medicaid HMO DRG,52144,,225% x Medicaid HMO amount,52144,Other,225% of NY Medicaid HMO DRG,52144,,225% x Medicaid HMO amount,52144,Other,225% of NY Medicaid HMO DRG,52144,,225% x Medicaid HMO amount,52144,Other,225% of NY Medicaid HMO DRG,52144,,225% x Medicaid HMO amount,52144,Other,225% of NY Medicaid HMO DRG,32445,,140% x Medicaid HMO amount,32445,Other,140% of NY Medicaid HMO DRG,52144,,225% x Medicaid HMO amount,52144,Other,225% of NY Medicaid HMO DRG,63731,,275% x Medicaid HMO amount,63731,Other,275% of NY Medicaid HMO DRG,75087,,324% x Medicaid HMO amount,75087,Other,324% of NY Medicaid HMO DRG,49826,,215% x Medicaid HMO amount,49826,Other,215% of NY Medicaid HMO DRG,49826,,215% x Medicaid HMO amount,49826,Other,215% of NY Medicaid HMO DRG,28969,,125% x Medicaid HMO amount,28969,Other,125% of NY Medicaid HMO DRG,0.01,129738,
"Post-op, post-trauma, other device infections w O.R. procedure",711-4,APR-DRG,,,,,,,,inpatient,,,754875.33,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,272388,,"45,128 x DRG weight",272388,Other,base rate x DRG weight,245148,,"40,615 x DRG weight",245148,Other,base rate x DRG weight,231531,,"38,359 x DRG weight",231531,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,88822,,186% x Medicaid HMO amount,88822,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,205685,,"34,077 x DRG weight",205685,Other,base rate x DRG weight,174836,,"28,966 x DRG weight",174836,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47754,,DRG base rate x DRG weight + capital per discharge,47754,Other,100% of NY Medicaid HMO DRG,47754,,100% x Medicaid HMO amount,47754,Other,100% of NY Medicaid HMO DRG,47754,,100% x Medicaid HMO amount,47754,Other,100% of NY Medicaid HMO DRG,47754,,100% x Medicaid HMO amount,47754,Other,100% of NY Medicaid HMO DRG,107447,,225% x Medicaid HMO amount,107447,Other,225% of NY Medicaid HMO DRG,107447,,225% x Medicaid HMO amount,107447,Other,225% of NY Medicaid HMO DRG,107447,,225% x Medicaid HMO amount,107447,Other,225% of NY Medicaid HMO DRG,107447,,225% x Medicaid HMO amount,107447,Other,225% of NY Medicaid HMO DRG,66856,,140% x Medicaid HMO amount,66856,Other,140% of NY Medicaid HMO DRG,107447,,225% x Medicaid HMO amount,107447,Other,225% of NY Medicaid HMO DRG,131324,,275% x Medicaid HMO amount,131324,Other,275% of NY Medicaid HMO DRG,154723,,324% x Medicaid HMO amount,154723,Other,324% of NY Medicaid HMO DRG,102671,,215% x Medicaid HMO amount,102671,Other,215% of NY Medicaid HMO DRG,102671,,215% x Medicaid HMO amount,102671,Other,215% of NY Medicaid HMO DRG,59693,,125% x Medicaid HMO amount,59693,Other,125% of NY Medicaid HMO DRG,0.01,272388,
Septicemia & disseminated infections,720-1,APR-DRG,,,,,,,,inpatient,,,93993.74,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27275,,"45,128 x DRG weight",27275,Other,base rate x DRG weight,24548,,"40,615 x DRG weight",24548,Other,base rate x DRG weight,23184,,"38,359 x DRG weight",23184,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10267,,186% x Medicaid HMO amount,10267,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20596,,"34,077 x DRG weight",20596,Other,base rate x DRG weight,17507,,"28,966 x DRG weight",17507,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5520,,DRG base rate x DRG weight + capital per discharge,5520,Other,100% of NY Medicaid HMO DRG,5520,,100% x Medicaid HMO amount,5520,Other,100% of NY Medicaid HMO DRG,5520,,100% x Medicaid HMO amount,5520,Other,100% of NY Medicaid HMO DRG,5520,,100% x Medicaid HMO amount,5520,Other,100% of NY Medicaid HMO DRG,12420,,225% x Medicaid HMO amount,12420,Other,225% of NY Medicaid HMO DRG,12420,,225% x Medicaid HMO amount,12420,Other,225% of NY Medicaid HMO DRG,12420,,225% x Medicaid HMO amount,12420,Other,225% of NY Medicaid HMO DRG,12420,,225% x Medicaid HMO amount,12420,Other,225% of NY Medicaid HMO DRG,7728,,140% x Medicaid HMO amount,7728,Other,140% of NY Medicaid HMO DRG,12420,,225% x Medicaid HMO amount,12420,Other,225% of NY Medicaid HMO DRG,15180,,275% x Medicaid HMO amount,15180,Other,275% of NY Medicaid HMO DRG,17885,,324% x Medicaid HMO amount,17885,Other,324% of NY Medicaid HMO DRG,11868,,215% x Medicaid HMO amount,11868,Other,215% of NY Medicaid HMO DRG,11868,,215% x Medicaid HMO amount,11868,Other,215% of NY Medicaid HMO DRG,6900,,125% x Medicaid HMO amount,6900,Other,125% of NY Medicaid HMO DRG,0.01,27275,
Septicemia & disseminated infections,720-2,APR-DRG,,,,,,,,inpatient,,,116439.33,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37623,,"45,128 x DRG weight",37623,Other,base rate x DRG weight,33861,,"40,615 x DRG weight",33861,Other,base rate x DRG weight,31980,,"38,359 x DRG weight",31980,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13584,,186% x Medicaid HMO amount,13584,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28410,,"34,077 x DRG weight",28410,Other,base rate x DRG weight,24149,,"28,966 x DRG weight",24149,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7303,,DRG base rate x DRG weight + capital per discharge,7303,Other,100% of NY Medicaid HMO DRG,7303,,100% x Medicaid HMO amount,7303,Other,100% of NY Medicaid HMO DRG,7303,,100% x Medicaid HMO amount,7303,Other,100% of NY Medicaid HMO DRG,7303,,100% x Medicaid HMO amount,7303,Other,100% of NY Medicaid HMO DRG,16432,,225% x Medicaid HMO amount,16432,Other,225% of NY Medicaid HMO DRG,16432,,225% x Medicaid HMO amount,16432,Other,225% of NY Medicaid HMO DRG,16432,,225% x Medicaid HMO amount,16432,Other,225% of NY Medicaid HMO DRG,16432,,225% x Medicaid HMO amount,16432,Other,225% of NY Medicaid HMO DRG,10224,,140% x Medicaid HMO amount,10224,Other,140% of NY Medicaid HMO DRG,16432,,225% x Medicaid HMO amount,16432,Other,225% of NY Medicaid HMO DRG,20083,,275% x Medicaid HMO amount,20083,Other,275% of NY Medicaid HMO DRG,23662,,324% x Medicaid HMO amount,23662,Other,324% of NY Medicaid HMO DRG,15701,,215% x Medicaid HMO amount,15701,Other,215% of NY Medicaid HMO DRG,15701,,215% x Medicaid HMO amount,15701,Other,215% of NY Medicaid HMO DRG,9129,,125% x Medicaid HMO amount,9129,Other,125% of NY Medicaid HMO DRG,0.01,37623,
Septicemia & disseminated infections,720-3,APR-DRG,,,,,,,,inpatient,,,187547.32,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,67150,,"45,128 x DRG weight",67150,Other,base rate x DRG weight,60435,,"40,615 x DRG weight",60435,Other,base rate x DRG weight,57078,,"38,359 x DRG weight",57078,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23047,,186% x Medicaid HMO amount,23047,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50707,,"34,077 x DRG weight",50707,Other,base rate x DRG weight,43101,,"28,966 x DRG weight",43101,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12391,,DRG base rate x DRG weight + capital per discharge,12391,Other,100% of NY Medicaid HMO DRG,12391,,100% x Medicaid HMO amount,12391,Other,100% of NY Medicaid HMO DRG,12391,,100% x Medicaid HMO amount,12391,Other,100% of NY Medicaid HMO DRG,12391,,100% x Medicaid HMO amount,12391,Other,100% of NY Medicaid HMO DRG,27880,,225% x Medicaid HMO amount,27880,Other,225% of NY Medicaid HMO DRG,27880,,225% x Medicaid HMO amount,27880,Other,225% of NY Medicaid HMO DRG,27880,,225% x Medicaid HMO amount,27880,Other,225% of NY Medicaid HMO DRG,27880,,225% x Medicaid HMO amount,27880,Other,225% of NY Medicaid HMO DRG,17347,,140% x Medicaid HMO amount,17347,Other,140% of NY Medicaid HMO DRG,27880,,225% x Medicaid HMO amount,27880,Other,225% of NY Medicaid HMO DRG,34075,,275% x Medicaid HMO amount,34075,Other,275% of NY Medicaid HMO DRG,40147,,324% x Medicaid HMO amount,40147,Other,324% of NY Medicaid HMO DRG,26641,,215% x Medicaid HMO amount,26641,Other,215% of NY Medicaid HMO DRG,26641,,215% x Medicaid HMO amount,26641,Other,215% of NY Medicaid HMO DRG,15489,,125% x Medicaid HMO amount,15489,Other,125% of NY Medicaid HMO DRG,0.01,67150,
Septicemia & disseminated infections,720-4,APR-DRG,,,,,,,,inpatient,,,358701.42,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,144423,,"45,128 x DRG weight",144423,Other,base rate x DRG weight,129980,,"40,615 x DRG weight",129980,Other,base rate x DRG weight,122760,,"38,359 x DRG weight",122760,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47811,,186% x Medicaid HMO amount,47811,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,109057,,"34,077 x DRG weight",109057,Other,base rate x DRG weight,92700,,"28,966 x DRG weight",92700,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25705,,DRG base rate x DRG weight + capital per discharge,25705,Other,100% of NY Medicaid HMO DRG,25705,,100% x Medicaid HMO amount,25705,Other,100% of NY Medicaid HMO DRG,25705,,100% x Medicaid HMO amount,25705,Other,100% of NY Medicaid HMO DRG,25705,,100% x Medicaid HMO amount,25705,Other,100% of NY Medicaid HMO DRG,57836,,225% x Medicaid HMO amount,57836,Other,225% of NY Medicaid HMO DRG,57836,,225% x Medicaid HMO amount,57836,Other,225% of NY Medicaid HMO DRG,57836,,225% x Medicaid HMO amount,57836,Other,225% of NY Medicaid HMO DRG,57836,,225% x Medicaid HMO amount,57836,Other,225% of NY Medicaid HMO DRG,35987,,140% x Medicaid HMO amount,35987,Other,140% of NY Medicaid HMO DRG,57836,,225% x Medicaid HMO amount,57836,Other,225% of NY Medicaid HMO DRG,70689,,275% x Medicaid HMO amount,70689,Other,275% of NY Medicaid HMO DRG,83284,,324% x Medicaid HMO amount,83284,Other,324% of NY Medicaid HMO DRG,55266,,215% x Medicaid HMO amount,55266,Other,215% of NY Medicaid HMO DRG,55266,,215% x Medicaid HMO amount,55266,Other,215% of NY Medicaid HMO DRG,32131,,125% x Medicaid HMO amount,32131,Other,125% of NY Medicaid HMO DRG,0.01,144423,
"Post-operative, post-traumatic, other device infections",721-1,APR-DRG,,,,,,,,inpatient,,,163560.5,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29053,,"45,128 x DRG weight",29053,Other,base rate x DRG weight,26148,,"40,615 x DRG weight",26148,Other,base rate x DRG weight,24696,,"38,359 x DRG weight",24696,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10838,,186% x Medicaid HMO amount,10838,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21939,,"34,077 x DRG weight",21939,Other,base rate x DRG weight,18648,,"28,966 x DRG weight",18648,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5827,,DRG base rate x DRG weight + capital per discharge,5827,Other,100% of NY Medicaid HMO DRG,5827,,100% x Medicaid HMO amount,5827,Other,100% of NY Medicaid HMO DRG,5827,,100% x Medicaid HMO amount,5827,Other,100% of NY Medicaid HMO DRG,5827,,100% x Medicaid HMO amount,5827,Other,100% of NY Medicaid HMO DRG,13111,,225% x Medicaid HMO amount,13111,Other,225% of NY Medicaid HMO DRG,13111,,225% x Medicaid HMO amount,13111,Other,225% of NY Medicaid HMO DRG,13111,,225% x Medicaid HMO amount,13111,Other,225% of NY Medicaid HMO DRG,13111,,225% x Medicaid HMO amount,13111,Other,225% of NY Medicaid HMO DRG,8158,,140% x Medicaid HMO amount,8158,Other,140% of NY Medicaid HMO DRG,13111,,225% x Medicaid HMO amount,13111,Other,225% of NY Medicaid HMO DRG,16024,,275% x Medicaid HMO amount,16024,Other,275% of NY Medicaid HMO DRG,18879,,324% x Medicaid HMO amount,18879,Other,324% of NY Medicaid HMO DRG,12528,,215% x Medicaid HMO amount,12528,Other,215% of NY Medicaid HMO DRG,12528,,215% x Medicaid HMO amount,12528,Other,215% of NY Medicaid HMO DRG,7284,,125% x Medicaid HMO amount,7284,Other,125% of NY Medicaid HMO DRG,0.01,29053,
"Post-operative, post-traumatic, other device infections",721-2,APR-DRG,,,,,,,,inpatient,,,139034.03,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38201,,"45,128 x DRG weight",38201,Other,base rate x DRG weight,34381,,"40,615 x DRG weight",34381,Other,base rate x DRG weight,32471,,"38,359 x DRG weight",32471,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13770,,186% x Medicaid HMO amount,13770,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28846,,"34,077 x DRG weight",28846,Other,base rate x DRG weight,24520,,"28,966 x DRG weight",24520,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7403,,DRG base rate x DRG weight + capital per discharge,7403,Other,100% of NY Medicaid HMO DRG,7403,,100% x Medicaid HMO amount,7403,Other,100% of NY Medicaid HMO DRG,7403,,100% x Medicaid HMO amount,7403,Other,100% of NY Medicaid HMO DRG,7403,,100% x Medicaid HMO amount,7403,Other,100% of NY Medicaid HMO DRG,16657,,225% x Medicaid HMO amount,16657,Other,225% of NY Medicaid HMO DRG,16657,,225% x Medicaid HMO amount,16657,Other,225% of NY Medicaid HMO DRG,16657,,225% x Medicaid HMO amount,16657,Other,225% of NY Medicaid HMO DRG,16657,,225% x Medicaid HMO amount,16657,Other,225% of NY Medicaid HMO DRG,10364,,140% x Medicaid HMO amount,10364,Other,140% of NY Medicaid HMO DRG,16657,,225% x Medicaid HMO amount,16657,Other,225% of NY Medicaid HMO DRG,20358,,275% x Medicaid HMO amount,20358,Other,275% of NY Medicaid HMO DRG,23986,,324% x Medicaid HMO amount,23986,Other,324% of NY Medicaid HMO DRG,15916,,215% x Medicaid HMO amount,15916,Other,215% of NY Medicaid HMO DRG,15916,,215% x Medicaid HMO amount,15916,Other,215% of NY Medicaid HMO DRG,9254,,125% x Medicaid HMO amount,9254,Other,125% of NY Medicaid HMO DRG,0.01,38201,
"Post-operative, post-traumatic, other device infections",721-3,APR-DRG,,,,,,,,inpatient,,,153353.48,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,64605,,"45,128 x DRG weight",64605,Other,base rate x DRG weight,58144,,"40,615 x DRG weight",58144,Other,base rate x DRG weight,54915,,"38,359 x DRG weight",54915,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22231,,186% x Medicaid HMO amount,22231,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48785,,"34,077 x DRG weight",48785,Other,base rate x DRG weight,41468,,"28,966 x DRG weight",41468,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11952,,DRG base rate x DRG weight + capital per discharge,11952,Other,100% of NY Medicaid HMO DRG,11952,,100% x Medicaid HMO amount,11952,Other,100% of NY Medicaid HMO DRG,11952,,100% x Medicaid HMO amount,11952,Other,100% of NY Medicaid HMO DRG,11952,,100% x Medicaid HMO amount,11952,Other,100% of NY Medicaid HMO DRG,26892,,225% x Medicaid HMO amount,26892,Other,225% of NY Medicaid HMO DRG,26892,,225% x Medicaid HMO amount,26892,Other,225% of NY Medicaid HMO DRG,26892,,225% x Medicaid HMO amount,26892,Other,225% of NY Medicaid HMO DRG,26892,,225% x Medicaid HMO amount,26892,Other,225% of NY Medicaid HMO DRG,16733,,140% x Medicaid HMO amount,16733,Other,140% of NY Medicaid HMO DRG,26892,,225% x Medicaid HMO amount,26892,Other,225% of NY Medicaid HMO DRG,32868,,275% x Medicaid HMO amount,32868,Other,275% of NY Medicaid HMO DRG,38724,,324% x Medicaid HMO amount,38724,Other,324% of NY Medicaid HMO DRG,25697,,215% x Medicaid HMO amount,25697,Other,215% of NY Medicaid HMO DRG,25697,,215% x Medicaid HMO amount,25697,Other,215% of NY Medicaid HMO DRG,14940,,125% x Medicaid HMO amount,14940,Other,125% of NY Medicaid HMO DRG,0.01,64605,
"Post-operative, post-traumatic, other device infections",721-4,APR-DRG,,,,,,,,inpatient,,,427372.44,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,127757,,"45,128 x DRG weight",127757,Other,base rate x DRG weight,114981,,"40,615 x DRG weight",114981,Other,base rate x DRG weight,108594,,"38,359 x DRG weight",108594,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42471,,186% x Medicaid HMO amount,42471,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,96472,,"34,077 x DRG weight",96472,Other,base rate x DRG weight,82003,,"28,966 x DRG weight",82003,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22834,,DRG base rate x DRG weight + capital per discharge,22834,Other,100% of NY Medicaid HMO DRG,22834,,100% x Medicaid HMO amount,22834,Other,100% of NY Medicaid HMO DRG,22834,,100% x Medicaid HMO amount,22834,Other,100% of NY Medicaid HMO DRG,22834,,100% x Medicaid HMO amount,22834,Other,100% of NY Medicaid HMO DRG,51377,,225% x Medicaid HMO amount,51377,Other,225% of NY Medicaid HMO DRG,51377,,225% x Medicaid HMO amount,51377,Other,225% of NY Medicaid HMO DRG,51377,,225% x Medicaid HMO amount,51377,Other,225% of NY Medicaid HMO DRG,51377,,225% x Medicaid HMO amount,51377,Other,225% of NY Medicaid HMO DRG,31968,,140% x Medicaid HMO amount,31968,Other,140% of NY Medicaid HMO DRG,51377,,225% x Medicaid HMO amount,51377,Other,225% of NY Medicaid HMO DRG,62794,,275% x Medicaid HMO amount,62794,Other,275% of NY Medicaid HMO DRG,73982,,324% x Medicaid HMO amount,73982,Other,324% of NY Medicaid HMO DRG,49093,,215% x Medicaid HMO amount,49093,Other,215% of NY Medicaid HMO DRG,49093,,215% x Medicaid HMO amount,49093,Other,215% of NY Medicaid HMO DRG,28543,,125% x Medicaid HMO amount,28543,Other,125% of NY Medicaid HMO DRG,0.01,127757,
Fever,722-1,APR-DRG,,,,,,,,inpatient,,,59760.53,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23169,,"45,128 x DRG weight",23169,Other,base rate x DRG weight,20852,,"40,615 x DRG weight",20852,Other,base rate x DRG weight,19694,,"38,359 x DRG weight",19694,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8952,,186% x Medicaid HMO amount,8952,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17495,,"34,077 x DRG weight",17495,Other,base rate x DRG weight,14871,,"28,966 x DRG weight",14871,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4813,,DRG base rate x DRG weight + capital per discharge,4813,Other,100% of NY Medicaid HMO DRG,4813,,100% x Medicaid HMO amount,4813,Other,100% of NY Medicaid HMO DRG,4813,,100% x Medicaid HMO amount,4813,Other,100% of NY Medicaid HMO DRG,4813,,100% x Medicaid HMO amount,4813,Other,100% of NY Medicaid HMO DRG,10829,,225% x Medicaid HMO amount,10829,Other,225% of NY Medicaid HMO DRG,10829,,225% x Medicaid HMO amount,10829,Other,225% of NY Medicaid HMO DRG,10829,,225% x Medicaid HMO amount,10829,Other,225% of NY Medicaid HMO DRG,10829,,225% x Medicaid HMO amount,10829,Other,225% of NY Medicaid HMO DRG,6738,,140% x Medicaid HMO amount,6738,Other,140% of NY Medicaid HMO DRG,10829,,225% x Medicaid HMO amount,10829,Other,225% of NY Medicaid HMO DRG,13236,,275% x Medicaid HMO amount,13236,Other,275% of NY Medicaid HMO DRG,15594,,324% x Medicaid HMO amount,15594,Other,324% of NY Medicaid HMO DRG,10348,,215% x Medicaid HMO amount,10348,Other,215% of NY Medicaid HMO DRG,10348,,215% x Medicaid HMO amount,10348,Other,215% of NY Medicaid HMO DRG,6016,,125% x Medicaid HMO amount,6016,Other,125% of NY Medicaid HMO DRG,0.01,23169,
Fever,722-2,APR-DRG,,,,,,,,inpatient,,,55665.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26395,,"45,128 x DRG weight",26395,Other,base rate x DRG weight,23756,,"40,615 x DRG weight",23756,Other,base rate x DRG weight,22436,,"38,359 x DRG weight",22436,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9986,,186% x Medicaid HMO amount,9986,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19932,,"34,077 x DRG weight",19932,Other,base rate x DRG weight,16942,,"28,966 x DRG weight",16942,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5369,,DRG base rate x DRG weight + capital per discharge,5369,Other,100% of NY Medicaid HMO DRG,5369,,100% x Medicaid HMO amount,5369,Other,100% of NY Medicaid HMO DRG,5369,,100% x Medicaid HMO amount,5369,Other,100% of NY Medicaid HMO DRG,5369,,100% x Medicaid HMO amount,5369,Other,100% of NY Medicaid HMO DRG,12080,,225% x Medicaid HMO amount,12080,Other,225% of NY Medicaid HMO DRG,12080,,225% x Medicaid HMO amount,12080,Other,225% of NY Medicaid HMO DRG,12080,,225% x Medicaid HMO amount,12080,Other,225% of NY Medicaid HMO DRG,12080,,225% x Medicaid HMO amount,12080,Other,225% of NY Medicaid HMO DRG,7517,,140% x Medicaid HMO amount,7517,Other,140% of NY Medicaid HMO DRG,12080,,225% x Medicaid HMO amount,12080,Other,225% of NY Medicaid HMO DRG,14765,,275% x Medicaid HMO amount,14765,Other,275% of NY Medicaid HMO DRG,17396,,324% x Medicaid HMO amount,17396,Other,324% of NY Medicaid HMO DRG,11543,,215% x Medicaid HMO amount,11543,Other,215% of NY Medicaid HMO DRG,11543,,215% x Medicaid HMO amount,11543,Other,215% of NY Medicaid HMO DRG,6711,,125% x Medicaid HMO amount,6711,Other,125% of NY Medicaid HMO DRG,0.01,26395,
Fever,722-3,APR-DRG,,,,,,,,inpatient,,,96880,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38314,,"45,128 x DRG weight",38314,Other,base rate x DRG weight,34482,,"40,615 x DRG weight",34482,Other,base rate x DRG weight,32567,,"38,359 x DRG weight",32567,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13805,,186% x Medicaid HMO amount,13805,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28931,,"34,077 x DRG weight",28931,Other,base rate x DRG weight,24592,,"28,966 x DRG weight",24592,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7422,,DRG base rate x DRG weight + capital per discharge,7422,Other,100% of NY Medicaid HMO DRG,7422,,100% x Medicaid HMO amount,7422,Other,100% of NY Medicaid HMO DRG,7422,,100% x Medicaid HMO amount,7422,Other,100% of NY Medicaid HMO DRG,7422,,100% x Medicaid HMO amount,7422,Other,100% of NY Medicaid HMO DRG,16700,,225% x Medicaid HMO amount,16700,Other,225% of NY Medicaid HMO DRG,16700,,225% x Medicaid HMO amount,16700,Other,225% of NY Medicaid HMO DRG,16700,,225% x Medicaid HMO amount,16700,Other,225% of NY Medicaid HMO DRG,16700,,225% x Medicaid HMO amount,16700,Other,225% of NY Medicaid HMO DRG,10391,,140% x Medicaid HMO amount,10391,Other,140% of NY Medicaid HMO DRG,16700,,225% x Medicaid HMO amount,16700,Other,225% of NY Medicaid HMO DRG,20411,,275% x Medicaid HMO amount,20411,Other,275% of NY Medicaid HMO DRG,24047,,324% x Medicaid HMO amount,24047,Other,324% of NY Medicaid HMO DRG,15957,,215% x Medicaid HMO amount,15957,Other,215% of NY Medicaid HMO DRG,15957,,215% x Medicaid HMO amount,15957,Other,215% of NY Medicaid HMO DRG,9278,,125% x Medicaid HMO amount,9278,Other,125% of NY Medicaid HMO DRG,0.01,38314,
Fever,722-4,APR-DRG,,,,,,,,inpatient,,,57528.7,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,80869,,"45,128 x DRG weight",80869,Other,base rate x DRG weight,72782,,"40,615 x DRG weight",72782,Other,base rate x DRG weight,68739,,"38,359 x DRG weight",68739,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27444,,186% x Medicaid HMO amount,27444,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,61066,,"34,077 x DRG weight",61066,Other,base rate x DRG weight,51907,,"28,966 x DRG weight",51907,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14755,,DRG base rate x DRG weight + capital per discharge,14755,Other,100% of NY Medicaid HMO DRG,14755,,100% x Medicaid HMO amount,14755,Other,100% of NY Medicaid HMO DRG,14755,,100% x Medicaid HMO amount,14755,Other,100% of NY Medicaid HMO DRG,14755,,100% x Medicaid HMO amount,14755,Other,100% of NY Medicaid HMO DRG,33199,,225% x Medicaid HMO amount,33199,Other,225% of NY Medicaid HMO DRG,33199,,225% x Medicaid HMO amount,33199,Other,225% of NY Medicaid HMO DRG,33199,,225% x Medicaid HMO amount,33199,Other,225% of NY Medicaid HMO DRG,33199,,225% x Medicaid HMO amount,33199,Other,225% of NY Medicaid HMO DRG,20657,,140% x Medicaid HMO amount,20657,Other,140% of NY Medicaid HMO DRG,33199,,225% x Medicaid HMO amount,33199,Other,225% of NY Medicaid HMO DRG,40576,,275% x Medicaid HMO amount,40576,Other,275% of NY Medicaid HMO DRG,47806,,324% x Medicaid HMO amount,47806,Other,324% of NY Medicaid HMO DRG,31723,,215% x Medicaid HMO amount,31723,Other,215% of NY Medicaid HMO DRG,31723,,215% x Medicaid HMO amount,31723,Other,215% of NY Medicaid HMO DRG,18444,,125% x Medicaid HMO amount,18444,Other,125% of NY Medicaid HMO DRG,0.01,80869,
Viral illness,723-1,APR-DRG,,,,,,,,inpatient,,,69955.71,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20750,,"45,128 x DRG weight",20750,Other,base rate x DRG weight,18675,,"40,615 x DRG weight",18675,Other,base rate x DRG weight,17637,,"38,359 x DRG weight",17637,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8177,,186% x Medicaid HMO amount,8177,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15669,,"34,077 x DRG weight",15669,Other,base rate x DRG weight,13319,,"28,966 x DRG weight",13319,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4396,,DRG base rate x DRG weight + capital per discharge,4396,Other,100% of NY Medicaid HMO DRG,4396,,100% x Medicaid HMO amount,4396,Other,100% of NY Medicaid HMO DRG,4396,,100% x Medicaid HMO amount,4396,Other,100% of NY Medicaid HMO DRG,4396,,100% x Medicaid HMO amount,4396,Other,100% of NY Medicaid HMO DRG,9891,,225% x Medicaid HMO amount,9891,Other,225% of NY Medicaid HMO DRG,9891,,225% x Medicaid HMO amount,9891,Other,225% of NY Medicaid HMO DRG,9891,,225% x Medicaid HMO amount,9891,Other,225% of NY Medicaid HMO DRG,9891,,225% x Medicaid HMO amount,9891,Other,225% of NY Medicaid HMO DRG,6154,,140% x Medicaid HMO amount,6154,Other,140% of NY Medicaid HMO DRG,9891,,225% x Medicaid HMO amount,9891,Other,225% of NY Medicaid HMO DRG,12089,,275% x Medicaid HMO amount,12089,Other,275% of NY Medicaid HMO DRG,14243,,324% x Medicaid HMO amount,14243,Other,324% of NY Medicaid HMO DRG,9451,,215% x Medicaid HMO amount,9451,Other,215% of NY Medicaid HMO DRG,9451,,215% x Medicaid HMO amount,9451,Other,215% of NY Medicaid HMO DRG,5495,,125% x Medicaid HMO amount,5495,Other,125% of NY Medicaid HMO DRG,0.01,20750,
Viral illness,723-2,APR-DRG,,,,,,,,inpatient,,,61965.4,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25064,,"45,128 x DRG weight",25064,Other,base rate x DRG weight,22558,,"40,615 x DRG weight",22558,Other,base rate x DRG weight,21305,,"38,359 x DRG weight",21305,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9559,,186% x Medicaid HMO amount,9559,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18926,,"34,077 x DRG weight",18926,Other,base rate x DRG weight,16088,,"28,966 x DRG weight",16088,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5139,,DRG base rate x DRG weight + capital per discharge,5139,Other,100% of NY Medicaid HMO DRG,5139,,100% x Medicaid HMO amount,5139,Other,100% of NY Medicaid HMO DRG,5139,,100% x Medicaid HMO amount,5139,Other,100% of NY Medicaid HMO DRG,5139,,100% x Medicaid HMO amount,5139,Other,100% of NY Medicaid HMO DRG,11563,,225% x Medicaid HMO amount,11563,Other,225% of NY Medicaid HMO DRG,11563,,225% x Medicaid HMO amount,11563,Other,225% of NY Medicaid HMO DRG,11563,,225% x Medicaid HMO amount,11563,Other,225% of NY Medicaid HMO DRG,11563,,225% x Medicaid HMO amount,11563,Other,225% of NY Medicaid HMO DRG,7195,,140% x Medicaid HMO amount,7195,Other,140% of NY Medicaid HMO DRG,11563,,225% x Medicaid HMO amount,11563,Other,225% of NY Medicaid HMO DRG,14132,,275% x Medicaid HMO amount,14132,Other,275% of NY Medicaid HMO DRG,16650,,324% x Medicaid HMO amount,16650,Other,324% of NY Medicaid HMO DRG,11049,,215% x Medicaid HMO amount,11049,Other,215% of NY Medicaid HMO DRG,11049,,215% x Medicaid HMO amount,11049,Other,215% of NY Medicaid HMO DRG,6424,,125% x Medicaid HMO amount,6424,Other,125% of NY Medicaid HMO DRG,0.01,25064,
Viral illness,723-3,APR-DRG,,,,,,,,inpatient,,,112808.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38557,,"45,128 x DRG weight",38557,Other,base rate x DRG weight,34701,,"40,615 x DRG weight",34701,Other,base rate x DRG weight,32774,,"38,359 x DRG weight",32774,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13883,,186% x Medicaid HMO amount,13883,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29115,,"34,077 x DRG weight",29115,Other,base rate x DRG weight,24749,,"28,966 x DRG weight",24749,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7464,,DRG base rate x DRG weight + capital per discharge,7464,Other,100% of NY Medicaid HMO DRG,7464,,100% x Medicaid HMO amount,7464,Other,100% of NY Medicaid HMO DRG,7464,,100% x Medicaid HMO amount,7464,Other,100% of NY Medicaid HMO DRG,7464,,100% x Medicaid HMO amount,7464,Other,100% of NY Medicaid HMO DRG,16794,,225% x Medicaid HMO amount,16794,Other,225% of NY Medicaid HMO DRG,16794,,225% x Medicaid HMO amount,16794,Other,225% of NY Medicaid HMO DRG,16794,,225% x Medicaid HMO amount,16794,Other,225% of NY Medicaid HMO DRG,16794,,225% x Medicaid HMO amount,16794,Other,225% of NY Medicaid HMO DRG,10450,,140% x Medicaid HMO amount,10450,Other,140% of NY Medicaid HMO DRG,16794,,225% x Medicaid HMO amount,16794,Other,225% of NY Medicaid HMO DRG,20526,,275% x Medicaid HMO amount,20526,Other,275% of NY Medicaid HMO DRG,24183,,324% x Medicaid HMO amount,24183,Other,324% of NY Medicaid HMO DRG,16048,,215% x Medicaid HMO amount,16048,Other,215% of NY Medicaid HMO DRG,16048,,215% x Medicaid HMO amount,16048,Other,215% of NY Medicaid HMO DRG,9330,,125% x Medicaid HMO amount,9330,Other,125% of NY Medicaid HMO DRG,0.01,38557,
Viral illness,723-4,APR-DRG,,,,,,,,inpatient,,,204410.98,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,121291,,"45,128 x DRG weight",121291,Other,base rate x DRG weight,109161,,"40,615 x DRG weight",109161,Other,base rate x DRG weight,103097,,"38,359 x DRG weight",103097,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40397,,186% x Medicaid HMO amount,40397,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,91589,,"34,077 x DRG weight",91589,Other,base rate x DRG weight,77852,,"28,966 x DRG weight",77852,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21719,,DRG base rate x DRG weight + capital per discharge,21719,Other,100% of NY Medicaid HMO DRG,21719,,100% x Medicaid HMO amount,21719,Other,100% of NY Medicaid HMO DRG,21719,,100% x Medicaid HMO amount,21719,Other,100% of NY Medicaid HMO DRG,21719,,100% x Medicaid HMO amount,21719,Other,100% of NY Medicaid HMO DRG,48868,,225% x Medicaid HMO amount,48868,Other,225% of NY Medicaid HMO DRG,48868,,225% x Medicaid HMO amount,48868,Other,225% of NY Medicaid HMO DRG,48868,,225% x Medicaid HMO amount,48868,Other,225% of NY Medicaid HMO DRG,48868,,225% x Medicaid HMO amount,48868,Other,225% of NY Medicaid HMO DRG,30407,,140% x Medicaid HMO amount,30407,Other,140% of NY Medicaid HMO DRG,48868,,225% x Medicaid HMO amount,48868,Other,225% of NY Medicaid HMO DRG,59727,,275% x Medicaid HMO amount,59727,Other,275% of NY Medicaid HMO DRG,70370,,324% x Medicaid HMO amount,70370,Other,324% of NY Medicaid HMO DRG,46696,,215% x Medicaid HMO amount,46696,Other,215% of NY Medicaid HMO DRG,46696,,215% x Medicaid HMO amount,46696,Other,215% of NY Medicaid HMO DRG,27149,,125% x Medicaid HMO amount,27149,Other,125% of NY Medicaid HMO DRG,0.01,121291,
Other infectious & parasitic diseases,724-1,APR-DRG,,,,,,,,inpatient,,,62714.23,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29157,,"45,128 x DRG weight",29157,Other,base rate x DRG weight,26241,,"40,615 x DRG weight",26241,Other,base rate x DRG weight,24784,,"38,359 x DRG weight",24784,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10872,,186% x Medicaid HMO amount,10872,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22017,,"34,077 x DRG weight",22017,Other,base rate x DRG weight,18715,,"28,966 x DRG weight",18715,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5845,,DRG base rate x DRG weight + capital per discharge,5845,Other,100% of NY Medicaid HMO DRG,5845,,100% x Medicaid HMO amount,5845,Other,100% of NY Medicaid HMO DRG,5845,,100% x Medicaid HMO amount,5845,Other,100% of NY Medicaid HMO DRG,5845,,100% x Medicaid HMO amount,5845,Other,100% of NY Medicaid HMO DRG,13151,,225% x Medicaid HMO amount,13151,Other,225% of NY Medicaid HMO DRG,13151,,225% x Medicaid HMO amount,13151,Other,225% of NY Medicaid HMO DRG,13151,,225% x Medicaid HMO amount,13151,Other,225% of NY Medicaid HMO DRG,13151,,225% x Medicaid HMO amount,13151,Other,225% of NY Medicaid HMO DRG,8183,,140% x Medicaid HMO amount,8183,Other,140% of NY Medicaid HMO DRG,13151,,225% x Medicaid HMO amount,13151,Other,225% of NY Medicaid HMO DRG,16074,,275% x Medicaid HMO amount,16074,Other,275% of NY Medicaid HMO DRG,18938,,324% x Medicaid HMO amount,18938,Other,324% of NY Medicaid HMO DRG,12567,,215% x Medicaid HMO amount,12567,Other,215% of NY Medicaid HMO DRG,12567,,215% x Medicaid HMO amount,12567,Other,215% of NY Medicaid HMO DRG,7306,,125% x Medicaid HMO amount,7306,Other,125% of NY Medicaid HMO DRG,0.01,29157,
Other infectious & parasitic diseases,724-2,APR-DRG,,,,,,,,inpatient,,,82056.58,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34622,,"45,128 x DRG weight",34622,Other,base rate x DRG weight,31160,,"40,615 x DRG weight",31160,Other,base rate x DRG weight,29429,,"38,359 x DRG weight",29429,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12622,,186% x Medicaid HMO amount,12622,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26144,,"34,077 x DRG weight",26144,Other,base rate x DRG weight,22223,,"28,966 x DRG weight",22223,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6786,,DRG base rate x DRG weight + capital per discharge,6786,Other,100% of NY Medicaid HMO DRG,6786,,100% x Medicaid HMO amount,6786,Other,100% of NY Medicaid HMO DRG,6786,,100% x Medicaid HMO amount,6786,Other,100% of NY Medicaid HMO DRG,6786,,100% x Medicaid HMO amount,6786,Other,100% of NY Medicaid HMO DRG,15269,,225% x Medicaid HMO amount,15269,Other,225% of NY Medicaid HMO DRG,15269,,225% x Medicaid HMO amount,15269,Other,225% of NY Medicaid HMO DRG,15269,,225% x Medicaid HMO amount,15269,Other,225% of NY Medicaid HMO DRG,15269,,225% x Medicaid HMO amount,15269,Other,225% of NY Medicaid HMO DRG,9500,,140% x Medicaid HMO amount,9500,Other,140% of NY Medicaid HMO DRG,15269,,225% x Medicaid HMO amount,15269,Other,225% of NY Medicaid HMO DRG,18662,,275% x Medicaid HMO amount,18662,Other,275% of NY Medicaid HMO DRG,21987,,324% x Medicaid HMO amount,21987,Other,324% of NY Medicaid HMO DRG,14590,,215% x Medicaid HMO amount,14590,Other,215% of NY Medicaid HMO DRG,14590,,215% x Medicaid HMO amount,14590,Other,215% of NY Medicaid HMO DRG,8483,,125% x Medicaid HMO amount,8483,Other,125% of NY Medicaid HMO DRG,0.01,34622,
Other infectious & parasitic diseases,724-3,APR-DRG,,,,,,,,inpatient,,,126325.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,61505,,"45,128 x DRG weight",61505,Other,base rate x DRG weight,55354,,"40,615 x DRG weight",55354,Other,base rate x DRG weight,52279,,"38,359 x DRG weight",52279,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21237,,186% x Medicaid HMO amount,21237,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46444,,"34,077 x DRG weight",46444,Other,base rate x DRG weight,39478,,"28,966 x DRG weight",39478,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11418,,DRG base rate x DRG weight + capital per discharge,11418,Other,100% of NY Medicaid HMO DRG,11418,,100% x Medicaid HMO amount,11418,Other,100% of NY Medicaid HMO DRG,11418,,100% x Medicaid HMO amount,11418,Other,100% of NY Medicaid HMO DRG,11418,,100% x Medicaid HMO amount,11418,Other,100% of NY Medicaid HMO DRG,25691,,225% x Medicaid HMO amount,25691,Other,225% of NY Medicaid HMO DRG,25691,,225% x Medicaid HMO amount,25691,Other,225% of NY Medicaid HMO DRG,25691,,225% x Medicaid HMO amount,25691,Other,225% of NY Medicaid HMO DRG,25691,,225% x Medicaid HMO amount,25691,Other,225% of NY Medicaid HMO DRG,15985,,140% x Medicaid HMO amount,15985,Other,140% of NY Medicaid HMO DRG,25691,,225% x Medicaid HMO amount,25691,Other,225% of NY Medicaid HMO DRG,31400,,275% x Medicaid HMO amount,31400,Other,275% of NY Medicaid HMO DRG,36994,,324% x Medicaid HMO amount,36994,Other,324% of NY Medicaid HMO DRG,24549,,215% x Medicaid HMO amount,24549,Other,215% of NY Medicaid HMO DRG,24549,,215% x Medicaid HMO amount,24549,Other,215% of NY Medicaid HMO DRG,14273,,125% x Medicaid HMO amount,14273,Other,125% of NY Medicaid HMO DRG,0.01,61505,
Other infectious & parasitic diseases,724-4,APR-DRG,,,,,,,,inpatient,,,93840.23,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,163390,,"45,128 x DRG weight",163390,Other,base rate x DRG weight,147051,,"40,615 x DRG weight",147051,Other,base rate x DRG weight,138883,,"38,359 x DRG weight",138883,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53890,,186% x Medicaid HMO amount,53890,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,123379,,"34,077 x DRG weight",123379,Other,base rate x DRG weight,104874,,"28,966 x DRG weight",104874,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28973,,DRG base rate x DRG weight + capital per discharge,28973,Other,100% of NY Medicaid HMO DRG,28973,,100% x Medicaid HMO amount,28973,Other,100% of NY Medicaid HMO DRG,28973,,100% x Medicaid HMO amount,28973,Other,100% of NY Medicaid HMO DRG,28973,,100% x Medicaid HMO amount,28973,Other,100% of NY Medicaid HMO DRG,65189,,225% x Medicaid HMO amount,65189,Other,225% of NY Medicaid HMO DRG,65189,,225% x Medicaid HMO amount,65189,Other,225% of NY Medicaid HMO DRG,65189,,225% x Medicaid HMO amount,65189,Other,225% of NY Medicaid HMO DRG,65189,,225% x Medicaid HMO amount,65189,Other,225% of NY Medicaid HMO DRG,40562,,140% x Medicaid HMO amount,40562,Other,140% of NY Medicaid HMO DRG,65189,,225% x Medicaid HMO amount,65189,Other,225% of NY Medicaid HMO DRG,79676,,275% x Medicaid HMO amount,79676,Other,275% of NY Medicaid HMO DRG,93873,,324% x Medicaid HMO amount,93873,Other,324% of NY Medicaid HMO DRG,62292,,215% x Medicaid HMO amount,62292,Other,215% of NY Medicaid HMO DRG,62292,,215% x Medicaid HMO amount,62292,Other,215% of NY Medicaid HMO DRG,36216,,125% x Medicaid HMO amount,36216,Other,125% of NY Medicaid HMO DRG,0.01,163390,
"Drug & alcohol abuse or dependence, left against medical advice",770-1,APR-DRG,,,,,,,,inpatient,,,26733.75,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6110,,"3,055 x patient days",6110,Per diem,,5500,,"2,750 x patient days",5500,Per diem,,5194,,"2,597 x patient days",5194,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3275.57,,"1,637.79 x patient days",3275.57,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3316,,"1,658 x patient days",3316,Per diem,,2818,,"1,409 x patient days",2818,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,1761.06,,880.53 x patient days,1761.06,Per diem,,1761.06,,880.53 x patient days,1761.06,Per diem,,5320,,,5320,case rate,,1764,,882 x patient days,1764,Per diem,,3962.39,,"1,981.19 x patient days",3962.39,Per diem,,2400,,"1,200 x patient days",2400,Per diem,,3962.39,,"1,981.19 x patient days",3962.39,Per diem,,3962.39,,"1,981.19 x patient days",3962.39,Per diem,,2465.48,,"1,232.74 x patient days",2465.48,Per diem,,3962.39,,"1,981.19 x patient days",3962.39,Per diem,,2800,,"1,400 x patient days",2800,Per diem,,3028,,"1,514 x patient days",3028,Per diem,,3786.28,,"1,893 x patient days",3786.28,Per diem,,3786.28,,"1,893 x patient days",3786.28,Per diem,,1764,,882 x patient days,1764,Per diem,,0.01,6110,
"Drug & alcohol abuse or dependence, left against medical advice",770-2,APR-DRG,,,,,,,,inpatient,,,31650.07,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6110,,"3,055 x patient days",6110,Per diem,,5500,,"2,750 x patient days",5500,Per diem,,5194,,"2,597 x patient days",5194,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3275.57,,"1,637.79 x patient days",3275.57,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3316,,"1,658 x patient days",3316,Per diem,,2818,,"1,409 x patient days",2818,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,1761.06,,880.53 x patient days,1761.06,Per diem,,1761.06,,880.53 x patient days,1761.06,Per diem,,5320,,,5320,case rate,,1764,,882 x patient days,1764,Per diem,,3962.39,,"1,981.19 x patient days",3962.39,Per diem,,2400,,"1,200 x patient days",2400,Per diem,,3962.39,,"1,981.19 x patient days",3962.39,Per diem,,3962.39,,"1,981.19 x patient days",3962.39,Per diem,,2465.48,,"1,232.74 x patient days",2465.48,Per diem,,3962.39,,"1,981.19 x patient days",3962.39,Per diem,,2800,,"1,400 x patient days",2800,Per diem,,3028,,"1,514 x patient days",3028,Per diem,,3786.28,,"1,893 x patient days",3786.28,Per diem,,3786.28,,"1,893 x patient days",3786.28,Per diem,,1764,,882 x patient days,1764,Per diem,,0.01,6110,
"Drug & alcohol abuse or dependence, left against medical advice",770-3,APR-DRG,,,,,,,,inpatient,,,101364.15,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6110,,"3,055 x patient days",6110,Per diem,,5500,,"2,750 x patient days",5500,Per diem,,5194,,"2,597 x patient days",5194,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3275.57,,"1,637.79 x patient days",3275.57,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3316,,"1,658 x patient days",3316,Per diem,,2818,,"1,409 x patient days",2818,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,1761.06,,880.53 x patient days,1761.06,Per diem,,1761.06,,880.53 x patient days,1761.06,Per diem,,5320,,,5320,case rate,,1764,,882 x patient days,1764,Per diem,,3962.39,,"1,981.19 x patient days",3962.39,Per diem,,2400,,"1,200 x patient days",2400,Per diem,,3962.39,,"1,981.19 x patient days",3962.39,Per diem,,3962.39,,"1,981.19 x patient days",3962.39,Per diem,,2465.48,,"1,232.74 x patient days",2465.48,Per diem,,3962.39,,"1,981.19 x patient days",3962.39,Per diem,,2800,,"1,400 x patient days",2800,Per diem,,3028,,"1,514 x patient days",3028,Per diem,,3786.28,,"1,893 x patient days",3786.28,Per diem,,3786.28,,"1,893 x patient days",3786.28,Per diem,,1764,,882 x patient days,1764,Per diem,,0.01,6110,
"Drug & alcohol abuse or dependence, left against medical advice",770-4,APR-DRG,,,,,,,,inpatient,,,511160.02,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6110,,"3,055 x patient days",6110,Per diem,,5500,,"2,750 x patient days",5500,Per diem,,5194,,"2,597 x patient days",5194,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3275.57,,"1,637.79 x patient days",3275.57,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3316,,"1,658 x patient days",3316,Per diem,,2818,,"1,409 x patient days",2818,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,1761.06,,880.53 x patient days,1761.06,Per diem,,1761.06,,880.53 x patient days,1761.06,Per diem,,5320,,,5320,case rate,,1764,,882 x patient days,1764,Per diem,,3962.39,,"1,981.19 x patient days",3962.39,Per diem,,2400,,"1,200 x patient days",2400,Per diem,,3962.39,,"1,981.19 x patient days",3962.39,Per diem,,3962.39,,"1,981.19 x patient days",3962.39,Per diem,,2465.48,,"1,232.74 x patient days",2465.48,Per diem,,3962.39,,"1,981.19 x patient days",3962.39,Per diem,,2800,,"1,400 x patient days",2800,Per diem,,3028,,"1,514 x patient days",3028,Per diem,,3786.28,,"1,893 x patient days",3786.28,Per diem,,3786.28,,"1,893 x patient days",3786.28,Per diem,,1764,,882 x patient days,1764,Per diem,,0.01,6110,
Alcohol & drug dependence w rehab or rehab/detox therapy,772-1,APR-DRG,,,,,,,,inpatient,,,84637.8,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,67210,,"3,055 x patient days",67210,Per diem,,60500,,"2,750 x patient days",60500,Per diem,,57134,,"2,597 x patient days",57134,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21780.9,,990.04 x patient days,21780.9,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36476,,"1,658 x patient days",36476,Per diem,,30998,,"1,409 x patient days",30998,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11710.16,,532.28 x patient days,11710.16,Per diem,,11710.16,,532.28 x patient days,11710.16,Per diem,,12826,,583 x patient days,12826,Per diem,,21076,,958 x patient days,21076,Per diem,,26347.86,,"1,197.63 x patient days",26347.86,Per diem,,26400,,"1,200 x patient days",26400,Per diem,,26347.86,,"1,197.63 x patient days",26347.86,Per diem,,26347.86,,"1,197.63 x patient days",26347.86,Per diem,,16394.22,,745.19 x patient days,16394.22,Per diem,,26347.86,,"1,197.63 x patient days",26347.86,Per diem,,30800,,"1,400 x patient days",30800,Per diem,,33308,,"1,514 x patient days",33308,Per diem,,41649.08,,"1,893.14 x patient days",41649.08,Per diem,,41649.08,,"1,893.14 x patient days",41649.08,Per diem,,21076,,958 x patient days,21076,Per diem,,0.01,67210,
Alcohol & drug dependence w rehab or rehab/detox therapy,772-2,APR-DRG,,,,,,,,inpatient,,,90396.32,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,67210,,"3,055 x patient days",67210,Per diem,,60500,,"2,750 x patient days",60500,Per diem,,57134,,"2,597 x patient days",57134,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21780.9,,990.04 x patient days,21780.9,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36476,,"1,658 x patient days",36476,Per diem,,30998,,"1,409 x patient days",30998,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11710.16,,532.28 x patient days,11710.16,Per diem,,11710.16,,532.28 x patient days,11710.16,Per diem,,12826,,583 x patient days,12826,Per diem,,21076,,958 x patient days,21076,Per diem,,26347.86,,"1,197.63 x patient days",26347.86,Per diem,,26400,,"1,200 x patient days",26400,Per diem,,26347.86,,"1,197.63 x patient days",26347.86,Per diem,,26347.86,,"1,197.63 x patient days",26347.86,Per diem,,16394.22,,745.19 x patient days,16394.22,Per diem,,26347.86,,"1,197.63 x patient days",26347.86,Per diem,,30800,,"1,400 x patient days",30800,Per diem,,33308,,"1,514 x patient days",33308,Per diem,,41649.08,,"1,893.14 x patient days",41649.08,Per diem,,41649.08,,"1,893.14 x patient days",41649.08,Per diem,,21076,,958 x patient days,21076,Per diem,,0.01,67210,
Alcohol & drug dependence w rehab or rehab/detox therapy,772-3,APR-DRG,,,,,,,,inpatient,,,93554.36,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,67210,,"3,055 x patient days",67210,Per diem,,60500,,"2,750 x patient days",60500,Per diem,,57134,,"2,597 x patient days",57134,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21780.9,,990.04 x patient days,21780.9,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36476,,"1,658 x patient days",36476,Per diem,,30998,,"1,409 x patient days",30998,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11710.16,,532.28 x patient days,11710.16,Per diem,,11710.16,,532.28 x patient days,11710.16,Per diem,,12826,,583 x patient days,12826,Per diem,,21076,,958 x patient days,21076,Per diem,,26347.86,,"1,197.63 x patient days",26347.86,Per diem,,26400,,"1,200 x patient days",26400,Per diem,,26347.86,,"1,197.63 x patient days",26347.86,Per diem,,26347.86,,"1,197.63 x patient days",26347.86,Per diem,,16394.22,,745.19 x patient days,16394.22,Per diem,,26347.86,,"1,197.63 x patient days",26347.86,Per diem,,30800,,"1,400 x patient days",30800,Per diem,,33308,,"1,514 x patient days",33308,Per diem,,41649.08,,"1,893.14 x patient days",41649.08,Per diem,,41649.08,,"1,893.14 x patient days",41649.08,Per diem,,21076,,958 x patient days,21076,Per diem,,0.01,67210,
Alcohol & drug dependence w rehab or rehab/detox therapy,772-4,APR-DRG,,,,,,,,inpatient,,,191985,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,67210,,"3,055 x patient days",67210,Per diem,,60500,,"2,750 x patient days",60500,Per diem,,57134,,"2,597 x patient days",57134,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21780.9,,990.04 x patient days,21780.9,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36476,,"1,658 x patient days",36476,Per diem,,30998,,"1,409 x patient days",30998,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11710.16,,532.28 x patient days,11710.16,Per diem,,11710.16,,532.28 x patient days,11710.16,Per diem,,12826,,583 x patient days,12826,Per diem,,21076,,958 x patient days,21076,Per diem,,26347.86,,"1,197.63 x patient days",26347.86,Per diem,,26400,,"1,200 x patient days",26400,Per diem,,26347.86,,"1,197.63 x patient days",26347.86,Per diem,,26347.86,,"1,197.63 x patient days",26347.86,Per diem,,16394.22,,745.19 x patient days,16394.22,Per diem,,26347.86,,"1,197.63 x patient days",26347.86,Per diem,,30800,,"1,400 x patient days",30800,Per diem,,33308,,"1,514 x patient days",33308,Per diem,,41649.08,,"1,893.14 x patient days",41649.08,Per diem,,41649.08,,"1,893.14 x patient days",41649.08,Per diem,,21076,,958 x patient days,21076,Per diem,,0.01,67210,
Opioid abuse & dependence,773-1,APR-DRG,,,,,,,,inpatient,,,41672.35,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12220,,"3,055 x patient days",12220,Per diem,,11000,,"2,750 x patient days",11000,Per diem,,10388,,"2,597 x patient days",10388,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6551.14,,"1,637.79 x patient days",6551.14,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6632,,"1,658 x patient days",6632,Per diem,,5636,,"1,409 x patient days",5636,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3522.12,,880.53 x patient days,3522.12,Per diem,,3522.12,,880.53 x patient days,3522.12,Per diem,,5320,,,5320,case rate,,3528,,882 x patient days,3528,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,4800,,"1,200 x patient days",4800,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,4930.97,,"1,232.74 x patient days",4930.97,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,5600,,"1,400 x patient days",5600,Per diem,,6056,,"1,514 x patient days",6056,Per diem,,7572.56,,"1,893 x patient days",7572.56,Per diem,,7572.56,,"1,893 x patient days",7572.56,Per diem,,3528,,882 x patient days,3528,Per diem,,0.01,12220,
Opioid abuse & dependence,773-2,APR-DRG,,,,,,,,inpatient,,,44466.79,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12220,,"3,055 x patient days",12220,Per diem,,11000,,"2,750 x patient days",11000,Per diem,,10388,,"2,597 x patient days",10388,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6551.14,,"1,637.79 x patient days",6551.14,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6632,,"1,658 x patient days",6632,Per diem,,5636,,"1,409 x patient days",5636,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3522.12,,880.53 x patient days,3522.12,Per diem,,3522.12,,880.53 x patient days,3522.12,Per diem,,5320,,,5320,case rate,,3528,,882 x patient days,3528,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,4800,,"1,200 x patient days",4800,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,4930.97,,"1,232.74 x patient days",4930.97,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,5600,,"1,400 x patient days",5600,Per diem,,6056,,"1,514 x patient days",6056,Per diem,,7572.56,,"1,893 x patient days",7572.56,Per diem,,7572.56,,"1,893 x patient days",7572.56,Per diem,,3528,,882 x patient days,3528,Per diem,,0.01,12220,
Opioid abuse & dependence,773-3,APR-DRG,,,,,,,,inpatient,,,55949.02,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12220,,"3,055 x patient days",12220,Per diem,,11000,,"2,750 x patient days",11000,Per diem,,10388,,"2,597 x patient days",10388,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6551.14,,"1,637.79 x patient days",6551.14,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6632,,"1,658 x patient days",6632,Per diem,,5636,,"1,409 x patient days",5636,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3522.12,,880.53 x patient days,3522.12,Per diem,,3522.12,,880.53 x patient days,3522.12,Per diem,,5320,,,5320,case rate,,3528,,882 x patient days,3528,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,4800,,"1,200 x patient days",4800,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,4930.97,,"1,232.74 x patient days",4930.97,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,5600,,"1,400 x patient days",5600,Per diem,,6056,,"1,514 x patient days",6056,Per diem,,7572.56,,"1,893 x patient days",7572.56,Per diem,,7572.56,,"1,893 x patient days",7572.56,Per diem,,3528,,882 x patient days,3528,Per diem,,0.01,12220,
Opioid abuse & dependence,773-4,APR-DRG,,,,,,,,inpatient,,,169388.82,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12220,,"3,055 x patient days",12220,Per diem,,11000,,"2,750 x patient days",11000,Per diem,,10388,,"2,597 x patient days",10388,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6551.14,,"1,637.79 x patient days",6551.14,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6632,,"1,658 x patient days",6632,Per diem,,5636,,"1,409 x patient days",5636,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3522.12,,880.53 x patient days,3522.12,Per diem,,3522.12,,880.53 x patient days,3522.12,Per diem,,5320,,,5320,case rate,,3528,,882 x patient days,3528,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,4800,,"1,200 x patient days",4800,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,4930.97,,"1,232.74 x patient days",4930.97,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,5600,,"1,400 x patient days",5600,Per diem,,6056,,"1,514 x patient days",6056,Per diem,,7572.56,,"1,893 x patient days",7572.56,Per diem,,7572.56,,"1,893 x patient days",7572.56,Per diem,,3528,,882 x patient days,3528,Per diem,,0.01,12220,
Cocaine abuse & dependence,774-1,APR-DRG,,,,,,,,inpatient,,,53217.35,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12220,,"3,055 x patient days",12220,Per diem,,11000,,"2,750 x patient days",11000,Per diem,,10388,,"2,597 x patient days",10388,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6551.14,,"1,637.79 x patient days",6551.14,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6632,,"1,658 x patient days",6632,Per diem,,5636,,"1,409 x patient days",5636,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3522.12,,880.53 x patient days,3522.12,Per diem,,3522.12,,880.53 x patient days,3522.12,Per diem,,5320,,,5320,case rate,,3528,,882 x patient days,3528,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,4800,,"1,200 x patient days",4800,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,4930.97,,"1,232.74 x patient days",4930.97,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,5600,,"1,400 x patient days",5600,Per diem,,6056,,"1,514 x patient days",6056,Per diem,,7572.56,,"1,893 x patient days",7572.56,Per diem,,7572.56,,"1,893 x patient days",7572.56,Per diem,,3528,,882 x patient days,3528,Per diem,,0.01,12220,
Cocaine abuse & dependence,774-2,APR-DRG,,,,,,,,inpatient,,,50531.66,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12220,,"3,055 x patient days",12220,Per diem,,11000,,"2,750 x patient days",11000,Per diem,,10388,,"2,597 x patient days",10388,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6551.14,,"1,637.79 x patient days",6551.14,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6632,,"1,658 x patient days",6632,Per diem,,5636,,"1,409 x patient days",5636,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3522.12,,880.53 x patient days,3522.12,Per diem,,3522.12,,880.53 x patient days,3522.12,Per diem,,5320,,,5320,case rate,,3528,,882 x patient days,3528,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,4800,,"1,200 x patient days",4800,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,4930.97,,"1,232.74 x patient days",4930.97,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,5600,,"1,400 x patient days",5600,Per diem,,6056,,"1,514 x patient days",6056,Per diem,,7572.56,,"1,893 x patient days",7572.56,Per diem,,7572.56,,"1,893 x patient days",7572.56,Per diem,,3528,,882 x patient days,3528,Per diem,,0.01,12220,
Cocaine abuse & dependence,774-3,APR-DRG,,,,,,,,inpatient,,,103713.28,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12220,,"3,055 x patient days",12220,Per diem,,11000,,"2,750 x patient days",11000,Per diem,,10388,,"2,597 x patient days",10388,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6551.14,,"1,637.79 x patient days",6551.14,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6632,,"1,658 x patient days",6632,Per diem,,5636,,"1,409 x patient days",5636,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3522.12,,880.53 x patient days,3522.12,Per diem,,3522.12,,880.53 x patient days,3522.12,Per diem,,5320,,,5320,case rate,,3528,,882 x patient days,3528,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,4800,,"1,200 x patient days",4800,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,4930.97,,"1,232.74 x patient days",4930.97,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,5600,,"1,400 x patient days",5600,Per diem,,6056,,"1,514 x patient days",6056,Per diem,,7572.56,,"1,893 x patient days",7572.56,Per diem,,7572.56,,"1,893 x patient days",7572.56,Per diem,,3528,,882 x patient days,3528,Per diem,,0.01,12220,
Cocaine abuse & dependence,774-4,APR-DRG,,,,,,,,inpatient,,,116645.6,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12220,,"3,055 x patient days",12220,Per diem,,11000,,"2,750 x patient days",11000,Per diem,,10388,,"2,597 x patient days",10388,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6551.14,,"1,637.79 x patient days",6551.14,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6632,,"1,658 x patient days",6632,Per diem,,5636,,"1,409 x patient days",5636,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3522.12,,880.53 x patient days,3522.12,Per diem,,3522.12,,880.53 x patient days,3522.12,Per diem,,5320,,,5320,case rate,,3528,,882 x patient days,3528,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,4800,,"1,200 x patient days",4800,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,4930.97,,"1,232.74 x patient days",4930.97,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,5600,,"1,400 x patient days",5600,Per diem,,6056,,"1,514 x patient days",6056,Per diem,,7572.56,,"1,893 x patient days",7572.56,Per diem,,7572.56,,"1,893 x patient days",7572.56,Per diem,,3528,,882 x patient days,3528,Per diem,,0.01,12220,
Alcohol abuse & dependence,775-1,APR-DRG,,,,,,,,inpatient,,,47007.32,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12220,,"3,055 x patient days",12220,Per diem,,11000,,"2,750 x patient days",11000,Per diem,,10388,,"2,597 x patient days",10388,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6551.14,,"1,637.79 x patient days",6551.14,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6632,,"1,658 x patient days",6632,Per diem,,5636,,"1,409 x patient days",5636,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3522.12,,880.53 x patient days,3522.12,Per diem,,3522.12,,880.53 x patient days,3522.12,Per diem,,5320,,,5320,case rate,,3528,,882 x patient days,3528,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,4800,,"1,200 x patient days",4800,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,4930.97,,"1,232.74 x patient days",4930.97,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,5600,,"1,400 x patient days",5600,Per diem,,6056,,"1,514 x patient days",6056,Per diem,,7572.56,,"1,893 x patient days",7572.56,Per diem,,7572.56,,"1,893 x patient days",7572.56,Per diem,,3528,,882 x patient days,3528,Per diem,,0.01,12220,
Alcohol abuse & dependence,775-2,APR-DRG,,,,,,,,inpatient,,,59759.43,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12220,,"3,055 x patient days",12220,Per diem,,11000,,"2,750 x patient days",11000,Per diem,,10388,,"2,597 x patient days",10388,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6551.14,,"1,637.79 x patient days",6551.14,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6632,,"1,658 x patient days",6632,Per diem,,5636,,"1,409 x patient days",5636,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3522.12,,880.53 x patient days,3522.12,Per diem,,3522.12,,880.53 x patient days,3522.12,Per diem,,5320,,,5320,case rate,,3528,,882 x patient days,3528,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,4800,,"1,200 x patient days",4800,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,4930.97,,"1,232.74 x patient days",4930.97,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,5600,,"1,400 x patient days",5600,Per diem,,6056,,"1,514 x patient days",6056,Per diem,,7572.56,,"1,893 x patient days",7572.56,Per diem,,7572.56,,"1,893 x patient days",7572.56,Per diem,,3528,,882 x patient days,3528,Per diem,,0.01,12220,
Alcohol abuse & dependence,775-3,APR-DRG,,,,,,,,inpatient,,,139133.89,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12220,,"3,055 x patient days",12220,Per diem,,11000,,"2,750 x patient days",11000,Per diem,,10388,,"2,597 x patient days",10388,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6551.14,,"1,637.79 x patient days",6551.14,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6632,,"1,658 x patient days",6632,Per diem,,5636,,"1,409 x patient days",5636,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3522.12,,880.53 x patient days,3522.12,Per diem,,3522.12,,880.53 x patient days,3522.12,Per diem,,5320,,,5320,case rate,,3528,,882 x patient days,3528,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,4800,,"1,200 x patient days",4800,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,4930.97,,"1,232.74 x patient days",4930.97,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,5600,,"1,400 x patient days",5600,Per diem,,6056,,"1,514 x patient days",6056,Per diem,,7572.56,,"1,893 x patient days",7572.56,Per diem,,7572.56,,"1,893 x patient days",7572.56,Per diem,,3528,,882 x patient days,3528,Per diem,,0.01,12220,
Alcohol abuse & dependence,775-4,APR-DRG,,,,,,,,inpatient,,,404300.87,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12220,,"3,055 x patient days",12220,Per diem,,11000,,"2,750 x patient days",11000,Per diem,,10388,,"2,597 x patient days",10388,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6551.14,,"1,637.79 x patient days",6551.14,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6632,,"1,658 x patient days",6632,Per diem,,5636,,"1,409 x patient days",5636,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3522.12,,880.53 x patient days,3522.12,Per diem,,3522.12,,880.53 x patient days,3522.12,Per diem,,5320,,,5320,case rate,,3528,,882 x patient days,3528,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,4800,,"1,200 x patient days",4800,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,4930.97,,"1,232.74 x patient days",4930.97,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,5600,,"1,400 x patient days",5600,Per diem,,6056,,"1,514 x patient days",6056,Per diem,,7572.56,,"1,893 x patient days",7572.56,Per diem,,7572.56,,"1,893 x patient days",7572.56,Per diem,,3528,,882 x patient days,3528,Per diem,,0.01,12220,
Other drug abuse & dependence,776-1,APR-DRG,,,,,,,,inpatient,,,52921.83,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12220,,"3,055 x patient days",12220,Per diem,,11000,,"2,750 x patient days",11000,Per diem,,10388,,"2,597 x patient days",10388,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6551.14,,"1,637.79 x patient days",6551.14,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6632,,"1,658 x patient days",6632,Per diem,,5636,,"1,409 x patient days",5636,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3522.12,,880.53 x patient days,3522.12,Per diem,,3522.12,,880.53 x patient days,3522.12,Per diem,,5320,,,5320,case rate,,3528,,882 x patient days,3528,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,4800,,"1,200 x patient days",4800,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,4930.97,,"1,232.74 x patient days",4930.97,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,5600,,"1,400 x patient days",5600,Per diem,,6056,,"1,514 x patient days",6056,Per diem,,7572.56,,"1,893 x patient days",7572.56,Per diem,,7572.56,,"1,893 x patient days",7572.56,Per diem,,3528,,882 x patient days,3528,Per diem,,0.01,12220,
Other drug abuse & dependence,776-2,APR-DRG,,,,,,,,inpatient,,,53333.61,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12220,,"3,055 x patient days",12220,Per diem,,11000,,"2,750 x patient days",11000,Per diem,,10388,,"2,597 x patient days",10388,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6551.14,,"1,637.79 x patient days",6551.14,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6632,,"1,658 x patient days",6632,Per diem,,5636,,"1,409 x patient days",5636,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3522.12,,880.53 x patient days,3522.12,Per diem,,3522.12,,880.53 x patient days,3522.12,Per diem,,5320,,,5320,case rate,,3528,,882 x patient days,3528,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,4800,,"1,200 x patient days",4800,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,4930.97,,"1,232.74 x patient days",4930.97,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,5600,,"1,400 x patient days",5600,Per diem,,6056,,"1,514 x patient days",6056,Per diem,,7572.56,,"1,893 x patient days",7572.56,Per diem,,7572.56,,"1,893 x patient days",7572.56,Per diem,,3528,,882 x patient days,3528,Per diem,,0.01,12220,
Other drug abuse & dependence,776-3,APR-DRG,,,,,,,,inpatient,,,105636.52,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12220,,"3,055 x patient days",12220,Per diem,,11000,,"2,750 x patient days",11000,Per diem,,10388,,"2,597 x patient days",10388,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6551.14,,"1,637.79 x patient days",6551.14,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6632,,"1,658 x patient days",6632,Per diem,,5636,,"1,409 x patient days",5636,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3522.12,,880.53 x patient days,3522.12,Per diem,,3522.12,,880.53 x patient days,3522.12,Per diem,,5320,,,5320,case rate,,3528,,882 x patient days,3528,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,4800,,"1,200 x patient days",4800,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,4930.97,,"1,232.74 x patient days",4930.97,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,5600,,"1,400 x patient days",5600,Per diem,,6056,,"1,514 x patient days",6056,Per diem,,7572.56,,"1,893 x patient days",7572.56,Per diem,,7572.56,,"1,893 x patient days",7572.56,Per diem,,3528,,882 x patient days,3528,Per diem,,0.01,12220,
Other drug abuse & dependence,776-4,APR-DRG,,,,,,,,inpatient,,,105636.52,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12220,,"3,055 x patient days",12220,Per diem,,11000,,"2,750 x patient days",11000,Per diem,,10388,,"2,597 x patient days",10388,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6551.14,,"1,637.79 x patient days",6551.14,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6632,,"1,658 x patient days",6632,Per diem,,5636,,"1,409 x patient days",5636,Per diem,,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3522.12,,880.53 x patient days,3522.12,Per diem,,3522.12,,880.53 x patient days,3522.12,Per diem,,5320,,,5320,case rate,,3528,,882 x patient days,3528,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,4800,,"1,200 x patient days",4800,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,4930.97,,"1,232.74 x patient days",4930.97,Per diem,,7924.77,,"1,981.19 x patient days",7924.77,Per diem,,5600,,"1,400 x patient days",5600,Per diem,,6056,,"1,514 x patient days",6056,Per diem,,7572.56,,"1,893 x patient days",7572.56,Per diem,,7572.56,,"1,893 x patient days",7572.56,Per diem,,3528,,882 x patient days,3528,Per diem,,0.01,12220,
O.R. procedure for other complications of treatment,791-1,APR-DRG,,,,,,,,inpatient,,,172544.08,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38269,,"45,128 x DRG weight",38269,Other,base rate x DRG weight,34442,,"40,615 x DRG weight",34442,Other,base rate x DRG weight,32528,,"38,359 x DRG weight",32528,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13792,,186% x Medicaid HMO amount,13792,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28897,,"34,077 x DRG weight",28897,Other,base rate x DRG weight,24563,,"28,966 x DRG weight",24563,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7415,,DRG base rate x DRG weight + capital per discharge,7415,Other,100% of NY Medicaid HMO DRG,7415,,100% x Medicaid HMO amount,7415,Other,100% of NY Medicaid HMO DRG,7415,,100% x Medicaid HMO amount,7415,Other,100% of NY Medicaid HMO DRG,7415,,100% x Medicaid HMO amount,7415,Other,100% of NY Medicaid HMO DRG,16684,,225% x Medicaid HMO amount,16684,Other,225% of NY Medicaid HMO DRG,16684,,225% x Medicaid HMO amount,16684,Other,225% of NY Medicaid HMO DRG,16684,,225% x Medicaid HMO amount,16684,Other,225% of NY Medicaid HMO DRG,16684,,225% x Medicaid HMO amount,16684,Other,225% of NY Medicaid HMO DRG,10381,,140% x Medicaid HMO amount,10381,Other,140% of NY Medicaid HMO DRG,16684,,225% x Medicaid HMO amount,16684,Other,225% of NY Medicaid HMO DRG,20391,,275% x Medicaid HMO amount,20391,Other,275% of NY Medicaid HMO DRG,24025,,324% x Medicaid HMO amount,24025,Other,324% of NY Medicaid HMO DRG,15942,,215% x Medicaid HMO amount,15942,Other,215% of NY Medicaid HMO DRG,15942,,215% x Medicaid HMO amount,15942,Other,215% of NY Medicaid HMO DRG,9269,,125% x Medicaid HMO amount,9269,Other,125% of NY Medicaid HMO DRG,0.01,38269,
O.R. procedure for other complications of treatment,791-2,APR-DRG,,,,,,,,inpatient,,,193040.14,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,64231,,"45,128 x DRG weight",64231,Other,base rate x DRG weight,57807,,"40,615 x DRG weight",57807,Other,base rate x DRG weight,54596,,"38,359 x DRG weight",54596,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22112,,186% x Medicaid HMO amount,22112,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48502,,"34,077 x DRG weight",48502,Other,base rate x DRG weight,41227,,"28,966 x DRG weight",41227,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11888,,DRG base rate x DRG weight + capital per discharge,11888,Other,100% of NY Medicaid HMO DRG,11888,,100% x Medicaid HMO amount,11888,Other,100% of NY Medicaid HMO DRG,11888,,100% x Medicaid HMO amount,11888,Other,100% of NY Medicaid HMO DRG,11888,,100% x Medicaid HMO amount,11888,Other,100% of NY Medicaid HMO DRG,26748,,225% x Medicaid HMO amount,26748,Other,225% of NY Medicaid HMO DRG,26748,,225% x Medicaid HMO amount,26748,Other,225% of NY Medicaid HMO DRG,26748,,225% x Medicaid HMO amount,26748,Other,225% of NY Medicaid HMO DRG,26748,,225% x Medicaid HMO amount,26748,Other,225% of NY Medicaid HMO DRG,16643,,140% x Medicaid HMO amount,16643,Other,140% of NY Medicaid HMO DRG,26748,,225% x Medicaid HMO amount,26748,Other,225% of NY Medicaid HMO DRG,32692,,275% x Medicaid HMO amount,32692,Other,275% of NY Medicaid HMO DRG,38517,,324% x Medicaid HMO amount,38517,Other,324% of NY Medicaid HMO DRG,25559,,215% x Medicaid HMO amount,25559,Other,215% of NY Medicaid HMO DRG,25559,,215% x Medicaid HMO amount,25559,Other,215% of NY Medicaid HMO DRG,14860,,125% x Medicaid HMO amount,14860,Other,125% of NY Medicaid HMO DRG,0.01,64231,
O.R. procedure for other complications of treatment,791-3,APR-DRG,,,,,,,,inpatient,,,318880.06,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,120677,,"45,128 x DRG weight",120677,Other,base rate x DRG weight,108609,,"40,615 x DRG weight",108609,Other,base rate x DRG weight,102576,,"38,359 x DRG weight",102576,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40202,,186% x Medicaid HMO amount,40202,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,91125,,"34,077 x DRG weight",91125,Other,base rate x DRG weight,77458,,"28,966 x DRG weight",77458,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21614,,DRG base rate x DRG weight + capital per discharge,21614,Other,100% of NY Medicaid HMO DRG,21614,,100% x Medicaid HMO amount,21614,Other,100% of NY Medicaid HMO DRG,21614,,100% x Medicaid HMO amount,21614,Other,100% of NY Medicaid HMO DRG,21614,,100% x Medicaid HMO amount,21614,Other,100% of NY Medicaid HMO DRG,48632,,225% x Medicaid HMO amount,48632,Other,225% of NY Medicaid HMO DRG,48632,,225% x Medicaid HMO amount,48632,Other,225% of NY Medicaid HMO DRG,48632,,225% x Medicaid HMO amount,48632,Other,225% of NY Medicaid HMO DRG,48632,,225% x Medicaid HMO amount,48632,Other,225% of NY Medicaid HMO DRG,30260,,140% x Medicaid HMO amount,30260,Other,140% of NY Medicaid HMO DRG,48632,,225% x Medicaid HMO amount,48632,Other,225% of NY Medicaid HMO DRG,59439,,275% x Medicaid HMO amount,59439,Other,275% of NY Medicaid HMO DRG,70029,,324% x Medicaid HMO amount,70029,Other,324% of NY Medicaid HMO DRG,46470,,215% x Medicaid HMO amount,46470,Other,215% of NY Medicaid HMO DRG,46470,,215% x Medicaid HMO amount,46470,Other,215% of NY Medicaid HMO DRG,27018,,125% x Medicaid HMO amount,27018,Other,125% of NY Medicaid HMO DRG,0.01,120677,
O.R. procedure for other complications of treatment,791-4,APR-DRG,,,,,,,,inpatient,,,277307.33,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,298328,,"45,128 x DRG weight",298328,Other,base rate x DRG weight,268494,,"40,615 x DRG weight",268494,Other,base rate x DRG weight,253580,,"38,359 x DRG weight",253580,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,97135,,186% x Medicaid HMO amount,97135,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,225273,,"34,077 x DRG weight",225273,Other,base rate x DRG weight,191486,,"28,966 x DRG weight",191486,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52223,,DRG base rate x DRG weight + capital per discharge,52223,Other,100% of NY Medicaid HMO DRG,52223,,100% x Medicaid HMO amount,52223,Other,100% of NY Medicaid HMO DRG,52223,,100% x Medicaid HMO amount,52223,Other,100% of NY Medicaid HMO DRG,52223,,100% x Medicaid HMO amount,52223,Other,100% of NY Medicaid HMO DRG,117502,,225% x Medicaid HMO amount,117502,Other,225% of NY Medicaid HMO DRG,117502,,225% x Medicaid HMO amount,117502,Other,225% of NY Medicaid HMO DRG,117502,,225% x Medicaid HMO amount,117502,Other,225% of NY Medicaid HMO DRG,117502,,225% x Medicaid HMO amount,117502,Other,225% of NY Medicaid HMO DRG,73112,,140% x Medicaid HMO amount,73112,Other,140% of NY Medicaid HMO DRG,117502,,225% x Medicaid HMO amount,117502,Other,225% of NY Medicaid HMO DRG,143613,,275% x Medicaid HMO amount,143613,Other,275% of NY Medicaid HMO DRG,169203,,324% x Medicaid HMO amount,169203,Other,324% of NY Medicaid HMO DRG,112279,,215% x Medicaid HMO amount,112279,Other,215% of NY Medicaid HMO DRG,112279,,215% x Medicaid HMO amount,112279,Other,215% of NY Medicaid HMO DRG,65279,,125% x Medicaid HMO amount,65279,Other,125% of NY Medicaid HMO DRG,0.01,298328,
Allergic reactions,811-1,APR-DRG,,,,,,,,inpatient,,,39948.24,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15298,,"45,128 x DRG weight",15298,Other,base rate x DRG weight,13768,,"40,615 x DRG weight",13768,Other,base rate x DRG weight,13004,,"38,359 x DRG weight",13004,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6430,,186% x Medicaid HMO amount,6430,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11552,,"34,077 x DRG weight",11552,Other,base rate x DRG weight,9819,,"28,966 x DRG weight",9819,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3457,,DRG base rate x DRG weight + capital per discharge,3457,Other,100% of NY Medicaid HMO DRG,3457,,100% x Medicaid HMO amount,3457,Other,100% of NY Medicaid HMO DRG,3457,,100% x Medicaid HMO amount,3457,Other,100% of NY Medicaid HMO DRG,3457,,100% x Medicaid HMO amount,3457,Other,100% of NY Medicaid HMO DRG,7778,,225% x Medicaid HMO amount,7778,Other,225% of NY Medicaid HMO DRG,7778,,225% x Medicaid HMO amount,7778,Other,225% of NY Medicaid HMO DRG,7778,,225% x Medicaid HMO amount,7778,Other,225% of NY Medicaid HMO DRG,7778,,225% x Medicaid HMO amount,7778,Other,225% of NY Medicaid HMO DRG,4840,,140% x Medicaid HMO amount,4840,Other,140% of NY Medicaid HMO DRG,7778,,225% x Medicaid HMO amount,7778,Other,225% of NY Medicaid HMO DRG,9507,,275% x Medicaid HMO amount,9507,Other,275% of NY Medicaid HMO DRG,11201,,324% x Medicaid HMO amount,11201,Other,324% of NY Medicaid HMO DRG,7433,,215% x Medicaid HMO amount,7433,Other,215% of NY Medicaid HMO DRG,7433,,215% x Medicaid HMO amount,7433,Other,215% of NY Medicaid HMO DRG,4321,,125% x Medicaid HMO amount,4321,Other,125% of NY Medicaid HMO DRG,0.01,15298,
Allergic reactions,811-2,APR-DRG,,,,,,,,inpatient,,,86685.39,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21300,,"45,128 x DRG weight",21300,Other,base rate x DRG weight,19170,,"40,615 x DRG weight",19170,Other,base rate x DRG weight,18105,,"38,359 x DRG weight",18105,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8353,,186% x Medicaid HMO amount,8353,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16084,,"34,077 x DRG weight",16084,Other,base rate x DRG weight,13672,,"28,966 x DRG weight",13672,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4491,,DRG base rate x DRG weight + capital per discharge,4491,Other,100% of NY Medicaid HMO DRG,4491,,100% x Medicaid HMO amount,4491,Other,100% of NY Medicaid HMO DRG,4491,,100% x Medicaid HMO amount,4491,Other,100% of NY Medicaid HMO DRG,4491,,100% x Medicaid HMO amount,4491,Other,100% of NY Medicaid HMO DRG,10105,,225% x Medicaid HMO amount,10105,Other,225% of NY Medicaid HMO DRG,10105,,225% x Medicaid HMO amount,10105,Other,225% of NY Medicaid HMO DRG,10105,,225% x Medicaid HMO amount,10105,Other,225% of NY Medicaid HMO DRG,10105,,225% x Medicaid HMO amount,10105,Other,225% of NY Medicaid HMO DRG,6287,,140% x Medicaid HMO amount,6287,Other,140% of NY Medicaid HMO DRG,10105,,225% x Medicaid HMO amount,10105,Other,225% of NY Medicaid HMO DRG,12350,,275% x Medicaid HMO amount,12350,Other,275% of NY Medicaid HMO DRG,14551,,324% x Medicaid HMO amount,14551,Other,324% of NY Medicaid HMO DRG,9656,,215% x Medicaid HMO amount,9656,Other,215% of NY Medicaid HMO DRG,9656,,215% x Medicaid HMO amount,9656,Other,215% of NY Medicaid HMO DRG,5614,,125% x Medicaid HMO amount,5614,Other,125% of NY Medicaid HMO DRG,0.01,21300,
Allergic reactions,811-3,APR-DRG,,,,,,,,inpatient,,,195596.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47267,,"45,128 x DRG weight",47267,Other,base rate x DRG weight,42540,,"40,615 x DRG weight",42540,Other,base rate x DRG weight,40177,,"38,359 x DRG weight",40177,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16675,,186% x Medicaid HMO amount,16675,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35692,,"34,077 x DRG weight",35692,Other,base rate x DRG weight,30339,,"28,966 x DRG weight",30339,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8965,,DRG base rate x DRG weight + capital per discharge,8965,Other,100% of NY Medicaid HMO DRG,8965,,100% x Medicaid HMO amount,8965,Other,100% of NY Medicaid HMO DRG,8965,,100% x Medicaid HMO amount,8965,Other,100% of NY Medicaid HMO DRG,8965,,100% x Medicaid HMO amount,8965,Other,100% of NY Medicaid HMO DRG,20171,,225% x Medicaid HMO amount,20171,Other,225% of NY Medicaid HMO DRG,20171,,225% x Medicaid HMO amount,20171,Other,225% of NY Medicaid HMO DRG,20171,,225% x Medicaid HMO amount,20171,Other,225% of NY Medicaid HMO DRG,20171,,225% x Medicaid HMO amount,20171,Other,225% of NY Medicaid HMO DRG,12551,,140% x Medicaid HMO amount,12551,Other,140% of NY Medicaid HMO DRG,20171,,225% x Medicaid HMO amount,20171,Other,225% of NY Medicaid HMO DRG,24654,,275% x Medicaid HMO amount,24654,Other,275% of NY Medicaid HMO DRG,29047,,324% x Medicaid HMO amount,29047,Other,324% of NY Medicaid HMO DRG,19275,,215% x Medicaid HMO amount,19275,Other,215% of NY Medicaid HMO DRG,19275,,215% x Medicaid HMO amount,19275,Other,215% of NY Medicaid HMO DRG,11206,,125% x Medicaid HMO amount,11206,Other,125% of NY Medicaid HMO DRG,0.01,47267,
Allergic reactions,811-4,APR-DRG,,,,,,,,inpatient,,,195596.31,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,106556,,"45,128 x DRG weight",106556,Other,base rate x DRG weight,95900,,"40,615 x DRG weight",95900,Other,base rate x DRG weight,90573,,"38,359 x DRG weight",90573,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35677,,186% x Medicaid HMO amount,35677,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,80463,,"34,077 x DRG weight",80463,Other,base rate x DRG weight,68395,,"28,966 x DRG weight",68395,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19181,,DRG base rate x DRG weight + capital per discharge,19181,Other,100% of NY Medicaid HMO DRG,19181,,100% x Medicaid HMO amount,19181,Other,100% of NY Medicaid HMO DRG,19181,,100% x Medicaid HMO amount,19181,Other,100% of NY Medicaid HMO DRG,19181,,100% x Medicaid HMO amount,19181,Other,100% of NY Medicaid HMO DRG,43157,,225% x Medicaid HMO amount,43157,Other,225% of NY Medicaid HMO DRG,43157,,225% x Medicaid HMO amount,43157,Other,225% of NY Medicaid HMO DRG,43157,,225% x Medicaid HMO amount,43157,Other,225% of NY Medicaid HMO DRG,43157,,225% x Medicaid HMO amount,43157,Other,225% of NY Medicaid HMO DRG,26853,,140% x Medicaid HMO amount,26853,Other,140% of NY Medicaid HMO DRG,43157,,225% x Medicaid HMO amount,43157,Other,225% of NY Medicaid HMO DRG,52748,,275% x Medicaid HMO amount,52748,Other,275% of NY Medicaid HMO DRG,62146,,324% x Medicaid HMO amount,62146,Other,324% of NY Medicaid HMO DRG,41239,,215% x Medicaid HMO amount,41239,Other,215% of NY Medicaid HMO DRG,41239,,215% x Medicaid HMO amount,41239,Other,215% of NY Medicaid HMO DRG,23976,,125% x Medicaid HMO amount,23976,Other,125% of NY Medicaid HMO DRG,0.01,106556,
Poisoning of medicinal agents,812-1,APR-DRG,,,,,,,,inpatient,,,46315.14,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18480,,"45,128 x DRG weight",18480,Other,base rate x DRG weight,16632,,"40,615 x DRG weight",16632,Other,base rate x DRG weight,15708,,"38,359 x DRG weight",15708,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7449,,186% x Medicaid HMO amount,7449,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13955,,"34,077 x DRG weight",13955,Other,base rate x DRG weight,11862,,"28,966 x DRG weight",11862,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4005,,DRG base rate x DRG weight + capital per discharge,4005,Other,100% of NY Medicaid HMO DRG,4005,,100% x Medicaid HMO amount,4005,Other,100% of NY Medicaid HMO DRG,4005,,100% x Medicaid HMO amount,4005,Other,100% of NY Medicaid HMO DRG,4005,,100% x Medicaid HMO amount,4005,Other,100% of NY Medicaid HMO DRG,9011,,225% x Medicaid HMO amount,9011,Other,225% of NY Medicaid HMO DRG,9011,,225% x Medicaid HMO amount,9011,Other,225% of NY Medicaid HMO DRG,9011,,225% x Medicaid HMO amount,9011,Other,225% of NY Medicaid HMO DRG,9011,,225% x Medicaid HMO amount,9011,Other,225% of NY Medicaid HMO DRG,5607,,140% x Medicaid HMO amount,5607,Other,140% of NY Medicaid HMO DRG,9011,,225% x Medicaid HMO amount,9011,Other,225% of NY Medicaid HMO DRG,11014,,275% x Medicaid HMO amount,11014,Other,275% of NY Medicaid HMO DRG,12976,,324% x Medicaid HMO amount,12976,Other,324% of NY Medicaid HMO DRG,8611,,215% x Medicaid HMO amount,8611,Other,215% of NY Medicaid HMO DRG,8611,,215% x Medicaid HMO amount,8611,Other,215% of NY Medicaid HMO DRG,5006,,125% x Medicaid HMO amount,5006,Other,125% of NY Medicaid HMO DRG,0.01,18480,
Poisoning of medicinal agents,812-2,APR-DRG,,,,,,,,inpatient,,,77729.8,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24473,,"45,128 x DRG weight",24473,Other,base rate x DRG weight,22026,,"40,615 x DRG weight",22026,Other,base rate x DRG weight,20802,,"38,359 x DRG weight",20802,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9371,,186% x Medicaid HMO amount,9371,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18480,,"34,077 x DRG weight",18480,Other,base rate x DRG weight,15708,,"28,966 x DRG weight",15708,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5038,,DRG base rate x DRG weight + capital per discharge,5038,Other,100% of NY Medicaid HMO DRG,5038,,100% x Medicaid HMO amount,5038,Other,100% of NY Medicaid HMO DRG,5038,,100% x Medicaid HMO amount,5038,Other,100% of NY Medicaid HMO DRG,5038,,100% x Medicaid HMO amount,5038,Other,100% of NY Medicaid HMO DRG,11336,,225% x Medicaid HMO amount,11336,Other,225% of NY Medicaid HMO DRG,11336,,225% x Medicaid HMO amount,11336,Other,225% of NY Medicaid HMO DRG,11336,,225% x Medicaid HMO amount,11336,Other,225% of NY Medicaid HMO DRG,11336,,225% x Medicaid HMO amount,11336,Other,225% of NY Medicaid HMO DRG,7053,,140% x Medicaid HMO amount,7053,Other,140% of NY Medicaid HMO DRG,11336,,225% x Medicaid HMO amount,11336,Other,225% of NY Medicaid HMO DRG,13855,,275% x Medicaid HMO amount,13855,Other,275% of NY Medicaid HMO DRG,16323,,324% x Medicaid HMO amount,16323,Other,324% of NY Medicaid HMO DRG,10832,,215% x Medicaid HMO amount,10832,Other,215% of NY Medicaid HMO DRG,10832,,215% x Medicaid HMO amount,10832,Other,215% of NY Medicaid HMO DRG,6298,,125% x Medicaid HMO amount,6298,Other,125% of NY Medicaid HMO DRG,0.01,24473,
Poisoning of medicinal agents,812-3,APR-DRG,,,,,,,,inpatient,,,110612.46,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41518,,"45,128 x DRG weight",41518,Other,base rate x DRG weight,37366,,"40,615 x DRG weight",37366,Other,base rate x DRG weight,35290,,"38,359 x DRG weight",35290,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14832,,186% x Medicaid HMO amount,14832,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31351,,"34,077 x DRG weight",31351,Other,base rate x DRG weight,26649,,"28,966 x DRG weight",26649,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7974,,DRG base rate x DRG weight + capital per discharge,7974,Other,100% of NY Medicaid HMO DRG,7974,,100% x Medicaid HMO amount,7974,Other,100% of NY Medicaid HMO DRG,7974,,100% x Medicaid HMO amount,7974,Other,100% of NY Medicaid HMO DRG,7974,,100% x Medicaid HMO amount,7974,Other,100% of NY Medicaid HMO DRG,17942,,225% x Medicaid HMO amount,17942,Other,225% of NY Medicaid HMO DRG,17942,,225% x Medicaid HMO amount,17942,Other,225% of NY Medicaid HMO DRG,17942,,225% x Medicaid HMO amount,17942,Other,225% of NY Medicaid HMO DRG,17942,,225% x Medicaid HMO amount,17942,Other,225% of NY Medicaid HMO DRG,11164,,140% x Medicaid HMO amount,11164,Other,140% of NY Medicaid HMO DRG,17942,,225% x Medicaid HMO amount,17942,Other,225% of NY Medicaid HMO DRG,21929,,275% x Medicaid HMO amount,21929,Other,275% of NY Medicaid HMO DRG,25836,,324% x Medicaid HMO amount,25836,Other,324% of NY Medicaid HMO DRG,17144,,215% x Medicaid HMO amount,17144,Other,215% of NY Medicaid HMO DRG,17144,,215% x Medicaid HMO amount,17144,Other,215% of NY Medicaid HMO DRG,9968,,125% x Medicaid HMO amount,9968,Other,125% of NY Medicaid HMO DRG,0.01,41518,
Poisoning of medicinal agents,812-4,APR-DRG,,,,,,,,inpatient,,,169448.14,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,98668,,"45,128 x DRG weight",98668,Other,base rate x DRG weight,88801,,"40,615 x DRG weight",88801,Other,base rate x DRG weight,83868,,"38,359 x DRG weight",83868,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33147,,186% x Medicaid HMO amount,33147,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,74506,,"34,077 x DRG weight",74506,Other,base rate x DRG weight,63331,,"28,966 x DRG weight",63331,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17821,,DRG base rate x DRG weight + capital per discharge,17821,Other,100% of NY Medicaid HMO DRG,17821,,100% x Medicaid HMO amount,17821,Other,100% of NY Medicaid HMO DRG,17821,,100% x Medicaid HMO amount,17821,Other,100% of NY Medicaid HMO DRG,17821,,100% x Medicaid HMO amount,17821,Other,100% of NY Medicaid HMO DRG,40097,,225% x Medicaid HMO amount,40097,Other,225% of NY Medicaid HMO DRG,40097,,225% x Medicaid HMO amount,40097,Other,225% of NY Medicaid HMO DRG,40097,,225% x Medicaid HMO amount,40097,Other,225% of NY Medicaid HMO DRG,40097,,225% x Medicaid HMO amount,40097,Other,225% of NY Medicaid HMO DRG,24949,,140% x Medicaid HMO amount,24949,Other,140% of NY Medicaid HMO DRG,40097,,225% x Medicaid HMO amount,40097,Other,225% of NY Medicaid HMO DRG,49008,,275% x Medicaid HMO amount,49008,Other,275% of NY Medicaid HMO DRG,57740,,324% x Medicaid HMO amount,57740,Other,324% of NY Medicaid HMO DRG,38315,,215% x Medicaid HMO amount,38315,Other,215% of NY Medicaid HMO DRG,38315,,215% x Medicaid HMO amount,38315,Other,215% of NY Medicaid HMO DRG,22276,,125% x Medicaid HMO amount,22276,Other,125% of NY Medicaid HMO DRG,0.01,98668,
Other complications of treatment,813-1,APR-DRG,,,,,,,,inpatient,,,64115.64,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22451,,"45,128 x DRG weight",22451,Other,base rate x DRG weight,20206,,"40,615 x DRG weight",20206,Other,base rate x DRG weight,19084,,"38,359 x DRG weight",19084,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8722,,186% x Medicaid HMO amount,8722,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16953,,"34,077 x DRG weight",16953,Other,base rate x DRG weight,14411,,"28,966 x DRG weight",14411,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4689,,DRG base rate x DRG weight + capital per discharge,4689,Other,100% of NY Medicaid HMO DRG,4689,,100% x Medicaid HMO amount,4689,Other,100% of NY Medicaid HMO DRG,4689,,100% x Medicaid HMO amount,4689,Other,100% of NY Medicaid HMO DRG,4689,,100% x Medicaid HMO amount,4689,Other,100% of NY Medicaid HMO DRG,10550,,225% x Medicaid HMO amount,10550,Other,225% of NY Medicaid HMO DRG,10550,,225% x Medicaid HMO amount,10550,Other,225% of NY Medicaid HMO DRG,10550,,225% x Medicaid HMO amount,10550,Other,225% of NY Medicaid HMO DRG,10550,,225% x Medicaid HMO amount,10550,Other,225% of NY Medicaid HMO DRG,6565,,140% x Medicaid HMO amount,6565,Other,140% of NY Medicaid HMO DRG,10550,,225% x Medicaid HMO amount,10550,Other,225% of NY Medicaid HMO DRG,12895,,275% x Medicaid HMO amount,12895,Other,275% of NY Medicaid HMO DRG,15192,,324% x Medicaid HMO amount,15192,Other,324% of NY Medicaid HMO DRG,10081,,215% x Medicaid HMO amount,10081,Other,215% of NY Medicaid HMO DRG,10081,,215% x Medicaid HMO amount,10081,Other,215% of NY Medicaid HMO DRG,5861,,125% x Medicaid HMO amount,5861,Other,125% of NY Medicaid HMO DRG,0.01,22451,
Other complications of treatment,813-2,APR-DRG,,,,,,,,inpatient,,,139069.74,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31007,,"45,128 x DRG weight",31007,Other,base rate x DRG weight,27907,,"40,615 x DRG weight",27907,Other,base rate x DRG weight,26356,,"38,359 x DRG weight",26356,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11463,,186% x Medicaid HMO amount,11463,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23414,,"34,077 x DRG weight",23414,Other,base rate x DRG weight,19903,,"28,966 x DRG weight",19903,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6163,,DRG base rate x DRG weight + capital per discharge,6163,Other,100% of NY Medicaid HMO DRG,6163,,100% x Medicaid HMO amount,6163,Other,100% of NY Medicaid HMO DRG,6163,,100% x Medicaid HMO amount,6163,Other,100% of NY Medicaid HMO DRG,6163,,100% x Medicaid HMO amount,6163,Other,100% of NY Medicaid HMO DRG,13867,,225% x Medicaid HMO amount,13867,Other,225% of NY Medicaid HMO DRG,13867,,225% x Medicaid HMO amount,13867,Other,225% of NY Medicaid HMO DRG,13867,,225% x Medicaid HMO amount,13867,Other,225% of NY Medicaid HMO DRG,13867,,225% x Medicaid HMO amount,13867,Other,225% of NY Medicaid HMO DRG,8628,,140% x Medicaid HMO amount,8628,Other,140% of NY Medicaid HMO DRG,13867,,225% x Medicaid HMO amount,13867,Other,225% of NY Medicaid HMO DRG,16948,,275% x Medicaid HMO amount,16948,Other,275% of NY Medicaid HMO DRG,19968,,324% x Medicaid HMO amount,19968,Other,324% of NY Medicaid HMO DRG,13250,,215% x Medicaid HMO amount,13250,Other,215% of NY Medicaid HMO DRG,13250,,215% x Medicaid HMO amount,13250,Other,215% of NY Medicaid HMO DRG,7704,,125% x Medicaid HMO amount,7704,Other,125% of NY Medicaid HMO DRG,0.01,31007,
Other complications of treatment,813-3,APR-DRG,,,,,,,,inpatient,,,157589.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51360,,"45,128 x DRG weight",51360,Other,base rate x DRG weight,46224,,"40,615 x DRG weight",46224,Other,base rate x DRG weight,43656,,"38,359 x DRG weight",43656,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17986,,186% x Medicaid HMO amount,17986,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38783,,"34,077 x DRG weight",38783,Other,base rate x DRG weight,32966,,"28,966 x DRG weight",32966,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9670,,DRG base rate x DRG weight + capital per discharge,9670,Other,100% of NY Medicaid HMO DRG,9670,,100% x Medicaid HMO amount,9670,Other,100% of NY Medicaid HMO DRG,9670,,100% x Medicaid HMO amount,9670,Other,100% of NY Medicaid HMO DRG,9670,,100% x Medicaid HMO amount,9670,Other,100% of NY Medicaid HMO DRG,21758,,225% x Medicaid HMO amount,21758,Other,225% of NY Medicaid HMO DRG,21758,,225% x Medicaid HMO amount,21758,Other,225% of NY Medicaid HMO DRG,21758,,225% x Medicaid HMO amount,21758,Other,225% of NY Medicaid HMO DRG,21758,,225% x Medicaid HMO amount,21758,Other,225% of NY Medicaid HMO DRG,13538,,140% x Medicaid HMO amount,13538,Other,140% of NY Medicaid HMO DRG,21758,,225% x Medicaid HMO amount,21758,Other,225% of NY Medicaid HMO DRG,26593,,275% x Medicaid HMO amount,26593,Other,275% of NY Medicaid HMO DRG,31331,,324% x Medicaid HMO amount,31331,Other,324% of NY Medicaid HMO DRG,20791,,215% x Medicaid HMO amount,20791,Other,215% of NY Medicaid HMO DRG,20791,,215% x Medicaid HMO amount,20791,Other,215% of NY Medicaid HMO DRG,12088,,125% x Medicaid HMO amount,12088,Other,125% of NY Medicaid HMO DRG,0.01,51360,
Other complications of treatment,813-4,APR-DRG,,,,,,,,inpatient,,,249158.17,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,117947,,"45,128 x DRG weight",117947,Other,base rate x DRG weight,106151,,"40,615 x DRG weight",106151,Other,base rate x DRG weight,100255,,"38,359 x DRG weight",100255,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39326,,186% x Medicaid HMO amount,39326,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,89064,,"34,077 x DRG weight",89064,Other,base rate x DRG weight,75706,,"28,966 x DRG weight",75706,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21143,,DRG base rate x DRG weight + capital per discharge,21143,Other,100% of NY Medicaid HMO DRG,21143,,100% x Medicaid HMO amount,21143,Other,100% of NY Medicaid HMO DRG,21143,,100% x Medicaid HMO amount,21143,Other,100% of NY Medicaid HMO DRG,21143,,100% x Medicaid HMO amount,21143,Other,100% of NY Medicaid HMO DRG,47572,,225% x Medicaid HMO amount,47572,Other,225% of NY Medicaid HMO DRG,47572,,225% x Medicaid HMO amount,47572,Other,225% of NY Medicaid HMO DRG,47572,,225% x Medicaid HMO amount,47572,Other,225% of NY Medicaid HMO DRG,47572,,225% x Medicaid HMO amount,47572,Other,225% of NY Medicaid HMO DRG,29600,,140% x Medicaid HMO amount,29600,Other,140% of NY Medicaid HMO DRG,47572,,225% x Medicaid HMO amount,47572,Other,225% of NY Medicaid HMO DRG,58143,,275% x Medicaid HMO amount,58143,Other,275% of NY Medicaid HMO DRG,68503,,324% x Medicaid HMO amount,68503,Other,324% of NY Medicaid HMO DRG,45457,,215% x Medicaid HMO amount,45457,Other,215% of NY Medicaid HMO DRG,45457,,215% x Medicaid HMO amount,45457,Other,215% of NY Medicaid HMO DRG,26429,,125% x Medicaid HMO amount,26429,Other,125% of NY Medicaid HMO DRG,0.01,117947,
"Other injury, poisoning & toxic effect diagnoses",815-1,APR-DRG,,,,,,,,inpatient,,,84439.99,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16305,,"45,128 x DRG weight",16305,Other,base rate x DRG weight,14674,,"40,615 x DRG weight",14674,Other,base rate x DRG weight,13859,,"38,359 x DRG weight",13859,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6752,,186% x Medicaid HMO amount,6752,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12312,,"34,077 x DRG weight",12312,Other,base rate x DRG weight,10465,,"28,966 x DRG weight",10465,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,3630,,DRG base rate x DRG weight + capital per discharge,3630,Other,100% of NY Medicaid HMO DRG,3630,,100% x Medicaid HMO amount,3630,Other,100% of NY Medicaid HMO DRG,3630,,100% x Medicaid HMO amount,3630,Other,100% of NY Medicaid HMO DRG,3630,,100% x Medicaid HMO amount,3630,Other,100% of NY Medicaid HMO DRG,8168,,225% x Medicaid HMO amount,8168,Other,225% of NY Medicaid HMO DRG,8168,,225% x Medicaid HMO amount,8168,Other,225% of NY Medicaid HMO DRG,8168,,225% x Medicaid HMO amount,8168,Other,225% of NY Medicaid HMO DRG,8168,,225% x Medicaid HMO amount,8168,Other,225% of NY Medicaid HMO DRG,5082,,140% x Medicaid HMO amount,5082,Other,140% of NY Medicaid HMO DRG,8168,,225% x Medicaid HMO amount,8168,Other,225% of NY Medicaid HMO DRG,9983,,275% x Medicaid HMO amount,9983,Other,275% of NY Medicaid HMO DRG,11761,,324% x Medicaid HMO amount,11761,Other,324% of NY Medicaid HMO DRG,7805,,215% x Medicaid HMO amount,7805,Other,215% of NY Medicaid HMO DRG,7805,,215% x Medicaid HMO amount,7805,Other,215% of NY Medicaid HMO DRG,4538,,125% x Medicaid HMO amount,4538,Other,125% of NY Medicaid HMO DRG,0.01,16305,
"Other injury, poisoning & toxic effect diagnoses",815-2,APR-DRG,,,,,,,,inpatient,,,143510.07,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27889,,"45,128 x DRG weight",27889,Other,base rate x DRG weight,25100,,"40,615 x DRG weight",25100,Other,base rate x DRG weight,23706,,"38,359 x DRG weight",23706,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10464,,186% x Medicaid HMO amount,10464,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21060,,"34,077 x DRG weight",21060,Other,base rate x DRG weight,17901,,"28,966 x DRG weight",17901,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5626,,DRG base rate x DRG weight + capital per discharge,5626,Other,100% of NY Medicaid HMO DRG,5626,,100% x Medicaid HMO amount,5626,Other,100% of NY Medicaid HMO DRG,5626,,100% x Medicaid HMO amount,5626,Other,100% of NY Medicaid HMO DRG,5626,,100% x Medicaid HMO amount,5626,Other,100% of NY Medicaid HMO DRG,12659,,225% x Medicaid HMO amount,12659,Other,225% of NY Medicaid HMO DRG,12659,,225% x Medicaid HMO amount,12659,Other,225% of NY Medicaid HMO DRG,12659,,225% x Medicaid HMO amount,12659,Other,225% of NY Medicaid HMO DRG,12659,,225% x Medicaid HMO amount,12659,Other,225% of NY Medicaid HMO DRG,7876,,140% x Medicaid HMO amount,7876,Other,140% of NY Medicaid HMO DRG,12659,,225% x Medicaid HMO amount,12659,Other,225% of NY Medicaid HMO DRG,15472,,275% x Medicaid HMO amount,15472,Other,275% of NY Medicaid HMO DRG,18228,,324% x Medicaid HMO amount,18228,Other,324% of NY Medicaid HMO DRG,12096,,215% x Medicaid HMO amount,12096,Other,215% of NY Medicaid HMO DRG,12096,,215% x Medicaid HMO amount,12096,Other,215% of NY Medicaid HMO DRG,7033,,125% x Medicaid HMO amount,7033,Other,125% of NY Medicaid HMO DRG,0.01,27889,
"Other injury, poisoning & toxic effect diagnoses",815-3,APR-DRG,,,,,,,,inpatient,,,328313.63,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47592,,"45,128 x DRG weight",47592,Other,base rate x DRG weight,42833,,"40,615 x DRG weight",42833,Other,base rate x DRG weight,40453,,"38,359 x DRG weight",40453,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16779,,186% x Medicaid HMO amount,16779,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35938,,"34,077 x DRG weight",35938,Other,base rate x DRG weight,30548,,"28,966 x DRG weight",30548,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9021,,DRG base rate x DRG weight + capital per discharge,9021,Other,100% of NY Medicaid HMO DRG,9021,,100% x Medicaid HMO amount,9021,Other,100% of NY Medicaid HMO DRG,9021,,100% x Medicaid HMO amount,9021,Other,100% of NY Medicaid HMO DRG,9021,,100% x Medicaid HMO amount,9021,Other,100% of NY Medicaid HMO DRG,20297,,225% x Medicaid HMO amount,20297,Other,225% of NY Medicaid HMO DRG,20297,,225% x Medicaid HMO amount,20297,Other,225% of NY Medicaid HMO DRG,20297,,225% x Medicaid HMO amount,20297,Other,225% of NY Medicaid HMO DRG,20297,,225% x Medicaid HMO amount,20297,Other,225% of NY Medicaid HMO DRG,12629,,140% x Medicaid HMO amount,12629,Other,140% of NY Medicaid HMO DRG,20297,,225% x Medicaid HMO amount,20297,Other,225% of NY Medicaid HMO DRG,24808,,275% x Medicaid HMO amount,24808,Other,275% of NY Medicaid HMO DRG,29228,,324% x Medicaid HMO amount,29228,Other,324% of NY Medicaid HMO DRG,19395,,215% x Medicaid HMO amount,19395,Other,215% of NY Medicaid HMO DRG,19395,,215% x Medicaid HMO amount,19395,Other,215% of NY Medicaid HMO DRG,11276,,125% x Medicaid HMO amount,11276,Other,125% of NY Medicaid HMO DRG,0.01,47592,
"Other injury, poisoning & toxic effect diagnoses",815-4,APR-DRG,,,,,,,,inpatient,,,295702.79,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,122049,,"45,128 x DRG weight",122049,Other,base rate x DRG weight,109843,,"40,615 x DRG weight",109843,Other,base rate x DRG weight,103742,,"38,359 x DRG weight",103742,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40641,,186% x Medicaid HMO amount,40641,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,92161,,"34,077 x DRG weight",92161,Other,base rate x DRG weight,78339,,"28,966 x DRG weight",78339,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21850,,DRG base rate x DRG weight + capital per discharge,21850,Other,100% of NY Medicaid HMO DRG,21850,,100% x Medicaid HMO amount,21850,Other,100% of NY Medicaid HMO DRG,21850,,100% x Medicaid HMO amount,21850,Other,100% of NY Medicaid HMO DRG,21850,,100% x Medicaid HMO amount,21850,Other,100% of NY Medicaid HMO DRG,49163,,225% x Medicaid HMO amount,49163,Other,225% of NY Medicaid HMO DRG,49163,,225% x Medicaid HMO amount,49163,Other,225% of NY Medicaid HMO DRG,49163,,225% x Medicaid HMO amount,49163,Other,225% of NY Medicaid HMO DRG,49163,,225% x Medicaid HMO amount,49163,Other,225% of NY Medicaid HMO DRG,30590,,140% x Medicaid HMO amount,30590,Other,140% of NY Medicaid HMO DRG,49163,,225% x Medicaid HMO amount,49163,Other,225% of NY Medicaid HMO DRG,60088,,275% x Medicaid HMO amount,60088,Other,275% of NY Medicaid HMO DRG,70794,,324% x Medicaid HMO amount,70794,Other,324% of NY Medicaid HMO DRG,46978,,215% x Medicaid HMO amount,46978,Other,215% of NY Medicaid HMO DRG,46978,,215% x Medicaid HMO amount,46978,Other,215% of NY Medicaid HMO DRG,27313,,125% x Medicaid HMO amount,27313,Other,125% of NY Medicaid HMO DRG,0.01,122049,
Toxic effects of non-medicinal substances,816-1,APR-DRG,,,,,,,,inpatient,,,106006.35,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20217,,"45,128 x DRG weight",20217,Other,base rate x DRG weight,18196,,"40,615 x DRG weight",18196,Other,base rate x DRG weight,17185,,"38,359 x DRG weight",17185,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8005,,186% x Medicaid HMO amount,8005,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15266,,"34,077 x DRG weight",15266,Other,base rate x DRG weight,12977,,"28,966 x DRG weight",12977,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4304,,DRG base rate x DRG weight + capital per discharge,4304,Other,100% of NY Medicaid HMO DRG,4304,,100% x Medicaid HMO amount,4304,Other,100% of NY Medicaid HMO DRG,4304,,100% x Medicaid HMO amount,4304,Other,100% of NY Medicaid HMO DRG,4304,,100% x Medicaid HMO amount,4304,Other,100% of NY Medicaid HMO DRG,9684,,225% x Medicaid HMO amount,9684,Other,225% of NY Medicaid HMO DRG,9684,,225% x Medicaid HMO amount,9684,Other,225% of NY Medicaid HMO DRG,9684,,225% x Medicaid HMO amount,9684,Other,225% of NY Medicaid HMO DRG,9684,,225% x Medicaid HMO amount,9684,Other,225% of NY Medicaid HMO DRG,6026,,140% x Medicaid HMO amount,6026,Other,140% of NY Medicaid HMO DRG,9684,,225% x Medicaid HMO amount,9684,Other,225% of NY Medicaid HMO DRG,11836,,275% x Medicaid HMO amount,11836,Other,275% of NY Medicaid HMO DRG,13945,,324% x Medicaid HMO amount,13945,Other,324% of NY Medicaid HMO DRG,9254,,215% x Medicaid HMO amount,9254,Other,215% of NY Medicaid HMO DRG,9254,,215% x Medicaid HMO amount,9254,Other,215% of NY Medicaid HMO DRG,5380,,125% x Medicaid HMO amount,5380,Other,125% of NY Medicaid HMO DRG,0.01,20217,
Toxic effects of non-medicinal substances,816-2,APR-DRG,,,,,,,,inpatient,,,83123.52,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25560,,"45,128 x DRG weight",25560,Other,base rate x DRG weight,23004,,"40,615 x DRG weight",23004,Other,base rate x DRG weight,21727,,"38,359 x DRG weight",21727,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9719,,186% x Medicaid HMO amount,9719,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19301,,"34,077 x DRG weight",19301,Other,base rate x DRG weight,16406,,"28,966 x DRG weight",16406,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5225,,DRG base rate x DRG weight + capital per discharge,5225,Other,100% of NY Medicaid HMO DRG,5225,,100% x Medicaid HMO amount,5225,Other,100% of NY Medicaid HMO DRG,5225,,100% x Medicaid HMO amount,5225,Other,100% of NY Medicaid HMO DRG,5225,,100% x Medicaid HMO amount,5225,Other,100% of NY Medicaid HMO DRG,11756,,225% x Medicaid HMO amount,11756,Other,225% of NY Medicaid HMO DRG,11756,,225% x Medicaid HMO amount,11756,Other,225% of NY Medicaid HMO DRG,11756,,225% x Medicaid HMO amount,11756,Other,225% of NY Medicaid HMO DRG,11756,,225% x Medicaid HMO amount,11756,Other,225% of NY Medicaid HMO DRG,7315,,140% x Medicaid HMO amount,7315,Other,140% of NY Medicaid HMO DRG,11756,,225% x Medicaid HMO amount,11756,Other,225% of NY Medicaid HMO DRG,14369,,275% x Medicaid HMO amount,14369,Other,275% of NY Medicaid HMO DRG,16929,,324% x Medicaid HMO amount,16929,Other,324% of NY Medicaid HMO DRG,11234,,215% x Medicaid HMO amount,11234,Other,215% of NY Medicaid HMO DRG,11234,,215% x Medicaid HMO amount,11234,Other,215% of NY Medicaid HMO DRG,6531,,125% x Medicaid HMO amount,6531,Other,125% of NY Medicaid HMO DRG,0.01,25560,
Toxic effects of non-medicinal substances,816-3,APR-DRG,,,,,,,,inpatient,,,137476.28,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39762,,"45,128 x DRG weight",39762,Other,base rate x DRG weight,35786,,"40,615 x DRG weight",35786,Other,base rate x DRG weight,33798,,"38,359 x DRG weight",33798,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14270,,186% x Medicaid HMO amount,14270,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30025,,"34,077 x DRG weight",30025,Other,base rate x DRG weight,25522,,"28,966 x DRG weight",25522,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7672,,DRG base rate x DRG weight + capital per discharge,7672,Other,100% of NY Medicaid HMO DRG,7672,,100% x Medicaid HMO amount,7672,Other,100% of NY Medicaid HMO DRG,7672,,100% x Medicaid HMO amount,7672,Other,100% of NY Medicaid HMO DRG,7672,,100% x Medicaid HMO amount,7672,Other,100% of NY Medicaid HMO DRG,17262,,225% x Medicaid HMO amount,17262,Other,225% of NY Medicaid HMO DRG,17262,,225% x Medicaid HMO amount,17262,Other,225% of NY Medicaid HMO DRG,17262,,225% x Medicaid HMO amount,17262,Other,225% of NY Medicaid HMO DRG,17262,,225% x Medicaid HMO amount,17262,Other,225% of NY Medicaid HMO DRG,10741,,140% x Medicaid HMO amount,10741,Other,140% of NY Medicaid HMO DRG,17262,,225% x Medicaid HMO amount,17262,Other,225% of NY Medicaid HMO DRG,21098,,275% x Medicaid HMO amount,21098,Other,275% of NY Medicaid HMO DRG,24857,,324% x Medicaid HMO amount,24857,Other,324% of NY Medicaid HMO DRG,16495,,215% x Medicaid HMO amount,16495,Other,215% of NY Medicaid HMO DRG,16495,,215% x Medicaid HMO amount,16495,Other,215% of NY Medicaid HMO DRG,9590,,125% x Medicaid HMO amount,9590,Other,125% of NY Medicaid HMO DRG,0.01,39762,
Toxic effects of non-medicinal substances,816-4,APR-DRG,,,,,,,,inpatient,,,157136.38,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,94498,,"45,128 x DRG weight",94498,Other,base rate x DRG weight,85048,,"40,615 x DRG weight",85048,Other,base rate x DRG weight,80324,,"38,359 x DRG weight",80324,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31812,,186% x Medicaid HMO amount,31812,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,71357,,"34,077 x DRG weight",71357,Other,base rate x DRG weight,60655,,"28,966 x DRG weight",60655,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17103,,DRG base rate x DRG weight + capital per discharge,17103,Other,100% of NY Medicaid HMO DRG,17103,,100% x Medicaid HMO amount,17103,Other,100% of NY Medicaid HMO DRG,17103,,100% x Medicaid HMO amount,17103,Other,100% of NY Medicaid HMO DRG,17103,,100% x Medicaid HMO amount,17103,Other,100% of NY Medicaid HMO DRG,38482,,225% x Medicaid HMO amount,38482,Other,225% of NY Medicaid HMO DRG,38482,,225% x Medicaid HMO amount,38482,Other,225% of NY Medicaid HMO DRG,38482,,225% x Medicaid HMO amount,38482,Other,225% of NY Medicaid HMO DRG,38482,,225% x Medicaid HMO amount,38482,Other,225% of NY Medicaid HMO DRG,23944,,140% x Medicaid HMO amount,23944,Other,140% of NY Medicaid HMO DRG,38482,,225% x Medicaid HMO amount,38482,Other,225% of NY Medicaid HMO DRG,47033,,275% x Medicaid HMO amount,47033,Other,275% of NY Medicaid HMO DRG,55414,,324% x Medicaid HMO amount,55414,Other,324% of NY Medicaid HMO DRG,36771,,215% x Medicaid HMO amount,36771,Other,215% of NY Medicaid HMO DRG,36771,,215% x Medicaid HMO amount,36771,Other,215% of NY Medicaid HMO DRG,21379,,125% x Medicaid HMO amount,21379,Other,125% of NY Medicaid HMO DRG,0.01,94498,
Extensive 3rd degree burns w skin graft,841-1,APR-DRG,,,,,,,,inpatient,,,1260874.74,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,242193,,"45,128 x DRG weight",242193,Other,base rate x DRG weight,217973,,"40,615 x DRG weight",217973,Other,base rate x DRG weight,205865,,"38,359 x DRG weight",205865,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,79145,,186% x Medicaid HMO amount,79145,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,182884,,"34,077 x DRG weight",182884,Other,base rate x DRG weight,155455,,"28,966 x DRG weight",155455,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42551,,DRG base rate x DRG weight + capital per discharge,42551,Other,100% of NY Medicaid HMO DRG,42551,,100% x Medicaid HMO amount,42551,Other,100% of NY Medicaid HMO DRG,42551,,100% x Medicaid HMO amount,42551,Other,100% of NY Medicaid HMO DRG,42551,,100% x Medicaid HMO amount,42551,Other,100% of NY Medicaid HMO DRG,95740,,225% x Medicaid HMO amount,95740,Other,225% of NY Medicaid HMO DRG,95740,,225% x Medicaid HMO amount,95740,Other,225% of NY Medicaid HMO DRG,95740,,225% x Medicaid HMO amount,95740,Other,225% of NY Medicaid HMO DRG,95740,,225% x Medicaid HMO amount,95740,Other,225% of NY Medicaid HMO DRG,59571,,140% x Medicaid HMO amount,59571,Other,140% of NY Medicaid HMO DRG,95740,,225% x Medicaid HMO amount,95740,Other,225% of NY Medicaid HMO DRG,117015,,275% x Medicaid HMO amount,117015,Other,275% of NY Medicaid HMO DRG,137865,,324% x Medicaid HMO amount,137865,Other,324% of NY Medicaid HMO DRG,91485,,215% x Medicaid HMO amount,91485,Other,215% of NY Medicaid HMO DRG,91485,,215% x Medicaid HMO amount,91485,Other,215% of NY Medicaid HMO DRG,53189,,125% x Medicaid HMO amount,53189,Other,125% of NY Medicaid HMO DRG,0.01,242193,
Extensive 3rd degree burns w skin graft,841-2,APR-DRG,,,,,,,,inpatient,,,1260874.74,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,319592,,"45,128 x DRG weight",319592,Other,base rate x DRG weight,287631,,"40,615 x DRG weight",287631,Other,base rate x DRG weight,271655,,"38,359 x DRG weight",271655,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,103950,,186% x Medicaid HMO amount,103950,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,241330,,"34,077 x DRG weight",241330,Other,base rate x DRG weight,205134,,"28,966 x DRG weight",205134,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55887,,DRG base rate x DRG weight + capital per discharge,55887,Other,100% of NY Medicaid HMO DRG,55887,,100% x Medicaid HMO amount,55887,Other,100% of NY Medicaid HMO DRG,55887,,100% x Medicaid HMO amount,55887,Other,100% of NY Medicaid HMO DRG,55887,,100% x Medicaid HMO amount,55887,Other,100% of NY Medicaid HMO DRG,125746,,225% x Medicaid HMO amount,125746,Other,225% of NY Medicaid HMO DRG,125746,,225% x Medicaid HMO amount,125746,Other,225% of NY Medicaid HMO DRG,125746,,225% x Medicaid HMO amount,125746,Other,225% of NY Medicaid HMO DRG,125746,,225% x Medicaid HMO amount,125746,Other,225% of NY Medicaid HMO DRG,78242,,140% x Medicaid HMO amount,78242,Other,140% of NY Medicaid HMO DRG,125746,,225% x Medicaid HMO amount,125746,Other,225% of NY Medicaid HMO DRG,153689,,275% x Medicaid HMO amount,153689,Other,275% of NY Medicaid HMO DRG,181074,,324% x Medicaid HMO amount,181074,Other,324% of NY Medicaid HMO DRG,120157,,215% x Medicaid HMO amount,120157,Other,215% of NY Medicaid HMO DRG,120157,,215% x Medicaid HMO amount,120157,Other,215% of NY Medicaid HMO DRG,69859,,125% x Medicaid HMO amount,69859,Other,125% of NY Medicaid HMO DRG,0.01,319592,
Extensive 3rd degree burns w skin graft,841-3,APR-DRG,,,,,,,,inpatient,,,1422878.29,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,660805,,"45,128 x DRG weight",660805,Other,base rate x DRG weight,594721,,"40,615 x DRG weight",594721,Other,base rate x DRG weight,561687,,"38,359 x DRG weight",561687,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,213301,,186% x Medicaid HMO amount,213301,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,498986,,"34,077 x DRG weight",498986,Other,base rate x DRG weight,424146,,"28,966 x DRG weight",424146,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,114678,,DRG base rate x DRG weight + capital per discharge,114678,Other,100% of NY Medicaid HMO DRG,114678,,100% x Medicaid HMO amount,114678,Other,100% of NY Medicaid HMO DRG,114678,,100% x Medicaid HMO amount,114678,Other,100% of NY Medicaid HMO DRG,114678,,100% x Medicaid HMO amount,114678,Other,100% of NY Medicaid HMO DRG,258026,,225% x Medicaid HMO amount,258026,Other,225% of NY Medicaid HMO DRG,258026,,225% x Medicaid HMO amount,258026,Other,225% of NY Medicaid HMO DRG,258026,,225% x Medicaid HMO amount,258026,Other,225% of NY Medicaid HMO DRG,258026,,225% x Medicaid HMO amount,258026,Other,225% of NY Medicaid HMO DRG,160549,,140% x Medicaid HMO amount,160549,Other,140% of NY Medicaid HMO DRG,258026,,225% x Medicaid HMO amount,258026,Other,225% of NY Medicaid HMO DRG,315365,,275% x Medicaid HMO amount,315365,Other,275% of NY Medicaid HMO DRG,371557,,324% x Medicaid HMO amount,371557,Other,324% of NY Medicaid HMO DRG,246558,,215% x Medicaid HMO amount,246558,Other,215% of NY Medicaid HMO DRG,246558,,215% x Medicaid HMO amount,246558,Other,215% of NY Medicaid HMO DRG,143348,,125% x Medicaid HMO amount,143348,Other,125% of NY Medicaid HMO DRG,0.01,660805,
Extensive 3rd degree burns w skin graft,841-4,APR-DRG,,,,,,,,inpatient,,,2504936.85,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,845627,,"45,128 x DRG weight",845627,Other,base rate x DRG weight,761060,,"40,615 x DRG weight",761060,Other,base rate x DRG weight,718786,,"38,359 x DRG weight",718786,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,272535,,186% x Medicaid HMO amount,272535,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,638548,,"34,077 x DRG weight",638548,Other,base rate x DRG weight,542776,,"28,966 x DRG weight",542776,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,146524,,DRG base rate x DRG weight + capital per discharge,146524,Other,100% of NY Medicaid HMO DRG,146524,,100% x Medicaid HMO amount,146524,Other,100% of NY Medicaid HMO DRG,146524,,100% x Medicaid HMO amount,146524,Other,100% of NY Medicaid HMO DRG,146524,,100% x Medicaid HMO amount,146524,Other,100% of NY Medicaid HMO DRG,329679,,225% x Medicaid HMO amount,329679,Other,225% of NY Medicaid HMO DRG,329679,,225% x Medicaid HMO amount,329679,Other,225% of NY Medicaid HMO DRG,329679,,225% x Medicaid HMO amount,329679,Other,225% of NY Medicaid HMO DRG,329679,,225% x Medicaid HMO amount,329679,Other,225% of NY Medicaid HMO DRG,205134,,140% x Medicaid HMO amount,205134,Other,140% of NY Medicaid HMO DRG,329679,,225% x Medicaid HMO amount,329679,Other,225% of NY Medicaid HMO DRG,402941,,275% x Medicaid HMO amount,402941,Other,275% of NY Medicaid HMO DRG,474738,,324% x Medicaid HMO amount,474738,Other,324% of NY Medicaid HMO DRG,315027,,215% x Medicaid HMO amount,315027,Other,215% of NY Medicaid HMO DRG,315027,,215% x Medicaid HMO amount,315027,Other,215% of NY Medicaid HMO DRG,183155,,125% x Medicaid HMO amount,183155,Other,125% of NY Medicaid HMO DRG,0.01,845627,
Burns with skin graft except extensive 3rd degree burns,842-1,APR-DRG,,,,,,,,inpatient,,,417507.42,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,97260,,"45,128 x DRG weight",97260,Other,base rate x DRG weight,87533,,"40,615 x DRG weight",87533,Other,base rate x DRG weight,82671,,"38,359 x DRG weight",82671,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32697,,186% x Medicaid HMO amount,32697,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73443,,"34,077 x DRG weight",73443,Other,base rate x DRG weight,62428,,"28,966 x DRG weight",62428,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17579,,DRG base rate x DRG weight + capital per discharge,17579,Other,100% of NY Medicaid HMO DRG,17579,,100% x Medicaid HMO amount,17579,Other,100% of NY Medicaid HMO DRG,17579,,100% x Medicaid HMO amount,17579,Other,100% of NY Medicaid HMO DRG,17579,,100% x Medicaid HMO amount,17579,Other,100% of NY Medicaid HMO DRG,39553,,225% x Medicaid HMO amount,39553,Other,225% of NY Medicaid HMO DRG,39553,,225% x Medicaid HMO amount,39553,Other,225% of NY Medicaid HMO DRG,39553,,225% x Medicaid HMO amount,39553,Other,225% of NY Medicaid HMO DRG,39553,,225% x Medicaid HMO amount,39553,Other,225% of NY Medicaid HMO DRG,24611,,140% x Medicaid HMO amount,24611,Other,140% of NY Medicaid HMO DRG,39553,,225% x Medicaid HMO amount,39553,Other,225% of NY Medicaid HMO DRG,48342,,275% x Medicaid HMO amount,48342,Other,275% of NY Medicaid HMO DRG,56956,,324% x Medicaid HMO amount,56956,Other,324% of NY Medicaid HMO DRG,37795,,215% x Medicaid HMO amount,37795,Other,215% of NY Medicaid HMO DRG,37795,,215% x Medicaid HMO amount,37795,Other,215% of NY Medicaid HMO DRG,21974,,125% x Medicaid HMO amount,21974,Other,125% of NY Medicaid HMO DRG,0.01,97260,
Burns with skin graft except extensive 3rd degree burns,842-2,APR-DRG,,,,,,,,inpatient,,,597490.13,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,127911,,"45,128 x DRG weight",127911,Other,base rate x DRG weight,115119,,"40,615 x DRG weight",115119,Other,base rate x DRG weight,108725,,"38,359 x DRG weight",108725,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42520,,186% x Medicaid HMO amount,42520,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,96588,,"34,077 x DRG weight",96588,Other,base rate x DRG weight,82101,,"28,966 x DRG weight",82101,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22860,,DRG base rate x DRG weight + capital per discharge,22860,Other,100% of NY Medicaid HMO DRG,22860,,100% x Medicaid HMO amount,22860,Other,100% of NY Medicaid HMO DRG,22860,,100% x Medicaid HMO amount,22860,Other,100% of NY Medicaid HMO DRG,22860,,100% x Medicaid HMO amount,22860,Other,100% of NY Medicaid HMO DRG,51435,,225% x Medicaid HMO amount,51435,Other,225% of NY Medicaid HMO DRG,51435,,225% x Medicaid HMO amount,51435,Other,225% of NY Medicaid HMO DRG,51435,,225% x Medicaid HMO amount,51435,Other,225% of NY Medicaid HMO DRG,51435,,225% x Medicaid HMO amount,51435,Other,225% of NY Medicaid HMO DRG,32004,,140% x Medicaid HMO amount,32004,Other,140% of NY Medicaid HMO DRG,51435,,225% x Medicaid HMO amount,51435,Other,225% of NY Medicaid HMO DRG,62865,,275% x Medicaid HMO amount,62865,Other,275% of NY Medicaid HMO DRG,74066,,324% x Medicaid HMO amount,74066,Other,324% of NY Medicaid HMO DRG,49149,,215% x Medicaid HMO amount,49149,Other,215% of NY Medicaid HMO DRG,49149,,215% x Medicaid HMO amount,49149,Other,215% of NY Medicaid HMO DRG,28575,,125% x Medicaid HMO amount,28575,Other,125% of NY Medicaid HMO DRG,0.01,127911,
Burns with skin graft except extensive 3rd degree burns,842-3,APR-DRG,,,,,,,,inpatient,,,644723.08,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,196916,,"45,128 x DRG weight",196916,Other,base rate x DRG weight,177224,,"40,615 x DRG weight",177224,Other,base rate x DRG weight,167379,,"38,359 x DRG weight",167379,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,64635,,186% x Medicaid HMO amount,64635,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,148695,,"34,077 x DRG weight",148695,Other,base rate x DRG weight,126393,,"28,966 x DRG weight",126393,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34750,,DRG base rate x DRG weight + capital per discharge,34750,Other,100% of NY Medicaid HMO DRG,34750,,100% x Medicaid HMO amount,34750,Other,100% of NY Medicaid HMO DRG,34750,,100% x Medicaid HMO amount,34750,Other,100% of NY Medicaid HMO DRG,34750,,100% x Medicaid HMO amount,34750,Other,100% of NY Medicaid HMO DRG,78188,,225% x Medicaid HMO amount,78188,Other,225% of NY Medicaid HMO DRG,78188,,225% x Medicaid HMO amount,78188,Other,225% of NY Medicaid HMO DRG,78188,,225% x Medicaid HMO amount,78188,Other,225% of NY Medicaid HMO DRG,78188,,225% x Medicaid HMO amount,78188,Other,225% of NY Medicaid HMO DRG,48650,,140% x Medicaid HMO amount,48650,Other,140% of NY Medicaid HMO DRG,78188,,225% x Medicaid HMO amount,78188,Other,225% of NY Medicaid HMO DRG,95563,,275% x Medicaid HMO amount,95563,Other,275% of NY Medicaid HMO DRG,112590,,324% x Medicaid HMO amount,112590,Other,324% of NY Medicaid HMO DRG,74713,,215% x Medicaid HMO amount,74713,Other,215% of NY Medicaid HMO DRG,74713,,215% x Medicaid HMO amount,74713,Other,215% of NY Medicaid HMO DRG,43438,,125% x Medicaid HMO amount,43438,Other,125% of NY Medicaid HMO DRG,0.01,196916,
Burns with skin graft except extensive 3rd degree burns,842-4,APR-DRG,,,,,,,,inpatient,,,1260874.74,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,389802,,"45,128 x DRG weight",389802,Other,base rate x DRG weight,350820,,"40,615 x DRG weight",350820,Other,base rate x DRG weight,331334,,"38,359 x DRG weight",331334,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,126450,,186% x Medicaid HMO amount,126450,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,294347,,"34,077 x DRG weight",294347,Other,base rate x DRG weight,250200,,"28,966 x DRG weight",250200,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,67984,,DRG base rate x DRG weight + capital per discharge,67984,Other,100% of NY Medicaid HMO DRG,67984,,100% x Medicaid HMO amount,67984,Other,100% of NY Medicaid HMO DRG,67984,,100% x Medicaid HMO amount,67984,Other,100% of NY Medicaid HMO DRG,67984,,100% x Medicaid HMO amount,67984,Other,100% of NY Medicaid HMO DRG,152964,,225% x Medicaid HMO amount,152964,Other,225% of NY Medicaid HMO DRG,152964,,225% x Medicaid HMO amount,152964,Other,225% of NY Medicaid HMO DRG,152964,,225% x Medicaid HMO amount,152964,Other,225% of NY Medicaid HMO DRG,152964,,225% x Medicaid HMO amount,152964,Other,225% of NY Medicaid HMO DRG,95178,,140% x Medicaid HMO amount,95178,Other,140% of NY Medicaid HMO DRG,152964,,225% x Medicaid HMO amount,152964,Other,225% of NY Medicaid HMO DRG,186956,,275% x Medicaid HMO amount,186956,Other,275% of NY Medicaid HMO DRG,220268,,324% x Medicaid HMO amount,220268,Other,324% of NY Medicaid HMO DRG,146166,,215% x Medicaid HMO amount,146166,Other,215% of NY Medicaid HMO DRG,146166,,215% x Medicaid HMO amount,146166,Other,215% of NY Medicaid HMO DRG,84980,,125% x Medicaid HMO amount,84980,Other,125% of NY Medicaid HMO DRG,0.01,389802,
Extensive 3rd degree or full thickness burns w/o skin graft,843-1,APR-DRG,,,,,,,,inpatient,,,232006.01,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,88965,,"45,128 x DRG weight",88965,Other,base rate x DRG weight,80068,,"40,615 x DRG weight",80068,Other,base rate x DRG weight,75621,,"38,359 x DRG weight",75621,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30039,,186% x Medicaid HMO amount,30039,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,67179,,"34,077 x DRG weight",67179,Other,base rate x DRG weight,57104,,"28,966 x DRG weight",57104,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16150,,DRG base rate x DRG weight + capital per discharge,16150,Other,100% of NY Medicaid HMO DRG,16150,,100% x Medicaid HMO amount,16150,Other,100% of NY Medicaid HMO DRG,16150,,100% x Medicaid HMO amount,16150,Other,100% of NY Medicaid HMO DRG,16150,,100% x Medicaid HMO amount,16150,Other,100% of NY Medicaid HMO DRG,36338,,225% x Medicaid HMO amount,36338,Other,225% of NY Medicaid HMO DRG,36338,,225% x Medicaid HMO amount,36338,Other,225% of NY Medicaid HMO DRG,36338,,225% x Medicaid HMO amount,36338,Other,225% of NY Medicaid HMO DRG,36338,,225% x Medicaid HMO amount,36338,Other,225% of NY Medicaid HMO DRG,22610,,140% x Medicaid HMO amount,22610,Other,140% of NY Medicaid HMO DRG,36338,,225% x Medicaid HMO amount,36338,Other,225% of NY Medicaid HMO DRG,44413,,275% x Medicaid HMO amount,44413,Other,275% of NY Medicaid HMO DRG,52326,,324% x Medicaid HMO amount,52326,Other,324% of NY Medicaid HMO DRG,34723,,215% x Medicaid HMO amount,34723,Other,215% of NY Medicaid HMO DRG,34723,,215% x Medicaid HMO amount,34723,Other,215% of NY Medicaid HMO DRG,20188,,125% x Medicaid HMO amount,20188,Other,125% of NY Medicaid HMO DRG,0.01,88965,
Extensive 3rd degree or full thickness burns w/o skin graft,843-2,APR-DRG,,,,,,,,inpatient,,,232006.01,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,88965,,"45,128 x DRG weight",88965,Other,base rate x DRG weight,80068,,"40,615 x DRG weight",80068,Other,base rate x DRG weight,75621,,"38,359 x DRG weight",75621,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30039,,186% x Medicaid HMO amount,30039,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,67179,,"34,077 x DRG weight",67179,Other,base rate x DRG weight,57104,,"28,966 x DRG weight",57104,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16150,,DRG base rate x DRG weight + capital per discharge,16150,Other,100% of NY Medicaid HMO DRG,16150,,100% x Medicaid HMO amount,16150,Other,100% of NY Medicaid HMO DRG,16150,,100% x Medicaid HMO amount,16150,Other,100% of NY Medicaid HMO DRG,16150,,100% x Medicaid HMO amount,16150,Other,100% of NY Medicaid HMO DRG,36338,,225% x Medicaid HMO amount,36338,Other,225% of NY Medicaid HMO DRG,36338,,225% x Medicaid HMO amount,36338,Other,225% of NY Medicaid HMO DRG,36338,,225% x Medicaid HMO amount,36338,Other,225% of NY Medicaid HMO DRG,36338,,225% x Medicaid HMO amount,36338,Other,225% of NY Medicaid HMO DRG,22610,,140% x Medicaid HMO amount,22610,Other,140% of NY Medicaid HMO DRG,36338,,225% x Medicaid HMO amount,36338,Other,225% of NY Medicaid HMO DRG,44413,,275% x Medicaid HMO amount,44413,Other,275% of NY Medicaid HMO DRG,52326,,324% x Medicaid HMO amount,52326,Other,324% of NY Medicaid HMO DRG,34723,,215% x Medicaid HMO amount,34723,Other,215% of NY Medicaid HMO DRG,34723,,215% x Medicaid HMO amount,34723,Other,215% of NY Medicaid HMO DRG,20188,,125% x Medicaid HMO amount,20188,Other,125% of NY Medicaid HMO DRG,0.01,88965,
Extensive 3rd degree or full thickness burns w/o skin graft,843-3,APR-DRG,,,,,,,,inpatient,,,232006.01,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,88965,,"45,128 x DRG weight",88965,Other,base rate x DRG weight,80068,,"40,615 x DRG weight",80068,Other,base rate x DRG weight,75621,,"38,359 x DRG weight",75621,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30039,,186% x Medicaid HMO amount,30039,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,67179,,"34,077 x DRG weight",67179,Other,base rate x DRG weight,57104,,"28,966 x DRG weight",57104,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16150,,DRG base rate x DRG weight + capital per discharge,16150,Other,100% of NY Medicaid HMO DRG,16150,,100% x Medicaid HMO amount,16150,Other,100% of NY Medicaid HMO DRG,16150,,100% x Medicaid HMO amount,16150,Other,100% of NY Medicaid HMO DRG,16150,,100% x Medicaid HMO amount,16150,Other,100% of NY Medicaid HMO DRG,36338,,225% x Medicaid HMO amount,36338,Other,225% of NY Medicaid HMO DRG,36338,,225% x Medicaid HMO amount,36338,Other,225% of NY Medicaid HMO DRG,36338,,225% x Medicaid HMO amount,36338,Other,225% of NY Medicaid HMO DRG,36338,,225% x Medicaid HMO amount,36338,Other,225% of NY Medicaid HMO DRG,22610,,140% x Medicaid HMO amount,22610,Other,140% of NY Medicaid HMO DRG,36338,,225% x Medicaid HMO amount,36338,Other,225% of NY Medicaid HMO DRG,44413,,275% x Medicaid HMO amount,44413,Other,275% of NY Medicaid HMO DRG,52326,,324% x Medicaid HMO amount,52326,Other,324% of NY Medicaid HMO DRG,34723,,215% x Medicaid HMO amount,34723,Other,215% of NY Medicaid HMO DRG,34723,,215% x Medicaid HMO amount,34723,Other,215% of NY Medicaid HMO DRG,20188,,125% x Medicaid HMO amount,20188,Other,125% of NY Medicaid HMO DRG,0.01,88965,
Extensive 3rd degree or full thickness burns w/o skin graft,843-4,APR-DRG,,,,,,,,inpatient,,,232006.01,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,88965,,"45,128 x DRG weight",88965,Other,base rate x DRG weight,80068,,"40,615 x DRG weight",80068,Other,base rate x DRG weight,75621,,"38,359 x DRG weight",75621,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30039,,186% x Medicaid HMO amount,30039,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,67179,,"34,077 x DRG weight",67179,Other,base rate x DRG weight,57104,,"28,966 x DRG weight",57104,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16150,,DRG base rate x DRG weight + capital per discharge,16150,Other,100% of NY Medicaid HMO DRG,16150,,100% x Medicaid HMO amount,16150,Other,100% of NY Medicaid HMO DRG,16150,,100% x Medicaid HMO amount,16150,Other,100% of NY Medicaid HMO DRG,16150,,100% x Medicaid HMO amount,16150,Other,100% of NY Medicaid HMO DRG,36338,,225% x Medicaid HMO amount,36338,Other,225% of NY Medicaid HMO DRG,36338,,225% x Medicaid HMO amount,36338,Other,225% of NY Medicaid HMO DRG,36338,,225% x Medicaid HMO amount,36338,Other,225% of NY Medicaid HMO DRG,36338,,225% x Medicaid HMO amount,36338,Other,225% of NY Medicaid HMO DRG,22610,,140% x Medicaid HMO amount,22610,Other,140% of NY Medicaid HMO DRG,36338,,225% x Medicaid HMO amount,36338,Other,225% of NY Medicaid HMO DRG,44413,,275% x Medicaid HMO amount,44413,Other,275% of NY Medicaid HMO DRG,52326,,324% x Medicaid HMO amount,52326,Other,324% of NY Medicaid HMO DRG,34723,,215% x Medicaid HMO amount,34723,Other,215% of NY Medicaid HMO DRG,34723,,215% x Medicaid HMO amount,34723,Other,215% of NY Medicaid HMO DRG,20188,,125% x Medicaid HMO amount,20188,Other,125% of NY Medicaid HMO DRG,0.01,88965,
Partial thickness burns without skin graft,844-1,APR-DRG,,,,,,,,inpatient,,,112166.66,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29302,,"45,128 x DRG weight",29302,Other,base rate x DRG weight,26371,,"40,615 x DRG weight",26371,Other,base rate x DRG weight,24906,,"38,359 x DRG weight",24906,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10918,,186% x Medicaid HMO amount,10918,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22126,,"34,077 x DRG weight",22126,Other,base rate x DRG weight,18808,,"28,966 x DRG weight",18808,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5870,,DRG base rate x DRG weight + capital per discharge,5870,Other,100% of NY Medicaid HMO DRG,5870,,100% x Medicaid HMO amount,5870,Other,100% of NY Medicaid HMO DRG,5870,,100% x Medicaid HMO amount,5870,Other,100% of NY Medicaid HMO DRG,5870,,100% x Medicaid HMO amount,5870,Other,100% of NY Medicaid HMO DRG,13208,,225% x Medicaid HMO amount,13208,Other,225% of NY Medicaid HMO DRG,13208,,225% x Medicaid HMO amount,13208,Other,225% of NY Medicaid HMO DRG,13208,,225% x Medicaid HMO amount,13208,Other,225% of NY Medicaid HMO DRG,13208,,225% x Medicaid HMO amount,13208,Other,225% of NY Medicaid HMO DRG,8218,,140% x Medicaid HMO amount,8218,Other,140% of NY Medicaid HMO DRG,13208,,225% x Medicaid HMO amount,13208,Other,225% of NY Medicaid HMO DRG,16143,,275% x Medicaid HMO amount,16143,Other,275% of NY Medicaid HMO DRG,19019,,324% x Medicaid HMO amount,19019,Other,324% of NY Medicaid HMO DRG,12621,,215% x Medicaid HMO amount,12621,Other,215% of NY Medicaid HMO DRG,12621,,215% x Medicaid HMO amount,12621,Other,215% of NY Medicaid HMO DRG,7338,,125% x Medicaid HMO amount,7338,Other,125% of NY Medicaid HMO DRG,0.01,29302,
Partial thickness burns without skin graft,844-2,APR-DRG,,,,,,,,inpatient,,,185513.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47998,,"45,128 x DRG weight",47998,Other,base rate x DRG weight,43198,,"40,615 x DRG weight",43198,Other,base rate x DRG weight,40799,,"38,359 x DRG weight",40799,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16909,,186% x Medicaid HMO amount,16909,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36244,,"34,077 x DRG weight",36244,Other,base rate x DRG weight,30808,,"28,966 x DRG weight",30808,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9091,,DRG base rate x DRG weight + capital per discharge,9091,Other,100% of NY Medicaid HMO DRG,9091,,100% x Medicaid HMO amount,9091,Other,100% of NY Medicaid HMO DRG,9091,,100% x Medicaid HMO amount,9091,Other,100% of NY Medicaid HMO DRG,9091,,100% x Medicaid HMO amount,9091,Other,100% of NY Medicaid HMO DRG,20455,,225% x Medicaid HMO amount,20455,Other,225% of NY Medicaid HMO DRG,20455,,225% x Medicaid HMO amount,20455,Other,225% of NY Medicaid HMO DRG,20455,,225% x Medicaid HMO amount,20455,Other,225% of NY Medicaid HMO DRG,20455,,225% x Medicaid HMO amount,20455,Other,225% of NY Medicaid HMO DRG,12727,,140% x Medicaid HMO amount,12727,Other,140% of NY Medicaid HMO DRG,20455,,225% x Medicaid HMO amount,20455,Other,225% of NY Medicaid HMO DRG,25000,,275% x Medicaid HMO amount,25000,Other,275% of NY Medicaid HMO DRG,29455,,324% x Medicaid HMO amount,29455,Other,324% of NY Medicaid HMO DRG,19546,,215% x Medicaid HMO amount,19546,Other,215% of NY Medicaid HMO DRG,19546,,215% x Medicaid HMO amount,19546,Other,215% of NY Medicaid HMO DRG,11364,,125% x Medicaid HMO amount,11364,Other,125% of NY Medicaid HMO DRG,0.01,47998,
Partial thickness burns without skin graft,844-3,APR-DRG,,,,,,,,inpatient,,,395848.34,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,84935,,"45,128 x DRG weight",84935,Other,base rate x DRG weight,76441,,"40,615 x DRG weight",76441,Other,base rate x DRG weight,72195,,"38,359 x DRG weight",72195,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28746,,186% x Medicaid HMO amount,28746,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,64136,,"34,077 x DRG weight",64136,Other,base rate x DRG weight,54517,,"28,966 x DRG weight",54517,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15455,,DRG base rate x DRG weight + capital per discharge,15455,Other,100% of NY Medicaid HMO DRG,15455,,100% x Medicaid HMO amount,15455,Other,100% of NY Medicaid HMO DRG,15455,,100% x Medicaid HMO amount,15455,Other,100% of NY Medicaid HMO DRG,15455,,100% x Medicaid HMO amount,15455,Other,100% of NY Medicaid HMO DRG,34774,,225% x Medicaid HMO amount,34774,Other,225% of NY Medicaid HMO DRG,34774,,225% x Medicaid HMO amount,34774,Other,225% of NY Medicaid HMO DRG,34774,,225% x Medicaid HMO amount,34774,Other,225% of NY Medicaid HMO DRG,34774,,225% x Medicaid HMO amount,34774,Other,225% of NY Medicaid HMO DRG,21637,,140% x Medicaid HMO amount,21637,Other,140% of NY Medicaid HMO DRG,34774,,225% x Medicaid HMO amount,34774,Other,225% of NY Medicaid HMO DRG,42501,,275% x Medicaid HMO amount,42501,Other,275% of NY Medicaid HMO DRG,50074,,324% x Medicaid HMO amount,50074,Other,324% of NY Medicaid HMO DRG,33228,,215% x Medicaid HMO amount,33228,Other,215% of NY Medicaid HMO DRG,33228,,215% x Medicaid HMO amount,33228,Other,215% of NY Medicaid HMO DRG,19319,,125% x Medicaid HMO amount,19319,Other,125% of NY Medicaid HMO DRG,0.01,84935,
Partial thickness burns without skin graft,844-4,APR-DRG,,,,,,,,inpatient,,,955048.21,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,229237,,"45,128 x DRG weight",229237,Other,base rate x DRG weight,206312,,"40,615 x DRG weight",206312,Other,base rate x DRG weight,194852,,"38,359 x DRG weight",194852,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,74993,,186% x Medicaid HMO amount,74993,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,173101,,"34,077 x DRG weight",173101,Other,base rate x DRG weight,147139,,"28,966 x DRG weight",147139,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40319,,DRG base rate x DRG weight + capital per discharge,40319,Other,100% of NY Medicaid HMO DRG,40319,,100% x Medicaid HMO amount,40319,Other,100% of NY Medicaid HMO DRG,40319,,100% x Medicaid HMO amount,40319,Other,100% of NY Medicaid HMO DRG,40319,,100% x Medicaid HMO amount,40319,Other,100% of NY Medicaid HMO DRG,90718,,225% x Medicaid HMO amount,90718,Other,225% of NY Medicaid HMO DRG,90718,,225% x Medicaid HMO amount,90718,Other,225% of NY Medicaid HMO DRG,90718,,225% x Medicaid HMO amount,90718,Other,225% of NY Medicaid HMO DRG,90718,,225% x Medicaid HMO amount,90718,Other,225% of NY Medicaid HMO DRG,56447,,140% x Medicaid HMO amount,56447,Other,140% of NY Medicaid HMO DRG,90718,,225% x Medicaid HMO amount,90718,Other,225% of NY Medicaid HMO DRG,110877,,275% x Medicaid HMO amount,110877,Other,275% of NY Medicaid HMO DRG,130634,,324% x Medicaid HMO amount,130634,Other,324% of NY Medicaid HMO DRG,86686,,215% x Medicaid HMO amount,86686,Other,215% of NY Medicaid HMO DRG,86686,,215% x Medicaid HMO amount,86686,Other,215% of NY Medicaid HMO DRG,50399,,125% x Medicaid HMO amount,50399,Other,125% of NY Medicaid HMO DRG,0.01,229237,
"Procedure w diag of rehab, aftercare or oth contact w health service",850-1,APR-DRG,,,,,,,,inpatient,,,137324.77,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52398,,"45,128 x DRG weight",52398,Other,base rate x DRG weight,47158,,"40,615 x DRG weight",47158,Other,base rate x DRG weight,44539,,"38,359 x DRG weight",44539,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18319,,186% x Medicaid HMO amount,18319,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39567,,"34,077 x DRG weight",39567,Other,base rate x DRG weight,33632,,"28,966 x DRG weight",33632,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9849,,DRG base rate x DRG weight + capital per discharge,9849,Other,100% of NY Medicaid HMO DRG,9849,,100% x Medicaid HMO amount,9849,Other,100% of NY Medicaid HMO DRG,9849,,100% x Medicaid HMO amount,9849,Other,100% of NY Medicaid HMO DRG,7968.05,,100% x Medicaid HMO amount,7968.05,Other,100% of NY Medicaid HMO DRG,22160,,225% x Medicaid HMO amount,22160,Other,225% of NY Medicaid HMO DRG,22160,,225% x Medicaid HMO amount,22160,Other,225% of NY Medicaid HMO DRG,22160,,225% x Medicaid HMO amount,22160,Other,225% of NY Medicaid HMO DRG,22160,,225% x Medicaid HMO amount,22160,Other,225% of NY Medicaid HMO DRG,13789,,140% x Medicaid HMO amount,13789,Other,140% of NY Medicaid HMO DRG,22160,,225% x Medicaid HMO amount,22160,Other,225% of NY Medicaid HMO DRG,27085,,275% x Medicaid HMO amount,27085,Other,275% of NY Medicaid HMO DRG,31911,,324% x Medicaid HMO amount,31911,Other,324% of NY Medicaid HMO DRG,21175,,215% x Medicaid HMO amount,21175,Other,215% of NY Medicaid HMO DRG,21175,,215% x Medicaid HMO amount,21175,Other,215% of NY Medicaid HMO DRG,12311,,125% x Medicaid HMO amount,12311,Other,125% of NY Medicaid HMO DRG,0.01,52398,
"Procedure w diag of rehab, aftercare or oth contact w health service",850-2,APR-DRG,,,,,,,,inpatient,,,301169.33,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,74813,,"45,128 x DRG weight",74813,Other,base rate x DRG weight,67332,,"40,615 x DRG weight",67332,Other,base rate x DRG weight,63592,,"38,359 x DRG weight",63592,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25502,,186% x Medicaid HMO amount,25502,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56493,,"34,077 x DRG weight",56493,Other,base rate x DRG weight,48020,,"28,966 x DRG weight",48020,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13711,,DRG base rate x DRG weight + capital per discharge,13711,Other,100% of NY Medicaid HMO DRG,13711,,100% x Medicaid HMO amount,13711,Other,100% of NY Medicaid HMO DRG,13711,,100% x Medicaid HMO amount,13711,Other,100% of NY Medicaid HMO DRG,7968.05,,100% x Medicaid HMO amount,7968.05,Other,100% of NY Medicaid HMO DRG,30850,,225% x Medicaid HMO amount,30850,Other,225% of NY Medicaid HMO DRG,30850,,225% x Medicaid HMO amount,30850,Other,225% of NY Medicaid HMO DRG,30850,,225% x Medicaid HMO amount,30850,Other,225% of NY Medicaid HMO DRG,30850,,225% x Medicaid HMO amount,30850,Other,225% of NY Medicaid HMO DRG,19195,,140% x Medicaid HMO amount,19195,Other,140% of NY Medicaid HMO DRG,30850,,225% x Medicaid HMO amount,30850,Other,225% of NY Medicaid HMO DRG,37705,,275% x Medicaid HMO amount,37705,Other,275% of NY Medicaid HMO DRG,44424,,324% x Medicaid HMO amount,44424,Other,324% of NY Medicaid HMO DRG,29479,,215% x Medicaid HMO amount,29479,Other,215% of NY Medicaid HMO DRG,29479,,215% x Medicaid HMO amount,29479,Other,215% of NY Medicaid HMO DRG,17139,,125% x Medicaid HMO amount,17139,Other,125% of NY Medicaid HMO DRG,0.01,74813,
"Procedure w diag of rehab, aftercare or oth contact w health service",850-3,APR-DRG,,,,,,,,inpatient,,,530193.7,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,146093,,"45,128 x DRG weight",146093,Other,base rate x DRG weight,131483,,"40,615 x DRG weight",131483,Other,base rate x DRG weight,124180,,"38,359 x DRG weight",124180,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,48347,,186% x Medicaid HMO amount,48347,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,110317,,"34,077 x DRG weight",110317,Other,base rate x DRG weight,93772,,"28,966 x DRG weight",93772,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25993,,DRG base rate x DRG weight + capital per discharge,25993,Other,100% of NY Medicaid HMO DRG,25993,,100% x Medicaid HMO amount,25993,Other,100% of NY Medicaid HMO DRG,25993,,100% x Medicaid HMO amount,25993,Other,100% of NY Medicaid HMO DRG,7968.05,,100% x Medicaid HMO amount,7968.05,Other,100% of NY Medicaid HMO DRG,58484,,225% x Medicaid HMO amount,58484,Other,225% of NY Medicaid HMO DRG,58484,,225% x Medicaid HMO amount,58484,Other,225% of NY Medicaid HMO DRG,58484,,225% x Medicaid HMO amount,58484,Other,225% of NY Medicaid HMO DRG,58484,,225% x Medicaid HMO amount,58484,Other,225% of NY Medicaid HMO DRG,36390,,140% x Medicaid HMO amount,36390,Other,140% of NY Medicaid HMO DRG,58484,,225% x Medicaid HMO amount,58484,Other,225% of NY Medicaid HMO DRG,71481,,275% x Medicaid HMO amount,71481,Other,275% of NY Medicaid HMO DRG,84217,,324% x Medicaid HMO amount,84217,Other,324% of NY Medicaid HMO DRG,55885,,215% x Medicaid HMO amount,55885,Other,215% of NY Medicaid HMO DRG,55885,,215% x Medicaid HMO amount,55885,Other,215% of NY Medicaid HMO DRG,32491,,125% x Medicaid HMO amount,32491,Other,125% of NY Medicaid HMO DRG,0.01,146093,
"Procedure w diag of rehab, aftercare or oth contact w health service",850-4,APR-DRG,,,,,,,,inpatient,,,83883.28,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,344178,,"45,128 x DRG weight",344178,Other,base rate x DRG weight,309758,,"40,615 x DRG weight",309758,Other,base rate x DRG weight,292553,,"38,359 x DRG weight",292553,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,111829,,186% x Medicaid HMO amount,111829,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,259895,,"34,077 x DRG weight",259895,Other,base rate x DRG weight,220915,,"28,966 x DRG weight",220915,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,60123,,DRG base rate x DRG weight + capital per discharge,60123,Other,100% of NY Medicaid HMO DRG,60123,,100% x Medicaid HMO amount,60123,Other,100% of NY Medicaid HMO DRG,60123,,100% x Medicaid HMO amount,60123,Other,100% of NY Medicaid HMO DRG,7968.05,,100% x Medicaid HMO amount,7968.05,Other,100% of NY Medicaid HMO DRG,135277,,225% x Medicaid HMO amount,135277,Other,225% of NY Medicaid HMO DRG,135277,,225% x Medicaid HMO amount,135277,Other,225% of NY Medicaid HMO DRG,135277,,225% x Medicaid HMO amount,135277,Other,225% of NY Medicaid HMO DRG,135277,,225% x Medicaid HMO amount,135277,Other,225% of NY Medicaid HMO DRG,84172,,140% x Medicaid HMO amount,84172,Other,140% of NY Medicaid HMO DRG,135277,,225% x Medicaid HMO amount,135277,Other,225% of NY Medicaid HMO DRG,165338,,275% x Medicaid HMO amount,165338,Other,275% of NY Medicaid HMO DRG,194799,,324% x Medicaid HMO amount,194799,Other,324% of NY Medicaid HMO DRG,129264,,215% x Medicaid HMO amount,129264,Other,215% of NY Medicaid HMO DRG,129264,,215% x Medicaid HMO amount,129264,Other,215% of NY Medicaid HMO DRG,75154,,125% x Medicaid HMO amount,75154,Other,125% of NY Medicaid HMO DRG,0.01,344178,
Rehabilitation,860-1,APR-DRG,,,,,,,,inpatient,,,123632.66,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,69150,,"45,128 x DRG weight",69150,Other,base rate x DRG weight,62234,,"40,615 x DRG weight",62234,Other,base rate x DRG weight,58777,,"38,359 x DRG weight",58777,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23687,,186% x Medicaid HMO amount,23687,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52216,,"34,077 x DRG weight",52216,Other,base rate x DRG weight,44385,,"28,966 x DRG weight",44385,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12735,,DRG base rate x DRG weight + capital per discharge,12735,Other,100% of NY Medicaid HMO DRG,12735,,100% x Medicaid HMO amount,12735,Other,100% of NY Medicaid HMO DRG,12735,,100% x Medicaid HMO amount,12735,Other,100% of NY Medicaid HMO DRG,25497.76,,100% x Medicaid HMO amount,25497.76,Other,100% of NY Medicaid HMO DRG,28654,,225% x Medicaid HMO amount,28654,Other,225% of NY Medicaid HMO DRG,28654,,225% x Medicaid HMO amount,28654,Other,225% of NY Medicaid HMO DRG,28654,,225% x Medicaid HMO amount,28654,Other,225% of NY Medicaid HMO DRG,28654,,225% x Medicaid HMO amount,28654,Other,225% of NY Medicaid HMO DRG,17829,,140% x Medicaid HMO amount,17829,Other,140% of NY Medicaid HMO DRG,28654,,225% x Medicaid HMO amount,28654,Other,225% of NY Medicaid HMO DRG,35021,,275% x Medicaid HMO amount,35021,Other,275% of NY Medicaid HMO DRG,41261,,324% x Medicaid HMO amount,41261,Other,324% of NY Medicaid HMO DRG,27380,,215% x Medicaid HMO amount,27380,Other,215% of NY Medicaid HMO DRG,27380,,215% x Medicaid HMO amount,27380,Other,215% of NY Medicaid HMO DRG,15919,,125% x Medicaid HMO amount,15919,Other,125% of NY Medicaid HMO DRG,0.01,69150,
Rehabilitation,860-2,APR-DRG,,,,,,,,inpatient,,,147364.47,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,80955,,"45,128 x DRG weight",80955,Other,base rate x DRG weight,72859,,"40,615 x DRG weight",72859,Other,base rate x DRG weight,68812,,"38,359 x DRG weight",68812,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27472,,186% x Medicaid HMO amount,27472,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,61131,,"34,077 x DRG weight",61131,Other,base rate x DRG weight,51962,,"28,966 x DRG weight",51962,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14770,,DRG base rate x DRG weight + capital per discharge,14770,Other,100% of NY Medicaid HMO DRG,14770,,100% x Medicaid HMO amount,14770,Other,100% of NY Medicaid HMO DRG,14770,,100% x Medicaid HMO amount,14770,Other,100% of NY Medicaid HMO DRG,25497.76,,100% x Medicaid HMO amount,25497.76,Other,100% of NY Medicaid HMO DRG,33233,,225% x Medicaid HMO amount,33233,Other,225% of NY Medicaid HMO DRG,33233,,225% x Medicaid HMO amount,33233,Other,225% of NY Medicaid HMO DRG,33233,,225% x Medicaid HMO amount,33233,Other,225% of NY Medicaid HMO DRG,33233,,225% x Medicaid HMO amount,33233,Other,225% of NY Medicaid HMO DRG,20678,,140% x Medicaid HMO amount,20678,Other,140% of NY Medicaid HMO DRG,33233,,225% x Medicaid HMO amount,33233,Other,225% of NY Medicaid HMO DRG,40618,,275% x Medicaid HMO amount,40618,Other,275% of NY Medicaid HMO DRG,47855,,324% x Medicaid HMO amount,47855,Other,324% of NY Medicaid HMO DRG,31756,,215% x Medicaid HMO amount,31756,Other,215% of NY Medicaid HMO DRG,31756,,215% x Medicaid HMO amount,31756,Other,215% of NY Medicaid HMO DRG,18463,,125% x Medicaid HMO amount,18463,Other,125% of NY Medicaid HMO DRG,0.01,80955,
Rehabilitation,860-3,APR-DRG,,,,,,,,inpatient,,,194966.74,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,107053,,"45,128 x DRG weight",107053,Other,base rate x DRG weight,96347,,"40,615 x DRG weight",96347,Other,base rate x DRG weight,90995,,"38,359 x DRG weight",90995,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35835,,186% x Medicaid HMO amount,35835,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,80837,,"34,077 x DRG weight",80837,Other,base rate x DRG weight,68713,,"28,966 x DRG weight",68713,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19266,,DRG base rate x DRG weight + capital per discharge,19266,Other,100% of NY Medicaid HMO DRG,19266,,100% x Medicaid HMO amount,19266,Other,100% of NY Medicaid HMO DRG,19266,,100% x Medicaid HMO amount,19266,Other,100% of NY Medicaid HMO DRG,25497.76,,100% x Medicaid HMO amount,25497.76,Other,100% of NY Medicaid HMO DRG,43349,,225% x Medicaid HMO amount,43349,Other,225% of NY Medicaid HMO DRG,43349,,225% x Medicaid HMO amount,43349,Other,225% of NY Medicaid HMO DRG,43349,,225% x Medicaid HMO amount,43349,Other,225% of NY Medicaid HMO DRG,43349,,225% x Medicaid HMO amount,43349,Other,225% of NY Medicaid HMO DRG,26972,,140% x Medicaid HMO amount,26972,Other,140% of NY Medicaid HMO DRG,43349,,225% x Medicaid HMO amount,43349,Other,225% of NY Medicaid HMO DRG,52982,,275% x Medicaid HMO amount,52982,Other,275% of NY Medicaid HMO DRG,62422,,324% x Medicaid HMO amount,62422,Other,324% of NY Medicaid HMO DRG,41422,,215% x Medicaid HMO amount,41422,Other,215% of NY Medicaid HMO DRG,41422,,215% x Medicaid HMO amount,41422,Other,215% of NY Medicaid HMO DRG,24083,,125% x Medicaid HMO amount,24083,Other,125% of NY Medicaid HMO DRG,0.01,107053,
Rehabilitation,860-4,APR-DRG,,,,,,,,inpatient,,,318384,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,107053,,"45,128 x DRG weight",107053,Other,base rate x DRG weight,96347,,"40,615 x DRG weight",96347,Other,base rate x DRG weight,90995,,"38,359 x DRG weight",90995,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35835,,186% x Medicaid HMO amount,35835,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,80837,,"34,077 x DRG weight",80837,Other,base rate x DRG weight,68713,,"28,966 x DRG weight",68713,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19266,,DRG base rate x DRG weight + capital per discharge,19266,Other,100% of NY Medicaid HMO DRG,19266,,100% x Medicaid HMO amount,19266,Other,100% of NY Medicaid HMO DRG,19266,,100% x Medicaid HMO amount,19266,Other,100% of NY Medicaid HMO DRG,25497.76,,100% x Medicaid HMO amount,25497.76,Other,100% of NY Medicaid HMO DRG,43349,,225% x Medicaid HMO amount,43349,Other,225% of NY Medicaid HMO DRG,43349,,225% x Medicaid HMO amount,43349,Other,225% of NY Medicaid HMO DRG,43349,,225% x Medicaid HMO amount,43349,Other,225% of NY Medicaid HMO DRG,43349,,225% x Medicaid HMO amount,43349,Other,225% of NY Medicaid HMO DRG,26972,,140% x Medicaid HMO amount,26972,Other,140% of NY Medicaid HMO DRG,43349,,225% x Medicaid HMO amount,43349,Other,225% of NY Medicaid HMO DRG,52982,,275% x Medicaid HMO amount,52982,Other,275% of NY Medicaid HMO DRG,62422,,324% x Medicaid HMO amount,62422,Other,324% of NY Medicaid HMO DRG,41422,,215% x Medicaid HMO amount,41422,Other,215% of NY Medicaid HMO DRG,41422,,215% x Medicaid HMO amount,41422,Other,215% of NY Medicaid HMO DRG,24083,,125% x Medicaid HMO amount,24083,Other,125% of NY Medicaid HMO DRG,0.01,107053,
"Signs, symptoms & other factors influencing health status",861-1,APR-DRG,,,,,,,,inpatient,,,66129.84,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20317,,"45,128 x DRG weight",20317,Other,base rate x DRG weight,18285,,"40,615 x DRG weight",18285,Other,base rate x DRG weight,17269,,"38,359 x DRG weight",17269,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8037,,186% x Medicaid HMO amount,8037,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15341,,"34,077 x DRG weight",15341,Other,base rate x DRG weight,13040,,"28,966 x DRG weight",13040,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4321,,DRG base rate x DRG weight + capital per discharge,4321,Other,100% of NY Medicaid HMO DRG,4321,,100% x Medicaid HMO amount,4321,Other,100% of NY Medicaid HMO DRG,4321,,100% x Medicaid HMO amount,4321,Other,100% of NY Medicaid HMO DRG,4321,,100% x Medicaid HMO amount,4321,Other,100% of NY Medicaid HMO DRG,9722,,225% x Medicaid HMO amount,9722,Other,225% of NY Medicaid HMO DRG,9722,,225% x Medicaid HMO amount,9722,Other,225% of NY Medicaid HMO DRG,9722,,225% x Medicaid HMO amount,9722,Other,225% of NY Medicaid HMO DRG,9722,,225% x Medicaid HMO amount,9722,Other,225% of NY Medicaid HMO DRG,6049,,140% x Medicaid HMO amount,6049,Other,140% of NY Medicaid HMO DRG,9722,,225% x Medicaid HMO amount,9722,Other,225% of NY Medicaid HMO DRG,11883,,275% x Medicaid HMO amount,11883,Other,275% of NY Medicaid HMO DRG,14000,,324% x Medicaid HMO amount,14000,Other,324% of NY Medicaid HMO DRG,9290,,215% x Medicaid HMO amount,9290,Other,215% of NY Medicaid HMO DRG,9290,,215% x Medicaid HMO amount,9290,Other,215% of NY Medicaid HMO DRG,5401,,125% x Medicaid HMO amount,5401,Other,125% of NY Medicaid HMO DRG,0.01,20317,
"Signs, symptoms & other factors influencing health status",861-2,APR-DRG,,,,,,,,inpatient,,,119714.86,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28444,,"45,128 x DRG weight",28444,Other,base rate x DRG weight,25600,,"40,615 x DRG weight",25600,Other,base rate x DRG weight,24178,,"38,359 x DRG weight",24178,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10643,,186% x Medicaid HMO amount,10643,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21479,,"34,077 x DRG weight",21479,Other,base rate x DRG weight,18257,,"28,966 x DRG weight",18257,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5722,,DRG base rate x DRG weight + capital per discharge,5722,Other,100% of NY Medicaid HMO DRG,5722,,100% x Medicaid HMO amount,5722,Other,100% of NY Medicaid HMO DRG,5722,,100% x Medicaid HMO amount,5722,Other,100% of NY Medicaid HMO DRG,5722,,100% x Medicaid HMO amount,5722,Other,100% of NY Medicaid HMO DRG,12875,,225% x Medicaid HMO amount,12875,Other,225% of NY Medicaid HMO DRG,12875,,225% x Medicaid HMO amount,12875,Other,225% of NY Medicaid HMO DRG,12875,,225% x Medicaid HMO amount,12875,Other,225% of NY Medicaid HMO DRG,12875,,225% x Medicaid HMO amount,12875,Other,225% of NY Medicaid HMO DRG,8011,,140% x Medicaid HMO amount,8011,Other,140% of NY Medicaid HMO DRG,12875,,225% x Medicaid HMO amount,12875,Other,225% of NY Medicaid HMO DRG,15736,,275% x Medicaid HMO amount,15736,Other,275% of NY Medicaid HMO DRG,18539,,324% x Medicaid HMO amount,18539,Other,324% of NY Medicaid HMO DRG,12302,,215% x Medicaid HMO amount,12302,Other,215% of NY Medicaid HMO DRG,12302,,215% x Medicaid HMO amount,12302,Other,215% of NY Medicaid HMO DRG,7153,,125% x Medicaid HMO amount,7153,Other,125% of NY Medicaid HMO DRG,0.01,28444,
"Signs, symptoms & other factors influencing health status",861-3,APR-DRG,,,,,,,,inpatient,,,152104.95,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47736,,"45,128 x DRG weight",47736,Other,base rate x DRG weight,42963,,"40,615 x DRG weight",42963,Other,base rate x DRG weight,40576,,"38,359 x DRG weight",40576,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,16826,,186% x Medicaid HMO amount,16826,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36047,,"34,077 x DRG weight",36047,Other,base rate x DRG weight,30640,,"28,966 x DRG weight",30640,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9046,,DRG base rate x DRG weight + capital per discharge,9046,Other,100% of NY Medicaid HMO DRG,9046,,100% x Medicaid HMO amount,9046,Other,100% of NY Medicaid HMO DRG,9046,,100% x Medicaid HMO amount,9046,Other,100% of NY Medicaid HMO DRG,9046,,100% x Medicaid HMO amount,9046,Other,100% of NY Medicaid HMO DRG,20354,,225% x Medicaid HMO amount,20354,Other,225% of NY Medicaid HMO DRG,20354,,225% x Medicaid HMO amount,20354,Other,225% of NY Medicaid HMO DRG,20354,,225% x Medicaid HMO amount,20354,Other,225% of NY Medicaid HMO DRG,20354,,225% x Medicaid HMO amount,20354,Other,225% of NY Medicaid HMO DRG,12664,,140% x Medicaid HMO amount,12664,Other,140% of NY Medicaid HMO DRG,20354,,225% x Medicaid HMO amount,20354,Other,225% of NY Medicaid HMO DRG,24877,,275% x Medicaid HMO amount,24877,Other,275% of NY Medicaid HMO DRG,29309,,324% x Medicaid HMO amount,29309,Other,324% of NY Medicaid HMO DRG,19449,,215% x Medicaid HMO amount,19449,Other,215% of NY Medicaid HMO DRG,19449,,215% x Medicaid HMO amount,19449,Other,215% of NY Medicaid HMO DRG,11308,,125% x Medicaid HMO amount,11308,Other,125% of NY Medicaid HMO DRG,0.01,47736,
"Signs, symptoms & other factors influencing health status",861-4,APR-DRG,,,,,,,,inpatient,,,398249,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,94327,,"45,128 x DRG weight",94327,Other,base rate x DRG weight,84893,,"40,615 x DRG weight",84893,Other,base rate x DRG weight,80178,,"38,359 x DRG weight",80178,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31756,,186% x Medicaid HMO amount,31756,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,71228,,"34,077 x DRG weight",71228,Other,base rate x DRG weight,60545,,"28,966 x DRG weight",60545,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17073,,DRG base rate x DRG weight + capital per discharge,17073,Other,100% of NY Medicaid HMO DRG,17073,,100% x Medicaid HMO amount,17073,Other,100% of NY Medicaid HMO DRG,17073,,100% x Medicaid HMO amount,17073,Other,100% of NY Medicaid HMO DRG,17073,,100% x Medicaid HMO amount,17073,Other,100% of NY Medicaid HMO DRG,38414,,225% x Medicaid HMO amount,38414,Other,225% of NY Medicaid HMO DRG,38414,,225% x Medicaid HMO amount,38414,Other,225% of NY Medicaid HMO DRG,38414,,225% x Medicaid HMO amount,38414,Other,225% of NY Medicaid HMO DRG,38414,,225% x Medicaid HMO amount,38414,Other,225% of NY Medicaid HMO DRG,23902,,140% x Medicaid HMO amount,23902,Other,140% of NY Medicaid HMO DRG,38414,,225% x Medicaid HMO amount,38414,Other,225% of NY Medicaid HMO DRG,46951,,275% x Medicaid HMO amount,46951,Other,275% of NY Medicaid HMO DRG,55317,,324% x Medicaid HMO amount,55317,Other,324% of NY Medicaid HMO DRG,36707,,215% x Medicaid HMO amount,36707,Other,215% of NY Medicaid HMO DRG,36707,,215% x Medicaid HMO amount,36707,Other,215% of NY Medicaid HMO DRG,21341,,125% x Medicaid HMO amount,21341,Other,125% of NY Medicaid HMO DRG,0.01,94327,
Other aftercare & convalescence,862-1,APR-DRG,,,,,,,,inpatient,,,69762.46,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,23110,,"45,128 x DRG weight",23110,Other,base rate x DRG weight,20799,,"40,615 x DRG weight",20799,Other,base rate x DRG weight,19644,,"38,359 x DRG weight",19644,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8934,,186% x Medicaid HMO amount,8934,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17451,,"34,077 x DRG weight",17451,Other,base rate x DRG weight,14833,,"28,966 x DRG weight",14833,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,4803,,DRG base rate x DRG weight + capital per discharge,4803,Other,100% of NY Medicaid HMO DRG,4803,,100% x Medicaid HMO amount,4803,Other,100% of NY Medicaid HMO DRG,4803,,100% x Medicaid HMO amount,4803,Other,100% of NY Medicaid HMO DRG,4780.83,,100% x Medicaid HMO amount,4780.83,Other,100% of NY Medicaid HMO DRG,10807,,225% x Medicaid HMO amount,10807,Other,225% of NY Medicaid HMO DRG,10807,,225% x Medicaid HMO amount,10807,Other,225% of NY Medicaid HMO DRG,10807,,225% x Medicaid HMO amount,10807,Other,225% of NY Medicaid HMO DRG,10807,,225% x Medicaid HMO amount,10807,Other,225% of NY Medicaid HMO DRG,6724,,140% x Medicaid HMO amount,6724,Other,140% of NY Medicaid HMO DRG,10807,,225% x Medicaid HMO amount,10807,Other,225% of NY Medicaid HMO DRG,13208,,275% x Medicaid HMO amount,13208,Other,275% of NY Medicaid HMO DRG,15562,,324% x Medicaid HMO amount,15562,Other,324% of NY Medicaid HMO DRG,10326,,215% x Medicaid HMO amount,10326,Other,215% of NY Medicaid HMO DRG,10326,,215% x Medicaid HMO amount,10326,Other,215% of NY Medicaid HMO DRG,6004,,125% x Medicaid HMO amount,6004,Other,125% of NY Medicaid HMO DRG,0.01,23110,
Other aftercare & convalescence,862-2,APR-DRG,,,,,,,,inpatient,,,101967.93,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33106,,"45,128 x DRG weight",33106,Other,base rate x DRG weight,29795,,"40,615 x DRG weight",29795,Other,base rate x DRG weight,28140,,"38,359 x DRG weight",28140,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12137,,186% x Medicaid HMO amount,12137,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24999,,"34,077 x DRG weight",24999,Other,base rate x DRG weight,21249,,"28,966 x DRG weight",21249,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6525,,DRG base rate x DRG weight + capital per discharge,6525,Other,100% of NY Medicaid HMO DRG,6525,,100% x Medicaid HMO amount,6525,Other,100% of NY Medicaid HMO DRG,6525,,100% x Medicaid HMO amount,6525,Other,100% of NY Medicaid HMO DRG,4780.83,,100% x Medicaid HMO amount,4780.83,Other,100% of NY Medicaid HMO DRG,14681,,225% x Medicaid HMO amount,14681,Other,225% of NY Medicaid HMO DRG,14681,,225% x Medicaid HMO amount,14681,Other,225% of NY Medicaid HMO DRG,14681,,225% x Medicaid HMO amount,14681,Other,225% of NY Medicaid HMO DRG,14681,,225% x Medicaid HMO amount,14681,Other,225% of NY Medicaid HMO DRG,9135,,140% x Medicaid HMO amount,9135,Other,140% of NY Medicaid HMO DRG,14681,,225% x Medicaid HMO amount,14681,Other,225% of NY Medicaid HMO DRG,17944,,275% x Medicaid HMO amount,17944,Other,275% of NY Medicaid HMO DRG,21141,,324% x Medicaid HMO amount,21141,Other,324% of NY Medicaid HMO DRG,14029,,215% x Medicaid HMO amount,14029,Other,215% of NY Medicaid HMO DRG,14029,,215% x Medicaid HMO amount,14029,Other,215% of NY Medicaid HMO DRG,8156,,125% x Medicaid HMO amount,8156,Other,125% of NY Medicaid HMO DRG,0.01,33106,
Other aftercare & convalescence,862-3,APR-DRG,,,,,,,,inpatient,,,100262,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55431,,"45,128 x DRG weight",55431,Other,base rate x DRG weight,49887,,"40,615 x DRG weight",49887,Other,base rate x DRG weight,47116,,"38,359 x DRG weight",47116,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19292,,186% x Medicaid HMO amount,19292,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41857,,"34,077 x DRG weight",41857,Other,base rate x DRG weight,35579,,"28,966 x DRG weight",35579,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10372,,DRG base rate x DRG weight + capital per discharge,10372,Other,100% of NY Medicaid HMO DRG,10372,,100% x Medicaid HMO amount,10372,Other,100% of NY Medicaid HMO DRG,10372,,100% x Medicaid HMO amount,10372,Other,100% of NY Medicaid HMO DRG,4780.83,,100% x Medicaid HMO amount,4780.83,Other,100% of NY Medicaid HMO DRG,23337,,225% x Medicaid HMO amount,23337,Other,225% of NY Medicaid HMO DRG,23337,,225% x Medicaid HMO amount,23337,Other,225% of NY Medicaid HMO DRG,23337,,225% x Medicaid HMO amount,23337,Other,225% of NY Medicaid HMO DRG,23337,,225% x Medicaid HMO amount,23337,Other,225% of NY Medicaid HMO DRG,14521,,140% x Medicaid HMO amount,14521,Other,140% of NY Medicaid HMO DRG,23337,,225% x Medicaid HMO amount,23337,Other,225% of NY Medicaid HMO DRG,28523,,275% x Medicaid HMO amount,28523,Other,275% of NY Medicaid HMO DRG,33605,,324% x Medicaid HMO amount,33605,Other,324% of NY Medicaid HMO DRG,22300,,215% x Medicaid HMO amount,22300,Other,215% of NY Medicaid HMO DRG,22300,,215% x Medicaid HMO amount,22300,Other,215% of NY Medicaid HMO DRG,12965,,125% x Medicaid HMO amount,12965,Other,125% of NY Medicaid HMO DRG,0.01,55431,
Other aftercare & convalescence,862-4,APR-DRG,,,,,,,,inpatient,,,336749,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,96687,,"45,128 x DRG weight",96687,Other,base rate x DRG weight,87018,,"40,615 x DRG weight",87018,Other,base rate x DRG weight,82184,,"38,359 x DRG weight",82184,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32513,,186% x Medicaid HMO amount,32513,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73010,,"34,077 x DRG weight",73010,Other,base rate x DRG weight,62060,,"28,966 x DRG weight",62060,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17480,,DRG base rate x DRG weight + capital per discharge,17480,Other,100% of NY Medicaid HMO DRG,17480,,100% x Medicaid HMO amount,17480,Other,100% of NY Medicaid HMO DRG,17480,,100% x Medicaid HMO amount,17480,Other,100% of NY Medicaid HMO DRG,4780.83,,100% x Medicaid HMO amount,4780.83,Other,100% of NY Medicaid HMO DRG,39330,,225% x Medicaid HMO amount,39330,Other,225% of NY Medicaid HMO DRG,39330,,225% x Medicaid HMO amount,39330,Other,225% of NY Medicaid HMO DRG,39330,,225% x Medicaid HMO amount,39330,Other,225% of NY Medicaid HMO DRG,39330,,225% x Medicaid HMO amount,39330,Other,225% of NY Medicaid HMO DRG,24472,,140% x Medicaid HMO amount,24472,Other,140% of NY Medicaid HMO DRG,39330,,225% x Medicaid HMO amount,39330,Other,225% of NY Medicaid HMO DRG,48070,,275% x Medicaid HMO amount,48070,Other,275% of NY Medicaid HMO DRG,56635,,324% x Medicaid HMO amount,56635,Other,324% of NY Medicaid HMO DRG,37582,,215% x Medicaid HMO amount,37582,Other,215% of NY Medicaid HMO DRG,37582,,215% x Medicaid HMO amount,37582,Other,215% of NY Medicaid HMO DRG,21850,,125% x Medicaid HMO amount,21850,Other,125% of NY Medicaid HMO DRG,0.01,96687,
Neonatal aftercare,863-1,APR-DRG,,,,,,,,inpatient,,,54897,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41089,,"45,128 x DRG weight",41089,Other,base rate x DRG weight,36980,,"40,615 x DRG weight",36980,Other,base rate x DRG weight,34926,,"38,359 x DRG weight",34926,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14696,,186% x Medicaid HMO amount,14696,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31027,,"34,077 x DRG weight",31027,Other,base rate x DRG weight,26374,,"28,966 x DRG weight",26374,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7901,,DRG base rate x DRG weight + capital per discharge,7901,Other,100% of NY Medicaid HMO DRG,7901,,100% x Medicaid HMO amount,7901,Other,100% of NY Medicaid HMO DRG,7901,,100% x Medicaid HMO amount,7901,Other,100% of NY Medicaid HMO DRG,7901,,100% x Medicaid HMO amount,7901,Other,100% of NY Medicaid HMO DRG,17777,,225% x Medicaid HMO amount,17777,Other,225% of NY Medicaid HMO DRG,17777,,225% x Medicaid HMO amount,17777,Other,225% of NY Medicaid HMO DRG,17777,,225% x Medicaid HMO amount,17777,Other,225% of NY Medicaid HMO DRG,17777,,225% x Medicaid HMO amount,17777,Other,225% of NY Medicaid HMO DRG,11061,,140% x Medicaid HMO amount,11061,Other,140% of NY Medicaid HMO DRG,17777,,225% x Medicaid HMO amount,17777,Other,225% of NY Medicaid HMO DRG,21728,,275% x Medicaid HMO amount,21728,Other,275% of NY Medicaid HMO DRG,25599,,324% x Medicaid HMO amount,25599,Other,324% of NY Medicaid HMO DRG,16987,,215% x Medicaid HMO amount,16987,Other,215% of NY Medicaid HMO DRG,16987,,215% x Medicaid HMO amount,16987,Other,215% of NY Medicaid HMO DRG,9876,,125% x Medicaid HMO amount,9876,Other,125% of NY Medicaid HMO DRG,0.01,41089,
Neonatal aftercare,863-2,APR-DRG,,,,,,,,inpatient,,,54897,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,98794,,"45,128 x DRG weight",98794,Other,base rate x DRG weight,88914,,"40,615 x DRG weight",88914,Other,base rate x DRG weight,83976,,"38,359 x DRG weight",83976,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33188,,186% x Medicaid HMO amount,33188,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,74601,,"34,077 x DRG weight",74601,Other,base rate x DRG weight,63412,,"28,966 x DRG weight",63412,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17843,,DRG base rate x DRG weight + capital per discharge,17843,Other,100% of NY Medicaid HMO DRG,17843,,100% x Medicaid HMO amount,17843,Other,100% of NY Medicaid HMO DRG,17843,,100% x Medicaid HMO amount,17843,Other,100% of NY Medicaid HMO DRG,17843,,100% x Medicaid HMO amount,17843,Other,100% of NY Medicaid HMO DRG,40147,,225% x Medicaid HMO amount,40147,Other,225% of NY Medicaid HMO DRG,40147,,225% x Medicaid HMO amount,40147,Other,225% of NY Medicaid HMO DRG,40147,,225% x Medicaid HMO amount,40147,Other,225% of NY Medicaid HMO DRG,40147,,225% x Medicaid HMO amount,40147,Other,225% of NY Medicaid HMO DRG,24980,,140% x Medicaid HMO amount,24980,Other,140% of NY Medicaid HMO DRG,40147,,225% x Medicaid HMO amount,40147,Other,225% of NY Medicaid HMO DRG,49068,,275% x Medicaid HMO amount,49068,Other,275% of NY Medicaid HMO DRG,57811,,324% x Medicaid HMO amount,57811,Other,324% of NY Medicaid HMO DRG,38362,,215% x Medicaid HMO amount,38362,Other,215% of NY Medicaid HMO DRG,38362,,215% x Medicaid HMO amount,38362,Other,215% of NY Medicaid HMO DRG,22304,,125% x Medicaid HMO amount,22304,Other,125% of NY Medicaid HMO DRG,0.01,98794,
Neonatal aftercare,863-3,APR-DRG,,,,,,,,inpatient,,,1325617.15,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,187349,,"45,128 x DRG weight",187349,Other,base rate x DRG weight,168613,,"40,615 x DRG weight",168613,Other,base rate x DRG weight,159247,,"38,359 x DRG weight",159247,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,61568,,186% x Medicaid HMO amount,61568,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,141471,,"34,077 x DRG weight",141471,Other,base rate x DRG weight,120252,,"28,966 x DRG weight",120252,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,33101,,DRG base rate x DRG weight + capital per discharge,33101,Other,100% of NY Medicaid HMO DRG,33101,,100% x Medicaid HMO amount,33101,Other,100% of NY Medicaid HMO DRG,33101,,100% x Medicaid HMO amount,33101,Other,100% of NY Medicaid HMO DRG,33101,,100% x Medicaid HMO amount,33101,Other,100% of NY Medicaid HMO DRG,74477,,225% x Medicaid HMO amount,74477,Other,225% of NY Medicaid HMO DRG,74477,,225% x Medicaid HMO amount,74477,Other,225% of NY Medicaid HMO DRG,74477,,225% x Medicaid HMO amount,74477,Other,225% of NY Medicaid HMO DRG,74477,,225% x Medicaid HMO amount,74477,Other,225% of NY Medicaid HMO DRG,46341,,140% x Medicaid HMO amount,46341,Other,140% of NY Medicaid HMO DRG,74477,,225% x Medicaid HMO amount,74477,Other,225% of NY Medicaid HMO DRG,91028,,275% x Medicaid HMO amount,91028,Other,275% of NY Medicaid HMO DRG,107247,,324% x Medicaid HMO amount,107247,Other,324% of NY Medicaid HMO DRG,71167,,215% x Medicaid HMO amount,71167,Other,215% of NY Medicaid HMO DRG,71167,,215% x Medicaid HMO amount,71167,Other,215% of NY Medicaid HMO DRG,41376,,125% x Medicaid HMO amount,41376,Other,125% of NY Medicaid HMO DRG,0.01,187349,
Neonatal aftercare,863-4,APR-DRG,,,,,,,,inpatient,,,160075,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,239133,,"45,128 x DRG weight",239133,Other,base rate x DRG weight,215219,,"40,615 x DRG weight",215219,Other,base rate x DRG weight,203264,,"38,359 x DRG weight",203264,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,78165,,186% x Medicaid HMO amount,78165,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,180574,,"34,077 x DRG weight",180574,Other,base rate x DRG weight,153491,,"28,966 x DRG weight",153491,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42024,,DRG base rate x DRG weight + capital per discharge,42024,Other,100% of NY Medicaid HMO DRG,42024,,100% x Medicaid HMO amount,42024,Other,100% of NY Medicaid HMO DRG,42024,,100% x Medicaid HMO amount,42024,Other,100% of NY Medicaid HMO DRG,42024,,100% x Medicaid HMO amount,42024,Other,100% of NY Medicaid HMO DRG,94554,,225% x Medicaid HMO amount,94554,Other,225% of NY Medicaid HMO DRG,94554,,225% x Medicaid HMO amount,94554,Other,225% of NY Medicaid HMO DRG,94554,,225% x Medicaid HMO amount,94554,Other,225% of NY Medicaid HMO DRG,94554,,225% x Medicaid HMO amount,94554,Other,225% of NY Medicaid HMO DRG,58834,,140% x Medicaid HMO amount,58834,Other,140% of NY Medicaid HMO DRG,94554,,225% x Medicaid HMO amount,94554,Other,225% of NY Medicaid HMO DRG,115566,,275% x Medicaid HMO amount,115566,Other,275% of NY Medicaid HMO DRG,136158,,324% x Medicaid HMO amount,136158,Other,324% of NY Medicaid HMO DRG,90352,,215% x Medicaid HMO amount,90352,Other,215% of NY Medicaid HMO DRG,90352,,215% x Medicaid HMO amount,90352,Other,215% of NY Medicaid HMO DRG,52530,,125% x Medicaid HMO amount,52530,Other,125% of NY Medicaid HMO DRG,0.01,239133,
HIV w multiple major HIV related conditions,890-1,APR-DRG,,,,,,,,inpatient,,,160075,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50250,,"45,128 x DRG weight",50250,Other,base rate x DRG weight,45225,,"40,615 x DRG weight",45225,Other,base rate x DRG weight,42713,,"38,359 x DRG weight",42713,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17631,,186% x Medicaid HMO amount,17631,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37945,,"34,077 x DRG weight",37945,Other,base rate x DRG weight,32254,,"28,966 x DRG weight",32254,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9479,,DRG base rate x DRG weight + capital per discharge,9479,Other,100% of NY Medicaid HMO DRG,9479,,100% x Medicaid HMO amount,9479,Other,100% of NY Medicaid HMO DRG,9479,,100% x Medicaid HMO amount,9479,Other,100% of NY Medicaid HMO DRG,9479,,100% x Medicaid HMO amount,9479,Other,100% of NY Medicaid HMO DRG,21328,,225% x Medicaid HMO amount,21328,Other,225% of NY Medicaid HMO DRG,21328,,225% x Medicaid HMO amount,21328,Other,225% of NY Medicaid HMO DRG,21328,,225% x Medicaid HMO amount,21328,Other,225% of NY Medicaid HMO DRG,21328,,225% x Medicaid HMO amount,21328,Other,225% of NY Medicaid HMO DRG,13271,,140% x Medicaid HMO amount,13271,Other,140% of NY Medicaid HMO DRG,21328,,225% x Medicaid HMO amount,21328,Other,225% of NY Medicaid HMO DRG,26067,,275% x Medicaid HMO amount,26067,Other,275% of NY Medicaid HMO DRG,30712,,324% x Medicaid HMO amount,30712,Other,324% of NY Medicaid HMO DRG,20380,,215% x Medicaid HMO amount,20380,Other,215% of NY Medicaid HMO DRG,20380,,215% x Medicaid HMO amount,20380,Other,215% of NY Medicaid HMO DRG,11849,,125% x Medicaid HMO amount,11849,Other,125% of NY Medicaid HMO DRG,0.01,50250,
HIV w multiple major HIV related conditions,890-2,APR-DRG,,,,,,,,inpatient,,,160075,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50322,,"45,128 x DRG weight",50322,Other,base rate x DRG weight,45290,,"40,615 x DRG weight",45290,Other,base rate x DRG weight,42774,,"38,359 x DRG weight",42774,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17653,,186% x Medicaid HMO amount,17653,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,37999,,"34,077 x DRG weight",37999,Other,base rate x DRG weight,32300,,"28,966 x DRG weight",32300,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9491,,DRG base rate x DRG weight + capital per discharge,9491,Other,100% of NY Medicaid HMO DRG,9491,,100% x Medicaid HMO amount,9491,Other,100% of NY Medicaid HMO DRG,9491,,100% x Medicaid HMO amount,9491,Other,100% of NY Medicaid HMO DRG,9491,,100% x Medicaid HMO amount,9491,Other,100% of NY Medicaid HMO DRG,21355,,225% x Medicaid HMO amount,21355,Other,225% of NY Medicaid HMO DRG,21355,,225% x Medicaid HMO amount,21355,Other,225% of NY Medicaid HMO DRG,21355,,225% x Medicaid HMO amount,21355,Other,225% of NY Medicaid HMO DRG,21355,,225% x Medicaid HMO amount,21355,Other,225% of NY Medicaid HMO DRG,13287,,140% x Medicaid HMO amount,13287,Other,140% of NY Medicaid HMO DRG,21355,,225% x Medicaid HMO amount,21355,Other,225% of NY Medicaid HMO DRG,26100,,275% x Medicaid HMO amount,26100,Other,275% of NY Medicaid HMO DRG,30751,,324% x Medicaid HMO amount,30751,Other,324% of NY Medicaid HMO DRG,20406,,215% x Medicaid HMO amount,20406,Other,215% of NY Medicaid HMO DRG,20406,,215% x Medicaid HMO amount,20406,Other,215% of NY Medicaid HMO DRG,11864,,125% x Medicaid HMO amount,11864,Other,125% of NY Medicaid HMO DRG,0.01,50322,
HIV w multiple major HIV related conditions,890-3,APR-DRG,,,,,,,,inpatient,,,192976.57,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,86917,,"45,128 x DRG weight",86917,Other,base rate x DRG weight,78224,,"40,615 x DRG weight",78224,Other,base rate x DRG weight,73879,,"38,359 x DRG weight",73879,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29382,,186% x Medicaid HMO amount,29382,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,65632,,"34,077 x DRG weight",65632,Other,base rate x DRG weight,55789,,"28,966 x DRG weight",55789,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15797,,DRG base rate x DRG weight + capital per discharge,15797,Other,100% of NY Medicaid HMO DRG,15797,,100% x Medicaid HMO amount,15797,Other,100% of NY Medicaid HMO DRG,15797,,100% x Medicaid HMO amount,15797,Other,100% of NY Medicaid HMO DRG,15797,,100% x Medicaid HMO amount,15797,Other,100% of NY Medicaid HMO DRG,35543,,225% x Medicaid HMO amount,35543,Other,225% of NY Medicaid HMO DRG,35543,,225% x Medicaid HMO amount,35543,Other,225% of NY Medicaid HMO DRG,35543,,225% x Medicaid HMO amount,35543,Other,225% of NY Medicaid HMO DRG,35543,,225% x Medicaid HMO amount,35543,Other,225% of NY Medicaid HMO DRG,22116,,140% x Medicaid HMO amount,22116,Other,140% of NY Medicaid HMO DRG,35543,,225% x Medicaid HMO amount,35543,Other,225% of NY Medicaid HMO DRG,43442,,275% x Medicaid HMO amount,43442,Other,275% of NY Medicaid HMO DRG,51182,,324% x Medicaid HMO amount,51182,Other,324% of NY Medicaid HMO DRG,33964,,215% x Medicaid HMO amount,33964,Other,215% of NY Medicaid HMO DRG,33964,,215% x Medicaid HMO amount,33964,Other,215% of NY Medicaid HMO DRG,19746,,125% x Medicaid HMO amount,19746,Other,125% of NY Medicaid HMO DRG,0.01,86917,
HIV w multiple major HIV related conditions,890-4,APR-DRG,,,,,,,,inpatient,,,1536016.66,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,170877,,"45,128 x DRG weight",170877,Other,base rate x DRG weight,153789,,"40,615 x DRG weight",153789,Other,base rate x DRG weight,145246,,"38,359 x DRG weight",145246,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56289,,186% x Medicaid HMO amount,56289,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,129033,,"34,077 x DRG weight",129033,Other,base rate x DRG weight,109680,,"28,966 x DRG weight",109680,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30263,,DRG base rate x DRG weight + capital per discharge,30263,Other,100% of NY Medicaid HMO DRG,30263,,100% x Medicaid HMO amount,30263,Other,100% of NY Medicaid HMO DRG,30263,,100% x Medicaid HMO amount,30263,Other,100% of NY Medicaid HMO DRG,30263,,100% x Medicaid HMO amount,30263,Other,100% of NY Medicaid HMO DRG,68092,,225% x Medicaid HMO amount,68092,Other,225% of NY Medicaid HMO DRG,68092,,225% x Medicaid HMO amount,68092,Other,225% of NY Medicaid HMO DRG,68092,,225% x Medicaid HMO amount,68092,Other,225% of NY Medicaid HMO DRG,68092,,225% x Medicaid HMO amount,68092,Other,225% of NY Medicaid HMO DRG,42368,,140% x Medicaid HMO amount,42368,Other,140% of NY Medicaid HMO DRG,68092,,225% x Medicaid HMO amount,68092,Other,225% of NY Medicaid HMO DRG,83223,,275% x Medicaid HMO amount,83223,Other,275% of NY Medicaid HMO DRG,98052,,324% x Medicaid HMO amount,98052,Other,324% of NY Medicaid HMO DRG,65065,,215% x Medicaid HMO amount,65065,Other,215% of NY Medicaid HMO DRG,65065,,215% x Medicaid HMO amount,65065,Other,215% of NY Medicaid HMO DRG,37829,,125% x Medicaid HMO amount,37829,Other,125% of NY Medicaid HMO DRG,0.01,170877,
HIV w major HIV related condition,892-1,APR-DRG,,,,,,,,inpatient,,,136575.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32497,,"45,128 x DRG weight",32497,Other,base rate x DRG weight,29247,,"40,615 x DRG weight",29247,Other,base rate x DRG weight,27622,,"38,359 x DRG weight",27622,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11941,,186% x Medicaid HMO amount,11941,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24539,,"34,077 x DRG weight",24539,Other,base rate x DRG weight,20858,,"28,966 x DRG weight",20858,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6420,,DRG base rate x DRG weight + capital per discharge,6420,Other,100% of NY Medicaid HMO DRG,6420,,100% x Medicaid HMO amount,6420,Other,100% of NY Medicaid HMO DRG,6420,,100% x Medicaid HMO amount,6420,Other,100% of NY Medicaid HMO DRG,6420,,100% x Medicaid HMO amount,6420,Other,100% of NY Medicaid HMO DRG,14445,,225% x Medicaid HMO amount,14445,Other,225% of NY Medicaid HMO DRG,14445,,225% x Medicaid HMO amount,14445,Other,225% of NY Medicaid HMO DRG,14445,,225% x Medicaid HMO amount,14445,Other,225% of NY Medicaid HMO DRG,14445,,225% x Medicaid HMO amount,14445,Other,225% of NY Medicaid HMO DRG,8988,,140% x Medicaid HMO amount,8988,Other,140% of NY Medicaid HMO DRG,14445,,225% x Medicaid HMO amount,14445,Other,225% of NY Medicaid HMO DRG,17655,,275% x Medicaid HMO amount,17655,Other,275% of NY Medicaid HMO DRG,20801,,324% x Medicaid HMO amount,20801,Other,324% of NY Medicaid HMO DRG,13803,,215% x Medicaid HMO amount,13803,Other,215% of NY Medicaid HMO DRG,13803,,215% x Medicaid HMO amount,13803,Other,215% of NY Medicaid HMO DRG,8025,,125% x Medicaid HMO amount,8025,Other,125% of NY Medicaid HMO DRG,0.01,32497,
HIV w major HIV related condition,892-2,APR-DRG,,,,,,,,inpatient,,,136575.41,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,42109,,"45,128 x DRG weight",42109,Other,base rate x DRG weight,37898,,"40,615 x DRG weight",37898,Other,base rate x DRG weight,35793,,"38,359 x DRG weight",35793,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15021,,186% x Medicaid HMO amount,15021,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31797,,"34,077 x DRG weight",31797,Other,base rate x DRG weight,27028,,"28,966 x DRG weight",27028,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8076,,DRG base rate x DRG weight + capital per discharge,8076,Other,100% of NY Medicaid HMO DRG,8076,,100% x Medicaid HMO amount,8076,Other,100% of NY Medicaid HMO DRG,8076,,100% x Medicaid HMO amount,8076,Other,100% of NY Medicaid HMO DRG,8076,,100% x Medicaid HMO amount,8076,Other,100% of NY Medicaid HMO DRG,18171,,225% x Medicaid HMO amount,18171,Other,225% of NY Medicaid HMO DRG,18171,,225% x Medicaid HMO amount,18171,Other,225% of NY Medicaid HMO DRG,18171,,225% x Medicaid HMO amount,18171,Other,225% of NY Medicaid HMO DRG,18171,,225% x Medicaid HMO amount,18171,Other,225% of NY Medicaid HMO DRG,11306,,140% x Medicaid HMO amount,11306,Other,140% of NY Medicaid HMO DRG,18171,,225% x Medicaid HMO amount,18171,Other,225% of NY Medicaid HMO DRG,22209,,275% x Medicaid HMO amount,22209,Other,275% of NY Medicaid HMO DRG,26166,,324% x Medicaid HMO amount,26166,Other,324% of NY Medicaid HMO DRG,17363,,215% x Medicaid HMO amount,17363,Other,215% of NY Medicaid HMO DRG,17363,,215% x Medicaid HMO amount,17363,Other,215% of NY Medicaid HMO DRG,10095,,125% x Medicaid HMO amount,10095,Other,125% of NY Medicaid HMO DRG,0.01,42109,
HIV w major HIV related condition,892-3,APR-DRG,,,,,,,,inpatient,,,238101.74,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59095,,"45,128 x DRG weight",59095,Other,base rate x DRG weight,53185,,"40,615 x DRG weight",53185,Other,base rate x DRG weight,50231,,"38,359 x DRG weight",50231,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20466,,186% x Medicaid HMO amount,20466,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,44624,,"34,077 x DRG weight",44624,Other,base rate x DRG weight,37931,,"28,966 x DRG weight",37931,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11003,,DRG base rate x DRG weight + capital per discharge,11003,Other,100% of NY Medicaid HMO DRG,11003,,100% x Medicaid HMO amount,11003,Other,100% of NY Medicaid HMO DRG,11003,,100% x Medicaid HMO amount,11003,Other,100% of NY Medicaid HMO DRG,11003,,100% x Medicaid HMO amount,11003,Other,100% of NY Medicaid HMO DRG,24757,,225% x Medicaid HMO amount,24757,Other,225% of NY Medicaid HMO DRG,24757,,225% x Medicaid HMO amount,24757,Other,225% of NY Medicaid HMO DRG,24757,,225% x Medicaid HMO amount,24757,Other,225% of NY Medicaid HMO DRG,24757,,225% x Medicaid HMO amount,24757,Other,225% of NY Medicaid HMO DRG,15404,,140% x Medicaid HMO amount,15404,Other,140% of NY Medicaid HMO DRG,24757,,225% x Medicaid HMO amount,24757,Other,225% of NY Medicaid HMO DRG,30258,,275% x Medicaid HMO amount,30258,Other,275% of NY Medicaid HMO DRG,35650,,324% x Medicaid HMO amount,35650,Other,324% of NY Medicaid HMO DRG,23656,,215% x Medicaid HMO amount,23656,Other,215% of NY Medicaid HMO DRG,23656,,215% x Medicaid HMO amount,23656,Other,215% of NY Medicaid HMO DRG,13754,,125% x Medicaid HMO amount,13754,Other,125% of NY Medicaid HMO DRG,0.01,59095,
HIV w major HIV related condition,892-4,APR-DRG,,,,,,,,inpatient,,,157591.6,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,105351,,"45,128 x DRG weight",105351,Other,base rate x DRG weight,94816,,"40,615 x DRG weight",94816,Other,base rate x DRG weight,89549,,"38,359 x DRG weight",89549,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35290,,186% x Medicaid HMO amount,35290,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,79553,,"34,077 x DRG weight",79553,Other,base rate x DRG weight,67621,,"28,966 x DRG weight",67621,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18973,,DRG base rate x DRG weight + capital per discharge,18973,Other,100% of NY Medicaid HMO DRG,18973,,100% x Medicaid HMO amount,18973,Other,100% of NY Medicaid HMO DRG,18973,,100% x Medicaid HMO amount,18973,Other,100% of NY Medicaid HMO DRG,18973,,100% x Medicaid HMO amount,18973,Other,100% of NY Medicaid HMO DRG,42689,,225% x Medicaid HMO amount,42689,Other,225% of NY Medicaid HMO DRG,42689,,225% x Medicaid HMO amount,42689,Other,225% of NY Medicaid HMO DRG,42689,,225% x Medicaid HMO amount,42689,Other,225% of NY Medicaid HMO DRG,42689,,225% x Medicaid HMO amount,42689,Other,225% of NY Medicaid HMO DRG,26562,,140% x Medicaid HMO amount,26562,Other,140% of NY Medicaid HMO DRG,42689,,225% x Medicaid HMO amount,42689,Other,225% of NY Medicaid HMO DRG,52176,,275% x Medicaid HMO amount,52176,Other,275% of NY Medicaid HMO DRG,61473,,324% x Medicaid HMO amount,61473,Other,324% of NY Medicaid HMO DRG,40792,,215% x Medicaid HMO amount,40792,Other,215% of NY Medicaid HMO DRG,40792,,215% x Medicaid HMO amount,40792,Other,215% of NY Medicaid HMO DRG,23716,,125% x Medicaid HMO amount,23716,Other,125% of NY Medicaid HMO DRG,0.01,105351,
HIV w multiple significant HIV related conditions,893-1,APR-DRG,,,,,,,,inpatient,,,610134.92,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35304,,"45,128 x DRG weight",35304,Other,base rate x DRG weight,31773,,"40,615 x DRG weight",31773,Other,base rate x DRG weight,30008,,"38,359 x DRG weight",30008,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12841,,186% x Medicaid HMO amount,12841,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26658,,"34,077 x DRG weight",26658,Other,base rate x DRG weight,22660,,"28,966 x DRG weight",22660,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6904,,DRG base rate x DRG weight + capital per discharge,6904,Other,100% of NY Medicaid HMO DRG,6904,,100% x Medicaid HMO amount,6904,Other,100% of NY Medicaid HMO DRG,6904,,100% x Medicaid HMO amount,6904,Other,100% of NY Medicaid HMO DRG,6904,,100% x Medicaid HMO amount,6904,Other,100% of NY Medicaid HMO DRG,15534,,225% x Medicaid HMO amount,15534,Other,225% of NY Medicaid HMO DRG,15534,,225% x Medicaid HMO amount,15534,Other,225% of NY Medicaid HMO DRG,15534,,225% x Medicaid HMO amount,15534,Other,225% of NY Medicaid HMO DRG,15534,,225% x Medicaid HMO amount,15534,Other,225% of NY Medicaid HMO DRG,9666,,140% x Medicaid HMO amount,9666,Other,140% of NY Medicaid HMO DRG,15534,,225% x Medicaid HMO amount,15534,Other,225% of NY Medicaid HMO DRG,18986,,275% x Medicaid HMO amount,18986,Other,275% of NY Medicaid HMO DRG,22369,,324% x Medicaid HMO amount,22369,Other,324% of NY Medicaid HMO DRG,14844,,215% x Medicaid HMO amount,14844,Other,215% of NY Medicaid HMO DRG,14844,,215% x Medicaid HMO amount,14844,Other,215% of NY Medicaid HMO DRG,8630,,125% x Medicaid HMO amount,8630,Other,125% of NY Medicaid HMO DRG,0.01,35304,
HIV w multiple significant HIV related conditions,893-2,APR-DRG,,,,,,,,inpatient,,,610134.92,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41721,,"45,128 x DRG weight",41721,Other,base rate x DRG weight,37549,,"40,615 x DRG weight",37549,Other,base rate x DRG weight,35463,,"38,359 x DRG weight",35463,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14897,,186% x Medicaid HMO amount,14897,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31504,,"34,077 x DRG weight",31504,Other,base rate x DRG weight,26779,,"28,966 x DRG weight",26779,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,8009,,DRG base rate x DRG weight + capital per discharge,8009,Other,100% of NY Medicaid HMO DRG,8009,,100% x Medicaid HMO amount,8009,Other,100% of NY Medicaid HMO DRG,8009,,100% x Medicaid HMO amount,8009,Other,100% of NY Medicaid HMO DRG,8009,,100% x Medicaid HMO amount,8009,Other,100% of NY Medicaid HMO DRG,18020,,225% x Medicaid HMO amount,18020,Other,225% of NY Medicaid HMO DRG,18020,,225% x Medicaid HMO amount,18020,Other,225% of NY Medicaid HMO DRG,18020,,225% x Medicaid HMO amount,18020,Other,225% of NY Medicaid HMO DRG,18020,,225% x Medicaid HMO amount,18020,Other,225% of NY Medicaid HMO DRG,11213,,140% x Medicaid HMO amount,11213,Other,140% of NY Medicaid HMO DRG,18020,,225% x Medicaid HMO amount,18020,Other,225% of NY Medicaid HMO DRG,22025,,275% x Medicaid HMO amount,22025,Other,275% of NY Medicaid HMO DRG,25949,,324% x Medicaid HMO amount,25949,Other,324% of NY Medicaid HMO DRG,17219,,215% x Medicaid HMO amount,17219,Other,215% of NY Medicaid HMO DRG,17219,,215% x Medicaid HMO amount,17219,Other,215% of NY Medicaid HMO DRG,10011,,125% x Medicaid HMO amount,10011,Other,125% of NY Medicaid HMO DRG,0.01,41721,
HIV w multiple significant HIV related conditions,893-3,APR-DRG,,,,,,,,inpatient,,,610134.92,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,65544,,"45,128 x DRG weight",65544,Other,base rate x DRG weight,58989,,"40,615 x DRG weight",58989,Other,base rate x DRG weight,55713,,"38,359 x DRG weight",55713,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22532,,186% x Medicaid HMO amount,22532,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49493,,"34,077 x DRG weight",49493,Other,base rate x DRG weight,42070,,"28,966 x DRG weight",42070,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12114,,DRG base rate x DRG weight + capital per discharge,12114,Other,100% of NY Medicaid HMO DRG,12114,,100% x Medicaid HMO amount,12114,Other,100% of NY Medicaid HMO DRG,12114,,100% x Medicaid HMO amount,12114,Other,100% of NY Medicaid HMO DRG,12114,,100% x Medicaid HMO amount,12114,Other,100% of NY Medicaid HMO DRG,27257,,225% x Medicaid HMO amount,27257,Other,225% of NY Medicaid HMO DRG,27257,,225% x Medicaid HMO amount,27257,Other,225% of NY Medicaid HMO DRG,27257,,225% x Medicaid HMO amount,27257,Other,225% of NY Medicaid HMO DRG,27257,,225% x Medicaid HMO amount,27257,Other,225% of NY Medicaid HMO DRG,16960,,140% x Medicaid HMO amount,16960,Other,140% of NY Medicaid HMO DRG,27257,,225% x Medicaid HMO amount,27257,Other,225% of NY Medicaid HMO DRG,33314,,275% x Medicaid HMO amount,33314,Other,275% of NY Medicaid HMO DRG,39249,,324% x Medicaid HMO amount,39249,Other,324% of NY Medicaid HMO DRG,26045,,215% x Medicaid HMO amount,26045,Other,215% of NY Medicaid HMO DRG,26045,,215% x Medicaid HMO amount,26045,Other,215% of NY Medicaid HMO DRG,15143,,125% x Medicaid HMO amount,15143,Other,125% of NY Medicaid HMO DRG,0.01,65544,
HIV w multiple significant HIV related conditions,893-4,APR-DRG,,,,,,,,inpatient,,,610134.92,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,66853,,"45,128 x DRG weight",66853,Other,base rate x DRG weight,60167,,"40,615 x DRG weight",60167,Other,base rate x DRG weight,56825,,"38,359 x DRG weight",56825,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,22952,,186% x Medicaid HMO amount,22952,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,50482,,"34,077 x DRG weight",50482,Other,base rate x DRG weight,42910,,"28,966 x DRG weight",42910,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12340,,DRG base rate x DRG weight + capital per discharge,12340,Other,100% of NY Medicaid HMO DRG,12340,,100% x Medicaid HMO amount,12340,Other,100% of NY Medicaid HMO DRG,12340,,100% x Medicaid HMO amount,12340,Other,100% of NY Medicaid HMO DRG,12340,,100% x Medicaid HMO amount,12340,Other,100% of NY Medicaid HMO DRG,27765,,225% x Medicaid HMO amount,27765,Other,225% of NY Medicaid HMO DRG,27765,,225% x Medicaid HMO amount,27765,Other,225% of NY Medicaid HMO DRG,27765,,225% x Medicaid HMO amount,27765,Other,225% of NY Medicaid HMO DRG,27765,,225% x Medicaid HMO amount,27765,Other,225% of NY Medicaid HMO DRG,17276,,140% x Medicaid HMO amount,17276,Other,140% of NY Medicaid HMO DRG,27765,,225% x Medicaid HMO amount,27765,Other,225% of NY Medicaid HMO DRG,33935,,275% x Medicaid HMO amount,33935,Other,275% of NY Medicaid HMO DRG,39982,,324% x Medicaid HMO amount,39982,Other,324% of NY Medicaid HMO DRG,26531,,215% x Medicaid HMO amount,26531,Other,215% of NY Medicaid HMO DRG,26531,,215% x Medicaid HMO amount,26531,Other,215% of NY Medicaid HMO DRG,15425,,125% x Medicaid HMO amount,15425,Other,125% of NY Medicaid HMO DRG,0.01,66853,
HIV w one signif HIV cond or w/o signif related cond,894-1,APR-DRG,,,,,,,,inpatient,,,79599,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,27700,,"45,128 x DRG weight",27700,Other,base rate x DRG weight,24929,,"40,615 x DRG weight",24929,Other,base rate x DRG weight,23545,,"38,359 x DRG weight",23545,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10405,,186% x Medicaid HMO amount,10405,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20916,,"34,077 x DRG weight",20916,Other,base rate x DRG weight,17779,,"28,966 x DRG weight",17779,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,5594,,DRG base rate x DRG weight + capital per discharge,5594,Other,100% of NY Medicaid HMO DRG,5594,,100% x Medicaid HMO amount,5594,Other,100% of NY Medicaid HMO DRG,5594,,100% x Medicaid HMO amount,5594,Other,100% of NY Medicaid HMO DRG,5594,,100% x Medicaid HMO amount,5594,Other,100% of NY Medicaid HMO DRG,12587,,225% x Medicaid HMO amount,12587,Other,225% of NY Medicaid HMO DRG,12587,,225% x Medicaid HMO amount,12587,Other,225% of NY Medicaid HMO DRG,12587,,225% x Medicaid HMO amount,12587,Other,225% of NY Medicaid HMO DRG,12587,,225% x Medicaid HMO amount,12587,Other,225% of NY Medicaid HMO DRG,7832,,140% x Medicaid HMO amount,7832,Other,140% of NY Medicaid HMO DRG,12587,,225% x Medicaid HMO amount,12587,Other,225% of NY Medicaid HMO DRG,15384,,275% x Medicaid HMO amount,15384,Other,275% of NY Medicaid HMO DRG,18125,,324% x Medicaid HMO amount,18125,Other,324% of NY Medicaid HMO DRG,12027,,215% x Medicaid HMO amount,12027,Other,215% of NY Medicaid HMO DRG,12027,,215% x Medicaid HMO amount,12027,Other,215% of NY Medicaid HMO DRG,6993,,125% x Medicaid HMO amount,6993,Other,125% of NY Medicaid HMO DRG,0.01,27700,
HIV w one signif HIV cond or w/o signif related cond,894-2,APR-DRG,,,,,,,,inpatient,,,108793.55,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,34388,,"45,128 x DRG weight",34388,Other,base rate x DRG weight,30949,,"40,615 x DRG weight",30949,Other,base rate x DRG weight,29230,,"38,359 x DRG weight",29230,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12548,,186% x Medicaid HMO amount,12548,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,25967,,"34,077 x DRG weight",25967,Other,base rate x DRG weight,22072,,"28,966 x DRG weight",22072,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6746,,DRG base rate x DRG weight + capital per discharge,6746,Other,100% of NY Medicaid HMO DRG,6746,,100% x Medicaid HMO amount,6746,Other,100% of NY Medicaid HMO DRG,6746,,100% x Medicaid HMO amount,6746,Other,100% of NY Medicaid HMO DRG,6746,,100% x Medicaid HMO amount,6746,Other,100% of NY Medicaid HMO DRG,15179,,225% x Medicaid HMO amount,15179,Other,225% of NY Medicaid HMO DRG,15179,,225% x Medicaid HMO amount,15179,Other,225% of NY Medicaid HMO DRG,15179,,225% x Medicaid HMO amount,15179,Other,225% of NY Medicaid HMO DRG,15179,,225% x Medicaid HMO amount,15179,Other,225% of NY Medicaid HMO DRG,9444,,140% x Medicaid HMO amount,9444,Other,140% of NY Medicaid HMO DRG,15179,,225% x Medicaid HMO amount,15179,Other,225% of NY Medicaid HMO DRG,18552,,275% x Medicaid HMO amount,18552,Other,275% of NY Medicaid HMO DRG,21857,,324% x Medicaid HMO amount,21857,Other,324% of NY Medicaid HMO DRG,14504,,215% x Medicaid HMO amount,14504,Other,215% of NY Medicaid HMO DRG,14504,,215% x Medicaid HMO amount,14504,Other,215% of NY Medicaid HMO DRG,8433,,125% x Medicaid HMO amount,8433,Other,125% of NY Medicaid HMO DRG,0.01,34388,
HIV w one signif HIV cond or w/o signif related cond,894-3,APR-DRG,,,,,,,,inpatient,,,338221.04,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52312,,"45,128 x DRG weight",52312,Other,base rate x DRG weight,47081,,"40,615 x DRG weight",47081,Other,base rate x DRG weight,44466,,"38,359 x DRG weight",44466,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18291,,186% x Medicaid HMO amount,18291,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39502,,"34,077 x DRG weight",39502,Other,base rate x DRG weight,33577,,"28,966 x DRG weight",33577,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9834,,DRG base rate x DRG weight + capital per discharge,9834,Other,100% of NY Medicaid HMO DRG,9834,,100% x Medicaid HMO amount,9834,Other,100% of NY Medicaid HMO DRG,9834,,100% x Medicaid HMO amount,9834,Other,100% of NY Medicaid HMO DRG,9834,,100% x Medicaid HMO amount,9834,Other,100% of NY Medicaid HMO DRG,22127,,225% x Medicaid HMO amount,22127,Other,225% of NY Medicaid HMO DRG,22127,,225% x Medicaid HMO amount,22127,Other,225% of NY Medicaid HMO DRG,22127,,225% x Medicaid HMO amount,22127,Other,225% of NY Medicaid HMO DRG,22127,,225% x Medicaid HMO amount,22127,Other,225% of NY Medicaid HMO DRG,13768,,140% x Medicaid HMO amount,13768,Other,140% of NY Medicaid HMO DRG,22127,,225% x Medicaid HMO amount,22127,Other,225% of NY Medicaid HMO DRG,27044,,275% x Medicaid HMO amount,27044,Other,275% of NY Medicaid HMO DRG,31862,,324% x Medicaid HMO amount,31862,Other,324% of NY Medicaid HMO DRG,21143,,215% x Medicaid HMO amount,21143,Other,215% of NY Medicaid HMO DRG,21143,,215% x Medicaid HMO amount,21143,Other,215% of NY Medicaid HMO DRG,12293,,125% x Medicaid HMO amount,12293,Other,125% of NY Medicaid HMO DRG,0.01,52312,
HIV w one signif HIV cond or w/o signif related cond,894-4,APR-DRG,,,,,,,,inpatient,,,338221.04,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,52312,,"45,128 x DRG weight",52312,Other,base rate x DRG weight,47081,,"40,615 x DRG weight",47081,Other,base rate x DRG weight,44466,,"38,359 x DRG weight",44466,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18291,,186% x Medicaid HMO amount,18291,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39502,,"34,077 x DRG weight",39502,Other,base rate x DRG weight,33577,,"28,966 x DRG weight",33577,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,9834,,DRG base rate x DRG weight + capital per discharge,9834,Other,100% of NY Medicaid HMO DRG,9834,,100% x Medicaid HMO amount,9834,Other,100% of NY Medicaid HMO DRG,9834,,100% x Medicaid HMO amount,9834,Other,100% of NY Medicaid HMO DRG,9834,,100% x Medicaid HMO amount,9834,Other,100% of NY Medicaid HMO DRG,22127,,225% x Medicaid HMO amount,22127,Other,225% of NY Medicaid HMO DRG,22127,,225% x Medicaid HMO amount,22127,Other,225% of NY Medicaid HMO DRG,22127,,225% x Medicaid HMO amount,22127,Other,225% of NY Medicaid HMO DRG,22127,,225% x Medicaid HMO amount,22127,Other,225% of NY Medicaid HMO DRG,13768,,140% x Medicaid HMO amount,13768,Other,140% of NY Medicaid HMO DRG,22127,,225% x Medicaid HMO amount,22127,Other,225% of NY Medicaid HMO DRG,27044,,275% x Medicaid HMO amount,27044,Other,275% of NY Medicaid HMO DRG,31862,,324% x Medicaid HMO amount,31862,Other,324% of NY Medicaid HMO DRG,21143,,215% x Medicaid HMO amount,21143,Other,215% of NY Medicaid HMO DRG,21143,,215% x Medicaid HMO amount,21143,Other,215% of NY Medicaid HMO DRG,12293,,125% x Medicaid HMO amount,12293,Other,125% of NY Medicaid HMO DRG,0.01,52312,
Craniotomy for multiple significant trauma,910-1,APR-DRG,,,,,,,,inpatient,,,471439.81,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,169654,,"45,128 x DRG weight",169654,Other,base rate x DRG weight,152688,,"40,615 x DRG weight",152688,Other,base rate x DRG weight,144207,,"38,359 x DRG weight",144207,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55899,,186% x Medicaid HMO amount,55899,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,128109,,"34,077 x DRG weight",128109,Other,base rate x DRG weight,108895,,"28,966 x DRG weight",108895,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30053,,DRG base rate x DRG weight + capital per discharge,30053,Other,100% of NY Medicaid HMO DRG,30053,,100% x Medicaid HMO amount,30053,Other,100% of NY Medicaid HMO DRG,30053,,100% x Medicaid HMO amount,30053,Other,100% of NY Medicaid HMO DRG,30053,,100% x Medicaid HMO amount,30053,Other,100% of NY Medicaid HMO DRG,67619,,225% x Medicaid HMO amount,67619,Other,225% of NY Medicaid HMO DRG,67619,,225% x Medicaid HMO amount,67619,Other,225% of NY Medicaid HMO DRG,67619,,225% x Medicaid HMO amount,67619,Other,225% of NY Medicaid HMO DRG,67619,,225% x Medicaid HMO amount,67619,Other,225% of NY Medicaid HMO DRG,42074,,140% x Medicaid HMO amount,42074,Other,140% of NY Medicaid HMO DRG,67619,,225% x Medicaid HMO amount,67619,Other,225% of NY Medicaid HMO DRG,82646,,275% x Medicaid HMO amount,82646,Other,275% of NY Medicaid HMO DRG,97372,,324% x Medicaid HMO amount,97372,Other,324% of NY Medicaid HMO DRG,64614,,215% x Medicaid HMO amount,64614,Other,215% of NY Medicaid HMO DRG,64614,,215% x Medicaid HMO amount,64614,Other,215% of NY Medicaid HMO DRG,37566,,125% x Medicaid HMO amount,37566,Other,125% of NY Medicaid HMO DRG,0.01,169654,
Craniotomy for multiple significant trauma,910-2,APR-DRG,,,,,,,,inpatient,,,268119.64,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,169654,,"45,128 x DRG weight",169654,Other,base rate x DRG weight,152688,,"40,615 x DRG weight",152688,Other,base rate x DRG weight,144207,,"38,359 x DRG weight",144207,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,55899,,186% x Medicaid HMO amount,55899,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,128109,,"34,077 x DRG weight",128109,Other,base rate x DRG weight,108895,,"28,966 x DRG weight",108895,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30053,,DRG base rate x DRG weight + capital per discharge,30053,Other,100% of NY Medicaid HMO DRG,30053,,100% x Medicaid HMO amount,30053,Other,100% of NY Medicaid HMO DRG,30053,,100% x Medicaid HMO amount,30053,Other,100% of NY Medicaid HMO DRG,30053,,100% x Medicaid HMO amount,30053,Other,100% of NY Medicaid HMO DRG,67619,,225% x Medicaid HMO amount,67619,Other,225% of NY Medicaid HMO DRG,67619,,225% x Medicaid HMO amount,67619,Other,225% of NY Medicaid HMO DRG,67619,,225% x Medicaid HMO amount,67619,Other,225% of NY Medicaid HMO DRG,67619,,225% x Medicaid HMO amount,67619,Other,225% of NY Medicaid HMO DRG,42074,,140% x Medicaid HMO amount,42074,Other,140% of NY Medicaid HMO DRG,67619,,225% x Medicaid HMO amount,67619,Other,225% of NY Medicaid HMO DRG,82646,,275% x Medicaid HMO amount,82646,Other,275% of NY Medicaid HMO DRG,97372,,324% x Medicaid HMO amount,97372,Other,324% of NY Medicaid HMO DRG,64614,,215% x Medicaid HMO amount,64614,Other,215% of NY Medicaid HMO DRG,64614,,215% x Medicaid HMO amount,64614,Other,215% of NY Medicaid HMO DRG,37566,,125% x Medicaid HMO amount,37566,Other,125% of NY Medicaid HMO DRG,0.01,169654,
Craniotomy for multiple significant trauma,910-3,APR-DRG,,,,,,,,inpatient,,,538732.64,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,174966,,"45,128 x DRG weight",174966,Other,base rate x DRG weight,157468,,"40,615 x DRG weight",157468,Other,base rate x DRG weight,148722,,"38,359 x DRG weight",148722,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,57600,,186% x Medicaid HMO amount,57600,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,132120,,"34,077 x DRG weight",132120,Other,base rate x DRG weight,112304,,"28,966 x DRG weight",112304,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30968,,DRG base rate x DRG weight + capital per discharge,30968,Other,100% of NY Medicaid HMO DRG,30968,,100% x Medicaid HMO amount,30968,Other,100% of NY Medicaid HMO DRG,30968,,100% x Medicaid HMO amount,30968,Other,100% of NY Medicaid HMO DRG,30968,,100% x Medicaid HMO amount,30968,Other,100% of NY Medicaid HMO DRG,69678,,225% x Medicaid HMO amount,69678,Other,225% of NY Medicaid HMO DRG,69678,,225% x Medicaid HMO amount,69678,Other,225% of NY Medicaid HMO DRG,69678,,225% x Medicaid HMO amount,69678,Other,225% of NY Medicaid HMO DRG,69678,,225% x Medicaid HMO amount,69678,Other,225% of NY Medicaid HMO DRG,43355,,140% x Medicaid HMO amount,43355,Other,140% of NY Medicaid HMO DRG,69678,,225% x Medicaid HMO amount,69678,Other,225% of NY Medicaid HMO DRG,85162,,275% x Medicaid HMO amount,85162,Other,275% of NY Medicaid HMO DRG,100336,,324% x Medicaid HMO amount,100336,Other,324% of NY Medicaid HMO DRG,66581,,215% x Medicaid HMO amount,66581,Other,215% of NY Medicaid HMO DRG,66581,,215% x Medicaid HMO amount,66581,Other,215% of NY Medicaid HMO DRG,38710,,125% x Medicaid HMO amount,38710,Other,125% of NY Medicaid HMO DRG,0.01,174966,
Craniotomy for multiple significant trauma,910-4,APR-DRG,,,,,,,,inpatient,,,814911.51,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,324132,,"45,128 x DRG weight",324132,Other,base rate x DRG weight,291717,,"40,615 x DRG weight",291717,Other,base rate x DRG weight,275514,,"38,359 x DRG weight",275514,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,105404,,186% x Medicaid HMO amount,105404,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,244758,,"34,077 x DRG weight",244758,Other,base rate x DRG weight,208048,,"28,966 x DRG weight",208048,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,56669,,DRG base rate x DRG weight + capital per discharge,56669,Other,100% of NY Medicaid HMO DRG,56669,,100% x Medicaid HMO amount,56669,Other,100% of NY Medicaid HMO DRG,56669,,100% x Medicaid HMO amount,56669,Other,100% of NY Medicaid HMO DRG,56669,,100% x Medicaid HMO amount,56669,Other,100% of NY Medicaid HMO DRG,127505,,225% x Medicaid HMO amount,127505,Other,225% of NY Medicaid HMO DRG,127505,,225% x Medicaid HMO amount,127505,Other,225% of NY Medicaid HMO DRG,127505,,225% x Medicaid HMO amount,127505,Other,225% of NY Medicaid HMO DRG,127505,,225% x Medicaid HMO amount,127505,Other,225% of NY Medicaid HMO DRG,79337,,140% x Medicaid HMO amount,79337,Other,140% of NY Medicaid HMO DRG,127505,,225% x Medicaid HMO amount,127505,Other,225% of NY Medicaid HMO DRG,155840,,275% x Medicaid HMO amount,155840,Other,275% of NY Medicaid HMO DRG,183608,,324% x Medicaid HMO amount,183608,Other,324% of NY Medicaid HMO DRG,121838,,215% x Medicaid HMO amount,121838,Other,215% of NY Medicaid HMO DRG,121838,,215% x Medicaid HMO amount,121838,Other,215% of NY Medicaid HMO DRG,70836,,125% x Medicaid HMO amount,70836,Other,125% of NY Medicaid HMO DRG,0.01,324132,
Extensive abdominal/thoracic procedures for mult significant trauma,911-1,APR-DRG,,,,,,,,inpatient,,,165345.37,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,84453,,"45,128 x DRG weight",84453,Other,base rate x DRG weight,76007,,"40,615 x DRG weight",76007,Other,base rate x DRG weight,71785,,"38,359 x DRG weight",71785,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28592,,186% x Medicaid HMO amount,28592,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,63772,,"34,077 x DRG weight",63772,Other,base rate x DRG weight,54207,,"28,966 x DRG weight",54207,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15372,,DRG base rate x DRG weight + capital per discharge,15372,Other,100% of NY Medicaid HMO DRG,15372,,100% x Medicaid HMO amount,15372,Other,100% of NY Medicaid HMO DRG,15372,,100% x Medicaid HMO amount,15372,Other,100% of NY Medicaid HMO DRG,15372,,100% x Medicaid HMO amount,15372,Other,100% of NY Medicaid HMO DRG,34587,,225% x Medicaid HMO amount,34587,Other,225% of NY Medicaid HMO DRG,34587,,225% x Medicaid HMO amount,34587,Other,225% of NY Medicaid HMO DRG,34587,,225% x Medicaid HMO amount,34587,Other,225% of NY Medicaid HMO DRG,34587,,225% x Medicaid HMO amount,34587,Other,225% of NY Medicaid HMO DRG,21521,,140% x Medicaid HMO amount,21521,Other,140% of NY Medicaid HMO DRG,34587,,225% x Medicaid HMO amount,34587,Other,225% of NY Medicaid HMO DRG,42273,,275% x Medicaid HMO amount,42273,Other,275% of NY Medicaid HMO DRG,49805,,324% x Medicaid HMO amount,49805,Other,324% of NY Medicaid HMO DRG,33050,,215% x Medicaid HMO amount,33050,Other,215% of NY Medicaid HMO DRG,33050,,215% x Medicaid HMO amount,33050,Other,215% of NY Medicaid HMO DRG,19215,,125% x Medicaid HMO amount,19215,Other,125% of NY Medicaid HMO DRG,0.01,84453,
Extensive abdominal/thoracic procedures for mult significant trauma,911-2,APR-DRG,,,,,,,,inpatient,,,165345.37,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,84453,,"45,128 x DRG weight",84453,Other,base rate x DRG weight,76007,,"40,615 x DRG weight",76007,Other,base rate x DRG weight,71785,,"38,359 x DRG weight",71785,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,28592,,186% x Medicaid HMO amount,28592,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,63772,,"34,077 x DRG weight",63772,Other,base rate x DRG weight,54207,,"28,966 x DRG weight",54207,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,15372,,DRG base rate x DRG weight + capital per discharge,15372,Other,100% of NY Medicaid HMO DRG,15372,,100% x Medicaid HMO amount,15372,Other,100% of NY Medicaid HMO DRG,15372,,100% x Medicaid HMO amount,15372,Other,100% of NY Medicaid HMO DRG,15372,,100% x Medicaid HMO amount,15372,Other,100% of NY Medicaid HMO DRG,34587,,225% x Medicaid HMO amount,34587,Other,225% of NY Medicaid HMO DRG,34587,,225% x Medicaid HMO amount,34587,Other,225% of NY Medicaid HMO DRG,34587,,225% x Medicaid HMO amount,34587,Other,225% of NY Medicaid HMO DRG,34587,,225% x Medicaid HMO amount,34587,Other,225% of NY Medicaid HMO DRG,21521,,140% x Medicaid HMO amount,21521,Other,140% of NY Medicaid HMO DRG,34587,,225% x Medicaid HMO amount,34587,Other,225% of NY Medicaid HMO DRG,42273,,275% x Medicaid HMO amount,42273,Other,275% of NY Medicaid HMO DRG,49805,,324% x Medicaid HMO amount,49805,Other,324% of NY Medicaid HMO DRG,33050,,215% x Medicaid HMO amount,33050,Other,215% of NY Medicaid HMO DRG,33050,,215% x Medicaid HMO amount,33050,Other,215% of NY Medicaid HMO DRG,19215,,125% x Medicaid HMO amount,19215,Other,125% of NY Medicaid HMO DRG,0.01,84453,
Extensive abdominal/thoracic procedures for mult significant trauma,911-3,APR-DRG,,,,,,,,inpatient,,,373998.98,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,115668,,"45,128 x DRG weight",115668,Other,base rate x DRG weight,104100,,"40,615 x DRG weight",104100,Other,base rate x DRG weight,98318,,"38,359 x DRG weight",98318,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,38597,,186% x Medicaid HMO amount,38597,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,87343,,"34,077 x DRG weight",87343,Other,base rate x DRG weight,74243,,"28,966 x DRG weight",74243,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,20751,,DRG base rate x DRG weight + capital per discharge,20751,Other,100% of NY Medicaid HMO DRG,20751,,100% x Medicaid HMO amount,20751,Other,100% of NY Medicaid HMO DRG,20751,,100% x Medicaid HMO amount,20751,Other,100% of NY Medicaid HMO DRG,20751,,100% x Medicaid HMO amount,20751,Other,100% of NY Medicaid HMO DRG,46690,,225% x Medicaid HMO amount,46690,Other,225% of NY Medicaid HMO DRG,46690,,225% x Medicaid HMO amount,46690,Other,225% of NY Medicaid HMO DRG,46690,,225% x Medicaid HMO amount,46690,Other,225% of NY Medicaid HMO DRG,46690,,225% x Medicaid HMO amount,46690,Other,225% of NY Medicaid HMO DRG,29051,,140% x Medicaid HMO amount,29051,Other,140% of NY Medicaid HMO DRG,46690,,225% x Medicaid HMO amount,46690,Other,225% of NY Medicaid HMO DRG,57065,,275% x Medicaid HMO amount,57065,Other,275% of NY Medicaid HMO DRG,67233,,324% x Medicaid HMO amount,67233,Other,324% of NY Medicaid HMO DRG,44615,,215% x Medicaid HMO amount,44615,Other,215% of NY Medicaid HMO DRG,44615,,215% x Medicaid HMO amount,44615,Other,215% of NY Medicaid HMO DRG,25939,,125% x Medicaid HMO amount,25939,Other,125% of NY Medicaid HMO DRG,0.01,115668,
Extensive abdominal/thoracic procedures for mult significant trauma,911-4,APR-DRG,,,,,,,,inpatient,,,704549.44,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,292894,,"45,128 x DRG weight",292894,Other,base rate x DRG weight,263604,,"40,615 x DRG weight",263604,Other,base rate x DRG weight,248961,,"38,359 x DRG weight",248961,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,95394,,186% x Medicaid HMO amount,95394,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,221170,,"34,077 x DRG weight",221170,Other,base rate x DRG weight,187998,,"28,966 x DRG weight",187998,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,51287,,DRG base rate x DRG weight + capital per discharge,51287,Other,100% of NY Medicaid HMO DRG,51287,,100% x Medicaid HMO amount,51287,Other,100% of NY Medicaid HMO DRG,51287,,100% x Medicaid HMO amount,51287,Other,100% of NY Medicaid HMO DRG,51287,,100% x Medicaid HMO amount,51287,Other,100% of NY Medicaid HMO DRG,115396,,225% x Medicaid HMO amount,115396,Other,225% of NY Medicaid HMO DRG,115396,,225% x Medicaid HMO amount,115396,Other,225% of NY Medicaid HMO DRG,115396,,225% x Medicaid HMO amount,115396,Other,225% of NY Medicaid HMO DRG,115396,,225% x Medicaid HMO amount,115396,Other,225% of NY Medicaid HMO DRG,71802,,140% x Medicaid HMO amount,71802,Other,140% of NY Medicaid HMO DRG,115396,,225% x Medicaid HMO amount,115396,Other,225% of NY Medicaid HMO DRG,141039,,275% x Medicaid HMO amount,141039,Other,275% of NY Medicaid HMO DRG,166170,,324% x Medicaid HMO amount,166170,Other,324% of NY Medicaid HMO DRG,110267,,215% x Medicaid HMO amount,110267,Other,215% of NY Medicaid HMO DRG,110267,,215% x Medicaid HMO amount,110267,Other,215% of NY Medicaid HMO DRG,64109,,125% x Medicaid HMO amount,64109,Other,125% of NY Medicaid HMO DRG,0.01,292894,
Musculoskeletal & other procedures for multiple significant trauma,912-1,APR-DRG,,,,,,,,inpatient,,,358233.46,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,106683,,"45,128 x DRG weight",106683,Other,base rate x DRG weight,96014,,"40,615 x DRG weight",96014,Other,base rate x DRG weight,90681,,"38,359 x DRG weight",90681,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35716,,186% x Medicaid HMO amount,35716,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,80558,,"34,077 x DRG weight",80558,Other,base rate x DRG weight,68476,,"28,966 x DRG weight",68476,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19202,,DRG base rate x DRG weight + capital per discharge,19202,Other,100% of NY Medicaid HMO DRG,19202,,100% x Medicaid HMO amount,19202,Other,100% of NY Medicaid HMO DRG,19202,,100% x Medicaid HMO amount,19202,Other,100% of NY Medicaid HMO DRG,19202,,100% x Medicaid HMO amount,19202,Other,100% of NY Medicaid HMO DRG,43205,,225% x Medicaid HMO amount,43205,Other,225% of NY Medicaid HMO DRG,43205,,225% x Medicaid HMO amount,43205,Other,225% of NY Medicaid HMO DRG,43205,,225% x Medicaid HMO amount,43205,Other,225% of NY Medicaid HMO DRG,43205,,225% x Medicaid HMO amount,43205,Other,225% of NY Medicaid HMO DRG,26883,,140% x Medicaid HMO amount,26883,Other,140% of NY Medicaid HMO DRG,43205,,225% x Medicaid HMO amount,43205,Other,225% of NY Medicaid HMO DRG,52806,,275% x Medicaid HMO amount,52806,Other,275% of NY Medicaid HMO DRG,62214,,324% x Medicaid HMO amount,62214,Other,324% of NY Medicaid HMO DRG,41284,,215% x Medicaid HMO amount,41284,Other,215% of NY Medicaid HMO DRG,41284,,215% x Medicaid HMO amount,41284,Other,215% of NY Medicaid HMO DRG,24003,,125% x Medicaid HMO amount,24003,Other,125% of NY Medicaid HMO DRG,0.01,106683,
Musculoskeletal & other procedures for multiple significant trauma,912-2,APR-DRG,,,,,,,,inpatient,,,330220.32,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,106764,,"45,128 x DRG weight",106764,Other,base rate x DRG weight,96087,,"40,615 x DRG weight",96087,Other,base rate x DRG weight,90750,,"38,359 x DRG weight",90750,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35742,,186% x Medicaid HMO amount,35742,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,80619,,"34,077 x DRG weight",80619,Other,base rate x DRG weight,68528,,"28,966 x DRG weight",68528,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19216,,DRG base rate x DRG weight + capital per discharge,19216,Other,100% of NY Medicaid HMO DRG,19216,,100% x Medicaid HMO amount,19216,Other,100% of NY Medicaid HMO DRG,19216,,100% x Medicaid HMO amount,19216,Other,100% of NY Medicaid HMO DRG,19216,,100% x Medicaid HMO amount,19216,Other,100% of NY Medicaid HMO DRG,43236,,225% x Medicaid HMO amount,43236,Other,225% of NY Medicaid HMO DRG,43236,,225% x Medicaid HMO amount,43236,Other,225% of NY Medicaid HMO DRG,43236,,225% x Medicaid HMO amount,43236,Other,225% of NY Medicaid HMO DRG,43236,,225% x Medicaid HMO amount,43236,Other,225% of NY Medicaid HMO DRG,26902,,140% x Medicaid HMO amount,26902,Other,140% of NY Medicaid HMO DRG,43236,,225% x Medicaid HMO amount,43236,Other,225% of NY Medicaid HMO DRG,52844,,275% x Medicaid HMO amount,52844,Other,275% of NY Medicaid HMO DRG,62260,,324% x Medicaid HMO amount,62260,Other,324% of NY Medicaid HMO DRG,41314,,215% x Medicaid HMO amount,41314,Other,215% of NY Medicaid HMO DRG,41314,,215% x Medicaid HMO amount,41314,Other,215% of NY Medicaid HMO DRG,24020,,125% x Medicaid HMO amount,24020,Other,125% of NY Medicaid HMO DRG,0.01,106764,
Musculoskeletal & other procedures for multiple significant trauma,912-3,APR-DRG,,,,,,,,inpatient,,,535118.73,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,177601,,"45,128 x DRG weight",177601,Other,base rate x DRG weight,159840,,"40,615 x DRG weight",159840,Other,base rate x DRG weight,150962,,"38,359 x DRG weight",150962,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,58445,,186% x Medicaid HMO amount,58445,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,134110,,"34,077 x DRG weight",134110,Other,base rate x DRG weight,113996,,"28,966 x DRG weight",113996,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31422,,DRG base rate x DRG weight + capital per discharge,31422,Other,100% of NY Medicaid HMO DRG,31422,,100% x Medicaid HMO amount,31422,Other,100% of NY Medicaid HMO DRG,31422,,100% x Medicaid HMO amount,31422,Other,100% of NY Medicaid HMO DRG,31422,,100% x Medicaid HMO amount,31422,Other,100% of NY Medicaid HMO DRG,70700,,225% x Medicaid HMO amount,70700,Other,225% of NY Medicaid HMO DRG,70700,,225% x Medicaid HMO amount,70700,Other,225% of NY Medicaid HMO DRG,70700,,225% x Medicaid HMO amount,70700,Other,225% of NY Medicaid HMO DRG,70700,,225% x Medicaid HMO amount,70700,Other,225% of NY Medicaid HMO DRG,43991,,140% x Medicaid HMO amount,43991,Other,140% of NY Medicaid HMO DRG,70700,,225% x Medicaid HMO amount,70700,Other,225% of NY Medicaid HMO DRG,86411,,275% x Medicaid HMO amount,86411,Other,275% of NY Medicaid HMO DRG,101807,,324% x Medicaid HMO amount,101807,Other,324% of NY Medicaid HMO DRG,67557,,215% x Medicaid HMO amount,67557,Other,215% of NY Medicaid HMO DRG,67557,,215% x Medicaid HMO amount,67557,Other,215% of NY Medicaid HMO DRG,39278,,125% x Medicaid HMO amount,39278,Other,125% of NY Medicaid HMO DRG,0.01,177601,
Musculoskeletal & other procedures for multiple significant trauma,912-4,APR-DRG,,,,,,,,inpatient,,,895444.01,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,341917,,"45,128 x DRG weight",341917,Other,base rate x DRG weight,307724,,"40,615 x DRG weight",307724,Other,base rate x DRG weight,290631,,"38,359 x DRG weight",290631,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,111105,,186% x Medicaid HMO amount,111105,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,258188,,"34,077 x DRG weight",258188,Other,base rate x DRG weight,219464,,"28,966 x DRG weight",219464,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59734,,DRG base rate x DRG weight + capital per discharge,59734,Other,100% of NY Medicaid HMO DRG,59734,,100% x Medicaid HMO amount,59734,Other,100% of NY Medicaid HMO DRG,59734,,100% x Medicaid HMO amount,59734,Other,100% of NY Medicaid HMO DRG,59734,,100% x Medicaid HMO amount,59734,Other,100% of NY Medicaid HMO DRG,134402,,225% x Medicaid HMO amount,134402,Other,225% of NY Medicaid HMO DRG,134402,,225% x Medicaid HMO amount,134402,Other,225% of NY Medicaid HMO DRG,134402,,225% x Medicaid HMO amount,134402,Other,225% of NY Medicaid HMO DRG,134402,,225% x Medicaid HMO amount,134402,Other,225% of NY Medicaid HMO DRG,83628,,140% x Medicaid HMO amount,83628,Other,140% of NY Medicaid HMO DRG,134402,,225% x Medicaid HMO amount,134402,Other,225% of NY Medicaid HMO DRG,164269,,275% x Medicaid HMO amount,164269,Other,275% of NY Medicaid HMO DRG,193538,,324% x Medicaid HMO amount,193538,Other,324% of NY Medicaid HMO DRG,128428,,215% x Medicaid HMO amount,128428,Other,215% of NY Medicaid HMO DRG,128428,,215% x Medicaid HMO amount,128428,Other,215% of NY Medicaid HMO DRG,74668,,125% x Medicaid HMO amount,74668,Other,125% of NY Medicaid HMO DRG,0.01,341917,
Multiple significant trauma w/o O.R. procedure,930-1,APR-DRG,,,,,,,,inpatient,,,157058,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,39798,,"45,128 x DRG weight",39798,Other,base rate x DRG weight,35818,,"40,615 x DRG weight",35818,Other,base rate x DRG weight,33829,,"38,359 x DRG weight",33829,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14281,,186% x Medicaid HMO amount,14281,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30053,,"34,077 x DRG weight",30053,Other,base rate x DRG weight,25545,,"28,966 x DRG weight",25545,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7678,,DRG base rate x DRG weight + capital per discharge,7678,Other,100% of NY Medicaid HMO DRG,7678,,100% x Medicaid HMO amount,7678,Other,100% of NY Medicaid HMO DRG,7678,,100% x Medicaid HMO amount,7678,Other,100% of NY Medicaid HMO DRG,7678,,100% x Medicaid HMO amount,7678,Other,100% of NY Medicaid HMO DRG,17276,,225% x Medicaid HMO amount,17276,Other,225% of NY Medicaid HMO DRG,17276,,225% x Medicaid HMO amount,17276,Other,225% of NY Medicaid HMO DRG,17276,,225% x Medicaid HMO amount,17276,Other,225% of NY Medicaid HMO DRG,17276,,225% x Medicaid HMO amount,17276,Other,225% of NY Medicaid HMO DRG,10749,,140% x Medicaid HMO amount,10749,Other,140% of NY Medicaid HMO DRG,17276,,225% x Medicaid HMO amount,17276,Other,225% of NY Medicaid HMO DRG,21115,,275% x Medicaid HMO amount,21115,Other,275% of NY Medicaid HMO DRG,24877,,324% x Medicaid HMO amount,24877,Other,324% of NY Medicaid HMO DRG,16508,,215% x Medicaid HMO amount,16508,Other,215% of NY Medicaid HMO DRG,16508,,215% x Medicaid HMO amount,16508,Other,215% of NY Medicaid HMO DRG,9598,,125% x Medicaid HMO amount,9598,Other,125% of NY Medicaid HMO DRG,0.01,39798,
Multiple significant trauma w/o O.R. procedure,930-2,APR-DRG,,,,,,,,inpatient,,,161187.65,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40006,,"45,128 x DRG weight",40006,Other,base rate x DRG weight,36005,,"40,615 x DRG weight",36005,Other,base rate x DRG weight,34005,,"38,359 x DRG weight",34005,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14348,,186% x Medicaid HMO amount,14348,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,30209,,"34,077 x DRG weight",30209,Other,base rate x DRG weight,25678,,"28,966 x DRG weight",25678,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7714,,DRG base rate x DRG weight + capital per discharge,7714,Other,100% of NY Medicaid HMO DRG,7714,,100% x Medicaid HMO amount,7714,Other,100% of NY Medicaid HMO DRG,7714,,100% x Medicaid HMO amount,7714,Other,100% of NY Medicaid HMO DRG,7714,,100% x Medicaid HMO amount,7714,Other,100% of NY Medicaid HMO DRG,17357,,225% x Medicaid HMO amount,17357,Other,225% of NY Medicaid HMO DRG,17357,,225% x Medicaid HMO amount,17357,Other,225% of NY Medicaid HMO DRG,17357,,225% x Medicaid HMO amount,17357,Other,225% of NY Medicaid HMO DRG,17357,,225% x Medicaid HMO amount,17357,Other,225% of NY Medicaid HMO DRG,10800,,140% x Medicaid HMO amount,10800,Other,140% of NY Medicaid HMO DRG,17357,,225% x Medicaid HMO amount,17357,Other,225% of NY Medicaid HMO DRG,21214,,275% x Medicaid HMO amount,21214,Other,275% of NY Medicaid HMO DRG,24993,,324% x Medicaid HMO amount,24993,Other,324% of NY Medicaid HMO DRG,16585,,215% x Medicaid HMO amount,16585,Other,215% of NY Medicaid HMO DRG,16585,,215% x Medicaid HMO amount,16585,Other,215% of NY Medicaid HMO DRG,9643,,125% x Medicaid HMO amount,9643,Other,125% of NY Medicaid HMO DRG,0.01,40006,
Multiple significant trauma w/o O.R. procedure,930-3,APR-DRG,,,,,,,,inpatient,,,194551.13,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,71424,,"45,128 x DRG weight",71424,Other,base rate x DRG weight,64281,,"40,615 x DRG weight",64281,Other,base rate x DRG weight,60711,,"38,359 x DRG weight",60711,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,24416,,186% x Medicaid HMO amount,24416,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53934,,"34,077 x DRG weight",53934,Other,base rate x DRG weight,45844,,"28,966 x DRG weight",45844,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,13127,,DRG base rate x DRG weight + capital per discharge,13127,Other,100% of NY Medicaid HMO DRG,13127,,100% x Medicaid HMO amount,13127,Other,100% of NY Medicaid HMO DRG,13127,,100% x Medicaid HMO amount,13127,Other,100% of NY Medicaid HMO DRG,13127,,100% x Medicaid HMO amount,13127,Other,100% of NY Medicaid HMO DRG,29536,,225% x Medicaid HMO amount,29536,Other,225% of NY Medicaid HMO DRG,29536,,225% x Medicaid HMO amount,29536,Other,225% of NY Medicaid HMO DRG,29536,,225% x Medicaid HMO amount,29536,Other,225% of NY Medicaid HMO DRG,29536,,225% x Medicaid HMO amount,29536,Other,225% of NY Medicaid HMO DRG,18378,,140% x Medicaid HMO amount,18378,Other,140% of NY Medicaid HMO DRG,29536,,225% x Medicaid HMO amount,29536,Other,225% of NY Medicaid HMO DRG,36099,,275% x Medicaid HMO amount,36099,Other,275% of NY Medicaid HMO DRG,42531,,324% x Medicaid HMO amount,42531,Other,324% of NY Medicaid HMO DRG,28223,,215% x Medicaid HMO amount,28223,Other,215% of NY Medicaid HMO DRG,28223,,215% x Medicaid HMO amount,28223,Other,215% of NY Medicaid HMO DRG,16409,,125% x Medicaid HMO amount,16409,Other,125% of NY Medicaid HMO DRG,0.01,71424,
Multiple significant trauma w/o O.R. procedure,930-4,APR-DRG,,,,,,,,inpatient,,,364385.02,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,164898,,"45,128 x DRG weight",164898,Other,base rate x DRG weight,148407,,"40,615 x DRG weight",148407,Other,base rate x DRG weight,140164,,"38,359 x DRG weight",140164,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,54373,,186% x Medicaid HMO amount,54373,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,124517,,"34,077 x DRG weight",124517,Other,base rate x DRG weight,105842,,"28,966 x DRG weight",105842,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,29233,,DRG base rate x DRG weight + capital per discharge,29233,Other,100% of NY Medicaid HMO DRG,29233,,100% x Medicaid HMO amount,29233,Other,100% of NY Medicaid HMO DRG,29233,,100% x Medicaid HMO amount,29233,Other,100% of NY Medicaid HMO DRG,29233,,100% x Medicaid HMO amount,29233,Other,100% of NY Medicaid HMO DRG,65774,,225% x Medicaid HMO amount,65774,Other,225% of NY Medicaid HMO DRG,65774,,225% x Medicaid HMO amount,65774,Other,225% of NY Medicaid HMO DRG,65774,,225% x Medicaid HMO amount,65774,Other,225% of NY Medicaid HMO DRG,65774,,225% x Medicaid HMO amount,65774,Other,225% of NY Medicaid HMO DRG,40926,,140% x Medicaid HMO amount,40926,Other,140% of NY Medicaid HMO DRG,65774,,225% x Medicaid HMO amount,65774,Other,225% of NY Medicaid HMO DRG,80391,,275% x Medicaid HMO amount,80391,Other,275% of NY Medicaid HMO DRG,94715,,324% x Medicaid HMO amount,94715,Other,324% of NY Medicaid HMO DRG,62851,,215% x Medicaid HMO amount,62851,Other,215% of NY Medicaid HMO DRG,62851,,215% x Medicaid HMO amount,62851,Other,215% of NY Medicaid HMO DRG,36541,,125% x Medicaid HMO amount,36541,Other,125% of NY Medicaid HMO DRG,0.01,164898,
Extensive procedure unrelated to principal diagnosis,950-1,APR-DRG,,,,,,,,inpatient,,,101207.35,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,61482,,"45,128 x DRG weight",61482,Other,base rate x DRG weight,55334,,"40,615 x DRG weight",55334,Other,base rate x DRG weight,52260,,"38,359 x DRG weight",52260,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21230,,186% x Medicaid HMO amount,21230,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46427,,"34,077 x DRG weight",46427,Other,base rate x DRG weight,39463,,"28,966 x DRG weight",39463,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11414,,DRG base rate x DRG weight + capital per discharge,11414,Other,100% of NY Medicaid HMO DRG,11414,,100% x Medicaid HMO amount,11414,Other,100% of NY Medicaid HMO DRG,11414,,100% x Medicaid HMO amount,11414,Other,100% of NY Medicaid HMO DRG,11414,,100% x Medicaid HMO amount,11414,Other,100% of NY Medicaid HMO DRG,25682,,225% x Medicaid HMO amount,25682,Other,225% of NY Medicaid HMO DRG,25682,,225% x Medicaid HMO amount,25682,Other,225% of NY Medicaid HMO DRG,25682,,225% x Medicaid HMO amount,25682,Other,225% of NY Medicaid HMO DRG,25682,,225% x Medicaid HMO amount,25682,Other,225% of NY Medicaid HMO DRG,15980,,140% x Medicaid HMO amount,15980,Other,140% of NY Medicaid HMO DRG,25682,,225% x Medicaid HMO amount,25682,Other,225% of NY Medicaid HMO DRG,31389,,275% x Medicaid HMO amount,31389,Other,275% of NY Medicaid HMO DRG,36981,,324% x Medicaid HMO amount,36981,Other,324% of NY Medicaid HMO DRG,24540,,215% x Medicaid HMO amount,24540,Other,215% of NY Medicaid HMO DRG,24540,,215% x Medicaid HMO amount,24540,Other,215% of NY Medicaid HMO DRG,14268,,125% x Medicaid HMO amount,14268,Other,125% of NY Medicaid HMO DRG,0.01,61482,
Extensive procedure unrelated to principal diagnosis,950-2,APR-DRG,,,,,,,,inpatient,,,199694.51,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,97431,,"45,128 x DRG weight",97431,Other,base rate x DRG weight,87688,,"40,615 x DRG weight",87688,Other,base rate x DRG weight,82817,,"38,359 x DRG weight",82817,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,32751,,186% x Medicaid HMO amount,32751,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,73572,,"34,077 x DRG weight",73572,Other,base rate x DRG weight,62538,,"28,966 x DRG weight",62538,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,17608,,DRG base rate x DRG weight + capital per discharge,17608,Other,100% of NY Medicaid HMO DRG,17608,,100% x Medicaid HMO amount,17608,Other,100% of NY Medicaid HMO DRG,17608,,100% x Medicaid HMO amount,17608,Other,100% of NY Medicaid HMO DRG,17608,,100% x Medicaid HMO amount,17608,Other,100% of NY Medicaid HMO DRG,39618,,225% x Medicaid HMO amount,39618,Other,225% of NY Medicaid HMO DRG,39618,,225% x Medicaid HMO amount,39618,Other,225% of NY Medicaid HMO DRG,39618,,225% x Medicaid HMO amount,39618,Other,225% of NY Medicaid HMO DRG,39618,,225% x Medicaid HMO amount,39618,Other,225% of NY Medicaid HMO DRG,24651,,140% x Medicaid HMO amount,24651,Other,140% of NY Medicaid HMO DRG,39618,,225% x Medicaid HMO amount,39618,Other,225% of NY Medicaid HMO DRG,48422,,275% x Medicaid HMO amount,48422,Other,275% of NY Medicaid HMO DRG,57050,,324% x Medicaid HMO amount,57050,Other,324% of NY Medicaid HMO DRG,37857,,215% x Medicaid HMO amount,37857,Other,215% of NY Medicaid HMO DRG,37857,,215% x Medicaid HMO amount,37857,Other,215% of NY Medicaid HMO DRG,22010,,125% x Medicaid HMO amount,22010,Other,125% of NY Medicaid HMO DRG,0.01,97431,
Extensive procedure unrelated to principal diagnosis,950-3,APR-DRG,,,,,,,,inpatient,,,333490.77,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,180259,,"45,128 x DRG weight",180259,Other,base rate x DRG weight,162233,,"40,615 x DRG weight",162233,Other,base rate x DRG weight,153221,,"38,359 x DRG weight",153221,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,59297,,186% x Medicaid HMO amount,59297,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,136117,,"34,077 x DRG weight",136117,Other,base rate x DRG weight,115702,,"28,966 x DRG weight",115702,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31880,,DRG base rate x DRG weight + capital per discharge,31880,Other,100% of NY Medicaid HMO DRG,31880,,100% x Medicaid HMO amount,31880,Other,100% of NY Medicaid HMO DRG,31880,,100% x Medicaid HMO amount,31880,Other,100% of NY Medicaid HMO DRG,31880,,100% x Medicaid HMO amount,31880,Other,100% of NY Medicaid HMO DRG,71730,,225% x Medicaid HMO amount,71730,Other,225% of NY Medicaid HMO DRG,71730,,225% x Medicaid HMO amount,71730,Other,225% of NY Medicaid HMO DRG,71730,,225% x Medicaid HMO amount,71730,Other,225% of NY Medicaid HMO DRG,71730,,225% x Medicaid HMO amount,71730,Other,225% of NY Medicaid HMO DRG,44632,,140% x Medicaid HMO amount,44632,Other,140% of NY Medicaid HMO DRG,71730,,225% x Medicaid HMO amount,71730,Other,225% of NY Medicaid HMO DRG,87670,,275% x Medicaid HMO amount,87670,Other,275% of NY Medicaid HMO DRG,103291,,324% x Medicaid HMO amount,103291,Other,324% of NY Medicaid HMO DRG,68542,,215% x Medicaid HMO amount,68542,Other,215% of NY Medicaid HMO DRG,68542,,215% x Medicaid HMO amount,68542,Other,215% of NY Medicaid HMO DRG,39850,,125% x Medicaid HMO amount,39850,Other,125% of NY Medicaid HMO DRG,0.01,180259,
Extensive procedure unrelated to principal diagnosis,950-4,APR-DRG,,,,,,,,inpatient,,,2096908.33,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,366182,,"45,128 x DRG weight",366182,Other,base rate x DRG weight,329562,,"40,615 x DRG weight",329562,Other,base rate x DRG weight,311256,,"38,359 x DRG weight",311256,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,118882,,186% x Medicaid HMO amount,118882,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,276511,,"34,077 x DRG weight",276511,Other,base rate x DRG weight,235039,,"28,966 x DRG weight",235039,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,63915,,DRG base rate x DRG weight + capital per discharge,63915,Other,100% of NY Medicaid HMO DRG,63915,,100% x Medicaid HMO amount,63915,Other,100% of NY Medicaid HMO DRG,63915,,100% x Medicaid HMO amount,63915,Other,100% of NY Medicaid HMO DRG,63915,,100% x Medicaid HMO amount,63915,Other,100% of NY Medicaid HMO DRG,143809,,225% x Medicaid HMO amount,143809,Other,225% of NY Medicaid HMO DRG,143809,,225% x Medicaid HMO amount,143809,Other,225% of NY Medicaid HMO DRG,143809,,225% x Medicaid HMO amount,143809,Other,225% of NY Medicaid HMO DRG,143809,,225% x Medicaid HMO amount,143809,Other,225% of NY Medicaid HMO DRG,89481,,140% x Medicaid HMO amount,89481,Other,140% of NY Medicaid HMO DRG,143809,,225% x Medicaid HMO amount,143809,Other,225% of NY Medicaid HMO DRG,175766,,275% x Medicaid HMO amount,175766,Other,275% of NY Medicaid HMO DRG,207085,,324% x Medicaid HMO amount,207085,Other,324% of NY Medicaid HMO DRG,137417,,215% x Medicaid HMO amount,137417,Other,215% of NY Medicaid HMO DRG,137417,,215% x Medicaid HMO amount,137417,Other,215% of NY Medicaid HMO DRG,79894,,125% x Medicaid HMO amount,79894,Other,125% of NY Medicaid HMO DRG,0.01,366182,
Moderately extensive procedure unrelated to principal diagnosis,951-1,APR-DRG,,,,,,,,inpatient,,,102862.03,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,41567,,"45,128 x DRG weight",41567,Other,base rate x DRG weight,37410,,"40,615 x DRG weight",37410,Other,base rate x DRG weight,35332,,"38,359 x DRG weight",35332,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,14848,,186% x Medicaid HMO amount,14848,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,31388,,"34,077 x DRG weight",31388,Other,base rate x DRG weight,26681,,"28,966 x DRG weight",26681,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,7983,,DRG base rate x DRG weight + capital per discharge,7983,Other,100% of NY Medicaid HMO DRG,7983,,100% x Medicaid HMO amount,7983,Other,100% of NY Medicaid HMO DRG,7983,,100% x Medicaid HMO amount,7983,Other,100% of NY Medicaid HMO DRG,7983,,100% x Medicaid HMO amount,7983,Other,100% of NY Medicaid HMO DRG,17962,,225% x Medicaid HMO amount,17962,Other,225% of NY Medicaid HMO DRG,17962,,225% x Medicaid HMO amount,17962,Other,225% of NY Medicaid HMO DRG,17962,,225% x Medicaid HMO amount,17962,Other,225% of NY Medicaid HMO DRG,17962,,225% x Medicaid HMO amount,17962,Other,225% of NY Medicaid HMO DRG,11176,,140% x Medicaid HMO amount,11176,Other,140% of NY Medicaid HMO DRG,17962,,225% x Medicaid HMO amount,17962,Other,225% of NY Medicaid HMO DRG,21953,,275% x Medicaid HMO amount,21953,Other,275% of NY Medicaid HMO DRG,25865,,324% x Medicaid HMO amount,25865,Other,324% of NY Medicaid HMO DRG,17163,,215% x Medicaid HMO amount,17163,Other,215% of NY Medicaid HMO DRG,17163,,215% x Medicaid HMO amount,17163,Other,215% of NY Medicaid HMO DRG,9979,,125% x Medicaid HMO amount,9979,Other,125% of NY Medicaid HMO DRG,0.01,41567,
Moderately extensive procedure unrelated to principal diagnosis,951-2,APR-DRG,,,,,,,,inpatient,,,210190.27,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,62755,,"45,128 x DRG weight",62755,Other,base rate x DRG weight,56479,,"40,615 x DRG weight",56479,Other,base rate x DRG weight,53342,,"38,359 x DRG weight",53342,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21639,,186% x Medicaid HMO amount,21639,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,47387,,"34,077 x DRG weight",47387,Other,base rate x DRG weight,40280,,"28,966 x DRG weight",40280,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,11634,,DRG base rate x DRG weight + capital per discharge,11634,Other,100% of NY Medicaid HMO DRG,11634,,100% x Medicaid HMO amount,11634,Other,100% of NY Medicaid HMO DRG,11634,,100% x Medicaid HMO amount,11634,Other,100% of NY Medicaid HMO DRG,11634,,100% x Medicaid HMO amount,11634,Other,100% of NY Medicaid HMO DRG,26177,,225% x Medicaid HMO amount,26177,Other,225% of NY Medicaid HMO DRG,26177,,225% x Medicaid HMO amount,26177,Other,225% of NY Medicaid HMO DRG,26177,,225% x Medicaid HMO amount,26177,Other,225% of NY Medicaid HMO DRG,26177,,225% x Medicaid HMO amount,26177,Other,225% of NY Medicaid HMO DRG,16288,,140% x Medicaid HMO amount,16288,Other,140% of NY Medicaid HMO DRG,26177,,225% x Medicaid HMO amount,26177,Other,225% of NY Medicaid HMO DRG,31994,,275% x Medicaid HMO amount,31994,Other,275% of NY Medicaid HMO DRG,37694,,324% x Medicaid HMO amount,37694,Other,324% of NY Medicaid HMO DRG,25013,,215% x Medicaid HMO amount,25013,Other,215% of NY Medicaid HMO DRG,25013,,215% x Medicaid HMO amount,25013,Other,215% of NY Medicaid HMO DRG,14543,,125% x Medicaid HMO amount,14543,Other,125% of NY Medicaid HMO DRG,0.01,62755,
Moderately extensive procedure unrelated to principal diagnosis,951-3,APR-DRG,,,,,,,,inpatient,,,357428,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,122378,,"45,128 x DRG weight",122378,Other,base rate x DRG weight,110140,,"40,615 x DRG weight",110140,Other,base rate x DRG weight,104022,,"38,359 x DRG weight",104022,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40747,,186% x Medicaid HMO amount,40747,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,92410,,"34,077 x DRG weight",92410,Other,base rate x DRG weight,78550,,"28,966 x DRG weight",78550,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,21907,,DRG base rate x DRG weight + capital per discharge,21907,Other,100% of NY Medicaid HMO DRG,21907,,100% x Medicaid HMO amount,21907,Other,100% of NY Medicaid HMO DRG,21907,,100% x Medicaid HMO amount,21907,Other,100% of NY Medicaid HMO DRG,21907,,100% x Medicaid HMO amount,21907,Other,100% of NY Medicaid HMO DRG,49291,,225% x Medicaid HMO amount,49291,Other,225% of NY Medicaid HMO DRG,49291,,225% x Medicaid HMO amount,49291,Other,225% of NY Medicaid HMO DRG,49291,,225% x Medicaid HMO amount,49291,Other,225% of NY Medicaid HMO DRG,49291,,225% x Medicaid HMO amount,49291,Other,225% of NY Medicaid HMO DRG,30670,,140% x Medicaid HMO amount,30670,Other,140% of NY Medicaid HMO DRG,49291,,225% x Medicaid HMO amount,49291,Other,225% of NY Medicaid HMO DRG,60244,,275% x Medicaid HMO amount,60244,Other,275% of NY Medicaid HMO DRG,70979,,324% x Medicaid HMO amount,70979,Other,324% of NY Medicaid HMO DRG,47100,,215% x Medicaid HMO amount,47100,Other,215% of NY Medicaid HMO DRG,47100,,215% x Medicaid HMO amount,47100,Other,215% of NY Medicaid HMO DRG,27384,,125% x Medicaid HMO amount,27384,Other,125% of NY Medicaid HMO DRG,0.01,122378,
Moderately extensive procedure unrelated to principal diagnosis,951-4,APR-DRG,,,,,,,,inpatient,,,535294.18,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,283183,,"45,128 x DRG weight",283183,Other,base rate x DRG weight,254863,,"40,615 x DRG weight",254863,Other,base rate x DRG weight,240707,,"38,359 x DRG weight",240707,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,92282,,186% x Medicaid HMO amount,92282,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,213837,,"34,077 x DRG weight",213837,Other,base rate x DRG weight,181765,,"28,966 x DRG weight",181765,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,49614,,DRG base rate x DRG weight + capital per discharge,49614,Other,100% of NY Medicaid HMO DRG,49614,,100% x Medicaid HMO amount,49614,Other,100% of NY Medicaid HMO DRG,49614,,100% x Medicaid HMO amount,49614,Other,100% of NY Medicaid HMO DRG,49614,,100% x Medicaid HMO amount,49614,Other,100% of NY Medicaid HMO DRG,111632,,225% x Medicaid HMO amount,111632,Other,225% of NY Medicaid HMO DRG,111632,,225% x Medicaid HMO amount,111632,Other,225% of NY Medicaid HMO DRG,111632,,225% x Medicaid HMO amount,111632,Other,225% of NY Medicaid HMO DRG,111632,,225% x Medicaid HMO amount,111632,Other,225% of NY Medicaid HMO DRG,69460,,140% x Medicaid HMO amount,69460,Other,140% of NY Medicaid HMO DRG,111632,,225% x Medicaid HMO amount,111632,Other,225% of NY Medicaid HMO DRG,136439,,275% x Medicaid HMO amount,136439,Other,275% of NY Medicaid HMO DRG,160749,,324% x Medicaid HMO amount,160749,Other,324% of NY Medicaid HMO DRG,106670,,215% x Medicaid HMO amount,106670,Other,215% of NY Medicaid HMO DRG,106670,,215% x Medicaid HMO amount,106670,Other,215% of NY Medicaid HMO DRG,62018,,125% x Medicaid HMO amount,62018,Other,125% of NY Medicaid HMO DRG,0.01,283183,
Nonextensive procedure unrelated to principal diagnosis,952-1,APR-DRG,,,,,,,,inpatient,,,86105.83,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,35421,,"45,128 x DRG weight",35421,Other,base rate x DRG weight,31879,,"40,615 x DRG weight",31879,Other,base rate x DRG weight,30108,,"38,359 x DRG weight",30108,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,12879,,186% x Medicaid HMO amount,12879,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,26747,,"34,077 x DRG weight",26747,Other,base rate x DRG weight,22735,,"28,966 x DRG weight",22735,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,6924,,DRG base rate x DRG weight + capital per discharge,6924,Other,100% of NY Medicaid HMO DRG,6924,,100% x Medicaid HMO amount,6924,Other,100% of NY Medicaid HMO DRG,6924,,100% x Medicaid HMO amount,6924,Other,100% of NY Medicaid HMO DRG,6924,,100% x Medicaid HMO amount,6924,Other,100% of NY Medicaid HMO DRG,15579,,225% x Medicaid HMO amount,15579,Other,225% of NY Medicaid HMO DRG,15579,,225% x Medicaid HMO amount,15579,Other,225% of NY Medicaid HMO DRG,15579,,225% x Medicaid HMO amount,15579,Other,225% of NY Medicaid HMO DRG,15579,,225% x Medicaid HMO amount,15579,Other,225% of NY Medicaid HMO DRG,9694,,140% x Medicaid HMO amount,9694,Other,140% of NY Medicaid HMO DRG,15579,,225% x Medicaid HMO amount,15579,Other,225% of NY Medicaid HMO DRG,19041,,275% x Medicaid HMO amount,19041,Other,275% of NY Medicaid HMO DRG,22434,,324% x Medicaid HMO amount,22434,Other,324% of NY Medicaid HMO DRG,14887,,215% x Medicaid HMO amount,14887,Other,215% of NY Medicaid HMO DRG,14887,,215% x Medicaid HMO amount,14887,Other,215% of NY Medicaid HMO DRG,8655,,125% x Medicaid HMO amount,8655,Other,125% of NY Medicaid HMO DRG,0.01,35421,
Nonextensive procedure unrelated to principal diagnosis,952-2,APR-DRG,,,,,,,,inpatient,,,194934,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,53982,,"45,128 x DRG weight",53982,Other,base rate x DRG weight,48584,,"40,615 x DRG weight",48584,Other,base rate x DRG weight,45885,,"38,359 x DRG weight",45885,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,18827,,186% x Medicaid HMO amount,18827,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,40763,,"34,077 x DRG weight",40763,Other,base rate x DRG weight,34649,,"28,966 x DRG weight",34649,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,10122,,DRG base rate x DRG weight + capital per discharge,10122,Other,100% of NY Medicaid HMO DRG,10122,,100% x Medicaid HMO amount,10122,Other,100% of NY Medicaid HMO DRG,10122,,100% x Medicaid HMO amount,10122,Other,100% of NY Medicaid HMO DRG,10122,,100% x Medicaid HMO amount,10122,Other,100% of NY Medicaid HMO DRG,22775,,225% x Medicaid HMO amount,22775,Other,225% of NY Medicaid HMO DRG,22775,,225% x Medicaid HMO amount,22775,Other,225% of NY Medicaid HMO DRG,22775,,225% x Medicaid HMO amount,22775,Other,225% of NY Medicaid HMO DRG,22775,,225% x Medicaid HMO amount,22775,Other,225% of NY Medicaid HMO DRG,14171,,140% x Medicaid HMO amount,14171,Other,140% of NY Medicaid HMO DRG,22775,,225% x Medicaid HMO amount,22775,Other,225% of NY Medicaid HMO DRG,27836,,275% x Medicaid HMO amount,27836,Other,275% of NY Medicaid HMO DRG,32795,,324% x Medicaid HMO amount,32795,Other,324% of NY Medicaid HMO DRG,21762,,215% x Medicaid HMO amount,21762,Other,215% of NY Medicaid HMO DRG,21762,,215% x Medicaid HMO amount,21762,Other,215% of NY Medicaid HMO DRG,12653,,125% x Medicaid HMO amount,12653,Other,125% of NY Medicaid HMO DRG,0.01,53982,
Nonextensive procedure unrelated to principal diagnosis,952-3,APR-DRG,,,,,,,,inpatient,,,322751.37,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,110288,,"45,128 x DRG weight",110288,Other,base rate x DRG weight,99259,,"40,615 x DRG weight",99259,Other,base rate x DRG weight,93746,,"38,359 x DRG weight",93746,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,36873,,186% x Medicaid HMO amount,36873,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,83281,,"34,077 x DRG weight",83281,Other,base rate x DRG weight,70790,,"28,966 x DRG weight",70790,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,19824,,DRG base rate x DRG weight + capital per discharge,19824,Other,100% of NY Medicaid HMO DRG,19824,,100% x Medicaid HMO amount,19824,Other,100% of NY Medicaid HMO DRG,19824,,100% x Medicaid HMO amount,19824,Other,100% of NY Medicaid HMO DRG,19824,,100% x Medicaid HMO amount,19824,Other,100% of NY Medicaid HMO DRG,44604,,225% x Medicaid HMO amount,44604,Other,225% of NY Medicaid HMO DRG,44604,,225% x Medicaid HMO amount,44604,Other,225% of NY Medicaid HMO DRG,44604,,225% x Medicaid HMO amount,44604,Other,225% of NY Medicaid HMO DRG,44604,,225% x Medicaid HMO amount,44604,Other,225% of NY Medicaid HMO DRG,27754,,140% x Medicaid HMO amount,27754,Other,140% of NY Medicaid HMO DRG,44604,,225% x Medicaid HMO amount,44604,Other,225% of NY Medicaid HMO DRG,54516,,275% x Medicaid HMO amount,54516,Other,275% of NY Medicaid HMO DRG,64230,,324% x Medicaid HMO amount,64230,Other,324% of NY Medicaid HMO DRG,42622,,215% x Medicaid HMO amount,42622,Other,215% of NY Medicaid HMO DRG,42622,,215% x Medicaid HMO amount,42622,Other,215% of NY Medicaid HMO DRG,24780,,125% x Medicaid HMO amount,24780,Other,125% of NY Medicaid HMO DRG,0.01,110288,
Nonextensive procedure unrelated to principal diagnosis,952-4,APR-DRG,,,,,,,,inpatient,,,411452.32,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,267681,,"45,128 x DRG weight",267681,Other,base rate x DRG weight,240912,,"40,615 x DRG weight",240912,Other,base rate x DRG weight,227530,,"38,359 x DRG weight",227530,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,87314,,186% x Medicaid HMO amount,87314,Other,186% of NY Medicaid HMO DRG,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,202131,,"34,077 x DRG weight",202131,Other,base rate x DRG weight,171815,,"28,966 x DRG weight",171815,Other,base rate x DRG weight,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,0.01,,,0.01,Other,See MS-DRG information,46943,,DRG base rate x DRG weight + capital per discharge,46943,Other,100% of NY Medicaid HMO DRG,46943,,100% x Medicaid HMO amount,46943,Other,100% of NY Medicaid HMO DRG,46943,,100% x Medicaid HMO amount,46943,Other,100% of NY Medicaid HMO DRG,46943,,100% x Medicaid HMO amount,46943,Other,100% of NY Medicaid HMO DRG,105622,,225% x Medicaid HMO amount,105622,Other,225% of NY Medicaid HMO DRG,105622,,225% x Medicaid HMO amount,105622,Other,225% of NY Medicaid HMO DRG,105622,,225% x Medicaid HMO amount,105622,Other,225% of NY Medicaid HMO DRG,105622,,225% x Medicaid HMO amount,105622,Other,225% of NY Medicaid HMO DRG,65720,,140% x Medicaid HMO amount,65720,Other,140% of NY Medicaid HMO DRG,105622,,225% x Medicaid HMO amount,105622,Other,225% of NY Medicaid HMO DRG,129093,,275% x Medicaid HMO amount,129093,Other,275% of NY Medicaid HMO DRG,152095,,324% x Medicaid HMO amount,152095,Other,324% of NY Medicaid HMO DRG,100927,,215% x Medicaid HMO amount,100927,Other,215% of NY Medicaid HMO DRG,100927,,215% x Medicaid HMO amount,100927,Other,215% of NY Medicaid HMO DRG,58679,,125% x Medicaid HMO amount,58679,Other,125% of NY Medicaid HMO DRG,0.01,267681,
Fna bx w/o img gdn ea addl,10004,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1296.67,,,1296.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,207.9,,,207.9,Fee Schedule,,176.4,,,176.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,697.14,,,697.14,Other,New York Medicaid APG methodology,697.14,,,697.14,Other,100% New York Medicaid APG,697.14,,,697.14,Other,100% New York Medicaid APG,697.14,,,697.14,Other,100% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,975.99,,,975.99,Other,140% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1812.56,,,1812.56,Other,260% New York Medicaid APG,2258.72,,,2258.72,Other,324% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,871.42,,,871.42,Other,125% New York Medicaid APG,0.01,22702.47,
Fna bx w/us gdn 1st les,10005,CPT,,,,,,,,both,,,21618.49,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,10809.25,50,,10809.25,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1296.67,,,1296.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,15132.94,70,,15132.94,percent of total billed charges,,359.7,,,359.7,Fee Schedule,,305.2,,,305.2,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,697.14,,,697.14,Other,New York Medicaid APG methodology,697.14,,,697.14,Other,100% New York Medicaid APG,697.14,,,697.14,Other,100% New York Medicaid APG,697.14,,,697.14,Other,100% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,975.99,,,975.99,Other,140% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1812.56,,,1812.56,Other,260% New York Medicaid APG,2258.72,,,2258.72,Other,324% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,871.42,,,871.42,Other,125% New York Medicaid APG,305.2,15132.94,
Fna bx w/us gdn ea addl,10006,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1296.67,,,1296.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,244.2,,,244.2,Fee Schedule,,207.2,,,207.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,697.14,,,697.14,Other,New York Medicaid APG methodology,697.14,,,697.14,Other,100% New York Medicaid APG,697.14,,,697.14,Other,100% New York Medicaid APG,697.14,,,697.14,Other,100% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,975.99,,,975.99,Other,140% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1812.56,,,1812.56,Other,260% New York Medicaid APG,2258.72,,,2258.72,Other,324% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,871.42,,,871.42,Other,125% New York Medicaid APG,0.01,22702.47,
Fna bx w/fluor gdn 1st les,10007,CPT,,,,,,,,both,,,14798.8,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7399.4,50,,7399.4,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1296.67,,,1296.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10359.16,70,,10359.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,697.14,,,697.14,Other,New York Medicaid APG methodology,697.14,,,697.14,Other,100% New York Medicaid APG,697.14,,,697.14,Other,100% New York Medicaid APG,697.14,,,697.14,Other,100% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,975.99,,,975.99,Other,140% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1812.56,,,1812.56,Other,260% New York Medicaid APG,2258.72,,,2258.72,Other,324% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,871.42,,,871.42,Other,125% New York Medicaid APG,697.14,13157,
Fna bx w/fluor gdn ea addl,10008,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1296.67,,,1296.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,255.75,,,255.75,Fee Schedule,,217,,,217,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,697.14,,,697.14,Other,New York Medicaid APG methodology,697.14,,,697.14,Other,100% New York Medicaid APG,697.14,,,697.14,Other,100% New York Medicaid APG,697.14,,,697.14,Other,100% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,975.99,,,975.99,Other,140% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1812.56,,,1812.56,Other,260% New York Medicaid APG,2258.72,,,2258.72,Other,324% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,871.42,,,871.42,Other,125% New York Medicaid APG,0.01,22702.47,
Fna bx w/ct gdn 1st les,10009,CPT,,,,,,,,both,,,14798.8,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7399.4,50,,7399.4,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1296.67,,,1296.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10359.16,70,,10359.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,697.14,,,697.14,Other,New York Medicaid APG methodology,697.14,,,697.14,Other,100% New York Medicaid APG,697.14,,,697.14,Other,100% New York Medicaid APG,697.14,,,697.14,Other,100% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,975.99,,,975.99,Other,140% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1812.56,,,1812.56,Other,260% New York Medicaid APG,2258.72,,,2258.72,Other,324% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,871.42,,,871.42,Other,125% New York Medicaid APG,697.14,13157,
Fna bx w/ct gdn ea addl,10010,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1296.67,,,1296.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,349.8,,,349.8,Fee Schedule,,296.8,,,296.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,697.14,,,697.14,Other,New York Medicaid APG methodology,697.14,,,697.14,Other,100% New York Medicaid APG,697.14,,,697.14,Other,100% New York Medicaid APG,697.14,,,697.14,Other,100% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,975.99,,,975.99,Other,140% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1812.56,,,1812.56,Other,260% New York Medicaid APG,2258.72,,,2258.72,Other,324% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,871.42,,,871.42,Other,125% New York Medicaid APG,0.01,22702.47,
Fna bx w/mr gdn 1st les,10011,CPT,,,,,,,,both,,,14798.8,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7399.4,50,,7399.4,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1296.67,,,1296.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10359.16,70,,10359.16,percent of total billed charges,,7399.4,50,,7399.4,percent of total billed charges,,7399.4,50,,7399.4,percent of total billed charges,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,697.14,,,697.14,Other,New York Medicaid APG methodology,697.14,,,697.14,Other,100% New York Medicaid APG,697.14,,,697.14,Other,100% New York Medicaid APG,697.14,,,697.14,Other,100% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,975.99,,,975.99,Other,140% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1812.56,,,1812.56,Other,260% New York Medicaid APG,2258.72,,,2258.72,Other,324% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,871.42,,,871.42,Other,125% New York Medicaid APG,697.14,10359.16,
Fna bx w/mr gdn ea addl,10012,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1296.67,,,1296.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,16216.05,50,,16216.05,percent of total billed charges,,16216.05,50,,16216.05,percent of total billed charges,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,697.14,,,697.14,Other,New York Medicaid APG methodology,697.14,,,697.14,Other,100% New York Medicaid APG,697.14,,,697.14,Other,100% New York Medicaid APG,697.14,,,697.14,Other,100% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,975.99,,,975.99,Other,140% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1812.56,,,1812.56,Other,260% New York Medicaid APG,2258.72,,,2258.72,Other,324% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,871.42,,,871.42,Other,125% New York Medicaid APG,0.01,22702.47,
Fna bx w/o img gdn 1st les,10021,CPT,,,,,,,,both,,,34782.5,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17391.25,50,,17391.25,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1296.67,,,1296.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24347.75,70,,24347.75,percent of total billed charges,,268.95,,,268.95,Fee Schedule,,228.2,,,228.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,697.14,,,697.14,Other,New York Medicaid APG methodology,697.14,,,697.14,Other,100% New York Medicaid APG,697.14,,,697.14,Other,100% New York Medicaid APG,697.14,,,697.14,Other,100% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,975.99,,,975.99,Other,140% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1812.56,,,1812.56,Other,260% New York Medicaid APG,2258.72,,,2258.72,Other,324% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,871.42,,,871.42,Other,125% New York Medicaid APG,0.01,24347.75,
Guide cathet fluid drainage,10030,CPT,,,,,,,,both,,,17675.66,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,8837.83,50,,8837.83,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1516.17,,,1516.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,12372.96,70,,12372.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,815.14,,,815.14,Other,New York Medicaid APG methodology,815.14,,,815.14,Other,100% New York Medicaid APG,815.14,,,815.14,Other,100% New York Medicaid APG,815.14,,,815.14,Other,100% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1141.2,,,1141.2,Other,140% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,2119.37,,,2119.37,Other,260% New York Medicaid APG,2641.06,,,2641.06,Other,324% New York Medicaid APG,1752.56,,,1752.56,Other,215% New York Medicaid APG,1752.56,,,1752.56,Other,215% New York Medicaid APG,1018.93,,,1018.93,Other,125% New York Medicaid APG,0.01,13157,
Perq dev soft tiss 1st imag,10035,CPT,,,,,,,,both,,,14798.8,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7399.4,50,,7399.4,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1516.17,,,1516.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10359.16,70,,10359.16,percent of total billed charges,,412.5,,,412.5,Fee Schedule,,350,,,350,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,815.14,,,815.14,Other,New York Medicaid APG methodology,815.14,,,815.14,Other,100% New York Medicaid APG,815.14,,,815.14,Other,100% New York Medicaid APG,815.14,,,815.14,Other,100% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1141.2,,,1141.2,Other,140% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,2119.37,,,2119.37,Other,260% New York Medicaid APG,2641.06,,,2641.06,Other,324% New York Medicaid APG,1752.56,,,1752.56,Other,215% New York Medicaid APG,1752.56,,,1752.56,Other,215% New York Medicaid APG,1018.93,,,1018.93,Other,125% New York Medicaid APG,350,10359.16,
Perq dev soft tiss add imag,10036,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1516.17,,,1516.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,207.9,,,207.9,Fee Schedule,,176.4,,,176.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,815.14,,,815.14,Other,New York Medicaid APG methodology,815.14,,,815.14,Other,100% New York Medicaid APG,815.14,,,815.14,Other,100% New York Medicaid APG,815.14,,,815.14,Other,100% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1141.2,,,1141.2,Other,140% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,2119.37,,,2119.37,Other,260% New York Medicaid APG,2641.06,,,2641.06,Other,324% New York Medicaid APG,1752.56,,,1752.56,Other,215% New York Medicaid APG,1752.56,,,1752.56,Other,215% New York Medicaid APG,1018.93,,,1018.93,Other,125% New York Medicaid APG,0.01,22702.47,
Acne surgery,10040,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,254.1,,,254.1,Fee Schedule,,215.6,,,215.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Drainage of skin abscess,10060,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,518.1,,,518.1,Fee Schedule,,439.6,,,439.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Drainage of skin abscess,10061,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,461.11,13157,
Drainage of pilonidal cyst,10080,CPT,,,,,,,,both,,,35124.08,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17562.04,50,,17562.04,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24586.86,70,,24586.86,percent of total billed charges,,514.8,,,514.8,Fee Schedule,,436.8,,,436.8,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,24586.86,
Drainage of pilonidal cyst,10081,CPT,,,,,,,,both,,,36188.86,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,18094.43,50,,18094.43,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1516.17,,,1516.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25332.2,70,,25332.2,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,815.14,,,815.14,Other,New York Medicaid APG methodology,815.14,,,815.14,Other,100% New York Medicaid APG,815.14,,,815.14,Other,100% New York Medicaid APG,815.14,,,815.14,Other,100% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1141.2,,,1141.2,Other,140% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,2119.37,,,2119.37,Other,260% New York Medicaid APG,2641.06,,,2641.06,Other,324% New York Medicaid APG,1752.56,,,1752.56,Other,215% New York Medicaid APG,1752.56,,,1752.56,Other,215% New York Medicaid APG,1018.93,,,1018.93,Other,125% New York Medicaid APG,0.01,25332.2,
Remove foreign body,10120,CPT,,,,,,,,both,,,35136.3,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17568.15,50,,17568.15,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24595.41,70,,24595.41,percent of total billed charges,,518.1,,,518.1,Fee Schedule,,439.6,,,439.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,24595.41,
Remove foreign body,10121,CPT,,,,,,,,both,,,34301.82,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17150.91,50,,17150.91,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2855.7,,,2855.7,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24011.27,70,,24011.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1535.32,,,1535.32,Other,New York Medicaid APG methodology,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,2149.45,,,2149.45,Other,140% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3991.84,,,3991.84,Other,260% New York Medicaid APG,4974.44,,,4974.44,Other,324% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,1919.15,,,1919.15,Other,125% New York Medicaid APG,1535.32,24011.27,
Drainage of hematoma/fluid,10140,CPT,,,,,,,,both,,,36245.27,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18122.64,50,,18122.64,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1516.17,,,1516.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25371.69,70,,25371.69,percent of total billed charges,,579.15,,,579.15,Fee Schedule,,491.4,,,491.4,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,815.14,,,815.14,Other,New York Medicaid APG methodology,815.14,,,815.14,Other,100% New York Medicaid APG,815.14,,,815.14,Other,100% New York Medicaid APG,815.14,,,815.14,Other,100% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1141.2,,,1141.2,Other,140% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,2119.37,,,2119.37,Other,260% New York Medicaid APG,2641.06,,,2641.06,Other,324% New York Medicaid APG,1752.56,,,1752.56,Other,215% New York Medicaid APG,1752.56,,,1752.56,Other,215% New York Medicaid APG,1018.93,,,1018.93,Other,125% New York Medicaid APG,0.01,25371.69,
Puncture drainage of lesion,10160,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,475.2,,,475.2,Fee Schedule,,403.2,,,403.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Complex drainage wound,10180,CPT,,,,,,,,both,,,39608.75,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19804.38,50,,19804.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3180.63,,,3180.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27726.13,70,,27726.13,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,2394.02,,,2394.02,Other,140% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,4446.04,,,4446.04,Other,260% New York Medicaid APG,5540.45,,,5540.45,Other,324% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,2137.52,,,2137.52,Other,125% New York Medicaid APG,1710.01,27726.13,
Debride infected skin,11000,CPT,,,,,,,,both,,,13210.22,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6605.11,50,,6605.11,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9247.15,70,,9247.15,percent of total billed charges,,132,,,132,Fee Schedule,,112,,,112,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,0.01,9473,
Debride infected skin add-on,11001,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,72.6,,,72.6,Fee Schedule,,61.6,,,61.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,0.01,22702.47,
Debride skin at fx site,11010,CPT,,,,,,,,both,,,14798.8,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7399.4,50,,7399.4,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10359.16,70,,10359.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,813.62,13157,
Debride skin musc at fx site,11011,CPT,,,,,,,,both,,,14798.8,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7399.4,50,,7399.4,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10359.16,70,,10359.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,813.62,13157,
Deb skin bone at fx site,11012,CPT,,,,,,,,both,,,60004.81,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,30002.41,50,,30002.41,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3180.63,,,3180.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,42003.37,70,,42003.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,2394.02,,,2394.02,Other,140% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,4446.04,,,4446.04,Other,260% New York Medicaid APG,5540.45,,,5540.45,Other,324% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,2137.52,,,2137.52,Other,125% New York Medicaid APG,1710.01,42003.37,
Deb subq tissue 20 sq cm/<,11042,CPT,,,,,,,,both,,,37094.72,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,18547.36,50,,18547.36,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25966.3,70,,25966.3,percent of total billed charges,,292.05,,,292.05,Fee Schedule,,247.8,,,247.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,247.8,25966.3,
Deb musc/fascia 20 sq cm/<,11043,CPT,,,,,,,,both,,,39574.92,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,19787.46,50,,19787.46,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27702.44,70,,27702.44,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,726.28,27702.44,
Deb bone 20 sq cm/<,11044,CPT,,,,,,,,both,,,38476.71,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19238.36,50,,19238.36,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3180.63,,,3180.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26933.7,70,,26933.7,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,2394.02,,,2394.02,Other,140% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,4446.04,,,4446.04,Other,260% New York Medicaid APG,5540.45,,,5540.45,Other,324% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,2137.52,,,2137.52,Other,125% New York Medicaid APG,1710.01,26933.7,
Deb subq tissue add-on,11045,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,3180.63,,,3180.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,123.75,,,123.75,Fee Schedule,,105,,,105,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,2394.02,,,2394.02,Other,140% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,4446.04,,,4446.04,Other,260% New York Medicaid APG,5540.45,,,5540.45,Other,324% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,2137.52,,,2137.52,Other,125% New York Medicaid APG,0.01,36100.43,
Deb musc/fascia add-on,11046,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,3180.63,,,3180.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,267.3,,,267.3,Fee Schedule,,226.8,,,226.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,2394.02,,,2394.02,Other,140% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,4446.04,,,4446.04,Other,260% New York Medicaid APG,5540.45,,,5540.45,Other,324% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,2137.52,,,2137.52,Other,125% New York Medicaid APG,0.01,36100.43,
Deb bone add-on,11047,CPT,,,,,,,,both,,,64479.48,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32239.74,50,,32239.74,percent of total billed charges,,45135.64,70,,45135.64,percent of total billed charges,,6152,,,6152,Case Rate,,3180.63,,,3180.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45135.64,70,,45135.64,percent of total billed charges,,473.55,,,473.55,Fee Schedule,,401.8,,,401.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,2394.02,,,2394.02,Other,140% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,4446.04,,,4446.04,Other,260% New York Medicaid APG,5540.45,,,5540.45,Other,324% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,2137.52,,,2137.52,Other,125% New York Medicaid APG,0.01,45135.64,
Trim skin lesion,11055,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,77.55,,,77.55,Fee Schedule,,65.8,,,65.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Trim skin lesions 2 to 4,11056,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,107.25,,,107.25,Fee Schedule,,91,,,91,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Trim skin lesions over 4,11057,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,138.6,,,138.6,Fee Schedule,,117.6,,,117.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Tangntl bx skin single les,11102,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,184.8,,,184.8,Fee Schedule,,156.8,,,156.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,0.01,9473,
Tangntl bx skin ea sep/addl,11103,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,105.6,,,105.6,Fee Schedule,,89.6,,,89.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,0.01,22702.47,
Punch bx skin single lesion,11104,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,229.35,,,229.35,Fee Schedule,,194.6,,,194.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,0.01,9473,
Punch bx skin ea sep/addl,11105,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,125.4,,,125.4,Fee Schedule,,106.4,,,106.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,0.01,22702.47,
Incal bx skn single les,11106,CPT,,,,,,,,both,,,13210.22,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6605.11,50,,6605.11,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9247.15,70,,9247.15,percent of total billed charges,,275.55,,,275.55,Fee Schedule,,233.8,,,233.8,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,233.8,9473,
Incal bx skn ea sep/addl,11107,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,150.15,,,150.15,Fee Schedule,,127.4,,,127.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,0.01,22702.47,
Removal of skin tags <w/15,11200,CPT,,,,,,,,both,,,36910.34,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,18455.17,50,,18455.17,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25837.24,70,,25837.24,percent of total billed charges,,376.2,,,376.2,Fee Schedule,,319.2,,,319.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,25837.24,
Remove skin tags add-on,11201,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,80.85,,,80.85,Fee Schedule,,68.6,,,68.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,22702.47,
Shave skin lesion 0.5 cm/<,11300,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,166.65,,,166.65,Fee Schedule,,141.4,,,141.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Shave skin lesion 0.6-1.0 cm,11301,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,250.8,,,250.8,Fee Schedule,,212.8,,,212.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Shave skin lesion 1.1-2.0 cm,11302,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,292.05,,,292.05,Fee Schedule,,247.8,,,247.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Shave skin lesion >2.0 cm,11303,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,346.5,,,346.5,Fee Schedule,,294,,,294,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Shave skin lesion 0.5 cm/<,11305,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,183.15,,,183.15,Fee Schedule,,155.4,,,155.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Shave skin lesion 0.6-1.0 cm,11306,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,240.9,,,240.9,Fee Schedule,,204.4,,,204.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Shave skin lesion 1.1-2.0 cm,11307,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,306.9,,,306.9,Fee Schedule,,260.4,,,260.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Shave skin lesion >2.0 cm,11308,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,341.55,,,341.55,Fee Schedule,,289.8,,,289.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Shave skin lesion 0.5 cm/<,11310,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,224.4,,,224.4,Fee Schedule,,190.4,,,190.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Shave skin lesion 0.6-1.0 cm,11311,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,306.9,,,306.9,Fee Schedule,,260.4,,,260.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Shave skin lesion 1.1-2.0 cm,11312,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,367.95,,,367.95,Fee Schedule,,312.2,,,312.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Shave skin lesion >2.0 cm,11313,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,466.95,,,466.95,Fee Schedule,,396.2,,,396.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Exc tr-ext b9+marg 0.5 cm<,11400,CPT,,,,,,,,both,,,35012.69,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17506.35,50,,17506.35,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24508.88,70,,24508.88,percent of total billed charges,,414.15,,,414.15,Fee Schedule,,351.4,,,351.4,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,351.4,24508.88,
Exc tr-ext b9+marg 0.6-1 cm,11401,CPT,,,,,,,,both,,,34943.81,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17471.91,50,,17471.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24460.67,70,,24460.67,percent of total billed charges,,523.05,,,523.05,Fee Schedule,,443.8,,,443.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,443.8,24460.67,
Exc tr-ext b9+marg 1.1-2 cm,11402,CPT,,,,,,,,both,,,35381.88,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17690.94,50,,17690.94,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24767.32,70,,24767.32,percent of total billed charges,,569.25,,,569.25,Fee Schedule,,483,,,483,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,483,24767.32,
Exc tr-ext b9+marg 2.1-3cm,11403,CPT,,,,,,,,both,,,35017.63,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17508.82,50,,17508.82,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24512.34,70,,24512.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,813.62,24512.34,
Exc tr-ext b9+marg 3.1-4 cm,11404,CPT,,,,,,,,both,,,35816.42,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17908.21,50,,17908.21,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2855.7,,,2855.7,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25071.49,70,,25071.49,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1535.32,,,1535.32,Other,New York Medicaid APG methodology,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,2149.45,,,2149.45,Other,140% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3991.84,,,3991.84,Other,260% New York Medicaid APG,4974.44,,,4974.44,Other,324% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,1919.15,,,1919.15,Other,125% New York Medicaid APG,1535.32,25071.49,
Exc tr-ext b9+marg >4.0 cm,11406,CPT,,,,,,,,both,,,37909.24,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18954.62,50,,18954.62,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26536.47,70,,26536.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,1874.86,26536.47,
Exc h-f-nk-sp b9+marg 0.5/<,11420,CPT,,,,,,,,both,,,37620.34,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18810.17,50,,18810.17,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2855.7,,,2855.7,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26334.24,70,,26334.24,percent of total billed charges,,404.25,,,404.25,Fee Schedule,,343,,,343,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1535.32,,,1535.32,Other,New York Medicaid APG methodology,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,2149.45,,,2149.45,Other,140% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3991.84,,,3991.84,Other,260% New York Medicaid APG,4974.44,,,4974.44,Other,324% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,1919.15,,,1919.15,Other,125% New York Medicaid APG,343,26334.24,
Exc h-f-nk-sp b9+marg 0.6-1,11421,CPT,,,,,,,,both,,,38590.22,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,19295.11,50,,19295.11,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27013.15,70,,27013.15,percent of total billed charges,,539.55,,,539.55,Fee Schedule,,457.8,,,457.8,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,457.8,27013.15,
Exc h-f-nk-sp b9+marg 1.1-2,11422,CPT,,,,,,,,both,,,37502.29,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18751.15,50,,18751.15,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2855.7,,,2855.7,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26251.6,70,,26251.6,percent of total billed charges,,668.25,,,668.25,Fee Schedule,,567,,,567,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1535.32,,,1535.32,Other,New York Medicaid APG methodology,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,2149.45,,,2149.45,Other,140% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3991.84,,,3991.84,Other,260% New York Medicaid APG,4974.44,,,4974.44,Other,324% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,1919.15,,,1919.15,Other,125% New York Medicaid APG,567,26251.6,
Exc h-f-nk-sp b9+marg 2.1-3,11423,CPT,,,,,,,,both,,,36267.22,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18133.61,50,,18133.61,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2855.7,,,2855.7,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25387.05,70,,25387.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1535.32,,,1535.32,Other,New York Medicaid APG methodology,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,2149.45,,,2149.45,Other,140% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3991.84,,,3991.84,Other,260% New York Medicaid APG,4974.44,,,4974.44,Other,324% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,1919.15,,,1919.15,Other,125% New York Medicaid APG,1535.32,25387.05,
Exc h-f-nk-sp b9+marg 3.1-4,11424,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2855.7,,,2855.7,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1535.32,,,1535.32,Other,New York Medicaid APG methodology,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,2149.45,,,2149.45,Other,140% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3991.84,,,3991.84,Other,260% New York Medicaid APG,4974.44,,,4974.44,Other,324% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,1919.15,,,1919.15,Other,125% New York Medicaid APG,1535.32,23871.23,
Exc h-f-nk-sp b9+marg >4 cm,11426,CPT,,,,,,,,both,,,36406.91,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18203.46,50,,18203.46,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25484.84,70,,25484.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2495.74,25484.84,
Exc face-mm b9+marg 0.5 cm/<,11440,CPT,,,,,,,,both,,,36219.26,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,18109.63,50,,18109.63,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25353.48,70,,25353.48,percent of total billed charges,,523.05,,,523.05,Fee Schedule,,443.8,,,443.8,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,443.8,25353.48,
Exc face-mm b9+marg 0.6-1 cm,11441,CPT,,,,,,,,both,,,34637.18,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17318.59,50,,17318.59,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24246.03,70,,24246.03,percent of total billed charges,,655.05,,,655.05,Fee Schedule,,555.8,,,555.8,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,555.8,24246.03,
Exc face-mm b9+marg 1.1-2 cm,11442,CPT,,,,,,,,both,,,35219.66,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17609.83,50,,17609.83,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24653.76,70,,24653.76,percent of total billed charges,,722.7,,,722.7,Fee Schedule,,613.2,,,613.2,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,613.2,24653.76,
Exc face-mm b9+marg 2.1-3 cm,11443,CPT,,,,,,,,both,,,37395.32,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18697.66,50,,18697.66,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2855.7,,,2855.7,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26176.72,70,,26176.72,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1535.32,,,1535.32,Other,New York Medicaid APG methodology,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,2149.45,,,2149.45,Other,140% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3991.84,,,3991.84,Other,260% New York Medicaid APG,4974.44,,,4974.44,Other,324% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,1919.15,,,1919.15,Other,125% New York Medicaid APG,1535.32,26176.72,
Exc face-mm b9+marg 3.1-4 cm,11444,CPT,,,,,,,,both,,,44236.91,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,22118.46,50,,22118.46,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2855.7,,,2855.7,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,30965.84,70,,30965.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1535.32,,,1535.32,Other,New York Medicaid APG methodology,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,2149.45,,,2149.45,Other,140% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3991.84,,,3991.84,Other,260% New York Medicaid APG,4974.44,,,4974.44,Other,324% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,1919.15,,,1919.15,Other,125% New York Medicaid APG,1535.32,30965.84,
Exc face-mm b9+marg >4 cm,11446,CPT,,,,,,,,both,,,43807.73,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,21903.87,50,,21903.87,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,30665.41,70,,30665.41,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2495.74,30665.41,
Removal sweat gland lesion,11450,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2495.74,41837.04,
Removal sweat gland lesion,11451,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2495.74,41837.04,
Removal sweat gland lesion,11462,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2495.74,41837.04,
Removal sweat gland lesion,11463,CPT,,,,,,,,both,,,79425.93,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,39712.97,50,,39712.97,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,55598.15,70,,55598.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2495.74,55598.15,
Removal sweat gland lesion,11470,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2495.74,41837.04,
Removal sweat gland lesion,11471,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2495.74,41837.04,
Exc tr-ext mal+marg 0.5 cm/<,11600,CPT,,,,,,,,both,,,14798.8,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7399.4,50,,7399.4,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10359.16,70,,10359.16,percent of total billed charges,,600.6,,,600.6,Fee Schedule,,509.6,,,509.6,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,509.6,10359.16,
Exc tr-ext mal+marg 0.6-1 cm,11601,CPT,,,,,,,,both,,,14798.8,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7399.4,50,,7399.4,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10359.16,70,,10359.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,813.62,13157,
Exc tr-ext mal+marg 1.1-2 cm,11602,CPT,,,,,,,,both,,,36725.63,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,18362.82,50,,18362.82,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25707.94,70,,25707.94,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,461.11,25707.94,
Exc tr-ext mal+marg 2.1-3 cm,11603,CPT,,,,,,,,both,,,39565.02,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,19782.51,50,,19782.51,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27695.51,70,,27695.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,813.62,27695.51,
Exc tr-ext mal+marg 3.1-4 cm,11604,CPT,,,,,,,,both,,,55886.11,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,27943.06,50,,27943.06,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2855.7,,,2855.7,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,39120.28,70,,39120.28,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1535.32,,,1535.32,Other,New York Medicaid APG methodology,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,2149.45,,,2149.45,Other,140% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3991.84,,,3991.84,Other,260% New York Medicaid APG,4974.44,,,4974.44,Other,324% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,1919.15,,,1919.15,Other,125% New York Medicaid APG,813.62,39120.28,
Exc tr-ext mal+marg >4 cm,11606,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,1874.86,23871.23,
Exc h-f-nk-sp mal+marg 0.5/<,11620,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2855.7,,,2855.7,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,603.9,,,603.9,Fee Schedule,,512.4,,,512.4,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1535.32,,,1535.32,Other,New York Medicaid APG methodology,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,2149.45,,,2149.45,Other,140% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3991.84,,,3991.84,Other,260% New York Medicaid APG,4974.44,,,4974.44,Other,324% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,1919.15,,,1919.15,Other,125% New York Medicaid APG,512.4,23871.23,
Exc s/n/h/f/g mal+mrg 0.6-1,11621,CPT,,,,,,,,both,,,14798.8,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7399.4,50,,7399.4,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10359.16,70,,10359.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,813.62,13157,
Exc s/n/h/f/g mal+mrg 1.1-2,11622,CPT,,,,,,,,both,,,37185.15,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,18592.58,50,,18592.58,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26029.61,70,,26029.61,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,813.62,26029.61,
Exc s/n/h/f/g mal+mrg 2.1-3,11623,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,2855.7,,,2855.7,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1535.32,,,1535.32,Other,New York Medicaid APG methodology,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,2149.45,,,2149.45,Other,140% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3991.84,,,3991.84,Other,260% New York Medicaid APG,4974.44,,,4974.44,Other,324% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,1919.15,,,1919.15,Other,125% New York Medicaid APG,0.01,23871.23,
Exc s/n/h/f/g mal+mrg 3.1-4,11624,CPT,,,,,,,,both,,,38581.78,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19290.89,50,,19290.89,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2855.7,,,2855.7,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27007.25,70,,27007.25,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1535.32,,,1535.32,Other,New York Medicaid APG methodology,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,2149.45,,,2149.45,Other,140% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3991.84,,,3991.84,Other,260% New York Medicaid APG,4974.44,,,4974.44,Other,324% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,1919.15,,,1919.15,Other,125% New York Medicaid APG,1535.32,27007.25,
Exc s/n/h/f/g mal+mrg >4 cm,11626,CPT,,,,,,,,both,,,39290.13,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19645.07,50,,19645.07,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27503.09,70,,27503.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2495.74,27503.09,
Exc f/e/e/n/l mal+mrg 0.5cm<,11640,CPT,,,,,,,,both,,,14798.8,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7399.4,50,,7399.4,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10359.16,70,,10359.16,percent of total billed charges,,620.4,,,620.4,Fee Schedule,,526.4,,,526.4,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,526.4,10359.16,
Exc f/e/e/n/l mal+mrg 0.6-1,11641,CPT,,,,,,,,both,,,37472.95,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,18736.48,50,,18736.48,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26231.07,70,,26231.07,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,813.62,26231.07,
Exc f/e/e/n/l mal+mrg 1.1-2,11642,CPT,,,,,,,,both,,,14798.8,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7399.4,50,,7399.4,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10359.16,70,,10359.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,813.62,13157,
Exc f/e/e/n/l mal+mrg 2.1-3,11643,CPT,,,,,,,,both,,,51235.38,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25617.69,50,,25617.69,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2855.7,,,2855.7,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,35864.77,70,,35864.77,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1535.32,,,1535.32,Other,New York Medicaid APG methodology,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,2149.45,,,2149.45,Other,140% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3991.84,,,3991.84,Other,260% New York Medicaid APG,4974.44,,,4974.44,Other,324% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,1919.15,,,1919.15,Other,125% New York Medicaid APG,1535.32,35864.77,
Exc f/e/e/n/l mal+mrg 3.1-4,11644,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2855.7,,,2855.7,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1535.32,,,1535.32,Other,New York Medicaid APG methodology,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,2149.45,,,2149.45,Other,140% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3991.84,,,3991.84,Other,260% New York Medicaid APG,4974.44,,,4974.44,Other,324% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,1919.15,,,1919.15,Other,125% New York Medicaid APG,1535.32,23871.23,
Exc f/e/e/n/l mal+mrg >4 cm,11646,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2495.74,41837.04,
Trim nail(s) any number,11719,CPT,,,,,,,,both,,,1286.58,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,643.29,50,,643.29,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,411.2,,,411.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,900.61,70,,900.61,percent of total billed charges,,36.3,,,36.3,Fee Schedule,,30.8,,,30.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,221.08,,,221.08,Other,New York Medicaid APG methodology,221.08,,,221.08,Other,100% New York Medicaid APG,221.08,,,221.08,Other,100% New York Medicaid APG,221.08,,,221.08,Other,100% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,309.51,,,309.51,Other,140% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,574.8,,,574.8,Other,260% New York Medicaid APG,716.29,,,716.29,Other,324% New York Medicaid APG,475.32,,,475.32,Other,215% New York Medicaid APG,475.32,,,475.32,Other,215% New York Medicaid APG,276.35,,,276.35,Other,125% New York Medicaid APG,0.01,9473,
Debride nail 1-5,11720,CPT,,,,,,,,both,,,1286.58,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,643.29,50,,643.29,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,411.2,,,411.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,900.61,70,,900.61,percent of total billed charges,,70.95,,,70.95,Fee Schedule,,60.2,,,60.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,221.08,,,221.08,Other,New York Medicaid APG methodology,221.08,,,221.08,Other,100% New York Medicaid APG,221.08,,,221.08,Other,100% New York Medicaid APG,221.08,,,221.08,Other,100% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,309.51,,,309.51,Other,140% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,574.8,,,574.8,Other,260% New York Medicaid APG,716.29,,,716.29,Other,324% New York Medicaid APG,475.32,,,475.32,Other,215% New York Medicaid APG,475.32,,,475.32,Other,215% New York Medicaid APG,276.35,,,276.35,Other,125% New York Medicaid APG,0.01,9473,
Debride nail 6 or more,11721,CPT,,,,,,,,both,,,1286.58,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,643.29,50,,643.29,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,411.2,,,411.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,900.61,70,,900.61,percent of total billed charges,,115.5,,,115.5,Fee Schedule,,98,,,98,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,221.08,,,221.08,Other,New York Medicaid APG methodology,221.08,,,221.08,Other,100% New York Medicaid APG,221.08,,,221.08,Other,100% New York Medicaid APG,221.08,,,221.08,Other,100% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,309.51,,,309.51,Other,140% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,574.8,,,574.8,Other,260% New York Medicaid APG,716.29,,,716.29,Other,324% New York Medicaid APG,475.32,,,475.32,Other,215% New York Medicaid APG,475.32,,,475.32,Other,215% New York Medicaid APG,276.35,,,276.35,Other,125% New York Medicaid APG,0.01,9473,
Removal of nail plate,11730,CPT,,,,,,,,both,,,35082.18,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17541.09,50,,17541.09,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,411.2,,,411.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24557.53,70,,24557.53,percent of total billed charges,,262.35,,,262.35,Fee Schedule,,222.6,,,222.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,221.08,,,221.08,Other,New York Medicaid APG methodology,221.08,,,221.08,Other,100% New York Medicaid APG,221.08,,,221.08,Other,100% New York Medicaid APG,221.08,,,221.08,Other,100% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,309.51,,,309.51,Other,140% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,574.8,,,574.8,Other,260% New York Medicaid APG,716.29,,,716.29,Other,324% New York Medicaid APG,475.32,,,475.32,Other,215% New York Medicaid APG,475.32,,,475.32,Other,215% New York Medicaid APG,276.35,,,276.35,Other,125% New York Medicaid APG,0.01,24557.53,
Remove nail plate add-on,11732,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,411.2,,,411.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,84.15,,,84.15,Fee Schedule,,71.4,,,71.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,221.08,,,221.08,Other,New York Medicaid APG methodology,221.08,,,221.08,Other,100% New York Medicaid APG,221.08,,,221.08,Other,100% New York Medicaid APG,221.08,,,221.08,Other,100% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,309.51,,,309.51,Other,140% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,574.8,,,574.8,Other,260% New York Medicaid APG,716.29,,,716.29,Other,324% New York Medicaid APG,475.32,,,475.32,Other,215% New York Medicaid APG,475.32,,,475.32,Other,215% New York Medicaid APG,276.35,,,276.35,Other,125% New York Medicaid APG,0.01,22702.47,
Drain blood from under nail,11740,CPT,,,,,,,,both,,,2686.86,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1343.43,50,,1343.43,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,411.2,,,411.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,1880.8,70,,1880.8,percent of total billed charges,,156.75,,,156.75,Fee Schedule,,133,,,133,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,221.08,,,221.08,Other,New York Medicaid APG methodology,221.08,,,221.08,Other,100% New York Medicaid APG,221.08,,,221.08,Other,100% New York Medicaid APG,221.08,,,221.08,Other,100% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,309.51,,,309.51,Other,140% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,574.8,,,574.8,Other,260% New York Medicaid APG,716.29,,,716.29,Other,324% New York Medicaid APG,475.32,,,475.32,Other,215% New York Medicaid APG,475.32,,,475.32,Other,215% New York Medicaid APG,276.35,,,276.35,Other,125% New York Medicaid APG,0.01,9473,
Removal of nail bed,11750,CPT,,,,,,,,both,,,34489.9,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17244.95,50,,17244.95,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24142.93,70,,24142.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,461.11,24142.93,
Biopsy nail unit,11755,CPT,,,,,,,,both,,,14798.8,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7399.4,50,,7399.4,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10359.16,70,,10359.16,percent of total billed charges,,295.35,,,295.35,Fee Schedule,,250.6,,,250.6,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,250.6,10359.16,
Repair of nail bed,11760,CPT,,,,,,,,both,,,35603.23,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17801.62,50,,17801.62,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,411.2,,,411.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24922.26,70,,24922.26,percent of total billed charges,,542.85,,,542.85,Fee Schedule,,460.6,,,460.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,221.08,,,221.08,Other,New York Medicaid APG methodology,221.08,,,221.08,Other,100% New York Medicaid APG,221.08,,,221.08,Other,100% New York Medicaid APG,221.08,,,221.08,Other,100% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,309.51,,,309.51,Other,140% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,574.8,,,574.8,Other,260% New York Medicaid APG,716.29,,,716.29,Other,324% New York Medicaid APG,475.32,,,475.32,Other,215% New York Medicaid APG,475.32,,,475.32,Other,215% New York Medicaid APG,276.35,,,276.35,Other,125% New York Medicaid APG,0.01,24922.26,
Reconstruction of nail bed,11762,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,2855.7,,,2855.7,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1535.32,,,1535.32,Other,New York Medicaid APG methodology,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,2149.45,,,2149.45,Other,140% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3991.84,,,3991.84,Other,260% New York Medicaid APG,4974.44,,,4974.44,Other,324% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,1919.15,,,1919.15,Other,125% New York Medicaid APG,0.01,26850.29,
Excision of nail fold toe,11765,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,411.2,,,411.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,452.1,,,452.1,Fee Schedule,,383.6,,,383.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,221.08,,,221.08,Other,New York Medicaid APG methodology,221.08,,,221.08,Other,100% New York Medicaid APG,221.08,,,221.08,Other,100% New York Medicaid APG,221.08,,,221.08,Other,100% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,309.51,,,309.51,Other,140% New York Medicaid APG,497.42,,,497.42,Other,225% New York Medicaid APG,574.8,,,574.8,Other,260% New York Medicaid APG,716.29,,,716.29,Other,324% New York Medicaid APG,475.32,,,475.32,Other,215% New York Medicaid APG,475.32,,,475.32,Other,215% New York Medicaid APG,276.35,,,276.35,Other,125% New York Medicaid APG,0.01,9473,
Remove pilonidal cyst simple,11770,CPT,,,,,,,,both,,,35492.13,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17746.07,50,,17746.07,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2855.7,,,2855.7,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24844.49,70,,24844.49,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1535.32,,,1535.32,Other,New York Medicaid APG methodology,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,2149.45,,,2149.45,Other,140% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3991.84,,,3991.84,Other,260% New York Medicaid APG,4974.44,,,4974.44,Other,324% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,1919.15,,,1919.15,Other,125% New York Medicaid APG,1535.32,24844.49,
Remove pilonidal cyst exten,11771,CPT,,,,,,,,both,,,36470.63,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18235.32,50,,18235.32,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25529.44,70,,25529.44,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2495.74,25529.44,
Remove pilonidal cyst compl,11772,CPT,,,,,,,,both,,,37285.68,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18642.84,50,,18642.84,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26099.98,70,,26099.98,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2495.74,26099.98,
Inject skin lesions </w 7,11900,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,146.85,,,146.85,Fee Schedule,,124.6,,,124.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Inject skin lesions >7,11901,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,222.75,,,222.75,Fee Schedule,,189,,,189,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Correct skin color 6.0 cm/<,11920,CPT,,,,,,,,both,,,13210.22,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6605.11,50,,6605.11,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9247.15,70,,9247.15,percent of total billed charges,,534.6,,,534.6,Fee Schedule,,453.6,,,453.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,0.01,9473,
Correct skn color 6.1-20.0cm,11921,CPT,,,,,,,,both,,,13210.22,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6605.11,50,,6605.11,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9247.15,70,,9247.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,0.01,13157,
Correct skin color ea 20.0cm,11922,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,143.55,,,143.55,Fee Schedule,,121.8,,,121.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,0.01,22702.47,
Tx contour defects 1 cc/<,11950,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,257.4,,,257.4,Fee Schedule,,218.4,,,218.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,0.01,9473,
Tx contour defects 1.1-5.0cc,11951,CPT,,,,,,,,both,,,13210.22,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6605.11,50,,6605.11,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9247.15,70,,9247.15,percent of total billed charges,,358.05,,,358.05,Fee Schedule,,303.8,,,303.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,0.01,9473,
Tx contour defects 5.1-10cc,11952,CPT,,,,,,,,both,,,13210.22,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6605.11,50,,6605.11,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9247.15,70,,9247.15,percent of total billed charges,,501.6,,,501.6,Fee Schedule,,425.6,,,425.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,0.01,9473,
Tx contour defects >10.0 cc,11954,CPT,,,,,,,,both,,,13210.22,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6605.11,50,,6605.11,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,2855.7,,,2855.7,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9247.15,70,,9247.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1535.32,,,1535.32,Other,New York Medicaid APG methodology,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,2149.45,,,2149.45,Other,140% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3991.84,,,3991.84,Other,260% New York Medicaid APG,4974.44,,,4974.44,Other,324% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,1919.15,,,1919.15,Other,125% New York Medicaid APG,0.01,13157,
Insert tissue expander(s),11960,CPT,,,,,,,,both,,,41203.11,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,20601.56,50,,20601.56,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28842.18,70,,28842.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2495.74,28842.18,
Rplcmt tiss xpndr perm implt,11970,CPT,,,,,,,,both,,,42031.03,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,21015.52,50,,21015.52,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4952.04,,,4952.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29421.72,70,,29421.72,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2662.39,,,2662.39,Other,New York Medicaid APG methodology,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,3727.34,,,3727.34,Other,140% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,6922.2,,,6922.2,Other,260% New York Medicaid APG,8626.13,,,8626.13,Other,324% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,3327.98,,,3327.98,Other,125% New York Medicaid APG,2662.39,29421.72,
Rmvl tis xpndr wo insj implt,11971,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3569.69,,,3569.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1919.19,,,1919.19,Other,New York Medicaid APG methodology,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,2686.86,,,2686.86,Other,140% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4989.89,,,4989.89,Other,260% New York Medicaid APG,6218.17,,,6218.17,Other,324% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,2398.98,,,2398.98,Other,125% New York Medicaid APG,1919.19,41837.04,
Remove contraceptive capsule,11976,CPT,,,,,,,,both,,,14798.8,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7399.4,50,,7399.4,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10359.16,70,,10359.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,813.62,13157,
Implant hormone pellet(s),11980,CPT,,,,,,,,both,,,8380.68,757.69,,,757.69,Other,150% of Medicare + 9.63% HCRA Surcharge,460.76,,,460.76,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4190.34,50,,4190.34,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5866.48,70,,5866.48,percent of total billed charges,,273.9,,,273.9,Fee Schedule,,232.4,,,232.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,0.01,9473,
Insert drug implant device,11981,CPT,,,,,,,,both,,,34479.41,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17239.71,50,,17239.71,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24135.59,70,,24135.59,percent of total billed charges,,306.9,,,306.9,Fee Schedule,,260.4,,,260.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,24135.59,
Remove drug implant device,11982,CPT,,,,,,,,both,,,34480.35,757.69,,,757.69,Other,150% of Medicare + 9.63% HCRA Surcharge,460.76,,,460.76,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17240.18,50,,17240.18,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24136.25,70,,24136.25,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,24136.25,
Remove/insert drug implant,11983,CPT,,,,,,,,both,,,34458.47,757.69,,,757.69,Other,150% of Medicare + 9.63% HCRA Surcharge,460.76,,,460.76,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17229.24,50,,17229.24,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24120.93,70,,24120.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,24120.93,
Rpr s/n/ax/gen/trnk 2.5cm/<,12001,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1193.32,,,1193.32,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,221.1,,,221.1,Fee Schedule,,187.6,,,187.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,898.2,,,898.2,Other,140% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1668.08,,,1668.08,Other,260% New York Medicaid APG,2078.69,,,2078.69,Other,324% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,801.96,,,801.96,Other,125% New York Medicaid APG,0.01,9473,
Rpr s/n/ax/gen/trnk2.6-7.5cm,12002,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1193.32,,,1193.32,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,288.75,,,288.75,Fee Schedule,,245,,,245,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,898.2,,,898.2,Other,140% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1668.08,,,1668.08,Other,260% New York Medicaid APG,2078.69,,,2078.69,Other,324% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,801.96,,,801.96,Other,125% New York Medicaid APG,0.01,9473,
Rpr s/n/ax/gen/trk7.6-12.5cm,12004,CPT,,,,,,,,both,,,35302.99,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17651.5,50,,17651.5,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1193.32,,,1193.32,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24712.09,70,,24712.09,percent of total billed charges,,358.05,,,358.05,Fee Schedule,,303.8,,,303.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,898.2,,,898.2,Other,140% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1668.08,,,1668.08,Other,260% New York Medicaid APG,2078.69,,,2078.69,Other,324% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,801.96,,,801.96,Other,125% New York Medicaid APG,0.01,24712.09,
Rpr s/n/a/gen/trk12.6-20.0cm,12005,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1193.32,,,1193.32,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,898.2,,,898.2,Other,140% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1668.08,,,1668.08,Other,260% New York Medicaid APG,2078.69,,,2078.69,Other,324% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,801.96,,,801.96,Other,125% New York Medicaid APG,461.11,13157,
Rpr s/n/a/gen/trk20.1-30.0cm,12006,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1193.32,,,1193.32,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,898.2,,,898.2,Other,140% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1668.08,,,1668.08,Other,260% New York Medicaid APG,2078.69,,,2078.69,Other,324% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,801.96,,,801.96,Other,125% New York Medicaid APG,461.11,13157,
Rpr s/n/ax/gen/trnk >30.0 cm,12007,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1193.32,,,1193.32,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,898.2,,,898.2,Other,140% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1668.08,,,1668.08,Other,260% New York Medicaid APG,2078.69,,,2078.69,Other,324% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,801.96,,,801.96,Other,125% New York Medicaid APG,231.51,13157,
Rpr f/e/e/n/l/m 2.5 cm/<,12011,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1193.32,,,1193.32,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,270.6,,,270.6,Fee Schedule,,229.6,,,229.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,898.2,,,898.2,Other,140% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1668.08,,,1668.08,Other,260% New York Medicaid APG,2078.69,,,2078.69,Other,324% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,801.96,,,801.96,Other,125% New York Medicaid APG,0.01,9473,
Rpr f/e/e/n/l/m 2.6-5.0 cm,12013,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1193.32,,,1193.32,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,287.1,,,287.1,Fee Schedule,,243.6,,,243.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,898.2,,,898.2,Other,140% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1668.08,,,1668.08,Other,260% New York Medicaid APG,2078.69,,,2078.69,Other,324% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,801.96,,,801.96,Other,125% New York Medicaid APG,0.01,9473,
Rpr f/e/e/n/l/m 5.1-7.5 cm,12014,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1193.32,,,1193.32,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,366.3,,,366.3,Fee Schedule,,310.8,,,310.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,898.2,,,898.2,Other,140% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1668.08,,,1668.08,Other,260% New York Medicaid APG,2078.69,,,2078.69,Other,324% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,801.96,,,801.96,Other,125% New York Medicaid APG,0.01,9473,
Rpr f/e/e/n/l/m 7.6-12.5 cm,12015,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1193.32,,,1193.32,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,898.2,,,898.2,Other,140% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1668.08,,,1668.08,Other,260% New York Medicaid APG,2078.69,,,2078.69,Other,324% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,801.96,,,801.96,Other,125% New York Medicaid APG,0.01,13157,
Rpr fe/e/en/l/m 12.6-20.0 cm,12016,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1193.32,,,1193.32,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,898.2,,,898.2,Other,140% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1668.08,,,1668.08,Other,260% New York Medicaid APG,2078.69,,,2078.69,Other,324% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,801.96,,,801.96,Other,125% New York Medicaid APG,461.11,13157,
Rpr fe/e/en/l/m 20.1-30.0 cm,12017,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1193.32,,,1193.32,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,898.2,,,898.2,Other,140% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1668.08,,,1668.08,Other,260% New York Medicaid APG,2078.69,,,2078.69,Other,324% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,801.96,,,801.96,Other,125% New York Medicaid APG,461.11,13157,
Rpr f/e/e/n/l/m >30.0 cm,12018,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1193.32,,,1193.32,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,898.2,,,898.2,Other,140% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1668.08,,,1668.08,Other,260% New York Medicaid APG,2078.69,,,2078.69,Other,324% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,801.96,,,801.96,Other,125% New York Medicaid APG,231.51,13157,
Closure of split wound,12020,CPT,,,,,,,,both,,,35741.92,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17870.96,50,,17870.96,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25019.34,70,,25019.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,726.28,25019.34,
Closure of split wound,12021,CPT,,,,,,,,both,,,33626.79,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16813.4,50,,16813.4,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23538.75,70,,23538.75,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,461.11,23538.75,
Intmd rpr s/a/t/ext 2.5 cm/<,12031,CPT,,,,,,,,both,,,37087.59,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,18543.8,50,,18543.8,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25961.31,70,,25961.31,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,0.01,25961.31,
Intmd rpr s/a/t/ext 2.6-7.5,12032,CPT,,,,,,,,both,,,34955.57,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17477.79,50,,17477.79,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24468.9,70,,24468.9,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,0.01,24468.9,
Intmd rpr s/tr/ext 7.6-12.5,12034,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,461.11,13157,
Intmd rpr s/a/t/ext 12.6-20,12035,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,461.11,13157,
Intmd rpr s/a/t/ext 20.1-30,12036,CPT,,,,,,,,both,,,13210.22,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6605.11,50,,6605.11,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9247.15,70,,9247.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,726.28,13157,
Intmd rpr s/tr/ext >30.0 cm,12037,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,916.36,26850.29,
Intmd rpr n-hf/genit 2.5cm/<,12041,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,0.01,13157,
Intmd rpr n-hf/genit2.6-7.5,12042,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,0.01,13157,
Intmd rpr n-hf/genit7.6-12.5,12044,CPT,,,,,,,,both,,,13210.22,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6605.11,50,,6605.11,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9247.15,70,,9247.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,726.28,13157,
Intmd rpr n-hf/genit12.6-20,12045,CPT,,,,,,,,both,,,13210.22,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6605.11,50,,6605.11,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9247.15,70,,9247.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,726.28,13157,
Intmd rpr n-hf/genit20.1-30,12046,CPT,,,,,,,,both,,,13210.22,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6605.11,50,,6605.11,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9247.15,70,,9247.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,726.28,13157,
Intmd rpr n-hf/genit >30.0cm,12047,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,916.36,26850.29,
Intmd rpr face/mm 2.5 cm/<,12051,CPT,,,,,,,,both,,,35324.33,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17662.17,50,,17662.17,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24727.03,70,,24727.03,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,0.01,24727.03,
Intmd rpr face/mm 2.6-5.0 cm,12052,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,0.01,13157,
Intmd rpr face/mm 5.1-7.5 cm,12053,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,0.01,13157,
Intmd rpr face/mm 7.6-12.5cm,12054,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,461.11,13157,
Intmd rpr face/mm 12.6-20 cm,12055,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,461.11,13157,
Intmd rpr face/mm 20.1-30.0,12056,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,461.11,13157,
Intmd rpr face/mm >30.0 cm,12057,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,461.11,13157,
Cmplx rpr trunk 1.1-2.5 cm,13100,CPT,,,,,,,,both,,,13210.22,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6605.11,50,,6605.11,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9247.15,70,,9247.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,726.28,13157,
Cmplx rpr trunk 2.6-7.5 cm,13101,CPT,,,,,,,,both,,,34403.66,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17201.83,50,,17201.83,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24082.56,70,,24082.56,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,726.28,24082.56,
Cmplx rpr trunk addl 5cm/<,13102,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,349.8,,,349.8,Fee Schedule,,296.8,,,296.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,0.01,36100.43,
Cmplx rpr s/a/l 1.1-2.5 cm,13120,CPT,,,,,,,,both,,,38708.34,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,19354.17,50,,19354.17,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27095.84,70,,27095.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,726.28,27095.84,
Cmplx rpr s/a/l 2.6-7.5 cm,13121,CPT,,,,,,,,both,,,34012,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17006,50,,17006,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23808.4,70,,23808.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,726.28,23808.4,
Cmplx rpr s/a/l addl 5 cm/>,13122,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,404.25,,,404.25,Fee Schedule,,343,,,343,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,0.01,36100.43,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13131,CPT,,,,,,,,both,,,34288.5,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17144.25,50,,17144.25,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24001.95,70,,24001.95,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,461.11,24001.95,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13132,CPT,,,,,,,,both,,,36334.59,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,18167.3,50,,18167.3,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25434.21,70,,25434.21,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,726.28,25434.21,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13133,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,0.01,36100.43,
Cmplx rpr e/n/e/l 1.1-2.5 cm,13151,CPT,,,,,,,,both,,,13210.22,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6605.11,50,,6605.11,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9247.15,70,,9247.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,726.28,13157,
Cmplx rpr e/n/e/l 2.6-7.5 cm,13152,CPT,,,,,,,,both,,,13210.22,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6605.11,50,,6605.11,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9247.15,70,,9247.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,726.28,13157,
Cmplx rpr e/n/e/l addl 5cm/<,13153,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,2855.7,,,2855.7,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1535.32,,,1535.32,Other,New York Medicaid APG methodology,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,2149.45,,,2149.45,Other,140% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3991.84,,,3991.84,Other,260% New York Medicaid APG,4974.44,,,4974.44,Other,324% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,1919.15,,,1919.15,Other,125% New York Medicaid APG,0.01,36100.43,
Late closure of wound,13160,CPT,,,,,,,,both,,,42510.74,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21255.37,50,,21255.37,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3180.63,,,3180.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29757.52,70,,29757.52,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,2394.02,,,2394.02,Other,140% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,4446.04,,,4446.04,Other,260% New York Medicaid APG,5540.45,,,5540.45,Other,324% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,2137.52,,,2137.52,Other,125% New York Medicaid APG,1710.01,29757.52,
Tis trnfr trunk 10 sq cm/<,14000,CPT,,,,,,,,both,,,37536.83,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18768.42,50,,18768.42,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26275.78,70,,26275.78,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,26275.78,
Tis trnfr trunk 10.1-30sqcm,14001,CPT,,,,,,,,both,,,45392.1,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,22696.05,50,,22696.05,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31774.47,70,,31774.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,31774.47,
Tis trnfr s/a/l 10 sq cm/<,14020,CPT,,,,,,,,both,,,39919.58,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19959.79,50,,19959.79,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27943.71,70,,27943.71,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,27943.71,
Tis trnfr s/a/l 10.1-30 sqcm,14021,CPT,,,,,,,,both,,,39136.09,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19568.05,50,,19568.05,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27395.26,70,,27395.26,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,27395.26,
Tis trnfr f/c/c/m/n/a/g/h/f,14040,CPT,,,,,,,,both,,,35494.9,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17747.45,50,,17747.45,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24846.43,70,,24846.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,24846.43,
Tis trnfr f/c/c/m/n/a/g/h/f,14041,CPT,,,,,,,,both,,,36489.01,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18244.51,50,,18244.51,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25542.31,70,,25542.31,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,25542.31,
Tis trnfr e/n/e/l 10 sq cm/<,14060,CPT,,,,,,,,both,,,37887.21,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18943.61,50,,18943.61,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26521.05,70,,26521.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,26521.05,
Tis trnfr e/n/e/l10.1-30sqcm,14061,CPT,,,,,,,,both,,,41980.43,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20990.22,50,,20990.22,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29386.3,70,,29386.3,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,29386.3,
Tis trnfr any 30.1-60 sq cm,14301,CPT,,,,,,,,both,,,38120.07,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19060.04,50,,19060.04,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26684.05,70,,26684.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,26684.05,
Tis trnfr addl 30 sq cm,14302,CPT,,,,,,,,both,,,83504,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,41752,50,,41752,percent of total billed charges,,58452.8,70,,58452.8,percent of total billed charges,,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,58452.8,70,,58452.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,0.01,58452.8,
Filleted finger/toe flap,14350,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,26850.29,
Wound prep trk/arm/leg,15002,CPT,,,,,,,,both,,,52099.26,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,26049.63,50,,26049.63,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3180.63,,,3180.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36469.48,70,,36469.48,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,2394.02,,,2394.02,Other,140% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,4446.04,,,4446.04,Other,260% New York Medicaid APG,5540.45,,,5540.45,Other,324% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,2137.52,,,2137.52,Other,125% New York Medicaid APG,1710.01,36469.48,
Wound prep addl 100 cm,15003,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,221.1,,,221.1,Fee Schedule,,187.6,,,187.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,0.01,22702.47,
Wound prep f/n/hf/g,15004,CPT,,,,,,,,both,,,53677.47,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,26838.74,50,,26838.74,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3180.63,,,3180.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,37574.23,70,,37574.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,2394.02,,,2394.02,Other,140% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,4446.04,,,4446.04,Other,260% New York Medicaid APG,5540.45,,,5540.45,Other,324% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,2137.52,,,2137.52,Other,125% New York Medicaid APG,726.28,37574.23,
Wnd prep f/n/hf/g addl cm,15005,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,437.25,,,437.25,Fee Schedule,,371,,,371,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,0.01,22702.47,
Harvest cultured skin graft,15040,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,26850.29,
Skin pinch graft,15050,CPT,,,,,,,,both,,,13210.22,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6605.11,50,,6605.11,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9247.15,70,,9247.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,726.28,13157,
Skin splt grft trnk/arm/leg,15100,CPT,,,,,,,,both,,,44592.35,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,22296.18,50,,22296.18,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31214.65,70,,31214.65,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,31214.65,
Skin splt grft t/a/l add-on,15101,CPT,,,,,,,,both,,,64479.48,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32239.74,50,,32239.74,percent of total billed charges,,45135.64,70,,45135.64,percent of total billed charges,,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45135.64,70,,45135.64,percent of total billed charges,,542.85,,,542.85,Fee Schedule,,460.6,,,460.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,0.01,45135.64,
Epidrm autogrft trnk/arm/leg,15110,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,26850.29,
Epidrm autogrft t/a/l add-on,15111,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,0.01,36100.43,
Epidrm a-grft face/nck/hf/g,15115,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,26850.29,
Epidrm a-grft f/n/hf/g addl,15116,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,0.01,22702.47,
Skn splt a-grft fac/nck/hf/g,15120,CPT,,,,,,,,both,,,43467.36,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,21733.68,50,,21733.68,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,30427.15,70,,30427.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,30427.15,
Skn splt a-grft f/n/hf/g add,15121,CPT,,,,,,,,both,,,64479.48,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32239.74,50,,32239.74,percent of total billed charges,,45135.64,70,,45135.64,percent of total billed charges,,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45135.64,70,,45135.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,0.01,45135.64,
Derm autograft trnk/arm/leg,15130,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,26850.29,
Derm autograft t/a/l add-on,15131,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,438.9,,,438.9,Fee Schedule,,372.4,,,372.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,0.01,22702.47,
Derm autograft face/nck/hf/g,15135,CPT,,,,,,,,both,,,75461.18,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,37730.59,50,,37730.59,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52822.83,70,,52822.83,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,52822.83,
Derm autograft f/n/hf/g add,15136,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,438.9,,,438.9,Fee Schedule,,372.4,,,372.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,0.01,22702.47,
Cult skin grft t/arm/leg,15150,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,26850.29,
Cult skin grft t/a/l addl,15151,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,0.01,22702.47,
Cult skin graft t/a/l +%,15152,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,0.01,22702.47,
Cult skin graft f/n/hf/g,15155,CPT,,,,,,,,both,,,75461.18,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,37730.59,50,,37730.59,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52822.83,70,,52822.83,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,52822.83,
Cult skin grft f/n/hfg add,15156,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,0.01,22702.47,
Cult epiderm grft f/n/hfg +%,15157,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,0.01,22702.47,
Skin full graft trunk,15200,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,26850.29,
Skin full graft trunk add-on,15201,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,374.55,,,374.55,Fee Schedule,,317.8,,,317.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,0.01,36100.43,
Skin full graft sclp/arm/leg,15220,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,26850.29,
Skin full graft add-on,15221,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,336.6,,,336.6,Fee Schedule,,285.6,,,285.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,0.01,36100.43,
Skin full grft face/genit/hf,15240,CPT,,,,,,,,both,,,35564.94,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17782.47,50,,17782.47,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24895.46,70,,24895.46,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,24895.46,
Skin full graft add-on,15241,CPT,,,,,,,,both,,,64479.48,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32239.74,50,,32239.74,percent of total billed charges,,45135.64,70,,45135.64,percent of total billed charges,,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45135.64,70,,45135.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,0.01,45135.64,
Skin full graft een & lips,15260,CPT,,,,,,,,both,,,36243.1,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18121.55,50,,18121.55,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25370.17,70,,25370.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,25370.17,
Skin full graft add-on,15261,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,0.01,36100.43,
Skin sub graft trnk/arm/leg,15271,CPT,,,,,,,,both,,,48047.99,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24024,50,,24024,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,33633.59,70,,33633.59,percent of total billed charges,,407.55,,,407.55,Fee Schedule,,345.8,,,345.8,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,345.8,33633.59,
Skin sub graft t/a/l add-on,15272,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,80.85,,,80.85,Fee Schedule,,68.6,,,68.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,0.01,22702.47,
Skin sub grft t/arm/lg child,15273,CPT,,,,,,,,both,,,76185.34,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,38092.67,50,,38092.67,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,53329.74,70,,53329.74,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,53329.74,
Skn sub grft t/a/l child add,15274,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,219.45,,,219.45,Fee Schedule,,186.2,,,186.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,0.01,22702.47,
Skin sub graft face/nk/hf/g,15275,CPT,,,,,,,,both,,,45432.24,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,22716.12,50,,22716.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31802.57,70,,31802.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,31802.57,
Skin sub graft f/n/hf/g addl,15276,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,122.1,,,122.1,Fee Schedule,,103.6,,,103.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,0.01,22702.47,
Skn sub grft f/n/hf/g child,15277,CPT,,,,,,,,both,,,68206.6,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,34103.3,50,,34103.3,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47744.62,70,,47744.62,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,47744.62,
Skn sub grft f/n/hf/g ch add,15278,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,272.25,,,272.25,Fee Schedule,,231,,,231,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,0.01,22702.47,
Skin pedicle flap trunk,15570,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,26850.29,
Skin pedicle flap arms/legs,15572,CPT,,,,,,,,both,,,75461.18,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,37730.59,50,,37730.59,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52822.83,70,,52822.83,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,52822.83,
Pedcle fh/ch/ch/m/n/ax/g/h/f,15574,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,26850.29,
Pedicle e/n/e/l/ntroral,15576,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,26850.29,
Delay flap trunk,15600,CPT,,,,,,,,both,,,75461.18,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,37730.59,50,,37730.59,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52822.83,70,,52822.83,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,52822.83,
Delay flap arms/legs,15610,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,26850.29,
Delay flap f/c/c/n/ax/g/h/f,15620,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,26850.29,
Delay flap eye/nos/ear/lip,15630,CPT,,,,,,,,both,,,35844.47,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17922.24,50,,17922.24,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25091.13,70,,25091.13,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,25091.13,
Transfer skin pedicle flap,15650,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,26850.29,
Mdfc flap w/prsrv vasc pedcl,15730,CPT,,,,,,,,both,,,75461.18,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,37730.59,50,,37730.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52822.83,70,,52822.83,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,52822.83,
Forehead flap w/vasc pedicle,15731,CPT,,,,,,,,both,,,37166,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18583,50,,18583,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26016.2,70,,26016.2,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,26016.2,
Musc myoq/fscq flp h&n pedcl,15733,CPT,,,,,,,,both,,,114832.81,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,57416.41,50,,57416.41,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80382.97,70,,80382.97,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,80382.97,
Muscle-skin graft trunk,15734,CPT,,,,,,,,both,,,41979.88,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,20989.94,50,,20989.94,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29385.92,70,,29385.92,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,29385.92,
Muscle-skin graft arm,15736,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,26850.29,
Muscle-skin graft leg,15738,CPT,,,,,,,,both,,,75461.18,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,37730.59,50,,37730.59,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52822.83,70,,52822.83,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,52822.83,
Island pedicle flap graft,15740,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,26850.29,
Neurovascular pedicle flap,15750,CPT,,,,,,,,both,,,75461.18,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,37730.59,50,,37730.59,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52822.83,70,,52822.83,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,52822.83,
Composite skin graft,15760,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,26850.29,
Grfg autol soft tiss dir exc,15769,CPT,,,,,,,,both,,,75461.18,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,37730.59,50,,37730.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52822.83,70,,52822.83,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,52822.83,
Derma-fat-fascia graft,15770,CPT,,,,,,,,both,,,75461.18,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,37730.59,50,,37730.59,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52822.83,70,,52822.83,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,52822.83,
Grfg autol fat lipo 50 cc/<,15771,CPT,,,,,,,,both,,,37767.03,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,18883.52,50,,18883.52,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26436.92,70,,26436.92,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,26436.92,
Grfg autol fat lipo 25 cc/<,15773,CPT,,,,,,,,both,,,36802.85,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,18401.43,50,,18401.43,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25762,70,,25762,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,25762,
Hair trnspl 1-15 punch grfts,15775,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,461.11,13157,
Hair trnspl >15 punch grafts,15776,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,461.11,13157,
Acellular derm matrix implt,15777,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,0.01,36100.43,
Dermabrasion total face,15780,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1516.17,,,1516.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,815.14,,,815.14,Other,New York Medicaid APG methodology,815.14,,,815.14,Other,100% New York Medicaid APG,815.14,,,815.14,Other,100% New York Medicaid APG,815.14,,,815.14,Other,100% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1141.2,,,1141.2,Other,140% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,2119.37,,,2119.37,Other,260% New York Medicaid APG,2641.06,,,2641.06,Other,324% New York Medicaid APG,1752.56,,,1752.56,Other,215% New York Medicaid APG,1752.56,,,1752.56,Other,215% New York Medicaid APG,1018.93,,,1018.93,Other,125% New York Medicaid APG,815.14,41837.04,
Dermabrasion segmental face,15781,CPT,,,,,,,,both,,,14798.8,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7399.4,50,,7399.4,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1516.17,,,1516.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10359.16,70,,10359.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,815.14,,,815.14,Other,New York Medicaid APG methodology,815.14,,,815.14,Other,100% New York Medicaid APG,815.14,,,815.14,Other,100% New York Medicaid APG,815.14,,,815.14,Other,100% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1141.2,,,1141.2,Other,140% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,2119.37,,,2119.37,Other,260% New York Medicaid APG,2641.06,,,2641.06,Other,324% New York Medicaid APG,1752.56,,,1752.56,Other,215% New York Medicaid APG,1752.56,,,1752.56,Other,215% New York Medicaid APG,1018.93,,,1018.93,Other,125% New York Medicaid APG,813.62,13157,
Dermabrasion other than face,15782,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1516.17,,,1516.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,815.14,,,815.14,Other,New York Medicaid APG methodology,815.14,,,815.14,Other,100% New York Medicaid APG,815.14,,,815.14,Other,100% New York Medicaid APG,815.14,,,815.14,Other,100% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1141.2,,,1141.2,Other,140% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,2119.37,,,2119.37,Other,260% New York Medicaid APG,2641.06,,,2641.06,Other,324% New York Medicaid APG,1752.56,,,1752.56,Other,215% New York Medicaid APG,1752.56,,,1752.56,Other,215% New York Medicaid APG,1018.93,,,1018.93,Other,125% New York Medicaid APG,815.14,41837.04,
Dermabrasion suprfl any site,15783,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1516.17,,,1516.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,815.14,,,815.14,Other,New York Medicaid APG methodology,815.14,,,815.14,Other,100% New York Medicaid APG,815.14,,,815.14,Other,100% New York Medicaid APG,815.14,,,815.14,Other,100% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1141.2,,,1141.2,Other,140% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,2119.37,,,2119.37,Other,260% New York Medicaid APG,2641.06,,,2641.06,Other,324% New York Medicaid APG,1752.56,,,1752.56,Other,215% New York Medicaid APG,1752.56,,,1752.56,Other,215% New York Medicaid APG,1018.93,,,1018.93,Other,125% New York Medicaid APG,461.11,13157,
Abrasion lesion single,15786,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,13157,
Abrasion lesions add-on,15787,CPT,,,,,,,,both,,,64479.48,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32239.74,50,,32239.74,percent of total billed charges,,45135.64,70,,45135.64,percent of total billed charges,,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45135.64,70,,45135.64,percent of total billed charges,,80.85,,,80.85,Fee Schedule,,68.6,,,68.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,45135.64,
Chemical peel face epiderm,15788,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,13157,
Chemical peel face dermal,15789,CPT,,,,,,,,both,,,13210.22,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6605.11,50,,6605.11,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9247.15,70,,9247.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,13157,
Chemical peel nonfacial,15792,CPT,,,,,,,,both,,,13210.22,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6605.11,50,,6605.11,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9247.15,70,,9247.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,13157,
Chemical peel nonfacial,15793,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,13157,
Plastic surgery neck,15819,CPT,,,,,,,,both,,,42554.16,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21277.08,50,,21277.08,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29787.91,70,,29787.91,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2108.84,29787.91,
Revision of lower eyelid,15820,CPT,,,,,,,,both,,,52507.66,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,26253.83,50,,26253.83,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36755.36,70,,36755.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2108.84,36755.36,
Revision of lower eyelid,15821,CPT,,,,,,,,both,,,38470.57,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19235.29,50,,19235.29,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26929.4,70,,26929.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2108.84,26929.4,
Revision of upper eyelid,15822,CPT,,,,,,,,both,,,33859.66,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16929.83,50,,16929.83,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23701.76,70,,23701.76,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2108.84,23701.76,
Revision of upper eyelid,15823,CPT,,,,,,,,both,,,35176.52,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17588.26,50,,17588.26,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24623.56,70,,24623.56,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2108.84,24623.56,
Removal of forehead wrinkles,15824,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,19178.78,50,,19178.78,percent of total billed charges,,19178.78,50,,19178.78,percent of total billed charges,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2108.84,26850.29,
Removal of neck wrinkles,15825,CPT,,,,,,,,both,,,75461.18,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,37730.59,50,,37730.59,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52822.83,70,,52822.83,percent of total billed charges,,37730.59,50,,37730.59,percent of total billed charges,,37730.59,50,,37730.59,percent of total billed charges,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2495.74,52822.83,
Removal of brow wrinkles,15826,CPT,,,,,,,,both,,,75461.18,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,37730.59,50,,37730.59,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52822.83,70,,52822.83,percent of total billed charges,,37730.59,50,,37730.59,percent of total billed charges,,37730.59,50,,37730.59,percent of total billed charges,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2495.74,52822.83,
Removal of face wrinkles,15828,CPT,,,,,,,,both,,,75461.18,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,37730.59,50,,37730.59,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52822.83,70,,52822.83,percent of total billed charges,,37730.59,50,,37730.59,percent of total billed charges,,37730.59,50,,37730.59,percent of total billed charges,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2495.74,52822.83,
Removal of skin wrinkles,15829,CPT,,,,,,,,both,,,70986.49,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,35493.25,50,,35493.25,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,49690.54,70,,49690.54,percent of total billed charges,,35493.25,50,,35493.25,percent of total billed charges,,35493.25,50,,35493.25,percent of total billed charges,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2495.74,49690.54,
Exc skin abd,15830,CPT,,,,,,,,both,,,54151.53,12400.81,,,12400.81,Other,150% of Medicare + 9.63% HCRA Surcharge,7541.01,,,7541.01,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,27075.77,50,,27075.77,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,37906.07,70,,37906.07,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2495.74,37906.07,
Excise excessive skin thigh,15832,CPT,,,,,,,,both,,,34291.71,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17145.86,50,,17145.86,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24004.2,70,,24004.2,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2495.74,24004.2,
Excise excessive skin leg,15833,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2495.74,41837.04,
Excise excessive skin hip,15834,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2495.74,41837.04,
Excise excessive skin buttck,15835,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2495.74,41837.04,
Excise excessive skin arm,15836,CPT,,,,,,,,both,,,67795.49,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33897.75,50,,33897.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47456.84,70,,47456.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2495.74,47456.84,
Excise excess skin arm/hand,15837,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2495.74,41837.04,
Excise excess skin fat pad,15838,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2495.74,41837.04,
Excise excess skin & tissue,15839,CPT,,,,,,,,both,,,42064.03,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,21032.02,50,,21032.02,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29444.82,70,,29444.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2495.74,29444.82,
Nerve palsy fascial graft,15840,CPT,,,,,,,,both,,,75461.18,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,37730.59,50,,37730.59,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52822.83,70,,52822.83,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,52822.83,
Nerve palsy muscle graft,15841,CPT,,,,,,,,both,,,75461.18,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,37730.59,50,,37730.59,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52822.83,70,,52822.83,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,52822.83,
Nerve palsy microsurg graft,15842,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,26850.29,
Skin and muscle repair face,15845,CPT,,,,,,,,both,,,75461.18,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,37730.59,50,,37730.59,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52822.83,70,,52822.83,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,52822.83,
Exc skin abd add-on,15847,CPT,,,,,,,,both,,,64479.48,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32239.74,50,,32239.74,percent of total billed charges,,45135.64,70,,45135.64,percent of total billed charges,,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45135.64,70,,45135.64,percent of total billed charges,,32239.74,50,,32239.74,percent of total billed charges,,32239.74,50,,32239.74,percent of total billed charges,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,0.01,45135.64,
Remove sutures diff surgeon,15851,CPT,,,,,,,,both,,,34850.17,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17425.09,50,,17425.09,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2855.7,,,2855.7,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24395.12,70,,24395.12,percent of total billed charges,,318.45,,,318.45,Fee Schedule,,270.2,,,270.2,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1535.32,,,1535.32,Other,New York Medicaid APG methodology,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,2149.45,,,2149.45,Other,140% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3991.84,,,3991.84,Other,260% New York Medicaid APG,4974.44,,,4974.44,Other,324% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,1919.15,,,1919.15,Other,125% New York Medicaid APG,270.2,24395.12,
Dressing change not for burn,15852,CPT,,,,,,,,both,,,35304.33,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17652.17,50,,17652.17,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1193.32,,,1193.32,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24713.03,70,,24713.03,percent of total billed charges,,226.05,,,226.05,Fee Schedule,,191.8,,,191.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,898.2,,,898.2,Other,140% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1668.08,,,1668.08,Other,260% New York Medicaid APG,2078.69,,,2078.69,Other,324% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,801.96,,,801.96,Other,125% New York Medicaid APG,0.01,24713.03,
Test for blood flow in graft,15860,CPT,,,,,,,,both,,,8380.68,757.69,,,757.69,Other,150% of Medicare + 9.63% HCRA Surcharge,460.76,,,460.76,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4190.34,50,,4190.34,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1205.26,,,1205.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5866.48,70,,5866.48,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.99,,,647.99,Other,New York Medicaid APG methodology,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,907.18,,,907.18,Other,140% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1684.77,,,1684.77,Other,260% New York Medicaid APG,2099.48,,,2099.48,Other,324% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,809.98,,,809.98,Other,125% New York Medicaid APG,0.01,13157,
Suction lipectomy head&neck,15876,CPT,,,,,,,,both,,,51329.22,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,25664.61,50,,25664.61,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,35930.45,70,,35930.45,percent of total billed charges,,25664.61,50,,25664.61,percent of total billed charges,,25664.61,50,,25664.61,percent of total billed charges,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2495.74,35930.45,
Suction lipectomy trunk,15877,CPT,,,,,,,,both,,,31862.45,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,15931.23,50,,15931.23,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22303.72,70,,22303.72,percent of total billed charges,,15931.23,50,,15931.23,percent of total billed charges,,15931.23,50,,15931.23,percent of total billed charges,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2495.74,22303.72,
Suction lipectomy upr extrem,15878,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,19178.78,50,,19178.78,percent of total billed charges,,19178.78,50,,19178.78,percent of total billed charges,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2108.84,26850.29,
Suction lipectomy lwr extrem,15879,CPT,,,,,,,,both,,,38854.71,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19427.36,50,,19427.36,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27198.3,70,,27198.3,percent of total billed charges,,19427.36,50,,19427.36,percent of total billed charges,,19427.36,50,,19427.36,percent of total billed charges,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2495.74,27198.3,
Removal of tail bone ulcer,15920,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3180.63,,,3180.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,2394.02,,,2394.02,Other,140% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,4446.04,,,4446.04,Other,260% New York Medicaid APG,5540.45,,,5540.45,Other,324% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,2137.52,,,2137.52,Other,125% New York Medicaid APG,1710.01,41837.04,
Removal of tail bone ulcer,15922,CPT,,,,,,,,both,,,75461.18,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,37730.59,50,,37730.59,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3180.63,,,3180.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52822.83,70,,52822.83,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,2394.02,,,2394.02,Other,140% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,4446.04,,,4446.04,Other,260% New York Medicaid APG,5540.45,,,5540.45,Other,324% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,2137.52,,,2137.52,Other,125% New York Medicaid APG,1710.01,52822.83,
Remove sacrum pressure sore,15931,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3180.63,,,3180.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,2394.02,,,2394.02,Other,140% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,4446.04,,,4446.04,Other,260% New York Medicaid APG,5540.45,,,5540.45,Other,324% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,2137.52,,,2137.52,Other,125% New York Medicaid APG,1710.01,41837.04,
Remove sacrum pressure sore,15933,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3180.63,,,3180.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,2394.02,,,2394.02,Other,140% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,4446.04,,,4446.04,Other,260% New York Medicaid APG,5540.45,,,5540.45,Other,324% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,2137.52,,,2137.52,Other,125% New York Medicaid APG,1710.01,41837.04,
Remove sacrum pressure sore,15934,CPT,,,,,,,,both,,,75461.18,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,37730.59,50,,37730.59,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3180.63,,,3180.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52822.83,70,,52822.83,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,2394.02,,,2394.02,Other,140% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,4446.04,,,4446.04,Other,260% New York Medicaid APG,5540.45,,,5540.45,Other,324% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,2137.52,,,2137.52,Other,125% New York Medicaid APG,1710.01,52822.83,
Remove sacrum pressure sore,15935,CPT,,,,,,,,both,,,75461.18,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,37730.59,50,,37730.59,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3180.63,,,3180.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52822.83,70,,52822.83,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,2394.02,,,2394.02,Other,140% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,4446.04,,,4446.04,Other,260% New York Medicaid APG,5540.45,,,5540.45,Other,324% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,2137.52,,,2137.52,Other,125% New York Medicaid APG,1710.01,52822.83,
Remove sacrum pressure sore,15936,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3180.63,,,3180.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,2394.02,,,2394.02,Other,140% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,4446.04,,,4446.04,Other,260% New York Medicaid APG,5540.45,,,5540.45,Other,324% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,2137.52,,,2137.52,Other,125% New York Medicaid APG,1710.01,26850.29,
Remove sacrum pressure sore,15937,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3180.63,,,3180.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,2394.02,,,2394.02,Other,140% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,4446.04,,,4446.04,Other,260% New York Medicaid APG,5540.45,,,5540.45,Other,324% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,2137.52,,,2137.52,Other,125% New York Medicaid APG,1710.01,26850.29,
Remove hip pressure sore,15940,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3180.63,,,3180.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,2394.02,,,2394.02,Other,140% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,4446.04,,,4446.04,Other,260% New York Medicaid APG,5540.45,,,5540.45,Other,324% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,2137.52,,,2137.52,Other,125% New York Medicaid APG,1710.01,41837.04,
Remove hip pressure sore,15941,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3180.63,,,3180.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,2394.02,,,2394.02,Other,140% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,4446.04,,,4446.04,Other,260% New York Medicaid APG,5540.45,,,5540.45,Other,324% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,2137.52,,,2137.52,Other,125% New York Medicaid APG,1710.01,41837.04,
Remove hip pressure sore,15944,CPT,,,,,,,,both,,,75461.18,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,37730.59,50,,37730.59,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3180.63,,,3180.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52822.83,70,,52822.83,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,2394.02,,,2394.02,Other,140% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,4446.04,,,4446.04,Other,260% New York Medicaid APG,5540.45,,,5540.45,Other,324% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,2137.52,,,2137.52,Other,125% New York Medicaid APG,1710.01,52822.83,
Remove hip pressure sore,15945,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3180.63,,,3180.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,2394.02,,,2394.02,Other,140% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,4446.04,,,4446.04,Other,260% New York Medicaid APG,5540.45,,,5540.45,Other,324% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,2137.52,,,2137.52,Other,125% New York Medicaid APG,1710.01,26850.29,
Remove hip pressure sore,15946,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3180.63,,,3180.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,2394.02,,,2394.02,Other,140% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,4446.04,,,4446.04,Other,260% New York Medicaid APG,5540.45,,,5540.45,Other,324% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,2137.52,,,2137.52,Other,125% New York Medicaid APG,1710.01,26850.29,
Remove thigh pressure sore,15950,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3180.63,,,3180.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,2394.02,,,2394.02,Other,140% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,4446.04,,,4446.04,Other,260% New York Medicaid APG,5540.45,,,5540.45,Other,324% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,2137.52,,,2137.52,Other,125% New York Medicaid APG,1710.01,23871.23,
Remove thigh pressure sore,15951,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3180.63,,,3180.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,2394.02,,,2394.02,Other,140% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,4446.04,,,4446.04,Other,260% New York Medicaid APG,5540.45,,,5540.45,Other,324% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,2137.52,,,2137.52,Other,125% New York Medicaid APG,1710.01,41837.04,
Remove thigh pressure sore,15952,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3180.63,,,3180.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,2394.02,,,2394.02,Other,140% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,4446.04,,,4446.04,Other,260% New York Medicaid APG,5540.45,,,5540.45,Other,324% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,2137.52,,,2137.52,Other,125% New York Medicaid APG,1710.01,26850.29,
Remove thigh pressure sore,15953,CPT,,,,,,,,both,,,75461.18,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,37730.59,50,,37730.59,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3180.63,,,3180.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52822.83,70,,52822.83,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,2394.02,,,2394.02,Other,140% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,4446.04,,,4446.04,Other,260% New York Medicaid APG,5540.45,,,5540.45,Other,324% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,2137.52,,,2137.52,Other,125% New York Medicaid APG,1710.01,52822.83,
Remove thigh pressure sore,15956,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3180.63,,,3180.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,2394.02,,,2394.02,Other,140% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,4446.04,,,4446.04,Other,260% New York Medicaid APG,5540.45,,,5540.45,Other,324% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,2137.52,,,2137.52,Other,125% New York Medicaid APG,1710.01,26850.29,
Remove thigh pressure sore,15958,CPT,,,,,,,,both,,,75461.18,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,37730.59,50,,37730.59,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3180.63,,,3180.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52822.83,70,,52822.83,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,2394.02,,,2394.02,Other,140% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,4446.04,,,4446.04,Other,260% New York Medicaid APG,5540.45,,,5540.45,Other,324% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,2137.52,,,2137.52,Other,125% New York Medicaid APG,1710.01,52822.83,
Initial treatment of burn(s),16000,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1193.32,,,1193.32,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,224.4,,,224.4,Fee Schedule,,190.4,,,190.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,898.2,,,898.2,Other,140% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1668.08,,,1668.08,Other,260% New York Medicaid APG,2078.69,,,2078.69,Other,324% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,801.96,,,801.96,Other,125% New York Medicaid APG,0.01,9473,
Dress/debrid p-thick burn s,16020,CPT,,,,,,,,both,,,33793.97,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16896.99,50,,16896.99,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1193.32,,,1193.32,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23655.78,70,,23655.78,percent of total billed charges,,272.25,,,272.25,Fee Schedule,,231,,,231,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,898.2,,,898.2,Other,140% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1668.08,,,1668.08,Other,260% New York Medicaid APG,2078.69,,,2078.69,Other,324% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,801.96,,,801.96,Other,125% New York Medicaid APG,231,23655.78,
Dress/debrid p-thick burn m,16025,CPT,,,,,,,,both,,,38051.11,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,19025.56,50,,19025.56,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1193.32,,,1193.32,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26635.78,70,,26635.78,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,641.57,,,641.57,Other,New York Medicaid APG methodology,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,641.57,,,641.57,Other,100% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,898.2,,,898.2,Other,140% New York Medicaid APG,1443.53,,,1443.53,Other,225% New York Medicaid APG,1668.08,,,1668.08,Other,260% New York Medicaid APG,2078.69,,,2078.69,Other,324% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,1379.38,,,1379.38,Other,215% New York Medicaid APG,801.96,,,801.96,Other,125% New York Medicaid APG,231.51,26635.78,
Dress/debrid p-thick burn l,16030,CPT,,,,,,,,both,,,34605.58,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17302.79,50,,17302.79,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24223.91,70,,24223.91,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,461.11,24223.91,
Incision of burn scab initi,16035,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,461.11,13157,
Destruct premalg lesion,17000,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,268.95,,,268.95,Fee Schedule,,228.2,,,228.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Destruct premalg les 2-14,17003,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,9.9,,,9.9,Fee Schedule,,8.4,,,8.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,22702.47,
Destroy premal lesions 15/>,17004,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,486.75,,,486.75,Fee Schedule,,413,,,413,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,413,9473,
Destruction of skin lesions,17106,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1516.17,,,1516.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,815.14,,,815.14,Other,New York Medicaid APG methodology,815.14,,,815.14,Other,100% New York Medicaid APG,815.14,,,815.14,Other,100% New York Medicaid APG,815.14,,,815.14,Other,100% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1141.2,,,1141.2,Other,140% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,2119.37,,,2119.37,Other,260% New York Medicaid APG,2641.06,,,2641.06,Other,324% New York Medicaid APG,1752.56,,,1752.56,Other,215% New York Medicaid APG,1752.56,,,1752.56,Other,215% New York Medicaid APG,1018.93,,,1018.93,Other,125% New York Medicaid APG,461.11,13157,
Destruction of skin lesions,17107,CPT,,,,,,,,both,,,13210.22,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6605.11,50,,6605.11,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1516.17,,,1516.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9247.15,70,,9247.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,815.14,,,815.14,Other,New York Medicaid APG methodology,815.14,,,815.14,Other,100% New York Medicaid APG,815.14,,,815.14,Other,100% New York Medicaid APG,815.14,,,815.14,Other,100% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1141.2,,,1141.2,Other,140% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,2119.37,,,2119.37,Other,260% New York Medicaid APG,2641.06,,,2641.06,Other,324% New York Medicaid APG,1752.56,,,1752.56,Other,215% New York Medicaid APG,1752.56,,,1752.56,Other,215% New York Medicaid APG,1018.93,,,1018.93,Other,125% New York Medicaid APG,726.28,13157,
Destruction of skin lesions,17108,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1516.17,,,1516.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,815.14,,,815.14,Other,New York Medicaid APG methodology,815.14,,,815.14,Other,100% New York Medicaid APG,815.14,,,815.14,Other,100% New York Medicaid APG,815.14,,,815.14,Other,100% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1141.2,,,1141.2,Other,140% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,2119.37,,,2119.37,Other,260% New York Medicaid APG,2641.06,,,2641.06,Other,324% New York Medicaid APG,1752.56,,,1752.56,Other,215% New York Medicaid APG,1752.56,,,1752.56,Other,215% New York Medicaid APG,1018.93,,,1018.93,Other,125% New York Medicaid APG,815.14,26850.29,
Destruct b9 lesion 1-14,17110,CPT,,,,,,,,both,,,36111.92,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,18055.96,50,,18055.96,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25278.34,70,,25278.34,percent of total billed charges,,330,,,330,Fee Schedule,,280,,,280,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,25278.34,
Destruct lesion 15 or more,17111,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,404.25,,,404.25,Fee Schedule,,343,,,343,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Chem caut of granltj tissue,17250,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,183.15,,,183.15,Fee Schedule,,155.4,,,155.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Destruction of skin lesions,17260,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,346.5,,,346.5,Fee Schedule,,294,,,294,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Destruction of skin lesions,17261,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,424.05,,,424.05,Fee Schedule,,359.8,,,359.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Destruction of skin lesions,17262,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,541.2,,,541.2,Fee Schedule,,459.2,,,459.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Destruction of skin lesions,17263,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,13157,
Destruction of skin lesions,17264,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,13157,
Destruction of skin lesions,17266,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,461.11,13157,
Destruction of skin lesions,17270,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,468.6,,,468.6,Fee Schedule,,397.6,,,397.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Destruction of skin lesions,17271,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,516.45,,,516.45,Fee Schedule,,438.2,,,438.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Destruction of skin lesions,17272,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,13157,
Destruction of skin lesions,17273,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,13157,
Destruction of skin lesions,17274,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,461.11,13157,
Destruction of skin lesions,17276,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,461.11,13157,
Destruction of skin lesions,17280,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,422.4,,,422.4,Fee Schedule,,358.4,,,358.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Destruction of skin lesions,17281,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,579.15,,,579.15,Fee Schedule,,491.4,,,491.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Destruction of skin lesions,17282,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,13157,
Destruction of skin lesions,17283,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,13157,
Destruction of skin lesions,17284,CPT,,,,,,,,both,,,13210.22,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6605.11,50,,6605.11,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9247.15,70,,9247.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,485.25,13157,
Destruction of skin lesions,17286,CPT,,,,,,,,both,,,13210.22,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6605.11,50,,6605.11,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9247.15,70,,9247.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,13157,
Mohs 1 stage h/n/hf/g,17311,CPT,,,,,,,,both,,,13210.22,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6605.11,50,,6605.11,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2855.71,,,2855.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9247.15,70,,9247.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1535.33,,,1535.33,Other,New York Medicaid APG methodology,1535.33,,,1535.33,Other,100% New York Medicaid APG,1535.33,,,1535.33,Other,100% New York Medicaid APG,1535.33,,,1535.33,Other,100% New York Medicaid APG,3454.49,,,3454.49,Other,225% New York Medicaid APG,3454.49,,,3454.49,Other,225% New York Medicaid APG,3454.49,,,3454.49,Other,225% New York Medicaid APG,3454.49,,,3454.49,Other,225% New York Medicaid APG,2149.46,,,2149.46,Other,140% New York Medicaid APG,3454.49,,,3454.49,Other,225% New York Medicaid APG,3991.85,,,3991.85,Other,260% New York Medicaid APG,4974.46,,,4974.46,Other,324% New York Medicaid APG,3300.95,,,3300.95,Other,215% New York Medicaid APG,3300.95,,,3300.95,Other,215% New York Medicaid APG,1919.16,,,1919.16,Other,125% New York Medicaid APG,726.28,13157,
Mohs addl stage,17312,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,2855.71,,,2855.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1535.33,,,1535.33,Other,New York Medicaid APG methodology,1535.33,,,1535.33,Other,100% New York Medicaid APG,1535.33,,,1535.33,Other,100% New York Medicaid APG,1535.33,,,1535.33,Other,100% New York Medicaid APG,3454.49,,,3454.49,Other,225% New York Medicaid APG,3454.49,,,3454.49,Other,225% New York Medicaid APG,3454.49,,,3454.49,Other,225% New York Medicaid APG,3454.49,,,3454.49,Other,225% New York Medicaid APG,2149.46,,,2149.46,Other,140% New York Medicaid APG,3454.49,,,3454.49,Other,225% New York Medicaid APG,3991.85,,,3991.85,Other,260% New York Medicaid APG,4974.46,,,4974.46,Other,324% New York Medicaid APG,3300.95,,,3300.95,Other,215% New York Medicaid APG,3300.95,,,3300.95,Other,215% New York Medicaid APG,1919.16,,,1919.16,Other,125% New York Medicaid APG,0.01,36100.43,
Mohs 1 stage t/a/l,17313,CPT,,,,,,,,both,,,13210.22,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6605.11,50,,6605.11,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2855.71,,,2855.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9247.15,70,,9247.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1535.33,,,1535.33,Other,New York Medicaid APG methodology,1535.33,,,1535.33,Other,100% New York Medicaid APG,1535.33,,,1535.33,Other,100% New York Medicaid APG,1535.33,,,1535.33,Other,100% New York Medicaid APG,3454.49,,,3454.49,Other,225% New York Medicaid APG,3454.49,,,3454.49,Other,225% New York Medicaid APG,3454.49,,,3454.49,Other,225% New York Medicaid APG,3454.49,,,3454.49,Other,225% New York Medicaid APG,2149.46,,,2149.46,Other,140% New York Medicaid APG,3454.49,,,3454.49,Other,225% New York Medicaid APG,3991.85,,,3991.85,Other,260% New York Medicaid APG,4974.46,,,4974.46,Other,324% New York Medicaid APG,3300.95,,,3300.95,Other,215% New York Medicaid APG,3300.95,,,3300.95,Other,215% New York Medicaid APG,1919.16,,,1919.16,Other,125% New York Medicaid APG,726.28,13157,
Mohs addl stage t/a/l,17314,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,2855.71,,,2855.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1535.33,,,1535.33,Other,New York Medicaid APG methodology,1535.33,,,1535.33,Other,100% New York Medicaid APG,1535.33,,,1535.33,Other,100% New York Medicaid APG,1535.33,,,1535.33,Other,100% New York Medicaid APG,3454.49,,,3454.49,Other,225% New York Medicaid APG,3454.49,,,3454.49,Other,225% New York Medicaid APG,3454.49,,,3454.49,Other,225% New York Medicaid APG,3454.49,,,3454.49,Other,225% New York Medicaid APG,2149.46,,,2149.46,Other,140% New York Medicaid APG,3454.49,,,3454.49,Other,225% New York Medicaid APG,3991.85,,,3991.85,Other,260% New York Medicaid APG,4974.46,,,4974.46,Other,324% New York Medicaid APG,3300.95,,,3300.95,Other,215% New York Medicaid APG,3300.95,,,3300.95,Other,215% New York Medicaid APG,1919.16,,,1919.16,Other,125% New York Medicaid APG,0.01,36100.43,
Mohs surg addl block,17315,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,2855.71,,,2855.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,245.85,,,245.85,Fee Schedule,,208.6,,,208.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1535.33,,,1535.33,Other,New York Medicaid APG methodology,1535.33,,,1535.33,Other,100% New York Medicaid APG,1535.33,,,1535.33,Other,100% New York Medicaid APG,1535.33,,,1535.33,Other,100% New York Medicaid APG,3454.49,,,3454.49,Other,225% New York Medicaid APG,3454.49,,,3454.49,Other,225% New York Medicaid APG,3454.49,,,3454.49,Other,225% New York Medicaid APG,3454.49,,,3454.49,Other,225% New York Medicaid APG,2149.46,,,2149.46,Other,140% New York Medicaid APG,3454.49,,,3454.49,Other,225% New York Medicaid APG,3991.85,,,3991.85,Other,260% New York Medicaid APG,4974.46,,,4974.46,Other,324% New York Medicaid APG,3300.95,,,3300.95,Other,215% New York Medicaid APG,3300.95,,,3300.95,Other,215% New York Medicaid APG,1919.16,,,1919.16,Other,125% New York Medicaid APG,0.01,36100.43,
Cryotherapy of skin,17340,CPT,,,,,,,,both,,,1286.58,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,643.29,50,,643.29,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,900.61,70,,900.61,percent of total billed charges,,242.55,,,242.55,Fee Schedule,,205.8,,,205.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Skin peel therapy,17360,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,457.05,,,457.05,Fee Schedule,,387.8,,,387.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Hair removal by electrolysis,17380,CPT,,,,,,,,both,,,13210.22,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6605.11,50,,6605.11,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9247.15,70,,9247.15,percent of total billed charges,,6605.11,50,,6605.11,percent of total billed charges,,6605.11,50,,6605.11,percent of total billed charges,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Drainage of breast lesion,19000,CPT,,,,,,,,both,,,14798.8,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7399.4,50,,7399.4,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1296.67,,,1296.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10359.16,70,,10359.16,percent of total billed charges,,207.9,,,207.9,Fee Schedule,,176.4,,,176.4,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,697.14,,,697.14,Other,New York Medicaid APG methodology,697.14,,,697.14,Other,100% New York Medicaid APG,697.14,,,697.14,Other,100% New York Medicaid APG,697.14,,,697.14,Other,100% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,975.99,,,975.99,Other,140% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1812.56,,,1812.56,Other,260% New York Medicaid APG,2258.72,,,2258.72,Other,324% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,871.42,,,871.42,Other,125% New York Medicaid APG,176.4,10359.16,
Drain breast lesion add-on,19001,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1296.67,,,1296.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,100.65,,,100.65,Fee Schedule,,85.4,,,85.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,697.14,,,697.14,Other,New York Medicaid APG methodology,697.14,,,697.14,Other,100% New York Medicaid APG,697.14,,,697.14,Other,100% New York Medicaid APG,697.14,,,697.14,Other,100% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,975.99,,,975.99,Other,140% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1812.56,,,1812.56,Other,260% New York Medicaid APG,2258.72,,,2258.72,Other,324% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,871.42,,,871.42,Other,125% New York Medicaid APG,0.01,22702.47,
Incision of breast lesion,19020,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3569.69,,,3569.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1919.19,,,1919.19,Other,New York Medicaid APG methodology,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,2686.86,,,2686.86,Other,140% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4989.89,,,4989.89,Other,260% New York Medicaid APG,6218.17,,,6218.17,Other,324% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,2398.98,,,2398.98,Other,125% New York Medicaid APG,1874.86,23871.23,
Injection for breast x-ray,19030,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1205.26,,,1205.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,372.9,,,372.9,Fee Schedule,,316.4,,,316.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.99,,,647.99,Other,New York Medicaid APG methodology,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,907.18,,,907.18,Other,140% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1684.77,,,1684.77,Other,260% New York Medicaid APG,2099.48,,,2099.48,Other,324% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,809.98,,,809.98,Other,125% New York Medicaid APG,0.01,22702.47,
Bx breast 1st lesion strtctc,19081,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3569.69,,,3569.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1919.19,,,1919.19,Other,New York Medicaid APG methodology,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,2686.86,,,2686.86,Other,140% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4989.89,,,4989.89,Other,260% New York Medicaid APG,6218.17,,,6218.17,Other,324% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,2398.98,,,2398.98,Other,125% New York Medicaid APG,1874.86,23871.23,
Bx breast add lesion strtctc,19082,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,3569.69,,,3569.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,400.95,,,400.95,Fee Schedule,,340.2,,,340.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1919.19,,,1919.19,Other,New York Medicaid APG methodology,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,2686.86,,,2686.86,Other,140% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4989.89,,,4989.89,Other,260% New York Medicaid APG,6218.17,,,6218.17,Other,324% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,2398.98,,,2398.98,Other,125% New York Medicaid APG,0.01,36100.43,
Bx breast 1st lesion us imag,19083,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3569.69,,,3569.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1919.19,,,1919.19,Other,New York Medicaid APG methodology,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,2686.86,,,2686.86,Other,140% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4989.89,,,4989.89,Other,260% New York Medicaid APG,6218.17,,,6218.17,Other,324% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,2398.98,,,2398.98,Other,125% New York Medicaid APG,1874.86,23871.23,
Bx breast add lesion us imag,19084,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,3569.69,,,3569.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,377.85,,,377.85,Fee Schedule,,320.6,,,320.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1919.19,,,1919.19,Other,New York Medicaid APG methodology,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,2686.86,,,2686.86,Other,140% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4989.89,,,4989.89,Other,260% New York Medicaid APG,6218.17,,,6218.17,Other,324% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,2398.98,,,2398.98,Other,125% New York Medicaid APG,0.01,36100.43,
Bx breast 1st lesion mr imag,19085,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3569.69,,,3569.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1919.19,,,1919.19,Other,New York Medicaid APG methodology,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,2686.86,,,2686.86,Other,140% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4989.89,,,4989.89,Other,260% New York Medicaid APG,6218.17,,,6218.17,Other,324% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,2398.98,,,2398.98,Other,125% New York Medicaid APG,1874.86,23871.23,
Bx breast add lesion mr imag,19086,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,3569.69,,,3569.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1919.19,,,1919.19,Other,New York Medicaid APG methodology,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,2686.86,,,2686.86,Other,140% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4989.89,,,4989.89,Other,260% New York Medicaid APG,6218.17,,,6218.17,Other,324% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,2398.98,,,2398.98,Other,125% New York Medicaid APG,0.01,36100.43,
Bx breast percut w/o image,19100,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3569.69,,,3569.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,338.25,,,338.25,Fee Schedule,,287,,,287,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1919.19,,,1919.19,Other,New York Medicaid APG methodology,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,2686.86,,,2686.86,Other,140% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4989.89,,,4989.89,Other,260% New York Medicaid APG,6218.17,,,6218.17,Other,324% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,2398.98,,,2398.98,Other,125% New York Medicaid APG,287,23871.23,
Biopsy of breast open,19101,CPT,,,,,,,,both,,,80175.05,7248.58,,,7248.58,Other,150% of Medicare + 9.63% HCRA Surcharge,4407.9,,,4407.9,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40087.53,50,,40087.53,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3569.69,,,3569.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56122.54,70,,56122.54,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1919.19,,,1919.19,Other,New York Medicaid APG methodology,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,2686.86,,,2686.86,Other,140% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4989.89,,,4989.89,Other,260% New York Medicaid APG,6218.17,,,6218.17,Other,324% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,2398.98,,,2398.98,Other,125% New York Medicaid APG,1919.19,56122.54,
Cryosurg ablate fa each,19105,CPT,,,,,,,,both,,,80175.05,7248.58,,,7248.58,Other,150% of Medicare + 9.63% HCRA Surcharge,4407.9,,,4407.9,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40087.53,50,,40087.53,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3569.69,,,3569.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56122.54,70,,56122.54,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1919.19,,,1919.19,Other,New York Medicaid APG methodology,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,2686.86,,,2686.86,Other,140% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4989.89,,,4989.89,Other,260% New York Medicaid APG,6218.17,,,6218.17,Other,324% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,2398.98,,,2398.98,Other,125% New York Medicaid APG,1919.19,56122.54,
Nipple exploration,19110,CPT,,,,,,,,both,,,80175.05,7248.58,,,7248.58,Other,150% of Medicare + 9.63% HCRA Surcharge,4407.9,,,4407.9,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40087.53,50,,40087.53,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3569.69,,,3569.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56122.54,70,,56122.54,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1919.19,,,1919.19,Other,New York Medicaid APG methodology,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,2686.86,,,2686.86,Other,140% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4989.89,,,4989.89,Other,260% New York Medicaid APG,6218.17,,,6218.17,Other,324% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,2398.98,,,2398.98,Other,125% New York Medicaid APG,1919.19,56122.54,
Excise breast duct fistula,19112,CPT,,,,,,,,both,,,80175.05,7248.58,,,7248.58,Other,150% of Medicare + 9.63% HCRA Surcharge,4407.9,,,4407.9,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40087.53,50,,40087.53,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3569.69,,,3569.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56122.54,70,,56122.54,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1919.19,,,1919.19,Other,New York Medicaid APG methodology,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,2686.86,,,2686.86,Other,140% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4989.89,,,4989.89,Other,260% New York Medicaid APG,6218.17,,,6218.17,Other,324% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,2398.98,,,2398.98,Other,125% New York Medicaid APG,1919.19,56122.54,
Removal of breast lesion,19120,CPT,,,,,,,,both,,,38519.06,7248.58,,,7248.58,Other,150% of Medicare + 9.63% HCRA Surcharge,4407.9,,,4407.9,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19259.53,50,,19259.53,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3569.69,,,3569.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26963.34,70,,26963.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1919.19,,,1919.19,Other,New York Medicaid APG methodology,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,2686.86,,,2686.86,Other,140% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4989.89,,,4989.89,Other,260% New York Medicaid APG,6218.17,,,6218.17,Other,324% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,2398.98,,,2398.98,Other,125% New York Medicaid APG,1919.19,26963.34,
Excision breast lesion,19125,CPT,,,,,,,,both,,,68236.71,7248.58,,,7248.58,Other,150% of Medicare + 9.63% HCRA Surcharge,4407.9,,,4407.9,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34118.36,50,,34118.36,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3569.69,,,3569.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47765.7,70,,47765.7,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1919.19,,,1919.19,Other,New York Medicaid APG methodology,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,2686.86,,,2686.86,Other,140% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4989.89,,,4989.89,Other,260% New York Medicaid APG,6218.17,,,6218.17,Other,324% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,2398.98,,,2398.98,Other,125% New York Medicaid APG,1919.19,47765.7,
Excision addl breast lesion,19126,CPT,,,,,,,,both,,,64479.48,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32239.74,50,,32239.74,percent of total billed charges,,45135.64,70,,45135.64,percent of total billed charges,,6152,,,6152,Case Rate,,3569.69,,,3569.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45135.64,70,,45135.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1919.19,,,1919.19,Other,New York Medicaid APG methodology,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,2686.86,,,2686.86,Other,140% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4989.89,,,4989.89,Other,260% New York Medicaid APG,6218.17,,,6218.17,Other,324% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,2398.98,,,2398.98,Other,125% New York Medicaid APG,0.01,45135.64,
Perq device breast 1st imag,19281,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3569.69,,,3569.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1919.19,,,1919.19,Other,New York Medicaid APG methodology,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,2686.86,,,2686.86,Other,140% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4989.89,,,4989.89,Other,260% New York Medicaid APG,6218.17,,,6218.17,Other,324% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,2398.98,,,2398.98,Other,125% New York Medicaid APG,1874.86,23871.23,
Perq device breast ea imag,19282,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,3569.69,,,3569.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,242.55,,,242.55,Fee Schedule,,205.8,,,205.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1919.19,,,1919.19,Other,New York Medicaid APG methodology,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,2686.86,,,2686.86,Other,140% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4989.89,,,4989.89,Other,260% New York Medicaid APG,6218.17,,,6218.17,Other,324% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,2398.98,,,2398.98,Other,125% New York Medicaid APG,0.01,22702.47,
Perq dev breast 1st strtctc,19283,CPT,,,,,,,,both,,,14798.8,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7399.4,50,,7399.4,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3569.69,,,3569.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10359.16,70,,10359.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1919.19,,,1919.19,Other,New York Medicaid APG methodology,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,2686.86,,,2686.86,Other,140% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4989.89,,,4989.89,Other,260% New York Medicaid APG,6218.17,,,6218.17,Other,324% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,2398.98,,,2398.98,Other,125% New York Medicaid APG,813.62,13157,
Perq dev breast add strtctc,19284,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,3569.69,,,3569.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,242.55,,,242.55,Fee Schedule,,205.8,,,205.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1919.19,,,1919.19,Other,New York Medicaid APG methodology,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,2686.86,,,2686.86,Other,140% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4989.89,,,4989.89,Other,260% New York Medicaid APG,6218.17,,,6218.17,Other,324% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,2398.98,,,2398.98,Other,125% New York Medicaid APG,0.01,22702.47,
Perq dev breast 1st us imag,19285,CPT,,,,,,,,both,,,14798.8,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7399.4,50,,7399.4,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3569.69,,,3569.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10359.16,70,,10359.16,percent of total billed charges,,412.5,,,412.5,Fee Schedule,,350,,,350,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1919.19,,,1919.19,Other,New York Medicaid APG methodology,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,2686.86,,,2686.86,Other,140% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4989.89,,,4989.89,Other,260% New York Medicaid APG,6218.17,,,6218.17,Other,324% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,2398.98,,,2398.98,Other,125% New York Medicaid APG,350,10359.16,
Perq dev breast add us imag,19286,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,3569.69,,,3569.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,207.9,,,207.9,Fee Schedule,,176.4,,,176.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1919.19,,,1919.19,Other,New York Medicaid APG methodology,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,2686.86,,,2686.86,Other,140% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4989.89,,,4989.89,Other,260% New York Medicaid APG,6218.17,,,6218.17,Other,324% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,2398.98,,,2398.98,Other,125% New York Medicaid APG,0.01,22702.47,
Perq dev breast 1st mr guide,19287,CPT,,,,,,,,both,,,14798.8,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7399.4,50,,7399.4,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3569.69,,,3569.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10359.16,70,,10359.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1919.19,,,1919.19,Other,New York Medicaid APG methodology,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,2686.86,,,2686.86,Other,140% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4989.89,,,4989.89,Other,260% New York Medicaid APG,6218.17,,,6218.17,Other,324% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,2398.98,,,2398.98,Other,125% New York Medicaid APG,813.62,13157,
Perq dev breast add mr guide,19288,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,3569.69,,,3569.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,306.9,,,306.9,Fee Schedule,,260.4,,,260.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1919.19,,,1919.19,Other,New York Medicaid APG methodology,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,2686.86,,,2686.86,Other,140% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4989.89,,,4989.89,Other,260% New York Medicaid APG,6218.17,,,6218.17,Other,324% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,2398.98,,,2398.98,Other,125% New York Medicaid APG,0.01,22702.47,
Prep tum cav iort prtl mast,19294,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,6999.37,,,6999.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,3763.1,,,3763.1,Other,New York Medicaid APG methodology,3763.1,,,3763.1,Other,100% New York Medicaid APG,3763.1,,,3763.1,Other,100% New York Medicaid APG,3763.1,,,3763.1,Other,100% New York Medicaid APG,8466.98,,,8466.98,Other,225% New York Medicaid APG,8466.98,,,8466.98,Other,225% New York Medicaid APG,8466.98,,,8466.98,Other,225% New York Medicaid APG,8466.98,,,8466.98,Other,225% New York Medicaid APG,5268.34,,,5268.34,Other,140% New York Medicaid APG,8466.98,,,8466.98,Other,225% New York Medicaid APG,9784.06,,,9784.06,Other,260% New York Medicaid APG,12192.45,,,12192.45,Other,324% New York Medicaid APG,8090.67,,,8090.67,Other,215% New York Medicaid APG,8090.67,,,8090.67,Other,215% New York Medicaid APG,4703.88,,,4703.88,Other,125% New York Medicaid APG,0.01,22702.47,
Place po breast cath for rad,19296,CPT,,,,,,,,both,,,198277.38,17926.14,,,17926.14,Other,150% of Medicare + 9.63% HCRA Surcharge,10900.99,,,10900.99,Other,Medicare OPPS methodology,15382,,"100% primary, 50% supplemental procedure",15382,Other,Aetna ASC Grouper,13844,,"100% primary, 50% supplemental procedure",13844,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,99138.69,50,,99138.69,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4952.04,,,4952.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,138794.17,70,,138794.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2662.39,,,2662.39,Other,New York Medicaid APG methodology,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,3727.34,,,3727.34,Other,140% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,6922.2,,,6922.2,Other,260% New York Medicaid APG,8626.13,,,8626.13,Other,324% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,3327.98,,,3327.98,Other,125% New York Medicaid APG,2662.39,138794.17,
Place breast cath for rad,19297,CPT,,,,,,,,both,,,98219.64,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,15382,,"100% primary, 50% supplemental procedure",15382,Other,Aetna ASC Grouper,13844,,"100% primary, 50% supplemental procedure",13844,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,49109.82,50,,49109.82,percent of total billed charges,,68753.75,70,,68753.75,percent of total billed charges,,6152,,,6152,Case Rate,,6999.37,,,6999.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,68753.75,70,,68753.75,percent of total billed charges,,462,,,462,Fee Schedule,,392,,,392,Fee Schedule,,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3763.1,,,3763.1,Other,New York Medicaid APG methodology,3763.1,,,3763.1,Other,100% New York Medicaid APG,3763.1,,,3763.1,Other,100% New York Medicaid APG,3763.1,,,3763.1,Other,100% New York Medicaid APG,8466.98,,,8466.98,Other,225% New York Medicaid APG,8466.98,,,8466.98,Other,225% New York Medicaid APG,8466.98,,,8466.98,Other,225% New York Medicaid APG,8466.98,,,8466.98,Other,225% New York Medicaid APG,5268.34,,,5268.34,Other,140% New York Medicaid APG,8466.98,,,8466.98,Other,225% New York Medicaid APG,9784.06,,,9784.06,Other,260% New York Medicaid APG,12192.45,,,12192.45,Other,324% New York Medicaid APG,8090.67,,,8090.67,Other,215% New York Medicaid APG,8090.67,,,8090.67,Other,215% New York Medicaid APG,4703.88,,,4703.88,Other,125% New York Medicaid APG,0.01,68753.75,
Place breast rad tube/caths,19298,CPT,,,,,,,,both,,,137162.89,12400.81,,,12400.81,Other,150% of Medicare + 9.63% HCRA Surcharge,7541.01,,,7541.01,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,68581.45,50,,68581.45,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4952.04,,,4952.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,96014.02,70,,96014.02,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2662.39,,,2662.39,Other,New York Medicaid APG methodology,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,3727.34,,,3727.34,Other,140% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,6922.2,,,6922.2,Other,260% New York Medicaid APG,8626.13,,,8626.13,Other,324% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,3327.98,,,3327.98,Other,125% New York Medicaid APG,2662.39,96014.02,
Removal of breast tissue,19300,CPT,,,,,,,,both,,,45740.64,7248.58,,,7248.58,Other,150% of Medicare + 9.63% HCRA Surcharge,4407.9,,,4407.9,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,22870.32,50,,22870.32,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3569.69,,,3569.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,32018.45,70,,32018.45,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1919.19,,,1919.19,Other,New York Medicaid APG methodology,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,2686.86,,,2686.86,Other,140% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4989.89,,,4989.89,Other,260% New York Medicaid APG,6218.17,,,6218.17,Other,324% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,2398.98,,,2398.98,Other,125% New York Medicaid APG,1919.19,32018.45,
Partial mastectomy,19301,CPT,,,,,,,,both,,,76143.29,7248.58,,,7248.58,Other,150% of Medicare + 9.63% HCRA Surcharge,4407.9,,,4407.9,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,38071.65,50,,38071.65,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4952.04,,,4952.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,53300.3,70,,53300.3,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2662.39,,,2662.39,Other,New York Medicaid APG methodology,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,3727.34,,,3727.34,Other,140% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,6922.2,,,6922.2,Other,260% New York Medicaid APG,8626.13,,,8626.13,Other,324% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,3327.98,,,3327.98,Other,125% New York Medicaid APG,2662.39,53300.3,
P-mastectomy w/ln removal,19302,CPT,,,,,,,,both,,,137162.89,12400.81,,,12400.81,Other,150% of Medicare + 9.63% HCRA Surcharge,7541.01,,,7541.01,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,68581.45,50,,68581.45,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4952.04,,,4952.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,96014.02,70,,96014.02,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2662.39,,,2662.39,Other,New York Medicaid APG methodology,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,3727.34,,,3727.34,Other,140% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,6922.2,,,6922.2,Other,260% New York Medicaid APG,8626.13,,,8626.13,Other,324% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,3327.98,,,3327.98,Other,125% New York Medicaid APG,2662.39,96014.02,
Mast simple complete,19303,CPT,,,,,,,,both,,,62715.23,12400.81,,,12400.81,Other,150% of Medicare + 9.63% HCRA Surcharge,7541.01,,,7541.01,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,31357.62,50,,31357.62,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4952.04,,,4952.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,43900.66,70,,43900.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2662.39,,,2662.39,Other,New York Medicaid APG methodology,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,3727.34,,,3727.34,Other,140% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,6922.2,,,6922.2,Other,260% New York Medicaid APG,8626.13,,,8626.13,Other,324% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,3327.98,,,3327.98,Other,125% New York Medicaid APG,2662.39,43900.66,
Mast mod rad,19307,CPT,,,,,,,,both,,,137162.89,12400.81,,,12400.81,Other,150% of Medicare + 9.63% HCRA Surcharge,7541.01,,,7541.01,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,68581.45,50,,68581.45,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6999.37,,,6999.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,96014.02,70,,96014.02,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3763.1,,,3763.1,Other,New York Medicaid APG methodology,3763.1,,,3763.1,Other,100% New York Medicaid APG,3763.1,,,3763.1,Other,100% New York Medicaid APG,3763.1,,,3763.1,Other,100% New York Medicaid APG,8466.98,,,8466.98,Other,225% New York Medicaid APG,8466.98,,,8466.98,Other,225% New York Medicaid APG,8466.98,,,8466.98,Other,225% New York Medicaid APG,8466.98,,,8466.98,Other,225% New York Medicaid APG,5268.34,,,5268.34,Other,140% New York Medicaid APG,8466.98,,,8466.98,Other,225% New York Medicaid APG,9784.06,,,9784.06,Other,260% New York Medicaid APG,12192.45,,,12192.45,Other,324% New York Medicaid APG,8090.67,,,8090.67,Other,215% New York Medicaid APG,8090.67,,,8090.67,Other,215% New York Medicaid APG,4703.88,,,4703.88,Other,125% New York Medicaid APG,3763.1,96014.02,
Suspension of breast,19316,CPT,,,,,,,,both,,,46805.83,12400.81,,,12400.81,Other,150% of Medicare + 9.63% HCRA Surcharge,7541.01,,,7541.01,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,23402.92,50,,23402.92,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4952.04,,,4952.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,32764.08,70,,32764.08,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2662.39,,,2662.39,Other,New York Medicaid APG methodology,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,3727.34,,,3727.34,Other,140% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,6922.2,,,6922.2,Other,260% New York Medicaid APG,8626.13,,,8626.13,Other,324% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,3327.98,,,3327.98,Other,125% New York Medicaid APG,2662.39,32764.08,
Breast reduction,19318,CPT,,,,,,,,both,,,61371.41,12400.81,,,12400.81,Other,150% of Medicare + 9.63% HCRA Surcharge,7541.01,,,7541.01,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,30685.71,50,,30685.71,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6999.37,,,6999.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,42959.99,70,,42959.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3763.1,,,3763.1,Other,New York Medicaid APG methodology,3763.1,,,3763.1,Other,100% New York Medicaid APG,3763.1,,,3763.1,Other,100% New York Medicaid APG,3763.1,,,3763.1,Other,100% New York Medicaid APG,8466.98,,,8466.98,Other,225% New York Medicaid APG,8466.98,,,8466.98,Other,225% New York Medicaid APG,8466.98,,,8466.98,Other,225% New York Medicaid APG,8466.98,,,8466.98,Other,225% New York Medicaid APG,5268.34,,,5268.34,Other,140% New York Medicaid APG,8466.98,,,8466.98,Other,225% New York Medicaid APG,9784.06,,,9784.06,Other,260% New York Medicaid APG,12192.45,,,12192.45,Other,324% New York Medicaid APG,8090.67,,,8090.67,Other,215% New York Medicaid APG,8090.67,,,8090.67,Other,215% New York Medicaid APG,4703.88,,,4703.88,Other,125% New York Medicaid APG,3763.1,42959.99,
Breast augmentation w/implt,19325,CPT,,,,,,,,both,,,47509.98,17926.14,,,17926.14,Other,150% of Medicare + 9.63% HCRA Surcharge,10900.99,,,10900.99,Other,Medicare OPPS methodology,15382,,"100% primary, 50% supplemental procedure",15382,Other,Aetna ASC Grouper,13844,,"100% primary, 50% supplemental procedure",13844,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,23754.99,50,,23754.99,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4952.04,,,4952.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,33256.99,70,,33256.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2662.39,,,2662.39,Other,New York Medicaid APG methodology,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,3727.34,,,3727.34,Other,140% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,6922.2,,,6922.2,Other,260% New York Medicaid APG,8626.13,,,8626.13,Other,324% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,3327.98,,,3327.98,Other,125% New York Medicaid APG,2662.39,33256.99,
Rmvl intact breast implant,19328,CPT,,,,,,,,both,,,39084.49,7248.58,,,7248.58,Other,150% of Medicare + 9.63% HCRA Surcharge,4407.9,,,4407.9,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19542.25,50,,19542.25,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4952.04,,,4952.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27359.14,70,,27359.14,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2662.39,,,2662.39,Other,New York Medicaid APG methodology,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,3727.34,,,3727.34,Other,140% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,6922.2,,,6922.2,Other,260% New York Medicaid APG,8626.13,,,8626.13,Other,324% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,3327.98,,,3327.98,Other,125% New York Medicaid APG,2662.39,27359.14,
Rmvl ruptured breast implant,19330,CPT,,,,,,,,both,,,40997.58,7248.58,,,7248.58,Other,150% of Medicare + 9.63% HCRA Surcharge,4407.9,,,4407.9,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,20498.79,50,,20498.79,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4952.04,,,4952.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28698.31,70,,28698.31,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2662.39,,,2662.39,Other,New York Medicaid APG methodology,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,3727.34,,,3727.34,Other,140% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,6922.2,,,6922.2,Other,260% New York Medicaid APG,8626.13,,,8626.13,Other,324% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,3327.98,,,3327.98,Other,125% New York Medicaid APG,2662.39,28698.31,
Insj breast implt sm d mast,19340,CPT,,,,,,,,both,,,137162.89,12400.81,,,12400.81,Other,150% of Medicare + 9.63% HCRA Surcharge,7541.01,,,7541.01,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,68581.45,50,,68581.45,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4952.04,,,4952.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,96014.02,70,,96014.02,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2662.39,,,2662.39,Other,New York Medicaid APG methodology,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,3727.34,,,3727.34,Other,140% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,6922.2,,,6922.2,Other,260% New York Medicaid APG,8626.13,,,8626.13,Other,324% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,3327.98,,,3327.98,Other,125% New York Medicaid APG,2662.39,96014.02,
Insj/rplcmt brst implt sep d,19342,CPT,,,,,,,,both,,,50740.85,17926.14,,,17926.14,Other,150% of Medicare + 9.63% HCRA Surcharge,10900.99,,,10900.99,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,25370.43,50,,25370.43,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4952.04,,,4952.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,35518.6,70,,35518.6,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2662.39,,,2662.39,Other,New York Medicaid APG methodology,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,3727.34,,,3727.34,Other,140% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,6922.2,,,6922.2,Other,260% New York Medicaid APG,8626.13,,,8626.13,Other,324% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,3327.98,,,3327.98,Other,125% New York Medicaid APG,2662.39,35518.6,
Breast reconstruction,19350,CPT,,,,,,,,both,,,80175.05,7248.58,,,7248.58,Other,150% of Medicare + 9.63% HCRA Surcharge,4407.9,,,4407.9,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40087.53,50,,40087.53,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4952.04,,,4952.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56122.54,70,,56122.54,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2662.39,,,2662.39,Other,New York Medicaid APG methodology,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,3727.34,,,3727.34,Other,140% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,6922.2,,,6922.2,Other,260% New York Medicaid APG,8626.13,,,8626.13,Other,324% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,3327.98,,,3327.98,Other,125% New York Medicaid APG,2662.39,56122.54,
Correct inverted nipple(s),19355,CPT,,,,,,,,both,,,35214.64,7248.58,,,7248.58,Other,150% of Medicare + 9.63% HCRA Surcharge,4407.9,,,4407.9,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17607.32,50,,17607.32,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4952.04,,,4952.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24650.25,70,,24650.25,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2662.39,,,2662.39,Other,New York Medicaid APG methodology,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,3727.34,,,3727.34,Other,140% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,6922.2,,,6922.2,Other,260% New York Medicaid APG,8626.13,,,8626.13,Other,324% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,3327.98,,,3327.98,Other,125% New York Medicaid APG,2662.39,24650.25,
Tiss xpndr plmt brst rcnstj,19357,CPT,,,,,,,,both,,,42861.71,33510.66,,,33510.66,Other,150% of Medicare + 9.63% HCRA Surcharge,20378.04,,,20378.04,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,21430.86,50,,21430.86,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6999.37,,,6999.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,30003.2,70,,30003.2,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3763.1,,,3763.1,Other,New York Medicaid APG methodology,3763.1,,,3763.1,Other,100% New York Medicaid APG,3763.1,,,3763.1,Other,100% New York Medicaid APG,3763.1,,,3763.1,Other,100% New York Medicaid APG,8466.98,,,8466.98,Other,225% New York Medicaid APG,8466.98,,,8466.98,Other,225% New York Medicaid APG,8466.98,,,8466.98,Other,225% New York Medicaid APG,8466.98,,,8466.98,Other,225% New York Medicaid APG,5268.34,,,5268.34,Other,140% New York Medicaid APG,8466.98,,,8466.98,Other,225% New York Medicaid APG,9784.06,,,9784.06,Other,260% New York Medicaid APG,12192.45,,,12192.45,Other,324% New York Medicaid APG,8090.67,,,8090.67,Other,215% New York Medicaid APG,8090.67,,,8090.67,Other,215% New York Medicaid APG,4703.88,,,4703.88,Other,125% New York Medicaid APG,3763.1,33510.66,
Revj peri-implt capsule brst,19370,CPT,,,,,,,,both,,,80175.05,7248.58,,,7248.58,Other,150% of Medicare + 9.63% HCRA Surcharge,4407.9,,,4407.9,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40087.53,50,,40087.53,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4952.04,,,4952.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56122.54,70,,56122.54,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2662.39,,,2662.39,Other,New York Medicaid APG methodology,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,3727.34,,,3727.34,Other,140% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,6922.2,,,6922.2,Other,260% New York Medicaid APG,8626.13,,,8626.13,Other,324% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,3327.98,,,3327.98,Other,125% New York Medicaid APG,2662.39,56122.54,
Peri-implt capslc brst compl,19371,CPT,,,,,,,,both,,,51010.09,7248.58,,,7248.58,Other,150% of Medicare + 9.63% HCRA Surcharge,4407.9,,,4407.9,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,25505.05,50,,25505.05,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4952.04,,,4952.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,35707.06,70,,35707.06,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2662.39,,,2662.39,Other,New York Medicaid APG methodology,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,3727.34,,,3727.34,Other,140% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,6922.2,,,6922.2,Other,260% New York Medicaid APG,8626.13,,,8626.13,Other,324% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,3327.98,,,3327.98,Other,125% New York Medicaid APG,2662.39,35707.06,
Revj reconstructed breast,19380,CPT,,,,,,,,both,,,42520.22,12400.81,,,12400.81,Other,150% of Medicare + 9.63% HCRA Surcharge,7541.01,,,7541.01,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,21260.11,50,,21260.11,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4952.04,,,4952.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29764.15,70,,29764.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2662.39,,,2662.39,Other,New York Medicaid APG methodology,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,2662.39,,,2662.39,Other,100% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,3727.34,,,3727.34,Other,140% New York Medicaid APG,5990.37,,,5990.37,Other,225% New York Medicaid APG,6922.2,,,6922.2,Other,260% New York Medicaid APG,8626.13,,,8626.13,Other,324% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,5724.13,,,5724.13,Other,215% New York Medicaid APG,3327.98,,,3327.98,Other,125% New York Medicaid APG,2662.39,29764.15,
Design custom breast implant,19396,CPT,,,,,,,,both,,,80175.05,7248.58,,,7248.58,Other,150% of Medicare + 9.63% HCRA Surcharge,4407.9,,,4407.9,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40087.53,50,,40087.53,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3569.69,,,3569.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56122.54,70,,56122.54,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1919.19,,,1919.19,Other,New York Medicaid APG methodology,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,1919.19,,,1919.19,Other,100% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,2686.86,,,2686.86,Other,140% New York Medicaid APG,4318.17,,,4318.17,Other,225% New York Medicaid APG,4989.89,,,4989.89,Other,260% New York Medicaid APG,6218.17,,,6218.17,Other,324% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,4126.25,,,4126.25,Other,215% New York Medicaid APG,2398.98,,,2398.98,Other,125% New York Medicaid APG,1919.19,56122.54,
Explore wound neck,20100,CPT,,,,,,,,both,,,11572.85,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5786.43,50,,5786.43,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3180.63,,,3180.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8101,70,,8101,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,2394.02,,,2394.02,Other,140% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,4446.04,,,4446.04,Other,260% New York Medicaid APG,5540.45,,,5540.45,Other,324% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,2137.52,,,2137.52,Other,125% New York Medicaid APG,636.26,13157,
Explore wound chest,20101,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3180.63,,,3180.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,2394.02,,,2394.02,Other,140% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,4446.04,,,4446.04,Other,260% New York Medicaid APG,5540.45,,,5540.45,Other,324% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,2137.52,,,2137.52,Other,125% New York Medicaid APG,1710.01,26850.29,
Explore wound abdomen,20102,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3180.63,,,3180.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1710.01,,,1710.01,Other,New York Medicaid APG methodology,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,1710.01,,,1710.01,Other,100% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,2394.02,,,2394.02,Other,140% New York Medicaid APG,3847.53,,,3847.53,Other,225% New York Medicaid APG,4446.04,,,4446.04,Other,260% New York Medicaid APG,5540.45,,,5540.45,Other,324% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,3676.53,,,3676.53,Other,215% New York Medicaid APG,2137.52,,,2137.52,Other,125% New York Medicaid APG,1710.01,26850.29,
Explore wound extremity,20103,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,916.36,23871.23,
Excise epiphyseal bar,20150,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,47657.93,
Muscle biopsy,20200,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,466.95,,,466.95,Fee Schedule,,396.2,,,396.2,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,396.2,23871.23,
Deep muscle biopsy,20205,CPT,,,,,,,,both,,,42752,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,21376,50,,21376,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29926.4,70,,29926.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,29926.4,
Needle biopsy muscle,20206,CPT,,,,,,,,both,,,67811.2,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33905.6,50,,33905.6,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1296.67,,,1296.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47467.84,70,,47467.84,percent of total billed charges,,278.85,,,278.85,Fee Schedule,,236.6,,,236.6,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,697.14,,,697.14,Other,New York Medicaid APG methodology,697.14,,,697.14,Other,100% New York Medicaid APG,697.14,,,697.14,Other,100% New York Medicaid APG,697.14,,,697.14,Other,100% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,975.99,,,975.99,Other,140% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1812.56,,,1812.56,Other,260% New York Medicaid APG,2258.72,,,2258.72,Other,324% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,871.42,,,871.42,Other,125% New York Medicaid APG,236.6,47467.84,
Bone biopsy trocar/needle,20220,CPT,,,,,,,,both,,,41632.49,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20816.25,50,,20816.25,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1296.67,,,1296.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29142.74,70,,29142.74,percent of total billed charges,,427.35,,,427.35,Fee Schedule,,362.6,,,362.6,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,697.14,,,697.14,Other,New York Medicaid APG methodology,697.14,,,697.14,Other,100% New York Medicaid APG,697.14,,,697.14,Other,100% New York Medicaid APG,697.14,,,697.14,Other,100% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,975.99,,,975.99,Other,140% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1812.56,,,1812.56,Other,260% New York Medicaid APG,2258.72,,,2258.72,Other,324% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,871.42,,,871.42,Other,125% New York Medicaid APG,362.6,29142.74,
Bone biopsy trocar/needle,20225,CPT,,,,,,,,both,,,40382.03,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20191.02,50,,20191.02,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28267.42,70,,28267.42,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,28267.42,
Bone biopsy open superficial,20240,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,41837.04,
Bone biopsy open deep,20245,CPT,,,,,,,,both,,,47982.32,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,23991.16,50,,23991.16,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,33587.62,70,,33587.62,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,33587.62,
Open bone biopsy,20250,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3743.09,47657.93,
Open bone biopsy,20251,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,105333.66,
Injection of sinus tract,20500,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,438.9,,,438.9,Fee Schedule,,372.4,,,372.4,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,0.01,22454.17,
Inject sinus tract for x-ray,20501,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1205.26,,,1205.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,178.2,,,178.2,Fee Schedule,,151.2,,,151.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.99,,,647.99,Other,New York Medicaid APG methodology,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,907.18,,,907.18,Other,140% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1684.77,,,1684.77,Other,260% New York Medicaid APG,2099.48,,,2099.48,Other,324% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,809.98,,,809.98,Other,125% New York Medicaid APG,0.01,22702.47,
Removal of foreign body,20520,CPT,,,,,,,,both,,,34057.08,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17028.54,50,,17028.54,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23839.96,70,,23839.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,23839.96,
Removal of foreign body,20525,CPT,,,,,,,,both,,,33471.9,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,16735.95,50,,16735.95,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23430.33,70,,23430.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,23430.33,
Ther injection carp tunnel,20526,CPT,,,,,,,,both,,,6229.82,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3114.91,50,,3114.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,841.15,,,841.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4360.87,70,,4360.87,percent of total billed charges,,280.5,,,280.5,Fee Schedule,,238,,,238,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,452.23,,,452.23,Other,New York Medicaid APG methodology,452.23,,,452.23,Other,100% New York Medicaid APG,452.23,,,452.23,Other,100% New York Medicaid APG,452.23,,,452.23,Other,100% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,633.12,,,633.12,Other,140% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1175.8,,,1175.8,Other,260% New York Medicaid APG,1465.23,,,1465.23,Other,324% New York Medicaid APG,972.3,,,972.3,Other,215% New York Medicaid APG,972.3,,,972.3,Other,215% New York Medicaid APG,565.29,,,565.29,Other,125% New York Medicaid APG,238,9473,
Inj dupuytren cord w/enzyme,20527,CPT,,,,,,,,both,,,6229.82,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3114.91,50,,3114.91,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,841.15,,,841.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4360.87,70,,4360.87,percent of total billed charges,,323.4,,,323.4,Fee Schedule,,274.4,,,274.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,452.23,,,452.23,Other,New York Medicaid APG methodology,452.23,,,452.23,Other,100% New York Medicaid APG,452.23,,,452.23,Other,100% New York Medicaid APG,452.23,,,452.23,Other,100% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,633.12,,,633.12,Other,140% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1175.8,,,1175.8,Other,260% New York Medicaid APG,1465.23,,,1465.23,Other,324% New York Medicaid APG,972.3,,,972.3,Other,215% New York Medicaid APG,972.3,,,972.3,Other,215% New York Medicaid APG,565.29,,,565.29,Other,125% New York Medicaid APG,0.01,9473,
Inj tendon sheath/ligament,20550,CPT,,,,,,,,both,,,6229.82,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3114.91,50,,3114.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,841.15,,,841.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4360.87,70,,4360.87,percent of total billed charges,,191.4,,,191.4,Fee Schedule,,162.4,,,162.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,452.23,,,452.23,Other,New York Medicaid APG methodology,452.23,,,452.23,Other,100% New York Medicaid APG,452.23,,,452.23,Other,100% New York Medicaid APG,452.23,,,452.23,Other,100% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,633.12,,,633.12,Other,140% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1175.8,,,1175.8,Other,260% New York Medicaid APG,1465.23,,,1465.23,Other,324% New York Medicaid APG,972.3,,,972.3,Other,215% New York Medicaid APG,972.3,,,972.3,Other,215% New York Medicaid APG,565.29,,,565.29,Other,125% New York Medicaid APG,162.4,9473,
Inj tendon origin/insertion,20551,CPT,,,,,,,,both,,,6229.82,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3114.91,50,,3114.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,841.15,,,841.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4360.87,70,,4360.87,percent of total billed charges,,191.4,,,191.4,Fee Schedule,,162.4,,,162.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,452.23,,,452.23,Other,New York Medicaid APG methodology,452.23,,,452.23,Other,100% New York Medicaid APG,452.23,,,452.23,Other,100% New York Medicaid APG,452.23,,,452.23,Other,100% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,633.12,,,633.12,Other,140% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1175.8,,,1175.8,Other,260% New York Medicaid APG,1465.23,,,1465.23,Other,324% New York Medicaid APG,972.3,,,972.3,Other,215% New York Medicaid APG,972.3,,,972.3,Other,215% New York Medicaid APG,565.29,,,565.29,Other,125% New York Medicaid APG,162.4,9473,
Inj trigger point 1/2 muscl,20552,CPT,,,,,,,,both,,,10572.63,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5286.32,50,,5286.32,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,841.15,,,841.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,7400.84,70,,7400.84,percent of total billed charges,,181.5,,,181.5,Fee Schedule,,154,,,154,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,452.23,,,452.23,Other,New York Medicaid APG methodology,452.23,,,452.23,Other,100% New York Medicaid APG,452.23,,,452.23,Other,100% New York Medicaid APG,452.23,,,452.23,Other,100% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,633.12,,,633.12,Other,140% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1175.8,,,1175.8,Other,260% New York Medicaid APG,1465.23,,,1465.23,Other,324% New York Medicaid APG,972.3,,,972.3,Other,215% New York Medicaid APG,972.3,,,972.3,Other,215% New York Medicaid APG,565.29,,,565.29,Other,125% New York Medicaid APG,154,9473,
Inject trigger points 3/>,20553,CPT,,,,,,,,both,,,6229.82,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3114.91,50,,3114.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,841.15,,,841.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4360.87,70,,4360.87,percent of total billed charges,,207.9,,,207.9,Fee Schedule,,176.4,,,176.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,452.23,,,452.23,Other,New York Medicaid APG methodology,452.23,,,452.23,Other,100% New York Medicaid APG,452.23,,,452.23,Other,100% New York Medicaid APG,452.23,,,452.23,Other,100% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,633.12,,,633.12,Other,140% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1175.8,,,1175.8,Other,260% New York Medicaid APG,1465.23,,,1465.23,Other,324% New York Medicaid APG,972.3,,,972.3,Other,215% New York Medicaid APG,972.3,,,972.3,Other,215% New York Medicaid APG,565.29,,,565.29,Other,125% New York Medicaid APG,176.4,9473,
Place ndl musc/tis for rt,20555,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,47657.93,
Drain/inj joint/bursa w/o us,20600,CPT,,,,,,,,both,,,34087.51,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17043.76,50,,17043.76,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,841.15,,,841.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23861.26,70,,23861.26,percent of total billed charges,,173.25,,,173.25,Fee Schedule,,147,,,147,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,452.23,,,452.23,Other,New York Medicaid APG methodology,452.23,,,452.23,Other,100% New York Medicaid APG,452.23,,,452.23,Other,100% New York Medicaid APG,452.23,,,452.23,Other,100% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,633.12,,,633.12,Other,140% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1175.8,,,1175.8,Other,260% New York Medicaid APG,1465.23,,,1465.23,Other,324% New York Medicaid APG,972.3,,,972.3,Other,215% New York Medicaid APG,972.3,,,972.3,Other,215% New York Medicaid APG,565.29,,,565.29,Other,125% New York Medicaid APG,147,23861.26,
Drain/inj joint/bursa w/us,20604,CPT,,,,,,,,both,,,6229.82,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3114.91,50,,3114.91,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1351.14,,,1351.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4360.87,70,,4360.87,percent of total billed charges,,224.4,,,224.4,Fee Schedule,,190.4,,,190.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,726.42,,,726.42,Other,New York Medicaid APG methodology,726.42,,,726.42,Other,100% New York Medicaid APG,726.42,,,726.42,Other,100% New York Medicaid APG,726.42,,,726.42,Other,100% New York Medicaid APG,1634.45,,,1634.45,Other,225% New York Medicaid APG,1634.45,,,1634.45,Other,225% New York Medicaid APG,1634.45,,,1634.45,Other,225% New York Medicaid APG,1634.45,,,1634.45,Other,225% New York Medicaid APG,1016.99,,,1016.99,Other,140% New York Medicaid APG,1634.45,,,1634.45,Other,225% New York Medicaid APG,1888.69,,,1888.69,Other,260% New York Medicaid APG,2353.6,,,2353.6,Other,324% New York Medicaid APG,1561.8,,,1561.8,Other,215% New York Medicaid APG,1561.8,,,1561.8,Other,215% New York Medicaid APG,908.03,,,908.03,Other,125% New York Medicaid APG,0.01,9473,
Drain/inj joint/bursa w/o us,20605,CPT,,,,,,,,both,,,3766.45,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1883.23,50,,1883.23,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,841.15,,,841.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2636.52,70,,2636.52,percent of total billed charges,,181.5,,,181.5,Fee Schedule,,154,,,154,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,452.23,,,452.23,Other,New York Medicaid APG methodology,452.23,,,452.23,Other,100% New York Medicaid APG,452.23,,,452.23,Other,100% New York Medicaid APG,452.23,,,452.23,Other,100% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,633.12,,,633.12,Other,140% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1175.8,,,1175.8,Other,260% New York Medicaid APG,1465.23,,,1465.23,Other,324% New York Medicaid APG,972.3,,,972.3,Other,215% New York Medicaid APG,972.3,,,972.3,Other,215% New York Medicaid APG,565.29,,,565.29,Other,125% New York Medicaid APG,154,9473,
Drain/inj joint/bursa w/us,20606,CPT,,,,,,,,both,,,3266.33,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1633.17,50,,1633.17,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1351.14,,,1351.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2286.43,70,,2286.43,percent of total billed charges,,254.1,,,254.1,Fee Schedule,,215.6,,,215.6,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,726.42,,,726.42,Other,New York Medicaid APG methodology,726.42,,,726.42,Other,100% New York Medicaid APG,726.42,,,726.42,Other,100% New York Medicaid APG,726.42,,,726.42,Other,100% New York Medicaid APG,1634.45,,,1634.45,Other,225% New York Medicaid APG,1634.45,,,1634.45,Other,225% New York Medicaid APG,1634.45,,,1634.45,Other,225% New York Medicaid APG,1634.45,,,1634.45,Other,225% New York Medicaid APG,1016.99,,,1016.99,Other,140% New York Medicaid APG,1634.45,,,1634.45,Other,225% New York Medicaid APG,1888.69,,,1888.69,Other,260% New York Medicaid APG,2353.6,,,2353.6,Other,324% New York Medicaid APG,1561.8,,,1561.8,Other,215% New York Medicaid APG,1561.8,,,1561.8,Other,215% New York Medicaid APG,908.03,,,908.03,Other,125% New York Medicaid APG,0.01,9473,
Drain/inj joint/bursa w/o us,20610,CPT,,,,,,,,both,,,9021.14,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4510.57,50,,4510.57,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,841.15,,,841.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,6314.8,70,,6314.8,percent of total billed charges,,221.1,,,221.1,Fee Schedule,,187.6,,,187.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,452.23,,,452.23,Other,New York Medicaid APG methodology,452.23,,,452.23,Other,100% New York Medicaid APG,452.23,,,452.23,Other,100% New York Medicaid APG,452.23,,,452.23,Other,100% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,633.12,,,633.12,Other,140% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1175.8,,,1175.8,Other,260% New York Medicaid APG,1465.23,,,1465.23,Other,324% New York Medicaid APG,972.3,,,972.3,Other,215% New York Medicaid APG,972.3,,,972.3,Other,215% New York Medicaid APG,565.29,,,565.29,Other,125% New York Medicaid APG,187.6,9473,
Drain/inj joint/bursa w/us,20611,CPT,,,,,,,,both,,,19379.67,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9689.84,50,,9689.84,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1351.14,,,1351.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13565.77,70,,13565.77,percent of total billed charges,,293.7,,,293.7,Fee Schedule,,249.2,,,249.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,726.42,,,726.42,Other,New York Medicaid APG methodology,726.42,,,726.42,Other,100% New York Medicaid APG,726.42,,,726.42,Other,100% New York Medicaid APG,726.42,,,726.42,Other,100% New York Medicaid APG,1634.45,,,1634.45,Other,225% New York Medicaid APG,1634.45,,,1634.45,Other,225% New York Medicaid APG,1634.45,,,1634.45,Other,225% New York Medicaid APG,1634.45,,,1634.45,Other,225% New York Medicaid APG,1016.99,,,1016.99,Other,140% New York Medicaid APG,1634.45,,,1634.45,Other,225% New York Medicaid APG,1888.69,,,1888.69,Other,260% New York Medicaid APG,2353.6,,,2353.6,Other,324% New York Medicaid APG,1561.8,,,1561.8,Other,215% New York Medicaid APG,1561.8,,,1561.8,Other,215% New York Medicaid APG,908.03,,,908.03,Other,125% New York Medicaid APG,0.01,13565.77,
Aspirate/inj ganglion cyst,20612,CPT,,,,,,,,both,,,6229.82,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3114.91,50,,3114.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,841.15,,,841.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4360.87,70,,4360.87,percent of total billed charges,,201.3,,,201.3,Fee Schedule,,170.8,,,170.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,452.23,,,452.23,Other,New York Medicaid APG methodology,452.23,,,452.23,Other,100% New York Medicaid APG,452.23,,,452.23,Other,100% New York Medicaid APG,452.23,,,452.23,Other,100% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,633.12,,,633.12,Other,140% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1175.8,,,1175.8,Other,260% New York Medicaid APG,1465.23,,,1465.23,Other,324% New York Medicaid APG,972.3,,,972.3,Other,215% New York Medicaid APG,972.3,,,972.3,Other,215% New York Medicaid APG,565.29,,,565.29,Other,125% New York Medicaid APG,170.8,9473,
Treatment of bone cyst,20615,CPT,,,,,,,,both,,,56392.4,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,28196.2,50,,28196.2,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1351.14,,,1351.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,39474.68,70,,39474.68,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,726.42,,,726.42,Other,New York Medicaid APG methodology,726.42,,,726.42,Other,100% New York Medicaid APG,726.42,,,726.42,Other,100% New York Medicaid APG,726.42,,,726.42,Other,100% New York Medicaid APG,1634.45,,,1634.45,Other,225% New York Medicaid APG,1634.45,,,1634.45,Other,225% New York Medicaid APG,1634.45,,,1634.45,Other,225% New York Medicaid APG,1634.45,,,1634.45,Other,225% New York Medicaid APG,1016.99,,,1016.99,Other,140% New York Medicaid APG,1634.45,,,1634.45,Other,225% New York Medicaid APG,1888.69,,,1888.69,Other,260% New York Medicaid APG,2353.6,,,2353.6,Other,324% New York Medicaid APG,1561.8,,,1561.8,Other,215% New York Medicaid APG,1561.8,,,1561.8,Other,215% New York Medicaid APG,908.03,,,908.03,Other,125% New York Medicaid APG,0.01,39474.68,
Insert and remove bone pin,20650,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3873.59,,,3873.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2082.57,,,2082.57,Other,New York Medicaid APG methodology,2082.57,,,2082.57,Other,100% New York Medicaid APG,2082.57,,,2082.57,Other,100% New York Medicaid APG,2082.57,,,2082.57,Other,100% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,2915.6,,,2915.6,Other,140% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,5414.69,,,5414.69,Other,260% New York Medicaid APG,6747.54,,,6747.54,Other,324% New York Medicaid APG,4477.53,,,4477.53,Other,215% New York Medicaid APG,4477.53,,,4477.53,Other,215% New York Medicaid APG,2603.22,,,2603.22,Other,125% New York Medicaid APG,2082.57,47657.93,
Apply rem fixation device,20660,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3873.59,,,3873.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2082.57,,,2082.57,Other,New York Medicaid APG methodology,2082.57,,,2082.57,Other,100% New York Medicaid APG,2082.57,,,2082.57,Other,100% New York Medicaid APG,2082.57,,,2082.57,Other,100% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,2915.6,,,2915.6,Other,140% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,5414.69,,,5414.69,Other,260% New York Medicaid APG,6747.54,,,6747.54,Other,324% New York Medicaid APG,4477.53,,,4477.53,Other,215% New York Medicaid APG,4477.53,,,4477.53,Other,215% New York Medicaid APG,2603.22,,,2603.22,Other,125% New York Medicaid APG,1858.58,23663.84,
Application of pelvis brace,20662,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3873.59,,,3873.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2082.57,,,2082.57,Other,New York Medicaid APG methodology,2082.57,,,2082.57,Other,100% New York Medicaid APG,2082.57,,,2082.57,Other,100% New York Medicaid APG,2082.57,,,2082.57,Other,100% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,2915.6,,,2915.6,Other,140% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,5414.69,,,5414.69,Other,260% New York Medicaid APG,6747.54,,,6747.54,Other,324% New York Medicaid APG,4477.53,,,4477.53,Other,215% New York Medicaid APG,4477.53,,,4477.53,Other,215% New York Medicaid APG,2603.22,,,2603.22,Other,125% New York Medicaid APG,1858.58,23663.84,
Application of thigh brace,20663,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3873.59,,,3873.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2082.57,,,2082.57,Other,New York Medicaid APG methodology,2082.57,,,2082.57,Other,100% New York Medicaid APG,2082.57,,,2082.57,Other,100% New York Medicaid APG,2082.57,,,2082.57,Other,100% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,2915.6,,,2915.6,Other,140% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,5414.69,,,5414.69,Other,260% New York Medicaid APG,6747.54,,,6747.54,Other,324% New York Medicaid APG,4477.53,,,4477.53,Other,215% New York Medicaid APG,4477.53,,,4477.53,Other,215% New York Medicaid APG,2603.22,,,2603.22,Other,125% New York Medicaid APG,2082.57,47657.93,
Removal of fixation device,20665,CPT,,,,,,,,both,,,8380.68,757.69,,,757.69,Other,150% of Medicare + 9.63% HCRA Surcharge,460.76,,,460.76,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4190.34,50,,4190.34,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1224.82,,,1224.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5866.48,70,,5866.48,percent of total billed charges,,480.15,,,480.15,Fee Schedule,,407.4,,,407.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,658.51,,,658.51,Other,New York Medicaid APG methodology,658.51,,,658.51,Other,100% New York Medicaid APG,658.51,,,658.51,Other,100% New York Medicaid APG,658.51,,,658.51,Other,100% New York Medicaid APG,1481.64,,,1481.64,Other,225% New York Medicaid APG,1481.64,,,1481.64,Other,225% New York Medicaid APG,1481.64,,,1481.64,Other,225% New York Medicaid APG,1481.64,,,1481.64,Other,225% New York Medicaid APG,921.91,,,921.91,Other,140% New York Medicaid APG,1481.64,,,1481.64,Other,225% New York Medicaid APG,1712.12,,,1712.12,Other,260% New York Medicaid APG,2133.56,,,2133.56,Other,324% New York Medicaid APG,1415.79,,,1415.79,Other,215% New York Medicaid APG,1415.79,,,1415.79,Other,215% New York Medicaid APG,823.13,,,823.13,Other,125% New York Medicaid APG,0.01,9473,
Removal of support implant,20670,CPT,,,,,,,,both,,,37746.38,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18873.19,50,,18873.19,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3873.59,,,3873.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26422.47,70,,26422.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2082.57,,,2082.57,Other,New York Medicaid APG methodology,2082.57,,,2082.57,Other,100% New York Medicaid APG,2082.57,,,2082.57,Other,100% New York Medicaid APG,2082.57,,,2082.57,Other,100% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,2915.6,,,2915.6,Other,140% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,5414.69,,,5414.69,Other,260% New York Medicaid APG,6747.54,,,6747.54,Other,324% New York Medicaid APG,4477.53,,,4477.53,Other,215% New York Medicaid APG,4477.53,,,4477.53,Other,215% New York Medicaid APG,2603.22,,,2603.22,Other,125% New York Medicaid APG,1874.86,26422.47,
Removal of support implant,20680,CPT,,,,,,,,both,,,50892.55,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,25446.28,50,,25446.28,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3873.59,,,3873.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,35624.79,70,,35624.79,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2082.57,,,2082.57,Other,New York Medicaid APG methodology,2082.57,,,2082.57,Other,100% New York Medicaid APG,2082.57,,,2082.57,Other,100% New York Medicaid APG,2082.57,,,2082.57,Other,100% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,2915.6,,,2915.6,Other,140% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,5414.69,,,5414.69,Other,260% New York Medicaid APG,6747.54,,,6747.54,Other,324% New York Medicaid APG,4477.53,,,4477.53,Other,215% New York Medicaid APG,4477.53,,,4477.53,Other,215% New York Medicaid APG,2603.22,,,2603.22,Other,125% New York Medicaid APG,2082.57,35624.79,
Apply bone fixation device,20690,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3873.59,,,3873.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2082.57,,,2082.57,Other,New York Medicaid APG methodology,2082.57,,,2082.57,Other,100% New York Medicaid APG,2082.57,,,2082.57,Other,100% New York Medicaid APG,2082.57,,,2082.57,Other,100% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,2915.6,,,2915.6,Other,140% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,5414.69,,,5414.69,Other,260% New York Medicaid APG,6747.54,,,6747.54,Other,324% New York Medicaid APG,4477.53,,,4477.53,Other,215% New York Medicaid APG,4477.53,,,4477.53,Other,215% New York Medicaid APG,2603.22,,,2603.22,Other,125% New York Medicaid APG,2082.57,105333.66,
Apply bone fixation device,20692,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3873.59,,,3873.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2082.57,,,2082.57,Other,New York Medicaid APG methodology,2082.57,,,2082.57,Other,100% New York Medicaid APG,2082.57,,,2082.57,Other,100% New York Medicaid APG,2082.57,,,2082.57,Other,100% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,2915.6,,,2915.6,Other,140% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,5414.69,,,5414.69,Other,260% New York Medicaid APG,6747.54,,,6747.54,Other,324% New York Medicaid APG,4477.53,,,4477.53,Other,215% New York Medicaid APG,4477.53,,,4477.53,Other,215% New York Medicaid APG,2603.22,,,2603.22,Other,125% New York Medicaid APG,2082.57,193779.51,
Adjust bone fixation device,20693,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3873.59,,,3873.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2082.57,,,2082.57,Other,New York Medicaid APG methodology,2082.57,,,2082.57,Other,100% New York Medicaid APG,2082.57,,,2082.57,Other,100% New York Medicaid APG,2082.57,,,2082.57,Other,100% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,2915.6,,,2915.6,Other,140% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,5414.69,,,5414.69,Other,260% New York Medicaid APG,6747.54,,,6747.54,Other,324% New York Medicaid APG,4477.53,,,4477.53,Other,215% New York Medicaid APG,4477.53,,,4477.53,Other,215% New York Medicaid APG,2603.22,,,2603.22,Other,125% New York Medicaid APG,2082.57,105333.66,
Remove bone fixation device,20694,CPT,,,,,,,,both,,,37783.1,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18891.55,50,,18891.55,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3873.59,,,3873.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26448.17,70,,26448.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2082.57,,,2082.57,Other,New York Medicaid APG methodology,2082.57,,,2082.57,Other,100% New York Medicaid APG,2082.57,,,2082.57,Other,100% New York Medicaid APG,2082.57,,,2082.57,Other,100% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,2915.6,,,2915.6,Other,140% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,5414.69,,,5414.69,Other,260% New York Medicaid APG,6747.54,,,6747.54,Other,324% New York Medicaid APG,4477.53,,,4477.53,Other,215% New York Medicaid APG,4477.53,,,4477.53,Other,215% New York Medicaid APG,2603.22,,,2603.22,Other,125% New York Medicaid APG,1858.58,26448.17,
Comp multiplane ext fixation,20696,CPT,,,,,,,,both,,,391985.94,35439.21,,,35439.21,Other,150% of Medicare + 9.63% HCRA Surcharge,21550.8,,,21550.8,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,195992.97,50,,195992.97,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3873.59,,,3873.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,274390.16,70,,274390.16,percent of total billed charges,,5781.6,,,5781.6,Fee Schedule,,4905.6,,,4905.6,Fee Schedule,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2082.57,,,2082.57,Other,New York Medicaid APG methodology,2082.57,,,2082.57,Other,100% New York Medicaid APG,2082.57,,,2082.57,Other,100% New York Medicaid APG,2082.57,,,2082.57,Other,100% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,2915.6,,,2915.6,Other,140% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,5414.69,,,5414.69,Other,260% New York Medicaid APG,6747.54,,,6747.54,Other,324% New York Medicaid APG,4477.53,,,4477.53,Other,215% New York Medicaid APG,4477.53,,,4477.53,Other,215% New York Medicaid APG,2603.22,,,2603.22,Other,125% New York Medicaid APG,2082.57,274390.16,
Comp ext fixate strut change,20697,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3873.59,,,3873.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,9060.15,,,9060.15,Fee Schedule,,7687.4,,,7687.4,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,2082.57,,,2082.57,Other,New York Medicaid APG methodology,2082.57,,,2082.57,Other,100% New York Medicaid APG,2082.57,,,2082.57,Other,100% New York Medicaid APG,2082.57,,,2082.57,Other,100% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,2915.6,,,2915.6,Other,140% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,5414.69,,,5414.69,Other,260% New York Medicaid APG,6747.54,,,6747.54,Other,324% New York Medicaid APG,4477.53,,,4477.53,Other,215% New York Medicaid APG,4477.53,,,4477.53,Other,215% New York Medicaid APG,2603.22,,,2603.22,Other,125% New York Medicaid APG,1858.58,23663.84,
Replantation digit complete,20822,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,1858.58,23663.84,
Removal of bone for graft,20900,CPT,,,,,,,,both,,,105951.37,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,52975.69,50,,52975.69,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,74165.96,70,,74165.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,74165.96,
Removal of bone for graft,20902,CPT,,,,,,,,both,,,144359.91,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,72179.96,50,,72179.96,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,101051.94,70,,101051.94,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,101051.94,
Remove cartilage for graft,20910,CPT,,,,,,,,both,,,13210.22,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6605.11,50,,6605.11,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9247.15,70,,9247.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,726.28,13157,
Remove cartilage for graft,20912,CPT,,,,,,,,both,,,75461.18,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,37730.59,50,,37730.59,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52822.83,70,,52822.83,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,52822.83,
Removal of fascia for graft,20920,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,26850.29,
Removal of fascia for graft,20922,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,26850.29,
Removal of tendon for graft,20924,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,105333.66,
Sp bone algrft morsel add-on,20930,CPT,,,,,,,,both,,,36356.27,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,21813.76,60,,21813.76,percent of total billed charges,,20359.51,56,,20359.51,percent of total billed charges,,19632.39,54,,19632.39,percent of total billed charges,,18178.14,50,,18178.14,percent of total billed charges,,25449.39,70,,25449.39,percent of total billed charges,,6152,,,6152,Case Rate,,8573.09,,,8573.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25449.39,70,,25449.39,percent of total billed charges,,18178.14,50,,18178.14,percent of total billed charges,,18178.14,50,,18178.14,percent of total billed charges,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,4609.19,,,4609.19,Other,New York Medicaid APG methodology,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,6452.86,,,6452.86,Other,140% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,11983.89,,,11983.89,Other,260% New York Medicaid APG,14933.77,,,14933.77,Other,324% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,5761.49,,,5761.49,Other,125% New York Medicaid APG,0.01,25449.39,
Sp bone algrft struct add-on,20931,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,8573.09,,,8573.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,4609.19,,,4609.19,Other,New York Medicaid APG methodology,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,6452.86,,,6452.86,Other,140% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,11983.89,,,11983.89,Other,260% New York Medicaid APG,14933.77,,,14933.77,Other,324% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,5761.49,,,5761.49,Other,125% New York Medicaid APG,0.01,36100.43,
Osteoart algrft w/surf & b1,20932,CPT,,,,,,,,both,,,64479.48,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32239.74,50,,32239.74,percent of total billed charges,,45135.64,70,,45135.64,percent of total billed charges,,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45135.64,70,,45135.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,0.01,45135.64,
Hemicrt intrclry algrft prtl,20933,CPT,,,,,,,,both,,,64479.48,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32239.74,50,,32239.74,percent of total billed charges,,45135.64,70,,45135.64,percent of total billed charges,,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45135.64,70,,45135.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,0.01,45135.64,
Intercalary algrft compl,20934,CPT,,,,,,,,both,,,64479.48,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32239.74,50,,32239.74,percent of total billed charges,,45135.64,70,,45135.64,percent of total billed charges,,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45135.64,70,,45135.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,0.01,45135.64,
Sp bone agrft local add-on,20936,CPT,,,,,,,,both,,,36356.27,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,21813.76,60,,21813.76,percent of total billed charges,,20359.51,56,,20359.51,percent of total billed charges,,19632.39,54,,19632.39,percent of total billed charges,,18178.14,50,,18178.14,percent of total billed charges,,25449.39,70,,25449.39,percent of total billed charges,,6152,,,6152,Case Rate,,8573.09,,,8573.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25449.39,70,,25449.39,percent of total billed charges,,18178.14,50,,18178.14,percent of total billed charges,,18178.14,50,,18178.14,percent of total billed charges,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,4609.19,,,4609.19,Other,New York Medicaid APG methodology,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,6452.86,,,6452.86,Other,140% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,11983.89,,,11983.89,Other,260% New York Medicaid APG,14933.77,,,14933.77,Other,324% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,5761.49,,,5761.49,Other,125% New York Medicaid APG,0.01,25449.39,
Sp bone agrft morsel add-on,20937,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,8573.09,,,8573.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,4609.19,,,4609.19,Other,New York Medicaid APG methodology,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,6452.86,,,6452.86,Other,140% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,11983.89,,,11983.89,Other,260% New York Medicaid APG,14933.77,,,14933.77,Other,324% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,5761.49,,,5761.49,Other,125% New York Medicaid APG,0.01,36100.43,
Sp bone agrft struct add-on,20938,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,8573.09,,,8573.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,4609.19,,,4609.19,Other,New York Medicaid APG methodology,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,6452.86,,,6452.86,Other,140% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,11983.89,,,11983.89,Other,260% New York Medicaid APG,14933.77,,,14933.77,Other,324% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,5761.49,,,5761.49,Other,125% New York Medicaid APG,0.01,36100.43,
Bone marrow aspir bone grfg,20939,CPT,,,,,,,,both,,,83504,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,41752,50,,41752,percent of total billed charges,,58452.8,70,,58452.8,percent of total billed charges,,6152,,,6152,Case Rate,,8573.09,,,8573.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,58452.8,70,,58452.8,percent of total billed charges,,344.85,,,344.85,Fee Schedule,,292.6,,,292.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,4609.19,,,4609.19,Other,New York Medicaid APG methodology,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,6452.86,,,6452.86,Other,140% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,11983.89,,,11983.89,Other,260% New York Medicaid APG,14933.77,,,14933.77,Other,324% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,5761.49,,,5761.49,Other,125% New York Medicaid APG,0.01,58452.8,
Fluid pressure muscle,20950,CPT,,,,,,,,both,,,14798.8,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7399.4,50,,7399.4,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1224.82,,,1224.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10359.16,70,,10359.16,percent of total billed charges,,430.65,,,430.65,Fee Schedule,,365.4,,,365.4,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,658.51,,,658.51,Other,New York Medicaid APG methodology,658.51,,,658.51,Other,100% New York Medicaid APG,658.51,,,658.51,Other,100% New York Medicaid APG,658.51,,,658.51,Other,100% New York Medicaid APG,1481.64,,,1481.64,Other,225% New York Medicaid APG,1481.64,,,1481.64,Other,225% New York Medicaid APG,1481.64,,,1481.64,Other,225% New York Medicaid APG,1481.64,,,1481.64,Other,225% New York Medicaid APG,921.91,,,921.91,Other,140% New York Medicaid APG,1481.64,,,1481.64,Other,225% New York Medicaid APG,1712.12,,,1712.12,Other,260% New York Medicaid APG,2133.56,,,2133.56,Other,324% New York Medicaid APG,1415.79,,,1415.79,Other,215% New York Medicaid APG,1415.79,,,1415.79,Other,215% New York Medicaid APG,823.13,,,823.13,Other,125% New York Medicaid APG,365.4,10359.16,
Bone/skin graft metatarsal,20972,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,105333.66,
Bone/skin graft great toe,20973,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,105333.66,
Electrical bone stimulation,20975,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,0.01,36100.43,
Us bone stimulation,20979,CPT,,,,,,,,both,,,626.29,56.62,,,56.62,Other,150% of Medicare + 9.63% HCRA Surcharge,34.43,,,34.43,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,313.15,50,,313.15,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1224.82,,,1224.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,438.4,70,,438.4,percent of total billed charges,,158.4,,,158.4,Fee Schedule,,134.4,,,134.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,658.51,,,658.51,Other,New York Medicaid APG methodology,658.51,,,658.51,Other,100% New York Medicaid APG,658.51,,,658.51,Other,100% New York Medicaid APG,658.51,,,658.51,Other,100% New York Medicaid APG,1481.64,,,1481.64,Other,225% New York Medicaid APG,1481.64,,,1481.64,Other,225% New York Medicaid APG,1481.64,,,1481.64,Other,225% New York Medicaid APG,1481.64,,,1481.64,Other,225% New York Medicaid APG,921.91,,,921.91,Other,140% New York Medicaid APG,1481.64,,,1481.64,Other,225% New York Medicaid APG,1712.12,,,1712.12,Other,260% New York Medicaid APG,2133.56,,,2133.56,Other,324% New York Medicaid APG,1415.79,,,1415.79,Other,215% New York Medicaid APG,1415.79,,,1415.79,Other,215% New York Medicaid APG,823.13,,,823.13,Other,125% New York Medicaid APG,0.01,9473,
Ablate bone tumor(s) perq,20982,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,193779.51,
Ablate bone tumor(s) perq,20983,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,105333.66,
Cptr-asst dir ms px,20985,CPT,,,,,,,,both,,,36356.27,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,21813.76,60,,21813.76,percent of total billed charges,,20359.51,56,,20359.51,percent of total billed charges,,19632.39,54,,19632.39,percent of total billed charges,,18178.14,50,,18178.14,percent of total billed charges,,25449.39,70,,25449.39,percent of total billed charges,,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25449.39,70,,25449.39,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,25449.39,
Incision of jaw joint,21010,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,47404.34,
Exc face les sc <2 cm,21011,CPT,,,,,,,,both,,,37587.99,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18794,50,,18794,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26311.59,70,,26311.59,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,0.01,26311.59,
Exc face les sbq 2 cm/>,21012,CPT,,,,,,,,both,,,35914.52,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17957.26,50,,17957.26,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25140.16,70,,25140.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,25140.16,
Exc face tum deep < 2 cm,21013,CPT,,,,,,,,both,,,42004.82,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21002.41,50,,21002.41,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29403.37,70,,29403.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,29403.37,
Exc face tum deep 2 cm/>,21014,CPT,,,,,,,,both,,,42535.57,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,21267.79,50,,21267.79,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29774.9,70,,29774.9,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,29774.9,
Resect face/scalp tum < 2 cm,21015,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,41837.04,
Resect face/scalp tum 2 cm/>,21016,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,41837.04,
Excision of bone lower jaw,21025,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,86224,
Excision of facial bone(s),21026,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,86224,
Contour of face bone lesion,21029,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,47404.34,
Excise max/zygoma b9 tumor,21030,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,86224,
Remove exostosis mandible,21031,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,47404.34,
Remove exostosis maxilla,21032,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,47404.34,
Excise max/zygoma mal tumor,21034,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Excise mandible lesion,21040,CPT,,,,,,,,both,,,92070.37,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,46035.19,50,,46035.19,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,64449.26,70,,64449.26,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,64449.26,
Removal of jaw bone lesion,21044,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Remove mandible cyst complex,21046,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Excise lwr jaw cyst w/repair,21047,CPT,,,,,,,,both,,,56587.86,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,28293.93,50,,28293.93,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,39611.5,70,,39611.5,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,39611.5,
Remove maxilla cyst complex,21048,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Excis uppr jaw cyst w/repair,21049,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Removal of jaw joint,21050,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Remove jaw joint cartilage,21060,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Remove coronoid process,21070,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Mnpj of tmj w/anesth,21073,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,2193.58,,,2193.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,1651.08,,,1651.08,Other,140% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,3066.3,,,3066.3,Other,260% New York Medicaid APG,3821.08,,,3821.08,Other,324% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,1474.18,,,1474.18,Other,125% New York Medicaid APG,0.01,22454.17,
Prepare face/oral prosthesis,21076,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,315.45,,,315.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,169.6,,,169.6,Other,New York Medicaid APG methodology,169.6,,,169.6,Other,100% New York Medicaid APG,169.6,,,169.6,Other,100% New York Medicaid APG,169.6,,,169.6,Other,100% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,237.43,,,237.43,Other,140% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,440.95,,,440.95,Other,260% New York Medicaid APG,549.49,,,549.49,Other,324% New York Medicaid APG,364.63,,,364.63,Other,215% New York Medicaid APG,364.63,,,364.63,Other,215% New York Medicaid APG,212,,,212,Other,125% New York Medicaid APG,169.6,22454.17,
Prepare face/oral prosthesis,21077,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,738.77,,,738.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,397.19,,,397.19,Other,New York Medicaid APG methodology,397.19,,,397.19,Other,100% New York Medicaid APG,397.19,,,397.19,Other,100% New York Medicaid APG,397.19,,,397.19,Other,100% New York Medicaid APG,893.67,,,893.67,Other,225% New York Medicaid APG,893.67,,,893.67,Other,225% New York Medicaid APG,893.67,,,893.67,Other,225% New York Medicaid APG,893.67,,,893.67,Other,225% New York Medicaid APG,556.06,,,556.06,Other,140% New York Medicaid APG,893.67,,,893.67,Other,225% New York Medicaid APG,1032.68,,,1032.68,Other,260% New York Medicaid APG,1286.88,,,1286.88,Other,324% New York Medicaid APG,853.95,,,853.95,Other,215% New York Medicaid APG,853.95,,,853.95,Other,215% New York Medicaid APG,496.48,,,496.48,Other,125% New York Medicaid APG,397.19,86224,
Prepare face/oral prosthesis,21079,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,315.45,,,315.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,169.6,,,169.6,Other,New York Medicaid APG methodology,169.6,,,169.6,Other,100% New York Medicaid APG,169.6,,,169.6,Other,100% New York Medicaid APG,169.6,,,169.6,Other,100% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,237.43,,,237.43,Other,140% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,440.95,,,440.95,Other,260% New York Medicaid APG,549.49,,,549.49,Other,324% New York Medicaid APG,364.63,,,364.63,Other,215% New York Medicaid APG,364.63,,,364.63,Other,215% New York Medicaid APG,212,,,212,Other,125% New York Medicaid APG,169.6,47404.34,
Prepare face/oral prosthesis,21080,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,315.45,,,315.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,169.6,,,169.6,Other,New York Medicaid APG methodology,169.6,,,169.6,Other,100% New York Medicaid APG,169.6,,,169.6,Other,100% New York Medicaid APG,169.6,,,169.6,Other,100% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,237.43,,,237.43,Other,140% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,440.95,,,440.95,Other,260% New York Medicaid APG,549.49,,,549.49,Other,324% New York Medicaid APG,364.63,,,364.63,Other,215% New York Medicaid APG,364.63,,,364.63,Other,215% New York Medicaid APG,212,,,212,Other,125% New York Medicaid APG,169.6,47404.34,
Prepare face/oral prosthesis,21081,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,738.77,,,738.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,397.19,,,397.19,Other,New York Medicaid APG methodology,397.19,,,397.19,Other,100% New York Medicaid APG,397.19,,,397.19,Other,100% New York Medicaid APG,397.19,,,397.19,Other,100% New York Medicaid APG,893.67,,,893.67,Other,225% New York Medicaid APG,893.67,,,893.67,Other,225% New York Medicaid APG,893.67,,,893.67,Other,225% New York Medicaid APG,893.67,,,893.67,Other,225% New York Medicaid APG,556.06,,,556.06,Other,140% New York Medicaid APG,893.67,,,893.67,Other,225% New York Medicaid APG,1032.68,,,1032.68,Other,260% New York Medicaid APG,1286.88,,,1286.88,Other,324% New York Medicaid APG,853.95,,,853.95,Other,215% New York Medicaid APG,853.95,,,853.95,Other,215% New York Medicaid APG,496.48,,,496.48,Other,125% New York Medicaid APG,397.19,86224,
Prepare face/oral prosthesis,21082,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,738.77,,,738.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,397.19,,,397.19,Other,New York Medicaid APG methodology,397.19,,,397.19,Other,100% New York Medicaid APG,397.19,,,397.19,Other,100% New York Medicaid APG,397.19,,,397.19,Other,100% New York Medicaid APG,893.67,,,893.67,Other,225% New York Medicaid APG,893.67,,,893.67,Other,225% New York Medicaid APG,893.67,,,893.67,Other,225% New York Medicaid APG,893.67,,,893.67,Other,225% New York Medicaid APG,556.06,,,556.06,Other,140% New York Medicaid APG,893.67,,,893.67,Other,225% New York Medicaid APG,1032.68,,,1032.68,Other,260% New York Medicaid APG,1286.88,,,1286.88,Other,324% New York Medicaid APG,853.95,,,853.95,Other,215% New York Medicaid APG,853.95,,,853.95,Other,215% New York Medicaid APG,496.48,,,496.48,Other,125% New York Medicaid APG,397.19,47404.34,
Prepare face/oral prosthesis,21083,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,315.45,,,315.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,169.6,,,169.6,Other,New York Medicaid APG methodology,169.6,,,169.6,Other,100% New York Medicaid APG,169.6,,,169.6,Other,100% New York Medicaid APG,169.6,,,169.6,Other,100% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,237.43,,,237.43,Other,140% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,440.95,,,440.95,Other,260% New York Medicaid APG,549.49,,,549.49,Other,324% New York Medicaid APG,364.63,,,364.63,Other,215% New York Medicaid APG,364.63,,,364.63,Other,215% New York Medicaid APG,212,,,212,Other,125% New York Medicaid APG,169.6,47404.34,
Prepare face/oral prosthesis,21084,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,315.45,,,315.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,169.6,,,169.6,Other,New York Medicaid APG methodology,169.6,,,169.6,Other,100% New York Medicaid APG,169.6,,,169.6,Other,100% New York Medicaid APG,169.6,,,169.6,Other,100% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,237.43,,,237.43,Other,140% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,440.95,,,440.95,Other,260% New York Medicaid APG,549.49,,,549.49,Other,324% New York Medicaid APG,364.63,,,364.63,Other,215% New York Medicaid APG,364.63,,,364.63,Other,215% New York Medicaid APG,212,,,212,Other,125% New York Medicaid APG,169.6,47404.34,
Prepare face/oral prosthesis,21085,CPT,,,,,,,,both,,,5137.73,464.5,,,464.5,Other,150% of Medicare + 9.63% HCRA Surcharge,282.46,,,282.46,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,2568.87,50,,2568.87,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,315.45,,,315.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3596.41,70,,3596.41,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,169.6,,,169.6,Other,New York Medicaid APG methodology,169.6,,,169.6,Other,100% New York Medicaid APG,169.6,,,169.6,Other,100% New York Medicaid APG,169.6,,,169.6,Other,100% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,237.43,,,237.43,Other,140% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,440.95,,,440.95,Other,260% New York Medicaid APG,549.49,,,549.49,Other,324% New York Medicaid APG,364.63,,,364.63,Other,215% New York Medicaid APG,364.63,,,364.63,Other,215% New York Medicaid APG,212,,,212,Other,125% New York Medicaid APG,169.6,13157,
Prepare face/oral prosthesis,21086,CPT,,,,,,,,both,,,117516.12,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,58758.06,50,,58758.06,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,738.77,,,738.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,82261.28,70,,82261.28,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,397.19,,,397.19,Other,New York Medicaid APG methodology,397.19,,,397.19,Other,100% New York Medicaid APG,397.19,,,397.19,Other,100% New York Medicaid APG,397.19,,,397.19,Other,100% New York Medicaid APG,893.67,,,893.67,Other,225% New York Medicaid APG,893.67,,,893.67,Other,225% New York Medicaid APG,893.67,,,893.67,Other,225% New York Medicaid APG,893.67,,,893.67,Other,225% New York Medicaid APG,556.06,,,556.06,Other,140% New York Medicaid APG,893.67,,,893.67,Other,225% New York Medicaid APG,1032.68,,,1032.68,Other,260% New York Medicaid APG,1286.88,,,1286.88,Other,324% New York Medicaid APG,853.95,,,853.95,Other,215% New York Medicaid APG,853.95,,,853.95,Other,215% New York Medicaid APG,496.48,,,496.48,Other,125% New York Medicaid APG,397.19,82261.28,
Prepare face/oral prosthesis,21087,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,738.77,,,738.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,397.19,,,397.19,Other,New York Medicaid APG methodology,397.19,,,397.19,Other,100% New York Medicaid APG,397.19,,,397.19,Other,100% New York Medicaid APG,397.19,,,397.19,Other,100% New York Medicaid APG,893.67,,,893.67,Other,225% New York Medicaid APG,893.67,,,893.67,Other,225% New York Medicaid APG,893.67,,,893.67,Other,225% New York Medicaid APG,893.67,,,893.67,Other,225% New York Medicaid APG,556.06,,,556.06,Other,140% New York Medicaid APG,893.67,,,893.67,Other,225% New York Medicaid APG,1032.68,,,1032.68,Other,260% New York Medicaid APG,1286.88,,,1286.88,Other,324% New York Medicaid APG,853.95,,,853.95,Other,215% New York Medicaid APG,853.95,,,853.95,Other,215% New York Medicaid APG,496.48,,,496.48,Other,125% New York Medicaid APG,397.19,86224,
Prepare face/oral prosthesis,21088,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,315.45,,,315.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,33860.25,50,,33860.25,percent of total billed charges,,33860.25,50,,33860.25,percent of total billed charges,,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,169.6,,,169.6,Other,New York Medicaid APG methodology,169.6,,,169.6,Other,100% New York Medicaid APG,169.6,,,169.6,Other,100% New York Medicaid APG,169.6,,,169.6,Other,100% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,237.43,,,237.43,Other,140% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,440.95,,,440.95,Other,260% New York Medicaid APG,549.49,,,549.49,Other,324% New York Medicaid APG,364.63,,,364.63,Other,215% New York Medicaid APG,364.63,,,364.63,Other,215% New York Medicaid APG,212,,,212,Other,125% New York Medicaid APG,169.6,47404.34,
Maxillofacial fixation,21100,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3873.59,,,3873.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2082.57,,,2082.57,Other,New York Medicaid APG methodology,2082.57,,,2082.57,Other,100% New York Medicaid APG,2082.57,,,2082.57,Other,100% New York Medicaid APG,2082.57,,,2082.57,Other,100% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,2915.6,,,2915.6,Other,140% New York Medicaid APG,4685.79,,,4685.79,Other,225% New York Medicaid APG,5414.69,,,5414.69,Other,260% New York Medicaid APG,6747.54,,,6747.54,Other,324% New York Medicaid APG,4477.53,,,4477.53,Other,215% New York Medicaid APG,4477.53,,,4477.53,Other,215% New York Medicaid APG,2603.22,,,2603.22,Other,125% New York Medicaid APG,2082.57,86224,
Interdental fixation,21110,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,508.35,,,508.35,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,273.31,,,273.31,Other,New York Medicaid APG methodology,273.31,,,273.31,Other,100% New York Medicaid APG,273.31,,,273.31,Other,100% New York Medicaid APG,273.31,,,273.31,Other,100% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,382.63,,,382.63,Other,140% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,710.6,,,710.6,Other,260% New York Medicaid APG,885.52,,,885.52,Other,324% New York Medicaid APG,587.61,,,587.61,Other,215% New York Medicaid APG,587.61,,,587.61,Other,215% New York Medicaid APG,341.64,,,341.64,Other,125% New York Medicaid APG,273.31,22454.17,
Injection jaw joint x-ray,21116,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1205.26,,,1205.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,219.45,,,219.45,Fee Schedule,,186.2,,,186.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.99,,,647.99,Other,New York Medicaid APG methodology,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,907.18,,,907.18,Other,140% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1684.77,,,1684.77,Other,260% New York Medicaid APG,2099.48,,,2099.48,Other,324% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,809.98,,,809.98,Other,125% New York Medicaid APG,0.01,22702.47,
Reconstruction of chin,21120,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Reconstruction of chin,21121,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,47404.34,
Reconstruction of chin,21122,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Reconstruction of chin,21123,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,47404.34,
Augmentation lower jaw bone,21125,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Augmentation lower jaw bone,21127,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Reduction of forehead,21137,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3723.17,47404.34,
Reduction of forehead,21138,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Reduction of forehead,21139,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Lefort ii anterior intrusion,21150,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Reconstruct orbit/forehead,21172,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Reconstruct orbit/forehead,21175,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Contour cranial bone lesion,21181,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,86224,
Reconst lwr jaw w/o graft,21193,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,86224,
Reconst lwr jaw w/o fixation,21195,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Reconstr lwr jaw segment,21198,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Reconstr lwr jaw w/advance,21199,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,86224,
Reconstruct upper jaw bone,21206,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Augmentation of facial bones,21208,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Reduction of facial bones,21209,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Face bone graft,21210,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Lower jaw bone graft,21215,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Rib cartilage graft,21230,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Ear cartilage graft,21235,CPT,,,,,,,,both,,,43855.99,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,21928,50,,21928,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,30699.19,70,,30699.19,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,30699.19,
Reconstruction of jaw joint,21240,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Reconstruction of jaw joint,21242,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Reconstruction of jaw joint,21243,CPT,,,,,,,,both,,,391985.94,35439.21,,,35439.21,Other,150% of Medicare + 9.63% HCRA Surcharge,21550.8,,,21550.8,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,195992.97,50,,195992.97,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7675.82,,,7675.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,274390.16,70,,274390.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4126.79,,,4126.79,Other,New York Medicaid APG methodology,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,5777.5,,,5777.5,Other,140% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,10729.65,,,10729.65,Other,260% New York Medicaid APG,13370.79,,,13370.79,Other,324% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,5158.48,,,5158.48,Other,125% New York Medicaid APG,4126.79,274390.16,
Reconstruction of lower jaw,21244,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Reconstruction of jaw,21245,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Reconstruction of jaw,21246,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Reconstruction of jaw,21248,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Reconstruction of jaw,21249,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Reconstruction of orbit,21256,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Revise eye sockets,21260,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Revise eye sockets,21261,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Revise eye sockets,21263,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Revise eye sockets,21267,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,86224,
Augmentation cheek bone,21270,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Revision orbitofacial bones,21275,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,86224,
Revision of eyelid,21280,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4289.29,,,4289.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2306.07,,,2306.07,Other,New York Medicaid APG methodology,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,3228.5,,,3228.5,Other,140% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5995.78,,,5995.78,Other,260% New York Medicaid APG,7471.67,,,7471.67,Other,324% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,2882.59,,,2882.59,Other,125% New York Medicaid APG,2306.07,47404.34,
Revision of eyelid,21282,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4289.29,,,4289.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2306.07,,,2306.07,Other,New York Medicaid APG methodology,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,3228.5,,,3228.5,Other,140% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5995.78,,,5995.78,Other,260% New York Medicaid APG,7471.67,,,7471.67,Other,324% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,2882.59,,,2882.59,Other,125% New York Medicaid APG,2306.07,47404.34,
Revision of jaw muscle/bone,21295,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,976.8,,,976.8,Fee Schedule,,828.8,,,828.8,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,828.8,22454.17,
Revision of jaw muscle/bone,21296,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,47404.34,
Closed tx nose fx w/o stablj,21315,CPT,,,,,,,,both,,,33597.35,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16798.68,50,,16798.68,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23518.15,70,,23518.15,percent of total billed charges,,297,,,297,Fee Schedule,,252,,,252,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,252,23518.15,
Closed tx nose fx w/ stablj,21320,CPT,,,,,,,,both,,,35105.05,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17552.53,50,,17552.53,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24573.54,70,,24573.54,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,24573.54,
Open tx nose fx uncomplicatd,21325,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,47404.34,
Open tx nose fx w/skele fixj,21330,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,86224,
Open tx nose & septal fx,21335,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,47404.34,
Open tx septal fx w/wo stabj,21336,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,47657.93,
Closed tx septal&nose fx,21337,CPT,,,,,,,,both,,,35285.27,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17642.64,50,,17642.64,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24699.69,70,,24699.69,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,24699.69,
Open nasoethmoid fx w/o fixj,21338,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Open nasoethmoid fx w/ fixj,21339,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Perq tx nasoethmoid fx,21340,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,47404.34,
Closed tx nose/jaw fx,21345,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,22454.17,
Opn tx nasomax fx w/fixj,21346,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Perq tx malar fracture,21355,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,47404.34,
Opn tx dprsd zygomatic arch,21356,CPT,,,,,,,,both,,,35212.73,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,17606.37,50,,17606.37,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24648.91,70,,24648.91,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,24648.91,
Opn tx dprsd malar fracture,21360,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,86224,
Opn tx complx malar fx,21365,CPT,,,,,,,,both,,,61736.97,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,30868.49,50,,30868.49,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,43215.88,70,,43215.88,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,43215.88,
Opn tx orbit fx transantral,21385,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Opn tx orbit fx periorbital,21386,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Opn tx orbit fx combined,21387,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Opn tx orbit periorbtl implt,21390,CPT,,,,,,,,both,,,53237.37,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,26618.69,50,,26618.69,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,37266.16,70,,37266.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,37266.16,
Opn tx orbit periorbt w/grft,21395,CPT,,,,,,,,both,,,36969.66,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,18484.83,50,,18484.83,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25878.76,70,,25878.76,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,25878.76,
Closed tx orbit w/o manipulj,21400,CPT,,,,,,,,both,,,11572.85,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5786.43,50,,5786.43,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8101,70,,8101,percent of total billed charges,,833.25,,,833.25,Fee Schedule,,707,,,707,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,636.26,9473,
Closed tx orbit w/manipulj,21401,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,22454.17,
Opn tx orbit fx w/o implant,21406,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Opn tx orbit fx w/implant,21407,CPT,,,,,,,,both,,,89055.11,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,44527.56,50,,44527.56,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,62338.58,70,,62338.58,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,62338.58,
Opn tx orbit fx w/bone grft,21408,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,86224,
Treat mouth roof fracture,21421,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,47404.34,
Treat dental ridge fracture,21440,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,47404.34,
Treat dental ridge fracture,21445,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Treat lower jaw fracture,21450,CPT,,,,,,,,both,,,11572.85,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5786.43,50,,5786.43,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8101,70,,8101,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,636.26,13157,
Treat lower jaw fracture,21451,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,22454.17,
Treat lower jaw fracture,21452,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3658,86224,
Treat lower jaw fracture,21453,CPT,,,,,,,,both,,,62366.91,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,31183.46,50,,31183.46,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,43656.84,70,,43656.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,43656.84,
Treat lower jaw fracture,21454,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Treat lower jaw fracture,21461,CPT,,,,,,,,both,,,78075.46,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,39037.73,50,,39037.73,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,54652.82,70,,54652.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,54652.82,
Treat lower jaw fracture,21462,CPT,,,,,,,,both,,,88543.08,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,44271.54,50,,44271.54,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,61980.16,70,,61980.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,61980.16,
Treat lower jaw fracture,21465,CPT,,,,,,,,both,,,131486.31,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,65743.16,50,,65743.16,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,92040.42,70,,92040.42,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,92040.42,
Treat lower jaw fracture,21470,CPT,,,,,,,,both,,,131285.49,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,65642.75,50,,65642.75,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,91899.84,70,,91899.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,91899.84,
Reset dislocated jaw,21480,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,153.45,,,153.45,Fee Schedule,,130.2,,,130.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,130.2,9473,
Reset dislocated jaw,21485,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2193.58,,,2193.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,1651.08,,,1651.08,Other,140% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,3066.3,,,3066.3,Other,260% New York Medicaid APG,3821.08,,,3821.08,Other,324% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,1474.18,,,1474.18,Other,125% New York Medicaid APG,1179.35,22454.17,
Repair dislocated jaw,21490,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,47404.34,
Interdental wiring,21497,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,508.35,,,508.35,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,273.31,,,273.31,Other,New York Medicaid APG methodology,273.31,,,273.31,Other,100% New York Medicaid APG,273.31,,,273.31,Other,100% New York Medicaid APG,273.31,,,273.31,Other,100% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,382.63,,,382.63,Other,140% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,710.6,,,710.6,Other,260% New York Medicaid APG,885.52,,,885.52,Other,324% New York Medicaid APG,587.61,,,587.61,Other,215% New York Medicaid APG,587.61,,,587.61,Other,215% New York Medicaid APG,341.64,,,341.64,Other,125% New York Medicaid APG,273.31,22454.17,
Drain neck/chest lesion,21501,CPT,,,,,,,,both,,,35589.06,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17794.53,50,,17794.53,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4050.15,,,4050.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24912.34,70,,24912.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2177.5,,,2177.5,Other,New York Medicaid APG methodology,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,3048.5,,,3048.5,Other,140% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,5661.5,,,5661.5,Other,260% New York Medicaid APG,7055.1,,,7055.1,Other,324% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,2721.88,,,2721.88,Other,125% New York Medicaid APG,2177.5,24912.34,
Drain chest lesion,21502,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4050.15,,,4050.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2177.5,,,2177.5,Other,New York Medicaid APG methodology,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,3048.5,,,3048.5,Other,140% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,5661.5,,,5661.5,Other,260% New York Medicaid APG,7055.1,,,7055.1,Other,324% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,2721.88,,,2721.88,Other,125% New York Medicaid APG,2177.5,47657.93,
Biopsy of neck/chest,21550,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4050.15,,,4050.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2177.5,,,2177.5,Other,New York Medicaid APG methodology,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,3048.5,,,3048.5,Other,140% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,5661.5,,,5661.5,Other,260% New York Medicaid APG,7055.1,,,7055.1,Other,324% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,2721.88,,,2721.88,Other,125% New York Medicaid APG,1874.86,23871.23,
Exc neck les sc 3 cm/>,21552,CPT,,,,,,,,both,,,36268.05,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18134.03,50,,18134.03,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4050.15,,,4050.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25387.64,70,,25387.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2177.5,,,2177.5,Other,New York Medicaid APG methodology,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,3048.5,,,3048.5,Other,140% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,5661.5,,,5661.5,Other,260% New York Medicaid APG,7055.1,,,7055.1,Other,324% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,2721.88,,,2721.88,Other,125% New York Medicaid APG,2177.5,25387.64,
Exc neck tum deep 5 cm/>,21554,CPT,,,,,,,,both,,,38757.88,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19378.94,50,,19378.94,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4050.15,,,4050.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27130.52,70,,27130.52,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2177.5,,,2177.5,Other,New York Medicaid APG methodology,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,3048.5,,,3048.5,Other,140% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,5661.5,,,5661.5,Other,260% New York Medicaid APG,7055.1,,,7055.1,Other,324% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,2721.88,,,2721.88,Other,125% New York Medicaid APG,2177.5,27130.52,
Exc neck les sc < 3 cm,21555,CPT,,,,,,,,both,,,39200.03,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19600.02,50,,19600.02,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4050.15,,,4050.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27440.02,70,,27440.02,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2177.5,,,2177.5,Other,New York Medicaid APG methodology,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,3048.5,,,3048.5,Other,140% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,5661.5,,,5661.5,Other,260% New York Medicaid APG,7055.1,,,7055.1,Other,324% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,2721.88,,,2721.88,Other,125% New York Medicaid APG,1874.86,27440.02,
Exc neck tum deep < 5 cm,21556,CPT,,,,,,,,both,,,47349.43,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,23674.72,50,,23674.72,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4050.15,,,4050.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,33144.6,70,,33144.6,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2177.5,,,2177.5,Other,New York Medicaid APG methodology,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,3048.5,,,3048.5,Other,140% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,5661.5,,,5661.5,Other,260% New York Medicaid APG,7055.1,,,7055.1,Other,324% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,2721.88,,,2721.88,Other,125% New York Medicaid APG,2177.5,33144.6,
Resect neck thorax tumor<5cm,21557,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4050.15,,,4050.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2177.5,,,2177.5,Other,New York Medicaid APG methodology,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,3048.5,,,3048.5,Other,140% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,5661.5,,,5661.5,Other,260% New York Medicaid APG,7055.1,,,7055.1,Other,324% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,2721.88,,,2721.88,Other,125% New York Medicaid APG,2177.5,41837.04,
Resect neck tumor 5 cm/>,21558,CPT,,,,,,,,both,,,38983.69,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19491.85,50,,19491.85,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5192.2,,,5192.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27288.58,70,,27288.58,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2791.5,,,2791.5,Other,New York Medicaid APG methodology,2791.5,,,2791.5,Other,100% New York Medicaid APG,2791.5,,,2791.5,Other,100% New York Medicaid APG,2791.5,,,2791.5,Other,100% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,3908.1,,,3908.1,Other,140% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,7257.91,,,7257.91,Other,260% New York Medicaid APG,9044.47,,,9044.47,Other,324% New York Medicaid APG,6001.73,,,6001.73,Other,215% New York Medicaid APG,6001.73,,,6001.73,Other,215% New York Medicaid APG,3489.38,,,3489.38,Other,125% New York Medicaid APG,2791.5,27288.58,
Partial removal of rib,21600,CPT,,,,,,,,both,,,38379.86,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,19189.93,50,,19189.93,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4050.15,,,4050.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26865.9,70,,26865.9,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2177.5,,,2177.5,Other,New York Medicaid APG methodology,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,3048.5,,,3048.5,Other,140% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,5661.5,,,5661.5,Other,260% New York Medicaid APG,7055.1,,,7055.1,Other,324% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,2721.88,,,2721.88,Other,125% New York Medicaid APG,2177.5,26865.9,
Exc chest wall tumor w/ribs,21601,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4050.15,,,4050.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2177.5,,,2177.5,Other,New York Medicaid APG methodology,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,3048.5,,,3048.5,Other,140% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,5661.5,,,5661.5,Other,260% New York Medicaid APG,7055.1,,,7055.1,Other,324% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,2721.88,,,2721.88,Other,125% New York Medicaid APG,2177.5,41837.04,
Partial removal of rib,21610,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3743.09,47657.93,
Hyoid myotomy & suspension,21685,CPT,,,,,,,,both,,,53041.12,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,26520.56,50,,26520.56,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,37128.78,70,,37128.78,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,37128.78,
Revision of neck muscle,21700,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,105333.66,
Revision of neck muscle,21720,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4050.15,,,4050.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2177.5,,,2177.5,Other,New York Medicaid APG methodology,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,3048.5,,,3048.5,Other,140% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,5661.5,,,5661.5,Other,260% New York Medicaid APG,7055.1,,,7055.1,Other,324% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,2721.88,,,2721.88,Other,125% New York Medicaid APG,2177.5,47657.93,
Revision of neck muscle,21725,CPT,,,,,,,,both,,,14798.8,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7399.4,50,,7399.4,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10359.16,70,,10359.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,813.62,13157,
Repair stern/nuss w/o scope,21742,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4050.15,,,4050.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,34041.38,50,,34041.38,percent of total billed charges,,34041.38,50,,34041.38,percent of total billed charges,,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2177.5,,,2177.5,Other,New York Medicaid APG methodology,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,3048.5,,,3048.5,Other,140% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,5661.5,,,5661.5,Other,260% New York Medicaid APG,7055.1,,,7055.1,Other,324% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,2721.88,,,2721.88,Other,125% New York Medicaid APG,2177.5,47657.93,
Repair sternum/nuss w/scope,21743,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4050.15,,,4050.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,34041.38,50,,34041.38,percent of total billed charges,,34041.38,50,,34041.38,percent of total billed charges,,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2177.5,,,2177.5,Other,New York Medicaid APG methodology,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,3048.5,,,3048.5,Other,140% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,5661.5,,,5661.5,Other,260% New York Medicaid APG,7055.1,,,7055.1,Other,324% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,2721.88,,,2721.88,Other,125% New York Medicaid APG,2177.5,47657.93,
Treat sternum fracture,21820,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,745.8,,,745.8,Fee Schedule,,632.8,,,632.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,9473,
Biopsy soft tissue of back,21920,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,23871.23,
Biopsy soft tissue of back,21925,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,23871.23,
Exc back les sc < 3 cm,21930,CPT,,,,,,,,both,,,34713.64,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17356.82,50,,17356.82,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24299.55,70,,24299.55,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,24299.55,
Exc back les sc 3 cm/>,21931,CPT,,,,,,,,both,,,35507.52,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17753.76,50,,17753.76,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24855.26,70,,24855.26,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,24855.26,
Exc back tum deep < 5 cm,21932,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,41837.04,
Exc back tum deep 5 cm/>,21933,CPT,,,,,,,,both,,,35676.57,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17838.29,50,,17838.29,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24973.6,70,,24973.6,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,24973.6,
Resect back tum < 5 cm,21935,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,41837.04,
Resect back tum 5 cm/>,21936,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,41837.04,
Remove part of neck vertebra,22100,CPT,,,,,,,,both,,,46679.93,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,23339.97,50,,23339.97,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,32675.95,70,,32675.95,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,32675.95,
Remove part thorax vertebra,22101,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,105333.66,
Remove part lumbar vertebra,22102,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,105333.66,
Remove extra spine segment,22103,CPT,,,,,,,,both,,,64479.48,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32239.74,50,,32239.74,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45135.64,70,,45135.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,0.01,45135.64,
Closed tx vert fx w/o manj,22310,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Closed tx vert fx w/manj,22315,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,47657.93,
Manipulation of spine,22505,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2193.58,,,2193.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,1651.08,,,1651.08,Other,140% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,3066.3,,,3066.3,Other,260% New York Medicaid APG,3821.08,,,3821.08,Other,324% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,1474.18,,,1474.18,Other,125% New York Medicaid APG,1179.35,23663.84,
Perq cervicothoracic inject,22510,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3743.09,47657.93,
Perq lumbosacral injection,22511,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3743.09,47657.93,
Vertebroplasty addl inject,22512,CPT,,,,,,,,both,,,64479.48,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32239.74,50,,32239.74,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45135.64,70,,45135.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,0.01,45135.64,
Perq vertebral augmentation,22513,CPT,,,,,,,,both,,,75398.29,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,37699.15,50,,37699.15,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52778.8,70,,52778.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,52778.8,
Perq vertebral augmentation,22514,CPT,,,,,,,,both,,,62785.99,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,31393,50,,31393,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,43950.19,70,,43950.19,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,43950.19,
Perq vertebral augmentation,22515,CPT,,,,,,,,both,,,83504,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,41752,50,,41752,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,58452.8,70,,58452.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,0.01,58452.8,
Neck spine fuse&remov bel c2,22551,CPT,,,,,,,,both,,,127397.61,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,63698.81,50,,63698.81,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,8573.09,,,8573.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,89178.33,70,,89178.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4609.19,,,4609.19,Other,New York Medicaid APG methodology,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,6452.86,,,6452.86,Other,140% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,11983.89,,,11983.89,Other,260% New York Medicaid APG,14933.77,,,14933.77,Other,324% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,5761.49,,,5761.49,Other,125% New York Medicaid APG,4609.19,89178.33,
Addl neck spine fusion,22552,CPT,,,,,,,,both,,,90852.2,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,45426.1,50,,45426.1,percent of total billed charges,,63596.54,70,,63596.54,percent of total billed charges,,6152,,,6152,Case Rate,,8573.09,,,8573.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,63596.54,70,,63596.54,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4609.19,,,4609.19,Other,New York Medicaid APG methodology,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,6452.86,,,6452.86,Other,140% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,11983.89,,,11983.89,Other,260% New York Medicaid APG,14933.77,,,14933.77,Other,324% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,5761.49,,,5761.49,Other,125% New York Medicaid APG,0.01,63596.54,
Neck spine fusion,22554,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,8573.09,,,8573.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4609.19,,,4609.19,Other,New York Medicaid APG methodology,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,6452.86,,,6452.86,Other,140% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,11983.89,,,11983.89,Other,260% New York Medicaid APG,14933.77,,,14933.77,Other,324% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,5761.49,,,5761.49,Other,125% New York Medicaid APG,4609.19,193779.51,
Additional spinal fusion,22585,CPT,,,,,,,,both,,,90852.2,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,45426.1,50,,45426.1,percent of total billed charges,,63596.54,70,,63596.54,percent of total billed charges,,6152,,,6152,Case Rate,,8573.09,,,8573.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,63596.54,70,,63596.54,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4609.19,,,4609.19,Other,New York Medicaid APG methodology,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,6452.86,,,6452.86,Other,140% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,11983.89,,,11983.89,Other,260% New York Medicaid APG,14933.77,,,14933.77,Other,324% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,5761.49,,,5761.49,Other,125% New York Medicaid APG,0.01,63596.54,
Lumbar spine fusion,22612,CPT,,,,,,,,both,,,165681.16,35439.21,,,35439.21,Other,150% of Medicare + 9.63% HCRA Surcharge,21550.8,,,21550.8,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,82840.58,50,,82840.58,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,8573.09,,,8573.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,115976.81,70,,115976.81,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4609.19,,,4609.19,Other,New York Medicaid APG methodology,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,6452.86,,,6452.86,Other,140% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,11983.89,,,11983.89,Other,260% New York Medicaid APG,14933.77,,,14933.77,Other,324% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,5761.49,,,5761.49,Other,125% New York Medicaid APG,4609.19,115976.81,
Spine fusion extra segment,22614,CPT,,,,,,,,both,,,86591.4,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,43295.7,50,,43295.7,percent of total billed charges,,60613.98,70,,60613.98,percent of total billed charges,,6152,,,6152,Case Rate,,8573.09,,,8573.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,60613.98,70,,60613.98,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,4609.19,,,4609.19,Other,New York Medicaid APG methodology,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,6452.86,,,6452.86,Other,140% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,11983.89,,,11983.89,Other,260% New York Medicaid APG,14933.77,,,14933.77,Other,324% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,5761.49,,,5761.49,Other,125% New York Medicaid APG,0.01,60613.98,
Insert spine fixation device,22840,CPT,,,,,,,,both,,,90852.2,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,45426.1,50,,45426.1,percent of total billed charges,,63596.54,70,,63596.54,percent of total billed charges,,6152,,,6152,Case Rate,,8573.09,,,8573.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,63596.54,70,,63596.54,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,4609.19,,,4609.19,Other,New York Medicaid APG methodology,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,6452.86,,,6452.86,Other,140% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,11983.89,,,11983.89,Other,260% New York Medicaid APG,14933.77,,,14933.77,Other,324% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,5761.49,,,5761.49,Other,125% New York Medicaid APG,0.01,63596.54,
Insert spine fixation device,22842,CPT,,,,,,,,both,,,90852.2,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,45426.1,50,,45426.1,percent of total billed charges,,63596.54,70,,63596.54,percent of total billed charges,,6152,,,6152,Case Rate,,8573.09,,,8573.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,63596.54,70,,63596.54,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,4609.19,,,4609.19,Other,New York Medicaid APG methodology,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,6452.86,,,6452.86,Other,140% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,11983.89,,,11983.89,Other,260% New York Medicaid APG,14933.77,,,14933.77,Other,324% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,5761.49,,,5761.49,Other,125% New York Medicaid APG,0.01,63596.54,
Insert spine fixation device,22845,CPT,,,,,,,,both,,,90852.2,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,45426.1,50,,45426.1,percent of total billed charges,,63596.54,70,,63596.54,percent of total billed charges,,6152,,,6152,Case Rate,,8573.09,,,8573.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,63596.54,70,,63596.54,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4609.19,,,4609.19,Other,New York Medicaid APG methodology,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,6452.86,,,6452.86,Other,140% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,11983.89,,,11983.89,Other,260% New York Medicaid APG,14933.77,,,14933.77,Other,324% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,5761.49,,,5761.49,Other,125% New York Medicaid APG,0.01,63596.54,
Insj biomechanical device,22853,CPT,,,,,,,,both,,,90852.2,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,45426.1,50,,45426.1,percent of total billed charges,,63596.54,70,,63596.54,percent of total billed charges,,6152,,,6152,Case Rate,,8573.09,,,8573.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,63596.54,70,,63596.54,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,4609.19,,,4609.19,Other,New York Medicaid APG methodology,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,6452.86,,,6452.86,Other,140% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,11983.89,,,11983.89,Other,260% New York Medicaid APG,14933.77,,,14933.77,Other,324% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,5761.49,,,5761.49,Other,125% New York Medicaid APG,0.01,63596.54,
Insj biomechanical device,22854,CPT,,,,,,,,both,,,90852.2,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,45426.1,50,,45426.1,percent of total billed charges,,63596.54,70,,63596.54,percent of total billed charges,,6152,,,6152,Case Rate,,8573.09,,,8573.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,63596.54,70,,63596.54,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,4609.19,,,4609.19,Other,New York Medicaid APG methodology,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,6452.86,,,6452.86,Other,140% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,11983.89,,,11983.89,Other,260% New York Medicaid APG,14933.77,,,14933.77,Other,324% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,5761.49,,,5761.49,Other,125% New York Medicaid APG,0.01,63596.54,
Cerv artific diskectomy,22856,CPT,,,,,,,,both,,,138249.61,35439.21,,,35439.21,Other,150% of Medicare + 9.63% HCRA Surcharge,21550.8,,,21550.8,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,69124.81,50,,69124.81,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,8573.09,,,8573.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,96774.73,70,,96774.73,percent of total billed charges,,8048.7,,,8048.7,Fee Schedule,,6829.2,,,6829.2,Fee Schedule,,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4609.19,,,4609.19,Other,New York Medicaid APG methodology,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,6452.86,,,6452.86,Other,140% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,11983.89,,,11983.89,Other,260% New York Medicaid APG,14933.77,,,14933.77,Other,324% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,5761.49,,,5761.49,Other,125% New York Medicaid APG,4609.19,96774.73,
Second level cer diskectomy,22858,CPT,,,,,,,,both,,,83504,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,41752,50,,41752,percent of total billed charges,,58452.8,70,,58452.8,percent of total billed charges,,6152,,,6152,Case Rate,,8573.09,,,8573.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,58452.8,70,,58452.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,4609.19,,,4609.19,Other,New York Medicaid APG methodology,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,6452.86,,,6452.86,Other,140% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,11983.89,,,11983.89,Other,260% New York Medicaid APG,14933.77,,,14933.77,Other,324% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,5761.49,,,5761.49,Other,125% New York Medicaid APG,0.01,58452.8,
Insj biomechanical device,22859,CPT,,,,,,,,both,,,90852.2,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,45426.1,50,,45426.1,percent of total billed charges,,63596.54,70,,63596.54,percent of total billed charges,,6152,,,6152,Case Rate,,8573.09,,,8573.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,63596.54,70,,63596.54,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,4609.19,,,4609.19,Other,New York Medicaid APG methodology,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,6452.86,,,6452.86,Other,140% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,11983.89,,,11983.89,Other,260% New York Medicaid APG,14933.77,,,14933.77,Other,324% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,5761.49,,,5761.49,Other,125% New York Medicaid APG,0.01,63596.54,
Insj stablj dev w/dcmprn,22867,CPT,,,,,,,,both,,,391985.94,35439.21,,,35439.21,Other,150% of Medicare + 9.63% HCRA Surcharge,21550.8,,,21550.8,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,195992.97,50,,195992.97,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,8573.09,,,8573.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,274390.16,70,,274390.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4609.19,,,4609.19,Other,New York Medicaid APG methodology,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,6452.86,,,6452.86,Other,140% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,11983.89,,,11983.89,Other,260% New York Medicaid APG,14933.77,,,14933.77,Other,324% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,5761.49,,,5761.49,Other,125% New York Medicaid APG,4609.19,274390.16,
Insj stablj dev w/dcmprn,22868,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,8573.09,,,8573.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,4609.19,,,4609.19,Other,New York Medicaid APG methodology,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,6452.86,,,6452.86,Other,140% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,11983.89,,,11983.89,Other,260% New York Medicaid APG,14933.77,,,14933.77,Other,324% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,5761.49,,,5761.49,Other,125% New York Medicaid APG,0.01,36100.43,
Insj stablj dev w/o dcmprn,22869,CPT,,,,,,,,both,,,60822,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,30411,50,,30411,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,8573.09,,,8573.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,42575.4,70,,42575.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4609.19,,,4609.19,Other,New York Medicaid APG methodology,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,6452.86,,,6452.86,Other,140% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,11983.89,,,11983.89,Other,260% New York Medicaid APG,14933.77,,,14933.77,Other,324% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,5761.49,,,5761.49,Other,125% New York Medicaid APG,4609.19,42575.4,
Insj stablj dev w/o dcmprn,22870,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,8573.09,,,8573.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,4609.19,,,4609.19,Other,New York Medicaid APG methodology,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,6452.86,,,6452.86,Other,140% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,11983.89,,,11983.89,Other,260% New York Medicaid APG,14933.77,,,14933.77,Other,324% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,5761.49,,,5761.49,Other,125% New York Medicaid APG,0.01,36100.43,
Exc abdl tum deep < 5 cm,22900,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,41837.04,
Exc abdl tum deep 5 cm/>,22901,CPT,,,,,,,,both,,,37474.21,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18737.11,50,,18737.11,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26231.95,70,,26231.95,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,26231.95,
Exc abd les sc < 3 cm,22902,CPT,,,,,,,,both,,,38632.15,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19316.08,50,,19316.08,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27042.51,70,,27042.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,27042.51,
Exc abd les sc 3 cm/>,22903,CPT,,,,,,,,both,,,36069.68,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18034.84,50,,18034.84,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25248.78,70,,25248.78,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,25248.78,
Radical resect abd tumor<5cm,22904,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,41837.04,
Rad resect abd tumor 5 cm/>,22905,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,41837.04,
Removal of calcium deposits,23000,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,41837.04,
Release shoulder joint,23020,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,47657.93,
Drain shoulder lesion,23030,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,41837.04,
Drain shoulder bursa,23031,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,41837.04,
Drain shoulder bone lesion,23035,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,1858.58,23663.84,
Exploratory shoulder surgery,23040,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,47657.93,
Exploratory shoulder surgery,23044,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,47657.93,
Biopsy shoulder tissues,23065,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,23871.23,
Biopsy shoulder tissues,23066,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,41837.04,
Exc shoulder les sc 3 cm/>,23071,CPT,,,,,,,,both,,,36184.86,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18092.43,50,,18092.43,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25329.4,70,,25329.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,25329.4,
Exc shoulder tum deep 5 cm/>,23073,CPT,,,,,,,,both,,,34368.36,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17184.18,50,,17184.18,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24057.85,70,,24057.85,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,24057.85,
Exc shoulder les sc < 3 cm,23075,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,23871.23,
Exc shoulder tum deep < 5 cm,23076,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,41837.04,
Resect shoulder tumor < 5 cm,23077,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,41837.04,
Resect shoulder tumor 5 cm/>,23078,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,41837.04,
Biopsy of shoulder joint,23100,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,47657.93,
Shoulder joint surgery,23101,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,47657.93,
Remove shoulder joint lining,23105,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,105333.66,
Incision of collarbone joint,23106,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,47657.93,
Explore treat shoulder joint,23107,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,105333.66,
Partial removal collar bone,23120,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,47657.93,
Removal of collar bone,23125,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,47657.93,
Remove shoulder bone part,23130,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,47657.93,
Removal of bone lesion,23140,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,47657.93,
Removal of bone lesion,23145,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,47657.93,
Removal of bone lesion,23146,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,105333.66,
Removal of humerus lesion,23150,CPT,,,,,,,,both,,,72471.02,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36235.51,50,,36235.51,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50729.71,70,,50729.71,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,50729.71,
Removal of humerus lesion,23155,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,105333.66,
Removal of humerus lesion,23156,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,105333.66,
Remove collar bone lesion,23170,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,47657.93,
Remove shoulder blade lesion,23172,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,47657.93,
Remove humerus lesion,23174,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,105333.66,
Remove collar bone lesion,23180,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,105333.66,
Remove shoulder blade lesion,23182,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,105333.66,
Remove humerus lesion,23184,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,105333.66,
Partial removal of scapula,23190,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,47657.93,
Removal of head of humerus,23195,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,105333.66,
Remove shoulder foreign body,23330,CPT,,,,,,,,both,,,36843.73,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,18421.87,50,,18421.87,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25790.61,70,,25790.61,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,25790.61,
Remove shoulder fb deep,23333,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,41837.04,
Shoulder prosthesis removal,23334,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,41837.04,
Injection for shoulder x-ray,23350,CPT,,,,,,,,both,,,17336.09,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,8668.05,50,,8668.05,percent of total billed charges,,12135.26,70,,12135.26,percent of total billed charges,,6152,,,6152,Case Rate,,1205.26,,,1205.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,12135.26,70,,12135.26,percent of total billed charges,,244.2,,,244.2,Fee Schedule,,207.2,,,207.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.99,,,647.99,Other,New York Medicaid APG methodology,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,907.18,,,907.18,Other,140% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1684.77,,,1684.77,Other,260% New York Medicaid APG,2099.48,,,2099.48,Other,324% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,809.98,,,809.98,Other,125% New York Medicaid APG,0.01,12135.26,
Muscle transfer shoulder/arm,23395,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,105333.66,
Muscle transfers,23397,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,105333.66,
Fixation of shoulder blade,23400,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,105333.66,
Incision of tendon & muscle,23405,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,105333.66,
Incise tendon(s) & muscle(s),23406,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,105333.66,
Repair rotator cuff acute,23410,CPT,,,,,,,,both,,,64366.42,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,32183.21,50,,32183.21,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45056.49,70,,45056.49,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,45056.49,
Repair rotator cuff chronic,23412,CPT,,,,,,,,both,,,77787.8,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,38893.9,50,,38893.9,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,54451.46,70,,54451.46,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,54451.46,
Release of shoulder ligament,23415,CPT,,,,,,,,both,,,33231.42,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,16615.71,50,,16615.71,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23261.99,70,,23261.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,23261.99,
Repair of shoulder,23420,CPT,,,,,,,,both,,,82673.24,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,41336.62,50,,41336.62,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,57871.27,70,,57871.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,57871.27,
Repair biceps tendon,23430,CPT,,,,,,,,both,,,75416.77,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,37708.39,50,,37708.39,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52791.74,70,,52791.74,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,52791.74,
Remove/transplant tendon,23440,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,105333.66,
Repair shoulder capsule,23450,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,105333.66,
Repair shoulder capsule,23455,CPT,,,,,,,,both,,,98387.69,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,49193.85,50,,49193.85,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,68871.38,70,,68871.38,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,68871.38,
Repair shoulder capsule,23460,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,105333.66,
Repair shoulder capsule,23462,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,105333.66,
Repair shoulder capsule,23465,CPT,,,,,,,,both,,,77128.57,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,38564.29,50,,38564.29,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,53990,70,,53990,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,53990,
Repair shoulder capsule,23466,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,105333.66,
Reconstruct shoulder joint,23470,CPT,,,,,,,,both,,,135326.42,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,67663.21,50,,67663.21,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7675.82,,,7675.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,94728.49,70,,94728.49,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,4126.79,,,4126.79,Other,New York Medicaid APG methodology,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,5777.5,,,5777.5,Other,140% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,10729.65,,,10729.65,Other,260% New York Medicaid APG,13370.79,,,13370.79,Other,324% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,5158.48,,,5158.48,Other,125% New York Medicaid APG,4126.79,94728.49,
Revis reconst shoulder joint,23473,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7675.82,,,7675.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4126.79,,,4126.79,Other,New York Medicaid APG methodology,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,5777.5,,,5777.5,Other,140% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,10729.65,,,10729.65,Other,260% New York Medicaid APG,13370.79,,,13370.79,Other,324% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,5158.48,,,5158.48,Other,125% New York Medicaid APG,4126.79,193779.51,
Revision of collar bone,23480,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,105333.66,
Revision of collar bone,23485,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,193779.51,
Reinforce clavicle,23490,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,105333.66,
Reinforce shoulder bones,23491,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,193779.51,
Treat clavicle fracture,23500,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treat clavicle fracture,23505,CPT,,,,,,,,both,,,34955.66,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17477.83,50,,17477.83,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24468.96,70,,24468.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,24468.96,
Treat clavicle fracture,23515,CPT,,,,,,,,both,,,90442.05,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,45221.03,50,,45221.03,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,63309.44,70,,63309.44,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,63309.44,
Treat clavicle dislocation,23520,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,23663.84,
Treat clavicle dislocation,23525,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treat clavicle dislocation,23530,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Treat clavicle dislocation,23532,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Treat clavicle dislocation,23540,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treat clavicle dislocation,23545,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treat clavicle dislocation,23550,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Treat clavicle dislocation,23552,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Treat shoulder blade fx,23570,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treat shoulder blade fx,23575,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,23663.84,
Treat scapula fracture,23585,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Treat humerus fracture,23600,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treat humerus fracture,23605,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,23663.84,
Treat humerus fracture,23615,CPT,,,,,,,,both,,,58174.44,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,29087.22,50,,29087.22,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,40722.11,70,,40722.11,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,40722.11,
Treat humerus fracture,23616,CPT,,,,,,,,both,,,391985.94,35439.21,,,35439.21,Other,150% of Medicare + 9.63% HCRA Surcharge,21550.8,,,21550.8,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,195992.97,50,,195992.97,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,274390.16,70,,274390.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,274390.16,
Treat humerus fracture,23620,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treat humerus fracture,23625,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,23663.84,
Treat humerus fracture,23630,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Treat shoulder dislocation,23650,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treat shoulder dislocation,23655,CPT,,,,,,,,both,,,32785,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16392.5,50,,16392.5,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2193.58,,,2193.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22949.5,70,,22949.5,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,1651.08,,,1651.08,Other,140% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,3066.3,,,3066.3,Other,260% New York Medicaid APG,3821.08,,,3821.08,Other,324% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,1474.18,,,1474.18,Other,125% New York Medicaid APG,1179.35,22949.5,
Treat shoulder dislocation,23660,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Treat dislocation/fracture,23665,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,23663.84,
Treat dislocation/fracture,23670,CPT,,,,,,,,both,,,113841.17,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,56920.59,50,,56920.59,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,79688.82,70,,79688.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,79688.82,
Treat dislocation/fracture,23675,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,23663.84,
Treat dislocation/fracture,23680,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,193779.51,
Fixation of shoulder,23700,CPT,,,,,,,,both,,,34321,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17160.5,50,,17160.5,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2193.58,,,2193.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24024.7,70,,24024.7,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,1651.08,,,1651.08,Other,140% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,3066.3,,,3066.3,Other,260% New York Medicaid APG,3821.08,,,3821.08,Other,324% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,1474.18,,,1474.18,Other,125% New York Medicaid APG,1179.35,24024.7,
Fusion of shoulder joint,23800,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,105333.66,
Fusion of shoulder joint,23802,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,193779.51,
Amputation follow-up surgery,23921,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,26850.29,
Drainage of arm lesion,23930,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,41837.04,
Drainage of arm bursa,23931,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,23871.23,
Drain arm/elbow bone lesion,23935,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,47657.93,
Exploratory elbow surgery,24000,CPT,,,,,,,,both,,,32829.65,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,16414.83,50,,16414.83,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22980.76,70,,22980.76,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,22980.76,
Release elbow joint,24006,CPT,,,,,,,,both,,,99422.14,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,49711.07,50,,49711.07,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,69595.5,70,,69595.5,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,69595.5,
Biopsy arm/elbow soft tissue,24065,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,23871.23,
Biopsy arm/elbow soft tissue,24066,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,41837.04,
Exc arm/elbow les sc 3 cm/>,24071,CPT,,,,,,,,both,,,38614.54,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19307.27,50,,19307.27,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27030.18,70,,27030.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,27030.18,
Ex arm/elbow tum deep 5 cm/>,24073,CPT,,,,,,,,both,,,36465.26,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18232.63,50,,18232.63,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25525.68,70,,25525.68,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,25525.68,
Exc arm/elbow les sc < 3 cm,24075,CPT,,,,,,,,both,,,34597,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17298.5,50,,17298.5,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24217.9,70,,24217.9,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,24217.9,
Ex arm/elbow tum deep < 5 cm,24076,CPT,,,,,,,,both,,,59475.75,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29737.88,50,,29737.88,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41633.03,70,,41633.03,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,41633.03,
Resect arm/elbow tum < 5 cm,24077,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,41837.04,
Resect arm/elbow tum 5 cm/>,24079,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,41837.04,
Biopsy elbow joint lining,24100,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Explore/treat elbow joint,24101,CPT,,,,,,,,both,,,57993.89,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,28996.95,50,,28996.95,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,40595.72,70,,40595.72,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,40595.72,
Remove elbow joint lining,24102,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Removal of elbow bursa,24105,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Remove humerus lesion,24110,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,47657.93,
Remove/graft bone lesion,24115,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,105333.66,
Remove/graft bone lesion,24116,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,105333.66,
Remove elbow lesion,24120,CPT,,,,,,,,both,,,44500.73,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,22250.37,50,,22250.37,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31150.51,70,,31150.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,31150.51,
Remove/graft bone lesion,24125,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Remove/graft bone lesion,24126,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,105333.66,
Removal of head of radius,24130,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,47657.93,
Removal of arm bone lesion,24134,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,105333.66,
Remove radius bone lesion,24136,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Remove elbow bone lesion,24138,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,105333.66,
Partial removal of arm bone,24140,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,47657.93,
Partial removal of radius,24145,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,105333.66,
Partial removal of elbow,24147,CPT,,,,,,,,both,,,53513.08,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,26756.54,50,,26756.54,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,37459.16,70,,37459.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,37459.16,
Radical resection of elbow,24149,CPT,,,,,,,,both,,,63247.95,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,31623.98,50,,31623.98,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,44273.57,70,,44273.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,44273.57,
Resect distal humerus tumor,24150,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,105333.66,
Resect radius tumor,24152,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,105333.66,
Removal of elbow joint,24155,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Remove elbow joint implant,24160,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Remove radius head implant,24164,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Removal of arm foreign body,24200,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,23871.23,
Removal of arm foreign body,24201,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,41837.04,
Injection for elbow x-ray,24220,CPT,,,,,,,,both,,,34215,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17107.5,50,,17107.5,percent of total billed charges,,23950.5,70,,23950.5,percent of total billed charges,,6152,,,6152,Case Rate,,1205.26,,,1205.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23950.5,70,,23950.5,percent of total billed charges,,325.05,,,325.05,Fee Schedule,,275.8,,,275.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.99,,,647.99,Other,New York Medicaid APG methodology,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,907.18,,,907.18,Other,140% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1684.77,,,1684.77,Other,260% New York Medicaid APG,2099.48,,,2099.48,Other,324% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,809.98,,,809.98,Other,125% New York Medicaid APG,0.01,23950.5,
Manipulate elbow w/anesth,24300,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2193.58,,,2193.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,1651.08,,,1651.08,Other,140% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,3066.3,,,3066.3,Other,260% New York Medicaid APG,3821.08,,,3821.08,Other,324% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,1474.18,,,1474.18,Other,125% New York Medicaid APG,1179.35,23663.84,
Muscle/tendon transfer,24301,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,105333.66,
Arm tendon lengthening,24305,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Revision of arm tendon,24310,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,47657.93,
Repair of arm tendon,24320,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,105333.66,
Revision of arm muscles,24330,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,105333.66,
Revision of arm muscles,24331,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,105333.66,
Tenolysis triceps,24332,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,47657.93,
Repair of biceps tendon,24340,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,105333.66,
Repair arm tendon/muscle,24341,CPT,,,,,,,,both,,,34715.08,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,17357.54,50,,17357.54,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24300.56,70,,24300.56,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,24300.56,
Repair of ruptured tendon,24342,CPT,,,,,,,,both,,,45187.14,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,22593.57,50,,22593.57,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31631,70,,31631,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,31631,
Repr elbow lat ligmnt w/tiss,24343,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Reconstruct elbow lat ligmnt,24344,CPT,,,,,,,,both,,,93480.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,14612,,"100% primary, 50% supplemental procedure",14612,Other,Aetna ASC Grouper,13151,,"100% primary, 50% supplemental procedure",13151,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,46740.33,50,,46740.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,65436.46,70,,65436.46,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,65436.46,
Repr elbw med ligmnt w/tissu,24345,CPT,,,,,,,,both,,,36880.56,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,18440.28,50,,18440.28,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25816.39,70,,25816.39,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,25816.39,
Reconstruct elbow med ligmnt,24346,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,193779.51,
Repair elbow perc,24357,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Repair elbow w/deb open,24358,CPT,,,,,,,,both,,,37172.82,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18586.41,50,,18586.41,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26020.97,70,,26020.97,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,26020.97,
Repair elbow deb/attch open,24359,CPT,,,,,,,,both,,,36006.59,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18003.3,50,,18003.3,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25204.61,70,,25204.61,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,25204.61,
Reconstruct elbow joint,24360,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6709.21,,,6709.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3607.1,,,3607.1,Other,New York Medicaid APG methodology,3607.1,,,3607.1,Other,100% New York Medicaid APG,3607.1,,,3607.1,Other,100% New York Medicaid APG,3607.1,,,3607.1,Other,100% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,5049.94,,,5049.94,Other,140% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,9378.47,,,9378.47,Other,260% New York Medicaid APG,11687.01,,,11687.01,Other,324% New York Medicaid APG,7755.27,,,7755.27,Other,215% New York Medicaid APG,7755.27,,,7755.27,Other,215% New York Medicaid APG,4508.88,,,4508.88,Other,125% New York Medicaid APG,3607.1,105333.66,
Reconstruct elbow joint,24361,CPT,,,,,,,,both,,,391985.94,35439.21,,,35439.21,Other,150% of Medicare + 9.63% HCRA Surcharge,21550.8,,,21550.8,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,195992.97,50,,195992.97,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7675.82,,,7675.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,274390.16,70,,274390.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,4126.79,,,4126.79,Other,New York Medicaid APG methodology,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,5777.5,,,5777.5,Other,140% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,10729.65,,,10729.65,Other,260% New York Medicaid APG,13370.79,,,13370.79,Other,324% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,5158.48,,,5158.48,Other,125% New York Medicaid APG,4126.79,274390.16,
Reconstruct elbow joint,24362,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7675.82,,,7675.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4126.79,,,4126.79,Other,New York Medicaid APG methodology,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,5777.5,,,5777.5,Other,140% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,10729.65,,,10729.65,Other,260% New York Medicaid APG,13370.79,,,13370.79,Other,324% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,5158.48,,,5158.48,Other,125% New York Medicaid APG,4126.79,193779.51,
Replace elbow joint,24363,CPT,,,,,,,,both,,,391985.94,35439.21,,,35439.21,Other,150% of Medicare + 9.63% HCRA Surcharge,21550.8,,,21550.8,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,195992.97,50,,195992.97,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7675.82,,,7675.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,274390.16,70,,274390.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,4126.79,,,4126.79,Other,New York Medicaid APG methodology,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,5777.5,,,5777.5,Other,140% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,10729.65,,,10729.65,Other,260% New York Medicaid APG,13370.79,,,13370.79,Other,324% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,5158.48,,,5158.48,Other,125% New York Medicaid APG,4126.79,274390.16,
Reconstruct head of radius,24365,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7675.82,,,7675.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4126.79,,,4126.79,Other,New York Medicaid APG methodology,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,5777.5,,,5777.5,Other,140% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,10729.65,,,10729.65,Other,260% New York Medicaid APG,13370.79,,,13370.79,Other,324% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,5158.48,,,5158.48,Other,125% New York Medicaid APG,4126.79,193779.51,
Reconstruct head of radius,24366,CPT,,,,,,,,both,,,140987.9,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,70493.95,50,,70493.95,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7675.82,,,7675.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,98691.53,70,,98691.53,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,4126.79,,,4126.79,Other,New York Medicaid APG methodology,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,5777.5,,,5777.5,Other,140% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,10729.65,,,10729.65,Other,260% New York Medicaid APG,13370.79,,,13370.79,Other,324% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,5158.48,,,5158.48,Other,125% New York Medicaid APG,4126.79,98691.53,
Revise reconst elbow joint,24370,CPT,,,,,,,,both,,,108194.17,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,54097.09,50,,54097.09,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7675.82,,,7675.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,75735.92,70,,75735.92,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,4126.79,,,4126.79,Other,New York Medicaid APG methodology,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,5777.5,,,5777.5,Other,140% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,10729.65,,,10729.65,Other,260% New York Medicaid APG,13370.79,,,13370.79,Other,324% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,5158.48,,,5158.48,Other,125% New York Medicaid APG,4126.79,75735.92,
Revise reconst elbow joint,24371,CPT,,,,,,,,both,,,391985.94,35439.21,,,35439.21,Other,150% of Medicare + 9.63% HCRA Surcharge,21550.8,,,21550.8,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,195992.97,50,,195992.97,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7675.82,,,7675.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,274390.16,70,,274390.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,4126.79,,,4126.79,Other,New York Medicaid APG methodology,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,5777.5,,,5777.5,Other,140% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,10729.65,,,10729.65,Other,260% New York Medicaid APG,13370.79,,,13370.79,Other,324% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,5158.48,,,5158.48,Other,125% New York Medicaid APG,4126.79,274390.16,
Revision of humerus,24400,CPT,,,,,,,,both,,,66665.03,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,33332.52,50,,33332.52,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46665.52,70,,46665.52,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,46665.52,
Revision of humerus,24410,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,193779.51,
Revision of humerus,24420,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,105333.66,
Repair of humerus,24430,CPT,,,,,,,,both,,,49923.06,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,24961.53,50,,24961.53,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34946.14,70,,34946.14,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,34946.14,
Repair humerus with graft,24435,CPT,,,,,,,,both,,,217636.6,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,108818.3,50,,108818.3,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,152345.62,70,,152345.62,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,152345.62,
Revision of elbow joint,24470,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Decompression of forearm,24495,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,105333.66,
Reinforce humerus,24498,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,193779.51,
Treat humerus fracture,24500,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treat humerus fracture,24505,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,23663.84,
Treat humerus fracture,24515,CPT,,,,,,,,both,,,94061.82,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,47030.91,50,,47030.91,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,65843.27,70,,65843.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,65843.27,
Treat humerus fracture,24516,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,193779.51,
Treat humerus fracture,24530,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treat humerus fracture,24535,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,23663.84,
Treat humerus fracture,24538,CPT,,,,,,,,both,,,36409.89,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,18204.95,50,,18204.95,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25486.92,70,,25486.92,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,25486.92,
Treat humerus fracture,24545,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,193779.51,
Treat humerus fracture,24546,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,193779.51,
Treat humerus fracture,24560,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treat humerus fracture,24565,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,23663.84,
Treat humerus fracture,24566,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,1858.58,23663.84,
Treat humerus fracture,24575,CPT,,,,,,,,both,,,69504.72,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,34752.36,50,,34752.36,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,48653.3,70,,48653.3,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,48653.3,
Treat humerus fracture,24576,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treat humerus fracture,24577,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,23663.84,
Treat humerus fracture,24579,CPT,,,,,,,,both,,,54780.48,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,27390.24,50,,27390.24,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,38346.34,70,,38346.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,38346.34,
Treat humerus fracture,24582,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Treat elbow fracture,24586,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,193779.51,
Treat elbow fracture,24587,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,193779.51,
Treat elbow dislocation,24600,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treat elbow dislocation,24605,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2193.58,,,2193.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,1651.08,,,1651.08,Other,140% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,3066.3,,,3066.3,Other,260% New York Medicaid APG,3821.08,,,3821.08,Other,324% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,1474.18,,,1474.18,Other,125% New York Medicaid APG,1179.35,23663.84,
Treat elbow dislocation,24615,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Treat elbow fracture,24620,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,23663.84,
Treat elbow fracture,24635,CPT,,,,,,,,both,,,105508.14,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,52754.07,50,,52754.07,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,73855.7,70,,73855.7,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,73855.7,
Treat elbow dislocation,24640,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,394.35,,,394.35,Fee Schedule,,334.6,,,334.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,9473,
Treat radius fracture,24650,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,13157,
Treat radius fracture,24655,CPT,,,,,,,,both,,,35625.51,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17812.76,50,,17812.76,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24937.86,70,,24937.86,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,24937.86,
Treat radius fracture,24665,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Treat radius fracture,24666,CPT,,,,,,,,both,,,147376.01,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,73688.01,50,,73688.01,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,103163.21,70,,103163.21,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,103163.21,
Treat ulnar fracture,24670,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treat ulnar fracture,24675,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,23663.84,
Treat ulnar fracture,24685,CPT,,,,,,,,both,,,81461.92,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,40730.96,50,,40730.96,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,57023.34,70,,57023.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,57023.34,
Fusion of elbow joint,24800,CPT,,,,,,,,both,,,121655.19,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,60827.6,50,,60827.6,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,85158.63,70,,85158.63,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,85158.63,
Fusion/graft of elbow joint,24802,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,193779.51,
Amputation follow-up surgery,24925,CPT,,,,,,,,both,,,33870,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,16935,50,,16935,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23709,70,,23709,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,23709,
Revision of amputation,24935,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,105333.66,
Incision of tendon sheath,25000,CPT,,,,,,,,both,,,33625.42,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16812.71,50,,16812.71,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23537.79,70,,23537.79,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,1858.58,23537.79,
Incise flexor carpi radialis,25001,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,47657.93,
Decompress forearm 1 space,25020,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,1858.58,23663.84,
Decompress forearm 1 space,25023,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Decompress forearm 2 spaces,25024,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Decompress forearm 2 spaces,25025,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,1858.58,23663.84,
Drainage of forearm lesion,25028,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Drainage of forearm bursa,25031,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,1858.58,23663.84,
Treat forearm bone lesion,25035,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,105333.66,
Explore/treat wrist joint,25040,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Biopsy forearm soft tissues,25065,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,1874.86,23871.23,
Biopsy forearm soft tissues,25066,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,41837.04,
Exc forearm les sc 3 cm/>,25071,CPT,,,,,,,,both,,,34918.19,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17459.1,50,,17459.1,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24442.73,70,,24442.73,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,1874.86,24442.73,
Exc forearm tum deep 3 cm/>,25073,CPT,,,,,,,,both,,,38778.36,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19389.18,50,,19389.18,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27144.85,70,,27144.85,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,27144.85,
Exc forearm les sc < 3 cm,25075,CPT,,,,,,,,both,,,36818.43,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18409.22,50,,18409.22,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25772.9,70,,25772.9,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,1874.86,25772.9,
Exc forearm tum deep < 3 cm,25076,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,1874.86,23871.23,
Resect forearm/wrist tum<3cm,25077,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,41837.04,
Resect forarm/wrist tum 3cm>,25078,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,41837.04,
Incision of wrist capsule,25085,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Biopsy of wrist joint,25100,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Explore/treat wrist joint,25101,CPT,,,,,,,,both,,,39926.3,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19963.15,50,,19963.15,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27948.41,70,,27948.41,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,27948.41,
Remove wrist joint lining,25105,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Remove wrist joint cartilage,25107,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Excise tendon forearm/wrist,25109,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Remove wrist tendon lesion,25110,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,1858.58,23663.84,
Remove wrist tendon lesion,25111,CPT,,,,,,,,both,,,34202.63,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17101.32,50,,17101.32,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23941.84,70,,23941.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,23941.84,
Reremove wrist tendon lesion,25112,CPT,,,,,,,,both,,,32239.98,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16119.99,50,,16119.99,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22567.99,70,,22567.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,22567.99,
Remove wrist/forearm lesion,25115,CPT,,,,,,,,both,,,34227.66,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17113.83,50,,17113.83,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23959.36,70,,23959.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,1858.58,23959.36,
Remove wrist/forearm lesion,25116,CPT,,,,,,,,both,,,32789.65,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,16394.83,50,,16394.83,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22952.76,70,,22952.76,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,22952.76,
Excise wrist tendon sheath,25118,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,1858.58,23663.84,
Partial removal of ulna,25119,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Removal of forearm lesion,25120,CPT,,,,,,,,both,,,71784.48,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,35892.24,50,,35892.24,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50249.14,70,,50249.14,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,50249.14,
Remove/graft forearm lesion,25125,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,1858.58,23663.84,
Remove/graft forearm lesion,25126,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Removal of wrist lesion,25130,CPT,,,,,,,,both,,,35523.66,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17761.83,50,,17761.83,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24866.56,70,,24866.56,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,24866.56,
Remove & graft wrist lesion,25135,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,105333.66,
Remove & graft wrist lesion,25136,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,105333.66,
Remove forearm bone lesion,25145,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,47657.93,
Partial removal of ulna,25150,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Partial removal of radius,25151,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Resect radius/ulnar tumor,25170,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,105333.66,
Removal of wrist bone,25210,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,47657.93,
Removal of wrist bones,25215,CPT,,,,,,,,both,,,37702.27,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18851.14,50,,18851.14,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26391.59,70,,26391.59,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,26391.59,
Partial removal of radius,25230,CPT,,,,,,,,both,,,44454.65,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,22227.33,50,,22227.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31118.26,70,,31118.26,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,31118.26,
Partial removal of ulna,25240,CPT,,,,,,,,both,,,44514.25,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,22257.13,50,,22257.13,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31159.98,70,,31159.98,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,31159.98,
Injection for wrist x-ray,25246,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1205.26,,,1205.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,354.75,,,354.75,Fee Schedule,,301,,,301,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.99,,,647.99,Other,New York Medicaid APG methodology,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,907.18,,,907.18,Other,140% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1684.77,,,1684.77,Other,260% New York Medicaid APG,2099.48,,,2099.48,Other,324% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,809.98,,,809.98,Other,125% New York Medicaid APG,0.01,22702.47,
Remove forearm foreign body,25248,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,1858.58,23663.84,
Removal of wrist prosthesis,25250,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,1858.58,23663.84,
Removal of wrist prosthesis,25251,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Manipulate wrist w/anesthes,25259,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2193.58,,,2193.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,1651.08,,,1651.08,Other,140% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,3066.3,,,3066.3,Other,260% New York Medicaid APG,3821.08,,,3821.08,Other,324% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,1474.18,,,1474.18,Other,125% New York Medicaid APG,1179.35,23663.84,
Repair forearm tendon/muscle,25260,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Repair forearm tendon/muscle,25263,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,105333.66,
Repair forearm tendon/muscle,25265,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Repair forearm tendon/muscle,25270,CPT,,,,,,,,both,,,36049.16,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18024.58,50,,18024.58,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25234.41,70,,25234.41,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,25234.41,
Repair forearm tendon/muscle,25272,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Repair forearm tendon/muscle,25274,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Repair forearm tendon sheath,25275,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Revise wrist/forearm tendon,25280,CPT,,,,,,,,both,,,33503.24,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,16751.62,50,,16751.62,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23452.27,70,,23452.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,23452.27,
Incise wrist/forearm tendon,25290,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Release wrist/forearm tendon,25295,CPT,,,,,,,,both,,,37971.28,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18985.64,50,,18985.64,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26579.9,70,,26579.9,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,26579.9,
Fusion of tendons at wrist,25300,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,47657.93,
Fusion of tendons at wrist,25301,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Transplant forearm tendon,25310,CPT,,,,,,,,both,,,33536.25,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,16768.13,50,,16768.13,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23475.38,70,,23475.38,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,23475.38,
Transplant forearm tendon,25312,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Revise palsy hand tendon(s),25315,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,105333.66,
Revise palsy hand tendon(s),25316,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,105333.66,
Repair/revise wrist joint,25320,CPT,,,,,,,,both,,,60861.39,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,30430.7,50,,30430.7,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,42602.97,70,,42602.97,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,42602.97,
Revise wrist joint,25332,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6709.21,,,6709.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3607.1,,,3607.1,Other,New York Medicaid APG methodology,3607.1,,,3607.1,Other,100% New York Medicaid APG,3607.1,,,3607.1,Other,100% New York Medicaid APG,3607.1,,,3607.1,Other,100% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,5049.94,,,5049.94,Other,140% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,9378.47,,,9378.47,Other,260% New York Medicaid APG,11687.01,,,11687.01,Other,324% New York Medicaid APG,7755.27,,,7755.27,Other,215% New York Medicaid APG,7755.27,,,7755.27,Other,215% New York Medicaid APG,4508.88,,,4508.88,Other,125% New York Medicaid APG,3607.1,47657.93,
Realignment of hand,25335,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Reconstruct ulna/radioulnar,25337,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,105333.66,
Revision of radius,25350,CPT,,,,,,,,both,,,67938.48,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,33969.24,50,,33969.24,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47556.94,70,,47556.94,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,47556.94,
Revision of radius,25355,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Revision of ulna,25360,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,105333.66,
Revise radius & ulna,25365,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,193779.51,
Revise radius or ulna,25370,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Revise radius & ulna,25375,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Shorten radius or ulna,25390,CPT,,,,,,,,both,,,79263.94,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,39631.97,50,,39631.97,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,55484.76,70,,55484.76,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,55484.76,
Lengthen radius or ulna,25391,CPT,,,,,,,,both,,,56622.67,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,28311.34,50,,28311.34,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,39635.87,70,,39635.87,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,39635.87,
Shorten radius & ulna,25392,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,105333.66,
Lengthen radius & ulna,25393,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,105333.66,
Repair carpal bone shorten,25394,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,47657.93,
Repair radius or ulna,25400,CPT,,,,,,,,both,,,68184.32,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,34092.16,50,,34092.16,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47729.02,70,,47729.02,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,47729.02,
Repair/graft radius or ulna,25405,CPT,,,,,,,,both,,,71753.49,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,35876.75,50,,35876.75,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50227.44,70,,50227.44,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,50227.44,
Repair radius & ulna,25415,CPT,,,,,,,,both,,,120422.45,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,60211.23,50,,60211.23,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84295.72,70,,84295.72,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,84295.72,
Repair/graft radius & ulna,25420,CPT,,,,,,,,both,,,89164.01,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,44582.01,50,,44582.01,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,62414.81,70,,62414.81,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,62414.81,
Repair/graft radius or ulna,25425,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,105333.66,
Repair/graft radius & ulna,25426,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,47657.93,
Vasc graft into carpal bone,25430,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,47657.93,
Repair nonunion carpal bone,25431,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Repair/graft wrist bone,25440,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,105333.66,
Reconstruct wrist joint,25441,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7675.82,,,7675.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,4126.79,,,4126.79,Other,New York Medicaid APG methodology,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,5777.5,,,5777.5,Other,140% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,10729.65,,,10729.65,Other,260% New York Medicaid APG,13370.79,,,13370.79,Other,324% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,5158.48,,,5158.48,Other,125% New York Medicaid APG,4126.79,193779.51,
Reconstruct wrist joint,25442,CPT,,,,,,,,both,,,391985.94,35439.21,,,35439.21,Other,150% of Medicare + 9.63% HCRA Surcharge,21550.8,,,21550.8,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,195992.97,50,,195992.97,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7675.82,,,7675.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,274390.16,70,,274390.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,4126.79,,,4126.79,Other,New York Medicaid APG methodology,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,5777.5,,,5777.5,Other,140% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,10729.65,,,10729.65,Other,260% New York Medicaid APG,13370.79,,,13370.79,Other,324% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,5158.48,,,5158.48,Other,125% New York Medicaid APG,4126.79,274390.16,
Reconstruct wrist joint,25443,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6709.21,,,6709.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3607.1,,,3607.1,Other,New York Medicaid APG methodology,3607.1,,,3607.1,Other,100% New York Medicaid APG,3607.1,,,3607.1,Other,100% New York Medicaid APG,3607.1,,,3607.1,Other,100% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,5049.94,,,5049.94,Other,140% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,9378.47,,,9378.47,Other,260% New York Medicaid APG,11687.01,,,11687.01,Other,324% New York Medicaid APG,7755.27,,,7755.27,Other,215% New York Medicaid APG,7755.27,,,7755.27,Other,215% New York Medicaid APG,4508.88,,,4508.88,Other,125% New York Medicaid APG,3607.1,105333.66,
Reconstruct wrist joint,25444,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7675.82,,,7675.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4126.79,,,4126.79,Other,New York Medicaid APG methodology,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,5777.5,,,5777.5,Other,140% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,10729.65,,,10729.65,Other,260% New York Medicaid APG,13370.79,,,13370.79,Other,324% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,5158.48,,,5158.48,Other,125% New York Medicaid APG,4126.79,193779.51,
Reconstruct wrist joint,25445,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6709.21,,,6709.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3607.1,,,3607.1,Other,New York Medicaid APG methodology,3607.1,,,3607.1,Other,100% New York Medicaid APG,3607.1,,,3607.1,Other,100% New York Medicaid APG,3607.1,,,3607.1,Other,100% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,5049.94,,,5049.94,Other,140% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,9378.47,,,9378.47,Other,260% New York Medicaid APG,11687.01,,,11687.01,Other,324% New York Medicaid APG,7755.27,,,7755.27,Other,215% New York Medicaid APG,7755.27,,,7755.27,Other,215% New York Medicaid APG,4508.88,,,4508.88,Other,125% New York Medicaid APG,3607.1,105333.66,
Wrist replacement,25446,CPT,,,,,,,,both,,,391985.94,35439.21,,,35439.21,Other,150% of Medicare + 9.63% HCRA Surcharge,21550.8,,,21550.8,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,195992.97,50,,195992.97,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7675.82,,,7675.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,274390.16,70,,274390.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,4126.79,,,4126.79,Other,New York Medicaid APG methodology,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,5777.5,,,5777.5,Other,140% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,10729.65,,,10729.65,Other,260% New York Medicaid APG,13370.79,,,13370.79,Other,324% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,5158.48,,,5158.48,Other,125% New York Medicaid APG,4126.79,274390.16,
Repair wrist joints,25447,CPT,,,,,,,,both,,,53642.7,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,26821.35,50,,26821.35,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6709.21,,,6709.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,37549.89,70,,37549.89,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3607.1,,,3607.1,Other,New York Medicaid APG methodology,3607.1,,,3607.1,Other,100% New York Medicaid APG,3607.1,,,3607.1,Other,100% New York Medicaid APG,3607.1,,,3607.1,Other,100% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,5049.94,,,5049.94,Other,140% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,9378.47,,,9378.47,Other,260% New York Medicaid APG,11687.01,,,11687.01,Other,324% New York Medicaid APG,7755.27,,,7755.27,Other,215% New York Medicaid APG,7755.27,,,7755.27,Other,215% New York Medicaid APG,4508.88,,,4508.88,Other,125% New York Medicaid APG,3607.1,37549.89,
Remove wrist joint implant,25449,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6709.21,,,6709.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3607.1,,,3607.1,Other,New York Medicaid APG methodology,3607.1,,,3607.1,Other,100% New York Medicaid APG,3607.1,,,3607.1,Other,100% New York Medicaid APG,3607.1,,,3607.1,Other,100% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,5049.94,,,5049.94,Other,140% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,9378.47,,,9378.47,Other,260% New York Medicaid APG,11687.01,,,11687.01,Other,324% New York Medicaid APG,7755.27,,,7755.27,Other,215% New York Medicaid APG,7755.27,,,7755.27,Other,215% New York Medicaid APG,4508.88,,,4508.88,Other,125% New York Medicaid APG,3607.1,105333.66,
Revision of wrist joint,25450,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Revision of wrist joint,25455,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Reinforce radius,25490,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,105333.66,
Reinforce ulna,25491,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,193779.51,
Reinforce radius and ulna,25492,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Treat fracture of radius,25500,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,13157,
Treat fracture of radius,25505,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,23663.84,
Treat fracture of radius,25515,CPT,,,,,,,,both,,,85719.93,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,42859.97,50,,42859.97,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,60003.95,70,,60003.95,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,60003.95,
Treat fracture of radius,25520,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,23663.84,
Treat fracture of radius,25525,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Treat fracture of radius,25526,CPT,,,,,,,,both,,,86255.66,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,43127.83,50,,43127.83,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,60378.96,70,,60378.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,60378.96,
Treat fracture of ulna,25530,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,13157,
Treat fracture of ulna,25535,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treat fracture of ulna,25545,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Treat fracture radius & ulna,25560,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,13157,
Treat fracture radius & ulna,25565,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,23663.84,
Treat fracture radius & ulna,25574,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Treat fracture radius/ulna,25575,CPT,,,,,,,,both,,,78802.27,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,39401.14,50,,39401.14,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,55161.59,70,,55161.59,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,55161.59,
Treat fracture radius/ulna,25600,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,13157,
Treat fracture radius/ulna,25605,CPT,,,,,,,,both,,,34409.3,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17204.65,50,,17204.65,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24086.51,70,,24086.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,24086.51,
Treat fx distal radial,25606,CPT,,,,,,,,both,,,36026.77,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18013.39,50,,18013.39,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25218.74,70,,25218.74,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,25218.74,
Treat fx rad extra-articul,25607,CPT,,,,,,,,both,,,99538.86,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,49769.43,50,,49769.43,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,69677.2,70,,69677.2,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,69677.2,
Treat fx rad intra-articul,25608,CPT,,,,,,,,both,,,62978.56,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,31489.28,50,,31489.28,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,44084.99,70,,44084.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,44084.99,
Treat fx radial 3+ frag,25609,CPT,,,,,,,,both,,,74400.22,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,37200.11,50,,37200.11,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52080.15,70,,52080.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,52080.15,
Treat wrist bone fracture,25622,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,13157,
Treat wrist bone fracture,25624,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,23663.84,
Treat wrist bone fracture,25628,CPT,,,,,,,,both,,,66045.92,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,33022.96,50,,33022.96,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46232.14,70,,46232.14,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,46232.14,
Treat wrist bone fracture,25630,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,13157,
Treat wrist bone fracture,25635,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,23663.84,
Treat wrist bone fracture,25645,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,47657.93,
Treat wrist bone fracture,25650,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,13157,
Pin ulnar styloid fracture,25651,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3323,47657.93,
Treat fracture ulnar styloid,25652,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Treat wrist dislocation,25660,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treat wrist dislocation,25670,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Pin radioulnar dislocation,25671,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3323,47657.93,
Treat wrist dislocation,25675,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treat wrist dislocation,25676,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Treat wrist fracture,25680,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treat wrist fracture,25685,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Treat wrist dislocation,25690,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,23663.84,
Treat wrist dislocation,25695,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Fusion of wrist joint,25800,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,105333.66,
Fusion/graft of wrist joint,25805,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,105333.66,
Fusion/graft of wrist joint,25810,CPT,,,,,,,,both,,,56204.17,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,28102.09,50,,28102.09,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,39342.92,70,,39342.92,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,39342.92,
Fusion of hand bones,25820,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,105333.66,
Fuse hand bones with graft,25825,CPT,,,,,,,,both,,,71599.92,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,35799.96,50,,35799.96,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50119.94,70,,50119.94,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,50119.94,
Fusion radioulnar jnt/ulna,25830,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,105333.66,
Amputation follow-up surgery,25907,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Amputation follow-up surgery,25909,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5050.42,,,5050.42,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2715.28,,,2715.28,Other,New York Medicaid APG methodology,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,2715.28,,,2715.28,Other,100% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,3801.39,,,3801.39,Other,140% New York Medicaid APG,6109.38,,,6109.38,Other,225% New York Medicaid APG,7059.72,,,7059.72,Other,260% New York Medicaid APG,8797.5,,,8797.5,Other,324% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,5837.85,,,5837.85,Other,215% New York Medicaid APG,3394.1,,,3394.1,Other,125% New York Medicaid APG,2715.28,105333.66,
Amputate hand at wrist,25922,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,1858.58,23663.84,
Amputation follow-up surgery,25929,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,26850.29,
Amputation follow-up surgery,25931,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4458.03,,,4458.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2396.79,,,2396.79,Other,New York Medicaid APG methodology,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,2396.79,,,2396.79,Other,100% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,3355.51,,,3355.51,Other,140% New York Medicaid APG,5392.78,,,5392.78,Other,225% New York Medicaid APG,6231.66,,,6231.66,Other,260% New York Medicaid APG,7765.6,,,7765.6,Other,324% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,5153.1,,,5153.1,Other,215% New York Medicaid APG,2995.99,,,2995.99,Other,125% New York Medicaid APG,2396.79,47657.93,
Drainage of finger abscess,26010,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,701.25,,,701.25,Fee Schedule,,595,,,595,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Drainage of finger abscess,26011,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1516.17,,,1516.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,815.14,,,815.14,Other,New York Medicaid APG methodology,815.14,,,815.14,Other,100% New York Medicaid APG,815.14,,,815.14,Other,100% New York Medicaid APG,815.14,,,815.14,Other,100% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,1141.2,,,1141.2,Other,140% New York Medicaid APG,1834.07,,,1834.07,Other,225% New York Medicaid APG,2119.37,,,2119.37,Other,260% New York Medicaid APG,2641.06,,,2641.06,Other,324% New York Medicaid APG,1752.56,,,1752.56,Other,215% New York Medicaid APG,1752.56,,,1752.56,Other,215% New York Medicaid APG,1018.93,,,1018.93,Other,125% New York Medicaid APG,815.14,23871.23,
Drain hand tendon sheath,26020,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,47657.93,
Drainage of palm bursa,26025,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,47657.93,
Drainage of palm bursas,26030,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,47657.93,
Treat hand bone lesion,26034,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,23663.84,
Decompress fingers/hand,26035,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,47657.93,
Decompress fingers/hand,26037,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,47657.93,
Release palm contracture,26040,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,23663.84,
Release palm contracture,26045,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,47657.93,
Incise finger tendon sheath,26055,CPT,,,,,,,,both,,,33711.03,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16855.52,50,,16855.52,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23597.72,70,,23597.72,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,23597.72,
Incision of finger tendon,26060,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,23663.84,
Explore/treat hand joint,26070,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,23663.84,
Explore/treat finger joint,26075,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,47657.93,
Explore/treat finger joint,26080,CPT,,,,,,,,both,,,33671.19,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16835.6,50,,16835.6,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23569.83,70,,23569.83,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,23569.83,
Biopsy hand joint lining,26100,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,47657.93,
Biopsy finger joint lining,26105,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,47657.93,
Biopsy finger joint lining,26110,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,23663.84,
Exc hand les sc 1.5 cm/>,26111,CPT,,,,,,,,both,,,35595.01,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17797.51,50,,17797.51,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24916.51,70,,24916.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,24916.51,
Exc hand tum deep 1.5 cm/>,26113,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,23871.23,
Exc hand les sc < 1.5 cm,26115,CPT,,,,,,,,both,,,33585.72,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16792.86,50,,16792.86,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23510,70,,23510,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,23510,
Exc hand tum deep < 1.5 cm,26116,CPT,,,,,,,,both,,,34505.64,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17252.82,50,,17252.82,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24153.95,70,,24153.95,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,24153.95,
Rad resect hand tumor < 3 cm,26117,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,41837.04,
Rad resect hand tumor 3 cm/>,26118,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,41837.04,
Release palm contracture,26121,CPT,,,,,,,,both,,,35559.44,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17779.72,50,,17779.72,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24891.61,70,,24891.61,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,24891.61,
Release palm contracture,26123,CPT,,,,,,,,both,,,35036.5,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17518.25,50,,17518.25,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24525.55,70,,24525.55,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,24525.55,
Release palm contracture,26125,CPT,,,,,,,,both,,,83504,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,41752,50,,41752,percent of total billed charges,,58452.8,70,,58452.8,percent of total billed charges,,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,58452.8,70,,58452.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,0.01,58452.8,
Remove wrist joint lining,26130,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,47657.93,
Revise finger joint each,26135,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,47657.93,
Revise finger joint each,26140,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,23663.84,
Tendon excision palm/finger,26145,CPT,,,,,,,,both,,,33317,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16658.5,50,,16658.5,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23321.9,70,,23321.9,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,1858.58,23321.9,
Remove tendon sheath lesion,26160,CPT,,,,,,,,both,,,33778.34,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16889.17,50,,16889.17,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23644.84,70,,23644.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,23644.84,
Removal of palm tendon each,26170,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,23663.84,
Removal of finger tendon,26180,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,23663.84,
Remove finger bone,26185,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,23663.84,
Remove hand bone lesion,26200,CPT,,,,,,,,both,,,41803.66,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20901.83,50,,20901.83,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29262.56,70,,29262.56,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,29262.56,
Remove/graft bone lesion,26205,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,105333.66,
Removal of finger lesion,26210,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,23663.84,
Remove/graft finger lesion,26215,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,47657.93,
Partial removal of hand bone,26230,CPT,,,,,,,,both,,,39242.3,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19621.15,50,,19621.15,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27469.61,70,,27469.61,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,27469.61,
Partial removal finger bone,26235,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,1858.58,23663.84,
Partial removal finger bone,26236,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,23663.84,
Extensive hand surgery,26250,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,47657.93,
Resect prox finger tumor,26260,CPT,,,,,,,,both,,,41609.73,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,20804.87,50,,20804.87,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29126.81,70,,29126.81,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,29126.81,
Resect distal finger tumor,26262,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,23663.84,
Removal of implant from hand,26320,CPT,,,,,,,,both,,,35678.49,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17839.25,50,,17839.25,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24974.94,70,,24974.94,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,24974.94,
Manipulate finger w/anesth,26340,CPT,,,,,,,,both,,,33748.75,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16874.38,50,,16874.38,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2193.58,,,2193.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23624.13,70,,23624.13,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,1651.08,,,1651.08,Other,140% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,3066.3,,,3066.3,Other,260% New York Medicaid APG,3821.08,,,3821.08,Other,324% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,1474.18,,,1474.18,Other,125% New York Medicaid APG,1179.35,23624.13,
Manipulat palm cord post inj,26341,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,389.4,,,389.4,Fee Schedule,,330.4,,,330.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,9473,
Repair finger/hand tendon,26350,CPT,,,,,,,,both,,,33832.37,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,16916.19,50,,16916.19,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23682.66,70,,23682.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,23682.66,
Repair/graft hand tendon,26352,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,105333.66,
Repair finger/hand tendon,26356,CPT,,,,,,,,both,,,40034.5,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,20017.25,50,,20017.25,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28024.15,70,,28024.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,28024.15,
Repair finger/hand tendon,26357,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,47657.93,
Repair/graft hand tendon,26358,CPT,,,,,,,,both,,,54507.34,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,27253.67,50,,27253.67,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,38155.14,70,,38155.14,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,38155.14,
Repair finger/hand tendon,26370,CPT,,,,,,,,both,,,37850.35,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18925.18,50,,18925.18,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26495.25,70,,26495.25,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,26495.25,
Repair/graft hand tendon,26372,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,105333.66,
Repair finger/hand tendon,26373,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,47657.93,
Revise hand/finger tendon,26390,CPT,,,,,,,,both,,,37645.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,18822.83,50,,18822.83,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26351.96,70,,26351.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,26351.96,
Repair/graft hand tendon,26392,CPT,,,,,,,,both,,,56888.22,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,28444.11,50,,28444.11,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,39821.75,70,,39821.75,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,39821.75,
Repair hand tendon,26410,CPT,,,,,,,,both,,,32157.65,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16078.83,50,,16078.83,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22510.36,70,,22510.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,22510.36,
Repair/graft hand tendon,26412,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,47657.93,
Excision hand/finger tendon,26415,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,47657.93,
Graft hand or finger tendon,26416,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,47657.93,
Repair finger tendon,26418,CPT,,,,,,,,both,,,34562.54,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17281.27,50,,17281.27,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24193.78,70,,24193.78,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,24193.78,
Repair/graft finger tendon,26420,CPT,,,,,,,,both,,,61393.55,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,30696.78,50,,30696.78,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,42975.49,70,,42975.49,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,42975.49,
Repair finger/hand tendon,26426,CPT,,,,,,,,both,,,35216.28,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17608.14,50,,17608.14,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24651.4,70,,24651.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,24651.4,
Repair/graft finger tendon,26428,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,47657.93,
Repair finger tendon,26432,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,23663.84,
Repair finger tendon,26433,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,47657.93,
Repair/graft finger tendon,26434,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,47657.93,
Realignment of tendons,26437,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,47657.93,
Release palm/finger tendon,26440,CPT,,,,,,,,both,,,38676.66,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19338.33,50,,19338.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27073.66,70,,27073.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,27073.66,
Release palm & finger tendon,26442,CPT,,,,,,,,both,,,42387.74,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,21193.87,50,,21193.87,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29671.42,70,,29671.42,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,29671.42,
Release hand/finger tendon,26445,CPT,,,,,,,,both,,,34927.48,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17463.74,50,,17463.74,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24449.24,70,,24449.24,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,24449.24,
Release forearm/hand tendon,26449,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,47657.93,
Incision of palm tendon,26450,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,47657.93,
Incision of finger tendon,26455,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,23663.84,
Incise hand/finger tendon,26460,CPT,,,,,,,,both,,,51889.91,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25944.96,50,,25944.96,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36322.94,70,,36322.94,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,36322.94,
Fusion of finger tendons,26471,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,47657.93,
Fusion of finger tendons,26474,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,23663.84,
Tendon lengthening,26476,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,47657.93,
Tendon shortening,26477,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,47657.93,
Lengthening of hand tendon,26478,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,47657.93,
Shortening of hand tendon,26479,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,47657.93,
Transplant hand tendon,26480,CPT,,,,,,,,both,,,41084.27,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,20542.14,50,,20542.14,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28758.99,70,,28758.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,28758.99,
Transplant/graft hand tendon,26483,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,47657.93,
Transplant palm tendon,26485,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,47657.93,
Transplant/graft palm tendon,26489,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,47657.93,
Revise thumb tendon,26490,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,47657.93,
Tendon transfer with graft,26492,CPT,,,,,,,,both,,,32843,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,16421.5,50,,16421.5,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22990.1,70,,22990.1,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,22990.1,
Hand tendon/muscle transfer,26494,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,47657.93,
Revise thumb tendon,26496,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,47657.93,
Finger tendon transfer,26497,CPT,,,,,,,,both,,,56674.81,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,28337.41,50,,28337.41,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,39672.37,70,,39672.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,39672.37,
Finger tendon transfer,26498,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,47657.93,
Revision of finger,26499,CPT,,,,,,,,both,,,34322.65,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17161.33,50,,17161.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24025.86,70,,24025.86,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,24025.86,
Hand tendon reconstruction,26500,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,105333.66,
Hand tendon reconstruction,26502,CPT,,,,,,,,both,,,39162.16,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19581.08,50,,19581.08,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27413.51,70,,27413.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,27413.51,
Release thumb contracture,26508,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,47657.93,
Thumb tendon transfer,26510,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,47657.93,
Fusion of knuckle joint,26516,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,47657.93,
Fusion of knuckle joints,26517,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,47657.93,
Fusion of knuckle joints,26518,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,105333.66,
Release knuckle contracture,26520,CPT,,,,,,,,both,,,36530.43,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18265.22,50,,18265.22,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25571.3,70,,25571.3,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,25571.3,
Release finger contracture,26525,CPT,,,,,,,,both,,,36510.01,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18255.01,50,,18255.01,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25557.01,70,,25557.01,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,25557.01,
Revise knuckle joint,26530,CPT,,,,,,,,both,,,37234.15,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18617.08,50,,18617.08,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6709.21,,,6709.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26063.91,70,,26063.91,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3607.1,,,3607.1,Other,New York Medicaid APG methodology,3607.1,,,3607.1,Other,100% New York Medicaid APG,3607.1,,,3607.1,Other,100% New York Medicaid APG,3607.1,,,3607.1,Other,100% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,5049.94,,,5049.94,Other,140% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,9378.47,,,9378.47,Other,260% New York Medicaid APG,11687.01,,,11687.01,Other,324% New York Medicaid APG,7755.27,,,7755.27,Other,215% New York Medicaid APG,7755.27,,,7755.27,Other,215% New York Medicaid APG,4508.88,,,4508.88,Other,125% New York Medicaid APG,3607.1,26063.91,
Revise knuckle with implant,26531,CPT,,,,,,,,both,,,50570.66,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,25285.33,50,,25285.33,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6709.21,,,6709.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,35399.46,70,,35399.46,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3607.1,,,3607.1,Other,New York Medicaid APG methodology,3607.1,,,3607.1,Other,100% New York Medicaid APG,3607.1,,,3607.1,Other,100% New York Medicaid APG,3607.1,,,3607.1,Other,100% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,5049.94,,,5049.94,Other,140% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,9378.47,,,9378.47,Other,260% New York Medicaid APG,11687.01,,,11687.01,Other,324% New York Medicaid APG,7755.27,,,7755.27,Other,215% New York Medicaid APG,7755.27,,,7755.27,Other,215% New York Medicaid APG,4508.88,,,4508.88,Other,125% New York Medicaid APG,3607.1,35399.46,
Revise finger joint,26535,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6709.21,,,6709.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3607.1,,,3607.1,Other,New York Medicaid APG methodology,3607.1,,,3607.1,Other,100% New York Medicaid APG,3607.1,,,3607.1,Other,100% New York Medicaid APG,3607.1,,,3607.1,Other,100% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,5049.94,,,5049.94,Other,140% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,9378.47,,,9378.47,Other,260% New York Medicaid APG,11687.01,,,11687.01,Other,324% New York Medicaid APG,7755.27,,,7755.27,Other,215% New York Medicaid APG,7755.27,,,7755.27,Other,215% New York Medicaid APG,4508.88,,,4508.88,Other,125% New York Medicaid APG,3607.1,47657.93,
Revise/implant finger joint,26536,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6709.21,,,6709.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3607.1,,,3607.1,Other,New York Medicaid APG methodology,3607.1,,,3607.1,Other,100% New York Medicaid APG,3607.1,,,3607.1,Other,100% New York Medicaid APG,3607.1,,,3607.1,Other,100% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,5049.94,,,5049.94,Other,140% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,9378.47,,,9378.47,Other,260% New York Medicaid APG,11687.01,,,11687.01,Other,324% New York Medicaid APG,7755.27,,,7755.27,Other,215% New York Medicaid APG,7755.27,,,7755.27,Other,215% New York Medicaid APG,4508.88,,,4508.88,Other,125% New York Medicaid APG,3607.1,105333.66,
Repair hand joint,26540,CPT,,,,,,,,both,,,47774.16,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,23887.08,50,,23887.08,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,33441.91,70,,33441.91,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,33441.91,
Repair hand joint with graft,26541,CPT,,,,,,,,both,,,51006.86,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,25503.43,50,,25503.43,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,35704.8,70,,35704.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,35704.8,
Repair hand joint with graft,26542,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,47657.93,
Reconstruct finger joint,26545,CPT,,,,,,,,both,,,42409.65,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,21204.83,50,,21204.83,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29686.76,70,,29686.76,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,29686.76,
Repair nonunion hand,26546,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,105333.66,
Reconstruct finger joint,26548,CPT,,,,,,,,both,,,39006.65,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19503.33,50,,19503.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27304.66,70,,27304.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,27304.66,
Construct thumb replacement,26550,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,47657.93,
Positional change of finger,26555,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,105333.66,
Repair of web finger,26560,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,1858.58,23663.84,
Repair of web finger,26561,CPT,,,,,,,,both,,,41047.15,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,20523.58,50,,20523.58,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28733.01,70,,28733.01,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,28733.01,
Repair of web finger,26562,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,47657.93,
Correct metacarpal flaw,26565,CPT,,,,,,,,both,,,55334.13,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,27667.07,50,,27667.07,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,38733.89,70,,38733.89,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,38733.89,
Correct finger deformity,26567,CPT,,,,,,,,both,,,49243.45,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,24621.73,50,,24621.73,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34470.42,70,,34470.42,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,34470.42,
Lengthen metacarpal/finger,26568,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,105333.66,
Repair hand deformity,26580,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,47657.93,
Reconstruct extra finger,26587,CPT,,,,,,,,both,,,34877.63,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17438.82,50,,17438.82,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24414.34,70,,24414.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,24414.34,
Repair finger deformity,26590,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,1858.58,23663.84,
Repair muscles of hand,26591,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,47657.93,
Release muscles of hand,26593,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,47657.93,
Excision constricting tissue,26596,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,47657.93,
Treat metacarpal fracture,26600,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,13157,
Treat metacarpal fracture,26605,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treat metacarpal fracture,26607,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,47657.93,
Treat metacarpal fracture,26608,CPT,,,,,,,,both,,,33165.32,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,16582.66,50,,16582.66,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23215.72,70,,23215.72,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,23215.72,
Treat metacarpal fracture,26615,CPT,,,,,,,,both,,,54008.81,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,27004.41,50,,27004.41,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,37806.17,70,,37806.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,37806.17,
Treat thumb dislocation,26641,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,13157,
Treat thumb fracture,26645,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,23663.84,
Treat thumb fracture,26650,CPT,,,,,,,,both,,,73072.3,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36536.15,50,,36536.15,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51150.61,70,,51150.61,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,51150.61,
Treat thumb fracture,26665,CPT,,,,,,,,both,,,38014.32,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19007.16,50,,19007.16,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26610.02,70,,26610.02,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,26610.02,
Treat hand dislocation,26670,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,13157,
Treat hand dislocation,26675,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2193.58,,,2193.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,1651.08,,,1651.08,Other,140% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,3066.3,,,3066.3,Other,260% New York Medicaid APG,3821.08,,,3821.08,Other,324% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,1474.18,,,1474.18,Other,125% New York Medicaid APG,1179.35,23663.84,
Pin hand dislocation,26676,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,47657.93,
Treat hand dislocation,26685,CPT,,,,,,,,both,,,45313.25,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,22656.63,50,,22656.63,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31719.28,70,,31719.28,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,31719.28,
Treat hand dislocation,26686,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,47657.93,
Treat knuckle dislocation,26700,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,13157,
Treat knuckle dislocation,26705,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2193.58,,,2193.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,1651.08,,,1651.08,Other,140% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,3066.3,,,3066.3,Other,260% New York Medicaid APG,3821.08,,,3821.08,Other,324% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,1474.18,,,1474.18,Other,125% New York Medicaid APG,1179.35,23663.84,
Pin knuckle dislocation,26706,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,47657.93,
Treat knuckle dislocation,26715,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,47657.93,
Treat finger fracture each,26720,CPT,,,,,,,,both,,,33713.65,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16856.83,50,,16856.83,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23599.56,70,,23599.56,percent of total billed charges,,961.95,,,961.95,Fee Schedule,,816.2,,,816.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,23599.56,
Treat finger fracture each,26725,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,13157,
Treat finger fracture each,26727,CPT,,,,,,,,both,,,36735.79,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18367.9,50,,18367.9,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25715.05,70,,25715.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,25715.05,
Treat finger fracture each,26735,CPT,,,,,,,,both,,,53414.96,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,26707.48,50,,26707.48,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,37390.47,70,,37390.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,37390.47,
Treat finger fracture each,26740,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,13157,
Treat finger fracture each,26742,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,23663.84,
Treat finger fracture each,26746,CPT,,,,,,,,both,,,44085.92,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,22042.96,50,,22042.96,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,30860.14,70,,30860.14,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,30860.14,
Treat finger fracture each,26750,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,966.9,,,966.9,Fee Schedule,,820.4,,,820.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,9473,
Treat finger fracture each,26755,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,13157,
Pin finger fracture each,26756,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,47657.93,
Treat finger fracture each,26765,CPT,,,,,,,,both,,,42356.52,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,21178.26,50,,21178.26,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29649.56,70,,29649.56,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,29649.56,
Treat finger dislocation,26770,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,13157,
Treat finger dislocation,26775,CPT,,,,,,,,both,,,5648.78,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2824.39,50,,2824.39,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2193.58,,,2193.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3954.15,70,,3954.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,1651.08,,,1651.08,Other,140% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,3066.3,,,3066.3,Other,260% New York Medicaid APG,3821.08,,,3821.08,Other,324% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,1474.18,,,1474.18,Other,125% New York Medicaid APG,310.56,13157,
Pin finger dislocation,26776,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,47657.93,
Treat finger dislocation,26785,CPT,,,,,,,,both,,,37112.76,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18556.38,50,,18556.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25978.93,70,,25978.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,25978.93,
Thumb fusion with graft,26820,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,105333.66,
Fusion of thumb,26841,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,105333.66,
Thumb fusion with graft,26842,CPT,,,,,,,,both,,,81392.29,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,40696.15,50,,40696.15,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56974.6,70,,56974.6,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,56974.6,
Fusion of hand joint,26843,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,105333.66,
Fusion/graft of hand joint,26844,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,105333.66,
Fusion of knuckle,26850,CPT,,,,,,,,both,,,59284.06,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,29642.03,50,,29642.03,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41498.84,70,,41498.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,41498.84,
Fusion of knuckle with graft,26852,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,105333.66,
Fusion of finger joint,26860,CPT,,,,,,,,both,,,41021.1,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,20510.55,50,,20510.55,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28714.77,70,,28714.77,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,28714.77,
Fusion of finger jnt add-on,26861,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,0.01,36100.43,
Fusion/graft of finger joint,26862,CPT,,,,,,,,both,,,32178.46,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,16089.23,50,,16089.23,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22524.92,70,,22524.92,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,22524.92,
Fuse/graft added joint,26863,CPT,,,,,,,,both,,,64479.48,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32239.74,50,,32239.74,percent of total billed charges,,45135.64,70,,45135.64,percent of total billed charges,,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45135.64,70,,45135.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,0.01,45135.64,
Amputate metacarpal bone,26910,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,47657.93,
Amputation of finger/thumb,26951,CPT,,,,,,,,both,,,37728.36,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18864.18,50,,18864.18,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2917.58,,,2917.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26409.85,70,,26409.85,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1568.59,,,1568.59,Other,New York Medicaid APG methodology,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,1568.59,,,1568.59,Other,100% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,2196.03,,,2196.03,Other,140% New York Medicaid APG,3529.33,,,3529.33,Other,225% New York Medicaid APG,4078.34,,,4078.34,Other,260% New York Medicaid APG,5082.24,,,5082.24,Other,324% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,3372.47,,,3372.47,Other,215% New York Medicaid APG,1960.74,,,1960.74,Other,125% New York Medicaid APG,1568.59,26409.85,
Amputation of finger/thumb,26952,CPT,,,,,,,,both,,,34439.27,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17219.64,50,,17219.64,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4684.96,,,4684.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24107.49,70,,24107.49,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2518.8,,,2518.8,Other,New York Medicaid APG methodology,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,2518.8,,,2518.8,Other,100% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,3526.31,,,3526.31,Other,140% New York Medicaid APG,5667.29,,,5667.29,Other,225% New York Medicaid APG,6548.87,,,6548.87,Other,260% New York Medicaid APG,8160.9,,,8160.9,Other,324% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,5415.41,,,5415.41,Other,215% New York Medicaid APG,3148.49,,,3148.49,Other,125% New York Medicaid APG,2518.8,24107.49,
Drainage of pelvis lesion,26990,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,47657.93,
Drainage of pelvis bursa,26991,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,23663.84,
Incision of hip tendon,27000,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,1858.58,23663.84,
Incision of hip tendon,27001,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,47657.93,
Incision of hip tendon,27003,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,105333.66,
Incision of hip tendons,27006,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,47657.93,
Buttock fasciotomy,27027,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,105333.66,
Exploration of hip joint,27033,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,105333.66,
Denervation of hip joint,27035,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,47657.93,
Biopsy of soft tissues,27040,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,23871.23,
Biopsy of soft tissues,27041,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,23871.23,
Exc hip pelvis les sc 3 cm/>,27043,CPT,,,,,,,,both,,,37916.56,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18958.28,50,,18958.28,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26541.59,70,,26541.59,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,26541.59,
Exc hip/pelv tum deep 5 cm/>,27045,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,41837.04,
Exc hip/pelvis les sc < 3 cm,27047,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,41837.04,
Exc hip/pelv tum deep < 5 cm,27048,CPT,,,,,,,,both,,,72101.84,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36050.92,50,,36050.92,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50471.29,70,,50471.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,50471.29,
Resect hip/pelv tum < 5 cm,27049,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,41837.04,
Biopsy of sacroiliac joint,27050,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,1858.58,23663.84,
Biopsy of hip joint,27052,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,1858.58,23663.84,
Buttock fasciotomy w/dbrdmt,27057,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,1858.58,23663.84,
Resect hip/pelv tum 5 cm/>,27059,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,41837.04,
Removal of ischial bursa,27060,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,105333.66,
Remove femur lesion/bursa,27062,CPT,,,,,,,,both,,,51263.95,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,25631.98,50,,25631.98,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,35884.77,70,,35884.77,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,35884.77,
Remove hip bone les super,27065,CPT,,,,,,,,both,,,38551,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19275.5,50,,19275.5,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26985.7,70,,26985.7,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,26985.7,
Remove hip bone les deep,27066,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,47657.93,
Remove/graft hip bone lesion,27067,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,105333.66,
Removal of tail bone,27080,CPT,,,,,,,,both,,,53815.49,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,26907.75,50,,26907.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,37670.84,70,,37670.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,37670.84,
Remove hip foreign body,27086,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,41837.04,
Remove hip foreign body,27087,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,47657.93,
Injection for hip x-ray,27093,CPT,,,,,,,,both,,,13750.07,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6875.04,50,,6875.04,percent of total billed charges,,9625.05,70,,9625.05,percent of total billed charges,,6152,,,6152,Case Rate,,1205.26,,,1205.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9625.05,70,,9625.05,percent of total billed charges,,334.95,,,334.95,Fee Schedule,,284.2,,,284.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.99,,,647.99,Other,New York Medicaid APG methodology,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,907.18,,,907.18,Other,140% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1684.77,,,1684.77,Other,260% New York Medicaid APG,2099.48,,,2099.48,Other,324% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,809.98,,,809.98,Other,125% New York Medicaid APG,0.01,9625.05,
Injection for hip x-ray,27095,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1205.26,,,1205.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,400.95,,,400.95,Fee Schedule,,340.2,,,340.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.99,,,647.99,Other,New York Medicaid APG methodology,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,907.18,,,907.18,Other,140% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1684.77,,,1684.77,Other,260% New York Medicaid APG,2099.48,,,2099.48,Other,324% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,809.98,,,809.98,Other,125% New York Medicaid APG,0.01,22702.47,
Revision of hip tendon,27097,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,47657.93,
Transfer tendon to pelvis,27098,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,47657.93,
Transfer of abdominal muscle,27100,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,105333.66,
Transfer of spinal muscle,27105,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,47657.93,
Transfer of iliopsoas muscle,27110,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,105333.66,
Transfer of iliopsoas muscle,27111,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,47657.93,
Total hip arthroplasty,27130,CPT,,,,,,,,both,,,95245.67,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,47622.84,50,,47622.84,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7675.82,,,7675.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,66671.97,70,,66671.97,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,4126.79,,,4126.79,Other,New York Medicaid APG methodology,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,5777.5,,,5777.5,Other,140% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,10729.65,,,10729.65,Other,260% New York Medicaid APG,13370.79,,,13370.79,Other,324% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,5158.48,,,5158.48,Other,125% New York Medicaid APG,4126.79,66671.97,
Revise head/neck of femur,27179,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,105333.66,
Clsd tx pelvic ring fx,27197,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,663.3,,,663.3,Fee Schedule,,562.8,,,562.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,9473,
Clsd tx pelvic ring fx,27198,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treat tail bone fracture,27200,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,13157,
Treat tail bone fracture,27202,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,47657.93,
Treat hip socket fracture,27220,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,13157,
Treat thigh fracture,27230,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treat thigh fracture,27235,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Treat thigh fracture,27238,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,23663.84,
Treat thigh fracture,27246,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treat hip dislocation,27250,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treat hip dislocation,27252,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2193.58,,,2193.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,1651.08,,,1651.08,Other,140% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,3066.3,,,3066.3,Other,260% New York Medicaid APG,3821.08,,,3821.08,Other,324% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,1474.18,,,1474.18,Other,125% New York Medicaid APG,1179.35,23663.84,
Treat hip dislocation,27256,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,13157,
Treat hip dislocation,27257,CPT,,,,,,,,both,,,48847.39,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24423.7,50,,24423.7,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2193.58,,,2193.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34193.17,70,,34193.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,1651.08,,,1651.08,Other,140% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,3066.3,,,3066.3,Other,260% New York Medicaid APG,3821.08,,,3821.08,Other,324% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,1474.18,,,1474.18,Other,125% New York Medicaid APG,1179.35,34193.17,
Treat hip dislocation,27265,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treat hip dislocation,27266,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2193.58,,,2193.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,1651.08,,,1651.08,Other,140% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,3066.3,,,3066.3,Other,260% New York Medicaid APG,3821.08,,,3821.08,Other,324% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,1474.18,,,1474.18,Other,125% New York Medicaid APG,1179.35,23663.84,
Cltx thigh fx,27267,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,2207.7,,,2207.7,Fee Schedule,,1873.2,,,1873.2,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,47657.93,
Manipulation of hip joint,27275,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2193.58,,,2193.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,1651.08,,,1651.08,Other,140% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,3066.3,,,3066.3,Other,260% New York Medicaid APG,3821.08,,,3821.08,Other,324% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,1474.18,,,1474.18,Other,125% New York Medicaid APG,1179.35,23663.84,
Arthrodesis sacroiliac joint,27279,CPT,,,,,,,,both,,,117408.93,35439.21,,,35439.21,Other,150% of Medicare + 9.63% HCRA Surcharge,21550.8,,,21550.8,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,58704.47,50,,58704.47,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,82186.25,70,,82186.25,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,82186.25,
Drain thigh/knee lesion,27301,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,41837.04,
Incise thigh tendon & fascia,27305,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,47657.93,
Incision of thigh tendon,27306,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,47657.93,
Incision of thigh tendons,27307,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,47657.93,
Exploration of knee joint,27310,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,47657.93,
Biopsy thigh soft tissues,27323,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,23871.23,
Biopsy thigh soft tissues,27324,CPT,,,,,,,,both,,,71152.91,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,35576.46,50,,35576.46,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,49807.04,70,,49807.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,49807.04,
Neurectomy hamstring,27325,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2232.76,28428.05,
Neurectomy popliteal,27326,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,28428.05,
Exc thigh/knee les sc < 3 cm,27327,CPT,,,,,,,,both,,,35232.08,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17616.04,50,,17616.04,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24662.46,70,,24662.46,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,24662.46,
Exc thigh/knee tum deep <5cm,27328,CPT,,,,,,,,both,,,39215.98,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19607.99,50,,19607.99,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27451.19,70,,27451.19,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,27451.19,
Resect thigh/knee tum < 5 cm,27329,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,41837.04,
Biopsy knee joint lining,27330,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,47657.93,
Explore/treat knee joint,27331,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,47657.93,
Removal of knee cartilage,27332,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,47657.93,
Removal of knee cartilage,27333,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,47657.93,
Remove knee joint lining,27334,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,47657.93,
Remove knee joint lining,27335,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,105333.66,
Exc thigh/knee les sc 3 cm/>,27337,CPT,,,,,,,,both,,,35216.67,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17608.34,50,,17608.34,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24651.67,70,,24651.67,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,24651.67,
Exc thigh/knee tum dep 5cm/>,27339,CPT,,,,,,,,both,,,39221.15,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19610.58,50,,19610.58,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27454.81,70,,27454.81,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,27454.81,
Removal of kneecap bursa,27340,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,47657.93,
Removal of knee cyst,27345,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,47657.93,
Remove knee cyst,27347,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,47657.93,
Removal of kneecap,27350,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,105333.66,
Remove femur lesion,27355,CPT,,,,,,,,both,,,37524.27,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18762.14,50,,18762.14,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26266.99,70,,26266.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,26266.99,
Remove femur lesion/graft,27356,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,193779.51,
Remove femur lesion/graft,27357,CPT,,,,,,,,both,,,49274.1,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,24637.05,50,,24637.05,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34491.87,70,,34491.87,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,34491.87,
Remove femur lesion/fixation,27358,CPT,,,,,,,,both,,,86591.4,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,43295.7,50,,43295.7,percent of total billed charges,,60613.98,70,,60613.98,percent of total billed charges,,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,60613.98,70,,60613.98,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,0.01,60613.98,
Partial removal leg bone(s),27360,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,47657.93,
Resect thigh/knee tum 5 cm/>,27364,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,41837.04,
Njx cntrst kne arthg/ct/mri,27369,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1205.26,,,1205.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,198,,,198,Fee Schedule,,168,,,168,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.99,,,647.99,Other,New York Medicaid APG methodology,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,907.18,,,907.18,Other,140% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1684.77,,,1684.77,Other,260% New York Medicaid APG,2099.48,,,2099.48,Other,324% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,809.98,,,809.98,Other,125% New York Medicaid APG,0.01,22702.47,
Removal of foreign body,27372,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,41837.04,
Repair of kneecap tendon,27380,CPT,,,,,,,,both,,,38422.81,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,19211.41,50,,19211.41,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26895.97,70,,26895.97,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,26895.97,
Repair/graft kneecap tendon,27381,CPT,,,,,,,,both,,,93520.15,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,46760.08,50,,46760.08,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,65464.11,70,,65464.11,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,65464.11,
Repair of thigh muscle,27385,CPT,,,,,,,,both,,,44183.39,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,22091.7,50,,22091.7,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,30928.37,70,,30928.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,30928.37,
Repair/graft of thigh muscle,27386,CPT,,,,,,,,both,,,66941.66,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,33470.83,50,,33470.83,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46859.16,70,,46859.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,46859.16,
Incision of thigh tendon,27390,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,47657.93,
Incision of thigh tendons,27391,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,47657.93,
Incision of thigh tendons,27392,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,47657.93,
Lengthening of thigh tendon,27393,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,105333.66,
Lengthening of thigh tendons,27394,CPT,,,,,,,,both,,,51096.05,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,25548.03,50,,25548.03,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,35767.24,70,,35767.24,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,35767.24,
Lengthening of thigh tendons,27395,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,47657.93,
Transplant of thigh tendon,27396,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,105333.66,
Transplants of thigh tendons,27397,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,105333.66,
Revise thigh muscles/tendons,27400,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,105333.66,
Repair of knee cartilage,27403,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,105333.66,
Repair of knee ligament,27405,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,105333.66,
Repair of knee ligament,27407,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,105333.66,
Repair of knee ligaments,27409,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,105333.66,
Autochondrocyte implant knee,27412,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7615.4,,,7615.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4094.3,,,4094.3,Other,New York Medicaid APG methodology,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,5732.02,,,5732.02,Other,140% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,10645.19,,,10645.19,Other,260% New York Medicaid APG,13265.54,,,13265.54,Other,324% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,5117.88,,,5117.88,Other,125% New York Medicaid APG,4094.3,105333.66,
Osteochondral knee allograft,27415,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7615.4,,,7615.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4094.3,,,4094.3,Other,New York Medicaid APG methodology,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,5732.02,,,5732.02,Other,140% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,10645.19,,,10645.19,Other,260% New York Medicaid APG,13265.54,,,13265.54,Other,324% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,5117.88,,,5117.88,Other,125% New York Medicaid APG,4094.3,193779.51,
Osteochondral knee autograft,27416,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,4854.3,,,4854.3,Fee Schedule,,4118.8,,,4118.8,Fee Schedule,,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,105333.66,
Repair degenerated kneecap,27418,CPT,,,,,,,,both,,,68506.97,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,34253.49,50,,34253.49,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47954.88,70,,47954.88,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,47954.88,
Revision of unstable kneecap,27420,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,105333.66,
Revision of unstable kneecap,27422,CPT,,,,,,,,both,,,70807.26,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,35403.63,50,,35403.63,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,49565.08,70,,49565.08,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,49565.08,
Revision/removal of kneecap,27424,CPT,,,,,,,,both,,,50657.5,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,25328.75,50,,25328.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,35460.25,70,,35460.25,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,35460.25,
Lat retinacular release open,27425,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,47657.93,
Reconstruction knee,27427,CPT,,,,,,,,both,,,100972.69,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,50486.35,50,,50486.35,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,70680.88,70,,70680.88,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,70680.88,
Reconstruction knee,27428,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,193779.51,
Reconstruction knee,27429,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,193779.51,
Revision of thigh muscles,27430,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,105333.66,
Incision of knee joint,27435,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,47657.93,
Revise kneecap,27437,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6709.21,,,6709.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3607.1,,,3607.1,Other,New York Medicaid APG methodology,3607.1,,,3607.1,Other,100% New York Medicaid APG,3607.1,,,3607.1,Other,100% New York Medicaid APG,3607.1,,,3607.1,Other,100% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,5049.94,,,5049.94,Other,140% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,9378.47,,,9378.47,Other,260% New York Medicaid APG,11687.01,,,11687.01,Other,324% New York Medicaid APG,7755.27,,,7755.27,Other,215% New York Medicaid APG,7755.27,,,7755.27,Other,215% New York Medicaid APG,4508.88,,,4508.88,Other,125% New York Medicaid APG,3607.1,105333.66,
Revise kneecap with implant,27438,CPT,,,,,,,,both,,,46878.57,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,23439.29,50,,23439.29,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7675.82,,,7675.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,32815,70,,32815,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4126.79,,,4126.79,Other,New York Medicaid APG methodology,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,5777.5,,,5777.5,Other,140% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,10729.65,,,10729.65,Other,260% New York Medicaid APG,13370.79,,,13370.79,Other,324% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,5158.48,,,5158.48,Other,125% New York Medicaid APG,4126.79,32815,
Revision of knee joint,27440,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7675.82,,,7675.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4126.79,,,4126.79,Other,New York Medicaid APG methodology,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,5777.5,,,5777.5,Other,140% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,10729.65,,,10729.65,Other,260% New York Medicaid APG,13370.79,,,13370.79,Other,324% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,5158.48,,,5158.48,Other,125% New York Medicaid APG,4126.79,193779.51,
Revision of knee joint,27441,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7675.82,,,7675.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4126.79,,,4126.79,Other,New York Medicaid APG methodology,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,5777.5,,,5777.5,Other,140% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,10729.65,,,10729.65,Other,260% New York Medicaid APG,13370.79,,,13370.79,Other,324% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,5158.48,,,5158.48,Other,125% New York Medicaid APG,4126.79,193779.51,
Revision of knee joint,27442,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7675.82,,,7675.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4126.79,,,4126.79,Other,New York Medicaid APG methodology,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,5777.5,,,5777.5,Other,140% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,10729.65,,,10729.65,Other,260% New York Medicaid APG,13370.79,,,13370.79,Other,324% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,5158.48,,,5158.48,Other,125% New York Medicaid APG,4126.79,193779.51,
Revision of knee joint,27443,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7675.82,,,7675.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4126.79,,,4126.79,Other,New York Medicaid APG methodology,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,5777.5,,,5777.5,Other,140% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,10729.65,,,10729.65,Other,260% New York Medicaid APG,13370.79,,,13370.79,Other,324% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,5158.48,,,5158.48,Other,125% New York Medicaid APG,4126.79,193779.51,
Revision of knee joint,27446,CPT,,,,,,,,both,,,77786.36,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,38893.18,50,,38893.18,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7675.82,,,7675.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,54450.45,70,,54450.45,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,4126.79,,,4126.79,Other,New York Medicaid APG methodology,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,5777.5,,,5777.5,Other,140% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,10729.65,,,10729.65,Other,260% New York Medicaid APG,13370.79,,,13370.79,Other,324% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,5158.48,,,5158.48,Other,125% New York Medicaid APG,4126.79,54450.45,
Total knee arthroplasty,27447,CPT,,,,,,,,both,,,86226.6,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,43113.3,50,,43113.3,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7675.82,,,7675.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,60358.62,70,,60358.62,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,4126.79,,,4126.79,Other,New York Medicaid APG methodology,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,4126.79,,,4126.79,Other,100% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,5777.5,,,5777.5,Other,140% New York Medicaid APG,9285.27,,,9285.27,Other,225% New York Medicaid APG,10729.65,,,10729.65,Other,260% New York Medicaid APG,13370.79,,,13370.79,Other,324% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,8872.59,,,8872.59,Other,215% New York Medicaid APG,5158.48,,,5158.48,Other,125% New York Medicaid APG,4126.79,60358.62,
Surgery to stop leg growth,27475,CPT,,,,,,,,both,,,38859.59,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,19429.8,50,,19429.8,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27201.71,70,,27201.71,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,27201.71,
Surgery to stop leg growth,27477,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,105333.66,
Surgery to stop leg growth,27479,CPT,,,,,,,,both,,,39487.52,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,19743.76,50,,19743.76,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27641.26,70,,27641.26,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,27641.26,
Surgery to stop leg growth,27485,CPT,,,,,,,,both,,,63947.43,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,31973.72,50,,31973.72,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,44763.2,70,,44763.2,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,44763.2,
Decompression of thigh/knee,27496,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,47657.93,
Decompression of thigh/knee,27497,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,47657.93,
Decompression of thigh/knee,27498,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,1858.58,23663.84,
Decompression of thigh/knee,27499,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,105333.66,
Treatment of thigh fracture,27500,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treatment of thigh fracture,27501,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treatment of thigh fracture,27502,CPT,,,,,,,,both,,,35094.81,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17547.41,50,,17547.41,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24566.37,70,,24566.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,24566.37,
Treatment of thigh fracture,27503,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,23663.84,
Treatment of thigh fracture,27508,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treatment of thigh fracture,27509,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Treatment of thigh fracture,27510,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,23663.84,
Treat thigh fx growth plate,27516,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treat thigh fx growth plate,27517,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,23663.84,
Treat kneecap fracture,27520,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treat kneecap fracture,27524,CPT,,,,,,,,both,,,78201.22,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,39100.61,50,,39100.61,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,54740.85,70,,54740.85,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,54740.85,
Treat knee fracture,27530,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treat knee fracture,27532,CPT,,,,,,,,both,,,39345.83,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19672.92,50,,19672.92,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27542.08,70,,27542.08,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,27542.08,
Treat knee fracture(s),27538,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treat knee dislocation,27550,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treat knee dislocation,27552,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2193.58,,,2193.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,1651.08,,,1651.08,Other,140% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,3066.3,,,3066.3,Other,260% New York Medicaid APG,3821.08,,,3821.08,Other,324% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,1474.18,,,1474.18,Other,125% New York Medicaid APG,1179.35,23663.84,
Treat kneecap dislocation,27560,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treat kneecap dislocation,27562,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2193.58,,,2193.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,1651.08,,,1651.08,Other,140% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,3066.3,,,3066.3,Other,260% New York Medicaid APG,3821.08,,,3821.08,Other,324% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,1474.18,,,1474.18,Other,125% New York Medicaid APG,272.71,13157,
Treat kneecap dislocation,27566,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Fixation of knee joint,27570,CPT,,,,,,,,both,,,44434.54,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,22217.27,50,,22217.27,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2193.58,,,2193.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31104.18,70,,31104.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,1651.08,,,1651.08,Other,140% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,3066.3,,,3066.3,Other,260% New York Medicaid APG,3821.08,,,3821.08,Other,324% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,1474.18,,,1474.18,Other,125% New York Medicaid APG,1179.35,31104.18,
Amputation follow-up surgery,27594,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,47657.93,
Decompression of lower leg,27600,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,47657.93,
Decompression of lower leg,27601,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,47657.93,
Decompression of lower leg,27602,CPT,,,,,,,,both,,,38724.79,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19362.4,50,,19362.4,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27107.35,70,,27107.35,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,27107.35,
Drain lower leg lesion,27603,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,41837.04,
Drain lower leg bursa,27604,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,47657.93,
Incision of achilles tendon,27605,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1858.58,23663.84,
Incision of achilles tendon,27606,CPT,,,,,,,,both,,,33463.8,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,16731.9,50,,16731.9,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23424.66,70,,23424.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,23424.66,
Treat lower leg bone lesion,27607,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,47657.93,
Explore/treat ankle joint,27610,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,47657.93,
Exploration of ankle joint,27612,CPT,,,,,,,,both,,,69465.45,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34732.73,50,,34732.73,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,48625.82,70,,48625.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,48625.82,
Biopsy lower leg soft tissue,27613,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,23871.23,
Biopsy lower leg soft tissue,27614,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,41837.04,
Resect leg/ankle tum < 5 cm,27615,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,41837.04,
Resect leg/ankle tum 5 cm/>,27616,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,41837.04,
Exc leg/ankle tum < 3 cm,27618,CPT,,,,,,,,both,,,34747.3,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17373.65,50,,17373.65,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24323.11,70,,24323.11,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,24323.11,
Exc leg/ankle tum deep <5 cm,27619,CPT,,,,,,,,both,,,42722.51,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,21361.26,50,,21361.26,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29905.76,70,,29905.76,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,29905.76,
Explore/treat ankle joint,27620,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,47657.93,
Remove ankle joint lining,27625,CPT,,,,,,,,both,,,121665.15,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,60832.58,50,,60832.58,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,85165.61,70,,85165.61,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,85165.61,
Remove ankle joint lining,27626,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,47657.93,
Removal of tendon lesion,27630,CPT,,,,,,,,both,,,35493.32,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17746.66,50,,17746.66,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24845.32,70,,24845.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,24845.32,
Exc leg/ankle les sc 3 cm/>,27632,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,41837.04,
Exc leg/ankle tum dep 5 cm/>,27634,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,41837.04,
Remove lower leg bone lesion,27635,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,47657.93,
Remove/graft leg bone lesion,27637,CPT,,,,,,,,both,,,161949.55,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,80974.78,50,,80974.78,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,113364.69,70,,113364.69,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,113364.69,
Remove/graft leg bone lesion,27638,CPT,,,,,,,,both,,,39228.79,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,19614.4,50,,19614.4,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27460.15,70,,27460.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,27460.15,
Partial removal of tibia,27640,CPT,,,,,,,,both,,,43528.56,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,21764.28,50,,21764.28,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,30469.99,70,,30469.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,30469.99,
Partial removal of fibula,27641,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,47657.93,
Resect talus/calcaneus tum,27647,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,47657.93,
Injection for ankle x-ray,27648,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1205.26,,,1205.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,249.15,,,249.15,Fee Schedule,,211.4,,,211.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.99,,,647.99,Other,New York Medicaid APG methodology,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,907.18,,,907.18,Other,140% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1684.77,,,1684.77,Other,260% New York Medicaid APG,2099.48,,,2099.48,Other,324% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,809.98,,,809.98,Other,125% New York Medicaid APG,0.01,22702.47,
Repair achilles tendon,27650,CPT,,,,,,,,both,,,65373.37,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32686.69,50,,32686.69,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45761.36,70,,45761.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,45761.36,
Repair/graft achilles tendon,27652,CPT,,,,,,,,both,,,56945.95,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,28472.98,50,,28472.98,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,39862.17,70,,39862.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,39862.17,
Repair of achilles tendon,27654,CPT,,,,,,,,both,,,84319.85,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,42159.93,50,,42159.93,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,59023.9,70,,59023.9,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,59023.9,
Repair leg fascia defect,27656,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,47657.93,
Repair of leg tendon each,27658,CPT,,,,,,,,both,,,87326.11,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,43663.06,50,,43663.06,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,61128.28,70,,61128.28,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,61128.28,
Repair of leg tendon each,27659,CPT,,,,,,,,both,,,61576.68,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,30788.34,50,,30788.34,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,43103.68,70,,43103.68,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,43103.68,
Repair of leg tendon each,27664,CPT,,,,,,,,both,,,45470.79,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,22735.4,50,,22735.4,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31829.55,70,,31829.55,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,31829.55,
Repair of leg tendon each,27665,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,105333.66,
Repair lower leg tendons,27675,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,47657.93,
Repair lower leg tendons,27676,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,105333.66,
Release of lower leg tendon,27680,CPT,,,,,,,,both,,,59649.87,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29824.94,50,,29824.94,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41754.91,70,,41754.91,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,41754.91,
Release of lower leg tendons,27681,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,47657.93,
Revision of lower leg tendon,27685,CPT,,,,,,,,both,,,40974.55,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,20487.28,50,,20487.28,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28682.19,70,,28682.19,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,28682.19,
Revise lower leg tendons,27686,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,47657.93,
Revision of calf tendon,27687,CPT,,,,,,,,both,,,46751.12,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,23375.56,50,,23375.56,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,32725.78,70,,32725.78,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,32725.78,
Revise lower leg tendon,27690,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,105333.66,
Revise lower leg tendon,27691,CPT,,,,,,,,both,,,97738.58,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,48869.29,50,,48869.29,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,68417.01,70,,68417.01,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,68417.01,
Revise additional leg tendon,27692,CPT,,,,,,,,both,,,64479.48,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32239.74,50,,32239.74,percent of total billed charges,,45135.64,70,,45135.64,percent of total billed charges,,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45135.64,70,,45135.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,0.01,45135.64,
Repair of ankle ligament,27695,CPT,,,,,,,,both,,,100988.85,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,50494.43,50,,50494.43,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,70692.2,70,,70692.2,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,70692.2,
Repair of ankle ligaments,27696,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,105333.66,
Repair of ankle ligament,27698,CPT,,,,,,,,both,,,79440.32,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,39720.16,50,,39720.16,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,55608.22,70,,55608.22,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,55608.22,
Revision of ankle joint,27700,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6709.21,,,6709.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3607.1,,,3607.1,Other,New York Medicaid APG methodology,3607.1,,,3607.1,Other,100% New York Medicaid APG,3607.1,,,3607.1,Other,100% New York Medicaid APG,3607.1,,,3607.1,Other,100% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,5049.94,,,5049.94,Other,140% New York Medicaid APG,8115.98,,,8115.98,Other,225% New York Medicaid APG,9378.47,,,9378.47,Other,260% New York Medicaid APG,11687.01,,,11687.01,Other,324% New York Medicaid APG,7755.27,,,7755.27,Other,215% New York Medicaid APG,7755.27,,,7755.27,Other,215% New York Medicaid APG,4508.88,,,4508.88,Other,125% New York Medicaid APG,3607.1,105333.66,
Removal of ankle implant,27704,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,47657.93,
Incision of tibia,27705,CPT,,,,,,,,both,,,48338.46,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,24169.23,50,,24169.23,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,33836.92,70,,33836.92,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,33836.92,
Incision of fibula,27707,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,47657.93,
Incision of tibia & fibula,27709,CPT,,,,,,,,both,,,110739.67,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,55369.84,50,,55369.84,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,77517.77,70,,77517.77,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,77517.77,
Repair of tibia,27720,CPT,,,,,,,,both,,,75013.17,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,37506.59,50,,37506.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52509.22,70,,52509.22,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,52509.22,
Repair/graft of tibia,27722,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Repair fibula nonunion,27726,CPT,,,,,,,,both,,,102271.53,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,51135.77,50,,51135.77,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,71590.07,70,,71590.07,percent of total billed charges,,4738.8,,,4738.8,Fee Schedule,,4020.8,,,4020.8,Fee Schedule,,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,71590.07,
Repair of tibia epiphysis,27730,CPT,,,,,,,,both,,,34131.15,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17065.58,50,,17065.58,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23891.81,70,,23891.81,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,23891.81,
Repair of fibula epiphysis,27732,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,47657.93,
Repair lower leg epiphyses,27734,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,47657.93,
Repair of leg epiphyses,27740,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,47657.93,
Repair of leg epiphyses,27742,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,47657.93,
Reinforce tibia,27745,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,105333.66,
Treatment of tibia fracture,27750,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treatment of tibia fracture,27752,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,23663.84,
Treatment of tibia fracture,27756,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Treatment of tibia fracture,27758,CPT,,,,,,,,both,,,170284.2,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,85142.1,50,,85142.1,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,119198.94,70,,119198.94,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,119198.94,
Treatment of tibia fracture,27759,CPT,,,,,,,,both,,,80308.42,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,40154.21,50,,40154.21,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56215.89,70,,56215.89,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,56215.89,
Cltx medial ankle fx,27760,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Cltx med ankle fx w/mnpj,27762,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,23663.84,
Optx medial ankle fx,27766,CPT,,,,,,,,both,,,50346.88,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,25173.44,50,,25173.44,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,35242.82,70,,35242.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,35242.82,
Cltx post ankle fx,27767,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,1473.45,,,1473.45,Fee Schedule,,1250.2,,,1250.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,9473,
Cltx post ankle fx w/mnpj,27768,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,2253.9,,,2253.9,Fee Schedule,,1912.4,,,1912.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,23663.84,
Optx post ankle fx,27769,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,3610.2,,,3610.2,Fee Schedule,,3063.2,,,3063.2,Fee Schedule,,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3063.2,105333.66,
Treatment of fibula fracture,27780,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treatment of fibula fracture,27781,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,23663.84,
Treatment of fibula fracture,27784,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Treatment of ankle fracture,27786,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treatment of ankle fracture,27788,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treatment of ankle fracture,27792,CPT,,,,,,,,both,,,82253.84,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,41126.92,50,,41126.92,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,57577.69,70,,57577.69,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,57577.69,
Treatment of ankle fracture,27808,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treatment of ankle fracture,27810,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,23663.84,
Treatment of ankle fracture,27814,CPT,,,,,,,,both,,,101018.81,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,50509.41,50,,50509.41,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,70713.17,70,,70713.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,70713.17,
Treatment of ankle fracture,27816,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treatment of ankle fracture,27818,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,23663.84,
Treatment of ankle fracture,27822,CPT,,,,,,,,both,,,110876.23,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,55438.12,50,,55438.12,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,77613.36,70,,77613.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,77613.36,
Treatment of ankle fracture,27823,CPT,,,,,,,,both,,,118330,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,59165,50,,59165,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,82831,70,,82831,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,82831,
Treat lower leg fracture,27824,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treat lower leg fracture,27825,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,23663.84,
Treat lower leg fracture,27826,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Treat lower leg fracture,27827,CPT,,,,,,,,both,,,66604.04,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,33302.02,50,,33302.02,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46622.83,70,,46622.83,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,46622.83,
Treat lower leg fracture,27828,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,193779.51,
Treat lower leg joint,27829,CPT,,,,,,,,both,,,52382.9,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,26191.45,50,,26191.45,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36668.03,70,,36668.03,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,36668.03,
Treat lower leg dislocation,27830,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treat lower leg dislocation,27831,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,47657.93,
Treat lower leg dislocation,27832,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Treat ankle dislocation,27840,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treat ankle dislocation,27842,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2193.58,,,2193.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,1651.08,,,1651.08,Other,140% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,3066.3,,,3066.3,Other,260% New York Medicaid APG,3821.08,,,3821.08,Other,324% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,1474.18,,,1474.18,Other,125% New York Medicaid APG,1179.35,23663.84,
Treat ankle dislocation,27846,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Treat ankle dislocation,27848,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Fixation of ankle joint,27860,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2193.58,,,2193.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,1651.08,,,1651.08,Other,140% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,3066.3,,,3066.3,Other,260% New York Medicaid APG,3821.08,,,3821.08,Other,324% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,1474.18,,,1474.18,Other,125% New York Medicaid APG,1179.35,47657.93,
Fusion of ankle joint open,27870,CPT,,,,,,,,both,,,124203.23,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,62101.62,50,,62101.62,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86942.26,70,,86942.26,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,86942.26,
Fusion of tibiofibular joint,27871,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,193779.51,
Amputation follow-up surgery,27884,CPT,,,,,,,,both,,,38158.9,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19079.45,50,,19079.45,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26711.23,70,,26711.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,26711.23,
Amputation of foot at ankle,27889,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4487.07,,,4487.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2412.4,,,2412.4,Other,New York Medicaid APG methodology,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,2412.4,,,2412.4,Other,100% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,3377.36,,,3377.36,Other,140% New York Medicaid APG,5427.9,,,5427.9,Other,225% New York Medicaid APG,6272.24,,,6272.24,Other,260% New York Medicaid APG,7816.18,,,7816.18,Other,324% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,5186.66,,,5186.66,Other,215% New York Medicaid APG,3015.5,,,3015.5,Other,125% New York Medicaid APG,2412.4,105333.66,
Decompression of leg,27892,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,47657.93,
Decompression of leg,27893,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,105333.66,
Decompression of leg,27894,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4895.88,,,4895.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2632.2,,,2632.2,Other,New York Medicaid APG methodology,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,2632.2,,,2632.2,Other,100% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,3685.07,,,3685.07,Other,140% New York Medicaid APG,5922.44,,,5922.44,Other,225% New York Medicaid APG,6843.71,,,6843.71,Other,260% New York Medicaid APG,8528.31,,,8528.31,Other,324% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,5659.22,,,5659.22,Other,215% New York Medicaid APG,3290.24,,,3290.24,Other,125% New York Medicaid APG,2632.2,47657.93,
Drainage of bursa of foot,28001,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1874.86,23871.23,
Treatment of foot infection,28002,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1858.58,23663.84,
Treatment of foot infection,28003,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,47657.93,
Treat foot bone lesion,28005,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,47657.93,
Incision of foot fascia,28008,CPT,,,,,,,,both,,,39365.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19682.88,50,,19682.88,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27556.03,70,,27556.03,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,27556.03,
Incision of toe tendon,28010,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1858.58,23663.84,
Incision of toe tendons,28011,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1858.58,23663.84,
Exploration of foot joint,28020,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,47657.93,
Exploration of foot joint,28022,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,47657.93,
Exploration of toe joint,28024,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1858.58,23663.84,
Decompression of tibia nerve,28035,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3963.08,,,3963.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2130.69,,,2130.69,Other,New York Medicaid APG methodology,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,2130.69,,,2130.69,Other,100% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,2982.96,,,2982.96,Other,140% New York Medicaid APG,4794.05,,,4794.05,Other,225% New York Medicaid APG,5539.79,,,5539.79,Other,260% New York Medicaid APG,6903.43,,,6903.43,Other,324% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,4580.98,,,4580.98,Other,215% New York Medicaid APG,2663.36,,,2663.36,Other,125% New York Medicaid APG,2130.69,28428.05,
Exc foot/toe tum sc 1.5 cm/>,28039,CPT,,,,,,,,both,,,41783.13,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,20891.57,50,,20891.57,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29248.19,70,,29248.19,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,29248.19,
Exc foot/toe tum dep 1.5cm/>,28041,CPT,,,,,,,,both,,,58093.92,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29046.96,50,,29046.96,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,40665.74,70,,40665.74,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,40665.74,
Exc foot/toe tum sc < 1.5 cm,28043,CPT,,,,,,,,both,,,36382.58,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18191.29,50,,18191.29,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25467.81,70,,25467.81,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,25467.81,
Exc foot/toe tum deep <1.5cm,28045,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,41837.04,
Resect foot/toe tumor < 3 cm,28046,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,41837.04,
Resect foot/toe tumor 3 cm/>,28047,CPT,,,,,,,,both,,,35622.92,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17811.46,50,,17811.46,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24936.04,70,,24936.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,24936.04,
Biopsy of foot joint lining,28050,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,47657.93,
Biopsy of foot joint lining,28052,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,47657.93,
Biopsy of toe joint lining,28054,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,47657.93,
Neurectomy foot,28055,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2232.76,28428.05,
Partial removal foot fascia,28060,CPT,,,,,,,,both,,,35068.64,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17534.32,50,,17534.32,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24548.05,70,,24548.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,24548.05,
Removal of foot fascia,28062,CPT,,,,,,,,both,,,51449.55,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,25724.78,50,,25724.78,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36014.69,70,,36014.69,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,36014.69,
Removal of foot joint lining,28070,CPT,,,,,,,,both,,,37759.44,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18879.72,50,,18879.72,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26431.61,70,,26431.61,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,26431.61,
Removal of foot joint lining,28072,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,47657.93,
Removal of foot lesion,28080,CPT,,,,,,,,both,,,34738.77,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17369.39,50,,17369.39,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24317.14,70,,24317.14,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1858.58,24317.14,
Excise foot tendon sheath,28086,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,47657.93,
Excise foot tendon sheath,28088,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,47657.93,
Removal of foot lesion,28090,CPT,,,,,,,,both,,,33789.97,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16894.99,50,,16894.99,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23652.98,70,,23652.98,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1858.58,23652.98,
Removal of toe lesions,28092,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1858.58,23663.84,
Removal of ankle/heel lesion,28100,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,47657.93,
Remove/graft foot lesion,28102,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,105333.66,
Remove/graft foot lesion,28103,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,105333.66,
Removal of foot lesion,28104,CPT,,,,,,,,both,,,35913.38,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17956.69,50,,17956.69,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25139.37,70,,25139.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,25139.37,
Remove/graft foot lesion,28106,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,105333.66,
Remove/graft foot lesion,28107,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,105333.66,
Removal of toe lesions,28108,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1858.58,23663.84,
Part removal of metatarsal,28110,CPT,,,,,,,,both,,,44380.59,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,22190.3,50,,22190.3,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31066.41,70,,31066.41,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,31066.41,
Part removal of metatarsal,28111,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,47657.93,
Part removal of metatarsal,28112,CPT,,,,,,,,both,,,34923.41,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17461.71,50,,17461.71,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24446.39,70,,24446.39,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,24446.39,
Part removal of metatarsal,28113,CPT,,,,,,,,both,,,34840.86,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17420.43,50,,17420.43,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24388.6,70,,24388.6,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,24388.6,
Removal of metatarsal heads,28114,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,47657.93,
Revision of foot,28116,CPT,,,,,,,,both,,,67355.24,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33677.62,50,,33677.62,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47148.67,70,,47148.67,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,47148.67,
Removal of heel bone,28118,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,47657.93,
Removal of heel spur,28119,CPT,,,,,,,,both,,,42571.64,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,21285.82,50,,21285.82,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29800.15,70,,29800.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,29800.15,
Part removal of ankle/heel,28120,CPT,,,,,,,,both,,,36961.26,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18480.63,50,,18480.63,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25872.88,70,,25872.88,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,25872.88,
Partial removal of foot bone,28122,CPT,,,,,,,,both,,,39159.77,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19579.89,50,,19579.89,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27411.84,70,,27411.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,27411.84,
Partial removal of toe,28124,CPT,,,,,,,,both,,,33224.17,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,16612.09,50,,16612.09,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23256.92,70,,23256.92,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,23256.92,
Partial removal of toe,28126,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,47657.93,
Removal of ankle bone,28130,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,105333.66,
Removal of metatarsal,28140,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,47657.93,
Removal of toe,28150,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,47657.93,
Partial removal of toe,28153,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,47657.93,
Partial removal of toe,28160,CPT,,,,,,,,both,,,45697.03,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,22848.52,50,,22848.52,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31987.92,70,,31987.92,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,31987.92,
Resect tarsal tumor,28171,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,47657.93,
Resect metatarsal tumor,28173,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,47657.93,
Resect phalanx of toe tumor,28175,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1858.58,23663.84,
Removal of foot foreign body,28190,CPT,,,,,,,,both,,,34116.99,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17058.5,50,,17058.5,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23881.89,70,,23881.89,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,813.62,23881.89,
Removal of foot foreign body,28192,CPT,,,,,,,,both,,,35216.74,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17608.37,50,,17608.37,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2507.74,,,2507.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24651.72,70,,24651.72,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1348.25,,,1348.25,Other,New York Medicaid APG methodology,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,1348.25,,,1348.25,Other,100% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,1887.55,,,1887.55,Other,140% New York Medicaid APG,3033.56,,,3033.56,Other,225% New York Medicaid APG,3505.45,,,3505.45,Other,260% New York Medicaid APG,4368.33,,,4368.33,Other,324% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,2898.73,,,2898.73,Other,215% New York Medicaid APG,1685.31,,,1685.31,Other,125% New York Medicaid APG,1348.25,24651.72,
Removal of foot foreign body,28193,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1874.86,23871.23,
Repair of foot tendon,28200,CPT,,,,,,,,both,,,66385.42,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33192.71,50,,33192.71,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46469.79,70,,46469.79,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,46469.79,
Repair/graft of foot tendon,28202,CPT,,,,,,,,both,,,58632.75,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,29316.38,50,,29316.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41042.93,70,,41042.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,41042.93,
Repair of foot tendon,28208,CPT,,,,,,,,both,,,33901.61,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,16950.81,50,,16950.81,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23731.13,70,,23731.13,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,23731.13,
Repair/graft of foot tendon,28210,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,105333.66,
Release of foot tendon,28220,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1858.58,23663.84,
Release of foot tendons,28222,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,47657.93,
Release of foot tendon,28225,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,47657.93,
Release of foot tendons,28226,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,47657.93,
Incision of foot tendon(s),28230,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1858.58,23663.84,
Incision of toe tendon,28232,CPT,,,,,,,,both,,,36409.48,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18204.74,50,,18204.74,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25486.64,70,,25486.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1858.58,25486.64,
Incision of foot tendon,28234,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1858.58,23663.84,
Revision of foot tendon,28238,CPT,,,,,,,,both,,,74342.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,37171.33,50,,37171.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52039.86,70,,52039.86,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,52039.86,
Release of big toe,28240,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,47657.93,
Revision of foot fascia,28250,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,47657.93,
Release of midfoot joint,28260,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,47657.93,
Revision of foot tendon,28261,CPT,,,,,,,,both,,,57176.73,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,28588.37,50,,28588.37,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,40023.71,70,,40023.71,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,1858.58,40023.71,
Revision of foot and ankle,28262,CPT,,,,,,,,both,,,93565.48,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,46782.74,50,,46782.74,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,65495.84,70,,65495.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,65495.84,
Release of midfoot joint,28264,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,1858.58,23663.84,
Release of foot contracture,28270,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,47657.93,
Release of toe joint each,28272,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1858.58,23663.84,
Fusion of toes,28280,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,47657.93,
Repair of hammertoe,28285,CPT,,,,,,,,both,,,39003.16,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19501.58,50,,19501.58,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27302.21,70,,27302.21,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,27302.21,
Repair of hammertoe,28286,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,47657.93,
Partial removal of foot bone,28288,CPT,,,,,,,,both,,,34275.11,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17137.56,50,,17137.56,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23992.58,70,,23992.58,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,23992.58,
Corrj halux rigdus w/o implt,28289,CPT,,,,,,,,both,,,34937.05,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17468.53,50,,17468.53,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24455.94,70,,24455.94,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,24455.94,
Corrj halux rigdus w/implt,28291,CPT,,,,,,,,both,,,74358.15,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,37179.08,50,,37179.08,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52050.71,70,,52050.71,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,52050.71,
Correction hallux valgus,28292,CPT,,,,,,,,both,,,40898.42,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,20449.21,50,,20449.21,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28628.89,70,,28628.89,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,28628.89,
Correction hallux valgus,28295,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,47657.93,
Correction hallux valgus,28296,CPT,,,,,,,,both,,,37862.65,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18931.33,50,,18931.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26503.86,70,,26503.86,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,26503.86,
Correction hallux valgus,28297,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,105333.66,
Correction hallux valgus,28298,CPT,,,,,,,,both,,,38569.2,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,19284.6,50,,19284.6,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26998.44,70,,26998.44,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,26998.44,
Correction hallux valgus,28299,CPT,,,,,,,,both,,,53511.09,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,26755.55,50,,26755.55,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,37457.76,70,,37457.76,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,37457.76,
Incision of heel bone,28300,CPT,,,,,,,,both,,,116501.74,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,58250.87,50,,58250.87,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,81551.22,70,,81551.22,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,81551.22,
Incision of ankle bone,28302,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,105333.66,
Incision of midfoot bones,28304,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,105333.66,
Incise/graft midfoot bones,28305,CPT,,,,,,,,both,,,99047.96,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,49523.98,50,,49523.98,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,69333.57,70,,69333.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,69333.57,
Incision of metatarsal,28306,CPT,,,,,,,,both,,,33438.04,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,16719.02,50,,16719.02,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23406.63,70,,23406.63,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,23406.63,
Incision of metatarsal,28307,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,105333.66,
Incision of metatarsal,28308,CPT,,,,,,,,both,,,50631.12,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,25315.56,50,,25315.56,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,35441.78,70,,35441.78,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,35441.78,
Incision of metatarsals,28309,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,105333.66,
Revision of big toe,28310,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,105333.66,
Revision of toe,28312,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,47657.93,
Repair deformity of toe,28313,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,47657.93,
Removal of sesamoid bone,28315,CPT,,,,,,,,both,,,33217,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,16608.5,50,,16608.5,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23251.9,70,,23251.9,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,23251.9,
Repair of foot bones,28320,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,193779.51,
Repair of metatarsals,28322,CPT,,,,,,,,both,,,78188.55,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,39094.28,50,,39094.28,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,54731.99,70,,54731.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,54731.99,
Resect enlarged toe tissue,28340,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,47657.93,
Resect enlarged toe,28341,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,47657.93,
Repair extra toe(s),28344,CPT,,,,,,,,both,,,38069.18,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19034.59,50,,19034.59,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26648.43,70,,26648.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,26648.43,
Repair webbed toe(s),28345,CPT,,,,,,,,both,,,51736.25,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25868.13,50,,25868.13,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36215.38,70,,36215.38,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1858.58,36215.38,
Reconstruct cleft foot,28360,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,105333.66,
Treatment of heel fracture,28400,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treatment of heel fracture,28405,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,13157,
Treatment of heel fracture,28406,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Treat heel fracture,28415,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Treat/graft heel fracture,28420,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,193779.51,
Treatment of ankle fracture,28430,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,13157,
Treatment of ankle fracture,28435,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,692.88,23663.84,
Treatment of ankle fracture,28436,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Treat ankle fracture,28445,CPT,,,,,,,,both,,,137108.27,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,68554.14,50,,68554.14,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,95975.79,70,,95975.79,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,95975.79,
Osteochondral talus autogrft,28446,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,6055.5,,,6055.5,Fee Schedule,,5138,,,5138,Fee Schedule,,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,105333.66,
Treat midfoot fracture each,28450,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,13157,
Treat midfoot fracture each,28455,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,23663.84,
Treat midfoot fracture,28456,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Treat midfoot fracture each,28465,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Treat metatarsal fracture,28470,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,13157,
Treat metatarsal fracture,28475,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,13157,
Treat metatarsal fracture,28476,CPT,,,,,,,,both,,,36963.26,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18481.63,50,,18481.63,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25874.28,70,,25874.28,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,25874.28,
Treat metatarsal fracture,28485,CPT,,,,,,,,both,,,77830.44,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,38915.22,50,,38915.22,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,54481.31,70,,54481.31,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,54481.31,
Treat big toe fracture,28490,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,627,,,627,Fee Schedule,,532,,,532,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,9473,
Treat big toe fracture,28495,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,742.5,,,742.5,Fee Schedule,,630,,,630,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,9473,
Treat big toe fracture,28496,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,47657.93,
Treat big toe fracture,28505,CPT,,,,,,,,both,,,64933,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32466.5,50,,32466.5,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45453.1,70,,45453.1,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,45453.1,
Treatment of toe fracture,28510,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,602.25,,,602.25,Fee Schedule,,511,,,511,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,9473,
Treatment of toe fracture,28515,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,716.1,,,716.1,Fee Schedule,,607.6,,,607.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,9473,
Treat toe fracture,28525,CPT,,,,,,,,both,,,52709.62,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,26354.81,50,,26354.81,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36896.73,70,,36896.73,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,36896.73,
Treat sesamoid bone fracture,28530,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,501.6,,,501.6,Fee Schedule,,425.6,,,425.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,9473,
Treat sesamoid bone fracture,28531,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Treat foot dislocation,28540,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,13157,
Treat foot dislocation,28545,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2193.58,,,2193.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,1651.08,,,1651.08,Other,140% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,3066.3,,,3066.3,Other,260% New York Medicaid APG,3821.08,,,3821.08,Other,324% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,1474.18,,,1474.18,Other,125% New York Medicaid APG,1179.35,47657.93,
Treat foot dislocation,28546,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,1858.58,23663.84,
Repair foot dislocation,28555,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Treat foot dislocation,28570,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,993.3,,,993.3,Fee Schedule,,842.8,,,842.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,9473,
Treat foot dislocation,28575,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2193.58,,,2193.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,1651.08,,,1651.08,Other,140% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,3066.3,,,3066.3,Other,260% New York Medicaid APG,3821.08,,,3821.08,Other,324% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,1474.18,,,1474.18,Other,125% New York Medicaid APG,1179.35,47657.93,
Treat foot dislocation,28576,CPT,,,,,,,,both,,,36779.05,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18389.53,50,,18389.53,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25745.34,70,,25745.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,25745.34,
Repair foot dislocation,28585,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Treat foot dislocation,28600,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,13157,
Treat foot dislocation,28605,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2193.58,,,2193.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,1651.08,,,1651.08,Other,140% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,3066.3,,,3066.3,Other,260% New York Medicaid APG,3821.08,,,3821.08,Other,324% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,1474.18,,,1474.18,Other,125% New York Medicaid APG,272.71,13157,
Treat foot dislocation,28606,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,47657.93,
Repair foot dislocation,28615,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,105333.66,
Treat toe dislocation,28630,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,547.8,,,547.8,Fee Schedule,,464.8,,,464.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,9473,
Treat toe dislocation,28635,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2193.58,,,2193.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,1651.08,,,1651.08,Other,140% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,3066.3,,,3066.3,Other,260% New York Medicaid APG,3821.08,,,3821.08,Other,324% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,1474.18,,,1474.18,Other,125% New York Medicaid APG,1179.35,23663.84,
Treat toe dislocation,28636,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,47657.93,
Repair toe dislocation,28645,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,47657.93,
Treat toe dislocation,28660,CPT,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,462,,,462,Fee Schedule,,392,,,392,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,0.01,9473,
Treat toe dislocation,28665,CPT,,,,,,,,both,,,5648.78,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2824.39,50,,2824.39,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2193.58,,,2193.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3954.15,70,,3954.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1179.35,,,1179.35,Other,New York Medicaid APG methodology,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,1179.35,,,1179.35,Other,100% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,1651.08,,,1651.08,Other,140% New York Medicaid APG,2653.53,,,2653.53,Other,225% New York Medicaid APG,3066.3,,,3066.3,Other,260% New York Medicaid APG,3821.08,,,3821.08,Other,324% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,2535.59,,,2535.59,Other,215% New York Medicaid APG,1474.18,,,1474.18,Other,125% New York Medicaid APG,310.56,13157,
Treat toe dislocation,28666,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,47657.93,
Repair of toe dislocation,28675,CPT,,,,,,,,both,,,41462.4,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,20731.2,50,,20731.2,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6546.01,,,6546.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29023.68,70,,29023.68,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3519.36,,,3519.36,Other,New York Medicaid APG methodology,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,3519.36,,,3519.36,Other,100% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,4927.1,,,4927.1,Other,140% New York Medicaid APG,7918.56,,,7918.56,Other,225% New York Medicaid APG,9150.34,,,9150.34,Other,260% New York Medicaid APG,11402.73,,,11402.73,Other,324% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,7566.62,,,7566.62,Other,215% New York Medicaid APG,4399.2,,,4399.2,Other,125% New York Medicaid APG,3519.36,29023.68,
Fusion of foot bones,28705,CPT,,,,,,,,both,,,391985.94,35439.21,,,35439.21,Other,150% of Medicare + 9.63% HCRA Surcharge,21550.8,,,21550.8,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,195992.97,50,,195992.97,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,274390.16,70,,274390.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,274390.16,
Fusion of foot bones,28715,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,193779.51,
Fusion of foot bones,28725,CPT,,,,,,,,both,,,111393.97,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,55696.99,50,,55696.99,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,77975.78,70,,77975.78,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,77975.78,
Fusion of foot bones,28730,CPT,,,,,,,,both,,,121482.05,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,60741.03,50,,60741.03,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,85037.44,70,,85037.44,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,85037.44,
Fusion of foot bones,28735,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,193779.51,
Revision of foot bones,28737,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,193779.51,
Fusion of foot bones,28740,CPT,,,,,,,,both,,,128635.84,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,64317.92,50,,64317.92,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,90045.09,70,,90045.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,90045.09,
Fusion of big toe joint,28750,CPT,,,,,,,,both,,,83667.26,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,41833.63,50,,41833.63,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,58567.08,70,,58567.08,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,58567.08,
Fusion of big toe joint,28755,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,105333.66,
Fusion of big toe joint,28760,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,105333.66,
Amputation thru metatarsal,28805,CPT,,,,,,,,both,,,38333.33,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19166.67,50,,19166.67,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26833.33,70,,26833.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,26833.33,
Amputation toe & metatarsal,28810,CPT,,,,,,,,both,,,48080.72,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,24040.36,50,,24040.36,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,33656.5,70,,33656.5,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,33656.5,
Amputation of toe,28820,CPT,,,,,,,,both,,,35523.77,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17761.89,50,,17761.89,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24866.64,70,,24866.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,24866.64,
Partial amputation of toe,28825,CPT,,,,,,,,both,,,36834.32,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18417.16,50,,18417.16,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25784.02,70,,25784.02,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,25784.02,
Hi enrgy eswt plantar fascia,28890,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1858.58,23663.84,
Application of body cast,29000,CPT,,,,,,,,both,,,5648.78,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2824.39,50,,2824.39,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3954.15,70,,3954.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,310.56,13157,
Application of body cast,29010,CPT,,,,,,,,both,,,5648.78,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2824.39,50,,2824.39,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3954.15,70,,3954.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,13157,
Application of body cast,29015,CPT,,,,,,,,both,,,5648.78,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2824.39,50,,2824.39,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3954.15,70,,3954.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,13157,
Application of body cast,29035,CPT,,,,,,,,both,,,5648.78,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2824.39,50,,2824.39,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3954.15,70,,3954.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,13157,
Application of body cast,29040,CPT,,,,,,,,both,,,5648.78,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2824.39,50,,2824.39,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3954.15,70,,3954.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,13157,
Application of body cast,29044,CPT,,,,,,,,both,,,3314.26,299.64,,,299.64,Other,150% of Medicare + 9.63% HCRA Surcharge,182.21,,,182.21,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1657.13,50,,1657.13,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2319.98,70,,2319.98,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,13157,
Application of body cast,29046,CPT,,,,,,,,both,,,5648.78,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2824.39,50,,2824.39,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3954.15,70,,3954.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,13157,
Application of figure eight,29049,CPT,,,,,,,,both,,,5648.78,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2824.39,50,,2824.39,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3954.15,70,,3954.15,percent of total billed charges,,341.55,,,341.55,Fee Schedule,,289.8,,,289.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,9473,
Application of shoulder cast,29055,CPT,,,,,,,,both,,,5648.78,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2824.39,50,,2824.39,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3954.15,70,,3954.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,13157,
Application of shoulder cast,29058,CPT,,,,,,,,both,,,5648.78,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2824.39,50,,2824.39,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3954.15,70,,3954.15,percent of total billed charges,,460.35,,,460.35,Fee Schedule,,390.6,,,390.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,9473,
Application of long arm cast,29065,CPT,,,,,,,,both,,,5648.78,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2824.39,50,,2824.39,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3954.15,70,,3954.15,percent of total billed charges,,336.6,,,336.6,Fee Schedule,,285.6,,,285.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,9473,
Application of forearm cast,29075,CPT,,,,,,,,both,,,5648.78,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2824.39,50,,2824.39,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3954.15,70,,3954.15,percent of total billed charges,,310.2,,,310.2,Fee Schedule,,263.2,,,263.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,9473,
Apply hand/wrist cast,29085,CPT,,,,,,,,both,,,3314.26,299.64,,,299.64,Other,150% of Medicare + 9.63% HCRA Surcharge,182.21,,,182.21,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1657.13,50,,1657.13,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2319.98,70,,2319.98,percent of total billed charges,,331.65,,,331.65,Fee Schedule,,281.4,,,281.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,9473,
Apply finger cast,29086,CPT,,,,,,,,both,,,3314.26,299.64,,,299.64,Other,150% of Medicare + 9.63% HCRA Surcharge,182.21,,,182.21,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1657.13,50,,1657.13,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2319.98,70,,2319.98,percent of total billed charges,,242.55,,,242.55,Fee Schedule,,205.8,,,205.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,9473,
Apply long arm splint,29105,CPT,,,,,,,,both,,,3314.26,299.64,,,299.64,Other,150% of Medicare + 9.63% HCRA Surcharge,182.21,,,182.21,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1657.13,50,,1657.13,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,668.03,,,668.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2319.98,70,,2319.98,percent of total billed charges,,207.9,,,207.9,Fee Schedule,,176.4,,,176.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,359.16,,,359.16,Other,New York Medicaid APG methodology,359.16,,,359.16,Other,100% New York Medicaid APG,359.16,,,359.16,Other,100% New York Medicaid APG,359.16,,,359.16,Other,100% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,502.82,,,502.82,Other,140% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,933.81,,,933.81,Other,260% New York Medicaid APG,1163.67,,,1163.67,Other,324% New York Medicaid APG,772.19,,,772.19,Other,215% New York Medicaid APG,772.19,,,772.19,Other,215% New York Medicaid APG,448.95,,,448.95,Other,125% New York Medicaid APG,0.01,9473,
Apply forearm splint,29125,CPT,,,,,,,,both,,,2686.86,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1343.43,50,,1343.43,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,668.03,,,668.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,1880.8,70,,1880.8,percent of total billed charges,,199.65,,,199.65,Fee Schedule,,169.4,,,169.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,359.16,,,359.16,Other,New York Medicaid APG methodology,359.16,,,359.16,Other,100% New York Medicaid APG,359.16,,,359.16,Other,100% New York Medicaid APG,359.16,,,359.16,Other,100% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,502.82,,,502.82,Other,140% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,933.81,,,933.81,Other,260% New York Medicaid APG,1163.67,,,1163.67,Other,324% New York Medicaid APG,772.19,,,772.19,Other,215% New York Medicaid APG,772.19,,,772.19,Other,215% New York Medicaid APG,448.95,,,448.95,Other,125% New York Medicaid APG,0.01,9473,
Apply forearm splint,29126,CPT,,,,,,,,both,,,2686.86,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1343.43,50,,1343.43,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,668.03,,,668.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,1880.8,70,,1880.8,percent of total billed charges,,242.55,,,242.55,Fee Schedule,,205.8,,,205.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,359.16,,,359.16,Other,New York Medicaid APG methodology,359.16,,,359.16,Other,100% New York Medicaid APG,359.16,,,359.16,Other,100% New York Medicaid APG,359.16,,,359.16,Other,100% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,502.82,,,502.82,Other,140% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,933.81,,,933.81,Other,260% New York Medicaid APG,1163.67,,,1163.67,Other,324% New York Medicaid APG,772.19,,,772.19,Other,215% New York Medicaid APG,772.19,,,772.19,Other,215% New York Medicaid APG,448.95,,,448.95,Other,125% New York Medicaid APG,0.01,9473,
Application of finger splint,29130,CPT,,,,,,,,both,,,2686.86,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1343.43,50,,1343.43,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,668.03,,,668.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,1880.8,70,,1880.8,percent of total billed charges,,145.2,,,145.2,Fee Schedule,,123.2,,,123.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,359.16,,,359.16,Other,New York Medicaid APG methodology,359.16,,,359.16,Other,100% New York Medicaid APG,359.16,,,359.16,Other,100% New York Medicaid APG,359.16,,,359.16,Other,100% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,502.82,,,502.82,Other,140% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,933.81,,,933.81,Other,260% New York Medicaid APG,1163.67,,,1163.67,Other,324% New York Medicaid APG,772.19,,,772.19,Other,215% New York Medicaid APG,772.19,,,772.19,Other,215% New York Medicaid APG,448.95,,,448.95,Other,125% New York Medicaid APG,0.01,9473,
Application of finger splint,29131,CPT,,,,,,,,both,,,1286.58,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,643.29,50,,643.29,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,668.03,,,668.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,900.61,70,,900.61,percent of total billed charges,,171.6,,,171.6,Fee Schedule,,145.6,,,145.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,359.16,,,359.16,Other,New York Medicaid APG methodology,359.16,,,359.16,Other,100% New York Medicaid APG,359.16,,,359.16,Other,100% New York Medicaid APG,359.16,,,359.16,Other,100% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,502.82,,,502.82,Other,140% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,933.81,,,933.81,Other,260% New York Medicaid APG,1163.67,,,1163.67,Other,324% New York Medicaid APG,772.19,,,772.19,Other,215% New York Medicaid APG,772.19,,,772.19,Other,215% New York Medicaid APG,448.95,,,448.95,Other,125% New York Medicaid APG,0.01,9473,
Strapping of chest,29200,CPT,,,,,,,,both,,,3314.26,299.64,,,299.64,Other,150% of Medicare + 9.63% HCRA Surcharge,182.21,,,182.21,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1657.13,50,,1657.13,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,668.03,,,668.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2319.98,70,,2319.98,percent of total billed charges,,90.75,,,90.75,Fee Schedule,,77,,,77,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,359.16,,,359.16,Other,New York Medicaid APG methodology,359.16,,,359.16,Other,100% New York Medicaid APG,359.16,,,359.16,Other,100% New York Medicaid APG,359.16,,,359.16,Other,100% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,502.82,,,502.82,Other,140% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,933.81,,,933.81,Other,260% New York Medicaid APG,1163.67,,,1163.67,Other,324% New York Medicaid APG,772.19,,,772.19,Other,215% New York Medicaid APG,772.19,,,772.19,Other,215% New York Medicaid APG,448.95,,,448.95,Other,125% New York Medicaid APG,0.01,9473,
Strapping of shoulder,29240,CPT,,,,,,,,both,,,2686.86,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1343.43,50,,1343.43,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,668.03,,,668.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,1880.8,70,,1880.8,percent of total billed charges,,89.1,,,89.1,Fee Schedule,,75.6,,,75.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,359.16,,,359.16,Other,New York Medicaid APG methodology,359.16,,,359.16,Other,100% New York Medicaid APG,359.16,,,359.16,Other,100% New York Medicaid APG,359.16,,,359.16,Other,100% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,502.82,,,502.82,Other,140% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,933.81,,,933.81,Other,260% New York Medicaid APG,1163.67,,,1163.67,Other,324% New York Medicaid APG,772.19,,,772.19,Other,215% New York Medicaid APG,772.19,,,772.19,Other,215% New York Medicaid APG,448.95,,,448.95,Other,125% New York Medicaid APG,0.01,9473,
Strapping of elbow or wrist,29260,CPT,,,,,,,,both,,,1286.58,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,643.29,50,,643.29,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,668.03,,,668.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,900.61,70,,900.61,percent of total billed charges,,94.05,,,94.05,Fee Schedule,,79.8,,,79.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,359.16,,,359.16,Other,New York Medicaid APG methodology,359.16,,,359.16,Other,100% New York Medicaid APG,359.16,,,359.16,Other,100% New York Medicaid APG,359.16,,,359.16,Other,100% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,502.82,,,502.82,Other,140% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,933.81,,,933.81,Other,260% New York Medicaid APG,1163.67,,,1163.67,Other,324% New York Medicaid APG,772.19,,,772.19,Other,215% New York Medicaid APG,772.19,,,772.19,Other,215% New York Medicaid APG,448.95,,,448.95,Other,125% New York Medicaid APG,0.01,9473,
Strapping of hand or finger,29280,CPT,,,,,,,,both,,,1286.58,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,643.29,50,,643.29,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,668.03,,,668.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,900.61,70,,900.61,percent of total billed charges,,97.35,,,97.35,Fee Schedule,,82.6,,,82.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,359.16,,,359.16,Other,New York Medicaid APG methodology,359.16,,,359.16,Other,100% New York Medicaid APG,359.16,,,359.16,Other,100% New York Medicaid APG,359.16,,,359.16,Other,100% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,502.82,,,502.82,Other,140% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,933.81,,,933.81,Other,260% New York Medicaid APG,1163.67,,,1163.67,Other,324% New York Medicaid APG,772.19,,,772.19,Other,215% New York Medicaid APG,772.19,,,772.19,Other,215% New York Medicaid APG,448.95,,,448.95,Other,125% New York Medicaid APG,0.01,9473,
Application of hip cast,29305,CPT,,,,,,,,both,,,5648.78,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2824.39,50,,2824.39,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3954.15,70,,3954.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,13157,
Application of hip casts,29325,CPT,,,,,,,,both,,,50856.25,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,25428.13,50,,25428.13,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,35599.38,70,,35599.38,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,35599.38,
Application of long leg cast,29345,CPT,,,,,,,,both,,,5648.78,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2824.39,50,,2824.39,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3954.15,70,,3954.15,percent of total billed charges,,490.05,,,490.05,Fee Schedule,,415.8,,,415.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,9473,
Application of long leg cast,29355,CPT,,,,,,,,both,,,5648.78,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2824.39,50,,2824.39,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3954.15,70,,3954.15,percent of total billed charges,,523.05,,,523.05,Fee Schedule,,443.8,,,443.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,9473,
Apply long leg cast brace,29358,CPT,,,,,,,,both,,,5648.78,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2824.39,50,,2824.39,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3954.15,70,,3954.15,percent of total billed charges,,506.55,,,506.55,Fee Schedule,,429.8,,,429.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,9473,
Application of long leg cast,29365,CPT,,,,,,,,both,,,5648.78,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2824.39,50,,2824.39,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3954.15,70,,3954.15,percent of total billed charges,,429,,,429,Fee Schedule,,364,,,364,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,9473,
Apply short leg cast,29405,CPT,,,,,,,,both,,,5648.78,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2824.39,50,,2824.39,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3954.15,70,,3954.15,percent of total billed charges,,287.1,,,287.1,Fee Schedule,,243.6,,,243.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,9473,
Apply short leg cast,29425,CPT,,,,,,,,both,,,5648.78,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2824.39,50,,2824.39,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3954.15,70,,3954.15,percent of total billed charges,,265.65,,,265.65,Fee Schedule,,225.4,,,225.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,9473,
Apply short leg cast,29435,CPT,,,,,,,,both,,,5648.78,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2824.39,50,,2824.39,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3954.15,70,,3954.15,percent of total billed charges,,397.65,,,397.65,Fee Schedule,,337.4,,,337.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,9473,
Addition of walker to cast,29440,CPT,,,,,,,,both,,,3314.26,299.64,,,299.64,Other,150% of Medicare + 9.63% HCRA Surcharge,182.21,,,182.21,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1657.13,50,,1657.13,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2319.98,70,,2319.98,percent of total billed charges,,135.3,,,135.3,Fee Schedule,,114.8,,,114.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,9473,
Apply rigid leg cast,29445,CPT,,,,,,,,both,,,5648.78,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2824.39,50,,2824.39,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3954.15,70,,3954.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,13157,
Application of leg cast,29450,CPT,,,,,,,,both,,,3314.26,299.64,,,299.64,Other,150% of Medicare + 9.63% HCRA Surcharge,182.21,,,182.21,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1657.13,50,,1657.13,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2319.98,70,,2319.98,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,13157,
Application long leg splint,29505,CPT,,,,,,,,both,,,3314.26,299.64,,,299.64,Other,150% of Medicare + 9.63% HCRA Surcharge,182.21,,,182.21,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1657.13,50,,1657.13,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,668.03,,,668.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2319.98,70,,2319.98,percent of total billed charges,,255.75,,,255.75,Fee Schedule,,217,,,217,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,359.16,,,359.16,Other,New York Medicaid APG methodology,359.16,,,359.16,Other,100% New York Medicaid APG,359.16,,,359.16,Other,100% New York Medicaid APG,359.16,,,359.16,Other,100% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,502.82,,,502.82,Other,140% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,933.81,,,933.81,Other,260% New York Medicaid APG,1163.67,,,1163.67,Other,324% New York Medicaid APG,772.19,,,772.19,Other,215% New York Medicaid APG,772.19,,,772.19,Other,215% New York Medicaid APG,448.95,,,448.95,Other,125% New York Medicaid APG,0.01,9473,
Application lower leg splint,29515,CPT,,,,,,,,both,,,3314.26,299.64,,,299.64,Other,150% of Medicare + 9.63% HCRA Surcharge,182.21,,,182.21,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1657.13,50,,1657.13,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,668.03,,,668.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2319.98,70,,2319.98,percent of total billed charges,,242.55,,,242.55,Fee Schedule,,205.8,,,205.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,359.16,,,359.16,Other,New York Medicaid APG methodology,359.16,,,359.16,Other,100% New York Medicaid APG,359.16,,,359.16,Other,100% New York Medicaid APG,359.16,,,359.16,Other,100% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,502.82,,,502.82,Other,140% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,933.81,,,933.81,Other,260% New York Medicaid APG,1163.67,,,1163.67,Other,324% New York Medicaid APG,772.19,,,772.19,Other,215% New York Medicaid APG,772.19,,,772.19,Other,215% New York Medicaid APG,448.95,,,448.95,Other,125% New York Medicaid APG,0.01,9473,
Strapping of hip,29520,CPT,,,,,,,,both,,,2686.86,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1343.43,50,,1343.43,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,668.03,,,668.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,1880.8,70,,1880.8,percent of total billed charges,,89.1,,,89.1,Fee Schedule,,75.6,,,75.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,359.16,,,359.16,Other,New York Medicaid APG methodology,359.16,,,359.16,Other,100% New York Medicaid APG,359.16,,,359.16,Other,100% New York Medicaid APG,359.16,,,359.16,Other,100% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,502.82,,,502.82,Other,140% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,933.81,,,933.81,Other,260% New York Medicaid APG,1163.67,,,1163.67,Other,324% New York Medicaid APG,772.19,,,772.19,Other,215% New York Medicaid APG,772.19,,,772.19,Other,215% New York Medicaid APG,448.95,,,448.95,Other,125% New York Medicaid APG,0.01,9473,
Strapping of knee,29530,CPT,,,,,,,,both,,,2686.86,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1343.43,50,,1343.43,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,668.03,,,668.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,1880.8,70,,1880.8,percent of total billed charges,,89.1,,,89.1,Fee Schedule,,75.6,,,75.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,359.16,,,359.16,Other,New York Medicaid APG methodology,359.16,,,359.16,Other,100% New York Medicaid APG,359.16,,,359.16,Other,100% New York Medicaid APG,359.16,,,359.16,Other,100% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,502.82,,,502.82,Other,140% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,933.81,,,933.81,Other,260% New York Medicaid APG,1163.67,,,1163.67,Other,324% New York Medicaid APG,772.19,,,772.19,Other,215% New York Medicaid APG,772.19,,,772.19,Other,215% New York Medicaid APG,448.95,,,448.95,Other,125% New York Medicaid APG,0.01,9473,
Strapping of ankle and/or ft,29540,CPT,,,,,,,,both,,,3314.26,299.64,,,299.64,Other,150% of Medicare + 9.63% HCRA Surcharge,182.21,,,182.21,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1657.13,50,,1657.13,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,668.03,,,668.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2319.98,70,,2319.98,percent of total billed charges,,85.8,,,85.8,Fee Schedule,,72.8,,,72.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,359.16,,,359.16,Other,New York Medicaid APG methodology,359.16,,,359.16,Other,100% New York Medicaid APG,359.16,,,359.16,Other,100% New York Medicaid APG,359.16,,,359.16,Other,100% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,502.82,,,502.82,Other,140% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,933.81,,,933.81,Other,260% New York Medicaid APG,1163.67,,,1163.67,Other,324% New York Medicaid APG,772.19,,,772.19,Other,215% New York Medicaid APG,772.19,,,772.19,Other,215% New York Medicaid APG,448.95,,,448.95,Other,125% New York Medicaid APG,0.01,9473,
Strapping of toes,29550,CPT,,,,,,,,both,,,1286.58,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,643.29,50,,643.29,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,668.03,,,668.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,900.61,70,,900.61,percent of total billed charges,,54.45,,,54.45,Fee Schedule,,46.2,,,46.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,359.16,,,359.16,Other,New York Medicaid APG methodology,359.16,,,359.16,Other,100% New York Medicaid APG,359.16,,,359.16,Other,100% New York Medicaid APG,359.16,,,359.16,Other,100% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,502.82,,,502.82,Other,140% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,933.81,,,933.81,Other,260% New York Medicaid APG,1163.67,,,1163.67,Other,324% New York Medicaid APG,772.19,,,772.19,Other,215% New York Medicaid APG,772.19,,,772.19,Other,215% New York Medicaid APG,448.95,,,448.95,Other,125% New York Medicaid APG,0.01,9473,
Application of paste boot,29580,CPT,,,,,,,,both,,,3314.26,299.64,,,299.64,Other,150% of Medicare + 9.63% HCRA Surcharge,182.21,,,182.21,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1657.13,50,,1657.13,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2319.98,70,,2319.98,percent of total billed charges,,128.7,,,128.7,Fee Schedule,,109.2,,,109.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,9473,
Apply multlay comprs lwr leg,29581,CPT,,,,,,,,both,,,3314.26,299.64,,,299.64,Other,150% of Medicare + 9.63% HCRA Surcharge,182.21,,,182.21,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1657.13,50,,1657.13,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2319.98,70,,2319.98,percent of total billed charges,,130.35,,,130.35,Fee Schedule,,110.6,,,110.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,9473,
Appl multlay comprs arm/hand,29584,CPT,,,,,,,,both,,,3314.26,299.64,,,299.64,Other,150% of Medicare + 9.63% HCRA Surcharge,182.21,,,182.21,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1657.13,50,,1657.13,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,668.03,,,668.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2319.98,70,,2319.98,percent of total billed charges,,77.55,,,77.55,Fee Schedule,,65.8,,,65.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,359.16,,,359.16,Other,New York Medicaid APG methodology,359.16,,,359.16,Other,100% New York Medicaid APG,359.16,,,359.16,Other,100% New York Medicaid APG,359.16,,,359.16,Other,100% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,502.82,,,502.82,Other,140% New York Medicaid APG,808.1,,,808.1,Other,225% New York Medicaid APG,933.81,,,933.81,Other,260% New York Medicaid APG,1163.67,,,1163.67,Other,324% New York Medicaid APG,772.19,,,772.19,Other,215% New York Medicaid APG,772.19,,,772.19,Other,215% New York Medicaid APG,448.95,,,448.95,Other,125% New York Medicaid APG,0.01,9473,
Removal/revision of cast,29700,CPT,,,,,,,,both,,,5648.78,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2824.39,50,,2824.39,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3954.15,70,,3954.15,percent of total billed charges,,161.7,,,161.7,Fee Schedule,,137.2,,,137.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,9473,
Removal/revision of cast,29705,CPT,,,,,,,,both,,,5648.78,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2824.39,50,,2824.39,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3954.15,70,,3954.15,percent of total billed charges,,219.45,,,219.45,Fee Schedule,,186.2,,,186.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,9473,
Removal/revision of cast,29710,CPT,,,,,,,,both,,,5648.78,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2824.39,50,,2824.39,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3954.15,70,,3954.15,percent of total billed charges,,404.25,,,404.25,Fee Schedule,,343,,,343,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,9473,
Repair of body cast,29720,CPT,,,,,,,,both,,,3314.26,299.64,,,299.64,Other,150% of Medicare + 9.63% HCRA Surcharge,182.21,,,182.21,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1657.13,50,,1657.13,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2319.98,70,,2319.98,percent of total billed charges,,214.5,,,214.5,Fee Schedule,,182,,,182,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,9473,
Windowing of cast,29730,CPT,,,,,,,,both,,,3314.26,299.64,,,299.64,Other,150% of Medicare + 9.63% HCRA Surcharge,182.21,,,182.21,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1657.13,50,,1657.13,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2319.98,70,,2319.98,percent of total billed charges,,217.8,,,217.8,Fee Schedule,,184.8,,,184.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,9473,
Wedging of cast,29740,CPT,,,,,,,,both,,,5648.78,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2824.39,50,,2824.39,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3954.15,70,,3954.15,percent of total billed charges,,338.25,,,338.25,Fee Schedule,,287,,,287,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,9473,
Wedging of clubfoot cast,29750,CPT,,,,,,,,both,,,5648.78,510.7,,,510.7,Other,150% of Medicare + 9.63% HCRA Surcharge,310.56,,,310.56,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2824.39,50,,2824.39,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,834.08,,,834.08,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3954.15,70,,3954.15,percent of total billed charges,,377.85,,,377.85,Fee Schedule,,320.6,,,320.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,448.43,,,448.43,Other,New York Medicaid APG methodology,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,448.43,,,448.43,Other,100% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,627.81,,,627.81,Other,140% New York Medicaid APG,1008.97,,,1008.97,Other,225% New York Medicaid APG,1165.92,,,1165.92,Other,260% New York Medicaid APG,1452.92,,,1452.92,Other,324% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,964.13,,,964.13,Other,215% New York Medicaid APG,560.54,,,560.54,Other,125% New York Medicaid APG,0.01,9473,
Jaw arthroscopy/surgery,29800,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,47657.93,
Jaw arthroscopy/surgery,29804,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,47657.93,
Sho arthrs dx +- synovial bx,29805,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,47657.93,
Sho arthrs srg capsulorpaphy,29806,CPT,,,,,,,,both,,,74747.75,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,37373.88,50,,37373.88,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7615.4,,,7615.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52323.43,70,,52323.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4094.3,,,4094.3,Other,New York Medicaid APG methodology,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,5732.02,,,5732.02,Other,140% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,10645.19,,,10645.19,Other,260% New York Medicaid APG,13265.54,,,13265.54,Other,324% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,5117.88,,,5117.88,Other,125% New York Medicaid APG,4094.3,52323.43,
Sho arthrs srg rpr slap les,29807,CPT,,,,,,,,both,,,62418.33,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,31209.17,50,,31209.17,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7615.4,,,7615.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,43692.83,70,,43692.83,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4094.3,,,4094.3,Other,New York Medicaid APG methodology,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,5732.02,,,5732.02,Other,140% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,10645.19,,,10645.19,Other,260% New York Medicaid APG,13265.54,,,13265.54,Other,324% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,5117.88,,,5117.88,Other,125% New York Medicaid APG,4094.3,43692.83,
Sho arthrs srg rmvl loose/fb,29819,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,47657.93,
Sho arthrs srg prtl synvct,29820,CPT,,,,,,,,both,,,64371.33,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,32185.67,50,,32185.67,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45059.93,70,,45059.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,45059.93,
Sho arthrs srg compl synvct,29821,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7615.4,,,7615.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4094.3,,,4094.3,Other,New York Medicaid APG methodology,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,5732.02,,,5732.02,Other,140% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,10645.19,,,10645.19,Other,260% New York Medicaid APG,13265.54,,,13265.54,Other,324% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,5117.88,,,5117.88,Other,125% New York Medicaid APG,3743.09,47657.93,
Sho arthrs srg lmtd dbrdmt,29822,CPT,,,,,,,,both,,,55898.02,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,27949.01,50,,27949.01,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,39128.61,70,,39128.61,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,39128.61,
Sho arthrs srg xtnsv dbrdmt,29823,CPT,,,,,,,,both,,,43934.41,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,21967.21,50,,21967.21,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,30754.09,70,,30754.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,30754.09,
Sho arthrs srg dstl claviclc,29824,CPT,,,,,,,,both,,,52694.18,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,26347.09,50,,26347.09,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36885.93,70,,36885.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,36885.93,
Sho arthrs srg lss&rescj ads,29825,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,47657.93,
Sho arthrs srg decompression,29826,CPT,,,,,,,,both,,,64222.15,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32111.08,50,,32111.08,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,44955.51,70,,44955.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,0.01,44955.51,
Sho arthrs srg rt8tr cuf rpr,29827,CPT,,,,,,,,both,,,88593.2,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,44296.6,50,,44296.6,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7615.4,,,7615.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,62015.24,70,,62015.24,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4094.3,,,4094.3,Other,New York Medicaid APG methodology,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,5732.02,,,5732.02,Other,140% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,10645.19,,,10645.19,Other,260% New York Medicaid APG,13265.54,,,13265.54,Other,324% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,5117.88,,,5117.88,Other,125% New York Medicaid APG,4094.3,62015.24,
Sho arthrs srg bicp tenodsis,29828,CPT,,,,,,,,both,,,65898.99,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,32949.5,50,,32949.5,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7615.4,,,7615.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46129.29,70,,46129.29,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4094.3,,,4094.3,Other,New York Medicaid APG methodology,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,5732.02,,,5732.02,Other,140% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,10645.19,,,10645.19,Other,260% New York Medicaid APG,13265.54,,,13265.54,Other,324% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,5117.88,,,5117.88,Other,125% New York Medicaid APG,4094.3,46129.29,
Elbow arthroscopy,29830,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,47657.93,
Elbow arthroscopy/surgery,29834,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,47657.93,
Elbow arthroscopy/surgery,29835,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,47657.93,
Elbow arthroscopy/surgery,29836,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7615.4,,,7615.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4094.3,,,4094.3,Other,New York Medicaid APG methodology,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,5732.02,,,5732.02,Other,140% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,10645.19,,,10645.19,Other,260% New York Medicaid APG,13265.54,,,13265.54,Other,324% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,5117.88,,,5117.88,Other,125% New York Medicaid APG,4094.3,105333.66,
Elbow arthroscopy/surgery,29837,CPT,,,,,,,,both,,,42892.81,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,21446.41,50,,21446.41,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,30024.97,70,,30024.97,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,30024.97,
Elbow arthroscopy/surgery,29838,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,47657.93,
Wrist arthroscopy,29840,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,47657.93,
Wrist arthroscopy/surgery,29843,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,47657.93,
Wrist arthroscopy/surgery,29844,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,47657.93,
Wrist arthroscopy/surgery,29845,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,47657.93,
Wrist arthroscopy/surgery,29846,CPT,,,,,,,,both,,,48604.71,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,24302.36,50,,24302.36,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34023.3,70,,34023.3,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,34023.3,
Wrist arthroscopy/surgery,29847,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7615.4,,,7615.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4094.3,,,4094.3,Other,New York Medicaid APG methodology,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,5732.02,,,5732.02,Other,140% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,10645.19,,,10645.19,Other,260% New York Medicaid APG,13265.54,,,13265.54,Other,324% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,5117.88,,,5117.88,Other,125% New York Medicaid APG,4094.3,105333.66,
Wrist endoscopy/surgery,29848,CPT,,,,,,,,both,,,32256.3,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16128.15,50,,16128.15,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22579.41,70,,22579.41,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,1858.58,22579.41,
Knee arthroscopy/surgery,29850,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,1858.58,23663.84,
Knee arthroscopy/surgery,29851,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,1858.58,23663.84,
Tibial arthroscopy/surgery,29855,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7615.4,,,7615.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4094.3,,,4094.3,Other,New York Medicaid APG methodology,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,5732.02,,,5732.02,Other,140% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,10645.19,,,10645.19,Other,260% New York Medicaid APG,13265.54,,,13265.54,Other,324% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,5117.88,,,5117.88,Other,125% New York Medicaid APG,4094.3,105333.66,
Tibial arthroscopy/surgery,29856,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7615.4,,,7615.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4094.3,,,4094.3,Other,New York Medicaid APG methodology,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,5732.02,,,5732.02,Other,140% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,10645.19,,,10645.19,Other,260% New York Medicaid APG,13265.54,,,13265.54,Other,324% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,5117.88,,,5117.88,Other,125% New York Medicaid APG,4094.3,193779.51,
Hip arthroscopy dx,29860,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7615.4,,,7615.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4094.3,,,4094.3,Other,New York Medicaid APG methodology,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,5732.02,,,5732.02,Other,140% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,10645.19,,,10645.19,Other,260% New York Medicaid APG,13265.54,,,13265.54,Other,324% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,5117.88,,,5117.88,Other,125% New York Medicaid APG,4094.3,105333.66,
Hip arthro w/fb removal,29861,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,105333.66,
Hip arthr0 w/debridement,29862,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7615.4,,,7615.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4094.3,,,4094.3,Other,New York Medicaid APG methodology,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,5732.02,,,5732.02,Other,140% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,10645.19,,,10645.19,Other,260% New York Medicaid APG,13265.54,,,13265.54,Other,324% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,5117.88,,,5117.88,Other,125% New York Medicaid APG,4094.3,105333.66,
Hip arthr0 w/synovectomy,29863,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,47657.93,
Autgrft implnt knee w/scope,29866,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7615.4,,,7615.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4094.3,,,4094.3,Other,New York Medicaid APG methodology,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,5732.02,,,5732.02,Other,140% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,10645.19,,,10645.19,Other,260% New York Medicaid APG,13265.54,,,13265.54,Other,324% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,5117.88,,,5117.88,Other,125% New York Medicaid APG,4094.3,105333.66,
Allgrft implnt knee w/scope,29867,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7615.4,,,7615.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4094.3,,,4094.3,Other,New York Medicaid APG methodology,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,5732.02,,,5732.02,Other,140% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,10645.19,,,10645.19,Other,260% New York Medicaid APG,13265.54,,,13265.54,Other,324% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,5117.88,,,5117.88,Other,125% New York Medicaid APG,4094.3,193779.51,
Meniscal trnspl knee w/scpe,29868,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7615.4,,,7615.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4094.3,,,4094.3,Other,New York Medicaid APG methodology,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,5732.02,,,5732.02,Other,140% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,10645.19,,,10645.19,Other,260% New York Medicaid APG,13265.54,,,13265.54,Other,324% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,5117.88,,,5117.88,Other,125% New York Medicaid APG,4094.3,105333.66,
Knee arthroscopy dx,29870,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,47657.93,
Knee arthroscopy/drainage,29871,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,47657.93,
Knee arthroscopy/surgery,29873,CPT,,,,,,,,both,,,35991.34,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17995.67,50,,17995.67,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25193.94,70,,25193.94,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,25193.94,
Knee arthroscopy/surgery,29874,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,47657.93,
Knee arthroscopy/surgery,29875,CPT,,,,,,,,both,,,39883.71,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19941.86,50,,19941.86,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27918.6,70,,27918.6,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,27918.6,
Knee arthroscopy/surgery,29876,CPT,,,,,,,,both,,,38574.18,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19287.09,50,,19287.09,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27001.93,70,,27001.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,27001.93,
Knee arthroscopy/surgery,29877,CPT,,,,,,,,both,,,40524.95,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,20262.48,50,,20262.48,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28367.47,70,,28367.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,28367.47,
Knee arthroscopy/surgery,29879,CPT,,,,,,,,both,,,39316.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19658.38,50,,19658.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27521.73,70,,27521.73,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,27521.73,
Knee arthroscopy/surgery,29880,CPT,,,,,,,,both,,,40879.28,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,20439.64,50,,20439.64,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28615.5,70,,28615.5,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,28615.5,
Knee arthroscopy/surgery,29881,CPT,,,,,,,,both,,,38920.36,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19460.18,50,,19460.18,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27244.25,70,,27244.25,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,27244.25,
Knee arthroscopy/surgery,29882,CPT,,,,,,,,both,,,58881.06,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29440.53,50,,29440.53,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41216.74,70,,41216.74,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,41216.74,
Knee arthroscopy/surgery,29883,CPT,,,,,,,,both,,,59564.36,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29782.18,50,,29782.18,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41695.05,70,,41695.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,41695.05,
Knee arthroscopy/surgery,29884,CPT,,,,,,,,both,,,40094.07,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,20047.04,50,,20047.04,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28065.85,70,,28065.85,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,28065.85,
Knee arthroscopy/surgery,29885,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7615.4,,,7615.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4094.3,,,4094.3,Other,New York Medicaid APG methodology,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,5732.02,,,5732.02,Other,140% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,10645.19,,,10645.19,Other,260% New York Medicaid APG,13265.54,,,13265.54,Other,324% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,5117.88,,,5117.88,Other,125% New York Medicaid APG,4094.3,105333.66,
Knee arthroscopy/surgery,29886,CPT,,,,,,,,both,,,48477.88,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,24238.94,50,,24238.94,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,33934.52,70,,33934.52,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,33934.52,
Knee arthroscopy/surgery,29887,CPT,,,,,,,,both,,,49933.99,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,24967,50,,24967,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7615.4,,,7615.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34953.79,70,,34953.79,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,4094.3,,,4094.3,Other,New York Medicaid APG methodology,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,5732.02,,,5732.02,Other,140% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,10645.19,,,10645.19,Other,260% New York Medicaid APG,13265.54,,,13265.54,Other,324% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,5117.88,,,5117.88,Other,125% New York Medicaid APG,4094.3,34953.79,
Knee arthroscopy/surgery,29888,CPT,,,,,,,,both,,,91694.76,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,45847.38,50,,45847.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7615.4,,,7615.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,64186.33,70,,64186.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4094.3,,,4094.3,Other,New York Medicaid APG methodology,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,5732.02,,,5732.02,Other,140% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,10645.19,,,10645.19,Other,260% New York Medicaid APG,13265.54,,,13265.54,Other,324% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,5117.88,,,5117.88,Other,125% New York Medicaid APG,4094.3,64186.33,
Knee arthroscopy/surgery,29889,CPT,,,,,,,,both,,,134126.7,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,67063.35,50,,67063.35,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7615.4,,,7615.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,93888.69,70,,93888.69,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4094.3,,,4094.3,Other,New York Medicaid APG methodology,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,5732.02,,,5732.02,Other,140% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,10645.19,,,10645.19,Other,260% New York Medicaid APG,13265.54,,,13265.54,Other,324% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,5117.88,,,5117.88,Other,125% New York Medicaid APG,4094.3,93888.69,
Ankle arthroscopy/surgery,29891,CPT,,,,,,,,both,,,33768.9,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,16884.45,50,,16884.45,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23638.23,70,,23638.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,23638.23,
Ankle arthroscopy/surgery,29892,CPT,,,,,,,,both,,,104708.88,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,52354.44,50,,52354.44,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7615.4,,,7615.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,73296.22,70,,73296.22,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4094.3,,,4094.3,Other,New York Medicaid APG methodology,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,5732.02,,,5732.02,Other,140% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,10645.19,,,10645.19,Other,260% New York Medicaid APG,13265.54,,,13265.54,Other,324% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,5117.88,,,5117.88,Other,125% New York Medicaid APG,4094.3,73296.22,
Scope plantar fasciotomy,29893,CPT,,,,,,,,both,,,41676.94,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,20838.47,50,,20838.47,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29173.86,70,,29173.86,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,29173.86,
Ankle arthroscopy/surgery,29894,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,47657.93,
Ankle arthroscopy/surgery,29895,CPT,,,,,,,,both,,,58681.23,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29340.62,50,,29340.62,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41076.86,70,,41076.86,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,41076.86,
Ankle arthroscopy/surgery,29897,CPT,,,,,,,,both,,,39196.19,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19598.1,50,,19598.1,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27437.33,70,,27437.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,27437.33,
Ankle arthroscopy/surgery,29898,CPT,,,,,,,,both,,,101597.45,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,50798.73,50,,50798.73,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,71118.22,70,,71118.22,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,71118.22,
Ankle arthroscopy/surgery,29899,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7615.4,,,7615.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4094.3,,,4094.3,Other,New York Medicaid APG methodology,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,5732.02,,,5732.02,Other,140% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,10645.19,,,10645.19,Other,260% New York Medicaid APG,13265.54,,,13265.54,Other,324% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,5117.88,,,5117.88,Other,125% New York Medicaid APG,4094.3,105333.66,
Mcp joint arthroscopy dx,29900,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,47657.93,
Mcp joint arthroscopy surg,29901,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,47657.93,
Mcp joint arthroscopy surg,29902,CPT,,,,,,,,both,,,33805.49,3056.33,,,3056.33,Other,150% of Medicare + 9.63% HCRA Surcharge,1858.58,,,1858.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16902.75,50,,16902.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23663.84,70,,23663.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,1858.58,23663.84,
Subtalar arthro w/fb rmvl,29904,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,47657.93,
Subtalar arthro w/exc,29905,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,105333.66,
Subtalar arthro w/deb,29906,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4109.23,,,4109.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2209.27,,,2209.27,Other,New York Medicaid APG methodology,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,2209.27,,,2209.27,Other,100% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,3092.97,,,3092.97,Other,140% New York Medicaid APG,4970.85,,,4970.85,Other,225% New York Medicaid APG,5744.09,,,5744.09,Other,260% New York Medicaid APG,7158.02,,,7158.02,Other,324% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,4749.92,,,4749.92,Other,215% New York Medicaid APG,2761.58,,,2761.58,Other,125% New York Medicaid APG,2209.27,47657.93,
Subtalar arthro w/fusion,29907,CPT,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7615.4,,,7615.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4094.3,,,4094.3,Other,New York Medicaid APG methodology,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,5732.02,,,5732.02,Other,140% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,10645.19,,,10645.19,Other,260% New York Medicaid APG,13265.54,,,13265.54,Other,324% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,5117.88,,,5117.88,Other,125% New York Medicaid APG,4094.3,193779.51,
Hip arthro w/femoroplasty,29914,CPT,,,,,,,,both,,,93714.83,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,46857.42,50,,46857.42,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7615.4,,,7615.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,65600.38,70,,65600.38,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4094.3,,,4094.3,Other,New York Medicaid APG methodology,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,5732.02,,,5732.02,Other,140% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,10645.19,,,10645.19,Other,260% New York Medicaid APG,13265.54,,,13265.54,Other,324% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,5117.88,,,5117.88,Other,125% New York Medicaid APG,4094.3,65600.38,
Hip arthro acetabuloplasty,29915,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7615.4,,,7615.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4094.3,,,4094.3,Other,New York Medicaid APG methodology,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,5732.02,,,5732.02,Other,140% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,10645.19,,,10645.19,Other,260% New York Medicaid APG,13265.54,,,13265.54,Other,324% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,5117.88,,,5117.88,Other,125% New York Medicaid APG,4094.3,105333.66,
Hip arthro w/labral repair,29916,CPT,,,,,,,,both,,,104264.25,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,52132.13,50,,52132.13,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7615.4,,,7615.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,72984.98,70,,72984.98,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4094.3,,,4094.3,Other,New York Medicaid APG methodology,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,4094.3,,,4094.3,Other,100% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,5732.02,,,5732.02,Other,140% New York Medicaid APG,9212.18,,,9212.18,Other,225% New York Medicaid APG,10645.19,,,10645.19,Other,260% New York Medicaid APG,13265.54,,,13265.54,Other,324% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,8802.75,,,8802.75,Other,215% New York Medicaid APG,5117.88,,,5117.88,Other,125% New York Medicaid APG,4094.3,72984.98,
Drainage of nose lesion,30000,CPT,,,,,,,,both,,,5137.73,464.5,,,464.5,Other,150% of Medicare + 9.63% HCRA Surcharge,282.46,,,282.46,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2568.87,50,,2568.87,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3596.41,70,,3596.41,percent of total billed charges,,602.25,,,602.25,Fee Schedule,,511,,,511,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,0.01,9473,
Drainage of nose lesion,30020,CPT,,,,,,,,both,,,11572.85,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5786.43,50,,5786.43,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8101,70,,8101,percent of total billed charges,,607.2,,,607.2,Fee Schedule,,515.2,,,515.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,0.01,9473,
Intranasal biopsy,30100,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,333.3,,,333.3,Fee Schedule,,282.8,,,282.8,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,282.8,22454.17,
Removal of nose polyp(s),30110,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,656.7,,,656.7,Fee Schedule,,557.2,,,557.2,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,557.2,22454.17,
Removal of nose polyp(s),30115,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,1545.56,47404.34,
Removal of intranasal lesion,30117,CPT,,,,,,,,both,,,35951.86,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17975.93,50,,17975.93,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3792.93,,,3792.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25166.3,70,,25166.3,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2039.21,,,2039.21,Other,New York Medicaid APG methodology,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,2854.89,,,2854.89,Other,140% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,5301.94,,,5301.94,Other,260% New York Medicaid APG,6607.03,,,6607.03,Other,324% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,2549.01,,,2549.01,Other,125% New York Medicaid APG,2039.21,25166.3,
Removal of intranasal lesion,30118,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3792.93,,,3792.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2039.21,,,2039.21,Other,New York Medicaid APG methodology,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,2854.89,,,2854.89,Other,140% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,5301.94,,,5301.94,Other,260% New York Medicaid APG,6607.03,,,6607.03,Other,324% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,2549.01,,,2549.01,Other,125% New York Medicaid APG,2039.21,47404.34,
Revision of nose,30120,CPT,,,,,,,,both,,,35129.63,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17564.82,50,,17564.82,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3792.93,,,3792.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24590.74,70,,24590.74,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2039.21,,,2039.21,Other,New York Medicaid APG methodology,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,2854.89,,,2854.89,Other,140% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,5301.94,,,5301.94,Other,260% New York Medicaid APG,6607.03,,,6607.03,Other,324% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,2549.01,,,2549.01,Other,125% New York Medicaid APG,2039.21,24590.74,
Removal of nose lesion,30124,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,1545.56,22454.17,
Removal of nose lesion,30125,CPT,,,,,,,,both,,,51239.1,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,25619.55,50,,25619.55,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,35867.37,70,,35867.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,1545.56,35867.37,
Excise inferior turbinate,30130,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,47404.34,
Resect inferior turbinate,30140,CPT,,,,,,,,both,,,35888.55,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17944.28,50,,17944.28,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25121.99,70,,25121.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,25121.99,
Partial removal of nose,30150,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Removal of nose,30160,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Injection treatment of nose,30200,CPT,,,,,,,,both,,,11572.85,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5786.43,50,,5786.43,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8101,70,,8101,percent of total billed charges,,293.7,,,293.7,Fee Schedule,,249.2,,,249.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,249.2,9473,
Nasal sinus therapy,30210,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,511.5,,,511.5,Fee Schedule,,434,,,434,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,269.45,22454.17,
Insert nasal septal button,30220,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,633.6,,,633.6,Fee Schedule,,537.6,,,537.6,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,537.6,22454.17,
Remove nasal foreign body,30300,CPT,,,,,,,,both,,,2686.86,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1343.43,50,,1343.43,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,1880.8,70,,1880.8,percent of total billed charges,,618.75,,,618.75,Fee Schedule,,525,,,525,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,0.01,9473,
Remove nasal foreign body,30310,CPT,,,,,,,,both,,,35579.78,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17789.89,50,,17789.89,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24905.85,70,,24905.85,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,1545.56,24905.85,
Remove nasal foreign body,30320,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,1545.56,22454.17,
Reconstruction of nose,30400,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,86224,
Reconstruction of nose,30410,CPT,,,,,,,,both,,,56761.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,28380.57,50,,28380.57,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,39732.8,70,,39732.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,39732.8,
Reconstruction of nose,30420,CPT,,,,,,,,both,,,55638.22,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,27819.11,50,,27819.11,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,38946.75,70,,38946.75,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,38946.75,
Revision of nose,30430,CPT,,,,,,,,both,,,44143.84,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,22071.92,50,,22071.92,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3792.93,,,3792.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,30900.69,70,,30900.69,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2039.21,,,2039.21,Other,New York Medicaid APG methodology,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,2854.89,,,2854.89,Other,140% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,5301.94,,,5301.94,Other,260% New York Medicaid APG,6607.03,,,6607.03,Other,324% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,2549.01,,,2549.01,Other,125% New York Medicaid APG,2039.21,30900.69,
Revision of nose,30435,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Revision of nose,30450,CPT,,,,,,,,both,,,82062.41,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,41031.21,50,,41031.21,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,57443.69,70,,57443.69,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,57443.69,
Revision of nose,30460,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Revision of nose,30462,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Repair nasal stenosis,30465,CPT,,,,,,,,both,,,46270.96,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,23135.48,50,,23135.48,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3792.93,,,3792.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,32389.67,70,,32389.67,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2039.21,,,2039.21,Other,New York Medicaid APG methodology,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,2854.89,,,2854.89,Other,140% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,5301.94,,,5301.94,Other,260% New York Medicaid APG,6607.03,,,6607.03,Other,324% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,2549.01,,,2549.01,Other,125% New York Medicaid APG,2039.21,32389.67,
Rpr nsl vlv collapse w/implt,30468,CPT,,,,,,,,both,,,36572.73,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,18286.37,50,,18286.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25600.91,70,,25600.91,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,25600.91,
Repair of nasal septum,30520,CPT,,,,,,,,both,,,39526.16,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19763.08,50,,19763.08,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27668.31,70,,27668.31,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,27668.31,
Repair nasal defect,30540,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,86224,
Repair nasal defect,30545,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6771.82,,,6771.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3640.76,,,3640.76,Other,New York Medicaid APG methodology,3640.76,,,3640.76,Other,100% New York Medicaid APG,3640.76,,,3640.76,Other,100% New York Medicaid APG,3640.76,,,3640.76,Other,100% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,5097.07,,,5097.07,Other,140% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,9465.98,,,9465.98,Other,260% New York Medicaid APG,11796.07,,,11796.07,Other,324% New York Medicaid APG,7827.64,,,7827.64,Other,215% New York Medicaid APG,7827.64,,,7827.64,Other,215% New York Medicaid APG,4550.95,,,4550.95,Other,125% New York Medicaid APG,3640.76,86224,
Release of nasal adhesions,30560,CPT,,,,,,,,both,,,11572.85,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5786.43,50,,5786.43,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8101,70,,8101,percent of total billed charges,,750.75,,,750.75,Fee Schedule,,637,,,637,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,636.26,9473,
Repair upper jaw fistula,30580,CPT,,,,,,,,both,,,44575.28,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,22287.64,50,,22287.64,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31202.7,70,,31202.7,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,31202.7,
Repair mouth/nose fistula,30600,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,86224,
Intranasal reconstruction,30620,CPT,,,,,,,,both,,,78477.05,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,39238.53,50,,39238.53,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,54933.94,70,,54933.94,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,54933.94,
Repair nasal septum defect,30630,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,47404.34,
Ablate inf turbinate superf,30801,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,762.3,,,762.3,Fee Schedule,,646.8,,,646.8,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,646.8,22454.17,
Ablate inf turbinate submuc,30802,CPT,,,,,,,,both,,,35088.16,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17544.08,50,,17544.08,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24561.71,70,,24561.71,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,1763.57,24561.71,
Control of nosebleed,30901,CPT,,,,,,,,both,,,11865.24,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5932.62,50,,5932.62,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8305.67,70,,8305.67,percent of total billed charges,,278.85,,,278.85,Fee Schedule,,236.6,,,236.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,0.01,9473,
Control of nosebleed,30903,CPT,,,,,,,,both,,,2686.86,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1343.43,50,,1343.43,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,1880.8,70,,1880.8,percent of total billed charges,,381.15,,,381.15,Fee Schedule,,323.4,,,323.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,147.72,9473,
Control of nosebleed,30905,CPT,,,,,,,,both,,,2686.86,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1343.43,50,,1343.43,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,1880.8,70,,1880.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,147.72,13157,
Repeat control of nosebleed,30906,CPT,,,,,,,,both,,,5137.73,464.5,,,464.5,Other,150% of Medicare + 9.63% HCRA Surcharge,282.46,,,282.46,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2568.87,50,,2568.87,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3596.41,70,,3596.41,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,269.45,13157,
Ligation nasal sinus artery,30915,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,46931.32,
Ligation upper jaw artery,30920,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,46931.32,
Ther fx nasal inf turbinate,30930,CPT,,,,,,,,both,,,36197.05,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18098.53,50,,18098.53,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25337.94,70,,25337.94,percent of total billed charges,,585.75,,,585.75,Fee Schedule,,497,,,497,Fee Schedule,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,497,25337.94,
Irrigation maxillary sinus,31000,CPT,,,,,,,,both,,,5137.73,464.5,,,464.5,Other,150% of Medicare + 9.63% HCRA Surcharge,282.46,,,282.46,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2568.87,50,,2568.87,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3596.41,70,,3596.41,percent of total billed charges,,547.8,,,547.8,Fee Schedule,,464.8,,,464.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,0.01,9473,
Irrigation sphenoid sinus,31002,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,269.45,22454.17,
Exploration maxillary sinus,31020,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,1545.56,47404.34,
Exploration maxillary sinus,31030,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,86224,
Explore sinus remove polyps,31032,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,86224,
Exploration behind upper jaw,31040,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Exploration sphenoid sinus,31050,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,86224,
Sphenoid sinus surgery,31051,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,86224,
Exploration of frontal sinus,31070,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,86224,
Exploration of frontal sinus,31075,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,86224,
Removal of frontal sinus,31080,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,86224,
Removal of frontal sinus,31081,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Removal of frontal sinus,31084,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,86224,
Removal of frontal sinus,31085,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,86224,
Removal of frontal sinus,31086,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,86224,
Removal of frontal sinus,31087,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,86224,
Exploration of sinuses,31090,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,86224,
Removal of ethmoid sinus,31200,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,86224,
Removal of ethmoid sinus,31201,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3792.93,,,3792.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2039.21,,,2039.21,Other,New York Medicaid APG methodology,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,2854.89,,,2854.89,Other,140% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,5301.94,,,5301.94,Other,260% New York Medicaid APG,6607.03,,,6607.03,Other,324% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,2549.01,,,2549.01,Other,125% New York Medicaid APG,1763.57,22454.17,
Removal of ethmoid sinus,31205,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3792.93,,,3792.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2039.21,,,2039.21,Other,New York Medicaid APG methodology,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,2854.89,,,2854.89,Other,140% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,5301.94,,,5301.94,Other,260% New York Medicaid APG,6607.03,,,6607.03,Other,324% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,2549.01,,,2549.01,Other,125% New York Medicaid APG,2039.21,47404.34,
Nasal endoscopy dx,31231,CPT,,,,,,,,both,,,35228.49,376.68,,,376.68,Other,150% of Medicare + 9.63% HCRA Surcharge,229.06,,,229.06,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17614.25,50,,17614.25,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24659.94,70,,24659.94,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,0.01,24659.94,
Nsl/sins ndsc dx max sinusc,31233,CPT,,,,,,,,both,,,8588.63,776.49,,,776.49,Other,150% of Medicare + 9.63% HCRA Surcharge,472.19,,,472.19,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4294.32,50,,4294.32,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1030.04,,,1030.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,6012.04,70,,6012.04,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,553.79,,,553.79,Other,New York Medicaid APG methodology,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,775.3,,,775.3,Other,140% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1439.85,,,1439.85,Other,260% New York Medicaid APG,1794.27,,,1794.27,Other,324% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,692.23,,,692.23,Other,125% New York Medicaid APG,472.19,9473,
Nsl/sins ndsc dx sphn sinusc,31235,CPT,,,,,,,,both,,,35699.83,3227.6,,,3227.6,Other,150% of Medicare + 9.63% HCRA Surcharge,1962.72,,,1962.72,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17849.92,50,,17849.92,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3814.26,,,3814.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24989.88,70,,24989.88,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2050.68,,,2050.68,Other,New York Medicaid APG methodology,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,2870.95,,,2870.95,Other,140% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,5331.77,,,5331.77,Other,260% New York Medicaid APG,6644.2,,,6644.2,Other,324% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,2563.35,,,2563.35,Other,125% New York Medicaid APG,1962.72,24989.88,
Nasal/sinus endoscopy surg,31237,CPT,,,,,,,,both,,,38391.34,3227.6,,,3227.6,Other,150% of Medicare + 9.63% HCRA Surcharge,1962.72,,,1962.72,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19195.67,50,,19195.67,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3814.26,,,3814.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26873.94,70,,26873.94,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2050.68,,,2050.68,Other,New York Medicaid APG methodology,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,2870.95,,,2870.95,Other,140% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,5331.77,,,5331.77,Other,260% New York Medicaid APG,6644.2,,,6644.2,Other,324% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,2563.35,,,2563.35,Other,125% New York Medicaid APG,1962.72,26873.94,
Nasal/sinus endoscopy surg,31238,CPT,,,,,,,,both,,,37288.61,3227.6,,,3227.6,Other,150% of Medicare + 9.63% HCRA Surcharge,1962.72,,,1962.72,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18644.31,50,,18644.31,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3814.26,,,3814.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26102.03,70,,26102.03,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2050.68,,,2050.68,Other,New York Medicaid APG methodology,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,2870.95,,,2870.95,Other,140% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,5331.77,,,5331.77,Other,260% New York Medicaid APG,6644.2,,,6644.2,Other,324% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,2563.35,,,2563.35,Other,125% New York Medicaid APG,1962.72,26102.03,
Nasal/sinus endoscopy surg,31239,CPT,,,,,,,,both,,,78767.93,7121.36,,,7121.36,Other,150% of Medicare + 9.63% HCRA Surcharge,4330.54,,,4330.54,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,39383.97,50,,39383.97,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3814.26,,,3814.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,55137.55,70,,55137.55,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2050.68,,,2050.68,Other,New York Medicaid APG methodology,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,2870.95,,,2870.95,Other,140% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,5331.77,,,5331.77,Other,260% New York Medicaid APG,6644.2,,,6644.2,Other,324% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,2563.35,,,2563.35,Other,125% New York Medicaid APG,2050.68,55137.55,
Nasal/sinus endoscopy surg,31240,CPT,,,,,,,,both,,,35699.83,3227.6,,,3227.6,Other,150% of Medicare + 9.63% HCRA Surcharge,1962.72,,,1962.72,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17849.92,50,,17849.92,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1030.04,,,1030.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24989.88,70,,24989.88,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,553.79,,,553.79,Other,New York Medicaid APG methodology,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,775.3,,,775.3,Other,140% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1439.85,,,1439.85,Other,260% New York Medicaid APG,1794.27,,,1794.27,Other,324% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,692.23,,,692.23,Other,125% New York Medicaid APG,553.79,24989.88,
Nsl/sins ndsc w/artery lig,31241,CPT,,,,,,,,both,,,35699.83,3227.6,,,3227.6,Other,150% of Medicare + 9.63% HCRA Surcharge,1962.72,,,1962.72,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17849.92,50,,17849.92,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3814.26,,,3814.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24989.88,70,,24989.88,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2050.68,,,2050.68,Other,New York Medicaid APG methodology,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,2870.95,,,2870.95,Other,140% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,5331.77,,,5331.77,Other,260% New York Medicaid APG,6644.2,,,6644.2,Other,324% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,2563.35,,,2563.35,Other,125% New York Medicaid APG,1962.72,24989.88,
Nsl/sins ndsc total,31253,CPT,,,,,,,,both,,,39119.74,13015.44,,,13015.44,Other,150% of Medicare + 9.63% HCRA Surcharge,7914.77,,,7914.77,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,19559.87,50,,19559.87,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27383.82,70,,27383.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,27383.82,
Nsl/sins ndsc w/prtl ethmdct,31254,CPT,,,,,,,,both,,,38226.57,13015.44,,,13015.44,Other,150% of Medicare + 9.63% HCRA Surcharge,7914.77,,,7914.77,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,19113.29,50,,19113.29,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3792.93,,,3792.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26758.6,70,,26758.6,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2039.21,,,2039.21,Other,New York Medicaid APG methodology,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,2854.89,,,2854.89,Other,140% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,5301.94,,,5301.94,Other,260% New York Medicaid APG,6607.03,,,6607.03,Other,324% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,2549.01,,,2549.01,Other,125% New York Medicaid APG,2039.21,26758.6,
Nsl/sins ndsc w/tot ethmdct,31255,CPT,,,,,,,,both,,,46439.9,13015.44,,,13015.44,Other,150% of Medicare + 9.63% HCRA Surcharge,7914.77,,,7914.77,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,23219.95,50,,23219.95,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,32507.93,70,,32507.93,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,32507.93,
Exploration maxillary sinus,31256,CPT,,,,,,,,both,,,41549.37,7121.36,,,7121.36,Other,150% of Medicare + 9.63% HCRA Surcharge,4330.54,,,4330.54,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,20774.69,50,,20774.69,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3792.93,,,3792.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29084.56,70,,29084.56,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2039.21,,,2039.21,Other,New York Medicaid APG methodology,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,2854.89,,,2854.89,Other,140% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,5301.94,,,5301.94,Other,260% New York Medicaid APG,6607.03,,,6607.03,Other,324% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,2549.01,,,2549.01,Other,125% New York Medicaid APG,2039.21,29084.56,
Nsl/sins ndsc tot w/sphendt,31257,CPT,,,,,,,,both,,,40828.4,13015.44,,,13015.44,Other,150% of Medicare + 9.63% HCRA Surcharge,7914.77,,,7914.77,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,20414.2,50,,20414.2,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28579.88,70,,28579.88,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,28579.88,
Nsl/sins ndsc sphn tiss rmvl,31259,CPT,,,,,,,,both,,,64583.51,13015.44,,,13015.44,Other,150% of Medicare + 9.63% HCRA Surcharge,7914.77,,,7914.77,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,32291.76,50,,32291.76,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45208.46,70,,45208.46,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,45208.46,
Endoscopy maxillary sinus,31267,CPT,,,,,,,,both,,,41890.73,13015.44,,,13015.44,Other,150% of Medicare + 9.63% HCRA Surcharge,7914.77,,,7914.77,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,20945.37,50,,20945.37,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1030.04,,,1030.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29323.51,70,,29323.51,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,553.79,,,553.79,Other,New York Medicaid APG methodology,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,775.3,,,775.3,Other,140% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1439.85,,,1439.85,Other,260% New York Medicaid APG,1794.27,,,1794.27,Other,324% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,692.23,,,692.23,Other,125% New York Medicaid APG,553.79,29323.51,
Nsl/sins ndsc frnt tiss rmvl,31276,CPT,,,,,,,,both,,,51273.89,13015.44,,,13015.44,Other,150% of Medicare + 9.63% HCRA Surcharge,7914.77,,,7914.77,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,25636.95,50,,25636.95,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1030.04,,,1030.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,35891.72,70,,35891.72,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,553.79,,,553.79,Other,New York Medicaid APG methodology,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,775.3,,,775.3,Other,140% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1439.85,,,1439.85,Other,260% New York Medicaid APG,1794.27,,,1794.27,Other,324% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,692.23,,,692.23,Other,125% New York Medicaid APG,553.79,35891.72,
Nasal/sinus endoscopy surg,31287,CPT,,,,,,,,both,,,143961.17,13015.44,,,13015.44,Other,150% of Medicare + 9.63% HCRA Surcharge,7914.77,,,7914.77,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,71980.59,50,,71980.59,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1030.04,,,1030.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,100772.82,70,,100772.82,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,553.79,,,553.79,Other,New York Medicaid APG methodology,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,775.3,,,775.3,Other,140% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1439.85,,,1439.85,Other,260% New York Medicaid APG,1794.27,,,1794.27,Other,324% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,692.23,,,692.23,Other,125% New York Medicaid APG,553.79,100772.82,
Nasal/sinus endoscopy surg,31288,CPT,,,,,,,,both,,,143961.17,13015.44,,,13015.44,Other,150% of Medicare + 9.63% HCRA Surcharge,7914.77,,,7914.77,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,71980.59,50,,71980.59,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1030.04,,,1030.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,100772.82,70,,100772.82,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,553.79,,,553.79,Other,New York Medicaid APG methodology,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,775.3,,,775.3,Other,140% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1439.85,,,1439.85,Other,260% New York Medicaid APG,1794.27,,,1794.27,Other,324% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,692.23,,,692.23,Other,125% New York Medicaid APG,553.79,100772.82,
Nsl/sins ndsc med/inf dcmprn,31292,CPT,,,,,,,,both,,,64741.66,13015.44,,,13015.44,Other,150% of Medicare + 9.63% HCRA Surcharge,7914.77,,,7914.77,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,32370.83,50,,32370.83,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3814.26,,,3814.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45319.16,70,,45319.16,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2050.68,,,2050.68,Other,New York Medicaid APG methodology,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,2870.95,,,2870.95,Other,140% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,5331.77,,,5331.77,Other,260% New York Medicaid APG,6644.2,,,6644.2,Other,324% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,2563.35,,,2563.35,Other,125% New York Medicaid APG,2050.68,45319.16,
Nsl/sins ndsc med&inf dcmprn,31293,CPT,,,,,,,,both,,,143961.17,13015.44,,,13015.44,Other,150% of Medicare + 9.63% HCRA Surcharge,7914.77,,,7914.77,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,71980.59,50,,71980.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3814.26,,,3814.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,100772.82,70,,100772.82,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2050.68,,,2050.68,Other,New York Medicaid APG methodology,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,2870.95,,,2870.95,Other,140% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,5331.77,,,5331.77,Other,260% New York Medicaid APG,6644.2,,,6644.2,Other,324% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,2563.35,,,2563.35,Other,125% New York Medicaid APG,2050.68,100772.82,
Nsl/sins ndsc surg on dcmprn,31294,CPT,,,,,,,,both,,,143961.17,13015.44,,,13015.44,Other,150% of Medicare + 9.63% HCRA Surcharge,7914.77,,,7914.77,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,71980.59,50,,71980.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3814.26,,,3814.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,100772.82,70,,100772.82,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2050.68,,,2050.68,Other,New York Medicaid APG methodology,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,2870.95,,,2870.95,Other,140% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,5331.77,,,5331.77,Other,260% New York Medicaid APG,6644.2,,,6644.2,Other,324% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,2563.35,,,2563.35,Other,125% New York Medicaid APG,2050.68,100772.82,
Nsl/sins ndsc surg max sins,31295,CPT,,,,,,,,both,,,143961.17,13015.44,,,13015.44,Other,150% of Medicare + 9.63% HCRA Surcharge,7914.77,,,7914.77,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,71980.59,50,,71980.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3814.26,,,3814.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,100772.82,70,,100772.82,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2050.68,,,2050.68,Other,New York Medicaid APG methodology,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,2870.95,,,2870.95,Other,140% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,5331.77,,,5331.77,Other,260% New York Medicaid APG,6644.2,,,6644.2,Other,324% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,2563.35,,,2563.35,Other,125% New York Medicaid APG,2050.68,100772.82,
Nsl/sins ndsc surg frnt sins,31296,CPT,,,,,,,,both,,,143961.17,13015.44,,,13015.44,Other,150% of Medicare + 9.63% HCRA Surcharge,7914.77,,,7914.77,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,71980.59,50,,71980.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1030.04,,,1030.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,100772.82,70,,100772.82,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,553.79,,,553.79,Other,New York Medicaid APG methodology,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,775.3,,,775.3,Other,140% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1439.85,,,1439.85,Other,260% New York Medicaid APG,1794.27,,,1794.27,Other,324% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,692.23,,,692.23,Other,125% New York Medicaid APG,553.79,100772.82,
Nsl/sins ndsc surg sphn sins,31297,CPT,,,,,,,,both,,,143961.17,13015.44,,,13015.44,Other,150% of Medicare + 9.63% HCRA Surcharge,7914.77,,,7914.77,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,71980.59,50,,71980.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1030.04,,,1030.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,100772.82,70,,100772.82,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,553.79,,,553.79,Other,New York Medicaid APG methodology,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,775.3,,,775.3,Other,140% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1439.85,,,1439.85,Other,260% New York Medicaid APG,1794.27,,,1794.27,Other,324% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,692.23,,,692.23,Other,125% New York Medicaid APG,553.79,100772.82,
Nsl/sins ndsc surg frnt&sphn,31298,CPT,,,,,,,,both,,,143961.17,13015.44,,,13015.44,Other,150% of Medicare + 9.63% HCRA Surcharge,7914.77,,,7914.77,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,71980.59,50,,71980.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1030.04,,,1030.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,100772.82,70,,100772.82,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,553.79,,,553.79,Other,New York Medicaid APG methodology,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,775.3,,,775.3,Other,140% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1439.85,,,1439.85,Other,260% New York Medicaid APG,1794.27,,,1794.27,Other,324% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,692.23,,,692.23,Other,125% New York Medicaid APG,553.79,100772.82,
Removal of larynx lesion,31300,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3792.93,,,3792.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2039.21,,,2039.21,Other,New York Medicaid APG methodology,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,2854.89,,,2854.89,Other,140% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,5301.94,,,5301.94,Other,260% New York Medicaid APG,6607.03,,,6607.03,Other,324% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,2549.01,,,2549.01,Other,125% New York Medicaid APG,2039.21,47404.34,
Revision of larynx,31400,CPT,,,,,,,,both,,,42086.37,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,21043.19,50,,21043.19,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29460.46,70,,29460.46,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,29460.46,
Removal of epiglottis,31420,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,86224,
Insert emergency airway,31500,CPT,,,,,,,,both,,,5137.73,464.5,,,464.5,Other,150% of Medicare + 9.63% HCRA Surcharge,282.46,,,282.46,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2568.87,50,,2568.87,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1439.48,,,1439.48,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3596.41,70,,3596.41,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,773.91,,,773.91,Other,New York Medicaid APG methodology,773.91,,,773.91,Other,100% New York Medicaid APG,773.91,,,773.91,Other,100% New York Medicaid APG,773.91,,,773.91,Other,100% New York Medicaid APG,1741.31,,,1741.31,Other,225% New York Medicaid APG,1741.31,,,1741.31,Other,225% New York Medicaid APG,1741.31,,,1741.31,Other,225% New York Medicaid APG,1741.31,,,1741.31,Other,225% New York Medicaid APG,1083.48,,,1083.48,Other,140% New York Medicaid APG,1741.31,,,1741.31,Other,225% New York Medicaid APG,2012.18,,,2012.18,Other,260% New York Medicaid APG,2507.48,,,2507.48,Other,324% New York Medicaid APG,1663.92,,,1663.92,Other,215% New York Medicaid APG,1663.92,,,1663.92,Other,215% New York Medicaid APG,967.39,,,967.39,Other,125% New York Medicaid APG,282.46,13157,
Change of windpipe airway,31502,CPT,,,,,,,,both,,,28281.42,464.5,,,464.5,Other,150% of Medicare + 9.63% HCRA Surcharge,282.46,,,282.46,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,14140.71,50,,14140.71,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,19796.99,70,,19796.99,percent of total billed charges,,171.6,,,171.6,Fee Schedule,,145.6,,,145.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,145.6,19796.99,
Diagnostic laryngoscopy,31505,CPT,,,,,,,,both,,,4166.39,376.68,,,376.68,Other,150% of Medicare + 9.63% HCRA Surcharge,229.06,,,229.06,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2083.2,50,,2083.2,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2916.47,70,,2916.47,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,0.01,9473,
Laryngoscopy with biopsy,31510,CPT,,,,,,,,both,,,78767.93,7121.36,,,7121.36,Other,150% of Medicare + 9.63% HCRA Surcharge,4330.54,,,4330.54,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,39383.97,50,,39383.97,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3814.26,,,3814.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,55137.55,70,,55137.55,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2050.68,,,2050.68,Other,New York Medicaid APG methodology,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,2870.95,,,2870.95,Other,140% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,5331.77,,,5331.77,Other,260% New York Medicaid APG,6644.2,,,6644.2,Other,324% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,2563.35,,,2563.35,Other,125% New York Medicaid APG,2050.68,55137.55,
Remove foreign body larynx,31511,CPT,,,,,,,,both,,,4166.39,376.68,,,376.68,Other,150% of Medicare + 9.63% HCRA Surcharge,229.06,,,229.06,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2083.2,50,,2083.2,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2916.47,70,,2916.47,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,229.06,9473,
Removal of larynx lesion,31512,CPT,,,,,,,,both,,,78767.93,7121.36,,,7121.36,Other,150% of Medicare + 9.63% HCRA Surcharge,4330.54,,,4330.54,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,39383.97,50,,39383.97,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3814.26,,,3814.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,55137.55,70,,55137.55,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2050.68,,,2050.68,Other,New York Medicaid APG methodology,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,2870.95,,,2870.95,Other,140% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,5331.77,,,5331.77,Other,260% New York Medicaid APG,6644.2,,,6644.2,Other,324% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,2563.35,,,2563.35,Other,125% New York Medicaid APG,2050.68,55137.55,
Injection into vocal cord,31513,CPT,,,,,,,,both,,,8588.63,776.49,,,776.49,Other,150% of Medicare + 9.63% HCRA Surcharge,472.19,,,472.19,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4294.32,50,,4294.32,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1030.04,,,1030.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,6012.04,70,,6012.04,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,553.79,,,553.79,Other,New York Medicaid APG methodology,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,775.3,,,775.3,Other,140% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1439.85,,,1439.85,Other,260% New York Medicaid APG,1794.27,,,1794.27,Other,324% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,692.23,,,692.23,Other,125% New York Medicaid APG,472.19,9473,
Laryngoscopy for aspiration,31515,CPT,,,,,,,,both,,,8588.63,776.49,,,776.49,Other,150% of Medicare + 9.63% HCRA Surcharge,472.19,,,472.19,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4294.32,50,,4294.32,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1030.04,,,1030.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,6012.04,70,,6012.04,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,553.79,,,553.79,Other,New York Medicaid APG methodology,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,775.3,,,775.3,Other,140% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1439.85,,,1439.85,Other,260% New York Medicaid APG,1794.27,,,1794.27,Other,324% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,692.23,,,692.23,Other,125% New York Medicaid APG,472.19,9473,
Dx laryngoscopy newborn,31520,CPT,,,,,,,,both,,,8588.63,776.49,,,776.49,Other,150% of Medicare + 9.63% HCRA Surcharge,472.19,,,472.19,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4294.32,50,,4294.32,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1030.04,,,1030.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,6012.04,70,,6012.04,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,553.79,,,553.79,Other,New York Medicaid APG methodology,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,775.3,,,775.3,Other,140% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1439.85,,,1439.85,Other,260% New York Medicaid APG,1794.27,,,1794.27,Other,324% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,692.23,,,692.23,Other,125% New York Medicaid APG,0.01,9473,
Dx laryngoscopy excl nb,31525,CPT,,,,,,,,both,,,34333.7,3227.6,,,3227.6,Other,150% of Medicare + 9.63% HCRA Surcharge,1962.72,,,1962.72,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17166.85,50,,17166.85,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1030.04,,,1030.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24033.59,70,,24033.59,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,553.79,,,553.79,Other,New York Medicaid APG methodology,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,775.3,,,775.3,Other,140% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1439.85,,,1439.85,Other,260% New York Medicaid APG,1794.27,,,1794.27,Other,324% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,692.23,,,692.23,Other,125% New York Medicaid APG,553.79,24033.59,
Dx laryngoscopy w/oper scope,31526,CPT,,,,,,,,both,,,38383.39,3227.6,,,3227.6,Other,150% of Medicare + 9.63% HCRA Surcharge,1962.72,,,1962.72,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19191.7,50,,19191.7,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1030.04,,,1030.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26868.37,70,,26868.37,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,553.79,,,553.79,Other,New York Medicaid APG methodology,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,775.3,,,775.3,Other,140% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1439.85,,,1439.85,Other,260% New York Medicaid APG,1794.27,,,1794.27,Other,324% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,692.23,,,692.23,Other,125% New York Medicaid APG,553.79,26868.37,
Laryngoscopy for treatment,31527,CPT,,,,,,,,both,,,78767.93,7121.36,,,7121.36,Other,150% of Medicare + 9.63% HCRA Surcharge,4330.54,,,4330.54,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,39383.97,50,,39383.97,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3814.26,,,3814.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,55137.55,70,,55137.55,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2050.68,,,2050.68,Other,New York Medicaid APG methodology,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,2870.95,,,2870.95,Other,140% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,5331.77,,,5331.77,Other,260% New York Medicaid APG,6644.2,,,6644.2,Other,324% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,2563.35,,,2563.35,Other,125% New York Medicaid APG,2050.68,55137.55,
Laryngoscopy and dilation,31528,CPT,,,,,,,,both,,,39598.13,7121.36,,,7121.36,Other,150% of Medicare + 9.63% HCRA Surcharge,4330.54,,,4330.54,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19799.07,50,,19799.07,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3814.26,,,3814.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27718.69,70,,27718.69,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2050.68,,,2050.68,Other,New York Medicaid APG methodology,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,2870.95,,,2870.95,Other,140% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,5331.77,,,5331.77,Other,260% New York Medicaid APG,6644.2,,,6644.2,Other,324% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,2563.35,,,2563.35,Other,125% New York Medicaid APG,2050.68,27718.69,
Laryngoscopy and dilation,31529,CPT,,,,,,,,both,,,38922.21,7121.36,,,7121.36,Other,150% of Medicare + 9.63% HCRA Surcharge,4330.54,,,4330.54,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19461.11,50,,19461.11,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3814.26,,,3814.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27245.55,70,,27245.55,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2050.68,,,2050.68,Other,New York Medicaid APG methodology,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,2870.95,,,2870.95,Other,140% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,5331.77,,,5331.77,Other,260% New York Medicaid APG,6644.2,,,6644.2,Other,324% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,2563.35,,,2563.35,Other,125% New York Medicaid APG,2050.68,27245.55,
Laryngoscopy w/fb removal,31530,CPT,,,,,,,,both,,,35699.83,3227.6,,,3227.6,Other,150% of Medicare + 9.63% HCRA Surcharge,1962.72,,,1962.72,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17849.92,50,,17849.92,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1030.04,,,1030.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24989.88,70,,24989.88,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,553.79,,,553.79,Other,New York Medicaid APG methodology,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,775.3,,,775.3,Other,140% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1439.85,,,1439.85,Other,260% New York Medicaid APG,1794.27,,,1794.27,Other,324% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,692.23,,,692.23,Other,125% New York Medicaid APG,553.79,24989.88,
Laryngoscopy w/fb & op scope,31531,CPT,,,,,,,,both,,,35300,7121.36,,,7121.36,Other,150% of Medicare + 9.63% HCRA Surcharge,4330.54,,,4330.54,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17650,50,,17650,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3814.26,,,3814.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24710,70,,24710,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2050.68,,,2050.68,Other,New York Medicaid APG methodology,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,2870.95,,,2870.95,Other,140% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,5331.77,,,5331.77,Other,260% New York Medicaid APG,6644.2,,,6644.2,Other,324% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,2563.35,,,2563.35,Other,125% New York Medicaid APG,2050.68,24710,
Laryngoscopy w/biopsy,31535,CPT,,,,,,,,both,,,40730.91,7121.36,,,7121.36,Other,150% of Medicare + 9.63% HCRA Surcharge,4330.54,,,4330.54,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,20365.46,50,,20365.46,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3814.26,,,3814.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28511.64,70,,28511.64,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2050.68,,,2050.68,Other,New York Medicaid APG methodology,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,2870.95,,,2870.95,Other,140% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,5331.77,,,5331.77,Other,260% New York Medicaid APG,6644.2,,,6644.2,Other,324% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,2563.35,,,2563.35,Other,125% New York Medicaid APG,2050.68,28511.64,
Laryngoscopy w/bx & op scope,31536,CPT,,,,,,,,both,,,38456,7121.36,,,7121.36,Other,150% of Medicare + 9.63% HCRA Surcharge,4330.54,,,4330.54,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19228,50,,19228,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3814.26,,,3814.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26919.2,70,,26919.2,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2050.68,,,2050.68,Other,New York Medicaid APG methodology,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,2870.95,,,2870.95,Other,140% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,5331.77,,,5331.77,Other,260% New York Medicaid APG,6644.2,,,6644.2,Other,324% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,2563.35,,,2563.35,Other,125% New York Medicaid APG,2050.68,26919.2,
Laryngoscopy w/exc of tumor,31540,CPT,,,,,,,,both,,,78767.93,7121.36,,,7121.36,Other,150% of Medicare + 9.63% HCRA Surcharge,4330.54,,,4330.54,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,39383.97,50,,39383.97,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3814.26,,,3814.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,55137.55,70,,55137.55,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2050.68,,,2050.68,Other,New York Medicaid APG methodology,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,2870.95,,,2870.95,Other,140% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,5331.77,,,5331.77,Other,260% New York Medicaid APG,6644.2,,,6644.2,Other,324% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,2563.35,,,2563.35,Other,125% New York Medicaid APG,2050.68,55137.55,
Larynscop w/tumr exc + scope,31541,CPT,,,,,,,,both,,,39879.43,7121.36,,,7121.36,Other,150% of Medicare + 9.63% HCRA Surcharge,4330.54,,,4330.54,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19939.72,50,,19939.72,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3814.26,,,3814.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27915.6,70,,27915.6,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2050.68,,,2050.68,Other,New York Medicaid APG methodology,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,2870.95,,,2870.95,Other,140% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,5331.77,,,5331.77,Other,260% New York Medicaid APG,6644.2,,,6644.2,Other,324% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,2563.35,,,2563.35,Other,125% New York Medicaid APG,2050.68,27915.6,
Remove vc lesion w/scope,31545,CPT,,,,,,,,both,,,36077,7121.36,,,7121.36,Other,150% of Medicare + 9.63% HCRA Surcharge,4330.54,,,4330.54,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18038.5,50,,18038.5,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3814.26,,,3814.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25253.9,70,,25253.9,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2050.68,,,2050.68,Other,New York Medicaid APG methodology,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,2870.95,,,2870.95,Other,140% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,5331.77,,,5331.77,Other,260% New York Medicaid APG,6644.2,,,6644.2,Other,324% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,2563.35,,,2563.35,Other,125% New York Medicaid APG,2050.68,25253.9,
Remove vc lesion scope/graft,31546,CPT,,,,,,,,both,,,143961.17,13015.44,,,13015.44,Other,150% of Medicare + 9.63% HCRA Surcharge,7914.77,,,7914.77,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,71980.59,50,,71980.59,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3814.26,,,3814.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,100772.82,70,,100772.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2050.68,,,2050.68,Other,New York Medicaid APG methodology,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,2870.95,,,2870.95,Other,140% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,5331.77,,,5331.77,Other,260% New York Medicaid APG,6644.2,,,6644.2,Other,324% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,2563.35,,,2563.35,Other,125% New York Medicaid APG,2050.68,100772.82,
Laryngoplasty laryngeal sten,31551,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,86224,
Laryngoplasty laryngeal sten,31552,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,86224,
Laryngoplasty laryngeal sten,31553,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,86224,
Laryngoplasty laryngeal sten,31554,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,86224,
Laryngoscop w/arytenoidectom,31560,CPT,,,,,,,,both,,,36585.05,13015.44,,,13015.44,Other,150% of Medicare + 9.63% HCRA Surcharge,7914.77,,,7914.77,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,18292.53,50,,18292.53,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3814.26,,,3814.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25609.54,70,,25609.54,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2050.68,,,2050.68,Other,New York Medicaid APG methodology,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,2870.95,,,2870.95,Other,140% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,5331.77,,,5331.77,Other,260% New York Medicaid APG,6644.2,,,6644.2,Other,324% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,2563.35,,,2563.35,Other,125% New York Medicaid APG,2050.68,25609.54,
Larynscop remve cart + scop,31561,CPT,,,,,,,,both,,,38171.03,13015.44,,,13015.44,Other,150% of Medicare + 9.63% HCRA Surcharge,7914.77,,,7914.77,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,19085.52,50,,19085.52,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3814.26,,,3814.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26719.72,70,,26719.72,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2050.68,,,2050.68,Other,New York Medicaid APG methodology,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,2870.95,,,2870.95,Other,140% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,5331.77,,,5331.77,Other,260% New York Medicaid APG,6644.2,,,6644.2,Other,324% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,2563.35,,,2563.35,Other,125% New York Medicaid APG,2050.68,26719.72,
Laryngoscope w/vc inj,31570,CPT,,,,,,,,both,,,37684.84,7121.36,,,7121.36,Other,150% of Medicare + 9.63% HCRA Surcharge,4330.54,,,4330.54,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18842.42,50,,18842.42,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3814.26,,,3814.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26379.39,70,,26379.39,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2050.68,,,2050.68,Other,New York Medicaid APG methodology,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,2870.95,,,2870.95,Other,140% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,5331.77,,,5331.77,Other,260% New York Medicaid APG,6644.2,,,6644.2,Other,324% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,2563.35,,,2563.35,Other,125% New York Medicaid APG,2050.68,26379.39,
Laryngoscop w/vc inj + scope,31571,CPT,,,,,,,,both,,,38146.33,7121.36,,,7121.36,Other,150% of Medicare + 9.63% HCRA Surcharge,4330.54,,,4330.54,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19073.17,50,,19073.17,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3814.26,,,3814.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26702.43,70,,26702.43,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2050.68,,,2050.68,Other,New York Medicaid APG methodology,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,2870.95,,,2870.95,Other,140% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,5331.77,,,5331.77,Other,260% New York Medicaid APG,6644.2,,,6644.2,Other,324% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,2563.35,,,2563.35,Other,125% New York Medicaid APG,2050.68,26702.43,
Largsc w/laser dstrj les,31572,CPT,,,,,,,,both,,,35485.78,7121.36,,,7121.36,Other,150% of Medicare + 9.63% HCRA Surcharge,4330.54,,,4330.54,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17742.89,50,,17742.89,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3814.26,,,3814.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24840.05,70,,24840.05,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2050.68,,,2050.68,Other,New York Medicaid APG methodology,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,2870.95,,,2870.95,Other,140% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,5331.77,,,5331.77,Other,260% New York Medicaid APG,6644.2,,,6644.2,Other,324% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,2563.35,,,2563.35,Other,125% New York Medicaid APG,2050.68,24840.05,
Largsc w/ther injection,31573,CPT,,,,,,,,both,,,35699.83,3227.6,,,3227.6,Other,150% of Medicare + 9.63% HCRA Surcharge,1962.72,,,1962.72,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17849.92,50,,17849.92,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3814.26,,,3814.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24989.88,70,,24989.88,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2050.68,,,2050.68,Other,New York Medicaid APG methodology,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,2870.95,,,2870.95,Other,140% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,5331.77,,,5331.77,Other,260% New York Medicaid APG,6644.2,,,6644.2,Other,324% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,2563.35,,,2563.35,Other,125% New York Medicaid APG,1962.72,24989.88,
Largsc w/njx augmentation,31574,CPT,,,,,,,,both,,,35276,3227.6,,,3227.6,Other,150% of Medicare + 9.63% HCRA Surcharge,1962.72,,,1962.72,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17638,50,,17638,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3814.26,,,3814.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24693.2,70,,24693.2,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2050.68,,,2050.68,Other,New York Medicaid APG methodology,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,2870.95,,,2870.95,Other,140% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,5331.77,,,5331.77,Other,260% New York Medicaid APG,6644.2,,,6644.2,Other,324% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,2563.35,,,2563.35,Other,125% New York Medicaid APG,1962.72,24693.2,
Diagnostic laryngoscopy,31575,CPT,,,,,,,,both,,,4166.39,376.68,,,376.68,Other,150% of Medicare + 9.63% HCRA Surcharge,229.06,,,229.06,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2083.2,50,,2083.2,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2916.47,70,,2916.47,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,0.01,9473,
Laryngoscopy with biopsy,31576,CPT,,,,,,,,both,,,35699.83,3227.6,,,3227.6,Other,150% of Medicare + 9.63% HCRA Surcharge,1962.72,,,1962.72,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17849.92,50,,17849.92,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3814.26,,,3814.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24989.88,70,,24989.88,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2050.68,,,2050.68,Other,New York Medicaid APG methodology,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,2870.95,,,2870.95,Other,140% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,5331.77,,,5331.77,Other,260% New York Medicaid APG,6644.2,,,6644.2,Other,324% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,2563.35,,,2563.35,Other,125% New York Medicaid APG,1962.72,24989.88,
Largsc w/rmvl foreign bdy(s),31577,CPT,,,,,,,,both,,,8588.63,776.49,,,776.49,Other,150% of Medicare + 9.63% HCRA Surcharge,472.19,,,472.19,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4294.32,50,,4294.32,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1030.04,,,1030.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,6012.04,70,,6012.04,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,553.79,,,553.79,Other,New York Medicaid APG methodology,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,775.3,,,775.3,Other,140% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1439.85,,,1439.85,Other,260% New York Medicaid APG,1794.27,,,1794.27,Other,324% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,692.23,,,692.23,Other,125% New York Medicaid APG,472.19,9473,
Largsc w/removal lesion,31578,CPT,,,,,,,,both,,,175702.48,7121.36,,,7121.36,Other,150% of Medicare + 9.63% HCRA Surcharge,4330.54,,,4330.54,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,87851.24,50,,87851.24,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3814.26,,,3814.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,122991.74,70,,122991.74,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2050.68,,,2050.68,Other,New York Medicaid APG methodology,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,2870.95,,,2870.95,Other,140% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,5331.77,,,5331.77,Other,260% New York Medicaid APG,6644.2,,,6644.2,Other,324% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,2563.35,,,2563.35,Other,125% New York Medicaid APG,2050.68,122991.74,
Laryngoscopy telescopic,31579,CPT,,,,,,,,both,,,8588.63,776.49,,,776.49,Other,150% of Medicare + 9.63% HCRA Surcharge,472.19,,,472.19,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4294.32,50,,4294.32,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1030.04,,,1030.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,6012.04,70,,6012.04,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,553.79,,,553.79,Other,New York Medicaid APG methodology,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,553.79,,,553.79,Other,100% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,775.3,,,775.3,Other,140% New York Medicaid APG,1246.02,,,1246.02,Other,225% New York Medicaid APG,1439.85,,,1439.85,Other,260% New York Medicaid APG,1794.27,,,1794.27,Other,324% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,1190.64,,,1190.64,Other,215% New York Medicaid APG,692.23,,,692.23,Other,125% New York Medicaid APG,472.19,9473,
Laryngoplasty laryngeal web,31580,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,86224,
Laryngoplasty fx rdctj fixj,31584,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,86224,
Laryngoplasty cricoid split,31587,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,86224,
Reinnervate larynx,31590,CPT,,,,,,,,both,,,55388,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,27694,50,,27694,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,38771.6,70,,38771.6,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,38771.6,
Laryngoplasty medialization,31591,CPT,,,,,,,,both,,,34997.18,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,17498.59,50,,17498.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24498.03,70,,24498.03,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,24498.03,
Cricotracheal resection,31592,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5192.2,,,5192.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2791.5,,,2791.5,Other,New York Medicaid APG methodology,2791.5,,,2791.5,Other,100% New York Medicaid APG,2791.5,,,2791.5,Other,100% New York Medicaid APG,2791.5,,,2791.5,Other,100% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,3908.1,,,3908.1,Other,140% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,7257.91,,,7257.91,Other,260% New York Medicaid APG,9044.47,,,9044.47,Other,324% New York Medicaid APG,6001.73,,,6001.73,Other,215% New York Medicaid APG,6001.73,,,6001.73,Other,215% New York Medicaid APG,3489.38,,,3489.38,Other,125% New York Medicaid APG,2791.5,86224,
Incision of windpipe,31600,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4476.31,,,4476.31,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2406.62,,,2406.62,Other,New York Medicaid APG methodology,2406.62,,,2406.62,Other,100% New York Medicaid APG,2406.62,,,2406.62,Other,100% New York Medicaid APG,2406.62,,,2406.62,Other,100% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,3369.26,,,3369.26,Other,140% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,6257.2,,,6257.2,Other,260% New York Medicaid APG,7797.43,,,7797.43,Other,324% New York Medicaid APG,5174.22,,,5174.22,Other,215% New York Medicaid APG,5174.22,,,5174.22,Other,215% New York Medicaid APG,3008.27,,,3008.27,Other,125% New York Medicaid APG,2406.62,47404.34,
Incision of windpipe,31601,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4476.31,,,4476.31,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2406.62,,,2406.62,Other,New York Medicaid APG methodology,2406.62,,,2406.62,Other,100% New York Medicaid APG,2406.62,,,2406.62,Other,100% New York Medicaid APG,2406.62,,,2406.62,Other,100% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,3369.26,,,3369.26,Other,140% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,6257.2,,,6257.2,Other,260% New York Medicaid APG,7797.43,,,7797.43,Other,324% New York Medicaid APG,5174.22,,,5174.22,Other,215% New York Medicaid APG,5174.22,,,5174.22,Other,215% New York Medicaid APG,3008.27,,,3008.27,Other,125% New York Medicaid APG,2406.62,86224,
Incision of windpipe,31603,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4476.31,,,4476.31,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2406.62,,,2406.62,Other,New York Medicaid APG methodology,2406.62,,,2406.62,Other,100% New York Medicaid APG,2406.62,,,2406.62,Other,100% New York Medicaid APG,2406.62,,,2406.62,Other,100% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,3369.26,,,3369.26,Other,140% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,6257.2,,,6257.2,Other,260% New York Medicaid APG,7797.43,,,7797.43,Other,324% New York Medicaid APG,5174.22,,,5174.22,Other,215% New York Medicaid APG,5174.22,,,5174.22,Other,215% New York Medicaid APG,3008.27,,,3008.27,Other,125% New York Medicaid APG,1763.57,22454.17,
Incision of windpipe,31605,CPT,,,,,,,,both,,,5137.73,464.5,,,464.5,Other,150% of Medicare + 9.63% HCRA Surcharge,282.46,,,282.46,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2568.87,50,,2568.87,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4476.31,,,4476.31,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3596.41,70,,3596.41,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2406.62,,,2406.62,Other,New York Medicaid APG methodology,2406.62,,,2406.62,Other,100% New York Medicaid APG,2406.62,,,2406.62,Other,100% New York Medicaid APG,2406.62,,,2406.62,Other,100% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,3369.26,,,3369.26,Other,140% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,6257.2,,,6257.2,Other,260% New York Medicaid APG,7797.43,,,7797.43,Other,324% New York Medicaid APG,5174.22,,,5174.22,Other,215% New York Medicaid APG,5174.22,,,5174.22,Other,215% New York Medicaid APG,3008.27,,,3008.27,Other,125% New York Medicaid APG,282.46,13157,
Incision of windpipe,31610,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4476.31,,,4476.31,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2406.62,,,2406.62,Other,New York Medicaid APG methodology,2406.62,,,2406.62,Other,100% New York Medicaid APG,2406.62,,,2406.62,Other,100% New York Medicaid APG,2406.62,,,2406.62,Other,100% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,3369.26,,,3369.26,Other,140% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,6257.2,,,6257.2,Other,260% New York Medicaid APG,7797.43,,,7797.43,Other,324% New York Medicaid APG,5174.22,,,5174.22,Other,215% New York Medicaid APG,5174.22,,,5174.22,Other,215% New York Medicaid APG,3008.27,,,3008.27,Other,125% New York Medicaid APG,2406.62,86224,
Surgery/speech prosthesis,31611,CPT,,,,,,,,both,,,39071.66,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19535.83,50,,19535.83,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4476.31,,,4476.31,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27350.16,70,,27350.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2406.62,,,2406.62,Other,New York Medicaid APG methodology,2406.62,,,2406.62,Other,100% New York Medicaid APG,2406.62,,,2406.62,Other,100% New York Medicaid APG,2406.62,,,2406.62,Other,100% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,3369.26,,,3369.26,Other,140% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,6257.2,,,6257.2,Other,260% New York Medicaid APG,7797.43,,,7797.43,Other,324% New York Medicaid APG,5174.22,,,5174.22,Other,215% New York Medicaid APG,5174.22,,,5174.22,Other,215% New York Medicaid APG,3008.27,,,3008.27,Other,125% New York Medicaid APG,2406.62,27350.16,
Puncture/clear windpipe,31612,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1502.62,,,1502.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,239.25,,,239.25,Fee Schedule,,203,,,203,Fee Schedule,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1131.01,,,1131.01,Other,140% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,2100.44,,,2100.44,Other,260% New York Medicaid APG,2617.47,,,2617.47,Other,324% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1009.83,,,1009.83,Other,125% New York Medicaid APG,203,47404.34,
Repair windpipe opening,31613,CPT,,,,,,,,both,,,36827.53,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18413.77,50,,18413.77,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4476.31,,,4476.31,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25779.27,70,,25779.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2406.62,,,2406.62,Other,New York Medicaid APG methodology,2406.62,,,2406.62,Other,100% New York Medicaid APG,2406.62,,,2406.62,Other,100% New York Medicaid APG,2406.62,,,2406.62,Other,100% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,3369.26,,,3369.26,Other,140% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,6257.2,,,6257.2,Other,260% New York Medicaid APG,7797.43,,,7797.43,Other,324% New York Medicaid APG,5174.22,,,5174.22,Other,215% New York Medicaid APG,5174.22,,,5174.22,Other,215% New York Medicaid APG,3008.27,,,3008.27,Other,125% New York Medicaid APG,2406.62,25779.27,
Repair windpipe opening,31614,CPT,,,,,,,,both,,,46626.08,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,23313.04,50,,23313.04,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4476.31,,,4476.31,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,32638.26,70,,32638.26,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2406.62,,,2406.62,Other,New York Medicaid APG methodology,2406.62,,,2406.62,Other,100% New York Medicaid APG,2406.62,,,2406.62,Other,100% New York Medicaid APG,2406.62,,,2406.62,Other,100% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,3369.26,,,3369.26,Other,140% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,6257.2,,,6257.2,Other,260% New York Medicaid APG,7797.43,,,7797.43,Other,324% New York Medicaid APG,5174.22,,,5174.22,Other,215% New York Medicaid APG,5174.22,,,5174.22,Other,215% New York Medicaid APG,3008.27,,,3008.27,Other,125% New York Medicaid APG,2406.62,32638.26,
Visualization of windpipe,31615,CPT,,,,,,,,both,,,11572.85,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5786.43,50,,5786.43,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2717.57,,,2717.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8101,70,,8101,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1461.06,,,1461.06,Other,New York Medicaid APG methodology,1461.06,,,1461.06,Other,100% New York Medicaid APG,1461.06,,,1461.06,Other,100% New York Medicaid APG,1461.06,,,1461.06,Other,100% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,2045.48,,,2045.48,Other,140% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3798.75,,,3798.75,Other,260% New York Medicaid APG,4733.83,,,4733.83,Other,324% New York Medicaid APG,3141.28,,,3141.28,Other,215% New York Medicaid APG,3141.28,,,3141.28,Other,215% New York Medicaid APG,1826.32,,,1826.32,Other,125% New York Medicaid APG,636.26,9473,
Dx bronchoscope/wash,31622,CPT,,,,,,,,both,,,37079.01,3227.6,,,3227.6,Other,150% of Medicare + 9.63% HCRA Surcharge,1962.72,,,1962.72,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18539.51,50,,18539.51,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2717.57,,,2717.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25955.31,70,,25955.31,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1461.06,,,1461.06,Other,New York Medicaid APG methodology,1461.06,,,1461.06,Other,100% New York Medicaid APG,1461.06,,,1461.06,Other,100% New York Medicaid APG,1461.06,,,1461.06,Other,100% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,2045.48,,,2045.48,Other,140% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3798.75,,,3798.75,Other,260% New York Medicaid APG,4733.83,,,4733.83,Other,324% New York Medicaid APG,3141.28,,,3141.28,Other,215% New York Medicaid APG,3141.28,,,3141.28,Other,215% New York Medicaid APG,1826.32,,,1826.32,Other,125% New York Medicaid APG,1461.06,25955.31,
Dx bronchoscope/brush,31623,CPT,,,,,,,,both,,,43100.6,3227.6,,,3227.6,Other,150% of Medicare + 9.63% HCRA Surcharge,1962.72,,,1962.72,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21550.3,50,,21550.3,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2717.57,,,2717.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,30170.42,70,,30170.42,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1461.06,,,1461.06,Other,New York Medicaid APG methodology,1461.06,,,1461.06,Other,100% New York Medicaid APG,1461.06,,,1461.06,Other,100% New York Medicaid APG,1461.06,,,1461.06,Other,100% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,2045.48,,,2045.48,Other,140% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3798.75,,,3798.75,Other,260% New York Medicaid APG,4733.83,,,4733.83,Other,324% New York Medicaid APG,3141.28,,,3141.28,Other,215% New York Medicaid APG,3141.28,,,3141.28,Other,215% New York Medicaid APG,1826.32,,,1826.32,Other,125% New York Medicaid APG,1461.06,30170.42,
Dx bronchoscope/lavage,31624,CPT,,,,,,,,both,,,39238.97,3227.6,,,3227.6,Other,150% of Medicare + 9.63% HCRA Surcharge,1962.72,,,1962.72,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19619.49,50,,19619.49,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2717.57,,,2717.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27467.28,70,,27467.28,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1461.06,,,1461.06,Other,New York Medicaid APG methodology,1461.06,,,1461.06,Other,100% New York Medicaid APG,1461.06,,,1461.06,Other,100% New York Medicaid APG,1461.06,,,1461.06,Other,100% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,2045.48,,,2045.48,Other,140% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3798.75,,,3798.75,Other,260% New York Medicaid APG,4733.83,,,4733.83,Other,324% New York Medicaid APG,3141.28,,,3141.28,Other,215% New York Medicaid APG,3141.28,,,3141.28,Other,215% New York Medicaid APG,1826.32,,,1826.32,Other,125% New York Medicaid APG,1461.06,27467.28,
Bronchoscopy w/biopsy(s),31625,CPT,,,,,,,,both,,,45889.33,3227.6,,,3227.6,Other,150% of Medicare + 9.63% HCRA Surcharge,1962.72,,,1962.72,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,22944.67,50,,22944.67,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2717.57,,,2717.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,32122.53,70,,32122.53,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1461.06,,,1461.06,Other,New York Medicaid APG methodology,1461.06,,,1461.06,Other,100% New York Medicaid APG,1461.06,,,1461.06,Other,100% New York Medicaid APG,1461.06,,,1461.06,Other,100% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,2045.48,,,2045.48,Other,140% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3798.75,,,3798.75,Other,260% New York Medicaid APG,4733.83,,,4733.83,Other,324% New York Medicaid APG,3141.28,,,3141.28,Other,215% New York Medicaid APG,3141.28,,,3141.28,Other,215% New York Medicaid APG,1826.32,,,1826.32,Other,125% New York Medicaid APG,1461.06,32122.53,
Bronchoscopy w/markers,31626,CPT,,,,,,,,both,,,143961.17,13015.44,,,13015.44,Other,150% of Medicare + 9.63% HCRA Surcharge,7914.77,,,7914.77,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,71980.59,50,,71980.59,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2717.57,,,2717.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,100772.82,70,,100772.82,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1461.06,,,1461.06,Other,New York Medicaid APG methodology,1461.06,,,1461.06,Other,100% New York Medicaid APG,1461.06,,,1461.06,Other,100% New York Medicaid APG,1461.06,,,1461.06,Other,100% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,2045.48,,,2045.48,Other,140% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3798.75,,,3798.75,Other,260% New York Medicaid APG,4733.83,,,4733.83,Other,324% New York Medicaid APG,3141.28,,,3141.28,Other,215% New York Medicaid APG,3141.28,,,3141.28,Other,215% New York Medicaid APG,1826.32,,,1826.32,Other,125% New York Medicaid APG,1461.06,100772.82,
Navigational bronchoscopy,31627,CPT,,,,,,,,both,,,59722.25,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,35833.35,60,,35833.35,percent of total billed charges,,33444.46,56,,33444.46,percent of total billed charges,,32250.02,54,,32250.02,percent of total billed charges,,29861.13,50,,29861.13,percent of total billed charges,,41805.58,70,,41805.58,percent of total billed charges,,6152,,,6152,Case Rate,,3840.4,,,3840.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41805.58,70,,41805.58,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2064.73,,,2064.73,Other,New York Medicaid APG methodology,2064.73,,,2064.73,Other,100% New York Medicaid APG,2064.73,,,2064.73,Other,100% New York Medicaid APG,2064.73,,,2064.73,Other,100% New York Medicaid APG,4645.65,,,4645.65,Other,225% New York Medicaid APG,4645.65,,,4645.65,Other,225% New York Medicaid APG,4645.65,,,4645.65,Other,225% New York Medicaid APG,4645.65,,,4645.65,Other,225% New York Medicaid APG,2890.62,,,2890.62,Other,140% New York Medicaid APG,4645.65,,,4645.65,Other,225% New York Medicaid APG,5368.3,,,5368.3,Other,260% New York Medicaid APG,6689.73,,,6689.73,Other,324% New York Medicaid APG,4439.17,,,4439.17,Other,215% New York Medicaid APG,4439.17,,,4439.17,Other,215% New York Medicaid APG,2580.91,,,2580.91,Other,125% New York Medicaid APG,0.01,41805.58,
Bronchoscopy/lung bx each,31628,CPT,,,,,,,,both,,,56748.72,7121.36,,,7121.36,Other,150% of Medicare + 9.63% HCRA Surcharge,4330.54,,,4330.54,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,28374.36,50,,28374.36,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2717.57,,,2717.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,39724.1,70,,39724.1,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1461.06,,,1461.06,Other,New York Medicaid APG methodology,1461.06,,,1461.06,Other,100% New York Medicaid APG,1461.06,,,1461.06,Other,100% New York Medicaid APG,1461.06,,,1461.06,Other,100% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,2045.48,,,2045.48,Other,140% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3798.75,,,3798.75,Other,260% New York Medicaid APG,4733.83,,,4733.83,Other,324% New York Medicaid APG,3141.28,,,3141.28,Other,215% New York Medicaid APG,3141.28,,,3141.28,Other,215% New York Medicaid APG,1826.32,,,1826.32,Other,125% New York Medicaid APG,1461.06,39724.1,
Bronchoscopy/needle bx each,31629,CPT,,,,,,,,both,,,68153.41,7121.36,,,7121.36,Other,150% of Medicare + 9.63% HCRA Surcharge,4330.54,,,4330.54,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34076.71,50,,34076.71,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2717.57,,,2717.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47707.39,70,,47707.39,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1461.06,,,1461.06,Other,New York Medicaid APG methodology,1461.06,,,1461.06,Other,100% New York Medicaid APG,1461.06,,,1461.06,Other,100% New York Medicaid APG,1461.06,,,1461.06,Other,100% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,2045.48,,,2045.48,Other,140% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3798.75,,,3798.75,Other,260% New York Medicaid APG,4733.83,,,4733.83,Other,324% New York Medicaid APG,3141.28,,,3141.28,Other,215% New York Medicaid APG,3141.28,,,3141.28,Other,215% New York Medicaid APG,1826.32,,,1826.32,Other,125% New York Medicaid APG,1461.06,47707.39,
Bronchoscopy dilate/fx repr,31630,CPT,,,,,,,,both,,,37547.22,7121.36,,,7121.36,Other,150% of Medicare + 9.63% HCRA Surcharge,4330.54,,,4330.54,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18773.61,50,,18773.61,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2967.81,,,2967.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26283.05,70,,26283.05,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1595.6,,,1595.6,Other,New York Medicaid APG methodology,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,2233.83,,,2233.83,Other,140% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,4148.55,,,4148.55,Other,260% New York Medicaid APG,5169.73,,,5169.73,Other,324% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,1994.49,,,1994.49,Other,125% New York Medicaid APG,1595.6,26283.05,
Bronchoscopy dilate w/stent,31631,CPT,,,,,,,,both,,,143961.17,13015.44,,,13015.44,Other,150% of Medicare + 9.63% HCRA Surcharge,7914.77,,,7914.77,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,71980.59,50,,71980.59,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2967.81,,,2967.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,100772.82,70,,100772.82,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1595.6,,,1595.6,Other,New York Medicaid APG methodology,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,2233.83,,,2233.83,Other,140% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,4148.55,,,4148.55,Other,260% New York Medicaid APG,5169.73,,,5169.73,Other,324% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,1994.49,,,1994.49,Other,125% New York Medicaid APG,1595.6,100772.82,
Bronchoscopy/lung bx addl,31632,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2717.57,,,2717.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1461.06,,,1461.06,Other,New York Medicaid APG methodology,1461.06,,,1461.06,Other,100% New York Medicaid APG,1461.06,,,1461.06,Other,100% New York Medicaid APG,1461.06,,,1461.06,Other,100% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,2045.48,,,2045.48,Other,140% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3798.75,,,3798.75,Other,260% New York Medicaid APG,4733.83,,,4733.83,Other,324% New York Medicaid APG,3141.28,,,3141.28,Other,215% New York Medicaid APG,3141.28,,,3141.28,Other,215% New York Medicaid APG,1826.32,,,1826.32,Other,125% New York Medicaid APG,0.01,36100.43,
Bronchoscopy/needle bx addl,31633,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2717.57,,,2717.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1461.06,,,1461.06,Other,New York Medicaid APG methodology,1461.06,,,1461.06,Other,100% New York Medicaid APG,1461.06,,,1461.06,Other,100% New York Medicaid APG,1461.06,,,1461.06,Other,100% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,2045.48,,,2045.48,Other,140% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3798.75,,,3798.75,Other,260% New York Medicaid APG,4733.83,,,4733.83,Other,324% New York Medicaid APG,3141.28,,,3141.28,Other,215% New York Medicaid APG,3141.28,,,3141.28,Other,215% New York Medicaid APG,1826.32,,,1826.32,Other,125% New York Medicaid APG,0.01,36100.43,
Bronch w/balloon occlusion,31634,CPT,,,,,,,,both,,,143961.17,13015.44,,,13015.44,Other,150% of Medicare + 9.63% HCRA Surcharge,7914.77,,,7914.77,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,71980.59,50,,71980.59,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2967.81,,,2967.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,100772.82,70,,100772.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1595.6,,,1595.6,Other,New York Medicaid APG methodology,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,2233.83,,,2233.83,Other,140% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,4148.55,,,4148.55,Other,260% New York Medicaid APG,5169.73,,,5169.73,Other,324% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,1994.49,,,1994.49,Other,125% New York Medicaid APG,1595.6,100772.82,
Bronchoscopy w/fb removal,31635,CPT,,,,,,,,both,,,35553.87,3227.6,,,3227.6,Other,150% of Medicare + 9.63% HCRA Surcharge,1962.72,,,1962.72,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17776.94,50,,17776.94,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2717.57,,,2717.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24887.71,70,,24887.71,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1461.06,,,1461.06,Other,New York Medicaid APG methodology,1461.06,,,1461.06,Other,100% New York Medicaid APG,1461.06,,,1461.06,Other,100% New York Medicaid APG,1461.06,,,1461.06,Other,100% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,2045.48,,,2045.48,Other,140% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3798.75,,,3798.75,Other,260% New York Medicaid APG,4733.83,,,4733.83,Other,324% New York Medicaid APG,3141.28,,,3141.28,Other,215% New York Medicaid APG,3141.28,,,3141.28,Other,215% New York Medicaid APG,1826.32,,,1826.32,Other,125% New York Medicaid APG,1461.06,24887.71,
Bronchoscopy bronch stents,31636,CPT,,,,,,,,both,,,44965.28,13015.44,,,13015.44,Other,150% of Medicare + 9.63% HCRA Surcharge,7914.77,,,7914.77,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,22482.64,50,,22482.64,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2967.81,,,2967.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31475.7,70,,31475.7,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1595.6,,,1595.6,Other,New York Medicaid APG methodology,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,2233.83,,,2233.83,Other,140% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,4148.55,,,4148.55,Other,260% New York Medicaid APG,5169.73,,,5169.73,Other,324% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,1994.49,,,1994.49,Other,125% New York Medicaid APG,1595.6,31475.7,
Bronchoscopy stent add-on,31637,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2967.81,,,2967.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1595.6,,,1595.6,Other,New York Medicaid APG methodology,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,2233.83,,,2233.83,Other,140% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,4148.55,,,4148.55,Other,260% New York Medicaid APG,5169.73,,,5169.73,Other,324% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,1994.49,,,1994.49,Other,125% New York Medicaid APG,0.01,22702.47,
Bronchoscopy revise stent,31638,CPT,,,,,,,,both,,,38273,13015.44,,,13015.44,Other,150% of Medicare + 9.63% HCRA Surcharge,7914.77,,,7914.77,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,19136.5,50,,19136.5,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2967.81,,,2967.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26791.1,70,,26791.1,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1595.6,,,1595.6,Other,New York Medicaid APG methodology,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,2233.83,,,2233.83,Other,140% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,4148.55,,,4148.55,Other,260% New York Medicaid APG,5169.73,,,5169.73,Other,324% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,1994.49,,,1994.49,Other,125% New York Medicaid APG,1595.6,26791.1,
Bronchoscopy w/tumor excise,31640,CPT,,,,,,,,both,,,46256.93,7121.36,,,7121.36,Other,150% of Medicare + 9.63% HCRA Surcharge,4330.54,,,4330.54,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,23128.47,50,,23128.47,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2967.81,,,2967.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,32379.85,70,,32379.85,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1595.6,,,1595.6,Other,New York Medicaid APG methodology,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,2233.83,,,2233.83,Other,140% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,4148.55,,,4148.55,Other,260% New York Medicaid APG,5169.73,,,5169.73,Other,324% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,1994.49,,,1994.49,Other,125% New York Medicaid APG,1595.6,32379.85,
Bronchoscopy treat blockage,31641,CPT,,,,,,,,both,,,37178.25,7121.36,,,7121.36,Other,150% of Medicare + 9.63% HCRA Surcharge,4330.54,,,4330.54,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18589.13,50,,18589.13,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2967.81,,,2967.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26024.78,70,,26024.78,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1595.6,,,1595.6,Other,New York Medicaid APG methodology,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,2233.83,,,2233.83,Other,140% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,4148.55,,,4148.55,Other,260% New York Medicaid APG,5169.73,,,5169.73,Other,324% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,1994.49,,,1994.49,Other,125% New York Medicaid APG,1595.6,26024.78,
Diag bronchoscope/catheter,31643,CPT,,,,,,,,both,,,35699.83,3227.6,,,3227.6,Other,150% of Medicare + 9.63% HCRA Surcharge,1962.72,,,1962.72,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17849.92,50,,17849.92,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2717.57,,,2717.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24989.88,70,,24989.88,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1461.06,,,1461.06,Other,New York Medicaid APG methodology,1461.06,,,1461.06,Other,100% New York Medicaid APG,1461.06,,,1461.06,Other,100% New York Medicaid APG,1461.06,,,1461.06,Other,100% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,2045.48,,,2045.48,Other,140% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3798.75,,,3798.75,Other,260% New York Medicaid APG,4733.83,,,4733.83,Other,324% New York Medicaid APG,3141.28,,,3141.28,Other,215% New York Medicaid APG,3141.28,,,3141.28,Other,215% New York Medicaid APG,1826.32,,,1826.32,Other,125% New York Medicaid APG,1461.06,24989.88,
Brnchsc w/ther aspir 1st,31645,CPT,,,,,,,,both,,,36693.03,3227.6,,,3227.6,Other,150% of Medicare + 9.63% HCRA Surcharge,1962.72,,,1962.72,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18346.52,50,,18346.52,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2717.57,,,2717.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25685.12,70,,25685.12,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1461.06,,,1461.06,Other,New York Medicaid APG methodology,1461.06,,,1461.06,Other,100% New York Medicaid APG,1461.06,,,1461.06,Other,100% New York Medicaid APG,1461.06,,,1461.06,Other,100% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,2045.48,,,2045.48,Other,140% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3798.75,,,3798.75,Other,260% New York Medicaid APG,4733.83,,,4733.83,Other,324% New York Medicaid APG,3141.28,,,3141.28,Other,215% New York Medicaid APG,3141.28,,,3141.28,Other,215% New York Medicaid APG,1826.32,,,1826.32,Other,125% New York Medicaid APG,1461.06,25685.12,
Brnchsc w/ther aspir sbsq,31646,CPT,,,,,,,,both,,,8588.63,776.49,,,776.49,Other,150% of Medicare + 9.63% HCRA Surcharge,472.19,,,472.19,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4294.32,50,,4294.32,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2717.57,,,2717.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,6012.04,70,,6012.04,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1461.06,,,1461.06,Other,New York Medicaid APG methodology,1461.06,,,1461.06,Other,100% New York Medicaid APG,1461.06,,,1461.06,Other,100% New York Medicaid APG,1461.06,,,1461.06,Other,100% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,2045.48,,,2045.48,Other,140% New York Medicaid APG,3287.38,,,3287.38,Other,225% New York Medicaid APG,3798.75,,,3798.75,Other,260% New York Medicaid APG,4733.83,,,4733.83,Other,324% New York Medicaid APG,3141.28,,,3141.28,Other,215% New York Medicaid APG,3141.28,,,3141.28,Other,215% New York Medicaid APG,1826.32,,,1826.32,Other,125% New York Medicaid APG,472.19,9473,
Bronchial valve init insert,31647,CPT,,,,,,,,both,,,143961.17,13015.44,,,13015.44,Other,150% of Medicare + 9.63% HCRA Surcharge,7914.77,,,7914.77,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,71980.59,50,,71980.59,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2967.81,,,2967.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,100772.82,70,,100772.82,percent of total billed charges,,986.7,,,986.7,Fee Schedule,,837.2,,,837.2,Fee Schedule,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1595.6,,,1595.6,Other,New York Medicaid APG methodology,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,2233.83,,,2233.83,Other,140% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,4148.55,,,4148.55,Other,260% New York Medicaid APG,5169.73,,,5169.73,Other,324% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,1994.49,,,1994.49,Other,125% New York Medicaid APG,837.2,100772.82,
Bronchial valve remov init,31648,CPT,,,,,,,,both,,,38917.96,7121.36,,,7121.36,Other,150% of Medicare + 9.63% HCRA Surcharge,4330.54,,,4330.54,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19458.98,50,,19458.98,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2967.81,,,2967.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27242.57,70,,27242.57,percent of total billed charges,,945.45,,,945.45,Fee Schedule,,802.2,,,802.2,Fee Schedule,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1595.6,,,1595.6,Other,New York Medicaid APG methodology,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,2233.83,,,2233.83,Other,140% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,4148.55,,,4148.55,Other,260% New York Medicaid APG,5169.73,,,5169.73,Other,324% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,1994.49,,,1994.49,Other,125% New York Medicaid APG,802.2,27242.57,
Bronchial valve remov addl,31649,CPT,,,,,,,,both,,,35699.83,3227.6,,,3227.6,Other,150% of Medicare + 9.63% HCRA Surcharge,1962.72,,,1962.72,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17849.92,50,,17849.92,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2967.81,,,2967.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24989.88,70,,24989.88,percent of total billed charges,,321.75,,,321.75,Fee Schedule,,273,,,273,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1595.6,,,1595.6,Other,New York Medicaid APG methodology,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,2233.83,,,2233.83,Other,140% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,4148.55,,,4148.55,Other,260% New York Medicaid APG,5169.73,,,5169.73,Other,324% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,1994.49,,,1994.49,Other,125% New York Medicaid APG,273,24989.88,
Bronchial valve addl insert,31651,CPT,,,,,,,,both,,,36356.27,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,21813.76,60,,21813.76,percent of total billed charges,,20359.51,56,,20359.51,percent of total billed charges,,19632.39,54,,19632.39,percent of total billed charges,,18178.14,50,,18178.14,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2967.81,,,2967.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25449.39,70,,25449.39,percent of total billed charges,,369.6,,,369.6,Fee Schedule,,313.6,,,313.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1595.6,,,1595.6,Other,New York Medicaid APG methodology,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,2233.83,,,2233.83,Other,140% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,4148.55,,,4148.55,Other,260% New York Medicaid APG,5169.73,,,5169.73,Other,324% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,1994.49,,,1994.49,Other,125% New York Medicaid APG,0.01,25449.39,
Bronch ebus samplng 1/2 node,31652,CPT,,,,,,,,both,,,57482.41,7121.36,,,7121.36,Other,150% of Medicare + 9.63% HCRA Surcharge,4330.54,,,4330.54,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,28741.21,50,,28741.21,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2967.81,,,2967.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,40237.69,70,,40237.69,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1595.6,,,1595.6,Other,New York Medicaid APG methodology,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,2233.83,,,2233.83,Other,140% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,4148.55,,,4148.55,Other,260% New York Medicaid APG,5169.73,,,5169.73,Other,324% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,1994.49,,,1994.49,Other,125% New York Medicaid APG,1595.6,40237.69,
Bronch ebus samplng 3/> node,31653,CPT,,,,,,,,both,,,61306.09,7121.36,,,7121.36,Other,150% of Medicare + 9.63% HCRA Surcharge,4330.54,,,4330.54,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,30653.05,50,,30653.05,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2967.81,,,2967.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,42914.26,70,,42914.26,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1595.6,,,1595.6,Other,New York Medicaid APG methodology,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,2233.83,,,2233.83,Other,140% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,4148.55,,,4148.55,Other,260% New York Medicaid APG,5169.73,,,5169.73,Other,324% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,1994.49,,,1994.49,Other,125% New York Medicaid APG,1595.6,42914.26,
Bronch ebus ivntj perph les,31654,CPT,,,,,,,,both,,,71595.02,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,35797.51,50,,35797.51,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2967.81,,,2967.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50116.51,70,,50116.51,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1595.6,,,1595.6,Other,New York Medicaid APG methodology,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,2233.83,,,2233.83,Other,140% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,4148.55,,,4148.55,Other,260% New York Medicaid APG,5169.73,,,5169.73,Other,324% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,1994.49,,,1994.49,Other,125% New York Medicaid APG,0.01,50116.51,
Bronch thermoplsty 1 lobe,31660,CPT,,,,,,,,both,,,143961.17,13015.44,,,13015.44,Other,150% of Medicare + 9.63% HCRA Surcharge,7914.77,,,7914.77,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,71980.59,50,,71980.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2967.81,,,2967.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,100772.82,70,,100772.82,percent of total billed charges,,952.05,,,952.05,Fee Schedule,,807.8,,,807.8,Fee Schedule,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1595.6,,,1595.6,Other,New York Medicaid APG methodology,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,2233.83,,,2233.83,Other,140% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,4148.55,,,4148.55,Other,260% New York Medicaid APG,5169.73,,,5169.73,Other,324% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,1994.49,,,1994.49,Other,125% New York Medicaid APG,807.8,100772.82,
Bronch thermoplsty 2/> lobes,31661,CPT,,,,,,,,both,,,143961.17,13015.44,,,13015.44,Other,150% of Medicare + 9.63% HCRA Surcharge,7914.77,,,7914.77,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,71980.59,50,,71980.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2967.81,,,2967.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,100772.82,70,,100772.82,percent of total billed charges,,963.6,,,963.6,Fee Schedule,,817.6,,,817.6,Fee Schedule,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1595.6,,,1595.6,Other,New York Medicaid APG methodology,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,2233.83,,,2233.83,Other,140% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,4148.55,,,4148.55,Other,260% New York Medicaid APG,5169.73,,,5169.73,Other,324% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,1994.49,,,1994.49,Other,125% New York Medicaid APG,817.6,100772.82,
Bronchial brush biopsy,31717,CPT,,,,,,,,both,,,8588.63,776.49,,,776.49,Other,150% of Medicare + 9.63% HCRA Surcharge,472.19,,,472.19,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4294.32,50,,4294.32,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2967.81,,,2967.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,6012.04,70,,6012.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1595.6,,,1595.6,Other,New York Medicaid APG methodology,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,2233.83,,,2233.83,Other,140% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,4148.55,,,4148.55,Other,260% New York Medicaid APG,5169.73,,,5169.73,Other,324% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,1994.49,,,1994.49,Other,125% New York Medicaid APG,472.19,13157,
Clearance of airways,31720,CPT,,,,,,,,both,,,4486.27,405.6,,,405.6,Other,150% of Medicare + 9.63% HCRA Surcharge,246.65,,,246.65,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2243.14,50,,2243.14,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,373.11,,,373.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3140.39,70,,3140.39,percent of total billed charges,,235.95,,,235.95,Fee Schedule,,200.2,,,200.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,200.6,,,200.6,Other,New York Medicaid APG methodology,200.6,,,200.6,Other,100% New York Medicaid APG,200.6,,,200.6,Other,100% New York Medicaid APG,200.6,,,200.6,Other,100% New York Medicaid APG,451.34,,,451.34,Other,225% New York Medicaid APG,451.34,,,451.34,Other,225% New York Medicaid APG,451.34,,,451.34,Other,225% New York Medicaid APG,451.34,,,451.34,Other,225% New York Medicaid APG,280.83,,,280.83,Other,140% New York Medicaid APG,451.34,,,451.34,Other,225% New York Medicaid APG,521.55,,,521.55,Other,260% New York Medicaid APG,649.93,,,649.93,Other,324% New York Medicaid APG,431.28,,,431.28,Other,215% New York Medicaid APG,431.28,,,431.28,Other,215% New York Medicaid APG,250.74,,,250.74,Other,125% New York Medicaid APG,200.2,9473,
Intro windpipe wire/tube,31730,CPT,,,,,,,,both,,,35699.83,3227.6,,,3227.6,Other,150% of Medicare + 9.63% HCRA Surcharge,1962.72,,,1962.72,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17849.92,50,,17849.92,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4476.31,,,4476.31,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24989.88,70,,24989.88,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2406.62,,,2406.62,Other,New York Medicaid APG methodology,2406.62,,,2406.62,Other,100% New York Medicaid APG,2406.62,,,2406.62,Other,100% New York Medicaid APG,2406.62,,,2406.62,Other,100% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,3369.26,,,3369.26,Other,140% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,6257.2,,,6257.2,Other,260% New York Medicaid APG,7797.43,,,7797.43,Other,324% New York Medicaid APG,5174.22,,,5174.22,Other,215% New York Medicaid APG,5174.22,,,5174.22,Other,215% New York Medicaid APG,3008.27,,,3008.27,Other,125% New York Medicaid APG,1962.72,24989.88,
Repair of windpipe,31750,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4476.31,,,4476.31,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2406.62,,,2406.62,Other,New York Medicaid APG methodology,2406.62,,,2406.62,Other,100% New York Medicaid APG,2406.62,,,2406.62,Other,100% New York Medicaid APG,2406.62,,,2406.62,Other,100% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,3369.26,,,3369.26,Other,140% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,6257.2,,,6257.2,Other,260% New York Medicaid APG,7797.43,,,7797.43,Other,324% New York Medicaid APG,5174.22,,,5174.22,Other,215% New York Medicaid APG,5174.22,,,5174.22,Other,215% New York Medicaid APG,3008.27,,,3008.27,Other,125% New York Medicaid APG,2406.62,86224,
Repair of windpipe,31755,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4476.31,,,4476.31,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2406.62,,,2406.62,Other,New York Medicaid APG methodology,2406.62,,,2406.62,Other,100% New York Medicaid APG,2406.62,,,2406.62,Other,100% New York Medicaid APG,2406.62,,,2406.62,Other,100% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,3369.26,,,3369.26,Other,140% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,6257.2,,,6257.2,Other,260% New York Medicaid APG,7797.43,,,7797.43,Other,324% New York Medicaid APG,5174.22,,,5174.22,Other,215% New York Medicaid APG,5174.22,,,5174.22,Other,215% New York Medicaid APG,3008.27,,,3008.27,Other,125% New York Medicaid APG,2406.62,86224,
Remove windpipe lesion,31785,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4476.31,,,4476.31,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2406.62,,,2406.62,Other,New York Medicaid APG methodology,2406.62,,,2406.62,Other,100% New York Medicaid APG,2406.62,,,2406.62,Other,100% New York Medicaid APG,2406.62,,,2406.62,Other,100% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,3369.26,,,3369.26,Other,140% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,6257.2,,,6257.2,Other,260% New York Medicaid APG,7797.43,,,7797.43,Other,324% New York Medicaid APG,5174.22,,,5174.22,Other,215% New York Medicaid APG,5174.22,,,5174.22,Other,215% New York Medicaid APG,3008.27,,,3008.27,Other,125% New York Medicaid APG,2406.62,86224,
Closure of windpipe lesion,31820,CPT,,,,,,,,both,,,36971.74,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18485.87,50,,18485.87,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4476.31,,,4476.31,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25880.22,70,,25880.22,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2406.62,,,2406.62,Other,New York Medicaid APG methodology,2406.62,,,2406.62,Other,100% New York Medicaid APG,2406.62,,,2406.62,Other,100% New York Medicaid APG,2406.62,,,2406.62,Other,100% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,3369.26,,,3369.26,Other,140% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,6257.2,,,6257.2,Other,260% New York Medicaid APG,7797.43,,,7797.43,Other,324% New York Medicaid APG,5174.22,,,5174.22,Other,215% New York Medicaid APG,5174.22,,,5174.22,Other,215% New York Medicaid APG,3008.27,,,3008.27,Other,125% New York Medicaid APG,2406.62,25880.22,
Repair of windpipe defect,31825,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4476.31,,,4476.31,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2406.62,,,2406.62,Other,New York Medicaid APG methodology,2406.62,,,2406.62,Other,100% New York Medicaid APG,2406.62,,,2406.62,Other,100% New York Medicaid APG,2406.62,,,2406.62,Other,100% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,3369.26,,,3369.26,Other,140% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,6257.2,,,6257.2,Other,260% New York Medicaid APG,7797.43,,,7797.43,Other,324% New York Medicaid APG,5174.22,,,5174.22,Other,215% New York Medicaid APG,5174.22,,,5174.22,Other,215% New York Medicaid APG,3008.27,,,3008.27,Other,125% New York Medicaid APG,2406.62,47404.34,
Revise windpipe scar,31830,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4476.31,,,4476.31,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2406.62,,,2406.62,Other,New York Medicaid APG methodology,2406.62,,,2406.62,Other,100% New York Medicaid APG,2406.62,,,2406.62,Other,100% New York Medicaid APG,2406.62,,,2406.62,Other,100% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,3369.26,,,3369.26,Other,140% New York Medicaid APG,5414.89,,,5414.89,Other,225% New York Medicaid APG,6257.2,,,6257.2,Other,260% New York Medicaid APG,7797.43,,,7797.43,Other,324% New York Medicaid APG,5174.22,,,5174.22,Other,215% New York Medicaid APG,5174.22,,,5174.22,Other,215% New York Medicaid APG,3008.27,,,3008.27,Other,125% New York Medicaid APG,2406.62,47404.34,
Needle biopsy chest lining,32400,CPT,,,,,,,,both,,,50166.38,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25083.19,50,,25083.19,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1502.62,,,1502.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,35116.47,70,,35116.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1131.01,,,1131.01,Other,140% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,2100.44,,,2100.44,Other,260% New York Medicaid APG,2617.47,,,2617.47,Other,324% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1009.83,,,1009.83,Other,125% New York Medicaid APG,807.86,35116.47,
Core ndl bx lng/med perq,32408,CPT,,,,,,,,both,,,48462.88,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24231.44,50,,24231.44,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1502.62,,,1502.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,33924.02,70,,33924.02,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1131.01,,,1131.01,Other,140% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,2100.44,,,2100.44,Other,260% New York Medicaid APG,2617.47,,,2617.47,Other,324% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1009.83,,,1009.83,Other,125% New York Medicaid APG,807.86,33924.02,
Insert pleural cath,32550,CPT,,,,,,,,both,,,34976,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17488,50,,17488,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1502.62,,,1502.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24483.2,70,,24483.2,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1131.01,,,1131.01,Other,140% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,2100.44,,,2100.44,Other,260% New York Medicaid APG,2617.47,,,2617.47,Other,324% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1009.83,,,1009.83,Other,125% New York Medicaid APG,807.86,24483.2,
Insertion of chest tube,32551,CPT,,,,,,,,both,,,33686.28,3045.56,,,3045.56,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.02,,,1852.02,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16843.14,50,,16843.14,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1502.62,,,1502.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23580.4,70,,23580.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1131.01,,,1131.01,Other,140% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,2100.44,,,2100.44,Other,260% New York Medicaid APG,2617.47,,,2617.47,Other,324% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1009.83,,,1009.83,Other,125% New York Medicaid APG,807.86,23580.4,
Remove lung catheter,32552,CPT,,,,,,,,both,,,33893,1194.63,,,1194.63,Other,150% of Medicare + 9.63% HCRA Surcharge,726.46,,,726.46,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16946.5,50,,16946.5,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1502.62,,,1502.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23725.1,70,,23725.1,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1131.01,,,1131.01,Other,140% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,2100.44,,,2100.44,Other,260% New York Medicaid APG,2617.47,,,2617.47,Other,324% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1009.83,,,1009.83,Other,125% New York Medicaid APG,0.01,23725.1,
Ins mark thor for rt perq,32553,CPT,,,,,,,,both,,,29144.83,2634.97,,,2634.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1602.34,,,1602.34,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,14572.42,50,,14572.42,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,574.46,,,574.46,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,20401.38,70,,20401.38,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,308.85,,,308.85,Other,New York Medicaid APG methodology,308.85,,,308.85,Other,100% New York Medicaid APG,308.85,,,308.85,Other,100% New York Medicaid APG,308.85,,,308.85,Other,100% New York Medicaid APG,694.91,,,694.91,Other,225% New York Medicaid APG,694.91,,,694.91,Other,225% New York Medicaid APG,694.91,,,694.91,Other,225% New York Medicaid APG,694.91,,,694.91,Other,225% New York Medicaid APG,432.39,,,432.39,Other,140% New York Medicaid APG,694.91,,,694.91,Other,225% New York Medicaid APG,803.01,,,803.01,Other,260% New York Medicaid APG,1000.67,,,1000.67,Other,324% New York Medicaid APG,664.02,,,664.02,Other,215% New York Medicaid APG,664.02,,,664.02,Other,215% New York Medicaid APG,386.06,,,386.06,Other,125% New York Medicaid APG,308.85,20401.38,
Aspirate pleura w/o imaging,32554,CPT,,,,,,,,both,,,13213.53,1194.63,,,1194.63,Other,150% of Medicare + 9.63% HCRA Surcharge,726.46,,,726.46,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6606.77,50,,6606.77,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1502.62,,,1502.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9249.47,70,,9249.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1131.01,,,1131.01,Other,140% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,2100.44,,,2100.44,Other,260% New York Medicaid APG,2617.47,,,2617.47,Other,324% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1009.83,,,1009.83,Other,125% New York Medicaid APG,726.46,13157,
Aspirate pleura w/ imaging,32555,CPT,,,,,,,,both,,,24290.55,1194.63,,,1194.63,Other,150% of Medicare + 9.63% HCRA Surcharge,726.46,,,726.46,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,12145.28,50,,12145.28,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1502.62,,,1502.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17003.39,70,,17003.39,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1131.01,,,1131.01,Other,140% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,2100.44,,,2100.44,Other,260% New York Medicaid APG,2617.47,,,2617.47,Other,324% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1009.83,,,1009.83,Other,125% New York Medicaid APG,726.46,17003.39,
Insert cath pleura w/o image,32556,CPT,,,,,,,,both,,,38003,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19001.5,50,,19001.5,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1502.62,,,1502.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26602.1,70,,26602.1,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1131.01,,,1131.01,Other,140% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,2100.44,,,2100.44,Other,260% New York Medicaid APG,2617.47,,,2617.47,Other,324% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1009.83,,,1009.83,Other,125% New York Medicaid APG,807.86,26602.1,
Insert cath pleura w/ image,32557,CPT,,,,,,,,both,,,33686.28,3045.56,,,3045.56,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.02,,,1852.02,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16843.14,50,,16843.14,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1502.62,,,1502.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23580.4,70,,23580.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1131.01,,,1131.01,Other,140% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,2100.44,,,2100.44,Other,260% New York Medicaid APG,2617.47,,,2617.47,Other,324% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1009.83,,,1009.83,Other,125% New York Medicaid APG,807.86,23580.4,
Treat pleurodesis w/agent,32560,CPT,,,,,,,,both,,,13213.53,1194.63,,,1194.63,Other,150% of Medicare + 9.63% HCRA Surcharge,726.46,,,726.46,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6606.77,50,,6606.77,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1502.62,,,1502.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9249.47,70,,9249.47,percent of total billed charges,,367.95,,,367.95,Fee Schedule,,312.2,,,312.2,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1131.01,,,1131.01,Other,140% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,2100.44,,,2100.44,Other,260% New York Medicaid APG,2617.47,,,2617.47,Other,324% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1009.83,,,1009.83,Other,125% New York Medicaid APG,312.2,9473,
Lyse chest fibrin init day,32561,CPT,,,,,,,,both,,,13213.53,1194.63,,,1194.63,Other,150% of Medicare + 9.63% HCRA Surcharge,726.46,,,726.46,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6606.77,50,,6606.77,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1502.62,,,1502.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9249.47,70,,9249.47,percent of total billed charges,,328.35,,,328.35,Fee Schedule,,278.6,,,278.6,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1131.01,,,1131.01,Other,140% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,2100.44,,,2100.44,Other,260% New York Medicaid APG,2617.47,,,2617.47,Other,324% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1009.83,,,1009.83,Other,125% New York Medicaid APG,278.6,9473,
Lyse chest fibrin subq day,32562,CPT,,,,,,,,both,,,13213.53,1194.63,,,1194.63,Other,150% of Medicare + 9.63% HCRA Surcharge,726.46,,,726.46,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6606.77,50,,6606.77,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1502.62,,,1502.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9249.47,70,,9249.47,percent of total billed charges,,292.05,,,292.05,Fee Schedule,,247.8,,,247.8,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1131.01,,,1131.01,Other,140% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,2100.44,,,2100.44,Other,260% New York Medicaid APG,2617.47,,,2617.47,Other,324% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1009.83,,,1009.83,Other,125% New York Medicaid APG,247.8,9473,
Thoracoscopy diagnostic,32601,CPT,,,,,,,,both,,,121364.27,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,60682.14,50,,60682.14,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5192.2,,,5192.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84954.99,70,,84954.99,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2791.5,,,2791.5,Other,New York Medicaid APG methodology,2791.5,,,2791.5,Other,100% New York Medicaid APG,2791.5,,,2791.5,Other,100% New York Medicaid APG,2791.5,,,2791.5,Other,100% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,3908.1,,,3908.1,Other,140% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,7257.91,,,7257.91,Other,260% New York Medicaid APG,9044.47,,,9044.47,Other,324% New York Medicaid APG,6001.73,,,6001.73,Other,215% New York Medicaid APG,6001.73,,,6001.73,Other,215% New York Medicaid APG,3489.38,,,3489.38,Other,125% New York Medicaid APG,2791.5,84954.99,
Thoracoscopy wbx sac,32604,CPT,,,,,,,,both,,,216515.17,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,108257.59,50,,108257.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4050.15,,,4050.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,151560.62,70,,151560.62,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2177.5,,,2177.5,Other,New York Medicaid APG methodology,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,3048.5,,,3048.5,Other,140% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,5661.5,,,5661.5,Other,260% New York Medicaid APG,7055.1,,,7055.1,Other,324% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,2721.88,,,2721.88,Other,125% New York Medicaid APG,2177.5,151560.62,
Thoracoscopy w/bx med space,32606,CPT,,,,,,,,both,,,115664.62,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,57832.31,50,,57832.31,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5192.2,,,5192.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80965.23,70,,80965.23,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2791.5,,,2791.5,Other,New York Medicaid APG methodology,2791.5,,,2791.5,Other,100% New York Medicaid APG,2791.5,,,2791.5,Other,100% New York Medicaid APG,2791.5,,,2791.5,Other,100% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,3908.1,,,3908.1,Other,140% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,7257.91,,,7257.91,Other,260% New York Medicaid APG,9044.47,,,9044.47,Other,324% New York Medicaid APG,6001.73,,,6001.73,Other,215% New York Medicaid APG,6001.73,,,6001.73,Other,215% New York Medicaid APG,3489.38,,,3489.38,Other,125% New York Medicaid APG,2791.5,80965.23,
Thoracoscopy w/bx infiltrate,32607,CPT,,,,,,,,both,,,216515.17,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,108257.59,50,,108257.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5192.2,,,5192.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,151560.62,70,,151560.62,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2791.5,,,2791.5,Other,New York Medicaid APG methodology,2791.5,,,2791.5,Other,100% New York Medicaid APG,2791.5,,,2791.5,Other,100% New York Medicaid APG,2791.5,,,2791.5,Other,100% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,3908.1,,,3908.1,Other,140% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,7257.91,,,7257.91,Other,260% New York Medicaid APG,9044.47,,,9044.47,Other,324% New York Medicaid APG,6001.73,,,6001.73,Other,215% New York Medicaid APG,6001.73,,,6001.73,Other,215% New York Medicaid APG,3489.38,,,3489.38,Other,125% New York Medicaid APG,2791.5,151560.62,
Thoracoscopy w/bx nodule,32608,CPT,,,,,,,,both,,,216515.17,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,108257.59,50,,108257.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5192.2,,,5192.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,151560.62,70,,151560.62,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2791.5,,,2791.5,Other,New York Medicaid APG methodology,2791.5,,,2791.5,Other,100% New York Medicaid APG,2791.5,,,2791.5,Other,100% New York Medicaid APG,2791.5,,,2791.5,Other,100% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,3908.1,,,3908.1,Other,140% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,7257.91,,,7257.91,Other,260% New York Medicaid APG,9044.47,,,9044.47,Other,324% New York Medicaid APG,6001.73,,,6001.73,Other,215% New York Medicaid APG,6001.73,,,6001.73,Other,215% New York Medicaid APG,3489.38,,,3489.38,Other,125% New York Medicaid APG,2791.5,151560.62,
Thoracoscopy w/bx pleura,32609,CPT,,,,,,,,both,,,121364.27,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,60682.14,50,,60682.14,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4050.15,,,4050.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84954.99,70,,84954.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2177.5,,,2177.5,Other,New York Medicaid APG methodology,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,3048.5,,,3048.5,Other,140% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,5661.5,,,5661.5,Other,260% New York Medicaid APG,7055.1,,,7055.1,Other,324% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,2721.88,,,2721.88,Other,125% New York Medicaid APG,2177.5,84954.99,
Therapeutic pneumothorax,32960,CPT,,,,,,,,both,,,13213.53,1194.63,,,1194.63,Other,150% of Medicare + 9.63% HCRA Surcharge,726.46,,,726.46,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6606.77,50,,6606.77,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1502.62,,,1502.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9249.47,70,,9249.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1131.01,,,1131.01,Other,140% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,2100.44,,,2100.44,Other,260% New York Medicaid APG,2617.47,,,2617.47,Other,324% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1009.83,,,1009.83,Other,125% New York Medicaid APG,726.46,13157,
Ablate pulm tumor perq crybl,32994,CPT,,,,,,,,both,,,216515.17,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,108257.59,50,,108257.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5192.2,,,5192.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,151560.62,70,,151560.62,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2791.5,,,2791.5,Other,New York Medicaid APG methodology,2791.5,,,2791.5,Other,100% New York Medicaid APG,2791.5,,,2791.5,Other,100% New York Medicaid APG,2791.5,,,2791.5,Other,100% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,3908.1,,,3908.1,Other,140% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,7257.91,,,7257.91,Other,260% New York Medicaid APG,9044.47,,,9044.47,Other,324% New York Medicaid APG,6001.73,,,6001.73,Other,215% New York Medicaid APG,6001.73,,,6001.73,Other,215% New York Medicaid APG,3489.38,,,3489.38,Other,125% New York Medicaid APG,2791.5,151560.62,
Ablate pulm tumor perq rf,32998,CPT,,,,,,,,both,,,121364.27,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,60682.14,50,,60682.14,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5192.2,,,5192.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84954.99,70,,84954.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2791.5,,,2791.5,Other,New York Medicaid APG methodology,2791.5,,,2791.5,Other,100% New York Medicaid APG,2791.5,,,2791.5,Other,100% New York Medicaid APG,2791.5,,,2791.5,Other,100% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,3908.1,,,3908.1,Other,140% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,7257.91,,,7257.91,Other,260% New York Medicaid APG,9044.47,,,9044.47,Other,324% New York Medicaid APG,6001.73,,,6001.73,Other,215% New York Medicaid APG,6001.73,,,6001.73,Other,215% New York Medicaid APG,3489.38,,,3489.38,Other,125% New York Medicaid APG,2791.5,84954.99,
Pericardiocentesis w/imaging,33016,CPT,,,,,,,,both,,,33686.28,3045.56,,,3045.56,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.02,,,1852.02,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16843.14,50,,16843.14,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1502.62,,,1502.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23580.4,70,,23580.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1131.01,,,1131.01,Other,140% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,2100.44,,,2100.44,Other,260% New York Medicaid APG,2617.47,,,2617.47,Other,324% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1009.83,,,1009.83,Other,125% New York Medicaid APG,807.86,23580.4,
Insert heart pm atrial,33206,CPT,,,,,,,,both,,,155525,20306.29,,,20306.29,Other,150% of Medicare + 9.63% HCRA Surcharge,12348.38,,,12348.38,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,77762.5,50,,77762.5,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,13784.15,,,13784.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,108867.5,70,,108867.5,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,7410.83,,,7410.83,Other,New York Medicaid APG methodology,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,10375.17,,,10375.17,Other,140% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,19268.17,,,19268.17,Other,260% New York Medicaid APG,24011.11,,,24011.11,Other,324% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,9263.54,,,9263.54,Other,125% New York Medicaid APG,5524,108867.5,
Insert heart pm ventricular,33207,CPT,,,,,,,,both,,,224603.78,20306.29,,,20306.29,Other,150% of Medicare + 9.63% HCRA Surcharge,12348.38,,,12348.38,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,112301.89,50,,112301.89,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,13784.15,,,13784.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,157222.65,70,,157222.65,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,7410.83,,,7410.83,Other,New York Medicaid APG methodology,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,10375.17,,,10375.17,Other,140% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,19268.17,,,19268.17,Other,260% New York Medicaid APG,24011.11,,,24011.11,Other,324% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,9263.54,,,9263.54,Other,125% New York Medicaid APG,5524,157222.65,
Insrt heart pm atrial & vent,33208,CPT,,,,,,,,both,,,119138.84,20306.29,,,20306.29,Other,150% of Medicare + 9.63% HCRA Surcharge,12348.38,,,12348.38,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,59569.42,50,,59569.42,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,13784.15,,,13784.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,83397.19,70,,83397.19,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,14938,,"100% primary, 50% secondary, 25% tertiary procedure",14938,Other,United Healthcare ASC Grouper,13443,,"100% primary, 50% secondary, 25% tertiary procedure",13443,Other,United Healthcare ASC Grouper,14938,,"100% primary, 50% secondary, 25% tertiary procedure",14938,Other,United Healthcare ASC Grouper,12698,,"100% primary, 50% secondary, 25% tertiary procedure",12698,Other,United Healthcare ASC Grouper,7410.83,,,7410.83,Other,New York Medicaid APG methodology,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,10375.17,,,10375.17,Other,140% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,19268.17,,,19268.17,Other,260% New York Medicaid APG,24011.11,,,24011.11,Other,324% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,9263.54,,,9263.54,Other,125% New York Medicaid APG,5524,83397.19,
Insert electrd/pm cath sngl,33210,CPT,,,,,,,,both,,,52092,16155.78,,,16155.78,Other,150% of Medicare + 9.63% HCRA Surcharge,9824.43,,,9824.43,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,26046,50,,26046,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5826.77,,,5826.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36464.4,70,,36464.4,percent of total billed charges,,782.1,,,782.1,Fee Schedule,,663.6,,,663.6,Fee Schedule,,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3132.67,,,3132.67,Other,New York Medicaid APG methodology,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,4385.74,,,4385.74,Other,140% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,8144.95,,,8144.95,Other,260% New York Medicaid APG,10149.86,,,10149.86,Other,324% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,3915.84,,,3915.84,Other,125% New York Medicaid APG,663.6,36464.4,
Insert card electrodes dual,33211,CPT,,,,,,,,both,,,178695.84,16155.78,,,16155.78,Other,150% of Medicare + 9.63% HCRA Surcharge,9824.43,,,9824.43,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,89347.92,50,,89347.92,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5826.77,,,5826.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,125087.09,70,,125087.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3132.67,,,3132.67,Other,New York Medicaid APG methodology,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,4385.74,,,4385.74,Other,140% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,8144.95,,,8144.95,Other,260% New York Medicaid APG,10149.86,,,10149.86,Other,324% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,3915.84,,,3915.84,Other,125% New York Medicaid APG,3132.67,125087.09,
Insert pulse gen sngl lead,33212,CPT,,,,,,,,both,,,178695.84,16155.78,,,16155.78,Other,150% of Medicare + 9.63% HCRA Surcharge,9824.43,,,9824.43,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,89347.92,50,,89347.92,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,13784.15,,,13784.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,125087.09,70,,125087.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,7410.83,,,7410.83,Other,New York Medicaid APG methodology,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,10375.17,,,10375.17,Other,140% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,19268.17,,,19268.17,Other,260% New York Medicaid APG,24011.11,,,24011.11,Other,324% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,9263.54,,,9263.54,Other,125% New York Medicaid APG,5919,125087.09,
Insert pulse gen dual leads,33213,CPT,,,,,,,,both,,,224603.78,20306.29,,,20306.29,Other,150% of Medicare + 9.63% HCRA Surcharge,12348.38,,,12348.38,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,112301.89,50,,112301.89,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,13784.15,,,13784.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,157222.65,70,,157222.65,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,7410.83,,,7410.83,Other,New York Medicaid APG methodology,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,10375.17,,,10375.17,Other,140% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,19268.17,,,19268.17,Other,260% New York Medicaid APG,24011.11,,,24011.11,Other,324% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,9263.54,,,9263.54,Other,125% New York Medicaid APG,5919,157222.65,
Upgrade of pacemaker system,33214,CPT,,,,,,,,both,,,224603.78,20306.29,,,20306.29,Other,150% of Medicare + 9.63% HCRA Surcharge,12348.38,,,12348.38,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,112301.89,50,,112301.89,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,13784.15,,,13784.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,157222.65,70,,157222.65,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,14938,,"100% primary, 50% secondary, 25% tertiary procedure",14938,Other,United Healthcare ASC Grouper,13443,,"100% primary, 50% secondary, 25% tertiary procedure",13443,Other,United Healthcare ASC Grouper,14938,,"100% primary, 50% secondary, 25% tertiary procedure",14938,Other,United Healthcare ASC Grouper,12698,,"100% primary, 50% secondary, 25% tertiary procedure",12698,Other,United Healthcare ASC Grouper,7410.83,,,7410.83,Other,New York Medicaid APG methodology,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,10375.17,,,10375.17,Other,140% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,19268.17,,,19268.17,Other,260% New York Medicaid APG,24011.11,,,24011.11,Other,324% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,9263.54,,,9263.54,Other,125% New York Medicaid APG,5524,157222.65,
Reposition pacing-defib lead,33215,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5826.77,,,5826.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3132.67,,,3132.67,Other,New York Medicaid APG methodology,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,4385.74,,,4385.74,Other,140% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,8144.95,,,8144.95,Other,260% New York Medicaid APG,10149.86,,,10149.86,Other,324% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,3915.84,,,3915.84,Other,125% New York Medicaid APG,3132.67,46931.32,
Insert 1 electrode pm-defib,33216,CPT,,,,,,,,both,,,122462.33,16155.78,,,16155.78,Other,150% of Medicare + 9.63% HCRA Surcharge,9824.43,,,9824.43,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,61231.17,50,,61231.17,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5826.77,,,5826.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,85723.63,70,,85723.63,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3132.67,,,3132.67,Other,New York Medicaid APG methodology,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,4385.74,,,4385.74,Other,140% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,8144.95,,,8144.95,Other,260% New York Medicaid APG,10149.86,,,10149.86,Other,324% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,3915.84,,,3915.84,Other,125% New York Medicaid APG,3132.67,85723.63,
Insert 2 electrode pm-defib,33217,CPT,,,,,,,,both,,,178695.84,16155.78,,,16155.78,Other,150% of Medicare + 9.63% HCRA Surcharge,9824.43,,,9824.43,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,89347.92,50,,89347.92,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5826.77,,,5826.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,125087.09,70,,125087.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3132.67,,,3132.67,Other,New York Medicaid APG methodology,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,4385.74,,,4385.74,Other,140% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,8144.95,,,8144.95,Other,260% New York Medicaid APG,10149.86,,,10149.86,Other,324% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,3915.84,,,3915.84,Other,125% New York Medicaid APG,3132.67,125087.09,
Repair lead pace-defib one,33218,CPT,,,,,,,,both,,,115106,7467.78,,,7467.78,Other,150% of Medicare + 9.63% HCRA Surcharge,4541.2,,,4541.2,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,57553,50,,57553,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5826.77,,,5826.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80574.2,70,,80574.2,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3132.67,,,3132.67,Other,New York Medicaid APG methodology,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,4385.74,,,4385.74,Other,140% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,8144.95,,,8144.95,Other,260% New York Medicaid APG,10149.86,,,10149.86,Other,324% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,3915.84,,,3915.84,Other,125% New York Medicaid APG,3132.67,80574.2,
Repair lead pace-defib dual,33220,CPT,,,,,,,,both,,,82599.65,7467.78,,,7467.78,Other,150% of Medicare + 9.63% HCRA Surcharge,4541.2,,,4541.2,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,41299.83,50,,41299.83,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5826.77,,,5826.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,57819.76,70,,57819.76,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3132.67,,,3132.67,Other,New York Medicaid APG methodology,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,4385.74,,,4385.74,Other,140% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,8144.95,,,8144.95,Other,260% New York Medicaid APG,10149.86,,,10149.86,Other,324% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,3915.84,,,3915.84,Other,125% New York Medicaid APG,3132.67,57819.76,
Insert pulse gen mult leads,33221,CPT,,,,,,,,both,,,409846.89,37054.01,,,37054.01,Other,150% of Medicare + 9.63% HCRA Surcharge,22532.77,,,22532.77,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,204923.45,50,,204923.45,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,13784.15,,,13784.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,286892.82,70,,286892.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,7410.83,,,7410.83,Other,New York Medicaid APG methodology,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,10375.17,,,10375.17,Other,140% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,19268.17,,,19268.17,Other,260% New York Medicaid APG,24011.11,,,24011.11,Other,324% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,9263.54,,,9263.54,Other,125% New York Medicaid APG,5524,286892.82,
Relocation pocket pacemaker,33222,CPT,,,,,,,,both,,,72120,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,36060,50,,36060,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5826.77,,,5826.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50484,70,,50484,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,3132.67,,,3132.67,Other,New York Medicaid APG methodology,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,4385.74,,,4385.74,Other,140% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,8144.95,,,8144.95,Other,260% New York Medicaid APG,10149.86,,,10149.86,Other,324% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,3915.84,,,3915.84,Other,125% New York Medicaid APG,2108.84,50484,
Relocate pocket for defib,33223,CPT,,,,,,,,both,,,107123.53,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,53561.77,50,,53561.77,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5826.77,,,5826.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,74986.47,70,,74986.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,3132.67,,,3132.67,Other,New York Medicaid APG methodology,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,4385.74,,,4385.74,Other,140% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,8144.95,,,8144.95,Other,260% New York Medicaid APG,10149.86,,,10149.86,Other,324% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,3915.84,,,3915.84,Other,125% New York Medicaid APG,2108.84,74986.47,
Insert pacing lead & connect,33224,CPT,,,,,,,,both,,,127078,20306.29,,,20306.29,Other,150% of Medicare + 9.63% HCRA Surcharge,12348.38,,,12348.38,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,63539,50,,63539,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,13784.15,,,13784.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,88954.6,70,,88954.6,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,14938,,"100% primary, 50% secondary, 25% tertiary procedure",14938,Other,United Healthcare ASC Grouper,13443,,"100% primary, 50% secondary, 25% tertiary procedure",13443,Other,United Healthcare ASC Grouper,14938,,"100% primary, 50% secondary, 25% tertiary procedure",14938,Other,United Healthcare ASC Grouper,12698,,"100% primary, 50% secondary, 25% tertiary procedure",12698,Other,United Healthcare ASC Grouper,7410.83,,,7410.83,Other,New York Medicaid APG methodology,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,10375.17,,,10375.17,Other,140% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,19268.17,,,19268.17,Other,260% New York Medicaid APG,24011.11,,,24011.11,Other,324% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,9263.54,,,9263.54,Other,125% New York Medicaid APG,5524,88954.6,
L ventric pacing lead add-on,33225,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,13784.15,,,13784.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,14938,,"100% primary, 50% secondary, 25% tertiary procedure",14938,Other,United Healthcare ASC Grouper,13443,,"100% primary, 50% secondary, 25% tertiary procedure",13443,Other,United Healthcare ASC Grouper,14938,,"100% primary, 50% secondary, 25% tertiary procedure",14938,Other,United Healthcare ASC Grouper,12698,,"100% primary, 50% secondary, 25% tertiary procedure",12698,Other,United Healthcare ASC Grouper,7410.83,,,7410.83,Other,New York Medicaid APG methodology,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,10375.17,,,10375.17,Other,140% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,19268.17,,,19268.17,Other,260% New York Medicaid APG,24011.11,,,24011.11,Other,324% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,9263.54,,,9263.54,Other,125% New York Medicaid APG,0.01,36100.43,
Reposition l ventric lead,33226,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5062.88,,,5062.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2721.98,,,2721.98,Other,New York Medicaid APG methodology,2721.98,,,2721.98,Other,100% New York Medicaid APG,2721.98,,,2721.98,Other,100% New York Medicaid APG,2721.98,,,2721.98,Other,100% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,3810.77,,,3810.77,Other,140% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,7077.15,,,7077.15,Other,260% New York Medicaid APG,8819.22,,,8819.22,Other,324% New York Medicaid APG,5852.26,,,5852.26,Other,215% New York Medicaid APG,5852.26,,,5852.26,Other,215% New York Medicaid APG,3402.48,,,3402.48,Other,125% New York Medicaid APG,2721.98,46931.32,
Remove&replace pm gen singl,33227,CPT,,,,,,,,both,,,80557,16155.78,,,16155.78,Other,150% of Medicare + 9.63% HCRA Surcharge,9824.43,,,9824.43,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,40278.5,50,,40278.5,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,13784.15,,,13784.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56389.9,70,,56389.9,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,7410.83,,,7410.83,Other,New York Medicaid APG methodology,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,10375.17,,,10375.17,Other,140% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,19268.17,,,19268.17,Other,260% New York Medicaid APG,24011.11,,,24011.11,Other,324% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,9263.54,,,9263.54,Other,125% New York Medicaid APG,5524,56389.9,
Remv&replc pm gen dual lead,33228,CPT,,,,,,,,both,,,90306.48,20306.29,,,20306.29,Other,150% of Medicare + 9.63% HCRA Surcharge,12348.38,,,12348.38,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,45153.24,50,,45153.24,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,13784.15,,,13784.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,63214.54,70,,63214.54,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,7410.83,,,7410.83,Other,New York Medicaid APG methodology,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,10375.17,,,10375.17,Other,140% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,19268.17,,,19268.17,Other,260% New York Medicaid APG,24011.11,,,24011.11,Other,324% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,9263.54,,,9263.54,Other,125% New York Medicaid APG,5524,63214.54,
Remv&replc pm gen mult leads,33229,CPT,,,,,,,,both,,,162903.47,37054.01,,,37054.01,Other,150% of Medicare + 9.63% HCRA Surcharge,22532.77,,,22532.77,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,81451.74,50,,81451.74,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,13784.15,,,13784.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,114032.43,70,,114032.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,7410.83,,,7410.83,Other,New York Medicaid APG methodology,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,10375.17,,,10375.17,Other,140% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,19268.17,,,19268.17,Other,260% New York Medicaid APG,24011.11,,,24011.11,Other,324% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,9263.54,,,9263.54,Other,125% New York Medicaid APG,5524,114032.43,
Insrt pulse gen w/dual leads,33230,CPT,,,,,,,,both,,,495795.01,44824.52,,,44824.52,Other,150% of Medicare + 9.63% HCRA Surcharge,27258.06,,,27258.06,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,247897.51,50,,247897.51,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,32450.33,,,32450.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,347056.51,70,,347056.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,19221,,"100% primary, 50% secondary, 25% tertiary procedure",19221,Other,United Healthcare ASC Grouper,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,18154,,"100% primary, 50% secondary, 25% tertiary procedure",18154,Other,United Healthcare ASC Grouper,17446.41,,,17446.41,Other,New York Medicaid APG methodology,17446.41,,,17446.41,Other,100% New York Medicaid APG,17446.41,,,17446.41,Other,100% New York Medicaid APG,17446.41,,,17446.41,Other,100% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,24424.98,,,24424.98,Other,140% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,45360.68,,,45360.68,Other,260% New York Medicaid APG,56526.38,,,56526.38,Other,324% New York Medicaid APG,37509.79,,,37509.79,Other,215% New York Medicaid APG,37509.79,,,37509.79,Other,215% New York Medicaid APG,21808.02,,,21808.02,Other,125% New York Medicaid APG,5524,347056.51,
Insrt pulse gen w/mult leads,33231,CPT,,,,,,,,both,,,691990.86,62562.47,,,62562.47,Other,150% of Medicare + 9.63% HCRA Surcharge,38044.62,,,38044.62,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,345995.43,50,,345995.43,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,32450.33,,,32450.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,484393.6,70,,484393.6,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,19221,,"100% primary, 50% secondary, 25% tertiary procedure",19221,Other,United Healthcare ASC Grouper,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,18154,,"100% primary, 50% secondary, 25% tertiary procedure",18154,Other,United Healthcare ASC Grouper,17446.41,,,17446.41,Other,New York Medicaid APG methodology,17446.41,,,17446.41,Other,100% New York Medicaid APG,17446.41,,,17446.41,Other,100% New York Medicaid APG,17446.41,,,17446.41,Other,100% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,24424.98,,,24424.98,Other,140% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,45360.68,,,45360.68,Other,260% New York Medicaid APG,56526.38,,,56526.38,Other,324% New York Medicaid APG,37509.79,,,37509.79,Other,215% New York Medicaid APG,37509.79,,,37509.79,Other,215% New York Medicaid APG,21808.02,,,21808.02,Other,125% New York Medicaid APG,5524,484393.6,
Removal of pm generator,33233,CPT,,,,,,,,both,,,178695.84,16155.78,,,16155.78,Other,150% of Medicare + 9.63% HCRA Surcharge,9824.43,,,9824.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,89347.92,50,,89347.92,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5062.88,,,5062.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,125087.09,70,,125087.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2721.98,,,2721.98,Other,New York Medicaid APG methodology,2721.98,,,2721.98,Other,100% New York Medicaid APG,2721.98,,,2721.98,Other,100% New York Medicaid APG,2721.98,,,2721.98,Other,100% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,3810.77,,,3810.77,Other,140% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,7077.15,,,7077.15,Other,260% New York Medicaid APG,8819.22,,,8819.22,Other,324% New York Medicaid APG,5852.26,,,5852.26,Other,215% New York Medicaid APG,5852.26,,,5852.26,Other,215% New York Medicaid APG,3402.48,,,3402.48,Other,125% New York Medicaid APG,2721.98,125087.09,
Removal of pacemaker system,33234,CPT,,,,,,,,both,,,82599.65,7467.78,,,7467.78,Other,150% of Medicare + 9.63% HCRA Surcharge,4541.2,,,4541.2,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,41299.83,50,,41299.83,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5826.77,,,5826.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,57819.76,70,,57819.76,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3132.67,,,3132.67,Other,New York Medicaid APG methodology,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,4385.74,,,4385.74,Other,140% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,8144.95,,,8144.95,Other,260% New York Medicaid APG,10149.86,,,10149.86,Other,324% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,3915.84,,,3915.84,Other,125% New York Medicaid APG,3132.67,57819.76,
Removal pacemaker electrode,33235,CPT,,,,,,,,both,,,82599.65,7467.78,,,7467.78,Other,150% of Medicare + 9.63% HCRA Surcharge,4541.2,,,4541.2,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,41299.83,50,,41299.83,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5826.77,,,5826.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,57819.76,70,,57819.76,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3132.67,,,3132.67,Other,New York Medicaid APG methodology,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,4385.74,,,4385.74,Other,140% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,8144.95,,,8144.95,Other,260% New York Medicaid APG,10149.86,,,10149.86,Other,324% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,3915.84,,,3915.84,Other,125% New York Medicaid APG,3132.67,57819.76,
Insrt pulse gen w/singl lead,33240,CPT,,,,,,,,both,,,495795.01,44824.52,,,44824.52,Other,150% of Medicare + 9.63% HCRA Surcharge,27258.06,,,27258.06,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,247897.51,50,,247897.51,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,32450.33,,,32450.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,347056.51,70,,347056.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,19221,,"100% primary, 50% secondary, 25% tertiary procedure",19221,Other,United Healthcare ASC Grouper,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,18154,,"100% primary, 50% secondary, 25% tertiary procedure",18154,Other,United Healthcare ASC Grouper,17446.41,,,17446.41,Other,New York Medicaid APG methodology,17446.41,,,17446.41,Other,100% New York Medicaid APG,17446.41,,,17446.41,Other,100% New York Medicaid APG,17446.41,,,17446.41,Other,100% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,24424.98,,,24424.98,Other,140% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,45360.68,,,45360.68,Other,260% New York Medicaid APG,56526.38,,,56526.38,Other,324% New York Medicaid APG,37509.79,,,37509.79,Other,215% New York Medicaid APG,37509.79,,,37509.79,Other,215% New York Medicaid APG,21808.02,,,21808.02,Other,125% New York Medicaid APG,5524,347056.51,
Remove pulse generator,33241,CPT,,,,,,,,both,,,82599.65,7467.78,,,7467.78,Other,150% of Medicare + 9.63% HCRA Surcharge,4541.2,,,4541.2,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,41299.83,50,,41299.83,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5062.88,,,5062.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,57819.76,70,,57819.76,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2721.98,,,2721.98,Other,New York Medicaid APG methodology,2721.98,,,2721.98,Other,100% New York Medicaid APG,2721.98,,,2721.98,Other,100% New York Medicaid APG,2721.98,,,2721.98,Other,100% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,3810.77,,,3810.77,Other,140% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,7077.15,,,7077.15,Other,260% New York Medicaid APG,8819.22,,,8819.22,Other,324% New York Medicaid APG,5852.26,,,5852.26,Other,215% New York Medicaid APG,5852.26,,,5852.26,Other,215% New York Medicaid APG,3402.48,,,3402.48,Other,125% New York Medicaid APG,2721.98,57819.76,
Remove elctrd transvenously,33244,CPT,,,,,,,,both,,,273034.86,7467.78,,,7467.78,Other,150% of Medicare + 9.63% HCRA Surcharge,4541.2,,,4541.2,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,136517.43,50,,136517.43,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5826.77,,,5826.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,191124.4,70,,191124.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3132.67,,,3132.67,Other,New York Medicaid APG methodology,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,4385.74,,,4385.74,Other,140% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,8144.95,,,8144.95,Other,260% New York Medicaid APG,10149.86,,,10149.86,Other,324% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,3915.84,,,3915.84,Other,125% New York Medicaid APG,3132.67,191124.4,
Insj/rplcmt defib w/lead(s),33249,CPT,,,,,,,,both,,,169009.67,62562.47,,,62562.47,Other,150% of Medicare + 9.63% HCRA Surcharge,38044.62,,,38044.62,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,84504.84,50,,84504.84,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,32450.33,,,32450.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,118306.77,70,,118306.77,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,19221,,"100% primary, 50% secondary, 25% tertiary procedure",19221,Other,United Healthcare ASC Grouper,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,18154,,"100% primary, 50% secondary, 25% tertiary procedure",18154,Other,United Healthcare ASC Grouper,17446.41,,,17446.41,Other,New York Medicaid APG methodology,17446.41,,,17446.41,Other,100% New York Medicaid APG,17446.41,,,17446.41,Other,100% New York Medicaid APG,17446.41,,,17446.41,Other,100% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,24424.98,,,24424.98,Other,140% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,45360.68,,,45360.68,Other,260% New York Medicaid APG,56526.38,,,56526.38,Other,324% New York Medicaid APG,37509.79,,,37509.79,Other,215% New York Medicaid APG,37509.79,,,37509.79,Other,215% New York Medicaid APG,21808.02,,,21808.02,Other,125% New York Medicaid APG,5524,118306.77,
Rmvl& replc pulse gen 1 lead,33262,CPT,,,,,,,,both,,,128383.53,44824.52,,,44824.52,Other,150% of Medicare + 9.63% HCRA Surcharge,27258.06,,,27258.06,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,64191.77,50,,64191.77,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,32450.33,,,32450.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,89868.47,70,,89868.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,19221,,"100% primary, 50% secondary, 25% tertiary procedure",19221,Other,United Healthcare ASC Grouper,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,18154,,"100% primary, 50% secondary, 25% tertiary procedure",18154,Other,United Healthcare ASC Grouper,17446.41,,,17446.41,Other,New York Medicaid APG methodology,17446.41,,,17446.41,Other,100% New York Medicaid APG,17446.41,,,17446.41,Other,100% New York Medicaid APG,17446.41,,,17446.41,Other,100% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,24424.98,,,24424.98,Other,140% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,45360.68,,,45360.68,Other,260% New York Medicaid APG,56526.38,,,56526.38,Other,324% New York Medicaid APG,37509.79,,,37509.79,Other,215% New York Medicaid APG,37509.79,,,37509.79,Other,215% New York Medicaid APG,21808.02,,,21808.02,Other,125% New York Medicaid APG,5524,89868.47,
Rmvl & rplcmt dfb gen 2 lead,33263,CPT,,,,,,,,both,,,135571.71,44824.52,,,44824.52,Other,150% of Medicare + 9.63% HCRA Surcharge,27258.06,,,27258.06,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,67785.86,50,,67785.86,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,32450.33,,,32450.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,94900.2,70,,94900.2,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,19221,,"100% primary, 50% secondary, 25% tertiary procedure",19221,Other,United Healthcare ASC Grouper,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,18154,,"100% primary, 50% secondary, 25% tertiary procedure",18154,Other,United Healthcare ASC Grouper,17446.41,,,17446.41,Other,New York Medicaid APG methodology,17446.41,,,17446.41,Other,100% New York Medicaid APG,17446.41,,,17446.41,Other,100% New York Medicaid APG,17446.41,,,17446.41,Other,100% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,24424.98,,,24424.98,Other,140% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,45360.68,,,45360.68,Other,260% New York Medicaid APG,56526.38,,,56526.38,Other,324% New York Medicaid APG,37509.79,,,37509.79,Other,215% New York Medicaid APG,37509.79,,,37509.79,Other,215% New York Medicaid APG,21808.02,,,21808.02,Other,125% New York Medicaid APG,5524,94900.2,
Rmvl & rplcmt dfb gen mlt ld,33264,CPT,,,,,,,,both,,,153330.86,62562.47,,,62562.47,Other,150% of Medicare + 9.63% HCRA Surcharge,38044.62,,,38044.62,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,76665.43,50,,76665.43,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,32450.33,,,32450.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,107331.6,70,,107331.6,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,19221,,"100% primary, 50% secondary, 25% tertiary procedure",19221,Other,United Healthcare ASC Grouper,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,18154,,"100% primary, 50% secondary, 25% tertiary procedure",18154,Other,United Healthcare ASC Grouper,17446.41,,,17446.41,Other,New York Medicaid APG methodology,17446.41,,,17446.41,Other,100% New York Medicaid APG,17446.41,,,17446.41,Other,100% New York Medicaid APG,17446.41,,,17446.41,Other,100% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,24424.98,,,24424.98,Other,140% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,45360.68,,,45360.68,Other,260% New York Medicaid APG,56526.38,,,56526.38,Other,324% New York Medicaid APG,37509.79,,,37509.79,Other,215% New York Medicaid APG,37509.79,,,37509.79,Other,215% New York Medicaid APG,21808.02,,,21808.02,Other,125% New York Medicaid APG,5524,107331.6,
Ins/rep subq defibrillator,33270,CPT,,,,,,,,both,,,209767.75,62562.47,,,62562.47,Other,150% of Medicare + 9.63% HCRA Surcharge,38044.62,,,38044.62,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,104883.88,50,,104883.88,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,32450.33,,,32450.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,146837.43,70,,146837.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,19221,,"100% primary, 50% secondary, 25% tertiary procedure",19221,Other,United Healthcare ASC Grouper,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,18154,,"100% primary, 50% secondary, 25% tertiary procedure",18154,Other,United Healthcare ASC Grouper,17446.41,,,17446.41,Other,New York Medicaid APG methodology,17446.41,,,17446.41,Other,100% New York Medicaid APG,17446.41,,,17446.41,Other,100% New York Medicaid APG,17446.41,,,17446.41,Other,100% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,24424.98,,,24424.98,Other,140% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,45360.68,,,45360.68,Other,260% New York Medicaid APG,56526.38,,,56526.38,Other,324% New York Medicaid APG,37509.79,,,37509.79,Other,215% New York Medicaid APG,37509.79,,,37509.79,Other,215% New York Medicaid APG,21808.02,,,21808.02,Other,125% New York Medicaid APG,5524,146837.43,
Insj subq impltbl dfb elctrd,33271,CPT,,,,,,,,both,,,178695.84,16155.78,,,16155.78,Other,150% of Medicare + 9.63% HCRA Surcharge,9824.43,,,9824.43,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,89347.92,50,,89347.92,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5826.77,,,5826.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,125087.09,70,,125087.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3132.67,,,3132.67,Other,New York Medicaid APG methodology,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,4385.74,,,4385.74,Other,140% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,8144.95,,,8144.95,Other,260% New York Medicaid APG,10149.86,,,10149.86,Other,324% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,3915.84,,,3915.84,Other,125% New York Medicaid APG,3132.67,125087.09,
Rmvl of subq defibrillator,33272,CPT,,,,,,,,both,,,82599.65,7467.78,,,7467.78,Other,150% of Medicare + 9.63% HCRA Surcharge,4541.2,,,4541.2,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,41299.83,50,,41299.83,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5826.77,,,5826.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,57819.76,70,,57819.76,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3132.67,,,3132.67,Other,New York Medicaid APG methodology,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,4385.74,,,4385.74,Other,140% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,8144.95,,,8144.95,Other,260% New York Medicaid APG,10149.86,,,10149.86,Other,324% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,3915.84,,,3915.84,Other,125% New York Medicaid APG,3132.67,57819.76,
Repos prev impltbl subq dfb,33273,CPT,,,,,,,,both,,,82599.65,7467.78,,,7467.78,Other,150% of Medicare + 9.63% HCRA Surcharge,4541.2,,,4541.2,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,41299.83,50,,41299.83,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5826.77,,,5826.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,57819.76,70,,57819.76,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3132.67,,,3132.67,Other,New York Medicaid APG methodology,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,4385.74,,,4385.74,Other,140% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,8144.95,,,8144.95,Other,260% New York Medicaid APG,10149.86,,,10149.86,Other,324% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,3915.84,,,3915.84,Other,125% New York Medicaid APG,3132.67,57819.76,
Tcat insj/rpl perm ldls pm,33274,CPT,,,,,,,,both,,,111843.5,37054.01,,,37054.01,Other,150% of Medicare + 9.63% HCRA Surcharge,22532.77,,,22532.77,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,55921.75,50,,55921.75,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,13784.15,,,13784.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,78290.45,70,,78290.45,percent of total billed charges,,2339.7,,,2339.7,Fee Schedule,,1985.2,,,1985.2,Fee Schedule,,17798,,"100% primary, 50% secondary, 25% tertiary procedure",17798,Other,United Healthcare ASC Grouper,16018,,"100% primary, 50% secondary, 25% tertiary procedure",16018,Other,United Healthcare ASC Grouper,17798,,"100% primary, 50% secondary, 25% tertiary procedure",17798,Other,United Healthcare ASC Grouper,15129,,"100% primary, 50% secondary, 25% tertiary procedure",15129,Other,United Healthcare ASC Grouper,7410.83,,,7410.83,Other,New York Medicaid APG methodology,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,10375.17,,,10375.17,Other,140% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,19268.17,,,19268.17,Other,260% New York Medicaid APG,24011.11,,,24011.11,Other,324% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,9263.54,,,9263.54,Other,125% New York Medicaid APG,1985.2,78290.45,
Tcat rmvl perm ldls pm w/img,33275,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5062.88,,,5062.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,2440.35,,,2440.35,Fee Schedule,,2070.6,,,2070.6,Fee Schedule,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2721.98,,,2721.98,Other,New York Medicaid APG methodology,2721.98,,,2721.98,Other,100% New York Medicaid APG,2721.98,,,2721.98,Other,100% New York Medicaid APG,2721.98,,,2721.98,Other,100% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,3810.77,,,3810.77,Other,140% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,7077.15,,,7077.15,Other,260% New York Medicaid APG,8819.22,,,8819.22,Other,324% New York Medicaid APG,5852.26,,,5852.26,Other,215% New York Medicaid APG,5852.26,,,5852.26,Other,215% New York Medicaid APG,3402.48,,,3402.48,Other,125% New York Medicaid APG,2070.6,46931.32,
Insj subq car rhythm mntr,33285,CPT,,,,,,,,both,,,63517.36,16155.78,,,16155.78,Other,150% of Medicare + 9.63% HCRA Surcharge,9824.43,,,9824.43,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,31758.68,50,,31758.68,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,13784.15,,,13784.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,44462.15,70,,44462.15,percent of total billed charges,,427.35,,,427.35,Fee Schedule,,362.6,,,362.6,Fee Schedule,,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,7410.83,,,7410.83,Other,New York Medicaid APG methodology,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,10375.17,,,10375.17,Other,140% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,19268.17,,,19268.17,Other,260% New York Medicaid APG,24011.11,,,24011.11,Other,324% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,9263.54,,,9263.54,Other,125% New York Medicaid APG,362.6,44462.15,
Rmvl subq car rhythm mntr,33286,CPT,,,,,,,,both,,,49862.63,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,24931.32,50,,24931.32,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5826.77,,,5826.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34903.84,70,,34903.84,percent of total billed charges,,420.75,,,420.75,Fee Schedule,,357,,,357,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,3132.67,,,3132.67,Other,New York Medicaid APG methodology,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,4385.74,,,4385.74,Other,140% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,8144.95,,,8144.95,Other,260% New York Medicaid APG,10149.86,,,10149.86,Other,324% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,3915.84,,,3915.84,Other,125% New York Medicaid APG,357,34903.84,
Repair tcat mitral valve,33419,CPT,,,,,,,,both,,,87274.28,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,52364.57,60,,52364.57,percent of total billed charges,,48873.6,56,,48873.6,percent of total billed charges,,47128.11,54,,47128.11,percent of total billed charges,,43637.14,50,,43637.14,percent of total billed charges,,61092,70,,61092,percent of total billed charges,,6152,,,6152,Case Rate,,6073.53,,,6073.53,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,61092,70,,61092,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,3265.34,,,3265.34,Other,New York Medicaid APG methodology,3265.34,,,3265.34,Other,100% New York Medicaid APG,3265.34,,,3265.34,Other,100% New York Medicaid APG,3265.34,,,3265.34,Other,100% New York Medicaid APG,7347.01,,,7347.01,Other,225% New York Medicaid APG,7347.01,,,7347.01,Other,225% New York Medicaid APG,7347.01,,,7347.01,Other,225% New York Medicaid APG,7347.01,,,7347.01,Other,225% New York Medicaid APG,4571.48,,,4571.48,Other,140% New York Medicaid APG,7347.01,,,7347.01,Other,225% New York Medicaid APG,8489.88,,,8489.88,Other,260% New York Medicaid APG,10579.7,,,10579.7,Other,324% New York Medicaid APG,7020.48,,,7020.48,Other,215% New York Medicaid APG,7020.48,,,7020.48,Other,215% New York Medicaid APG,4081.67,,,4081.67,Other,125% New York Medicaid APG,0.01,61092,
Endoscopic vein harvest,33508,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,22702.47,
Aortic hemiarch graft,33866,CPT,,,,,,,,both,,,86591.4,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,43295.7,50,,43295.7,percent of total billed charges,,60613.98,70,,60613.98,percent of total billed charges,,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,60613.98,70,,60613.98,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,0.01,60613.98,
Removal of artery clot,34101,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,80911.37,
Removal of arm artery clot,34111,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,80911.37,
Removal of artery clot,34201,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,80911.37,
Removal of leg artery clot,34203,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,80911.37,
Removal of vein clot,34421,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,46931.32,
Removal of vein clot,34471,CPT,,,,,,,,both,,,13213.53,1194.63,,,1194.63,Other,150% of Medicare + 9.63% HCRA Surcharge,726.46,,,726.46,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6606.77,50,,6606.77,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9249.47,70,,9249.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,726.46,13157,
Removal of vein clot,34490,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,46931.32,
Repair valve femoral vein,34501,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,80911.37,
Transposition of vein valve,34510,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,80911.37,
Cross-over vein graft,34520,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,80911.37,
Leg vein fusion,34530,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,46931.32,
Perq access & clsr fem art,34713,CPT,,,,,,,,both,,,98219.64,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,49109.82,50,,49109.82,percent of total billed charges,,68753.75,70,,68753.75,percent of total billed charges,,6152,,,6152,Case Rate,,3523.82,,,3523.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,68753.75,70,,68753.75,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1894.53,,,1894.53,Other,New York Medicaid APG methodology,1894.53,,,1894.53,Other,100% New York Medicaid APG,1894.53,,,1894.53,Other,100% New York Medicaid APG,1894.53,,,1894.53,Other,100% New York Medicaid APG,4262.68,,,4262.68,Other,225% New York Medicaid APG,4262.68,,,4262.68,Other,225% New York Medicaid APG,4262.68,,,4262.68,Other,225% New York Medicaid APG,4262.68,,,4262.68,Other,225% New York Medicaid APG,2652.34,,,2652.34,Other,140% New York Medicaid APG,4262.68,,,4262.68,Other,225% New York Medicaid APG,4925.77,,,4925.77,Other,260% New York Medicaid APG,6138.27,,,6138.27,Other,324% New York Medicaid APG,4073.23,,,4073.23,Other,215% New York Medicaid APG,4073.23,,,4073.23,Other,215% New York Medicaid APG,2368.16,,,2368.16,Other,125% New York Medicaid APG,0.01,68753.75,
Opn fem art expos cndt crtj,34714,CPT,,,,,,,,both,,,83504,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,41752,50,,41752,percent of total billed charges,,58452.8,70,,58452.8,percent of total billed charges,,6152,,,6152,Case Rate,,3840.4,,,3840.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,58452.8,70,,58452.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2064.73,,,2064.73,Other,New York Medicaid APG methodology,2064.73,,,2064.73,Other,100% New York Medicaid APG,2064.73,,,2064.73,Other,100% New York Medicaid APG,2064.73,,,2064.73,Other,100% New York Medicaid APG,4645.65,,,4645.65,Other,225% New York Medicaid APG,4645.65,,,4645.65,Other,225% New York Medicaid APG,4645.65,,,4645.65,Other,225% New York Medicaid APG,4645.65,,,4645.65,Other,225% New York Medicaid APG,2890.62,,,2890.62,Other,140% New York Medicaid APG,4645.65,,,4645.65,Other,225% New York Medicaid APG,5368.3,,,5368.3,Other,260% New York Medicaid APG,6689.73,,,6689.73,Other,324% New York Medicaid APG,4439.17,,,4439.17,Other,215% New York Medicaid APG,4439.17,,,4439.17,Other,215% New York Medicaid APG,2580.91,,,2580.91,Other,125% New York Medicaid APG,0.01,58452.8,
Opn ax/subcla art expos,34715,CPT,,,,,,,,both,,,83504,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,41752,50,,41752,percent of total billed charges,,58452.8,70,,58452.8,percent of total billed charges,,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,58452.8,70,,58452.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,0.01,58452.8,
Opn ax/subcla art expos cndt,34716,CPT,,,,,,,,both,,,83504,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,41752,50,,41752,percent of total billed charges,,58452.8,70,,58452.8,percent of total billed charges,,6152,,,6152,Case Rate,,3840.4,,,3840.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,58452.8,70,,58452.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2064.73,,,2064.73,Other,New York Medicaid APG methodology,2064.73,,,2064.73,Other,100% New York Medicaid APG,2064.73,,,2064.73,Other,100% New York Medicaid APG,2064.73,,,2064.73,Other,100% New York Medicaid APG,4645.65,,,4645.65,Other,225% New York Medicaid APG,4645.65,,,4645.65,Other,225% New York Medicaid APG,4645.65,,,4645.65,Other,225% New York Medicaid APG,4645.65,,,4645.65,Other,225% New York Medicaid APG,2890.62,,,2890.62,Other,140% New York Medicaid APG,4645.65,,,4645.65,Other,225% New York Medicaid APG,5368.3,,,5368.3,Other,260% New York Medicaid APG,6689.73,,,6689.73,Other,324% New York Medicaid APG,4439.17,,,4439.17,Other,215% New York Medicaid APG,4439.17,,,4439.17,Other,215% New York Medicaid APG,2580.91,,,2580.91,Other,125% New York Medicaid APG,0.01,58452.8,
Repair defect of artery,35011,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,80911.37,
Repair defect of arm artery,35045,CPT,,,,,,,,both,,,32847.72,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,16423.86,50,,16423.86,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22993.4,70,,22993.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,22993.4,
Repair blood vessel lesion,35180,CPT,,,,,,,,both,,,33686.28,3045.56,,,3045.56,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.02,,,1852.02,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16843.14,50,,16843.14,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23580.4,70,,23580.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,1852.02,23580.4,
Repair blood vessel lesion,35184,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,46931.32,
Repair blood vessel lesion,35188,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,80911.37,
Repair blood vessel lesion,35190,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,80911.37,
Repair blood vessel lesion,35201,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,80911.37,
Repair blood vessel lesion,35206,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,46931.32,
Repair blood vessel lesion,35207,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,46931.32,
Repair blood vessel lesion,35226,CPT,,,,,,,,both,,,14798.8,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7399.4,50,,7399.4,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10359.16,70,,10359.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,813.62,13157,
Repair blood vessel lesion,35231,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,46931.32,
Repair blood vessel lesion,35236,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,80911.37,
Repair blood vessel lesion,35256,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,80911.37,
Repair blood vessel lesion,35261,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,46931.32,
Repair blood vessel lesion,35266,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,80911.37,
Repair blood vessel lesion,35286,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5230.74,,,5230.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2812.23,,,2812.23,Other,New York Medicaid APG methodology,2812.23,,,2812.23,Other,100% New York Medicaid APG,2812.23,,,2812.23,Other,100% New York Medicaid APG,2812.23,,,2812.23,Other,100% New York Medicaid APG,6327.51,,,6327.51,Other,225% New York Medicaid APG,6327.51,,,6327.51,Other,225% New York Medicaid APG,6327.51,,,6327.51,Other,225% New York Medicaid APG,6327.51,,,6327.51,Other,225% New York Medicaid APG,3937.12,,,3937.12,Other,140% New York Medicaid APG,6327.51,,,6327.51,Other,225% New York Medicaid APG,7311.79,,,7311.79,Other,260% New York Medicaid APG,9111.61,,,9111.61,Other,324% New York Medicaid APG,6046.29,,,6046.29,Other,215% New York Medicaid APG,6046.29,,,6046.29,Other,215% New York Medicaid APG,3515.28,,,3515.28,Other,125% New York Medicaid APG,2812.23,80911.37,
Rechanneling of artery,35321,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,80911.37,
Harvest femoropopliteal vein,35572,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,5230.74,,,5230.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2812.23,,,2812.23,Other,New York Medicaid APG methodology,2812.23,,,2812.23,Other,100% New York Medicaid APG,2812.23,,,2812.23,Other,100% New York Medicaid APG,2812.23,,,2812.23,Other,100% New York Medicaid APG,6327.51,,,6327.51,Other,225% New York Medicaid APG,6327.51,,,6327.51,Other,225% New York Medicaid APG,6327.51,,,6327.51,Other,225% New York Medicaid APG,6327.51,,,6327.51,Other,225% New York Medicaid APG,3937.12,,,3937.12,Other,140% New York Medicaid APG,6327.51,,,6327.51,Other,225% New York Medicaid APG,7311.79,,,7311.79,Other,260% New York Medicaid APG,9111.61,,,9111.61,Other,324% New York Medicaid APG,6046.29,,,6046.29,Other,215% New York Medicaid APG,6046.29,,,6046.29,Other,215% New York Medicaid APG,3515.28,,,3515.28,Other,125% New York Medicaid APG,0.01,36100.43,
Explore limb vessels,35860,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,46931.32,
Removal of clot in graft,35875,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,80911.37,
Removal of clot in graft,35876,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,80911.37,
Revise graft w/vein,35879,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5230.74,,,5230.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2812.23,,,2812.23,Other,New York Medicaid APG methodology,2812.23,,,2812.23,Other,100% New York Medicaid APG,2812.23,,,2812.23,Other,100% New York Medicaid APG,2812.23,,,2812.23,Other,100% New York Medicaid APG,6327.51,,,6327.51,Other,225% New York Medicaid APG,6327.51,,,6327.51,Other,225% New York Medicaid APG,6327.51,,,6327.51,Other,225% New York Medicaid APG,6327.51,,,6327.51,Other,225% New York Medicaid APG,3937.12,,,3937.12,Other,140% New York Medicaid APG,6327.51,,,6327.51,Other,225% New York Medicaid APG,7311.79,,,7311.79,Other,260% New York Medicaid APG,9111.61,,,9111.61,Other,324% New York Medicaid APG,6046.29,,,6046.29,Other,215% New York Medicaid APG,6046.29,,,6046.29,Other,215% New York Medicaid APG,3515.28,,,3515.28,Other,125% New York Medicaid APG,2812.23,80911.37,
Revise graft w/vein,35881,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5230.74,,,5230.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2812.23,,,2812.23,Other,New York Medicaid APG methodology,2812.23,,,2812.23,Other,100% New York Medicaid APG,2812.23,,,2812.23,Other,100% New York Medicaid APG,2812.23,,,2812.23,Other,100% New York Medicaid APG,6327.51,,,6327.51,Other,225% New York Medicaid APG,6327.51,,,6327.51,Other,225% New York Medicaid APG,6327.51,,,6327.51,Other,225% New York Medicaid APG,6327.51,,,6327.51,Other,225% New York Medicaid APG,3937.12,,,3937.12,Other,140% New York Medicaid APG,6327.51,,,6327.51,Other,225% New York Medicaid APG,7311.79,,,7311.79,Other,260% New York Medicaid APG,9111.61,,,9111.61,Other,324% New York Medicaid APG,6046.29,,,6046.29,Other,215% New York Medicaid APG,6046.29,,,6046.29,Other,215% New York Medicaid APG,3515.28,,,3515.28,Other,125% New York Medicaid APG,2812.23,80911.37,
Revise graft w/nonauto graft,35883,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5230.74,,,5230.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2812.23,,,2812.23,Other,New York Medicaid APG methodology,2812.23,,,2812.23,Other,100% New York Medicaid APG,2812.23,,,2812.23,Other,100% New York Medicaid APG,2812.23,,,2812.23,Other,100% New York Medicaid APG,6327.51,,,6327.51,Other,225% New York Medicaid APG,6327.51,,,6327.51,Other,225% New York Medicaid APG,6327.51,,,6327.51,Other,225% New York Medicaid APG,6327.51,,,6327.51,Other,225% New York Medicaid APG,3937.12,,,3937.12,Other,140% New York Medicaid APG,6327.51,,,6327.51,Other,225% New York Medicaid APG,7311.79,,,7311.79,Other,260% New York Medicaid APG,9111.61,,,9111.61,Other,324% New York Medicaid APG,6046.29,,,6046.29,Other,215% New York Medicaid APG,6046.29,,,6046.29,Other,215% New York Medicaid APG,3515.28,,,3515.28,Other,125% New York Medicaid APG,2812.23,80911.37,
Revise graft w/vein,35884,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5230.74,,,5230.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2812.23,,,2812.23,Other,New York Medicaid APG methodology,2812.23,,,2812.23,Other,100% New York Medicaid APG,2812.23,,,2812.23,Other,100% New York Medicaid APG,2812.23,,,2812.23,Other,100% New York Medicaid APG,6327.51,,,6327.51,Other,225% New York Medicaid APG,6327.51,,,6327.51,Other,225% New York Medicaid APG,6327.51,,,6327.51,Other,225% New York Medicaid APG,6327.51,,,6327.51,Other,225% New York Medicaid APG,3937.12,,,3937.12,Other,140% New York Medicaid APG,6327.51,,,6327.51,Other,225% New York Medicaid APG,7311.79,,,7311.79,Other,260% New York Medicaid APG,9111.61,,,9111.61,Other,324% New York Medicaid APG,6046.29,,,6046.29,Other,215% New York Medicaid APG,6046.29,,,6046.29,Other,215% New York Medicaid APG,3515.28,,,3515.28,Other,125% New York Medicaid APG,2812.23,80911.37,
Excision graft extremity,35903,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,46931.32,
Place needle in vein,36000,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,283.45,,,283.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,44.55,,,44.55,Fee Schedule,,37.8,,,37.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,152.39,,,152.39,Other,New York Medicaid APG methodology,152.39,,,152.39,Other,100% New York Medicaid APG,152.39,,,152.39,Other,100% New York Medicaid APG,152.39,,,152.39,Other,100% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,213.35,,,213.35,Other,140% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,396.22,,,396.22,Other,260% New York Medicaid APG,493.75,,,493.75,Other,324% New York Medicaid APG,327.64,,,327.64,Other,215% New York Medicaid APG,327.64,,,327.64,Other,215% New York Medicaid APG,190.49,,,190.49,Other,125% New York Medicaid APG,0.01,22702.47,
Pseudoaneurysm injection trt,36002,CPT,,,,,,,,both,,,13213.53,1194.63,,,1194.63,Other,150% of Medicare + 9.63% HCRA Surcharge,726.46,,,726.46,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6606.77,50,,6606.77,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,896.55,,,896.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9249.47,70,,9249.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,482.02,,,482.02,Other,New York Medicaid APG methodology,482.02,,,482.02,Other,100% New York Medicaid APG,482.02,,,482.02,Other,100% New York Medicaid APG,482.02,,,482.02,Other,100% New York Medicaid APG,1084.54,,,1084.54,Other,225% New York Medicaid APG,1084.54,,,1084.54,Other,225% New York Medicaid APG,1084.54,,,1084.54,Other,225% New York Medicaid APG,1084.54,,,1084.54,Other,225% New York Medicaid APG,674.83,,,674.83,Other,140% New York Medicaid APG,1084.54,,,1084.54,Other,225% New York Medicaid APG,1253.25,,,1253.25,Other,260% New York Medicaid APG,1561.74,,,1561.74,Other,324% New York Medicaid APG,1036.34,,,1036.34,Other,215% New York Medicaid APG,1036.34,,,1036.34,Other,215% New York Medicaid APG,602.52,,,602.52,Other,125% New York Medicaid APG,482.02,13157,
Injection ext venography,36005,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,621.52,,,621.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,232.65,,,232.65,Fee Schedule,,197.4,,,197.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,334.15,,,334.15,Other,New York Medicaid APG methodology,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,467.81,,,467.81,Other,140% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,868.8,,,868.8,Other,260% New York Medicaid APG,1082.66,,,1082.66,Other,324% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,417.69,,,417.69,Other,125% New York Medicaid APG,0.01,22702.47,
Place catheter in vein,36010,CPT,,,,,,,,both,,,70032,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,35016,50,,35016,percent of total billed charges,,49022.4,70,,49022.4,percent of total billed charges,,6152,,,6152,Case Rate,,621.52,,,621.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,49022.4,70,,49022.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,334.15,,,334.15,Other,New York Medicaid APG methodology,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,467.81,,,467.81,Other,140% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,868.8,,,868.8,Other,260% New York Medicaid APG,1082.66,,,1082.66,Other,324% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,417.69,,,417.69,Other,125% New York Medicaid APG,0.01,49022.4,
Place catheter in vein,36011,CPT,,,,,,,,both,,,71652,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,35826,50,,35826,percent of total billed charges,,50156.4,70,,50156.4,percent of total billed charges,,6152,,,6152,Case Rate,,621.52,,,621.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50156.4,70,,50156.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,334.15,,,334.15,Other,New York Medicaid APG methodology,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,467.81,,,467.81,Other,140% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,868.8,,,868.8,Other,260% New York Medicaid APG,1082.66,,,1082.66,Other,324% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,417.69,,,417.69,Other,125% New York Medicaid APG,0.01,50156.4,
Place catheter in vein,36012,CPT,,,,,,,,both,,,35764.36,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17882.18,50,,17882.18,percent of total billed charges,,25035.05,70,,25035.05,percent of total billed charges,,6152,,,6152,Case Rate,,621.52,,,621.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25035.05,70,,25035.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,334.15,,,334.15,Other,New York Medicaid APG methodology,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,467.81,,,467.81,Other,140% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,868.8,,,868.8,Other,260% New York Medicaid APG,1082.66,,,1082.66,Other,324% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,417.69,,,417.69,Other,125% New York Medicaid APG,0.01,25035.05,
Place catheter in artery,36013,CPT,,,,,,,,both,,,83504,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,41752,50,,41752,percent of total billed charges,,58452.8,70,,58452.8,percent of total billed charges,,6152,,,6152,Case Rate,,621.52,,,621.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,58452.8,70,,58452.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,334.15,,,334.15,Other,New York Medicaid APG methodology,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,467.81,,,467.81,Other,140% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,868.8,,,868.8,Other,260% New York Medicaid APG,1082.66,,,1082.66,Other,324% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,417.69,,,417.69,Other,125% New York Medicaid APG,0.01,58452.8,
Place catheter in artery,36014,CPT,,,,,,,,both,,,83504,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,41752,50,,41752,percent of total billed charges,,58452.8,70,,58452.8,percent of total billed charges,,6152,,,6152,Case Rate,,621.52,,,621.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,58452.8,70,,58452.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,334.15,,,334.15,Other,New York Medicaid APG methodology,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,467.81,,,467.81,Other,140% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,868.8,,,868.8,Other,260% New York Medicaid APG,1082.66,,,1082.66,Other,324% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,417.69,,,417.69,Other,125% New York Medicaid APG,0.01,58452.8,
Place catheter in artery,36015,CPT,,,,,,,,both,,,83504,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,41752,50,,41752,percent of total billed charges,,58452.8,70,,58452.8,percent of total billed charges,,6152,,,6152,Case Rate,,621.52,,,621.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,58452.8,70,,58452.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,334.15,,,334.15,Other,New York Medicaid APG methodology,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,467.81,,,467.81,Other,140% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,868.8,,,868.8,Other,260% New York Medicaid APG,1082.66,,,1082.66,Other,324% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,417.69,,,417.69,Other,125% New York Medicaid APG,0.01,58452.8,
Establish access to artery,36100,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,621.52,,,621.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,334.15,,,334.15,Other,New York Medicaid APG methodology,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,467.81,,,467.81,Other,140% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,868.8,,,868.8,Other,260% New York Medicaid APG,1082.66,,,1082.66,Other,324% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,417.69,,,417.69,Other,125% New York Medicaid APG,0.01,22702.47,
Intro ndl icath upr/lxtr art,36140,CPT,,,,,,,,both,,,82502.75,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,41251.38,50,,41251.38,percent of total billed charges,,57751.93,70,,57751.93,percent of total billed charges,,6152,,,6152,Case Rate,,621.52,,,621.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,57751.93,70,,57751.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,334.15,,,334.15,Other,New York Medicaid APG methodology,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,467.81,,,467.81,Other,140% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,868.8,,,868.8,Other,260% New York Medicaid APG,1082.66,,,1082.66,Other,324% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,417.69,,,417.69,Other,125% New York Medicaid APG,0.01,57751.93,
Establish access to aorta,36160,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,621.52,,,621.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,334.15,,,334.15,Other,New York Medicaid APG methodology,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,467.81,,,467.81,Other,140% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,868.8,,,868.8,Other,260% New York Medicaid APG,1082.66,,,1082.66,Other,324% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,417.69,,,417.69,Other,125% New York Medicaid APG,0.01,36100.43,
Place catheter in aorta,36200,CPT,,,,,,,,both,,,32242.94,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16121.47,50,,16121.47,percent of total billed charges,,22570.06,70,,22570.06,percent of total billed charges,,6152,,,6152,Case Rate,,621.52,,,621.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22570.06,70,,22570.06,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,334.15,,,334.15,Other,New York Medicaid APG methodology,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,467.81,,,467.81,Other,140% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,868.8,,,868.8,Other,260% New York Medicaid APG,1082.66,,,1082.66,Other,324% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,417.69,,,417.69,Other,125% New York Medicaid APG,0.01,22570.06,
Place catheter in artery,36215,CPT,,,,,,,,both,,,64479.48,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32239.74,50,,32239.74,percent of total billed charges,,45135.64,70,,45135.64,percent of total billed charges,,6152,,,6152,Case Rate,,621.52,,,621.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45135.64,70,,45135.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,334.15,,,334.15,Other,New York Medicaid APG methodology,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,467.81,,,467.81,Other,140% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,868.8,,,868.8,Other,260% New York Medicaid APG,1082.66,,,1082.66,Other,324% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,417.69,,,417.69,Other,125% New York Medicaid APG,0.01,45135.64,
Place catheter in artery,36216,CPT,,,,,,,,both,,,64479.48,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32239.74,50,,32239.74,percent of total billed charges,,45135.64,70,,45135.64,percent of total billed charges,,6152,,,6152,Case Rate,,621.52,,,621.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45135.64,70,,45135.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,334.15,,,334.15,Other,New York Medicaid APG methodology,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,467.81,,,467.81,Other,140% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,868.8,,,868.8,Other,260% New York Medicaid APG,1082.66,,,1082.66,Other,324% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,417.69,,,417.69,Other,125% New York Medicaid APG,0.01,45135.64,
Place catheter in artery,36217,CPT,,,,,,,,both,,,64479.48,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32239.74,50,,32239.74,percent of total billed charges,,45135.64,70,,45135.64,percent of total billed charges,,6152,,,6152,Case Rate,,621.52,,,621.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45135.64,70,,45135.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,334.15,,,334.15,Other,New York Medicaid APG methodology,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,467.81,,,467.81,Other,140% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,868.8,,,868.8,Other,260% New York Medicaid APG,1082.66,,,1082.66,Other,324% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,417.69,,,417.69,Other,125% New York Medicaid APG,0.01,45135.64,
Place catheter in artery,36218,CPT,,,,,,,,both,,,64479.48,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32239.74,50,,32239.74,percent of total billed charges,,45135.64,70,,45135.64,percent of total billed charges,,6152,,,6152,Case Rate,,621.52,,,621.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45135.64,70,,45135.64,percent of total billed charges,,250.8,,,250.8,Fee Schedule,,212.8,,,212.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,334.15,,,334.15,Other,New York Medicaid APG methodology,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,467.81,,,467.81,Other,140% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,868.8,,,868.8,Other,260% New York Medicaid APG,1082.66,,,1082.66,Other,324% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,417.69,,,417.69,Other,125% New York Medicaid APG,0.01,45135.64,
Place cath thoracic aorta,36221,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2192.39,,,2192.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1178.7,,,1178.7,Other,New York Medicaid APG methodology,1178.7,,,1178.7,Other,100% New York Medicaid APG,1178.7,,,1178.7,Other,100% New York Medicaid APG,1178.7,,,1178.7,Other,100% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,1650.19,,,1650.19,Other,140% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,3064.63,,,3064.63,Other,260% New York Medicaid APG,3819,,,3819,Other,324% New York Medicaid APG,2534.21,,,2534.21,Other,215% New York Medicaid APG,2534.21,,,2534.21,Other,215% New York Medicaid APG,1473.38,,,1473.38,Other,125% New York Medicaid APG,1178.7,46931.32,
Place cath carotid/inom art,36222,CPT,,,,,,,,both,,,23345,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,11672.5,50,,11672.5,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2192.39,,,2192.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,16341.5,70,,16341.5,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1178.7,,,1178.7,Other,New York Medicaid APG methodology,1178.7,,,1178.7,Other,100% New York Medicaid APG,1178.7,,,1178.7,Other,100% New York Medicaid APG,1178.7,,,1178.7,Other,100% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,1650.19,,,1650.19,Other,140% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,3064.63,,,3064.63,Other,260% New York Medicaid APG,3819,,,3819,Other,324% New York Medicaid APG,2534.21,,,2534.21,Other,215% New York Medicaid APG,2534.21,,,2534.21,Other,215% New York Medicaid APG,1473.38,,,1473.38,Other,125% New York Medicaid APG,1178.7,16341.5,
Place cath carotid/inom art,36223,CPT,,,,,,,,both,,,25923.2,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,12961.6,50,,12961.6,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2192.39,,,2192.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,18146.24,70,,18146.24,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,1178.7,,,1178.7,Other,New York Medicaid APG methodology,1178.7,,,1178.7,Other,100% New York Medicaid APG,1178.7,,,1178.7,Other,100% New York Medicaid APG,1178.7,,,1178.7,Other,100% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,1650.19,,,1650.19,Other,140% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,3064.63,,,3064.63,Other,260% New York Medicaid APG,3819,,,3819,Other,324% New York Medicaid APG,2534.21,,,2534.21,Other,215% New York Medicaid APG,2534.21,,,2534.21,Other,215% New York Medicaid APG,1473.38,,,1473.38,Other,125% New York Medicaid APG,1178.7,18146.24,
Place cath carotd art,36224,CPT,,,,,,,,both,,,28636.41,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,14318.21,50,,14318.21,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2192.39,,,2192.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,20045.49,70,,20045.49,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,1178.7,,,1178.7,Other,New York Medicaid APG methodology,1178.7,,,1178.7,Other,100% New York Medicaid APG,1178.7,,,1178.7,Other,100% New York Medicaid APG,1178.7,,,1178.7,Other,100% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,1650.19,,,1650.19,Other,140% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,3064.63,,,3064.63,Other,260% New York Medicaid APG,3819,,,3819,Other,324% New York Medicaid APG,2534.21,,,2534.21,Other,215% New York Medicaid APG,2534.21,,,2534.21,Other,215% New York Medicaid APG,1473.38,,,1473.38,Other,125% New York Medicaid APG,1178.7,20045.49,
Place cath subclavian art,36225,CPT,,,,,,,,both,,,29080.31,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,14540.16,50,,14540.16,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2192.39,,,2192.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,20356.22,70,,20356.22,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1178.7,,,1178.7,Other,New York Medicaid APG methodology,1178.7,,,1178.7,Other,100% New York Medicaid APG,1178.7,,,1178.7,Other,100% New York Medicaid APG,1178.7,,,1178.7,Other,100% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,1650.19,,,1650.19,Other,140% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,3064.63,,,3064.63,Other,260% New York Medicaid APG,3819,,,3819,Other,324% New York Medicaid APG,2534.21,,,2534.21,Other,215% New York Medicaid APG,2534.21,,,2534.21,Other,215% New York Medicaid APG,1473.38,,,1473.38,Other,125% New York Medicaid APG,1178.7,20356.22,
Place cath vertebral art,36226,CPT,,,,,,,,both,,,29146.36,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,14573.18,50,,14573.18,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2192.39,,,2192.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,20402.45,70,,20402.45,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,1178.7,,,1178.7,Other,New York Medicaid APG methodology,1178.7,,,1178.7,Other,100% New York Medicaid APG,1178.7,,,1178.7,Other,100% New York Medicaid APG,1178.7,,,1178.7,Other,100% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,1650.19,,,1650.19,Other,140% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,3064.63,,,3064.63,Other,260% New York Medicaid APG,3819,,,3819,Other,324% New York Medicaid APG,2534.21,,,2534.21,Other,215% New York Medicaid APG,2534.21,,,2534.21,Other,215% New York Medicaid APG,1473.38,,,1473.38,Other,125% New York Medicaid APG,1178.7,20402.45,
Place cath xtrnl carotid,36227,CPT,,,,,,,,both,,,64479.48,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32239.74,50,,32239.74,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2192.39,,,2192.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45135.64,70,,45135.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1178.7,,,1178.7,Other,New York Medicaid APG methodology,1178.7,,,1178.7,Other,100% New York Medicaid APG,1178.7,,,1178.7,Other,100% New York Medicaid APG,1178.7,,,1178.7,Other,100% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,1650.19,,,1650.19,Other,140% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,3064.63,,,3064.63,Other,260% New York Medicaid APG,3819,,,3819,Other,324% New York Medicaid APG,2534.21,,,2534.21,Other,215% New York Medicaid APG,2534.21,,,2534.21,Other,215% New York Medicaid APG,1473.38,,,1473.38,Other,125% New York Medicaid APG,0.01,45135.64,
Place cath intracranial art,36228,CPT,,,,,,,,both,,,64479.48,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32239.74,50,,32239.74,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2192.39,,,2192.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45135.64,70,,45135.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1178.7,,,1178.7,Other,New York Medicaid APG methodology,1178.7,,,1178.7,Other,100% New York Medicaid APG,1178.7,,,1178.7,Other,100% New York Medicaid APG,1178.7,,,1178.7,Other,100% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,1650.19,,,1650.19,Other,140% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,3064.63,,,3064.63,Other,260% New York Medicaid APG,3819,,,3819,Other,324% New York Medicaid APG,2534.21,,,2534.21,Other,215% New York Medicaid APG,2534.21,,,2534.21,Other,215% New York Medicaid APG,1473.38,,,1473.38,Other,125% New York Medicaid APG,0.01,45135.64,
Ins cath abd/l-ext art 1st,36245,CPT,,,,,,,,both,,,50737.16,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,25368.58,50,,25368.58,percent of total billed charges,,35516.01,70,,35516.01,percent of total billed charges,,6152,,,6152,Case Rate,,621.52,,,621.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,35516.01,70,,35516.01,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,334.15,,,334.15,Other,New York Medicaid APG methodology,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,467.81,,,467.81,Other,140% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,868.8,,,868.8,Other,260% New York Medicaid APG,1082.66,,,1082.66,Other,324% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,417.69,,,417.69,Other,125% New York Medicaid APG,0.01,35516.01,
Ins cath abd/l-ext art 2nd,36246,CPT,,,,,,,,both,,,68028.63,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,34014.32,50,,34014.32,percent of total billed charges,,47620.04,70,,47620.04,percent of total billed charges,,6152,,,6152,Case Rate,,621.52,,,621.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47620.04,70,,47620.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,334.15,,,334.15,Other,New York Medicaid APG methodology,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,467.81,,,467.81,Other,140% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,868.8,,,868.8,Other,260% New York Medicaid APG,1082.66,,,1082.66,Other,324% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,417.69,,,417.69,Other,125% New York Medicaid APG,0.01,47620.04,
Ins cath abd/l-ext art 3rd,36247,CPT,,,,,,,,both,,,81571.9,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,40785.95,50,,40785.95,percent of total billed charges,,57100.33,70,,57100.33,percent of total billed charges,,6152,,,6152,Case Rate,,621.52,,,621.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,57100.33,70,,57100.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,334.15,,,334.15,Other,New York Medicaid APG methodology,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,467.81,,,467.81,Other,140% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,868.8,,,868.8,Other,260% New York Medicaid APG,1082.66,,,1082.66,Other,324% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,417.69,,,417.69,Other,125% New York Medicaid APG,0.01,57100.33,
Ins cath abd/l-ext art addl,36248,CPT,,,,,,,,both,,,50142.2,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,25071.1,50,,25071.1,percent of total billed charges,,35099.54,70,,35099.54,percent of total billed charges,,6152,,,6152,Case Rate,,621.52,,,621.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,35099.54,70,,35099.54,percent of total billed charges,,232.65,,,232.65,Fee Schedule,,197.4,,,197.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,334.15,,,334.15,Other,New York Medicaid APG methodology,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,467.81,,,467.81,Other,140% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,868.8,,,868.8,Other,260% New York Medicaid APG,1082.66,,,1082.66,Other,324% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,417.69,,,417.69,Other,125% New York Medicaid APG,0.01,35099.54,
Ins cath ren art 1st unilat,36251,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2192.39,,,2192.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1178.7,,,1178.7,Other,New York Medicaid APG methodology,1178.7,,,1178.7,Other,100% New York Medicaid APG,1178.7,,,1178.7,Other,100% New York Medicaid APG,1178.7,,,1178.7,Other,100% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,1650.19,,,1650.19,Other,140% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,3064.63,,,3064.63,Other,260% New York Medicaid APG,3819,,,3819,Other,324% New York Medicaid APG,2534.21,,,2534.21,Other,215% New York Medicaid APG,2534.21,,,2534.21,Other,215% New York Medicaid APG,1473.38,,,1473.38,Other,125% New York Medicaid APG,1178.7,46931.32,
Ins cath ren art 1st bilat,36252,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2192.39,,,2192.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1178.7,,,1178.7,Other,New York Medicaid APG methodology,1178.7,,,1178.7,Other,100% New York Medicaid APG,1178.7,,,1178.7,Other,100% New York Medicaid APG,1178.7,,,1178.7,Other,100% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,1650.19,,,1650.19,Other,140% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,3064.63,,,3064.63,Other,260% New York Medicaid APG,3819,,,3819,Other,324% New York Medicaid APG,2534.21,,,2534.21,Other,215% New York Medicaid APG,2534.21,,,2534.21,Other,215% New York Medicaid APG,1473.38,,,1473.38,Other,125% New York Medicaid APG,1178.7,46931.32,
Ins cath ren art 2nd+ unilat,36253,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2192.39,,,2192.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,1178.7,,,1178.7,Other,New York Medicaid APG methodology,1178.7,,,1178.7,Other,100% New York Medicaid APG,1178.7,,,1178.7,Other,100% New York Medicaid APG,1178.7,,,1178.7,Other,100% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,1650.19,,,1650.19,Other,140% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,3064.63,,,3064.63,Other,260% New York Medicaid APG,3819,,,3819,Other,324% New York Medicaid APG,2534.21,,,2534.21,Other,215% New York Medicaid APG,2534.21,,,2534.21,Other,215% New York Medicaid APG,1473.38,,,1473.38,Other,125% New York Medicaid APG,1178.7,80911.37,
Ins cath ren art 2nd+ bilat,36254,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2192.39,,,2192.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1178.7,,,1178.7,Other,New York Medicaid APG methodology,1178.7,,,1178.7,Other,100% New York Medicaid APG,1178.7,,,1178.7,Other,100% New York Medicaid APG,1178.7,,,1178.7,Other,100% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,1650.19,,,1650.19,Other,140% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,3064.63,,,3064.63,Other,260% New York Medicaid APG,3819,,,3819,Other,324% New York Medicaid APG,2534.21,,,2534.21,Other,215% New York Medicaid APG,2534.21,,,2534.21,Other,215% New York Medicaid APG,1473.38,,,1473.38,Other,125% New York Medicaid APG,1178.7,46931.32,
Insertion of infusion pump,36260,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,13784.15,,,13784.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,7410.83,,,7410.83,Other,New York Medicaid APG methodology,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,10375.17,,,10375.17,Other,140% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,19268.17,,,19268.17,Other,260% New York Medicaid APG,24011.11,,,24011.11,Other,324% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,9263.54,,,9263.54,Other,125% New York Medicaid APG,5919,80911.37,
Revision of infusion pump,36261,CPT,,,,,,,,both,,,82599.65,7467.78,,,7467.78,Other,150% of Medicare + 9.63% HCRA Surcharge,4541.2,,,4541.2,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,41299.83,50,,41299.83,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5826.77,,,5826.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,57819.76,70,,57819.76,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3132.67,,,3132.67,Other,New York Medicaid APG methodology,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,4385.74,,,4385.74,Other,140% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,8144.95,,,8144.95,Other,260% New York Medicaid APG,10149.86,,,10149.86,Other,324% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,3915.84,,,3915.84,Other,125% New York Medicaid APG,3132.67,57819.76,
Removal of infusion pump,36262,CPT,,,,,,,,both,,,82599.65,7467.78,,,7467.78,Other,150% of Medicare + 9.63% HCRA Surcharge,4541.2,,,4541.2,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,41299.83,50,,41299.83,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5826.77,,,5826.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,57819.76,70,,57819.76,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3132.67,,,3132.67,Other,New York Medicaid APG methodology,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,4385.74,,,4385.74,Other,140% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,8144.95,,,8144.95,Other,260% New York Medicaid APG,10149.86,,,10149.86,Other,324% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,3915.84,,,3915.84,Other,125% New York Medicaid APG,3132.67,57819.76,
Bl draw < 3 yrs fem/jugular,36400,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,300.2,,,300.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,92.4,,,92.4,Fee Schedule,,78.4,,,78.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,161.4,,,161.4,Other,New York Medicaid APG methodology,161.4,,,161.4,Other,100% New York Medicaid APG,161.4,,,161.4,Other,100% New York Medicaid APG,161.4,,,161.4,Other,100% New York Medicaid APG,363.14,,,363.14,Other,225% New York Medicaid APG,363.14,,,363.14,Other,225% New York Medicaid APG,363.14,,,363.14,Other,225% New York Medicaid APG,363.14,,,363.14,Other,225% New York Medicaid APG,225.96,,,225.96,Other,140% New York Medicaid APG,363.14,,,363.14,Other,225% New York Medicaid APG,419.63,,,419.63,Other,260% New York Medicaid APG,522.93,,,522.93,Other,324% New York Medicaid APG,347,,,347,Other,215% New York Medicaid APG,347,,,347,Other,215% New York Medicaid APG,201.75,,,201.75,Other,125% New York Medicaid APG,0.01,22702.47,
Bl draw <3 yrs scalp vein,36405,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,300.2,,,300.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,72.6,,,72.6,Fee Schedule,,61.6,,,61.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,161.4,,,161.4,Other,New York Medicaid APG methodology,161.4,,,161.4,Other,100% New York Medicaid APG,161.4,,,161.4,Other,100% New York Medicaid APG,161.4,,,161.4,Other,100% New York Medicaid APG,363.14,,,363.14,Other,225% New York Medicaid APG,363.14,,,363.14,Other,225% New York Medicaid APG,363.14,,,363.14,Other,225% New York Medicaid APG,363.14,,,363.14,Other,225% New York Medicaid APG,225.96,,,225.96,Other,140% New York Medicaid APG,363.14,,,363.14,Other,225% New York Medicaid APG,419.63,,,419.63,Other,260% New York Medicaid APG,522.93,,,522.93,Other,324% New York Medicaid APG,347,,,347,Other,215% New York Medicaid APG,347,,,347,Other,215% New York Medicaid APG,201.75,,,201.75,Other,125% New York Medicaid APG,0.01,22702.47,
Bl draw <3 yrs other vein,36406,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,300.2,,,300.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,42.9,,,42.9,Fee Schedule,,36.4,,,36.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,161.4,,,161.4,Other,New York Medicaid APG methodology,161.4,,,161.4,Other,100% New York Medicaid APG,161.4,,,161.4,Other,100% New York Medicaid APG,161.4,,,161.4,Other,100% New York Medicaid APG,363.14,,,363.14,Other,225% New York Medicaid APG,363.14,,,363.14,Other,225% New York Medicaid APG,363.14,,,363.14,Other,225% New York Medicaid APG,363.14,,,363.14,Other,225% New York Medicaid APG,225.96,,,225.96,Other,140% New York Medicaid APG,363.14,,,363.14,Other,225% New York Medicaid APG,419.63,,,419.63,Other,260% New York Medicaid APG,522.93,,,522.93,Other,324% New York Medicaid APG,347,,,347,Other,215% New York Medicaid APG,347,,,347,Other,215% New York Medicaid APG,201.75,,,201.75,Other,125% New York Medicaid APG,0.01,22702.47,
Non-routine bl draw 3/> yrs,36410,CPT,,,,,,,,both,,,35243,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,158.75,,,158.75,Fee Schedule,,142.83,,,142.83,Fee Schedule,,134.87,,,134.87,Fee Schedule,,17621.5,50,,17621.5,percent of total billed charges,,24670.1,70,,24670.1,percent of total billed charges,,6152,,,6152,Case Rate,,283.45,,,283.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24670.1,70,,24670.1,percent of total billed charges,,44.55,,,44.55,Fee Schedule,,37.8,,,37.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,152.39,,,152.39,Other,New York Medicaid APG methodology,152.39,,,152.39,Other,100% New York Medicaid APG,152.39,,,152.39,Other,100% New York Medicaid APG,152.39,,,152.39,Other,100% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,213.35,,,213.35,Other,140% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,396.22,,,396.22,Other,260% New York Medicaid APG,493.75,,,493.75,Other,324% New York Medicaid APG,327.64,,,327.64,Other,215% New York Medicaid APG,327.64,,,327.64,Other,215% New York Medicaid APG,190.49,,,190.49,Other,125% New York Medicaid APG,0.01,24670.1,
Capillary blood draw,36416,CPT,,,,,,,,both,,,11.73,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,1.22,,,1.22,Fee Schedule,,1.22,,,1.22,Fee Schedule,,1.22,,,1.22,Fee Schedule,,5.87,50,,5.87,percent of total billed charges,,8.21,70,,8.21,percent of total billed charges,,6152,,,6152,Case Rate,,300.2,,,300.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8.21,70,,8.21,percent of total billed charges,,5.87,50,,5.87,percent of total billed charges,,5.87,50,,5.87,percent of total billed charges,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,161.4,,,161.4,Other,New York Medicaid APG methodology,161.4,,,161.4,Other,100% New York Medicaid APG,161.4,,,161.4,Other,100% New York Medicaid APG,161.4,,,161.4,Other,100% New York Medicaid APG,363.14,,,363.14,Other,225% New York Medicaid APG,363.14,,,363.14,Other,225% New York Medicaid APG,363.14,,,363.14,Other,225% New York Medicaid APG,363.14,,,363.14,Other,225% New York Medicaid APG,225.96,,,225.96,Other,140% New York Medicaid APG,363.14,,,363.14,Other,225% New York Medicaid APG,419.63,,,419.63,Other,260% New York Medicaid APG,522.93,,,522.93,Other,324% New York Medicaid APG,347,,,347,Other,215% New York Medicaid APG,347,,,347,Other,215% New York Medicaid APG,201.75,,,201.75,Other,125% New York Medicaid APG,0.01,9473,
Vein access cutdown < 1 yr,36420,CPT,,,,,,,,both,,,2686.86,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1343.43,50,,1343.43,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,283.45,,,283.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,1880.8,70,,1880.8,percent of total billed charges,,232.65,,,232.65,Fee Schedule,,197.4,,,197.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,152.39,,,152.39,Other,New York Medicaid APG methodology,152.39,,,152.39,Other,100% New York Medicaid APG,152.39,,,152.39,Other,100% New York Medicaid APG,152.39,,,152.39,Other,100% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,213.35,,,213.35,Other,140% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,396.22,,,396.22,Other,260% New York Medicaid APG,493.75,,,493.75,Other,324% New York Medicaid APG,327.64,,,327.64,Other,215% New York Medicaid APG,327.64,,,327.64,Other,215% New York Medicaid APG,190.49,,,190.49,Other,125% New York Medicaid APG,0.01,9473,
Vein access cutdown > 1 yr,36425,CPT,,,,,,,,both,,,8380.68,757.69,,,757.69,Other,150% of Medicare + 9.63% HCRA Surcharge,460.76,,,460.76,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4190.34,50,,4190.34,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,283.45,,,283.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5866.48,70,,5866.48,percent of total billed charges,,193.05,,,193.05,Fee Schedule,,163.8,,,163.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,152.39,,,152.39,Other,New York Medicaid APG methodology,152.39,,,152.39,Other,100% New York Medicaid APG,152.39,,,152.39,Other,100% New York Medicaid APG,152.39,,,152.39,Other,100% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,213.35,,,213.35,Other,140% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,396.22,,,396.22,Other,260% New York Medicaid APG,493.75,,,493.75,Other,324% New York Medicaid APG,327.64,,,327.64,Other,215% New York Medicaid APG,327.64,,,327.64,Other,215% New York Medicaid APG,190.49,,,190.49,Other,125% New York Medicaid APG,0.01,9473,
Blood transfusion service,36430,CPT,,,,,,,,both,,,11735,825.51,,,825.51,Other,150% of Medicare + 9.63% HCRA Surcharge,502,,,502,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5867.5,50,,5867.5,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1373.44,,,1373.44,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8214.5,70,,8214.5,percent of total billed charges,,193.05,,,193.05,Fee Schedule,,163.8,,,163.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,738.41,,,738.41,Other,New York Medicaid APG methodology,738.41,,,738.41,Other,100% New York Medicaid APG,738.41,,,738.41,Other,100% New York Medicaid APG,738.41,,,738.41,Other,100% New York Medicaid APG,1661.41,,,1661.41,Other,225% New York Medicaid APG,1661.41,,,1661.41,Other,225% New York Medicaid APG,1661.41,,,1661.41,Other,225% New York Medicaid APG,1661.41,,,1661.41,Other,225% New York Medicaid APG,1033.77,,,1033.77,Other,140% New York Medicaid APG,1661.41,,,1661.41,Other,225% New York Medicaid APG,1919.86,,,1919.86,Other,260% New York Medicaid APG,2392.44,,,2392.44,Other,324% New York Medicaid APG,1587.57,,,1587.57,Other,215% New York Medicaid APG,1587.57,,,1587.57,Other,215% New York Medicaid APG,923.01,,,923.01,Other,125% New York Medicaid APG,163.8,9473,
Bl push transfuse 2 yr/<,36440,CPT,,,,,,,,both,,,9130.81,825.51,,,825.51,Other,150% of Medicare + 9.63% HCRA Surcharge,502,,,502,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4565.41,50,,4565.41,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1373.44,,,1373.44,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,6391.57,70,,6391.57,percent of total billed charges,,244.2,,,244.2,Fee Schedule,,207.2,,,207.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,738.41,,,738.41,Other,New York Medicaid APG methodology,738.41,,,738.41,Other,100% New York Medicaid APG,738.41,,,738.41,Other,100% New York Medicaid APG,738.41,,,738.41,Other,100% New York Medicaid APG,1661.41,,,1661.41,Other,225% New York Medicaid APG,1661.41,,,1661.41,Other,225% New York Medicaid APG,1661.41,,,1661.41,Other,225% New York Medicaid APG,1661.41,,,1661.41,Other,225% New York Medicaid APG,1033.77,,,1033.77,Other,140% New York Medicaid APG,1661.41,,,1661.41,Other,225% New York Medicaid APG,1919.86,,,1919.86,Other,260% New York Medicaid APG,2392.44,,,2392.44,Other,324% New York Medicaid APG,1587.57,,,1587.57,Other,215% New York Medicaid APG,1587.57,,,1587.57,Other,215% New York Medicaid APG,923.01,,,923.01,Other,125% New York Medicaid APG,207.2,9473,
Bl exchange/transfuse nb,36450,CPT,,,,,,,,both,,,9130.81,825.51,,,825.51,Other,150% of Medicare + 9.63% HCRA Surcharge,502,,,502,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4565.41,50,,4565.41,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1373.44,,,1373.44,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,6391.57,70,,6391.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,738.41,,,738.41,Other,New York Medicaid APG methodology,738.41,,,738.41,Other,100% New York Medicaid APG,738.41,,,738.41,Other,100% New York Medicaid APG,738.41,,,738.41,Other,100% New York Medicaid APG,1661.41,,,1661.41,Other,225% New York Medicaid APG,1661.41,,,1661.41,Other,225% New York Medicaid APG,1661.41,,,1661.41,Other,225% New York Medicaid APG,1661.41,,,1661.41,Other,225% New York Medicaid APG,1033.77,,,1033.77,Other,140% New York Medicaid APG,1661.41,,,1661.41,Other,225% New York Medicaid APG,1919.86,,,1919.86,Other,260% New York Medicaid APG,2392.44,,,2392.44,Other,324% New York Medicaid APG,1587.57,,,1587.57,Other,215% New York Medicaid APG,1587.57,,,1587.57,Other,215% New York Medicaid APG,923.01,,,923.01,Other,125% New York Medicaid APG,502,13157,
Bl exchange/transfuse non-nb,36455,CPT,,,,,,,,both,,,9130.81,825.51,,,825.51,Other,150% of Medicare + 9.63% HCRA Surcharge,502,,,502,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4565.41,50,,4565.41,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1373.44,,,1373.44,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,6391.57,70,,6391.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,738.41,,,738.41,Other,New York Medicaid APG methodology,738.41,,,738.41,Other,100% New York Medicaid APG,738.41,,,738.41,Other,100% New York Medicaid APG,738.41,,,738.41,Other,100% New York Medicaid APG,1661.41,,,1661.41,Other,225% New York Medicaid APG,1661.41,,,1661.41,Other,225% New York Medicaid APG,1661.41,,,1661.41,Other,225% New York Medicaid APG,1661.41,,,1661.41,Other,225% New York Medicaid APG,1033.77,,,1033.77,Other,140% New York Medicaid APG,1661.41,,,1661.41,Other,225% New York Medicaid APG,1919.86,,,1919.86,Other,260% New York Medicaid APG,2392.44,,,2392.44,Other,324% New York Medicaid APG,1587.57,,,1587.57,Other,215% New York Medicaid APG,1587.57,,,1587.57,Other,215% New York Medicaid APG,923.01,,,923.01,Other,125% New York Medicaid APG,502,13157,
Transfusion service fetal,36460,CPT,,,,,,,,both,,,9130.81,825.51,,,825.51,Other,150% of Medicare + 9.63% HCRA Surcharge,502,,,502,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4565.41,50,,4565.41,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1373.44,,,1373.44,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,6391.57,70,,6391.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,738.41,,,738.41,Other,New York Medicaid APG methodology,738.41,,,738.41,Other,100% New York Medicaid APG,738.41,,,738.41,Other,100% New York Medicaid APG,738.41,,,738.41,Other,100% New York Medicaid APG,1661.41,,,1661.41,Other,225% New York Medicaid APG,1661.41,,,1661.41,Other,225% New York Medicaid APG,1661.41,,,1661.41,Other,225% New York Medicaid APG,1661.41,,,1661.41,Other,225% New York Medicaid APG,1033.77,,,1033.77,Other,140% New York Medicaid APG,1661.41,,,1661.41,Other,225% New York Medicaid APG,1919.86,,,1919.86,Other,260% New York Medicaid APG,2392.44,,,2392.44,Other,324% New York Medicaid APG,1587.57,,,1587.57,Other,215% New York Medicaid APG,1587.57,,,1587.57,Other,215% New York Medicaid APG,923.01,,,923.01,Other,125% New York Medicaid APG,502,13157,
Njx noncmpnd sclrsnt 1 vein,36465,CPT,,,,,,,,both,,,32059.3,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16029.65,50,,16029.65,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2452.29,,,2452.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22441.51,70,,22441.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1318.43,,,1318.43,Other,New York Medicaid APG methodology,1318.43,,,1318.43,Other,100% New York Medicaid APG,1318.43,,,1318.43,Other,100% New York Medicaid APG,1318.43,,,1318.43,Other,100% New York Medicaid APG,2966.48,,,2966.48,Other,225% New York Medicaid APG,2966.48,,,2966.48,Other,225% New York Medicaid APG,2966.48,,,2966.48,Other,225% New York Medicaid APG,2966.48,,,2966.48,Other,225% New York Medicaid APG,1845.81,,,1845.81,Other,140% New York Medicaid APG,2966.48,,,2966.48,Other,225% New York Medicaid APG,3427.93,,,3427.93,Other,260% New York Medicaid APG,4271.73,,,4271.73,Other,324% New York Medicaid APG,2834.63,,,2834.63,Other,215% New York Medicaid APG,2834.63,,,2834.63,Other,215% New York Medicaid APG,1648.04,,,1648.04,Other,125% New York Medicaid APG,1318.43,22441.51,
Njx noncmpnd sclrsnt mlt vn,36466,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2452.29,,,2452.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1318.43,,,1318.43,Other,New York Medicaid APG methodology,1318.43,,,1318.43,Other,100% New York Medicaid APG,1318.43,,,1318.43,Other,100% New York Medicaid APG,1318.43,,,1318.43,Other,100% New York Medicaid APG,2966.48,,,2966.48,Other,225% New York Medicaid APG,2966.48,,,2966.48,Other,225% New York Medicaid APG,2966.48,,,2966.48,Other,225% New York Medicaid APG,2966.48,,,2966.48,Other,225% New York Medicaid APG,1845.81,,,1845.81,Other,140% New York Medicaid APG,2966.48,,,2966.48,Other,225% New York Medicaid APG,3427.93,,,3427.93,Other,260% New York Medicaid APG,4271.73,,,4271.73,Other,324% New York Medicaid APG,2834.63,,,2834.63,Other,215% New York Medicaid APG,2834.63,,,2834.63,Other,215% New York Medicaid APG,1648.04,,,1648.04,Other,125% New York Medicaid APG,1318.43,26850.29,
Njx sclrsnt spider veins,36468,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,2452.29,,,2452.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,4193.54,50,,4193.54,percent of total billed charges,,4193.54,50,,4193.54,percent of total billed charges,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1318.43,,,1318.43,Other,New York Medicaid APG methodology,1318.43,,,1318.43,Other,100% New York Medicaid APG,1318.43,,,1318.43,Other,100% New York Medicaid APG,1318.43,,,1318.43,Other,100% New York Medicaid APG,2966.48,,,2966.48,Other,225% New York Medicaid APG,2966.48,,,2966.48,Other,225% New York Medicaid APG,2966.48,,,2966.48,Other,225% New York Medicaid APG,2966.48,,,2966.48,Other,225% New York Medicaid APG,1845.81,,,1845.81,Other,140% New York Medicaid APG,2966.48,,,2966.48,Other,225% New York Medicaid APG,3427.93,,,3427.93,Other,260% New York Medicaid APG,4271.73,,,4271.73,Other,324% New York Medicaid APG,2834.63,,,2834.63,Other,215% New York Medicaid APG,2834.63,,,2834.63,Other,215% New York Medicaid APG,1648.04,,,1648.04,Other,125% New York Medicaid APG,0.01,9473,
Njx sclrsnt 1 incmptnt vein,36470,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,2452.29,,,2452.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,188.1,,,188.1,Fee Schedule,,159.6,,,159.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1318.43,,,1318.43,Other,New York Medicaid APG methodology,1318.43,,,1318.43,Other,100% New York Medicaid APG,1318.43,,,1318.43,Other,100% New York Medicaid APG,1318.43,,,1318.43,Other,100% New York Medicaid APG,2966.48,,,2966.48,Other,225% New York Medicaid APG,2966.48,,,2966.48,Other,225% New York Medicaid APG,2966.48,,,2966.48,Other,225% New York Medicaid APG,2966.48,,,2966.48,Other,225% New York Medicaid APG,1845.81,,,1845.81,Other,140% New York Medicaid APG,2966.48,,,2966.48,Other,225% New York Medicaid APG,3427.93,,,3427.93,Other,260% New York Medicaid APG,4271.73,,,4271.73,Other,324% New York Medicaid APG,2834.63,,,2834.63,Other,215% New York Medicaid APG,2834.63,,,2834.63,Other,215% New York Medicaid APG,1648.04,,,1648.04,Other,125% New York Medicaid APG,0.01,9473,
Njx sclrsnt mlt incmptnt vn,36471,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,2452.29,,,2452.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,367.95,,,367.95,Fee Schedule,,312.2,,,312.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1318.43,,,1318.43,Other,New York Medicaid APG methodology,1318.43,,,1318.43,Other,100% New York Medicaid APG,1318.43,,,1318.43,Other,100% New York Medicaid APG,1318.43,,,1318.43,Other,100% New York Medicaid APG,2966.48,,,2966.48,Other,225% New York Medicaid APG,2966.48,,,2966.48,Other,225% New York Medicaid APG,2966.48,,,2966.48,Other,225% New York Medicaid APG,2966.48,,,2966.48,Other,225% New York Medicaid APG,1845.81,,,1845.81,Other,140% New York Medicaid APG,2966.48,,,2966.48,Other,225% New York Medicaid APG,3427.93,,,3427.93,Other,260% New York Medicaid APG,4271.73,,,4271.73,Other,324% New York Medicaid APG,2834.63,,,2834.63,Other,215% New York Medicaid APG,2834.63,,,2834.63,Other,215% New York Medicaid APG,1648.04,,,1648.04,Other,125% New York Medicaid APG,0.01,9473,
Endovenous mchnchem 1st vein,36473,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,5334.25,,,5334.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2867.87,,,2867.87,Other,New York Medicaid APG methodology,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,4015.02,,,4015.02,Other,140% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,7456.47,,,7456.47,Other,260% New York Medicaid APG,9291.91,,,9291.91,Other,324% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,3584.84,,,3584.84,Other,125% New York Medicaid APG,0.01,46931.32,
Endovenous mchnchem add-on,36474,CPT,,,,,,,,both,,,64479.48,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32239.74,50,,32239.74,percent of total billed charges,,45135.64,70,,45135.64,percent of total billed charges,,6152,,,6152,Case Rate,,5334.25,,,5334.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45135.64,70,,45135.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2867.87,,,2867.87,Other,New York Medicaid APG methodology,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,4015.02,,,4015.02,Other,140% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,7456.47,,,7456.47,Other,260% New York Medicaid APG,9291.91,,,9291.91,Other,324% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,3584.84,,,3584.84,Other,125% New York Medicaid APG,0.01,45135.64,
Endovenous rf 1st vein,36475,CPT,,,,,,,,both,,,35971.87,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17985.94,50,,17985.94,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5334.25,,,5334.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25180.31,70,,25180.31,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2867.87,,,2867.87,Other,New York Medicaid APG methodology,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,4015.02,,,4015.02,Other,140% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,7456.47,,,7456.47,Other,260% New York Medicaid APG,9291.91,,,9291.91,Other,324% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,3584.84,,,3584.84,Other,125% New York Medicaid APG,2867.87,25180.31,
Endovenous rf vein add-on,36476,CPT,,,,,,,,both,,,64479.48,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32239.74,50,,32239.74,percent of total billed charges,,45135.64,70,,45135.64,percent of total billed charges,,6152,,,6152,Case Rate,,5334.25,,,5334.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45135.64,70,,45135.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2867.87,,,2867.87,Other,New York Medicaid APG methodology,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,4015.02,,,4015.02,Other,140% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,7456.47,,,7456.47,Other,260% New York Medicaid APG,9291.91,,,9291.91,Other,324% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,3584.84,,,3584.84,Other,125% New York Medicaid APG,0.01,45135.64,
Endovenous laser 1st vein,36478,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5334.25,,,5334.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2867.87,,,2867.87,Other,New York Medicaid APG methodology,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,4015.02,,,4015.02,Other,140% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,7456.47,,,7456.47,Other,260% New York Medicaid APG,9291.91,,,9291.91,Other,324% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,3584.84,,,3584.84,Other,125% New York Medicaid APG,2867.87,46931.32,
Endovenous laser vein addon,36479,CPT,,,,,,,,both,,,64479.48,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32239.74,50,,32239.74,percent of total billed charges,,45135.64,70,,45135.64,percent of total billed charges,,6152,,,6152,Case Rate,,5334.25,,,5334.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45135.64,70,,45135.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2867.87,,,2867.87,Other,New York Medicaid APG methodology,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,4015.02,,,4015.02,Other,140% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,7456.47,,,7456.47,Other,260% New York Medicaid APG,9291.91,,,9291.91,Other,324% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,3584.84,,,3584.84,Other,125% New York Medicaid APG,0.01,45135.64,
Insertion of catheter vein,36481,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,621.52,,,621.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,334.15,,,334.15,Other,New York Medicaid APG methodology,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,467.81,,,467.81,Other,140% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,868.8,,,868.8,Other,260% New York Medicaid APG,1082.66,,,1082.66,Other,324% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,417.69,,,417.69,Other,125% New York Medicaid APG,0.01,22702.47,
Endoven ther chem adhes 1st,36482,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5334.25,,,5334.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2867.87,,,2867.87,Other,New York Medicaid APG methodology,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,4015.02,,,4015.02,Other,140% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,7456.47,,,7456.47,Other,260% New York Medicaid APG,9291.91,,,9291.91,Other,324% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,3584.84,,,3584.84,Other,125% New York Medicaid APG,2867.87,80911.37,
Endoven ther chem adhes sbsq,36483,CPT,,,,,,,,both,,,64479.48,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32239.74,50,,32239.74,percent of total billed charges,,45135.64,70,,45135.64,percent of total billed charges,,6152,,,6152,Case Rate,,5334.25,,,5334.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45135.64,70,,45135.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2867.87,,,2867.87,Other,New York Medicaid APG methodology,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,4015.02,,,4015.02,Other,140% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,7456.47,,,7456.47,Other,260% New York Medicaid APG,9291.91,,,9291.91,Other,324% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,3584.84,,,3584.84,Other,125% New York Medicaid APG,0.01,45135.64,
Insertion of catheter vein,36500,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,621.52,,,621.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,334.15,,,334.15,Other,New York Medicaid APG methodology,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,467.81,,,467.81,Other,140% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,868.8,,,868.8,Other,260% New York Medicaid APG,1082.66,,,1082.66,Other,324% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,417.69,,,417.69,Other,125% New York Medicaid APG,0.01,22702.47,
Insertion of catheter vein,36510,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,283.45,,,283.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,259.05,,,259.05,Fee Schedule,,219.8,,,219.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,152.39,,,152.39,Other,New York Medicaid APG methodology,152.39,,,152.39,Other,100% New York Medicaid APG,152.39,,,152.39,Other,100% New York Medicaid APG,152.39,,,152.39,Other,100% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,213.35,,,213.35,Other,140% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,396.22,,,396.22,Other,260% New York Medicaid APG,493.75,,,493.75,Other,324% New York Medicaid APG,327.64,,,327.64,Other,215% New York Medicaid APG,327.64,,,327.64,Other,215% New York Medicaid APG,190.49,,,190.49,Other,125% New York Medicaid APG,0.01,22702.47,
Apheresis wbc,36511,CPT,,,,,,,,both,,,32272.54,2917.74,,,2917.74,Other,150% of Medicare + 9.63% HCRA Surcharge,1774.3,,,1774.3,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16136.27,50,,16136.27,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4580.06,,,4580.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22590.78,70,,22590.78,percent of total billed charges,,531.3,,,531.3,Fee Schedule,,450.8,,,450.8,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2462.4,,,2462.4,Other,New York Medicaid APG methodology,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,3447.35,,,3447.35,Other,140% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,6402.23,,,6402.23,Other,260% New York Medicaid APG,7978.16,,,7978.16,Other,324% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,3077.99,,,3077.99,Other,125% New York Medicaid APG,450.8,22590.78,
Apheresis rbc,36512,CPT,,,,,,,,both,,,32272.54,2917.74,,,2917.74,Other,150% of Medicare + 9.63% HCRA Surcharge,1774.3,,,1774.3,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16136.27,50,,16136.27,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4580.06,,,4580.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22590.78,70,,22590.78,percent of total billed charges,,516.45,,,516.45,Fee Schedule,,438.2,,,438.2,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2462.4,,,2462.4,Other,New York Medicaid APG methodology,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,3447.35,,,3447.35,Other,140% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,6402.23,,,6402.23,Other,260% New York Medicaid APG,7978.16,,,7978.16,Other,324% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,3077.99,,,3077.99,Other,125% New York Medicaid APG,438.2,22590.78,
Apheresis platelets,36513,CPT,,,,,,,,both,,,9130.81,825.51,,,825.51,Other,150% of Medicare + 9.63% HCRA Surcharge,502,,,502,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4565.41,50,,4565.41,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4580.06,,,4580.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,6391.57,70,,6391.57,percent of total billed charges,,514.8,,,514.8,Fee Schedule,,436.8,,,436.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2462.4,,,2462.4,Other,New York Medicaid APG methodology,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,3447.35,,,3447.35,Other,140% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,6402.23,,,6402.23,Other,260% New York Medicaid APG,7978.16,,,7978.16,Other,324% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,3077.99,,,3077.99,Other,125% New York Medicaid APG,436.8,9473,
Apheresis plasma,36514,CPT,,,,,,,,both,,,32272.54,2917.74,,,2917.74,Other,150% of Medicare + 9.63% HCRA Surcharge,1774.3,,,1774.3,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16136.27,50,,16136.27,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4580.06,,,4580.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22590.78,70,,22590.78,percent of total billed charges,,452.1,,,452.1,Fee Schedule,,383.6,,,383.6,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2462.4,,,2462.4,Other,New York Medicaid APG methodology,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,3447.35,,,3447.35,Other,140% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,6402.23,,,6402.23,Other,260% New York Medicaid APG,7978.16,,,7978.16,Other,324% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,3077.99,,,3077.99,Other,125% New York Medicaid APG,383.6,22590.78,
Apheresis immunoads slctv,36516,CPT,,,,,,,,both,,,97340.17,8800.46,,,8800.46,Other,150% of Medicare + 9.63% HCRA Surcharge,5351.62,,,5351.62,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,48670.09,50,,48670.09,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4580.05,,,4580.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,68138.12,70,,68138.12,percent of total billed charges,,414.15,,,414.15,Fee Schedule,,351.4,,,351.4,Fee Schedule,,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2462.39,,,2462.39,Other,New York Medicaid APG methodology,2462.39,,,2462.39,Other,100% New York Medicaid APG,2462.39,,,2462.39,Other,100% New York Medicaid APG,2462.39,,,2462.39,Other,100% New York Medicaid APG,5540.38,,,5540.38,Other,225% New York Medicaid APG,5540.38,,,5540.38,Other,225% New York Medicaid APG,5540.38,,,5540.38,Other,225% New York Medicaid APG,5540.38,,,5540.38,Other,225% New York Medicaid APG,3447.35,,,3447.35,Other,140% New York Medicaid APG,5540.38,,,5540.38,Other,225% New York Medicaid APG,6402.21,,,6402.21,Other,260% New York Medicaid APG,7978.14,,,7978.14,Other,324% New York Medicaid APG,5294.14,,,5294.14,Other,215% New York Medicaid APG,5294.14,,,5294.14,Other,215% New York Medicaid APG,3077.99,,,3077.99,Other,125% New York Medicaid APG,351.4,68138.12,
Photopheresis,36522,CPT,,,,,,,,both,,,97340.17,8800.46,,,8800.46,Other,150% of Medicare + 9.63% HCRA Surcharge,5351.62,,,5351.62,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,48670.09,50,,48670.09,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4580.05,,,4580.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,68138.12,70,,68138.12,percent of total billed charges,,466.95,,,466.95,Fee Schedule,,396.2,,,396.2,Fee Schedule,,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2462.39,,,2462.39,Other,New York Medicaid APG methodology,2462.39,,,2462.39,Other,100% New York Medicaid APG,2462.39,,,2462.39,Other,100% New York Medicaid APG,2462.39,,,2462.39,Other,100% New York Medicaid APG,5540.38,,,5540.38,Other,225% New York Medicaid APG,5540.38,,,5540.38,Other,225% New York Medicaid APG,5540.38,,,5540.38,Other,225% New York Medicaid APG,5540.38,,,5540.38,Other,225% New York Medicaid APG,3447.35,,,3447.35,Other,140% New York Medicaid APG,5540.38,,,5540.38,Other,225% New York Medicaid APG,6402.21,,,6402.21,Other,260% New York Medicaid APG,7978.14,,,7978.14,Other,324% New York Medicaid APG,5294.14,,,5294.14,Other,215% New York Medicaid APG,5294.14,,,5294.14,Other,215% New York Medicaid APG,3077.99,,,3077.99,Other,125% New York Medicaid APG,396.2,68138.12,
Insert non-tunnel cv cath,36555,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,713.01,,,713.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,383.34,,,383.34,Other,New York Medicaid APG methodology,383.34,,,383.34,Other,100% New York Medicaid APG,383.34,,,383.34,Other,100% New York Medicaid APG,383.34,,,383.34,Other,100% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,536.67,,,536.67,Other,140% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,996.68,,,996.68,Other,260% New York Medicaid APG,1242.01,,,1242.01,Other,324% New York Medicaid APG,824.17,,,824.17,Other,215% New York Medicaid APG,824.17,,,824.17,Other,215% New York Medicaid APG,479.17,,,479.17,Other,125% New York Medicaid APG,383.34,46931.32,
Insert non-tunnel cv cath,36556,CPT,,,,,,,,both,,,24711.85,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12355.93,50,,12355.93,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,713.01,,,713.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17298.3,70,,17298.3,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,383.34,,,383.34,Other,New York Medicaid APG methodology,383.34,,,383.34,Other,100% New York Medicaid APG,383.34,,,383.34,Other,100% New York Medicaid APG,383.34,,,383.34,Other,100% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,536.67,,,536.67,Other,140% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,996.68,,,996.68,Other,260% New York Medicaid APG,1242.01,,,1242.01,Other,324% New York Medicaid APG,824.17,,,824.17,Other,215% New York Medicaid APG,824.17,,,824.17,Other,215% New York Medicaid APG,479.17,,,479.17,Other,125% New York Medicaid APG,383.34,17298.3,
Insert tunneled cv cath,36557,CPT,,,,,,,,both,,,48529.02,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,24264.51,50,,24264.51,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3177.13,,,3177.13,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,33970.31,70,,33970.31,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,1708.14,,,1708.14,Other,New York Medicaid APG methodology,1708.14,,,1708.14,Other,100% New York Medicaid APG,1708.14,,,1708.14,Other,100% New York Medicaid APG,1708.14,,,1708.14,Other,100% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,2391.39,,,2391.39,Other,140% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,4441.15,,,4441.15,Other,260% New York Medicaid APG,5534.36,,,5534.36,Other,324% New York Medicaid APG,3672.49,,,3672.49,Other,215% New York Medicaid APG,3672.49,,,3672.49,Other,215% New York Medicaid APG,2135.17,,,2135.17,Other,125% New York Medicaid APG,1708.14,33970.31,
Insert tunneled cv cath,36558,CPT,,,,,,,,both,,,24444.27,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,12222.14,50,,12222.14,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3177.13,,,3177.13,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17110.99,70,,17110.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1708.14,,,1708.14,Other,New York Medicaid APG methodology,1708.14,,,1708.14,Other,100% New York Medicaid APG,1708.14,,,1708.14,Other,100% New York Medicaid APG,1708.14,,,1708.14,Other,100% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,2391.39,,,2391.39,Other,140% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,4441.15,,,4441.15,Other,260% New York Medicaid APG,5534.36,,,5534.36,Other,324% New York Medicaid APG,3672.49,,,3672.49,Other,215% New York Medicaid APG,3672.49,,,3672.49,Other,215% New York Medicaid APG,2135.17,,,2135.17,Other,125% New York Medicaid APG,1708.14,17110.99,
Insert tunneled cv cath,36560,CPT,,,,,,,,both,,,37353.29,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18676.65,50,,18676.65,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3177.13,,,3177.13,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26147.3,70,,26147.3,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1708.14,,,1708.14,Other,New York Medicaid APG methodology,1708.14,,,1708.14,Other,100% New York Medicaid APG,1708.14,,,1708.14,Other,100% New York Medicaid APG,1708.14,,,1708.14,Other,100% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,2391.39,,,2391.39,Other,140% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,4441.15,,,4441.15,Other,260% New York Medicaid APG,5534.36,,,5534.36,Other,324% New York Medicaid APG,3672.49,,,3672.49,Other,215% New York Medicaid APG,3672.49,,,3672.49,Other,215% New York Medicaid APG,2135.17,,,2135.17,Other,125% New York Medicaid APG,1708.14,26147.3,
Insert tunneled cv cath,36561,CPT,,,,,,,,both,,,26377.3,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,13188.65,50,,13188.65,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3177.13,,,3177.13,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,18464.11,70,,18464.11,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1708.14,,,1708.14,Other,New York Medicaid APG methodology,1708.14,,,1708.14,Other,100% New York Medicaid APG,1708.14,,,1708.14,Other,100% New York Medicaid APG,1708.14,,,1708.14,Other,100% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,2391.39,,,2391.39,Other,140% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,4441.15,,,4441.15,Other,260% New York Medicaid APG,5534.36,,,5534.36,Other,324% New York Medicaid APG,3672.49,,,3672.49,Other,215% New York Medicaid APG,3672.49,,,3672.49,Other,215% New York Medicaid APG,2135.17,,,2135.17,Other,125% New York Medicaid APG,1708.14,18464.11,
Insert tunneled cv cath,36563,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3177.13,,,3177.13,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,1708.14,,,1708.14,Other,New York Medicaid APG methodology,1708.14,,,1708.14,Other,100% New York Medicaid APG,1708.14,,,1708.14,Other,100% New York Medicaid APG,1708.14,,,1708.14,Other,100% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,2391.39,,,2391.39,Other,140% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,4441.15,,,4441.15,Other,260% New York Medicaid APG,5534.36,,,5534.36,Other,324% New York Medicaid APG,3672.49,,,3672.49,Other,215% New York Medicaid APG,3672.49,,,3672.49,Other,215% New York Medicaid APG,2135.17,,,2135.17,Other,125% New York Medicaid APG,1708.14,80911.37,
Insert tunneled cv cath,36565,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3177.13,,,3177.13,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1708.14,,,1708.14,Other,New York Medicaid APG methodology,1708.14,,,1708.14,Other,100% New York Medicaid APG,1708.14,,,1708.14,Other,100% New York Medicaid APG,1708.14,,,1708.14,Other,100% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,2391.39,,,2391.39,Other,140% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,4441.15,,,4441.15,Other,260% New York Medicaid APG,5534.36,,,5534.36,Other,324% New York Medicaid APG,3672.49,,,3672.49,Other,215% New York Medicaid APG,3672.49,,,3672.49,Other,215% New York Medicaid APG,2135.17,,,2135.17,Other,125% New York Medicaid APG,1708.14,46931.32,
Insert tunneled cv cath,36566,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3177.13,,,3177.13,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,1708.14,,,1708.14,Other,New York Medicaid APG methodology,1708.14,,,1708.14,Other,100% New York Medicaid APG,1708.14,,,1708.14,Other,100% New York Medicaid APG,1708.14,,,1708.14,Other,100% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,2391.39,,,2391.39,Other,140% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,4441.15,,,4441.15,Other,260% New York Medicaid APG,5534.36,,,5534.36,Other,324% New York Medicaid APG,3672.49,,,3672.49,Other,215% New York Medicaid APG,3672.49,,,3672.49,Other,215% New York Medicaid APG,2135.17,,,2135.17,Other,125% New York Medicaid APG,1708.14,80911.37,
Insj picc <5 yr w/o imaging,36568,CPT,,,,,,,,both,,,33686.28,3045.56,,,3045.56,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.02,,,1852.02,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16843.14,50,,16843.14,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,713.01,,,713.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23580.4,70,,23580.4,percent of total billed charges,,447.15,,,447.15,Fee Schedule,,379.4,,,379.4,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,383.34,,,383.34,Other,New York Medicaid APG methodology,383.34,,,383.34,Other,100% New York Medicaid APG,383.34,,,383.34,Other,100% New York Medicaid APG,383.34,,,383.34,Other,100% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,536.67,,,536.67,Other,140% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,996.68,,,996.68,Other,260% New York Medicaid APG,1242.01,,,1242.01,Other,324% New York Medicaid APG,824.17,,,824.17,Other,215% New York Medicaid APG,824.17,,,824.17,Other,215% New York Medicaid APG,479.17,,,479.17,Other,125% New York Medicaid APG,379.4,23580.4,
Insj picc 5 yr+ w/o imaging,36569,CPT,,,,,,,,both,,,33686.28,3045.56,,,3045.56,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.02,,,1852.02,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16843.14,50,,16843.14,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,713.01,,,713.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23580.4,70,,23580.4,percent of total billed charges,,453.75,,,453.75,Fee Schedule,,385,,,385,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,383.34,,,383.34,Other,New York Medicaid APG methodology,383.34,,,383.34,Other,100% New York Medicaid APG,383.34,,,383.34,Other,100% New York Medicaid APG,383.34,,,383.34,Other,100% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,536.67,,,536.67,Other,140% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,996.68,,,996.68,Other,260% New York Medicaid APG,1242.01,,,1242.01,Other,324% New York Medicaid APG,824.17,,,824.17,Other,215% New York Medicaid APG,824.17,,,824.17,Other,215% New York Medicaid APG,479.17,,,479.17,Other,125% New York Medicaid APG,383.34,23580.4,
Insert picvad cath,36570,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,713.01,,,713.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,383.34,,,383.34,Other,New York Medicaid APG methodology,383.34,,,383.34,Other,100% New York Medicaid APG,383.34,,,383.34,Other,100% New York Medicaid APG,383.34,,,383.34,Other,100% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,536.67,,,536.67,Other,140% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,996.68,,,996.68,Other,260% New York Medicaid APG,1242.01,,,1242.01,Other,324% New York Medicaid APG,824.17,,,824.17,Other,215% New York Medicaid APG,824.17,,,824.17,Other,215% New York Medicaid APG,479.17,,,479.17,Other,125% New York Medicaid APG,383.34,46931.32,
Insert picvad cath,36571,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,713.01,,,713.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,383.34,,,383.34,Other,New York Medicaid APG methodology,383.34,,,383.34,Other,100% New York Medicaid APG,383.34,,,383.34,Other,100% New York Medicaid APG,383.34,,,383.34,Other,100% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,536.67,,,536.67,Other,140% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,996.68,,,996.68,Other,260% New York Medicaid APG,1242.01,,,1242.01,Other,324% New York Medicaid APG,824.17,,,824.17,Other,215% New York Medicaid APG,824.17,,,824.17,Other,215% New York Medicaid APG,479.17,,,479.17,Other,125% New York Medicaid APG,383.34,46931.32,
Insj picc rs&i <5 yr,36572,CPT,,,,,,,,both,,,13213.53,1194.63,,,1194.63,Other,150% of Medicare + 9.63% HCRA Surcharge,726.46,,,726.46,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6606.77,50,,6606.77,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,713.01,,,713.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9249.47,70,,9249.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,383.34,,,383.34,Other,New York Medicaid APG methodology,383.34,,,383.34,Other,100% New York Medicaid APG,383.34,,,383.34,Other,100% New York Medicaid APG,383.34,,,383.34,Other,100% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,536.67,,,536.67,Other,140% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,996.68,,,996.68,Other,260% New York Medicaid APG,1242.01,,,1242.01,Other,324% New York Medicaid APG,824.17,,,824.17,Other,215% New York Medicaid APG,824.17,,,824.17,Other,215% New York Medicaid APG,479.17,,,479.17,Other,125% New York Medicaid APG,383.34,13157,
Insj picc rs&i 5 yr+,36573,CPT,,,,,,,,both,,,15068.01,3045.56,,,3045.56,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.02,,,1852.02,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,7534.01,50,,7534.01,percent of total billed charges,,7394,,"100% primary, 50% supplemental procedure",7394,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,713.01,,,713.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10547.61,70,,10547.61,percent of total billed charges,,407.55,,,407.55,Fee Schedule,,345.8,,,345.8,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,383.34,,,383.34,Other,New York Medicaid APG methodology,383.34,,,383.34,Other,100% New York Medicaid APG,383.34,,,383.34,Other,100% New York Medicaid APG,383.34,,,383.34,Other,100% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,536.67,,,536.67,Other,140% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,996.68,,,996.68,Other,260% New York Medicaid APG,1242.01,,,1242.01,Other,324% New York Medicaid APG,824.17,,,824.17,Other,215% New York Medicaid APG,824.17,,,824.17,Other,215% New York Medicaid APG,479.17,,,479.17,Other,125% New York Medicaid APG,345.8,10547.61,
Repair tunneled cv cath,36575,CPT,,,,,,,,both,,,13213.53,1194.63,,,1194.63,Other,150% of Medicare + 9.63% HCRA Surcharge,726.46,,,726.46,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6606.77,50,,6606.77,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1968.77,,,1968.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9249.47,70,,9249.47,percent of total billed charges,,161.7,,,161.7,Fee Schedule,,137.2,,,137.2,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1058.48,,,1058.48,Other,New York Medicaid APG methodology,1058.48,,,1058.48,Other,100% New York Medicaid APG,1058.48,,,1058.48,Other,100% New York Medicaid APG,1058.48,,,1058.48,Other,100% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,1481.87,,,1481.87,Other,140% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,2752.04,,,2752.04,Other,260% New York Medicaid APG,3429.47,,,3429.47,Other,324% New York Medicaid APG,2275.73,,,2275.73,Other,215% New York Medicaid APG,2275.73,,,2275.73,Other,215% New York Medicaid APG,1323.1,,,1323.1,Other,125% New York Medicaid APG,137.2,9473,
Repair tunneled cv cath,36576,CPT,,,,,,,,both,,,33686.28,3045.56,,,3045.56,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.02,,,1852.02,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16843.14,50,,16843.14,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1968.77,,,1968.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23580.4,70,,23580.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1058.48,,,1058.48,Other,New York Medicaid APG methodology,1058.48,,,1058.48,Other,100% New York Medicaid APG,1058.48,,,1058.48,Other,100% New York Medicaid APG,1058.48,,,1058.48,Other,100% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,1481.87,,,1481.87,Other,140% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,2752.04,,,2752.04,Other,260% New York Medicaid APG,3429.47,,,3429.47,Other,324% New York Medicaid APG,2275.73,,,2275.73,Other,215% New York Medicaid APG,2275.73,,,2275.73,Other,215% New York Medicaid APG,1323.1,,,1323.1,Other,125% New York Medicaid APG,1058.48,23580.4,
Replace tunneled cv cath,36578,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1968.77,,,1968.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1058.48,,,1058.48,Other,New York Medicaid APG methodology,1058.48,,,1058.48,Other,100% New York Medicaid APG,1058.48,,,1058.48,Other,100% New York Medicaid APG,1058.48,,,1058.48,Other,100% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,1481.87,,,1481.87,Other,140% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,2752.04,,,2752.04,Other,260% New York Medicaid APG,3429.47,,,3429.47,Other,324% New York Medicaid APG,2275.73,,,2275.73,Other,215% New York Medicaid APG,2275.73,,,2275.73,Other,215% New York Medicaid APG,1323.1,,,1323.1,Other,125% New York Medicaid APG,1058.48,46931.32,
Replace cvad cath,36580,CPT,,,,,,,,both,,,14619,3045.56,,,3045.56,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.02,,,1852.02,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,7309.5,50,,7309.5,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,713.01,,,713.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10233.3,70,,10233.3,percent of total billed charges,,318.45,,,318.45,Fee Schedule,,270.2,,,270.2,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,383.34,,,383.34,Other,New York Medicaid APG methodology,383.34,,,383.34,Other,100% New York Medicaid APG,383.34,,,383.34,Other,100% New York Medicaid APG,383.34,,,383.34,Other,100% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,536.67,,,536.67,Other,140% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,996.68,,,996.68,Other,260% New York Medicaid APG,1242.01,,,1242.01,Other,324% New York Medicaid APG,824.17,,,824.17,Other,215% New York Medicaid APG,824.17,,,824.17,Other,215% New York Medicaid APG,479.17,,,479.17,Other,125% New York Medicaid APG,270.2,10233.3,
Replace tunneled cv cath,36581,CPT,,,,,,,,both,,,21192.57,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,10596.29,50,,10596.29,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3177.13,,,3177.13,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,14834.8,70,,14834.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1708.14,,,1708.14,Other,New York Medicaid APG methodology,1708.14,,,1708.14,Other,100% New York Medicaid APG,1708.14,,,1708.14,Other,100% New York Medicaid APG,1708.14,,,1708.14,Other,100% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,2391.39,,,2391.39,Other,140% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,4441.15,,,4441.15,Other,260% New York Medicaid APG,5534.36,,,5534.36,Other,324% New York Medicaid APG,3672.49,,,3672.49,Other,215% New York Medicaid APG,3672.49,,,3672.49,Other,215% New York Medicaid APG,2135.17,,,2135.17,Other,125% New York Medicaid APG,1708.14,14834.8,
Replace tunneled cv cath,36582,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3177.13,,,3177.13,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1708.14,,,1708.14,Other,New York Medicaid APG methodology,1708.14,,,1708.14,Other,100% New York Medicaid APG,1708.14,,,1708.14,Other,100% New York Medicaid APG,1708.14,,,1708.14,Other,100% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,2391.39,,,2391.39,Other,140% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,4441.15,,,4441.15,Other,260% New York Medicaid APG,5534.36,,,5534.36,Other,324% New York Medicaid APG,3672.49,,,3672.49,Other,215% New York Medicaid APG,3672.49,,,3672.49,Other,215% New York Medicaid APG,2135.17,,,2135.17,Other,125% New York Medicaid APG,1708.14,46931.32,
Replace tunneled cv cath,36583,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3177.13,,,3177.13,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,1708.14,,,1708.14,Other,New York Medicaid APG methodology,1708.14,,,1708.14,Other,100% New York Medicaid APG,1708.14,,,1708.14,Other,100% New York Medicaid APG,1708.14,,,1708.14,Other,100% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,2391.39,,,2391.39,Other,140% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,4441.15,,,4441.15,Other,260% New York Medicaid APG,5534.36,,,5534.36,Other,324% New York Medicaid APG,3672.49,,,3672.49,Other,215% New York Medicaid APG,3672.49,,,3672.49,Other,215% New York Medicaid APG,2135.17,,,2135.17,Other,125% New York Medicaid APG,1708.14,80911.37,
Compl rplcmt picc rs&i,36584,CPT,,,,,,,,both,,,33686.28,3045.56,,,3045.56,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.02,,,1852.02,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16843.14,50,,16843.14,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,713.01,,,713.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23580.4,70,,23580.4,percent of total billed charges,,283.8,,,283.8,Fee Schedule,,240.8,,,240.8,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,383.34,,,383.34,Other,New York Medicaid APG methodology,383.34,,,383.34,Other,100% New York Medicaid APG,383.34,,,383.34,Other,100% New York Medicaid APG,383.34,,,383.34,Other,100% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,536.67,,,536.67,Other,140% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,996.68,,,996.68,Other,260% New York Medicaid APG,1242.01,,,1242.01,Other,324% New York Medicaid APG,824.17,,,824.17,Other,215% New York Medicaid APG,824.17,,,824.17,Other,215% New York Medicaid APG,479.17,,,479.17,Other,125% New York Medicaid APG,240.8,23580.4,
Replace picvad cath,36585,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,713.01,,,713.01,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,383.34,,,383.34,Other,New York Medicaid APG methodology,383.34,,,383.34,Other,100% New York Medicaid APG,383.34,,,383.34,Other,100% New York Medicaid APG,383.34,,,383.34,Other,100% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,536.67,,,536.67,Other,140% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,996.68,,,996.68,Other,260% New York Medicaid APG,1242.01,,,1242.01,Other,324% New York Medicaid APG,824.17,,,824.17,Other,215% New York Medicaid APG,824.17,,,824.17,Other,215% New York Medicaid APG,479.17,,,479.17,Other,125% New York Medicaid APG,383.34,46931.32,
Removal tunneled cv cath,36589,CPT,,,,,,,,both,,,35837.87,1194.63,,,1194.63,Other,150% of Medicare + 9.63% HCRA Surcharge,726.46,,,726.46,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17918.94,50,,17918.94,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1968.77,,,1968.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25086.51,70,,25086.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1058.48,,,1058.48,Other,New York Medicaid APG methodology,1058.48,,,1058.48,Other,100% New York Medicaid APG,1058.48,,,1058.48,Other,100% New York Medicaid APG,1058.48,,,1058.48,Other,100% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,1481.87,,,1481.87,Other,140% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,2752.04,,,2752.04,Other,260% New York Medicaid APG,3429.47,,,3429.47,Other,324% New York Medicaid APG,2275.73,,,2275.73,Other,215% New York Medicaid APG,2275.73,,,2275.73,Other,215% New York Medicaid APG,1323.1,,,1323.1,Other,125% New York Medicaid APG,726.46,25086.51,
Removal tunneled cv cath,36590,CPT,,,,,,,,both,,,26044.81,3045.56,,,3045.56,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.02,,,1852.02,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,13022.41,50,,13022.41,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1968.77,,,1968.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,18231.37,70,,18231.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1058.48,,,1058.48,Other,New York Medicaid APG methodology,1058.48,,,1058.48,Other,100% New York Medicaid APG,1058.48,,,1058.48,Other,100% New York Medicaid APG,1058.48,,,1058.48,Other,100% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,1481.87,,,1481.87,Other,140% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,2752.04,,,2752.04,Other,260% New York Medicaid APG,3429.47,,,3429.47,Other,324% New York Medicaid APG,2275.73,,,2275.73,Other,215% New York Medicaid APG,2275.73,,,2275.73,Other,215% New York Medicaid APG,1323.1,,,1323.1,Other,125% New York Medicaid APG,1058.48,18231.37,
Draw blood off venous device,36591,CPT,,,,,,,,both,,,2686.86,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,212.17,,,212.17,Fee Schedule,,190.89,,,190.89,Fee Schedule,,180.26,,,180.26,Fee Schedule,,1343.43,50,,1343.43,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,283.45,,,283.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,1880.8,70,,1880.8,percent of total billed charges,,132,,,132,Fee Schedule,,112,,,112,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,152.39,,,152.39,Other,New York Medicaid APG methodology,152.39,,,152.39,Other,100% New York Medicaid APG,152.39,,,152.39,Other,100% New York Medicaid APG,152.39,,,152.39,Other,100% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,213.35,,,213.35,Other,140% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,396.22,,,396.22,Other,260% New York Medicaid APG,493.75,,,493.75,Other,324% New York Medicaid APG,327.64,,,327.64,Other,215% New York Medicaid APG,327.64,,,327.64,Other,215% New York Medicaid APG,190.49,,,190.49,Other,125% New York Medicaid APG,0.01,9473,
Collect blood from picc,36592,CPT,,,,,,,,both,,,2686.86,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,237.08,,,237.08,Fee Schedule,,213.31,,,213.31,Fee Schedule,,201.42,,,201.42,Fee Schedule,,1343.43,50,,1343.43,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,283.45,,,283.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,1880.8,70,,1880.8,percent of total billed charges,,143.55,,,143.55,Fee Schedule,,121.8,,,121.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,152.39,,,152.39,Other,New York Medicaid APG methodology,152.39,,,152.39,Other,100% New York Medicaid APG,152.39,,,152.39,Other,100% New York Medicaid APG,152.39,,,152.39,Other,100% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,213.35,,,213.35,Other,140% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,396.22,,,396.22,Other,260% New York Medicaid APG,493.75,,,493.75,Other,324% New York Medicaid APG,327.64,,,327.64,Other,215% New York Medicaid APG,327.64,,,327.64,Other,215% New York Medicaid APG,190.49,,,190.49,Other,125% New York Medicaid APG,0.01,9473,
Declot vascular device,36593,CPT,,,,,,,,both,,,41600.5,644.03,,,644.03,Other,150% of Medicare + 9.63% HCRA Surcharge,391.64,,,391.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,20800.25,50,,20800.25,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,787.49,,,787.49,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29120.35,70,,29120.35,percent of total billed charges,,163.35,,,163.35,Fee Schedule,,138.6,,,138.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,423.38,,,423.38,Other,New York Medicaid APG methodology,423.38,,,423.38,Other,100% New York Medicaid APG,423.38,,,423.38,Other,100% New York Medicaid APG,423.38,,,423.38,Other,100% New York Medicaid APG,952.61,,,952.61,Other,225% New York Medicaid APG,952.61,,,952.61,Other,225% New York Medicaid APG,952.61,,,952.61,Other,225% New York Medicaid APG,952.61,,,952.61,Other,225% New York Medicaid APG,592.73,,,592.73,Other,140% New York Medicaid APG,952.61,,,952.61,Other,225% New York Medicaid APG,1100.79,,,1100.79,Other,260% New York Medicaid APG,1371.76,,,1371.76,Other,324% New York Medicaid APG,910.27,,,910.27,Other,215% New York Medicaid APG,910.27,,,910.27,Other,215% New York Medicaid APG,529.23,,,529.23,Other,125% New York Medicaid APG,0.01,29120.35,
Mech remov tunneled cv cath,36595,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1968.77,,,1968.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1058.48,,,1058.48,Other,New York Medicaid APG methodology,1058.48,,,1058.48,Other,100% New York Medicaid APG,1058.48,,,1058.48,Other,100% New York Medicaid APG,1058.48,,,1058.48,Other,100% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,1481.87,,,1481.87,Other,140% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,2752.04,,,2752.04,Other,260% New York Medicaid APG,3429.47,,,3429.47,Other,324% New York Medicaid APG,2275.73,,,2275.73,Other,215% New York Medicaid APG,2275.73,,,2275.73,Other,215% New York Medicaid APG,1323.1,,,1323.1,Other,125% New York Medicaid APG,1058.48,46931.32,
Mech remov tunneled cv cath,36596,CPT,,,,,,,,both,,,33686.28,3045.56,,,3045.56,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.02,,,1852.02,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16843.14,50,,16843.14,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1968.77,,,1968.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23580.4,70,,23580.4,percent of total billed charges,,214.5,,,214.5,Fee Schedule,,182,,,182,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1058.48,,,1058.48,Other,New York Medicaid APG methodology,1058.48,,,1058.48,Other,100% New York Medicaid APG,1058.48,,,1058.48,Other,100% New York Medicaid APG,1058.48,,,1058.48,Other,100% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,1481.87,,,1481.87,Other,140% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,2752.04,,,2752.04,Other,260% New York Medicaid APG,3429.47,,,3429.47,Other,324% New York Medicaid APG,2275.73,,,2275.73,Other,215% New York Medicaid APG,2275.73,,,2275.73,Other,215% New York Medicaid APG,1323.1,,,1323.1,Other,125% New York Medicaid APG,182,23580.4,
Reposition venous catheter,36597,CPT,,,,,,,,both,,,33686.28,3045.56,,,3045.56,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.02,,,1852.02,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16843.14,50,,16843.14,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1968.77,,,1968.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23580.4,70,,23580.4,percent of total billed charges,,295.35,,,295.35,Fee Schedule,,250.6,,,250.6,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1058.48,,,1058.48,Other,New York Medicaid APG methodology,1058.48,,,1058.48,Other,100% New York Medicaid APG,1058.48,,,1058.48,Other,100% New York Medicaid APG,1058.48,,,1058.48,Other,100% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,1481.87,,,1481.87,Other,140% New York Medicaid APG,2381.58,,,2381.58,Other,225% New York Medicaid APG,2752.04,,,2752.04,Other,260% New York Medicaid APG,3429.47,,,3429.47,Other,324% New York Medicaid APG,2275.73,,,2275.73,Other,215% New York Medicaid APG,2275.73,,,2275.73,Other,215% New York Medicaid APG,1323.1,,,1323.1,Other,125% New York Medicaid APG,250.6,23580.4,
Inj w/fluor eval cv device,36598,CPT,,,,,,,,both,,,13047.71,407.6,,,407.6,Other,150% of Medicare + 9.63% HCRA Surcharge,247.86,,,247.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6523.86,50,,6523.86,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1205.26,,,1205.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9133.4,70,,9133.4,percent of total billed charges,,173.25,,,173.25,Fee Schedule,,147,,,147,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.99,,,647.99,Other,New York Medicaid APG methodology,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,907.18,,,907.18,Other,140% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1684.77,,,1684.77,Other,260% New York Medicaid APG,2099.48,,,2099.48,Other,324% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,809.98,,,809.98,Other,125% New York Medicaid APG,147,9473,
Withdrawal of arterial blood,36600,CPT,,,,,,,,both,,,2686.86,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Aetna ASC Grouper,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1343.43,50,,1343.43,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,283.45,,,283.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,1880.8,70,,1880.8,percent of total billed charges,,72.6,,,72.6,Fee Schedule,,61.6,,,61.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,152.39,,,152.39,Other,New York Medicaid APG methodology,152.39,,,152.39,Other,100% New York Medicaid APG,152.39,,,152.39,Other,100% New York Medicaid APG,152.39,,,152.39,Other,100% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,213.35,,,213.35,Other,140% New York Medicaid APG,342.88,,,342.88,Other,225% New York Medicaid APG,396.22,,,396.22,Other,260% New York Medicaid APG,493.75,,,493.75,Other,324% New York Medicaid APG,327.64,,,327.64,Other,215% New York Medicaid APG,327.64,,,327.64,Other,215% New York Medicaid APG,190.49,,,190.49,Other,125% New York Medicaid APG,0.01,9473,
Insertion catheter artery,36620,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,621.52,,,621.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,216.15,,,216.15,Fee Schedule,,183.4,,,183.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,334.15,,,334.15,Other,New York Medicaid APG methodology,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,467.81,,,467.81,Other,140% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,868.8,,,868.8,Other,260% New York Medicaid APG,1082.66,,,1082.66,Other,324% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,417.69,,,417.69,Other,125% New York Medicaid APG,0.01,22702.47,
Insertion catheter artery,36625,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,621.52,,,621.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,334.15,,,334.15,Other,New York Medicaid APG methodology,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,467.81,,,467.81,Other,140% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,868.8,,,868.8,Other,260% New York Medicaid APG,1082.66,,,1082.66,Other,324% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,417.69,,,417.69,Other,125% New York Medicaid APG,0.01,22702.47,
Insertion catheter artery,36640,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2192.39,,,2192.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1178.7,,,1178.7,Other,New York Medicaid APG methodology,1178.7,,,1178.7,Other,100% New York Medicaid APG,1178.7,,,1178.7,Other,100% New York Medicaid APG,1178.7,,,1178.7,Other,100% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,1650.19,,,1650.19,Other,140% New York Medicaid APG,2652.08,,,2652.08,Other,225% New York Medicaid APG,3064.63,,,3064.63,Other,260% New York Medicaid APG,3819,,,3819,Other,324% New York Medicaid APG,2534.21,,,2534.21,Other,215% New York Medicaid APG,2534.21,,,2534.21,Other,215% New York Medicaid APG,1473.38,,,1473.38,Other,125% New York Medicaid APG,1178.7,46931.32,
Insert needle bone cavity,36680,CPT,,,,,,,,both,,,8380.68,757.69,,,757.69,Other,150% of Medicare + 9.63% HCRA Surcharge,460.76,,,460.76,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4190.34,50,,4190.34,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,841.15,,,841.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5866.48,70,,5866.48,percent of total billed charges,,290.4,,,290.4,Fee Schedule,,246.4,,,246.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,452.23,,,452.23,Other,New York Medicaid APG methodology,452.23,,,452.23,Other,100% New York Medicaid APG,452.23,,,452.23,Other,100% New York Medicaid APG,452.23,,,452.23,Other,100% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,633.12,,,633.12,Other,140% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1175.8,,,1175.8,Other,260% New York Medicaid APG,1465.23,,,1465.23,Other,324% New York Medicaid APG,972.3,,,972.3,Other,215% New York Medicaid APG,972.3,,,972.3,Other,215% New York Medicaid APG,565.29,,,565.29,Other,125% New York Medicaid APG,0.01,9473,
Insertion of cannula,36800,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3177.13,,,3177.13,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,1708.14,,,1708.14,Other,New York Medicaid APG methodology,1708.14,,,1708.14,Other,100% New York Medicaid APG,1708.14,,,1708.14,Other,100% New York Medicaid APG,1708.14,,,1708.14,Other,100% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,2391.39,,,2391.39,Other,140% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,4441.15,,,4441.15,Other,260% New York Medicaid APG,5534.36,,,5534.36,Other,324% New York Medicaid APG,3672.49,,,3672.49,Other,215% New York Medicaid APG,3672.49,,,3672.49,Other,215% New York Medicaid APG,2135.17,,,2135.17,Other,125% New York Medicaid APG,1708.14,80911.37,
Insertion of cannula,36810,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3177.13,,,3177.13,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1708.14,,,1708.14,Other,New York Medicaid APG methodology,1708.14,,,1708.14,Other,100% New York Medicaid APG,1708.14,,,1708.14,Other,100% New York Medicaid APG,1708.14,,,1708.14,Other,100% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,2391.39,,,2391.39,Other,140% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,4441.15,,,4441.15,Other,260% New York Medicaid APG,5534.36,,,5534.36,Other,324% New York Medicaid APG,3672.49,,,3672.49,Other,215% New York Medicaid APG,3672.49,,,3672.49,Other,215% New York Medicaid APG,2135.17,,,2135.17,Other,125% New York Medicaid APG,1708.14,46931.32,
Insertion of cannula,36815,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3177.13,,,3177.13,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,1708.14,,,1708.14,Other,New York Medicaid APG methodology,1708.14,,,1708.14,Other,100% New York Medicaid APG,1708.14,,,1708.14,Other,100% New York Medicaid APG,1708.14,,,1708.14,Other,100% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,2391.39,,,2391.39,Other,140% New York Medicaid APG,3843.31,,,3843.31,Other,225% New York Medicaid APG,4441.15,,,4441.15,Other,260% New York Medicaid APG,5534.36,,,5534.36,Other,324% New York Medicaid APG,3672.49,,,3672.49,Other,215% New York Medicaid APG,3672.49,,,3672.49,Other,215% New York Medicaid APG,2135.17,,,2135.17,Other,125% New York Medicaid APG,1708.14,80911.37,
Av fuse uppr arm cephalic,36818,CPT,,,,,,,,both,,,46108.27,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,23054.14,50,,23054.14,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5635.96,,,5635.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,32275.79,70,,32275.79,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3030.09,,,3030.09,Other,New York Medicaid APG methodology,3030.09,,,3030.09,Other,100% New York Medicaid APG,3030.09,,,3030.09,Other,100% New York Medicaid APG,3030.09,,,3030.09,Other,100% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,4242.12,,,4242.12,Other,140% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,7878.22,,,7878.22,Other,260% New York Medicaid APG,9817.48,,,9817.48,Other,324% New York Medicaid APG,6514.68,,,6514.68,Other,215% New York Medicaid APG,6514.68,,,6514.68,Other,215% New York Medicaid APG,3787.61,,,3787.61,Other,125% New York Medicaid APG,3030.09,32275.79,
Av fuse uppr arm basilic,36819,CPT,,,,,,,,both,,,39936.33,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,19968.17,50,,19968.17,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5635.96,,,5635.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27955.43,70,,27955.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3030.09,,,3030.09,Other,New York Medicaid APG methodology,3030.09,,,3030.09,Other,100% New York Medicaid APG,3030.09,,,3030.09,Other,100% New York Medicaid APG,3030.09,,,3030.09,Other,100% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,4242.12,,,4242.12,Other,140% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,7878.22,,,7878.22,Other,260% New York Medicaid APG,9817.48,,,9817.48,Other,324% New York Medicaid APG,6514.68,,,6514.68,Other,215% New York Medicaid APG,6514.68,,,6514.68,Other,215% New York Medicaid APG,3787.61,,,3787.61,Other,125% New York Medicaid APG,3030.09,27955.43,
Av fusion/forearm vein,36820,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5635.96,,,5635.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3030.09,,,3030.09,Other,New York Medicaid APG methodology,3030.09,,,3030.09,Other,100% New York Medicaid APG,3030.09,,,3030.09,Other,100% New York Medicaid APG,3030.09,,,3030.09,Other,100% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,4242.12,,,4242.12,Other,140% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,7878.22,,,7878.22,Other,260% New York Medicaid APG,9817.48,,,9817.48,Other,324% New York Medicaid APG,6514.68,,,6514.68,Other,215% New York Medicaid APG,6514.68,,,6514.68,Other,215% New York Medicaid APG,3787.61,,,3787.61,Other,125% New York Medicaid APG,3030.09,80911.37,
Av fusion direct any site,36821,CPT,,,,,,,,both,,,40013.59,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,20006.8,50,,20006.8,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5635.96,,,5635.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28009.51,70,,28009.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3030.09,,,3030.09,Other,New York Medicaid APG methodology,3030.09,,,3030.09,Other,100% New York Medicaid APG,3030.09,,,3030.09,Other,100% New York Medicaid APG,3030.09,,,3030.09,Other,100% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,4242.12,,,4242.12,Other,140% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,7878.22,,,7878.22,Other,260% New York Medicaid APG,9817.48,,,9817.48,Other,324% New York Medicaid APG,6514.68,,,6514.68,Other,215% New York Medicaid APG,6514.68,,,6514.68,Other,215% New York Medicaid APG,3787.61,,,3787.61,Other,125% New York Medicaid APG,3030.09,28009.51,
Artery-vein autograft,36825,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5635.96,,,5635.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3030.09,,,3030.09,Other,New York Medicaid APG methodology,3030.09,,,3030.09,Other,100% New York Medicaid APG,3030.09,,,3030.09,Other,100% New York Medicaid APG,3030.09,,,3030.09,Other,100% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,4242.12,,,4242.12,Other,140% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,7878.22,,,7878.22,Other,260% New York Medicaid APG,9817.48,,,9817.48,Other,324% New York Medicaid APG,6514.68,,,6514.68,Other,215% New York Medicaid APG,6514.68,,,6514.68,Other,215% New York Medicaid APG,3787.61,,,3787.61,Other,125% New York Medicaid APG,3030.09,80911.37,
Artery-vein nonautograft,36830,CPT,,,,,,,,both,,,47662.49,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,23831.25,50,,23831.25,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5635.96,,,5635.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,33363.74,70,,33363.74,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3030.09,,,3030.09,Other,New York Medicaid APG methodology,3030.09,,,3030.09,Other,100% New York Medicaid APG,3030.09,,,3030.09,Other,100% New York Medicaid APG,3030.09,,,3030.09,Other,100% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,4242.12,,,4242.12,Other,140% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,7878.22,,,7878.22,Other,260% New York Medicaid APG,9817.48,,,9817.48,Other,324% New York Medicaid APG,6514.68,,,6514.68,Other,215% New York Medicaid APG,6514.68,,,6514.68,Other,215% New York Medicaid APG,3787.61,,,3787.61,Other,125% New York Medicaid APG,3030.09,33363.74,
Open thrombect av fistula,36831,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5635.96,,,5635.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3030.09,,,3030.09,Other,New York Medicaid APG methodology,3030.09,,,3030.09,Other,100% New York Medicaid APG,3030.09,,,3030.09,Other,100% New York Medicaid APG,3030.09,,,3030.09,Other,100% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,4242.12,,,4242.12,Other,140% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,7878.22,,,7878.22,Other,260% New York Medicaid APG,9817.48,,,9817.48,Other,324% New York Medicaid APG,6514.68,,,6514.68,Other,215% New York Medicaid APG,6514.68,,,6514.68,Other,215% New York Medicaid APG,3787.61,,,3787.61,Other,125% New York Medicaid APG,3030.09,80911.37,
Av fistula revision open,36832,CPT,,,,,,,,both,,,46489.03,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,23244.52,50,,23244.52,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5635.96,,,5635.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,32542.32,70,,32542.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3030.09,,,3030.09,Other,New York Medicaid APG methodology,3030.09,,,3030.09,Other,100% New York Medicaid APG,3030.09,,,3030.09,Other,100% New York Medicaid APG,3030.09,,,3030.09,Other,100% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,4242.12,,,4242.12,Other,140% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,7878.22,,,7878.22,Other,260% New York Medicaid APG,9817.48,,,9817.48,Other,324% New York Medicaid APG,6514.68,,,6514.68,Other,215% New York Medicaid APG,6514.68,,,6514.68,Other,215% New York Medicaid APG,3787.61,,,3787.61,Other,125% New York Medicaid APG,3030.09,32542.32,
Av fistula revision,36833,CPT,,,,,,,,both,,,48927.34,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,24463.67,50,,24463.67,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5635.96,,,5635.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34249.14,70,,34249.14,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3030.09,,,3030.09,Other,New York Medicaid APG methodology,3030.09,,,3030.09,Other,100% New York Medicaid APG,3030.09,,,3030.09,Other,100% New York Medicaid APG,3030.09,,,3030.09,Other,100% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,4242.12,,,4242.12,Other,140% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,7878.22,,,7878.22,Other,260% New York Medicaid APG,9817.48,,,9817.48,Other,324% New York Medicaid APG,6514.68,,,6514.68,Other,215% New York Medicaid APG,6514.68,,,6514.68,Other,215% New York Medicaid APG,3787.61,,,3787.61,Other,125% New York Medicaid APG,3030.09,34249.14,
Artery to vein shunt,36835,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5635.96,,,5635.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3030.09,,,3030.09,Other,New York Medicaid APG methodology,3030.09,,,3030.09,Other,100% New York Medicaid APG,3030.09,,,3030.09,Other,100% New York Medicaid APG,3030.09,,,3030.09,Other,100% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,4242.12,,,4242.12,Other,140% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,7878.22,,,7878.22,Other,260% New York Medicaid APG,9817.48,,,9817.48,Other,324% New York Medicaid APG,6514.68,,,6514.68,Other,215% New York Medicaid APG,6514.68,,,6514.68,Other,215% New York Medicaid APG,3787.61,,,3787.61,Other,125% New York Medicaid APG,3030.09,46931.32,
Dist revas ligation hemo,36838,CPT,,,,,,,,both,,,71342.33,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,35671.17,50,,35671.17,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5635.96,,,5635.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,49939.63,70,,49939.63,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3030.09,,,3030.09,Other,New York Medicaid APG methodology,3030.09,,,3030.09,Other,100% New York Medicaid APG,3030.09,,,3030.09,Other,100% New York Medicaid APG,3030.09,,,3030.09,Other,100% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,4242.12,,,4242.12,Other,140% New York Medicaid APG,6817.69,,,6817.69,Other,225% New York Medicaid APG,7878.22,,,7878.22,Other,260% New York Medicaid APG,9817.48,,,9817.48,Other,324% New York Medicaid APG,6514.68,,,6514.68,Other,215% New York Medicaid APG,6514.68,,,6514.68,Other,215% New York Medicaid APG,3787.61,,,3787.61,Other,125% New York Medicaid APG,3030.09,49939.63,
External cannula declotting,36860,CPT,,,,,,,,both,,,33686.28,3045.56,,,3045.56,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.02,,,1852.02,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16843.14,50,,16843.14,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,787.49,,,787.49,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23580.4,70,,23580.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,423.38,,,423.38,Other,New York Medicaid APG methodology,423.38,,,423.38,Other,100% New York Medicaid APG,423.38,,,423.38,Other,100% New York Medicaid APG,423.38,,,423.38,Other,100% New York Medicaid APG,952.61,,,952.61,Other,225% New York Medicaid APG,952.61,,,952.61,Other,225% New York Medicaid APG,952.61,,,952.61,Other,225% New York Medicaid APG,952.61,,,952.61,Other,225% New York Medicaid APG,592.73,,,592.73,Other,140% New York Medicaid APG,952.61,,,952.61,Other,225% New York Medicaid APG,1100.79,,,1100.79,Other,260% New York Medicaid APG,1371.76,,,1371.76,Other,324% New York Medicaid APG,910.27,,,910.27,Other,215% New York Medicaid APG,910.27,,,910.27,Other,215% New York Medicaid APG,529.23,,,529.23,Other,125% New York Medicaid APG,423.38,23580.4,
Cannula declotting,36861,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4941.98,,,4941.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2656.98,,,2656.98,Other,New York Medicaid APG methodology,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,3719.77,,,3719.77,Other,140% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,6908.15,,,6908.15,Other,260% New York Medicaid APG,8608.61,,,8608.61,Other,324% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,3321.22,,,3321.22,Other,125% New York Medicaid APG,2656.98,80911.37,
Intro cath dialysis circuit,36901,CPT,,,,,,,,both,,,45783.33,3045.56,,,3045.56,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.02,,,1852.02,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,22891.67,50,,22891.67,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,972.26,,,972.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,32048.33,70,,32048.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,522.72,,,522.72,Other,New York Medicaid APG methodology,522.72,,,522.72,Other,100% New York Medicaid APG,522.72,,,522.72,Other,100% New York Medicaid APG,522.72,,,522.72,Other,100% New York Medicaid APG,1176.12,,,1176.12,Other,225% New York Medicaid APG,1176.12,,,1176.12,Other,225% New York Medicaid APG,1176.12,,,1176.12,Other,225% New York Medicaid APG,1176.12,,,1176.12,Other,225% New York Medicaid APG,731.81,,,731.81,Other,140% New York Medicaid APG,1176.12,,,1176.12,Other,225% New York Medicaid APG,1359.07,,,1359.07,Other,260% New York Medicaid APG,1693.61,,,1693.61,Other,324% New York Medicaid APG,1123.85,,,1123.85,Other,215% New York Medicaid APG,1123.85,,,1123.85,Other,215% New York Medicaid APG,653.4,,,653.4,Other,125% New York Medicaid APG,0.01,32048.33,
Intro cath dialysis circuit,36902,CPT,,,,,,,,both,,,59916.11,10869.18,,,10869.18,Other,150% of Medicare + 9.63% HCRA Surcharge,6609.62,,,6609.62,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,29958.06,50,,29958.06,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4941.98,,,4941.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41941.28,70,,41941.28,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2656.98,,,2656.98,Other,New York Medicaid APG methodology,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,3719.77,,,3719.77,Other,140% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,6908.15,,,6908.15,Other,260% New York Medicaid APG,8608.61,,,8608.61,Other,324% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,3321.22,,,3321.22,Other,125% New York Medicaid APG,2656.98,41941.28,
Intro cath dialysis circuit,36903,CPT,,,,,,,,both,,,84539,20920.32,,,20920.32,Other,150% of Medicare + 9.63% HCRA Surcharge,12721.77,,,12721.77,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,42269.5,50,,42269.5,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,59177.3,70,,59177.3,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,3180.44,59177.3,
Thrmbc/nfs dialysis circuit,36904,CPT,,,,,,,,both,,,120221.84,10869.18,,,10869.18,Other,150% of Medicare + 9.63% HCRA Surcharge,6609.62,,,6609.62,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,60110.92,50,,60110.92,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4941.98,,,4941.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84155.29,70,,84155.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2656.98,,,2656.98,Other,New York Medicaid APG methodology,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,3719.77,,,3719.77,Other,140% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,6908.15,,,6908.15,Other,260% New York Medicaid APG,8608.61,,,8608.61,Other,324% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,3321.22,,,3321.22,Other,125% New York Medicaid APG,2656.98,84155.29,
Thrmbc/nfs dialysis circuit,36905,CPT,,,,,,,,both,,,33272.33,20920.32,,,20920.32,Other,150% of Medicare + 9.63% HCRA Surcharge,12721.77,,,12721.77,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,16636.17,50,,16636.17,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5915.6,,,5915.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23290.63,70,,23290.63,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3180.43,,,3180.43,Other,New York Medicaid APG methodology,3180.43,,,3180.43,Other,100% New York Medicaid APG,3180.43,,,3180.43,Other,100% New York Medicaid APG,3180.43,,,3180.43,Other,100% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,4452.6,,,4452.6,Other,140% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,8269.12,,,8269.12,Other,260% New York Medicaid APG,10304.59,,,10304.59,Other,324% New York Medicaid APG,6837.92,,,6837.92,Other,215% New York Medicaid APG,6837.92,,,6837.92,Other,215% New York Medicaid APG,3975.54,,,3975.54,Other,125% New York Medicaid APG,3180.43,23290.63,
Thrmbc/nfs dialysis circuit,36906,CPT,,,,,,,,both,,,37210,33345.6,,,33345.6,Other,150% of Medicare + 9.63% HCRA Surcharge,20277.66,,,20277.66,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,18605,50,,18605,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26047,70,,26047,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,17798,,"100% primary, 50% secondary, 25% tertiary procedure",17798,Other,United Healthcare ASC Grouper,16018,,"100% primary, 50% secondary, 25% tertiary procedure",16018,Other,United Healthcare ASC Grouper,17798,,"100% primary, 50% secondary, 25% tertiary procedure",17798,Other,United Healthcare ASC Grouper,15129,,"100% primary, 50% secondary, 25% tertiary procedure",15129,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,3180.44,34107,
Balo angiop ctr dialysis seg,36907,CPT,,,,,,,,both,,,86591.4,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,43295.7,50,,43295.7,percent of total billed charges,,60613.98,70,,60613.98,percent of total billed charges,,6152,,,6152,Case Rate,,5915.6,,,5915.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,60613.98,70,,60613.98,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,3180.43,,,3180.43,Other,New York Medicaid APG methodology,3180.43,,,3180.43,Other,100% New York Medicaid APG,3180.43,,,3180.43,Other,100% New York Medicaid APG,3180.43,,,3180.43,Other,100% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,4452.6,,,4452.6,Other,140% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,8269.12,,,8269.12,Other,260% New York Medicaid APG,10304.59,,,10304.59,Other,324% New York Medicaid APG,6837.92,,,6837.92,Other,215% New York Medicaid APG,6837.92,,,6837.92,Other,215% New York Medicaid APG,3975.54,,,3975.54,Other,125% New York Medicaid APG,0.01,60613.98,
Stent plmt ctr dialysis seg,36908,CPT,,,,,,,,both,,,83504,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,41752,50,,41752,percent of total billed charges,,58452.8,70,,58452.8,percent of total billed charges,,6152,,,6152,Case Rate,,5915.6,,,5915.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,58452.8,70,,58452.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,3180.43,,,3180.43,Other,New York Medicaid APG methodology,3180.43,,,3180.43,Other,100% New York Medicaid APG,3180.43,,,3180.43,Other,100% New York Medicaid APG,3180.43,,,3180.43,Other,100% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,4452.6,,,4452.6,Other,140% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,8269.12,,,8269.12,Other,260% New York Medicaid APG,10304.59,,,10304.59,Other,324% New York Medicaid APG,6837.92,,,6837.92,Other,215% New York Medicaid APG,6837.92,,,6837.92,Other,215% New York Medicaid APG,3975.54,,,3975.54,Other,125% New York Medicaid APG,0.01,58452.8,
Dialysis circuit embolj,36909,CPT,,,,,,,,both,,,64479.48,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32239.74,50,,32239.74,percent of total billed charges,,45135.64,70,,45135.64,percent of total billed charges,,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45135.64,70,,45135.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,0.01,45135.64,
Remove hepatic shunt (tips),37183,CPT,,,,,,,,both,,,53851.78,10869.18,,,10869.18,Other,150% of Medicare + 9.63% HCRA Surcharge,6609.62,,,6609.62,Other,Medicare OPPS methodology,15382,,"100% primary, 50% supplemental procedure",15382,Other,Aetna ASC Grouper,13844,,"100% primary, 50% supplemental procedure",13844,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,26925.89,50,,26925.89,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5915.6,,,5915.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,37696.25,70,,37696.25,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3180.43,,,3180.43,Other,New York Medicaid APG methodology,3180.43,,,3180.43,Other,100% New York Medicaid APG,3180.43,,,3180.43,Other,100% New York Medicaid APG,3180.43,,,3180.43,Other,100% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,4452.6,,,4452.6,Other,140% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,8269.12,,,8269.12,Other,260% New York Medicaid APG,10304.59,,,10304.59,Other,324% New York Medicaid APG,6837.92,,,6837.92,Other,215% New York Medicaid APG,6837.92,,,6837.92,Other,215% New York Medicaid APG,3975.54,,,3975.54,Other,125% New York Medicaid APG,3180.43,37696.25,
Prim art m-thrmbc 1st vsl,37184,CPT,,,,,,,,both,,,150309.5,33345.6,,,33345.6,Other,150% of Medicare + 9.63% HCRA Surcharge,20277.66,,,20277.66,Other,Medicare OPPS methodology,15382,,"100% primary, 50% supplemental procedure",15382,Other,Aetna ASC Grouper,13844,,"100% primary, 50% supplemental procedure",13844,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,75154.75,50,,75154.75,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5915.6,,,5915.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105216.65,70,,105216.65,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3180.43,,,3180.43,Other,New York Medicaid APG methodology,3180.43,,,3180.43,Other,100% New York Medicaid APG,3180.43,,,3180.43,Other,100% New York Medicaid APG,3180.43,,,3180.43,Other,100% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,4452.6,,,4452.6,Other,140% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,8269.12,,,8269.12,Other,260% New York Medicaid APG,10304.59,,,10304.59,Other,324% New York Medicaid APG,6837.92,,,6837.92,Other,215% New York Medicaid APG,6837.92,,,6837.92,Other,215% New York Medicaid APG,3975.54,,,3975.54,Other,125% New York Medicaid APG,3180.43,105216.65,
Prim art m-thrmbc sbsq vsl,37185,CPT,,,,,,,,both,,,64479.48,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32239.74,50,,32239.74,percent of total billed charges,,45135.64,70,,45135.64,percent of total billed charges,,6152,,,6152,Case Rate,,5915.6,,,5915.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45135.64,70,,45135.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,3180.43,,,3180.43,Other,New York Medicaid APG methodology,3180.43,,,3180.43,Other,100% New York Medicaid APG,3180.43,,,3180.43,Other,100% New York Medicaid APG,3180.43,,,3180.43,Other,100% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,4452.6,,,4452.6,Other,140% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,8269.12,,,8269.12,Other,260% New York Medicaid APG,10304.59,,,10304.59,Other,324% New York Medicaid APG,6837.92,,,6837.92,Other,215% New York Medicaid APG,6837.92,,,6837.92,Other,215% New York Medicaid APG,3975.54,,,3975.54,Other,125% New York Medicaid APG,0.01,45135.64,
Sec art thrombectomy add-on,37186,CPT,,,,,,,,both,,,64479.48,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32239.74,50,,32239.74,percent of total billed charges,,45135.64,70,,45135.64,percent of total billed charges,,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45135.64,70,,45135.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,0.01,45135.64,
Venous mech thrombectomy,37187,CPT,,,,,,,,both,,,126314.5,20920.32,,,20920.32,Other,150% of Medicare + 9.63% HCRA Surcharge,12721.77,,,12721.77,Other,Medicare OPPS methodology,15382,,"100% primary, 50% supplemental procedure",15382,Other,Aetna ASC Grouper,13844,,"100% primary, 50% supplemental procedure",13844,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,63157.25,50,,63157.25,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4941.98,,,4941.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,88420.15,70,,88420.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2656.98,,,2656.98,Other,New York Medicaid APG methodology,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,3719.77,,,3719.77,Other,140% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,6908.15,,,6908.15,Other,260% New York Medicaid APG,8608.61,,,8608.61,Other,324% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,3321.22,,,3321.22,Other,125% New York Medicaid APG,2656.98,88420.15,
Ven mechnl thrmbc repeat tx,37188,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,15382,,"100% primary, 50% supplemental procedure",15382,Other,Aetna ASC Grouper,13844,,"100% primary, 50% supplemental procedure",13844,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4941.98,,,4941.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2656.98,,,2656.98,Other,New York Medicaid APG methodology,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,3719.77,,,3719.77,Other,140% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,6908.15,,,6908.15,Other,260% New York Medicaid APG,8608.61,,,8608.61,Other,324% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,3321.22,,,3321.22,Other,125% New York Medicaid APG,2656.98,46931.32,
Ins endovas vena cava filtr,37191,CPT,,,,,,,,both,,,20501.41,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,10250.71,50,,10250.71,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4941.98,,,4941.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,14350.99,70,,14350.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2656.98,,,2656.98,Other,New York Medicaid APG methodology,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,3719.77,,,3719.77,Other,140% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,6908.15,,,6908.15,Other,260% New York Medicaid APG,8608.61,,,8608.61,Other,324% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,3321.22,,,3321.22,Other,125% New York Medicaid APG,2656.98,14350.99,
Redo endovas vena cava filtr,37192,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4941.98,,,4941.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2656.98,,,2656.98,Other,New York Medicaid APG methodology,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,3719.77,,,3719.77,Other,140% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,6908.15,,,6908.15,Other,260% New York Medicaid APG,8608.61,,,8608.61,Other,324% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,3321.22,,,3321.22,Other,125% New York Medicaid APG,2656.98,46931.32,
Rem endovas vena cava filter,37193,CPT,,,,,,,,both,,,41084.31,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,20542.16,50,,20542.16,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4941.98,,,4941.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28759.02,70,,28759.02,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2656.98,,,2656.98,Other,New York Medicaid APG methodology,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,3719.77,,,3719.77,Other,140% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,6908.15,,,6908.15,Other,260% New York Medicaid APG,8608.61,,,8608.61,Other,324% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,3321.22,,,3321.22,Other,125% New York Medicaid APG,2656.98,28759.02,
Thrombolytic therapy stroke,37195,CPT,,,,,,,,both,,,7123.45,644.03,,,644.03,Other,150% of Medicare + 9.63% HCRA Surcharge,391.64,,,391.64,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3561.73,50,,3561.73,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,787.49,,,787.49,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4986.42,70,,4986.42,percent of total billed charges,,3561.73,50,,3561.73,percent of total billed charges,,3561.73,50,,3561.73,percent of total billed charges,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,423.38,,,423.38,Other,New York Medicaid APG methodology,423.38,,,423.38,Other,100% New York Medicaid APG,423.38,,,423.38,Other,100% New York Medicaid APG,423.38,,,423.38,Other,100% New York Medicaid APG,952.61,,,952.61,Other,225% New York Medicaid APG,952.61,,,952.61,Other,225% New York Medicaid APG,952.61,,,952.61,Other,225% New York Medicaid APG,952.61,,,952.61,Other,225% New York Medicaid APG,592.73,,,592.73,Other,140% New York Medicaid APG,952.61,,,952.61,Other,225% New York Medicaid APG,1100.79,,,1100.79,Other,260% New York Medicaid APG,1371.76,,,1371.76,Other,324% New York Medicaid APG,910.27,,,910.27,Other,215% New York Medicaid APG,910.27,,,910.27,Other,215% New York Medicaid APG,529.23,,,529.23,Other,125% New York Medicaid APG,391.64,9473,
Remove intrvas foreign body,37197,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4941.98,,,4941.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2656.98,,,2656.98,Other,New York Medicaid APG methodology,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,3719.77,,,3719.77,Other,140% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,6908.15,,,6908.15,Other,260% New York Medicaid APG,8608.61,,,8608.61,Other,324% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,3321.22,,,3321.22,Other,125% New York Medicaid APG,2656.98,46931.32,
Transcatheter biopsy,37200,CPT,,,,,,,,both,,,27909.7,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,13954.85,50,,13954.85,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4941.98,,,4941.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,19536.79,70,,19536.79,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2656.98,,,2656.98,Other,New York Medicaid APG methodology,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,3719.77,,,3719.77,Other,140% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,6908.15,,,6908.15,Other,260% New York Medicaid APG,8608.61,,,8608.61,Other,324% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,3321.22,,,3321.22,Other,125% New York Medicaid APG,2656.98,19536.79,
Thrombolytic art therapy,37211,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4941.98,,,4941.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2656.98,,,2656.98,Other,New York Medicaid APG methodology,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,3719.77,,,3719.77,Other,140% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,6908.15,,,6908.15,Other,260% New York Medicaid APG,8608.61,,,8608.61,Other,324% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,3321.22,,,3321.22,Other,125% New York Medicaid APG,2656.98,80911.37,
Thrombolytic venous therapy,37212,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4941.98,,,4941.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2656.98,,,2656.98,Other,New York Medicaid APG methodology,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,3719.77,,,3719.77,Other,140% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,6908.15,,,6908.15,Other,260% New York Medicaid APG,8608.61,,,8608.61,Other,324% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,3321.22,,,3321.22,Other,125% New York Medicaid APG,2656.98,46931.32,
Thromblytic art/ven therapy,37213,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4941.98,,,4941.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,2656.98,,,2656.98,Other,New York Medicaid APG methodology,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,3719.77,,,3719.77,Other,140% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,6908.15,,,6908.15,Other,260% New York Medicaid APG,8608.61,,,8608.61,Other,324% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,3321.22,,,3321.22,Other,125% New York Medicaid APG,2656.98,46931.32,
Cessj therapy cath removal,37214,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4941.98,,,4941.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,2656.98,,,2656.98,Other,New York Medicaid APG methodology,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,3719.77,,,3719.77,Other,140% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,6908.15,,,6908.15,Other,260% New York Medicaid APG,8608.61,,,8608.61,Other,324% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,3321.22,,,3321.22,Other,125% New York Medicaid APG,2656.98,46931.32,
Iliac revasc,37220,CPT,,,,,,,,both,,,27747,10869.18,,,10869.18,Other,150% of Medicare + 9.63% HCRA Surcharge,6609.62,,,6609.62,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,13873.5,50,,13873.5,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5915.6,,,5915.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,19422.9,70,,19422.9,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3180.43,,,3180.43,Other,New York Medicaid APG methodology,3180.43,,,3180.43,Other,100% New York Medicaid APG,3180.43,,,3180.43,Other,100% New York Medicaid APG,3180.43,,,3180.43,Other,100% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,4452.6,,,4452.6,Other,140% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,8269.12,,,8269.12,Other,260% New York Medicaid APG,10304.59,,,10304.59,Other,324% New York Medicaid APG,6837.92,,,6837.92,Other,215% New York Medicaid APG,6837.92,,,6837.92,Other,215% New York Medicaid APG,3975.54,,,3975.54,Other,125% New York Medicaid APG,3180.43,19422.9,
Iliac revasc w/stent,37221,CPT,,,,,,,,both,,,147449.05,20920.32,,,20920.32,Other,150% of Medicare + 9.63% HCRA Surcharge,12721.77,,,12721.77,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,73724.53,50,,73724.53,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,103214.34,70,,103214.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,3180.44,103214.34,
Iliac revasc add-on,37222,CPT,,,,,,,,both,,,98219.64,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,49109.82,50,,49109.82,percent of total billed charges,,68753.75,70,,68753.75,percent of total billed charges,,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,68753.75,70,,68753.75,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,0.01,68753.75,
Iliac revasc w/stent add-on,37223,CPT,,,,,,,,both,,,98219.64,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,49109.82,50,,49109.82,percent of total billed charges,,68753.75,70,,68753.75,percent of total billed charges,,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,68753.75,70,,68753.75,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,0.01,68753.75,
Fem/popl revas w/tla,37224,CPT,,,,,,,,both,,,93611,10869.18,,,10869.18,Other,150% of Medicare + 9.63% HCRA Surcharge,6609.62,,,6609.62,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,46805.5,50,,46805.5,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5915.6,,,5915.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,65527.7,70,,65527.7,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3180.43,,,3180.43,Other,New York Medicaid APG methodology,3180.43,,,3180.43,Other,100% New York Medicaid APG,3180.43,,,3180.43,Other,100% New York Medicaid APG,3180.43,,,3180.43,Other,100% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,4452.6,,,4452.6,Other,140% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,8269.12,,,8269.12,Other,260% New York Medicaid APG,10304.59,,,10304.59,Other,324% New York Medicaid APG,6837.92,,,6837.92,Other,215% New York Medicaid APG,6837.92,,,6837.92,Other,215% New York Medicaid APG,3975.54,,,3975.54,Other,125% New York Medicaid APG,3180.43,65527.7,
Fem/popl revas w/ather,37225,CPT,,,,,,,,both,,,368828.98,33345.6,,,33345.6,Other,150% of Medicare + 9.63% HCRA Surcharge,20277.66,,,20277.66,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,184414.49,50,,184414.49,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,258180.29,70,,258180.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,3180.44,258180.29,
Fem/popl revasc w/stent,37226,CPT,,,,,,,,both,,,108112.64,20920.32,,,20920.32,Other,150% of Medicare + 9.63% HCRA Surcharge,12721.77,,,12721.77,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,54056.32,50,,54056.32,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,75678.85,70,,75678.85,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,3180.44,75678.85,
Fem/popl revasc stnt & ather,37227,CPT,,,,,,,,both,,,368828.98,33345.6,,,33345.6,Other,150% of Medicare + 9.63% HCRA Surcharge,20277.66,,,20277.66,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,184414.49,50,,184414.49,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,258180.29,70,,258180.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,17798,,"100% primary, 50% secondary, 25% tertiary procedure",17798,Other,United Healthcare ASC Grouper,16018,,"100% primary, 50% secondary, 25% tertiary procedure",16018,Other,United Healthcare ASC Grouper,17798,,"100% primary, 50% secondary, 25% tertiary procedure",17798,Other,United Healthcare ASC Grouper,15129,,"100% primary, 50% secondary, 25% tertiary procedure",15129,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,3180.44,258180.29,
Tib/per revasc w/tla,37228,CPT,,,,,,,,both,,,148904.54,20920.32,,,20920.32,Other,150% of Medicare + 9.63% HCRA Surcharge,12721.77,,,12721.77,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,74452.27,50,,74452.27,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5915.6,,,5915.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,104233.18,70,,104233.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3180.43,,,3180.43,Other,New York Medicaid APG methodology,3180.43,,,3180.43,Other,100% New York Medicaid APG,3180.43,,,3180.43,Other,100% New York Medicaid APG,3180.43,,,3180.43,Other,100% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,4452.6,,,4452.6,Other,140% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,8269.12,,,8269.12,Other,260% New York Medicaid APG,10304.59,,,10304.59,Other,324% New York Medicaid APG,6837.92,,,6837.92,Other,215% New York Medicaid APG,6837.92,,,6837.92,Other,215% New York Medicaid APG,3975.54,,,3975.54,Other,125% New York Medicaid APG,3180.43,104233.18,
Tib/per revasc w/ather,37229,CPT,,,,,,,,both,,,368828.98,33345.6,,,33345.6,Other,150% of Medicare + 9.63% HCRA Surcharge,20277.66,,,20277.66,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,184414.49,50,,184414.49,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,258180.29,70,,258180.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,3180.44,258180.29,
Tib/per revasc w/stent,37230,CPT,,,,,,,,both,,,368828.98,33345.6,,,33345.6,Other,150% of Medicare + 9.63% HCRA Surcharge,20277.66,,,20277.66,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,184414.49,50,,184414.49,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,258180.29,70,,258180.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,3180.44,258180.29,
Tib/per revasc stent & ather,37231,CPT,,,,,,,,both,,,368828.98,33345.6,,,33345.6,Other,150% of Medicare + 9.63% HCRA Surcharge,20277.66,,,20277.66,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,184414.49,50,,184414.49,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,258180.29,70,,258180.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,17798,,"100% primary, 50% secondary, 25% tertiary procedure",17798,Other,United Healthcare ASC Grouper,16018,,"100% primary, 50% secondary, 25% tertiary procedure",16018,Other,United Healthcare ASC Grouper,17798,,"100% primary, 50% secondary, 25% tertiary procedure",17798,Other,United Healthcare ASC Grouper,15129,,"100% primary, 50% secondary, 25% tertiary procedure",15129,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,3180.44,258180.29,
Tib/per revasc add-on,37232,CPT,,,,,,,,both,,,86591.4,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,43295.7,50,,43295.7,percent of total billed charges,,60613.98,70,,60613.98,percent of total billed charges,,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,60613.98,70,,60613.98,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,0.01,60613.98,
Tibper revasc w/ather add-on,37233,CPT,,,,,,,,both,,,86591.4,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,43295.7,50,,43295.7,percent of total billed charges,,60613.98,70,,60613.98,percent of total billed charges,,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,60613.98,70,,60613.98,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,0.01,60613.98,
Revsc opn/prq tib/pero stent,37234,CPT,,,,,,,,both,,,86591.4,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,43295.7,50,,43295.7,percent of total billed charges,,60613.98,70,,60613.98,percent of total billed charges,,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,60613.98,70,,60613.98,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,0.01,60613.98,
Tib/per revasc stnt & ather,37235,CPT,,,,,,,,both,,,86591.4,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,43295.7,50,,43295.7,percent of total billed charges,,60613.98,70,,60613.98,percent of total billed charges,,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,60613.98,70,,60613.98,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,0.01,60613.98,
Open/perq place stent 1st,37236,CPT,,,,,,,,both,,,128514,20920.32,,,20920.32,Other,150% of Medicare + 9.63% HCRA Surcharge,12721.77,,,12721.77,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,64257,50,,64257,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,89959.8,70,,89959.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,3180.44,89959.8,
Open/perq place stent ea add,37237,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,0.01,36100.43,
Open/perq place stent same,37238,CPT,,,,,,,,both,,,99592.33,20920.32,,,20920.32,Other,150% of Medicare + 9.63% HCRA Surcharge,12721.77,,,12721.77,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,49796.17,50,,49796.17,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,69714.63,70,,69714.63,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,3180.44,69714.63,
Open/perq place stent ea add,37239,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,0.01,36100.43,
Vasc embolize/occlude venous,37241,CPT,,,,,,,,both,,,71391.01,20920.32,,,20920.32,Other,150% of Medicare + 9.63% HCRA Surcharge,12721.77,,,12721.77,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,35695.51,50,,35695.51,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,49973.71,70,,49973.71,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,3180.44,49973.71,
Vasc embolize/occlude artery,37242,CPT,,,,,,,,both,,,58008,33345.6,,,33345.6,Other,150% of Medicare + 9.63% HCRA Surcharge,20277.66,,,20277.66,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,29004,50,,29004,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,40605.6,70,,40605.6,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,3180.44,40605.6,
Vasc embolize/occlude organ,37243,CPT,,,,,,,,both,,,105190.95,20920.32,,,20920.32,Other,150% of Medicare + 9.63% HCRA Surcharge,12721.77,,,12721.77,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,52595.48,50,,52595.48,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,73633.67,70,,73633.67,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,3180.44,73633.67,
Vasc embolize/occlude bleed,37244,CPT,,,,,,,,both,,,59963.33,20920.32,,,20920.32,Other,150% of Medicare + 9.63% HCRA Surcharge,12721.77,,,12721.77,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,29981.67,50,,29981.67,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41974.33,70,,41974.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,3180.44,41974.33,
Trluml balo angiop 1st art,37246,CPT,,,,,,,,both,,,120221.84,10869.18,,,10869.18,Other,150% of Medicare + 9.63% HCRA Surcharge,6609.62,,,6609.62,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,60110.92,50,,60110.92,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4941.98,,,4941.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84155.29,70,,84155.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2656.98,,,2656.98,Other,New York Medicaid APG methodology,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,3719.77,,,3719.77,Other,140% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,6908.15,,,6908.15,Other,260% New York Medicaid APG,8608.61,,,8608.61,Other,324% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,3321.22,,,3321.22,Other,125% New York Medicaid APG,2656.98,84155.29,
Trluml balo angiop addl art,37247,CPT,,,,,,,,both,,,83504,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,41752,50,,41752,percent of total billed charges,,58452.8,70,,58452.8,percent of total billed charges,,6152,,,6152,Case Rate,,5915.6,,,5915.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,58452.8,70,,58452.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,3180.43,,,3180.43,Other,New York Medicaid APG methodology,3180.43,,,3180.43,Other,100% New York Medicaid APG,3180.43,,,3180.43,Other,100% New York Medicaid APG,3180.43,,,3180.43,Other,100% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,4452.6,,,4452.6,Other,140% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,8269.12,,,8269.12,Other,260% New York Medicaid APG,10304.59,,,10304.59,Other,324% New York Medicaid APG,6837.92,,,6837.92,Other,215% New York Medicaid APG,6837.92,,,6837.92,Other,215% New York Medicaid APG,3975.54,,,3975.54,Other,125% New York Medicaid APG,0.01,58452.8,
Trluml balo angiop 1st vein,37248,CPT,,,,,,,,both,,,76655,10869.18,,,10869.18,Other,150% of Medicare + 9.63% HCRA Surcharge,6609.62,,,6609.62,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,38327.5,50,,38327.5,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4941.98,,,4941.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,53658.5,70,,53658.5,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2656.98,,,2656.98,Other,New York Medicaid APG methodology,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,3719.77,,,3719.77,Other,140% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,6908.15,,,6908.15,Other,260% New York Medicaid APG,8608.61,,,8608.61,Other,324% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,3321.22,,,3321.22,Other,125% New York Medicaid APG,2656.98,53658.5,
Trluml balo angiop addl vein,37249,CPT,,,,,,,,both,,,83504,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,41752,50,,41752,percent of total billed charges,,58452.8,70,,58452.8,percent of total billed charges,,6152,,,6152,Case Rate,,5915.6,,,5915.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,58452.8,70,,58452.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,3180.43,,,3180.43,Other,New York Medicaid APG methodology,3180.43,,,3180.43,Other,100% New York Medicaid APG,3180.43,,,3180.43,Other,100% New York Medicaid APG,3180.43,,,3180.43,Other,100% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,4452.6,,,4452.6,Other,140% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,8269.12,,,8269.12,Other,260% New York Medicaid APG,10304.59,,,10304.59,Other,324% New York Medicaid APG,6837.92,,,6837.92,Other,215% New York Medicaid APG,6837.92,,,6837.92,Other,215% New York Medicaid APG,3975.54,,,3975.54,Other,125% New York Medicaid APG,0.01,58452.8,
Intrvasc us noncoronary 1st,37252,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,3840.4,,,3840.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2064.73,,,2064.73,Other,New York Medicaid APG methodology,2064.73,,,2064.73,Other,100% New York Medicaid APG,2064.73,,,2064.73,Other,100% New York Medicaid APG,2064.73,,,2064.73,Other,100% New York Medicaid APG,4645.65,,,4645.65,Other,225% New York Medicaid APG,4645.65,,,4645.65,Other,225% New York Medicaid APG,4645.65,,,4645.65,Other,225% New York Medicaid APG,4645.65,,,4645.65,Other,225% New York Medicaid APG,2890.62,,,2890.62,Other,140% New York Medicaid APG,4645.65,,,4645.65,Other,225% New York Medicaid APG,5368.3,,,5368.3,Other,260% New York Medicaid APG,6689.73,,,6689.73,Other,324% New York Medicaid APG,4439.17,,,4439.17,Other,215% New York Medicaid APG,4439.17,,,4439.17,Other,215% New York Medicaid APG,2580.91,,,2580.91,Other,125% New York Medicaid APG,0.01,22702.47,
Intrvasc us noncoronary addl,37253,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,3840.4,,,3840.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,339.9,,,339.9,Fee Schedule,,288.4,,,288.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2064.73,,,2064.73,Other,New York Medicaid APG methodology,2064.73,,,2064.73,Other,100% New York Medicaid APG,2064.73,,,2064.73,Other,100% New York Medicaid APG,2064.73,,,2064.73,Other,100% New York Medicaid APG,4645.65,,,4645.65,Other,225% New York Medicaid APG,4645.65,,,4645.65,Other,225% New York Medicaid APG,4645.65,,,4645.65,Other,225% New York Medicaid APG,4645.65,,,4645.65,Other,225% New York Medicaid APG,2890.62,,,2890.62,Other,140% New York Medicaid APG,4645.65,,,4645.65,Other,225% New York Medicaid APG,5368.3,,,5368.3,Other,260% New York Medicaid APG,6689.73,,,6689.73,Other,324% New York Medicaid APG,4439.17,,,4439.17,Other,215% New York Medicaid APG,4439.17,,,4439.17,Other,215% New York Medicaid APG,2580.91,,,2580.91,Other,125% New York Medicaid APG,0.01,22702.47,
Endoscopy ligate perf veins,37500,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,80911.37,
Ligation of neck vein,37565,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3032,46931.32,
Ligation of neck artery,37600,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5584.77,,,5584.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3002.57,,,3002.57,Other,New York Medicaid APG methodology,3002.57,,,3002.57,Other,100% New York Medicaid APG,3002.57,,,3002.57,Other,100% New York Medicaid APG,3002.57,,,3002.57,Other,100% New York Medicaid APG,6755.77,,,6755.77,Other,225% New York Medicaid APG,6755.77,,,6755.77,Other,225% New York Medicaid APG,6755.77,,,6755.77,Other,225% New York Medicaid APG,6755.77,,,6755.77,Other,225% New York Medicaid APG,4203.59,,,4203.59,Other,140% New York Medicaid APG,6755.77,,,6755.77,Other,225% New York Medicaid APG,7806.67,,,7806.67,Other,260% New York Medicaid APG,9728.32,,,9728.32,Other,324% New York Medicaid APG,6455.52,,,6455.52,Other,215% New York Medicaid APG,6455.52,,,6455.52,Other,215% New York Medicaid APG,3753.21,,,3753.21,Other,125% New York Medicaid APG,3002.57,46931.32,
Ligation of neck artery,37605,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5584.77,,,5584.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3002.57,,,3002.57,Other,New York Medicaid APG methodology,3002.57,,,3002.57,Other,100% New York Medicaid APG,3002.57,,,3002.57,Other,100% New York Medicaid APG,3002.57,,,3002.57,Other,100% New York Medicaid APG,6755.77,,,6755.77,Other,225% New York Medicaid APG,6755.77,,,6755.77,Other,225% New York Medicaid APG,6755.77,,,6755.77,Other,225% New York Medicaid APG,6755.77,,,6755.77,Other,225% New York Medicaid APG,4203.59,,,4203.59,Other,140% New York Medicaid APG,6755.77,,,6755.77,Other,225% New York Medicaid APG,7806.67,,,7806.67,Other,260% New York Medicaid APG,9728.32,,,9728.32,Other,324% New York Medicaid APG,6455.52,,,6455.52,Other,215% New York Medicaid APG,6455.52,,,6455.52,Other,215% New York Medicaid APG,3753.21,,,3753.21,Other,125% New York Medicaid APG,3002.57,46931.32,
Ligation of neck artery,37606,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5584.77,,,5584.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3002.57,,,3002.57,Other,New York Medicaid APG methodology,3002.57,,,3002.57,Other,100% New York Medicaid APG,3002.57,,,3002.57,Other,100% New York Medicaid APG,3002.57,,,3002.57,Other,100% New York Medicaid APG,6755.77,,,6755.77,Other,225% New York Medicaid APG,6755.77,,,6755.77,Other,225% New York Medicaid APG,6755.77,,,6755.77,Other,225% New York Medicaid APG,6755.77,,,6755.77,Other,225% New York Medicaid APG,4203.59,,,4203.59,Other,140% New York Medicaid APG,6755.77,,,6755.77,Other,225% New York Medicaid APG,7806.67,,,7806.67,Other,260% New York Medicaid APG,9728.32,,,9728.32,Other,324% New York Medicaid APG,6455.52,,,6455.52,Other,215% New York Medicaid APG,6455.52,,,6455.52,Other,215% New York Medicaid APG,3753.21,,,3753.21,Other,125% New York Medicaid APG,3002.57,46931.32,
Ligation of a-v fistula,37607,CPT,,,,,,,,both,,,37131.52,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18565.76,50,,18565.76,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25992.06,70,,25992.06,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,25992.06,
Temporal artery procedure,37609,CPT,,,,,,,,both,,,34281.79,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17140.9,50,,17140.9,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23997.25,70,,23997.25,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,1874.86,23997.25,
Ligation of neck artery,37615,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3032,46931.32,
Ligation of inf vena cava,37619,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.86,,,6862.86,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,80911.37,
Revision of major vein,37650,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5673.29,,,5673.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3050.16,,,3050.16,Other,New York Medicaid APG methodology,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,3050.16,,,3050.16,Other,100% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,4270.22,,,4270.22,Other,140% New York Medicaid APG,6862.85,,,6862.85,Other,225% New York Medicaid APG,7930.41,,,7930.41,Other,260% New York Medicaid APG,9882.51,,,9882.51,Other,324% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,6557.84,,,6557.84,Other,215% New York Medicaid APG,3812.7,,,3812.7,Other,125% New York Medicaid APG,3050.16,46931.32,
Revise leg vein,37700,CPT,,,,,,,,both,,,41492.11,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,20746.06,50,,20746.06,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5334.25,,,5334.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29044.48,70,,29044.48,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2867.87,,,2867.87,Other,New York Medicaid APG methodology,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,4015.02,,,4015.02,Other,140% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,7456.47,,,7456.47,Other,260% New York Medicaid APG,9291.91,,,9291.91,Other,324% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,3584.84,,,3584.84,Other,125% New York Medicaid APG,2867.87,29044.48,
Ligate/strip short leg vein,37718,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5334.25,,,5334.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2867.87,,,2867.87,Other,New York Medicaid APG methodology,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,4015.02,,,4015.02,Other,140% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,7456.47,,,7456.47,Other,260% New York Medicaid APG,9291.91,,,9291.91,Other,324% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,3584.84,,,3584.84,Other,125% New York Medicaid APG,2867.87,46931.32,
Ligate/strip long leg vein,37722,CPT,,,,,,,,both,,,44299.77,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,22149.89,50,,22149.89,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5334.25,,,5334.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31009.84,70,,31009.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2867.87,,,2867.87,Other,New York Medicaid APG methodology,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,4015.02,,,4015.02,Other,140% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,7456.47,,,7456.47,Other,260% New York Medicaid APG,9291.91,,,9291.91,Other,324% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,3584.84,,,3584.84,Other,125% New York Medicaid APG,2867.87,31009.84,
Removal of leg veins/lesion,37735,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5334.25,,,5334.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2867.87,,,2867.87,Other,New York Medicaid APG methodology,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,4015.02,,,4015.02,Other,140% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,7456.47,,,7456.47,Other,260% New York Medicaid APG,9291.91,,,9291.91,Other,324% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,3584.84,,,3584.84,Other,125% New York Medicaid APG,2867.87,46931.32,
Ligate leg veins radical,37760,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5334.25,,,5334.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2867.87,,,2867.87,Other,New York Medicaid APG methodology,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,4015.02,,,4015.02,Other,140% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,7456.47,,,7456.47,Other,260% New York Medicaid APG,9291.91,,,9291.91,Other,324% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,3584.84,,,3584.84,Other,125% New York Medicaid APG,2867.87,46931.32,
Ligate leg veins open,37761,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5334.25,,,5334.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,2867.87,,,2867.87,Other,New York Medicaid APG methodology,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,4015.02,,,4015.02,Other,140% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,7456.47,,,7456.47,Other,260% New York Medicaid APG,9291.91,,,9291.91,Other,324% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,3584.84,,,3584.84,Other,125% New York Medicaid APG,2867.87,46931.32,
Stab phleb veins xtr 10-20,37765,CPT,,,,,,,,both,,,38028.55,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19014.28,50,,19014.28,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5334.25,,,5334.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26619.99,70,,26619.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2867.87,,,2867.87,Other,New York Medicaid APG methodology,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,4015.02,,,4015.02,Other,140% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,7456.47,,,7456.47,Other,260% New York Medicaid APG,9291.91,,,9291.91,Other,324% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,3584.84,,,3584.84,Other,125% New York Medicaid APG,2867.87,26619.99,
Phleb veins - extrem 20+,37766,CPT,,,,,,,,both,,,52151.56,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,26075.78,50,,26075.78,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5334.25,,,5334.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36506.09,70,,36506.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2867.87,,,2867.87,Other,New York Medicaid APG methodology,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,4015.02,,,4015.02,Other,140% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,7456.47,,,7456.47,Other,260% New York Medicaid APG,9291.91,,,9291.91,Other,324% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,3584.84,,,3584.84,Other,125% New York Medicaid APG,2867.87,36506.09,
Revision of leg vein,37780,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5334.25,,,5334.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,2867.87,,,2867.87,Other,New York Medicaid APG methodology,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,4015.02,,,4015.02,Other,140% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,7456.47,,,7456.47,Other,260% New York Medicaid APG,9291.91,,,9291.91,Other,324% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,3584.84,,,3584.84,Other,125% New York Medicaid APG,2867.87,46931.32,
Ligate/divide/excise vein,37785,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5334.25,,,5334.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2867.87,,,2867.87,Other,New York Medicaid APG methodology,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,4015.02,,,4015.02,Other,140% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,7456.47,,,7456.47,Other,260% New York Medicaid APG,9291.91,,,9291.91,Other,324% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,3584.84,,,3584.84,Other,125% New York Medicaid APG,2867.87,46931.32,
Penile venous occlusion,37790,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,51328.82,
Laparoscopy splenectomy,38120,CPT,,,,,,,,both,,,44931.54,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,22465.77,50,,22465.77,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4656.12,,,4656.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31452.08,70,,31452.08,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2503.29,,,2503.29,Other,New York Medicaid APG methodology,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,3504.61,,,3504.61,Other,140% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,6508.55,,,6508.55,Other,260% New York Medicaid APG,8110.66,,,8110.66,Other,324% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,3129.11,,,3129.11,Other,125% New York Medicaid APG,2503.29,31452.08,
Injection for spleen x-ray,38200,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1205.26,,,1205.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.99,,,647.99,Other,New York Medicaid APG methodology,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,907.18,,,907.18,Other,140% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1684.77,,,1684.77,Other,260% New York Medicaid APG,2099.48,,,2099.48,Other,324% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,809.98,,,809.98,Other,125% New York Medicaid APG,0.01,22702.47,
Bl donor search management,38204,CPT,,,,,,,,both,,,87274.28,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,52364.57,60,,52364.57,percent of total billed charges,,48873.6,56,,48873.6,percent of total billed charges,,47128.11,54,,47128.11,percent of total billed charges,,43637.14,50,,43637.14,percent of total billed charges,,61092,70,,61092,percent of total billed charges,,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,61092,70,,61092,percent of total billed charges,,490.05,,,490.05,Fee Schedule,,415.8,,,415.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,61092,
Harvest auto stem cells,38206,CPT,,,,,,,,both,,,32272.54,2917.74,,,2917.74,Other,150% of Medicare + 9.63% HCRA Surcharge,1774.3,,,1774.3,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16136.27,50,,16136.27,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4580.06,,,4580.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22590.78,70,,22590.78,percent of total billed charges,,405.9,,,405.9,Fee Schedule,,344.4,,,344.4,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2462.4,,,2462.4,Other,New York Medicaid APG methodology,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,3447.35,,,3447.35,Other,140% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,6402.23,,,6402.23,Other,260% New York Medicaid APG,7978.16,,,7978.16,Other,324% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,3077.99,,,3077.99,Other,125% New York Medicaid APG,344.4,22590.78,
Cryopreserve stem cells,38207,CPT,,,,,,,,both,,,9130.81,825.51,,,825.51,Other,150% of Medicare + 9.63% HCRA Surcharge,502,,,502,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4565.41,50,,4565.41,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4580.06,,,4580.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,6391.57,70,,6391.57,percent of total billed charges,,219.45,,,219.45,Fee Schedule,,186.2,,,186.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2462.4,,,2462.4,Other,New York Medicaid APG methodology,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,3447.35,,,3447.35,Other,140% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,6402.23,,,6402.23,Other,260% New York Medicaid APG,7978.16,,,7978.16,Other,324% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,3077.99,,,3077.99,Other,125% New York Medicaid APG,186.2,9473,
Thaw preserved stem cells,38208,CPT,,,,,,,,both,,,9130.81,825.51,,,825.51,Other,150% of Medicare + 9.63% HCRA Surcharge,502,,,502,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4565.41,50,,4565.41,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4580.06,,,4580.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,6391.57,70,,6391.57,percent of total billed charges,,138.6,,,138.6,Fee Schedule,,117.6,,,117.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2462.4,,,2462.4,Other,New York Medicaid APG methodology,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,3447.35,,,3447.35,Other,140% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,6402.23,,,6402.23,Other,260% New York Medicaid APG,7978.16,,,7978.16,Other,324% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,3077.99,,,3077.99,Other,125% New York Medicaid APG,117.6,9473,
Wash harvest stem cells,38209,CPT,,,,,,,,both,,,9130.81,825.51,,,825.51,Other,150% of Medicare + 9.63% HCRA Surcharge,502,,,502,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5478.49,60,,5478.49,percent of total billed charges,,5113.25,56,,5113.25,percent of total billed charges,,4930.64,54,,4930.64,percent of total billed charges,,4565.41,50,,4565.41,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4580.06,,,4580.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,6391.57,70,,6391.57,percent of total billed charges,,57.75,,,57.75,Fee Schedule,,49,,,49,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2462.4,,,2462.4,Other,New York Medicaid APG methodology,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,3447.35,,,3447.35,Other,140% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,6402.23,,,6402.23,Other,260% New York Medicaid APG,7978.16,,,7978.16,Other,324% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,3077.99,,,3077.99,Other,125% New York Medicaid APG,49,9473,
T-cell depletion of harvest,38210,CPT,,,,,,,,both,,,9130.81,825.51,,,825.51,Other,150% of Medicare + 9.63% HCRA Surcharge,502,,,502,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5478.49,60,,5478.49,percent of total billed charges,,5113.25,56,,5113.25,percent of total billed charges,,4930.64,54,,4930.64,percent of total billed charges,,4565.41,50,,4565.41,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4580.06,,,4580.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,6391.57,70,,6391.57,percent of total billed charges,,387.75,,,387.75,Fee Schedule,,329,,,329,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2462.4,,,2462.4,Other,New York Medicaid APG methodology,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,3447.35,,,3447.35,Other,140% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,6402.23,,,6402.23,Other,260% New York Medicaid APG,7978.16,,,7978.16,Other,324% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,3077.99,,,3077.99,Other,125% New York Medicaid APG,329,9473,
Tumor cell deplete of harvst,38211,CPT,,,,,,,,both,,,9130.81,825.51,,,825.51,Other,150% of Medicare + 9.63% HCRA Surcharge,502,,,502,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5478.49,60,,5478.49,percent of total billed charges,,5113.25,56,,5113.25,percent of total billed charges,,4930.64,54,,4930.64,percent of total billed charges,,4565.41,50,,4565.41,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4580.06,,,4580.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,6391.57,70,,6391.57,percent of total billed charges,,353.1,,,353.1,Fee Schedule,,299.6,,,299.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2462.4,,,2462.4,Other,New York Medicaid APG methodology,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,3447.35,,,3447.35,Other,140% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,6402.23,,,6402.23,Other,260% New York Medicaid APG,7978.16,,,7978.16,Other,324% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,3077.99,,,3077.99,Other,125% New York Medicaid APG,299.6,9473,
Rbc depletion of harvest,38212,CPT,,,,,,,,both,,,9130.81,825.51,,,825.51,Other,150% of Medicare + 9.63% HCRA Surcharge,502,,,502,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4565.41,50,,4565.41,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1373.44,,,1373.44,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,6391.57,70,,6391.57,percent of total billed charges,,231,,,231,Fee Schedule,,196,,,196,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,738.41,,,738.41,Other,New York Medicaid APG methodology,738.41,,,738.41,Other,100% New York Medicaid APG,738.41,,,738.41,Other,100% New York Medicaid APG,738.41,,,738.41,Other,100% New York Medicaid APG,1661.41,,,1661.41,Other,225% New York Medicaid APG,1661.41,,,1661.41,Other,225% New York Medicaid APG,1661.41,,,1661.41,Other,225% New York Medicaid APG,1661.41,,,1661.41,Other,225% New York Medicaid APG,1033.77,,,1033.77,Other,140% New York Medicaid APG,1661.41,,,1661.41,Other,225% New York Medicaid APG,1919.86,,,1919.86,Other,260% New York Medicaid APG,2392.44,,,2392.44,Other,324% New York Medicaid APG,1587.57,,,1587.57,Other,215% New York Medicaid APG,1587.57,,,1587.57,Other,215% New York Medicaid APG,923.01,,,923.01,Other,125% New York Medicaid APG,196,9473,
Platelet deplete of harvest,38213,CPT,,,,,,,,both,,,9130.81,825.51,,,825.51,Other,150% of Medicare + 9.63% HCRA Surcharge,502,,,502,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4565.41,50,,4565.41,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4580.06,,,4580.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,6391.57,70,,6391.57,percent of total billed charges,,57.75,,,57.75,Fee Schedule,,49,,,49,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2462.4,,,2462.4,Other,New York Medicaid APG methodology,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,3447.35,,,3447.35,Other,140% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,6402.23,,,6402.23,Other,260% New York Medicaid APG,7978.16,,,7978.16,Other,324% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,3077.99,,,3077.99,Other,125% New York Medicaid APG,49,9473,
Volume deplete of harvest,38214,CPT,,,,,,,,both,,,9130.81,825.51,,,825.51,Other,150% of Medicare + 9.63% HCRA Surcharge,502,,,502,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4565.41,50,,4565.41,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4580.06,,,4580.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,6391.57,70,,6391.57,percent of total billed charges,,198,,,198,Fee Schedule,,168,,,168,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2462.4,,,2462.4,Other,New York Medicaid APG methodology,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,3447.35,,,3447.35,Other,140% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,6402.23,,,6402.23,Other,260% New York Medicaid APG,7978.16,,,7978.16,Other,324% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,3077.99,,,3077.99,Other,125% New York Medicaid APG,168,9473,
Harvest stem cell concentrte,38215,CPT,,,,,,,,both,,,9130.81,825.51,,,825.51,Other,150% of Medicare + 9.63% HCRA Surcharge,502,,,502,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4565.41,50,,4565.41,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4580.06,,,4580.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,6391.57,70,,6391.57,percent of total billed charges,,231,,,231,Fee Schedule,,196,,,196,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2462.4,,,2462.4,Other,New York Medicaid APG methodology,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,3447.35,,,3447.35,Other,140% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,6402.23,,,6402.23,Other,260% New York Medicaid APG,7978.16,,,7978.16,Other,324% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,3077.99,,,3077.99,Other,125% New York Medicaid APG,196,9473,
Dx bone marrow aspirations,38220,CPT,,,,,,,,both,,,55779.91,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,27889.96,50,,27889.96,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1296.67,,,1296.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,39045.94,70,,39045.94,percent of total billed charges,,330,,,330,Fee Schedule,,280,,,280,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,697.13,,,697.13,Other,New York Medicaid APG methodology,697.13,,,697.13,Other,100% New York Medicaid APG,697.13,,,697.13,Other,100% New York Medicaid APG,697.13,,,697.13,Other,100% New York Medicaid APG,1568.55,,,1568.55,Other,225% New York Medicaid APG,1568.55,,,1568.55,Other,225% New York Medicaid APG,1568.55,,,1568.55,Other,225% New York Medicaid APG,1568.55,,,1568.55,Other,225% New York Medicaid APG,975.99,,,975.99,Other,140% New York Medicaid APG,1568.55,,,1568.55,Other,225% New York Medicaid APG,1812.55,,,1812.55,Other,260% New York Medicaid APG,2258.71,,,2258.71,Other,324% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,871.42,,,871.42,Other,125% New York Medicaid APG,280,39045.94,
Dx bone marrow biopsies,38221,CPT,,,,,,,,both,,,71841.53,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,35920.77,50,,35920.77,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1296.67,,,1296.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50289.07,70,,50289.07,percent of total billed charges,,341.55,,,341.55,Fee Schedule,,289.8,,,289.8,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,697.13,,,697.13,Other,New York Medicaid APG methodology,697.13,,,697.13,Other,100% New York Medicaid APG,697.13,,,697.13,Other,100% New York Medicaid APG,697.13,,,697.13,Other,100% New York Medicaid APG,1568.55,,,1568.55,Other,225% New York Medicaid APG,1568.55,,,1568.55,Other,225% New York Medicaid APG,1568.55,,,1568.55,Other,225% New York Medicaid APG,1568.55,,,1568.55,Other,225% New York Medicaid APG,975.99,,,975.99,Other,140% New York Medicaid APG,1568.55,,,1568.55,Other,225% New York Medicaid APG,1812.55,,,1812.55,Other,260% New York Medicaid APG,2258.71,,,2258.71,Other,324% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,871.42,,,871.42,Other,125% New York Medicaid APG,289.8,50289.07,
Dx bone marrow bx & aspir,38222,CPT,,,,,,,,both,,,65070.68,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32535.34,50,,32535.34,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1296.67,,,1296.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45549.48,70,,45549.48,percent of total billed charges,,367.95,,,367.95,Fee Schedule,,312.2,,,312.2,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,697.13,,,697.13,Other,New York Medicaid APG methodology,697.13,,,697.13,Other,100% New York Medicaid APG,697.13,,,697.13,Other,100% New York Medicaid APG,697.13,,,697.13,Other,100% New York Medicaid APG,1568.55,,,1568.55,Other,225% New York Medicaid APG,1568.55,,,1568.55,Other,225% New York Medicaid APG,1568.55,,,1568.55,Other,225% New York Medicaid APG,1568.55,,,1568.55,Other,225% New York Medicaid APG,975.99,,,975.99,Other,140% New York Medicaid APG,1568.55,,,1568.55,Other,225% New York Medicaid APG,1812.55,,,1812.55,Other,260% New York Medicaid APG,2258.71,,,2258.71,Other,324% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,871.42,,,871.42,Other,125% New York Medicaid APG,312.2,45549.48,
Bone marrow harvest allogen,38230,CPT,,,,,,,,both,,,45489.38,2917.74,,,2917.74,Other,150% of Medicare + 9.63% HCRA Surcharge,1774.3,,,1774.3,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,22744.69,50,,22744.69,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4580.06,,,4580.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31842.57,70,,31842.57,percent of total billed charges,,994.95,,,994.95,Fee Schedule,,844.2,,,844.2,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2462.4,,,2462.4,Other,New York Medicaid APG methodology,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,3447.35,,,3447.35,Other,140% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,6402.23,,,6402.23,Other,260% New York Medicaid APG,7978.16,,,7978.16,Other,324% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,3077.99,,,3077.99,Other,125% New York Medicaid APG,844.2,31842.57,
Bone marrow harvest autolog,38232,CPT,,,,,,,,both,,,97340.17,8800.46,,,8800.46,Other,150% of Medicare + 9.63% HCRA Surcharge,5351.62,,,5351.62,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,48670.09,50,,48670.09,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4580.06,,,4580.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,68138.12,70,,68138.12,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2462.4,,,2462.4,Other,New York Medicaid APG methodology,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,3447.35,,,3447.35,Other,140% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,6402.23,,,6402.23,Other,260% New York Medicaid APG,7978.16,,,7978.16,Other,324% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,3077.99,,,3077.99,Other,125% New York Medicaid APG,2462.4,68138.12,
Transplt allo hct/donor,38240,CPT,,,,,,,,both,,,50891.17,103917.25,,,103917.25,Other,150% of Medicare + 9.63% HCRA Surcharge,63192.71,,,63192.71,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,25445.59,50,,25445.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4580.05,,,4580.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,35623.82,70,,35623.82,percent of total billed charges,,1166.55,,,1166.55,Fee Schedule,,989.8,,,989.8,Fee Schedule,,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2462.39,,,2462.39,Other,New York Medicaid APG methodology,2462.39,,,2462.39,Other,100% New York Medicaid APG,2462.39,,,2462.39,Other,100% New York Medicaid APG,2462.39,,,2462.39,Other,100% New York Medicaid APG,5540.38,,,5540.38,Other,225% New York Medicaid APG,5540.38,,,5540.38,Other,225% New York Medicaid APG,5540.38,,,5540.38,Other,225% New York Medicaid APG,5540.38,,,5540.38,Other,225% New York Medicaid APG,3447.35,,,3447.35,Other,140% New York Medicaid APG,5540.38,,,5540.38,Other,225% New York Medicaid APG,6402.21,,,6402.21,Other,260% New York Medicaid APG,7978.14,,,7978.14,Other,324% New York Medicaid APG,5294.14,,,5294.14,Other,215% New York Medicaid APG,5294.14,,,5294.14,Other,215% New York Medicaid APG,3077.99,,,3077.99,Other,125% New York Medicaid APG,989.8,103917.25,
Transplt autol hct/donor,38241,CPT,,,,,,,,both,,,32272.54,2917.74,,,2917.74,Other,150% of Medicare + 9.63% HCRA Surcharge,1774.3,,,1774.3,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16136.27,50,,16136.27,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4580.06,,,4580.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22590.78,70,,22590.78,percent of total billed charges,,861.3,,,861.3,Fee Schedule,,730.8,,,730.8,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2462.4,,,2462.4,Other,New York Medicaid APG methodology,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,3447.35,,,3447.35,Other,140% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,6402.23,,,6402.23,Other,260% New York Medicaid APG,7978.16,,,7978.16,Other,324% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,3077.99,,,3077.99,Other,125% New York Medicaid APG,730.8,22590.78,
Transplt allo lymphocytes,38242,CPT,,,,,,,,both,,,32272.54,2917.74,,,2917.74,Other,150% of Medicare + 9.63% HCRA Surcharge,1774.3,,,1774.3,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16136.27,50,,16136.27,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4580.06,,,4580.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22590.78,70,,22590.78,percent of total billed charges,,610.5,,,610.5,Fee Schedule,,518,,,518,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2462.4,,,2462.4,Other,New York Medicaid APG methodology,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,3447.35,,,3447.35,Other,140% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,6402.23,,,6402.23,Other,260% New York Medicaid APG,7978.16,,,7978.16,Other,324% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,3077.99,,,3077.99,Other,125% New York Medicaid APG,518,22590.78,
Transplj hematopoietic boost,38243,CPT,,,,,,,,both,,,32272.54,2917.74,,,2917.74,Other,150% of Medicare + 9.63% HCRA Surcharge,1774.3,,,1774.3,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16136.27,50,,16136.27,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,4580.06,,,4580.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22590.78,70,,22590.78,percent of total billed charges,,597.3,,,597.3,Fee Schedule,,506.8,,,506.8,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2462.4,,,2462.4,Other,New York Medicaid APG methodology,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,3447.35,,,3447.35,Other,140% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,6402.23,,,6402.23,Other,260% New York Medicaid APG,7978.16,,,7978.16,Other,324% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,3077.99,,,3077.99,Other,125% New York Medicaid APG,0.01,22590.78,
Drainage lymph node lesion,38300,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3283.8,,,3283.8,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1765.48,,,1765.48,Other,New York Medicaid APG methodology,1765.48,,,1765.48,Other,100% New York Medicaid APG,1765.48,,,1765.48,Other,100% New York Medicaid APG,1765.48,,,1765.48,Other,100% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,2471.68,,,2471.68,Other,140% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,4590.26,,,4590.26,Other,260% New York Medicaid APG,5720.17,,,5720.17,Other,324% New York Medicaid APG,3795.79,,,3795.79,Other,215% New York Medicaid APG,3795.79,,,3795.79,Other,215% New York Medicaid APG,2206.85,,,2206.85,Other,125% New York Medicaid APG,1765.48,41837.04,
Drainage lymph node lesion,38305,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3283.8,,,3283.8,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1765.48,,,1765.48,Other,New York Medicaid APG methodology,1765.48,,,1765.48,Other,100% New York Medicaid APG,1765.48,,,1765.48,Other,100% New York Medicaid APG,1765.48,,,1765.48,Other,100% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,2471.68,,,2471.68,Other,140% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,4590.26,,,4590.26,Other,260% New York Medicaid APG,5720.17,,,5720.17,Other,324% New York Medicaid APG,3795.79,,,3795.79,Other,215% New York Medicaid APG,3795.79,,,3795.79,Other,215% New York Medicaid APG,2206.85,,,2206.85,Other,125% New York Medicaid APG,1765.48,41837.04,
Incision of lymph channels,38308,CPT,,,,,,,,both,,,80175.05,7248.58,,,7248.58,Other,150% of Medicare + 9.63% HCRA Surcharge,4407.9,,,4407.9,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40087.53,50,,40087.53,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3283.8,,,3283.8,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56122.54,70,,56122.54,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1765.48,,,1765.48,Other,New York Medicaid APG methodology,1765.48,,,1765.48,Other,100% New York Medicaid APG,1765.48,,,1765.48,Other,100% New York Medicaid APG,1765.48,,,1765.48,Other,100% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,2471.68,,,2471.68,Other,140% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,4590.26,,,4590.26,Other,260% New York Medicaid APG,5720.17,,,5720.17,Other,324% New York Medicaid APG,3795.79,,,3795.79,Other,215% New York Medicaid APG,3795.79,,,3795.79,Other,215% New York Medicaid APG,2206.85,,,2206.85,Other,125% New York Medicaid APG,1765.48,56122.54,
Biopsy/removal lymph nodes,38500,CPT,,,,,,,,both,,,80175.05,7248.58,,,7248.58,Other,150% of Medicare + 9.63% HCRA Surcharge,4407.9,,,4407.9,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40087.53,50,,40087.53,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3283.8,,,3283.8,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56122.54,70,,56122.54,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1765.48,,,1765.48,Other,New York Medicaid APG methodology,1765.48,,,1765.48,Other,100% New York Medicaid APG,1765.48,,,1765.48,Other,100% New York Medicaid APG,1765.48,,,1765.48,Other,100% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,2471.68,,,2471.68,Other,140% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,4590.26,,,4590.26,Other,260% New York Medicaid APG,5720.17,,,5720.17,Other,324% New York Medicaid APG,3795.79,,,3795.79,Other,215% New York Medicaid APG,3795.79,,,3795.79,Other,215% New York Medicaid APG,2206.85,,,2206.85,Other,125% New York Medicaid APG,1765.48,56122.54,
Needle biopsy lymph nodes,38505,CPT,,,,,,,,both,,,47084.53,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,23542.27,50,,23542.27,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2855.7,,,2855.7,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,32959.17,70,,32959.17,percent of total billed charges,,419.1,,,419.1,Fee Schedule,,355.6,,,355.6,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1535.32,,,1535.32,Other,New York Medicaid APG methodology,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,1535.32,,,1535.32,Other,100% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,2149.45,,,2149.45,Other,140% New York Medicaid APG,3454.48,,,3454.48,Other,225% New York Medicaid APG,3991.84,,,3991.84,Other,260% New York Medicaid APG,4974.44,,,4974.44,Other,324% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,3300.94,,,3300.94,Other,215% New York Medicaid APG,1919.15,,,1919.15,Other,125% New York Medicaid APG,355.6,32959.17,
Biopsy/removal lymph nodes,38510,CPT,,,,,,,,both,,,54121.87,7248.58,,,7248.58,Other,150% of Medicare + 9.63% HCRA Surcharge,4407.9,,,4407.9,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,27060.94,50,,27060.94,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3283.8,,,3283.8,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,37885.31,70,,37885.31,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1765.48,,,1765.48,Other,New York Medicaid APG methodology,1765.48,,,1765.48,Other,100% New York Medicaid APG,1765.48,,,1765.48,Other,100% New York Medicaid APG,1765.48,,,1765.48,Other,100% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,2471.68,,,2471.68,Other,140% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,4590.26,,,4590.26,Other,260% New York Medicaid APG,5720.17,,,5720.17,Other,324% New York Medicaid APG,3795.79,,,3795.79,Other,215% New York Medicaid APG,3795.79,,,3795.79,Other,215% New York Medicaid APG,2206.85,,,2206.85,Other,125% New York Medicaid APG,1765.48,37885.31,
Biopsy/removal lymph nodes,38520,CPT,,,,,,,,both,,,80175.05,7248.58,,,7248.58,Other,150% of Medicare + 9.63% HCRA Surcharge,4407.9,,,4407.9,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40087.53,50,,40087.53,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3283.8,,,3283.8,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56122.54,70,,56122.54,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1765.48,,,1765.48,Other,New York Medicaid APG methodology,1765.48,,,1765.48,Other,100% New York Medicaid APG,1765.48,,,1765.48,Other,100% New York Medicaid APG,1765.48,,,1765.48,Other,100% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,2471.68,,,2471.68,Other,140% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,4590.26,,,4590.26,Other,260% New York Medicaid APG,5720.17,,,5720.17,Other,324% New York Medicaid APG,3795.79,,,3795.79,Other,215% New York Medicaid APG,3795.79,,,3795.79,Other,215% New York Medicaid APG,2206.85,,,2206.85,Other,125% New York Medicaid APG,1765.48,56122.54,
Biopsy/removal lymph nodes,38525,CPT,,,,,,,,both,,,80175.05,7248.58,,,7248.58,Other,150% of Medicare + 9.63% HCRA Surcharge,4407.9,,,4407.9,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40087.53,50,,40087.53,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3283.8,,,3283.8,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56122.54,70,,56122.54,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1765.48,,,1765.48,Other,New York Medicaid APG methodology,1765.48,,,1765.48,Other,100% New York Medicaid APG,1765.48,,,1765.48,Other,100% New York Medicaid APG,1765.48,,,1765.48,Other,100% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,2471.68,,,2471.68,Other,140% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,4590.26,,,4590.26,Other,260% New York Medicaid APG,5720.17,,,5720.17,Other,324% New York Medicaid APG,3795.79,,,3795.79,Other,215% New York Medicaid APG,3795.79,,,3795.79,Other,215% New York Medicaid APG,2206.85,,,2206.85,Other,125% New York Medicaid APG,1765.48,56122.54,
Biopsy/removal lymph nodes,38530,CPT,,,,,,,,both,,,80175.05,7248.58,,,7248.58,Other,150% of Medicare + 9.63% HCRA Surcharge,4407.9,,,4407.9,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40087.53,50,,40087.53,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3283.8,,,3283.8,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56122.54,70,,56122.54,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1765.48,,,1765.48,Other,New York Medicaid APG methodology,1765.48,,,1765.48,Other,100% New York Medicaid APG,1765.48,,,1765.48,Other,100% New York Medicaid APG,1765.48,,,1765.48,Other,100% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,2471.68,,,2471.68,Other,140% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,4590.26,,,4590.26,Other,260% New York Medicaid APG,5720.17,,,5720.17,Other,324% New York Medicaid APG,3795.79,,,3795.79,Other,215% New York Medicaid APG,3795.79,,,3795.79,Other,215% New York Medicaid APG,2206.85,,,2206.85,Other,125% New York Medicaid APG,1765.48,56122.54,
Open bx/exc inguinofem nodes,38531,CPT,,,,,,,,both,,,49445.29,7248.58,,,7248.58,Other,150% of Medicare + 9.63% HCRA Surcharge,4407.9,,,4407.9,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,24722.65,50,,24722.65,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3283.8,,,3283.8,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34611.7,70,,34611.7,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1765.48,,,1765.48,Other,New York Medicaid APG methodology,1765.48,,,1765.48,Other,100% New York Medicaid APG,1765.48,,,1765.48,Other,100% New York Medicaid APG,1765.48,,,1765.48,Other,100% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,2471.68,,,2471.68,Other,140% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,4590.26,,,4590.26,Other,260% New York Medicaid APG,5720.17,,,5720.17,Other,324% New York Medicaid APG,3795.79,,,3795.79,Other,215% New York Medicaid APG,3795.79,,,3795.79,Other,215% New York Medicaid APG,2206.85,,,2206.85,Other,125% New York Medicaid APG,1765.48,34611.7,
Explore deep node(s) neck,38542,CPT,,,,,,,,both,,,121364.27,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,60682.14,50,,60682.14,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3283.8,,,3283.8,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84954.99,70,,84954.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,1765.48,,,1765.48,Other,New York Medicaid APG methodology,1765.48,,,1765.48,Other,100% New York Medicaid APG,1765.48,,,1765.48,Other,100% New York Medicaid APG,1765.48,,,1765.48,Other,100% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,2471.68,,,2471.68,Other,140% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,4590.26,,,4590.26,Other,260% New York Medicaid APG,5720.17,,,5720.17,Other,324% New York Medicaid APG,3795.79,,,3795.79,Other,215% New York Medicaid APG,3795.79,,,3795.79,Other,215% New York Medicaid APG,2206.85,,,2206.85,Other,125% New York Medicaid APG,1765.48,84954.99,
Removal neck/armpit lesion,38550,CPT,,,,,,,,both,,,80175.05,7248.58,,,7248.58,Other,150% of Medicare + 9.63% HCRA Surcharge,4407.9,,,4407.9,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40087.53,50,,40087.53,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3283.8,,,3283.8,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56122.54,70,,56122.54,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1765.48,,,1765.48,Other,New York Medicaid APG methodology,1765.48,,,1765.48,Other,100% New York Medicaid APG,1765.48,,,1765.48,Other,100% New York Medicaid APG,1765.48,,,1765.48,Other,100% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,2471.68,,,2471.68,Other,140% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,4590.26,,,4590.26,Other,260% New York Medicaid APG,5720.17,,,5720.17,Other,324% New York Medicaid APG,3795.79,,,3795.79,Other,215% New York Medicaid APG,3795.79,,,3795.79,Other,215% New York Medicaid APG,2206.85,,,2206.85,Other,125% New York Medicaid APG,1765.48,56122.54,
Removal neck/armpit lesion,38555,CPT,,,,,,,,both,,,137162.89,12400.81,,,12400.81,Other,150% of Medicare + 9.63% HCRA Surcharge,7541.01,,,7541.01,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,68581.45,50,,68581.45,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3283.8,,,3283.8,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,96014.02,70,,96014.02,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1765.48,,,1765.48,Other,New York Medicaid APG methodology,1765.48,,,1765.48,Other,100% New York Medicaid APG,1765.48,,,1765.48,Other,100% New York Medicaid APG,1765.48,,,1765.48,Other,100% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,2471.68,,,2471.68,Other,140% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,4590.26,,,4590.26,Other,260% New York Medicaid APG,5720.17,,,5720.17,Other,324% New York Medicaid APG,3795.79,,,3795.79,Other,215% New York Medicaid APG,3795.79,,,3795.79,Other,215% New York Medicaid APG,2206.85,,,2206.85,Other,125% New York Medicaid APG,1765.48,96014.02,
Laparoscopy lymph node biop,38570,CPT,,,,,,,,both,,,64506.8,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,32253.4,50,,32253.4,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4656.12,,,4656.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45154.76,70,,45154.76,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2503.29,,,2503.29,Other,New York Medicaid APG methodology,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,3504.61,,,3504.61,Other,140% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,6508.55,,,6508.55,Other,260% New York Medicaid APG,8110.66,,,8110.66,Other,324% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,3129.11,,,3129.11,Other,125% New York Medicaid APG,2503.29,45154.76,
Laparoscopy lymphadenectomy,38571,CPT,,,,,,,,both,,,76185.64,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,15382,,"100% primary, 50% supplemental procedure",15382,Other,Aetna ASC Grouper,13844,,"100% primary, 50% supplemental procedure",13844,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,38092.82,50,,38092.82,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4656.12,,,4656.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,53329.95,70,,53329.95,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2503.29,,,2503.29,Other,New York Medicaid APG methodology,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,3504.61,,,3504.61,Other,140% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,6508.55,,,6508.55,Other,260% New York Medicaid APG,8110.66,,,8110.66,Other,324% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,3129.11,,,3129.11,Other,125% New York Medicaid APG,2503.29,53329.95,
Laparoscopy lymphadenectomy,38572,CPT,,,,,,,,both,,,216515.17,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,15382,,"100% primary, 50% supplemental procedure",15382,Other,Aetna ASC Grouper,13844,,"100% primary, 50% supplemental procedure",13844,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,108257.59,50,,108257.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4656.12,,,4656.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,151560.62,70,,151560.62,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2503.29,,,2503.29,Other,New York Medicaid APG methodology,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,3504.61,,,3504.61,Other,140% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,6508.55,,,6508.55,Other,260% New York Medicaid APG,8110.66,,,8110.66,Other,324% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,3129.11,,,3129.11,Other,125% New York Medicaid APG,2503.29,151560.62,
Laps pelvic lymphadec,38573,CPT,,,,,,,,both,,,216515.17,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,108257.59,50,,108257.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4656.12,,,4656.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,151560.62,70,,151560.62,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2503.29,,,2503.29,Other,New York Medicaid APG methodology,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,3504.61,,,3504.61,Other,140% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,6508.55,,,6508.55,Other,260% New York Medicaid APG,8110.66,,,8110.66,Other,324% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,3129.11,,,3129.11,Other,125% New York Medicaid APG,2503.29,151560.62,
Removal of lymph nodes neck,38700,CPT,,,,,,,,both,,,137162.89,12400.81,,,12400.81,Other,150% of Medicare + 9.63% HCRA Surcharge,7541.01,,,7541.01,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,68581.45,50,,68581.45,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3283.8,,,3283.8,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,96014.02,70,,96014.02,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1765.48,,,1765.48,Other,New York Medicaid APG methodology,1765.48,,,1765.48,Other,100% New York Medicaid APG,1765.48,,,1765.48,Other,100% New York Medicaid APG,1765.48,,,1765.48,Other,100% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,2471.68,,,2471.68,Other,140% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,4590.26,,,4590.26,Other,260% New York Medicaid APG,5720.17,,,5720.17,Other,324% New York Medicaid APG,3795.79,,,3795.79,Other,215% New York Medicaid APG,3795.79,,,3795.79,Other,215% New York Medicaid APG,2206.85,,,2206.85,Other,125% New York Medicaid APG,1765.48,96014.02,
Removal of lymph nodes neck,38720,CPT,,,,,,,,both,,,137162.89,12400.81,,,12400.81,Other,150% of Medicare + 9.63% HCRA Surcharge,7541.01,,,7541.01,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,68581.45,50,,68581.45,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3283.8,,,3283.8,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,96014.02,70,,96014.02,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1765.48,,,1765.48,Other,New York Medicaid APG methodology,1765.48,,,1765.48,Other,100% New York Medicaid APG,1765.48,,,1765.48,Other,100% New York Medicaid APG,1765.48,,,1765.48,Other,100% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,2471.68,,,2471.68,Other,140% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,4590.26,,,4590.26,Other,260% New York Medicaid APG,5720.17,,,5720.17,Other,324% New York Medicaid APG,3795.79,,,3795.79,Other,215% New York Medicaid APG,3795.79,,,3795.79,Other,215% New York Medicaid APG,2206.85,,,2206.85,Other,125% New York Medicaid APG,1765.48,96014.02,
Remove armpit lymph nodes,38740,CPT,,,,,,,,both,,,121364.27,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,60682.14,50,,60682.14,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84954.99,70,,84954.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2495.74,84954.99,
Remove armpit lymph nodes,38745,CPT,,,,,,,,both,,,121364.27,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,60682.14,50,,60682.14,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4642.07,,,4642.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84954.99,70,,84954.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2495.74,,,2495.74,Other,New York Medicaid APG methodology,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,2495.74,,,2495.74,Other,100% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,3494.03,,,3494.03,Other,140% New York Medicaid APG,5615.41,,,5615.41,Other,225% New York Medicaid APG,6488.92,,,6488.92,Other,260% New York Medicaid APG,8086.19,,,8086.19,Other,324% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,5365.84,,,5365.84,Other,215% New York Medicaid APG,3119.67,,,3119.67,Other,125% New York Medicaid APG,2495.74,84954.99,
Remove groin lymph nodes,38760,CPT,,,,,,,,both,,,137162.89,12400.81,,,12400.81,Other,150% of Medicare + 9.63% HCRA Surcharge,7541.01,,,7541.01,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,68581.45,50,,68581.45,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3283.8,,,3283.8,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,96014.02,70,,96014.02,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1765.48,,,1765.48,Other,New York Medicaid APG methodology,1765.48,,,1765.48,Other,100% New York Medicaid APG,1765.48,,,1765.48,Other,100% New York Medicaid APG,1765.48,,,1765.48,Other,100% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,2471.68,,,2471.68,Other,140% New York Medicaid APG,3972.34,,,3972.34,Other,225% New York Medicaid APG,4590.26,,,4590.26,Other,260% New York Medicaid APG,5720.17,,,5720.17,Other,324% New York Medicaid APG,3795.79,,,3795.79,Other,215% New York Medicaid APG,3795.79,,,3795.79,Other,215% New York Medicaid APG,2206.85,,,2206.85,Other,125% New York Medicaid APG,1765.48,96014.02,
Inject for lymphatic x-ray,38790,CPT,,,,,,,,both,,,31549.03,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,15774.52,50,,15774.52,percent of total billed charges,,22084.32,70,,22084.32,percent of total billed charges,,6152,,,6152,Case Rate,,1205.26,,,1205.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22084.32,70,,22084.32,percent of total billed charges,,400.95,,,400.95,Fee Schedule,,340.2,,,340.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.99,,,647.99,Other,New York Medicaid APG methodology,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,907.18,,,907.18,Other,140% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1684.77,,,1684.77,Other,260% New York Medicaid APG,2099.48,,,2099.48,Other,324% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,809.98,,,809.98,Other,125% New York Medicaid APG,0.01,22084.32,
Ra tracer id of sentinl node,38792,CPT,,,,,,,,both,,,8675.17,784.32,,,784.32,Other,150% of Medicare + 9.63% HCRA Surcharge,476.95,,,476.95,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4337.59,50,,4337.59,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,944.94,,,944.94,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,6072.62,70,,6072.62,percent of total billed charges,,158.4,,,158.4,Fee Schedule,,134.4,,,134.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,508.03,,,508.03,Other,New York Medicaid APG methodology,508.03,,,508.03,Other,100% New York Medicaid APG,508.03,,,508.03,Other,100% New York Medicaid APG,508.03,,,508.03,Other,100% New York Medicaid APG,1143.07,,,1143.07,Other,225% New York Medicaid APG,1143.07,,,1143.07,Other,225% New York Medicaid APG,1143.07,,,1143.07,Other,225% New York Medicaid APG,1143.07,,,1143.07,Other,225% New York Medicaid APG,711.24,,,711.24,Other,140% New York Medicaid APG,1143.07,,,1143.07,Other,225% New York Medicaid APG,1320.88,,,1320.88,Other,260% New York Medicaid APG,1646.02,,,1646.02,Other,324% New York Medicaid APG,1092.26,,,1092.26,Other,215% New York Medicaid APG,1092.26,,,1092.26,Other,215% New York Medicaid APG,635.04,,,635.04,Other,125% New York Medicaid APG,134.4,9473,
Access thoracic lymph duct,38794,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,621.52,,,621.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,334.15,,,334.15,Other,New York Medicaid APG methodology,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,334.15,,,334.15,Other,100% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,467.81,,,467.81,Other,140% New York Medicaid APG,751.84,,,751.84,Other,225% New York Medicaid APG,868.8,,,868.8,Other,260% New York Medicaid APG,1082.66,,,1082.66,Other,324% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,718.43,,,718.43,Other,215% New York Medicaid APG,417.69,,,417.69,Other,125% New York Medicaid APG,0.01,36100.43,
Io map of sent lymph node,38900,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1205.26,,,1205.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.99,,,647.99,Other,New York Medicaid APG methodology,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,907.18,,,907.18,Other,140% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1684.77,,,1684.77,Other,260% New York Medicaid APG,2099.48,,,2099.48,Other,324% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,809.98,,,809.98,Other,125% New York Medicaid APG,0.01,22702.47,
Mediastinoscpy w/medstnl bx,39401,CPT,,,,,,,,both,,,121364.27,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,60682.14,50,,60682.14,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4050.15,,,4050.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84954.99,70,,84954.99,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2177.5,,,2177.5,Other,New York Medicaid APG methodology,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,3048.5,,,3048.5,Other,140% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,5661.5,,,5661.5,Other,260% New York Medicaid APG,7055.1,,,7055.1,Other,324% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,2721.88,,,2721.88,Other,125% New York Medicaid APG,2177.5,84954.99,
Mediastinoscpy w/lmph nod bx,39402,CPT,,,,,,,,both,,,121364.27,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,60682.14,50,,60682.14,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4050.15,,,4050.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84954.99,70,,84954.99,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2177.5,,,2177.5,Other,New York Medicaid APG methodology,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,2177.5,,,2177.5,Other,100% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,3048.5,,,3048.5,Other,140% New York Medicaid APG,4899.38,,,4899.38,Other,225% New York Medicaid APG,5661.5,,,5661.5,Other,260% New York Medicaid APG,7055.1,,,7055.1,Other,324% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,4681.63,,,4681.63,Other,215% New York Medicaid APG,2721.88,,,2721.88,Other,125% New York Medicaid APG,2177.5,84954.99,
Biopsy of lip,40490,CPT,,,,,,,,both,,,34446.73,464.5,,,464.5,Other,150% of Medicare + 9.63% HCRA Surcharge,282.46,,,282.46,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17223.37,50,,17223.37,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24112.71,70,,24112.71,percent of total billed charges,,338.25,,,338.25,Fee Schedule,,287,,,287,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,0.01,24112.71,
Partial excision of lip,40500,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,1545.56,47404.34,
Partial excision of lip,40510,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3792.93,,,3792.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2039.21,,,2039.21,Other,New York Medicaid APG methodology,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,2854.89,,,2854.89,Other,140% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,5301.94,,,5301.94,Other,260% New York Medicaid APG,6607.03,,,6607.03,Other,324% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,2549.01,,,2549.01,Other,125% New York Medicaid APG,2039.21,47404.34,
Partial excision of lip,40520,CPT,,,,,,,,both,,,35222.09,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17611.05,50,,17611.05,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24655.46,70,,24655.46,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,1545.56,24655.46,
Reconstruct lip with flap,40525,CPT,,,,,,,,both,,,60680.73,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,30340.37,50,,30340.37,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3792.93,,,3792.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,42476.51,70,,42476.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2039.21,,,2039.21,Other,New York Medicaid APG methodology,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,2854.89,,,2854.89,Other,140% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,5301.94,,,5301.94,Other,260% New York Medicaid APG,6607.03,,,6607.03,Other,324% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,2549.01,,,2549.01,Other,125% New York Medicaid APG,2039.21,42476.51,
Reconstruct lip with flap,40527,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,86224,
Partial removal of lip,40530,CPT,,,,,,,,both,,,36028.54,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18014.27,50,,18014.27,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3792.93,,,3792.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25219.98,70,,25219.98,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2039.21,,,2039.21,Other,New York Medicaid APG methodology,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,2854.89,,,2854.89,Other,140% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,5301.94,,,5301.94,Other,260% New York Medicaid APG,6607.03,,,6607.03,Other,324% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,2549.01,,,2549.01,Other,125% New York Medicaid APG,2039.21,25219.98,
Repair lip,40650,CPT,,,,,,,,both,,,11572.85,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5786.43,50,,5786.43,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8101,70,,8101,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,269.45,13157,
Repair lip,40652,CPT,,,,,,,,both,,,11572.85,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5786.43,50,,5786.43,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8101,70,,8101,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,269.45,13157,
Repair lip,40654,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,1545.56,22454.17,
Repair cleft lip/nasal,40700,CPT,,,,,,,,both,,,37061.46,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,18530.73,50,,18530.73,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6771.82,,,6771.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25943.02,70,,25943.02,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3640.76,,,3640.76,Other,New York Medicaid APG methodology,3640.76,,,3640.76,Other,100% New York Medicaid APG,3640.76,,,3640.76,Other,100% New York Medicaid APG,3640.76,,,3640.76,Other,100% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,5097.07,,,5097.07,Other,140% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,9465.98,,,9465.98,Other,260% New York Medicaid APG,11796.07,,,11796.07,Other,324% New York Medicaid APG,7827.64,,,7827.64,Other,215% New York Medicaid APG,7827.64,,,7827.64,Other,215% New York Medicaid APG,4550.95,,,4550.95,Other,125% New York Medicaid APG,3640.76,25943.02,
Repair cleft lip/nasal,40701,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6771.82,,,6771.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3640.76,,,3640.76,Other,New York Medicaid APG methodology,3640.76,,,3640.76,Other,100% New York Medicaid APG,3640.76,,,3640.76,Other,100% New York Medicaid APG,3640.76,,,3640.76,Other,100% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,5097.07,,,5097.07,Other,140% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,9465.98,,,9465.98,Other,260% New York Medicaid APG,11796.07,,,11796.07,Other,324% New York Medicaid APG,7827.64,,,7827.64,Other,215% New York Medicaid APG,7827.64,,,7827.64,Other,215% New York Medicaid APG,4550.95,,,4550.95,Other,125% New York Medicaid APG,3640.76,86224,
Repair cleft lip/nasal,40702,CPT,,,,,,,,both,,,37204.04,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,18602.02,50,,18602.02,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6771.82,,,6771.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26042.83,70,,26042.83,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3640.76,,,3640.76,Other,New York Medicaid APG methodology,3640.76,,,3640.76,Other,100% New York Medicaid APG,3640.76,,,3640.76,Other,100% New York Medicaid APG,3640.76,,,3640.76,Other,100% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,5097.07,,,5097.07,Other,140% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,9465.98,,,9465.98,Other,260% New York Medicaid APG,11796.07,,,11796.07,Other,324% New York Medicaid APG,7827.64,,,7827.64,Other,215% New York Medicaid APG,7827.64,,,7827.64,Other,215% New York Medicaid APG,4550.95,,,4550.95,Other,125% New York Medicaid APG,3640.76,26042.83,
Repair cleft lip/nasal,40720,CPT,,,,,,,,both,,,46637.53,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,23318.77,50,,23318.77,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6771.82,,,6771.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,32646.27,70,,32646.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3640.76,,,3640.76,Other,New York Medicaid APG methodology,3640.76,,,3640.76,Other,100% New York Medicaid APG,3640.76,,,3640.76,Other,100% New York Medicaid APG,3640.76,,,3640.76,Other,100% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,5097.07,,,5097.07,Other,140% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,9465.98,,,9465.98,Other,260% New York Medicaid APG,11796.07,,,11796.07,Other,324% New York Medicaid APG,7827.64,,,7827.64,Other,215% New York Medicaid APG,7827.64,,,7827.64,Other,215% New York Medicaid APG,4550.95,,,4550.95,Other,125% New York Medicaid APG,3640.76,32646.27,
Repair cleft lip/nasal,40761,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6771.82,,,6771.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3640.76,,,3640.76,Other,New York Medicaid APG methodology,3640.76,,,3640.76,Other,100% New York Medicaid APG,3640.76,,,3640.76,Other,100% New York Medicaid APG,3640.76,,,3640.76,Other,100% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,5097.07,,,5097.07,Other,140% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,9465.98,,,9465.98,Other,260% New York Medicaid APG,11796.07,,,11796.07,Other,324% New York Medicaid APG,7827.64,,,7827.64,Other,215% New York Medicaid APG,7827.64,,,7827.64,Other,215% New York Medicaid APG,4550.95,,,4550.95,Other,125% New York Medicaid APG,3640.76,86224,
Drainage of mouth lesion,40800,CPT,,,,,,,,both,,,14798.8,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7399.4,50,,7399.4,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,508.35,,,508.35,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10359.16,70,,10359.16,percent of total billed charges,,584.1,,,584.1,Fee Schedule,,495.6,,,495.6,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,273.31,,,273.31,Other,New York Medicaid APG methodology,273.31,,,273.31,Other,100% New York Medicaid APG,273.31,,,273.31,Other,100% New York Medicaid APG,273.31,,,273.31,Other,100% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,382.63,,,382.63,Other,140% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,710.6,,,710.6,Other,260% New York Medicaid APG,885.52,,,885.52,Other,324% New York Medicaid APG,587.61,,,587.61,Other,215% New York Medicaid APG,587.61,,,587.61,Other,215% New York Medicaid APG,341.64,,,341.64,Other,125% New York Medicaid APG,0.01,10359.16,
Drainage of mouth lesion,40801,CPT,,,,,,,,both,,,11572.85,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5786.43,50,,5786.43,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,508.35,,,508.35,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8101,70,,8101,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,273.31,,,273.31,Other,New York Medicaid APG methodology,273.31,,,273.31,Other,100% New York Medicaid APG,273.31,,,273.31,Other,100% New York Medicaid APG,273.31,,,273.31,Other,100% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,382.63,,,382.63,Other,140% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,710.6,,,710.6,Other,260% New York Medicaid APG,885.52,,,885.52,Other,324% New York Medicaid APG,587.61,,,587.61,Other,215% New York Medicaid APG,587.61,,,587.61,Other,215% New York Medicaid APG,341.64,,,341.64,Other,125% New York Medicaid APG,273.31,13157,
Removal foreign body mouth,40804,CPT,,,,,,,,both,,,19066.74,1723.81,,,1723.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.26,,,1048.26,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9533.37,50,,9533.37,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,508.35,,,508.35,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13346.72,70,,13346.72,percent of total billed charges,,557.7,,,557.7,Fee Schedule,,473.2,,,473.2,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,273.31,,,273.31,Other,New York Medicaid APG methodology,273.31,,,273.31,Other,100% New York Medicaid APG,273.31,,,273.31,Other,100% New York Medicaid APG,273.31,,,273.31,Other,100% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,382.63,,,382.63,Other,140% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,710.6,,,710.6,Other,260% New York Medicaid APG,885.52,,,885.52,Other,324% New York Medicaid APG,587.61,,,587.61,Other,215% New York Medicaid APG,587.61,,,587.61,Other,215% New York Medicaid APG,341.64,,,341.64,Other,125% New York Medicaid APG,0.01,13346.72,
Removal foreign body mouth,40805,CPT,,,,,,,,both,,,11572.85,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5786.43,50,,5786.43,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,508.35,,,508.35,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8101,70,,8101,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,273.31,,,273.31,Other,New York Medicaid APG methodology,273.31,,,273.31,Other,100% New York Medicaid APG,273.31,,,273.31,Other,100% New York Medicaid APG,273.31,,,273.31,Other,100% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,382.63,,,382.63,Other,140% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,710.6,,,710.6,Other,260% New York Medicaid APG,885.52,,,885.52,Other,324% New York Medicaid APG,587.61,,,587.61,Other,215% New York Medicaid APG,587.61,,,587.61,Other,215% New York Medicaid APG,341.64,,,341.64,Other,125% New York Medicaid APG,273.31,13157,
Incision of lip fold,40806,CPT,,,,,,,,both,,,11572.85,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5786.43,50,,5786.43,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8101,70,,8101,percent of total billed charges,,141.9,,,141.9,Fee Schedule,,120.4,,,120.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,0.01,9473,
Biopsy of mouth lesion,40808,CPT,,,,,,,,both,,,11572.85,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5786.43,50,,5786.43,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,508.35,,,508.35,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8101,70,,8101,percent of total billed charges,,437.25,,,437.25,Fee Schedule,,371,,,371,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,273.31,,,273.31,Other,New York Medicaid APG methodology,273.31,,,273.31,Other,100% New York Medicaid APG,273.31,,,273.31,Other,100% New York Medicaid APG,273.31,,,273.31,Other,100% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,382.63,,,382.63,Other,140% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,710.6,,,710.6,Other,260% New York Medicaid APG,885.52,,,885.52,Other,324% New York Medicaid APG,587.61,,,587.61,Other,215% New York Medicaid APG,587.61,,,587.61,Other,215% New York Medicaid APG,341.64,,,341.64,Other,125% New York Medicaid APG,0.01,9473,
Excision of mouth lesion,40810,CPT,,,,,,,,both,,,36908.56,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18454.28,50,,18454.28,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25835.99,70,,25835.99,percent of total billed charges,,608.85,,,608.85,Fee Schedule,,516.6,,,516.6,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,516.6,25835.99,
Excise/repair mouth lesion,40812,CPT,,,,,,,,both,,,35262.79,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17631.4,50,,17631.4,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24683.95,70,,24683.95,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,24683.95,
Excise/repair mouth lesion,40814,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,47404.34,
Excision of mouth lesion,40816,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,47404.34,
Excise oral mucosa for graft,40818,CPT,,,,,,,,both,,,11572.85,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5786.43,50,,5786.43,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8101,70,,8101,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,13157,
Excise lip or cheek fold,40819,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,1545.56,22454.17,
Treatment of mouth lesion,40820,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,821.7,,,821.7,Fee Schedule,,697.2,,,697.2,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,47404.34,
Repair mouth laceration,40830,CPT,,,,,,,,both,,,5137.73,464.5,,,464.5,Other,150% of Medicare + 9.63% HCRA Surcharge,282.46,,,282.46,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2568.87,50,,2568.87,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3596.41,70,,3596.41,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,0.01,13157,
Repair mouth laceration,40831,CPT,,,,,,,,both,,,11572.85,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5786.43,50,,5786.43,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,508.35,,,508.35,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8101,70,,8101,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,273.31,,,273.31,Other,New York Medicaid APG methodology,273.31,,,273.31,Other,100% New York Medicaid APG,273.31,,,273.31,Other,100% New York Medicaid APG,273.31,,,273.31,Other,100% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,382.63,,,382.63,Other,140% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,710.6,,,710.6,Other,260% New York Medicaid APG,885.52,,,885.52,Other,324% New York Medicaid APG,587.61,,,587.61,Other,215% New York Medicaid APG,587.61,,,587.61,Other,215% New York Medicaid APG,341.64,,,341.64,Other,125% New York Medicaid APG,273.31,13157,
Reconstruction of mouth,40840,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,86224,
Reconstruction of mouth,40842,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,86224,
Reconstruction of mouth,40843,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,86224,
Reconstruction of mouth,40844,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,86224,
Reconstruction of mouth,40845,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,86224,
Drainage of mouth lesion,41000,CPT,,,,,,,,both,,,11572.85,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5786.43,50,,5786.43,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8101,70,,8101,percent of total billed charges,,521.4,,,521.4,Fee Schedule,,442.4,,,442.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,442.4,9473,
Drainage of mouth lesion,41005,CPT,,,,,,,,both,,,5137.73,464.5,,,464.5,Other,150% of Medicare + 9.63% HCRA Surcharge,282.46,,,282.46,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2568.87,50,,2568.87,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3596.41,70,,3596.41,percent of total billed charges,,592.35,,,592.35,Fee Schedule,,502.6,,,502.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,269.45,9473,
Drainage of mouth lesion,41006,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,1545.56,22454.17,
Drainage of mouth lesion,41007,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,1545.56,22454.17,
Drainage of mouth lesion,41008,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,1545.56,47404.34,
Drainage of mouth lesion,41009,CPT,,,,,,,,both,,,11572.85,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5786.43,50,,5786.43,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8101,70,,8101,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,636.26,13157,
Incision of tongue fold,41010,CPT,,,,,,,,both,,,33613.92,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16806.96,50,,16806.96,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23529.74,70,,23529.74,percent of total billed charges,,547.8,,,547.8,Fee Schedule,,464.8,,,464.8,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,464.8,23529.74,
Drainage of mouth lesion,41015,CPT,,,,,,,,both,,,11572.85,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5786.43,50,,5786.43,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,508.35,,,508.35,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8101,70,,8101,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,273.31,,,273.31,Other,New York Medicaid APG methodology,273.31,,,273.31,Other,100% New York Medicaid APG,273.31,,,273.31,Other,100% New York Medicaid APG,273.31,,,273.31,Other,100% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,382.63,,,382.63,Other,140% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,710.6,,,710.6,Other,260% New York Medicaid APG,885.52,,,885.52,Other,324% New York Medicaid APG,587.61,,,587.61,Other,215% New York Medicaid APG,587.61,,,587.61,Other,215% New York Medicaid APG,341.64,,,341.64,Other,125% New York Medicaid APG,273.31,13157,
Drainage of mouth lesion,41016,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,86224,
Drainage of mouth lesion,41017,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,47404.34,
Drainage of mouth lesion,41018,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,22454.17,
Place needles h&n for rt,41019,CPT,,,,,,,,both,,,39024.79,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,19512.4,50,,19512.4,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27317.35,70,,27317.35,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,3323,27317.35,
Biopsy of tongue,41100,CPT,,,,,,,,both,,,11572.85,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5786.43,50,,5786.43,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8101,70,,8101,percent of total billed charges,,531.3,,,531.3,Fee Schedule,,450.8,,,450.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,269.45,9473,
Biopsy of tongue,41105,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,544.5,,,544.5,Fee Schedule,,462,,,462,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,462,47404.34,
Biopsy of floor of mouth,41108,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,453.75,,,453.75,Fee Schedule,,385,,,385,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,385,23871.23,
Excision of tongue lesion,41110,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,645.15,,,645.15,Fee Schedule,,547.4,,,547.4,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,547.4,47404.34,
Excision of tongue lesion,41112,CPT,,,,,,,,both,,,48875.01,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24437.51,50,,24437.51,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34212.51,70,,34212.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,1545.56,34212.51,
Excision of tongue lesion,41113,CPT,,,,,,,,both,,,34482.73,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17241.37,50,,17241.37,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24137.91,70,,24137.91,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,1545.56,24137.91,
Excision of tongue lesion,41114,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3792.93,,,3792.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2039.21,,,2039.21,Other,New York Medicaid APG methodology,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,2854.89,,,2854.89,Other,140% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,5301.94,,,5301.94,Other,260% New York Medicaid APG,6607.03,,,6607.03,Other,324% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,2549.01,,,2549.01,Other,125% New York Medicaid APG,2039.21,47404.34,
Excision of tongue fold,41115,CPT,,,,,,,,both,,,34373.25,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17186.63,50,,17186.63,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24061.28,70,,24061.28,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,1545.56,24061.28,
Excision of mouth lesion,41116,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,47404.34,
Partial removal of tongue,41120,CPT,,,,,,,,both,,,50582.73,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,25291.37,50,,25291.37,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,35407.91,70,,35407.91,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,35407.91,
Repair tongue laceration,41250,CPT,,,,,,,,both,,,8380.68,757.69,,,757.69,Other,150% of Medicare + 9.63% HCRA Surcharge,460.76,,,460.76,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4190.34,50,,4190.34,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5866.48,70,,5866.48,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,269.45,13157,
Repair tongue laceration,41251,CPT,,,,,,,,both,,,5137.73,464.5,,,464.5,Other,150% of Medicare + 9.63% HCRA Surcharge,282.46,,,282.46,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2568.87,50,,2568.87,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3596.41,70,,3596.41,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,269.45,13157,
Repair tongue laceration,41252,CPT,,,,,,,,both,,,5137.73,464.5,,,464.5,Other,150% of Medicare + 9.63% HCRA Surcharge,282.46,,,282.46,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2568.87,50,,2568.87,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3596.41,70,,3596.41,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,269.45,13157,
Tongue to lip surgery,41510,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,1545.56,47404.34,
Tongue suspension,41512,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,86224,
Reconstruction tongue fold,41520,CPT,,,,,,,,both,,,34094.95,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17047.48,50,,17047.48,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23866.47,70,,23866.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,23866.47,
Tongue base vol reduction,41530,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3792.93,,,3792.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,1877.7,,,1877.7,Fee Schedule,,1593.2,,,1593.2,Fee Schedule,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2039.21,,,2039.21,Other,New York Medicaid APG methodology,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,2854.89,,,2854.89,Other,140% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,5301.94,,,5301.94,Other,260% New York Medicaid APG,6607.03,,,6607.03,Other,324% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,2549.01,,,2549.01,Other,125% New York Medicaid APG,1593.2,47404.34,
Drainage of gum lesion,41800,CPT,,,,,,,,both,,,2686.86,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1343.43,50,,1343.43,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,1880.8,70,,1880.8,percent of total billed charges,,762.3,,,762.3,Fee Schedule,,646.8,,,646.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,147.72,9473,
Removal foreign body gum,41805,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,508.35,,,508.35,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,978.45,,,978.45,Fee Schedule,,830.2,,,830.2,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,273.31,,,273.31,Other,New York Medicaid APG methodology,273.31,,,273.31,Other,100% New York Medicaid APG,273.31,,,273.31,Other,100% New York Medicaid APG,273.31,,,273.31,Other,100% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,382.63,,,382.63,Other,140% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,710.6,,,710.6,Other,260% New York Medicaid APG,885.52,,,885.52,Other,324% New York Medicaid APG,587.61,,,587.61,Other,215% New York Medicaid APG,587.61,,,587.61,Other,215% New York Medicaid APG,341.64,,,341.64,Other,125% New York Medicaid APG,273.31,22454.17,
Removal foreign body jawbone,41806,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,22454.17,
Excision gum each quadrant,41820,CPT,,,,,,,,both,,,11190,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,5595,50,,5595,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,7833,70,,7833,percent of total billed charges,,5595,50,,5595,percent of total billed charges,,5595,50,,5595,percent of total billed charges,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,9473,
Excision of gum flap,41821,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,396.74,,,396.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,16038.7,50,,16038.7,percent of total billed charges,,16038.7,50,,16038.7,percent of total billed charges,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,213.3,,,213.3,Other,New York Medicaid APG methodology,213.3,,,213.3,Other,100% New York Medicaid APG,213.3,,,213.3,Other,100% New York Medicaid APG,213.3,,,213.3,Other,100% New York Medicaid APG,479.93,,,479.93,Other,225% New York Medicaid APG,479.93,,,479.93,Other,225% New York Medicaid APG,479.93,,,479.93,Other,225% New York Medicaid APG,479.93,,,479.93,Other,225% New York Medicaid APG,298.62,,,298.62,Other,140% New York Medicaid APG,479.93,,,479.93,Other,225% New York Medicaid APG,554.58,,,554.58,Other,260% New York Medicaid APG,691.1,,,691.1,Other,324% New York Medicaid APG,458.6,,,458.6,Other,215% New York Medicaid APG,458.6,,,458.6,Other,215% New York Medicaid APG,266.63,,,266.63,Other,125% New York Medicaid APG,213.3,22454.17,
Excision of gum lesion,41822,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,22454.17,
Excision of gum lesion,41823,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,86224,
Excision of gum lesion,41825,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,598.95,,,598.95,Fee Schedule,,508.2,,,508.2,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,508.2,47404.34,
Excision of gum lesion,41826,CPT,,,,,,,,both,,,33723,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16861.5,50,,16861.5,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23606.1,70,,23606.1,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,23606.1,
Excision of gum lesion,41827,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,86224,
Excision of gum lesion,41828,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,22454.17,
Removal of gum tissue,41830,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,47404.34,
Treatment of gum lesion,41850,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,16038.7,50,,16038.7,percent of total billed charges,,16038.7,50,,16038.7,percent of total billed charges,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,22454.17,
Gum graft,41870,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,16038.7,50,,16038.7,percent of total billed charges,,16038.7,50,,16038.7,percent of total billed charges,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,22454.17,
Repair gum,41872,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,47404.34,
Repair tooth socket,41874,CPT,,,,,,,,both,,,12102.9,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,6051.45,50,,6051.45,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8472.03,70,,8472.03,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,13157,
Drainage mouth roof lesion,42000,CPT,,,,,,,,both,,,5137.73,464.5,,,464.5,Other,150% of Medicare + 9.63% HCRA Surcharge,282.46,,,282.46,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2568.87,50,,2568.87,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3596.41,70,,3596.41,percent of total billed charges,,539.55,,,539.55,Fee Schedule,,457.8,,,457.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,269.45,9473,
Biopsy roof of mouth,42100,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,544.5,,,544.5,Fee Schedule,,462,,,462,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,462,22454.17,
Excision lesion mouth roof,42104,CPT,,,,,,,,both,,,32876,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16438,50,,16438,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3792.93,,,3792.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23013.2,70,,23013.2,percent of total billed charges,,666.6,,,666.6,Fee Schedule,,565.6,,,565.6,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2039.21,,,2039.21,Other,New York Medicaid APG methodology,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,2854.89,,,2854.89,Other,140% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,5301.94,,,5301.94,Other,260% New York Medicaid APG,6607.03,,,6607.03,Other,324% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,2549.01,,,2549.01,Other,125% New York Medicaid APG,565.6,23013.2,
Excision lesion mouth roof,42106,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3792.93,,,3792.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2039.21,,,2039.21,Other,New York Medicaid APG methodology,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,2854.89,,,2854.89,Other,140% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,5301.94,,,5301.94,Other,260% New York Medicaid APG,6607.03,,,6607.03,Other,324% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,2549.01,,,2549.01,Other,125% New York Medicaid APG,2039.21,47404.34,
Excision lesion mouth roof,42107,CPT,,,,,,,,both,,,45847.43,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,22923.72,50,,22923.72,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3792.93,,,3792.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,32093.2,70,,32093.2,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2039.21,,,2039.21,Other,New York Medicaid APG methodology,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,2854.89,,,2854.89,Other,140% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,5301.94,,,5301.94,Other,260% New York Medicaid APG,6607.03,,,6607.03,Other,324% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,2549.01,,,2549.01,Other,125% New York Medicaid APG,2039.21,32093.2,
Remove palate/lesion,42120,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,86224,
Excision of uvula,42140,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3792.93,,,3792.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,805.2,,,805.2,Fee Schedule,,683.2,,,683.2,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2039.21,,,2039.21,Other,New York Medicaid APG methodology,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,2854.89,,,2854.89,Other,140% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,5301.94,,,5301.94,Other,260% New York Medicaid APG,6607.03,,,6607.03,Other,324% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,2549.01,,,2549.01,Other,125% New York Medicaid APG,683.2,47404.34,
Repair palate pharynx/uvula,42145,CPT,,,,,,,,both,,,40196.92,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,20098.46,50,,20098.46,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6771.82,,,6771.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28137.84,70,,28137.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3640.76,,,3640.76,Other,New York Medicaid APG methodology,3640.76,,,3640.76,Other,100% New York Medicaid APG,3640.76,,,3640.76,Other,100% New York Medicaid APG,3640.76,,,3640.76,Other,100% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,5097.07,,,5097.07,Other,140% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,9465.98,,,9465.98,Other,260% New York Medicaid APG,11796.07,,,11796.07,Other,324% New York Medicaid APG,7827.64,,,7827.64,Other,215% New York Medicaid APG,7827.64,,,7827.64,Other,215% New York Medicaid APG,4550.95,,,4550.95,Other,125% New York Medicaid APG,3640.76,28137.84,
Treatment mouth roof lesion,42160,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3792.93,,,3792.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2039.21,,,2039.21,Other,New York Medicaid APG methodology,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,2854.89,,,2854.89,Other,140% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,5301.94,,,5301.94,Other,260% New York Medicaid APG,6607.03,,,6607.03,Other,324% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,2549.01,,,2549.01,Other,125% New York Medicaid APG,2039.21,47404.34,
Repair palate,42180,CPT,,,,,,,,both,,,11572.85,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5786.43,50,,5786.43,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,508.35,,,508.35,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8101,70,,8101,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,273.31,,,273.31,Other,New York Medicaid APG methodology,273.31,,,273.31,Other,100% New York Medicaid APG,273.31,,,273.31,Other,100% New York Medicaid APG,273.31,,,273.31,Other,100% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,382.63,,,382.63,Other,140% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,710.6,,,710.6,Other,260% New York Medicaid APG,885.52,,,885.52,Other,324% New York Medicaid APG,587.61,,,587.61,Other,215% New York Medicaid APG,587.61,,,587.61,Other,215% New York Medicaid APG,341.64,,,341.64,Other,125% New York Medicaid APG,273.31,13157,
Repair palate,42182,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,86224,
Reconstruct cleft palate,42200,CPT,,,,,,,,both,,,57820.07,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,28910.04,50,,28910.04,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6771.82,,,6771.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,40474.05,70,,40474.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3640.76,,,3640.76,Other,New York Medicaid APG methodology,3640.76,,,3640.76,Other,100% New York Medicaid APG,3640.76,,,3640.76,Other,100% New York Medicaid APG,3640.76,,,3640.76,Other,100% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,5097.07,,,5097.07,Other,140% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,9465.98,,,9465.98,Other,260% New York Medicaid APG,11796.07,,,11796.07,Other,324% New York Medicaid APG,7827.64,,,7827.64,Other,215% New York Medicaid APG,7827.64,,,7827.64,Other,215% New York Medicaid APG,4550.95,,,4550.95,Other,125% New York Medicaid APG,3640.76,40474.05,
Reconstruct cleft palate,42205,CPT,,,,,,,,both,,,49217.65,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24608.83,50,,24608.83,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6771.82,,,6771.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34452.36,70,,34452.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3640.76,,,3640.76,Other,New York Medicaid APG methodology,3640.76,,,3640.76,Other,100% New York Medicaid APG,3640.76,,,3640.76,Other,100% New York Medicaid APG,3640.76,,,3640.76,Other,100% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,5097.07,,,5097.07,Other,140% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,9465.98,,,9465.98,Other,260% New York Medicaid APG,11796.07,,,11796.07,Other,324% New York Medicaid APG,7827.64,,,7827.64,Other,215% New York Medicaid APG,7827.64,,,7827.64,Other,215% New York Medicaid APG,4550.95,,,4550.95,Other,125% New York Medicaid APG,3640.76,34452.36,
Reconstruct cleft palate,42210,CPT,,,,,,,,both,,,34416.87,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,17208.44,50,,17208.44,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6771.82,,,6771.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24091.81,70,,24091.81,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3640.76,,,3640.76,Other,New York Medicaid APG methodology,3640.76,,,3640.76,Other,100% New York Medicaid APG,3640.76,,,3640.76,Other,100% New York Medicaid APG,3640.76,,,3640.76,Other,100% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,5097.07,,,5097.07,Other,140% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,9465.98,,,9465.98,Other,260% New York Medicaid APG,11796.07,,,11796.07,Other,324% New York Medicaid APG,7827.64,,,7827.64,Other,215% New York Medicaid APG,7827.64,,,7827.64,Other,215% New York Medicaid APG,4550.95,,,4550.95,Other,125% New York Medicaid APG,3640.76,24091.81,
Reconstruct cleft palate,42215,CPT,,,,,,,,both,,,36696.4,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,18348.2,50,,18348.2,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6771.82,,,6771.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25687.48,70,,25687.48,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3640.76,,,3640.76,Other,New York Medicaid APG methodology,3640.76,,,3640.76,Other,100% New York Medicaid APG,3640.76,,,3640.76,Other,100% New York Medicaid APG,3640.76,,,3640.76,Other,100% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,5097.07,,,5097.07,Other,140% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,9465.98,,,9465.98,Other,260% New York Medicaid APG,11796.07,,,11796.07,Other,324% New York Medicaid APG,7827.64,,,7827.64,Other,215% New York Medicaid APG,7827.64,,,7827.64,Other,215% New York Medicaid APG,4550.95,,,4550.95,Other,125% New York Medicaid APG,3640.76,25687.48,
Reconstruct cleft palate,42220,CPT,,,,,,,,both,,,37009.4,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,18504.7,50,,18504.7,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6771.82,,,6771.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25906.58,70,,25906.58,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3640.76,,,3640.76,Other,New York Medicaid APG methodology,3640.76,,,3640.76,Other,100% New York Medicaid APG,3640.76,,,3640.76,Other,100% New York Medicaid APG,3640.76,,,3640.76,Other,100% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,5097.07,,,5097.07,Other,140% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,9465.98,,,9465.98,Other,260% New York Medicaid APG,11796.07,,,11796.07,Other,324% New York Medicaid APG,7827.64,,,7827.64,Other,215% New York Medicaid APG,7827.64,,,7827.64,Other,215% New York Medicaid APG,4550.95,,,4550.95,Other,125% New York Medicaid APG,3640.76,25906.58,
Reconstruct cleft palate,42225,CPT,,,,,,,,both,,,36570.71,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,18285.36,50,,18285.36,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6771.82,,,6771.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25599.5,70,,25599.5,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3640.76,,,3640.76,Other,New York Medicaid APG methodology,3640.76,,,3640.76,Other,100% New York Medicaid APG,3640.76,,,3640.76,Other,100% New York Medicaid APG,3640.76,,,3640.76,Other,100% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,5097.07,,,5097.07,Other,140% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,9465.98,,,9465.98,Other,260% New York Medicaid APG,11796.07,,,11796.07,Other,324% New York Medicaid APG,7827.64,,,7827.64,Other,215% New York Medicaid APG,7827.64,,,7827.64,Other,215% New York Medicaid APG,4550.95,,,4550.95,Other,125% New York Medicaid APG,3640.76,25599.5,
Lengthening of palate,42226,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6771.82,,,6771.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3640.76,,,3640.76,Other,New York Medicaid APG methodology,3640.76,,,3640.76,Other,100% New York Medicaid APG,3640.76,,,3640.76,Other,100% New York Medicaid APG,3640.76,,,3640.76,Other,100% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,5097.07,,,5097.07,Other,140% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,9465.98,,,9465.98,Other,260% New York Medicaid APG,11796.07,,,11796.07,Other,324% New York Medicaid APG,7827.64,,,7827.64,Other,215% New York Medicaid APG,7827.64,,,7827.64,Other,215% New York Medicaid APG,4550.95,,,4550.95,Other,125% New York Medicaid APG,3640.76,86224,
Lengthening of palate,42227,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6771.82,,,6771.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3640.76,,,3640.76,Other,New York Medicaid APG methodology,3640.76,,,3640.76,Other,100% New York Medicaid APG,3640.76,,,3640.76,Other,100% New York Medicaid APG,3640.76,,,3640.76,Other,100% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,5097.07,,,5097.07,Other,140% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,9465.98,,,9465.98,Other,260% New York Medicaid APG,11796.07,,,11796.07,Other,324% New York Medicaid APG,7827.64,,,7827.64,Other,215% New York Medicaid APG,7827.64,,,7827.64,Other,215% New York Medicaid APG,4550.95,,,4550.95,Other,125% New York Medicaid APG,3640.76,86224,
Repair palate,42235,CPT,,,,,,,,both,,,33741.06,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,16870.53,50,,16870.53,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6771.82,,,6771.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23618.74,70,,23618.74,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3640.76,,,3640.76,Other,New York Medicaid APG methodology,3640.76,,,3640.76,Other,100% New York Medicaid APG,3640.76,,,3640.76,Other,100% New York Medicaid APG,3640.76,,,3640.76,Other,100% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,5097.07,,,5097.07,Other,140% New York Medicaid APG,8191.72,,,8191.72,Other,225% New York Medicaid APG,9465.98,,,9465.98,Other,260% New York Medicaid APG,11796.07,,,11796.07,Other,324% New York Medicaid APG,7827.64,,,7827.64,Other,215% New York Medicaid APG,7827.64,,,7827.64,Other,215% New York Medicaid APG,4550.95,,,4550.95,Other,125% New York Medicaid APG,3640.76,23618.74,
Repair nose to lip fistula,42260,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,86224,
Preparation palate mold,42280,CPT,,,,,,,,both,,,11572.85,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5786.43,50,,5786.43,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,315.45,,,315.45,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8101,70,,8101,percent of total billed charges,,539.55,,,539.55,Fee Schedule,,457.8,,,457.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,169.6,,,169.6,Other,New York Medicaid APG methodology,169.6,,,169.6,Other,100% New York Medicaid APG,169.6,,,169.6,Other,100% New York Medicaid APG,169.6,,,169.6,Other,100% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,237.43,,,237.43,Other,140% New York Medicaid APG,381.59,,,381.59,Other,225% New York Medicaid APG,440.95,,,440.95,Other,260% New York Medicaid APG,549.49,,,549.49,Other,324% New York Medicaid APG,364.63,,,364.63,Other,215% New York Medicaid APG,364.63,,,364.63,Other,215% New York Medicaid APG,212,,,212,Other,125% New York Medicaid APG,0.01,9473,
Insertion palate prosthesis,42281,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,86224,
Drainage of salivary gland,42300,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,508.35,,,508.35,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,273.31,,,273.31,Other,New York Medicaid APG methodology,273.31,,,273.31,Other,100% New York Medicaid APG,273.31,,,273.31,Other,100% New York Medicaid APG,273.31,,,273.31,Other,100% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,382.63,,,382.63,Other,140% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,710.6,,,710.6,Other,260% New York Medicaid APG,885.52,,,885.52,Other,324% New York Medicaid APG,587.61,,,587.61,Other,215% New York Medicaid APG,587.61,,,587.61,Other,215% New York Medicaid APG,341.64,,,341.64,Other,125% New York Medicaid APG,273.31,22454.17,
Drainage of salivary gland,42305,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3792.93,,,3792.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2039.21,,,2039.21,Other,New York Medicaid APG methodology,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,2854.89,,,2854.89,Other,140% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,5301.94,,,5301.94,Other,260% New York Medicaid APG,6607.03,,,6607.03,Other,324% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,2549.01,,,2549.01,Other,125% New York Medicaid APG,2039.21,47404.34,
Drainage of salivary gland,42310,CPT,,,,,,,,both,,,11572.85,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5786.43,50,,5786.43,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,508.35,,,508.35,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8101,70,,8101,percent of total billed charges,,669.9,,,669.9,Fee Schedule,,568.4,,,568.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,273.31,,,273.31,Other,New York Medicaid APG methodology,273.31,,,273.31,Other,100% New York Medicaid APG,273.31,,,273.31,Other,100% New York Medicaid APG,273.31,,,273.31,Other,100% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,382.63,,,382.63,Other,140% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,710.6,,,710.6,Other,260% New York Medicaid APG,885.52,,,885.52,Other,324% New York Medicaid APG,587.61,,,587.61,Other,215% New York Medicaid APG,587.61,,,587.61,Other,215% New York Medicaid APG,341.64,,,341.64,Other,125% New York Medicaid APG,273.31,9473,
Drainage of salivary gland,42320,CPT,,,,,,,,both,,,11572.85,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5786.43,50,,5786.43,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,508.35,,,508.35,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8101,70,,8101,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,273.31,,,273.31,Other,New York Medicaid APG methodology,273.31,,,273.31,Other,100% New York Medicaid APG,273.31,,,273.31,Other,100% New York Medicaid APG,273.31,,,273.31,Other,100% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,382.63,,,382.63,Other,140% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,710.6,,,710.6,Other,260% New York Medicaid APG,885.52,,,885.52,Other,324% New York Medicaid APG,587.61,,,587.61,Other,215% New York Medicaid APG,587.61,,,587.61,Other,215% New York Medicaid APG,341.64,,,341.64,Other,125% New York Medicaid APG,273.31,13157,
Removal of salivary stone,42330,CPT,,,,,,,,both,,,19986.89,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,9993.45,50,,9993.45,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13990.82,70,,13990.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,13990.82,
Removal of salivary stone,42335,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,47404.34,
Removal of salivary stone,42340,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,47404.34,
Biopsy of salivary gland,42400,CPT,,,,,,,,both,,,14798.8,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7399.4,50,,7399.4,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,508.35,,,508.35,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10359.16,70,,10359.16,percent of total billed charges,,259.05,,,259.05,Fee Schedule,,219.8,,,219.8,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,273.31,,,273.31,Other,New York Medicaid APG methodology,273.31,,,273.31,Other,100% New York Medicaid APG,273.31,,,273.31,Other,100% New York Medicaid APG,273.31,,,273.31,Other,100% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,382.63,,,382.63,Other,140% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,710.6,,,710.6,Other,260% New York Medicaid APG,885.52,,,885.52,Other,324% New York Medicaid APG,587.61,,,587.61,Other,215% New York Medicaid APG,587.61,,,587.61,Other,215% New York Medicaid APG,341.64,,,341.64,Other,125% New York Medicaid APG,219.8,10359.16,
Biopsy of salivary gland,42405,CPT,,,,,,,,both,,,40860,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20430,50,,20430,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28602,70,,28602,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,28602,
Excision of salivary cyst,42408,CPT,,,,,,,,both,,,42114.67,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21057.34,50,,21057.34,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29480.27,70,,29480.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,29480.27,
Drainage of salivary cyst,42409,CPT,,,,,,,,both,,,36553.88,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18276.94,50,,18276.94,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25587.72,70,,25587.72,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,25587.72,
Excise parotid gland/lesion,42410,CPT,,,,,,,,both,,,52234.44,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,26117.22,50,,26117.22,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36564.11,70,,36564.11,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,36564.11,
Excise parotid gland/lesion,42415,CPT,,,,,,,,both,,,47640.68,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,23820.34,50,,23820.34,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,33348.48,70,,33348.48,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,33348.48,
Excise parotid gland/lesion,42420,CPT,,,,,,,,both,,,105173.42,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,52586.71,50,,52586.71,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,73621.39,70,,73621.39,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,73621.39,
Excise parotid gland/lesion,42425,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,86224,
Excise submaxillary gland,42440,CPT,,,,,,,,both,,,46934.86,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,23467.43,50,,23467.43,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,32854.4,70,,32854.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,32854.4,
Excise sublingual gland,42450,CPT,,,,,,,,both,,,41640.28,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,20820.14,50,,20820.14,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29148.2,70,,29148.2,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,29148.2,
Repair salivary duct,42500,CPT,,,,,,,,both,,,35276.6,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,17638.3,50,,17638.3,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24693.62,70,,24693.62,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,24693.62,
Repair salivary duct,42505,CPT,,,,,,,,both,,,34960,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,17480,50,,17480,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24472,70,,24472,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,552.27,24472,
Parotid duct diversion,42507,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,86224,
Parotid duct diversion,42509,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,86224,
Parotid duct diversion,42510,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,47404.34,
Injection for salivary x-ray,42550,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1205.26,,,1205.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,300.3,,,300.3,Fee Schedule,,254.8,,,254.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.99,,,647.99,Other,New York Medicaid APG methodology,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,907.18,,,907.18,Other,140% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1684.77,,,1684.77,Other,260% New York Medicaid APG,2099.48,,,2099.48,Other,324% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,809.98,,,809.98,Other,125% New York Medicaid APG,0.01,22702.47,
Closure of salivary fistula,42600,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,47404.34,
Dilation of salivary duct,42650,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,290.4,,,290.4,Fee Schedule,,246.4,,,246.4,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,246.4,22454.17,
Dilation of salivary duct,42660,CPT,,,,,,,,both,,,33480.3,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16740.15,50,,16740.15,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1027.22,,,1027.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23436.21,70,,23436.21,percent of total billed charges,,437.25,,,437.25,Fee Schedule,,371,,,371,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,552.27,,,552.27,Other,New York Medicaid APG methodology,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,552.27,,,552.27,Other,100% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,773.18,,,773.18,Other,140% New York Medicaid APG,1242.61,,,1242.61,Other,225% New York Medicaid APG,1435.91,,,1435.91,Other,260% New York Medicaid APG,1789.36,,,1789.36,Other,324% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,1187.38,,,1187.38,Other,215% New York Medicaid APG,690.34,,,690.34,Other,125% New York Medicaid APG,0.01,23436.21,
Ligation of salivary duct,42665,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,508.35,,,508.35,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,273.31,,,273.31,Other,New York Medicaid APG methodology,273.31,,,273.31,Other,100% New York Medicaid APG,273.31,,,273.31,Other,100% New York Medicaid APG,273.31,,,273.31,Other,100% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,382.63,,,382.63,Other,140% New York Medicaid APG,614.94,,,614.94,Other,225% New York Medicaid APG,710.6,,,710.6,Other,260% New York Medicaid APG,885.52,,,885.52,Other,324% New York Medicaid APG,587.61,,,587.61,Other,215% New York Medicaid APG,587.61,,,587.61,Other,215% New York Medicaid APG,341.64,,,341.64,Other,125% New York Medicaid APG,273.31,47404.34,
Drainage of tonsil abscess,42700,CPT,,,,,,,,both,,,5137.73,464.5,,,464.5,Other,150% of Medicare + 9.63% HCRA Surcharge,282.46,,,282.46,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2568.87,50,,2568.87,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3596.41,70,,3596.41,percent of total billed charges,,674.85,,,674.85,Fee Schedule,,572.6,,,572.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,269.45,9473,
Drainage of throat abscess,42720,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,1545.56,47404.34,
Drainage of throat abscess,42725,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,1545.56,86224,
Biopsy of throat,42800,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,577.5,,,577.5,Fee Schedule,,490,,,490,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,490,22454.17,
Biopsy of upper nose/throat,42804,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,610.5,,,610.5,Fee Schedule,,518,,,518,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,518,47404.34,
Biopsy of upper nose/throat,42806,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,701.25,,,701.25,Fee Schedule,,595,,,595,Fee Schedule,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,595,47404.34,
Excise pharynx lesion,42808,CPT,,,,,,,,both,,,99331.66,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,49665.83,50,,49665.83,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3792.93,,,3792.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,69532.16,70,,69532.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2039.21,,,2039.21,Other,New York Medicaid APG methodology,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,2854.89,,,2854.89,Other,140% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,5301.94,,,5301.94,Other,260% New York Medicaid APG,6607.03,,,6607.03,Other,324% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,2549.01,,,2549.01,Other,125% New York Medicaid APG,2039.21,69532.16,
Remove pharynx foreign body,42809,CPT,,,,,,,,both,,,8380.68,757.69,,,757.69,Other,150% of Medicare + 9.63% HCRA Surcharge,460.76,,,460.76,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4190.34,50,,4190.34,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5866.48,70,,5866.48,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,269.45,13157,
Excision of neck cyst,42810,CPT,,,,,,,,both,,,36766.28,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18383.14,50,,18383.14,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25736.4,70,,25736.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,1545.56,25736.4,
Excision of neck cyst,42815,CPT,,,,,,,,both,,,36519.76,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,18259.88,50,,18259.88,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25563.83,70,,25563.83,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,25563.83,
Remove tonsils and adenoids,42820,CPT,,,,,,,,both,,,35805.32,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,17902.66,50,,17902.66,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3295.52,,,3295.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25063.72,70,,25063.72,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1771.79,,,1771.79,Other,New York Medicaid APG methodology,1771.79,,,1771.79,Other,100% New York Medicaid APG,1771.79,,,1771.79,Other,100% New York Medicaid APG,1771.79,,,1771.79,Other,100% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,2480.5,,,2480.5,Other,140% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,4606.64,,,4606.64,Other,260% New York Medicaid APG,5740.58,,,5740.58,Other,324% New York Medicaid APG,3809.34,,,3809.34,Other,215% New York Medicaid APG,3809.34,,,3809.34,Other,215% New York Medicaid APG,2214.73,,,2214.73,Other,125% New York Medicaid APG,1771.79,25063.72,
Remove tonsils and adenoids,42821,CPT,,,,,,,,both,,,36490.36,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18245.18,50,,18245.18,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3295.52,,,3295.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25543.25,70,,25543.25,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1771.79,,,1771.79,Other,New York Medicaid APG methodology,1771.79,,,1771.79,Other,100% New York Medicaid APG,1771.79,,,1771.79,Other,100% New York Medicaid APG,1771.79,,,1771.79,Other,100% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,2480.5,,,2480.5,Other,140% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,4606.64,,,4606.64,Other,260% New York Medicaid APG,5740.58,,,5740.58,Other,324% New York Medicaid APG,3809.34,,,3809.34,Other,215% New York Medicaid APG,3809.34,,,3809.34,Other,215% New York Medicaid APG,2214.73,,,2214.73,Other,125% New York Medicaid APG,1771.79,25543.25,
Removal of tonsils,42825,CPT,,,,,,,,both,,,36380.39,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,18190.2,50,,18190.2,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3295.52,,,3295.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25466.27,70,,25466.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1771.79,,,1771.79,Other,New York Medicaid APG methodology,1771.79,,,1771.79,Other,100% New York Medicaid APG,1771.79,,,1771.79,Other,100% New York Medicaid APG,1771.79,,,1771.79,Other,100% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,2480.5,,,2480.5,Other,140% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,4606.64,,,4606.64,Other,260% New York Medicaid APG,5740.58,,,5740.58,Other,324% New York Medicaid APG,3809.34,,,3809.34,Other,215% New York Medicaid APG,3809.34,,,3809.34,Other,215% New York Medicaid APG,2214.73,,,2214.73,Other,125% New York Medicaid APG,1771.79,25466.27,
Removal of tonsils,42826,CPT,,,,,,,,both,,,38466.62,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19233.31,50,,19233.31,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3295.52,,,3295.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26926.63,70,,26926.63,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1771.79,,,1771.79,Other,New York Medicaid APG methodology,1771.79,,,1771.79,Other,100% New York Medicaid APG,1771.79,,,1771.79,Other,100% New York Medicaid APG,1771.79,,,1771.79,Other,100% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,2480.5,,,2480.5,Other,140% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,4606.64,,,4606.64,Other,260% New York Medicaid APG,5740.58,,,5740.58,Other,324% New York Medicaid APG,3809.34,,,3809.34,Other,215% New York Medicaid APG,3809.34,,,3809.34,Other,215% New York Medicaid APG,2214.73,,,2214.73,Other,125% New York Medicaid APG,1771.79,26926.63,
Removal of adenoids,42830,CPT,,,,,,,,both,,,34982.02,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17491.01,50,,17491.01,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3295.52,,,3295.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24487.41,70,,24487.41,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1771.79,,,1771.79,Other,New York Medicaid APG methodology,1771.79,,,1771.79,Other,100% New York Medicaid APG,1771.79,,,1771.79,Other,100% New York Medicaid APG,1771.79,,,1771.79,Other,100% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,2480.5,,,2480.5,Other,140% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,4606.64,,,4606.64,Other,260% New York Medicaid APG,5740.58,,,5740.58,Other,324% New York Medicaid APG,3809.34,,,3809.34,Other,215% New York Medicaid APG,3809.34,,,3809.34,Other,215% New York Medicaid APG,2214.73,,,2214.73,Other,125% New York Medicaid APG,1771.79,24487.41,
Removal of adenoids,42831,CPT,,,,,,,,both,,,34792.95,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17396.48,50,,17396.48,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3295.52,,,3295.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24355.07,70,,24355.07,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1771.79,,,1771.79,Other,New York Medicaid APG methodology,1771.79,,,1771.79,Other,100% New York Medicaid APG,1771.79,,,1771.79,Other,100% New York Medicaid APG,1771.79,,,1771.79,Other,100% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,2480.5,,,2480.5,Other,140% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,4606.64,,,4606.64,Other,260% New York Medicaid APG,5740.58,,,5740.58,Other,324% New York Medicaid APG,3809.34,,,3809.34,Other,215% New York Medicaid APG,3809.34,,,3809.34,Other,215% New York Medicaid APG,2214.73,,,2214.73,Other,125% New York Medicaid APG,1771.79,24355.07,
Removal of adenoids,42835,CPT,,,,,,,,both,,,35678.62,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17839.31,50,,17839.31,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3295.52,,,3295.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24975.03,70,,24975.03,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1771.79,,,1771.79,Other,New York Medicaid APG methodology,1771.79,,,1771.79,Other,100% New York Medicaid APG,1771.79,,,1771.79,Other,100% New York Medicaid APG,1771.79,,,1771.79,Other,100% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,2480.5,,,2480.5,Other,140% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,4606.64,,,4606.64,Other,260% New York Medicaid APG,5740.58,,,5740.58,Other,324% New York Medicaid APG,3809.34,,,3809.34,Other,215% New York Medicaid APG,3809.34,,,3809.34,Other,215% New York Medicaid APG,2214.73,,,2214.73,Other,125% New York Medicaid APG,1771.79,24975.03,
Removal of adenoids,42836,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3295.52,,,3295.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1771.79,,,1771.79,Other,New York Medicaid APG methodology,1771.79,,,1771.79,Other,100% New York Medicaid APG,1771.79,,,1771.79,Other,100% New York Medicaid APG,1771.79,,,1771.79,Other,100% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,2480.5,,,2480.5,Other,140% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,4606.64,,,4606.64,Other,260% New York Medicaid APG,5740.58,,,5740.58,Other,324% New York Medicaid APG,3809.34,,,3809.34,Other,215% New York Medicaid APG,3809.34,,,3809.34,Other,215% New York Medicaid APG,2214.73,,,2214.73,Other,125% New York Medicaid APG,1771.79,47404.34,
Extensive surgery of throat,42842,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3295.52,,,3295.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1771.79,,,1771.79,Other,New York Medicaid APG methodology,1771.79,,,1771.79,Other,100% New York Medicaid APG,1771.79,,,1771.79,Other,100% New York Medicaid APG,1771.79,,,1771.79,Other,100% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,2480.5,,,2480.5,Other,140% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,4606.64,,,4606.64,Other,260% New York Medicaid APG,5740.58,,,5740.58,Other,324% New York Medicaid APG,3809.34,,,3809.34,Other,215% New York Medicaid APG,3809.34,,,3809.34,Other,215% New York Medicaid APG,2214.73,,,2214.73,Other,125% New York Medicaid APG,1771.79,86224,
Extensive surgery of throat,42844,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3295.52,,,3295.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1771.79,,,1771.79,Other,New York Medicaid APG methodology,1771.79,,,1771.79,Other,100% New York Medicaid APG,1771.79,,,1771.79,Other,100% New York Medicaid APG,1771.79,,,1771.79,Other,100% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,2480.5,,,2480.5,Other,140% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,4606.64,,,4606.64,Other,260% New York Medicaid APG,5740.58,,,5740.58,Other,324% New York Medicaid APG,3809.34,,,3809.34,Other,215% New York Medicaid APG,3809.34,,,3809.34,Other,215% New York Medicaid APG,2214.73,,,2214.73,Other,125% New York Medicaid APG,1771.79,86224,
Excision of tonsil tags,42860,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3295.52,,,3295.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1771.79,,,1771.79,Other,New York Medicaid APG methodology,1771.79,,,1771.79,Other,100% New York Medicaid APG,1771.79,,,1771.79,Other,100% New York Medicaid APG,1771.79,,,1771.79,Other,100% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,2480.5,,,2480.5,Other,140% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,4606.64,,,4606.64,Other,260% New York Medicaid APG,5740.58,,,5740.58,Other,324% New York Medicaid APG,3809.34,,,3809.34,Other,215% New York Medicaid APG,3809.34,,,3809.34,Other,215% New York Medicaid APG,2214.73,,,2214.73,Other,125% New York Medicaid APG,1771.79,47404.34,
Excision of lingual tonsil,42870,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3295.52,,,3295.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1771.79,,,1771.79,Other,New York Medicaid APG methodology,1771.79,,,1771.79,Other,100% New York Medicaid APG,1771.79,,,1771.79,Other,100% New York Medicaid APG,1771.79,,,1771.79,Other,100% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,2480.5,,,2480.5,Other,140% New York Medicaid APG,3986.52,,,3986.52,Other,225% New York Medicaid APG,4606.64,,,4606.64,Other,260% New York Medicaid APG,5740.58,,,5740.58,Other,324% New York Medicaid APG,3809.34,,,3809.34,Other,215% New York Medicaid APG,3809.34,,,3809.34,Other,215% New York Medicaid APG,2214.73,,,2214.73,Other,125% New York Medicaid APG,1771.79,86224,
Partial removal of pharynx,42890,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,86224,
Revision of pharyngeal walls,42892,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,86224,
Repair throat wound,42900,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,1545.56,22454.17,
Reconstruction of throat,42950,CPT,,,,,,,,both,,,35704.71,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,17852.36,50,,17852.36,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24993.3,70,,24993.3,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,24993.3,
Surgical opening of throat,42955,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,1545.56,22454.17,
Control throat bleeding,42960,CPT,,,,,,,,both,,,11572.85,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5786.43,50,,5786.43,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8101,70,,8101,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,636.26,13157,
Control throat bleeding,42962,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,1545.56,47404.34,
Control nose/throat bleeding,42970,CPT,,,,,,,,both,,,5137.73,464.5,,,464.5,Other,150% of Medicare + 9.63% HCRA Surcharge,282.46,,,282.46,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2568.87,50,,2568.87,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3596.41,70,,3596.41,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,0.01,13157,
Control nose/throat bleeding,42972,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,1545.56,47404.34,
Incision of esophagus,43020,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,1545.56,22454.17,
Throat muscle surgery,43030,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,86224,
Removal of esophagus pouch,43130,CPT,,,,,,,,both,,,35116.91,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,17558.46,50,,17558.46,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5342.07,,,5342.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24581.84,70,,24581.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2872.08,,,2872.08,Other,New York Medicaid APG methodology,2872.08,,,2872.08,Other,100% New York Medicaid APG,2872.08,,,2872.08,Other,100% New York Medicaid APG,2872.08,,,2872.08,Other,100% New York Medicaid APG,6462.19,,,6462.19,Other,225% New York Medicaid APG,6462.19,,,6462.19,Other,225% New York Medicaid APG,6462.19,,,6462.19,Other,225% New York Medicaid APG,6462.19,,,6462.19,Other,225% New York Medicaid APG,4020.92,,,4020.92,Other,140% New York Medicaid APG,6462.19,,,6462.19,Other,225% New York Medicaid APG,7467.41,,,7467.41,Other,260% New York Medicaid APG,9305.55,,,9305.55,Other,324% New York Medicaid APG,6174.98,,,6174.98,Other,215% New York Medicaid APG,6174.98,,,6174.98,Other,215% New York Medicaid APG,3590.1,,,3590.1,Other,125% New York Medicaid APG,2872.08,24581.84,
Esophagoscopy rigid trnso,43180,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2301.59,,,2301.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1237.42,,,1237.42,Other,New York Medicaid APG methodology,1237.42,,,1237.42,Other,100% New York Medicaid APG,1237.42,,,1237.42,Other,100% New York Medicaid APG,1237.42,,,1237.42,Other,100% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,1732.38,,,1732.38,Other,140% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,3217.28,,,3217.28,Other,260% New York Medicaid APG,4009.23,,,4009.23,Other,324% New York Medicaid APG,2660.44,,,2660.44,Other,215% New York Medicaid APG,2660.44,,,2660.44,Other,215% New York Medicaid APG,1546.77,,,1546.77,Other,125% New York Medicaid APG,1237.42,86224,
Esophagoscopy rigid trnso dx,43191,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2182.57,,,2182.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1173.42,,,1173.42,Other,New York Medicaid APG methodology,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,1642.79,,,1642.79,Other,140% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,3050.9,,,3050.9,Other,260% New York Medicaid APG,3801.89,,,3801.89,Other,324% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,1466.78,,,1466.78,Other,125% New York Medicaid APG,1173.42,28016.37,
Esophagoscp rig trnso inject,43192,CPT,,,,,,,,both,,,34010.82,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17005.41,50,,17005.41,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2182.57,,,2182.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23807.57,70,,23807.57,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1173.42,,,1173.42,Other,New York Medicaid APG methodology,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,1642.79,,,1642.79,Other,140% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,3050.9,,,3050.9,Other,260% New York Medicaid APG,3801.89,,,3801.89,Other,324% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,1466.78,,,1466.78,Other,125% New York Medicaid APG,1173.42,23807.57,
Esophagoscp rig trnso biopsy,43193,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2182.57,,,2182.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1173.42,,,1173.42,Other,New York Medicaid APG methodology,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,1642.79,,,1642.79,Other,140% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,3050.9,,,3050.9,Other,260% New York Medicaid APG,3801.89,,,3801.89,Other,324% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,1466.78,,,1466.78,Other,125% New York Medicaid APG,1173.42,28016.37,
Esophagoscp rig trnso rem fb,43194,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2182.57,,,2182.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1173.42,,,1173.42,Other,New York Medicaid APG methodology,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,1642.79,,,1642.79,Other,140% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,3050.9,,,3050.9,Other,260% New York Medicaid APG,3801.89,,,3801.89,Other,324% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,1466.78,,,1466.78,Other,125% New York Medicaid APG,1173.42,28016.37,
Esophagoscopy rigid balloon,43195,CPT,,,,,,,,both,,,37422.98,7282.85,,,7282.85,Other,150% of Medicare + 9.63% HCRA Surcharge,4428.74,,,4428.74,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18711.49,50,,18711.49,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2301.59,,,2301.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26196.09,70,,26196.09,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1237.42,,,1237.42,Other,New York Medicaid APG methodology,1237.42,,,1237.42,Other,100% New York Medicaid APG,1237.42,,,1237.42,Other,100% New York Medicaid APG,1237.42,,,1237.42,Other,100% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,1732.38,,,1732.38,Other,140% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,3217.28,,,3217.28,Other,260% New York Medicaid APG,4009.23,,,4009.23,Other,324% New York Medicaid APG,2660.44,,,2660.44,Other,215% New York Medicaid APG,2660.44,,,2660.44,Other,215% New York Medicaid APG,1546.77,,,1546.77,Other,125% New York Medicaid APG,1237.42,26196.09,
Esophagoscp guide wire dilat,43196,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2182.57,,,2182.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1173.42,,,1173.42,Other,New York Medicaid APG methodology,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,1642.79,,,1642.79,Other,140% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,3050.9,,,3050.9,Other,260% New York Medicaid APG,3801.89,,,3801.89,Other,324% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,1466.78,,,1466.78,Other,125% New York Medicaid APG,1173.42,28016.37,
Esophagoscopy flex dx brush,43197,CPT,,,,,,,,both,,,19066.74,1723.81,,,1723.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.26,,,1048.26,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9533.37,50,,9533.37,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13346.72,70,,13346.72,percent of total billed charges,,400.95,,,400.95,Fee Schedule,,340.2,,,340.2,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,340.2,13346.72,
Esophagosc flex trnsn biopsy,43198,CPT,,,,,,,,both,,,19066.74,1723.81,,,1723.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.26,,,1048.26,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9533.37,50,,9533.37,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13346.72,70,,13346.72,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,13346.72,
Esophagoscopy flexible brush,43200,CPT,,,,,,,,both,,,19066.74,1723.81,,,1723.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.26,,,1048.26,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9533.37,50,,9533.37,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13346.72,70,,13346.72,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,13346.72,
Esoph scope w/submucous inj,43201,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,28016.37,
Esophagoscopy flex biopsy,43202,CPT,,,,,,,,both,,,37898,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18949,50,,18949,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26528.6,70,,26528.6,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,26528.6,
Esoph scope w/sclerosis inj,43204,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,28016.37,
Esophagus endoscopy/ligation,43205,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,28016.37,
Esoph optical endomicroscopy,43206,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2182.57,,,2182.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,643.5,,,643.5,Fee Schedule,,546,,,546,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1173.42,,,1173.42,Other,New York Medicaid APG methodology,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,1642.79,,,1642.79,Other,140% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,3050.9,,,3050.9,Other,260% New York Medicaid APG,3801.89,,,3801.89,Other,324% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,1466.78,,,1466.78,Other,125% New York Medicaid APG,546,28016.37,
Egd esophagogastrc fndoplsty,43210,CPT,,,,,,,,both,,,216515.17,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,108257.59,50,,108257.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2301.59,,,2301.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,151560.62,70,,151560.62,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1237.42,,,1237.42,Other,New York Medicaid APG methodology,1237.42,,,1237.42,Other,100% New York Medicaid APG,1237.42,,,1237.42,Other,100% New York Medicaid APG,1237.42,,,1237.42,Other,100% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,1732.38,,,1732.38,Other,140% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,3217.28,,,3217.28,Other,260% New York Medicaid APG,4009.23,,,4009.23,Other,324% New York Medicaid APG,2660.44,,,2660.44,Other,215% New York Medicaid APG,2660.44,,,2660.44,Other,215% New York Medicaid APG,1546.77,,,1546.77,Other,125% New York Medicaid APG,1237.42,151560.62,
Esophagoscop mucosal resect,43211,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,28016.37,
Esophagoscop stent placement,43212,CPT,,,,,,,,both,,,119876.35,10837.95,,,10837.95,Other,150% of Medicare + 9.63% HCRA Surcharge,6590.62,,,6590.62,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,59938.18,50,,59938.18,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2301.59,,,2301.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,83913.45,70,,83913.45,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1237.42,,,1237.42,Other,New York Medicaid APG methodology,1237.42,,,1237.42,Other,100% New York Medicaid APG,1237.42,,,1237.42,Other,100% New York Medicaid APG,1237.42,,,1237.42,Other,100% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,1732.38,,,1732.38,Other,140% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,3217.28,,,3217.28,Other,260% New York Medicaid APG,4009.23,,,4009.23,Other,324% New York Medicaid APG,2660.44,,,2660.44,Other,215% New York Medicaid APG,2660.44,,,2660.44,Other,215% New York Medicaid APG,1546.77,,,1546.77,Other,125% New York Medicaid APG,1237.42,83913.45,
Esophagoscopy retro balloon,43213,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,28016.37,
Esophagosc dilate balloon 30,43214,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2182.57,,,2182.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1173.42,,,1173.42,Other,New York Medicaid APG methodology,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,1642.79,,,1642.79,Other,140% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,3050.9,,,3050.9,Other,260% New York Medicaid APG,3801.89,,,3801.89,Other,324% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,1466.78,,,1466.78,Other,125% New York Medicaid APG,1173.42,28016.37,
Esophagoscopy flex remove fb,43215,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,28016.37,
Esophagoscopy lesion removal,43216,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,28016.37,
Esophagoscopy snare les remv,43217,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,28016.37,
Esophagoscopy balloon <30mm,43220,CPT,,,,,,,,both,,,31351.03,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,15675.52,50,,15675.52,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,21945.72,70,,21945.72,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,21945.72,
Esoph endoscopy dilation,43226,CPT,,,,,,,,both,,,36025,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18012.5,50,,18012.5,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25217.5,70,,25217.5,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,25217.5,
Esophagoscopy control bleed,43227,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,28016.37,
Esophagoscopy lesion ablate,43229,CPT,,,,,,,,both,,,80554.09,7282.85,,,7282.85,Other,150% of Medicare + 9.63% HCRA Surcharge,4428.74,,,4428.74,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40277.05,50,,40277.05,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2182.57,,,2182.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56387.86,70,,56387.86,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1173.42,,,1173.42,Other,New York Medicaid APG methodology,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,1642.79,,,1642.79,Other,140% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,3050.9,,,3050.9,Other,260% New York Medicaid APG,3801.89,,,3801.89,Other,324% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,1466.78,,,1466.78,Other,125% New York Medicaid APG,1173.42,56387.86,
Esophagoscop ultrasound exam,43231,CPT,,,,,,,,both,,,12293.8,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,6146.9,50,,6146.9,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8605.66,70,,8605.66,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,9473,
Esophagoscopy w/us needle bx,43232,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,28016.37,
Egd balloon dil esoph30 mm/>,43233,CPT,,,,,,,,both,,,31175.65,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,15587.83,50,,15587.83,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,21822.96,70,,21822.96,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,21822.96,
Egd diagnostic brush wash,43235,CPT,,,,,,,,both,,,13363.62,1723.81,,,1723.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.26,,,1048.26,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6681.81,50,,6681.81,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9354.53,70,,9354.53,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,9473,
Uppr gi scope w/submuc inj,43236,CPT,,,,,,,,both,,,16160.18,1723.81,,,1723.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.26,,,1048.26,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,8080.09,50,,8080.09,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,11312.13,70,,11312.13,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,11312.13,
Endoscopic us exam esoph,43237,CPT,,,,,,,,both,,,17728.21,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,8864.11,50,,8864.11,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,12409.75,70,,12409.75,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,12409.75,
Egd us fine needle bx/aspir,43238,CPT,,,,,,,,both,,,29340.91,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,14670.46,50,,14670.46,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,20538.64,70,,20538.64,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,20538.64,
Egd biopsy single/multiple,43239,CPT,,,,,,,,both,,,23634.5,1723.81,,,1723.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.26,,,1048.26,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,11817.25,50,,11817.25,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,16544.15,70,,16544.15,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,16544.15,
Egd w/transmural drain cyst,43240,CPT,,,,,,,,both,,,119876.35,10837.95,,,10837.95,Other,150% of Medicare + 9.63% HCRA Surcharge,6590.62,,,6590.62,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,59938.18,50,,59938.18,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2301.59,,,2301.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,83913.45,70,,83913.45,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1237.42,,,1237.42,Other,New York Medicaid APG methodology,1237.42,,,1237.42,Other,100% New York Medicaid APG,1237.42,,,1237.42,Other,100% New York Medicaid APG,1237.42,,,1237.42,Other,100% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,1732.38,,,1732.38,Other,140% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,3217.28,,,3217.28,Other,260% New York Medicaid APG,4009.23,,,4009.23,Other,324% New York Medicaid APG,2660.44,,,2660.44,Other,215% New York Medicaid APG,2660.44,,,2660.44,Other,215% New York Medicaid APG,1546.77,,,1546.77,Other,125% New York Medicaid APG,1237.42,83913.45,
Egd tube/cath insertion,43241,CPT,,,,,,,,both,,,44542.16,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,22271.08,50,,22271.08,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31179.51,70,,31179.51,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,31179.51,
Egd us fine needle bx/aspir,43242,CPT,,,,,,,,both,,,29434.97,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,14717.49,50,,14717.49,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,20604.48,70,,20604.48,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,20604.48,
Egd injection varices,43243,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,28016.37,
Egd varices ligation,43244,CPT,,,,,,,,both,,,15264.53,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,7632.27,50,,7632.27,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10685.17,70,,10685.17,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,10685.17,
Egd dilate stricture,43245,CPT,,,,,,,,both,,,21612.12,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,10806.06,50,,10806.06,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,15128.48,70,,15128.48,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,15128.48,
Egd place gastrostomy tube,43246,CPT,,,,,,,,both,,,25442.5,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12721.25,50,,12721.25,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17809.75,70,,17809.75,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,17809.75,
Egd remove foreign body,43247,CPT,,,,,,,,both,,,22283.81,1723.81,,,1723.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.26,,,1048.26,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,11141.91,50,,11141.91,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,15598.67,70,,15598.67,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,15598.67,
Egd guide wire insertion,43248,CPT,,,,,,,,both,,,19066.74,1723.81,,,1723.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.26,,,1048.26,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9533.37,50,,9533.37,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13346.72,70,,13346.72,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,13346.72,
Esoph egd dilation <30 mm,43249,CPT,,,,,,,,both,,,20422.88,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,10211.44,50,,10211.44,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,14296.02,70,,14296.02,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,14296.02,
Egd cautery tumor polyp,43250,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,28016.37,
Egd remove lesion snare,43251,CPT,,,,,,,,both,,,23659.1,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,11829.55,50,,11829.55,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,16561.37,70,,16561.37,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,16561.37,
Egd optical endomicroscopy,43252,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2301.59,,,2301.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,813.45,,,813.45,Fee Schedule,,690.2,,,690.2,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1237.42,,,1237.42,Other,New York Medicaid APG methodology,1237.42,,,1237.42,Other,100% New York Medicaid APG,1237.42,,,1237.42,Other,100% New York Medicaid APG,1237.42,,,1237.42,Other,100% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,1732.38,,,1732.38,Other,140% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,3217.28,,,3217.28,Other,260% New York Medicaid APG,4009.23,,,4009.23,Other,324% New York Medicaid APG,2660.44,,,2660.44,Other,215% New York Medicaid APG,2660.44,,,2660.44,Other,215% New York Medicaid APG,1546.77,,,1546.77,Other,125% New York Medicaid APG,690.2,28016.37,
Egd us transmural injxn/mark,43253,CPT,,,,,,,,both,,,28190.73,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,14095.37,50,,14095.37,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,19733.51,70,,19733.51,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,19733.51,
Egd endo mucosal resection,43254,CPT,,,,,,,,both,,,28195.3,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,14097.65,50,,14097.65,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2182.57,,,2182.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,19736.71,70,,19736.71,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1173.42,,,1173.42,Other,New York Medicaid APG methodology,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,1642.79,,,1642.79,Other,140% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,3050.9,,,3050.9,Other,260% New York Medicaid APG,3801.89,,,3801.89,Other,324% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,1466.78,,,1466.78,Other,125% New York Medicaid APG,1173.42,19736.71,
Egd control bleeding any,43255,CPT,,,,,,,,both,,,14839.33,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,7419.67,50,,7419.67,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10387.53,70,,10387.53,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,10387.53,
Egd w/thrml txmnt gerd,43257,CPT,,,,,,,,both,,,80554.09,7282.85,,,7282.85,Other,150% of Medicare + 9.63% HCRA Surcharge,4428.74,,,4428.74,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40277.05,50,,40277.05,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2182.57,,,2182.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56387.86,70,,56387.86,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1173.42,,,1173.42,Other,New York Medicaid APG methodology,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,1642.79,,,1642.79,Other,140% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,3050.9,,,3050.9,Other,260% New York Medicaid APG,3801.89,,,3801.89,Other,324% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,1466.78,,,1466.78,Other,125% New York Medicaid APG,1173.42,56387.86,
Egd us exam duodenum/jejunum,43259,CPT,,,,,,,,both,,,16503.83,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,8251.92,50,,8251.92,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,11552.68,70,,11552.68,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,11552.68,
Ercp w/specimen collection,43260,CPT,,,,,,,,both,,,44600.39,7282.85,,,7282.85,Other,150% of Medicare + 9.63% HCRA Surcharge,4428.74,,,4428.74,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,22300.2,50,,22300.2,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2994.65,,,2994.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31220.27,70,,31220.27,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1610.03,,,1610.03,Other,New York Medicaid APG methodology,1610.03,,,1610.03,Other,100% New York Medicaid APG,1610.03,,,1610.03,Other,100% New York Medicaid APG,1610.03,,,1610.03,Other,100% New York Medicaid APG,3622.56,,,3622.56,Other,225% New York Medicaid APG,3622.56,,,3622.56,Other,225% New York Medicaid APG,3622.56,,,3622.56,Other,225% New York Medicaid APG,3622.56,,,3622.56,Other,225% New York Medicaid APG,2254.04,,,2254.04,Other,140% New York Medicaid APG,3622.56,,,3622.56,Other,225% New York Medicaid APG,4186.07,,,4186.07,Other,260% New York Medicaid APG,5216.49,,,5216.49,Other,324% New York Medicaid APG,3461.56,,,3461.56,Other,215% New York Medicaid APG,3461.56,,,3461.56,Other,215% New York Medicaid APG,2012.53,,,2012.53,Other,125% New York Medicaid APG,1610.03,31220.27,
Endo cholangiopancreatograph,43261,CPT,,,,,,,,both,,,48894.68,7282.85,,,7282.85,Other,150% of Medicare + 9.63% HCRA Surcharge,4428.74,,,4428.74,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,24447.34,50,,24447.34,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2994.65,,,2994.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34226.28,70,,34226.28,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1610.03,,,1610.03,Other,New York Medicaid APG methodology,1610.03,,,1610.03,Other,100% New York Medicaid APG,1610.03,,,1610.03,Other,100% New York Medicaid APG,1610.03,,,1610.03,Other,100% New York Medicaid APG,3622.56,,,3622.56,Other,225% New York Medicaid APG,3622.56,,,3622.56,Other,225% New York Medicaid APG,3622.56,,,3622.56,Other,225% New York Medicaid APG,3622.56,,,3622.56,Other,225% New York Medicaid APG,2254.04,,,2254.04,Other,140% New York Medicaid APG,3622.56,,,3622.56,Other,225% New York Medicaid APG,4186.07,,,4186.07,Other,260% New York Medicaid APG,5216.49,,,5216.49,Other,324% New York Medicaid APG,3461.56,,,3461.56,Other,215% New York Medicaid APG,3461.56,,,3461.56,Other,215% New York Medicaid APG,2012.53,,,2012.53,Other,125% New York Medicaid APG,1610.03,34226.28,
Endo cholangiopancreatograph,43262,CPT,,,,,,,,both,,,35727.6,7282.85,,,7282.85,Other,150% of Medicare + 9.63% HCRA Surcharge,4428.74,,,4428.74,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17863.8,50,,17863.8,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2994.65,,,2994.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25009.32,70,,25009.32,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1610.03,,,1610.03,Other,New York Medicaid APG methodology,1610.03,,,1610.03,Other,100% New York Medicaid APG,1610.03,,,1610.03,Other,100% New York Medicaid APG,1610.03,,,1610.03,Other,100% New York Medicaid APG,3622.56,,,3622.56,Other,225% New York Medicaid APG,3622.56,,,3622.56,Other,225% New York Medicaid APG,3622.56,,,3622.56,Other,225% New York Medicaid APG,3622.56,,,3622.56,Other,225% New York Medicaid APG,2254.04,,,2254.04,Other,140% New York Medicaid APG,3622.56,,,3622.56,Other,225% New York Medicaid APG,4186.07,,,4186.07,Other,260% New York Medicaid APG,5216.49,,,5216.49,Other,324% New York Medicaid APG,3461.56,,,3461.56,Other,215% New York Medicaid APG,3461.56,,,3461.56,Other,215% New York Medicaid APG,2012.53,,,2012.53,Other,125% New York Medicaid APG,1610.03,25009.32,
Ercp sphincter pressure meas,43263,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2994.65,,,2994.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1610.03,,,1610.03,Other,New York Medicaid APG methodology,1610.03,,,1610.03,Other,100% New York Medicaid APG,1610.03,,,1610.03,Other,100% New York Medicaid APG,1610.03,,,1610.03,Other,100% New York Medicaid APG,3622.56,,,3622.56,Other,225% New York Medicaid APG,3622.56,,,3622.56,Other,225% New York Medicaid APG,3622.56,,,3622.56,Other,225% New York Medicaid APG,3622.56,,,3622.56,Other,225% New York Medicaid APG,2254.04,,,2254.04,Other,140% New York Medicaid APG,3622.56,,,3622.56,Other,225% New York Medicaid APG,4186.07,,,4186.07,Other,260% New York Medicaid APG,5216.49,,,5216.49,Other,324% New York Medicaid APG,3461.56,,,3461.56,Other,215% New York Medicaid APG,3461.56,,,3461.56,Other,215% New York Medicaid APG,2012.53,,,2012.53,Other,125% New York Medicaid APG,1610.03,28016.37,
Ercp remove duct calculi,43264,CPT,,,,,,,,both,,,32360.33,7282.85,,,7282.85,Other,150% of Medicare + 9.63% HCRA Surcharge,4428.74,,,4428.74,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,16180.17,50,,16180.17,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2994.65,,,2994.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22652.23,70,,22652.23,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1610.03,,,1610.03,Other,New York Medicaid APG methodology,1610.03,,,1610.03,Other,100% New York Medicaid APG,1610.03,,,1610.03,Other,100% New York Medicaid APG,1610.03,,,1610.03,Other,100% New York Medicaid APG,3622.56,,,3622.56,Other,225% New York Medicaid APG,3622.56,,,3622.56,Other,225% New York Medicaid APG,3622.56,,,3622.56,Other,225% New York Medicaid APG,3622.56,,,3622.56,Other,225% New York Medicaid APG,2254.04,,,2254.04,Other,140% New York Medicaid APG,3622.56,,,3622.56,Other,225% New York Medicaid APG,4186.07,,,4186.07,Other,260% New York Medicaid APG,5216.49,,,5216.49,Other,324% New York Medicaid APG,3461.56,,,3461.56,Other,215% New York Medicaid APG,3461.56,,,3461.56,Other,215% New York Medicaid APG,2012.53,,,2012.53,Other,125% New York Medicaid APG,1610.03,22652.23,
Ercp lithotripsy calculi,43265,CPT,,,,,,,,both,,,119876.35,10837.95,,,10837.95,Other,150% of Medicare + 9.63% HCRA Surcharge,6590.62,,,6590.62,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,59938.18,50,,59938.18,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3272.59,,,3272.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,83913.45,70,,83913.45,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1759.46,,,1759.46,Other,New York Medicaid APG methodology,1759.46,,,1759.46,Other,100% New York Medicaid APG,1759.46,,,1759.46,Other,100% New York Medicaid APG,1759.46,,,1759.46,Other,100% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,2463.24,,,2463.24,Other,140% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,4574.59,,,4574.59,Other,260% New York Medicaid APG,5700.64,,,5700.64,Other,324% New York Medicaid APG,3782.83,,,3782.83,Other,215% New York Medicaid APG,3782.83,,,3782.83,Other,215% New York Medicaid APG,2199.32,,,2199.32,Other,125% New York Medicaid APG,1759.46,83913.45,
Egd endoscopic stent place,43266,CPT,,,,,,,,both,,,29477.85,10837.95,,,10837.95,Other,150% of Medicare + 9.63% HCRA Surcharge,6590.62,,,6590.62,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,14738.93,50,,14738.93,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2301.59,,,2301.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,20634.5,70,,20634.5,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1237.42,,,1237.42,Other,New York Medicaid APG methodology,1237.42,,,1237.42,Other,100% New York Medicaid APG,1237.42,,,1237.42,Other,100% New York Medicaid APG,1237.42,,,1237.42,Other,100% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,1732.38,,,1732.38,Other,140% New York Medicaid APG,2784.18,,,2784.18,Other,225% New York Medicaid APG,3217.28,,,3217.28,Other,260% New York Medicaid APG,4009.23,,,4009.23,Other,324% New York Medicaid APG,2660.44,,,2660.44,Other,215% New York Medicaid APG,2660.44,,,2660.44,Other,215% New York Medicaid APG,1546.77,,,1546.77,Other,125% New York Medicaid APG,1237.42,20634.5,
Egd lesion ablation,43270,CPT,,,,,,,,both,,,20371.8,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,10185.9,50,,10185.9,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2182.57,,,2182.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,14260.26,70,,14260.26,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1173.42,,,1173.42,Other,New York Medicaid APG methodology,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,1642.79,,,1642.79,Other,140% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,3050.9,,,3050.9,Other,260% New York Medicaid APG,3801.89,,,3801.89,Other,324% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,1466.78,,,1466.78,Other,125% New York Medicaid APG,1173.42,14260.26,
Endoscopic pancreatoscopy,43273,CPT,,,,,,,,both,,,25918.71,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12959.36,50,,12959.36,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3272.59,,,3272.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,18143.1,70,,18143.1,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1759.46,,,1759.46,Other,New York Medicaid APG methodology,1759.46,,,1759.46,Other,100% New York Medicaid APG,1759.46,,,1759.46,Other,100% New York Medicaid APG,1759.46,,,1759.46,Other,100% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,2463.24,,,2463.24,Other,140% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,4574.59,,,4574.59,Other,260% New York Medicaid APG,5700.64,,,5700.64,Other,324% New York Medicaid APG,3782.83,,,3782.83,Other,215% New York Medicaid APG,3782.83,,,3782.83,Other,215% New York Medicaid APG,2199.32,,,2199.32,Other,125% New York Medicaid APG,0.01,18143.1,
Ercp duct stent placement,43274,CPT,,,,,,,,both,,,44985.34,10837.95,,,10837.95,Other,150% of Medicare + 9.63% HCRA Surcharge,6590.62,,,6590.62,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,22492.67,50,,22492.67,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3272.59,,,3272.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31489.74,70,,31489.74,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1759.46,,,1759.46,Other,New York Medicaid APG methodology,1759.46,,,1759.46,Other,100% New York Medicaid APG,1759.46,,,1759.46,Other,100% New York Medicaid APG,1759.46,,,1759.46,Other,100% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,2463.24,,,2463.24,Other,140% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,4574.59,,,4574.59,Other,260% New York Medicaid APG,5700.64,,,5700.64,Other,324% New York Medicaid APG,3782.83,,,3782.83,Other,215% New York Medicaid APG,3782.83,,,3782.83,Other,215% New York Medicaid APG,2199.32,,,2199.32,Other,125% New York Medicaid APG,1759.46,31489.74,
Ercp remove forgn body duct,43275,CPT,,,,,,,,both,,,29252.14,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,14626.07,50,,14626.07,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2994.65,,,2994.65,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,20476.5,70,,20476.5,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1610.03,,,1610.03,Other,New York Medicaid APG methodology,1610.03,,,1610.03,Other,100% New York Medicaid APG,1610.03,,,1610.03,Other,100% New York Medicaid APG,1610.03,,,1610.03,Other,100% New York Medicaid APG,3622.56,,,3622.56,Other,225% New York Medicaid APG,3622.56,,,3622.56,Other,225% New York Medicaid APG,3622.56,,,3622.56,Other,225% New York Medicaid APG,3622.56,,,3622.56,Other,225% New York Medicaid APG,2254.04,,,2254.04,Other,140% New York Medicaid APG,3622.56,,,3622.56,Other,225% New York Medicaid APG,4186.07,,,4186.07,Other,260% New York Medicaid APG,5216.49,,,5216.49,Other,324% New York Medicaid APG,3461.56,,,3461.56,Other,215% New York Medicaid APG,3461.56,,,3461.56,Other,215% New York Medicaid APG,2012.53,,,2012.53,Other,125% New York Medicaid APG,1610.03,20476.5,
Ercp stent exchange w/dilate,43276,CPT,,,,,,,,both,,,37978.7,10837.95,,,10837.95,Other,150% of Medicare + 9.63% HCRA Surcharge,6590.62,,,6590.62,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,18989.35,50,,18989.35,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3272.59,,,3272.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26585.09,70,,26585.09,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1759.46,,,1759.46,Other,New York Medicaid APG methodology,1759.46,,,1759.46,Other,100% New York Medicaid APG,1759.46,,,1759.46,Other,100% New York Medicaid APG,1759.46,,,1759.46,Other,100% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,2463.24,,,2463.24,Other,140% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,4574.59,,,4574.59,Other,260% New York Medicaid APG,5700.64,,,5700.64,Other,324% New York Medicaid APG,3782.83,,,3782.83,Other,215% New York Medicaid APG,3782.83,,,3782.83,Other,215% New York Medicaid APG,2199.32,,,2199.32,Other,125% New York Medicaid APG,1759.46,26585.09,
Ercp ea duct/ampulla dilate,43277,CPT,,,,,,,,both,,,22214.78,7282.85,,,7282.85,Other,150% of Medicare + 9.63% HCRA Surcharge,4428.74,,,4428.74,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,11107.39,50,,11107.39,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3272.59,,,3272.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,15550.35,70,,15550.35,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1759.46,,,1759.46,Other,New York Medicaid APG methodology,1759.46,,,1759.46,Other,100% New York Medicaid APG,1759.46,,,1759.46,Other,100% New York Medicaid APG,1759.46,,,1759.46,Other,100% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,2463.24,,,2463.24,Other,140% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,4574.59,,,4574.59,Other,260% New York Medicaid APG,5700.64,,,5700.64,Other,324% New York Medicaid APG,3782.83,,,3782.83,Other,215% New York Medicaid APG,3782.83,,,3782.83,Other,215% New York Medicaid APG,2199.32,,,2199.32,Other,125% New York Medicaid APG,1759.46,15550.35,
Ercp lesion ablate w/dilate,43278,CPT,,,,,,,,both,,,33649.33,7282.85,,,7282.85,Other,150% of Medicare + 9.63% HCRA Surcharge,4428.74,,,4428.74,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,16824.67,50,,16824.67,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3272.59,,,3272.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23554.53,70,,23554.53,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1759.46,,,1759.46,Other,New York Medicaid APG methodology,1759.46,,,1759.46,Other,100% New York Medicaid APG,1759.46,,,1759.46,Other,100% New York Medicaid APG,1759.46,,,1759.46,Other,100% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,2463.24,,,2463.24,Other,140% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,4574.59,,,4574.59,Other,260% New York Medicaid APG,5700.64,,,5700.64,Other,324% New York Medicaid APG,3782.83,,,3782.83,Other,215% New York Medicaid APG,3782.83,,,3782.83,Other,215% New York Medicaid APG,2199.32,,,2199.32,Other,125% New York Medicaid APG,1759.46,23554.53,
Laparoscopy fundoplasty,43280,CPT,,,,,,,,both,,,68977.61,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,34488.81,50,,34488.81,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5606.88,,,5606.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,48284.33,70,,48284.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3014.45,,,3014.45,Other,New York Medicaid APG methodology,3014.45,,,3014.45,Other,100% New York Medicaid APG,3014.45,,,3014.45,Other,100% New York Medicaid APG,3014.45,,,3014.45,Other,100% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,4220.23,,,4220.23,Other,140% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,7837.58,,,7837.58,Other,260% New York Medicaid APG,9766.83,,,9766.83,Other,324% New York Medicaid APG,6481.07,,,6481.07,Other,215% New York Medicaid APG,6481.07,,,6481.07,Other,215% New York Medicaid APG,3768.07,,,3768.07,Other,125% New York Medicaid APG,3014.45,48284.33,
Lap paraesophag hern repair,43281,CPT,,,,,,,,both,,,51978.93,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,25989.47,50,,25989.47,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5175.8,,,5175.8,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36385.25,70,,36385.25,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2782.69,,,2782.69,Other,New York Medicaid APG methodology,2782.69,,,2782.69,Other,100% New York Medicaid APG,2782.69,,,2782.69,Other,100% New York Medicaid APG,2782.69,,,2782.69,Other,100% New York Medicaid APG,6261.05,,,6261.05,Other,225% New York Medicaid APG,6261.05,,,6261.05,Other,225% New York Medicaid APG,6261.05,,,6261.05,Other,225% New York Medicaid APG,6261.05,,,6261.05,Other,225% New York Medicaid APG,3895.76,,,3895.76,Other,140% New York Medicaid APG,6261.05,,,6261.05,Other,225% New York Medicaid APG,7234.99,,,7234.99,Other,260% New York Medicaid APG,9015.91,,,9015.91,Other,324% New York Medicaid APG,5982.78,,,5982.78,Other,215% New York Medicaid APG,5982.78,,,5982.78,Other,215% New York Medicaid APG,3478.36,,,3478.36,Other,125% New York Medicaid APG,2782.69,36385.25,
Lap paraesoph her rpr w/mesh,43282,CPT,,,,,,,,both,,,50030.79,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,25015.4,50,,25015.4,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5175.8,,,5175.8,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,35021.55,70,,35021.55,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2782.69,,,2782.69,Other,New York Medicaid APG methodology,2782.69,,,2782.69,Other,100% New York Medicaid APG,2782.69,,,2782.69,Other,100% New York Medicaid APG,2782.69,,,2782.69,Other,100% New York Medicaid APG,6261.05,,,6261.05,Other,225% New York Medicaid APG,6261.05,,,6261.05,Other,225% New York Medicaid APG,6261.05,,,6261.05,Other,225% New York Medicaid APG,6261.05,,,6261.05,Other,225% New York Medicaid APG,3895.76,,,3895.76,Other,140% New York Medicaid APG,6261.05,,,6261.05,Other,225% New York Medicaid APG,7234.99,,,7234.99,Other,260% New York Medicaid APG,9015.91,,,9015.91,Other,324% New York Medicaid APG,5982.78,,,5982.78,Other,215% New York Medicaid APG,5982.78,,,5982.78,Other,215% New York Medicaid APG,3478.36,,,3478.36,Other,125% New York Medicaid APG,2782.69,35021.55,
Laps esophgl sphnctr agmntj,43284,CPT,,,,,,,,both,,,216515.17,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,108257.59,50,,108257.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5606.88,,,5606.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,151560.62,70,,151560.62,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3014.45,,,3014.45,Other,New York Medicaid APG methodology,3014.45,,,3014.45,Other,100% New York Medicaid APG,3014.45,,,3014.45,Other,100% New York Medicaid APG,3014.45,,,3014.45,Other,100% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,4220.23,,,4220.23,Other,140% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,7837.58,,,7837.58,Other,260% New York Medicaid APG,9766.83,,,9766.83,Other,324% New York Medicaid APG,6481.07,,,6481.07,Other,215% New York Medicaid APG,6481.07,,,6481.07,Other,215% New York Medicaid APG,3768.07,,,3768.07,Other,125% New York Medicaid APG,3014.45,151560.62,
Rmvl esophgl sphnctr dev,43285,CPT,,,,,,,,both,,,121364.27,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,60682.14,50,,60682.14,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5606.88,,,5606.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84954.99,70,,84954.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3014.45,,,3014.45,Other,New York Medicaid APG methodology,3014.45,,,3014.45,Other,100% New York Medicaid APG,3014.45,,,3014.45,Other,100% New York Medicaid APG,3014.45,,,3014.45,Other,100% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,4220.23,,,4220.23,Other,140% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,7837.58,,,7837.58,Other,260% New York Medicaid APG,9766.83,,,9766.83,Other,324% New York Medicaid APG,6481.07,,,6481.07,Other,215% New York Medicaid APG,6481.07,,,6481.07,Other,215% New York Medicaid APG,3768.07,,,3768.07,Other,125% New York Medicaid APG,3014.45,84954.99,
Repair esophagus opening,43420,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5342.07,,,5342.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2872.08,,,2872.08,Other,New York Medicaid APG methodology,2872.08,,,2872.08,Other,100% New York Medicaid APG,2872.08,,,2872.08,Other,100% New York Medicaid APG,2872.08,,,2872.08,Other,100% New York Medicaid APG,6462.19,,,6462.19,Other,225% New York Medicaid APG,6462.19,,,6462.19,Other,225% New York Medicaid APG,6462.19,,,6462.19,Other,225% New York Medicaid APG,6462.19,,,6462.19,Other,225% New York Medicaid APG,4020.92,,,4020.92,Other,140% New York Medicaid APG,6462.19,,,6462.19,Other,225% New York Medicaid APG,7467.41,,,7467.41,Other,260% New York Medicaid APG,9305.55,,,9305.55,Other,324% New York Medicaid APG,6174.98,,,6174.98,Other,215% New York Medicaid APG,6174.98,,,6174.98,Other,215% New York Medicaid APG,3590.1,,,3590.1,Other,125% New York Medicaid APG,2872.08,47404.34,
Dilate esophagus 1/mult pass,43450,CPT,,,,,,,,both,,,19066.74,1723.81,,,1723.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.26,,,1048.26,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9533.37,50,,9533.37,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1287.38,,,1287.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13346.72,70,,13346.72,percent of total billed charges,,389.4,,,389.4,Fee Schedule,,330.4,,,330.4,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,692.14,,,692.14,Other,New York Medicaid APG methodology,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,968.99,,,968.99,Other,140% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1799.56,,,1799.56,Other,260% New York Medicaid APG,2242.53,,,2242.53,Other,324% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,865.17,,,865.17,Other,125% New York Medicaid APG,330.4,13346.72,
Dilate esophagus,43453,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1287.38,,,1287.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,420.75,,,420.75,Fee Schedule,,357,,,357,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,692.14,,,692.14,Other,New York Medicaid APG methodology,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,968.99,,,968.99,Other,140% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1799.56,,,1799.56,Other,260% New York Medicaid APG,2242.53,,,2242.53,Other,324% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,865.17,,,865.17,Other,125% New York Medicaid APG,357,28016.37,
Surgical opening of stomach,43510,CPT,,,,,,,,both,,,19066.74,1723.81,,,1723.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.26,,,1048.26,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9533.37,50,,9533.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5342.07,,,5342.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13346.72,70,,13346.72,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2872.08,,,2872.08,Other,New York Medicaid APG methodology,2872.08,,,2872.08,Other,100% New York Medicaid APG,2872.08,,,2872.08,Other,100% New York Medicaid APG,2872.08,,,2872.08,Other,100% New York Medicaid APG,6462.19,,,6462.19,Other,225% New York Medicaid APG,6462.19,,,6462.19,Other,225% New York Medicaid APG,6462.19,,,6462.19,Other,225% New York Medicaid APG,6462.19,,,6462.19,Other,225% New York Medicaid APG,4020.92,,,4020.92,Other,140% New York Medicaid APG,6462.19,,,6462.19,Other,225% New York Medicaid APG,7467.41,,,7467.41,Other,260% New York Medicaid APG,9305.55,,,9305.55,Other,324% New York Medicaid APG,6174.98,,,6174.98,Other,215% New York Medicaid APG,6174.98,,,6174.98,Other,215% New York Medicaid APG,3590.1,,,3590.1,Other,125% New York Medicaid APG,1048.26,13346.72,
Lap impl electrode antrum,43647,CPT,,,,,,,,both,,,71765.7,25904.28,,,25904.28,Other,150% of Medicare + 9.63% HCRA Surcharge,15752.55,,,15752.55,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,35882.85,50,,35882.85,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4656.12,,,4656.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50235.99,70,,50235.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,2503.29,,,2503.29,Other,New York Medicaid APG methodology,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,3504.61,,,3504.61,Other,140% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,6508.55,,,6508.55,Other,260% New York Medicaid APG,8110.66,,,8110.66,Other,324% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,3129.11,,,3129.11,Other,125% New York Medicaid APG,2503.29,50235.99,
Lap revise/remv eltrd antrum,43648,CPT,,,,,,,,both,,,38857.5,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,19428.75,50,,19428.75,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4656.12,,,4656.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27200.25,70,,27200.25,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2503.29,,,2503.29,Other,New York Medicaid APG methodology,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,3504.61,,,3504.61,Other,140% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,6508.55,,,6508.55,Other,260% New York Medicaid APG,8110.66,,,8110.66,Other,324% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,3129.11,,,3129.11,Other,125% New York Medicaid APG,2503.29,27200.25,
Laparoscopy vagus nerve,43651,CPT,,,,,,,,both,,,121364.27,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,60682.14,50,,60682.14,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4656.12,,,4656.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84954.99,70,,84954.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2503.29,,,2503.29,Other,New York Medicaid APG methodology,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,3504.61,,,3504.61,Other,140% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,6508.55,,,6508.55,Other,260% New York Medicaid APG,8110.66,,,8110.66,Other,324% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,3129.11,,,3129.11,Other,125% New York Medicaid APG,2503.29,84954.99,
Laparoscopy vagus nerve,43652,CPT,,,,,,,,both,,,121364.27,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,60682.14,50,,60682.14,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4656.12,,,4656.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84954.99,70,,84954.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2503.29,,,2503.29,Other,New York Medicaid APG methodology,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,3504.61,,,3504.61,Other,140% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,6508.55,,,6508.55,Other,260% New York Medicaid APG,8110.66,,,8110.66,Other,324% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,3129.11,,,3129.11,Other,125% New York Medicaid APG,2503.29,84954.99,
Laparoscopy gastrostomy,43653,CPT,,,,,,,,both,,,40291.87,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,20145.94,50,,20145.94,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5342.07,,,5342.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28204.31,70,,28204.31,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2872.08,,,2872.08,Other,New York Medicaid APG methodology,2872.08,,,2872.08,Other,100% New York Medicaid APG,2872.08,,,2872.08,Other,100% New York Medicaid APG,2872.08,,,2872.08,Other,100% New York Medicaid APG,6462.19,,,6462.19,Other,225% New York Medicaid APG,6462.19,,,6462.19,Other,225% New York Medicaid APG,6462.19,,,6462.19,Other,225% New York Medicaid APG,6462.19,,,6462.19,Other,225% New York Medicaid APG,4020.92,,,4020.92,Other,140% New York Medicaid APG,6462.19,,,6462.19,Other,225% New York Medicaid APG,7467.41,,,7467.41,Other,260% New York Medicaid APG,9305.55,,,9305.55,Other,324% New York Medicaid APG,6174.98,,,6174.98,Other,215% New York Medicaid APG,6174.98,,,6174.98,Other,215% New York Medicaid APG,3590.1,,,3590.1,Other,125% New York Medicaid APG,2872.08,28204.31,
Nasal/orogastric w/tube plmt,43752,CPT,,,,,,,,both,,,8380.68,757.69,,,757.69,Other,150% of Medicare + 9.63% HCRA Surcharge,460.76,,,460.76,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4190.34,50,,4190.34,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1287.38,,,1287.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5866.48,70,,5866.48,percent of total billed charges,,196.35,,,196.35,Fee Schedule,,166.6,,,166.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.14,,,692.14,Other,New York Medicaid APG methodology,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,968.99,,,968.99,Other,140% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1799.56,,,1799.56,Other,260% New York Medicaid APG,2242.53,,,2242.53,Other,324% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,865.17,,,865.17,Other,125% New York Medicaid APG,0.01,9473,
Tx gastro intub w/asp,43753,CPT,,,,,,,,both,,,6602.02,596.88,,,596.88,Other,150% of Medicare + 9.63% HCRA Surcharge,362.97,,,362.97,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3301.01,50,,3301.01,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4621.41,70,,4621.41,percent of total billed charges,,105.6,,,105.6,Fee Schedule,,89.6,,,89.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,9473,
Dx gastr intub w/asp spec,43754,CPT,,,,,,,,both,,,6602.02,596.88,,,596.88,Other,150% of Medicare + 9.63% HCRA Surcharge,362.97,,,362.97,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3301.01,50,,3301.01,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4621.41,70,,4621.41,percent of total billed charges,,184.8,,,184.8,Fee Schedule,,156.8,,,156.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,9473,
Dx gastr intub w/asp specs,43755,CPT,,,,,,,,both,,,3285.56,297.05,,,297.05,Other,150% of Medicare + 9.63% HCRA Surcharge,180.63,,,180.63,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1642.78,50,,1642.78,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1287.38,,,1287.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2299.89,70,,2299.89,percent of total billed charges,,290.4,,,290.4,Fee Schedule,,246.4,,,246.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.14,,,692.14,Other,New York Medicaid APG methodology,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,968.99,,,968.99,Other,140% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1799.56,,,1799.56,Other,260% New York Medicaid APG,2242.53,,,2242.53,Other,324% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,865.17,,,865.17,Other,125% New York Medicaid APG,180.63,9473,
Dx duod intub w/asp spec,43756,CPT,,,,,,,,both,,,19066.74,1723.81,,,1723.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.26,,,1048.26,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9533.37,50,,9533.37,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1287.38,,,1287.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13346.72,70,,13346.72,percent of total billed charges,,249.15,,,249.15,Fee Schedule,,211.4,,,211.4,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,692.14,,,692.14,Other,New York Medicaid APG methodology,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,968.99,,,968.99,Other,140% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1799.56,,,1799.56,Other,260% New York Medicaid APG,2242.53,,,2242.53,Other,324% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,865.17,,,865.17,Other,125% New York Medicaid APG,211.4,13346.72,
Dx duod intub w/asp specs,43757,CPT,,,,,,,,both,,,19066.74,1723.81,,,1723.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.26,,,1048.26,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9533.37,50,,9533.37,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1287.38,,,1287.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13346.72,70,,13346.72,percent of total billed charges,,376.2,,,376.2,Fee Schedule,,319.2,,,319.2,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,692.14,,,692.14,Other,New York Medicaid APG methodology,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,968.99,,,968.99,Other,140% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1799.56,,,1799.56,Other,260% New York Medicaid APG,2242.53,,,2242.53,Other,324% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,865.17,,,865.17,Other,125% New York Medicaid APG,319.2,13346.72,
Reposition gastrostomy tube,43761,CPT,,,,,,,,both,,,5198.43,469.99,,,469.99,Other,150% of Medicare + 9.63% HCRA Surcharge,285.8,,,285.8,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2599.22,50,,2599.22,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1287.38,,,1287.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3638.9,70,,3638.9,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.14,,,692.14,Other,New York Medicaid APG methodology,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,968.99,,,968.99,Other,140% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1799.56,,,1799.56,Other,260% New York Medicaid APG,2242.53,,,2242.53,Other,324% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,865.17,,,865.17,Other,125% New York Medicaid APG,285.8,13157,
Rplc gtube no revj trc,43762,CPT,,,,,,,,both,,,34227.74,469.99,,,469.99,Other,150% of Medicare + 9.63% HCRA Surcharge,285.8,,,285.8,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17113.87,50,,17113.87,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1287.38,,,1287.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23959.42,70,,23959.42,percent of total billed charges,,179.85,,,179.85,Fee Schedule,,152.6,,,152.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.14,,,692.14,Other,New York Medicaid APG methodology,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,968.99,,,968.99,Other,140% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1799.56,,,1799.56,Other,260% New York Medicaid APG,2242.53,,,2242.53,Other,324% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,865.17,,,865.17,Other,125% New York Medicaid APG,152.6,23959.42,
Rplc gtube revj gstrst trc,43763,CPT,,,,,,,,both,,,5198.43,469.99,,,469.99,Other,150% of Medicare + 9.63% HCRA Surcharge,285.8,,,285.8,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2599.22,50,,2599.22,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1287.38,,,1287.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3638.9,70,,3638.9,percent of total billed charges,,427.35,,,427.35,Fee Schedule,,362.6,,,362.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.14,,,692.14,Other,New York Medicaid APG methodology,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,968.99,,,968.99,Other,140% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1799.56,,,1799.56,Other,260% New York Medicaid APG,2242.53,,,2242.53,Other,324% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,865.17,,,865.17,Other,125% New York Medicaid APG,285.8,9473,
Lap place gastr adj device,43770,CPT,,,,,,,,both,,,216515.17,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,108257.59,50,,108257.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5606.88,,,5606.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,151560.62,70,,151560.62,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3014.45,,,3014.45,Other,New York Medicaid APG methodology,3014.45,,,3014.45,Other,100% New York Medicaid APG,3014.45,,,3014.45,Other,100% New York Medicaid APG,3014.45,,,3014.45,Other,100% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,4220.23,,,4220.23,Other,140% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,7837.58,,,7837.58,Other,260% New York Medicaid APG,9766.83,,,9766.83,Other,324% New York Medicaid APG,6481.07,,,6481.07,Other,215% New York Medicaid APG,6481.07,,,6481.07,Other,215% New York Medicaid APG,3768.07,,,3768.07,Other,125% New York Medicaid APG,3014.45,151560.62,
Lap rmvl gastr adj device,43772,CPT,,,,,,,,both,,,80554.09,7282.85,,,7282.85,Other,150% of Medicare + 9.63% HCRA Surcharge,4428.74,,,4428.74,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40277.05,50,,40277.05,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5606.88,,,5606.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56387.86,70,,56387.86,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3014.45,,,3014.45,Other,New York Medicaid APG methodology,3014.45,,,3014.45,Other,100% New York Medicaid APG,3014.45,,,3014.45,Other,100% New York Medicaid APG,3014.45,,,3014.45,Other,100% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,4220.23,,,4220.23,Other,140% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,7837.58,,,7837.58,Other,260% New York Medicaid APG,9766.83,,,9766.83,Other,324% New York Medicaid APG,6481.07,,,6481.07,Other,215% New York Medicaid APG,6481.07,,,6481.07,Other,215% New York Medicaid APG,3768.07,,,3768.07,Other,125% New York Medicaid APG,3014.45,56387.86,
Lap replace gastr adj device,43773,CPT,,,,,,,,both,,,121364.27,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,60682.14,50,,60682.14,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5606.88,,,5606.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84954.99,70,,84954.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3014.45,,,3014.45,Other,New York Medicaid APG methodology,3014.45,,,3014.45,Other,100% New York Medicaid APG,3014.45,,,3014.45,Other,100% New York Medicaid APG,3014.45,,,3014.45,Other,100% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,4220.23,,,4220.23,Other,140% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,7837.58,,,7837.58,Other,260% New York Medicaid APG,9766.83,,,9766.83,Other,324% New York Medicaid APG,6481.07,,,6481.07,Other,215% New York Medicaid APG,6481.07,,,6481.07,Other,215% New York Medicaid APG,3768.07,,,3768.07,Other,125% New York Medicaid APG,3014.45,84954.99,
Lap rmvl gastr adj all parts,43774,CPT,,,,,,,,both,,,43538.66,7282.85,,,7282.85,Other,150% of Medicare + 9.63% HCRA Surcharge,4428.74,,,4428.74,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,21769.33,50,,21769.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5606.88,,,5606.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,30477.06,70,,30477.06,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3014.45,,,3014.45,Other,New York Medicaid APG methodology,3014.45,,,3014.45,Other,100% New York Medicaid APG,3014.45,,,3014.45,Other,100% New York Medicaid APG,3014.45,,,3014.45,Other,100% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,4220.23,,,4220.23,Other,140% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,7837.58,,,7837.58,Other,260% New York Medicaid APG,9766.83,,,9766.83,Other,324% New York Medicaid APG,6481.07,,,6481.07,Other,215% New York Medicaid APG,6481.07,,,6481.07,Other,215% New York Medicaid APG,3768.07,,,3768.07,Other,125% New York Medicaid APG,3014.45,30477.06,
Place gastrostomy tube,43830,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4040.84,,,4040.84,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2172.49,,,2172.49,Other,New York Medicaid APG methodology,2172.49,,,2172.49,Other,100% New York Medicaid APG,2172.49,,,2172.49,Other,100% New York Medicaid APG,2172.49,,,2172.49,Other,100% New York Medicaid APG,4888.11,,,4888.11,Other,225% New York Medicaid APG,4888.11,,,4888.11,Other,225% New York Medicaid APG,4888.11,,,4888.11,Other,225% New York Medicaid APG,4888.11,,,4888.11,Other,225% New York Medicaid APG,3041.49,,,3041.49,Other,140% New York Medicaid APG,4888.11,,,4888.11,Other,225% New York Medicaid APG,5648.48,,,5648.48,Other,260% New York Medicaid APG,7038.88,,,7038.88,Other,324% New York Medicaid APG,4670.86,,,4670.86,Other,215% New York Medicaid APG,4670.86,,,4670.86,Other,215% New York Medicaid APG,2715.62,,,2715.62,Other,125% New York Medicaid APG,2172.49,28016.37,
Place gastrostomy tube,43831,CPT,,,,,,,,both,,,19066.74,1723.81,,,1723.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.26,,,1048.26,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9533.37,50,,9533.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4040.84,,,4040.84,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13346.72,70,,13346.72,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2172.49,,,2172.49,Other,New York Medicaid APG methodology,2172.49,,,2172.49,Other,100% New York Medicaid APG,2172.49,,,2172.49,Other,100% New York Medicaid APG,2172.49,,,2172.49,Other,100% New York Medicaid APG,4888.11,,,4888.11,Other,225% New York Medicaid APG,4888.11,,,4888.11,Other,225% New York Medicaid APG,4888.11,,,4888.11,Other,225% New York Medicaid APG,4888.11,,,4888.11,Other,225% New York Medicaid APG,3041.49,,,3041.49,Other,140% New York Medicaid APG,4888.11,,,4888.11,Other,225% New York Medicaid APG,5648.48,,,5648.48,Other,260% New York Medicaid APG,7038.88,,,7038.88,Other,324% New York Medicaid APG,4670.86,,,4670.86,Other,215% New York Medicaid APG,4670.86,,,4670.86,Other,215% New York Medicaid APG,2715.62,,,2715.62,Other,125% New York Medicaid APG,1048.26,13346.72,
Repair stomach opening,43870,CPT,,,,,,,,both,,,35558.33,7282.85,,,7282.85,Other,150% of Medicare + 9.63% HCRA Surcharge,4428.74,,,4428.74,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17779.17,50,,17779.17,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4040.84,,,4040.84,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24890.83,70,,24890.83,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2172.49,,,2172.49,Other,New York Medicaid APG methodology,2172.49,,,2172.49,Other,100% New York Medicaid APG,2172.49,,,2172.49,Other,100% New York Medicaid APG,2172.49,,,2172.49,Other,100% New York Medicaid APG,4888.11,,,4888.11,Other,225% New York Medicaid APG,4888.11,,,4888.11,Other,225% New York Medicaid APG,4888.11,,,4888.11,Other,225% New York Medicaid APG,4888.11,,,4888.11,Other,225% New York Medicaid APG,3041.49,,,3041.49,Other,140% New York Medicaid APG,4888.11,,,4888.11,Other,225% New York Medicaid APG,5648.48,,,5648.48,Other,260% New York Medicaid APG,7038.88,,,7038.88,Other,324% New York Medicaid APG,4670.86,,,4670.86,Other,215% New York Medicaid APG,4670.86,,,4670.86,Other,215% New York Medicaid APG,2715.62,,,2715.62,Other,125% New York Medicaid APG,2172.49,24890.83,
Revise gastric port open,43886,CPT,,,,,,,,both,,,75461.18,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,37730.59,50,,37730.59,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4040.84,,,4040.84,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52822.83,70,,52822.83,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2172.49,,,2172.49,Other,New York Medicaid APG methodology,2172.49,,,2172.49,Other,100% New York Medicaid APG,2172.49,,,2172.49,Other,100% New York Medicaid APG,2172.49,,,2172.49,Other,100% New York Medicaid APG,4888.11,,,4888.11,Other,225% New York Medicaid APG,4888.11,,,4888.11,Other,225% New York Medicaid APG,4888.11,,,4888.11,Other,225% New York Medicaid APG,4888.11,,,4888.11,Other,225% New York Medicaid APG,3041.49,,,3041.49,Other,140% New York Medicaid APG,4888.11,,,4888.11,Other,225% New York Medicaid APG,5648.48,,,5648.48,Other,260% New York Medicaid APG,7038.88,,,7038.88,Other,324% New York Medicaid APG,4670.86,,,4670.86,Other,215% New York Medicaid APG,4670.86,,,4670.86,Other,215% New York Medicaid APG,2715.62,,,2715.62,Other,125% New York Medicaid APG,2172.49,52822.83,
Remove gastric port open,43887,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4040.84,,,4040.84,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2172.49,,,2172.49,Other,New York Medicaid APG methodology,2172.49,,,2172.49,Other,100% New York Medicaid APG,2172.49,,,2172.49,Other,100% New York Medicaid APG,2172.49,,,2172.49,Other,100% New York Medicaid APG,4888.11,,,4888.11,Other,225% New York Medicaid APG,4888.11,,,4888.11,Other,225% New York Medicaid APG,4888.11,,,4888.11,Other,225% New York Medicaid APG,4888.11,,,4888.11,Other,225% New York Medicaid APG,3041.49,,,3041.49,Other,140% New York Medicaid APG,4888.11,,,4888.11,Other,225% New York Medicaid APG,5648.48,,,5648.48,Other,260% New York Medicaid APG,7038.88,,,7038.88,Other,324% New York Medicaid APG,4670.86,,,4670.86,Other,215% New York Medicaid APG,4670.86,,,4670.86,Other,215% New York Medicaid APG,2715.62,,,2715.62,Other,125% New York Medicaid APG,2108.84,26850.29,
Change gastric port open,43888,CPT,,,,,,,,both,,,75461.18,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,37730.59,50,,37730.59,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5606.88,,,5606.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52822.83,70,,52822.83,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3014.45,,,3014.45,Other,New York Medicaid APG methodology,3014.45,,,3014.45,Other,100% New York Medicaid APG,3014.45,,,3014.45,Other,100% New York Medicaid APG,3014.45,,,3014.45,Other,100% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,4220.23,,,4220.23,Other,140% New York Medicaid APG,6782.52,,,6782.52,Other,225% New York Medicaid APG,7837.58,,,7837.58,Other,260% New York Medicaid APG,9766.83,,,9766.83,Other,324% New York Medicaid APG,6481.07,,,6481.07,Other,215% New York Medicaid APG,6481.07,,,6481.07,Other,215% New York Medicaid APG,3768.07,,,3768.07,Other,125% New York Medicaid APG,3014.45,52822.83,
Biopsy of bowel,44100,CPT,,,,,,,,both,,,19066.74,1723.81,,,1723.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.26,,,1048.26,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9533.37,50,,9533.37,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13346.72,70,,13346.72,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,13346.72,
Lap enterolysis,44180,CPT,,,,,,,,both,,,36727.13,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,18363.57,50,,18363.57,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5601.44,,,5601.44,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25708.99,70,,25708.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3011.53,,,3011.53,Other,New York Medicaid APG methodology,3011.53,,,3011.53,Other,100% New York Medicaid APG,3011.53,,,3011.53,Other,100% New York Medicaid APG,3011.53,,,3011.53,Other,100% New York Medicaid APG,6775.94,,,6775.94,Other,225% New York Medicaid APG,6775.94,,,6775.94,Other,225% New York Medicaid APG,6775.94,,,6775.94,Other,225% New York Medicaid APG,6775.94,,,6775.94,Other,225% New York Medicaid APG,4216.14,,,4216.14,Other,140% New York Medicaid APG,6775.94,,,6775.94,Other,225% New York Medicaid APG,7829.98,,,7829.98,Other,260% New York Medicaid APG,9757.35,,,9757.35,Other,324% New York Medicaid APG,6474.79,,,6474.79,Other,215% New York Medicaid APG,6474.79,,,6474.79,Other,215% New York Medicaid APG,3764.41,,,3764.41,Other,125% New York Medicaid APG,3011.53,25708.99,
Lap jejunostomy,44186,CPT,,,,,,,,both,,,121364.27,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,60682.14,50,,60682.14,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5601.44,,,5601.44,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84954.99,70,,84954.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3011.53,,,3011.53,Other,New York Medicaid APG methodology,3011.53,,,3011.53,Other,100% New York Medicaid APG,3011.53,,,3011.53,Other,100% New York Medicaid APG,3011.53,,,3011.53,Other,100% New York Medicaid APG,6775.94,,,6775.94,Other,225% New York Medicaid APG,6775.94,,,6775.94,Other,225% New York Medicaid APG,6775.94,,,6775.94,Other,225% New York Medicaid APG,6775.94,,,6775.94,Other,225% New York Medicaid APG,4216.14,,,4216.14,Other,140% New York Medicaid APG,6775.94,,,6775.94,Other,225% New York Medicaid APG,7829.98,,,7829.98,Other,260% New York Medicaid APG,9757.35,,,9757.35,Other,324% New York Medicaid APG,6474.79,,,6474.79,Other,215% New York Medicaid APG,6474.79,,,6474.79,Other,215% New York Medicaid APG,3764.41,,,3764.41,Other,125% New York Medicaid APG,3011.53,84954.99,
Revision of ileostomy,44312,CPT,,,,,,,,both,,,75461.18,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,37730.59,50,,37730.59,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5125.4,,,5125.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52822.83,70,,52822.83,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2755.59,,,2755.59,Other,New York Medicaid APG methodology,2755.59,,,2755.59,Other,100% New York Medicaid APG,2755.59,,,2755.59,Other,100% New York Medicaid APG,2755.59,,,2755.59,Other,100% New York Medicaid APG,6200.08,,,6200.08,Other,225% New York Medicaid APG,6200.08,,,6200.08,Other,225% New York Medicaid APG,6200.08,,,6200.08,Other,225% New York Medicaid APG,6200.08,,,6200.08,Other,225% New York Medicaid APG,3857.83,,,3857.83,Other,140% New York Medicaid APG,6200.08,,,6200.08,Other,225% New York Medicaid APG,7164.53,,,7164.53,Other,260% New York Medicaid APG,8928.11,,,8928.11,Other,324% New York Medicaid APG,5924.52,,,5924.52,Other,215% New York Medicaid APG,5924.52,,,5924.52,Other,215% New York Medicaid APG,3444.49,,,3444.49,Other,125% New York Medicaid APG,2755.59,52822.83,
Revision of colostomy,44340,CPT,,,,,,,,both,,,75461.18,6822.4,,,6822.4,Other,150% of Medicare + 9.63% HCRA Surcharge,4148.74,,,4148.74,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,37730.59,50,,37730.59,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5125.4,,,5125.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52822.83,70,,52822.83,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2755.59,,,2755.59,Other,New York Medicaid APG methodology,2755.59,,,2755.59,Other,100% New York Medicaid APG,2755.59,,,2755.59,Other,100% New York Medicaid APG,2755.59,,,2755.59,Other,100% New York Medicaid APG,6200.08,,,6200.08,Other,225% New York Medicaid APG,6200.08,,,6200.08,Other,225% New York Medicaid APG,6200.08,,,6200.08,Other,225% New York Medicaid APG,6200.08,,,6200.08,Other,225% New York Medicaid APG,3857.83,,,3857.83,Other,140% New York Medicaid APG,6200.08,,,6200.08,Other,225% New York Medicaid APG,7164.53,,,7164.53,Other,260% New York Medicaid APG,8928.11,,,8928.11,Other,324% New York Medicaid APG,5924.52,,,5924.52,Other,215% New York Medicaid APG,5924.52,,,5924.52,Other,215% New York Medicaid APG,3444.49,,,3444.49,Other,125% New York Medicaid APG,2755.59,52822.83,
Small bowel endoscopy,44360,CPT,,,,,,,,both,,,12741.73,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,6370.87,50,,6370.87,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8919.21,70,,8919.21,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,9473,
Small bowel endoscopy/biopsy,44361,CPT,,,,,,,,both,,,18601.74,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,9300.87,50,,9300.87,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13021.22,70,,13021.22,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,13021.22,
Small bowel endoscopy,44363,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2182.57,,,2182.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1173.42,,,1173.42,Other,New York Medicaid APG methodology,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,1642.79,,,1642.79,Other,140% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,3050.9,,,3050.9,Other,260% New York Medicaid APG,3801.89,,,3801.89,Other,324% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,1466.78,,,1466.78,Other,125% New York Medicaid APG,1173.42,28016.37,
Small bowel endoscopy,44364,CPT,,,,,,,,both,,,20520,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,10260,50,,10260,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2182.57,,,2182.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,14364,70,,14364,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1173.42,,,1173.42,Other,New York Medicaid APG methodology,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,1642.79,,,1642.79,Other,140% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,3050.9,,,3050.9,Other,260% New York Medicaid APG,3801.89,,,3801.89,Other,324% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,1466.78,,,1466.78,Other,125% New York Medicaid APG,1173.42,14364,
Small bowel endoscopy,44365,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2182.57,,,2182.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1173.42,,,1173.42,Other,New York Medicaid APG methodology,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,1642.79,,,1642.79,Other,140% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,3050.9,,,3050.9,Other,260% New York Medicaid APG,3801.89,,,3801.89,Other,324% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,1466.78,,,1466.78,Other,125% New York Medicaid APG,1173.42,28016.37,
Small bowel endoscopy,44366,CPT,,,,,,,,both,,,13853.17,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,6926.59,50,,6926.59,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2182.57,,,2182.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9697.22,70,,9697.22,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1173.42,,,1173.42,Other,New York Medicaid APG methodology,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,1642.79,,,1642.79,Other,140% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,3050.9,,,3050.9,Other,260% New York Medicaid APG,3801.89,,,3801.89,Other,324% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,1466.78,,,1466.78,Other,125% New York Medicaid APG,1173.42,9697.22,
Small bowel endoscopy,44369,CPT,,,,,,,,both,,,21770.89,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,10885.45,50,,10885.45,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,15239.62,70,,15239.62,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,15239.62,
Small bowel endoscopy/stent,44370,CPT,,,,,,,,both,,,119876.35,10837.95,,,10837.95,Other,150% of Medicare + 9.63% HCRA Surcharge,6590.62,,,6590.62,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,59938.18,50,,59938.18,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2182.57,,,2182.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,83913.45,70,,83913.45,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1173.42,,,1173.42,Other,New York Medicaid APG methodology,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,1642.79,,,1642.79,Other,140% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,3050.9,,,3050.9,Other,260% New York Medicaid APG,3801.89,,,3801.89,Other,324% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,1466.78,,,1466.78,Other,125% New York Medicaid APG,1173.42,83913.45,
Small bowel endoscopy,44372,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,28016.37,
Small bowel endoscopy,44373,CPT,,,,,,,,both,,,14298,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,7149,50,,7149,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10008.6,70,,10008.6,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,10008.6,
Small bowel endoscopy,44376,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,28016.37,
Small bowel endoscopy/biopsy,44377,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1935.29,,,1935.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1040.48,,,1040.48,Other,New York Medicaid APG methodology,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,1040.48,,,1040.48,Other,100% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,1456.67,,,1456.67,Other,140% New York Medicaid APG,2341.08,,,2341.08,Other,225% New York Medicaid APG,2705.25,,,2705.25,Other,260% New York Medicaid APG,3371.15,,,3371.15,Other,324% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,2237.03,,,2237.03,Other,215% New York Medicaid APG,1300.6,,,1300.6,Other,125% New York Medicaid APG,1040.48,28016.37,
Small bowel endoscopy,44378,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2182.57,,,2182.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1173.42,,,1173.42,Other,New York Medicaid APG methodology,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,1642.79,,,1642.79,Other,140% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,3050.9,,,3050.9,Other,260% New York Medicaid APG,3801.89,,,3801.89,Other,324% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,1466.78,,,1466.78,Other,125% New York Medicaid APG,1173.42,28016.37,
S bowel endoscope w/stent,44379,CPT,,,,,,,,both,,,119876.35,10837.95,,,10837.95,Other,150% of Medicare + 9.63% HCRA Surcharge,6590.62,,,6590.62,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,59938.18,50,,59938.18,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2182.57,,,2182.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,83913.45,70,,83913.45,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1173.42,,,1173.42,Other,New York Medicaid APG methodology,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,1173.42,,,1173.42,Other,100% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,1642.79,,,1642.79,Other,140% New York Medicaid APG,2640.2,,,2640.2,Other,225% New York Medicaid APG,3050.9,,,3050.9,Other,260% New York Medicaid APG,3801.89,,,3801.89,Other,324% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,2522.86,,,2522.86,Other,215% New York Medicaid APG,1466.78,,,1466.78,Other,125% New York Medicaid APG,1173.42,83913.45,
Small bowel endoscopy br/wa,44380,CPT,,,,,,,,both,,,19066.74,1723.81,,,1723.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.26,,,1048.26,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9533.37,50,,9533.37,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13346.72,70,,13346.72,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,13346.72,
Small bowel endoscopy br/wa,44381,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,28016.37,
Small bowel endoscopy,44382,CPT,,,,,,,,both,,,14892,1723.81,,,1723.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.26,,,1048.26,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7446,50,,7446,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10424.4,70,,10424.4,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,10424.4,
Small bowel endoscopy,44384,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2087.24,,,2087.24,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1122.17,,,1122.17,Other,New York Medicaid APG methodology,1122.17,,,1122.17,Other,100% New York Medicaid APG,1122.17,,,1122.17,Other,100% New York Medicaid APG,1122.17,,,1122.17,Other,100% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,1571.04,,,1571.04,Other,140% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2917.65,,,2917.65,Other,260% New York Medicaid APG,3635.85,,,3635.85,Other,324% New York Medicaid APG,2412.68,,,2412.68,Other,215% New York Medicaid APG,2412.68,,,2412.68,Other,215% New York Medicaid APG,1402.72,,,1402.72,Other,125% New York Medicaid APG,1122.17,28016.37,
Endoscopy of bowel pouch,44385,CPT,,,,,,,,both,,,11038,1738.02,,,1738.02,Other,150% of Medicare + 9.63% HCRA Surcharge,1056.9,,,1056.9,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5519,50,,5519,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,7726.6,70,,7726.6,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,9473,
Endoscopy bowel pouch/biop,44386,CPT,,,,,,,,both,,,15400,1738.02,,,1738.02,Other,150% of Medicare + 9.63% HCRA Surcharge,1056.9,,,1056.9,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7700,50,,7700,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10780,70,,10780,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,10780,
Colonoscopy thru stoma spx,44388,CPT,,,,,,,,both,,,17317.69,1738.02,,,1738.02,Other,150% of Medicare + 9.63% HCRA Surcharge,1056.9,,,1056.9,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,8658.85,50,,8658.85,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,12122.38,70,,12122.38,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,12122.38,
Colonoscopy with biopsy,44389,CPT,,,,,,,,both,,,22258.28,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,11129.14,50,,11129.14,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,15580.8,70,,15580.8,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,15580.8,
Colonoscopy for foreign body,44390,CPT,,,,,,,,both,,,19223.92,1738.02,,,1738.02,Other,150% of Medicare + 9.63% HCRA Surcharge,1056.9,,,1056.9,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,9611.96,50,,9611.96,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13456.74,70,,13456.74,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,13456.74,
Colonoscopy for bleeding,44391,CPT,,,,,,,,both,,,24821.26,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12410.63,50,,12410.63,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17374.88,70,,17374.88,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,17374.88,
Colonoscopy & polypectomy,44392,CPT,,,,,,,,both,,,24821.26,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12410.63,50,,12410.63,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17374.88,70,,17374.88,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,17374.88,
Colonoscopy w/snare,44394,CPT,,,,,,,,both,,,23738.78,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,11869.39,50,,11869.39,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,16617.15,70,,16617.15,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,16617.15,
Colonoscopy with ablation,44401,CPT,,,,,,,,both,,,24821.26,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12410.63,50,,12410.63,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17374.88,70,,17374.88,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,17374.88,
Colonoscopy w/stent plcmt,44402,CPT,,,,,,,,both,,,119876.35,10837.95,,,10837.95,Other,150% of Medicare + 9.63% HCRA Surcharge,6590.62,,,6590.62,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,59938.18,50,,59938.18,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2087.24,,,2087.24,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,83913.45,70,,83913.45,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1122.17,,,1122.17,Other,New York Medicaid APG methodology,1122.17,,,1122.17,Other,100% New York Medicaid APG,1122.17,,,1122.17,Other,100% New York Medicaid APG,1122.17,,,1122.17,Other,100% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,1571.04,,,1571.04,Other,140% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2917.65,,,2917.65,Other,260% New York Medicaid APG,3635.85,,,3635.85,Other,324% New York Medicaid APG,2412.68,,,2412.68,Other,215% New York Medicaid APG,2412.68,,,2412.68,Other,215% New York Medicaid APG,1402.72,,,1402.72,Other,125% New York Medicaid APG,1122.17,83913.45,
Colonoscopy w/resection,44403,CPT,,,,,,,,both,,,24821.26,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12410.63,50,,12410.63,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17374.88,70,,17374.88,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,17374.88,
Colonoscopy w/injection,44404,CPT,,,,,,,,both,,,24821.26,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12410.63,50,,12410.63,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17374.88,70,,17374.88,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,17374.88,
Colonoscopy w/dilation,44405,CPT,,,,,,,,both,,,24821.26,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12410.63,50,,12410.63,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17374.88,70,,17374.88,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,17374.88,
Colonoscopy w/ultrasound,44406,CPT,,,,,,,,both,,,24821.26,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12410.63,50,,12410.63,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17374.88,70,,17374.88,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,17374.88,
Colonoscopy w/ndl aspir/bx,44407,CPT,,,,,,,,both,,,24821.26,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12410.63,50,,12410.63,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17374.88,70,,17374.88,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,17374.88,
Colonoscopy w/decompression,44408,CPT,,,,,,,,both,,,19223.92,1738.02,,,1738.02,Other,150% of Medicare + 9.63% HCRA Surcharge,1056.9,,,1056.9,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9611.96,50,,9611.96,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13456.74,70,,13456.74,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,13456.74,
Intro gastrointestinal tube,44500,CPT,,,,,,,,both,,,19066.74,1723.81,,,1723.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.26,,,1048.26,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9533.37,50,,9533.37,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1287.38,,,1287.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13346.72,70,,13346.72,percent of total billed charges,,94.05,,,94.05,Fee Schedule,,79.8,,,79.8,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,692.14,,,692.14,Other,New York Medicaid APG methodology,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,968.99,,,968.99,Other,140% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1799.56,,,1799.56,Other,260% New York Medicaid APG,2242.53,,,2242.53,Other,324% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,865.17,,,865.17,Other,125% New York Medicaid APG,79.8,13346.72,
Intraop colon lavage add-on,44701,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,5601.44,,,5601.44,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,3011.53,,,3011.53,Other,New York Medicaid APG methodology,3011.53,,,3011.53,Other,100% New York Medicaid APG,3011.53,,,3011.53,Other,100% New York Medicaid APG,3011.53,,,3011.53,Other,100% New York Medicaid APG,6775.94,,,6775.94,Other,225% New York Medicaid APG,6775.94,,,6775.94,Other,225% New York Medicaid APG,6775.94,,,6775.94,Other,225% New York Medicaid APG,6775.94,,,6775.94,Other,225% New York Medicaid APG,4216.14,,,4216.14,Other,140% New York Medicaid APG,6775.94,,,6775.94,Other,225% New York Medicaid APG,7829.98,,,7829.98,Other,260% New York Medicaid APG,9757.35,,,9757.35,Other,324% New York Medicaid APG,6474.79,,,6474.79,Other,215% New York Medicaid APG,6474.79,,,6474.79,Other,215% New York Medicaid APG,3764.41,,,3764.41,Other,125% New York Medicaid APG,0.01,22702.47,
Appendectomy,44950,CPT,,,,,,,,both,,,40609.56,14387.04,,,14387.04,Other,150% of Medicare + 9.63% HCRA Surcharge,8748.85,,,8748.85,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,20304.78,50,,20304.78,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5601.44,,,5601.44,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28426.69,70,,28426.69,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3011.53,,,3011.53,Other,New York Medicaid APG methodology,3011.53,,,3011.53,Other,100% New York Medicaid APG,3011.53,,,3011.53,Other,100% New York Medicaid APG,3011.53,,,3011.53,Other,100% New York Medicaid APG,6775.94,,,6775.94,Other,225% New York Medicaid APG,6775.94,,,6775.94,Other,225% New York Medicaid APG,6775.94,,,6775.94,Other,225% New York Medicaid APG,6775.94,,,6775.94,Other,225% New York Medicaid APG,4216.14,,,4216.14,Other,140% New York Medicaid APG,6775.94,,,6775.94,Other,225% New York Medicaid APG,7829.98,,,7829.98,Other,260% New York Medicaid APG,9757.35,,,9757.35,Other,324% New York Medicaid APG,6474.79,,,6474.79,Other,215% New York Medicaid APG,6474.79,,,6474.79,Other,215% New York Medicaid APG,3764.41,,,3764.41,Other,125% New York Medicaid APG,3011.53,28426.69,
Appendectomy add-on,44955,CPT,,,,,,,,both,,,86591.4,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,43295.7,50,,43295.7,percent of total billed charges,,60613.98,70,,60613.98,percent of total billed charges,,6152,,,6152,Case Rate,,4656.12,,,4656.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,60613.98,70,,60613.98,percent of total billed charges,,409.2,,,409.2,Fee Schedule,,347.2,,,347.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2503.29,,,2503.29,Other,New York Medicaid APG methodology,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,3504.61,,,3504.61,Other,140% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,6508.55,,,6508.55,Other,260% New York Medicaid APG,8110.66,,,8110.66,Other,324% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,3129.11,,,3129.11,Other,125% New York Medicaid APG,0.01,60613.98,
Laparoscopy appendectomy,44970,CPT,,,,,,,,both,,,44035.36,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,22017.68,50,,22017.68,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5601.44,,,5601.44,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,30824.75,70,,30824.75,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3011.53,,,3011.53,Other,New York Medicaid APG methodology,3011.53,,,3011.53,Other,100% New York Medicaid APG,3011.53,,,3011.53,Other,100% New York Medicaid APG,3011.53,,,3011.53,Other,100% New York Medicaid APG,6775.94,,,6775.94,Other,225% New York Medicaid APG,6775.94,,,6775.94,Other,225% New York Medicaid APG,6775.94,,,6775.94,Other,225% New York Medicaid APG,6775.94,,,6775.94,Other,225% New York Medicaid APG,4216.14,,,4216.14,Other,140% New York Medicaid APG,6775.94,,,6775.94,Other,225% New York Medicaid APG,7829.98,,,7829.98,Other,260% New York Medicaid APG,9757.35,,,9757.35,Other,324% New York Medicaid APG,6474.79,,,6474.79,Other,215% New York Medicaid APG,6474.79,,,6474.79,Other,215% New York Medicaid APG,3764.41,,,3764.41,Other,125% New York Medicaid APG,3011.53,30824.75,
Drainage of pelvic abscess,45000,CPT,,,,,,,,both,,,24821.26,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12410.63,50,,12410.63,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17374.88,70,,17374.88,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1364.64,17374.88,
Drainage of rectal abscess,45005,CPT,,,,,,,,both,,,24821.26,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12410.63,50,,12410.63,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17374.88,70,,17374.88,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,1364.64,17374.88,
Drainage of rectal abscess,45020,CPT,,,,,,,,both,,,59058.34,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29529.17,50,,29529.17,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41340.84,70,,41340.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1876.99,41340.84,
Biopsy of rectum,45100,CPT,,,,,,,,both,,,37185.79,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18592.9,50,,18592.9,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26030.05,70,,26030.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,1367.11,26030.05,
Removal of anorectal lesion,45108,CPT,,,,,,,,both,,,59058.34,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29529.17,50,,29529.17,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41340.84,70,,41340.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1876.99,41340.84,
Excision of rectal stricture,45150,CPT,,,,,,,,both,,,24821.26,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12410.63,50,,12410.63,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17374.88,70,,17374.88,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1364.64,17374.88,
Excision of rectal lesion,45160,CPT,,,,,,,,both,,,59058.34,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29529.17,50,,29529.17,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41340.84,70,,41340.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1876.99,41340.84,
Exc rect tum transanal part,45171,CPT,,,,,,,,both,,,35248.2,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17624.1,50,,17624.1,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24673.74,70,,24673.74,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1876.99,24673.74,
Exc rect tum transanal full,45172,CPT,,,,,,,,both,,,59058.34,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29529.17,50,,29529.17,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41340.84,70,,41340.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1876.99,41340.84,
Destruction rectal tumor,45190,CPT,,,,,,,,both,,,59058.34,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29529.17,50,,29529.17,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41340.84,70,,41340.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1876.99,41340.84,
Proctosigmoidoscopy dx,45300,CPT,,,,,,,,both,,,19223.92,1738.02,,,1738.02,Other,150% of Medicare + 9.63% HCRA Surcharge,1056.9,,,1056.9,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9611.96,50,,9611.96,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13456.74,70,,13456.74,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,13456.74,
Proctosigmoidoscopy dilate,45303,CPT,,,,,,,,both,,,24821.26,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12410.63,50,,12410.63,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2087.24,,,2087.24,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17374.88,70,,17374.88,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1122.17,,,1122.17,Other,New York Medicaid APG methodology,1122.17,,,1122.17,Other,100% New York Medicaid APG,1122.17,,,1122.17,Other,100% New York Medicaid APG,1122.17,,,1122.17,Other,100% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,1571.04,,,1571.04,Other,140% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2917.65,,,2917.65,Other,260% New York Medicaid APG,3635.85,,,3635.85,Other,324% New York Medicaid APG,2412.68,,,2412.68,Other,215% New York Medicaid APG,2412.68,,,2412.68,Other,215% New York Medicaid APG,1402.72,,,1402.72,Other,125% New York Medicaid APG,1122.17,17374.88,
Proctosigmoidoscopy w/bx,45305,CPT,,,,,,,,both,,,24821.26,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12410.63,50,,12410.63,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17374.88,70,,17374.88,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,17374.88,
Proctosigmoidoscopy fb,45307,CPT,,,,,,,,both,,,59058.34,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29529.17,50,,29529.17,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41340.84,70,,41340.84,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,41340.84,
Proctosigmoidoscopy removal,45308,CPT,,,,,,,,both,,,59058.34,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29529.17,50,,29529.17,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2087.24,,,2087.24,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41340.84,70,,41340.84,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1122.17,,,1122.17,Other,New York Medicaid APG methodology,1122.17,,,1122.17,Other,100% New York Medicaid APG,1122.17,,,1122.17,Other,100% New York Medicaid APG,1122.17,,,1122.17,Other,100% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,1571.04,,,1571.04,Other,140% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2917.65,,,2917.65,Other,260% New York Medicaid APG,3635.85,,,3635.85,Other,324% New York Medicaid APG,2412.68,,,2412.68,Other,215% New York Medicaid APG,2412.68,,,2412.68,Other,215% New York Medicaid APG,1402.72,,,1402.72,Other,125% New York Medicaid APG,1122.17,41340.84,
Proctosigmoidoscopy removal,45309,CPT,,,,,,,,both,,,24821.26,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12410.63,50,,12410.63,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17374.88,70,,17374.88,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,17374.88,
Proctosigmoidoscopy removal,45315,CPT,,,,,,,,both,,,24821.26,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12410.63,50,,12410.63,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17374.88,70,,17374.88,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,17374.88,
Proctosigmoidoscopy bleed,45317,CPT,,,,,,,,both,,,24821.26,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12410.63,50,,12410.63,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2087.24,,,2087.24,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17374.88,70,,17374.88,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1122.17,,,1122.17,Other,New York Medicaid APG methodology,1122.17,,,1122.17,Other,100% New York Medicaid APG,1122.17,,,1122.17,Other,100% New York Medicaid APG,1122.17,,,1122.17,Other,100% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,1571.04,,,1571.04,Other,140% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2917.65,,,2917.65,Other,260% New York Medicaid APG,3635.85,,,3635.85,Other,324% New York Medicaid APG,2412.68,,,2412.68,Other,215% New York Medicaid APG,2412.68,,,2412.68,Other,215% New York Medicaid APG,1402.72,,,1402.72,Other,125% New York Medicaid APG,1122.17,17374.88,
Proctosigmoidoscopy ablate,45320,CPT,,,,,,,,both,,,59058.34,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29529.17,50,,29529.17,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2087.24,,,2087.24,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41340.84,70,,41340.84,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1122.17,,,1122.17,Other,New York Medicaid APG methodology,1122.17,,,1122.17,Other,100% New York Medicaid APG,1122.17,,,1122.17,Other,100% New York Medicaid APG,1122.17,,,1122.17,Other,100% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,1571.04,,,1571.04,Other,140% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2917.65,,,2917.65,Other,260% New York Medicaid APG,3635.85,,,3635.85,Other,324% New York Medicaid APG,2412.68,,,2412.68,Other,215% New York Medicaid APG,2412.68,,,2412.68,Other,215% New York Medicaid APG,1402.72,,,1402.72,Other,125% New York Medicaid APG,1122.17,41340.84,
Proctosigmoidoscopy volvul,45321,CPT,,,,,,,,both,,,59058.34,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29529.17,50,,29529.17,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2087.24,,,2087.24,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41340.84,70,,41340.84,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1122.17,,,1122.17,Other,New York Medicaid APG methodology,1122.17,,,1122.17,Other,100% New York Medicaid APG,1122.17,,,1122.17,Other,100% New York Medicaid APG,1122.17,,,1122.17,Other,100% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,1571.04,,,1571.04,Other,140% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2917.65,,,2917.65,Other,260% New York Medicaid APG,3635.85,,,3635.85,Other,324% New York Medicaid APG,2412.68,,,2412.68,Other,215% New York Medicaid APG,2412.68,,,2412.68,Other,215% New York Medicaid APG,1402.72,,,1402.72,Other,125% New York Medicaid APG,1122.17,41340.84,
Proctosigmoidoscopy w/stent,45327,CPT,,,,,,,,both,,,119876.35,10837.95,,,10837.95,Other,150% of Medicare + 9.63% HCRA Surcharge,6590.62,,,6590.62,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,59938.18,50,,59938.18,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2087.24,,,2087.24,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,83913.45,70,,83913.45,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1122.17,,,1122.17,Other,New York Medicaid APG methodology,1122.17,,,1122.17,Other,100% New York Medicaid APG,1122.17,,,1122.17,Other,100% New York Medicaid APG,1122.17,,,1122.17,Other,100% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,1571.04,,,1571.04,Other,140% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2917.65,,,2917.65,Other,260% New York Medicaid APG,3635.85,,,3635.85,Other,324% New York Medicaid APG,2412.68,,,2412.68,Other,215% New York Medicaid APG,2412.68,,,2412.68,Other,215% New York Medicaid APG,1402.72,,,1402.72,Other,125% New York Medicaid APG,1122.17,83913.45,
Diagnostic sigmoidoscopy,45330,CPT,,,,,,,,both,,,12997.89,1738.02,,,1738.02,Other,150% of Medicare + 9.63% HCRA Surcharge,1056.9,,,1056.9,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6498.95,50,,6498.95,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9098.52,70,,9098.52,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,9473,
Sigmoidoscopy and biopsy,45331,CPT,,,,,,,,both,,,17108.6,1738.02,,,1738.02,Other,150% of Medicare + 9.63% HCRA Surcharge,1056.9,,,1056.9,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,8554.3,50,,8554.3,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,11976.02,70,,11976.02,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,11976.02,
Sigmoidoscopy w/fb removal,45332,CPT,,,,,,,,both,,,24821.26,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12410.63,50,,12410.63,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17374.88,70,,17374.88,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,17374.88,
Sigmoidoscopy & polypectomy,45333,CPT,,,,,,,,both,,,19223.92,1738.02,,,1738.02,Other,150% of Medicare + 9.63% HCRA Surcharge,1056.9,,,1056.9,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9611.96,50,,9611.96,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13456.74,70,,13456.74,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,13456.74,
Sigmoidoscopy for bleeding,45334,CPT,,,,,,,,both,,,24821.26,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12410.63,50,,12410.63,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17374.88,70,,17374.88,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,17374.88,
Sigmoidoscopy w/submuc inj,45335,CPT,,,,,,,,both,,,13730.67,1738.02,,,1738.02,Other,150% of Medicare + 9.63% HCRA Surcharge,1056.9,,,1056.9,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6865.34,50,,6865.34,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9611.47,70,,9611.47,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,9611.47,
Sigmoidoscopy & decompress,45337,CPT,,,,,,,,both,,,19223.92,1738.02,,,1738.02,Other,150% of Medicare + 9.63% HCRA Surcharge,1056.9,,,1056.9,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,9611.96,50,,9611.96,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13456.74,70,,13456.74,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,13456.74,
Sigmoidoscopy w/tumr remove,45338,CPT,,,,,,,,both,,,20445.33,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,10222.67,50,,10222.67,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,14311.73,70,,14311.73,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,14311.73,
Sig w/tndsc balloon dilation,45340,CPT,,,,,,,,both,,,20062.56,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,10031.28,50,,10031.28,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,14043.79,70,,14043.79,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,14043.79,
Sigmoidoscopy w/ultrasound,45341,CPT,,,,,,,,both,,,12269.31,1738.02,,,1738.02,Other,150% of Medicare + 9.63% HCRA Surcharge,1056.9,,,1056.9,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,6134.66,50,,6134.66,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8588.52,70,,8588.52,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,9473,
Sigmoidoscopy w/us guide bx,45342,CPT,,,,,,,,both,,,29003,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,14501.5,50,,14501.5,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,20302.1,70,,20302.1,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,20302.1,
Sigmoidoscopy w/ablation,45346,CPT,,,,,,,,both,,,11592,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,5796,50,,5796,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8114.4,70,,8114.4,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,9473,
Sigmoidoscopy w/plcmt stent,45347,CPT,,,,,,,,both,,,36950.9,10837.95,,,10837.95,Other,150% of Medicare + 9.63% HCRA Surcharge,6590.62,,,6590.62,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,18475.45,50,,18475.45,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2087.24,,,2087.24,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25865.63,70,,25865.63,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1122.17,,,1122.17,Other,New York Medicaid APG methodology,1122.17,,,1122.17,Other,100% New York Medicaid APG,1122.17,,,1122.17,Other,100% New York Medicaid APG,1122.17,,,1122.17,Other,100% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,1571.04,,,1571.04,Other,140% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2917.65,,,2917.65,Other,260% New York Medicaid APG,3635.85,,,3635.85,Other,324% New York Medicaid APG,2412.68,,,2412.68,Other,215% New York Medicaid APG,2412.68,,,2412.68,Other,215% New York Medicaid APG,1402.72,,,1402.72,Other,125% New York Medicaid APG,1122.17,25865.63,
Sigmoidoscopy w/resection,45349,CPT,,,,,,,,both,,,26478,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,13239,50,,13239,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2087.24,,,2087.24,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,18534.6,70,,18534.6,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1122.17,,,1122.17,Other,New York Medicaid APG methodology,1122.17,,,1122.17,Other,100% New York Medicaid APG,1122.17,,,1122.17,Other,100% New York Medicaid APG,1122.17,,,1122.17,Other,100% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,1571.04,,,1571.04,Other,140% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2917.65,,,2917.65,Other,260% New York Medicaid APG,3635.85,,,3635.85,Other,324% New York Medicaid APG,2412.68,,,2412.68,Other,215% New York Medicaid APG,2412.68,,,2412.68,Other,215% New York Medicaid APG,1402.72,,,1402.72,Other,125% New York Medicaid APG,1122.17,18534.6,
Sgmdsc w/band ligation,45350,CPT,,,,,,,,both,,,21132,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,10566,50,,10566,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,14792.4,70,,14792.4,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,14792.4,
Diagnostic colonoscopy,45378,CPT,,,,,,,,both,,,18300.47,1738.02,,,1738.02,Other,150% of Medicare + 9.63% HCRA Surcharge,1056.9,,,1056.9,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9150.24,50,,9150.24,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,12810.33,70,,12810.33,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,12810.33,
Colonoscopy w/fb removal,45379,CPT,,,,,,,,both,,,15782.42,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,7891.21,50,,7891.21,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,11047.69,70,,11047.69,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,11047.69,
Colonoscopy and biopsy,45380,CPT,,,,,,,,both,,,25392.05,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12696.03,50,,12696.03,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17774.44,70,,17774.44,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,17774.44,
Colonoscopy submucous njx,45381,CPT,,,,,,,,both,,,30844.27,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,15422.14,50,,15422.14,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,21590.99,70,,21590.99,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,21590.99,
Colonoscopy w/control bleed,45382,CPT,,,,,,,,both,,,12868.66,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,6434.33,50,,6434.33,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9008.06,70,,9008.06,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,9473,
Colonoscopy w/lesion removal,45384,CPT,,,,,,,,both,,,17656,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,8828,50,,8828,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,12359.2,70,,12359.2,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,12359.2,
Colonoscopy w/lesion removal,45385,CPT,,,,,,,,both,,,23753.5,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,11876.75,50,,11876.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,16627.45,70,,16627.45,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,16627.45,
Colonoscopy w/balloon dilat,45386,CPT,,,,,,,,both,,,32175.67,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16087.84,50,,16087.84,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22522.97,70,,22522.97,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,22522.97,
Colonoscopy w/ablation,45388,CPT,,,,,,,,both,,,24635.95,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12317.98,50,,12317.98,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17245.17,70,,17245.17,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,17245.17,
Colonoscopy w/stent plcmt,45389,CPT,,,,,,,,both,,,119876.35,10837.95,,,10837.95,Other,150% of Medicare + 9.63% HCRA Surcharge,6590.62,,,6590.62,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,59938.18,50,,59938.18,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2087.24,,,2087.24,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,83913.45,70,,83913.45,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1122.17,,,1122.17,Other,New York Medicaid APG methodology,1122.17,,,1122.17,Other,100% New York Medicaid APG,1122.17,,,1122.17,Other,100% New York Medicaid APG,1122.17,,,1122.17,Other,100% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,1571.04,,,1571.04,Other,140% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2917.65,,,2917.65,Other,260% New York Medicaid APG,3635.85,,,3635.85,Other,324% New York Medicaid APG,2412.68,,,2412.68,Other,215% New York Medicaid APG,2412.68,,,2412.68,Other,215% New York Medicaid APG,1402.72,,,1402.72,Other,125% New York Medicaid APG,1122.17,83913.45,
Colonoscopy w/resection,45390,CPT,,,,,,,,both,,,32260.86,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16130.43,50,,16130.43,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2087.24,,,2087.24,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22582.6,70,,22582.6,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1122.17,,,1122.17,Other,New York Medicaid APG methodology,1122.17,,,1122.17,Other,100% New York Medicaid APG,1122.17,,,1122.17,Other,100% New York Medicaid APG,1122.17,,,1122.17,Other,100% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,1571.04,,,1571.04,Other,140% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2917.65,,,2917.65,Other,260% New York Medicaid APG,3635.85,,,3635.85,Other,324% New York Medicaid APG,2412.68,,,2412.68,Other,215% New York Medicaid APG,2412.68,,,2412.68,Other,215% New York Medicaid APG,1402.72,,,1402.72,Other,125% New York Medicaid APG,1122.17,22582.6,
Colonoscopy w/endoscope us,45391,CPT,,,,,,,,both,,,14789.75,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,7394.88,50,,7394.88,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10352.83,70,,10352.83,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,10352.83,
Colonoscopy w/endoscopic fnb,45392,CPT,,,,,,,,both,,,25125,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12562.5,50,,12562.5,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2087.24,,,2087.24,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17587.5,70,,17587.5,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1122.17,,,1122.17,Other,New York Medicaid APG methodology,1122.17,,,1122.17,Other,100% New York Medicaid APG,1122.17,,,1122.17,Other,100% New York Medicaid APG,1122.17,,,1122.17,Other,100% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,1571.04,,,1571.04,Other,140% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2917.65,,,2917.65,Other,260% New York Medicaid APG,3635.85,,,3635.85,Other,324% New York Medicaid APG,2412.68,,,2412.68,Other,215% New York Medicaid APG,2412.68,,,2412.68,Other,215% New York Medicaid APG,1402.72,,,1402.72,Other,125% New York Medicaid APG,1122.17,17587.5,
Colonoscopy w/decompression,45393,CPT,,,,,,,,both,,,24821.26,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12410.63,50,,12410.63,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17374.88,70,,17374.88,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,17374.88,
Colonoscopy w/band ligation,45398,CPT,,,,,,,,both,,,20872.6,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,10436.3,50,,10436.3,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,14610.82,70,,14610.82,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,14610.82,
Repair of rectum,45500,CPT,,,,,,,,both,,,59058.34,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29529.17,50,,29529.17,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41340.84,70,,41340.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1876.99,41340.84,
Repair of rectum,45505,CPT,,,,,,,,both,,,34496.71,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17248.36,50,,17248.36,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24147.7,70,,24147.7,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1876.99,24147.7,
Treatment of rectal prolapse,45520,CPT,,,,,,,,both,,,19223.92,1738.02,,,1738.02,Other,150% of Medicare + 9.63% HCRA Surcharge,1056.9,,,1056.9,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9611.96,50,,9611.96,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13456.74,70,,13456.74,percent of total billed charges,,198,,,198,Fee Schedule,,168,,,168,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,0.01,13456.74,
Correct rectal prolapse,45541,CPT,,,,,,,,both,,,59058.34,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29529.17,50,,29529.17,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41340.84,70,,41340.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1876.99,41340.84,
Repair of rectocele,45560,CPT,,,,,,,,both,,,59058.34,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29529.17,50,,29529.17,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41340.84,70,,41340.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1876.99,41340.84,
Reduction of rectal prolapse,45900,CPT,,,,,,,,both,,,19223.92,1738.02,,,1738.02,Other,150% of Medicare + 9.63% HCRA Surcharge,1056.9,,,1056.9,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9611.96,50,,9611.96,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13456.74,70,,13456.74,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,1056.9,13456.74,
Dilation of anal sphincter,45905,CPT,,,,,,,,both,,,34516.73,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17258.37,50,,17258.37,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24161.71,70,,24161.71,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,1364.64,24161.71,
Dilation of rectal narrowing,45910,CPT,,,,,,,,both,,,19172.43,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,9586.22,50,,9586.22,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13420.7,70,,13420.7,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,1364.64,13420.7,
Remove rectal obstruction,45915,CPT,,,,,,,,both,,,24821.26,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12410.63,50,,12410.63,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17374.88,70,,17374.88,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,1364.64,17374.88,
Surg dx exam anorectal,45990,CPT,,,,,,,,both,,,34896.01,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17448.01,50,,17448.01,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24427.21,70,,24427.21,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,1367.11,24427.21,
Placement of seton,46020,CPT,,,,,,,,both,,,36040.94,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18020.47,50,,18020.47,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25228.66,70,,25228.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,1367.11,25228.66,
Removal of rectal marker,46030,CPT,,,,,,,,both,,,24821.26,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12410.63,50,,12410.63,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17374.88,70,,17374.88,percent of total billed charges,,427.35,,,427.35,Fee Schedule,,362.6,,,362.6,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,362.6,17374.88,
Incision of rectal abscess,46040,CPT,,,,,,,,both,,,33065.33,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16532.67,50,,16532.67,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23145.73,70,,23145.73,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,1364.64,23145.73,
Incision of rectal abscess,46045,CPT,,,,,,,,both,,,59058.34,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29529.17,50,,29529.17,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41340.84,70,,41340.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1876.99,41340.84,
Incision of anal abscess,46050,CPT,,,,,,,,both,,,19223.92,1738.02,,,1738.02,Other,150% of Medicare + 9.63% HCRA Surcharge,1056.9,,,1056.9,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9611.96,50,,9611.96,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13456.74,70,,13456.74,percent of total billed charges,,501.6,,,501.6,Fee Schedule,,425.6,,,425.6,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,425.6,13456.74,
Incision of rectal abscess,46060,CPT,,,,,,,,both,,,59058.34,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29529.17,50,,29529.17,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41340.84,70,,41340.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1876.99,41340.84,
Incision of anal septum,46070,CPT,,,,,,,,both,,,59058.34,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29529.17,50,,29529.17,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41340.84,70,,41340.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,1367.11,41340.84,
Incision of anal sphincter,46080,CPT,,,,,,,,both,,,34783.06,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17391.53,50,,17391.53,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24348.14,70,,24348.14,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,1367.11,24348.14,
Incise external hemorrhoid,46083,CPT,,,,,,,,both,,,5198.43,469.99,,,469.99,Other,150% of Medicare + 9.63% HCRA Surcharge,285.8,,,285.8,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2599.22,50,,2599.22,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3638.9,70,,3638.9,percent of total billed charges,,542.85,,,542.85,Fee Schedule,,460.6,,,460.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,285.8,9473,
Removal of anal fissure,46200,CPT,,,,,,,,both,,,36254.69,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18127.35,50,,18127.35,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25378.28,70,,25378.28,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,1367.11,25378.28,
Excise anal ext tag/papilla,46220,CPT,,,,,,,,both,,,24821.26,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12410.63,50,,12410.63,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17374.88,70,,17374.88,percent of total billed charges,,600.6,,,600.6,Fee Schedule,,509.6,,,509.6,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,509.6,17374.88,
Ligation of hemorrhoid(s),46221,CPT,,,,,,,,both,,,19223.92,1738.02,,,1738.02,Other,150% of Medicare + 9.63% HCRA Surcharge,1056.9,,,1056.9,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9611.96,50,,9611.96,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13456.74,70,,13456.74,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,1056.9,13456.74,
Removal of anal tags,46230,CPT,,,,,,,,both,,,34206.69,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17103.35,50,,17103.35,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23944.68,70,,23944.68,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,1367.11,23944.68,
Remove ext hem groups 2+,46250,CPT,,,,,,,,both,,,36111.37,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18055.69,50,,18055.69,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25277.96,70,,25277.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1876.99,25277.96,
Remove int/ext hem 1 group,46255,CPT,,,,,,,,both,,,30279.6,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,15139.8,50,,15139.8,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,21195.72,70,,21195.72,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1876.99,21195.72,
Remove in/ex hem grp & fiss,46257,CPT,,,,,,,,both,,,59058.34,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29529.17,50,,29529.17,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41340.84,70,,41340.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1876.99,41340.84,
Remove in/ex hem grp w/fistu,46258,CPT,,,,,,,,both,,,59058.34,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29529.17,50,,29529.17,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41340.84,70,,41340.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1876.99,41340.84,
Remove in/ex hem groups 2+,46260,CPT,,,,,,,,both,,,37527.47,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18763.74,50,,18763.74,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26269.23,70,,26269.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1876.99,26269.23,
Remove in/ex hem grps & fiss,46261,CPT,,,,,,,,both,,,38923.23,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19461.62,50,,19461.62,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27246.26,70,,27246.26,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1876.99,27246.26,
Remove in/ex hem grps w/fist,46262,CPT,,,,,,,,both,,,59058.34,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29529.17,50,,29529.17,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41340.84,70,,41340.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1876.99,41340.84,
Remove anal fist subq,46270,CPT,,,,,,,,both,,,34672.13,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17336.07,50,,17336.07,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24270.49,70,,24270.49,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1876.99,24270.49,
Remove anal fist inter,46275,CPT,,,,,,,,both,,,35748.17,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17874.09,50,,17874.09,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25023.72,70,,25023.72,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1876.99,25023.72,
Remove anal fist complex,46280,CPT,,,,,,,,both,,,36371.95,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18185.98,50,,18185.98,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25460.37,70,,25460.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1876.99,25460.37,
Remove anal fist 2 stage,46285,CPT,,,,,,,,both,,,32112.66,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16056.33,50,,16056.33,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22478.86,70,,22478.86,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,1367.11,22478.86,
Repair anal fistula,46288,CPT,,,,,,,,both,,,35532.32,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17766.16,50,,17766.16,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24872.62,70,,24872.62,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1876.99,24872.62,
Removal of hemorrhoid clot,46320,CPT,,,,,,,,both,,,34261.11,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17130.56,50,,17130.56,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23982.78,70,,23982.78,percent of total billed charges,,557.7,,,557.7,Fee Schedule,,473.2,,,473.2,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,473.2,23982.78,
Injection into hemorrhoid(s),46500,CPT,,,,,,,,both,,,19223.92,1738.02,,,1738.02,Other,150% of Medicare + 9.63% HCRA Surcharge,1056.9,,,1056.9,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9611.96,50,,9611.96,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13456.74,70,,13456.74,percent of total billed charges,,915.75,,,915.75,Fee Schedule,,777,,,777,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,777,13456.74,
Chemodenervation anal musc,46505,CPT,,,,,,,,both,,,25418.06,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12709.03,50,,12709.03,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17792.64,70,,17792.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,1364.64,17792.64,
Diagnostic anoscopy spx,46600,CPT,,,,,,,,both,,,38102.91,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,19051.46,50,,19051.46,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1287.38,,,1287.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26672.04,70,,26672.04,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.14,,,692.14,Other,New York Medicaid APG methodology,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,968.99,,,968.99,Other,140% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1799.56,,,1799.56,Other,260% New York Medicaid APG,2242.53,,,2242.53,Other,324% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,865.17,,,865.17,Other,125% New York Medicaid APG,0.01,26672.04,
Diagnostic anoscopy,46601,CPT,,,,,,,,both,,,2686.86,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1343.43,50,,1343.43,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1287.38,,,1287.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,1880.8,70,,1880.8,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,692.14,,,692.14,Other,New York Medicaid APG methodology,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,968.99,,,968.99,Other,140% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1799.56,,,1799.56,Other,260% New York Medicaid APG,2242.53,,,2242.53,Other,324% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,865.17,,,865.17,Other,125% New York Medicaid APG,147.72,9473,
Anoscopy and dilation,46604,CPT,,,,,,,,both,,,24821.26,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12410.63,50,,12410.63,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17374.88,70,,17374.88,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,17374.88,
Anoscopy and biopsy,46606,CPT,,,,,,,,both,,,42463.29,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21231.65,50,,21231.65,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29724.3,70,,29724.3,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,29724.3,
Diagnostic anoscopy & biopsy,46607,CPT,,,,,,,,both,,,24821.26,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12410.63,50,,12410.63,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17374.88,70,,17374.88,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,17374.88,
Anoscopy remove for body,46608,CPT,,,,,,,,both,,,19223.92,1738.02,,,1738.02,Other,150% of Medicare + 9.63% HCRA Surcharge,1056.9,,,1056.9,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9611.96,50,,9611.96,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13456.74,70,,13456.74,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,13456.74,
Anoscopy remove lesion,46610,CPT,,,,,,,,both,,,59058.34,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29529.17,50,,29529.17,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2087.24,,,2087.24,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41340.84,70,,41340.84,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1122.17,,,1122.17,Other,New York Medicaid APG methodology,1122.17,,,1122.17,Other,100% New York Medicaid APG,1122.17,,,1122.17,Other,100% New York Medicaid APG,1122.17,,,1122.17,Other,100% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,1571.04,,,1571.04,Other,140% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2917.65,,,2917.65,Other,260% New York Medicaid APG,3635.85,,,3635.85,Other,324% New York Medicaid APG,2412.68,,,2412.68,Other,215% New York Medicaid APG,2412.68,,,2412.68,Other,215% New York Medicaid APG,1402.72,,,1402.72,Other,125% New York Medicaid APG,1122.17,41340.84,
Anoscopy,46611,CPT,,,,,,,,both,,,19223.92,1738.02,,,1738.02,Other,150% of Medicare + 9.63% HCRA Surcharge,1056.9,,,1056.9,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9611.96,50,,9611.96,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13456.74,70,,13456.74,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,13456.74,
Anoscopy remove lesions,46612,CPT,,,,,,,,both,,,59058.34,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29529.17,50,,29529.17,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2087.24,,,2087.24,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41340.84,70,,41340.84,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1122.17,,,1122.17,Other,New York Medicaid APG methodology,1122.17,,,1122.17,Other,100% New York Medicaid APG,1122.17,,,1122.17,Other,100% New York Medicaid APG,1122.17,,,1122.17,Other,100% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,1571.04,,,1571.04,Other,140% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2917.65,,,2917.65,Other,260% New York Medicaid APG,3635.85,,,3635.85,Other,324% New York Medicaid APG,2412.68,,,2412.68,Other,215% New York Medicaid APG,2412.68,,,2412.68,Other,215% New York Medicaid APG,1402.72,,,1402.72,Other,125% New York Medicaid APG,1122.17,41340.84,
Anoscopy control bleeding,46614,CPT,,,,,,,,both,,,25806,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12903,50,,12903,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,18064.2,70,,18064.2,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1004.06,18064.2,
Anoscopy,46615,CPT,,,,,,,,both,,,33680.29,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16840.15,50,,16840.15,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2087.24,,,2087.24,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23576.2,70,,23576.2,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1122.17,,,1122.17,Other,New York Medicaid APG methodology,1122.17,,,1122.17,Other,100% New York Medicaid APG,1122.17,,,1122.17,Other,100% New York Medicaid APG,1122.17,,,1122.17,Other,100% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,1571.04,,,1571.04,Other,140% New York Medicaid APG,2524.89,,,2524.89,Other,225% New York Medicaid APG,2917.65,,,2917.65,Other,260% New York Medicaid APG,3635.85,,,3635.85,Other,324% New York Medicaid APG,2412.68,,,2412.68,Other,215% New York Medicaid APG,2412.68,,,2412.68,Other,215% New York Medicaid APG,1402.72,,,1402.72,Other,125% New York Medicaid APG,1122.17,23576.2,
Repair of anal stricture,46700,CPT,,,,,,,,both,,,59058.34,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29529.17,50,,29529.17,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41340.84,70,,41340.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1876.99,41340.84,
Repr of anal fistula w/glue,46706,CPT,,,,,,,,both,,,59058.34,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29529.17,50,,29529.17,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41340.84,70,,41340.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,1367.11,41340.84,
Repair anorectal fist w/plug,46707,CPT,,,,,,,,both,,,59058.34,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29529.17,50,,29529.17,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41340.84,70,,41340.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,1367.11,41340.84,
Repair of anal sphincter,46750,CPT,,,,,,,,both,,,59058.34,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29529.17,50,,29529.17,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41340.84,70,,41340.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1876.99,41340.84,
Reconstruction of anus,46753,CPT,,,,,,,,both,,,59058.34,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29529.17,50,,29529.17,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41340.84,70,,41340.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1876.99,41340.84,
Removal of suture from anus,46754,CPT,,,,,,,,both,,,59058.34,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29529.17,50,,29529.17,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41340.84,70,,41340.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,1367.11,41340.84,
Repair of anal sphincter,46760,CPT,,,,,,,,both,,,59058.34,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29529.17,50,,29529.17,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41340.84,70,,41340.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1876.99,41340.84,
Repair of anal sphincter,46761,CPT,,,,,,,,both,,,59058.34,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29529.17,50,,29529.17,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41340.84,70,,41340.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1876.99,41340.84,
Destruction anal lesion(s),46900,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,461.11,13157,
Destruction anal lesion(s),46910,CPT,,,,,,,,both,,,38456.29,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19228.15,50,,19228.15,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26919.4,70,,26919.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,1367.11,26919.4,
Cryosurgery anal lesion(s),46916,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,0.01,13157,
Laser surgery anal lesions,46917,CPT,,,,,,,,both,,,44593.69,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,22296.85,50,,22296.85,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31215.58,70,,31215.58,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,1367.11,31215.58,
Excision of anal lesion(s),46922,CPT,,,,,,,,both,,,35119.53,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17559.77,50,,17559.77,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24583.67,70,,24583.67,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,1367.11,24583.67,
Destruction anal lesion(s),46924,CPT,,,,,,,,both,,,40608.23,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20304.12,50,,20304.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28425.76,70,,28425.76,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,1367.11,28425.76,
Destroy internal hemorrhoids,46930,CPT,,,,,,,,both,,,24821.26,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12410.63,50,,12410.63,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17374.88,70,,17374.88,percent of total billed charges,,749.1,,,749.1,Fee Schedule,,635.6,,,635.6,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,635.6,17374.88,
Treatment of anal fissure,46940,CPT,,,,,,,,both,,,59058.34,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29529.17,50,,29529.17,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41340.84,70,,41340.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,1367.11,41340.84,
Treatment of anal fissure,46942,CPT,,,,,,,,both,,,19223.92,1738.02,,,1738.02,Other,150% of Medicare + 9.63% HCRA Surcharge,1056.9,,,1056.9,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9611.96,50,,9611.96,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13456.74,70,,13456.74,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,1056.9,13456.74,
Int hrhc lig 1 hroid w/o img,46945,CPT,,,,,,,,both,,,31715.04,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,15857.52,50,,15857.52,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22200.53,70,,22200.53,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,1367.11,22200.53,
Int hrhc lig 2+hroid w/o img,46946,CPT,,,,,,,,both,,,34725.26,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17362.63,50,,17362.63,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24307.68,70,,24307.68,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,1367.11,24307.68,
Hemorrhoidopexy by stapling,46947,CPT,,,,,,,,both,,,59058.34,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29529.17,50,,29529.17,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41340.84,70,,41340.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1876.99,41340.84,
Int hrhc tranal dartlzj 2+,46948,CPT,,,,,,,,both,,,39511.68,5339.43,,,5339.43,Other,150% of Medicare + 9.63% HCRA Surcharge,3246.94,,,3246.94,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19755.84,50,,19755.84,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27658.18,70,,27658.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1876.99,27658.18,
Needle biopsy of liver,47000,CPT,,,,,,,,both,,,29488.87,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,14744.44,50,,14744.44,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1502.62,,,1502.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,20642.21,70,,20642.21,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1131.01,,,1131.01,Other,140% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,2100.44,,,2100.44,Other,260% New York Medicaid APG,2617.47,,,2617.47,Other,324% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1009.83,,,1009.83,Other,125% New York Medicaid APG,807.86,20642.21,
Needle biopsy liver add-on,47001,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1502.62,,,1502.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1131.01,,,1131.01,Other,140% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,2100.44,,,2100.44,Other,260% New York Medicaid APG,2617.47,,,2617.47,Other,324% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1009.83,,,1009.83,Other,125% New York Medicaid APG,0.01,22702.47,
Laparo ablate liver tumor rf,47370,CPT,,,,,,,,both,,,216515.17,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,108257.59,50,,108257.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5117.96,,,5117.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,151560.62,70,,151560.62,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,2751.59,,,2751.59,Other,New York Medicaid APG methodology,2751.59,,,2751.59,Other,100% New York Medicaid APG,2751.59,,,2751.59,Other,100% New York Medicaid APG,2751.59,,,2751.59,Other,100% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,3852.23,,,3852.23,Other,140% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,7154.14,,,7154.14,Other,260% New York Medicaid APG,8915.16,,,8915.16,Other,324% New York Medicaid APG,5915.92,,,5915.92,Other,215% New York Medicaid APG,5915.92,,,5915.92,Other,215% New York Medicaid APG,3439.49,,,3439.49,Other,125% New York Medicaid APG,2751.59,151560.62,
Laparo ablate liver cryosurg,47371,CPT,,,,,,,,both,,,216515.17,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,108257.59,50,,108257.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5117.96,,,5117.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,151560.62,70,,151560.62,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,2751.59,,,2751.59,Other,New York Medicaid APG methodology,2751.59,,,2751.59,Other,100% New York Medicaid APG,2751.59,,,2751.59,Other,100% New York Medicaid APG,2751.59,,,2751.59,Other,100% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,3852.23,,,3852.23,Other,140% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,7154.14,,,7154.14,Other,260% New York Medicaid APG,8915.16,,,8915.16,Other,324% New York Medicaid APG,5915.92,,,5915.92,Other,215% New York Medicaid APG,5915.92,,,5915.92,Other,215% New York Medicaid APG,3439.49,,,3439.49,Other,125% New York Medicaid APG,2751.59,151560.62,
Percut ablate liver rf,47382,CPT,,,,,,,,both,,,49249.91,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,24624.96,50,,24624.96,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5117.96,,,5117.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34474.94,70,,34474.94,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2751.59,,,2751.59,Other,New York Medicaid APG methodology,2751.59,,,2751.59,Other,100% New York Medicaid APG,2751.59,,,2751.59,Other,100% New York Medicaid APG,2751.59,,,2751.59,Other,100% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,3852.23,,,3852.23,Other,140% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,7154.14,,,7154.14,Other,260% New York Medicaid APG,8915.16,,,8915.16,Other,324% New York Medicaid APG,5915.92,,,5915.92,Other,215% New York Medicaid APG,5915.92,,,5915.92,Other,215% New York Medicaid APG,3439.49,,,3439.49,Other,125% New York Medicaid APG,2751.59,34474.94,
Perq abltj lvr cryoablation,47383,CPT,,,,,,,,both,,,216515.17,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,15382,,"100% primary, 50% supplemental procedure",15382,Other,Aetna ASC Grouper,13844,,"100% primary, 50% supplemental procedure",13844,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,108257.59,50,,108257.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5117.96,,,5117.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,151560.62,70,,151560.62,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2751.59,,,2751.59,Other,New York Medicaid APG methodology,2751.59,,,2751.59,Other,100% New York Medicaid APG,2751.59,,,2751.59,Other,100% New York Medicaid APG,2751.59,,,2751.59,Other,100% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,3852.23,,,3852.23,Other,140% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,7154.14,,,7154.14,Other,260% New York Medicaid APG,8915.16,,,8915.16,Other,324% New York Medicaid APG,5915.92,,,5915.92,Other,215% New York Medicaid APG,5915.92,,,5915.92,Other,215% New York Medicaid APG,3439.49,,,3439.49,Other,125% New York Medicaid APG,2751.59,151560.62,
Incision of gallbladder,47490,CPT,,,,,,,,both,,,72769.69,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36384.85,50,,36384.85,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3304.99,,,3304.99,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50938.78,70,,50938.78,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1776.88,,,1776.88,Other,New York Medicaid APG methodology,1776.88,,,1776.88,Other,100% New York Medicaid APG,1776.88,,,1776.88,Other,100% New York Medicaid APG,1776.88,,,1776.88,Other,100% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,2487.63,,,2487.63,Other,140% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,4619.88,,,4619.88,Other,260% New York Medicaid APG,5757.08,,,5757.08,Other,324% New York Medicaid APG,3820.28,,,3820.28,Other,215% New York Medicaid APG,3820.28,,,3820.28,Other,215% New York Medicaid APG,2221.1,,,2221.1,Other,125% New York Medicaid APG,1776.88,50938.78,
Injection for cholangiogram,47531,CPT,,,,,,,,both,,,17151.17,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,8575.59,50,,8575.59,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,972.26,,,972.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,12005.82,70,,12005.82,percent of total billed charges,,338.25,,,338.25,Fee Schedule,,287,,,287,Fee Schedule,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,522.72,,,522.72,Other,New York Medicaid APG methodology,522.72,,,522.72,Other,100% New York Medicaid APG,522.72,,,522.72,Other,100% New York Medicaid APG,522.72,,,522.72,Other,100% New York Medicaid APG,1176.12,,,1176.12,Other,225% New York Medicaid APG,1176.12,,,1176.12,Other,225% New York Medicaid APG,1176.12,,,1176.12,Other,225% New York Medicaid APG,1176.12,,,1176.12,Other,225% New York Medicaid APG,731.81,,,731.81,Other,140% New York Medicaid APG,1176.12,,,1176.12,Other,225% New York Medicaid APG,1359.07,,,1359.07,Other,260% New York Medicaid APG,1693.61,,,1693.61,Other,324% New York Medicaid APG,1123.85,,,1123.85,Other,215% New York Medicaid APG,1123.85,,,1123.85,Other,215% New York Medicaid APG,653.4,,,653.4,Other,125% New York Medicaid APG,287,12005.82,
Injection for cholangiogram,47532,CPT,,,,,,,,both,,,72769.69,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36384.85,50,,36384.85,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,972.26,,,972.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50938.78,70,,50938.78,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,522.72,,,522.72,Other,New York Medicaid APG methodology,522.72,,,522.72,Other,100% New York Medicaid APG,522.72,,,522.72,Other,100% New York Medicaid APG,522.72,,,522.72,Other,100% New York Medicaid APG,1176.12,,,1176.12,Other,225% New York Medicaid APG,1176.12,,,1176.12,Other,225% New York Medicaid APG,1176.12,,,1176.12,Other,225% New York Medicaid APG,1176.12,,,1176.12,Other,225% New York Medicaid APG,731.81,,,731.81,Other,140% New York Medicaid APG,1176.12,,,1176.12,Other,225% New York Medicaid APG,1359.07,,,1359.07,Other,260% New York Medicaid APG,1693.61,,,1693.61,Other,324% New York Medicaid APG,1123.85,,,1123.85,Other,215% New York Medicaid APG,1123.85,,,1123.85,Other,215% New York Medicaid APG,653.4,,,653.4,Other,125% New York Medicaid APG,522.72,50938.78,
Plmt biliary drainage cath,47533,CPT,,,,,,,,both,,,72769.69,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36384.85,50,,36384.85,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3304.99,,,3304.99,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50938.78,70,,50938.78,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1776.88,,,1776.88,Other,New York Medicaid APG methodology,1776.88,,,1776.88,Other,100% New York Medicaid APG,1776.88,,,1776.88,Other,100% New York Medicaid APG,1776.88,,,1776.88,Other,100% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,2487.63,,,2487.63,Other,140% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,4619.88,,,4619.88,Other,260% New York Medicaid APG,5757.08,,,5757.08,Other,324% New York Medicaid APG,3820.28,,,3820.28,Other,215% New York Medicaid APG,3820.28,,,3820.28,Other,215% New York Medicaid APG,2221.1,,,2221.1,Other,125% New York Medicaid APG,1776.88,50938.78,
Plmt biliary drainage cath,47534,CPT,,,,,,,,both,,,45203,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,22601.5,50,,22601.5,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3304.99,,,3304.99,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31642.1,70,,31642.1,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1776.88,,,1776.88,Other,New York Medicaid APG methodology,1776.88,,,1776.88,Other,100% New York Medicaid APG,1776.88,,,1776.88,Other,100% New York Medicaid APG,1776.88,,,1776.88,Other,100% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,2487.63,,,2487.63,Other,140% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,4619.88,,,4619.88,Other,260% New York Medicaid APG,5757.08,,,5757.08,Other,324% New York Medicaid APG,3820.28,,,3820.28,Other,215% New York Medicaid APG,3820.28,,,3820.28,Other,215% New York Medicaid APG,2221.1,,,2221.1,Other,125% New York Medicaid APG,1776.88,31642.1,
Conversion ext bil drg cath,47535,CPT,,,,,,,,both,,,72769.69,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36384.85,50,,36384.85,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3304.99,,,3304.99,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50938.78,70,,50938.78,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1776.88,,,1776.88,Other,New York Medicaid APG methodology,1776.88,,,1776.88,Other,100% New York Medicaid APG,1776.88,,,1776.88,Other,100% New York Medicaid APG,1776.88,,,1776.88,Other,100% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,2487.63,,,2487.63,Other,140% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,4619.88,,,4619.88,Other,260% New York Medicaid APG,5757.08,,,5757.08,Other,324% New York Medicaid APG,3820.28,,,3820.28,Other,215% New York Medicaid APG,3820.28,,,3820.28,Other,215% New York Medicaid APG,2221.1,,,2221.1,Other,125% New York Medicaid APG,1776.88,50938.78,
Exchange biliary drg cath,47536,CPT,,,,,,,,both,,,22519.57,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,11259.79,50,,11259.79,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3304.99,,,3304.99,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,15763.7,70,,15763.7,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1776.88,,,1776.88,Other,New York Medicaid APG methodology,1776.88,,,1776.88,Other,100% New York Medicaid APG,1776.88,,,1776.88,Other,100% New York Medicaid APG,1776.88,,,1776.88,Other,100% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,2487.63,,,2487.63,Other,140% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,4619.88,,,4619.88,Other,260% New York Medicaid APG,5757.08,,,5757.08,Other,324% New York Medicaid APG,3820.28,,,3820.28,Other,215% New York Medicaid APG,3820.28,,,3820.28,Other,215% New York Medicaid APG,2221.1,,,2221.1,Other,125% New York Medicaid APG,1776.88,15763.7,
Removal biliary drg cath,47537,CPT,,,,,,,,both,,,16182.01,1723.81,,,1723.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.26,,,1048.26,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,8091.01,50,,8091.01,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1287.38,,,1287.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,11327.41,70,,11327.41,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,692.14,,,692.14,Other,New York Medicaid APG methodology,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,968.99,,,968.99,Other,140% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1799.56,,,1799.56,Other,260% New York Medicaid APG,2242.53,,,2242.53,Other,324% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,865.17,,,865.17,Other,125% New York Medicaid APG,692.14,13157,
Perq plmt bile duct stent,47538,CPT,,,,,,,,both,,,121364.27,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,60682.14,50,,60682.14,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3304.99,,,3304.99,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84954.99,70,,84954.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,1776.88,,,1776.88,Other,New York Medicaid APG methodology,1776.88,,,1776.88,Other,100% New York Medicaid APG,1776.88,,,1776.88,Other,100% New York Medicaid APG,1776.88,,,1776.88,Other,100% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,2487.63,,,2487.63,Other,140% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,4619.88,,,4619.88,Other,260% New York Medicaid APG,5757.08,,,5757.08,Other,324% New York Medicaid APG,3820.28,,,3820.28,Other,215% New York Medicaid APG,3820.28,,,3820.28,Other,215% New York Medicaid APG,2221.1,,,2221.1,Other,125% New York Medicaid APG,1776.88,84954.99,
Perq plmt bile duct stent,47539,CPT,,,,,,,,both,,,121364.27,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,60682.14,50,,60682.14,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3304.99,,,3304.99,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84954.99,70,,84954.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,1776.88,,,1776.88,Other,New York Medicaid APG methodology,1776.88,,,1776.88,Other,100% New York Medicaid APG,1776.88,,,1776.88,Other,100% New York Medicaid APG,1776.88,,,1776.88,Other,100% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,2487.63,,,2487.63,Other,140% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,4619.88,,,4619.88,Other,260% New York Medicaid APG,5757.08,,,5757.08,Other,324% New York Medicaid APG,3820.28,,,3820.28,Other,215% New York Medicaid APG,3820.28,,,3820.28,Other,215% New York Medicaid APG,2221.1,,,2221.1,Other,125% New York Medicaid APG,1776.88,84954.99,
Perq plmt bile duct stent,47540,CPT,,,,,,,,both,,,121364.27,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,60682.14,50,,60682.14,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5117.96,,,5117.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84954.99,70,,84954.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2751.59,,,2751.59,Other,New York Medicaid APG methodology,2751.59,,,2751.59,Other,100% New York Medicaid APG,2751.59,,,2751.59,Other,100% New York Medicaid APG,2751.59,,,2751.59,Other,100% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,3852.23,,,3852.23,Other,140% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,7154.14,,,7154.14,Other,260% New York Medicaid APG,8915.16,,,8915.16,Other,324% New York Medicaid APG,5915.92,,,5915.92,Other,215% New York Medicaid APG,5915.92,,,5915.92,Other,215% New York Medicaid APG,3439.49,,,3439.49,Other,125% New York Medicaid APG,2751.59,84954.99,
Plmt access bil tree sm bwl,47541,CPT,,,,,,,,both,,,159132.17,14387.04,,,14387.04,Other,150% of Medicare + 9.63% HCRA Surcharge,8748.85,,,8748.85,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,79566.09,50,,79566.09,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5117.96,,,5117.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,111392.52,70,,111392.52,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2751.59,,,2751.59,Other,New York Medicaid APG methodology,2751.59,,,2751.59,Other,100% New York Medicaid APG,2751.59,,,2751.59,Other,100% New York Medicaid APG,2751.59,,,2751.59,Other,100% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,3852.23,,,3852.23,Other,140% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,7154.14,,,7154.14,Other,260% New York Medicaid APG,8915.16,,,8915.16,Other,324% New York Medicaid APG,5915.92,,,5915.92,Other,215% New York Medicaid APG,5915.92,,,5915.92,Other,215% New York Medicaid APG,3439.49,,,3439.49,Other,125% New York Medicaid APG,2751.59,111392.52,
Dilate biliary duct/ampulla,47542,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,5117.96,,,5117.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2751.59,,,2751.59,Other,New York Medicaid APG methodology,2751.59,,,2751.59,Other,100% New York Medicaid APG,2751.59,,,2751.59,Other,100% New York Medicaid APG,2751.59,,,2751.59,Other,100% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,3852.23,,,3852.23,Other,140% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,7154.14,,,7154.14,Other,260% New York Medicaid APG,8915.16,,,8915.16,Other,324% New York Medicaid APG,5915.92,,,5915.92,Other,215% New York Medicaid APG,5915.92,,,5915.92,Other,215% New York Medicaid APG,3439.49,,,3439.49,Other,125% New York Medicaid APG,0.01,36100.43,
Endoluminal bx biliary tree,47543,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,5117.96,,,5117.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2751.59,,,2751.59,Other,New York Medicaid APG methodology,2751.59,,,2751.59,Other,100% New York Medicaid APG,2751.59,,,2751.59,Other,100% New York Medicaid APG,2751.59,,,2751.59,Other,100% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,3852.23,,,3852.23,Other,140% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,7154.14,,,7154.14,Other,260% New York Medicaid APG,8915.16,,,8915.16,Other,324% New York Medicaid APG,5915.92,,,5915.92,Other,215% New York Medicaid APG,5915.92,,,5915.92,Other,215% New York Medicaid APG,3439.49,,,3439.49,Other,125% New York Medicaid APG,0.01,36100.43,
Removal duct glbldr calculi,47544,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,5117.96,,,5117.96,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2751.59,,,2751.59,Other,New York Medicaid APG methodology,2751.59,,,2751.59,Other,100% New York Medicaid APG,2751.59,,,2751.59,Other,100% New York Medicaid APG,2751.59,,,2751.59,Other,100% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,3852.23,,,3852.23,Other,140% New York Medicaid APG,6191.08,,,6191.08,Other,225% New York Medicaid APG,7154.14,,,7154.14,Other,260% New York Medicaid APG,8915.16,,,8915.16,Other,324% New York Medicaid APG,5915.92,,,5915.92,Other,215% New York Medicaid APG,5915.92,,,5915.92,Other,215% New York Medicaid APG,3439.49,,,3439.49,Other,125% New York Medicaid APG,0.01,36100.43,
Biliary endo perq dx w/speci,47552,CPT,,,,,,,,both,,,159132.17,14387.04,,,14387.04,Other,150% of Medicare + 9.63% HCRA Surcharge,8748.85,,,8748.85,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,79566.09,50,,79566.09,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3272.59,,,3272.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,111392.52,70,,111392.52,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1759.46,,,1759.46,Other,New York Medicaid APG methodology,1759.46,,,1759.46,Other,100% New York Medicaid APG,1759.46,,,1759.46,Other,100% New York Medicaid APG,1759.46,,,1759.46,Other,100% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,2463.24,,,2463.24,Other,140% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,4574.59,,,4574.59,Other,260% New York Medicaid APG,5700.64,,,5700.64,Other,324% New York Medicaid APG,3782.83,,,3782.83,Other,215% New York Medicaid APG,3782.83,,,3782.83,Other,215% New York Medicaid APG,2199.32,,,2199.32,Other,125% New York Medicaid APG,1759.46,111392.52,
Biliary endoscopy thru skin,47553,CPT,,,,,,,,both,,,159132.17,14387.04,,,14387.04,Other,150% of Medicare + 9.63% HCRA Surcharge,8748.85,,,8748.85,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,79566.09,50,,79566.09,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3272.59,,,3272.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,111392.52,70,,111392.52,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,1759.46,,,1759.46,Other,New York Medicaid APG methodology,1759.46,,,1759.46,Other,100% New York Medicaid APG,1759.46,,,1759.46,Other,100% New York Medicaid APG,1759.46,,,1759.46,Other,100% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,2463.24,,,2463.24,Other,140% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,4574.59,,,4574.59,Other,260% New York Medicaid APG,5700.64,,,5700.64,Other,324% New York Medicaid APG,3782.83,,,3782.83,Other,215% New York Medicaid APG,3782.83,,,3782.83,Other,215% New York Medicaid APG,2199.32,,,2199.32,Other,125% New York Medicaid APG,1759.46,111392.52,
Biliary endoscopy thru skin,47554,CPT,,,,,,,,both,,,216515.17,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,108257.59,50,,108257.59,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3272.59,,,3272.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,151560.62,70,,151560.62,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,1759.46,,,1759.46,Other,New York Medicaid APG methodology,1759.46,,,1759.46,Other,100% New York Medicaid APG,1759.46,,,1759.46,Other,100% New York Medicaid APG,1759.46,,,1759.46,Other,100% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,2463.24,,,2463.24,Other,140% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,4574.59,,,4574.59,Other,260% New York Medicaid APG,5700.64,,,5700.64,Other,324% New York Medicaid APG,3782.83,,,3782.83,Other,215% New York Medicaid APG,3782.83,,,3782.83,Other,215% New York Medicaid APG,2199.32,,,2199.32,Other,125% New York Medicaid APG,1759.46,151560.62,
Biliary endoscopy thru skin,47555,CPT,,,,,,,,both,,,72769.69,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36384.85,50,,36384.85,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3272.59,,,3272.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50938.78,70,,50938.78,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1759.46,,,1759.46,Other,New York Medicaid APG methodology,1759.46,,,1759.46,Other,100% New York Medicaid APG,1759.46,,,1759.46,Other,100% New York Medicaid APG,1759.46,,,1759.46,Other,100% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,2463.24,,,2463.24,Other,140% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,4574.59,,,4574.59,Other,260% New York Medicaid APG,5700.64,,,5700.64,Other,324% New York Medicaid APG,3782.83,,,3782.83,Other,215% New York Medicaid APG,3782.83,,,3782.83,Other,215% New York Medicaid APG,2199.32,,,2199.32,Other,125% New York Medicaid APG,1759.46,50938.78,
Biliary endoscopy thru skin,47556,CPT,,,,,,,,both,,,216515.17,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,108257.59,50,,108257.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3272.59,,,3272.59,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,151560.62,70,,151560.62,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,1759.46,,,1759.46,Other,New York Medicaid APG methodology,1759.46,,,1759.46,Other,100% New York Medicaid APG,1759.46,,,1759.46,Other,100% New York Medicaid APG,1759.46,,,1759.46,Other,100% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,2463.24,,,2463.24,Other,140% New York Medicaid APG,3958.78,,,3958.78,Other,225% New York Medicaid APG,4574.59,,,4574.59,Other,260% New York Medicaid APG,5700.64,,,5700.64,Other,324% New York Medicaid APG,3782.83,,,3782.83,Other,215% New York Medicaid APG,3782.83,,,3782.83,Other,215% New York Medicaid APG,2199.32,,,2199.32,Other,125% New York Medicaid APG,1759.46,151560.62,
Laparoscopic cholecystectomy,47562,CPT,,,,,,,,both,,,39561.06,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,19780.53,50,,19780.53,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5971.64,,,5971.64,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27692.74,70,,27692.74,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3210.56,,,3210.56,Other,New York Medicaid APG methodology,3210.56,,,3210.56,Other,100% New York Medicaid APG,3210.56,,,3210.56,Other,100% New York Medicaid APG,3210.56,,,3210.56,Other,100% New York Medicaid APG,7223.76,,,7223.76,Other,225% New York Medicaid APG,7223.76,,,7223.76,Other,225% New York Medicaid APG,7223.76,,,7223.76,Other,225% New York Medicaid APG,7223.76,,,7223.76,Other,225% New York Medicaid APG,4494.78,,,4494.78,Other,140% New York Medicaid APG,7223.76,,,7223.76,Other,225% New York Medicaid APG,8347.45,,,8347.45,Other,260% New York Medicaid APG,10402.21,,,10402.21,Other,324% New York Medicaid APG,6902.7,,,6902.7,Other,215% New York Medicaid APG,6902.7,,,6902.7,Other,215% New York Medicaid APG,4013.2,,,4013.2,Other,125% New York Medicaid APG,3210.56,27692.74,
Laparo cholecystectomy/graph,47563,CPT,,,,,,,,both,,,39396.88,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,19698.44,50,,19698.44,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5971.64,,,5971.64,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27577.82,70,,27577.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3210.56,,,3210.56,Other,New York Medicaid APG methodology,3210.56,,,3210.56,Other,100% New York Medicaid APG,3210.56,,,3210.56,Other,100% New York Medicaid APG,3210.56,,,3210.56,Other,100% New York Medicaid APG,7223.76,,,7223.76,Other,225% New York Medicaid APG,7223.76,,,7223.76,Other,225% New York Medicaid APG,7223.76,,,7223.76,Other,225% New York Medicaid APG,7223.76,,,7223.76,Other,225% New York Medicaid APG,4494.78,,,4494.78,Other,140% New York Medicaid APG,7223.76,,,7223.76,Other,225% New York Medicaid APG,8347.45,,,8347.45,Other,260% New York Medicaid APG,10402.21,,,10402.21,Other,324% New York Medicaid APG,6902.7,,,6902.7,Other,215% New York Medicaid APG,6902.7,,,6902.7,Other,215% New York Medicaid APG,4013.2,,,4013.2,Other,125% New York Medicaid APG,3210.56,27577.82,
Laparo cholecystectomy/explr,47564,CPT,,,,,,,,both,,,216515.17,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,108257.59,50,,108257.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5971.64,,,5971.64,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,151560.62,70,,151560.62,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3210.56,,,3210.56,Other,New York Medicaid APG methodology,3210.56,,,3210.56,Other,100% New York Medicaid APG,3210.56,,,3210.56,Other,100% New York Medicaid APG,3210.56,,,3210.56,Other,100% New York Medicaid APG,7223.76,,,7223.76,Other,225% New York Medicaid APG,7223.76,,,7223.76,Other,225% New York Medicaid APG,7223.76,,,7223.76,Other,225% New York Medicaid APG,7223.76,,,7223.76,Other,225% New York Medicaid APG,4494.78,,,4494.78,Other,140% New York Medicaid APG,7223.76,,,7223.76,Other,225% New York Medicaid APG,8347.45,,,8347.45,Other,260% New York Medicaid APG,10402.21,,,10402.21,Other,324% New York Medicaid APG,6902.7,,,6902.7,Other,215% New York Medicaid APG,6902.7,,,6902.7,Other,215% New York Medicaid APG,4013.2,,,4013.2,Other,125% New York Medicaid APG,3210.56,151560.62,
Needle biopsy pancreas,48102,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1502.62,,,1502.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1131.01,,,1131.01,Other,140% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,2100.44,,,2100.44,Other,260% New York Medicaid APG,2617.47,,,2617.47,Other,324% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1009.83,,,1009.83,Other,125% New York Medicaid APG,807.86,23871.23,
Abd paracentesis,49082,CPT,,,,,,,,both,,,19066.74,1723.81,,,1723.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.26,,,1048.26,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9533.37,50,,9533.37,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1502.62,,,1502.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13346.72,70,,13346.72,percent of total billed charges,,356.4,,,356.4,Fee Schedule,,302.4,,,302.4,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1131.01,,,1131.01,Other,140% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,2100.44,,,2100.44,Other,260% New York Medicaid APG,2617.47,,,2617.47,Other,324% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1009.83,,,1009.83,Other,125% New York Medicaid APG,302.4,13346.72,
Abd paracentesis w/imaging,49083,CPT,,,,,,,,both,,,22401.51,1723.81,,,1723.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.26,,,1048.26,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,11200.76,50,,11200.76,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1502.62,,,1502.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,15681.06,70,,15681.06,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1131.01,,,1131.01,Other,140% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,2100.44,,,2100.44,Other,260% New York Medicaid APG,2617.47,,,2617.47,Other,324% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1009.83,,,1009.83,Other,125% New York Medicaid APG,807.86,15681.06,
Peritoneal lavage,49084,CPT,,,,,,,,both,,,19066.74,1723.81,,,1723.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.26,,,1048.26,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9533.37,50,,9533.37,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1502.62,,,1502.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13346.72,70,,13346.72,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1131.01,,,1131.01,Other,140% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,2100.44,,,2100.44,Other,260% New York Medicaid APG,2617.47,,,2617.47,Other,324% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1009.83,,,1009.83,Other,125% New York Medicaid APG,807.86,13346.72,
Biopsy abdominal mass,49180,CPT,,,,,,,,both,,,39815.4,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19907.7,50,,19907.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1502.62,,,1502.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27870.78,70,,27870.78,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1131.01,,,1131.01,Other,140% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,2100.44,,,2100.44,Other,260% New York Medicaid APG,2617.47,,,2617.47,Other,324% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1009.83,,,1009.83,Other,125% New York Medicaid APG,807.86,27870.78,
Sclerotx fluid collection,49185,CPT,,,,,,,,both,,,36148.51,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,18074.26,50,,18074.26,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1502.62,,,1502.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25303.96,70,,25303.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1131.01,,,1131.01,Other,140% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,2100.44,,,2100.44,Other,260% New York Medicaid APG,2617.47,,,2617.47,Other,324% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1009.83,,,1009.83,Other,125% New York Medicaid APG,807.86,25303.96,
Excision of umbilicus,49250,CPT,,,,,,,,both,,,35159.27,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17579.64,50,,17579.64,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4664.81,,,4664.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24611.49,70,,24611.49,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2507.96,,,2507.96,Other,New York Medicaid APG methodology,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,3511.14,,,3511.14,Other,140% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,6520.7,,,6520.7,Other,260% New York Medicaid APG,8125.79,,,8125.79,Other,324% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,3134.95,,,3134.95,Other,125% New York Medicaid APG,2507.96,24611.49,
Diag laparo separate proc,49320,CPT,,,,,,,,both,,,41980.23,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,20990.12,50,,20990.12,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4656.12,,,4656.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29386.16,70,,29386.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2503.29,,,2503.29,Other,New York Medicaid APG methodology,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,3504.61,,,3504.61,Other,140% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,6508.55,,,6508.55,Other,260% New York Medicaid APG,8110.66,,,8110.66,Other,324% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,3129.11,,,3129.11,Other,125% New York Medicaid APG,2503.29,29386.16,
Laparoscopy biopsy,49321,CPT,,,,,,,,both,,,47480.52,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,23740.26,50,,23740.26,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4656.12,,,4656.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,33236.36,70,,33236.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2503.29,,,2503.29,Other,New York Medicaid APG methodology,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,3504.61,,,3504.61,Other,140% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,6508.55,,,6508.55,Other,260% New York Medicaid APG,8110.66,,,8110.66,Other,324% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,3129.11,,,3129.11,Other,125% New York Medicaid APG,2503.29,33236.36,
Laparoscopy aspiration,49322,CPT,,,,,,,,both,,,121364.27,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,60682.14,50,,60682.14,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4656.12,,,4656.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84954.99,70,,84954.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2503.29,,,2503.29,Other,New York Medicaid APG methodology,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,3504.61,,,3504.61,Other,140% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,6508.55,,,6508.55,Other,260% New York Medicaid APG,8110.66,,,8110.66,Other,324% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,3129.11,,,3129.11,Other,125% New York Medicaid APG,2503.29,84954.99,
Laparo drain lymphocele,49323,CPT,,,,,,,,both,,,121364.27,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,60682.14,50,,60682.14,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4656.12,,,4656.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84954.99,70,,84954.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2503.29,,,2503.29,Other,New York Medicaid APG methodology,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,3504.61,,,3504.61,Other,140% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,6508.55,,,6508.55,Other,260% New York Medicaid APG,8110.66,,,8110.66,Other,324% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,3129.11,,,3129.11,Other,125% New York Medicaid APG,2503.29,84954.99,
Lap insert tunnel ip cath,49324,CPT,,,,,,,,both,,,40853.43,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,20426.72,50,,20426.72,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4656.12,,,4656.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28597.4,70,,28597.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2503.29,,,2503.29,Other,New York Medicaid APG methodology,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,3504.61,,,3504.61,Other,140% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,6508.55,,,6508.55,Other,260% New York Medicaid APG,8110.66,,,8110.66,Other,324% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,3129.11,,,3129.11,Other,125% New York Medicaid APG,2503.29,28597.4,
Lap revision perm ip cath,49325,CPT,,,,,,,,both,,,121364.27,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,60682.14,50,,60682.14,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4656.12,,,4656.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84954.99,70,,84954.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2503.29,,,2503.29,Other,New York Medicaid APG methodology,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,3504.61,,,3504.61,Other,140% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,6508.55,,,6508.55,Other,260% New York Medicaid APG,8110.66,,,8110.66,Other,324% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,3129.11,,,3129.11,Other,125% New York Medicaid APG,2503.29,84954.99,
Lap w/omentopexy add-on,49326,CPT,,,,,,,,both,,,83504,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,41752,50,,41752,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4656.12,,,4656.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,58452.8,70,,58452.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2503.29,,,2503.29,Other,New York Medicaid APG methodology,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,3504.61,,,3504.61,Other,140% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,6508.55,,,6508.55,Other,260% New York Medicaid APG,8110.66,,,8110.66,Other,324% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,3129.11,,,3129.11,Other,125% New York Medicaid APG,0.01,58452.8,
Lap ins device for rt,49327,CPT,,,,,,,,both,,,98219.64,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,49109.82,50,,49109.82,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,68753.75,70,,68753.75,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,68753.75,
Air injection into abdomen,49400,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1205.26,,,1205.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.99,,,647.99,Other,New York Medicaid APG methodology,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,907.18,,,907.18,Other,140% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1684.77,,,1684.77,Other,260% New York Medicaid APG,2099.48,,,2099.48,Other,324% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,809.98,,,809.98,Other,125% New York Medicaid APG,0.01,22702.47,
Remove foreign body adbomen,49402,CPT,,,,,,,,both,,,72769.69,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36384.85,50,,36384.85,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4656.12,,,4656.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50938.78,70,,50938.78,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2503.29,,,2503.29,Other,New York Medicaid APG methodology,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,3504.61,,,3504.61,Other,140% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,6508.55,,,6508.55,Other,260% New York Medicaid APG,8110.66,,,8110.66,Other,324% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,3129.11,,,3129.11,Other,125% New York Medicaid APG,2503.29,50938.78,
Image cath fluid colxn visc,49405,CPT,,,,,,,,both,,,12479.89,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,6239.95,50,,6239.95,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1502.62,,,1502.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8735.92,70,,8735.92,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1131.01,,,1131.01,Other,140% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,2100.44,,,2100.44,Other,260% New York Medicaid APG,2617.47,,,2617.47,Other,324% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1009.83,,,1009.83,Other,125% New York Medicaid APG,807.86,13157,
Image cath fluid peri/retro,49406,CPT,,,,,,,,both,,,13910.07,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,6955.04,50,,6955.04,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1502.62,,,1502.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9737.05,70,,9737.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1131.01,,,1131.01,Other,140% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,2100.44,,,2100.44,Other,260% New York Medicaid APG,2617.47,,,2617.47,Other,324% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1009.83,,,1009.83,Other,125% New York Medicaid APG,807.86,13157,
Image cath fluid trns/vgnl,49407,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1502.62,,,1502.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1131.01,,,1131.01,Other,140% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,2100.44,,,2100.44,Other,260% New York Medicaid APG,2617.47,,,2617.47,Other,324% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1009.83,,,1009.83,Other,125% New York Medicaid APG,807.86,23871.23,
Ins mark abd/pel for rt perq,49411,CPT,,,,,,,,both,,,29144.83,2634.97,,,2634.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1602.34,,,1602.34,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,14572.42,50,,14572.42,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,574.46,,,574.46,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,20401.38,70,,20401.38,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,308.85,,,308.85,Other,New York Medicaid APG methodology,308.85,,,308.85,Other,100% New York Medicaid APG,308.85,,,308.85,Other,100% New York Medicaid APG,308.85,,,308.85,Other,100% New York Medicaid APG,694.91,,,694.91,Other,225% New York Medicaid APG,694.91,,,694.91,Other,225% New York Medicaid APG,694.91,,,694.91,Other,225% New York Medicaid APG,694.91,,,694.91,Other,225% New York Medicaid APG,432.39,,,432.39,Other,140% New York Medicaid APG,694.91,,,694.91,Other,225% New York Medicaid APG,803.01,,,803.01,Other,260% New York Medicaid APG,1000.67,,,1000.67,Other,324% New York Medicaid APG,664.02,,,664.02,Other,215% New York Medicaid APG,664.02,,,664.02,Other,215% New York Medicaid APG,386.06,,,386.06,Other,125% New York Medicaid APG,308.85,20401.38,
Insert tun ip cath perc,49418,CPT,,,,,,,,both,,,26173,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,13086.5,50,,13086.5,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4656.12,,,4656.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,18321.1,70,,18321.1,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2503.29,,,2503.29,Other,New York Medicaid APG methodology,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,3504.61,,,3504.61,Other,140% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,6508.55,,,6508.55,Other,260% New York Medicaid APG,8110.66,,,8110.66,Other,324% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,3129.11,,,3129.11,Other,125% New York Medicaid APG,2503.29,18321.1,
Insert tun ip cath w/port,49419,CPT,,,,,,,,both,,,115587.67,10450.21,,,10450.21,Other,150% of Medicare + 9.63% HCRA Surcharge,6354.84,,,6354.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,57793.84,50,,57793.84,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4656.12,,,4656.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,80911.37,70,,80911.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2503.29,,,2503.29,Other,New York Medicaid APG methodology,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,3504.61,,,3504.61,Other,140% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,6508.55,,,6508.55,Other,260% New York Medicaid APG,8110.66,,,8110.66,Other,324% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,3129.11,,,3129.11,Other,125% New York Medicaid APG,2503.29,80911.37,
Ins tun ip cath for dial opn,49421,CPT,,,,,,,,both,,,72769.69,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36384.85,50,,36384.85,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4656.12,,,4656.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50938.78,70,,50938.78,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2503.29,,,2503.29,Other,New York Medicaid APG methodology,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,3504.61,,,3504.61,Other,140% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,6508.55,,,6508.55,Other,260% New York Medicaid APG,8110.66,,,8110.66,Other,324% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,3129.11,,,3129.11,Other,125% New York Medicaid APG,2503.29,50938.78,
Remove tunneled ip cath,49422,CPT,,,,,,,,both,,,34083.58,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17041.79,50,,17041.79,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1502.62,,,1502.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23858.51,70,,23858.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1131.01,,,1131.01,Other,140% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,2100.44,,,2100.44,Other,260% New York Medicaid APG,2617.47,,,2617.47,Other,324% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1009.83,,,1009.83,Other,125% New York Medicaid APG,807.86,23858.51,
Exchange drainage catheter,49423,CPT,,,,,,,,both,,,20387,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,10193.5,50,,10193.5,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1502.62,,,1502.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,14270.9,70,,14270.9,percent of total billed charges,,343.2,,,343.2,Fee Schedule,,291.2,,,291.2,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1131.01,,,1131.01,Other,140% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,2100.44,,,2100.44,Other,260% New York Medicaid APG,2617.47,,,2617.47,Other,324% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1009.83,,,1009.83,Other,125% New York Medicaid APG,291.2,14270.9,
Assess cyst contrast inject,49424,CPT,,,,,,,,both,,,12706.39,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6353.2,50,,6353.2,percent of total billed charges,,8894.47,70,,8894.47,percent of total billed charges,,6152,,,6152,Case Rate,,1205.26,,,1205.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8894.47,70,,8894.47,percent of total billed charges,,181.5,,,181.5,Fee Schedule,,154,,,154,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.99,,,647.99,Other,New York Medicaid APG methodology,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,907.18,,,907.18,Other,140% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1684.77,,,1684.77,Other,260% New York Medicaid APG,2099.48,,,2099.48,Other,324% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,809.98,,,809.98,Other,125% New York Medicaid APG,0.01,9473,
Revise abdomen-venous shunt,49426,CPT,,,,,,,,both,,,72769.69,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36384.85,50,,36384.85,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4656.12,,,4656.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50938.78,70,,50938.78,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2503.29,,,2503.29,Other,New York Medicaid APG methodology,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,3504.61,,,3504.61,Other,140% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,6508.55,,,6508.55,Other,260% New York Medicaid APG,8110.66,,,8110.66,Other,324% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,3129.11,,,3129.11,Other,125% New York Medicaid APG,2503.29,50938.78,
Injection abdominal shunt,49427,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1205.26,,,1205.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,189.75,,,189.75,Fee Schedule,,161,,,161,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.99,,,647.99,Other,New York Medicaid APG methodology,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,907.18,,,907.18,Other,140% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1684.77,,,1684.77,Other,260% New York Medicaid APG,2099.48,,,2099.48,Other,324% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,809.98,,,809.98,Other,125% New York Medicaid APG,0.01,22702.47,
Removal of shunt,49429,CPT,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4656.12,,,4656.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2503.29,,,2503.29,Other,New York Medicaid APG methodology,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,2503.29,,,2503.29,Other,100% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,3504.61,,,3504.61,Other,140% New York Medicaid APG,5632.4,,,5632.4,Other,225% New York Medicaid APG,6508.55,,,6508.55,Other,260% New York Medicaid APG,8110.66,,,8110.66,Other,324% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,5382.07,,,5382.07,Other,215% New York Medicaid APG,3129.11,,,3129.11,Other,125% New York Medicaid APG,2503.29,46931.32,
Insert subq exten to ip cath,49435,CPT,,,,,,,,both,,,86591.4,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,43295.7,50,,43295.7,percent of total billed charges,,60613.98,70,,60613.98,percent of total billed charges,,6152,,,6152,Case Rate,,1502.62,,,1502.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,60613.98,70,,60613.98,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1131.01,,,1131.01,Other,140% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,2100.44,,,2100.44,Other,260% New York Medicaid APG,2617.47,,,2617.47,Other,324% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1009.83,,,1009.83,Other,125% New York Medicaid APG,0.01,60613.98,
Embedded ip cath exit-site,49436,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1502.62,,,1502.62,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,807.86,,,807.86,Other,New York Medicaid APG methodology,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,807.86,,,807.86,Other,100% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,1131.01,,,1131.01,Other,140% New York Medicaid APG,1817.69,,,1817.69,Other,225% New York Medicaid APG,2100.44,,,2100.44,Other,260% New York Medicaid APG,2617.47,,,2617.47,Other,324% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1736.9,,,1736.9,Other,215% New York Medicaid APG,1009.83,,,1009.83,Other,125% New York Medicaid APG,807.86,28016.37,
Place gastrostomy tube perc,49440,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1287.38,,,1287.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,692.14,,,692.14,Other,New York Medicaid APG methodology,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,968.99,,,968.99,Other,140% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1799.56,,,1799.56,Other,260% New York Medicaid APG,2242.53,,,2242.53,Other,324% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,865.17,,,865.17,Other,125% New York Medicaid APG,692.14,28016.37,
Place duod/jej tube perc,49441,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1287.38,,,1287.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,692.14,,,692.14,Other,New York Medicaid APG methodology,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,968.99,,,968.99,Other,140% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1799.56,,,1799.56,Other,260% New York Medicaid APG,2242.53,,,2242.53,Other,324% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,865.17,,,865.17,Other,125% New York Medicaid APG,692.14,28016.37,
Place cecostomy tube perc,49442,CPT,,,,,,,,both,,,24821.26,2244.08,,,2244.08,Other,150% of Medicare + 9.63% HCRA Surcharge,1364.64,,,1364.64,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12410.63,50,,12410.63,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17374.88,70,,17374.88,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1364.64,17374.88,
Change g-tube to g-j perc,49446,CPT,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1287.38,,,1287.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,692.14,,,692.14,Other,New York Medicaid APG methodology,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,968.99,,,968.99,Other,140% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1799.56,,,1799.56,Other,260% New York Medicaid APG,2242.53,,,2242.53,Other,324% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,865.17,,,865.17,Other,125% New York Medicaid APG,692.14,28016.37,
Replace g/c tube perc,49450,CPT,,,,,,,,both,,,32413.64,1723.81,,,1723.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.26,,,1048.26,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16206.82,50,,16206.82,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1287.38,,,1287.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22689.55,70,,22689.55,percent of total billed charges,,321.75,,,321.75,Fee Schedule,,273,,,273,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,692.14,,,692.14,Other,New York Medicaid APG methodology,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,968.99,,,968.99,Other,140% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1799.56,,,1799.56,Other,260% New York Medicaid APG,2242.53,,,2242.53,Other,324% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,865.17,,,865.17,Other,125% New York Medicaid APG,273,22689.55,
Replace duod/jej tube perc,49451,CPT,,,,,,,,both,,,19066.74,1723.81,,,1723.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.26,,,1048.26,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9533.37,50,,9533.37,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1287.38,,,1287.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13346.72,70,,13346.72,percent of total billed charges,,425.7,,,425.7,Fee Schedule,,361.2,,,361.2,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,692.14,,,692.14,Other,New York Medicaid APG methodology,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,968.99,,,968.99,Other,140% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1799.56,,,1799.56,Other,260% New York Medicaid APG,2242.53,,,2242.53,Other,324% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,865.17,,,865.17,Other,125% New York Medicaid APG,361.2,13346.72,
Replace g-j tube perc,49452,CPT,,,,,,,,both,,,19066.74,1723.81,,,1723.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.26,,,1048.26,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9533.37,50,,9533.37,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1287.38,,,1287.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13346.72,70,,13346.72,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,692.14,,,692.14,Other,New York Medicaid APG methodology,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,968.99,,,968.99,Other,140% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1799.56,,,1799.56,Other,260% New York Medicaid APG,2242.53,,,2242.53,Other,324% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,865.17,,,865.17,Other,125% New York Medicaid APG,692.14,13346.72,
Fix g/colon tube w/device,49460,CPT,,,,,,,,both,,,19066.74,1723.81,,,1723.81,Other,150% of Medicare + 9.63% HCRA Surcharge,1048.26,,,1048.26,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9533.37,50,,9533.37,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1287.38,,,1287.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13346.72,70,,13346.72,percent of total billed charges,,240.9,,,240.9,Fee Schedule,,204.4,,,204.4,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,692.14,,,692.14,Other,New York Medicaid APG methodology,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,692.14,,,692.14,Other,100% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,968.99,,,968.99,Other,140% New York Medicaid APG,1557.31,,,1557.31,Other,225% New York Medicaid APG,1799.56,,,1799.56,Other,260% New York Medicaid APG,2242.53,,,2242.53,Other,324% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,1488.1,,,1488.1,Other,215% New York Medicaid APG,865.17,,,865.17,Other,125% New York Medicaid APG,204.4,13346.72,
Fluoro exam of g/colon tube,49465,CPT,,,,,,,,both,,,5154.06,465.98,,,465.98,Other,150% of Medicare + 9.63% HCRA Surcharge,283.36,,,283.36,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2577.03,50,,2577.03,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,760.32,,,760.32,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3607.84,70,,3607.84,percent of total billed charges,,148.5,,,148.5,Fee Schedule,,126,,,126,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,408.77,,,408.77,Other,New York Medicaid APG methodology,408.77,,,408.77,Other,100% New York Medicaid APG,408.77,,,408.77,Other,100% New York Medicaid APG,408.77,,,408.77,Other,100% New York Medicaid APG,919.74,,,919.74,Other,225% New York Medicaid APG,919.74,,,919.74,Other,225% New York Medicaid APG,919.74,,,919.74,Other,225% New York Medicaid APG,919.74,,,919.74,Other,225% New York Medicaid APG,572.28,,,572.28,Other,140% New York Medicaid APG,919.74,,,919.74,Other,225% New York Medicaid APG,1062.81,,,1062.81,Other,260% New York Medicaid APG,1324.43,,,1324.43,Other,324% New York Medicaid APG,878.86,,,878.86,Other,215% New York Medicaid APG,878.86,,,878.86,Other,215% New York Medicaid APG,510.97,,,510.97,Other,125% New York Medicaid APG,0.01,9473,
Rpr hern preemie reduc,49491,CPT,,,,,,,,both,,,36476.2,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,18238.1,50,,18238.1,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4664.81,,,4664.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25533.34,70,,25533.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2507.96,,,2507.96,Other,New York Medicaid APG methodology,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,3511.14,,,3511.14,Other,140% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,6520.7,,,6520.7,Other,260% New York Medicaid APG,8125.79,,,8125.79,Other,324% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,3134.95,,,3134.95,Other,125% New York Medicaid APG,2507.96,25533.34,
Rpr ing hern premie blocked,49492,CPT,,,,,,,,both,,,72769.69,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36384.85,50,,36384.85,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4664.81,,,4664.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50938.78,70,,50938.78,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2507.96,,,2507.96,Other,New York Medicaid APG methodology,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,3511.14,,,3511.14,Other,140% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,6520.7,,,6520.7,Other,260% New York Medicaid APG,8125.79,,,8125.79,Other,324% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,3134.95,,,3134.95,Other,125% New York Medicaid APG,2507.96,50938.78,
Rpr ing hernia baby reduc,49495,CPT,,,,,,,,both,,,34971.91,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17485.96,50,,17485.96,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4664.81,,,4664.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24480.34,70,,24480.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2507.96,,,2507.96,Other,New York Medicaid APG methodology,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,3511.14,,,3511.14,Other,140% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,6520.7,,,6520.7,Other,260% New York Medicaid APG,8125.79,,,8125.79,Other,324% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,3134.95,,,3134.95,Other,125% New York Medicaid APG,2507.96,24480.34,
Rpr ing hernia baby blocked,49496,CPT,,,,,,,,both,,,72769.69,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36384.85,50,,36384.85,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4664.81,,,4664.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50938.78,70,,50938.78,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2507.96,,,2507.96,Other,New York Medicaid APG methodology,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,3511.14,,,3511.14,Other,140% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,6520.7,,,6520.7,Other,260% New York Medicaid APG,8125.79,,,8125.79,Other,324% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,3134.95,,,3134.95,Other,125% New York Medicaid APG,2507.96,50938.78,
Rpr ing hernia init reduce,49500,CPT,,,,,,,,both,,,35650.88,14387.04,,,14387.04,Other,150% of Medicare + 9.63% HCRA Surcharge,8748.85,,,8748.85,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17825.44,50,,17825.44,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4664.81,,,4664.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24955.62,70,,24955.62,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2507.96,,,2507.96,Other,New York Medicaid APG methodology,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,3511.14,,,3511.14,Other,140% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,6520.7,,,6520.7,Other,260% New York Medicaid APG,8125.79,,,8125.79,Other,324% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,3134.95,,,3134.95,Other,125% New York Medicaid APG,2507.96,24955.62,
Rpr ing hernia init blocked,49501,CPT,,,,,,,,both,,,72769.69,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36384.85,50,,36384.85,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4664.81,,,4664.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50938.78,70,,50938.78,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2507.96,,,2507.96,Other,New York Medicaid APG methodology,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,3511.14,,,3511.14,Other,140% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,6520.7,,,6520.7,Other,260% New York Medicaid APG,8125.79,,,8125.79,Other,324% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,3134.95,,,3134.95,Other,125% New York Medicaid APG,2507.96,50938.78,
Prp i/hern init reduc >5 yr,49505,CPT,,,,,,,,both,,,37203.27,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18601.64,50,,18601.64,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4664.81,,,4664.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26042.29,70,,26042.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2507.96,,,2507.96,Other,New York Medicaid APG methodology,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,3511.14,,,3511.14,Other,140% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,6520.7,,,6520.7,Other,260% New York Medicaid APG,8125.79,,,8125.79,Other,324% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,3134.95,,,3134.95,Other,125% New York Medicaid APG,2507.96,26042.29,
Prp i/hern init block >5 yr,49507,CPT,,,,,,,,both,,,44660.6,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,22330.3,50,,22330.3,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4664.81,,,4664.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31262.42,70,,31262.42,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2507.96,,,2507.96,Other,New York Medicaid APG methodology,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,3511.14,,,3511.14,Other,140% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,6520.7,,,6520.7,Other,260% New York Medicaid APG,8125.79,,,8125.79,Other,324% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,3134.95,,,3134.95,Other,125% New York Medicaid APG,2507.96,31262.42,
Rerepair ing hernia reduce,49520,CPT,,,,,,,,both,,,40414.17,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,20207.09,50,,20207.09,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4664.81,,,4664.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28289.92,70,,28289.92,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2507.96,,,2507.96,Other,New York Medicaid APG methodology,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,3511.14,,,3511.14,Other,140% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,6520.7,,,6520.7,Other,260% New York Medicaid APG,8125.79,,,8125.79,Other,324% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,3134.95,,,3134.95,Other,125% New York Medicaid APG,2507.96,28289.92,
Rerepair ing hernia blocked,49521,CPT,,,,,,,,both,,,37127.91,14387.04,,,14387.04,Other,150% of Medicare + 9.63% HCRA Surcharge,8748.85,,,8748.85,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18563.96,50,,18563.96,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4664.81,,,4664.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25989.54,70,,25989.54,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2507.96,,,2507.96,Other,New York Medicaid APG methodology,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,3511.14,,,3511.14,Other,140% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,6520.7,,,6520.7,Other,260% New York Medicaid APG,8125.79,,,8125.79,Other,324% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,3134.95,,,3134.95,Other,125% New York Medicaid APG,2507.96,25989.54,
Repair ing hernia sliding,49525,CPT,,,,,,,,both,,,43308.47,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,21654.24,50,,21654.24,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4664.81,,,4664.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,30315.93,70,,30315.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2507.96,,,2507.96,Other,New York Medicaid APG methodology,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,3511.14,,,3511.14,Other,140% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,6520.7,,,6520.7,Other,260% New York Medicaid APG,8125.79,,,8125.79,Other,324% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,3134.95,,,3134.95,Other,125% New York Medicaid APG,2507.96,30315.93,
Repair lumbar hernia,49540,CPT,,,,,,,,both,,,121364.27,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,60682.14,50,,60682.14,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4862.07,,,4862.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84954.99,70,,84954.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2614.02,,,2614.02,Other,New York Medicaid APG methodology,2614.02,,,2614.02,Other,100% New York Medicaid APG,2614.02,,,2614.02,Other,100% New York Medicaid APG,2614.02,,,2614.02,Other,100% New York Medicaid APG,5881.54,,,5881.54,Other,225% New York Medicaid APG,5881.54,,,5881.54,Other,225% New York Medicaid APG,5881.54,,,5881.54,Other,225% New York Medicaid APG,5881.54,,,5881.54,Other,225% New York Medicaid APG,3659.63,,,3659.63,Other,140% New York Medicaid APG,5881.54,,,5881.54,Other,225% New York Medicaid APG,6796.45,,,6796.45,Other,260% New York Medicaid APG,8469.42,,,8469.42,Other,324% New York Medicaid APG,5620.14,,,5620.14,Other,215% New York Medicaid APG,5620.14,,,5620.14,Other,215% New York Medicaid APG,3267.52,,,3267.52,Other,125% New York Medicaid APG,2614.02,84954.99,
Rpr rem hernia init reduce,49550,CPT,,,,,,,,both,,,72769.69,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36384.85,50,,36384.85,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4664.81,,,4664.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50938.78,70,,50938.78,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2507.96,,,2507.96,Other,New York Medicaid APG methodology,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,3511.14,,,3511.14,Other,140% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,6520.7,,,6520.7,Other,260% New York Medicaid APG,8125.79,,,8125.79,Other,324% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,3134.95,,,3134.95,Other,125% New York Medicaid APG,2507.96,50938.78,
Rpr fem hernia init blocked,49553,CPT,,,,,,,,both,,,61084.35,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,30542.18,50,,30542.18,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4664.81,,,4664.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,42759.05,70,,42759.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2507.96,,,2507.96,Other,New York Medicaid APG methodology,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,3511.14,,,3511.14,Other,140% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,6520.7,,,6520.7,Other,260% New York Medicaid APG,8125.79,,,8125.79,Other,324% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,3134.95,,,3134.95,Other,125% New York Medicaid APG,2507.96,42759.05,
Rerepair fem hernia reduce,49555,CPT,,,,,,,,both,,,72769.69,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36384.85,50,,36384.85,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4664.81,,,4664.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50938.78,70,,50938.78,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2507.96,,,2507.96,Other,New York Medicaid APG methodology,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,3511.14,,,3511.14,Other,140% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,6520.7,,,6520.7,Other,260% New York Medicaid APG,8125.79,,,8125.79,Other,324% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,3134.95,,,3134.95,Other,125% New York Medicaid APG,2507.96,50938.78,
Rerepair fem hernia blocked,49557,CPT,,,,,,,,both,,,72769.69,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36384.85,50,,36384.85,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4664.81,,,4664.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50938.78,70,,50938.78,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2507.96,,,2507.96,Other,New York Medicaid APG methodology,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,3511.14,,,3511.14,Other,140% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,6520.7,,,6520.7,Other,260% New York Medicaid APG,8125.79,,,8125.79,Other,324% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,3134.95,,,3134.95,Other,125% New York Medicaid APG,2507.96,50938.78,
Repair umbilical lesion,49600,CPT,,,,,,,,both,,,39921.1,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19960.55,50,,19960.55,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4862.07,,,4862.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27944.77,70,,27944.77,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2614.02,,,2614.02,Other,New York Medicaid APG methodology,2614.02,,,2614.02,Other,100% New York Medicaid APG,2614.02,,,2614.02,Other,100% New York Medicaid APG,2614.02,,,2614.02,Other,100% New York Medicaid APG,5881.54,,,5881.54,Other,225% New York Medicaid APG,5881.54,,,5881.54,Other,225% New York Medicaid APG,5881.54,,,5881.54,Other,225% New York Medicaid APG,5881.54,,,5881.54,Other,225% New York Medicaid APG,3659.63,,,3659.63,Other,140% New York Medicaid APG,5881.54,,,5881.54,Other,225% New York Medicaid APG,6796.45,,,6796.45,Other,260% New York Medicaid APG,8469.42,,,8469.42,Other,324% New York Medicaid APG,5620.14,,,5620.14,Other,215% New York Medicaid APG,5620.14,,,5620.14,Other,215% New York Medicaid APG,3267.52,,,3267.52,Other,125% New York Medicaid APG,2614.02,27944.77,
Lap ing hernia repair init,49650,CPT,,,,,,,,both,,,42549.81,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,21274.91,50,,21274.91,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4664.81,,,4664.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29784.87,70,,29784.87,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2507.96,,,2507.96,Other,New York Medicaid APG methodology,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,3511.14,,,3511.14,Other,140% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,6520.7,,,6520.7,Other,260% New York Medicaid APG,8125.79,,,8125.79,Other,324% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,3134.95,,,3134.95,Other,125% New York Medicaid APG,2507.96,29784.87,
Lap ing hernia repair recur,49651,CPT,,,,,,,,both,,,46480.03,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,23240.02,50,,23240.02,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4664.81,,,4664.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,32536.02,70,,32536.02,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2507.96,,,2507.96,Other,New York Medicaid APG methodology,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,3511.14,,,3511.14,Other,140% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,6520.7,,,6520.7,Other,260% New York Medicaid APG,8125.79,,,8125.79,Other,324% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,3134.95,,,3134.95,Other,125% New York Medicaid APG,2507.96,32536.02,
Renal abscess open drain,50020,CPT,,,,,,,,both,,,42841.82,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21420.91,50,,21420.91,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4401.21,,,4401.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29989.27,70,,29989.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2366.24,,,2366.24,Other,New York Medicaid APG methodology,2366.24,,,2366.24,Other,100% New York Medicaid APG,2366.24,,,2366.24,Other,100% New York Medicaid APG,2366.24,,,2366.24,Other,100% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,3312.74,,,3312.74,Other,140% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,6152.23,,,6152.23,Other,260% New York Medicaid APG,7666.62,,,7666.62,Other,324% New York Medicaid APG,5087.42,,,5087.42,Other,215% New York Medicaid APG,5087.42,,,5087.42,Other,215% New York Medicaid APG,2957.8,,,2957.8,Other,125% New York Medicaid APG,2355.38,29989.27,
Removal of kidney stone,50080,CPT,,,,,,,,both,,,43674.9,17518.56,,,17518.56,Other,150% of Medicare + 9.63% HCRA Surcharge,10653.14,,,10653.14,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,21837.45,50,,21837.45,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4401.21,,,4401.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,30572.43,70,,30572.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2366.24,,,2366.24,Other,New York Medicaid APG methodology,2366.24,,,2366.24,Other,100% New York Medicaid APG,2366.24,,,2366.24,Other,100% New York Medicaid APG,2366.24,,,2366.24,Other,100% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,3312.74,,,3312.74,Other,140% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,6152.23,,,6152.23,Other,260% New York Medicaid APG,7666.62,,,7666.62,Other,324% New York Medicaid APG,5087.42,,,5087.42,Other,215% New York Medicaid APG,5087.42,,,5087.42,Other,215% New York Medicaid APG,2957.8,,,2957.8,Other,125% New York Medicaid APG,2366.24,30572.43,
Removal of kidney stone,50081,CPT,,,,,,,,both,,,45007.64,17518.56,,,17518.56,Other,150% of Medicare + 9.63% HCRA Surcharge,10653.14,,,10653.14,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,22503.82,50,,22503.82,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4401.21,,,4401.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31505.35,70,,31505.35,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2366.24,,,2366.24,Other,New York Medicaid APG methodology,2366.24,,,2366.24,Other,100% New York Medicaid APG,2366.24,,,2366.24,Other,100% New York Medicaid APG,2366.24,,,2366.24,Other,100% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,3312.74,,,3312.74,Other,140% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,6152.23,,,6152.23,Other,260% New York Medicaid APG,7666.62,,,7666.62,Other,324% New York Medicaid APG,5087.42,,,5087.42,Other,215% New York Medicaid APG,5087.42,,,5087.42,Other,215% New York Medicaid APG,2957.8,,,2957.8,Other,125% New York Medicaid APG,2366.24,31505.35,
Renal biopsy perq,50200,CPT,,,,,,,,both,,,31170.32,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,15585.16,50,,15585.16,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2557.09,,,2557.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,21819.22,70,,21819.22,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1374.78,,,1374.78,Other,New York Medicaid APG methodology,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,1924.69,,,1924.69,Other,140% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3574.43,,,3574.43,Other,260% New York Medicaid APG,4454.28,,,4454.28,Other,324% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,1718.47,,,1718.47,Other,125% New York Medicaid APG,1374.78,21819.22,
Change ureter stent percut,50382,CPT,,,,,,,,both,,,42841.82,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21420.91,50,,21420.91,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2557.09,,,2557.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29989.27,70,,29989.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1374.78,,,1374.78,Other,New York Medicaid APG methodology,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,1924.69,,,1924.69,Other,140% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3574.43,,,3574.43,Other,260% New York Medicaid APG,4454.28,,,4454.28,Other,324% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,1718.47,,,1718.47,Other,125% New York Medicaid APG,1374.78,29989.27,
Remove ureter stent percut,50384,CPT,,,,,,,,both,,,42841.82,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21420.91,50,,21420.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2557.09,,,2557.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29989.27,70,,29989.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1374.78,,,1374.78,Other,New York Medicaid APG methodology,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,1924.69,,,1924.69,Other,140% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3574.43,,,3574.43,Other,260% New York Medicaid APG,4454.28,,,4454.28,Other,324% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,1718.47,,,1718.47,Other,125% New York Medicaid APG,1374.78,29989.27,
Change stent via transureth,50385,CPT,,,,,,,,both,,,42841.82,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21420.91,50,,21420.91,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2557.09,,,2557.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29989.27,70,,29989.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1374.78,,,1374.78,Other,New York Medicaid APG methodology,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,1924.69,,,1924.69,Other,140% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3574.43,,,3574.43,Other,260% New York Medicaid APG,4454.28,,,4454.28,Other,324% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,1718.47,,,1718.47,Other,125% New York Medicaid APG,1374.78,29989.27,
Remove stent via transureth,50386,CPT,,,,,,,,both,,,42841.82,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21420.91,50,,21420.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2557.09,,,2557.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29989.27,70,,29989.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1374.78,,,1374.78,Other,New York Medicaid APG methodology,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,1924.69,,,1924.69,Other,140% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3574.43,,,3574.43,Other,260% New York Medicaid APG,4454.28,,,4454.28,Other,324% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,1718.47,,,1718.47,Other,125% New York Medicaid APG,1374.78,29989.27,
Change nephroureteral cath,50387,CPT,,,,,,,,both,,,26629,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,13314.5,50,,13314.5,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2557.09,,,2557.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,18640.3,70,,18640.3,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1374.78,,,1374.78,Other,New York Medicaid APG methodology,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,1924.69,,,1924.69,Other,140% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3574.43,,,3574.43,Other,260% New York Medicaid APG,4454.28,,,4454.28,Other,324% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,1718.47,,,1718.47,Other,125% New York Medicaid APG,1374.78,18640.3,
Remove renal tube w/fluoro,50389,CPT,,,,,,,,both,,,10806,1299.03,,,1299.03,Other,150% of Medicare + 9.63% HCRA Surcharge,789.95,,,789.95,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5403,50,,5403,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1123.05,,,1123.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,7564.2,70,,7564.2,percent of total billed charges,,257.4,,,257.4,Fee Schedule,,218.4,,,218.4,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,603.79,,,603.79,Other,New York Medicaid APG methodology,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,845.31,,,845.31,Other,140% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1569.85,,,1569.85,Other,260% New York Medicaid APG,1956.28,,,1956.28,Other,324% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,754.74,,,754.74,Other,125% New York Medicaid APG,218.4,9473,
Drainage of kidney lesion,50390,CPT,,,,,,,,both,,,28765,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,14382.5,50,,14382.5,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1123.05,,,1123.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,20135.5,70,,20135.5,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,603.79,,,603.79,Other,New York Medicaid APG methodology,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,845.31,,,845.31,Other,140% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1569.85,,,1569.85,Other,260% New York Medicaid APG,1956.28,,,1956.28,Other,324% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,754.74,,,754.74,Other,125% New York Medicaid APG,603.79,20135.5,
Instll rx agnt into rnal tub,50391,CPT,,,,,,,,both,,,35086.55,469.99,,,469.99,Other,150% of Medicare + 9.63% HCRA Surcharge,285.8,,,285.8,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17543.28,50,,17543.28,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1123.05,,,1123.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24560.59,70,,24560.59,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,603.79,,,603.79,Other,New York Medicaid APG methodology,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,845.31,,,845.31,Other,140% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1569.85,,,1569.85,Other,260% New York Medicaid APG,1956.28,,,1956.28,Other,324% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,754.74,,,754.74,Other,125% New York Medicaid APG,285.8,24560.59,
Measure kidney pressure,50396,CPT,,,,,,,,both,,,14368.32,1299.03,,,1299.03,Other,150% of Medicare + 9.63% HCRA Surcharge,789.95,,,789.95,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7184.16,50,,7184.16,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1123.05,,,1123.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10057.82,70,,10057.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,603.79,,,603.79,Other,New York Medicaid APG methodology,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,845.31,,,845.31,Other,140% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1569.85,,,1569.85,Other,260% New York Medicaid APG,1956.28,,,1956.28,Other,324% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,754.74,,,754.74,Other,125% New York Medicaid APG,603.79,13157,
Njx px nfrosgrm &/urtrgrm,50430,CPT,,,,,,,,both,,,14368.32,1299.03,,,1299.03,Other,150% of Medicare + 9.63% HCRA Surcharge,789.95,,,789.95,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7184.16,50,,7184.16,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1123.05,,,1123.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10057.82,70,,10057.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,603.79,,,603.79,Other,New York Medicaid APG methodology,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,845.31,,,845.31,Other,140% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1569.85,,,1569.85,Other,260% New York Medicaid APG,1956.28,,,1956.28,Other,324% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,754.74,,,754.74,Other,125% New York Medicaid APG,603.79,13157,
Njx px nfrosgrm &/urtrgrm,50431,CPT,,,,,,,,both,,,14368.32,1299.03,,,1299.03,Other,150% of Medicare + 9.63% HCRA Surcharge,789.95,,,789.95,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7184.16,50,,7184.16,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1123.05,,,1123.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10057.82,70,,10057.82,percent of total billed charges,,318.45,,,318.45,Fee Schedule,,270.2,,,270.2,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,603.79,,,603.79,Other,New York Medicaid APG methodology,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,845.31,,,845.31,Other,140% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1569.85,,,1569.85,Other,260% New York Medicaid APG,1956.28,,,1956.28,Other,324% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,754.74,,,754.74,Other,125% New York Medicaid APG,270.2,10057.82,
Plmt nephrostomy catheter,50432,CPT,,,,,,,,both,,,18708.67,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,9354.34,50,,9354.34,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2557.09,,,2557.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13096.07,70,,13096.07,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1374.78,,,1374.78,Other,New York Medicaid APG methodology,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,1924.69,,,1924.69,Other,140% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3574.43,,,3574.43,Other,260% New York Medicaid APG,4454.28,,,4454.28,Other,324% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,1718.47,,,1718.47,Other,125% New York Medicaid APG,1374.78,13157,
Plmt nephroureteral catheter,50433,CPT,,,,,,,,both,,,31502,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,15751,50,,15751,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3301.55,,,3301.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22051.4,70,,22051.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1775.02,,,1775.02,Other,New York Medicaid APG methodology,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,2485.03,,,2485.03,Other,140% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,4615.06,,,4615.06,Other,260% New York Medicaid APG,5751.08,,,5751.08,Other,324% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,2218.78,,,2218.78,Other,125% New York Medicaid APG,1775.02,22051.4,
Convert nephrostomy catheter,50434,CPT,,,,,,,,both,,,42841.82,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21420.91,50,,21420.91,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2557.09,,,2557.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29989.27,70,,29989.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1374.78,,,1374.78,Other,New York Medicaid APG methodology,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,1924.69,,,1924.69,Other,140% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3574.43,,,3574.43,Other,260% New York Medicaid APG,4454.28,,,4454.28,Other,324% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,1718.47,,,1718.47,Other,125% New York Medicaid APG,1374.78,29989.27,
Exchange nephrostomy cath,50435,CPT,,,,,,,,both,,,21380.09,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,10690.05,50,,10690.05,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2557.09,,,2557.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,14966.06,70,,14966.06,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1374.78,,,1374.78,Other,New York Medicaid APG methodology,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,1924.69,,,1924.69,Other,140% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3574.43,,,3574.43,Other,260% New York Medicaid APG,4454.28,,,4454.28,Other,324% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,1718.47,,,1718.47,Other,125% New York Medicaid APG,1374.78,14966.06,
Dilat xst trc ndurlgc px,50436,CPT,,,,,,,,both,,,48568.73,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24284.37,50,,24284.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2557.09,,,2557.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,33998.11,70,,33998.11,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1374.78,,,1374.78,Other,New York Medicaid APG methodology,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,1924.69,,,1924.69,Other,140% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3574.43,,,3574.43,Other,260% New York Medicaid APG,4454.28,,,4454.28,Other,324% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,1718.47,,,1718.47,Other,125% New York Medicaid APG,1374.78,33998.11,
Dilat xst trc new access rcs,50437,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2557.09,,,2557.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1374.78,,,1374.78,Other,New York Medicaid APG methodology,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,1924.69,,,1924.69,Other,140% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3574.43,,,3574.43,Other,260% New York Medicaid APG,4454.28,,,4454.28,Other,324% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,1718.47,,,1718.47,Other,125% New York Medicaid APG,1374.78,51328.82,
Laparo ablate renal cyst,50541,CPT,,,,,,,,both,,,43179.12,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,21589.56,50,,21589.56,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3301.55,,,3301.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,30225.38,70,,30225.38,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1775.02,,,1775.02,Other,New York Medicaid APG methodology,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,2485.03,,,2485.03,Other,140% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,4615.06,,,4615.06,Other,260% New York Medicaid APG,5751.08,,,5751.08,Other,324% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,2218.78,,,2218.78,Other,125% New York Medicaid APG,1775.02,30225.38,
Laparo ablate renal mass,50542,CPT,,,,,,,,both,,,216515.17,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,108257.59,50,,108257.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4401.21,,,4401.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,151560.62,70,,151560.62,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,2366.24,,,2366.24,Other,New York Medicaid APG methodology,2366.24,,,2366.24,Other,100% New York Medicaid APG,2366.24,,,2366.24,Other,100% New York Medicaid APG,2366.24,,,2366.24,Other,100% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,3312.74,,,3312.74,Other,140% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,6152.23,,,6152.23,Other,260% New York Medicaid APG,7666.62,,,7666.62,Other,324% New York Medicaid APG,5087.42,,,5087.42,Other,215% New York Medicaid APG,5087.42,,,5087.42,Other,215% New York Medicaid APG,2957.8,,,2957.8,Other,125% New York Medicaid APG,2366.24,151560.62,
Laparo partial nephrectomy,50543,CPT,,,,,,,,both,,,53399.3,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,26699.65,50,,26699.65,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4401.21,,,4401.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,37379.51,70,,37379.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2366.24,,,2366.24,Other,New York Medicaid APG methodology,2366.24,,,2366.24,Other,100% New York Medicaid APG,2366.24,,,2366.24,Other,100% New York Medicaid APG,2366.24,,,2366.24,Other,100% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,3312.74,,,3312.74,Other,140% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,6152.23,,,6152.23,Other,260% New York Medicaid APG,7666.62,,,7666.62,Other,324% New York Medicaid APG,5087.42,,,5087.42,Other,215% New York Medicaid APG,5087.42,,,5087.42,Other,215% New York Medicaid APG,2957.8,,,2957.8,Other,125% New York Medicaid APG,2366.24,37379.51,
Laparoscopy pyeloplasty,50544,CPT,,,,,,,,both,,,44766.15,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,22383.08,50,,22383.08,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4401.21,,,4401.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31336.31,70,,31336.31,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2366.24,,,2366.24,Other,New York Medicaid APG methodology,2366.24,,,2366.24,Other,100% New York Medicaid APG,2366.24,,,2366.24,Other,100% New York Medicaid APG,2366.24,,,2366.24,Other,100% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,3312.74,,,3312.74,Other,140% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,6152.23,,,6152.23,Other,260% New York Medicaid APG,7666.62,,,7666.62,Other,324% New York Medicaid APG,5087.42,,,5087.42,Other,215% New York Medicaid APG,5087.42,,,5087.42,Other,215% New York Medicaid APG,2957.8,,,2957.8,Other,125% New York Medicaid APG,2366.24,31336.31,
Kidney endoscopy,50551,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3301.55,,,3301.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1775.02,,,1775.02,Other,New York Medicaid APG methodology,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,2485.03,,,2485.03,Other,140% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,4615.06,,,4615.06,Other,260% New York Medicaid APG,5751.08,,,5751.08,Other,324% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,2218.78,,,2218.78,Other,125% New York Medicaid APG,1775.02,76185.18,
Kidney endoscopy,50553,CPT,,,,,,,,both,,,36540,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,18270,50,,18270,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3301.55,,,3301.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25578,70,,25578,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1775.02,,,1775.02,Other,New York Medicaid APG methodology,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,2485.03,,,2485.03,Other,140% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,4615.06,,,4615.06,Other,260% New York Medicaid APG,5751.08,,,5751.08,Other,324% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,2218.78,,,2218.78,Other,125% New York Medicaid APG,1775.02,25578,
Kidney endoscopy & biopsy,50555,CPT,,,,,,,,both,,,193769.26,17518.56,,,17518.56,Other,150% of Medicare + 9.63% HCRA Surcharge,10653.14,,,10653.14,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,96884.63,50,,96884.63,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3301.55,,,3301.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,135638.48,70,,135638.48,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1775.02,,,1775.02,Other,New York Medicaid APG methodology,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,2485.03,,,2485.03,Other,140% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,4615.06,,,4615.06,Other,260% New York Medicaid APG,5751.08,,,5751.08,Other,324% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,2218.78,,,2218.78,Other,125% New York Medicaid APG,1775.02,135638.48,
Kidney endoscopy & treatment,50557,CPT,,,,,,,,both,,,57942.78,17518.56,,,17518.56,Other,150% of Medicare + 9.63% HCRA Surcharge,10653.14,,,10653.14,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,28971.39,50,,28971.39,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3301.55,,,3301.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,40559.95,70,,40559.95,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1775.02,,,1775.02,Other,New York Medicaid APG methodology,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,2485.03,,,2485.03,Other,140% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,4615.06,,,4615.06,Other,260% New York Medicaid APG,5751.08,,,5751.08,Other,324% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,2218.78,,,2218.78,Other,125% New York Medicaid APG,1775.02,40559.95,
Kidney endoscopy & treatment,50561,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3301.55,,,3301.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1775.02,,,1775.02,Other,New York Medicaid APG methodology,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,2485.03,,,2485.03,Other,140% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,4615.06,,,4615.06,Other,260% New York Medicaid APG,5751.08,,,5751.08,Other,324% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,2218.78,,,2218.78,Other,125% New York Medicaid APG,1775.02,76185.18,
Renal scope w/tumor resect,50562,CPT,,,,,,,,both,,,193769.26,17518.56,,,17518.56,Other,150% of Medicare + 9.63% HCRA Surcharge,10653.14,,,10653.14,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,96884.63,50,,96884.63,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3301.55,,,3301.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,135638.48,70,,135638.48,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1775.02,,,1775.02,Other,New York Medicaid APG methodology,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,2485.03,,,2485.03,Other,140% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,4615.06,,,4615.06,Other,260% New York Medicaid APG,5751.08,,,5751.08,Other,324% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,2218.78,,,2218.78,Other,125% New York Medicaid APG,1775.02,135638.48,
Kidney endoscopy,50570,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3301.55,,,3301.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1775.02,,,1775.02,Other,New York Medicaid APG methodology,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,2485.03,,,2485.03,Other,140% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,4615.06,,,4615.06,Other,260% New York Medicaid APG,5751.08,,,5751.08,Other,324% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,2218.78,,,2218.78,Other,125% New York Medicaid APG,1775.02,51328.82,
Kidney endoscopy,50572,CPT,,,,,,,,both,,,14368.32,1299.03,,,1299.03,Other,150% of Medicare + 9.63% HCRA Surcharge,789.95,,,789.95,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7184.16,50,,7184.16,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2557.09,,,2557.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10057.82,70,,10057.82,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1374.78,,,1374.78,Other,New York Medicaid APG methodology,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,1924.69,,,1924.69,Other,140% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3574.43,,,3574.43,Other,260% New York Medicaid APG,4454.28,,,4454.28,Other,324% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,1718.47,,,1718.47,Other,125% New York Medicaid APG,789.95,10057.82,
Kidney endoscopy & biopsy,50574,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3301.55,,,3301.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1775.02,,,1775.02,Other,New York Medicaid APG methodology,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,2485.03,,,2485.03,Other,140% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,4615.06,,,4615.06,Other,260% New York Medicaid APG,5751.08,,,5751.08,Other,324% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,2218.78,,,2218.78,Other,125% New York Medicaid APG,1775.02,51328.82,
Kidney endoscopy,50575,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3301.55,,,3301.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1775.02,,,1775.02,Other,New York Medicaid APG methodology,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,2485.03,,,2485.03,Other,140% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,4615.06,,,4615.06,Other,260% New York Medicaid APG,5751.08,,,5751.08,Other,324% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,2218.78,,,2218.78,Other,125% New York Medicaid APG,1775.02,76185.18,
Kidney endoscopy & treatment,50576,CPT,,,,,,,,both,,,193769.26,17518.56,,,17518.56,Other,150% of Medicare + 9.63% HCRA Surcharge,10653.14,,,10653.14,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,96884.63,50,,96884.63,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3301.55,,,3301.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,135638.48,70,,135638.48,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1775.02,,,1775.02,Other,New York Medicaid APG methodology,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,2485.03,,,2485.03,Other,140% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,4615.06,,,4615.06,Other,260% New York Medicaid APG,5751.08,,,5751.08,Other,324% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,2218.78,,,2218.78,Other,125% New York Medicaid APG,1775.02,135638.48,
Kidney endoscopy & treatment,50580,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3301.55,,,3301.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1775.02,,,1775.02,Other,New York Medicaid APG methodology,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,2485.03,,,2485.03,Other,140% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,4615.06,,,4615.06,Other,260% New York Medicaid APG,5751.08,,,5751.08,Other,324% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,2218.78,,,2218.78,Other,125% New York Medicaid APG,1775.02,76185.18,
Fragmenting of kidney stone,50590,CPT,,,,,,,,both,,,33416.74,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,15382,,"100% primary, 50% supplemental procedure",15382,Other,Aetna ASC Grouper,13844,,"100% primary, 50% supplemental procedure",13844,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,16708.37,50,,16708.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3301.55,,,3301.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23391.72,70,,23391.72,percent of total billed charges,,2786.85,,,2786.85,Fee Schedule,,2364.6,,,2364.6,Fee Schedule,,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,1775.02,,,1775.02,Other,New York Medicaid APG methodology,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,2485.03,,,2485.03,Other,140% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,4615.06,,,4615.06,Other,260% New York Medicaid APG,5751.08,,,5751.08,Other,324% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,2218.78,,,2218.78,Other,125% New York Medicaid APG,1775.02,23391.72,
Perc rf ablate renal tumor,50592,CPT,,,,,,,,both,,,39799.33,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,19899.67,50,,19899.67,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3301.55,,,3301.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27859.53,70,,27859.53,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,1775.02,,,1775.02,Other,New York Medicaid APG methodology,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,2485.03,,,2485.03,Other,140% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,4615.06,,,4615.06,Other,260% New York Medicaid APG,5751.08,,,5751.08,Other,324% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,2218.78,,,2218.78,Other,125% New York Medicaid APG,1775.02,27859.53,
Perc cryo ablate renal tum,50593,CPT,,,,,,,,both,,,216515.17,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,15382,,"100% primary, 50% supplemental procedure",15382,Other,Aetna ASC Grouper,13844,,"100% primary, 50% supplemental procedure",13844,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,108257.59,50,,108257.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4401.21,,,4401.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,151560.62,70,,151560.62,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2366.24,,,2366.24,Other,New York Medicaid APG methodology,2366.24,,,2366.24,Other,100% New York Medicaid APG,2366.24,,,2366.24,Other,100% New York Medicaid APG,2366.24,,,2366.24,Other,100% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,3312.74,,,3312.74,Other,140% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,6152.23,,,6152.23,Other,260% New York Medicaid APG,7666.62,,,7666.62,Other,324% New York Medicaid APG,5087.42,,,5087.42,Other,215% New York Medicaid APG,5087.42,,,5087.42,Other,215% New York Medicaid APG,2957.8,,,2957.8,Other,125% New York Medicaid APG,2366.24,151560.62,
Endoluminal bx urtr rnl plvs,50606,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,4401.21,,,4401.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2366.24,,,2366.24,Other,New York Medicaid APG methodology,2366.24,,,2366.24,Other,100% New York Medicaid APG,2366.24,,,2366.24,Other,100% New York Medicaid APG,2366.24,,,2366.24,Other,100% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,3312.74,,,3312.74,Other,140% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,6152.23,,,6152.23,Other,260% New York Medicaid APG,7666.62,,,7666.62,Other,324% New York Medicaid APG,5087.42,,,5087.42,Other,215% New York Medicaid APG,5087.42,,,5087.42,Other,215% New York Medicaid APG,2957.8,,,2957.8,Other,125% New York Medicaid APG,0.01,22702.47,
Injection for ureter x-ray,50684,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1205.26,,,1205.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,247.5,,,247.5,Fee Schedule,,210,,,210,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.99,,,647.99,Other,New York Medicaid APG methodology,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,907.18,,,907.18,Other,140% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1684.77,,,1684.77,Other,260% New York Medicaid APG,2099.48,,,2099.48,Other,324% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,809.98,,,809.98,Other,125% New York Medicaid APG,0.01,22702.47,
Measure ureter pressure,50686,CPT,,,,,,,,both,,,3285.56,297.05,,,297.05,Other,150% of Medicare + 9.63% HCRA Surcharge,180.63,,,180.63,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1642.78,50,,1642.78,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1051.03,,,1051.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2299.89,70,,2299.89,percent of total billed charges,,427.35,,,427.35,Fee Schedule,,362.6,,,362.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,565.07,,,565.07,Other,New York Medicaid APG methodology,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,791.1,,,791.1,Other,140% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1469.19,,,1469.19,Other,260% New York Medicaid APG,1830.83,,,1830.83,Other,324% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,706.34,,,706.34,Other,125% New York Medicaid APG,0.01,9473,
Change of ureter tube/stent,50688,CPT,,,,,,,,both,,,42841.82,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21420.91,50,,21420.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2557.09,,,2557.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29989.27,70,,29989.27,percent of total billed charges,,376.2,,,376.2,Fee Schedule,,319.2,,,319.2,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1374.78,,,1374.78,Other,New York Medicaid APG methodology,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,1924.69,,,1924.69,Other,140% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3574.43,,,3574.43,Other,260% New York Medicaid APG,4454.28,,,4454.28,Other,324% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,1718.47,,,1718.47,Other,125% New York Medicaid APG,319.2,29989.27,
Injection for ureter x-ray,50690,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1205.26,,,1205.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,339.9,,,339.9,Fee Schedule,,288.4,,,288.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.99,,,647.99,Other,New York Medicaid APG methodology,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,907.18,,,907.18,Other,140% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1684.77,,,1684.77,Other,260% New York Medicaid APG,2099.48,,,2099.48,Other,324% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,809.98,,,809.98,Other,125% New York Medicaid APG,0.01,22702.47,
Plmt ureteral stent prq,50693,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3301.55,,,3301.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1775.02,,,1775.02,Other,New York Medicaid APG methodology,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,2485.03,,,2485.03,Other,140% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,4615.06,,,4615.06,Other,260% New York Medicaid APG,5751.08,,,5751.08,Other,324% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,2218.78,,,2218.78,Other,125% New York Medicaid APG,1775.02,51328.82,
Plmt ureteral stent prq,50694,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3301.55,,,3301.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1775.02,,,1775.02,Other,New York Medicaid APG methodology,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,2485.03,,,2485.03,Other,140% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,4615.06,,,4615.06,Other,260% New York Medicaid APG,5751.08,,,5751.08,Other,324% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,2218.78,,,2218.78,Other,125% New York Medicaid APG,1775.02,51328.82,
Plmt ureteral stent prq,50695,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3301.55,,,3301.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1775.02,,,1775.02,Other,New York Medicaid APG methodology,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,2485.03,,,2485.03,Other,140% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,4615.06,,,4615.06,Other,260% New York Medicaid APG,5751.08,,,5751.08,Other,324% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,2218.78,,,2218.78,Other,125% New York Medicaid APG,1775.02,51328.82,
Ureteral embolization/occl,50705,CPT,,,,,,,,both,,,64479.48,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32239.74,50,,32239.74,percent of total billed charges,,45135.64,70,,45135.64,percent of total billed charges,,6152,,,6152,Case Rate,,4401.21,,,4401.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45135.64,70,,45135.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2366.24,,,2366.24,Other,New York Medicaid APG methodology,2366.24,,,2366.24,Other,100% New York Medicaid APG,2366.24,,,2366.24,Other,100% New York Medicaid APG,2366.24,,,2366.24,Other,100% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,3312.74,,,3312.74,Other,140% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,6152.23,,,6152.23,Other,260% New York Medicaid APG,7666.62,,,7666.62,Other,324% New York Medicaid APG,5087.42,,,5087.42,Other,215% New York Medicaid APG,5087.42,,,5087.42,Other,215% New York Medicaid APG,2957.8,,,2957.8,Other,125% New York Medicaid APG,0.01,45135.64,
Balloon dilate urtrl strix,50706,CPT,,,,,,,,both,,,64479.48,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32239.74,50,,32239.74,percent of total billed charges,,45135.64,70,,45135.64,percent of total billed charges,,6152,,,6152,Case Rate,,4401.21,,,4401.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45135.64,70,,45135.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2366.24,,,2366.24,Other,New York Medicaid APG methodology,2366.24,,,2366.24,Other,100% New York Medicaid APG,2366.24,,,2366.24,Other,100% New York Medicaid APG,2366.24,,,2366.24,Other,100% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,3312.74,,,3312.74,Other,140% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,6152.23,,,6152.23,Other,260% New York Medicaid APG,7666.62,,,7666.62,Other,324% New York Medicaid APG,5087.42,,,5087.42,Other,215% New York Medicaid APG,5087.42,,,5087.42,Other,215% New York Medicaid APG,2957.8,,,2957.8,Other,125% New York Medicaid APG,0.01,45135.64,
Revise ureter,50727,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,51328.82,
Laparoscopy ureterolithotomy,50945,CPT,,,,,,,,both,,,121364.27,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,60682.14,50,,60682.14,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3301.55,,,3301.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84954.99,70,,84954.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,1775.02,,,1775.02,Other,New York Medicaid APG methodology,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,2485.03,,,2485.03,Other,140% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,4615.06,,,4615.06,Other,260% New York Medicaid APG,5751.08,,,5751.08,Other,324% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,2218.78,,,2218.78,Other,125% New York Medicaid APG,1775.02,84954.99,
Laparo new ureter/bladder,50947,CPT,,,,,,,,both,,,216515.17,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,108257.59,50,,108257.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4401.21,,,4401.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,151560.62,70,,151560.62,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2366.24,,,2366.24,Other,New York Medicaid APG methodology,2366.24,,,2366.24,Other,100% New York Medicaid APG,2366.24,,,2366.24,Other,100% New York Medicaid APG,2366.24,,,2366.24,Other,100% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,3312.74,,,3312.74,Other,140% New York Medicaid APG,5324.04,,,5324.04,Other,225% New York Medicaid APG,6152.23,,,6152.23,Other,260% New York Medicaid APG,7666.62,,,7666.62,Other,324% New York Medicaid APG,5087.42,,,5087.42,Other,215% New York Medicaid APG,5087.42,,,5087.42,Other,215% New York Medicaid APG,2957.8,,,2957.8,Other,125% New York Medicaid APG,2366.24,151560.62,
Laparo new ureter/bladder,50948,CPT,,,,,,,,both,,,216515.17,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,108257.59,50,,108257.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3301.55,,,3301.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,151560.62,70,,151560.62,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,1775.02,,,1775.02,Other,New York Medicaid APG methodology,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,2485.03,,,2485.03,Other,140% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,4615.06,,,4615.06,Other,260% New York Medicaid APG,5751.08,,,5751.08,Other,324% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,2218.78,,,2218.78,Other,125% New York Medicaid APG,1775.02,151560.62,
Endoscopy of ureter,50951,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2557.09,,,2557.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1374.78,,,1374.78,Other,New York Medicaid APG methodology,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,1924.69,,,1924.69,Other,140% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3574.43,,,3574.43,Other,260% New York Medicaid APG,4454.28,,,4454.28,Other,324% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,1718.47,,,1718.47,Other,125% New York Medicaid APG,1374.78,51328.82,
Endoscopy of ureter,50953,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2557.09,,,2557.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1374.78,,,1374.78,Other,New York Medicaid APG methodology,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,1924.69,,,1924.69,Other,140% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3574.43,,,3574.43,Other,260% New York Medicaid APG,4454.28,,,4454.28,Other,324% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,1718.47,,,1718.47,Other,125% New York Medicaid APG,1374.78,51328.82,
Ureter endoscopy & biopsy,50955,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3301.55,,,3301.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1775.02,,,1775.02,Other,New York Medicaid APG methodology,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,2485.03,,,2485.03,Other,140% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,4615.06,,,4615.06,Other,260% New York Medicaid APG,5751.08,,,5751.08,Other,324% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,2218.78,,,2218.78,Other,125% New York Medicaid APG,1775.02,76185.18,
Ureter endoscopy & treatment,50957,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3301.55,,,3301.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1775.02,,,1775.02,Other,New York Medicaid APG methodology,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,2485.03,,,2485.03,Other,140% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,4615.06,,,4615.06,Other,260% New York Medicaid APG,5751.08,,,5751.08,Other,324% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,2218.78,,,2218.78,Other,125% New York Medicaid APG,1775.02,76185.18,
Ureter endoscopy & treatment,50961,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3301.55,,,3301.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1775.02,,,1775.02,Other,New York Medicaid APG methodology,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,2485.03,,,2485.03,Other,140% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,4615.06,,,4615.06,Other,260% New York Medicaid APG,5751.08,,,5751.08,Other,324% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,2218.78,,,2218.78,Other,125% New York Medicaid APG,1775.02,76185.18,
Ureter endoscopy,50970,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2557.09,,,2557.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1374.78,,,1374.78,Other,New York Medicaid APG methodology,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,1924.69,,,1924.69,Other,140% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3574.43,,,3574.43,Other,260% New York Medicaid APG,4454.28,,,4454.28,Other,324% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,1718.47,,,1718.47,Other,125% New York Medicaid APG,1374.78,51328.82,
Ureter endoscopy & catheter,50972,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2557.09,,,2557.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1374.78,,,1374.78,Other,New York Medicaid APG methodology,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,1924.69,,,1924.69,Other,140% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3574.43,,,3574.43,Other,260% New York Medicaid APG,4454.28,,,4454.28,Other,324% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,1718.47,,,1718.47,Other,125% New York Medicaid APG,1374.78,51328.82,
Ureter endoscopy & biopsy,50974,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3301.55,,,3301.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1775.02,,,1775.02,Other,New York Medicaid APG methodology,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,2485.03,,,2485.03,Other,140% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,4615.06,,,4615.06,Other,260% New York Medicaid APG,5751.08,,,5751.08,Other,324% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,2218.78,,,2218.78,Other,125% New York Medicaid APG,1775.02,76185.18,
Ureter endoscopy & treatment,50976,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3301.55,,,3301.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1775.02,,,1775.02,Other,New York Medicaid APG methodology,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,2485.03,,,2485.03,Other,140% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,4615.06,,,4615.06,Other,260% New York Medicaid APG,5751.08,,,5751.08,Other,324% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,2218.78,,,2218.78,Other,125% New York Medicaid APG,1775.02,76185.18,
Ureter endoscopy & treatment,50980,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3301.55,,,3301.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1775.02,,,1775.02,Other,New York Medicaid APG methodology,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,2485.03,,,2485.03,Other,140% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,4615.06,,,4615.06,Other,260% New York Medicaid APG,5751.08,,,5751.08,Other,324% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,2218.78,,,2218.78,Other,125% New York Medicaid APG,1775.02,76185.18,
Incise & treat bladder,51020,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,51328.82,
Incise & treat bladder,51030,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,51328.82,
Incise & drain bladder,51040,CPT,,,,,,,,both,,,31647.7,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,15823.85,50,,15823.85,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22153.39,70,,22153.39,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,22153.39,
Incise bladder/drain ureter,51045,CPT,,,,,,,,both,,,42841.82,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21420.91,50,,21420.91,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29989.27,70,,29989.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,29989.27,
Removal of bladder stone,51050,CPT,,,,,,,,both,,,35106.99,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,17553.5,50,,17553.5,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4370.69,,,4370.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24574.89,70,,24574.89,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2349.83,,,2349.83,Other,New York Medicaid APG methodology,2349.83,,,2349.83,Other,100% New York Medicaid APG,2349.83,,,2349.83,Other,100% New York Medicaid APG,2349.83,,,2349.83,Other,100% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,3289.76,,,3289.76,Other,140% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,6109.56,,,6109.56,Other,260% New York Medicaid APG,7613.45,,,7613.45,Other,324% New York Medicaid APG,5052.14,,,5052.14,Other,215% New York Medicaid APG,5052.14,,,5052.14,Other,215% New York Medicaid APG,2937.29,,,2937.29,Other,125% New York Medicaid APG,2349.83,24574.89,
Removal of ureter stone,51060,CPT,,,,,,,,both,,,42841.82,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21420.91,50,,21420.91,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2557.09,,,2557.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29989.27,70,,29989.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1374.78,,,1374.78,Other,New York Medicaid APG methodology,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,1924.69,,,1924.69,Other,140% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3574.43,,,3574.43,Other,260% New York Medicaid APG,4454.28,,,4454.28,Other,324% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,1718.47,,,1718.47,Other,125% New York Medicaid APG,1374.78,29989.27,
Remove ureter calculus,51065,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,51328.82,
Drainage of bladder abscess,51080,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,41837.04,
Drain bladder by needle,51100,CPT,,,,,,,,both,,,5198.43,469.99,,,469.99,Other,150% of Medicare + 9.63% HCRA Surcharge,285.8,,,285.8,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2599.22,50,,2599.22,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1123.05,,,1123.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3638.9,70,,3638.9,percent of total billed charges,,189.75,,,189.75,Fee Schedule,,161,,,161,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,603.79,,,603.79,Other,New York Medicaid APG methodology,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,845.31,,,845.31,Other,140% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1569.85,,,1569.85,Other,260% New York Medicaid APG,1956.28,,,1956.28,Other,324% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,754.74,,,754.74,Other,125% New York Medicaid APG,0.01,9473,
Drain bladder by trocar/cath,51101,CPT,,,,,,,,both,,,21991.57,1988.24,,,1988.24,Other,150% of Medicare + 9.63% HCRA Surcharge,1209.06,,,1209.06,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,10995.79,50,,10995.79,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1123.05,,,1123.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,15394.1,70,,15394.1,percent of total billed charges,,245.85,,,245.85,Fee Schedule,,208.6,,,208.6,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,603.79,,,603.79,Other,New York Medicaid APG methodology,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,845.31,,,845.31,Other,140% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1569.85,,,1569.85,Other,260% New York Medicaid APG,1956.28,,,1956.28,Other,324% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,754.74,,,754.74,Other,125% New York Medicaid APG,0.01,15394.1,
Drain bl w/cath insertion,51102,CPT,,,,,,,,both,,,24721.94,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,12360.97,50,,12360.97,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,17305.36,70,,17305.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,17305.36,
Removal of bladder cyst,51500,CPT,,,,,,,,both,,,121364.27,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,60682.14,50,,60682.14,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4664.81,,,4664.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84954.99,70,,84954.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2507.96,,,2507.96,Other,New York Medicaid APG methodology,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,2507.96,,,2507.96,Other,100% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,3511.14,,,3511.14,Other,140% New York Medicaid APG,5642.91,,,5642.91,Other,225% New York Medicaid APG,6520.7,,,6520.7,Other,260% New York Medicaid APG,8125.79,,,8125.79,Other,324% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,5392.12,,,5392.12,Other,215% New York Medicaid APG,3134.95,,,3134.95,Other,125% New York Medicaid APG,2507.96,84954.99,
Removal of bladder lesion,51520,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,51328.82,
Repair of ureter lesion,51535,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,51328.82,
Injection for bladder x-ray,51600,CPT,,,,,,,,both,,,11088.61,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5544.31,50,,5544.31,percent of total billed charges,,7762.03,70,,7762.03,percent of total billed charges,,6152,,,6152,Case Rate,,1205.26,,,1205.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,7762.03,70,,7762.03,percent of total billed charges,,212.85,,,212.85,Fee Schedule,,180.6,,,180.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.99,,,647.99,Other,New York Medicaid APG methodology,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,907.18,,,907.18,Other,140% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1684.77,,,1684.77,Other,260% New York Medicaid APG,2099.48,,,2099.48,Other,324% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,809.98,,,809.98,Other,125% New York Medicaid APG,0.01,9473,
Preparation for bladder xray,51605,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1205.26,,,1205.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,186.45,,,186.45,Fee Schedule,,158.2,,,158.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.99,,,647.99,Other,New York Medicaid APG methodology,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,907.18,,,907.18,Other,140% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1684.77,,,1684.77,Other,260% New York Medicaid APG,2099.48,,,2099.48,Other,324% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,809.98,,,809.98,Other,125% New York Medicaid APG,0.01,22702.47,
Injection for bladder x-ray,51610,CPT,,,,,,,,both,,,13768.75,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6884.38,50,,6884.38,percent of total billed charges,,9638.13,70,,9638.13,percent of total billed charges,,6152,,,6152,Case Rate,,1205.26,,,1205.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9638.13,70,,9638.13,percent of total billed charges,,311.85,,,311.85,Fee Schedule,,264.6,,,264.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.99,,,647.99,Other,New York Medicaid APG methodology,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,907.18,,,907.18,Other,140% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1684.77,,,1684.77,Other,260% New York Medicaid APG,2099.48,,,2099.48,Other,324% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,809.98,,,809.98,Other,125% New York Medicaid APG,0.01,9638.13,
Irrigation of bladder,51700,CPT,,,,,,,,both,,,31905.96,469.99,,,469.99,Other,150% of Medicare + 9.63% HCRA Surcharge,285.8,,,285.8,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,15952.98,50,,15952.98,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1051.03,,,1051.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22334.17,70,,22334.17,percent of total billed charges,,146.85,,,146.85,Fee Schedule,,124.6,,,124.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,565.07,,,565.07,Other,New York Medicaid APG methodology,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,791.1,,,791.1,Other,140% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1469.19,,,1469.19,Other,260% New York Medicaid APG,1830.83,,,1830.83,Other,324% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,706.34,,,706.34,Other,125% New York Medicaid APG,0.01,22334.17,
Insert bladder catheter,51701,CPT,,,,,,,,both,,,35280.75,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17640.38,50,,17640.38,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1051.03,,,1051.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24696.53,70,,24696.53,percent of total billed charges,,123.75,,,123.75,Fee Schedule,,105,,,105,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,565.07,,,565.07,Other,New York Medicaid APG methodology,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,791.1,,,791.1,Other,140% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1469.19,,,1469.19,Other,260% New York Medicaid APG,1830.83,,,1830.83,Other,324% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,706.34,,,706.34,Other,125% New York Medicaid APG,0.01,24696.53,
Insert temp bladder cath,51702,CPT,,,,,,,,both,,,2686.86,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1343.43,50,,1343.43,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1051.03,,,1051.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,1880.8,70,,1880.8,percent of total billed charges,,122.1,,,122.1,Fee Schedule,,103.6,,,103.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,565.07,,,565.07,Other,New York Medicaid APG methodology,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,791.1,,,791.1,Other,140% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1469.19,,,1469.19,Other,260% New York Medicaid APG,1830.83,,,1830.83,Other,324% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,706.34,,,706.34,Other,125% New York Medicaid APG,0.01,9473,
Insert bladder cath complex,51703,CPT,,,,,,,,both,,,3285.56,297.05,,,297.05,Other,150% of Medicare + 9.63% HCRA Surcharge,180.63,,,180.63,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1642.78,50,,1642.78,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1051.03,,,1051.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2299.89,70,,2299.89,percent of total billed charges,,371.25,,,371.25,Fee Schedule,,315,,,315,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,565.07,,,565.07,Other,New York Medicaid APG methodology,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,791.1,,,791.1,Other,140% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1469.19,,,1469.19,Other,260% New York Medicaid APG,1830.83,,,1830.83,Other,324% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,706.34,,,706.34,Other,125% New York Medicaid APG,180.63,9473,
Change of bladder tube,51705,CPT,,,,,,,,both,,,17435.51,469.99,,,469.99,Other,150% of Medicare + 9.63% HCRA Surcharge,285.8,,,285.8,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,8717.76,50,,8717.76,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1051.03,,,1051.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,12204.86,70,,12204.86,percent of total billed charges,,250.8,,,250.8,Fee Schedule,,212.8,,,212.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,565.07,,,565.07,Other,New York Medicaid APG methodology,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,791.1,,,791.1,Other,140% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1469.19,,,1469.19,Other,260% New York Medicaid APG,1830.83,,,1830.83,Other,324% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,706.34,,,706.34,Other,125% New York Medicaid APG,212.8,12204.86,
Change of bladder tube,51710,CPT,,,,,,,,both,,,35147.83,1299.03,,,1299.03,Other,150% of Medicare + 9.63% HCRA Surcharge,789.95,,,789.95,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17573.92,50,,17573.92,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1123.05,,,1123.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24603.48,70,,24603.48,percent of total billed charges,,389.4,,,389.4,Fee Schedule,,330.4,,,330.4,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,603.79,,,603.79,Other,New York Medicaid APG methodology,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,845.31,,,845.31,Other,140% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1569.85,,,1569.85,Other,260% New York Medicaid APG,1956.28,,,1956.28,Other,324% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,754.74,,,754.74,Other,125% New York Medicaid APG,330.4,24603.48,
Endoscopic injection/implant,51715,CPT,,,,,,,,both,,,32444.16,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,16222.08,50,,16222.08,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22710.91,70,,22710.91,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,22710.91,
Treatment of bladder lesion,51720,CPT,,,,,,,,both,,,98730.7,1299.03,,,1299.03,Other,150% of Medicare + 9.63% HCRA Surcharge,789.95,,,789.95,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,49365.35,50,,49365.35,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1123.05,,,1123.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,69111.49,70,,69111.49,percent of total billed charges,,212.85,,,212.85,Fee Schedule,,180.6,,,180.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,603.79,,,603.79,Other,New York Medicaid APG methodology,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,845.31,,,845.31,Other,140% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1569.85,,,1569.85,Other,260% New York Medicaid APG,1956.28,,,1956.28,Other,324% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,754.74,,,754.74,Other,125% New York Medicaid APG,180.6,69111.49,
Simple cystometrogram,51725,CPT,,,,,,,,both,,,5198.43,469.99,,,469.99,Other,150% of Medicare + 9.63% HCRA Surcharge,285.8,,,285.8,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,1222.25,,,1222.25,Fee Schedule,,1099.69,,,1099.69,Fee Schedule,,1038.4,,,1038.4,Fee Schedule,,2599.22,50,,2599.22,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1123.05,,,1123.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3638.9,70,,3638.9,percent of total billed charges,,2599.22,50,,2599.22,percent of total billed charges,,2599.22,50,,2599.22,percent of total billed charges,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,603.79,,,603.79,Other,New York Medicaid APG methodology,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,845.31,,,845.31,Other,140% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1569.85,,,1569.85,Other,260% New York Medicaid APG,1956.28,,,1956.28,Other,324% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,754.74,,,754.74,Other,125% New York Medicaid APG,285.8,9473,
Complex cystometrogram,51726,CPT,,,,,,,,both,,,5198.43,469.99,,,469.99,Other,150% of Medicare + 9.63% HCRA Surcharge,285.8,,,285.8,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,2014.42,,,2014.42,Fee Schedule,,1812.42,,,1812.42,Fee Schedule,,1711.42,,,1711.42,Fee Schedule,,2599.22,50,,2599.22,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1123.05,,,1123.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3638.9,70,,3638.9,percent of total billed charges,,2599.22,50,,2599.22,percent of total billed charges,,2599.22,50,,2599.22,percent of total billed charges,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,603.79,,,603.79,Other,New York Medicaid APG methodology,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,845.31,,,845.31,Other,140% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1569.85,,,1569.85,Other,260% New York Medicaid APG,1956.28,,,1956.28,Other,324% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,754.74,,,754.74,Other,125% New York Medicaid APG,285.8,9473,
Cystometrogram w/up,51727,CPT,,,,,,,,both,,,14368.32,1299.03,,,1299.03,Other,150% of Medicare + 9.63% HCRA Surcharge,789.95,,,789.95,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,1805.27,,,1805.27,Fee Schedule,,1624.24,,,1624.24,Fee Schedule,,1533.72,,,1533.72,Fee Schedule,,7184.16,50,,7184.16,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1123.05,,,1123.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10057.82,70,,10057.82,percent of total billed charges,,7184.16,50,,7184.16,percent of total billed charges,,7184.16,50,,7184.16,percent of total billed charges,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,603.79,,,603.79,Other,New York Medicaid APG methodology,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,845.31,,,845.31,Other,140% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1569.85,,,1569.85,Other,260% New York Medicaid APG,1956.28,,,1956.28,Other,324% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,754.74,,,754.74,Other,125% New York Medicaid APG,0.01,10057.82,
Cystometrogram w/vp,51728,CPT,,,,,,,,both,,,13756.02,1299.03,,,1299.03,Other,150% of Medicare + 9.63% HCRA Surcharge,789.95,,,789.95,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,1799.02,,,1799.02,Fee Schedule,,1618.62,,,1618.62,Fee Schedule,,1528.42,,,1528.42,Fee Schedule,,6878.01,50,,6878.01,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1123.05,,,1123.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9629.21,70,,9629.21,percent of total billed charges,,6878.01,50,,6878.01,percent of total billed charges,,6878.01,50,,6878.01,percent of total billed charges,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,603.79,,,603.79,Other,New York Medicaid APG methodology,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,845.31,,,845.31,Other,140% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1569.85,,,1569.85,Other,260% New York Medicaid APG,1956.28,,,1956.28,Other,324% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,754.74,,,754.74,Other,125% New York Medicaid APG,0.01,9629.21,
Cystometrogram w/vp&up,51729,CPT,,,,,,,,both,,,16915.05,1299.03,,,1299.03,Other,150% of Medicare + 9.63% HCRA Surcharge,789.95,,,789.95,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,1861.42,,,1861.42,Fee Schedule,,1674.76,,,1674.76,Fee Schedule,,1581.43,,,1581.43,Fee Schedule,,8457.53,50,,8457.53,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1123.05,,,1123.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,11840.54,70,,11840.54,percent of total billed charges,,8457.53,50,,8457.53,percent of total billed charges,,8457.53,50,,8457.53,percent of total billed charges,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,603.79,,,603.79,Other,New York Medicaid APG methodology,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,845.31,,,845.31,Other,140% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1569.85,,,1569.85,Other,260% New York Medicaid APG,1956.28,,,1956.28,Other,324% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,754.74,,,754.74,Other,125% New York Medicaid APG,0.01,11840.54,
Urine flow measurement,51736,CPT,,,,,,,,both,,,2686.86,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,212.17,,,212.17,Fee Schedule,,190.89,,,190.89,Fee Schedule,,180.26,,,180.26,Fee Schedule,,1343.43,50,,1343.43,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1051.03,,,1051.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,1880.8,70,,1880.8,percent of total billed charges,,1343.43,50,,1343.43,percent of total billed charges,,1343.43,50,,1343.43,percent of total billed charges,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,565.07,,,565.07,Other,New York Medicaid APG methodology,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,791.1,,,791.1,Other,140% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1469.19,,,1469.19,Other,260% New York Medicaid APG,1830.83,,,1830.83,Other,324% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,706.34,,,706.34,Other,125% New York Medicaid APG,0.01,9473,
Electro-uroflowmetry first,51741,CPT,,,,,,,,both,,,3263,596.88,,,596.88,Other,150% of Medicare + 9.63% HCRA Surcharge,362.97,,,362.97,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,243.33,,,243.33,Fee Schedule,,218.93,,,218.93,Fee Schedule,,206.73,,,206.73,Fee Schedule,,1631.5,50,,1631.5,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1123.05,,,1123.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2284.1,70,,2284.1,percent of total billed charges,,1631.5,50,,1631.5,percent of total billed charges,,1631.5,50,,1631.5,percent of total billed charges,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,603.79,,,603.79,Other,New York Medicaid APG methodology,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,845.31,,,845.31,Other,140% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1569.85,,,1569.85,Other,260% New York Medicaid APG,1956.28,,,1956.28,Other,324% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,754.74,,,754.74,Other,125% New York Medicaid APG,0.01,9473,
Anal/urinary muscle study,51784,CPT,,,,,,,,both,,,3285.56,297.05,,,297.05,Other,150% of Medicare + 9.63% HCRA Surcharge,180.63,,,180.63,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,1166.18,,,1166.18,Fee Schedule,,1049.23,,,1049.23,Fee Schedule,,990.76,,,990.76,Fee Schedule,,1642.78,50,,1642.78,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,507.8,,,507.8,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2299.89,70,,2299.89,percent of total billed charges,,1642.78,50,,1642.78,percent of total billed charges,,1642.78,50,,1642.78,percent of total billed charges,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,273.01,,,273.01,Other,New York Medicaid APG methodology,273.01,,,273.01,Other,100% New York Medicaid APG,273.01,,,273.01,Other,100% New York Medicaid APG,273.01,,,273.01,Other,100% New York Medicaid APG,614.27,,,614.27,Other,225% New York Medicaid APG,614.27,,,614.27,Other,225% New York Medicaid APG,614.27,,,614.27,Other,225% New York Medicaid APG,614.27,,,614.27,Other,225% New York Medicaid APG,382.21,,,382.21,Other,140% New York Medicaid APG,614.27,,,614.27,Other,225% New York Medicaid APG,709.82,,,709.82,Other,260% New York Medicaid APG,884.55,,,884.55,Other,324% New York Medicaid APG,586.97,,,586.97,Other,215% New York Medicaid APG,586.97,,,586.97,Other,215% New York Medicaid APG,341.26,,,341.26,Other,125% New York Medicaid APG,0.01,9473,
Anal/urinary muscle study,51785,CPT,,,,,,,,both,,,5198.43,469.99,,,469.99,Other,150% of Medicare + 9.63% HCRA Surcharge,285.8,,,285.8,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,1350.13,,,1350.13,Fee Schedule,,1214.74,,,1214.74,Fee Schedule,,1147.04,,,1147.04,Fee Schedule,,2599.22,50,,2599.22,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,507.8,,,507.8,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3638.9,70,,3638.9,percent of total billed charges,,2599.22,50,,2599.22,percent of total billed charges,,2599.22,50,,2599.22,percent of total billed charges,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,273.01,,,273.01,Other,New York Medicaid APG methodology,273.01,,,273.01,Other,100% New York Medicaid APG,273.01,,,273.01,Other,100% New York Medicaid APG,273.01,,,273.01,Other,100% New York Medicaid APG,614.27,,,614.27,Other,225% New York Medicaid APG,614.27,,,614.27,Other,225% New York Medicaid APG,614.27,,,614.27,Other,225% New York Medicaid APG,614.27,,,614.27,Other,225% New York Medicaid APG,382.21,,,382.21,Other,140% New York Medicaid APG,614.27,,,614.27,Other,225% New York Medicaid APG,709.82,,,709.82,Other,260% New York Medicaid APG,884.55,,,884.55,Other,324% New York Medicaid APG,586.97,,,586.97,Other,215% New York Medicaid APG,586.97,,,586.97,Other,215% New York Medicaid APG,341.26,,,341.26,Other,125% New York Medicaid APG,273.01,9473,
Urinary reflex study,51792,CPT,,,,,,,,both,,,1286.58,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,1611.98,,,1611.98,Fee Schedule,,1450.33,,,1450.33,Fee Schedule,,1369.51,,,1369.51,Fee Schedule,,643.29,50,,643.29,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,507.8,,,507.8,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,900.61,70,,900.61,percent of total billed charges,,643.29,50,,643.29,percent of total billed charges,,643.29,50,,643.29,percent of total billed charges,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,273.01,,,273.01,Other,New York Medicaid APG methodology,273.01,,,273.01,Other,100% New York Medicaid APG,273.01,,,273.01,Other,100% New York Medicaid APG,273.01,,,273.01,Other,100% New York Medicaid APG,614.27,,,614.27,Other,225% New York Medicaid APG,614.27,,,614.27,Other,225% New York Medicaid APG,614.27,,,614.27,Other,225% New York Medicaid APG,614.27,,,614.27,Other,225% New York Medicaid APG,382.21,,,382.21,Other,140% New York Medicaid APG,614.27,,,614.27,Other,225% New York Medicaid APG,709.82,,,709.82,Other,260% New York Medicaid APG,884.55,,,884.55,Other,324% New York Medicaid APG,586.97,,,586.97,Other,215% New York Medicaid APG,586.97,,,586.97,Other,215% New York Medicaid APG,341.26,,,341.26,Other,125% New York Medicaid APG,0.01,9473,
Intraabdominal pressure test,51797,CPT,,,,,,,,both,,,9018.37,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,854.42,,,854.42,Fee Schedule,,768.74,,,768.74,Fee Schedule,,725.9,,,725.9,Fee Schedule,,4509.19,50,,4509.19,percent of total billed charges,,6312.86,70,,6312.86,percent of total billed charges,,6152,,,6152,Case Rate,,1051.03,,,1051.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,6312.86,70,,6312.86,percent of total billed charges,,4509.19,50,,4509.19,percent of total billed charges,,4509.19,50,,4509.19,percent of total billed charges,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,565.07,,,565.07,Other,New York Medicaid APG methodology,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,791.1,,,791.1,Other,140% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1469.19,,,1469.19,Other,260% New York Medicaid APG,1830.83,,,1830.83,Other,324% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,706.34,,,706.34,Other,125% New York Medicaid APG,0.01,9473,
Us urine capacity measure,51798,CPT,,,,,,,,both,,,1286.58,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,180.94,,,180.94,Fee Schedule,,162.79,,,162.79,Fee Schedule,,153.72,,,153.72,Fee Schedule,,643.29,50,,643.29,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1051.03,,,1051.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,900.61,70,,900.61,percent of total billed charges,,52.8,,,52.8,Fee Schedule,,44.8,,,44.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,565.07,,,565.07,Other,New York Medicaid APG methodology,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,791.1,,,791.1,Other,140% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1469.19,,,1469.19,Other,260% New York Medicaid APG,1830.83,,,1830.83,Other,324% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,706.34,,,706.34,Other,125% New York Medicaid APG,0.01,9473,
Repair bladder neck,51845,CPT,,,,,,,,both,,,104619.92,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,52309.96,50,,52309.96,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4370.69,,,4370.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,73233.94,70,,73233.94,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2349.83,,,2349.83,Other,New York Medicaid APG methodology,2349.83,,,2349.83,Other,100% New York Medicaid APG,2349.83,,,2349.83,Other,100% New York Medicaid APG,2349.83,,,2349.83,Other,100% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,3289.76,,,3289.76,Other,140% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,6109.56,,,6109.56,Other,260% New York Medicaid APG,7613.45,,,7613.45,Other,324% New York Medicaid APG,5052.14,,,5052.14,Other,215% New York Medicaid APG,5052.14,,,5052.14,Other,215% New York Medicaid APG,2937.29,,,2937.29,Other,125% New York Medicaid APG,2349.83,73233.94,
Repair of bladder wound,51860,CPT,,,,,,,,both,,,193769.26,17518.56,,,17518.56,Other,150% of Medicare + 9.63% HCRA Surcharge,10653.14,,,10653.14,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,96884.63,50,,96884.63,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4370.69,,,4370.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,135638.48,70,,135638.48,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2349.83,,,2349.83,Other,New York Medicaid APG methodology,2349.83,,,2349.83,Other,100% New York Medicaid APG,2349.83,,,2349.83,Other,100% New York Medicaid APG,2349.83,,,2349.83,Other,100% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,3289.76,,,3289.76,Other,140% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,6109.56,,,6109.56,Other,260% New York Medicaid APG,7613.45,,,7613.45,Other,324% New York Medicaid APG,5052.14,,,5052.14,Other,215% New York Medicaid APG,5052.14,,,5052.14,Other,215% New York Medicaid APG,2937.29,,,2937.29,Other,125% New York Medicaid APG,2349.83,135638.48,
Repair of bladder opening,51880,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,51328.82,
Laparo urethral suspension,51990,CPT,,,,,,,,both,,,121364.27,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,60682.14,50,,60682.14,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84954.99,70,,84954.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,84954.99,
Laparo sling operation,51992,CPT,,,,,,,,both,,,38182.29,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,19091.15,50,,19091.15,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26727.6,70,,26727.6,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,26727.6,
Cystoscopy,52000,CPT,,,,,,,,both,,,16926.21,1299.03,,,1299.03,Other,150% of Medicare + 9.63% HCRA Surcharge,789.95,,,789.95,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,8463.11,50,,8463.11,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,11848.35,70,,11848.35,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,789.95,11848.35,
Cystoscopy removal of clots,52001,CPT,,,,,,,,both,,,35649.23,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17824.62,50,,17824.62,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24954.46,70,,24954.46,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,24954.46,
Cystoscopy & ureter catheter,52005,CPT,,,,,,,,both,,,47893.05,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,23946.53,50,,23946.53,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,33525.14,70,,33525.14,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,33525.14,
Cystoscopy and biopsy,52007,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2557.09,,,2557.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1374.78,,,1374.78,Other,New York Medicaid APG methodology,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,1924.69,,,1924.69,Other,140% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3574.43,,,3574.43,Other,260% New York Medicaid APG,4454.28,,,4454.28,Other,324% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,1718.47,,,1718.47,Other,125% New York Medicaid APG,1374.78,51328.82,
Cystoscopy & duct catheter,52010,CPT,,,,,,,,both,,,14368.32,1299.03,,,1299.03,Other,150% of Medicare + 9.63% HCRA Surcharge,789.95,,,789.95,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7184.16,50,,7184.16,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10057.82,70,,10057.82,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,789.95,10057.82,
Cystoscopy w/biopsy(s),52204,CPT,,,,,,,,both,,,41108.08,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20554.04,50,,20554.04,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28775.66,70,,28775.66,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,28775.66,
Cystoscopy and treatment,52214,CPT,,,,,,,,both,,,38081.64,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19040.82,50,,19040.82,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26657.15,70,,26657.15,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,26657.15,
Cystoscopy and treatment,52224,CPT,,,,,,,,both,,,39655,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19827.5,50,,19827.5,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27758.5,70,,27758.5,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,27758.5,
Cystoscopy and treatment,52234,CPT,,,,,,,,both,,,42962.38,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,21481.19,50,,21481.19,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,30073.67,70,,30073.67,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,30073.67,
Cystoscopy and treatment,52235,CPT,,,,,,,,both,,,50035.16,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,25017.58,50,,25017.58,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,35024.61,70,,35024.61,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,35024.61,
Cystoscopy and treatment,52240,CPT,,,,,,,,both,,,49683.71,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,24841.86,50,,24841.86,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34778.6,70,,34778.6,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,34778.6,
Cystoscopy and radiotracer,52250,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,51328.82,
Cystoscopy and treatment,52260,CPT,,,,,,,,both,,,34343.96,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17171.98,50,,17171.98,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24040.77,70,,24040.77,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,24040.77,
Cystoscopy and treatment,52265,CPT,,,,,,,,both,,,42841.82,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21420.91,50,,21420.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29989.27,70,,29989.27,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,29989.27,
Cystoscopy & revise urethra,52270,CPT,,,,,,,,both,,,42841.82,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21420.91,50,,21420.91,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29989.27,70,,29989.27,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,29989.27,
Cystoscopy & revise urethra,52275,CPT,,,,,,,,both,,,34791.72,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17395.86,50,,17395.86,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24354.2,70,,24354.2,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,24354.2,
Cystoscopy and treatment,52276,CPT,,,,,,,,both,,,35920.96,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17960.48,50,,17960.48,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25144.67,70,,25144.67,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,25144.67,
Cystoscopy and treatment,52277,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,51328.82,
Cystoscopy and treatment,52281,CPT,,,,,,,,both,,,35971.51,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17985.76,50,,17985.76,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25180.06,70,,25180.06,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,25180.06,
Cystoscopy implant stent,52282,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,51328.82,
Cystoscopy and treatment,52283,CPT,,,,,,,,both,,,42841.82,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21420.91,50,,21420.91,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29989.27,70,,29989.27,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,29989.27,
Cystoscopy and treatment,52285,CPT,,,,,,,,both,,,14368.32,1299.03,,,1299.03,Other,150% of Medicare + 9.63% HCRA Surcharge,789.95,,,789.95,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7184.16,50,,7184.16,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10057.82,70,,10057.82,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,789.95,10057.82,
Cystoscopy chemodenervation,52287,CPT,,,,,,,,both,,,31072.26,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,15536.13,50,,15536.13,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,21750.58,70,,21750.58,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,21750.58,
Cystoscopy and treatment,52290,CPT,,,,,,,,both,,,42841.82,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21420.91,50,,21420.91,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29989.27,70,,29989.27,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,29989.27,
Cystoscopy and treatment,52300,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4370.69,,,4370.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2349.83,,,2349.83,Other,New York Medicaid APG methodology,2349.83,,,2349.83,Other,100% New York Medicaid APG,2349.83,,,2349.83,Other,100% New York Medicaid APG,2349.83,,,2349.83,Other,100% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,3289.76,,,3289.76,Other,140% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,6109.56,,,6109.56,Other,260% New York Medicaid APG,7613.45,,,7613.45,Other,324% New York Medicaid APG,5052.14,,,5052.14,Other,215% New York Medicaid APG,5052.14,,,5052.14,Other,215% New York Medicaid APG,2937.29,,,2937.29,Other,125% New York Medicaid APG,2349.83,51328.82,
Cystoscopy and treatment,52301,CPT,,,,,,,,both,,,35370.79,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17685.4,50,,17685.4,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24759.55,70,,24759.55,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,24759.55,
Cystoscopy and treatment,52305,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4370.69,,,4370.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2349.83,,,2349.83,Other,New York Medicaid APG methodology,2349.83,,,2349.83,Other,100% New York Medicaid APG,2349.83,,,2349.83,Other,100% New York Medicaid APG,2349.83,,,2349.83,Other,100% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,3289.76,,,3289.76,Other,140% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,6109.56,,,6109.56,Other,260% New York Medicaid APG,7613.45,,,7613.45,Other,324% New York Medicaid APG,5052.14,,,5052.14,Other,215% New York Medicaid APG,5052.14,,,5052.14,Other,215% New York Medicaid APG,2937.29,,,2937.29,Other,125% New York Medicaid APG,2349.83,76185.18,
Cystoscopy and treatment,52310,CPT,,,,,,,,both,,,29225.24,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,14612.62,50,,14612.62,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,20457.67,70,,20457.67,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,20457.67,
Cystoscopy and treatment,52315,CPT,,,,,,,,both,,,40381.04,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20190.52,50,,20190.52,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28266.73,70,,28266.73,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,28266.73,
Remove bladder stone,52317,CPT,,,,,,,,both,,,38038.46,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19019.23,50,,19019.23,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26626.92,70,,26626.92,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,26626.92,
Remove bladder stone,52318,CPT,,,,,,,,both,,,37429.91,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18714.96,50,,18714.96,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26200.94,70,,26200.94,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,26200.94,
Cystoscopy and treatment,52320,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,51328.82,
Cystoscopy stone removal,52325,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4370.69,,,4370.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2349.83,,,2349.83,Other,New York Medicaid APG methodology,2349.83,,,2349.83,Other,100% New York Medicaid APG,2349.83,,,2349.83,Other,100% New York Medicaid APG,2349.83,,,2349.83,Other,100% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,3289.76,,,3289.76,Other,140% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,6109.56,,,6109.56,Other,260% New York Medicaid APG,7613.45,,,7613.45,Other,324% New York Medicaid APG,5052.14,,,5052.14,Other,215% New York Medicaid APG,5052.14,,,5052.14,Other,215% New York Medicaid APG,2937.29,,,2937.29,Other,125% New York Medicaid APG,2349.83,76185.18,
Cystoscopy inject material,52327,CPT,,,,,,,,both,,,51504.42,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,25752.21,50,,25752.21,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4370.69,,,4370.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36053.09,70,,36053.09,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2349.83,,,2349.83,Other,New York Medicaid APG methodology,2349.83,,,2349.83,Other,100% New York Medicaid APG,2349.83,,,2349.83,Other,100% New York Medicaid APG,2349.83,,,2349.83,Other,100% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,3289.76,,,3289.76,Other,140% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,6109.56,,,6109.56,Other,260% New York Medicaid APG,7613.45,,,7613.45,Other,324% New York Medicaid APG,5052.14,,,5052.14,Other,215% New York Medicaid APG,5052.14,,,5052.14,Other,215% New York Medicaid APG,2937.29,,,2937.29,Other,125% New York Medicaid APG,2349.83,36053.09,
Cystoscopy and treatment,52330,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,51328.82,
Cystoscopy and treatment,52332,CPT,,,,,,,,both,,,35791.89,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17895.95,50,,17895.95,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25054.32,70,,25054.32,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,25054.32,
Create passage to kidney,52334,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2557.09,,,2557.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1374.78,,,1374.78,Other,New York Medicaid APG methodology,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,1924.69,,,1924.69,Other,140% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3574.43,,,3574.43,Other,260% New York Medicaid APG,4454.28,,,4454.28,Other,324% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,1718.47,,,1718.47,Other,125% New York Medicaid APG,1374.78,51328.82,
Cysto w/ureter stricture tx,52341,CPT,,,,,,,,both,,,36893.08,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18446.54,50,,18446.54,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25825.16,70,,25825.16,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,25825.16,
Cysto w/up stricture tx,52342,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2557.09,,,2557.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1374.78,,,1374.78,Other,New York Medicaid APG methodology,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,1924.69,,,1924.69,Other,140% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3574.43,,,3574.43,Other,260% New York Medicaid APG,4454.28,,,4454.28,Other,324% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,1718.47,,,1718.47,Other,125% New York Medicaid APG,1374.78,51328.82,
Cysto w/renal stricture tx,52343,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2557.09,,,2557.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1374.78,,,1374.78,Other,New York Medicaid APG methodology,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,1374.78,,,1374.78,Other,100% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,1924.69,,,1924.69,Other,140% New York Medicaid APG,3093.25,,,3093.25,Other,225% New York Medicaid APG,3574.43,,,3574.43,Other,260% New York Medicaid APG,4454.28,,,4454.28,Other,324% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,2955.77,,,2955.77,Other,215% New York Medicaid APG,1718.47,,,1718.47,Other,125% New York Medicaid APG,1374.78,51328.82,
Cysto/uretero stricture tx,52344,CPT,,,,,,,,both,,,45216.91,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,22608.46,50,,22608.46,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31651.84,70,,31651.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,31651.84,
Cysto/uretero w/up stricture,52345,CPT,,,,,,,,both,,,43912.97,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,21956.49,50,,21956.49,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4370.69,,,4370.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,30739.08,70,,30739.08,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2349.83,,,2349.83,Other,New York Medicaid APG methodology,2349.83,,,2349.83,Other,100% New York Medicaid APG,2349.83,,,2349.83,Other,100% New York Medicaid APG,2349.83,,,2349.83,Other,100% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,3289.76,,,3289.76,Other,140% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,6109.56,,,6109.56,Other,260% New York Medicaid APG,7613.45,,,7613.45,Other,324% New York Medicaid APG,5052.14,,,5052.14,Other,215% New York Medicaid APG,5052.14,,,5052.14,Other,215% New York Medicaid APG,2937.29,,,2937.29,Other,125% New York Medicaid APG,2349.83,30739.08,
Cystouretero w/renal strict,52346,CPT,,,,,,,,both,,,37179.82,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,18589.91,50,,18589.91,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3301.55,,,3301.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26025.87,70,,26025.87,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1775.02,,,1775.02,Other,New York Medicaid APG methodology,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,2485.03,,,2485.03,Other,140% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,4615.06,,,4615.06,Other,260% New York Medicaid APG,5751.08,,,5751.08,Other,324% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,2218.78,,,2218.78,Other,125% New York Medicaid APG,1775.02,26025.87,
Cystouretero & or pyeloscope,52351,CPT,,,,,,,,both,,,37162.02,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18581.01,50,,18581.01,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26013.41,70,,26013.41,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,26013.41,
Cystouretero w/stone remove,52352,CPT,,,,,,,,both,,,36808.59,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18404.3,50,,18404.3,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25766.01,70,,25766.01,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,25766.01,
Cystouretero w/lithotripsy,52353,CPT,,,,,,,,both,,,38384.49,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,19192.25,50,,19192.25,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3301.55,,,3301.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26869.14,70,,26869.14,percent of total billed charges,,1885.95,,,1885.95,Fee Schedule,,1600.2,,,1600.2,Fee Schedule,,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1775.02,,,1775.02,Other,New York Medicaid APG methodology,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,2485.03,,,2485.03,Other,140% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,4615.06,,,4615.06,Other,260% New York Medicaid APG,5751.08,,,5751.08,Other,324% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,2218.78,,,2218.78,Other,125% New York Medicaid APG,1600.2,26869.14,
Cystouretero w/biopsy,52354,CPT,,,,,,,,both,,,43957.07,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,21978.54,50,,21978.54,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3301.55,,,3301.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,30769.95,70,,30769.95,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1775.02,,,1775.02,Other,New York Medicaid APG methodology,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,2485.03,,,2485.03,Other,140% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,4615.06,,,4615.06,Other,260% New York Medicaid APG,5751.08,,,5751.08,Other,324% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,2218.78,,,2218.78,Other,125% New York Medicaid APG,1775.02,30769.95,
Cystouretero w/excise tumor,52355,CPT,,,,,,,,both,,,42146.56,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,21073.28,50,,21073.28,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3301.55,,,3301.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29502.59,70,,29502.59,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1775.02,,,1775.02,Other,New York Medicaid APG methodology,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,2485.03,,,2485.03,Other,140% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,4615.06,,,4615.06,Other,260% New York Medicaid APG,5751.08,,,5751.08,Other,324% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,2218.78,,,2218.78,Other,125% New York Medicaid APG,1775.02,29502.59,
Cysto/uretero w/lithotripsy,52356,CPT,,,,,,,,both,,,39439.09,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,19719.55,50,,19719.55,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4370.69,,,4370.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27607.36,70,,27607.36,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2349.83,,,2349.83,Other,New York Medicaid APG methodology,2349.83,,,2349.83,Other,100% New York Medicaid APG,2349.83,,,2349.83,Other,100% New York Medicaid APG,2349.83,,,2349.83,Other,100% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,3289.76,,,3289.76,Other,140% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,6109.56,,,6109.56,Other,260% New York Medicaid APG,7613.45,,,7613.45,Other,324% New York Medicaid APG,5052.14,,,5052.14,Other,215% New York Medicaid APG,5052.14,,,5052.14,Other,215% New York Medicaid APG,2937.29,,,2937.29,Other,125% New York Medicaid APG,2349.83,27607.36,
Cystouretero w/congen repr,52400,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,51328.82,
Cystourethro cut ejacul duct,52402,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,51328.82,
Incision of prostate,52450,CPT,,,,,,,,both,,,35499.75,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17749.88,50,,17749.88,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4467.58,,,4467.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24849.83,70,,24849.83,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2401.92,,,2401.92,Other,New York Medicaid APG methodology,2401.92,,,2401.92,Other,100% New York Medicaid APG,2401.92,,,2401.92,Other,100% New York Medicaid APG,2401.92,,,2401.92,Other,100% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,3362.69,,,3362.69,Other,140% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,6245,,,6245,Other,260% New York Medicaid APG,7782.23,,,7782.23,Other,324% New York Medicaid APG,5164.14,,,5164.14,Other,215% New York Medicaid APG,5164.14,,,5164.14,Other,215% New York Medicaid APG,3002.4,,,3002.4,Other,125% New York Medicaid APG,2401.92,24849.83,
Revision of bladder neck,52500,CPT,,,,,,,,both,,,47447.14,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,23723.57,50,,23723.57,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,33213,70,,33213,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,33213,
Prostatectomy (turp),52601,CPT,,,,,,,,both,,,40724.65,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,20362.33,50,,20362.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5967.34,,,5967.34,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28507.26,70,,28507.26,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3208.25,,,3208.25,Other,New York Medicaid APG methodology,3208.25,,,3208.25,Other,100% New York Medicaid APG,3208.25,,,3208.25,Other,100% New York Medicaid APG,3208.25,,,3208.25,Other,100% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,4491.55,,,4491.55,Other,140% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,8341.45,,,8341.45,Other,260% New York Medicaid APG,10394.73,,,10394.73,Other,324% New York Medicaid APG,6897.73,,,6897.73,Other,215% New York Medicaid APG,6897.73,,,6897.73,Other,215% New York Medicaid APG,4010.31,,,4010.31,Other,125% New York Medicaid APG,3208.25,28507.26,
Remove prostate regrowth,52630,CPT,,,,,,,,both,,,41807.35,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,20903.68,50,,20903.68,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5967.34,,,5967.34,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29265.15,70,,29265.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3208.25,,,3208.25,Other,New York Medicaid APG methodology,3208.25,,,3208.25,Other,100% New York Medicaid APG,3208.25,,,3208.25,Other,100% New York Medicaid APG,3208.25,,,3208.25,Other,100% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,4491.55,,,4491.55,Other,140% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,8341.45,,,8341.45,Other,260% New York Medicaid APG,10394.73,,,10394.73,Other,324% New York Medicaid APG,6897.73,,,6897.73,Other,215% New York Medicaid APG,6897.73,,,6897.73,Other,215% New York Medicaid APG,4010.31,,,4010.31,Other,125% New York Medicaid APG,3208.25,29265.15,
Relieve bladder contracture,52640,CPT,,,,,,,,both,,,36213.63,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18106.82,50,,18106.82,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3677.57,,,3677.57,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25349.54,70,,25349.54,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1977.19,,,1977.19,Other,New York Medicaid APG methodology,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,1977.19,,,1977.19,Other,100% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,2768.06,,,2768.06,Other,140% New York Medicaid APG,4448.67,,,4448.67,Other,225% New York Medicaid APG,5140.69,,,5140.69,Other,260% New York Medicaid APG,6406.09,,,6406.09,Other,324% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,4250.96,,,4250.96,Other,215% New York Medicaid APG,2471.49,,,2471.49,Other,125% New York Medicaid APG,1977.19,25349.54,
Laser surgery of prostate,52647,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5967.34,,,5967.34,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3208.25,,,3208.25,Other,New York Medicaid APG methodology,3208.25,,,3208.25,Other,100% New York Medicaid APG,3208.25,,,3208.25,Other,100% New York Medicaid APG,3208.25,,,3208.25,Other,100% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,4491.55,,,4491.55,Other,140% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,8341.45,,,8341.45,Other,260% New York Medicaid APG,10394.73,,,10394.73,Other,324% New York Medicaid APG,6897.73,,,6897.73,Other,215% New York Medicaid APG,6897.73,,,6897.73,Other,215% New York Medicaid APG,4010.31,,,4010.31,Other,125% New York Medicaid APG,3208.25,76185.18,
Laser surgery of prostate,52648,CPT,,,,,,,,both,,,44600.84,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,22300.42,50,,22300.42,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5967.34,,,5967.34,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31220.59,70,,31220.59,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3208.25,,,3208.25,Other,New York Medicaid APG methodology,3208.25,,,3208.25,Other,100% New York Medicaid APG,3208.25,,,3208.25,Other,100% New York Medicaid APG,3208.25,,,3208.25,Other,100% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,4491.55,,,4491.55,Other,140% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,8341.45,,,8341.45,Other,260% New York Medicaid APG,10394.73,,,10394.73,Other,324% New York Medicaid APG,6897.73,,,6897.73,Other,215% New York Medicaid APG,6897.73,,,6897.73,Other,215% New York Medicaid APG,4010.31,,,4010.31,Other,125% New York Medicaid APG,3208.25,31220.59,
Prostate laser enucleation,52649,CPT,,,,,,,,both,,,42526.4,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,21263.2,50,,21263.2,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5967.34,,,5967.34,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29768.48,70,,29768.48,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3208.25,,,3208.25,Other,New York Medicaid APG methodology,3208.25,,,3208.25,Other,100% New York Medicaid APG,3208.25,,,3208.25,Other,100% New York Medicaid APG,3208.25,,,3208.25,Other,100% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,4491.55,,,4491.55,Other,140% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,8341.45,,,8341.45,Other,260% New York Medicaid APG,10394.73,,,10394.73,Other,324% New York Medicaid APG,6897.73,,,6897.73,Other,215% New York Medicaid APG,6897.73,,,6897.73,Other,215% New York Medicaid APG,4010.31,,,4010.31,Other,125% New York Medicaid APG,3208.25,29768.48,
Drainage of prostate abscess,52700,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4467.58,,,4467.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2401.92,,,2401.92,Other,New York Medicaid APG methodology,2401.92,,,2401.92,Other,100% New York Medicaid APG,2401.92,,,2401.92,Other,100% New York Medicaid APG,2401.92,,,2401.92,Other,100% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,3362.69,,,3362.69,Other,140% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,6245,,,6245,Other,260% New York Medicaid APG,7782.23,,,7782.23,Other,324% New York Medicaid APG,5164.14,,,5164.14,Other,215% New York Medicaid APG,5164.14,,,5164.14,Other,215% New York Medicaid APG,3002.4,,,3002.4,Other,125% New York Medicaid APG,2401.92,51328.82,
Incision of urethra,53000,CPT,,,,,,,,both,,,42841.82,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21420.91,50,,21420.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29989.27,70,,29989.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,29989.27,
Incision of urethra,53010,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5620.98,,,5620.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3022.03,,,3022.03,Other,New York Medicaid APG methodology,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,4230.84,,,4230.84,Other,140% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,7857.28,,,7857.28,Other,260% New York Medicaid APG,9791.38,,,9791.38,Other,324% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,3777.54,,,3777.54,Other,125% New York Medicaid APG,3022.03,76185.18,
Incision of urethra,53020,CPT,,,,,,,,both,,,36826.76,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18413.38,50,,18413.38,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25778.73,70,,25778.73,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,25778.73,
Incision of urethra,53025,CPT,,,,,,,,both,,,42841.82,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21420.91,50,,21420.91,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29989.27,70,,29989.27,percent of total billed charges,,333.3,,,333.3,Fee Schedule,,282.8,,,282.8,Fee Schedule,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,282.8,29989.27,
Drainage of urethra abscess,53040,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,51328.82,
Drainage of urethra abscess,53060,CPT,,,,,,,,both,,,42841.82,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21420.91,50,,21420.91,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29989.27,70,,29989.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,29989.27,
Drainage of urinary leakage,53080,CPT,,,,,,,,both,,,14368.32,1299.03,,,1299.03,Other,150% of Medicare + 9.63% HCRA Surcharge,789.95,,,789.95,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7184.16,50,,7184.16,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1123.05,,,1123.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10057.82,70,,10057.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,603.79,,,603.79,Other,New York Medicaid APG methodology,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,845.31,,,845.31,Other,140% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1569.85,,,1569.85,Other,260% New York Medicaid APG,1956.28,,,1956.28,Other,324% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,754.74,,,754.74,Other,125% New York Medicaid APG,603.79,13157,
Drainage of urinary leakage,53085,CPT,,,,,,,,both,,,42841.82,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21420.91,50,,21420.91,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29989.27,70,,29989.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,29989.27,
Biopsy of urethra,53200,CPT,,,,,,,,both,,,42841.82,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21420.91,50,,21420.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29989.27,70,,29989.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,29989.27,
Removal of urethra,53210,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,51328.82,
Removal of urethra,53215,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5620.98,,,5620.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3022.03,,,3022.03,Other,New York Medicaid APG methodology,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,4230.84,,,4230.84,Other,140% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,7857.28,,,7857.28,Other,260% New York Medicaid APG,9791.38,,,9791.38,Other,324% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,3777.54,,,3777.54,Other,125% New York Medicaid APG,3022.03,76185.18,
Treatment of urethra lesion,53220,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,51328.82,
Removal of urethra lesion,53230,CPT,,,,,,,,both,,,40310.96,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,20155.48,50,,20155.48,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5620.98,,,5620.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28217.67,70,,28217.67,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3022.03,,,3022.03,Other,New York Medicaid APG methodology,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,4230.84,,,4230.84,Other,140% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,7857.28,,,7857.28,Other,260% New York Medicaid APG,9791.38,,,9791.38,Other,324% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,3777.54,,,3777.54,Other,125% New York Medicaid APG,3022.03,28217.67,
Removal of urethra lesion,53235,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5620.98,,,5620.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3022.03,,,3022.03,Other,New York Medicaid APG methodology,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,4230.84,,,4230.84,Other,140% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,7857.28,,,7857.28,Other,260% New York Medicaid APG,9791.38,,,9791.38,Other,324% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,3777.54,,,3777.54,Other,125% New York Medicaid APG,3022.03,76185.18,
Surgery for urethra pouch,53240,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,51328.82,
Removal of urethra gland,53250,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,51328.82,
Treatment of urethra lesion,53260,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,51328.82,
Treatment of urethra lesion,53265,CPT,,,,,,,,both,,,40279.92,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20139.96,50,,20139.96,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28195.94,70,,28195.94,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,28195.94,
Removal of urethra gland,53270,CPT,,,,,,,,both,,,40917.43,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20458.72,50,,20458.72,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28642.2,70,,28642.2,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,28642.2,
Repair of urethra defect,53275,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,51328.82,
Revise urethra stage 1,53400,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5620.98,,,5620.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3022.03,,,3022.03,Other,New York Medicaid APG methodology,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,4230.84,,,4230.84,Other,140% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,7857.28,,,7857.28,Other,260% New York Medicaid APG,9791.38,,,9791.38,Other,324% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,3777.54,,,3777.54,Other,125% New York Medicaid APG,3022.03,76185.18,
Revise urethra stage 2,53405,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5620.98,,,5620.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3022.03,,,3022.03,Other,New York Medicaid APG methodology,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,4230.84,,,4230.84,Other,140% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,7857.28,,,7857.28,Other,260% New York Medicaid APG,9791.38,,,9791.38,Other,324% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,3777.54,,,3777.54,Other,125% New York Medicaid APG,3022.03,76185.18,
Reconstruction of urethra,53410,CPT,,,,,,,,both,,,69570.13,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,34785.07,50,,34785.07,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5620.98,,,5620.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,48699.09,70,,48699.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3022.03,,,3022.03,Other,New York Medicaid APG methodology,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,4230.84,,,4230.84,Other,140% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,7857.28,,,7857.28,Other,260% New York Medicaid APG,9791.38,,,9791.38,Other,324% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,3777.54,,,3777.54,Other,125% New York Medicaid APG,3022.03,48699.09,
Reconstruct urethra stage 1,53420,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5620.98,,,5620.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3022.03,,,3022.03,Other,New York Medicaid APG methodology,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,4230.84,,,4230.84,Other,140% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,7857.28,,,7857.28,Other,260% New York Medicaid APG,9791.38,,,9791.38,Other,324% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,3777.54,,,3777.54,Other,125% New York Medicaid APG,3022.03,76185.18,
Reconstruct urethra stage 2,53425,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5620.98,,,5620.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3022.03,,,3022.03,Other,New York Medicaid APG methodology,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,4230.84,,,4230.84,Other,140% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,7857.28,,,7857.28,Other,260% New York Medicaid APG,9791.38,,,9791.38,Other,324% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,3777.54,,,3777.54,Other,125% New York Medicaid APG,3022.03,76185.18,
Reconstruction of urethra,53430,CPT,,,,,,,,both,,,44694.44,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,22347.22,50,,22347.22,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5620.98,,,5620.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31286.11,70,,31286.11,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3022.03,,,3022.03,Other,New York Medicaid APG methodology,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,4230.84,,,4230.84,Other,140% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,7857.28,,,7857.28,Other,260% New York Medicaid APG,9791.38,,,9791.38,Other,324% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,3777.54,,,3777.54,Other,125% New York Medicaid APG,3022.03,31286.11,
Reconstruct urethra/bladder,53431,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5620.98,,,5620.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3022.03,,,3022.03,Other,New York Medicaid APG methodology,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,4230.84,,,4230.84,Other,140% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,7857.28,,,7857.28,Other,260% New York Medicaid APG,9791.38,,,9791.38,Other,324% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,3777.54,,,3777.54,Other,125% New York Medicaid APG,3022.03,76185.18,
Male sling procedure,53440,CPT,,,,,,,,both,,,79572.43,24411.13,,,24411.13,Other,150% of Medicare + 9.63% HCRA Surcharge,14844.56,,,14844.56,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,39786.22,50,,39786.22,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5620.98,,,5620.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,55700.7,70,,55700.7,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3022.03,,,3022.03,Other,New York Medicaid APG methodology,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,4230.84,,,4230.84,Other,140% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,7857.28,,,7857.28,Other,260% New York Medicaid APG,9791.38,,,9791.38,Other,324% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,3777.54,,,3777.54,Other,125% New York Medicaid APG,3022.03,55700.7,
Remove/revise male sling,53442,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5620.98,,,5620.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3022.03,,,3022.03,Other,New York Medicaid APG methodology,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,4230.84,,,4230.84,Other,140% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,7857.28,,,7857.28,Other,260% New York Medicaid APG,9791.38,,,9791.38,Other,324% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,3777.54,,,3777.54,Other,125% New York Medicaid APG,3022.03,76185.18,
Insert tandem cuff,53444,CPT,,,,,,,,both,,,424287.84,38359.6,,,38359.6,Other,150% of Medicare + 9.63% HCRA Surcharge,23326.71,,,23326.71,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,212143.92,50,,212143.92,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5620.98,,,5620.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,297001.49,70,,297001.49,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3022.03,,,3022.03,Other,New York Medicaid APG methodology,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,4230.84,,,4230.84,Other,140% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,7857.28,,,7857.28,Other,260% New York Medicaid APG,9791.38,,,9791.38,Other,324% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,3777.54,,,3777.54,Other,125% New York Medicaid APG,3022.03,297001.49,
Insert uro/ves nck sphincter,53445,CPT,,,,,,,,both,,,110991.64,38359.6,,,38359.6,Other,150% of Medicare + 9.63% HCRA Surcharge,23326.71,,,23326.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,55495.82,50,,55495.82,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4370.69,,,4370.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,77694.15,70,,77694.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,14938,,"100% primary, 50% secondary, 25% tertiary procedure",14938,Other,United Healthcare ASC Grouper,13443,,"100% primary, 50% secondary, 25% tertiary procedure",13443,Other,United Healthcare ASC Grouper,14938,,"100% primary, 50% secondary, 25% tertiary procedure",14938,Other,United Healthcare ASC Grouper,12698,,"100% primary, 50% secondary, 25% tertiary procedure",12698,Other,United Healthcare ASC Grouper,2349.83,,,2349.83,Other,New York Medicaid APG methodology,2349.83,,,2349.83,Other,100% New York Medicaid APG,2349.83,,,2349.83,Other,100% New York Medicaid APG,2349.83,,,2349.83,Other,100% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,3289.76,,,3289.76,Other,140% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,6109.56,,,6109.56,Other,260% New York Medicaid APG,7613.45,,,7613.45,Other,324% New York Medicaid APG,5052.14,,,5052.14,Other,215% New York Medicaid APG,5052.14,,,5052.14,Other,215% New York Medicaid APG,2937.29,,,2937.29,Other,125% New York Medicaid APG,2349.83,77694.15,
Remove uro sphincter,53446,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5620.98,,,5620.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3022.03,,,3022.03,Other,New York Medicaid APG methodology,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,4230.84,,,4230.84,Other,140% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,7857.28,,,7857.28,Other,260% New York Medicaid APG,9791.38,,,9791.38,Other,324% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,3777.54,,,3777.54,Other,125% New York Medicaid APG,3022.03,76185.18,
Remove/replace ur sphincter,53447,CPT,,,,,,,,both,,,424287.84,38359.6,,,38359.6,Other,150% of Medicare + 9.63% HCRA Surcharge,23326.71,,,23326.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,212143.92,50,,212143.92,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4370.69,,,4370.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,297001.49,70,,297001.49,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,14938,,"100% primary, 50% secondary, 25% tertiary procedure",14938,Other,United Healthcare ASC Grouper,13443,,"100% primary, 50% secondary, 25% tertiary procedure",13443,Other,United Healthcare ASC Grouper,14938,,"100% primary, 50% secondary, 25% tertiary procedure",14938,Other,United Healthcare ASC Grouper,12698,,"100% primary, 50% secondary, 25% tertiary procedure",12698,Other,United Healthcare ASC Grouper,2349.83,,,2349.83,Other,New York Medicaid APG methodology,2349.83,,,2349.83,Other,100% New York Medicaid APG,2349.83,,,2349.83,Other,100% New York Medicaid APG,2349.83,,,2349.83,Other,100% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,3289.76,,,3289.76,Other,140% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,6109.56,,,6109.56,Other,260% New York Medicaid APG,7613.45,,,7613.45,Other,324% New York Medicaid APG,5052.14,,,5052.14,Other,215% New York Medicaid APG,5052.14,,,5052.14,Other,215% New York Medicaid APG,2937.29,,,2937.29,Other,125% New York Medicaid APG,2349.83,297001.49,
Repair uro sphincter,53449,CPT,,,,,,,,both,,,193769.26,17518.56,,,17518.56,Other,150% of Medicare + 9.63% HCRA Surcharge,10653.14,,,10653.14,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,96884.63,50,,96884.63,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5620.98,,,5620.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,135638.48,70,,135638.48,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3022.03,,,3022.03,Other,New York Medicaid APG methodology,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,4230.84,,,4230.84,Other,140% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,7857.28,,,7857.28,Other,260% New York Medicaid APG,9791.38,,,9791.38,Other,324% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,3777.54,,,3777.54,Other,125% New York Medicaid APG,3022.03,135638.48,
Revision of urethra,53450,CPT,,,,,,,,both,,,34741.59,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17370.8,50,,17370.8,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24319.11,70,,24319.11,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,24319.11,
Revision of urethra,53460,CPT,,,,,,,,both,,,35421.42,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17710.71,50,,17710.71,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24794.99,70,,24794.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,24794.99,
Urethrlys transvag w/ scope,53500,CPT,,,,,,,,both,,,38827.66,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19413.83,50,,19413.83,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27179.36,70,,27179.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,27179.36,
Repair of urethra injury,53502,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,51328.82,
Repair of urethra injury,53505,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,76185.18,
Repair of urethra injury,53510,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5620.98,,,5620.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3022.03,,,3022.03,Other,New York Medicaid APG methodology,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,4230.84,,,4230.84,Other,140% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,7857.28,,,7857.28,Other,260% New York Medicaid APG,9791.38,,,9791.38,Other,324% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,3777.54,,,3777.54,Other,125% New York Medicaid APG,3022.03,76185.18,
Repair of urethra injury,53515,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5620.98,,,5620.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3022.03,,,3022.03,Other,New York Medicaid APG methodology,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,4230.84,,,4230.84,Other,140% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,7857.28,,,7857.28,Other,260% New York Medicaid APG,9791.38,,,9791.38,Other,324% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,3777.54,,,3777.54,Other,125% New York Medicaid APG,3022.03,76185.18,
Repair of urethra defect,53520,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5620.98,,,5620.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3022.03,,,3022.03,Other,New York Medicaid APG methodology,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,4230.84,,,4230.84,Other,140% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,7857.28,,,7857.28,Other,260% New York Medicaid APG,9791.38,,,9791.38,Other,324% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,3777.54,,,3777.54,Other,125% New York Medicaid APG,3022.03,76185.18,
Dilate urethra stricture,53600,CPT,,,,,,,,both,,,5198.43,469.99,,,469.99,Other,150% of Medicare + 9.63% HCRA Surcharge,285.8,,,285.8,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2599.22,50,,2599.22,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1051.03,,,1051.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3638.9,70,,3638.9,percent of total billed charges,,311.85,,,311.85,Fee Schedule,,264.6,,,264.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,565.07,,,565.07,Other,New York Medicaid APG methodology,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,791.1,,,791.1,Other,140% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1469.19,,,1469.19,Other,260% New York Medicaid APG,1830.83,,,1830.83,Other,324% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,706.34,,,706.34,Other,125% New York Medicaid APG,264.6,9473,
Dilate urethra stricture,53601,CPT,,,,,,,,both,,,2686.86,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1343.43,50,,1343.43,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1051.03,,,1051.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,1880.8,70,,1880.8,percent of total billed charges,,259.05,,,259.05,Fee Schedule,,219.8,,,219.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,565.07,,,565.07,Other,New York Medicaid APG methodology,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,791.1,,,791.1,Other,140% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1469.19,,,1469.19,Other,260% New York Medicaid APG,1830.83,,,1830.83,Other,324% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,706.34,,,706.34,Other,125% New York Medicaid APG,147.72,9473,
Dilate urethra stricture,53605,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1123.05,,,1123.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,311.85,,,311.85,Fee Schedule,,264.6,,,264.6,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,603.79,,,603.79,Other,New York Medicaid APG methodology,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,845.31,,,845.31,Other,140% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1569.85,,,1569.85,Other,260% New York Medicaid APG,1956.28,,,1956.28,Other,324% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,754.74,,,754.74,Other,125% New York Medicaid APG,264.6,51328.82,
Dilate urethra stricture,53620,CPT,,,,,,,,both,,,14368.32,1299.03,,,1299.03,Other,150% of Medicare + 9.63% HCRA Surcharge,789.95,,,789.95,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7184.16,50,,7184.16,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1123.05,,,1123.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10057.82,70,,10057.82,percent of total billed charges,,420.75,,,420.75,Fee Schedule,,357,,,357,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,603.79,,,603.79,Other,New York Medicaid APG methodology,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,845.31,,,845.31,Other,140% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1569.85,,,1569.85,Other,260% New York Medicaid APG,1956.28,,,1956.28,Other,324% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,754.74,,,754.74,Other,125% New York Medicaid APG,357,10057.82,
Dilate urethra stricture,53621,CPT,,,,,,,,both,,,5198.43,469.99,,,469.99,Other,150% of Medicare + 9.63% HCRA Surcharge,285.8,,,285.8,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2599.22,50,,2599.22,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1123.05,,,1123.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3638.9,70,,3638.9,percent of total billed charges,,349.8,,,349.8,Fee Schedule,,296.8,,,296.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,603.79,,,603.79,Other,New York Medicaid APG methodology,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,845.31,,,845.31,Other,140% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1569.85,,,1569.85,Other,260% New York Medicaid APG,1956.28,,,1956.28,Other,324% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,754.74,,,754.74,Other,125% New York Medicaid APG,285.8,9473,
Dilation of urethra,53660,CPT,,,,,,,,both,,,3285.56,297.05,,,297.05,Other,150% of Medicare + 9.63% HCRA Surcharge,180.63,,,180.63,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1642.78,50,,1642.78,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1051.03,,,1051.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2299.89,70,,2299.89,percent of total billed charges,,202.95,,,202.95,Fee Schedule,,172.2,,,172.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,565.07,,,565.07,Other,New York Medicaid APG methodology,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,791.1,,,791.1,Other,140% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1469.19,,,1469.19,Other,260% New York Medicaid APG,1830.83,,,1830.83,Other,324% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,706.34,,,706.34,Other,125% New York Medicaid APG,0.01,9473,
Dilation of urethra,53661,CPT,,,,,,,,both,,,2686.86,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1343.43,50,,1343.43,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1051.03,,,1051.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,1880.8,70,,1880.8,percent of total billed charges,,198,,,198,Fee Schedule,,168,,,168,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,565.07,,,565.07,Other,New York Medicaid APG methodology,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,791.1,,,791.1,Other,140% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1469.19,,,1469.19,Other,260% New York Medicaid APG,1830.83,,,1830.83,Other,324% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,706.34,,,706.34,Other,125% New York Medicaid APG,0.01,9473,
Dilation of urethra,53665,CPT,,,,,,,,both,,,42841.82,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21420.91,50,,21420.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1123.05,,,1123.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29989.27,70,,29989.27,percent of total billed charges,,184.8,,,184.8,Fee Schedule,,156.8,,,156.8,Fee Schedule,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,603.79,,,603.79,Other,New York Medicaid APG methodology,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,845.31,,,845.31,Other,140% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1569.85,,,1569.85,Other,260% New York Medicaid APG,1956.28,,,1956.28,Other,324% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,754.74,,,754.74,Other,125% New York Medicaid APG,156.8,29989.27,
Prostatic microwave thermotx,53850,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,15382,,"100% primary, 50% supplemental procedure",15382,Other,Aetna ASC Grouper,13844,,"100% primary, 50% supplemental procedure",13844,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4467.58,,,4467.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2401.92,,,2401.92,Other,New York Medicaid APG methodology,2401.92,,,2401.92,Other,100% New York Medicaid APG,2401.92,,,2401.92,Other,100% New York Medicaid APG,2401.92,,,2401.92,Other,100% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,3362.69,,,3362.69,Other,140% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,6245,,,6245,Other,260% New York Medicaid APG,7782.23,,,7782.23,Other,324% New York Medicaid APG,5164.14,,,5164.14,Other,215% New York Medicaid APG,5164.14,,,5164.14,Other,215% New York Medicaid APG,3002.4,,,3002.4,Other,125% New York Medicaid APG,2401.92,51328.82,
Prostatic rf thermotx,53852,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4467.58,,,4467.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2401.92,,,2401.92,Other,New York Medicaid APG methodology,2401.92,,,2401.92,Other,100% New York Medicaid APG,2401.92,,,2401.92,Other,100% New York Medicaid APG,2401.92,,,2401.92,Other,100% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,3362.69,,,3362.69,Other,140% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,6245,,,6245,Other,260% New York Medicaid APG,7782.23,,,7782.23,Other,324% New York Medicaid APG,5164.14,,,5164.14,Other,215% New York Medicaid APG,5164.14,,,5164.14,Other,215% New York Medicaid APG,3002.4,,,3002.4,Other,125% New York Medicaid APG,2401.92,51328.82,
Trurl dstrj prst8 tiss rf wv,53854,CPT,,,,,,,,both,,,36141.18,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18070.59,50,,18070.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4467.58,,,4467.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25298.83,70,,25298.83,percent of total billed charges,,1861.2,,,1861.2,Fee Schedule,,1579.2,,,1579.2,Fee Schedule,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2401.92,,,2401.92,Other,New York Medicaid APG methodology,2401.92,,,2401.92,Other,100% New York Medicaid APG,2401.92,,,2401.92,Other,100% New York Medicaid APG,2401.92,,,2401.92,Other,100% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,3362.69,,,3362.69,Other,140% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,6245,,,6245,Other,260% New York Medicaid APG,7782.23,,,7782.23,Other,324% New York Medicaid APG,5164.14,,,5164.14,Other,215% New York Medicaid APG,5164.14,,,5164.14,Other,215% New York Medicaid APG,3002.4,,,3002.4,Other,125% New York Medicaid APG,1579.2,25298.83,
Insert prost urethral stent,53855,CPT,,,,,,,,both,,,42841.82,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21420.91,50,,21420.91,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29989.27,70,,29989.27,percent of total billed charges,,396,,,396,Fee Schedule,,336,,,336,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,0.01,29989.27,
Transurethral rf treatment,53860,CPT,,,,,,,,both,,,42841.82,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21420.91,50,,21420.91,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29989.27,70,,29989.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,29989.27,
Slitting of prepuce,54000,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1123.05,,,1123.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,541.2,,,541.2,Fee Schedule,,459.2,,,459.2,Fee Schedule,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,603.79,,,603.79,Other,New York Medicaid APG methodology,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,845.31,,,845.31,Other,140% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1569.85,,,1569.85,Other,260% New York Medicaid APG,1956.28,,,1956.28,Other,324% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,754.74,,,754.74,Other,125% New York Medicaid APG,459.2,51328.82,
Slitting of prepuce,54001,CPT,,,,,,,,both,,,42841.82,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21420.91,50,,21420.91,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29989.27,70,,29989.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,29989.27,
Drain penis lesion,54015,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,23871.23,
Destruction penis lesion(s),54050,CPT,,,,,,,,both,,,8387.08,758.27,,,758.27,Other,150% of Medicare + 9.63% HCRA Surcharge,461.11,,,461.11,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4193.54,50,,4193.54,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1123.05,,,1123.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5870.96,70,,5870.96,percent of total billed charges,,526.35,,,526.35,Fee Schedule,,446.6,,,446.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,603.79,,,603.79,Other,New York Medicaid APG methodology,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,845.31,,,845.31,Other,140% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1569.85,,,1569.85,Other,260% New York Medicaid APG,1956.28,,,1956.28,Other,324% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,754.74,,,754.74,Other,125% New York Medicaid APG,0.01,9473,
Destruction penis lesion(s),54055,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,471.9,,,471.9,Fee Schedule,,400.4,,,400.4,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,400.4,26850.29,
Cryosurgery penis lesion(s),54056,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1123.05,,,1123.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,547.8,,,547.8,Fee Schedule,,464.8,,,464.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,603.79,,,603.79,Other,New York Medicaid APG methodology,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,845.31,,,845.31,Other,140% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1569.85,,,1569.85,Other,260% New York Medicaid APG,1956.28,,,1956.28,Other,324% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,754.74,,,754.74,Other,125% New York Medicaid APG,0.01,9473,
Laser surg penis lesion(s),54057,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,481.8,,,481.8,Fee Schedule,,408.8,,,408.8,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,408.8,26850.29,
Excision of penis lesion(s),54060,CPT,,,,,,,,both,,,38953.63,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19476.82,50,,19476.82,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27267.54,70,,27267.54,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,27267.54,
Destruction penis lesion(s),54065,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,26850.29,
Biopsy of penis,54100,CPT,,,,,,,,both,,,39273.29,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19636.65,50,,19636.65,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27491.3,70,,27491.3,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,27491.3,
Biopsy of penis,54105,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,41837.04,
Treatment of penis lesion,54110,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,51328.82,
Treat penis lesion graft,54111,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2331.29,,,2331.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1253.38,,,1253.38,Other,New York Medicaid APG methodology,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,1754.73,,,1754.73,Other,140% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,3258.79,,,3258.79,Other,260% New York Medicaid APG,4060.96,,,4060.96,Other,324% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,1566.73,,,1566.73,Other,125% New York Medicaid APG,1253.38,76185.18,
Treat penis lesion graft,54112,CPT,,,,,,,,both,,,193769.26,17518.56,,,17518.56,Other,150% of Medicare + 9.63% HCRA Surcharge,10653.14,,,10653.14,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,96884.63,50,,96884.63,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2331.29,,,2331.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,135638.48,70,,135638.48,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1253.38,,,1253.38,Other,New York Medicaid APG methodology,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,1754.73,,,1754.73,Other,140% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,3258.79,,,3258.79,Other,260% New York Medicaid APG,4060.96,,,4060.96,Other,324% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,1566.73,,,1566.73,Other,125% New York Medicaid APG,1253.38,135638.48,
Treatment of penis lesion,54115,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,41837.04,
Partial removal of penis,54120,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2331.29,,,2331.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1253.38,,,1253.38,Other,New York Medicaid APG methodology,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,1754.73,,,1754.73,Other,140% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,3258.79,,,3258.79,Other,260% New York Medicaid APG,4060.96,,,4060.96,Other,324% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,1566.73,,,1566.73,Other,125% New York Medicaid APG,1253.38,51328.82,
Circumcision w/regionl block,54150,CPT,,,,,,,,both,,,35318.53,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17659.27,50,,17659.27,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24722.97,70,,24722.97,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,24722.97,
Circumcision neonate,54160,CPT,,,,,,,,both,,,14368.32,1299.03,,,1299.03,Other,150% of Medicare + 9.63% HCRA Surcharge,789.95,,,789.95,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7184.16,50,,7184.16,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10057.82,70,,10057.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,789.95,13157,
Circum 28 days or older,54161,CPT,,,,,,,,both,,,35519.59,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17759.8,50,,17759.8,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24863.71,70,,24863.71,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,24863.71,
Lysis penil circumic lesion,54162,CPT,,,,,,,,both,,,35190.53,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17595.27,50,,17595.27,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24633.37,70,,24633.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,24633.37,
Repair of circumcision,54163,CPT,,,,,,,,both,,,35023.11,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17511.56,50,,17511.56,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24516.18,70,,24516.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,24516.18,
Frenulotomy of penis,54164,CPT,,,,,,,,both,,,35753.88,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17876.94,50,,17876.94,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25027.72,70,,25027.72,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,25027.72,
Treatment of penis lesion,54200,CPT,,,,,,,,both,,,5198.43,469.99,,,469.99,Other,150% of Medicare + 9.63% HCRA Surcharge,285.8,,,285.8,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2599.22,50,,2599.22,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1051.03,,,1051.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3638.9,70,,3638.9,percent of total billed charges,,424.05,,,424.05,Fee Schedule,,359.8,,,359.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,565.07,,,565.07,Other,New York Medicaid APG methodology,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,791.1,,,791.1,Other,140% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1469.19,,,1469.19,Other,260% New York Medicaid APG,1830.83,,,1830.83,Other,324% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,706.34,,,706.34,Other,125% New York Medicaid APG,285.8,9473,
Treatment of penis lesion,54205,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2331.29,,,2331.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1253.38,,,1253.38,Other,New York Medicaid APG methodology,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,1754.73,,,1754.73,Other,140% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,3258.79,,,3258.79,Other,260% New York Medicaid APG,4060.96,,,4060.96,Other,324% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,1566.73,,,1566.73,Other,125% New York Medicaid APG,1253.38,76185.18,
Treatment of penis lesion,54220,CPT,,,,,,,,both,,,5198.43,469.99,,,469.99,Other,150% of Medicare + 9.63% HCRA Surcharge,285.8,,,285.8,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2599.22,50,,2599.22,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1051.03,,,1051.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3638.9,70,,3638.9,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,565.07,,,565.07,Other,New York Medicaid APG methodology,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,791.1,,,791.1,Other,140% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1469.19,,,1469.19,Other,260% New York Medicaid APG,1830.83,,,1830.83,Other,324% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,706.34,,,706.34,Other,125% New York Medicaid APG,285.8,13157,
Prepare penis study,54230,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,387.75,,,387.75,Fee Schedule,,329,,,329,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,0.01,22702.47,
Dynamic cavernosometry,54231,CPT,,,,,,,,both,,,5198.43,469.99,,,469.99,Other,150% of Medicare + 9.63% HCRA Surcharge,285.8,,,285.8,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2599.22,50,,2599.22,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3638.9,70,,3638.9,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,285.8,13157,
Penile injection,54235,CPT,,,,,,,,both,,,5198.43,469.99,,,469.99,Other,150% of Medicare + 9.63% HCRA Surcharge,285.8,,,285.8,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2599.22,50,,2599.22,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1051.03,,,1051.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3638.9,70,,3638.9,percent of total billed charges,,361.35,,,361.35,Fee Schedule,,306.6,,,306.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,565.07,,,565.07,Other,New York Medicaid APG methodology,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,791.1,,,791.1,Other,140% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1469.19,,,1469.19,Other,260% New York Medicaid APG,1830.83,,,1830.83,Other,324% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,706.34,,,706.34,Other,125% New York Medicaid APG,0.01,9473,
Penis study,54240,CPT,,,,,,,,both,,,6602.02,596.88,,,596.88,Other,150% of Medicare + 9.63% HCRA Surcharge,362.97,,,362.97,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,324.39,,,324.39,Fee Schedule,,291.86,,,291.86,Fee Schedule,,275.6,,,275.6,Fee Schedule,,3301.01,50,,3301.01,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1051.03,,,1051.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4621.41,70,,4621.41,percent of total billed charges,,3301.01,50,,3301.01,percent of total billed charges,,3301.01,50,,3301.01,percent of total billed charges,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,565.07,,,565.07,Other,New York Medicaid APG methodology,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,791.1,,,791.1,Other,140% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1469.19,,,1469.19,Other,260% New York Medicaid APG,1830.83,,,1830.83,Other,324% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,706.34,,,706.34,Other,125% New York Medicaid APG,0.01,9473,
Penis study,54250,CPT,,,,,,,,both,,,5198.43,469.99,,,469.99,Other,150% of Medicare + 9.63% HCRA Surcharge,285.8,,,285.8,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,109.28,,,109.28,Fee Schedule,,98.32,,,98.32,Fee Schedule,,92.84,,,92.84,Fee Schedule,,2599.22,50,,2599.22,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1051.03,,,1051.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3638.9,70,,3638.9,percent of total billed charges,,2599.22,50,,2599.22,percent of total billed charges,,2599.22,50,,2599.22,percent of total billed charges,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,565.07,,,565.07,Other,New York Medicaid APG methodology,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,791.1,,,791.1,Other,140% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1469.19,,,1469.19,Other,260% New York Medicaid APG,1830.83,,,1830.83,Other,324% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,706.34,,,706.34,Other,125% New York Medicaid APG,0.01,9473,
Revision of penis,54300,CPT,,,,,,,,both,,,34835.02,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17417.51,50,,17417.51,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24384.51,70,,24384.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,24384.51,
Revision of penis,54304,CPT,,,,,,,,both,,,34641.1,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17320.55,50,,17320.55,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24248.77,70,,24248.77,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,24248.77,
Reconstruction of urethra,54308,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2331.29,,,2331.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1253.38,,,1253.38,Other,New York Medicaid APG methodology,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,1754.73,,,1754.73,Other,140% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,3258.79,,,3258.79,Other,260% New York Medicaid APG,4060.96,,,4060.96,Other,324% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,1566.73,,,1566.73,Other,125% New York Medicaid APG,1253.38,76185.18,
Reconstruction of urethra,54312,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2331.29,,,2331.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1253.38,,,1253.38,Other,New York Medicaid APG methodology,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,1754.73,,,1754.73,Other,140% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,3258.79,,,3258.79,Other,260% New York Medicaid APG,4060.96,,,4060.96,Other,324% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,1566.73,,,1566.73,Other,125% New York Medicaid APG,1253.38,51328.82,
Reconstruction of urethra,54316,CPT,,,,,,,,both,,,193769.26,17518.56,,,17518.56,Other,150% of Medicare + 9.63% HCRA Surcharge,10653.14,,,10653.14,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,96884.63,50,,96884.63,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2331.29,,,2331.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,135638.48,70,,135638.48,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1253.38,,,1253.38,Other,New York Medicaid APG methodology,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,1754.73,,,1754.73,Other,140% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,3258.79,,,3258.79,Other,260% New York Medicaid APG,4060.96,,,4060.96,Other,324% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,1566.73,,,1566.73,Other,125% New York Medicaid APG,1253.38,135638.48,
Reconstruction of urethra,54318,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2331.29,,,2331.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1253.38,,,1253.38,Other,New York Medicaid APG methodology,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,1754.73,,,1754.73,Other,140% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,3258.79,,,3258.79,Other,260% New York Medicaid APG,4060.96,,,4060.96,Other,324% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,1566.73,,,1566.73,Other,125% New York Medicaid APG,1253.38,51328.82,
Reconstruction of urethra,54322,CPT,,,,,,,,both,,,35358.69,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17679.35,50,,17679.35,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2331.29,,,2331.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24751.08,70,,24751.08,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1253.38,,,1253.38,Other,New York Medicaid APG methodology,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,1754.73,,,1754.73,Other,140% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,3258.79,,,3258.79,Other,260% New York Medicaid APG,4060.96,,,4060.96,Other,324% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,1566.73,,,1566.73,Other,125% New York Medicaid APG,1253.38,24751.08,
Reconstruction of urethra,54324,CPT,,,,,,,,both,,,35720.35,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17860.18,50,,17860.18,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2331.29,,,2331.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25004.25,70,,25004.25,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1253.38,,,1253.38,Other,New York Medicaid APG methodology,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,1754.73,,,1754.73,Other,140% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,3258.79,,,3258.79,Other,260% New York Medicaid APG,4060.96,,,4060.96,Other,324% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,1566.73,,,1566.73,Other,125% New York Medicaid APG,1253.38,25004.25,
Reconstruction of urethra,54326,CPT,,,,,,,,both,,,37150.74,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18575.37,50,,18575.37,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2331.29,,,2331.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26005.52,70,,26005.52,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1253.38,,,1253.38,Other,New York Medicaid APG methodology,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,1754.73,,,1754.73,Other,140% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,3258.79,,,3258.79,Other,260% New York Medicaid APG,4060.96,,,4060.96,Other,324% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,1566.73,,,1566.73,Other,125% New York Medicaid APG,1253.38,26005.52,
Revise penis/urethra,54328,CPT,,,,,,,,both,,,37096.03,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18548.02,50,,18548.02,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2331.29,,,2331.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25967.22,70,,25967.22,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1253.38,,,1253.38,Other,New York Medicaid APG methodology,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,1754.73,,,1754.73,Other,140% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,3258.79,,,3258.79,Other,260% New York Medicaid APG,4060.96,,,4060.96,Other,324% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,1566.73,,,1566.73,Other,125% New York Medicaid APG,1253.38,25967.22,
Revise penis/urethra,54332,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2331.29,,,2331.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1253.38,,,1253.38,Other,New York Medicaid APG methodology,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,1754.73,,,1754.73,Other,140% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,3258.79,,,3258.79,Other,260% New York Medicaid APG,4060.96,,,4060.96,Other,324% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,1566.73,,,1566.73,Other,125% New York Medicaid APG,1253.38,51328.82,
Revise penis/urethra,54336,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2331.29,,,2331.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1253.38,,,1253.38,Other,New York Medicaid APG methodology,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,1754.73,,,1754.73,Other,140% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,3258.79,,,3258.79,Other,260% New York Medicaid APG,4060.96,,,4060.96,Other,324% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,1566.73,,,1566.73,Other,125% New York Medicaid APG,1253.38,51328.82,
Secondary urethral surgery,54340,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,51328.82,
Secondary urethral surgery,54344,CPT,,,,,,,,both,,,35737.57,17518.56,,,17518.56,Other,150% of Medicare + 9.63% HCRA Surcharge,10653.14,,,10653.14,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,17868.79,50,,17868.79,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2331.29,,,2331.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25016.3,70,,25016.3,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1253.38,,,1253.38,Other,New York Medicaid APG methodology,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,1754.73,,,1754.73,Other,140% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,3258.79,,,3258.79,Other,260% New York Medicaid APG,4060.96,,,4060.96,Other,324% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,1566.73,,,1566.73,Other,125% New York Medicaid APG,1253.38,25016.3,
Secondary urethral surgery,54348,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2331.29,,,2331.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1253.38,,,1253.38,Other,New York Medicaid APG methodology,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,1754.73,,,1754.73,Other,140% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,3258.79,,,3258.79,Other,260% New York Medicaid APG,4060.96,,,4060.96,Other,324% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,1566.73,,,1566.73,Other,125% New York Medicaid APG,1253.38,76185.18,
Reconstruct urethra/penis,54352,CPT,,,,,,,,both,,,43661.58,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,21830.79,50,,21830.79,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2331.29,,,2331.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,30563.11,70,,30563.11,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1253.38,,,1253.38,Other,New York Medicaid APG methodology,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,1754.73,,,1754.73,Other,140% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,3258.79,,,3258.79,Other,260% New York Medicaid APG,4060.96,,,4060.96,Other,324% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,1566.73,,,1566.73,Other,125% New York Medicaid APG,1253.38,30563.11,
Penis plastic surgery,54360,CPT,,,,,,,,both,,,34270.38,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17135.19,50,,17135.19,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23989.27,70,,23989.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,23989.27,
Repair penis,54380,CPT,,,,,,,,both,,,49175.08,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24587.54,50,,24587.54,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34422.56,70,,34422.56,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,34422.56,
Repair penis,54385,CPT,,,,,,,,both,,,42841.82,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21420.91,50,,21420.91,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29989.27,70,,29989.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,29989.27,
Insert semi-rigid prosthesis,54400,CPT,,,,,,,,both,,,270006.63,24411.13,,,24411.13,Other,150% of Medicare + 9.63% HCRA Surcharge,14844.56,,,14844.56,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,135003.32,50,,135003.32,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,11507.63,,,11507.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,189004.64,70,,189004.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,6186.9,,,6186.9,Other,New York Medicaid APG methodology,6186.9,,,6186.9,Other,100% New York Medicaid APG,6186.9,,,6186.9,Other,100% New York Medicaid APG,6186.9,,,6186.9,Other,100% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,8661.66,,,8661.66,Other,140% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,16085.94,,,16085.94,Other,260% New York Medicaid APG,20045.56,,,20045.56,Other,324% New York Medicaid APG,13301.84,,,13301.84,Other,215% New York Medicaid APG,13301.84,,,13301.84,Other,215% New York Medicaid APG,7733.63,,,7733.63,Other,125% New York Medicaid APG,5919,189004.64,
Insert self-contd prosthesis,54401,CPT,,,,,,,,both,,,424287.84,38359.6,,,38359.6,Other,150% of Medicare + 9.63% HCRA Surcharge,23326.71,,,23326.71,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,212143.92,50,,212143.92,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,11507.63,,,11507.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,297001.49,70,,297001.49,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,14938,,"100% primary, 50% secondary, 25% tertiary procedure",14938,Other,United Healthcare ASC Grouper,13443,,"100% primary, 50% secondary, 25% tertiary procedure",13443,Other,United Healthcare ASC Grouper,14938,,"100% primary, 50% secondary, 25% tertiary procedure",14938,Other,United Healthcare ASC Grouper,12698,,"100% primary, 50% secondary, 25% tertiary procedure",12698,Other,United Healthcare ASC Grouper,6186.9,,,6186.9,Other,New York Medicaid APG methodology,6186.9,,,6186.9,Other,100% New York Medicaid APG,6186.9,,,6186.9,Other,100% New York Medicaid APG,6186.9,,,6186.9,Other,100% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,8661.66,,,8661.66,Other,140% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,16085.94,,,16085.94,Other,260% New York Medicaid APG,20045.56,,,20045.56,Other,324% New York Medicaid APG,13301.84,,,13301.84,Other,215% New York Medicaid APG,13301.84,,,13301.84,Other,215% New York Medicaid APG,7733.63,,,7733.63,Other,125% New York Medicaid APG,5919,297001.49,
Insert multi-comp penis pros,54405,CPT,,,,,,,,both,,,79905.35,38359.6,,,38359.6,Other,150% of Medicare + 9.63% HCRA Surcharge,23326.71,,,23326.71,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,39952.68,50,,39952.68,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,11507.63,,,11507.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,55933.75,70,,55933.75,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,14938,,"100% primary, 50% secondary, 25% tertiary procedure",14938,Other,United Healthcare ASC Grouper,13443,,"100% primary, 50% secondary, 25% tertiary procedure",13443,Other,United Healthcare ASC Grouper,14938,,"100% primary, 50% secondary, 25% tertiary procedure",14938,Other,United Healthcare ASC Grouper,12698,,"100% primary, 50% secondary, 25% tertiary procedure",12698,Other,United Healthcare ASC Grouper,6186.9,,,6186.9,Other,New York Medicaid APG methodology,6186.9,,,6186.9,Other,100% New York Medicaid APG,6186.9,,,6186.9,Other,100% New York Medicaid APG,6186.9,,,6186.9,Other,100% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,8661.66,,,8661.66,Other,140% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,16085.94,,,16085.94,Other,260% New York Medicaid APG,20045.56,,,20045.56,Other,324% New York Medicaid APG,13301.84,,,13301.84,Other,215% New York Medicaid APG,13301.84,,,13301.84,Other,215% New York Medicaid APG,7733.63,,,7733.63,Other,125% New York Medicaid APG,5919,55933.75,
Remove muti-comp penis pros,54406,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,51328.82,
Repair multi-comp penis pros,54408,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,76185.18,
Remove/replace penis prosth,54410,CPT,,,,,,,,both,,,103369.65,38359.6,,,38359.6,Other,150% of Medicare + 9.63% HCRA Surcharge,23326.71,,,23326.71,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,51684.83,50,,51684.83,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,11507.63,,,11507.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,72358.76,70,,72358.76,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,14938,,"100% primary, 50% secondary, 25% tertiary procedure",14938,Other,United Healthcare ASC Grouper,13443,,"100% primary, 50% secondary, 25% tertiary procedure",13443,Other,United Healthcare ASC Grouper,14938,,"100% primary, 50% secondary, 25% tertiary procedure",14938,Other,United Healthcare ASC Grouper,12698,,"100% primary, 50% secondary, 25% tertiary procedure",12698,Other,United Healthcare ASC Grouper,6186.9,,,6186.9,Other,New York Medicaid APG methodology,6186.9,,,6186.9,Other,100% New York Medicaid APG,6186.9,,,6186.9,Other,100% New York Medicaid APG,6186.9,,,6186.9,Other,100% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,8661.66,,,8661.66,Other,140% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,16085.94,,,16085.94,Other,260% New York Medicaid APG,20045.56,,,20045.56,Other,324% New York Medicaid APG,13301.84,,,13301.84,Other,215% New York Medicaid APG,13301.84,,,13301.84,Other,215% New York Medicaid APG,7733.63,,,7733.63,Other,125% New York Medicaid APG,5919,72358.76,
Remov/replc penis pros comp,54411,CPT,,,,,,,,both,,,424287.84,38359.6,,,38359.6,Other,150% of Medicare + 9.63% HCRA Surcharge,23326.71,,,23326.71,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,212143.92,50,,212143.92,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,11507.63,,,11507.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,297001.49,70,,297001.49,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,6186.9,,,6186.9,Other,New York Medicaid APG methodology,6186.9,,,6186.9,Other,100% New York Medicaid APG,6186.9,,,6186.9,Other,100% New York Medicaid APG,6186.9,,,6186.9,Other,100% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,8661.66,,,8661.66,Other,140% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,16085.94,,,16085.94,Other,260% New York Medicaid APG,20045.56,,,20045.56,Other,324% New York Medicaid APG,13301.84,,,13301.84,Other,215% New York Medicaid APG,13301.84,,,13301.84,Other,215% New York Medicaid APG,7733.63,,,7733.63,Other,125% New York Medicaid APG,2184,297001.49,
Remove self-contd penis pros,54415,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,51328.82,
Remv/repl penis contain pros,54416,CPT,,,,,,,,both,,,47066.38,38359.6,,,38359.6,Other,150% of Medicare + 9.63% HCRA Surcharge,23326.71,,,23326.71,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,23533.19,50,,23533.19,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,11507.63,,,11507.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,32946.47,70,,32946.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,14938,,"100% primary, 50% secondary, 25% tertiary procedure",14938,Other,United Healthcare ASC Grouper,13443,,"100% primary, 50% secondary, 25% tertiary procedure",13443,Other,United Healthcare ASC Grouper,14938,,"100% primary, 50% secondary, 25% tertiary procedure",14938,Other,United Healthcare ASC Grouper,12698,,"100% primary, 50% secondary, 25% tertiary procedure",12698,Other,United Healthcare ASC Grouper,6186.9,,,6186.9,Other,New York Medicaid APG methodology,6186.9,,,6186.9,Other,100% New York Medicaid APG,6186.9,,,6186.9,Other,100% New York Medicaid APG,6186.9,,,6186.9,Other,100% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,8661.66,,,8661.66,Other,140% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,16085.94,,,16085.94,Other,260% New York Medicaid APG,20045.56,,,20045.56,Other,324% New York Medicaid APG,13301.84,,,13301.84,Other,215% New York Medicaid APG,13301.84,,,13301.84,Other,215% New York Medicaid APG,7733.63,,,7733.63,Other,125% New York Medicaid APG,5919,38359.6,
Remv/replc penis pros compl,54417,CPT,,,,,,,,both,,,270006.63,24411.13,,,24411.13,Other,150% of Medicare + 9.63% HCRA Surcharge,14844.56,,,14844.56,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,135003.32,50,,135003.32,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,11507.63,,,11507.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,189004.64,70,,189004.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,6186.9,,,6186.9,Other,New York Medicaid APG methodology,6186.9,,,6186.9,Other,100% New York Medicaid APG,6186.9,,,6186.9,Other,100% New York Medicaid APG,6186.9,,,6186.9,Other,100% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,8661.66,,,8661.66,Other,140% New York Medicaid APG,13920.53,,,13920.53,Other,225% New York Medicaid APG,16085.94,,,16085.94,Other,260% New York Medicaid APG,20045.56,,,20045.56,Other,324% New York Medicaid APG,13301.84,,,13301.84,Other,215% New York Medicaid APG,13301.84,,,13301.84,Other,215% New York Medicaid APG,7733.63,,,7733.63,Other,125% New York Medicaid APG,3032,189004.64,
Revision of penis,54420,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,51328.82,
Revision of penis,54435,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,51328.82,
Repair corporeal tear,54437,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2331.29,,,2331.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1253.38,,,1253.38,Other,New York Medicaid APG methodology,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,1253.38,,,1253.38,Other,100% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,1754.73,,,1754.73,Other,140% New York Medicaid APG,2820.11,,,2820.11,Other,225% New York Medicaid APG,3258.79,,,3258.79,Other,260% New York Medicaid APG,4060.96,,,4060.96,Other,324% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,2694.77,,,2694.77,Other,215% New York Medicaid APG,1566.73,,,1566.73,Other,125% New York Medicaid APG,1253.38,51328.82,
Repair of penis,54440,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,36663.44,50,,36663.44,percent of total billed charges,,36663.44,50,,36663.44,percent of total billed charges,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,51328.82,
Preputial stretching,54450,CPT,,,,,,,,both,,,34263.79,469.99,,,469.99,Other,150% of Medicare + 9.63% HCRA Surcharge,285.8,,,285.8,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17131.9,50,,17131.9,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1123.05,,,1123.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23984.65,70,,23984.65,percent of total billed charges,,277.2,,,277.2,Fee Schedule,,235.2,,,235.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,603.79,,,603.79,Other,New York Medicaid APG methodology,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,845.31,,,845.31,Other,140% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1569.85,,,1569.85,Other,260% New York Medicaid APG,1956.28,,,1956.28,Other,324% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,754.74,,,754.74,Other,125% New York Medicaid APG,235.2,23984.65,
Biopsy of testis,54500,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1123.05,,,1123.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,363,,,363,Fee Schedule,,308,,,308,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,603.79,,,603.79,Other,New York Medicaid APG methodology,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,845.31,,,845.31,Other,140% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1569.85,,,1569.85,Other,260% New York Medicaid APG,1956.28,,,1956.28,Other,324% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,754.74,,,754.74,Other,125% New York Medicaid APG,308,41837.04,
Biopsy of testis,54505,CPT,,,,,,,,both,,,43881.96,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,21940.98,50,,21940.98,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,30717.37,70,,30717.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,30717.37,
Excise lesion testis,54512,CPT,,,,,,,,both,,,35393.63,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17696.82,50,,17696.82,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2992,,,2992,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24775.54,70,,24775.54,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1608.6,,,1608.6,Other,New York Medicaid APG methodology,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,2252.04,,,2252.04,Other,140% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,4182.36,,,4182.36,Other,260% New York Medicaid APG,5211.87,,,5211.87,Other,324% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,2010.75,,,2010.75,Other,125% New York Medicaid APG,1608.6,24775.54,
Removal of testis,54520,CPT,,,,,,,,both,,,35952.94,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17976.47,50,,17976.47,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2992,,,2992,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25167.06,70,,25167.06,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1608.6,,,1608.6,Other,New York Medicaid APG methodology,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,2252.04,,,2252.04,Other,140% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,4182.36,,,4182.36,Other,260% New York Medicaid APG,5211.87,,,5211.87,Other,324% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,2010.75,,,2010.75,Other,125% New York Medicaid APG,1608.6,25167.06,
Orchiectomy partial,54522,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,51328.82,
Removal of testis,54530,CPT,,,,,,,,both,,,46027.24,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,23013.62,50,,23013.62,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,32219.07,70,,32219.07,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,32219.07,
Extensive testis surgery,54535,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,51328.82,
Exploration for testis,54550,CPT,,,,,,,,both,,,36454.18,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18227.09,50,,18227.09,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2992,,,2992,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25517.93,70,,25517.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1608.6,,,1608.6,Other,New York Medicaid APG methodology,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,2252.04,,,2252.04,Other,140% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,4182.36,,,4182.36,Other,260% New York Medicaid APG,5211.87,,,5211.87,Other,324% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,2010.75,,,2010.75,Other,125% New York Medicaid APG,1608.6,25517.93,
Exploration for testis,54560,CPT,,,,,,,,both,,,42841.82,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21420.91,50,,21420.91,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29989.27,70,,29989.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,29989.27,
Reduce testis torsion,54600,CPT,,,,,,,,both,,,33768.86,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16884.43,50,,16884.43,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2992,,,2992,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23638.2,70,,23638.2,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1608.6,,,1608.6,Other,New York Medicaid APG methodology,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,2252.04,,,2252.04,Other,140% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,4182.36,,,4182.36,Other,260% New York Medicaid APG,5211.87,,,5211.87,Other,324% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,2010.75,,,2010.75,Other,125% New York Medicaid APG,1608.6,23638.2,
Suspension of testis,54620,CPT,,,,,,,,both,,,35695.25,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17847.63,50,,17847.63,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2992,,,2992,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24986.68,70,,24986.68,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1608.6,,,1608.6,Other,New York Medicaid APG methodology,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,2252.04,,,2252.04,Other,140% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,4182.36,,,4182.36,Other,260% New York Medicaid APG,5211.87,,,5211.87,Other,324% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,2010.75,,,2010.75,Other,125% New York Medicaid APG,1608.6,24986.68,
Orchiopexy ingun/scrot appr,54640,CPT,,,,,,,,both,,,35467.74,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17733.87,50,,17733.87,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2992,,,2992,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24827.42,70,,24827.42,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1608.6,,,1608.6,Other,New York Medicaid APG methodology,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,2252.04,,,2252.04,Other,140% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,4182.36,,,4182.36,Other,260% New York Medicaid APG,5211.87,,,5211.87,Other,324% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,2010.75,,,2010.75,Other,125% New York Medicaid APG,1608.6,24827.42,
Orchiopexy (fowler-stephens),54650,CPT,,,,,,,,both,,,72769.69,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36384.85,50,,36384.85,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50938.78,70,,50938.78,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,50938.78,
Revision of testis,54660,CPT,,,,,,,,both,,,41031.71,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,20515.86,50,,20515.86,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28722.2,70,,28722.2,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,28722.2,
Repair testis injury,54670,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2992,,,2992,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1608.6,,,1608.6,Other,New York Medicaid APG methodology,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,2252.04,,,2252.04,Other,140% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,4182.36,,,4182.36,Other,260% New York Medicaid APG,5211.87,,,5211.87,Other,324% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,2010.75,,,2010.75,Other,125% New York Medicaid APG,1608.6,51328.82,
Relocation of testis(es),54680,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,51328.82,
Laparoscopy orchiectomy,54690,CPT,,,,,,,,both,,,36925.31,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,18462.66,50,,18462.66,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25847.72,70,,25847.72,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,25847.72,
Laparoscopy orchiopexy,54692,CPT,,,,,,,,both,,,36506.42,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,18253.21,50,,18253.21,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25554.49,70,,25554.49,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,25554.49,
Drainage of scrotum,54700,CPT,,,,,,,,both,,,42841.82,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21420.91,50,,21420.91,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2992,,,2992,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29989.27,70,,29989.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1608.6,,,1608.6,Other,New York Medicaid APG methodology,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,2252.04,,,2252.04,Other,140% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,4182.36,,,4182.36,Other,260% New York Medicaid APG,5211.87,,,5211.87,Other,324% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,2010.75,,,2010.75,Other,125% New York Medicaid APG,1608.6,29989.27,
Biopsy of epididymis,54800,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2992,,,2992,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1608.6,,,1608.6,Other,New York Medicaid APG methodology,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,2252.04,,,2252.04,Other,140% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,4182.36,,,4182.36,Other,260% New York Medicaid APG,5211.87,,,5211.87,Other,324% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,2010.75,,,2010.75,Other,125% New York Medicaid APG,1608.6,23871.23,
Remove epididymis lesion,54830,CPT,,,,,,,,both,,,46383.69,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,23191.85,50,,23191.85,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2992,,,2992,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,32468.58,70,,32468.58,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1608.6,,,1608.6,Other,New York Medicaid APG methodology,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,2252.04,,,2252.04,Other,140% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,4182.36,,,4182.36,Other,260% New York Medicaid APG,5211.87,,,5211.87,Other,324% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,2010.75,,,2010.75,Other,125% New York Medicaid APG,1608.6,32468.58,
Remove epididymis lesion,54840,CPT,,,,,,,,both,,,33168.4,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16584.2,50,,16584.2,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2992,,,2992,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23217.88,70,,23217.88,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1608.6,,,1608.6,Other,New York Medicaid APG methodology,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,2252.04,,,2252.04,Other,140% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,4182.36,,,4182.36,Other,260% New York Medicaid APG,5211.87,,,5211.87,Other,324% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,2010.75,,,2010.75,Other,125% New York Medicaid APG,1608.6,23217.88,
Removal of epididymis,54860,CPT,,,,,,,,both,,,38579.03,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19289.52,50,,19289.52,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2992,,,2992,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27005.32,70,,27005.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1608.6,,,1608.6,Other,New York Medicaid APG methodology,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,2252.04,,,2252.04,Other,140% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,4182.36,,,4182.36,Other,260% New York Medicaid APG,5211.87,,,5211.87,Other,324% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,2010.75,,,2010.75,Other,125% New York Medicaid APG,1608.6,27005.32,
Removal of epididymis,54861,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,51328.82,
Explore epididymis,54865,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2992,,,2992,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1608.6,,,1608.6,Other,New York Medicaid APG methodology,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,2252.04,,,2252.04,Other,140% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,4182.36,,,4182.36,Other,260% New York Medicaid APG,5211.87,,,5211.87,Other,324% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,2010.75,,,2010.75,Other,125% New York Medicaid APG,1608.6,51328.82,
Fusion of spermatic ducts,54900,CPT,,,,,,,,both,,,42841.82,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21420.91,50,,21420.91,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2992,,,2992,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29989.27,70,,29989.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1608.6,,,1608.6,Other,New York Medicaid APG methodology,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,2252.04,,,2252.04,Other,140% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,4182.36,,,4182.36,Other,260% New York Medicaid APG,5211.87,,,5211.87,Other,324% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,2010.75,,,2010.75,Other,125% New York Medicaid APG,1608.6,29989.27,
Fusion of spermatic ducts,54901,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,51328.82,
Drainage of hydrocele,55000,CPT,,,,,,,,both,,,14798.8,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7399.4,50,,7399.4,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1051.03,,,1051.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10359.16,70,,10359.16,percent of total billed charges,,410.85,,,410.85,Fee Schedule,,348.6,,,348.6,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,565.07,,,565.07,Other,New York Medicaid APG methodology,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,791.1,,,791.1,Other,140% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1469.19,,,1469.19,Other,260% New York Medicaid APG,1830.83,,,1830.83,Other,324% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,706.34,,,706.34,Other,125% New York Medicaid APG,0.01,10359.16,
Removal of hydrocele,55040,CPT,,,,,,,,both,,,35509.29,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17754.65,50,,17754.65,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24856.5,70,,24856.5,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,24856.5,
Removal of hydroceles,55041,CPT,,,,,,,,both,,,37008.86,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18504.43,50,,18504.43,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25906.2,70,,25906.2,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,25906.2,
Repair of hydrocele,55060,CPT,,,,,,,,both,,,35016.25,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17508.13,50,,17508.13,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2992,,,2992,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24511.38,70,,24511.38,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1608.6,,,1608.6,Other,New York Medicaid APG methodology,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,2252.04,,,2252.04,Other,140% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,4182.36,,,4182.36,Other,260% New York Medicaid APG,5211.87,,,5211.87,Other,324% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,2010.75,,,2010.75,Other,125% New York Medicaid APG,1608.6,24511.38,
Drainage of scrotum abscess,55100,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2992,,,2992,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1608.6,,,1608.6,Other,New York Medicaid APG methodology,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,2252.04,,,2252.04,Other,140% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,4182.36,,,4182.36,Other,260% New York Medicaid APG,5211.87,,,5211.87,Other,324% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,2010.75,,,2010.75,Other,125% New York Medicaid APG,1608.6,23871.23,
Explore scrotum,55110,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,51328.82,
Removal of scrotum lesion,55120,CPT,,,,,,,,both,,,42841.82,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21420.91,50,,21420.91,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2992,,,2992,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29989.27,70,,29989.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1608.6,,,1608.6,Other,New York Medicaid APG methodology,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,2252.04,,,2252.04,Other,140% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,4182.36,,,4182.36,Other,260% New York Medicaid APG,5211.87,,,5211.87,Other,324% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,2010.75,,,2010.75,Other,125% New York Medicaid APG,1608.6,29989.27,
Removal of scrotum,55150,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2992,,,2992,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1608.6,,,1608.6,Other,New York Medicaid APG methodology,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,2252.04,,,2252.04,Other,140% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,4182.36,,,4182.36,Other,260% New York Medicaid APG,5211.87,,,5211.87,Other,324% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,2010.75,,,2010.75,Other,125% New York Medicaid APG,1608.6,51328.82,
Revision of scrotum,55175,CPT,,,,,,,,both,,,35943.65,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17971.83,50,,17971.83,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2992,,,2992,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25160.56,70,,25160.56,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1608.6,,,1608.6,Other,New York Medicaid APG methodology,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,2252.04,,,2252.04,Other,140% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,4182.36,,,4182.36,Other,260% New York Medicaid APG,5211.87,,,5211.87,Other,324% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,2010.75,,,2010.75,Other,125% New York Medicaid APG,1608.6,25160.56,
Revision of scrotum,55180,CPT,,,,,,,,both,,,35884.32,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,17942.16,50,,17942.16,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25119.02,70,,25119.02,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,25119.02,
Incision of sperm duct,55200,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2992,,,2992,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1608.6,,,1608.6,Other,New York Medicaid APG methodology,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,2252.04,,,2252.04,Other,140% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,4182.36,,,4182.36,Other,260% New York Medicaid APG,5211.87,,,5211.87,Other,324% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,2010.75,,,2010.75,Other,125% New York Medicaid APG,1608.6,51328.82,
Removal of sperm duct(s),55250,CPT,,,,,,,,both,,,35521.46,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17760.73,50,,17760.73,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2992,,,2992,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24865.02,70,,24865.02,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1608.6,,,1608.6,Other,New York Medicaid APG methodology,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,2252.04,,,2252.04,Other,140% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,4182.36,,,4182.36,Other,260% New York Medicaid APG,5211.87,,,5211.87,Other,324% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,2010.75,,,2010.75,Other,125% New York Medicaid APG,1608.6,24865.02,
Prepare sperm duct x-ray,55300,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1051.03,,,1051.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,565.07,,,565.07,Other,New York Medicaid APG methodology,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,565.07,,,565.07,Other,100% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,791.1,,,791.1,Other,140% New York Medicaid APG,1271.41,,,1271.41,Other,225% New York Medicaid APG,1469.19,,,1469.19,Other,260% New York Medicaid APG,1830.83,,,1830.83,Other,324% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,1214.9,,,1214.9,Other,215% New York Medicaid APG,706.34,,,706.34,Other,125% New York Medicaid APG,0.01,22702.47,
Repair of sperm duct,55400,CPT,,,,,,,,both,,,70514.14,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,35257.07,50,,35257.07,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,49359.9,70,,49359.9,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,49359.9,
Removal of hydrocele,55500,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2992,,,2992,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1608.6,,,1608.6,Other,New York Medicaid APG methodology,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,2252.04,,,2252.04,Other,140% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,4182.36,,,4182.36,Other,260% New York Medicaid APG,5211.87,,,5211.87,Other,324% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,2010.75,,,2010.75,Other,125% New York Medicaid APG,1608.6,51328.82,
Removal of sperm cord lesion,55520,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2992,,,2992,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1608.6,,,1608.6,Other,New York Medicaid APG methodology,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,2252.04,,,2252.04,Other,140% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,4182.36,,,4182.36,Other,260% New York Medicaid APG,5211.87,,,5211.87,Other,324% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,2010.75,,,2010.75,Other,125% New York Medicaid APG,1608.6,51328.82,
Revise spermatic cord veins,55530,CPT,,,,,,,,both,,,36449.42,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18224.71,50,,18224.71,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25514.59,70,,25514.59,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,25514.59,
Revise spermatic cord veins,55535,CPT,,,,,,,,both,,,159132.17,14387.04,,,14387.04,Other,150% of Medicare + 9.63% HCRA Surcharge,8748.85,,,8748.85,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,79566.09,50,,79566.09,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2992,,,2992,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,111392.52,70,,111392.52,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1608.6,,,1608.6,Other,New York Medicaid APG methodology,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,2252.04,,,2252.04,Other,140% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,4182.36,,,4182.36,Other,260% New York Medicaid APG,5211.87,,,5211.87,Other,324% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,2010.75,,,2010.75,Other,125% New York Medicaid APG,1608.6,111392.52,
Revise hernia & sperm veins,55540,CPT,,,,,,,,both,,,72769.69,6579.06,,,6579.06,Other,150% of Medicare + 9.63% HCRA Surcharge,4000.77,,,4000.77,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36384.85,50,,36384.85,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50938.78,70,,50938.78,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,50938.78,
Laparo ligate spermatic vein,55550,CPT,,,,,,,,both,,,36303.04,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,18151.52,50,,18151.52,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25412.13,70,,25412.13,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,25412.13,
Incise sperm duct pouch,55600,CPT,,,,,,,,both,,,42841.82,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21420.91,50,,21420.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2992,,,2992,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29989.27,70,,29989.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1608.6,,,1608.6,Other,New York Medicaid APG methodology,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,1608.6,,,1608.6,Other,100% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,2252.04,,,2252.04,Other,140% New York Medicaid APG,3619.35,,,3619.35,Other,225% New York Medicaid APG,4182.36,,,4182.36,Other,260% New York Medicaid APG,5211.87,,,5211.87,Other,324% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,3458.49,,,3458.49,Other,215% New York Medicaid APG,2010.75,,,2010.75,Other,125% New York Medicaid APG,1608.6,29989.27,
Remove sperm pouch lesion,55680,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2235.12,,,2235.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1201.68,,,1201.68,Other,New York Medicaid APG methodology,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,1201.68,,,1201.68,Other,100% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,1682.35,,,1682.35,Other,140% New York Medicaid APG,2703.77,,,2703.77,Other,225% New York Medicaid APG,3124.36,,,3124.36,Other,260% New York Medicaid APG,3893.43,,,3893.43,Other,324% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,2583.61,,,2583.61,Other,215% New York Medicaid APG,1502.1,,,1502.1,Other,125% New York Medicaid APG,1201.68,51328.82,
Biopsy of prostate,55700,CPT,,,,,,,,both,,,42130.06,3873.3,,,3873.3,Other,150% of Medicare + 9.63% HCRA Surcharge,2355.38,,,2355.38,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21065.03,50,,21065.03,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4467.58,,,4467.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29491.04,70,,29491.04,percent of total billed charges,,628.65,,,628.65,Fee Schedule,,533.4,,,533.4,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2401.92,,,2401.92,Other,New York Medicaid APG methodology,2401.92,,,2401.92,Other,100% New York Medicaid APG,2401.92,,,2401.92,Other,100% New York Medicaid APG,2401.92,,,2401.92,Other,100% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,3362.69,,,3362.69,Other,140% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,6245,,,6245,Other,260% New York Medicaid APG,7782.23,,,7782.23,Other,324% New York Medicaid APG,5164.14,,,5164.14,Other,215% New York Medicaid APG,5164.14,,,5164.14,Other,215% New York Medicaid APG,3002.4,,,3002.4,Other,125% New York Medicaid APG,533.4,29491.04,
Biopsy of prostate,55705,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4467.58,,,4467.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2401.92,,,2401.92,Other,New York Medicaid APG methodology,2401.92,,,2401.92,Other,100% New York Medicaid APG,2401.92,,,2401.92,Other,100% New York Medicaid APG,2401.92,,,2401.92,Other,100% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,3362.69,,,3362.69,Other,140% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,6245,,,6245,Other,260% New York Medicaid APG,7782.23,,,7782.23,Other,324% New York Medicaid APG,5164.14,,,5164.14,Other,215% New York Medicaid APG,5164.14,,,5164.14,Other,215% New York Medicaid APG,3002.4,,,3002.4,Other,125% New York Medicaid APG,2401.92,51328.82,
Prostate saturation sampling,55706,CPT,,,,,,,,both,,,46242.51,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,23121.26,50,,23121.26,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4467.58,,,4467.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,32369.76,70,,32369.76,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2401.92,,,2401.92,Other,New York Medicaid APG methodology,2401.92,,,2401.92,Other,100% New York Medicaid APG,2401.92,,,2401.92,Other,100% New York Medicaid APG,2401.92,,,2401.92,Other,100% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,3362.69,,,3362.69,Other,140% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,6245,,,6245,Other,260% New York Medicaid APG,7782.23,,,7782.23,Other,324% New York Medicaid APG,5164.14,,,5164.14,Other,215% New York Medicaid APG,5164.14,,,5164.14,Other,215% New York Medicaid APG,3002.4,,,3002.4,Other,125% New York Medicaid APG,2401.92,32369.76,
Drainage of prostate abscess,55720,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4467.58,,,4467.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2401.92,,,2401.92,Other,New York Medicaid APG methodology,2401.92,,,2401.92,Other,100% New York Medicaid APG,2401.92,,,2401.92,Other,100% New York Medicaid APG,2401.92,,,2401.92,Other,100% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,3362.69,,,3362.69,Other,140% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,6245,,,6245,Other,260% New York Medicaid APG,7782.23,,,7782.23,Other,324% New York Medicaid APG,5164.14,,,5164.14,Other,215% New York Medicaid APG,5164.14,,,5164.14,Other,215% New York Medicaid APG,3002.4,,,3002.4,Other,125% New York Medicaid APG,2401.92,51328.82,
Drainage of prostate abscess,55725,CPT,,,,,,,,both,,,73326.88,6629.44,,,6629.44,Other,150% of Medicare + 9.63% HCRA Surcharge,4031.4,,,4031.4,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,36663.44,50,,36663.44,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4467.58,,,4467.58,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51328.82,70,,51328.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2401.92,,,2401.92,Other,New York Medicaid APG methodology,2401.92,,,2401.92,Other,100% New York Medicaid APG,2401.92,,,2401.92,Other,100% New York Medicaid APG,2401.92,,,2401.92,Other,100% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,3362.69,,,3362.69,Other,140% New York Medicaid APG,5404.33,,,5404.33,Other,225% New York Medicaid APG,6245,,,6245,Other,260% New York Medicaid APG,7782.23,,,7782.23,Other,324% New York Medicaid APG,5164.14,,,5164.14,Other,215% New York Medicaid APG,5164.14,,,5164.14,Other,215% New York Medicaid APG,3002.4,,,3002.4,Other,125% New York Medicaid APG,2401.92,51328.82,
Surgical exposure prostate,55860,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5967.34,,,5967.34,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3208.25,,,3208.25,Other,New York Medicaid APG methodology,3208.25,,,3208.25,Other,100% New York Medicaid APG,3208.25,,,3208.25,Other,100% New York Medicaid APG,3208.25,,,3208.25,Other,100% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,4491.55,,,4491.55,Other,140% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,8341.45,,,8341.45,Other,260% New York Medicaid APG,10394.73,,,10394.73,Other,324% New York Medicaid APG,6897.73,,,6897.73,Other,215% New York Medicaid APG,6897.73,,,6897.73,Other,215% New York Medicaid APG,4010.31,,,4010.31,Other,125% New York Medicaid APG,3208.25,76185.18,
Laparo radical prostatectomy,55866,CPT,,,,,,,,both,,,74675.71,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,37337.86,50,,37337.86,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5967.34,,,5967.34,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52273,70,,52273,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3208.25,,,3208.25,Other,New York Medicaid APG methodology,3208.25,,,3208.25,Other,100% New York Medicaid APG,3208.25,,,3208.25,Other,100% New York Medicaid APG,3208.25,,,3208.25,Other,100% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,4491.55,,,4491.55,Other,140% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,8341.45,,,8341.45,Other,260% New York Medicaid APG,10394.73,,,10394.73,Other,324% New York Medicaid APG,6897.73,,,6897.73,Other,215% New York Medicaid APG,6897.73,,,6897.73,Other,215% New York Medicaid APG,4010.31,,,4010.31,Other,125% New York Medicaid APG,3208.25,52273,
Electroejaculation,55870,CPT,,,,,,,,both,,,16909.26,1528.76,,,1528.76,Other,150% of Medicare + 9.63% HCRA Surcharge,929.65,,,929.65,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,1524.96,,,1524.96,Fee Schedule,,1372.04,,,1372.04,Fee Schedule,,1295.58,,,1295.58,Fee Schedule,,8454.63,50,,8454.63,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1123.05,,,1123.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,11836.48,70,,11836.48,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,603.79,,,603.79,Other,New York Medicaid APG methodology,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,845.31,,,845.31,Other,140% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1569.85,,,1569.85,Other,260% New York Medicaid APG,1956.28,,,1956.28,Other,324% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,754.74,,,754.74,Other,125% New York Medicaid APG,603.79,13157,
Cryoablate prostate,55873,CPT,,,,,,,,both,,,193769.26,17518.56,,,17518.56,Other,150% of Medicare + 9.63% HCRA Surcharge,10653.14,,,10653.14,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,96884.63,50,,96884.63,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5967.34,,,5967.34,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,135638.48,70,,135638.48,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3208.25,,,3208.25,Other,New York Medicaid APG methodology,3208.25,,,3208.25,Other,100% New York Medicaid APG,3208.25,,,3208.25,Other,100% New York Medicaid APG,3208.25,,,3208.25,Other,100% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,4491.55,,,4491.55,Other,140% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,8341.45,,,8341.45,Other,260% New York Medicaid APG,10394.73,,,10394.73,Other,324% New York Medicaid APG,6897.73,,,6897.73,Other,215% New York Medicaid APG,6897.73,,,6897.73,Other,215% New York Medicaid APG,4010.31,,,4010.31,Other,125% New York Medicaid APG,3208.25,135638.48,
Tprnl plmt biodegrdabl matrl,55874,CPT,,,,,,,,both,,,47733.67,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,23866.84,50,,23866.84,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5967.34,,,5967.34,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,33413.57,70,,33413.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3208.25,,,3208.25,Other,New York Medicaid APG methodology,3208.25,,,3208.25,Other,100% New York Medicaid APG,3208.25,,,3208.25,Other,100% New York Medicaid APG,3208.25,,,3208.25,Other,100% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,4491.55,,,4491.55,Other,140% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,8341.45,,,8341.45,Other,260% New York Medicaid APG,10394.73,,,10394.73,Other,324% New York Medicaid APG,6897.73,,,6897.73,Other,215% New York Medicaid APG,6897.73,,,6897.73,Other,215% New York Medicaid APG,4010.31,,,4010.31,Other,125% New York Medicaid APG,3208.25,33413.57,
Transperi needle place pros,55875,CPT,,,,,,,,both,,,108835.97,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54417.99,50,,54417.99,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5967.34,,,5967.34,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76185.18,70,,76185.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3208.25,,,3208.25,Other,New York Medicaid APG methodology,3208.25,,,3208.25,Other,100% New York Medicaid APG,3208.25,,,3208.25,Other,100% New York Medicaid APG,3208.25,,,3208.25,Other,100% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,4491.55,,,4491.55,Other,140% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,8341.45,,,8341.45,Other,260% New York Medicaid APG,10394.73,,,10394.73,Other,324% New York Medicaid APG,6897.73,,,6897.73,Other,215% New York Medicaid APG,6897.73,,,6897.73,Other,215% New York Medicaid APG,4010.31,,,4010.31,Other,125% New York Medicaid APG,3208.25,76185.18,
Place rt device/marker pros,55876,CPT,,,,,,,,both,,,45265.72,2634.97,,,2634.97,Other,150% of Medicare + 9.63% HCRA Surcharge,1602.34,,,1602.34,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,22632.86,50,,22632.86,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,574.46,,,574.46,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31686,70,,31686,percent of total billed charges,,495,,,495,Fee Schedule,,420,,,420,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,308.85,,,308.85,Other,New York Medicaid APG methodology,308.85,,,308.85,Other,100% New York Medicaid APG,308.85,,,308.85,Other,100% New York Medicaid APG,308.85,,,308.85,Other,100% New York Medicaid APG,694.91,,,694.91,Other,225% New York Medicaid APG,694.91,,,694.91,Other,225% New York Medicaid APG,694.91,,,694.91,Other,225% New York Medicaid APG,694.91,,,694.91,Other,225% New York Medicaid APG,432.39,,,432.39,Other,140% New York Medicaid APG,694.91,,,694.91,Other,225% New York Medicaid APG,803.01,,,803.01,Other,260% New York Medicaid APG,1000.67,,,1000.67,Other,324% New York Medicaid APG,664.02,,,664.02,Other,215% New York Medicaid APG,664.02,,,664.02,Other,215% New York Medicaid APG,386.06,,,386.06,Other,125% New York Medicaid APG,308.85,31686,
Abltj mal prst8 tiss hifu,55880,CPT,,,,,,,,both,,,193769.26,17518.56,,,17518.56,Other,150% of Medicare + 9.63% HCRA Surcharge,10653.14,,,10653.14,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,96884.63,50,,96884.63,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5967.34,,,5967.34,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,135638.48,70,,135638.48,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3208.25,,,3208.25,Other,New York Medicaid APG methodology,3208.25,,,3208.25,Other,100% New York Medicaid APG,3208.25,,,3208.25,Other,100% New York Medicaid APG,3208.25,,,3208.25,Other,100% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,4491.55,,,4491.55,Other,140% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,8341.45,,,8341.45,Other,260% New York Medicaid APG,10394.73,,,10394.73,Other,324% New York Medicaid APG,6897.73,,,6897.73,Other,215% New York Medicaid APG,6897.73,,,6897.73,Other,215% New York Medicaid APG,4010.31,,,4010.31,Other,125% New York Medicaid APG,3208.25,135638.48,
Place needles pelvic for rt,55920,CPT,,,,,,,,both,,,104619.92,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,52309.96,50,,52309.96,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4370.69,,,4370.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,73233.94,70,,73233.94,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2349.83,,,2349.83,Other,New York Medicaid APG methodology,2349.83,,,2349.83,Other,100% New York Medicaid APG,2349.83,,,2349.83,Other,100% New York Medicaid APG,2349.83,,,2349.83,Other,100% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,3289.76,,,3289.76,Other,140% New York Medicaid APG,5287.12,,,5287.12,Other,225% New York Medicaid APG,6109.56,,,6109.56,Other,260% New York Medicaid APG,7613.45,,,7613.45,Other,324% New York Medicaid APG,5052.14,,,5052.14,Other,215% New York Medicaid APG,5052.14,,,5052.14,Other,215% New York Medicaid APG,2937.29,,,2937.29,Other,125% New York Medicaid APG,2349.83,73233.94,
I & d of vulva/perineum,56405,CPT,,,,,,,,both,,,33103.16,610.06,,,610.06,Other,150% of Medicare + 9.63% HCRA Surcharge,370.98,,,370.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16551.58,50,,16551.58,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,529.85,,,529.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23172.21,70,,23172.21,percent of total billed charges,,631.95,,,631.95,Fee Schedule,,536.2,,,536.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,284.87,,,284.87,Other,New York Medicaid APG methodology,284.87,,,284.87,Other,100% New York Medicaid APG,284.87,,,284.87,Other,100% New York Medicaid APG,284.87,,,284.87,Other,100% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,398.81,,,398.81,Other,140% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,740.65,,,740.65,Other,260% New York Medicaid APG,922.97,,,922.97,Other,324% New York Medicaid APG,612.46,,,612.46,Other,215% New York Medicaid APG,612.46,,,612.46,Other,215% New York Medicaid APG,356.08,,,356.08,Other,125% New York Medicaid APG,284.87,23172.21,
Drainage of gland abscess,56420,CPT,,,,,,,,both,,,4191.33,378.94,,,378.94,Other,150% of Medicare + 9.63% HCRA Surcharge,230.43,,,230.43,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2095.67,50,,2095.67,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,529.85,,,529.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2933.93,70,,2933.93,percent of total billed charges,,552.75,,,552.75,Fee Schedule,,469,,,469,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,284.87,,,284.87,Other,New York Medicaid APG methodology,284.87,,,284.87,Other,100% New York Medicaid APG,284.87,,,284.87,Other,100% New York Medicaid APG,284.87,,,284.87,Other,100% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,398.81,,,398.81,Other,140% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,740.65,,,740.65,Other,260% New York Medicaid APG,922.97,,,922.97,Other,324% New York Medicaid APG,612.46,,,612.46,Other,215% New York Medicaid APG,612.46,,,612.46,Other,215% New York Medicaid APG,356.08,,,356.08,Other,125% New York Medicaid APG,230.43,9473,
Surgery for vulva lesion,56440,CPT,,,,,,,,both,,,33439.03,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16719.52,50,,16719.52,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2981.36,,,2981.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23407.32,70,,23407.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1602.88,,,1602.88,Other,New York Medicaid APG methodology,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,2244.04,,,2244.04,Other,140% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,4167.5,,,4167.5,Other,260% New York Medicaid APG,5193.34,,,5193.34,Other,324% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,2003.6,,,2003.6,Other,125% New York Medicaid APG,1602.88,23407.32,
Lysis of labial lesion(s),56441,CPT,,,,,,,,both,,,44954.42,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,22477.21,50,,22477.21,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2981.36,,,2981.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31468.09,70,,31468.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1602.88,,,1602.88,Other,New York Medicaid APG methodology,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,2244.04,,,2244.04,Other,140% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,4167.5,,,4167.5,Other,260% New York Medicaid APG,5193.34,,,5193.34,Other,324% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,2003.6,,,2003.6,Other,125% New York Medicaid APG,1602.88,31468.09,
Hymenotomy,56442,CPT,,,,,,,,both,,,35682.23,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17841.12,50,,17841.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1419.19,,,1419.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24977.56,70,,24977.56,percent of total billed charges,,234.3,,,234.3,Fee Schedule,,198.8,,,198.8,Fee Schedule,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,763.01,,,763.01,Other,New York Medicaid APG methodology,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1068.21,,,1068.21,Other,140% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1983.82,,,1983.82,Other,260% New York Medicaid APG,2472.14,,,2472.14,Other,324% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,953.76,,,953.76,Other,125% New York Medicaid APG,198.8,24977.56,
Destroy vulva lesions sim,56501,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2981.36,,,2981.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,664.95,,,664.95,Fee Schedule,,564.2,,,564.2,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1602.88,,,1602.88,Other,New York Medicaid APG methodology,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,2244.04,,,2244.04,Other,140% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,4167.5,,,4167.5,Other,260% New York Medicaid APG,5193.34,,,5193.34,Other,324% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,2003.6,,,2003.6,Other,125% New York Medicaid APG,564.2,26850.29,
Destroy vulva lesion/s compl,56515,CPT,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2981.36,,,2981.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1602.88,,,1602.88,Other,New York Medicaid APG methodology,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,2244.04,,,2244.04,Other,140% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,4167.5,,,4167.5,Other,260% New York Medicaid APG,5193.34,,,5193.34,Other,324% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,2003.6,,,2003.6,Other,125% New York Medicaid APG,1602.88,26850.29,
Biopsy of vulva/perineum,56605,CPT,,,,,,,,both,,,43090.66,1528.76,,,1528.76,Other,150% of Medicare + 9.63% HCRA Surcharge,929.65,,,929.65,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,21545.33,50,,21545.33,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1419.19,,,1419.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,30163.46,70,,30163.46,percent of total billed charges,,292.05,,,292.05,Fee Schedule,,247.8,,,247.8,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,763.01,,,763.01,Other,New York Medicaid APG methodology,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1068.21,,,1068.21,Other,140% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1983.82,,,1983.82,Other,260% New York Medicaid APG,2472.14,,,2472.14,Other,324% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,953.76,,,953.76,Other,125% New York Medicaid APG,247.8,30163.46,
Biopsy of vulva/perineum,56606,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1419.19,,,1419.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,145.2,,,145.2,Fee Schedule,,123.2,,,123.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,763.01,,,763.01,Other,New York Medicaid APG methodology,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1068.21,,,1068.21,Other,140% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1983.82,,,1983.82,Other,260% New York Medicaid APG,2472.14,,,2472.14,Other,324% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,953.76,,,953.76,Other,125% New York Medicaid APG,0.01,22702.47,
Partial removal of vulva,56620,CPT,,,,,,,,both,,,43594.74,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21797.37,50,,21797.37,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2981.36,,,2981.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,30516.32,70,,30516.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1602.88,,,1602.88,Other,New York Medicaid APG methodology,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,2244.04,,,2244.04,Other,140% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,4167.5,,,4167.5,Other,260% New York Medicaid APG,5193.34,,,5193.34,Other,324% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,2003.6,,,2003.6,Other,125% New York Medicaid APG,1602.88,30516.32,
Complete removal of vulva,56625,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3334.07,,,3334.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1792.51,,,1792.51,Other,New York Medicaid APG methodology,1792.51,,,1792.51,Other,100% New York Medicaid APG,1792.51,,,1792.51,Other,100% New York Medicaid APG,1792.51,,,1792.51,Other,100% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,2509.51,,,2509.51,Other,140% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4660.52,,,4660.52,Other,260% New York Medicaid APG,5807.73,,,5807.73,Other,324% New York Medicaid APG,3853.89,,,3853.89,Other,215% New York Medicaid APG,3853.89,,,3853.89,Other,215% New York Medicaid APG,2240.64,,,2240.64,Other,125% New York Medicaid APG,1792.51,46031.33,
Partial removal of hymen,56700,CPT,,,,,,,,both,,,33094.53,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16547.27,50,,16547.27,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2981.36,,,2981.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23166.17,70,,23166.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1602.88,,,1602.88,Other,New York Medicaid APG methodology,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,2244.04,,,2244.04,Other,140% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,4167.5,,,4167.5,Other,260% New York Medicaid APG,5193.34,,,5193.34,Other,324% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,2003.6,,,2003.6,Other,125% New York Medicaid APG,1602.88,23166.17,
Remove vagina gland lesion,56740,CPT,,,,,,,,both,,,41024.22,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20512.11,50,,20512.11,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2981.36,,,2981.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28716.95,70,,28716.95,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1602.88,,,1602.88,Other,New York Medicaid APG methodology,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,2244.04,,,2244.04,Other,140% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,4167.5,,,4167.5,Other,260% New York Medicaid APG,5193.34,,,5193.34,Other,324% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,2003.6,,,2003.6,Other,125% New York Medicaid APG,1602.88,28716.95,
Repair of vagina,56800,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2981.36,,,2981.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1602.88,,,1602.88,Other,New York Medicaid APG methodology,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,2244.04,,,2244.04,Other,140% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,4167.5,,,4167.5,Other,260% New York Medicaid APG,5193.34,,,5193.34,Other,324% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,2003.6,,,2003.6,Other,125% New York Medicaid APG,1602.88,46031.33,
Repair clitoris,56805,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2981.36,,,2981.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1602.88,,,1602.88,Other,New York Medicaid APG methodology,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,2244.04,,,2244.04,Other,140% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,4167.5,,,4167.5,Other,260% New York Medicaid APG,5193.34,,,5193.34,Other,324% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,2003.6,,,2003.6,Other,125% New York Medicaid APG,1602.88,46031.33,
Repair of perineum,56810,CPT,,,,,,,,both,,,39228.34,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19614.17,50,,19614.17,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2981.36,,,2981.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27459.84,70,,27459.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1602.88,,,1602.88,Other,New York Medicaid APG methodology,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,2244.04,,,2244.04,Other,140% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,4167.5,,,4167.5,Other,260% New York Medicaid APG,5193.34,,,5193.34,Other,324% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,2003.6,,,2003.6,Other,125% New York Medicaid APG,1602.88,27459.84,
Exam of vulva w/scope,56820,CPT,,,,,,,,both,,,4191.33,378.94,,,378.94,Other,150% of Medicare + 9.63% HCRA Surcharge,230.43,,,230.43,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2095.67,50,,2095.67,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,529.85,,,529.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2933.93,70,,2933.93,percent of total billed charges,,415.8,,,415.8,Fee Schedule,,352.8,,,352.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,284.87,,,284.87,Other,New York Medicaid APG methodology,284.87,,,284.87,Other,100% New York Medicaid APG,284.87,,,284.87,Other,100% New York Medicaid APG,284.87,,,284.87,Other,100% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,398.81,,,398.81,Other,140% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,740.65,,,740.65,Other,260% New York Medicaid APG,922.97,,,922.97,Other,324% New York Medicaid APG,612.46,,,612.46,Other,215% New York Medicaid APG,612.46,,,612.46,Other,215% New York Medicaid APG,356.08,,,356.08,Other,125% New York Medicaid APG,0.01,9473,
Exam/biopsy of vulva w/scope,56821,CPT,,,,,,,,both,,,6747.72,610.06,,,610.06,Other,150% of Medicare + 9.63% HCRA Surcharge,370.98,,,370.98,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3373.86,50,,3373.86,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1419.19,,,1419.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4723.4,70,,4723.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,763.01,,,763.01,Other,New York Medicaid APG methodology,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1068.21,,,1068.21,Other,140% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1983.82,,,1983.82,Other,260% New York Medicaid APG,2472.14,,,2472.14,Other,324% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,953.76,,,953.76,Other,125% New York Medicaid APG,370.98,13157,
Exploration of vagina,57000,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2981.36,,,2981.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1602.88,,,1602.88,Other,New York Medicaid APG methodology,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,2244.04,,,2244.04,Other,140% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,4167.5,,,4167.5,Other,260% New York Medicaid APG,5193.34,,,5193.34,Other,324% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,2003.6,,,2003.6,Other,125% New York Medicaid APG,1602.88,46031.33,
Drainage of pelvic abscess,57010,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2981.36,,,2981.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1602.88,,,1602.88,Other,New York Medicaid APG methodology,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,2244.04,,,2244.04,Other,140% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,4167.5,,,4167.5,Other,260% New York Medicaid APG,5193.34,,,5193.34,Other,324% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,2003.6,,,2003.6,Other,125% New York Medicaid APG,1602.88,46031.33,
Drainage of pelvic fluid,57020,CPT,,,,,,,,both,,,104619.92,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,52309.96,50,,52309.96,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1419.19,,,1419.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,73233.94,70,,73233.94,percent of total billed charges,,391.05,,,391.05,Fee Schedule,,331.8,,,331.8,Fee Schedule,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,763.01,,,763.01,Other,New York Medicaid APG methodology,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1068.21,,,1068.21,Other,140% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1983.82,,,1983.82,Other,260% New York Medicaid APG,2472.14,,,2472.14,Other,324% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,953.76,,,953.76,Other,125% New York Medicaid APG,331.8,73233.94,
I & d vaginal hematoma pp,57022,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2416.17,,,2416.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1299.02,,,1299.02,Other,New York Medicaid APG methodology,1299.02,,,1299.02,Other,100% New York Medicaid APG,1299.02,,,1299.02,Other,100% New York Medicaid APG,1299.02,,,1299.02,Other,100% New York Medicaid APG,2922.79,,,2922.79,Other,225% New York Medicaid APG,2922.79,,,2922.79,Other,225% New York Medicaid APG,2922.79,,,2922.79,Other,225% New York Medicaid APG,2922.79,,,2922.79,Other,225% New York Medicaid APG,1818.62,,,1818.62,Other,140% New York Medicaid APG,2922.79,,,2922.79,Other,225% New York Medicaid APG,3377.45,,,3377.45,Other,260% New York Medicaid APG,4208.82,,,4208.82,Other,324% New York Medicaid APG,2792.89,,,2792.89,Other,215% New York Medicaid APG,2792.89,,,2792.89,Other,215% New York Medicaid APG,1623.77,,,1623.77,Other,125% New York Medicaid APG,1299.02,41837.04,
I & d vag hematoma non-ob,57023,CPT,,,,,,,,both,,,59767.2,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,29883.6,50,,29883.6,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2981.36,,,2981.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41837.04,70,,41837.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1602.88,,,1602.88,Other,New York Medicaid APG methodology,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,2244.04,,,2244.04,Other,140% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,4167.5,,,4167.5,Other,260% New York Medicaid APG,5193.34,,,5193.34,Other,324% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,2003.6,,,2003.6,Other,125% New York Medicaid APG,1602.88,41837.04,
Destroy vag lesions simple,57061,CPT,,,,,,,,both,,,35477.16,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17738.58,50,,17738.58,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2981.36,,,2981.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24834.01,70,,24834.01,percent of total billed charges,,574.2,,,574.2,Fee Schedule,,487.2,,,487.2,Fee Schedule,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1602.88,,,1602.88,Other,New York Medicaid APG methodology,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,2244.04,,,2244.04,Other,140% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,4167.5,,,4167.5,Other,260% New York Medicaid APG,5193.34,,,5193.34,Other,324% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,2003.6,,,2003.6,Other,125% New York Medicaid APG,487.2,24834.01,
Destroy vag lesions complex,57065,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2981.36,,,2981.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1602.88,,,1602.88,Other,New York Medicaid APG methodology,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,2244.04,,,2244.04,Other,140% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,4167.5,,,4167.5,Other,260% New York Medicaid APG,5193.34,,,5193.34,Other,324% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,2003.6,,,2003.6,Other,125% New York Medicaid APG,1602.88,46031.33,
Biopsy of vagina,57100,CPT,,,,,,,,both,,,42428.87,1528.76,,,1528.76,Other,150% of Medicare + 9.63% HCRA Surcharge,929.65,,,929.65,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,21214.44,50,,21214.44,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1419.19,,,1419.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29700.21,70,,29700.21,percent of total billed charges,,320.1,,,320.1,Fee Schedule,,271.6,,,271.6,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,763.01,,,763.01,Other,New York Medicaid APG methodology,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1068.21,,,1068.21,Other,140% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1983.82,,,1983.82,Other,260% New York Medicaid APG,2472.14,,,2472.14,Other,324% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,953.76,,,953.76,Other,125% New York Medicaid APG,271.6,29700.21,
Biopsy of vagina,57105,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2981.36,,,2981.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,727.65,,,727.65,Fee Schedule,,617.4,,,617.4,Fee Schedule,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1602.88,,,1602.88,Other,New York Medicaid APG methodology,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,2244.04,,,2244.04,Other,140% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,4167.5,,,4167.5,Other,260% New York Medicaid APG,5193.34,,,5193.34,Other,324% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,2003.6,,,2003.6,Other,125% New York Medicaid APG,617.4,46031.33,
Remove vagina wall partial,57106,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2981.36,,,2981.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1602.88,,,1602.88,Other,New York Medicaid APG methodology,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,2244.04,,,2244.04,Other,140% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,4167.5,,,4167.5,Other,260% New York Medicaid APG,5193.34,,,5193.34,Other,324% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,2003.6,,,2003.6,Other,125% New York Medicaid APG,1602.88,46031.33,
Remove vagina tissue part,57107,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3334.07,,,3334.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1792.51,,,1792.51,Other,New York Medicaid APG methodology,1792.51,,,1792.51,Other,100% New York Medicaid APG,1792.51,,,1792.51,Other,100% New York Medicaid APG,1792.51,,,1792.51,Other,100% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,2509.51,,,2509.51,Other,140% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4660.52,,,4660.52,Other,260% New York Medicaid APG,5807.73,,,5807.73,Other,324% New York Medicaid APG,3853.89,,,3853.89,Other,215% New York Medicaid APG,3853.89,,,3853.89,Other,215% New York Medicaid APG,2240.64,,,2240.64,Other,125% New York Medicaid APG,1792.51,46031.33,
Vaginectomy partial w/nodes,57109,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3334.07,,,3334.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1792.51,,,1792.51,Other,New York Medicaid APG methodology,1792.51,,,1792.51,Other,100% New York Medicaid APG,1792.51,,,1792.51,Other,100% New York Medicaid APG,1792.51,,,1792.51,Other,100% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,2509.51,,,2509.51,Other,140% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4660.52,,,4660.52,Other,260% New York Medicaid APG,5807.73,,,5807.73,Other,324% New York Medicaid APG,3853.89,,,3853.89,Other,215% New York Medicaid APG,3853.89,,,3853.89,Other,215% New York Medicaid APG,2240.64,,,2240.64,Other,125% New York Medicaid APG,1792.51,46031.33,
Closure of vagina,57120,CPT,,,,,,,,both,,,42611.09,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,21305.55,50,,21305.55,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3334.07,,,3334.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29827.76,70,,29827.76,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1792.51,,,1792.51,Other,New York Medicaid APG methodology,1792.51,,,1792.51,Other,100% New York Medicaid APG,1792.51,,,1792.51,Other,100% New York Medicaid APG,1792.51,,,1792.51,Other,100% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,2509.51,,,2509.51,Other,140% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4660.52,,,4660.52,Other,260% New York Medicaid APG,5807.73,,,5807.73,Other,324% New York Medicaid APG,3853.89,,,3853.89,Other,215% New York Medicaid APG,3853.89,,,3853.89,Other,215% New York Medicaid APG,2240.64,,,2240.64,Other,125% New York Medicaid APG,1792.51,29827.76,
Remove vagina lesion,57130,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2981.36,,,2981.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1602.88,,,1602.88,Other,New York Medicaid APG methodology,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,2244.04,,,2244.04,Other,140% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,4167.5,,,4167.5,Other,260% New York Medicaid APG,5193.34,,,5193.34,Other,324% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,2003.6,,,2003.6,Other,125% New York Medicaid APG,1602.88,46031.33,
Remove vagina lesion,57135,CPT,,,,,,,,both,,,36783.79,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18391.9,50,,18391.9,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2981.36,,,2981.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25748.65,70,,25748.65,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1602.88,,,1602.88,Other,New York Medicaid APG methodology,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,2244.04,,,2244.04,Other,140% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,4167.5,,,4167.5,Other,260% New York Medicaid APG,5193.34,,,5193.34,Other,324% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,2003.6,,,2003.6,Other,125% New York Medicaid APG,1602.88,25748.65,
Treat vagina infection,57150,CPT,,,,,,,,both,,,1286.58,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,643.29,50,,643.29,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,529.85,,,529.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,900.61,70,,900.61,percent of total billed charges,,127.05,,,127.05,Fee Schedule,,107.8,,,107.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,284.87,,,284.87,Other,New York Medicaid APG methodology,284.87,,,284.87,Other,100% New York Medicaid APG,284.87,,,284.87,Other,100% New York Medicaid APG,284.87,,,284.87,Other,100% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,398.81,,,398.81,Other,140% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,740.65,,,740.65,Other,260% New York Medicaid APG,922.97,,,922.97,Other,324% New York Medicaid APG,612.46,,,612.46,Other,215% New York Medicaid APG,612.46,,,612.46,Other,215% New York Medicaid APG,356.08,,,356.08,Other,125% New York Medicaid APG,0.01,9473,
Insert uteri tandem/ovoids,57155,CPT,,,,,,,,both,,,61324.15,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,30662.08,50,,30662.08,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3197.73,,,3197.73,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,42926.91,70,,42926.91,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1719.21,,,1719.21,Other,New York Medicaid APG methodology,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,2406.89,,,2406.89,Other,140% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,4469.94,,,4469.94,Other,260% New York Medicaid APG,5570.24,,,5570.24,Other,324% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,2149.01,,,2149.01,Other,125% New York Medicaid APG,1719.21,42926.91,
Ins vag brachytx device,57156,CPT,,,,,,,,both,,,31449.57,610.06,,,610.06,Other,150% of Medicare + 9.63% HCRA Surcharge,370.98,,,370.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,15724.79,50,,15724.79,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1419.19,,,1419.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22014.7,70,,22014.7,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,763.01,,,763.01,Other,New York Medicaid APG methodology,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1068.21,,,1068.21,Other,140% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1983.82,,,1983.82,Other,260% New York Medicaid APG,2472.14,,,2472.14,Other,324% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,953.76,,,953.76,Other,125% New York Medicaid APG,370.98,22014.7,
Insert pessary/other device,57160,CPT,,,,,,,,both,,,4191.33,378.94,,,378.94,Other,150% of Medicare + 9.63% HCRA Surcharge,230.43,,,230.43,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2095.67,50,,2095.67,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,529.85,,,529.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2933.93,70,,2933.93,percent of total billed charges,,226.05,,,226.05,Fee Schedule,,191.8,,,191.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,284.87,,,284.87,Other,New York Medicaid APG methodology,284.87,,,284.87,Other,100% New York Medicaid APG,284.87,,,284.87,Other,100% New York Medicaid APG,284.87,,,284.87,Other,100% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,398.81,,,398.81,Other,140% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,740.65,,,740.65,Other,260% New York Medicaid APG,922.97,,,922.97,Other,324% New York Medicaid APG,612.46,,,612.46,Other,215% New York Medicaid APG,612.46,,,612.46,Other,215% New York Medicaid APG,356.08,,,356.08,Other,125% New York Medicaid APG,0.01,9473,
Fitting of diaphragm/cap,57170,CPT,,,,,,,,both,,,4191.33,378.94,,,378.94,Other,150% of Medicare + 9.63% HCRA Surcharge,230.43,,,230.43,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,2514.8,60,,2514.8,percent of total billed charges,,2347.14,56,,2347.14,percent of total billed charges,,2263.32,54,,2263.32,percent of total billed charges,,2095.67,50,,2095.67,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,529.85,,,529.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2933.93,70,,2933.93,percent of total billed charges,,235.95,,,235.95,Fee Schedule,,200.2,,,200.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,284.87,,,284.87,Other,New York Medicaid APG methodology,284.87,,,284.87,Other,100% New York Medicaid APG,284.87,,,284.87,Other,100% New York Medicaid APG,284.87,,,284.87,Other,100% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,398.81,,,398.81,Other,140% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,740.65,,,740.65,Other,260% New York Medicaid APG,922.97,,,922.97,Other,324% New York Medicaid APG,612.46,,,612.46,Other,215% New York Medicaid APG,612.46,,,612.46,Other,215% New York Medicaid APG,356.08,,,356.08,Other,125% New York Medicaid APG,0.01,9473,
Treat vaginal bleeding,57180,CPT,,,,,,,,both,,,4191.33,378.94,,,378.94,Other,150% of Medicare + 9.63% HCRA Surcharge,230.43,,,230.43,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2095.67,50,,2095.67,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1419.19,,,1419.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2933.93,70,,2933.93,percent of total billed charges,,603.9,,,603.9,Fee Schedule,,512.4,,,512.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,763.01,,,763.01,Other,New York Medicaid APG methodology,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1068.21,,,1068.21,Other,140% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1983.82,,,1983.82,Other,260% New York Medicaid APG,2472.14,,,2472.14,Other,324% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,953.76,,,953.76,Other,125% New York Medicaid APG,230.43,9473,
Repair of vagina,57200,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2981.36,,,2981.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1602.88,,,1602.88,Other,New York Medicaid APG methodology,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,2244.04,,,2244.04,Other,140% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,4167.5,,,4167.5,Other,260% New York Medicaid APG,5193.34,,,5193.34,Other,324% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,2003.6,,,2003.6,Other,125% New York Medicaid APG,1602.88,46031.33,
Repair vagina/perineum,57210,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2981.36,,,2981.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1602.88,,,1602.88,Other,New York Medicaid APG methodology,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,2244.04,,,2244.04,Other,140% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,4167.5,,,4167.5,Other,260% New York Medicaid APG,5193.34,,,5193.34,Other,324% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,2003.6,,,2003.6,Other,125% New York Medicaid APG,1602.88,46031.33,
Revision of urethra,57220,CPT,,,,,,,,both,,,104619.92,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,52309.96,50,,52309.96,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,73233.94,70,,73233.94,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,73233.94,
Repair of urethral lesion,57230,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,46031.33,
Anterior colporrhaphy,57240,CPT,,,,,,,,both,,,39831.69,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,19915.85,50,,19915.85,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27882.18,70,,27882.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,27882.18,
Repair rectum & vagina,57250,CPT,,,,,,,,both,,,42205.47,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,21102.74,50,,21102.74,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29543.83,70,,29543.83,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,1367.11,29543.83,
Cmbn ant pst colprhy,57260,CPT,,,,,,,,both,,,39020.79,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,19510.4,50,,19510.4,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27314.55,70,,27314.55,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,27314.55,
Cmbn ap colprhy w/ntrcl rpr,57265,CPT,,,,,,,,both,,,45645.86,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,22822.93,50,,22822.93,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31952.1,70,,31952.1,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,1367.11,31952.1,
Insert mesh/pelvic flr addon,57267,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,5620.98,,,5620.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,3022.03,,,3022.03,Other,New York Medicaid APG methodology,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,3022.03,,,3022.03,Other,100% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,4230.84,,,4230.84,Other,140% New York Medicaid APG,6799.57,,,6799.57,Other,225% New York Medicaid APG,7857.28,,,7857.28,Other,260% New York Medicaid APG,9791.38,,,9791.38,Other,324% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,6497.36,,,6497.36,Other,215% New York Medicaid APG,3777.54,,,3777.54,Other,125% New York Medicaid APG,0.01,22702.47,
Repair of bowel bulge,57268,CPT,,,,,,,,both,,,39241.66,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19620.83,50,,19620.83,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27469.16,70,,27469.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,1367.11,27469.16,
Colpopexy extraperitoneal,57282,CPT,,,,,,,,both,,,43146.62,14369.86,,,14369.86,Other,150% of Medicare + 9.63% HCRA Surcharge,8738.4,,,8738.4,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,21573.31,50,,21573.31,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2981.36,,,2981.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,30202.63,70,,30202.63,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1602.88,,,1602.88,Other,New York Medicaid APG methodology,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,2244.04,,,2244.04,Other,140% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,4167.5,,,4167.5,Other,260% New York Medicaid APG,5193.34,,,5193.34,Other,324% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,2003.6,,,2003.6,Other,125% New York Medicaid APG,1602.88,30202.63,
Colpopexy intraperitoneal,57283,CPT,,,,,,,,both,,,56441.72,14369.86,,,14369.86,Other,150% of Medicare + 9.63% HCRA Surcharge,8738.4,,,8738.4,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,28220.86,50,,28220.86,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2981.36,,,2981.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,39509.2,70,,39509.2,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1602.88,,,1602.88,Other,New York Medicaid APG methodology,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,2244.04,,,2244.04,Other,140% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,4167.5,,,4167.5,Other,260% New York Medicaid APG,5193.34,,,5193.34,Other,324% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,2003.6,,,2003.6,Other,125% New York Medicaid APG,1602.88,39509.2,
Repair paravag defect open,57284,CPT,,,,,,,,both,,,104619.92,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,52309.96,50,,52309.96,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3334.07,,,3334.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,73233.94,70,,73233.94,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1792.51,,,1792.51,Other,New York Medicaid APG methodology,1792.51,,,1792.51,Other,100% New York Medicaid APG,1792.51,,,1792.51,Other,100% New York Medicaid APG,1792.51,,,1792.51,Other,100% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,2509.51,,,2509.51,Other,140% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4660.52,,,4660.52,Other,260% New York Medicaid APG,5807.73,,,5807.73,Other,324% New York Medicaid APG,3853.89,,,3853.89,Other,215% New York Medicaid APG,3853.89,,,3853.89,Other,215% New York Medicaid APG,2240.64,,,2240.64,Other,125% New York Medicaid APG,1792.51,73233.94,
Repair paravag defect vag,57285,CPT,,,,,,,,both,,,158942.1,14369.86,,,14369.86,Other,150% of Medicare + 9.63% HCRA Surcharge,8738.4,,,8738.4,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,79471.05,50,,79471.05,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2981.36,,,2981.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,111259.47,70,,111259.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1602.88,,,1602.88,Other,New York Medicaid APG methodology,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,2244.04,,,2244.04,Other,140% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,4167.5,,,4167.5,Other,260% New York Medicaid APG,5193.34,,,5193.34,Other,324% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,2003.6,,,2003.6,Other,125% New York Medicaid APG,1602.88,111259.47,
Revise/remove sling repair,57287,CPT,,,,,,,,both,,,33689.25,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16844.63,50,,16844.63,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23582.48,70,,23582.48,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,23582.48,
Repair bladder defect,57288,CPT,,,,,,,,both,,,40467.29,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,20233.65,50,,20233.65,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28327.1,70,,28327.1,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,28327.1,
Repair bladder & vagina,57289,CPT,,,,,,,,both,,,158942.1,14369.86,,,14369.86,Other,150% of Medicare + 9.63% HCRA Surcharge,8738.4,,,8738.4,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,79471.05,50,,79471.05,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2358.14,,,2358.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,111259.47,70,,111259.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1267.82,,,1267.82,Other,New York Medicaid APG methodology,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,1267.82,,,1267.82,Other,100% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,1774.94,,,1774.94,Other,140% New York Medicaid APG,2852.59,,,2852.59,Other,225% New York Medicaid APG,3296.32,,,3296.32,Other,260% New York Medicaid APG,4107.72,,,4107.72,Other,324% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,2725.8,,,2725.8,Other,215% New York Medicaid APG,1584.77,,,1584.77,Other,125% New York Medicaid APG,1267.82,111259.47,
Construction of vagina,57291,CPT,,,,,,,,both,,,104619.92,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,52309.96,50,,52309.96,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3334.07,,,3334.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,73233.94,70,,73233.94,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1792.51,,,1792.51,Other,New York Medicaid APG methodology,1792.51,,,1792.51,Other,100% New York Medicaid APG,1792.51,,,1792.51,Other,100% New York Medicaid APG,1792.51,,,1792.51,Other,100% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,2509.51,,,2509.51,Other,140% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4660.52,,,4660.52,Other,260% New York Medicaid APG,5807.73,,,5807.73,Other,324% New York Medicaid APG,3853.89,,,3853.89,Other,215% New York Medicaid APG,3853.89,,,3853.89,Other,215% New York Medicaid APG,2240.64,,,2240.64,Other,125% New York Medicaid APG,1792.51,73233.94,
Construct vagina with graft,57292,CPT,,,,,,,,both,,,104619.92,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,52309.96,50,,52309.96,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3334.07,,,3334.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,73233.94,70,,73233.94,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1792.51,,,1792.51,Other,New York Medicaid APG methodology,1792.51,,,1792.51,Other,100% New York Medicaid APG,1792.51,,,1792.51,Other,100% New York Medicaid APG,1792.51,,,1792.51,Other,100% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,2509.51,,,2509.51,Other,140% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4660.52,,,4660.52,Other,260% New York Medicaid APG,5807.73,,,5807.73,Other,324% New York Medicaid APG,3853.89,,,3853.89,Other,215% New York Medicaid APG,3853.89,,,3853.89,Other,215% New York Medicaid APG,2240.64,,,2240.64,Other,125% New York Medicaid APG,1792.51,73233.94,
Revise vag graft via vagina,57295,CPT,,,,,,,,both,,,37502.18,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18751.09,50,,18751.09,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2981.36,,,2981.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26251.53,70,,26251.53,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1602.88,,,1602.88,Other,New York Medicaid APG methodology,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,2244.04,,,2244.04,Other,140% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,4167.5,,,4167.5,Other,260% New York Medicaid APG,5193.34,,,5193.34,Other,324% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,2003.6,,,2003.6,Other,125% New York Medicaid APG,1602.88,26251.53,
Repair rectum-vagina fistula,57300,CPT,,,,,,,,both,,,39120.59,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19560.3,50,,19560.3,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3334.07,,,3334.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27384.41,70,,27384.41,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1792.51,,,1792.51,Other,New York Medicaid APG methodology,1792.51,,,1792.51,Other,100% New York Medicaid APG,1792.51,,,1792.51,Other,100% New York Medicaid APG,1792.51,,,1792.51,Other,100% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,2509.51,,,2509.51,Other,140% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4660.52,,,4660.52,Other,260% New York Medicaid APG,5807.73,,,5807.73,Other,324% New York Medicaid APG,3853.89,,,3853.89,Other,215% New York Medicaid APG,3853.89,,,3853.89,Other,215% New York Medicaid APG,2240.64,,,2240.64,Other,125% New York Medicaid APG,1792.51,27384.41,
Repair urethrovaginal lesion,57310,CPT,,,,,,,,both,,,158942.1,14369.86,,,14369.86,Other,150% of Medicare + 9.63% HCRA Surcharge,8738.4,,,8738.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,79471.05,50,,79471.05,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3334.07,,,3334.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,111259.47,70,,111259.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1792.51,,,1792.51,Other,New York Medicaid APG methodology,1792.51,,,1792.51,Other,100% New York Medicaid APG,1792.51,,,1792.51,Other,100% New York Medicaid APG,1792.51,,,1792.51,Other,100% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,2509.51,,,2509.51,Other,140% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4660.52,,,4660.52,Other,260% New York Medicaid APG,5807.73,,,5807.73,Other,324% New York Medicaid APG,3853.89,,,3853.89,Other,215% New York Medicaid APG,3853.89,,,3853.89,Other,215% New York Medicaid APG,2240.64,,,2240.64,Other,125% New York Medicaid APG,1792.51,111259.47,
Repair bladder-vagina lesion,57320,CPT,,,,,,,,both,,,49528.37,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,24764.19,50,,24764.19,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3334.07,,,3334.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34669.86,70,,34669.86,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1792.51,,,1792.51,Other,New York Medicaid APG methodology,1792.51,,,1792.51,Other,100% New York Medicaid APG,1792.51,,,1792.51,Other,100% New York Medicaid APG,1792.51,,,1792.51,Other,100% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,2509.51,,,2509.51,Other,140% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4660.52,,,4660.52,Other,260% New York Medicaid APG,5807.73,,,5807.73,Other,324% New York Medicaid APG,3853.89,,,3853.89,Other,215% New York Medicaid APG,3853.89,,,3853.89,Other,215% New York Medicaid APG,2240.64,,,2240.64,Other,125% New York Medicaid APG,1792.51,34669.86,
Repair bladder-vagina lesion,57330,CPT,,,,,,,,both,,,158942.1,14369.86,,,14369.86,Other,150% of Medicare + 9.63% HCRA Surcharge,8738.4,,,8738.4,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,79471.05,50,,79471.05,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3334.07,,,3334.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,111259.47,70,,111259.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1792.51,,,1792.51,Other,New York Medicaid APG methodology,1792.51,,,1792.51,Other,100% New York Medicaid APG,1792.51,,,1792.51,Other,100% New York Medicaid APG,1792.51,,,1792.51,Other,100% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,2509.51,,,2509.51,Other,140% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4660.52,,,4660.52,Other,260% New York Medicaid APG,5807.73,,,5807.73,Other,324% New York Medicaid APG,3853.89,,,3853.89,Other,215% New York Medicaid APG,3853.89,,,3853.89,Other,215% New York Medicaid APG,2240.64,,,2240.64,Other,125% New York Medicaid APG,1792.51,111259.47,
Repair vagina,57335,CPT,,,,,,,,both,,,104619.92,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,52309.96,50,,52309.96,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3334.07,,,3334.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,73233.94,70,,73233.94,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1792.51,,,1792.51,Other,New York Medicaid APG methodology,1792.51,,,1792.51,Other,100% New York Medicaid APG,1792.51,,,1792.51,Other,100% New York Medicaid APG,1792.51,,,1792.51,Other,100% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,2509.51,,,2509.51,Other,140% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4660.52,,,4660.52,Other,260% New York Medicaid APG,5807.73,,,5807.73,Other,324% New York Medicaid APG,3853.89,,,3853.89,Other,215% New York Medicaid APG,3853.89,,,3853.89,Other,215% New York Medicaid APG,2240.64,,,2240.64,Other,125% New York Medicaid APG,1792.51,73233.94,
Dilation of vagina,57400,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2981.36,,,2981.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1602.88,,,1602.88,Other,New York Medicaid APG methodology,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,2244.04,,,2244.04,Other,140% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,4167.5,,,4167.5,Other,260% New York Medicaid APG,5193.34,,,5193.34,Other,324% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,2003.6,,,2003.6,Other,125% New York Medicaid APG,1602.88,46031.33,
Pelvic examination,57410,CPT,,,,,,,,both,,,31115.46,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,15557.73,50,,15557.73,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,529.85,,,529.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,21780.82,70,,21780.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,284.87,,,284.87,Other,New York Medicaid APG methodology,284.87,,,284.87,Other,100% New York Medicaid APG,284.87,,,284.87,Other,100% New York Medicaid APG,284.87,,,284.87,Other,100% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,398.81,,,398.81,Other,140% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,740.65,,,740.65,Other,260% New York Medicaid APG,922.97,,,922.97,Other,324% New York Medicaid APG,612.46,,,612.46,Other,215% New York Medicaid APG,612.46,,,612.46,Other,215% New York Medicaid APG,356.08,,,356.08,Other,125% New York Medicaid APG,284.87,21780.82,
Remove vaginal foreign body,57415,CPT,,,,,,,,both,,,33811.25,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16905.63,50,,16905.63,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2981.36,,,2981.36,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23667.88,70,,23667.88,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1602.88,,,1602.88,Other,New York Medicaid APG methodology,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,1602.88,,,1602.88,Other,100% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,2244.04,,,2244.04,Other,140% New York Medicaid APG,3606.49,,,3606.49,Other,225% New York Medicaid APG,4167.5,,,4167.5,Other,260% New York Medicaid APG,5193.34,,,5193.34,Other,324% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,3446.2,,,3446.2,Other,215% New York Medicaid APG,2003.6,,,2003.6,Other,125% New York Medicaid APG,1602.88,23667.88,
Exam of vagina w/scope,57420,CPT,,,,,,,,both,,,34222.09,610.06,,,610.06,Other,150% of Medicare + 9.63% HCRA Surcharge,370.98,,,370.98,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17111.05,50,,17111.05,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1419.19,,,1419.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23955.46,70,,23955.46,percent of total billed charges,,438.9,,,438.9,Fee Schedule,,372.4,,,372.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,763.01,,,763.01,Other,New York Medicaid APG methodology,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1068.21,,,1068.21,Other,140% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1983.82,,,1983.82,Other,260% New York Medicaid APG,2472.14,,,2472.14,Other,324% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,953.76,,,953.76,Other,125% New York Medicaid APG,370.98,23955.46,
Exam/biopsy of vag w/scope,57421,CPT,,,,,,,,both,,,33260,1528.76,,,1528.76,Other,150% of Medicare + 9.63% HCRA Surcharge,929.65,,,929.65,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16630,50,,16630,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1419.19,,,1419.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23282,70,,23282,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,763.01,,,763.01,Other,New York Medicaid APG methodology,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1068.21,,,1068.21,Other,140% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1983.82,,,1983.82,Other,260% New York Medicaid APG,2472.14,,,2472.14,Other,324% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,953.76,,,953.76,Other,125% New York Medicaid APG,763.01,23282,
Repair paravag defect lap,57423,CPT,,,,,,,,both,,,216515.17,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,108257.59,50,,108257.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3334.07,,,3334.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,151560.62,70,,151560.62,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,1792.51,,,1792.51,Other,New York Medicaid APG methodology,1792.51,,,1792.51,Other,100% New York Medicaid APG,1792.51,,,1792.51,Other,100% New York Medicaid APG,1792.51,,,1792.51,Other,100% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,2509.51,,,2509.51,Other,140% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4660.52,,,4660.52,Other,260% New York Medicaid APG,5807.73,,,5807.73,Other,324% New York Medicaid APG,3853.89,,,3853.89,Other,215% New York Medicaid APG,3853.89,,,3853.89,Other,215% New York Medicaid APG,2240.64,,,2240.64,Other,125% New York Medicaid APG,1792.51,151560.62,
Laparoscopy surg colpopexy,57425,CPT,,,,,,,,both,,,65062.69,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,32531.35,50,,32531.35,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3334.07,,,3334.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45543.88,70,,45543.88,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,1792.51,,,1792.51,Other,New York Medicaid APG methodology,1792.51,,,1792.51,Other,100% New York Medicaid APG,1792.51,,,1792.51,Other,100% New York Medicaid APG,1792.51,,,1792.51,Other,100% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,2509.51,,,2509.51,Other,140% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4660.52,,,4660.52,Other,260% New York Medicaid APG,5807.73,,,5807.73,Other,324% New York Medicaid APG,3853.89,,,3853.89,Other,215% New York Medicaid APG,3853.89,,,3853.89,Other,215% New York Medicaid APG,2240.64,,,2240.64,Other,125% New York Medicaid APG,1792.51,45543.88,
Revise prosth vag graft lap,57426,CPT,,,,,,,,both,,,158942.1,14369.86,,,14369.86,Other,150% of Medicare + 9.63% HCRA Surcharge,8738.4,,,8738.4,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,79471.05,50,,79471.05,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3334.07,,,3334.07,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,111259.47,70,,111259.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1792.51,,,1792.51,Other,New York Medicaid APG methodology,1792.51,,,1792.51,Other,100% New York Medicaid APG,1792.51,,,1792.51,Other,100% New York Medicaid APG,1792.51,,,1792.51,Other,100% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,2509.51,,,2509.51,Other,140% New York Medicaid APG,4033.14,,,4033.14,Other,225% New York Medicaid APG,4660.52,,,4660.52,Other,260% New York Medicaid APG,5807.73,,,5807.73,Other,324% New York Medicaid APG,3853.89,,,3853.89,Other,215% New York Medicaid APG,3853.89,,,3853.89,Other,215% New York Medicaid APG,2240.64,,,2240.64,Other,125% New York Medicaid APG,1792.51,111259.47,
Exam of cervix w/scope,57452,CPT,,,,,,,,both,,,4191.33,378.94,,,378.94,Other,150% of Medicare + 9.63% HCRA Surcharge,230.43,,,230.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2095.67,50,,2095.67,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1419.19,,,1419.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2933.93,70,,2933.93,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,763.01,,,763.01,Other,New York Medicaid APG methodology,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1068.21,,,1068.21,Other,140% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1983.82,,,1983.82,Other,260% New York Medicaid APG,2472.14,,,2472.14,Other,324% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,953.76,,,953.76,Other,125% New York Medicaid APG,230.43,9473,
Bx/curett of cervix w/scope,57454,CPT,,,,,,,,both,,,6747.72,610.06,,,610.06,Other,150% of Medicare + 9.63% HCRA Surcharge,370.98,,,370.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3373.86,50,,3373.86,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1419.19,,,1419.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4723.4,70,,4723.4,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,763.01,,,763.01,Other,New York Medicaid APG methodology,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1068.21,,,1068.21,Other,140% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1983.82,,,1983.82,Other,260% New York Medicaid APG,2472.14,,,2472.14,Other,324% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,953.76,,,953.76,Other,125% New York Medicaid APG,370.98,9473,
Biopsy of cervix w/scope,57455,CPT,,,,,,,,both,,,6747.72,610.06,,,610.06,Other,150% of Medicare + 9.63% HCRA Surcharge,370.98,,,370.98,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3373.86,50,,3373.86,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1419.19,,,1419.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4723.4,70,,4723.4,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,763.01,,,763.01,Other,New York Medicaid APG methodology,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1068.21,,,1068.21,Other,140% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1983.82,,,1983.82,Other,260% New York Medicaid APG,2472.14,,,2472.14,Other,324% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,953.76,,,953.76,Other,125% New York Medicaid APG,370.98,9473,
Endocerv curettage w/scope,57456,CPT,,,,,,,,both,,,6747.72,610.06,,,610.06,Other,150% of Medicare + 9.63% HCRA Surcharge,370.98,,,370.98,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3373.86,50,,3373.86,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1419.19,,,1419.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4723.4,70,,4723.4,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,763.01,,,763.01,Other,New York Medicaid APG methodology,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1068.21,,,1068.21,Other,140% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1983.82,,,1983.82,Other,260% New York Medicaid APG,2472.14,,,2472.14,Other,324% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,953.76,,,953.76,Other,125% New York Medicaid APG,370.98,9473,
Bx of cervix w/scope leep,57460,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3197.73,,,3197.73,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1719.21,,,1719.21,Other,New York Medicaid APG methodology,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,2406.89,,,2406.89,Other,140% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,4469.94,,,4469.94,Other,260% New York Medicaid APG,5570.24,,,5570.24,Other,324% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,2149.01,,,2149.01,Other,125% New York Medicaid APG,1719.21,46031.33,
Conz of cervix w/scope leep,57461,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3197.73,,,3197.73,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1719.21,,,1719.21,Other,New York Medicaid APG methodology,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,2406.89,,,2406.89,Other,140% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,4469.94,,,4469.94,Other,260% New York Medicaid APG,5570.24,,,5570.24,Other,324% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,2149.01,,,2149.01,Other,125% New York Medicaid APG,1719.21,46031.33,
Biopsy of cervix,57500,CPT,,,,,,,,both,,,16909.26,1528.76,,,1528.76,Other,150% of Medicare + 9.63% HCRA Surcharge,929.65,,,929.65,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,8454.63,50,,8454.63,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1419.19,,,1419.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,11836.48,70,,11836.48,percent of total billed charges,,367.95,,,367.95,Fee Schedule,,312.2,,,312.2,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,763.01,,,763.01,Other,New York Medicaid APG methodology,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1068.21,,,1068.21,Other,140% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1983.82,,,1983.82,Other,260% New York Medicaid APG,2472.14,,,2472.14,Other,324% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,953.76,,,953.76,Other,125% New York Medicaid APG,312.2,11836.48,
Endocervical curettage,57505,CPT,,,,,,,,both,,,16909.26,1528.76,,,1528.76,Other,150% of Medicare + 9.63% HCRA Surcharge,929.65,,,929.65,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,8454.63,50,,8454.63,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1419.19,,,1419.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,11836.48,70,,11836.48,percent of total billed charges,,542.85,,,542.85,Fee Schedule,,460.6,,,460.6,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,763.01,,,763.01,Other,New York Medicaid APG methodology,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1068.21,,,1068.21,Other,140% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1983.82,,,1983.82,Other,260% New York Medicaid APG,2472.14,,,2472.14,Other,324% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,953.76,,,953.76,Other,125% New York Medicaid APG,460.6,11836.48,
Cauterization of cervix,57510,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3197.73,,,3197.73,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1719.21,,,1719.21,Other,New York Medicaid APG methodology,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,2406.89,,,2406.89,Other,140% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,4469.94,,,4469.94,Other,260% New York Medicaid APG,5570.24,,,5570.24,Other,324% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,2149.01,,,2149.01,Other,125% New York Medicaid APG,1719.21,46031.33,
Cryocautery of cervix,57511,CPT,,,,,,,,both,,,6747.72,610.06,,,610.06,Other,150% of Medicare + 9.63% HCRA Surcharge,370.98,,,370.98,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3373.86,50,,3373.86,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1419.19,,,1419.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4723.4,70,,4723.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,763.01,,,763.01,Other,New York Medicaid APG methodology,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1068.21,,,1068.21,Other,140% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1983.82,,,1983.82,Other,260% New York Medicaid APG,2472.14,,,2472.14,Other,324% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,953.76,,,953.76,Other,125% New York Medicaid APG,370.98,13157,
Laser surgery of cervix,57513,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3197.73,,,3197.73,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1719.21,,,1719.21,Other,New York Medicaid APG methodology,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,2406.89,,,2406.89,Other,140% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,4469.94,,,4469.94,Other,260% New York Medicaid APG,5570.24,,,5570.24,Other,324% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,2149.01,,,2149.01,Other,125% New York Medicaid APG,1719.21,46031.33,
Conization of cervix,57520,CPT,,,,,,,,both,,,41976.39,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20988.2,50,,20988.2,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3197.73,,,3197.73,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29383.47,70,,29383.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1719.21,,,1719.21,Other,New York Medicaid APG methodology,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,2406.89,,,2406.89,Other,140% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,4469.94,,,4469.94,Other,260% New York Medicaid APG,5570.24,,,5570.24,Other,324% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,2149.01,,,2149.01,Other,125% New York Medicaid APG,1719.21,29383.47,
Conization of cervix,57522,CPT,,,,,,,,both,,,40520.37,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20260.19,50,,20260.19,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3197.73,,,3197.73,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28364.26,70,,28364.26,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1719.21,,,1719.21,Other,New York Medicaid APG methodology,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,2406.89,,,2406.89,Other,140% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,4469.94,,,4469.94,Other,260% New York Medicaid APG,5570.24,,,5570.24,Other,324% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,2149.01,,,2149.01,Other,125% New York Medicaid APG,1719.21,28364.26,
Removal of cervix,57530,CPT,,,,,,,,both,,,104619.92,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,52309.96,50,,52309.96,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3197.73,,,3197.73,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,73233.94,70,,73233.94,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1719.21,,,1719.21,Other,New York Medicaid APG methodology,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,2406.89,,,2406.89,Other,140% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,4469.94,,,4469.94,Other,260% New York Medicaid APG,5570.24,,,5570.24,Other,324% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,2149.01,,,2149.01,Other,125% New York Medicaid APG,1719.21,73233.94,
Removal of residual cervix,57550,CPT,,,,,,,,both,,,104619.92,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,52309.96,50,,52309.96,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3197.73,,,3197.73,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,73233.94,70,,73233.94,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1719.21,,,1719.21,Other,New York Medicaid APG methodology,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,2406.89,,,2406.89,Other,140% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,4469.94,,,4469.94,Other,260% New York Medicaid APG,5570.24,,,5570.24,Other,324% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,2149.01,,,2149.01,Other,125% New York Medicaid APG,1719.21,73233.94,
Remove cervix/repair vagina,57555,CPT,,,,,,,,both,,,104619.92,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,52309.96,50,,52309.96,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3197.73,,,3197.73,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,73233.94,70,,73233.94,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1719.21,,,1719.21,Other,New York Medicaid APG methodology,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,2406.89,,,2406.89,Other,140% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,4469.94,,,4469.94,Other,260% New York Medicaid APG,5570.24,,,5570.24,Other,324% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,2149.01,,,2149.01,Other,125% New York Medicaid APG,1719.21,73233.94,
Remove cervix repair bowel,57556,CPT,,,,,,,,both,,,104619.92,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,52309.96,50,,52309.96,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3900.51,,,3900.51,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,73233.94,70,,73233.94,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2097.05,,,2097.05,Other,New York Medicaid APG methodology,2097.05,,,2097.05,Other,100% New York Medicaid APG,2097.05,,,2097.05,Other,100% New York Medicaid APG,2097.05,,,2097.05,Other,100% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,2935.87,,,2935.87,Other,140% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,5452.32,,,5452.32,Other,260% New York Medicaid APG,6794.43,,,6794.43,Other,324% New York Medicaid APG,4508.65,,,4508.65,Other,215% New York Medicaid APG,4508.65,,,4508.65,Other,215% New York Medicaid APG,2621.31,,,2621.31,Other,125% New York Medicaid APG,2097.05,73233.94,
D&c of cervical stump,57558,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3197.73,,,3197.73,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,640.2,,,640.2,Fee Schedule,,543.2,,,543.2,Fee Schedule,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1719.21,,,1719.21,Other,New York Medicaid APG methodology,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,2406.89,,,2406.89,Other,140% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,4469.94,,,4469.94,Other,260% New York Medicaid APG,5570.24,,,5570.24,Other,324% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,2149.01,,,2149.01,Other,125% New York Medicaid APG,543.2,46031.33,
Revision of cervix,57700,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3197.73,,,3197.73,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1719.21,,,1719.21,Other,New York Medicaid APG methodology,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,2406.89,,,2406.89,Other,140% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,4469.94,,,4469.94,Other,260% New York Medicaid APG,5570.24,,,5570.24,Other,324% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,2149.01,,,2149.01,Other,125% New York Medicaid APG,1719.21,46031.33,
Revision of cervix,57720,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3197.73,,,3197.73,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1719.21,,,1719.21,Other,New York Medicaid APG methodology,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,2406.89,,,2406.89,Other,140% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,4469.94,,,4469.94,Other,260% New York Medicaid APG,5570.24,,,5570.24,Other,324% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,2149.01,,,2149.01,Other,125% New York Medicaid APG,1719.21,46031.33,
Dilation of cervical canal,57800,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3197.73,,,3197.73,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,234.3,,,234.3,Fee Schedule,,198.8,,,198.8,Fee Schedule,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1719.21,,,1719.21,Other,New York Medicaid APG methodology,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,2406.89,,,2406.89,Other,140% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,4469.94,,,4469.94,Other,260% New York Medicaid APG,5570.24,,,5570.24,Other,324% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,2149.01,,,2149.01,Other,125% New York Medicaid APG,198.8,46031.33,
Biopsy of uterus lining,58100,CPT,,,,,,,,both,,,37490.66,378.94,,,378.94,Other,150% of Medicare + 9.63% HCRA Surcharge,230.43,,,230.43,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,18745.33,50,,18745.33,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1419.19,,,1419.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26243.46,70,,26243.46,percent of total billed charges,,310.2,,,310.2,Fee Schedule,,263.2,,,263.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,763.01,,,763.01,Other,New York Medicaid APG methodology,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1068.21,,,1068.21,Other,140% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1983.82,,,1983.82,Other,260% New York Medicaid APG,2472.14,,,2472.14,Other,324% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,953.76,,,953.76,Other,125% New York Medicaid APG,0.01,26243.46,
Bx done w/colposcopy add-on,58110,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1419.19,,,1419.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,196.35,,,196.35,Fee Schedule,,166.6,,,166.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,763.01,,,763.01,Other,New York Medicaid APG methodology,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,763.01,,,763.01,Other,100% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1068.21,,,1068.21,Other,140% New York Medicaid APG,1716.77,,,1716.77,Other,225% New York Medicaid APG,1983.82,,,1983.82,Other,260% New York Medicaid APG,2472.14,,,2472.14,Other,324% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,1640.46,,,1640.46,Other,215% New York Medicaid APG,953.76,,,953.76,Other,125% New York Medicaid APG,0.01,22702.47,
Dilation and curettage,58120,CPT,,,,,,,,both,,,37545.36,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18772.68,50,,18772.68,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3197.73,,,3197.73,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26281.75,70,,26281.75,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1719.21,,,1719.21,Other,New York Medicaid APG methodology,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,2406.89,,,2406.89,Other,140% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,4469.94,,,4469.94,Other,260% New York Medicaid APG,5570.24,,,5570.24,Other,324% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,2149.01,,,2149.01,Other,125% New York Medicaid APG,1719.21,26281.75,
Myomectomy vag method,58145,CPT,,,,,,,,both,,,38290.05,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19145.03,50,,19145.03,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2778.74,,,2778.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26803.04,70,,26803.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1493.94,,,1493.94,Other,New York Medicaid APG methodology,1493.94,,,1493.94,Other,100% New York Medicaid APG,1493.94,,,1493.94,Other,100% New York Medicaid APG,1493.94,,,1493.94,Other,100% New York Medicaid APG,3361.37,,,3361.37,Other,225% New York Medicaid APG,3361.37,,,3361.37,Other,225% New York Medicaid APG,3361.37,,,3361.37,Other,225% New York Medicaid APG,3361.37,,,3361.37,Other,225% New York Medicaid APG,2091.52,,,2091.52,Other,140% New York Medicaid APG,3361.37,,,3361.37,Other,225% New York Medicaid APG,3884.25,,,3884.25,Other,260% New York Medicaid APG,4840.38,,,4840.38,Other,324% New York Medicaid APG,3211.98,,,3211.98,Other,215% New York Medicaid APG,3211.98,,,3211.98,Other,215% New York Medicaid APG,1867.43,,,1867.43,Other,125% New York Medicaid APG,1493.94,26803.04,
Vaginal hysterectomy,58260,CPT,,,,,,,,both,,,49369.2,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,24684.6,50,,24684.6,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2778.74,,,2778.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34558.44,70,,34558.44,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1493.94,,,1493.94,Other,New York Medicaid APG methodology,1493.94,,,1493.94,Other,100% New York Medicaid APG,1493.94,,,1493.94,Other,100% New York Medicaid APG,1493.94,,,1493.94,Other,100% New York Medicaid APG,3361.37,,,3361.37,Other,225% New York Medicaid APG,3361.37,,,3361.37,Other,225% New York Medicaid APG,3361.37,,,3361.37,Other,225% New York Medicaid APG,3361.37,,,3361.37,Other,225% New York Medicaid APG,2091.52,,,2091.52,Other,140% New York Medicaid APG,3361.37,,,3361.37,Other,225% New York Medicaid APG,3884.25,,,3884.25,Other,260% New York Medicaid APG,4840.38,,,4840.38,Other,324% New York Medicaid APG,3211.98,,,3211.98,Other,215% New York Medicaid APG,3211.98,,,3211.98,Other,215% New York Medicaid APG,1867.43,,,1867.43,Other,125% New York Medicaid APG,1493.94,34558.44,
Vag hyst including t/o,58262,CPT,,,,,,,,both,,,59177.42,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,29588.71,50,,29588.71,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2778.74,,,2778.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41424.19,70,,41424.19,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1493.94,,,1493.94,Other,New York Medicaid APG methodology,1493.94,,,1493.94,Other,100% New York Medicaid APG,1493.94,,,1493.94,Other,100% New York Medicaid APG,1493.94,,,1493.94,Other,100% New York Medicaid APG,3361.37,,,3361.37,Other,225% New York Medicaid APG,3361.37,,,3361.37,Other,225% New York Medicaid APG,3361.37,,,3361.37,Other,225% New York Medicaid APG,3361.37,,,3361.37,Other,225% New York Medicaid APG,2091.52,,,2091.52,Other,140% New York Medicaid APG,3361.37,,,3361.37,Other,225% New York Medicaid APG,3884.25,,,3884.25,Other,260% New York Medicaid APG,4840.38,,,4840.38,Other,324% New York Medicaid APG,3211.98,,,3211.98,Other,215% New York Medicaid APG,3211.98,,,3211.98,Other,215% New York Medicaid APG,1867.43,,,1867.43,Other,125% New York Medicaid APG,1493.94,41424.19,
Vag hyst w/t/o & vag repair,58263,CPT,,,,,,,,both,,,61845.31,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,30922.66,50,,30922.66,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2778.74,,,2778.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,43291.72,70,,43291.72,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1493.94,,,1493.94,Other,New York Medicaid APG methodology,1493.94,,,1493.94,Other,100% New York Medicaid APG,1493.94,,,1493.94,Other,100% New York Medicaid APG,1493.94,,,1493.94,Other,100% New York Medicaid APG,3361.37,,,3361.37,Other,225% New York Medicaid APG,3361.37,,,3361.37,Other,225% New York Medicaid APG,3361.37,,,3361.37,Other,225% New York Medicaid APG,3361.37,,,3361.37,Other,225% New York Medicaid APG,2091.52,,,2091.52,Other,140% New York Medicaid APG,3361.37,,,3361.37,Other,225% New York Medicaid APG,3884.25,,,3884.25,Other,260% New York Medicaid APG,4840.38,,,4840.38,Other,324% New York Medicaid APG,3211.98,,,3211.98,Other,215% New York Medicaid APG,3211.98,,,3211.98,Other,215% New York Medicaid APG,1867.43,,,1867.43,Other,125% New York Medicaid APG,1493.94,43291.72,
Vag hyst w/enterocele repair,58270,CPT,,,,,,,,both,,,104619.92,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,52309.96,50,,52309.96,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2778.74,,,2778.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,73233.94,70,,73233.94,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1493.94,,,1493.94,Other,New York Medicaid APG methodology,1493.94,,,1493.94,Other,100% New York Medicaid APG,1493.94,,,1493.94,Other,100% New York Medicaid APG,1493.94,,,1493.94,Other,100% New York Medicaid APG,3361.37,,,3361.37,Other,225% New York Medicaid APG,3361.37,,,3361.37,Other,225% New York Medicaid APG,3361.37,,,3361.37,Other,225% New York Medicaid APG,3361.37,,,3361.37,Other,225% New York Medicaid APG,2091.52,,,2091.52,Other,140% New York Medicaid APG,3361.37,,,3361.37,Other,225% New York Medicaid APG,3884.25,,,3884.25,Other,260% New York Medicaid APG,4840.38,,,4840.38,Other,324% New York Medicaid APG,3211.98,,,3211.98,Other,215% New York Medicaid APG,3211.98,,,3211.98,Other,215% New York Medicaid APG,1867.43,,,1867.43,Other,125% New York Medicaid APG,1493.94,73233.94,
Vag hyst complex,58290,CPT,,,,,,,,both,,,49648.56,14369.86,,,14369.86,Other,150% of Medicare + 9.63% HCRA Surcharge,8738.4,,,8738.4,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,24824.28,50,,24824.28,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4601.69,,,4601.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34753.99,70,,34753.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2474.02,,,2474.02,Other,New York Medicaid APG methodology,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,3463.63,,,3463.63,Other,140% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,6432.46,,,6432.46,Other,260% New York Medicaid APG,8015.84,,,8015.84,Other,324% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,3092.53,,,3092.53,Other,125% New York Medicaid APG,2474.02,34753.99,
Vag hyst incl t/o complex,58291,CPT,,,,,,,,both,,,48303.82,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,24151.91,50,,24151.91,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4601.69,,,4601.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,33812.67,70,,33812.67,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2474.02,,,2474.02,Other,New York Medicaid APG methodology,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,3463.63,,,3463.63,Other,140% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,6432.46,,,6432.46,Other,260% New York Medicaid APG,8015.84,,,8015.84,Other,324% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,3092.53,,,3092.53,Other,125% New York Medicaid APG,2474.02,33812.67,
Vag hyst t/o & repair compl,58292,CPT,,,,,,,,both,,,158942.1,14369.86,,,14369.86,Other,150% of Medicare + 9.63% HCRA Surcharge,8738.4,,,8738.4,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,79471.05,50,,79471.05,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4601.69,,,4601.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,111259.47,70,,111259.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2474.02,,,2474.02,Other,New York Medicaid APG methodology,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,3463.63,,,3463.63,Other,140% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,6432.46,,,6432.46,Other,260% New York Medicaid APG,8015.84,,,8015.84,Other,324% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,3092.53,,,3092.53,Other,125% New York Medicaid APG,2474.02,111259.47,
Vag hyst w/enterocele compl,58294,CPT,,,,,,,,both,,,104619.92,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,52309.96,50,,52309.96,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4601.69,,,4601.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,73233.94,70,,73233.94,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2474.02,,,2474.02,Other,New York Medicaid APG methodology,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,3463.63,,,3463.63,Other,140% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,6432.46,,,6432.46,Other,260% New York Medicaid APG,8015.84,,,8015.84,Other,324% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,3092.53,,,3092.53,Other,125% New York Medicaid APG,2474.02,73233.94,
Remove intrauterine device,58301,CPT,,,,,,,,both,,,36346.93,610.06,,,610.06,Other,150% of Medicare + 9.63% HCRA Surcharge,370.98,,,370.98,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,18173.47,50,,18173.47,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,529.85,,,529.85,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25442.85,70,,25442.85,percent of total billed charges,,325.05,,,325.05,Fee Schedule,,275.8,,,275.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,284.87,,,284.87,Other,New York Medicaid APG methodology,284.87,,,284.87,Other,100% New York Medicaid APG,284.87,,,284.87,Other,100% New York Medicaid APG,284.87,,,284.87,Other,100% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,398.81,,,398.81,Other,140% New York Medicaid APG,640.95,,,640.95,Other,225% New York Medicaid APG,740.65,,,740.65,Other,260% New York Medicaid APG,922.97,,,922.97,Other,324% New York Medicaid APG,612.46,,,612.46,Other,215% New York Medicaid APG,612.46,,,612.46,Other,215% New York Medicaid APG,356.08,,,356.08,Other,125% New York Medicaid APG,275.8,25442.85,
Artificial insemination,58321,CPT,,,,,,,,both,,,6747.72,610.06,,,610.06,Other,150% of Medicare + 9.63% HCRA Surcharge,370.98,,,370.98,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4048.63,60,,4048.63,percent of total billed charges,,3778.72,56,,3778.72,percent of total billed charges,,3643.77,54,,3643.77,percent of total billed charges,,3373.86,50,,3373.86,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4723.4,70,,4723.4,percent of total billed charges,,239.25,,,239.25,Fee Schedule,,203,,,203,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,9473,
Artificial insemination,58322,CPT,,,,,,,,both,,,4191.33,378.94,,,378.94,Other,150% of Medicare + 9.63% HCRA Surcharge,230.43,,,230.43,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,2514.8,60,,2514.8,percent of total billed charges,,2347.14,56,,2347.14,percent of total billed charges,,2263.32,54,,2263.32,percent of total billed charges,,2095.67,50,,2095.67,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2933.93,70,,2933.93,percent of total billed charges,,283.8,,,283.8,Fee Schedule,,240.8,,,240.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,9473,
Sperm washing,58323,CPT,,,,,,,,both,,,4191.33,378.94,,,378.94,Other,150% of Medicare + 9.63% HCRA Surcharge,230.43,,,230.43,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,2514.8,60,,2514.8,percent of total billed charges,,2347.14,56,,2347.14,percent of total billed charges,,2263.32,54,,2263.32,percent of total billed charges,,2095.67,50,,2095.67,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2933.93,70,,2933.93,percent of total billed charges,,59.4,,,59.4,Fee Schedule,,50.4,,,50.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,9473,
Catheter for hysterography,58340,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1205.26,,,1205.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,282.15,,,282.15,Fee Schedule,,239.4,,,239.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.99,,,647.99,Other,New York Medicaid APG methodology,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,907.18,,,907.18,Other,140% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1684.77,,,1684.77,Other,260% New York Medicaid APG,2099.48,,,2099.48,Other,324% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,809.98,,,809.98,Other,125% New York Medicaid APG,0.01,22702.47,
Reopen fallopian tube,58345,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3197.73,,,3197.73,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1719.21,,,1719.21,Other,New York Medicaid APG methodology,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,2406.89,,,2406.89,Other,140% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,4469.94,,,4469.94,Other,260% New York Medicaid APG,5570.24,,,5570.24,Other,324% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,2149.01,,,2149.01,Other,125% New York Medicaid APG,1719.21,46031.33,
Insert heyman uteri capsule,58346,CPT,,,,,,,,both,,,104619.92,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,52309.96,50,,52309.96,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3197.73,,,3197.73,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,73233.94,70,,73233.94,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1719.21,,,1719.21,Other,New York Medicaid APG methodology,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,2406.89,,,2406.89,Other,140% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,4469.94,,,4469.94,Other,260% New York Medicaid APG,5570.24,,,5570.24,Other,324% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,2149.01,,,2149.01,Other,125% New York Medicaid APG,1719.21,73233.94,
Reopen fallopian tube,58350,CPT,,,,,,,,both,,,104619.92,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,52309.96,50,,52309.96,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3197.73,,,3197.73,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,73233.94,70,,73233.94,percent of total billed charges,,475.2,,,475.2,Fee Schedule,,403.2,,,403.2,Fee Schedule,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1719.21,,,1719.21,Other,New York Medicaid APG methodology,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,2406.89,,,2406.89,Other,140% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,4469.94,,,4469.94,Other,260% New York Medicaid APG,5570.24,,,5570.24,Other,324% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,2149.01,,,2149.01,Other,125% New York Medicaid APG,403.2,73233.94,
Endometr ablate thermal,58353,CPT,,,,,,,,both,,,36275.62,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,18137.81,50,,18137.81,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3197.73,,,3197.73,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25392.93,70,,25392.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1719.21,,,1719.21,Other,New York Medicaid APG methodology,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,2406.89,,,2406.89,Other,140% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,4469.94,,,4469.94,Other,260% New York Medicaid APG,5570.24,,,5570.24,Other,324% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,2149.01,,,2149.01,Other,125% New York Medicaid APG,1719.21,25392.93,
Endometrial cryoablation,58356,CPT,,,,,,,,both,,,104619.92,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,52309.96,50,,52309.96,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3900.51,,,3900.51,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,73233.94,70,,73233.94,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2097.05,,,2097.05,Other,New York Medicaid APG methodology,2097.05,,,2097.05,Other,100% New York Medicaid APG,2097.05,,,2097.05,Other,100% New York Medicaid APG,2097.05,,,2097.05,Other,100% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,2935.87,,,2935.87,Other,140% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,5452.32,,,5452.32,Other,260% New York Medicaid APG,6794.43,,,6794.43,Other,324% New York Medicaid APG,4508.65,,,4508.65,Other,215% New York Medicaid APG,4508.65,,,4508.65,Other,215% New York Medicaid APG,2621.31,,,2621.31,Other,125% New York Medicaid APG,2097.05,73233.94,
Lsh uterus 250 g or less,58541,CPT,,,,,,,,both,,,72794.83,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,36397.42,50,,36397.42,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4601.69,,,4601.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50956.38,70,,50956.38,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2474.02,,,2474.02,Other,New York Medicaid APG methodology,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,3463.63,,,3463.63,Other,140% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,6432.46,,,6432.46,Other,260% New York Medicaid APG,8015.84,,,8015.84,Other,324% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,3092.53,,,3092.53,Other,125% New York Medicaid APG,2474.02,50956.38,
Lsh w/t/o ut 250 g or less,58542,CPT,,,,,,,,both,,,74539.51,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,37269.76,50,,37269.76,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4601.69,,,4601.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52177.66,70,,52177.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2474.02,,,2474.02,Other,New York Medicaid APG methodology,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,3463.63,,,3463.63,Other,140% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,6432.46,,,6432.46,Other,260% New York Medicaid APG,8015.84,,,8015.84,Other,324% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,3092.53,,,3092.53,Other,125% New York Medicaid APG,2474.02,52177.66,
Lsh uterus above 250 g,58543,CPT,,,,,,,,both,,,216515.17,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,108257.59,50,,108257.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4601.69,,,4601.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,151560.62,70,,151560.62,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2474.02,,,2474.02,Other,New York Medicaid APG methodology,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,3463.63,,,3463.63,Other,140% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,6432.46,,,6432.46,Other,260% New York Medicaid APG,8015.84,,,8015.84,Other,324% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,3092.53,,,3092.53,Other,125% New York Medicaid APG,2474.02,151560.62,
Lsh w/t/o uterus above 250 g,58544,CPT,,,,,,,,both,,,61808.81,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,30904.41,50,,30904.41,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4601.69,,,4601.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,43266.17,70,,43266.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2474.02,,,2474.02,Other,New York Medicaid APG methodology,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,3463.63,,,3463.63,Other,140% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,6432.46,,,6432.46,Other,260% New York Medicaid APG,8015.84,,,8015.84,Other,324% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,3092.53,,,3092.53,Other,125% New York Medicaid APG,2474.02,43266.17,
Laparoscopic myomectomy,58545,CPT,,,,,,,,both,,,55214.27,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,27607.14,50,,27607.14,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4601.69,,,4601.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,38649.99,70,,38649.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2474.02,,,2474.02,Other,New York Medicaid APG methodology,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,3463.63,,,3463.63,Other,140% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,6432.46,,,6432.46,Other,260% New York Medicaid APG,8015.84,,,8015.84,Other,324% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,3092.53,,,3092.53,Other,125% New York Medicaid APG,2474.02,38649.99,
Laparo-myomectomy complex,58546,CPT,,,,,,,,both,,,63611.71,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,31805.86,50,,31805.86,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4601.69,,,4601.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,44528.2,70,,44528.2,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2474.02,,,2474.02,Other,New York Medicaid APG methodology,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,3463.63,,,3463.63,Other,140% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,6432.46,,,6432.46,Other,260% New York Medicaid APG,8015.84,,,8015.84,Other,324% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,3092.53,,,3092.53,Other,125% New York Medicaid APG,2474.02,44528.2,
Laparo-asst vag hysterectomy,58550,CPT,,,,,,,,both,,,121364.27,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,60682.14,50,,60682.14,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4601.69,,,4601.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84954.99,70,,84954.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2474.02,,,2474.02,Other,New York Medicaid APG methodology,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,3463.63,,,3463.63,Other,140% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,6432.46,,,6432.46,Other,260% New York Medicaid APG,8015.84,,,8015.84,Other,324% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,3092.53,,,3092.53,Other,125% New York Medicaid APG,2474.02,84954.99,
Laparo-vag hyst incl t/o,58552,CPT,,,,,,,,both,,,66652.29,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,33326.15,50,,33326.15,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4601.69,,,4601.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46656.6,70,,46656.6,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2474.02,,,2474.02,Other,New York Medicaid APG methodology,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,3463.63,,,3463.63,Other,140% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,6432.46,,,6432.46,Other,260% New York Medicaid APG,8015.84,,,8015.84,Other,324% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,3092.53,,,3092.53,Other,125% New York Medicaid APG,2474.02,46656.6,
Laparo-vag hyst complex,58553,CPT,,,,,,,,both,,,71770.12,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,35885.06,50,,35885.06,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4601.69,,,4601.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50239.08,70,,50239.08,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2474.02,,,2474.02,Other,New York Medicaid APG methodology,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,3463.63,,,3463.63,Other,140% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,6432.46,,,6432.46,Other,260% New York Medicaid APG,8015.84,,,8015.84,Other,324% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,3092.53,,,3092.53,Other,125% New York Medicaid APG,2474.02,50239.08,
Laparo-vag hyst w/t/o compl,58554,CPT,,,,,,,,both,,,97317.14,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,48658.57,50,,48658.57,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4601.69,,,4601.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,68122,70,,68122,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2474.02,,,2474.02,Other,New York Medicaid APG methodology,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,3463.63,,,3463.63,Other,140% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,6432.46,,,6432.46,Other,260% New York Medicaid APG,8015.84,,,8015.84,Other,324% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,3092.53,,,3092.53,Other,125% New York Medicaid APG,2474.02,68122,
Hysteroscopy dx sep proc,58555,CPT,,,,,,,,both,,,34430.83,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17215.42,50,,17215.42,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3197.73,,,3197.73,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24101.58,70,,24101.58,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1719.21,,,1719.21,Other,New York Medicaid APG methodology,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,2406.89,,,2406.89,Other,140% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,4469.94,,,4469.94,Other,260% New York Medicaid APG,5570.24,,,5570.24,Other,324% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,2149.01,,,2149.01,Other,125% New York Medicaid APG,1719.21,24101.58,
Hysteroscopy biopsy,58558,CPT,,,,,,,,both,,,39392.83,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19696.42,50,,19696.42,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3197.73,,,3197.73,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27574.98,70,,27574.98,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1719.21,,,1719.21,Other,New York Medicaid APG methodology,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,2406.89,,,2406.89,Other,140% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,4469.94,,,4469.94,Other,260% New York Medicaid APG,5570.24,,,5570.24,Other,324% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,2149.01,,,2149.01,Other,125% New York Medicaid APG,1719.21,27574.98,
Hysteroscopy lysis,58559,CPT,,,,,,,,both,,,36552.16,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,18276.08,50,,18276.08,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3197.73,,,3197.73,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25586.51,70,,25586.51,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1719.21,,,1719.21,Other,New York Medicaid APG methodology,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,2406.89,,,2406.89,Other,140% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,4469.94,,,4469.94,Other,260% New York Medicaid APG,5570.24,,,5570.24,Other,324% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,2149.01,,,2149.01,Other,125% New York Medicaid APG,1719.21,25586.51,
Hysteroscopy resect septum,58560,CPT,,,,,,,,both,,,37501.05,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,18750.53,50,,18750.53,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3197.73,,,3197.73,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26250.74,70,,26250.74,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1719.21,,,1719.21,Other,New York Medicaid APG methodology,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,2406.89,,,2406.89,Other,140% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,4469.94,,,4469.94,Other,260% New York Medicaid APG,5570.24,,,5570.24,Other,324% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,2149.01,,,2149.01,Other,125% New York Medicaid APG,1719.21,26250.74,
Hysteroscopy remove myoma,58561,CPT,,,,,,,,both,,,40296.84,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,20148.42,50,,20148.42,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2778.74,,,2778.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28207.79,70,,28207.79,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1493.94,,,1493.94,Other,New York Medicaid APG methodology,1493.94,,,1493.94,Other,100% New York Medicaid APG,1493.94,,,1493.94,Other,100% New York Medicaid APG,1493.94,,,1493.94,Other,100% New York Medicaid APG,3361.37,,,3361.37,Other,225% New York Medicaid APG,3361.37,,,3361.37,Other,225% New York Medicaid APG,3361.37,,,3361.37,Other,225% New York Medicaid APG,3361.37,,,3361.37,Other,225% New York Medicaid APG,2091.52,,,2091.52,Other,140% New York Medicaid APG,3361.37,,,3361.37,Other,225% New York Medicaid APG,3884.25,,,3884.25,Other,260% New York Medicaid APG,4840.38,,,4840.38,Other,324% New York Medicaid APG,3211.98,,,3211.98,Other,215% New York Medicaid APG,3211.98,,,3211.98,Other,215% New York Medicaid APG,1867.43,,,1867.43,Other,125% New York Medicaid APG,1493.94,28207.79,
Hysteroscopy remove fb,58562,CPT,,,,,,,,both,,,37612.98,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18806.49,50,,18806.49,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3197.73,,,3197.73,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26329.09,70,,26329.09,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1719.21,,,1719.21,Other,New York Medicaid APG methodology,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,2406.89,,,2406.89,Other,140% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,4469.94,,,4469.94,Other,260% New York Medicaid APG,5570.24,,,5570.24,Other,324% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,2149.01,,,2149.01,Other,125% New York Medicaid APG,1719.21,26329.09,
Hysteroscopy ablation,58563,CPT,,,,,,,,both,,,39521.04,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,19760.52,50,,19760.52,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3197.73,,,3197.73,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27664.73,70,,27664.73,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1719.21,,,1719.21,Other,New York Medicaid APG methodology,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,2406.89,,,2406.89,Other,140% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,4469.94,,,4469.94,Other,260% New York Medicaid APG,5570.24,,,5570.24,Other,324% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,2149.01,,,2149.01,Other,125% New York Medicaid APG,1719.21,27664.73,
Hysteroscopy sterilization,58565,CPT,,,,,,,,both,,,104619.92,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,52309.96,50,,52309.96,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3900.51,,,3900.51,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,73233.94,70,,73233.94,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2097.05,,,2097.05,Other,New York Medicaid APG methodology,2097.05,,,2097.05,Other,100% New York Medicaid APG,2097.05,,,2097.05,Other,100% New York Medicaid APG,2097.05,,,2097.05,Other,100% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,2935.87,,,2935.87,Other,140% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,5452.32,,,5452.32,Other,260% New York Medicaid APG,6794.43,,,6794.43,Other,324% New York Medicaid APG,4508.65,,,4508.65,Other,215% New York Medicaid APG,4508.65,,,4508.65,Other,215% New York Medicaid APG,2621.31,,,2621.31,Other,125% New York Medicaid APG,2097.05,73233.94,
Tlh uterus 250 g or less,58570,CPT,,,,,,,,both,,,56767.61,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,28383.81,50,,28383.81,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4601.69,,,4601.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,39737.33,70,,39737.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2474.02,,,2474.02,Other,New York Medicaid APG methodology,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,3463.63,,,3463.63,Other,140% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,6432.46,,,6432.46,Other,260% New York Medicaid APG,8015.84,,,8015.84,Other,324% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,3092.53,,,3092.53,Other,125% New York Medicaid APG,2474.02,39737.33,
Tlh w/t/o 250 g or less,58571,CPT,,,,,,,,both,,,69079.78,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,34539.89,50,,34539.89,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4601.69,,,4601.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,48355.85,70,,48355.85,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2474.02,,,2474.02,Other,New York Medicaid APG methodology,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,3463.63,,,3463.63,Other,140% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,6432.46,,,6432.46,Other,260% New York Medicaid APG,8015.84,,,8015.84,Other,324% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,3092.53,,,3092.53,Other,125% New York Medicaid APG,2474.02,48355.85,
Tlh uterus over 250 g,58572,CPT,,,,,,,,both,,,66943.71,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,33471.86,50,,33471.86,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4601.69,,,4601.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46860.6,70,,46860.6,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2474.02,,,2474.02,Other,New York Medicaid APG methodology,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,3463.63,,,3463.63,Other,140% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,6432.46,,,6432.46,Other,260% New York Medicaid APG,8015.84,,,8015.84,Other,324% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,3092.53,,,3092.53,Other,125% New York Medicaid APG,2474.02,46860.6,
Tlh w/t/o uterus over 250 g,58573,CPT,,,,,,,,both,,,65388.32,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,32694.16,50,,32694.16,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4601.69,,,4601.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45771.82,70,,45771.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2474.02,,,2474.02,Other,New York Medicaid APG methodology,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,3463.63,,,3463.63,Other,140% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,6432.46,,,6432.46,Other,260% New York Medicaid APG,8015.84,,,8015.84,Other,324% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,3092.53,,,3092.53,Other,125% New York Medicaid APG,2474.02,45771.82,
Division of fallopian tube,58600,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3197.73,,,3197.73,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1719.21,,,1719.21,Other,New York Medicaid APG methodology,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,2406.89,,,2406.89,Other,140% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,4469.94,,,4469.94,Other,260% New York Medicaid APG,5570.24,,,5570.24,Other,324% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,2149.01,,,2149.01,Other,125% New York Medicaid APG,1719.21,46031.33,
Occlude fallopian tube(s),58615,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3197.73,,,3197.73,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1719.21,,,1719.21,Other,New York Medicaid APG methodology,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,2406.89,,,2406.89,Other,140% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,4469.94,,,4469.94,Other,260% New York Medicaid APG,5570.24,,,5570.24,Other,324% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,2149.01,,,2149.01,Other,125% New York Medicaid APG,1719.21,46031.33,
Laparoscopy lysis,58660,CPT,,,,,,,,both,,,121364.27,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,60682.14,50,,60682.14,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3900.51,,,3900.51,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84954.99,70,,84954.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2097.05,,,2097.05,Other,New York Medicaid APG methodology,2097.05,,,2097.05,Other,100% New York Medicaid APG,2097.05,,,2097.05,Other,100% New York Medicaid APG,2097.05,,,2097.05,Other,100% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,2935.87,,,2935.87,Other,140% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,5452.32,,,5452.32,Other,260% New York Medicaid APG,6794.43,,,6794.43,Other,324% New York Medicaid APG,4508.65,,,4508.65,Other,215% New York Medicaid APG,4508.65,,,4508.65,Other,215% New York Medicaid APG,2621.31,,,2621.31,Other,125% New York Medicaid APG,2097.05,84954.99,
Laparoscopy remove adnexa,58661,CPT,,,,,,,,both,,,47043.3,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,23521.65,50,,23521.65,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3900.51,,,3900.51,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,32930.31,70,,32930.31,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2097.05,,,2097.05,Other,New York Medicaid APG methodology,2097.05,,,2097.05,Other,100% New York Medicaid APG,2097.05,,,2097.05,Other,100% New York Medicaid APG,2097.05,,,2097.05,Other,100% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,2935.87,,,2935.87,Other,140% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,5452.32,,,5452.32,Other,260% New York Medicaid APG,6794.43,,,6794.43,Other,324% New York Medicaid APG,4508.65,,,4508.65,Other,215% New York Medicaid APG,4508.65,,,4508.65,Other,215% New York Medicaid APG,2621.31,,,2621.31,Other,125% New York Medicaid APG,2097.05,32930.31,
Laparoscopy excise lesions,58662,CPT,,,,,,,,both,,,51210.47,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,25605.24,50,,25605.24,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3900.51,,,3900.51,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,35847.33,70,,35847.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2097.05,,,2097.05,Other,New York Medicaid APG methodology,2097.05,,,2097.05,Other,100% New York Medicaid APG,2097.05,,,2097.05,Other,100% New York Medicaid APG,2097.05,,,2097.05,Other,100% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,2935.87,,,2935.87,Other,140% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,5452.32,,,5452.32,Other,260% New York Medicaid APG,6794.43,,,6794.43,Other,324% New York Medicaid APG,4508.65,,,4508.65,Other,215% New York Medicaid APG,4508.65,,,4508.65,Other,215% New York Medicaid APG,2621.31,,,2621.31,Other,125% New York Medicaid APG,2097.05,35847.33,
Laparoscopy tubal cautery,58670,CPT,,,,,,,,both,,,40404.53,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,20202.27,50,,20202.27,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3900.51,,,3900.51,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28283.17,70,,28283.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2097.05,,,2097.05,Other,New York Medicaid APG methodology,2097.05,,,2097.05,Other,100% New York Medicaid APG,2097.05,,,2097.05,Other,100% New York Medicaid APG,2097.05,,,2097.05,Other,100% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,2935.87,,,2935.87,Other,140% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,5452.32,,,5452.32,Other,260% New York Medicaid APG,6794.43,,,6794.43,Other,324% New York Medicaid APG,4508.65,,,4508.65,Other,215% New York Medicaid APG,4508.65,,,4508.65,Other,215% New York Medicaid APG,2621.31,,,2621.31,Other,125% New York Medicaid APG,2097.05,28283.17,
Laparoscopy tubal block,58671,CPT,,,,,,,,both,,,121364.27,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,60682.14,50,,60682.14,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3900.51,,,3900.51,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84954.99,70,,84954.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2097.05,,,2097.05,Other,New York Medicaid APG methodology,2097.05,,,2097.05,Other,100% New York Medicaid APG,2097.05,,,2097.05,Other,100% New York Medicaid APG,2097.05,,,2097.05,Other,100% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,2935.87,,,2935.87,Other,140% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,5452.32,,,5452.32,Other,260% New York Medicaid APG,6794.43,,,6794.43,Other,324% New York Medicaid APG,4508.65,,,4508.65,Other,215% New York Medicaid APG,4508.65,,,4508.65,Other,215% New York Medicaid APG,2621.31,,,2621.31,Other,125% New York Medicaid APG,2097.05,84954.99,
Laparoscopy fimbrioplasty,58672,CPT,,,,,,,,both,,,121364.27,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,60682.14,50,,60682.14,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3900.51,,,3900.51,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84954.99,70,,84954.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2097.05,,,2097.05,Other,New York Medicaid APG methodology,2097.05,,,2097.05,Other,100% New York Medicaid APG,2097.05,,,2097.05,Other,100% New York Medicaid APG,2097.05,,,2097.05,Other,100% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,2935.87,,,2935.87,Other,140% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,5452.32,,,5452.32,Other,260% New York Medicaid APG,6794.43,,,6794.43,Other,324% New York Medicaid APG,4508.65,,,4508.65,Other,215% New York Medicaid APG,4508.65,,,4508.65,Other,215% New York Medicaid APG,2621.31,,,2621.31,Other,125% New York Medicaid APG,2097.05,84954.99,
Laparoscopy salpingostomy,58673,CPT,,,,,,,,both,,,216515.17,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,108257.59,50,,108257.59,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3900.51,,,3900.51,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,151560.62,70,,151560.62,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2097.05,,,2097.05,Other,New York Medicaid APG methodology,2097.05,,,2097.05,Other,100% New York Medicaid APG,2097.05,,,2097.05,Other,100% New York Medicaid APG,2097.05,,,2097.05,Other,100% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,2935.87,,,2935.87,Other,140% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,5452.32,,,5452.32,Other,260% New York Medicaid APG,6794.43,,,6794.43,Other,324% New York Medicaid APG,4508.65,,,4508.65,Other,215% New York Medicaid APG,4508.65,,,4508.65,Other,215% New York Medicaid APG,2621.31,,,2621.31,Other,125% New York Medicaid APG,2097.05,151560.62,
Laps abltj uterine fibroids,58674,CPT,,,,,,,,both,,,216515.17,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,108257.59,50,,108257.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4601.69,,,4601.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,151560.62,70,,151560.62,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2474.02,,,2474.02,Other,New York Medicaid APG methodology,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,2474.02,,,2474.02,Other,100% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,3463.63,,,3463.63,Other,140% New York Medicaid APG,5566.56,,,5566.56,Other,225% New York Medicaid APG,6432.46,,,6432.46,Other,260% New York Medicaid APG,8015.84,,,8015.84,Other,324% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,5319.15,,,5319.15,Other,215% New York Medicaid APG,3092.53,,,3092.53,Other,125% New York Medicaid APG,2474.02,151560.62,
Create new tubal opening,58770,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3197.73,,,3197.73,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1719.21,,,1719.21,Other,New York Medicaid APG methodology,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,2406.89,,,2406.89,Other,140% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,4469.94,,,4469.94,Other,260% New York Medicaid APG,5570.24,,,5570.24,Other,324% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,2149.01,,,2149.01,Other,125% New York Medicaid APG,1719.21,46031.33,
Drainage of ovarian cyst(s),58800,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3197.73,,,3197.73,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1719.21,,,1719.21,Other,New York Medicaid APG methodology,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,2406.89,,,2406.89,Other,140% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,4469.94,,,4469.94,Other,260% New York Medicaid APG,5570.24,,,5570.24,Other,324% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,2149.01,,,2149.01,Other,125% New York Medicaid APG,1719.21,46031.33,
Drainage of ovarian cyst(s),58805,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3197.73,,,3197.73,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1719.21,,,1719.21,Other,New York Medicaid APG methodology,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,2406.89,,,2406.89,Other,140% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,4469.94,,,4469.94,Other,260% New York Medicaid APG,5570.24,,,5570.24,Other,324% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,2149.01,,,2149.01,Other,125% New York Medicaid APG,1719.21,46031.33,
Drain ovary abscess open,58820,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3197.73,,,3197.73,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1719.21,,,1719.21,Other,New York Medicaid APG methodology,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,2406.89,,,2406.89,Other,140% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,4469.94,,,4469.94,Other,260% New York Medicaid APG,5570.24,,,5570.24,Other,324% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,2149.01,,,2149.01,Other,125% New York Medicaid APG,1719.21,46031.33,
Biopsy of ovary(s),58900,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3197.73,,,3197.73,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1719.21,,,1719.21,Other,New York Medicaid APG methodology,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,1719.21,,,1719.21,Other,100% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,2406.89,,,2406.89,Other,140% New York Medicaid APG,3868.22,,,3868.22,Other,225% New York Medicaid APG,4469.94,,,4469.94,Other,260% New York Medicaid APG,5570.24,,,5570.24,Other,324% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,3696.3,,,3696.3,Other,215% New York Medicaid APG,2149.01,,,2149.01,Other,125% New York Medicaid APG,1719.21,46031.33,
Partial removal of ovary(s),58920,CPT,,,,,,,,both,,,158942.1,14369.86,,,14369.86,Other,150% of Medicare + 9.63% HCRA Surcharge,8738.4,,,8738.4,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,79471.05,50,,79471.05,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3900.51,,,3900.51,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,111259.47,70,,111259.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2097.05,,,2097.05,Other,New York Medicaid APG methodology,2097.05,,,2097.05,Other,100% New York Medicaid APG,2097.05,,,2097.05,Other,100% New York Medicaid APG,2097.05,,,2097.05,Other,100% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,2935.87,,,2935.87,Other,140% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,5452.32,,,5452.32,Other,260% New York Medicaid APG,6794.43,,,6794.43,Other,324% New York Medicaid APG,4508.65,,,4508.65,Other,215% New York Medicaid APG,4508.65,,,4508.65,Other,215% New York Medicaid APG,2621.31,,,2621.31,Other,125% New York Medicaid APG,2097.05,111259.47,
Removal of ovarian cyst(s),58925,CPT,,,,,,,,both,,,42664.12,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,21332.06,50,,21332.06,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3900.51,,,3900.51,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29864.88,70,,29864.88,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2097.05,,,2097.05,Other,New York Medicaid APG methodology,2097.05,,,2097.05,Other,100% New York Medicaid APG,2097.05,,,2097.05,Other,100% New York Medicaid APG,2097.05,,,2097.05,Other,100% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,2935.87,,,2935.87,Other,140% New York Medicaid APG,4718.36,,,4718.36,Other,225% New York Medicaid APG,5452.32,,,5452.32,Other,260% New York Medicaid APG,6794.43,,,6794.43,Other,324% New York Medicaid APG,4508.65,,,4508.65,Other,215% New York Medicaid APG,4508.65,,,4508.65,Other,215% New York Medicaid APG,2621.31,,,2621.31,Other,125% New York Medicaid APG,2097.05,29864.88,
Retrieval of oocyte,58970,CPT,,,,,,,,both,,,16909.26,1528.76,,,1528.76,Other,150% of Medicare + 9.63% HCRA Surcharge,929.65,,,929.65,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,8454.63,50,,8454.63,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,11836.48,70,,11836.48,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,13157,
Transfer of embryo,58974,CPT,,,,,,,,both,,,16909.26,1528.76,,,1528.76,Other,150% of Medicare + 9.63% HCRA Surcharge,929.65,,,929.65,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,8454.63,50,,8454.63,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,11836.48,70,,11836.48,percent of total billed charges,,8454.63,50,,8454.63,percent of total billed charges,,8454.63,50,,8454.63,percent of total billed charges,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,11836.48,
Transfer of embryo,58976,CPT,,,,,,,,both,,,6747.72,610.06,,,610.06,Other,150% of Medicare + 9.63% HCRA Surcharge,370.98,,,370.98,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3373.86,50,,3373.86,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4723.4,70,,4723.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,13157,
Amniocentesis diagnostic,59000,CPT,,,,,,,,both,,,16909.26,1528.76,,,1528.76,Other,150% of Medicare + 9.63% HCRA Surcharge,929.65,,,929.65,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,8454.63,50,,8454.63,percent of total billed charges,,11836.48,70,,11836.48,percent of total billed charges,,6152,,,6152,Case Rate,,1835.13,,,1835.13,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,11836.48,70,,11836.48,percent of total billed charges,,396,,,396,Fee Schedule,,336,,,336,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,986.63,,,986.63,Other,New York Medicaid APG methodology,986.63,,,986.63,Other,100% New York Medicaid APG,986.63,,,986.63,Other,100% New York Medicaid APG,986.63,,,986.63,Other,100% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,1381.28,,,1381.28,Other,140% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,2565.24,,,2565.24,Other,260% New York Medicaid APG,3196.68,,,3196.68,Other,324% New York Medicaid APG,2121.26,,,2121.26,Other,215% New York Medicaid APG,2121.26,,,2121.26,Other,215% New York Medicaid APG,1233.29,,,1233.29,Other,125% New York Medicaid APG,336,11836.48,
Amniocentesis therapeutic,59001,CPT,,,,,,,,both,,,6747.72,610.06,,,610.06,Other,150% of Medicare + 9.63% HCRA Surcharge,370.98,,,370.98,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3373.86,50,,3373.86,percent of total billed charges,,4723.4,70,,4723.4,percent of total billed charges,,6152,,,6152,Case Rate,,1835.13,,,1835.13,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4723.4,70,,4723.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,986.63,,,986.63,Other,New York Medicaid APG methodology,986.63,,,986.63,Other,100% New York Medicaid APG,986.63,,,986.63,Other,100% New York Medicaid APG,986.63,,,986.63,Other,100% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,1381.28,,,1381.28,Other,140% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,2565.24,,,2565.24,Other,260% New York Medicaid APG,3196.68,,,3196.68,Other,324% New York Medicaid APG,2121.26,,,2121.26,Other,215% New York Medicaid APG,2121.26,,,2121.26,Other,215% New York Medicaid APG,1233.29,,,1233.29,Other,125% New York Medicaid APG,370.98,13157,
Fetal cord puncture prenatal,59012,CPT,,,,,,,,both,,,6747.72,610.06,,,610.06,Other,150% of Medicare + 9.63% HCRA Surcharge,370.98,,,370.98,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3373.86,50,,3373.86,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1835.13,,,1835.13,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4723.4,70,,4723.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,986.63,,,986.63,Other,New York Medicaid APG methodology,986.63,,,986.63,Other,100% New York Medicaid APG,986.63,,,986.63,Other,100% New York Medicaid APG,986.63,,,986.63,Other,100% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,1381.28,,,1381.28,Other,140% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,2565.24,,,2565.24,Other,260% New York Medicaid APG,3196.68,,,3196.68,Other,324% New York Medicaid APG,2121.26,,,2121.26,Other,215% New York Medicaid APG,2121.26,,,2121.26,Other,215% New York Medicaid APG,1233.29,,,1233.29,Other,125% New York Medicaid APG,0.01,13157,
Chorion biopsy,59015,CPT,,,,,,,,both,,,16909.26,1528.76,,,1528.76,Other,150% of Medicare + 9.63% HCRA Surcharge,929.65,,,929.65,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,8454.63,50,,8454.63,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1835.13,,,1835.13,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,11836.48,70,,11836.48,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,986.63,,,986.63,Other,New York Medicaid APG methodology,986.63,,,986.63,Other,100% New York Medicaid APG,986.63,,,986.63,Other,100% New York Medicaid APG,986.63,,,986.63,Other,100% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,1381.28,,,1381.28,Other,140% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,2565.24,,,2565.24,Other,260% New York Medicaid APG,3196.68,,,3196.68,Other,324% New York Medicaid APG,2121.26,,,2121.26,Other,215% New York Medicaid APG,2121.26,,,2121.26,Other,215% New York Medicaid APG,1233.29,,,1233.29,Other,125% New York Medicaid APG,0.01,13157,
Fetal contract stress test,59020,CPT,,,,,,,,both,,,4191.33,378.94,,,378.94,Other,150% of Medicare + 9.63% HCRA Surcharge,230.43,,,230.43,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2095.67,50,,2095.67,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,722.7,,,722.7,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2933.93,70,,2933.93,percent of total billed charges,,2095.67,50,,2095.67,percent of total billed charges,,2095.67,50,,2095.67,percent of total billed charges,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,388.55,,,388.55,Other,New York Medicaid APG methodology,388.55,,,388.55,Other,100% New York Medicaid APG,388.55,,,388.55,Other,100% New York Medicaid APG,388.55,,,388.55,Other,100% New York Medicaid APG,874.24,,,874.24,Other,225% New York Medicaid APG,874.24,,,874.24,Other,225% New York Medicaid APG,874.24,,,874.24,Other,225% New York Medicaid APG,874.24,,,874.24,Other,225% New York Medicaid APG,543.97,,,543.97,Other,140% New York Medicaid APG,874.24,,,874.24,Other,225% New York Medicaid APG,1010.23,,,1010.23,Other,260% New York Medicaid APG,1258.91,,,1258.91,Other,324% New York Medicaid APG,835.38,,,835.38,Other,215% New York Medicaid APG,835.38,,,835.38,Other,215% New York Medicaid APG,485.69,,,485.69,Other,125% New York Medicaid APG,0.01,9473,
Fetal non-stress test,59025,CPT,,,,,,,,both,,,4191.33,378.94,,,378.94,Other,150% of Medicare + 9.63% HCRA Surcharge,230.43,,,230.43,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,159.11,,,159.11,Fee Schedule,,143.15,,,143.15,Fee Schedule,,135.18,,,135.18,Fee Schedule,,2095.67,50,,2095.67,percent of total billed charges,,2933.93,70,,2933.93,percent of total billed charges,,6152,,,6152,Case Rate,,722.7,,,722.7,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2933.93,70,,2933.93,percent of total billed charges,,2095.67,50,,2095.67,percent of total billed charges,,2095.67,50,,2095.67,percent of total billed charges,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,388.55,,,388.55,Other,New York Medicaid APG methodology,388.55,,,388.55,Other,100% New York Medicaid APG,388.55,,,388.55,Other,100% New York Medicaid APG,388.55,,,388.55,Other,100% New York Medicaid APG,874.24,,,874.24,Other,225% New York Medicaid APG,874.24,,,874.24,Other,225% New York Medicaid APG,874.24,,,874.24,Other,225% New York Medicaid APG,874.24,,,874.24,Other,225% New York Medicaid APG,543.97,,,543.97,Other,140% New York Medicaid APG,874.24,,,874.24,Other,225% New York Medicaid APG,1010.23,,,1010.23,Other,260% New York Medicaid APG,1258.91,,,1258.91,Other,324% New York Medicaid APG,835.38,,,835.38,Other,215% New York Medicaid APG,835.38,,,835.38,Other,215% New York Medicaid APG,485.69,,,485.69,Other,125% New York Medicaid APG,135.18,9473,
Fetal scalp blood sample,59030,CPT,,,,,,,,both,,,6747.72,610.06,,,610.06,Other,150% of Medicare + 9.63% HCRA Surcharge,370.98,,,370.98,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3373.86,50,,3373.86,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,722.7,,,722.7,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4723.4,70,,4723.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,388.55,,,388.55,Other,New York Medicaid APG methodology,388.55,,,388.55,Other,100% New York Medicaid APG,388.55,,,388.55,Other,100% New York Medicaid APG,388.55,,,388.55,Other,100% New York Medicaid APG,874.24,,,874.24,Other,225% New York Medicaid APG,874.24,,,874.24,Other,225% New York Medicaid APG,874.24,,,874.24,Other,225% New York Medicaid APG,874.24,,,874.24,Other,225% New York Medicaid APG,543.97,,,543.97,Other,140% New York Medicaid APG,874.24,,,874.24,Other,225% New York Medicaid APG,1010.23,,,1010.23,Other,260% New York Medicaid APG,1258.91,,,1258.91,Other,324% New York Medicaid APG,835.38,,,835.38,Other,215% New York Medicaid APG,835.38,,,835.38,Other,215% New York Medicaid APG,485.69,,,485.69,Other,125% New York Medicaid APG,0.01,13157,
Transabdom amnioinfus w/us,59070,CPT,,,,,,,,both,,,6747.72,610.06,,,610.06,Other,150% of Medicare + 9.63% HCRA Surcharge,370.98,,,370.98,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3373.86,50,,3373.86,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1835.13,,,1835.13,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4723.4,70,,4723.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,986.63,,,986.63,Other,New York Medicaid APG methodology,986.63,,,986.63,Other,100% New York Medicaid APG,986.63,,,986.63,Other,100% New York Medicaid APG,986.63,,,986.63,Other,100% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,1381.28,,,1381.28,Other,140% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,2565.24,,,2565.24,Other,260% New York Medicaid APG,3196.68,,,3196.68,Other,324% New York Medicaid APG,2121.26,,,2121.26,Other,215% New York Medicaid APG,2121.26,,,2121.26,Other,215% New York Medicaid APG,1233.29,,,1233.29,Other,125% New York Medicaid APG,370.98,13157,
Umbilical cord occlud w/us,59072,CPT,,,,,,,,both,,,6747.72,610.06,,,610.06,Other,150% of Medicare + 9.63% HCRA Surcharge,370.98,,,370.98,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3373.86,50,,3373.86,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1735.75,,,1735.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4723.4,70,,4723.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,933.2,,,933.2,Other,New York Medicaid APG methodology,933.2,,,933.2,Other,100% New York Medicaid APG,933.2,,,933.2,Other,100% New York Medicaid APG,933.2,,,933.2,Other,100% New York Medicaid APG,2099.69,,,2099.69,Other,225% New York Medicaid APG,2099.69,,,2099.69,Other,225% New York Medicaid APG,2099.69,,,2099.69,Other,225% New York Medicaid APG,2099.69,,,2099.69,Other,225% New York Medicaid APG,1306.48,,,1306.48,Other,140% New York Medicaid APG,2099.69,,,2099.69,Other,225% New York Medicaid APG,2426.31,,,2426.31,Other,260% New York Medicaid APG,3023.56,,,3023.56,Other,324% New York Medicaid APG,2006.37,,,2006.37,Other,215% New York Medicaid APG,2006.37,,,2006.37,Other,215% New York Medicaid APG,1166.5,,,1166.5,Other,125% New York Medicaid APG,370.98,13157,
Fetal fluid drainage w/us,59074,CPT,,,,,,,,both,,,6747.72,610.06,,,610.06,Other,150% of Medicare + 9.63% HCRA Surcharge,370.98,,,370.98,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3373.86,50,,3373.86,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,722.7,,,722.7,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4723.4,70,,4723.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,388.55,,,388.55,Other,New York Medicaid APG methodology,388.55,,,388.55,Other,100% New York Medicaid APG,388.55,,,388.55,Other,100% New York Medicaid APG,388.55,,,388.55,Other,100% New York Medicaid APG,874.24,,,874.24,Other,225% New York Medicaid APG,874.24,,,874.24,Other,225% New York Medicaid APG,874.24,,,874.24,Other,225% New York Medicaid APG,874.24,,,874.24,Other,225% New York Medicaid APG,543.97,,,543.97,Other,140% New York Medicaid APG,874.24,,,874.24,Other,225% New York Medicaid APG,1010.23,,,1010.23,Other,260% New York Medicaid APG,1258.91,,,1258.91,Other,324% New York Medicaid APG,835.38,,,835.38,Other,215% New York Medicaid APG,835.38,,,835.38,Other,215% New York Medicaid APG,485.69,,,485.69,Other,125% New York Medicaid APG,370.98,13157,
Fetal shunt placement w/us,59076,CPT,,,,,,,,both,,,6747.72,610.06,,,610.06,Other,150% of Medicare + 9.63% HCRA Surcharge,370.98,,,370.98,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3373.86,50,,3373.86,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1735.75,,,1735.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4723.4,70,,4723.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,933.2,,,933.2,Other,New York Medicaid APG methodology,933.2,,,933.2,Other,100% New York Medicaid APG,933.2,,,933.2,Other,100% New York Medicaid APG,933.2,,,933.2,Other,100% New York Medicaid APG,2099.69,,,2099.69,Other,225% New York Medicaid APG,2099.69,,,2099.69,Other,225% New York Medicaid APG,2099.69,,,2099.69,Other,225% New York Medicaid APG,2099.69,,,2099.69,Other,225% New York Medicaid APG,1306.48,,,1306.48,Other,140% New York Medicaid APG,2099.69,,,2099.69,Other,225% New York Medicaid APG,2426.31,,,2426.31,Other,260% New York Medicaid APG,3023.56,,,3023.56,Other,324% New York Medicaid APG,2006.37,,,2006.37,Other,215% New York Medicaid APG,2006.37,,,2006.37,Other,215% New York Medicaid APG,1166.5,,,1166.5,Other,125% New York Medicaid APG,370.98,13157,
Remove uterus lesion,59100,CPT,,,,,,,,both,,,104619.92,9458.62,,,9458.62,Other,150% of Medicare + 9.63% HCRA Surcharge,5751.85,,,5751.85,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,52309.96,50,,52309.96,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3656.4,,,3656.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,73233.94,70,,73233.94,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1965.81,,,1965.81,Other,New York Medicaid APG methodology,1965.81,,,1965.81,Other,100% New York Medicaid APG,1965.81,,,1965.81,Other,100% New York Medicaid APG,1965.81,,,1965.81,Other,100% New York Medicaid APG,4423.06,,,4423.06,Other,225% New York Medicaid APG,4423.06,,,4423.06,Other,225% New York Medicaid APG,4423.06,,,4423.06,Other,225% New York Medicaid APG,4423.06,,,4423.06,Other,225% New York Medicaid APG,2752.13,,,2752.13,Other,140% New York Medicaid APG,4423.06,,,4423.06,Other,225% New York Medicaid APG,5111.1,,,5111.1,Other,260% New York Medicaid APG,6369.21,,,6369.21,Other,324% New York Medicaid APG,4226.48,,,4226.48,Other,215% New York Medicaid APG,4226.48,,,4226.48,Other,215% New York Medicaid APG,2457.26,,,2457.26,Other,125% New York Medicaid APG,1965.81,73233.94,
Treat ectopic pregnancy,59150,CPT,,,,,,,,both,,,121364.27,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,60682.14,50,,60682.14,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3656.4,,,3656.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84954.99,70,,84954.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,1965.81,,,1965.81,Other,New York Medicaid APG methodology,1965.81,,,1965.81,Other,100% New York Medicaid APG,1965.81,,,1965.81,Other,100% New York Medicaid APG,1965.81,,,1965.81,Other,100% New York Medicaid APG,4423.06,,,4423.06,Other,225% New York Medicaid APG,4423.06,,,4423.06,Other,225% New York Medicaid APG,4423.06,,,4423.06,Other,225% New York Medicaid APG,4423.06,,,4423.06,Other,225% New York Medicaid APG,2752.13,,,2752.13,Other,140% New York Medicaid APG,4423.06,,,4423.06,Other,225% New York Medicaid APG,5111.1,,,5111.1,Other,260% New York Medicaid APG,6369.21,,,6369.21,Other,324% New York Medicaid APG,4226.48,,,4226.48,Other,215% New York Medicaid APG,4226.48,,,4226.48,Other,215% New York Medicaid APG,2457.26,,,2457.26,Other,125% New York Medicaid APG,1965.81,84954.99,
Treat ectopic pregnancy,59151,CPT,,,,,,,,both,,,121364.27,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,60682.14,50,,60682.14,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3656.4,,,3656.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84954.99,70,,84954.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,1965.81,,,1965.81,Other,New York Medicaid APG methodology,1965.81,,,1965.81,Other,100% New York Medicaid APG,1965.81,,,1965.81,Other,100% New York Medicaid APG,1965.81,,,1965.81,Other,100% New York Medicaid APG,4423.06,,,4423.06,Other,225% New York Medicaid APG,4423.06,,,4423.06,Other,225% New York Medicaid APG,4423.06,,,4423.06,Other,225% New York Medicaid APG,4423.06,,,4423.06,Other,225% New York Medicaid APG,2752.13,,,2752.13,Other,140% New York Medicaid APG,4423.06,,,4423.06,Other,225% New York Medicaid APG,5111.1,,,5111.1,Other,260% New York Medicaid APG,6369.21,,,6369.21,Other,324% New York Medicaid APG,4226.48,,,4226.48,Other,215% New York Medicaid APG,4226.48,,,4226.48,Other,215% New York Medicaid APG,2457.26,,,2457.26,Other,125% New York Medicaid APG,1965.81,84954.99,
D & c after delivery,59160,CPT,,,,,,,,both,,,38362.92,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19181.46,50,,19181.46,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2416.17,,,2416.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26854.04,70,,26854.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1299.02,,,1299.02,Other,New York Medicaid APG methodology,1299.02,,,1299.02,Other,100% New York Medicaid APG,1299.02,,,1299.02,Other,100% New York Medicaid APG,1299.02,,,1299.02,Other,100% New York Medicaid APG,2922.79,,,2922.79,Other,225% New York Medicaid APG,2922.79,,,2922.79,Other,225% New York Medicaid APG,2922.79,,,2922.79,Other,225% New York Medicaid APG,2922.79,,,2922.79,Other,225% New York Medicaid APG,1818.62,,,1818.62,Other,140% New York Medicaid APG,2922.79,,,2922.79,Other,225% New York Medicaid APG,3377.45,,,3377.45,Other,260% New York Medicaid APG,4208.82,,,4208.82,Other,324% New York Medicaid APG,2792.89,,,2792.89,Other,215% New York Medicaid APG,2792.89,,,2792.89,Other,215% New York Medicaid APG,1623.77,,,1623.77,Other,125% New York Medicaid APG,1299.02,26854.04,
Insert cervical dilator,59200,CPT,,,,,,,,both,,,38886.96,610.06,,,610.06,Other,150% of Medicare + 9.63% HCRA Surcharge,370.98,,,370.98,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,19443.48,50,,19443.48,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1835.13,,,1835.13,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27220.87,70,,27220.87,percent of total billed charges,,217.8,,,217.8,Fee Schedule,,184.8,,,184.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,986.63,,,986.63,Other,New York Medicaid APG methodology,986.63,,,986.63,Other,100% New York Medicaid APG,986.63,,,986.63,Other,100% New York Medicaid APG,986.63,,,986.63,Other,100% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,1381.28,,,1381.28,Other,140% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,2565.24,,,2565.24,Other,260% New York Medicaid APG,3196.68,,,3196.68,Other,324% New York Medicaid APG,2121.26,,,2121.26,Other,215% New York Medicaid APG,2121.26,,,2121.26,Other,215% New York Medicaid APG,1233.29,,,1233.29,Other,125% New York Medicaid APG,184.8,27220.87,
Episiotomy or vaginal repair,59300,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2416.17,,,2416.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1299.02,,,1299.02,Other,New York Medicaid APG methodology,1299.02,,,1299.02,Other,100% New York Medicaid APG,1299.02,,,1299.02,Other,100% New York Medicaid APG,1299.02,,,1299.02,Other,100% New York Medicaid APG,2922.79,,,2922.79,Other,225% New York Medicaid APG,2922.79,,,2922.79,Other,225% New York Medicaid APG,2922.79,,,2922.79,Other,225% New York Medicaid APG,2922.79,,,2922.79,Other,225% New York Medicaid APG,1818.62,,,1818.62,Other,140% New York Medicaid APG,2922.79,,,2922.79,Other,225% New York Medicaid APG,3377.45,,,3377.45,Other,260% New York Medicaid APG,4208.82,,,4208.82,Other,324% New York Medicaid APG,2792.89,,,2792.89,Other,215% New York Medicaid APG,2792.89,,,2792.89,Other,215% New York Medicaid APG,1623.77,,,1623.77,Other,125% New York Medicaid APG,1299.02,46031.33,
Revision of cervix,59320,CPT,,,,,,,,both,,,36825.48,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18412.74,50,,18412.74,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2416.17,,,2416.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25777.84,70,,25777.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1299.02,,,1299.02,Other,New York Medicaid APG methodology,1299.02,,,1299.02,Other,100% New York Medicaid APG,1299.02,,,1299.02,Other,100% New York Medicaid APG,1299.02,,,1299.02,Other,100% New York Medicaid APG,2922.79,,,2922.79,Other,225% New York Medicaid APG,2922.79,,,2922.79,Other,225% New York Medicaid APG,2922.79,,,2922.79,Other,225% New York Medicaid APG,2922.79,,,2922.79,Other,225% New York Medicaid APG,1818.62,,,1818.62,Other,140% New York Medicaid APG,2922.79,,,2922.79,Other,225% New York Medicaid APG,3377.45,,,3377.45,Other,260% New York Medicaid APG,4208.82,,,4208.82,Other,324% New York Medicaid APG,2792.89,,,2792.89,Other,215% New York Medicaid APG,2792.89,,,2792.89,Other,215% New York Medicaid APG,1623.77,,,1623.77,Other,125% New York Medicaid APG,1299.02,25777.84,
Obstetrical care,59409,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,39455.42,60,,39455.42,percent of total billed charges,,36825.06,56,,36825.06,percent of total billed charges,,35509.88,54,,35509.88,percent of total billed charges,,32879.52,50,,32879.52,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4484.21,,,4484.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2410.87,,,2410.87,Other,New York Medicaid APG methodology,2410.87,,,2410.87,Other,100% New York Medicaid APG,2410.87,,,2410.87,Other,100% New York Medicaid APG,2410.87,,,2410.87,Other,100% New York Medicaid APG,5424.45,,,5424.45,Other,225% New York Medicaid APG,5424.45,,,5424.45,Other,225% New York Medicaid APG,5424.45,,,5424.45,Other,225% New York Medicaid APG,5424.45,,,5424.45,Other,225% New York Medicaid APG,3375.21,,,3375.21,Other,140% New York Medicaid APG,5424.45,,,5424.45,Other,225% New York Medicaid APG,6268.25,,,6268.25,Other,260% New York Medicaid APG,7811.2,,,7811.2,Other,324% New York Medicaid APG,5183.36,,,5183.36,Other,215% New York Medicaid APG,5183.36,,,5183.36,Other,215% New York Medicaid APG,3013.58,,,3013.58,Other,125% New York Medicaid APG,2410.87,46031.33,
Antepartum manipulation,59412,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1835.13,,,1835.13,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,506.55,,,506.55,Fee Schedule,,429.8,,,429.8,Fee Schedule,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,986.63,,,986.63,Other,New York Medicaid APG methodology,986.63,,,986.63,Other,100% New York Medicaid APG,986.63,,,986.63,Other,100% New York Medicaid APG,986.63,,,986.63,Other,100% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,1381.28,,,1381.28,Other,140% New York Medicaid APG,2219.92,,,2219.92,Other,225% New York Medicaid APG,2565.24,,,2565.24,Other,260% New York Medicaid APG,3196.68,,,3196.68,Other,324% New York Medicaid APG,2121.26,,,2121.26,Other,215% New York Medicaid APG,2121.26,,,2121.26,Other,215% New York Medicaid APG,1233.29,,,1233.29,Other,125% New York Medicaid APG,429.8,46031.33,
Deliver placenta,59414,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,39455.42,60,,39455.42,percent of total billed charges,,36825.06,56,,36825.06,percent of total billed charges,,35509.88,54,,35509.88,percent of total billed charges,,32879.52,50,,32879.52,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2416.17,,,2416.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,447.15,,,447.15,Fee Schedule,,379.4,,,379.4,Fee Schedule,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1299.02,,,1299.02,Other,New York Medicaid APG methodology,1299.02,,,1299.02,Other,100% New York Medicaid APG,1299.02,,,1299.02,Other,100% New York Medicaid APG,1299.02,,,1299.02,Other,100% New York Medicaid APG,2922.79,,,2922.79,Other,225% New York Medicaid APG,2922.79,,,2922.79,Other,225% New York Medicaid APG,2922.79,,,2922.79,Other,225% New York Medicaid APG,2922.79,,,2922.79,Other,225% New York Medicaid APG,1818.62,,,1818.62,Other,140% New York Medicaid APG,2922.79,,,2922.79,Other,225% New York Medicaid APG,3377.45,,,3377.45,Other,260% New York Medicaid APG,4208.82,,,4208.82,Other,324% New York Medicaid APG,2792.89,,,2792.89,Other,215% New York Medicaid APG,2792.89,,,2792.89,Other,215% New York Medicaid APG,1623.77,,,1623.77,Other,125% New York Medicaid APG,379.4,46031.33,
Vbac delivery only,59612,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,39455.42,60,,39455.42,percent of total billed charges,,36825.06,56,,36825.06,percent of total billed charges,,35509.88,54,,35509.88,percent of total billed charges,,32879.52,50,,32879.52,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4484.21,,,4484.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2410.87,,,2410.87,Other,New York Medicaid APG methodology,2410.87,,,2410.87,Other,100% New York Medicaid APG,2410.87,,,2410.87,Other,100% New York Medicaid APG,2410.87,,,2410.87,Other,100% New York Medicaid APG,5424.45,,,5424.45,Other,225% New York Medicaid APG,5424.45,,,5424.45,Other,225% New York Medicaid APG,5424.45,,,5424.45,Other,225% New York Medicaid APG,5424.45,,,5424.45,Other,225% New York Medicaid APG,3375.21,,,3375.21,Other,140% New York Medicaid APG,5424.45,,,5424.45,Other,225% New York Medicaid APG,6268.25,,,6268.25,Other,260% New York Medicaid APG,7811.2,,,7811.2,Other,324% New York Medicaid APG,5183.36,,,5183.36,Other,215% New York Medicaid APG,5183.36,,,5183.36,Other,215% New York Medicaid APG,3013.58,,,3013.58,Other,125% New York Medicaid APG,2410.87,46031.33,
Treatment of miscarriage,59812,CPT,,,,,,,,both,,,40386.74,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20193.37,50,,20193.37,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1838.27,,,1838.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28270.72,70,,28270.72,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,988.32,,,988.32,Other,New York Medicaid APG methodology,988.32,,,988.32,Other,100% New York Medicaid APG,988.32,,,988.32,Other,100% New York Medicaid APG,988.32,,,988.32,Other,100% New York Medicaid APG,2223.72,,,2223.72,Other,225% New York Medicaid APG,2223.72,,,2223.72,Other,225% New York Medicaid APG,2223.72,,,2223.72,Other,225% New York Medicaid APG,2223.72,,,2223.72,Other,225% New York Medicaid APG,1383.65,,,1383.65,Other,140% New York Medicaid APG,2223.72,,,2223.72,Other,225% New York Medicaid APG,2569.63,,,2569.63,Other,260% New York Medicaid APG,3202.16,,,3202.16,Other,324% New York Medicaid APG,2124.89,,,2124.89,Other,215% New York Medicaid APG,2124.89,,,2124.89,Other,215% New York Medicaid APG,1235.4,,,1235.4,Other,125% New York Medicaid APG,988.32,28270.72,
Care of miscarriage,59820,CPT,,,,,,,,both,,,39754.42,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19877.21,50,,19877.21,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1838.27,,,1838.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27828.09,70,,27828.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,988.32,,,988.32,Other,New York Medicaid APG methodology,988.32,,,988.32,Other,100% New York Medicaid APG,988.32,,,988.32,Other,100% New York Medicaid APG,988.32,,,988.32,Other,100% New York Medicaid APG,2223.72,,,2223.72,Other,225% New York Medicaid APG,2223.72,,,2223.72,Other,225% New York Medicaid APG,2223.72,,,2223.72,Other,225% New York Medicaid APG,2223.72,,,2223.72,Other,225% New York Medicaid APG,1383.65,,,1383.65,Other,140% New York Medicaid APG,2223.72,,,2223.72,Other,225% New York Medicaid APG,2569.63,,,2569.63,Other,260% New York Medicaid APG,3202.16,,,3202.16,Other,324% New York Medicaid APG,2124.89,,,2124.89,Other,215% New York Medicaid APG,2124.89,,,2124.89,Other,215% New York Medicaid APG,1235.4,,,1235.4,Other,125% New York Medicaid APG,988.32,27828.09,
Treatment of miscarriage,59821,CPT,,,,,,,,both,,,40901.98,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20450.99,50,,20450.99,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1838.27,,,1838.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28631.39,70,,28631.39,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,988.32,,,988.32,Other,New York Medicaid APG methodology,988.32,,,988.32,Other,100% New York Medicaid APG,988.32,,,988.32,Other,100% New York Medicaid APG,988.32,,,988.32,Other,100% New York Medicaid APG,2223.72,,,2223.72,Other,225% New York Medicaid APG,2223.72,,,2223.72,Other,225% New York Medicaid APG,2223.72,,,2223.72,Other,225% New York Medicaid APG,2223.72,,,2223.72,Other,225% New York Medicaid APG,1383.65,,,1383.65,Other,140% New York Medicaid APG,2223.72,,,2223.72,Other,225% New York Medicaid APG,2569.63,,,2569.63,Other,260% New York Medicaid APG,3202.16,,,3202.16,Other,324% New York Medicaid APG,2124.89,,,2124.89,Other,215% New York Medicaid APG,2124.89,,,2124.89,Other,215% New York Medicaid APG,1235.4,,,1235.4,Other,125% New York Medicaid APG,988.32,28631.39,
Abortion,59840,CPT,,,,,,,,both,,,37030.15,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18515.08,50,,18515.08,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1838.27,,,1838.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25921.11,70,,25921.11,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,988.32,,,988.32,Other,New York Medicaid APG methodology,988.32,,,988.32,Other,100% New York Medicaid APG,988.32,,,988.32,Other,100% New York Medicaid APG,988.32,,,988.32,Other,100% New York Medicaid APG,2223.72,,,2223.72,Other,225% New York Medicaid APG,2223.72,,,2223.72,Other,225% New York Medicaid APG,2223.72,,,2223.72,Other,225% New York Medicaid APG,2223.72,,,2223.72,Other,225% New York Medicaid APG,1383.65,,,1383.65,Other,140% New York Medicaid APG,2223.72,,,2223.72,Other,225% New York Medicaid APG,2569.63,,,2569.63,Other,260% New York Medicaid APG,3202.16,,,3202.16,Other,324% New York Medicaid APG,2124.89,,,2124.89,Other,215% New York Medicaid APG,2124.89,,,2124.89,Other,215% New York Medicaid APG,1235.4,,,1235.4,Other,125% New York Medicaid APG,988.32,25921.11,
Abortion,59841,CPT,,,,,,,,both,,,38231,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19115.5,50,,19115.5,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1838.27,,,1838.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26761.7,70,,26761.7,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,988.32,,,988.32,Other,New York Medicaid APG methodology,988.32,,,988.32,Other,100% New York Medicaid APG,988.32,,,988.32,Other,100% New York Medicaid APG,988.32,,,988.32,Other,100% New York Medicaid APG,2223.72,,,2223.72,Other,225% New York Medicaid APG,2223.72,,,2223.72,Other,225% New York Medicaid APG,2223.72,,,2223.72,Other,225% New York Medicaid APG,2223.72,,,2223.72,Other,225% New York Medicaid APG,1383.65,,,1383.65,Other,140% New York Medicaid APG,2223.72,,,2223.72,Other,225% New York Medicaid APG,2569.63,,,2569.63,Other,260% New York Medicaid APG,3202.16,,,3202.16,Other,324% New York Medicaid APG,2124.89,,,2124.89,Other,215% New York Medicaid APG,2124.89,,,2124.89,Other,215% New York Medicaid APG,1235.4,,,1235.4,Other,125% New York Medicaid APG,988.32,26761.7,
Abortion (mpr),59866,CPT,,,,,,,,both,,,6747.72,610.06,,,610.06,Other,150% of Medicare + 9.63% HCRA Surcharge,370.98,,,370.98,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3373.86,50,,3373.86,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1838.27,,,1838.27,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4723.4,70,,4723.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,988.32,,,988.32,Other,New York Medicaid APG methodology,988.32,,,988.32,Other,100% New York Medicaid APG,988.32,,,988.32,Other,100% New York Medicaid APG,988.32,,,988.32,Other,100% New York Medicaid APG,2223.72,,,2223.72,Other,225% New York Medicaid APG,2223.72,,,2223.72,Other,225% New York Medicaid APG,2223.72,,,2223.72,Other,225% New York Medicaid APG,2223.72,,,2223.72,Other,225% New York Medicaid APG,1383.65,,,1383.65,Other,140% New York Medicaid APG,2223.72,,,2223.72,Other,225% New York Medicaid APG,2569.63,,,2569.63,Other,260% New York Medicaid APG,3202.16,,,3202.16,Other,324% New York Medicaid APG,2124.89,,,2124.89,Other,215% New York Medicaid APG,2124.89,,,2124.89,Other,215% New York Medicaid APG,1235.4,,,1235.4,Other,125% New York Medicaid APG,370.98,13157,
Evacuate mole of uterus,59870,CPT,,,,,,,,both,,,41359.84,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20679.92,50,,20679.92,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3656.4,,,3656.4,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28951.89,70,,28951.89,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1965.81,,,1965.81,Other,New York Medicaid APG methodology,1965.81,,,1965.81,Other,100% New York Medicaid APG,1965.81,,,1965.81,Other,100% New York Medicaid APG,1965.81,,,1965.81,Other,100% New York Medicaid APG,4423.06,,,4423.06,Other,225% New York Medicaid APG,4423.06,,,4423.06,Other,225% New York Medicaid APG,4423.06,,,4423.06,Other,225% New York Medicaid APG,4423.06,,,4423.06,Other,225% New York Medicaid APG,2752.13,,,2752.13,Other,140% New York Medicaid APG,4423.06,,,4423.06,Other,225% New York Medicaid APG,5111.1,,,5111.1,Other,260% New York Medicaid APG,6369.21,,,6369.21,Other,324% New York Medicaid APG,4226.48,,,4226.48,Other,215% New York Medicaid APG,4226.48,,,4226.48,Other,215% New York Medicaid APG,2457.26,,,2457.26,Other,125% New York Medicaid APG,1965.81,28951.89,
Remove cerclage suture,59871,CPT,,,,,,,,both,,,65759.04,5945.23,,,5945.23,Other,150% of Medicare + 9.63% HCRA Surcharge,3615.33,,,3615.33,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32879.52,50,,32879.52,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2416.17,,,2416.17,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46031.33,70,,46031.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1299.02,,,1299.02,Other,New York Medicaid APG methodology,1299.02,,,1299.02,Other,100% New York Medicaid APG,1299.02,,,1299.02,Other,100% New York Medicaid APG,1299.02,,,1299.02,Other,100% New York Medicaid APG,2922.79,,,2922.79,Other,225% New York Medicaid APG,2922.79,,,2922.79,Other,225% New York Medicaid APG,2922.79,,,2922.79,Other,225% New York Medicaid APG,2922.79,,,2922.79,Other,225% New York Medicaid APG,1818.62,,,1818.62,Other,140% New York Medicaid APG,2922.79,,,2922.79,Other,225% New York Medicaid APG,3377.45,,,3377.45,Other,260% New York Medicaid APG,4208.82,,,4208.82,Other,324% New York Medicaid APG,2792.89,,,2792.89,Other,215% New York Medicaid APG,2792.89,,,2792.89,Other,215% New York Medicaid APG,1623.77,,,1623.77,Other,125% New York Medicaid APG,1299.02,46031.33,
Drain thyroid/tongue cyst,60000,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,1545.56,22454.17,
Biopsy of thyroid,60100,CPT,,,,,,,,both,,,17214.5,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,8607.25,50,,8607.25,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1296.67,,,1296.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,12050.15,70,,12050.15,percent of total billed charges,,376.2,,,376.2,Fee Schedule,,319.2,,,319.2,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,697.14,,,697.14,Other,New York Medicaid APG methodology,697.14,,,697.14,Other,100% New York Medicaid APG,697.14,,,697.14,Other,100% New York Medicaid APG,697.14,,,697.14,Other,100% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,975.99,,,975.99,Other,140% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1812.56,,,1812.56,Other,260% New York Medicaid APG,2258.72,,,2258.72,Other,324% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,871.42,,,871.42,Other,125% New York Medicaid APG,319.2,12050.15,
Remove thyroid lesion,60200,CPT,,,,,,,,both,,,39149.27,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,19574.64,50,,19574.64,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6453.63,,,6453.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27404.49,70,,27404.49,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3469.7,,,3469.7,Other,New York Medicaid APG methodology,3469.7,,,3469.7,Other,100% New York Medicaid APG,3469.7,,,3469.7,Other,100% New York Medicaid APG,3469.7,,,3469.7,Other,100% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,4857.57,,,4857.57,Other,140% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,9021.21,,,9021.21,Other,260% New York Medicaid APG,11241.81,,,11241.81,Other,324% New York Medicaid APG,7459.84,,,7459.84,Other,215% New York Medicaid APG,7459.84,,,7459.84,Other,215% New York Medicaid APG,4337.12,,,4337.12,Other,125% New York Medicaid APG,3469.7,27404.49,
Partial thyroid excision,60210,CPT,,,,,,,,both,,,47061.73,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,23530.87,50,,23530.87,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6453.63,,,6453.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,32943.21,70,,32943.21,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3469.7,,,3469.7,Other,New York Medicaid APG methodology,3469.7,,,3469.7,Other,100% New York Medicaid APG,3469.7,,,3469.7,Other,100% New York Medicaid APG,3469.7,,,3469.7,Other,100% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,4857.57,,,4857.57,Other,140% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,9021.21,,,9021.21,Other,260% New York Medicaid APG,11241.81,,,11241.81,Other,324% New York Medicaid APG,7459.84,,,7459.84,Other,215% New York Medicaid APG,7459.84,,,7459.84,Other,215% New York Medicaid APG,4337.12,,,4337.12,Other,125% New York Medicaid APG,3469.7,32943.21,
Partial thyroid excision,60212,CPT,,,,,,,,both,,,121364.27,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,60682.14,50,,60682.14,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6453.63,,,6453.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84954.99,70,,84954.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3469.7,,,3469.7,Other,New York Medicaid APG methodology,3469.7,,,3469.7,Other,100% New York Medicaid APG,3469.7,,,3469.7,Other,100% New York Medicaid APG,3469.7,,,3469.7,Other,100% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,4857.57,,,4857.57,Other,140% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,9021.21,,,9021.21,Other,260% New York Medicaid APG,11241.81,,,11241.81,Other,324% New York Medicaid APG,7459.84,,,7459.84,Other,215% New York Medicaid APG,7459.84,,,7459.84,Other,215% New York Medicaid APG,4337.12,,,4337.12,Other,125% New York Medicaid APG,3469.7,84954.99,
Partial removal of thyroid,60220,CPT,,,,,,,,both,,,46869.66,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,23434.83,50,,23434.83,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6453.63,,,6453.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,32808.76,70,,32808.76,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3469.7,,,3469.7,Other,New York Medicaid APG methodology,3469.7,,,3469.7,Other,100% New York Medicaid APG,3469.7,,,3469.7,Other,100% New York Medicaid APG,3469.7,,,3469.7,Other,100% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,4857.57,,,4857.57,Other,140% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,9021.21,,,9021.21,Other,260% New York Medicaid APG,11241.81,,,11241.81,Other,324% New York Medicaid APG,7459.84,,,7459.84,Other,215% New York Medicaid APG,7459.84,,,7459.84,Other,215% New York Medicaid APG,4337.12,,,4337.12,Other,125% New York Medicaid APG,3469.7,32808.76,
Partial removal of thyroid,60225,CPT,,,,,,,,both,,,121364.27,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,60682.14,50,,60682.14,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6453.63,,,6453.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84954.99,70,,84954.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3469.7,,,3469.7,Other,New York Medicaid APG methodology,3469.7,,,3469.7,Other,100% New York Medicaid APG,3469.7,,,3469.7,Other,100% New York Medicaid APG,3469.7,,,3469.7,Other,100% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,4857.57,,,4857.57,Other,140% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,9021.21,,,9021.21,Other,260% New York Medicaid APG,11241.81,,,11241.81,Other,324% New York Medicaid APG,7459.84,,,7459.84,Other,215% New York Medicaid APG,7459.84,,,7459.84,Other,215% New York Medicaid APG,4337.12,,,4337.12,Other,125% New York Medicaid APG,3469.7,84954.99,
Removal of thyroid,60240,CPT,,,,,,,,both,,,52929.92,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,26464.96,50,,26464.96,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6453.63,,,6453.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,37050.94,70,,37050.94,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3469.7,,,3469.7,Other,New York Medicaid APG methodology,3469.7,,,3469.7,Other,100% New York Medicaid APG,3469.7,,,3469.7,Other,100% New York Medicaid APG,3469.7,,,3469.7,Other,100% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,4857.57,,,4857.57,Other,140% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,9021.21,,,9021.21,Other,260% New York Medicaid APG,11241.81,,,11241.81,Other,324% New York Medicaid APG,7459.84,,,7459.84,Other,215% New York Medicaid APG,7459.84,,,7459.84,Other,215% New York Medicaid APG,4337.12,,,4337.12,Other,125% New York Medicaid APG,3469.7,37050.94,
Removal of thyroid,60252,CPT,,,,,,,,both,,,71608.73,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,35804.37,50,,35804.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6453.63,,,6453.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50126.11,70,,50126.11,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3469.7,,,3469.7,Other,New York Medicaid APG methodology,3469.7,,,3469.7,Other,100% New York Medicaid APG,3469.7,,,3469.7,Other,100% New York Medicaid APG,3469.7,,,3469.7,Other,100% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,4857.57,,,4857.57,Other,140% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,9021.21,,,9021.21,Other,260% New York Medicaid APG,11241.81,,,11241.81,Other,324% New York Medicaid APG,7459.84,,,7459.84,Other,215% New York Medicaid APG,7459.84,,,7459.84,Other,215% New York Medicaid APG,4337.12,,,4337.12,Other,125% New York Medicaid APG,3469.7,50126.11,
Repeat thyroid surgery,60260,CPT,,,,,,,,both,,,51516.16,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,25758.08,50,,25758.08,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6453.63,,,6453.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36061.31,70,,36061.31,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3469.7,,,3469.7,Other,New York Medicaid APG methodology,3469.7,,,3469.7,Other,100% New York Medicaid APG,3469.7,,,3469.7,Other,100% New York Medicaid APG,3469.7,,,3469.7,Other,100% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,4857.57,,,4857.57,Other,140% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,9021.21,,,9021.21,Other,260% New York Medicaid APG,11241.81,,,11241.81,Other,324% New York Medicaid APG,7459.84,,,7459.84,Other,215% New York Medicaid APG,7459.84,,,7459.84,Other,215% New York Medicaid APG,4337.12,,,4337.12,Other,125% New York Medicaid APG,3469.7,36061.31,
Removal of thyroid,60271,CPT,,,,,,,,both,,,60382.91,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,30191.46,50,,30191.46,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6453.63,,,6453.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,42268.04,70,,42268.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3469.7,,,3469.7,Other,New York Medicaid APG methodology,3469.7,,,3469.7,Other,100% New York Medicaid APG,3469.7,,,3469.7,Other,100% New York Medicaid APG,3469.7,,,3469.7,Other,100% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,4857.57,,,4857.57,Other,140% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,9021.21,,,9021.21,Other,260% New York Medicaid APG,11241.81,,,11241.81,Other,324% New York Medicaid APG,7459.84,,,7459.84,Other,215% New York Medicaid APG,7459.84,,,7459.84,Other,215% New York Medicaid APG,4337.12,,,4337.12,Other,125% New York Medicaid APG,3469.7,42268.04,
Remove thyroid duct lesion,60280,CPT,,,,,,,,both,,,35344.62,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,17672.31,50,,17672.31,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6453.63,,,6453.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24741.23,70,,24741.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3469.7,,,3469.7,Other,New York Medicaid APG methodology,3469.7,,,3469.7,Other,100% New York Medicaid APG,3469.7,,,3469.7,Other,100% New York Medicaid APG,3469.7,,,3469.7,Other,100% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,4857.57,,,4857.57,Other,140% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,9021.21,,,9021.21,Other,260% New York Medicaid APG,11241.81,,,11241.81,Other,324% New York Medicaid APG,7459.84,,,7459.84,Other,215% New York Medicaid APG,7459.84,,,7459.84,Other,215% New York Medicaid APG,4337.12,,,4337.12,Other,125% New York Medicaid APG,3469.7,24741.23,
Remove thyroid duct lesion,60281,CPT,,,,,,,,both,,,68111.61,10972.47,,,10972.47,Other,150% of Medicare + 9.63% HCRA Surcharge,6672.42,,,6672.42,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,34055.81,50,,34055.81,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6453.63,,,6453.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47678.13,70,,47678.13,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3469.7,,,3469.7,Other,New York Medicaid APG methodology,3469.7,,,3469.7,Other,100% New York Medicaid APG,3469.7,,,3469.7,Other,100% New York Medicaid APG,3469.7,,,3469.7,Other,100% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,4857.57,,,4857.57,Other,140% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,9021.21,,,9021.21,Other,260% New York Medicaid APG,11241.81,,,11241.81,Other,324% New York Medicaid APG,7459.84,,,7459.84,Other,215% New York Medicaid APG,7459.84,,,7459.84,Other,215% New York Medicaid APG,4337.12,,,4337.12,Other,125% New York Medicaid APG,3469.7,47678.13,
Aspir/inj thyroid cyst,60300,CPT,,,,,,,,both,,,14798.8,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7399.4,50,,7399.4,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1296.67,,,1296.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10359.16,70,,10359.16,percent of total billed charges,,235.95,,,235.95,Fee Schedule,,200.2,,,200.2,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,697.14,,,697.14,Other,New York Medicaid APG methodology,697.14,,,697.14,Other,100% New York Medicaid APG,697.14,,,697.14,Other,100% New York Medicaid APG,697.14,,,697.14,Other,100% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,975.99,,,975.99,Other,140% New York Medicaid APG,1568.56,,,1568.56,Other,225% New York Medicaid APG,1812.56,,,1812.56,Other,260% New York Medicaid APG,2258.72,,,2258.72,Other,324% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,1498.84,,,1498.84,Other,215% New York Medicaid APG,871.42,,,871.42,Other,125% New York Medicaid APG,0.01,10359.16,
Explore parathyroid glands,60500,CPT,,,,,,,,both,,,51334.91,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,25667.46,50,,25667.46,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6453.63,,,6453.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,35934.44,70,,35934.44,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3469.7,,,3469.7,Other,New York Medicaid APG methodology,3469.7,,,3469.7,Other,100% New York Medicaid APG,3469.7,,,3469.7,Other,100% New York Medicaid APG,3469.7,,,3469.7,Other,100% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,4857.57,,,4857.57,Other,140% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,9021.21,,,9021.21,Other,260% New York Medicaid APG,11241.81,,,11241.81,Other,324% New York Medicaid APG,7459.84,,,7459.84,Other,215% New York Medicaid APG,7459.84,,,7459.84,Other,215% New York Medicaid APG,4337.12,,,4337.12,Other,125% New York Medicaid APG,3469.7,35934.44,
Re-explore parathyroids,60502,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6453.63,,,6453.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3469.7,,,3469.7,Other,New York Medicaid APG methodology,3469.7,,,3469.7,Other,100% New York Medicaid APG,3469.7,,,3469.7,Other,100% New York Medicaid APG,3469.7,,,3469.7,Other,100% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,4857.57,,,4857.57,Other,140% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,9021.21,,,9021.21,Other,260% New York Medicaid APG,11241.81,,,11241.81,Other,324% New York Medicaid APG,7459.84,,,7459.84,Other,215% New York Medicaid APG,7459.84,,,7459.84,Other,215% New York Medicaid APG,4337.12,,,4337.12,Other,125% New York Medicaid APG,3469.7,86224,
Autotransplant parathyroid,60512,CPT,,,,,,,,both,,,83504,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,41752,50,,41752,percent of total billed charges,,58452.8,70,,58452.8,percent of total billed charges,,6152,,,6152,Case Rate,,6453.63,,,6453.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,58452.8,70,,58452.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,3469.7,,,3469.7,Other,New York Medicaid APG methodology,3469.7,,,3469.7,Other,100% New York Medicaid APG,3469.7,,,3469.7,Other,100% New York Medicaid APG,3469.7,,,3469.7,Other,100% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,4857.57,,,4857.57,Other,140% New York Medicaid APG,7806.81,,,7806.81,Other,225% New York Medicaid APG,9021.21,,,9021.21,Other,260% New York Medicaid APG,11241.81,,,11241.81,Other,324% New York Medicaid APG,7459.84,,,7459.84,Other,215% New York Medicaid APG,7459.84,,,7459.84,Other,215% New York Medicaid APG,4337.12,,,4337.12,Other,125% New York Medicaid APG,0.01,58452.8,
Removal of thymus gland,60520,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5192.2,,,5192.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2791.5,,,2791.5,Other,New York Medicaid APG methodology,2791.5,,,2791.5,Other,100% New York Medicaid APG,2791.5,,,2791.5,Other,100% New York Medicaid APG,2791.5,,,2791.5,Other,100% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,3908.1,,,3908.1,Other,140% New York Medicaid APG,6280.88,,,6280.88,Other,225% New York Medicaid APG,7257.91,,,7257.91,Other,260% New York Medicaid APG,9044.47,,,9044.47,Other,324% New York Medicaid APG,6001.73,,,6001.73,Other,215% New York Medicaid APG,6001.73,,,6001.73,Other,215% New York Medicaid APG,3489.38,,,3489.38,Other,125% New York Medicaid APG,2791.5,86224,
Remove cranial cavity fluid,61000,CPT,,,,,,,,both,,,14545.81,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7272.91,50,,7272.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10182.07,70,,10182.07,percent of total billed charges,,562.65,,,562.65,Fee Schedule,,477.4,,,477.4,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,477.4,10182.07,
Remove cranial cavity fluid,61001,CPT,,,,,,,,both,,,14545.81,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7272.91,50,,7272.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10182.07,70,,10182.07,percent of total billed charges,,531.3,,,531.3,Fee Schedule,,450.8,,,450.8,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,450.8,10182.07,
Remove brain cavity fluid,61020,CPT,,,,,,,,both,,,19171.82,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9585.91,50,,9585.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1403.21,,,1403.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13420.27,70,,13420.27,percent of total billed charges,,524.7,,,524.7,Fee Schedule,,445.2,,,445.2,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,754.41,,,754.41,Other,New York Medicaid APG methodology,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1056.18,,,1056.18,Other,140% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1961.47,,,1961.47,Other,260% New York Medicaid APG,2444.29,,,2444.29,Other,324% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,943.01,,,943.01,Other,125% New York Medicaid APG,445.2,13420.27,
Injection into brain canal,61026,CPT,,,,,,,,both,,,14545.81,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7272.91,50,,7272.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1403.21,,,1403.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10182.07,70,,10182.07,percent of total billed charges,,526.35,,,526.35,Fee Schedule,,446.6,,,446.6,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,754.41,,,754.41,Other,New York Medicaid APG methodology,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1056.18,,,1056.18,Other,140% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1961.47,,,1961.47,Other,260% New York Medicaid APG,2444.29,,,2444.29,Other,324% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,943.01,,,943.01,Other,125% New York Medicaid APG,446.6,10182.07,
Remove brain canal fluid,61050,CPT,,,,,,,,both,,,6229.82,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3114.91,50,,3114.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4360.87,70,,4360.87,percent of total billed charges,,391.05,,,391.05,Fee Schedule,,331.8,,,331.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,331.8,9473,
Injection into brain canal,61055,CPT,,,,,,,,both,,,6229.82,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3114.91,50,,3114.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4360.87,70,,4360.87,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,342.51,13157,
Brain canal shunt procedure,61070,CPT,,,,,,,,both,,,31698,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,15849,50,,15849,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22188.6,70,,22188.6,percent of total billed charges,,277.2,,,277.2,Fee Schedule,,235.2,,,235.2,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,235.2,22188.6,
Insert brain-fluid device,61215,CPT,,,,,,,,both,,,140115.1,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,70057.55,50,,70057.55,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,98080.57,70,,98080.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,98080.57,
Decompress eye socket,61330,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,47404.34,
Endovasc tempory vessel occl,61623,CPT,,,,,,,,both,,,231395.43,20920.32,,,20920.32,Other,150% of Medicare + 9.63% HCRA Surcharge,12721.77,,,12721.77,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,115697.72,50,,115697.72,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5850.68,,,5850.68,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,161976.8,70,,161976.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3145.53,,,3145.53,Other,New York Medicaid APG methodology,3145.53,,,3145.53,Other,100% New York Medicaid APG,3145.53,,,3145.53,Other,100% New York Medicaid APG,3145.53,,,3145.53,Other,100% New York Medicaid APG,7077.43,,,7077.43,Other,225% New York Medicaid APG,7077.43,,,7077.43,Other,225% New York Medicaid APG,7077.43,,,7077.43,Other,225% New York Medicaid APG,7077.43,,,7077.43,Other,225% New York Medicaid APG,4403.74,,,4403.74,Other,140% New York Medicaid APG,7077.43,,,7077.43,Other,225% New York Medicaid APG,8178.37,,,8178.37,Other,260% New York Medicaid APG,10191.51,,,10191.51,Other,324% New York Medicaid APG,6762.88,,,6762.88,Other,215% New York Medicaid APG,6762.88,,,6762.88,Other,215% New York Medicaid APG,3931.91,,,3931.91,Other,125% New York Medicaid APG,3145.53,161976.8,
Transcath occlusion non-cns,61626,CPT,,,,,,,,both,,,231395.43,20920.32,,,20920.32,Other,150% of Medicare + 9.63% HCRA Surcharge,12721.77,,,12721.77,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,115697.72,50,,115697.72,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5850.68,,,5850.68,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,161976.8,70,,161976.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3145.53,,,3145.53,Other,New York Medicaid APG methodology,3145.53,,,3145.53,Other,100% New York Medicaid APG,3145.53,,,3145.53,Other,100% New York Medicaid APG,3145.53,,,3145.53,Other,100% New York Medicaid APG,7077.43,,,7077.43,Other,225% New York Medicaid APG,7077.43,,,7077.43,Other,225% New York Medicaid APG,7077.43,,,7077.43,Other,225% New York Medicaid APG,7077.43,,,7077.43,Other,225% New York Medicaid APG,4403.74,,,4403.74,Other,140% New York Medicaid APG,7077.43,,,7077.43,Other,225% New York Medicaid APG,8178.37,,,8178.37,Other,260% New York Medicaid APG,10191.51,,,10191.51,Other,324% New York Medicaid APG,6762.88,,,6762.88,Other,215% New York Medicaid APG,6762.88,,,6762.88,Other,215% New York Medicaid APG,3931.91,,,3931.91,Other,125% New York Medicaid APG,3145.53,161976.8,
Incise skull/brain surgery,61720,CPT,,,,,,,,both,,,140115.1,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,70057.55,50,,70057.55,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5985.06,,,5985.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,98080.57,70,,98080.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3217.77,,,3217.77,Other,New York Medicaid APG methodology,3217.77,,,3217.77,Other,100% New York Medicaid APG,3217.77,,,3217.77,Other,100% New York Medicaid APG,3217.77,,,3217.77,Other,100% New York Medicaid APG,7239.99,,,7239.99,Other,225% New York Medicaid APG,7239.99,,,7239.99,Other,225% New York Medicaid APG,7239.99,,,7239.99,Other,225% New York Medicaid APG,7239.99,,,7239.99,Other,225% New York Medicaid APG,4504.88,,,4504.88,Other,140% New York Medicaid APG,7239.99,,,7239.99,Other,225% New York Medicaid APG,8366.21,,,8366.21,Other,260% New York Medicaid APG,10425.59,,,10425.59,Other,324% New York Medicaid APG,6918.21,,,6918.21,Other,215% New York Medicaid APG,6918.21,,,6918.21,Other,215% New York Medicaid APG,4022.22,,,4022.22,Other,125% New York Medicaid APG,3217.77,98080.57,
Incise skull for treatment,61770,CPT,,,,,,,,both,,,140115.1,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,70057.55,50,,70057.55,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5985.06,,,5985.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,98080.57,70,,98080.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3217.77,,,3217.77,Other,New York Medicaid APG methodology,3217.77,,,3217.77,Other,100% New York Medicaid APG,3217.77,,,3217.77,Other,100% New York Medicaid APG,3217.77,,,3217.77,Other,100% New York Medicaid APG,7239.99,,,7239.99,Other,225% New York Medicaid APG,7239.99,,,7239.99,Other,225% New York Medicaid APG,7239.99,,,7239.99,Other,225% New York Medicaid APG,7239.99,,,7239.99,Other,225% New York Medicaid APG,4504.88,,,4504.88,Other,140% New York Medicaid APG,7239.99,,,7239.99,Other,225% New York Medicaid APG,8366.21,,,8366.21,Other,260% New York Medicaid APG,10425.59,,,10425.59,Other,324% New York Medicaid APG,6918.21,,,6918.21,Other,215% New York Medicaid APG,6918.21,,,6918.21,Other,215% New York Medicaid APG,4022.22,,,4022.22,Other,125% New York Medicaid APG,3217.77,98080.57,
Scan proc cranial intra,61781,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,36100.43,
Scan proc cranial extra,61782,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,36100.43,
Scan proc spinal,61783,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,0.01,36100.43,
Treat trigeminal nerve,61790,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,28428.05,
Treat trigeminal tract,61791,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,28428.05,
Revise/remove neuroelectrode,61880,CPT,,,,,,,,both,,,71436.43,6470.41,,,6470.41,Other,150% of Medicare + 9.63% HCRA Surcharge,3934.69,,,3934.69,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,35718.22,50,,35718.22,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4340.32,,,4340.32,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50005.5,70,,50005.5,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2333.51,,,2333.51,Other,New York Medicaid APG methodology,2333.51,,,2333.51,Other,100% New York Medicaid APG,2333.51,,,2333.51,Other,100% New York Medicaid APG,2333.51,,,2333.51,Other,100% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,3266.91,,,3266.91,Other,140% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,6067.11,,,6067.11,Other,260% New York Medicaid APG,7560.56,,,7560.56,Other,324% New York Medicaid APG,5017.04,,,5017.04,Other,215% New York Medicaid APG,5017.04,,,5017.04,Other,215% New York Medicaid APG,2916.88,,,2916.88,Other,125% New York Medicaid APG,2333.51,50005.5,
Insrt/redo neurostim 1 array,61885,CPT,,,,,,,,both,,,136359.6,41599.58,,,41599.58,Other,150% of Medicare + 9.63% HCRA Surcharge,25296.95,,,25296.95,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,68179.8,50,,68179.8,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,40570.63,,,40570.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,95451.72,70,,95451.72,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,17798,,"100% primary, 50% secondary, 25% tertiary procedure",17798,Other,United Healthcare ASC Grouper,16018,,"100% primary, 50% secondary, 25% tertiary procedure",16018,Other,United Healthcare ASC Grouper,17798,,"100% primary, 50% secondary, 25% tertiary procedure",17798,Other,United Healthcare ASC Grouper,15129,,"100% primary, 50% secondary, 25% tertiary procedure",15129,Other,United Healthcare ASC Grouper,21812.17,,,21812.17,Other,New York Medicaid APG methodology,21812.17,,,21812.17,Other,100% New York Medicaid APG,21812.17,,,21812.17,Other,100% New York Medicaid APG,21812.17,,,21812.17,Other,100% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,30537.04,,,30537.04,Other,140% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,56711.64,,,56711.64,Other,260% New York Medicaid APG,70671.43,,,70671.43,Other,324% New York Medicaid APG,46896.16,,,46896.16,Other,215% New York Medicaid APG,46896.16,,,46896.16,Other,215% New York Medicaid APG,27265.21,,,27265.21,Other,125% New York Medicaid APG,5261,95451.72,
Implant neurostim arrays,61886,CPT,,,,,,,,both,,,127026.69,59050.36,,,59050.36,Other,150% of Medicare + 9.63% HCRA Surcharge,35908.88,,,35908.88,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,63513.35,50,,63513.35,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,40570.63,,,40570.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,88918.68,70,,88918.68,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,19221,,"100% primary, 50% secondary, 25% tertiary procedure",19221,Other,United Healthcare ASC Grouper,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,18154,,"100% primary, 50% secondary, 25% tertiary procedure",18154,Other,United Healthcare ASC Grouper,21812.17,,,21812.17,Other,New York Medicaid APG methodology,21812.17,,,21812.17,Other,100% New York Medicaid APG,21812.17,,,21812.17,Other,100% New York Medicaid APG,21812.17,,,21812.17,Other,100% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,30537.04,,,30537.04,Other,140% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,56711.64,,,56711.64,Other,260% New York Medicaid APG,70671.43,,,70671.43,Other,324% New York Medicaid APG,46896.16,,,46896.16,Other,215% New York Medicaid APG,46896.16,,,46896.16,Other,215% New York Medicaid APG,27265.21,,,27265.21,Other,125% New York Medicaid APG,5919,88918.68,
Revise/remove neuroreceiver,61888,CPT,,,,,,,,both,,,215576.2,25904.28,,,25904.28,Other,150% of Medicare + 9.63% HCRA Surcharge,15752.55,,,15752.55,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,107788.1,50,,107788.1,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4340.32,,,4340.32,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,150903.34,70,,150903.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2333.51,,,2333.51,Other,New York Medicaid APG methodology,2333.51,,,2333.51,Other,100% New York Medicaid APG,2333.51,,,2333.51,Other,100% New York Medicaid APG,2333.51,,,2333.51,Other,100% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,3266.91,,,3266.91,Other,140% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,6067.11,,,6067.11,Other,260% New York Medicaid APG,7560.56,,,7560.56,Other,324% New York Medicaid APG,5017.04,,,5017.04,Other,215% New York Medicaid APG,5017.04,,,5017.04,Other,215% New York Medicaid APG,2916.88,,,2916.88,Other,125% New York Medicaid APG,2333.51,150903.34,
Treat skull fracture,62000,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5985.06,,,5985.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3217.77,,,3217.77,Other,New York Medicaid APG methodology,3217.77,,,3217.77,Other,100% New York Medicaid APG,3217.77,,,3217.77,Other,100% New York Medicaid APG,3217.77,,,3217.77,Other,100% New York Medicaid APG,7239.99,,,7239.99,Other,225% New York Medicaid APG,7239.99,,,7239.99,Other,225% New York Medicaid APG,7239.99,,,7239.99,Other,225% New York Medicaid APG,7239.99,,,7239.99,Other,225% New York Medicaid APG,4504.88,,,4504.88,Other,140% New York Medicaid APG,7239.99,,,7239.99,Other,225% New York Medicaid APG,8366.21,,,8366.21,Other,260% New York Medicaid APG,10425.59,,,10425.59,Other,324% New York Medicaid APG,6918.21,,,6918.21,Other,215% New York Medicaid APG,6918.21,,,6918.21,Other,215% New York Medicaid APG,4022.22,,,4022.22,Other,125% New York Medicaid APG,3217.77,47404.34,
Neuroendoscopy add-on,62160,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,5985.06,,,5985.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,3217.77,,,3217.77,Other,New York Medicaid APG methodology,3217.77,,,3217.77,Other,100% New York Medicaid APG,3217.77,,,3217.77,Other,100% New York Medicaid APG,3217.77,,,3217.77,Other,100% New York Medicaid APG,7239.99,,,7239.99,Other,225% New York Medicaid APG,7239.99,,,7239.99,Other,225% New York Medicaid APG,7239.99,,,7239.99,Other,225% New York Medicaid APG,7239.99,,,7239.99,Other,225% New York Medicaid APG,4504.88,,,4504.88,Other,140% New York Medicaid APG,7239.99,,,7239.99,Other,225% New York Medicaid APG,8366.21,,,8366.21,Other,260% New York Medicaid APG,10425.59,,,10425.59,Other,324% New York Medicaid APG,6918.21,,,6918.21,Other,215% New York Medicaid APG,6918.21,,,6918.21,Other,215% New York Medicaid APG,4022.22,,,4022.22,Other,125% New York Medicaid APG,0.01,36100.43,
Replace/irrigate catheter,62194,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,751.98,28428.05,
Replace/irrigate catheter,62225,CPT,,,,,,,,both,,,140115.1,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,70057.55,50,,70057.55,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.75,,,7783.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,98080.57,70,,98080.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.74,,,5858.74,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.51,,,10880.51,Other,260% New York Medicaid APG,13558.79,,,13558.79,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,3323,98080.57,
Replace/revise brain shunt,62230,CPT,,,,,,,,both,,,96963.46,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,48481.73,50,,48481.73,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.75,,,7783.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,67874.42,70,,67874.42,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.74,,,5858.74,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.51,,,10880.51,Other,260% New York Medicaid APG,13558.79,,,13558.79,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,4184.81,67874.42,
Csf shunt reprogram,62252,CPT,,,,,,,,both,,,6282.58,568,,,568,Other,150% of Medicare + 9.63% HCRA Surcharge,345.41,,,345.41,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3141.29,50,,3141.29,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,393.03,,,393.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4397.81,70,,4397.81,percent of total billed charges,,3141.29,50,,3141.29,percent of total billed charges,,3141.29,50,,3141.29,percent of total billed charges,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,211.31,,,211.31,Other,New York Medicaid APG methodology,211.31,,,211.31,Other,100% New York Medicaid APG,211.31,,,211.31,Other,100% New York Medicaid APG,211.31,,,211.31,Other,100% New York Medicaid APG,475.44,,,475.44,Other,225% New York Medicaid APG,475.44,,,475.44,Other,225% New York Medicaid APG,475.44,,,475.44,Other,225% New York Medicaid APG,475.44,,,475.44,Other,225% New York Medicaid APG,295.83,,,295.83,Other,140% New York Medicaid APG,475.44,,,475.44,Other,225% New York Medicaid APG,549.4,,,549.4,Other,260% New York Medicaid APG,684.64,,,684.64,Other,324% New York Medicaid APG,454.31,,,454.31,Other,215% New York Medicaid APG,454.31,,,454.31,Other,215% New York Medicaid APG,264.14,,,264.14,Other,125% New York Medicaid APG,211.31,9473,
Epidural lysis mult sessions,62263,CPT,,,,,,,,both,,,19171.82,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9585.91,50,,9585.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13420.27,70,,13420.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,751.98,13420.27,
Epidural lysis on single day,62264,CPT,,,,,,,,both,,,19171.82,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9585.91,50,,9585.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13420.27,70,,13420.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,751.98,13420.27,
Interdiscal perq aspir dx,62267,CPT,,,,,,,,both,,,33788,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16894,50,,16894,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23651.6,70,,23651.6,percent of total billed charges,,750.75,,,750.75,Fee Schedule,,637,,,637,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,637,23651.6,
Drain spinal cord cyst,62268,CPT,,,,,,,,both,,,19171.82,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9585.91,50,,9585.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13420.27,70,,13420.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,751.98,13420.27,
Needle biopsy spinal cord,62269,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,751.98,23871.23,
Dx lmbr spi pnxr,62270,CPT,,,,,,,,both,,,15589.61,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7794.81,50,,7794.81,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10912.73,70,,10912.73,percent of total billed charges,,306.9,,,306.9,Fee Schedule,,260.4,,,260.4,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,260.4,10912.73,
Ther spi pnxr drg csf,62272,CPT,,,,,,,,both,,,402930,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,201465,50,,201465,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,282051,70,,282051,percent of total billed charges,,445.5,,,445.5,Fee Schedule,,378,,,378,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,378,282051,
Inject epidural patch,62273,CPT,,,,,,,,both,,,3306,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1653,50,,1653,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2314.2,70,,2314.2,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,751.98,13157,
Treat spinal cord lesion,62280,CPT,,,,,,,,both,,,19171.82,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9585.91,50,,9585.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13420.27,70,,13420.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,751.98,13420.27,
Treat spinal cord lesion,62281,CPT,,,,,,,,both,,,19171.82,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9585.91,50,,9585.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13420.27,70,,13420.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,751.98,13420.27,
Treat spinal canal lesion,62282,CPT,,,,,,,,both,,,19171.82,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9585.91,50,,9585.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13420.27,70,,13420.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,751.98,13420.27,
Injection for myelogram,62284,CPT,,,,,,,,both,,,32979.4,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16489.7,50,,16489.7,percent of total billed charges,,23085.58,70,,23085.58,percent of total billed charges,,6152,,,6152,Case Rate,,1205.26,,,1205.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23085.58,70,,23085.58,percent of total billed charges,,410.85,,,410.85,Fee Schedule,,348.6,,,348.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.99,,,647.99,Other,New York Medicaid APG methodology,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,907.18,,,907.18,Other,140% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1684.77,,,1684.77,Other,260% New York Medicaid APG,2099.48,,,2099.48,Other,324% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,809.98,,,809.98,Other,125% New York Medicaid APG,0.01,23085.58,
Percutaneous diskectomy,62287,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,2232.76,28428.05,
Njx px discography lumbar,62290,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1205.26,,,1205.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.99,,,647.99,Other,New York Medicaid APG methodology,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,907.18,,,907.18,Other,140% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1684.77,,,1684.77,Other,260% New York Medicaid APG,2099.48,,,2099.48,Other,324% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,809.98,,,809.98,Other,125% New York Medicaid APG,0.01,22702.47,
Njx px discography crv/thrc,62291,CPT,,,,,,,,both,,,36356.27,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,21813.76,60,,21813.76,percent of total billed charges,,20359.51,56,,20359.51,percent of total billed charges,,19632.39,54,,19632.39,percent of total billed charges,,18178.14,50,,18178.14,percent of total billed charges,,25449.39,70,,25449.39,percent of total billed charges,,6152,,,6152,Case Rate,,1205.26,,,1205.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25449.39,70,,25449.39,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.99,,,647.99,Other,New York Medicaid APG methodology,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,907.18,,,907.18,Other,140% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1684.77,,,1684.77,Other,260% New York Medicaid APG,2099.48,,,2099.48,Other,324% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,809.98,,,809.98,Other,125% New York Medicaid APG,0.01,25449.39,
Njx chemonucleolysis lmbr,62292,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,751.98,28428.05,
Injection into spinal artery,62294,CPT,,,,,,,,both,,,19171.82,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9585.91,50,,9585.91,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13420.27,70,,13420.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,751.98,13420.27,
Myelography lumbar injection,62302,CPT,,,,,,,,both,,,16841.27,1522.61,,,1522.61,Other,150% of Medicare + 9.63% HCRA Surcharge,925.91,,,925.91,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,8420.64,50,,8420.64,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1487.99,,,1487.99,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,11788.89,70,,11788.89,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,799.99,,,799.99,Other,New York Medicaid APG methodology,799.99,,,799.99,Other,100% New York Medicaid APG,799.99,,,799.99,Other,100% New York Medicaid APG,799.99,,,799.99,Other,100% New York Medicaid APG,1799.98,,,1799.98,Other,225% New York Medicaid APG,1799.98,,,1799.98,Other,225% New York Medicaid APG,1799.98,,,1799.98,Other,225% New York Medicaid APG,1799.98,,,1799.98,Other,225% New York Medicaid APG,1119.99,,,1119.99,Other,140% New York Medicaid APG,1799.98,,,1799.98,Other,225% New York Medicaid APG,2079.98,,,2079.98,Other,260% New York Medicaid APG,2591.98,,,2591.98,Other,324% New York Medicaid APG,1719.98,,,1719.98,Other,215% New York Medicaid APG,1719.98,,,1719.98,Other,215% New York Medicaid APG,999.99,,,999.99,Other,125% New York Medicaid APG,799.99,13157,
Myelography lumbar injection,62303,CPT,,,,,,,,both,,,16841.27,1522.61,,,1522.61,Other,150% of Medicare + 9.63% HCRA Surcharge,925.91,,,925.91,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,8420.64,50,,8420.64,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1487.99,,,1487.99,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,11788.89,70,,11788.89,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,799.99,,,799.99,Other,New York Medicaid APG methodology,799.99,,,799.99,Other,100% New York Medicaid APG,799.99,,,799.99,Other,100% New York Medicaid APG,799.99,,,799.99,Other,100% New York Medicaid APG,1799.98,,,1799.98,Other,225% New York Medicaid APG,1799.98,,,1799.98,Other,225% New York Medicaid APG,1799.98,,,1799.98,Other,225% New York Medicaid APG,1799.98,,,1799.98,Other,225% New York Medicaid APG,1119.99,,,1119.99,Other,140% New York Medicaid APG,1799.98,,,1799.98,Other,225% New York Medicaid APG,2079.98,,,2079.98,Other,260% New York Medicaid APG,2591.98,,,2591.98,Other,324% New York Medicaid APG,1719.98,,,1719.98,Other,215% New York Medicaid APG,1719.98,,,1719.98,Other,215% New York Medicaid APG,999.99,,,999.99,Other,125% New York Medicaid APG,799.99,13157,
Myelography lumbar injection,62304,CPT,,,,,,,,both,,,4472.8,1522.61,,,1522.61,Other,150% of Medicare + 9.63% HCRA Surcharge,925.91,,,925.91,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2236.4,50,,2236.4,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1487.99,,,1487.99,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3130.96,70,,3130.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,799.99,,,799.99,Other,New York Medicaid APG methodology,799.99,,,799.99,Other,100% New York Medicaid APG,799.99,,,799.99,Other,100% New York Medicaid APG,799.99,,,799.99,Other,100% New York Medicaid APG,1799.98,,,1799.98,Other,225% New York Medicaid APG,1799.98,,,1799.98,Other,225% New York Medicaid APG,1799.98,,,1799.98,Other,225% New York Medicaid APG,1799.98,,,1799.98,Other,225% New York Medicaid APG,1119.99,,,1119.99,Other,140% New York Medicaid APG,1799.98,,,1799.98,Other,225% New York Medicaid APG,2079.98,,,2079.98,Other,260% New York Medicaid APG,2591.98,,,2591.98,Other,324% New York Medicaid APG,1719.98,,,1719.98,Other,215% New York Medicaid APG,1719.98,,,1719.98,Other,215% New York Medicaid APG,999.99,,,999.99,Other,125% New York Medicaid APG,799.99,13157,
Myelography lumbar injection,62305,CPT,,,,,,,,both,,,16841.27,1522.61,,,1522.61,Other,150% of Medicare + 9.63% HCRA Surcharge,925.91,,,925.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,8420.64,50,,8420.64,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1487.99,,,1487.99,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,11788.89,70,,11788.89,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,799.99,,,799.99,Other,New York Medicaid APG methodology,799.99,,,799.99,Other,100% New York Medicaid APG,799.99,,,799.99,Other,100% New York Medicaid APG,799.99,,,799.99,Other,100% New York Medicaid APG,1799.98,,,1799.98,Other,225% New York Medicaid APG,1799.98,,,1799.98,Other,225% New York Medicaid APG,1799.98,,,1799.98,Other,225% New York Medicaid APG,1799.98,,,1799.98,Other,225% New York Medicaid APG,1119.99,,,1119.99,Other,140% New York Medicaid APG,1799.98,,,1799.98,Other,225% New York Medicaid APG,2079.98,,,2079.98,Other,260% New York Medicaid APG,2591.98,,,2591.98,Other,324% New York Medicaid APG,1719.98,,,1719.98,Other,215% New York Medicaid APG,1719.98,,,1719.98,Other,215% New York Medicaid APG,999.99,,,999.99,Other,125% New York Medicaid APG,799.99,13157,
Njx interlaminar crv/thrc,62320,CPT,,,,,,,,both,,,14545.81,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7272.91,50,,7272.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10182.07,70,,10182.07,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,751.98,13157,
Njx interlaminar crv/thrc,62321,CPT,,,,,,,,both,,,4598.34,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2299.17,50,,2299.17,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3218.84,70,,3218.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,751.98,13157,
Njx interlaminar lmbr/sac,62322,CPT,,,,,,,,both,,,19171.82,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9585.91,50,,9585.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13420.27,70,,13420.27,percent of total billed charges,,392.7,,,392.7,Fee Schedule,,333.2,,,333.2,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,333.2,13420.27,
Njx interlaminar lmbr/sac,62323,CPT,,,,,,,,both,,,4568.12,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2284.06,50,,2284.06,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3197.68,70,,3197.68,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,751.98,13157,
Njx interlaminar crv/thrc,62324,CPT,,,,,,,,both,,,19171.82,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9585.91,50,,9585.91,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13420.27,70,,13420.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,751.98,13420.27,
Njx interlaminar crv/thrc,62325,CPT,,,,,,,,both,,,19171.82,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9585.91,50,,9585.91,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13420.27,70,,13420.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,751.98,13420.27,
Njx interlaminar lmbr/sac,62326,CPT,,,,,,,,both,,,19171.82,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9585.91,50,,9585.91,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13420.27,70,,13420.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,751.98,13420.27,
Njx interlaminar lmbr/sac,62327,CPT,,,,,,,,both,,,19171.82,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9585.91,50,,9585.91,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13420.27,70,,13420.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,751.98,13420.27,
Dx lmbr spi pnxr w/fluor/ct,62328,CPT,,,,,,,,both,,,13095.35,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6547.68,50,,6547.68,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9166.75,70,,9166.75,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,751.98,13157,
Ther spi pnxr csf fluor/ct,62329,CPT,,,,,,,,both,,,402933,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,201466.5,50,,201466.5,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,282053.1,70,,282053.1,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,751.98,282053.1,
Implant spinal canal cath,62350,CPT,,,,,,,,both,,,69692.06,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,34846.03,50,,34846.03,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,48784.44,70,,48784.44,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,48784.44,
Implant spinal canal cath,62351,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,8573.09,,,8573.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4609.19,,,4609.19,Other,New York Medicaid APG methodology,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,6452.86,,,6452.86,Other,140% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,11983.89,,,11983.89,Other,260% New York Medicaid APG,14933.77,,,14933.77,Other,324% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,5761.49,,,5761.49,Other,125% New York Medicaid APG,4609.19,105333.66,
Remove spinal canal catheter,62355,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,751.98,28428.05,
Insert spine infusion device,62360,CPT,,,,,,,,both,,,94708.62,33914.56,,,33914.56,Other,150% of Medicare + 9.63% HCRA Surcharge,20623.65,,,20623.65,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,47354.31,50,,47354.31,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,30511.22,,,30511.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,66296.03,70,,66296.03,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,16403.88,,,16403.88,Other,New York Medicaid APG methodology,16403.88,,,16403.88,Other,100% New York Medicaid APG,16403.88,,,16403.88,Other,100% New York Medicaid APG,16403.88,,,16403.88,Other,100% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,22965.44,,,22965.44,Other,140% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,42650.1,,,42650.1,Other,260% New York Medicaid APG,53148.58,,,53148.58,Other,324% New York Medicaid APG,35268.35,,,35268.35,Other,215% New York Medicaid APG,35268.35,,,35268.35,Other,215% New York Medicaid APG,20504.85,,,20504.85,Other,125% New York Medicaid APG,5261,66296.03,
Implant spine infusion pump,62361,CPT,,,,,,,,both,,,63160.62,33914.56,,,33914.56,Other,150% of Medicare + 9.63% HCRA Surcharge,20623.65,,,20623.65,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,31580.31,50,,31580.31,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,30511.22,,,30511.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,44212.43,70,,44212.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,17798,,"100% primary, 50% secondary, 25% tertiary procedure",17798,Other,United Healthcare ASC Grouper,16018,,"100% primary, 50% secondary, 25% tertiary procedure",16018,Other,United Healthcare ASC Grouper,17798,,"100% primary, 50% secondary, 25% tertiary procedure",17798,Other,United Healthcare ASC Grouper,15129,,"100% primary, 50% secondary, 25% tertiary procedure",15129,Other,United Healthcare ASC Grouper,16403.88,,,16403.88,Other,New York Medicaid APG methodology,16403.88,,,16403.88,Other,100% New York Medicaid APG,16403.88,,,16403.88,Other,100% New York Medicaid APG,16403.88,,,16403.88,Other,100% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,22965.44,,,22965.44,Other,140% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,42650.1,,,42650.1,Other,260% New York Medicaid APG,53148.58,,,53148.58,Other,324% New York Medicaid APG,35268.35,,,35268.35,Other,215% New York Medicaid APG,35268.35,,,35268.35,Other,215% New York Medicaid APG,20504.85,,,20504.85,Other,125% New York Medicaid APG,5261,53148.58,
Implant spine infusion pump,62362,CPT,,,,,,,,both,,,94208.46,33914.56,,,33914.56,Other,150% of Medicare + 9.63% HCRA Surcharge,20623.65,,,20623.65,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,47104.23,50,,47104.23,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,30511.22,,,30511.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,65945.92,70,,65945.92,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,17798,,"100% primary, 50% secondary, 25% tertiary procedure",17798,Other,United Healthcare ASC Grouper,16018,,"100% primary, 50% secondary, 25% tertiary procedure",16018,Other,United Healthcare ASC Grouper,17798,,"100% primary, 50% secondary, 25% tertiary procedure",17798,Other,United Healthcare ASC Grouper,15129,,"100% primary, 50% secondary, 25% tertiary procedure",15129,Other,United Healthcare ASC Grouper,16403.88,,,16403.88,Other,New York Medicaid APG methodology,16403.88,,,16403.88,Other,100% New York Medicaid APG,16403.88,,,16403.88,Other,100% New York Medicaid APG,16403.88,,,16403.88,Other,100% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,22965.44,,,22965.44,Other,140% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,42650.1,,,42650.1,Other,260% New York Medicaid APG,53148.58,,,53148.58,Other,324% New York Medicaid APG,35268.35,,,35268.35,Other,215% New York Medicaid APG,35268.35,,,35268.35,Other,215% New York Medicaid APG,20504.85,,,20504.85,Other,125% New York Medicaid APG,5261,65945.92,
Remove spine infusion device,62365,CPT,,,,,,,,both,,,60516.25,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,30258.13,50,,30258.13,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,42361.38,70,,42361.38,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,42361.38,
Analyze spine infus pump,62367,CPT,,,,,,,,both,,,6282.58,568,,,568,Other,150% of Medicare + 9.63% HCRA Surcharge,345.41,,,345.41,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3141.29,50,,3141.29,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,393.03,,,393.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4397.81,70,,4397.81,percent of total billed charges,,120.45,,,120.45,Fee Schedule,,102.2,,,102.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,211.31,,,211.31,Other,New York Medicaid APG methodology,211.31,,,211.31,Other,100% New York Medicaid APG,211.31,,,211.31,Other,100% New York Medicaid APG,211.31,,,211.31,Other,100% New York Medicaid APG,475.44,,,475.44,Other,225% New York Medicaid APG,475.44,,,475.44,Other,225% New York Medicaid APG,475.44,,,475.44,Other,225% New York Medicaid APG,475.44,,,475.44,Other,225% New York Medicaid APG,295.83,,,295.83,Other,140% New York Medicaid APG,475.44,,,475.44,Other,225% New York Medicaid APG,549.4,,,549.4,Other,260% New York Medicaid APG,684.64,,,684.64,Other,324% New York Medicaid APG,454.31,,,454.31,Other,215% New York Medicaid APG,454.31,,,454.31,Other,215% New York Medicaid APG,264.14,,,264.14,Other,125% New York Medicaid APG,102.2,9473,
Analyze sp inf pump w/reprog,62368,CPT,,,,,,,,both,,,6282.58,568,,,568,Other,150% of Medicare + 9.63% HCRA Surcharge,345.41,,,345.41,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3141.29,50,,3141.29,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,393.03,,,393.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4397.81,70,,4397.81,percent of total billed charges,,168.3,,,168.3,Fee Schedule,,142.8,,,142.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,211.31,,,211.31,Other,New York Medicaid APG methodology,211.31,,,211.31,Other,100% New York Medicaid APG,211.31,,,211.31,Other,100% New York Medicaid APG,211.31,,,211.31,Other,100% New York Medicaid APG,475.44,,,475.44,Other,225% New York Medicaid APG,475.44,,,475.44,Other,225% New York Medicaid APG,475.44,,,475.44,Other,225% New York Medicaid APG,475.44,,,475.44,Other,225% New York Medicaid APG,295.83,,,295.83,Other,140% New York Medicaid APG,475.44,,,475.44,Other,225% New York Medicaid APG,549.4,,,549.4,Other,260% New York Medicaid APG,684.64,,,684.64,Other,324% New York Medicaid APG,454.31,,,454.31,Other,215% New York Medicaid APG,454.31,,,454.31,Other,215% New York Medicaid APG,264.14,,,264.14,Other,125% New York Medicaid APG,142.8,9473,
Anal sp inf pmp w/reprg&fill,62369,CPT,,,,,,,,both,,,6282.58,568,,,568,Other,150% of Medicare + 9.63% HCRA Surcharge,345.41,,,345.41,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3141.29,50,,3141.29,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,393.03,,,393.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4397.81,70,,4397.81,percent of total billed charges,,169.95,,,169.95,Fee Schedule,,144.2,,,144.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,211.31,,,211.31,Other,New York Medicaid APG methodology,211.31,,,211.31,Other,100% New York Medicaid APG,211.31,,,211.31,Other,100% New York Medicaid APG,211.31,,,211.31,Other,100% New York Medicaid APG,475.44,,,475.44,Other,225% New York Medicaid APG,475.44,,,475.44,Other,225% New York Medicaid APG,475.44,,,475.44,Other,225% New York Medicaid APG,475.44,,,475.44,Other,225% New York Medicaid APG,295.83,,,295.83,Other,140% New York Medicaid APG,475.44,,,475.44,Other,225% New York Medicaid APG,549.4,,,549.4,Other,260% New York Medicaid APG,684.64,,,684.64,Other,324% New York Medicaid APG,454.31,,,454.31,Other,215% New York Medicaid APG,454.31,,,454.31,Other,215% New York Medicaid APG,264.14,,,264.14,Other,125% New York Medicaid APG,0.01,9473,
Anl sp inf pmp w/mdreprg&fil,62370,CPT,,,,,,,,both,,,32757.93,568,,,568,Other,150% of Medicare + 9.63% HCRA Surcharge,345.41,,,345.41,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16378.97,50,,16378.97,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,393.03,,,393.03,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22930.55,70,,22930.55,percent of total billed charges,,224.4,,,224.4,Fee Schedule,,190.4,,,190.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,211.31,,,211.31,Other,New York Medicaid APG methodology,211.31,,,211.31,Other,100% New York Medicaid APG,211.31,,,211.31,Other,100% New York Medicaid APG,211.31,,,211.31,Other,100% New York Medicaid APG,475.44,,,475.44,Other,225% New York Medicaid APG,475.44,,,475.44,Other,225% New York Medicaid APG,475.44,,,475.44,Other,225% New York Medicaid APG,475.44,,,475.44,Other,225% New York Medicaid APG,295.83,,,295.83,Other,140% New York Medicaid APG,475.44,,,475.44,Other,225% New York Medicaid APG,549.4,,,549.4,Other,260% New York Medicaid APG,684.64,,,684.64,Other,324% New York Medicaid APG,454.31,,,454.31,Other,215% New York Medicaid APG,454.31,,,454.31,Other,215% New York Medicaid APG,264.14,,,264.14,Other,125% New York Medicaid APG,0.01,22930.55,
Ndsc dcmprn 1 ntrspc lumbar,62380,CPT,,,,,,,,both,,,65343.2,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,32671.6,50,,32671.6,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45740.24,70,,45740.24,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,45740.24,
Remove spine lamina 1/2 crvl,63001,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,105333.66,
Remove spine lamina 1/2 thrc,63003,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,105333.66,
Remove spine lamina 1/2 lmbr,63005,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,105333.66,
Remove spine lamina 1/2 scrl,63011,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,105333.66,
Remove lamina/facets lumbar,63012,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,105333.66,
Remove spine lamina >2 crvcl,63015,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,105333.66,
Remove spine lamina >2 thrc,63016,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,105333.66,
Remove spine lamina >2 lmbr,63017,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,105333.66,
Neck spine disk surgery,63020,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,105333.66,
Low back disk surgery,63030,CPT,,,,,,,,both,,,83836.24,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,41918.12,50,,41918.12,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,58685.37,70,,58685.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,58685.37,
Spinal disk surgery add-on,63035,CPT,,,,,,,,both,,,86591.4,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,43295.7,50,,43295.7,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,60613.98,70,,60613.98,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,0.01,60613.98,
Laminotomy single cervical,63040,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,105333.66,
Laminotomy single lumbar,63042,CPT,,,,,,,,both,,,52792.86,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,26396.43,50,,26396.43,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36955,70,,36955,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,36955,
Laminotomy addl cervical,63043,CPT,,,,,,,,both,,,86591.4,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,43295.7,50,,43295.7,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,60613.98,70,,60613.98,percent of total billed charges,,43295.7,50,,43295.7,percent of total billed charges,,43295.7,50,,43295.7,percent of total billed charges,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,0.01,60613.98,
Laminotomy addl lumbar,63044,CPT,,,,,,,,both,,,86591.4,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,43295.7,50,,43295.7,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,8573.09,,,8573.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,60613.98,70,,60613.98,percent of total billed charges,,43295.7,50,,43295.7,percent of total billed charges,,43295.7,50,,43295.7,percent of total billed charges,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,4609.19,,,4609.19,Other,New York Medicaid APG methodology,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,6452.86,,,6452.86,Other,140% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,11983.89,,,11983.89,Other,260% New York Medicaid APG,14933.77,,,14933.77,Other,324% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,5761.49,,,5761.49,Other,125% New York Medicaid APG,0.01,60613.98,
Remove spine lamina 1 crvl,63045,CPT,,,,,,,,both,,,58179.26,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,29089.63,50,,29089.63,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,40725.48,70,,40725.48,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,40725.48,
Remove spine lamina 1 thrc,63046,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,105333.66,
Remove spine lamina 1 lmbr,63047,CPT,,,,,,,,both,,,87385.96,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,43692.98,50,,43692.98,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,61170.17,70,,61170.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,61170.17,
Remove spinal lamina add-on,63048,CPT,,,,,,,,both,,,95161.09,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,47580.55,50,,47580.55,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,66612.76,70,,66612.76,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,0.01,66612.76,
Decompress spinal cord thrc,63055,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,105333.66,
Decompress spinal cord lmbr,63056,CPT,,,,,,,,both,,,81823.59,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,40911.8,50,,40911.8,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,57276.51,70,,57276.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,57276.51,
Decompress spine cord add-on,63057,CPT,,,,,,,,both,,,86591.4,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,43295.7,50,,43295.7,percent of total billed charges,,60613.98,70,,60613.98,percent of total billed charges,,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,60613.98,70,,60613.98,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,0.01,60613.98,
Decompress spinal cord thrc,63064,CPT,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,105333.66,
Decompress spine cord add-on,63066,CPT,,,,,,,,both,,,86591.4,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,43295.7,50,,43295.7,percent of total billed charges,,60613.98,70,,60613.98,percent of total billed charges,,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,60613.98,70,,60613.98,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,0.01,60613.98,
Neck spine disk surgery,63075,CPT,,,,,,,,both,,,248791,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,124395.5,50,,124395.5,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,8573.09,,,8573.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,174153.7,70,,174153.7,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4609.19,,,4609.19,Other,New York Medicaid APG methodology,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,6452.86,,,6452.86,Other,140% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,11983.89,,,11983.89,Other,260% New York Medicaid APG,14933.77,,,14933.77,Other,324% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,5761.49,,,5761.49,Other,125% New York Medicaid APG,4609.19,174153.7,
Neck spine disk surgery,63076,CPT,,,,,,,,both,,,83504,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,41752,50,,41752,percent of total billed charges,,58452.8,70,,58452.8,percent of total billed charges,,6152,,,6152,Case Rate,,8573.09,,,8573.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,58452.8,70,,58452.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,4609.19,,,4609.19,Other,New York Medicaid APG methodology,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,6452.86,,,6452.86,Other,140% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,11983.89,,,11983.89,Other,260% New York Medicaid APG,14933.77,,,14933.77,Other,324% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,5761.49,,,5761.49,Other,125% New York Medicaid APG,0.01,58452.8,
Remove spinal cord lesion,63600,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,2232.76,28428.05,
Stimulation of spinal cord,63610,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,2232.76,28428.05,
Implant neuroelectrodes,63650,CPT,,,,,,,,both,,,100920.91,13005.64,,,13005.64,Other,150% of Medicare + 9.63% HCRA Surcharge,7908.81,,,7908.81,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,50460.46,50,,50460.46,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,30511.22,,,30511.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,70644.64,70,,70644.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,16403.88,,,16403.88,Other,New York Medicaid APG methodology,16403.88,,,16403.88,Other,100% New York Medicaid APG,16403.88,,,16403.88,Other,100% New York Medicaid APG,16403.88,,,16403.88,Other,100% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,22965.44,,,22965.44,Other,140% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,42650.09,,,42650.09,Other,260% New York Medicaid APG,53148.58,,,53148.58,Other,324% New York Medicaid APG,35268.35,,,35268.35,Other,215% New York Medicaid APG,35268.35,,,35268.35,Other,215% New York Medicaid APG,20504.85,,,20504.85,Other,125% New York Medicaid APG,5261,70644.64,
Implant neuroelectrodes,63655,CPT,,,,,,,,both,,,128738.78,41599.58,,,41599.58,Other,150% of Medicare + 9.63% HCRA Surcharge,25296.95,,,25296.95,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,64369.39,50,,64369.39,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,40570.63,,,40570.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,90117.15,70,,90117.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,21812.17,,,21812.17,Other,New York Medicaid APG methodology,21812.17,,,21812.17,Other,100% New York Medicaid APG,21812.17,,,21812.17,Other,100% New York Medicaid APG,21812.17,,,21812.17,Other,100% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,30537.04,,,30537.04,Other,140% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,56711.64,,,56711.64,Other,260% New York Medicaid APG,70671.43,,,70671.43,Other,324% New York Medicaid APG,46896.16,,,46896.16,Other,215% New York Medicaid APG,46896.16,,,46896.16,Other,215% New York Medicaid APG,27265.21,,,27265.21,Other,125% New York Medicaid APG,5524,90117.15,
Remove spine eltrd perq aray,63661,CPT,,,,,,,,both,,,58200.2,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29100.1,50,,29100.1,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4340.32,,,4340.32,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,40740.14,70,,40740.14,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2333.51,,,2333.51,Other,New York Medicaid APG methodology,2333.51,,,2333.51,Other,100% New York Medicaid APG,2333.51,,,2333.51,Other,100% New York Medicaid APG,2333.51,,,2333.51,Other,100% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,3266.91,,,3266.91,Other,140% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,6067.11,,,6067.11,Other,260% New York Medicaid APG,7560.56,,,7560.56,Other,324% New York Medicaid APG,5017.04,,,5017.04,Other,215% New York Medicaid APG,5017.04,,,5017.04,Other,215% New York Medicaid APG,2916.88,,,2916.88,Other,125% New York Medicaid APG,2232.76,40740.14,
Remove spine eltrd plate,63662,CPT,,,,,,,,both,,,74313.89,6470.41,,,6470.41,Other,150% of Medicare + 9.63% HCRA Surcharge,3934.69,,,3934.69,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,37156.95,50,,37156.95,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4340.32,,,4340.32,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,52019.72,70,,52019.72,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2333.51,,,2333.51,Other,New York Medicaid APG methodology,2333.51,,,2333.51,Other,100% New York Medicaid APG,2333.51,,,2333.51,Other,100% New York Medicaid APG,2333.51,,,2333.51,Other,100% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,3266.91,,,3266.91,Other,140% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,6067.11,,,6067.11,Other,260% New York Medicaid APG,7560.56,,,7560.56,Other,324% New York Medicaid APG,5017.04,,,5017.04,Other,215% New York Medicaid APG,5017.04,,,5017.04,Other,215% New York Medicaid APG,2916.88,,,2916.88,Other,125% New York Medicaid APG,2333.51,52019.72,
Revise spine eltrd perq aray,63663,CPT,,,,,,,,both,,,65841.59,13005.64,,,13005.64,Other,150% of Medicare + 9.63% HCRA Surcharge,7908.81,,,7908.81,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,32920.8,50,,32920.8,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,30511.22,,,30511.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46089.11,70,,46089.11,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,16403.88,,,16403.88,Other,New York Medicaid APG methodology,16403.88,,,16403.88,Other,100% New York Medicaid APG,16403.88,,,16403.88,Other,100% New York Medicaid APG,16403.88,,,16403.88,Other,100% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,22965.44,,,22965.44,Other,140% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,42650.09,,,42650.09,Other,260% New York Medicaid APG,53148.58,,,53148.58,Other,324% New York Medicaid APG,35268.35,,,35268.35,Other,215% New York Medicaid APG,35268.35,,,35268.35,Other,215% New York Medicaid APG,20504.85,,,20504.85,Other,125% New York Medicaid APG,3323,53148.58,
Revise spine eltrd plate,63664,CPT,,,,,,,,both,,,286522.06,25904.28,,,25904.28,Other,150% of Medicare + 9.63% HCRA Surcharge,15752.55,,,15752.55,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,143261.03,50,,143261.03,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,40570.63,,,40570.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,200565.44,70,,200565.44,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,21812.17,,,21812.17,Other,New York Medicaid APG methodology,21812.17,,,21812.17,Other,100% New York Medicaid APG,21812.17,,,21812.17,Other,100% New York Medicaid APG,21812.17,,,21812.17,Other,100% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,30537.04,,,30537.04,Other,140% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,56711.64,,,56711.64,Other,260% New York Medicaid APG,70671.43,,,70671.43,Other,324% New York Medicaid APG,46896.16,,,46896.16,Other,215% New York Medicaid APG,46896.16,,,46896.16,Other,215% New York Medicaid APG,27265.21,,,27265.21,Other,125% New York Medicaid APG,3323,200565.44,
Insrt/redo spine n generator,63685,CPT,,,,,,,,both,,,143297.21,59050.36,,,59050.36,Other,150% of Medicare + 9.63% HCRA Surcharge,35908.88,,,35908.88,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,71648.61,50,,71648.61,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,40570.63,,,40570.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,100308.05,70,,100308.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,17798,,"100% primary, 50% secondary, 25% tertiary procedure",17798,Other,United Healthcare ASC Grouper,16018,,"100% primary, 50% secondary, 25% tertiary procedure",16018,Other,United Healthcare ASC Grouper,17798,,"100% primary, 50% secondary, 25% tertiary procedure",17798,Other,United Healthcare ASC Grouper,15129,,"100% primary, 50% secondary, 25% tertiary procedure",15129,Other,United Healthcare ASC Grouper,21812.17,,,21812.17,Other,New York Medicaid APG methodology,21812.17,,,21812.17,Other,100% New York Medicaid APG,21812.17,,,21812.17,Other,100% New York Medicaid APG,21812.17,,,21812.17,Other,100% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,30537.04,,,30537.04,Other,140% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,56711.64,,,56711.64,Other,260% New York Medicaid APG,70671.43,,,70671.43,Other,324% New York Medicaid APG,46896.16,,,46896.16,Other,215% New York Medicaid APG,46896.16,,,46896.16,Other,215% New York Medicaid APG,27265.21,,,27265.21,Other,125% New York Medicaid APG,5261,100308.05,
Revise/remove neuroreceiver,63688,CPT,,,,,,,,both,,,54133.48,6470.41,,,6470.41,Other,150% of Medicare + 9.63% HCRA Surcharge,3934.69,,,3934.69,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,27066.74,50,,27066.74,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4340.32,,,4340.32,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,37893.44,70,,37893.44,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2333.51,,,2333.51,Other,New York Medicaid APG methodology,2333.51,,,2333.51,Other,100% New York Medicaid APG,2333.51,,,2333.51,Other,100% New York Medicaid APG,2333.51,,,2333.51,Other,100% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,3266.91,,,3266.91,Other,140% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,6067.11,,,6067.11,Other,260% New York Medicaid APG,7560.56,,,7560.56,Other,324% New York Medicaid APG,5017.04,,,5017.04,Other,215% New York Medicaid APG,5017.04,,,5017.04,Other,215% New York Medicaid APG,2916.88,,,2916.88,Other,125% New York Medicaid APG,2333.51,37893.44,
Install spinal shunt,63741,CPT,,,,,,,,both,,,140115.1,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,70057.55,50,,70057.55,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.75,,,7783.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,98080.57,70,,98080.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.74,,,5858.74,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.51,,,10880.51,Other,260% New York Medicaid APG,13558.79,,,13558.79,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,4184.81,98080.57,
Revision of spinal shunt,63744,CPT,,,,,,,,both,,,96667.79,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,48333.9,50,,48333.9,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.75,,,7783.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,67667.45,70,,67667.45,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.74,,,5858.74,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.51,,,10880.51,Other,260% New York Medicaid APG,13558.79,,,13558.79,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,4184.81,67667.45,
Removal of spinal shunt,63746,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,28428.05,
Njx aa&/strd trigeminal nrv,64400,CPT,,,,,,,,both,,,3311,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1655.5,50,,1655.5,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2317.7,70,,2317.7,percent of total billed charges,,247.5,,,247.5,Fee Schedule,,210,,,210,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,210,9473,
Njx aa&/strd gr ocpl nrv,64405,CPT,,,,,,,,both,,,12430.65,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6215.33,50,,6215.33,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8701.46,70,,8701.46,percent of total billed charges,,259.05,,,259.05,Fee Schedule,,219.8,,,219.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,219.8,9473,
Njx aa&/strd vagus nrv,64408,CPT,,,,,,,,both,,,6229.82,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3114.91,50,,3114.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4360.87,70,,4360.87,percent of total billed charges,,221.1,,,221.1,Fee Schedule,,187.6,,,187.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,187.6,9473,
Njx aa&/strd brach plexus,64415,CPT,,,,,,,,both,,,19171.82,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9585.91,50,,9585.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1403.21,,,1403.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13420.27,70,,13420.27,percent of total billed charges,,338.25,,,338.25,Fee Schedule,,287,,,287,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,754.41,,,754.41,Other,New York Medicaid APG methodology,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1056.18,,,1056.18,Other,140% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1961.47,,,1961.47,Other,260% New York Medicaid APG,2444.29,,,2444.29,Other,324% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,943.01,,,943.01,Other,125% New York Medicaid APG,287,13420.27,
Njx aa&/strd brach plex nfs,64416,CPT,,,,,,,,both,,,19171.82,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9585.91,50,,9585.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1403.21,,,1403.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13420.27,70,,13420.27,percent of total billed charges,,381.15,,,381.15,Fee Schedule,,323.4,,,323.4,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,754.41,,,754.41,Other,New York Medicaid APG methodology,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1056.18,,,1056.18,Other,140% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1961.47,,,1961.47,Other,260% New York Medicaid APG,2444.29,,,2444.29,Other,324% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,943.01,,,943.01,Other,125% New York Medicaid APG,323.4,13420.27,
Njx aa&/strd axillary nrv,64417,CPT,,,,,,,,both,,,19171.82,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9585.91,50,,9585.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13420.27,70,,13420.27,percent of total billed charges,,308.55,,,308.55,Fee Schedule,,261.8,,,261.8,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,261.8,13420.27,
Njx aa&/strd sprscap nrv,64418,CPT,,,,,,,,both,,,3215,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1607.5,50,,1607.5,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2250.5,70,,2250.5,percent of total billed charges,,272.25,,,272.25,Fee Schedule,,231,,,231,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,231,9473,
Njx aa&/strd ntrcost nrv 1,64420,CPT,,,,,,,,both,,,3260.17,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1630.09,50,,1630.09,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2282.12,70,,2282.12,percent of total billed charges,,285.45,,,285.45,Fee Schedule,,242.2,,,242.2,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,242.2,9473,
Njx aa&/strd ntrcost nrv ea,64421,CPT,,,,,,,,both,,,19171.82,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9585.91,50,,9585.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1403.21,,,1403.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13420.27,70,,13420.27,percent of total billed charges,,118.8,,,118.8,Fee Schedule,,100.8,,,100.8,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,754.41,,,754.41,Other,New York Medicaid APG methodology,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1056.18,,,1056.18,Other,140% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1961.47,,,1961.47,Other,260% New York Medicaid APG,2444.29,,,2444.29,Other,324% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,943.01,,,943.01,Other,125% New York Medicaid APG,100.8,13420.27,
Njx aa&/strd ii ih nerves,64425,CPT,,,,,,,,both,,,3245,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1622.5,50,,1622.5,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2271.5,70,,2271.5,percent of total billed charges,,267.3,,,267.3,Fee Schedule,,226.8,,,226.8,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,226.8,9473,
Njx aa&/strd pudendal nerve,64430,CPT,,,,,,,,both,,,19171.82,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9585.91,50,,9585.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1403.21,,,1403.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13420.27,70,,13420.27,percent of total billed charges,,267.3,,,267.3,Fee Schedule,,226.8,,,226.8,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,754.41,,,754.41,Other,New York Medicaid APG methodology,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1056.18,,,1056.18,Other,140% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1961.47,,,1961.47,Other,260% New York Medicaid APG,2444.29,,,2444.29,Other,324% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,943.01,,,943.01,Other,125% New York Medicaid APG,226.8,13420.27,
Njx aa&/strd paracrv nrv,64435,CPT,,,,,,,,both,,,14545.81,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7272.91,50,,7272.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10182.07,70,,10182.07,percent of total billed charges,,212.85,,,212.85,Fee Schedule,,180.6,,,180.6,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,180.6,10182.07,
Njx aa&/strd sciatic nerve,64445,CPT,,,,,,,,both,,,4328,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2164,50,,2164,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3029.6,70,,3029.6,percent of total billed charges,,358.05,,,358.05,Fee Schedule,,303.8,,,303.8,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,303.8,9473,
Njx aa&/strd sciatic nrv nfs,64446,CPT,,,,,,,,both,,,19171.82,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9585.91,50,,9585.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1403.21,,,1403.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13420.27,70,,13420.27,percent of total billed charges,,372.9,,,372.9,Fee Schedule,,316.4,,,316.4,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,754.41,,,754.41,Other,New York Medicaid APG methodology,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1056.18,,,1056.18,Other,140% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1961.47,,,1961.47,Other,260% New York Medicaid APG,2444.29,,,2444.29,Other,324% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,943.01,,,943.01,Other,125% New York Medicaid APG,316.4,13420.27,
Njx aa&/strd femoral nerve,64447,CPT,,,,,,,,both,,,2169.93,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1084.97,50,,1084.97,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1403.21,,,1403.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,1518.95,70,,1518.95,percent of total billed charges,,306.9,,,306.9,Fee Schedule,,260.4,,,260.4,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,754.41,,,754.41,Other,New York Medicaid APG methodology,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1056.18,,,1056.18,Other,140% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1961.47,,,1961.47,Other,260% New York Medicaid APG,2444.29,,,2444.29,Other,324% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,943.01,,,943.01,Other,125% New York Medicaid APG,260.4,9473,
Njx aa&/strd fem nerve nfs,64448,CPT,,,,,,,,both,,,19171.82,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9585.91,50,,9585.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1403.21,,,1403.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13420.27,70,,13420.27,percent of total billed charges,,351.45,,,351.45,Fee Schedule,,298.2,,,298.2,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,754.41,,,754.41,Other,New York Medicaid APG methodology,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1056.18,,,1056.18,Other,140% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1961.47,,,1961.47,Other,260% New York Medicaid APG,2444.29,,,2444.29,Other,324% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,943.01,,,943.01,Other,125% New York Medicaid APG,298.2,13420.27,
Njx aa&/strd lmbr plex nfs,64449,CPT,,,,,,,,both,,,19171.82,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9585.91,50,,9585.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1403.21,,,1403.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13420.27,70,,13420.27,percent of total billed charges,,301.95,,,301.95,Fee Schedule,,256.2,,,256.2,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,754.41,,,754.41,Other,New York Medicaid APG methodology,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1056.18,,,1056.18,Other,140% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1961.47,,,1961.47,Other,260% New York Medicaid APG,2444.29,,,2444.29,Other,324% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,943.01,,,943.01,Other,125% New York Medicaid APG,256.2,13420.27,
Njx aa&/strd other pn/branch,64450,CPT,,,,,,,,both,,,3878.41,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1939.21,50,,1939.21,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2714.89,70,,2714.89,percent of total billed charges,,204.6,,,204.6,Fee Schedule,,173.6,,,173.6,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,173.6,9473,
Njx aa&/strd nrv nrvtg si jt,64451,CPT,,,,,,,,both,,,14545.81,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7272.91,50,,7272.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1403.21,,,1403.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10182.07,70,,10182.07,percent of total billed charges,,397.65,,,397.65,Fee Schedule,,337.4,,,337.4,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,754.41,,,754.41,Other,New York Medicaid APG methodology,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1056.18,,,1056.18,Other,140% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1961.47,,,1961.47,Other,260% New York Medicaid APG,2444.29,,,2444.29,Other,324% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,943.01,,,943.01,Other,125% New York Medicaid APG,337.4,10182.07,
Njx aa&/strd gnclr nrv brnch,64454,CPT,,,,,,,,both,,,3540.73,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1770.37,50,,1770.37,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2478.51,70,,2478.51,percent of total billed charges,,399.3,,,399.3,Fee Schedule,,338.8,,,338.8,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,338.8,9473,
Njx aa&/strd pltr com dg nrv,64455,CPT,,,,,,,,both,,,6229.82,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3114.91,50,,3114.91,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4360.87,70,,4360.87,percent of total billed charges,,163.35,,,163.35,Fee Schedule,,138.6,,,138.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,0.01,9473,
Pvb thoracic single inj site,64461,CPT,,,,,,,,both,,,4296.71,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2148.36,50,,2148.36,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3007.7,70,,3007.7,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,0.01,13157,
Pvb thoracic 2nd+ inj site,64462,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,237.6,,,237.6,Fee Schedule,,201.6,,,201.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,0.01,22702.47,
Pvb thoracic cont infusion,64463,CPT,,,,,,,,both,,,14545.81,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7272.91,50,,7272.91,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10182.07,70,,10182.07,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,0.01,13157,
Njx aa&/strd tfrm epi c/t 1,64479,CPT,,,,,,,,both,,,3200.4,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1600.2,50,,1600.2,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2240.28,70,,2240.28,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,751.98,13157,
Njx aa&/strd tfrm epi c/t ea,64480,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,298.65,,,298.65,Fee Schedule,,253.4,,,253.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,0.01,22702.47,
Njx aa&/strd tfrm epi l/s 1,64483,CPT,,,,,,,,both,,,5501.56,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2750.78,50,,2750.78,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3851.09,70,,3851.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,751.98,13157,
Njx aa&/strd tfrm epi l/s ea,64484,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,250.8,,,250.8,Fee Schedule,,212.8,,,212.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,0.01,22702.47,
Tap block unil by injection,64486,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,268.95,,,268.95,Fee Schedule,,228.2,,,228.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,0.01,22702.47,
Tap block uni by infusion,64487,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,308.55,,,308.55,Fee Schedule,,261.8,,,261.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,0.01,22702.47,
Tap block bi injection,64488,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1403.21,,,1403.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,333.3,,,333.3,Fee Schedule,,282.8,,,282.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,754.41,,,754.41,Other,New York Medicaid APG methodology,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1056.18,,,1056.18,Other,140% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1961.47,,,1961.47,Other,260% New York Medicaid APG,2444.29,,,2444.29,Other,324% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,943.01,,,943.01,Other,125% New York Medicaid APG,0.01,22702.47,
Tap block bi by infusion,64489,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1403.21,,,1403.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,754.41,,,754.41,Other,New York Medicaid APG methodology,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1056.18,,,1056.18,Other,140% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1961.47,,,1961.47,Other,260% New York Medicaid APG,2444.29,,,2444.29,Other,324% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,943.01,,,943.01,Other,125% New York Medicaid APG,0.01,22702.47,
Inj paravert f jnt c/t 1 lev,64490,CPT,,,,,,,,both,,,3824.58,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1912.29,50,,1912.29,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2677.21,70,,2677.21,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,751.98,13157,
Inj paravert f jnt c/t 2 lev,64491,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,288.75,,,288.75,Fee Schedule,,245,,,245,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,0.01,22702.47,
Inj paravert f jnt c/t 3 lev,64492,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,293.7,,,293.7,Fee Schedule,,249.2,,,249.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,0.01,22702.47,
Inj paravert f jnt l/s 1 lev,64493,CPT,,,,,,,,both,,,4305.72,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2152.86,50,,2152.86,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3014,70,,3014,percent of total billed charges,,440.55,,,440.55,Fee Schedule,,373.8,,,373.8,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,373.8,9473,
Inj paravert f jnt l/s 2 lev,64494,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,249.15,,,249.15,Fee Schedule,,211.4,,,211.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,0.01,22702.47,
Inj paravert f jnt l/s 3 lev,64495,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,252.45,,,252.45,Fee Schedule,,214.2,,,214.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,0.01,22702.47,
N block spenopalatine gangl,64505,CPT,,,,,,,,both,,,6229.82,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3114.91,50,,3114.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4360.87,70,,4360.87,percent of total billed charges,,513.15,,,513.15,Fee Schedule,,435.4,,,435.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,342.51,9473,
N block stellate ganglion,64510,CPT,,,,,,,,both,,,3927.29,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1963.65,50,,1963.65,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1403.21,,,1403.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2749.1,70,,2749.1,percent of total billed charges,,374.55,,,374.55,Fee Schedule,,317.8,,,317.8,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,754.41,,,754.41,Other,New York Medicaid APG methodology,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1056.18,,,1056.18,Other,140% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1961.47,,,1961.47,Other,260% New York Medicaid APG,2444.29,,,2444.29,Other,324% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,943.01,,,943.01,Other,125% New York Medicaid APG,317.8,9473,
N block inj hypogas plxs,64517,CPT,,,,,,,,both,,,19171.82,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9585.91,50,,9585.91,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1403.21,,,1403.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13420.27,70,,13420.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,754.41,,,754.41,Other,New York Medicaid APG methodology,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1056.18,,,1056.18,Other,140% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1961.47,,,1961.47,Other,260% New York Medicaid APG,2444.29,,,2444.29,Other,324% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,943.01,,,943.01,Other,125% New York Medicaid APG,754.41,13420.27,
N block lumbar/thoracic,64520,CPT,,,,,,,,both,,,4279.6,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2139.8,50,,2139.8,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2995.72,70,,2995.72,percent of total billed charges,,410.85,,,410.85,Fee Schedule,,348.6,,,348.6,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,348.6,9473,
N block inj celiac pelus,64530,CPT,,,,,,,,both,,,12137.22,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6068.61,50,,6068.61,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1403.21,,,1403.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8496.05,70,,8496.05,percent of total billed charges,,462,,,462,Fee Schedule,,392,,,392,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,754.41,,,754.41,Other,New York Medicaid APG methodology,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1056.18,,,1056.18,Other,140% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1961.47,,,1961.47,Other,260% New York Medicaid APG,2444.29,,,2444.29,Other,324% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,943.01,,,943.01,Other,125% New York Medicaid APG,392,9473,
Implant neuroelectrodes,64553,CPT,,,,,,,,both,,,80880.22,25904.28,,,25904.28,Other,150% of Medicare + 9.63% HCRA Surcharge,15752.55,,,15752.55,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,40440.11,50,,40440.11,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,40570.63,,,40570.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56616.15,70,,56616.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,21812.17,,,21812.17,Other,New York Medicaid APG methodology,21812.17,,,21812.17,Other,100% New York Medicaid APG,21812.17,,,21812.17,Other,100% New York Medicaid APG,21812.17,,,21812.17,Other,100% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,30537.04,,,30537.04,Other,140% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,56711.64,,,56711.64,Other,260% New York Medicaid APG,70671.43,,,70671.43,Other,324% New York Medicaid APG,46896.16,,,46896.16,Other,215% New York Medicaid APG,46896.16,,,46896.16,Other,215% New York Medicaid APG,27265.21,,,27265.21,Other,125% New York Medicaid APG,3323,70671.43,
Implant neuroelectrodes,64555,CPT,,,,,,,,both,,,39267.55,13005.64,,,13005.64,Other,150% of Medicare + 9.63% HCRA Surcharge,7908.81,,,7908.81,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,19633.78,50,,19633.78,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,30511.22,,,30511.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27487.29,70,,27487.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,16403.88,,,16403.88,Other,New York Medicaid APG methodology,16403.88,,,16403.88,Other,100% New York Medicaid APG,16403.88,,,16403.88,Other,100% New York Medicaid APG,16403.88,,,16403.88,Other,100% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,22965.44,,,22965.44,Other,140% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,42650.09,,,42650.09,Other,260% New York Medicaid APG,53148.58,,,53148.58,Other,324% New York Medicaid APG,35268.35,,,35268.35,Other,215% New York Medicaid APG,35268.35,,,35268.35,Other,215% New York Medicaid APG,20504.85,,,20504.85,Other,125% New York Medicaid APG,3323,53148.58,
Implant neuroelectrodes,64561,CPT,,,,,,,,both,,,36824.15,13005.64,,,13005.64,Other,150% of Medicare + 9.63% HCRA Surcharge,7908.81,,,7908.81,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,18412.08,50,,18412.08,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,30511.22,,,30511.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25776.91,70,,25776.91,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,16403.88,,,16403.88,Other,New York Medicaid APG methodology,16403.88,,,16403.88,Other,100% New York Medicaid APG,16403.88,,,16403.88,Other,100% New York Medicaid APG,16403.88,,,16403.88,Other,100% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,22965.44,,,22965.44,Other,140% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,42650.09,,,42650.09,Other,260% New York Medicaid APG,53148.58,,,53148.58,Other,324% New York Medicaid APG,35268.35,,,35268.35,Other,215% New York Medicaid APG,35268.35,,,35268.35,Other,215% New York Medicaid APG,20504.85,,,20504.85,Other,125% New York Medicaid APG,5919,53148.58,
Neuroeltrd stim post tibial,64566,CPT,,,,,,,,both,,,6229.82,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3114.91,50,,3114.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4360.87,70,,4360.87,percent of total billed charges,,146.85,,,146.85,Fee Schedule,,124.6,,,124.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,124.6,9473,
Inc for vagus n elect impl,64568,CPT,,,,,,,,both,,,196832.52,59050.36,,,59050.36,Other,150% of Medicare + 9.63% HCRA Surcharge,35908.88,,,35908.88,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,98416.26,50,,98416.26,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,40570.63,,,40570.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,137782.76,70,,137782.76,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,19221,,"100% primary, 50% secondary, 25% tertiary procedure",19221,Other,United Healthcare ASC Grouper,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,18154,,"100% primary, 50% secondary, 25% tertiary procedure",18154,Other,United Healthcare ASC Grouper,21812.17,,,21812.17,Other,New York Medicaid APG methodology,21812.17,,,21812.17,Other,100% New York Medicaid APG,21812.17,,,21812.17,Other,100% New York Medicaid APG,21812.17,,,21812.17,Other,100% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,30537.04,,,30537.04,Other,140% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,56711.64,,,56711.64,Other,260% New York Medicaid APG,70671.43,,,70671.43,Other,324% New York Medicaid APG,46896.16,,,46896.16,Other,215% New York Medicaid APG,46896.16,,,46896.16,Other,215% New York Medicaid APG,27265.21,,,27265.21,Other,125% New York Medicaid APG,5261,137782.76,
Revise/repl vagus n eltrd,64569,CPT,,,,,,,,both,,,214748.89,25904.28,,,25904.28,Other,150% of Medicare + 9.63% HCRA Surcharge,15752.55,,,15752.55,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,107374.45,50,,107374.45,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,40570.63,,,40570.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,150324.22,70,,150324.22,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,21812.17,,,21812.17,Other,New York Medicaid APG methodology,21812.17,,,21812.17,Other,100% New York Medicaid APG,21812.17,,,21812.17,Other,100% New York Medicaid APG,21812.17,,,21812.17,Other,100% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,30537.04,,,30537.04,Other,140% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,56711.64,,,56711.64,Other,260% New York Medicaid APG,70671.43,,,70671.43,Other,324% New York Medicaid APG,46896.16,,,46896.16,Other,215% New York Medicaid APG,46896.16,,,46896.16,Other,215% New York Medicaid APG,27265.21,,,27265.21,Other,125% New York Medicaid APG,5261,150324.22,
Remove vagus n eltrd,64570,CPT,,,,,,,,both,,,57908.89,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,28954.45,50,,28954.45,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4340.32,,,4340.32,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,40536.22,70,,40536.22,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2333.51,,,2333.51,Other,New York Medicaid APG methodology,2333.51,,,2333.51,Other,100% New York Medicaid APG,2333.51,,,2333.51,Other,100% New York Medicaid APG,2333.51,,,2333.51,Other,100% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,3266.91,,,3266.91,Other,140% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,6067.11,,,6067.11,Other,260% New York Medicaid APG,7560.56,,,7560.56,Other,324% New York Medicaid APG,5017.04,,,5017.04,Other,215% New York Medicaid APG,5017.04,,,5017.04,Other,215% New York Medicaid APG,2916.88,,,2916.88,Other,125% New York Medicaid APG,2333.51,40536.22,
Implant neuroelectrodes,64575,CPT,,,,,,,,both,,,286522.06,25904.28,,,25904.28,Other,150% of Medicare + 9.63% HCRA Surcharge,15752.55,,,15752.55,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,143261.03,50,,143261.03,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,40570.63,,,40570.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,200565.44,70,,200565.44,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,21812.17,,,21812.17,Other,New York Medicaid APG methodology,21812.17,,,21812.17,Other,100% New York Medicaid APG,21812.17,,,21812.17,Other,100% New York Medicaid APG,21812.17,,,21812.17,Other,100% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,30537.04,,,30537.04,Other,140% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,56711.64,,,56711.64,Other,260% New York Medicaid APG,70671.43,,,70671.43,Other,324% New York Medicaid APG,46896.16,,,46896.16,Other,215% New York Medicaid APG,46896.16,,,46896.16,Other,215% New York Medicaid APG,27265.21,,,27265.21,Other,125% New York Medicaid APG,3323,200565.44,
Implant neuroelectrodes,64580,CPT,,,,,,,,both,,,460124.54,41599.58,,,41599.58,Other,150% of Medicare + 9.63% HCRA Surcharge,25296.95,,,25296.95,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,230062.27,50,,230062.27,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,40570.63,,,40570.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,322087.18,70,,322087.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,21812.17,,,21812.17,Other,New York Medicaid APG methodology,21812.17,,,21812.17,Other,100% New York Medicaid APG,21812.17,,,21812.17,Other,100% New York Medicaid APG,21812.17,,,21812.17,Other,100% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,30537.04,,,30537.04,Other,140% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,56711.64,,,56711.64,Other,260% New York Medicaid APG,70671.43,,,70671.43,Other,324% New York Medicaid APG,46896.16,,,46896.16,Other,215% New York Medicaid APG,46896.16,,,46896.16,Other,215% New York Medicaid APG,27265.21,,,27265.21,Other,125% New York Medicaid APG,3323,322087.18,
Implant neuroelectrodes,64581,CPT,,,,,,,,both,,,54207.22,13005.64,,,13005.64,Other,150% of Medicare + 9.63% HCRA Surcharge,7908.81,,,7908.81,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,27103.61,50,,27103.61,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,30511.22,,,30511.22,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,37945.05,70,,37945.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,16403.88,,,16403.88,Other,New York Medicaid APG methodology,16403.88,,,16403.88,Other,100% New York Medicaid APG,16403.88,,,16403.88,Other,100% New York Medicaid APG,16403.88,,,16403.88,Other,100% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,22965.44,,,22965.44,Other,140% New York Medicaid APG,36908.74,,,36908.74,Other,225% New York Medicaid APG,42650.09,,,42650.09,Other,260% New York Medicaid APG,53148.58,,,53148.58,Other,324% New York Medicaid APG,35268.35,,,35268.35,Other,215% New York Medicaid APG,35268.35,,,35268.35,Other,215% New York Medicaid APG,20504.85,,,20504.85,Other,125% New York Medicaid APG,5919,53148.58,
Revise/remove neuroelectrode,64585,CPT,,,,,,,,both,,,48312.19,6470.41,,,6470.41,Other,150% of Medicare + 9.63% HCRA Surcharge,3934.69,,,3934.69,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,24156.1,50,,24156.1,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4340.32,,,4340.32,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,33818.53,70,,33818.53,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2333.51,,,2333.51,Other,New York Medicaid APG methodology,2333.51,,,2333.51,Other,100% New York Medicaid APG,2333.51,,,2333.51,Other,100% New York Medicaid APG,2333.51,,,2333.51,Other,100% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,3266.91,,,3266.91,Other,140% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,6067.11,,,6067.11,Other,260% New York Medicaid APG,7560.56,,,7560.56,Other,324% New York Medicaid APG,5017.04,,,5017.04,Other,215% New York Medicaid APG,5017.04,,,5017.04,Other,215% New York Medicaid APG,2916.88,,,2916.88,Other,125% New York Medicaid APG,2333.51,33818.53,
Insrt/redo pn/gastr stimul,64590,CPT,,,,,,,,both,,,79112.92,41599.58,,,41599.58,Other,150% of Medicare + 9.63% HCRA Surcharge,25296.95,,,25296.95,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,39556.46,50,,39556.46,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,40570.63,,,40570.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,55379.04,70,,55379.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,17798,,"100% primary, 50% secondary, 25% tertiary procedure",17798,Other,United Healthcare ASC Grouper,16018,,"100% primary, 50% secondary, 25% tertiary procedure",16018,Other,United Healthcare ASC Grouper,17798,,"100% primary, 50% secondary, 25% tertiary procedure",17798,Other,United Healthcare ASC Grouper,15129,,"100% primary, 50% secondary, 25% tertiary procedure",15129,Other,United Healthcare ASC Grouper,21812.17,,,21812.17,Other,New York Medicaid APG methodology,21812.17,,,21812.17,Other,100% New York Medicaid APG,21812.17,,,21812.17,Other,100% New York Medicaid APG,21812.17,,,21812.17,Other,100% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,30537.04,,,30537.04,Other,140% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,56711.64,,,56711.64,Other,260% New York Medicaid APG,70671.43,,,70671.43,Other,324% New York Medicaid APG,46896.16,,,46896.16,Other,215% New York Medicaid APG,46896.16,,,46896.16,Other,215% New York Medicaid APG,27265.21,,,27265.21,Other,125% New York Medicaid APG,5261,70671.43,
Revise/rmv pn/gastr stimul,64595,CPT,,,,,,,,both,,,36457.37,6470.41,,,6470.41,Other,150% of Medicare + 9.63% HCRA Surcharge,3934.69,,,3934.69,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18228.69,50,,18228.69,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4340.32,,,4340.32,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25520.16,70,,25520.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2333.51,,,2333.51,Other,New York Medicaid APG methodology,2333.51,,,2333.51,Other,100% New York Medicaid APG,2333.51,,,2333.51,Other,100% New York Medicaid APG,2333.51,,,2333.51,Other,100% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,3266.91,,,3266.91,Other,140% New York Medicaid APG,5250.39,,,5250.39,Other,225% New York Medicaid APG,6067.11,,,6067.11,Other,260% New York Medicaid APG,7560.56,,,7560.56,Other,324% New York Medicaid APG,5017.04,,,5017.04,Other,215% New York Medicaid APG,5017.04,,,5017.04,Other,215% New York Medicaid APG,2916.88,,,2916.88,Other,125% New York Medicaid APG,2333.51,25520.16,
Injection treatment of nerve,64600,CPT,,,,,,,,both,,,19171.82,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9585.91,50,,9585.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1403.21,,,1403.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13420.27,70,,13420.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,754.41,,,754.41,Other,New York Medicaid APG methodology,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1056.18,,,1056.18,Other,140% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1961.47,,,1961.47,Other,260% New York Medicaid APG,2444.29,,,2444.29,Other,324% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,943.01,,,943.01,Other,125% New York Medicaid APG,754.41,13420.27,
Injection treatment of nerve,64605,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1403.21,,,1403.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,754.41,,,754.41,Other,New York Medicaid APG methodology,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1056.18,,,1056.18,Other,140% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1961.47,,,1961.47,Other,260% New York Medicaid APG,2444.29,,,2444.29,Other,324% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,943.01,,,943.01,Other,125% New York Medicaid APG,754.41,28428.05,
Injection treatment of nerve,64610,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1403.21,,,1403.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,754.41,,,754.41,Other,New York Medicaid APG methodology,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1056.18,,,1056.18,Other,140% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1961.47,,,1961.47,Other,260% New York Medicaid APG,2444.29,,,2444.29,Other,324% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,943.01,,,943.01,Other,125% New York Medicaid APG,754.41,28428.05,
Chemodenerv saliv glands,64611,CPT,,,,,,,,both,,,31532.05,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,15766.03,50,,15766.03,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22072.44,70,,22072.44,percent of total billed charges,,549.45,,,549.45,Fee Schedule,,466.2,,,466.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,0.01,22072.44,
Destroy nerve face muscle,64612,CPT,,,,,,,,both,,,6229.82,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3114.91,50,,3114.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4360.87,70,,4360.87,percent of total billed charges,,584.1,,,584.1,Fee Schedule,,495.6,,,495.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,342.51,9473,
Chemodenerv musc migraine,64615,CPT,,,,,,,,both,,,6229.82,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3114.91,50,,3114.91,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4360.87,70,,4360.87,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,0.01,13157,
Chemodenerv musc neck dyston,64616,CPT,,,,,,,,both,,,6229.82,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3114.91,50,,3114.91,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4360.87,70,,4360.87,percent of total billed charges,,536.25,,,536.25,Fee Schedule,,455,,,455,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,0.01,9473,
Chemodener muscle larynx emg,64617,CPT,,,,,,,,both,,,14545.81,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7272.91,50,,7272.91,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10182.07,70,,10182.07,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,0.01,13157,
Injection treatment of nerve,64620,CPT,,,,,,,,both,,,3105,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1552.5,50,,1552.5,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1403.21,,,1403.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2173.5,70,,2173.5,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,754.41,,,754.41,Other,New York Medicaid APG methodology,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1056.18,,,1056.18,Other,140% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1961.47,,,1961.47,Other,260% New York Medicaid APG,2444.29,,,2444.29,Other,324% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,943.01,,,943.01,Other,125% New York Medicaid APG,754.41,13157,
Dstrj nulyt agt gnclr nrv,64624,CPT,,,,,,,,both,,,11278.42,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5639.21,50,,5639.21,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1403.21,,,1403.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,7894.89,70,,7894.89,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,754.41,,,754.41,Other,New York Medicaid APG methodology,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1056.18,,,1056.18,Other,140% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1961.47,,,1961.47,Other,260% New York Medicaid APG,2444.29,,,2444.29,Other,324% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,943.01,,,943.01,Other,125% New York Medicaid APG,754.41,13157,
Rf abltj nrv nrvtg si jt,64625,CPT,,,,,,,,both,,,16895.98,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,8447.99,50,,8447.99,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,11827.19,70,,11827.19,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,13157,
Injection treatment of nerve,64630,CPT,,,,,,,,both,,,19171.82,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9585.91,50,,9585.91,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1403.21,,,1403.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13420.27,70,,13420.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,754.41,,,754.41,Other,New York Medicaid APG methodology,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1056.18,,,1056.18,Other,140% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1961.47,,,1961.47,Other,260% New York Medicaid APG,2444.29,,,2444.29,Other,324% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,943.01,,,943.01,Other,125% New York Medicaid APG,754.41,13420.27,
N block inj common digit,64632,CPT,,,,,,,,both,,,32316.64,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16158.32,50,,16158.32,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22621.65,70,,22621.65,percent of total billed charges,,326.7,,,326.7,Fee Schedule,,277.2,,,277.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,0.01,22621.65,
Destroy cerv/thor facet jnt,64633,CPT,,,,,,,,both,,,7145.41,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,3572.71,50,,3572.71,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1403.21,,,1403.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5001.79,70,,5001.79,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,754.41,,,754.41,Other,New York Medicaid APG methodology,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1056.18,,,1056.18,Other,140% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1961.47,,,1961.47,Other,260% New York Medicaid APG,2444.29,,,2444.29,Other,324% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,943.01,,,943.01,Other,125% New York Medicaid APG,754.41,13157,
Destroy c/th facet jnt addl,64634,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,325.05,,,325.05,Fee Schedule,,275.8,,,275.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,0.01,22702.47,
Destroy lumb/sac facet jnt,64635,CPT,,,,,,,,both,,,7323.18,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,3661.59,50,,3661.59,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1403.21,,,1403.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5126.23,70,,5126.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,754.41,,,754.41,Other,New York Medicaid APG methodology,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1056.18,,,1056.18,Other,140% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1961.47,,,1961.47,Other,260% New York Medicaid APG,2444.29,,,2444.29,Other,324% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,943.01,,,943.01,Other,125% New York Medicaid APG,754.41,13157,
Destroy l/s facet jnt addl,64636,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1403.21,,,1403.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,287.1,,,287.1,Fee Schedule,,243.6,,,243.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,754.41,,,754.41,Other,New York Medicaid APG methodology,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1056.18,,,1056.18,Other,140% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1961.47,,,1961.47,Other,260% New York Medicaid APG,2444.29,,,2444.29,Other,324% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,943.01,,,943.01,Other,125% New York Medicaid APG,0.01,22702.47,
Injection treatment of nerve,64640,CPT,,,,,,,,both,,,8581.36,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4290.68,50,,4290.68,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1403.21,,,1403.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,6006.95,70,,6006.95,percent of total billed charges,,577.5,,,577.5,Fee Schedule,,490,,,490,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,754.41,,,754.41,Other,New York Medicaid APG methodology,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1056.18,,,1056.18,Other,140% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1961.47,,,1961.47,Other,260% New York Medicaid APG,2444.29,,,2444.29,Other,324% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,943.01,,,943.01,Other,125% New York Medicaid APG,490,9473,
Chemodenerv 1 extremity 1-4,64642,CPT,,,,,,,,both,,,14545.81,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7272.91,50,,7272.91,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10182.07,70,,10182.07,percent of total billed charges,,521.4,,,521.4,Fee Schedule,,442.4,,,442.4,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,0.01,10182.07,
Chemodenerv 1 extrem 1-4 ea,64643,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,344.85,,,344.85,Fee Schedule,,292.6,,,292.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,0.01,22702.47,
Chemodenerv 1 extrem 5/> mus,64644,CPT,,,,,,,,both,,,14545.81,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7272.91,50,,7272.91,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10182.07,70,,10182.07,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,0.01,13157,
Chemodenerv 1 extrem 5/> ea,64645,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,400.95,,,400.95,Fee Schedule,,340.2,,,340.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,0.01,22702.47,
Chemodenerv trunk musc 1-5,64646,CPT,,,,,,,,both,,,14545.81,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7272.91,50,,7272.91,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10182.07,70,,10182.07,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,0.01,13157,
Chemodenerv trunk musc 6/>,64647,CPT,,,,,,,,both,,,14545.81,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7272.91,50,,7272.91,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10182.07,70,,10182.07,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,0.01,13157,
Chemodenerv eccrine glands,64650,CPT,,,,,,,,both,,,6229.82,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3114.91,50,,3114.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4360.87,70,,4360.87,percent of total billed charges,,199.65,,,199.65,Fee Schedule,,169.4,,,169.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,169.4,9473,
Chemodenerv eccrine glands,64653,CPT,,,,,,,,both,,,37692.12,563.23,,,563.23,Other,150% of Medicare + 9.63% HCRA Surcharge,342.51,,,342.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,18846.06,50,,18846.06,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26384.48,70,,26384.48,percent of total billed charges,,254.1,,,254.1,Fee Schedule,,215.6,,,215.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,215.6,26384.48,
Injection treatment of nerve,64680,CPT,,,,,,,,both,,,22394,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,11197,50,,11197,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1403.21,,,1403.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,15675.8,70,,15675.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,754.41,,,754.41,Other,New York Medicaid APG methodology,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1056.18,,,1056.18,Other,140% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1961.47,,,1961.47,Other,260% New York Medicaid APG,2444.29,,,2444.29,Other,324% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,943.01,,,943.01,Other,125% New York Medicaid APG,754.41,15675.8,
Injection treatment of nerve,64681,CPT,,,,,,,,both,,,19171.82,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9585.91,50,,9585.91,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1403.21,,,1403.21,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13420.27,70,,13420.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,754.41,,,754.41,Other,New York Medicaid APG methodology,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,754.41,,,754.41,Other,100% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1056.18,,,1056.18,Other,140% New York Medicaid APG,1697.43,,,1697.43,Other,225% New York Medicaid APG,1961.47,,,1961.47,Other,260% New York Medicaid APG,2444.29,,,2444.29,Other,324% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,1621.98,,,1621.98,Other,215% New York Medicaid APG,943.01,,,943.01,Other,125% New York Medicaid APG,754.41,13420.27,
Revise finger/toe nerve,64702,CPT,,,,,,,,both,,,39486.15,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19743.08,50,,19743.08,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27640.31,70,,27640.31,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,27640.31,
Revise hand/foot nerve,64704,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,28428.05,
Revise arm/leg nerve,64708,CPT,,,,,,,,both,,,44531.93,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,22265.97,50,,22265.97,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31172.35,70,,31172.35,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,31172.35,
Revision of sciatic nerve,64712,CPT,,,,,,,,both,,,66847.9,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33423.95,50,,33423.95,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46793.53,70,,46793.53,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,2232.76,46793.53,
Revision of arm nerve(s),64713,CPT,,,,,,,,both,,,67907.61,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33953.81,50,,33953.81,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47535.33,70,,47535.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,2232.76,47535.33,
Revise low back nerve(s),64714,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,2232.76,28428.05,
Revision of cranial nerve,64716,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,2232.76,28428.05,
Revise ulnar nerve at elbow,64718,CPT,,,,,,,,both,,,46351.11,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,23175.56,50,,23175.56,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,32445.78,70,,32445.78,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,32445.78,
Revise ulnar nerve at wrist,64719,CPT,,,,,,,,both,,,55878.32,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,27939.16,50,,27939.16,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,39114.82,70,,39114.82,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,39114.82,
Carpal tunnel surgery,64721,CPT,,,,,,,,both,,,35340.41,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17670.21,50,,17670.21,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24738.29,70,,24738.29,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,24738.29,
Relieve pressure on nerve(s),64722,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,28428.05,
Release foot/toe nerve,64726,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,28428.05,
Internal nerve revision,64727,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,0.01,22702.47,
Incision of brow nerve,64732,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,28428.05,
Incision of cheek nerve,64734,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,28428.05,
Incision of chin nerve,64736,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,28428.05,
Incision of jaw nerve,64738,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,28428.05,
Incision of tongue nerve,64740,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,28428.05,
Incision of facial nerve,64742,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,28428.05,
Incise nerve back of head,64744,CPT,,,,,,,,both,,,65635.43,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,32817.72,50,,32817.72,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45944.8,70,,45944.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,2232.76,45944.8,
Incise diaphragm nerve,64746,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,2232.76,28428.05,
Incise hip/thigh nerve,64763,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,28428.05,
Incise hip/thigh nerve,64766,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,28428.05,
Sever cranial nerve,64771,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,2232.76,28428.05,
Incision of spinal nerve,64772,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,28428.05,
Remove skin nerve lesion,64774,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,28428.05,
Remove digit nerve lesion,64776,CPT,,,,,,,,both,,,32128.65,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16064.33,50,,16064.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22490.06,70,,22490.06,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,22490.06,
Digit nerve surgery add-on,64778,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,0.01,36100.43,
Remove limb nerve lesion,64782,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,28428.05,
Limb nerve surgery add-on,64783,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,0.01,36100.43,
Remove nerve lesion,64784,CPT,,,,,,,,both,,,71512.33,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,35756.17,50,,35756.17,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50058.63,70,,50058.63,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,50058.63,
Remove sciatic nerve lesion,64786,CPT,,,,,,,,both,,,140115.1,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,70057.55,50,,70057.55,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,98080.57,70,,98080.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,4184.81,98080.57,
Implant nerve end,64787,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,0.01,36100.43,
Remove skin nerve lesion,64788,CPT,,,,,,,,both,,,40767.87,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20383.94,50,,20383.94,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28537.51,70,,28537.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,28537.51,
Removal of nerve lesion,64790,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,2232.76,28428.05,
Removal of nerve lesion,64792,CPT,,,,,,,,both,,,74117.29,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,37058.65,50,,37058.65,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,51882.1,70,,51882.1,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,4184.81,51882.1,
Biopsy of nerve,64795,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,28428.05,
Sympathectomy cervical,64802,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,28428.05,
Remove sympathetic nerves,64804,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,2232.76,28428.05,
Sympathectomy digital artery,64820,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,28428.05,
Remove sympathetic nerves,64821,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,47657.93,
Remove sympathetic nerves,64822,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,47657.93,
Sympathectomy supfc palmar,64823,CPT,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,47657.93,
Repair of digit nerve,64831,CPT,,,,,,,,both,,,39185.65,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,19592.83,50,,19592.83,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27429.96,70,,27429.96,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,27429.96,
Repair nerve add-on,64832,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,0.01,22702.47,
Repair of hand or foot nerve,64834,CPT,,,,,,,,both,,,140115.1,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,70057.55,50,,70057.55,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,98080.57,70,,98080.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,4184.81,98080.57,
Repair of hand or foot nerve,64835,CPT,,,,,,,,both,,,140115.1,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,70057.55,50,,70057.55,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,98080.57,70,,98080.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,4184.81,98080.57,
Repair of hand or foot nerve,64836,CPT,,,,,,,,both,,,140115.1,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,70057.55,50,,70057.55,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,98080.57,70,,98080.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,4184.81,98080.57,
Repair nerve add-on,64837,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,0.01,22702.47,
Repair of leg nerve,64840,CPT,,,,,,,,both,,,140115.1,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,70057.55,50,,70057.55,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,98080.57,70,,98080.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,4184.81,98080.57,
Repair/transpose nerve,64856,CPT,,,,,,,,both,,,140115.1,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,70057.55,50,,70057.55,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,98080.57,70,,98080.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,4184.81,98080.57,
Repair arm/leg nerve,64857,CPT,,,,,,,,both,,,140115.1,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,70057.55,50,,70057.55,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,98080.57,70,,98080.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,4184.81,98080.57,
Repair sciatic nerve,64858,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,2232.76,28428.05,
Nerve surgery,64859,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,0.01,22702.47,
Repair of arm nerves,64861,CPT,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,2232.76,28428.05,
Repair of low back nerves,64862,CPT,,,,,,,,both,,,140115.1,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,70057.55,50,,70057.55,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,98080.57,70,,98080.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,4184.81,98080.57,
Repair of facial nerve,64864,CPT,,,,,,,,both,,,140115.1,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,70057.55,50,,70057.55,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,98080.57,70,,98080.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,4184.81,98080.57,
Repair of facial nerve,64865,CPT,,,,,,,,both,,,140115.1,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,70057.55,50,,70057.55,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,98080.57,70,,98080.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,4184.81,98080.57,
Subsequent repair of nerve,64872,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,0.01,36100.43,
Repair & revise nerve add-on,64874,CPT,,,,,,,,both,,,64479.48,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32239.74,50,,32239.74,percent of total billed charges,,45135.64,70,,45135.64,percent of total billed charges,,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45135.64,70,,45135.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,0.01,45135.64,
Repair nerve/shorten bone,64876,CPT,,,,,,,,both,,,64479.48,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32239.74,50,,32239.74,percent of total billed charges,,45135.64,70,,45135.64,percent of total billed charges,,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45135.64,70,,45135.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,0.01,45135.64,
Nerve graft head/neck </4 cm,64885,CPT,,,,,,,,both,,,140115.1,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,70057.55,50,,70057.55,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,98080.57,70,,98080.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,4184.81,98080.57,
Nerve graft head/neck >4 cm,64886,CPT,,,,,,,,both,,,86224.88,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,43112.44,50,,43112.44,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,60357.42,70,,60357.42,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,4184.81,60357.42,
Nerve graft hand/foot </4 cm,64890,CPT,,,,,,,,both,,,140115.1,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,70057.55,50,,70057.55,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,98080.57,70,,98080.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,4184.81,98080.57,
Nerve graft hand/foot >4 cm,64891,CPT,,,,,,,,both,,,140115.1,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,70057.55,50,,70057.55,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,98080.57,70,,98080.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,4184.81,98080.57,
Nerve graft arm/leg <4 cm,64892,CPT,,,,,,,,both,,,140115.1,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,70057.55,50,,70057.55,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,98080.57,70,,98080.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,4184.81,98080.57,
Nerve graft arm/leg >4 cm,64893,CPT,,,,,,,,both,,,60558.97,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,30279.49,50,,30279.49,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,42391.28,70,,42391.28,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,4184.81,42391.28,
Nerve graft hand/foot </4 cm,64895,CPT,,,,,,,,both,,,140115.1,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,70057.55,50,,70057.55,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,98080.57,70,,98080.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,4184.81,98080.57,
Nerve graft hand/foot >4 cm,64896,CPT,,,,,,,,both,,,140115.1,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,70057.55,50,,70057.55,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,98080.57,70,,98080.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,4184.81,98080.57,
Nerve graft arm/leg </4 cm,64897,CPT,,,,,,,,both,,,140115.1,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,70057.55,50,,70057.55,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,98080.57,70,,98080.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,4184.81,98080.57,
Nerve graft arm/leg >4 cm,64898,CPT,,,,,,,,both,,,140115.1,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,70057.55,50,,70057.55,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,98080.57,70,,98080.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,4184.81,98080.57,
Nerve graft add-on,64901,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,0.01,36100.43,
Nerve graft add-on,64902,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,0.01,36100.43,
Nerve pedicle transfer,64905,CPT,,,,,,,,both,,,143860.38,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,71930.19,50,,71930.19,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,100702.27,70,,100702.27,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,4184.81,100702.27,
Nerve pedicle transfer,64907,CPT,,,,,,,,both,,,140115.1,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,70057.55,50,,70057.55,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,98080.57,70,,98080.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,3323,98080.57,
Nerve repair w/allograft,64910,CPT,,,,,,,,both,,,59519.34,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,29759.67,50,,29759.67,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41663.54,70,,41663.54,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,4184.81,41663.54,
Neurorraphy w/vein autograft,64911,CPT,,,,,,,,both,,,140115.1,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,70057.55,50,,70057.55,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,98080.57,70,,98080.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,4184.81,98080.57,
Nrv rpr w/nrv algrft 1st,64912,CPT,,,,,,,,both,,,124326.97,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,62163.49,50,,62163.49,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,87028.88,70,,87028.88,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,4184.81,87028.88,
Nrv rpr w/nrv algrft ea addl,64913,CPT,,,,,,,,both,,,51572.04,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25786.02,50,,25786.02,percent of total billed charges,,36100.43,70,,36100.43,percent of total billed charges,,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36100.43,70,,36100.43,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,0.01,36100.43,
Revise eye,65091,CPT,,,,,,,,both,,,39067.66,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19533.83,50,,19533.83,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4289.29,,,4289.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27347.36,70,,27347.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2306.07,,,2306.07,Other,New York Medicaid APG methodology,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,3228.5,,,3228.5,Other,140% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5995.78,,,5995.78,Other,260% New York Medicaid APG,7471.67,,,7471.67,Other,324% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,2882.59,,,2882.59,Other,125% New York Medicaid APG,2306.07,27347.36,
Revise eye with implant,65093,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4289.29,,,4289.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2306.07,,,2306.07,Other,New York Medicaid APG methodology,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,3228.5,,,3228.5,Other,140% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5995.78,,,5995.78,Other,260% New York Medicaid APG,7471.67,,,7471.67,Other,324% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,2882.59,,,2882.59,Other,125% New York Medicaid APG,2306.07,56927.18,
Removal of eye,65101,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4289.29,,,4289.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2306.07,,,2306.07,Other,New York Medicaid APG methodology,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,3228.5,,,3228.5,Other,140% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5995.78,,,5995.78,Other,260% New York Medicaid APG,7471.67,,,7471.67,Other,324% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,2882.59,,,2882.59,Other,125% New York Medicaid APG,2306.07,56927.18,
Remove eye/insert implant,65103,CPT,,,,,,,,both,,,49058.26,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,24529.13,50,,24529.13,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4289.29,,,4289.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34340.78,70,,34340.78,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2306.07,,,2306.07,Other,New York Medicaid APG methodology,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,3228.5,,,3228.5,Other,140% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5995.78,,,5995.78,Other,260% New York Medicaid APG,7471.67,,,7471.67,Other,324% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,2882.59,,,2882.59,Other,125% New York Medicaid APG,2306.07,34340.78,
Remove eye/attach implant,65105,CPT,,,,,,,,both,,,55881.02,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,27940.51,50,,27940.51,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4289.29,,,4289.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,39116.71,70,,39116.71,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2306.07,,,2306.07,Other,New York Medicaid APG methodology,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,3228.5,,,3228.5,Other,140% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5995.78,,,5995.78,Other,260% New York Medicaid APG,7471.67,,,7471.67,Other,324% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,2882.59,,,2882.59,Other,125% New York Medicaid APG,2306.07,39116.71,
Removal of eye,65110,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4289.29,,,4289.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2306.07,,,2306.07,Other,New York Medicaid APG methodology,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,3228.5,,,3228.5,Other,140% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5995.78,,,5995.78,Other,260% New York Medicaid APG,7471.67,,,7471.67,Other,324% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,2882.59,,,2882.59,Other,125% New York Medicaid APG,2306.07,56927.18,
Remove eye/revise socket,65112,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4289.29,,,4289.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2306.07,,,2306.07,Other,New York Medicaid APG methodology,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,3228.5,,,3228.5,Other,140% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5995.78,,,5995.78,Other,260% New York Medicaid APG,7471.67,,,7471.67,Other,324% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,2882.59,,,2882.59,Other,125% New York Medicaid APG,2306.07,56927.18,
Remove eye/revise socket,65114,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4289.29,,,4289.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2306.07,,,2306.07,Other,New York Medicaid APG methodology,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,3228.5,,,3228.5,Other,140% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5995.78,,,5995.78,Other,260% New York Medicaid APG,7471.67,,,7471.67,Other,324% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,2882.59,,,2882.59,Other,125% New York Medicaid APG,2306.07,56927.18,
Revise ocular implant,65125,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4289.29,,,4289.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2306.07,,,2306.07,Other,New York Medicaid APG methodology,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,3228.5,,,3228.5,Other,140% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5995.78,,,5995.78,Other,260% New York Medicaid APG,7471.67,,,7471.67,Other,324% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,2882.59,,,2882.59,Other,125% New York Medicaid APG,2306.07,34406.09,
Insert ocular implant,65130,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4289.29,,,4289.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2306.07,,,2306.07,Other,New York Medicaid APG methodology,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,3228.5,,,3228.5,Other,140% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5995.78,,,5995.78,Other,260% New York Medicaid APG,7471.67,,,7471.67,Other,324% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,2882.59,,,2882.59,Other,125% New York Medicaid APG,2306.07,56927.18,
Insert ocular implant,65135,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4289.29,,,4289.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2306.07,,,2306.07,Other,New York Medicaid APG methodology,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,3228.5,,,3228.5,Other,140% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5995.78,,,5995.78,Other,260% New York Medicaid APG,7471.67,,,7471.67,Other,324% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,2882.59,,,2882.59,Other,125% New York Medicaid APG,2306.07,56927.18,
Attach ocular implant,65140,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4289.29,,,4289.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2306.07,,,2306.07,Other,New York Medicaid APG methodology,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,3228.5,,,3228.5,Other,140% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5995.78,,,5995.78,Other,260% New York Medicaid APG,7471.67,,,7471.67,Other,324% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,2882.59,,,2882.59,Other,125% New York Medicaid APG,2306.07,56927.18,
Revise ocular implant,65150,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4289.29,,,4289.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2306.07,,,2306.07,Other,New York Medicaid APG methodology,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,3228.5,,,3228.5,Other,140% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5995.78,,,5995.78,Other,260% New York Medicaid APG,7471.67,,,7471.67,Other,324% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,2882.59,,,2882.59,Other,125% New York Medicaid APG,2306.07,56927.18,
Reinsert ocular implant,65155,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4289.29,,,4289.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2306.07,,,2306.07,Other,New York Medicaid APG methodology,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,3228.5,,,3228.5,Other,140% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5995.78,,,5995.78,Other,260% New York Medicaid APG,7471.67,,,7471.67,Other,324% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,2882.59,,,2882.59,Other,125% New York Medicaid APG,2306.07,56927.18,
Removal of ocular implant,65175,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4289.29,,,4289.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2306.07,,,2306.07,Other,New York Medicaid APG methodology,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,3228.5,,,3228.5,Other,140% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5995.78,,,5995.78,Other,260% New York Medicaid APG,7471.67,,,7471.67,Other,324% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,2882.59,,,2882.59,Other,125% New York Medicaid APG,2306.07,56927.18,
Remove foreign body from eye,65205,CPT,,,,,,,,both,,,2686.86,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1343.43,50,,1343.43,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,408.99,,,408.99,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,1880.8,70,,1880.8,percent of total billed charges,,141.9,,,141.9,Fee Schedule,,120.4,,,120.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,219.89,,,219.89,Other,New York Medicaid APG methodology,219.89,,,219.89,Other,100% New York Medicaid APG,219.89,,,219.89,Other,100% New York Medicaid APG,219.89,,,219.89,Other,100% New York Medicaid APG,494.75,,,494.75,Other,225% New York Medicaid APG,494.75,,,494.75,Other,225% New York Medicaid APG,494.75,,,494.75,Other,225% New York Medicaid APG,494.75,,,494.75,Other,225% New York Medicaid APG,307.84,,,307.84,Other,140% New York Medicaid APG,494.75,,,494.75,Other,225% New York Medicaid APG,571.71,,,571.71,Other,260% New York Medicaid APG,712.44,,,712.44,Other,324% New York Medicaid APG,472.76,,,472.76,Other,215% New York Medicaid APG,472.76,,,472.76,Other,215% New York Medicaid APG,274.86,,,274.86,Other,125% New York Medicaid APG,0.01,9473,
Remove foreign body from eye,65210,CPT,,,,,,,,both,,,8380.68,757.69,,,757.69,Other,150% of Medicare + 9.63% HCRA Surcharge,460.76,,,460.76,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4190.34,50,,4190.34,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,408.99,,,408.99,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5866.48,70,,5866.48,percent of total billed charges,,174.9,,,174.9,Fee Schedule,,148.4,,,148.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,219.89,,,219.89,Other,New York Medicaid APG methodology,219.89,,,219.89,Other,100% New York Medicaid APG,219.89,,,219.89,Other,100% New York Medicaid APG,219.89,,,219.89,Other,100% New York Medicaid APG,494.75,,,494.75,Other,225% New York Medicaid APG,494.75,,,494.75,Other,225% New York Medicaid APG,494.75,,,494.75,Other,225% New York Medicaid APG,494.75,,,494.75,Other,225% New York Medicaid APG,307.84,,,307.84,Other,140% New York Medicaid APG,494.75,,,494.75,Other,225% New York Medicaid APG,571.71,,,571.71,Other,260% New York Medicaid APG,712.44,,,712.44,Other,324% New York Medicaid APG,472.76,,,472.76,Other,215% New York Medicaid APG,472.76,,,472.76,Other,215% New York Medicaid APG,274.86,,,274.86,Other,125% New York Medicaid APG,0.01,9473,
Remove foreign body from eye,65220,CPT,,,,,,,,both,,,8380.68,757.69,,,757.69,Other,150% of Medicare + 9.63% HCRA Surcharge,460.76,,,460.76,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4190.34,50,,4190.34,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,408.99,,,408.99,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5866.48,70,,5866.48,percent of total billed charges,,202.95,,,202.95,Fee Schedule,,172.2,,,172.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,219.89,,,219.89,Other,New York Medicaid APG methodology,219.89,,,219.89,Other,100% New York Medicaid APG,219.89,,,219.89,Other,100% New York Medicaid APG,219.89,,,219.89,Other,100% New York Medicaid APG,494.75,,,494.75,Other,225% New York Medicaid APG,494.75,,,494.75,Other,225% New York Medicaid APG,494.75,,,494.75,Other,225% New York Medicaid APG,494.75,,,494.75,Other,225% New York Medicaid APG,307.84,,,307.84,Other,140% New York Medicaid APG,494.75,,,494.75,Other,225% New York Medicaid APG,571.71,,,571.71,Other,260% New York Medicaid APG,712.44,,,712.44,Other,324% New York Medicaid APG,472.76,,,472.76,Other,215% New York Medicaid APG,472.76,,,472.76,Other,215% New York Medicaid APG,274.86,,,274.86,Other,125% New York Medicaid APG,0.01,9473,
Remove foreign body from eye,65222,CPT,,,,,,,,both,,,2686.86,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1343.43,50,,1343.43,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,408.99,,,408.99,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,1880.8,70,,1880.8,percent of total billed charges,,242.55,,,242.55,Fee Schedule,,205.8,,,205.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,219.89,,,219.89,Other,New York Medicaid APG methodology,219.89,,,219.89,Other,100% New York Medicaid APG,219.89,,,219.89,Other,100% New York Medicaid APG,219.89,,,219.89,Other,100% New York Medicaid APG,494.75,,,494.75,Other,225% New York Medicaid APG,494.75,,,494.75,Other,225% New York Medicaid APG,494.75,,,494.75,Other,225% New York Medicaid APG,494.75,,,494.75,Other,225% New York Medicaid APG,307.84,,,307.84,Other,140% New York Medicaid APG,494.75,,,494.75,Other,225% New York Medicaid APG,571.71,,,571.71,Other,260% New York Medicaid APG,712.44,,,712.44,Other,324% New York Medicaid APG,472.76,,,472.76,Other,215% New York Medicaid APG,472.76,,,472.76,Other,215% New York Medicaid APG,274.86,,,274.86,Other,125% New York Medicaid APG,0.01,9473,
Remove foreign body from eye,65235,CPT,,,,,,,,both,,,34057.95,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17028.98,50,,17028.98,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23840.57,70,,23840.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,1994.68,23840.57,
Remove foreign body from eye,65260,CPT,,,,,,,,both,,,49016.23,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24508.12,50,,24508.12,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1455.98,,,1455.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34311.36,70,,34311.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,782.79,,,782.79,Other,New York Medicaid APG methodology,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1095.9,,,1095.9,Other,140% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,2035.24,,,2035.24,Other,260% New York Medicaid APG,2536.23,,,2536.23,Other,324% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,978.48,,,978.48,Other,125% New York Medicaid APG,782.79,34311.36,
Remove foreign body from eye,65265,CPT,,,,,,,,both,,,49016.23,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24508.12,50,,24508.12,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1455.98,,,1455.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34311.36,70,,34311.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,782.79,,,782.79,Other,New York Medicaid APG methodology,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1095.9,,,1095.9,Other,140% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,2035.24,,,2035.24,Other,260% New York Medicaid APG,2536.23,,,2536.23,Other,324% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,978.48,,,978.48,Other,125% New York Medicaid APG,782.79,34311.36,
Repair of eye wound,65270,CPT,,,,,,,,both,,,33818.71,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16909.36,50,,16909.36,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23673.1,70,,23673.1,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,23673.1,
Repair of eye wound,65272,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2759.56,,,2759.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,2077.09,,,2077.09,Other,140% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3857.45,,,3857.45,Other,260% New York Medicaid APG,4806.98,,,4806.98,Other,324% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,1854.54,,,1854.54,Other,125% New York Medicaid APG,1483.63,34406.09,
Repair of eye wound,65275,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6502.71,,,6502.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3496.08,,,3496.08,Other,New York Medicaid APG methodology,3496.08,,,3496.08,Other,100% New York Medicaid APG,3496.08,,,3496.08,Other,100% New York Medicaid APG,3496.08,,,3496.08,Other,100% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,4894.51,,,4894.51,Other,140% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,9089.8,,,9089.8,Other,260% New York Medicaid APG,11327.29,,,11327.29,Other,324% New York Medicaid APG,7516.57,,,7516.57,Other,215% New York Medicaid APG,7516.57,,,7516.57,Other,215% New York Medicaid APG,4370.1,,,4370.1,Other,125% New York Medicaid APG,3496.08,56927.18,
Repair of eye wound,65280,CPT,,,,,,,,both,,,109933.59,9939.03,,,9939.03,Other,150% of Medicare + 9.63% HCRA Surcharge,6043.98,,,6043.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54966.8,50,,54966.8,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6502.71,,,6502.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76953.51,70,,76953.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3496.08,,,3496.08,Other,New York Medicaid APG methodology,3496.08,,,3496.08,Other,100% New York Medicaid APG,3496.08,,,3496.08,Other,100% New York Medicaid APG,3496.08,,,3496.08,Other,100% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,4894.51,,,4894.51,Other,140% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,9089.8,,,9089.8,Other,260% New York Medicaid APG,11327.29,,,11327.29,Other,324% New York Medicaid APG,7516.57,,,7516.57,Other,215% New York Medicaid APG,7516.57,,,7516.57,Other,215% New York Medicaid APG,4370.1,,,4370.1,Other,125% New York Medicaid APG,3496.08,76953.51,
Repair of eye wound,65285,CPT,,,,,,,,both,,,109933.59,9939.03,,,9939.03,Other,150% of Medicare + 9.63% HCRA Surcharge,6043.98,,,6043.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54966.8,50,,54966.8,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6502.71,,,6502.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76953.51,70,,76953.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3496.08,,,3496.08,Other,New York Medicaid APG methodology,3496.08,,,3496.08,Other,100% New York Medicaid APG,3496.08,,,3496.08,Other,100% New York Medicaid APG,3496.08,,,3496.08,Other,100% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,4894.51,,,4894.51,Other,140% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,9089.8,,,9089.8,Other,260% New York Medicaid APG,11327.29,,,11327.29,Other,324% New York Medicaid APG,7516.57,,,7516.57,Other,215% New York Medicaid APG,7516.57,,,7516.57,Other,215% New York Medicaid APG,4370.1,,,4370.1,Other,125% New York Medicaid APG,3496.08,76953.51,
Repair of eye wound,65286,CPT,,,,,,,,both,,,49016.23,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24508.12,50,,24508.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3655.3,,,3655.3,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34311.36,70,,34311.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1965.22,,,1965.22,Other,New York Medicaid APG methodology,1965.22,,,1965.22,Other,100% New York Medicaid APG,1965.22,,,1965.22,Other,100% New York Medicaid APG,1965.22,,,1965.22,Other,100% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,2751.3,,,2751.3,Other,140% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,5109.57,,,5109.57,Other,260% New York Medicaid APG,6367.3,,,6367.3,Other,324% New York Medicaid APG,4225.22,,,4225.22,Other,215% New York Medicaid APG,4225.22,,,4225.22,Other,215% New York Medicaid APG,2456.52,,,2456.52,Other,125% New York Medicaid APG,1965.22,34311.36,
Repair of eye socket wound,65290,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4289.29,,,4289.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2306.07,,,2306.07,Other,New York Medicaid APG methodology,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,3228.5,,,3228.5,Other,140% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5995.78,,,5995.78,Other,260% New York Medicaid APG,7471.67,,,7471.67,Other,324% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,2882.59,,,2882.59,Other,125% New York Medicaid APG,2306.07,56927.18,
Removal of eye lesion,65400,CPT,,,,,,,,both,,,35141.42,1925.3,,,1925.3,Other,150% of Medicare + 9.63% HCRA Surcharge,1170.78,,,1170.78,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17570.71,50,,17570.71,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3655.3,,,3655.3,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24598.99,70,,24598.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1965.22,,,1965.22,Other,New York Medicaid APG methodology,1965.22,,,1965.22,Other,100% New York Medicaid APG,1965.22,,,1965.22,Other,100% New York Medicaid APG,1965.22,,,1965.22,Other,100% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,2751.3,,,2751.3,Other,140% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,5109.57,,,5109.57,Other,260% New York Medicaid APG,6367.3,,,6367.3,Other,324% New York Medicaid APG,4225.22,,,4225.22,Other,215% New York Medicaid APG,4225.22,,,4225.22,Other,215% New York Medicaid APG,2456.52,,,2456.52,Other,125% New York Medicaid APG,1170.78,24598.99,
Biopsy of cornea,65410,CPT,,,,,,,,both,,,35214.66,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17607.33,50,,17607.33,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3655.3,,,3655.3,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24650.26,70,,24650.26,percent of total billed charges,,493.35,,,493.35,Fee Schedule,,418.6,,,418.6,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1965.22,,,1965.22,Other,New York Medicaid APG methodology,1965.22,,,1965.22,Other,100% New York Medicaid APG,1965.22,,,1965.22,Other,100% New York Medicaid APG,1965.22,,,1965.22,Other,100% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,2751.3,,,2751.3,Other,140% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,5109.57,,,5109.57,Other,260% New York Medicaid APG,6367.3,,,6367.3,Other,324% New York Medicaid APG,4225.22,,,4225.22,Other,215% New York Medicaid APG,4225.22,,,4225.22,Other,215% New York Medicaid APG,2456.52,,,2456.52,Other,125% New York Medicaid APG,418.6,24650.26,
Removal of eye lesion,65420,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3655.3,,,3655.3,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1965.22,,,1965.22,Other,New York Medicaid APG methodology,1965.22,,,1965.22,Other,100% New York Medicaid APG,1965.22,,,1965.22,Other,100% New York Medicaid APG,1965.22,,,1965.22,Other,100% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,2751.3,,,2751.3,Other,140% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,5109.57,,,5109.57,Other,260% New York Medicaid APG,6367.3,,,6367.3,Other,324% New York Medicaid APG,4225.22,,,4225.22,Other,215% New York Medicaid APG,4225.22,,,4225.22,Other,215% New York Medicaid APG,2456.52,,,2456.52,Other,125% New York Medicaid APG,1965.22,34406.09,
Removal of eye lesion,65426,CPT,,,,,,,,both,,,37961.77,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18980.89,50,,18980.89,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6502.71,,,6502.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26573.24,70,,26573.24,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3496.08,,,3496.08,Other,New York Medicaid APG methodology,3496.08,,,3496.08,Other,100% New York Medicaid APG,3496.08,,,3496.08,Other,100% New York Medicaid APG,3496.08,,,3496.08,Other,100% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,4894.51,,,4894.51,Other,140% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,9089.8,,,9089.8,Other,260% New York Medicaid APG,11327.29,,,11327.29,Other,324% New York Medicaid APG,7516.57,,,7516.57,Other,215% New York Medicaid APG,7516.57,,,7516.57,Other,215% New York Medicaid APG,4370.1,,,4370.1,Other,125% New York Medicaid APG,2702.28,26573.24,
Corneal smear,65430,CPT,,,,,,,,both,,,8380.68,757.69,,,757.69,Other,150% of Medicare + 9.63% HCRA Surcharge,460.76,,,460.76,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4190.34,50,,4190.34,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,634.14,,,634.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5866.48,70,,5866.48,percent of total billed charges,,490.05,,,490.05,Fee Schedule,,415.8,,,415.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,340.93,,,340.93,Other,New York Medicaid APG methodology,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,477.31,,,477.31,Other,140% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,886.43,,,886.43,Other,260% New York Medicaid APG,1104.63,,,1104.63,Other,324% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,426.17,,,426.17,Other,125% New York Medicaid APG,0.01,9473,
Curette/treat cornea,65435,CPT,,,,,,,,both,,,38018.76,1925.3,,,1925.3,Other,150% of Medicare + 9.63% HCRA Surcharge,1170.78,,,1170.78,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19009.38,50,,19009.38,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3655.3,,,3655.3,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26613.13,70,,26613.13,percent of total billed charges,,334.95,,,334.95,Fee Schedule,,284.2,,,284.2,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1965.22,,,1965.22,Other,New York Medicaid APG methodology,1965.22,,,1965.22,Other,100% New York Medicaid APG,1965.22,,,1965.22,Other,100% New York Medicaid APG,1965.22,,,1965.22,Other,100% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,2751.3,,,2751.3,Other,140% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,5109.57,,,5109.57,Other,260% New York Medicaid APG,6367.3,,,6367.3,Other,324% New York Medicaid APG,4225.22,,,4225.22,Other,215% New York Medicaid APG,4225.22,,,4225.22,Other,215% New York Medicaid APG,2456.52,,,2456.52,Other,125% New York Medicaid APG,284.2,26613.13,
Curette/treat cornea,65436,CPT,,,,,,,,both,,,34632.26,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17316.13,50,,17316.13,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,3655.3,,,3655.3,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24242.58,70,,24242.58,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1965.22,,,1965.22,Other,New York Medicaid APG methodology,1965.22,,,1965.22,Other,100% New York Medicaid APG,1965.22,,,1965.22,Other,100% New York Medicaid APG,1965.22,,,1965.22,Other,100% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,2751.3,,,2751.3,Other,140% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,5109.57,,,5109.57,Other,260% New York Medicaid APG,6367.3,,,6367.3,Other,324% New York Medicaid APG,4225.22,,,4225.22,Other,215% New York Medicaid APG,4225.22,,,4225.22,Other,215% New York Medicaid APG,2456.52,,,2456.52,Other,125% New York Medicaid APG,0.01,24242.58,
Treatment of corneal lesion,65450,CPT,,,,,,,,both,,,6127.39,553.97,,,553.97,Other,150% of Medicare + 9.63% HCRA Surcharge,336.87,,,336.87,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3063.7,50,,3063.7,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,3655.3,,,3655.3,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4289.17,70,,4289.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1965.22,,,1965.22,Other,New York Medicaid APG methodology,1965.22,,,1965.22,Other,100% New York Medicaid APG,1965.22,,,1965.22,Other,100% New York Medicaid APG,1965.22,,,1965.22,Other,100% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,2751.3,,,2751.3,Other,140% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,5109.57,,,5109.57,Other,260% New York Medicaid APG,6367.3,,,6367.3,Other,324% New York Medicaid APG,4225.22,,,4225.22,Other,215% New York Medicaid APG,4225.22,,,4225.22,Other,215% New York Medicaid APG,2456.52,,,2456.52,Other,125% New York Medicaid APG,0.01,13157,
Revision of cornea,65600,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3655.3,,,3655.3,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1965.22,,,1965.22,Other,New York Medicaid APG methodology,1965.22,,,1965.22,Other,100% New York Medicaid APG,1965.22,,,1965.22,Other,100% New York Medicaid APG,1965.22,,,1965.22,Other,100% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,2751.3,,,2751.3,Other,140% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,5109.57,,,5109.57,Other,260% New York Medicaid APG,6367.3,,,6367.3,Other,324% New York Medicaid APG,4225.22,,,4225.22,Other,215% New York Medicaid APG,4225.22,,,4225.22,Other,215% New York Medicaid APG,2456.52,,,2456.52,Other,125% New York Medicaid APG,1965.22,34406.09,
Corneal transplant,65710,CPT,,,,,,,,both,,,53411.26,9939.03,,,9939.03,Other,150% of Medicare + 9.63% HCRA Surcharge,6043.98,,,6043.98,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,26705.63,50,,26705.63,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6502.71,,,6502.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,37387.88,70,,37387.88,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3496.08,,,3496.08,Other,New York Medicaid APG methodology,3496.08,,,3496.08,Other,100% New York Medicaid APG,3496.08,,,3496.08,Other,100% New York Medicaid APG,3496.08,,,3496.08,Other,100% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,4894.51,,,4894.51,Other,140% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,9089.8,,,9089.8,Other,260% New York Medicaid APG,11327.29,,,11327.29,Other,324% New York Medicaid APG,7516.57,,,7516.57,Other,215% New York Medicaid APG,7516.57,,,7516.57,Other,215% New York Medicaid APG,4370.1,,,4370.1,Other,125% New York Medicaid APG,3496.08,37387.88,
Corneal transplant,65730,CPT,,,,,,,,both,,,50825.67,7731.8,,,7731.8,Other,150% of Medicare + 9.63% HCRA Surcharge,4701.75,,,4701.75,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,25412.84,50,,25412.84,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6502.71,,,6502.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,35577.97,70,,35577.97,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3496.08,,,3496.08,Other,New York Medicaid APG methodology,3496.08,,,3496.08,Other,100% New York Medicaid APG,3496.08,,,3496.08,Other,100% New York Medicaid APG,3496.08,,,3496.08,Other,100% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,4894.51,,,4894.51,Other,140% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,9089.8,,,9089.8,Other,260% New York Medicaid APG,11327.29,,,11327.29,Other,324% New York Medicaid APG,7516.57,,,7516.57,Other,215% New York Medicaid APG,7516.57,,,7516.57,Other,215% New York Medicaid APG,4370.1,,,4370.1,Other,125% New York Medicaid APG,3496.08,35577.97,
Corneal transplant,65750,CPT,,,,,,,,both,,,63976.41,9939.03,,,9939.03,Other,150% of Medicare + 9.63% HCRA Surcharge,6043.98,,,6043.98,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,31988.21,50,,31988.21,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6502.71,,,6502.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,44783.49,70,,44783.49,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3496.08,,,3496.08,Other,New York Medicaid APG methodology,3496.08,,,3496.08,Other,100% New York Medicaid APG,3496.08,,,3496.08,Other,100% New York Medicaid APG,3496.08,,,3496.08,Other,100% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,4894.51,,,4894.51,Other,140% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,9089.8,,,9089.8,Other,260% New York Medicaid APG,11327.29,,,11327.29,Other,324% New York Medicaid APG,7516.57,,,7516.57,Other,215% New York Medicaid APG,7516.57,,,7516.57,Other,215% New York Medicaid APG,4370.1,,,4370.1,Other,125% New York Medicaid APG,3496.08,44783.49,
Corneal transplant,65755,CPT,,,,,,,,both,,,56854.87,7731.8,,,7731.8,Other,150% of Medicare + 9.63% HCRA Surcharge,4701.75,,,4701.75,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,28427.44,50,,28427.44,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6502.71,,,6502.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,39798.41,70,,39798.41,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3496.08,,,3496.08,Other,New York Medicaid APG methodology,3496.08,,,3496.08,Other,100% New York Medicaid APG,3496.08,,,3496.08,Other,100% New York Medicaid APG,3496.08,,,3496.08,Other,100% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,4894.51,,,4894.51,Other,140% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,9089.8,,,9089.8,Other,260% New York Medicaid APG,11327.29,,,11327.29,Other,324% New York Medicaid APG,7516.57,,,7516.57,Other,215% New York Medicaid APG,7516.57,,,7516.57,Other,215% New York Medicaid APG,4370.1,,,4370.1,Other,125% New York Medicaid APG,3496.08,39798.41,
Corneal trnspl endothelial,65756,CPT,,,,,,,,both,,,49335.48,7731.8,,,7731.8,Other,150% of Medicare + 9.63% HCRA Surcharge,4701.75,,,4701.75,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,24667.74,50,,24667.74,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6502.71,,,6502.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34534.84,70,,34534.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3496.08,,,3496.08,Other,New York Medicaid APG methodology,3496.08,,,3496.08,Other,100% New York Medicaid APG,3496.08,,,3496.08,Other,100% New York Medicaid APG,3496.08,,,3496.08,Other,100% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,4894.51,,,4894.51,Other,140% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,9089.8,,,9089.8,Other,260% New York Medicaid APG,11327.29,,,11327.29,Other,324% New York Medicaid APG,7516.57,,,7516.57,Other,215% New York Medicaid APG,7516.57,,,7516.57,Other,215% New York Medicaid APG,4370.1,,,4370.1,Other,125% New York Medicaid APG,3496.08,34534.84,
Prep corneal endo allograft,65757,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,6502.71,,,6502.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,16216.05,50,,16216.05,percent of total billed charges,,16216.05,50,,16216.05,percent of total billed charges,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,3496.08,,,3496.08,Other,New York Medicaid APG methodology,3496.08,,,3496.08,Other,100% New York Medicaid APG,3496.08,,,3496.08,Other,100% New York Medicaid APG,3496.08,,,3496.08,Other,100% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,4894.51,,,4894.51,Other,140% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,9089.8,,,9089.8,Other,260% New York Medicaid APG,11327.29,,,11327.29,Other,324% New York Medicaid APG,7516.57,,,7516.57,Other,215% New York Medicaid APG,7516.57,,,7516.57,Other,215% New York Medicaid APG,4370.1,,,4370.1,Other,125% New York Medicaid APG,0.01,22702.47,
Revise cornea with implant,65770,CPT,,,,,,,,both,,,260759.04,23575.06,,,23575.06,Other,150% of Medicare + 9.63% HCRA Surcharge,14336.14,,,14336.14,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,130379.52,50,,130379.52,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6502.71,,,6502.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,182531.33,70,,182531.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3496.08,,,3496.08,Other,New York Medicaid APG methodology,3496.08,,,3496.08,Other,100% New York Medicaid APG,3496.08,,,3496.08,Other,100% New York Medicaid APG,3496.08,,,3496.08,Other,100% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,4894.51,,,4894.51,Other,140% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,9089.8,,,9089.8,Other,260% New York Medicaid APG,11327.29,,,11327.29,Other,324% New York Medicaid APG,7516.57,,,7516.57,Other,215% New York Medicaid APG,7516.57,,,7516.57,Other,215% New York Medicaid APG,4370.1,,,4370.1,Other,125% New York Medicaid APG,3496.08,182531.33,
Correction of astigmatism,65772,CPT,,,,,,,,both,,,21295.3,1925.3,,,1925.3,Other,150% of Medicare + 9.63% HCRA Surcharge,1170.78,,,1170.78,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,10647.65,50,,10647.65,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3655.3,,,3655.3,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,14906.71,70,,14906.71,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1965.22,,,1965.22,Other,New York Medicaid APG methodology,1965.22,,,1965.22,Other,100% New York Medicaid APG,1965.22,,,1965.22,Other,100% New York Medicaid APG,1965.22,,,1965.22,Other,100% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,2751.3,,,2751.3,Other,140% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,5109.57,,,5109.57,Other,260% New York Medicaid APG,6367.3,,,6367.3,Other,324% New York Medicaid APG,4225.22,,,4225.22,Other,215% New York Medicaid APG,4225.22,,,4225.22,Other,215% New York Medicaid APG,2456.52,,,2456.52,Other,125% New York Medicaid APG,1170.78,14906.71,
Correction of astigmatism,65775,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3655.3,,,3655.3,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1965.22,,,1965.22,Other,New York Medicaid APG methodology,1965.22,,,1965.22,Other,100% New York Medicaid APG,1965.22,,,1965.22,Other,100% New York Medicaid APG,1965.22,,,1965.22,Other,100% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,2751.3,,,2751.3,Other,140% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,5109.57,,,5109.57,Other,260% New York Medicaid APG,6367.3,,,6367.3,Other,324% New York Medicaid APG,4225.22,,,4225.22,Other,215% New York Medicaid APG,4225.22,,,4225.22,Other,215% New York Medicaid APG,2456.52,,,2456.52,Other,125% New York Medicaid APG,1965.22,34406.09,
Cover eye w/membrane,65778,CPT,,,,,,,,both,,,21295.3,1925.3,,,1925.3,Other,150% of Medicare + 9.63% HCRA Surcharge,1170.78,,,1170.78,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,10647.65,50,,10647.65,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3655.3,,,3655.3,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,14906.71,70,,14906.71,percent of total billed charges,,255.75,,,255.75,Fee Schedule,,217,,,217,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1965.22,,,1965.22,Other,New York Medicaid APG methodology,1965.22,,,1965.22,Other,100% New York Medicaid APG,1965.22,,,1965.22,Other,100% New York Medicaid APG,1965.22,,,1965.22,Other,100% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,2751.3,,,2751.3,Other,140% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,5109.57,,,5109.57,Other,260% New York Medicaid APG,6367.3,,,6367.3,Other,324% New York Medicaid APG,4225.22,,,4225.22,Other,215% New York Medicaid APG,4225.22,,,4225.22,Other,215% New York Medicaid APG,2456.52,,,2456.52,Other,125% New York Medicaid APG,217,14906.71,
Cover eye w/membrane suture,65779,CPT,,,,,,,,both,,,33053.92,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,16526.96,50,,16526.96,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3655.3,,,3655.3,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23137.74,70,,23137.74,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1965.22,,,1965.22,Other,New York Medicaid APG methodology,1965.22,,,1965.22,Other,100% New York Medicaid APG,1965.22,,,1965.22,Other,100% New York Medicaid APG,1965.22,,,1965.22,Other,100% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,2751.3,,,2751.3,Other,140% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,5109.57,,,5109.57,Other,260% New York Medicaid APG,6367.3,,,6367.3,Other,324% New York Medicaid APG,4225.22,,,4225.22,Other,215% New York Medicaid APG,4225.22,,,4225.22,Other,215% New York Medicaid APG,2456.52,,,2456.52,Other,125% New York Medicaid APG,1965.22,23137.74,
Ocular reconst transplant,65780,CPT,,,,,,,,both,,,38106.26,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,19053.13,50,,19053.13,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6502.71,,,6502.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26674.38,70,,26674.38,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3496.08,,,3496.08,Other,New York Medicaid APG methodology,3496.08,,,3496.08,Other,100% New York Medicaid APG,3496.08,,,3496.08,Other,100% New York Medicaid APG,3496.08,,,3496.08,Other,100% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,4894.51,,,4894.51,Other,140% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,9089.8,,,9089.8,Other,260% New York Medicaid APG,11327.29,,,11327.29,Other,324% New York Medicaid APG,7516.57,,,7516.57,Other,215% New York Medicaid APG,7516.57,,,7516.57,Other,215% New York Medicaid APG,4370.1,,,4370.1,Other,125% New York Medicaid APG,3496.08,26674.38,
Ocular reconst transplant,65781,CPT,,,,,,,,both,,,109933.59,9939.03,,,9939.03,Other,150% of Medicare + 9.63% HCRA Surcharge,6043.98,,,6043.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54966.8,50,,54966.8,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6502.71,,,6502.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76953.51,70,,76953.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3496.08,,,3496.08,Other,New York Medicaid APG methodology,3496.08,,,3496.08,Other,100% New York Medicaid APG,3496.08,,,3496.08,Other,100% New York Medicaid APG,3496.08,,,3496.08,Other,100% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,4894.51,,,4894.51,Other,140% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,9089.8,,,9089.8,Other,260% New York Medicaid APG,11327.29,,,11327.29,Other,324% New York Medicaid APG,7516.57,,,7516.57,Other,215% New York Medicaid APG,7516.57,,,7516.57,Other,215% New York Medicaid APG,4370.1,,,4370.1,Other,125% New York Medicaid APG,3496.08,76953.51,
Ocular reconst transplant,65782,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6502.71,,,6502.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3496.08,,,3496.08,Other,New York Medicaid APG methodology,3496.08,,,3496.08,Other,100% New York Medicaid APG,3496.08,,,3496.08,Other,100% New York Medicaid APG,3496.08,,,3496.08,Other,100% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,4894.51,,,4894.51,Other,140% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,9089.8,,,9089.8,Other,260% New York Medicaid APG,11327.29,,,11327.29,Other,324% New York Medicaid APG,7516.57,,,7516.57,Other,215% New York Medicaid APG,7516.57,,,7516.57,Other,215% New York Medicaid APG,4370.1,,,4370.1,Other,125% New York Medicaid APG,3496.08,56927.18,
Impltj ntrstrml crnl rng seg,65785,CPT,,,,,,,,both,,,85519.85,7731.8,,,7731.8,Other,150% of Medicare + 9.63% HCRA Surcharge,4701.75,,,4701.75,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,42759.93,50,,42759.93,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6502.71,,,6502.71,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,59863.9,70,,59863.9,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3496.08,,,3496.08,Other,New York Medicaid APG methodology,3496.08,,,3496.08,Other,100% New York Medicaid APG,3496.08,,,3496.08,Other,100% New York Medicaid APG,3496.08,,,3496.08,Other,100% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,4894.51,,,4894.51,Other,140% New York Medicaid APG,7866.18,,,7866.18,Other,225% New York Medicaid APG,9089.8,,,9089.8,Other,260% New York Medicaid APG,11327.29,,,11327.29,Other,324% New York Medicaid APG,7516.57,,,7516.57,Other,215% New York Medicaid APG,7516.57,,,7516.57,Other,215% New York Medicaid APG,4370.1,,,4370.1,Other,125% New York Medicaid APG,3496.08,59863.9,
Drainage of eye,65800,CPT,,,,,,,,both,,,49016.23,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24508.12,50,,24508.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34311.36,70,,34311.36,percent of total billed charges,,430.65,,,430.65,Fee Schedule,,365.4,,,365.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,365.4,34311.36,
Drainage of eye,65810,CPT,,,,,,,,both,,,35561.95,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17780.98,50,,17780.98,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24893.37,70,,24893.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,1994.68,24893.37,
Drainage of eye,65815,CPT,,,,,,,,both,,,49016.23,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24508.12,50,,24508.12,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34311.36,70,,34311.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,1994.68,34311.36,
Relieve inner eye pressure,65820,CPT,,,,,,,,both,,,36931.35,7731.8,,,7731.8,Other,150% of Medicare + 9.63% HCRA Surcharge,4701.75,,,4701.75,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,18465.68,50,,18465.68,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25851.95,70,,25851.95,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,1994.68,25851.95,
Incision of eye,65850,CPT,,,,,,,,both,,,49016.23,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24508.12,50,,24508.12,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4898.55,,,4898.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34311.36,70,,34311.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2633.63,,,2633.63,Other,New York Medicaid APG methodology,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,3687.08,,,3687.08,Other,140% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,6847.44,,,6847.44,Other,260% New York Medicaid APG,8532.97,,,8532.97,Other,324% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,3292.04,,,3292.04,Other,125% New York Medicaid APG,2633.63,34311.36,
Trabeculoplasty laser surg,65855,CPT,,,,,,,,both,,,12226.3,1105.37,,,1105.37,Other,150% of Medicare + 9.63% HCRA Surcharge,672.18,,,672.18,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6113.15,50,,6113.15,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8558.41,70,,8558.41,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,672.18,13157,
Incise inner eye adhesions,65860,CPT,,,,,,,,both,,,12226.3,1105.37,,,1105.37,Other,150% of Medicare + 9.63% HCRA Surcharge,672.18,,,672.18,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6113.15,50,,6113.15,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8558.41,70,,8558.41,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,672.18,13157,
Incise inner eye adhesions,65865,CPT,,,,,,,,both,,,49016.23,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24508.12,50,,24508.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34311.36,70,,34311.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,1994.68,34311.36,
Incise inner eye adhesions,65870,CPT,,,,,,,,both,,,49016.23,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24508.12,50,,24508.12,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34311.36,70,,34311.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,1994.68,34311.36,
Incise inner eye adhesions,65875,CPT,,,,,,,,both,,,49016.23,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24508.12,50,,24508.12,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34311.36,70,,34311.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,1994.68,34311.36,
Incise inner eye adhesions,65880,CPT,,,,,,,,both,,,85519.85,7731.8,,,7731.8,Other,150% of Medicare + 9.63% HCRA Surcharge,4701.75,,,4701.75,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,42759.93,50,,42759.93,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4898.55,,,4898.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,59863.9,70,,59863.9,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2633.63,,,2633.63,Other,New York Medicaid APG methodology,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,3687.08,,,3687.08,Other,140% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,6847.44,,,6847.44,Other,260% New York Medicaid APG,8532.97,,,8532.97,Other,324% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,3292.04,,,3292.04,Other,125% New York Medicaid APG,2633.63,59863.9,
Remove eye lesion,65900,CPT,,,,,,,,both,,,35724.95,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17862.48,50,,17862.48,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4898.55,,,4898.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25007.47,70,,25007.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2633.63,,,2633.63,Other,New York Medicaid APG methodology,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,3687.08,,,3687.08,Other,140% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,6847.44,,,6847.44,Other,260% New York Medicaid APG,8532.97,,,8532.97,Other,324% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,3292.04,,,3292.04,Other,125% New York Medicaid APG,2633.63,25007.47,
Remove implant of eye,65920,CPT,,,,,,,,both,,,35663.57,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17831.79,50,,17831.79,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24964.5,70,,24964.5,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,1994.68,24964.5,
Remove blood clot from eye,65930,CPT,,,,,,,,both,,,49016.23,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24508.12,50,,24508.12,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34311.36,70,,34311.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,1994.68,34311.36,
Injection treatment of eye,66020,CPT,,,,,,,,both,,,49016.23,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24508.12,50,,24508.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34311.36,70,,34311.36,percent of total billed charges,,636.9,,,636.9,Fee Schedule,,540.4,,,540.4,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,540.4,34311.36,
Injection treatment of eye,66030,CPT,,,,,,,,both,,,49016.23,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24508.12,50,,24508.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34311.36,70,,34311.36,percent of total billed charges,,541.2,,,541.2,Fee Schedule,,459.2,,,459.2,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,459.2,34311.36,
Remove eye lesion,66130,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,1994.68,34406.09,
Glaucoma surgery,66150,CPT,,,,,,,,both,,,85519.85,7731.8,,,7731.8,Other,150% of Medicare + 9.63% HCRA Surcharge,4701.75,,,4701.75,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,42759.93,50,,42759.93,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4898.55,,,4898.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,59863.9,70,,59863.9,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2633.63,,,2633.63,Other,New York Medicaid APG methodology,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,3687.08,,,3687.08,Other,140% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,6847.44,,,6847.44,Other,260% New York Medicaid APG,8532.97,,,8532.97,Other,324% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,3292.04,,,3292.04,Other,125% New York Medicaid APG,2633.63,59863.9,
Glaucoma surgery,66155,CPT,,,,,,,,both,,,85519.85,7731.8,,,7731.8,Other,150% of Medicare + 9.63% HCRA Surcharge,4701.75,,,4701.75,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,42759.93,50,,42759.93,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4898.55,,,4898.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,59863.9,70,,59863.9,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2633.63,,,2633.63,Other,New York Medicaid APG methodology,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,3687.08,,,3687.08,Other,140% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,6847.44,,,6847.44,Other,260% New York Medicaid APG,8532.97,,,8532.97,Other,324% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,3292.04,,,3292.04,Other,125% New York Medicaid APG,2633.63,59863.9,
Glaucoma surgery,66160,CPT,,,,,,,,both,,,49016.23,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24508.12,50,,24508.12,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4898.55,,,4898.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34311.36,70,,34311.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2633.63,,,2633.63,Other,New York Medicaid APG methodology,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,3687.08,,,3687.08,Other,140% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,6847.44,,,6847.44,Other,260% New York Medicaid APG,8532.97,,,8532.97,Other,324% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,3292.04,,,3292.04,Other,125% New York Medicaid APG,2633.63,34311.36,
Glaucoma surgery,66170,CPT,,,,,,,,both,,,33203.28,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16601.64,50,,16601.64,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4898.55,,,4898.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23242.3,70,,23242.3,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2633.63,,,2633.63,Other,New York Medicaid APG methodology,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,3687.08,,,3687.08,Other,140% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,6847.44,,,6847.44,Other,260% New York Medicaid APG,8532.97,,,8532.97,Other,324% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,3292.04,,,3292.04,Other,125% New York Medicaid APG,2633.63,23242.3,
Incision of eye,66172,CPT,,,,,,,,both,,,49016.23,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24508.12,50,,24508.12,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4898.55,,,4898.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34311.36,70,,34311.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2633.63,,,2633.63,Other,New York Medicaid APG methodology,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,3687.08,,,3687.08,Other,140% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,6847.44,,,6847.44,Other,260% New York Medicaid APG,8532.97,,,8532.97,Other,324% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,3292.04,,,3292.04,Other,125% New York Medicaid APG,2633.63,34311.36,
Translum dil eye canal,66174,CPT,,,,,,,,both,,,85519.85,7731.8,,,7731.8,Other,150% of Medicare + 9.63% HCRA Surcharge,4701.75,,,4701.75,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,42759.93,50,,42759.93,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4898.55,,,4898.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,59863.9,70,,59863.9,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2633.63,,,2633.63,Other,New York Medicaid APG methodology,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,3687.08,,,3687.08,Other,140% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,6847.44,,,6847.44,Other,260% New York Medicaid APG,8532.97,,,8532.97,Other,324% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,3292.04,,,3292.04,Other,125% New York Medicaid APG,2633.63,59863.9,
Trnslum dil eye canal w/stnt,66175,CPT,,,,,,,,both,,,109933.59,9939.03,,,9939.03,Other,150% of Medicare + 9.63% HCRA Surcharge,6043.98,,,6043.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54966.8,50,,54966.8,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4898.55,,,4898.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76953.51,70,,76953.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2633.63,,,2633.63,Other,New York Medicaid APG methodology,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,3687.08,,,3687.08,Other,140% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,6847.44,,,6847.44,Other,260% New York Medicaid APG,8532.97,,,8532.97,Other,324% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,3292.04,,,3292.04,Other,125% New York Medicaid APG,2633.63,76953.51,
Aqueous shunt eye w/o graft,66179,CPT,,,,,,,,both,,,109933.59,9939.03,,,9939.03,Other,150% of Medicare + 9.63% HCRA Surcharge,6043.98,,,6043.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54966.8,50,,54966.8,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4898.55,,,4898.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76953.51,70,,76953.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2633.63,,,2633.63,Other,New York Medicaid APG methodology,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,3687.08,,,3687.08,Other,140% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,6847.44,,,6847.44,Other,260% New York Medicaid APG,8532.97,,,8532.97,Other,324% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,3292.04,,,3292.04,Other,125% New York Medicaid APG,2633.63,76953.51,
Aqueous shunt eye w/graft,66180,CPT,,,,,,,,both,,,37790.35,7731.8,,,7731.8,Other,150% of Medicare + 9.63% HCRA Surcharge,4701.75,,,4701.75,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,18895.18,50,,18895.18,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4898.55,,,4898.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26453.25,70,,26453.25,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2633.63,,,2633.63,Other,New York Medicaid APG methodology,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,3687.08,,,3687.08,Other,140% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,6847.44,,,6847.44,Other,260% New York Medicaid APG,8532.97,,,8532.97,Other,324% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,3292.04,,,3292.04,Other,125% New York Medicaid APG,2633.63,26453.25,
Insert ant drainage device,66183,CPT,,,,,,,,both,,,40479.02,7731.8,,,7731.8,Other,150% of Medicare + 9.63% HCRA Surcharge,4701.75,,,4701.75,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,20239.51,50,,20239.51,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4898.55,,,4898.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28335.31,70,,28335.31,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2633.63,,,2633.63,Other,New York Medicaid APG methodology,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,3687.08,,,3687.08,Other,140% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,6847.44,,,6847.44,Other,260% New York Medicaid APG,8532.97,,,8532.97,Other,324% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,3292.04,,,3292.04,Other,125% New York Medicaid APG,2633.63,28335.31,
Revision of aqueous shunt,66184,CPT,,,,,,,,both,,,49016.23,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24508.12,50,,24508.12,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34311.36,70,,34311.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,1994.68,34311.36,
Revise aqueous shunt eye,66185,CPT,,,,,,,,both,,,49016.23,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24508.12,50,,24508.12,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34311.36,70,,34311.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,1994.68,34311.36,
Repair/graft eye lesion,66225,CPT,,,,,,,,both,,,109933.59,9939.03,,,9939.03,Other,150% of Medicare + 9.63% HCRA Surcharge,6043.98,,,6043.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54966.8,50,,54966.8,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4898.55,,,4898.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76953.51,70,,76953.51,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2633.63,,,2633.63,Other,New York Medicaid APG methodology,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,3687.08,,,3687.08,Other,140% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,6847.44,,,6847.44,Other,260% New York Medicaid APG,8532.97,,,8532.97,Other,324% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,3292.04,,,3292.04,Other,125% New York Medicaid APG,2633.63,76953.51,
Follow-up surgery of eye,66250,CPT,,,,,,,,both,,,35284.74,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17642.37,50,,17642.37,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24699.32,70,,24699.32,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,1994.68,24699.32,
Incision of iris,66500,CPT,,,,,,,,both,,,49016.23,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24508.12,50,,24508.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34311.36,70,,34311.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,1994.68,34311.36,
Incision of iris,66505,CPT,,,,,,,,both,,,49016.23,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24508.12,50,,24508.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34311.36,70,,34311.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,1994.68,34311.36,
Remove iris and lesion,66600,CPT,,,,,,,,both,,,85519.85,7731.8,,,7731.8,Other,150% of Medicare + 9.63% HCRA Surcharge,4701.75,,,4701.75,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,42759.93,50,,42759.93,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4898.55,,,4898.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,59863.9,70,,59863.9,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2633.63,,,2633.63,Other,New York Medicaid APG methodology,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,3687.08,,,3687.08,Other,140% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,6847.44,,,6847.44,Other,260% New York Medicaid APG,8532.97,,,8532.97,Other,324% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,3292.04,,,3292.04,Other,125% New York Medicaid APG,2633.63,59863.9,
Removal of iris,66605,CPT,,,,,,,,both,,,49016.23,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24508.12,50,,24508.12,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4898.55,,,4898.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34311.36,70,,34311.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2633.63,,,2633.63,Other,New York Medicaid APG methodology,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,3687.08,,,3687.08,Other,140% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,6847.44,,,6847.44,Other,260% New York Medicaid APG,8532.97,,,8532.97,Other,324% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,3292.04,,,3292.04,Other,125% New York Medicaid APG,2633.63,34311.36,
Removal of iris,66625,CPT,,,,,,,,both,,,49016.23,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24508.12,50,,24508.12,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34311.36,70,,34311.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,1994.68,34311.36,
Removal of iris,66630,CPT,,,,,,,,both,,,49016.23,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24508.12,50,,24508.12,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34311.36,70,,34311.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,1994.68,34311.36,
Removal of iris,66635,CPT,,,,,,,,both,,,34653.65,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17326.83,50,,17326.83,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24257.56,70,,24257.56,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,1994.68,24257.56,
Repair iris & ciliary body,66680,CPT,,,,,,,,both,,,49016.23,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24508.12,50,,24508.12,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34311.36,70,,34311.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,1994.68,34311.36,
Repair iris & ciliary body,66682,CPT,,,,,,,,both,,,34563.38,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17281.69,50,,17281.69,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24194.37,70,,24194.37,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,1994.68,24194.37,
Destruction ciliary body,66700,CPT,,,,,,,,both,,,49016.23,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24508.12,50,,24508.12,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34311.36,70,,34311.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,1994.68,34311.36,
Ciliary transsleral therapy,66710,CPT,,,,,,,,both,,,35866.05,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17933.03,50,,17933.03,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25106.24,70,,25106.24,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,1994.68,25106.24,
Ecp ciliary body destruction,66711,CPT,,,,,,,,both,,,49016.23,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24508.12,50,,24508.12,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34311.36,70,,34311.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,1994.68,34311.36,
Destruction ciliary body,66720,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,1994.68,34406.09,
Destruction ciliary body,66740,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,1994.68,34406.09,
Revision of iris,66761,CPT,,,,,,,,both,,,12226.3,1105.37,,,1105.37,Other,150% of Medicare + 9.63% HCRA Surcharge,672.18,,,672.18,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6113.15,50,,6113.15,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8558.41,70,,8558.41,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,672.18,13157,
Revision of iris,66762,CPT,,,,,,,,both,,,12226.3,1105.37,,,1105.37,Other,150% of Medicare + 9.63% HCRA Surcharge,672.18,,,672.18,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6113.15,50,,6113.15,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8558.41,70,,8558.41,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,672.18,13157,
Removal of inner eye lesion,66770,CPT,,,,,,,,both,,,12226.3,1105.37,,,1105.37,Other,150% of Medicare + 9.63% HCRA Surcharge,672.18,,,672.18,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6113.15,50,,6113.15,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8558.41,70,,8558.41,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,672.18,13157,
Incision secondary cataract,66820,CPT,,,,,,,,both,,,36328.3,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18164.15,50,,18164.15,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3655.3,,,3655.3,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25429.81,70,,25429.81,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1965.22,,,1965.22,Other,New York Medicaid APG methodology,1965.22,,,1965.22,Other,100% New York Medicaid APG,1965.22,,,1965.22,Other,100% New York Medicaid APG,1965.22,,,1965.22,Other,100% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,2751.3,,,2751.3,Other,140% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,5109.57,,,5109.57,Other,260% New York Medicaid APG,6367.3,,,6367.3,Other,324% New York Medicaid APG,4225.22,,,4225.22,Other,215% New York Medicaid APG,4225.22,,,4225.22,Other,215% New York Medicaid APG,2456.52,,,2456.52,Other,125% New York Medicaid APG,1965.22,25429.81,
After cataract laser surgery,66821,CPT,,,,,,,,both,,,12226.3,1105.37,,,1105.37,Other,150% of Medicare + 9.63% HCRA Surcharge,672.18,,,672.18,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6113.15,50,,6113.15,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3655.3,,,3655.3,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8558.41,70,,8558.41,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1965.22,,,1965.22,Other,New York Medicaid APG methodology,1965.22,,,1965.22,Other,100% New York Medicaid APG,1965.22,,,1965.22,Other,100% New York Medicaid APG,1965.22,,,1965.22,Other,100% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,2751.3,,,2751.3,Other,140% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,5109.57,,,5109.57,Other,260% New York Medicaid APG,6367.3,,,6367.3,Other,324% New York Medicaid APG,4225.22,,,4225.22,Other,215% New York Medicaid APG,4225.22,,,4225.22,Other,215% New York Medicaid APG,2456.52,,,2456.52,Other,125% New York Medicaid APG,672.18,13157,
Reposition intraocular lens,66825,CPT,,,,,,,,both,,,34585.06,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17292.53,50,,17292.53,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4567.39,,,4567.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24209.54,70,,24209.54,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2455.59,,,2455.59,Other,New York Medicaid APG methodology,2455.59,,,2455.59,Other,100% New York Medicaid APG,2455.59,,,2455.59,Other,100% New York Medicaid APG,2455.59,,,2455.59,Other,100% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,3437.82,,,3437.82,Other,140% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,6384.53,,,6384.53,Other,260% New York Medicaid APG,7956.11,,,7956.11,Other,324% New York Medicaid APG,5279.52,,,5279.52,Other,215% New York Medicaid APG,5279.52,,,5279.52,Other,215% New York Medicaid APG,3069.49,,,3069.49,Other,125% New York Medicaid APG,2455.59,24209.54,
Removal of lens lesion,66830,CPT,,,,,,,,both,,,36830.68,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18415.34,50,,18415.34,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3655.3,,,3655.3,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25781.48,70,,25781.48,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1965.22,,,1965.22,Other,New York Medicaid APG methodology,1965.22,,,1965.22,Other,100% New York Medicaid APG,1965.22,,,1965.22,Other,100% New York Medicaid APG,1965.22,,,1965.22,Other,100% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,2751.3,,,2751.3,Other,140% New York Medicaid APG,4421.74,,,4421.74,Other,225% New York Medicaid APG,5109.57,,,5109.57,Other,260% New York Medicaid APG,6367.3,,,6367.3,Other,324% New York Medicaid APG,4225.22,,,4225.22,Other,215% New York Medicaid APG,4225.22,,,4225.22,Other,215% New York Medicaid APG,2456.52,,,2456.52,Other,125% New York Medicaid APG,1965.22,25781.48,
Removal of lens material,66840,CPT,,,,,,,,both,,,34704.95,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17352.48,50,,17352.48,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4567.39,,,4567.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24293.47,70,,24293.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2455.59,,,2455.59,Other,New York Medicaid APG methodology,2455.59,,,2455.59,Other,100% New York Medicaid APG,2455.59,,,2455.59,Other,100% New York Medicaid APG,2455.59,,,2455.59,Other,100% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,3437.82,,,3437.82,Other,140% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,6384.53,,,6384.53,Other,260% New York Medicaid APG,7956.11,,,7956.11,Other,324% New York Medicaid APG,5279.52,,,5279.52,Other,215% New York Medicaid APG,5279.52,,,5279.52,Other,215% New York Medicaid APG,3069.49,,,3069.49,Other,125% New York Medicaid APG,2455.59,24293.47,
Removal of lens material,66850,CPT,,,,,,,,both,,,35390.55,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17695.28,50,,17695.28,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4567.39,,,4567.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24773.39,70,,24773.39,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2455.59,,,2455.59,Other,New York Medicaid APG methodology,2455.59,,,2455.59,Other,100% New York Medicaid APG,2455.59,,,2455.59,Other,100% New York Medicaid APG,2455.59,,,2455.59,Other,100% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,3437.82,,,3437.82,Other,140% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,6384.53,,,6384.53,Other,260% New York Medicaid APG,7956.11,,,7956.11,Other,324% New York Medicaid APG,5279.52,,,5279.52,Other,215% New York Medicaid APG,5279.52,,,5279.52,Other,215% New York Medicaid APG,3069.49,,,3069.49,Other,125% New York Medicaid APG,2455.59,24773.39,
Removal of lens material,66852,CPT,,,,,,,,both,,,36152.09,7731.8,,,7731.8,Other,150% of Medicare + 9.63% HCRA Surcharge,4701.75,,,4701.75,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,18076.05,50,,18076.05,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4567.39,,,4567.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25306.46,70,,25306.46,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2455.59,,,2455.59,Other,New York Medicaid APG methodology,2455.59,,,2455.59,Other,100% New York Medicaid APG,2455.59,,,2455.59,Other,100% New York Medicaid APG,2455.59,,,2455.59,Other,100% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,3437.82,,,3437.82,Other,140% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,6384.53,,,6384.53,Other,260% New York Medicaid APG,7956.11,,,7956.11,Other,324% New York Medicaid APG,5279.52,,,5279.52,Other,215% New York Medicaid APG,5279.52,,,5279.52,Other,215% New York Medicaid APG,3069.49,,,3069.49,Other,125% New York Medicaid APG,2455.59,25306.46,
Extraction of lens,66920,CPT,,,,,,,,both,,,49016.23,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24508.12,50,,24508.12,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4567.39,,,4567.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34311.36,70,,34311.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2455.59,,,2455.59,Other,New York Medicaid APG methodology,2455.59,,,2455.59,Other,100% New York Medicaid APG,2455.59,,,2455.59,Other,100% New York Medicaid APG,2455.59,,,2455.59,Other,100% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,3437.82,,,3437.82,Other,140% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,6384.53,,,6384.53,Other,260% New York Medicaid APG,7956.11,,,7956.11,Other,324% New York Medicaid APG,5279.52,,,5279.52,Other,215% New York Medicaid APG,5279.52,,,5279.52,Other,215% New York Medicaid APG,3069.49,,,3069.49,Other,125% New York Medicaid APG,2455.59,34311.36,
Extraction of lens,66930,CPT,,,,,,,,both,,,85519.85,7731.8,,,7731.8,Other,150% of Medicare + 9.63% HCRA Surcharge,4701.75,,,4701.75,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,42759.93,50,,42759.93,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4567.39,,,4567.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,59863.9,70,,59863.9,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2455.59,,,2455.59,Other,New York Medicaid APG methodology,2455.59,,,2455.59,Other,100% New York Medicaid APG,2455.59,,,2455.59,Other,100% New York Medicaid APG,2455.59,,,2455.59,Other,100% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,3437.82,,,3437.82,Other,140% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,6384.53,,,6384.53,Other,260% New York Medicaid APG,7956.11,,,7956.11,Other,324% New York Medicaid APG,5279.52,,,5279.52,Other,215% New York Medicaid APG,5279.52,,,5279.52,Other,215% New York Medicaid APG,3069.49,,,3069.49,Other,125% New York Medicaid APG,2455.59,59863.9,
Extraction of lens,66940,CPT,,,,,,,,both,,,34887.95,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17443.98,50,,17443.98,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4567.39,,,4567.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24421.57,70,,24421.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2455.59,,,2455.59,Other,New York Medicaid APG methodology,2455.59,,,2455.59,Other,100% New York Medicaid APG,2455.59,,,2455.59,Other,100% New York Medicaid APG,2455.59,,,2455.59,Other,100% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,3437.82,,,3437.82,Other,140% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,6384.53,,,6384.53,Other,260% New York Medicaid APG,7956.11,,,7956.11,Other,324% New York Medicaid APG,5279.52,,,5279.52,Other,215% New York Medicaid APG,5279.52,,,5279.52,Other,215% New York Medicaid APG,3069.49,,,3069.49,Other,125% New York Medicaid APG,2455.59,24421.57,
Xcapsl ctrc rmvl cplx wo ecp,66982,CPT,,,,,,,,both,,,36521.55,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18260.78,50,,18260.78,percent of total billed charges,,7841,,"100% primary, 50% supplemental procedure",7841,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4567.39,,,4567.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25565.09,70,,25565.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2455.59,,,2455.59,Other,New York Medicaid APG methodology,2455.59,,,2455.59,Other,100% New York Medicaid APG,2455.59,,,2455.59,Other,100% New York Medicaid APG,2455.59,,,2455.59,Other,100% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,3437.82,,,3437.82,Other,140% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,6384.53,,,6384.53,Other,260% New York Medicaid APG,7956.11,,,7956.11,Other,324% New York Medicaid APG,5279.52,,,5279.52,Other,215% New York Medicaid APG,5279.52,,,5279.52,Other,215% New York Medicaid APG,3069.49,,,3069.49,Other,125% New York Medicaid APG,2455.59,25565.09,
Cataract surg w/iol 1 stage,66983,CPT,,,,,,,,both,,,49016.23,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24508.12,50,,24508.12,percent of total billed charges,,7841,,"100% primary, 50% supplemental procedure",7841,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4567.39,,,4567.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34311.36,70,,34311.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2455.59,,,2455.59,Other,New York Medicaid APG methodology,2455.59,,,2455.59,Other,100% New York Medicaid APG,2455.59,,,2455.59,Other,100% New York Medicaid APG,2455.59,,,2455.59,Other,100% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,3437.82,,,3437.82,Other,140% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,6384.53,,,6384.53,Other,260% New York Medicaid APG,7956.11,,,7956.11,Other,324% New York Medicaid APG,5279.52,,,5279.52,Other,215% New York Medicaid APG,5279.52,,,5279.52,Other,215% New York Medicaid APG,3069.49,,,3069.49,Other,125% New York Medicaid APG,2455.59,34311.36,
Xcapsl ctrc rmvl w/o ecp,66984,CPT,,,,,,,,both,,,35854.93,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17927.47,50,,17927.47,percent of total billed charges,,7841,,"100% primary, 50% supplemental procedure",7841,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4567.39,,,4567.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25098.45,70,,25098.45,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2455.59,,,2455.59,Other,New York Medicaid APG methodology,2455.59,,,2455.59,Other,100% New York Medicaid APG,2455.59,,,2455.59,Other,100% New York Medicaid APG,2455.59,,,2455.59,Other,100% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,3437.82,,,3437.82,Other,140% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,6384.53,,,6384.53,Other,260% New York Medicaid APG,7956.11,,,7956.11,Other,324% New York Medicaid APG,5279.52,,,5279.52,Other,215% New York Medicaid APG,5279.52,,,5279.52,Other,215% New York Medicaid APG,3069.49,,,3069.49,Other,125% New York Medicaid APG,2455.59,25098.45,
Insert lens prosthesis,66985,CPT,,,,,,,,both,,,36877,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18438.5,50,,18438.5,percent of total billed charges,,7394,,"100% primary, 50% supplemental procedure",7394,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4567.39,,,4567.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25813.9,70,,25813.9,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2455.59,,,2455.59,Other,New York Medicaid APG methodology,2455.59,,,2455.59,Other,100% New York Medicaid APG,2455.59,,,2455.59,Other,100% New York Medicaid APG,2455.59,,,2455.59,Other,100% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,3437.82,,,3437.82,Other,140% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,6384.53,,,6384.53,Other,260% New York Medicaid APG,7956.11,,,7956.11,Other,324% New York Medicaid APG,5279.52,,,5279.52,Other,215% New York Medicaid APG,5279.52,,,5279.52,Other,215% New York Medicaid APG,3069.49,,,3069.49,Other,125% New York Medicaid APG,2455.59,25813.9,
Exchange lens prosthesis,66986,CPT,,,,,,,,both,,,36572.97,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18286.49,50,,18286.49,percent of total billed charges,,7394,,"100% primary, 50% supplemental procedure",7394,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4567.39,,,4567.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25601.08,70,,25601.08,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2455.59,,,2455.59,Other,New York Medicaid APG methodology,2455.59,,,2455.59,Other,100% New York Medicaid APG,2455.59,,,2455.59,Other,100% New York Medicaid APG,2455.59,,,2455.59,Other,100% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,3437.82,,,3437.82,Other,140% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,6384.53,,,6384.53,Other,260% New York Medicaid APG,7956.11,,,7956.11,Other,324% New York Medicaid APG,5279.52,,,5279.52,Other,215% New York Medicaid APG,5279.52,,,5279.52,Other,215% New York Medicaid APG,3069.49,,,3069.49,Other,125% New York Medicaid APG,2455.59,25601.08,
Xcapsl ctrc rmvl cplx w/ecp,66987,CPT,,,,,,,,both,,,85519.85,7731.8,,,7731.8,Other,150% of Medicare + 9.63% HCRA Surcharge,4701.75,,,4701.75,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,42759.93,50,,42759.93,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4567.39,,,4567.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,59863.9,70,,59863.9,percent of total billed charges,,42759.93,50,,42759.93,percent of total billed charges,,42759.93,50,,42759.93,percent of total billed charges,,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2455.59,,,2455.59,Other,New York Medicaid APG methodology,2455.59,,,2455.59,Other,100% New York Medicaid APG,2455.59,,,2455.59,Other,100% New York Medicaid APG,2455.59,,,2455.59,Other,100% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,3437.82,,,3437.82,Other,140% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,6384.53,,,6384.53,Other,260% New York Medicaid APG,7956.11,,,7956.11,Other,324% New York Medicaid APG,5279.52,,,5279.52,Other,215% New York Medicaid APG,5279.52,,,5279.52,Other,215% New York Medicaid APG,3069.49,,,3069.49,Other,125% New York Medicaid APG,2455.59,59863.9,
Xcapsl ctrc rmvl w/ecp,66988,CPT,,,,,,,,both,,,85519.85,7731.8,,,7731.8,Other,150% of Medicare + 9.63% HCRA Surcharge,4701.75,,,4701.75,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,42759.93,50,,42759.93,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4567.39,,,4567.39,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,59863.9,70,,59863.9,percent of total billed charges,,42759.93,50,,42759.93,percent of total billed charges,,42759.93,50,,42759.93,percent of total billed charges,,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2455.59,,,2455.59,Other,New York Medicaid APG methodology,2455.59,,,2455.59,Other,100% New York Medicaid APG,2455.59,,,2455.59,Other,100% New York Medicaid APG,2455.59,,,2455.59,Other,100% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,3437.82,,,3437.82,Other,140% New York Medicaid APG,5525.07,,,5525.07,Other,225% New York Medicaid APG,6384.53,,,6384.53,Other,260% New York Medicaid APG,7956.11,,,7956.11,Other,324% New York Medicaid APG,5279.52,,,5279.52,Other,215% New York Medicaid APG,5279.52,,,5279.52,Other,215% New York Medicaid APG,3069.49,,,3069.49,Other,125% New York Medicaid APG,2455.59,59863.9,
Ophthalmic endoscope add-on,66990,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,7012,,,7012,Case Rate,MVP ASC Grouper,5960,,,5960,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,22702.47,
Partial removal of eye fluid,67005,CPT,,,,,,,,both,,,38164.45,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19082.23,50,,19082.23,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1455.98,,,1455.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26715.12,70,,26715.12,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,782.79,,,782.79,Other,New York Medicaid APG methodology,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1095.9,,,1095.9,Other,140% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,2035.24,,,2035.24,Other,260% New York Medicaid APG,2536.23,,,2536.23,Other,324% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,978.48,,,978.48,Other,125% New York Medicaid APG,782.79,26715.12,
Partial removal of eye fluid,67010,CPT,,,,,,,,both,,,37177.13,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18588.57,50,,18588.57,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1455.98,,,1455.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26023.99,70,,26023.99,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,782.79,,,782.79,Other,New York Medicaid APG methodology,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1095.9,,,1095.9,Other,140% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,2035.24,,,2035.24,Other,260% New York Medicaid APG,2536.23,,,2536.23,Other,324% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,978.48,,,978.48,Other,125% New York Medicaid APG,782.79,26023.99,
Release of eye fluid,67015,CPT,,,,,,,,both,,,39587.11,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19793.56,50,,19793.56,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6145.86,,,6145.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27710.98,70,,27710.98,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3304.22,,,3304.22,Other,New York Medicaid APG methodology,3304.22,,,3304.22,Other,100% New York Medicaid APG,3304.22,,,3304.22,Other,100% New York Medicaid APG,3304.22,,,3304.22,Other,100% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,4625.91,,,4625.91,Other,140% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,8590.98,,,8590.98,Other,260% New York Medicaid APG,10705.69,,,10705.69,Other,324% New York Medicaid APG,7104.08,,,7104.08,Other,215% New York Medicaid APG,7104.08,,,7104.08,Other,215% New York Medicaid APG,4130.28,,,4130.28,Other,125% New York Medicaid APG,2694.84,27710.98,
Replace eye fluid,67025,CPT,,,,,,,,both,,,49016.23,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24508.12,50,,24508.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1455.98,,,1455.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34311.36,70,,34311.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,782.79,,,782.79,Other,New York Medicaid APG methodology,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1095.9,,,1095.9,Other,140% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,2035.24,,,2035.24,Other,260% New York Medicaid APG,2536.23,,,2536.23,Other,324% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,978.48,,,978.48,Other,125% New York Medicaid APG,782.79,34311.36,
Implant eye drug system,67027,CPT,,,,,,,,both,,,331986.72,30014.72,,,30014.72,Other,150% of Medicare + 9.63% HCRA Surcharge,18252.13,,,18252.13,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,165993.36,50,,165993.36,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6145.86,,,6145.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,232390.7,70,,232390.7,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3304.22,,,3304.22,Other,New York Medicaid APG methodology,3304.22,,,3304.22,Other,100% New York Medicaid APG,3304.22,,,3304.22,Other,100% New York Medicaid APG,3304.22,,,3304.22,Other,100% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,4625.91,,,4625.91,Other,140% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,8590.98,,,8590.98,Other,260% New York Medicaid APG,10705.69,,,10705.69,Other,324% New York Medicaid APG,7104.08,,,7104.08,Other,215% New York Medicaid APG,7104.08,,,7104.08,Other,215% New York Medicaid APG,4130.28,,,4130.28,Other,125% New York Medicaid APG,3304.22,232390.7,
Injection eye drug,67028,CPT,,,,,,,,both,,,7123.45,644.03,,,644.03,Other,150% of Medicare + 9.63% HCRA Surcharge,391.64,,,391.64,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3561.73,50,,3561.73,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,634.14,,,634.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4986.42,70,,4986.42,percent of total billed charges,,443.85,,,443.85,Fee Schedule,,376.6,,,376.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,340.93,,,340.93,Other,New York Medicaid APG methodology,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,477.31,,,477.31,Other,140% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,886.43,,,886.43,Other,260% New York Medicaid APG,1104.63,,,1104.63,Other,324% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,426.17,,,426.17,Other,125% New York Medicaid APG,340.93,9473,
Incise inner eye strands,67030,CPT,,,,,,,,both,,,49016.23,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24508.12,50,,24508.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1455.98,,,1455.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34311.36,70,,34311.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,782.79,,,782.79,Other,New York Medicaid APG methodology,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1095.9,,,1095.9,Other,140% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,2035.24,,,2035.24,Other,260% New York Medicaid APG,2536.23,,,2536.23,Other,324% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,978.48,,,978.48,Other,125% New York Medicaid APG,782.79,34311.36,
Laser surgery eye strands,67031,CPT,,,,,,,,both,,,12226.3,1105.37,,,1105.37,Other,150% of Medicare + 9.63% HCRA Surcharge,672.18,,,672.18,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6113.15,50,,6113.15,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1455.98,,,1455.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8558.41,70,,8558.41,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,782.79,,,782.79,Other,New York Medicaid APG methodology,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1095.9,,,1095.9,Other,140% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,2035.24,,,2035.24,Other,260% New York Medicaid APG,2536.23,,,2536.23,Other,324% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,978.48,,,978.48,Other,125% New York Medicaid APG,672.18,13157,
Removal of inner eye fluid,67036,CPT,,,,,,,,both,,,39683.14,7731.8,,,7731.8,Other,150% of Medicare + 9.63% HCRA Surcharge,4701.75,,,4701.75,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,19841.57,50,,19841.57,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6145.86,,,6145.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27778.2,70,,27778.2,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3304.22,,,3304.22,Other,New York Medicaid APG methodology,3304.22,,,3304.22,Other,100% New York Medicaid APG,3304.22,,,3304.22,Other,100% New York Medicaid APG,3304.22,,,3304.22,Other,100% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,4625.91,,,4625.91,Other,140% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,8590.98,,,8590.98,Other,260% New York Medicaid APG,10705.69,,,10705.69,Other,324% New York Medicaid APG,7104.08,,,7104.08,Other,215% New York Medicaid APG,7104.08,,,7104.08,Other,215% New York Medicaid APG,4130.28,,,4130.28,Other,125% New York Medicaid APG,3304.22,27778.2,
Laser treatment of retina,67039,CPT,,,,,,,,both,,,36633.79,7731.8,,,7731.8,Other,150% of Medicare + 9.63% HCRA Surcharge,4701.75,,,4701.75,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,18316.9,50,,18316.9,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6145.86,,,6145.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25643.65,70,,25643.65,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3304.22,,,3304.22,Other,New York Medicaid APG methodology,3304.22,,,3304.22,Other,100% New York Medicaid APG,3304.22,,,3304.22,Other,100% New York Medicaid APG,3304.22,,,3304.22,Other,100% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,4625.91,,,4625.91,Other,140% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,8590.98,,,8590.98,Other,260% New York Medicaid APG,10705.69,,,10705.69,Other,324% New York Medicaid APG,7104.08,,,7104.08,Other,215% New York Medicaid APG,7104.08,,,7104.08,Other,215% New York Medicaid APG,4130.28,,,4130.28,Other,125% New York Medicaid APG,3304.22,25643.65,
Laser treatment of retina,67040,CPT,,,,,,,,both,,,36695.92,7731.8,,,7731.8,Other,150% of Medicare + 9.63% HCRA Surcharge,4701.75,,,4701.75,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,18347.96,50,,18347.96,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6145.86,,,6145.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25687.14,70,,25687.14,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3304.22,,,3304.22,Other,New York Medicaid APG methodology,3304.22,,,3304.22,Other,100% New York Medicaid APG,3304.22,,,3304.22,Other,100% New York Medicaid APG,3304.22,,,3304.22,Other,100% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,4625.91,,,4625.91,Other,140% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,8590.98,,,8590.98,Other,260% New York Medicaid APG,10705.69,,,10705.69,Other,324% New York Medicaid APG,7104.08,,,7104.08,Other,215% New York Medicaid APG,7104.08,,,7104.08,Other,215% New York Medicaid APG,4130.28,,,4130.28,Other,125% New York Medicaid APG,3304.22,25687.14,
Vit for macular pucker,67041,CPT,,,,,,,,both,,,34629.14,7731.8,,,7731.8,Other,150% of Medicare + 9.63% HCRA Surcharge,4701.75,,,4701.75,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,17314.57,50,,17314.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6145.86,,,6145.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24240.4,70,,24240.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3304.22,,,3304.22,Other,New York Medicaid APG methodology,3304.22,,,3304.22,Other,100% New York Medicaid APG,3304.22,,,3304.22,Other,100% New York Medicaid APG,3304.22,,,3304.22,Other,100% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,4625.91,,,4625.91,Other,140% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,8590.98,,,8590.98,Other,260% New York Medicaid APG,10705.69,,,10705.69,Other,324% New York Medicaid APG,7104.08,,,7104.08,Other,215% New York Medicaid APG,7104.08,,,7104.08,Other,215% New York Medicaid APG,4130.28,,,4130.28,Other,125% New York Medicaid APG,3304.22,24240.4,
Vit for macular hole,67042,CPT,,,,,,,,both,,,36517.02,7731.8,,,7731.8,Other,150% of Medicare + 9.63% HCRA Surcharge,4701.75,,,4701.75,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,18258.51,50,,18258.51,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6145.86,,,6145.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25561.91,70,,25561.91,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3304.22,,,3304.22,Other,New York Medicaid APG methodology,3304.22,,,3304.22,Other,100% New York Medicaid APG,3304.22,,,3304.22,Other,100% New York Medicaid APG,3304.22,,,3304.22,Other,100% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,4625.91,,,4625.91,Other,140% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,8590.98,,,8590.98,Other,260% New York Medicaid APG,10705.69,,,10705.69,Other,324% New York Medicaid APG,7104.08,,,7104.08,Other,215% New York Medicaid APG,7104.08,,,7104.08,Other,215% New York Medicaid APG,4130.28,,,4130.28,Other,125% New York Medicaid APG,3304.22,25561.91,
Vit for membrane dissect,67043,CPT,,,,,,,,both,,,34704.14,7731.8,,,7731.8,Other,150% of Medicare + 9.63% HCRA Surcharge,4701.75,,,4701.75,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,17352.07,50,,17352.07,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6145.86,,,6145.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24292.9,70,,24292.9,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3304.22,,,3304.22,Other,New York Medicaid APG methodology,3304.22,,,3304.22,Other,100% New York Medicaid APG,3304.22,,,3304.22,Other,100% New York Medicaid APG,3304.22,,,3304.22,Other,100% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,4625.91,,,4625.91,Other,140% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,8590.98,,,8590.98,Other,260% New York Medicaid APG,10705.69,,,10705.69,Other,324% New York Medicaid APG,7104.08,,,7104.08,Other,215% New York Medicaid APG,7104.08,,,7104.08,Other,215% New York Medicaid APG,4130.28,,,4130.28,Other,125% New York Medicaid APG,3304.22,24292.9,
Repair detached retina crtx,67101,CPT,,,,,,,,both,,,49016.23,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24508.12,50,,24508.12,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6145.86,,,6145.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34311.36,70,,34311.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3304.22,,,3304.22,Other,New York Medicaid APG methodology,3304.22,,,3304.22,Other,100% New York Medicaid APG,3304.22,,,3304.22,Other,100% New York Medicaid APG,3304.22,,,3304.22,Other,100% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,4625.91,,,4625.91,Other,140% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,8590.98,,,8590.98,Other,260% New York Medicaid APG,10705.69,,,10705.69,Other,324% New York Medicaid APG,7104.08,,,7104.08,Other,215% New York Medicaid APG,7104.08,,,7104.08,Other,215% New York Medicaid APG,4130.28,,,4130.28,Other,125% New York Medicaid APG,2694.84,34311.36,
Repair detached retina pc,67105,CPT,,,,,,,,both,,,12226.3,1105.37,,,1105.37,Other,150% of Medicare + 9.63% HCRA Surcharge,672.18,,,672.18,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6113.15,50,,6113.15,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1455.98,,,1455.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8558.41,70,,8558.41,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,782.79,,,782.79,Other,New York Medicaid APG methodology,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1095.9,,,1095.9,Other,140% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,2035.24,,,2035.24,Other,260% New York Medicaid APG,2536.23,,,2536.23,Other,324% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,978.48,,,978.48,Other,125% New York Medicaid APG,672.18,13157,
Repair detached retina,67107,CPT,,,,,,,,both,,,37944.14,7731.8,,,7731.8,Other,150% of Medicare + 9.63% HCRA Surcharge,4701.75,,,4701.75,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,18972.07,50,,18972.07,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6145.86,,,6145.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26560.9,70,,26560.9,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3304.22,,,3304.22,Other,New York Medicaid APG methodology,3304.22,,,3304.22,Other,100% New York Medicaid APG,3304.22,,,3304.22,Other,100% New York Medicaid APG,3304.22,,,3304.22,Other,100% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,4625.91,,,4625.91,Other,140% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,8590.98,,,8590.98,Other,260% New York Medicaid APG,10705.69,,,10705.69,Other,324% New York Medicaid APG,7104.08,,,7104.08,Other,215% New York Medicaid APG,7104.08,,,7104.08,Other,215% New York Medicaid APG,4130.28,,,4130.28,Other,125% New York Medicaid APG,3304.22,26560.9,
Repair detached retina,67108,CPT,,,,,,,,both,,,37702.06,7731.8,,,7731.8,Other,150% of Medicare + 9.63% HCRA Surcharge,4701.75,,,4701.75,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,18851.03,50,,18851.03,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6145.86,,,6145.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26391.44,70,,26391.44,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3304.22,,,3304.22,Other,New York Medicaid APG methodology,3304.22,,,3304.22,Other,100% New York Medicaid APG,3304.22,,,3304.22,Other,100% New York Medicaid APG,3304.22,,,3304.22,Other,100% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,4625.91,,,4625.91,Other,140% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,8590.98,,,8590.98,Other,260% New York Medicaid APG,10705.69,,,10705.69,Other,324% New York Medicaid APG,7104.08,,,7104.08,Other,215% New York Medicaid APG,7104.08,,,7104.08,Other,215% New York Medicaid APG,4130.28,,,4130.28,Other,125% New York Medicaid APG,3304.22,26391.44,
Repair detached retina,67110,CPT,,,,,,,,both,,,34169.97,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17084.99,50,,17084.99,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1455.98,,,1455.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23918.98,70,,23918.98,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,782.79,,,782.79,Other,New York Medicaid APG methodology,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1095.9,,,1095.9,Other,140% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,2035.24,,,2035.24,Other,260% New York Medicaid APG,2536.23,,,2536.23,Other,324% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,978.48,,,978.48,Other,125% New York Medicaid APG,782.79,23918.98,
Repair retinal detach cplx,67113,CPT,,,,,,,,both,,,38858.37,9939.03,,,9939.03,Other,150% of Medicare + 9.63% HCRA Surcharge,6043.98,,,6043.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,19429.19,50,,19429.19,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6145.86,,,6145.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27200.86,70,,27200.86,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3304.22,,,3304.22,Other,New York Medicaid APG methodology,3304.22,,,3304.22,Other,100% New York Medicaid APG,3304.22,,,3304.22,Other,100% New York Medicaid APG,3304.22,,,3304.22,Other,100% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,4625.91,,,4625.91,Other,140% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,8590.98,,,8590.98,Other,260% New York Medicaid APG,10705.69,,,10705.69,Other,324% New York Medicaid APG,7104.08,,,7104.08,Other,215% New York Medicaid APG,7104.08,,,7104.08,Other,215% New York Medicaid APG,4130.28,,,4130.28,Other,125% New York Medicaid APG,3304.22,27200.86,
Release encircling material,67115,CPT,,,,,,,,both,,,85519.85,7731.8,,,7731.8,Other,150% of Medicare + 9.63% HCRA Surcharge,4701.75,,,4701.75,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,42759.93,50,,42759.93,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1455.98,,,1455.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,59863.9,70,,59863.9,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,782.79,,,782.79,Other,New York Medicaid APG methodology,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1095.9,,,1095.9,Other,140% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,2035.24,,,2035.24,Other,260% New York Medicaid APG,2536.23,,,2536.23,Other,324% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,978.48,,,978.48,Other,125% New York Medicaid APG,782.79,59863.9,
Remove eye implant material,67120,CPT,,,,,,,,both,,,34478.92,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17239.46,50,,17239.46,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1455.98,,,1455.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24135.24,70,,24135.24,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,782.79,,,782.79,Other,New York Medicaid APG methodology,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1095.9,,,1095.9,Other,140% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,2035.24,,,2035.24,Other,260% New York Medicaid APG,2536.23,,,2536.23,Other,324% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,978.48,,,978.48,Other,125% New York Medicaid APG,782.79,24135.24,
Remove eye implant material,67121,CPT,,,,,,,,both,,,49016.23,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24508.12,50,,24508.12,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1455.98,,,1455.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34311.36,70,,34311.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,782.79,,,782.79,Other,New York Medicaid APG methodology,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1095.9,,,1095.9,Other,140% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,2035.24,,,2035.24,Other,260% New York Medicaid APG,2536.23,,,2536.23,Other,324% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,978.48,,,978.48,Other,125% New York Medicaid APG,782.79,34311.36,
Treatment of retina,67141,CPT,,,,,,,,both,,,6127.39,553.97,,,553.97,Other,150% of Medicare + 9.63% HCRA Surcharge,336.87,,,336.87,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3063.7,50,,3063.7,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,634.14,,,634.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4289.17,70,,4289.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,340.93,,,340.93,Other,New York Medicaid APG methodology,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,477.31,,,477.31,Other,140% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,886.43,,,886.43,Other,260% New York Medicaid APG,1104.63,,,1104.63,Other,324% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,426.17,,,426.17,Other,125% New York Medicaid APG,336.87,13157,
Treatment of retina,67145,CPT,,,,,,,,both,,,36129.72,1105.37,,,1105.37,Other,150% of Medicare + 9.63% HCRA Surcharge,672.18,,,672.18,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,18064.86,50,,18064.86,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1455.98,,,1455.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25290.8,70,,25290.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,782.79,,,782.79,Other,New York Medicaid APG methodology,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1095.9,,,1095.9,Other,140% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,2035.24,,,2035.24,Other,260% New York Medicaid APG,2536.23,,,2536.23,Other,324% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,978.48,,,978.48,Other,125% New York Medicaid APG,672.18,25290.8,
Treatment of retinal lesion,67208,CPT,,,,,,,,both,,,6127.39,553.97,,,553.97,Other,150% of Medicare + 9.63% HCRA Surcharge,336.87,,,336.87,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3063.7,50,,3063.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,634.14,,,634.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4289.17,70,,4289.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,340.93,,,340.93,Other,New York Medicaid APG methodology,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,477.31,,,477.31,Other,140% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,886.43,,,886.43,Other,260% New York Medicaid APG,1104.63,,,1104.63,Other,324% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,426.17,,,426.17,Other,125% New York Medicaid APG,336.87,13157,
Treatment of retinal lesion,67210,CPT,,,,,,,,both,,,12226.3,1105.37,,,1105.37,Other,150% of Medicare + 9.63% HCRA Surcharge,672.18,,,672.18,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6113.15,50,,6113.15,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1455.98,,,1455.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8558.41,70,,8558.41,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,782.79,,,782.79,Other,New York Medicaid APG methodology,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1095.9,,,1095.9,Other,140% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,2035.24,,,2035.24,Other,260% New York Medicaid APG,2536.23,,,2536.23,Other,324% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,978.48,,,978.48,Other,125% New York Medicaid APG,672.18,13157,
Treatment of retinal lesion,67218,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6145.86,,,6145.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3304.22,,,3304.22,Other,New York Medicaid APG methodology,3304.22,,,3304.22,Other,100% New York Medicaid APG,3304.22,,,3304.22,Other,100% New York Medicaid APG,3304.22,,,3304.22,Other,100% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,4625.91,,,4625.91,Other,140% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,8590.98,,,8590.98,Other,260% New York Medicaid APG,10705.69,,,10705.69,Other,324% New York Medicaid APG,7104.08,,,7104.08,Other,215% New York Medicaid APG,7104.08,,,7104.08,Other,215% New York Medicaid APG,4130.28,,,4130.28,Other,125% New York Medicaid APG,3304.22,56927.18,
Treatment of choroid lesion,67220,CPT,,,,,,,,both,,,12226.3,1105.37,,,1105.37,Other,150% of Medicare + 9.63% HCRA Surcharge,672.18,,,672.18,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6113.15,50,,6113.15,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1455.98,,,1455.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8558.41,70,,8558.41,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,782.79,,,782.79,Other,New York Medicaid APG methodology,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1095.9,,,1095.9,Other,140% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,2035.24,,,2035.24,Other,260% New York Medicaid APG,2536.23,,,2536.23,Other,324% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,978.48,,,978.48,Other,125% New York Medicaid APG,672.18,13157,
Ocular photodynamic ther,67221,CPT,,,,,,,,both,,,12226.3,1105.37,,,1105.37,Other,150% of Medicare + 9.63% HCRA Surcharge,672.18,,,672.18,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6113.15,50,,6113.15,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1455.98,,,1455.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8558.41,70,,8558.41,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,782.79,,,782.79,Other,New York Medicaid APG methodology,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1095.9,,,1095.9,Other,140% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,2035.24,,,2035.24,Other,260% New York Medicaid APG,2536.23,,,2536.23,Other,324% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,978.48,,,978.48,Other,125% New York Medicaid APG,672.18,13157,
Eye photodynamic ther add-on,67225,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1455.98,,,1455.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,133.65,,,133.65,Fee Schedule,,113.4,,,113.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,782.79,,,782.79,Other,New York Medicaid APG methodology,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1095.9,,,1095.9,Other,140% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,2035.24,,,2035.24,Other,260% New York Medicaid APG,2536.23,,,2536.23,Other,324% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,978.48,,,978.48,Other,125% New York Medicaid APG,0.01,22702.47,
Dstrj extensive retinopathy,67227,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6145.86,,,6145.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3304.22,,,3304.22,Other,New York Medicaid APG methodology,3304.22,,,3304.22,Other,100% New York Medicaid APG,3304.22,,,3304.22,Other,100% New York Medicaid APG,3304.22,,,3304.22,Other,100% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,4625.91,,,4625.91,Other,140% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,8590.98,,,8590.98,Other,260% New York Medicaid APG,10705.69,,,10705.69,Other,324% New York Medicaid APG,7104.08,,,7104.08,Other,215% New York Medicaid APG,7104.08,,,7104.08,Other,215% New York Medicaid APG,4130.28,,,4130.28,Other,125% New York Medicaid APG,3304.22,56927.18,
Treatment x10sv retinopathy,67228,CPT,,,,,,,,both,,,32171.72,1105.37,,,1105.37,Other,150% of Medicare + 9.63% HCRA Surcharge,672.18,,,672.18,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16085.86,50,,16085.86,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1455.98,,,1455.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22520.2,70,,22520.2,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,782.79,,,782.79,Other,New York Medicaid APG methodology,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1095.9,,,1095.9,Other,140% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,2035.24,,,2035.24,Other,260% New York Medicaid APG,2536.23,,,2536.23,Other,324% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,978.48,,,978.48,Other,125% New York Medicaid APG,672.18,22520.2,
Tr retinal les preterm inf,67229,CPT,,,,,,,,both,,,12226.3,1105.37,,,1105.37,Other,150% of Medicare + 9.63% HCRA Surcharge,672.18,,,672.18,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6113.15,50,,6113.15,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1455.98,,,1455.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8558.41,70,,8558.41,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,782.79,,,782.79,Other,New York Medicaid APG methodology,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1095.9,,,1095.9,Other,140% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,2035.24,,,2035.24,Other,260% New York Medicaid APG,2536.23,,,2536.23,Other,324% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,978.48,,,978.48,Other,125% New York Medicaid APG,0.01,13157,
Reinforce eye wall,67250,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1455.98,,,1455.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,782.79,,,782.79,Other,New York Medicaid APG methodology,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1095.9,,,1095.9,Other,140% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,2035.24,,,2035.24,Other,260% New York Medicaid APG,2536.23,,,2536.23,Other,324% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,978.48,,,978.48,Other,125% New York Medicaid APG,782.79,34406.09,
Reinforce/graft eye wall,67255,CPT,,,,,,,,both,,,85519.85,7731.8,,,7731.8,Other,150% of Medicare + 9.63% HCRA Surcharge,4701.75,,,4701.75,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,42759.93,50,,42759.93,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1455.98,,,1455.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,59863.9,70,,59863.9,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,782.79,,,782.79,Other,New York Medicaid APG methodology,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1095.9,,,1095.9,Other,140% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,2035.24,,,2035.24,Other,260% New York Medicaid APG,2536.23,,,2536.23,Other,324% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,978.48,,,978.48,Other,125% New York Medicaid APG,782.79,59863.9,
Revise eye muscle,67311,CPT,,,,,,,,both,,,35853.95,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17926.98,50,,17926.98,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3927.38,,,3927.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25097.77,70,,25097.77,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2111.5,,,2111.5,Other,New York Medicaid APG methodology,2111.5,,,2111.5,Other,100% New York Medicaid APG,2111.5,,,2111.5,Other,100% New York Medicaid APG,2111.5,,,2111.5,Other,100% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,2956.09,,,2956.09,Other,140% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,5489.89,,,5489.89,Other,260% New York Medicaid APG,6841.25,,,6841.25,Other,324% New York Medicaid APG,4539.72,,,4539.72,Other,215% New York Medicaid APG,4539.72,,,4539.72,Other,215% New York Medicaid APG,2639.37,,,2639.37,Other,125% New York Medicaid APG,2111.5,25097.77,
Revise two eye muscles,67312,CPT,,,,,,,,both,,,36970.21,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18485.11,50,,18485.11,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3927.38,,,3927.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25879.15,70,,25879.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2111.5,,,2111.5,Other,New York Medicaid APG methodology,2111.5,,,2111.5,Other,100% New York Medicaid APG,2111.5,,,2111.5,Other,100% New York Medicaid APG,2111.5,,,2111.5,Other,100% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,2956.09,,,2956.09,Other,140% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,5489.89,,,5489.89,Other,260% New York Medicaid APG,6841.25,,,6841.25,Other,324% New York Medicaid APG,4539.72,,,4539.72,Other,215% New York Medicaid APG,4539.72,,,4539.72,Other,215% New York Medicaid APG,2639.37,,,2639.37,Other,125% New York Medicaid APG,2111.5,25879.15,
Revise eye muscle,67314,CPT,,,,,,,,both,,,38694.02,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19347.01,50,,19347.01,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3927.38,,,3927.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27085.81,70,,27085.81,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2111.5,,,2111.5,Other,New York Medicaid APG methodology,2111.5,,,2111.5,Other,100% New York Medicaid APG,2111.5,,,2111.5,Other,100% New York Medicaid APG,2111.5,,,2111.5,Other,100% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,2956.09,,,2956.09,Other,140% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,5489.89,,,5489.89,Other,260% New York Medicaid APG,6841.25,,,6841.25,Other,324% New York Medicaid APG,4539.72,,,4539.72,Other,215% New York Medicaid APG,4539.72,,,4539.72,Other,215% New York Medicaid APG,2639.37,,,2639.37,Other,125% New York Medicaid APG,2111.5,27085.81,
Revise two eye muscles,67316,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3927.38,,,3927.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2111.5,,,2111.5,Other,New York Medicaid APG methodology,2111.5,,,2111.5,Other,100% New York Medicaid APG,2111.5,,,2111.5,Other,100% New York Medicaid APG,2111.5,,,2111.5,Other,100% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,2956.09,,,2956.09,Other,140% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,5489.89,,,5489.89,Other,260% New York Medicaid APG,6841.25,,,6841.25,Other,324% New York Medicaid APG,4539.72,,,4539.72,Other,215% New York Medicaid APG,4539.72,,,4539.72,Other,215% New York Medicaid APG,2639.37,,,2639.37,Other,125% New York Medicaid APG,2111.5,34406.09,
Revise eye muscle(s),67318,CPT,,,,,,,,both,,,38658.01,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19329.01,50,,19329.01,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3927.38,,,3927.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27060.61,70,,27060.61,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2111.5,,,2111.5,Other,New York Medicaid APG methodology,2111.5,,,2111.5,Other,100% New York Medicaid APG,2111.5,,,2111.5,Other,100% New York Medicaid APG,2111.5,,,2111.5,Other,100% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,2956.09,,,2956.09,Other,140% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,5489.89,,,5489.89,Other,260% New York Medicaid APG,6841.25,,,6841.25,Other,324% New York Medicaid APG,4539.72,,,4539.72,Other,215% New York Medicaid APG,4539.72,,,4539.72,Other,215% New York Medicaid APG,2639.37,,,2639.37,Other,125% New York Medicaid APG,2111.5,27060.61,
Revise eye muscle(s) add-on,67320,CPT,,,,,,,,both,,,83504,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,41752,50,,41752,percent of total billed charges,,58452.8,70,,58452.8,percent of total billed charges,,6152,,,6152,Case Rate,,3927.38,,,3927.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,58452.8,70,,58452.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2111.5,,,2111.5,Other,New York Medicaid APG methodology,2111.5,,,2111.5,Other,100% New York Medicaid APG,2111.5,,,2111.5,Other,100% New York Medicaid APG,2111.5,,,2111.5,Other,100% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,2956.09,,,2956.09,Other,140% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,5489.89,,,5489.89,Other,260% New York Medicaid APG,6841.25,,,6841.25,Other,324% New York Medicaid APG,4539.72,,,4539.72,Other,215% New York Medicaid APG,4539.72,,,4539.72,Other,215% New York Medicaid APG,2639.37,,,2639.37,Other,125% New York Medicaid APG,0.01,58452.8,
Eye surgery follow-up add-on,67331,CPT,,,,,,,,both,,,83504,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,41752,50,,41752,percent of total billed charges,,58452.8,70,,58452.8,percent of total billed charges,,6152,,,6152,Case Rate,,3927.38,,,3927.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,58452.8,70,,58452.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2111.5,,,2111.5,Other,New York Medicaid APG methodology,2111.5,,,2111.5,Other,100% New York Medicaid APG,2111.5,,,2111.5,Other,100% New York Medicaid APG,2111.5,,,2111.5,Other,100% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,2956.09,,,2956.09,Other,140% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,5489.89,,,5489.89,Other,260% New York Medicaid APG,6841.25,,,6841.25,Other,324% New York Medicaid APG,4539.72,,,4539.72,Other,215% New York Medicaid APG,4539.72,,,4539.72,Other,215% New York Medicaid APG,2639.37,,,2639.37,Other,125% New York Medicaid APG,0.01,58452.8,
Rerevise eye muscles add-on,67332,CPT,,,,,,,,both,,,83504,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,41752,50,,41752,percent of total billed charges,,58452.8,70,,58452.8,percent of total billed charges,,6152,,,6152,Case Rate,,3927.38,,,3927.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,58452.8,70,,58452.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2111.5,,,2111.5,Other,New York Medicaid APG methodology,2111.5,,,2111.5,Other,100% New York Medicaid APG,2111.5,,,2111.5,Other,100% New York Medicaid APG,2111.5,,,2111.5,Other,100% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,2956.09,,,2956.09,Other,140% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,5489.89,,,5489.89,Other,260% New York Medicaid APG,6841.25,,,6841.25,Other,324% New York Medicaid APG,4539.72,,,4539.72,Other,215% New York Medicaid APG,4539.72,,,4539.72,Other,215% New York Medicaid APG,2639.37,,,2639.37,Other,125% New York Medicaid APG,0.01,58452.8,
Revise eye muscle w/suture,67334,CPT,,,,,,,,both,,,83504,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,41752,50,,41752,percent of total billed charges,,58452.8,70,,58452.8,percent of total billed charges,,6152,,,6152,Case Rate,,3927.38,,,3927.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,58452.8,70,,58452.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2111.5,,,2111.5,Other,New York Medicaid APG methodology,2111.5,,,2111.5,Other,100% New York Medicaid APG,2111.5,,,2111.5,Other,100% New York Medicaid APG,2111.5,,,2111.5,Other,100% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,2956.09,,,2956.09,Other,140% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,5489.89,,,5489.89,Other,260% New York Medicaid APG,6841.25,,,6841.25,Other,324% New York Medicaid APG,4539.72,,,4539.72,Other,215% New York Medicaid APG,4539.72,,,4539.72,Other,215% New York Medicaid APG,2639.37,,,2639.37,Other,125% New York Medicaid APG,0.01,58452.8,
Eye suture during surgery,67335,CPT,,,,,,,,both,,,83504,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,41752,50,,41752,percent of total billed charges,,58452.8,70,,58452.8,percent of total billed charges,,6152,,,6152,Case Rate,,3927.38,,,3927.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,58452.8,70,,58452.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2111.5,,,2111.5,Other,New York Medicaid APG methodology,2111.5,,,2111.5,Other,100% New York Medicaid APG,2111.5,,,2111.5,Other,100% New York Medicaid APG,2111.5,,,2111.5,Other,100% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,2956.09,,,2956.09,Other,140% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,5489.89,,,5489.89,Other,260% New York Medicaid APG,6841.25,,,6841.25,Other,324% New York Medicaid APG,4539.72,,,4539.72,Other,215% New York Medicaid APG,4539.72,,,4539.72,Other,215% New York Medicaid APG,2639.37,,,2639.37,Other,125% New York Medicaid APG,0.01,58452.8,
Revise eye muscle add-on,67340,CPT,,,,,,,,both,,,83504,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,41752,50,,41752,percent of total billed charges,,58452.8,70,,58452.8,percent of total billed charges,,6152,,,6152,Case Rate,,3927.38,,,3927.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,58452.8,70,,58452.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,2111.5,,,2111.5,Other,New York Medicaid APG methodology,2111.5,,,2111.5,Other,100% New York Medicaid APG,2111.5,,,2111.5,Other,100% New York Medicaid APG,2111.5,,,2111.5,Other,100% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,2956.09,,,2956.09,Other,140% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,5489.89,,,5489.89,Other,260% New York Medicaid APG,6841.25,,,6841.25,Other,324% New York Medicaid APG,4539.72,,,4539.72,Other,215% New York Medicaid APG,4539.72,,,4539.72,Other,215% New York Medicaid APG,2639.37,,,2639.37,Other,125% New York Medicaid APG,0.01,58452.8,
Release eye tissue,67343,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3927.38,,,3927.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2111.5,,,2111.5,Other,New York Medicaid APG methodology,2111.5,,,2111.5,Other,100% New York Medicaid APG,2111.5,,,2111.5,Other,100% New York Medicaid APG,2111.5,,,2111.5,Other,100% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,2956.09,,,2956.09,Other,140% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,5489.89,,,5489.89,Other,260% New York Medicaid APG,6841.25,,,6841.25,Other,324% New York Medicaid APG,4539.72,,,4539.72,Other,215% New York Medicaid APG,4539.72,,,4539.72,Other,215% New York Medicaid APG,2639.37,,,2639.37,Other,125% New York Medicaid APG,2111.5,34406.09,
Destroy nerve of eye muscle,67345,CPT,,,,,,,,both,,,35389.26,553.97,,,553.97,Other,150% of Medicare + 9.63% HCRA Surcharge,336.87,,,336.87,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17694.63,50,,17694.63,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,634.14,,,634.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24772.48,70,,24772.48,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,340.93,,,340.93,Other,New York Medicaid APG methodology,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,477.31,,,477.31,Other,140% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,886.43,,,886.43,Other,260% New York Medicaid APG,1104.63,,,1104.63,Other,324% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,426.17,,,426.17,Other,125% New York Medicaid APG,336.87,24772.48,
Biopsy eye muscle,67346,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3927.38,,,3927.38,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2111.5,,,2111.5,Other,New York Medicaid APG methodology,2111.5,,,2111.5,Other,100% New York Medicaid APG,2111.5,,,2111.5,Other,100% New York Medicaid APG,2111.5,,,2111.5,Other,100% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,2956.09,,,2956.09,Other,140% New York Medicaid APG,4750.87,,,4750.87,Other,225% New York Medicaid APG,5489.89,,,5489.89,Other,260% New York Medicaid APG,6841.25,,,6841.25,Other,324% New York Medicaid APG,4539.72,,,4539.72,Other,215% New York Medicaid APG,4539.72,,,4539.72,Other,215% New York Medicaid APG,2639.37,,,2639.37,Other,125% New York Medicaid APG,2111.5,56927.18,
Explore/biopsy eye socket,67400,CPT,,,,,,,,both,,,47822.67,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,23911.34,50,,23911.34,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4289.29,,,4289.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,33475.87,70,,33475.87,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2306.07,,,2306.07,Other,New York Medicaid APG methodology,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,3228.5,,,3228.5,Other,140% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5995.78,,,5995.78,Other,260% New York Medicaid APG,7471.67,,,7471.67,Other,324% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,2882.59,,,2882.59,Other,125% New York Medicaid APG,2306.07,33475.87,
Explore/drain eye socket,67405,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4289.29,,,4289.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2306.07,,,2306.07,Other,New York Medicaid APG methodology,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,3228.5,,,3228.5,Other,140% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5995.78,,,5995.78,Other,260% New York Medicaid APG,7471.67,,,7471.67,Other,324% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,2882.59,,,2882.59,Other,125% New York Medicaid APG,2306.07,34406.09,
Explore/treat eye socket,67412,CPT,,,,,,,,both,,,45885.35,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,22942.68,50,,22942.68,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4289.29,,,4289.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,32119.75,70,,32119.75,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2306.07,,,2306.07,Other,New York Medicaid APG methodology,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,3228.5,,,3228.5,Other,140% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5995.78,,,5995.78,Other,260% New York Medicaid APG,7471.67,,,7471.67,Other,324% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,2882.59,,,2882.59,Other,125% New York Medicaid APG,2306.07,32119.75,
Explore/treat eye socket,67413,CPT,,,,,,,,both,,,34994.66,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17497.33,50,,17497.33,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4289.29,,,4289.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24496.26,70,,24496.26,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2306.07,,,2306.07,Other,New York Medicaid APG methodology,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,3228.5,,,3228.5,Other,140% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5995.78,,,5995.78,Other,260% New York Medicaid APG,7471.67,,,7471.67,Other,324% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,2882.59,,,2882.59,Other,125% New York Medicaid APG,2306.07,24496.26,
Explr/decompress eye socket,67414,CPT,,,,,,,,both,,,71687.2,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,35843.6,50,,35843.6,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4289.29,,,4289.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50181.04,70,,50181.04,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2306.07,,,2306.07,Other,New York Medicaid APG methodology,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,3228.5,,,3228.5,Other,140% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5995.78,,,5995.78,Other,260% New York Medicaid APG,7471.67,,,7471.67,Other,324% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,2882.59,,,2882.59,Other,125% New York Medicaid APG,2306.07,50181.04,
Aspiration orbital contents,67415,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1455.98,,,1455.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,782.79,,,782.79,Other,New York Medicaid APG methodology,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1095.9,,,1095.9,Other,140% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,2035.24,,,2035.24,Other,260% New York Medicaid APG,2536.23,,,2536.23,Other,324% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,978.48,,,978.48,Other,125% New York Medicaid APG,782.79,34406.09,
Explore/treat eye socket,67420,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,56927.18,
Explore/treat eye socket,67430,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5647.23,,,5647.23,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3036.14,,,3036.14,Other,New York Medicaid APG methodology,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,3036.14,,,3036.14,Other,100% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,4250.6,,,4250.6,Other,140% New York Medicaid APG,6831.33,,,6831.33,Other,225% New York Medicaid APG,7893.98,,,7893.98,Other,260% New York Medicaid APG,9837.11,,,9837.11,Other,324% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,6527.71,,,6527.71,Other,215% New York Medicaid APG,3795.18,,,3795.18,Other,125% New York Medicaid APG,3036.14,56927.18,
Explore/drain eye socket,67440,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,56927.18,
Explr/decompress eye socket,67445,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,56927.18,
Explore/biopsy eye socket,67450,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,56927.18,
Inject/treat eye socket,67500,CPT,,,,,,,,both,,,6127.39,553.97,,,553.97,Other,150% of Medicare + 9.63% HCRA Surcharge,336.87,,,336.87,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3063.7,50,,3063.7,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,634.14,,,634.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4289.17,70,,4289.17,percent of total billed charges,,310.2,,,310.2,Fee Schedule,,263.2,,,263.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,340.93,,,340.93,Other,New York Medicaid APG methodology,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,477.31,,,477.31,Other,140% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,886.43,,,886.43,Other,260% New York Medicaid APG,1104.63,,,1104.63,Other,324% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,426.17,,,426.17,Other,125% New York Medicaid APG,0.01,9473,
Inject/treat eye socket,67505,CPT,,,,,,,,both,,,6127.39,553.97,,,553.97,Other,150% of Medicare + 9.63% HCRA Surcharge,336.87,,,336.87,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3063.7,50,,3063.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,634.14,,,634.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4289.17,70,,4289.17,percent of total billed charges,,351.45,,,351.45,Fee Schedule,,298.2,,,298.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,340.93,,,340.93,Other,New York Medicaid APG methodology,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,477.31,,,477.31,Other,140% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,886.43,,,886.43,Other,260% New York Medicaid APG,1104.63,,,1104.63,Other,324% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,426.17,,,426.17,Other,125% New York Medicaid APG,298.2,9473,
Inject/treat eye socket,67515,CPT,,,,,,,,both,,,6127.39,553.97,,,553.97,Other,150% of Medicare + 9.63% HCRA Surcharge,336.87,,,336.87,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3063.7,50,,3063.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,634.14,,,634.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4289.17,70,,4289.17,percent of total billed charges,,229.35,,,229.35,Fee Schedule,,194.6,,,194.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,340.93,,,340.93,Other,New York Medicaid APG methodology,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,477.31,,,477.31,Other,140% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,886.43,,,886.43,Other,260% New York Medicaid APG,1104.63,,,1104.63,Other,324% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,426.17,,,426.17,Other,125% New York Medicaid APG,194.6,9473,
Insert eye socket implant,67550,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4289.29,,,4289.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2306.07,,,2306.07,Other,New York Medicaid APG methodology,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,3228.5,,,3228.5,Other,140% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5995.78,,,5995.78,Other,260% New York Medicaid APG,7471.67,,,7471.67,Other,324% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,2882.59,,,2882.59,Other,125% New York Medicaid APG,2306.07,56927.18,
Revise eye socket implant,67560,CPT,,,,,,,,both,,,43213.48,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,21606.74,50,,21606.74,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4289.29,,,4289.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,30249.44,70,,30249.44,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2306.07,,,2306.07,Other,New York Medicaid APG methodology,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,3228.5,,,3228.5,Other,140% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5995.78,,,5995.78,Other,260% New York Medicaid APG,7471.67,,,7471.67,Other,324% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,2882.59,,,2882.59,Other,125% New York Medicaid APG,2306.07,30249.44,
Decompress optic nerve,67570,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4289.29,,,4289.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2306.07,,,2306.07,Other,New York Medicaid APG methodology,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,2306.07,,,2306.07,Other,100% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,3228.5,,,3228.5,Other,140% New York Medicaid APG,5188.66,,,5188.66,Other,225% New York Medicaid APG,5995.78,,,5995.78,Other,260% New York Medicaid APG,7471.67,,,7471.67,Other,324% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,4958.05,,,4958.05,Other,215% New York Medicaid APG,2882.59,,,2882.59,Other,125% New York Medicaid APG,2306.07,56927.18,
Drainage of eyelid abscess,67700,CPT,,,,,,,,both,,,6127.39,553.97,,,553.97,Other,150% of Medicare + 9.63% HCRA Surcharge,336.87,,,336.87,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3063.7,50,,3063.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,634.14,,,634.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4289.17,70,,4289.17,percent of total billed charges,,565.95,,,565.95,Fee Schedule,,480.2,,,480.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,340.93,,,340.93,Other,New York Medicaid APG methodology,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,477.31,,,477.31,Other,140% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,886.43,,,886.43,Other,260% New York Medicaid APG,1104.63,,,1104.63,Other,324% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,426.17,,,426.17,Other,125% New York Medicaid APG,336.87,9473,
Incision of eyelid,67710,CPT,,,,,,,,both,,,21295.3,1925.3,,,1925.3,Other,150% of Medicare + 9.63% HCRA Surcharge,1170.78,,,1170.78,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,10647.65,50,,10647.65,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2759.56,,,2759.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,14906.71,70,,14906.71,percent of total billed charges,,478.5,,,478.5,Fee Schedule,,406,,,406,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,2077.09,,,2077.09,Other,140% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3857.45,,,3857.45,Other,260% New York Medicaid APG,4806.98,,,4806.98,Other,324% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,1854.54,,,1854.54,Other,125% New York Medicaid APG,406,14906.71,
Incision of eyelid fold,67715,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2759.56,,,2759.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,529.65,,,529.65,Fee Schedule,,449.4,,,449.4,Fee Schedule,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,2077.09,,,2077.09,Other,140% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3857.45,,,3857.45,Other,260% New York Medicaid APG,4806.98,,,4806.98,Other,324% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,1854.54,,,1854.54,Other,125% New York Medicaid APG,449.4,34406.09,
Remove eyelid lesion,67800,CPT,,,,,,,,both,,,35091.21,553.97,,,553.97,Other,150% of Medicare + 9.63% HCRA Surcharge,336.87,,,336.87,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17545.61,50,,17545.61,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,634.14,,,634.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24563.85,70,,24563.85,percent of total billed charges,,496.65,,,496.65,Fee Schedule,,421.4,,,421.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,340.93,,,340.93,Other,New York Medicaid APG methodology,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,477.31,,,477.31,Other,140% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,886.43,,,886.43,Other,260% New York Medicaid APG,1104.63,,,1104.63,Other,324% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,426.17,,,426.17,Other,125% New York Medicaid APG,336.87,24563.85,
Remove eyelid lesions,67801,CPT,,,,,,,,both,,,21295.3,1925.3,,,1925.3,Other,150% of Medicare + 9.63% HCRA Surcharge,1170.78,,,1170.78,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,10647.65,50,,10647.65,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2759.56,,,2759.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,14906.71,70,,14906.71,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,2077.09,,,2077.09,Other,140% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3857.45,,,3857.45,Other,260% New York Medicaid APG,4806.98,,,4806.98,Other,324% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,1854.54,,,1854.54,Other,125% New York Medicaid APG,1170.78,14906.71,
Remove eyelid lesions,67805,CPT,,,,,,,,both,,,6127.39,553.97,,,553.97,Other,150% of Medicare + 9.63% HCRA Surcharge,336.87,,,336.87,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3063.7,50,,3063.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,634.14,,,634.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4289.17,70,,4289.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,340.93,,,340.93,Other,New York Medicaid APG methodology,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,477.31,,,477.31,Other,140% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,886.43,,,886.43,Other,260% New York Medicaid APG,1104.63,,,1104.63,Other,324% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,426.17,,,426.17,Other,125% New York Medicaid APG,336.87,13157,
Remove eyelid lesion(s),67808,CPT,,,,,,,,both,,,34585.73,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17292.87,50,,17292.87,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2759.56,,,2759.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24210.01,70,,24210.01,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,2077.09,,,2077.09,Other,140% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3857.45,,,3857.45,Other,260% New York Medicaid APG,4806.98,,,4806.98,Other,324% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,1854.54,,,1854.54,Other,125% New York Medicaid APG,1483.63,24210.01,
Biopsy eyelid & lid margin,67810,CPT,,,,,,,,both,,,6127.39,553.97,,,553.97,Other,150% of Medicare + 9.63% HCRA Surcharge,336.87,,,336.87,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3063.7,50,,3063.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,634.14,,,634.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4289.17,70,,4289.17,percent of total billed charges,,331.65,,,331.65,Fee Schedule,,281.4,,,281.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,340.93,,,340.93,Other,New York Medicaid APG methodology,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,477.31,,,477.31,Other,140% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,886.43,,,886.43,Other,260% New York Medicaid APG,1104.63,,,1104.63,Other,324% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,426.17,,,426.17,Other,125% New York Medicaid APG,281.4,9473,
Revise eyelashes,67820,CPT,,,,,,,,both,,,2686.86,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1343.43,50,,1343.43,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,408.99,,,408.99,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,1880.8,70,,1880.8,percent of total billed charges,,107.25,,,107.25,Fee Schedule,,91,,,91,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,219.89,,,219.89,Other,New York Medicaid APG methodology,219.89,,,219.89,Other,100% New York Medicaid APG,219.89,,,219.89,Other,100% New York Medicaid APG,219.89,,,219.89,Other,100% New York Medicaid APG,494.75,,,494.75,Other,225% New York Medicaid APG,494.75,,,494.75,Other,225% New York Medicaid APG,494.75,,,494.75,Other,225% New York Medicaid APG,494.75,,,494.75,Other,225% New York Medicaid APG,307.84,,,307.84,Other,140% New York Medicaid APG,494.75,,,494.75,Other,225% New York Medicaid APG,571.71,,,571.71,Other,260% New York Medicaid APG,712.44,,,712.44,Other,324% New York Medicaid APG,472.76,,,472.76,Other,215% New York Medicaid APG,472.76,,,472.76,Other,215% New York Medicaid APG,274.86,,,274.86,Other,125% New York Medicaid APG,0.01,9473,
Revise eyelashes,67825,CPT,,,,,,,,both,,,6127.39,553.97,,,553.97,Other,150% of Medicare + 9.63% HCRA Surcharge,336.87,,,336.87,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3063.7,50,,3063.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,634.14,,,634.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4289.17,70,,4289.17,percent of total billed charges,,592.35,,,592.35,Fee Schedule,,502.6,,,502.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,340.93,,,340.93,Other,New York Medicaid APG methodology,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,477.31,,,477.31,Other,140% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,886.43,,,886.43,Other,260% New York Medicaid APG,1104.63,,,1104.63,Other,324% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,426.17,,,426.17,Other,125% New York Medicaid APG,336.87,9473,
Revise eyelashes,67830,CPT,,,,,,,,both,,,33992.81,1925.3,,,1925.3,Other,150% of Medicare + 9.63% HCRA Surcharge,1170.78,,,1170.78,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16996.41,50,,16996.41,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,634.14,,,634.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23794.97,70,,23794.97,percent of total billed charges,,668.25,,,668.25,Fee Schedule,,567,,,567,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,340.93,,,340.93,Other,New York Medicaid APG methodology,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,477.31,,,477.31,Other,140% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,886.43,,,886.43,Other,260% New York Medicaid APG,1104.63,,,1104.63,Other,324% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,426.17,,,426.17,Other,125% New York Medicaid APG,340.93,23794.97,
Revise eyelashes,67835,CPT,,,,,,,,both,,,33679.66,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16839.83,50,,16839.83,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23575.76,70,,23575.76,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,23575.76,
Remove eyelid lesion,67840,CPT,,,,,,,,both,,,35626.99,1925.3,,,1925.3,Other,150% of Medicare + 9.63% HCRA Surcharge,1170.78,,,1170.78,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17813.5,50,,17813.5,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2759.56,,,2759.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24938.89,70,,24938.89,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,2077.09,,,2077.09,Other,140% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3857.45,,,3857.45,Other,260% New York Medicaid APG,4806.98,,,4806.98,Other,324% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,1854.54,,,1854.54,Other,125% New York Medicaid APG,1170.78,24938.89,
Treat eyelid lesion,67850,CPT,,,,,,,,both,,,21295.3,1925.3,,,1925.3,Other,150% of Medicare + 9.63% HCRA Surcharge,1170.78,,,1170.78,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,10647.65,50,,10647.65,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,634.14,,,634.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,14906.71,70,,14906.71,percent of total billed charges,,641.85,,,641.85,Fee Schedule,,544.6,,,544.6,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,340.93,,,340.93,Other,New York Medicaid APG methodology,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,477.31,,,477.31,Other,140% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,886.43,,,886.43,Other,260% New York Medicaid APG,1104.63,,,1104.63,Other,324% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,426.17,,,426.17,Other,125% New York Medicaid APG,340.93,14906.71,
Closure of eyelid by suture,67875,CPT,,,,,,,,both,,,21295.3,1925.3,,,1925.3,Other,150% of Medicare + 9.63% HCRA Surcharge,1170.78,,,1170.78,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,10647.65,50,,10647.65,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2759.56,,,2759.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,14906.71,70,,14906.71,percent of total billed charges,,462,,,462,Fee Schedule,,392,,,392,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,2077.09,,,2077.09,Other,140% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3857.45,,,3857.45,Other,260% New York Medicaid APG,4806.98,,,4806.98,Other,324% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,1854.54,,,1854.54,Other,125% New York Medicaid APG,392,14906.71,
Revision of eyelid,67880,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2759.56,,,2759.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,2077.09,,,2077.09,Other,140% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3857.45,,,3857.45,Other,260% New York Medicaid APG,4806.98,,,4806.98,Other,324% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,1854.54,,,1854.54,Other,125% New York Medicaid APG,1483.63,34406.09,
Revision of eyelid,67882,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,34406.09,
Repair brow defect,67900,CPT,,,,,,,,both,,,32669.57,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16334.79,50,,16334.79,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22868.7,70,,22868.7,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,22868.7,
Repair eyelid defect,67901,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,34406.09,
Repair eyelid defect,67902,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,56927.18,
Repair eyelid defect,67903,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,34406.09,
Repair eyelid defect,67904,CPT,,,,,,,,both,,,33846.09,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16923.05,50,,16923.05,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23692.26,70,,23692.26,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,23692.26,
Repair eyelid defect,67906,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,56927.18,
Repair eyelid defect,67908,CPT,,,,,,,,both,,,43046.76,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21523.38,50,,21523.38,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,30132.73,70,,30132.73,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,30132.73,
Revise eyelid defect,67909,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,34406.09,
Revise eyelid defect,67911,CPT,,,,,,,,both,,,35896.32,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17948.16,50,,17948.16,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2759.56,,,2759.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25127.42,70,,25127.42,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,2077.09,,,2077.09,Other,140% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3857.45,,,3857.45,Other,260% New York Medicaid APG,4806.98,,,4806.98,Other,324% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,1854.54,,,1854.54,Other,125% New York Medicaid APG,1483.63,25127.42,
Correction eyelid w/implant,67912,CPT,,,,,,,,both,,,36009.67,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18004.84,50,,18004.84,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2759.56,,,2759.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25206.77,70,,25206.77,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,2077.09,,,2077.09,Other,140% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3857.45,,,3857.45,Other,260% New York Medicaid APG,4806.98,,,4806.98,Other,324% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,1854.54,,,1854.54,Other,125% New York Medicaid APG,1483.63,25206.77,
Repair eyelid defect,67914,CPT,,,,,,,,both,,,33626.66,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16813.33,50,,16813.33,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2759.56,,,2759.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23538.66,70,,23538.66,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,2077.09,,,2077.09,Other,140% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3857.45,,,3857.45,Other,260% New York Medicaid APG,4806.98,,,4806.98,Other,324% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,1854.54,,,1854.54,Other,125% New York Medicaid APG,1483.63,23538.66,
Repair eyelid defect,67915,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2759.56,,,2759.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,2077.09,,,2077.09,Other,140% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3857.45,,,3857.45,Other,260% New York Medicaid APG,4806.98,,,4806.98,Other,324% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,1854.54,,,1854.54,Other,125% New York Medicaid APG,1483.63,34406.09,
Repair eyelid defect,67916,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2759.56,,,2759.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,2077.09,,,2077.09,Other,140% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3857.45,,,3857.45,Other,260% New York Medicaid APG,4806.98,,,4806.98,Other,324% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,1854.54,,,1854.54,Other,125% New York Medicaid APG,1483.63,34406.09,
Repair eyelid defect,67917,CPT,,,,,,,,both,,,34560.91,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17280.46,50,,17280.46,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24192.64,70,,24192.64,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,24192.64,
Repair eyelid defect,67921,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2759.56,,,2759.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,2077.09,,,2077.09,Other,140% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3857.45,,,3857.45,Other,260% New York Medicaid APG,4806.98,,,4806.98,Other,324% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,1854.54,,,1854.54,Other,125% New York Medicaid APG,1483.63,34406.09,
Repair eyelid defect,67922,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2759.56,,,2759.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,2077.09,,,2077.09,Other,140% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3857.45,,,3857.45,Other,260% New York Medicaid APG,4806.98,,,4806.98,Other,324% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,1854.54,,,1854.54,Other,125% New York Medicaid APG,1483.63,34406.09,
Repair eyelid defect,67923,CPT,,,,,,,,both,,,35662.66,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17831.33,50,,17831.33,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24963.86,70,,24963.86,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,24963.86,
Repair eyelid defect,67924,CPT,,,,,,,,both,,,34504.61,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17252.31,50,,17252.31,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24153.23,70,,24153.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,24153.23,
Repair eyelid wound,67930,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2759.56,,,2759.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,2077.09,,,2077.09,Other,140% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3857.45,,,3857.45,Other,260% New York Medicaid APG,4806.98,,,4806.98,Other,324% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,1854.54,,,1854.54,Other,125% New York Medicaid APG,1483.63,34406.09,
Repair eyelid wound,67935,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2759.56,,,2759.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,2077.09,,,2077.09,Other,140% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3857.45,,,3857.45,Other,260% New York Medicaid APG,4806.98,,,4806.98,Other,324% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,1854.54,,,1854.54,Other,125% New York Medicaid APG,1483.63,34406.09,
Remove eyelid foreign body,67938,CPT,,,,,,,,both,,,35326.8,553.97,,,553.97,Other,150% of Medicare + 9.63% HCRA Surcharge,336.87,,,336.87,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17663.4,50,,17663.4,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,634.14,,,634.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24728.76,70,,24728.76,percent of total billed charges,,575.85,,,575.85,Fee Schedule,,488.6,,,488.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,340.93,,,340.93,Other,New York Medicaid APG methodology,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,477.31,,,477.31,Other,140% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,886.43,,,886.43,Other,260% New York Medicaid APG,1104.63,,,1104.63,Other,324% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,426.17,,,426.17,Other,125% New York Medicaid APG,0.01,24728.76,
Revision of eyelid,67950,CPT,,,,,,,,both,,,38209.71,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19104.86,50,,19104.86,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2759.56,,,2759.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26746.8,70,,26746.8,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,2077.09,,,2077.09,Other,140% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3857.45,,,3857.45,Other,260% New York Medicaid APG,4806.98,,,4806.98,Other,324% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,1854.54,,,1854.54,Other,125% New York Medicaid APG,1483.63,26746.8,
Revision of eyelid,67961,CPT,,,,,,,,both,,,32676.36,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16338.18,50,,16338.18,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22873.45,70,,22873.45,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,22873.45,
Revision of eyelid,67966,CPT,,,,,,,,both,,,45328.93,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,22664.47,50,,22664.47,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31730.25,70,,31730.25,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,31730.25,
Reconstruction of eyelid,67971,CPT,,,,,,,,both,,,37061.66,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18530.83,50,,18530.83,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25943.16,70,,25943.16,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,25943.16,
Reconstruction of eyelid,67973,CPT,,,,,,,,both,,,44410.93,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,22205.47,50,,22205.47,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31087.65,70,,31087.65,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,31087.65,
Reconstruction of eyelid,67974,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,56927.18,
Reconstruction of eyelid,67975,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,34406.09,
Incise/drain eyelid lining,68020,CPT,,,,,,,,both,,,21295.3,1925.3,,,1925.3,Other,150% of Medicare + 9.63% HCRA Surcharge,1170.78,,,1170.78,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,10647.65,50,,10647.65,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2759.56,,,2759.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,14906.71,70,,14906.71,percent of total billed charges,,536.25,,,536.25,Fee Schedule,,455,,,455,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,2077.09,,,2077.09,Other,140% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3857.45,,,3857.45,Other,260% New York Medicaid APG,4806.98,,,4806.98,Other,324% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,1854.54,,,1854.54,Other,125% New York Medicaid APG,455,14906.71,
Treatment of eyelid lesions,68040,CPT,,,,,,,,both,,,6127.39,553.97,,,553.97,Other,150% of Medicare + 9.63% HCRA Surcharge,336.87,,,336.87,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3063.7,50,,3063.7,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,634.14,,,634.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4289.17,70,,4289.17,percent of total billed charges,,229.35,,,229.35,Fee Schedule,,194.6,,,194.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,340.93,,,340.93,Other,New York Medicaid APG methodology,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,477.31,,,477.31,Other,140% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,886.43,,,886.43,Other,260% New York Medicaid APG,1104.63,,,1104.63,Other,324% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,426.17,,,426.17,Other,125% New York Medicaid APG,0.01,9473,
Biopsy of eyelid lining,68100,CPT,,,,,,,,both,,,47374.26,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,23687.13,50,,23687.13,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2759.56,,,2759.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,33161.98,70,,33161.98,percent of total billed charges,,462,,,462,Fee Schedule,,392,,,392,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,2077.09,,,2077.09,Other,140% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3857.45,,,3857.45,Other,260% New York Medicaid APG,4806.98,,,4806.98,Other,324% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,1854.54,,,1854.54,Other,125% New York Medicaid APG,392,33161.98,
Remove eyelid lining lesion,68110,CPT,,,,,,,,both,,,37675.27,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18837.64,50,,18837.64,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26372.69,70,,26372.69,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,1994.68,26372.69,
Remove eyelid lining lesion,68115,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,34406.09,
Remove eyelid lining lesion,68130,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,34406.09,
Remove eyelid lining lesion,68135,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2759.56,,,2759.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,2077.09,,,2077.09,Other,140% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3857.45,,,3857.45,Other,260% New York Medicaid APG,4806.98,,,4806.98,Other,324% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,1854.54,,,1854.54,Other,125% New York Medicaid APG,1483.63,34406.09,
Treat eyelid by injection,68200,CPT,,,,,,,,both,,,8380.68,757.69,,,757.69,Other,150% of Medicare + 9.63% HCRA Surcharge,460.76,,,460.76,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,4190.34,50,,4190.34,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,408.99,,,408.99,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,5866.48,70,,5866.48,percent of total billed charges,,165,,,165,Fee Schedule,,140,,,140,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,219.89,,,219.89,Other,New York Medicaid APG methodology,219.89,,,219.89,Other,100% New York Medicaid APG,219.89,,,219.89,Other,100% New York Medicaid APG,219.89,,,219.89,Other,100% New York Medicaid APG,494.75,,,494.75,Other,225% New York Medicaid APG,494.75,,,494.75,Other,225% New York Medicaid APG,494.75,,,494.75,Other,225% New York Medicaid APG,494.75,,,494.75,Other,225% New York Medicaid APG,307.84,,,307.84,Other,140% New York Medicaid APG,494.75,,,494.75,Other,225% New York Medicaid APG,571.71,,,571.71,Other,260% New York Medicaid APG,712.44,,,712.44,Other,324% New York Medicaid APG,472.76,,,472.76,Other,215% New York Medicaid APG,472.76,,,472.76,Other,215% New York Medicaid APG,274.86,,,274.86,Other,125% New York Medicaid APG,0.01,9473,
Revise/graft eyelid lining,68320,CPT,,,,,,,,both,,,38099.24,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19049.62,50,,19049.62,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2759.56,,,2759.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26669.47,70,,26669.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,2077.09,,,2077.09,Other,140% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3857.45,,,3857.45,Other,260% New York Medicaid APG,4806.98,,,4806.98,Other,324% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,1854.54,,,1854.54,Other,125% New York Medicaid APG,1483.63,26669.47,
Revise/graft eyelid lining,68325,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,56927.18,
Revise/graft eyelid lining,68326,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,56927.18,
Revise/graft eyelid lining,68328,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,34406.09,
Revise eyelid lining,68330,CPT,,,,,,,,both,,,49016.23,4431.53,,,4431.53,Other,150% of Medicare + 9.63% HCRA Surcharge,2694.84,,,2694.84,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24508.12,50,,24508.12,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2759.56,,,2759.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34311.36,70,,34311.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,2077.09,,,2077.09,Other,140% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3857.45,,,3857.45,Other,260% New York Medicaid APG,4806.98,,,4806.98,Other,324% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,1854.54,,,1854.54,Other,125% New York Medicaid APG,1483.63,34311.36,
Revise/graft eyelid lining,68335,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,56927.18,
Separate eyelid adhesions,68340,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2759.56,,,2759.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,2077.09,,,2077.09,Other,140% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3857.45,,,3857.45,Other,260% New York Medicaid APG,4806.98,,,4806.98,Other,324% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,1854.54,,,1854.54,Other,125% New York Medicaid APG,1483.63,34406.09,
Revise eyelid lining,68360,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,56927.18,
Revise eyelid lining,68362,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,34406.09,
Harvest eye tissue alograft,68371,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2759.56,,,2759.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,2077.09,,,2077.09,Other,140% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3857.45,,,3857.45,Other,260% New York Medicaid APG,4806.98,,,4806.98,Other,324% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,1854.54,,,1854.54,Other,125% New York Medicaid APG,1483.63,34406.09,
Incise/drain tear gland,68400,CPT,,,,,,,,both,,,21295.3,1925.3,,,1925.3,Other,150% of Medicare + 9.63% HCRA Surcharge,1170.78,,,1170.78,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,10647.65,50,,10647.65,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2759.56,,,2759.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,14906.71,70,,14906.71,percent of total billed charges,,636.9,,,636.9,Fee Schedule,,540.4,,,540.4,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,2077.09,,,2077.09,Other,140% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3857.45,,,3857.45,Other,260% New York Medicaid APG,4806.98,,,4806.98,Other,324% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,1854.54,,,1854.54,Other,125% New York Medicaid APG,540.4,14906.71,
Incise/drain tear sac,68420,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,34406.09,
Incise tear duct opening,68440,CPT,,,,,,,,both,,,6127.39,553.97,,,553.97,Other,150% of Medicare + 9.63% HCRA Surcharge,336.87,,,336.87,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3063.7,50,,3063.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,634.14,,,634.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4289.17,70,,4289.17,percent of total billed charges,,486.75,,,486.75,Fee Schedule,,413,,,413,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,340.93,,,340.93,Other,New York Medicaid APG methodology,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,477.31,,,477.31,Other,140% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,886.43,,,886.43,Other,260% New York Medicaid APG,1104.63,,,1104.63,Other,324% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,426.17,,,426.17,Other,125% New York Medicaid APG,336.87,9473,
Removal of tear gland,68500,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,56927.18,
Partial removal tear gland,68505,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,56927.18,
Biopsy of tear gland,68510,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,34406.09,
Removal of tear sac,68520,CPT,,,,,,,,both,,,35849.33,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17924.67,50,,17924.67,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25094.53,70,,25094.53,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,25094.53,
Biopsy of tear sac,68525,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2759.56,,,2759.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,2077.09,,,2077.09,Other,140% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3857.45,,,3857.45,Other,260% New York Medicaid APG,4806.98,,,4806.98,Other,324% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,1854.54,,,1854.54,Other,125% New York Medicaid APG,1483.63,34406.09,
Clearance of tear duct,68530,CPT,,,,,,,,both,,,6127.39,553.97,,,553.97,Other,150% of Medicare + 9.63% HCRA Surcharge,336.87,,,336.87,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3063.7,50,,3063.7,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,634.14,,,634.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4289.17,70,,4289.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,340.93,,,340.93,Other,New York Medicaid APG methodology,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,477.31,,,477.31,Other,140% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,886.43,,,886.43,Other,260% New York Medicaid APG,1104.63,,,1104.63,Other,324% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,426.17,,,426.17,Other,125% New York Medicaid APG,0.01,13157,
Remove tear gland lesion,68540,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,34406.09,
Remove tear gland lesion,68550,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,56927.18,
Repair tear ducts,68700,CPT,,,,,,,,both,,,51267.66,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,25633.83,50,,25633.83,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2759.56,,,2759.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,35887.36,70,,35887.36,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,2077.09,,,2077.09,Other,140% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3857.45,,,3857.45,Other,260% New York Medicaid APG,4806.98,,,4806.98,Other,324% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,1854.54,,,1854.54,Other,125% New York Medicaid APG,1483.63,35887.36,
Revise tear duct opening,68705,CPT,,,,,,,,both,,,6127.39,553.97,,,553.97,Other,150% of Medicare + 9.63% HCRA Surcharge,336.87,,,336.87,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3063.7,50,,3063.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,634.14,,,634.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4289.17,70,,4289.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,340.93,,,340.93,Other,New York Medicaid APG methodology,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,477.31,,,477.31,Other,140% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,886.43,,,886.43,Other,260% New York Medicaid APG,1104.63,,,1104.63,Other,324% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,426.17,,,426.17,Other,125% New York Medicaid APG,336.87,13157,
Create tear sac drain,68720,CPT,,,,,,,,both,,,42835.34,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,21417.67,50,,21417.67,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29984.74,70,,29984.74,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,29984.74,
Create tear duct drain,68745,CPT,,,,,,,,both,,,81324.54,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,40662.27,50,,40662.27,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,56927.18,70,,56927.18,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,56927.18,
Create tear duct drain,68750,CPT,,,,,,,,both,,,36863.66,7352.5,,,7352.5,Other,150% of Medicare + 9.63% HCRA Surcharge,4471.1,,,4471.1,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,18431.83,50,,18431.83,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25804.56,70,,25804.56,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,25804.56,
Close tear duct opening,68760,CPT,,,,,,,,both,,,6127.39,553.97,,,553.97,Other,150% of Medicare + 9.63% HCRA Surcharge,336.87,,,336.87,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3063.7,50,,3063.7,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,634.14,,,634.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4289.17,70,,4289.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,340.93,,,340.93,Other,New York Medicaid APG methodology,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,477.31,,,477.31,Other,140% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,886.43,,,886.43,Other,260% New York Medicaid APG,1104.63,,,1104.63,Other,324% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,426.17,,,426.17,Other,125% New York Medicaid APG,0.01,13157,
Close tear duct opening,68761,CPT,,,,,,,,both,,,6127.39,553.97,,,553.97,Other,150% of Medicare + 9.63% HCRA Surcharge,336.87,,,336.87,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,3063.7,50,,3063.7,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,634.14,,,634.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,4289.17,70,,4289.17,percent of total billed charges,,570.9,,,570.9,Fee Schedule,,484.4,,,484.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,340.93,,,340.93,Other,New York Medicaid APG methodology,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,477.31,,,477.31,Other,140% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,886.43,,,886.43,Other,260% New York Medicaid APG,1104.63,,,1104.63,Other,324% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,426.17,,,426.17,Other,125% New York Medicaid APG,0.01,9473,
Close tear system fistula,68770,CPT,,,,,,,,both,,,49151.56,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,24575.78,50,,24575.78,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4056.18,,,4056.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,34406.09,70,,34406.09,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,2180.74,,,2180.74,Other,New York Medicaid APG methodology,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,2180.74,,,2180.74,Other,100% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,3053.04,,,3053.04,Other,140% New York Medicaid APG,4906.67,,,4906.67,Other,225% New York Medicaid APG,5669.93,,,5669.93,Other,260% New York Medicaid APG,7065.6,,,7065.6,Other,324% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,4688.59,,,4688.59,Other,215% New York Medicaid APG,2725.93,,,2725.93,Other,125% New York Medicaid APG,2180.74,34406.09,
Dilate tear duct opening,68801,CPT,,,,,,,,both,,,34022.66,757.69,,,757.69,Other,150% of Medicare + 9.63% HCRA Surcharge,460.76,,,460.76,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17011.33,50,,17011.33,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,634.14,,,634.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23815.86,70,,23815.86,percent of total billed charges,,384.45,,,384.45,Fee Schedule,,326.2,,,326.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,340.93,,,340.93,Other,New York Medicaid APG methodology,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,477.31,,,477.31,Other,140% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,886.43,,,886.43,Other,260% New York Medicaid APG,1104.63,,,1104.63,Other,324% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,426.17,,,426.17,Other,125% New York Medicaid APG,0.01,23815.86,
Probe nasolacrimal duct,68810,CPT,,,,,,,,both,,,35689.63,553.97,,,553.97,Other,150% of Medicare + 9.63% HCRA Surcharge,336.87,,,336.87,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17844.82,50,,17844.82,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,634.14,,,634.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24982.74,70,,24982.74,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,340.93,,,340.93,Other,New York Medicaid APG methodology,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,477.31,,,477.31,Other,140% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,886.43,,,886.43,Other,260% New York Medicaid APG,1104.63,,,1104.63,Other,324% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,426.17,,,426.17,Other,125% New York Medicaid APG,336.87,24982.74,
Probe nasolacrimal duct,68811,CPT,,,,,,,,both,,,34474.4,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17237.2,50,,17237.2,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2759.56,,,2759.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24132.08,70,,24132.08,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,2077.09,,,2077.09,Other,140% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3857.45,,,3857.45,Other,260% New York Medicaid APG,4806.98,,,4806.98,Other,324% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,1854.54,,,1854.54,Other,125% New York Medicaid APG,1483.63,24132.08,
Probe nasolacrimal duct,68815,CPT,,,,,,,,both,,,35564.69,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17782.35,50,,17782.35,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2759.56,,,2759.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24895.28,70,,24895.28,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,2077.09,,,2077.09,Other,140% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3857.45,,,3857.45,Other,260% New York Medicaid APG,4806.98,,,4806.98,Other,324% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,1854.54,,,1854.54,Other,125% New York Medicaid APG,1483.63,24895.28,
Probe nl duct w/balloon,68816,CPT,,,,,,,,both,,,37327.44,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18663.72,50,,18663.72,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2759.56,,,2759.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26129.21,70,,26129.21,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1483.63,,,1483.63,Other,New York Medicaid APG methodology,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,1483.63,,,1483.63,Other,100% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,2077.09,,,2077.09,Other,140% New York Medicaid APG,3338.18,,,3338.18,Other,225% New York Medicaid APG,3857.45,,,3857.45,Other,260% New York Medicaid APG,4806.98,,,4806.98,Other,324% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,3189.81,,,3189.81,Other,215% New York Medicaid APG,1854.54,,,1854.54,Other,125% New York Medicaid APG,1483.63,26129.21,
Explore/irrigate tear ducts,68840,CPT,,,,,,,,both,,,34394.38,553.97,,,553.97,Other,150% of Medicare + 9.63% HCRA Surcharge,336.87,,,336.87,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17197.19,50,,17197.19,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,634.14,,,634.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24076.07,70,,24076.07,percent of total billed charges,,570.9,,,570.9,Fee Schedule,,484.4,,,484.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,340.93,,,340.93,Other,New York Medicaid APG methodology,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,340.93,,,340.93,Other,100% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,477.31,,,477.31,Other,140% New York Medicaid APG,767.1,,,767.1,Other,225% New York Medicaid APG,886.43,,,886.43,Other,260% New York Medicaid APG,1104.63,,,1104.63,Other,324% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,733.01,,,733.01,Other,215% New York Medicaid APG,426.17,,,426.17,Other,125% New York Medicaid APG,0.01,24076.07,
Injection for tear sac x-ray,68850,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,1205.26,,,1205.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,252.45,,,252.45,Fee Schedule,,214.2,,,214.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,647.99,,,647.99,Other,New York Medicaid APG methodology,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,647.99,,,647.99,Other,100% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,907.18,,,907.18,Other,140% New York Medicaid APG,1457.97,,,1457.97,Other,225% New York Medicaid APG,1684.77,,,1684.77,Other,260% New York Medicaid APG,2099.48,,,2099.48,Other,324% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,1393.17,,,1393.17,Other,215% New York Medicaid APG,809.98,,,809.98,Other,125% New York Medicaid APG,0.01,22702.47,
Drain external ear lesion,69000,CPT,,,,,,,,both,,,14798.8,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7399.4,50,,7399.4,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10359.16,70,,10359.16,percent of total billed charges,,618.75,,,618.75,Fee Schedule,,525,,,525,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,0.01,10359.16,
Drain external ear lesion,69005,CPT,,,,,,,,both,,,34101.75,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17050.88,50,,17050.88,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23871.23,70,,23871.23,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,1545.56,23871.23,
Drain outer ear canal lesion,69020,CPT,,,,,,,,both,,,14798.8,1337.95,,,1337.95,Other,150% of Medicare + 9.63% HCRA Surcharge,813.62,,,813.62,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7399.4,50,,7399.4,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10359.16,70,,10359.16,percent of total billed charges,,717.75,,,717.75,Fee Schedule,,609,,,609,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,0.01,10359.16,
Biopsy of external ear,69100,CPT,,,,,,,,both,,,5137.73,464.5,,,464.5,Other,150% of Medicare + 9.63% HCRA Surcharge,282.46,,,282.46,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2568.87,50,,2568.87,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3596.41,70,,3596.41,percent of total billed charges,,229.35,,,229.35,Fee Schedule,,194.6,,,194.6,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,194.6,9473,
Biopsy of external ear canal,69105,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,313.5,,,313.5,Fee Schedule,,266,,,266,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,266,22454.17,
Remove external ear partial,69110,CPT,,,,,,,,both,,,44858,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,22429,50,,22429,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3792.93,,,3792.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,31400.6,70,,31400.6,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2039.21,,,2039.21,Other,New York Medicaid APG methodology,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,2854.89,,,2854.89,Other,140% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,5301.94,,,5301.94,Other,260% New York Medicaid APG,6607.03,,,6607.03,Other,324% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,2549.01,,,2549.01,Other,125% New York Medicaid APG,2039.21,31400.6,
Removal of external ear,69120,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,86224,
Remove ear canal lesion(s),69140,CPT,,,,,,,,both,,,35546.28,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,17773.14,50,,17773.14,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24882.4,70,,24882.4,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,24882.4,
Remove ear canal lesion(s),69145,CPT,,,,,,,,both,,,35810.3,5403.52,,,5403.52,Other,150% of Medicare + 9.63% HCRA Surcharge,3285.91,,,3285.91,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,17905.15,50,,17905.15,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3792.93,,,3792.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25067.21,70,,25067.21,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2039.21,,,2039.21,Other,New York Medicaid APG methodology,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,2854.89,,,2854.89,Other,140% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,5301.94,,,5301.94,Other,260% New York Medicaid APG,6607.03,,,6607.03,Other,324% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,2549.01,,,2549.01,Other,125% New York Medicaid APG,2039.21,25067.21,
Extensive ear canal surgery,69150,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,86224,
Clear outer ear canal,69200,CPT,,,,,,,,both,,,2686.86,242.92,,,242.92,Other,150% of Medicare + 9.63% HCRA Surcharge,147.72,,,147.72,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1343.43,50,,1343.43,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,1880.8,70,,1880.8,percent of total billed charges,,232.65,,,232.65,Fee Schedule,,197.4,,,197.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,9473,
Clear outer ear canal,69205,CPT,,,,,,,,both,,,34377.37,3083.12,,,3083.12,Other,150% of Medicare + 9.63% HCRA Surcharge,1874.86,,,1874.86,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17188.69,50,,17188.69,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24064.16,70,,24064.16,percent of total billed charges,,475.2,,,475.2,Fee Schedule,,403.2,,,403.2,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,403.2,24064.16,
Remove impacted ear wax uni,69209,CPT,,,,,,,,both,,,33401,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16700.5,50,,16700.5,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23380.7,70,,23380.7,percent of total billed charges,,75.9,,,75.9,Fee Schedule,,64.4,,,64.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,23380.7,
Remove impacted ear wax uni,69210,CPT,,,,,,,,both,,,34338.86,116.32,,,116.32,Other,150% of Medicare + 9.63% HCRA Surcharge,70.73,,,70.73,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,17169.43,50,,17169.43,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,24037.2,70,,24037.2,percent of total billed charges,,160.05,,,160.05,Fee Schedule,,135.8,,,135.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,24037.2,
Clean out mastoid cavity,69220,CPT,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,252.45,,,252.45,Fee Schedule,,214.2,,,214.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,0.01,9473,
Clean out mastoid cavity,69222,CPT,,,,,,,,both,,,11572.85,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5786.43,50,,5786.43,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8101,70,,8101,percent of total billed charges,,678.15,,,678.15,Fee Schedule,,575.4,,,575.4,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,575.4,9473,
Revise external ear,69300,CPT,,,,,,,,both,,,37965.27,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18982.64,50,,18982.64,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26575.69,70,,26575.69,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,26575.69,
Rebuild outer ear canal,69310,CPT,,,,,,,,both,,,35952.72,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,17976.36,50,,17976.36,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25166.9,70,,25166.9,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,25166.9,
Rebuild outer ear canal,69320,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,86224,
Incision of eardrum,69420,CPT,,,,,,,,both,,,5137.73,464.5,,,464.5,Other,150% of Medicare + 9.63% HCRA Surcharge,282.46,,,282.46,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2568.87,50,,2568.87,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3596.41,70,,3596.41,percent of total billed charges,,597.3,,,597.3,Fee Schedule,,506.8,,,506.8,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,269.45,9473,
Incision of eardrum,69421,CPT,,,,,,,,both,,,37342.12,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,18671.06,50,,18671.06,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26139.48,70,,26139.48,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,1545.56,26139.48,
Remove ventilating tube,69424,CPT,,,,,,,,both,,,34127.61,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17063.81,50,,17063.81,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23889.33,70,,23889.33,percent of total billed charges,,297,,,297,Fee Schedule,,252,,,252,Fee Schedule,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,252,23889.33,
Create eardrum opening,69433,CPT,,,,,,,,both,,,11572.85,1046.29,,,1046.29,Other,150% of Medicare + 9.63% HCRA Surcharge,636.26,,,636.26,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,5786.43,50,,5786.43,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,501.18,,,501.18,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8101,70,,8101,percent of total billed charges,,656.7,,,656.7,Fee Schedule,,557.2,,,557.2,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,269.45,,,269.45,Other,New York Medicaid APG methodology,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,269.45,,,269.45,Other,100% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,377.23,,,377.23,Other,140% New York Medicaid APG,606.27,,,606.27,Other,225% New York Medicaid APG,700.58,,,700.58,Other,260% New York Medicaid APG,873.03,,,873.03,Other,324% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,579.32,,,579.32,Other,215% New York Medicaid APG,336.82,,,336.82,Other,125% New York Medicaid APG,269.45,9473,
Create eardrum opening,69436,CPT,,,,,,,,both,,,34207.45,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,17103.73,50,,17103.73,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23945.22,70,,23945.22,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,1545.56,23945.22,
Exploration of middle ear,69440,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3792.93,,,3792.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2039.21,,,2039.21,Other,New York Medicaid APG methodology,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,2854.89,,,2854.89,Other,140% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,5301.94,,,5301.94,Other,260% New York Medicaid APG,6607.03,,,6607.03,Other,324% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,2549.01,,,2549.01,Other,125% New York Medicaid APG,2039.21,47404.34,
Eardrum revision,69450,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3792.93,,,3792.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2039.21,,,2039.21,Other,New York Medicaid APG methodology,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,2854.89,,,2854.89,Other,140% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,5301.94,,,5301.94,Other,260% New York Medicaid APG,6607.03,,,6607.03,Other,324% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,2549.01,,,2549.01,Other,125% New York Medicaid APG,2039.21,47404.34,
Mastoidectomy,69501,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,86224,
Mastoidectomy,69502,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,86224,
Remove mastoid structures,69505,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,86224,
Extensive mastoid surgery,69511,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,86224,
Extensive mastoid surgery,69530,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,86224,
Remove ear lesion,69540,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,650.1,,,650.1,Fee Schedule,,551.6,,,551.6,Fee Schedule,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,551.6,22454.17,
Remove ear lesion,69550,CPT,,,,,,,,both,,,37626.87,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,18813.44,50,,18813.44,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26338.81,70,,26338.81,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,26338.81,
Remove ear lesion,69552,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,86224,
Mastoid surgery revision,69601,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,86224,
Mastoid surgery revision,69602,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,86224,
Mastoid surgery revision,69603,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,86224,
Mastoid surgery revision,69604,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,86224,
Repair of eardrum,69610,CPT,,,,,,,,both,,,33921.46,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16960.73,50,,16960.73,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23745.02,70,,23745.02,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,1545.56,23745.02,
Repair of eardrum,69620,CPT,,,,,,,,both,,,33597.07,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16798.54,50,,16798.54,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3792.93,,,3792.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,23517.95,70,,23517.95,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2039.21,,,2039.21,Other,New York Medicaid APG methodology,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,2854.89,,,2854.89,Other,140% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,5301.94,,,5301.94,Other,260% New York Medicaid APG,6607.03,,,6607.03,Other,324% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,2549.01,,,2549.01,Other,125% New York Medicaid APG,2039.21,23517.95,
Repair eardrum structures,69631,CPT,,,,,,,,both,,,36367.95,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,18183.98,50,,18183.98,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,25457.57,70,,25457.57,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,25457.57,
Rebuild eardrum structures,69632,CPT,,,,,,,,both,,,37346.62,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,18673.31,50,,18673.31,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26142.63,70,,26142.63,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,26142.63,
Rebuild eardrum structures,69633,CPT,,,,,,,,both,,,39184.76,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,19592.38,50,,19592.38,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,27429.33,70,,27429.33,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,27429.33,
Repair eardrum structures,69635,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,86224,
Rebuild eardrum structures,69636,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,86224,
Rebuild eardrum structures,69637,CPT,,,,,,,,both,,,52926.47,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,26463.24,50,,26463.24,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,37048.53,70,,37048.53,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,37048.53,
Revise middle ear & mastoid,69641,CPT,,,,,,,,both,,,40642.42,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,20321.21,50,,20321.21,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28449.69,70,,28449.69,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,28449.69,
Revise middle ear & mastoid,69642,CPT,,,,,,,,both,,,41363.34,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,20681.67,50,,20681.67,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28954.34,70,,28954.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,28954.34,
Revise middle ear & mastoid,69643,CPT,,,,,,,,both,,,38155.74,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,19077.87,50,,19077.87,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26709.02,70,,26709.02,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,26709.02,
Revise middle ear & mastoid,69644,CPT,,,,,,,,both,,,43513.63,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,21756.82,50,,21756.82,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,30459.54,70,,30459.54,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,30459.54,
Revise middle ear & mastoid,69645,CPT,,,,,,,,both,,,53911.16,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,26955.58,50,,26955.58,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,37737.81,70,,37737.81,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,37737.81,
Revise middle ear & mastoid,69646,CPT,,,,,,,,both,,,51043.02,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,25521.51,50,,25521.51,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,35730.11,70,,35730.11,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,35730.11,
Release middle ear bone,69650,CPT,,,,,,,,both,,,38340.88,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19170.44,50,,19170.44,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26838.62,70,,26838.62,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,26838.62,
Revise middle ear bone,69660,CPT,,,,,,,,both,,,37994.47,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,18997.24,50,,18997.24,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26596.13,70,,26596.13,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,26596.13,
Revise middle ear bone,69661,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,86224,
Revise middle ear bone,69662,CPT,,,,,,,,both,,,41026.91,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,20513.46,50,,20513.46,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28718.84,70,,28718.84,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,28718.84,
Repair middle ear structures,69666,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3792.93,,,3792.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2039.21,,,2039.21,Other,New York Medicaid APG methodology,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,2854.89,,,2854.89,Other,140% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,5301.94,,,5301.94,Other,260% New York Medicaid APG,6607.03,,,6607.03,Other,324% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,2549.01,,,2549.01,Other,125% New York Medicaid APG,2039.21,47404.34,
Repair middle ear structures,69667,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3792.93,,,3792.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2039.21,,,2039.21,Other,New York Medicaid APG methodology,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,2854.89,,,2854.89,Other,140% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,5301.94,,,5301.94,Other,260% New York Medicaid APG,6607.03,,,6607.03,Other,324% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,2549.01,,,2549.01,Other,125% New York Medicaid APG,2039.21,47404.34,
Remove mastoid air cells,69670,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,86224,
Remove middle ear nerve,69676,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,47404.34,
Close mastoid fistula,69700,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3792.93,,,3792.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,2039.21,,,2039.21,Other,New York Medicaid APG methodology,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,2039.21,,,2039.21,Other,100% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,2854.89,,,2854.89,Other,140% New York Medicaid APG,4588.22,,,4588.22,Other,225% New York Medicaid APG,5301.94,,,5301.94,Other,260% New York Medicaid APG,6607.03,,,6607.03,Other,324% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,4384.3,,,4384.3,Other,215% New York Medicaid APG,2549.01,,,2549.01,Other,125% New York Medicaid APG,1763.57,22454.17,
Nps surg dilat eust tube uni,69705,CPT,,,,,,,,both,,,42766.21,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,21383.11,50,,21383.11,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3814.26,,,3814.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29936.35,70,,29936.35,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2050.68,,,2050.68,Other,New York Medicaid APG methodology,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,2870.95,,,2870.95,Other,140% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,5331.77,,,5331.77,Other,260% New York Medicaid APG,6644.2,,,6644.2,Other,324% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,2563.35,,,2563.35,Other,125% New York Medicaid APG,2050.68,29936.35,
Nps surg dilat eust tube bi,69706,CPT,,,,,,,,both,,,41447.35,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,20723.68,50,,20723.68,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3814.26,,,3814.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29013.15,70,,29013.15,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2050.68,,,2050.68,Other,New York Medicaid APG methodology,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,2050.68,,,2050.68,Other,100% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,2870.95,,,2870.95,Other,140% New York Medicaid APG,4614.03,,,4614.03,Other,225% New York Medicaid APG,5331.77,,,5331.77,Other,260% New York Medicaid APG,6644.2,,,6644.2,Other,324% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,4408.96,,,4408.96,Other,215% New York Medicaid APG,2563.35,,,2563.35,Other,125% New York Medicaid APG,2050.68,29013.15,
Remove/repair hearing aid,69711,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,47404.34,
Implant temple bone w/stimul,69714,CPT,,,,,,,,both,,,66923.42,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,15382,,"100% primary, 50% supplemental procedure",15382,Other,Aetna ASC Grouper,13844,,"100% primary, 50% supplemental procedure",13844,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,33461.71,50,,33461.71,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46846.39,70,,46846.39,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.84,,,9091.84,Other,225% New York Medicaid APG,9091.84,,,9091.84,Other,225% New York Medicaid APG,9091.84,,,9091.84,Other,225% New York Medicaid APG,9091.84,,,9091.84,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.84,,,9091.84,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.02,,,5051.02,Other,125% New York Medicaid APG,4040.82,46846.39,
Temple bone implant revision,69717,CPT,,,,,,,,both,,,66227.05,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,15382,,"100% primary, 50% supplemental procedure",15382,Other,Aetna ASC Grouper,13844,,"100% primary, 50% supplemental procedure",13844,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,33113.53,50,,33113.53,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46358.94,70,,46358.94,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,46358.94,
Release facial nerve,69720,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,86224,
Release facial nerve,69725,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,86224,
Repair facial nerve,69740,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,86224,
Repair facial nerve,69745,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,86224,
Incise inner ear,69801,CPT,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,7178,,"100% primary, 50% supplemental procedure",7178,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,1545.56,22454.17,
Explore inner ear,69805,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,86224,
Explore inner ear,69806,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,86224,
Remove inner ear,69905,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,86224,
Remove inner ear & mastoid,69910,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7515.93,,,7515.93,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,4040.82,,,4040.82,Other,New York Medicaid APG methodology,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,4040.82,,,4040.82,Other,100% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,5657.15,,,5657.15,Other,140% New York Medicaid APG,9091.85,,,9091.85,Other,225% New York Medicaid APG,10506.13,,,10506.13,Other,260% New York Medicaid APG,13092.26,,,13092.26,Other,324% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,8687.76,,,8687.76,Other,215% New York Medicaid APG,5051.03,,,5051.03,Other,125% New York Medicaid APG,4040.82,86224,
Incise inner ear nerve,69915,CPT,,,,,,,,both,,,67720.49,6122.57,,,6122.57,Other,150% of Medicare + 9.63% HCRA Surcharge,3723.17,,,3723.17,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,33860.25,50,,33860.25,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5286.12,,,5286.12,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47404.34,70,,47404.34,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2842,,,2842,Other,New York Medicaid APG methodology,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,2842,,,2842,Other,100% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,3978.8,,,3978.8,Other,140% New York Medicaid APG,6394.5,,,6394.5,Other,225% New York Medicaid APG,7389.2,,,7389.2,Other,260% New York Medicaid APG,9208.08,,,9208.08,Other,324% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,6110.3,,,6110.3,Other,215% New York Medicaid APG,3552.5,,,3552.5,Other,125% New York Medicaid APG,2842,47404.34,
Implant cochlear device,69930,CPT,,,,,,,,both,,,144542.65,63770.81,,,63770.81,Other,150% of Medicare + 9.63% HCRA Surcharge,38779.41,,,38779.41,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,72271.33,50,,72271.33,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,66128.63,,,66128.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,101179.86,70,,101179.86,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,19221,,"100% primary, 50% secondary, 25% tertiary procedure",19221,Other,United Healthcare ASC Grouper,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,18154,,"100% primary, 50% secondary, 25% tertiary procedure",18154,Other,United Healthcare ASC Grouper,35553.03,,,35553.03,Other,New York Medicaid APG methodology,35553.03,,,35553.03,Other,100% New York Medicaid APG,35553.03,,,35553.03,Other,100% New York Medicaid APG,35553.03,,,35553.03,Other,100% New York Medicaid APG,79994.31,,,79994.31,Other,225% New York Medicaid APG,79994.31,,,79994.31,Other,225% New York Medicaid APG,79994.31,,,79994.31,Other,225% New York Medicaid APG,79994.31,,,79994.31,Other,225% New York Medicaid APG,49774.24,,,49774.24,Other,140% New York Medicaid APG,79994.31,,,79994.31,Other,225% New York Medicaid APG,92437.87,,,92437.87,Other,260% New York Medicaid APG,115191.81,,,115191.81,Other,324% New York Medicaid APG,76439.01,,,76439.01,Other,215% New York Medicaid APG,76439.01,,,76439.01,Other,215% New York Medicaid APG,44441.28,,,44441.28,Other,125% New York Medicaid APG,6152,115191.81,
Release facial nerve,69955,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5985.06,,,5985.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3217.77,,,3217.77,Other,New York Medicaid APG methodology,3217.77,,,3217.77,Other,100% New York Medicaid APG,3217.77,,,3217.77,Other,100% New York Medicaid APG,3217.77,,,3217.77,Other,100% New York Medicaid APG,7239.99,,,7239.99,Other,225% New York Medicaid APG,7239.99,,,7239.99,Other,225% New York Medicaid APG,7239.99,,,7239.99,Other,225% New York Medicaid APG,7239.99,,,7239.99,Other,225% New York Medicaid APG,4504.88,,,4504.88,Other,140% New York Medicaid APG,7239.99,,,7239.99,Other,225% New York Medicaid APG,8366.21,,,8366.21,Other,260% New York Medicaid APG,10425.59,,,10425.59,Other,324% New York Medicaid APG,6918.21,,,6918.21,Other,215% New York Medicaid APG,6918.21,,,6918.21,Other,215% New York Medicaid APG,4022.22,,,4022.22,Other,125% New York Medicaid APG,3217.77,86224,
Release inner ear canal,69960,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5985.06,,,5985.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3217.77,,,3217.77,Other,New York Medicaid APG methodology,3217.77,,,3217.77,Other,100% New York Medicaid APG,3217.77,,,3217.77,Other,100% New York Medicaid APG,3217.77,,,3217.77,Other,100% New York Medicaid APG,7239.99,,,7239.99,Other,225% New York Medicaid APG,7239.99,,,7239.99,Other,225% New York Medicaid APG,7239.99,,,7239.99,Other,225% New York Medicaid APG,7239.99,,,7239.99,Other,225% New York Medicaid APG,4504.88,,,4504.88,Other,140% New York Medicaid APG,7239.99,,,7239.99,Other,225% New York Medicaid APG,8366.21,,,8366.21,Other,260% New York Medicaid APG,10425.59,,,10425.59,Other,324% New York Medicaid APG,6918.21,,,6918.21,Other,215% New York Medicaid APG,6918.21,,,6918.21,Other,215% New York Medicaid APG,4022.22,,,4022.22,Other,125% New York Medicaid APG,3217.77,86224,
Remove inner ear lesion,69970,CPT,,,,,,,,both,,,123177.14,11136.37,,,11136.37,Other,150% of Medicare + 9.63% HCRA Surcharge,6772.09,,,6772.09,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,61588.57,50,,61588.57,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7051.19,,,7051.19,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,86224,70,,86224,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3790.96,,,3790.96,Other,New York Medicaid APG methodology,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,3790.96,,,3790.96,Other,100% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,5307.35,,,5307.35,Other,140% New York Medicaid APG,8529.66,,,8529.66,Other,225% New York Medicaid APG,9856.5,,,9856.5,Other,260% New York Medicaid APG,12282.71,,,12282.71,Other,324% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,8150.57,,,8150.57,Other,215% New York Medicaid APG,4738.7,,,4738.7,Other,125% New York Medicaid APG,3790.96,86224,
Microsurgery add-on,69990,CPT,,,,,,,,both,,,32432.1,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16216.05,50,,16216.05,percent of total billed charges,,22702.47,70,,22702.47,percent of total billed charges,,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22702.47,70,,22702.47,percent of total billed charges,,13157,,,13157,Case Rate,MVP ASC Grouper,11183,,,11183,Case Rate,MVP ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,22702.47,
Insert/place heart catheter,93503,CPT,,,,,,,,both,,,33686.28,3045.56,,,3045.56,Other,150% of Medicare + 9.63% HCRA Surcharge,1852.02,,,1852.02,Other,Medicare OPPS methodology,15431,,"100% primary, 50% supplemental procedure",15431,Other,Aetna ASC Grouper,13888,,"100% primary, 50% supplemental procedure",13888,Other,Aetna ASC Grouper,22198,,"100% primary, 50% secondary, 25% supplemental procedure",22198,Other,Blue Cross ASC Grouper,19978,,"100% primary, 50% secondary, 25% supplemental procedure",19978,Other,Blue Cross ASC Grouper,18868,,"100% primary, 50% secondary, 25% supplemental procedure",18868,Other,Blue Cross ASC Grouper,16843.14,50,,16843.14,percent of total billed charges,,14794,,,14794,Case Rate,Cardiac Cath Case Rate,22906.67,68,,22906.67,percent of total billed charges,,713.01,,,713.01,Other,186% of Medicaid,26949.02,80,,26949.02,percent of total billed charges,,10971,,,10971,Case Rate,,10971,,,10971,Case Rate,,26949.02,80,,26949.02,percent of total billed charges,,10971,,,10971,Case Rate,,14729,,,14729,Case Rate,Cardiac Cath Case Rate,23580.4,70,,23580.4,percent of total billed charges,,17890,,,17890,Case Rate,Cardiac Cath Case Rate,15207,,,15207,Case Rate,Cardiac Cath Case Rate,9348,,"100% primary, 50% secondary, 25% tertiary procedure",9348,Other,United Healthcare ASC Grouper,8412,,"100% primary, 50% secondary, 25% tertiary procedure",8412,Other,United Healthcare ASC Grouper,9348,,"100% primary, 50% secondary, 25% tertiary procedure",9348,Other,United Healthcare ASC Grouper,7946,,"100% primary, 50% secondary, 25% tertiary procedure",7946,Other,United Healthcare ASC Grouper,383.34,,,383.34,Other,New York Medicaid APG methodology,383.34,,,383.34,Other,100% New York Medicaid APG,383.34,,,383.34,Other,100% New York Medicaid APG,383.34,,,383.34,Other,100% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,536.67,,,536.67,Other,140% New York Medicaid APG,862.51,,,862.51,Other,225% New York Medicaid APG,996.68,,,996.68,Other,260% New York Medicaid APG,1242.01,,,1242.01,Other,324% New York Medicaid APG,824.17,,,824.17,Other,215% New York Medicaid APG,824.17,,,824.17,Other,215% New York Medicaid APG,479.17,,,479.17,Other,125% New York Medicaid APG,383.34,26949.02,
Biopsy of heart lining,93505,CPT,,,,,,,,both,,,72939.09,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,15431,,"100% primary, 50% supplemental procedure",15431,Other,Aetna ASC Grouper,13888,,"100% primary, 50% supplemental procedure",13888,Other,Aetna ASC Grouper,22198,,"100% primary, 50% secondary, 25% supplemental procedure",22198,Other,Blue Cross ASC Grouper,19978,,"100% primary, 50% secondary, 25% supplemental procedure",19978,Other,Blue Cross ASC Grouper,18868,,"100% primary, 50% secondary, 25% supplemental procedure",18868,Other,Blue Cross ASC Grouper,36469.55,50,,36469.55,percent of total billed charges,,14794,,,14794,Case Rate,Cardiac Cath Case Rate,49598.58,68,,49598.58,percent of total billed charges,,4058.18,,,4058.18,Other,186% of Medicaid,58351.27,80,,58351.27,percent of total billed charges,,10971,,,10971,Case Rate,,10971,,,10971,Case Rate,,58351.27,80,,58351.27,percent of total billed charges,,10971,,,10971,Case Rate,,14729,,,14729,Case Rate,Cardiac Cath Case Rate,51057.36,70,,51057.36,percent of total billed charges,,17890,,,17890,Case Rate,Cardiac Cath Case Rate,15207,,,15207,Case Rate,Cardiac Cath Case Rate,9348,,"100% primary, 50% secondary, 25% tertiary procedure",9348,Other,United Healthcare ASC Grouper,8412,,"100% primary, 50% secondary, 25% tertiary procedure",8412,Other,United Healthcare ASC Grouper,9348,,"100% primary, 50% secondary, 25% tertiary procedure",9348,Other,United Healthcare ASC Grouper,7946,,"100% primary, 50% secondary, 25% tertiary procedure",7946,Other,United Healthcare ASC Grouper,2181.82,,,2181.82,Other,New York Medicaid APG methodology,2181.82,,,2181.82,Other,100% New York Medicaid APG,2181.82,,,2181.82,Other,100% New York Medicaid APG,2181.82,,,2181.82,Other,100% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,3054.54,,,3054.54,Other,140% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,5672.73,,,5672.73,Other,260% New York Medicaid APG,7069.09,,,7069.09,Other,324% New York Medicaid APG,4690.91,,,4690.91,Other,215% New York Medicaid APG,4690.91,,,4690.91,Other,215% New York Medicaid APG,2727.27,,,2727.27,Other,125% New York Medicaid APG,2181.82,58351.27,
Right heart cath,93451,CPT,,,,,,,,both,,,61830.11,6196.63,,,6196.63,Other,150% of Medicare + 9.63% HCRA Surcharge,3768.21,,,3768.21,Other,Medicare OPPS methodology,15431,,"100% primary, 50% supplemental procedure",15431,Other,Aetna ASC Grouper,13888,,"100% primary, 50% supplemental procedure",13888,Other,Aetna ASC Grouper,22198,,"100% primary, 50% secondary, 25% supplemental procedure",22198,Other,Blue Cross ASC Grouper,19978,,"100% primary, 50% secondary, 25% supplemental procedure",19978,Other,Blue Cross ASC Grouper,18868,,"100% primary, 50% secondary, 25% supplemental procedure",18868,Other,Blue Cross ASC Grouper,30915.06,50,,30915.06,percent of total billed charges,,14794,,,14794,Case Rate,Cardiac Cath Case Rate,42044.47,68,,42044.47,percent of total billed charges,,4058.18,,,4058.18,Other,186% of Medicaid,49464.09,80,,49464.09,percent of total billed charges,,10971,,,10971,Case Rate,,10971,,,10971,Case Rate,,49464.09,80,,49464.09,percent of total billed charges,,10971,,,10971,Case Rate,,14729,,,14729,Case Rate,Cardiac Cath Case Rate,43281.08,70,,43281.08,percent of total billed charges,,17890,,,17890,Case Rate,Cardiac Cath Case Rate,15207,,,15207,Case Rate,Cardiac Cath Case Rate,9348,,"100% primary, 50% secondary, 25% tertiary procedure",9348,Other,United Healthcare ASC Grouper,8412,,"100% primary, 50% secondary, 25% tertiary procedure",8412,Other,United Healthcare ASC Grouper,9348,,"100% primary, 50% secondary, 25% tertiary procedure",9348,Other,United Healthcare ASC Grouper,7946,,"100% primary, 50% secondary, 25% tertiary procedure",7946,Other,United Healthcare ASC Grouper,2181.82,,,2181.82,Other,New York Medicaid APG methodology,2181.82,,,2181.82,Other,100% New York Medicaid APG,2181.82,,,2181.82,Other,100% New York Medicaid APG,2181.82,,,2181.82,Other,100% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,3054.54,,,3054.54,Other,140% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,5672.73,,,5672.73,Other,260% New York Medicaid APG,7069.09,,,7069.09,Other,324% New York Medicaid APG,4690.91,,,4690.91,Other,215% New York Medicaid APG,4690.91,,,4690.91,Other,215% New York Medicaid APG,2727.27,,,2727.27,Other,125% New York Medicaid APG,2181.82,49464.09,
Left hrt cath w/ventrclgrphy,93452,CPT,,,,,,,,both,,,68539.72,6196.63,,,6196.63,Other,150% of Medicare + 9.63% HCRA Surcharge,3768.21,,,3768.21,Other,Medicare OPPS methodology,15431,,"100% primary, 50% supplemental procedure",15431,Other,Aetna ASC Grouper,13888,,"100% primary, 50% supplemental procedure",13888,Other,Aetna ASC Grouper,22198,,"100% primary, 50% secondary, 25% supplemental procedure",22198,Other,Blue Cross ASC Grouper,19978,,"100% primary, 50% secondary, 25% supplemental procedure",19978,Other,Blue Cross ASC Grouper,18868,,"100% primary, 50% secondary, 25% supplemental procedure",18868,Other,Blue Cross ASC Grouper,34269.86,50,,34269.86,percent of total billed charges,,14794,,,14794,Case Rate,Cardiac Cath Case Rate,46607.01,68,,46607.01,percent of total billed charges,,4058.18,,,4058.18,Other,186% of Medicaid,54831.78,80,,54831.78,percent of total billed charges,,10971,,,10971,Case Rate,,10971,,,10971,Case Rate,,54831.78,80,,54831.78,percent of total billed charges,,10971,,,10971,Case Rate,,14729,,,14729,Case Rate,Cardiac Cath Case Rate,47977.8,70,,47977.8,percent of total billed charges,,17890,,,17890,Case Rate,Cardiac Cath Case Rate,15207,,,15207,Case Rate,Cardiac Cath Case Rate,9348,,"100% primary, 50% secondary, 25% tertiary procedure",9348,Other,United Healthcare ASC Grouper,8412,,"100% primary, 50% secondary, 25% tertiary procedure",8412,Other,United Healthcare ASC Grouper,9348,,"100% primary, 50% secondary, 25% tertiary procedure",9348,Other,United Healthcare ASC Grouper,7946,,"100% primary, 50% secondary, 25% tertiary procedure",7946,Other,United Healthcare ASC Grouper,2181.82,,,2181.82,Other,New York Medicaid APG methodology,2181.82,,,2181.82,Other,100% New York Medicaid APG,2181.82,,,2181.82,Other,100% New York Medicaid APG,2181.82,,,2181.82,Other,100% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,3054.54,,,3054.54,Other,140% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,5672.73,,,5672.73,Other,260% New York Medicaid APG,7069.09,,,7069.09,Other,324% New York Medicaid APG,4690.91,,,4690.91,Other,215% New York Medicaid APG,4690.91,,,4690.91,Other,215% New York Medicaid APG,2727.27,,,2727.27,Other,125% New York Medicaid APG,2181.82,54831.78,
R&l hrt cath w/ventriclgrphy,93453,CPT,,,,,,,,both,,,75685.6,6196.63,,,6196.63,Other,150% of Medicare + 9.63% HCRA Surcharge,3768.21,,,3768.21,Other,Medicare OPPS methodology,15431,,"100% primary, 50% supplemental procedure",15431,Other,Aetna ASC Grouper,13888,,"100% primary, 50% supplemental procedure",13888,Other,Aetna ASC Grouper,22198,,"100% primary, 50% secondary, 25% supplemental procedure",22198,Other,Blue Cross ASC Grouper,19978,,"100% primary, 50% secondary, 25% supplemental procedure",19978,Other,Blue Cross ASC Grouper,18868,,"100% primary, 50% secondary, 25% supplemental procedure",18868,Other,Blue Cross ASC Grouper,37842.8,50,,37842.8,percent of total billed charges,,14794,,,14794,Case Rate,Cardiac Cath Case Rate,51466.21,68,,51466.21,percent of total billed charges,,4058.18,,,4058.18,Other,186% of Medicaid,60548.48,80,,60548.48,percent of total billed charges,,10971,,,10971,Case Rate,,10971,,,10971,Case Rate,,60548.48,80,,60548.48,percent of total billed charges,,10971,,,10971,Case Rate,,14729,,,14729,Case Rate,Cardiac Cath Case Rate,52979.92,70,,52979.92,percent of total billed charges,,17890,,,17890,Case Rate,Cardiac Cath Case Rate,15207,,,15207,Case Rate,Cardiac Cath Case Rate,9348,,"100% primary, 50% secondary, 25% tertiary procedure",9348,Other,United Healthcare ASC Grouper,8412,,"100% primary, 50% secondary, 25% tertiary procedure",8412,Other,United Healthcare ASC Grouper,9348,,"100% primary, 50% secondary, 25% tertiary procedure",9348,Other,United Healthcare ASC Grouper,7946,,"100% primary, 50% secondary, 25% tertiary procedure",7946,Other,United Healthcare ASC Grouper,2181.82,,,2181.82,Other,New York Medicaid APG methodology,2181.82,,,2181.82,Other,100% New York Medicaid APG,2181.82,,,2181.82,Other,100% New York Medicaid APG,2181.82,,,2181.82,Other,100% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,3054.54,,,3054.54,Other,140% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,5672.73,,,5672.73,Other,260% New York Medicaid APG,7069.09,,,7069.09,Other,324% New York Medicaid APG,4690.91,,,4690.91,Other,215% New York Medicaid APG,4690.91,,,4690.91,Other,215% New York Medicaid APG,2727.27,,,2727.27,Other,125% New York Medicaid APG,2181.82,60548.48,
Coronary artery angio s&i,93454,CPT,,,,,,,,both,,,65729.71,6196.63,,,6196.63,Other,150% of Medicare + 9.63% HCRA Surcharge,3768.21,,,3768.21,Other,Medicare OPPS methodology,15431,,"100% primary, 50% supplemental procedure",15431,Other,Aetna ASC Grouper,13888,,"100% primary, 50% supplemental procedure",13888,Other,Aetna ASC Grouper,22198,,"100% primary, 50% secondary, 25% supplemental procedure",22198,Other,Blue Cross ASC Grouper,19978,,"100% primary, 50% secondary, 25% supplemental procedure",19978,Other,Blue Cross ASC Grouper,18868,,"100% primary, 50% secondary, 25% supplemental procedure",18868,Other,Blue Cross ASC Grouper,32864.86,50,,32864.86,percent of total billed charges,,14794,,,14794,Case Rate,Cardiac Cath Case Rate,44696.2,68,,44696.2,percent of total billed charges,,4058.18,,,4058.18,Other,186% of Medicaid,52583.77,80,,52583.77,percent of total billed charges,,10971,,,10971,Case Rate,,10971,,,10971,Case Rate,,52583.77,80,,52583.77,percent of total billed charges,,10971,,,10971,Case Rate,,14729,,,14729,Case Rate,Cardiac Cath Case Rate,46010.8,70,,46010.8,percent of total billed charges,,17890,,,17890,Case Rate,Cardiac Cath Case Rate,15207,,,15207,Case Rate,Cardiac Cath Case Rate,9348,,"100% primary, 50% secondary, 25% tertiary procedure",9348,Other,United Healthcare ASC Grouper,8412,,"100% primary, 50% secondary, 25% tertiary procedure",8412,Other,United Healthcare ASC Grouper,9348,,"100% primary, 50% secondary, 25% tertiary procedure",9348,Other,United Healthcare ASC Grouper,7946,,"100% primary, 50% secondary, 25% tertiary procedure",7946,Other,United Healthcare ASC Grouper,2181.82,,,2181.82,Other,New York Medicaid APG methodology,2181.82,,,2181.82,Other,100% New York Medicaid APG,2181.82,,,2181.82,Other,100% New York Medicaid APG,2181.82,,,2181.82,Other,100% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,3054.54,,,3054.54,Other,140% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,5672.73,,,5672.73,Other,260% New York Medicaid APG,7069.09,,,7069.09,Other,324% New York Medicaid APG,4690.91,,,4690.91,Other,215% New York Medicaid APG,4690.91,,,4690.91,Other,215% New York Medicaid APG,2727.27,,,2727.27,Other,125% New York Medicaid APG,2181.82,52583.77,
Coronary art/grft angio s&i,93455,CPT,,,,,,,,both,,,74923,6196.63,,,6196.63,Other,150% of Medicare + 9.63% HCRA Surcharge,3768.21,,,3768.21,Other,Medicare OPPS methodology,15431,,"100% primary, 50% supplemental procedure",15431,Other,Aetna ASC Grouper,13888,,"100% primary, 50% supplemental procedure",13888,Other,Aetna ASC Grouper,22198,,"100% primary, 50% secondary, 25% supplemental procedure",22198,Other,Blue Cross ASC Grouper,19978,,"100% primary, 50% secondary, 25% supplemental procedure",19978,Other,Blue Cross ASC Grouper,18868,,"100% primary, 50% secondary, 25% supplemental procedure",18868,Other,Blue Cross ASC Grouper,37461.5,50,,37461.5,percent of total billed charges,,14794,,,14794,Case Rate,Cardiac Cath Case Rate,50947.64,68,,50947.64,percent of total billed charges,,4058.18,,,4058.18,Other,186% of Medicaid,59938.4,80,,59938.4,percent of total billed charges,,10971,,,10971,Case Rate,,10971,,,10971,Case Rate,,59938.4,80,,59938.4,percent of total billed charges,,10971,,,10971,Case Rate,,14729,,,14729,Case Rate,Cardiac Cath Case Rate,52446.1,70,,52446.1,percent of total billed charges,,17890,,,17890,Case Rate,Cardiac Cath Case Rate,15207,,,15207,Case Rate,Cardiac Cath Case Rate,9348,,"100% primary, 50% secondary, 25% tertiary procedure",9348,Other,United Healthcare ASC Grouper,8412,,"100% primary, 50% secondary, 25% tertiary procedure",8412,Other,United Healthcare ASC Grouper,9348,,"100% primary, 50% secondary, 25% tertiary procedure",9348,Other,United Healthcare ASC Grouper,7946,,"100% primary, 50% secondary, 25% tertiary procedure",7946,Other,United Healthcare ASC Grouper,2181.82,,,2181.82,Other,New York Medicaid APG methodology,2181.82,,,2181.82,Other,100% New York Medicaid APG,2181.82,,,2181.82,Other,100% New York Medicaid APG,2181.82,,,2181.82,Other,100% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,3054.54,,,3054.54,Other,140% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,5672.73,,,5672.73,Other,260% New York Medicaid APG,7069.09,,,7069.09,Other,324% New York Medicaid APG,4690.91,,,4690.91,Other,215% New York Medicaid APG,4690.91,,,4690.91,Other,215% New York Medicaid APG,2727.27,,,2727.27,Other,125% New York Medicaid APG,2181.82,59938.4,
R hrt coronary artery angio,93456,CPT,,,,,,,,both,,,80496.47,6196.63,,,6196.63,Other,150% of Medicare + 9.63% HCRA Surcharge,3768.21,,,3768.21,Other,Medicare OPPS methodology,15431,,"100% primary, 50% supplemental procedure",15431,Other,Aetna ASC Grouper,13888,,"100% primary, 50% supplemental procedure",13888,Other,Aetna ASC Grouper,22198,,"100% primary, 50% secondary, 25% supplemental procedure",22198,Other,Blue Cross ASC Grouper,19978,,"100% primary, 50% secondary, 25% supplemental procedure",19978,Other,Blue Cross ASC Grouper,18868,,"100% primary, 50% secondary, 25% supplemental procedure",18868,Other,Blue Cross ASC Grouper,40248.24,50,,40248.24,percent of total billed charges,,14794,,,14794,Case Rate,Cardiac Cath Case Rate,54737.6,68,,54737.6,percent of total billed charges,,4058.18,,,4058.18,Other,186% of Medicaid,64397.18,80,,64397.18,percent of total billed charges,,10971,,,10971,Case Rate,,10971,,,10971,Case Rate,,64397.18,80,,64397.18,percent of total billed charges,,10971,,,10971,Case Rate,,14729,,,14729,Case Rate,Cardiac Cath Case Rate,56347.53,70,,56347.53,percent of total billed charges,,17890,,,17890,Case Rate,Cardiac Cath Case Rate,15207,,,15207,Case Rate,Cardiac Cath Case Rate,9348,,"100% primary, 50% secondary, 25% tertiary procedure",9348,Other,United Healthcare ASC Grouper,8412,,"100% primary, 50% secondary, 25% tertiary procedure",8412,Other,United Healthcare ASC Grouper,9348,,"100% primary, 50% secondary, 25% tertiary procedure",9348,Other,United Healthcare ASC Grouper,7946,,"100% primary, 50% secondary, 25% tertiary procedure",7946,Other,United Healthcare ASC Grouper,2181.82,,,2181.82,Other,New York Medicaid APG methodology,2181.82,,,2181.82,Other,100% New York Medicaid APG,2181.82,,,2181.82,Other,100% New York Medicaid APG,2181.82,,,2181.82,Other,100% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,3054.54,,,3054.54,Other,140% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,5672.73,,,5672.73,Other,260% New York Medicaid APG,7069.09,,,7069.09,Other,324% New York Medicaid APG,4690.91,,,4690.91,Other,215% New York Medicaid APG,4690.91,,,4690.91,Other,215% New York Medicaid APG,2727.27,,,2727.27,Other,125% New York Medicaid APG,2181.82,64397.18,
R hrt art/grft angio,93457,CPT,,,,,,,,both,,,77610,6196.63,,,6196.63,Other,150% of Medicare + 9.63% HCRA Surcharge,3768.21,,,3768.21,Other,Medicare OPPS methodology,15431,,"100% primary, 50% supplemental procedure",15431,Other,Aetna ASC Grouper,13888,,"100% primary, 50% supplemental procedure",13888,Other,Aetna ASC Grouper,22198,,"100% primary, 50% secondary, 25% supplemental procedure",22198,Other,Blue Cross ASC Grouper,19978,,"100% primary, 50% secondary, 25% supplemental procedure",19978,Other,Blue Cross ASC Grouper,18868,,"100% primary, 50% secondary, 25% supplemental procedure",18868,Other,Blue Cross ASC Grouper,38805,50,,38805,percent of total billed charges,,14794,,,14794,Case Rate,Cardiac Cath Case Rate,52774.8,68,,52774.8,percent of total billed charges,,4058.18,,,4058.18,Other,186% of Medicaid,62088,80,,62088,percent of total billed charges,,10971,,,10971,Case Rate,,10971,,,10971,Case Rate,,62088,80,,62088,percent of total billed charges,,10971,,,10971,Case Rate,,14729,,,14729,Case Rate,Cardiac Cath Case Rate,54327,70,,54327,percent of total billed charges,,17890,,,17890,Case Rate,Cardiac Cath Case Rate,15207,,,15207,Case Rate,Cardiac Cath Case Rate,9348,,"100% primary, 50% secondary, 25% tertiary procedure",9348,Other,United Healthcare ASC Grouper,8412,,"100% primary, 50% secondary, 25% tertiary procedure",8412,Other,United Healthcare ASC Grouper,9348,,"100% primary, 50% secondary, 25% tertiary procedure",9348,Other,United Healthcare ASC Grouper,7946,,"100% primary, 50% secondary, 25% tertiary procedure",7946,Other,United Healthcare ASC Grouper,2181.82,,,2181.82,Other,New York Medicaid APG methodology,2181.82,,,2181.82,Other,100% New York Medicaid APG,2181.82,,,2181.82,Other,100% New York Medicaid APG,2181.82,,,2181.82,Other,100% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,3054.54,,,3054.54,Other,140% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,5672.73,,,5672.73,Other,260% New York Medicaid APG,7069.09,,,7069.09,Other,324% New York Medicaid APG,4690.91,,,4690.91,Other,215% New York Medicaid APG,4690.91,,,4690.91,Other,215% New York Medicaid APG,2727.27,,,2727.27,Other,125% New York Medicaid APG,2181.82,62088,
L hrt artery/ventricle angio,93458,CPT,,,,,,,,both,,,72973.25,6196.63,,,6196.63,Other,150% of Medicare + 9.63% HCRA Surcharge,3768.21,,,3768.21,Other,Medicare OPPS methodology,15431,,"100% primary, 50% supplemental procedure",15431,Other,Aetna ASC Grouper,13888,,"100% primary, 50% supplemental procedure",13888,Other,Aetna ASC Grouper,22198,,"100% primary, 50% secondary, 25% supplemental procedure",22198,Other,Blue Cross ASC Grouper,19978,,"100% primary, 50% secondary, 25% supplemental procedure",19978,Other,Blue Cross ASC Grouper,18868,,"100% primary, 50% secondary, 25% supplemental procedure",18868,Other,Blue Cross ASC Grouper,36486.63,50,,36486.63,percent of total billed charges,,14794,,,14794,Case Rate,Cardiac Cath Case Rate,49621.81,68,,49621.81,percent of total billed charges,,4058.18,,,4058.18,Other,186% of Medicaid,58378.6,80,,58378.6,percent of total billed charges,,10971,,,10971,Case Rate,,10971,,,10971,Case Rate,,58378.6,80,,58378.6,percent of total billed charges,,10971,,,10971,Case Rate,,14729,,,14729,Case Rate,Cardiac Cath Case Rate,51081.28,70,,51081.28,percent of total billed charges,,17890,,,17890,Case Rate,Cardiac Cath Case Rate,15207,,,15207,Case Rate,Cardiac Cath Case Rate,9348,,"100% primary, 50% secondary, 25% tertiary procedure",9348,Other,United Healthcare ASC Grouper,8412,,"100% primary, 50% secondary, 25% tertiary procedure",8412,Other,United Healthcare ASC Grouper,9348,,"100% primary, 50% secondary, 25% tertiary procedure",9348,Other,United Healthcare ASC Grouper,7946,,"100% primary, 50% secondary, 25% tertiary procedure",7946,Other,United Healthcare ASC Grouper,2181.82,,,2181.82,Other,New York Medicaid APG methodology,2181.82,,,2181.82,Other,100% New York Medicaid APG,2181.82,,,2181.82,Other,100% New York Medicaid APG,2181.82,,,2181.82,Other,100% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,3054.54,,,3054.54,Other,140% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,5672.73,,,5672.73,Other,260% New York Medicaid APG,7069.09,,,7069.09,Other,324% New York Medicaid APG,4690.91,,,4690.91,Other,215% New York Medicaid APG,4690.91,,,4690.91,Other,215% New York Medicaid APG,2727.27,,,2727.27,Other,125% New York Medicaid APG,2181.82,58378.6,
L hrt art/grft angio,93459,CPT,,,,,,,,both,,,79193.42,6196.63,,,6196.63,Other,150% of Medicare + 9.63% HCRA Surcharge,3768.21,,,3768.21,Other,Medicare OPPS methodology,15431,,"100% primary, 50% supplemental procedure",15431,Other,Aetna ASC Grouper,13888,,"100% primary, 50% supplemental procedure",13888,Other,Aetna ASC Grouper,22198,,"100% primary, 50% secondary, 25% supplemental procedure",22198,Other,Blue Cross ASC Grouper,19978,,"100% primary, 50% secondary, 25% supplemental procedure",19978,Other,Blue Cross ASC Grouper,18868,,"100% primary, 50% secondary, 25% supplemental procedure",18868,Other,Blue Cross ASC Grouper,39596.71,50,,39596.71,percent of total billed charges,,14794,,,14794,Case Rate,Cardiac Cath Case Rate,53851.53,68,,53851.53,percent of total billed charges,,4058.18,,,4058.18,Other,186% of Medicaid,63354.74,80,,63354.74,percent of total billed charges,,10971,,,10971,Case Rate,,10971,,,10971,Case Rate,,63354.74,80,,63354.74,percent of total billed charges,,10971,,,10971,Case Rate,,14729,,,14729,Case Rate,Cardiac Cath Case Rate,55435.39,70,,55435.39,percent of total billed charges,,17890,,,17890,Case Rate,Cardiac Cath Case Rate,15207,,,15207,Case Rate,Cardiac Cath Case Rate,9348,,"100% primary, 50% secondary, 25% tertiary procedure",9348,Other,United Healthcare ASC Grouper,8412,,"100% primary, 50% secondary, 25% tertiary procedure",8412,Other,United Healthcare ASC Grouper,9348,,"100% primary, 50% secondary, 25% tertiary procedure",9348,Other,United Healthcare ASC Grouper,7946,,"100% primary, 50% secondary, 25% tertiary procedure",7946,Other,United Healthcare ASC Grouper,2181.82,,,2181.82,Other,New York Medicaid APG methodology,2181.82,,,2181.82,Other,100% New York Medicaid APG,2181.82,,,2181.82,Other,100% New York Medicaid APG,2181.82,,,2181.82,Other,100% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,3054.54,,,3054.54,Other,140% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,5672.73,,,5672.73,Other,260% New York Medicaid APG,7069.09,,,7069.09,Other,324% New York Medicaid APG,4690.91,,,4690.91,Other,215% New York Medicaid APG,4690.91,,,4690.91,Other,215% New York Medicaid APG,2727.27,,,2727.27,Other,125% New York Medicaid APG,2181.82,63354.74,
R&l hrt art/ventricle angio,93460,CPT,,,,,,,,both,,,78047.52,6196.63,,,6196.63,Other,150% of Medicare + 9.63% HCRA Surcharge,3768.21,,,3768.21,Other,Medicare OPPS methodology,15431,,"100% primary, 50% supplemental procedure",15431,Other,Aetna ASC Grouper,13888,,"100% primary, 50% supplemental procedure",13888,Other,Aetna ASC Grouper,22198,,"100% primary, 50% secondary, 25% supplemental procedure",22198,Other,Blue Cross ASC Grouper,19978,,"100% primary, 50% secondary, 25% supplemental procedure",19978,Other,Blue Cross ASC Grouper,18868,,"100% primary, 50% secondary, 25% supplemental procedure",18868,Other,Blue Cross ASC Grouper,39023.76,50,,39023.76,percent of total billed charges,,14794,,,14794,Case Rate,Cardiac Cath Case Rate,53072.31,68,,53072.31,percent of total billed charges,,4058.18,,,4058.18,Other,186% of Medicaid,62438.02,80,,62438.02,percent of total billed charges,,10971,,,10971,Case Rate,,10971,,,10971,Case Rate,,62438.02,80,,62438.02,percent of total billed charges,,10971,,,10971,Case Rate,,14729,,,14729,Case Rate,Cardiac Cath Case Rate,54633.26,70,,54633.26,percent of total billed charges,,17890,,,17890,Case Rate,Cardiac Cath Case Rate,15207,,,15207,Case Rate,Cardiac Cath Case Rate,9348,,"100% primary, 50% secondary, 25% tertiary procedure",9348,Other,United Healthcare ASC Grouper,8412,,"100% primary, 50% secondary, 25% tertiary procedure",8412,Other,United Healthcare ASC Grouper,9348,,"100% primary, 50% secondary, 25% tertiary procedure",9348,Other,United Healthcare ASC Grouper,7946,,"100% primary, 50% secondary, 25% tertiary procedure",7946,Other,United Healthcare ASC Grouper,2181.82,,,2181.82,Other,New York Medicaid APG methodology,2181.82,,,2181.82,Other,100% New York Medicaid APG,2181.82,,,2181.82,Other,100% New York Medicaid APG,2181.82,,,2181.82,Other,100% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,3054.54,,,3054.54,Other,140% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,5672.73,,,5672.73,Other,260% New York Medicaid APG,7069.09,,,7069.09,Other,324% New York Medicaid APG,4690.91,,,4690.91,Other,215% New York Medicaid APG,4690.91,,,4690.91,Other,215% New York Medicaid APG,2727.27,,,2727.27,Other,125% New York Medicaid APG,2181.82,62438.02,
R&l hrt art/ventricle angio,93461,CPT,,,,,,,,both,,,92590.93,6196.63,,,6196.63,Other,150% of Medicare + 9.63% HCRA Surcharge,3768.21,,,3768.21,Other,Medicare OPPS methodology,15431,,"100% primary, 50% supplemental procedure",15431,Other,Aetna ASC Grouper,13888,,"100% primary, 50% supplemental procedure",13888,Other,Aetna ASC Grouper,22198,,"100% primary, 50% secondary, 25% supplemental procedure",22198,Other,Blue Cross ASC Grouper,19978,,"100% primary, 50% secondary, 25% supplemental procedure",19978,Other,Blue Cross ASC Grouper,18868,,"100% primary, 50% secondary, 25% supplemental procedure",18868,Other,Blue Cross ASC Grouper,46295.47,50,,46295.47,percent of total billed charges,,14794,,,14794,Case Rate,Cardiac Cath Case Rate,62961.83,68,,62961.83,percent of total billed charges,,4058.18,,,4058.18,Other,186% of Medicaid,74072.74,80,,74072.74,percent of total billed charges,,10971,,,10971,Case Rate,,10971,,,10971,Case Rate,,74072.74,80,,74072.74,percent of total billed charges,,10971,,,10971,Case Rate,,14729,,,14729,Case Rate,Cardiac Cath Case Rate,64813.65,70,,64813.65,percent of total billed charges,,17890,,,17890,Case Rate,Cardiac Cath Case Rate,15207,,,15207,Case Rate,Cardiac Cath Case Rate,9348,,"100% primary, 50% secondary, 25% tertiary procedure",9348,Other,United Healthcare ASC Grouper,8412,,"100% primary, 50% secondary, 25% tertiary procedure",8412,Other,United Healthcare ASC Grouper,9348,,"100% primary, 50% secondary, 25% tertiary procedure",9348,Other,United Healthcare ASC Grouper,7946,,"100% primary, 50% secondary, 25% tertiary procedure",7946,Other,United Healthcare ASC Grouper,2181.82,,,2181.82,Other,New York Medicaid APG methodology,2181.82,,,2181.82,Other,100% New York Medicaid APG,2181.82,,,2181.82,Other,100% New York Medicaid APG,2181.82,,,2181.82,Other,100% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,3054.54,,,3054.54,Other,140% New York Medicaid APG,4909.09,,,4909.09,Other,225% New York Medicaid APG,5672.73,,,5672.73,Other,260% New York Medicaid APG,7069.09,,,7069.09,Other,324% New York Medicaid APG,4690.91,,,4690.91,Other,215% New York Medicaid APG,4690.91,,,4690.91,Other,215% New York Medicaid APG,2727.27,,,2727.27,Other,125% New York Medicaid APG,2181.82,74072.74,
"Microwave bronch, 3d, ebus",C9751,HCPCS,,,,,,,,both,,,82795.68,7485.51,,,7485.51,Other,150% of Medicare + 9.63% HCRA Surcharge,4551.98,,,4551.98,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,41397.84,50,,41397.84,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2967.81,,,2967.81,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,57956.98,70,,57956.98,percent of total billed charges,,41397.84,50,,41397.84,percent of total billed charges,,41397.84,50,,41397.84,percent of total billed charges,,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1595.6,,,1595.6,Other,New York Medicaid APG methodology,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,1595.6,,,1595.6,Other,100% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,2233.83,,,2233.83,Other,140% New York Medicaid APG,3590.09,,,3590.09,Other,225% New York Medicaid APG,4148.55,,,4148.55,Other,260% New York Medicaid APG,5169.73,,,5169.73,Other,324% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,3430.53,,,3430.53,Other,215% New York Medicaid APG,1994.49,,,1994.49,Other,125% New York Medicaid APG,1595.6,57956.98,
Blind interatrial shunt ide,C9758,HCPCS,,,,,,,,both,,,386339.36,34928.7,,,34928.7,Other,150% of Medicare + 9.63% HCRA Surcharge,21240.36,,,21240.36,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,193169.68,50,,193169.68,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6073.53,,,6073.53,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,270437.55,70,,270437.55,percent of total billed charges,,193169.68,50,,193169.68,percent of total billed charges,,193169.68,50,,193169.68,percent of total billed charges,,17798,,"100% primary, 50% secondary, 25% tertiary procedure",17798,Other,United Healthcare ASC Grouper,16018,,"100% primary, 50% secondary, 25% tertiary procedure",16018,Other,United Healthcare ASC Grouper,17798,,"100% primary, 50% secondary, 25% tertiary procedure",17798,Other,United Healthcare ASC Grouper,15129,,"100% primary, 50% secondary, 25% tertiary procedure",15129,Other,United Healthcare ASC Grouper,3265.34,,,3265.34,Other,New York Medicaid APG methodology,3265.34,,,3265.34,Other,100% New York Medicaid APG,3265.34,,,3265.34,Other,100% New York Medicaid APG,3265.34,,,3265.34,Other,100% New York Medicaid APG,7347.01,,,7347.01,Other,225% New York Medicaid APG,7347.01,,,7347.01,Other,225% New York Medicaid APG,7347.01,,,7347.01,Other,225% New York Medicaid APG,7347.01,,,7347.01,Other,225% New York Medicaid APG,4571.48,,,4571.48,Other,140% New York Medicaid APG,7347.01,,,7347.01,Other,225% New York Medicaid APG,8489.88,,,8489.88,Other,260% New York Medicaid APG,10579.7,,,10579.7,Other,324% New York Medicaid APG,7020.48,,,7020.48,Other,215% New York Medicaid APG,7020.48,,,7020.48,Other,215% New York Medicaid APG,4081.67,,,4081.67,Other,125% New York Medicaid APG,3265.34,270437.55,
Prosth retina receive&gen,0100T,HCPCS,,,,,,,,both,,,98219.64,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,49109.82,50,,49109.82,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6145.86,,,6145.86,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,68753.75,70,,68753.75,percent of total billed charges,,49109.82,50,,49109.82,percent of total billed charges,,49109.82,50,,49109.82,percent of total billed charges,,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,19221,,"100% primary, 50% secondary, 25% tertiary procedure",19221,Other,United Healthcare ASC Grouper,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,18154,,"100% primary, 50% secondary, 25% tertiary procedure",18154,Other,United Healthcare ASC Grouper,3304.22,,,3304.22,Other,New York Medicaid APG methodology,3304.22,,,3304.22,Other,100% New York Medicaid APG,3304.22,,,3304.22,Other,100% New York Medicaid APG,3304.22,,,3304.22,Other,100% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,4625.91,,,4625.91,Other,140% New York Medicaid APG,7434.5,,,7434.5,Other,225% New York Medicaid APG,8590.98,,,8590.98,Other,260% New York Medicaid APG,10705.69,,,10705.69,Other,324% New York Medicaid APG,7104.08,,,7104.08,Other,215% New York Medicaid APG,7104.08,,,7104.08,Other,215% New York Medicaid APG,4130.28,,,4130.28,Other,125% New York Medicaid APG,0.01,68753.75,
Rmvl impltbl glucose sensor,0447T,HCPCS,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,1.95,,,1.95,Fee Schedule,,321.75,,,321.75,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,0.01,9473,
Esw integ wnd hlg 1st wnd,0512T,HCPCS,,,,,,,,both,,,4210.98,380.71,,,380.71,Other,150% of Medicare + 9.63% HCRA Surcharge,231.51,,,231.51,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2105.49,50,,2105.49,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2947.69,70,,2947.69,percent of total billed charges,,2105.49,50,,2105.49,percent of total billed charges,,2105.49,50,,2105.49,percent of total billed charges,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,231.51,9473,
Dstrj neurofibroma xtnsv,0419T,HCPCS,,,,,,,,both,,,13210.22,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6605.11,50,,6605.11,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9247.15,70,,9247.15,percent of total billed charges,,6605.11,50,,6605.11,percent of total billed charges,,6605.11,50,,6605.11,percent of total billed charges,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,485.25,9473,
Dstrj neurofibroma xtnsv,0420T,HCPCS,,,,,,,,both,,,13210.22,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6605.11,50,,6605.11,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,902.56,,,902.56,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9247.15,70,,9247.15,percent of total billed charges,,6605.11,50,,6605.11,percent of total billed charges,,6605.11,50,,6605.11,percent of total billed charges,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,485.25,,,485.25,Other,New York Medicaid APG methodology,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,485.25,,,485.25,Other,100% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,679.35,,,679.35,Other,140% New York Medicaid APG,1091.81,,,1091.81,Other,225% New York Medicaid APG,1261.65,,,1261.65,Other,260% New York Medicaid APG,1572.2,,,1572.2,Other,324% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,1043.28,,,1043.28,Other,215% New York Medicaid APG,606.56,,,606.56,Other,125% New York Medicaid APG,485.25,9473,
Fxjl abl lsr 1st 100 sq cm,0479T,HCPCS,,,,,,,,both,,,38421.99,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,19211,50,,19211,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1704.43,,,1704.43,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26895.39,70,,26895.39,percent of total billed charges,,19211,50,,19211,percent of total billed charges,,19211,50,,19211,percent of total billed charges,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,916.36,,,916.36,Other,New York Medicaid APG methodology,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,916.36,,,916.36,Other,100% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,1282.9,,,1282.9,Other,140% New York Medicaid APG,2061.81,,,2061.81,Other,225% New York Medicaid APG,2382.54,,,2382.54,Other,260% New York Medicaid APG,2969.01,,,2969.01,Other,324% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1970.17,,,1970.17,Other,215% New York Medicaid APG,1145.45,,,1145.45,Other,125% New York Medicaid APG,726.28,26895.39,
Low cost skin substitute app,C5271,HCPCS,,,,,,,,both,,,13210.22,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6605.11,50,,6605.11,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9247.15,70,,9247.15,percent of total billed charges,,6605.11,50,,6605.11,percent of total billed charges,,6605.11,50,,6605.11,percent of total billed charges,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,726.28,9473,
Low cost skin substitute app,C5275,HCPCS,,,,,,,,both,,,42128.5,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,21064.25,50,,21064.25,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29489.95,70,,29489.95,percent of total billed charges,,21064.25,50,,21064.25,percent of total billed charges,,21064.25,50,,21064.25,percent of total billed charges,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,726.28,29489.95,
Low cost skin substitute app,C5277,HCPCS,,,,,,,,both,,,13210.22,1194.33,,,1194.33,Other,150% of Medicare + 9.63% HCRA Surcharge,726.28,,,726.28,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6605.11,50,,6605.11,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9247.15,70,,9247.15,percent of total billed charges,,6605.11,50,,6605.11,percent of total billed charges,,6605.11,50,,6605.11,percent of total billed charges,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,726.28,9473,
Reloc skin pocket pls gen,0416T,HCPCS,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5826.77,,,5826.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,19178.78,50,,19178.78,percent of total billed charges,,19178.78,50,,19178.78,percent of total billed charges,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,3132.67,,,3132.67,Other,New York Medicaid APG methodology,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,4385.74,,,4385.74,Other,140% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,8144.95,,,8144.95,Other,260% New York Medicaid APG,10149.86,,,10149.86,Other,324% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,3915.84,,,3915.84,Other,125% New York Medicaid APG,2108.84,26850.29,
Insj impltbl glucose sensor,0446T,HCPCS,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,1.66,,,1.66,Fee Schedule,,273.9,,,273.9,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,1.66,26850.29,
Remvl insj impltbl gluc sens,0448T,HCPCS,,,,,,,,both,,,38357.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,19178.78,50,,19178.78,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1559.83,,,1559.83,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,26850.29,70,,26850.29,percent of total billed charges,,2.78,,,2.78,Fee Schedule,,458.7,,,458.7,Fee Schedule,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,838.62,,,838.62,Other,New York Medicaid APG methodology,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,838.62,,,838.62,Other,100% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,1174.07,,,1174.07,Other,140% New York Medicaid APG,1886.89,,,1886.89,Other,225% New York Medicaid APG,2180.41,,,2180.41,Other,260% New York Medicaid APG,2717.12,,,2717.12,Other,324% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1803.03,,,1803.03,Other,215% New York Medicaid APG,1048.27,,,1048.27,Other,125% New York Medicaid APG,2.78,26850.29,
Low cost skin substitute app,C5273,HCPCS,,,,,,,,both,,,59774.55,3467.88,,,3467.88,Other,150% of Medicare + 9.63% HCRA Surcharge,2108.84,,,2108.84,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,29887.28,50,,29887.28,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3310.98,,,3310.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,41842.19,70,,41842.19,percent of total billed charges,,29887.28,50,,29887.28,percent of total billed charges,,29887.28,50,,29887.28,percent of total billed charges,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1780.1,,,1780.1,Other,New York Medicaid APG methodology,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,1780.1,,,1780.1,Other,100% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,2492.13,,,2492.13,Other,140% New York Medicaid APG,4005.21,,,4005.21,Other,225% New York Medicaid APG,4628.25,,,4628.25,Other,260% New York Medicaid APG,5767.51,,,5767.51,Other,324% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,3827.2,,,3827.2,Other,215% New York Medicaid APG,2225.12,,,2225.12,Other,125% New York Medicaid APG,1780.1,41842.19,
Extracorp shockwv tx hi enrg,0101T,HCPCS,,,,,,,,both,,,4960.23,448.45,,,448.45,Other,150% of Medicare + 9.63% HCRA Surcharge,272.71,,,272.71,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,2480.12,50,,2480.12,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1288.75,,,1288.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3472.16,70,,3472.16,percent of total billed charges,,2480.12,50,,2480.12,percent of total billed charges,,2480.12,50,,2480.12,percent of total billed charges,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,692.88,,,692.88,Other,New York Medicaid APG methodology,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,692.88,,,692.88,Other,100% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,970.03,,,970.03,Other,140% New York Medicaid APG,1558.97,,,1558.97,Other,225% New York Medicaid APG,1801.48,,,1801.48,Other,260% New York Medicaid APG,2244.92,,,2244.92,Other,324% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,1489.68,,,1489.68,Other,215% New York Medicaid APG,866.09,,,866.09,Other,125% New York Medicaid APG,272.71,11390,
Extracorp shockwv tx anesth,0102T,HCPCS,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,34041.38,50,,34041.38,percent of total billed charges,,34041.38,50,,34041.38,percent of total billed charges,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,47657.93,
Rmvl sinus tarsi implant,0510T,HCPCS,,,,,,,,both,,,68082.75,6155.32,,,6155.32,Other,150% of Medicare + 9.63% HCRA Surcharge,3743.09,,,3743.09,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,34041.38,50,,34041.38,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,47657.93,70,,47657.93,percent of total billed charges,,34041.38,50,,34041.38,percent of total billed charges,,34041.38,50,,34041.38,percent of total billed charges,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,1987.23,47657.93,
Perq sacral augmt unilat inj,0200T,HCPCS,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,7615,,"100% primary, 50% supplemental procedure",7615,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,75238.33,50,,75238.33,percent of total billed charges,,75238.33,50,,75238.33,percent of total billed charges,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,105333.66,
Perq sacral augmt bilat inj,0201T,HCPCS,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,75238.33,50,,75238.33,percent of total billed charges,,75238.33,50,,75238.33,percent of total billed charges,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,105333.66,
Plmt post facet implt lumb,0221T,HCPCS,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,75238.33,50,,75238.33,percent of total billed charges,,75238.33,50,,75238.33,percent of total billed charges,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,105333.66,
Perq lamot/lam crv/thrc,0274T,HCPCS,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,75238.33,50,,75238.33,percent of total billed charges,,75238.33,50,,75238.33,percent of total billed charges,,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,105333.66,
Perq lamot/lam lumbar,0275T,HCPCS,,,,,,,,both,,,152786.49,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,76393.25,50,,76393.25,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7106.52,,,7106.52,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,106950.54,70,,106950.54,percent of total billed charges,,76393.25,50,,76393.25,percent of total billed charges,,76393.25,50,,76393.25,percent of total billed charges,,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3820.71,,,3820.71,Other,New York Medicaid APG methodology,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,3820.71,,,3820.71,Other,100% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,5348.99,,,5348.99,Other,140% New York Medicaid APG,8596.6,,,8596.6,Other,225% New York Medicaid APG,9933.85,,,9933.85,Other,260% New York Medicaid APG,12379.1,,,12379.1,Other,324% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,8214.53,,,8214.53,Other,215% New York Medicaid APG,4775.89,,,4775.89,Other,125% New York Medicaid APG,3820.71,106950.54,
Insj sinus tarsi implant,0335T,HCPCS,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Aetna ASC Grouper,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3696.26,,,3696.26,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,75238.33,50,,75238.33,percent of total billed charges,,75238.33,50,,75238.33,percent of total billed charges,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1987.23,,,1987.23,Other,New York Medicaid APG methodology,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,1987.23,,,1987.23,Other,100% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,2782.13,,,2782.13,Other,140% New York Medicaid APG,4471.28,,,4471.28,Other,225% New York Medicaid APG,5166.81,,,5166.81,Other,260% New York Medicaid APG,6438.64,,,6438.64,Other,324% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,4272.55,,,4272.55,Other,215% New York Medicaid APG,2484.04,,,2484.04,Other,125% New York Medicaid APG,0.01,105333.66,
Rmvl&rinsj sinus tarsi implt,0511T,HCPCS,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4669.37,,,4669.37,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,75238.33,50,,75238.33,percent of total billed charges,,75238.33,50,,75238.33,percent of total billed charges,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,2510.41,,,2510.41,Other,New York Medicaid APG methodology,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,2510.41,,,2510.41,Other,100% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,3514.58,,,3514.58,Other,140% New York Medicaid APG,5648.43,,,5648.43,Other,225% New York Medicaid APG,6527.08,,,6527.08,Other,260% New York Medicaid APG,8133.74,,,8133.74,Other,324% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,5397.39,,,5397.39,Other,215% New York Medicaid APG,3138.02,,,3138.02,Other,125% New York Medicaid APG,2510.41,105333.66,
Osteot hum xtrnl lngth dev,0594T,HCPCS,,,,,,,,both,,,150476.65,13604.5,,,13604.5,Other,150% of Medicare + 9.63% HCRA Surcharge,8272.98,,,8272.98,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13747,,"100% primary, 50% secondary, 25% supplemental procedure",13747,Other,Blue Cross ASC Grouper,12372,,"100% primary, 50% secondary, 25% supplemental procedure",12372,Other,Blue Cross ASC Grouper,11685,,"100% primary, 50% secondary, 25% supplemental procedure",11685,Other,Blue Cross ASC Grouper,75238.33,50,,75238.33,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5080.67,,,5080.67,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,105333.66,70,,105333.66,percent of total billed charges,,75238.33,50,,75238.33,percent of total billed charges,,75238.33,50,,75238.33,percent of total billed charges,,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2731.54,,,2731.54,Other,New York Medicaid APG methodology,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,2731.54,,,2731.54,Other,100% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,3824.16,,,3824.16,Other,140% New York Medicaid APG,6145.97,,,6145.97,Other,225% New York Medicaid APG,7102.01,,,7102.01,Other,260% New York Medicaid APG,8850.2,,,8850.2,Other,324% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,5872.82,,,5872.82,Other,215% New York Medicaid APG,3414.43,,,3414.43,Other,125% New York Medicaid APG,2731.54,105333.66,
Perq njx algc fluor lmbr 1st,0627T,HCPCS,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,138413.94,50,,138413.94,percent of total billed charges,,138413.94,50,,138413.94,percent of total billed charges,,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,751.98,193779.51,
Perq njx algc ct lmbr 1st,0629T,HCPCS,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,138413.94,50,,138413.94,percent of total billed charges,,138413.94,50,,138413.94,percent of total billed charges,,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,751.98,193779.51,
Spine/lumbar disk surgery,C9757,HCPCS,,,,,,,,both,,,276827.87,25027.84,,,25027.84,Other,150% of Medicare + 9.63% HCRA Surcharge,15219.58,,,15219.58,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,138413.94,50,,138413.94,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,8573.09,,,8573.09,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,193779.51,70,,193779.51,percent of total billed charges,,138413.94,50,,138413.94,percent of total billed charges,,138413.94,50,,138413.94,percent of total billed charges,,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,4609.19,,,4609.19,Other,New York Medicaid APG methodology,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,4609.19,,,4609.19,Other,100% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,6452.86,,,6452.86,Other,140% New York Medicaid APG,10370.67,,,10370.67,Other,225% New York Medicaid APG,11983.89,,,11983.89,Other,260% New York Medicaid APG,14933.77,,,14933.77,Other,324% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,9909.76,,,9909.76,Other,215% New York Medicaid APG,5761.49,,,5761.49,Other,125% New York Medicaid APG,4609.19,193779.51,
Tmpst auto tube dlvr sys,0583T,HCPCS,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,16038.7,50,,16038.7,percent of total billed charges,,16038.7,50,,16038.7,percent of total billed charges,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,1545.56,22454.17,
Insert palate implants,C9727,HCPCS,,,,,,,,both,,,32077.39,2900.1,,,2900.1,Other,150% of Medicare + 9.63% HCRA Surcharge,1763.57,,,1763.57,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,16038.7,50,,16038.7,percent of total billed charges,,22454.17,70,,22454.17,percent of total billed charges,,6152,,,6152,Case Rate,,2874.75,,,2874.75,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,22454.17,70,,22454.17,percent of total billed charges,,16038.7,50,,16038.7,percent of total billed charges,,16038.7,50,,16038.7,percent of total billed charges,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,1545.56,,,1545.56,Other,New York Medicaid APG methodology,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,1545.56,,,1545.56,Other,100% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,2163.79,,,2163.79,Other,140% New York Medicaid APG,3477.52,,,3477.52,Other,225% New York Medicaid APG,4018.47,,,4018.47,Other,260% New York Medicaid APG,5007.63,,,5007.63,Other,324% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,3322.96,,,3322.96,Other,215% New York Medicaid APG,1931.96,,,1931.96,Other,125% New York Medicaid APG,1545.56,22454.17,
Repos car modulj tranvns elt,0415T,HCPCS,,,,,,,,both,,,13213.53,1194.63,,,1194.63,Other,150% of Medicare + 9.63% HCRA Surcharge,726.46,,,726.46,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,6606.77,50,,6606.77,percent of total billed charges,,6857,,"100% primary, 50% supplemental procedure",6857,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5826.77,,,5826.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,9249.47,70,,9249.47,percent of total billed charges,,6606.77,50,,6606.77,percent of total billed charges,,6606.77,50,,6606.77,percent of total billed charges,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,3132.67,,,3132.67,Other,New York Medicaid APG methodology,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,4385.74,,,4385.74,Other,140% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,8144.95,,,8144.95,Other,260% New York Medicaid APG,10149.86,,,10149.86,Other,324% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,3915.84,,,3915.84,Other,125% New York Medicaid APG,726.46,10149.86,
Ev cath dir chem abltj w/img,0524T,HCPCS,,,,,,,,both,,,67044.74,6061.47,,,6061.47,Other,150% of Medicare + 9.63% HCRA Surcharge,3686.02,,,3686.02,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,33522.37,50,,33522.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5334.25,,,5334.25,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,46931.32,70,,46931.32,percent of total billed charges,,33522.37,50,,33522.37,percent of total billed charges,,33522.37,50,,33522.37,percent of total billed charges,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2867.87,,,2867.87,Other,New York Medicaid APG methodology,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,2867.87,,,2867.87,Other,100% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,4015.02,,,4015.02,Other,140% New York Medicaid APG,6452.72,,,6452.72,Other,225% New York Medicaid APG,7456.47,,,7456.47,Other,260% New York Medicaid APG,9291.91,,,9291.91,Other,324% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,6165.93,,,6165.93,Other,215% New York Medicaid APG,3584.84,,,3584.84,Other,125% New York Medicaid APG,2867.87,46931.32,
Trnscth renal symp denrv unl,0338T,HCPCS,,,,,,,,both,,,120221.84,10869.18,,,10869.18,Other,150% of Medicare + 9.63% HCRA Surcharge,6609.62,,,6609.62,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,60110.92,50,,60110.92,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3523.82,,,3523.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84155.29,70,,84155.29,percent of total billed charges,,60110.92,50,,60110.92,percent of total billed charges,,60110.92,50,,60110.92,percent of total billed charges,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1894.53,,,1894.53,Other,New York Medicaid APG methodology,1894.53,,,1894.53,Other,100% New York Medicaid APG,1894.53,,,1894.53,Other,100% New York Medicaid APG,1894.53,,,1894.53,Other,100% New York Medicaid APG,4262.68,,,4262.68,Other,225% New York Medicaid APG,4262.68,,,4262.68,Other,225% New York Medicaid APG,4262.68,,,4262.68,Other,225% New York Medicaid APG,4262.68,,,4262.68,Other,225% New York Medicaid APG,2652.34,,,2652.34,Other,140% New York Medicaid APG,4262.68,,,4262.68,Other,225% New York Medicaid APG,4925.77,,,4925.77,Other,260% New York Medicaid APG,6138.27,,,6138.27,Other,324% New York Medicaid APG,4073.23,,,4073.23,Other,215% New York Medicaid APG,4073.23,,,4073.23,Other,215% New York Medicaid APG,2368.16,,,2368.16,Other,125% New York Medicaid APG,1894.53,84155.29,
Trnscth renal symp denrv bil,0339T,HCPCS,,,,,,,,both,,,120221.84,10869.18,,,10869.18,Other,150% of Medicare + 9.63% HCRA Surcharge,6609.62,,,6609.62,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,60110.92,50,,60110.92,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3523.82,,,3523.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84155.29,70,,84155.29,percent of total billed charges,,60110.92,50,,60110.92,percent of total billed charges,,60110.92,50,,60110.92,percent of total billed charges,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1894.53,,,1894.53,Other,New York Medicaid APG methodology,1894.53,,,1894.53,Other,100% New York Medicaid APG,1894.53,,,1894.53,Other,100% New York Medicaid APG,1894.53,,,1894.53,Other,100% New York Medicaid APG,4262.68,,,4262.68,Other,225% New York Medicaid APG,4262.68,,,4262.68,Other,225% New York Medicaid APG,4262.68,,,4262.68,Other,225% New York Medicaid APG,4262.68,,,4262.68,Other,225% New York Medicaid APG,2652.34,,,2652.34,Other,140% New York Medicaid APG,4262.68,,,4262.68,Other,225% New York Medicaid APG,4925.77,,,4925.77,Other,260% New York Medicaid APG,6138.27,,,6138.27,Other,324% New York Medicaid APG,4073.23,,,4073.23,Other,215% New York Medicaid APG,4073.23,,,4073.23,Other,215% New York Medicaid APG,2368.16,,,2368.16,Other,125% New York Medicaid APG,1894.53,84155.29,
Prq cardiac angioplast 1 art,92920,CPT,,,,,,,,both,,,120221.84,10869.18,,,10869.18,Other,150% of Medicare + 9.63% HCRA Surcharge,6609.62,,,6609.62,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,60110.92,50,,60110.92,percent of total billed charges,,84155.29,70,,84155.29,percent of total billed charges,,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84155.29,70,,84155.29,percent of total billed charges,,2539.35,,,2539.35,Fee Schedule,,2154.6,,,2154.6,Fee Schedule,,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,2154.6,84155.29,
Revasc intravasc lithotripsy,C9764,HCPCS,,,,,,,,both,,,119648,20920.32,,,20920.32,Other,150% of Medicare + 9.63% HCRA Surcharge,12721.77,,,12721.77,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,12503,,"100% primary, 50% secondary, 25% supplemental procedure",12503,Other,Blue Cross ASC Grouper,11253,,"100% primary, 50% secondary, 25% supplemental procedure",11253,Other,Blue Cross ASC Grouper,10628,,"100% primary, 50% secondary, 25% supplemental procedure",10628,Other,Blue Cross ASC Grouper,59824,50,,59824,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4941.98,,,4941.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,83753.6,70,,83753.6,percent of total billed charges,,59824,50,,59824,percent of total billed charges,,59824,50,,59824,percent of total billed charges,,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,2656.98,,,2656.98,Other,New York Medicaid APG methodology,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,2656.98,,,2656.98,Other,100% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,3719.77,,,3719.77,Other,140% New York Medicaid APG,5978.2,,,5978.2,Other,225% New York Medicaid APG,6908.15,,,6908.15,Other,260% New York Medicaid APG,8608.61,,,8608.61,Other,324% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,5712.51,,,5712.51,Other,215% New York Medicaid APG,3321.22,,,3321.22,Other,125% New York Medicaid APG,2656.98,83753.6,
Ev fempop artl revsc,0505T,HCPCS,,,,,,,,both,,,231395.43,20920.32,,,20920.32,Other,150% of Medicare + 9.63% HCRA Surcharge,12721.77,,,12721.77,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,115697.72,50,,115697.72,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5915.6,,,5915.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,161976.8,70,,161976.8,percent of total billed charges,,115697.72,50,,115697.72,percent of total billed charges,,115697.72,50,,115697.72,percent of total billed charges,,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3180.43,,,3180.43,Other,New York Medicaid APG methodology,3180.43,,,3180.43,Other,100% New York Medicaid APG,3180.43,,,3180.43,Other,100% New York Medicaid APG,3180.43,,,3180.43,Other,100% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,4452.6,,,4452.6,Other,140% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,8269.12,,,8269.12,Other,260% New York Medicaid APG,10304.59,,,10304.59,Other,324% New York Medicaid APG,6837.92,,,6837.92,Other,215% New York Medicaid APG,6837.92,,,6837.92,Other,215% New York Medicaid APG,3975.54,,,3975.54,Other,125% New York Medicaid APG,3180.43,161976.8,
Prq card stent w/angio 1 vsl,92928,CPT,,,,,,,,both,,,231395.43,20920.32,,,20920.32,Other,150% of Medicare + 9.63% HCRA Surcharge,12721.77,,,12721.77,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,115697.72,50,,115697.72,percent of total billed charges,,161976.8,70,,161976.8,percent of total billed charges,,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,161976.8,70,,161976.8,percent of total billed charges,,2831.4,,,2831.4,Fee Schedule,,2402.4,,,2402.4,Fee Schedule,,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,2402.4,161976.8,
Perc drug-el cor stent sing,C9600,HCPCS,,,,,,,,both,,,100522.73,20920.32,,,20920.32,Other,150% of Medicare + 9.63% HCRA Surcharge,12721.77,,,12721.77,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,50261.37,50,,50261.37,percent of total billed charges,,70365.91,70,,70365.91,percent of total billed charges,,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,70365.91,70,,70365.91,percent of total billed charges,,50261.37,50,,50261.37,percent of total billed charges,,50261.37,50,,50261.37,percent of total billed charges,,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,3180.44,70365.91,
Perc d-e cor revasc t cabg s,C9604,HCPCS,,,,,,,,both,,,120990,20920.32,,,20920.32,Other,150% of Medicare + 9.63% HCRA Surcharge,12721.77,,,12721.77,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,60495,50,,60495,percent of total billed charges,,84693,70,,84693,percent of total billed charges,,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,84693,70,,84693,percent of total billed charges,,60495,50,,60495,percent of total billed charges,,60495,50,,60495,percent of total billed charges,,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,3180.44,84693,
Revasc intra lithotrip-stent,C9765,HCPCS,,,,,,,,both,,,183637,33345.6,,,33345.6,Other,150% of Medicare + 9.63% HCRA Surcharge,20277.66,,,20277.66,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,91818.5,50,,91818.5,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5915.6,,,5915.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,128545.9,70,,128545.9,percent of total billed charges,,91818.5,50,,91818.5,percent of total billed charges,,91818.5,50,,91818.5,percent of total billed charges,,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3180.43,,,3180.43,Other,New York Medicaid APG methodology,3180.43,,,3180.43,Other,100% New York Medicaid APG,3180.43,,,3180.43,Other,100% New York Medicaid APG,3180.43,,,3180.43,Other,100% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,4452.6,,,4452.6,Other,140% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,8269.12,,,8269.12,Other,260% New York Medicaid APG,10304.59,,,10304.59,Other,324% New York Medicaid APG,6837.92,,,6837.92,Other,215% New York Medicaid APG,6837.92,,,6837.92,Other,215% New York Medicaid APG,3975.54,,,3975.54,Other,125% New York Medicaid APG,3180.43,128545.9,
Revasc intra lithotrip-ather,C9766,HCPCS,,,,,,,,both,,,368828.98,33345.6,,,33345.6,Other,150% of Medicare + 9.63% HCRA Surcharge,20277.66,,,20277.66,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,184414.49,50,,184414.49,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5915.6,,,5915.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,258180.29,70,,258180.29,percent of total billed charges,,184414.49,50,,184414.49,percent of total billed charges,,184414.49,50,,184414.49,percent of total billed charges,,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3180.43,,,3180.43,Other,New York Medicaid APG methodology,3180.43,,,3180.43,Other,100% New York Medicaid APG,3180.43,,,3180.43,Other,100% New York Medicaid APG,3180.43,,,3180.43,Other,100% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,4452.6,,,4452.6,Other,140% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,8269.12,,,8269.12,Other,260% New York Medicaid APG,10304.59,,,10304.59,Other,324% New York Medicaid APG,6837.92,,,6837.92,Other,215% New York Medicaid APG,6837.92,,,6837.92,Other,215% New York Medicaid APG,3975.54,,,3975.54,Other,125% New York Medicaid APG,3180.43,258180.29,
Revasc lithotrip tibi/perone,C9772,HCPCS,,,,,,,,both,,,231395.43,20920.32,,,20920.32,Other,150% of Medicare + 9.63% HCRA Surcharge,12721.77,,,12721.77,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,115697.72,50,,115697.72,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5915.6,,,5915.6,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,161976.8,70,,161976.8,percent of total billed charges,,115697.72,50,,115697.72,percent of total billed charges,,115697.72,50,,115697.72,percent of total billed charges,,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3180.43,,,3180.43,Other,New York Medicaid APG methodology,3180.43,,,3180.43,Other,100% New York Medicaid APG,3180.43,,,3180.43,Other,100% New York Medicaid APG,3180.43,,,3180.43,Other,100% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,4452.6,,,4452.6,Other,140% New York Medicaid APG,7155.97,,,7155.97,Other,225% New York Medicaid APG,8269.12,,,8269.12,Other,260% New York Medicaid APG,10304.59,,,10304.59,Other,324% New York Medicaid APG,6837.92,,,6837.92,Other,215% New York Medicaid APG,6837.92,,,6837.92,Other,215% New York Medicaid APG,3975.54,,,3975.54,Other,125% New York Medicaid APG,3180.43,161976.8,
Trluml perip athrc iliac art,0238T,HCPCS,,,,,,,,both,,,368828.98,33345.6,,,33345.6,Other,150% of Medicare + 9.63% HCRA Surcharge,20277.66,,,20277.66,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,184414.49,50,,184414.49,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,258180.29,70,,258180.29,percent of total billed charges,,184414.49,50,,184414.49,percent of total billed charges,,184414.49,50,,184414.49,percent of total billed charges,,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,3180.44,258180.29,
Evasc ven artlz tibl/prnl vn,0620T,HCPCS,,,,,,,,both,,,607098.41,54887.39,,,54887.39,Other,150% of Medicare + 9.63% HCRA Surcharge,33377.36,,,33377.36,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,303549.21,50,,303549.21,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,424968.89,70,,424968.89,percent of total billed charges,,303549.21,50,,303549.21,percent of total billed charges,,303549.21,50,,303549.21,percent of total billed charges,,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,3180.44,424968.89,
Perq tcat us abltj nrv p-art,0632T,HCPCS,,,,,,,,both,,,368828.98,33345.6,,,33345.6,Other,150% of Medicare + 9.63% HCRA Surcharge,20277.66,,,20277.66,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,184414.49,50,,184414.49,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,258180.29,70,,258180.29,percent of total billed charges,,184414.49,50,,184414.49,percent of total billed charges,,184414.49,50,,184414.49,percent of total billed charges,,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,3180.44,258180.29,
Perc d-e cor stent ather s,C9602,HCPCS,,,,,,,,both,,,131418,33345.6,,,33345.6,Other,150% of Medicare + 9.63% HCRA Surcharge,20277.66,,,20277.66,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,65709,50,,65709,percent of total billed charges,,91992.6,70,,91992.6,percent of total billed charges,,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,91992.6,70,,91992.6,percent of total billed charges,,65709,50,,65709,percent of total billed charges,,65709,50,,65709,percent of total billed charges,,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,3180.44,91992.6,
Perc d-e cor revasc chro sin,C9607,HCPCS,,,,,,,,both,,,131274,33345.6,,,33345.6,Other,150% of Medicare + 9.63% HCRA Surcharge,20277.66,,,20277.66,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,65637,50,,65637,percent of total billed charges,,91891.8,70,,91891.8,percent of total billed charges,,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,91891.8,70,,91891.8,percent of total billed charges,,65637,50,,65637,percent of total billed charges,,65637,50,,65637,percent of total billed charges,,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,3180.44,91891.8,
Revasc lithotrip-stent-ather,C9767,HCPCS,,,,,,,,both,,,368828.98,33345.6,,,33345.6,Other,150% of Medicare + 9.63% HCRA Surcharge,20277.66,,,20277.66,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,184414.49,50,,184414.49,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,258180.29,70,,258180.29,percent of total billed charges,,184414.49,50,,184414.49,percent of total billed charges,,184414.49,50,,184414.49,percent of total billed charges,,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,3180.44,258180.29,
Revasc lithotr-stent tib/per,C9773,HCPCS,,,,,,,,both,,,368828.98,33345.6,,,33345.6,Other,150% of Medicare + 9.63% HCRA Surcharge,20277.66,,,20277.66,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,184414.49,50,,184414.49,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,258180.29,70,,258180.29,percent of total billed charges,,184414.49,50,,184414.49,percent of total billed charges,,184414.49,50,,184414.49,percent of total billed charges,,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,3180.44,258180.29,
Revasc lithotr-ather tib/per,C9774,HCPCS,,,,,,,,both,,,368828.98,33345.6,,,33345.6,Other,150% of Medicare + 9.63% HCRA Surcharge,20277.66,,,20277.66,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,184414.49,50,,184414.49,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,258180.29,70,,258180.29,percent of total billed charges,,184414.49,50,,184414.49,percent of total billed charges,,184414.49,50,,184414.49,percent of total billed charges,,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,3180.44,258180.29,
Revasc lith-sten-ath tib/per,C9775,HCPCS,,,,,,,,both,,,368828.98,33345.6,,,33345.6,Other,150% of Medicare + 9.63% HCRA Surcharge,20277.66,,,20277.66,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,184414.49,50,,184414.49,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5915.61,,,5915.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,258180.29,70,,258180.29,percent of total billed charges,,184414.49,50,,184414.49,percent of total billed charges,,184414.49,50,,184414.49,percent of total billed charges,,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3180.44,,,3180.44,Other,New York Medicaid APG methodology,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,3180.44,,,3180.44,Other,100% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,4452.61,,,4452.61,Other,140% New York Medicaid APG,7155.98,,,7155.98,Other,225% New York Medicaid APG,8269.14,,,8269.14,Other,260% New York Medicaid APG,10304.62,,,10304.62,Other,324% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,6837.94,,,6837.94,Other,215% New York Medicaid APG,3975.55,,,3975.55,Other,125% New York Medicaid APG,3180.44,258180.29,
Rmvl cardiac modulj pls gen,0412T,HCPCS,,,,,,,,both,,,82599.65,7467.78,,,7467.78,Other,150% of Medicare + 9.63% HCRA Surcharge,4541.2,,,4541.2,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,41299.83,50,,41299.83,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5062.88,,,5062.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,57819.76,70,,57819.76,percent of total billed charges,,41299.83,50,,41299.83,percent of total billed charges,,41299.83,50,,41299.83,percent of total billed charges,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2721.98,,,2721.98,Other,New York Medicaid APG methodology,2721.98,,,2721.98,Other,100% New York Medicaid APG,2721.98,,,2721.98,Other,100% New York Medicaid APG,2721.98,,,2721.98,Other,100% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,3810.77,,,3810.77,Other,140% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,7077.15,,,7077.15,Other,260% New York Medicaid APG,8819.22,,,8819.22,Other,324% New York Medicaid APG,5852.26,,,5852.26,Other,215% New York Medicaid APG,5852.26,,,5852.26,Other,215% New York Medicaid APG,3402.48,,,3402.48,Other,125% New York Medicaid APG,2721.98,57819.76,
Rmvl car modulj tranvns elt,0413T,HCPCS,,,,,,,,both,,,82599.65,7467.78,,,7467.78,Other,150% of Medicare + 9.63% HCRA Surcharge,4541.2,,,4541.2,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,41299.83,50,,41299.83,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5826.77,,,5826.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,57819.76,70,,57819.76,percent of total billed charges,,41299.83,50,,41299.83,percent of total billed charges,,41299.83,50,,41299.83,percent of total billed charges,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3132.67,,,3132.67,Other,New York Medicaid APG methodology,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,4385.74,,,4385.74,Other,140% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,8144.95,,,8144.95,Other,260% New York Medicaid APG,10149.86,,,10149.86,Other,324% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,3915.84,,,3915.84,Other,125% New York Medicaid APG,3132.67,57819.76,
Rmvl pg compnt wcs,0518T,HCPCS,,,,,,,,both,,,82599.65,7467.78,,,7467.78,Other,150% of Medicare + 9.63% HCRA Surcharge,4541.2,,,4541.2,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,41299.83,50,,41299.83,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5062.88,,,5062.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,57819.76,70,,57819.76,percent of total billed charges,,41299.83,50,,41299.83,percent of total billed charges,,41299.83,50,,41299.83,percent of total billed charges,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2721.98,,,2721.98,Other,New York Medicaid APG methodology,2721.98,,,2721.98,Other,100% New York Medicaid APG,2721.98,,,2721.98,Other,100% New York Medicaid APG,2721.98,,,2721.98,Other,100% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,3810.77,,,3810.77,Other,140% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,7077.15,,,7077.15,Other,260% New York Medicaid APG,8819.22,,,8819.22,Other,324% New York Medicaid APG,5852.26,,,5852.26,Other,215% New York Medicaid APG,5852.26,,,5852.26,Other,215% New York Medicaid APG,3402.48,,,3402.48,Other,125% New York Medicaid APG,2721.98,57819.76,
Rmvl & rplcmt pg compnt wcs,0519T,HCPCS,,,,,,,,both,,,224603.78,20306.29,,,20306.29,Other,150% of Medicare + 9.63% HCRA Surcharge,12348.38,,,12348.38,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,112301.89,50,,112301.89,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,13784.15,,,13784.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,157222.65,70,,157222.65,percent of total billed charges,,112301.89,50,,112301.89,percent of total billed charges,,112301.89,50,,112301.89,percent of total billed charges,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,7410.83,,,7410.83,Other,New York Medicaid APG methodology,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,10375.17,,,10375.17,Other,140% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,19268.17,,,19268.17,Other,260% New York Medicaid APG,24011.11,,,24011.11,Other,324% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,9263.54,,,9263.54,Other,125% New York Medicaid APG,5524,157222.65,
Removal complete iims,0530T,HCPCS,,,,,,,,both,,,82599.65,7467.78,,,7467.78,Other,150% of Medicare + 9.63% HCRA Surcharge,4541.2,,,4541.2,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,41299.83,50,,41299.83,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5062.88,,,5062.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,57819.76,70,,57819.76,percent of total billed charges,,41299.83,50,,41299.83,percent of total billed charges,,41299.83,50,,41299.83,percent of total billed charges,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2721.98,,,2721.98,Other,New York Medicaid APG methodology,2721.98,,,2721.98,Other,100% New York Medicaid APG,2721.98,,,2721.98,Other,100% New York Medicaid APG,2721.98,,,2721.98,Other,100% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,3810.77,,,3810.77,Other,140% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,7077.15,,,7077.15,Other,260% New York Medicaid APG,8819.22,,,8819.22,Other,324% New York Medicaid APG,5852.26,,,5852.26,Other,215% New York Medicaid APG,5852.26,,,5852.26,Other,215% New York Medicaid APG,3402.48,,,3402.48,Other,125% New York Medicaid APG,2721.98,57819.76,
Removal iims electrode only,0531T,HCPCS,,,,,,,,both,,,82599.65,7467.78,,,7467.78,Other,150% of Medicare + 9.63% HCRA Surcharge,4541.2,,,4541.2,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,41299.83,50,,41299.83,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5826.77,,,5826.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,57819.76,70,,57819.76,percent of total billed charges,,41299.83,50,,41299.83,percent of total billed charges,,41299.83,50,,41299.83,percent of total billed charges,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,3132.67,,,3132.67,Other,New York Medicaid APG methodology,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,4385.74,,,4385.74,Other,140% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,8144.95,,,8144.95,Other,260% New York Medicaid APG,10149.86,,,10149.86,Other,324% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,3915.84,,,3915.84,Other,125% New York Medicaid APG,3132.67,57819.76,
Removal iims implt mntr only,0532T,HCPCS,,,,,,,,both,,,82599.65,7467.78,,,7467.78,Other,150% of Medicare + 9.63% HCRA Surcharge,4541.2,,,4541.2,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,41299.83,50,,41299.83,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5062.88,,,5062.88,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,57819.76,70,,57819.76,percent of total billed charges,,41299.83,50,,41299.83,percent of total billed charges,,41299.83,50,,41299.83,percent of total billed charges,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,2721.98,,,2721.98,Other,New York Medicaid APG methodology,2721.98,,,2721.98,Other,100% New York Medicaid APG,2721.98,,,2721.98,Other,100% New York Medicaid APG,2721.98,,,2721.98,Other,100% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,3810.77,,,3810.77,Other,140% New York Medicaid APG,6124.46,,,6124.46,Other,225% New York Medicaid APG,7077.15,,,7077.15,Other,260% New York Medicaid APG,8819.22,,,8819.22,Other,324% New York Medicaid APG,5852.26,,,5852.26,Other,215% New York Medicaid APG,5852.26,,,5852.26,Other,215% New York Medicaid APG,3402.48,,,3402.48,Other,125% New York Medicaid APG,2721.98,57819.76,
Insj/rplc car modulj atr elt,0410T,HCPCS,,,,,,,,both,,,178695.84,16155.78,,,16155.78,Other,150% of Medicare + 9.63% HCRA Surcharge,9824.43,,,9824.43,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,89347.92,50,,89347.92,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5826.77,,,5826.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,125087.09,70,,125087.09,percent of total billed charges,,89347.92,50,,89347.92,percent of total billed charges,,89347.92,50,,89347.92,percent of total billed charges,,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3132.67,,,3132.67,Other,New York Medicaid APG methodology,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,4385.74,,,4385.74,Other,140% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,8144.95,,,8144.95,Other,260% New York Medicaid APG,10149.86,,,10149.86,Other,324% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,3915.84,,,3915.84,Other,125% New York Medicaid APG,3132.67,125087.09,
Insj/rplc car modulj vnt elt,0411T,HCPCS,,,,,,,,both,,,178695.84,16155.78,,,16155.78,Other,150% of Medicare + 9.63% HCRA Surcharge,9824.43,,,9824.43,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,89347.92,50,,89347.92,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5826.77,,,5826.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,125087.09,70,,125087.09,percent of total billed charges,,89347.92,50,,89347.92,percent of total billed charges,,89347.92,50,,89347.92,percent of total billed charges,,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3132.67,,,3132.67,Other,New York Medicaid APG methodology,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,4385.74,,,4385.74,Other,140% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,8144.95,,,8144.95,Other,260% New York Medicaid APG,10149.86,,,10149.86,Other,324% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,3915.84,,,3915.84,Other,125% New York Medicaid APG,3132.67,125087.09,
Insj wcs lv eltrd only,0516T,HCPCS,,,,,,,,both,,,224603.78,20306.29,,,20306.29,Other,150% of Medicare + 9.63% HCRA Surcharge,12348.38,,,12348.38,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,112301.89,50,,112301.89,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5826.77,,,5826.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,157222.65,70,,157222.65,percent of total billed charges,,112301.89,50,,112301.89,percent of total billed charges,,112301.89,50,,112301.89,percent of total billed charges,,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3132.67,,,3132.67,Other,New York Medicaid APG methodology,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,4385.74,,,4385.74,Other,140% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,8144.95,,,8144.95,Other,260% New York Medicaid APG,10149.86,,,10149.86,Other,324% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,3915.84,,,3915.84,Other,125% New York Medicaid APG,3132.67,157222.65,
Insj wcs lv pg compnt,0517T,HCPCS,,,,,,,,both,,,224603.78,20306.29,,,20306.29,Other,150% of Medicare + 9.63% HCRA Surcharge,12348.38,,,12348.38,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,112301.89,50,,112301.89,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,13784.15,,,13784.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,157222.65,70,,157222.65,percent of total billed charges,,112301.89,50,,112301.89,percent of total billed charges,,112301.89,50,,112301.89,percent of total billed charges,,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,7410.83,,,7410.83,Other,New York Medicaid APG methodology,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,10375.17,,,10375.17,Other,140% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,19268.17,,,19268.17,Other,260% New York Medicaid APG,24011.11,,,24011.11,Other,324% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,9263.54,,,9263.54,Other,125% New York Medicaid APG,5524,157222.65,
Insj/rplcmt iims eltrd only,0526T,HCPCS,,,,,,,,both,,,178695.84,16155.78,,,16155.78,Other,150% of Medicare + 9.63% HCRA Surcharge,9824.43,,,9824.43,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,89347.92,50,,89347.92,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5826.77,,,5826.77,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,125087.09,70,,125087.09,percent of total billed charges,,89347.92,50,,89347.92,percent of total billed charges,,89347.92,50,,89347.92,percent of total billed charges,,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,3132.67,,,3132.67,Other,New York Medicaid APG methodology,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,3132.67,,,3132.67,Other,100% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,4385.74,,,4385.74,Other,140% New York Medicaid APG,7048.51,,,7048.51,Other,225% New York Medicaid APG,8144.95,,,8144.95,Other,260% New York Medicaid APG,10149.86,,,10149.86,Other,324% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,6735.24,,,6735.24,Other,215% New York Medicaid APG,3915.84,,,3915.84,Other,125% New York Medicaid APG,3132.67,125087.09,
Insj/rplcmt iims implt mntr,0527T,HCPCS,,,,,,,,both,,,178695.84,16155.78,,,16155.78,Other,150% of Medicare + 9.63% HCRA Surcharge,9824.43,,,9824.43,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,89347.92,50,,89347.92,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,13784.15,,,13784.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,125087.09,70,,125087.09,percent of total billed charges,,89347.92,50,,89347.92,percent of total billed charges,,89347.92,50,,89347.92,percent of total billed charges,,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,7410.83,,,7410.83,Other,New York Medicaid APG methodology,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,10375.17,,,10375.17,Other,140% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,19268.17,,,19268.17,Other,260% New York Medicaid APG,24011.11,,,24011.11,Other,324% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,9263.54,,,9263.54,Other,125% New York Medicaid APG,5524,125087.09,
Insj/rplcmt compl iims,0525T,HCPCS,,,,,,,,both,,,224603.78,20306.29,,,20306.29,Other,150% of Medicare + 9.63% HCRA Surcharge,12348.38,,,12348.38,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,112301.89,50,,112301.89,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,13784.15,,,13784.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,157222.65,70,,157222.65,percent of total billed charges,,112301.89,50,,112301.89,percent of total billed charges,,112301.89,50,,112301.89,percent of total billed charges,,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,11524,,"100% primary, 50% secondary, 25% tertiary procedure",11524,Other,United Healthcare ASC Grouper,12804,,"100% primary, 50% secondary, 25% tertiary procedure",12804,Other,United Healthcare ASC Grouper,10883,,"100% primary, 50% secondary, 25% tertiary procedure",10883,Other,United Healthcare ASC Grouper,7410.83,,,7410.83,Other,New York Medicaid APG methodology,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,10375.17,,,10375.17,Other,140% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,19268.17,,,19268.17,Other,260% New York Medicaid APG,24011.11,,,24011.11,Other,324% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,9263.54,,,9263.54,Other,125% New York Medicaid APG,5524,157222.65,
Insj/rplc cardiac modulj sys,0408T,HCPCS,,,,,,,,both,,,691990.86,62562.47,,,62562.47,Other,150% of Medicare + 9.63% HCRA Surcharge,38044.62,,,38044.62,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,345995.43,50,,345995.43,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,13784.15,,,13784.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,484393.6,70,,484393.6,percent of total billed charges,,345995.43,50,,345995.43,percent of total billed charges,,345995.43,50,,345995.43,percent of total billed charges,,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,19221,,"100% primary, 50% secondary, 25% tertiary procedure",19221,Other,United Healthcare ASC Grouper,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,18154,,"100% primary, 50% secondary, 25% tertiary procedure",18154,Other,United Healthcare ASC Grouper,7410.83,,,7410.83,Other,New York Medicaid APG methodology,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,10375.17,,,10375.17,Other,140% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,19268.17,,,19268.17,Other,260% New York Medicaid APG,24011.11,,,24011.11,Other,324% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,9263.54,,,9263.54,Other,125% New York Medicaid APG,5524,484393.6,
Insj/rplc car modulj pls gn,0409T,HCPCS,,,,,,,,both,,,495795.01,44824.52,,,44824.52,Other,150% of Medicare + 9.63% HCRA Surcharge,27258.06,,,27258.06,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,247897.51,50,,247897.51,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,32450.33,,,32450.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,347056.51,70,,347056.51,percent of total billed charges,,247897.51,50,,247897.51,percent of total billed charges,,247897.51,50,,247897.51,percent of total billed charges,,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,19221,,"100% primary, 50% secondary, 25% tertiary procedure",19221,Other,United Healthcare ASC Grouper,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,18154,,"100% primary, 50% secondary, 25% tertiary procedure",18154,Other,United Healthcare ASC Grouper,17446.41,,,17446.41,Other,New York Medicaid APG methodology,17446.41,,,17446.41,Other,100% New York Medicaid APG,17446.41,,,17446.41,Other,100% New York Medicaid APG,17446.41,,,17446.41,Other,100% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,24424.98,,,24424.98,Other,140% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,45360.68,,,45360.68,Other,260% New York Medicaid APG,56526.38,,,56526.38,Other,324% New York Medicaid APG,37509.79,,,37509.79,Other,215% New York Medicaid APG,37509.79,,,37509.79,Other,215% New York Medicaid APG,21808.02,,,21808.02,Other,125% New York Medicaid APG,5524,347056.51,
Rmvl & rpl car modulj pls gn,0414T,HCPCS,,,,,,,,both,,,495795.01,44824.52,,,44824.52,Other,150% of Medicare + 9.63% HCRA Surcharge,27258.06,,,27258.06,Other,Medicare OPPS methodology,14304,,"100% primary, 50% supplemental procedure",14304,Other,Aetna ASC Grouper,12874,,"100% primary, 50% supplemental procedure",12874,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,247897.51,50,,247897.51,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,32450.33,,,32450.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,347056.51,70,,347056.51,percent of total billed charges,,247897.51,50,,247897.51,percent of total billed charges,,247897.51,50,,247897.51,percent of total billed charges,,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,19221,,"100% primary, 50% secondary, 25% tertiary procedure",19221,Other,United Healthcare ASC Grouper,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,18154,,"100% primary, 50% secondary, 25% tertiary procedure",18154,Other,United Healthcare ASC Grouper,17446.41,,,17446.41,Other,New York Medicaid APG methodology,17446.41,,,17446.41,Other,100% New York Medicaid APG,17446.41,,,17446.41,Other,100% New York Medicaid APG,17446.41,,,17446.41,Other,100% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,24424.98,,,24424.98,Other,140% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,45360.68,,,45360.68,Other,260% New York Medicaid APG,56526.38,,,56526.38,Other,324% New York Medicaid APG,37509.79,,,37509.79,Other,215% New York Medicaid APG,37509.79,,,37509.79,Other,215% New York Medicaid APG,21808.02,,,21808.02,Other,125% New York Medicaid APG,5524,347056.51,
Insj wcs lv compl sys,0515T,HCPCS,,,,,,,,both,,,495795.01,44824.52,,,44824.52,Other,150% of Medicare + 9.63% HCRA Surcharge,27258.06,,,27258.06,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,247897.51,50,,247897.51,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,13784.15,,,13784.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,347056.51,70,,347056.51,percent of total billed charges,,247897.51,50,,247897.51,percent of total billed charges,,247897.51,50,,247897.51,percent of total billed charges,,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,19221,,"100% primary, 50% secondary, 25% tertiary procedure",19221,Other,United Healthcare ASC Grouper,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,18154,,"100% primary, 50% secondary, 25% tertiary procedure",18154,Other,United Healthcare ASC Grouper,7410.83,,,7410.83,Other,New York Medicaid APG methodology,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,7410.83,,,7410.83,Other,100% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,10375.17,,,10375.17,Other,140% New York Medicaid APG,16674.38,,,16674.38,Other,225% New York Medicaid APG,19268.17,,,19268.17,Other,260% New York Medicaid APG,24011.11,,,24011.11,Other,324% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,15933.3,,,15933.3,Other,215% New York Medicaid APG,9263.54,,,9263.54,Other,125% New York Medicaid APG,5524,347056.51,
Rmvl&rplcmt pg wcs new eltrd,0520T,HCPCS,,,,,,,,both,,,224603.78,20306.29,,,20306.29,Other,150% of Medicare + 9.63% HCRA Surcharge,12348.38,,,12348.38,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,112301.89,50,,112301.89,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,32450.33,,,32450.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,157222.65,70,,157222.65,percent of total billed charges,,112301.89,50,,112301.89,percent of total billed charges,,112301.89,50,,112301.89,percent of total billed charges,,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,19221,,"100% primary, 50% secondary, 25% tertiary procedure",19221,Other,United Healthcare ASC Grouper,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,18154,,"100% primary, 50% secondary, 25% tertiary procedure",18154,Other,United Healthcare ASC Grouper,17446.41,,,17446.41,Other,New York Medicaid APG methodology,17446.41,,,17446.41,Other,100% New York Medicaid APG,17446.41,,,17446.41,Other,100% New York Medicaid APG,17446.41,,,17446.41,Other,100% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,24424.98,,,24424.98,Other,140% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,45360.68,,,45360.68,Other,260% New York Medicaid APG,56526.38,,,56526.38,Other,324% New York Medicaid APG,37509.79,,,37509.79,Other,215% New York Medicaid APG,37509.79,,,37509.79,Other,215% New York Medicaid APG,21808.02,,,21808.02,Other,125% New York Medicaid APG,5524,157222.65,
Rmvl&rplcmt ss impl dfb pg,0614T,HCPCS,,,,,,,,both,,,495795.01,44824.52,,,44824.52,Other,150% of Medicare + 9.63% HCRA Surcharge,27258.06,,,27258.06,Other,Medicare OPPS methodology,10768,,"100% primary, 50% supplemental procedure",10768,Other,Aetna ASC Grouper,9691,,"100% primary, 50% supplemental procedure",9691,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,247897.51,50,,247897.51,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,32450.33,,,32450.33,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,347056.51,70,,347056.51,percent of total billed charges,,247897.51,50,,247897.51,percent of total billed charges,,247897.51,50,,247897.51,percent of total billed charges,,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,19221,,"100% primary, 50% secondary, 25% tertiary procedure",19221,Other,United Healthcare ASC Grouper,21357,,"100% primary, 50% secondary, 25% tertiary procedure",21357,Other,United Healthcare ASC Grouper,18154,,"100% primary, 50% secondary, 25% tertiary procedure",18154,Other,United Healthcare ASC Grouper,17446.41,,,17446.41,Other,New York Medicaid APG methodology,17446.41,,,17446.41,Other,100% New York Medicaid APG,17446.41,,,17446.41,Other,100% New York Medicaid APG,17446.41,,,17446.41,Other,100% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,24424.98,,,24424.98,Other,140% New York Medicaid APG,39254.43,,,39254.43,Other,225% New York Medicaid APG,45360.68,,,45360.68,Other,260% New York Medicaid APG,56526.38,,,56526.38,Other,324% New York Medicaid APG,37509.79,,,37509.79,Other,215% New York Medicaid APG,37509.79,,,37509.79,Other,215% New York Medicaid APG,21808.02,,,21808.02,Other,125% New York Medicaid APG,5524,347056.51,
Im b1 mrw cel ther cmpl,0263T,HCPCS,,,,,,,,both,,,97340.17,8800.46,,,8800.46,Other,150% of Medicare + 9.63% HCRA Surcharge,5351.62,,,5351.62,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,48670.09,50,,48670.09,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4580.06,,,4580.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,68138.12,70,,68138.12,percent of total billed charges,,48670.09,50,,48670.09,percent of total billed charges,,48670.09,50,,48670.09,percent of total billed charges,,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2462.4,,,2462.4,Other,New York Medicaid APG methodology,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,3447.35,,,3447.35,Other,140% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,6402.23,,,6402.23,Other,260% New York Medicaid APG,7978.16,,,7978.16,Other,324% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,3077.99,,,3077.99,Other,125% New York Medicaid APG,2462.4,68138.12,
Im b1 mrw cel ther xcl hrvst,0264T,HCPCS,,,,,,,,both,,,97340.17,8800.46,,,8800.46,Other,150% of Medicare + 9.63% HCRA Surcharge,5351.62,,,5351.62,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,48670.09,50,,48670.09,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4580.06,,,4580.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,68138.12,70,,68138.12,percent of total billed charges,,48670.09,50,,48670.09,percent of total billed charges,,48670.09,50,,48670.09,percent of total billed charges,,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2462.4,,,2462.4,Other,New York Medicaid APG methodology,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,3447.35,,,3447.35,Other,140% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,6402.23,,,6402.23,Other,260% New York Medicaid APG,7978.16,,,7978.16,Other,324% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,3077.99,,,3077.99,Other,125% New York Medicaid APG,2462.4,68138.12,
Im b1 mrw cel ther hrvst onl,0265T,HCPCS,,,,,,,,both,,,97340.17,8800.46,,,8800.46,Other,150% of Medicare + 9.63% HCRA Surcharge,5351.62,,,5351.62,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,48670.09,50,,48670.09,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4580.06,,,4580.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,68138.12,70,,68138.12,percent of total billed charges,,48670.09,50,,48670.09,percent of total billed charges,,48670.09,50,,48670.09,percent of total billed charges,,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2462.4,,,2462.4,Other,New York Medicaid APG methodology,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,3447.35,,,3447.35,Other,140% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,6402.23,,,6402.23,Other,260% New York Medicaid APG,7978.16,,,7978.16,Other,324% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,3077.99,,,3077.99,Other,125% New York Medicaid APG,2462.4,68138.12,
Thxp apheresis w/hdl delip,0342T,HCPCS,,,,,,,,both,,,97340.17,8800.46,,,8800.46,Other,150% of Medicare + 9.63% HCRA Surcharge,5351.62,,,5351.62,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,48670.09,50,,48670.09,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4580.06,,,4580.06,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,68138.12,70,,68138.12,percent of total billed charges,,48670.09,50,,48670.09,percent of total billed charges,,48670.09,50,,48670.09,percent of total billed charges,,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2462.4,,,2462.4,Other,New York Medicaid APG methodology,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,2462.4,,,2462.4,Other,100% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,3447.35,,,3447.35,Other,140% New York Medicaid APG,5540.39,,,5540.39,Other,225% New York Medicaid APG,6402.23,,,6402.23,Other,260% New York Medicaid APG,7978.16,,,7978.16,Other,324% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,5294.15,,,5294.15,Other,215% New York Medicaid APG,3077.99,,,3077.99,Other,125% New York Medicaid APG,2462.4,68138.12,
Egd flx transnasal dx br/wa,0652T,HCPCS,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,28016.37,70,,28016.37,percent of total billed charges,,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,20011.7,50,,20011.7,percent of total billed charges,,20011.7,50,,20011.7,percent of total billed charges,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,28016.37,
Egd flx transnasal bx 1/ml,0653T,HCPCS,,,,,,,,both,,,40023.39,3618.49,,,3618.49,Other,150% of Medicare + 9.63% HCRA Surcharge,2200.43,,,2200.43,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,20011.7,50,,20011.7,percent of total billed charges,,28016.37,70,,28016.37,percent of total billed charges,,6152,,,6152,Case Rate,,0.02,,,0.02,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28016.37,70,,28016.37,percent of total billed charges,,20011.7,50,,20011.7,percent of total billed charges,,20011.7,50,,20011.7,percent of total billed charges,,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3873,,"100% primary, 50% secondary, 25% tertiary procedure",3873,Other,United Healthcare ASC Grouper,4304,,"100% primary, 50% secondary, 25% tertiary procedure",4304,Other,United Healthcare ASC Grouper,3658,,"100% primary, 50% secondary, 25% tertiary procedure",3658,Other,United Healthcare ASC Grouper,0.01,,,0.01,Other,New York Medicaid APG methodology,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.01,,,0.01,Other,100% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.01,,,0.01,Other,140% New York Medicaid APG,0.02,,,0.02,Other,225% New York Medicaid APG,0.03,,,0.03,Other,260% New York Medicaid APG,0.03,,,0.03,Other,324% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.02,,,0.02,Other,215% New York Medicaid APG,0.01,,,0.01,Other,125% New York Medicaid APG,0.01,28016.37,
Place endorectal app,C9725,HCPCS,,,,,,,,both,,,19223.92,1738.02,,,1738.02,Other,150% of Medicare + 9.63% HCRA Surcharge,1056.9,,,1056.9,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9611.96,50,,9611.96,percent of total billed charges,,13456.74,70,,13456.74,percent of total billed charges,,6152,,,6152,Case Rate,,2542.82,,,2542.82,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13456.74,70,,13456.74,percent of total billed charges,,9611.96,50,,9611.96,percent of total billed charges,,9611.96,50,,9611.96,percent of total billed charges,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1367.11,,,1367.11,Other,New York Medicaid APG methodology,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,1367.11,,,1367.11,Other,100% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,1913.95,,,1913.95,Other,140% New York Medicaid APG,3075.99,,,3075.99,Other,225% New York Medicaid APG,3554.48,,,3554.48,Other,260% New York Medicaid APG,4429.43,,,4429.43,Other,324% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,2939.28,,,2939.28,Other,215% New York Medicaid APG,1708.88,,,1708.88,Other,125% New York Medicaid APG,1056.9,13456.74,
Ca screen;flexi sigmoidscope,G0104,HCPCS,,,,,,,,both,,,19223.92,1738.02,,,1738.02,Other,150% of Medicare + 9.63% HCRA Surcharge,1056.9,,,1056.9,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9611.96,50,,9611.96,percent of total billed charges,,13456.74,70,,13456.74,percent of total billed charges,,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13456.74,70,,13456.74,percent of total billed charges,,1.65,,,1.65,Fee Schedule,,272.25,,,272.25,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,1.65,13456.74,
Colorectal scrn; hi risk ind,G0105,HCPCS,,,,,,,,both,,,18767.42,1738.02,,,1738.02,Other,150% of Medicare + 9.63% HCRA Surcharge,1056.9,,,1056.9,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9383.71,50,,9383.71,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13137.19,70,,13137.19,percent of total billed charges,,5.42,,,5.42,Fee Schedule,,894.3,,,894.3,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,5.42,13137.19,
Colon ca scrn not hi rsk ind,G0121,HCPCS,,,,,,,,both,,,17927.96,1738.02,,,1738.02,Other,150% of Medicare + 9.63% HCRA Surcharge,1056.9,,,1056.9,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,8963.98,50,,8963.98,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1867.55,,,1867.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,12549.57,70,,12549.57,percent of total billed charges,,5.43,,,5.43,Fee Schedule,,895.95,,,895.95,Fee Schedule,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,1004.06,,,1004.06,Other,New York Medicaid APG methodology,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,1004.06,,,1004.06,Other,100% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,1405.69,,,1405.69,Other,140% New York Medicaid APG,2259.14,,,2259.14,Other,225% New York Medicaid APG,2610.56,,,2610.56,Other,260% New York Medicaid APG,3253.16,,,3253.16,Other,324% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,2158.73,,,2158.73,Other,215% New York Medicaid APG,1255.08,,,1255.08,Other,125% New York Medicaid APG,5.43,12549.57,
Exc rectal tumor endoscopic,0184T,HCPCS,,,,,,,,both,,,119876.35,10837.95,,,10837.95,Other,150% of Medicare + 9.63% HCRA Surcharge,6590.62,,,6590.62,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,59938.18,50,,59938.18,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3491.2,,,3491.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,83913.45,70,,83913.45,percent of total billed charges,,59938.18,50,,59938.18,percent of total billed charges,,59938.18,50,,59938.18,percent of total billed charges,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1876.99,,,1876.99,Other,New York Medicaid APG methodology,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,1876.99,,,1876.99,Other,100% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,2627.79,,,2627.79,Other,140% New York Medicaid APG,4223.23,,,4223.23,Other,225% New York Medicaid APG,4880.18,,,4880.18,Other,260% New York Medicaid APG,6081.45,,,6081.45,Other,324% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,4035.53,,,4035.53,Other,215% New York Medicaid APG,2346.24,,,2346.24,Other,125% New York Medicaid APG,1876.99,83913.45,
Ire abltj 1+tum organ perq,0600T,HCPCS,,,,,,,,both,,,216515.17,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,108257.59,50,,108257.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3304.99,,,3304.99,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,151560.62,70,,151560.62,percent of total billed charges,,108257.59,50,,108257.59,percent of total billed charges,,108257.59,50,,108257.59,percent of total billed charges,,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,1776.88,,,1776.88,Other,New York Medicaid APG methodology,1776.88,,,1776.88,Other,100% New York Medicaid APG,1776.88,,,1776.88,Other,100% New York Medicaid APG,1776.88,,,1776.88,Other,100% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,2487.63,,,2487.63,Other,140% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,4619.88,,,4619.88,Other,260% New York Medicaid APG,5757.08,,,5757.08,Other,324% New York Medicaid APG,3820.28,,,3820.28,Other,215% New York Medicaid APG,3820.28,,,3820.28,Other,215% New York Medicaid APG,2221.1,,,2221.1,Other,125% New York Medicaid APG,1776.88,151560.62,
Ire abltj 1+tumors open,0601T,HCPCS,,,,,,,,both,,,216515.17,19575,,,19575,Other,150% of Medicare + 9.63% HCRA Surcharge,11903.68,,,11903.68,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,13019,,"100% primary, 50% secondary, 25% supplemental procedure",13019,Other,Blue Cross ASC Grouper,11717,,"100% primary, 50% secondary, 25% supplemental procedure",11717,Other,Blue Cross ASC Grouper,11066,,"100% primary, 50% secondary, 25% supplemental procedure",11066,Other,Blue Cross ASC Grouper,108257.59,50,,108257.59,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3304.99,,,3304.99,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,151560.62,70,,151560.62,percent of total billed charges,,108257.59,50,,108257.59,percent of total billed charges,,108257.59,50,,108257.59,percent of total billed charges,,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,1776.88,,,1776.88,Other,New York Medicaid APG methodology,1776.88,,,1776.88,Other,100% New York Medicaid APG,1776.88,,,1776.88,Other,100% New York Medicaid APG,1776.88,,,1776.88,Other,100% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,2487.63,,,2487.63,Other,140% New York Medicaid APG,3997.97,,,3997.97,Other,225% New York Medicaid APG,4619.88,,,4619.88,Other,260% New York Medicaid APG,5757.08,,,5757.08,Other,324% New York Medicaid APG,3820.28,,,3820.28,Other,215% New York Medicaid APG,3820.28,,,3820.28,Other,215% New York Medicaid APG,2221.1,,,2221.1,Other,125% New York Medicaid APG,1776.88,151560.62,
Temp fml iu vlv-pmp 1st insj,0596T,HCPCS,,,,,,,,both,,,14368.32,1299.03,,,1299.03,Other,150% of Medicare + 9.63% HCRA Surcharge,789.95,,,789.95,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7184.16,50,,7184.16,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1123.05,,,1123.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10057.82,70,,10057.82,percent of total billed charges,,7184.16,50,,7184.16,percent of total billed charges,,7184.16,50,,7184.16,percent of total billed charges,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,603.79,,,603.79,Other,New York Medicaid APG methodology,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,845.31,,,845.31,Other,140% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1569.85,,,1569.85,Other,260% New York Medicaid APG,1956.28,,,1956.28,Other,324% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,754.74,,,754.74,Other,125% New York Medicaid APG,603.79,10057.82,
Temp fml iu valve-pmp rplcmt,0597T,HCPCS,,,,,,,,both,,,14368.32,1299.03,,,1299.03,Other,150% of Medicare + 9.63% HCRA Surcharge,789.95,,,789.95,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,7184.16,50,,7184.16,percent of total billed charges,,5413,,"100% primary, 50% supplemental procedure",5413,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1123.05,,,1123.05,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,10057.82,70,,10057.82,percent of total billed charges,,7184.16,50,,7184.16,percent of total billed charges,,7184.16,50,,7184.16,percent of total billed charges,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,603.79,,,603.79,Other,New York Medicaid APG methodology,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,603.79,,,603.79,Other,100% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,845.31,,,845.31,Other,140% New York Medicaid APG,1358.53,,,1358.53,Other,225% New York Medicaid APG,1569.85,,,1569.85,Other,260% New York Medicaid APG,1956.28,,,1956.28,Other,324% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,1298.15,,,1298.15,Other,215% New York Medicaid APG,754.74,,,754.74,Other,125% New York Medicaid APG,603.79,10057.82,
Cysto w/prst8 commissurotomy,0619T,HCPCS,,,,,,,,both,,,193769.26,17518.56,,,17518.56,Other,150% of Medicare + 9.63% HCRA Surcharge,10653.14,,,10653.14,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,96884.63,50,,96884.63,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5967.34,,,5967.34,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,135638.48,70,,135638.48,percent of total billed charges,,96884.63,50,,96884.63,percent of total billed charges,,96884.63,50,,96884.63,percent of total billed charges,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3208.25,,,3208.25,Other,New York Medicaid APG methodology,3208.25,,,3208.25,Other,100% New York Medicaid APG,3208.25,,,3208.25,Other,100% New York Medicaid APG,3208.25,,,3208.25,Other,100% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,4491.55,,,4491.55,Other,140% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,8341.45,,,8341.45,Other,260% New York Medicaid APG,10394.73,,,10394.73,Other,324% New York Medicaid APG,6897.73,,,6897.73,Other,215% New York Medicaid APG,6897.73,,,6897.73,Other,215% New York Medicaid APG,4010.31,,,4010.31,Other,125% New York Medicaid APG,3208.25,135638.48,
Cystoscopy prostatic imp 1-3,C9739,HCPCS,,,,,,,,both,,,52017.94,9839.79,,,9839.79,Other,150% of Medicare + 9.63% HCRA Surcharge,5983.64,,,5983.64,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,26008.97,50,,26008.97,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5967.34,,,5967.34,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,36412.56,70,,36412.56,percent of total billed charges,,26008.97,50,,26008.97,percent of total billed charges,,26008.97,50,,26008.97,percent of total billed charges,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3208.25,,,3208.25,Other,New York Medicaid APG methodology,3208.25,,,3208.25,Other,100% New York Medicaid APG,3208.25,,,3208.25,Other,100% New York Medicaid APG,3208.25,,,3208.25,Other,100% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,4491.55,,,4491.55,Other,140% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,8341.45,,,8341.45,Other,260% New York Medicaid APG,10394.73,,,10394.73,Other,324% New York Medicaid APG,6897.73,,,6897.73,Other,215% New York Medicaid APG,6897.73,,,6897.73,Other,215% New York Medicaid APG,4010.31,,,4010.31,Other,125% New York Medicaid APG,3208.25,36412.56,
"Cysto, litho, vacuum kidney",C9761,HCPCS,,,,,,,,both,,,193769.26,17518.56,,,17518.56,Other,150% of Medicare + 9.63% HCRA Surcharge,10653.14,,,10653.14,Other,Medicare OPPS methodology,9229,,"100% primary, 50% supplemental procedure",9229,Other,Aetna ASC Grouper,8306,,"100% primary, 50% supplemental procedure",8306,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,96884.63,50,,96884.63,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3301.55,,,3301.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,135638.48,70,,135638.48,percent of total billed charges,,96884.63,50,,96884.63,percent of total billed charges,,96884.63,50,,96884.63,percent of total billed charges,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1775.02,,,1775.02,Other,New York Medicaid APG methodology,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,1775.02,,,1775.02,Other,100% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,2485.03,,,2485.03,Other,140% New York Medicaid APG,3993.81,,,3993.81,Other,225% New York Medicaid APG,4615.06,,,4615.06,Other,260% New York Medicaid APG,5751.08,,,5751.08,Other,324% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,3816.3,,,3816.3,Other,215% New York Medicaid APG,2218.78,,,2218.78,Other,125% New York Medicaid APG,1775.02,135638.48,
Cysto w/temp pros implant,C9769,HCPCS,,,,,,,,both,,,46339.76,17518.56,,,17518.56,Other,150% of Medicare + 9.63% HCRA Surcharge,10653.14,,,10653.14,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,23169.88,50,,23169.88,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5967.34,,,5967.34,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,32437.83,70,,32437.83,percent of total billed charges,,23169.88,50,,23169.88,percent of total billed charges,,23169.88,50,,23169.88,percent of total billed charges,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,3208.25,,,3208.25,Other,New York Medicaid APG methodology,3208.25,,,3208.25,Other,100% New York Medicaid APG,3208.25,,,3208.25,Other,100% New York Medicaid APG,3208.25,,,3208.25,Other,100% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,4491.55,,,4491.55,Other,140% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,8341.45,,,8341.45,Other,260% New York Medicaid APG,10394.73,,,10394.73,Other,324% New York Medicaid APG,6897.73,,,6897.73,Other,215% New York Medicaid APG,6897.73,,,6897.73,Other,215% New York Medicaid APG,4010.31,,,4010.31,Other,125% New York Medicaid APG,3208.25,32437.83,
Waterjet prostate abltj cmpl,0421T,HCPCS,,,,,,,,both,,,193769.26,17518.56,,,17518.56,Other,150% of Medicare + 9.63% HCRA Surcharge,10653.14,,,10653.14,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,96884.63,50,,96884.63,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5967.34,,,5967.34,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,135638.48,70,,135638.48,percent of total billed charges,,96884.63,50,,96884.63,percent of total billed charges,,96884.63,50,,96884.63,percent of total billed charges,,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3208.25,,,3208.25,Other,New York Medicaid APG methodology,3208.25,,,3208.25,Other,100% New York Medicaid APG,3208.25,,,3208.25,Other,100% New York Medicaid APG,3208.25,,,3208.25,Other,100% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,4491.55,,,4491.55,Other,140% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,8341.45,,,8341.45,Other,260% New York Medicaid APG,10394.73,,,10394.73,Other,324% New York Medicaid APG,6897.73,,,6897.73,Other,215% New York Medicaid APG,6897.73,,,6897.73,Other,215% New York Medicaid APG,4010.31,,,4010.31,Other,125% New York Medicaid APG,3208.25,135638.48,
Cysto impl 4 or more,C9740,HCPCS,,,,,,,,both,,,50923.5,17518.56,,,17518.56,Other,150% of Medicare + 9.63% HCRA Surcharge,10653.14,,,10653.14,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,14198,,"100% primary, 50% secondary, 25% supplemental procedure",14198,Other,Blue Cross ASC Grouper,12778,,"100% primary, 50% secondary, 25% supplemental procedure",12778,Other,Blue Cross ASC Grouper,12068,,"100% primary, 50% secondary, 25% supplemental procedure",12068,Other,Blue Cross ASC Grouper,25461.75,50,,25461.75,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,5967.34,,,5967.34,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,35646.45,70,,35646.45,percent of total billed charges,,25461.75,50,,25461.75,percent of total billed charges,,25461.75,50,,25461.75,percent of total billed charges,,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,3208.25,,,3208.25,Other,New York Medicaid APG methodology,3208.25,,,3208.25,Other,100% New York Medicaid APG,3208.25,,,3208.25,Other,100% New York Medicaid APG,3208.25,,,3208.25,Other,100% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,4491.55,,,4491.55,Other,140% New York Medicaid APG,7218.56,,,7218.56,Other,225% New York Medicaid APG,8341.45,,,8341.45,Other,260% New York Medicaid APG,10394.73,,,10394.73,Other,324% New York Medicaid APG,6897.73,,,6897.73,Other,215% New York Medicaid APG,6897.73,,,6897.73,Other,215% New York Medicaid APG,4010.31,,,4010.31,Other,125% New York Medicaid APG,3208.25,35646.45,
Abltj perc uxtr/perph nrv,0440T,HCPCS,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,20305.75,50,,20305.75,percent of total billed charges,,20305.75,50,,20305.75,percent of total billed charges,,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,28428.05,
Abltj perc lxtr/perph nrv,0441T,HCPCS,,,,,,,,both,,,40611.5,3671.66,,,3671.66,Other,150% of Medicare + 9.63% HCRA Surcharge,2232.76,,,2232.76,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,20305.75,50,,20305.75,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,28428.05,70,,28428.05,percent of total billed charges,,20305.75,50,,20305.75,percent of total billed charges,,20305.75,50,,20305.75,percent of total billed charges,,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,28428.05,
Rev/remvl crtd sns dev total,0269T,HCPCS,,,,,,,,both,,,140115.1,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,70057.55,50,,70057.55,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,98080.57,70,,98080.57,percent of total billed charges,,70057.55,50,,70057.55,percent of total billed charges,,70057.55,50,,70057.55,percent of total billed charges,,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,10242,,"100% primary, 50% secondary, 25% tertiary procedure",10242,Other,United Healthcare ASC Grouper,11381,,"100% primary, 50% secondary, 25% tertiary procedure",11381,Other,United Healthcare ASC Grouper,9674,,"100% primary, 50% secondary, 25% tertiary procedure",9674,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,98080.57,
Abltj perc plex/trncl nrv,0442T,HCPCS,,,,,,,,both,,,140115.1,12667.72,,,12667.72,Other,150% of Medicare + 9.63% HCRA Surcharge,7703.32,,,7703.32,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,70057.55,50,,70057.55,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,98080.57,70,,98080.57,percent of total billed charges,,70057.55,50,,70057.55,percent of total billed charges,,70057.55,50,,70057.55,percent of total billed charges,,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,98080.57,
Autol cell implt adps njx,0566T,HCPCS,,,,,,,,both,,,64479.48,0.02,,,0.02,Other,150% of Medicare + 9.63% HCRA Surcharge,0.01,,,0.01,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,32239.74,50,,32239.74,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,841.15,,,841.15,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,45135.64,70,,45135.64,percent of total billed charges,,32239.74,50,,32239.74,percent of total billed charges,,32239.74,50,,32239.74,percent of total billed charges,,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2312,,"100% primary, 50% secondary, 25% tertiary procedure",2312,Other,United Healthcare ASC Grouper,2569,,"100% primary, 50% secondary, 25% tertiary procedure",2569,Other,United Healthcare ASC Grouper,2184,,"100% primary, 50% secondary, 25% tertiary procedure",2184,Other,United Healthcare ASC Grouper,452.23,,,452.23,Other,New York Medicaid APG methodology,452.23,,,452.23,Other,100% New York Medicaid APG,452.23,,,452.23,Other,100% New York Medicaid APG,452.23,,,452.23,Other,100% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,633.12,,,633.12,Other,140% New York Medicaid APG,1017.52,,,1017.52,Other,225% New York Medicaid APG,1175.8,,,1175.8,Other,260% New York Medicaid APG,1465.23,,,1465.23,Other,324% New York Medicaid APG,972.3,,,972.3,Other,215% New York Medicaid APG,972.3,,,972.3,Other,215% New York Medicaid APG,565.29,,,565.29,Other,125% New York Medicaid APG,0.01,45135.64,
Inj for sacroiliac jt anesth,G0260,HCPCS,,,,,,,,both,,,4530.6,1315.08,,,1315.08,Other,150% of Medicare + 9.63% HCRA Surcharge,799.71,,,799.71,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,2265.3,50,,2265.3,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1351.14,,,1351.14,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,3171.42,70,,3171.42,percent of total billed charges,,2265.3,50,,2265.3,percent of total billed charges,,2265.3,50,,2265.3,percent of total billed charges,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,726.42,,,726.42,Other,New York Medicaid APG methodology,726.42,,,726.42,Other,100% New York Medicaid APG,726.42,,,726.42,Other,100% New York Medicaid APG,726.42,,,726.42,Other,100% New York Medicaid APG,1634.45,,,1634.45,Other,225% New York Medicaid APG,1634.45,,,1634.45,Other,225% New York Medicaid APG,1634.45,,,1634.45,Other,225% New York Medicaid APG,1634.45,,,1634.45,Other,225% New York Medicaid APG,1016.99,,,1016.99,Other,140% New York Medicaid APG,1634.45,,,1634.45,Other,225% New York Medicaid APG,1888.69,,,1888.69,Other,260% New York Medicaid APG,2353.6,,,2353.6,Other,324% New York Medicaid APG,1561.8,,,1561.8,Other,215% New York Medicaid APG,1561.8,,,1561.8,Other,215% New York Medicaid APG,908.03,,,908.03,Other,125% New York Medicaid APG,726.42,9473,
Njx paravert w/us cer/thor,0213T,HCPCS,,,,,,,,both,,,3238,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,1619,50,,1619,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,2266.6,70,,2266.6,percent of total billed charges,,1619,50,,1619,percent of total billed charges,,1619,50,,1619,percent of total billed charges,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,751.98,9473,
Njx paravert w/us lumb/sac,0216T,HCPCS,,,,,,,,both,,,19171.82,1733.31,,,1733.31,Other,150% of Medicare + 9.63% HCRA Surcharge,1054.04,,,1054.04,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,4343,,"100% primary, 50% secondary, 25% supplemental procedure",4343,Other,Blue Cross ASC Grouper,3909,,"100% primary, 50% secondary, 25% supplemental procedure",3909,Other,Blue Cross ASC Grouper,3692,,"100% primary, 50% secondary, 25% supplemental procedure",3692,Other,Blue Cross ASC Grouper,9585.91,50,,9585.91,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1398.69,,,1398.69,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,13420.27,70,,13420.27,percent of total billed charges,,9585.91,50,,9585.91,percent of total billed charges,,9585.91,50,,9585.91,percent of total billed charges,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,751.98,,,751.98,Other,New York Medicaid APG methodology,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,751.98,,,751.98,Other,100% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1052.78,,,1052.78,Other,140% New York Medicaid APG,1691.96,,,1691.96,Other,225% New York Medicaid APG,1955.15,,,1955.15,Other,260% New York Medicaid APG,2436.42,,,2436.42,Other,324% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,1616.76,,,1616.76,Other,215% New York Medicaid APG,939.98,,,939.98,Other,125% New York Medicaid APG,751.98,13420.27,
Implt/rpl crtd sns dev lead,0267T,HCPCS,,,,,,,,both,,,71567.87,6470.41,,,6470.41,Other,150% of Medicare + 9.63% HCRA Surcharge,3934.69,,,3934.69,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,35783.94,50,,35783.94,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,7783.74,,,7783.74,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50097.51,70,,50097.51,percent of total billed charges,,35783.94,50,,35783.94,percent of total billed charges,,35783.94,50,,35783.94,percent of total billed charges,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,4184.81,,,4184.81,Other,New York Medicaid APG methodology,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,4184.81,,,4184.81,Other,100% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,5858.73,,,5858.73,Other,140% New York Medicaid APG,9415.82,,,9415.82,Other,225% New York Medicaid APG,10880.5,,,10880.5,Other,260% New York Medicaid APG,13558.78,,,13558.78,Other,324% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,8997.34,,,8997.34,Other,215% New York Medicaid APG,5231.01,,,5231.01,Other,125% New York Medicaid APG,3934.69,50097.51,
Rev/remvl crtd sns dev lead,0270T,HCPCS,,,,,,,,both,,,71567.87,6470.41,,,6470.41,Other,150% of Medicare + 9.63% HCRA Surcharge,3934.69,,,3934.69,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,35783.94,50,,35783.94,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50097.51,70,,50097.51,percent of total billed charges,,35783.94,50,,35783.94,percent of total billed charges,,35783.94,50,,35783.94,percent of total billed charges,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,50097.51,
Rev/remvl crtd sns dev gen,0271T,HCPCS,,,,,,,,both,,,71567.87,6470.41,,,6470.41,Other,150% of Medicare + 9.63% HCRA Surcharge,3934.69,,,3934.69,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11390,,"100% primary, 50% secondary, 25% supplemental procedure",11390,Other,Blue Cross ASC Grouper,10251,,"100% primary, 50% secondary, 25% supplemental procedure",10251,Other,Blue Cross ASC Grouper,9682,,"100% primary, 50% secondary, 25% supplemental procedure",9682,Other,Blue Cross ASC Grouper,35783.94,50,,35783.94,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3049.04,,,3049.04,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50097.51,70,,50097.51,percent of total billed charges,,35783.94,50,,35783.94,percent of total billed charges,,35783.94,50,,35783.94,percent of total billed charges,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,1639.27,,,1639.27,Other,New York Medicaid APG methodology,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,1639.27,,,1639.27,Other,100% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,2294.98,,,2294.98,Other,140% New York Medicaid APG,3688.36,,,3688.36,Other,225% New York Medicaid APG,4262.1,,,4262.1,Other,260% New York Medicaid APG,5311.24,,,5311.24,Other,324% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,3524.43,,,3524.43,Other,215% New York Medicaid APG,2049.09,,,2049.09,Other,125% New York Medicaid APG,1639.27,50097.51,
Revision/removal isdns ptn,0588T,HCPCS,,,,,,,,both,,,71567.87,6470.41,,,6470.41,Other,150% of Medicare + 9.63% HCRA Surcharge,3934.69,,,3934.69,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,35783.94,50,,35783.94,percent of total billed charges,,0.01,,"100% primary, 50% supplemental procedure",0.01,Other,Cigna ASC Grouper Office only procedure,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,50097.51,70,,50097.51,percent of total billed charges,,35783.94,50,,35783.94,percent of total billed charges,,35783.94,50,,35783.94,percent of total billed charges,,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6854,,"100% primary, 50% secondary, 25% tertiary procedure",6854,Other,United Healthcare ASC Grouper,7616,,"100% primary, 50% secondary, 25% tertiary procedure",7616,Other,United Healthcare ASC Grouper,6474,,"100% primary, 50% secondary, 25% tertiary procedure",6474,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,0.01,50097.51,
Perq impltj/rplcmt isdns ptn,0587T,HCPCS,,,,,,,,both,,,143852.77,13005.64,,,13005.64,Other,150% of Medicare + 9.63% HCRA Surcharge,7908.81,,,7908.81,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,71926.39,50,,71926.39,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1204.2,,,1204.2,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,100696.94,70,,100696.94,percent of total billed charges,,71926.39,50,,71926.39,percent of total billed charges,,71926.39,50,,71926.39,percent of total billed charges,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,647.42,,,647.42,Other,New York Medicaid APG methodology,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,647.42,,,647.42,Other,100% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,906.38,,,906.38,Other,140% New York Medicaid APG,1456.69,,,1456.69,Other,225% New York Medicaid APG,1683.28,,,1683.28,Other,260% New York Medicaid APG,2097.63,,,2097.63,Other,324% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,1391.95,,,1391.95,Other,215% New York Medicaid APG,809.27,,,809.27,Other,125% New York Medicaid APG,647.42,100696.94,
Implt/rpl crtd sns dev total,0266T,HCPCS,,,,,,,,both,,,993426.73,89815.1,,,89815.1,Other,150% of Medicare + 9.63% HCRA Surcharge,54617.11,,,54617.11,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,496713.37,50,,496713.37,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,40570.63,,,40570.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,695398.71,70,,695398.71,percent of total billed charges,,496713.37,50,,496713.37,percent of total billed charges,,496713.37,50,,496713.37,percent of total billed charges,,17798,,"100% primary, 50% secondary, 25% tertiary procedure",17798,Other,United Healthcare ASC Grouper,16018,,"100% primary, 50% secondary, 25% tertiary procedure",16018,Other,United Healthcare ASC Grouper,17798,,"100% primary, 50% secondary, 25% tertiary procedure",17798,Other,United Healthcare ASC Grouper,15129,,"100% primary, 50% secondary, 25% tertiary procedure",15129,Other,United Healthcare ASC Grouper,21812.17,,,21812.17,Other,New York Medicaid APG methodology,21812.17,,,21812.17,Other,100% New York Medicaid APG,21812.17,,,21812.17,Other,100% New York Medicaid APG,21812.17,,,21812.17,Other,100% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,30537.04,,,30537.04,Other,140% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,56711.64,,,56711.64,Other,260% New York Medicaid APG,70671.43,,,70671.43,Other,324% New York Medicaid APG,46896.16,,,46896.16,Other,215% New York Medicaid APG,46896.16,,,46896.16,Other,215% New York Medicaid APG,27265.21,,,27265.21,Other,125% New York Medicaid APG,5524,695398.71,
Implt/rpl crtd sns dev gen,0268T,HCPCS,,,,,,,,both,,,653144.11,59050.36,,,59050.36,Other,150% of Medicare + 9.63% HCRA Surcharge,35908.88,,,35908.88,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,326572.06,50,,326572.06,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,40570.63,,,40570.63,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,457200.88,70,,457200.88,percent of total billed charges,,326572.06,50,,326572.06,percent of total billed charges,,326572.06,50,,326572.06,percent of total billed charges,,17798,,"100% primary, 50% secondary, 25% tertiary procedure",17798,Other,United Healthcare ASC Grouper,16018,,"100% primary, 50% secondary, 25% tertiary procedure",16018,Other,United Healthcare ASC Grouper,17798,,"100% primary, 50% secondary, 25% tertiary procedure",17798,Other,United Healthcare ASC Grouper,15129,,"100% primary, 50% secondary, 25% tertiary procedure",15129,Other,United Healthcare ASC Grouper,21812.17,,,21812.17,Other,New York Medicaid APG methodology,21812.17,,,21812.17,Other,100% New York Medicaid APG,21812.17,,,21812.17,Other,100% New York Medicaid APG,21812.17,,,21812.17,Other,100% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,30537.04,,,30537.04,Other,140% New York Medicaid APG,49077.38,,,49077.38,Other,225% New York Medicaid APG,56711.64,,,56711.64,Other,260% New York Medicaid APG,70671.43,,,70671.43,Other,324% New York Medicaid APG,46896.16,,,46896.16,Other,215% New York Medicaid APG,46896.16,,,46896.16,Other,215% New York Medicaid APG,27265.21,,,27265.21,Other,125% New York Medicaid APG,5524,457200.88,
"Dstry eye lesn,fdr vssl tech",G0186,HCPCS,,,,,,,,both,,,12226.3,1105.37,,,1105.37,Other,150% of Medicare + 9.63% HCRA Surcharge,672.18,,,672.18,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,6113.15,50,,6113.15,percent of total billed charges,,4094,,"100% primary, 50% supplemental procedure",4094,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1455.98,,,1455.98,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,8558.41,70,,8558.41,percent of total billed charges,,6113.15,50,,6113.15,percent of total billed charges,,6113.15,50,,6113.15,percent of total billed charges,,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3210,,"100% primary, 50% secondary, 25% tertiary procedure",3210,Other,United Healthcare ASC Grouper,3567,,"100% primary, 50% secondary, 25% tertiary procedure",3567,Other,United Healthcare ASC Grouper,3032,,"100% primary, 50% secondary, 25% tertiary procedure",3032,Other,United Healthcare ASC Grouper,782.79,,,782.79,Other,New York Medicaid APG methodology,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,782.79,,,782.79,Other,100% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,1095.9,,,1095.9,Other,140% New York Medicaid APG,1761.27,,,1761.27,Other,225% New York Medicaid APG,2035.24,,,2035.24,Other,260% New York Medicaid APG,2536.23,,,2536.23,Other,324% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,1682.99,,,1682.99,Other,215% New York Medicaid APG,978.48,,,978.48,Other,125% New York Medicaid APG,672.18,9473,
Insertion of iris prosthesis,0616T,HCPCS,,,,,,,,both,,,364923.31,32992.49,,,32992.49,Other,150% of Medicare + 9.63% HCRA Surcharge,20062.93,,,20062.93,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,182461.66,50,,182461.66,percent of total billed charges,,7841,,"100% primary, 50% supplemental procedure",7841,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,3710.11,,,3710.11,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,255446.32,70,,255446.32,percent of total billed charges,,182461.66,50,,182461.66,percent of total billed charges,,182461.66,50,,182461.66,percent of total billed charges,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,1994.68,,,1994.68,Other,New York Medicaid APG methodology,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,1994.68,,,1994.68,Other,100% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,2792.56,,,2792.56,Other,140% New York Medicaid APG,4488.04,,,4488.04,Other,225% New York Medicaid APG,5186.18,,,5186.18,Other,260% New York Medicaid APG,6462.78,,,6462.78,Other,324% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,4288.57,,,4288.57,Other,215% New York Medicaid APG,2493.36,,,2493.36,Other,125% New York Medicaid APG,1994.68,255446.32,
Insert aqueous drain device,0253T,HCPCS,,,,,,,,both,,,85519.85,7731.8,,,7731.8,Other,150% of Medicare + 9.63% HCRA Surcharge,4701.75,,,4701.75,Other,Medicare OPPS methodology,9074,,"100% primary, 50% supplemental procedure",9074,Other,Aetna ASC Grouper,8167,,"100% primary, 50% supplemental procedure",8167,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,42759.93,50,,42759.93,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6964.29,,,6964.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,59863.9,70,,59863.9,percent of total billed charges,,42759.93,50,,42759.93,percent of total billed charges,,42759.93,50,,42759.93,percent of total billed charges,,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,3744.24,,,3744.24,Other,New York Medicaid APG methodology,3744.24,,,3744.24,Other,100% New York Medicaid APG,3744.24,,,3744.24,Other,100% New York Medicaid APG,3744.24,,,3744.24,Other,100% New York Medicaid APG,8424.55,,,8424.55,Other,225% New York Medicaid APG,8424.55,,,8424.55,Other,225% New York Medicaid APG,8424.55,,,8424.55,Other,225% New York Medicaid APG,8424.55,,,8424.55,Other,225% New York Medicaid APG,5241.94,,,5241.94,Other,140% New York Medicaid APG,8424.55,,,8424.55,Other,225% New York Medicaid APG,9735.03,,,9735.03,Other,260% New York Medicaid APG,12131.35,,,12131.35,Other,324% New York Medicaid APG,8050.12,,,8050.12,Other,215% New York Medicaid APG,8050.12,,,8050.12,Other,215% New York Medicaid APG,4680.3,,,4680.3,Other,125% New York Medicaid APG,3744.24,59863.9,
Insj aqueous drain dev 1st,0449T,HCPCS,,,,,,,,both,,,109933.59,9939.03,,,9939.03,Other,150% of Medicare + 9.63% HCRA Surcharge,6043.98,,,6043.98,Other,Medicare OPPS methodology,6614,,"100% primary, 50% supplemental procedure",6614,Other,Aetna ASC Grouper,5953,,"100% primary, 50% supplemental procedure",5953,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,54966.8,50,,54966.8,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4898.55,,,4898.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,76953.51,70,,76953.51,percent of total billed charges,,54966.8,50,,54966.8,percent of total billed charges,,54966.8,50,,54966.8,percent of total billed charges,,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2633.63,,,2633.63,Other,New York Medicaid APG methodology,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,3687.08,,,3687.08,Other,140% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,6847.44,,,6847.44,Other,260% New York Medicaid APG,8532.97,,,8532.97,Other,324% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,3292.04,,,3292.04,Other,125% New York Medicaid APG,2633.63,76953.51,
Insj iris prosth w/rmvl&insj,0617T,HCPCS,,,,,,,,both,,,364923.31,32992.49,,,32992.49,Other,150% of Medicare + 9.63% HCRA Surcharge,20062.93,,,20062.93,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,182461.66,50,,182461.66,percent of total billed charges,,7841,,"100% primary, 50% supplemental procedure",7841,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4898.55,,,4898.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,255446.32,70,,255446.32,percent of total billed charges,,182461.66,50,,182461.66,percent of total billed charges,,182461.66,50,,182461.66,percent of total billed charges,,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2633.63,,,2633.63,Other,New York Medicaid APG methodology,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,3687.08,,,3687.08,Other,140% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,6847.44,,,6847.44,Other,260% New York Medicaid APG,8532.97,,,8532.97,Other,324% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,3292.04,,,3292.04,Other,125% New York Medicaid APG,2633.63,255446.32,
Insj iris prosth sec io lens,0618T,HCPCS,,,,,,,,both,,,41438.26,32992.49,,,32992.49,Other,150% of Medicare + 9.63% HCRA Surcharge,20062.93,,,20062.93,Other,Medicare OPPS methodology,9999,,"100% primary, 50% supplemental procedure",9999,Other,Aetna ASC Grouper,8999,,"100% primary, 50% supplemental procedure",8999,Other,Aetna ASC Grouper,11880,,"100% primary, 50% secondary, 25% supplemental procedure",11880,Other,Blue Cross ASC Grouper,10692,,"100% primary, 50% secondary, 25% supplemental procedure",10692,Other,Blue Cross ASC Grouper,10098,,"100% primary, 50% secondary, 25% supplemental procedure",10098,Other,Blue Cross ASC Grouper,20719.13,50,,20719.13,percent of total billed charges,,7841,,"100% primary, 50% supplemental procedure",7841,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,4898.55,,,4898.55,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29006.78,70,,29006.78,percent of total billed charges,,20719.13,50,,20719.13,percent of total billed charges,,20719.13,50,,20719.13,percent of total billed charges,,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,8452,,"100% primary, 50% secondary, 25% tertiary procedure",8452,Other,United Healthcare ASC Grouper,9390,,"100% primary, 50% secondary, 25% tertiary procedure",9390,Other,United Healthcare ASC Grouper,7982,,"100% primary, 50% secondary, 25% tertiary procedure",7982,Other,United Healthcare ASC Grouper,2633.63,,,2633.63,Other,New York Medicaid APG methodology,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,2633.63,,,2633.63,Other,100% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,3687.08,,,3687.08,Other,140% New York Medicaid APG,5925.67,,,5925.67,Other,225% New York Medicaid APG,6847.44,,,6847.44,Other,260% New York Medicaid APG,8532.97,,,8532.97,Other,324% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,5662.31,,,5662.31,Other,215% New York Medicaid APG,3292.04,,,3292.04,Other,125% New York Medicaid APG,2633.63,32992.49,
Insj ocular telescope prosth,0308T,HCPCS,,,,,,,,both,,,364923.31,32992.49,,,32992.49,Other,150% of Medicare + 9.63% HCRA Surcharge,20062.93,,,20062.93,Other,Medicare OPPS methodology,5845,,"100% primary, 50% supplemental procedure",5845,Other,Aetna ASC Grouper,5261,,"100% primary, 50% supplemental procedure",5261,Other,Aetna ASC Grouper,34107,,"100% primary, 50% secondary, 25% supplemental procedure",34107,Other,Blue Cross ASC Grouper,30696,,"100% primary, 50% secondary, 25% supplemental procedure",30696,Other,Blue Cross ASC Grouper,28991,,"100% primary, 50% secondary, 25% supplemental procedure",28991,Other,Blue Cross ASC Grouper,182461.66,50,,182461.66,percent of total billed charges,,5524,,"100% primary, 50% supplemental procedure",5524,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,6964.29,,,6964.29,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,255446.32,70,,255446.32,percent of total billed charges,,182461.66,50,,182461.66,percent of total billed charges,,182461.66,50,,182461.66,percent of total billed charges,,17798,,"100% primary, 50% secondary, 25% tertiary procedure",17798,Other,United Healthcare ASC Grouper,16018,,"100% primary, 50% secondary, 25% tertiary procedure",16018,Other,United Healthcare ASC Grouper,17798,,"100% primary, 50% secondary, 25% tertiary procedure",17798,Other,United Healthcare ASC Grouper,15129,,"100% primary, 50% secondary, 25% tertiary procedure",15129,Other,United Healthcare ASC Grouper,3744.24,,,3744.24,Other,New York Medicaid APG methodology,3744.24,,,3744.24,Other,100% New York Medicaid APG,3744.24,,,3744.24,Other,100% New York Medicaid APG,3744.24,,,3744.24,Other,100% New York Medicaid APG,8424.55,,,8424.55,Other,225% New York Medicaid APG,8424.55,,,8424.55,Other,225% New York Medicaid APG,8424.55,,,8424.55,Other,225% New York Medicaid APG,8424.55,,,8424.55,Other,225% New York Medicaid APG,5241.94,,,5241.94,Other,140% New York Medicaid APG,8424.55,,,8424.55,Other,225% New York Medicaid APG,9735.03,,,9735.03,Other,260% New York Medicaid APG,12131.35,,,12131.35,Other,324% New York Medicaid APG,8050.12,,,8050.12,Other,215% New York Medicaid APG,8050.12,,,8050.12,Other,215% New York Medicaid APG,4680.3,,,4680.3,Other,125% New York Medicaid APG,3744.24,255446.32,
Colgn cross-link crn med sep,0402T,HCPCS,,,,,,,,both,,,42122.79,4443.76,,,4443.76,Other,150% of Medicare + 9.63% HCRA Surcharge,2702.28,,,2702.28,Other,Medicare OPPS methodology,3692,,"100% primary, 50% supplemental procedure",3692,Other,Aetna ASC Grouper,3323,,"100% primary, 50% supplemental procedure",3323,Other,Aetna ASC Grouper,5044,,"100% primary, 50% secondary, 25% supplemental procedure",5044,Other,Blue Cross ASC Grouper,4540,,"100% primary, 50% secondary, 25% supplemental procedure",4540,Other,Blue Cross ASC Grouper,4287,,"100% primary, 50% secondary, 25% supplemental procedure",4287,Other,Blue Cross ASC Grouper,21061.4,50,,21061.4,percent of total billed charges,,5919,,"100% primary, 50% supplemental procedure",5919,Other,Cigna ASC Grouper,6152,,,6152,Case Rate,,1849.61,,,1849.61,Other,186% of Medicaid,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,9473,,,9473,Case Rate,,7237,,,7237,Case Rate,,9473,,,9473,Case Rate,,7796,,,7796,Case Rate,Ambulatory Surgery Case Rate,29485.95,70,,29485.95,percent of total billed charges,,21061.4,50,,21061.4,percent of total billed charges,,21061.4,50,,21061.4,percent of total billed charges,,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5683,,"100% primary, 50% secondary, 25% tertiary procedure",5683,Other,United Healthcare ASC Grouper,6315,,"100% primary, 50% secondary, 25% tertiary procedure",6315,Other,United Healthcare ASC Grouper,5368,,"100% primary, 50% secondary, 25% tertiary procedure",5368,Other,United Healthcare ASC Grouper,994.41,,,994.41,Other,New York Medicaid APG methodology,994.41,,,994.41,Other,100% New York Medicaid APG,994.41,,,994.41,Other,100% New York Medicaid APG,994.41,,,994.41,Other,100% New York Medicaid APG,2237.43,,,2237.43,Other,225% New York Medicaid APG,2237.43,,,2237.43,Other,225% New York Medicaid APG,2237.43,,,2237.43,Other,225% New York Medicaid APG,2237.43,,,2237.43,Other,225% New York Medicaid APG,1392.18,,,1392.18,Other,140% New York Medicaid APG,2237.43,,,2237.43,Other,225% New York Medicaid APG,2585.47,,,2585.47,Other,260% New York Medicaid APG,3221.9,,,3221.9,Other,324% New York Medicaid APG,2137.99,,,2137.99,Other,215% New York Medicaid APG,2137.99,,,2137.99,Other,215% New York Medicaid APG,1243.02,,,1243.02,Other,125% New York Medicaid APG,994.41,29485.95,